Medicare Participating Provider Program

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KENTUCKY PART B Medicare Participating Provider Program 2014 Enrollment Package (Includes Fee Schedule) © 2014 Copyright, CGS Administrators, LLC.

Transcript of Medicare Participating Provider Program

KENTUCKY PART B

Medicare Participating Provider Program

2014 Enrollment Package(Includes Fee Schedule)

© 2014 Copyright, CGS Administrators, LLC.

We wish to emphasize the importance and advantages of being a Medicare participating provider, and we are pleased that the favorable trend of participation continued into 2013 with a participation rate of 96.6 percent, the highest ever. As you plan for 2014 and become familiar with the coming changes, we are hopeful that you will continue to be a participating provider or, if you are non-participating, will consider becoming a participating provider.

Medicare, in partnership with the provider community, continues to explore and promote ways to improve the quality and efficiency of the health care services its beneficiaries receive. Level part B premiums for 2014 and decreased readmission rates are both early signals of success in this endeavor. We strongly believe that together we can continue the trend of increased quality of care for our beneficiaries. CMS recognizes the crucial role that health care providers play in educating Medicare beneficiaries about potentially life-saving preventive services and screenings. While Medicare now pays for more preventive benefits without requiring a coinsurance from the beneficiary, many Medicare beneficiaries do not fully realize that using preventive services and screenings can help them live longer, healthier lives. As a health care professional, you can help your Medicare patients understand the importance of disease prevention, early detection, and lifestyle modifications that support a healthier life.

We know that many of you remain concerned about the scheduled reduction to the Medicare Physician Fee Schedule (MPFS) currently expected to take effect on January 1, 2014. The Administration remains strongly opposed to letting this cut take effect. As he has repeatedly made clear, President Obama is committed to a permanent solution to eliminating the Sustainable Growth Rate’s cut. We will continue to work with Congress to achieve this goal.

WHY BECOME A PARTICIPATING MEDICARE PROVIDER

All physicians, practitioners and suppliers must make their CY 2014 Medicare participation decision by December 31, 2013. Providers who want to maintain their current participation (PAR) status (PAR or Non PAR) do not need to take any action during the upcoming annual participation enrollment program. To sign a participation agreement is to agree to accept assignment for all covered services that you provide to Medicare patients in CY 2014. The overwhelming majority of physicians, practitioners and suppliers have chosen to participate in Medicare. As indicated, during CY 2013, 96.6 percent of all physicians and practitioners are billing under Medicare participation agreements.

If you participate and you bill for services paid under the Medicare physician fee schedule, your Medicare fee schedule amounts are 5 percent higher than if you do not participate.

WHAT TO DO

If you choose to be a participant in CY 2014:

• Do nothing if you are currently participating, or

• If you are not currently a Medicare participant, complete the available blank agreement and mail it (or a copy) to each Medicare contractor to which you submit Part B claims. (On the form show the name(s) and identification number(s) under which you bill.)

If you decide not to participate in CY 2014:

• Do nothing if you are currently not participating, or

• If you are currently a participant, write to each Medicare contractor to which you submit claims, advising of your termination effective January 1, 2014. This written notice must be postmarked prior to January 1, 2014.

ANNOUNCEMENTAbout Medicare Participation for Calendar Year 2014

ANNOUNCEMENT: About Medicare Participation for Calendar Year 2013

We hope you will decide to be a Medicare participant in CY 2014. Please call 1.866.276.9558 if you have any questions or need further information on participation.

The Medicare Learning Network® has developed products in an effort to educate Medicare providers about important Medicare enrollment information and how to use Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to enroll in the Medicare Program and maintain their enrollment information. Please see the list of available products at http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/Medicare_Provider-Supplier_Enrollment_National_Education_Products.pdf on the CMS website.

To view updates and the latest information about Medicare, or to obtain telephone numbers of the various Medicare contractors contacts including the contractor medical directors, please visit the CMS website at http://www.cms.gov/. For CGS, you may contact the following toll-free number(s) for assistance: 1.866.276.9558.

The Health Insurance Marketplace – Expanding Health Insurance Coverage:

A primary goal of the Affordable Care Act is to help uninsured and other eligible Americans gain access to quality, affordable health care. Central to this goal is the creation of the Health Insurance Marketplace. Through the Marketplace, eligible Americans will be able to enroll in a health plan to get coverage that starts as soon as January 2014, and no one will be denied coverage on the basis of pre-existing conditions. Beginning in January 2014, expect to see previously uninsured patients newly covered by private health insurance plans and, in many states, expanded Medicaid eligibility. Many of these private plans continue to develop their provider networks.

As a trusted source for health information, your patients may look to you for help navigating the Marketplace. Resources concerning the Marketplace may be found at:

Marketplace.cms.gov: Where organizations and individuals looking to help can get the latest resources and learn more about the Marketplace.

HealthCare.gov: Where individuals can learn about the Marketplace and the upcoming benefits (including where they can find local assistance), or be connected to appropriate resources in states that are running their own Marketplace.

Health Insurance Marketplace Call Center: If you have questions, call 1.800.318.2596. TTY users should call 1.855.889.4325.

At Marketplace.cms.gov, there are two articles particularly relevant for clinicians: “10 Things Providers Need to Know” (http://marketplace.cms.gov/getofficialresources/publications-and-articles/10-things-providers-need-to-know.pdf) and “10 Things to Tell Your Patients” (http://marketplace.cms.gov/getofficialresources/publications-and-articles/10-things-to-tell-your-patients.pdf).

Information Related to Medicare Prescription Drug (Part D) Coverage:

Prescription drug abuse is the nation’s fastest growing drug problem. Additional prescriber awareness and engagement are crucial to addressing this problem. The Centers for Medicare & Medicaid Services (CMS) has implemented an approach to help Medicare prescription drug plans identify and manage the most egregious cases of opioid overutilization, which often involves multiple prescribers who are not aware of each other. In addition, many opioid analgesics also contain acetaminophen, which is subject to a maximum daily dose of 4 grams as established by the Food and Drug Administration. As you know, higher acetaminophen doses, often involving the use of multiple products, are associated with acute liver failure and may result in liver transplant and death. If you are contacted by a prescription drug plan about the opioid or acetaminophen use of one of your patients, please take the time to provide your feedback and expertise to help assure the safe use of these products.

Many states have operational Prescription Drug Monitoring Programs (PDMPs). PDMPs are tools used by states to reduce prescription drug abuse and diversion. We encourage you to actively participate in your state’s PDMP. For more information about your state’s PDMP

ANNOUNCEMENT: About Medicare Participation for Calendar Year 2013

program and how to obtain access, please visit the following website: http://www.pmpalliance.org/content/pmp-access.

CMS is requesting your help so that prescribers do not override a Medicare beneficiary’s choice of pharmacy to fill their Part D prescriptions. CMS is aware that some Part D plans have dispensed prescriptions without confirming that the beneficiary wants to fill that prescription, and if so, if they want the prescription filled by the particular pharmacy that is dispensing it. An example is the plan’s/Pharmacy Benefit Managers (PBM’s) use of prior authorization forms to re-direct a prescription to the plan’s and/or PBM’s own pharmacy or to mail order instead of the pharmacy at which the beneficiary presented the original prescription. While CMS is addressing this issue directly with Part D plans, we want Medicare providers to assist in this area.

Please check your data in the National Plan and Provider Enumeration System (NPPES) and confirm that it still correctly describes you as a health care provider. There is increased focus on the NPI as a health care provider identifier for program integrity purposes. Incorrect taxonomy data in NPPES may lead to unnecessary inquiries about your credentials, because it may appear to Medicare oversight authorities that you may not be lawfully prescribing Part D drugs. Comprehensive information about how the NPI rule pertains to prescribers may be obtained from the CMS website at: http://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/NationalProvIdentStand/Downloads/NPI-Requirements-for-Prescribers.pdf.

Medicare Shared Savings Program:

Currently, over 75,000 physicians participate in Accountable Care Organizations (ACO) in the Medicare Shared Savings Program. When an ACO succeeds in both delivering high-quality care and lowering growth in Medicare spending on patients its providers serve, it will share in the savings it achieves for the Medicare program.

Eligible professionals (i.e. physicians and other practitioners) in an ACO that successfully reports the PQRS group practice reporting option quality measures required under the Shared Savings Program in any year of the program will be deemed eligible for the PQRS bonus and/or avoid the PQRS payment adjustment, regardless of whether the ACO qualifies to share in savings. Groups of physicians that participate in an ACO are also exempt from the application of the value modifier.

We encourage physicians and other practitioners to collaborate with their ACOs so that together they can achieve the goals of the program including successful reporting and performance on quality measures.

We encourage you to consider joining the Medicare Shared Savings Program. Please visit the Medicare Shared Savings Program webpage for more information about the program including how to apply or learn about ACOs in your area - http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/index.html?redirect=/sharedsavingsprogram/.

New Payment and Care Delivery Model Tests Underway from the CMS Innovation Center:

The CMS Innovation Center, created by the Affordable Care Act, provides a new opportunity to the Medicare, Medicaid, and the Children’s Health Insurance Programs to test, evaluate and spread new models of care delivery and payment that can deliver better care and better health at lower cost through continuous improvement. There are many new opportunities for physicians to participate in testing and learning about these new models such as the Comprehensive Primary Care Initiative, the several Accountable Care Organization Models, the Partnership for Patients patient safety campaign, among others. We encourage you to visit the CMS Innovation Center website to obtain up-to-date opportunities and more information at: http://www.innovations.cms.gov.

We encourage physicians to join Million Hearts, a U.S. Department of Health and Human Services initiative co-led by the Centers for Disease Control and Prevention and CMS, aimed at preventing 1 million heart attacks and strokes by 2017. Joining this effort means working with your staff and patients to excel in the ABCS: aspirin for those patients at risk, blood pressure control, cholesterol management, and smoking cessation. The initial milestone in Million Hearts is better blood pressure control for the 67 million Americans with hypertension, 36 million of

ANNOUNCEMENT: About Medicare Participation for Calendar Year 2013

whom are not yet under control. Please visit http://millionhearts.hhs.gov for resources that can be helpful. For questions, contact the Million Hearts team at [email protected].

Primary Care Incentives:

In 2014, CMS will continue to make a 10 percent incentive payment for primary care services furnished by primary care practitioners as authorized by the Affordable Care Act. To be eligible for this incentive payment, a physician’s Medicare specialty needs to be family medicine, geriatric medicine, pediatric medicine, or internal medicine, and primary care services need to constitute 60 percent of Medicare Part B outpatient services (excluding services provided to hospital inpatients or those in emergency departments) in 2012. Nurse practitioners, clinical nurse specialists, and physician assistants are also eligible for these incentive payments.

In 2014, Medicare will continue to make payments to physicians to coordinate a patient’s care during their transition back to the community following a discharge from a hospital or nursing facility. More information on billing for this service is available at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Transitional-Care-Management-Services-Fact-Sheet-ICN908628.pdf. We also answer frequently asked questions on billing for this service: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/FAQ-TCMS.pdf.

Also please see the Special Edition MLN Matters Article developed by the Medicare Learning Network®. The article provides a list of questions and answers that respond to the inquiries CMS has received about the Primary Care Incentive Program. The article can be found at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/mm7060.pdf on the CMS website.

Engaging Physicians in Quality:

We believe that physicians are leaders in quality improvement. We continue our efforts to collaborate with physicians and other professionals to facilitate quality improvement through quality reporting programs and, pay for performance programs such as the Value Modifier (VM) program. The VM program links quality to payment by providing for differential payment to physicians based on the quality and cost of care furnished to Medicare patients.

CMS recognizes that physician practices vary and measurement must be meaningful and relevant to clinical practice. We also know that engaging in quality reporting and improvement requires significant time and

resources from physicians and their practices. Thus, developing quality programs that maximize flexibility while minimizing burden is critical. This principle is reflected in ongoing improvements to CMS quality programs, such as:

• Physicians can choose what measures best reflect their practice and how they report measures to CMS.

• Physicians can “report once” for multiple programs, including the Medicare Electronic Health Record (EHR) Incentive Program, PQRS, and the VM.

• Practicing physicians and others can contribute new quality measures through open calls for measures and help select measures through the Measures Application Partnership.

• CMS is aligning related measures across CMS programs and the private sector to reduce provider reporting burden.

• New for the 2014 PQRS program is the option for EPs to participate in Qualified Clinical Data Registries (QCDRs). QCDRs will be able to report, on behalf of EPs, quality measures that meet certain CMS requirements but are not necessarily measures currently in PQRS. Physician specialty societies and boards as well as regional quality improvement collaboratives and others are interested in becoming QCDRs so we encourage you to investigate QCDR options that may be available to you. QCDRs will enable physicians to measure and report on quality metrics that are particularly meaningful to the care they provide.

• You can view the Medicare Learning Network® YouTube video regarding “Implications for the Value-Based Payment” Modifier at: http://www.youtube.com/watch?v=ZxIiW33jkSs

ANNOUNCEMENT: About Medicare Participation for Calendar Year 2013

Availability of the 2013 Quality and Resource Use Reports (QRURs):

In the late summer of 2014, we plan to provide QRURs at the Tax Identification Number level to all groups of physicians and to solo practitioners. The QRURs will be based on CY 2013 performance data. These reports will contain performance on the quality and cost measures used to score the quality and cost composites of the Value-Based Payment Modifier and additional information to help physicians coordinate care and improve the quality of care furnished to Medicare beneficiaries. For groups of 100 or more eligible professionals, these QRURs will provide information on how their 2015 payments under the Medicare Physician Fee Schedule will be affected.

Incentives and Payment Adjustments for Quality Reporting:

In 2014, eligible professionals (EPs) will have the opportunity to earn incentive payments equal to 0.5 percent of their total allowed Medicare Part B Fee-for-Service charges for services provided during 2014 under the Physician Quality Reporting System (PQRS). 2014 is the last year that an incentive is available for PQRS. Incentive payments earned in 2014 will be paid in CY 2015.

The Electronic Prescribing (eRx) Incentive Program, including any payment adjustments for unsuccessful e-prescribing or reporting, will end in 2014. No reporting of electronic prescribing for this program is required in 2014.

EPs should note that 2014 will also serve as the reporting period for the 2016 PQRS payment adjustment. The payment adjustment for 2016 based on 2104 reporting is negative 2.0%. The reporting requirements to avoid the 2016 PQRS payment adjustment are detailed in the CYs 2013 and 2014 Medicare Physician Fee Schedule (MPFS) Final Rule.

Please use the links below to visit the PQRS and eRx Incentive Program websites where more detailed information about these programs are available.

PQRS website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html

eRx Incentive Program website: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ERxIncentive/index.html

You can also find more information by clicking on the Medicare Learning Network® Fact Sheet titled “2013 Physician Quality Reporting System (PQRS): 2015 PQRS Payment Adjustment “located at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/2013-PQRS-Updates-ICN908705.pdf on the CMS website and also the Fact Sheet titled 2013 Electronic Prescribing (eRx) Incentive Program: Participation for the Incentive Payment Made Simple located at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/2013-eRx-Participation-Incentive-Payment.pdf.

Medicare and Medicaid EHR Incentive Programs:

Stage 2 is just around the corner. Starting in 2014, providers who have met criteria for Stage 1, for a period of two or three years, will need to meet meaningful use criteria for Stage 2. Stage 2 criteria include new objectives to improve patient care through better clinical decision support, care coordination, and patient engagement. This will help reduce health care costs, save time for doctors and hospitals, and save lives. Beginning in 2014, EPs, hospitals, and critical access hospitals will also be required to report on a new set of clinical quality measures, regardless of whether at Stage 1 or Stage 2.

In order to align programs and reduce the burden on physicians and providers, physicians may simultaneously submit clinical quality measure data for both the Medicare EHR Incentive Program and the PQRS program electronically; and eligible hospitals and critical access hospitals may do the same through the Inpatient Quality Reporting Program. Beginning in 2014, all physicians and providers beyond the first year of demonstrating meaningful use will be able to report clinical quality measures electronically. For more information about the EHR Incentive Programs and Stage 2, visit http://www.cms.gov/EHRIncentivePrograms.

ANNOUNCEMENT: About Medicare Participation for Calendar Year 2013

Beginning in 2015, those who fail to meet meaningful use for the applicable period may be subject to a payment adjustment to their Medicare claims. To avoid 2015 payment adjustments, Medicare EPs must demonstrate meaningful use prior to October 1, 2014. Don’t wait until the last minute to meet meaningful use! For more information about payment adjustments, please visit http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_HardshipExcepTipSheetforEP.pdf.

The Medicare Learning Network® also offers a Quick Reference Guide about EHR reporting. You can view the guide at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PQRS-EHR-Incentive-Pilot-Quick-Ref-Guide.pdf on the CMS website.

eHealth:

CMS recently launched the eHealth initiative to help providers deliver high-quality health care by simplifying the use of electronic standards and encouraging the adoption of health information technology. eHealth addresses recent federal electronic health directives that require new paradigms for standardized data-driven operational processes to support three national health care goals: improved quality of care, improved health outcomes, and reduced costs without compromising quality. The eHealth initiative will help to achieve these goals by encouraging interoperability—standardizing and facilitating the sharing of health care data securely and easily among health care providers across different sites of care.

For more information, visit http://www.cms.gov/eHealth.

Revalidation:

Over the coming months, many providers will receive requests from their respective Medicare Administrative Contractors (MACs) to revalidate their Medicare enrollment information. Providers can revalidate their enrollment information using either Internet-based Provider Enrollment,

Chain and Ownership System found at https://pecos.cms.hhs.gov/pecos/login.do or the CMS 855 paper application found at http://www.cms.gov/CMSForms/CMSForms/list.asp. We encourage all practitioners to respond timely to revalidation requests received by their MAC. Failure to submit a complete revalidation application, including all supporting documents may result in deactivation of your Medicare billing privileges.

See the Medicare Learning Network® MLN Matters Special Edition Article on this subject. It can be found at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1126.pdf on the CMS website.

The Medicare Learning Network:

The Medicare Learning Network® (MLN) now offers a weekly electronic newsletter, the MLN Connects Provider eNews. View past editions at http://www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive.html. The clickable table of contents allows you to move directly to items of interest to you, such as upcoming calls and events; and CMS program information, including ICD-10, EHR incentive programs, Medicare enrollment, CMS quality incentive programs and MLN educational materials. To subscribe, go to https://public.govdelivery.com/accounts/USCMS/subscriber/new?pop=t&topic_id=USCMS_7819. All you need is a valid e-mail address.

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 8

ANES 21.81 20.72 23.83 23.36 G0101 35.07 33.32 38.32 37.55# G0101 26.01 24.71 28.42 27.85 G0102 17.93 17.03 19.58 19.19# G0102 8.55 8.12 9.34 9.15 G0104 124.52 118.29 136.03 133.31# G0104 60.49 57.47 66.09 64.77 G0105 359.50 341.53 392.76 384.91# G0105 208.31 197.89 227.57 223.02 G0105 53 124.52 118.29 136.03 133.31# G0105 53 60.49 57.47 66.09 64.77 G0106 200.57 190.54 219.12 214.74 G0106 TC 153.03 145.38 167.19 163.84 G0106 26 47.54 45.16 51.93 50.90 G0108 50.50 47.98 55.18 54.07 G0109 13.92 13.22 15.20 14.90 G0117 50.69 48.16 55.38 54.28 G0118 40.10 38.10 43.82 42.94 G0120 200.57 190.54 219.12 214.74 G0120 TC 153.03 145.38 167.19 163.84 G0120 26 47.54 45.16 51.93 50.90 G0121 359.50 341.53 392.76 384.91# G0121 208.31 197.89 227.57 223.02 G0121 53 124.52 118.29 136.03 133.31# G0121 53 60.49 57.47 66.09 64.77 G0124 29.62 28.14 32.36 31.72 G0127 21.05 20.00 23.00 22.54# G0127 7.62 7.24 8.33 8.17 G0128 6.84 6.50 7.48 7.33 G0130 30.93 29.38 33.79 33.11 G0130 TC 19.96 18.96 21.80 21.37 G0130 26 10.97 10.42 11.98 11.74 G0141 29.62 28.14 32.36 31.72 G0166 119.54 113.56 130.59 127.98 G0168 90.67 86.14 99.06 97.08# G0168 26.01 24.71 28.42 27.85 G0179 37.88 35.99 41.39 40.56 G0180 49.48 47.01 54.06 52.98 G0181 101.61 96.53 111.01 108.79 G0182 102.23 97.12 111.69 109.46 G0202 120.80 114.76 131.97 129.33 G0202 TC 86.81 82.47 94.84 92.94 G0202 26 33.99 32.29 37.13 36.39 G0204 147.47 140.10 161.12 157.90 G0204 TC 104.92 99.67 114.62 112.33 G0204 26 42.55 40.42 46.48 45.55 G0206 116.11 110.30 126.85 124.30 G0206 TC 82.12 78.01 89.71 87.92 G0206 26 33.99 32.29 37.13 36.39 G0237 8.71 8.27 9.51 9.32 G0238 9.34 8.87 10.20 9.99 G0239 11.21 10.65 12.25 12.01

G0245 61.65 58.57 67.36 66.01# G0245 41.97 39.87 45.85 44.93 G0246 35.38 33.61 38.65 37.88# G0246 20.70 19.67 22.62 22.17 G0247 65.88 62.59 71.98 70.54# G0247 23.08 21.93 25.22 24.71 G0248 96.49 91.67 105.42 103.32 G0249 96.80 91.96 105.75 103.64 G0250 8.91 8.46 9.73 9.53 G0268 48.61 46.18 53.11 52.05# G0268 31.43 29.86 34.34 33.65 G0270 28.82 27.38 31.49 30.85# G0270 26.95 25.60 29.44 28.85 G0271 15.17 14.41 16.57 16.24# G0271 14.54 13.81 15.88 15.56 G0278 12.04 11.44 13.16 12.89 G0281 12.97 12.32 14.17 13.88 G0283 12.97 12.32 14.17 13.88 G0288 32.76 31.12 35.79 35.08 G0289 84.21 80.00 92.00 90.16 G0329 8.99 8.54 9.82 9.63 G0339 3,129.34 2,972.87 3,418.80 3,350.42 G0340 2,299.41 2,184.44 2,512.11 2,461.86 G0341 1,994.26 1,894.55 2,178.73 2,135.16# G0341 356.79 338.95 389.79 382.00 G0342 655.36 622.59 715.98 701.66 G0343 1,108.72 1,053.28 1,211.27 1,187.04 G0364 11.63 11.05 12.71 12.45# G0364 8.51 8.08 9.29 9.11C G0365 178.43 169.51 194.94 191.04C G0365 TC 166.46 158.14 181.86 178.23 G0365 26 11.97 11.37 13.08 12.81 G0372 8.55 8.12 9.34 9.15 G0389 60.31 57.29 65.88 64.56 G0389 TC 32.14 30.53 35.11 34.41 G0389 26 28.17 26.76 30.77 30.15 G0396 35.01 33.26 38.25 37.48# G0396 33.14 31.48 36.20 35.48 G0397 67.53 64.15 73.77 72.30# G0397 65.34 62.07 71.38 69.95 G0398 167.44 159.07 182.93 179.27 G0398 TC 111.63 106.05 121.96 119.52 G0398 26 55.82 53.03 60.98 59.77 G0399 162.00 153.90 176.99 173.44 G0399 TC 107.99 102.59 117.98 115.62 G0399 26 54.00 51.30 59.00 57.81 G0400 156.54 148.71 171.02 167.60 G0400 TC 104.37 99.15 114.02 111.75 G0400 26 52.18 49.57 57.01 55.87 G0402 154.45 146.73 168.74 165.37# G0402 121.02 114.97 132.22 129.57 G0403 15.39 14.62 16.81 16.48

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 9

G0404 7.15 6.79 7.81 7.65 G0405 8.24 7.83 9.00 8.82 G0406 37.67 35.79 41.16 40.33 G0407 69.19 65.73 75.59 74.08 G0408 99.69 94.71 108.92 106.74 G0409 13.71 13.02 14.97 14.67 G0412 688.31 653.89 751.97 736.93 G0413 1,014.27 963.56 1,108.09 1,085.93 G0414 944.08 896.88 1,031.41 1,010.78 G0415 1,308.52 1,243.09 1,429.55 1,400.96 G0416 581.64 552.56 635.44 622.74 G0416 TC 406.99 386.64 444.64 435.75 G0416 26 174.66 165.93 190.82 187.00 G0417 1,130.27 1,073.76 1,234.82 1,210.12 G0417 TC 794.96 755.21 868.49 851.13 G0417 26 335.31 318.54 366.32 359.00 G0418 1,940.38 1,843.36 2,119.86 2,077.46 G0418 TC 1,357.55 1,289.67 1,483.12 1,453.46 G0418 26 582.83 553.69 636.74 624.01 G0419 2,300.16 2,185.15 2,512.92 2,462.67 G0419 TC 1,629.00 1,547.55 1,779.68 1,744.09 G0419 26 671.17 637.61 733.25 718.59 G0420 105.23 99.97 114.97 112.67 G0421 24.37 23.15 26.62 26.09 G0422 96.42 91.60 105.34 103.24 G0423 96.42 91.60 105.34 103.24 G0424 27.73 26.34 30.29 29.68# G0424 13.99 13.29 15.28 14.97 G0425 97.23 92.37 106.23 104.10 G0426 132.12 125.51 144.34 141.45 G0427 194.77 185.03 212.78 208.53 G0429 93.36 88.69 101.99 99.96# G0429 69.94 66.44 76.41 74.88 G0436 13.56 12.88 14.81 14.51# G0436 11.69 11.11 12.78 12.52 G0437 26.86 25.52 29.35 28.76# G0437 24.99 23.74 27.30 26.76 G0438 159.13 151.17 173.85 170.37 G0439 105.80 100.51 115.59 113.28 G0442 16.41 15.59 17.93 17.57# G0442 9.22 8.76 10.07 9.87 G0443 24.45 23.23 26.71 26.19# G0443 22.89 21.75 25.01 24.52 G0444 16.41 15.59 17.93 17.57# G0444 8.91 8.46 9.73 9.53 G0445 25.70 24.42 28.08 27.52# G0445 22.89 21.75 25.01 24.52 G0446 24.76 23.52 27.05 26.51# G0446 22.89 21.75 25.01 24.52 G0447 24.76 23.52 27.05 26.51# G0447 22.89 21.75 25.01 24.52 G0451 7.15 6.79 7.81 7.65

G0452 26 18.46 17.54 20.17 19.77 G0453 31.07 29.52 33.95 33.27 G0454 8.91 8.46 9.73 9.53 G0455 115.82 110.03 126.53 124.00# G0455 68.34 64.92 74.66 73.16 G0459 46.70 44.37 51.03 50.00 G0461 79.80 75.81 87.18 85.43 G0461 TC 50.26 47.75 54.91 53.82 G0461 26 29.55 28.07 32.28 31.64 G0462 60.69 57.66 66.31 64.99 G0462 TC 48.70 46.27 53.21 52.14 G0462 26 12.00 11.40 13.11 12.85 G9157 107.30 101.94 117.23 114.89 G9187 42.96 40.81 46.93 45.99 M0064 49.45 46.98 54.03 52.95# M0064 15.72 14.93 17.17 16.82 P3001 29.62 28.14 32.36 31.72 Q0035 18.83 17.89 20.57 20.16 Q0035 TC 10.27 9.76 11.22 10.99 Q0035 26 8.55 8.12 9.34 9.15 Q0091 40.64 38.61 44.40 43.52# Q0091 18.77 17.83 20.50 20.09 Q0092 21.21 20.15 23.17 22.71 R0070 112.39 106.77 122.79 120.32 R0075 112.39 106.77 122.79 120.32 0073T 344.51 327.28 376.37 368.84 0171T 706.79 671.45 772.17 756.72 0172T 130.19 123.68 142.23 139.39 0191T 835.48 793.71 912.77 894.52 0275T 549.51 522.03 600.33 588.33 0320T 362.81 344.67 396.37 388.45 10021 136.28 129.47 148.89 145.91# 10021 68.50 65.08 74.84 73.35 10022 128.44 122.02 140.32 137.52# 10022 64.09 60.89 70.02 68.62 10030 702.22 667.11 767.18 751.84# 10030 151.81 144.22 165.85 162.54 10040 93.67 88.99 102.34 100.29# 10040 82.73 78.59 90.38 88.57 10060 106.73 101.39 116.60 114.26# 10060 90.17 85.66 98.51 96.54 10061 190.77 181.23 208.41 204.25# 10061 168.59 160.16 184.18 180.50 10080 161.74 153.65 176.70 173.17# 10080 96.45 91.63 105.37 103.27 10081 247.67 235.29 270.58 265.17# 10081 163.33 155.16 178.43 174.87 10120 138.14 131.23 150.91 147.90# 10120 96.59 91.76 105.52 103.41 10121 252.35 239.73 275.69 270.18# 10121 176.44 167.62 192.76 188.91 10140 149.33 141.86 163.14 159.87

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 10

# 10140 111.54 105.96 121.85 119.42 10160 119.22 113.26 130.25 127.64# 10160 90.17 85.66 98.51 96.54 10180 225.72 214.43 246.59 241.66# 10180 167.62 159.24 183.13 179.47 11000 50.37 47.85 55.03 53.92# 11000 28.19 26.78 30.80 30.18 11001 20.01 19.01 21.86 21.42# 11001 14.08 13.38 15.39 15.08 11004 561.71 533.62 613.66 601.39 11005 753.79 716.10 823.52 807.05 11006 680.70 646.67 743.67 728.80 11008 264.32 251.10 288.77 282.99 11010 445.23 422.97 486.42 476.69# 11010 264.36 251.14 288.81 283.04 11011 493.22 468.56 538.84 528.07# 11011 288.31 273.89 314.97 308.67 11012 653.42 620.75 713.86 699.59# 11012 406.96 386.61 444.60 435.71 11042 106.36 101.04 116.20 113.87# 11042 59.19 56.23 64.66 63.38 11043 213.60 202.92 233.36 228.69# 11043 151.44 143.87 165.45 162.14 11044 297.51 282.63 325.02 318.53# 11044 225.98 214.68 246.88 241.95 11045 39.39 37.42 43.03 42.17# 11045 26.58 25.25 29.04 28.46 11046 69.10 65.65 75.50 73.99# 11046 54.42 51.70 59.46 58.27 11047 118.02 112.12 128.94 126.36# 11047 97.09 92.24 106.08 103.96 11055 43.08 40.93 47.07 46.13# 11055 15.90 15.11 17.38 17.03 11056 53.10 50.45 58.02 56.86# 11056 22.49 21.37 24.58 24.08 11057 60.32 57.30 65.90 64.57# 11057 29.39 27.92 32.11 31.46 11100 92.67 88.04 101.25 99.22# 11100 46.75 44.41 51.07 50.05 11101 30.13 28.62 32.91 32.26# 11101 23.57 22.39 25.75 25.23 11200 80.22 76.21 87.64 85.89# 11200 68.04 64.64 74.34 72.85 11201 18.06 17.16 19.73 19.34# 11201 16.18 15.37 17.68 17.32 11300 86.19 81.88 94.16 92.28# 11300 33.71 32.02 36.82 36.09 11301 106.82 101.48 116.70 114.37# 11301 51.22 48.66 55.96 54.84 11302 125.87 119.58 137.52 134.77# 11302 59.96 56.96 65.50 64.19 11303 140.08 133.08 153.04 149.98

# 11303 71.36 67.79 77.96 76.39 11305 89.05 84.60 97.29 95.35# 11305 38.13 36.22 41.65 40.83 11306 109.29 103.83 119.40 117.01# 11306 50.25 47.74 54.90 53.81 11307 129.34 122.87 141.30 138.47# 11307 64.36 61.14 70.31 68.91 11308 137.12 130.26 149.80 146.80# 11308 71.84 68.25 78.49 76.92 11310 101.37 96.30 110.75 108.53# 11310 45.45 43.18 49.66 48.67 11311 100.76 95.72 110.08 107.88# 11311 62.65 59.52 68.45 67.08 11312 144.30 137.09 157.65 154.50# 11312 75.27 71.51 82.24 80.59 11313 168.36 159.94 183.93 180.25# 11313 96.51 91.68 105.43 103.33 11400 110.57 105.04 120.80 118.38# 11400 74.02 70.32 80.87 79.25 11401 134.53 127.80 146.97 144.03# 11401 96.73 91.89 105.67 103.56 11402 149.85 142.36 163.71 160.44# 11402 106.74 101.40 116.61 114.28 11403 174.19 165.48 190.30 186.50# 11403 137.33 130.46 150.03 147.03 11404 197.75 187.86 216.04 211.72# 11404 151.20 143.64 165.19 161.89 11406 287.53 273.15 314.12 307.84# 11406 231.62 220.04 253.05 247.99 11420 110.86 105.32 121.12 118.69# 11420 76.50 72.68 83.58 81.91 11421 143.14 135.98 156.38 153.25# 11421 104.09 98.89 113.72 111.45 11422 159.89 151.90 174.69 171.19# 11422 126.47 120.15 138.17 135.41 11423 184.81 175.57 201.91 197.87# 11423 147.33 139.96 160.95 157.73 11424 213.67 202.99 233.44 228.77# 11424 168.69 160.26 184.30 180.61 11426 308.44 293.02 336.97 330.23# 11426 259.39 246.42 283.38 277.71 11440 122.37 116.25 133.69 131.02# 11440 95.81 91.02 104.67 102.58 11441 153.02 145.37 167.18 163.83# 11441 122.41 116.29 133.73 131.05 11442 171.44 162.87 187.30 183.55# 11442 136.14 129.33 148.73 145.75 11443 205.32 195.05 224.31 219.82# 11443 167.22 158.86 182.69 179.03 11444 260.27 247.26 284.35 278.66# 11444 214.67 203.94 234.53 229.84 11446 363.23 345.07 396.83 388.90

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 11

# 11446 309.50 294.03 338.13 331.37 11450 343.39 326.22 375.15 367.66# 11450 234.69 222.96 256.40 251.28 11451 440.87 418.83 481.65 472.02# 11451 304.37 289.15 332.52 325.88 11462 334.75 318.01 365.71 358.40# 11462 223.86 212.67 244.57 239.68 11463 450.94 428.39 492.65 482.79# 11463 307.25 291.89 335.67 328.96 11470 378.37 359.45 413.37 405.10# 11470 264.66 251.43 289.14 283.36 11471 470.44 446.92 513.96 503.68# 11471 332.37 315.75 363.11 355.86 11600 174.65 165.92 190.81 186.99# 11600 112.80 107.16 123.23 120.77 11601 207.11 196.75 226.26 221.74# 11601 140.26 133.25 153.24 150.18 11602 224.79 213.55 245.58 240.67# 11602 153.88 146.19 168.12 164.76 11603 257.37 244.50 281.18 275.55# 11603 184.27 175.06 201.32 197.29 11604 287.36 272.99 313.94 307.66# 11604 203.95 193.75 222.81 218.36 11606 413.66 392.98 451.93 442.89# 11606 304.64 289.41 332.82 326.16 11620 176.57 167.74 192.90 189.05# 11620 114.41 108.69 124.99 122.50 11621 208.40 197.98 227.68 223.12# 11621 140.93 133.88 153.96 150.88 11622 232.86 221.22 254.40 249.32# 11622 161.64 153.56 176.59 173.06 11623 275.01 261.26 300.45 294.43# 11623 200.97 190.92 219.56 215.17 11624 310.73 295.19 339.47 332.68# 11624 228.26 216.85 249.38 244.39 11626 376.73 357.89 411.57 403.34# 11626 281.14 267.08 307.14 301.00 11640 181.71 172.62 198.51 194.55# 11640 117.99 112.09 128.90 126.33 11641 216.24 205.43 236.24 231.52# 11641 147.52 140.14 161.16 157.94 11642 246.87 234.53 269.71 264.32# 11642 173.77 165.08 189.84 186.05 11643 294.37 279.65 321.60 315.17# 11643 219.40 208.43 239.69 234.90 11644 363.62 345.44 397.26 389.31# 11644 272.10 258.50 297.28 291.33 11646 478.45 454.53 522.71 512.26# 11646 379.11 360.15 414.17 405.89 11719 12.93 12.28 14.12 13.83# 11719 7.62 7.24 8.33 8.17 11720 29.79 28.30 32.55 31.89

# 11720 14.79 14.05 16.16 15.84 11721 41.69 39.61 45.55 44.64# 11721 24.51 23.28 26.77 26.23 11730 91.60 87.02 100.07 98.07# 11730 50.37 47.85 55.03 53.92 11732 33.15 31.49 36.21 35.49# 11732 20.03 19.03 21.88 21.45 11740 45.01 42.76 49.17 48.19# 11740 30.64 29.11 33.48 32.81 11750 207.52 197.14 226.71 222.18# 11750 165.04 156.79 180.31 176.70 11752 298.36 283.44 325.96 319.44# 11752 246.50 234.18 269.31 263.93 11755 123.07 116.92 134.46 131.77# 11755 75.59 71.81 82.58 80.93 11760 210.58 200.05 230.06 225.46# 11760 125.30 119.04 136.90 134.16 11762 260.77 247.73 284.89 279.20# 11762 177.67 168.79 194.11 190.22 11765 150.88 143.34 164.84 161.54# 11765 88.09 83.69 96.24 94.32 11770 253.78 241.09 277.25 271.71# 11770 173.81 165.12 189.89 186.09 11771 525.11 498.85 573.68 562.20# 11771 407.34 386.97 445.02 436.11 11772 637.57 605.69 696.54 682.62# 11772 536.99 510.14 586.66 574.93 11900 50.24 47.73 54.89 53.80# 11900 29.94 28.44 32.71 32.05 11901 64.20 60.99 70.14 68.74# 11901 46.70 44.37 51.03 50.00 11920 156.89 149.05 171.41 167.98# 11920 109.41 103.94 119.53 117.14 11921 182.55 173.42 199.43 195.44# 11921 128.82 122.38 140.74 137.92 11922 56.01 53.21 61.19 59.97# 11922 28.83 27.39 31.50 30.87 11950 70.35 66.83 76.85 75.31# 11950 50.98 48.43 55.69 54.58 11951 95.86 91.07 104.73 102.64# 11951 72.75 69.11 79.48 77.89 11952 126.89 120.55 138.63 135.86# 11952 96.91 92.06 105.87 103.75 11954 147.27 139.91 160.90 157.68# 11954 111.03 105.48 121.30 118.88 11960 875.24 831.48 956.20 937.08 11970 578.12 549.21 631.59 618.96 11971 428.33 406.91 467.95 458.59# 11971 298.38 283.46 325.98 319.46 11976 135.22 128.46 147.73 144.77# 11976 93.98 89.28 102.67 100.61 11980 97.23 92.37 106.23 104.10

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 12

# 11980 77.55 73.67 84.72 83.03 11981 126.87 120.53 138.61 135.84# 11981 78.76 74.82 86.04 84.32 11982 144.17 136.96 157.50 154.35# 11982 94.51 89.78 103.25 101.18 11983 204.52 194.29 223.43 218.96# 11983 165.47 157.20 180.78 177.17 12001 82.11 78.00 89.70 87.91# 12001 43.69 41.51 47.74 46.78 12002 100.18 95.17 109.45 107.26# 12002 57.70 54.82 63.04 61.78 12004 118.56 112.63 129.52 126.94# 12004 72.02 68.42 78.68 77.11 12005 154.73 146.99 169.04 165.66# 12005 97.56 92.68 106.58 104.45 12006 186.08 176.78 203.30 199.23# 12006 118.30 112.39 129.25 126.66 12007 216.53 205.70 236.56 231.83# 12007 146.56 139.23 160.11 156.92 12011 100.49 95.47 109.79 107.59# 12011 54.57 51.84 59.62 58.42 12013 110.20 104.69 120.39 117.99# 12013 61.15 58.09 66.80 65.47 12014 130.65 124.12 142.74 139.89# 12014 77.86 73.97 85.07 83.36 12015 159.77 151.78 174.55 171.05# 12015 96.98 92.13 105.95 103.83 12016 198.48 188.56 216.84 212.51# 12016 131.63 125.05 143.81 140.93 12017 151.07 143.52 165.05 161.75 12018 170.91 162.36 186.71 182.98 12020 262.30 249.19 286.57 280.84# 12020 180.46 171.44 197.16 193.21 12021 154.74 147.00 169.05 165.67# 12021 133.19 126.53 145.51 142.60 12031 214.25 203.54 234.07 229.39# 12031 143.65 136.47 156.94 153.80 12032 273.00 259.35 298.25 292.28# 12032 182.41 173.29 199.28 195.29 12034 283.70 269.52 309.95 303.75# 12034 195.61 185.83 213.70 209.43 12035 351.24 333.68 383.73 376.06# 12035 229.72 218.23 250.96 245.95 12036 388.73 369.29 424.68 416.19# 12036 267.22 253.86 291.94 286.10 12037 438.59 416.66 479.16 469.58# 12037 312.70 297.07 341.63 334.80 12041 218.77 207.83 239.00 234.22# 12041 147.24 139.88 160.86 157.64 12042 262.26 249.15 286.52 280.80# 12042 188.54 179.11 205.98 201.86 12044 326.50 310.18 356.71 349.58

# 12044 204.67 194.44 223.61 219.13 12045 366.48 348.16 400.38 392.38# 12045 255.58 242.80 279.22 273.63 12046 435.18 413.42 475.43 465.92# 12046 289.92 275.42 316.73 310.40 12047 479.28 455.32 523.62 513.14# 12047 323.72 307.53 353.66 346.59 12051 234.40 222.68 256.08 250.96# 12051 161.62 153.54 176.57 173.04 12052 267.59 254.21 292.34 286.50# 12052 192.00 182.40 209.76 205.56 12053 313.98 298.28 343.02 336.16# 12053 206.52 196.19 225.62 221.11 12054 335.83 319.04 366.90 359.56# 12054 218.06 207.16 238.23 233.47 12055 435.51 413.73 475.79 466.28# 12055 289.01 274.56 315.74 309.43 12056 502.80 477.66 549.31 538.33# 12056 358.48 340.56 391.64 383.81 12057 516.94 491.09 564.75 553.46# 12057 364.19 345.98 397.88 389.92 13100 303.31 288.14 331.36 324.74# 13100 195.23 185.47 213.29 209.02 13101 358.46 340.54 391.62 383.79# 13101 239.45 227.48 261.60 256.37 13102 111.75 106.16 122.08 119.65# 13102 71.76 68.17 78.40 76.83 13120 317.69 301.81 347.08 340.14# 13120 223.04 211.89 243.67 238.80 13121 387.72 368.33 423.58 415.10# 13121 254.02 241.32 277.52 271.96 13122 122.87 116.73 134.24 131.56# 13122 82.57 78.44 90.21 88.40 13131 350.98 333.43 383.44 375.77# 13131 238.21 226.30 260.25 255.04 13132 434.05 412.35 474.20 464.72# 13132 299.42 284.45 327.12 320.57 13133 165.38 157.11 180.68 177.07# 13133 126.34 120.02 138.02 135.26 13151 386.01 366.71 421.72 413.29# 13151 273.56 259.88 298.86 292.88 13152 463.48 440.31 506.36 496.23# 13152 331.97 315.37 362.68 355.42 13153 180.21 171.20 196.88 192.95# 13153 136.79 129.95 149.44 146.45 13160 770.25 731.74 841.50 824.68 14000 571.45 542.88 624.31 611.82# 14000 472.11 448.50 515.78 505.46 14001 735.76 698.97 803.82 787.74# 14001 615.80 585.01 672.76 659.31 14020 640.98 608.93 700.27 686.26# 14020 535.08 508.33 584.58 572.88

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 13

14021 803.13 762.97 877.42 859.87# 14021 678.18 644.27 740.91 726.09 14040 704.74 669.50 769.93 754.53# 14040 598.53 568.60 653.89 640.81 14041 870.45 826.93 950.97 931.95# 14041 735.19 698.43 803.19 787.13 14060 721.65 685.57 788.41 772.64# 14060 637.93 606.03 696.93 683.00 14061 934.96 888.21 1,021.44 1,001.02# 14061 785.96 746.66 858.66 841.49 14301 999.18 949.22 1,091.60 1,069.78# 14301 838.62 796.69 916.19 897.87 14302 213.98 203.28 233.77 229.09 14350 679.28 645.32 742.12 727.27 15002 320.37 304.35 350.00 343.00# 15002 217.92 207.02 238.07 233.31 15003 69.99 66.49 76.46 74.93# 15003 44.06 41.86 48.14 47.17 15004 373.61 354.93 408.17 400.00# 15004 262.72 249.58 287.02 281.28 15005 117.18 111.32 128.02 125.45# 15005 88.44 84.02 96.62 94.69 15040 233.79 222.10 255.42 250.31# 15040 121.96 115.86 133.24 130.57 15050 521.38 495.31 569.61 558.21# 15050 419.86 398.87 458.70 449.52 15100 798.25 758.34 872.09 854.65# 15100 679.23 645.27 742.06 727.21 15101 170.10 161.60 185.84 182.13# 15101 106.06 100.76 115.87 113.55 15110 809.01 768.56 883.84 866.17# 15110 714.99 679.24 781.13 765.51 15111 108.43 103.01 118.46 116.09# 15111 98.74 93.80 107.87 105.71 15115 815.20 774.44 890.61 872.79# 15115 722.11 686.00 788.90 773.12 15116 144.13 136.92 157.46 154.31# 15116 131.01 124.46 143.13 140.27 15120 795.34 755.57 868.91 851.53# 15120 667.27 633.91 729.00 714.41 15121 190.37 180.85 207.98 203.81# 15121 126.02 119.72 137.68 134.93 15130 629.61 598.13 687.85 674.10# 15130 537.46 510.59 587.18 575.44 15131 96.41 91.59 105.33 103.22# 15131 89.54 85.06 97.82 95.86 15135 802.39 762.27 876.61 859.07# 15135 713.05 677.40 779.01 763.43 15136 88.68 84.25 96.89 94.96# 15136 83.06 78.91 90.75 88.93 15150 646.77 614.43 706.59 692.46# 15150 595.22 565.46 650.28 637.27

15151 113.35 107.68 123.83 121.36# 15151 105.54 100.26 115.30 112.99 15152 144.45 137.23 157.81 154.66# 15152 136.01 129.21 148.59 145.62 15155 665.87 632.58 727.47 712.92# 15155 619.33 588.36 676.61 663.08 15156 153.40 145.73 167.59 164.24# 15156 145.28 138.02 158.72 155.55 15157 158.59 150.66 173.26 169.80# 15157 149.21 141.75 163.01 159.76 15200 768.93 730.48 840.05 823.25# 15200 637.11 605.25 696.04 682.12 15201 136.06 129.26 148.65 145.67# 15201 77.02 73.17 84.15 82.47 15220 710.28 674.77 775.99 760.46# 15220 580.96 551.91 634.70 622.00 15221 125.26 119.00 136.85 134.11# 15221 69.35 65.88 75.76 74.24 15240 863.24 820.08 943.09 924.23# 15240 755.79 718.00 825.70 809.19 15241 170.78 162.24 186.58 182.85# 15241 108.30 102.89 118.32 115.95 15260 938.02 891.12 1,024.79 1,004.30# 15260 813.38 772.71 888.62 870.85 15261 199.23 189.27 217.66 213.30# 15261 135.20 128.44 147.71 144.75 15271 130.99 124.44 143.11 140.24# 15271 83.19 79.03 90.88 89.07 15272 24.80 23.56 27.09 26.55# 15272 16.68 15.85 18.23 17.86 15273 274.81 261.07 300.23 294.23# 15273 194.84 185.10 212.87 208.61 15274 64.23 61.02 70.17 68.77# 15274 42.68 40.55 46.63 45.70 15275 142.28 135.17 155.45 152.34# 15275 96.99 92.14 105.96 103.85 15276 32.38 30.76 35.37 34.66# 15276 24.57 23.34 26.84 26.30 15277 295.33 280.56 322.64 316.19# 15277 213.80 203.11 233.58 228.91 15278 76.95 73.10 84.07 82.39# 15278 53.21 50.55 58.13 56.97 15570 848.92 806.47 927.44 908.89# 15570 700.85 665.81 765.68 750.36 15572 823.11 781.95 899.24 881.26# 15572 705.97 670.67 771.27 755.85 15574 852.01 809.41 930.82 912.20# 15574 730.18 693.67 797.72 781.77 15576 753.77 716.08 823.49 807.02# 15576 641.31 609.24 700.63 686.62 15600 289.09 274.64 315.84 309.52# 15600 191.32 181.75 209.01 204.84

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 14

15610 320.86 304.82 350.54 343.53# 15610 223.71 212.52 244.40 239.51 15620 401.88 381.79 439.06 430.27# 15620 305.67 290.39 333.95 327.27 15630 419.81 398.82 458.64 449.47# 15630 324.85 308.61 354.90 347.81 15650 465.31 442.04 508.35 498.18# 15650 361.60 343.52 395.05 387.15 15731 1,063.08 1,009.93 1,161.42 1,138.19# 15731 965.00 916.75 1,054.26 1,033.18 15732 1,221.76 1,160.67 1,334.77 1,308.08# 15732 1,085.56 1,031.28 1,185.97 1,162.25 15734 1,410.24 1,339.73 1,540.69 1,509.88# 15734 1,261.55 1,198.47 1,378.24 1,350.68 15736 1,240.46 1,178.44 1,355.21 1,328.10# 15736 1,093.95 1,039.25 1,195.14 1,171.24 15738 1,327.46 1,261.09 1,450.25 1,421.25# 15738 1,189.08 1,129.63 1,299.07 1,273.10 15740 943.44 896.27 1,030.71 1,010.09# 15740 807.56 767.18 882.26 864.62 15750 868.91 825.46 949.28 930.29 15756 2,247.82 2,135.43 2,455.74 2,406.63 15757 2,222.46 2,111.34 2,428.04 2,379.48 15758 2,222.56 2,111.43 2,428.14 2,379.58 15760 795.86 756.07 869.48 852.09# 15760 675.28 641.52 737.75 722.99 15770 641.93 609.83 701.30 687.27 15775 275.46 261.69 300.94 294.93# 15775 209.24 198.78 228.60 224.02 15776 446.42 424.10 487.72 477.96# 15776 326.47 310.15 356.67 349.54 15777 205.31 195.04 224.30 219.81 15780 771.95 733.35 843.35 826.48# 15780 596.08 566.28 651.22 638.19 15781 505.89 480.60 552.69 541.64# 15781 404.36 384.14 441.76 432.93 15782 574.90 546.16 628.08 615.53# 15782 412.78 392.14 450.96 441.95 15783 439.51 417.53 480.16 470.56# 15783 347.36 329.99 379.49 371.90 15786 226.45 215.13 247.40 242.45# 15786 132.11 125.50 144.33 141.44 15787 44.79 42.55 48.93 47.96# 15787 17.30 16.44 18.91 18.53 15788 412.33 391.71 450.47 441.46# 15788 230.52 218.99 251.84 246.80 15789 491.61 467.03 537.08 526.34# 15789 381.34 362.27 416.61 408.27 15792 385.17 365.91 420.80 412.38# 15792 237.11 225.25 259.04 253.86 15793 443.59 421.41 484.62 474.93# 15793 338.32 321.40 369.61 362.22

15819 699.33 664.36 764.01 748.73 15820 545.61 518.33 596.08 584.15# 15820 498.13 473.22 544.20 533.32 15821 582.62 553.49 636.51 623.78# 15821 529.20 502.74 578.15 566.59 15822 420.78 399.74 459.70 450.51# 15822 373.93 355.23 408.51 400.35 15823 583.32 554.15 637.27 624.53# 15823 529.59 503.11 578.58 567.01 15830 1,116.97 1,061.12 1,220.29 1,195.89 15832 872.77 829.13 953.50 934.43 15833 831.11 789.55 907.98 889.82 15834 847.72 805.33 926.13 907.60 15835 895.62 850.84 978.47 958.89 15836 724.20 687.99 791.19 775.36 15837 739.58 702.60 807.99 791.83# 15837 619.94 588.94 677.28 663.73 15838 545.02 517.77 595.44 583.52 15839 825.71 784.42 902.08 884.04# 15839 701.39 666.32 766.27 750.94 15840 976.23 927.42 1,066.53 1,045.20 15841 1,545.14 1,467.88 1,688.06 1,654.30 15842 2,544.05 2,416.85 2,779.38 2,723.79 15845 973.18 924.52 1,063.20 1,041.93 15847 646.08 613.78 705.85 691.73 15851 90.40 85.88 98.76 96.78# 15851 45.10 42.85 49.28 48.29 15852 45.35 43.08 49.54 48.55 15860 107.64 102.26 117.60 115.24 15920 572.66 544.03 625.63 613.12 15922 742.69 705.56 811.39 795.17 15931 648.04 615.64 707.99 693.83 15933 805.59 765.31 880.11 862.50 15934 876.50 832.68 957.58 938.43 15935 1,036.61 984.78 1,132.50 1,109.84 15936 850.76 808.22 929.45 910.87 15937 990.64 941.11 1,082.28 1,060.63 15940 664.26 631.05 725.71 711.19 15941 856.38 813.56 935.59 916.88 15944 844.27 802.06 922.37 903.92 15945 930.06 883.56 1,016.09 995.77 15946 1,565.39 1,487.12 1,710.19 1,675.99 15950 558.15 530.24 609.78 597.59 15951 835.16 793.40 912.41 894.16 15952 867.27 823.91 947.50 928.54 15953 947.91 900.51 1,035.59 1,014.88 15956 1,105.72 1,050.43 1,207.99 1,183.83 15958 1,119.07 1,063.12 1,222.59 1,198.14 16000 64.61 61.38 70.59 69.17# 16000 44.93 42.68 49.08 48.10 16020 74.75 71.01 81.66 80.03# 16020 51.32 48.75 56.06 54.95

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 15

16025 137.26 130.40 149.96 146.96# 16025 107.27 101.91 117.20 114.85 16030 173.24 164.58 189.27 185.48# 16030 129.51 123.03 141.48 138.66 16035 193.10 183.45 210.97 206.75 16036 79.37 75.40 86.71 84.97 17000 68.11 64.70 74.41 72.92# 17000 49.06 46.61 53.60 52.53 17003 8.89 8.45 9.72 9.52# 17003 2.33 2.21 2.54 2.50 17004 135.88 129.09 148.45 145.49# 17004 93.70 89.02 102.37 100.33 17106 310.64 295.11 339.38 332.59# 17106 256.60 243.77 280.34 274.72 17107 401.85 381.76 439.02 430.24# 17107 329.69 313.21 360.19 352.99 17108 586.61 557.28 640.87 628.05# 17108 494.14 469.43 539.84 529.05 17110 98.20 93.29 107.28 105.13# 17110 63.84 60.65 69.75 68.36 17111 117.14 111.28 127.97 125.41# 17111 79.03 75.08 86.34 84.62 17250 71.39 67.82 77.99 76.43# 17250 35.16 33.40 38.41 37.64 17260 85.55 81.27 93.46 91.59# 17260 65.24 61.98 71.28 69.85 17261 129.32 122.85 141.28 138.45# 17261 85.90 81.61 93.85 91.98 17262 158.20 150.29 172.83 169.37# 17262 109.47 104.00 119.60 117.21 17263 173.12 164.46 189.13 185.35# 17263 121.58 115.50 132.83 130.17 17264 186.20 176.89 203.42 199.35# 17264 130.28 123.77 142.34 139.48 17266 211.91 201.31 231.51 226.87# 17266 152.87 145.23 167.01 163.68 17270 135.88 129.09 148.45 145.49# 17270 94.02 89.32 102.72 100.66 17271 148.11 140.70 161.81 158.57# 17271 104.69 99.46 114.38 112.09 17272 168.97 160.52 184.60 180.91# 17272 120.55 114.52 131.70 129.06 17273 189.16 179.70 206.66 202.53# 17273 137.00 130.15 149.67 146.68 17274 224.23 213.02 244.97 240.07# 17274 166.75 158.41 182.17 178.53 17276 261.31 248.24 285.48 279.77# 17276 201.65 191.57 220.31 215.90 17280 127.14 120.78 138.90 136.11# 17280 85.28 81.02 93.17 91.31 17281 161.55 153.47 176.49 172.96# 17281 117.82 111.93 128.72 126.14

17282 185.99 176.69 203.19 199.13# 17282 136.33 129.51 148.94 145.96 17283 223.80 212.61 244.50 239.61# 17283 170.07 161.57 185.81 182.09 17284 256.54 243.71 280.27 274.67# 17284 199.06 189.11 217.48 213.13 17286 332.23 315.62 362.96 355.71# 17286 269.13 255.67 294.02 288.14 17311 597.79 567.90 653.09 640.02# 17311 360.38 342.36 393.71 385.84 17312 349.11 331.65 381.40 373.77# 17312 191.36 181.79 209.06 204.87 17313 557.96 530.06 609.57 597.38# 17313 323.37 307.20 353.28 346.22 17314 334.37 317.65 365.30 358.00# 17314 177.56 168.68 193.98 190.11 17315 72.64 69.01 79.36 77.77# 17315 50.15 47.64 54.79 53.69 17340 49.10 46.65 53.65 52.58# 17340 46.91 44.56 51.24 50.22 17360 118.72 112.78 129.70 127.10# 17360 93.73 89.04 102.40 100.35 19000 102.18 97.07 111.63 109.40# 19000 42.82 40.68 46.78 45.85 19001 25.49 24.22 27.85 27.30# 19001 21.12 20.06 23.07 22.61 19020 427.26 405.90 466.79 457.45# 19020 284.20 269.99 310.49 304.28 19030 150.25 142.74 164.15 160.87# 19030 75.91 72.11 82.93 81.27 19081 607.28 576.92 663.46 650.19# 19081 175.89 167.10 192.17 188.32 19082 487.16 462.80 532.22 521.57# 19082 84.50 80.28 92.32 90.47 19083 602.60 572.47 658.34 645.17# 19083 164.96 156.71 180.22 176.62 19084 480.21 456.20 524.63 514.14# 19084 79.43 75.46 86.78 85.04 19085 908.07 862.67 992.07 972.23# 19085 192.74 183.10 210.57 206.36 19086 720.66 684.63 787.32 771.58# 19086 87.79 83.40 95.91 93.99 19100 136.77 129.93 149.42 146.43# 19100 66.80 63.46 72.98 71.52 19101 310.26 294.75 338.96 332.19# 19101 207.80 197.41 227.02 222.48 19105 1,701.20 1,616.14 1,858.56 1,821.39# 19105 186.18 176.87 203.40 199.33 19110 441.75 419.66 482.61 472.96# 19110 318.36 302.44 347.81 340.85 19112 417.11 396.25 455.69 446.58# 19112 289.97 275.47 316.79 310.45

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 16

19120 456.20 433.39 498.40 488.43# 19120 387.79 368.40 423.66 415.18 19125 506.33 481.01 553.16 542.10# 19125 431.05 409.50 470.93 461.51 19126 155.02 147.27 169.36 165.97 19260 1,141.85 1,084.76 1,247.47 1,222.52 19271 1,528.28 1,451.87 1,669.65 1,636.25 19272 1,708.19 1,622.78 1,866.20 1,828.87 19281 222.79 211.65 243.40 238.53# 19281 100.03 95.03 109.28 107.10 19282 153.17 145.51 167.34 163.99# 19282 48.21 45.80 52.67 51.61 19283 251.84 239.25 275.14 269.64# 19283 100.97 95.92 110.31 108.10 19284 182.85 173.71 199.77 195.78# 19284 48.52 46.09 53.00 51.95 19285 418.94 397.99 457.69 448.53# 19285 85.64 81.36 93.56 91.69 19286 348.97 331.52 381.25 373.62# 19286 41.59 39.51 45.44 44.53 19287 772.58 733.95 844.04 827.16# 19287 137.21 130.35 149.90 146.90 19288 612.99 582.34 669.69 656.29# 19288 62.27 59.16 68.03 66.68 19296 3,482.48 3,308.36 3,804.61 3,728.52# 19296 200.68 190.65 219.25 214.87 19297 90.44 85.92 98.81 96.83 19298 942.39 895.27 1,029.56 1,008.96# 19298 314.21 298.50 343.28 336.41 19300 479.12 455.16 523.43 512.97# 19300 384.16 364.95 419.69 411.30 19301 615.86 585.07 672.83 659.38 19302 848.20 805.79 926.66 908.12 19303 954.42 906.70 1,042.71 1,021.86 19304 535.32 508.55 584.83 573.14 19305 1,067.44 1,014.07 1,166.18 1,142.86 19306 1,129.72 1,073.23 1,234.21 1,209.54 19307 1,127.68 1,071.30 1,232.00 1,207.35 19316 734.49 697.77 802.44 786.38 19318 1,058.44 1,005.52 1,156.35 1,133.22 19324 458.90 435.96 501.35 491.33 19325 613.39 582.72 670.13 656.73 19328 469.94 446.44 513.41 503.14 19330 602.10 572.00 657.80 644.64 19340 959.24 911.28 1,047.97 1,027.01 19342 880.34 836.32 961.77 942.53 19350 768.64 730.21 839.74 822.95# 19350 641.19 609.13 700.50 686.49 19355 649.27 616.81 709.33 695.14# 19355 536.82 509.98 586.48 574.75 19357 1,424.02 1,352.82 1,555.74 1,524.62 19361 1,515.78 1,439.99 1,655.99 1,622.87

19364 2,663.11 2,529.95 2,909.44 2,851.25 19366 1,348.71 1,281.27 1,473.46 1,443.99 19367 1,726.11 1,639.80 1,885.77 1,848.05 19368 2,127.87 2,021.48 2,324.70 2,278.21 19369 1,973.74 1,875.05 2,156.31 2,113.18 19370 652.32 619.70 712.66 698.41 19371 747.40 710.03 816.53 800.20 19380 735.96 699.16 804.03 787.96 19396 266.77 253.43 291.44 285.61# 19396 141.51 134.43 154.59 151.50 20005 287.47 273.10 314.07 307.79# 20005 223.12 211.96 243.75 238.88 20100 581.75 552.66 635.56 622.85 20101 408.27 387.86 446.04 437.12# 20101 197.11 187.25 215.34 211.04 20102 447.56 425.18 488.96 479.18# 20102 242.64 230.51 265.09 259.79 20103 534.38 507.66 583.81 572.14# 20103 332.90 316.26 363.70 356.42 20150 873.10 829.45 953.87 934.79 20200 187.37 178.00 204.70 200.61# 20200 90.54 86.01 98.91 96.93 20205 261.90 248.81 286.13 280.40# 20205 146.95 139.60 160.54 157.33 20206 210.67 200.14 230.16 225.56# 20206 57.60 54.72 62.93 61.67 20220 153.50 145.83 167.70 164.35# 20220 70.72 67.18 77.26 75.72 20225 470.74 447.20 514.28 504.00# 20225 107.14 101.78 117.05 114.70 20240 209.46 198.99 228.84 224.26 20245 589.96 560.46 644.53 631.64 20250 365.18 346.92 398.96 390.98 20251 397.90 378.01 434.71 426.02 20500 97.95 93.05 107.01 104.87# 20500 80.77 76.73 88.24 86.48 20501 106.64 101.31 116.51 114.17# 20501 37.60 35.72 41.08 40.26 20520 187.31 177.94 204.63 200.54# 20520 138.27 131.36 151.06 148.04 20525 436.11 414.30 476.45 466.91# 20525 235.56 223.78 257.35 252.20 20526 71.01 67.46 77.58 76.03# 20526 54.46 51.74 59.50 58.32 20527 77.19 73.33 84.33 82.64# 20527 62.20 59.09 67.95 66.60 20550 54.70 51.97 59.77 58.57# 20550 40.33 38.31 44.06 43.17 20551 56.57 53.74 61.80 60.57# 20551 41.27 39.21 45.09 44.19 20552 51.51 48.93 56.27 55.14# 20552 36.83 34.99 40.24 39.43

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 17

20553 59.42 56.45 64.92 63.62# 20553 41.62 39.54 45.47 44.56 20555 322.33 306.21 352.14 345.10 20600 44.95 42.70 49.11 48.13# 20600 34.64 32.91 37.85 37.09 20605 46.88 44.54 51.22 50.20# 20605 36.26 34.45 39.62 38.82 20610 56.34 53.52 61.55 60.32# 20610 44.47 42.25 48.59 47.62 20612 56.03 53.23 61.21 60.00# 20612 40.10 38.10 43.82 42.94 20615 224.61 213.38 245.39 240.48# 20615 154.96 147.21 169.29 165.91 20650 190.02 180.52 207.60 203.45# 20650 147.23 139.87 160.85 157.63 20660 231.13 219.57 252.51 247.46 20661 466.21 442.90 509.34 499.15 20662 417.37 396.50 455.98 446.86 20663 423.27 402.11 462.43 453.18 20664 804.96 764.71 879.42 861.83 20665 98.63 93.70 107.76 105.60# 20665 86.13 81.82 94.09 92.21 20670 340.49 323.47 371.99 364.55# 20670 138.39 131.47 151.19 148.17 20680 572.00 543.40 624.91 612.41# 20680 403.32 383.15 440.62 431.81 20690 563.36 535.19 615.47 603.16 20692 1,063.54 1,010.36 1,161.91 1,138.67 20693 424.95 403.70 464.26 454.97 20694 392.54 372.91 428.85 420.27# 20694 317.88 301.99 347.29 340.34 20696 1,084.65 1,030.42 1,184.98 1,161.28 20697 1,622.13 1,541.02 1,772.17 1,736.73 20802 2,257.78 2,144.89 2,466.62 2,417.29 20805 2,937.37 2,790.50 3,209.08 3,144.89 20808 3,796.44 3,606.62 4,147.61 4,064.66 20816 1,909.88 1,814.39 2,086.55 2,044.82 20822 1,735.15 1,648.39 1,895.65 1,857.73 20824 2,036.48 1,934.66 2,224.86 2,180.37 20827 1,734.98 1,648.23 1,895.46 1,857.56 20838 2,516.34 2,390.52 2,749.10 2,694.12 20900 382.96 363.81 418.38 410.01# 20900 183.35 174.18 200.31 196.31 20902 274.86 261.12 300.29 294.29 20910 389.70 370.22 425.75 417.24 20912 458.04 435.14 500.41 490.41 20920 376.24 357.43 411.04 402.82 20922 571.96 543.36 624.86 612.36# 20922 473.56 449.88 517.36 507.01 20924 476.10 452.30 520.15 509.74 20926 414.02 393.32 452.32 443.27 20931 107.30 101.94 117.23 114.89

20937 161.08 153.03 175.98 172.47 20938 176.01 167.21 192.29 188.45 20950 225.54 214.26 246.40 241.47# 20950 86.22 81.91 94.20 92.31 20955 2,419.43 2,298.46 2,643.23 2,590.36 20956 2,529.97 2,403.47 2,763.99 2,708.71 20957 2,217.27 2,106.41 2,422.37 2,373.92 20962 2,118.68 2,012.75 2,314.66 2,268.38 20969 2,688.04 2,553.64 2,936.69 2,877.96 20970 2,737.54 2,600.66 2,990.76 2,930.95 20972 2,163.98 2,055.78 2,364.15 2,316.86 20973 2,728.46 2,592.04 2,980.85 2,921.23 20974 68.99 65.54 75.37 73.86# 20974 46.50 44.18 50.81 49.80 20975 167.71 159.32 183.22 179.55 20979 49.42 46.95 53.99 52.91# 20979 31.93 30.33 34.88 34.18 20982 3,274.02 3,110.32 3,576.87 3,505.33# 20982 372.06 353.46 406.48 398.35 20985 141.95 134.85 155.08 151.97 21010 714.64 678.91 780.75 765.13 21011 316.45 300.63 345.72 338.81# 21011 239.92 227.92 262.11 256.86 21012 315.68 299.90 344.89 337.99 21013 476.62 452.79 520.71 510.29# 21013 375.72 356.93 410.47 402.26 21014 489.24 464.78 534.50 523.80 21015 674.78 641.04 737.20 722.45 21016 987.03 937.68 1,078.33 1,056.77 21025 838.33 796.41 915.87 897.55# 21025 715.56 679.78 781.75 766.11 21026 575.02 546.27 628.21 615.64# 21026 470.68 447.15 514.22 503.94 21029 729.21 692.75 796.66 780.74# 21029 615.82 585.03 672.78 659.33 21030 485.39 461.12 530.29 519.69# 21030 396.36 376.54 433.02 424.36 21031 364.25 346.04 397.95 389.99# 21031 276.78 262.94 302.38 296.33 21032 370.64 352.11 404.93 396.83# 21032 274.43 260.71 299.82 293.83 21034 1,251.04 1,188.49 1,366.76 1,339.43# 21034 1,113.28 1,057.62 1,216.26 1,191.94 21040 488.86 464.42 534.08 523.40# 21040 397.02 377.17 433.75 425.07 21044 843.97 801.77 922.04 903.59 21045 1,175.96 1,117.16 1,284.73 1,259.04 21046 1,055.52 1,002.74 1,153.15 1,130.09 21047 1,255.04 1,192.29 1,371.13 1,343.71 21048 1,084.75 1,030.51 1,185.09 1,161.39 21049 1,172.71 1,114.07 1,281.18 1,255.56 21050 821.20 780.14 897.16 879.22

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 18

21060 786.35 747.03 859.08 841.90 21070 586.24 556.93 640.47 627.66 21073 362.77 344.63 396.32 388.40# 21073 244.69 232.46 267.33 261.98 21076 948.18 900.77 1,035.89 1,015.16# 21076 804.48 764.26 878.90 861.32 21077 2,381.91 2,262.81 2,602.23 2,550.18# 21077 2,033.92 1,932.22 2,222.05 2,177.62 21079 1,597.70 1,517.82 1,745.49 1,710.58# 21079 1,342.18 1,275.07 1,466.33 1,437.01 21080 1,795.88 1,706.09 1,962.00 1,922.77# 21080 1,498.81 1,423.87 1,637.45 1,604.70 21081 1,658.00 1,575.10 1,811.37 1,775.14# 21081 1,377.17 1,308.31 1,504.56 1,474.46 21082 1,569.76 1,491.27 1,714.96 1,680.66# 21082 1,294.87 1,230.13 1,414.65 1,386.36 21083 1,464.46 1,391.24 1,599.93 1,567.93# 21083 1,173.01 1,114.36 1,281.51 1,255.88 21084 1,704.27 1,619.06 1,861.92 1,824.68# 21084 1,389.40 1,319.93 1,517.92 1,487.56 21085 775.31 736.54 847.02 830.08# 21085 605.07 574.82 661.04 647.82 21086 1,773.30 1,684.64 1,937.34 1,898.59# 21086 1,500.28 1,425.27 1,639.06 1,606.27 21087 1,773.30 1,684.64 1,937.34 1,898.59# 21087 1,500.28 1,425.27 1,639.06 1,606.27 21100 650.54 618.01 710.71 696.50# 21100 359.41 341.44 392.66 384.80 21110 742.12 705.01 810.76 794.55# 21110 626.85 595.51 684.84 671.14 21116 130.05 123.55 142.08 139.24# 21116 41.96 39.86 45.84 44.92 21120 613.18 582.52 669.90 656.50# 21120 493.85 469.16 539.53 528.75 21121 714.96 679.21 781.09 765.47# 21121 600.63 570.60 656.19 643.07 21122 657.03 624.18 717.81 703.46 21123 832.42 790.80 909.42 891.23 21125 2,765.61 2,627.33 3,021.43 2,961.00# 21125 766.41 728.09 837.30 820.56 21127 3,827.69 3,636.31 4,181.76 4,098.12# 21127 826.71 785.37 903.18 885.11 21137 718.73 682.79 785.21 769.50 21138 871.01 827.46 951.58 932.55 21139 1,025.57 974.29 1,120.43 1,098.02 21141 1,306.32 1,241.00 1,427.15 1,398.61 21142 1,344.35 1,277.13 1,468.70 1,439.33 21143 1,363.45 1,295.28 1,489.57 1,459.78 21145 1,459.17 1,386.21 1,594.14 1,562.26 21146 1,661.63 1,578.55 1,815.33 1,779.03 21147 1,472.95 1,399.30 1,609.20 1,577.01 21150 1,728.46 1,642.04 1,888.35 1,850.58

21151 1,948.52 1,851.09 2,128.75 2,086.18 21154 2,120.48 2,014.46 2,316.63 2,270.30 21155 2,165.74 2,057.45 2,366.07 2,318.75 21159 2,418.65 2,297.72 2,642.38 2,589.54 21160 2,554.80 2,427.06 2,791.12 2,735.30 21172 1,797.11 1,707.25 1,963.34 1,924.08 21175 2,033.05 1,931.40 2,221.11 2,176.69 21179 1,486.43 1,412.11 1,623.93 1,591.45 21180 1,483.18 1,409.02 1,620.37 1,587.97 21181 689.99 655.49 753.81 738.74 21182 1,858.09 1,765.19 2,029.97 1,989.37 21183 2,280.84 2,166.80 2,491.82 2,441.98 21184 2,141.32 2,034.25 2,339.39 2,292.61 21188 1,505.58 1,430.30 1,644.85 1,611.94 21193 1,237.96 1,176.06 1,352.47 1,325.42 21194 1,316.71 1,250.87 1,438.50 1,409.73 21195 1,276.66 1,212.83 1,394.75 1,366.86 21196 1,413.84 1,343.15 1,544.62 1,513.73 21198 1,108.07 1,052.67 1,210.57 1,186.36 21199 1,012.85 962.21 1,106.54 1,084.42 21206 1,141.29 1,084.23 1,246.86 1,221.93 21208 1,745.70 1,658.42 1,907.18 1,869.04# 21208 816.69 775.86 892.24 874.39 21209 774.46 735.74 846.10 829.18# 21209 601.72 571.63 657.37 644.23 21210 2,096.16 1,991.35 2,290.05 2,244.25# 21210 820.11 779.10 895.97 878.05 21215 3,732.78 3,546.14 4,078.06 3,996.50# 21215 875.48 831.71 956.47 937.34 21230 705.18 669.92 770.41 755.00 21235 677.63 643.75 740.31 725.51# 21235 539.25 512.29 589.13 577.35 21240 1,056.76 1,003.92 1,154.51 1,131.42 21242 968.34 919.92 1,057.91 1,036.75 21243 1,605.65 1,525.37 1,754.18 1,719.09 21244 1,015.89 965.10 1,109.87 1,087.67 21245 1,049.77 997.28 1,146.87 1,123.93# 21245 851.10 808.55 929.83 911.24 21246 791.21 751.65 864.40 847.11 21247 1,519.05 1,443.10 1,659.57 1,626.38 21248 1,043.48 991.31 1,140.01 1,117.20# 21248 861.99 818.89 941.72 922.89 21249 1,437.45 1,365.58 1,570.42 1,539.01# 21249 1,232.22 1,170.61 1,346.20 1,319.28 21255 1,319.69 1,253.71 1,441.77 1,412.94 21256 1,176.39 1,117.57 1,285.21 1,259.50 21260 1,277.97 1,214.07 1,396.18 1,368.26 21261 2,084.74 1,980.50 2,277.58 2,232.02 21263 1,818.21 1,727.30 1,986.40 1,946.66 21267 1,569.64 1,491.16 1,714.83 1,680.54 21268 1,713.04 1,627.39 1,871.50 1,834.07 21270 903.34 858.17 986.90 967.16

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 19

# 21270 700.30 665.29 765.08 749.78 21275 802.46 762.34 876.69 859.15 21280 554.97 527.22 606.30 594.18 21282 363.37 345.20 396.98 389.05 21295 190.22 180.71 207.82 203.67 21296 433.47 411.80 473.57 464.09 21310 118.20 112.29 129.13 126.55# 21310 27.30 25.94 29.83 29.23 21315 254.81 242.07 278.38 272.81# 21315 143.92 136.72 157.23 154.09 21320 236.68 224.85 258.58 253.40# 21320 128.91 122.46 140.83 138.01 21325 437.06 415.21 477.49 467.95 21330 526.08 499.78 574.75 563.25 21335 690.12 655.61 753.95 738.88 21336 604.94 574.69 660.89 647.68 21337 374.89 356.15 409.57 401.38# 21337 278.68 264.75 304.46 298.38 21338 668.87 635.43 730.74 716.13 21339 726.24 689.93 793.42 777.55 21340 720.56 684.53 787.21 771.47 21343 1,147.90 1,090.51 1,254.09 1,229.01 21344 1,468.62 1,395.19 1,604.47 1,572.38 21345 729.52 693.04 797.00 781.06# 21345 596.14 566.33 651.28 638.25 21346 861.88 818.79 941.61 922.77 21347 1,045.26 993.00 1,141.95 1,119.11 21348 1,131.11 1,074.55 1,235.73 1,211.02 21355 403.04 382.89 440.32 431.51# 21355 306.83 291.49 335.21 328.51 21356 465.21 441.95 508.24 498.08# 21356 357.75 339.86 390.84 383.02 21360 509.10 483.65 556.20 545.08 21365 1,072.08 1,018.48 1,171.25 1,147.83 21366 1,141.29 1,084.23 1,246.86 1,221.93 21385 652.65 620.02 713.02 698.76 21386 666.37 633.05 728.01 713.45 21387 699.18 664.22 763.85 748.58 21390 770.16 731.65 841.40 824.57 21395 943.86 896.67 1,031.17 1,010.55 21400 177.46 168.59 193.88 190.00# 21400 145.28 138.02 158.72 155.55 21401 453.96 431.26 495.95 486.02# 21401 291.84 277.25 318.84 312.47 21406 491.27 466.71 536.72 525.99 21407 624.85 593.61 682.65 669.00 21408 864.50 821.28 944.47 925.58 21421 708.67 673.24 774.23 758.75# 21421 604.34 574.12 660.24 647.04 21422 634.44 602.72 693.13 679.27 21423 786.63 747.30 859.40 842.20 21431 678.89 644.95 741.69 726.86

21432 625.07 593.82 682.89 669.23 21433 1,681.88 1,597.79 1,837.46 1,800.70 21435 1,219.33 1,158.36 1,332.11 1,305.47 21436 1,970.65 1,872.12 2,152.94 2,109.88 21440 535.51 508.73 585.04 573.34# 21440 438.67 416.74 479.25 469.67 21445 715.72 679.93 781.92 766.28# 21445 587.96 558.56 642.34 629.50 21450 561.49 533.42 613.43 601.16# 21450 454.66 431.93 496.72 486.78 21451 706.96 671.61 772.35 756.91# 21451 597.94 568.04 653.25 640.18 21452 568.85 540.41 621.47 609.04# 21452 339.88 322.89 371.32 363.89 21453 846.30 803.99 924.59 906.10# 21453 730.09 693.59 797.63 781.68 21454 557.29 529.43 608.84 596.67 21461 1,963.46 1,865.29 2,145.08 2,102.18# 21461 886.08 841.78 968.05 948.68 21462 2,073.02 1,969.37 2,264.78 2,219.48# 21462 981.27 932.21 1,072.04 1,050.61 21465 934.54 887.81 1,020.98 1,000.56 21470 1,164.64 1,106.41 1,272.37 1,246.92 21480 91.47 86.90 99.94 97.93# 21480 31.18 29.62 34.06 33.38 21485 648.65 616.22 708.65 694.49# 21485 546.19 518.88 596.71 584.78 21490 890.75 846.21 973.14 953.68 21495 663.63 630.45 725.02 710.52 21497 678.93 644.98 741.73 726.89# 21497 568.35 539.93 620.92 608.50 21501 418.69 397.76 457.42 448.27# 21501 302.79 287.65 330.80 324.19 21502 503.40 478.23 549.96 538.97 21510 420.85 399.81 459.78 450.58 21550 241.06 229.01 263.36 258.09# 21550 149.54 142.06 163.37 160.10 21552 420.32 399.30 459.20 450.01 21554 692.54 657.91 756.60 741.46 21555 382.57 363.44 417.96 409.60# 21555 288.23 273.82 314.89 308.59 21556 505.71 480.42 552.48 541.43 21557 916.98 871.13 1,001.80 981.77 21558 1,288.22 1,223.81 1,407.38 1,379.23 21600 529.70 503.22 578.70 567.13 21610 1,120.82 1,064.78 1,224.50 1,200.00 21615 606.94 576.59 663.08 649.82 21616 810.79 770.25 885.79 868.08 21620 483.07 458.92 527.76 517.20 21627 513.36 487.69 560.84 549.63 21630 1,165.21 1,106.95 1,272.99 1,247.53 21632 1,164.48 1,106.26 1,272.20 1,246.75

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 20

21685 963.05 914.90 1,052.14 1,031.09 21700 357.22 339.36 390.26 382.46 21705 535.86 509.07 585.43 573.72 21720 451.97 429.37 493.78 483.90 21725 448.34 425.92 489.81 480.01 21740 982.61 933.48 1,073.50 1,052.03 21742 718.58 682.65 785.05 769.35 21743 793.95 754.25 867.39 850.05 21750 661.99 628.89 723.22 708.76 21800 103.68 98.50 113.28 111.01# 21800 106.81 101.47 116.69 114.36 21805 254.92 242.17 278.50 272.93 21810 484.07 459.87 528.85 518.27 21820 131.87 125.28 144.07 141.19# 21820 134.99 128.24 147.48 144.53 21825 519.90 493.91 568.00 556.63 21920 236.86 225.02 258.77 253.60# 21920 152.83 145.19 166.97 163.63 21925 411.07 390.52 449.10 440.12# 21925 332.04 315.44 362.76 355.50 21930 435.92 414.12 476.24 466.72# 21930 343.14 325.98 374.88 367.38 21931 443.48 421.31 484.51 474.81 21932 624.37 593.15 682.12 668.48 21933 696.31 661.49 760.71 745.50 21935 976.56 927.73 1,066.89 1,045.56 21936 1,345.57 1,278.29 1,470.03 1,440.63 22010 893.94 849.24 976.63 957.10 22015 848.84 806.40 927.36 908.81 22100 817.45 776.58 893.07 875.21 22101 830.90 789.36 907.76 889.61 22102 770.94 732.39 842.25 825.40 22103 136.35 129.53 148.96 145.98 22110 1,014.70 963.97 1,108.57 1,086.39 22112 1,002.80 952.66 1,095.56 1,073.65 22114 942.63 895.50 1,029.83 1,009.23 22116 134.21 127.50 146.63 143.69 22206 2,256.31 2,143.49 2,465.01 2,415.71 22207 2,278.31 2,164.39 2,489.05 2,439.27 22208 563.50 535.33 615.63 603.31 22210 1,675.25 1,591.49 1,830.21 1,793.61 22212 1,394.36 1,324.64 1,523.34 1,492.87 22214 1,403.65 1,333.47 1,533.49 1,502.82 22216 349.03 331.58 381.32 373.69 22220 1,527.74 1,451.35 1,669.05 1,635.67 22222 1,486.92 1,412.57 1,624.46 1,591.97 22224 1,506.91 1,431.56 1,646.29 1,613.37 22226 350.03 332.53 382.41 374.76 22305 177.70 168.82 194.14 190.26# 22305 162.09 153.99 177.09 173.55 22310 287.91 273.51 314.54 308.25# 22310 266.67 253.34 291.34 285.51

22315 822.48 781.36 898.56 880.59# 22315 726.89 690.55 794.13 778.25 22318 1,535.33 1,458.56 1,677.34 1,643.80 22319 1,711.79 1,626.20 1,870.13 1,832.73 22325 1,358.37 1,290.45 1,484.02 1,454.34 22326 1,402.02 1,331.92 1,531.71 1,501.07 22327 1,403.67 1,333.49 1,533.51 1,502.84 22328 270.18 256.67 295.17 289.27 22505 116.92 111.07 127.73 125.18 22520 2,018.25 1,917.34 2,204.94 2,160.84# 22520 494.80 470.06 540.57 529.76 22521 2,018.28 1,917.37 2,204.98 2,160.87# 22521 471.08 447.53 514.66 504.37 22522 220.31 209.29 240.68 235.87 22523 6,564.43 6,236.21 7,171.64 7,028.21# 22523 538.72 511.78 588.55 576.77 22524 6,504.04 6,178.84 7,105.67 6,963.55# 22524 511.44 485.87 558.75 547.57 22525 3,974.15 3,775.44 4,341.76 4,254.92# 22525 246.90 234.56 269.74 264.35 22532 1,694.36 1,609.64 1,851.09 1,814.07 22533 1,591.34 1,511.77 1,738.54 1,703.76 22534 347.62 330.24 379.78 372.19 22548 1,838.54 1,746.61 2,008.60 1,968.43 22551 1,622.66 1,541.53 1,772.76 1,737.31 22552 377.76 358.87 412.70 404.44 22554 1,198.24 1,138.33 1,309.08 1,282.89 22556 1,582.90 1,503.76 1,729.32 1,694.73 22558 1,467.41 1,394.04 1,603.15 1,571.08 22585 320.79 304.75 350.46 343.46 22586 1,785.59 1,696.31 1,950.76 1,911.74 22590 1,485.86 1,411.57 1,623.31 1,590.84 22595 1,414.87 1,344.13 1,545.75 1,514.84 22600 1,212.70 1,152.07 1,324.88 1,298.38 22610 1,189.33 1,129.86 1,299.34 1,273.35 22612 1,513.90 1,438.21 1,653.94 1,620.87 22614 374.97 356.22 409.65 401.47 22630 1,466.23 1,392.92 1,601.86 1,569.82 22632 305.36 290.09 333.60 326.93 22633 1,753.78 1,666.09 1,916.00 1,877.69 22634 475.63 451.85 519.63 509.23 22800 1,287.77 1,223.38 1,406.89 1,378.75 22802 2,000.34 1,900.32 2,185.37 2,141.66 22804 2,304.94 2,189.69 2,518.14 2,467.79 22808 1,734.84 1,648.10 1,895.32 1,857.41 22810 1,947.09 1,849.74 2,127.20 2,084.66 22812 2,144.19 2,036.98 2,342.53 2,295.68 22818 2,080.83 1,976.79 2,273.31 2,227.84 22819 2,579.28 2,450.32 2,817.87 2,761.51 22830 767.37 729.00 838.35 821.58 22840 731.07 694.52 798.70 782.72 22842 732.02 695.42 799.73 783.74

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 21

22843 779.57 740.59 851.68 834.65 22844 941.30 894.24 1,028.38 1,007.81 22845 704.07 668.87 769.20 753.81 22846 730.78 694.24 798.38 782.41 22847 835.95 794.15 913.27 895.01 22848 344.23 327.02 376.07 368.55 22849 1,235.79 1,174.00 1,350.10 1,323.10 22850 682.55 648.42 745.68 730.77 22851 391.41 371.84 427.62 419.06 22852 652.77 620.13 713.15 698.89 22855 1,057.01 1,004.16 1,154.78 1,131.69 22856 1,569.31 1,490.84 1,714.47 1,680.17 22857 1,739.96 1,652.96 1,900.90 1,862.89 22861 2,095.00 1,990.25 2,288.79 2,243.02 22862 2,035.42 1,933.65 2,223.70 2,179.23 22864 1,882.10 1,788.00 2,056.20 2,015.08 22865 1,959.79 1,861.80 2,141.07 2,098.24 22900 531.88 505.29 581.08 569.46 22901 626.57 595.24 684.53 670.84 22902 398.04 378.14 434.86 426.17# 22902 304.95 289.70 333.16 326.50 22903 409.14 388.68 446.98 438.05 22904 997.07 947.22 1,089.30 1,067.52 22905 1,271.47 1,207.90 1,389.09 1,361.30 23000 530.90 504.36 580.01 568.41# 23000 346.59 329.26 378.65 371.07 23020 650.38 617.86 710.54 696.33 23030 401.91 381.81 439.08 430.30# 23030 240.73 228.69 262.99 257.74 23031 384.60 365.37 420.18 411.77# 23031 205.92 195.62 224.96 220.47 23035 644.47 612.25 704.09 690.01 23040 678.03 644.13 740.75 725.94 23044 534.27 507.56 583.69 572.02 23065 200.14 190.13 218.65 214.28# 23065 158.29 150.38 172.94 169.48 23066 505.46 480.19 552.22 541.18# 23066 332.41 315.79 363.16 355.89 23071 394.44 374.72 430.93 422.31 23073 654.04 621.34 714.54 700.25 23075 428.45 407.03 468.08 458.72# 23075 305.68 290.40 333.96 327.28 23076 507.48 482.11 554.43 543.34 23077 1,088.53 1,034.10 1,189.22 1,165.43 23078 1,374.51 1,305.78 1,501.65 1,471.61 23100 468.21 444.80 511.52 501.29 23101 426.96 405.61 466.45 457.13 23105 600.89 570.85 656.48 643.34 23106 464.17 440.96 507.10 496.96 23107 623.43 592.26 681.10 667.47 23120 549.39 521.92 600.21 588.20 23125 667.60 634.22 729.35 714.77

23130 571.26 542.70 624.11 611.63 23140 498.31 473.39 544.40 533.51 23145 654.45 621.73 714.99 700.70 23146 582.74 553.60 636.64 623.91 23150 621.74 590.65 679.25 665.67 23155 747.63 710.25 816.79 800.46 23156 637.99 606.09 697.00 683.07 23170 525.59 499.31 574.21 562.72 23172 531.84 505.25 581.04 569.42 23174 712.65 677.02 778.57 763.00 23180 627.41 596.04 685.45 671.74 23182 621.37 590.30 678.85 665.26 23184 692.15 657.54 756.17 741.05 23190 535.94 509.14 585.51 573.80 23195 711.99 676.39 777.85 762.29 23200 1,442.63 1,370.50 1,576.08 1,544.55 23210 1,698.62 1,613.69 1,855.74 1,818.63 23220 1,864.69 1,771.46 2,037.18 1,996.43 23330 219.97 208.97 240.32 235.51# 23330 141.87 134.78 155.00 151.89 23333 429.98 408.48 469.75 460.36 23334 1,020.19 969.18 1,114.56 1,092.27 23335 1,218.57 1,157.64 1,331.29 1,304.66 23350 118.56 112.63 129.52 126.94# 23350 50.47 47.95 55.14 54.04 23395 1,220.64 1,159.61 1,333.55 1,306.88 23397 1,083.13 1,028.97 1,183.32 1,159.65 23400 919.05 873.10 1,004.07 983.99 23405 593.66 563.98 648.58 635.61 23406 730.75 694.21 798.34 782.38 23410 776.68 737.85 848.53 831.55 23412 806.95 766.60 881.59 863.96 23415 655.38 622.61 716.00 701.68 23420 916.92 871.07 1,001.73 981.70 23430 706.33 671.01 771.66 756.23 23440 715.63 679.85 781.83 766.19 23450 898.39 853.47 981.49 961.86 23455 951.98 904.38 1,040.04 1,019.23 23460 1,033.22 981.56 1,128.79 1,106.22 23462 1,017.80 966.91 1,111.95 1,089.71 23465 1,060.13 1,007.12 1,158.19 1,135.03 23466 1,062.21 1,009.10 1,160.47 1,137.26 23470 1,147.93 1,090.53 1,254.11 1,229.03 23472 1,394.26 1,324.55 1,523.23 1,492.77 23473 1,556.09 1,478.29 1,700.03 1,666.03 23474 1,682.69 1,598.56 1,838.34 1,801.58 23480 775.35 736.58 847.07 830.13 23485 906.50 861.18 990.36 970.55 23490 815.19 774.43 890.59 872.78 23491 960.44 912.42 1,049.28 1,028.30 23500 202.12 192.01 220.81 216.40# 23500 205.25 194.99 224.24 219.75

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 22

23505 326.89 310.55 357.13 349.99# 23505 310.02 294.52 338.70 331.92 23515 680.32 646.30 743.25 728.38 23520 212.38 201.76 232.02 227.38# 23520 215.51 204.73 235.44 230.74 23525 353.22 335.56 385.89 378.18# 23525 328.23 311.82 358.59 351.42 23530 537.55 510.67 587.27 575.53 23532 586.03 556.73 640.24 627.44 23540 207.46 197.09 226.65 222.12# 23540 210.59 200.06 230.07 225.47 23545 314.54 298.81 343.63 336.75# 23545 287.68 273.30 314.30 308.00 23550 539.02 512.07 588.88 577.10 23552 617.61 586.73 674.74 661.25 23570 213.64 202.96 233.40 228.74# 23570 219.89 208.90 240.24 235.43 23575 369.61 351.13 403.80 395.73# 23575 348.05 330.65 380.25 372.65 23585 930.94 884.39 1,017.05 996.71 23600 299.83 284.84 327.57 321.01# 23600 283.90 269.71 310.17 303.97 23605 430.67 409.14 470.51 461.10# 23605 396.94 377.09 433.65 424.98 23615 837.38 795.51 914.84 896.54 23616 1,181.47 1,122.40 1,290.76 1,264.94 23620 247.76 235.37 270.68 265.26# 23620 236.51 224.68 258.38 253.22 23625 351.97 334.37 384.53 376.83# 23625 329.48 313.01 359.96 352.76 23630 738.74 701.80 807.07 790.92 23650 291.23 276.67 318.17 311.81# 23650 269.05 255.60 293.94 288.06 23655 372.49 353.87 406.95 398.81 23660 548.96 521.51 599.74 587.74 23665 394.83 375.09 431.35 422.73# 23665 369.53 351.05 403.71 395.63 23670 830.73 789.19 907.57 889.42 23675 510.77 485.23 558.01 546.86# 23675 468.28 444.87 511.60 501.37 23680 879.77 835.78 961.15 941.92 23700 183.81 174.62 200.81 196.80 23800 972.03 923.43 1,061.94 1,040.70 23802 1,216.23 1,155.42 1,328.73 1,302.16 23900 1,320.12 1,254.11 1,442.23 1,413.38 23920 1,067.96 1,014.56 1,166.74 1,143.41 23921 443.37 421.20 484.38 474.70 23930 321.86 305.77 351.64 344.60# 23930 202.85 192.71 221.62 217.19 23931 261.24 248.18 285.41 279.70# 23931 149.72 142.23 163.56 160.30 23935 477.08 453.23 521.21 510.80

24000 447.53 425.15 488.92 479.15 24006 671.42 637.85 733.53 718.85 24065 233.83 222.14 255.46 250.36# 24065 157.61 149.73 172.19 168.75 24066 564.14 535.93 616.32 603.99# 24066 386.39 367.07 422.13 413.69 24071 382.41 363.29 417.78 409.42 24073 653.53 620.85 713.98 699.69 24075 447.40 425.03 488.78 479.01# 24075 308.70 293.27 337.26 330.51 24076 511.30 485.74 558.60 547.43 24077 985.10 935.85 1,076.23 1,054.70 24079 1,262.76 1,199.62 1,379.56 1,351.97 24100 390.32 370.80 426.42 417.89 24101 468.08 444.68 511.38 501.16 24102 579.96 550.96 633.60 620.93 24105 324.16 307.95 354.14 347.06 24110 551.40 523.83 602.40 590.35 24115 695.10 660.35 759.40 744.21 24116 814.88 774.14 890.26 872.46 24120 496.14 471.33 542.03 531.19 24125 582.39 553.27 636.26 623.53 24126 610.17 579.66 666.61 653.28 24130 475.53 451.75 519.51 509.13 24134 703.95 668.75 769.06 753.69 24136 598.68 568.75 654.06 640.99 24138 631.59 600.01 690.01 676.21 24140 659.14 626.18 720.11 705.71 24145 556.07 528.27 607.51 595.36 24147 582.86 553.72 636.78 624.05 24149 1,108.64 1,053.21 1,211.19 1,186.97 24150 1,482.09 1,407.99 1,619.19 1,586.80 24152 1,306.72 1,241.38 1,427.59 1,399.03 24155 807.13 766.77 881.79 864.14 24160 1,198.04 1,138.14 1,308.86 1,282.69 24164 687.81 653.42 751.43 736.40 24200 188.42 179.00 205.85 201.73# 24200 130.95 124.40 143.06 140.20 24201 512.29 486.68 559.68 548.49# 24201 345.80 328.51 377.79 370.23 24220 146.19 138.88 159.71 156.52# 24220 67.16 63.80 73.37 71.90 24300 380.64 361.61 415.85 407.54 24301 710.52 674.99 776.24 760.71 24305 542.05 514.95 592.19 580.35 24310 446.43 424.11 487.73 477.97 24320 737.01 700.16 805.18 789.08 24330 675.99 642.19 738.52 723.75 24331 742.35 705.23 811.01 794.80 24332 574.61 545.88 627.76 615.20 24340 578.40 549.48 631.90 619.26 24341 701.72 666.63 766.62 751.30

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 23

24342 734.44 697.72 802.38 786.34 24343 663.01 629.86 724.34 709.85 24344 1,037.37 985.50 1,133.33 1,110.66 24345 659.57 626.59 720.58 706.17 24346 1,037.37 985.50 1,133.33 1,110.66 24357 412.25 391.64 450.39 441.38 24358 490.51 465.98 535.88 525.16 24359 622.20 591.09 679.75 666.16 24360 849.46 806.99 928.04 909.48 24361 952.73 905.09 1,040.85 1,020.04 24362 1,004.96 954.71 1,097.92 1,075.96 24363 1,389.44 1,319.97 1,517.97 1,487.61 24365 601.42 571.35 657.05 643.91 24366 642.68 610.55 702.13 688.09 24370 1,471.78 1,398.19 1,607.92 1,575.76 24371 1,701.10 1,616.05 1,858.46 1,821.29 24400 772.76 734.12 844.24 827.36 24410 1,000.74 950.70 1,093.31 1,071.44 24420 937.88 890.99 1,024.64 1,004.15 24430 1,004.02 953.82 1,096.89 1,074.95 24435 1,020.08 969.08 1,114.44 1,092.16 24470 556.37 528.55 607.83 595.68 24495 609.79 579.30 666.20 652.87 24498 821.05 780.00 897.00 879.06 24500 328.68 312.25 359.09 351.91# 24500 300.88 285.84 328.72 322.14 24505 462.28 439.17 505.05 494.95# 24505 421.04 399.99 459.99 450.79 24515 828.33 786.91 904.95 886.85 24516 814.77 774.03 890.13 872.33 24530 349.47 332.00 381.80 374.16# 24530 318.23 302.32 347.67 340.71 24535 572.78 544.14 625.76 613.25# 24535 532.18 505.57 581.41 569.78 24538 698.07 663.17 762.65 747.40 24545 880.74 836.70 962.21 942.97 24546 986.71 937.37 1,077.98 1,056.41 24560 295.40 280.63 322.72 316.27# 24560 266.67 253.34 291.34 285.51 24565 493.11 468.45 538.72 527.94# 24565 455.00 432.25 497.09 487.15 24566 672.12 638.51 734.29 719.60 24575 691.38 656.81 755.33 740.22 24576 311.01 295.46 339.78 332.98# 24576 281.64 267.56 307.69 301.54 24577 508.08 482.68 555.08 543.98# 24577 468.10 444.70 511.41 501.18 24579 788.54 749.11 861.48 844.25 24582 757.04 719.19 827.07 810.53 24586 1,029.84 978.35 1,125.10 1,102.60 24587 1,027.81 976.42 1,122.88 1,100.42 24600 340.47 323.45 371.97 364.53

# 24600 314.23 298.52 343.30 336.43 24605 437.98 416.08 478.49 468.92 24615 671.45 637.88 733.56 718.89 24620 519.91 493.91 568.00 556.63 24635 633.24 601.58 691.82 677.98 24640 128.03 121.63 139.87 137.08# 24640 88.99 84.54 97.22 95.28 24650 239.72 227.73 261.89 256.66# 24650 221.29 210.23 241.76 236.93 24655 405.65 385.37 443.18 434.31# 24655 371.91 353.31 406.31 398.18 24665 611.83 581.24 668.43 655.06 24666 690.58 656.05 754.46 739.37 24670 267.11 253.75 291.81 285.98# 24670 242.74 230.60 265.19 259.89 24675 421.10 400.05 460.06 450.86# 24675 386.43 367.11 422.18 413.74 24685 614.58 583.85 671.43 658.00 24800 782.29 743.18 854.66 837.57 24802 947.98 900.58 1,035.67 1,014.96 24900 693.74 659.05 757.91 742.75 24920 690.77 656.23 754.66 739.58 24925 530.61 504.08 579.69 568.10 24930 730.94 694.39 798.55 782.58 24931 748.16 710.75 817.36 801.02 24935 995.73 945.94 1,087.83 1,066.07 25000 310.27 294.76 338.97 332.19 25001 317.82 301.93 347.22 340.27 25020 530.60 504.07 579.68 568.09 25023 1,033.51 981.83 1,129.10 1,106.52 25024 732.70 696.07 800.48 784.47 25025 1,151.80 1,094.21 1,258.34 1,233.18 25028 482.62 458.49 527.26 516.72 25031 338.82 321.88 370.16 362.76 25035 545.20 517.94 595.63 583.72 25040 528.06 501.66 576.91 565.37 25065 230.64 219.11 251.98 246.94# 25065 153.48 145.81 167.68 164.32 25066 332.69 316.06 363.47 356.20 25071 400.20 380.19 437.22 428.48 25073 498.88 473.94 545.03 534.13 25075 436.36 414.54 476.72 467.19# 25075 296.11 281.30 323.50 317.02 25076 485.19 460.93 530.07 519.47 25077 837.70 795.82 915.19 896.89 25078 1,110.84 1,055.30 1,213.60 1,189.32 25085 421.08 400.03 460.03 450.83 25100 321.93 305.83 351.70 344.67 25101 376.48 357.66 411.31 403.09 25105 451.56 428.98 493.33 483.46 25107 576.15 547.34 629.44 616.85 25109 504.64 479.41 551.32 540.29

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 24

25110 316.81 300.97 346.12 339.19 25111 296.64 281.81 324.08 317.60 25112 360.55 342.52 393.90 386.02 25115 712.77 677.13 778.70 763.13 25116 561.24 533.18 613.16 600.90 25118 354.40 336.68 387.18 379.44 25119 465.13 441.87 508.15 497.98 25120 465.58 442.30 508.65 498.47 25125 555.84 528.05 607.26 595.11 25126 559.88 531.89 611.67 599.44 25130 417.65 396.77 456.29 447.15 25135 522.28 496.17 570.60 559.19 25136 461.09 438.04 503.75 493.67 25145 483.65 459.47 528.39 517.82 25150 529.70 503.22 578.70 567.13 25151 548.39 520.97 599.12 587.13 25170 1,406.95 1,336.60 1,537.09 1,506.35 25210 456.15 433.34 498.34 488.37 25215 578.34 549.42 631.83 619.19 25230 401.45 381.38 438.59 429.81 25240 399.58 379.60 436.54 427.81 25246 148.95 141.50 162.73 159.47# 25246 73.35 69.68 80.13 78.53 25248 388.19 368.78 424.10 415.61 25250 499.24 474.28 545.42 534.51 25251 677.65 643.77 740.34 725.52 25259 382.83 363.69 418.24 409.88 25260 591.34 561.77 646.04 633.11 25263 586.03 556.73 640.24 627.44 25265 703.82 668.63 768.92 753.55 25270 460.16 437.15 502.72 492.67 25272 519.07 493.12 567.09 555.75 25274 630.13 598.62 688.41 674.65 25275 632.10 600.50 690.58 676.76 25280 527.84 501.45 576.67 565.13 25290 407.69 387.31 445.41 436.49 25295 489.47 465.00 534.75 524.06 25300 644.21 612.00 703.80 689.72 25301 603.89 573.70 659.76 646.56 25310 579.97 550.97 633.62 620.94 25312 674.74 641.00 737.15 722.41 25315 726.64 690.31 793.86 777.98 25316 838.74 796.80 916.32 897.99 25320 924.28 878.07 1,009.78 989.59 25332 796.23 756.42 869.88 852.48 25335 846.64 804.31 924.96 906.45 25337 832.36 790.74 909.35 891.17 25350 633.85 602.16 692.48 678.64 25355 722.00 685.90 788.79 773.01 25360 616.17 585.36 673.16 659.70 25365 864.37 821.15 944.32 925.44 25370 950.58 903.05 1,038.51 1,017.74

25375 855.18 812.42 934.28 915.60 25390 724.35 688.13 791.35 775.53 25391 942.80 895.66 1,030.01 1,009.41 25392 959.89 911.90 1,048.69 1,027.71 25393 1,072.01 1,018.41 1,171.17 1,147.75 25394 739.46 702.49 807.86 791.71 25400 757.61 719.73 827.69 811.14 25405 981.13 932.07 1,071.88 1,050.44 25415 914.74 869.00 999.35 979.36 25420 1,107.31 1,051.94 1,209.73 1,185.54 25425 910.35 864.83 994.55 974.66 25426 1,065.39 1,012.12 1,163.94 1,140.66 25430 668.64 635.21 730.49 715.89 25431 743.98 706.78 812.80 796.54 25440 724.22 688.01 791.21 775.39 25441 872.25 828.64 952.94 933.88 25442 744.79 707.55 813.68 797.41 25443 735.61 698.83 803.65 787.58 25444 740.63 703.60 809.14 792.96 25445 678.07 644.17 740.80 725.98 25446 1,110.26 1,054.75 1,212.96 1,188.71 25447 777.97 739.07 849.93 832.93 25449 983.86 934.67 1,074.87 1,053.38 25450 577.69 548.81 631.13 618.50 25455 649.19 616.73 709.24 695.06 25490 658.90 625.96 719.85 705.46 25491 696.48 661.66 760.91 745.69 25492 853.16 810.50 932.08 913.43 25500 250.32 237.80 273.47 268.00# 25500 231.26 219.70 252.66 247.61 25505 465.09 441.84 508.12 497.95# 25505 428.54 407.11 468.18 458.82 25515 629.18 597.72 687.38 673.64 25520 526.57 500.24 575.28 563.78# 25520 501.27 476.21 547.64 536.69 25525 739.79 702.80 808.22 792.05 25526 900.59 855.56 983.89 964.22 25530 239.43 227.46 261.58 256.35# 25530 217.88 206.99 238.04 233.28 25535 452.84 430.20 494.73 484.84# 25535 421.60 400.52 460.60 451.39 25545 584.26 555.05 638.31 625.54 25560 256.10 243.30 279.80 274.19# 25560 232.67 221.04 254.20 249.11 25565 482.33 458.21 526.94 516.41# 25565 439.85 417.86 480.54 470.93 25574 632.51 600.88 691.01 677.19 25575 849.42 806.95 927.99 909.43 25600 299.94 284.94 327.68 321.13# 25600 284.63 270.40 310.96 304.74 25605 509.74 484.25 556.89 545.76# 25605 481.63 457.55 526.18 515.66

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 25

25606 619.96 588.96 677.30 663.76 25607 690.28 655.77 754.14 739.05 25608 775.70 736.92 847.46 830.51 25609 987.79 938.40 1,079.16 1,057.57 25622 279.06 265.11 304.88 298.78# 25622 255.94 243.14 279.61 274.02 25624 438.44 416.52 479.00 469.42# 25624 401.58 381.50 438.73 429.95 25628 677.63 643.75 740.31 725.51 25630 281.26 267.20 307.28 301.14# 25630 259.71 246.72 283.73 278.06 25635 410.46 389.94 448.43 439.46# 25635 367.67 349.29 401.68 393.65 25645 533.87 507.18 583.26 571.60 25650 296.13 281.32 323.52 317.04# 25650 279.27 265.31 305.11 299.00 25651 452.52 429.89 494.37 484.48 25652 583.97 554.77 637.99 625.22 25660 378.11 359.20 413.08 404.82 25670 569.67 541.19 622.37 609.93 25671 494.56 469.83 540.30 529.49 25675 405.29 385.03 442.78 433.93# 25675 372.49 353.87 406.95 398.81 25676 590.44 560.92 645.06 632.16 25680 443.85 421.66 484.91 475.21 25685 692.53 657.90 756.59 741.45 25690 447.86 425.47 489.29 479.50 25695 595.40 565.63 650.47 637.47 25800 689.53 655.05 753.31 738.24 25805 796.70 756.87 870.40 852.99 25810 817.98 777.08 893.64 875.77 25820 574.59 545.86 627.74 615.18 25825 709.73 674.24 775.38 759.87 25830 884.51 840.28 966.32 946.99 25900 666.77 633.43 728.44 713.87 25905 602.39 572.27 658.11 644.94 25907 575.29 546.53 628.51 615.94 25909 645.02 612.77 704.69 690.59 25915 998.32 948.40 1,090.66 1,068.84 25920 653.31 620.64 713.74 699.46 25922 471.55 447.97 515.17 504.86 25924 579.42 550.45 633.02 620.36 25927 753.48 715.81 823.18 806.71 25929 559.86 531.87 611.65 599.41 25931 626.53 595.20 684.48 670.80 26010 237.85 225.96 259.85 254.66# 26010 128.83 122.39 140.75 137.93 26011 350.09 332.59 382.48 374.83# 26011 172.66 164.03 188.63 184.86 26020 403.14 382.98 440.43 431.62 26025 392.28 372.67 428.57 420.00 26030 461.46 438.39 504.15 494.06

26034 500.17 475.16 546.43 535.51 26035 813.72 773.03 888.98 871.21 26037 533.41 506.74 582.75 571.10 26040 287.61 273.23 314.21 307.94 26045 437.14 415.28 477.57 468.02 26055 500.61 475.58 546.92 535.98# 26055 285.69 271.41 312.12 305.88 26060 245.49 233.22 268.20 262.84 26070 292.99 278.34 320.09 313.69 26075 306.82 291.48 335.20 328.50 26080 362.41 344.29 395.93 388.01 26100 310.74 295.20 339.48 332.70 26105 310.23 294.72 338.93 332.15 26110 297.92 283.02 325.47 318.96 26111 390.74 371.20 426.88 418.35 26113 514.22 488.51 561.79 550.55 26115 457.47 434.60 499.79 489.80# 26115 309.72 294.23 338.36 331.60 26116 492.93 468.28 538.52 527.75 26117 702.78 667.64 767.79 752.43 26118 996.11 946.30 1,088.25 1,066.48 26121 559.28 531.32 611.02 598.79 26123 781.26 742.20 853.53 836.46 26125 263.26 250.10 287.62 281.87 26130 430.05 408.55 469.83 460.44 26135 515.75 489.96 563.45 552.18 26140 471.00 447.45 514.57 504.28 26145 478.11 454.20 522.33 511.89 26160 516.18 490.37 563.93 552.64# 26160 308.14 292.73 336.64 329.91 26170 378.55 359.62 413.56 405.29 26180 412.61 391.98 450.78 441.76 26185 513.54 487.86 561.04 549.82 26200 420.71 399.67 459.62 450.43 26205 565.26 537.00 617.55 605.20 26210 411.36 390.79 449.41 440.42 26215 527.98 501.58 576.82 565.28 26230 467.57 444.19 510.82 500.61 26235 461.41 438.34 504.09 494.01 26236 411.58 391.00 449.65 440.66 26250 1,032.68 981.05 1,128.21 1,105.64 26260 770.42 731.90 841.69 824.85 26262 599.84 569.85 655.33 642.22 26320 321.92 305.82 351.69 344.66 26340 304.72 289.48 332.90 326.24 26341 89.62 85.14 97.91 95.96# 26341 69.00 65.55 75.38 73.88 26350 642.56 610.43 701.99 687.95 26352 743.73 706.54 812.52 796.27 26356 996.85 947.01 1,089.06 1,067.28 26357 794.78 755.04 868.30 850.93 26358 839.20 797.24 916.83 898.50

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 26

26370 689.49 655.02 753.27 738.21 26372 808.79 768.35 883.60 865.93 26373 774.59 735.86 846.24 829.31 26390 769.20 730.74 840.35 823.55 26392 893.35 848.68 975.98 956.47 26410 509.39 483.92 556.51 545.38 26412 617.45 586.58 674.57 661.08 26415 731.06 694.51 798.69 782.71 26416 702.87 667.73 767.89 752.54 26418 519.12 493.16 567.13 555.80 26420 646.66 614.33 706.48 692.35 26426 468.41 444.99 511.74 501.50 26428 689.97 655.47 753.79 738.71 26432 448.94 426.49 490.46 480.65 26433 479.74 455.75 524.11 513.64 26434 589.30 559.84 643.82 630.94 26437 564.09 535.89 616.27 603.95 26440 556.68 528.85 608.18 596.01 26442 879.48 835.51 960.84 941.62 26445 516.95 491.10 564.77 553.47 26449 647.52 615.14 707.41 693.27 26450 369.02 350.57 403.16 395.09 26455 366.03 347.73 399.89 391.90 26460 356.98 339.13 390.00 382.20 26471 558.36 530.44 610.01 597.80 26474 545.10 517.85 595.53 583.61 26476 529.22 502.76 578.17 566.61 26477 527.63 501.25 576.44 564.91 26478 564.44 536.22 616.65 604.33 26479 562.01 533.91 614.00 601.71 26480 681.99 647.89 745.07 730.17 26483 768.64 730.21 839.74 822.95 26485 732.13 695.52 799.85 783.85 26489 851.52 808.94 930.28 911.67 26490 726.28 689.97 793.47 777.60 26492 808.63 768.20 883.43 865.77 26494 732.80 696.16 800.58 784.58 26496 772.75 734.11 844.23 827.34 26497 795.80 756.01 869.41 852.02 26498 1,059.41 1,006.44 1,157.41 1,134.26 26499 762.25 724.14 832.76 816.11 26500 566.88 538.54 619.32 606.94 26502 644.61 612.38 704.24 690.15 26508 581.30 552.24 635.08 622.38 26510 542.17 515.06 592.32 580.47 26516 638.69 606.76 697.77 683.81 26517 757.49 719.62 827.56 811.01 26518 765.48 727.21 836.29 819.57 26520 586.21 556.90 640.44 627.62 26525 585.86 556.57 640.06 627.26 26530 502.25 477.14 548.71 537.74 26531 583.95 554.75 637.96 625.21

26535 392.20 372.59 428.48 419.91 26536 645.73 613.44 705.46 691.35 26540 598.88 568.94 654.28 641.19 26541 732.21 695.60 799.94 783.94 26542 620.85 589.81 678.28 664.71 26545 631.24 599.68 689.63 675.84 26546 908.72 863.28 992.77 972.91 26548 698.03 663.13 762.60 747.35 26550 1,533.60 1,456.92 1,675.46 1,641.95 26551 2,812.94 2,672.29 3,073.13 3,011.67 26553 2,935.14 2,788.38 3,206.64 3,142.50 26554 3,085.40 2,931.13 3,370.80 3,303.39 26555 1,276.18 1,212.37 1,394.23 1,366.34 26556 2,648.53 2,516.10 2,893.52 2,835.65 26560 519.90 493.91 568.00 556.63 26561 872.04 828.44 952.71 933.65 26562 1,196.13 1,136.32 1,306.77 1,280.63 26565 620.95 589.90 678.39 664.82 26567 620.76 589.72 678.18 664.62 26568 823.27 782.11 899.43 881.44 26580 1,421.34 1,350.27 1,552.81 1,521.75 26587 892.32 847.70 974.86 955.36 26590 1,313.93 1,248.23 1,435.46 1,406.76 26591 391.75 372.16 427.98 419.43 26593 540.95 513.90 590.99 579.16 26596 707.13 671.77 772.54 757.08 26600 269.58 256.10 294.52 288.63# 26600 254.90 242.16 278.48 272.92 26605 295.32 280.55 322.63 316.18# 26605 270.64 257.11 295.68 289.77 26607 424.86 403.62 464.16 454.88 26608 443.68 421.50 484.73 475.03 26615 537.27 510.41 586.97 575.23 26641 344.20 326.99 376.04 368.52# 26641 317.33 301.46 346.68 339.74 26645 394.15 374.44 430.61 421.99# 26645 363.85 345.66 397.51 389.56 26650 443.11 420.95 484.09 474.41 26665 588.73 559.29 643.18 630.32 26670 314.57 298.84 343.67 336.79# 26670 288.02 273.62 314.66 308.37 26675 419.42 398.45 458.22 449.05# 26675 387.87 368.48 423.75 415.28 26676 465.10 441.85 508.13 497.96 26685 541.61 514.53 591.71 579.88 26686 585.27 556.01 639.41 626.62 26700 303.39 288.22 331.45 324.83# 26700 285.90 271.61 312.35 306.11 26705 382.20 363.09 417.55 409.20# 26705 352.21 334.60 384.79 377.10 26706 410.06 389.56 447.99 439.04 26715 535.77 508.98 585.33 573.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 27

26720 182.19 173.08 199.04 195.06# 26720 170.01 161.51 185.74 182.02 26725 310.88 295.34 339.64 332.84# 26725 282.77 268.63 308.92 302.75 26727 435.73 413.94 476.03 466.51 26735 557.65 529.77 609.24 597.05 26740 209.81 199.32 229.22 224.63# 26740 197.63 187.75 215.91 211.60 26742 340.74 323.70 372.26 364.81# 26742 311.69 296.11 340.53 333.72 26746 695.89 661.10 760.27 745.06 26750 170.19 161.68 185.93 182.22# 26750 170.50 161.98 186.28 182.55 26755 290.55 276.02 317.42 311.08# 26755 255.25 242.49 278.86 273.29 26756 386.52 367.19 422.27 413.83 26765 467.10 443.75 510.31 500.11 26770 256.90 244.06 280.67 275.06# 26770 239.40 227.43 261.54 256.31 26775 351.68 334.10 384.22 376.53# 26775 320.44 304.42 350.08 343.08 26776 410.30 389.79 448.26 439.29 26785 510.06 484.56 557.24 546.10 26820 721.64 685.56 788.39 772.63 26841 664.09 630.89 725.52 711.01 26842 721.51 685.43 788.24 772.48 26843 675.57 641.79 738.06 723.29 26844 748.98 711.53 818.26 801.90 26850 630.82 599.28 689.17 675.38 26852 726.90 690.56 794.14 778.26 26860 507.81 482.42 554.78 543.69 26861 99.70 94.72 108.93 106.75 26862 660.34 627.32 721.42 706.99 26863 220.54 209.51 240.94 236.12 26910 657.32 624.45 718.12 703.75 26951 593.02 563.37 647.88 634.92 26952 588.85 559.41 643.32 630.45 26990 584.06 554.86 638.09 625.32 26991 649.95 617.45 710.07 695.87# 26991 492.83 468.19 538.42 527.65 26992 910.64 865.11 994.88 974.98 27000 396.62 376.79 433.31 424.64 27001 509.40 483.93 556.52 545.39 27003 559.50 531.53 611.26 599.04 27005 686.50 652.18 750.01 735.01 27006 694.53 659.80 758.77 743.59 27025 867.64 824.26 947.90 928.94 27027 812.06 771.46 887.18 869.43 27030 871.43 827.86 952.04 933.00 27033 924.07 877.87 1,009.55 989.36 27035 1,117.71 1,061.82 1,221.09 1,196.67 27036 958.39 910.47 1,047.04 1,026.10

27040 316.34 300.52 345.60 338.69# 27040 191.08 181.53 208.76 204.59 27041 653.80 621.11 714.28 699.99 27043 442.23 420.12 483.14 473.48 27045 709.43 673.96 775.05 759.55 27047 431.86 410.27 471.81 462.37# 27047 341.58 324.50 373.18 365.71 27048 576.48 547.66 629.81 617.22 27049 1,302.23 1,237.12 1,422.69 1,394.24 27050 374.40 355.68 409.03 400.86 27052 542.30 515.19 592.47 580.62 27054 646.23 613.92 706.01 691.89 27057 912.61 866.98 997.03 977.09 27059 1,727.64 1,641.26 1,887.45 1,849.69 27060 435.63 413.85 475.93 466.41 27062 427.10 405.75 466.61 457.29 27065 481.51 457.43 526.04 515.52 27066 767.76 729.37 838.78 822.00 27067 978.93 929.98 1,069.48 1,048.09 27070 803.21 763.05 877.51 859.96 27071 865.49 822.22 945.55 926.65 27075 2,007.29 1,906.93 2,192.97 2,149.11 27076 2,417.17 2,296.31 2,640.76 2,587.94 27077 2,717.62 2,581.74 2,969.00 2,909.63 27078 1,978.80 1,879.86 2,161.84 2,118.60 27080 481.64 457.56 526.19 515.67 27086 264.84 251.60 289.34 283.56# 27086 154.57 146.84 168.87 165.49 27087 593.60 563.92 648.51 635.54 27090 784.06 744.86 856.59 839.45 27091 1,527.15 1,450.79 1,668.41 1,635.04 27093 169.81 161.32 185.52 181.80# 27093 68.60 65.17 74.95 73.45 27095 216.20 205.39 236.20 231.47# 27095 80.00 76.00 87.40 85.65 27096 150.37 142.85 164.28 160.99# 27096 82.27 78.16 89.88 88.09 27097 642.40 610.28 701.82 687.78 27098 653.18 620.52 713.60 699.33 27100 773.02 734.37 844.53 827.63 27105 817.62 776.74 893.25 875.39 27110 916.48 870.66 1,001.26 981.24 27111 849.20 806.74 927.75 909.20 27120 1,235.37 1,173.60 1,349.64 1,322.65 27122 1,044.66 992.43 1,141.29 1,118.47 27125 1,078.31 1,024.39 1,178.05 1,154.49 27130 1,297.70 1,232.82 1,417.74 1,389.38 27132 1,603.64 1,523.46 1,751.98 1,716.94 27134 1,839.39 1,747.42 2,009.53 1,969.34 27137 1,409.82 1,339.33 1,540.23 1,509.42 27138 1,466.18 1,392.87 1,601.80 1,569.76 27140 846.70 804.37 925.03 906.52

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 28

27146 1,221.23 1,160.17 1,334.20 1,307.52 27147 1,399.23 1,329.27 1,528.66 1,498.08 27151 1,516.24 1,440.43 1,656.49 1,623.36 27156 1,635.79 1,554.00 1,787.10 1,751.36 27158 1,334.22 1,267.51 1,457.64 1,428.48 27161 1,156.99 1,099.14 1,264.01 1,238.73 27165 1,311.32 1,245.75 1,432.61 1,403.97 27170 1,120.86 1,064.82 1,224.54 1,200.05 27175 562.52 534.39 614.55 602.26 27176 868.44 825.02 948.77 929.80 27177 1,055.87 1,003.08 1,153.54 1,130.47 27178 868.44 825.02 948.77 929.80 27179 924.16 877.95 1,009.64 989.45 27181 973.40 924.73 1,063.44 1,042.18 27185 566.74 538.40 619.16 606.77 27187 941.42 894.35 1,028.50 1,007.93 27193 442.47 420.35 483.40 473.73# 27193 448.09 425.69 489.54 479.76 27194 665.31 632.04 726.85 712.31 27200 166.96 158.61 182.40 178.76# 27200 173.52 164.84 189.57 185.77 27202 502.79 477.65 549.30 538.32 27220 498.23 473.32 544.32 533.43# 27220 494.17 469.46 539.88 529.08 27222 924.77 878.53 1,010.31 990.10 27226 1,007.22 956.86 1,100.39 1,078.38 27227 1,586.60 1,507.27 1,733.36 1,698.69 27228 1,809.08 1,718.63 1,976.42 1,936.90 27230 444.21 422.00 485.30 475.59# 27230 441.40 419.33 482.23 472.58 27232 725.29 689.03 792.38 776.54 27235 861.93 818.83 941.65 922.82 27236 1,139.29 1,082.33 1,244.68 1,219.78 27238 430.85 409.31 470.71 461.29 27240 907.08 861.73 990.99 971.18 27244 1,171.57 1,112.99 1,279.94 1,254.34 27245 1,171.89 1,113.30 1,280.30 1,254.68 27246 360.14 342.13 393.45 385.58# 27246 362.01 343.91 395.50 387.58 27248 706.10 670.80 771.42 755.99 27250 179.58 170.60 196.19 192.27 27252 720.30 684.29 786.93 771.19 27253 894.23 849.52 976.95 957.41 27254 1,206.36 1,146.04 1,317.95 1,291.59 27256 283.87 269.68 310.13 303.93# 27256 227.64 216.26 248.70 243.72 27257 343.12 325.96 374.85 367.36 27258 1,053.36 1,000.69 1,150.79 1,127.78 27259 1,477.32 1,403.45 1,613.97 1,581.69 27265 376.39 357.57 411.21 402.98 27266 547.25 519.89 597.87 585.91 27267 410.16 389.65 448.10 439.14

27268 505.88 480.59 552.68 541.63 27269 1,186.87 1,127.53 1,296.66 1,270.73 27275 170.52 161.99 186.29 182.56 27280 985.92 936.62 1,077.11 1,055.57 27282 806.59 766.26 881.20 863.57 27284 1,545.85 1,468.56 1,688.84 1,655.07 27286 1,575.96 1,497.16 1,721.73 1,687.30 27290 1,547.57 1,470.19 1,690.72 1,656.91 27295 1,207.81 1,147.42 1,319.53 1,293.14 27301 608.44 578.02 664.72 651.43# 27301 466.63 443.30 509.80 499.59 27303 602.09 571.99 657.79 644.63 27305 454.37 431.65 496.40 486.47 27306 347.23 329.87 379.35 371.76 27307 449.52 427.04 491.10 481.28 27310 690.28 655.77 754.14 739.05 27323 248.28 235.87 271.25 265.82# 27323 167.69 159.31 183.21 179.54 27324 370.40 351.88 404.66 396.57 27325 522.73 496.59 571.08 559.66 27326 480.86 456.82 525.34 514.83 27327 420.29 399.28 459.17 449.98# 27327 293.78 279.09 320.95 314.54 27328 584.91 555.66 639.01 626.23 27329 987.60 938.22 1,078.95 1,057.38 27330 390.71 371.17 426.85 418.31 27331 446.28 423.97 487.57 477.81 27332 602.39 572.27 658.11 644.94 27333 549.39 521.92 600.21 588.20 27334 644.88 612.64 704.54 690.45 27335 722.09 685.99 788.89 773.11 27337 393.82 374.13 430.25 421.65 27339 710.37 674.85 776.08 760.55 27340 346.24 328.93 378.27 370.70 27345 450.90 428.36 492.61 482.76 27347 496.25 471.44 542.16 531.31 27350 615.35 584.58 672.27 658.82 27355 567.73 539.34 620.24 607.83 27356 696.28 661.47 760.69 745.48 27357 768.20 729.79 839.26 822.47 27358 268.22 254.81 293.03 287.17 27360 803.72 763.53 878.06 860.50 27364 1,491.93 1,417.33 1,629.93 1,597.33 27365 1,979.04 1,880.09 2,162.10 2,118.86 27370 145.52 138.24 158.98 155.80# 27370 50.56 48.03 55.23 54.13 27372 557.70 529.82 609.29 597.10# 27372 380.27 361.26 415.45 407.13 27380 557.75 529.86 609.34 597.15 27381 754.11 716.40 823.86 807.38 27385 538.26 511.35 588.05 576.29 27386 783.09 743.94 855.53 838.42

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 29

27390 419.05 398.10 457.82 448.66 27391 541.34 514.27 591.41 579.58 27392 670.36 636.84 732.37 717.72 27393 478.22 454.31 522.46 512.00 27394 614.35 583.63 671.17 657.75 27395 829.30 787.84 906.02 887.89 27396 578.93 549.98 632.48 619.83 27397 864.72 821.48 944.70 925.81 27400 653.54 620.86 713.99 699.71 27403 603.68 573.50 659.53 646.33 27405 637.86 605.97 696.87 682.93 27407 746.96 709.61 816.05 799.73 27409 913.12 867.46 997.58 977.63 27412 1,574.86 1,496.12 1,720.54 1,686.13 27415 1,304.89 1,239.65 1,425.60 1,397.09 27416 929.27 882.81 1,015.23 994.92 27418 785.94 746.64 858.64 841.47 27420 694.77 660.03 759.03 743.85 27422 702.38 667.26 767.35 752.00 27424 704.67 669.44 769.86 754.46 27425 417.89 397.00 456.55 447.42 27427 675.05 641.30 737.50 722.74 27428 1,053.46 1,000.79 1,150.91 1,127.89 27429 1,184.89 1,125.65 1,294.50 1,268.61 27430 699.65 664.67 764.37 749.09 27435 763.93 725.73 834.59 817.90 27437 621.97 590.87 679.50 665.91 27438 797.95 758.05 871.76 854.32 27440 752.95 715.30 822.60 806.14 27441 778.48 739.56 850.49 833.49 27442 824.86 783.62 901.16 883.14 27443 771.35 732.78 842.70 825.84 27445 1,193.31 1,133.64 1,303.69 1,277.62 27446 1,108.15 1,052.74 1,210.65 1,186.44 27447 1,297.11 1,232.25 1,417.09 1,388.75 27448 765.53 727.25 836.34 819.62 27450 961.28 913.22 1,050.20 1,029.20 27454 1,234.76 1,173.02 1,348.97 1,321.99 27455 891.45 846.88 973.91 954.43 27457 908.78 863.34 992.84 972.98 27465 1,191.82 1,132.23 1,302.06 1,276.03 27466 1,119.83 1,063.84 1,223.42 1,198.94 27468 1,153.88 1,096.19 1,260.62 1,235.41 27470 1,118.67 1,062.74 1,222.15 1,197.71 27472 1,203.58 1,143.40 1,314.91 1,288.61 27475 623.22 592.06 680.87 667.25 27477 691.13 656.57 755.06 739.96 27479 827.22 785.86 903.74 885.66 27485 632.11 600.50 690.58 676.76 27486 1,343.96 1,276.76 1,468.27 1,438.90 27487 1,684.49 1,600.27 1,840.31 1,803.50 27488 1,143.93 1,086.73 1,249.74 1,224.75

27495 1,072.64 1,019.01 1,171.86 1,148.42 27496 508.62 483.19 555.67 544.56 27497 547.85 520.46 598.53 586.56 27498 615.35 584.58 672.27 658.82 27499 659.24 626.28 720.22 705.81 27500 483.66 459.48 528.40 517.83# 27500 450.23 427.72 491.88 482.05 27501 471.71 448.12 515.34 505.03# 27501 468.27 444.86 511.59 501.35 27502 732.29 695.68 800.03 784.04 27503 759.33 721.36 829.56 812.97 27506 1,273.51 1,209.83 1,391.30 1,363.47 27507 927.05 880.70 1,012.81 992.55 27508 491.08 466.53 536.51 525.78# 27508 464.22 441.01 507.16 497.02 27509 604.57 574.34 660.49 647.28 27510 649.31 616.84 709.37 695.18 27511 951.73 904.14 1,039.76 1,018.97 27513 1,186.64 1,127.31 1,296.41 1,270.47 27514 921.98 875.88 1,007.26 987.11 27516 471.14 447.58 514.72 504.42# 27516 444.28 422.07 485.38 475.67 27517 644.60 612.37 704.23 690.14 27519 846.97 804.62 925.31 906.81 27520 297.48 282.61 325.00 318.50# 27520 273.12 259.46 298.38 292.41 27524 711.10 675.55 776.88 761.35 27530 276.89 263.05 302.51 296.46# 27530 258.14 245.23 282.01 276.38 27532 575.35 546.58 628.57 616.00# 27532 542.55 515.42 592.73 580.88 27535 854.82 812.08 933.89 915.22 27536 1,132.80 1,076.16 1,237.58 1,212.84 27538 439.21 417.25 479.84 470.25# 27538 412.97 392.32 451.17 442.14 27540 769.08 730.63 840.22 823.42 27550 472.62 448.99 516.34 506.01# 27550 441.38 419.31 482.21 472.56 27552 588.44 559.02 642.87 630.02 27556 830.35 788.83 907.15 889.01 27557 997.94 948.04 1,090.25 1,068.44 27558 1,138.94 1,081.99 1,244.29 1,219.40 27560 335.29 318.53 366.31 358.98# 27560 311.86 296.27 340.71 333.89 27562 452.03 429.43 493.84 483.97 27566 844.88 802.64 923.04 904.58 27570 140.75 133.71 153.77 150.70 27580 1,366.36 1,298.04 1,492.75 1,462.89 27590 780.32 741.30 852.50 835.44 27591 920.06 874.06 1,005.17 985.07 27592 658.49 625.57 719.41 705.02 27594 486.49 462.17 531.50 520.87

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 30

27596 698.12 663.21 762.69 747.44 27598 699.61 664.63 764.32 749.04 27600 394.50 374.78 431.00 422.37 27601 418.34 397.42 457.03 447.89 27602 478.91 454.96 523.20 512.74 27603 488.20 463.79 533.36 522.69# 27603 367.00 348.65 400.95 392.93 27604 429.50 408.03 469.23 459.85# 27604 314.54 298.81 343.63 336.75 27605 314.61 298.88 343.71 336.84# 27605 178.10 169.20 194.58 190.69 27606 271.95 258.35 297.10 291.16 27607 579.32 550.35 632.90 620.24 27610 620.22 589.21 677.59 664.04 27612 537.65 510.77 587.39 575.63 27613 232.16 220.55 253.63 248.56# 27613 154.38 146.66 168.66 165.29 27614 536.98 510.13 586.65 574.92# 27614 386.41 367.09 422.15 413.71 27615 975.56 926.78 1,065.80 1,044.48 27616 1,207.68 1,147.30 1,319.40 1,293.00 27618 410.54 390.01 448.51 439.54# 27618 287.47 273.10 314.07 307.79 27619 448.66 426.23 490.16 480.37 27620 430.46 408.94 470.28 460.87 27625 552.29 524.68 603.38 591.32 27626 595.79 566.00 650.90 637.88 27630 519.51 493.53 567.56 556.21# 27630 348.32 330.90 380.54 372.92 27632 390.97 371.42 427.13 418.59 27634 648.60 616.17 708.60 694.43 27635 557.84 529.95 609.44 597.25 27637 711.52 675.94 777.33 761.78 27638 730.66 694.13 798.25 782.29 27640 793.14 753.48 866.50 849.17 27641 637.39 605.52 696.35 682.42 27645 1,698.62 1,613.69 1,855.74 1,818.63 27646 1,470.84 1,397.30 1,606.90 1,574.75 27647 1,021.65 970.57 1,116.16 1,093.83 27648 147.71 140.32 161.37 158.14# 27648 50.87 48.33 55.58 54.46 27650 629.75 598.26 688.00 674.23 27652 660.69 627.66 721.81 707.38 27654 676.41 642.59 738.98 724.20 27656 578.32 549.40 631.81 619.17# 27656 369.34 350.87 403.50 395.43 27658 354.77 337.03 387.58 379.83 27659 464.36 441.14 507.31 497.17 27664 341.53 324.45 373.12 365.65 27665 392.44 372.82 428.74 420.16 27675 464.46 441.24 507.43 497.28 27676 583.46 554.29 637.43 624.68

27680 406.32 386.00 443.90 435.02 27681 512.78 487.14 560.21 549.01 27685 620.51 589.48 677.90 664.34# 27685 444.02 421.82 485.09 475.39 27686 524.46 498.24 572.98 561.52 27687 432.46 410.84 472.47 463.01 27690 602.40 572.28 658.12 644.95 27691 714.85 679.11 780.98 765.36 27692 102.69 97.56 112.19 109.95 27695 455.37 432.60 497.49 487.54 27696 537.12 510.26 586.80 575.06 27698 612.84 582.20 669.53 656.14 27700 570.67 542.14 623.46 611.00 27702 926.27 879.96 1,011.95 991.71 27703 1,070.04 1,016.54 1,169.02 1,145.64 27704 545.83 518.54 596.32 584.40 27705 720.60 684.57 787.26 771.51 27707 378.44 359.52 413.45 405.18 27709 1,113.71 1,058.02 1,216.72 1,192.39 27712 1,047.78 995.39 1,144.70 1,121.80 27715 1,015.65 964.87 1,109.60 1,087.41 27720 830.47 788.95 907.29 889.15 27722 841.09 799.04 918.90 900.52 27724 1,211.28 1,150.72 1,323.33 1,296.87 27725 1,156.28 1,098.47 1,263.24 1,237.98 27726 923.26 877.10 1,008.67 988.49 27727 880.04 836.04 961.45 942.22 27730 550.63 523.10 601.57 589.54 27732 361.91 343.81 395.38 387.47 27734 588.16 558.75 642.56 629.72 27740 590.61 561.08 645.24 632.34 27742 650.26 617.75 710.41 696.21 27745 716.30 680.49 782.56 766.91 27750 319.44 303.47 348.99 342.01# 27750 295.07 280.32 322.37 315.92 27752 501.05 476.00 547.40 536.45# 27752 465.13 441.87 508.15 497.98 27756 540.60 513.57 590.61 578.80 27758 844.28 802.07 922.38 903.93 27759 948.85 901.41 1,036.62 1,015.89 27760 308.57 293.14 337.11 330.37# 27760 283.58 269.40 309.81 303.61 27762 445.57 423.29 486.78 477.04# 27762 409.96 389.46 447.88 438.92 27766 574.03 545.33 627.13 614.58 27767 260.63 247.60 284.74 279.05# 27767 262.19 249.08 286.44 280.72 27768 410.28 389.77 448.24 439.27 27769 690.50 655.98 754.38 739.29 27780 282.01 267.91 308.10 301.93# 27780 258.27 245.36 282.16 276.52 27781 388.61 369.18 424.56 416.07

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 31

# 27781 362.37 344.25 395.89 387.98 27784 677.76 643.87 740.45 725.64 27786 292.22 277.61 319.25 312.87# 27786 265.98 252.68 290.58 284.77 27788 391.44 371.87 427.65 419.09# 27788 359.89 341.90 393.19 385.32 27792 617.43 586.56 674.54 661.05 27808 308.13 292.72 336.63 329.90# 27808 278.77 264.83 304.55 298.46 27810 436.76 414.92 477.16 467.61# 27810 399.27 379.31 436.21 427.48 27814 731.57 694.99 799.24 783.25 27816 294.33 279.61 321.55 315.12# 27816 265.90 252.61 290.50 284.69 27818 453.03 430.38 494.94 485.04# 27818 409.92 389.42 447.83 438.87 27822 795.71 755.92 869.31 851.92 27823 905.18 859.92 988.91 969.13 27824 291.15 276.59 318.08 311.72# 27824 283.66 269.48 309.90 303.70 27825 510.26 484.75 557.46 546.32# 27825 466.22 442.91 509.35 499.16 27826 791.84 752.25 865.09 847.79 27827 1,025.83 974.54 1,120.72 1,098.31 27828 1,231.06 1,169.51 1,344.94 1,318.04 27829 645.98 613.68 705.73 691.62 27830 351.40 333.83 383.90 376.22# 27830 328.91 312.46 359.33 352.14 27831 372.24 353.63 406.67 398.54 27832 712.19 676.58 778.07 762.51 27840 348.65 331.22 380.90 373.29 27842 465.37 442.10 508.42 498.25 27846 694.10 659.40 758.31 743.14 27848 775.09 736.34 846.79 829.85 27860 168.03 159.63 183.57 179.91 27870 987.75 938.36 1,079.11 1,057.53 27871 651.97 619.37 712.28 698.03 27880 890.26 845.75 972.61 953.17 27881 844.23 802.02 922.32 903.88 27882 584.00 554.80 638.02 625.26 27884 553.40 525.73 604.59 592.50 27886 633.20 601.54 691.77 677.94 27888 646.44 614.12 706.24 692.12 27889 639.92 607.92 699.11 685.12 27892 527.29 500.93 576.07 564.55 27893 575.70 546.92 628.96 616.38 27894 816.65 775.82 892.19 874.35 28001 258.44 245.52 282.35 276.70# 28001 163.48 155.31 178.61 175.03 28002 421.39 400.32 460.37 451.16# 28002 311.12 295.56 339.89 333.10 28003 675.87 642.08 738.39 723.63

# 28003 550.29 522.78 601.20 589.17 28005 560.89 532.85 612.78 600.52 28008 405.77 385.48 443.30 434.44# 28008 282.07 267.97 308.17 302.00 28010 220.75 209.71 241.17 236.35# 28010 200.44 190.42 218.98 214.60 28011 308.17 292.76 336.67 329.94# 28011 277.87 263.98 303.58 297.51 28020 504.61 479.38 551.29 540.26# 28020 345.30 328.04 377.25 369.70 28022 457.42 434.55 499.73 489.74# 28022 311.23 295.67 340.02 333.22 28024 430.41 408.89 470.22 460.82# 28024 291.40 276.83 318.35 311.98 28035 496.61 471.78 542.55 531.69# 28035 342.30 325.19 373.97 366.49 28039 480.97 456.92 525.46 514.95# 28039 336.96 320.11 368.13 360.77 28041 442.26 420.15 483.17 473.51 28043 373.59 354.91 408.15 399.98# 28043 251.45 238.88 274.71 269.22 28045 467.60 444.22 510.85 500.64# 28045 335.78 318.99 366.84 359.50 28046 711.23 675.67 777.02 761.48 28047 996.44 946.62 1,088.61 1,066.84 28050 400.24 380.23 437.26 428.52# 28050 271.23 257.67 296.32 290.40 28052 409.93 389.43 447.84 438.89# 28052 269.05 255.60 293.94 288.06 28054 350.95 333.40 383.41 375.74# 28054 226.31 214.99 247.24 242.29 28055 365.04 346.79 398.81 390.83 28060 485.56 461.28 530.47 519.86# 28060 341.56 324.48 373.15 365.69 28062 553.15 525.49 604.31 592.23# 28062 393.53 373.85 429.93 421.33 28070 497.88 472.99 543.94 533.06# 28070 339.19 322.23 370.56 363.16 28072 474.63 450.90 518.54 508.16# 28072 318.44 302.52 347.90 340.94 28080 487.98 463.58 533.12 522.46# 28080 347.73 330.34 379.89 372.29 28086 508.38 482.96 555.40 544.30# 28086 342.82 325.68 374.53 367.05 28088 433.44 411.77 473.54 464.06# 28088 279.13 265.17 304.95 298.85 28090 440.02 418.02 480.72 471.11# 28090 295.08 280.33 322.38 315.93 28092 394.01 374.31 430.46 421.84# 28092 256.56 243.73 280.29 274.69 28100 565.52 537.24 617.83 605.48# 28100 391.52 371.94 427.73 419.18

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 32

28102 544.70 517.47 595.09 583.19 28103 380.01 361.01 415.16 406.86 28104 490.86 466.32 536.27 525.54# 28104 335.92 319.12 366.99 359.65 28106 431.33 409.76 471.22 461.79 28107 515.61 489.83 563.30 552.03# 28107 352.55 334.92 385.16 377.45 28108 413.29 392.63 451.52 442.50# 28108 276.79 262.95 302.39 296.34 28110 431.57 409.99 471.49 462.06# 28110 276.31 262.49 301.86 295.83 28111 466.44 443.12 509.59 499.40# 28111 315.87 300.08 345.09 338.19 28112 457.74 434.85 500.08 490.07# 28112 300.30 285.29 328.08 321.52 28113 556.32 528.50 607.78 595.62# 28113 407.32 386.95 444.99 436.09 28114 1,010.34 959.82 1,103.79 1,081.71# 28114 799.18 759.22 873.10 855.65 28116 705.01 669.76 770.22 754.81# 28116 543.83 516.64 594.14 582.26 28118 552.24 524.63 603.32 591.26# 28118 392.62 372.99 428.94 420.36 28119 494.14 469.43 539.84 529.05# 28119 347.01 329.66 379.11 371.53 28120 637.99 606.09 697.00 683.07# 28120 477.12 453.26 521.25 510.82 28122 564.61 536.38 616.84 604.50# 28122 423.10 401.95 462.24 453.00 28124 447.91 425.51 489.34 479.55# 28124 316.72 300.88 346.01 339.09 28126 370.70 352.17 405.00 396.90# 28126 238.57 226.64 260.64 255.43 28130 631.76 600.17 690.20 676.40 28140 567.94 539.54 620.47 608.06# 28140 426.44 405.12 465.89 456.57 28150 400.65 380.62 437.71 428.96# 28150 269.77 256.28 294.72 288.82 28153 385.73 366.44 421.41 412.98# 28153 253.29 240.63 276.72 271.19 28160 392.63 373.00 428.95 420.37# 28160 257.68 244.80 281.52 275.89 28171 833.85 792.16 910.98 892.77 28173 753.13 715.47 822.79 806.33 28175 473.26 449.60 517.04 506.70 28190 237.52 225.64 259.49 254.30# 28190 128.50 122.08 140.39 137.59 28192 442.29 420.18 483.21 473.55# 28192 302.03 286.93 329.97 323.37 28193 502.47 477.35 548.95 537.97# 28193 357.21 339.35 390.25 382.44 28200 455.05 432.30 497.15 487.20

# 28200 305.11 289.85 333.33 326.66 28202 564.44 536.22 616.65 604.33# 28202 412.00 391.40 450.11 441.11 28208 442.61 420.48 483.55 473.88# 28208 297.67 282.79 325.21 318.70 28210 533.18 506.52 582.50 570.85# 28210 389.17 369.71 425.17 416.67 28220 420.51 399.48 459.40 450.21# 28220 289.00 274.55 315.73 309.42 28222 480.17 456.16 524.58 514.10# 28222 338.66 321.73 369.99 362.60 28225 381.65 362.57 416.96 408.62# 28225 247.33 234.96 270.20 264.80 28226 546.29 518.98 596.83 584.89# 28226 352.31 334.69 384.89 377.20 28230 409.16 388.70 447.01 438.07# 28230 272.65 259.02 297.87 291.92 28232 362.61 344.48 396.15 388.23# 28232 233.29 221.63 254.87 249.78 28234 379.93 360.93 415.07 406.77# 28234 250.60 238.07 273.78 268.31 28238 637.44 605.57 696.41 682.48# 28238 471.57 447.99 515.19 504.88 28240 412.66 392.03 450.83 441.82# 28240 278.34 264.42 304.08 298.00 28250 543.45 516.28 593.72 581.84# 28250 386.64 367.31 422.41 413.95 28260 646.96 614.61 706.80 692.67# 28260 490.77 466.23 536.16 525.45 28261 921.42 875.35 1,006.65 986.52# 28261 741.49 704.42 810.08 793.88 28262 1,371.41 1,302.84 1,498.27 1,468.30# 28262 1,114.95 1,059.20 1,218.08 1,193.72 28264 906.06 860.76 989.87 970.07# 28264 692.09 657.49 756.11 740.99 28270 460.74 437.70 503.36 493.29# 28270 319.86 303.87 349.45 342.46 28272 369.28 350.82 403.44 395.37# 28272 244.33 232.11 266.93 261.59 28280 489.13 464.67 534.37 523.69# 28280 337.94 321.04 369.20 361.81 28285 501.29 476.23 547.66 536.72# 28285 361.03 342.98 394.43 386.54 28286 426.34 405.02 465.77 456.46# 28286 289.21 274.75 315.96 309.65 28288 566.70 538.37 619.13 606.74# 28288 409.89 389.40 447.81 438.85 28289 692.87 658.23 756.96 741.83# 28289 526.06 499.76 574.72 563.22 28290 548.58 521.15 599.32 587.34# 28290 377.09 358.24 411.98 403.74 28292 745.49 708.22 814.45 798.17

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 33

# 28292 577.43 548.56 630.84 618.23 28293 985.01 935.76 1,076.12 1,054.60# 28293 686.06 651.76 749.52 734.53 28294 708.60 673.17 774.15 758.67# 28294 516.18 490.37 563.93 552.64 28296 673.91 640.21 736.24 721.52# 28296 502.10 477.00 548.55 537.58 28297 768.98 730.53 840.11 823.31# 28297 563.44 535.27 615.56 603.24 28298 680.67 646.64 743.64 728.77# 28298 487.31 462.94 532.38 521.73 28299 848.59 806.16 927.08 908.55# 28299 653.98 621.28 714.47 700.18 28300 626.16 594.85 684.08 670.39 28302 674.51 640.78 736.90 722.15 28304 765.97 727.67 836.82 820.09# 28304 573.86 545.17 626.95 614.41 28305 617.98 587.08 675.14 661.64 28306 575.46 546.69 628.69 616.12# 28306 387.72 368.33 423.58 415.10 28307 650.90 618.36 711.11 696.89# 28307 441.92 419.82 482.79 473.13 28308 526.33 500.01 575.01 563.51# 28308 358.89 340.95 392.09 384.25 28309 860.05 817.05 939.61 920.82 28310 508.52 483.09 555.55 544.44# 28310 341.71 324.62 373.31 365.85 28312 477.45 453.58 521.62 511.19# 28312 306.58 291.25 334.94 328.24 28313 497.67 472.79 543.71 532.83# 28313 344.61 327.38 376.49 368.95 28315 450.79 428.25 492.49 482.64# 28315 311.47 295.90 340.29 333.48 28320 592.76 563.12 647.59 634.64 28322 744.75 707.51 813.64 797.36# 28322 555.14 527.38 606.49 594.35 28340 549.81 522.32 600.67 588.65# 28340 401.75 381.66 438.91 430.13 28341 640.31 608.29 699.53 685.54# 28341 479.75 455.76 524.12 513.64 28344 406.99 386.64 444.64 435.75# 28344 275.79 262.00 301.30 295.27 28345 494.35 469.63 540.07 529.28# 28345 353.16 335.50 385.83 378.11 28360 853.67 810.99 932.64 913.99 28400 230.84 219.30 252.20 247.15# 28400 212.09 201.49 231.71 227.08 28405 365.36 347.09 399.15 391.17# 28405 334.12 317.41 365.02 357.72 28406 497.83 472.94 543.88 533.00 28415 1,057.45 1,004.58 1,155.27 1,132.16 28420 1,187.02 1,127.67 1,296.82 1,270.89

28430 218.31 207.39 238.50 233.73# 28430 195.20 185.44 213.26 208.99 28435 304.11 288.90 332.24 325.59# 28435 273.81 260.12 299.14 293.16 28436 418.07 397.17 456.75 447.61 28445 1,012.23 961.62 1,105.86 1,083.75 28446 1,162.13 1,104.02 1,269.62 1,244.23 28450 200.71 190.67 219.27 214.89# 28450 179.78 170.79 196.41 192.48 28455 279.21 265.25 305.04 298.94# 28455 252.35 239.73 275.69 270.18 28456 293.61 278.93 320.77 314.35 28465 595.57 565.79 650.66 637.64 28470 204.36 194.14 223.26 218.80# 28470 191.55 181.97 209.27 205.08 28475 240.26 228.25 262.49 257.24# 28475 214.96 204.21 234.84 230.15 28476 325.84 309.55 355.98 348.86 28485 500.11 475.10 546.37 535.44 28490 133.85 127.16 146.23 143.31# 28490 115.73 109.94 126.43 123.90 28495 164.47 156.25 179.69 176.10# 28495 139.80 132.81 152.73 149.67 28496 399.12 379.16 436.03 427.32# 28496 217.63 206.75 237.76 233.01 28505 623.25 592.09 680.90 667.29# 28505 475.19 451.43 519.14 508.76 28510 114.55 108.82 125.14 122.64# 28510 111.43 105.86 121.74 119.30 28515 149.31 141.84 163.12 159.85# 28515 132.76 126.12 145.04 142.14 28525 533.49 506.82 582.84 571.18# 28525 382.30 363.19 417.67 409.32 28530 106.54 101.21 116.39 114.07# 28530 95.29 90.53 104.11 102.03 28531 324.97 308.72 355.03 347.93# 28531 182.22 173.11 199.08 195.10 28540 191.11 181.55 208.78 204.61# 28540 173.30 164.64 189.34 185.55 28545 271.69 258.11 296.83 290.89# 28545 242.33 230.21 264.74 259.45 28546 525.33 499.06 573.92 562.44# 28546 314.16 298.45 343.22 336.35 28555 814.16 773.45 889.47 871.68# 28555 629.86 598.37 688.13 674.36 28570 199.79 189.80 218.27 213.90# 28570 169.81 161.32 185.52 181.80 28575 336.40 319.58 367.52 360.17# 28575 305.79 290.50 334.08 327.39 28576 369.18 350.72 403.33 395.27 28585 819.55 778.57 895.36 877.45# 28585 657.12 624.26 717.90 703.54

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 34

28600 203.83 193.64 222.69 218.24# 28600 176.65 167.82 192.99 189.13 28605 300.61 285.58 328.42 321.85# 28605 272.19 258.58 297.37 291.42 28606 376.64 357.81 411.48 403.25 28615 749.10 711.65 818.40 802.03 28630 147.20 139.84 160.82 157.60# 28630 105.34 100.07 115.08 112.78 28635 164.44 156.22 179.65 176.07# 28635 126.64 120.31 138.36 135.59 28636 242.87 230.73 265.34 260.04# 28636 166.65 158.32 182.07 178.42 28645 618.05 587.15 675.22 661.72# 28645 464.68 441.45 507.67 497.51 28660 108.60 103.17 118.65 116.28# 28660 84.86 80.62 92.71 90.86 28665 145.36 138.09 158.80 155.63# 28665 125.68 119.40 137.31 134.56 28666 180.06 171.06 196.72 192.79 28675 530.23 503.72 579.28 567.70# 28675 382.79 363.65 418.20 409.84 28705 1,219.89 1,158.90 1,332.74 1,306.08 28715 891.67 847.09 974.15 954.67 28725 737.56 700.68 805.78 789.67 28730 702.00 666.90 766.94 751.59 28735 751.39 713.82 820.89 804.47 28737 664.80 631.56 726.29 711.77 28740 801.17 761.11 875.28 857.77# 28740 600.62 570.59 656.18 643.06 28750 766.18 727.87 837.05 820.31# 28750 567.51 539.13 620.00 607.60 28755 476.38 452.56 520.44 510.04# 28755 316.75 300.91 346.05 339.12 28760 739.06 702.11 807.43 791.28# 28760 552.26 524.65 603.35 591.28 28800 526.03 499.73 574.69 563.20 28805 721.13 685.07 787.83 772.08 28810 418.51 397.58 457.22 448.07 28820 533.95 507.25 583.34 571.68# 28820 382.14 363.03 417.48 409.14 28825 508.46 483.04 555.50 544.39# 28825 357.59 339.71 390.67 382.86 28890 304.54 289.31 332.71 326.05# 28890 216.77 205.93 236.82 232.08 29000 275.24 261.48 300.70 294.69# 29000 159.04 151.09 173.75 170.28 29010 224.93 213.68 245.73 240.82# 29010 142.47 135.35 155.65 152.54 29015 256.46 243.64 280.19 274.59# 29015 165.87 157.58 181.22 177.59 29020 181.83 172.74 198.65 194.68# 29020 122.79 116.65 134.15 131.47

29025 268.35 254.93 293.17 287.30# 29025 171.20 162.64 187.04 183.30 29035 212.81 202.17 232.50 227.85# 29035 128.16 121.75 140.01 137.22 29040 318.03 302.13 347.45 340.50# 29040 175.27 166.51 191.49 187.66 29044 242.95 230.80 265.42 260.11# 29044 151.11 143.55 165.08 161.78 29046 254.34 241.62 277.86 272.31# 29046 165.31 157.04 180.60 176.99 29049 90.95 86.40 99.36 97.37# 29049 65.96 62.66 72.06 70.62 29055 203.49 193.32 222.32 217.87# 29055 130.08 123.58 142.12 139.28 29058 113.94 108.24 124.48 121.99# 29058 88.95 84.50 97.18 95.23 29065 88.74 84.30 96.95 95.00# 29065 64.38 61.16 70.33 68.93 29075 79.92 75.92 87.31 85.56# 29075 58.68 55.75 64.11 62.84 29085 87.56 83.18 95.66 93.75# 29085 63.51 60.33 69.38 67.99 29086 72.22 68.61 78.90 77.33# 29086 48.17 45.76 52.62 51.57 29105 81.31 77.24 88.83 87.06# 29105 56.64 53.81 61.88 60.64 29125 59.18 56.22 64.65 63.37# 29125 37.31 35.44 40.76 39.94 29126 70.55 67.02 77.07 75.53# 29126 46.19 43.88 50.46 49.45 29130 38.59 36.66 42.16 41.32# 29130 27.66 26.28 30.22 29.61 29131 47.85 45.46 52.28 51.23# 29131 31.92 30.32 34.87 34.17 29200 49.35 46.88 53.91 52.83# 29200 38.10 36.20 41.63 40.80 29240 53.37 50.70 58.31 57.14# 29240 41.81 39.72 45.68 44.77 29260 47.33 44.96 51.70 50.67# 29260 35.15 33.39 38.40 37.63 29280 46.56 44.23 50.86 49.85# 29280 34.06 32.36 37.21 36.47 29305 226.36 215.04 247.30 242.35# 29305 149.52 142.04 163.35 160.08 29325 250.91 238.36 274.11 268.63# 29325 168.13 159.72 183.68 180.01 29345 126.71 120.37 138.43 135.65# 29345 96.10 91.30 105.00 102.89 29355 132.23 125.62 144.46 141.58# 29355 102.24 97.13 111.70 109.47 29358 148.02 140.62 161.71 158.48# 29358 98.66 93.73 107.79 105.64

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 35

29365 113.97 108.27 124.51 122.02# 29365 83.36 79.19 91.07 89.25 29405 75.75 71.96 82.75 81.10# 29405 56.70 53.87 61.95 60.71 29425 72.98 69.33 79.73 78.13# 29425 53.92 51.22 58.90 57.73 29435 107.10 101.75 117.01 114.68# 29435 78.67 74.74 85.95 84.24 29440 42.32 40.20 46.23 45.31# 29440 29.51 28.03 32.23 31.59 29445 128.24 121.83 140.10 137.30# 29445 101.69 96.61 111.10 108.88 29450 135.31 128.54 147.82 144.87# 29450 109.07 103.62 119.16 116.78 29505 76.50 72.68 83.58 81.91# 29505 47.45 45.08 51.84 50.81 29515 66.72 63.38 72.89 71.43# 29515 47.67 45.29 52.08 51.04 29520 44.51 42.28 48.62 47.64# 29520 33.26 31.60 36.34 35.62 29530 47.11 44.75 51.46 50.44# 29530 35.24 33.48 38.50 37.73 29540 34.48 32.76 37.67 36.92# 29540 24.80 23.56 27.09 26.55 29550 28.60 27.17 31.25 30.62# 29550 18.29 17.38 19.99 19.58 29580 48.82 46.38 53.34 52.27# 29580 34.14 32.43 37.29 36.55 29581 55.46 52.69 60.59 59.39# 29581 12.36 11.74 13.50 13.24 29582 63.42 60.25 69.29 67.91# 29582 15.63 14.85 17.08 16.73 29583 39.53 37.55 43.18 42.32# 29583 11.11 10.55 12.13 11.89 29584 63.42 60.25 69.29 67.91# 29584 15.63 14.85 17.08 16.73 29700 57.24 54.38 62.54 61.28# 29700 32.56 30.93 35.57 34.86 29705 62.14 59.03 67.88 66.53# 29705 44.96 42.71 49.12 48.14 29710 108.32 102.90 118.34 115.97# 29710 78.01 74.11 85.23 83.52 29715 71.40 67.83 78.00 76.44# 29715 47.97 45.57 52.41 51.36 29720 77.39 73.52 84.55 82.86# 29720 41.78 39.69 45.64 44.74 29730 60.53 57.50 66.13 64.80# 29730 43.35 41.18 47.36 46.41 29740 91.38 86.81 99.83 97.83# 29740 66.08 62.78 72.20 70.75 29750 81.43 77.36 88.96 87.18# 29750 64.25 61.04 70.20 68.79

29800 491.09 466.54 536.52 525.79 29804 619.92 588.92 677.26 663.71 29805 443.51 421.33 484.53 474.84 29806 1,006.85 956.51 1,099.99 1,077.99 29807 980.72 931.68 1,071.43 1,050.01 29819 552.61 524.98 603.73 591.65 29820 510.04 484.54 557.22 546.08 29821 557.65 529.77 609.24 597.05 29822 542.12 515.01 592.26 580.42 29823 592.01 562.41 646.77 633.83 29824 639.06 607.11 698.18 684.22 29825 552.92 525.27 604.06 591.97 29826 170.16 161.65 185.90 182.18 29827 1,021.37 970.30 1,115.85 1,093.52 29828 877.24 833.38 958.39 939.22 29830 428.18 406.77 467.79 458.42 29834 462.34 439.22 505.10 495.01 29835 477.11 453.25 521.24 510.82 29836 544.79 517.55 595.18 583.28 29837 498.64 473.71 544.77 533.88 29838 555.28 527.52 606.65 594.52 29840 424.28 403.07 463.53 454.26 29843 454.27 431.56 496.29 486.37 29844 468.83 445.39 512.20 501.95 29845 545.14 517.88 595.56 583.65 29846 490.42 465.90 535.79 525.07 29847 513.14 487.48 560.60 549.39 29848 478.31 454.39 522.55 512.10 29850 587.57 558.19 641.92 629.08 29851 883.25 839.09 964.95 945.66 29855 744.43 707.21 813.29 797.03 29856 945.30 898.04 1,032.75 1,012.09 29860 629.44 597.97 687.67 673.91 29861 687.26 652.90 750.84 735.82 29862 772.65 734.02 844.12 827.24 29863 774.80 736.06 846.47 829.54 29866 993.38 943.71 1,085.27 1,063.57 29867 1,213.28 1,152.62 1,325.51 1,299.01 29868 1,594.76 1,515.02 1,742.27 1,707.43 29870 537.65 510.77 587.39 575.63# 29870 387.71 368.32 423.57 415.09 29871 484.23 460.02 529.02 518.44 29873 491.19 466.63 536.62 525.90 29874 507.76 482.37 554.73 543.63 29875 466.71 443.37 509.88 499.68 29876 620.55 589.52 677.95 664.39 29877 588.33 558.91 642.75 629.89 29879 627.24 595.88 685.26 671.55 29880 531.62 505.04 580.80 569.18 29881 510.88 485.34 558.14 546.97 29882 662.41 629.29 723.68 709.21 29883 798.76 758.82 872.64 855.19

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 36

29884 585.74 556.45 639.92 627.12 29885 710.47 674.95 776.19 760.67 29886 600.00 570.00 655.50 642.39 29887 707.46 672.09 772.90 757.45 29888 939.87 892.88 1,026.81 1,006.27 29889 1,159.48 1,101.51 1,266.74 1,241.40 29891 652.92 620.27 713.31 699.04 29892 596.38 566.56 651.54 638.51 29893 572.39 543.77 625.34 612.82# 29893 409.02 388.57 446.86 437.92 29894 484.41 460.19 529.22 518.64 29895 453.73 431.04 495.70 485.78 29897 487.02 462.67 532.07 521.43 29898 540.66 513.63 590.67 578.86 29899 987.54 938.16 1,078.88 1,057.31 29900 443.24 421.08 484.24 474.56 29901 499.46 474.49 545.66 534.75 29902 565.85 537.56 618.19 605.83 29904 601.87 571.78 657.55 644.39 29905 650.46 617.94 710.63 696.42 29906 684.82 650.58 748.17 733.21 29907 829.02 787.57 905.71 887.59 29914 960.58 912.55 1,049.43 1,028.45 29915 980.39 931.37 1,071.08 1,049.65 29916 980.70 931.67 1,071.42 1,050.00 30000 213.15 202.49 232.86 228.21# 30000 112.88 107.24 123.33 120.87 30020 214.47 203.75 234.31 229.63# 30020 112.64 107.01 123.06 120.60 30100 129.50 123.03 141.48 138.66# 30100 65.46 62.19 71.52 70.09 30110 212.79 202.15 232.47 227.83# 30110 123.76 117.57 135.21 132.50 30115 401.12 381.06 438.22 429.46 30117 791.70 752.12 864.94 847.64# 30117 313.77 298.08 342.79 335.94 30118 726.14 689.83 793.30 777.43 30120 481.10 457.05 525.61 515.10# 30120 410.50 389.98 448.48 439.51 30124 268.20 254.79 293.01 287.14 30125 572.63 544.00 625.60 613.09 30130 351.80 334.21 384.34 376.66 30140 406.58 386.25 444.19 435.31 30150 726.86 690.52 794.10 778.22 30160 731.56 694.98 799.23 783.24 30200 105.06 99.81 114.78 112.48# 30200 56.95 54.10 62.22 60.97 30210 138.42 131.50 151.23 148.20# 30210 93.75 89.06 102.42 100.37 30220 277.69 263.81 303.38 297.31# 30220 118.70 112.77 129.69 127.09 30300 210.40 199.88 229.86 225.26

# 30300 117.31 111.44 128.16 125.59 30310 193.26 183.60 211.14 206.92 30320 421.30 400.24 460.28 451.08 30400 943.21 896.05 1,030.46 1,009.85 30410 1,112.42 1,056.80 1,215.32 1,191.01 30420 1,292.99 1,228.34 1,412.59 1,384.34 30430 895.12 850.36 977.91 958.35 30435 1,044.06 991.86 1,140.64 1,117.82 30450 1,416.46 1,345.64 1,547.49 1,516.54 30460 711.56 675.98 777.38 761.83 30462 1,480.23 1,406.22 1,617.15 1,584.82 30465 928.31 881.89 1,014.17 993.89 30520 585.78 556.49 639.96 627.16 30540 645.44 613.17 705.15 691.05 30545 868.97 825.52 949.35 930.36 30560 245.94 233.64 268.69 263.32# 30560 128.49 122.07 140.38 137.57 30580 605.28 575.02 661.27 648.05# 30580 480.95 456.90 525.44 514.92 30600 546.97 519.62 597.56 585.61# 30600 419.52 398.54 458.32 449.16 30620 582.26 553.15 636.12 623.40 30630 588.93 559.48 643.40 630.53 30801 207.50 197.13 226.70 222.17# 30801 126.91 120.56 138.64 135.87 30802 266.33 253.01 290.96 285.14# 30802 178.56 169.63 195.07 191.18 30901 89.48 85.01 97.76 95.81# 30901 55.43 52.66 60.56 59.35 30903 189.97 180.47 207.54 203.39# 30903 77.82 73.93 85.02 83.32 30905 236.36 224.54 258.22 253.06# 30905 98.92 93.97 108.07 105.90 30906 261.26 248.20 285.43 279.73# 30906 128.19 121.78 140.05 137.24 30915 546.20 518.89 596.72 584.79 30920 792.43 752.81 865.73 848.41 30930 115.99 110.19 126.72 124.19 31000 167.48 159.11 182.98 179.32# 31000 98.76 93.82 107.89 105.73 31002 187.41 178.04 204.75 200.65 31020 440.42 418.40 481.16 471.53# 31020 330.78 314.24 361.38 354.15 31030 636.35 604.53 695.21 681.31# 31030 493.59 468.91 539.25 528.46 31032 538.18 511.27 587.96 576.20 31040 721.73 685.64 788.49 772.72 31050 453.11 430.45 495.02 485.12 31051 603.71 573.52 659.55 646.36 31070 409.30 388.84 447.17 438.22 31075 735.16 698.40 803.16 787.09 31080 970.07 921.57 1,059.81 1,038.61

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 37

31081 1,366.82 1,298.48 1,493.25 1,463.39 31084 1,089.18 1,034.72 1,189.93 1,166.13 31085 1,454.18 1,381.47 1,588.69 1,556.92 31086 1,057.36 1,004.49 1,155.16 1,132.06 31087 1,023.30 972.14 1,117.96 1,095.61 31090 961.53 913.45 1,050.47 1,029.46 31200 530.91 504.36 580.01 568.41 31201 696.59 661.76 761.02 745.80 31205 853.79 811.10 932.77 914.11 31225 1,782.04 1,692.94 1,946.88 1,907.94 31230 1,981.65 1,882.57 2,164.96 2,121.66 31231 189.58 180.10 207.12 202.98# 31231 62.45 59.33 68.23 66.86 31233 244.54 232.31 267.16 261.81# 31233 132.40 125.78 144.65 141.75 31235 278.06 264.16 303.78 297.71# 31235 156.55 148.72 171.03 167.61 31237 240.39 228.37 262.63 257.37# 31237 156.05 148.25 170.49 167.08 31238 240.06 228.06 262.27 257.03# 31238 163.22 155.06 178.32 174.75 31239 595.00 565.25 650.04 637.04 31240 155.75 147.96 170.15 166.75 31254 264.49 251.27 288.96 283.18 31255 388.15 368.74 424.05 415.58 31256 191.15 181.59 208.83 204.65 31267 307.56 292.18 336.01 329.29 31276 490.28 465.77 535.64 524.92 31287 224.91 213.66 245.71 240.80 31288 260.73 247.69 284.84 279.15 31290 1,114.51 1,058.78 1,217.60 1,193.24 31291 1,181.53 1,122.45 1,290.82 1,265.00 31292 961.64 913.56 1,050.59 1,029.58 31293 1,044.43 992.21 1,141.04 1,118.23 31294 1,197.34 1,137.47 1,308.09 1,281.93 31295 1,846.11 1,753.80 2,016.87 1,976.53# 31295 161.16 153.10 176.07 172.55 31296 1,876.06 1,782.26 2,049.60 2,008.60# 31296 192.98 183.33 210.83 206.61 31297 1,842.71 1,750.57 2,013.16 1,972.89# 31297 158.39 150.47 173.04 169.58 31300 1,189.13 1,129.67 1,299.12 1,273.14 31320 607.37 577.00 663.55 650.28 31360 1,984.49 1,885.27 2,168.06 2,124.69 31365 2,463.41 2,340.24 2,691.28 2,637.46 31367 2,094.79 1,990.05 2,288.56 2,242.79 31368 2,323.38 2,207.21 2,538.29 2,487.53 31370 1,962.53 1,864.40 2,144.06 2,101.18 31375 1,862.57 1,769.44 2,034.86 1,994.16 31380 1,835.50 1,743.73 2,005.29 1,965.19 31382 2,016.91 1,916.06 2,203.47 2,159.40 31390 2,738.06 2,601.16 2,991.33 2,931.51

31395 2,868.06 2,724.66 3,133.36 3,070.70 31400 935.31 888.54 1,021.82 1,001.39 31420 793.41 753.74 866.80 849.47 31500 108.97 103.52 119.05 116.67 31502 34.28 32.57 37.46 36.71 31505 76.58 72.75 83.66 82.00# 31505 46.60 44.27 50.91 49.89 31510 195.04 185.29 213.08 208.82# 31510 116.94 111.09 127.75 125.20 31511 195.96 186.16 214.08 209.81# 31511 125.99 119.69 137.64 134.90 31512 193.19 183.53 211.06 206.84# 31512 126.03 119.73 137.69 134.94 31513 128.04 121.64 139.89 137.09 31515 193.31 183.64 211.19 206.97# 31515 107.72 102.33 117.68 115.32 31520 152.75 145.11 166.88 163.54 31525 237.06 225.21 258.99 253.82# 31525 155.53 147.75 169.91 166.52 31526 153.10 145.45 167.27 163.92 31527 190.12 180.61 207.70 203.55 31528 140.70 133.67 153.72 150.65 31529 157.63 149.75 172.21 168.77 31530 192.70 183.07 210.53 206.32 31531 207.02 196.67 226.17 221.65 31535 184.30 175.09 201.35 197.33 31536 205.32 195.05 224.31 219.82 31540 236.08 224.28 257.92 252.76 31541 257.73 244.84 281.57 275.93 31545 354.80 337.06 387.62 379.87 31546 539.58 512.60 589.49 577.70 31560 306.00 290.70 334.31 327.62 31561 335.40 318.63 366.42 359.10 31570 319.85 303.86 349.44 342.45# 31570 223.33 212.16 243.98 239.11 31571 243.55 231.37 266.08 260.75 31575 105.87 100.58 115.67 113.36# 31575 72.76 69.12 79.49 77.90 31576 208.46 198.04 227.75 223.19# 31576 119.74 113.75 130.81 128.20 31577 226.37 215.05 247.31 242.36# 31577 145.15 137.89 158.57 155.40 31578 261.45 248.38 285.64 279.92# 31578 166.49 158.17 181.90 178.26 31579 198.64 188.71 217.02 212.68# 31579 137.11 130.25 149.79 146.80 31580 1,148.59 1,091.16 1,254.83 1,229.74 31582 1,783.25 1,694.09 1,948.20 1,909.24 31584 1,431.35 1,359.78 1,563.75 1,532.47 31587 960.94 912.89 1,049.82 1,028.82 31588 1,081.83 1,027.74 1,181.90 1,158.27 31590 822.24 781.13 898.30 880.34

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 38

31595 716.75 680.91 783.05 767.38 31600 385.05 365.80 420.67 412.25 31601 251.81 239.22 275.10 269.61 31603 219.09 208.14 239.36 234.58 31605 180.13 171.12 196.79 192.86 31610 678.02 644.12 740.74 725.93 31611 507.57 482.19 554.52 543.43 31612 77.82 73.93 85.02 83.32# 31612 46.58 44.25 50.89 49.88 31613 425.57 404.29 464.93 455.63 31614 712.83 677.19 778.77 763.20 31615 171.14 162.58 186.97 183.23# 31615 124.60 118.37 136.13 133.40 31620 259.68 246.70 283.71 278.04# 31620 66.63 63.30 72.80 71.33 31622 287.42 273.05 314.01 307.73# 31622 143.72 136.53 157.01 153.87 31623 304.09 288.89 332.22 325.58# 31623 144.46 137.24 157.83 154.68 31624 286.91 272.56 313.44 307.18# 31624 145.40 138.13 158.85 155.68 31625 309.55 294.07 338.18 331.42# 31625 168.04 159.64 183.59 179.92 31626 410.36 389.84 448.32 439.35# 31626 203.88 193.69 222.74 218.29 31627 1,150.76 1,093.22 1,257.20 1,232.06# 31627 93.99 89.29 102.68 100.63 31628 348.77 331.33 381.03 373.41# 31628 187.28 177.92 204.61 200.51 31629 540.51 513.48 590.50 578.69# 31629 201.58 191.50 220.23 215.82 31630 197.00 187.15 215.22 210.92 31631 225.41 214.14 246.26 241.34 31632 67.58 64.20 73.83 72.36# 31632 48.52 46.09 53.00 51.95 31633 83.80 79.61 91.55 89.72# 31633 62.55 59.42 68.33 66.96 31634 1,662.18 1,579.07 1,815.93 1,779.61# 31634 197.77 187.88 216.06 211.74 31635 322.59 306.46 352.43 345.38# 31635 185.15 175.89 202.27 198.23 31636 218.05 207.15 238.22 233.46 31637 73.39 69.72 80.18 78.58 31638 250.11 237.60 273.24 267.78 31640 250.68 238.15 273.87 268.40 31641 254.08 241.38 277.59 272.03 31643 173.71 165.02 189.77 185.98 31645 295.27 280.51 322.59 316.14# 31645 159.07 151.12 173.79 170.32 31646 264.93 251.68 289.43 283.65# 31646 137.79 130.90 150.54 147.52 31647 216.91 206.06 236.97 232.23

31648 207.60 197.22 226.80 222.27 31649 67.79 64.40 74.06 72.58 31651 78.39 74.47 85.64 83.93 31660 207.55 197.17 226.75 222.21 31661 218.87 207.93 239.12 234.34 31717 240.98 228.93 263.27 258.00# 31717 106.97 101.62 116.86 114.53 31720 50.50 47.98 55.18 54.07 31725 90.79 86.25 99.19 97.21 31730 1,081.75 1,027.66 1,181.81 1,158.18# 31730 143.07 135.92 156.31 153.18 31750 1,284.65 1,220.42 1,403.48 1,375.41 31755 1,608.20 1,527.79 1,756.96 1,721.81 31760 1,326.90 1,260.56 1,449.64 1,420.65 31766 1,726.91 1,640.56 1,886.64 1,848.91 31770 1,292.74 1,228.10 1,412.32 1,384.07 31775 1,321.35 1,255.28 1,443.57 1,414.70 31780 1,140.64 1,083.61 1,246.15 1,221.23 31781 1,478.56 1,404.63 1,615.32 1,583.02 31785 1,048.10 995.70 1,145.06 1,122.16 31786 1,399.78 1,329.79 1,529.26 1,498.67 31800 669.68 636.20 731.63 717.00 31805 786.58 747.25 859.34 842.16 31820 408.25 387.84 446.02 437.09# 31820 314.54 298.81 343.63 336.75 31825 569.18 540.72 621.83 609.40# 31825 461.10 438.05 503.76 493.68 31830 414.26 393.55 452.58 443.53# 31830 325.24 308.98 355.33 348.22 32035 688.19 653.78 751.85 736.81 32036 747.64 710.26 816.80 800.46 32096 780.69 741.66 852.91 835.85 32097 781.01 741.96 853.25 836.19 32098 736.94 700.09 805.10 789.00 32100 788.08 748.68 860.98 843.77 32110 1,410.80 1,340.26 1,541.30 1,510.47 32120 841.76 799.67 919.62 901.23 32124 897.25 852.39 980.25 960.64 32140 959.22 911.26 1,047.95 1,026.98 32141 1,487.59 1,413.21 1,625.19 1,592.69 32150 971.06 922.51 1,060.89 1,039.67 32151 968.66 920.23 1,058.26 1,037.10 32160 760.37 722.35 830.70 814.09 32200 1,094.91 1,040.16 1,196.18 1,172.26 32215 771.80 733.21 843.19 826.33 32220 1,534.24 1,457.53 1,676.16 1,642.64 32225 962.34 914.22 1,051.35 1,030.33 32310 886.96 842.61 969.00 949.62 32320 1,546.88 1,469.54 1,689.97 1,656.17 32400 141.48 134.41 154.57 151.48# 32400 86.50 82.18 94.51 92.62 32405 402.47 382.35 439.70 430.91

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 39

# 32405 101.97 96.87 111.40 109.17 32440 1,519.74 1,443.75 1,660.31 1,627.11 32442 3,120.93 2,964.88 3,409.61 3,341.42 32445 3,440.34 3,268.32 3,758.57 3,683.39 32480 1,435.62 1,363.84 1,568.42 1,537.04 32482 1,536.82 1,459.98 1,678.98 1,645.40 32484 1,394.15 1,324.44 1,523.11 1,492.64 32486 2,287.96 2,173.56 2,499.59 2,449.60 32488 2,335.43 2,218.66 2,551.46 2,500.43 32491 1,425.47 1,354.20 1,557.33 1,526.19 32501 239.91 227.91 262.10 256.85 32503 1,762.21 1,674.10 1,925.22 1,886.71 32504 2,011.31 1,910.74 2,197.35 2,153.41 32505 901.02 855.97 984.37 964.68 32506 154.12 146.41 168.37 165.00 32507 154.12 146.41 168.37 165.00 32540 1,685.01 1,600.76 1,840.87 1,804.05 32550 709.96 674.46 775.63 760.12# 32550 219.22 208.26 239.50 234.70 32551 172.88 164.24 188.88 185.10 32552 180.78 171.74 197.50 193.56# 32552 159.23 151.27 173.96 170.48 32553 535.20 508.44 584.71 573.01# 32553 205.65 195.37 224.68 220.18 32554 183.03 173.88 199.96 195.96# 32554 89.00 84.55 97.23 95.29 32555 271.09 257.54 296.17 290.25# 32555 111.78 106.19 122.12 119.68 32556 483.24 459.08 527.94 517.39# 32556 122.76 116.62 134.11 131.43 32557 515.85 490.06 563.57 552.30# 32557 161.62 153.54 176.57 173.04 32560 222.62 211.49 243.21 238.35# 32560 77.37 73.50 84.53 82.83 32561 90.22 85.71 98.57 96.60# 32561 69.92 66.42 76.38 74.85 32562 81.13 77.07 88.63 86.86# 32562 62.39 59.27 68.16 66.79 32601 300.51 285.48 328.30 321.74 32604 468.82 445.38 512.19 501.94 32606 450.25 427.74 491.90 482.07 32607 300.82 285.78 328.65 322.07 32608 369.60 351.12 403.79 395.72 32609 254.37 241.65 277.90 272.34 32650 642.04 609.94 701.43 687.40 32651 1,059.07 1,006.12 1,157.04 1,133.90 32652 1,611.02 1,530.47 1,760.04 1,724.84 32653 1,024.10 972.90 1,118.84 1,096.46 32654 1,138.67 1,081.74 1,244.00 1,219.13 32655 924.25 878.04 1,009.75 989.55 32656 771.03 732.48 842.35 825.50 32658 688.89 654.45 752.62 737.56

32659 705.39 670.12 770.64 755.23 32661 771.59 733.01 842.96 826.10 32662 864.46 821.24 944.43 925.54 32663 1,360.08 1,292.08 1,485.89 1,456.18 32664 820.46 779.44 896.36 878.43 32665 1,184.71 1,125.47 1,294.29 1,268.40 32666 841.36 799.29 919.18 900.80 32667 154.44 146.72 168.73 165.36 32668 154.37 146.65 168.65 165.28 32669 1,306.20 1,240.89 1,427.02 1,398.48 32670 1,554.05 1,476.35 1,697.80 1,663.84 32671 1,731.97 1,645.37 1,892.18 1,854.33 32672 1,483.47 1,409.30 1,620.70 1,588.28 32673 1,172.57 1,113.94 1,281.03 1,255.41 32674 211.21 200.65 230.75 226.14 32701 215.58 204.80 235.52 230.81 32800 911.49 865.92 995.81 975.89 32810 871.12 827.56 951.69 932.66 32815 2,734.68 2,597.95 2,987.64 2,927.89 32820 1,287.51 1,223.13 1,406.60 1,378.47 32851 3,207.28 3,046.92 3,503.96 3,433.88 32852 3,501.25 3,326.19 3,825.12 3,748.62 32853 4,479.48 4,255.51 4,893.84 4,795.96 32854 4,768.15 4,529.74 5,209.20 5,105.02 32855 201.04 190.99 219.64 215.25 32856 301.55 286.47 329.44 322.85 32900 1,359.96 1,291.96 1,485.75 1,456.04 32905 1,296.49 1,231.67 1,416.42 1,388.10 32906 1,604.75 1,524.51 1,753.19 1,718.12 32940 1,197.46 1,137.59 1,308.23 1,282.07 32960 140.73 133.69 153.74 150.67# 32960 100.12 95.11 109.38 107.19 32997 349.40 331.93 381.72 374.08 32998 2,632.69 2,501.06 2,876.22 2,818.70# 32998 283.63 269.45 309.87 303.67 33010 115.91 110.11 126.63 124.10 33011 117.33 111.46 128.18 125.61 33015 490.45 465.93 535.82 525.10 33020 849.87 807.38 928.49 909.91 33025 775.99 737.19 847.77 830.82 33030 1,953.13 1,855.47 2,133.79 2,091.11 33031 2,424.07 2,302.87 2,648.30 2,595.33 33050 968.80 920.36 1,058.41 1,037.24 33120 2,055.90 1,953.11 2,246.08 2,201.16 33130 1,352.22 1,284.61 1,477.30 1,447.76 33140 1,540.61 1,463.58 1,683.12 1,649.46 33141 130.19 123.68 142.23 139.39 33202 750.89 713.35 820.35 803.94 33203 781.80 742.71 854.12 837.04 33206 439.84 417.85 480.53 470.91 33207 469.55 446.07 512.98 502.72 33208 508.56 483.13 555.60 544.49

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 40

33210 173.62 164.94 189.68 185.89 33211 178.26 169.35 194.75 190.85 33212 317.64 301.76 347.02 340.08 33213 332.06 315.46 362.78 355.52 33214 468.18 444.77 511.49 501.25 33215 294.46 279.74 321.70 315.27 33216 362.81 344.67 396.37 388.45 33217 357.67 339.79 390.76 382.94 33218 378.89 359.95 413.94 405.66 33220 381.72 362.63 417.02 408.69 33221 352.77 335.13 385.40 377.69 33222 330.68 314.15 361.27 354.05 33223 399.97 379.97 436.97 428.23 33224 494.28 469.57 540.01 529.21 33225 448.80 426.36 490.31 480.50 33226 474.45 450.73 518.34 507.98 33227 334.39 317.67 365.32 358.02 33228 348.57 331.14 380.81 373.20 33229 365.84 347.55 399.68 391.69 33230 380.35 361.33 415.53 407.22 33231 392.62 372.99 428.94 420.36 33233 228.00 216.60 249.09 244.11 33234 472.14 448.53 515.81 505.49 33235 615.32 584.55 672.23 658.79 33236 760.23 722.22 830.55 813.95 33237 811.34 770.77 886.39 868.65 33238 908.19 862.78 992.20 972.35 33240 361.51 343.43 394.94 387.04 33241 215.12 204.36 235.01 230.31 33243 1,328.24 1,261.83 1,451.10 1,422.08 33244 828.45 787.03 905.08 886.98 33249 883.10 838.95 964.79 945.50 33250 1,433.72 1,362.03 1,566.33 1,535.01 33251 1,588.81 1,509.37 1,735.78 1,701.06 33254 1,330.23 1,263.72 1,453.28 1,424.22 33255 1,618.85 1,537.91 1,768.60 1,733.22 33256 1,914.93 1,819.18 2,092.06 2,050.22 33257 565.87 537.58 618.22 605.85 33258 636.67 604.84 695.57 681.65 33259 822.70 781.57 898.81 880.83 33261 1,606.81 1,526.47 1,755.44 1,720.33 33262 366.56 348.23 400.46 392.46 33263 381.33 362.26 416.60 408.26 33264 397.35 377.48 434.10 425.42 33265 1,329.26 1,262.80 1,452.22 1,423.17 33266 1,807.48 1,717.11 1,974.68 1,935.19 33282 225.55 214.27 246.41 241.48 33284 198.69 188.76 217.07 212.73 33300 2,393.63 2,273.95 2,615.04 2,562.74 33305 4,023.42 3,822.25 4,395.59 4,307.68 33310 1,132.78 1,076.14 1,237.56 1,212.81 33315 1,878.44 1,784.52 2,052.20 2,011.15

33320 1,037.07 985.22 1,133.00 1,110.35 33321 1,164.88 1,106.64 1,272.64 1,247.19 33322 1,354.90 1,287.16 1,480.23 1,450.63 33330 1,402.95 1,332.80 1,532.72 1,502.06 33332 1,270.04 1,206.54 1,387.52 1,359.77 33335 1,840.79 1,748.75 2,011.06 1,970.85 33361 1,320.30 1,254.29 1,442.43 1,413.58 33362 1,444.11 1,371.90 1,577.69 1,546.13 33363 1,494.72 1,419.98 1,632.98 1,600.32 33364 1,572.60 1,493.97 1,718.07 1,683.70 33365 1,732.74 1,646.10 1,893.02 1,855.16 33366 1,875.31 1,781.54 2,048.77 2,007.80 33367 606.26 575.95 662.34 649.09 33368 734.75 698.01 802.71 786.66 33369 969.62 921.14 1,059.31 1,038.13 33400 2,238.43 2,126.51 2,445.49 2,396.58 33401 1,385.59 1,316.31 1,513.76 1,483.48 33403 1,448.84 1,376.40 1,582.86 1,551.20 33404 1,711.37 1,625.80 1,869.67 1,832.27 33405 2,226.88 2,115.54 2,432.87 2,384.21 33406 2,822.95 2,681.80 3,084.07 3,022.38 33410 2,491.64 2,367.06 2,722.12 2,667.68 33411 3,297.31 3,132.44 3,602.31 3,530.26 33412 3,124.49 2,968.27 3,413.51 3,345.24 33413 3,168.14 3,009.73 3,461.19 3,391.97 33414 2,108.27 2,002.86 2,303.29 2,257.22 33415 1,989.04 1,889.59 2,173.03 2,129.57 33416 1,991.05 1,891.50 2,175.23 2,131.72 33417 1,623.07 1,541.92 1,773.21 1,737.74 33420 1,432.39 1,360.77 1,564.89 1,533.58 33422 1,647.66 1,565.28 1,800.07 1,764.07 33425 2,681.57 2,547.49 2,929.61 2,871.02 33426 2,336.99 2,220.14 2,553.16 2,502.10 33427 2,400.66 2,280.63 2,622.72 2,570.27 33430 2,745.43 2,608.16 2,999.38 2,939.40 33460 2,391.27 2,271.71 2,612.47 2,560.22 33463 3,034.61 2,882.88 3,315.31 3,249.00 33464 2,401.09 2,281.04 2,623.20 2,570.73 33465 2,706.87 2,571.53 2,957.26 2,898.12 33468 2,405.28 2,285.02 2,627.77 2,575.22 33470 1,250.41 1,187.89 1,366.07 1,338.75 33471 1,346.37 1,279.05 1,470.91 1,441.49 33472 1,333.88 1,267.19 1,457.27 1,428.13 33474 2,126.37 2,020.05 2,323.06 2,276.60 33475 2,297.65 2,182.77 2,510.19 2,459.98 33476 1,492.42 1,417.80 1,630.47 1,597.86 33478 1,534.76 1,458.02 1,676.72 1,643.19 33496 1,629.33 1,547.86 1,780.04 1,744.44 33500 1,546.27 1,468.96 1,689.30 1,655.52 33501 1,102.93 1,047.78 1,204.95 1,180.84 33502 1,243.90 1,181.71 1,358.97 1,331.79 33503 1,278.70 1,214.77 1,396.99 1,369.04

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 41

33504 1,436.42 1,364.60 1,569.29 1,537.91 33505 2,035.59 1,933.81 2,223.88 2,179.40 33506 2,009.29 1,908.83 2,195.15 2,151.25 33507 1,676.18 1,592.37 1,831.23 1,794.60 33508 15.86 15.07 17.33 16.99 33510 1,896.77 1,801.93 2,072.22 2,030.77 33511 2,082.90 1,978.76 2,275.57 2,230.06 33512 2,369.24 2,250.78 2,588.40 2,536.62 33513 2,438.11 2,316.20 2,663.63 2,610.36 33514 2,573.25 2,444.59 2,811.28 2,755.06 33516 2,674.49 2,540.77 2,921.89 2,863.44 33517 184.86 175.62 201.96 197.93 33518 406.66 386.33 444.28 435.39 33519 537.56 510.68 587.28 575.54 33521 645.68 613.40 705.41 691.30 33522 724.62 688.39 791.65 775.81 33523 822.00 780.90 898.04 880.07 33530 518.77 492.83 566.75 555.42 33533 1,833.04 1,741.39 2,002.60 1,962.54 33534 2,155.84 2,048.05 2,355.26 2,308.15 33535 2,404.46 2,284.24 2,626.88 2,574.34 33536 2,583.07 2,453.92 2,822.01 2,765.57 33542 2,578.52 2,449.59 2,817.03 2,760.69 33545 3,035.53 2,883.75 3,316.31 3,249.99 33548 2,917.20 2,771.34 3,187.04 3,123.30 33572 227.91 216.51 248.99 244.01 33600 1,664.91 1,581.66 1,818.91 1,782.53 33602 1,607.63 1,527.25 1,756.34 1,721.22 33606 1,714.80 1,629.06 1,873.42 1,835.95 33608 1,744.87 1,657.63 1,906.27 1,868.15 33610 1,720.84 1,634.80 1,880.02 1,842.42 33611 1,913.45 1,817.78 2,090.45 2,048.63 33612 1,942.99 1,845.84 2,122.72 2,080.26 33615 1,967.17 1,868.81 2,149.13 2,106.14 33617 2,101.77 1,996.68 2,296.18 2,250.26 33619 2,774.21 2,635.50 3,030.83 2,970.21 33620 1,443.73 1,371.54 1,577.27 1,545.73 33621 858.73 815.79 938.16 919.39 33622 3,380.02 3,211.02 3,692.67 3,618.82 33641 1,603.00 1,522.85 1,751.28 1,716.25 33645 1,695.07 1,610.32 1,851.87 1,814.83 33647 1,789.82 1,700.33 1,955.38 1,916.27 33660 1,721.41 1,635.34 1,880.64 1,843.02 33665 1,886.00 1,791.70 2,060.46 2,019.25 33670 1,947.38 1,850.01 2,127.51 2,084.96 33675 1,933.65 1,836.97 2,112.52 2,070.26 33676 2,090.66 1,986.13 2,284.05 2,238.37 33677 2,172.46 2,063.84 2,373.42 2,325.94 33681 1,792.68 1,703.05 1,958.51 1,919.34 33684 1,851.49 1,758.92 2,022.76 1,982.30 33688 1,850.07 1,757.57 2,021.21 1,980.78 33690 1,158.51 1,100.58 1,265.67 1,240.36

33692 2,025.99 1,924.69 2,213.39 2,169.13 33694 1,922.51 1,826.38 2,100.34 2,058.33 33697 2,023.09 1,921.94 2,210.23 2,166.03 33702 1,509.92 1,434.42 1,649.58 1,616.59 33710 2,065.13 1,961.87 2,256.15 2,211.02 33720 1,507.08 1,431.73 1,646.49 1,613.57 33722 1,598.56 1,518.63 1,746.42 1,711.50 33724 1,502.28 1,427.17 1,641.25 1,608.42 33726 2,031.75 1,930.16 2,219.68 2,175.29 33730 1,963.05 1,864.90 2,144.64 2,101.74 33732 1,692.24 1,607.63 1,848.77 1,811.80 33735 1,262.61 1,199.48 1,379.40 1,351.81 33736 1,370.33 1,301.81 1,497.08 1,467.14 33737 1,310.16 1,244.65 1,431.35 1,402.72 33750 1,296.49 1,231.67 1,416.42 1,388.10 33755 1,316.57 1,250.74 1,438.35 1,409.59 33762 1,311.09 1,245.54 1,432.37 1,403.72 33764 1,267.56 1,204.18 1,384.81 1,357.12 33766 1,341.90 1,274.81 1,466.03 1,436.71 33767 1,397.37 1,327.50 1,526.63 1,496.09 33768 435.16 413.40 475.41 465.90 33770 2,173.21 2,064.55 2,374.23 2,326.75 33771 2,263.31 2,150.14 2,472.66 2,423.21 33774 1,766.03 1,677.73 1,929.39 1,890.81 33775 1,898.66 1,803.73 2,074.29 2,032.81 33776 1,915.91 1,820.11 2,093.13 2,051.27 33777 1,945.81 1,848.52 2,125.80 2,083.28 33778 2,423.99 2,302.79 2,648.21 2,595.24 33779 2,169.58 2,061.10 2,370.27 2,322.86 33780 2,330.54 2,214.01 2,546.11 2,495.19 33781 2,404.71 2,284.47 2,627.14 2,574.60 33782 3,226.72 3,065.38 3,525.19 3,454.68 33783 3,590.92 3,411.37 3,923.08 3,844.61 33786 2,247.11 2,134.75 2,454.96 2,405.87 33788 1,506.79 1,431.45 1,646.17 1,613.24 33800 897.87 852.98 980.93 961.31 33802 1,060.26 1,007.25 1,158.34 1,135.18 33803 1,175.31 1,116.54 1,284.02 1,258.34 33813 1,205.68 1,145.40 1,317.21 1,290.86 33814 1,486.17 1,411.86 1,623.64 1,591.16 33820 949.63 902.15 1,037.47 1,016.73 33822 1,002.44 952.32 1,095.17 1,073.26 33824 1,140.49 1,083.47 1,245.99 1,221.07 33840 1,257.88 1,194.99 1,374.24 1,346.75 33845 1,299.17 1,234.21 1,419.34 1,390.96 33851 1,292.22 1,227.61 1,411.75 1,383.52 33852 1,371.57 1,302.99 1,498.44 1,468.47 33853 1,800.15 1,710.14 1,966.66 1,927.33 33860 3,155.81 2,998.02 3,447.72 3,378.77 33863 3,096.48 2,941.66 3,382.91 3,315.25 33864 3,158.75 3,000.81 3,450.93 3,381.91 33870 2,471.78 2,348.19 2,700.42 2,646.41

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 42

33875 2,703.06 2,567.91 2,953.10 2,894.03 33877 3,591.85 3,412.26 3,924.10 3,845.61 33880 1,786.05 1,696.75 1,951.26 1,912.24 33881 1,535.72 1,458.93 1,677.77 1,644.21 33883 1,111.15 1,055.59 1,213.93 1,189.65 33884 409.39 388.92 447.26 438.31 33886 964.41 916.19 1,053.62 1,032.55 33889 795.34 755.57 868.91 851.53 33891 975.10 926.35 1,065.30 1,043.99 33910 2,599.99 2,469.99 2,840.49 2,783.68 33915 1,254.75 1,192.01 1,370.81 1,343.40 33916 4,133.18 3,926.52 4,515.50 4,425.19 33917 1,410.30 1,339.79 1,540.76 1,509.94 33920 1,780.44 1,691.42 1,945.13 1,906.23 33922 1,362.06 1,293.96 1,488.05 1,458.29 33924 279.22 265.26 305.05 298.94 33925 1,670.82 1,587.28 1,825.37 1,788.86 33926 2,373.29 2,254.63 2,592.82 2,540.97 33933 201.04 190.99 219.64 215.25 33935 4,907.61 4,662.23 5,361.56 5,254.34 33944 201.04 190.99 219.64 215.25 33945 4,760.40 4,522.38 5,200.74 5,096.72 33960 982.02 932.92 1,072.86 1,051.40 33961 550.49 522.97 601.42 589.39 33967 252.86 240.22 276.25 270.73 33968 33.09 31.44 36.16 35.43 33970 348.32 330.90 380.54 372.92 33971 690.00 655.50 753.83 738.75 33973 505.06 479.81 551.78 540.74 33974 866.23 822.92 946.36 927.43 33975 1,304.80 1,239.56 1,425.49 1,396.99 33976 1,589.01 1,509.56 1,735.99 1,701.28 33977 1,107.97 1,052.57 1,210.46 1,186.25 33978 1,321.24 1,255.18 1,443.46 1,414.59 33979 1,924.83 1,828.59 2,102.88 2,060.82 33980 1,755.82 1,668.03 1,918.23 1,879.87 33981 826.64 785.31 903.11 885.04 33982 1,932.76 1,836.12 2,111.54 2,069.31 33983 2,277.26 2,163.40 2,487.91 2,438.15 33990 427.04 405.69 466.54 457.22 33991 622.55 591.42 680.13 666.53 33992 202.47 192.35 221.20 216.78 33993 177.77 168.88 194.21 190.33 34001 952.35 904.73 1,040.44 1,019.64 34051 970.48 921.96 1,060.25 1,039.05 34101 596.02 566.22 651.15 638.14 34111 595.78 565.99 650.89 637.87 34151 1,395.73 1,325.94 1,524.83 1,494.33 34201 1,027.66 976.28 1,122.72 1,100.26 34203 952.74 905.10 1,040.87 1,020.05 34401 1,438.64 1,366.71 1,571.72 1,540.29 34421 721.69 685.61 788.45 772.69

34451 1,445.61 1,373.33 1,579.33 1,547.74 34471 1,070.37 1,016.85 1,169.38 1,145.99 34490 599.51 569.53 654.96 641.86 34501 972.20 923.59 1,062.13 1,040.89 34502 1,499.95 1,424.95 1,638.69 1,605.92 34510 1,144.46 1,087.24 1,250.33 1,225.33 34520 992.93 943.28 1,084.77 1,063.07 34530 1,060.88 1,007.84 1,159.02 1,135.83 34800 1,120.51 1,064.48 1,224.15 1,199.67 34802 1,237.78 1,175.89 1,352.27 1,325.23 34803 1,281.64 1,217.56 1,400.19 1,372.19 34804 1,236.35 1,174.53 1,350.71 1,323.70 34805 1,186.90 1,127.56 1,296.69 1,270.76 34806 99.46 94.49 108.66 106.49 34808 205.17 194.91 224.15 219.66 34812 336.83 319.99 367.99 360.63 34813 237.25 225.39 259.20 254.01 34820 489.37 464.90 534.64 523.94 34825 690.76 656.22 754.65 739.57 34826 204.62 194.39 223.55 219.08 34830 1,775.02 1,686.27 1,939.21 1,900.42 34831 1,909.40 1,813.93 2,086.02 2,044.30 34832 1,909.40 1,813.93 2,086.02 2,044.30 34833 609.08 578.63 665.42 652.12 34834 273.02 259.37 298.28 292.31 34841 1,120.51 1,064.48 1,224.15 1,199.67 34842 1,362.53 1,294.40 1,488.56 1,458.79 34843 1,328.47 1,262.05 1,451.36 1,422.33 34844 1,375.30 1,306.54 1,502.52 1,472.47 34845 1,120.51 1,064.48 1,224.15 1,199.67 34846 1,362.53 1,294.40 1,488.56 1,458.79 34847 1,328.47 1,262.05 1,451.36 1,422.33 34848 1,375.30 1,306.54 1,502.52 1,472.47 34900 885.55 841.27 967.46 948.11 35001 1,115.70 1,059.92 1,218.91 1,194.53 35002 1,127.14 1,070.78 1,231.40 1,206.76 35005 1,127.69 1,071.31 1,232.01 1,207.36 35011 991.89 942.30 1,083.65 1,061.97 35013 1,243.33 1,181.16 1,358.33 1,331.17 35021 1,227.19 1,165.83 1,340.70 1,313.89 35022 1,413.97 1,343.27 1,544.76 1,513.86 35045 986.27 936.96 1,077.50 1,055.95 35081 1,746.39 1,659.07 1,907.93 1,869.77 35082 2,186.00 2,076.70 2,388.21 2,340.45 35091 1,796.44 1,706.62 1,962.61 1,923.36 35092 2,611.89 2,481.30 2,853.50 2,796.42 35102 1,893.43 1,798.76 2,068.57 2,027.20 35103 2,248.46 2,136.04 2,456.45 2,407.32 35111 1,480.20 1,406.19 1,617.12 1,584.78 35112 1,816.61 1,725.78 1,984.65 1,944.95 35121 1,632.09 1,550.49 1,783.06 1,747.40 35122 2,097.38 1,992.51 2,291.39 2,245.56

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 43

35131 1,383.20 1,314.04 1,511.15 1,480.92 35132 1,637.80 1,555.91 1,789.30 1,753.51 35141 1,102.69 1,047.56 1,204.69 1,180.60 35142 1,322.02 1,255.92 1,444.31 1,415.42 35151 1,241.19 1,179.13 1,356.00 1,328.88 35152 1,406.14 1,335.83 1,536.20 1,505.48 35180 892.52 847.89 975.07 955.57 35182 1,714.58 1,628.85 1,873.18 1,835.71 35184 1,021.53 970.45 1,116.02 1,093.70 35188 1,156.37 1,098.55 1,263.33 1,238.07 35189 1,529.54 1,453.06 1,671.02 1,637.60 35190 746.91 709.56 815.99 799.68 35201 933.71 887.02 1,020.07 999.67 35206 764.14 725.93 834.82 818.12 35207 716.52 680.69 782.79 767.14 35211 1,357.05 1,289.20 1,482.58 1,452.93 35216 2,015.31 1,914.54 2,201.72 2,157.69 35221 1,423.82 1,352.63 1,555.52 1,524.42 35226 827.39 786.02 903.92 885.85 35231 1,192.30 1,132.69 1,302.59 1,276.55 35236 971.36 922.79 1,061.21 1,039.98 35241 1,405.95 1,335.65 1,536.00 1,505.28 35246 1,533.56 1,456.88 1,675.41 1,641.90 35251 1,665.34 1,582.07 1,819.38 1,782.99 35256 1,015.19 964.43 1,109.09 1,086.91 35261 1,047.52 995.14 1,144.41 1,121.53 35266 861.37 818.30 941.05 922.22 35271 1,354.72 1,286.98 1,480.03 1,450.43 35276 1,421.68 1,350.60 1,553.19 1,522.13 35281 1,609.76 1,529.27 1,758.66 1,723.48 35286 931.73 885.14 1,017.91 997.56 35301 1,127.26 1,070.90 1,231.54 1,206.90 35302 1,125.94 1,069.64 1,230.09 1,205.49 35303 1,243.28 1,181.12 1,358.29 1,331.13 35304 1,286.80 1,222.46 1,405.83 1,377.71 35305 1,235.47 1,173.70 1,349.76 1,322.76 35306 463.03 439.88 505.86 495.74 35311 1,437.79 1,365.90 1,570.79 1,539.37 35321 880.88 836.84 962.37 943.12 35331 1,448.38 1,375.96 1,582.35 1,550.71 35341 1,374.93 1,306.18 1,502.11 1,472.07 35351 1,281.54 1,217.46 1,400.08 1,372.08 35355 1,037.87 985.98 1,133.88 1,111.20 35361 1,532.38 1,455.76 1,674.12 1,640.64 35363 1,731.02 1,644.47 1,891.14 1,853.32 35371 818.07 777.17 893.75 875.87 35372 979.29 930.33 1,069.88 1,048.48 35390 159.30 151.34 174.04 170.56 35400 148.92 141.47 162.69 159.44 35450 510.85 485.31 558.11 546.94 35452 341.84 324.75 373.46 366.00 35458 488.59 464.16 533.78 523.11

35460 309.67 294.19 338.32 331.56 35471 2,276.95 2,163.10 2,487.57 2,437.82# 35471 517.35 491.48 565.20 553.90 35472 1,657.08 1,574.23 1,810.36 1,774.16# 35472 353.23 335.57 385.91 378.19 35475 1,430.84 1,359.30 1,563.20 1,531.93# 35475 336.59 319.76 367.72 360.36 35476 1,302.08 1,236.98 1,422.53 1,394.08# 35476 267.50 254.13 292.25 286.41 35500 320.33 304.31 349.96 342.95 35501 1,495.95 1,421.15 1,634.32 1,601.64 35506 1,283.89 1,219.70 1,402.66 1,374.61 35508 1,345.66 1,278.38 1,470.14 1,440.73 35509 1,424.31 1,353.09 1,556.05 1,524.93 35510 1,238.53 1,176.60 1,353.09 1,326.03 35511 1,261.72 1,198.63 1,378.42 1,350.86 35512 1,214.72 1,153.98 1,327.08 1,300.54 35515 1,336.79 1,269.95 1,460.44 1,431.23 35516 1,228.78 1,167.34 1,342.44 1,315.59 35518 1,150.35 1,092.83 1,256.75 1,231.62 35521 1,234.07 1,172.37 1,348.23 1,321.26 35522 1,212.30 1,151.69 1,324.44 1,297.96 35523 1,280.21 1,216.20 1,398.63 1,370.66 35525 1,136.25 1,079.44 1,241.36 1,216.53 35526 1,709.71 1,624.22 1,867.85 1,830.50 35531 2,021.80 1,920.71 2,208.82 2,164.65 35533 1,516.54 1,440.71 1,656.82 1,623.69 35535 1,749.49 1,662.02 1,911.32 1,873.10 35536 1,702.42 1,617.30 1,859.90 1,822.69 35537 2,101.62 1,996.54 2,296.02 2,250.10 35538 2,353.57 2,235.89 2,571.27 2,519.85 35539 2,210.64 2,100.11 2,415.13 2,366.83 35540 2,455.01 2,332.26 2,682.10 2,628.45 35556 1,404.03 1,333.83 1,533.90 1,503.22 35558 1,234.53 1,172.80 1,348.72 1,321.74 35560 1,716.70 1,630.87 1,875.50 1,837.99 35563 1,330.99 1,264.44 1,454.11 1,425.02 35565 1,317.03 1,251.18 1,438.86 1,410.08 35566 1,677.23 1,593.37 1,832.38 1,795.73 35570 1,395.27 1,325.51 1,524.34 1,493.85 35571 1,333.01 1,266.36 1,456.31 1,427.18 35572 344.82 327.58 376.72 369.18 35583 1,449.11 1,376.65 1,583.15 1,551.49 35585 1,681.29 1,597.23 1,836.81 1,800.08 35587 1,371.26 1,302.70 1,498.11 1,468.15 35600 254.14 241.43 277.64 272.09 35601 1,405.23 1,334.97 1,535.22 1,504.51 35606 1,175.86 1,117.07 1,284.63 1,258.94 35612 1,049.79 997.30 1,146.90 1,123.95 35616 1,095.59 1,040.81 1,196.93 1,172.99 35621 1,100.60 1,045.57 1,202.41 1,178.36 35623 1,320.88 1,254.84 1,443.07 1,414.20

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 44

35626 1,567.08 1,488.73 1,712.04 1,677.80 35631 1,855.95 1,763.15 2,027.62 1,987.07 35632 1,661.12 1,578.06 1,814.77 1,778.48 35633 1,849.63 1,757.15 2,020.72 1,980.31 35634 1,625.21 1,543.95 1,775.54 1,740.03 35636 1,605.61 1,525.33 1,754.13 1,719.04 35637 1,732.39 1,645.77 1,892.64 1,854.78 35638 1,766.18 1,677.87 1,929.55 1,890.96 35642 990.17 940.66 1,081.76 1,060.13 35645 1,031.45 979.88 1,126.86 1,104.32 35646 1,719.79 1,633.80 1,878.87 1,841.29 35647 1,559.13 1,481.17 1,703.35 1,669.28 35650 1,074.09 1,020.39 1,173.45 1,149.98 35654 1,373.69 1,305.01 1,500.76 1,470.75 35656 1,084.85 1,030.61 1,185.20 1,161.50 35661 1,084.96 1,030.71 1,185.32 1,161.62 35663 1,257.46 1,194.59 1,373.78 1,346.31 35665 1,177.34 1,118.47 1,286.24 1,260.52 35666 1,270.07 1,206.57 1,387.56 1,359.81 35671 1,120.96 1,064.91 1,224.65 1,200.15 35681 80.14 76.13 87.55 85.80 35682 356.00 338.20 388.93 381.16 35683 413.32 392.65 451.55 442.52 35685 200.64 190.61 219.20 214.82 35686 161.79 153.70 176.76 173.22 35691 949.70 902.22 1,037.55 1,016.81 35693 836.44 794.62 913.81 895.54 35694 991.76 942.17 1,083.50 1,061.83 35695 1,030.00 978.50 1,125.28 1,102.77 35697 148.57 141.14 162.31 159.07 35700 153.55 145.87 167.75 164.39 35701 556.20 528.39 607.65 595.49 35721 446.28 423.97 487.57 477.81 35741 505.66 480.38 552.44 541.39 35761 379.29 360.33 414.38 406.09 35800 701.58 666.50 766.48 751.15 35820 1,975.35 1,876.58 2,158.07 2,114.91 35840 1,155.07 1,097.32 1,261.92 1,236.68 35860 835.11 793.35 912.35 894.10 35870 1,251.73 1,189.14 1,367.51 1,340.16 35875 589.82 560.33 644.38 631.49 35876 943.61 896.43 1,030.89 1,010.28 35879 925.10 878.85 1,010.68 990.46 35881 1,021.10 970.05 1,115.56 1,093.25 35883 1,210.26 1,149.75 1,322.21 1,295.77 35884 1,248.91 1,186.46 1,364.43 1,337.14 35901 468.08 444.68 511.38 501.16 35903 557.51 529.63 609.07 596.90 35905 1,691.67 1,607.09 1,848.15 1,811.19 35907 1,911.36 1,815.79 2,088.16 2,046.39 36002 152.91 145.26 167.05 163.70# 36002 105.43 100.16 115.18 112.88

36005 288.79 274.35 315.50 309.19# 36005 47.63 45.25 52.04 51.00 36010 455.43 432.66 497.56 487.61# 36010 119.94 113.94 131.03 128.41 36011 753.25 715.59 822.93 806.47# 36011 155.37 147.60 169.74 166.35 36012 780.91 741.86 853.14 836.07# 36012 174.90 166.16 191.08 187.27 36013 706.64 671.31 772.01 756.56# 36013 128.44 122.02 140.32 137.52 36014 732.44 695.82 800.19 784.19# 36014 147.98 140.58 161.67 158.44 36015 785.81 746.52 858.50 841.33# 36015 171.68 163.10 187.57 183.82 36100 461.11 438.05 503.76 493.68# 36100 156.23 148.42 170.68 167.27 36120 387.32 367.95 423.14 414.68# 36120 98.99 94.04 108.15 105.98 36140 396.51 376.68 433.18 424.52# 36140 101.32 96.25 110.69 108.48 36147 759.14 721.18 829.36 812.77# 36147 184.99 175.74 202.10 198.06 36148 235.67 223.89 257.47 252.32# 36148 48.56 46.13 53.05 51.99 36160 463.55 440.37 506.43 496.29# 36160 126.81 120.47 138.54 135.77 36200 565.37 537.10 617.67 605.31# 36200 150.54 143.01 164.46 161.17 36215 995.78 945.99 1,087.89 1,066.13# 36215 238.59 226.66 260.66 255.45 36216 1,123.10 1,066.95 1,226.99 1,202.45# 36216 272.19 258.58 297.37 291.42 36217 1,919.54 1,823.56 2,097.09 2,055.15# 36217 326.43 310.11 356.63 349.50 36218 181.85 172.76 198.67 194.70# 36218 51.90 49.31 56.71 55.57 36221 1,003.76 953.57 1,096.61 1,074.68# 36221 210.96 200.41 230.47 225.86 36222 1,271.24 1,207.68 1,388.83 1,361.06# 36222 286.64 272.31 313.16 306.89 36223 1,384.36 1,315.14 1,512.41 1,482.17# 36223 309.48 294.01 338.11 331.35 36224 1,521.46 1,445.39 1,662.20 1,628.95# 36224 338.49 321.57 369.81 362.41 36225 1,370.96 1,302.41 1,497.77 1,467.81# 36225 308.26 292.85 336.78 330.04 36226 1,551.44 1,473.87 1,694.95 1,661.05# 36226 339.43 322.46 370.83 363.41 36227 228.68 217.25 249.84 244.85# 36227 107.80 102.41 117.77 115.41 36228 1,054.64 1,001.91 1,152.20 1,129.15# 36228 219.03 208.08 239.29 234.51

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 45

36245 1,226.74 1,165.40 1,340.21 1,313.40# 36245 251.82 239.23 275.11 269.62 36246 811.49 770.92 886.56 868.83# 36246 265.14 251.88 289.66 283.87 36247 1,426.50 1,355.18 1,558.46 1,527.29# 36247 316.95 301.10 346.27 339.34 36248 140.61 133.58 153.62 150.55# 36248 50.65 48.12 55.34 54.23 36251 1,273.16 1,209.50 1,390.93 1,363.11# 36251 275.75 261.96 301.25 295.23 36252 1,389.03 1,319.58 1,517.52 1,487.17# 36252 361.00 342.95 394.39 386.50 36253 2,041.57 1,939.49 2,230.41 2,185.81# 36253 386.92 367.57 422.71 414.25 36254 1,960.57 1,862.54 2,141.92 2,099.08# 36254 419.62 398.64 458.44 449.27 36260 594.97 565.22 650.00 637.01 36261 345.29 328.03 377.23 369.69 36262 287.70 273.32 314.32 308.03 36400 28.43 27.01 31.06 30.44# 36400 20.00 19.00 21.85 21.41 36405 24.99 23.74 27.30 26.76# 36405 16.55 15.72 18.08 17.72 36406 17.59 16.71 19.22 18.84# 36406 9.15 8.69 9.99 9.80 36410 15.71 14.92 17.16 16.81# 36410 9.47 9.00 10.35 10.14 36420 47.98 45.58 52.42 51.37 36425 39.33 37.36 42.96 42.10 36430 29.64 28.16 32.38 31.74 36440 55.77 52.98 60.93 59.71 36450 106.68 101.35 116.55 114.22 36455 112.21 106.60 122.59 120.14 36460 354.40 336.68 387.18 379.44 36470 138.94 131.99 151.79 148.75# 36470 80.84 76.80 88.32 86.55 36471 161.69 153.61 176.65 173.12# 36471 97.97 93.07 107.03 104.89 36475 1,507.63 1,432.25 1,647.09 1,614.15# 36475 349.35 331.88 381.66 374.03 36476 350.44 332.92 382.86 375.20# 36476 171.76 163.17 187.65 183.90 36478 1,207.48 1,147.11 1,319.18 1,292.80# 36478 346.57 329.24 378.63 371.06 36479 358.50 340.58 391.67 383.84# 36479 171.07 162.52 186.90 183.16 36481 1,836.77 1,744.93 2,006.67 1,966.53# 36481 351.43 333.86 383.94 376.26 36500 177.68 168.80 194.12 190.23 36510 92.28 87.67 100.82 98.81# 36510 60.11 57.10 65.67 64.35 36511 92.66 88.03 101.23 99.21

36512 91.79 87.20 100.28 98.28 36513 96.16 91.35 105.05 102.95 36514 465.32 442.05 508.36 498.19# 36514 92.03 87.43 100.54 98.53 36515 1,827.38 1,736.01 1,996.41 1,956.48# 36515 85.89 81.60 93.84 91.97 36516 1,785.60 1,696.32 1,950.77 1,911.75# 36516 68.16 64.75 74.46 72.98 36522 1,191.66 1,132.08 1,301.89 1,275.86# 36522 98.34 93.42 107.43 105.28 36555 238.34 226.42 260.38 255.17# 36555 117.76 111.87 128.65 126.07 36556 217.51 206.63 237.62 232.88# 36556 120.05 114.05 131.16 128.54 36557 914.25 868.54 998.82 978.85# 36557 313.55 297.87 342.55 335.70 36558 714.49 678.77 780.59 764.97# 36558 272.17 258.56 297.34 291.40 36560 1,215.15 1,154.39 1,327.55 1,301.00# 36560 354.24 336.53 387.01 379.27 36561 1,068.90 1,015.46 1,167.78 1,144.42# 36561 345.76 328.47 377.74 370.19 36563 1,192.19 1,132.58 1,302.47 1,276.42# 36563 365.34 347.07 399.13 391.15 36565 896.46 851.64 979.39 959.80# 36565 340.13 323.12 371.59 364.16 36566 4,758.53 4,520.60 5,198.69 5,094.72# 36566 373.10 354.45 407.62 399.46 36568 272.16 258.55 297.33 291.39# 36568 96.92 92.07 105.88 103.76 36569 227.97 216.57 249.06 244.08# 36569 90.84 86.30 99.25 97.26 36570 1,071.57 1,017.99 1,170.69 1,147.27# 36570 302.19 287.08 330.14 323.54 36571 1,175.58 1,116.80 1,284.32 1,258.63# 36571 312.80 297.16 341.73 334.90 36575 150.16 142.65 164.05 160.77# 36575 34.90 33.16 38.13 37.38 36576 358.45 340.53 391.61 383.78# 36576 190.39 180.87 208.00 203.84 36578 478.94 454.99 523.24 512.77# 36578 209.99 199.49 229.41 224.83 36580 195.40 185.63 213.47 209.21# 36580 66.39 63.07 72.53 71.08 36581 695.15 660.39 759.45 744.26# 36581 192.85 183.21 210.69 206.48 36582 1,005.68 955.40 1,098.71 1,076.73# 36582 298.15 283.24 325.73 319.22 36583 1,221.51 1,160.43 1,334.49 1,307.80# 36583 322.18 306.07 351.98 344.94 36584 185.67 176.39 202.85 198.79# 36584 65.40 62.13 71.45 70.02

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 46

36585 1,043.60 991.42 1,140.13 1,117.33# 36585 274.53 260.80 299.92 293.92 36589 156.98 149.13 171.50 168.07# 36589 134.49 127.77 146.94 143.99 36590 275.34 261.57 300.81 294.79# 36590 198.81 188.87 217.20 212.85 36591 20.27 19.26 22.15 21.70 36592 22.77 21.63 24.87 24.38 36593 26.83 25.49 29.31 28.73 36595 530.89 504.35 580.00 568.40# 36595 182.60 173.47 199.49 195.50 36596 122.10 116.00 133.40 130.73# 36596 44.01 41.81 48.08 47.12 36597 117.30 111.44 128.16 125.59# 36597 60.45 57.43 66.04 64.72 36598 100.92 95.87 110.25 108.04# 36598 36.57 34.74 39.95 39.16 36600 28.85 27.41 31.52 30.89# 36600 15.42 14.65 16.85 16.51 36620 50.84 48.30 55.55 54.43 36625 104.17 98.96 113.80 111.53 36640 125.37 119.10 136.97 134.23 36660 66.80 63.46 72.98 71.52 36680 58.81 55.87 64.25 62.96 36800 123.13 116.97 134.52 131.82 36810 212.81 202.17 232.50 227.85 36815 143.19 136.03 156.43 153.31 36818 659.14 626.18 720.11 705.71 36819 724.73 688.49 791.76 775.93 36820 792.05 752.45 865.32 848.01 36821 680.56 646.53 743.51 728.64 36822 367.33 348.96 401.30 393.28 36823 1,299.01 1,234.06 1,419.17 1,390.79 36825 782.79 743.65 855.20 838.10 36830 647.39 615.02 707.27 693.13 36831 446.29 423.98 487.58 477.83 36832 570.52 541.99 623.29 610.82 36833 646.92 614.57 706.76 692.62 36835 483.91 459.71 528.67 518.10 36838 1,139.65 1,082.67 1,245.07 1,220.17 36860 196.08 186.28 214.22 209.93# 36860 111.11 105.55 121.38 118.96 36861 128.64 122.21 140.54 137.74 36870 1,649.03 1,566.58 1,801.57 1,765.54# 36870 294.58 279.85 321.83 315.39 37140 2,214.25 2,103.54 2,419.07 2,370.69 37145 2,057.72 1,954.83 2,248.05 2,203.09 37160 2,109.30 2,003.84 2,304.42 2,258.32 37180 2,028.86 1,927.42 2,216.53 2,172.20 37181 2,213.98 2,103.28 2,418.77 2,370.39 37182 835.50 793.73 912.79 894.54 37183 5,227.72 4,966.33 5,711.28 5,597.05

# 37183 393.10 373.45 429.47 420.88 37184 2,036.04 1,934.24 2,224.38 2,179.89# 37184 447.30 424.94 488.68 478.91 37185 655.25 622.49 715.86 701.55# 37185 164.82 156.58 180.07 176.47 37186 1,251.06 1,188.51 1,366.79 1,339.45# 37186 248.96 236.51 271.99 266.55 37187 1,866.36 1,773.04 2,039.00 1,998.22# 37187 401.32 381.25 438.44 429.67 37188 1,602.92 1,522.77 1,751.19 1,716.16# 37188 288.13 273.72 314.78 308.49 37191 2,358.97 2,241.02 2,577.17 2,525.63# 37191 237.01 225.16 258.93 253.76 37192 1,385.79 1,316.50 1,513.98 1,483.70# 37192 358.39 340.47 391.54 383.71 37193 1,458.58 1,385.65 1,593.50 1,561.63# 37193 365.58 347.30 399.40 391.40 37195 122.30 116.19 133.62 130.95 37197 1,370.75 1,302.21 1,497.54 1,467.60# 37197 303.05 287.90 331.09 324.46 37200 220.94 209.89 241.37 236.54 37202 295.98 281.18 323.36 316.89 37211 397.49 377.62 434.26 425.58 37212 350.91 333.36 383.36 375.69 37213 244.92 232.67 267.57 262.22 37214 143.71 136.52 157.00 153.86 37215 1,059.20 1,006.24 1,157.18 1,134.04 37217 1,094.10 1,039.40 1,195.31 1,171.40 37220 2,853.12 2,710.46 3,117.03 3,054.69# 37220 411.29 390.73 449.34 440.36 37221 4,181.59 3,972.51 4,568.39 4,477.02# 37221 502.13 477.02 548.57 537.60 37222 809.22 768.76 884.07 866.39# 37222 185.41 176.14 202.56 198.51 37223 2,317.32 2,201.45 2,531.67 2,481.03# 37223 212.23 201.62 231.86 227.23 37224 3,452.57 3,279.94 3,771.93 3,696.49# 37224 455.03 432.28 497.12 487.17 37225 9,803.90 9,313.71 10,710.77 10,496.56# 37225 612.90 582.26 669.60 656.20 37226 8,055.57 7,652.79 8,800.71 8,624.69# 37226 508.60 483.17 555.65 544.54 37227 13,192.53 12,532.90 14,412.84 14,124.58# 37227 738.46 701.54 806.77 790.64 37228 4,899.03 4,654.08 5,352.19 5,245.15# 37228 554.84 527.10 606.17 594.04 37229 9,664.63 9,181.40 10,558.61 10,347.44# 37229 716.65 680.82 782.94 767.28 37230 7,408.74 7,038.30 8,094.05 7,932.16# 37230 696.43 661.61 760.85 745.64 37231 11,799.21 11,209.25 12,890.64 12,632.83# 37231 762.39 724.27 832.91 816.25

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 47

37232 1,094.86 1,040.12 1,196.14 1,172.22# 37232 201.15 191.09 219.75 215.36 37233 1,321.25 1,255.19 1,443.47 1,414.60# 37233 328.52 312.09 358.90 351.73 37234 3,453.01 3,280.36 3,772.41 3,696.96# 37234 278.65 264.72 304.43 298.34 37235 3,533.54 3,356.86 3,860.39 3,783.18# 37235 403.55 383.37 440.88 432.06 37236 2,531.77 2,405.18 2,765.96 2,710.64# 37236 456.04 433.24 498.23 488.27 37237 1,100.93 1,045.88 1,202.76 1,178.70# 37237 213.16 202.50 232.88 228.22 37238 3,674.97 3,491.22 4,014.90 3,934.61# 37238 319.44 303.47 348.99 342.01 37239 1,825.93 1,734.63 1,994.82 1,954.93# 37239 148.78 141.34 162.54 159.29 37241 4,078.46 3,874.54 4,455.72 4,366.61# 37241 442.11 420.00 483.00 473.34 37242 6,848.27 6,505.86 7,481.74 7,332.10# 37242 493.63 468.95 539.29 528.51 37243 8,642.21 8,210.10 9,441.62 9,252.79# 37243 588.56 559.13 643.00 630.14 37244 6,074.46 5,770.74 6,636.35 6,503.63# 37244 686.62 652.29 750.13 735.13 37250 105.89 100.60 115.69 113.38 37251 79.27 75.31 86.61 84.87 37500 736.26 699.45 804.37 788.28 37565 710.41 674.89 776.12 760.60 37600 696.25 661.44 760.66 745.44 37605 785.69 746.41 858.37 841.20 37606 551.06 523.51 602.04 590.00 37607 368.61 350.18 402.71 394.66 37609 289.23 274.77 315.99 309.66# 37609 199.58 189.60 218.04 213.68 37615 509.40 483.93 556.52 545.39 37616 1,061.09 1,008.04 1,159.25 1,136.06 37617 1,300.50 1,235.48 1,420.80 1,392.39 37618 375.27 356.51 409.99 401.79 37619 1,607.26 1,526.90 1,755.94 1,720.81 37650 497.42 472.55 543.43 532.57 37660 1,117.68 1,061.80 1,221.07 1,196.64 37700 243.68 231.50 266.23 260.90 37718 425.08 403.83 464.40 455.11 37722 471.48 447.91 515.10 504.79 37735 663.53 630.35 724.90 710.40 37760 603.39 573.22 659.20 646.02 37761 538.22 511.31 588.01 576.24 37765 619.54 588.56 676.84 663.31# 37765 441.17 419.11 481.98 472.34 37766 744.15 706.94 812.98 796.72# 37766 543.29 516.13 593.55 581.68 37780 248.49 236.07 271.48 266.05

37785 334.08 317.38 364.99 357.68# 37785 253.48 240.81 276.93 271.39 37788 1,291.03 1,226.48 1,410.45 1,382.24 37790 467.31 443.94 510.53 500.32 38100 1,102.42 1,047.30 1,204.40 1,180.30 38101 1,109.94 1,054.44 1,212.61 1,188.35 38102 252.60 239.97 275.97 270.45 38115 1,216.11 1,155.30 1,328.60 1,302.02 38120 1,002.66 952.53 1,095.41 1,073.50 38200 129.01 122.56 140.94 138.13 38205 79.07 75.12 86.39 84.66 38206 80.21 76.20 87.63 85.88 38220 145.76 138.47 159.24 156.06# 38220 58.92 55.97 64.37 63.08 38221 152.19 144.58 166.27 162.94# 38221 73.16 69.50 79.93 78.33 38230 201.74 191.65 220.40 215.99 38232 200.18 190.17 218.70 214.33 38240 218.56 207.63 238.77 234.00 38241 163.38 155.21 178.49 174.93 38242 114.25 108.54 124.82 122.33 38243 115.28 109.52 125.95 123.43 38300 252.17 239.56 275.49 269.99# 38300 172.51 163.88 188.46 184.69 38305 450.38 427.86 492.04 482.20 38308 425.21 403.95 464.54 455.25 38380 549.00 521.55 599.78 587.79 38381 773.03 734.38 844.54 827.64 38382 578.85 549.91 632.40 619.75 38500 307.44 292.07 335.88 329.16# 38500 240.28 228.27 262.51 257.26 38505 116.98 111.13 127.80 125.25# 38505 69.19 65.73 75.59 74.08 38510 490.08 465.58 535.42 524.71# 38510 403.56 383.38 440.89 432.07 38520 443.54 421.36 484.56 474.87 38525 411.64 391.06 449.72 440.73 38530 524.12 497.91 572.60 561.14 38542 498.68 473.75 544.81 533.92 38550 477.33 453.46 521.48 511.05 38555 952.71 905.07 1,040.83 1,020.02 38562 667.65 634.27 729.41 714.82 38564 668.76 635.32 730.62 716.00 38570 513.66 487.98 561.18 549.95 38571 765.54 727.26 836.35 819.62 38572 925.51 879.23 1,011.11 990.90 38700 779.39 740.42 851.48 834.45 38720 1,303.16 1,238.00 1,423.70 1,395.23 38724 1,410.56 1,340.03 1,541.03 1,510.21 38740 657.17 624.31 717.96 703.59 38745 831.82 790.23 908.76 890.59 38746 211.21 200.65 230.75 226.14

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 48

38747 256.62 243.79 280.36 274.75 38760 803.09 762.94 877.38 859.83 38765 1,234.85 1,173.11 1,349.08 1,322.10 38770 772.00 733.40 843.41 826.54 38780 987.50 938.13 1,078.85 1,057.28 38790 80.39 76.37 87.83 86.07 38792 38.34 36.42 41.88 41.04 38794 287.49 273.12 314.09 307.81 38900 132.44 125.82 144.69 141.80 39000 477.35 453.48 521.50 511.07 39010 763.45 725.28 834.07 817.39 39200 848.54 806.11 927.03 908.49 39220 1,109.00 1,053.55 1,211.58 1,187.35 39400 487.91 463.51 533.04 522.38 39501 814.52 773.79 889.86 872.06 39503 5,888.56 5,594.13 6,433.25 6,304.59 39540 829.79 788.30 906.55 888.41 39541 903.28 858.12 986.84 967.10 39545 862.03 818.93 941.77 922.93 39560 764.91 726.66 835.66 818.95 39561 1,191.19 1,131.63 1,301.37 1,275.35 40490 118.08 112.18 129.01 126.43# 40490 70.91 67.36 77.46 75.91 40500 470.26 446.75 513.76 503.49# 40500 345.93 328.63 377.92 370.37 40510 454.85 432.11 496.93 486.99# 40510 342.08 324.98 373.73 366.25 40520 458.64 435.71 501.07 491.05# 40520 343.68 326.50 375.48 367.97 40525 531.26 504.70 580.41 568.80 40527 597.54 567.66 652.81 639.76 40530 505.14 479.88 551.86 540.82# 40530 385.82 366.53 421.51 413.08 40650 408.12 387.71 445.87 436.95# 40650 285.05 270.80 311.42 305.19 40652 452.58 429.95 494.44 484.55# 40652 333.56 316.88 364.41 357.12 40654 529.61 503.13 578.60 567.03# 40654 404.35 384.13 441.75 432.92 40700 875.41 831.64 956.39 937.26 40701 981.58 932.50 1,072.38 1,050.93 40702 863.86 820.67 943.77 924.90 40720 993.30 943.64 1,085.19 1,063.49 40761 1,049.55 997.07 1,146.63 1,123.70 40800 197.15 187.29 215.38 211.07# 40800 124.68 118.45 136.22 133.49 40801 295.72 280.93 323.07 316.61# 40801 212.00 201.40 231.61 226.98 40804 203.48 193.31 222.31 217.86# 40804 126.64 120.31 138.36 135.59 40805 361.18 343.12 394.59 386.70# 40805 225.30 214.04 246.15 241.22

40806 120.30 114.29 131.43 128.80# 40806 33.14 31.48 36.20 35.48 40808 172.62 163.99 188.59 184.82# 40808 102.02 96.92 111.46 109.23 40810 192.75 183.11 210.58 206.37# 40810 121.84 115.75 133.11 130.46 40812 270.33 256.81 295.33 289.42# 40812 189.12 179.66 206.61 202.48 40814 363.14 344.98 396.73 388.79# 40814 292.85 278.21 319.94 313.55 40816 381.01 361.96 416.25 407.93# 40816 305.10 289.85 333.33 326.66 40818 335.37 318.60 366.39 359.06# 40818 259.77 246.78 283.80 278.12 40819 291.84 277.25 318.84 312.47# 40819 225.30 214.04 246.15 241.22 40820 244.51 232.28 267.12 261.77# 40820 161.73 153.64 176.69 173.16 40830 248.45 236.03 271.43 266.01# 40830 158.79 150.85 173.48 170.00 40831 317.13 301.27 346.46 339.53# 40831 215.61 204.83 235.55 230.84 40840 764.26 726.05 834.96 818.26# 40840 602.45 572.33 658.18 645.01 40842 743.02 705.87 811.75 795.51# 40842 582.77 553.63 636.67 623.94 40843 1,050.72 998.18 1,147.91 1,124.95# 40843 848.93 806.48 927.45 908.90 40844 1,264.80 1,201.56 1,381.79 1,354.16# 40844 1,049.89 997.40 1,147.01 1,124.07 40845 1,393.99 1,324.29 1,522.93 1,492.47# 40845 1,184.07 1,124.87 1,293.60 1,267.73 41000 152.72 145.08 166.84 163.51# 41000 107.43 102.06 117.37 115.02 41005 212.27 201.66 231.91 227.27# 41005 119.50 113.53 130.56 127.95 41006 337.53 320.65 368.75 361.38# 41006 242.57 230.44 265.01 259.70 41007 331.61 315.03 362.28 355.04# 41007 235.40 223.63 257.17 252.03 41008 355.19 337.43 388.04 380.28# 41008 259.29 246.33 283.28 277.61 41009 377.75 358.86 412.69 404.43# 41009 280.29 266.28 306.22 300.09 41010 188.93 179.48 206.40 202.27# 41010 103.34 98.17 112.90 110.64 41015 421.48 400.41 460.47 451.26# 41015 331.51 314.93 362.17 354.92 41016 414.14 393.43 452.44 443.39# 41016 335.42 318.65 366.45 359.12 41017 417.89 397.00 456.55 447.42# 41017 336.98 320.13 368.15 360.79

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 49

41018 475.26 451.50 519.23 508.84# 41018 393.73 374.04 430.15 421.54 41019 456.07 433.27 498.26 488.29 41100 157.97 150.07 172.58 169.13# 41100 104.24 99.03 113.88 111.61 41105 160.39 152.37 175.23 171.72# 41105 107.60 102.22 117.55 115.21 41108 138.28 131.37 151.08 148.05# 41108 86.74 82.40 94.76 92.86 41110 199.78 189.79 218.26 213.89# 41110 126.68 120.35 138.40 135.63 41112 314.44 298.72 343.53 336.66# 41112 241.97 229.87 264.35 259.06 41113 343.86 326.67 375.67 368.16# 41113 267.95 254.55 292.73 286.88 41114 612.53 581.90 669.19 655.80 41115 231.41 219.84 252.82 247.76# 41115 146.13 138.82 159.64 156.45 41116 311.84 296.25 340.69 333.88# 41116 211.57 200.99 231.14 226.52 41120 990.09 940.59 1,081.68 1,060.05 41130 1,235.34 1,173.57 1,349.61 1,322.62 41135 2,068.25 1,964.84 2,259.57 2,214.37 41140 2,080.86 1,976.82 2,273.34 2,227.87 41145 2,636.26 2,504.45 2,880.12 2,822.51 41150 2,093.45 1,988.78 2,287.10 2,241.35 41153 2,280.85 2,166.81 2,491.83 2,441.99 41155 2,884.05 2,739.85 3,150.83 3,087.81 41250 248.70 236.27 271.71 266.27# 41250 148.43 141.01 162.16 158.92 41251 269.52 256.04 294.45 288.56# 41251 172.99 164.34 188.99 185.21 41252 297.43 282.56 324.94 318.45# 41252 204.03 193.83 222.90 218.44 41500 352.83 335.19 385.47 377.76 41510 412.27 391.66 450.41 441.40 41512 591.77 562.18 646.51 633.58 41520 330.75 314.21 361.34 354.12# 41520 245.47 233.20 268.18 262.82 41530 2,920.65 2,774.62 3,190.81 3,127.00# 41530 385.42 366.15 421.07 412.65 41800 248.11 235.70 271.06 265.64# 41800 138.78 131.84 151.62 148.58 41805 240.45 228.43 262.69 257.44# 41805 164.55 156.32 179.77 176.17 41806 337.09 320.24 368.28 360.92# 41806 253.37 240.70 276.81 271.27 41822 273.64 259.96 298.95 292.97# 41822 177.12 168.26 193.50 189.62 41823 403.64 383.46 440.98 432.16# 41823 310.55 295.02 339.27 332.49 41825 197.60 187.72 215.88 211.57

# 41825 117.32 111.45 128.17 125.60 41826 294.26 279.55 321.48 315.05# 41826 203.05 192.90 221.84 217.40 41827 413.88 393.19 452.17 443.13# 41827 294.24 279.53 321.46 315.03 41828 290.18 275.67 317.02 310.68# 41828 207.08 196.73 226.24 221.72 41830 370.14 351.63 404.37 396.29# 41830 272.99 259.34 298.24 292.27 41872 342.29 325.18 373.96 366.48# 41872 247.02 234.67 269.87 264.48 41874 351.94 334.34 384.49 376.80# 41874 244.80 232.56 267.44 262.10 42000 147.79 140.40 161.46 158.23# 42000 99.06 94.11 108.23 106.06 42100 141.52 134.44 154.61 151.51# 42100 105.29 100.03 115.03 112.73 42104 203.15 192.99 221.94 217.50# 42104 133.80 127.11 146.18 143.26 42106 256.59 243.76 280.32 274.71# 42106 171.31 162.74 187.15 183.41 42107 435.96 414.16 476.28 466.76# 42107 333.50 316.83 364.35 357.06 42120 945.63 898.35 1,033.10 1,012.44 42140 236.62 224.79 258.51 253.33# 42140 148.22 140.81 161.93 158.69 42145 678.50 644.58 741.27 726.44 42160 218.22 207.31 238.41 233.63# 42160 141.37 134.30 154.45 151.35 42180 232.04 220.44 253.51 248.43# 42180 177.69 168.81 194.13 190.24 42182 306.29 290.98 334.63 327.93# 42182 248.19 235.78 271.15 265.72 42200 822.36 781.24 898.43 880.46 42205 861.07 818.02 940.72 921.91 42210 984.83 935.59 1,075.93 1,054.41 42215 638.14 606.23 697.16 683.23 42220 500.02 475.02 546.27 535.35 42225 832.14 790.53 909.11 890.93 42226 848.34 805.92 926.81 908.27 42227 796.78 756.94 870.48 853.07 42235 695.18 660.42 759.48 744.29 42260 776.55 737.72 848.38 831.42# 42260 640.05 608.05 699.26 685.27 42280 158.57 150.64 173.24 169.77# 42280 109.22 103.76 119.32 116.93 42281 194.38 184.66 212.36 208.12# 42281 145.65 138.37 159.13 155.94 42300 198.09 188.19 216.42 212.09# 42300 146.86 139.52 160.45 157.24 42305 415.90 395.11 454.38 445.29 42310 153.15 145.49 167.31 163.97

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 50

# 42310 119.72 113.73 130.79 128.18 42320 236.74 224.90 258.64 253.46# 42320 169.58 161.10 185.27 181.56 42330 219.89 208.90 240.24 235.43# 42330 159.28 151.32 174.02 170.53 42335 353.78 336.09 386.50 378.78# 42335 248.20 235.79 271.16 265.73 42340 440.38 418.36 481.11 471.49# 42340 324.48 308.26 354.50 347.40 42400 98.88 93.94 108.03 105.87# 42400 53.28 50.62 58.21 57.05 42405 283.49 269.32 309.72 303.52# 42405 218.52 207.59 238.73 233.96 42408 429.20 407.74 468.90 459.53# 42408 315.19 299.43 344.34 337.46 42409 314.18 298.47 343.24 336.38# 42409 213.60 202.92 233.36 228.69 42410 602.25 572.14 657.96 644.81 42415 1,026.55 975.22 1,121.50 1,099.08 42420 1,153.40 1,095.73 1,260.09 1,234.89 42425 812.24 771.63 887.37 869.63 42426 1,315.45 1,249.68 1,437.13 1,408.39 42440 398.39 378.47 435.24 426.54 42450 429.74 408.25 469.49 460.10# 42450 345.71 328.42 377.68 370.13 42500 412.17 391.56 450.29 441.29# 42500 330.33 313.81 360.88 353.66 42505 530.76 504.22 579.85 568.26# 42505 438.92 416.97 479.52 469.92 42507 491.39 466.82 536.84 526.10 42508 684.42 650.20 747.73 732.78 42509 836.20 794.39 913.55 895.28 42510 604.13 573.92 660.01 646.81 42550 124.05 117.85 135.53 132.81# 42550 62.20 59.09 67.95 66.60 42600 454.71 431.97 496.77 486.83# 42600 336.32 319.50 367.43 360.08 42650 79.40 75.43 86.74 85.01# 42650 56.91 54.06 62.17 60.93 42660 114.68 108.95 125.29 122.79# 42660 80.01 76.01 87.41 85.66 42665 295.79 281.00 323.15 316.69# 42665 198.95 189.00 217.35 213.00 42700 179.00 170.05 195.56 191.65# 42700 130.59 124.06 142.67 139.82 42720 436.62 414.79 477.01 467.46# 42720 381.33 362.26 416.60 408.26 42725 786.27 746.96 859.00 841.82 42800 149.94 142.44 163.81 160.53# 42800 108.08 102.68 118.08 115.72 42804 182.19 173.08 199.04 195.06# 42804 107.85 102.46 117.83 115.47

42806 205.72 195.43 224.74 220.25# 42806 126.38 120.06 138.07 135.31 42808 215.30 204.54 235.22 230.52# 42808 156.57 148.74 171.05 167.64 42809 163.49 155.32 178.62 175.04# 42809 127.88 121.49 139.71 136.92 42810 365.83 347.54 399.67 391.68# 42810 276.80 262.96 302.40 296.36 42815 536.16 509.35 585.75 574.03 42820 280.27 266.26 306.20 300.07 42821 291.11 276.55 318.03 311.67 42825 251.71 239.12 274.99 269.49 42826 242.07 229.97 264.47 259.18 42830 199.35 189.38 217.79 213.43 42831 214.15 203.44 233.96 229.28 42835 171.39 162.82 187.24 183.49 42836 231.62 220.04 253.05 247.99 42842 948.54 901.11 1,036.28 1,015.55 42844 1,306.23 1,240.92 1,427.06 1,398.52 42845 2,135.70 2,028.92 2,333.26 2,286.59 42860 180.40 171.38 197.09 193.14 42870 544.90 517.66 595.31 583.41 42890 1,355.93 1,288.13 1,481.35 1,451.73 42892 1,803.76 1,713.57 1,970.61 1,931.20 42894 2,272.95 2,159.30 2,483.20 2,433.53 42900 329.04 312.59 359.48 352.29 42950 750.06 712.56 819.44 803.06 42953 895.16 850.40 977.96 958.40 42955 712.04 676.44 777.91 762.35 42960 164.17 155.96 179.35 175.77 42961 406.03 385.73 443.59 434.72 42962 499.61 474.63 545.82 534.91 42970 396.23 376.42 432.88 424.22 42971 441.66 419.58 482.52 472.87 42972 495.38 470.61 541.20 530.38 43020 480.89 456.85 525.38 514.87 43030 502.20 477.09 548.65 537.68 43045 1,259.22 1,196.26 1,375.70 1,348.18 43100 607.70 577.32 663.92 650.64 43101 974.77 926.03 1,064.93 1,043.64 43107 2,458.83 2,335.89 2,686.27 2,632.55 43108 4,500.54 4,275.51 4,916.84 4,818.50 43112 2,603.71 2,473.52 2,844.55 2,787.66 43113 4,395.63 4,175.85 4,802.23 4,706.18 43116 5,114.40 4,858.68 5,587.48 5,475.74 43117 2,389.56 2,270.08 2,610.59 2,558.38 43118 3,510.08 3,334.58 3,834.77 3,758.07 43121 2,784.73 2,645.49 3,042.31 2,981.47 43122 2,470.54 2,347.01 2,699.06 2,645.08 43123 4,556.53 4,328.70 4,978.01 4,878.45 43124 3,713.92 3,528.22 4,057.45 3,976.31 43130 764.25 726.04 834.95 818.25

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 51

43135 1,448.79 1,376.35 1,582.80 1,551.14 43191 122.14 116.03 133.43 130.77 43192 145.89 138.60 159.39 156.20 43193 174.13 165.42 190.23 186.43 43194 159.14 151.18 173.86 170.38 43195 174.44 165.72 190.58 186.77 43196 191.09 181.54 208.77 204.60 43197 169.94 161.44 185.66 181.94# 43197 78.42 74.50 85.68 83.96 43198 190.27 180.76 207.87 203.71# 43198 93.43 88.76 102.07 100.03 43200 245.73 233.44 268.46 263.09# 43200 90.79 86.25 99.19 97.21 43201 251.65 239.07 274.93 269.43# 43201 106.71 101.37 116.58 114.24 43202 328.11 311.70 358.46 351.29# 43202 106.95 101.60 116.84 114.51 43204 140.94 133.89 153.97 150.89 43205 145.85 138.56 159.34 156.16 43206 303.75 288.56 331.84 325.21# 43206 139.44 132.47 152.34 149.29 43211 237.84 225.95 259.84 254.64 43212 187.56 178.18 204.91 200.81 43213 1,111.71 1,056.12 1,214.54 1,190.25# 43213 264.55 251.32 289.02 283.23 43214 191.24 181.68 208.93 204.76 43215 370.66 352.13 404.95 396.85# 43215 144.18 136.97 157.52 154.36 43216 381.88 362.79 417.21 408.86# 43216 140.11 133.10 153.07 150.01 43217 409.30 388.84 447.17 438.22# 43217 166.90 158.56 182.34 178.70 43220 898.53 853.60 981.64 962.01# 43220 122.91 116.76 134.27 131.58 43226 348.12 330.71 380.32 372.72# 43226 135.39 128.62 147.91 144.96 43227 363.31 345.14 396.91 388.98# 43227 171.51 162.93 187.37 183.62 43229 658.45 625.53 719.36 704.97# 43229 201.76 191.67 220.42 216.02 43231 372.30 353.69 406.74 398.61# 43231 167.07 158.72 182.53 178.88 43232 439.20 417.24 479.83 470.24# 43232 199.30 189.34 217.74 213.38 43233 227.11 215.75 248.11 243.16 43235 285.87 271.58 312.32 306.07# 43235 127.49 121.12 139.29 136.51 43236 355.62 337.84 388.52 380.74# 43236 143.52 136.34 156.79 153.65 43237 202.28 192.17 221.00 216.58 43238 231.10 219.55 252.48 247.43 43239 363.74 345.55 397.38 389.44

# 43239 142.89 135.75 156.11 153.00 43240 402.57 382.44 439.81 431.01 43241 148.02 140.62 161.71 158.48 43242 263.42 250.25 287.79 282.04 43243 244.33 232.11 266.93 261.59 43244 253.05 240.40 276.46 270.93 43245 559.24 531.28 610.97 598.75# 43245 180.95 171.90 197.69 193.73 43246 207.27 196.91 226.45 221.92 43247 374.04 355.34 408.64 400.46# 43247 181.30 172.24 198.08 194.12 43248 378.15 359.24 413.13 404.87# 43248 172.61 163.98 188.58 184.81 43249 941.62 894.54 1,028.72 1,008.15# 43249 159.12 151.16 173.83 170.36 43250 418.48 397.56 457.19 448.05# 43250 175.14 166.38 191.34 187.51 43251 461.55 438.47 504.24 494.16# 43251 202.91 192.76 221.67 217.24 43252 340.55 323.52 372.05 364.61# 43252 174.68 165.95 190.84 187.02 43253 263.42 250.25 287.79 282.04 43254 273.53 259.85 298.83 292.85 43255 399.80 379.81 436.78 428.04# 43255 208.00 197.60 227.24 222.70 43257 232.70 221.07 254.23 249.15 43259 233.77 222.08 255.39 250.29 43260 331.75 315.16 362.43 355.19 43261 347.97 330.57 380.16 372.55 43262 367.17 348.81 401.13 393.10 43263 367.45 349.08 401.44 393.42 43264 374.26 355.55 408.88 400.71 43265 444.53 422.30 485.65 475.93 43266 226.38 215.06 247.32 242.37 43270 659.44 626.47 720.44 706.03# 43270 237.73 225.84 259.72 254.52 43273 121.29 115.23 132.51 129.87 43274 469.18 445.72 512.58 502.33 43275 386.73 367.39 422.50 414.05 43276 488.19 463.78 533.35 522.68 43277 389.10 369.65 425.10 416.60 43278 442.51 420.38 483.44 473.77 43279 1,236.01 1,174.21 1,350.34 1,323.34 43280 1,033.44 981.77 1,129.04 1,106.45 43281 1,478.36 1,404.44 1,615.11 1,582.80 43282 1,663.17 1,580.01 1,817.01 1,780.67 43283 151.78 144.19 165.82 162.51 43300 596.02 566.22 651.15 638.14 43305 1,062.65 1,009.52 1,160.95 1,137.73 43310 1,442.39 1,370.27 1,575.81 1,544.29 43312 1,558.32 1,480.40 1,702.46 1,668.41 43313 2,781.78 2,642.69 3,039.09 2,978.32

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 52

43314 2,847.13 2,704.77 3,110.49 3,048.27 43320 1,330.61 1,264.08 1,453.69 1,424.62 43325 1,284.43 1,220.21 1,403.24 1,375.18 43327 782.62 743.49 855.01 837.91 43328 1,114.79 1,059.05 1,217.91 1,193.55 43330 1,272.73 1,209.09 1,390.45 1,362.65 43331 1,300.57 1,235.54 1,420.87 1,392.45 43332 1,111.44 1,055.87 1,214.25 1,189.96 43333 1,209.87 1,149.38 1,321.79 1,295.35 43334 1,203.62 1,143.44 1,314.96 1,288.66 43335 1,290.81 1,226.27 1,410.21 1,382.00 43336 1,456.62 1,383.79 1,591.36 1,559.53 43337 1,571.70 1,493.12 1,717.09 1,682.75 43338 113.41 107.74 123.90 121.43 43340 1,313.77 1,248.08 1,435.29 1,406.59 43341 1,353.72 1,286.03 1,478.93 1,449.36 43350 1,149.06 1,091.61 1,255.35 1,230.25 43351 1,273.63 1,209.95 1,391.44 1,363.61 43352 1,031.99 980.39 1,127.45 1,104.90 43360 2,295.87 2,181.08 2,508.24 2,458.08 43361 2,456.48 2,333.66 2,683.71 2,630.04 43400 1,480.10 1,406.10 1,617.02 1,584.68 43401 1,493.83 1,419.14 1,632.01 1,599.37 43405 1,397.33 1,327.46 1,526.58 1,496.05 43410 1,008.23 957.82 1,101.49 1,079.46 43415 2,495.77 2,370.98 2,726.63 2,672.09 43420 990.90 941.36 1,082.56 1,060.91 43425 1,388.51 1,319.08 1,516.94 1,486.61 43450 194.58 184.85 212.58 208.32# 43450 84.93 80.68 92.78 90.93 43453 870.49 826.97 951.02 931.99# 43453 91.74 87.15 100.22 98.22 43460 214.54 203.81 234.38 229.69 43500 750.52 712.99 819.94 803.54 43501 1,286.48 1,222.16 1,405.48 1,377.38 43502 1,453.89 1,381.20 1,588.38 1,556.62 43510 870.72 827.18 951.26 932.24 43520 655.94 623.14 716.61 702.28 43605 792.99 753.34 866.34 849.01 43610 936.39 889.57 1,023.01 1,002.55 43611 1,166.08 1,107.78 1,273.95 1,248.46 43620 1,880.12 1,786.11 2,054.03 2,012.95 43621 2,171.29 2,062.73 2,372.14 2,324.70 43622 2,210.88 2,100.34 2,415.39 2,367.08 43631 1,385.36 1,316.09 1,513.50 1,483.24 43632 1,943.29 1,846.13 2,123.05 2,080.59 43633 1,836.22 1,744.41 2,006.07 1,965.95 43634 2,031.65 1,930.07 2,219.58 2,175.19 43635 107.69 102.31 117.66 115.30 43640 1,126.37 1,070.05 1,230.56 1,205.95 43641 1,144.04 1,086.84 1,249.87 1,224.87 43644 1,655.80 1,573.01 1,808.96 1,772.78

43645 1,770.33 1,681.81 1,934.08 1,895.40 43647 292.97 278.32 320.07 313.66 43648 292.97 278.32 320.07 313.66 43651 620.20 589.19 677.57 664.02 43652 725.70 689.42 792.83 776.97 43653 541.67 514.59 591.78 579.95 43752 40.29 38.28 44.02 43.14 43753 20.70 19.67 22.62 22.17 43754 81.89 77.80 89.47 87.68# 43754 31.60 30.02 34.52 33.83 43755 125.86 119.57 137.51 134.76# 43755 55.88 53.09 61.05 59.83 43756 190.16 180.65 207.75 203.60# 43756 48.96 46.51 53.49 52.42 43757 267.58 254.20 292.33 286.49# 43757 74.53 70.80 81.42 79.79 43760 433.50 411.83 473.60 464.13# 43760 46.47 44.15 50.77 49.76 43761 113.68 108.00 124.20 121.72# 43761 102.12 97.01 111.56 109.33 43770 1,063.11 1,009.95 1,161.44 1,138.21 43771 1,215.89 1,155.10 1,328.37 1,301.80 43772 909.44 863.97 993.57 973.69 43773 1,210.27 1,149.76 1,322.22 1,295.77 43774 915.97 870.17 1,000.70 980.69 43775 1,201.23 1,141.17 1,312.35 1,286.10 43800 888.04 843.64 970.19 950.79 43810 969.06 920.61 1,058.70 1,037.53 43820 1,280.61 1,216.58 1,399.07 1,371.09 43825 1,247.16 1,184.80 1,362.52 1,335.27 43830 663.59 630.41 724.97 710.47 43831 560.46 532.44 612.31 600.06 43832 995.26 945.50 1,087.33 1,065.58 43840 1,297.39 1,232.52 1,417.40 1,389.05 43843 1,219.13 1,158.17 1,331.90 1,305.26 43845 1,872.05 1,778.45 2,045.22 2,004.31 43846 1,540.62 1,463.59 1,683.13 1,649.47 43847 1,718.42 1,632.50 1,877.38 1,839.83 43848 1,840.55 1,748.52 2,010.80 1,970.58 43850 1,553.65 1,475.97 1,697.37 1,663.42 43855 1,612.01 1,531.41 1,761.12 1,725.90 43860 1,564.45 1,486.23 1,709.16 1,674.99 43865 1,631.19 1,549.63 1,782.07 1,746.44 43870 677.12 643.26 739.75 724.95 43880 1,528.36 1,451.94 1,669.73 1,636.34 43881 588.91 559.46 643.38 630.51 43882 588.91 559.46 643.38 630.51 43886 340.31 323.29 371.78 364.34 43887 306.33 291.01 334.66 327.97 43888 433.52 411.84 473.62 464.14 44005 1,045.12 992.86 1,141.79 1,118.95 44010 831.84 790.25 908.79 890.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 53

44015 137.57 130.69 150.29 147.29 44020 927.62 881.24 1,013.43 993.16 44021 936.95 890.10 1,023.62 1,003.15 44025 945.71 898.42 1,033.18 1,012.52 44050 892.76 848.12 975.34 955.83 44055 1,431.30 1,359.74 1,563.70 1,532.43 44100 109.06 103.61 119.15 116.77 44110 813.72 773.03 888.98 871.21 44111 942.60 895.47 1,029.79 1,009.19 44120 1,170.50 1,111.98 1,278.78 1,253.20 44121 233.19 221.53 254.76 249.67 44125 1,131.83 1,075.24 1,236.53 1,211.80 44126 2,355.66 2,237.88 2,573.56 2,522.09 44127 2,725.70 2,589.42 2,977.83 2,918.27 44128 234.02 222.32 255.67 250.55 44130 1,256.86 1,194.02 1,373.12 1,345.66 44139 116.83 110.99 127.64 125.09 44140 1,283.14 1,218.98 1,401.83 1,373.79 44141 1,744.81 1,657.57 1,906.21 1,868.08 44143 1,592.56 1,512.93 1,739.87 1,705.07 44144 1,696.39 1,611.57 1,853.31 1,816.24 44145 1,594.90 1,515.16 1,742.43 1,707.59 44146 2,032.73 1,931.09 2,220.75 2,176.34 44147 1,869.16 1,775.70 2,042.06 2,001.22 44150 1,789.68 1,700.20 1,955.23 1,916.13 44151 2,050.92 1,948.37 2,240.63 2,195.81 44155 2,001.63 1,901.55 2,186.78 2,143.05 44156 2,201.44 2,091.37 2,405.08 2,356.97 44157 2,084.20 1,979.99 2,276.99 2,231.45 44158 2,148.06 2,040.66 2,346.76 2,299.83 44160 1,188.87 1,129.43 1,298.84 1,272.87 44180 877.80 833.91 959.00 939.81 44186 620.23 589.22 677.60 664.06 44187 1,061.07 1,008.02 1,159.22 1,136.04 44188 1,172.59 1,113.96 1,281.05 1,255.43 44202 1,327.65 1,261.27 1,450.46 1,421.45 44203 233.40 221.73 254.99 249.90 44204 1,480.85 1,406.81 1,617.83 1,585.47 44205 1,288.72 1,224.28 1,407.92 1,379.76 44206 1,687.17 1,602.81 1,843.23 1,806.36 44207 1,763.71 1,675.52 1,926.85 1,888.31 44208 1,917.41 1,821.54 2,094.77 2,052.88 44210 1,731.87 1,645.28 1,892.07 1,854.23 44211 2,152.64 2,045.01 2,351.76 2,304.73 44212 1,994.56 1,894.83 2,179.05 2,135.47 44213 183.11 173.95 200.04 196.04 44227 1,602.92 1,522.77 1,751.19 1,716.16 44300 803.30 763.14 877.61 860.06 44310 1,002.41 952.29 1,095.13 1,073.23 44312 563.52 535.34 615.64 603.32 44314 967.05 918.70 1,056.51 1,035.38 44316 1,347.93 1,280.53 1,472.61 1,443.16

44320 1,151.27 1,093.71 1,257.77 1,232.62 44322 940.23 893.22 1,027.20 1,006.66 44340 593.20 563.54 648.07 635.11 44345 1,008.28 957.87 1,101.55 1,079.52 44346 1,134.37 1,077.65 1,239.30 1,214.52 44360 150.24 142.73 164.14 160.86 44361 165.17 156.91 180.45 176.84 44363 197.92 188.02 216.22 211.90 44364 211.14 200.58 230.67 226.06 44365 187.52 178.14 204.86 200.77 44366 247.94 235.54 270.87 265.45 44369 254.03 241.33 277.53 271.98 44370 273.61 259.93 298.92 292.94 44372 246.83 234.49 269.66 264.27 44373 197.26 187.40 215.51 211.20 44376 292.16 277.55 319.18 312.80 44377 307.77 292.38 336.24 329.51 44378 395.24 375.48 431.80 423.17 44379 419.46 398.49 458.26 449.10 44380 64.96 61.71 70.97 69.55 44382 78.25 74.34 85.49 83.78 44383 158.86 150.92 173.56 170.09 44385 240.19 228.18 262.41 257.16# 44385 103.99 98.79 113.61 111.33 44386 320.35 304.33 349.98 342.98# 44386 123.24 117.08 134.64 131.95 44388 322.86 306.72 352.73 345.68# 44388 160.42 152.40 175.26 171.75 44389 362.87 344.73 396.44 388.52# 44389 177.95 169.05 194.41 190.52 44390 424.83 403.59 464.13 454.85# 44390 216.79 205.95 236.84 232.10 44391 457.41 434.54 499.72 489.73# 44391 241.87 229.78 264.25 258.96 44392 404.58 384.35 442.00 433.16# 44392 212.47 201.85 232.13 227.48 44393 465.03 441.78 508.05 497.88# 44393 267.30 253.94 292.03 286.19 44394 457.15 434.29 499.43 489.44# 44394 247.23 234.87 270.10 264.70 44397 263.86 250.67 288.27 282.51 44500 24.28 23.07 26.53 26.00 44602 1,354.46 1,286.74 1,479.75 1,450.16 44603 1,552.33 1,474.71 1,695.92 1,662.00 44604 1,012.89 962.25 1,106.59 1,084.46 44605 1,251.10 1,188.55 1,366.83 1,339.50 44615 1,030.98 979.43 1,126.34 1,103.82 44620 832.59 790.96 909.60 891.41 44625 981.04 931.99 1,071.79 1,050.35 44626 1,542.29 1,465.18 1,684.96 1,651.26 44640 1,347.78 1,280.39 1,472.45 1,443.00 44650 1,393.92 1,324.22 1,522.85 1,492.40

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 54

44660 1,287.18 1,222.82 1,406.24 1,378.11 44661 1,496.47 1,421.65 1,634.90 1,602.20 44680 1,022.84 971.70 1,117.46 1,095.11 44700 983.94 934.74 1,074.95 1,053.46 44701 161.88 153.79 176.86 173.32 44720 247.93 235.53 270.86 265.44 44721 374.13 355.42 408.73 400.56 44800 726.18 689.87 793.35 777.48 44820 802.83 762.69 877.09 859.56 44850 714.92 679.17 781.05 765.43 44900 737.89 701.00 806.15 790.03 44950 611.84 581.25 668.44 655.07 44955 80.93 76.88 88.41 86.64 44960 833.63 791.95 910.74 892.53 44970 569.64 541.16 622.33 609.89 45000 405.40 385.13 442.90 434.04 45005 243.84 231.65 266.40 261.07# 45005 147.94 140.54 161.62 158.39 45020 541.73 514.64 591.84 580.00 45100 283.81 269.62 310.06 303.86 45108 346.88 329.54 378.97 371.39 45110 1,782.04 1,692.94 1,946.88 1,907.94 45111 1,045.91 993.61 1,142.65 1,119.80 45112 1,824.50 1,733.28 1,993.27 1,953.40 45113 1,915.97 1,820.17 2,093.20 2,051.34 45114 1,734.11 1,647.40 1,894.51 1,856.62 45116 1,520.11 1,444.10 1,660.72 1,627.50 45119 1,888.43 1,794.01 2,063.11 2,021.85 45120 1,522.22 1,446.11 1,663.03 1,629.77 45121 1,656.31 1,573.49 1,809.51 1,773.32 45123 1,081.69 1,027.61 1,181.75 1,158.12 45126 2,762.09 2,623.99 3,017.59 2,957.24 45130 1,056.75 1,003.91 1,154.50 1,131.40 45135 1,309.19 1,243.73 1,430.29 1,401.69 45136 1,767.41 1,679.04 1,930.90 1,892.28 45150 377.35 358.48 412.25 404.01 45160 970.95 922.40 1,060.76 1,039.54 45171 568.57 540.14 621.16 608.74 45172 776.29 737.48 848.10 831.14 45190 663.47 630.30 724.85 710.34 45300 111.99 106.39 122.35 119.90# 45300 51.70 49.12 56.49 55.36 45303 837.54 795.66 915.01 896.71# 45303 88.78 84.34 96.99 95.05 45305 178.64 169.71 195.17 191.27# 45305 76.18 72.37 83.23 81.56 45307 210.96 200.41 230.47 225.86# 45307 100.07 95.07 109.33 107.15 45308 198.59 188.66 216.96 212.62# 45308 84.26 80.05 92.06 90.22 45309 204.01 193.81 222.88 218.42# 45309 89.06 84.61 97.30 95.36

45315 211.11 200.55 230.63 226.02# 45315 107.40 102.03 117.33 114.99 45317 225.15 213.89 245.97 241.05# 45317 114.88 109.14 125.51 123.00 45320 221.09 210.04 241.55 236.72# 45320 103.32 98.15 112.87 110.62 45321 103.74 98.55 113.33 111.07 45327 116.47 110.65 127.25 124.71 45330 124.52 118.29 136.03 133.31# 45330 60.49 57.47 66.09 64.77 45331 148.99 141.54 162.77 159.52# 45331 72.15 68.54 78.82 77.25 45332 265.56 252.28 290.12 284.31# 45332 106.87 101.53 116.76 114.43 45333 269.93 256.43 294.89 289.00# 45333 105.94 100.64 115.74 113.42 45334 156.79 148.95 171.29 167.87 45335 248.64 236.21 271.64 266.21# 45335 88.39 83.97 96.57 94.63 45337 137.01 130.16 149.68 146.69 45338 291.33 276.76 318.27 311.90# 45338 135.77 128.98 148.33 145.36 45339 315.47 299.70 344.66 337.77# 45339 179.28 170.32 195.87 191.95 45340 438.41 416.49 478.96 469.38# 45340 111.36 105.79 121.66 119.22 45341 150.29 142.78 164.20 160.91 45342 228.98 217.53 250.16 245.16 45345 167.48 159.11 182.98 179.32 45355 198.12 188.21 216.44 212.12 45378 359.50 341.53 392.76 384.91# 45378 208.31 197.89 227.57 223.02 45378 53 124.52 118.29 136.03 133.31# 45378 53 60.49 57.47 66.09 64.77 45379 461.67 438.59 504.38 494.29# 45379 261.75 248.66 285.96 280.24 45380 428.21 406.80 467.82 458.46# 45380 248.91 236.46 271.93 266.49 45381 428.82 407.38 468.49 459.11# 45381 236.08 224.28 257.92 252.76 45382 556.15 528.34 607.59 595.44# 45382 316.56 300.73 345.84 338.93 45383 522.37 496.25 570.69 559.28# 45383 324.32 308.10 354.32 347.23 45384 429.51 408.03 469.23 459.85# 45384 260.83 247.79 284.96 279.25 45385 484.54 460.31 529.36 518.77# 45385 295.86 281.07 323.23 316.77 45386 607.98 577.58 664.22 650.93# 45386 255.94 243.14 279.61 274.02 45387 332.42 315.80 363.17 355.90 45391 283.59 269.41 309.82 303.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 55

45392 364.54 346.31 398.26 390.29 45395 1,914.55 1,818.82 2,091.64 2,049.81 45397 2,082.30 1,978.19 2,274.92 2,229.42 45400 1,112.69 1,057.06 1,215.62 1,191.31 45402 1,482.32 1,408.20 1,619.43 1,587.05 45500 505.56 480.28 552.32 541.27 45505 562.44 534.32 614.47 602.17 45520 141.60 134.52 154.70 151.60# 45520 38.82 36.88 42.41 41.56 45540 1,023.18 972.02 1,117.82 1,095.47 45541 889.99 845.49 972.31 952.87 45550 1,415.66 1,344.88 1,546.61 1,515.68 45560 672.38 638.76 734.57 719.88 45562 1,069.14 1,015.68 1,168.03 1,144.68 45563 1,564.30 1,486.09 1,709.00 1,674.83 45800 1,154.45 1,096.73 1,261.24 1,236.02 45805 1,387.20 1,317.84 1,515.52 1,485.20 45820 1,139.23 1,082.27 1,244.61 1,219.71 45825 1,335.27 1,268.51 1,458.79 1,429.61 45900 193.93 184.23 211.86 207.63 45905 159.97 151.97 174.77 171.27 45910 186.07 176.77 203.29 199.21 45915 304.63 289.40 332.81 326.15# 45915 214.98 204.23 234.86 230.17 45990 103.41 98.24 112.98 110.72 46020 257.14 244.28 280.92 275.30# 46020 221.22 210.16 241.68 236.85 46030 128.39 121.97 140.27 137.46# 46030 86.22 81.91 94.20 92.31 46040 490.61 466.08 535.99 525.27# 46040 387.84 368.45 423.72 415.24 46045 407.52 387.14 445.21 436.31 46050 182.93 173.78 199.85 195.85# 46050 92.34 87.72 100.88 98.87 46060 448.51 426.08 489.99 480.19 46070 225.79 214.50 246.68 241.74 46080 229.82 218.33 251.08 246.05# 46080 152.66 145.03 166.78 163.45 46083 161.09 153.04 176.00 172.48# 46083 100.80 95.76 110.12 107.92 46200 405.14 384.88 442.61 433.76# 46200 302.68 287.55 330.68 324.07 46220 189.10 179.65 206.60 202.47# 46220 112.88 107.24 123.33 120.87 46221 246.86 234.52 269.70 264.30# 46221 180.01 171.01 196.66 192.73 46230 253.74 241.05 277.21 271.66# 46230 165.65 157.37 180.98 177.35 46250 423.77 402.58 462.97 453.71# 46250 296.01 281.21 323.39 316.93 46255 464.99 441.74 508.00 497.85# 46255 333.80 317.11 364.68 357.39

46257 396.71 376.87 433.40 424.73 46258 437.13 415.27 477.56 468.00 46260 448.63 426.20 490.13 480.33 46261 498.85 473.91 545.00 534.09 46262 524.04 497.84 572.52 561.06 46270 466.58 443.25 509.74 499.55# 46270 367.25 348.89 401.22 393.20 46275 496.99 472.14 542.96 532.11# 46275 390.78 371.24 426.93 418.39 46280 444.40 422.18 485.51 475.80 46285 495.36 470.59 541.18 530.36# 46285 390.40 370.88 426.51 417.98 46288 521.78 495.69 570.04 558.65 46320 169.25 160.79 184.91 181.21# 46320 106.15 100.84 115.97 113.64 46500 217.93 207.03 238.08 233.32# 46500 122.97 116.82 134.34 131.65 46505 267.83 254.44 292.61 286.75# 46505 227.53 216.15 248.57 243.60 46600 80.33 76.31 87.76 86.00# 46600 38.79 36.85 42.38 41.53 46604 551.48 523.91 602.50 590.44# 46604 63.86 60.67 69.77 68.38 46606 205.27 195.01 224.26 219.78# 46606 74.08 70.38 80.94 79.32 46608 205.39 195.12 224.39 219.90# 46608 77.31 73.44 84.46 82.77 46610 205.29 195.03 224.28 219.80# 46610 77.53 73.65 84.70 83.01 46611 160.75 152.71 175.62 172.11# 46611 78.91 74.96 86.20 84.48 46612 247.60 235.22 270.50 265.10# 46612 90.17 85.66 98.51 96.54 46614 117.52 111.64 128.39 125.82# 46614 61.61 58.53 67.31 65.96 46615 134.28 127.57 146.71 143.77# 46615 89.92 85.42 98.23 96.27 46700 624.90 593.66 682.71 669.06 46705 464.02 440.82 506.94 496.80 46706 161.60 153.52 176.55 173.02 46707 438.30 416.39 478.85 469.27 46710 1,047.13 994.77 1,143.99 1,121.10 46712 1,989.57 1,890.09 2,173.60 2,130.13 46715 477.66 453.78 521.85 511.41 46716 1,034.30 982.59 1,129.98 1,107.38 46730 1,707.92 1,622.52 1,865.90 1,828.58 46735 1,980.72 1,881.68 2,163.93 2,120.66 46740 2,035.42 1,933.65 2,223.70 2,179.23 46742 2,330.99 2,214.44 2,546.61 2,495.67 46744 3,241.73 3,079.64 3,541.59 3,470.76 46746 3,440.40 3,268.38 3,758.64 3,683.46 46748 3,737.80 3,550.91 4,083.55 4,001.87

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 56

46750 732.59 695.96 800.35 784.35 46751 579.04 550.09 632.60 619.95 46753 562.37 534.25 614.39 602.11 46754 270.11 256.60 295.09 289.19# 46754 214.82 204.08 234.69 230.00 46760 1,056.92 1,004.07 1,154.68 1,131.59 46761 896.98 852.13 979.95 960.35 46762 892.37 847.75 974.91 955.42 46900 221.09 210.04 241.55 236.72# 46900 131.13 124.57 143.26 140.39 46910 233.45 221.78 255.05 249.94# 46910 128.49 122.07 140.38 137.57 46916 208.39 197.97 227.67 223.11# 46916 134.67 127.94 147.13 144.19 46917 401.23 381.17 438.35 429.58# 46917 127.59 121.21 139.39 136.61 46922 243.13 230.97 265.62 260.30# 46922 128.49 122.07 140.38 137.57 46924 484.31 460.09 529.10 518.52# 46924 176.31 167.49 192.61 188.76 46930 187.37 178.00 204.70 200.61# 46930 137.70 130.82 150.44 147.43 46940 212.90 202.26 232.60 227.94# 46940 141.06 134.01 154.11 151.03 46942 201.73 191.64 220.39 215.98# 46942 127.38 121.01 139.16 136.38 46945 277.20 263.34 302.84 296.78# 46945 207.54 197.16 226.73 222.20 46946 285.16 270.90 311.54 305.30# 46946 209.88 199.39 229.30 224.71 46947 362.38 344.26 395.90 387.98 47000 327.92 311.52 358.25 351.08# 47000 101.76 96.67 111.17 108.95 47001 99.29 94.33 108.48 106.31 47010 1,146.16 1,088.85 1,252.18 1,227.13 47015 1,092.78 1,038.14 1,193.86 1,169.99 47100 799.25 759.29 873.18 855.72 47120 2,220.00 2,109.00 2,425.35 2,376.84 47122 3,279.07 3,115.12 3,582.39 3,510.74 47125 2,936.70 2,789.87 3,208.35 3,144.18 47130 3,155.96 2,998.16 3,447.88 3,378.93 47135 4,674.49 4,440.77 5,106.89 5,004.74 47136 4,000.65 3,800.62 4,370.71 4,283.30 47140 3,398.86 3,228.92 3,713.26 3,638.99 47141 3,794.70 3,604.97 4,145.72 4,062.80 47142 4,482.62 4,258.49 4,897.26 4,799.32 47143 329.64 313.16 360.13 352.94 47144 329.64 313.16 360.13 352.94 47145 329.64 313.16 360.13 352.94 47146 316.24 300.43 345.49 338.58 47147 368.85 350.41 402.97 394.91 47300 1,072.39 1,018.77 1,171.59 1,148.15

47350 1,305.94 1,240.64 1,426.74 1,398.20 47360 1,778.94 1,689.99 1,943.49 1,904.62 47361 2,885.45 2,741.18 3,152.36 3,089.31 47362 1,376.17 1,307.36 1,503.46 1,473.39 47370 1,182.94 1,123.79 1,292.36 1,266.51 47371 1,171.89 1,113.30 1,280.30 1,254.68 47380 1,377.37 1,308.50 1,504.78 1,474.68 47381 1,388.23 1,318.82 1,516.64 1,486.31 47382 4,475.54 4,251.76 4,889.52 4,791.73# 47382 767.02 728.67 837.97 821.22 47400 2,054.35 1,951.63 2,244.37 2,199.49 47420 1,278.59 1,214.66 1,396.86 1,368.93 47425 1,300.21 1,235.20 1,420.48 1,392.08 47460 1,205.53 1,145.25 1,317.04 1,290.70 47480 828.71 787.27 905.36 887.25 47490 319.29 303.33 348.83 341.85 47500 96.10 91.30 105.00 102.89 47505 37.29 35.43 40.74 39.93 47510 458.95 436.00 501.40 491.37 47511 567.30 538.94 619.78 607.38 47525 461.42 438.35 504.10 494.02# 47525 82.82 78.68 90.48 88.68 47530 1,241.78 1,179.69 1,356.64 1,329.52# 47530 341.52 324.44 373.11 365.64 47550 158.87 150.93 173.57 170.10 47552 310.12 294.61 338.80 332.03 47553 309.98 294.48 338.65 331.88 47554 475.33 451.56 519.29 508.91 47555 368.03 349.63 402.07 394.04 47556 417.91 397.01 456.56 447.43 47560 257.21 244.35 281.00 275.38 47561 281.48 267.41 307.52 301.37 47562 624.43 593.21 682.19 668.55 47563 678.88 644.94 741.68 726.85 47564 1,058.94 1,005.99 1,156.89 1,133.75 47570 736.49 699.67 804.62 788.53 47600 1,017.34 966.47 1,111.44 1,089.21 47605 1,070.82 1,017.28 1,169.87 1,146.47 47610 1,195.52 1,135.74 1,306.10 1,279.98 47612 1,210.46 1,149.94 1,322.43 1,295.98 47620 1,314.35 1,248.63 1,435.92 1,407.21 47630 529.04 502.59 577.98 566.42 47700 997.83 947.94 1,090.13 1,068.33 47701 1,651.24 1,568.68 1,803.98 1,767.91 47711 1,487.31 1,412.94 1,624.88 1,592.38 47712 1,906.59 1,811.26 2,082.95 2,041.28 47715 1,264.77 1,201.53 1,381.76 1,354.13 47720 1,094.41 1,039.69 1,195.64 1,171.74 47721 1,288.02 1,223.62 1,407.16 1,379.02 47740 1,247.65 1,185.27 1,363.06 1,335.79 47741 1,404.43 1,334.21 1,534.34 1,503.66 47760 2,153.91 2,046.21 2,353.14 2,306.08

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 57

47765 2,902.75 2,757.61 3,171.25 3,107.83 47780 2,363.95 2,245.75 2,582.61 2,530.97 47785 3,108.41 2,952.99 3,395.94 3,328.02 47800 1,507.21 1,431.85 1,646.63 1,613.69 47801 976.53 927.70 1,066.86 1,045.52 47802 1,451.84 1,379.25 1,586.14 1,554.42 47900 1,305.95 1,240.65 1,426.75 1,398.22 48000 1,775.72 1,686.93 1,939.97 1,901.17 48001 2,206.13 2,095.82 2,410.19 2,361.99 48020 1,119.36 1,063.39 1,222.90 1,198.44 48100 845.01 802.76 923.17 904.71 48102 490.83 466.29 536.23 525.50# 48102 239.36 227.39 261.50 256.27 48105 2,724.65 2,588.42 2,976.68 2,917.15 48120 1,056.83 1,003.99 1,154.59 1,131.50 48140 1,491.38 1,416.81 1,629.33 1,596.74 48145 1,556.67 1,478.84 1,700.67 1,666.65 48146 1,787.42 1,698.05 1,952.76 1,913.70 48148 1,187.54 1,128.16 1,297.38 1,271.44 48150 2,968.16 2,819.75 3,242.71 3,177.86 48152 2,753.12 2,615.46 3,007.78 2,947.62 48153 2,958.32 2,810.40 3,231.96 3,167.32 48154 2,764.97 2,626.72 3,020.73 2,960.32 48155 1,728.64 1,642.21 1,888.54 1,850.78 48400 106.04 100.74 115.85 113.54 48500 1,092.06 1,037.46 1,193.08 1,169.22 48510 1,035.45 983.68 1,131.23 1,108.61 48520 1,040.89 988.85 1,137.18 1,114.43 48540 1,249.13 1,186.67 1,364.67 1,337.38 48545 1,281.14 1,217.08 1,399.64 1,371.65 48547 1,710.41 1,624.89 1,868.62 1,831.25 48548 1,588.48 1,509.06 1,735.42 1,700.71 48551 357.78 339.89 390.87 383.05 48552 226.30 214.99 247.24 242.29 48554 2,423.72 2,302.53 2,647.91 2,594.95 48556 1,206.14 1,145.83 1,317.70 1,291.35 49000 735.15 698.39 803.15 787.08 49002 1,000.68 950.65 1,093.25 1,071.39 49010 896.63 851.80 979.57 959.97 49020 1,519.48 1,443.51 1,660.04 1,626.84 49040 954.33 906.61 1,042.60 1,021.75 49060 1,053.43 1,000.76 1,150.87 1,127.85 49062 701.27 666.21 766.14 750.82 49082 173.67 164.99 189.74 185.94# 49082 71.52 67.94 78.13 76.57 49083 270.03 256.53 295.01 289.11# 49083 106.66 101.33 116.53 114.20 49084 99.16 94.20 108.33 106.17 49180 151.72 144.13 165.75 162.44# 49180 85.19 80.93 93.07 91.21 49203 1,145.55 1,088.27 1,251.51 1,226.48 49204 1,465.02 1,391.77 1,600.54 1,568.52

49205 1,683.52 1,599.34 1,839.24 1,802.45 49215 2,129.45 2,022.98 2,326.43 2,279.90 49220 911.00 865.45 995.27 975.36 49250 553.68 526.00 604.90 592.80 49255 754.99 717.24 824.83 808.34 49320 312.16 296.55 341.03 334.21 49321 330.40 313.88 360.96 353.74 49322 354.47 336.75 387.26 379.52 49323 614.79 584.05 671.66 658.23 49324 373.13 354.47 407.64 399.49 49325 399.92 379.92 436.91 428.17 49326 182.27 173.16 199.13 195.16 49327 124.88 118.64 136.44 133.71 49400 129.01 122.56 140.94 138.13# 49400 93.40 88.73 102.04 100.00 49402 815.20 774.44 890.61 872.79 49405 791.00 751.45 864.17 846.88# 49405 210.30 199.79 229.76 225.16 49406 790.69 751.16 863.83 846.56# 49406 210.61 200.08 230.09 225.49 49407 672.09 638.49 734.26 719.58# 49407 224.15 212.94 244.88 239.98 49411 484.29 460.08 529.09 518.51# 49411 194.72 184.98 212.73 208.47 49412 78.64 74.71 85.92 84.20 49418 1,283.88 1,219.69 1,402.64 1,374.60# 49418 220.87 209.83 241.30 236.47 49419 423.82 402.63 463.02 453.77 49421 221.45 210.38 241.94 237.10 49422 363.76 345.57 397.41 389.46 49423 490.49 465.97 535.87 525.15# 49423 71.59 68.01 78.21 76.65 49424 132.56 125.93 144.82 141.92# 49424 38.23 36.32 41.77 40.93 49425 716.19 680.38 782.44 766.79 49426 591.50 561.93 646.22 633.29 49427 44.65 42.42 48.78 47.81 49428 410.15 389.64 448.09 439.13 49429 436.43 414.61 476.80 467.27 49435 115.64 109.86 126.34 123.81 49436 176.38 167.56 192.69 188.84 49440 944.37 897.15 1,031.72 1,011.09# 49440 220.91 209.86 241.34 236.51 49441 1,064.94 1,011.69 1,163.44 1,140.18# 49441 250.89 238.35 274.10 268.62 49442 863.65 820.47 943.54 924.67# 49442 216.72 205.88 236.76 232.02 49446 900.33 855.31 983.61 963.93# 49446 162.19 154.08 177.19 173.65 49450 596.55 566.72 651.73 638.70# 49450 66.45 63.13 72.60 71.15 49451 655.32 622.55 715.93 701.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 58

# 49451 90.86 86.32 99.27 97.28 49452 810.94 770.39 885.95 868.23# 49452 139.96 132.96 152.90 149.85 49460 656.91 624.06 717.67 703.32# 49460 47.78 45.39 52.20 51.15 49465 151.05 143.50 165.03 161.72# 49465 30.47 28.95 33.29 32.63 49491 751.97 714.37 821.53 805.09 49492 897.79 852.90 980.84 961.22 49495 377.93 359.03 412.88 404.63 49496 577.48 548.61 630.90 618.29 49500 359.97 341.97 393.27 385.40 49501 572.28 543.67 625.22 612.72 49505 492.29 467.68 537.83 527.08 49507 554.70 526.97 606.02 593.89 49520 598.84 568.90 654.24 641.15 49521 679.31 645.34 742.14 727.29 49525 542.62 515.49 592.81 580.96 49540 638.61 606.68 697.68 683.73 49550 544.66 517.43 595.04 583.14 49553 598.52 568.59 653.88 640.80 49555 564.37 536.15 616.57 604.24 49557 686.68 652.35 750.20 735.20 49560 700.76 665.72 765.58 750.27 49561 885.87 841.58 967.82 948.46 49565 731.14 694.58 798.77 782.79 49566 895.44 850.67 978.27 958.71 49568 257.24 244.38 281.04 275.41 49570 393.00 373.35 429.35 420.76 49572 487.86 463.47 532.99 522.33 49580 311.87 296.28 340.72 333.90 49582 455.24 432.48 497.35 487.40 49585 419.52 398.54 458.32 449.16 49587 449.18 426.72 490.73 480.92 49590 543.35 516.18 593.61 581.74 49600 691.99 657.39 756.00 740.88 49605 4,723.94 4,487.74 5,160.90 5,057.69 49606 1,078.72 1,024.78 1,178.50 1,154.92 49610 651.40 618.83 711.65 697.42 49611 537.01 510.16 586.68 574.95 49650 404.55 384.32 441.97 433.12 49651 526.63 500.30 575.35 563.83 49652 662.26 629.15 723.52 709.06 49653 827.43 786.06 903.97 885.89 49654 753.30 715.64 822.99 806.53 49655 920.06 874.06 1,005.17 985.07 49656 818.67 777.74 894.40 876.52 49657 1,177.24 1,118.38 1,286.14 1,260.41 49900 773.05 734.40 844.56 827.67 49904 1,376.65 1,307.82 1,503.99 1,473.91 49905 341.00 323.95 372.54 365.09 50010 708.76 673.32 774.32 758.83

50020 990.40 940.88 1,082.01 1,060.37 50040 891.72 847.13 974.20 954.72 50045 896.98 852.13 979.95 960.35 50060 1,098.61 1,043.68 1,200.23 1,176.23 50065 1,166.52 1,108.19 1,274.42 1,248.93 50070 1,143.58 1,086.40 1,249.36 1,224.37 50075 1,407.66 1,337.28 1,537.87 1,507.11 50080 837.92 796.02 915.42 897.12 50081 1,231.73 1,170.14 1,345.66 1,318.75 50100 1,024.60 973.37 1,119.38 1,096.99 50120 913.93 868.23 998.46 978.50 50125 945.92 898.62 1,033.41 1,012.75 50130 994.82 945.08 1,086.84 1,065.11 50135 1,081.41 1,027.34 1,181.44 1,157.81 50200 528.61 502.18 577.51 565.96# 50200 140.64 133.61 153.65 150.58 50205 718.01 682.11 784.43 768.74 50220 1,004.61 954.38 1,097.54 1,075.58 50225 1,155.33 1,097.56 1,262.19 1,236.95 50230 1,236.76 1,174.92 1,351.16 1,324.13 50234 1,255.07 1,192.32 1,371.17 1,343.74 50236 1,413.54 1,342.86 1,544.29 1,513.40 50240 1,276.18 1,212.37 1,394.23 1,366.34 50250 1,172.59 1,113.96 1,281.05 1,255.43 50280 918.34 872.42 1,003.28 983.22 50290 864.41 821.19 944.37 925.49 50320 1,355.57 1,287.79 1,480.96 1,451.33 50323 157.76 149.87 172.35 168.90 50325 157.76 149.87 172.35 168.90 50327 207.82 197.43 227.04 222.50 50328 182.17 173.06 199.02 195.04 50329 169.26 160.80 184.92 181.22 50340 894.87 850.13 977.65 958.10 50360 2,300.14 2,185.13 2,512.90 2,462.64 50365 2,696.23 2,561.42 2,945.63 2,886.72 50370 1,136.94 1,080.09 1,242.10 1,217.26 50380 1,890.83 1,796.29 2,065.73 2,024.41 50382 1,073.67 1,019.99 1,172.99 1,149.53# 50382 268.99 255.54 293.87 287.99 50384 860.04 817.04 939.60 920.81# 50384 245.91 233.61 268.65 263.28 50385 1,022.30 971.19 1,116.87 1,094.54# 50385 226.06 214.76 246.97 242.03 50386 663.19 630.03 724.53 710.04# 50386 171.20 162.64 187.04 183.30 50387 494.25 469.54 539.97 529.17# 50387 97.84 92.95 106.89 104.75 50389 270.52 256.99 295.54 289.63# 50389 54.05 51.35 59.05 57.87 50390 95.86 91.07 104.73 102.64 50391 116.40 110.58 127.17 124.63# 50391 96.10 91.30 105.00 102.89

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 59

50392 175.90 167.11 192.18 188.34 50393 213.62 202.94 233.38 228.71 50394 93.20 88.54 101.82 99.79# 50394 48.22 45.81 52.68 51.62 50395 176.14 167.33 192.43 188.58 50396 115.12 109.36 125.76 123.25 50398 444.57 422.34 485.69 475.97# 50398 71.91 68.31 78.56 76.98 50400 1,116.00 1,060.20 1,219.23 1,194.85 50405 1,346.88 1,279.54 1,471.47 1,442.04 50500 1,222.93 1,161.78 1,336.05 1,309.32 50520 1,041.88 989.79 1,138.26 1,115.49 50525 1,403.86 1,333.67 1,533.72 1,503.05 50526 1,392.63 1,323.00 1,521.45 1,491.02 50540 1,106.09 1,050.79 1,208.41 1,184.24 50541 887.51 843.13 969.60 950.21 50542 1,124.53 1,068.30 1,228.55 1,203.97 50543 1,436.34 1,364.52 1,569.20 1,537.81 50544 1,204.27 1,144.06 1,315.67 1,289.36 50545 1,296.49 1,231.67 1,416.42 1,388.10 50546 1,158.07 1,100.17 1,265.20 1,239.90 50547 1,529.61 1,453.13 1,671.10 1,637.68 50548 1,302.73 1,237.59 1,423.23 1,394.77 50551 339.62 322.64 371.04 363.62# 50551 285.58 271.30 312.00 305.75 50553 364.48 346.26 398.20 390.23# 50553 305.13 289.87 333.35 326.68 50555 389.83 370.34 425.89 417.37# 50555 331.11 314.55 361.73 354.50 50557 396.15 376.34 432.79 424.13# 50557 335.23 318.47 366.24 358.92 50561 450.81 428.27 492.51 482.66# 50561 383.34 364.17 418.80 410.42 50562 562.48 534.36 614.51 602.22 50570 477.03 453.18 521.16 510.74 50572 516.90 491.06 564.72 553.43 50574 549.75 522.26 600.60 588.58 50575 694.82 660.08 759.09 743.91 50576 547.80 520.41 598.47 586.50 50580 591.43 561.86 646.14 633.21 50590 673.54 639.86 735.84 721.12# 50590 544.21 517.00 594.55 582.66 50592 2,781.06 2,642.01 3,038.31 2,977.55# 50592 356.41 338.59 389.38 381.59 50593 4,077.05 3,873.20 4,454.18 4,365.10# 50593 472.25 448.64 515.94 505.62 50600 905.00 859.75 988.71 968.94 50605 934.01 887.31 1,020.41 999.99 50610 910.99 865.44 995.26 975.35 50620 870.93 827.38 951.49 932.45 50630 860.00 817.00 939.55 920.76 50650 997.39 947.52 1,089.65 1,067.86

50660 1,102.60 1,047.47 1,204.59 1,180.50 50684 96.01 91.21 104.89 102.80# 50684 48.22 45.81 52.68 51.62 50686 141.13 134.07 154.18 151.10# 50686 89.90 85.41 98.22 96.26 50688 76.65 72.82 83.74 82.06 50690 91.81 87.22 100.30 98.30# 50690 68.07 64.67 74.37 72.89 50700 893.88 849.19 976.57 957.04 50715 1,154.73 1,096.99 1,261.54 1,236.31 50722 1,015.11 964.35 1,109.00 1,086.82 50725 1,062.26 1,009.15 1,160.52 1,137.32 50727 482.48 458.36 527.11 516.57 50728 670.07 636.57 732.06 717.42 50740 1,162.82 1,104.68 1,270.38 1,244.98 50750 1,112.23 1,056.62 1,215.11 1,190.81 50760 1,085.17 1,030.91 1,185.55 1,161.83 50770 1,112.23 1,056.62 1,215.11 1,190.81 50780 1,066.14 1,012.83 1,164.75 1,141.46 50782 1,006.63 956.30 1,099.75 1,077.75 50783 1,086.87 1,032.53 1,187.41 1,163.66 50785 1,167.08 1,108.73 1,275.04 1,249.54 50800 889.71 845.22 972.00 952.57 50810 1,272.29 1,208.68 1,389.98 1,362.19 50815 1,178.12 1,119.21 1,287.09 1,261.35 50820 1,270.39 1,206.87 1,387.90 1,360.14 50825 1,599.14 1,519.18 1,747.06 1,712.12 50830 1,742.21 1,655.10 1,903.37 1,865.30 50840 1,184.30 1,125.09 1,293.85 1,267.98 50845 1,201.80 1,141.71 1,312.97 1,286.71 50860 909.93 864.43 994.09 974.21 50900 817.46 776.59 893.08 875.22 50920 847.96 805.56 926.39 907.87 50930 1,168.65 1,110.22 1,276.75 1,251.22 50940 853.78 811.09 932.75 914.10 50945 939.04 892.09 1,025.90 1,005.39 50947 1,339.33 1,272.36 1,463.21 1,433.95 50948 1,231.67 1,170.09 1,345.60 1,318.69 50951 354.70 336.97 387.52 379.76# 50951 297.23 282.37 324.73 318.23 50953 375.77 356.98 410.53 402.32# 50953 316.41 300.59 345.68 338.77 50955 402.33 382.21 439.54 430.76# 50955 342.04 324.94 373.68 366.21 50957 405.95 385.65 443.50 434.63# 50957 343.79 326.60 375.59 368.08 50961 364.97 346.72 398.73 390.76# 50961 307.49 292.12 335.94 329.22 50970 359.65 341.67 392.92 385.07 50972 347.61 330.23 379.76 372.17 50974 459.20 436.24 501.68 491.65 50976 452.70 430.07 494.58 484.69

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 60

50980 345.31 328.04 377.25 369.70 51020 448.40 425.98 489.88 480.08 51030 449.37 426.90 490.94 481.11 51040 274.32 260.60 299.69 293.70 51045 467.40 444.03 510.63 500.42 51050 451.87 429.28 493.67 483.79 51060 556.81 528.97 608.32 596.15 51065 554.31 526.59 605.58 593.47 51080 389.70 370.22 425.75 417.24 51100 57.02 54.17 62.30 61.05# 51100 38.28 36.37 41.83 40.99 51101 113.00 107.35 123.45 120.98# 51101 51.15 48.59 55.88 54.76 51102 211.63 201.05 231.21 226.58# 51102 141.35 134.28 154.42 151.33 51500 610.26 579.75 666.71 653.38 51520 568.90 540.46 621.53 609.10 51525 827.63 786.25 904.19 886.11 51530 760.16 722.15 830.47 813.87 51535 748.69 711.26 817.95 801.58 51550 929.90 883.41 1,015.92 995.60 51555 1,223.66 1,162.48 1,336.85 1,310.11 51565 1,246.89 1,184.55 1,362.23 1,334.99 51570 1,427.85 1,356.46 1,559.93 1,528.73 51575 1,759.22 1,671.26 1,921.95 1,883.50 51580 1,831.21 1,739.65 2,000.60 1,960.59 51585 2,039.97 1,937.97 2,228.67 2,184.09 51590 1,869.20 1,775.74 2,042.10 2,001.26 51595 2,118.02 2,012.12 2,313.94 2,267.66 51596 2,273.79 2,160.10 2,484.12 2,434.44 51597 2,221.45 2,110.38 2,426.94 2,378.40 51600 163.38 155.21 178.49 174.93# 51600 43.43 41.26 47.45 46.49 51605 36.50 34.68 39.88 39.09 51610 97.86 92.97 106.92 104.78# 51610 61.94 58.84 67.67 66.31 51700 76.23 72.42 83.28 81.62# 51700 43.43 41.26 47.45 46.49 51701 49.91 47.41 54.52 53.43# 51701 26.79 25.45 29.27 28.68 51702 63.65 60.47 69.54 68.15# 51702 28.98 27.53 31.66 31.03 51703 119.36 113.39 130.40 127.79# 51703 78.44 74.52 85.70 83.98 51705 83.47 79.30 91.20 89.37# 51705 50.04 47.54 54.67 53.58 51710 117.63 111.75 128.51 125.95# 51710 76.09 72.29 83.13 81.47 51715 269.45 255.98 294.38 288.49# 51715 193.86 184.17 211.80 207.56 51720 101.70 96.62 111.11 108.89# 51720 77.33 73.46 84.48 82.79

51725 169.56 161.08 185.24 181.54 51725 TC 95.24 90.48 104.05 101.97 51725 26 74.32 70.60 81.19 79.57 51726 236.87 225.03 258.78 253.61 51726 TC 153.27 145.61 167.45 164.11 51726 26 83.60 79.42 91.33 89.50 51727 282.54 268.41 308.67 302.50 51727 TC 176.77 167.93 193.12 189.26 51727 26 105.77 100.48 115.55 113.24 51728 283.31 269.14 309.51 303.32 51728 TC 180.21 171.20 196.88 192.95 51728 26 103.10 97.95 112.64 110.39 51729 308.36 292.94 336.88 330.14 51729 TC 183.64 174.46 200.63 196.62 51729 26 124.72 118.48 136.25 133.53 51736 14.14 13.43 15.44 15.13 51736 TC 5.90 5.61 6.45 6.33 51736 26 8.24 7.83 9.00 8.82 51741 14.45 13.73 15.79 15.48 51741 TC 6.21 5.90 6.79 6.65 51741 26 8.24 7.83 9.00 8.82 51784 174.03 165.33 190.13 186.32 51784 TC 98.99 94.04 108.15 105.98 51784 26 75.04 71.29 81.98 80.34 51785 230.57 219.04 251.90 246.86 51785 TC 153.03 145.38 167.19 163.84 51785 26 77.54 73.66 84.71 83.02 51792 188.33 178.91 205.75 201.63 51792 TC 133.97 127.27 146.36 143.43 51792 26 54.36 51.64 59.39 58.20 51797 100.61 95.58 109.92 107.72 51797 TC 61.82 58.73 67.54 66.19 51797 26 38.79 36.85 42.38 41.53 51798 16.52 15.69 18.04 17.69 51800 1,004.72 954.48 1,097.65 1,075.70 51820 1,042.46 990.34 1,138.89 1,116.11 51840 637.77 605.88 696.76 682.82 51841 758.14 720.23 828.26 811.70 51845 568.23 539.82 620.79 608.37 51860 717.86 681.97 784.27 768.58 51865 861.92 818.82 941.64 922.81 51880 450.71 428.17 492.40 482.55 51900 797.95 758.05 871.76 854.32 51920 772.82 734.18 844.31 827.43 51925 1,007.22 956.86 1,100.39 1,078.38 51940 1,575.31 1,496.54 1,721.02 1,686.60 51960 1,342.72 1,275.58 1,466.92 1,437.58 51980 684.84 650.60 748.19 733.23 51990 733.80 697.11 801.68 785.65 51992 826.34 785.02 902.77 884.72 52000 186.57 177.24 203.83 199.76# 52000 121.60 115.52 132.85 130.19

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 61

52001 348.02 330.62 380.21 372.61# 52001 278.36 264.44 304.11 298.02 52005 239.97 227.97 262.17 256.92# 52005 128.45 122.03 140.33 137.53 52007 397.05 377.20 433.78 425.11# 52007 160.27 152.26 175.10 171.59 52010 330.83 314.29 361.43 354.20# 52010 160.27 152.26 175.10 171.59 52204 330.25 313.74 360.80 353.59# 52204 136.89 130.05 149.56 146.57 52214 585.63 556.35 639.80 627.00# 52214 171.42 162.85 187.28 183.53 52224 615.12 584.36 672.01 658.57# 52224 198.73 188.79 217.11 212.76 52234 237.75 225.86 259.74 254.54 52235 279.30 265.34 305.14 299.03 52240 380.23 361.22 415.40 407.10 52250 232.12 220.51 253.59 248.52 52260 203.74 193.55 222.58 218.13 52265 330.94 314.39 361.55 354.32# 52265 158.51 150.58 173.17 169.71 52270 322.60 306.47 352.44 345.39# 52270 176.09 167.29 192.38 188.53 52275 436.39 414.57 476.76 467.22# 52275 240.53 228.50 262.78 257.52 52276 256.45 243.63 280.17 274.57 52277 313.32 297.65 342.30 335.46 52281 248.09 235.69 271.04 265.63# 52281 147.51 140.13 161.15 157.93 52282 326.38 310.06 356.57 349.44 52283 257.03 244.18 280.81 275.20# 52283 194.87 185.13 212.90 208.64 52285 258.62 245.69 282.54 276.90# 52285 189.58 180.10 207.12 202.98 52287 284.38 270.16 310.68 304.47# 52287 164.11 155.90 179.29 175.70 52290 236.00 224.20 257.83 252.68 52300 273.56 259.88 298.86 292.88 52301 281.14 267.08 307.14 301.00 52305 270.26 256.75 295.26 289.36 52310 223.38 212.21 244.04 239.17# 52310 146.85 139.51 160.44 157.23 52315 381.39 362.32 416.67 408.33# 52315 265.50 252.23 290.06 284.27 52317 726.12 689.81 793.28 777.41# 52317 337.22 320.36 368.41 361.04 52318 459.60 436.62 502.11 492.07 52320 238.66 226.73 260.74 255.53 52325 310.77 295.23 339.51 332.73 52327 255.03 242.28 278.62 273.04 52330 450.30 427.79 491.96 482.11# 52330 255.70 242.92 279.36 273.77

52332 436.19 414.38 476.54 467.00# 52332 150.36 142.84 164.27 160.98 52334 248.21 235.80 271.17 265.74 52341 274.86 261.12 300.29 294.29 52342 299.19 284.23 326.86 320.33 52343 333.71 317.02 364.57 357.28 52344 358.04 340.14 391.16 383.34 52345 382.37 363.25 417.74 409.39 52346 433.28 411.62 473.36 463.90 52351 293.15 278.49 320.26 313.86 52352 343.61 326.43 375.39 367.89 52353 379.95 360.95 415.09 406.79 52354 404.56 384.33 441.98 433.14 52355 453.78 431.09 495.75 485.84 52356 403.62 383.44 440.96 432.14 52400 460.62 437.59 503.23 493.17 52402 259.26 246.30 283.25 277.58 52450 448.60 426.17 490.10 480.30 52500 466.39 443.07 509.53 499.34 52601 814.03 773.33 889.33 871.54 52630 381.81 362.72 417.13 408.79 52640 298.47 283.55 326.08 319.56 52647 1,592.20 1,512.59 1,739.48 1,704.69# 52647 621.02 589.97 678.47 664.90 52648 1,642.29 1,560.18 1,794.21 1,758.33# 52648 663.30 630.14 724.66 710.17 52649 790.17 750.66 863.26 846.00 52700 421.77 400.68 460.78 451.57 53000 141.07 134.02 154.12 151.04 53010 278.58 264.65 304.35 298.26 53020 93.73 89.04 102.40 100.35 53025 64.60 61.37 70.58 69.16 53040 375.25 356.49 409.96 401.76 53060 177.31 168.44 193.71 189.83# 53060 161.69 153.61 176.65 173.12 53080 400.90 380.86 437.99 429.23 53085 631.74 600.15 690.17 676.37 53200 148.72 141.28 162.47 159.22# 53200 137.16 130.30 149.85 146.84 53210 739.78 702.79 808.21 792.04 53215 893.96 849.26 976.65 957.11 53220 433.31 411.64 473.39 463.92 53230 583.72 554.53 637.71 624.96 53235 606.31 575.99 662.39 649.14 53240 405.66 385.38 443.19 434.32 53250 398.41 378.49 435.26 426.56 53260 191.41 181.84 209.12 204.93# 53260 173.30 164.64 189.34 185.55 53265 205.80 195.51 224.84 220.34# 53265 178.62 169.69 195.14 191.25 53270 200.34 190.32 218.87 214.49# 53270 181.60 172.52 198.40 194.43

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 62

53275 251.85 239.26 275.15 269.64 53400 770.04 731.54 841.27 824.45 53405 840.16 798.15 917.87 899.52 53410 943.09 895.94 1,030.33 1,009.72 53415 1,089.86 1,035.37 1,190.68 1,166.86 53420 809.59 769.11 884.48 866.79 53425 902.39 857.27 985.86 966.14 53430 935.16 888.40 1,021.66 1,001.22 53431 1,112.36 1,056.74 1,215.25 1,190.95 53440 723.48 687.31 790.41 774.59 53442 749.69 712.21 819.04 802.67 53444 762.37 724.25 832.89 816.24 53445 721.93 685.83 788.70 772.93 53446 615.09 584.34 671.99 658.55 53447 776.74 737.90 848.59 831.61 53448 1,233.82 1,172.13 1,347.95 1,320.99 53449 586.26 556.95 640.49 627.68 53450 389.97 370.47 426.04 417.52 53460 437.60 415.72 478.08 468.52 53500 722.13 686.02 788.92 773.15 53502 465.94 442.64 509.04 498.86 53505 465.31 442.04 508.35 498.18 53510 604.92 574.67 660.87 647.66 53515 764.70 726.47 835.44 818.73 53520 532.40 505.78 581.65 570.01 53600 78.26 74.35 85.50 83.79# 53600 61.70 58.62 67.41 66.07 53601 74.81 71.07 81.73 80.10# 53601 51.38 48.81 56.13 55.00 53605 62.65 59.52 68.45 67.08 53620 108.74 103.30 118.80 116.41# 53620 84.37 80.15 92.17 90.33 53621 101.08 96.03 110.43 108.23# 53621 69.22 65.76 75.62 74.11 53660 64.55 61.32 70.52 69.10# 53660 39.87 37.88 43.56 42.69 53661 63.66 60.48 69.55 68.16# 53661 38.98 37.03 42.58 41.73 53665 37.88 35.99 41.39 40.56 53850 1,841.85 1,749.76 2,012.22 1,971.97# 53850 579.86 550.87 633.50 620.83 53852 1,702.32 1,617.20 1,859.78 1,822.59# 53852 596.83 566.99 652.04 639.00 53855 678.29 644.38 741.04 726.21# 53855 80.40 76.38 87.84 86.08 53860 1,364.44 1,296.22 1,490.65 1,460.85# 53860 224.90 213.66 245.71 240.80 54000 135.53 128.75 148.06 145.11# 54000 101.80 96.71 111.22 109.00 54001 171.31 162.74 187.15 183.41# 54001 132.57 125.94 144.83 141.93 54015 296.63 281.80 324.07 317.58

54050 119.72 113.73 130.79 128.18# 54050 97.54 92.66 106.56 104.43 54055 107.73 102.34 117.69 115.33# 54055 86.18 81.87 94.15 92.26 54056 129.02 122.57 140.96 138.14# 54056 103.40 98.23 112.96 110.71 54057 123.29 117.13 134.70 132.01# 54057 88.62 84.19 96.82 94.89 54060 164.84 156.60 180.09 176.49# 54060 123.61 117.43 135.04 132.34 54065 202.70 192.57 221.46 217.03# 54065 163.96 155.76 179.12 175.54 54100 179.71 170.72 196.33 192.41# 54100 118.80 112.86 129.79 127.19 54105 247.17 234.81 270.03 264.63# 54105 203.44 193.27 222.26 217.81 54110 598.80 568.86 654.19 641.10 54111 770.51 731.98 841.78 824.94 54112 902.67 857.54 986.17 966.45 54115 427.59 406.21 467.14 457.80# 54115 404.47 384.25 441.89 433.06 54120 606.30 575.99 662.39 649.14 54125 781.80 742.71 854.12 837.04 54130 1,150.41 1,092.89 1,256.82 1,231.68 54135 1,460.06 1,387.06 1,595.12 1,563.22 54150 144.14 136.93 157.47 154.32# 54150 95.72 90.93 104.57 102.48 54160 202.59 192.46 221.33 216.90# 54160 138.24 131.33 151.03 148.01 54161 188.37 178.95 205.79 201.68 54162 239.95 227.95 262.14 256.90# 54162 190.28 180.77 207.89 203.72 54163 207.15 196.79 226.31 221.78 54164 183.13 173.97 200.07 196.06 54200 98.14 93.23 107.21 105.08# 54200 78.77 74.83 86.05 84.33 54205 508.69 483.26 555.75 544.63 54220 188.58 179.15 206.02 201.91# 54220 129.23 122.77 141.19 138.36 54230 90.41 85.89 98.77 96.80# 54230 76.04 72.24 83.08 81.42 54231 132.08 125.48 144.30 141.42# 54231 111.77 106.18 122.11 119.67 54235 84.41 80.19 92.22 90.38# 54235 70.36 66.84 76.87 75.33 54240 93.16 88.50 101.78 99.74 54240 TC 30.27 28.76 33.07 32.41 54240 26 62.89 59.75 68.71 67.34 54250 115.90 110.11 126.63 124.10 54250 TC 9.34 8.87 10.20 9.99 54250 26 106.56 101.23 116.41 114.09 54300 614.98 584.23 671.86 658.43

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 63

54304 720.09 684.09 786.70 770.97 54308 686.94 652.59 750.48 735.47 54312 786.23 746.92 858.96 841.78 54316 960.65 912.62 1,049.51 1,028.53 54318 673.21 639.55 735.48 720.77 54322 751.14 713.58 820.62 804.21 54324 932.88 886.24 1,019.18 998.80 54326 910.28 864.77 994.49 974.59 54328 904.14 858.93 987.77 968.01 54332 976.34 927.52 1,066.65 1,045.32 54336 1,146.03 1,088.73 1,252.04 1,227.00 54340 545.26 518.00 595.70 583.79 54344 955.76 907.97 1,044.17 1,023.28 54348 963.08 914.93 1,052.17 1,031.12 54352 1,367.31 1,298.94 1,493.78 1,463.90 54360 692.92 658.27 757.01 741.87 54380 767.95 729.55 838.98 822.20 54385 944.35 897.13 1,031.70 1,011.07 54390 1,235.64 1,173.86 1,349.94 1,322.94 54400 507.35 481.98 554.28 543.19 54401 624.16 592.95 681.89 668.25 54405 778.08 739.18 850.06 833.06 54406 701.20 666.14 766.06 750.74 54408 758.90 720.96 829.10 812.52 54410 825.88 784.59 902.28 884.24 54411 986.56 937.23 1,077.81 1,056.26 54415 505.15 479.89 551.87 540.83 54416 679.92 645.92 742.81 727.95 54417 864.80 821.56 944.79 925.90 54420 676.86 643.02 739.47 724.68 54430 613.75 583.06 670.52 657.11 54435 397.34 377.47 434.09 425.41 54450 66.32 63.00 72.45 71.00# 54450 55.70 52.92 60.86 59.64 54500 71.53 67.95 78.14 76.58 54505 200.44 190.42 218.98 214.60 54512 517.59 491.71 565.47 554.16 54520 311.53 295.95 340.34 333.53 54522 577.13 548.27 630.51 617.90 54530 483.82 459.63 528.57 518.01 54535 715.00 679.25 781.14 765.52 54550 471.27 447.71 514.87 504.57 54560 659.71 626.72 720.73 706.32 54600 433.35 411.68 473.43 463.97 54620 287.41 273.04 314.00 307.72 54640 456.11 433.30 498.30 488.32 54650 682.80 648.66 745.96 731.04 54660 339.99 322.99 371.44 364.01 54670 386.64 367.31 422.41 413.95 54680 756.72 718.88 826.71 810.18 54690 700.07 665.07 764.83 749.54 54692 764.23 726.02 834.92 818.23

54700 203.60 193.42 222.43 217.98 54800 124.51 118.28 136.02 133.30 54830 355.32 337.55 388.18 380.42 54840 306.67 291.34 335.04 328.34 54860 400.06 380.06 437.07 428.33 54861 541.78 514.69 591.89 580.06 54865 341.93 324.83 373.55 366.08 54900 759.83 721.84 830.12 813.51 54901 1,037.95 986.05 1,133.96 1,111.28 55000 108.56 103.13 118.60 116.23# 55000 81.07 77.02 88.57 86.80 55040 323.15 306.99 353.04 345.98 55041 488.15 463.74 533.30 522.64 55060 363.63 345.45 397.27 389.32 55100 200.76 190.72 219.33 214.95# 55100 158.28 150.37 172.93 169.46 55110 370.67 352.14 404.96 396.87 55120 341.88 324.79 373.51 366.03 55150 470.52 446.99 514.04 503.76 55175 346.04 328.74 378.05 370.50 55180 666.01 632.71 727.62 713.07 55200 403.61 383.43 440.94 432.12# 55200 267.10 253.75 291.81 285.98 55250 349.51 332.03 381.83 374.20# 55250 215.19 204.43 235.09 230.39 55300 181.39 172.32 198.17 194.20 55400 506.52 481.19 553.37 542.31 55450 332.53 315.90 363.29 356.02# 55450 246.32 234.00 269.10 263.72 55500 378.24 359.33 413.23 404.96 55520 428.31 406.89 467.92 458.56 55530 336.95 320.10 368.12 360.76 55535 411.12 390.56 449.14 440.16 55540 513.26 487.60 560.74 549.53 55550 409.61 389.13 447.50 438.55 55600 402.84 382.70 440.11 431.31 55605 516.54 490.71 564.32 553.04 55650 689.27 654.81 753.03 737.97 55680 330.30 313.79 360.86 353.64 55700 201.50 191.43 220.14 215.74# 55700 134.97 128.22 147.45 144.51 55705 254.85 242.11 278.43 272.86 55706 352.50 334.88 385.11 377.41 55720 432.51 410.88 472.51 463.06 55725 567.88 539.49 620.41 608.01 55801 1,053.00 1,000.35 1,150.40 1,127.39 55810 1,271.03 1,207.48 1,388.60 1,360.83 55812 1,553.60 1,475.92 1,697.31 1,663.36 55815 1,703.47 1,618.30 1,861.05 1,823.82 55821 841.45 799.38 919.29 900.90 55831 910.72 865.18 994.96 975.06 55840 1,290.32 1,225.80 1,409.67 1,381.47

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 64

55842 1,382.53 1,313.40 1,510.41 1,480.20 55845 1,580.46 1,501.44 1,726.66 1,692.12 55860 842.23 800.12 920.14 901.74 55862 1,056.88 1,004.04 1,154.65 1,131.55 55865 1,287.00 1,222.65 1,406.05 1,377.93 55866 1,675.72 1,591.93 1,830.72 1,794.10 55870 165.27 157.01 180.56 176.95# 55870 137.46 130.59 150.18 147.18 55873 6,013.85 5,713.16 6,570.13 6,438.74# 55873 735.96 699.16 804.03 787.96 55875 733.07 696.42 800.88 784.86 55876 125.80 119.51 137.44 134.69# 55876 96.43 91.61 105.35 103.25 55920 433.37 411.70 473.46 463.99 56405 104.35 99.13 114.00 111.72# 56405 103.73 98.54 113.32 111.06 56420 114.19 108.48 124.75 122.26# 56420 88.26 83.85 96.43 94.50 56440 176.54 167.71 192.87 189.01 56441 136.35 129.53 148.96 145.98# 56441 132.29 125.68 144.53 141.65 56442 46.15 43.84 50.42 49.40 56501 123.16 117.00 134.55 131.86# 56501 109.73 104.24 119.88 117.48 56515 213.61 202.93 233.37 228.70# 56515 192.37 182.75 210.16 205.97 56605 78.17 74.26 85.40 83.69# 56605 59.11 56.15 64.57 63.28 56606 35.67 33.89 38.97 38.19# 56606 28.79 27.35 31.45 30.82 56620 489.47 465.00 534.75 524.06 56625 590.60 561.07 645.23 632.33 56630 873.31 829.64 954.09 935.01 56631 1,111.82 1,056.23 1,214.66 1,190.38 56632 1,289.51 1,225.03 1,408.78 1,380.61 56633 1,139.97 1,082.97 1,245.42 1,220.51 56634 1,210.65 1,150.12 1,322.64 1,296.19 56637 1,415.79 1,345.00 1,546.75 1,515.82 56640 1,418.12 1,347.21 1,549.29 1,518.31 56700 180.40 171.38 197.09 193.14 56740 289.18 274.72 315.93 309.61 56800 232.35 220.73 253.84 248.77 56805 1,119.71 1,063.72 1,223.28 1,198.82 56810 251.64 239.06 274.92 269.42 56820 105.96 100.66 115.76 113.45# 56820 83.78 79.59 91.53 89.70 56821 140.06 133.06 153.02 149.96# 56821 112.57 106.94 122.98 120.52 57000 183.03 173.88 199.96 195.96 57010 420.43 399.41 459.32 450.13 57020 90.65 86.12 99.04 97.06# 57020 80.35 76.33 87.78 86.02

57022 167.20 158.84 182.67 179.01 57023 301.98 286.88 329.91 323.31 57061 106.43 101.11 116.28 113.95# 57061 93.63 88.95 102.29 100.25 57065 183.47 174.30 200.45 196.43# 57065 165.97 157.67 181.32 177.70 57100 83.87 79.68 91.63 89.80# 57100 64.81 61.57 70.81 69.39 57105 127.88 121.49 139.71 136.92# 57105 119.76 113.77 130.84 128.21 57106 467.64 444.26 510.90 500.68 57107 1,384.41 1,315.19 1,512.47 1,482.22 57109 1,622.25 1,541.14 1,772.31 1,736.87 57110 875.07 831.32 956.02 936.89 57111 1,571.34 1,492.77 1,716.69 1,682.35 57112 1,664.35 1,581.13 1,818.30 1,781.94 57120 494.47 469.75 540.21 529.41 57130 168.91 160.46 184.53 180.84# 57130 153.29 145.63 167.47 164.13 57135 182.40 173.28 199.27 195.28# 57135 166.16 157.85 181.53 177.89 57150 42.54 40.41 46.47 45.54# 57150 28.79 27.35 31.45 30.82 57155 398.62 378.69 435.49 426.79# 57155 279.61 265.63 305.47 299.37 57156 184.62 175.39 201.70 197.66# 57156 141.51 134.43 154.59 151.50 57160 71.72 68.13 78.35 76.79# 57160 46.42 44.10 50.72 49.70 57170 58.07 55.17 63.45 62.18# 57170 47.45 45.08 51.84 50.81 57180 131.82 125.23 144.01 141.14# 57180 101.84 96.75 111.26 109.04 57200 287.15 272.79 313.71 307.43 57210 353.31 335.64 385.99 378.27 57220 307.55 292.17 336.00 329.28 57230 382.70 363.57 418.11 409.75 57240 648.89 616.45 708.92 694.74 57250 658.42 625.50 719.33 704.94 57260 812.73 772.09 887.90 870.15 57265 890.69 846.16 973.08 953.63 57267 251.74 239.15 275.02 269.53 57268 465.74 442.45 508.82 498.64 57270 778.91 739.96 850.95 833.93 57280 929.77 883.28 1,015.77 995.45 57282 483.12 458.96 527.80 517.25 57283 671.13 637.57 733.21 718.54 57284 795.02 755.27 868.56 851.18 57285 654.72 621.98 715.28 700.97 57287 653.12 620.46 713.53 699.26 57288 688.78 654.34 752.49 737.44 57289 699.57 664.59 764.28 749.00

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 65

57291 596.32 566.50 651.48 638.45 57292 797.02 757.17 870.75 853.33 57295 462.27 439.16 505.03 494.94 57296 928.09 881.69 1,013.94 993.67 57300 537.77 510.88 587.51 575.76 57305 896.64 851.81 979.58 959.99 57307 1,016.34 965.52 1,110.35 1,088.14 57308 643.22 611.06 702.72 688.67 57310 439.33 417.36 479.96 470.36 57311 501.23 476.17 547.60 536.65 57320 510.77 485.23 558.01 546.86 57330 710.40 674.88 776.11 760.59 57335 1,098.77 1,043.83 1,200.40 1,176.39 57400 130.35 123.83 142.40 139.55 57410 104.19 98.98 113.83 111.55 57415 153.57 145.89 167.77 164.42 57420 110.79 105.25 121.04 118.62# 57420 88.61 84.18 96.81 94.88 57421 148.80 141.36 162.56 159.31# 57421 120.69 114.66 131.86 129.23 57423 896.15 851.34 979.04 959.46 57425 945.97 898.67 1,033.47 1,012.81 57426 824.38 783.16 900.63 882.63 57452 103.53 98.35 113.10 110.84# 57452 89.16 84.70 97.41 95.46 57454 147.18 139.82 160.79 157.57# 57454 132.81 126.17 145.10 142.20 57455 136.08 129.28 148.67 145.69# 57455 108.90 103.46 118.98 116.60 57456 128.63 122.20 140.53 137.72# 57456 101.45 96.38 110.84 108.62 57460 263.14 249.98 287.48 281.73# 57460 159.74 151.75 174.51 171.03 57461 298.96 284.01 326.61 320.08# 57461 184.94 175.69 202.04 198.01 57500 118.23 112.32 129.17 126.58# 57500 73.56 69.88 80.36 78.75 57505 95.69 90.91 104.55 102.45# 57505 87.26 82.90 95.34 93.43 57510 125.74 119.45 137.37 134.62# 57510 112.62 106.99 123.04 120.58 57511 138.08 131.18 150.86 147.84# 57511 127.46 121.09 139.25 136.47 57513 137.45 130.58 150.17 147.17# 57513 128.08 121.68 139.93 137.14 57520 289.89 275.40 316.71 310.37# 57520 262.72 249.58 287.02 281.28 57522 251.19 238.63 274.42 268.94# 57522 234.32 222.60 255.99 250.87 57530 332.06 315.46 362.78 355.52 57531 1,712.83 1,627.19 1,871.27 1,833.85 57540 759.43 721.46 829.68 813.08

57545 801.77 761.68 875.93 858.42 57550 394.06 374.36 430.51 421.90 57555 583.84 554.65 637.85 625.09 57556 549.67 522.19 600.52 588.51 57558 119.36 113.39 130.40 127.79# 57558 109.68 104.20 119.83 117.44 57700 297.10 282.25 324.59 318.10 57720 295.65 280.87 323.00 316.54 57800 56.87 54.03 62.13 60.89# 57800 46.88 44.54 51.22 50.20 58100 104.22 99.01 113.86 111.58# 58100 86.11 81.80 94.07 92.18 58110 46.25 43.94 50.53 49.52# 58110 40.32 38.30 44.05 43.16 58120 245.58 233.30 268.30 262.92# 58120 211.85 201.26 231.45 226.81 58140 896.72 851.88 979.66 960.07 58145 528.45 502.03 577.33 565.79 58146 1,129.11 1,072.65 1,233.55 1,208.88 58150 977.58 928.70 1,068.01 1,046.65 58152 1,217.84 1,156.95 1,330.49 1,303.88 58180 936.36 889.54 1,022.97 1,002.51 58200 1,297.38 1,232.51 1,417.39 1,389.04 58210 1,740.58 1,653.55 1,901.58 1,863.55 58240 2,766.25 2,627.94 3,022.13 2,961.69 58260 806.58 766.25 881.19 863.57 58262 900.61 855.58 983.92 964.24 58263 967.64 919.26 1,057.15 1,036.00 58267 1,030.84 979.30 1,126.20 1,103.67 58270 861.20 818.14 940.86 922.05 58275 960.82 912.78 1,049.70 1,028.70 58280 1,027.69 976.31 1,122.76 1,100.30 58285 1,284.15 1,219.94 1,402.93 1,374.87 58290 1,126.01 1,069.71 1,230.17 1,205.57 58291 1,219.73 1,158.74 1,332.55 1,305.91 58292 1,287.14 1,222.78 1,406.20 1,378.07 58293 1,339.14 1,272.18 1,463.01 1,433.75 58294 1,192.96 1,133.31 1,303.31 1,277.24 58301 90.68 86.15 99.07 97.09# 58301 66.94 63.59 73.13 71.67 58321 69.33 65.86 75.74 74.22# 58321 45.90 43.61 50.15 49.15 58322 81.29 77.23 88.81 87.04# 58322 57.86 54.97 63.22 61.95 58323 14.97 14.22 16.35 16.03# 58323 12.16 11.55 13.28 13.02 58340 107.36 101.99 117.29 114.94# 58340 55.50 52.73 60.64 59.43 58345 271.32 257.75 296.41 290.49 58346 426.15 404.84 465.57 456.25 58350 90.17 85.66 98.51 96.54# 58350 74.86 71.12 81.79 80.16

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 66

58353 894.43 849.71 977.17 957.63# 58353 212.83 202.19 232.52 227.87 58356 1,673.24 1,589.58 1,828.02 1,791.46# 58356 340.34 323.32 371.82 364.38 58400 424.59 403.36 463.86 454.58 58410 784.29 745.08 856.84 839.71 58520 798.35 758.43 872.19 854.75 58540 887.20 842.84 969.27 949.88 58541 841.65 799.57 919.51 901.12 58542 941.49 894.42 1,028.58 1,008.01 58543 956.13 908.32 1,044.57 1,023.67 58544 1,039.01 987.06 1,135.12 1,112.42 58545 875.15 831.39 956.10 936.97 58546 1,102.46 1,047.34 1,204.44 1,180.35 58548 1,789.94 1,700.44 1,955.51 1,916.39 58550 861.25 818.19 940.92 922.10 58552 957.87 909.98 1,046.48 1,025.55 58553 1,111.10 1,055.55 1,213.88 1,189.61 58554 1,289.16 1,224.70 1,408.41 1,380.24 58555 282.95 268.80 309.12 302.93# 58555 186.12 176.81 203.33 199.26 58558 372.33 353.71 406.77 398.64# 58558 261.12 248.06 285.27 279.57 58559 335.55 318.77 366.59 359.25 58560 379.51 360.53 414.61 406.32 58561 537.49 510.62 587.21 575.47 58562 387.03 367.68 422.83 414.38# 58562 283.95 269.75 310.21 304.01 58563 1,477.59 1,403.71 1,614.27 1,581.99# 58563 335.86 319.07 366.93 359.59 58565 1,663.27 1,580.11 1,817.13 1,780.79# 58565 421.27 400.21 460.24 451.04 58570 906.27 860.96 990.10 970.30 58571 1,014.38 963.66 1,108.21 1,086.05 58572 1,130.91 1,074.36 1,235.51 1,210.80 58573 1,302.73 1,237.59 1,423.23 1,394.77 58600 353.87 336.18 386.61 378.88 58605 318.95 303.00 348.45 341.48 58611 76.44 72.62 83.51 81.85 58615 236.36 224.54 258.22 253.06 58660 655.43 622.66 716.06 701.74 58661 630.00 598.50 688.28 674.51 58662 688.19 653.78 751.85 736.81 58670 354.19 336.48 386.95 379.21 58671 354.50 336.78 387.30 379.55 58672 719.13 683.17 785.65 769.94 58673 781.81 742.72 854.13 837.05 58700 752.59 714.96 822.20 805.76 58720 705.76 670.47 771.04 755.62 58740 851.97 809.37 930.78 912.16 58750 891.60 847.02 974.07 954.59 58752 839.91 797.91 917.60 899.24

58760 790.09 750.59 863.18 845.92 58770 843.15 800.99 921.14 902.72 58800 304.44 289.22 332.60 325.96# 58800 287.58 273.20 314.18 307.90 58805 391.58 372.00 427.80 419.24 58820 300.68 285.65 328.50 321.93 58822 712.92 677.27 778.86 763.28 58825 676.54 642.71 739.12 724.34 58900 427.85 406.46 467.43 458.08 58920 695.95 661.15 760.32 745.12 58925 719.87 683.88 786.46 770.73 58940 502.03 476.93 548.47 537.50 58943 1,115.70 1,059.92 1,218.91 1,194.53 58950 1,066.67 1,013.34 1,165.34 1,142.03 58951 1,372.62 1,303.99 1,499.59 1,469.60 58952 1,549.28 1,471.82 1,692.59 1,658.74 58953 1,917.93 1,822.03 2,095.33 2,053.43 58954 2,080.63 1,976.60 2,273.09 2,227.63 58956 1,307.52 1,242.14 1,428.46 1,399.90 58957 1,499.80 1,424.81 1,638.53 1,605.76 58958 1,648.67 1,566.24 1,801.18 1,765.16 58960 914.67 868.94 999.28 979.29 58970 206.12 195.81 225.18 220.67# 58970 187.69 178.31 205.06 200.95 58976 232.14 220.53 253.61 248.54# 58976 202.47 192.35 221.20 216.78 59000 117.19 111.33 128.03 125.47# 59000 78.45 74.53 85.71 84.00 59001 175.19 166.43 191.39 187.57 59012 198.30 188.39 216.65 212.31 59015 149.17 141.71 162.97 159.71# 59015 128.87 122.43 140.79 137.98 59020 65.25 61.99 71.29 69.86 59020 TC 29.33 27.86 32.04 31.40 59020 26 35.92 34.12 39.24 38.46 59025 44.49 42.27 48.61 47.63 59025 TC 15.90 15.11 17.38 17.03 59025 26 28.60 27.17 31.25 30.62 59030 98.39 93.47 107.49 105.34 59050 49.75 47.26 54.35 53.26 59051 41.39 39.32 45.22 44.31 59070 389.45 369.98 425.48 416.97# 59070 303.23 288.07 331.28 324.66 59072 511.39 485.82 558.69 547.52 59074 371.33 352.76 405.67 397.56# 59074 303.55 288.37 331.63 324.99 59076 513.26 487.60 560.74 549.53 59100 809.05 768.60 883.89 866.21 59120 770.52 731.99 841.79 824.95 59121 771.12 732.56 842.44 825.60 59130 815.23 774.47 890.64 872.83 59135 808.32 767.90 883.09 865.42

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 67

59136 856.88 814.04 936.15 917.42 59140 364.17 345.96 397.85 389.90 59150 746.36 709.04 815.40 799.09 59151 726.69 690.36 793.91 778.03 59160 194.01 184.31 211.96 207.71# 59160 167.77 159.38 183.29 179.62 59200 67.82 64.43 74.09 72.61# 59200 44.40 42.18 48.51 47.54 59300 182.45 173.33 199.33 195.34# 59300 144.34 137.12 157.69 154.54 59320 148.06 140.66 161.76 158.53 59325 213.49 202.82 233.24 228.57 59350 274.34 260.62 299.71 293.72 59400 2,021.61 1,920.53 2,208.61 2,164.44 59409 800.97 760.92 875.06 857.56 59410 1,018.89 967.95 1,113.14 1,090.88 59412 100.84 95.80 110.17 107.96 59414 89.87 85.38 98.19 96.22 59425 435.75 413.96 476.05 466.53# 59425 350.47 332.95 382.89 375.23 59426 779.20 740.24 851.28 834.26# 59426 618.64 587.71 675.87 662.35 59430 175.89 167.10 192.17 188.32# 59430 136.84 130.00 149.50 146.51 59510 2,235.05 2,123.30 2,441.80 2,392.95 59514 900.47 855.45 983.77 964.09 59515 1,231.93 1,170.33 1,345.88 1,318.96 59525 475.75 451.96 519.75 509.36 59610 2,119.29 2,013.33 2,315.33 2,269.02 59612 898.24 853.33 981.33 961.70 59614 1,115.43 1,059.66 1,218.61 1,194.24 59618 2,265.33 2,152.06 2,474.87 2,425.37 59620 929.96 883.46 1,015.98 995.66 59622 1,265.10 1,201.85 1,382.13 1,354.48 59812 303.84 288.65 331.95 325.31# 59812 284.48 270.26 310.80 304.58 59820 359.89 341.90 393.19 385.32# 59820 340.21 323.20 371.68 364.25 59821 364.19 345.98 397.88 389.92# 59821 342.63 325.50 374.33 366.84 59830 420.58 399.55 459.48 450.29 59840 205.71 195.42 224.73 220.24# 59840 198.21 188.30 216.55 212.21 59841 367.20 348.84 401.17 393.14# 59841 348.77 331.33 381.03 373.41 59850 333.06 316.41 363.87 356.59 59851 383.50 364.33 418.98 410.60 59852 485.59 461.31 530.51 519.89 59855 401.24 381.18 438.36 429.59 59856 472.44 448.82 516.14 505.82 59857 501.67 476.59 548.08 537.12 59866 211.30 200.74 230.85 226.24

59870 451.41 428.84 493.17 483.30 59871 129.87 123.38 141.89 139.05 59899 456.71 433.87 498.95 488.97 60000 161.49 153.42 176.43 172.90# 60000 145.87 138.58 159.37 156.18 60100 106.90 101.56 116.79 114.46# 60100 77.85 73.96 85.05 83.35 60200 630.92 599.37 689.28 675.49 60210 676.48 642.66 739.06 724.28 60212 965.94 917.64 1,055.29 1,034.18 60220 679.84 645.85 742.73 727.87 60225 891.76 847.17 974.25 954.76 60240 883.19 839.03 964.88 945.59 60252 1,268.36 1,204.94 1,385.68 1,357.97 60254 1,608.58 1,528.15 1,757.37 1,722.23 60260 1,053.46 1,000.79 1,150.91 1,127.89 60270 1,315.87 1,250.08 1,437.59 1,408.84 60271 1,016.87 966.03 1,110.93 1,088.72 60280 422.78 401.64 461.89 452.65 60281 566.40 538.08 618.79 606.42 60300 108.08 102.68 118.08 115.72# 60300 49.04 46.59 53.58 52.51 60500 924.20 877.99 1,009.69 989.49 60502 1,232.58 1,170.95 1,346.59 1,319.66 60505 1,331.02 1,264.47 1,454.14 1,425.06 60512 235.00 223.25 256.74 251.61 60520 996.66 946.83 1,088.85 1,067.07 60521 1,087.65 1,033.27 1,188.26 1,164.49 60522 1,318.85 1,252.91 1,440.85 1,412.03 60540 1,013.91 963.21 1,107.69 1,085.54 60545 1,166.89 1,108.55 1,274.83 1,249.34 60600 1,377.32 1,308.45 1,504.72 1,474.62 60605 1,554.06 1,476.36 1,697.81 1,663.85 60650 1,143.31 1,086.14 1,249.06 1,224.08 61000 86.13 81.82 94.09 92.21 61001 101.57 96.49 110.96 108.74 61020 99.58 94.60 108.79 106.62 61026 102.38 97.26 111.85 109.61 61050 83.38 79.21 91.09 89.27 61055 114.54 108.81 125.13 122.62 61070 56.83 53.99 62.09 60.85 61105 430.87 409.33 470.73 461.31 61107 299.30 284.34 326.99 320.45 61108 849.15 806.69 927.69 909.14 61120 699.32 664.35 764.00 748.72 61140 1,184.61 1,125.38 1,294.19 1,268.30 61150 1,272.49 1,208.87 1,390.20 1,362.39 61151 932.71 886.07 1,018.98 998.60 61154 1,192.66 1,133.03 1,302.98 1,276.93 61156 1,168.54 1,110.11 1,276.63 1,251.10 61210 349.61 332.13 381.95 374.31 61215 469.38 445.91 512.80 502.54

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 68

61250 812.29 771.68 887.43 869.69 61253 792.68 753.05 866.01 848.69 61304 1,544.41 1,467.19 1,687.27 1,653.53 61305 1,890.47 1,795.95 2,065.34 2,024.03 61312 1,961.36 1,863.29 2,142.78 2,099.92 61313 1,867.24 1,773.88 2,039.96 1,999.16 61314 1,722.59 1,636.46 1,881.93 1,844.29 61315 1,950.06 1,852.56 2,130.44 2,087.84 61316 83.44 79.27 91.16 89.33 61320 1,793.75 1,704.06 1,959.67 1,920.48 61321 2,004.28 1,904.07 2,189.68 2,145.89 61322 2,237.32 2,125.45 2,444.27 2,395.38 61323 2,248.41 2,135.99 2,456.39 2,407.26 61330 1,743.59 1,656.41 1,904.87 1,866.77 61332 1,947.83 1,850.44 2,128.01 2,085.44 61333 1,991.92 1,892.32 2,176.17 2,132.64 61334 1,326.75 1,260.41 1,449.47 1,420.48 61340 1,358.37 1,290.45 1,484.02 1,454.34 61343 2,072.84 1,969.20 2,264.58 2,219.29 61345 1,919.34 1,823.37 2,096.88 2,054.94 61440 1,885.25 1,790.99 2,059.64 2,018.45 61450 1,810.08 1,719.58 1,977.52 1,937.97 61458 1,890.87 1,796.33 2,065.78 2,024.46 61460 1,980.22 1,881.21 2,163.39 2,120.13 61470 1,805.80 1,715.51 1,972.84 1,933.38 61480 1,461.48 1,388.41 1,596.67 1,564.74 61490 1,782.21 1,693.10 1,947.07 1,908.13 61500 1,260.87 1,197.83 1,377.50 1,349.95 61501 1,092.30 1,037.69 1,193.34 1,169.48 61510 2,058.30 1,955.39 2,248.70 2,203.72 61512 2,404.80 2,284.56 2,627.24 2,574.70 61514 1,796.53 1,706.70 1,962.71 1,923.46 61516 1,752.09 1,664.49 1,914.16 1,875.88 61517 82.77 78.63 90.42 88.62 61518 2,602.33 2,472.21 2,843.04 2,786.19 61519 2,783.90 2,644.71 3,041.42 2,980.59 61520 3,549.46 3,371.99 3,877.79 3,800.23 61521 3,001.48 2,851.41 3,279.12 3,213.54 61522 2,058.63 1,955.70 2,249.06 2,204.08 61524 1,959.63 1,861.65 2,140.90 2,098.08 61526 3,441.82 3,269.73 3,760.19 3,684.99 61530 2,901.61 2,756.53 3,170.01 3,106.61 61531 1,145.67 1,088.39 1,251.65 1,226.61 61533 1,431.74 1,360.15 1,564.17 1,532.89 61534 1,545.62 1,468.34 1,688.59 1,654.82 61535 935.98 889.18 1,022.56 1,002.11 61536 2,430.01 2,308.51 2,654.79 2,601.69 61537 2,325.08 2,208.83 2,540.15 2,489.35 61538 2,517.33 2,391.46 2,750.18 2,695.17 61539 2,223.18 2,112.02 2,428.82 2,380.25 61540 2,054.52 1,951.79 2,244.56 2,199.66 61541 2,022.26 1,921.15 2,209.32 2,165.14

61542 1,977.60 1,878.72 2,160.53 2,117.32 61543 2,044.46 1,942.24 2,233.58 2,188.91 61544 1,790.52 1,700.99 1,956.14 1,917.02 61545 2,999.58 2,849.60 3,277.04 3,211.50 61546 2,172.55 2,063.92 2,373.51 2,326.04 61548 1,476.08 1,402.28 1,612.62 1,580.36 61550 858.11 815.20 937.48 918.74 61552 1,093.22 1,038.56 1,194.34 1,170.46 61556 1,602.03 1,521.93 1,750.22 1,715.21 61557 1,578.20 1,499.29 1,724.18 1,689.70 61558 1,602.74 1,522.60 1,750.99 1,715.97 61559 1,722.29 1,636.18 1,881.61 1,843.98 61563 1,863.25 1,770.09 2,035.60 1,994.89 61564 2,265.06 2,151.81 2,474.58 2,425.09 61566 2,115.79 2,010.00 2,311.50 2,265.27 61567 2,412.83 2,292.19 2,636.02 2,583.30 61570 1,755.85 1,668.06 1,918.27 1,879.91 61571 1,870.72 1,777.18 2,043.76 2,002.89 61575 2,279.59 2,165.61 2,490.45 2,440.65 61576 3,310.10 3,144.60 3,616.29 3,543.97 61580 2,362.58 2,244.45 2,581.12 2,529.49 61581 2,571.54 2,442.96 2,809.40 2,753.22 61582 2,744.58 2,607.35 2,998.45 2,938.48 61583 2,725.51 2,589.23 2,977.61 2,918.07 61584 2,678.25 2,544.34 2,925.99 2,867.47 61585 3,031.50 2,879.93 3,311.92 3,245.68 61586 2,272.30 2,158.69 2,482.49 2,432.85 61590 2,925.61 2,779.33 3,196.23 3,132.30 61591 2,965.07 2,816.82 3,239.34 3,174.55 61592 2,985.48 2,836.21 3,261.64 3,196.41 61595 2,253.60 2,140.92 2,462.06 2,412.82 61596 2,373.23 2,254.57 2,592.76 2,540.90 61597 2,683.50 2,549.33 2,931.73 2,873.09 61598 2,652.15 2,519.54 2,897.47 2,839.52 61600 2,036.57 1,934.74 2,224.95 2,180.46 61601 2,261.20 2,148.14 2,470.36 2,420.96 61605 2,095.39 1,990.62 2,289.21 2,243.43 61606 2,829.57 2,688.09 3,091.30 3,029.48 61607 2,718.88 2,582.94 2,970.38 2,910.97 61608 3,053.20 2,900.54 3,335.62 3,268.91 61609 559.13 531.17 610.85 598.63 61610 1,677.31 1,593.44 1,832.46 1,795.81 61611 387.08 367.73 422.89 414.44 61612 1,382.46 1,313.34 1,510.34 1,480.13 61613 3,081.03 2,926.98 3,366.03 3,298.71 61615 2,181.51 2,072.43 2,383.29 2,335.63 61616 3,138.50 2,981.58 3,428.82 3,360.24 61618 1,232.14 1,170.53 1,346.11 1,319.19 61619 1,405.19 1,334.93 1,535.17 1,504.46 61623 536.71 509.87 586.35 574.62 61624 1,072.62 1,018.99 1,171.84 1,148.40 61626 839.86 797.87 917.55 899.20

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 69

61630 1,229.51 1,168.03 1,343.23 1,316.37 61635 1,344.99 1,277.74 1,469.40 1,440.02 61680 2,121.73 2,015.64 2,317.99 2,271.63 61682 3,950.33 3,752.81 4,315.73 4,229.41 61684 2,680.37 2,546.35 2,928.30 2,869.73 61686 4,248.71 4,036.27 4,641.71 4,548.87 61690 2,057.30 1,954.44 2,247.61 2,202.65 61692 3,454.78 3,282.04 3,774.35 3,698.86 61697 3,988.27 3,788.86 4,357.19 4,270.04 61698 4,376.52 4,157.69 4,781.34 4,685.72 61700 3,224.32 3,063.10 3,522.57 3,452.12 61702 3,799.98 3,609.98 4,151.48 4,068.45 61703 1,275.85 1,212.06 1,393.87 1,365.99 61705 2,452.85 2,330.21 2,679.74 2,626.15 61708 1,914.83 1,819.09 2,091.95 2,050.12 61710 1,901.48 1,806.41 2,077.37 2,035.82 61711 2,457.99 2,335.09 2,685.35 2,631.65 61720 1,192.54 1,132.91 1,302.85 1,276.79 61735 1,494.05 1,419.35 1,632.25 1,599.60 61750 1,322.35 1,256.23 1,444.66 1,415.78 61751 1,290.35 1,225.83 1,409.70 1,381.51 61760 1,485.76 1,411.47 1,623.19 1,590.73 61770 1,523.89 1,447.70 1,664.86 1,631.56 61781 222.59 211.46 243.18 238.31 61782 183.47 174.30 200.45 196.43 61783 223.21 212.05 243.86 238.98 61790 819.22 778.26 895.00 877.09 61791 1,046.25 993.94 1,143.03 1,120.17 61796 943.90 896.71 1,031.22 1,010.60 61797 206.98 196.63 226.12 221.61 61798 1,292.75 1,228.11 1,412.33 1,384.08 61799 285.36 271.09 311.75 305.52 61800 144.05 136.85 157.38 154.23 61850 920.95 874.90 1,006.14 986.01 61860 1,471.56 1,397.98 1,607.68 1,575.52 61863 1,411.76 1,341.17 1,542.35 1,511.50 61864 269.77 256.28 294.72 288.82 61867 2,148.74 2,041.30 2,347.50 2,300.54 61868 474.98 451.23 518.91 508.54 61870 1,111.06 1,055.51 1,213.84 1,189.56 61875 880.59 836.56 962.04 942.80 61880 533.73 507.04 583.10 571.44 61885 482.48 458.36 527.11 516.57 61886 787.77 748.38 860.64 843.42 61888 367.46 349.09 401.45 393.43 62000 966.38 918.06 1,055.77 1,034.66 62005 1,193.21 1,133.55 1,303.58 1,277.51 62010 1,438.79 1,366.85 1,571.88 1,540.44 62100 1,521.48 1,445.41 1,662.22 1,628.98 62115 1,231.65 1,170.07 1,345.58 1,318.67 62116 1,588.65 1,509.22 1,735.60 1,700.90 62117 1,521.83 1,445.74 1,662.60 1,629.35

62120 1,603.08 1,522.93 1,751.37 1,716.34 62121 1,601.28 1,521.22 1,749.40 1,714.42 62140 978.53 929.60 1,069.04 1,047.66 62141 1,076.69 1,022.86 1,176.29 1,152.76 62142 833.67 791.99 910.79 892.57 62143 978.32 929.40 1,068.81 1,047.43 62145 1,338.64 1,271.71 1,462.47 1,433.22 62146 1,172.31 1,113.69 1,280.74 1,255.13 62147 1,369.71 1,301.22 1,496.40 1,466.48 62148 120.18 114.17 131.30 128.67 62160 180.38 171.36 197.06 193.12 62161 1,426.21 1,354.90 1,558.14 1,526.97 62162 1,777.14 1,688.28 1,941.52 1,902.69 62163 1,147.36 1,089.99 1,253.49 1,228.42 62164 1,964.02 1,865.82 2,145.69 2,102.78 62165 1,471.14 1,397.58 1,607.22 1,575.07 62180 1,505.10 1,429.85 1,644.33 1,611.44 62190 865.17 821.91 945.20 926.29 62192 915.94 870.14 1,000.66 980.65 62194 409.84 389.35 447.75 438.79 62200 1,293.12 1,228.46 1,412.73 1,384.47 62201 1,126.69 1,070.36 1,230.91 1,206.29 62220 959.01 911.06 1,047.72 1,026.77 62223 988.69 939.26 1,080.15 1,058.54 62225 487.39 463.02 532.47 521.82 62230 791.58 752.00 864.80 847.50 62252 77.83 73.94 85.03 83.33 62252 TC 34.01 32.31 37.16 36.41 62252 26 43.82 41.63 47.87 46.92 62256 560.09 532.09 611.90 599.67 62258 1,059.34 1,006.37 1,157.33 1,134.18 62263 632.91 601.26 691.45 677.61# 62263 336.15 319.34 367.24 359.89 62264 393.33 373.66 429.71 421.12# 62264 233.40 221.73 254.99 249.90 62267 233.59 221.91 255.20 250.09# 62267 157.37 149.50 171.93 168.49 62268 255.40 242.63 279.02 273.45 62269 262.23 249.12 286.49 280.76 62270 147.02 139.67 160.62 157.41# 62270 76.42 72.60 83.49 81.82 62272 184.37 175.15 201.42 197.40# 62272 81.60 77.52 89.15 87.37 62273 163.19 155.03 178.28 174.72# 62273 111.34 105.77 121.64 119.20 62280 293.70 279.02 320.87 314.46# 62280 165.00 156.75 180.26 176.66 62281 227.14 215.78 248.15 243.18# 62281 154.66 146.93 168.97 165.59 62282 264.29 251.08 288.74 282.97# 62282 139.65 132.67 152.57 149.52 62284 177.65 168.77 194.09 190.20

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 70

# 62284 84.25 80.04 92.05 90.21 62287 543.15 515.99 593.39 581.52 62290 309.81 294.32 338.47 331.69# 62290 169.24 160.78 184.90 181.19 62291 298.57 283.64 326.19 319.67# 62291 165.49 157.22 180.80 177.19 62292 563.69 535.51 615.84 603.52 62294 699.06 664.11 763.73 748.45 62310 101.58 96.50 110.98 108.76# 62310 69.72 66.23 76.16 74.65 62311 100.01 95.01 109.26 107.08# 62311 68.46 65.04 74.80 73.30 62318 103.82 98.63 113.42 111.16# 62318 76.02 72.22 83.05 81.40 62319 106.73 101.39 116.60 114.26# 62319 77.37 73.50 84.53 82.83 62350 384.71 365.47 420.29 411.88 62351 826.15 784.84 902.57 884.51 62355 252.31 239.69 275.64 270.14 62360 296.52 281.69 323.94 317.47 62361 332.35 315.73 363.09 355.83 62362 368.03 349.63 402.07 394.04 62365 277.30 263.44 302.96 296.90 62367 38.89 36.95 42.49 41.64# 62367 24.83 23.59 27.13 26.59 62368 52.60 49.97 57.47 56.32# 62368 33.86 32.17 37.00 36.26 62369 108.83 103.39 118.90 116.52# 62369 34.48 32.76 37.67 36.92 62370 115.43 109.66 126.11 123.59# 62370 45.46 43.19 49.67 48.68 63001 1,168.08 1,109.68 1,276.13 1,250.61 63003 1,167.95 1,109.55 1,275.98 1,250.46 63005 1,116.29 1,060.48 1,219.55 1,195.16 63011 1,037.24 985.38 1,133.19 1,110.52 63012 1,126.89 1,070.55 1,231.13 1,206.51 63015 1,398.74 1,328.80 1,528.12 1,497.55 63016 1,435.22 1,363.46 1,567.98 1,536.62 63017 1,178.12 1,119.21 1,287.09 1,261.35 63020 1,104.37 1,049.15 1,206.52 1,182.40 63030 915.85 870.06 1,000.57 980.56 63035 184.24 175.03 201.28 197.26 63040 1,331.56 1,264.98 1,454.73 1,425.63 63042 1,233.42 1,171.75 1,347.51 1,320.57 63043 283.76 269.57 310.01 303.81 63044 283.76 269.57 310.01 303.81 63045 1,201.67 1,141.59 1,312.83 1,286.57 63046 1,146.08 1,088.78 1,252.10 1,227.05 63047 1,042.77 990.63 1,139.22 1,116.44 63048 203.99 193.79 222.86 218.40 63050 1,468.82 1,395.38 1,604.69 1,572.59 63051 1,628.94 1,547.49 1,779.61 1,744.02

63055 1,537.61 1,460.73 1,679.84 1,646.25 63056 1,405.80 1,335.51 1,535.84 1,505.12 63057 307.65 292.27 336.11 329.38 63064 1,680.41 1,596.39 1,835.85 1,799.13 63066 196.25 186.44 214.41 210.12 63075 1,293.57 1,228.89 1,413.22 1,384.96 63076 237.97 226.07 259.98 254.78 63077 1,425.62 1,354.34 1,557.49 1,526.34 63078 187.44 178.07 204.78 200.69 63081 1,679.10 1,595.15 1,834.42 1,797.74 63082 256.44 243.62 280.16 274.56 63085 1,810.65 1,720.12 1,978.14 1,938.58 63086 182.58 173.45 199.47 195.48 63087 2,282.29 2,168.18 2,493.41 2,443.54 63088 247.11 234.75 269.96 264.57 63090 1,880.99 1,786.94 2,054.98 2,013.88 63091 171.86 163.27 187.76 184.00 63101 2,196.70 2,086.87 2,399.90 2,351.90 63102 2,136.70 2,029.87 2,334.35 2,287.66 63103 279.55 265.57 305.41 299.30 63170 1,496.05 1,421.25 1,634.44 1,601.75 63172 1,326.02 1,259.72 1,448.68 1,419.71 63173 1,623.03 1,541.88 1,773.16 1,737.70 63180 1,395.14 1,325.38 1,524.19 1,493.70 63182 1,386.31 1,316.99 1,514.54 1,484.25 63185 1,126.56 1,070.23 1,230.76 1,206.15 63190 1,206.14 1,145.83 1,317.70 1,291.35 63191 1,212.79 1,152.15 1,324.97 1,298.48 63194 1,215.40 1,154.63 1,327.82 1,301.27 63195 1,444.78 1,372.54 1,578.42 1,546.85 63196 1,331.53 1,264.95 1,454.69 1,425.60 63197 1,459.23 1,386.27 1,594.21 1,562.32 63198 1,568.77 1,490.33 1,713.88 1,679.60 63199 1,646.53 1,564.20 1,798.83 1,762.86 63200 1,447.93 1,375.53 1,581.86 1,550.22 63250 2,799.05 2,659.10 3,057.97 2,996.81 63251 2,860.72 2,717.68 3,125.33 3,062.83 63252 2,860.05 2,717.05 3,124.61 3,062.12 63265 1,575.86 1,497.07 1,721.63 1,687.20 63266 1,626.86 1,545.52 1,777.35 1,741.80 63267 1,300.16 1,235.15 1,420.42 1,392.02 63268 1,366.19 1,297.88 1,492.56 1,462.71 63270 1,954.01 1,856.31 2,134.76 2,092.06 63271 1,953.46 1,855.79 2,134.16 2,091.47 63272 1,797.98 1,708.08 1,964.29 1,925.01 63273 1,753.79 1,666.10 1,916.02 1,877.70 63275 1,700.84 1,615.80 1,858.17 1,821.00 63276 1,685.10 1,600.85 1,840.98 1,804.15 63277 1,468.62 1,395.19 1,604.47 1,572.38 63278 1,492.30 1,417.69 1,630.34 1,597.74 63280 1,994.26 1,894.55 2,178.73 2,135.16 63281 1,970.02 1,871.52 2,152.25 2,109.20

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 71

63282 1,861.51 1,768.43 2,033.69 1,993.02 63283 1,785.73 1,696.44 1,950.91 1,911.89 63285 2,464.25 2,341.04 2,692.20 2,638.35 63286 2,428.52 2,307.09 2,653.15 2,600.09 63287 2,586.96 2,457.61 2,826.25 2,769.73 63290 2,626.96 2,495.61 2,869.95 2,812.56 63295 315.45 299.68 344.63 337.74 63300 1,738.09 1,651.19 1,898.87 1,860.90 63301 2,074.98 1,971.23 2,266.91 2,221.58 63302 2,049.25 1,946.79 2,238.81 2,194.03 63303 2,178.89 2,069.95 2,380.44 2,332.83 63304 2,211.74 2,101.15 2,416.32 2,368.00 63305 2,355.67 2,237.89 2,573.57 2,522.10 63306 2,059.05 1,956.10 2,249.52 2,204.53 63307 2,266.97 2,153.62 2,476.66 2,427.13 63308 306.46 291.14 334.81 328.12 63600 882.45 838.33 964.08 944.79 63610 388.81 369.37 424.78 416.28 63615 1,162.50 1,104.38 1,270.04 1,244.63 63620 1,041.85 989.76 1,138.22 1,115.45 63621 237.27 225.41 259.22 254.04 63650 1,207.36 1,146.99 1,319.04 1,292.66# 63650 403.31 383.14 440.61 431.80 63655 777.36 738.49 849.26 832.28 63661 530.39 503.87 579.45 567.86# 63661 308.29 292.88 336.81 330.07 63662 735.59 698.81 803.63 787.55 63663 739.41 702.44 807.81 791.65# 63663 445.47 423.20 486.68 476.95 63664 762.13 724.02 832.62 815.97 63685 346.13 328.82 378.14 370.58 63688 349.83 332.34 382.19 374.54 63700 1,188.62 1,129.19 1,298.57 1,272.60 63702 1,307.59 1,242.21 1,428.54 1,399.98 63704 1,546.51 1,469.18 1,689.56 1,655.77 63706 1,694.04 1,609.34 1,850.74 1,813.72 63707 865.29 822.03 945.33 926.43 63709 1,043.14 990.98 1,139.63 1,116.83 63710 1,042.96 990.81 1,139.43 1,116.64 63740 887.04 842.69 969.09 949.72 63741 617.06 586.21 674.14 660.66 63744 641.09 609.04 700.40 686.39 63746 559.55 531.57 611.31 599.08 64400 114.45 108.73 125.04 122.54# 64400 66.34 63.02 72.47 71.02 64402 113.84 108.15 124.37 121.89# 64402 71.98 68.38 78.64 77.06 64405 92.71 88.07 101.28 99.26# 64405 59.91 56.91 65.45 64.14 64408 94.03 89.33 102.73 100.67# 64408 71.85 68.26 78.50 76.92 64410 118.83 112.89 129.82 127.22

# 64410 73.53 69.85 80.33 78.72 64412 126.88 120.54 138.62 135.85# 64412 70.03 66.53 76.51 74.98 64413 115.71 109.92 126.41 123.88# 64413 78.22 74.31 85.46 83.74 64415 111.05 105.50 121.33 118.90# 64415 64.81 61.57 70.81 69.39 64416 78.44 74.52 85.70 83.98 64417 120.55 114.52 131.70 129.06# 64417 69.32 65.85 75.73 74.21 64418 131.55 124.97 143.72 140.84# 64418 73.14 69.48 79.90 78.30 64420 104.98 99.73 114.69 112.40# 64420 66.56 63.23 72.71 71.27 64421 142.61 135.48 155.80 152.69# 64421 91.69 87.11 100.18 98.18 64425 125.75 119.46 137.38 134.63# 64425 92.32 87.70 100.86 98.84 64430 128.06 121.66 139.91 137.11# 64430 79.65 75.67 87.02 85.28 64435 126.11 119.80 137.77 135.01# 64435 82.06 77.96 89.65 87.86 64445 125.59 119.31 137.21 134.46# 64445 70.92 67.37 77.48 75.92 64446 78.75 74.81 86.03 84.31 64447 111.14 105.58 121.42 118.99# 64447 65.53 62.25 71.59 70.16 64448 70.50 66.98 77.03 75.49 64449 81.88 77.79 89.46 87.66 64450 73.83 70.14 80.66 79.05# 64450 44.15 41.94 48.23 47.27 64455 45.95 43.65 50.20 49.20# 64455 35.02 33.27 38.26 37.49 64479 222.63 211.50 243.23 238.36# 64479 131.10 124.55 143.23 140.37 64480 107.05 101.70 116.96 114.62# 64480 63.94 60.74 69.85 68.46 64483 204.67 194.44 223.61 219.13# 64483 109.71 104.22 119.85 117.46 64484 82.40 78.28 90.02 88.22# 64484 51.47 48.90 56.24 55.11 64490 178.86 169.92 195.41 191.50# 64490 105.14 99.88 114.86 112.56 64491 88.96 84.51 97.19 95.24# 64491 59.91 56.91 65.45 64.14 64492 89.59 85.11 97.88 95.92# 64492 60.54 57.51 66.14 64.81 64493 161.14 153.08 176.04 172.52# 64493 88.98 84.53 97.21 95.27 64494 81.46 77.39 89.00 87.22# 64494 51.16 48.60 55.89 54.77 64495 81.77 77.68 89.33 87.55

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 72

# 64495 51.79 49.20 56.58 55.45 64505 97.72 92.83 106.75 104.62# 64505 82.73 78.59 90.38 88.57 64508 62.43 59.31 68.21 66.84# 64508 74.30 70.59 81.18 79.56 64510 117.70 111.82 128.59 126.02# 64510 71.47 67.90 78.09 76.52 64517 165.05 156.80 180.32 176.71# 64517 117.26 111.40 128.11 125.55 64520 169.49 161.02 185.17 181.47# 64520 77.96 74.06 85.17 83.47 64530 176.10 167.30 192.40 188.54# 64530 89.88 85.39 98.20 96.23 64550 14.85 14.11 16.23 15.90# 64550 8.91 8.46 9.73 9.53 64553 194.80 185.06 212.82 208.56# 64553 148.56 141.13 162.30 159.06 64555 189.06 179.61 206.55 202.42# 64555 143.77 136.58 157.07 153.93 64561 734.87 698.13 802.85 786.80# 64561 385.63 366.35 421.30 412.87 64565 171.49 162.92 187.36 183.61# 64565 124.32 118.10 135.82 133.10 64566 107.85 102.46 117.83 115.47# 64566 29.44 27.97 32.17 31.52 64568 584.65 555.42 638.73 625.96 64569 736.43 699.61 804.55 788.46 64570 648.62 616.19 708.62 694.45 64575 293.37 278.70 320.51 314.10 64580 281.47 267.40 307.51 301.36 64581 647.28 614.92 707.16 693.01 64585 224.93 213.68 245.73 240.82# 64585 136.84 130.00 149.50 146.51 64590 242.35 230.23 264.76 259.47# 64590 152.69 145.06 166.82 163.48 64595 222.65 211.52 243.25 238.38# 64595 119.88 113.89 130.97 128.35 64600 354.39 336.67 387.17 379.43# 64600 206.32 196.00 225.40 220.89 64605 677.92 644.02 740.62 725.81# 64605 350.86 333.32 383.32 375.65 64610 679.58 645.60 742.44 727.59# 64610 458.73 435.79 501.16 491.13 64611 103.39 98.22 112.95 110.70# 64611 91.20 86.64 99.64 97.65 64612 126.75 120.41 138.47 135.70# 64612 114.56 108.83 125.15 122.65 64615 133.62 126.94 145.98 143.06# 64615 119.56 113.58 130.62 128.01 64616 114.21 108.50 124.78 122.28# 64616 101.41 96.34 110.79 108.57 64617 176.59 167.76 192.92 189.06

# 64617 109.74 104.25 119.89 117.50 64620 195.32 185.55 213.38 209.12# 64620 167.52 159.14 183.01 179.35 64630 214.62 203.89 234.47 229.78# 64630 181.82 172.73 198.64 194.67 64632 81.51 77.43 89.04 87.26# 64632 67.45 64.08 73.69 72.22 64633 400.71 380.67 437.77 429.02# 64633 222.03 210.93 242.57 237.72 64634 179.97 170.97 196.62 192.68# 64634 67.83 64.44 74.11 72.62 64635 395.15 375.39 431.70 423.06# 64635 218.66 207.73 238.89 234.12 64636 162.44 154.32 177.47 173.91# 64636 59.36 56.39 64.85 63.55 64640 123.33 117.16 134.73 132.04# 64640 88.97 84.52 97.20 95.25 64642 129.87 123.38 141.89 139.05# 64642 102.06 96.96 111.50 109.27 64643 86.04 81.74 94.00 92.13# 64643 68.86 65.42 75.23 73.73 64644 148.07 140.67 161.77 158.54# 64644 111.52 105.94 121.83 119.39 64645 104.80 99.56 114.49 112.21# 64645 78.87 74.93 86.17 84.44 64646 139.85 132.86 152.79 149.73# 64646 110.49 104.97 120.72 118.30 64647 162.03 153.93 177.02 173.48# 64647 127.67 121.29 139.48 136.69 64650 69.98 66.48 76.45 74.92# 64650 39.68 37.70 43.36 42.49 64653 88.19 83.78 96.35 94.42# 64653 51.65 49.07 56.43 55.30 64680 288.30 273.89 314.97 308.67# 64680 162.10 154.00 177.10 173.56 64681 316.82 300.98 346.13 339.20# 64681 186.56 177.23 203.81 199.74 64702 466.54 443.21 509.69 499.50 64704 303.94 288.74 332.05 325.42 64708 466.03 442.73 509.14 498.96 64712 533.91 507.21 583.29 571.63 64713 692.27 657.66 756.31 741.19 64714 609.27 578.81 665.63 652.31 64716 509.94 484.44 557.11 545.96 64718 555.28 527.52 606.65 594.52 64719 373.59 354.91 408.15 399.98 64721 399.65 379.67 436.62 427.89# 64721 397.15 377.29 433.88 425.20 64722 346.66 329.33 378.73 371.15 64726 261.00 247.95 285.14 279.44 64727 176.52 167.69 192.84 188.99 64732 383.53 364.35 419.00 410.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 73

64734 369.80 351.31 404.01 395.92 64736 406.57 386.24 444.18 435.30 64738 451.68 429.10 493.47 483.60 64740 436.28 414.47 476.64 467.11 64742 478.32 454.40 522.56 512.11 64744 457.33 434.46 499.63 489.64 64746 412.26 391.65 450.40 441.39 64752 470.26 446.75 513.76 503.49 64755 873.53 829.85 954.33 935.24 64760 484.21 460.00 529.00 518.42 64761 439.96 417.96 480.65 471.04 64763 479.70 455.72 524.08 513.60 64766 541.73 514.64 591.84 580.00 64771 555.84 528.05 607.26 595.11 64772 528.11 501.70 576.96 565.42 64774 394.50 374.78 431.00 422.37 64776 372.10 353.50 406.53 398.39 64778 151.23 143.67 165.22 161.92 64782 430.74 409.20 470.58 461.17 64783 209.49 199.02 228.87 224.30 64784 699.54 664.56 764.24 748.96 64786 1,029.60 978.12 1,124.84 1,102.34 64787 235.11 223.35 256.85 251.71 64788 374.33 355.61 408.95 400.78 64790 782.83 743.69 855.24 838.14 64792 1,113.51 1,057.83 1,216.50 1,192.17 64795 184.74 175.50 201.83 197.79 64802 649.57 617.09 709.65 695.46 64804 988.96 939.51 1,080.44 1,058.83 64809 704.82 669.58 770.02 754.62 64818 622.32 591.20 679.88 666.29 64820 691.94 657.34 755.94 740.82 64821 659.48 626.51 720.49 706.08 64822 659.48 626.51 720.49 706.08 64823 753.58 715.90 823.29 806.82 64831 646.28 613.97 706.07 691.94 64832 325.82 309.53 355.96 348.84 64834 705.59 670.31 770.86 755.44 64835 772.02 733.42 843.43 826.56 64836 772.02 733.42 843.43 826.56 64837 353.15 335.49 385.81 378.10 64840 888.78 844.34 970.99 951.57 64856 961.69 913.61 1,050.65 1,029.64 64857 1,007.40 957.03 1,100.58 1,078.57 64858 1,027.34 975.97 1,122.37 1,099.92 64859 248.18 235.77 271.14 265.71 64861 1,307.09 1,241.74 1,428.00 1,399.45 64862 1,287.05 1,222.70 1,406.11 1,377.99 64864 838.58 796.65 916.15 897.83 64865 1,065.91 1,012.61 1,164.50 1,141.21 64866 1,106.36 1,051.04 1,208.70 1,184.52 64868 977.15 928.29 1,067.53 1,046.18

64870 993.56 943.88 1,085.46 1,063.75 64872 115.08 109.33 125.73 123.21 64874 163.62 155.44 178.76 175.18 64876 178.52 169.59 195.03 191.13 64885 1,096.49 1,041.67 1,197.92 1,173.97 64886 1,252.30 1,189.69 1,368.14 1,340.79 64890 1,056.76 1,003.92 1,154.51 1,131.42 64891 1,126.37 1,070.05 1,230.56 1,205.95 64892 1,027.57 976.19 1,122.62 1,100.17 64893 1,097.89 1,043.00 1,199.45 1,175.46 64895 1,293.94 1,229.24 1,413.63 1,385.36 64896 1,490.18 1,415.67 1,628.02 1,595.46 64897 1,246.83 1,184.49 1,362.16 1,334.92 64898 1,311.76 1,246.17 1,433.10 1,404.44 64901 566.73 538.39 619.15 606.76 64902 655.84 623.05 716.51 702.18 64905 989.84 940.35 1,081.40 1,059.77 64907 1,176.95 1,118.10 1,285.82 1,260.10 64910 780.96 741.91 853.20 836.13 64911 976.69 927.86 1,067.04 1,045.70 65091 615.08 584.33 671.98 658.54 65093 606.44 576.12 662.54 649.29 65101 712.31 676.69 778.19 762.63 65103 744.73 707.49 813.61 797.34 65105 823.38 782.21 899.54 881.56 65110 1,168.59 1,110.16 1,276.68 1,251.15 65112 1,357.40 1,289.53 1,482.96 1,453.30 65114 1,425.16 1,353.90 1,556.99 1,525.84 65125 425.19 403.93 464.52 455.23# 65125 282.74 268.60 308.89 302.71 65130 708.73 673.29 774.28 758.79 65135 719.48 683.51 786.04 770.32 65140 766.48 728.16 837.38 820.64 65150 535.90 509.11 585.48 573.77 65155 821.90 780.81 897.93 879.97 65175 621.75 590.66 679.26 665.68 65205 54.13 51.42 59.13 57.95# 65205 43.83 41.64 47.89 46.93 65210 65.63 62.35 71.70 70.27# 65210 52.51 49.88 57.36 56.21 65220 54.72 51.98 59.78 58.58# 65220 41.29 39.23 45.11 44.22 65222 64.66 61.43 70.64 69.23# 65222 52.16 49.55 56.98 55.84 65235 679.69 645.71 742.57 727.72 65260 899.84 854.85 983.08 963.41 65265 1,070.30 1,016.79 1,169.31 1,145.92 65270 245.43 233.16 268.13 262.78# 65270 136.41 129.59 149.03 146.05 65272 461.45 438.38 504.14 494.05# 65272 330.56 314.03 361.13 353.91 65273 358.86 340.92 392.06 384.22

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 74

65275 546.69 519.36 597.26 585.32# 65275 446.73 424.39 488.05 478.29 65280 663.56 630.38 724.94 710.44 65285 1,089.68 1,035.20 1,190.48 1,166.68 65286 659.00 626.05 719.96 705.56# 65286 478.45 454.53 522.71 512.26 65290 482.98 458.83 527.65 517.10 65400 644.42 612.20 704.03 689.95# 65400 578.20 549.29 631.68 619.05 65410 137.51 130.63 150.22 147.22# 65410 104.40 99.18 114.06 111.78 65420 473.54 449.86 517.34 506.99# 65420 355.15 337.39 388.00 380.24 65426 609.73 579.24 666.13 652.81# 65426 459.48 436.51 501.99 491.95 65430 110.65 105.12 120.89 118.47# 65430 101.28 96.22 110.65 108.45 65435 76.79 72.95 83.89 82.21# 65435 68.04 64.64 74.34 72.85 65436 375.71 356.92 410.46 402.25# 65436 362.28 344.17 395.80 387.88 65450 307.30 291.94 335.73 329.02# 65450 304.80 289.56 332.99 326.34 65600 373.05 354.40 407.56 399.41# 65600 329.63 313.15 360.12 352.92 65710 1,064.26 1,011.05 1,162.71 1,139.45 65730 1,182.98 1,123.83 1,292.40 1,266.55 65750 1,189.46 1,129.99 1,299.49 1,273.50 65755 1,186.35 1,127.03 1,296.08 1,270.16 65756 1,120.57 1,064.54 1,224.22 1,199.74 65757 125.63 119.35 137.25 134.50 65770 1,479.31 1,405.34 1,616.14 1,583.81 65772 426.94 405.59 466.43 457.10# 65772 388.52 369.09 424.45 415.97 65775 516.71 490.87 564.50 553.21 65778 1,215.94 1,155.14 1,328.41 1,301.85# 65778 70.77 67.23 77.31 75.77 65779 1,095.33 1,040.56 1,196.64 1,172.71# 65779 275.66 261.88 301.16 295.14 65780 847.96 805.56 926.39 907.87 65781 1,256.86 1,194.02 1,373.12 1,345.66 65782 1,135.66 1,078.88 1,240.71 1,215.90 65800 114.67 108.94 125.28 122.77# 65800 90.93 86.38 99.34 97.35 65810 446.83 424.49 488.16 478.40 65815 603.42 573.25 659.24 646.06# 65815 464.41 441.19 507.37 497.23 65820 699.42 664.45 764.12 748.83 65850 823.06 781.91 899.20 881.21 65855 324.19 307.98 354.18 347.09# 65855 289.52 275.04 316.30 309.97 65860 315.98 300.18 345.21 338.31

# 65860 267.87 254.48 292.65 286.80 65865 441.55 419.47 482.39 472.74 65870 574.04 545.34 627.14 614.59 65875 603.53 573.35 659.35 646.16 65880 621.72 590.63 679.22 665.64 65900 904.70 859.47 988.39 968.62 65920 754.64 716.91 824.45 807.96 65930 622.62 591.49 680.21 666.61 66020 170.82 162.28 186.62 182.88# 66020 123.02 116.87 134.40 131.71 66030 153.12 145.46 167.28 163.93# 66030 105.32 100.05 115.06 112.76 66130 676.31 642.49 738.86 724.09# 66130 566.36 538.04 618.75 606.37 66150 818.33 777.41 894.02 876.14 66155 817.66 776.78 893.30 875.43 66160 925.42 879.15 1,011.02 990.81 66165 687.71 653.32 751.32 736.29 66170 1,147.60 1,090.22 1,253.75 1,228.68 66172 1,446.61 1,374.28 1,580.42 1,548.81 66174 928.45 882.03 1,014.33 994.05 66175 1,039.67 987.69 1,135.84 1,113.13 66180 1,126.25 1,069.94 1,230.43 1,205.82 66183 1,003.01 952.86 1,095.79 1,073.87 66185 730.22 693.71 797.77 781.82 66220 713.02 677.37 778.98 763.39 66225 920.18 874.17 1,005.30 985.19 66250 712.89 677.25 778.84 763.27# 66250 547.02 519.67 597.62 585.67 66500 328.40 311.98 358.78 351.60 66505 360.07 342.07 393.38 385.51 66600 779.48 740.51 851.59 834.56 66605 995.14 945.38 1,087.19 1,065.44 66625 411.10 390.55 449.13 440.15 66630 553.13 525.47 604.29 592.20 66635 539.65 512.67 589.57 577.78 66680 508.29 482.88 555.31 544.20 66682 618.77 587.83 676.00 662.48 66700 422.07 400.97 461.12 451.89# 66700 373.03 354.38 407.54 399.38 66710 427.46 406.09 467.00 457.67# 66710 387.17 367.81 422.98 414.52 66711 601.43 571.36 657.06 643.92 66720 444.85 422.61 486.00 476.28# 66720 401.43 381.36 438.56 429.79 66740 407.26 386.90 444.94 436.03# 66740 369.15 350.69 403.29 395.23 66761 279.95 265.95 305.84 299.72# 66761 227.47 216.10 248.52 243.55 66762 449.09 426.64 490.64 480.83# 66762 407.23 386.87 444.90 436.00 66770 491.52 466.94 536.98 526.24

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 75

# 66770 453.41 430.74 495.35 485.45 66820 373.81 355.12 408.39 400.22 66821 312.52 296.89 341.42 334.59# 66821 296.90 282.06 324.37 317.88 66825 723.36 687.19 790.27 774.47 66830 670.61 637.08 732.64 717.99 66840 686.07 651.77 749.54 734.54 66850 765.05 726.80 835.82 819.10 66852 827.49 786.12 904.04 885.96 66920 710.05 674.55 775.73 760.22 66930 807.38 767.01 882.06 864.42 66940 762.68 724.55 833.23 816.57 66982 775.69 736.91 847.45 830.50 66983 707.29 671.93 772.72 757.26 66984 621.53 590.45 679.02 665.44 66985 739.29 702.33 807.68 791.52 66986 874.37 830.65 955.25 936.15 66990 86.85 82.51 94.89 92.99 67005 464.81 441.57 507.81 497.65 67010 522.62 496.49 570.96 559.54 67015 555.76 527.97 607.17 595.02 67025 698.01 663.11 762.58 747.33# 67025 616.80 585.96 673.85 660.38 67027 835.53 793.75 912.81 894.56 67028 98.71 93.77 107.84 105.67# 67028 97.46 92.59 106.48 104.35 67030 495.49 470.72 541.33 530.51 67031 368.70 350.27 402.81 394.75# 67031 341.21 324.15 372.77 365.32 67036 928.37 881.95 1,014.24 993.96 67039 1,209.77 1,149.28 1,321.67 1,295.23 67040 1,373.50 1,304.83 1,500.55 1,470.54 67041 1,288.62 1,224.19 1,407.82 1,379.67 67042 1,474.80 1,401.06 1,611.22 1,579.00 67043 1,572.83 1,494.19 1,718.32 1,683.96 67101 752.68 715.05 822.31 805.86# 67101 658.03 625.13 718.90 704.52 67105 686.17 651.86 749.64 734.64# 67105 621.20 590.14 678.66 665.09 67107 1,193.14 1,133.48 1,303.50 1,277.43 67108 1,558.21 1,480.30 1,702.35 1,668.29 67110 825.42 784.15 901.77 883.74# 67110 744.52 707.29 813.38 797.11 67112 1,286.54 1,222.21 1,405.54 1,377.44 67113 1,697.35 1,612.48 1,854.35 1,817.26 67115 476.45 452.63 520.52 510.12 67120 633.55 601.87 692.15 678.30# 67120 547.96 520.56 598.64 586.67 67121 890.13 845.62 972.46 953.02 67141 505.61 480.33 552.38 541.33# 67141 474.68 450.95 518.59 508.22 67145 502.78 477.64 549.29 538.30

# 67145 478.11 454.20 522.33 511.89 67208 561.83 533.74 613.80 601.53# 67208 544.02 516.82 594.34 582.45 67210 497.69 472.81 543.73 532.85# 67210 482.38 458.26 527.00 516.45 67218 1,312.33 1,246.71 1,433.72 1,405.05 67220 516.74 490.90 564.54 553.24# 67220 487.37 463.00 532.45 521.80 67221 274.10 260.40 299.46 293.47# 67221 210.69 200.16 230.18 225.58 67225 28.29 26.88 30.91 30.29# 67225 27.04 25.69 29.54 28.96 67227 570.96 542.41 623.77 611.29# 67227 537.22 510.36 586.91 575.17 67228 973.13 924.47 1,063.14 1,041.88# 67228 927.84 881.45 1,013.67 993.39 67229 1,051.98 999.38 1,149.29 1,126.30 67250 755.52 717.74 825.40 808.90 67255 819.96 778.96 895.80 877.89 67311 582.27 553.16 636.13 623.42 67312 703.85 668.66 768.96 753.58 67314 655.38 622.61 716.00 701.68 67316 791.65 752.07 864.88 847.58 67318 662.24 629.13 723.50 709.03 67320 309.32 293.85 337.93 331.17 67331 307.09 291.74 335.50 328.80 67332 333.50 316.83 364.35 357.06 67334 289.70 275.22 316.50 310.18 67335 149.37 141.90 163.19 159.92 67340 344.42 327.20 376.28 368.76 67343 641.76 609.67 701.12 687.10 67345 237.26 225.40 259.21 254.02# 67345 216.02 205.22 236.00 231.29 67346 195.11 185.35 213.15 208.89 67400 901.56 856.48 984.95 965.25 67405 750.43 712.91 819.85 803.45 67412 823.79 782.60 899.99 881.99 67413 828.68 787.25 905.34 887.24 67414 1,273.78 1,210.09 1,391.60 1,363.77 67415 103.47 98.30 113.05 110.78 67420 1,587.40 1,508.03 1,734.23 1,699.55 67430 1,166.02 1,107.72 1,273.88 1,248.41 67440 1,150.56 1,093.03 1,256.98 1,231.85 67445 1,381.04 1,311.99 1,508.79 1,478.61 67450 1,189.55 1,130.07 1,299.58 1,273.59 67500 75.88 72.09 82.90 81.25# 67500 70.57 67.04 77.10 75.56 67505 88.97 84.52 97.20 95.25# 67505 82.41 78.29 90.03 88.23 67515 96.13 91.32 105.02 102.91# 67515 89.57 85.09 97.85 95.90 67550 935.26 888.50 1,021.78 1,001.34

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 76

67560 941.48 894.41 1,028.57 1,008.00 67570 1,176.71 1,117.87 1,285.55 1,259.84 67700 243.05 230.90 265.54 260.22# 67700 111.85 106.26 122.20 119.75 67710 203.78 193.59 222.63 218.18# 67710 94.45 89.73 103.19 101.13 67715 216.74 205.90 236.79 232.05# 67715 105.53 100.25 115.29 112.99 67800 121.55 115.47 132.79 130.13# 67800 101.56 96.48 110.95 108.73 67801 156.84 149.00 171.35 167.92# 67801 132.48 125.86 144.74 141.84 67805 194.48 184.76 212.47 208.22# 67805 162.62 154.49 177.66 174.11 67808 359.81 341.82 393.09 385.23 67810 154.44 146.72 168.73 165.36# 67810 69.16 65.70 75.56 74.05 67820 49.10 46.65 53.65 52.58# 67820 52.22 49.61 57.05 55.91 67825 123.72 117.53 135.16 132.46# 67825 117.79 111.90 128.69 126.11 67830 245.83 233.54 268.57 263.20# 67830 134.94 128.19 147.42 144.47 67835 431.56 409.98 471.48 462.05 67840 254.58 241.85 278.13 272.56# 67840 153.68 146.00 167.90 164.54 67850 195.85 186.06 213.97 209.69# 67850 128.37 121.95 140.24 137.44 67875 159.38 151.41 174.12 170.64# 67875 95.66 90.88 104.51 102.42 67880 435.37 413.60 475.64 466.13# 67880 357.59 339.71 390.67 382.86 67882 541.55 514.47 591.64 579.81# 67882 462.84 439.70 505.66 495.55 67900 609.12 578.66 665.46 652.15# 67900 496.66 471.83 542.60 531.75 67901 721.07 685.02 787.77 772.02# 67901 566.44 538.12 618.84 606.46 67902 712.95 677.30 778.90 763.31 67903 570.07 541.57 622.81 610.35# 67903 476.05 452.25 520.09 509.69 67904 702.12 667.01 767.06 751.72# 67904 586.54 557.21 640.79 627.98 67906 479.32 455.35 523.65 513.18 67908 474.67 450.94 518.58 508.21# 67908 415.32 394.55 453.73 444.66 67909 511.35 485.78 558.65 547.47# 67909 427.63 406.25 467.19 457.85 67911 551.66 524.08 602.69 590.64 67912 810.41 769.89 885.37 867.66# 67912 470.55 447.02 514.07 503.79 67914 437.87 415.98 478.38 468.81

# 67914 315.42 299.65 344.60 337.71 67915 268.26 254.85 293.08 287.21# 67915 186.73 177.39 204.00 199.92 67916 557.03 529.18 608.56 596.39# 67916 418.34 397.42 457.03 447.89 67917 572.31 543.69 625.24 612.74# 67917 447.99 425.59 489.43 479.64 67921 429.40 407.93 469.12 459.74# 67921 300.39 285.37 328.18 321.61 67922 266.10 252.80 290.72 284.90# 67922 186.45 177.13 203.70 199.63 67923 559.28 531.32 611.02 598.79# 67923 420.59 399.56 459.49 450.31 67924 597.23 567.37 652.48 639.42# 67924 448.54 426.11 490.03 480.23 67930 345.47 328.20 377.43 369.89# 67930 238.63 226.70 260.71 255.50 67935 568.17 539.76 620.72 608.30# 67935 437.28 415.42 477.73 468.18 67938 220.50 209.48 240.90 236.08# 67938 111.17 105.61 121.45 119.03 67950 544.82 517.58 595.22 583.31# 67950 451.42 428.85 493.18 483.31 67961 547.66 520.28 598.32 586.35# 67961 444.58 422.35 485.70 475.99 67966 742.00 704.90 810.64 794.42# 67966 647.04 614.69 706.89 692.76 67971 715.00 679.25 781.14 765.52 67973 922.40 876.28 1,007.72 987.56 67974 921.33 875.26 1,006.55 986.41 67975 675.19 641.43 737.64 722.89 68020 113.93 108.23 124.46 121.98# 68020 106.74 101.40 116.61 114.28 68040 63.03 59.88 68.86 67.48# 68040 52.73 50.09 57.60 56.45 68100 157.02 149.17 171.55 168.12# 68100 94.55 89.82 103.29 101.22 68110 211.17 200.61 230.70 226.09# 68110 144.94 137.69 158.34 155.18 68115 286.76 272.42 313.28 307.02# 68115 176.81 167.97 193.17 189.30 68130 494.54 469.81 540.28 529.47# 68130 385.52 366.24 421.18 412.76 68135 149.61 142.13 163.45 160.18# 68135 144.92 137.67 158.32 155.16 68200 39.76 37.77 43.44 42.56# 68200 34.14 32.43 37.29 36.55 68320 685.55 651.27 748.96 733.98# 68320 526.24 499.93 574.92 563.42 68325 647.08 614.73 706.94 692.81 68326 634.38 602.66 693.06 679.20 68328 697.13 662.27 761.61 746.37

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 77

68330 574.33 545.61 627.45 614.91# 68330 451.25 428.69 492.99 483.14 68335 637.03 605.18 695.96 682.04 68340 516.44 490.62 564.21 552.93# 68340 390.87 371.33 427.03 418.49 68360 506.32 481.00 553.15 542.09# 68360 402.92 382.77 440.19 431.38 68362 646.36 614.04 706.15 692.02 68371 386.10 366.80 421.82 413.38 68400 261.41 248.34 285.59 279.88# 68400 129.58 123.10 141.57 138.74 68420 294.33 279.61 321.55 315.12# 68420 162.51 154.38 177.54 173.98 68440 97.27 92.41 106.27 104.14# 68440 94.77 90.03 103.53 101.46 68500 972.21 923.60 1,062.14 1,040.90 68505 954.19 906.48 1,042.45 1,021.60 68510 427.91 406.51 467.49 458.14# 68510 295.46 280.69 322.79 316.34 68520 657.75 624.86 718.59 704.21 68525 267.60 254.22 292.35 286.51 68530 402.83 382.69 440.09 431.30# 68530 256.01 243.21 279.69 274.10 68540 892.12 847.51 974.64 955.14 68550 1,094.48 1,039.76 1,195.72 1,171.80 68700 593.20 563.54 648.07 635.11 68705 223.22 212.06 243.87 238.99# 68705 162.62 154.49 177.66 174.11 68720 736.06 699.26 804.15 788.06 68745 747.33 709.96 816.45 800.12 68750 770.04 731.54 841.27 824.45 68760 190.05 180.55 207.63 203.48# 68760 142.57 135.44 155.76 152.64 68761 139.11 132.15 151.97 148.94# 68761 114.75 109.01 125.36 122.85 68770 618.90 587.96 676.15 662.63 68801 115.89 110.10 126.62 124.09# 68801 101.21 96.15 110.57 108.36 68810 227.85 216.46 248.93 243.95# 68810 180.68 171.65 197.40 193.45 68811 200.48 190.46 219.03 214.65 68815 416.13 395.32 454.62 445.52# 68815 250.88 238.34 274.09 268.61 68816 669.27 635.81 731.18 716.55# 68816 243.81 231.62 266.36 261.04 68840 122.29 116.18 133.61 130.94# 68840 112.92 107.27 123.36 120.89 68850 56.53 53.70 61.76 60.52# 68850 52.47 49.85 57.33 56.18 69000 173.57 164.89 189.62 185.83# 69000 113.60 107.92 124.11 121.62 69005 201.03 190.98 219.63 215.23

# 69005 150.11 142.60 163.99 160.71 69020 214.39 203.67 234.22 229.54# 69020 134.11 127.40 146.51 143.58 69100 90.48 85.96 98.85 96.88# 69100 47.06 44.71 51.42 50.39 69105 128.81 122.37 140.73 137.91# 69105 60.71 57.67 66.32 65.00 69110 420.17 399.16 459.03 449.86# 69110 303.34 288.17 331.40 324.77 69120 380.90 361.86 416.14 407.81 69140 818.19 777.28 893.87 875.99 69145 367.02 348.67 400.97 392.96# 69145 235.82 224.03 257.63 252.48 69150 997.37 947.50 1,089.63 1,067.83 69155 1,596.36 1,516.54 1,744.02 1,709.14 69200 112.51 106.88 122.91 120.45# 69200 55.35 52.58 60.47 59.26 69205 96.24 91.43 105.14 103.04 69210 46.28 43.97 50.57 49.55# 69210 32.23 30.62 35.21 34.51 69220 126.22 119.91 137.90 135.14# 69220 59.37 56.40 64.86 63.56 69222 202.85 192.71 221.62 217.19# 69222 128.82 122.38 140.74 137.92 69300 683.47 649.30 746.70 731.76# 69300 455.44 432.67 497.57 487.62 69310 1,021.63 970.55 1,116.13 1,093.81 69320 1,438.98 1,367.03 1,572.08 1,540.64 69400 135.90 129.11 148.48 145.51# 69400 59.37 56.40 64.86 63.56 69401 81.67 77.59 89.23 87.45# 69401 47.62 45.24 52.03 50.99 69405 245.72 233.43 268.44 263.07# 69405 184.19 174.98 201.23 197.20 69420 177.22 168.36 193.61 189.74# 69420 114.12 108.41 124.67 122.18 69421 141.09 134.04 154.15 151.06 69424 117.56 111.68 128.43 125.87# 69424 59.46 56.49 64.96 63.66 69433 188.26 178.85 205.68 201.56# 69433 126.10 119.80 137.77 135.01 69436 152.66 145.03 166.78 163.45 69440 653.02 620.37 713.43 699.15 69450 513.47 487.80 560.97 549.75 69501 697.37 662.50 761.88 746.64 69502 927.80 881.41 1,013.62 993.35 69505 1,132.67 1,076.04 1,237.45 1,212.70 69511 1,161.13 1,103.07 1,268.53 1,243.16 69530 1,565.95 1,487.65 1,710.80 1,676.59 69535 2,563.06 2,434.91 2,800.15 2,744.14 69540 192.32 182.70 210.11 205.91# 69540 119.22 113.26 130.25 127.64

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 78

69550 978.72 929.78 1,069.25 1,047.86 69552 1,489.52 1,415.04 1,627.30 1,594.75 69554 2,412.92 2,292.27 2,636.11 2,583.38 69601 998.35 948.43 1,090.69 1,068.88 69602 1,037.39 985.52 1,133.35 1,110.68 69603 1,187.61 1,128.23 1,297.46 1,271.52 69604 1,060.79 1,007.75 1,158.91 1,135.74 69605 1,475.19 1,401.43 1,611.64 1,579.41 69610 363.39 345.22 397.00 389.07# 69610 280.93 266.88 306.91 300.77 69620 643.28 611.12 702.79 688.74# 69620 463.04 439.89 505.87 495.75 69631 837.70 795.82 915.19 896.89 69632 1,025.02 973.77 1,119.84 1,097.43 69633 990.42 940.90 1,082.04 1,060.39 69635 1,160.05 1,102.05 1,267.36 1,242.01 69636 1,299.59 1,234.61 1,419.80 1,391.41 69637 1,294.92 1,230.17 1,414.70 1,386.41 69641 991.55 941.97 1,083.27 1,061.60 69642 1,275.09 1,211.34 1,393.04 1,365.18 69643 1,167.15 1,108.79 1,275.11 1,249.60 69644 1,395.72 1,325.93 1,524.82 1,494.32 69645 1,371.61 1,303.03 1,498.48 1,468.52 69646 1,458.28 1,385.37 1,593.18 1,561.31 69650 764.50 726.28 835.22 818.51 69660 884.32 840.10 966.12 946.80 69661 1,153.04 1,095.39 1,259.70 1,234.50 69662 1,105.35 1,050.08 1,207.59 1,183.44 69666 769.21 730.75 840.36 823.56 69667 770.51 731.98 841.78 824.94 69670 898.70 853.77 981.84 962.19 69676 789.02 749.57 862.01 844.77 69700 652.33 619.71 712.67 698.42 69711 820.70 779.67 896.62 878.69 69714 1,029.00 977.55 1,124.18 1,101.70 69715 1,275.54 1,211.76 1,393.52 1,365.65 69717 1,081.24 1,027.18 1,181.26 1,157.64 69718 1,289.07 1,224.62 1,408.31 1,380.15 69720 1,135.98 1,079.18 1,241.06 1,216.24 69725 1,809.16 1,718.70 1,976.51 1,936.98 69740 1,119.38 1,063.41 1,222.92 1,198.46 69745 1,189.35 1,129.88 1,299.36 1,273.37 69801 184.40 175.18 201.46 197.43# 69801 122.24 116.13 133.55 130.88 69805 1,011.03 960.48 1,104.55 1,082.46 69806 905.53 860.25 989.29 969.51 69820 815.86 775.07 891.33 873.51 69840 842.91 800.76 920.87 902.45 69905 873.88 830.19 954.72 935.63 69910 974.56 925.83 1,064.70 1,043.41 69915 1,482.32 1,408.20 1,619.43 1,587.05 69930 1,176.99 1,118.14 1,285.86 1,260.15

69950 1,721.02 1,634.97 1,880.22 1,842.61 69955 1,905.26 1,810.00 2,081.50 2,039.87 69960 1,856.84 1,764.00 2,028.60 1,988.03 69970 2,065.74 1,962.45 2,256.82 2,211.68 69990 205.95 195.65 225.00 220.50 70010 62.20 59.09 67.95 66.60 70015 140.12 133.11 153.08 150.02 70015 TC 81.81 77.72 89.38 87.60 70015 26 58.31 55.39 63.70 62.42 70030 26.95 25.60 29.44 28.85 70030 TC 18.71 17.77 20.44 20.02 70030 26 8.24 7.83 9.00 8.82 70100 31.68 30.10 34.62 33.93 70100 TC 22.77 21.63 24.87 24.38 70100 26 8.91 8.46 9.73 9.53 70110 36.69 34.86 40.09 39.28 70110 TC 24.33 23.11 26.58 26.05 70110 26 12.36 11.74 13.50 13.24 70120 32.93 31.28 35.97 35.25 70120 TC 24.02 22.82 26.24 25.71 70120 26 8.91 8.46 9.73 9.53 70130 53.03 50.38 57.94 56.78 70130 TC 36.51 34.68 39.88 39.09 70130 26 16.52 15.69 18.04 17.69 70134 50.84 48.30 55.55 54.43 70134 TC 33.39 31.72 36.48 35.75 70134 26 17.46 16.59 19.08 18.70 70140 27.67 26.29 30.23 29.62 70140 TC 17.77 16.88 19.41 19.02 70140 26 9.89 9.40 10.81 10.59 70150 39.23 37.27 42.86 42.00 70150 TC 26.52 25.19 28.97 28.39 70150 26 12.71 12.07 13.88 13.60 70160 31.01 29.46 33.88 33.20 70160 TC 22.46 21.34 24.54 24.05 70160 26 8.55 8.12 9.34 9.15 70170 49.16 46.70 53.71 52.64 70170 TC 34.15 32.44 37.31 36.56 70170 26 15.01 14.26 16.40 16.07 70190 33.38 31.71 36.47 35.74 70190 TC 22.77 21.63 24.87 24.38 70190 26 10.61 10.08 11.59 11.36 70200 40.26 38.25 43.99 43.11 70200 TC 26.52 25.19 28.97 28.39 70200 26 13.74 13.05 15.01 14.71 70210 28.20 26.79 30.81 30.19 70210 TC 19.64 18.66 21.46 21.03 70210 26 8.55 8.12 9.34 9.15 70220 35.75 33.96 39.05 38.27 70220 TC 23.39 22.22 25.55 25.05 70220 26 12.36 11.74 13.50 13.24 70240 28.29 26.88 30.91 30.29

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 79

70240 TC 18.71 17.77 20.44 20.02 70240 26 9.58 9.10 10.47 10.26 70250 34.45 32.73 37.64 36.89 70250 TC 22.14 21.03 24.18 23.70 70250 26 12.31 11.69 13.44 13.18 70260 43.97 41.77 48.04 47.07 70260 TC 27.14 25.78 29.65 29.05 70260 26 16.83 15.99 18.39 18.02 70300 13.82 13.13 15.10 14.80 70300 TC 8.09 7.69 8.84 8.67 70300 26 5.73 5.44 6.26 6.13 70310 34.71 32.97 37.92 37.16 70310 TC 26.83 25.49 29.31 28.73 70310 26 7.88 7.49 8.61 8.44 70320 48.11 45.70 52.56 51.51 70320 TC 36.51 34.68 39.88 39.09 70320 26 11.59 11.01 12.66 12.41 70328 29.18 27.72 31.88 31.25 70328 TC 19.96 18.96 21.80 21.37 70328 26 9.22 8.76 10.07 9.87 70330 44.76 42.52 48.90 47.92 70330 TC 32.45 30.83 35.45 34.74 70330 26 12.31 11.69 13.44 13.18 70332 76.37 72.55 83.43 81.77 70332 TC 46.51 44.18 50.81 49.80 70332 26 29.86 28.37 32.63 31.97 70336 291.98 277.38 318.99 312.60 70336 TC 220.19 209.18 240.56 235.75 70336 26 71.79 68.20 78.43 76.87 70350 19.76 18.77 21.59 21.15 70350 TC 10.27 9.76 11.22 10.99 70350 26 9.49 9.02 10.37 10.17 70355 19.28 18.32 21.07 20.64 70355 TC 8.71 8.27 9.51 9.32 70355 26 10.57 10.04 11.55 11.32 70360 26.64 25.31 29.11 28.52 70360 TC 18.40 17.48 20.10 19.70 70360 26 8.24 7.83 9.00 8.82 70370 72.93 69.28 79.67 78.07 70370 TC 57.75 54.86 63.09 61.82 70370 26 15.18 14.42 16.58 16.25 70371 85.87 81.58 93.82 91.94 70371 TC 44.32 42.10 48.42 47.45 70371 26 41.54 39.46 45.38 44.47 70373 79.10 75.15 86.42 84.70 70373 TC 57.44 54.57 62.76 61.50 70373 26 21.66 20.58 23.67 23.20 70380 34.76 33.02 37.97 37.21 70380 TC 25.89 24.60 28.29 27.73 70380 26 8.87 8.43 9.69 9.50 70390 91.57 86.99 100.04 98.04 70390 TC 72.75 69.11 79.48 77.89

70390 26 18.82 17.88 20.56 20.15 70450 112.74 107.10 123.17 120.70 70450 TC 71.50 67.93 78.12 76.56 70450 26 41.24 39.18 45.06 44.16 70460 153.97 146.27 168.21 164.84 70460 TC 98.99 94.04 108.15 105.98 70460 26 54.99 52.24 60.08 58.88 70470 184.53 175.30 201.60 197.56 70470 TC 122.42 116.30 133.75 131.07 70470 26 62.12 59.01 67.86 66.50C 70480 172.71 164.07 188.68 184.91C 70480 TC 110.23 104.72 120.43 118.02 70480 26 62.48 59.36 68.26 66.90 70481 263.72 250.53 288.11 282.35 70481 TC 196.14 186.33 214.28 209.99 70481 26 67.58 64.20 73.83 72.36 70482 291.22 276.66 318.16 311.80 70482 TC 220.50 209.48 240.90 236.08 70482 26 70.72 67.18 77.26 75.72C 70486 165.89 157.60 181.24 177.62C 70486 TC 110.23 104.72 120.43 118.02 70486 26 55.66 52.88 60.81 59.59 70487 226.22 214.91 247.15 242.20 70487 TC 162.71 154.57 177.76 174.20 70487 26 63.50 60.33 69.38 67.99 70488 270.15 256.64 295.14 289.24 70488 TC 200.82 190.78 219.40 215.00 70488 26 69.33 65.86 75.74 74.22C 70490 172.71 164.07 188.68 184.91C 70490 TC 110.23 104.72 120.43 118.02 70490 26 62.48 59.36 68.26 66.90 70491 222.21 211.10 242.77 237.91 70491 TC 154.90 147.16 169.23 165.85 70491 26 67.31 63.94 73.53 72.06 70492 263.10 249.95 287.44 281.69 70492 TC 192.39 182.77 210.19 205.98 70492 26 70.72 67.18 77.26 75.72C 70496 340.00 323.00 371.45 364.02C 70496 TC 254.55 241.82 278.09 272.53 70496 26 85.45 81.18 93.36 91.49C 70498 339.69 322.71 371.12 363.70C 70498 TC 254.55 241.82 278.09 272.53 70498 26 85.14 80.88 93.01 91.15C 70540 322.93 306.78 352.80 345.74C 70540 TC 257.05 244.20 280.83 275.22 70540 26 65.89 62.60 71.99 70.55 70542 370.65 352.12 404.94 396.84 70542 TC 291.41 276.84 318.37 312.00 70542 26 79.24 75.28 86.57 84.84 70543 454.57 431.84 496.62 486.68 70543 TC 350.14 332.63 382.52 374.88 70543 26 104.43 99.21 114.09 111.81

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 80

C 70544 315.72 299.93 344.92 338.02C 70544 TC 257.05 244.20 280.83 275.22 70544 26 58.67 55.74 64.10 62.82 70545 356.96 339.11 389.98 382.18 70545 TC 298.28 283.37 325.88 319.36 70545 26 58.67 55.74 64.10 62.82C 70546 517.94 492.04 565.85 554.53C 70546 TC 429.79 408.30 469.55 460.15 70546 26 88.15 83.74 96.30 94.38C 70547 315.72 299.93 344.92 338.02C 70547 TC 257.05 244.20 280.83 275.22 70547 26 58.67 55.74 64.10 62.82 70548 380.70 361.67 415.92 407.61 70548 TC 322.02 305.92 351.81 344.77 70548 26 58.67 55.74 64.10 62.82C 70549 517.66 491.78 565.55 554.23C 70549 TC 429.79 408.30 469.55 460.15 70549 26 87.87 83.48 96.00 94.08 70551 222.32 211.20 242.88 238.03 70551 TC 150.22 142.71 164.12 160.84 70551 26 72.10 68.50 78.78 77.20 70552 301.37 286.30 329.25 322.66 70552 TC 213.94 203.24 233.73 229.06 70552 26 87.43 83.06 95.52 93.61 70553 356.43 338.61 389.40 381.62 70553 TC 244.55 232.32 267.17 261.82 70553 26 111.88 106.29 122.23 119.78 70554 407.84 387.45 445.57 436.66 70554 TC 304.84 289.60 333.04 326.38 70554 26 103.00 97.85 112.53 110.27 70555 571.21 542.65 624.05 611.57 70555 TC 444.79 422.55 485.93 476.22 70555 26 126.42 120.10 138.12 135.36 70557 26 165.04 156.79 180.31 176.70 70558 26 159.53 151.55 174.28 170.80 70559 26 159.85 151.86 174.64 171.14 71010 21.68 20.60 23.69 23.22 71010 TC 12.77 12.13 13.95 13.67 71010 26 8.91 8.46 9.73 9.53 71015 27.76 26.37 30.33 29.72 71015 TC 17.46 16.59 19.08 18.70 71015 26 10.30 9.79 11.26 11.03 71020 28.12 26.71 30.72 30.11 71020 TC 17.46 16.59 19.08 18.70 71020 26 10.66 10.13 11.65 11.42 71021 34.59 32.86 37.79 37.03 71021 TC 21.21 20.15 23.17 22.71 71021 26 13.39 12.72 14.63 14.34 71022 42.90 40.76 46.87 45.93 71022 TC 26.83 25.49 29.31 28.73 71022 26 16.07 15.27 17.56 17.20 71023 60.40 57.38 65.99 64.66

71023 TC 42.14 40.03 46.03 45.11 71023 26 18.26 17.35 19.95 19.55 71030 42.58 40.45 46.52 45.59 71030 TC 27.77 26.38 30.34 29.73 71030 26 14.82 14.08 16.19 15.87 71034 79.51 75.53 86.86 85.12 71034 TC 57.44 54.57 62.76 61.50 71034 26 22.07 20.97 24.12 23.63 71035 33.24 31.58 36.32 35.59 71035 TC 24.33 23.11 26.58 26.05 71035 26 8.91 8.46 9.73 9.53 71100 30.30 28.79 33.11 32.44 71100 TC 19.33 18.36 21.11 20.69 71100 26 10.97 10.42 11.98 11.74 71101 36.78 34.94 40.18 39.38 71101 TC 23.71 22.52 25.90 25.38 71101 26 13.07 12.42 14.28 14.00 71110 37.72 35.83 41.20 40.38 71110 TC 24.33 23.11 26.58 26.05 71110 26 13.39 12.72 14.63 14.34 71111 49.19 46.73 53.74 52.67 71111 TC 33.39 31.72 36.48 35.75 71111 26 15.80 15.01 17.26 16.92 71120 29.27 27.81 31.98 31.34 71120 TC 19.33 18.36 21.11 20.69 71120 26 9.94 9.44 10.86 10.64 71130 34.36 32.64 37.54 36.79 71130 TC 23.39 22.22 25.55 25.05 71130 26 10.97 10.42 11.98 11.74C 71250 159.72 151.73 174.49 171.01C 71250 TC 110.23 104.72 120.43 118.02 71250 26 49.48 47.01 54.06 52.98 71260 216.26 205.45 236.27 231.54 71260 TC 155.53 147.75 169.91 166.52 71260 26 60.73 57.69 66.34 65.02 71270 260.32 247.30 284.40 278.70 71270 TC 193.32 183.65 211.20 206.98 71270 26 67.00 63.65 73.20 71.74 71275 337.31 320.44 368.51 361.13 71275 TC 243.62 231.44 266.16 260.83 71275 26 93.70 89.02 102.37 100.33C 71550 328.12 311.71 358.47 351.30C 71550 TC 257.05 244.20 280.83 275.22 71550 26 71.08 67.53 77.66 76.11 71551 422.07 400.97 461.12 451.89 71551 TC 337.64 320.76 368.87 361.49 71551 26 84.43 80.21 92.24 90.40 71552 531.61 505.03 580.78 569.17 71552 TC 421.67 400.59 460.68 451.47 71552 26 109.94 104.44 120.11 117.70 71555 373.70 355.02 408.27 400.11 71555 TC 285.79 271.50 312.23 305.98

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 81

71555 26 87.92 83.52 96.05 94.13 72010 72.52 68.89 79.22 77.64 72010 TC 49.63 47.15 54.22 53.14 72010 26 22.89 21.75 25.01 24.52 72020 21.23 20.17 23.20 22.74 72020 TC 13.71 13.02 14.97 14.67 72020 26 7.52 7.14 8.21 8.05 72040 33.04 31.39 36.10 35.37 72040 TC 21.52 20.44 23.51 23.03 72040 26 11.52 10.94 12.58 12.33 72050 44.70 42.47 48.84 47.86 72050 TC 29.02 27.57 31.71 31.07 72050 26 15.69 14.91 17.15 16.80 72052 57.11 54.25 62.39 61.15 72052 TC 39.01 37.06 42.62 41.77 72052 26 18.10 17.20 19.78 19.39 72069 35.23 33.47 38.49 37.72 72069 TC 23.71 22.52 25.90 25.38 72069 26 11.52 10.94 12.58 12.33 72070 30.93 29.38 33.79 33.11 72070 TC 19.96 18.96 21.80 21.37 72070 26 10.97 10.42 11.98 11.74 72072 34.36 32.64 37.54 36.79 72072 TC 23.71 22.52 25.90 25.38 72072 26 10.66 10.13 11.65 11.42 72074 40.61 38.58 44.37 43.48 72074 TC 29.95 28.45 32.72 32.06 72074 26 10.66 10.13 11.65 11.42 72080 33.36 31.69 36.44 35.72 72080 TC 21.83 20.74 23.85 23.38 72080 26 11.52 10.94 12.58 12.33 72090 47.65 45.27 52.06 51.01 72090 TC 32.76 31.12 35.79 35.08 72090 26 14.89 14.15 16.27 15.95 72100 33.04 31.39 36.10 35.37 72100 TC 21.52 20.44 23.51 23.03 72100 26 11.52 10.94 12.58 12.33 72110 45.33 43.06 49.52 48.53 72110 TC 29.64 28.16 32.38 31.74 72110 26 15.69 14.91 17.15 16.80 72114 58.77 55.83 64.20 62.92 72114 TC 42.14 40.03 46.03 45.11 72114 26 16.63 15.80 18.17 17.80 72120 37.10 35.25 40.54 39.73 72120 TC 25.58 24.30 27.95 27.38 72120 26 11.52 10.94 12.58 12.33C 72125 162.13 154.02 177.12 173.58C 72125 TC 110.23 104.72 120.43 118.02 72125 26 51.90 49.31 56.71 55.57 72126 216.17 205.36 236.16 231.44 72126 TC 156.46 148.64 170.94 167.52 72126 26 59.70 56.72 65.23 63.93

72127 256.38 243.56 280.09 274.49 72127 TC 194.57 184.84 212.57 208.31 72127 26 61.81 58.72 67.53 66.18C 72128 159.00 151.05 173.71 170.23C 72128 TC 110.23 104.72 120.43 118.02 72128 26 48.77 46.33 53.28 52.21 72129 216.17 205.36 236.16 231.44 72129 TC 156.46 148.64 170.94 167.52 72129 26 59.70 56.72 65.23 63.93 72130 259.19 246.23 283.16 277.51 72130 TC 197.39 187.52 215.65 211.34 72130 26 61.81 58.72 67.53 66.18C 72131 159.00 151.05 173.71 170.23C 72131 TC 110.23 104.72 120.43 118.02 72131 26 48.77 46.33 53.28 52.21 72132 215.54 204.76 235.47 230.76 72132 TC 155.84 148.05 170.26 166.85 72132 26 59.70 56.72 65.23 63.93 72133 256.69 243.86 280.44 274.83 72133 TC 194.89 185.15 212.92 208.67 72133 26 61.81 58.72 67.53 66.18 72141 220.72 209.68 241.13 236.31 72141 TC 148.03 140.63 161.72 158.49 72141 26 72.69 69.06 79.42 77.83 72142 302.35 287.23 330.31 323.71 72142 TC 215.19 204.43 235.09 230.39 72142 26 87.15 82.79 95.21 93.30 72146 220.72 209.68 241.13 236.31 72146 TC 148.03 140.63 161.72 158.49 72146 26 72.69 69.06 79.42 77.83 72147 299.53 284.55 327.23 320.69 72147 TC 212.38 201.76 232.02 227.38 72147 26 87.15 82.79 95.21 93.30 72148 221.00 209.95 241.44 236.61 72148 TC 148.03 140.63 161.72 158.49 72148 26 72.97 69.32 79.72 78.12 72149 298.56 283.63 326.17 319.65 72149 TC 211.13 200.57 230.66 226.04 72149 26 87.43 83.06 95.52 93.61 72156 356.74 338.90 389.74 381.94 72156 TC 244.87 232.63 267.52 262.18 72156 26 111.88 106.29 122.23 119.78 72157 357.06 339.21 390.09 382.29 72157 TC 245.18 232.92 267.86 262.50 72157 26 111.88 106.29 122.23 119.78 72158 355.74 337.95 388.64 380.87 72158 TC 243.30 231.14 265.81 260.50 72158 26 112.43 106.81 122.83 120.37 72159 389.07 369.62 425.06 416.56 72159 TC 301.72 286.63 329.62 323.04 72159 26 87.35 82.98 95.43 93.52 72170 26.57 25.24 29.03 28.45

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 82

72170 TC 17.46 16.59 19.08 18.70 72170 26 9.11 8.65 9.95 9.75 72190 39.24 37.28 42.87 42.01 72190 TC 28.08 26.68 30.68 30.07 72190 26 11.17 10.61 12.20 11.96C 72191 342.74 325.60 374.44 366.95C 72191 TC 254.55 241.82 278.09 272.53 72191 26 88.19 83.78 96.35 94.42 72192 137.86 130.97 150.62 147.60 72192 TC 84.93 80.68 92.78 90.93 72192 26 52.93 50.28 57.82 56.66 72193 212.45 201.83 232.10 227.46 72193 TC 155.53 147.75 169.91 166.52 72193 26 56.93 54.08 62.19 60.95 72194 248.03 235.63 270.97 265.56 72194 TC 188.64 179.21 206.09 201.97 72194 26 59.39 56.42 64.88 63.58C 72195 328.99 312.54 359.42 352.23C 72195 TC 257.05 244.20 280.83 275.22 72195 26 71.94 68.34 78.59 77.02 72196 381.15 362.09 416.40 408.08 72196 TC 296.41 281.59 323.83 317.35 72196 26 84.74 80.50 92.58 90.72 72197 466.01 442.71 509.12 498.94 72197 TC 356.07 338.27 389.01 381.23 72197 26 109.94 104.44 120.11 117.70 72198 378.03 359.13 413.00 404.74 72198 TC 290.79 276.25 317.69 311.34 72198 26 87.25 82.89 95.32 93.41 72200 27.26 25.90 29.79 29.19 72200 TC 18.71 17.77 20.44 20.02 72200 26 8.55 8.12 9.34 9.15 72202 32.04 30.44 35.01 34.30 72202 TC 22.77 21.63 24.87 24.38 72202 26 9.27 8.81 10.13 9.92 72220 26.64 25.31 29.11 28.52 72220 TC 18.08 17.18 19.76 19.37 72220 26 8.55 8.12 9.34 9.15 72240 118.92 112.97 129.92 127.32 72240 TC 74.62 70.89 81.52 79.89 72240 26 44.29 42.08 48.39 47.43 72255 113.33 107.66 123.81 121.34 72255 TC 68.69 65.26 75.05 73.54 72255 26 44.64 42.41 48.77 47.79 72265 115.77 109.98 126.48 123.95 72265 TC 75.25 71.49 82.21 80.57 72265 26 40.53 38.50 44.28 43.39 72270 180.12 171.11 196.78 192.84 72270 TC 115.23 109.47 125.89 123.37 72270 26 64.89 61.65 70.90 69.48 72275 106.39 101.07 116.23 113.91 72275 TC 67.75 64.36 74.01 72.53

72275 26 38.64 36.71 42.22 41.38 72285 106.94 101.59 116.83 114.49 72285 TC 47.76 45.37 52.18 51.13 72285 26 59.18 56.22 64.65 63.37 72291 222.14 211.03 242.68 237.83 72291 TC 152.83 145.19 166.97 163.63 72291 26 69.31 65.84 75.72 74.20 72292 26 71.26 67.70 77.86 76.30 72295 91.72 87.13 100.20 98.20 72295 TC 49.63 47.15 54.22 53.14 72295 26 42.09 39.99 45.99 45.07 73000 26.59 25.26 29.05 28.46 73000 TC 18.40 17.48 20.10 19.70 73000 26 8.20 7.79 8.96 8.77 73010 29.38 27.91 32.10 31.45 73010 TC 19.96 18.96 21.80 21.37 73010 26 9.42 8.95 10.29 10.09 73020 21.86 20.77 23.89 23.40 73020 TC 14.33 13.61 15.65 15.34 73020 26 7.52 7.14 8.21 8.05 73030 28.49 27.07 31.13 30.51 73030 TC 18.71 17.77 20.44 20.02 73030 26 9.78 9.29 10.68 10.47 73040 96.01 91.21 104.89 102.80 73040 TC 69.00 65.55 75.38 73.88 73040 26 27.01 25.66 29.51 28.92 73050 36.39 34.57 39.76 38.96 73050 TC 25.58 24.30 27.95 27.38 73050 26 10.81 10.27 11.81 11.57 73060 26.64 25.31 29.11 28.52 73060 TC 18.08 17.18 19.76 19.37 73060 26 8.55 8.12 9.34 9.15 73070 25.92 24.62 28.31 27.75 73070 TC 18.08 17.18 19.76 19.37 73070 26 7.84 7.45 8.57 8.40 73080 30.70 29.17 33.55 32.88 73080 TC 22.14 21.03 24.18 23.70 73080 26 8.55 8.12 9.34 9.15 73085 92.92 88.27 101.51 99.48 73085 TC 64.94 61.69 70.94 69.53 73085 26 27.99 26.59 30.58 29.97 73090 25.65 24.37 28.03 27.46 73090 TC 17.46 16.59 19.08 18.70 73090 26 8.20 7.79 8.96 8.77 73092 25.97 24.67 28.37 27.81 73092 TC 18.08 17.18 19.76 19.37 73092 26 7.88 7.49 8.61 8.44 73100 28.71 27.27 31.36 30.73 73100 TC 19.96 18.96 21.80 21.37 73100 26 8.75 8.31 9.56 9.36 73110 34.45 32.73 37.64 36.89 73110 TC 25.89 24.60 28.29 27.73

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 83

73110 26 8.55 8.12 9.34 9.15 73115 101.01 95.96 110.35 108.15 73115 TC 73.37 69.70 80.16 78.56 73115 26 27.64 26.26 30.20 29.59 73120 25.34 24.07 27.68 27.13 73120 TC 17.15 16.29 18.73 18.35 73120 26 8.20 7.79 8.96 8.77 73130 30.07 28.57 32.86 32.20 73130 TC 21.52 20.44 23.51 23.03 73130 26 8.55 8.12 9.34 9.15 73140 30.20 28.69 32.99 32.34 73140 TC 23.39 22.22 25.55 25.05 73140 26 6.81 6.47 7.44 7.29C 73200 159.55 151.57 174.31 170.82C 73200 TC 110.23 104.72 120.43 118.02 73200 26 49.32 46.85 53.88 52.80 73201 210.89 200.35 230.40 225.79 73201 TC 153.97 146.27 168.21 164.84 73201 26 56.93 54.08 62.19 60.95 73202 267.71 254.32 292.47 286.61 73202 TC 208.32 197.90 227.59 223.03 73202 26 59.39 56.42 64.88 63.58 73206 303.18 288.02 331.22 324.60 73206 TC 215.82 205.03 235.78 231.07 73206 26 87.36 82.99 95.44 93.53C 73218 322.97 306.82 352.84 345.78C 73218 TC 257.05 244.20 280.83 275.22 73218 26 65.92 62.62 72.01 70.58 73219 375.02 356.27 409.71 401.51 73219 TC 295.47 280.70 322.81 316.35 73219 26 79.55 75.57 86.91 85.17 73220 460.82 437.78 503.45 493.37 73220 TC 356.07 338.27 389.01 381.23 73220 26 104.75 99.51 114.44 112.15 73221 230.09 218.59 251.38 246.35 73221 TC 163.02 154.87 178.10 174.54 73221 26 67.06 63.71 73.27 71.81 73222 350.65 333.12 383.09 375.43 73222 TC 271.11 257.55 296.18 290.26 73222 26 79.55 75.57 86.91 85.17 73223 435.20 413.44 475.46 465.95 73223 TC 330.46 313.94 361.03 353.81 73223 26 104.75 99.51 114.44 112.15 73225 383.44 364.27 418.91 410.53 73225 TC 299.84 284.85 327.58 321.02 73225 26 83.59 79.41 91.32 89.49 73500 25.00 23.75 27.31 26.77 73500 TC 15.90 15.11 17.38 17.03 73500 26 9.11 8.65 9.95 9.75 73510 36.12 34.31 39.46 38.66 73510 TC 24.95 23.70 27.26 26.71 73510 26 11.17 10.61 12.20 11.96

73520 38.22 36.31 41.76 40.92 73520 TC 24.64 23.41 26.92 26.38 73520 26 13.58 12.90 14.84 14.54 73525 94.14 89.43 102.84 100.79 73525 TC 66.19 62.88 72.31 70.86 73525 26 27.95 26.55 30.53 29.92 73530 32.91 31.26 35.95 35.22 73530 TC 18.25 17.34 19.94 19.54 73530 26 14.66 13.93 16.02 15.70 73540 39.51 37.53 43.16 42.30 73540 TC 29.02 27.57 31.71 31.07 73540 26 10.50 9.98 11.48 11.25 73550 26.25 24.94 28.68 28.11 73550 TC 17.15 16.29 18.73 18.35 73550 26 9.11 8.65 9.95 9.75 73560 28.13 26.72 30.73 30.12 73560 TC 19.02 18.07 20.78 20.37 73560 26 9.11 8.65 9.95 9.75 73562 34.11 32.40 37.26 36.51 73562 TC 24.33 23.11 26.58 26.05 73562 26 9.78 9.29 10.68 10.47 73564 39.60 37.62 43.26 42.40 73564 TC 28.08 26.68 30.68 30.07 73564 26 11.52 10.94 12.58 12.33 73565 32.50 30.88 35.51 34.80 73565 TC 23.08 21.93 25.22 24.71 73565 26 9.42 8.95 10.29 10.09 73580 115.03 109.28 125.67 123.15 73580 TC 86.81 82.47 94.84 92.94 73580 26 28.23 26.82 30.84 30.22 73590 25.39 24.12 27.74 27.19 73590 TC 16.83 15.99 18.39 18.02 73590 26 8.55 8.12 9.34 9.15 73592 25.97 24.67 28.37 27.81 73592 TC 18.08 17.18 19.76 19.37 73592 26 7.88 7.49 8.61 8.44 73600 26.28 24.97 28.72 28.14 73600 TC 18.08 17.18 19.76 19.37 73600 26 8.20 7.79 8.96 8.77 73610 30.70 29.17 33.55 32.88 73610 TC 22.14 21.03 24.18 23.70 73610 26 8.55 8.12 9.34 9.15 73615 94.14 89.43 102.84 100.79 73615 TC 66.19 62.88 72.31 70.86 73615 26 27.95 26.55 30.53 29.92 73620 25.03 23.78 27.35 26.80 73620 TC 17.46 16.59 19.08 18.70 73620 26 7.57 7.19 8.27 8.11 73630 28.82 27.38 31.49 30.85 73630 TC 20.58 19.55 22.48 22.03 73630 26 8.24 7.83 9.00 8.82 73650 25.97 24.67 28.37 27.81

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 84

73650 TC 18.08 17.18 19.76 19.37 73650 26 7.88 7.49 8.61 8.44 73660 27.70 26.32 30.27 29.66 73660 TC 21.21 20.15 23.17 22.71 73660 26 6.50 6.18 7.11 6.97C 73700 159.55 151.57 174.31 170.82C 73700 TC 110.23 104.72 120.43 118.02 73700 26 49.32 46.85 53.88 52.80 73701 213.39 202.72 233.13 228.47 73701 TC 156.46 148.64 170.94 167.52 73701 26 56.93 54.08 62.19 60.95 73702 265.52 252.24 290.08 284.28 73702 TC 206.13 195.82 225.19 220.69 73702 26 59.39 56.42 64.88 63.58 73706 336.60 319.77 367.74 360.38 73706 TC 244.24 232.03 266.83 261.50 73706 26 92.35 87.73 100.89 98.88C 73718 322.93 306.78 352.80 345.74C 73718 TC 257.05 244.20 280.83 275.22 73718 26 65.89 62.60 71.99 70.55 73719 376.27 357.46 411.08 402.86 73719 TC 296.72 281.88 324.16 317.68 73719 26 79.55 75.57 86.91 85.17 73720 463.32 440.15 506.17 496.05 73720 TC 358.88 340.94 392.08 384.24 73720 26 104.43 99.21 114.09 111.81 73721 230.40 218.88 251.71 246.68 73721 TC 163.34 155.17 178.45 174.88 73721 26 67.06 63.71 73.27 71.81 73722 355.30 337.54 388.17 380.41 73722 TC 275.48 261.71 300.97 294.95 73722 26 79.83 75.84 87.22 85.47 73723 436.45 414.63 476.82 467.29 73723 TC 331.71 315.12 362.39 355.14 73723 26 104.75 99.51 114.44 112.15 73725 379.06 360.11 414.13 405.85 73725 TC 290.79 276.25 317.69 311.34 73725 26 88.27 83.86 96.44 94.51 74000 22.62 21.49 24.71 24.22 74000 TC 13.71 13.02 14.97 14.67 74000 26 8.91 8.46 9.73 9.53 74010 35.66 33.88 38.96 38.18 74010 TC 24.33 23.11 26.58 26.05 74010 26 11.33 10.76 12.37 12.12 74020 37.40 35.53 40.86 40.04 74020 TC 24.33 23.11 26.58 26.05 74020 26 13.07 12.42 14.28 14.00 74022 45.13 42.87 49.30 48.31 74022 TC 29.64 28.16 32.38 31.74 74022 26 15.49 14.72 16.93 16.59 74150 141.37 134.30 154.45 151.35 74150 TC 83.06 78.91 90.75 88.93

74150 26 58.31 55.39 63.70 62.42 74160 217.02 206.17 237.10 232.36 74160 TC 154.90 147.16 169.23 165.85 74160 26 62.12 59.01 67.86 66.50 74170 250.38 237.86 273.54 268.07 74170 TC 182.08 172.98 198.93 194.95 74170 26 68.30 64.89 74.62 73.13C 74174 447.23 424.87 488.60 478.83C 74174 TC 340.14 323.13 371.60 364.17 74174 26 107.09 101.74 117.00 114.67C 74175 347.22 329.86 379.34 371.75C 74175 TC 254.55 241.82 278.09 272.53 74175 26 92.67 88.04 101.25 99.22 74176 198.45 188.53 216.81 212.47 74176 TC 113.36 107.69 123.84 121.37 74176 26 85.10 80.85 92.98 91.11 74177 293.47 278.80 320.62 314.20 74177 TC 204.57 194.34 223.49 219.02 74177 26 88.90 84.46 97.13 95.19 74178 341.16 324.10 372.72 365.26 74178 TC 242.99 230.84 265.47 260.15 74178 26 98.17 93.26 107.25 105.10 74181 303.13 287.97 331.17 324.54 74181 TC 232.06 220.46 253.53 248.46 74181 26 71.08 67.53 77.66 76.11 74182 416.45 395.63 454.97 445.88 74182 TC 332.02 315.42 362.73 355.48 74182 26 84.43 80.21 92.24 90.40 74183 467.57 444.19 510.82 500.61 74183 TC 357.63 339.75 390.71 382.90 74183 26 109.94 104.44 120.11 117.70 74185 378.97 360.02 414.02 405.74 74185 TC 291.41 276.84 318.37 312.00 74185 26 87.56 83.18 95.66 93.75 74190 69.95 66.45 76.42 74.89 74190 TC 46.65 44.32 50.97 49.94 74190 26 23.30 22.14 25.46 24.96 74210 71.55 67.97 78.17 76.60 74210 TC 54.32 51.60 59.34 58.16 74210 26 17.23 16.37 18.83 18.45 74220 83.81 79.62 91.56 89.73 74220 TC 61.19 58.13 66.85 65.52 74220 26 22.62 21.49 24.71 24.22 74230 84.13 79.92 91.91 90.07 74230 TC 58.07 55.17 63.45 62.18 74230 26 26.07 24.77 28.49 27.91 74235 26 56.33 53.51 61.54 60.31 74240 105.45 100.18 115.21 112.91 74240 TC 71.50 67.93 78.12 76.56 74240 26 33.95 32.25 37.09 36.35 74241 109.54 104.06 119.67 117.28 74241 TC 76.18 72.37 83.23 81.56

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 85

74241 26 33.36 31.69 36.44 35.72 74245 163.27 155.11 178.38 174.81 74245 TC 118.98 113.03 129.98 127.39 74245 26 44.29 42.08 48.39 47.43 74246 118.25 112.34 129.19 126.60 74246 TC 84.62 80.39 92.45 90.60 74246 26 33.64 31.96 36.75 36.02 74247 131.06 124.51 143.19 140.32 74247 TC 97.43 92.56 106.44 104.32 74247 26 33.64 31.96 36.75 36.02 74249 175.77 166.98 192.03 188.19 74249 TC 131.47 124.90 143.64 140.76 74249 26 44.29 42.08 48.39 47.43 74250 98.85 93.91 108.00 105.83 74250 TC 75.87 72.08 82.89 81.24 74250 26 22.98 21.83 25.10 24.60C 74251 165.42 157.15 180.72 177.11C 74251 TC 131.79 125.20 143.98 141.11 74251 26 33.64 31.96 36.75 36.02C 74260 113.05 107.40 123.51 121.04C 74260 TC 88.68 84.25 96.89 94.96 74260 26 24.37 23.15 26.62 26.09C 74261 227.06 215.71 248.07 243.11C 74261 TC 110.23 104.72 120.43 118.02 74261 26 116.83 110.99 127.64 125.09C 74262 338.65 321.72 369.98 362.58C 74262 TC 217.07 206.22 237.15 232.42 74262 26 121.59 115.51 132.84 130.18 74270 143.87 136.68 157.18 154.04 74270 TC 110.23 104.72 120.43 118.02 74270 26 33.64 31.96 36.75 36.02C 74280 179.88 170.89 196.52 192.59C 74280 TC 131.79 125.20 143.98 141.11 74280 26 48.10 45.70 52.56 51.51 74283 190.23 180.72 207.83 203.68 74283 TC 93.36 88.69 101.99 99.96 74283 26 96.86 92.02 105.82 103.71 74290 63.87 60.68 69.78 68.39 74290 TC 48.38 45.96 52.85 51.80 74290 26 15.49 14.72 16.93 16.59 74291 61.14 58.08 66.79 65.46 74291 TC 51.19 48.63 55.92 54.81 74291 26 9.94 9.44 10.86 10.64 74300 26 17.79 16.90 19.44 19.04 74301 26 10.54 10.01 11.51 11.28 74305 44.42 42.20 48.53 47.56 74305 TC 23.89 22.70 26.11 25.59 74305 26 20.53 19.50 22.43 21.98 74320 88.86 84.42 97.08 95.14 74320 TC 63.06 59.91 68.90 67.52 74320 26 25.80 24.51 28.19 27.62 74327 127.11 120.75 138.86 136.09

74327 TC 91.49 86.92 99.96 97.96 74327 26 35.62 33.84 38.92 38.13 74328 147.50 140.13 161.15 157.93 74328 TC 112.60 106.97 123.02 120.55 74328 26 34.90 33.16 38.13 37.38 74329 26 35.21 33.45 38.47 37.70 74330 157.71 149.82 172.29 168.84 74330 TC 112.60 106.97 123.02 120.55 74330 26 45.11 42.85 49.28 48.29 74340 120.37 114.35 131.50 128.87 74340 TC 93.67 88.99 102.34 100.29 74340 26 26.70 25.37 29.18 28.59 74355 131.27 124.71 143.42 140.55 74355 TC 93.67 88.99 102.34 100.29 74355 26 37.60 35.72 41.08 40.26 74360 139.93 132.93 152.87 149.81 74360 TC 112.60 106.97 123.02 120.55 74360 26 27.33 25.96 29.85 29.26 74363 26 43.11 40.95 47.09 46.15 74400 103.00 97.85 112.53 110.27 74400 TC 79.00 75.05 86.31 84.58 74400 26 24.01 22.81 26.23 25.70 74410 101.13 96.07 110.48 108.27 74410 TC 77.43 73.56 84.59 82.90 74410 26 23.70 22.52 25.90 25.38 74415 125.18 118.92 136.76 134.02 74415 TC 101.17 96.11 110.53 108.32 74415 26 24.01 22.81 26.23 25.70 74420 111.46 105.89 121.77 119.34 74420 TC 93.67 88.99 102.34 100.29 74420 26 17.79 16.90 19.44 19.04 74425 64.13 60.92 70.06 68.66 74425 TC 46.65 44.32 50.97 49.94 74425 26 17.48 16.61 19.10 18.72 74430 37.94 36.04 41.45 40.62 74430 TC 22.77 21.63 24.87 24.38 74430 26 15.18 14.42 16.58 16.25 74440 74.70 70.97 81.62 79.98 74440 TC 56.19 53.38 61.39 60.16 74440 26 18.51 17.58 20.22 19.81 74445 96.03 91.23 104.91 102.82 74445 TC 40.24 38.23 43.96 43.09 74445 26 55.79 53.00 60.95 59.73 74450 68.48 65.06 74.82 73.32 74450 TC 52.08 49.48 56.90 55.76 74450 26 16.40 15.58 17.92 17.56 74455 75.79 72.00 82.80 81.14 74455 TC 59.94 56.94 65.48 64.17 74455 26 15.85 15.06 17.32 16.97 74470 70.71 67.17 77.25 75.70 74470 TC 44.63 42.40 48.76 47.78 74470 26 26.08 24.78 28.50 27.92

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 86

74475 88.24 83.83 96.40 94.47 74475 TC 62.13 59.02 67.87 66.52 74475 26 26.11 24.80 28.52 27.95 74480 88.24 83.83 96.40 94.47 74480 TC 62.13 59.02 67.87 66.52 74480 26 26.11 24.80 28.52 27.95 74485 87.93 83.53 96.06 94.14 74485 TC 62.13 59.02 67.87 66.52 74485 26 25.80 24.51 28.19 27.62 74710 34.60 32.87 37.80 37.04 74710 TC 18.08 17.18 19.76 19.37 74710 26 16.52 15.69 18.04 17.69 74740 70.39 66.87 76.90 75.36 74740 TC 52.13 49.52 56.95 55.81 74740 26 18.26 17.35 19.95 19.55 74742 26 30.42 28.90 33.24 32.57 74775 82.55 78.42 90.18 88.38 74775 TC 52.08 49.48 56.90 55.76 74775 26 30.47 28.95 33.29 32.63 75557 299.65 284.67 327.37 320.83 75557 TC 186.45 177.13 203.70 199.63 75557 26 113.20 107.54 123.67 121.20C 75559 397.33 377.46 434.08 425.40C 75559 TC 257.05 244.20 280.83 275.22 75559 26 140.28 133.27 153.26 150.19 75561 392.60 372.97 428.92 420.34 75561 TC 267.67 254.29 292.43 286.58 75561 26 124.93 118.68 136.48 133.76 75563 462.84 439.70 505.66 495.55 75563 TC 319.52 303.54 349.07 342.09 75563 26 143.32 136.15 156.57 153.44 75565 50.12 47.61 54.75 53.66 75565 TC 38.07 36.17 41.60 40.77 75565 26 12.04 11.44 13.16 12.89C 75571 46.32 44.00 50.60 49.59C 75571 TC 19.02 18.07 20.78 20.37 75571 26 27.30 25.94 29.83 29.23 75572 261.15 248.09 285.30 279.60 75572 TC 177.71 168.82 194.14 190.26 75572 26 83.44 79.27 91.16 89.33C 75573 315.32 299.55 344.48 337.59C 75573 TC 193.64 183.96 211.55 207.32 75573 26 121.68 115.60 132.94 130.28C 75574 308.38 292.96 336.90 330.17C 75574 TC 193.64 183.96 211.55 207.32 75574 26 114.74 109.00 125.35 122.84 75600 187.03 177.68 204.33 200.25 75600 TC 163.65 155.47 178.79 175.21 75600 26 23.38 22.21 25.54 25.04 75605 138.64 131.71 151.47 148.44 75605 TC 84.62 80.39 92.45 90.60 75605 26 54.02 51.32 59.02 57.83

75625 138.23 131.32 151.02 147.99 75625 TC 83.99 79.79 91.76 89.92 75625 26 54.23 51.52 59.25 58.06 75630 167.76 159.37 183.28 179.61 75630 TC 83.37 79.20 91.08 89.26 75630 26 84.39 80.17 92.20 90.36C 75635 370.06 351.56 404.29 396.21C 75635 TC 254.48 241.76 278.02 272.46 75635 26 115.58 109.80 126.27 123.74 75658 160.94 152.89 175.82 172.30 75658 TC 100.24 95.23 109.51 107.33 75658 26 60.70 57.67 66.32 65.00 75705 227.44 216.07 248.48 243.51 75705 TC 122.10 116.00 133.40 130.73 75705 26 105.34 100.07 115.08 112.78 75710 159.02 151.07 173.73 170.26 75710 TC 105.86 100.57 115.66 113.34 75710 26 53.16 50.50 58.08 56.91 75716 189.85 180.36 207.41 203.26 75716 TC 127.66 121.28 139.47 136.68 75716 26 62.20 59.09 67.95 66.60 75726 148.92 141.47 162.69 159.44 75726 TC 94.30 89.59 103.03 100.97 75726 26 54.61 51.88 59.66 58.47 75731 164.68 156.45 179.92 176.32 75731 TC 109.61 104.13 119.75 117.36 75731 26 55.07 52.32 60.17 58.96 75733 184.44 175.22 201.50 197.48 75733 TC 122.35 116.23 133.66 131.00 75733 26 62.09 58.99 67.84 66.48 75736 156.52 148.69 170.99 167.58 75736 TC 103.36 98.19 112.92 110.66 75736 26 53.16 50.50 58.08 56.91 75741 148.45 141.03 162.18 158.94 75741 TC 85.87 81.58 93.82 91.94 75741 26 62.58 59.45 68.37 67.00 75743 172.47 163.85 188.43 184.66 75743 TC 93.68 89.00 102.35 100.30 75743 26 78.79 74.85 86.08 84.35 75746 153.01 145.36 167.16 163.82 75746 TC 97.74 92.85 106.78 104.64 75746 26 55.27 52.51 60.39 59.18 75756 165.95 157.65 181.30 177.68 75756 TC 108.98 103.53 119.06 116.68 75756 26 56.97 54.12 62.24 61.00 75774 88.04 83.64 96.19 94.27 75774 TC 70.87 67.33 77.43 75.88 75774 26 17.16 16.30 18.75 18.37 75791 296.40 281.58 323.82 317.34 75791 TC 216.13 205.32 236.12 231.39 75791 26 80.27 76.26 87.70 85.94 75801 236.20 224.39 258.05 252.89

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 87

75801 TC 193.41 183.74 211.30 207.08 75801 26 42.79 40.65 46.75 45.82 75803 251.53 238.95 274.79 269.30 75803 TC 193.41 183.74 211.30 207.08 75803 26 58.12 55.21 63.49 62.23 75805 258.43 245.51 282.34 276.69 75805 TC 218.10 207.20 238.28 233.52 75805 26 40.33 38.31 44.06 43.17 75807 26 58.12 55.21 63.49 62.23 75809 93.23 88.57 101.86 99.82 75809 TC 69.94 66.44 76.41 74.88 75809 26 23.29 22.13 25.45 24.94 75810 506.10 480.80 552.92 541.86 75810 TC 449.37 426.90 490.94 481.11 75810 26 56.73 53.89 61.97 60.73 75820 112.99 107.34 123.44 120.97 75820 TC 79.31 75.34 86.64 84.90 75820 26 33.68 32.00 36.80 36.06 75822 141.71 134.62 154.81 151.72 75822 TC 90.87 86.33 99.28 97.29 75822 26 50.85 48.31 55.56 54.44 75825 133.61 126.93 145.97 143.05 75825 TC 79.62 75.64 86.99 85.25 75825 26 53.99 51.29 58.98 57.80 75827 135.21 128.45 147.72 144.76 75827 TC 81.81 77.72 89.38 87.60 75827 26 53.40 50.73 58.34 57.18 75831 143.39 136.22 156.65 153.53 75831 TC 85.24 80.98 93.13 91.26 75831 26 58.15 55.24 63.53 62.26 75833 164.58 156.35 179.80 176.20 75833 TC 96.18 91.37 105.08 102.97 75833 26 68.40 64.98 74.73 73.23 75840 148.39 140.97 162.12 158.87 75840 TC 88.05 83.65 96.20 94.28 75840 26 60.33 57.31 65.91 64.58 75842 178.63 169.70 195.16 191.26 75842 TC 105.86 100.57 115.66 113.34 75842 26 72.77 69.13 79.50 77.91 75860 140.17 133.16 153.13 150.08 75860 TC 85.56 81.28 93.47 91.60 75860 26 54.61 51.88 59.66 58.47 75870 143.33 136.16 156.58 153.46 75870 TC 87.43 83.06 95.52 93.61 75870 26 55.90 53.11 61.08 59.86 75872 137.71 130.82 150.44 147.43 75872 TC 87.12 82.76 95.17 93.27 75872 26 50.59 48.06 55.27 54.17 75880 122.67 116.54 134.02 131.34 75880 TC 88.37 83.95 96.54 94.61 75880 26 34.31 32.59 37.48 36.73 75885 155.29 147.53 169.66 166.27

75885 TC 86.49 82.17 94.50 92.61 75885 26 68.80 65.36 75.16 73.66 75887 154.46 146.74 168.75 165.38 75887 TC 86.49 82.17 94.50 92.61 75887 26 67.97 64.57 74.26 72.77 75889 141.77 134.68 154.88 151.79 75889 TC 87.12 82.76 95.17 93.27 75889 26 54.65 51.92 59.71 58.51 75891 142.70 135.57 155.91 152.79 75891 TC 87.43 83.06 95.52 93.61 75891 26 55.27 52.51 60.39 59.18 75893 113.92 108.22 124.45 121.97 75893 TC 88.05 83.65 96.20 94.28 75893 26 25.87 24.58 28.27 27.70 75894 925.74 879.45 1,011.37 991.14 75894 TC 861.22 818.16 940.88 922.07 75894 26 64.52 61.29 70.48 69.07 75896 812.84 772.20 888.03 870.27 75896 TC 748.95 711.50 818.23 801.86 75896 26 63.89 60.70 69.81 68.41 75898 119.41 113.44 130.46 127.85 75898 TC 37.54 35.66 41.01 40.19 75898 26 81.87 77.78 89.45 87.65 75901 158.29 150.38 172.94 169.48 75901 TC 134.91 128.16 147.38 144.44 75901 26 23.38 22.21 25.54 25.04 75902 67.84 64.45 74.12 72.63 75902 TC 49.01 46.56 53.54 52.47 75902 26 18.83 17.89 20.57 20.16 75945 181.79 172.70 198.61 194.64 75945 TC 162.64 154.51 177.69 174.13 75945 26 19.15 18.19 20.92 20.50 75946 26 19.39 18.42 21.18 20.76 75952 233.11 221.45 254.67 249.57 75952 26 221.07 210.02 241.52 236.69 75953 94.19 89.48 102.90 100.84 75953 26 67.17 63.81 73.38 71.91 75954 26 109.84 104.35 120.00 117.60 75956 26 345.87 328.58 377.87 370.31 75957 26 296.14 281.33 323.53 317.06 75958 26 197.09 187.24 215.33 211.03 75959 26 174.77 166.03 190.93 187.12 75962 130.72 124.18 142.81 139.96 75962 TC 105.24 99.98 114.98 112.68 75962 26 25.49 24.22 27.85 27.30 75964 83.94 79.74 91.70 89.87 75964 TC 66.50 63.18 72.66 71.21 75964 26 17.44 16.57 19.06 18.68 75966 158.79 150.85 173.48 170.00 75966 TC 97.43 92.56 106.44 104.32 75966 26 61.36 58.29 67.03 65.69 75968 78.74 74.80 86.02 84.30

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 88

75968 TC 61.82 58.73 67.54 66.19 75968 26 16.92 16.07 18.48 18.11 75970 451.61 429.03 493.38 483.52 75970 TC 411.50 390.93 449.57 440.58 75970 26 40.11 38.10 43.82 42.94 75978 129.16 122.70 141.11 138.29 75978 TC 103.67 98.49 113.26 111.00 75978 26 25.49 24.22 27.85 27.30 75980 263.35 250.18 287.71 281.96 75980 TC 193.41 183.74 211.30 207.08 75980 26 69.94 66.44 76.41 74.88 75982 26 69.63 66.15 76.07 74.55 75984 101.21 96.15 110.57 108.36 75984 TC 66.81 63.47 72.99 71.53 75984 26 34.40 32.68 37.58 36.83 75989 115.83 110.04 126.55 124.02 75989 TC 59.00 56.05 64.46 63.17 75989 26 56.82 53.98 62.08 60.84 76000 45.38 43.11 49.58 48.59 76000 TC 37.14 35.28 40.57 39.76 76000 26 8.24 7.83 9.00 8.82 76001 128.32 121.90 140.19 137.38 76001 TC 93.67 88.99 102.34 100.29 76001 26 34.65 32.92 37.86 37.10 76010 25.12 23.86 27.44 26.89 76010 TC 16.21 15.40 17.71 17.35 76010 26 8.91 8.46 9.73 9.53 76080 56.06 53.26 61.25 60.02 76080 TC 30.27 28.76 33.07 32.41 76080 26 25.80 24.51 28.19 27.62 76098 17.53 16.65 19.15 18.77 76098 TC 9.65 9.17 10.55 10.34 76098 26 7.88 7.49 8.61 8.44 76100 91.79 87.20 100.28 98.28 76100 TC 61.19 58.13 66.85 65.52 76100 26 30.60 29.07 33.43 32.76 76101 135.10 128.35 147.60 144.65 76101 TC 100.86 95.82 110.19 107.99 76101 26 34.24 32.53 37.41 36.66 76102 180.01 171.01 196.66 192.73 76102 TC 145.22 137.96 158.65 155.48 76102 26 34.80 33.06 38.02 37.26 76120 83.76 79.57 91.51 89.68 76120 TC 64.63 61.40 70.61 69.20 76120 26 19.13 18.17 20.90 20.48 76125 42.01 39.91 45.90 44.98 76125 TC 28.07 26.67 30.67 30.06 76125 26 13.94 13.24 15.23 14.93 76376 26.15 24.84 28.57 27.99 76376 TC 16.52 15.69 18.04 17.69 76376 26 9.63 9.15 10.52 10.32 76377 76.85 73.01 83.96 82.28

76377 TC 38.39 36.47 41.94 41.10 76377 26 38.47 36.55 42.03 41.19C 76380 116.77 110.93 127.57 125.02C 76380 TC 69.31 65.84 75.72 74.20 76380 26 47.46 45.09 51.85 50.82 76506 111.73 106.14 122.06 119.62 76506 TC 80.87 76.83 88.35 86.58 76506 26 30.86 29.32 33.72 33.04 76510 163.32 155.15 178.42 174.86 76510 TC 70.56 67.03 77.08 75.54 76510 26 92.76 88.12 101.34 99.31 76511 94.52 89.79 103.26 101.19 76511 TC 42.76 40.62 46.71 45.78 76511 26 51.76 49.17 56.55 55.42 76512 86.91 82.56 94.94 93.05 76512 TC 34.64 32.91 37.85 37.09 76512 26 52.28 49.67 57.12 55.98 76513 87.61 83.23 95.71 93.81 76513 TC 52.44 49.82 57.29 56.14 76513 26 35.17 33.41 38.42 37.65 76514 14.14 13.43 15.44 15.13 76514 TC 4.65 4.42 5.08 4.98 76514 26 9.49 9.02 10.37 10.17 76516 71.44 67.87 78.05 76.49 76516 TC 41.51 39.43 45.34 44.44 76516 26 29.93 28.43 32.69 32.04 76519 76.99 73.14 84.11 82.43 76519 TC 46.20 43.89 50.47 49.46 76519 26 30.80 29.26 33.65 32.97 76529 73.07 69.42 79.83 78.23 76529 TC 40.89 38.85 44.68 43.78 76529 26 32.18 30.57 35.16 34.45 76536 110.20 104.69 120.39 117.99 76536 TC 82.74 78.60 90.39 88.58 76536 26 27.45 26.08 29.99 29.39 76604 80.48 76.46 87.93 86.17 76604 TC 54.01 51.31 59.01 57.82 76604 26 26.47 25.15 28.92 28.35 76645 89.45 84.98 97.73 95.77 76645 TC 62.75 59.61 68.55 67.18 76645 26 26.70 25.37 29.18 28.59 76700 128.18 121.77 140.04 137.23 76700 TC 88.68 84.25 96.89 94.96 76700 26 39.50 37.53 43.16 42.30 76705 98.46 93.54 107.57 105.42 76705 TC 69.94 66.44 76.41 74.88 76705 26 28.53 27.10 31.17 30.54 76770 120.67 114.64 131.84 129.20 76770 TC 84.62 80.39 92.45 90.60 76770 26 36.05 34.25 39.39 38.61 76775 60.31 57.29 65.88 64.56 76775 TC 32.14 30.53 35.11 34.41

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 89

76775 26 28.17 26.76 30.77 30.15 76776 139.82 132.83 152.75 149.70 76776 TC 102.74 97.60 112.24 110.00 76776 26 37.08 35.23 40.51 39.71 76800 127.46 121.09 139.25 136.47 76800 TC 72.44 68.82 79.14 77.56 76800 26 55.02 52.27 60.11 58.90 76801 115.92 110.12 126.64 124.11 76801 TC 68.06 64.66 74.36 72.88 76801 26 47.85 45.46 52.28 51.23 76802 63.02 59.87 68.85 67.47 76802 TC 22.46 21.34 24.54 24.05 76802 26 40.56 38.53 44.31 43.42 76805 133.41 126.74 145.75 142.84 76805 TC 85.24 80.98 93.13 91.26 76805 26 48.17 45.76 52.62 51.57 76810 89.94 85.44 98.26 96.29 76810 TC 42.14 40.03 46.03 45.11 76810 26 47.81 45.42 52.23 51.19 76811 171.87 163.28 187.77 184.01 76811 TC 79.00 75.05 86.31 84.58 76811 26 92.88 88.24 101.48 99.45 76812 193.19 183.53 211.06 206.84 76812 TC 105.86 100.57 115.66 113.34 76812 26 87.33 82.96 95.40 93.50 76813 112.07 106.47 122.44 119.99 76813 TC 54.32 51.60 59.34 58.16 76813 26 57.75 54.86 63.09 61.82 76814 74.68 70.95 81.59 79.96 76814 TC 26.20 24.89 28.62 28.05 76814 26 48.48 46.06 52.97 51.91 76815 82.57 78.44 90.21 88.40 76815 TC 51.19 48.63 55.92 54.81 76815 26 31.37 29.80 34.27 33.58 76816 106.53 101.20 116.38 114.06 76816 TC 64.94 61.69 70.94 69.53 76816 26 41.59 39.51 45.44 44.53 76817 92.95 88.30 101.55 99.51 76817 TC 56.19 53.38 61.39 60.16 76817 26 36.76 34.92 40.16 39.35 76818 112.44 106.82 122.84 120.38 76818 TC 60.88 57.84 66.52 65.18 76818 26 51.57 48.99 56.34 55.21 76819 82.42 78.30 90.05 88.24 76819 TC 44.63 42.40 48.76 47.78 76819 26 37.79 35.90 41.29 40.46 76820 45.33 43.06 49.52 48.53 76820 TC 20.89 19.85 22.83 22.37 76820 26 24.44 23.22 26.70 26.17 76821 86.16 81.85 94.13 92.24 76821 TC 51.51 48.93 56.27 55.14 76821 26 34.65 32.92 37.86 37.10

76825 248.95 236.50 271.98 266.54 76825 TC 168.33 159.91 183.90 180.22 76825 26 80.61 76.58 88.07 86.31 76826 148.29 140.88 162.01 158.77 76826 TC 108.05 102.65 118.05 115.69 76826 26 40.25 38.24 43.98 43.10 76827 69.13 65.67 75.52 74.01 76827 TC 41.20 39.14 45.01 44.11 76827 26 27.93 26.53 30.51 29.90 76828 49.04 46.59 53.58 52.51 76828 TC 21.83 20.74 23.85 23.38 76828 26 27.21 25.85 29.73 29.13 76830 114.54 108.81 125.13 122.62 76830 TC 80.87 76.83 88.35 86.58 76830 26 33.67 31.99 36.79 36.05 76831 112.49 106.87 122.90 120.44 76831 TC 77.12 73.26 84.25 82.56 76831 26 35.37 33.60 38.64 37.87 76856 112.67 107.04 123.10 120.64 76856 TC 79.31 75.34 86.64 84.90 76856 26 33.36 31.69 36.44 35.72 76857 49.08 46.63 53.62 52.56 76857 TC 30.58 29.05 33.41 32.74 76857 26 18.51 17.58 20.22 19.81 76870 68.05 64.65 74.35 72.86 76870 TC 36.83 34.99 40.24 39.43 76870 26 31.22 29.66 34.11 33.43 76872 84.83 80.59 92.68 90.83 76872 TC 51.51 48.93 56.27 55.14 76872 26 33.32 31.65 36.40 35.67 76873 158.29 150.38 172.94 169.48 76873 TC 82.12 78.01 89.71 87.92 76873 26 76.17 72.36 83.21 81.55 76881 107.36 101.99 117.29 114.94 76881 TC 76.50 72.68 83.58 81.91 76881 26 30.86 29.32 33.72 33.04 76882 33.62 31.94 36.73 36.00 76882 TC 9.65 9.17 10.55 10.34 76882 26 23.97 22.77 26.19 25.66C 76885 114.74 109.00 125.35 122.84C 76885 TC 78.68 74.75 85.96 84.25 76885 26 36.05 34.25 39.39 38.61 76886 97.11 92.25 106.09 103.97 76886 TC 67.44 64.07 73.68 72.21 76886 26 29.67 28.19 32.42 31.77 76930 76.72 72.88 83.81 82.13 76930 TC 45.26 43.00 49.45 48.46 76930 26 31.46 29.89 34.37 33.68 76932 87.07 82.72 95.13 93.23 76932 TC 54.78 52.04 59.85 58.65 76932 26 32.29 30.68 35.28 34.58C 76936 208.86 198.42 228.18 223.62

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 90

C 76936 TC 114.29 108.58 124.87 122.37 76936 26 94.57 89.84 103.32 101.25 76937 33.10 31.45 36.17 35.44 76937 TC 18.40 17.48 20.10 19.70 76937 26 14.70 13.97 16.07 15.74 76940 162.31 154.19 177.32 173.78 76940 TC 61.35 58.28 67.02 65.68 76940 26 100.96 95.91 110.30 108.09 76941 122.05 115.95 133.34 130.67 76941 TC 54.44 51.72 59.48 58.29 76941 26 67.61 64.23 73.86 72.39 76942 67.56 64.18 73.81 72.34 76942 TC 34.95 33.20 38.18 37.42 76942 26 32.61 30.98 35.63 34.91 76945 87.98 83.58 96.12 94.20 76945 TC 54.44 51.72 59.48 58.29 76945 26 33.54 31.86 36.64 35.90 76946 30.10 28.60 32.89 32.23 76946 TC 11.52 10.94 12.58 12.33 76946 26 18.58 17.65 20.30 19.90 76948 30.65 29.12 33.49 32.82 76948 TC 11.52 10.94 12.58 12.33 76948 26 19.13 18.17 20.90 20.48 76950 47.50 45.13 51.90 50.86 76950 TC 18.71 17.77 20.44 20.02 76950 26 28.79 27.35 31.45 30.82 76965 86.11 81.80 94.07 92.18 76965 TC 20.58 19.55 22.48 22.03 76965 26 65.53 62.25 71.59 70.16 76970 85.06 80.81 92.93 91.07 76970 TC 65.25 61.99 71.29 69.86 76970 26 19.81 18.82 21.64 21.21 76975 96.30 91.49 105.21 103.11 76975 TC 54.44 51.72 59.48 58.29 76975 26 41.86 39.77 45.74 44.82 76977 6.41 6.09 7.00 6.87 76977 TC 3.71 3.52 4.05 3.97 76977 26 2.69 2.56 2.94 2.89 76998 155.77 147.98 170.18 166.77 76998 TC 93.67 88.99 102.34 100.29 76998 26 62.10 59.00 67.85 66.49 77001 71.26 67.70 77.86 76.30 77001 TC 52.76 50.12 57.64 56.49 77001 26 18.51 17.58 20.22 19.81 77002 92.30 87.69 100.84 98.83 77002 TC 65.25 61.99 71.29 69.86 77002 26 27.05 25.70 29.56 28.97 77003 81.95 77.85 89.53 87.73 77003 TC 52.44 49.82 57.29 56.14 77003 26 29.51 28.03 32.23 31.59 77011 202.48 192.36 221.21 216.79 77011 TC 142.72 135.58 155.92 152.80

77011 26 59.76 56.77 65.29 63.97 77012 117.91 112.01 128.81 126.24 77012 TC 62.44 59.32 68.22 66.85 77012 26 55.47 52.70 60.61 59.40 77013 525.19 498.93 573.77 562.29 77013 TC 330.07 313.57 360.61 353.40 77013 26 195.12 185.36 213.16 208.90 77014 111.80 106.21 122.14 119.70 77014 TC 69.62 66.14 76.06 74.54 77014 26 42.18 40.07 46.08 45.16 77021 354.75 337.01 387.56 379.81 77021 TC 280.79 266.75 306.76 300.63 77021 26 73.96 70.26 80.80 79.18 77022 641.00 608.95 700.29 686.29 77022 TC 433.52 411.84 473.62 464.14 77022 26 207.48 197.11 226.68 222.15 77051 9.26 8.80 10.12 9.91 77051 TC 6.21 5.90 6.79 6.65 77051 26 3.05 2.90 3.34 3.27 77052 9.26 8.80 10.12 9.91 77052 TC 6.21 5.90 6.79 6.65 77052 26 3.05 2.90 3.34 3.27 77053 54.06 51.36 59.06 57.88 77053 TC 36.83 34.99 40.24 39.43 77053 26 17.23 16.37 18.83 18.45 77054 72.83 69.19 79.57 77.98 77054 TC 50.57 48.04 55.25 54.14 77054 26 22.26 21.15 24.32 23.84 77055 81.75 77.66 89.31 87.53 77055 TC 47.45 45.08 51.84 50.81 77055 26 34.31 32.59 37.48 36.73 77056 104.99 99.74 114.70 112.41 77056 TC 62.44 59.32 68.22 66.85 77056 26 42.55 40.42 46.48 45.55 77057 75.19 71.43 82.14 80.50 77057 TC 40.89 38.85 44.68 43.78 77057 26 34.31 32.59 37.48 36.73 77058 490.02 465.52 535.35 524.64 77058 TC 410.43 389.91 448.40 439.43 77058 26 79.59 75.61 86.95 85.22 77059 488.15 463.74 533.30 522.64 77059 TC 408.55 388.12 446.34 437.41 77059 26 79.59 75.61 86.95 85.22 77071 46.62 44.29 50.93 49.91 77072 21.73 20.64 23.74 23.26 77072 TC 12.46 11.84 13.62 13.34 77072 26 9.27 8.81 10.13 9.92 77073 34.80 33.06 38.02 37.26 77073 TC 20.27 19.26 22.15 21.70 77073 26 14.53 13.80 15.87 15.55 77074 65.02 61.77 71.04 69.61 77074 TC 42.76 40.62 46.71 45.78

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 91

77074 26 22.26 21.15 24.32 23.84 77075 96.67 91.84 105.62 103.50 77075 TC 70.25 66.74 76.75 75.22 77075 26 26.42 25.10 28.87 28.29 77076 98.00 93.10 107.07 104.93 77076 TC 63.69 60.51 69.59 68.20 77076 26 34.31 32.59 37.48 36.73 77077 36.86 35.02 40.27 39.47 77077 TC 20.58 19.55 22.48 22.03 77077 26 16.28 15.47 17.79 17.43C 77078 90.73 86.19 99.12 97.14C 77078 TC 78.68 74.75 85.96 84.25 77078 26 12.04 11.44 13.16 12.89 77080 43.95 41.75 48.01 47.06 77080 TC 34.01 32.31 37.16 36.41 77080 26 9.94 9.44 10.86 10.64 77081 25.30 24.04 27.65 27.09 77081 TC 14.65 13.92 16.01 15.69 77081 26 10.66 10.13 11.65 11.42 77082 25.07 23.82 27.39 26.84 77082 TC 16.52 15.69 18.04 17.69 77082 26 8.55 8.12 9.34 9.15C 77084 335.57 318.79 366.61 359.27C 77084 TC 257.05 244.20 280.83 275.22 77084 26 78.52 74.59 85.78 84.07 77261 71.62 68.04 78.25 76.68 77262 107.48 102.11 117.43 115.08 77263 158.77 150.83 173.45 169.98 77280 239.85 227.86 262.04 256.80 77280 TC 205.20 194.94 224.18 219.70 77280 26 34.65 32.92 37.86 37.10 77285 373.52 354.84 408.07 399.90 77285 TC 321.40 305.33 351.13 344.10 77285 26 52.12 49.51 56.94 55.80 77290 449.19 426.73 490.74 480.93 77290 TC 371.69 353.11 406.08 397.96 77290 26 77.50 73.63 84.67 82.98 77293 409.56 389.08 447.44 438.50 77293 TC 310.15 294.64 338.84 332.06 77293 26 99.41 94.44 108.61 106.43 77295 441.75 419.66 482.61 472.96 77295 TC 228.52 217.09 249.65 244.66 77295 26 213.23 202.57 232.96 228.30 77300 61.43 58.36 67.11 65.77 77300 TC 30.58 29.05 33.41 32.74 77300 26 30.85 29.31 33.71 33.03 77301 1,743.53 1,656.35 1,904.80 1,866.70 77301 TC 1,346.54 1,279.21 1,471.09 1,441.67 77301 26 397.00 377.15 433.72 425.05 77305 55.24 52.48 60.35 59.14 77305 TC 20.58 19.55 22.48 22.03 77305 26 34.65 32.92 37.86 37.10

77310 79.89 75.90 87.29 85.54 77310 TC 27.77 26.38 30.34 29.73 77310 26 52.12 49.51 56.94 55.80 77315 125.57 119.29 137.18 134.44 77315 TC 48.07 45.67 52.52 51.47 77315 26 77.50 73.63 84.67 82.98 77321 84.15 79.94 91.93 90.09 77321 TC 37.14 35.28 40.57 39.76 77321 26 47.01 44.66 51.36 50.34 77326 130.53 124.00 142.60 139.75 77326 TC 84.55 80.32 92.37 90.52 77326 26 45.98 43.68 50.23 49.23 77327 183.76 174.57 200.76 196.74 77327 TC 114.54 108.81 125.13 122.62 77327 26 69.23 65.77 75.64 74.12 77328 246.81 234.47 269.64 264.25 77328 TC 142.93 135.78 156.15 153.02 77328 26 103.88 98.69 113.49 111.23 77331 59.42 56.45 64.92 63.62 77331 TC 16.21 15.40 17.71 17.35 77331 26 43.21 41.05 47.21 46.26 77332 72.62 68.99 79.34 77.75 77332 TC 45.57 43.29 49.78 48.78 77332 26 27.05 25.70 29.56 28.97 77333 49.91 47.41 54.52 53.43 77333 TC 8.09 7.69 8.84 8.67 77333 26 41.82 39.73 45.69 44.78 77334 136.67 129.84 149.32 146.33 77334 TC 75.25 71.49 82.21 80.57 77334 26 61.43 58.36 67.11 65.77 77336 65.25 61.99 71.29 69.86 77338 456.40 433.58 498.62 488.65 77338 TC 242.89 230.75 265.36 260.06 77338 26 213.51 202.83 233.25 228.59 77370 99.82 94.83 109.05 106.87 77372 911.33 865.76 995.62 975.71 77373 1,091.19 1,036.63 1,192.12 1,168.29 77401 17.46 16.59 19.08 18.70 77402 122.10 116.00 133.40 130.73 77403 108.05 102.65 118.05 115.69 77404 120.54 114.51 131.69 129.05 77406 119.92 113.92 131.01 128.39 77407 221.75 210.66 242.26 237.42 77408 148.66 141.23 162.41 159.17 77409 165.21 156.95 180.49 176.88 77411 164.27 156.06 179.47 175.88 77412 210.51 199.98 229.98 225.38 77413 195.51 185.73 213.59 209.32 77414 220.19 209.18 240.56 235.75 77416 220.19 209.18 240.56 235.75 77417 12.15 11.54 13.27 13.01 77418 344.51 327.28 376.37 368.84

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 92

77421 66.38 63.06 72.52 71.07 77421 TC 47.13 44.77 51.49 50.45 77421 26 19.25 18.29 21.03 20.61 77422 36.51 34.68 39.88 39.09 77423 43.38 41.21 47.39 46.45 77427 176.97 168.12 193.34 189.47 77431 96.87 92.03 105.83 103.72 77432 399.93 379.93 436.92 428.18 77435 603.68 573.50 659.53 646.33 77469 298.11 283.20 325.68 319.17 77470 144.46 137.24 157.83 154.68 77470 TC 40.57 38.54 44.32 43.44 77470 26 103.88 98.69 113.49 111.23 77600 353.85 336.16 386.58 378.86 77600 TC 276.35 262.53 301.91 295.87 77600 26 77.50 73.63 84.67 82.98 77605 638.27 606.36 697.31 683.36 77605 TC 527.81 501.42 576.63 565.10 77605 26 110.47 104.95 120.69 118.28 77610 876.77 832.93 957.87 938.71 77610 TC 801.14 761.08 875.24 857.74 77610 26 75.63 71.85 82.63 80.97 77615 879.26 835.30 960.60 941.38 77615 TC 775.38 736.61 847.10 830.16 77615 26 103.88 98.69 113.49 111.23 77620 325.49 309.22 355.60 348.50 77620 TC 248.82 236.38 271.84 266.40 77620 26 76.67 72.84 83.77 82.09 77750 343.69 326.51 375.49 367.98 77750 TC 95.48 90.71 104.32 102.24 77750 26 248.21 235.80 271.17 265.74 77761 354.52 336.79 387.31 379.56 77761 TC 164.79 156.55 180.03 176.43 77761 26 189.73 180.24 207.28 203.14 77762 472.23 448.62 515.91 505.60 77762 TC 186.94 177.59 204.23 200.15 77762 26 285.29 271.03 311.68 305.45 77763 672.11 638.50 734.28 719.59 77763 TC 241.84 229.75 264.21 258.93 77763 26 430.26 408.75 470.06 460.67 77776 399.55 379.57 436.51 427.78 77776 TC 164.13 155.92 179.31 175.72 77776 26 235.41 223.64 257.19 252.05 77777 544.33 517.11 594.68 582.79 77777 TC 167.88 159.49 183.41 179.75 77777 26 376.44 357.62 411.26 403.04 77778 809.63 769.15 884.52 866.84 77778 TC 248.06 235.66 271.01 265.59 77778 26 561.57 533.49 613.51 601.24 77785 213.26 202.60 232.99 228.33 77785 TC 142.65 135.52 155.85 152.73 77785 26 70.61 67.08 77.14 75.60

77786 436.84 415.00 477.25 467.71 77786 TC 275.34 261.57 300.81 294.79 77786 26 161.50 153.43 176.44 172.91 77787 694.43 659.71 758.67 743.50 77787 TC 451.10 428.55 492.83 482.98 77787 26 243.33 231.16 265.83 260.52 77789 108.10 102.70 118.11 115.75 77789 TC 51.51 48.93 56.27 55.14 77789 26 56.59 53.76 61.82 60.58 77790 88.36 83.94 96.53 94.60 77790 TC 36.83 34.99 40.24 39.43 77790 26 51.53 48.95 56.29 55.17 78012 69.21 65.75 75.61 74.11 78012 TC 60.25 57.24 65.83 64.52 78012 26 8.96 8.51 9.79 9.59 78013 173.99 165.29 190.08 186.28 78013 TC 156.39 148.57 170.86 167.44 78013 26 17.59 16.71 19.22 18.84 78014 211.06 200.51 230.59 225.98 78014 TC 187.01 177.66 204.31 200.23 78014 26 24.05 22.85 26.28 25.75 78015 196.81 186.97 215.02 210.71 78015 TC 164.52 156.29 179.73 176.13 78015 26 32.29 30.68 35.28 34.58 78016 253.45 240.78 276.90 271.35 78016 TC 218.87 207.93 239.12 234.34 78016 26 34.58 32.85 37.78 37.02 78018 282.34 268.22 308.45 302.29 78018 TC 241.99 229.89 264.37 259.08 78018 26 40.35 38.33 44.08 43.19 78020 76.33 72.51 83.39 81.72 78020 TC 49.01 46.56 53.54 52.47 78020 26 27.32 25.95 29.84 29.24 78070 268.63 255.20 293.48 287.62 78070 TC 230.43 218.91 251.75 246.71 78070 26 38.20 36.29 41.73 40.89 78071 316.62 300.79 345.91 338.99 78071 TC 259.48 246.51 283.49 277.82 78071 26 57.15 54.29 62.43 61.18 78072 396.31 376.49 432.96 424.30 78072 TC 319.14 303.18 348.66 341.69 78072 26 77.17 73.31 84.31 82.62 78075 381.71 362.62 417.01 408.68 78075 TC 347.22 329.86 379.34 371.75 78075 26 34.49 32.77 37.69 36.93 78102 152.88 145.24 167.03 163.69 78102 TC 127.03 120.68 138.78 136.01 78102 26 25.84 24.55 28.23 27.67 78103 203.11 192.95 221.89 217.45 78103 TC 167.33 158.96 182.80 179.15 78103 26 35.79 34.00 39.10 38.32 78104 219.59 208.61 239.90 235.11

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 93

78104 TC 182.32 173.20 199.18 195.20 78104 26 37.26 35.40 40.71 39.89 78110 84.45 80.23 92.26 90.42 78110 TC 75.18 71.42 82.13 80.49 78110 26 9.27 8.81 10.13 9.92 78111 88.65 84.22 96.85 94.92 78111 TC 77.99 74.09 85.20 83.50 78111 26 10.66 10.13 11.65 11.42 78120 85.57 81.29 93.48 91.61 78120 TC 74.24 70.53 81.11 79.49 78120 26 11.33 10.76 12.37 12.12 78121 90.67 86.14 99.06 97.08 78121 TC 75.18 71.42 82.13 80.49 78121 26 15.49 14.72 16.93 16.59 78122 89.39 84.92 97.66 95.70 78122 TC 68.62 65.19 74.97 73.47 78122 26 20.77 19.73 22.69 22.24 78130 154.02 146.32 168.27 164.90 78130 TC 123.87 117.68 135.33 132.63 78130 26 30.15 28.64 32.94 32.28 78135 314.44 298.72 343.53 336.66 78135 TC 282.91 268.76 309.07 302.89 78135 26 31.53 29.95 34.44 33.75 78140 123.44 117.27 134.86 132.16 78140 TC 93.29 88.63 101.92 99.89 78140 26 30.15 28.64 32.94 32.28 78185 189.12 179.66 206.61 202.48 78185 TC 169.83 161.34 185.54 181.83 78185 26 19.29 18.33 21.08 20.65C 78190 277.49 263.62 303.16 297.10C 78190 TC 224.21 213.00 244.95 240.05 78190 26 53.28 50.62 58.21 57.05 78191 154.02 146.32 168.27 164.90 78191 TC 123.87 117.68 135.33 132.63 78191 26 30.15 28.64 32.94 32.28 78195 322.84 306.70 352.71 345.66 78195 TC 265.41 252.14 289.96 284.17 78195 26 57.42 54.55 62.73 61.48 78201 168.27 159.86 183.84 180.16 78201 TC 147.34 139.97 160.97 157.75 78201 26 20.93 19.88 22.86 22.40 78202 182.75 173.61 199.65 195.66 78202 TC 159.52 151.54 174.27 170.79 78202 26 23.23 22.07 25.38 24.87 78205 192.93 183.28 210.77 206.55 78205 TC 159.52 151.54 174.27 170.79 78205 26 33.42 31.75 36.51 35.79 78206 306.22 290.91 334.55 327.85 78206 TC 261.04 247.99 285.19 279.48 78206 26 45.18 42.92 49.36 48.37 78215 175.40 166.63 191.62 187.80 78215 TC 151.71 144.12 165.74 162.43

78215 26 23.70 22.52 25.90 25.38 78216 111.73 106.14 122.06 119.62 78216 TC 85.17 80.91 93.05 91.18 78216 26 26.56 25.23 29.01 28.44 78226 298.34 283.42 325.93 319.41 78226 TC 262.60 249.47 286.89 281.15 78226 26 35.74 33.95 39.04 38.26C 78227 368.07 349.67 402.12 394.08C 78227 TC 324.73 308.49 354.76 347.67 78227 26 43.35 41.18 47.36 46.41 78230 123.68 117.50 135.13 132.42 78230 TC 104.54 99.31 114.21 111.92 78230 26 19.14 18.18 20.91 20.49 78231 117.20 111.34 128.04 125.48 78231 TC 92.36 87.74 100.90 98.89 78231 26 24.84 23.60 27.14 26.60 78232 90.35 85.83 98.70 96.73 78232 TC 70.18 66.67 76.67 75.14 78232 26 20.17 19.16 22.03 21.60 78258 199.98 189.98 218.48 214.11 78258 TC 164.83 156.59 180.08 176.48 78258 26 35.15 33.39 38.40 37.63 78261 228.14 216.73 249.24 244.26 78261 TC 194.19 184.48 212.15 207.91 78261 26 33.95 32.25 37.09 36.35 78262 220.08 209.08 240.44 235.64 78262 TC 188.26 178.85 205.68 201.56 78262 26 31.82 30.23 34.76 34.07 78264 259.88 246.89 283.92 278.24 78264 TC 221.37 210.30 241.85 237.00 78264 26 38.51 36.58 42.07 41.23 78270 80.81 76.77 88.29 86.51 78270 TC 70.87 67.33 77.43 75.88 78270 26 9.94 9.44 10.86 10.64 78271 80.81 76.77 88.29 86.51 78271 TC 70.87 67.33 77.43 75.88 78271 26 9.94 9.44 10.86 10.64 78272 92.00 87.40 100.51 98.50 78272 TC 78.61 74.68 85.88 84.17 78272 26 13.39 12.72 14.63 14.34 78278 315.07 299.32 344.22 337.33 78278 TC 267.60 254.22 292.35 286.51 78278 26 47.47 45.10 51.87 50.83 78282 26 18.82 17.88 20.56 20.15 78290 300.57 285.54 328.37 321.80 78290 TC 267.60 254.22 292.35 286.51 78290 26 32.97 31.32 36.02 35.29 78291 227.41 216.04 248.45 243.48 78291 TC 185.76 176.47 202.94 198.88 78291 26 41.66 39.58 45.52 44.61 78300 163.82 155.63 178.97 175.40 78300 TC 133.59 126.91 145.95 143.03

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 94

78300 26 30.23 28.72 33.03 32.37 78305 209.10 198.65 228.45 223.88 78305 TC 169.20 160.74 184.85 181.16 78305 26 39.90 37.91 43.60 42.72 78306 227.36 215.99 248.39 243.42 78306 TC 186.07 176.77 203.29 199.21 78306 26 41.29 39.23 45.11 44.22 78315 314.58 298.85 343.68 336.80 78315 TC 265.73 252.44 290.31 284.50 78315 26 48.86 46.42 53.38 52.31 78320 207.22 196.86 226.39 221.86 78320 TC 158.27 150.36 172.91 169.45 78320 26 48.95 46.50 53.48 52.41 78414 26 21.95 20.85 23.98 23.49 78428 166.11 157.80 181.47 177.84 78428 TC 129.22 122.76 141.17 138.35 78428 26 36.90 35.06 40.32 39.51 78445 154.86 147.12 169.19 165.81 78445 TC 132.65 126.02 144.92 142.03 78445 26 22.20 21.09 24.25 23.77 78451 311.86 296.27 340.71 333.89 78451 TC 246.36 234.04 269.15 263.76 78451 26 65.50 62.23 71.56 70.14 78452 431.32 409.75 471.21 461.79 78452 TC 354.40 336.68 387.18 379.44 78452 26 76.91 73.06 84.02 82.34 78453 277.32 263.45 302.97 296.91 78453 TC 228.87 217.43 250.04 245.04 78453 26 48.45 46.03 52.93 51.88 78454 394.42 374.70 430.91 422.29 78454 TC 330.04 313.54 360.57 353.36 78454 26 64.38 61.16 70.33 68.93 78456 289.57 275.09 316.35 310.03 78456 TC 241.99 229.89 264.37 259.08 78456 26 47.59 45.21 51.99 50.96 78457 176.65 167.82 192.99 189.13 78457 TC 139.84 132.85 152.78 149.72 78457 26 36.81 34.97 40.22 39.41 78458 148.48 141.06 162.22 158.98 78458 TC 110.48 104.96 120.70 118.29 78458 26 38.00 36.10 41.52 40.69 78459 815.55 774.77 890.99 873.16 78459 TC 744.67 707.44 813.56 797.28 78459 26 70.88 67.34 77.44 75.89 78466 165.70 157.42 181.03 177.41 78466 TC 132.03 125.43 144.24 141.36 78466 26 33.67 31.99 36.79 36.05 78468 178.70 169.77 195.24 191.33 78468 TC 140.46 133.44 153.46 150.39 78468 26 38.24 36.33 41.78 40.94 78469 204.86 194.62 223.81 219.34 78469 TC 160.46 152.44 175.31 171.80

78469 26 44.41 42.19 48.52 47.55 78472 208.85 198.41 228.17 223.61 78472 TC 162.33 154.21 177.34 173.80 78472 26 46.52 44.19 50.82 49.81 78473 265.11 251.85 289.63 283.83 78473 TC 195.44 185.67 213.52 209.25 78473 26 69.66 66.18 76.11 74.59 78481 161.48 153.41 176.42 172.89 78481 TC 115.23 109.47 125.89 123.37 78481 26 46.25 43.94 50.53 49.52 78483 220.75 209.71 241.17 236.35 78483 TC 150.77 143.23 164.71 161.43 78483 26 69.98 66.48 76.45 74.92 78491 816.17 775.36 891.66 873.83 78491 TC 744.67 707.44 813.56 797.28 78491 26 71.50 67.93 78.12 76.56 78492 833.45 791.78 910.55 892.33 78492 TC 744.67 707.44 813.56 797.28 78492 26 88.78 84.34 96.99 95.05 78494 207.32 196.95 226.49 221.96 78494 TC 150.77 143.23 164.71 161.43 78494 26 56.55 53.72 61.78 60.55 78496 41.89 39.80 45.77 44.85 78496 TC 18.08 17.18 19.76 19.37 78496 26 23.81 22.62 26.01 25.50 78579 168.25 159.84 183.82 180.14 78579 TC 144.87 137.63 158.27 155.11 78579 26 23.38 22.21 25.54 25.04 78580 216.22 205.41 236.22 231.50 78580 TC 180.76 171.72 197.48 193.53 78580 26 35.46 33.69 38.74 37.97 78582 303.57 288.39 331.65 325.01 78582 TC 252.29 239.68 275.63 270.12 78582 26 51.27 48.71 56.02 54.90 78597 183.23 174.07 200.18 196.18 78597 TC 148.62 141.19 162.37 159.13 78597 26 34.61 32.88 37.81 37.05 78598 277.33 263.46 302.98 296.92 78598 TC 237.30 225.44 259.26 254.07 78598 26 40.03 38.03 43.73 42.86C 78600 162.75 154.61 177.80 174.25C 78600 TC 141.71 134.62 154.81 151.72 78600 26 21.04 19.99 22.99 22.53 78601 194.86 185.12 212.89 208.63 78601 TC 170.14 161.63 185.87 182.16 78601 26 24.72 23.48 27.00 26.46 78605 178.71 169.77 195.24 191.33 78605 TC 152.65 145.02 166.77 163.44 78605 26 26.07 24.77 28.49 27.91 78606 296.11 281.30 323.50 317.02 78606 TC 266.04 252.74 290.65 284.84 78606 26 30.08 28.58 32.87 32.21

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 95

78607 315.86 300.07 345.08 338.18 78607 TC 258.54 245.61 282.45 276.81 78607 26 57.32 54.45 62.62 61.36 78608 969.67 921.19 1,059.37 1,038.19 78608 TC 898.20 853.29 981.28 961.65 78608 26 71.47 67.90 78.09 76.52 78610 156.49 148.67 170.97 167.56 78610 TC 142.03 134.93 155.17 152.06 78610 26 14.46 13.74 15.80 15.49 78630 303.72 288.53 331.81 325.17 78630 TC 271.04 257.49 296.11 290.19 78630 26 32.69 31.06 35.72 35.01 78635 304.41 289.19 332.57 325.92 78635 TC 275.10 261.35 300.55 294.54 78635 26 29.31 27.84 32.02 31.37 78645 290.10 275.60 316.94 310.60 78645 TC 263.23 250.07 287.58 281.83 78645 26 26.87 25.53 29.36 28.77 78647 315.91 300.11 345.13 338.23 78647 TC 271.97 258.37 297.13 291.18 78647 26 43.94 41.74 48.00 47.05 78650 301.81 286.72 329.73 323.14 78650 TC 272.29 258.68 297.48 291.54 78650 26 29.52 28.04 32.25 31.60C 78660 168.09 159.69 183.64 179.98C 78660 TC 141.71 134.62 154.81 151.72 78660 26 26.38 25.06 28.82 28.24 78700 156.79 148.95 171.29 167.87 78700 TC 135.15 128.39 147.65 144.69 78700 26 21.64 20.56 23.64 23.17 78701 192.58 182.95 210.39 206.18 78701 TC 168.89 160.45 184.52 180.83 78701 26 23.70 22.52 25.90 25.38 78707 210.32 199.80 229.77 225.17 78707 TC 164.83 156.59 180.08 176.48 78707 26 45.49 43.22 49.70 48.71 78708 159.27 151.31 174.01 170.52 78708 TC 101.73 96.64 111.14 108.92 78708 26 57.54 54.66 62.86 61.61 78709 331.92 315.32 362.62 355.36 78709 TC 265.10 251.85 289.63 283.83 78709 26 66.82 63.48 73.00 71.54 78710 180.00 171.00 196.65 192.72 78710 TC 150.77 143.23 164.71 161.43 78710 26 29.23 27.77 31.94 31.29 78725 98.44 93.52 107.55 105.40 78725 TC 80.80 76.76 88.27 86.50 78725 26 17.64 16.76 19.27 18.88 78730 68.09 64.69 74.39 72.91 78730 TC 60.57 57.54 66.17 64.85 78730 26 7.52 7.14 8.21 8.05 78740 198.26 188.35 216.60 212.27

78740 TC 171.08 162.53 186.91 183.17 78740 26 27.19 25.83 29.70 29.11 78761 190.43 180.91 208.05 203.88 78761 TC 155.77 147.98 170.18 166.77 78761 26 34.67 32.94 37.88 37.12 78800 172.40 163.78 188.35 184.58 78800 TC 140.15 133.14 153.11 150.05 78800 26 32.25 30.64 35.24 34.53 78801 226.41 215.09 247.35 242.41 78801 TC 188.26 178.85 205.68 201.56 78801 26 38.16 36.25 41.69 40.86 78802 290.46 275.94 317.33 310.98 78802 TC 249.79 237.30 272.90 267.43 78802 26 40.66 38.63 44.42 43.54 78803 307.10 291.75 335.51 328.81 78803 TC 256.35 243.53 280.06 274.46 78803 26 50.74 48.20 55.43 54.33 78804 509.67 484.19 556.82 545.69 78804 TC 459.02 436.07 501.48 491.45 78804 26 50.65 48.12 55.34 54.23 78805 165.85 157.56 181.19 177.57 78805 TC 130.78 124.24 142.88 140.02 78805 26 35.07 33.32 38.32 37.55 78806 297.95 283.05 325.51 319.00 78806 TC 257.29 244.43 281.09 275.47 78806 26 40.66 38.63 44.42 43.54 78807 305.88 290.59 334.18 327.50 78807 TC 255.42 242.65 279.05 273.47 78807 26 50.46 47.94 55.13 54.03 78808 41.95 39.85 45.83 44.91C 78811 1,220.01 1,159.01 1,332.86 1,306.20C 78811 TC 1,142.94 1,085.79 1,248.66 1,223.68 78811 26 77.06 73.21 84.19 82.51C 78812 1,236.23 1,174.42 1,350.58 1,323.57C 78812 TC 1,142.94 1,085.79 1,248.66 1,223.68 78812 26 93.29 88.63 101.92 99.89C 78813 1,240.86 1,178.82 1,355.64 1,328.53C 78813 TC 1,142.94 1,085.79 1,248.66 1,223.68 78813 26 97.91 93.01 106.96 104.82C 78814 1,250.76 1,188.22 1,366.45 1,339.13C 78814 TC 1,142.94 1,085.79 1,248.66 1,223.68 78814 26 107.82 102.43 117.79 115.44C 78815 1,261.79 1,198.70 1,378.51 1,350.94C 78815 TC 1,142.94 1,085.79 1,248.66 1,223.68 78815 26 118.85 112.91 129.85 127.25C 78816 1,263.00 1,199.85 1,379.83 1,352.23C 78816 TC 1,142.94 1,085.79 1,248.66 1,223.68 78816 26 120.06 114.06 131.17 128.55 79005 127.92 121.52 139.75 136.95 79005 TC 42.45 40.33 46.38 45.45 79005 26 85.48 81.21 93.39 91.53 79101 135.53 128.75 148.06 145.11

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 96

79101 TC 43.07 40.92 47.06 46.12 79101 26 92.46 87.84 101.02 98.99 79200 148.02 140.62 161.71 158.48 79200 TC 48.70 46.27 53.21 52.14 79200 26 99.33 94.36 108.51 106.34 79300 26 79.35 75.38 86.69 84.95 79403 180.38 171.36 197.06 193.12 79403 TC 70.80 67.26 77.35 75.80 79403 26 109.58 104.10 119.72 117.32 79440 137.30 130.44 150.01 147.00 79440 TC 41.51 39.43 45.34 44.44 79440 26 95.79 91.00 104.65 102.56 79445 26 114.05 108.35 124.60 122.11 80500 20.02 19.02 21.87 21.44# 80500 18.15 17.24 19.83 19.44 80502 65.52 62.24 71.58 70.15# 80502 63.64 60.46 69.53 68.14 83020 26 18.46 17.54 20.17 19.77 84165 26 18.46 17.54 20.17 19.77 84166 26 18.46 17.54 20.17 19.77 84181 26 18.46 17.54 20.17 19.77 84182 26 18.46 17.54 20.17 19.77 85060 23.51 22.33 25.68 25.16 85097 79.42 75.45 86.77 85.03# 85097 46.93 44.58 51.27 50.24 85390 26 18.46 17.54 20.17 19.77 85396 19.40 18.43 21.19 20.77 85576 26 18.46 17.54 20.17 19.77 86077 51.93 49.33 56.73 55.59# 86077 48.80 46.36 53.31 52.24 86078 51.93 49.33 56.73 55.59# 86078 48.80 46.36 53.31 52.24 86079 51.62 49.04 56.40 55.27# 86079 48.18 45.77 52.64 51.58 86153 26 33.71 32.02 36.82 36.09 86255 26 18.46 17.54 20.17 19.77 86256 26 17.90 17.01 19.56 19.17 86320 26 17.90 17.01 19.56 19.17 86325 26 17.90 17.01 19.56 19.17 86327 26 20.88 19.84 22.82 22.36 86334 26 18.46 17.54 20.17 19.77 86335 26 18.46 17.54 20.17 19.77 86485 39.58 37.60 43.24 42.38 86486 4.34 4.12 4.74 4.65 86490 4.34 4.12 4.74 4.65 86510 5.59 5.31 6.11 5.98 86580 6.84 6.50 7.48 7.33 87164 26 18.46 17.54 20.17 19.77 87207 26 18.46 17.54 20.17 19.77 88104 67.16 63.80 73.37 71.90 88104 TC 39.01 37.06 42.62 41.77 88104 26 28.15 26.74 30.75 30.14

88106 75.35 71.58 82.32 80.67 88106 TC 56.50 53.68 61.73 60.50 88106 26 18.84 17.90 20.59 20.17 88108 70.67 67.14 77.21 75.67 88108 TC 48.70 46.27 53.21 52.14 88108 26 21.97 20.87 24.00 23.52 88112 57.48 54.61 62.80 61.55 88112 TC 30.27 28.76 33.07 32.41 88112 26 27.21 25.85 29.73 29.13 88120 544.76 517.52 595.15 583.25 88120 TC 487.82 463.43 532.94 522.28 88120 26 56.94 54.09 62.20 60.96 88121 471.13 447.57 514.71 504.41 88121 TC 422.30 401.19 461.37 452.15 88121 26 48.84 46.40 53.36 52.29 88125 20.49 19.47 22.39 21.94 88125 TC 7.77 7.38 8.49 8.31 88125 26 12.71 12.07 13.88 13.60 88141 29.62 28.14 32.36 31.72 88160 58.45 55.53 63.86 62.58 88160 TC 33.08 31.43 36.14 35.42 88160 26 25.37 24.10 27.72 27.16 88161 53.45 50.78 58.40 57.22 88161 TC 29.02 27.57 31.71 31.07 88161 26 24.44 23.22 26.70 26.17 88162 87.37 83.00 95.45 93.54 88162 TC 48.70 46.27 53.21 52.14 88162 26 38.68 36.75 42.26 41.42 88172 50.57 48.04 55.25 54.14 88172 TC 15.90 15.11 17.38 17.03 88172 26 34.68 32.95 37.89 37.13 88173 134.27 127.56 146.69 143.76 88173 TC 65.25 61.99 71.29 69.86 88173 26 69.02 65.57 75.41 73.90 88177 27.78 26.39 30.35 29.74 88177 TC 6.52 6.19 7.12 6.98 88177 26 21.26 20.20 23.23 22.77 88182 99.22 94.26 108.40 106.23 88182 TC 63.62 60.44 69.51 68.11 88182 26 35.60 33.82 38.89 38.11 88184 76.50 72.68 83.58 81.91 88185 46.82 44.48 51.15 50.13 88187 68.43 65.01 74.76 73.27 88188 86.12 81.81 94.08 92.20 88189 106.36 101.04 116.20 113.87 88291 29.46 27.99 32.19 31.54 88300 13.10 12.45 14.32 14.03 88300 TC 8.71 8.27 9.51 9.32 88300 26 4.39 4.17 4.80 4.70 88302 26.77 25.43 29.24 28.66 88302 TC 19.96 18.96 21.80 21.37 88302 26 6.81 6.47 7.44 7.29

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 97

88304 38.74 36.80 42.32 41.47 88304 TC 27.77 26.38 30.34 29.73 88304 26 10.97 10.42 11.98 11.74 88305 64.91 61.66 70.91 69.49 88305 TC 28.08 26.68 30.68 30.07 88305 26 36.83 34.99 40.24 39.43 88307 258.58 245.65 282.50 276.85 88307 TC 178.02 169.12 194.49 190.60 88307 26 80.56 76.53 88.01 86.25 88309 395.11 375.35 431.65 423.02 88309 TC 252.61 239.98 275.98 270.46 88309 26 142.51 135.38 155.69 152.57 88311 18.84 17.90 20.59 20.17 88311 TC 6.84 6.50 7.48 7.33 88311 26 12.00 11.40 13.11 12.85 88312 84.87 80.63 92.72 90.87 88312 TC 58.38 55.46 63.78 62.50 88312 26 26.49 25.17 28.95 28.37 88313 58.51 55.58 63.92 62.64 88313 TC 46.82 44.48 51.15 50.13 88313 26 11.69 11.11 12.78 12.52 88314 70.09 66.59 76.58 75.05 88314 TC 48.07 45.67 52.52 51.47 88314 26 22.02 20.92 24.06 23.58 88319 77.26 73.40 84.41 82.72 88319 TC 50.26 47.75 54.91 53.82 88319 26 27.00 25.65 29.50 28.91 88321 90.21 85.70 98.56 96.59# 88321 82.09 77.99 89.69 87.89 88323 136.91 130.06 149.57 146.58 88323 TC 51.82 49.23 56.61 55.49 88323 26 85.09 80.84 92.97 91.10 88325 196.63 186.80 214.82 210.52# 88325 128.53 122.10 140.42 137.61 88329 52.91 50.26 57.80 56.64# 88329 34.79 33.05 38.01 37.25 88331 91.60 87.02 100.07 98.07 88331 TC 31.51 29.93 34.42 33.73 88331 26 60.09 57.09 65.65 64.34 88332 40.74 38.70 44.51 43.62 88332 TC 10.90 10.36 11.91 11.67 88332 26 29.85 28.36 32.61 31.96 88333 96.54 91.71 105.47 103.36 88333 TC 35.58 33.80 38.87 38.09 88333 26 60.96 57.91 66.60 65.26 88334 60.06 57.06 65.62 64.31 88334 TC 22.46 21.34 24.54 24.05 88334 26 37.60 35.72 41.08 40.26 88346 96.65 91.82 105.59 103.48 88346 TC 55.26 52.50 60.38 59.17 88346 26 41.39 39.32 45.22 44.31 88347 81.34 77.27 88.86 87.08

88347 TC 40.89 38.85 44.68 43.78 88347 26 40.46 38.44 44.21 43.32 88348 619.07 588.12 676.34 662.81 88348 TC 545.44 518.17 595.90 583.98 88348 26 73.63 69.95 80.44 78.83 88349 359.66 341.68 392.93 385.08 88349 TC 320.36 304.34 349.99 342.99 88349 26 39.30 37.34 42.94 42.08 88355 161.96 153.86 176.94 173.40 88355 TC 79.93 75.93 87.32 85.57 88355 26 82.03 77.93 89.62 87.83 88356 257.22 244.36 281.01 275.39 88356 TC 127.00 120.65 138.75 135.98 88356 26 130.22 123.71 142.27 139.43 88358 77.00 73.15 84.12 82.44 88358 TC 33.08 31.43 36.14 35.42 88358 26 43.92 41.72 47.98 47.02 88360 118.30 112.39 129.25 126.66 88360 TC 65.56 62.28 71.62 70.18 88360 26 52.73 50.09 57.60 56.45 88361 142.99 135.84 156.22 153.09 88361 TC 85.87 81.58 93.82 91.94 88361 26 57.12 54.26 62.40 61.15 88362 278.10 264.20 303.83 297.76 88362 TC 169.48 161.01 185.16 181.46 88362 26 108.62 103.19 118.67 116.30 88363 20.96 19.91 22.90 22.44# 88363 18.46 17.54 20.17 19.77 88365 159.99 151.99 174.79 171.29 88365 TC 102.11 97.00 111.55 109.32 88365 26 57.88 54.99 63.24 61.97 88367 228.79 217.35 249.95 244.95 88367 TC 168.33 159.91 183.90 180.22 88367 26 60.45 57.43 66.04 64.72 88368 208.98 198.53 228.31 223.74 88368 TC 146.16 138.85 159.68 156.48 88368 26 62.82 59.68 68.63 67.26 88371 26 18.46 17.54 20.17 19.77 88372 26 18.46 17.54 20.17 19.77 88380 173.16 164.50 189.18 185.39 88380 TC 96.18 91.37 105.08 102.97 88380 26 76.98 73.13 84.10 82.42 88381 145.53 138.25 158.99 155.81 88381 TC 92.12 87.51 100.64 98.62 88381 26 53.41 50.74 58.35 57.19 88387 34.01 32.31 37.16 36.41 88387 TC 5.59 5.31 6.11 5.98 88387 26 28.42 27.00 31.05 30.43 88388 30.73 29.19 33.57 32.90 88388 TC 7.77 7.38 8.49 8.31 88388 26 22.96 21.81 25.08 24.58 89049 231.92 220.32 253.37 248.30

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 98

# 89049 63.55 60.37 69.43 68.03 89060 26 18.46 17.54 20.17 19.77 89220 14.96 14.21 16.34 16.02 89230 4.34 4.12 4.74 4.65 90460 22.61 21.48 24.70 24.21 90461 11.59 11.01 12.66 12.41 90471 22.61 21.48 24.70 24.21 90472 11.59 11.01 12.66 12.41 90473 22.61 21.48 24.70 24.21 90474 11.59 11.01 12.66 12.41 90785 13.97 13.27 15.26 14.95 90791 130.20 123.69 142.24 139.40# 90791 126.45 120.13 138.15 135.39 90792 140.40 133.38 153.39 150.32# 90792 136.65 129.82 149.29 146.30 90832 63.21 60.05 69.06 67.68# 90832 62.58 59.45 68.37 67.00 90833 64.46 61.24 70.43 69.02# 90833 64.14 60.93 70.07 68.67 90834 83.86 79.67 91.62 89.79# 90834 83.55 79.37 91.28 89.45 90836 81.56 77.48 89.10 87.32# 90836 80.94 76.89 88.42 86.65 90837 125.51 119.23 137.11 134.38# 90837 124.89 118.65 136.45 133.72 90838 107.64 102.26 117.60 115.24# 90838 107.01 101.66 116.91 114.57 90839 131.11 124.55 143.23 140.37# 90839 130.17 123.66 142.21 139.37 90840 62.89 59.75 68.71 67.34# 90840 62.58 59.45 68.37 67.00 90845 90.25 85.74 98.60 96.63# 90845 89.63 85.15 97.92 95.97 90846 101.59 96.51 110.99 108.77# 90846 100.97 95.92 110.31 108.10 90847 104.86 99.62 114.56 112.27# 90847 104.24 99.03 113.88 111.61 90849 32.59 30.96 35.60 34.89# 90849 29.46 27.99 32.19 31.54 90853 25.72 24.43 28.09 27.53# 90853 25.09 23.84 27.42 26.86 90865 160.39 152.37 175.23 171.72# 90865 125.40 119.13 137.00 134.26 90870 166.64 158.31 182.06 178.41# 90870 109.16 103.70 119.26 116.87 90880 98.79 93.85 107.93 105.77# 90880 92.54 87.91 101.10 99.07 90901 36.83 34.99 40.24 39.43# 90901 19.65 18.67 21.47 21.05 90911 78.49 74.57 85.76 84.04# 90911 43.82 41.63 47.87 46.92 90935 70.54 67.01 77.06 75.52

90937 101.13 96.07 110.48 108.27 90945 82.47 78.35 90.10 88.30 90947 120.71 114.67 131.87 129.24 90951 903.38 858.21 986.94 967.21 90954 783.72 744.53 856.21 839.09 90955 440.99 418.94 481.78 472.14 90956 306.32 291.00 334.65 327.96 90957 622.57 591.44 680.16 666.55 90958 420.54 399.51 459.44 450.25 90959 284.06 269.86 310.34 304.13 90960 272.91 259.26 298.15 292.18 90961 229.20 217.74 250.40 245.40 90962 176.21 167.40 192.51 188.66 90963 527.48 501.11 576.28 564.75 90964 459.36 436.39 501.85 491.81 90965 435.85 414.06 476.17 466.65 90966 228.88 217.44 250.06 245.05 90967 17.19 16.33 18.78 18.40 90968 14.77 14.03 16.13 15.81 90969 14.41 13.69 15.74 15.43 90970 7.48 7.11 8.18 8.02 90997 89.62 85.14 97.91 95.96 91010 160.84 152.80 175.72 172.20 91010 TC 94.93 90.18 103.71 101.64 91010 26 65.91 62.61 72.00 70.56 91013 21.68 20.60 23.69 23.22 91013 TC 12.46 11.84 13.62 13.34 91013 26 9.22 8.76 10.07 9.87 91020 212.49 201.87 232.15 227.50 91020 TC 138.35 131.43 151.14 148.12 91020 26 74.14 70.43 80.99 79.37 91022 155.08 147.33 169.43 166.04 91022 TC 81.49 77.42 89.03 87.25 91022 26 73.59 69.91 80.40 78.79 91030 125.20 118.94 136.78 134.04 91030 TC 78.37 74.45 85.62 83.90 91030 26 46.83 44.49 51.16 50.14 91034 171.08 162.53 186.91 183.17 91034 TC 121.48 115.41 132.72 130.07 91034 26 49.60 47.12 54.19 53.11 91035 431.21 409.65 471.10 461.68 91035 TC 350.14 332.63 382.52 374.88 91035 26 81.08 77.03 88.58 86.81 91037 146.61 139.28 160.17 156.96 91037 TC 96.18 91.37 105.08 102.97 91037 26 50.43 47.91 55.10 53.99 91038 402.49 382.37 439.73 430.93 91038 TC 346.08 328.78 378.10 370.53 91038 26 56.41 53.59 61.63 60.40 91040 356.04 338.24 388.98 381.20 91040 TC 307.65 292.27 336.11 329.38 91040 26 48.39 45.97 52.87 51.81

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 99

91065 73.32 69.65 80.10 78.50 91065 TC 63.06 59.91 68.90 67.52 91065 26 10.25 9.74 11.20 10.98 91110 800.81 760.77 874.89 857.38 91110 TC 613.78 583.09 670.55 657.14 91110 26 187.03 177.68 204.33 200.25 91111 646.34 614.02 706.12 692.00 91111 TC 595.04 565.29 650.08 637.08 91111 26 51.30 48.74 56.05 54.94 91112 953.27 905.61 1,041.45 1,020.63 91112 TC 845.25 802.99 923.44 904.97 91112 26 108.02 102.62 118.01 115.66 91117 142.10 135.00 155.25 152.15 91120 355.55 337.77 388.44 380.66 91120 TC 306.09 290.79 334.41 327.72 91120 26 49.46 46.99 54.04 52.96 91122 202.96 192.81 221.73 217.29 91122 TC 115.54 109.76 126.22 123.69 91122 26 87.42 83.05 95.51 93.60 91132 136.88 130.04 149.55 146.56 91132 TC 109.92 104.42 120.08 117.68 91132 26 26.96 25.61 29.45 28.87 91133 160.29 152.28 175.12 171.61 91133 TC 125.85 119.56 137.49 134.75 91133 26 34.44 32.72 37.63 36.88 92002 76.26 72.45 83.32 81.65# 92002 47.52 45.14 51.91 50.88 92004 139.78 132.79 152.71 149.65# 92004 97.61 92.73 106.64 104.51 92012 79.88 75.89 87.27 85.53# 92012 51.77 49.18 56.56 55.43 92014 116.12 110.31 126.86 124.32# 92014 78.32 74.40 85.56 83.85 92018 142.13 135.02 155.27 152.17 92019 69.49 66.02 75.92 74.41 92020 25.96 24.66 28.36 27.80# 92020 20.96 19.91 22.90 22.44 92025 34.96 33.21 38.19 37.43 92025 TC 15.58 14.80 17.02 16.68 92025 26 19.38 18.41 21.17 20.75 92060 60.81 57.77 66.44 65.10 92060 TC 23.08 21.93 25.22 24.71 92060 26 37.73 35.84 41.22 40.39 92065 48.48 46.06 52.97 51.91 92065 TC 30.89 29.35 33.75 33.07 92065 26 17.59 16.71 19.22 18.84 92071 36.43 34.61 39.80 39.01# 92071 32.99 31.34 36.04 35.32 92072 130.47 123.95 142.54 139.69# 92072 102.98 97.83 112.50 110.25 92081 31.54 29.96 34.45 33.76 92081 TC 15.27 14.51 16.69 16.35

92081 26 16.26 15.45 17.77 17.41 92082 45.08 42.83 49.25 48.27 92082 TC 23.08 21.93 25.22 24.71 92082 26 22.00 20.90 24.04 23.55 92083 59.00 56.05 64.46 63.17 92083 TC 31.51 29.93 34.42 33.73 92083 26 27.49 26.12 30.04 29.44 92100 73.29 69.63 80.07 78.48# 92100 33.30 31.64 36.39 35.66 92132 33.01 31.36 36.06 35.34 92132 TC 13.71 13.02 14.97 14.67 92132 26 19.30 18.34 21.09 20.67 92133 41.51 39.43 45.34 44.44 92133 TC 14.02 13.32 15.32 15.01 92133 26 27.49 26.12 30.04 29.44 92134 42.45 40.33 46.38 45.45 92134 TC 14.02 13.32 15.32 15.01 92134 26 28.43 27.01 31.06 30.44 92136 81.44 77.37 88.98 87.19 92136 TC 51.19 48.63 55.92 54.81 92136 26 30.24 28.73 33.04 32.38 92140 57.79 54.90 63.14 61.87# 92140 26.24 24.93 28.67 28.09 92225 26.00 24.70 28.41 27.84# 92225 21.32 20.25 23.29 22.83 92226 23.34 22.17 25.50 24.99# 92226 18.35 17.43 20.04 19.64 92227 12.46 11.84 13.62 13.34 92228 32.55 30.92 35.56 34.85 92228 TC 11.84 11.25 12.94 12.68 92228 26 20.72 19.68 22.63 22.18 92230 54.78 52.04 59.85 58.65# 92230 33.22 31.56 36.29 35.57 92235 100.10 95.10 109.37 107.18 92235 TC 54.32 51.60 59.34 58.16 92235 26 45.78 43.49 50.01 49.01C 92240 220.75 209.71 241.17 236.35C 92240 TC 158.65 150.72 173.33 169.87 92240 26 62.10 59.00 67.85 66.49 92250 70.98 67.43 77.54 75.99 92250 TC 47.76 45.37 52.18 51.13 92250 26 23.22 22.06 25.37 24.86 92260 17.44 16.57 19.06 18.68# 92260 10.88 10.34 11.89 11.65 92265 71.12 67.56 77.69 76.14 92265 TC 30.58 29.05 33.41 32.74 92265 26 40.54 38.51 44.29 43.40 92270 82.92 78.77 90.59 88.77 92270 TC 42.76 40.62 46.71 45.78 92270 26 40.16 38.15 43.87 43.00 92275 144.40 137.18 157.76 154.61 92275 TC 87.43 83.06 95.52 93.61

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 100

92275 26 56.97 54.12 62.24 61.00 92283 49.13 46.67 53.67 52.60 92283 TC 39.95 37.95 43.64 42.77 92283 26 9.18 8.72 10.03 9.83 92284 54.13 51.42 59.13 57.95 92284 TC 42.14 40.03 46.03 45.11 92284 26 12.00 11.40 13.11 12.85 92285 18.28 17.37 19.98 19.57 92285 TC 15.27 14.51 16.69 16.35 92285 26 3.01 2.86 3.29 3.22 92286 35.50 33.73 38.79 38.02 92286 TC 14.02 13.32 15.32 15.01 92286 26 21.48 20.41 23.47 23.00C 92287 113.22 107.56 123.69 121.22C 92287 TC 67.44 64.07 73.68 72.21 92287 26 45.78 43.49 50.01 49.01 92311 94.95 90.20 103.73 101.66# 92311 55.59 52.81 60.73 59.51 92312 107.44 102.07 117.38 115.03# 92312 62.45 59.33 68.23 66.86 92313 90.57 86.04 98.95 96.97# 92313 47.46 45.09 51.85 50.82 92315 66.58 63.25 72.74 71.29# 92315 22.23 21.12 24.29 23.81 92316 83.57 79.39 91.30 89.47# 92316 32.97 31.32 36.02 35.29 92317 68.56 65.13 74.90 73.40# 92317 21.40 20.33 23.38 22.91 92325 36.20 34.39 39.55 38.76 92326 31.20 29.64 34.09 33.41 92502 92.58 87.95 101.14 99.12 92504 27.34 25.97 29.87 29.27# 92504 9.22 8.76 10.07 9.87 92507 76.00 72.20 83.03 81.37 92508 22.09 20.99 24.14 23.66 92511 123.27 117.11 134.68 131.99# 92511 45.80 43.51 50.04 49.04 92512 56.15 53.34 61.34 60.11# 92512 27.72 26.33 30.28 29.67 92516 63.40 60.23 69.26 67.88# 92516 22.48 21.36 24.56 24.07 92520 68.90 65.46 75.28 73.77# 92520 39.85 37.86 43.54 42.67 92521 107.53 102.15 117.47 115.13 92522 87.68 83.30 95.80 93.87 92523 181.57 172.49 198.36 194.40 92524 90.94 86.39 99.35 97.36 92526 82.43 78.31 90.06 88.25 92540 96.04 91.24 104.93 102.83 92540 TC 19.02 18.07 20.78 20.37 92540 26 77.02 73.17 84.15 82.47 92541 28.63 27.20 31.28 30.66

92541 TC 8.40 7.98 9.18 8.99 92541 26 20.23 19.22 22.10 21.67 92542 24.56 23.33 26.83 26.29 92542 TC 7.77 7.38 8.49 8.31 92542 26 16.78 15.94 18.33 17.96 92543 14.45 13.73 15.79 15.48 92543 TC 9.02 8.57 9.86 9.66 92543 26 5.42 5.15 5.92 5.81 92544 22.05 20.95 24.09 23.61 92544 TC 8.71 8.27 9.51 9.32 92544 26 13.34 12.67 14.57 14.28 92545 19.10 18.15 20.87 20.46 92545 TC 7.46 7.09 8.15 7.99 92545 26 11.64 11.06 12.72 12.47 92546 91.54 86.96 100.00 98.00 92546 TC 76.81 72.97 83.92 82.24 92546 26 14.73 13.99 16.09 15.77 92547 5.28 5.02 5.77 5.66 92548 93.44 88.77 102.09 100.04 92548 TC 68.37 64.95 74.69 73.20 92548 26 25.06 23.81 27.38 26.83 92550 20.00 19.00 21.85 21.41 92552 26.83 25.49 29.31 28.73 92553 32.14 30.53 35.11 34.41 92555 19.96 18.96 21.80 21.37 92556 31.83 30.24 34.78 34.09 92557 35.76 33.97 39.07 38.28# 92557 31.38 29.81 34.28 33.59 92561 32.76 31.12 35.79 35.08 92562 40.26 38.25 43.99 43.11 92563 26.52 25.19 28.97 28.39 92564 24.64 23.41 26.92 26.38 92565 14.33 13.61 15.65 15.34 92567 13.69 13.01 14.96 14.66# 92567 10.57 10.04 11.55 11.32 92568 15.04 14.29 16.43 16.10 92570 30.84 29.30 33.70 33.02# 92570 28.97 27.52 31.65 31.02 92571 23.39 22.22 25.55 25.05 92572 44.63 42.40 48.76 47.78 92575 65.25 61.99 71.29 69.86 92576 30.27 28.76 33.07 32.41 92577 16.83 15.99 18.39 18.02 92579 40.28 38.27 44.01 43.13# 92579 36.22 34.41 39.57 38.78 92582 59.63 56.65 65.15 63.85 92583 45.26 43.00 49.45 48.46 92584 61.50 58.43 67.19 65.85 92585 116.86 111.02 127.67 125.12 92585 TC 91.18 86.62 99.61 97.62 92585 26 25.69 24.41 28.07 27.51 92586 73.37 69.70 80.16 78.56

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 101

92587 20.83 19.79 22.76 22.30 92587 TC 2.46 2.34 2.69 2.63 92587 26 18.37 17.45 20.07 19.67 92588 31.78 30.19 34.72 34.03 92588 TC 3.40 3.23 3.71 3.65 92588 26 28.38 26.96 31.00 30.38 92596 37.14 35.28 40.57 39.76 92597 69.57 66.09 76.00 74.49 92601 132.92 126.27 145.21 142.30# 92601 116.06 110.26 126.80 124.26 92602 78.19 74.28 85.42 83.71# 92602 64.13 60.92 70.06 68.66 92603 139.57 132.59 152.48 149.43# 92603 118.32 112.40 129.26 126.67 92604 83.65 79.47 91.39 89.56# 92604 65.53 62.25 71.59 70.16 92607 121.52 115.44 132.76 130.10 92608 49.93 47.43 54.54 53.45 92609 104.72 99.48 114.40 112.11 92610 80.69 76.66 88.16 86.40# 92610 70.06 66.56 76.54 75.01 92611 86.14 81.83 94.10 92.22 92612 161.77 153.68 176.73 173.20# 92612 66.18 62.87 72.30 70.85 92613 36.54 34.71 39.92 39.12 92614 137.71 130.82 150.44 147.43# 92614 66.18 62.87 72.30 70.85 92615 32.77 31.13 35.80 35.09# 92615 32.46 30.84 35.47 34.75 92616 194.44 184.72 212.43 208.18# 92616 98.23 93.32 107.32 105.17 92617 40.65 38.62 44.41 43.53 92620 89.41 84.94 97.68 95.73# 92620 80.67 76.64 88.14 86.38 92621 21.25 20.19 23.22 22.76# 92621 18.44 17.52 20.15 19.75 92625 66.64 63.31 72.81 71.35# 92625 60.39 57.37 65.98 64.65 92626 85.52 81.24 93.43 91.56# 92626 73.96 70.26 80.80 79.18 92627 20.53 19.50 22.43 21.98# 92627 17.10 16.25 18.69 18.32 92640 115.86 110.07 126.58 124.05# 92640 100.55 95.52 109.85 107.65 92920 528.47 502.05 577.36 565.81 92924 628.47 597.05 686.61 672.88 92928 586.72 557.38 640.99 628.16 92933 656.50 623.68 717.23 702.89 92937 586.36 557.04 640.60 627.79 92941 657.80 624.91 718.65 704.27 92943 657.80 624.91 718.65 704.27 92950 283.40 269.23 309.61 303.43

# 92950 182.50 173.38 199.39 195.40 92953 10.70 10.17 11.70 11.47 92960 189.48 180.01 207.01 202.87# 92960 117.63 111.75 128.51 125.95 92961 235.42 223.65 257.20 252.06 92970 171.16 162.60 186.99 183.25 92971 89.88 85.39 98.20 96.23 92973 171.65 163.07 187.53 183.78 92974 156.83 148.99 171.34 167.91 92975 378.69 359.76 413.72 405.44 92977 110.48 104.96 120.70 118.29 92978 249.54 237.06 272.62 267.17 92978 TC 162.64 154.51 177.69 174.13 92978 26 86.90 82.56 94.94 93.05 92979 152.15 144.54 166.22 162.90 92979 TC 82.17 78.06 89.77 87.98 92979 26 69.98 66.48 76.45 74.92 92986 1,283.21 1,219.05 1,401.91 1,373.87 92987 1,325.27 1,259.01 1,447.86 1,418.90 92990 1,040.91 988.86 1,137.19 1,114.44 92992 2,526.91 2,400.56 2,760.64 2,705.43 92993 2,526.91 2,400.56 2,760.64 2,705.43 92997 632.17 600.56 690.64 676.83 92998 312.96 297.31 341.91 335.06 93000 15.39 14.62 16.81 16.48 93005 7.15 6.79 7.81 7.65 93010 8.24 7.83 9.00 8.82 93015 69.56 66.08 75.99 74.47 93016 21.40 20.33 23.38 22.91 93017 34.01 32.31 37.16 36.41 93018 14.15 13.44 15.46 15.15 93024 102.96 97.81 112.48 110.23 93024 TC 47.13 44.77 51.49 50.45 93024 26 55.83 53.04 61.00 59.78 93025 146.68 139.35 160.25 157.04 93025 TC 110.55 105.02 120.77 118.36 93025 26 36.13 34.32 39.47 38.67 93040 11.86 11.27 12.96 12.70 93041 4.96 4.71 5.42 5.31 93042 6.90 6.56 7.54 7.39 93224 82.25 78.14 89.86 88.07 93225 23.39 22.22 25.55 25.05 93226 33.08 31.43 36.14 35.42 93227 25.78 24.49 28.16 27.60 93228 25.39 24.12 27.74 27.19 93229 583.48 554.31 637.46 624.70 93268 181.27 172.21 198.04 194.09 93270 8.09 7.69 8.84 8.67 93271 148.66 141.23 162.41 159.17 93272 24.53 23.30 26.80 26.25 93278 27.63 26.25 30.19 29.59 93278 TC 15.58 14.80 17.02 16.68

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 102

93278 26 12.04 11.44 13.16 12.89 93279 46.57 44.24 50.88 49.86 93279 TC 14.96 14.21 16.34 16.02 93279 26 31.61 30.03 34.53 33.84 93280 54.62 51.89 59.67 58.48 93280 TC 17.15 16.29 18.73 18.35 93280 26 37.47 35.60 40.94 40.12 93281 63.65 60.47 69.54 68.15 93281 TC 19.96 18.96 21.80 21.37 93281 26 43.69 41.51 47.74 46.78 93282 58.74 55.80 64.17 62.88 93282 TC 17.46 16.59 19.08 18.70 93282 26 41.28 39.22 45.10 44.21 93283 76.63 72.80 83.72 82.04 93283 TC 20.58 19.55 22.48 22.03 93283 26 56.05 53.25 61.24 60.02 93284 84.27 80.06 92.07 90.23 93284 TC 23.39 22.22 25.55 25.05 93284 26 60.88 57.84 66.52 65.18 93285 38.86 36.92 42.46 41.61 93285 TC 13.71 13.02 14.97 14.67 93285 26 25.15 23.89 27.47 26.92 93286 25.05 23.80 27.37 26.82 93286 TC 10.27 9.76 11.22 10.99 93286 26 14.77 14.03 16.13 15.81 93287 33.23 31.57 36.31 35.58 93287 TC 11.21 10.65 12.25 12.01 93287 26 22.02 20.92 24.06 23.58 93288 34.08 32.38 37.24 36.49 93288 TC 13.71 13.02 14.97 14.67 93288 26 20.37 19.35 22.25 21.80 93289 61.24 58.18 66.91 65.57 93289 TC 16.83 15.99 18.39 18.02 93289 26 44.41 42.19 48.52 47.55 93290 28.77 27.33 31.43 30.80 93290 TC 8.09 7.69 8.84 8.67 93290 26 20.68 19.65 22.60 22.15 93291 33.45 31.78 36.55 35.81 93291 TC 12.77 12.13 13.95 13.67 93291 26 20.68 19.65 22.60 22.15 93292 29.70 28.22 32.45 31.81 93292 TC 9.34 8.87 10.20 9.99 93292 26 20.37 19.35 22.25 21.80 93293 48.25 45.84 52.72 51.66 93293 TC 32.76 31.12 35.79 35.08 93293 26 15.49 14.72 16.93 16.59 93294 32.52 30.89 35.52 34.81 93295 64.67 61.44 70.66 69.24 93296 22.46 21.34 24.54 24.05 93297 25.39 24.12 27.74 27.19 93298 25.71 24.42 28.08 27.52 93299 27.99 26.59 30.58 29.97

93303 214.45 203.73 234.29 229.61 93303 TC 152.40 144.78 166.50 163.16 93303 26 62.05 58.95 67.79 66.44 93304 141.68 134.60 154.79 151.70 93304 TC 105.86 100.57 115.66 113.34 93304 26 35.82 34.03 39.13 38.35 93306 205.71 195.42 224.73 220.24 93306 TC 143.66 136.48 156.95 153.81 93306 26 62.05 58.95 67.79 66.44 93307 119.66 113.68 130.73 128.12 93307 TC 75.56 71.78 82.55 80.89 93307 26 44.10 41.90 48.19 47.22 93308 110.13 104.62 120.31 117.91 93308 TC 85.24 80.98 93.13 91.26 93308 26 24.89 23.65 27.20 26.66 93312 300.56 285.53 328.36 321.79 93312 TC 198.25 188.34 216.59 212.26 93312 26 102.30 97.19 111.77 109.54 93313 41.28 39.22 45.10 44.21 93314 275.07 261.32 300.52 294.50 93314 TC 216.68 205.85 236.73 231.99 93314 26 58.38 55.46 63.78 62.50 93315 26 134.43 127.71 146.87 143.93 93316 41.91 39.81 45.78 44.86 93317 221.99 210.89 242.52 237.67 93317 TC 131.28 124.72 143.43 140.56 93317 26 90.71 86.17 99.10 97.12 93318 26 108.37 102.95 118.39 116.02 93320 49.47 47.00 54.05 52.97 93320 TC 31.51 29.93 34.42 33.73 93320 26 17.95 17.05 19.61 19.22 93321 27.79 26.40 30.36 29.75 93321 TC 20.58 19.55 22.48 22.03 93321 26 7.21 6.85 7.88 7.72 93325 23.05 21.90 25.19 24.68 93325 TC 19.64 18.66 21.46 21.03 93325 26 3.41 3.24 3.73 3.66 93350 217.65 206.77 237.79 233.02 93350 TC 148.03 140.63 161.72 158.49 93350 26 69.62 66.14 76.06 74.54 93351 253.27 240.61 276.70 271.17 93351 TC 170.14 161.63 185.87 182.16 93351 26 83.13 78.97 90.82 89.00 93352 30.20 28.69 32.99 32.34 93451 698.87 663.93 763.52 748.25 93451 TC 556.55 528.72 608.03 595.87 93451 26 142.33 135.21 155.49 152.39 93452 791.26 751.70 864.46 847.17 93452 TC 541.86 514.77 591.99 580.14 93452 26 249.39 236.92 272.46 267.01 93453 1,025.66 974.38 1,120.54 1,098.12 93453 TC 698.64 663.71 763.27 748.01

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 103

93453 26 327.02 310.67 357.27 350.13 93454 806.12 765.81 880.68 863.06 93454 TC 554.98 527.23 606.31 594.19 93454 26 251.14 238.58 274.37 268.88 93455 938.32 891.40 1,025.11 1,004.61 93455 TC 648.35 615.93 708.32 694.15 93455 26 289.97 275.47 316.79 310.45 93456 1,010.71 960.17 1,104.20 1,082.12 93456 TC 689.27 654.81 753.03 737.97 93456 26 321.43 305.36 351.16 344.14 93457 1,142.24 1,085.13 1,247.90 1,222.94 93457 TC 781.73 742.64 854.04 836.96 93457 26 360.50 342.48 393.85 385.97 93458 967.30 918.94 1,056.78 1,035.64 93458 TC 660.84 627.80 721.97 707.53 93458 26 306.45 291.13 334.80 328.11 93459 1,068.96 1,015.51 1,167.84 1,144.48 93459 TC 723.63 687.45 790.57 774.76 93459 26 345.33 328.06 377.27 369.73 93460 1,147.46 1,090.09 1,253.60 1,228.53 93460 TC 762.99 724.84 833.57 816.89 93460 26 384.47 365.25 420.04 411.64 93461 1,311.46 1,245.89 1,432.77 1,404.12 93461 TC 887.28 842.92 969.36 949.97 93461 26 424.18 402.97 463.42 454.15 93462 201.51 191.43 220.14 215.74 93463 103.15 97.99 112.69 110.43 93464 255.09 242.34 278.69 273.11 93464 TC 162.09 153.99 177.09 173.55 93464 26 93.00 88.35 101.60 99.57 93503 128.63 122.20 140.53 137.72 93505 683.77 649.58 747.02 732.08 93505 TC 458.15 435.24 500.53 490.52 93505 26 225.62 214.34 246.49 241.56 93530 829.97 788.47 906.74 888.61 93530 TC 608.76 578.32 665.07 651.76 93530 26 221.21 210.15 241.67 236.84 93531 2,176.74 2,067.90 2,378.09 2,330.52 93531 TC 1,740.71 1,653.67 1,901.72 1,863.69 93531 26 436.03 414.23 476.36 466.84 93532 26 522.69 496.56 571.04 559.62 93533 26 350.28 332.77 382.69 375.03 93561 43.34 41.17 47.35 46.40 93561 TC 19.63 18.65 21.45 21.02 93561 26 23.71 22.52 25.90 25.38 93562 19.76 18.77 21.59 21.15 93562 TC 12.19 11.58 13.32 13.05 93562 26 7.57 7.19 8.27 8.11 93563 54.41 51.69 59.44 58.26 93564 55.71 52.92 60.86 59.64 93565 42.40 40.28 46.32 45.39 93566 154.23 146.52 168.50 165.13

# 93566 42.40 40.28 46.32 45.39 93567 128.18 121.77 140.04 137.23# 93567 47.59 45.21 51.99 50.96 93568 138.39 131.47 151.19 148.17# 93568 43.11 40.95 47.09 46.15 93571 249.54 237.06 272.62 267.17 93571 TC 162.64 154.51 177.69 174.13 93571 26 86.90 82.56 94.94 93.05 93572 26 70.25 66.74 76.75 75.22 93580 951.38 903.81 1,039.38 1,018.59 93581 1,285.05 1,220.80 1,403.92 1,375.84 93582 656.59 623.76 717.32 702.97 93583 730.86 694.32 798.47 782.49 93600 185.73 176.44 202.91 198.85 93600 TC 70.69 67.16 77.23 75.69 93600 26 115.04 109.29 125.68 123.17 93602 153.69 146.01 167.91 164.55 93602 TC 39.90 37.91 43.60 42.72 93602 26 113.79 108.10 124.32 121.83 93603 173.71 165.02 189.77 185.98 93603 TC 60.54 57.51 66.14 64.81 93603 26 113.17 107.51 123.64 121.16 93609 367.21 348.85 401.18 393.15 93609 TC 98.08 93.18 107.16 105.02 93609 26 269.13 255.67 294.02 288.14 93610 210.35 199.83 229.80 225.20 93610 TC 49.05 46.60 53.59 52.52 93610 26 161.30 153.24 176.23 172.71 93612 218.24 207.33 238.43 233.66 93612 TC 58.19 55.28 63.57 62.30 93612 26 160.05 152.05 174.86 171.36 93613 378.38 359.46 413.38 405.11 93615 62.73 59.59 68.53 67.16 93615 TC 11.51 10.93 12.57 12.32 93615 26 51.22 48.66 55.96 54.84 93616 26 64.55 61.32 70.52 69.10 93618 373.10 354.45 407.62 399.46 93618 TC 142.38 135.26 155.55 152.43 93618 26 230.72 219.18 252.06 247.02 93619 670.63 637.10 732.67 718.01 93619 TC 276.97 263.12 302.59 296.54 93619 26 393.66 373.98 430.08 421.48 93620 932.34 885.72 1,018.58 998.21 93620 TC 306.73 291.39 335.10 328.39 93620 26 625.61 594.33 683.48 669.81 93621 26 113.39 107.72 123.88 121.41 93622 26 166.59 158.26 182.00 178.35 93623 26 154.34 146.62 168.61 165.24 93624 26 254.03 241.33 277.53 271.98 93631 26 394.21 374.50 430.68 422.06 93640 443.94 421.74 485.00 475.31 93640 TC 257.35 244.48 281.15 275.53

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 104

93640 26 186.59 177.26 203.85 199.77 93641 575.37 546.60 628.59 616.02 93641 TC 257.35 244.48 281.15 275.53 93641 26 318.02 302.12 347.44 340.49 93642 370.60 352.07 404.88 396.78 93642 TC 130.78 124.24 142.88 140.02 93642 26 239.82 227.83 262.00 256.76 93650 577.45 548.58 630.87 618.25 93653 812.18 771.57 887.31 869.56 93654 1,081.66 1,027.58 1,181.72 1,158.08 93655 405.95 385.65 443.50 434.63 93656 1,083.01 1,028.86 1,183.19 1,159.52 93657 406.23 385.92 443.81 434.93 93660 146.14 138.83 159.65 156.46 93660 TC 54.32 51.60 59.34 58.16 93660 26 91.82 87.23 100.31 98.31 93662 281.10 267.05 307.11 300.97 93662 TC 140.54 133.51 153.54 150.47 93662 26 140.56 133.53 153.56 150.49 93701 20.89 19.85 22.83 22.37 93724 260.40 247.38 284.49 278.79 93724 TC 24.33 23.11 26.58 26.05 93724 26 236.07 224.27 257.91 252.75 93750 51.84 49.25 56.64 55.51# 93750 44.03 41.83 48.10 47.14 93784 48.81 46.37 53.33 52.26 93786 25.89 24.60 28.29 27.73 93788 4.65 4.42 5.08 4.98 93790 18.26 17.35 19.95 19.55 93797 15.16 14.40 16.56 16.23# 93797 8.60 8.17 9.40 9.21 93798 22.80 21.66 24.91 24.41# 93798 13.43 12.76 14.67 14.38 93880 170.01 161.51 185.74 182.02 93880 TC 140.85 133.81 153.88 150.80 93880 26 29.16 27.70 31.86 31.22 93882 110.02 104.52 120.20 117.79 93882 TC 90.24 85.73 98.59 96.62 93882 26 19.78 18.79 21.61 21.17C 93886 213.43 202.76 233.17 228.51C 93886 TC 166.46 158.14 181.86 178.23 93886 26 46.97 44.62 51.31 50.29C 93888 147.92 140.52 161.60 158.37C 93888 TC 117.42 111.55 128.28 125.72 93888 26 30.50 28.98 33.33 32.66C 93890 166.84 158.50 182.28 178.63C 93890 TC 117.42 111.55 128.28 125.72 93890 26 49.43 46.96 54.00 52.92C 93892 174.37 165.65 190.50 186.69C 93892 TC 117.11 111.25 127.94 125.38 93892 26 57.26 54.40 62.56 61.31C 93893 174.68 165.95 190.84 187.02

C 93893 TC 117.11 111.25 127.94 125.38 93893 26 57.58 54.70 62.91 61.65 93922 78.86 74.92 86.16 84.43 93922 TC 67.13 63.77 73.34 71.86 93922 26 11.73 11.14 12.81 12.56 93923 124.03 117.83 135.50 132.79 93923 TC 102.42 97.30 111.90 109.65 93923 26 21.60 20.52 23.60 23.13 93924 155.49 147.72 169.88 166.49 93924 TC 131.47 124.90 143.64 140.76 93924 26 24.02 22.82 26.24 25.71C 93925 205.15 194.89 224.12 219.64C 93925 TC 166.39 158.07 181.78 178.15 93925 26 38.76 36.82 42.34 41.49 93926 126.06 119.76 137.72 134.96 93926 TC 101.80 96.71 111.22 109.00 93926 26 24.26 23.05 26.51 25.98C 93930 188.73 179.29 206.18 202.06C 93930 TC 166.46 158.14 181.86 178.23 93930 26 22.27 21.16 24.33 23.85C 93931 132.48 125.86 144.74 141.84C 93931 TC 117.42 111.55 128.28 125.72 93931 26 15.06 14.31 16.46 16.12 93965 107.67 102.29 117.63 115.28 93965 TC 90.55 86.02 98.92 96.95 93965 26 17.12 16.26 18.70 18.32 93970 167.55 159.17 183.05 179.39 93970 TC 133.35 126.68 145.68 142.77 93970 26 34.20 32.49 37.36 36.62 93971 101.85 96.76 111.27 109.04 93971 TC 79.93 75.93 87.32 85.57 93971 26 21.91 20.81 23.93 23.45C 93975 253.57 240.89 277.02 271.48C 93975 TC 166.43 158.11 181.83 178.19 93975 26 87.14 82.78 95.20 93.29 93976 191.41 181.84 209.12 204.93 93976 TC 132.41 125.79 144.66 141.76 93976 26 59.00 56.05 64.46 63.17C 93978 197.93 188.03 216.23 211.91C 93978 TC 166.46 158.14 181.86 178.23 93978 26 31.47 29.90 34.39 33.70C 93979 138.35 131.43 151.14 148.12C 93979 TC 117.42 111.55 128.28 125.72 93979 26 20.93 19.88 22.86 22.40 93980 113.22 107.56 123.69 121.22 93980 TC 52.76 50.12 57.64 56.49 93980 26 60.46 57.44 66.06 64.73 93981 67.16 63.80 73.37 71.90 93981 TC 45.88 43.59 50.13 49.13 93981 26 21.28 20.22 23.25 22.79 93982 39.31 37.34 42.94 42.08C 93990 129.67 123.19 141.67 138.84

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 105

C 93990 TC 117.42 111.55 128.28 125.72 93990 26 12.25 11.64 13.39 13.12 94002 91.07 86.52 99.50 97.51 94003 65.28 62.02 71.32 69.90 94004 48.07 45.67 52.52 51.47 94010 32.26 30.65 35.25 34.55 94010 TC 24.02 22.82 26.24 25.71 94010 26 8.24 7.83 9.00 8.82 94011 99.30 94.34 108.49 106.32 94012 155.26 147.50 169.63 166.23 94013 31.00 29.45 33.87 33.19 94014 47.92 45.52 52.35 51.30 94015 23.39 22.22 25.55 25.05 94016 24.53 23.30 26.80 26.25 94060 54.27 51.56 59.29 58.11 94060 TC 41.51 39.43 45.34 44.44 94060 26 12.76 12.12 13.94 13.66 94070 55.09 52.34 60.19 58.98 94070 TC 26.83 25.49 29.31 28.73 94070 26 28.26 26.85 30.88 30.26 94200 21.99 20.89 24.02 23.54 94200 TC 16.52 15.69 18.04 17.69 94200 26 5.47 5.20 5.98 5.87 94250 23.55 22.37 25.73 25.21 94250 TC 18.08 17.18 19.76 19.37 94250 26 5.47 5.20 5.98 5.87 94375 35.71 33.92 39.01 38.23 94375 TC 21.21 20.15 23.17 22.71 94375 26 14.51 13.78 15.85 15.53 94400 50.81 48.27 55.51 54.40 94400 TC 31.83 30.24 34.78 34.09 94400 26 18.98 18.03 20.73 20.32 94450 61.43 58.36 67.11 65.77 94450 TC 42.14 40.03 46.03 45.11 94450 26 19.29 18.33 21.08 20.65 94452 51.96 49.36 56.76 55.63 94452 TC 37.76 35.87 41.25 40.42 94452 26 14.19 13.48 15.50 15.19 94453 72.05 68.45 78.72 77.14 94453 TC 53.69 51.01 58.66 57.49 94453 26 18.35 17.43 20.04 19.64 94610 57.86 54.97 63.22 61.95 94620 51.84 49.25 56.64 55.51 94620 TC 21.83 20.74 23.85 23.38 94620 26 30.01 28.51 32.79 32.13 94621 149.99 142.49 163.86 160.59 94621 TC 82.43 78.31 90.06 88.25 94621 26 67.56 64.18 73.81 72.34 94640 15.90 15.11 17.38 17.03 94644 38.39 36.47 41.94 41.10 94645 12.46 11.84 13.62 13.34 94660 58.60 55.67 64.02 62.74

# 94660 36.73 34.89 40.12 39.32 94662 38.92 36.97 42.52 41.66 94664 14.96 14.21 16.34 16.02 94667 22.14 21.03 24.18 23.70 94668 25.58 24.30 27.95 27.38 94669 30.89 29.35 33.75 33.07 94680 51.73 49.14 56.51 55.38 94680 TC 39.32 37.35 42.95 42.09 94680 26 12.40 11.78 13.55 13.27 94681 45.52 43.24 49.73 48.74 94681 TC 35.89 34.10 39.22 38.43 94681 26 9.63 9.15 10.52 10.32 94690 43.05 40.90 47.04 46.09 94690 TC 39.32 37.35 42.95 42.09 94690 26 3.72 3.53 4.06 3.98 94726 47.63 45.25 52.04 51.00 94726 TC 35.54 33.76 38.82 38.04 94726 26 12.09 11.49 13.21 12.95 94727 37.98 36.08 41.49 40.66 94727 TC 25.89 24.60 28.29 27.73 94727 26 12.09 11.49 13.21 12.95 94728 36.42 34.60 39.79 39.00 94728 TC 24.02 22.82 26.24 25.71 94728 26 12.40 11.78 13.55 13.27 94729 48.28 45.87 52.75 51.69 94729 TC 39.32 37.35 42.95 42.09 94729 26 8.96 8.51 9.79 9.59 94750 72.21 68.60 78.89 77.31 94750 TC 61.19 58.13 66.85 65.52 94750 26 11.02 10.47 12.04 11.80 94760 2.78 2.64 3.04 2.98 94761 4.34 4.12 4.74 4.65 94762 21.52 20.44 23.51 23.03 94770 7.77 7.38 8.49 8.31 94780 47.39 45.02 51.77 50.74# 94780 22.40 21.28 24.47 23.98 94781 18.55 17.62 20.26 19.86# 94781 8.24 7.83 9.00 8.82 95004 5.63 5.35 6.15 6.03 95012 16.83 15.99 18.39 18.02 95017 7.47 7.10 8.17 8.00# 95017 3.72 3.53 4.06 3.98 95018 18.10 17.20 19.78 19.39# 95018 6.85 6.51 7.49 7.34 95024 6.88 6.54 7.52 7.37# 95024 0.95 0.90 1.04 1.01 95027 4.07 3.87 4.45 4.36 95028 11.84 11.25 12.94 12.68 95044 4.65 4.42 5.08 4.98 95052 5.59 5.31 6.11 5.98 95056 37.76 35.87 41.25 40.42 95060 29.33 27.86 32.04 31.40

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 106

95065 23.08 21.93 25.22 24.71 95070 25.58 24.30 27.95 27.38 95071 30.58 29.05 33.41 32.74 95076 109.16 103.70 119.26 116.87# 95076 71.68 68.10 78.32 76.75 95079 79.56 75.58 86.92 85.18# 95079 66.13 62.82 72.24 70.79 95115 7.77 7.38 8.49 8.31 95117 9.02 8.57 9.86 9.66 95144 11.17 10.61 12.20 11.96# 95144 3.05 2.90 3.34 3.27 95145 19.29 18.33 21.08 20.65# 95145 3.05 2.90 3.34 3.27 95146 34.29 32.58 37.47 36.72# 95146 3.05 2.90 3.34 3.27 95147 30.85 29.31 33.71 33.03# 95147 3.05 2.90 3.34 3.27 95148 46.16 43.85 50.43 49.42# 95148 3.05 2.90 3.34 3.27 95149 61.47 58.40 67.16 65.81# 95149 3.05 2.90 3.34 3.27 95165 11.49 10.92 12.56 12.31# 95165 3.05 2.90 3.34 3.27 95170 8.67 8.24 9.48 9.29# 95170 3.05 2.90 3.34 3.27 95180 127.05 120.70 138.81 136.03# 95180 98.62 93.69 107.74 105.59 95250 137.10 130.25 149.79 146.80 95251 42.18 40.07 46.08 45.16 95782 905.89 860.60 989.69 969.90 95782 TC 778.74 739.80 850.77 833.75 95782 26 127.15 120.79 138.91 136.13 95783 965.88 917.59 1,055.23 1,034.13 95783 TC 827.40 786.03 903.93 885.86 95783 26 138.48 131.56 151.29 148.27 95800 161.14 153.08 176.04 172.52 95800 TC 110.55 105.02 120.77 118.36 95800 26 50.59 48.06 55.27 54.17 95801 87.50 83.13 95.60 93.69 95801 TC 39.95 37.95 43.64 42.77 95801 26 47.55 45.17 51.95 50.91 95803 135.77 128.98 148.33 145.36 95803 TC 93.36 88.69 101.99 99.96 95803 26 42.41 40.29 46.33 45.40 95805 374.14 355.43 408.74 400.57 95805 TC 316.30 300.49 345.56 338.65 95805 26 57.84 54.95 63.19 61.93 95806 156.33 148.51 170.79 167.37 95806 TC 96.42 91.60 105.34 103.24 95806 26 59.91 56.91 65.45 64.14 95807 420.80 399.76 459.72 450.52 95807 TC 360.13 342.12 393.44 385.57

95807 26 60.67 57.64 66.29 64.96 95808 564.35 536.13 616.55 604.22 95808 TC 479.46 455.49 523.81 513.34 95808 26 84.89 80.65 92.75 90.90 95810 552.38 524.76 603.47 591.40 95810 TC 433.19 411.53 473.26 463.80 95810 26 119.19 113.23 130.21 127.62 95811 579.36 550.39 632.95 620.29 95811 TC 455.37 432.60 497.49 487.54 95811 26 123.99 117.79 135.46 132.74 95812 382.99 363.84 418.42 410.04 95812 TC 327.58 311.20 357.88 350.73 95812 26 55.42 52.65 60.55 59.34 95813 450.18 427.67 491.82 481.99 95813 TC 361.28 343.22 394.70 386.81 95813 26 88.90 84.46 97.13 95.19 95816 313.92 298.22 342.95 336.10 95816 TC 258.23 245.32 282.12 276.47 95816 26 55.69 52.91 60.85 59.63 95819 357.69 339.81 390.78 382.96 95819 TC 302.27 287.16 330.23 323.63 95819 26 55.42 52.65 60.55 59.34 95822 319.27 303.31 348.81 341.83 95822 TC 263.85 250.66 288.26 282.50 95822 26 55.42 52.65 60.55 59.34 95824 54.08 51.38 59.09 57.90 95824 TC 15.25 14.49 16.66 16.33 95824 26 38.83 36.89 42.42 41.57 95827 684.22 650.01 747.51 732.56 95827 TC 628.53 597.10 686.67 672.93 95827 26 55.69 52.91 60.85 59.63 95829 1,647.70 1,565.32 1,800.12 1,764.11 95829 TC 1,332.42 1,265.80 1,455.67 1,426.55 95829 26 315.29 299.53 344.46 337.57 95830 228.50 217.08 249.64 244.65# 95830 88.87 84.43 97.09 95.15 95831 25.23 23.97 27.57 27.01# 95831 13.67 12.99 14.94 14.64 95832 23.40 22.23 25.56 25.06# 95832 13.72 13.03 14.98 14.69 95833 34.92 33.17 38.15 37.39# 95833 21.17 20.11 23.13 22.67 95834 47.63 45.25 52.04 51.00# 95834 30.45 28.93 33.27 32.60 95851 16.32 15.50 17.83 17.47# 95851 7.57 7.19 8.27 8.11 95852 15.15 14.39 16.55 16.22# 95852 5.78 5.49 6.31 6.19 95857 50.71 48.17 55.40 54.29# 95857 28.53 27.10 31.17 30.54 95860 110.47 104.95 120.69 118.28 95860 TC 60.57 57.54 66.17 64.85

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 107

95860 26 49.90 47.41 54.52 53.43 95861 153.98 146.28 168.22 164.85 95861 TC 74.31 70.59 81.18 79.56 95861 26 79.67 75.69 87.04 85.31 95863 187.28 177.92 204.61 200.51 95863 TC 90.87 86.33 99.28 97.29 95863 26 96.42 91.60 105.34 103.24 95864 215.01 204.26 234.90 230.20 95864 TC 112.42 106.80 122.82 120.36 95864 26 102.59 97.46 112.08 109.84 95865 126.66 120.33 138.38 135.61 95865 TC 46.82 44.48 51.15 50.13 95865 26 79.84 75.85 87.23 85.48 95866 121.10 115.05 132.31 129.66 95866 TC 55.88 53.09 61.05 59.83 95866 26 65.22 61.96 71.25 69.83 95867 85.32 81.05 93.21 91.34 95867 TC 44.63 42.40 48.76 47.78 95867 26 40.69 38.66 44.46 43.57 95868 119.25 113.29 130.28 127.67 95868 TC 58.69 55.76 64.12 62.84 95868 26 60.56 57.53 66.16 64.84 95869 67.54 64.16 73.78 72.31 95869 TC 48.70 46.27 53.21 52.14 95869 26 18.84 17.90 20.59 20.17 95870 78.47 74.55 85.73 84.02 95870 TC 59.32 56.35 64.80 63.50 95870 26 19.15 18.19 20.92 20.50 95872 191.78 182.19 209.52 205.33 95872 TC 42.45 40.33 46.38 45.45 95872 26 149.33 141.86 163.14 159.87 95873 66.91 63.56 73.09 71.63 95873 TC 47.13 44.77 51.49 50.45 95873 26 19.78 18.79 21.61 21.17 95874 64.73 61.49 70.71 69.30 95874 TC 45.57 43.29 49.78 48.78 95874 26 19.15 18.19 20.92 20.50 95875 116.04 110.24 126.78 124.25 95875 TC 59.32 56.35 64.80 63.50 95875 26 56.72 53.88 61.96 60.72 95885 52.76 50.12 57.64 56.49 95885 TC 34.64 32.91 37.85 37.09 95885 26 18.13 17.22 19.80 19.41 95886 84.08 79.88 91.86 90.02 95886 TC 39.32 37.35 42.95 42.09 95886 26 44.76 42.52 48.90 47.92 95887 78.74 74.80 86.02 84.30 95887 TC 42.14 40.03 46.03 45.11 95887 26 36.61 34.78 40.00 39.19 95905 59.82 56.83 65.35 64.04 95905 TC 57.13 54.27 62.41 61.16 95905 26 2.69 2.56 2.94 2.89

95907 87.47 83.10 95.57 93.66 95907 TC 36.13 34.32 39.47 38.67 95907 26 51.34 48.77 56.09 54.96 95908 107.94 102.54 117.92 115.56 95908 TC 43.94 41.74 48.00 47.05 95908 26 64.01 60.81 69.93 68.53 95909 129.95 123.45 141.97 139.13 95909 TC 53.24 50.58 58.17 57.01 95909 26 76.71 72.87 83.80 82.12 95910 170.87 162.33 186.68 182.94 95910 TC 68.51 65.08 74.84 73.35 95910 26 102.36 97.24 111.83 109.60 95911 208.05 197.65 227.30 222.76 95911 TC 80.00 76.00 87.40 85.65 95911 26 128.05 121.65 139.90 137.10 95912 244.91 232.66 267.56 262.21 95912 TC 91.21 86.65 99.65 97.66 95912 26 153.70 146.02 167.92 164.57 95913 283.92 269.72 310.18 303.98 95913 TC 101.76 96.67 111.17 108.95 95913 26 182.16 173.05 199.01 195.03 95921 82.36 78.24 89.98 88.18 95921 TC 37.76 35.87 41.25 40.42 95921 26 44.60 42.37 48.73 47.75 95922 98.25 93.34 107.34 105.19 95922 TC 50.26 47.75 54.91 53.82 95922 26 47.99 45.59 52.43 51.38 95923 184.82 175.58 201.92 197.88 95923 TC 139.60 132.62 152.51 149.47 95923 26 45.22 42.96 49.40 48.42 95924 135.38 128.61 147.90 144.95 95924 TC 49.63 47.15 54.22 53.14 95924 26 85.75 81.46 93.68 91.80 95925 154.53 146.80 168.82 165.44 95925 TC 127.41 121.04 139.20 136.41 95925 26 27.12 25.76 29.62 29.03 95926 129.47 123.00 141.45 138.62 95926 TC 102.42 97.30 111.90 109.65 95926 26 27.05 25.70 29.56 28.97 95927 144.22 137.01 157.56 154.41 95927 TC 117.42 111.55 128.28 125.72 95927 26 26.81 25.47 29.29 28.70 95928 228.00 216.60 249.09 244.11 95928 TC 150.46 142.94 164.38 161.09 95928 26 77.54 73.66 84.71 83.02 95929 222.38 211.26 242.95 238.08 95929 TC 145.46 138.19 158.92 155.74 95929 26 76.92 73.07 84.03 82.35 95930 118.36 112.44 129.31 126.72 95930 TC 100.55 95.52 109.85 107.65 95930 26 17.81 16.92 19.46 19.07 95933 75.35 71.58 82.32 80.67

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 108

95933 TC 44.95 42.70 49.11 48.13 95933 26 30.40 28.88 33.21 32.55 95937 74.03 70.33 80.88 79.26 95937 TC 40.26 38.25 43.99 43.11 95937 26 33.77 32.08 36.89 36.16 95938 298.89 283.95 326.54 320.01 95938 TC 254.48 241.76 278.02 272.46 95938 26 44.41 42.19 48.52 47.55 95939 441.18 419.12 481.99 472.35 95939 TC 325.04 308.79 355.11 348.00 95939 26 116.14 110.33 126.88 124.34 95940 31.07 29.52 33.95 33.27 95943 135.38 128.61 147.90 144.95 95943 TC 49.63 47.15 54.22 53.14 95943 26 85.75 81.46 93.68 91.80 95950 298.96 284.01 326.61 320.08 95950 TC 221.06 210.01 241.51 236.68 95950 26 77.90 74.01 85.11 83.41 95951 1,594.92 1,515.17 1,742.45 1,707.60 95951 TC 1,280.43 1,216.41 1,398.87 1,370.89 95951 26 314.49 298.77 343.59 336.71 95953 392.12 372.51 428.39 419.82 95953 TC 233.86 222.17 255.50 250.39 95953 26 158.26 150.35 172.90 169.44 95954 394.93 375.18 431.46 422.83 95954 TC 275.69 261.91 301.20 295.17 95954 26 119.24 113.28 130.27 127.66 95955 204.69 194.46 223.63 219.16 95955 TC 152.72 145.08 166.84 163.51 95955 26 51.97 49.37 56.78 55.64 95956 1,471.17 1,397.61 1,607.25 1,575.11 95956 TC 1,285.83 1,221.54 1,404.77 1,376.68 95956 26 185.33 176.06 202.47 198.42 95957 394.79 375.05 431.31 422.68 95957 TC 292.66 278.03 319.73 313.34 95957 26 102.13 97.02 111.57 109.34 95958 513.68 488.00 561.20 549.98 95958 TC 296.62 281.79 324.06 317.57 95958 26 217.06 206.21 237.14 232.40 95961 263.65 250.47 288.04 282.28 95961 TC 111.80 106.21 122.14 119.70 95961 26 151.86 144.27 165.91 162.59 95962 235.08 223.33 256.83 251.69 95962 TC 71.19 67.63 77.77 76.22 95962 26 163.89 155.70 179.06 175.48 95965 26 412.78 392.14 450.96 441.95 95966 26 209.35 198.88 228.71 224.14 95967 26 183.70 174.52 200.70 196.68 95970 62.21 59.10 67.97 66.61# 95970 23.48 22.31 25.66 25.14 95971 56.43 53.61 61.65 60.42# 95971 39.57 37.59 43.23 42.37

95972 102.32 97.20 111.78 109.55# 95972 75.77 71.98 82.78 81.12 95973 59.54 56.56 65.04 63.74# 95973 47.36 44.99 51.74 50.70 95974 195.31 185.54 213.37 209.10# 95974 157.51 149.63 172.07 168.64 95975 104.87 99.63 114.57 112.29# 95975 88.94 84.49 97.16 95.22 95978 235.01 223.26 256.75 251.61# 95978 186.28 176.97 203.52 199.44 95979 102.34 97.22 111.80 109.57# 95979 86.41 82.09 94.40 92.52 95980 42.81 40.67 46.77 45.84 95981 29.38 27.91 32.10 31.45# 95981 16.89 16.05 18.46 18.09 95982 48.10 45.70 52.56 51.51# 95982 34.35 32.63 37.52 36.78 95990 80.80 76.76 88.27 86.50 95991 109.87 104.38 120.04 117.63# 95991 38.34 36.42 41.88 41.04 95992 41.69 39.61 45.55 44.64# 95992 37.00 35.15 40.42 39.62 96000 91.58 87.00 100.05 98.05 96001 96.62 91.79 105.56 103.44 96002 20.52 19.49 22.41 21.97 96003 19.08 18.13 20.85 20.44 96004 112.75 107.11 123.18 120.72 96020 26 165.55 157.27 180.86 177.24 96101 78.88 74.94 86.18 84.46# 96101 78.25 74.34 85.49 83.78 96102 59.98 56.98 65.53 64.22# 96102 22.80 21.66 24.91 24.41 96103 26.60 25.27 29.06 28.47# 96103 25.66 24.38 28.04 27.47 96105 96.60 91.77 105.54 103.42 96111 124.79 118.55 136.33 133.61# 96111 118.54 112.61 129.50 126.91 96116 90.96 86.41 99.37 97.38# 96116 85.65 81.37 93.58 91.70 96118 94.81 90.07 103.58 101.51# 96118 77.94 74.04 85.15 83.44 96119 73.40 69.73 80.19 78.59# 96119 23.10 21.95 25.24 24.74 96120 44.09 41.89 48.17 47.21# 96120 25.04 23.79 27.36 26.81 96125 107.51 102.13 117.45 115.10 96150 21.00 19.95 22.94 22.48# 96150 20.69 19.66 22.61 22.16 96151 20.28 19.27 22.16 21.71# 96151 19.97 18.97 21.82 21.38 96152 19.25 18.29 21.03 20.61# 96152 18.94 17.99 20.69 20.27

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 109

96153 4.48 4.26 4.90 4.80 96154 18.90 17.96 20.65 20.24# 96154 18.58 17.65 20.30 19.90 96360 50.34 47.82 54.99 53.89 96361 13.50 12.83 14.75 14.46 96365 60.83 57.79 66.46 65.12 96366 17.03 16.18 18.61 18.24 96367 27.08 25.73 29.59 29.00 96368 18.55 17.62 20.26 19.86 96369 170.79 162.25 186.59 182.86 96370 14.22 13.51 15.54 15.23 96371 79.31 75.34 86.64 84.90 96372 22.61 21.48 24.70 24.21 96373 17.61 16.73 19.24 18.86 96374 49.76 47.27 54.36 53.27 96375 19.79 18.80 21.62 21.18 96401 65.17 61.91 71.20 69.77 96402 28.64 27.21 31.29 30.67 96405 73.19 69.53 79.96 78.36# 96405 28.83 27.39 31.50 30.87 96406 102.55 97.42 112.03 109.79# 96406 44.14 41.93 48.22 47.25 96409 95.89 91.10 104.77 102.67 96411 54.23 51.52 59.25 58.06 96413 117.31 111.44 128.16 125.59 96415 25.20 23.94 27.53 26.98 96416 121.92 115.82 133.19 130.53 96417 54.90 52.16 59.98 58.79 96420 91.40 86.83 99.85 97.85 96422 146.69 139.36 160.26 157.06 96423 68.11 64.70 74.41 72.92 96425 157.87 149.98 172.48 169.03 96440 754.37 716.65 824.15 807.67# 96440 133.05 126.40 145.36 142.45 96446 170.13 161.62 185.86 182.15# 96446 20.82 19.78 22.75 22.29 96450 165.32 157.05 180.61 177.00# 96450 78.16 74.25 85.39 83.69 96521 118.55 112.62 129.51 126.93 96522 97.62 92.74 106.65 104.52 96523 21.70 20.62 23.71 23.24 96542 106.69 101.36 116.56 114.23# 96542 40.47 38.45 44.22 43.33 96549 0.01 0.01 0.01 0.01 96567 115.23 109.47 125.89 123.37 96570 55.05 52.30 60.15 58.94 96571 25.81 24.52 28.20 27.63 96900 17.77 16.88 19.41 19.02 96904 58.38 55.46 63.78 62.50 96910 60.57 57.54 66.17 64.85 96912 78.06 74.16 85.28 83.58 96913 109.92 104.42 120.08 117.68

96920 138.83 131.89 151.67 148.64# 96920 63.55 60.37 69.43 68.03 96921 153.26 145.60 167.44 164.09# 96921 71.73 68.14 78.36 76.80 96922 213.95 203.25 233.74 229.07# 96922 116.49 110.67 127.27 124.73 97001 71.55 67.97 78.17 76.60 97002 39.82 37.83 43.50 42.63 97003 79.67 75.69 87.04 85.31 97004 49.19 46.73 53.74 52.67 97012 15.17 14.41 16.57 16.24 97016 17.66 16.78 19.30 18.91 97018 9.92 9.42 10.83 10.61 97022 21.36 20.29 23.33 22.86 97024 5.86 5.57 6.41 6.28 97026 5.55 5.27 6.06 5.93 97028 6.89 6.55 7.53 7.38 97032 17.98 17.08 19.64 19.25 97033 29.58 28.10 32.32 31.67 97034 16.86 16.02 18.42 18.06 97035 12.17 11.56 13.29 13.03 97036 29.99 28.49 32.76 32.11 97110 30.14 28.63 32.92 32.27 97112 31.39 29.82 34.29 33.60 97113 39.78 37.79 43.46 42.58 97116 26.79 25.45 29.27 28.68 97124 24.69 23.46 26.98 26.44 97140 28.18 26.77 30.79 30.16 97150 16.60 15.77 18.14 17.77 97530 32.60 30.97 35.62 34.90 97532 25.41 24.14 27.76 27.21 97533 27.60 26.22 30.15 29.56 97535 32.64 31.01 35.66 34.95 97537 28.58 27.15 31.22 30.60 97542 28.89 27.45 31.57 30.94 97597 69.32 65.85 75.73 74.21# 97597 23.72 22.53 25.91 25.39 97598 23.17 22.01 25.31 24.81# 97598 11.30 10.74 12.35 12.11 97605 39.73 37.74 43.40 42.54# 97605 26.29 24.98 28.73 28.15 97606 42.38 40.26 46.30 45.37# 97606 28.95 27.50 31.63 30.99 97750 31.32 29.75 34.21 33.53 97755 34.60 32.87 37.80 37.04 97760 35.69 33.91 39.00 38.21 97761 31.32 29.75 34.21 33.53 97762 42.97 40.82 46.94 46.00 97802 33.56 31.88 36.66 35.93# 97802 31.38 29.81 34.28 33.59 97803 28.82 27.38 31.49 30.85# 97803 26.95 25.60 29.44 28.85

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 110

97804 15.17 14.41 16.57 16.24# 97804 14.54 13.81 15.88 15.56 98925 29.49 28.02 32.22 31.58# 98925 22.93 21.78 25.05 24.54 98926 42.82 40.68 46.78 45.85# 98926 34.70 32.97 37.92 37.16 98927 56.12 53.31 61.31 60.08# 98927 45.81 43.52 50.05 49.05 98928 69.37 65.90 75.79 74.27# 98928 58.44 55.52 63.85 62.57 98929 83.22 79.06 90.92 89.10# 98929 70.10 66.60 76.59 75.06 98940 26.22 24.91 28.65 28.07# 98940 21.32 20.25 23.29 22.83 98941 38.60 36.67 42.17 41.33# 98941 33.40 31.73 36.49 35.77 98942 50.13 47.62 54.76 53.67# 98942 44.92 42.67 49.07 48.09 99143 35.03 33.28 38.27 37.50# 99143 30.03 28.53 32.81 32.15 99144 35.03 33.28 38.27 37.50# 99144 30.03 28.53 32.81 32.15 99145 15.01 14.26 16.40 16.07 99148 51.84 49.25 56.64 55.51 99149 51.84 49.25 56.64 55.51 99150 15.01 14.26 16.40 16.07 99170 159.76 151.77 174.54 171.04# 99170 86.67 82.34 94.69 92.79 99175 14.65 13.92 16.01 15.69 99183 197.28 187.42 215.53 211.22# 99183 117.62 111.74 128.50 125.94 99195 86.04 81.74 94.00 92.13 99201 39.86 37.87 43.55 42.68# 99201 25.18 23.92 27.51 26.96 99202 68.99 65.54 75.37 73.86# 99202 48.06 45.66 52.51 51.46 99203 100.39 95.37 109.68 107.48# 99203 73.22 69.56 79.99 78.40 99204 155.31 147.54 169.67 166.28# 99204 125.32 119.05 136.91 134.17 99205 194.18 184.47 212.14 207.90# 99205 162.00 153.90 176.99 173.44 99211 18.28 17.37 19.98 19.57# 99211 8.91 8.46 9.73 9.53 99212 40.17 38.16 43.88 43.01# 99212 24.24 23.03 26.48 25.96 99213 67.93 64.53 74.21 72.73# 99213 49.18 46.72 53.73 52.66 99214 100.55 95.52 109.85 107.65# 99214 75.56 71.78 82.55 80.89 99215 135.11 128.35 147.60 144.65# 99215 106.37 101.05 116.21 113.88

99217 69.00 65.55 75.38 73.88 99218 95.26 90.50 104.08 101.99 99219 130.06 123.56 142.09 139.25 99220 177.95 169.05 194.41 190.52 99221 97.23 92.37 106.23 104.10 99222 132.12 125.51 144.34 141.45 99223 194.77 185.03 212.78 208.53 99224 38.26 36.35 41.80 40.96 99225 69.54 66.06 75.97 74.45 99226 100.31 95.29 109.58 107.39 99231 37.67 35.79 41.16 40.33 99232 69.19 65.73 75.59 74.08 99233 99.69 94.71 108.92 106.74 99234 129.39 122.92 141.36 138.53 99235 162.18 154.07 177.18 173.64 99236 209.45 198.98 228.83 224.25 99238 69.04 65.59 75.43 73.92 99239 102.04 96.94 111.48 109.25 99281 20.39 19.37 22.28 21.83 99282 40.02 38.02 43.72 42.85 99283 59.83 56.84 65.37 64.06 99284 114.08 108.38 124.64 122.14 99285 167.91 159.51 183.44 179.77 99291 259.07 246.12 283.04 277.38# 99291 215.33 204.56 235.24 230.54 99292 117.18 111.32 128.02 125.45# 99292 107.81 102.42 117.78 115.43 99304 88.59 84.16 96.78 94.85 99305 126.31 119.99 137.99 135.23 99306 160.39 152.37 175.23 171.72 99307 42.39 40.27 46.31 45.38 99308 65.36 62.09 71.40 69.98 99309 86.17 81.86 94.14 92.25 99310 128.40 121.98 140.28 137.47 99315 69.63 66.15 76.07 74.55 99316 100.20 95.19 109.47 107.28 99318 91.52 86.94 99.98 97.98 99324 53.12 50.46 58.03 56.87 99325 77.53 73.65 84.70 83.01 99326 133.67 126.99 146.04 143.12 99327 178.19 169.28 194.67 190.77 99328 206.93 196.58 226.07 221.55 99334 57.76 54.87 63.10 61.84 99335 90.63 86.10 99.02 97.04 99336 127.96 121.56 139.79 137.00 99337 184.64 175.41 201.72 197.69 99341 52.80 50.16 57.68 56.53 99342 76.56 72.73 83.64 81.97 99343 125.33 119.06 136.92 134.18 99344 174.38 165.66 190.51 186.70 99345 210.30 199.79 229.76 225.16 99347 53.07 50.42 57.98 56.82

CGS PART B Kentucky - 2014 FEE SCHEDULE

# These amounts apply when service is performed in a facility setting.C - The payment for the technical component is capped at the OPPS amount.Limiting charge applies to unassigned claims by non-participating providers.*** - Limiting charge reduced based on status of an unsuccessful E-Prescriber per the Electronic Prescribing (ERX) Incentive Program.© All Current Procedural Terminology (CPT) codes and descriptors are copyrighted 2013 by the American Medical Association.

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

PROC PAR NON-PAR LIMITING eRX LIMITING NOTE CODE MOD AMOUNT AMOUNT CHARGE CHARGE***

Updated 09.29.14 © 2014 Copyright, CGS Administrators, LLC. Page: 111

99348 80.52 76.49 87.96 86.20 99349 121.75 115.66 133.01 130.35 99350 169.87 161.38 185.59 181.87 99354 95.19 90.43 103.99 101.91# 99354 89.26 84.80 97.52 95.57 99355 93.32 88.65 101.95 99.91# 99355 87.39 83.02 95.47 93.56 99356 88.05 83.65 96.20 94.28 99357 87.42 83.05 95.51 93.60 99406 13.25 12.59 14.48 14.19# 99406 11.69 11.11 12.78 12.52 99407 26.24 24.93 28.67 28.09# 99407 24.68 23.45 26.97 26.43 99460 91.30 86.74 99.75 97.76 99461 91.40 86.83 99.85 97.85# 99461 62.35 59.23 68.11 66.76 99462 40.54 38.51 44.29 43.40 99463 109.65 104.17 119.80 117.40 99464 68.79 65.35 75.15 73.65 99465 142.02 134.92 155.16 152.05 99466 249.06 236.61 272.10 266.66 99467 118.32 112.40 129.26 126.67 99468 896.73 851.89 979.67 960.08 99469 381.66 362.58 416.97 408.63 99471 818.18 777.27 893.86 875.98 99472 387.07 367.72 422.88 414.43 99475 553.50 525.83 604.70 592.61 99476 334.39 317.67 365.32 358.02 99477 334.77 318.03 365.73 358.42 99478 132.59 125.96 144.85 141.96 99479 120.27 114.26 131.40 128.77 99480 115.75 109.96 126.45 123.92 99495 152.29 144.68 166.38 163.06# 99495 106.37 101.05 116.21 113.88 99496 215.42 204.65 235.35 230.64# 99496 153.89 146.20 168.13 164.77

2014 MEDICARE PARTICIPATION ENROLLMENT

2014 Enrollment Package(Includes Fee Schedule)

Dated Material

Enrollment Period Ends December 31, 2013

Open Immediately.Package contains 2014 Medicare Payment Information

from the Centers for Medicare & Medicaid Services.