APPENDIX B NEW JERSEY ADMINISTRATIVE CODE - Gann … · APPENDIX B NEW JERSEY ADMINISTRATIVE CODE Current Through N.J. Register Volume 48, Number 17 (48 N.J.R. 1842) Includes …

APPENDIX BNEW JERSEY ADMINISTRATIVE CODE

Current Through N.J. Register Volume 48, Number 17 (48 N.J.R. 1842)Includes Adopted Rules Filed Through August 12, 2016

SUBCHAPTER 3. BASIC AUTOMOBILE INSURANCE POLICYSource and Effective Date. R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999).Section11:3-3.1. Purpose and scope.11:3-3.2. Definitions.11:3-3.3. General provisions.11:3-3.4. Coverages; mandatory and optional.11:3-3.5. Election of basic automobile insurance policy coverage and

reporting.11:3-3.6. Filing requirements.

11:3-3.1. Purpose and scope. (a) This subchapter provides rules to be utilizedby insurers in developing the policy forms and rates for basic automobile insur-ance policies to be filed with and approved by the Department in accordance withthe provisions of N.J.S.A. 39:6A-3.1.

(b) This subchapter shall apply to all insurers writing private passenger auto-mobile insurance on personal lines policy forms, including the New Jersey Per-sonal Automobile Insurance Plan established by N.J.A.C. 11:3-2.

11:3-3.2. Definitions. The following words and terms, when used in this sub-chapter, shall have the following meanings unless the context clearly indicatesotherwise:

“Basic automobile insurance policy” or “basic policy” means that automobileinsurance policy offered pursuant to N.J.S.A. 39:6A-3.1 and this subchapter.

“Basic policy servicing carrier” means a limited assignment distribution carrierthat is a participating insurer that agrees to accept assignments of basic policiespursuant to this subchapter and the procedures set forth in the PAIP plan of oper-ation.

“Commissioner” means the Commissioner of the Department of Banking andInsurance.

“Department” means the Department of Banking and Insurance. “Insurer” means any person or persons, corporation, association, partnership,

company, reciprocal exchange, or other legal entity authorized or admitted totransact private passenger automobile insurance in this State, or any one memberof a group of affiliated companies that transacts business in accordance with acommon rating system.

“Medically necessary” is as defined in N.J.A.C. 11:3-4.2.“PAIP” means the New Jersey Personal Automobile Insurance Plan established

pursuant to N.J.S.A. 17:29D-1 and N.J.A.C. 11:3-2.“Personal injury protection” or “PIP” means the benefits and coverages set

forth at N.J.S.A. 39:6A-4 and 39:6A-3.1 and N.J.A.C. 11:3-4.“Significant disfigurement” means the result and/or manifestation of a serious

traumatic injury that is observable as a permanent and substantial defect in the ap-pearance and functional ability of the person injured. “Significant disfigurement”is a serious outward change that substantially detracts from the appearance andfunctional ability of the person injured.

11:3-3.3 APPENDIX B - REGULATIONS

“Standard automobile insurance policy” or “standard policy” means that policyform filed by private passenger automobile insurers and approved by the Commis-sioner that contains the coverages and options pursuant to N.J.S.A. 39:6A-4.

Amended. R.2000 d.454, effective November 6, 2000; R.2007 d.151, effective May 7, 2007.

11:3-3.3. General provisions. (a) All insurers writing private passenger auto-mobile insurance and the Personal Automobile Insurance Plan shall file for ap-proval with the Department their rates, rules and policy forms for a basic automo-bile insurance policy to be issued in accordance with N.J.S.A. 39:6A-3.1 and thissubchapter.

(b) An insurer shall make available the basic policy at either a single tier rateor at multiple tier rates, consistent with its tier rating system filed and approvedpursuant to N.J.A.C. 11:3-19A. If more than one basic policy rate is offered, eachshall be identified as part of a standard, non-standard or preferred tier.

(c) If a named insured has elected basic automobile insurance coverage andother immediate family members or resident relatives of the named insured havehigher policy limits under a standard policy, the provisions of N.J.S.A. 39:6A-4.2shall apply and the named insured shall only be entitled to the coverages providedunder his or her basic policy.

(d) Basic policies shall provide the tort option provided under N.J.S.A. 39:6A-8a.(e) Initial rates by coverage for basic policies filed in accordance with this sub-

chapter shall demonstrate consistency with the rates in the insurer's standard pol-icy, adjusted for reduced coverage limits.

(f) Insurers shall file for approval an initial basic policy rating system by Janu-ary 20, 1999.

(g) An insurer may write basic policies through a basic policy servicing carrier.Amended. R.2007 d.151, effective May 7, 2007.

11:3-3.4. Coverages; mandatory and optional. (a) The following coveragesshall be included in all basic policies:

1. Personal injury protection medical expense benefits coverage in an amountnot to exceed $15,000 per person, per accident; except that all medically necessarytreatment of permanent or significant brain injury, spinal cord injury or disfigure-ment or medically necessary treatment of other permanent or significant injuriesrendered at a trauma center or acute care hospital immediately following the acci-dent and until the patient is stable, no longer requiring critical care and can be safe-ly discharged or transferred to another facility in the judgment of the attendingphysician shall be covered in an amount not to exceed $250,000, including the$15,000 above. The medical expense benefits provided herein shall be in accor-dance with N.J.A.C. 11:3-4; and

2. Liability insurance coverage insuring against loss resulting from liability im-posed by law for property damage sustained by any person arising out of the own-ership, maintenance, operation or use of an automobile in an amount or limit of$5,000, exclusive of interest and costs, for damage to property in any one accident.

(b) Insurers shall also make available in the basic policy, at the option of theinsured, liability insurance coverage for bodily injury or death in an amount orlimit of $10,000, exclusive of interest and costs, on account of the injury or deathof one or more persons in any one accident.

(c) Insurers may make available with the basic policy, at the option of the in-sured, comprehensive and collision coverage with deductibles filed and approvedpursuant to N.J.A.C. 11:3-13.

(d) Basic policies shall not contain any other coverages, options, limits or de-ductibles other than those which are set forth in (a) through (c) above. Increasedpolicy limits, the health insurance primary option for automobile medical expense

PIP BENEFITS; PROTOCOLS; TESTS 11:3-3.4

coverage and uninsured/under-insured motorist coverages shall not be provided inbasic policies.

11:3-3.5. Election of basic automobile insurance policy coverage and re-porting. No insurer shall issue a basic automobile insurance policy unless thenamed insured has signed a written document entitled “basic automobile insur-ance policy coverage selection form” set forth in N.J.A.C. 11:3-15.7.

Amended. R.2003 d.95, effective March 3, 2003; R.2006 d.243, effective July 3, 2006.

11:3-3.6. Filing requirements. (a) Insurers initially filing basic policy ratingsystems shall include the following:

1. A complete set of policy forms and endorsements that provide the mandatoryand optional coverages as set forth in this subchapter;

2. Rates and rules as necessary;3. An actuarial memorandum that supports the rate differentials from the insur-

er's standard policy rates;4. The declaration page;5. The rating information form; and6. The personal lines filing forms as set forth in N.J.A.C. 11:3-16.3(f) and (g).(b) Subsequent amendments to the rating systems shall be filed pursuant to

N.J.A.C. 11:3-16 and other applicable statutes and rules.

SUBCHAPTER 4. PERSONAL INJURY PROTECTION BENEFITS; MEDICAL PROTOCOLS; DIAGNOSTIC TESTS

Source and Effective Date: R.1998 d.597, effective December 21, 1998 (operative March 22, 1999).Section11:3-4.1. Scope and purpose.11:3-4.2. Definitions.11:3-4.3. Personal injury protection benefits applicable to basic and standard

policies.11:3-4.4. Deductibles and co-pays. 11:3-4.5. Diagnostic tests.11:3-4.6. Medical protocols.11:3-4.7. Decision point review plans.11:3-4.7A PIP vendor registration requirements11:3-4.7B Requirements for insurer internal appeals procedures11:3-4.8. Voluntary networks.11:3-4.9. Assignment of benefits; public information.11:3-4.10. ReservedAPPENDIX

Exhibit 1. Glossary of TermsExhibit 2. Care Path OverviewExhibit 3. Care Path 1Exhibit 4. Care Path 2Exhibit 5. Care Path 3Exhibit 6. Care Path 4Exhibit 7. Care Path 5Exhibit 8. Care Path 6Exhibit 9. Care Path Diagnosis Coding Exhibit 10. Addendum to Care PathsExhibit 11. Monthly Decision Point Review/Precertification Implementation Report - Not Included


11:3-4.1. Scope and purpose. (a) This subchapter implements the provisionsof N.J.S.A. 39:6A-3.1, 39:6A-4 and 39:6A-4.3 by identifying the personal injuryprotection medical expense benefits and emergency personal injury protectioncoverage for which reimbursement of eligible charges will be made by automobileinsurers under basic, standard and special automobile insurance policies and bymotor bus insurers under medical expense benefits coverage.

(b) This subchapter applies to all insurers that issue policies of automobile in-surance containing PIP coverage, emergency personal injury protection coverageand policies of motor bus insurance containing medical expense benefits coverage.

(c) This subchapter shall apply to those policies that are issued or renewed onor after March 22, 1999.Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004).

11:3-4.2. Definitions. The following words, phrases, and terms, when used inthis subchapter, shall have the following meanings unless the context clearly indi-cates otherwise.

“Ambulatory surgery facility” or “ambulatory surgical center” (ASC) means:1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey

in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are per-formed and which is separate and apart from any other facility license. (The am-bulatory surgery facility may be physically connected to another licensed facility,such as a hospital, but is corporately, financially and administratively distinct, forexample, it uses a separate tax-id number); or

2. A physician-owned single operating room in an office setting that is certifiedby Medicare.

“Basic automobile insurance policy” or “basic policy” means those private pas-senger automobile insurance policies issued in accordance with N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3.

“Clinically supported” means that a health care provider prior to selecting, per-forming or ordering the administration of a treatment or diagnostic test has:

1. Personally examined the patient to ensure that the proper medical indicationsexist to justify ordering the treatment or test;

2. Physically examined the patient including making an assessment of any cur-rent and/or historical subjective complaints, observations, objective findings, neu-rologic indications, and physical tests;

3. Considered any and all previously performed tests that relate to the injuryand the results and which are relevant to the proposed treatment or test; and

4. Recorded and documented these observations, positive and negative find-ings and conclusions on the patient's medical records.

“Days” means calendar days unless specifically designated as business days.1. A calendar and business day both end at the time of the close of business

hours. Insurers shall set a close of business time in their Decision Point Reviewplans;

2. In computing any period of time designated as either calendar or businessdays, the day from which the designated period of time begins to run shall not beincluded. The last day of a period of time designated as calendar days is to be in-cluded unless it is a Saturday, Sunday, or legal holiday, in which event the periodruns until the end of the next day which is neither a Saturday, Sunday, or legal hol-iday.“Decision point” means those junctures in the treatment of identified injuriesindicated by hexagonal boxes on the Care Paths where a decision must be madeabout the continuation or choice of further treatment. The determination whetherto administer one of the tests listed in N.J.A.C. 11:3-4.5(b) is also a decision pointfor both identified and all other injuries.


“Decision point review” means the procedures in an insurer's approved deci-sion point review plan for the insurer to receive notice and respond to requests forproposed treatment or testing at decision points.

“Diagnostic test” means a medical service or procedure utilizing biomechani-cal, neurological, neurodiagnostic, radiological, vascular or any means, other thanbioanalysis, intended to assist in establishing a medical, dental, physical therapy,chiropractic or psychological diagnosis, for the purpose of recommending or de-veloping a course of treatment for the tested patient to be implemented by thetreating practitioner or by the consultant.

“Eligible charge” means the treating health care provider's usual, customaryand reasonable charge or the upper limit of the medical fee schedule as found inN.J.A.C. 11:3-29.6, whichever is lower.

“Emergency care” means all medically necessary treatment of a traumatic in-jury or a medical condition manifesting itself by acute symptoms of sufficient se-verity such that absence of immediate attention could reasonably be expected toresult in: death; serious impairment to bodily functions; or serious dysfunction ofa bodily organ or part. Such emergency care shall include all medically necessarycare immediately following an automobile accident, including, but not limited to,immediate pre-hospitalization care, transportation to a hospital or trauma center,emergency room care, surgery, critical and acute care. Emergency care extendsduring the period of initial hospitalization until the patient is discharged fromacute care by the attending physician. Emergency care shall be presumed whenmedical care is initiated at a hospital within 120 hours of the accident.

“Emergency personal injury protection coverage” means the coverage providedby a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003, c.89.

“Health care provider” or “provider” means those persons licensed or certifiedto perform health care treatment or services compensable as medical expenses andshall include, but not be limited to:

1. A hospital or health care facility that is maintained by State or any politicalsubdivision;

2. A hospital or health care facility licensed by the Department of Health andSenior Services;

3. Other hospitals or health care facilities designated by the Department ofHealth and Senior Services to provide health care services, or other facilities, in-cluding facilities for radiological and diagnostic testing, free-standing emergencyclinics or offices, and private treatment centers;

4. A nonprofit voluntary visiting nurse organization providing health care ser-vices other than a hospital;

5. Hospitals or other health care facilities or treatment centers located in otherStates or nations;

6. Physicians licensed to practice medicine and surgery;7. Licensed chiropractors;8. Licensed dentists;9. Licensed optometrists;10. Licensed pharmacists;11. Licensed chiropodists (podiatrists);12. Registered bioanalytical laboratories;13. Licensed psychologists;14. Licensed physical therapists;15. Certified nurse mid-wives;16. Certified nurse practitioners/clinical nurse-specialist;17. Licensed health maintenance organizations;18. Licensed orthotists and prosthetists;19. Licensed professional nurses;


20. Licensed occupational therapists;21. Licensed speech-language pathologists;22. Licensed audiologists;23. Licensed physicians assistants;24. Licensed physical therapy assistants;25. Licensed occupational therapy assistants; and26. Providers of other health care services or supplies, including durable med-

ical goods.“Identified injury” means those injuries identified by the Department in the

subchapter Appendix as being suitable for medical treatment protocols in accor-dance with N.J.S.A. 39:6A-3.1a and 39:6A-4a.

“Insurer” means any person or persons, corporation, association, partnership,company, reciprocal exchange or other legal entity authorized or admitted to trans-act private passenger automobile insurance in this State, or any one member of agroup of affiliated companies that transacts business in accordance with a com-mon rating system. Insurer does not include an entity that is self-insured pursuantto N.J.S.A. 39:6-52. For purposes of communicating with insureds and providersconcerning the administration of decision point review plans, “insurer” alsomeans the insurer’s PIP vendor.

“Medical expense” means the reasonable and necessary expenses for treatmentor services rendered by a provider, including medical, surgical, rehabilitative anddiagnostic services and hospital expenses and reasonable and necessary expensesfor ambulance services or other transportation, medication and other services,subject to limitations as provided for in the policy forms that are filed and ap-proved by the Commissioner.

“Medically necessary” or “medical necessity” means that the medical treat-ment or diagnostic test is consistent with the clinically supported symptoms, diag-nosis or indications of the injured person, and:

1. The treatment is the most appropriate level of service that is in accordancewith the standards of good practice and standard professional treatment protocolsincluding the Care Paths in the Appendix, as applicable;

2. The treatment of the injury is not primarily for the convenience of the injuredperson or provider; and

3. Does not include unnecessary testing or treatment.“Non-medical expense” means charges for those:1. Products and devices, not exclusively used for medical purposes or as dura-

ble medical equipment, such as any vehicles, durable goods, equipment, appurte-nances, improvements to real or personal property, fixtures; and

2. Services and activities such as recreational activities, trips and leisure activ-ities.

“Network” means an entity other than an insurer that contracts with providersto render health care services or provide supplies at predetermined fees or reim-bursement levels.

“Organized delivery system” (ODS) means an organized delivery system cer-tified or licensed pursuant to N.J.S.A. 17:48H-1 et seq., N.J.A.C. 11:22-4 orN.J.A.C. 11:24B.

"PIP vendor" means a company used by an insurer for utilization management.“Precertification” or “precertification request” means the procedures in an in-

surer’s approved decision point review plan for the insurer to receive notice andrespond to requests for listed specific medical procedures, treatments, diagnostictests, other services and durable medical equipment that are not subject to decisionpoint review and that may be subject to overutilization.

“Standard automobile insurance policy” or “standard policy” means a privatepassenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A-4.


"Standard professional treatment protocols" means evidence-based clinicalguidelines/practice/treatment published in peer-reviewed journals.

"Utilization management" means a system for administering some or all of aninsurer's decision point review plan, including, but not limited to, receiving andresponding to decision point review and precertification requests, making deter-minations of medical necessity, scheduling and performing independent medicalexaminations (IMEs), bill review and handling of provider appeals.

Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (op-erative October 27, 2004); R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013);R.2016 d.140, effective October 17, 2016 (operative April 17, 2017).

11:3-4.3. Personal injury protection benefits applicable to basic and stan-dard policies. (a) Personal injury protection coverage shall provide reimburse-ment for all medically necessary expenses for the diagnosis and treatment of inju-ries sustained from a covered automobile accident up to the limits set forth in thepolicy and in accordance with this subchapter.

(b) Personal injury protection coverage shall only provide reimbursement forclinically supported necessary non-medical expenses that are prescribed by atreating medical provider for a permanent or significant brain, spinal cord or dis-figuring injuries.

11:3-4.4. Deductibles and co-pays. (a) Each insurer shall offer a standard$250.00 deductible and 20 percent copayment on medical expense benefits pay-able between $250.00 and $5,000.

(b) Each insurer shall also offer, at appropriately reduced premiums, the optionto select medical expense benefit deductibles of $500.00, $1,000, $2,000 and$2,500 in accordance with the following provisions:

1. Any medical expense deductible elected by the named insured shall applyonly to the named insured and any resident relative in the named insured's house-hold, who is not a named insured under another automobile policy and not to anyother person eligible for personal injury protection benefits required to be provid-ed in accordance with N.J.S.A. 39:6A-3.1 and 39:6A-4;

2. Premium credits calculated and represented as a percentage of the applicablepremium shall be provided for each deductible. The premium percentage shall beuniform by filer on a statewide basis; and

3. The deductible option elected by the named insured shall continue in forceas to subsequent renewal or replacement policies until the insurer or its authorizedrepresentative receives a properly executed coverage selection form to eliminateor change the deductible.

(c) All deductibles and co-pays in (a) and (b) above shall apply on a per acci-dent basis.

(d) An insurer may file policy language that waives the co-payment and de-ductible in (a) and (b) above when the insured receives medical treatment from aprovider that is part of an ODS that has contracted with the insurer or its PIP ven-dor. The insured shall not be required to elect to use the providers or facilities insuch an ODS either at issuance of the policy or when the claim is made.

1. Upon receipt of notification of a claim, the insurer or its PIP vendor shallmake available to the insured information about physicians and facilities in anyODS with which it has a contract.

i. The information shall include a notice that the insured is not required to usethe providers or facilities of an ODS with which the insurer or its PIP vendor hascontracted and indicate that if the insured chooses to receive covered servicesfrom such providers or facilities, the deductible and copayments in (a) and (b)above would not apply.


ii. The information shall also indicate that the insured may seek treatment fromproviders and facilities that are not part of an ODS with which the insurer or itsPIP vendor has contracted, in which case the deductible and copayments in (a) and(b) above would apply.

2. The actual ODS access fee or 25 percent of the reduction in charges resultingfrom the use of the ODS provider, whichever is less, may be included within thepolicy limits for any single bill from an in-network provider in the ODS withbilled charges of $ 10,000 or more.

Example: A $10,000 charge is reduced by the ODS contract with the insurer by45 percent to $5,500. The insurer could include the ODS access fee or $1,125 (25percent of the $4,500 reduction), whichever is less, within the policy limits.

(e) Failure to request decision point review or precertification where requiredor failure to provide clinically supported findings that support the treatment, diag-nostic test or durable medical equipment requested shall result in an additional co-payment not to exceed 50 percent of the eligible charge for medically necessarydiagnostic tests, treatments or durable medical goods that were provided betweenthe time notification to the insurer was required and the time that proper notifica-tion is made and the insurer has an opportunity to respond in accordance with itsapproved decision point review plan.

Example: Assume that all days are business days and the insurer’s DecisionPoint Review Plan gives the insurer three days to respond to decision pint reviewand precertification requests. By the terms of the insurer’s Decision Point ReviewPlan, a treating medical provider is required to make a decision point review re-quest on day 21 of treatment (time notification was required). The provider doesnot give the required notification in a timely manner but continues to treat the pa-tient. The provider then makes the notification and it is received by the insurer onday 35 (time proper notification made). The insurer responds on day 38 that thetreatment can proceed (time for insurer to respond). Assuming that the treatmentmade between day 21 and 38 was medically necessary, it is subject to the 50 per-cent co-payment.

1. No insurer may impose the additional co-payment where the insurer receivedthe required notice but failed to act in accordance with its approved decision pointreview plan to request further information, modify or deny reimbursement of fur-ther treatment, diagnostic tests or durable medical equipment.

(f) An insurer may require that the insured advise and inform the insurer aboutthe injury and the claim. This requirement may include the production of informa-tion from the insured regarding the facts of the accident, the nature and cause ofthe injury, the diagnosis and the anticipated course of treatment.

1. This information may be required to be provided as promptly as possible af-ter the accident, and periodically thereafter.

2. An insurer may impose an additional co-payment as a penalty for failure tosupply the required information. Such penalties shall result in a reduction in theamount of reimbursement of the eligible charge for medically necessary expensesthat are incurred after notification to the insurer is required and until notificationis received. The additional co-payment shall be an amount no greater than:

i. Twenty-five percent when received 30 or more days after the accident; or ii. Fifty percent when received 60 or more days after the accident. 3. Any reduction in the amount of reimbursement for PIP claims shall be in ad-

dition to any other deductible or co-payment requirement. 4. Information about this requirement and how to comply with it shall be in-

cluded in the informational materials required by N.J.A.C. 11:3-4.7(d).(g) An insurer may impose an additional co-payment not to exceed 30 percent

of the eligible charge for failure to use an approved network pursuant to N.J.A.C.


11:3-4.8 for the medically necessary non-emergency benefits listed in N.J.A.C.11:3-4.8(b).

(h) For the purpose of the co-payments permitted in (e), (f) and (g) above, thepercentage reduction shall be applied to the amount that the insurer would other-wise have paid to the insured or the provider after the application of the provisionsof N.J.A.C. 11:3-29. Insurers may apply the co-payments and deductibles in (a)through (g) above in any order, provided that they use the same order of applica-tion for all insureds. Upon receipt of a request for PIP benefits under the policy,the insurer or its PIP vendor shall make its co-payment and deductible applicationmethodology available to the insured and the treating medical provider upon re-quest.

(i) For private passenger automobiles insured under a commercial automobileinsurance policy where no natural person is a named insured, insurers shall onlyprovide personal injury protection with medical expense benefits coverage in anamount not to exceed $250,000 per person, per accident, with the deductible andcopayment amount set forth in (a) above.

Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (op-erative October 27, 2004, section (g) operative March 4, 2005); R.2010 d.142, effective July 6, 2010.Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5,2012 (operative January 4, 2013).

11:3-4.5. Diagnostic tests. (a) The personal injury protection medical expensebenefits coverage shall not provide reimbursement for the following diagnostictests, which have been determined to yield no data of any significant value in thedevelopment, evaluation and implementation of an appropriate plan of treatmentfor injuries sustained in motor vehicle accidents:

1. (Reserved) 2. Spinal diagnostic ultrasound; 3. Iridology; 4. Reflexology; 5. Surrogate arm mentoring; 6. Surface electromyography (surface EMG); 7. (Reserved); and 8. Mandibular tracking and stimulation. (b) The personal injury protection medical expense benefits coverage shall

provide for reimbursement of the following diagnostic tests, which have been de-termined to have value in the evaluation of injuries, the diagnosis and develop-ment of a treatment plan for persons injured in a covered accident, when medicallynecessary and consistent with clinically supported findings:

1. Needle electromyography (needle EMG) when used in the evaluation anddiagnosis of neuropathies and radicular syndrome where clinically supported find-ings reveal a loss of sensation, numbness or tingling. A needle EMG is not indi-cated in the evaluation of TMJ/D and is contraindicated in the presence of infec-tion on the skin or cellulitis. This test should not normally be performed within 14days of the traumatic event and should not be repeated where initial results arenegative. Only one follow up exam is appropriate.

2. Somasensory evoked potential (SSEP), visual evoked potential (VEP),brain audio evoked potential (BAEP), or brain evoked potential (BEP), nerve con-duction velocity (NCV) and H-reflex Study are reimbursable when used to evalu-ate neuropathies and/or signs of atrophy, but not within 21 days following the trau-matic injury.

3. Electroencephalogram (EEG) when used to evaluate head injuries, wherethere are clinically supported findings of an altered level of sensorium and/or asuspicion of seizure disorder. This test, if indicated by clinically supported find-


ings, can be administered immediately following the insured event. When medi-cally necessary, repeat testing is not normally conducted more than four times peryear.

4. Videofluroscopy only when used in the evaluation of hypomobility syn-drome and wrist/carpal hypomobility, where there are clinically supported find-ings of no range or aberrant range of motion or dysmmetry of facets exist. Thistest should not be performed within three months following the insured event andfollow up tests are not normally appropriate.

5. Magnetic resonance imaging (MRI) when used in accordance with theguidelines contained in the American College of Radiology, Appropriateness Cri-teria to evaluate injuries in numerous parts of the body, particularly the assessmentof nerve root compression and/or motor loss. MRI is not normally performedwithin five days of the insured event. However, clinically supported indication ofneurological gross motor deficits, incontinence or acute nerve root compressionwith neurologic symptoms may justify MRI testing during the acute phase imme-diately post injury. In the case of TMJ/D where there are clinical signs of internalderangement such as nonself-induced clicking, deviation, limited opening, andpain with a history of trauma to the lower jaw, an MRI is allowable to show dis-placement of the condylar disc, such procedure following a panographic or tran-scranial x-ray and six or eight weeks of conservative treatment. This TMJ/D diag-nostic test may be repeated post surgery and/or post appliance therapy.

6. Computer assisted tomographic studies (CT, CAT Scan) when used to eval-uate injuries in numerous aspects of the body. With the exception of suspectedbrain injuries, CAT Scan is not normally administered immediately post injury,but may become appropriate within five days of the insured event. Repeat CATScans should not be undertaken unless there is clinically supported indication ofan adverse change in the patient's condition. In the case of TMJ/D where there areclinical signs of degenerative joint disease as a result of traumatic injury of thetemporomandibular joint, tomograms may not be performed sooner than 12months following traumatic injury.

7. Dynatron/cyber station/cybex when used to evaluate muscle deteriorationor atrophy. These tests should not be performed within 21 days of the insuredevent and should not be repeated if results are negative. Repeat tests are not ap-propriate at less than six months intervals.

8. Sonograms/ultrasound when used in the acute phase to evaluate the abdo-men and pelvis for intra-abdominal bleeding. These tests are not normally used toassess joints (knee and elbow) because other tests are more appropriate. WhereMRI is performed, sonograms/ultrasound are not necessary. However, echocar-diogram is appropriate in the evaluation of possible cardiac injuries when clinical-ly supported.

9. Thermography/thermograms only when used to evaluate pain associatedwith reflex sympathetic dystrophy (“RSD”), in a controlled setting by a physicianexperienced in such use and properly trained.

10. Brain mapping, when done in conjunction with appropriate neurodiagnos-tic testing.

(c) The terms “normal,” “normally,” “appropriate” and “indicated” as used in(b) above, are intended to recognize that no single rule can replace the good faitheducated judgment of a health care provider. Thus, “normal,” “normally,” “appro-priate” and “indicated” pertain to the usual, routine, customary or common expe-rience and conclusion, which may in unusual circumstances differ from the actualjudgment of course of treatment. The unusual circumstances shall be based onclinically supported findings of a health care provider. The use of these terms is


intended to indicate some flexibility and avoid rigidity in the application of theserules in the decision point review required in (d) below.

(d) Except as provided in (e) below, a determination to administer any of thetests in (b) above shall be subject to decision point review pursuant to N.J.A.C.11:3-4.7.

(e) The requirements of (b) and (d) above shall not apply to diagnostic testsadministered during emergency care.

(f) Pursuant to N.J.A.C. 13:30-8.22(b), the personal injury protection medicalexpense coverage shall not provide reimbursement for the following diagnostictests which have been identified by the New Jersey State Board of Dentistry asfailing to yield data of sufficient volume to alter or influence the diagnosis or treat-ment plan employed to treat TMJ/D:

1. Mandibular tracking; 2. Surface EMG; 3. Sonography; 4. Doppler ultrasound; 5. Needle EMG; 6. Electroencephalogram (EEG); 7. Thermograms/thermographs; 8. Video fluoroscopy; and 9. Reflexology.Amended. R.2000 d.454, effective November 6, 2000.

11:3-4.6. Medical protocols. (a) Pursuant to N.J.S.A. 39:6A-3.1 and 39:6A-4,the Commissioner designates the care paths, set forth in the subchapter Appendixincorporated herein by reference, as the standard course of medically necessarytreatment, including diagnostic tests, for the identified injuries.

(b) Where the care path indicates a decision point either by a hexagon in thecare path itself or by reference in the text to a second opinion, referral for a secondindependent consultative medical opinion, development of a treatment plan ormandatory case management, the policy shall provide for a decision point reviewin accordance with N.J.A.C. 11:3-4.7.

(c) Treatments that vary from the care paths shall be reimbursable only whenwarranted by reason of medical necessity.

(d) The care paths do not apply to treatment administered during emergencycare.

11:3-4.7. Decision point review plans. (a) No insurer shall impose the co-pay-ments permitted in N.J.A.C. 11:3-4.4(e), (f) and (g) unless it has an approved de-cision point review plan.

1. Initial decision point review plan filings and amendments to approved plansshall be submitted to the Department through the use of the NAIC electronic filingsystem SERFF (System for Electronic Rate and Form Filing).

(b) No decision point or precertification requirements shall apply within 10days of the insured event or to emergency care. This provision should not be con-strued so as to require reimbursement of tests and treatment that are not medicallynecessary.

(c) A decision point review plan filing shall include the following information:1. Identification of any PIP vendor with which the insurer has contracted and a

copy of the contract between the insurer and the PIP vendor. No insurer shall con-tract with a PIP vendor unless the vendor is registered with the Department pursu-ant to N.J.A.C. 11:3-4.7A;

2. Identification of any specific medical procedures, treatments, diagnoses, di-agnostic tests, other services or durable medical equipment that are subject to pre-certification. The inclusion of precertification requirements in a decision point re-


view plan is optional. The medical procedures, treatments, diagnoses, diagnostictests or durable medical equipment required to be precertified shall be those thatthe insurer has determined may be subject to overutiliztion and that are not alreadysubject to decision point review. The insurer shall not require the precertificationof a new-patient evaluation and management visit that is necessary for the provid-er to develop the plan of care that is incorporated into a precertification request fortreatment or diagnostic testing;

3. Copies of the informational materials described in (d) below and an expla-nation of how the insurer will distribute information to policyholders, injured per-sons and providers at policy issuance, renewal and upon notification of claim.

4. Procedures for the prompt review, not to exceed three business days, of de-cision point review and precertification requests by insureds or providers. All de-terminations on treatments or tests shall be based on medical necessity and shallnot encourage over or underutilization of benefits. Denials of decision point re-view and precertification requests on the basis of medical necessity shall be thedetermination of a physician. In the case of treatment prescribed by a dentist, thedenial shall be by a dentist;

5. Procedures for the scheduling of physical examinations pursuant to (e) be-low;

6. An internal appeals procedure that permits the provider to provide additionalinformation and have a rapid review of a decision to modify or deny reimburse-ment for a treatment or the administration of a test;

7. Reasonable restrictions on the assignment of benefits pursuant to N.J.A.C.11:3-4.9(a);

8. An explanation of the alternatives available to the provider if reimbursementfor a proposed treatment, diagnostic test or durable medical equipment is deniedor modified, including insurer's internal appeal process and how to use it; and

9. The information required in order to use a network pursuant to N.J.A.C.11:3-4.8(d), if applicable.

(d) The informational materials for policyholders, injured persons and provid-ers shall be on forms approved by the Commissioner and shall include at a mini-mum the information in (d)1 through 9 below. In order to make the requirementsof this subchapter easier for insureds and providers to use, the Commissioner maybe Order require the use of uniform forms, layouts and language of informationmaterials.

1. How to contact the insurer or vendor to submit decision point review/precer-tification requests including the telephone, facsimile numbers, e-mail addresses orthrough a website. The insurer or its vendor shall be available, at a minimum, dur-ing normal working hours to respond to decision point review/precertification re-quests;

2. An explanation of the decision point review process including a list of theidentified injuries and the diagnostic tests in N.J.A.C. 11:3-4.5(b). The materialsshall include copies of the Care Paths or indicate how copies may be obtained;

3. A list of the medical procedures, treatments, diagnoses, diagnostic tests, du-rable medical equipment or other services that require precertification, if any;

4. An explanation of how the insurer will respond to decision point review/pre-certification requests, including time frames. The materials should indicate that:

i. Telephonic responses will be followed up with a written authorization, denialor request for more information within three business days;


5. An explanation of the insurer’s option to require a physical examination pur-suant to (e) below;

6. An explanation of the penalty co-payments imposed for the failure to submitdecision point review/precertification requests where required in accordance withN.J.A.C. 11:3-4.4(e);

7. An explanation of the insurer’s voluntary network or networks for certaintypes of testing, durable medical equipment or prescription drugs authorized byN.J.A.C. 11:3-4.8, if any;

8. An explanation of the alternatives available to the provider if reimbursementfor a proposed treatment, diagnostic test or durable medical equipment is deniedor modified, including insurers internal appeal process and how to use it; and

9. An explanation of the insurer’s restrictions on assignment of benefits, if any.(e) A physical examination of the injured party shall be conducted as follows:1. The insurer shall notify the injured person or his or her designee that a phys-

ical examination is required to determine the medical necessity of further treat-ment, diagnostic tests or durable medical equipment. An insurer shall include rea-sonable procedures for the notification of the injured person and the treating med-ical provider where reimbursement of further treatment, diagnostic testing ordurable medical equipment will be denied for failure to appear at scheduled med-ical examinations.

2. The appointment for the physical examination shall be scheduled within sev-en calendar days of receipt of the notice in (e)1 above unless the injured personagrees to extend the time period.

3. The medical examination shall be conducted by a provider in the same dis-cipline as the treating provider.

4. The medical examination shall be conducted at a location reasonably conve-nient to the injured person.

5. The injured person, upon the request of the insurer, shall provide medicalrecords and other pertinent information to the provider conducting the medical ex-amination. The requested records shall be provided at the time of the examinationor before.

6. The insurer shall notify the injured person or his or her designee and thetreating medical provider whether it will reimburse for further treatment, diagnos-tic tests or durable medical equipment as promptly as possible but in no case laterthan three business days after the examination. If the examining provider preparesa written report concerning the examination, the injured person or his or her des-ignee shall be entitled to a copy upon request.

7. Insurers may include in their decision point review plan a procedure for thedenial or reimbursement for treatment, diagnostic testing or durable medicalequipment after repeated unexcused failure to attend a scheduled physical exami-nation. The procedure shall provide for adequate notification of the insured andthe treating provider of the consequences of failure to attend the examination.

(f) In administering decision point review and precertification, insurers shallavoid undue interruptions in a course of treatment. As part of their decision pointreview plans, insurers may include provisions that encourage providers to estab-lish an agreed upon voluntary comprehensive treatment plan for all of a coveredperson’s injuries to minimize the need for piecemeal review. An agreed compre-hensive treatment plan may replace the requirements for notification to the insurerat decision points and for treatment, diagnostic testing or durable medical equip-

11:3-4.7A APPENDIX B - REGULATIONS

ment requiring precertification. In addition, the insurer may provide that reim-bursement for treatment, diagnostic tests or durable medical equipment consistentwith the agreed plan will be made without review or audit.

(g) An insurer shall not retrospectively deny payment for treatment, diagnostictesting or durable medical equipment on the basis of medical necessity where a de-cision point review or precertification request for that treatment or testing wasproperly submitted to the insurer unless the request involved fraud or misrepresen-tation, as defined in N.J.A.C. 11:16-6.2, by the provider or the person receivingthe treatment, diagnostic testing or durable medical equipment.Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended.R.2006 d.243, effective July 3, 2006; R.2009 d.243, effective June 15, 2009; R.2010 d.142, effectiveJuly 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effectiveNovember 5, 2012 (operative January 4, 2013).

11:3-4.7A PIP vendor registration requirements (a) No company shall per-form utilization management services for an insurer unless registered as a PIP ven-dor pursuant to this section.

(b) Any PIP vendor working for an insurer prior to November 5, 2012 shall filefor registration by February 3, 2013.

(c) Application for registration shall be made on a form prescribed by the Com-missioner, which can be found on the Department's website at http://www.state.nj.us/dobi/pipinfo/aicrapg.htm.

(d) The application shall be accompanied by the applicant’s business plan,which shall include the following information:

1. A statement generally describing the applicant, its facilities, personnel, andthe services to be offered by the PIP vendor;

2. The name of its medical director(s) licensed to practice as physician(s) inNew Jersey and a detailed explanation about how the medical director(s) pro-vide(s) oversight of determinations of medical necessity;

3. The name and contact information of a person at the vendor who is designat-ed to receive and handle complaints and inquiries from the Department;

4. Information on activities undertaken or to be undertaken in New Jersey bythe company;

5. A demonstration of the applicant's capability to provide a sufficient numberof experienced and qualified personnel in the areas of PIP utilization management,and information on staffing levels, including, but not limited to, training, hiringrequirements, experience of staff in general and with PIP utilization managementin particular;

6. A statement about whether the applicant is licensed or certified as an entitythat has networks as that term is defined in N.J.A.C. 11:3-4.8(a) or accredited bynationally recognized accrediting agencies such as URAC (http://www.urac.org/)in Health Utilization Management; and

7. A copy of the applicant's certificate of incorporation.(e) The application shall also be accompanied by the following information

concerning how the applicant will handle PIP utilization management:1. The vendor’s clinical review criteria and protocols. The information shall in-

clude a descriptive flow chart of its processes used in decision-making, whichshall be based on written clinical criteria and protocols developed with involve-ment from practicing physicians and other licensed health care providers, and bebased upon generally accepted medical standards and standard professional treat-ment protocols;

PIP BENEFITS; PROTOCOLS; TESTS 11:3-4.7A

2. A copy of the vendor’s policies and procedures that demonstrate that thevendor is handling utilization management in accordance with N.J.A.C. 11:3-4, 5and 29; and

3. The mechanisms it uses to detect underutilization and overutilization of ser-vices.

(f) A PIP vendor that arranges the physical examinations of injured parties pur-suant to N.J.A.C. 11:3-4.7(e) shall submit the criteria it uses to select providers tobe on the vendor’s panel of examining providers, how it evaluates the quality ofan examining provider’s examination report and how it avoids conflicts of interestwhen examinations are ordered and scheduled.

(g) Two copies of the information in (a) through (f) above shall be submitted tothe Department at the following address:

New Jersey Department of Banking and InsuranceOffice of Property and CasualtyP.O. Box 325Trenton, NJ 08625-0325(h) The Department shall advise the applicant if the application is incomplete

not later than 60 days after receipt of the application. Notice to the applicant thatthe application is incomplete shall specify the missing items or information. TheDepartment shall disapprove an incomplete application if the requested informa-tion is not provided within 30 days of the notification to the applicant. If the De-partment does not notify the applicant of missing items or information within 60days of receipt, the application shall be deemed complete.

(i) The Commissioner shall approve an application for registration if he or shefinds that the applicant has demonstrated the ability to perform services in a man-ner that meets the requirements of this subchapter.

(j) The Commissioner may deny an application for registration as a PIP vendorif he or she finds that any of standards established by this subchapter have not beenmet or for any other reasonable grounds.

1. If the application for registration is denied, the Commissioner shall notify theapplicant in writing of the reasons for the denial.

2. When the Department denies an application for registration, the applicantmay request a hearing within 30 days of receipt of the denial by submitting a re-quest in writing to the address in (g) above setting forth, with specificity, the rea-sons that the applicant disputes the Department's denial notice.

(k) Registration shall be effective for a period of two years. Registered PIP ven-dors shall reapply for registration 90 days prior to expiration by submitting the in-formation in (d) through (f) above showing changes to the items previously sub-mitted.

(l) All data or information in the PIP vendor's application for registration andthe vendor’s contract with the insurer required to be submitted pursuant toN.J.A.C. 11:3-4.7(c)1 shall be confidential and shall not be disclosed to the public,except as follows:

1. The PIP vendor’s certificate of incorporation;2. The PIP vendor’s address;3. The names of the PIP vendor's officers and directors, or the individuals in the

organization responsible for the administration of utilization management includ-ing the medical director(s); and

4. The date of registration of the PIP vendor and date that registration expires.

11:3-4.7B APPENDIX B - REGULATIONS

(m) The Commissioner may suspend or revoke the registration of a PIP vendorupon finding that the PIP vendor no longer meets the standards set forth in thissubchapter; that PIP utilization review services are not being provided in accor-dance with the requirements of this subchapter; or that the registration was grantedbased on false or misleading information.

1. Proceedings to revoke or suspend the registration shall be conducted pursu-ant to N.J.A.C. 11:17D.

2. Upon request of the PIP vendor for a hearing, the matter shall be transferredto the Office of Administrative Law for a hearing conducted pursuant to the Ad-ministratve Procedure Act, N.J.S.A. 52:14B-1 et seq. and 52:14F-1 et seq., and theUniform Administrative Procedure Rules, N.J.A.C. 1:1. New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-4.7B. Requirements for insurer internal appeals procedures. (a) Theinternal appeal procedure in an insurer’s Decision Point Review Plan (DPR Plan)shall meet the requirements in this section.

(b) Insurers shall only require a one-level appeal procedure for each appealedissue before making a request for alternate dispute resolution in accordance withN.J.A.C. 11:3-5. That is, each issue shall only be required to receive one internalappeal review by the insurer prior to making a request for alternate dispute reso-lution. An appeal of the denial of a medical procedure, treatment, diagnostic test,other service, and/or durable medical equipment on the grounds of medical neces-sity is a different issue than an appeal of what the insurer should reimburse the pro-vider for that same service.

(c) All appeals shall be initiated using the forms established by the Departmentby Order in accordance with N.J.A.C. 11:3-4.7(d) and posted on the Department'swebsite.

(d) The appeal forms and any supporting documentation shall be submitted bythe provider to the address and/or fax number designated for appeals in the insur-er's DPR Plan. Pursuant to N.J.A.C. 11:1-47, insurers may permit electronic filingof appeals by providing the process for electronic filing in its DPR Plan.

(e) There shall be two types of internal appeals:1. Pre-service: Appeals of decision point review and/or precertification denials

or modifications prior to the performance or issuance of the requested medicalprocedure, treatment, diagnostic test, other service and/or durable medical equip-ment (collectively known as “services”); and

2. Post-service: Appeals subsequent to the performance or issuance of the ser-vices.

(f) A pre-service appeal shall be submitted no later than 30 days after receiptof a written denial or modification of requested services.

(g) A post-service appeal shall be submitted at least 45 days prior to initiatingalternate dispute resolution pursuant to N.J.A.C. 11:3-5 or filing an action in Su-perior Court.

(h) Decisions on pre-service appeals shall be issued by the insurer to the pro-vider who submitted the appeal no later than 14 days after receipt of the pre-ser-vice appeal form and any supporting documentation.

(i) Decisions on post-service appeals shall be issued by the insurer to the pro-vider who submitted the appeal no later than 30 days after receipt of the appealform and any supporting documention.


(j) Nothing in this section shall be construed so as to require reimbursement ofservices that are not medically necessary or to prevent the application of the pen-alty co-payments in N.J.A.C. 11:3-4.4(e), (f), and (g).New Rule. R.2012 d.187, effective November 5, 2012 (operative November 5, 2016). Repeal andNew Rule. R.2016 d.140, effective October 17, 2016 (operative April 17, 2017).

11:3-4.8. Voluntary networks. (a) No insurer shall file a decision point reviewplan utilizing a voluntary network or networks unless the network is a healthmaintenance organization licensed pursuant to N.J.S.A. 26:2J-1 et seq.; or ap-proved by the Department as part of a selective contracting arrangement with ahealth benefits plan pursuant to N.J.A.C. 11:4-37 and 11:24A-4.10; or approvedas part of a workers’ compensation managed care organization pursuant toN.J.A.C. 11:6; or is licensed or certified as an organized delivery system pursuantto N.J.A.C. 11:22-4 and 11:24B.

(b) Voluntary networks may be offered for the provisions of the following typesof non-emergency benefits only:

1. Magnetic Resonance Imagery;2. Computer Assisted Tomography;3. The electrodiagnostic tests listed in N.J.A.C. 11:3-4.5(b)1 through 3 except

for needle EMGs, H-reflex and nerve conduction velocity (NCV) tests performedtogether by the treating physician;

4. Durable medical equipment with a cost or monthly rental in excess of$50.00;

5. Prescription drugs; or6. Services, equipment or accomodations provided by an ambulatory surgery

facility.(c) Insurers that offer voluntary networks either directly or through a PIP ven-

dor shall meet the following requirements:1. The insurers shall notify all insureds upon application for and issuance of the

policy and upon renewal of the types of benefits for which it has voluntary net-works. Use of the network by the insured is voluntary but bills for out-of-networkservices or equipment are subject to the penalty deductibles set forth in N.J.A.C.11:3-4.4(g).

2. Upon receipt of a request for PIP benefits under the policy, the insurer or itsPIP vendor shall make available to the insured and the treating medical providerinformation about approved networks and providers in the network, including ad-dresses and telephone numbers. Insureds shall be able to choose to go to any pro-vider in the network.

(d) An insurer offering a voluntary network or networks directly or through aPIP vendor shall submit the following information to the Department with its De-cision Point Review Plan:

1. A narrative description of the benefits to be offered through the network ornetworks;

2. The identity and a description of the network and the specific services or sup-plies to be provided by the network or networks;

3. A description of the procedures by which benefits may be obtained by per-sons using the network;

4. A statement of how the network meets the requirement of (a) above.(e) Any voluntary network used by an insurer pursuant to this subchapter shall

agree to disclose to a participating provider, upon written request, a list of all the


clients or other payers that are entitled to a specific rate under the network’s con-tract with the participating provider.Repeal and New Rule. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004). Amended.R.2010 d.142, effective July 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a). Amended.R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-4.9. Assignment of benefits; public information. (a) Pursuant toN.J.S.A. 39:6A-4, an insured may only assign benefits and duties under the policyto a provider of service benefits. Insurers may file for approval policy forms thatinclude reasonable procedures for restrictions on the assignment of personal inju-ry protection benefits and duties under the policy, consistent with the efficient ad-ministration of the coverage and the prevention of fraud. Insurers may not prohibitthe assignment of benefits to providers. Reasonable restrictions may include, butare not limited to:

1. A requirement that as a condition of assignment, the provider agrees to fol-low the requirements of the insurer's decision point review plan for making deci-sion point review and precertification requests;

2. A requirement that as a condition of assignment, the provider shall hold theinsured harmless for penalty co-payments imposed by the insurer based on theprovider's failure to follow the requirements of the insurer's decision point reviewplan; and/or

3. A requirement that as a condition of assignment, the provider agrees to sub-mit disputes to alternate dispute resolution pursuant to N.J.A.C. 11:3-5.

(b) Insurers may file policy language requiring that providers who are assignedbenefits by the insured or have a power of attorney from the insured make an in-ternal appeal pursuant to N.J.A.C. 11:3-4.7B prior to making a request for disputeresolution in accordance with N.J.A.C. 11:3-5.

(c) An insurer shall identify documents containing proprietary information inits decision point review plan submission. Documents containing proprietary in-formation shall be confidential and shall not be subject to public inspection andcopying pursuant to the "Right-to-Know" law, N.J.S.A. 47:1A-1 et seq. The De-partment shall notify the insurer prior to responding to any public record requestfor proprietary information.Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004 (operativeOctober 27, 2004); R.2012 d.187, effective November 5, 2012 (operative January 4, 2013); R.2016d.140, effective October 17, 2016 (operative April 17, 2017).

11:3-4.10. (Reserved). Repealed. R.2004 d.218, effective June 7, 2004.APPENDIX - TREATMENT OF ACCIDENTAL INJURY TO THE SPINE

AND BACK CARE PATHSExhibit 1

Glossary of TermsAcute Disease--a disease with rapid onset and short course to recovery. Not

chronic.Care Path--a recommended extensive course of care based on professionally

recognized standards.Case Management--a method of coordinating the provision of healthcare to

persons injured in automobile accidents, with the goal of ensuring continuity andquality of care and cost effective outcomes. The Case Manager may be a nurse,social worker, or physician, preferably with certification in case management.


Cauda Equina--a collection of spinal roots that descend from the lower part ofthe spinal cord. They exist in the lower part of the vertebral canal.

Chronis Disease--a disease with long duration that changes little and progress-es slowly. The apposite of acute.

Clinical Evaluation--the evaluation of the symptoms and signs of an injuredperson by a treating practitioner.

Conservative Therapy--treatment which is not considered aggressive; avoidingthe administration of medicine or utilization of invasive procedures until such pro-cedures are clearly indicated.

Contusion--an injury to underlying soft tissues when the skin is not broken. Abruise.

Diagnostic Evaluation--the process of differentiating between two or more dis-eases with similar signs and symptoms through the use of evaluative proceduressuch as imaging, laboratory, and physical tests.

Herniation--the protrusion or projection of an organ or other body structurethrough a defect or natural opening in a covering membrane, muscle, or bone.

Independent Consultative Opinion--physical examination by a physician ofsimilar specialty to the injured person's treating practitioner to provide a secondmedical opinion. The independent physician may support, refute, or provide alter-natives to the current diagnosis and treatment plans.

Non-Compliant--a patient who wilfully chooses not to participate in the treat-ment plan agreed upon by the patient and his/her healthcare provider and does nothave secondary issues such as lack of transportation, pre-existing conditions or co-morbidities.

PT--Physical Therapy--the therapeutic use of heat, light, water, electricity, mas-sage, exercise, and non-ionizing radiation in treatment of injuries to the soft tissueand muscles/skeleton. PT rendered to persons injured in automobile accidentsmust be provided by a person whose scope of licensure includes physical therapy.

Radicular--pertaining to a root (such as a nerve root) disorder.Radiculopathy--a disorder of a nerve root.Sign--an objective manifestation, usually indicative of a disease or disorder.

Signs can be observed by the clinician, as opposed to symptoms, which areperceived only by the affected individual.Soft Tissue Injury--injuries sustained to the muscle, skin, connective tissue.Spine--the vertebral column.Spinal Shock--an acute condition resulting from spinal cord severance. Char-

acterized by a total sensory loss and loss of reflexes below the level of injury andflaccid paralysis.

Sprain--an injury at a joint where a ligament is stretched or torn.Strain--an injury caused by the over-stretching or tearing of a muscle or tendon.

In its most severe form, the muscle ruptures.Symptom--a subjective manifestation, usually indicative of a disease or disor-

der. Symptoms are experienced only by the affected individual, as opposed tosigns, which can be observed by others.

Treatment Plan--specific medical, surgical, chiropractic, acupuncture, or psy-chiatric procedures used to improve the signs or symptoms associated with inju-ries sustained in automobile accidents, e.g., physical therapy, surgery, administra-tion of medications, etc.


.

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


1, 2, 3, 4 See Addendum to Care Paths


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


4 See Addendum to Care PathsICD-9 CODES728.0728.85739.0739.1847.0847.9922.3922.31953.0

CARE PATH 1




1, 2, 4 See Addendum to Care PathsICD-9 CODES722.0722.2722.70722.71728.0739.0953.0


1, 2, 3, 4 See Addendum to Care PathsNOTE: These Care Paths identify typical courses of intervention. There may be patients who require moreor less treatment. However, cases that deviate from the Care Paths may be subject to more careful scrutinyand may require documentation of the special circumstances. Treatments must be based on patient need andprofessional judgment. Deviations may be justified by individual circumstances, such as pre-existingconditions and/or comorbidities. The Care Paths are only intended for use when the injury was caused by amotor vehicle accident (MVA). If at any point in the decision making process the healthcare provider findsevidence that the injury was not caused by a MVA, the provider must contact the patient’s PIP carrier andmedical insurance carrier.


ICD-9 CODES728.0728.85739.0739.7739.8847.1847.9922.3922.33953.24 See Addendum to Care Paths

CARE PATH 3

1,3 See Addendum to Care Paths





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


728.0 846.8728.85 846.9739.0 847.2739.3 847.3739.4 847.4846 847.9846.0 922.3846.1 922.31846.2 953.2846.3 953.3

CARE PATH 54 See Addendum to Care Paths





EXHIBIT 9TREATMENT OF ACCIDENTAL INJURY TO THE SPINE AND BACK

CARE PATH DIAGNOSIS CODINGThe following International Classification of Diseases, 9th Revision Clinical

Modification--fifth edition ICD-9-CM diagnostic codes are associated with CarePath 1 through Care Path 6 for treatment of Accidental Injury to the Spine andBack and are included on each appropriate Care Path. The ICD9 codes referenceddo not include codes for multiple diagnoses or co-morbidity.

Care Path 1728.0 Disorders of muscle, ligament and fascia728.85 Spasm of muscle739.0 Non allopathic lesions--not elsewhere classified739.1 Somatic dysfunction of cervical region847.0 Sprains and strains of neck847.9 Sprains and strains of back, unspecified site922.3 Contusion of back922.31 Contusion of back, excludes interscapular region953.0 Injury to cervical rootCare Path 2722.0 Displacement of cervical intervertebral disc without myelopathy722.2 Displacement of intervertebral disc, site unspecified, without myelop-

athy722.70 Intervertebral disc disorder with myelopathy, unspecified region722.71 Intervertebral disc disorder with myelopathy, cervical region728.0 Disorders of muscle, ligament and fascia739.0 Non allopathic lesions--not elsewhere classified953.0 Injury to cervical rootCare Path 3728.0 Disorders of muscle, ligament and fascia728.85 Spasm of muscle739.0 Non allopathic lesions--not elsewhere classified739.2 Somatic dysfunction of thoracic region739.8 Somatic dysfunction of rib cage847.1 Sprains and strains, thoracic847.9 Sprains and strains of back, unspecified site922.3 Contusion of back922.33 Contusion of back, interscapular regionCare Path 4722.0 Displacement of cervical intervertebral disc without myelopathy722.1 Displacement of thoracic or lumbar intervertebral disc without myel-

opathy722.11 Displacement of thoracic intervertebral disc without myelopathy722.2 Displacement of intervertebral disc, site unspecified, without myelop-

athy722.70 Intervertebral disc disorder with myelopathy, unspecified region722.72 Intervertebral disc disorder with myelopathy, thoracic region728.0 Disorders of muscle, ligament and fascia


739.0 Non allopathic lesions--not elsewhere classifiedCare Path 5728.0 Disorders of muscle, ligament and fascia728.85 Spasm of muscle739.0 Non allopathic lesions--not elsewhere classified739.3 Somatic dysfunction of lumbar region739.4 Somatic dysfunction of sacral region846 Sprains and strains of sacroiliac region846.0 Sprains and strains of lumbosacral (joint) (ligament)846.1 Sprains and strains of sacroiliac ligament846.2 Sprains and strains of sacrospinatus (ligament)846.3 Sprains and strains of sacrotuberous (ligament)846.8 Sprains and strains of other specified sites of sacroiliac region846.9 Sprains and strains, unspecified site of sacroiliac region847.2 Sprains and strains, lumbar847.3 Sprains and strains, sacrum847.4 Sprains and strains, coccyx847.9 Sprains and strains, unspecified site of back922.3 Contusion of back922.31 Contusion of back, excludes interscapular region953.2 Injury to lumbar root953.3 Injury to sacral rootCare Path 6722.1 Displacement of thoracic or lumbar intervertebral disc without myel-

opathy722.10 Displacement of lumbar intervertebral disc without myelopathy722.2 Displacement of intervertebral disc, site unspecified, without myelop-

athy722.70 Intervertebral disc disorder with myelopathy, unspecified region722.73 Intervertebral disc disorder with myelopathy, lumbar region728.0 Disorders of muscle, ligament and fascia739.0 Non allopathic lesions--not elsewhere classified953.3 Injury to sacral rootThe following ICD-9-CM supplemental classification of external causes of in-

jury may be used in addition to the specific diagnostic codes noted above and oneach Care Path:

• E 810 through E 819, selected E 820 series codes.These codes may be used to indicate cause of injury as motor vehicle accident

but should not be used without an associated diagnostic code.EXHIBIT 10

ADDENDUM TO CARE PATHS1. MedicationsMuscle Relaxants• Muscle relaxants are an option in the treatment of patients with acute neck,

thoracic, and low back problems. While probably more effective than placebo,muscle relaxants have not been shown to be more effective than NSAIDs.

• No additional benefit is gained by using muscle relaxants in combination withNSAIDs over using NSAIDs alone.

11:3-5 APPENDIX B - REGULATIONS

• Muscle relaxants have potential side effects in 30 percent of patients. Whenconsidering the option of using relaxants, the clinician should balance thepotential patient's intolerance of other agents.

Opioid Analgesics• When used for a time-limited course, opioid analgesics are an option in the

management of patients with acute neck, thoracic, and low back problems. Thedecision to use opioids should be guided by consideration of their potentialcomplications relative to other options.

• Opioids appear to be more effective in relieving neck, thoracic, and low backsymptoms than safer analgesics, such as acetaminophen or aspirin or otherNSAIDs.

• Clinicians should be aware of the side effects of opioids, such as decreasedreaction time, clouded judgment, and drowsiness, which lead to earlydiscontinuation by as many as 35 percent of patients.

• Patients should be warned about dependence and the danger of opioids whileoperating heavy machinery.

Oral Steroids• Oral steroids are not recommended for the treatment of acute neck, thoracic,

or low back problems.• A potential for severe side effects is associated with the extended use of oral

steroids or steroids in high doses.

2. Who May Perform Spinal Manipulation: Spinal manipulation may be performed by those providers licensed or certified

to perform this procedure within their scope of practice.

3. Spinal ManipulationA course of spinal manipulation/chiropractic care may be considered as con-

servative therapy on all Care Paths. If there is no improvement within one month,then immediate reevaluation is indicated to determine appropriate further treat-ment and treatment options, including referral to other health care providers and/or modification of conservative therapy.

When findings suggest progressive or severe neurologic deficits, an appropri-ate diagnostic assessment to rule out serious neurologic conditions is indicated inany conservative therapy.

4. Mental Health/Rehabilitation Assessment Option If Patient Has NotResponded To Treatment

A mental health/rehabilitation assessment can be obtained if psychological/psychosocial or psychiatric distress is obvious from the history, i.e., presence of“non-organic” physical signs, repetitive back injuries, failed previous treatments,litigation or disability compensation claims, family or financial problems, appar-ent secondary gain, boredom and dissatisfaction with job, frequent bouts of pain,depression, alcohol and substance abuse, extreme obesity, and apparent psychiat-ric behavior.

SUBCHAPTER 5. PERSONAL INJURY PROTECTION DISPUTE RESOLUTION

Source and Effective Date.R. 1998 d. 592, effective December 21, 1998 (operative March 22, 1999).Section11:3-5.1. Purpose and scope.

PIP DISPUTE RESOLUTION 11:3-5.2

11:3-5.2. Definitions.11:3-5.3. Designation of the administrator. 11:3-5.4. Dispute resolution organizations.11:3-5.5. Dispute resolution professionals.11:3-5.6. Conduct of PIP dispute resolution proceedings.11:3-5.7. Recordkeeping.11:3-5.8. Medical review organizations.11:3-5.9. Standards for medical review organizations.11:3-5.10. Medical review organization certification process.11:3-5.11. Fees.11:3-5.12. Prohibition of conflicts of interest.

11:3-5.1. Purpose and scope. (a) The purpose of this subchapter is to establishprocedures for the resolution of disputes concerning the payment of medical ex-pense and other benefits provided by the personal injury protection coverage inpolicies of automobile insurance. This subchapter implements N.J.S.A. 39:6A-5.1and 5.2, which provide that PIP disputes shall be resolved by binding alternate dis-pute resolution as provided in the policy form approved by the Commissioner.This subchapter also implements provisions of N.J.S.A. 2A:23A-1 et seq., as ap-plicable to PIP dispute resolution.

(b) This subchapter shall apply to disputes arising under policies of private pas-senger automobile insurance, on either a personal lines or commercial lines policyform, that provide medical expense benefits and other benefits under personal in-jury protection coverage, as follows:

1. PIP benefits under a standard automobile insurance policy pursuant toN.J.S.A. 39:6A-4;

2. PIP benefits under a basic automobile insurance policy pursuant to N.J.S.A.39:6A-3.1;

3. PIP benefits provided by the UCJF pursuant to N.J.S.A. 39:6-86.1; and4. Additional PIP benefits provided pursuant to N.J.S.A. 39:6A-10.(c) This subchapter shall apply to policies issued or renewed on or after March

22, 1999 in accordance with the approved policy terms.11:3-5.2. Definitions. The following words and terms, when used in this sub-

chapter, shall have the following meanings unless the context clearly indicatesotherwise:

“Administrator” means the dispute resolution organization designated by theCommissioner pursuant to N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.3.

“Basic policy” means an automobile insurance policy issued pursuant toN.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3.

“Commissioner” means the Commissioner of the New Jersey Department ofBanking and Insurance.

“Control” or “controlled” means the possession, direct or indirect, of the powerto direct or cause the direction of the management and policies of a person, wheth-er through the ownership of voting securities, by contract other than a commercialcontract for goods or nonmanagement services, or otherwise, unless the power isthe result of an official position with or corporate office held by the person. Con-trol shall be presumed to exist if any person, directly or indirectly, owns, controls,holds the power to vote, or holds proxies representing, 10 percent or more of thevoting securities of any other person, provided that no such presumption of controlshall of itself relieve any person so presumed to have control from any require-


ment of P.L. 1970, c.22 (N.J.S.A. 17:27A-1 et seq.). This presumption may be re-butted by a showing made in the manner provided by N.J.S.A. 17:27A-3j that con-trol does not exist in fact. The Commissioner may determine, after furnishing allpersons in interest notice and an opportunity to be heard, and making specific find-ings of fact to support such determination, that control exists in fact, notwithstand-ing the absence of a presumption to that effect.

“Department” means the New Jersey Department of Banking and Insurance.“Dispute resolution organization” or “DRO” means an organization that meets

the standards set forth in N.J.S.A. 39:6A-5.1 and N.J.A.C. 11:3-5.4.“Dispute resolution professional” or “DRP” means a natural person who meets

the standards set forth in N.J.A.C. 11:3-5.5."In-person proceeding" or "in-person case" means a PIP dispute where the par-

ties or their representatives appear in person or telephonically before the DRP topresent their cases in accordance with the rules of the dispute resolution organiza-tion.

“Medical review organization” or “MRO” means an organization of health careprofessionals who are licensed in New Jersey, which is certified by the Commis-sioner to engage in unbiased medical review of the medical care provided to per-sons injured in automobile accidents in accordance with N.J.S.A. 39:6A-5.2 andthis subchapter. The term includes either;

1. Any peer review organization with which the Federal Health Care FinancingAdministration or the State contracts for medical review of Medicare or medicalassistance services; or

2. Any independent health care review company."On-the-papers proceeding" or "on-the-papers case" means a PIP dispute

where the parties or their representatives submit written documentation support-ing their case and the DRP decides the case based solely upon the documentationwithout any in person or telephonic appearances by the parties or their represen-tatives in accordance with the rules of the dispute resolution organization. On-the-papers proceedings are only permitted where all parties consent or where there isno further treatment at issue and the amount at issue in the dispute is less than $1,000.

“Personal Automobile Insurance Plan” or “PAIP” means the personal lines au-tomobile insurance residual market mechanism established pursuant to N.J.S.A.17:29D-1 by N.J.A.C. 11:3-2.

“Personal injury protection” or “PIP” means the coverage provided by a policyof automobile insurance pursuant to N.J.S.A. 39:6A-3.1, 39:6A-4 or the emergen-cy personal injury protection coverage provided by a Special Automobile Insur-ance Policy pursuant to section 45 of P.L. 2003, c.89.

“PIP dispute” includes, but is not limited to, matters concerning:1. Interpretation of the insurance contract's PIP provisions;2. Whether the medical treatment or diagnostic tests are in accordance with the

provisions of applicable statutes and rules for the basic and standard policies andin compliance with the terms of the policy;

3. Eligibility of the treatment or service for compensation or reimbursement,including whether the injury is causally related to the accident and the applicationof deductible and copayment provisions;

4. Eligibility of the provider performing the service to be compensated or reim-bursed under the terms of the policy and the provisions of N.J.A.C. 11:3-4, and


including whether the provider is licensed or certified to perform the treatment orservice;

5. Whether the treatment was actually performed;6. Whether the diagnostic tests performed are recognized by the Professional

Boards in the Division of Consumer Affairs, Department of Law and Public Safe-ty, administered in accordance with their standards, and approved by the Commis-sioner at N.J.A.C. 11:3-4;

7. The necessity and appropriateness of consultation with other health care pro-viders;

8. Disputes involving the application of, or adherence to, the automobile insur-ance medical fee schedule at N.J.A.C. 11:3-29;

9. Whether the treatment or service is reasonable, necessary and in accordancewith medical protocols adopted by the Commissioner at N.J.A.C. 11:3-4; or

10. Amounts claimed for PIP income continuation benefits, essential servicesbenefits, death benefits and funeral expense benefits.

“Provider” or “health care provider” is as defined at N.J.A.C. 11:3-4.2.“Standard policy” means an automobile insurance policy including PIP cover-

age as provided in N.J.S.A. 39:6A-4.“UCJF” means the Unsatisfied Claim and Judgement Fund created pursuant to

N.J.S.A. 39:6-61 et seq.Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2012 d.187, effectiveNovember 5, 2012 (operative January 4, 2013).

11:3-5.3. Designation of the administrator. (a) The Commissioner shall des-ignate a dispute resolution organization as the administrator of the PIP alternatedispute resolution system by entering into a contract with a dispute resolution or-ganization.

(b) The contract designating the administrator shall be for a term not to exceedfive years, but may be extended according to its terms until a new administrator isdesignated and substituted. Nothing in this subsection shall prohibit an adminis-trator from succeeding itself, if so designated in accordance with N.J.S.A. 39:6A-5.1 and this subchapter. The contract may provide for adjustments in the price paidfor services performed over the life of the contract.

(c) The Commissioner shall request competitive proposals from among quali-fied dispute resolution organizations interested in serving as administrator.

(d) Dispute resolution organizations shall submit the following documents andinformation in connection with their proposal to serve as administrator:

1. A dispute resolution plan that describes how the organization shall meet therequirements of the Act and these rules, which shall include procedures and rulesgoverning the dispute resolution process to ensure adherence to the standards ofperformance set forth in N.J.S.A. 39:6A-5.1 and 5.2 and this subchapter;

2. A description of the organization and biographical information about the keypersonnel that shall be responsible for executing the duties of the administrator;

3. A description of the management information systems that shall be utilizedby the organization;

4. A draft budget for at least the first two years;5. A cost proposal, which shall provide for the payment of the administrator's

expenses, including the cost of dispute resolution professionals, from fees gener-ated from the users of the system;


6. Such other information as may be provided by law, and that the Commission-er or the Treasurer may request in order to understand and evaluate the applicant'sproposal.

11:3-5.4. Dispute resolution organizations. (a) In order to be eligible for des-ignation as administrator, a dispute resolution organization shall meet the follow-ing criteria:

1. The dispute resolution organization shall not be owned or controlled by aninsurer or affiliate of an insurer;

2. The dispute resolution organization shall utilize full-time dispute resolutionprofessionals that meet the standards set forth in N.J.A.C. 11:3-5.5. For the pur-pose of this paragraph, “full-time” shall be construed to include persons who workfewer than five days per week, but who do not engage in other, conflicting em-ployment;

3. The dispute resolution organization shall utilize an advisory council com-posed of parties who are users of the dispute resolution mechanism in connectionwith the selection of dispute resolution professionals and the periodic review ofthe organization's rules and processes;

4. The dispute resolution organization shall utilize procedures to avoid con-flicts of interests as prohibited at N.J.A.C. 11:3-5.12;

5. The dispute resolution organization shall arrange for proceedings in loca-tions reasonably convenient to the parties;

6. The dispute resolution organization shall maintain published rules for theconduct of the proceedings, and shall make them available to the parties and thepublic upon request;

7. The dispute resolution organization shall perform its functions in a promptand efficient manner, giving due regard to the nature of the proceeding and theneed for special attention when required by the exigencies of a particular matter;and

8. The dispute resolution organization shall provide sufficient oversight andtraining of its dispute resolution professionals so as to promote fair, efficient andconsistent determinations consistent with substantive law and with rules adoptedby the Commissioner.

(b) The dispute resolution organization shall develop and maintain a disputeresolution plan approved by the Commissioner that sets forth its procedures andrules. The dispute resolution plan shall be reviewed at least annually and revisionsmade upon approval by the Commissioner. The plan shall include the followingelements:

1. The plan shall provide that PIP dispute resolution be initiated by written no-tice to the administrator and to all other parties of the party's demand for disputeresolution, which notice shall set forth concisely the claims, and where appropri-ate the defenses, in dispute and the relief sought. Where the arbitration is filed bya provider acting as an assignee of benefits or with a power of attorney from theinsured, the notice shall include proof of compliance with the internal appeal pro-cess required by N.J.A.C. 11:3-4.7B. All notices shall also include such other in-formation as may be required for administrative purposes;

2. The plan shall provide for consolidation of claims into a single proceedingwhere appropriate in order to promote prompt, efficient resolution of PIP disputesconsistent with fairness and due process of law;

3. The plan shall provide the assigned dispute resolution professional with suf-ficient authority to provide all relief and to determine all claims arising under PIP


coverage, but may provide for limited, procedural or emergent matters to be de-termined by one or more specially designated dispute resolution professionals;

i. Emergent or expedited relief shall be granted upon demonstration that imme-diate and irreparable loss or damage will result in the absence of such relief;

4. The plan shall provide for the assignment of a medical review organizationto review the case and report its determination when requested pursuant toN.J.S.A. 39:6A-5.2 and this subchapter;

5. The plan shall provide for the prompt, fair and efficient resolution of PIP dis-putes, including in-person and on-the-papers proceedings in accordance with therules of the dispute resolution organization. The plan shall also provide that alter-nate procedures may be utilized when appropriate, which may include mediation,conferences to promote consensual resolution and expedited hearings upon receiptof a medical review organization report, consistent with principles of substantivelaw and rules adopted by the Commissioner;

6. The plan shall provide for a procedure whereby a demand for arbitrationbased on an insurer's denial of a decision point review or precertification requestas not medically necessary, as defined in N.J.A.C. 11:3-4.2, may be submitted di-rectly to an MRO for an expedited determination of medical necessity. No DRPwill be assigned and no attorney fees may be charged. The administrator shall seta fee for handling such requests in addition to the MRO fee. The plan shall providethat if the expedited MRO review does not resolve the dispute, the claimant/in-sured may continue with the standard arbitration procedure before a DRP; and

7. The plan shall provide for the fair and efficient conduct of adversarial pro-ceedings when other methods of dispute resolution are either unsuccessful or in-appropriate, consistent with traditional notions of due process and fundamentalfairness. It shall address, at least, the following procedural issues;

i. Discovery;ii. Receipt of evidence by the dispute resolution professional;iii. Submission of briefs or memoranda of law and fact;iv. Provision for decisions without testimony on consent of parties;v. Notice and place of hearing;vi. Methods to request adjournments;vii. Presentation of testimony and evidence at a hearing; andviii. Supplementation of the record.(c) If consistent with its dispute resolution plan, a dispute resolution organiza-

tion may utilize one or more dispute resolution professionals specifically to handlepreliminary matters on actions including motions to disqualify an appointed DRP.Amended. R.2010 d.142, effective July 6, 2004; R.2010 d.142, effective July 6, 2010. Administrativecorrection. See: 42 N.J.R. 2129(a). Amended. R.2012 d.187, effective November 5, 2012 (operativeJanuary 4, 2013).

11:3-5.5. Dispute resolution professionals. (a) A dispute resolution profes-sional employed by the dispute resolution organization shall be either:

1. An attorney licensed to practice in New Jersey with at least 10 years of ex-perience in cases involving personal injury or workers' compensation;

2. A former judge of the Superior Court or the Workers' Compensation Court,or a former Administrative Law Judge; or

3. Any other person, qualified by education and at least 10 years' experience,with sufficient understanding of automobile insurance claims and practices, con-tract law, and judicial or alternate dispute resolution practices nd procedures.

(b) Dispute resolution professionals shall avoid conflicts of interest as prohib-ited at N.J.A.C. 11:3-5.12 in any matter assigned to them for determination.


1. Dispute resolution professionals shall complete and file with the dispute res-olution organization a conflict of interest questionnaire that shall provide suffi-cient detail about financial interests of themselves and their immediate family soas to avoid any assignment to a particular case where there is a conflict of interest.Conflict of interest questionnaires shall remain confidential with the dispute reso-lution organization, and the information set forth therein shall only be disclosed asnecessary to individuals responsible for assigning cases to dispute resolution pro-fessionals, or reviewing motions to disqualify an assigned dispute resolution pro-fessional.

2. If during the course of an assignment a dispute resolution professional deter-mines that he or she has conflict of interest, based upon facts determined in thecourse of the proceedings, then the DRP shall promptly advise the administratorof the circumstances, who shall assign another DRP.

3. A party may challenge the assignment of a particular DRP by submitting thespecific grounds for challenge in accordance with the rules of the dispute resolu-tion organization approved by the Commissioner. The rules of the dispute resolu-tion organization approved by the Commissioner shall provide that a party maychallenge the assignment of the DRP as follows:

i. When the party receives notification of the assignment of the DRP for an in-person case; or

ii. As part of the appeal process provided in the rules for on-the-papers cases.(c) Dispute resolution professionals shall be compensated by the administrator

in accordance with the terms of the contract designating the administrator. Com-pensation shall not be contingent in any way upon the decision or determinationof the DRP.

(d) Dispute resolution professionals shall create and maintain such records asmay be necessary to carry out their responsibilities and provide such records to theadministrator as required in the contract designating the administrator.Amended. R.2006 d.243, effective July 3, 2006; R.2012 d.187, effective November 5, 2012 (operativeJanuary 4, 2013).

11:3-5.6. Conduct of PIP dispute resolution proceedings. (a) A request fordispute resolution of a PIP dispute may be made by the injured party, the insured,a provider who is an assignee of PIP benefits pursuant to N.J.A.C. 11:3-4.9 or theinsurer, in accordance with the terms of the policy as approved by the Commis-sioner. The request for dispute resolution may include a request for review by amedical review organization. The request shall be made to the administrator andcopies sent to other parties.

1. Every insurer shall establish a single address where requests for dispute res-olution shall be sent. Insurers shall notify the administrator of the address and anychanges thereto. The administrator shall make the list of insurer addresses avail-able to the user community on a web page and any other available means of com-munication.

2. Providers who are the assignee of benefits by the insured or have a power ofattorney from the insured shall follow the insurer's internal appeal process man-dated by N.J.A.C. 11:3-4.7B before making a request for dispute resolution in ac-cordance with (a) above. The dispute resolution organization's plan shall includea procedure for how the provider shall demonstrate that this requirement has beensatisfied.

(b) Upon receipt of the request, the administrator shall promptly assign thematter to a dispute resolution professional. For in-person proceedings, the admin-istrator shall notify all parties of the DRP assigned at the time the assignment is


made. For on-the-papers proceedings, the parties will receive notice of the DRPassigned at the time the decision is issued.

(c) If the request for dispute resolution includes a request for review by a med-ical review organization, the administrator shall refer the matter to a certified med-ical review organization contemporaneously with the assignment of the DRP, andshall notify the parties and the DRP that the matter has been referred. If the initialrequest does not include a request for review by a medical review organization,then a request for such review may be made by any party to the assigned DRP. TheDRP may refer a matter to a MRO on his or her own initiative upon a finding thatthe dispute concerns the diagnosis, medical necessity of treatment or diagnostictest administered to the injured person, whether the injury is causally related to theaccident or is the product of a preexisting condition, or the protocols utilized by aprovider. Whenever a DRP receives or initiates a request for MRO review, he orshe shall transmit it to the administrator for referral who shall refer the matter to acertified MRO and notify the parties that the matter has been referred.

1. The administrator shall refer cases on a random or rotating basis to an MROthat does not have a conflict of interest, in accordance with the administrator's dis-pute resolution plan. Referrals shall be made in such a manner so as not to disclosethe medical reviewer the identity of the insurer, nor to disclose to the insurer theidentity of the medical reviewer.

2. Upon request of the MRO, a provider whose services are the subject of re-view shall promptly furnish a written report of the history, condition, treatmentdates and results of diagnostic tests performed, and shall produce and permit thecopying and inspection of all records relating to the history, treatment and condi-tion of the injured person, and shall submit all necessary documentation as re-quested. Upon request of the MRO through the administrator, the insurer shallsubmit any and all documentation concerning its review of the treatment and test-ing of the injured person, and any reports by its reviewing provider why reim-bursement for the treatment, test or item of durable medical equipment was de-nied.

3. The MRO may request an injured person to submit to a mental or physicalexamination by an independent provider in the same discipline as the treating pro-viders who is not affiliated with either the treating provider, the insurer or theMRO health care provider performing the review. Any such examination shall beconducted in a place reasonably convenient to the injured person. The MRO shallmake available to the examining provider any pertinent medical records.

4. If at any time the MRO determines that it has a conflict of interest in per-forming a particular review, it shall notify the administrator which shall refer thecase to another MRO.

i. Under such circumstances, the first-assigned MRO shall transmit to the new-ly assigned MRO such documents from the treating provider and the insurer as ithas accumulated on the case, as may be directed by the administrator.

ii. The first-assigned MRO shall not be entitled to any reimbursement for workperformed on the transferred case.

(d) Determination by the dispute resolution professional shall be in writing andshall state the issues in dispute, the DRP's findings and legal conclusions based onthe record of the proceedings and the determination of the medical review organi-zation, if any. The findings and conclusions shall be made in accordance with ap-plicable principles of substantive law, the provisions of the policy and the Depart-ment's rules. The award shall set forth a decision on all issues submitted by theparties for resolution.


1. If the DRP finds that the determination of a medical review organization isovercome by a preponderance of the evidence, the reasons supporting that findingshall be set forth in the written determination.

2. The award shall apportion the costs of the proceedings, regardless of whoinitiated the proceedings, in a reasonable and equitable manner consistent with theresolution of the issues in dispute.

(e) Pursuant to N.J.S.A. 39:6A-5.2(g), the costs of the proceedings shall be ap-portioned by the DRP and the award may include reasonable attorney's fees for asuccessful claimant in an amount consonant with the award. Where attorney's feesfor a successful claimant are requested, the DRP shall make the following analysisconsistent with the jurisprudence of this State to determine reasonable attorney'sfees, and shall address each item below in the award:

1. Calculate the "lodestar," which is the number of hours reasonably expendedby the successful claimant's counsel in the arbitration multiplied by a reasonablehourly rate in accordance with the standards in Rule 1.5 of the Supreme Court'sRules of Professional Conduct (http://www.judiciary.state.nj.us/rules/appendices/rpc.htm#P65_6482).

i. The "lodestar" calculation shall exclude hours not reasonably expended;ii. If the DRP determines that the hours expended exceed those that competent

counsel reasonably would have expended to achieve a comparable result, in thecontext of the damages prospectively recoverable, the interests vindicated, and theunderlying statutory objectives, then the DRP shall reduce the hours expended inthe "lodestar" calculation accordingly; and

iii. The "lodestar" total calculation may also be reduced if the claimant has onlyachieved partial or limited success and the DRP determines that the "lodestar" to-tal calculation is therefore an excessive amount. If the same evidence adduced tosupport a successful claim was also offered on an unsuccessful claim, the DRPshould consider whether it is nevertheless reasonable to award legal fees for thetime expended on the unsuccessful claim.

2. DRPs, in cases when the amount actually recovered is less than the attorney'sfee request, shall also analyze whether the attorney's fees are consonant with theamount of the award. This analysis will focus on whether the amount of the attor-ney's fee request is compatible and/or consistent with the amount of the arbitrationaward. Additionally, where a request for attorney's fees is grossly disproportionateto the amount of the award, the DRP's review must make a heightened review ofthe "lodestar" calculation described in (e)1 above.

(f) The award shall be signed by the dispute resolution professional. The orig-inal shall be filed with the administrator, and copies provided to each party. If theaward requires payment by the insurer for a treatment or test, payment shall bemade together with any accrued interest ordered in the award pursuant to N.J.S.A.39:6A-5, within 45 days of the insurer's receipt of a copy of the determination, un-less one of the actions permitted in (g) below has been filed. Where the arbitrationhas been filed by a provider who is the assignee of benefits pursuant to N.J.A.C.11:3-4.9, the payment shall be made payable to the provider.

(g) The final determination of the dispute resolution professional shall be bind-ing upon the parties, but subject to clarification/modification and/or appeal as pro-vided by the rules of the dispute resolution organization, and/or vacation, modifi-cation or correction by the Superior Court in an action filed pursuant to N.J.S.A.2A:23A-13 for review of the award.Amended. R.2000 d.454, effective November 6, 2000; R.2004 d.218, effective June 7, 2004; R.2012d.187, effective November 5, 2012 (operative January 4, 2013). Administrative correction. See: 45N.J.R. 214(a).


11:3-5.7. Recordkeeping. (a) The administrator shall maintain records of alldeterminations for a period of five years.

(b) The administrator shall file a copy of each determination, except consentdeterminations, with the Department in either hard copy or electronic form, as pro-vided in the contract designating the administrator.

1. Any determination filed with the Department shall be indexed and coded soas to facilitate retrieval.

2. The name of any injured party, except when appearing in the caption of thematter or used as identification of the particular case, shall be redacted in the copyfiled with the Department so as to protect the privacy of the injured person.

(c) The administrator shall keep such other records as may be required by theCommissioner and as set forth in the contract designating the administrator.

11:3-5.8. Medical review organizations. (a) Medical review organizationsshall be authorized to determine in connection with the PIP dispute resolution pro-cess set forth in this subchapter:

1. Whether the medical treatment or diagnostic test is medically necessary;2. Whether the treatment is in accordance with medically recognized standard

protocols including those protocols approved by the Commissioner and set forthin N.J.A.C. 11:3-4;

3. Whether the treatment is consistent with symptoms or diagnosis of the inju-ry;

4. Whether the injury is causally related to the accident;5. Whether the treatment is of a palliative rather than a restorative nature; and6. Whether medical procedures and tests that have been repeated are medically

necessary.(b) The findings of a medical review organization shall be presumed to be cor-

rect, but may be rebutted by a preponderance of the evidence submitted to the dis-pute resolution professional.

11:3-5.9. Standards for medical review organizations. (a) Medical revieworganizations shall be capable of performing medical reviews for all primary spe-cialties and disciplines.

(b) Medical review organizations shall employ a medical director to activelyparticipate in the review of cases to assure quality and consistency.

(c) Medical review organizations shall utilize health care providers in the samediscipline as the treating provider to perform the reviews who meet the followingstandards:

1. Reviewing health care providers shall be active practitioners who obtain aminimum of one-half of their income from practice in their area of specialty;

2. Reviewing health care providers shall be licensed in New Jersey and boardcertified in their specialty;

3. Reviewing health care providers shall have at least two years' experience inmedical review, or be certified as a medical review physician; and

4. Reviewing health care providers shall have completed an orientation withthe MRO, including medical review instruction and report writing.

(d) A medical review organization shall have adequate procedures in place toassure confidentiality of patient records.

1. All MRO files shall be indexed and referred to by reference number ratherthan patient name.

2. Medical files shall be maintained in a secure area of the MRO’s offices.3. Only the MRO shall request additional documents relating to the injured per-

son's medical condition, or direct that the injured person be physically examined.


(e) A medical review organization shall utilize procedures to provide for thefair and open exchange of information and records related to the review betweenthe treating health care provider, any provider that has reviewed the case on behalfof the insurer, and the MRO's reviewing health care provider.

(f) A medical review organization shall complete its review and submit its re-port to the dispute resolution professional in accordance with the medical exigen-cies of the case, but in no event in excess of 20 business days from receipt of med-ical records from the treating health care provider.

(g) A medical review organization shall have a procedure for obtaining mentalor physical examinations of injured persons that may be required in the course ofits review.

(h) A medical review organization shall utilize written review procedures. Inreaching its determinations, the MRO shall consider all information submitted bythe parties and information deemed appropriate by the MRO, including: pertinentmedical records, consulting physician reports and other documents submitted bythe parties; applicable commonly accepted protocols, professional standards andpractices by national standard setting organizations, and protocols and diagnostictests approved by the Commissioner and set forth in N.J.A.C. 11:3-4.

(i) A medical review organization shall utilize audit procedures to ensure com-pliance with statutory and regulatory requirements.

(j) A medical review organization shall retain records of its determinations forfive years.

11:3-5.10. Medical review organization certification process. (a) The Com-missioner shall certify a medical review organization to provide medical reviewservices in connection with the resolutions of PIP disputes if the Commissionerdetermines that the MRO complies with the standards set forth in N.J.A.C. 11:3-5.9 to provide an impartial review of the medical necessity or appropriateness oftreatments, health care services or items of durable medical equipment for whichmedical expense benefits may be provided under personal injury protection cov-erage.

(b) For the purpose of obtaining certification by the Commissioner to act as amedical review organization to perform medical review in connection with theresolution of PIP disputes, an MRO shall submit two copies of a written applica-tion that sets forth the information in (b) below to:

Medical Review Organization CertificationNew Jersey Department of Banking and InsurancePO Box 325Trenton, NJ 08625-0325(c) The MRO application shall include the following:1. A list of the names, addresses and specialties of the individual health care

providers that will provide the medical review services. If the MRO will be limitedin its service area, the application shall provide a map of the service area, includ-ing the providers by specialty;

2. A copy of the MRO's certificate of incorporation and by-laws;3. A diagram of the MRO's organizational structure;4. The location of the MRO's place of business where it administers its services

and maintains its records;


5. A listing and biography of the MRO's officers and directors, or the individ-uals in the organization responsible for administration of medical reviews, includ-ing the medical director;

6. A detailed description of the MRO's experience in the review of medicalcare;

7. A description of its procedures for review of medical treatments, diagnostictests and items of durable medical equipment in conjunction with PIP medical ex-pense benefits;

8. A current list identifying all property/casualty insurers, health insurers,health maintenance organizations and health care providers with whom the MROmaintains any health related business arrangement. The list shall include a briefdescription of the nature of the arrangement, so as to permit the administrator toavoid assignments that may create a conflict of interest;

9. The fee(s) for determination by the MRO;10. Such other information as the Commissioner may specifically request in

connection with the certification of a particular applicant; and11. A fee in the amount of $1,000 payable to the Department of Banking and

Insurance.(d) The materials specified in (c) above shall be retained by the Department and

may be referred to the Department of Health and Senior Services for consultationas necessary. Any significant changes in the materials filed with the Departmentshall be reported as an amendment to the materials filed within 30 days of thechange.

(e) The Department, in consultation with the Department of Health and SeniorServices, shall review the materials and grant or deny certification within 45 daysof receipt of a complete filing. The Commissioner may extend the time an addi-tional 30 days for good cause shown, and shall notify the applicant of any exten-sion. A decision to deny certification shall be in writing and include an explana-tion of the reason for the denial.

(f) Initial certification shall be effective for a period of two years. CertifiedMROs shall reapply for certification 90 days prior to expiration by submitting theitems set forth in (b)1, 6, 7, 8, 9 and 10 above and any changes to items previouslysubmitted in (b)2, 3, 4 and 5 above. Renewal certification may be effective for aperiod of up to five years.

(g) All data or information in the MRO's application for certification shall beconfidential and shall not be disclosed to the public, except as follows:

1. The MRO's certificate of incorporation;2. The MRO's address;3. The names of the MRO's officers and directors, or the individuals in the or-

ganization responsible for the administration of medical reviews including themedical director; and

4. The date of certification of the MRO and date that certification expires.(h) Upon certification, the Department shall advise the administrator of the

name and address of the MRO, any limitations on its geographical service area andinformation about persons with whom it maintains health related business ar-rangements.

(i) The Commissioner may suspend or revoke the certification of an MRO uponfinding that the MRO no longer meets the standards set forth in N.J.A.C. 11:3-5.9;that medical review services are not being provided in accordance with the re-


quirements of this subchapter; or that the certification was granted based on falseor misleading information.

1. Proceedings to revoke or suspend the certification shall be conducted pursu-ant to N.J.A.C. 11:17D.

2. Upon request of the MRO for a hearing, the matter shall be transferred to theOffice of Administrative Law for a hearing conducted pursuant to the UniformAdministrative Procedure Rules, N.J.A.C. 1:1.Amended. R.2006 d.243, effective July 3, 2006; R.2010 d.142, effective July 6, 2010. Administrativecorrection. See: 42 N.J.R. 2129(a).

11:3-5.11. Fees. When a mental or physical examination is performed in con-nection with the medical review organization's services, the health care providerperforming the examination shall be paid the fee provided for that service set forthon the Department's medical fee schedule, N.J.A.C. 11:3-29.Amended. R.2004 d.218, effective June 7, 2004 (operative October 27, 2004); R.2010 d.142, effectiveJuly 6, 2010. Administrative correction. See: 42 N.J.R. 2129(a).

11:3-5.12. Prohibition of conflicts of interest. (a) No administrator or em-ployee thereof, dispute resolution professional, medical review organization or re-viewing health care provider shall have any personal or financial interest, director indirect, or engage in any business or transaction which is in conflict with theproper conduct of his or her duties under this subchapter.

(b) No administrator or employee thereof, dispute resolution professional,medical review organization or reviewing health care provider shall act in such ca-pacity in any matter wherein he or she has a direct or indirect personal or financialinterest that might reasonably be expected to impair his or her objectivity or inde-pendence of judgment.

(c) No administrator or employee thereof, dispute resolution professional,medical review organization or reviewing health care provider shall accept anygift, favor, service or other thing of value under circumstances from which it mightbe reasonably inferred that such gift, service or other thing of value was given oroffered for the purpose of influencing him or her in the conduct of duties underthis subchapter.

(d) No dispute resolution professional shall accept from any person, whetherdirectly or indirectly and whether by him or herself or through a spouse or anyfamily member or through any partner or associate or controlled business, any gift,favor, service, employment or offer of employment or any other thing of valuewhich he or she knows or has reason to believe is offered with the intent to influ-ence the performance of his or her duties as a dispute resolution professional.

(e) No dispute resolution professional shall make any determination in any PIPdispute in which he or she directly or indirectly or through a spouse, family mem-ber or by partner or associate or controlled business has any personal or financialinterest.

SUBCHAPTER 7. AUTOMOBILE REPARATION REFORM ACTSection11:3-7.1. Purpose.11:3-7.2. General requirements applicable to additional personal injury

protection benefits.11:3-7.3. Personal injury protection policy forms or endorsements.11:3-7.4. Minimum schedule of additional personal injury protection

coverage benefits.

AUTOMOBILE REPARATION REFORM 11:3-7.2

11:3-7.5. Notice requirements.11:3-7.6. Cancellation of automobile coverage for nonpayment of premium.

11:3-7.1. Purpose. This subchapter implements certain provisions of the Au-tomobile Reparation Reform Act, N.J.S.A. 39:6A-1 et seq., including the Com-missioner’s authority to establish the amounts and terms of additional personal in-jury protection benefits that must be made available to insureds electing a standardautomobile insurance policy pursuant to N.J.S.A. 39:6A-4.Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).

11:3-7.2. General requirements applicable to additional personal injuryprotection benefits. (a) In addition to the personal injury protection benefits thatinsurers must provide pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, insurers shallmake available to the named insured, and, at his or her option, to any resident rel-atives in the named insured’s household who are not named insureds on anotherstandard or basic policy, additional income continuation benefits, essential servic-es benefits, death benefits and funeral expense benefits pursuant to N.J.S.A.39:6A-10 and this subchapter.

(b) The additional benefit indicated in each option that an insurer may offer forincome continuation benefits and essential services benefits represents the aggre-gate of the basic and additional personal injury protection benefits.

(c) Any additional income continuation benefits that an insurer may offer shallbe limited to 75 percent of the insured’s weekly income.

(d) The limits which are applicable to any additional personal injury protectionbenefits that an insurer may offer shall apply on a per person, per accident basis.

(e) Each insurer shall make available as an option additional income continua-tion benefits for as long as the disability persists.

1. Each insurer shall furnish rates for such benefits upon the request of the in-sured.

(f) Any additional death benefits which an insurer may offer shall be payablewithout regard to the period of time elapsing between the date of the accident andthe date of death provided death occurs within two years of the accident and re-sults from bodily injury from that accident.

1. The requirements of (f) above shall apply to any claim for additional deathbenefits where death occurs on or after April 21, 1986.

i. With respect to any claim presented on or after the effective date of this sub-chapter, each insurer shall disclose the availability of additional death benefits inconformance with the applicable provisions of N.J.A.C. 11:2-17.1 et seq.

ii. With respect to any claim initiated prior to the effective date of this subchap-ter, each insurer shall take appropriate steps to determine whether additional deathbenefits are payable, pursuant to (fl above. These steps shall include, but need notbe limited to, review of claims closed on or after April 21, 1986 for the purpose ofascertaining the applicability of additional death benefits. Upon determining thatsuch benefits are payable, each insurer shall provide written notice to eligible ben-eficiaries and process the claim in accord with N.J.S.A. 39:6A-5 and the applica-ble provisions of N.J.A.C. 11:2-17.1 et seq.

(g) In addition to the minimum schedule of additional personal injury protec-tion benefits set forth at N.J.A.C. 11:3-7.4(b), any insurer may provide other ad-ditional personal injury protection benefit options subject to review and approvalof its filing by the Department of Insurance. Any additional options offered by the


insurer must be in compliance with the standards and requirements set forth in thissubchapter.

(h) Insurers may also make available to named insureds covered under N.J.S.A.39:6A-4, and at their option, to resident relatives in the household of the namedinsured or to other persons provided medical expense coverage pursuant to thisstatutory provision, or both, additional first party medical expense benefit cover-age pursuant to N.J.S.A. 39:6A-l0.Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); R. 1998 d. 591,effective December 21, 1998 (operative March 22, 1999); R. 2001 d. 44, effective February 5, 2001.

11:3-7.3. Personal injury protection policy forms or endorsements. (a) Allpolicy forms or endorsements that provide personal injury protection benefits re-quired by N.J.S.A. 39:6A-4 shall specify that such benefits shall be afforded bythe insurer of the injured person subject to any deductibles or exclusions electedby the policyholder pursuant to N.J.S.A. 39:6A-4.3. The required personal injuryprotection benefits are set forth below:

1. Medical expense benefits;2. Income continuation benefits;3. Essential services benefits;4. Death benefits; and5. Funeral expense benefits.(b) Each policy form or endorsement covering an automobile as defined at

N.J.S.A. 39:6A-2 shall include excess medical payments coverage, correspondingto Section II, Extended Medical Expense Benefits Coverage of the personal auto-mobile policy. Insurers must include a minimum coverage of $1,000 and may of-fer coverage of $10,000.

(c) Each policy form or endorsement providing additional personal injury pro-tection benefits shall specify that, pursuant to N.J.S.A. 39:6A-10, additional deathbenefits under the policy shall be payable without regard to the period of timeelapsing between the date of the accident and the date of death provided death oc-curs within two years of the accident and results from bodily injury from that ac-cidentAmended. R. 1996 d. 58, effective February 5, 1996.

11:3-7.4. Minimum schedule of additional personal injury protection cov-erage benefits. (a) Every rate filer’s schedule of rates for additional personal in-jury protection benefits, other than medical expense benefits, shall provide at leastthe benefit schedules set forth in Table 1 in (b) below.

(b) The additional personal injury protection coverage table follows:

Table 1Income Essential Services Funeral

Option Weekly Total Per Day Total Death Expense1 $100 $10,400 $12 $8,760 $10,000 $2,0002 125 13,000 20 14,600 10,000 2,0003 175 18,200 20 14,600 10,000 2,0004 250 26,000 20 14,600 10,000 2,0005 400 41,600 20 14,600 10,000 2,0006 500 52,000 20 14,600 10,000 2,0007 600 62,400 20 14,600 10,000 2,0008 700 72,800 20 14,600 10,000 2,000

AUTOMOBILE REPARATION REFORM 11:3-7.6

9 100 unlimited 12 8,760 10,000 2,00010 125 unlimited 20 14,600 10,000 2,00011 175 unlimited 20 14,600 10,000 2,00012 250 unlimited 20 14,600 10,000 2,00013 400 unlimited 20 14,600 10,000 2,00014 500 unlimited 20 14,600 10,000 2,00015 600 unlimited 20 14,600 10,000 2,00016 700 unlimited 20 14,600 10,000 2,000Amended. R. 1990, d. 580, effective November 19, 1990 (operative January 1, 1991).

11:3-7.5. Notice requirement. (a) Additional personal injury protection bene-fits that are required to be offered by an insurer shall be offered by the insurer atleast annually as part of the Coverage Selection Form required pursuant toN.J.S.A. 39:6A-23 and N.J.A.C. 11:3-15.

1. The buyer’s guide and coverage selection form specified at N.J.S.A. 39:6A-23 and any rules promulgated thereunder shall meet the requirements of (a) above.

(b) Each insurer shall distribute copies of this subchapter to every person re-sponsible for the handling and settlement of claims subject to this subchapter. Ev-ery insurer shall satisfy itself that all such responsible persons are thoroughly con-versant with and are complying with this subchapter.Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991); Amended. R.1996 d. 58, effective February 5, 1996.

11:3-7.6. Cancellation of automobile coverage for nonpayment of premi-um. (a) This rule applies to all automobile policies delivered or issued for deliveryin this State, insuring a single individual or husband and wife resident of the samehousehold, as named insured, and under which the insured vehicles therein desig-nated are of the following types only:

1. A motor vehicle of the private passenger or station wagon type that is notused as a public or livery conveyance for passengers, not rented to others; or

2. Any other four-wheel motor vehicle with a load capacity of 1,500 pounds orless which is not customarily used in the occupation, profession or business of in-sured, other than farming or ranching, provided, however, that this rule shall notapply to any policy insuring more than four automobiles, or to any policy coveringgarage, automobile sales agency, repair shop, service station or public parkingplace operation hazards.

(b) The effective date of the cancellation of a policy for nonpayment of premi-um shall not be earlier than 10 days prior to the last full day of which premiumreceived by the company prior to the date of preparation of the cancellation notice,would pay for coverage on a pro rata basis. In calculating the effective date of thecancellation as provided in this section, the premium applicable to the coverageprovided by the policy and the premium received by the company at or prior to thetime cancellation notice was prepared shall be the premium used for the calcula-tion and determination of such effective date.

(c) Cancellation for nonpayment of premium does not include cancellation atthe request of a premium finance company or of a producer of record underN.J.A.C. 11:17C-2.2(d).

(d) No cancellation notice shall be mailed prior to 30 days in advance of its ef-fective date.

(e) The rule shall not apply to deposits accompanying New Jersey AutomobilePersonal Insurance Plan or Commercial Automobile Insurance Plan applications


which are insufficient under Plan rules or those of any succeeding residual marketavailability plan.Amended. R. 1996 d. 58, effective February 5, 1996. Administrative correction. 40 N.J.R. 5043.

SUBCHAPTER 11. MOPED INSURANCESection11:3-11.1. Required coverages for mopeds.

11:3-11.1. Required coverages for mopeds. (a) No policy insuring againstloss resulting from liability imposed by law for bodily injury, death and propertydamage sustained by any person arising out of the ownership, operation or use ofa motorized bicycle as defined in N.J.S.A. 39:1-1, as amended, shall be issued inthe State to the owner (or parent or guardian of an owner under 18 years of age)of any motorized bicycle principally garaged or operated in this State unless it in-cludes coverage for the owner and operator in the following minimum amounts orlimits.

1. Bodily injury;i. An amount or limit of $15,000, exclusive of interest and costs, on account of

injury to, or death of, one person, in any one accident; andii. An amount or limit, subject to such limit for any one person so injured or

killed, of $30,000, exclusive of interest and costs, On account of injury to or deathof more than one person, in any one accident.

2. Property damage: An amount or limit of $5,000 in the aggregate or damageto property of others resulting from one accident.

(b) Every liability insurance policy as described in (a) above, issued or renewedon or after April 22, 1985, shall provide personal injury protection coverage ben-efits, in accordance with N.J.S.A. 39:6A-4, to pedestrians who sustain bodily in-jury in this State caused by the named insured’s motorized bicycle or caused bybeing struck by or from the motorized bicycle.

1. Every rating organization and insurer making its own rates for policies cov-ering motorized bicycles shall submit to the Commissioner of insurance filings ofrules, rates and forms within 30 days of the effective date of this subsection.

(c) Every business entity or individual owner who rents motorized bicyclesshall maintain liability insurance coverage pursuant to N.J.S.A. 39:4-14.3e in theminimum amounts or limits set forth in subsection (a) of his section.

(d) Any such coverages as described in subsections (a), (b) and (c) above shalldescribe the make and model, piston displacement, and serial number (VIN) ofeach motorized bicycle insured. This information shall also constitute the descrip-tion of vehicle required on insurance identification cards, and N.J.A.C. 11:3-5.1through 6.4 shall apply to moped coverage except where the language is clearlyinappropriate.

(e) The policy period for the coverages described is subsection (a) of this sec-tion shall commence at 12:01 A.M. of the effective date shown in the policy dec-laration page, unless expressly set forth in the policy or in a binder or other con-tracts for temporary insurance.

(f) Any insurer authorized to write motor vehicle coverage may write mopedcoverage.Adopted. R. 1978 d. 12, eff. January 19, 1978. Amended. R. 1985 d. 72, effective February 19, 1985(operative April 22, 1985); R. 2001 d. 44, effective February 5, 2001.

PIP OPTIONS 11:3-14

SUBCHAPTER 14. PERSONAL INJURY PROTECTION OPTIONSSection11:3-14.1. Purpose.11:3-14.2. Scope.11:3-14.3. Optional medical expense benefit deductibles for personal injury

protection coverage.11:3-14.4. Optional exclusion of income continuation benefits, essential

services benefits, death benefits and funeral expense benefits.11:3-14.5. Option to choose health care insurance coverage as primary

coverage.11:3-14.6. Refund or credit of unearned premium.11:3-14.7. Filing requirements.11:3-14.8. Application of the option to choose health care insurance coverage

as the primary insurer.

11:3-14.1. Purpose. This subchapter establishes rules for the provision of op-tional deductibles and benefits for personal injury protection offered under stan-dard private passenger automobile insurance policies pursuant to N.J.S.A. 39:6A-4.Amended. R. 1989 d. 117, effective February 21, 1989; R. 1996 d. 58, effective February 5, 1996; R.1998 d. 591, effective December 21, 1998 (operative March 22, 1999).

11:3-14.2. Scope. This subchapter applies to every insurer, including any re-sidual market mechanism created by any New Jersey statute, authorized to trans-act the business of automobile insurance in this State.Amended. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991)

11:3-14.3. Optional medical expense benefits for standard policies. (a)With respect to personal injury protection under standard automobile insurancepolicies, issued pursuant to N.J.S.A. 39:6A-4, each insurer shall make available asan option, at appropriately reduced premiums, medical expense benefits inamounts of $150,000, $75,000, $50,000, and $15,000. If none of these options isaffirmatively chosen in writing, the policy shall provide medical expense benefitsin an amount not to exceed $250,000 per person per accident.

(b) Notwithstanding (a) above, if an optional medical expense benefit option ischosen, the policy shall provide that medical expense benefits shall be paid in anamount not to exceed $250,000, inclusive of any limit of medical expense benefitspursuant to (a) above, for all medically necessary treatment of permanent or sig-nificant brain injury, spinal cord injury or disfigurement or for medically neces-sary treatment of other permanent or significant injuries rendered at a trauma cen-ter or acute care hospital immediately following the accident and until the patientis stable, no longer requires critical care and can be safely discharged or trans-ferred to another facility in the judgment of the attending physician.

(c) “Significant disfigurement” as used in (b) above means the result and/ormanifestation of a serious traumatic injury that is observable as a permanent andsubstantial defect in the appearance and functional ability of the person injured.“Significant disfigurement” is a serious outward change that substantially detractsfrom the appearance and functional ability of the person injured.

Amended. R. 1984 d. 480, eff. November 5, 1984; R. 1989 d. 117, effective February 21, 1989; R.1996 d. 58, effective February 5, 1996; R. 1998 d. 591, effective December 21, 1998 (operative March22, 1999); R.2000 d.454, effective November 6, 2000.


11:3-14.4. Optional exclusion of income continuation benefits, essentialservices benefits, death benefits and funeral expense benefits. (a) Automobileinsurers offering personal injury protection coverage pursuant to N.J.S.A. 39:6A-4 shall, at an appropriate reduced premium, provide the named insured the optionto exclude all of the following benefits from such coverage:

1. Income continuation benefits;2. Essential services benefits;3. Death benefits;4. Funeral expense benefits.(b) Election of the exclusion shall result in the elimination of all elements of

personal injury protection coverage except medical expense benefits.(c) An exclusion elected by the named insured in accordance with this subchap-

ter shall apply only to the named insured, and any resident relative in the namedinsured’s household, who is not a named insured under another automobile insur-ance policy but not to any other person eligible for personal injury protection ben-efits to be provided under that policy in accordance with N.J.S.A. 39:6A-4.

(d) Additional personal injury protection coverage pursuant to N.J.S.A. 39:6A-l0 shall not be available to any named insured selecting the exclusion or to any rel-ative resident in his household.

(e) No new automobile insurance policy shall be issued on or after July 1, 1984unless the option to exclude personal injury protection benefits in accord with thissection is made available to the applicant. In the case of any automobile policy ex-pected to be in force on July 1, 1984, the named insured shall be provided not laterthan May 15, 1984 with the opportunity to elect, effective July l, 1984, the person-al injury protection coverage exclusion in accord with this section. Any notice ofrenewal of an automobile insurance policy with an effective date subsequent toJuly 1, 1984 shall be accompanied by a notice to the named insured providing theopportunity to elect personal injury protection coverage exclusion in accord withthis subchapter.

(f) A premium credit calculated and represented as a percentage of the applica-ble premium shall be provided for the exclusion. The premium percentage shallbe uniform by filer on a statewide basis.

(g) The buyer’s guide and written notice specified in N.J.S.A. 39:6A-23 shallsatisfy the requirements of this subchapter.

(h) Should an applicant or named insured fail to elect the exclusion, full per-sonal injury protection coverage pursuant to N.J.S.A. 39:6A-4 shall be deemed tohave been selected and an appropriate premium shall be charged.

(i) The exclusion elected by a named insured shall continue in force as to sub-sequent renewal or replacement policies until the insurer or its authorized repre-sentative receives a properly executed written request for its elimination.Amended. R.1984 d. 480, eff. November 5, 1984; R. 1996 d. 58, effective February 5, 1996; R. 1998d. 591, effective December 21, 1998 (operative March 22, 1999).

11:3-14.5. Option to choose health care insurance coverage as primarycoverage. (a) Pursuant to N.J.S.A. 39:6A-4.3, for policies issued or renewed onor after January 1, 1991, an insurer shall provide the option that other health in-surance coverage or benefits of the insured, including health care services provid-ed by a health maintenance organization and any coverage or benefits providedunder any Federal or State program, are the primary coverage for medical expensebenefits for personal injury protection coverage; provided, however, that this op-

BUYER’S GUIDE; COVERAGE SELECTION FORM 11:3-14.5

tion shall not apply to any coverage or benefits provided pursuant to Medicare orMedicaid.

(b) The Coverage Selection Form (see N.J.A.C. 11:3-15.7) shall require in-sureds or prospective insureds to identify the health insurer(s) providing primarypersonal injury protection medical expense benefits. This identification shall ful-fill the requirement in N.J.S.A. 39:6A-4.3 that named insureds provide proof thatthey and members of their family residing in the household are covered by healthinsurance coverage or benefits.Amended. R.1984 d.480, eff. November 5, 1984. Repealed. R. 1989 d. 117,effective February 21,1989. Adopted. R. 1990 d. 580, effective November 19, 1990 (operative January 1, 1991).

11:3-14.6. Refund or credit of unearned premium. Every automobile insureroffering personal injury protection coverage shall establish a fair, practicable andnon-discriminatory plan for the refund or application of credit of any unearnedpremium resulting from the selection of any deductible and/or exclusion optionpursuant to this subchapter.Amended. R. 1989 d. 117, effective February 21, 1989.

11:3-14.7. Filing requirements. (a) Every automobile filer shall submit to theCommissioner for approval filings of rates or manual rules which provide the op-tional medical expense benefit deductibles for personal injury protection cover-age.

(b) Within 30 days of the effective date of this subchapter, every automobilefiler shall submit to the Commissioner for approval filings of rates or manual ruleswhich provide the optional exclusion from personal injury protection coverage ofincome continuation benefits, essential service benefits, death benefits, and funer-al expense benefits.

(c) All filings submitted for approval pursuant to this subchapter, and all chang-es and amendments thereto, shall be prepared in accordance with insurance lawsand regulations, including the applicable provisions of N.J.S.A. 17:29A-1 et seq.and N.J.A.C. 11:1-2 and the Department’s existing filing procedures.

(d) The filing of a rating organization shall be applicable to the members andsubscribers of the organization who have authorized the organization to file ontheir behalf.Amended. R. 1989 d. 117, effective February 21, 1989.

11:3-14.8. Application of the option to choose health care insurance cover-age as the primary insurer. When an insured or prospective insured elects tohave a health insurer provide primary personal injury protection medical expensesbenefits, the medical expenses benefits available to the insured under his or herautomobile policy’s personal injury protection provisions shall become a second-ary benefits provider. The order of benefit determination shall be in accordancewith N.J.A.C. 11:3-37.Adopted. R. 1991 d. 90, effective January 25, 1991.

SUBCHAPTER 15. BUYER’S GUIDE, COVERAGE SELECTION FORM, AND AUTOMOBILE INSURANCE CONSUMER BILL OF RIGHTS FOR

STANDARD AND BASIC POLICIESSection11:3-15.1. Purpose.11:3-15.2. Scope.11:3-15.3. Definitions.


11:3-15.4. Compliance.11:3-15.5. New Jersey Auto Insurance Buyer's Guide.11:3-15.6. Minimum standards for Coverage Selection Forms.11:3-15.7. Use of Coverage Selection Form; availability.11:3-15.8. New Jersey Automobile Insurance Consumer Bill of Rights.11:3-15.9. Penalties.11:3-15.10. (Reserved).11:3-15.11. (Reserved).APPENDIXExhibit 1. Standard Policy Coverage Selection FormExhibit 2. Certification of Compliance with N.J.A.C. 11:3-15.6(g)4Exhibit 3. Basic Policy Coverage Selection Form

11:3-15.1. Purpose. (a) N.J.S.A. 39:6A-23 requires the Commissioner of theDepartment of Banking and Insurance to promulgate standards for the written no-tice to be provided to applicants for private passenger automobile insurance andto policyholders offered renewal of coverage. This written notice includes one oftwo versions of the Buyer's Guide and one of two versions of the Coverage Selec-tion Form.

(b) N.J.S.A. 17:29A-52a requires every insurer writing private passenger auto-mobile insurance in this State to provide each insured at least annually and eachapplicant for insurance with an Automobile Insurance Consumer Bill of Rights.The Automobile Insurance Consumer Bill of Rights shall contain the informationnecessary, relevant or appropriate to improve the understanding of the rights andresponsibilities of consumers and insurers regarding automobile insurance.

(c) This subchapter implements the statutory requirements in (a) and (b) aboveand establishes the necessary minimum standards insurers shall use in giving no-tice of available coverages, options and rate credits and of the rights and respon-sibilities of consumers and insurers regarding automobile insurance.Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1990 d.580, effective November19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March22, 1999); R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.

11:3-15.2. Scope. (a) This subchapter applies to every insurer authorized totransact the business of private passenger automobile insurance in this State andto any automobile residual market mechanism created by any New Jersey statute.

(b) This subchapter applies to every personal lines private passenger automo-bile insurance policies and individually-owned private passenger automobileswritten on commercial insurance policies.Adopted. R.1989 d.117, effective February 21, 1989. Amended. R. 1990 d. 580, effective November19, 1990 (operative January 1, 1991); R.1998 d.595, effective December 21, 1998 (operative March22, 1999); R.2004 d.117, effective March 15, 2004.

11:3-15.3. Definitions. The following words and terms, when used in this sub-chapter, shall have the following meanings, unless the context clearly indicatesotherwise.

“Basic automobile insurance policy” or “basic policy” means those private pas-senger automobile insurance policies issued in accordance with N.J.S.A. 39:6A-3.1 and N.J.A.C. 11:3-3.

“Commissioner” means the Commissioner of the Department of Banking andInsurance.

“Department” means the Department of Banking and Insurance of the State ofNew Jersey.

11:3-15.1 11:3-15.4

“Insurer” means any person, corporation, association, partnership, company,reciprocal exchange and any other legal entity issuing a contract of private passen-ger automobile insurance, including any residual market mechanism establishedpursuant to any New Jersey statute. As appropriate, “insurer” shall also mean aservicing carrier for a residual market mechanism.

“Private passenger automobile insurance policy” means a Standard policy asdefined in N.J.S.A. 39:6a-3 or a Basic policy as defined in N.J.S.A. 39:6A-3.1 pro-viding direct insurance on an automobile as defined in N.J.S.A. 39:6A-2.

“Standard automobile insurance policy” or “standard policy” means a privatepassenger automobile insurance policy issued in accordance with N.J.S.A. 39:6A-3 that includes the personal injury protection coverage described in N.J.S.A.39:6A-4.Adopted. R. 1989 d. 117, effective February 21, 1989. Amended. R. 1989 d. 624, effective December18, 1989 (operative January 1, 1990); R. 1990 d. 580, effective November 19, 1990 (operative January1, 1991); R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d. 117, ef-fective March 15, 2004.

11:3-15.4. Compliance. (a) No new private passenger automobile insurancepolicy or renewal shall be issued unless the application for the policy or renewaloffer is accompanied by a Buyer's Guide, a Coverage Selection Form and an Au-tomobile Insurance Consumer Bill of Rights that meet the minimum standardsprescribed in this subchapter.

1. The renewal offer shall include the appropriate Buyer’s Guide and CoverageSelection Form for the policy being renewed.

2. Where application for or renewal of an insurance policy is made via the In-ternet, compliance with (a) above shall be satisfied by having the Buyer’s Guide,Coverage Selection Form and Automobile Insurance Consumer Bill of Rightsreadily available to the applicant/insured on the insurer’s website. In addition tobeing readily available on the insurer’s website, this information also may beplaced on the producer’s website, if provided or authorized by the insurer.

3. Where application for or renewal of an insurance policy is made via the tele-phone and coverage is bound during the telephonic transaction, compliance with(a) above shall be satisfied if the insurer, with the agreement of the applicant orinsured, sends the insured the Buyer’s Guide, a completed Coverage SelectionForm showing the coverage choices made by the insured, and an Automobile In-surance Consumer Bill of Rights within five business days after the telephonictransaction is completed. Insureds may alter coverages based on their review ofsuch documents by returning a signed Coverage Selection Form with the changesnoted therein, or electronically, provided that the requirements of N.J.S.A.12A:12-1 et seq. are satisfied and that such process is made available by the insur-er. Such alterations shall be effective in accordance with N.J.A.C. 11:3-15.7(d)2.

(b) The Buyer's Guide, Coverage Selection Form and Automobile InsuranceConsumer Bill of Rights incorporate and therefore satisfy any and all other noticerequirements previously set forth for the coverage options required by the NewJersey Automobile Reparation Reform Act, the New Jersey Automobile InsuranceReform Act of 1982, the New Jersey Automobile Insurance Freedom of Choiceand Cost Containment Act of 1984, the Automobile Insurance Cost Reduction Actof 1998 and P.L. 2003, c.89.

(c) As of June 6, 2011, each insurer that becomes authorized to write privatepassenger automobile insurance shall make a filing pursuant to N.J.A.C. 11:1-2.The filing shall consist of a certification in the form set forth in Exhibit 2 in the


subchapter Appendix, incorporated herein by reference, that the Lawsuit Optionrate differentials in its Standard Policy Coverage Selection Form were calculatedin accordance with N.J.A.C. 11:3-15.6(g)4.

(d) An insurer may change the Lawsuit Option rate differentials in its approvedStandard Policy Coverage Selection Forms by making a filing pursuant toN.J.A.C. 11:1-2 that specifies the effective date of the revised rate differentialsthat will be used and that includes the certification required by (c) above.Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1996 d.58, effective February 5,1996; R.1998 d.595, effective December 21, 1998 (operative March 22, 1999); R.2004 d.117, effectiveMarch 15, 2004; R.2005 d.83, effective March 7, 2005; R.2011 d.166, effective June 6, 2011.

11:3-15.5. New Jersey Auto Insurance Buyer's Guide. (a) There are estab-lished two Buyer’s Guides for use by insurers: a personal lines Buyer’s Guide anda commercial lines Buyer’s Guide for individually owned vehicles written oncommercial policies. The Buyer’s Guides shall be available on the Department’swebsite.

1. The personal lines Buyer’s Guide can be found at http://www.state.nj.us/dobi/division_insurance/byguide.doc.

2. The commercial Buyer’s Guide can be found at http://www.state.nj.us/dobi/division_insurance/commbyguide.doc.

(b) The Buyer’s Guide shall be reproduced in the format presented on the web-site, duplicating the information provided therein and, to the extent practicable,the layout, fonts, type-point sizes, colors and illustrations. Notwithstanding theforegoing, consistent with the requirements of N.J.A.C. 11:2-18.4, all text in theBuyer’s Guide shall be printed on at least 10-point type on paper of a quality suf-ficient to assure that the printing does not bleed form one side to the other.

(c) The Department shall notify insurers of any changes to the Buyer’s Guidesby Bulletin. Insurers shall provide the Buyer’s Guide, as revised, for new and re-newal business as soon as practicable, but no later than 90 days after the date ofthe Bulletin. The Buyer’s Guide shall provide general descriptions of:

1. How to begin to shop for auto insurance;2. The types of policies available and the basic differences between them;3. Various insurance coverages such as Personal Injury Protection (PIP), Lia-

bility (including bodily injury and property damage liability coverage), Unin-sured/Underinsured Motorists, Collision and Comprehensive;

4. Policy terms such as limits, deductibles, producer and direct writer;5. PIP options such as deductibles and health care primary and PIP package

coverage such as income continuation, essential services, death benefit and funer-al expense benefit;

6. Comprehensive and Collision options such as limits, deductibles and nameddriver exclusions;

7. A Lawsuit Limitation Selection Guide that explains the tort threshold op-tions with a warning that insurance companies and their producers shall not beheld liable for the consumer’s choice of right to sue options; and

8. Information on how the consumer can contact the Department of Bankingand Insurance.

(d) In addition, the Buyer’s Guide may include company-specific information,such as its name and/or company logo, contact information and company-specificcoverage options, provided that the information is consistent with the purposes ofthis subchapter.

11:3-15.1 11:3-15.6

(e) The Buyer’s Guide shall contain a statement advising the insured or appli-cant that additional information concerning coverages or premiums is available bycontacting the insurer or the producer. Insurers that write at least two percent ofthe New Jersey private passenger automobile market shall provide a toll-free tele-phone number for this purpose.

(f) As required by N.J.S.A. 17:29E-11, the Buyer’s Guide shall contain a noticedescribing the functions of the Insurance Claims Ombudsman, the mailing addressof the Ombudsman and a toll-free information telephone number.Adopted. R.1989 d.117, effective February 21, 1989. Amended. R.1989 d. 624, effective December18, 1989 (operative January 1, 1990); R.1990 d.580, effective November 19, 1990 (operative January1, 1991). Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22,1999). Amended. R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.

11:3-15.6. Minimum standards for Coverage Selection Forms. (a) Each in-surer shall have a separate Coverage Selection Form for the Standard Policy andfor the Basic Policy using the text found in the Appendix, Exhibits 1 and 3 incor-porated herein by reference.

(b) The Coverage Selection Forms shall contain a statement advising the in-sured or applicant that additional information concerning coverages or premiumsis available by contacting the insurer or the producer. Insurers that write at leasttwo percent of the New Jersey private passenger automobile market shall providea toll-free telephone number for this purpose.

(c) Except as otherwise provided in the text, each Coverage Selection Formshall be printed in at least 10-point type on a paper size that is easily readable.

(d) In addition to the required text, each Coverage Selection Form shall includespace at the top for the consumer's name and any other necessary information suchas policy number, etc. The bottom of each Coverage Selection Form shall havespace for the consumer's signature and date.

1. Text in the Appendix, Exhibits 1 and 3 in italics, thus, is instructions or op-tions for the insurer and should not be printed in the Coverage Selection Form.

2. Text in uppercase letters denotes section headings, defined terms or isfor emphasis. Insurers are not restricted to uppercase for these purposes in for-

matting the Coverage Selection Forms.(e) An insurer may expand the form to solicit additional relevant information,

including, but not limited to, the names of resident relatives eligible for PIP ben-efits.

(f) Each Coverage Selection Form shall include the range of premium rate dif-ferences as indicated by the text in the Exhibits. Each insurer shall determine therange of premium rate differences for use in these sections. Premium rate differ-ences for the Lawsuit Options in the Standard Policy Coverage Selection Form,Appendix, Exhibit 1 shall be calculated according to (g) below. When the range ofpremium rate differences on a Coverage Selection Form changes for any reason,including, but not limited to, rate changes, a new Coverage Selection Form withthe current numbers shall be filed with the Department in accordance withN.J.A.C. 11:3-15.4(d).

(g) Each insurer shall calculate the percentage and dollar change in premium(or rate) from the selection of the No Limitation on Lawsuit Option in accordancewith (g)1 through 4 below. In these calculations, premium (or rate) shall includeany expense fee.


1. The Percentage Change Calculation: The range of percentage increase in thebodily injury liability premium arising from the selection of the No Limitation onLawsuit Option shall be calculated as follows:

i. The low end of the percentage range shall be produced by calculating the per-centage increase in the bodily injury liability premium of a policy with a$250,000/$500,000 split limit or a $500,000 single limit for a change from theLimitation on Lawsuit Option to the No Limitation on Lawsuit Option. This cal-culation shall be made for the territory with the lowest basic limit Limitation onLawsuit Option rate, and shall assume standard tier, pleasure usage by an age 30-64, married male principal operator.

ii. The high end of the percentage range shall be produced by making the sametype of calculation using a policy with minimum limits for the territory with thehighest basic limit Limitation on Lawsuit Option rate, and shall assume businessusage by a standard-tier, 22 year old, unmarried male principal operator.

2. The Dollar Change Calculation: The range of dollar increase in the bodilyinjury liability premium arising from the selection of the No Limitation on Law-suit Option shall be determined by subtracting the Limitation on Lawsuit Optionrate from the comparable No Limitation on Lawsuit Option rate for the followingtwo rating examples:

i. The low end of the dollar range shall be a policy with minimum limits for theterritory with the lowest basic limit Limitation on Lawsuit Option rate, and shallassume standard tier, pleasure usage by an age 30-64, married male principal op-erator.

ii. The high end of the dollar range shall be calculated at a $250,000/$500,000split limit or a $500,000 single limit policy for the territory with the highest basiclimit Limitation on Lawsuit Threshold Option, and shall assume business usageby a standard tier, 22 year old, unmarried male principal operator.

iii. Because the range of the possible additional dollar cost will depend uponterritory, bodily injury liability loss limits, and other factors, insurers shall be per-mitted to use round numbers to represent the approximate range of the cost in-crease. For example, if the smallest dollar rate increase was $54.00 and the largest$305.00, the insurer may use the range $50.00 to $310.00 on its Coverage Selec-tion Form.

3. Premium Basis for Single Limit Liability Coverage:i. For single limit liability coverage, the percentage range calculation that is de-

scribed in (g)1 above shall be based upon the applicable liability rate. This calcu-lation shall be made on the basis of a combined rate containing a charge for bodilyinjury liability, and property damage liability.

ii. For single limit liability coverage, the dollar range calculation that is de-scribed in (g)2 above shall be based upon the applicable liability rate. In contrastto the procedure in (g)3i above, the dollar change calculation shall be made on thebasis of a complete rate containing a charge for bodily injury liability, personal in-jury protection (PIP), and property damage liability.

4. Insurers shall prepare:i. An example showing the calculation of the high and low values for the per-

centage and dollar change ranges;ii. Data about the insurer's territorial rates to confirm that the highest and lowest

basic limit Limitation on Lawsuit Option rates have been used in the example. Arating page showing a list of Standard tier, basic limit rates by territory shall besufficient;

11:3-15.1 11:3-15.8

iii. Data about the insurer's increased limits liability rating, vehicle usage, andtype of driver factors to confirm that the proper relativities have been used in theexample. The appropriate rating pages shall be sufficient; and

iv. For those insurers offering only single limit liability coverage, an explana-tion of the procedure used to develop the bodily injury liability rate from whichthe percentage and dollar change amounts have been determined. This explanationshall include an example of the calculation methodology.Repeal and New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999);R.2011 d.166, effective June 6, 2011.

11:3-15.7. Use of Coverage Selection Form; availability. (a) For all new pol-icies, an insurer or an insurance producer shall receive a Coverage Selection Formsigned by the named insured and indicating the prospective insured's coveragechoices. Coverage shall not become effective until the signed Coverage SelectionForm is received from the named insured, unless otherwise authorized by law.

(b) For the mid-term policy changes set forth in (b)1 through 5 below, the in-surer shall receive a Coverage Selection Form signed by the named insured priorto making the change.

1. Change of policy type to Standard or Basic; 2. Change of Lawsuit Option (Standard Policy only): 3. Change of primary coverage for PIP medical expense benefits coverage

(from or to Health Insurer Primary) (Standard Policy only); 4. Change in PIP Medical Expense Coverage Limit (Standard Policy only); and 5. Addition or deletion of Liability Coverage (Basic Policy only). (c) An insurer may require that other policy changes be made by signed Cov-

erage Selection Form. (d) All coverage changes that are required to be made by a signed Coverage

Selection Form, either by this subchapter or by the insurer, shall become effectivein the following manner, except when coverage for comprehensive or collision iseffected by a required inspection pursuant to N.J.A.C. 11:3-36.

1. For new policies, the choices on the Coverage Selection Form shall be effec-tive on the policy effective date;

2. For mid-term policy changes, the choices on the Coverage Selection Formshall be effective the day following the date of postmark or, when personal deliv-ery is made or if the postmark is illegible, the day following receipt of the signedCoverage Selection Form by the insurer or an insurance producer. If the change ismade electronically, the change shall be effective the day following date of receiptas determined in accordance with N.J.S.A. 12A:12-15;

3. For changes upon renewal, the changes shall be effective on the date of thenext policy renewal if postmarked or received by the insurer or by an insuranceproducer prior to the renewal date. New Rule. R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended. R.2001 d. 44, effective February 5, 2001; R.2004 d.117, effective March 15, 2004; R.2005 d.83, effectiveMarch 7, 2005.

11:3-15.8. New Jersey Automobile Insurance Consumer Bill of Rights. (a)The insurer shall produce a Consumer Bill of Rights by reproducing the New Jer-sey Automobile Insurance Consumer Bill of Rights available on the Department’swebsite at http:www.state.nj.us/dobi/autorights.pdf. The Department shall notifyinsurers of any changes to the Consumer Bill of Rights by Bulletin. Insurers shall


provide the Consumer Bill of Rights, as revised, with new and renewal business60 days after the date of the Bulletin.

(b) The Consumer Bill of Rights shall be reproduced in the format as presentedon the website, duplicating the language provided therein, and to the extent prac-ticable, the layout, fonts, type-point sizes, colors and illustrations. Notwithstand-ing the foregoing, all language bolded on the Consumer Bill of Rights as depictedon the Department’s website shall be bolded and no type-point sizes less than 10point shall be used.

(c) The Consumer Bill of Rights shall contain:1. An overview containing the purpose of the Bill of Rights;2. The consumer’s obligations with regard to their insurance;3. The duties of the insurer concerning the application process;4. The consumer’s general insurance rights regarding denials and right to pur-

chase;5. The consumer’s right to appeal a cancellation of insurance;6. Instructions on how to be an educated insurance consumer; and7. A statement advising the insured or applicant that additional information

concerning the Coverage Selection Form and Buyer’s Guide is available by con-tacting the insurer or the producer.Amended. R.2006 d.243, effective July 3, 2006.

11:3-15.9. Penalties. Failure to comply with the provisions of this subchaptermay result in the imposition of penalties as prescribed by law.Recodified from N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March22, 1999); Re-recodified from 11:3-15.8 by R.2004 d.117, effective March 15, 2004.

11:3-15.10. (Reserved).Repealed by R.1998 d.595, effective December 21, 1998 (operative March 22, 1999).

11:3-15.11. (Reserved).Recodified to N.J.A.C. 11:3-15.11 by R.1998 d.595, effective December 21, 1998 (operative March22, 1999).

EXHIBIT 1STANDARD POLICY COVERAGE SELECTION FORMName:___________________________________________________This Coverage Selection Form is for a STANDARD POLICY, see Buyer's

Guide, page insert page # here. A BASIC POLICY with the minimum of requiredcoverages is also available for a lower premium. A SPECIAL POLICY with avery low premium is also available for persons enrolled in Medicaid. Contact yourinsurer or producer for more information.

BODILY INJURY LIABILITY--Buyer's Guide page insert page # hereChoose the Bodily Injury Liability Limits that you want:________________________________________________________________________________________________________________________________________________________________________At least four of the most popular coverage limits shall be listed, including the

lowest limit offered. If a complete list is not provided, state that other coveragelimits are available.

PROPERTY DAMAGE LIABILITY--Buyer's Guide page insert page # hereChoose the Property Damage Limits you want:________________________________________________________________________________________________________________

11:3-15.1 11:3-15.11

________________________________________________________At least four of the most popular coverage limits shall be listed, including the

lowest limit offered. If a complete list is not provided, state that other coveragelimits are available. For insurers offering combined single limits, substitute atleast four of the most popular combined single limits, including the lowest offered.

PERSONAL INJURY PROTECTION (PIP)--Buyer's Guide insert page # here[ ] I choose the standard PIP Medical Expense Limit of $250,000. Include high-

er limit if offered[ ] I choose one of the lower PIP Medical Expense Limits below.WARNING: Prior to insert effective date of P.L. 1998, c.21, all auto insurance

policies had PIP Medical Expense Benefit limits of $250,000. The limits belowprovide you with less coverage. Warning must be in at least 12 point type.

[ ] $150,000* for a ___% to ___% reduction in the PIP premium[ ] $75,000* for a ___% to ___% reduction in the PIP premium[ ] $50,000* for a ___% to ___% reduction in the PIP premium[ ] $15,000* for a ___% to ___% reduction in the PIP premium* Even if you choose one of the amounts above, all medically necessary treat-

ment over the policy limit up to $250,000 will be paid for permanent or significantbrain injury, spinal cord injury or disfigurement or treatment of other permanentor significant injuries rendered at a trauma center or acute care hospital immedi-ately following the accident and until a doctor says that you no longer require crit-ical care.

Choose the PIP Medical Expenses Deductible you want:[ ] $250 deductible, minimum required by law.[ ] $500 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $1,000 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $2,000 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $2,500 deductible, for a ___% to ___% reduction in the PIP premium.Health Insurer for PIP Option[ ] I choose the health insurer for PIP option--Buyer's Guide, page insert page

# here.The name of my health insurer(s) is (are):1._____________________________________________________Policy/Group #/Certificate #2._____________________________________________________Policy/Group #/Certificate #_________________________________Extra PIP Package Coverage OptionsThe Extra PIP Package benefits include income continuation, essential servic-

es, death benefits and funeral expense benefits--Buyer's Guide page insert page #here

You may choose not to have the Extra PIP Package benefits for a ___% to___%savings in the ___ PIP premium. Include the range of percentage savings and

the base PIP premiumI choose PIP Medical Expense OnlyYou may choose to have higher limits for the Extra PIP Package of Income

Continuation, Essential Services, Death and Funeral Benefits. Buyer's Guide pageinsert page # here

Insert a chart listing options and choices


UNINSURED/UNDERINSURED MOTORIST COVERAGE--Buyer'sGuide, Page insert page # here

You may choose one of the following higher limits of Uninsured/UnderinsuredMotorist Coverage, up to your Bodily Injury Liability Insurance Limit.

_____________________________________________________________________________________________________________________________________________________________________List the same options available for bodily injury liability coverage above. Oth-

er options may also be listed.COLLISION COVERAGE--Buyer's Guide, page insert page # here[ ] No, I choose not to be covered for collision damage.[ ] Yes, I choose to be covered for collision damage with the default $750 de-

ductible.[ ] Yes, I choose to be covered for collision damage with the deductible circled

here: $1,000, $1,500 or $2,000. This premium will be less than the premium withthe default $750 deductible. Details available from company or insurance produc-er (i.e., agent or broker).

[ ] Yes, I choose to be covered for collision damage with the deductible circledhere: $100, $150, $200, $250 or $500. This premium will be more than the premi-um with the default $750 deductible. Details available from insurer or insuranceproducer.

Insert provision for coverage/no coverage per car if availableCOMPREHENSIVE COVERAGE Buyer’s Guide page insert page # here. If

appropriate, use the term “other than collision” coverage throughout this section[ ] No, I choose not to be covered for comprehensive damage.[ ] Yes, I choose to be covered for comprehensive damage with the default $750

deductible.[ ] Yes, I choose to be covered for comprehensive damage with the deductible

circled here: $1,000, $1,500 or $2,000. This premium will be less than the premi-um with the default $750 deductible. Details available from insurer or insuranceproducer.

[ ] Yes, I choose to be covered for comprehensive damage with the deductiblecircled here: $100, $150, $200, $250 or $500. This premium will be more than thepremium with the default $750 deductible. Details available from insurer or insur-ance producer.

Insert provision for coverage/no coverage per car if availableFor both collision and comprehensive, if either the $200 deductible or $250 de-

ductible is not offered, that option may be deleted from this form. Also, all otheravailable collision and comprehensive deductibles shall be listed where appropri-ate.

WARNING: Insurers or their producers or representatives shall not be held li-able for choices you make for insurance coverages or limits as long as your choic-es provide at least the minimum coverage required by law. Insurers or their pro-ducers or representatives also shall not be held liable if you choose not to purchasehigher limits of PIP medical expense coverage, higher limits of uninsured/under-insured motorists coverage, collision coverage or comprehensive coverage. Insur-ers, their producers and representatives can lose this limitation on liability for fail-ing to act in accordance with the law. See N.J.S.A. 17:28-1.9 for more informa-tion. Warning must be in at least 12 point type.

11:3-15.1 11:3-15.11

LAWSUIT OPTIONS, Buyer's Guide, page insert page # here[ ] I want the Limitation on Lawsuit Option.[ ] I want the No Limitation on Lawsuit Option. My bodily injury liability pre-

mium will be ___% to ___% higher if I select the No Limitation on Lawsuit optioninstead of the Limitation on Lawsuit option, depending upon where my car is ga-raged, my bodily injury liability coverage limit, and other factors. Per vehicle, mybodily injury liability premium at current rates will be $___ to $___ higher on each___renewal of my policy if I select the No Limitation on Lawsuit option insteadof the Lawsuit option. I understand that I can contact my insurer or my insuranceproducer for specific details.

Insurance companies writing six month policies should insert the word “semi-annual” in the blank space above. Companies writing 12 month policies shouldinsert the word “annual.”

Insurance companies writing single limit liability coverage may add a footnoteto inform insureds that the policy declaration page will not include a specific pre-mium for “bodily injury liability” coverage.

WARNING: Insurance companies or their producers or representatives shallnot be held liable for your choice of lawsuit option (limitation on lawsuit optionor no limitation on lawsuit option). Insurers or their producers or representativesalso shall not be liable if the limitation on lawsuit option is imposed by law be-cause no choice was made on the coverage selection form. Insurers, their produc-ers or representatives can lose this limitation on liability for failing to act in accor-dance with the law. See N.J.S.A. 17:28-1.9 for more information. Warning mustbe in at least 12 point type.

STATEMENT OF INSURED or APPLICANT:I have read the Buyer's Guide outlining the coverage options available to me.

The limits available for PIP medical expense coverage and uninsured and under-insured motorists coverage have been explained to me. My choices are shownabove. I agree that each of these choices will apply for all vehicles insured by mypolicy and to each subsequent renewal, continuation, replacement or amendmentuntil the insurer or its insurance producer receives my request that a change bemade.

For new policyholders, I understand that:(a) If I do not make a choice to have the No Limitation on Lawsuit Option, I

will receive the Limitation on Lawsuit option;(b) If I carry collision and/or comprehensive coverage without making a writ-

ten choice of deductible, I will receive the default $750 deductible;(c) If I do not choose to have my health insurer provide PIP medical expense

benefits, my auto insurer will provide PIP medical expense benefits; and(d) If I do not choose a lower PIP medical expense limit, I will receive the

$250,000 limit.I understand that if this is a policy renewal and if I do not complete choices, I

will receive the same coverage as in my previous policy except when changes arerequired by a law becoming effective during the term of my previous policy. I un-derstand that these choices take effect in the following manner:

(1) For new policies, on the effective date of the policy;(2) For mid-term policy changes, on the day following the date of postmark or,

when personal delivery is made or the postmark is illegible, the day following re-ceipt of this form by the insurer or producer; and


(3) For changes upon renewal, on the date of the next policy renewal if post-marked or received by the insurance company or by an insurance producer priorto the renewal date.

ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FORMOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATE-MENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THISSTATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILEDIN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL ANDCRIMINAL PENALTIES.

Please check the appropriate box to which this form applies:[ ] New Policy [ ] Mid-Term Change [ ] Renewal ChangeSIGNATURE OF NAMED INSUREDOR APPLICANT________________________________________DATE __________________

EXHIBIT 2CERTIFICATION OF COMPLIANCE WITH N.J.A.C. 11:3-15.6(G)4I hereby certify that the Lawsuit Option rate differentials in the Standard Policy

Coverage Selection Form for __________________ (Name of Insurance Compa-ny) were calculated in accordance with N.J.A.C. 11:3-15.6(g)4.

_______________________Signature_______________________Print Name_______________________Title_______________________Telephone Number

EXHIBIT 3BASIC POLICY COVERAGE SELECTION FORMName:_______________________________________________This Coverage Selection Form is for a BASIC POLICY, see Buyer's Guide,

page insert page # here. A STANDARD POLICY with more coverages and higherlimits is also available for a higher premium. A SPECIAL POLICY with a verylow premium is also available for persons enrolled in Medicaid. Contact your in-surer or producer for more information.

BODILY INJURY LIABILITY--Buyer's Guide page--insert page # here[ ] Yes, I choose the $10,000 Bodily Injury Liability Limit.[ ] No, I do not choose to have Bodily Injury Liability Coverage.WARNING: If you do not choose to have Bodily Injury Liability Coverage and

you are at fault in an accident where people are injured or die, you will be respon-sible for paying for the pain, suffering and other personal hardships and some eco-nomic damages, such as lost wages that you cause. Your insurer will not pay ajudgment against you or pay for a lawyer to defend you if you are sued. Your as-sets will be at risk, including having money deducted from your wages if a judg-ment is entered against you. Warning must be in at least 12 point type.

WARNING: Insurers or their producers or representatives shall not be held li-able for choices you make for insurance coverages or limits as long as your choic-es provide at least the minimum coverage required by law. Insurers or their pro-ducers or representatives also shall not be held liable if you choose to purchase a

11:3-15.1 11:3-15.11

basic policy instead of a standard policy, or if you choose not to purchase bodilyinjury liability coverage, collision coverage or comprehensive coverage. Insurers,their producers and representatives can lose this limitation on liability for failingto act in accordance with the law. See N.J.S.A. 17:28-1.9 for more information.

PERSONAL INJURY PROTECTION--Buyer's Guide, page insert page # hereWARNING: For a BASIC POLICY, the limit on PIP Medical Expense Cover-

age is $15,000 but includes up to $250,000 for emergency care of certain cata-strophic injuries (See Buyer's Guide page insert page # here). Prior to insert effec-tive date of P.L. 1998, c.21, all automobile insurance policies had PIP Medical Ex-pense limits of $250,000. The PIP Medical Expense Coverage for a BASICPOLICY is significantly less than previously required by law. Warning must be inat least 12 point type.

Choose the PIP Medical Expenses Deductible youwant:[ ] $250 deductible, minimum required by law.[ ] $500 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $1,000 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $2,000 deductible, for a ___% to ___% reduction in the PIP premium.[ ] $2,500 deductible, for a ___% to ___% reduction in the PIP premium.COLLISION COVERAGE--Buyer's Guide, page insert page # here[ ] No, I choose not to be covered for collision damage.[ ] Yes, I choose to be covered for collision damage with the basic deductible.[ ] Yes, I choose to be covered for collision damage with the deductible circled

here: $1,000, $1,500 or $2,000. This premium will be less than the premium withthe default $750 deductible. Details available from insurer or insurance producer.

[ ] Yes, I choose to be covered for collision damage with the deductible circledhere: $100, $150, $200, $250 or $500. This premium will be more than the premi-um with the default $750 deductible. Details available from insurer or insuranceproducer.

Insert provision for coverage/no coverage per car if availableCOMPREHENSIVE COVERAGE Buyer's Guide page insert page # here. If

appropriate, use the term “other than collision” coverage throughout this section[ ] No, I choose not to be covered for comprehensive damage.[ ] Yes, I choose to be covered for comprehensive damage with the default $750

deductible.[ ] Yes, I choose to be covered for comprehensive damage with the deductible

circled here: $1,000, $1,500 or $2,000. This premium will be less than the premi-um with the default $750 deductible. Details available from insurer or insuranceproducer.

[ ] Yes, I choose to be covered for comprehensive damage with the deductiblecircled here: $100, $150, $200, $250 or $500. This premium will be more than thepremium with the $750 deductible. Details available from insurer or insuranceproducer.

Insert provision for coverage/no coverage per car if available.These sections should be omitted by insurers that do not offer collision and

comprehensive coverage in the Basic Policy. For both collision and comprehen-sive, if either the $200 deductible or $250 deductible is not offered, that optionmay be deleted from this form. Also, all other available collision and comprehen-sive deductibles shall be listed where appropriate.

STATEMENT OF INSURED or APPLICANT:


I have read the Buyer's Guide outlining the coverage options available to me. Iunderstand that this is a BASIC POLICY with the minimum coverages requiredby law and that a Standard Policy with higher limits and additional coverages isavailable. The option to buy Bodily Liability Coverage has been explained to me.My choices are shown above. I agree that each of these choices will apply for allvehicles insured by my policy and to each subsequent renewal, continuation, re-placement or amendment until the insurer or its insurance producer receives myrequest that a change be made.

For new policyholders, I understand that:(a) Unless I choose to have the $10,000 Bodily Injury Liability Coverage, I will

not receive any Bodily Injury Liability Coverage;(b) If I choose collision or comprehensive coverage without making a written

choice of deductible, I will receive the $750 deductible; I understand that if this isa policy renewal and if I do not complete choices, I will receive the same coverageas in my previous policy except when changes are required by a law becoming ef-fective during the term of my previous policy.

I understand that these choices take effect in the following manner:(1) For new policies, on the effective date of the policy;(2) For mid-term policy changes, on the date of postmark or, when personal de-

livery is made or if the postmark is illegible, the day following receipt of this Formby the insurers or by a producer; and

(3) For changes upon renewal, on the date of the next policy renewal if post-marked or received by the insurance company or by an insurance producer priorto the renewal date.

ANY PERSON WHO KNOWINGLY MAKES AN APPLICATION FORMOTOR VEHICLE INSURANCE COVERAGE CONTAINING ANY STATE-MENT THAT THE APPLICANT RESIDES OR IS DOMICILED IN THISSTATE WHEN, IN FACT, THAT APPLICANT RESIDES OR IS DOMICILEDIN A STATE OTHER THAN THIS STATE, IS SUBJECT TO CIVIL ANDCRIMINAL PENALTIES.

Please check the appropriate box to which this formapplies.[ ] NEW POLICY [ ] Mid-Term Change [ ] Renewal ChangeSIGNATURE OF NAMED INSUREDOR APPLICANT_________________________________________DATE ________________________________________________New Rule, R.1998 d.595, effective December 21, 1998 (operative March 22, 1999). Amended,

R.2004 d.117, effective March 15, 2004; R.2011 d.166, effective June 6, 2011.

SUBCHAPTER 25. PRIVATE PASSENGER AUTOMOBILE INSURANCE: NOTIFICATION BY TREATING HEALTH CARE

PROVIDERSSource and Effective Date. R.1997 d.14, effective January 6, 1997.

Section11:3-25.1. Purpose and scope.11:3-25.2. Definitions.11:3-25.3. Notification of commencement of treatment.11:3-25.4. Content of notice and proof of receipt.11:3-25.5. Late notification.11:3-25.6. Standards for adjustment of reduction.11:3-25.7. Payment from insurers only.

NOTIFICATION BY MEDICAL PROVIDERS 11:3-25.2

11:3-25.8. Procedure for appeals.11:3-25.9. Reporting requirement.11:3-25.10. Compliance.APPENDIX A

Notification of Commencement of Medical TreatmentAPPENDIX B

Address for Notification of Commencement of Medical Treatment

11:3-25.1 Purpose and scope. (a) The purpose of this subchapter is to imple-ment N.J.S.A. 39:6A-5, as amended by P.L. 1995, c.407, by establishing proce-dures to be followed by treating medical providers to give timely notification ofthe commencement of medical treatment for injuries sustained in automobile ac-cidents. The subchapter sets forth:

1. Time limits for the filing of notification of the commencement of treatmentfor PIP claims;

2. The actions to be taken upon failure to comply with the notification timelimits, including reduction or denial of claim payments;

3. The factors to be considered in evaluation of a late notification; and 4. The rights of providers when payment is reduced or denied for failure to

comply with the notification requirements. (b) This subchapter shall apply to every insurer authorized to transact the busi-

ness of automobile insurance in this State. The subchapter applies to treatment forinjuries resulting from automobile accidents that occur after July 8, 1996.

11:3-25.2 Definitions. The following words and terms, when used in this sub-chapter, shall have the following meanings, unless the context clearly indicatesotherwise.

“Coverage status” means the status of PIP coverage for an injured party pursu-ant to N.J.S.A. 39:6A-5.


“Eligible charge” means the treating medical provider's usual, customary andreasonable charge or the upper limit on the medical fee schedule as found inN.J.A.C. 11:3-29.6, whichever is lower subject to provisions of N.J.A.C. 11:3-29.4.

“Emergency care” means all medically necessary treatment of a traumatic in-jury or a medical condition manifesting itself by acute symptoms of sufficient se-verity (including severe pain, psychiatric disturbance and/or symptoms of sub-stance abuse) such that absence of immediate attention could reasonably be ex-pected to result in: death; serious impairment to bodily functions; or seriousdysfunction of a bodily organ or part. Such emergency care shall include all nec-essary care immediately following an automobile accident, including, but not lim-ited to, immediate pre-hospital care, transportation to a hospital or trauma center,emergency room care, surgery, critical and acute care. Emergency care extendsduring the period of initial hospitalization until the patient is discharged fromacute care by the attending physician.

“Multiple treating medical provider” means a treating health care provider asdefined herein that provides emergency care, in association with one or more othertreating medical providers.

“Notification” or “notice” means a written communication, transmitted bymail, facsimile or electronic message (“E-mail”).


“Personal injury protection” or “PIP” means the coverage set forth at N.J.S.A.39:6A-4, 39:6A-3.1, or the emergency personal injury protection coverage provid-ed by a Special Automobile Insurance Policy pursuant to section 45 of P.L. 2003,c.89.

“PIP information” means: the name and address of the insured and the nameand address of the injured party, if different; the name of the PIP insurer and theaddress established by the insurer for notification of commencement of medicaltreatment pursuant to N.J.A.C. 11:3-25.3(c); the policy number of the insurancepolicy providing PIP benefits; and the date of the accident/injury. A treating med-ical provider may obtain this information from the insured, the injured party, thehospital, a police report or any other reasonably available source.

“Secondary medical providers” means those health care providers who providemedical products, care and services to a person injured in an automobile accidentonly after having received a prescription from a treating health care provider. Sec-ondary medical providers shall include, but are not limited to, pharmacists, visit-ing nurses, prosthetics fabricators and providers of durable medical equipmentproducts. Notwithstanding the existence of a prescription of a treating medicalprovider, physical therapists, chiropractors and any secondary medical providerwho seeks payment of an eligible charge in excess of $500.00 for individual ser-vices or products provided on one occasion or in the course of 30 days shall notbe considered secondary medical providers.

“Treating health care provider” means those persons licensed or certified toperform health care treatment or services compensable as medical expenses andshall include, but not be limited to:

1. A hospital or health care facility which is maintained by a state or any of itspolitical subdivisions;


3. Other hospitals or health care facilities designated by the Department ofHealth and Senior Services to provide health care services, or other facilities, in-cluding facilities for radiology and diagnostic testing, freestanding emergencyclinics or offices, and private treatment centers;

4. A nonprofit voluntary visiting nurse organization providing health care ser-vices other than in a hospital;

5. Hospitals or other health care facilities or treatment centers located in otherstates or nations;

6. Physicians licensed to practice medicine and surgery;7. Licensed chiropractors;8. Licensed dentists;9. Licensed optometrists;10. Licensed pharmacists;11. Licensed chiropodists (podiatrists);12. Registered bio-analytical laboratories;13. Licensed psychologists;14. Licensed physical therapists;15. Certified nurse-midwives;16. Certified nurse-practitioners/clinical nurse-specialists17. Licensed health maintenance organizations;18. Licensed orthotists and prosthetists;19. Licensed professional nurses;20. Licensed occupational therapists;21. Licensed speech-language pathologists;22. Licensed audiologists;


23. Licensed physician assistants;24. Licensed physical therapists assistants;25. Licensed occupational therapy assistants; and26. Providers of other health care services or supplies, including durable med-

ical goods.Amended. R 1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, ef-fective June 7, 2004.

11:3-25.3 Notification of commencement of treatment(a) When medical treatment is rendered for which a claim for payment will be

made pursuant to the PIP coverage of a private passenger automobile insurancepolicy, a treating health care provider shall provide notice to the PIP insurer no lat-er than 21 days following the date of the commencement of such treatment.

(b) In accordance with the PIP information provided by the injured party or theinsured, notice shall be sent by the treating health care provider to the insurer atthe address established by the insurer for the receipt of such notice.

(c) Insurers shall establish one address where notice must be sent by treatinghealth care providers pursuant to these rules. Insurers shall provide this address,and may provide a facsimile transmission number, and E-mail address if any, onall insurance identification cards issued by the insurer after January 6, 1997.

(d) In accordance with the provisions of N.J.A.C. 11:3-25.10, insurers shall filewith the Department the address, and may provide a facsimile transmission num-ber, and E-mail address, if any, where notice of commencement of treatmentshould be sent. Insurers shall also include the name and telephone number of acontact person at the insurer for this purpose. Such information shall be added toa list of insurer addresses maintained by the Department.

(e) Notice sent to the address printed on a valid insurance identification card oron the Department's current list of addresses shall be presumed to have been sentto the proper address.

(f) Within 14 days after receiving notice of the commencement of treatment,the insurer shall notify the treating health care provider of the coverage status ofthe person receiving treatment. If the notice from the insurer states that the cover-age status of the person receiving treatment is unknown, the insurer shall make adetermination of coverage and provide written confirmation to the treating healthcare provider no later than 60 days from receipt of notice of commencement oftreatment. Examples where the coverage status may not be known are when theinjured person is not a named insured, principal or occasional operator, or is nototherwise listed as a resident of the insured household on the most recent informa-tion provided to the insurer by the named insured.

(g) The notice requirements set forth in (a) through (c) above and the eligiblecharge reductions contained in N.J.A.C. 11:3-25.5 shall not apply to secondarymedical providers, except as noted in the definition of that term found in N.J.A.C.11:3-25.2.

(h) In calculating the time for notice in (a) and (f) above, the day treatment be-gins or the day the insurer receives notice from the treating health care provider isnot to be included. If the last day for providing notice falls on a Saturday, Sundayor legal holiday, the time runs to the next business day.Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).

11:3-25.4 Content of notice and proof of receipt(a) The treating health care provider shall send the written notice required by

N.J.A.C. 11:3-25.3(a) to the PIP insurer on either:


1.The “Notification of Commencement of Medical Treatment Form” found inAppendix A, appended to and incorporated by reference in this subchapter; or

2.A bill or invoice rendered by the treating health care provider that includesthe information required in the “Notification of Commencement of Medical Treat-ment Form” in Appendix A.

(b) When any notice required by this subchapter is mailed, the postmark shallbe the proof of mailing. The insurer shall retain evidence of untimely mailing ofthe notice whenever it denies or reduces payment pursuant to N.J.A.C. 11:3-25.5.

(c) If facsimile or E-mail notice is authorized by the insurer, and any notice re-quired by this subchapter is sent by facsimile or by E-mail, the proof of noticeshall be the facsimile transmission receipt generated by the sender's facsimile ma-chine, a copy of the E-mail message showing the date and time of transmittal oran acknowledgment of receipt generated by the receiving system. Nothing in thissection shall prohibit treating health care providers and insurers from mutuallyagreeing to accept other proofs of notice for electronic transmissions. It shall bethe responsibility of the treating health care provider to retain proof of notice ofcommencement of treatment transmitted by facsimile or other electronic means.

(d) Any notice given pursuant to this subchapter shall be deemed to have beenmade on the date of postmark or the date of transmission in the case of facsimiletransmission and E-mail.

(e) When a bill or invoice is used to provide notice of the commencement oftreatment in accordance with this subchapter, it shall not be deemed to constitutenotice unless the following message appears on the first page of the bill or invoice:“21 DAY NOTICE” or “FIRST BILL 21 DAY NOTICE.” this message shall bein contrasting color ink and be in at least 12 point capital letters. Use of a rubberstamp or affixed label is acceptable for purposes of complying with this subsec-tion.Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).

11:3-25.5 Late notification(a) In the event notice of commencement of medical treatment is made after 21

days, the insurer shall advise the treating health care provider in writing of the latenotification and may reserve the right to deny or reduce payment in accordancewith (b) below.

(b) Where notice of the commencement of medical treatment is not timely pro-vided in accordance with this subchapter, an insurer may apply the following re-ductions to the eligible charges:

1. 22 to 30 days after the commencement of treatment: 10 percent reduction.2. 31 to 60 days after the commencement of treatment: 25 percent reduction.3. 61 to 120 days after the commencement of treatment: 50 percent reduction.4. 121 to 160 days after the commencement of treatment: 75 percent reduction.5. 161 or more days from the commencement of treatment: 100 percent reduction.(c) If notice is not provided as required by this subchapter, the reduction for-

mula set forth in (b) above shall apply to all eligible charges for which the treatinghealth care provider seeks payment through such late notice.

(d) Insurers shall not reduce an eligible charge under the following circum-stances:

1. When the provider is a multiple treating health care provider giving emer-gency care as defined in N.J.A.C. 11:3-25.2;

2. When the provider is a secondary medical provider as defined in N.J.A.C.11:3-25.2;


3. When the medical condition of the injured party made it impossible to com-ply with the notice requirement; or

4. When the provider has submitted a request for decision point review or pre-certification of treatment, diagnostic testing or durable medical equipment in ac-cordance with an insurer’s decision point review plan approved in accordancewith N.J.A.C. 11:3-4.7Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999); R.2004 d.218, ef-fective June 7, 2004.

11:3-25.6 Standards for adjustment of reduction(a) Notwithstanding the reductions set forth in N.J.A.C. 11:3-25.5(b), insurers

may choose to pay the full or a less reduced amount of an eligible charge basedupon consideration of the following factors:

1. Whether the treating health care provider has previously provided untimelynotice under this subchapter or has established a pattern of untimely notice;

2. The cost of medical treatment provided by the treating health care providerbetween the time treatment commenced, when notice was due and when it wasprovided;

3. The injured party was a pedestrian who did not have PIP coverage as thenamed insured or resident relative under another policy and the circumstances aresuch that additional time is necessary to identity the policy under which coverageis being provided;

4. Any potential adverse impact on the public and5. Such other factors as the insurer may determine.(b) Within 60 days of receipt of notice, or such additional time as may be af-

forded under N.J.S.A. 39:6A-5g, the insurer shall give the treating health care pro-vider notice of its final determination as to payment, reduction or denial of pay-ment of an eligible charge. Such notice shall be clearly labeled “Final Determina-tion,” and it shall refer clearly to the injured party, the insured, the claim number,the date of accident, the date of first treatment, the date notice of the commence-ment of treatment was made and the acceptance or rejection of any of the stan-dards of adjustment of the reduction in (a) above and N.J.A.C. 11:3-25.5(b).Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).

11:3-25.7 Responsibility for paymentWhenever an eligible charge has been reduced or denied pursuant to N.J.A.C.

11:3-25.5(b), the treating health care provider shall not seek to obtain payment di-rectly from the insured or the person receiving treatment.Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).

11:3-25.8 Procedure for appealsA treating health care provider who fails to notify the insurer within 21 days

and whose claim has been reduced or denied by the insurer pursuant to N.J.A.C.11:3-25.5(b) may, in the discretion of a judge of Superior Court, be permitted torefile such claim provided that the insurer has not been substantially prejudicedthereby. Application to the court for permission to refile a claim shall be madewithin 14 days of the receipt of the insurer's final determination of reduction ordenial of payment and shall be made upon motion based upon affidavits showingsufficient reasons for the failure to notify the insurer within 21 days of the com-mencement of treatment.Amended. R.1998 d.591, effective December 21, 1998 (operative March 22, 1999).


11:3-25.9 Reporting requirement(a) By February 5, 1997, every insurer shall file with the Department the ad-

dress, facsimile number (if notice by facsimile is permitted) and E-mail address,if any, of the designated location for the filing of notice required under this sub-chapter. Insurers shall use Appendix B, appended to and incorporated by referencein this subchapter, to report the information required by this subsection.

(b) Insurers shall complete and file the information in Appendix B by January1 of each year.

(c) Completed copies of Appendix B shall be submitted to:Department of Banking and InsuranceDirector of Public AffairsPO Box 325Trenton, New Jersey 08625-0325

11:3-25.10. Compliance.For treatments rendered between January 6, 1997 and July 6, 1997, all eligible

charge reductions set forth in N.J.A.C. 11:3-25.5(b) shall be reduced by 50 percent(for example, a 10 percent reduction shall be five percent, a 25 percent reductionshall be 12.5 percent, etc.).

APPENDIX ANotification of Commencement of Medical Treatment

(to be filed with insurer)Name, address and phone No. of Treating Health Care Provider:________________________________________________________________Fax No. (optional)_________________________________________________

Name and address of insured:Name and address of patient: (if different)_____________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ _______________________________

Insurer Name: __________________________________________________

Insurer Address:_______________________________________________________________________________________________ Policy No. _____________________

Date of accident/injury: ___________________________________________

Date of first treatment:____________________________________________

APPENDIX BAddress for Notification of Commencement of Medical Treatment

Insurance Co. Name: _____________________________________________


NAIC Group #: _________________ NAIC Company #: ______________

Address established by insurer for the filing of the notification of the commencement of PIP treatment by Treating Health Care Providers

Address: __________________________________________________________________________________________________________________

Facsimile No: ____________________________________________________

E-mail: _________________________________________________________

Contact Person: __________________________________________________

Phone: __________________________________________________________

To be filed with:Department of Banking and InsuranceDivision of Public AffairsPO Box 325Trenton, New Jersey 08625-0325Attn: Notification of Treatment List

SUBCHAPTER 26. UNSATISFIED CLAIM AND JUDGMENT FUND: NOTICE OF INTENT

Section11:3-26.1. Claim information.11:3-26.2. Claim filing; form.

11:3-26.1. Claim information. (a) Notice of intention to make a claim underN.J.S.A. 39:6-65 shall contain the following information:

1. The claimant’s name, address, date of birth and social security number;2. The time, date, location, municipality and county in which the loss occurred;3. The identity of the operators and vehicles involved in the accident, including

the name and address of the owner and operator and the license plate number ofthe vehicle;

4. Such witnesses to said accident as are then known;5. A short description of the accident, including the claimant’s role or position

therein;6. A description of the injuries then known, and attached thereto a medical cer-

tificate if then available. In any event the medical certificate shall be filed as soonas available;

7. A description of the damage sustained to property, and attached thereto anestimate of the cost of repairs if then available; and

8. The policy number of any insurance applicable to the accident, including thename and address of all insurance companies involved.Amended. R. 1991 d. 45, effective February 4, 1991; Amended. R. 1996 d. 58, effective February 5,1996.

11:3-26.2. Claim filing; form. (a) A Notice of Intention to Make Claim underN.J.S.A. 39:6-65 may be filed on the form designated by the Unsatisfied Claim


and Judgment Fund Board identified as a “Notice of Intention to Make Claim”,incorporated herein by reference as Appendix A [See Appendix C-20]

(b) A written notice to the Board in any other form that contains the informa-tion required by this section shall be acceptable.

(c) A notice of intention to make a claim that does not contain the items iden-tified in N.J.A.C. 11:3-26.1(a)1 through 8 shall be returned to the sender anddeemed to be not filed with the Unsatisfied Claim and Judgment Fund (UCJF) forthe purpose of complying with N.J.S.A. 39:6-65 and shall not toll the statute oflimitations.Amended. R.1991 d.45, effective February 4, 1991; R.1996 d.58, effective February 5, 1996; R.1997d.85, effective February 18, 1997; R.2006 d.243, effective July 3, 2006.

SUBCHAPTER 27. UNSATISFIED CLAIM AND JUDGMENT FUND BOARD

Section11:3-27.1. Uninsured’s Current Financial Status.

11:3-27.1. Uninsured’s Current Financial Status. (a) Upon review of a caseby the Unsatisfied Claim and Judgment Fund Board’s designee, if the designeedoes not have sufficient current information to determine whether or not the unin-sured’s installment payment is reasonable, a request will be addressed to the un-insured asking for a statement of current financial status.

(b) If the uninsured fails to furnish a completed statement of current financialstatus within a time period to be established by the executive director, the Unsat-isfied Claim and Judgment Fund Board’s designee will request the Director ofMotor Vehicles to suspend the license and all registrations of the uninsured pursu-ant to N.J.S.A. 39:5-30 and 39:5-87, for failure to furnish this information.Amended. R.2006 d.243, effective July 3, 2006.

SUBCHAPTER 28. UNSATISFIED CLAIM AND JUDGMENT FUND’S REIMBURSEMENT OF EXCESS MEDICAL EXPENSE BENEFITS PAID

BY INSURERSSection11:3-28.1. Purpose and scope.11:3-28.2. Definitions.11:3-28.3. Report of such claims when the carrier has paid at least $50,000 for

medical expense benefits.11:3-28.4. Notice of change in the amount of reserves.11:3-28.5. Supplemental form to be submitted to the Fund.11:3-28.6. Insurer's continuing obligation to investigate claims.11:3-28.7. Reimbursement of excess medical expense benefits paid by insurers.11:3-28.8. Audits.11:3-28.9. Reporting of losses for personal injury protection payments in

excess of $75,000.11:3-28.10. Insurers' obligations to investigate and audit bills for medical

benefits.11:3-28.11. Modifications to vehicles.11:3-28.12. Modifications to a claimant's residence.11:3-28.13. Insurer's obligation to obtain recovery of payments for paid medical

expense benefit claims.

UCJF 11:3-28.2

11:3-28.14. Insurer’s responsibility upon assignment of an uninsured motorist claim.

11:3-28.15. Reserved.11:3-28.16. Reserved.11:3-28.17. Reserved.

11:3-28.1 Purpose and scope (a) The purpose of this subchapter is to establish procedures to ensure that

only appropriate, reimbursable claims are submitted to the Fund by insurers by re-quiring investigation of the medical necessity for certain claims; requiring the au-dit of claims of $10,000 or more submitted by licensed providers of health careservices or claims of $25,000 or more by health care facilities; and requiring priorapproval of claims for alterations to vehicles and residences. This subchapter alsorequires insurers to pursue the proper, alternative sources for reimbursementwhere such other sources of funds are available.

(b) This subchapter applies to all insurers authorized in this State to write thekinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1. In accor-dance with N.J.S.A. 39:6-73.1, reimbursement for medical expense benefits maybe sought from the Fund on account of personal injury to any one person in anyone accident occurring on or after February 19, 1978.

(c) N.J.A.C. 11:3-28.13 establishes standards for insurers to demonstrate dili-gent pursuit of any potentially responsible tortfeasor for the purpose of recoveringPIP medical expense benefits paid on behalf of the injured party by the Fund. In-surers shall obtain reimbursement from the Fund for excess medical expense ben-efit payments once they comply with the standards established herein. The pur-pose of these provisions are to contain costs for automobile insurance in this State.Accordingly, consistent with this purpose and N.J.S.A. 39:6A-9.1, for accidentsoccurring outside this State, insurers are expected to assert appropriate legal rem-edies to pursue recovery actions against potentially responsible tortfeasors, con-sistent with the legal rights and remedies asserted by the injured party.Repeal and New Rule, R.1993 d.583, effective November 15, 1993. See:25 N.J.R. 2636(b), 25 N.J.R.5219(a). Amended. R. 2001 d. 151, effective May 7, 2001.

11:3-28.2 Definitions The following words and terms, when used in this subchapter, shall have the

following meanings unless the context clearly indicates otherwise: “Board” means the Board of the New Jersey Property-Liability Insurance

Guaranty Association created in accordance with N.J.S.A. 17:30A-1 et seq. “Diagnosis related groups” or “DRG” means a patient classification scheme in

which cases are grouped by shared characteristics of principal diagnosis, second-ary diagnosis, age, surgical procedure, and other complications. Each DRG exhib-its a consistent amount of resource consumption as measured by some unit (for ex-ample, length of stay or dollars).

“Excess medical expense benefits” means medical expense benefits paid inaccordance with N.J.S.A. 39:6A-4a or 39:6A-3.1 that are in excess of $75,000 re-sulting from personal injury to any one person in any one accident.

“Fund” means the Unsatisfied Claim and Judgment Fund established pursu-ant to N.J.S.A. 39:6-61 et seq.

“Health care facility” means a health care provider that is a facility or insti-tution, whether public or private, engaged principally in providing services for di-agnosis of treatment of pain, injury, deformity or physical condition, including,but not limited to, a general hospital, special hospital, public health center, diag-


nostic center, treatment center, rehabilitation center, extended care facility, skillednursing home, nursing home, intermediate care facility, outpatient clinic, dispen-sary or residential health care facility.

“Health care provider” or “provider” means those persons licensed or certi-fied to perform health care treatment or services compensable as medical expensesand shall include, but not be limited to:

1. A hospital or health care facility which is maintained by a state or any of itspolitical subdivisions;


3. Other hospitals or health care facilities designated by the Department ofHealth and Senior Services to provide health care services, or other facilities, in-cluding facilities for radiology and diagnostic testing, freestanding emergencyclinics or offices, and private treatment centers;

4. A nonprofit voluntary visiting nurse organization providing health care ser-vices other than in a hospital;

5. Hospitals or other health care facilities or treatment centers located in otherstates or nations;

6. Physicians licensed to practice medicine and surgery;7. Licensed chiropractors;8. Licensed dentists;9. Licensed optometrists;10. Licensed pharmacists;11. Licensed chiropodists (podiatrists);12. Registered bio-analytical laboratories;13. Licensed psychologists;14. Licensed physical therapists;15. Certified nurse-midwives;16. Certified nurse-practitioners/clinical nurse-specialists17. Licensed health maintenance organizations;18. Licensed orthotists and prosthetists;19. Licensed professional nurses;20. Licensed occupational therapists;21. Licensed speech-language pathologists;22. Licensed audiologists;23. Licensed physician assistants;24. Licensed physical therapists assistants;25. Licensed occupational therapy assistants; and26. Providers of other health care services or supplies, including durable med-

ical goods.“Health care service” means the preadmission, outpatient, inpatient and post-

discharge care provided in or by a health care facility, and such other items or ser-vices as are necessary for such care, which are provided by or under the supervi-sion of a physician for the purpose of diagnosis or treatment of pain, injury, dis-ability, deformity or physical condition, including, but not limited to, nursingservice, home care nursing and other paramedical service, ambulance service, ser-vice provided by an intern, resident in training or physician whose compensationis provided through agreement with a health care facility, laboratory service, med-ical social service, drugs, biologicals, supplies, appliances, equipment, bed andboard.

“Insurer” means any person authorized or admitted in this State to write thekinds of insurance specified in paragraphs d and e of N.J.S.A. 17:17-1, pursuant

UCJF 11:3-28.5

to N.J.S.A. 17:17-1et seq. or 17:32-1 et seq., as applicable. “Insurer” shall not in-clude a surplus lines insurer eligible to write business pursuant to N.J.S.A. 17:22-6.40 et seq.

“Licensed nursing personnel” or “licensed nurse” means a nurse licensed bythe New Jersey State Board of Nursing or the equivalent from another jurisdiction.

“Medical expense benefits” means medical expense benefits paid in accor-dance with N.J.S.A. 39:6A-4a or 39:6A-3.1 and N.J.A.C. 11:3-4.

“Medically necessary” is as defined in N.J.A.C. 11:3-4.2. “Per diem” means a daily fixed charge which includes room and board and

other fees for services and supplies. “PIP coverage” means personal injury protection coverage as described at

N.J.S.A. 39:6A-4 or 39:6A-3.1. “Person” means any individual, association, company, corporation, insurer,

joint stock company, organization, partnership, society, syndicate, trust, any com-bination of the foregoing acting in concert or any other entity.

“Pre-screen means an off-site review of the billings from a health care facilityto determine whether the care given and amounts charged are appropriate.

“Provider” means any person that furnishes services or equipment for medicalexpense benefits for which payment is required to be made under PIP coverage inautomobile insurance policies, but does not include health care facilities.

“Reimbursement” refers to reimbursement to insurers by the Fund as provid-ed at N.J.S.A. 39:6-73.1.

“Uninsured motorist claims” means claims submitted against operators ofuninsured vehicles and hit and run claims submitted pursuant to N.J.S. 39:6-61.

New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.1994 d.597, effective De-cember 5, 1994; R.1997 d.535, effective December 15, 1997; R.1998 d.591, effective December 21,1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006.

11:3-28.3 Report of such claims when the carrier has paid at least $50,000for medical expense benefits

In cases where the potential exposure to the automobile liability insurer ex-ceeds $75,000, the insurer shall report on form UCJF Form 1(321) (incorporatedherein by reference as Form 1 in Appendix A) [Publishers note: not included here-in] whenever medical expense benefits in a total amount of $50,000 have beenpaid on account of personal injury to any one person in any one accident.Recodified from 11:3-28.2 and amended by R.1993 d.583, effective November 15, 1993. See: 25N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997.

11:3-28.4 Notice of change in the amount of reserves Whenever an automobile liability insurer has paid medical expense benefits

on account of personal injury to any one person in any one accident in a totalamount of $50,000, said insurer shall notify the Fund of any changes in the amountof reserves established for payment of the claim or closing of the file.Recodified from 11:3-28.3 and amended by R.1993 d.583, effective November 15, 1993. See: 25N.J.R. 2636(b), 25 N.J.R. 5219(a).

11:3-28.5 Supplemental form to be submitted to the Fund (a) UCJF Form 2(RR) (incorporated herein by reference as Form 2 in Ap-

pendix A), shall be filed with the Fund within 90 days after an automobile insurerhas paid medical expense benefits on account of personal injury to any one personin any one accident in a total amount in excess of $75,000. Such form togetherwith UCJF Form 3(323) (incorporated herein by reference as Form 3 in AppendixA) [Publishers note: not included herein] shall be filed each quarter thereafter thatthe insurer seeks reimbursement.


(b) Any office of an insurer seeking reimbursement of funds from the UCJF forpersonal injury protection medical expense must also complete and file with theUCJF a New Jersey Information Questionnaire, UCJF Form 4(W-9) (incorporatedherein by reference as Form 4 in Appendix A) [Publishers note: not included here-in].Recodified from 11:3-28.4 and amended by R.1993 d.583, effective November 15, 1993. See: 25N.J.R. 2636(b), 25 N.J.R. 5219(a); Amended R.1997 d.85, effective February 18, 1997.

11:3-28.6 Insurer's continuing obligation to investigate claims (a) An automobile liability insurer shall be required to discharge its duty of

investigating claims where the potential exposure to the insurer exceeds $75,000.Said insurer's duty and obligation with regard to claim handling shall exist andcontinue to exist notwithstanding this rule. The Executive Director may directsuch investigations as often as he or she deems necessary. All expenses relating tothe investigation of claims, including expenses for medical examinations, filemaintenance and cost containment measures, are the responsibility of the automo-bile liability insurer.

(b) The failure to properly discharge the duty of investigating a claim mayresult in the imposition of a penalty, to be determined by the Board’s designee,against the insurer's request for reimbursement.Amended. R.1991 d.45, effective February 4, 1991. Recodified from 11:3-28.5 and amended byR.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3, 2006.

11:3-28.7 Reimbursement of excess medical benefits paid by insurers (a) Insurers shall submit to the Fund itemized accounts with supporting doc-

umentation of excess medical expense benefit claim payments as soon as practi-cable after the close of the quarter for which reimbursement is sought for claimpayments of $20,000 or more. For claim payments of less than $20,000, insurersshall submit to the Fund itemized accounts with supporting documentation of ex-cess medical expense benefits either quarterly or at the close of the calendar yearin which such expenses are incurred. Insurers shall not be reimbursed for interest,attorney fees or punitive damages.

1. Regardless of the size of a claim payment for excess medical expense bene-fits, an insurer shall submit to the Fund a request for reimbursement within a pe-riod of two years from the date of payment by the insurer of the excess medicalexpense benefit for which reimbursement is sought.

2. Failure to comply with the requirements set forth in (a) 1 above shall resultin a denial by the Fund of the reimbursement request which was omitted from thequarterly submission.

(b) The Fund shall not reimburse an insurer for excess medical expense ben-efits if it is determined that there are multiple insurance policies applicable to aclaim unless an insurer has expended medical benefits in an amount exceeding$75,000 on account of personal injury to any one person in any one accident.Where there are two or more different primary insurers liable, the Fund shall notreimburse such an insurer for excess medical expense benefits unless each prima-ry insurer has expended medical benefits in an amount exceeding $75,000 on ac-count of personal injury to any one person in any one accident.

(c) Where the Fund has reimbursed an insurer for excess medical expensebenefits and thereafter determines that there were or are multiple insurance poli-cies applicable to the underlying claim, the insurer shall return all moneys paidfrom the Fund. The insurer(s) shall apportion the medical benefits payment andmake individual application to the Fund where the potential exposure to the insur-

UCJF 11:3-28.10

er(s) exceeds $75,000 on account of personal injury to any one person in any oneaccident.

(d) Whenever an insurer recovers amounts expended by it for medical ben-efits, it shall not be reimbursed for excess medical expense benefits unless it hasfully repaid the amount previously reimbursed by the Fund.Recodified from 11:3-28.6 and amended by R.1993 d.583, effective November 15, 1993. Amended.R.2006 d.243, effective July 3, 2006; R.2007 d.61, effective February 20, 2007.

11:3-28.8 Audits Upon request of the Fund, the insurer(s) shall present for audit at the direction

of the Executive Director at a New Jersey location all policy and claim records onwhich notice of potential for payment of excess medical expense benefits havebeen submitted.Recodified from 11:3-28.7 and amended by R.1993 d.583, effective November 15, 1993. See: 25N.J.R. 2636(b), 25 N.J.R. 5219(a).

11:3-28.9 Reporting of losses for personal injury protection payments inexcess of $75,000

(a) For purposes of completing page 14, Exhibit of Premiums and Losses, ofthe annual statement filed pursuant to N.J.S.A. 17:23-1, the insurer shall includethe total amount of losses for private passenger automobile and commercial auto-mobile personal injury protection payments (lines 19.1 and 19.3), including thosein excess of $75,000. Insurers shall also provide a footnote on page 14 that indi-cates the amount of losses reported, excluding losses from payments of privatepassenger automobile and commercial automobile personal injury protection pay-ments in excess of $75,000.

(b) For purposes of completing Schedule F of the annual statement, insurersshall consider the assumption and reimbursement by the Fund of private passengerautomobile and commercial automobile personal injury protection payments inexcess of $75,000 as a reinsurance transaction. Insurers shall consider assess-ments paid to the UCJF pursuant to N.J.S.A. 39:6-63 based on the insurer's premi-ums for private passenger automobile liability insurance (including PIP) and com-mercial automobile liability insurance (including PIP) as ceded premium, pro rat-ed for the appropriate line of business on which the assessment was based.

(c) Insurers shall comply with the provisions of this section beginning withthe annual statement due March 1, 1994 (covering the calendar year ended De-cember 31, 1993). For purposes of completing the annual statement due March 1,1993 (covering the calendar year ended December 31, 1992), insurers shall file byno later than July 1, 1993 a supplemental page 14 and schedule F of the annualstatement in accordance with the provisions of this section.New Rule, R.1993 d.178, effective April 19, 1993. See:24 N.J.R. 3215(a), 24 N.J.R. 1769(a). Recod-ified from 11:3-28.8 and amended by R.1993 d.583, effective November 15, 1993. See: 25 N.J.R.2636(b), 25 N.J.R. 5219(a).

11:3-28.10 Insurers' obligations to investigate and audit bills for medicalbenefits

(a) For purposes of reimbursement by the Fund, an insurer shall conduct aninvestigation and audit of claims submitted by health care facilities where suchclaims are equal to or in excess of $25,000 and an on-site audit where such claimsare equal to or in excess of $50,000.

1. Failure of an insurer to complete an audit in accordance withthese rules shall result in a 20 percent reduction in payment to the insurer by

the Fund of the unaudited, reimbursable bill.


2. Per diem billings for health care facilities are not subject to the audit require-ments set forth in this subchapter.

3. An insurer shall conduct any such audit to determine whether the level ofcare, need and charges are appropriate.

4. An insurer may pay 80 percent of the provider's bill prior to completion ofthe initial on-site audit. The remaining amount due, if any, shall be paid followingcompletion of the insurer's audit.

5. Annual on-site audits shall be completed in 12-month intervals, from the ini-tial on-site audit and shall be filed with the Fund within 90 days of completion ofthe audit; and

6. Whenever a change in services occurs such as, but not limited to, the levelof care, the daily boom rate or additional charges, an insurer shall conduct an on-site audit and shall provide the audit and auditor's statement to the Fund with thenext reimbursement request.

7. All other audits shall be conducted prior to payment to the health care facilityand may be performed on a pre-screen basis as set forth in (e) below.

(b) For purposes of reimbursement by the Fund, an insurer shall conduct an in-vestigation and audit of claims submitted by providers other than health care fa-cilities where such claims are equal to or in excess of $10,000.

1. Failure of an insurer to complete an audit in accordance with this subchaptershall result in a 20 percent reduction in payment to the insurer by the Fund of theunaudited, reimbursable bill.

(c) The thresholds in (a) and (b) above are cumulative for each confinementassociated with damages resulting from bodily injuries arising out of the owner-ship, maintenance or use of a motor vehicle in this State and shall incorporate allclaims submitted per confinement by the provider.

(d) To be eligible for reimbursement by the Fund, insurers shall audit, priorto payment, bills submitted for continuous treatment from any provider which ex-ceed or may exceed the applicable threshold.

(e) Audits of all providers conducted pursuant to this subchapter, includingthe audit of DRG bills and any successor pricing, shall be performed by:

1. Licensed nursing personnel with two years experience or training in requiredauditing and hospital practices; or

2. An outside auditing firm retained by the insurer for such purposes. (f) Audits performed shall include, but not be limited to, confirmation of

compliance with the medical fee schedule set forth at N.J.A.C. 11:3-29 includingthose situations where the insurer does not provide the primary coverage to theclaimant.

(g) An insurer is not required to conduct a separate, independent audit, if ithas obtained a true copy of an audit conducted by the primary insurer or healthinsurer.

(h) Insurers shall append copies of audits conducted, including those con-ducted by the primary insurer or health insurer, and the auditor's statements withthe reimbursement request filed with the Fund in accordance with N.J.A.C. 11:3-28.7.New Rule. R.1993 d.583, effective November 15, 1993. Amended. R. 1998 d. 591, effective Decem-ber 21, 1998 (operative March 22, 1999); R.2006 d.243, effective July 3, 2006.

11:3-28.11 Modifications to vehicles. (a) An insurer shall obtain prior approv-al from the Fund for modifications to a claimant's vehicle, or vehicle to be usedfor the benefit of the claimant, the cost of which may be reimbursed by the Fund.

(b) An insurer shall submit a written request to the Fund, including a VanPurchase and Modification Agreement seeking approval of modifications which

UCJF 11:3-28.12

are equal to or in excess of $1,000, within 30 days of a claimant's request for mod-ifications.

(c) A request to obtain prior approval from the Fund shall include the follow-ing:

1. A written recommendation for the modification by the claimant's primarycare physician including:

i. Where the claimant is the operator of the vehicle, current findings on theclaimant's physical ability to drive and a copy of the claimant's current driver's li-cense

ii.A brief analysis of the medical necessity and medical purpose for the request-ed modifications

iii. A description of the purpose for which the vehicle will be used and iv.Verification that the requested modifications are necessitated by injuries

sustained by the claimant in the subject accident 2. A cost benefit analysis, supported by appropriate documentation, comparing

the cost of modifying the claimant's vehicle to the cost of alternate methods oftransporting the claimant. This analysis shall incorporate an evaluation of the an-ticipated miles to be driven per year for medically necessary health care services,including a breakdown reflecting the number of miles to be driven to obtain healthcare service and the frequency of such services, the cost per mile of alternatemeans of such transportation, as well as the useful life of the vehicle

3.An agreement between the insurer and the claimant setting forth, but not lim-ited to:

i. The claimant's responsibility to maintain insurance on the vehicle; andii. The claimant's responsibility to repair and maintain the vehicle; and4.Any additional information specifically requested by the Fund with regard to

a particular application for approval. (d) The insurer may independently evaluate, or be required by the Fund to

evaluate, the claimant by a physician chosen by the insurer and approved by theFund, at the insurer's cost, to determine whether a medical necessity and medicalpurpose exist for modifications to the vehicle. The evaluation shall include a re-view of the elements considered in the primary evaluation as set forth at (c) above.

(e) The Fund shall not approve modifications to a vehicle unless it is dem-onstrated that the modifications are required for purposes of medical necessity re-sulting from injuries sustained by the claimant in the subject accident, are requiredfor a medical purpose and the modifications are shown to be cost effective or asthe Fund may otherwise determine.

(f) A request for modifications may be denied for failure to fulfill any of theabove conditions.New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2006 d.243, effective July 3,2006.

11:3-28.12 Modifications to a claimant's residence (a) An insurer shall obtain prior approval from the Fund for any modifica-

tions to a claimant's primary residence the cost of which may be reimbursed by theFund.

(b) An insurer shall submit a written request to the Fund, seeking approvalof modifications which are equal to or in excess of $10,000, within 30 days of aclaimant's request for modifications.

(c) A request to obtain prior approval from the Fund shall include the follow-ing:

1. A written recommendation for the modification by the claimant's primarycare physician including:


i. A brief analysis of the medical necessity for the requested modifications andii. Verification that the requested modifications are necessitated by injuries

sustained by the claimant in the subject accident;2. Medical documentation estimating the claimant's life expectancy;3. A cost benefit analysis, supported by appropriate documentation, which es-

tablishes that the proposed modifications are more cost effective than long termresidential care services. The analysis shall include, in accordance with AppendixB incorporated herein by reference [Publishers note: not included herein], an eval-uation based on the life expectancy of the claimant and a comparison between thecosts of the modifications and home care to be provided, to the costs of other res-idential care alternatives;

4. An evaluation prepared by an independent consultant experienced in barrierfree designs that sets forth the type of modifications required and the costs of suchmodifications.

5. An agreement setting forth the responsibilities regarding the obligations ofthe claimant, the owner of the property or both and the insurer for, but not limitedto:

i. The claimant's or property owner's responsibility for:1) The expenses for upkeep of the residence2) Maintenance of insurance on the property; and3) Repayment to the insurer in the event of the claimant's relocation, death or

upon the sale of the modified premises; andii. The insurer's obligation to remove nonessential equipment;6. A repayment agreement with an amortization provision which provides an

amortization term and amount, once a modification is determined to be cost effec-tive, calculated in accordance with the formula provided in Appendix B to thissubchapter; and

7. Any other additional information specifically requested by the Fund with re-gard to a particular application for approval.

(d) The insurer may independently evaluate, or be required by the Fund toevaluate, the claimant by a physician chosen by the insurer and approved by theFund, at the insurer's cost, to determine whether a medical necessity for the mod-ifications exist. The evaluation shall include a review of the elements consideredin the primary evaluation as set forth at (c) above.

(e) The Fund shall not approve modifications to a residence unless it is dem-onstrated that the modifications are required for purposes of medical necessity re-sulting from injuries sustained by the claimant in the subject accident and themodifications are shown to be cost effective or as the Fund may otherwise deter-mine.

(f) A request for modification may be denied for failure to fulfill any of theabove requirements.

(g) Where a request for modifications is approved, the insurer shall record alien against the modified property in the county in which the property is locatedand shall file a copy of the recorded lien with the Fund within 30 days.

1. This provision shall not apply to rental property. (h) Where a claimant seeks to modify rental property, the insurer shall obtain:1. A written consent from the owner of the property which permits the modifi-

cations and indemnifies the insurer and the Fund from any other liabilities relatingthereto and

UCJF 11:3-28.13

2. A written agreement between the claimant and the insurer in which theclaimant agrees to reimburse the insurer for the unamortized costs of the improve-ments in the event of the claimant's relocation or death.

(i) Upon the claimant's relocation or death, the claimant, the claimant's estateor the owner of the property against which the lien is recorded, shall reimburse theinsurer for the unamortized cost of the modifications to the claimant's residence.

(j) The claimant, the claimant's estate or the owner of the property againstwhich the lien was recorded, shall have a reasonable period in which to reimbursethe insurer.

(k) Where repayment by the claimant or the claimant's estate is required pur-suant to this section, interest shall accrue at the prevailing rate of post judgmentinterest as set forth in the rules governing civil practice in the New Jersey CourtRules in effect at the time of execution of the repayment agreement, until theamount owed is paid in full.

(l) Within 30 days from the date of the claimant's relocation or death, theinsurer shall so notify the Fund in writing and shall include the terms of repaymentby the claimant to the insurer. The insurer shall repay the Fund for such reimburse-ment.

1.The insurer shall be required to repay the Fund within 60 days from receiptof any and all partial payments or from the receipt of a payment made in full bythe claimant.

(m) A warrant discharging the lien shall be filed by the insurer when the fullamount owed to the insurer, in accordance with the amortization agreement, is sat-isfied.New Rule, R.1993 d.583, effective November 15, 1993. See: 25 N.J.R. 2636(b), 25 N.J.R. 5219(a).

11:3-28.13 Insurer's obligation to obtain recovery of payments for paidmedical expense benefit claims

(a) The Fund shall reimburse insurers for paid medical expense benefit claimsif an insurer demonstrates that it has diligently pursued all potentially responsibletortfeasors within the time prescribed at N.J.S.A. 39:6A-9.1, or any other applica-ble limitation period.

1. An insurer shall demonstrate, in accordance with (c) below, that it has dili-gently pursued any potentially responsible tortfeasor to obtain reimbursement ofPIP medical expense benefit claim payments made by the insurer from the Fund.

2. Where the insurer has failed to diligently pursue any potentially responsibletortfeasor as set forth in (c) below, the Fund shall be entitled to discontinue reim-bursements on that claim. The Fund shall also be entitled to recover from the in-surer any reimbursement payments already made to the insurer on that claim, afternotice and opportunity for a hearing in accordance with the Administrative Proce-dure Act, N.J.S.A. 52:14B-1 et seq. and Uniform Administrative Procedure Rules,N.J.A.C. 1:1.

3. An insurer shall obtain prior approval from the Fund before settling or com-promising a claim against a potentially responsible tortfeasor or a tortfeasor.

(b) Any and all expenses and fees incurred by the insurer as a result of the pur-suit of a potentially responsible tortfeasor, shall be borne by the insurer.

(c) For purposes of this section, “diligently pursue” means that the insurer haseither prosecuted or is prosecuting an action, including by agreement or arbitra-tion, in matters subject to N.J.S.A. 39:6A-9.1, against all potentially responsibletortfeasors, or determined not to do so after:

1. Examining or reviewing the following documents, where applicable:


i. Police accident reports, including fatal accident reports and supplemental re-ports;

ii. Statements of the parties involved; iii. Witness statements; iv. Central Index Bureau return results; v. Information about the assets of uninsured tortfeasors; vi. Scene photographs and diagrams; vii. Reports of blood alcohol content; viii. Relevant court records and information on any related suits, arbitrations,

settlements or judgments, either within or outside the State, including, but not lim-ited to:

(1) Pleadings; (2) Transcripts of depositions and other related discovery materials; and (3) Amounts of settlements or judgments; and ix. Information about the amount of any potentially responsible tortfeasor's in-

surance liability limits, including, but not limited to, umbrella and excess insur-ance policies; and

2. Considering the following factors in determining whether to prosecute an ac-tion against potentially responsible tortfeasors:

i. The liability of the parties involved; ii. Relevant law regarding right of recovery actions; and iii. The basis for denial of coverage by the insurer of the potentially responsible

tortfeasor. (d) Insurers shall file a certification, in the form of Appendix C incorporated

herein by reference, that they have diligently pursued recovery of medical expensebenefits, and that the insurer has not received from any source reimbursement,contribution, or indemnification of the excess medical benefits paid by the insurerfor which reimbursement from the Fund is sought. This certification shall besigned by an officer of the insurer or other person authorized to sign the certifica-tion on behalf of the insurer, and shall be filed no later than two years from thedate of the accident, prior to expiration of any applicable statute of limitations, orat the time filing for reimbursement is made, whichever occurs first. Failure to filethe certification shall result in denial of reimbursement to the insurer by the Fund.

(e) All recovery amounts obtained or that should have been obtained from thetortfeasor will be deducted from the reimbursement claim.New Rule. R.1993 d.583, effective November 15, 1993. Amended. R.2001 d.151, effective May 7,2001; R.2006 d.243, effective July 3, 2006.

11:3-28.14 Insurer's responsibility upon assignment of an uninsured mo-torist claim. (a) An insurer shall, within 10 business days of receipt of a claim as-signment and accompanying instruction sheet (see Appendix B, Item 1, incorpo-rated herein by reference) from the Fund, submit a letter to the Fund which:

1. Acknowledges receipt of the assignment and the accompanying instructionsheet; and

2. Provides the names and telephone numbers of the case handler or manager,the claim investigator and the claim adjuster.

(b) An insurer shall, within 10 business days from the date it assigns the claimto defense counsel, provide the Fund with the name, address and telephone num-ber of defense counsel.

UCJF 11:3-29.1

(c) An insurer shall, within 10 business days, provide written notice to the Fundof any changes, substitutions or replacements which occur with respect to any ofthe persons identified pursuant to (a)2 or (b) above.New Rule, R.1994 d.597, effective December 5, 1994. See: 26 N.J.R. 2190(a), 26 N.J.R. 4772(a).

11:3-28.15 (Reserved)Repealed. R.2006 d.243, effective July 3, 2006.

11:3-28.16 (Reserved)

11:3-28.17 (Reserved)Repealed. R.2006 d.243, effective July 3, 2006.

SUBCHAPTER 29. MEDICAL FEE SCHEDULES: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS

MEDICAL EXPENSE INSURANCE COVERAGESection11:3-29.1. Purpose and scope.11:3-29.2. Definitions.11:3-29.3. Regions.11:3-29.4. Application of Medical Fee Schedules.11:3-29.5. ASC facility fees; hospital outpatient surgical facility fees.11:3-29.6. Balance billing prohibitedAPPENDIX

11:3-29.1. Purpose and scope. (a) Every policy of automobile insurance andmotor bus insurance issued in this State shall provide that the automobile insurer'slimit of liability for medically necessary expenses payable under PIP coverage,and the motor bus insurer's limit of liability for medically necessary expenses pay-able under medical expense benefits coverage, is the fee set forth in this subchap-ter or the usual, customary and reasonable fee, whichever is less.

(b) This subchapter implements the provisions of N.J.S.A. 39:6A-4.6 to estab-lish medical fee schedules on a regional basis for the reimbursement of health careproviders providing services or equipment for medical expense benefits for whichpayment is required to be made by automobile insurers under PIP coverage and bymotor bus insurers under medical expense benefits coverage.

(c) This subchapter applies to all insurers who issue policies of automobile in-surance containing PIP coverage and policies of motor bus insurance containingmedical expense benefits coverage.

(d) This subchapter does not apply to the following:1. Other coverages contained in an automobile or motor bus insurance policy

such as coverage for bodily injury liability;2. Any other kind of insurance including health insurance, even when the

health insurer may be required pursuant to its health insurance contract to pay ben-efits to, or on behalf of, a person who sustained bodily injury as a result of an ac-cident while occupying, entering into, alighting from or using an automobile ormotor bus, or as a pedestrian, caused by an automobile or motor bus or an objectpropelled by or from an automobile or motor bus;

3. Medical services or equipment provided outside of the geographic bound-aries of New Jersey except as set forth in N.J.A.C. 11:3-29.4(d)2; and


4. Inpatient services provided by acute care hospitals, trauma centers, rehabil-itation facilities, other specialized hospitals, residential alcohol treatment facilitiesand nursing homes, except as specifically set forth in this subchapter.Amended: R.1993 d. 25, effective January 4, 1993; R.2001 d.158, effective May 21, 2001; R.2007d.305, effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4,2013).

11:3-29.2. Definitions. The following words and terms, when used in this sub-chapter, shall have the following meanings unless the context clearly indicatesotherwise:

“Ambulatory surgery facility” or “ASC” means:1. A surgical facility, licensed as an ambulatory surgery facility in New Jersey

in accordance with N.J.A.C. 8:43A, in which ambulatory surgical cases are per-formed and which is separate and apart from any other facility license. (The am-bulatory surgery facility may be physically connected to another licensed facility,such as a hospital, but is corporately, financially and administratively distinct, forexample, it uses a separate tax-id number); or

2. A physician-owned single operating room in an office setting that is certifiedby Medicare.

“Basic Life Support” (“BLS”) means volunteer ambulance services, whosepersonnel are not required to be Emergency Medical Technicians, and municipaland proprietary ambulance services whose personnel are required to be Emergen-cy Medical Technicians.

“Bilateral surgery” means identical procedures (requiring use of the same CPTcode) performed on the same anatomic site but on opposite sides of the body. Fur-thermore, each procedure is performed through its own separate incision.

"CDT" means the American Dental Association's Current Dental Terminology2011-2012, copyright 2010.

“Co-surgery” means two surgeons (each in a different specialty) are requiredto perform a specific procedure. Co-surgery also refers to surgical procedures in-volving two surgeons performing the parts of one procedure simultaneously.

"CPT" means the American Medical Association's Current Procedural Termi-nology, Fourth Edition, Version 2011, coding system. Current Procedural Termi-nology (CPT) is copyright 2011 American Medical Association (AMA), all rightsreserved. No fee schedules, basic units, relative values, or related listings are in-cluded in CPT. The AMA assumes no liability for the data contained in the CPT.Applicable Federal Acquisition Regulation and Defense Federal Acquisition Reg-ulation Supplement (FARS/DFARS), 48 CFR, restrictions apply to governmentuse. CPT<(R)> is a trademark of the American Medical Association.

"Eligible charge or expense" means the usual, customary and reasonablecharge as determined pursuant to N.J.A.C. 11:3-29.4(e)1 or the upper limit in thefee schedule, whichever is lower.

“Emergency care” means all medically necessary treatment of a traumatic in-jury or a medical condition manifesting itself by acute symptoms of sufficient se-verity such that absence of immediate attention could reasonably be expected toresult in: death; serious impairment to bodily functions; or serious dysfunction ofa bodily organ or part. Such emergency care shall include all medically necessarycare immediately following an automobile accident, including, but not limited to,immediate pre-hospitalization care, transportation to a hospital or trauma center,emergency room care, surgery, critical and acute care. Emergency care extends

UCJF 11:3-29.2

during the period of initial hospitalization until the patient is discharged fromacute care by the attending physician.

“Global service” means the sum of the technical and professional components.“HCPCS” means the Federal Center for Medicare and Medicaid Services

(CMS) Common Procedure Code System.“Health care provider” or “provider” is as defined in N.J.A.C. 11:3-4.“Health insurance” means a contract or agreement whereby an insurer is obli-

gated to pay or allow a benefit of pecuniary value with respect to the bodily injury,disability, sickness, death by accident or accidental means of a human being, orbecause of any expense relating thereto, or because of any expense incurred in pre-vention of sickness, and includes every risk pertaining to any of the enumeratedrisks. As used in this subchapter, health insurance includes workers' compensationcoverage but does not include any PIP coverage.

“Health insurer” includes any insurer issuing a policy of health insurance as de-fined in this subchapter.

"Hospital" means a general acute care hospital, a long-term acute care hospitalor a comprehensive rehabilitation hospital.

"Hospital outpatient" means a person who has not been admitted by the hospi-tal as an inpatient but is registered on the hospital records as an outpatient and re-ceives services (rather than supplies alone) from the hospital. When a patient witha known diagnosis enters a hospital for a specific surgical procedure or other treat-ment that is expected to keep him or her in the hospital for only a few hours (lessthan 24), he or she is considered an outpatient for coverage purposes regardless ofthe hour he or she came to the hospital; whether he or she used a bed; or whetherhe or she remained in the hospital past midnight.

"Hospital outpatient surgical facility" or "HOSF" means a facility where hos-pital outpatients are treated.

“Medically necessary” or “medical necessity” means that:1. The medical treatment or diagnostic test is consistent with the clinically sup-

ported symptoms, diagnosis or indications of the injured person;2. The treatment is the most appropriate level of service that is in accordance

with the standards of good practice and the provisions of N.J.A.C. 11:3-4, as ap-plicable;

3. The treatment is not primarily for the convenience of the injured person orprovider;

4. The treatment is not unnecessary; and5. The treatment does not include unnecessary testing.“Modifier” means an addition to the five-digit CPT code of either two letters

or numbers that indicates that a service or procedure was performed that has beenaltered by some specific circumstance but not changed in its definition or code.

“Motor bus” means motor bus as defined in N.J.S.A. 17:28-1.5.“Motor bus insurer” includes any insurer issuing a policy of insurance on a mo-

tor bus the owner, registered owner, or operator of which is required to maintainmedical expense benefits coverage pursuant to N.J.S.A. 17:28-1.6.

“Multiple surgeries” means additional procedures, unrelated to the major pro-cedure and adding significant time or complexity, performed on the same patientat the same operative session or on the same day. Co-surgeons, surgical teams, orassistants-at-surgery may participate in performing multiple surgeries on the samepatient on the same day.


“PIP coverage” means personal injury protection coverage described inN.J.S.A. 39:6A-3.1(a), 39:6A-4a and 39:6A-10 as amended.

“PIP insurer” includes any insurer issuing a policy of automobile insurance onany vehicle that contains PIP coverage.

“Powered traction device” means VAX-D, DRX or similar devices determinedby the Federal Food and Drug Administration to provide traction services.

“Three-digit zip code” refers to the first three digits of the U.S. postal code."Trauma services" means the care provided in the Level I or Level II trauma

hospital to patients whose arrival requires trauma center activation. It does not in-clude transportation to the hospital, treatment of patients whose arrival at the hos-pital does not require trauma activiation or outpatient visits after a patient who hasreceived trauma care is discharged from acute care.Amended. R 1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1,1995); R.2001, d.158, effective May 21, 2001; R.2003 d.143, effective April 7, 2003; R.2007 d.305,effective October 1, 2007; R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-29.3. Regions. (a) The Regions in Appendix, Exhibit 1, Physicians' FeeSchedule, Exhibit 2, Dental Fee Schedule and Exhibit 4, Ambulance Services, areas follows:

1. South Region consists of Atlantic, Burlington, Camden, Cape May, Cumber-land, Gloucester, Mercer, Monmouth, Ocean and Salem counties, which are com-prised of the following three- and five-digit zip codes in New Jersey: 077, 080,081, 082, 083, 084, 086 and 087. The South Region also includes: 08501, 08505,08510, 08511, 08514 through 08527, 08533 through 08535, 08540 through08550, 08554, 08555 and 08560 through 08562.

2. North Region consists of Bergen, Essex, Hudson, Hunterdon, Middlesex,Morris, Passaic, Somerset, Sussex, Union and Warren counties, which are com-prised of the following three- and five-digit zip codes in New Jersey: 070, 071,072, 073, 074, 075, 076, 078, 079, 088 and 089. The North Region also includes:08502, 08504, 08512, 08528, 08530, 08536, 08551, 08553, 08556 through 08559and 08570.Amended. R.2001 d.253, effective July 16, 2001; R.2007 d.305, effective October 1, 2007; R.2012d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-29.4. Application of Medical Fee Schedules. (a) Nothing in this sub-chapter shall compel the PIP insurer or a motor bus insurer to pay more for anyservice or equipment than the usual, customary and reasonable fee, even if suchfee is well below the automobile insurer's or motor bus insurer's limit of liabilityas set forth in the fee schedules. Insurers are not required to pay for services orequipment that are not medically necessary.

1. The fees for physicians' services in subchapter Appendix, Exhibit 1, the pro-visions in (f)1 through 7 below and the non-physician facility fees in subchapterAppendix, Exhibit 7 shall not apply to trauma services at Level I and Level II trau-ma hospitals. Bills for services subject to the trauma services exemption shall usethe modifier "-TS".

2. The non-physician facility fees in subchapter Appendix, Exhibit 7 shall notapply to services provided in hospital emergency rooms. The bills for these ser-vices shall use the modifier "-ER".

3. The physician fees for surgical services (CPT 10000 though 69999) providedin emergency care in acute care hospitals that are not subject to the trauma careexemption shall be reimbursed at 150 percent of the physicians' fees in subchapterAppendix, Exhibit 1. The bills for these services shall use the modifier "-ER".

UCJF 11:3-29.4

4. Except as provided in (a)1 through 3 above, the fees in Appendix, Exhibits1 through 7 apply regardless of the site of service.

(b) The region used to determine the proper fee set forth in the schedules shallbe determined by the region in which the services were rendered or the equipmentwas provided or, in the case of elective services or equipment provided to NewJersey residents outside the State, by the region in which the insured resides.

(c) The fees set forth in the schedule for durable medical equipment, subchapterAppendix, Exhibit 5, are retail prices, which may include purchase prices for bothnew and used equipment, and/or monthly rentals. New equipment shall be distin-guished with the use of modifier-NU, used equipment with modifier-UE and rent-al equipment with modifier-RR.

1. The insurer's total limit of liability for the rental of a single item of durablemedical equipment set forth in the schedule is 15 times the monthly rental fee orthe purchase price of the item, whichever is less.

2. For the provision and billing of durable medical equipment, payors shall fol-low the relevant provisions of Chapter 20 of the Medicare Claims ProcessingManual, updated periodically by CMS and incorporated by reference, that were ineffect at the time the service was provided (http://www.cms.gov/manuals/down-loads/clm104c20.pdf).

(d) The insurer's limit of liability for any medical expense benefit for service orequipment provided outside the State of New Jersey shall be as follows:

1. When the service or equipment is provided by reason of emergency or med-ical necessity, the reasonable and necessary costs shall not exceed fees that areusual, customary and reasonable for that provider in the geographic locationwhere the service or equipment is provided.

2. When the service or equipment is provided by reason of the election by theinsured to receive treatment outside the State of New Jersey, the reasonable andnecessary costs shall not exceed fees set forth in the fee schedules for the geo-graphic region in which the insured resides.

(e) Except as noted in (e)1 through 3 below, the insurer's limit of liability forany medical expense benefit for any service or equipment not set forth in or notcovered by the fee schedules shall be a reasonable amount considering the feeschedule amount for similar services or equipment in the region where the serviceor equipment was provided or, in the case of elective services or equipment pro-vided outside the State, the region in which the insured resides. When a CPT,CDT, or HCPCS code for the service performed has been changed since the feeschedule rule was last amended, the provider shall always bill the actual and cor-rect code found in the most recent version of the American Medical Association'sCurrent Procedural Terminology or the American Dental Association's CurrentDental Terminology. The amount that the insurer pays for the service shall be inaccordance with this subsection. Where the fee schedule does not contain a refer-ence to similar services or equipment as set forth in the preceding sentence, theinsurer's limit of liability for any medical expense benefit for any service or equip-ment not set forth in the fee schedules shall not exceed the usual, customary andreasonable fee.

1. For the purposes of this subchapter, determination of the usual, reasonableand customary fee means that the provider submits to the insurer his or her usualand customary fee by means of explanations of benefits from payors showing theprovider's billed and paid fee(s). The insurer determines the reasonableness of theprovider's fee by comparison of its experience with that provider and with otherproviders in the region. National databases of fees, such as those published byFAIR Health (www.fairhealthus.org) or Wasserman (http://www.medfees.com/),


for example, are evidence of the reasonableness of fees for the provider's geo-graphic region or ZIP code. The use of national databases of fees is not limited tothe above examples. When using a database as evidence of the reasonableness ofa fee, the insurer shall identify the database used, the edition date, the geozip, andthe percentile.

2. All applicable provisions of this section concerning billing and payment ap-ply to fees for services provided outside of New Jersey and to fees that are not onthe fee schedule.

3. Codes in Appendix, Exhibit 1 that do not have an amount in the ASC facilityfee column are not reimbursable if performed in an ASC and are not subject to theprovision in (e) above concerning services not set forth in or covered by the feeschedules.

(f) Except as specifically stated to the contrary, the following shall apply tophysician charges for multiple and bilateral surgeries (CPT 10000 through69999), co-surgeries and assistant surgeons:

1. For multiple surgeries, rank the surgical procedures in descending order bythe fee amount, using the fee schedule or UCR amount, as appropriate. The high-est valued procedure is reimbursed at 100 percent of the eligible charge. Addition-al procedures are reported with the modifier "-51" and are reimbursed at 50 per-cent of the eligible charge. If any of the multiple surgeries are bilateral surgeriesusing the modifier "-50," consider the bilateral procedure at 150 percent as onepayment amount, rank this with the remaining procedures, and apply the appropri-ate multiple surgery reductions.

2. There are two types of procedures that are exempt from the multiple proce-dure reduction. Codes in CPT that have the note, "Modifier -51 exempt" shall bereimbursed at 100 percent of the eligible charge. In addition, some related proce-dures are commonly carried out in addition to the primary procedure. These pro-cedure codes contain a specific descriptor that includes the words, "each addition-al" or "list separately in addition to the primary procedure." These add-on codescannot be reported as stand-alone codes but when reported with the primary pro-cedure are not subject to the 50 percent multiple procedure reduction.

3. The terminology for some procedure codes includes the terms "bilateral" or"unilateral or bilateral." The payment adjustment rules for bilateral surgeries donot apply to procedures identified by CPT as "bilateral" or "unilateral or bilateral"since the fee schedule reflects any additional work required for bilateral surgeries.If a procedure is not identified by its terminology as a bilateral procedure (or uni-lateral or bilateral) and is performed bilaterally, providers must report the proce-dure with modifier "-50" as a single line item. Reimbursement for bilateral surger-ies reported with the modifier "-50" shall be 150 percent of the eligible charge.

4. For co-surgeries, each surgeon bills for the procedure with a modifier "-62".For co-surgeries (modifier 62), the fee schedule amount applicable to the paymentfor each co-surgeon is 62.5 percent of the eligible charge.

5. The eligible charge for medically necessary assistant surgeon expenses shallbe 20 percent of the primary physician's allowable fee determined pursuant to thefee schedule and rules. Assistant surgeon expenses shall be reported using modi-fier -80, -81 or -82 as designated in CPT. When the assistant surgeon is someoneother than a physician surgeon, the reimbursement shall not exceed 85 percent ofthe amount that would have been reimbursed had a physician surgeon provided theservice. Non-physician assistant surgeon services shall be reported using modifi-er-AS.

6. The necessity for co-surgeons and assistant surgeons for an operation shallbe determined by reference to authorities such as the Medicare physician fee

UCJF 11:3-29.4

schedule database (www.cms.gov). Fees for assistant surgeons and co-surgeonsare not rendered eligible for reimbursement simply because it is the policy of aprovider or an outpatient surgical facility that one be present.

7. It is the responsibility of providers that are acting as co-surgeons or assistantsurgeons to include the correct modifier in their bills, especially as they may notbe submitted to the insurer at the same time. If a surgeon submits a bill without amodifier and is paid 100 percent of the eligible charge and the insurer subsequent-ly receives a bill from a co-surgeon or assistant surgeon for the same procedure,the insurer shall notify both providers that it has already paid 100 percent of theeligible charge and that it cannot reimburse the co-surgeon or assistant surgeonuntil the overpayment has been offset or refunded.

8. Prosthetic and other devices, including neuro-stimulators, internal/externalfixators, single use spine wands and spine probes, tissue grafts, plates, screws, an-chors and wires, whether implanted, inserted, or otherwise applied by covered sur-gical procedures shall be reimbursed at no more than the invoice for the deviceplus 20 percent. This provision applies regardless of where the procedure is per-formed, including trauma centers, hospital emergency rooms, inpatient surgeriesand outpatient surgical facilities.

(g) Except as specifically stated to the contrary in this subchapter, the feeschedules shall be interpreted in accordance with the following, incorporatedhererin by reference, as amended and supplemented: the relevant chapters of theMedicare Claims Processing Manual, updated periodically by CMS, that were ineffect at the time the service was provided. The Medicare Claims Processing Man-ual is available at https: //www.cms.gov/Manuals/IOM/itemde-tail.asp?itemID=CMS018912; the NCCI Policy Manual for Medicare Services, asupdated periodically by CMS and available at http://www.cms.gov/NationalCor-rectCodInitEd/Downloads/NCCI_Policy_Manual.zip; Modifier 59 Article: Prop-er Usage Regarding Distinct Procedural Service, available from CMS at https://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf; and theCPT Assistant available from the American Medical Association (www.AMA-bookstore.com).

1. Artificially separating or partitioning what is inherently one total procedureinto subparts that are integral to the whole for the purpose of increasing medicalfees is prohibited. Such practice is commonly referred to as "unbundling" or "frag-mented" billing. Providers and payors shall use the National Correct Coding Ini-tiative (NCCI) Edits, incorporated herein by reference, as updated quarterly byCMS and available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Mod-ifier 59 and other NCCI-associated modifiers should not be used to bypass anNCCI edit unless the proper criteria for use of the modifier are met. Documenta-tion in the medical record must satisfy the criteria required by any NCCI-associ-ated modifier used. For more information on the criteria for the use of modifiers,see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above.

2. CPT 97010 (application of hot/cold packs) is bundled into the payment forother services and shall not be reimbursed separately.

3. X-ray digitization or computer aided radiographic mensuration reported un-der CPT 76499 or any other code are not reimbursable under PIP.

4. Kinesio taping or other taping is not reimbursable under PIP. Kinesio tapingshall not be billed using the strapping codes, CPT 29200 through 29280 and 29520through 29590.

5. Platelet Rich Plasma (PRP) injections are only reimbursable for treatment ofchronically injured tendons that have failed to improve despite appropriate con-


servative treatments. PRP injections shall be billed under code 0232T in subchap-ter Appendix, Exhibit 1.

6. Leads, pads, batteries and any other supplies for use of TENS or EMS devic-es are included in the fee for the rental of the unit and are not separately reimburs-able when rented. For purchase of the unit, the first month's supply of leads, pads,batteries and any other supplies for TENS or EMS units are included.

7. The eligible charge for an office visit includes reviewing the report of an im-aging study when the provider of the imaging study has billed for the technical andprofessional component of the service. In these circumstances, it is not appropriatefor the provider to bill for an office visit, CPT 76140 or for the physician compo-nent of the imaging study. CPT 76140 is not reimbursable. Where a provider in adifferent practice or facility performs a medically necessary review of an imagingstudy and produces a written report as part of a consultation, the provider shall billthe professional component (modifier -26) for each specific radiology service.

8. When CPT 77003, fluoroscopic guidance, can be billed separately and is notincluded as part of another procedure, it is reimbursable only per spinal region, notper level.

9. HCPCS code G0289 is an add-on code and should be added to the knee ar-throscopy code for the major procedure being performed. This code is only to bereported once per extra compartment, even if chondroplasty, loose body removaland foreign body removal are all performed. The code may be reported twice ifthe physician performs these procedures in two compartments in addition to thecompartment where the main procedure was performed.

i. This code shall be reported only when the physician spends at least 15 min-utes in the additional compartment performing the procedure. It shall not be re-ported if the reason for performing the procedure is due to a problem caused bythe arthroscopic procedure itself. This code is to be used when a procedure is per-formed in the lateral, medial, or patellar compartments in addition to the main pro-cedure. The billing of CPT codes 29874 and 29877 is not permitted with other ar-throscopic procedures on the same knee and CPT code 29874 shall not be used toreport the services described by code G0289.

10. Appendix J of the CPT manual, Electrodiagnostic Medicine Listing of Sen-sory, Motor and Mixed Nerves may be used as a reference for the appropriate re-imbursement of this type of Electrodiagnostic testing.

11. Moderate (conscious) sedation performed by the physician who also fur-nishes the medical or surgical service cannot be reimbursed separately for the pro-cedures listed in Appendix G of the CPT manual. In that case, payment for the se-dation is bundled into the payment for the medical or surgical service. As a result,CPT codes 99143 through 99145 are not reimbursable for the procedures in Ap-pendix G of the CPT manual.

12. CPT codes 99148 through 99150 are only reimburseable when a secondphysician other than the provider performing the diagnostic or therapeutic servic-es provides moderate sedation in a facility setting (for example, hospital, outpa-tient hospital/ambulatory surgery center or skilled nursing facility). CPT codes99148 through 99150 are not reimburseable for services performed by a secondphysician in a physician office, freestanding imaging center or for any procedurecode identified in CPT as including moderate (conscious) sedation.

13. CPT 22505, "Manipulation of spine requiring anesthesia, any region," ifmedically necessary, can only be reported once for any and all regions manipulat-ed on that date.

(h) To be reimbursable, nerve conduction studies (NCS) (CPT 95900 - 95904)must be interpreted by a provider who was on site and directly supervised or per-

UCJF 11:3-29.4

formed the nerve conduction study in accordance with N.J.A.C. 13:35-2.6(n)3.Needle Electromyography (EMG) interpretation must be performed in the samefacility on the same day by the same physician who performed and/or supervisedthe needle EMG.

(i) The reporting of nerve conduction studies and needle electromyography(EMG) (CPT 95860 through 95872) results should be integrated into a unified di-agnostic impression. Separate reports for needle EMG and NCS are not reimburs-able under the codes above in this subsection.

(j) For surgery and many other procedures, it is established practice to includefollow-up care and visits as part of the basic procedure charge. Such charges shallnot be subject to additional billings. The existence of a CPT code, per se, does notimply the right to receive separate compensation for the procedure/sub-procedureso described. If a procedure is judged to be part of the primary procedure, only thecharges for the primary procedure are eligible. As identified in CPT, separate pro-cedures are commonly carried out as an integral part of another procedure. Theyshall not be billed in conjunction with the other procedure, but may be billed whenperformed independently of the other procedure.

(k) CPT codes for procedures described in CPT as "unlisted procedure" or "un-listed service" (example: 64999 Unlisted procedure nervous system) are not reim-bursable without documentation from the provider describing the procedure orservice performed, demonstrating its medical appropriateness and indicating whyit is not duplicative of a code for a listed procedure or service. Documentation mayinclude the existence of temporary or AMA Category III or HCPCS codes for theprocedure or information in the AMA CPT Assistant publication. In submittingbills for unlisted codes, the provider should base the fee on a comparable proce-dure. It is never appropriate for the provider to bill an unlisted code for a list ofservices that have CPT codes. Providers that intend to use unlisted codes in non-emergency situations are encouraged to notify the insurer in advance through theprecertification process. Based on the information submitted by the provider, theinsurer shall determine whether the CPT coding is appropriate.

(l) Certain CPT codes are listed in the fee schedule with three entries. There isa global fee with no modifier, a technical component with modifier "TC" and aphysician component with modifier "-26". Services with physician componentamounts of zero in the fee schedule are considered to be 100 percent technical. Aprovider shall not bill the global fee and a technical or physician component. Thetechnical or physician component shall be billed when only that part of the serviceis being provided.

(m) The daily maximum allowable fee shall be $ 105.00 for the Physical Med-icine and Rehabilitation CPT codes listed in subchapter Appendix, Exhibit 6, in-corporated herein by reference, that are commonly provided together. The dailymaximum applies when such services are performed for the same patient on thesame date. In determining whether a provider has reached the daily maximum, theinsurer shall apply the NCCI edits. The daily maximum applies to all providers,including dentists. However, when the provider can demonstrate that the severityor extent of the injury is such that extraordinary time and effort is needed for ef-fective treatment, the insurer shall reimburse in excess of the daily maximum.Such injuries could include, but are not limited to, severe brain injury and non-soft-tissue injuries to more than one part of the body. Such injuries would not in-clude diagnoses for which there are care paths in N.J.A.C. 11:3-4. Treatment thatthe provider believes should not be subject to the daily maximum shall be billedusing modifier -22 as designated in CPT for unusual procedural services. Unlessalready provided to the insurer as part of a decision point review or precertifica-


tion request, the billing shall be accompanied by documentation of why the ex-traordinary time and effort for treatment was needed.

1. Supervised modalities and those therapeutic procedures that do not list a spe-cific time increment in their description shall be limited to one unit per day.

2. CPT 97012 is the appropriate code for billing powered traction therapy.3. CPT 97026 is the appropriate code for billing cold or low-powered laser

therapy.4. HPCPS code G0283 is the appropriate code for billing unattended electrical

stimulation.5. Pursuant to N.J.S.A. 39:6A-4, physical therapy, as defined in N.J.S.A. 45:9-

37.13, shall not be reimbursable under PIP unless rendered by a licensed physicaltherapist pursuant to a referral from a licensed physician, dentist, podiatrist or chi-ropractor within the scope of the respective practices.

(n) Follow-up evaluation and management services for the re-examination ofan established patient shall be reimbursed in addition to physical medicine and re-habilitation procedures only when any of the circumstances set forth in (n)1through 4 below is present and not more than twice in any 30-day period. Modifier-25 shall be added to an evaluation and management service when a significantseparately identifiable evaluation and management service is provided and docu-mented as medically necessary as follows:

1. There is a definite measurable change in the patient's condition requiring sig-nificant change in the treatment plan;

2. The patient fails to respond to treatment, requiring a change in the treatmentplan;

3. The patient's condition becomes permanent and stationary, or the patient isready for discharge; or

4. It is medically necessary to provide evaluation services over and above thosenormally provided during the therapeutic services.

(o) Regardless of the specific codes that are included in a DPR/Precertificationrequest, the insurer's reimbursement for those services shall be consistent with therules contained in this subchapter, including the NCCI edits and the CPT Manualcurrent at the time the services were provided.

(p) The ANES code on the Physicians' Fee Schedule is the conversion factorfor anesthesia units. Payors shall follow the Medicare Claims Processing Manualand other guidelines for calculating the number of units for the various CPT codesfor the administration of anesthesia and other billing situations, such as directingor supervising Certified Nurse Anesthetists and other non-physician anesthesiaproviders. These can be found at: www.cms.hhs.gov/center/anesth.asp.Amended. R.1992 d.170, effective April 6, 1992; R.1993 d.25, effective January 4, 1993; R.1993d.395, effective August 2, 1993; R.1994 d.564, effective November 21, 1994 (operative January 1,1995); R.2001 d.158, effective May 21, 2001; R.2001 d.253, effective July 16, 2001; R.2003 d.143,effective April 7, 2003; R.2007 d.305, effective October 1, 2007; R.2012 d.187, effective November5, 2012 (operative January 4, 2013); R.2014 d.004, effective January 6, 2014.

11:3-29.5 ASC facility fees; hospital outpatient surgical facility fees. (a)ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that donot have an amount in the ASC facility fee column are not reimbursable if per-formed in an ASC. The ASC facility fees include services that would be coveredif the services were furnished in a hospital on an inpatient or outpatient basis, in-cluding:

1. Use of operating and recovery rooms, patient preparation areas, waitingrooms, and other areas used by the patient or offered for use to persons accompa-nying the patient;

UCJF 11:3-29.6

2. All services and procedures in connection with covered procedures fur-nished by nurses, technical personnel and others involved in the patient's care;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances,and equipment;

4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicatesthose CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary servicesthat are integral to surgical procedures and are not permitted to be reimbursed sep-arately in an ASC. Appendix, Exhibit 7 indicates those services that, according toMedicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgicalprocedures and are not permitted to be reimbursed separately in a HOSF;

5. Administrative, recordkeeping, and housekeeping items and services;6. Blood, blood plasma, platelets, etc.;7. Anesthesia materials, including the anesthetic itself, and any materials,

whether disposable or re-usable, necessary for its administration; and8. Implantable DME and prosthetics.(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The

hospital outpatient surgical facility fee is the maximum that can be reimbursed foroutpatient procedures performed in an HOSF. The hospital outpatient facility feesin Appendix Exhibit 7 include services that would be covered if furnished in a hos-pital on an inpatient basis, including those set forth in (a)1 through 8 above.

(c) The sale, lease or rental of durable medical equipment (DME) to patientsfor use in their homes are not included in the ASC or HOSF fee. If the ASC orHOSF furnishes items of DME to patients, billing for such items should be madein accordance with subchapter Appendix, Exhibit 5.

(d) When multiple procedures are performed in an ASC or in an HOSF in thesame operative session, the ASC facility fee or the HOSF fee, as applicable, forthe procedure with the highest payment amount is reimbursed at 100 percent andreimbursement of any additional procedures furnished in the same session is 50percent of the applicable facility fee.

1. A procedure performed bilaterally in one operative session is reported as twoprocedures and is subject to the multiple procedure reduction formula.

2. Subchapter Appendices, Exhibit 1, the Physicians’ and ASC Facility FeeSchedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, ac-cording to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp and http://www.cms.gov/HospitalOutpatientPPS/) are exempt from the multiple procedurereduction formula.New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-29.6 ASC facility fees; hospital outpatient surgical facility fees (a)ASC facility fees are listed in Appendix, Exhibit 1, by CPT code. Codes that donot have an amount in the ASC facility fee column are not reimbursable if per-formed in an ASC. The ASC facility fees include services that would be coveredif the services were furnished in a hospital on an inpatient or outpatient basis, in-cluding:

1. Use of operating and recovery rooms, patient preparation areas, waitingrooms, and other areas used by the patient or offered for use to persons accompa-nying the patient;


2. All services and procedures in connection with covered procedures fur-nished by nurses, technical personnel and others involved in the patient’s care;

3. Drugs, biologicals, surgical dressings, supplies, splints, casts, appliances,and equipment;

4. Diagnostic and therapeutic items and services. Appendix, Exhibit 1 indicatesthose CPT codes that, according to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp, CMS-1504-FC, Exhibit AA) are considered ancillary servicesthat are integral to surgical procedures and are not permitted to be reimbursed sep-arately in an ASC. Appendix, Exhibit 7 indicates those services that, according toMedicare (see: https://www.cms.gov/HospitalOutpatientPPS/Downloads/CMS1506FC_Addendum_D1.pdf) are considered ancillary services to surgicalprocedures and are not permitted to be reimbursed separately in a HOSF;

5. Administrative, recordkeeping, and housekeeping items and services;6. Blood, blood plasma, platelets, etc.;7. Anesthesia materials, including the anesthetic itself, and any materials,

whether disposable or re-usable, necessary for its administration; and8. Implantable DME and prosthetics.(b) HOSF fees are listed on subchapter Appendix, Exhibit 7 by CPT code. The

hospital outpatient surgical facility fee is the maximum that can be reimbursed foroutpatient procedures performed in an HOSF. The hospital outpatient facility feesin Appendix Exhibit 7 include services that would be covered if furnished in a hos-pital on an inpatient basis, including those set forth in (a)1 through 8 above.

(c) The sale, lease or rental of durable medical equipment (DME) to patientsfor use in their homes are not included in the ASC or HOSF fee. If the ASC orHOSF furnishes items of DME to patients, billing for such items should be madein accordance with subchapter Appendix, Exhibit 5.

(d) When multiple procedures are performed in an ASC or in an HOSF in thesame operative session, the ASC facility fee or the HOSF fee, as applicable, forthe procedure with the highest payment amount is reimbursed at 100 percent andreimbursement of any additional procedures furnished in the same session is 50percent of the applicable facility fee.

1. A procedure performed bilaterally in one operative session is reported as twoprocedures and is subject to the multiple procedure reduction formula.

2. Subchapter Appendices, Exhibit 1, the Physicians’ and ASC Facility FeeSchedule and Exhibit 7, the HOSF fee schedule, indicate those CPT codes that, ac-cording to Medicare (see: www.cms.gov/ASCPayment/ASCRN/list.asp and http://www.cms.gov/HospitalOutpatientPPS/) are exempt from the multiple procedurereduction formula.New Rule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013).

11:3-29.6. Balance billing prohibited. No health care provider may demandor request any payment from any person in excess of those permitted by the med-ical fee schedules and this subchapter, nor shall any person be liable to any healthcare provider for any amount of money that results from the charging of fees inexcess of those permitted by the medical fee schedules and this subchapter.Amended. R. 2001, d. 158, effective May 21, 2001. Recodified from N.J.A.C. 11:3-29.5 by R.2012d.187, effective November 5, 2012 (operative January 4, 2013).

UCJF 11:3-29.6

APPENDIX: AUTOMOBILE INSURANCE PERSONAL INJURY PROTECTION AND MOTOR BUS MEDICAL EXPENSE INSURANCE

COVERAGEExhibit 1

Physicians’ & Ambulatory Surgical Center (ASC) Facility Fee SchedulePay-mentIndi

cator(See

Phys- Phys- bot-ician’s ician’s ASC ASC tom)Fees Fees Fees Fees for)

CPT Mod Description North South North South codes)*Current Procedural Teminology (CPT) is copyright 2010 American Medical Association(AMA). All Rights Reserved. No fee schedules, basic units, relative values, or relatedlistings are included in CPT. The AMA assumes no liability for the data contained herein.Applicable FARS/DFARS restrictions apply to government use. CPT is a trademark of theAmerican Medical Association.Anes ANESTHESIA BASE UNITS 86.47 84.360232T NJX PLATELET PLASMA 63.95 63.95 89.55 82.44 XG0283 ELECTRICAL STIMULATION, 20.14 19.26

(UNATTENDED), TO ONE ORMORE AREAS

00289 ARTHRO, LOOSE BODY + CHONDRO 483.50 467.0 X, N110060 DRAIN SKIN ABSCESS 176.46 168.00 198.84 183.0310061 DRAIN SKIN ABSCESS 290.74 278.25 198.84 183.0310120 REMOVE FOREIGN BODY 219.66 208.52 297.15 273.5110121 REMOVE FOREIGN BODY 423.57 403.23 2,411.70 2,219.8510140 DRAIN HEMATOMA/FLUID 250.71 238.43 321.75 296.1310160 PUNCTURE DRAIN LESION 203.36 193.31 198.84 183.0310180 COMPLEX DRAIN WOUND 381.01 362.70 2,694.69 2,480.3411000 DEBRIDE INFECTED SKIN 84.28 80.26 102.96 94.7711001 DEBRIDE INFECTED SKIN, ADDED 33.67 32.24 3.93 31.2311010 DEBRIDE SKIN, FX 770.97 732.08 678.84 624.8411011 DEBRIDE SKIN/MUSCLE, FX 842.60 801.49 678.84 624.8411012 DEBRIDE SKIN/MUSCLEBONE, FX 1,128.89 1,074.42 678.84 624.8411042 DEBRIDE SKIN/TISSUE 141.88 134.65 364.44 335.4311043 DEBRIDE TISSUE/MUSCLE 309.64 294.89 364.44 335.4311044 DEBRIDETISSUE/MUSCLE/BONE 467.58 447.17 1,132.98 1,042.8311045 DEBRIDE SUBQ TISSUE ADD-ON 50.08 47.78 364.44 335.4311046 DEBRIDE MUSCLE/FASCIA ADD-ON 86.02 82.37 364.44 335.4311047 DEBRIDE BONE ADD-ON 141.04 135.27 1,132.98 1,042.8311055 TRIM SKIN LESION 78.70 74.56 111.15 102.3011056 TRIM SKIN LESIONS, 2 TO 4 93.59 88.93 121.44 111.7811057 TRIM SKIN LESIONS, OVER 4 110.23 104.93 121.44 111.7811100 BIOPSY SKIN LESION 168.53 159.57 199.77 183.9011101 BIOPSY SKIN, ADDED 52.52 50.16 58.50 53.8511200 REMOVE SKIN TAGS 136.42 129.65 121.44 111.7811300 SHAVE SKIN LESION 111.63 105.61 121.44 111.7811301 SHAVE SKIN LESION 150.18 142.55 121.44 111.7811302 SHAVE SKIN LESION 179.35 170.36 121.44 111.7811305 SHAVE SKIN LESION 110.55 104.93 121.44 111.7811306 SHAVE SKIN LESION 152.62 145.18 121.44 111.7811310 SHAVE SKIN LESION 137.16 130.09 121.44 111.7811311 SHAVE SKIN LESION 171.78 163.30 121.44 111.7811400 EXCISE TRT-EXT BENIGN+MARG

0.5 < CM 192.83 182.50 283.11 260.5811401 EXCISE TRT-EXT BENIGN+MARG

0.6-1 CM 234.32 222.41 319.41 294.0011402 EXCISE TRT-EXT BENIGN+MARG



3.1-4 CM 338.86 322.54 2,411.70 2,219.8511406 EXCISE TRT-EXT BENIGN+MARG

11:3-29.6 APPENDIX B - REGULATIONS> 4.0 CM 457.22 457.22 2,411.70 2,219.85

11420 EXCISE H-F-NECK-SP BENIGN+MARG0.5 < 191.28 181.36 266.76 245.52

11421 EXCISE H-F-NECK-SP BENIGN+MARG0.6-1 247.34 235.08 324.03 298.26



11424 EXCISE H-F-NECK-SP BENIGN+MARG3.1-4 364.37 347.38 2,411.70 2,219.85

11426 EXCISE H-F-NECK-SP BENIGN+MARG> 4 CM 516.41 494.20 3,188.13 2,934.54

11440 EXCISE FACE-MM BENIGN+MARG0.5 < CM 211.84 200.73 301.83 277.83

11441 EXCISE FACE-MM BENIGN+MARG0.6-1 CM 264.80 251.60 350.97 323.04



11444 EXCISE FACE-MM BENIGN+MARG3.1-4 CM 442.21 422.12 1,132.98 1,042.83

11719 TRIM NAIL(S) 34.77 32.88 51.48 47.3711720 DEBRIDE NAIL, 1-5 49.82 47.36 64.35 59.2511721 DEBRIDE NAIL, 6 OR MORE 67.33 64.26 76.02 69.9911730 REMOVE NAIL PLATE 151.98 144.74 121.44 111.7811732 REMOVE NAIL PLATE, ADDED 68.85 65.77 76.02 69.9911740 DRAIN BLOOD UNDER NAIL 75.08 71.04 57.72 53.1311750 REMOVE NAIL BED 343.28 327.09 411.81 379.0511752 REMOVE NAIL BED/FINGER TIP 494.47 471.49 582.60 536.2511760 REPAIR NAIL BED 346.62 328.23 177.81 163.6811762 RECONSTRUCT NAIL BED 429.68 409.09 531.12 488.8811765 EXCISE NAIL FOLD, TOE 223.00 209.99 121.44 111.7811900 INJECTION INTO SKIN LESIONS 90.58 86.02 121.44 111.7811901 ADDED SKIN LESIONS INJECTION 113.27 108.02 121.44 111.7811950 THERAPY FOR CONTOUR DEFECTS 113.05 107.85 131.01 120.6011951 THERAPY FOR CONTOUR DEFECTS 160.21 153.19 175.47 161.5211960 INSERT TISSUE EXPANDER(S) 1,436.90 1,374.88 2,972.49 2,736.0311981 INSERT DRUG IMPLANT DEVICE 216.27 206.20 89.55 82.44 X11982 REMOVE DRUG IMPLANT DEVICE 240.23 229.28 89.55 82.44 X12001 REPAIR SUPERFICIAL WOUND(S) 156.46 148.50 177.81 163.6812002 REPAIR SUPERFICIAL WOUND(S) 182.44 173.64 177.81 163.6812004 REPAIR SUPERFICIAL WOUND(S) 215.99 205.84 177.81 163.6812005 REPAIR SUPERFICIAL WOUND(S) 277.27 264.61 177.81 163.6812006 REPAIR SUPERFICIAL WOUND(S) 334.76 319.54 177.81 163.6812011 REPAIR SUPERFICIAL WOUND(S) 187.04 177.76 177.81 163.6812013 REPAIR SUPERFICIAL WOUND(S) 200.42 190.64 177.81 163.6812014 REPAIR SUPERFICIAL WOUND(S) 236.44 225.30 177.81 163.6812015 REPAIR SUPERFICIAL WOUND(S) 289.42 275.96 177.81 163.6812016 REPAIR SUPERFICIAL WOUND(S) 360.23 344.19 177.81 163.6812017 REPAIR SUPERFICIAL WOUND(S) 268.51 260.21 177.81 163.6812018 REPAIR SUPERFICIAL WOUND(S) 319.54 309.13 177.81 1 63.6812020 CLOSE SPLIT WOUND 431.60 410.59 619.29 570.0312021 CLOSE SPLIT WOUND 254.10 242.74 421.80 388.2612031 INTERMED WOUND REPAIR

S/TRT/EXT 392.46 372.69 177.81 163.6812032 INTERMED WOUND REPAIR






N-HF/GENITAL 408.73 388.48 177.81 163.6812042 INTERMED WOUND REPAIR

N-HG/GENITAL 468.02 444.84 177.81 163.6812044 INTERMED WOUND REPAIR

UCJF 11:3-29.6N-HG/GENITAL 555.19 527.51 177.81 163.68

12045 INTERMED WOUND REPAIRN-HG/GENITAL 592.76 564.13 421.80 388.26



12051 INTERMED WOUND REPAIRFACE/MM 432.90 411.35 421.80 388.26







13100 REPAIR WOUND OR LESION 503.63 479.30 619.29 570.0313101 REPAIR WOUND OR LESION 640.87 609.63 619.29 570.0313102 REPAIR WOUND/LESION, ADDED 172.70 164.94 619.29 570.0313120 REPAIR WOUND OR LESION 523.71 498.53 421.80 388.2613121 REPAIR WOUND OR LESION 714.49 679.65 421.80 388.2613122 REPAIR WOUND/LESION, ADDED 190.24 181.88 177.81 163.6813131 REPAIR WOUND OR LESION 577.33 549.97 421.80 388.2613132 REPAIR WOUND OR LESION 932.23 889.11 619.29 570.0313133 REPAIR WOUND/LESION, ADDED 267.99 256.52 421.80 388.2613150 REPAIR WOUND OR LESION 573.56 546.58 619.29 570.0313151 REPAIR WOUND OR LESION 652.83 622.29 619.29 570.0313152 REPAIR WOUND OR LESION 901.38 859.71 619.29 570.0313153 REPAIR WOUND/LESION, ADDED 294.26 281.64 421.80 388.2613160 LATE CLOSE WOUND 1,274.88 1,226.45 2,972.49 2,736.0314000 SKIN TISSUE REARRANGEMENT 1,001.58 953.82 2,296.11 2,113.4414001 SKIN TISSUE REARRANGEMENT 1,289.02 1,229.26 2,296.11 2,113.4414020 SKIN TISSUE REARRANGEMENT 1,124.57 1,070.90 2,296.11 2,113.4414021 SKIN TISSUE REARRANGEMENT 1,408.28 1,342.85 2,296.11 2,113.4414040 SKIN TISSUE REARRANGEMENT 1,235.25 1,177.91 2,296.11 2,113.4414041 SKIN TISSUE REARRANGEMENT 1,529.97 1,459.32 2,296.11 2,113.4414060 SKIN TISSUE REARRANGEMENT 1,251.46 1,194.92 2,296.11 2,113.4414061 SKIN TISSUE REARRANGEMENT 1,643.34 1,566.97 2,296.11 2,113.4414301 SKIN TISSUE REARRANGEMENT 1,770.48 1,689.95 2,972.49 2,736.0314302 SKIN TISSUE REARRANGE ADDED 369.95 356.41 2,972.49 2,736.0315002 WOUND PREP, TRUNK/ARM/LEG 538.12 513.17 619.29 570.0315003 WOUND PREP, ADDED 100 CM 117.04 111.70 619.29 570.0315004 WOUND PREP, F/N/HF/G 631.19 602.33 619.29 570.0315005 WOUND PREP, F/N/HF/G, ADDED CM 191.65 183.76 619.29 570.0315050 SKIN PINCH GRAFT 898.35 854.77 619.29 570.0315100 SKIN SPLIT GRAFT,

TRUNK/ARM/LEG 1,374.74 1,313.41 2,972.49 2,736.0315101 SKIN SPLIT GRAFT T/A/L, ADDED 300.62 285.81 2,972.49 2,736.0315120 SKIN SPLIT A-GRAFT

FAC/NEC/HF/G 1,518.58 1,450.58 2,972.49 2,736.0315121 SKIN SPLIT A-GRAFT F/N/HF/G

ADDED 428.19 407.69 2,972.49 2,736.0315130 DERM AUTOGRAFT,

TRUNK/ARM/LEG 1,077.48 1,028.66 2,296.11 2,113.4415170 ACELLULAR GRAFT

TRUNK/ARMS/LEGS 684.41 656.88 619.29 570.0315171 ACELLULAR GRAFT T/ARM/LEG,

ADDED 147.18 142.17 421.80 388.2615175 ACELLULAR GRAFT, F/N/HF/G 810.60 779.34 619.29 570.0315220 SKIN FULL GRAFT SCALP/ARM/LEG1,237.46 1,178.97 2,296.11 2,113.4415221 SKIN FULL GRAFT, ADDED 222.58 211.34 619.29 570.0315240 SKIN FULL GRAFT

FACE/GENITAL/HF 1,491.27 1,422.47 2,296.11 2,113.4415241 SKIN FULL GRAFT, ADDED 297.89 283.58 619.29 570.0315260 SKIN FULL GRAFT EEN & LIPS 1,614.97 1,541.12 2,296.11 2,113.4415330 APPLY ACELLULAR ALLOGRAFT

T/ARM/LEG 513.93 491.81 619.29 570.03

11:3-29.6 APPENDIX B - REGULATIONS15331 APPLY ACELLULAR GRAFT T/A/L,

ADDED 100.16 96.58 619.29 570.0315340 APPLY CULT SKIN SUBSTITUTE 497.48 475.21 421.80 388.2615341 APPLY CULT SKIN SUB, ADDED 75.02 71.44 421.80 388.2615365 APPLY CULT DERM SUB F/N/HF/G 542.33 517.83 421.80 388.2615366 APPLY CULT DERM F/KF/G ADDED 126.15 121.79 421.80 388.2615430 APPLY ACELLULAR XENOGRAFT 861.84 822.78 619.29 570.0315431 APPLY ACELLULAR XENOGRAFT

ADDED 328.03 316.57 619.29 570.0315570 FORM SKIN PEDICLE FLAP 1,424.66 1,361.15 2,972.49 2,736.0315572 FORM SKIN PEDICLE FLAP 1,388.47 1,326.28 2,972.49 2,736.0315574 FORM SKIN PEDICLE FLAP 1,451.66 1,386.66 2,972.49 2,736.0315576 FORM SKIN PEDICLE FLAP 1,291.01 1,232.56 2,972.49 2,736.0315620 SKIN GRAFT 709.40 673.04 2,972.49 2,736.0315732 MUSCLE-SKIN GRAFT, HEAD/NECK 2,390.54 2,290.95 2,972.49 2,736.0315734 MUSCLE-SKIN GRAFT, TRUNK 2,429.96 2,329.20 2,972.49 2,736.0315736 MUSCLE-SKIN GRAFT, ARM 2,142.30 2,051.77 2,972.49 2,736.0315738 MUSCLE-SKIN GRAFT, LEG 2,272.44 2,179.61 2,972.49 2,736.0315756 FREE MYO/SKIN FLAP MICROVASC 3,749.52 3,610.1315770 DERMA-FAT-FASCIA GRAFT 1,066.42 1,022.37 2,972.49 2,736.0315780 ABRASION TREAT SKIN 1,322.37 1,259.08 1,641.36 1,510.8015781 ABRASION TREAT SKIN 879.47 835.31 678.84 624.8415782 ABRASION TREAT SKIN 900.92 853.46 678.84 624.8415786 ABRASION, LESION, SING 391.74 371.66 121.44 111.7815787 ABRASION, LESIONS, ADDED 78.22 7 3.91 119.34 109.8615823 REVISE UPPER EYELID 979.35 934.65 2,972.49 2,736.0315830 EXCISE SKIN ABD 979.35 934.65 3,188.13 2,934.5415832 EXCISE EXCESSIVE SKIN TISSUE 979.35 934.65 3,188.13 2,934.5415851 REMOVE SUTURES 152.95 145.19 207.09 190.5915852 DRESSING CHANGE NOT FOR BURN 73.04 70.73 89.55 82.44 X15940 REMOVE HIP PRESSURE SORE 1,088.76 1,047.78 3,188.13 2,934.5415941 REMOVE HIP PRESSURE SORE 1,419.04 1,362.70 3,188.13 2,934.5415944 REMOVE HIP PRESSURE SORE 1,410.54 1,354.92 2,972.49 2,736.0315945 REMOVE HIP PRESSURE SORE 1,566.36 1,504.31 2,972.49 2,736.0315946 REMOVE HIP PRESSURE SORE 2,593.22 2,494.79 2,972.49 2,736.0315950 REMOVE THIGH PRESSURE SORE 898.37 863.19 3,188.13 2,934.5415951 REMOVE THIGH PRESSURE SORE 1,357.84 1,302.86 3,188.13 2,934.5415952 REMOVE THIGH PRESSURE SORE 1,316.96 1,267.76 2,296.11 2,113.4415953 REMOVE THIGH PRESSURE SORE 1,445.87 1,391.23 2,296.11 2,113.4415956 REMOVE THIGH PRESSURE SORE 1,823.53 1,754.01 2,296.11 2,113.4415958 REMOVE THIGH PRESSURE SORE 1,864.20 1,791.74 2,296.11 2,113.4416000 INITIAL TREAT BURN(S) 107.89 103.23 113.49 104.4616020 DRESS/DEBRIDE P-THICK BURN, S 132.50 125.94 173.16 159.3916025 DRESS/DEBRIDE P-THICK BURN, M 234.02 223.91 199.77 183.9016030 DRESS/DEBRIDE P-THICK BURN, L 282.60 269.99 199.77 183.9017000 DESTROY PREMALIG LESION 130.90 123.98 121.44 111.7817003 DESTROY PREMALIG LES, 2-14 11.64 11.07 15.21 14.0117004 DESTROY PREMALIG LESIONS 15+ 279.11 265.83 343.95 316.5917106 DESTROY SKIN LESIONS 550.21 524.12 364.44 335.4317107 DESTROY SKIN LESIONS 713.68 679.99 364.44 335.4317108 DESTROY SKIN LESIONS 1,013.03 967.87 364.44 335.4317110 DESTROY B9 LESION, 1-14 180.01 169.92 121.44 111.7817111 DSTRJ B9 SK TGS/CUTAN VASC 15/> 213.26 201.74 199.77 183.9017250 CHEM CAUT GRANLTJ TISS PROUD 123.93 117.07 190.68 175.53

FLESH SINUS/FSTL17261 DESTROY SKIN LESIONS 32.56 220.55 199.77 183.9017262 DESTROY SKIN LESIONS 281.00 266.92 199.77 183.9019000 DRAIN BREAST LESION 179.37 169.75 263.25 242.3119120 REMOVE BREAST LESION 750.90 719.29 3,413.91 3,142.3519125 EXCISE BREAST LESION 832.58 797.97 3,413.91 3,142.3519290 PLACE NEEDLE WIRE, BREAST 262.84 248.72 X, N120100 EXPLORE WOUND, NECK 927.38 897.3020101 EXPLORE WOUND, CHEST 648.74 615.4720102 EXPLORE WOUND, ABDOMEN 764.14 725.3320103 EXPLORE WOUND, EXTREMITY 914.65 8 69.73 1,735.95 1,597.8620520 REMOVE FOREIGN BODY 311.74 296.49 401.28 369.3620525 REMOVE FOREIGN BODY 763.77 723.36 3,188.13 2,934.5420526 THERAPEUTIC INJECTION,

CARP TUNNEL 118.45 113.27 127.50 117.3620550 INJECT TENDON SHEATH/LIGAMENT 89.97 86.03 95.94 88.2920551 INJECT TENDON ORIGIN/INSERT 91.72 87.67 99.45 91.5320552 INJECT TRIGGER POINT, 1/2 MUSCLE 129.69 123.83 94.77 87.21

UCJF 11:3-29.620553 INJECT TRIGGER POINTS, =/> 3 256.49 244.86 107.64 99.0620600 DRAIN/INJ, JOINTBURSA 85.46 81.58 97.11 89.3720605 DRAIN/INJ, JOINTBURSA 93.41 89.07 109.98 101.2220610 DRAIN/INJ, JOINTBURSA 168.19 160.06 157.95 145.3820612 ASPIRATE/INJECT GANGLION CYST 92.67 88.43 106.47 98.0120615 TREAT BONE CYST 347.60 330.96 430.50 396.2720650 INSERT & REMOVE BONE PIN 313.04 298.60 3,064.83 2,821.0520662 APPLY PELVIS BRACE 680.98 652.96 3,064.83 2,821.0520663 APPLY THIGH BRACE 724.98 694.28 3,064.83 2,821.0520665 REMOVE FIXATION DEVICE 89.55 82.44 X20670 REMOVE SUPPORT IMPLANT 2,411.70 2,219.8520680 REMOVE SUPPORT IMPLANT 976.54 929.22 3,188.13 2,934.5420690 APPLY BONE FIXATION DEVICE 2,428.13 2,338.02 4,301.40 3,959.2520692 APPLY BONE FIXATION DEVICE 4,571.37 4,397.67 4,301.40 3 ,959.2520693 ADJUST BONE FIXATION DEVICE 1,941.73 1,861.31 3,064.83 2,821.0520694 REMOVE BONE FIXATION DEVICE 1,824.61 1,737.34 3,064.83 2,821.0520696 COMP MULTIPLANE EXT FIXATION 4,555.72 4,376.97 4,301.40 3,959.2520697 COMP EXT FIXATE STRUT CHANGE 7,725.55 7,206.79 2,779.53 2,558.4320900 REMOVE BONE FOR GRAFT 673.98 637.99 4,301.40 3,959.2520902 REMOVE BONE FOR GRAFT 519.31 498.66 4,301.40 3,959.2520910 REMOVE CARTILAGE FOR GRAFT 1,037.67 992.57 2,972.49 2,736.0320912 REMOVE CARTILAGE FOR GRAFT 1,198.06 1,147.49 2,972.49 2,736.0320920 REMOVE FASCIA FOR GRAFT 985.25 943.49 2,296.11 2,113.4420922 REMOVE FASCIA FOR GRAFT 1,471.19 1,405.30 2,296.11 2,113.4420924 REMOVE TENDON FOR GRAFT 800.25 767.01 4,301.40 3,959.2520926 REMOVE TISSUE FOR GRAFT 692.39 664.11 619.29 570.0320931 SP BONE ALLOGRAFT STRUCT,

ADDED 480.89 465.7820950 FLUID PRESSURE, MUSCLE 1,090.10 1,027.35 198.84 183.0320955 FIBULA BONE GRAFT, MICROVASC10,896.00 10,491.6720974 ELECTRICAL BONE STIMULATION 388.51 369.1320975 ELECTRICAL BONE STIMULATION 968.04 932.18 X, N120979 US BONE STIMULATION 288.61 275.42 89.55 82.44 X20985 COMPUTER-ASSIST DIR MS PX 233.28 225.44 X, N121060 REMOVE JAW JOINT CARTILAGE 1,303.59 1,251.23 5,961.75 5,487.5121070 REMOVE CORONOID PROCESS 2,683.05 2,569.88 5,961.75 5,487.5121073 MANIPULATE TMJ W/ANESTH 625.03 593.86 832.95 766.7121085 PREPARE FACE/ORAL PROSTHESIS 1,453.19 1,375.54 1,265.82 1,165.1121110 INTERDENTAL FIXATION 1,453.19 1,375.54 1,056.45 972.42 X, N121116 INJECTION, JAW JOINT X-RAY 242.27 228.1521209 REDUCE FACIAL BONES 1,356.76 1,290.12 5,961.75 5,487.5121210 FACE BONE GRAFT 3,584.38 3,377.47 5,961.75 5,487.5121240 RECONSTRUCT JAW JOINT 3,361.24 3,224.68 5,961.75 5,487.5121242 RECONSTRUCT JAW JOINT 3,085.47 2,959.40 5,961.75 5,487.5121243 RECONSTRUCT JAW JOINT 5,070.37 4,866.28 5,961.75 5,487.5121244 RECONSTRUCT LOWER JAW 1,701.06 1,626.83 5,961.75 5,487.5121245 RECONSTRUCT JAW 1,819.98 1,735.61 5,961.75 5,487.5121246 RECONSTRUCT JAW 1,327.80 1,275.95 5,961.75 5,487.5121247 RECONSTRUCT LOWER JAW BONE 2,579.70 2,482.80 5,961.75 5,487.5121248 RECONSTRUCT JAW 1,730.48 1,651.07 5,961.75 5,487.5121249 RECONSTRUCT JAW 2,370.58 2,265.59 5,961.75 5,487.5121310 TREAT NOSE FX 185.45 174.76 151.17 139.1421315 TREAT NOSE FX 443.93 419.60 2,313.03 2,129.0421320 TREAT NOSE FX 417.47 394.98 2,313.03 2,129.0421325 TREAT NOSE FX 772.19 732.88 3,421.41 3,149.2521330 TREAT NOSE FX 926.89 881.33 3,421.41 3,149.2521335 TREAT NOSE FX 1,181.49 1,128.42 3,421.41 3,149.2521356 TREAT CHEEK BONE FX 2,159.27 2,052.68 3,421.41 3,149.2521360 TREAT CHEEK BONE FX 2,285.49 2,187.85 3,421.41 3,149.2521365 TREAT CHEEK BONE FX 4,774.53 4,590.4621366 TREAT CHEEK BONE FX 5,417.56 5,210.5021385 TREAT EYE SOCKET FX 3,005.24 2,877.7921386 TREAT EYE SOCKET FX 2,849.94 2,739.1421390 TREAT EYE SOCKET FX 3,399.51 3,262.80 5,961.75 5,487.5121395 TREAT EYE SOCKET FX 4,165.36 3,999.9621400 TREAT EYE SOCKET FX 807.13 765.31 1,056.45 972.4221401 TREAT EYE SOCKET FX 2,088.19 1,978.92 2,313.03 2,129.0421406 TREAT EYE SOCKET FX 2,367.98 2,266.67 5,961.75 5,487.5121407 TREAT EYE SOCKET FX 2,782.80 2,670.16 5,961.75 5,487.5121408 TREAT EYE SOCKET FX 3,870.37 3,718.1721450 TREAT LOWER JAW FX 954.01 901.26 474.09 436.3821451 TREAT LOWER JAW FX 1,231.95 1,165.53 1,056.45 972.42

11:3-29.6 APPENDIX B - REGULATIONS21452 TREAT LOWER JAW FX 969.53 911.95 2,313.03 2,129.0421453 TREAT LOWER JAW FX 1,437.35 1,360.70 5,961.75 5,487.5121454 TREAT LOWER JAW FX 889.43 850.92 3,421.41 3,149.2521461 TREAT LOWER JAW FX 3,370.55 3,171.80 5,961.75 5,487.5121462 TREAT LOWER JAW FX 3,567.33 3,359.58 5,961.75 5,487.5121465 TREAT LOWER JAW FX 1,514.36 1,453.74 5,961.75 5,487.5121470 TREAT LOWER JAW FX 1,919.57 1,843.6121800 TREAT RIB FX 164.26 156.32 210.60 193.8321820 TREAT STERNUM FX 217.62 207.24 210.60 193.8321825 TREAT STERNUM FX 900.11 864.9722305 TREAT SPINE PROCESS FX 210.60 193.8322310 TREAT SPINE FX 734.37 675.9622315 TREAT SPINE FX 3,738.68 3,578.03 2,779.53 2,558.4322505 MANIPULATE SPINE 214.24 206.29 2,074.56 1,909.5322520 PERCUT VERTEBROPLASTY THORACIC 4,301.40 3,959.2522521 PERCUT VERTEBROPLASTY LUMBAR 4,301.40 3,959.2522522 PERCUT VERTEBROPLASTY ADDED 4,301.40 3,959.2522554 NECK SPINE FUSION 6,185.12 5,961.4222585 ADDED SPINAL FUSION 1,650.20 1,597.9522845 INSERT SPINE FIXATION DEVICE 4,518.17 4,376.0622851 APPLY SPINE PROSTH DEVICE 2,507.61 2,427.5423120 PARTIAL REMOVE COLLAR BONE 3,521.55 3,374.09 4,301.40 3,959.2523125 REMOVE COLLAR BONE 4,270.68 4,099.77 4,301.40 3,959.2523130 REMOVE SHOULDER BONE, PART 3,681.64 3,527.78 6,312.78 5,810.6123331 REMOVE SHOULDER FOREIGN

BODY 3,576.37 3,428.03 3,188.13 2,934.5423332 REMOVE SHOULDER FOREIGN

BODY 5,348.95 5,138.1423350 INJECTION FOR SHOULDER X-RAY 245.78 232.06 X, N123405 TX SHO AREA 1 TDN 989.02 949.25 4,301.40 3,959.2523406 TX SHO AREA MLT TDN THRU SM

INC 1,228.87 1,180.78 4,301.40 3,959.2523410 OPEN REPAIR OF ROTATOR CUFF,

RECENT 3,500.51 3,361.17 6,312.78 5,810.6123412 OPEN REPAIR OF ROTATOR CUFF,

OLD 3,640.20 3,495.88 6,312.78 5,810.6123415 CORACOACROMIAL LIGM RLS

+-ACROMP 1,096.46 1,051.70 6,312.78 5,810.6123420 RECONSTRUCTION ROTATOR CUFF,

OLD 4,128.82 3,965.45 6,312.78 5,810.6123430 TENODIS LONG TDN BICEPS 1,169.96 1,123.11 6,312.78 5,810.6123440 RESCJ/TRNSPLJ LONG TDN BICEPS 1,192.02 1,145.18 6,312.78 5,810.6123470 RECONSTRUCT SHOULDER JOINT 5,149.21 4,954.0423472 RECONSTRUCT SHOULDER JOINT 6,369.05 6,131.8023480 REVISE COLLAR BONE 3,481.15 3,344.49 6,312.78 5,810.6123485 REVISE COLLAR BONE 4,080.99 3,923.94 11,871.09 10,926.7823500 TREAT CLAVICLE FX 517.10 320.37 210.60 193.8323505 TREAT CLAVICLE FX 836.78 519.25 2,779.53 2,558.4323515 TREAT CLAVICLE FX 2,182.75 2,094.37 8,925.39 8,215.4123520 TREAT CLAVICLE DISLOCATION 543.64 518.10 734.37 675.9623525 TREAT CLAVICLE DISLOCATION 889.99 848.39 734.37 675.9623530 TREAT CLAVICLE DISLOCATION 1,683.11 1,615.14 6,420.90 5,910.1523540 TREAT CLAVICLE DISLOCATION 526.02 501.82 210.60 193.8323545 TREAT CLAVICLE DISLOCATION 963.58 919.00 734.37 675.9623550 TREAT CLAVICLE DISLOCATION 1,729.78 1,659.14 6,420.90 5,910.1523552 TREAT CLAVICLE DISLOCATION 1,992.63 1,911.66 6,420.90 5,910.1523570 TREAT SHOULDER BLADE FX 550.00 524.31 210.60 193.8323600 TREAT HUMERUS FX 774.56 479.33 210.60 193.8323605 TREAT HUMERUS FX 1,118.44 693.94 2,779.53 2,558.4323615 TREAT HUMERUS FX 3,210.58 1,336.23 8,925.39 8,215.4123616 TREAT HUMERUS FX 4,569.61 1,904.53 8,925.39 8,215.4123620 TREAT HUMERUS FX 640.51 609.71 210.60 193.8323625 TREAT HUMERUS FX 910.15 868.61 2,779.53 2,558.4323630 TREAT HUMERUS FX 2,340.39 2,246.76 8,925.39 8,215.4123650 TREAT SHOULDER DISLOCATION 713.19 443.19 210.60 193.8323655 TREAT SHOULDER DISLOCATION 941.00 585.27 2,074.56 1,909.5323700 FIXATE SHOULDER 470.07 338.09 2,074.56 1,909.5324220 INJECTION FOR ELBOW X-RAY 265.46 251.25 X, N124300 MANIPULATE ELBOW W/ANESTH 640.74 610.08 2,074.56 1,909.5324305 ARM TENDON LENGTHENING 912.18 874.28 4,301.40 3,959.2524340 REPAIR BICEPS TENDON 2,601.25 2,494.51 6,312.78 5,810.6124341 REPAIR ARM TENDON/MUSCLE 3,143.66 3,012.32 6,312.78 5,810.61

UCJF 11:3-29.624342 REPAIR RUPTURED TENDON 3,306.76 3,175.53 6,312.78 5,810.6124343 REPAIR ELBOW LAT LIGAMENT

W/TISS 2,987.14 2,862.45 4,301.40 3,959.2524500 TREAT HUMERUS FX 549.29 522.97 210.60 193.8324505 TREAT HUMERUS FX 780.56 744.97 210.60 193.8324515 TREAT HUMERUS FX 1,381.32 1,326.32 8,925.39 8,215.4124516 TREAT HUMERUS FX 1,358.43 1,305.28 8,925.39 8,215.4124530 TREAT HUMERUS FX 588.23 560.15 210.60 193.8324535 TREAT HUMERUS FX 965.43 922.74 734.37 675.9624545 TREAT HUMERUS FX 1,456.68 1,399.91 8,925.39 8,215.4124546 TREAT RUS FX 1,648.10 1,583.95 8,925.39 8,215.4124560 TREAT HUMERUS FX 494.20 470.24 210.60 193.8324565 TREAT HUMERUS FX 817.85 781.01 210.60 193.8324575 TREAT RUS FX 1,155.33 1,108.02 8,925.39 8,215.4124576 TREAT HUMERUS FX 524.86 499.14 210.60 193.8324577 TREAT HUMERUS FX 846.15 808.13 210.60 193.8324579 TREAT RUS FX 1,314.50 1,261.84 8,925.39 8,215.4125000 INCISE TENDON SHEATH 547.09 521.24 3,064.83 2,821.0525001 INCISE FLEXOR CARPI RADIALIS 536.36 511.94 3,064.83 2,821.0525020 DECOMPRESS FOREARM 1 SPACE 1,767.91 1,684.75 4,301.40 3,959.2525023 DECOMPRESS FOREARM 1 SPACE 3,363.81 3,221.26 ,301.40 3,959.2525024 DECOMPRESS FOREARM 2 SPACES 2,353.42 2,260.29 4,301.40 3,959.2525025 DECOMPRESS FOREARM 2 SPACES 3,669.10 3,530.71 4,301.40 3,959.2525118 EXCISE WRIST TENDON SHEATH 607.03 580.07 4,301.40 3,959.2525215 REMOVE WRIST BONES 1,898.51 1,818.66 4,301.40 3,959.2525246 INJECTION FOR WRIST X-RAY 268.94 254.91 X, N125259 MANIPULATE WRIST W/ANESTH 644.82 613.89 2,779.53 2,558.4325260 REPAIR FOREARM TENDON/MUSCLE2,008.73 1,921.52 4,301.40 3,959.2525263 REPAIR FOREARM TENDON/MUSCLE1,999.71 1,913.76 4,301.40 3,959.2525265 REPAIR FOREARM TENDON/MUSCLE2,368.51 2,270.10 4,301.40 3,959.2525270 REPAIR FOREARM TENDON/MUSCLE1,592.68 1,522.50 4,301.40 3,959.2525272 REPAIR FOREARM TENDON/MUSCLE1,784.09 1,706.99 4,301.40 3,959.2525274 REPAIR FOREARM TENDON/MUSCLE2,130.04 2,040.87 4,301.40 3,959.2525295 RELEASE WRIST/FOREARM TENDON 876.95 838.58 3,064.83 2,821.0525500 TREAT FX RADIUS 413.29 393.45 210.60 193.8325505 TREAT FX RADIUS 781.41 745.83 734.37 675.9625515 TREAT FX RADIUS 1,050.48 1,007.25 6,420.90 5,910.1525525 TREAT FX RADIUS 1,246.06 1,195.16 6,420.90 5,910.1525526 TREAT FX RADIUS 1,533.29 1,471.52 6,420.90 5,910.1525530 TREAT FX ULNA 402.85 382.70 210.60 193.8325535 TREAT FX ULNA 760.01 725.62 210.60 193.8325545 TREAT FX ULNA 981.64 940.37 6,420.90 5,910.1525560 TREAT FX RADIUS & ULNA 808.02 769.13 210.60 193.8325565 TREAT FX RADIUS & ULNA 1,566.66 1,496.29 734.37 675.9625574 TREAT FX RADIUS & ULNA 2,025.40 1,942.13 8,925.39 8,215.4125575 TREAT FX RADIUS/ULNA 2,717.76 2,608.67 8,925.39 8,215.4125600 TREAT FX RADIUSIULNA 869.76 827.89 210.60 193.8325605 TREAT FX RADIUS/ULNA 1,865.53 1,783.62 734.37 675.9625606 TREAT FX DISTAL RADIAL 2,018.97 1,933.22 3,542.43 3,260.6425607 TREAT FX RADIAL

EXTRA-ARTICULAR 2,204.51 2,113.59 8,925.39 8,215.4125608 TREAT FX RADIAL

INTRA-ARTICULAR 2,472.05 2,371.92 8,925.39 8,215.4125609 TREAT FX RADIAL 3+ FRAG 3,148.22 3,022.40 8,925.39 8,215.4125622 TREAT WRIST BONE FX 900.97 857.05 210.60 193.8325624 TREAT WRIST BONE FX 1,384.38 1,319.72 734.37 675.9625628 TREAT WRIST BONE FX 2,177.02 2,087.90 6,420.90 5,910.1525630 TREAT WRIST BONE FX 909.36 866.26 210.60 193.8325635 TREAT WRIST BONE FX 1,342.79 1,280.29 210.60 193.8325645 TREAT WRIST BONE FX 1,718.80 1,648.07 6,420.90 5,910.1525650 TREAT WRIST BONE FX 953.03 908.21 210.60 193.8325652 TREAT FX ULNAR STYLOID 1,879.79 1,801.28 6,420.90 5,910.1525670 TREAT FX ULNAR STYLOID 1,831.97 1,757.00 3,542.43 3,260.6425671 TREAT FX ULNAR STYLOID 1,598.39 1,529.90 3,542.43 3,260.6425676 TREAT WRIST DISLOCATION 1,911.46 1,832.38 3,542.43 3,260.6425680 TREAT WRIST FX 1,383.37 1,326.99 210.60 193.8325685 TREAT WRIST FX 2,218.61 2,130.23 3,542.43 3,260.6426055 INCISE FINGER TENDON SHEATH 910.15 858.58 2,289.75 2,107.6226116 EXCISE HAND TUMOR DEEP

< 1.5 CM 1,590.71 1,523.59 2,411.70 2,219.8526140 REVISE FINGER JOINT, EACH 1,527.77 1,462.59 2,289.75 2,107.6226145 TENDON EXCISE PALM/FINGER 2,479.64 2,374.52 2,289.75 2,107.62

11:3-29.6 APPENDIX B - REGULATIONS26340 MANIPULATE FINGER W/ANESTH 521.42 495.05 734.37 675.9626410 REPAIR HAND TENDON 1,739.49 1,650.91 2,289.75 2,107.6226418 REPAIR FINGER TENDON 2,125.52 2,014.58 2,289.75 2,107.6226445 RELEASE HAND/FINGER TENDON 1,786.60 1,692.75 2,289.75 2,107.6226480 TRANSPLANT HAND TENDON 2,307.21 2,192.78 3,971.19 3,655.3226525 RELEASE FINGER CONTRACTURE 2,010.20 1,907.42 2,289.75 2,107.6226540 REPAIR HAND JOINT 2,010.67 1,914.55 2,289.75 2,107.6226600 TREAT METACARPAL FX 447.47 425.44 210.60 193.8326605 TREAT METACARPAL FX 499.07 474.91 210.60 193.8326607 TREAT METACARPAL FX 702.97 672.84 2,779.53 2,558.4326608 TREAT METACARPAL FX 1,155.32 1,104.12 3,542.43 3,260.6426615 TREAT METACARPAL FX 1,371.83 1,313.19 6,420.90 5,910.1526720 TREAT FINGER FX, EACH 303.29 288.37 210.60 193.8326725 TREAT FINGER FX, EACH 526.64 502.01 210.60 193.8326727 TREAT FINGER FX, EACH 739.96 706.95 3,542.43 3,260.6426735 TREAT FINGER FX, EACH 925.25 886.02 3,542.43 3,260.6426740 TREAT FINGER FX, EACH 352.67 335.26 210.60 193.8326742 TREAT FINGER FX, EACH 571.25 545.14 210.60 193.8326746 TREAT FINGER FX, EACH 1,143.63 1,096.98 3,542.43 3,260.6426750 TREAT FINGER FX, EACH 280.86 267.55 210.60 193.8326755 TREAT FINGER FX, EACH 484.57 461.98 210.60 193.8327036 EXCISE HIP JOINT/MUSCLE 3,050.71 2,932.1027093 INJECTION FOR HIP X-RAY 313.73 296.32 X, N127095 INJECTION FOR HIP X-RAY 384.77 363.23 X, N127096 INJECT SACROILIAC JOINT 586.47 554.47 1,012.32 931.8027130 TOTAL HIP ARTHROPLASTY 5,258.22 5,062.4427132 TOTAL HIP ARTHROPLASTY 6,133.86 5,907.4827193 TREAT PELVIC RING FX 1,417.56 1,359.02 210.60 193.8327194 TREAT PELVIC RING FX 2,095.30 2,013.65 2,074.56 1,909.5327227 TREAT HIP FX(S) 5,066.90 4,879.6127228 TREAT HIP FX(S) 5,779.51 5,567.9427236 TREAT THIGH FX 3,627.64 3,490.0427245 TREAT THIGH FX 3,775.02 3,630.8627275 MANIPULATE HIP JOINT 323.19 309.59 2,074.56 1,909.5327403 REPAIR KNEE CARTILAGE 3,103.82 2,978.06 4,301.40 3,959.2527405 REPAIR KNEE LIGAMENT 3,282.44 3,149.55 6,312.78 5,810.6127420 REVISE UNSTABLE KNEECAP 2,261.71 2,171.44 6,312.78 5,810.6127422 REVISE UNSTABLE KNEECAP 2,252.47 2,162.50 6,312.78 5,810.6127424 REVISION/REMOVE KNEECAP 2,255.28 2,165.35 6,312.78 5,810.6127447 TOTAL KNEE ARTHROPLASTY 4,684.46 4,509.7527487 REVISE/REPLACE KNEE JOINT 4,295.95 4,137.9927500 TREAT THIGH FX 2,180.66 2,087.12 34.37 675.9627501 TREAT THIGH FX 2,131.34 2,042.54 210.60 193.8327502 TREAT THIGH FX 3,311.93 3,184.79 2,779.53 2,558.4327503 TREAT THIGH FX 3,407.62 3,273.56 210.60 193.8327506 TREAT THIGH FX 5,689.32 5,472.8527507 TREAT THIGH FX 4,156.52 3,999.4627508 TREAT THIGH FX 2,209.66 2,113.32 210.60 193.8327509 TREAT THIGH FX 2,744.11 2,628.26 3,542.43 3,260.6427510 TREAT THIGH FX 2,936.26 2,821.17 734.37 675.9627511 TREAT THIGH FX 4,295.44 4,134.3327513 TREAT THIGH FX 5,359.94 5,162.2927514 TREAT THIGH FX 4,219.76 4,059.3427520 TREAT KNEECAP FX 1,349.20 1,284.12 210.60 193.8327524 TREAT KNEECAP FX 3,198.15 3,070.6227530 TREAT KNEE FX 1,671.35 1,593.30 210.60 193.8327532 TREAT KNEE FX 2,604.20 2,492.86 2,779.53 2,558.4327535 TREAT KNEE FX 3,857.40 3,711.2527536 TREAT KNEE FX 5,066.57 4,872.9027538 TREAT KNEE FX(S) 1,987.87 1,897.12 210.60 193.8327540 TREAT KNEE FX 3,478.82 3,340.3627570 FIXATE KNEE JOINT 235.46 225.20 2,074.56 1,909.5327685 REVISE LOWER LEG TENDON 2,767.45 2,634.16 4,301.40 3,959.2527686 REVISE LOWER LEG TENDONS 2,372.88 2,276.62 4,301.40 3,959.2527690 REVISE LOWER LEG TENDON 2,704.36 2,595.44 6,312.78 5,810.6127691 REVISE LOWER LEG TENDON 3,202.39 3,073.42 6,312.78 5,810.6127692 REVISE ADDEDITIONAL LEG TENDON461.41 445.92 6,312.78 5,810.6127695 REPAIR ANKLE LIGAMENT 1,477.41 1,416.90 4,301.40 3,959.2527696 REPAIR ANKLE LIGAMENTS 1,723.72 1,656.05 4,301.40 3,959.2527698 REPAIR ANKLE LIGAMENT 1,965.63 1,888.89 4,301.40 3,959.2527750 TREAT TIBIA FX 1,446.76 1,377.78 210.60 193.8327752 TREAT TIBIA FX 2,273.94 2,173.81 2,779.53 2,558.43

UCJF 11:3-29.627758 TREAT TIBIA FX 3,785.47 3,636.72 6,420.90 5,910.1527759 TREAT TIBIA FX 4,257.79 4,093.54 8,925.39 8,215.4127760 CLOSED TREAT MEDIAL ANKLE FX 999.35 951.28 210.60 193.8327762 CLOSED TREAT MED ANKLE FX

W/MANIP 1,452.26 1,387.19 2,779.53 2,558.4327766 OPEN TREAT MEDIAL ANKLE FX 1,856.02 1,778.54 6,420.90 5,910.1527786 TREAT ANKLE FX 491.69 467.93 210.60 193.8327788 TREAT ANKLE FX 662.30 632.08 210.60 193.8327792 TREAT ANKLE FX 1,121.80 1,076.61 6,420.90 5,910.1527808 TREAT ANKLE FX 518.87 493.37 210.60 193.8327810 TREAT ANKLE FX 739.42 706.28 210.60 193.8327814 TREAT ANKLE FX 1,223.81 1,174.68 6,420.90 5,910.1527816 TREAT ANKLE FX 491.32 467.71 210.60 193.8327818 TREAT ANKLE FX 756.19 722.98 734.37 675.9627822 TREAT ANKLE FX 1,342.67 1,287.42 6,420.90 5,910.1527823 TREAT ANKLE FX 1,523.63 1,462.35 8,925.39 8,215.4127824 TREAT LOWER LEG FX 936.08 892.85 210.60 193.8327825 TREAT LOWER LEG FX 1,653.18 1,582.18 2,779.53 2,558.4327826 TREAT LOWER LEG FX 2,537.97 2,434.01 6,420.90 5,910.1527827 TREAT LOWER LEG FX 3,313.36 3,179.78 8,925.39 8,215.4127828 TREAT LOWER LEG FX 3,955.96 3,800.93 8,925.39 8,215.4127829 TREAT LOWER LEG JOINT 2,062.48 1,976.64 6,420.90 5,910.1527840 TREAT ANKLE DISLOCATION 1,072.56 1,028.51 210.60 193.8327842 TREAT ANKLE DISLOCATION 1,488.26 1,426.77 2,074.56 1,909.5327846 TREAT ANKLE DISLOCATION 2,235.14 2,146.41 6,420.90 5,910.1527848 TREAT ANKLE DISLOCATION 2,511.52 2,412.81 6,420.90 5,910.1527860 FIXATE ANKLE JOINT 276.66 265.27 2,074.56 1,909.5328120 PART REMOVE ANKLE/HEEL 1,107.25 1,057.06 3,014.25 2,774.4928122 PARTIAL REMOVE FOOT BONE 1,028.92 981.54 3,014.25 2,774.4928400 TREAT HEEL FX 389.18 369.98 210.60 193.8328405 TREAT HEEL FX 613.23 585.90 2,779.53 2,558.4328415 TREAT HEEL FX 1,782.79 1,712.47 8,925.39 8,215.4128420 TREAT/GRAFT HEEL FX 2,997.32 2,880.42 6,420.90 5,910.1528430 TREAT ANKLE FX 563.23 535.64 210.60 193.8328435 TREAT ANKLE FX 827.86 789.27 210.60 193.8328436 TREAT ANKLE FX 1,073.70 1,025.26 3,542.43 3,260.6428445 TREAT ANKLE FX 2,583.35 2,483.99 6,420.90 ,910.1528470 TREAT METATARSAL FX 511.87 486.88 210.60 193.8328475 TREAT METATARSAL FX 622.83 594.36 210.60 193.8328476 TREAT METATARSAL FX 843.05 802.80 3,542.43 3,260.6428485 TREAT METATARSAL FX 1,291.11 1,237.46 6,420.90 5,910.1528725 FUSE FOOT BONES 1,926.38 1,852.85 7,371.54 6,785.1628730 FUSE FOOT BONES 2,050.42 1,969.71 7,371.54 6,785.1628740 FUSE FOOT BONES 2,079.28 1,981.86 7,371.54 6,785.1628750 FUSE BIG TOE JOINT 2,027.14 1,930.24 7,371.54 6,785.1629065 APPLY LONG ARM CAST 149.13 141.80 194.19 178.74 X29075 APPLY FOREARM CAST 139.52 132.52 187.17 172.29 X29085 APPLY HANDIWRIST CAST 147.51 140.22 149.40 137.52 X29086 APPLY FINGER CAST 117.72 111.61 149.40 137.52 X29105 APPLY LONG ARM SPLINT 155.41 148.00 149.40 137.52 X29125 APPLY FOREARM SPLINT 125.21 118.86 147.42 135.69 X29126 APPLY FOREARM SPLINT 141.72 134.82 149.40 137.52 X29130 APPLY FINGER SPLINT 72.44 69.28 67.86 62.46 X29131 APPLY FINGER SPLINT 92.77 88.41 97.11 89.37 X29200 STRAP CHEST 82.75 78.96 94.77 87.21 X29240 STRAP SHOULDER 89.29 85.21 101.79 93.69 X29260 STRAP ELBOW OR WRIST 80.59 76.70 100.62 92.61 X29280 STRAP HAND OR FINGER 78.61 74.72 101.79 93.69 X29345 APPLY LONG LEG CAST 212.03 202.15 255.03 234.75 X29355 APPLY LONG LEG CAST 219.66 209.65 255.03 234.75 X29365 APPLY LONG LEG CAST 191.79 182.59 240.99 221.82 X29405 APPLY SHORT LEG CAST 138.97 132.16 178.98 164.73 X29425 APPLY SHORT LEG CAST 147.75 140.72 181.32 166.89 X29450 APPLY LEG CAST 226.46 217.10 149.40 137.52 X29505 APPLY LONG LEG SPLINT 121.67 115.58 149.40 137.52 X29515 APPLY LOWER LEG SPLINT 112.71 107.26 141.54 130.29 X29520 STRAP HIP 77.82 74.05 97.11 89.37 X29530 STRAP KNEE 81.60 77.69 100.62 92.61 X29540 STRAP ANKLE AND/OR FT 53.90 51.17 72.54 66.78 X29550 STRAP TOES 44.24 41.67 72.54 66.78 X29580 APPLY PASTE BOOT 82.79 78.81 102.96 94.77 X29581 APPLY MULTILAY COMPRESS LWR

11:3-29.6 APPENDIX B - REGULATIONSLEG 152.30 143.77 149.40 137.52 X

29590 APPLY FOOT SPLINT 82.51 79.00 83.04 76.44 X29700 REMOVE/REVISE CAST 103.41 98.21 139.20 128.13 X29705 REMOVE/REVISE CAST 104.21 99.48 119.34 109.86 X29710 REMOVE/REVISE CAST 190.34 181.78 217.62 200.3129740 WEDGE CAST 141.31 135.19 149.40 137.52 X29800 JAW ARTHROSCOPY/SURG 2,870.02 2,751.17 3,997.71 3,679.7129804 JAW ARTHROSCOPY/SURG 3,578.52 3,434.24 3,997.71 3,679.7129805 SHOULDER ARTHROSCOPY, DIAG 2,575.75 2,467.98 3,997.71 3,679.7129806 SHOULDER ARTHROSCOPY/SURG 5,808.16 5,582.08 6,462.39 5,948.3429807 SHOULDER ARTHROSCOPY/SURG 5,671.51 5,449.31 6,462.39 5,948.3429819 SHOULDER ARTHROSCOPY/SURG 3,210.18 3,078.79 6,462.39 5,948.3429820 SHOULDER ARTHROSCOPY/SURG 2,953.64 2,833.12 6,462.39 5,948.3429821 SHOULDER ARTHROSCOPY/SURG 3,233.10 3,101.41 6,462.39 5,948.3429822 SHOULDER ARTHROSCOPY/SURG 3,144.95 3,016.12 3,997.71 3,679.7129823 SHOULDER ARTHROSCOPY/SURG 3,430.85 3,290.80 6,462.39 5,948.3429824 SHOULDER ARTHROSCOPY/SURG 3,689.94 3,539.41 3,997.71 3,679.7129825 SHOULDER ARTHROSCOPY/SURG 3,202.11 3,071.26 6,462.39 5,948.3429826 SHOULDER ARTHROSCOPY/SURG3,650,34 3,504.39 6,462.39 5,948.3429827 ARTHROSCOPY ROTATOR CUFF

REPAIR 4,596.05 4,418.87 6,462.39 5,948.3429828 ARTHROSCOPY BICEPS TENODESIS3,899.18 3,748.17 6,462.39 5,948.3429830 ELBOW ARTHROSCOPY 1,932.85 1,852.70 3,997.71 3,679.7129834 ELBOW ARTHROSCOPY/SURG 2,095.15 2,008.15 3,997.71 3,679.7129835 ELBOW ARTHROSCOPY/SURG 2,154.22 2,065.19 3,997.71 3,679.7129837 ELBOW ARTHROSCOPY/SURG 2,251.82 2,159.47 3,997.71 3,679.7129840 WRIST ARTHROSCOPY 1,918.73 1,837.85 3,997.71 3,679.7129844 WRIST ARTHROSCOPY/SURG 2,115.96 2,027.77 3,997.71 3,679.7129845 WRIST ARTHROSCOPY/SURG 2,440.18 2,339.75 3,997.7 3,679.7129846 WRIST ARTHROSCOPY/SURG 2,218.96 2,126.68 3,997.71 3,679.7129847 WRIST ARTHROSCOPY/SURG 2,310.86 2,216.47 6,462.39 5,948.3429848 WRIST ENDOSCOPY/SURG 2,159.31 2,067.30 3,997.71 3,679.7129850 KNEE ARTHROSCOPY/SURG 2,540.30 2,439.30 3,997.71 3,679.7129855 TIBIAL ARTHROSCOPY/SURG 3,347.13 3,213.03 6,462.39 5,948.3429860 HIP ARTHROSCOPY, DIAG 2,809.81 2,697.02 6,462.39 5,948.3429861 HIP ARTHROSCOPY/SURG 3,088.61 2,966.10 6,462.39 5,948.3429862 HIP ARTHROSCOPY/SURG 3,469.37 3,330.41 6,462.39 5,948.3429863 HIP ARTHROSCOPY/SURG 3,458.24 3,320.12 6,462.39 5,948.3429870 KNEE ARTHROSCOPY, DIAG 2,543.44 2,416.34 3,997.71 3,679.7129871 KNEE ARTHROSCOPY/DRAIN 2,182.27 2,092.01 3,997.71 3,679.7129873 KNEE ARTHROSCOPY/SURG 2,221.06 2,124.42 3,997.71 3,679.7129874 KNEE ARTHROSCOPY/SURG 2,291.42 2,197.95 3,997.71 3,679.7129875 KNEE ARTHROSCOPY/SURG 2,712.06 2,599.81 3,997.71 3,679.7129876 KNEE ARTHROSCOPY/SURG 3,584.57 3,439.85 3,997.71 3,679.7129879 KNEE ARTHROSCOPY/SURG 2,818.03 2,704.52 3,997.71 3,679.7129880 KNEE ARTHROSCOPY/SURG 3,774.79 3,623.53 3,997.71 3,679.7129881 KNEE ARTHROSCOPY/SURG 3,531.15 3,388.20 3,997.71 3,679.7129882 KNEE ARTHROSCOPY/SURG 3,812.37 3,660.32 3,997.71 3,679.7129883 KNEE ARTHROSCOPY/SURG 3,576.15 3,435.01 3,997.71 3,679.7129884 KNEE ARTHROSCOPY/SURG 2,635.72 2,528.41 3,997.71 3,679.7129886 KNEE ARTHROSCOPY/SURG 2,695.10 2,585.53 3,997.71 3,679.7129887 KNEE ARTHROSCOPY/SURG 3,168.57 3,041.28 3,997.71 3,679.7129888 KNEE ARTHROSCOPY/SURG 4,211.31 4,048.82 11,871.09 10,926.7829889 KNEE ARTHROSCOPY/SURG 5,187.05 4,985.30 11,871.09 10,926.7829891 ANKLE ARTHROSCOPY/SURG 2,944.29 2,825.65 6,462.39 5,948.3429894 ANKLE ARTHROSCOPY/SURG 2,194.01 2,106.44 3,997.71 3,679.7129895 ANKLE ARTHROSCOPY/SURG 2,096.49 2,013.20 3,997.71 3,679.7129897 ANKLE ARTHROSCOPY/SURG 2,198.99 2,111.07 3,997.71 3,679.7129898 ANKLE ARTHROSCOPY/SURG 2,437.92 2,342.16 3,997.71 3,679.7129899 ANKLE ARTHROSCOPY/SURG 4,454.29 4,283.43 6,462.39 5,948.3430100 INTRANASAL BIOPSY 231.61 218.73 357.99 329.5230130 EXCISE INFERIOR TURBINATE 616.48 585.09 2,313.03 2,129.0430140 RESECT INFERIOR TURBINATE 714.07 676.41 3,421.41 3,149.2530200 INJECTION TREAT NOSE 185.69 175.48 283.11 260.5830300 REMOVE NASAL FOREIGN BODY 377.61 355.40 89.55 82.44 X30310 REMOVE NASAL FOREIGN BODY 333.88 317.27 2,313.03 2,129.0430520 REPAIR NASAL SEPTUM 1,533.94 1,462.07 3,421.41 3,149.2530802 ABLATE INF TURBINATE

SUBMUCOSAL 475.96 450.01 2;313.03 2,129.0430901 CONTROL NOSEBLEED 154.98 147.82 151.17 139.1430903 CONTROL NOSEBLEED 323.03 305.90 151.17 139.1430905 CONTROL NOSEBLEED 400.32 379.29 151.17 139.14

UCJF 11:3-29.630930 THERAPEUTIC FX, NASAL INF TURB 199.28 189.73 2,313.03 2,129.0431000 IRRIGATE MAXILLARY SINUS 295.86 279.40 457.44 421.0531020 EXPLORE MAXILLARY SINUS 793.30 748.88 3,421.41 3,149.2531231 NASAL ENDOSCOPY, DIAG 316.52 298.37 268.32 246.9931237 NASAL/SINUS ENDOSCOPY, SURG 533.18 505.96 2,927.49 2,694.6031238 NASAL/SINUS ENDOSCOPY, SURG 547.19 519.83 2,927.49 2,694.6031255 REMOVE ETHMOID SINUS 1,735.89 1,673.26 4,128.33 3,799.9231256 EXPLORE MAXILLARY SINUS 1,228.03 1,181.96 4,128.33 3,799.9231267 ENDOSCOPY, MAXILLARY SINUS 983.83 947.97 4,128.33 3,799.9231500 INSERT EMERGENCY AIRWAY 169.29 164.70 315.78 290.67 X31505 DIAGNOSTIC LARYNGOSCOPY 137.08 129.60 124.02 114.1531515 LARYNGOSCOPY FOR ASPIRATION 342.57 324.79 2,927.49 2,694.6031525 DIAG LARYNGOSCOPY EXCL NB 409.68 389.77 2,927.49 2,694.6031575 DIAGNOSTIC LARYNGOSCOPY 188.42 178.87 253.86 233.6731579 DIAGNOSTIC LARYNGOSCOPY 352.14 335.06 445.74 410.2831600 INCISE WINDPIPE 629.61 609.2731605 INCISE WINDPIPE 287.29 278.92 1,056.45 972.4231622 DIAG BRONCHOSCOPE/WASH 515.11 488.50 1,400.82 1,289.4031624 DIAG BRONCHOSCOPE/LAVAGE 516.04 489.32 1,400.82 1,289.4031645 BRONCHOSCOPY, CLEAR AIRWAYS 493.95 469.51 1,400.82 1,289.4031646 BRONCHOSCOPY, RECLEAR AIRWAY451.44 428.67 1,400.82 1,289.4032405 BIOPSY LUNG OR MEDIASTINUM 154.47 149.43 1,298.73 1,195.4129877 KNEE ARTHROSCOPY/SURG 3,398.38 3,259.86 3,997.71 3,679.7132551 INSERT CHEST TUBE 523.12 506.9432601 THORACOSCOPY, DIAGNOSTIC 499.24 483.4732651 THORACOSCOPY, SURGICAL 1,750.69 1,694.0332653 THORACOSCOPY, SURGICAL 1,686.57 1,632.0633210 INSERT HEART ELECTRODE 297.55 288.11 3,763.15 3,209.0533212 INSERT PULSE GENERATOR 564.31 544.12 11,119.83 9,530.1036000 PLACE NEEDLE IN VEIN 41.55 39.31 X, N136005 INJECTION EXT VENOGRAPHY 590.62 553.75 X, N136010 PLACE CATHETER IN VEIN 952.65 895.82 X, N136011 PLACE CATHETER IN VEIN 1,569.24 1,473.07 X, N136013 PLACE CATHETER IN ARTERY 1,386.90 1,301.48 X, N136014 PLACE CATHETER IN ARTERY 1,452.05 1,363.05 X, N136140 ESTABLISH ACCESS TO ARTERY 818.12 769.44 X, N136200 PLACE CATHETER IN AORTA 1,104.48 1,039.78 X, N136215 PLACE CATHETER IN ARTERY 1,968.28 1,850.35 X, N136216 PLACE CATHETER IN ARTERY 2,164.58 2,035.32 X, N136217 PLACE CATHETER IN ARTERY 3,554.81 3,335.12 X, N136218 PLACE CATHETER IN ARTERY 325.68 306.84 X, N136245 PLACE CATHETER IN ARTERY 2,078.60 1,953.45 X, N136246 PLACE CATHETER IN ARTERY 2,094.97 1,970.56 X, N136247 PLACE CATHETER IN ARTERY 3,310.67 3,107.79 X, N136248 PLACE CATHETER IN ARTERY 272.11 256.86 X, N136400 BLOOD DRAW < 3 YRS FEM/JUGULAR 46.92 44.88 X, N136406 BLOOD DRAW < 3 YRS OTHER VEIN 28.17 26.82 X, N136410 NON-ROUTINE BL DRAW > 3 YRS 29.91 28.45 X, N136425 VEIN ACCESS CUTDOWN > 1 YR 62.34 60.40 35.67 32.82 X36430 BLOOD TRANSFUSION SERVICE 59.91 55.92 119.34 109.86 X36471 INJECTION THERAPY VEINS 290.72 276.37 121.44 111.7836513 APHERESIS PLATELETS 158.96 153.73 1,652.49 1,521.03 X36514 APHERESIS PLASMA 878.54 824.72 1,652.49 1,521.03 X36515 APHERESIS, ADSORP/REINFUSE 3,313.31 3,095.86 4,195.89 3,862.11 X36555 INSERT NON-TUNNEL CV CATH 442.67 420.24 1,516.71 1,396.0836556 INSERT NON-TUNNEL CV CATH 383.48 364.91 1,516.71 1,396.0836558 INSERT TUNNELED CV CATH 1,353.89 1,277.30 2,289.41 2,017.0136569 INSERT PICC CATH 430.72 406.86 1,516.71 1,396.0836571 INSERT PICVAD CATH 2,151.26 2,023.38 2,289.41 2,017.0136576 REPAIR TUNNELED CV CATH 619.78 588.02 1,516.71 1,396.0836578 REPLACE TUNNELED CV CATH 855.29 808.35 2,289.41 2,017.0136580 REPLACE CVAD CATH 375.27 353.82 1,516.71 1,396.0836584 REPLACE PICC CATH 360.67 339.77 1,516.71 1,396.0836589 REMOVE TUNNELED CV CATH 271.78 260.38 844.41 777.2436592 COLLECT BLOOD PICC 44.20 41.25 X, N136593 DECLOT VASCULAR DEVICE 49.44 46.14 98.28 90.4536598 INJECT W/FLUOR, EVAL CV DEVICE 189.67 178.99 298.32 274.5936600 WITHDRAW ARTERIAL BLOOD 50.41 47.90 X, N136620 INSERT CATHETER, ARTERY 210.31 204.69 X, N136625 INSERT CATHETER, ARTERY 169.68 164.90 X, N136800 INSERT CANNULA 261.61 251.45 4,009.88 3,637.5536810 INSERT CANNULA 340.24 329.61 4,009.88 3,637.55

11:3-29.6 APPENDIX B - REGULATIONS36815 INSERT CANNULA 244.77 236.68 4,009.88 3,637.5536818 AV FUSE, UPPER ARM, CEPHALIC 1,105.69 1,069.72 5,565.66 5,122.9536833 AV FISTULA REVISION 1,079.72 1,045.86 5,565.66 5,122.9536860 EXTERNAL CANNULA DECLOTTING 331.55 315.10 313.14 288.2137140 REVISE CIRCULATION 2,310.08 2,235.3337609 TEMPORAL ARTERY PROCEDURE 503.08 478.98 2,411.70 2,219.8537620 REVISE MAJOR VEIN 2,029.20 1,958.6937650 REVISE MAJOR VEIN 1,545.07 1,493.80 3,662.31 3,370.9838100 REMOVE SPLEEN, TOTAL 1,765.00 1,708.4537204 TRANSCATHETER OCCLUSION 1,460.69 1,414.57 8,466.97 7,482.9738115 REPAIR RUPTURED SPLEEN 1,947.72 1,885.3438200 INJECTION FOR SPLEEN X-RAY 234.86 227.73 X, N138206 HARVEST AUTO STEM CELLS 292.33 282.03 1,652.49 1,521.03 X38220 BONE MARROW ASPIRATION 250.35 236.57 381.36 351.0338221 BONE MARROW BIOPSY 269.34 254.87 393.09 361.8038230 BONE MARROW COLLECTION 838.42 806.23 4,195.89 3,862.11 X39501 REPAIR DIAPHRAGM LACERATION 1,328.67 1,283.8843235 UPPER GI ENDOSCOPY, DIAGNOSIS 490.49 464.67 1,184.82 1,090.5643236 UPPER GI SCOPE W/SUBMUCOSA

INJECT 608.49 576.22 1,184.82 1,090.5643239 UPPER GI ENDOSCOPY, BIOPSY 567.52 537.88 1,184.82 1,090.5643246 PLACE GASTROSTOMY TUBE 403.59 389.45 1,184.82 1,090.5643248 UPPER GI ENDOSCOPY/GUIDE WIRE 303.20 292.10 1,184.82 1,090.5643249 ESOPH ENDOSCOPY, DILATION 279.64 269.41 1,184.82 1,090.5643255 OPERATIVE UPPER GI ENDOSCOPY 453.95 437.69 1,184.82 1,090.5643259 ENDOSCOPIC ULTRASOUND EXAM 488.13 470.63 1,184.82 1,090.5643260 ENDO

CHOLANGIOPANCREATOGRAPHY 556.81 536.98 3,099.69 2,853.1243450 DILATE ESOPHAGUS 258.48 245.26 875.61 805.9843760 CHANGE GASTROSTOMY TUBE 684.75 641.43 313.14 288.2143830 PLACE GASTROSTOMY TUBE 1,076.48 1,038.4844139 MOBILIZATION COLON 187.28 181.6944500 INTRODUCE GASTROINTESTINAL

TUBE 38.60 37.33 844.41 777.2445300 PROCTOSIGMOIDOSCOPY DIAG 187.75 177.52 283.11 260.5845330 DIAGNOSTIC SIGMOIDOSCOPY 227.77 215.31 345.12 317.6745355 SURGICAL COLONOSCOPY 324.09 312.96 1,246.23 1,147.0845378 DIAGNOSTIC COLONOSCOPY 647.09 614.70 1,246.23 1,147.0846040 INCISE RECTAL ABSCESS 811.58 773.85 3,247.68 2,989.3246600 DIAGNOSTIC ANOSCOPY 136.30 128.76 89.55 82.44 X47000 NEEDLE BIOPSY LIVER 575.57 542.24 1,298.73 1,195.4149080 PUNCTURE, PERITONEAL CAVITY 269.24 254.87 742.11 683.1049320 DIAG LAP SEPARATE PROC 508.88 490.86 5,156.19 4,746.0349421 INSERT ABDOM DRAIN, PERM 425.09 409.71 3,521.06 3,192.0849505 PART RPR I/HERNIA INIT REDUCT

>5 YR 799.46 771.01 4,412.82 4,061.8250392 INSERT KIDNEY DRAIN 289.62 279.48 2,344.41 2,157.9350394 INJECTION FOR KIDNEY X-RAY 173.81 164.23 X, N151600 INJECTION FOR BLADDER X-RAY 328.90 309.24 X, N151610 INJECTION FOR BLADDER X-RAY 184.26 174.79 X, N151700 IRRIGATION BLADDER 143.15 135.97 189.51 174.4551701 INSERT BLADDER CATHETER 98.42 93.21 89.55 82.44 X51702 INSERT TEMP BLADDER CATH 128.12 120.92 89.55 82.44 X51703 INSERT BLADDER CATH, COMPLEX 227.44 216.26 148.20 136.4151705 CHANGE BLADDER TUBE 186.01 176.43 256.20 235.8351720 TREAT BLADDER LESION 185.88 177.55 205.92 189.5451725 SIMPLE CYSTOMETROGRAM 349.50 330.1651725 TC SIMPLE CYSTOMETROGRAM 228.20 212.91 428.43 394.3551725 26 SIMPLE CYSTOMETROGRAM 121.30 117.2551726 COMPLEX CYSTOMETROGRAM 514.29 484.5251726 TC COMPLEX CYSTOMETROGRAMI 375.98 350.82 428.43 394.3551726 26 COMPLEX CYSTOMETROGRAM 138.31 133.6851741 ELECTRO-UROFLOWMETRY, FIRST 72.56 68.1751741 TC ELECTRO-UROFLOWMETRY, FIRST 45.36 42.35 90.09 82.9251741 26 ELECTRO-UROFLOWMETRY, FIRST 27.20 25.8251784 ANAL/URINARY MUSCLE STUDY 340.60 321,9351784 TC ANAL/URINARY MUSCLE STUDY 217.71. 203.13 148.20 136.4151784 26 ANAL/URINARY MUSCLE STUDY 122.90 118.8051797 INTRAABDOMINAL PRESSURE TEST 225.40 212.4251797 TC INTRAABDOMINAL PRESSURE TEST 159.49 148.82 271.74 250.1451797 26 INTRAABDOMINAL PRESSURE TEST 65.91 63.6151798 US URINE CAPACITY MEASURE 33.71 31.48 66.69 61.38 X

UCJF 11:3-29.652000 CYSTOSCOPY 348.14 331.01 992.58 913.6252005 CYSTOSCOPY & URETER CATHETER 482.13 456.37 3,512.94 3,233.4952204 CYSTOSCOPY W/BIOPSY(S) 706.29 666.08 3,512.94 3,233.4952281 CYSTOSCOPY & TREAT 481.96 456.89 2,344.41 2,157.9352310 CYSTOSCOPY & TREAT 412.14 392.33 2,344.41 2,157.9352332 CYSTOSCOPY & TREAT 837.81 788.80 3,512.94 3,233.4952351 CYSTOURETERO & OR PYELOSCOPE 511.15 493.07 3,512.94 3,233.4953600 DILATE URETHRA STRICTURE 139.91 133.85 146.22 134.6153601 DILATE URETHRA STRICTURE 137.75 131.17 148.20 136.4153660 DILATE URETHRA 121.77 115.58 148.20 136.4153661 DILATE URETHRA 120.54 114.44 148.20 136.4154235 PENILE INJECTION 149.95 143.17 168.48 155.0757452 EXAM CERVIX W/SCOPE 174.20 167.01 171.99 158.3157500 BIOPSY CERVIX 213.96 203.21 286.62 263.8257511 CRYOCAUTERY CERVIX 234.32 224.50 218.10 200.7658340 CATHETER FOR HYSTERORRHAPHY 203.46 192.36 X, N158558 HYSTEROSCOPY, BIOPSY 576.77 552.42 3,079.32 2,834.3759000 AMNIOCENTESIS, DIAGNOSTIC 208.66 199.11 248.01 228.3059025 FETAL NON-STRESS TEST 117.18 112.0059025 TC FETAL NON-STRESS TEST 45,58 42.59 58.50 53.8559025 26 FETAL NON-STRESS TEST 71.58 69.4159841 ABORTION 611.45 589.83 2,758.50 2,539.0561107 DRILL SKULL FOR IMPLANTATION 1,155.41 1,120.2861790 TREAT TRIGEMINAL NERVE 2,552.34 2,349.3062263 EPIDURAL LYSIS MULT SESSIONS 1,788.44 1,102.21 1,012.32 931.8062264 EPIDURAL LYSIS ON SINGLE DAY 1,033.30 638.56 1,706.88 1,571.1062270 SPINAL FLUID TAP, DIAGNOSTIC 391.43 371.51 517.89 476.7062273 INJECT EPIDURAL PATCH 414.98 396.26 1,012.32 931.8062280 TREAT SPINAL CORD LESION 817.78 775.41 1,012.32 931.8062281 TREAT SPINAL CORD LESION 650.31 618.08 1,012.32 931.8062282 TREAT SPINAL CANAL LESION 743.51 703.87 1,012.32 931.8062284 INJECTION FOR MYELOGRAM 544.03 514.23 X, N162287 PERCUTANEOUS DISKECTOMY 5,347.03 5,141.26 4,972.53 4,576.9862290 INJECT FOR SPINE DISK X-RAY 1,256.74 1,191.64 X, N162291 INJECT FOR SPINE DISK X-RAY 1,184.82 1,123.82 X, N162292 INJECTION INTO DISK LESION 1,982.34 1,907.34 1,012.32 931.8062310 INJECT SPINE C/T 1,021.73 967.17 1,012.32 931.8062311 INJECT SPINE L/S (CD) 879.37 831.58 1,012.32 931.8062318 INJECT SPINE W/CATH, C/T 749.21 709.56 1,012.32 931.8062319 INJECT SPINE W/CATH L/S (CD) 475.01 451.01 1,706.88 1,571.1062350 IMPLANT SPINAL CANAL CATH 5,591.79 5,146.9862355 REMOVE SPINAL CANAL CATHETER 1,706.88 1,571.1062360 INSERT SPINE INFUSION DEVICE 5,591.79 5,146.9862362 IMPLANT SPINE INFUSION PUMP 22,241.41 18,893.9862365 REMOVE SPINE INFUSION DEVICE 4,972.53 4,576.9862367 ANALYZE SPINE INFUSION PUMP 76.02 69.99 X62368 ANALYZE SPINE INFUSION PUMP 102.96 94.77 X63075 NECK SPINE DISK SURG 10,012.99 9,659.9363076 NECK SPINE DISK SURG 1,837.46 1,779.7463650 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X63655 IMPLANT NEUROELECTRODES 10,702.41 9,271.65 X63685 INSERT/REDO SPINE N GENERATOR 24,642.86 20,858.66 X63688 REVISE/REMOVE NEURORECEIVER 3,880.14 3,571.4764400 NERVE BLOCK INJ, TRIGEMINAL 237.48 218.5864402 NERVE BLOCK INJ, FACIAL 280.41 267.23 219.96 202.4764405 NERVE BLOCK INJ, OCCIPITAL 278.84 266.46 202.38 186.3064412 NERVE BLOCK INJ, SPINAL ACCESSORY 352.14 324.1264413 NERVE BLOCK INJ, CERV PLEXUS 294.62 281.16 221.13 203.5564415 NERVE BLOCK INJ, BRACHIAL

PLEXUS 304.42 290.12 51.7.89 476.7064416 NERVE BLOCK CONT INFUSE,

B PLEX 191.93 186.58 1,012.32 931.8064417 NERVE BLOCK INJ, AXILLARY 320.99 305.45 517.89 476.7064418 NERVE BLOCK INJ,

SUPRASCAPULAR 344.67 327.13 303.00 278.9164420 NERVE BLOCK INJ, INTERCOSTAL,

SING 343.60 325.60 517.89 476.7064421 NERVE BLOCK INJ, INTERCOSTAL,

MULT 493.86 468.06 1,012.32 931.8064425 NERVE BLOCK INJ, ILIO-ING/HYPOGI321.93 307.96 221.13 203.5564430 NERVE BLOCK INJ, PUDENDAL 1,012.32 931.8064435 NERVE BLOCK INJ, PARACERV 352.78 335.81 287.79 264.90

11:3-29.6 APPENDIX B - REGULATIONS64445 NERVE BLOCK INJ, SCIATIC, SING 333.50 317.51 267.93 246.6064446 NERVE BLOCK INJ, SCIATIC, CONT INF 1,012.32 931.8064447 NERVE BLOCK INJ, FEM, SING 295.21 281.61 221.13 203.5564448 NERVE BLOCK INJ, FEM, CONT INF 1,012.32 931.8064449 NERVE BLOCK INJ, LUMBAR PLEXUS199.08 193.27 1,012.32 931.8064450 NERVE BLOCK, OTHER PERIPHERAL 253.98 242.28 190.68 175.5364455 NERVE BLOCK INJ, PLANTAR DIGIT 71.37 65.7064479 INJECT FORAMEN EPIDURAL C/T 670.71 635.70 1,012.32 931.8064480 INJECT FORAMEN EPIDURAL, ADDED397.14 377.32 517.89 476.7064483 INJECT FORAMEN EPIDURAL L/S 611.76 578.07 1,012.32 931.8064484 INJECT FORAMEN EPIDURAL, ADDED268.13 254.31 517.89 476.7064490 INJECT PARAVERT F JNT C/T 1 LEV 494.93 469.59 1,012.32 931.8064491 INJECT PARAVERT F JNT C/T 2 LEV 241.80 230.50 355.95 327.6664492 INJECT PARAVERT F JNT C/T 3 LEV 244.49 233.01 355.95 327.6664493 INJECT PARAVERT F JNT L/S 1 LEV 442.52 419.26 1,012.32 931.8064494 INJECT PARAVERT F JNT L/S 2 LEV 218.85 208.33 355.95 327.6664495 INJECT PARAVERT F JNT L/S 3 LEV 222.43 211.68 355.95 327.6664505 NERVE BLOCK SPHENOPALATINE

GANGLIA 241.39 230.83 166.14 152.9164510 NERVE BLOCK STELLATE GANGLION340.64 322.89 1,012.32 931.8064517 NERVE BLOCK INJ, HYPOGAS PLXS 429.82 410.19 1,012.32 931.8064520 NERVE BLOCK LUMBAR/THORACIC 486.86 459.82 1,012.32 931.8064550 APPLY NEUROSTIMULATOR 25.38 24.1464555 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X64561 IMPLANT NEUROELECTRODES 7,941.86 6,926.39 X64565 IMPLANT NEUROELECTRODES 286.59 272.61 7,941.86 6,926.39 X64600 INJECTION TREAT NERVE 673.41 638.56 1,706.88 1,571.1064605 INJECTION TREAT NERVE 1,063.67 1,007.56 2,552.34 2,349.3064610 INJECTION TREAT NERVE 1,180.01 1,125.84 2,552.34 2,349.3064612 DESTROY NERVE, FACE MUSCLE 316.60 303.63 278.43 256.2664613 DESTROY NERVE, NECK MUSCLE 302.92 290.62 260.91 240.1564614 DESTROY NERVE, EXTREMITY MUSC324.01 310.13 295.98 272.4364620 INJECTION TREAT NERVE 385.92 368.07 1,012.32 931.8064622 DESTROY PARAVERTEBRAL NERVE

L/S 634.27 601.31 1,706.88 1,571.1064623 DESTROY PARAVERT NERVE, ADDED317.51 300.33 1,012.32 931.8064626 DESTROY PARAVERTEBRAL NERVE

C/T 751.82 713.75 1,012.32 931.8064627 DESTROY PARAVERT NERVE,

ADDED 436.29 411.90 355.95 327.6664640 INJECTION TREAT NERVE 404.68 386.40 393.09 361.8064680 INJECTION TREAT NERVE 594.94 563.72 1,012.32 931.8064702 REVISE FINGER/TOE NERVE 2,552.34 2,349.3064704 REVISE HAND/FOOT NERVE 2,552.34 2,349.3064708 REVISE ARM/LEG NERVE 2,552.34 2,349.3064712 REVISE SCIATIC NERVE 2,552.34 2,349.3064713 REVISE ARM NERVE(S) 2,552.34 2,349.3064714 REVISE LOW BACK NERVE(S) 2,552.34 2,349.3064716 REVISE CRANIAL NERVE 2,552.34 2,349.3064718 REVISE ULNAR NERVE AT ELBOW 2,552.34 2,349.3064719 REVISE ULNAR NERVE AT WRIST 2,552.34 2,349.3064721 CARPAL TUNNEL SURG 2,074.12 1,982.69 2,552.34 2,349.3064818 REMOVE SYMPATHETIC NERVES 1,606.35 1,552.1965205 REMOVE FOREIGN BODY EYE 132.40 126.72 90.09 82.92 X65210 REMOVE FOREIGN BODY EYE 164.76 157.50 117.00 107.70 X65220 REMOVE FOREIGN BODY EYE 136.80 130.87 129.36 119.07 X65222 REMOVE FOREIGN BODY EYE 181.46 173.50 127.50 117.36 X65265 REMOVE FOREIGN BODY EYE 2,640.72 2,533.79 3,125.70 2,877.0667412 EXPLORE/TREAT EYE SOCKET 2,070.04 1,979.70 2,669.28 2,456.9469210 REMOVE IMPACTED EAR WAX 80.59 76.92 89.55 82.44 X69310 REBUILD OUTER EAR CANAL 1,786.26 1,698.11 5,961.75 5,487.5169320 REBUILD OUTER EAR CANAL 2,511.83 2,392.78 5,961.75 5,487.5169666 REPAIR MIDDLE EAR STRUCTURES3,035.82 2,897.99 5,961.75 5,487.5169667 REPAIR MIDDLE EAR STRUCTURES3,041.01 2,902.91 5,961.75 5,487.5169990 MICROSURG, ADDED 529.56 513.23 X, N170030 X-RAY EYE FOR FOREIGN BODY 48.10 45.3570030 TC X-RAY EYE FOR FOREIGN BODY 34.87 32.57 69.03 63.5470030 26 X-RAY EYE FOR FOREIGN BODY 13.22 12.7970100 X-RAY JAW < 4 VIEWS 55.59 52.3770100 TC X-RAY JAW < 4 VIEWS 41.28 38.54 81.87 75.3670110 X-RAY JAW MINIMUM 4 VIEWS 66.14 62.3770100 26 X-RAY JAW < 4 VIEWS 14.31 13.83

UCJF 11:3-29.670110 TC X-RAY JAW MINIMUM 4 VIEWS 47.11 43.97 87.24 80.3170110 26 X-RAY JAW MINIMUM 4 VIEWS 19.03 18.4070120 X-RAY MASTOIDS < 3 VIEWS/SIDE 59.09 55.6270120 TC X-RAY MASTOIDS < 3 VIEWS/SIDE 44.78 41.81 87.24 80.3170120 26 X-RAY MASTOIDS < 3 VIEWS/SIDE 14.31 13.8370130 X-RAY MASTOIDS MINIMUM

3 VIEWS/SIDE 93.99 88.5870130 TC X-RAY MASTOIDS MINIMUM

3 VIEWS/SIDE 68.07 63.54 87.24 80.3170130 26 X-RAY MASTOIDS MINIMUM

3 VIEWS/SIDE 25.92 25.0570140 X-RAY FACIAL BONES < 3 VIEWS 50.86 47.9870140 TC X-RAY FACIAL BONES < 3 VIEWS 35.46 33.11 70.20 64.6270140 26 X-RAY FACIAL BONES < 3 VIEWS 15.40 14.8670150 X-RAY FACIAL BONES MINIMUM

3 VIEWS 71.88 67.7670150 TC X-RAY FACIAL BONES MINIMUM

3 VIEWS 51.76 48.32 87.24 80.3170150 26 X-RAY FACIAL BONES MINIMUM

3 VIEWS 20.12 19.4470160 X-RAY NASAL BONES MINIMUM

3 VIEWS 55.66 52.4170160 TC X-RAY NASAL BONES M 3 VIEWS 42.45 39.63 84.21 77.5270160 26 X-RAY NASAL BONES MINIMUM

3 VIEWS 13.22 12.7970190 X-RAY OPTIC FORAMINA 60.03 56.5770190 TC X-RAY OPTIC FORAMINA 43.61 40.71 86.55 79.6870190 26 X-RAY OPTIC FORAMINA 16.41 15.8670200 X-RAY ORBITS, MINIMUM 4 VIEWS 74.07 69.8570200 TC X-RAY ORBITS, MINIMUM 4 VIEWS 52.34 48.86 87.24 80.3170200 26 X-RAY ORBITS, MINIMUM 4 VIEWS 21.71 20.9870210 X-RAY SINUSES < 3 VIEWS 52.17 49.1670210 TC X-RAY SINUSES < 3 VIEWS 38.37 35.83 76.02 69.9970210 26 X-RAY SINUSES < 3 VIEWS 13.80 13.3370220 X-RAY SINUSES MINIMUM 3 VIEWS 64.97 61.2970220 TC X-RAY SINUSES MINIMUM 3 VIEWS 45.94 42.89 87.24 80.3170220 26 X-RAY SINUSES MINIMUM 3 VIEWS 19.03 18.4070250 X-RAY SKULL < 4 VIEWS 62.13 58.6270250 TC X-RAY SKULL < 4 VIEWS 43.03 40.17 85.38 78.6070250 26 X-RAY SKULL < 4 VIEWS 19.10 18.4570260 X-RAY SKULL MINIMUM 4 VIEWS 78.86 74.4570260 TC X-RAY SKULL MIN 4 VIEWS 52.92 49.41 105.30 96.9370260 26 X-RAY SKULL MINIMUM 4 VIEWS 25.92 25.0570300 X-RAY TEETH SINGLE VIEW 24.17 22.8570300 TC X-RAY TEETH SINGLE VIEW 15.08 14.10 29.22 26.9170300 26 X-RAY TEETH SINGLE VIEW 9.09 8.7570310 X-RAY TEETH < FULL MOUTH 63.31 59.5170310 TC X-RAY TEETH < FULL MOUTH 49.44 46.14 59.04 54.3670310 26 X-RAY TEETH < FULL MOUTH 13.88 13.3770320 X-RAY TEETH FULL MOUTH 83.72 79.8970320 TC X-RAY TEETH FULL MOUTH 66.90 62.44 59.04 54.3670320 26 X-RAY TEETH FULL MOUTH 18.09 17.4570328 X-RAY TMJ UNILATERAL 52.10 49.1170328 TC X-RAY TMJ UNILATERAL 37.79 35.29 74.85 68.9170328 26 X-RAY TMJ UNILATERAL 14.31 13.8370330 X-RAY TMJ BILATERAL 81.34 76.5470330 TC X-RAY TMJ BILATERAL 62.24 58.09 87.24 80.3170330 26 X-RAY TMJ BILATERAL 19.10 18.4570332 TMJ ARTHOGRAPHY; RAD SUPER &

INTERP 143.03 134.89 N170332 TC TMJ ARTHOGRAPHY; RAD SUPER &

INTERP 98.34 91.77 N170332 26 TMJ ARTHOGRAPHY; RAD SUPER &

INTERP 44.68 43.10 N170336 MRI TMJ 763.99 716.5970336 TC MRI TMJ 649.78 606.18 664.20 611.3770336 26 MRI TMJ 114.20 110.4370350 CEPHALOORAM, ORTHODONTIC 35.29 33.4170350 TC CEPHALOGRAM, ORTHODONTIC 20.32 18.99 39.78 36.6070350 26 CEPHALOGRAM, ORTHODONTIC 14.96 14.4170355 ORTHOPANTOGRAM 35.64 33.8170355 TC ORTHOPANTOGRAM 19.16 17.91 37.44 34.44

11:3-29.6 APPENDIX B - REGULATIONS70355 26 ORTHOPANTOGRAM 16.50 15.9070360 X-RAY NECK SOFT TISSUE 46.36 43.7370360 TC X-RAY NECK SOFT TISSUE 33.13 30.94 65.52 60.3070360 26 X-RAY NECK SOFT TISSUE 13.22 12.7970450 CT HEAD/BRAIN W/O DYE 426.03 400.3170450 TC CT HEAD/BRAIN W/O DYE 341.76 318.85 375.45 345.6070450 26 CT HEAD/BRAIN W/O DYE 84.27 81.4670460 CT HEAD/BRAIN W/DYE 431.97 405.9270460 TC CT HEAD/BRAIN W/DYE 344.66 321.55 580.71 534.5170460 26 CT HEAD/BRAIN W/DYE 87.31 84.3870470 CT HEAD/BRAIN W/O & W/DYE 523.38 491.6170470 TC CT HEAD/BRAIN W/O & W/DYE 424.43 395.96 647.37 595.8670470 26 CT HEAD/BRAIN W/O & W/DYE 98.95 95.6570480 CT ORBIT/EAR/FOSSA W/O DYE 531.46 499.1770480 TC CT ORBIT/EAR/FOSSA W/O DYE 431.99 403.02 375.45 345.6070480 26 CT ORBITBAR/FOSSA W/O DYE 99.46 96.1570481 CT ORBIT/EAR/FOSSA W/DYE 617.99 580.1770481 TC CT ORBIT/EAR/FOSSA W/DYE 510.61 476.35 580.71 534.5170481 26 CT ORBITBAR/FOSSA W/DYE 107.38 103.8270482 CT ORBIT/EAR/FOSSA W/O & W/DYE 698.40 655.3670482 TC CT ORBIT/EAR/FOSSA W/O & W/DYE 586.31 546.96 647.37 595.8670482 26 CT ORBIT/EAR/FOSSA W/O & W/DYE 112.09 108.3970486 CT MAXILLOFACIAL W/O DYE 442.37 415.6570486 TC CT MAXILLOFACIAL W/O DYE 353.98 330.23 375.45 345.6070486 26 CT MAXILLOFACIAL W/O DYE 88.41 85.4270487 CT MAXILLOFACIAL W/DYE 533.63 501.2470487 TC CT MAXILLOFACIAL W/DYE 432.58 403.56 580.71 534.5170487 26 CT MAXILLOFACIAL W/DYE 101.05 97.6970488 CT MAXILLOFACIAL W/O & W/DYE 649.72 609.8670488 TC CT MAXILLOFACIAL W/O & W/DYE 539.73 503.52 647.37 595.8670488 26 CT MAXILLOFACIAL W/O &W/DYE 109.99 106.3570490 CT SOFT TISSUE NECK W/O DYE 432.46 406.8370490 TC CT SOFT TISSUE NECK W/O DYE 333.02 310.68 375.45 345.6070490 26 CT SOFT TISSUE NECK W/O DYE 99.46 96.1570491 CT SOFT TISSUE NECK W/DYE 521.98 490.5770491 TC CT SOFT TISSUE NECK W/DYE 415.11 387.27 580.71 534.5170491 26 CT SOFT TISSUE NECK W/DYE 106.87 103.3070492 CT SOFT TISSUE NECK W/O & W/DYE632.03 593.4370492 TC CT SOFT TISSUE NECK W/O & W/DYE519.93 485.04 647.37 595.8670492 26 CT SOFT TISSUE NECK W/O & W/DYE112.09 108.3970496 CT ANGIOGRAPHY, HEAD 1,008.14 945.0970496 TC CT ANGIOGRAPHY, HEAD 871.63 813.13 655.71 603.5470496 26 CT ANGIOGRAPHY, HEAD 136.51 131.9670498 CT ANGIOGRAPHY, NECK 1,025.62 961.3970498 TC CT ANGIOGRAPHY, NECK 889.10 829.43 655.71 603.5470498 26 CT ANGIOGRAPHY, NECK 136.51 131.9670540 MRI ORBIT/FACE/NECK W/O DYE 849.38 795.9570540 TC MRI ORBIT/FACE/NECK W/O DYE 744.69 694.71 664.20 611.3770540 26 MRI ORBIT/FACE/NECK W/O DYE 104.69 101.2470542 MRI ORBIT/FACE/NECK W/DYE 948.56 889.2070542 TC MRI ORBIT/FACE/NECK W/DYE 822.72 767.50 846.36 779.0470542 26 MRI ORBIT/FACE/NECK W/DYE 125.84 121.6970543 MRI ORBIT/FACE/NECK W/O &

W/DYE 1,239.11 1,161.5970543 TC MRI ORBIT/FACE/NECK W/O &

W/DYE 1,073.12 1,001.07 1,033.50 951.2770543 26 MRI ORBIT/FACE/NECK W/O &

W/DYE 166.00 160.5370544 MR ANGIOGRAPHY HEAD W/O DYE 930.92 871.6270544 TC MR ANGIOGRAPHY HEAD W/O DYE 837.86 781.62 664.20 611.3770544 26 MR ANGIOGRAPHY HEAD W/O DYE 93.07 90.0070545 MR ANGIOGRAPHY HEAD W/DYE 925.11 866.1870545 TC MR ANGIOGRAPHY HEAD W/DYE 832.04 776.19 846.36 779.0470545 26 MR ANGIOGRAPHY HEAD W/DYE 93.07 90.0070546 MR ANGIOGRAPH HEAD W/O &

W/DYE 1,457.83 1,364.7270546 TC MR ANGIOGRAPH HEAD W/O &

W/DYE 1,317.67 1,229.21 1,033.50 951.2770546 26 MR ANGIOGRAPH HEAD W/O &

W/DYE 140.15 135.5170547 MR ANGIOGRAPHY NECK W/O DYE 929.19 869.9970547 TC MR ANGIOGRAPHY NECK W/O DYE 836.11 779.99 664.20 611.37

UCJF 11:3-29.670547 26 MR ANGIOGRAPHY NECK W/O DYE 93.07 90.0070548 MR ANGIOGRAPHY NECK W/DYE 975.77 913.4470548 TC MR ANGIOGRAPHY NECK W/DYE 882.71 823.45 846.36 779.0470548 26 MR ANGIOGRAPHY NECK W/DYE 93.07 90.0070549 MR ANGIOGRAPH NECK W/O &

W/DYE 1,458.47 1,365.2970549 TC MR ANGIOGRAPH NECK W/O &

W/DYE 1,318.84 1,230.29 1,033.50 951.2770549 26 MR ANGIOGRAPH NECK W/O &

W/DYE 139.64 135.0070551 MRI BRAIN W/O DYE 878.11 823.0670551 TC MRI BRAIN W/O DYE 763.33 712.09 664.20 611.3770551 26 MRI BRAIN W/0 DYE 114.78 110.9770552 MRI BRAIN W/DYE 978.74 917.7870552 TC MRI BRAIN W/DYE 839.60 783.26 846.36 779.0470552 26 MRI BRAIN W/DYE 139.14 134.5270553 MRI BRAIN W/O & W/DYE 1,228.68 1,152.4470553 TC MRI BRAIN W/O & W/DYE 1,045.16 974.99 1,033.50 951.2770553 26 MRI BRAIN W/O & W/DYE 183.52 177.4570554 FMRI BRAIN BY TECH 964.57 905.3970554 TC FMRI BRAIN BY TECH 799.43 745.77 664.20 611.3770554 26 FMRI BRAIN BY TECH 165.14 159.6270555 26 FMRI BRAIN BY PHYS/PSYCH 203.10 196.4971010 CHEST X-RAY SINGLE VIEW FRONTAL46.85 44.3171010 TC CHEST X-RAY SINGLE VIEW FRONTAL30.48 28.47 50.31 46.2971010 26 CHEST X-RAY SINGLE VIEW FRONTAL16.37 15.8471020 CHEST X-RAY 2 VIEWS FRONTAL &

LATERAL 55.78 52.6971020 TC CHEST X-RAY 2 VIEWS FRONTAL &

LATERAL 37.56 35.08 69.03 63.5471020 26 CHEST X-RAY 2 VIEWS FRONTAL &

LATERAL 18.23 17.6171021 CHEST X-RAY 2 VIEWS W/APICAL

LORD PROC 63.65 60.1171021 TC CHEST X-RAY 2 VIEWS W/APICAL

LORD PROC 43.03 40.17 85.38 78.6071021 26 CHEST X-RAY 2 VIEWS W/APICAL

LORD PROC 20.62 19.9471022 CHEST X-RAY 2 VIEWS W/OBLIQUE

PROJ 77.92 73.5171022 TC CHEST X-RAY 2 VIEWS W/OBLIQUE

PROJ 54.09 50.49 87.24 80.3171022 26 CHEST X-RAY 2 VIEWS W/OBLIQUE

PROJ 23.82 23.0171030 CHEST X-RAY MINIMUM 4 VIEWS 77.34 72.9671030 TC CHEST X-RAY MINIMUM 4 VIEWS 53.50 49.95 87.24 80.31'71030 26 CHEST X-RAY MINIMUM 4 VIEWS 23.82 23.0171035 CHEST X-RAY SPECIAL VIEWS 59.67 56.1871035 TC CHEST X-RAY SPECIAL VIEWS 45.36 42.35 87.24 80.3171035 26 CHEST X-RAY SPECIAL VIEWS 14.31 13.8371040 CONTRAST X-RAY BRONCHI

UNILATERAL 162.07 152.67 N171040 TC CONTRAST X-RAY BRONCHI

UNILATERAL 118.73 110.79 N171040 26 CONTRAST X-RAY BRONCHI

UNILATERAL 43.34 41.88 N171090 X-RAY & PACEMAKER INSERT 169.62 163.54 N171090 TC X-RAY & PACEMAKER INSERT 123.65 119.31 N171090 26 X-RAY & PACEMAKER INSERT 44.62 43.09 N171100 X-RAY RIBS 2 VIEWS 54.13 51.1071100 TC X-RAY RIBS 2 VIEWS 37.20 34.75 73.71 67.8671100 26 X-RAY RIBS 2 VIEWS 16.93 16.3671101 X-RAY RIBS/CHEST MINIMUM 3

VIEWS 82.73 78.1071101 TC X-RAY RIBS/CHEST MINIMUM 3

VIEWS 56.88 53.10 87.24 80.3171101 26 X-RAY RIBS/CHEST MINIMUM 3

VIEWS 25.85 25.0071110 X-RAY RIBS BILATERAL 3 VIEWS 68.31 64.4671110 TC X-RAY RIBS BILATERAL 3 VIEWS 47.69 44.52 87.24 80.3171110 26 X-RAY RIBS BILATERAL 3 VIEWS 20.62 19.9471111 X-RAY RIBS/CHEST MINIMUM 4 VIEWS88.32 83.23

11:3-29.6 APPENDIX B - REGULATIONS71111 TC X-RAY RIBS/CHEST MINIMUM 4 VIEWS63.99 59.73 127.50 117.3671111 26 X-RAY RIBS/CHEST 4 VIEWS 24.33 23.5071120 X-RAY STE MINIMUM 2 VIEWS 53.70 50.6571120 TC X-RAY STERNUM MINIMUM 2 VIEWS 38.37 35.83 76.02 69.9971120 26 X-RAY STERNUM MINIMUM 2 VIEWS 15.33 14.8271130 X-RAY STERNOCLAV JOINT MINIMUM62.87 59.24

3 VIEWS71130 TC X-RAY STERNOCLAV JOINT MINIMUM45.94 42.89 87.24 80.31

3 VIEWS71130 26 X-RAY STERNOCLAV JOINT MINIMUM16.93 16.36

3 VIEWS71250 CT THORAX W/O DYE 423.62 397.8271250 TC CT THORAX W/O DYE 344.07 320.99 375.45 345.6071250 26 CT THORAX W/O DYE 79.55 76.8271260 CT THORAX W/DYE 525.35 493.3771260 TC CT THORAX W/DYE 428.51 399.76 580.71 534.5171260 26 CT THORAX W/DYE 96.85 93.6171270 CT THORAX W/O &W/DYE 646.01 606.2671270 TC CT THORAX W/O & W/DYE 539.14 502.96 647.37 595.8671270 26 CT THORAX W/O & W/DYE 106.87 103.3071275 CT ANGIOGRAPHY, CHEST 802.43 753.6471275 TC CT ANGIOGRAPHY, CHEST 652.69 608.89 655.71 603.5471275 26 CT ANGIOGRAPHY, CHEST 149.74 144.7571550 MRI CHEST W/O DYE 960.37 899.7471550 TC MRI CHEST W/O DYE 847.76 790.86 664.20 611.3771550 26 MRI CHEST W/O DYE 112.61 108.8871552 MRI CHEST W/O & W/DYE 1,425.20 1,335.4671552 TC MRI CHEST W/O & W/DYE 1,249.54 1,165.66 1,033.50 951.2771552 26 MRI CHEST W/O & W/DYE 175.66 169.8171555 MRI ANGIO CHEST W OR W/O DYE 940.15 881.8171555 TC MRI ANGIO CHEST W OR W/O DYE 798.85 745.2371555 26 MRI ANGIO CHEST W OR W/O DYE 141.30 136.5872010 X-RAY SPINE ANTEROPOST &

LATERAL 124.49 117.3772010 TC X-RAY SPINE ANTEROPOST &

LATERAL 89.03 83.09 146.91 135.2472010 26 X-RAY SPINE ANTEROPOST &

LATERAL 35.46 34.2872020 X-RAY SPINE SINGLE VIEW SPECIFY

LEVEL 40.10 37.8472020 TC X-RAY SPINE SINGLE VIEW SPECIFY

LEVEL 27.88 26.05 54.99 50.6172020 26 X-RAY SPINE SINGLE VIEW SPECIFY

LEVEL 12.21 11.7972040 X-RAY NECK SPINE CERV 2/3 VIEWS 102.52 96.6972040 TC X-RAY NECK SPINE CERV 2/3 VIEWS 73.56 68.66 87.24 80.3172040 26 X-RAY NECK SPINE CERV 2/3 VIEWS 28.96 28.0372050 X-RAY NECK SPINE CERV MINIMUM 4

VIEWS 119.60 112.7972050 TC X-RAY NECK SPINE CERV MINIMUM

4 VIEWS 86.14 80.40 127.50 117.3672050 26 X-RAY NECK SPINE CERV MINIMUM 4

VIEWS 33.46 32.3972052 X-RAY NECK SPINE COMPLETE 147.68 139.1072052 TC X-RAY NECK SPINE COMPLETE 110.33 102.97 146.91 135.2472052 26 X-RAY NECK SPINE COMPLETE 37.35 36.1372069 X-RAY TRUNK SPINE STANDING 62.74 59.2072069 TC X-RAY TRUNK SPINE STANDING 44.20 41.25 87.24 80.3172069 26 X-RAY TRUNK SPINE STANDING 18.55 17.9572070 X-RAY THORACIC SPINE 2 VIEWS 80.74 76.1772070 TC X-RAY THORACIC SPINE 2 VIEWS 55.96 52.26 78.36 72.1272070 26 X-RAY THORACIC SPINE 2 VIEWS 24.78 23.9272072 X-RAY THORACIC SPINE 3 VIEWS 63.45 59.8072072 TC X-RAY THORACIC SPINE 3 VIEWS 46.53 43.43 87.24 80.3172072 26 X-RAY THORACIC SPINE 3 VIEWS 16.93 16.3672074 X-RAY THORACIC SPINE MINIMUM 4

VIEWS 75.09 70.6672074 TC X-RAY THORACIC SPINE MINIMUM 4

VIEWS 58.16 54.30 87.24 80.3172074 26 X-RAY THORACIC SPINE MINIMUM 4

VIEWS 16.93 16.3672080 X-RAY TRUNK SPINE 2 VIEWS 61.58 58.12

UCJF 11:3-29.672080 TC X-RAY TRUNK SPINE 2 VIEWS 43.03 40.17 85.38 78.6072080 26 X-RAY TRUNK SPINE 2 VIEWS 18.55 17.9572090 X-RAY TRUNK SPINE SCOLIOSIS

STUDY 83.19 78.4672090 TC X-RAY TRUNK SPINE SCOLIOSIS

STUDY 59.33 55.38 118.17 108.7872090 26 X-RAY TRUNK SPINE SCOLIOSIS

STUDY 23.86 23.0872100 X-RAY LOWER SPINE 2/3 VIEWS 68.57 64.6372100 TC X-RAY LOWER SPINE 2/3 VIEWS 50.02 46.70 87.24 80.3172100 26 X-RAY LOWER SPINE 2/3 VIEWS 18.55 17.9572110 X-RAY LOWER SPINE MINIMUM 4

VIEWS 129.47 122.0172110 TC X-RAY LOWER SPINE MINIMUM 4

VIEWS 95.06 88.72 136.86 125.9772110 26 X-RAY LOWER SPINE MINIMUM 4

VIEWS 34.41 33.3172114 X-RAY LOWER SPINE COMPLETE 125.68 118.2972114 TC X-RAY LOWER SPINE COMPLETE 96.02 89.60 146.91 135.2472114 26 X-RAY LOWER SPINE COMPLETE 29.67 28.6972120 X-RAY LOWER SPINE BENDING

MINIMUM 4 VIEWS 87.20 82.01 72120 TC X-RAY LOWER SPINE BENDING

MINIMUM 4 VIEWS 68.65 64.08 87.24 80.3172120 26 X-RAY LOWER SPINE BENDING

MINIMUM 4 VIEWS 18.55 17.9572125 CT NECK SPINE W/O DYE 425.96 399.9972125 TC CT NECK SPINE W/O DYE 346.40 323.17 375.45 345.6072125 26 CT NECK SPINE W/O DYE 79.55 76.8272126 CT NECK SPINE W/DYE 524.34 492.3872126 TC CT NECK SPINE W/DYE 429.68 400.84 580.71 534.5172126 26 CT NECK SPINE W/DYE 94.66 91.5372127 CT NECK SPINE W/O & W/DYE 636.93 597.5472127 TC CT NECK SPINE W/O & W/DYE 538.56 502.42 647.37 595.8672127 26 CT NECK SPINE W/O &W/DYE 98.37 95.1172128 CT CHEST SPINE W/O DYE 425.37 399.4572128 TC CT CHEST SPINE W/O DYE 345.82 322.63 375.45 345.6072128 26 CT CHEST SPINE W/O DYE 79.55 76.8272129 CT CHEST SPINE W/DYE 525.50 493.4772129 TC CT CHEST SPINE W/DYE 430.26 401.38 580.71 534.5172129 26 CT CHEST SPINE W/DYE 95.24 92.0772130 CT CHEST SPINE W/O & W/DYE 637.51 598.0872130 TC CT CHEST SPINE W/O & W/DYE 539.14 502.96 647.37 595.8672130 26 CT CHEST SPINE W/O & W/DYE 98.37 95.1172131 CT LUMBAR SPINE W/O DYE 424.21 398.3772131 TC CT LUMBAR SPINE W/O DYE 344.66 321.55 375.45 345.6072131 26 CT LUMBAR SPINE W/O DYE 79.55 76.8272132 CT LUMBAR SPINE W/DYE 524.34 492.3872132 TC CT LUMBAR SPINE W/DYE 429.10 400.30 580.71 534.5172132 26 CT LUMBAR SPINE W/DYE 95.24 92.0772133 CT LUMBAR SPINE W/O & W/DYE 636.93 597.5472133 TC CT LUMBAR SPINE W/O & W/DYE 538.56 502.42 647.37 595.8672133 26 CT LUMBAR SPINE W/O & W/DYE 98.37 95.1172141 MRI NECK SPINE W/O DYE 936.23 878.4372141 TC MRI NECK SPINE W/O DYE 788.37 735.46 664.20 611.3772141 26 MRI NECK SPINE W/O DYE 147.87 142.9772142 MRI NECK SPINE W/DYE 989.34 928.0172142 TC MRI NECK SPINE W/DYE 840.19 783.80 846.36 779.0472142 26 MRI NECK SPINE W/DYE 149.16 144.2172146 MRI CHEST SPINE W/O DYE 801.97 752.4172146 TC MRI CHEST SPINE W/O DYE 677.15 631.70 664.20 611,3772146 26 MRI CHEST SPINE W/O DYE 124.83 120.6972147 MRI CHEST SPINE W/DYE 890.93 836.2172147 TC MRI CHEST SPINE W/DYE 741.19 691.46 846.36 779.0472147 26 MRI CHEST SPINE W/DYE 149.74 144.7572148 MRI LUMBAR SPINE W/O DYE 901.45 845.4572148 TC MRI LUMBAR SPINE W/O DYE 769.58 717.94 664.20 611.3772148 26 MRI LUMBAR SPINE W/O DYE 131.85 127.5272149 MRI LUMBAR SPINE W/DYE 887.91 833.0472149 TC MRI LUMBAR SPINE W/DYE 748.77 698.52 846.36 779.0472149 26 MRI LUMBAR SPINE W/DYE 139.14 134.5272156 MRI NECK SPINE W/O & W/DYE 1,227.571,151,99

11:3-29.6 APPENDIX B - REGULATIONS72156 TC MRI NECK SPINE W/O &W/DYE 1,027.10 958.16 1,033.50 951.2772156 26 MRI NECK SPINE W/O & W/DYE 200.46 193.8472157 MRI CHEST SPINE W/O & W/DYE 1,153.62 1,083.0172157 TC MRI CHEST SPINE W/O & W/DYE 953.16 889.17 1,033.50 951.2772157 26 MRI CHEST SPINE W/O & W/DYE 200.46 193.8472158 MRI LUMBAR SPINE W/O & W/DYE 1,209.34 1,134.4872158 TC MRI LUMBAR SPINE W/O & W/DYE 1,024.78 955.99 1,033.50 951.2772158 26 MRI LUMBAR SPINE W/O & W/DYE 184.56 178.4972170 X-RAY PELVIS 1/2 VIEWS 68.47 64.6972170 TC X-RAY PELVIS 1/2 VIEWS 46.19 43.14 60.84 56.0172170 26 X-RAY PELVIS 1/2 VIEWS 22.28 21.5572190 X-RAY PELVIS MINIMUM 3 VIEWS 70.97 66.8572190 TC X-RAY PELVIS MINIMUM 3 VIEWS 52.92 49.41 87.24 80.3172190 26 X-RAY PELVIS MINIMUM 3 VIEWS 18.03 17.4572191 CT ANGIOGRAPH PELVIS W/O &

W/DYE 769.42 722.6172191 TC CT ANGIOGRAPH PELVIS W/O &

W/DYE 627.65 585.53 655.71 603.5472191 26 CT ANGIOGRAPH PELVIS W/O &

W/DYE 141.77 137.0872192 CT PELVIS W/O DYE 409.56 384.9372192 TC CT PELVIS W/O DYE 325.44 303.61 375.45 345.6072192 26 CT PELVIS W/O DYE 84.11 81.3072193 CT PELVIS W/DYE 497.42 467.1272193 TC CT PELVIS W/DYE 406.97 379.67 580.71 534.5172193 26 CT PELVIS W/DYE 90.45 87.4572194 CT PELVIS W/O & W/DYE 639.05 599.3872194 TC CT PELVIS W/O & W/DYE 544.39 507.85 647.37 595.8672194 26 CT PELVIS W/O & W/DYE 94.66 91.5372195 MRI PELVIS W/O DYE 873.48 818.7672195 TC MRI PELVIS W/O DYE 759.26 708.30 664.20 611.3772195 26 MRI PELVIS W/0 DYE 114.23 110.4772196 MRI PELVIS W/DYE 966.38 906.0872196 TC MRI PELVIS W/DYE 831.46 775.64 846.36 779.0472196 26 MRI PELVIS W/DYE 134.92 130.4372197 MRI PELVIS W/O & W/DYE 1,259.25 1,180.6572197 TC MRI PELVIS W/O & W/DYE 1,084.17 1,011.38 1,033.50 951.2772197 26 MRI PELVIS W/O & W/DYE 175.08 169.2772198 MR ANGIO PELVIS W/O & W/DYE 936.15 878.0672198 TC MR ANGIO PELVIS W/O & W/DYE 796.52 743.0672198 26 MR ANGIO PELVIS W/O & W/DYE 139.64 135.0072200 X-RAY EXAM SACROILIAC JOINTS 49.85 46.9872200 TC X-RAY EXAM SACROILIAC JOINTS 36.62 34.19 72.54 66.7872200 26 X-RAY EXAM SACROILIAC JOINTS 13.22 12.7972202 X-RAY EXAM SACROILIAC JOINTS 58.43 55.0472202 TC X-RAY EXAM SACROILIAC JOINTS 43.61 40.71 86.55 79.6872202 26 X-RAY EXAM SACROILIAC JOINTS 14.82 14.3272220 X-RAY TAILBONE 49.27 46.4472220 TC X-RAY TAILBONE 36.04 33.65 71.37 65.7072220 26 X-RAY TAILBONE 13.22 12.7972240 CONTRAST X-RAY NECK SPINE 372.37 351.09 N172240 TC CONTRAST X-RAY NECK SPINE 263.27 245.65 N172240 26 CONTRAST X-RAY NECK SPINE 109.10 105.44 N172255 CONTRAST X-RAY THORAX SPINE 349.17 329.41 N172255 TC CONTRAST X-RAY THORAX SPINE 241.78 225.60 N172255 26 CONTRAST X-RAY THORAX SPINE 107.39 103.80 N172265 CONTRAST X-RAY LOWER SPINE 355.47 334.98 N172265 TC CONTRAST X-RAY LOWER SPINE 256.12 238.96 N172265 26 CONTRAST X-RAY LOWER SPINE 99.34 96.02 N172270 CONTRAST X-RAY SPINE 552.78 521.08 N172270 TC CONTRAST X-RAY SPINE 394.08 367.67 N172270 26 CONTRAST X-RAY SPINE 158.70 153.41 N172275 EPIDUROGRAPHY 572.81 540.58 N172275 TC EPIDUROGRAPHY 390.38 364.28 N172275 26 EPIDUROGRAPHY 182.38 176.30 N172285 X-RAY C/T SPINE DISK 376.65 356.04 N172285 TC X-RAY C/T SPINE DISK 236.40 220.57 N172285 26 X-RAY C/T SPINE DISK 140.25 135.46 N172291 PERCUT VERT/SACROPLASTY,

FLUOR 267.82 258.54 N172291 TC PERCUT VERT/SACROPLASTY,

FLUOR 161.82 156.18 N1

UCJF 11:3-29.672291 26 PERCUT VERT/SACROPLASTY,

FLUOR 113.43 109.79 N172295 X-RAY LOWER SPINE DISK 217.08 204.71 N172295 TC X-RAY LOWER SPINE DISK 151.33 141.20 N172295 26 X-RAY LOWER SPINE DISK 65.74 63.49 N173000 X-RAY COLLAR BONE 48.17 45.4073000 TC X-RAY COLLAR BONE 35.46 33.11 70.20 64.6273000 26 X-RAY COLLAR BONE 12.72 12.2973010 X-RAY SHOULDER BLADE 51.47 48.5773010 TC X-RAY SHOULDER BLADE 36.62 34.19 72.54 66.7873010 26 X-RAY SHOULDER BLADE 14.85 14.3773020 X-RAY SHOULDER 1 VIEW 39.52 37.2973020 TC X-RAY SHOULDER 1 VIEW 27.88 26.05 54.99 50.6173020 26 X-RAY SHOULDER 1 VIEW 11.62 11.2473030 X-RAY SHOULDER MINIMUM 2 VIEWS74.36 70.2173030 TC X-RAY SHOULDER MINIMUM 2 VIEWS51.56 48.15 71.37 65.7073030 26 X-RAY SHOULDER MINIMUM 2 VIEWS22.79 22.0473040 CONTRAST X-RAY SHOULDER 181.40 170.71 N173040 TC CONTRAST X-RAY SHOULDER 138.53 129.26 N173040 26 CONTRAST X-RAY SHOULDER 42.87 41.45 N173060 X-RAY HUMERUS MINIMUM 2 VIEWS 49.27 46.4473060 TC X-RAY HUMERUS MINIMUM 2 VIEWS 35.46 33.11 70.20 64.6273060 26 X-RAY HUMERUS MINIMUM 2 VIEWS 13.80 13.3373070 X-RAY ELBOW 2 VIEWS 47.66 44.9173070 TC X-RAY ELBOW 2 VIEWS 35.46 33.11 70.20 64.6273070 26 X-RAY ELBOW 2 VIEWS 12.21 11.7973080 X-RAY ELBOW MINIMUM 3 VIEWS 57.41 54.0473080 TC X-RAY ELBOW MINIMUM 3 VIEWS 44.20 41.25 87.24 80.3173080 26 X-RAY ELBOW MINIMUM 3 VIEWS 13.22 12.7973090 X-RAY FOREARM 47.01 44.3173090 TC X-RAY FOREARM 34.29 32.03 67.86 62.4673090 26 X-RAY FOREARM 12.72 12.2973092 X-RAY ARM, INFANT 51.67 48.6673092 TC X-RAY ARM, INFANT 38.95 36.37 77.19 71.0773050 X-RAY SHOULDERS 64.63 60.9273050 TC X-RAY SHOULDERS 47.11 43.97 87.24 80.3173050 26 X-RAY SHOULDERS 17.54 16.9573092 26 X-RAY ARM, INFANT 12.72 12.2973100 X-RAY WRIST 2 VIEWS 52.13 49.1673100 TC X-RAY WRIST 2 VIEWS 37.79 35.29 74.85 68.9173100 26 X-RAY WRIST 2 VIEWS 14.34 13.8773110 X-RAY WRIST MIN 3 VIEWS 70.95 66.7573110 TC X-RAY WRIST M 3 VIEWS 55.03 51.37 87.24 80.3173110 26 X-RAY WRIST MINIMUM 3 VIEWS 15.92 15.3873115 CONTRAST X-RAY WRIST 183.73 172.89 N173115 TC CONTRAST X-RAY WRIST 139.69 130.34 N173115 26 CONTRAST X-RAY WRIST 44.04 42.55 N173120 X-RAY HAND 2 VIEWS 46.43 43.7773120 TC X-RAY HAND 2 VIEWS 33.71 31.48 66.69 61.3873120 26 X-RAY HAND 2 VIEWS 12.72 12.2973130 X-RAY HAND MINIMUM 3 VIEWS 62.21 58.6073130 TC X-RAY HAND MINIMUM 3 VIEWS 46.96 43.85 80.70 74.2873130 26 X-RAY HAND MINIMUM 3 VIEWS 15.25 14.7673140 X-RAY FINGER(S) M 2 VIEWS 53.05 49.8873140 TC X-RAY FINGER(S) MINIMUM 2 VIEWS 42.45 39.63 84.21 77.5273140 26 X-RAY FINGER(S) MINIMUM 2 VIEWS 10.62 10.2573200 CT UPPER EXTREMITY W/O DYE 414.19 389.0973200 TC CT UPPER EXTREMITY W/O DYE 334.76 312.31 375.45 345.6073200 26 CT UPPER EXTREMITY W/O DYE 79.42 76.7873201 CT UPPER EXTREMITY W/DYE 506.15 475.2773201 TC CT UPPER EXTREMITY W/DYE 415.69 387.81 580.71 534.5173201 26 CT UPPER EXTREMITY W/DYE 90.45 87.4573202 CT UPPER EXTREMITY W/O & W/DYE649.53 609.1673202 TC CT UPPER EXTREMITY W/O & W/DYE554.86 517.63 647.37 595.8673202 26 CT UPPER EXTREMITY W/O & W/DYE 94.66 91.5373206 CT ANGIO UPR EXTREMITY W/O &

W/DYE 732.98 688.4973206 TC CT ANGIO UPR EXTREMITY W/O &

W/DYE 592.72 552.94 655.71 603.5473206 26 CT ANGIO UPR EXTREMITY W/O &

W/DYE 140.26 135.5473218 MRI UPPER EXTREMITY W/O DYE 879.74 824.21

11:3-29.6 APPENDIX B - REGULATIONS73218 TC MRI UPPER EXTREMITY W/O DYE 774.97 722.96 664.20 611.3773218 26 MRI UPPER EXTREMITY W/O DYE 104.76 101.2773219 MRI UPPER EXTREMITY W/DYE 950.89 891.3673219 TC MRI UPPER EXTREMITY W/DYE 824.47 769.13 846.36 779.0473219 26 MRI UPPER EXTREMITY W/DYE 126.42 122.2473220 MRI UPPER EXTREMITY W/O &

W/DYE 1,255.99 1,177.3573220 TC MRI UPPER EXTREMITY W/O &

W/DYE 1,088.83 1,015.73 1,033.50 951.2773220 26 MRI UPPER EXTREMITY W/O &

W/DYE 167.16 161.6173221 MRI JOINT UPPER EXTREMITY W/O

DYE 828.31 776.3573221 TC MRI JOINT UPPER EXTREMITY W/O

DYE 721.40 672.98 664.20 611.3773221 26 MRI JOINT UPPER EXTREMITY W/O

DYE 106.89 103.3773222 MRI JOINT UPPER EXTREMITY

W/DYE 901.39 845.1973222 TC MRI JOINT UPPER EXTREMITY

W/DYE 774.97 722.96 846.36 779.0473222 26 MRI JOINT UPPER EXTREMITY

W/DYE 126.42 122.2473223 MRI JOINT UPPER EXTREMITY W/O

& W/DYE 1,191.36 1,117.0673223 TC MRI JOINT UPPER EXTREMITY W/O

& W/DYE 1,024.78 955.99 1,033.50 951.2773223 26 MRI JOINT UPPER EXTREMITY W/O

& W/DYE 166.58 161.0773225 MR ANGIO UPPER EXTREMITY W/O

& W/DYE 1,024.20 959.9373225 TC MR ANGIO UPPER EXTREMITY W/O

& W/DYE 889.10 829.4373225 26 MR ANGIO UPPER EXTREMITY W/O

& W/DYE 135.10 130.5073500 X-RAY HIP UNILATERAL 1 VIEW 45.06 42.5973500 TC X-RAY HIP UNILATERAL 1 VIEW 30.21 28,22 59.67 54.9373500 26 X-RAY HIP UNILATERAL 1 VIEW 14.85 14.3773510 X-RAY HIP COMPLETE MINIMUM 2

VIEWS 71.16 67.0973510 TC X-RAY HIP COMPLETE 2 VIEWS 51.46 48.03 87.24 80.3173510 26 X-RAY HIP COMPLETE MINIMUM 2

VIEWS 19.70 19.0673520 X-RAY HIPS MINIMUM 2 VIEWS 68.27 64.4573520 TC X-RAY HIPS MINIMUM 2 VIEWS 47.11 43.97 87.24 80.3173520 26 X-RAY HIPS MINIMUM 2 VIEWS 21.16 20.4873525 X-RAY HIP ARTHROGRAPHY 168.58 158.76 N173525 TC X-RAY HIP ARTHROGRAPHY 124.54 116.22 N173525 26 X-RAY HIP ARTHROGRAPHY 44.04 42.55 N173530 X-RAY HIP DURING OPERATIVE

PROCEDURE 60.32 58.24 N173530 TC X-RAY HIP DURING OPERATIVE

PROCEDURE 37.53 36.22 N173530 26 X-RAY HIP DURING OPERATIVE

PROCEDURE 23.26 22.51 N173540 X-RAY PELVIS & HIPS MINIMUM 2

VIEWS 68.71 64.7373540 TC X-RAY PELVIS & HIPS MINIMUM 2

VIEWS 51.76 48.32 87.24 80.3173540 26 X-RAY PELVIS & HIPS MINIMUM 2

VIEWS 16.95 16.4073542 X-RAY EXAM, SACROILIAC JOINT 137.42 129.77 N173542 TC X-RAY EXAM, SACROILIAC JOINT 91.36 85.25 N173542 26 X-RAY EXAM, SACROILIAC JOINT 46.06 44.51 N173550 X-RAY THIGH 2 VIEWS 53.51 50.5373550 TC X-RAY THIGH 2 VIEWS 37.60 35.11 66.69 61.3873550 26 X-RAY THIGH 2 VIEWS 15.91 15.4273560 X-RAY KNEE 1/2 VIEWS 57.41 54.1873560 TC X-RAY KNEE 1/2 VIEWS 40.85 38.14 72.54 66.7873560 26 X-RAY KNEE 1/2 VIEWS 16.56 16.0273562 X-RAY KNEE 3 VIEWS 74.25 69.9573562 TC X-RAY KNEE 3 VIEWS 55.13 51.47 87.24 80.31

UCJF 11:3-29.673562 26 X-RAY KNEE 3 VIEWS 19.12 18.4973564 X-RAY KNEE, COMPLETE 4/MORE

VIEWS 85.62 80.6873564 TC X-RAY KNEE, COMPLETE 4/MORE

VIEWS 63.21 59.00 87.24 80.3173564 26 X-RAY KNEE, COMPLETE 4/MORE

VIEWS 22.40 21.6873565 X-RAY KNEES STANDING

ANTEROPOST 57.28 54.0073565 TC X-RAY KNEES STANDING

ANTEROPOST 41.87 39.08 83.04 76.4473565 26 X-RAY KNEES STANDING

ANTEROPOST 15.43 14.9173580 X-RAY KNEE ARTHOGRAPHY 222.68 209.25 N173580 TC X-RAY KNEE ARTHOGRAPHY 176.95 165.10 N173580 26 X-RAY KNEE ARTHOGRAPHY 45.73 44.15 N173590 X-RAY TIBIA & FIBULA 2 VIEWS 56.34 53.1473590 TC X-RAY TIBIA & FIBULA 2 VIEWS 40.26 37.60 65.52 60.3073590 26 X-RAY TIBIA & FIBULA 2 VIEWS 16.06 15.5473592 X-RAY LEG, INFANT MINIMUM 2

VIEWS 52.25 49.2073592 TC X-RAY LEG, INFANT MINIMUM 2

VIEWS 39.53 36.92 78.36 72.1273592 26 X-RAY LEG, INFANT MINIMUM 2

VIEWS 12.72 12.2973600 X-RAY ANKLE 2 VIEWS 47.59 44.8573600 TC X-RAY ANKLE 2 VIEWS 34.87 32.57 69.03 63.5473600 26 X-RAY ANKLE 2 VIEWS 12.72 12.2973610 X-RAY ANKLE MINIMUM 3 VIEWS 62.88 59.2373610 TC X-RAY ANKLE MINIMUM 3 VIEWS 47.63 44.47 81.87 75.3673610 26 X-RAY ANKLE MINIMUM 3 VIEWS 15.25 14.7673615 CONTRAST X-RAY ANKLE 174.99 164.73 N173615 TC CONTRAST X-RAY ANKLE 130.95 122.20 N173615 26 CONTRAST X-RAY ANKLE 44.04 42.55 N173620 X-RAY FOOT 2 VIEWS 45.84 43.2373620 TC X-RAY FOOT 2 VIEWS 33.71 31.48 66.69 61.3873620 26 X-RAY FOOT 2 VIEWS 12.14 11.7473630 X-RAY FOOT MINIMUM 3 VIEWS 61.95 58.3573630 TC X-RAY FOOT MINIMUM 3 VIEWS 46.60 43.51 79.53 73.2073630 26 X-RAY FOOT MINIMUM 3 VIEWS 15.35 14.8673650 X-RAY HEEL 47.01 44.3173650 TC X-RAY HEEL 34.29 32.03 67.86 62.4673650 26 X-RAY HEEL 12.72 12.2973660 X-RAY TOE(S) 49.57 46.6373660 TC X-RAY TOE(S) 39.53 36.92 78.36 72.1273660 26 X-RAY TOE(S) 10.03 9.7173700 CT LOWER EXTREMITY W/O DYE 414.77 389.6373700 TC CT LOWER EXTREMITY W/O DYE 335.35 312.85 375.45 345.6073700 26 CT LOWER EXTREMITY W/O DYE 79.42 76.7873701 CT LOWER EXTREMITY W/DYE 510.81 479.6273701 TC CT LOWER EXTREMITY W/DYE 420.36 392.16 580.71 534.5173701 26 CT LOWER EXTREMITY W/DYE 90.45 87.4573706 CT ANGIO LWR EXTREMITY W/O &

W/DYE 807.23 758.0873706 TC CT ANGIO LWR EXTREMITY W/O &

W/DYE 658.52 614.32 655.71 603.5473706 26 CT ANGIO LWR EXTREMITY W/O &

W/DYE 148.72 143.7673718 MRI LOWER EXTREMITY W/O DYE 861.62 807.3673718 TC MRI LOWER EXTREMITY W/O DYE 756.93 706.12 664.20 611.3773718 26 MRI LOWER EXTREMITY W/O DYE 104.69 101.2473719 MRI LOWER EXTREMITY W/DYE 947.98 888.6573719 TC MRI LOWER EXTREMITY W/DYE 822.14 766.96 846.36 779.0473719 26 MRI LOWER EXTREMITY W/DYE 125.84 121.6973720 MRI LOWER EXTREMITY W/O &

W/DYE 1,257.16 1,178.4373720 TC MRI LOWER EXTREMITY W/O &

W/DYE 1,090.58 1,017.37 1,033.50 951.2773720 26 MRI LOWER EXTREMITY W/O &

W/DYE 166.58 161.0773721 MRI JOINT LOWER EXTREMITY W/O

DYE 844.02 791.02

11:3-29.6 APPENDIX B - REGULATIONS73721 TC MRI JOINT LOWER EXTREMITY W/O

DYE 737.71 688.19 664.20 611.3773721 26 MRI JOINT LOWER EXTREMITY W/O

DYE 106.31 102.8273722 MRI JOINT LOWER EXTREMITY

W/DYE 916.47 859.3073722 TC MRI JOINT LOWER EXTREMITY

W/DYE 788.94 735.99 846.36 779.0473722 26 MRI JOINT LOWER EXTREMITY

W/DYE 127.53 123.3173723 MRI JOINT LWR EXTREMITY W/O &

W/DYE 1,189.03 1,114.8873723 TC MRI JOINT LWR EXTREMITY W/O &

W/DYE 1,022.45 953.82 1,033.50 951.2773723 26 MRI JOINT LWR EXTREMITY W/O &

W/DYE 166.58 161.0773725 MR ANGIO LOWER EXT W OR W/O

DYE 938.33 880.1373725 TC MR ANGIO LOWER EXT W OR W/O

DYE 797.10 743.6073725 26 MR ANGIO LOWER EXT W OR W/O

DYE 141.23 136.5474000 X-RAY ABDOMEN SINGLE

ANTEROPOST 41.62 39.3474000 TC X-RAY ABDOMEN SINGLE

ANTEROPOST 27.88 26.05 54.99 50.6174000 26 X-RAY ABDOMEN SINGLE

ANTEROPOST 13.73 13.2974010 X-RAY ABDOMEN ANTEROPOST &

ADDED VW 63.95 60.3074010 TC X-RAY ABDOMEN ANTEROPOST &

ADDED VW 46.53 43.43 87.24 80.3174010 26 X-RAY ABDOMEN ANTEROPOST &

ADDED VW 17.44 16.8574020 X-RAY ABDOMEN COMPLETE 67.15 63,3774020 TC X-RAY ABDOMEN COMPLETE 46.53 43.43 87.24 80.3174020 26 X-RAY ABDOMEN COMPLETE 20.62 19.9474022 X-RAY EXAM SERIES, ABDOMEN 80.75 76.1774022 TC X-RAY EXAM SERIES, ABDOMEN 56.42 52.67 112.32 103.3874022 26 X-RAY EXAM SERIES, ABDOMEN 24.33 23.5074150 CT ABDOMEN W/O DYE 415.67 390.9474150 TC CT ABDOMEN W/O DYE 323.11 301.44 375.45 345.6074150 26 CT ABDOMEN W/O DYE 92.56 89.5074160 CT ABDOMEN W/DYE 621.20 583.1974160 TC CT ABDOMEN W/DYE 512.35 477.98 580.71 534.5174160 26 CT ABDOMEN W/DYE 108.84 105.2274170 CT ABDOMEN W/O & W/DYE 748.27 701.7674170 TC CT ABDOMEN W/O & W/DYE 639.30 596.40 647.37 595.8674170 26 CT ABDOMEN W/O & W/DYE 108.98 105.3674175 CT ANGIO ABDOM W/O & W/DYE 817.07 767.2874175 TC CT ANGIO ABDOM W/O & W/DYE 668.42 623.56 655.71 603.5474175 26 CT ANGIO ABDOM W/O & W/DYE 148.66 143.7374176 CT ANGIO ABDOM & PELVIS 357.22 337.8674176 TC CT ANGIO ABDOM & PELVIS 225.87 210.73 375.45 345.6074176 26 CT ANGIO ABDOM & PELVIS 131.35 127.1374177 CT ANGIO ABDOM & PELVIS

W/CONTRAST 568.57 535.2174177 TC CT ANGIO ABDOM & PELVIS

W/CONTRAST 430.84 401.94 580.71 534.5174177 26 CT ANGIO ABDOM & PELVIS

W/CONTRAST 137.73 133.2874178 CT ANGIO ABDOM & PELVIS 1+

REGNS 721.91 678.7974178 TC CT ANGIO ABDOM & PELVIS 1+

REGNS 569.43 531.21 647.37 595.8674178 26 CT ANGIO ABDOM & PELVIS 1+

REGNS 152.50 147.5874181 MRI ABDOMEN W/O DYE 780.43 731.9074181 TC MRI ABDOMEN W/O DYE 667.25 622.46 664.20 611.3774181 26 MRI ABDOMEN W/O DYE 113.19 109.4274183 MRI ABDOMEN W/O & W/DYE 1,261.00 1,182.2874183 TC MRI ABDOMEN W/O & W/DYE 1,086.50 1,013.56 1,033.50 951.27

UCJF 11:3-29.674183 26 MRI ABDOMEN W/O & W/DYE 174.49 168.7174220 CONTRAST X-RAY, ESOPHAGUS 151.79 142.8574220 TC CONTRAST X-RAY, ESOPHAGUS 115.82 108.07 167.97 154.5974220 26 CONTRAST X-RAY, ESOPHAGUS 35.97 34.7774230 CINE/VIDEO X-RAY, THROAT/ESOPH 153.59 144.7174230 TC CINE/VIDEO X-RAY, THROAT/ESOPH 112.32 104.80 167.97 154.5974230 26 CINE/VIDEO X-RAY, THROAT/ESOPH 41.27 39.8974241 X-RAY EXAM, UPPER GI TRACT

W/KUB 198.98 187.4474241 TC X-RAY EXAM, UPPER GI TRACT

W/KUB 146.09 136.31 167.97 154.5974241 26 X-RAY EXAM, UPPER GI TRACT

W/KUB 52.88 51.1274246 CONTRAST X-RAY UGI TRACT W/O

KUB 213.47 200.9874246 TC CONTRAST X-RAY UGI TRACT W/O

KUB 159.49 148.82 167.97 154.5974246 26 CONTRAST X-RAY UGI TRACT W/O

KUB 53.99 52.1874280 CONTRAST X-RAY COLON W/WO

GLUCOGEN 357.90 336.4874280 TC CONTRAST X-RAY COLON W/WO

GLUCOGEN 281.19 262.33 274.98 253.1174280 26 CONTRAST X-RAY COLON W/WO

GLUCOGEN 76.71 74.1574290 CONTRAST X-RAY, GALLBLADDER 115.11 108.2374290 TC CONTRAST X-RAY, GALLBLADDER 90.78 84.71 167.97 154.5974290 26 CONTRAST X-RAY, GALLBLADDER 24.33 23.5074330 X-RAY BILE/PANCREAS ENDOSCOPY300.56 290.09 N174330 TC X-RAY BILE/PANCREAS ENDOSCOPY230.31 222.27 N174330 26 X-RAY BILE/PANCREAS ENDOSCOPY 72.02 69.63 N174400 CONTRAST X-RAY URINARY TRACT 188.82 177.4874400 TC CONTRAST X-RAY URINARY TRACT 150.75 140.66 301.83 277.8374400 26 CONTRAST X-RAY URINARY TRACT 38.07 36.8274410 CONTRAST X-RAY URINARY TRACT 194.65 182.9174410 TC CONTRAST X-RAY URINARY TRACT 155.99 145.55 312.36 287.5274410 26 CONTRAST X-RAY URINARY TRACT 38.65 37.3674415 CONTRAST X-RAY URINARY TRACT 230.76 216.5974415 TC CONTRAST X-RAY URINARY TRACT 192.68 179.77 341.13 313.9874415 26 CONTRAST X-RAY URINARY TRACT 38.07 36.8274420 CONTRAST X-RAY URINARY TRACT 219.86 212.1874420 TC CONTRAST X-RAY URINARY TRACT 190.87 184.20 341.13 313.9874420 26 CONTRAST X-RAY URINARY TRACT 28.56 27.6374425 CONTRAST X-RAY URINARY TRACT 124.29 119.97 N174425 TC CONTRAST X-RAY URINARY TRACT 95.30 91.97 N174425 26 CONTRAST X-RAY URINARY TRACT 28.56 27.63 N174430 CONTRAST X-RAY BLADDER 102.29 96.28 N174430 TC CONTRAST X-RAY BLADDER 77.96 72.76 N174430 26 CONTRAST X-RAY BLADDER 24.33 23.50 N174450 X-RAY URETHRA/BLADDER 132.84 128.21 N174450 TC X-RAY URETHRA/BLADDER 106.33 102.60 N174450 26 X-RAY URETHRA/BLADDER 26.46 25.59 N174455 X-RAY URETHRA/BLADDER 151.71 142.41 N174455 TC X-RAY URETHRA/BLADDER 126.29 117.85 N174455 26 X-RAY URETHRA/BLADDER 25.42 24.56 N174475 X-RAY CONTROL, CATH INSERT 188.45 177.25 N174475 TC X-RAY CONTROL, OATH INSERT 146.09 136.31 N174475 26 X-RAY CONTROL, OATH INSERT 42.36 40.94 N174480 X-RAY CONTROL, OATH INSERT 189.03 177.79 N174480 TC X-RAY CONTROL, OATH INSERT 146.67 136.86 N174480 26 X-RAY CONTROL, OATH INSERT 42.36 40.94 N174485 X-RAY GUIDE, GU DILATION 186.12 175.08 N174485 TC X-RAY GUIDE, GU DILATION 143.77 134.15 N174485 26 X-RAY GUIDE, GU DILATION 42.36 40.94 N175561 CARDIAC MRI FOR MORPH W/DYE 1,022.10 960.2375561 TC CARDIAC MRI FOR MORPH W/DYE 816.31 761.53 1,033.50 951.2775561 26 CARDIAC MRI FOR MORPH W/DYE 205.79 198.7075572 CT HEART W/3D IMAGE 489.05 460.6975572 TC CT HEART W/3D IMAGE 358.64 334.58 497.49 457.9275572 26 CT HEART NV/3D IMAGE 130.41 126.1175574 CT ANGIO HEART W/3D IMAGE 745.46 701.5675574 TC CT ANGIO HEART W/3D IMAGE 565.93 527.96 497.49 457.92

11:3-29.6 APPENDIX B - REGULATIONS75574 26 CT ANGIO HEART W/3D IMAGE 179.53 173.6075605 CONTRAST X-RAY AORTA 360.73 339.57 N175605 TC CONTRAST X-RAY AORTA 270.12 252.01 N175605 26 CONTRAST X-RAY AORTA 90.61 87.55 N175625 CONTRAST X-RAY AORTA 361.13 340.04 N175625 TC CONTRAST X-RAY AORTA 270.70 252.55 N175625 26 CONTRAST X-RAY AORTA 90.42 87.48 N175630 X-RAY AORTA, LEG ARTERIES 417.40 394.12 N175630 TC X-RAY AORTA, LEG ARTERIES 277.11 258.54 N175630 26 X-RAY AORTA, LEG ARTERIES 140.29 135.59 N175635 CT ANGIO ABDOMINAL ARTERIES 913.36 858.40 N175635 TC CT ANGIO ABDOMINAL ARTERIES 725.35 676.75 N175635 26 CT ANGIO ABDOMINAL ARTERIES 188.01 181.66 N175650 ARTERY X-RAYS HEAD & NECK 389.94 367.78 N175650 TC ARTERY X-RAYS HEAD & NECK 272.45 254.19 N175650 26 ARTERY X-RAYS HEAD & NECK 117.50 113.59 N175665 ARTERY X-RAYS HEAD & NECK 425.00 400.08 N175665 TC ARTERY X-RAYS HEAD & NECK 319.62 298.19 N175665 26 ARTERY X-RAYS HEAD & NECK 105.39 101.89 N175671 ARTERY X-RAYS HEAD & NECK 494.52 465.82 N175671 TC ARTERY X-RAYS HEAD & NECK 363.17 338.89 N175671 26 ARTERY X-RAYS HEAD & NECK 131.36 126.95 N175676 ARTERY X-RAYS NECK UNILATERAL407.54 383.78 N175676 TC ARTERY X-RAYS NECK UNILATERAL302.73 282.44 N175676 26 ARTERY X-RAYS NECK UNILATERAL104.80 101.35 N175680 ARTERY X-RAYS NECK BILATERAL 460.30 433.83 N175680 TC ARTERY X-RAYS NECK BILATERAL 328.94 306.88 N175680 26 ARTERY X-RAYS NECK BILATERAL 131.36 126.95 N175685 ARTERY X-RAYS SPINE 409.47 385.48 N175685 TC ARTERY X-RAYS SPINE 305.65 285.15 N175685 26 ARTERY X-RAYS SPINE 103.82 100.33 N175705 ARTERY X-RAYS SPINE 472.31 446.19 N175705 TC ARTERY X-RAYS SPINE 303.32 282.98 N175705 26 ARTERY X-RAYS SPINE 169.00 163.23 N175710 ARTERY X-RAYS ARM/LEG 392.29 368.94 N175710 TC ARTERY X-RAYS ARM/LEG 304.48 284.06 N175710 26 ARTERY X-RAYS ARM/LEG 87.82 84.88 N175716 ARTERY X-RAYS ARMS/LEGS 453.48 426.68 N175716 TC ARTERY X-RAYS ARMS/LEGS 350.35 326.93 N175716 26 ARTERY X-RAYS ARMS/LEGS 103.13 99.75 N175722 ARTERY X-RAYS KIDNEY 379.94 357.49 N175722 TC ARTERY X-RAYS KIDNEY 289.33 269.93 N175722 26 ARTERY X-RAYS KIDNEY 90.61 87.55 N175724 ARTERY X-RAYS KIDNEYS 449.53 423.26 N175724 TC ARTERY X-RAYS KIDNEYS 329.39 307.38 N175724 26 ARTERY X-RAYS KIDNEYS 120.14 115.88 N175726 ARTERY X-RAYS ABDOMEN 389.19 366.16 N175726 TC ARTERY X-RAYS ABDOMEN 299.82 '279.71 N175726 26 ARTERY X-RAYS ABDOMEN 89.37 86.44 N175736 ARTERY X-RAYS PELVIS 387.64 364.59 N175736 TC ARTERY X-RAYS PELVIS 299.24 279.17 N175736 26 ARTERY X-RAYS PELVIS 88.41 85.42 N175743 ARTERY X-RAYS LUNGS 408.48 385.48 N175743 TC ARTERY X-RAYS LUNGS 278.28 259.62 N175743 26 ARTERY X-RAYS LUNGS 130.20 125.85 N175774 ARTERY X-RAY, EACH VESSEL 270.73 253.58 N175774 TC ARTERY X-RAY, EACH VESSEL 242.17 225.94 N175774 26 ARTERY X-RAY, EACH VESSEL 28.56 27.63 N175809 NONVASCULAR SHUNT, X-RAY 164.52 154.76 N175809 TC NONVASCULAR SHUNT, X-RAY 127.46 118.93 N175809 26 NONVASCULAR SHUNT, X-RAY 37.06 35.83 N175820 VEIN X-RAY ARM/LEG 210.48 198.23 N175820 TC VEIN X-RAY ARM/LEG 155.41 145.01 N175820 26 VEIN X-RAY ARM/LEG 55.07 53.22 N175822 VEIN X-RAY ARMS/LEGS 256.52 242.15 N175822 TC VEIN X-RAY ARMS/LEGS 174.04 162.39 N175822 26 VEIN X-RAY ARMS/LEGS 82.47 79.77 N175825 VEIN X-RAY TRUNK 345.52 325.41 N175825 TC VEIN X-RAY TRUNK 257.32 240.06 N175825 26 VEIN X-RAY TRUNK 88.21 85.35 N175894 X-RAYS, TRANSCATH THERAPY 1,855.82 1,791.12 N175894 TC X-RAYS, TRANSCATH THERAPY 1,753.06 1,691.80 N1

UCJF 11:3-29.675894 26 X-RAYS, TRANSCATH THERAPY 106.24 102.86 N175898 F/U ANGIOGRAPHY 209.00 201.67 N175898 TC F/U ANGIOGRAPHY 78.78 76.03 N175898 26 F/U ANGIOGRAPHY 135.47 131.11 N175940 X-RAY PLACE VEIN FILTER 957.35 924.02 N175940 TC X-RAY PLACE VEIN FILTER 914.34 882.41 N175940 26 X-RAY PLACE VEIN FILTER 43.27 41.92 N175954 26 ILIAC ANEURYSM ENDOVASC

REPAIR 183.83 178.4275957 26 X-RAY, ENDOVASC THOR AO REPAIR494.34 480.0175960 TRANSCATH IV STENT RS & I 326.56 306.84 N175960 TC TRANSCATH IV STENT RS & I 262.56 244.95 N175960 26 TRANSCATH IV STENT RS & I 64.01 61.89 N175961 RETRIEVE BROKEN CATHETER 601.23 572.18 N175961 TC RETRIEVE BROKEN CATHETER 271.28 253.09 N175961 26 RETRIEVE BROKEN CATHETER 329.93 319.08 N175962 REPAIR ARTERIAL BLOCKAGE 360.81 338.03 N175962 TC REPAIR ARTERIAL BLOCKAGE 319.03 297.65 N175962 26 REPAIR ARTERIAL BLOCKAGE 41.78 40.39 N175964 REPAIR ARTERY BLOCKAGE, EACH 224.67 210.63 N175964 TC REPAIR ARTERY BLOCKAGE, EACH 196.17 183.04 N175964 26 REPAIR ARTERY BLOCKAGE, EACH 28.51 27.61 N175978 REPAIR VENOUS BLOCKAGE 361.40 338.57 N175978 TC REPAIR VENOUS BLOCKAGE 320.20 298.73 N175978 26 REPAIR VENOUS BLOCKAGE 41.20 39.85 N175984 X-RAY CONTROL CATHETER

CHANGE 192.29 181.30 N175984 TC X-RAY CONTROL CATHETER

CHANGE 136.20 127.09 N175984 26 X-RAY CONTROL CATHETER

CHANGE 56.09 54.21 N175989 ABSCESS DRAIN UNDER X-RAY 224.22 212.28 N175989 TC ABSCESS DRAIN UNDER X-RAY 132.70 123.82 N175989 26 ABSCESS DRAIN UNDER X-RAY 91.52 88.45 N176000 FLUOROSCOPE EXAM 304.49 285.18 N176000 TC FLUOROSCOPE EXAM 274.00 255.66 N176000 26 FLUOROSCOPE EXAM 30.50 29.51 N176001 FLUOROSCOPE EXAM, EXTENSIVE 576.95 556.98 N176001 TC FLUOROSCOPE EXAM, EXTENSIVE 453.41 437.54 N176001 26 FLUOROSCOPE EXAM, EXTENSIVE 128.39 124.16 N176010 X-RAY NOSE TO RECTUM 46.27 43.6876010 TC X-RAY NOSE TO RECTUM 31.96 29.86 63.18 58.1776010 26 X-RAY NOSE TO RECTUM 14.31 13.8376080 X-RAY FISTULA 103.44 97.94 N176080 TC X-RAY FISTULA 61.08 57.01 N176080 26 X-RAY FISTULA 42.36 40.94 N176098 X-RAY EXAM, BREAST SPECIMEN 31.87 30.18 N176098 TC X-RAY EXAM, BREAST SPECIMEN 19.16 17.91 N176098 26 X-RAY EXAM, BREAST SPECIMEN 12.72 12.29 N176100 X-RAY BODY SECTION 206.65 194.4076100 TC X-RAY BODY SECTION 158.32 147.72 146.91 135.2476100 26 X-RAY BODY SECTION 48.33 46.6876102 COMPLEX BODY SECTION X-RAYS 403.16 377.8876102 TC COMPLEX BODY SECTION X-RAYS 349.32 325.88 445.38 409.9576102 26 COMPLEX BODY SECTION X-RAYS 53.84 52.0076120 CINEIVIDEO X-RAYS 129.09 121.4976120 TC CINE/VIDEO X-RAYS 99.50 92.87 161.73 148.8676120 26 CINE/VIDEO X-RAYS 29.57 28.6276125 26 CINEIVIDEO X-RAYS, ADDED 22.84 22.06 N176376 3D RENDER W/O POST PROCESS 234.29 219.61 N176376 TC 3D RENDER W/O POST PROCESS 203.68 190.07 N176376 26 3D RENDER W/O POST PROCESS 30.61 29.54 N176377 3D RENDERING W/POST PROCESS 297.09 281.18 N176377 TC 3D RENDERING W/POST PROCESS 179.06 167.09 N176377 26 3D RENDERING W/POST PROCESS 118.06 114.10 N176380 CAT SCAN F/U STUDY 318.44 299.6276380 TC CAT SCAN F/U STUDY 242.75 226.49 219.81 202.3276380 26 CAT SCAN F/U STUDY 75.69 73.1376506 ECHO EXAM HEAD 202.86 190.9476506 TC ECHO EXAM HEAD 153.66 143.37 120.54 110.9776506 26 ECHO EXAM HEAD 49.18 47.5676510 OPHTHALMIC US, B & QUANT A 273.79 260.13

11:3-29.6 APPENDIX B - REGULATIONS76510 TC OPHTHALMIC US, B & QUANT A 127.46 118.93 255.03 234.7576510 26 OPHTHALMIC US, B &QUANT A 146.33 141.2076511 OPHTHALMIC US, QUANT A ONLY 163.45 154.8476511 TC OPHTHALMIC US, QUANT A ONLY 83.20 77.65 166.14 152.9176511 26 OPHTHALMIC US, QUANT A ONLY 80.25 77.1976512 OPHTHALMIC US, B W/NON-QUANT A151.03 143.3676512 TC OPHTHALMIC US, B W/NON-QUANT A 69.24 64.62 138.03 127.0576512 26 OPHTHALMIC US, B W/NON-QUANT A 81.81 78.7476514 ECHO EXAM EYE, THICKNESS 22.48 21.4676514 TC ECHO EXAM EYE, THICKNESS 7.50 7.03 14.04 12.9376514 26 ECHO EXAM EYE, THICKNESS 14.96 14.4176516 ECHO EXAM EYE 119.29 112.6676516 TC ECHO EXAM EYE 73.31 68.43 120.54 110.9776516 26 ECHO EXAM EYE 45.97 44.2476519 ECHO EXAM EYE 129.63 122.3876519 TC ECHO EXAM EYE 82.04 76.57 163.80 150.7876519 26 ECHO EXAM EYE 47.59 45.8376536 US EXAM HEAD & NECK 199.36 187.4876536 TC US EXAM HEAD & NECK 155.99 145,55 186.48 171.6676536 26 US EXAM HEAD & NECK 43.37 41.9476604 US EXAM, CHEST 147.03 138.6476604 TC US EXAM, CHEST 104.75 97.76 120.54 110.9776604 26 US EXAM, CHEST 42.28 40.8876645 US EXAM, BREAST(S) 161.02 151.7076645 TC US EXAM, BREAST(S) 118.73 110.79 120.54 110.9776645 26 US EXAM, BREAST(S) 42.29 40.9176700 US EXAM, ABDOM, COMPLETE 235.86 222.1776700 TC US EXAM, ABDOM, COMPLETE 167.06 161.85 186.48 171.6676700 26 US EXAM, ABDOM, COMPLETE 62.40 60.3276705 ECHO EXAM ABDOMEN 179.34 168.8876705 TC ECHO EXAM ABDOMEN 133.87 124.91 186.48 171.6676705 26 ECHO EXAM ABDOMEN 45.47 43.9776770 US EXAM ABDOM BACK WALL, COMP224.16 211.0976770 TC US EXAM ABDOM BACK WALL, COMP167.06 155.86 186.48 171.6676770 26 US EXAM ABDOM BACK WALL, COMP57.10 55.2176775 US EXAM ABDOM BACK WALL, LIM 187.57 176.5376775 TC US EXAM ABDOM BACK WALL, LIM 142.02 132.52 186.48 171.6676775 26 US EXAM ABDOM BACK WALL, LIM 45.55 44.0176776 US EXAM K TRANSPLANT W/DOPPLER254.87 239.7876776 TC US EXAM K TRANSPLANT W/DOPPLER196.17 183.04 186.48 171.6676776 26 US EXAM K TRANSPLANT W/DOPPLER58.70 56.7676800 US EXAM, SPINAL CANAL 220.65 208.7776800 TC US EXAM, SPINAL CANAL 135.03 125.99 186.48 171.6676800 26 US EXAM, SPINAL CANAL 85.62 82.7876801 OBSTET US < 14 WKS, SINGLE FETUS 216.53 204.5476801 TC OBSTET US < 14 WKS, SINGLE FETUS 140.28 130.88 186.48 171.6676801 26 OBSTET US < 14 WKS, SINGLE FETUS 76.26 73.6576805 OBSTET US >/= 14 WKS, SINGLE

FETUS 249.13 234.9676805 TC OBSTET US >/= 14 WKS, SINGLE

FETUS 172.87 161.31 186.48 171.6676805 26 OBSTET US >/= 14 WKS, SINGLE

FETUS 76.26 73.6576810 OBSTET US >/= 14 WKS, ADDED

FETUS 160.70 152.4476810 TC OBSTET US >/= 14 WKS, ADDED

FETUS 85.53 79.82 170.82 157.2376810 26 OBSTET US >/= 14 WKS, ADDED

FETUS 75.16 72.6276811 OBSTET US, DETAILED, SINGLE

FETUS 317.90 301.4076811 TC OBSTET US, DETAILED, SINGLE

FETUS 171.71 160.21 296.28 272.7376811 26 OBSTET US, DETAILED, SINGLE

FETUS 146.19 141.1876814 OBSTET US NUCHAL MEAS, ADDED 131.51 125.2476814 TC OBSTET US NUCHAL MEAS, ADDED 55.83 52.13 111.15 102.3076814 26 OBSTET US NUCHAL MEAS, ADDED 75.67 73.1176815 OBSTET US, LIMITED, FETUS(S) 152.23 143.6676815 TC OBSTET US, LIMITED, FETUS(S) 103.00 96.12 120.54 110.9776815 26 OBSTET US, LIMITED, FETUS(S) 49.23 47.5576816 OBSTET US, F/U, PER FETUS 194.86 183.99

UCJF 11:3-29.676816 TC OBSTET US, F/U, PER FETUS 129.20 120.56 120.54 110.9776816 26 OBSTET US, F/U, PER FETUS 65.65 63.4276817 TRANSVAGINAL US, OBSTETRIC 172.32 162.7176817 TC TRANSVAGINAL US, OBSTETRIC 114.65 106.98 120.54 110.9776817 26 TRANSVAGINAL US, OBSTETRIC 57.67 55.7376818 FETAL BIOPHYS PROFILE W/NST 202.69 191.7876818 TC FETAL BIOPHYS PROFILE W/NST 121.64 113.50 186.48 171.6676818 26 FETAL BIOPHYS PROFILE W/NST 81.04 78.2776819 FETAL BIOPHYS PROFILE W/O NST 152.37 144.1576819 TC FETAL BIOPHYS PROFILE W/O NST 92.53 86.34 184.83 170.1376819 26 FETAL BIOPHYS PROFILE W/O NST 59.86 57.8176820 UMBILICAL ARTERY ECHO 76.50 72.6576820 TC UMBILICAL ARTERY ECHO 38.37 35.83 76.02 69.9976820 26 UMBILICAL ARTERY ECHO 38.13 36.8276821 MIDDLE CEREBRAL ARTERY ECHO 162.22 153.1676821 TC MIDDLE CEREBRAL ARTERY ECHO 107.66 100.47 120.54 110.9776821 26 MIDDLE CEREBRAL ARTERY ECHO 54.56 52.7176826 ECHO EXAM FETAL HEART 208.98 197.1276826 TC ECHO EXAM FETAL HEART 145.52 135.77 291.30 268.1476826 26 ECHO EXAM FETAL HEART 63.48 61.3576827 ECHO EXAM FETAL HEART 109.66 103.7876827 TC ECHO EXAM FETAL HEART 65.74 61.36 120.54 110.9776827 26 ECHO EXAM FETAL HEART 43.93 42.4376828 ECHO EXAM FETAL HEART 79.54 75.6376828 TC ECHO EXAM FETAL HEART 36.62 34.19 72.54 66.7876828 26 ECHO EXAM FETAL HEART 42.92 41.4476830 TRANSVAGINAL US, NON-OB 210.04 197.7676830 TC TRANSVAGINAL US, NON-OB 156.57 146.09 186.48 171.6676830 26 TRANSVAGINAL US, NON-0B 53.46 51.6676856 US EXAM, PELVIC, COMPLETE 209.45 197.2276856 TC US EXAM, PELVIC, COMPLETE 155.99 145.55 186.48 171.6676856 26 US EXAM, PELVIC, COMPLETE 53.46 51.6676857 US EXAM, PELVIC, LIMITED 171.60 161.1476857 TC US EXAM, PELVIC, LIMITED 140.86 131.42 120.54 110.9776857 26 US EXAM, PELVIC, LIMITED 30.74 29.7176870 US EXAM, SCROTUM 208.60 196.3276870 TC US EXAM, SCROTUM 158.32 147.72 186.48 171.6676870 26 US EXAM, SCROTUM 50.28 48.6076872 US, TRANSRECTAL 236.77 222.7176872 TC US, TRANSRECTAL 181.61 169.45 186.48 171.6676872 26 US, TRANSRECTAL 55.15 53.2676881 US XTR NON-VASC COMPLETE 192.67 181.3476881 TC US XTR NON-VASC COMPLETE 147.84 137.94 186.48 171.6676881 26 US XTR NON-VASC COMPLETE 44.84 43.4076882 US XTR NON-VASC LMTD 48.50 46.3876882 TC US XTR NON-VASC LMTD 17.41 16.27 33.93 31.2376882 26 US XTR NON-VASC LMTD 31.09 30.1176937 US GUIDE VASCULAR ACCESS 57.48 54.50 N176937 TC US GUIDE VASCULAR ACCESS 33.71 31.48 N176937 26 US GUIDE VASCULAR ACCESS 23.77 23.01 N176942 ECHO GUIDE FOR BIOPSY 334.15 313.52 N176942 TC ECHO GUIDE FOR BIOPSY 281.77 262.89 N176942 26 ECHO GUIDE FOR BIOPSY 52.38 50.65 N176998 US GUIDE, INTRAOP 293.61 283.70 N176998 TC US GUIDE, INTRAOP 197.37 190.50 N176998 26 US GUIDE, INTRAOP 101.78 98.78 N177001 FLUOROGUIDE FOR VEIN DEVICE 193.72 181.78 N177001 TC FLUOROGUIDE FOR VEIN DEVICE 163.57 152.61 N177001 26 FLUOROGUIDE FOR VEIN DEVICE 30.16 29.16 N177002 NEEDLE LOCALIZATION BY X-RAY 289.77 273.67 N177002 TC NEEDLE LOCALIZATION BY X-RAY 190.67 177.94 N177002 26 NEEDLE LOCALIZATION BY X-RAY 99.07 95.73 N177003 FLUOROGUIDE FOR SPINE INJECT 236.32 224.15 N177003 TC FLUOROGUIDE FOR SPINE INJECT 130.19 121.54 N177003 26 FLUOROGUIDE FOR SPINE INJECT 106.12 102.61 N177011 CT SCAN FOR LOCALIZATION 819.82 767.90 N177011 TC CT SCAN FOR LOCALIZATION 724.89 676.25 N177011 26 CT SCAN FOR LOCALIZATION 94.93 91.65 N177012 CT SCAN FOR NEEDLE BIOPSY 271.67 256.43 N177012 TC CT SCAN FOR NEEDLE BIOPSY 182.78 170.54 N177012 26 CT SCAN FOR NEEDLE BIOPSY 88.89 85.90 N177032 GUIDANCE FOR NEEDLE, BREAST 91.65 86.98 N1

11:3-29.6 APPENDIX B - REGULATIONS77032 TC GUIDANCE FOR NEEDLE, BREAST 48.27 45.06 N177032 26 GUIDANCE FOR NEEDLE, BREAST 43.37 41.94 N177051 COMPUTER DIAG MAMMOGRAM,

ADDED 19.23 18.1577051 TC COMPUTER DIAG MAMMOGRAM,

ADDED 14.50 13.5677051 26 COMPUTER DIAG MAMMOGRAM,

ADDED 4.73 4.5977052 COMP SCREEN MAMMOGRAM, ADDED19.23 18.1577052 TC COMP SCREEN MAMMOGRAM, ADDED14.50 13.5677052 26 COMP SCREEN MAMMOGRAM, ADDED 4.73 4.5977055 MAMMOGRAM, ONE BREAST 142.93 135.2277055 TC MAMMOGRAM, ONE BREAST 88.45 82.5477055 26 MAMMOGRAM, ONE BREAST 54.48 52.6877056 MAMMOGRAM, BOTH BREASTS 182.95 172.9977056 TC MAMMOGRAM, BOTH BREASTS 115.24 107.5377056 26 MAMMOGRAM, BOTH BREASTS 67.71 65.4777057 MAMMOGRAM, SCREENING 133.62 126.5377057 TC MAMMOGRAM, SCREENING 79.13 73.8577057 26 MAMMOGRAM, SCREENING 54.48 52.6877058 MRI ONE BREAST 1,287.39 1,205.2877058 TC MRI ONE BREAST 1,160.46 1,082.5577058 26 MRI ONE BREAST 126.93 122.7477059 MRI BOTH BREASTS 1,336.30 1,250.9177059 TC MRI BOTH BREASTS 1,209.37 1,128.1777059 26 MRI BOTH BREASTS 126.93 122.7477072 X-RAYS FOR BONE AGE 39.21 37.1277072 TC X-RAYS FOR BONE AGE 24.40 22.79 47.97 44.1677072 26 X-RAYS FOR BONE AGE 14.82 14.3277073 X-RAYS, BONE LENGTH STUDIES 65.21 61.6777073 TC X-RAYS, BONE LENGTH STUDIES 41.87 39.08 83.04 76.4477073 26 X-RAYS, BONE LENGTH STUDIES 23.35 22.5877074 X-RAYS, BONE SURVEY, LIMITED 116.91 110.3077074 TC X-RAYS, BONE SURVEY, LIMITED 81.46 76.03 146.91 135.2477074 26 X-RAYS, BONE SURVEY, LIMITED 35.46 34.2877075 X-RAYS, BONE SURVEY COMPLETE 172.73 162.5977075 TC X-RAYS, BONE SURVEY COMPLETE 130.95 122.20 146.91 135.2477075 26 X-RAYS, BONE SURVEY COMPLETE 41.78 40.3977076 X-RAYS, BONE SURVEY, INFANT 167.39 158.0477076 TC X-RAYS, BONE SURVEY, INFANT 114.07 106.44 146.91 135.2477076 26 X-RAYS, BONE SURVEY, INFANT 53.32 51.5977077 JOINT SURVEY, SINGLE VIEW 70.16 66.3877077 TC JOINT SURVEY, SINGLE VIEW 44.20 41.25 87.24 80.3177077 26 JOINT SURVEY, SINGLE VIEW 25.96 25.1177080 DIAG BONE DENSITY, AXIAL 164.52 154.5377080 TC DIAG BONE DENSITY, AXIAL 147.68 138.21 136.59 125.7377080 26 DIAG BONE DENSITY, AXIAL 16.85 16.3177081 DIAG BONE DENSITY/PERIPHERAL 47.72 45.1277081 TC DIAG BONE DENSITY/PERIPHERAL 32.54 30.40 62.19 57.2477081 26 DIAG BONE DENSITY/PERIPHERAL 15.18 14.7477082 DIAG BONE DENSITY, VERTEBRAL FX46.47 43.8477082 TC DIAG BONE DENSITY, VERTEBRAL FX36.44 34.13 69.03 63.5477082 26 DIAG BONE DENSITY, VERTEBRAL FX10.03 9.7177261 RADIATION THERAPY PLANNING 113.00 109.1577262 RADIATION THERAPY PLANNING 170.00 164.3677263 RADIATION THERAPY PLANNING 252.06 243.7077280 SET RADIATION THERAPY FIELD 318.27 298.7477280 TC SET RADIATION THERAPY FIELD 263.72 246.05 202.35 186.2777280 26 SET RADIATION THERAPY FIELD 54.56 52.7177285 SET RADIATION THERAPY FIELD 559.51 524.7177285 TC SET RADIATION THERAPY FIELD 477.43 445.40 526.05 484.2077285 26 SET RADIATION THERAPY FIELD 82.08 79.3177290 SET RADIATION THERAPY FIELD 896.21 840.1077290 TC SET RADIATION THERAPY FIELD 774.39 722.42 526.05 484.2077290 26 SET RADIATION THERAPY FIELD 121.82 117.6977295 SET RADIATION THERAPY FIELD 931.90 881.4377295 TC SET RADIATION THERAPY FIELD 574.47 536.03 1,150.02 1,058.5277295 26 SET RADIATION THERAPY FIELD 357.43 345.3977300 RADIATION THERAPY DOSE PLAN 115.07 108.9877300 TC RADIATION THERAPY DOSE PLAN 66.32 61.90 132.18 121.6877300 26 RADIATION THERAPY DOSE PLAN 48.74 47.0977305 TELETX ISODOSE PLAN SIMPLE 108.64 103.20

UCJF 11:3-29.677305 TC TELETX ISODOSE PLAN SIMPLE 54.09 50.49 107.64 99.0677305 26 TELETX ISODOSE PLAN SIMPLE 54.56 52.7177310 TELETX ISODOSE PLAN INTERMED 153.06 145.5677310 TC TELETX ISODOSE PLAN INTERMED 70.98 66.25 141.54 130.2977310 26 TELETX ISODOSE PLAN INTERMED 82.08 79.3177315 TELETX ISODOSE PLAN COMPLEX 232.39 220.8877315 TC TELETX ISODOSE PLAN COMPLEX 110.57 103.18 221.13 203.5577315 26 TELETX ISODOSE PLAN COMPLEX 121.82 117.6977321 SPECIAL TELETX PORT PLAN 176.00 166.6877321 TC SPECIAL TELETX PORT PLAN 102.42 95.58 204.75 188.4677321 26 SPECIAL TELETX PORT PLAN 73.58 71.1077331 SPECIAL RADIATION DOSIMETRY 101.48 96.9777331 TC SPECIAL RADIATION DOSIMETRY 33.13 30.94 65.52 60.3077331 26 SPECIAL RADIATION DOSIMETRY 68.35 66.0277332 RADIATION TREAT AID(S) 130.80 123.4877332 TC RADIATION TREAT AID(S) 88.45 82.54 176.64 162.6077332 26 RADIATION TREAT AID(S) 42.36 40.9477333 RADIATION TREAT AID(S) 95.88 91.6777333 TC RADIATION TREAT AID(S) 30.21 28.22 59.67 54.9377333 26 RADIATION TREAT AID(S) 65.67 63.4577334 RADIATION TREAT AID(S) 253.55 239.7577334 TC RADIATION TREAT AID(S) 157.16 146.64 314.70 289.6877334 26 RADIATION TREAT AID(S) 96.39 93.1177336 RADIATION PHYSICS CONSULT 89.61 83.63 178.98 164.7377371 SRS, MULTISOURCE 2,070.29 1,900.21 14,838.51 13,658.1677403 RADIATION TX SING AREA 6-10MEV 224.70 209.65 189.45 174.3977413 RADIATION TX 3/MORE AREA

6-10MEV 401.73 374.78 310.95 286.2377414 RADIATION TX 3/MORE AREA

11-19MEV 449.47 419.32 310.95 286.2377417 RADIOLOGY PORT FILM(S) 25.57 23.87 N177427 RADIATION TX MANAGEMENT, X5 282.30 272.5177431 RADIATION THERAPY MANAGEMENT155.03 149.5377470 SPECIAL RADIATION TREAT 330.15 313.4677470 TC SPECIAL RADIATION TREAT 166.48 155.32 333.42 306.9077470 26 SPECIAL RADIATION TREAT 163.67 158.1278006 THYROID IMAGING W/UPTAKE 400.08 374.6178006 TC THYROID IMAGING W/UPTAKE 362.01 337.79 425.13 391.3278006 26 THYROID IMAGING W/UPTAKE 38.07 36.8278007 THYROID IMAGE, MULT UPTAKES 330.70 309.9278007 TC THYROID IMAGE, MULT UPTAKES 292.13 272.61 425.13 391.3278007 26 THYROID IMAGE, MULT UPTAKES 38.58 37.3278102 BONE MARROW IMAGING, LTD 280.83 263.5378102 TC BONE MARROW IMAGING, LTD 239.14 223.18 497.82 458.2278102 26 BONE MARROW IMAGING, LTD 41.69 40.3478103 BONE MARROW IMAGING, MULT 370.12 347.3378103 TC BONE MARROW IMAGING, MULT 313.68 292.71 497.82 458.2278103 26 BONE MARROW IMAGING, MULT 56.45 54.6378215 LIVER & SPLEEN IMAGING 325.54 305.0878215 TC LIVER & SPLEEN IMAGING 287.47 268.26 513.54 472.6878215 26 LIVER & SPLEEN IMAGING 38.07 36.8278220 LIVER FUNCTION STUDY 230.17 216.0578220 TC LIVER FUNCTION STUDY 193.72 180.82 513.54 472.6878220 26 LIVER FUNCTION STUDY 36.45 35.2378223 HEPATOBILIARY IMAGING 560.43 525.0978223 TC HEPATOBILIARY IMAGING 495.93 462.72 513.54 472.6878223 26 HEPATOBILIARY IMAGING 64.50 62.3678232 SALIVARY GLAND FUNCTION EXAM197.59 185.6678232 TC SALIVARY GLAND FUNCTION EXAM163.44 152.57 463.50 426.6378232 26 SALIVARY GLAND FUNCTION EXAM 34.15 33.1178300 BONE IMAGING, LIMITED AREA 297.19 278.9678300 TC BONE IMAGING, LIMITED AREA 249.03 232.42 473.94 436.2378300 26 BONE IMAGING, LIMITED AREA 48.16 46.5478305 BONE IMAGING, MULTIPLE AREAS 392.22 368.1678305 TC BONE IMAGING, MULTIPLE AREAS 328.81 306.83 473.94 436.2378305 26 BONE IMAGING, MULTIPLE AREAS 63.41 61.3278306 BONE IMAGING, WHOLE BODY 427.52 401.1678306 TC BONE IMAGING, WHOLE BODY 361.42 337.25 473.94 436.2378306 26 BONE IMAGING, WHOLE BODY 66.11 63.9178315 BONE IMAGING, 3 PHASE 583.48 547.0678315 26 BONE IMAGING, 3 PHASE 78.23 75.6478320 BONE IMAGING (3D) 410.39 385.64

11:3-29.6 APPENDIX B - REGULATIONS78320 TC BONE IMAGING (3D) 331.14 309.00 473.94 436.2378320 26 BONE IMAGING (3D) 79.25 76.6478445 VASCULAR FLOW IMAGING 289.56 271.4678445 TC VASCULAR FLOW IMAGING 253.11 236.21 388.05 357.1878445 26 VASCULAR FLOW IMAGING 36.45 35.2378451 HEART MUSCLE IMAGE SPECT, SING 573.80 538.9278451 TC HEART MUSCLE IMAGE SPECT, SING 471.47 439.91 1,471.83 1,354.7478451 26 HEART MUSCLE IMAGE SPECT, SING 102.33 98.9978452 HEART MUSCLE IMAGE SPECT, MULT806.02 756.1678452 TC HEART MUSCLE IMAGE SPECT, MULT685.12 639.23 1,471.83 1,354.7478452 26 HEART MUSCLE IMAGE SPECT, MULT120.91 116.9378469 HEART INFARCT IMAGE (3D) 434.71 407.9678469 TC HEART INFARCT IMAGE (3D) 360.26 336.16 564.39 519.4878469 26 HEART INFARCT IMAGE (3D) 74.45 71.8178472 GATED HEART, PLANAR, SING 424.29 398.4378472 TC GATED HEART, PLANAR, SING 347.44 324.22 564.39 519.4878472 26 GATED HEART, PLANAR, SING 76.85 74.2278481 HEART FIRST PASS, SING 352.85 331.6978481 TC HEART FIRST PASS, SING 273.62 255.27 564.39 519.4878481 26 HEART FIRST PASS, SING 79.24 76.4178494 HEART IMAGE, SPECT 450.67 423.5578494 TC HEART IMAGE, SPECT 356.18 332.36 564.39 519.4878494 26 HEART IMAGE, SPECT 94.49 91.1978580 LUNG PERFUSION IMAGING 358.61 336.5478580 TC LUNG PERFUSION IMAGING 302.02 281.84 381.24 350.9178580 26 LUNG PERFUSION IMAGING 56.59 54.7078584 LUNG V/Q IMAGE SINGLE BREATH 254.13 239.7578584 TC LUNG V/Q IMAGE SINGLE BREATH 177.41 165.60 619.65 570.3678584 26 LUNG V/Q IMAGE SINGLE BREATH 76.71 74.1578585 LUNG V/Q IMAGING 596.93 559.7878585 TC LUNG V/Q IMAGING 513.39 479.02 619.65 570.3678585 26 LUNG V/Q IMAGING 83.53 80.7678588 PERFUSION LUNG IMAGE 578.30 542.4078588 TC PERFUSION LUNG IMAGE 494.76 461.64 619.65 570.3678588 26 PERFUSION LUNG IMAGE 83.53 80.7678594 VENT IMAGE, MULT PROD, GAS 367.16 344.0278594 TC VENT IMAGE, MULT PROJ, GAS 327.06 305.21 381.24 350.9178594 26 VENT IMAGE, MULT PROJ, GAS 40.10 38.8178596 LUNG DIFFERENTIAL FUNCTION 628.84 589.9578596 TC LUNG DIFFERENTIAL FUNCTION 534.36 498.57 619.65 570.3678596 26 LUNG DIFFERENTIAL FUNCTION 94.47 91.3878607 BRAIN IMAGING (3D) 612.19 574.3678607 TC BRAIN IMAGING (3D) 519.80 485.00 1,154.88 1,062.9978607 26 BRAIN IMAGING (3D) 92.38 89.3678707 KID FLOW/FUNCT IMAGE W/O DRUG 399.99 375.7178707 TC KID FLOW/FUNCT IMAGE W/O DRUG 327.06 305.21 622.62 573.0978707 26 KID FLOW/FUNCT IMAGE W/O DRUG 72.93 70.5178708 KID FLOW/FUNCT IMAGE W/DRUG 300.23 283.2978315 TC BONE IMAGING, 3 PHASE 505.25 471.42 473.94 436.2378708 TC KID FLOW/FUNCT IMAGE W/DRUG 207.69 193.85 622.62 573.0978708 26 KID FLOW/FUNCT IMAGE W/DRUG 92.54 89.4678709 KIDNEY IMG MORPHOLOGY

VASCULAR FLOW MULTIPLE 617.12 579.4678709 TC KIDNEY IMG MORPHOLOGY

VASCULAR FLOW MULTIPLE 509.32 475.22 622.62 573.0978709 26 KIDNEY IMG MORPHOLOGY

VASCULAR FLOW MULTIPLE 107.80 104.2578802 TUMOR IMAGING, WHOLE BODY 553.30 518.4878802 TC TUMOR IMAGING, WHOLE BODY 487.77 455.12 919.98 846.7878802 26 TUMOR IMAGING, WHOLE BODY 65.53 63.3778803 TUMOR IMAGING (3D) 593.44 556.5278803 TC TUMOR IMAGING (3D) 511.06 476.84 919.98 846.7878803 26 TUMOR IMAGING (3D) 82.37 79.6878805 ABSCESS IMAGING, LID AREA 310.29 291.4878805 TC ABSCESS IMAGING, LTD AREA 254.27 237.31 919.98 846.7878805 26 ABSCESS IMAGING, LTD AREA 56.00 54.1778806 ABSCESS IMAGING, WHOLE BODY 573.09 536.9478806 TC ABSCESS IMAGING, WHOLE BODY 507.58 473.59 919.98 846.7878806 26 ABSCESS IMAGING, WHOLE BODY 65.53 63.3778815 PET IMAGE W/CT, SKULL-THIGH 1,978.16 1,852.0778815 TC PET IMAGE W/CT, SKULL-THIGH 1,785.85 1,665.93 2,018.19 1,857.6678815 26 PET IMAGE W/CT, SKULL-THIGH 192.33 186.13

UCJF 11:3-29.679101 NUCLEAR RX, IV ADMIN 261.42 248.9379101 TC NUCLEAR RX, IV ADMIN 101.83 95.03 203.55 187.3879101 26 NUCLEAR RX, IV ADMIN 159.59 153.9080500 LAB PATHOLOGY CONSULTATION 32.57 31.3983020 26 ASSAY HEMOGLOBIN

ELECTROPHORESIS 30.24 29.2283912 26 ASSAY GENETIC EXAM 28.49 27.5884165 26 ASSAY PROTEIN E-PHORESIS, SERUM 29.66 28.6684166 26 ASSAY PROTEIN

E-PHORESIS/URINE/CSF 29.66 28.6684182 26 ASSAY PROTEIN, WESTERN BLOT

TEST 29.66 28.6685060 BLOOD SMEAR INTERPRETATION 36.04 34.8385097 BONE MARROW INTERPRETATION 139.39 132.5085576 26 BLOOD PLATELET AGGREGATION 30.24 29.2286255 26 FLUORESCENT ANTIBODY, SCREEN 30.24 29.2286256 26 FLUORESCENT ANTIBODY, TITER 29.19 28.1786334 26 IMMUNOFLX E-PHORESIS, SERUM 30.24 29.2286335 26 IMMUNOFIX E-PHORESIS/URINE/CSF 29.66 28.6686510 HISTOPLASMOSIS SKIN TEST 11.00 10.3086580 TB INTRADERMAL TEST 12.75 11.9288104 CYTOPATH FL NONGYN, SMEARS 107.49 101.7188104 TC CYTOPATH FL NONGYN, SMEARS 64.57 60.2788104 26 CYTOPATH FL NONGYN, SMEARS 42.92 41.4488106 CYTOPATH FL NONGYN, FILTER 132.53 125.0688106 TC CYTOPATH FL NONGYN, FILTER 90.20 84.1788106 26 CYTOPATH FL NONGYN, FILTER 42.33 40.8888108 CYTOPATH, CONCENTRATE TECH 124.96 117.9988108 TC CYTOPATH, CONCENTRATE TECH 82.62 77.1188108 26 CYTOPATH, CONCENTRATE TECH 42.33 40.8888112 CYTOPATH, CELL ENHANCE TECH 166.71 158.5688112 TC CYTOPATH, CELL ENHANCE TECH 79.13 73.8588112 26 CYTOPATH, CELL ENHANCE TECH 87.58 84.7288120 CYTOPATH, URINE 3-5 PROBES EA

SPEC 772.67 723.9188120 TC CYTOPATH, URINE 3-5 PROBES EA

SPEC 692.17 645.7888120 26 CYTOPATH, URINE 3-5 PROBES EA

SPEC 80.50 78.1388121 CYTOPATH, URINE 3-5 PROBES

COMPUTER 652.59 611.3488121 TC CYTOPATH, URINE 3-5 PROBES

COMPUTER 580.48 541.5388121 26 CYTOPATH, URINE 3-5 PROBES

COMPUTER 72.11 69.8088141 CYTOPATH, C/V, INTERPRET 46.17 44.2088172 CYTOPATH FNA; 1ST EVAL, EACH

SITE 82.15 78.1688172 TC CYTOPATH FNA; 1ST EVAL, EACH

SITE 35.46 33.1188172 26 CYTOPATH FNA; 1 ST EVAL, EACH

SITE 46.68 45.0588173 CYTOPATH FNA; INTERPRET &

REPORT 225.11 213.5688173 TC CYTOPATH FNA; INTERPRET &

REPORT 118.73 110.7988173 26 CYTOPATH FNA; INTERPRET &

REPORT 106.40 102.7788177 CYTOPATH FNA; ADDED EVAL, SAME

SITE 44.48 42.5988177 TC CYTOPATH FNA; ADDED EVAL, SAME

SITE 11.00 10.3088177 26 CYTOPATH FNA; ADDED EVAL, SAME

SITE 33.48 32.2988184 FLOW CYTOMETRY/ TC, 1 MARKER 143.77 134.1588185 FLOW CYTOMETRY/TC, ADDED 86.12 80.3688187 FLOW CYTOMETRY/READ, 2-8 105.20 101.7488300 SURGICAL PATH, GROSS 45.28 42.5088300 TC SURGICAL PATH, GROSS 38.37 35.8388300 26 SURGICAL PATH, GROSS 6.91 6.6888302 TISSUE EXAM BY PATHOLOGIST 90.32 84.6488302 TC TISSUE EXAM BY PATHOLOGIST 80.29 74.93

11:3-29.6 APPENDIX B - REGULATIONS88302 26 TISSUE EXAM BY PATHOLOGIST 10.03 9.7188304 TISSUE EXAM BY PATHOLOGIST 105.37 98.9188304 TC TISSUE EXAM BY PATHOLOGIST 88.45 82.5488304 26 TISSUE EXAM BY PATHOLOGIST 16.93 16.3688305 TISSUE EXAM BY PATHOLOGIST 175.94 166.0388305 TC TISSUE EXAM BY PATHOLOGIST 119.31 111.3388305 26 TISSUE EXAM BY PATHOLOGIST 56.63 54.7088307 TISSUE EXAM BY PATHOLOGIST 375.59 354.4388307 TC TISSUE EXAM BY PATHOLOGIST 251.49 234.6388307 26 TISSUE EXAM BY PATHOLOGIST 124.10 119.8088309 TISSUE EXAM BY PATHOLOGIST 565.90 535.1188309 TC TISSUE EXAM BY PATHOLOGIST 349.19 325.8488309 26 TISSUE EXAM BY PATHOLOGIST 216.70 209.2788311 DECALCIFY TISSUE 30.10 28.7388311 TC DECALCIFY TISSUE 11.58 10.8488311 26 DECALCIFY TISSUE 18.52 17.9188312 SPECIAL STAINS GROUP 1 178.67 168.0688312 TC SPECIAL STAINS GROUP 1 137.94 128.7188312 26 SPECIAL STAINS GROUP 1 40.73 39.3588313 SPECIAL STAINS GROUP 2 131.42 123.2588313 TC SPECIAL STAINS GROUP 2 113.49 105.9088313 26 SPECIAL STAINS GROUP 2 17.93 17.3588331 PATH CONSULT INTRAOP, 1 BLOC 147.61 140.6788331 TC PATH CONSULT INTRAOP, 1 BLOC 54.67 51.0388331 26 PATH CONSULT INTRAOP, 1 BLOC 92.94 89.6388332 PATH CONSULT INTRAOP, ADDED 64.76 61.9288332 TC PATH CONSULT INTRAOP, ADDED 19.16 17.9188332 26 PATH CONSULT INTRAOP, ADDED 45.60 44.0188334 INTRAOP CYTO PATH CONSULT, 2 95.03 90.5788334 TC INTRAOP CYTO PATH CONSULT, 2 37.79 35.2988334 26 INTRAOP CYTO PATH CONSULT, 2 57.24 55.2888342 OHISTOCHEMISTRY 171.57 162.2688342 TC OHISTOCHEMISTRY 107.66 100.4788342 26 IMMUNOHISTOCHEMISTRY 63.91 61.8088346 IMMUNOFLUORESCENT STUDY 168.13 159.0088346 TC IMMUNOFLUORESCENT STUDY 104.17 97.2088346 26 IMMUNOFLUORESCENT STUDY 63.96 61.8088360 TUMOR OHISTOCHEM/MANUAL 202.89 192.0988360 TC TUMOR

IMMUNOHISTOCHEM/MANUAL 121.64 113.5088360 26 TUMOR

IMMUNOHISTOCHEM/MANUAL 81.26 78.5988363 EXAM ARCHIVAL TISSUE MOLECULAR

ANAL 62.26 59.0988367 INSITU HYBRIDIZATION, AUTO 428.95 403.5388367 TC INSITU HYBRIDIZATION, AUTO 334.76 312.3188367 26 INSITU HYBRIDIZATION, AUTO 94.19 91.2288368 INSITU HYBRIDIZATION, MANUAL 365.96 344.9788368 TC INSITU HYBRIDIZATION, MANUAL 270.12 252.0188368 26 INSITU HYBRIDIZATION, MANUAL 95.84 92.9588372 26 PROTEIN ANALYSIS W/PROBE 30.24 29.2290461 IMM ADMIN 0-18 ANY ROUTE, EA

ADDED 18.62 17.7690471 IMMUNIZATION ADMIN 38.26 36.1490472 IMMUNIZATION ADMIN, EACH ADDED18.62 17.7690801 PSYCH DIAG INTERVIEW 242.14 233.1090802 INTERACT PSYCH DIAG INTERVIEW 263.21 253.3190804 PSYCH, OFF, 20-30 MIN 103.95 100.2390805 PSYCH, OFF, 20-30 MINIMUM W/E &

M 118.52 114.2790806 PSYCH, OFF, 45-50 MIN 137.79 133.5590807 PSYCH, OFF, 45-50 MINIMUM W/E &

M 163.35 157.8790808 PSYCH, OFF, 75-80 MIN 202.42 196.3590809 PSYCH, OFF, 75-80, W/E & M 228.55 221.2190810 INTERACT PSYCH, OFF, 20-30 MIN 106.69 103.0990811 INTERACT PSYCH, 20-30, W/E & M 134.04 129.0990812 INTERACT PSYCH, OFF, 45-50 MIN 151.59 146.7390813 INTERACT PSYCH, 45-50 MINIMUM

W/E & M 177.78 171.6090814 INTERACT PSYCH, OFF, 75-80 MIN 218.01 211.2090816 PSYCH, HOSP, 20-30 MTN 84.68 82.35

UCJF 11:3-29.690817 PSYCH, HOSP, 20-30 MINIMUM W/E &

M 102.93 99.8090818 PSYCH, HOSP, 45-50 MIN 125.31 122.0090819 PSYCH, HOSP, 45-50 MINIMUM W/E &

M 147.22 142.8990826 INTERACT PSYCH, HOSP, 45-50 MIN 134.16 130.5790846 FAMILY PSYCH W/O PATIENT 130.28 126.2590847 FAMILY PSYCH W/PATIENT 162.90 157.6390853 GROUP PSYCHOTHERAPY 77.13 74.3390857 INTERACT GROUP PSYCH 57.98 55.7390862 MEDICATION MANAGEMENT 105.73 101.4790880 HYPNOTHERAPY 155.47 150.6690901 BIOFEEDBACK TRAIN, ANY METHOD114.92 109.2090911 BIOFEEDBACK PERI/URO/RECTAL 142.55 135.4090935 HEMODIALYSIS, ONE EVAL 116.53 112.5990945 DIALYSIS, ONE EVAL 166.37 160.7290961 ESRD SERVICE, 2-3 VISITS P MO, 20+ 129.32 124.7390962 ESRD SERVICE, 1 VISIT P MO, 20+ 275.65 265.5391010 ESOPHAGUS MOTILITY STUDY 311.34 293.8491010 TC ESOPHAGUS MOTILITY STUDY 203.16 189.5491010 26 ESOPHAGUS MOTILITY STUDY 108.19 104.2991013 ESOPH MOTILITY STUDY

W/STIM/PERFUS 38.13 36.0791013 TC ESOPH MOTILITY STUDY

W/STIM/PERFUS 22.65 21.1691013 26 ESOPH MOTILITY STUDY

W/STIM/PERFUS 15.48 14.9192002 EYE EXAM, NEW PATIENT 122.24 116.4392004 EYE EXAM, NEW PATIENT 225.54 215.2592012 EYE EXAM ESTABLISHED PAT 129.52 123.3192014 EYE EXAM & TREAT 187.31 178.5492020 SPECIAL EYE EVAL 41.88 40.0792025 CORNEAL TOPOGRAPHY 57.23 54.3192025 TC CORNEAL TOPOGRAPHY 27.30 25.5192025 26 CORNEAL TOPOGRAPHY 29.93 28.8192060 SPECIAL EYE EVAL 98.24 93.4692060 TC SPECIAL EYE EVAL 39.53 36.9292060 26 SPECIAL EYE EVAL 58.70 56.5492065 ORTHOPTIC/PLEOPTIC TRAINING 123.66 116.8692065 TC ORTHOPTIC/PLEOPTIC TRAINING 81.42 76.0292065 26 ORTHOPTIC/PLEOPTIC TRAINING 42.22 40.8492070 FIT CONTACT LENS 109.22 103.7492081 VISUAL FIELD EXAM(S) LIMITED 80.77 76.2392081 TC VISUAL FIELD EXAM(S) LIMITED 54.67 51.0392081 26 VISUAL FIELD EXAM(S) LIMITED 26.11 25.1892082 VISUAL FIELD EXAM(S)

INTERMEDIATE 112.58 106.1792082 TC VISUAL FIELD EXAM(S)

INTERMEDIATE 77.96 72.7692082 26 VISUAL FIELD EXAM(S)

INTERMEDIATE 34.60 33.4092083 VISUAL FIELD EXAM(S) EXTENDED 140.42 132.3592083 TC VISUAL FIELD EXAM(S) EXTENDED 97.19 90.6992083 26 VISUAL FIELD EXAM(S) EXTENDED 43.24 41.6792132 SCAN COMP OPTH DX IMAGING, ANT

SEG 59.44 56.4592132 TC SCAN COMP OPTH DX IMAGING, ANT

SEG 26.15 24.4192132 26 SCAN COMP OPTH DX IMAGING, ANT

SEG 33.30 32.0292133 SCAN COMP OPTH DX IMAGING, POST

SEG 72.29 68.7992133 TC SCAN COMP OPTH DX IMAGING, POST

SEG 26.15 24.4192133 26 SCAN COMP OPTH DX IMAGING, POST

SEG 46.14 44.3892134 SCAN COMP OPTH DX IMAGING,

RETINA 72.29 68.7992134 TC SCAN COMP OPTH DX IMAGING,

RETINA 26.15 24.4192134 26 SCAN COMP OPTH DX IMAGING,

RETINA 46.14 44.38

11:3-29.6 APPENDIX B - REGULATIONS92136 OPHTHALMIC BIOMETRY 137.92 130.0492136 TC OPHTHALMIC BIOMETRY 91.36 85.2592136 26 OPHTHALMIC BIOMETRY 46.55 44.7892225 SPECIAL EYE EXAM, INITIAL 40.64 38.9592226 SPECIAL EYE EXAM, SUBSEQUENT 36.48 34.8792227 REMOTE IMAGING RETINAL DISEASE 19.74 18.4592228 REMOTE IMAGING MONITOR RETINAL

DIS 48.87 46.4092228 TC REMOTE IMAGING MONITOR RETINAL

DIS 21.49 20.0892228 26 REMOTE IMAGING MONITOR RETINAL

DIS 27.38 26.3292230 26 FLUORESCEIN ANGIOSCOPY 93.66 88.9992235 FLUORESCEIN ANGIOGRAPHY 217.30 204.8292235 TC FLUORESCEIN ANGIOGRAPHY 146.09 136.3192235 26 FLUORESCEIN ANGIOGRAPHY 71.20 68.5092250 EYE EXAM W/PHOTOS 122.36 115.2892250 TC EYE EXAM W/PHOTOS 86.12 80.3692250 26 EYE EXAM W/PHOTOS 36.24 34.9292275 ELECTRORETINOGRAPHY 234.95 221.8092275 TC ELECTRORETINOGRAPHY 147.25 137.4092275 26 ELECTRORETINOGRAPHY 87.69 84.4192285 EYE PHOTOGRAPHY 47.25 44.2792285 TC EYE PHOTOGRAPHY 40.70 38.0092285 26 EYE PHOTOGRAPHY 6.55 6.2792286 INTERNAL EYE PHOTOGRAPHY 198.16 186.5392286 TC INTERNAL EYE PHOTOGRAPHY 143.19 133.6092286 26 INTERNAL EYE PHOTOGRAPHY 54.98 52.9492311 CONTACT LENS FITTING APHAKIA

ONE EYE 156.21 148.6392326 REPLACE CONTACT LENS 61.08 57.0192371 EXT PAT/AUTO ECG TO 30 DAYS,

DOWNLOAD 359.22 335.1292504 EAR MICROSCOPY EXAM 154.22 147.7992506 SPEECH/HEARING EVAL 50.42 47.5192507 SPEECH/HEARING THERAPY 279.74 263.2392508 SPEECH/HEARING THERAPY 130.75 125.3892511 NASOPHARYNGOSCOPY 43.47 41.4092526 ORAL FUNCTION THERAPY 267.73 251.9392540 BASIC VESTIBULAR EVALUATION 155.00 148.4392540 TC BASIC VESTIBULAR EVALUATION 31.96 29.8692540 26 BASIC VESTIBULAR EVALUATION 123.04 118.5892541 SPONTANEOUS NYSTAGMUS TEST 74.91 70.9392541 TC SPONTANEOUS NYSTAGMUS TEST 43.03 40.1792541 26 SPONTANEOUS NYSTAGMUS TEST 31.87 30.7592542 POSITIONAL NYSTAGMUS TEST 74.85 70.7092542 TC POSITIONAL NYSTAGMUS TEST 48.27 45.0692542 26 POSITIONAL NYSTAGMUS TEST 26.59 25.6492543 CALORIC VESTIBULAR TEST 37.56 35.3692543 TC CALORIC VESTIBULAR TEST 29.05 27.1492543 26 CALORIC VESTIBULAR TEST 8.51 8.2192544 OPTOKINETIC NYSTAGMUS TEST 61.40 57.9892544 TC OPTOKINETIC NYSTAGMUS TEST 40.70 38.0092544 26 OPTOKINETIC NYSTAGMUS TEST 20.71 19.9892545 OSCILLATING TRACKING TEST 57.55 54.3192545 TC OSCILLATING TRACKING TEST 38.95 36.3792545 26 OSCILLATING TRACKING TEST 18.60 17.9592546 SINUSOIDAL ROTATIONAL TEST 159.00 149.1092546 TC SINUSOIDAL ROTATIONAL TEST 136.20 127.0992546 26 SINUSOIDAL ROTATIONAL TEST 22.81 22.0192547 SUPPLEMENTAL ELECTRICAL TEST 8.67 8.1392548 POSTUROGRAPHY 171.41 161.1892548 TC POSTUROGRAPHY 131.54 122.7492548 26 POSTUROGRAPHY 39.86 38.4492550 TYMPANOMETRY & REFLEX THRESH 32.84 31.5292552 PURE TONE AUDIOMETRY, AIR 43.61 40.7192553 AUDIOMETRY, AIR & BONE 55.25 51.5992556 SPEECH AUDIOMETRY, COMPLETE 49.44 46.1492557 COMPREHENSIVE HEARING TEST 64.62 61.8592563 TONE DECAY HEARING TEST 42.45 39.6392564 SISI HEARING TEST 38.37 35.8392565 STENGER TEST, PURE TONE 22.07 20.62

UCJF 11:3-29.692567 TYMPANOMETRY 24.64 23.5292568 ACOUSTIC REFLEX THRESHOLD TEST26.30 25.2892570 ACOUSTIC IMMITTANCE TESTING 50.43 48.4992582 CONDITIONING PLAY AUDIOMETRY 87.87 82.0092584 ELECTROCOCHLEOGRAPHY 114.07 106.4492585 AUDITOR EVOKE POTENT, COMPRE 292.37 274.7192585 TC AUDITOR EVOKE POTENT, COMPRE 231.02 215.5792585 26 AUDITOR EVOKE POTENT, COMPRE 61.33 59.1492586 AUDITOR EVOKE POTENT, LIMIT 120.48 112.4292587 EVOKED AUDITORY TEST 62.37 58.5892587 TC EVOKED AUDITORY TEST 51.17 47.7892587 26 EVOKED AUDITORY TEST 11.20 10.8092588 EVOKED AUDITORY TEST 110.73 104.2492588 TC EVOKED AUDITORY TEST 81.46 76.0392588 26 EVOKED AUDITORY TEST 29.27 28.2292607 EXCISE FOR SPEECH DEVICE RX, 1HR287.74 273.2992611 MOTION FLUOROSCOPY/SWALLOW 183.96 175.1692612 ENDOSCOPY SWALLOW TEST (FEES) 275.96 260.7892613 ENDOSCOPY SWALLOW TEST (FEES) 60.24 58.0792620 AUDITORY FUNCTION, 60 MIN 129.83 125.0392621 AUDITORY FUNCTION, + 15 MIN 29.93 28.8192625 TINNITUS ASSESS 99.39 95.7092626 EVAL AUDITORY REHAB STATUS 132.91 127.6692950 HEART/LUNG RESUSCITATION CPR 451.32 431.3192960 CARDIOVERSION ELECTRIC, EXT 395.13 374.5892971 CARDIOASSIST, EXTERNAL 156.11 150.3292975 DISSOLVE CLOT, HEART VESSEL 660.35 639.2092982 CORONARY ARTERY DILATION 1,011.84 978.9793000 ELECTROCARDIOGRAM, COMPLETE 37.35 35.4093005 ELECTROCARDIOGRAM, TRACING 28.57 26.7293010 ELECTROCARDIOGRAM REPORT 19.11 18.4693015 CARDIOVASCULAR STRESS TEST 152.58 144.2793016 CARDIOVASCULAR STRESS TEST 36.17 34.8793017 CARDIOVASCULAR STRESS TEST 92.53 86.3493018 CARDIOVASCULAR STRESS TEST 23.90 23.0693040 RHYTHM ECG W/R.EPORT 21.46 20.4693042 RHYTHM ECG, REPORT 26.83 25.9493224 ECG MONITOR/REPORT, 24 HRS 161.88 152.3893225 ECG MONITOR/RECORD, 24 HRS 48.27 45.0693226 ECG MONITOR/REPORT, 24 HRS 70.98 66.2593227 ECG MONITOR/REVIEW, 24 HRS 42.63 41.0793228 REMOTE 30 DAY ECG REV/REPORT 40.17 38.8593229 REMOTE 30 DAY ECG TECH SUPP 1,167.45 1,089.0693268 EXT PAT/AUTO ECG TO 30 DAYS,

COMPLETE 425.66 398.4493270 EXT PAT/AUTO ECG TO 30 DAYS,

RECORDING 26.15 24.4193272 EXT PAT/AUTO ECG TO 30 DAYS,

REPORT 40.30 38.9093280 PM DEVICE PROGRAM EVAL, DUAL 100.54 95.8193280 TC PM DEVICE PROGRAM EVAL, DUAL 36.62 34.1993280 26 PM DEVICE PROGRAM EVAL, DUAL 63.92 61.6293281 PM DEVICE PROGRAM EVAL, MULTI 117.04 111.5393281 TC PM DEVICE PROGRAM EVAL, MULTI 42.45 39.6393281 26 PM DEVICE PROGRAM EVAL, MULTI 74.59 71.8993282 ICD DEVICE PROGRAM EVAL, 1

SINGLE 107.52 102.5293282 TC ICD DEVICE PROGRAM EVAL, 1

SINGLE 37.79 35.2993282 26 ICD DEVICE PROGRAM EVAL, 1

SINGLE 69.73 67.2393283 ICD DEVICE PROGRAM EVAL, DUAL 137.23 131.0193283 TC ICD DEVICE PROGRAM EVAL, DUAL 43.61 40.7193283 26 ICD DEVICE PROGRAM EVAL, DUAL 93.64 90.3093284 ICD DEVICE PROGRAM EVAL, MULT 152.79 145.7693284 TC ICD DEVICE PROGRAM EVAL, MULT 49.44 46.1493284 26 ICD DEVICE PROGRAM EVAL, MULT 103.36 99.6293285 ILR DEVICE EVAL PROGRAM 71.68 68.2193285 TC ILR DEVICE EVAL PROGRAM 29.05 27.1493285 26 ILR DEVICE EVAL PROGRAM 42.63 41.0793288 PM DEVICE EVAL IN PERSON 64.79 61.5693288 TC PM DEVICE EVAL IN PERSON 29.63 27.68

11:3-29.6 APPENDIX B - REGULATIONS93288 26 PM DEVICE EVAL IN PERSON 35.16 33.8893289 ICD DEVICE INTERROGATE 109.91 104.9293289 TC ICD DEVICE INTERROGATE 36.62 34.1993289 26 ICD DEVICE INTERROGATE 73.29 70.7193290 ICM DEVICE EVAL 49.07 46.9093290 TC ICM DEVICE EVAL 16.83 15.7393290 26 ICM DEVICE EVAL 32.24 31.1693293 PM PHONE R-STRIP DEVICE EVAL 93.56 88.1293293 TC PM PHONE R-STRIP DEVICE EVAL 68.65 64.0893293 26 PM PHONE R-STRIP DEVICE EVAL 24.91 24.0693294 PM DEVICE INTERROGATE REMOTE 54.29 52.3793295 ICD DEVICE INTERROGATE REMOTE 106.89 103.1493296 PM/ICD REMOTE TECH SERV 55.83 52.1393297 ICM DEVICE INTERROGATE REMOTE 40.17 38.8593299 ICM/ILR REMOTE TECH SERV 73.04 68.8593303 ECHO TRANSTHORACIC 350.40 330.2293303 TC ECHO TRANSTHORACIC 246.83 230.2993303 26 ECHO TRANSTHORACIC 103.57 99.9393306 TTE W/DOPPLER, COMPLETE 388.84 366.0793306 TC TTE W/DOPPLER, COMPLETE 282.94 263.9793306 26 TTE W/DOPPLER, COMPLETE 105.90 102.1093307 TTE W/O DOPPLER, COMPLETE 246.74 232.5693307 TC TTE W/O DOPPLER, COMPLETE 172.29 160.7793307 26 TTE W/O DOPPLER, COMPLETE 74.45 71.8193308 TTE, F-UP OR LIMITED 176.43 165.9493308 TC TTE, F-UP OR LIMITED 133.87 124.9193308 26 TTE, F-UP OR LIMITED 42.56 41.0393312 ECHO TRANSESOPHAGEAL 537.84 507.4493312 TC ECHO TRANSESOPHAGEAL 366.07 341.6093312 26 ECHO TRANSESOPHAGEAL 171.77 165.8493313 ECHO TRANSESOPHAGEAL 63.49 61.7993314 ECHO TRANSESOPHAGEAL 479.33 450.4493314 TC ECHO TRANSESOPHAGEAL 381.22 355.7193314 26 ECHO TRANSESOPHAGEAL 98.13 94.7393320 DOPPLER ECHO EXAM, HEART 104.18 98.1793320 TC DOPPLER ECHO EXAM, HEART 73.90 68.9793320 26 DOPPLER ECHO EXAM,. HEART 30.28 29.2293321 DOPPLER ECHO EXAM, HEART 48.83 45.9993321 TC DOPPLER ECHO EXAM, HEART 36.62 34.1993321 26 DOPPLER ECHO EXAM, HEART 12.21 11.7993325 DOPPLER COLOR FLOW, ADDED 60.50 56.6793325 TC DOPPLER COLOR FLOW, ADDED 54.67 51.0393325 26 DOPPLER COLOR FLOW, ADDED 5.81 5.6393350 STRESS TTE ONLY 349.1.5 329.4693350 TC STRESS TTE ONLY 229.95 214.5493350 26 STRESS TTE ONLY 119.20 114.9493351 STRESS TTE COMPLETE 410.89 387.8693351 TC STRESS TTE COMPLETE 267.09 249.2693351 26 STRESS TTE COMPLETE 143.81 138.6093451 RIGHT HEART CATH 1,284.20 1,206.7593451 TC RIGHT HEART CATH 1,053.77 983.1093451 26 RIGHT HEART CATH 230.43 223.6693452 LEFT HEART CATH

W/VENTRCLGRPHY 1,410.49 1,331.1793452 TC LEFT HEART CATH

W/VENTRCLGRPHY 1,006.61 939.0993452 26 LEFT HEART CATH

W/VENTRCLGRPHY403.89 392.0693453 R&L HEART CATH

W/VENTRICLGRPHY 1,845.72 1,741.9293453 TC R&L HEART CATH

W/VENTRICLGRPHY 1,316.32 1,228.0693453 26 R&L HEART CATH

W/VENTRICLGRPHY 529.40 513.8693454 CATH PLACE CORONARY ANGIO 1,455.61 1,373.3593454 TC CATH PLACE CORONARY ANGIO 1,048.53 978.2293454 26 CATH PLACE CORONARY ANGIO 407.08 395.1593455 CATH PLACE BYPASS GRAFTS 1,698.80 1,602.6193455 TC CATH PLACE BYPASS GRAFTS 1,228.98 1,146.5793455 26 CATH PLACE BYPASS GRAFTS 469.82 456.0393456 CATH PLACE WITH R HEART CATH 1,820.43 1,717.9793456 TC CATH PLACE WITH R HEART CATH 1,299.44 1,212.30

UCJF 11:3-29.693456 26 CATH PLACE WITH R HEART CATH 521.00 505.6893457 R HEART ART/GRAFT ANGIO 2,063.64 1,947.2593457 TC R HEART ART/GRAFT ANGIO 1,479.36 1,380.1493457 26 R HEART ART/GRAFT ANGIO 584.28 567.1093458 L HEART ARTERY/VENTRICLE

ANGIO 1,755.96 1,656.9793458 TC L HEART ARTERY/VENTRICLE

ANGIO 1,259.26 1,174.8293458 26 L HEART ARTERY/VENTRICLE

ANGIO 496.71 482.1493459 L HEART ART/GRAFT ANGIO 1,938.14 1,829.2393459 TC L HEART ART/GRAFT ANGIO 1,379.22 1,286.7293459 26 L HEART ART/GRAFT ANGIO 558.94 542.5193460 R & L HEART ART/VENTRICLE

ANGIO 2,071.87 1,956.3693460 TC R & L HEART ART/VENTRICLE

ANGIO 1,449.09 1,351.9093460 26 R & L HEART ART/VENTRICLE

ANGIO 622.77 604.4693461 R & L HEART ART/VENTRICLE

ANGIO 2,376.60 2,243.1293461 TC R & L HEART ART/VENTRICLE

ANGIO 1,689.51 1,576.2193461 26 R & L HEART ART/VENTRICLE

ANGIO 687.09 666.9193462 L HEART CATH TRANSPLANT

PUNCTURE 316.47 307.1293463 DRUG ADMIN & HEMODYNMIC

MEAS 167.77 162.7693464 EXERCISE W/HEMODYNAMIC MEAS 416.35 394.0493464 TC EXERCISE W/HEMODYNAMIC MEAS 268.95 250.9393464 26 EXERCISE W/HEMODYNAMIC MEAS 147.39 143.1293503 INSERT/PLACE HEART CATHETER 206.54 200.7393563 INJECT CONGENITAL CARD CATH 87.15 84.3693564 INJECT HEART CONGNTL ART/GRAFT 88.69 85.8893565 INJECT L VENTR/ATRIAL ANGIO 67.02 64.9093566 INJECT R VENTR/ATRIAL ANGIO 283.05 266.4293567 INJECT SUPRVLV AORTOGRAPHY 231.57 218.6693568 INJECT PULM ART HEART CATH 254.94 240.2593609 26 MAP TACHYCARDIA, ADDED 453.72 439.2693610 26 INTRA-ATRIAL PACING 271.48 262.9093612 26 INTRAVENTRICULAR PACING 270.32 261.8193620 ELECTROPHYSIOLOGY EVAL 1,831.99 1,764.3693620 TC ELECTROPHYSIOLOGY EVAL 809.16 780.9093620 26 ELECTROPHYSIOLOGY EVAL 1,055.32 1,021.5093623 26 STIMULATION, PACING HEART 259.49 251.2293641 ELECTROPHYSIOLOGY EVAL 800.92 770.3193641 TC ELECTROPHYSIOLOGY EVAL 260.71 250.4193641 26 ELECTROPHYSIOLOGY EVAL 538.69 521.4893642 ELECTROPHYSIOLOGY EVAL 695.28 661.2493642 TC ELECTROPHYSIOLOGY EVAL 293.87 274.2493642 26 ELECTROPHYSIOLOGY EVAL 401.41 387.0093660 TILT TABLE EVAL 267.19 254.1393660 TC TILT TABLE EVAL 112.90 105.3693660 26 TILT TABLE EVAL 154.29 148.7993701 BIOIMPD TIIRC ELEC 45.94 42.8993720 BIOIMPEDANCE, CV ANALYSIS 82.45 77.4193722 TOTAL BODY PLETHYSMOGRAPHY 12.65 12.2493784 AMBULATORY BP MONITORING 103.53 97.6193798 CARDIAC REHAB/MONITOR 41.51 39.4593875 EXTRACRANIAL STUDY 179.33 167.8993875 TC EXTRACRANIAL STUDY 162.40 151.5393875 26 EXTRACRANIAL STUDY 16.93 16.3693880 EXTRACRANIAL STUDY 424.35 397.4993880 TC EXTRACRANIAL STUDY 377.27 351.9693880 26 EXTRACRANIAL STUDY 47.08 45.5393882 EXTRACRANIAL STUDY 294.19 275.6293882 TC EXTRACRANIAL STUDY 262.56 244.9593882 26 EXTRACRANIAL STUDY 31.63 30.6793886 INTRACRANIAL STUDY 560.39 525.2293886 TC INTRACRANIAL STUDY 487.32 454.6293886 26 INTRACRANIAL STUDY 73.07 70.60

11:3-29.6 APPENDIX B - REGULATIONS93922 EXTREMITY STUDY 187.26 175.3693922 TC EXTREMITY STUDY 168.23 156.9693922 26 EXTREMITY STUDY 19.03 18.4093923 EXTREMITY STUDY 289.22 271.0793923 TC EXTREMITY STUDY 253.82 236.8193923 26 EXTREMITY STUDY 35.40 34.2693924 EXTREMITY STUDY 361.62 338.7393924 TC EXTREMITY STUDY 322.53 300.9093924 26 EXTREMITY STUDY 39.09 37.8393925 LOWER EXTREMITY STUDY 537.92 503.4693925 TC LOWER EXTREMITY STUDY 493.02 460.0093925 26 LOWER EXTREMITY STUDY 44.91 43.4493926 LOWER EXTREMITY STUDY 349.57 327.2693926 TC LOWER EXTREMITY STUDY 318.45 297.1193926 26 LOWER EXTREMITY STUDY 31.12 30.1693930 UPPER EXTREMITY STUDY 423.65 396.5093930 TC UPPER EXTREMITY STUDY 387.74 361.7493930 26 UPPER EXTREMITY STUDY 35.91 34.7693931 UPPER EXTREMITY STUDY 283.34 265.2093931 TC UPPER EXTREMITY STUDY 259.06 241.7093931 26 UPPER EXTREMITY STUDY 24.27 23.5093965 EXTREMITY STUDY 214.33 200.9393965 TC EXTREMITY STUDY 186.86 174.3493965 26 EXTREMITY STUDY 27.47 26.5993970 EXTREMITY STUDY 436.95 409.5693970 TC EXTREMITY STUDY 383.10 357.3993970 26 EXTREMITY STUDY 53.87 52.1593971 EXTREMITY STUDY 286.89 268.9093971 TC EXTREMITY STUDY 251.49 234.6393971 26 EXTREMITY STUDY 35.40 34.2693975 VASCULAR STUDY 637.06 599.2693975 TC VASCULAR STUDY 495.93 462.7293975 26 VASCULAR STUDY 141.13 136.5493976 VASCULAR STUDY 363.64 342.4893976 TC VASCULAR STUDY 268.95 250.9393976 26 VASCULAR STUDY 94.67 91.5693978 VASCULAR STUDY 410.98 385.2493978 TC VASCULAR STUDY 359.22 335.1293978 26 VASCULAR STUDY 51.77 50.1293979 VASCULAR STUDY 284.63 266.7793979 TC VASCULAR STUDY 250.32 233.5493979 26 VASCULAR STUDY 34.30 33.2194002 VENT MGMT INPATIENT, INIT DAY 139.58 135.6394003 VENT MGMT INPATIENT, SUBCUT

DAY 100.93 97,8494010 BREATHING CAPACITY TEST 59.16 55.6894010 TC BREATHING CAPACITY TEST 45.94 42.8994010 26 BREATHING CAPACITY TEST 13.22 12.7994060 EVALUATE WHEEZING 101.79 95.7894060 TC EVALUATE WHEEZING 79.13 73.8594060 26 EVALUATE WHEEZING 22.65 21.9394070 EVALUATE WHEEZING 97.74 92.7894070 TC EVALUATE WHEEZING 53.50 49.9594070 26 EVALUATE WHEEZING 44.24 42.8394200 LUNG FUNCTION TEST (MBC/MVV) 40.40 38.0194200 TC LUNG FUNCTION TEST (MBC/IvIVV) 31.96 29.8694200 26 LUNG FUNCTION TEST (MBC/MVV) 8.43 8.1794240 RESIDUAL LUNG CAPACITY 66.63 62.8794240 TC RESIDUAL LUNG CAPACITY 47.69 44.5294240 26 RESIDUAL LUNG CAPACITY 18.96 18.3594250 EXPIRED GAS COLLECTION 42.72 40.1994250 TC EXPIRED GAS COLLECTION 34.29 32.0394250 26 EXPIRED GAS COLLECTION 8.43 8.1794260 THORACIC GAS VOLUME 54.80 51.5194260 TC THORACIC GAS VOLUME 45.36 42.3594260 26 THORACIC GAS VOLUME 9.45 9.1794350 LUNG NITROGEN WASHOUT CURVE 57.33 54.1794350 TC LUNG NITROGEN WASHOUT CURVE 38.37 35.8394350 26 LUNG NITROGEN WASHOUT CURVE 18.96 18.3594360 MEASURE AIRFLOW RESISTANCE 74.21 69.9394360 TC MEASURE AIRFLOW RESISTANCE 55.25 51.5994360 26 MEASURE AIRFLOW RESISTANCE 18.96 18.35

UCJF 11:3-29.694370 BREATH AIRWAY CLOSING VOLUME 56.74 53.6394370 TC BREATH AIRWAY CLOSING VOLUME37,79 35.2994370 26 BREATH AIRWAY CLOSING VOLUME 18.96 18.3594375 RESPIRATORY FLOW VOLUME LOOP 63.35 59.9394375 TC RESPIRATORY FLOW VOLUME LOOP 40.70 38.0094375 26 RESPIRATORY FLOW VOLUME LOOP 22.65 21.9394620 PULMONARY STRESS TEST/SIMPLE 103.85 98.5894620 TC PULMONARY STRESS TEST/SIMPLE 56.42 52.6794620 26 PULMONARY STRESS TEST/SIMPLE 47.44 45.9294640 AIRWAY INHALATION TREAT 27.30 25.5194660 POS AIRWAY PRESSURE, CPAP 95.91 91.4994664 EVALUATE PAT USE INHALER 27.30 25.5194667 CHEST WALL MANIPULATION 38.37 35.8394720 MONOXIDE DIFFUSING CAPACITY 87.61 82.4294720 TC MONOXIDE DIFFUSING CAPACITY 68.65 64.0894720 26 MONOXIDE DIFFUSING CAPACITY 18.96 18.3594750 PULMONARY COMPLIANCE STUDY 131.51 123.2994750 TC PULMONARY COMPLIANCE STUDY114,65 106.9894750 26 PULMONARY COMPLIANCE STUDY 16.85 16.3194760 MEASURE BLOOD OXYGEN LEVEL 28.25 26.5994761 MEASURE BLOOD OXYGEN LEVEL 46.17 43.2994762 MEASURE BLOOD OXYGEN LEVEL 59.35 55.4494770 EXHALED CARBON DIOXIDE TEST 38.28 36.1895004 PERCUT ALLERGY SKIN TESTS 10.93 10.2595015 ID ALLERGY TITRATE-DRUG/BUG 23.28 22.1195024 ID ALLERGY TEST, DRUG/BUG 12.68 11.8895027 ID ALLERGY TITRATE-AIRBORNE 8.01 7.5395028 ID ALLERGY TEST-DELAYED TYPE 21.49 20.0895044 ALLERGY PATCH TESTS 10.42 9.7595115 OTHERAPY, ONE INJECTION 17.41 16.2795117 IMMUNOTHERAPY INJECTIONS 21.49 20.0895144 ANTIGEN THERAPY SERVICES 21.03 19.8095800 SLEEP STUDY UNATT; COMP

W/SLEEP TIME 344.12 323.7595800 TC SLEEP STUDY UNATT; COMP

W/SLEEP TIME 252.65 235.7195800 26 SLEEP STUDY UNATT; COMP

W/SLEEP TIME 91.46 88.0295801 SLEEP STUDY UNATT; COMP

W/O SLEEP TIME 158.15 150.1595801 TC SLEEP STUDY UNATT; COMP

W/O SLEEP TIME 77.96 72.7695801 26 SLEEP STUDY UNATT; COMP

W/O SLEEP TIME 80.19 77.3995803 ACTIGRAPHY TESTING 271.28 255.4495803 TC ACTIGRAPHY TESTING 197.91 184.6695803 26 ACTIGRAPHY TESTING 73.37 70.7895805 MULTIPLE SLEEP LATENCY TEST 693.93 650.5495805 TC MULTIPLE SLEEP LATENCY TEST 597.18 557.2295805 26 MULTIPLE SLEEP LATENCY TEST 96.75 93.3295810 POLYSOMNOGRAPHY, 4 OR MORE 1,169.61 1,097.9095810 TC POLYSOMNOGRAPHY, 4 OR MORE 974.08 909.0495810 26 POLYSOMNOGRAPHY, 4 OR MORE 195.54 188.8695811 POLYSOMNOGRAPHY W/CPAP 1,263.07 1,185.4095811 TC POLYSOMNOGRAPHY W/CPAP 1,058.45 987.7895811 26 POLYSOMNOGRAPHY W/CPAP 204.62 197.6295812 EEG, 41-60 MINUTES 531.27 498.4795812 TC EEG, 41-60 MINUTES 447.02 417.1095812 26 EEG, 41-60 MINUTES 84.26 81.3795813 EEG, OVER 1 HOUR 594.86 559.5295813 TC EEG, OVER 1 HOUR 460.35 429.5695813 26 EEG, OVER 1 HOUR 134.52 129.9695816 EEG, AWAKE & DROWSY 378.16 355.0195816 TC EEG, AWAKE & DROWSY 312.51 291.6095816 26 EEG, AWAKE & DROWSY 65.65 63.4195819 EEG, AWAKE & ASLEEP 549.32 515.3195819 TC EEG, AWAKE & ASLEEP 464.48 433.3995819 26 EEG, AWAKE & ASLEEP 84.84 81.9195822 EEG, COMA OR SLEEP ONLY 513.22 481.6395822 TC EEG, COMA OR SLEEP ONLY 428.39 399.7295822 26 EEG, COMA OR SLEEP ONLY 84.84 81.9195831 LIMB MUSCLE TESTING, MANUAL 47.21 44.84

11:3-29.6 APPENDIX B - REGULATIONS95832 HAND MUSCLE TESTING, MANUAL 52.37 49.8095833 BODY MUSCLE TESTING, MANUAL 68.43 65.1995834 BODY MUSCLE TESTING, MANUAL 85.99 82.0295851 RANGE MOTION MEASUREMENTS 43.75 41.4795852 RANGE MOTION MEASUREMENTS 24.16 22.8495857 TENSILON TEST 76.14 72.4695860 MUSCLE TEST, ONE LIMB 226.85 215.4495860 TC MUSCLE TEST, ONE LIMB 107.41 100.2495860 26 MUSCLE TEST, ONE LIMB 119.46 115.2095861 MUSCLE TEST, 2 LIMBS 327.48 311.6195861 TC MUSCLE TEST, 2 LIMBS 136.97 127.8395861 26 MUSCLE TEST, 2 LIMBS 190.51 183.7895863 MUSCLE TEST, 3 LIMBS 395.17 376.0895863 TC MUSCLE TEST, 3 LIMBS 166.53 155.4095863 26 MUSCLE TEST, 3 LIMBS 228.64 220.6895864 MUSCLE TEST, 4 LIMBS 434.98 413.6995864 TC MUSCLE TEST, 4 LIMBS 190.71 177.9695864 26 MUSCLE TEST, 4 LIMBS 244.27 235.7295865 MUSCLE TEST, LARYNX 296.79 283.0195865 TC MUSCLE TEST, LARYNX 101.14 94.4095865 26 MUSCLE TEST, LARYNX 195.65 188.6195867 MUSCLE TEST CRANIAL NERVE

UNILAT 201.95 191.5695867 TC MUSCLE TEST CRANIAL NERVE

UNILAT 103.83 96.9095867 26 MUSCLE TEST CRANIAL NERVE

UNILAT 98.12 94.6795868 MUSCLE TEST CRANIAL NERVE

BILAT 272.61 258.9995868 TC MUSCLE TEST CRANIAL NERVE

BILAT 128.01 119.4695868 26 MUSCLE TEST CRANIAL NERVE

BILAT 144.60 139.5395869 MUSCLE TEST, THOR PARASPINAL 149.63 141.0895869 TC MUSCLE TEST, THOR PARASPTNAL 103.83 96.9095869 26 MUSCLE TEST, THOR PARASPINAL 45.80 44.1895870 MUSCLE TEST, NONPARASPINAL 146.04 137.7495870 TC MUSCLE TEST, NONPARASPINAL 101.14 94.4095870 26 MUSCLE TEST, NONPARASPINAL 44.91 43.3395873 GUIDE NERVE DESTROY, ELECT

STIM 148.73 140.2595873 TC GUIDE NERVE DESTROY, ELECT

STIM 101.14 94.4095873 26 GUIDE NERVE DESTROY, ELECT

STIM 47.60 45.8595874 GUIDE NERVE DESTROY, NEEDLE

EMG 141.56 133.5695874 TC GUIDE NERVE DESTROY, NEEDLE

EMG 95.76 89.3895874 26 GUIDE NERVE DESTROY, NEEDLE

EMG 45.80 44.1895900 MOTOR NERVE CONDUCTION TEST 153.54 144.9195900 TC MOTOR NERVE CONDUCTION TEST 102.03 95.2395900 26 MOTOR NERVE CONDUCTION TEST 51.51 49.6795903 MOTOR NERVE CONDUCTION TEST 176.35 166.9995903 TC MOTOR NERVE CONDUCTION TEST 102.93 96.0795903 26 MOTOR NERVE CONDUCTION TEST 73.44 70.9295904 SENSE NERVE CONDUCTION TEST 135.64 127.9295904 TC SENSE NERVE CONDUCTION TEST 93.97 87.7195904 26 SENSE NERVE CONDUCTION TEST 41.67 40.2195920 INTRAOP NERVE TEST, ADDED 392.31 374.3895920 TC INTRAOP NERVE TEST, ADDED 136.07 126.9895920 26 INTRAOP NERVE TEST, ADDED 256.23 247.3895921 AUTONOMIC NERVE FUNCTION TEST129.86 123.4895921 TC AUTONOMIC NERVE FUNCTION TEST 60.50 56.4795921 26 AUTONOMIC NERVE FUNCTION TEST 69.36 67.0095922 AUTONOMIC NERVE FUNCTION TEST161.43 153.0895922 TC AUTONOMIC NERVE FUNCTION TEST 87.28 81.4695922 26 AUTONOMIC NERVE FUNCTION TEST 74.15 71.6295923 AUTONOMIC NERVE FUNCTION TEST241.02 227.2095923 TC AUTONOMIC NERVE FUNCTION TEST169.96 158.5995923 26 AUTONOMIC NERVE FUNCTION TEST 71.04 68.61

UCJF 11:3-29.695925 SOMATOSENSORY TESTING 640.37 600.7095925 TC SOMATOSENSORY TESTING 538.82 502.7495925 26 SOMATOSENSORY TESTING 101.51 98.0095926 SOMATOSENSORY TESTING 393.84 369.6395926 TC SOMATOSENSORY TESTING 327.79 305.8295926 26 SOMATOSENSORY TESTING 66.05 63.8295927 SOMATOSENSORY TESTING 368.96 346.3195927 TC SOMATOSENSORY TESTING 303.59 283.2595927 26 SOMATOSENSORY TESTING 65.35 63.0595928 C MOTOR EVOKED, UPPER LIMBS 388.77 366.6795928 TC C MOTOR EVOKED, UPPER LIMBS 270.57 252.5195928 26 C MOTOR EVOKED, UPPER LIMBS 118.19 114.1695929 C MOTOR EVOKED, LOWER LIMBS 412.64 388.9595929 TC C MOTOR EVOKED, LOWER LIMBS 293.87 274.2495929 26 C MOTOR EVOKED, LOWER LIMBS 118.77 114.7195930 VISUAL EVOKED POTENTIAL TEST 225.51 211.3095930 TC VISUAL EVOKED POTENTIAL TEST 197.91 184.6695930 26 VISUAL EVOKED POTENTIAL TEST 27.60 26.6395933 BLINK REFLEX TEST 122.27 115.6595933 TC BLINK REFLEX TEST 75.05 70.0595933 26 BLINK REFLEX TEST 47.22 45.6095934 H-REFLEX TEST 155.93 147.6995934 TC H-REFLEX TEST 87.59 81.7795934 26 H-REFLEX TEST 68.32 65.8995936 H-REFLEX TEST 126.83 120.7095936 TC H-REFLEX TEST 54.09 50.5395936 26 H-REFLEX TEST 72.75 70.2095937 NEUROMUSCULAR JUNCTION TEST 105.46 100.1495937 TC NEUROMUSCULAR JUNCTION TEST 53.50 49.9595937 26 NEUROMUSCULAR JUNCTION TEST 51.95 50.1995950 AMBULATORY EEG MONITORING 451.58 425.2995950 TC AMBULATORY EEG MONITORING 332.89 310.6395950 26 AMBULATORY EEG MONITORING 118.70 114.6595951 EEG MONITORING/VIDEO RECORD 3,074.98 2,967.7695951 TC EEG MONITORING/VIDEO RECORD 2,599.66 2,508.8195951 26 EEG MONITORING/VIDEO RECORD 483.24 467.0895953 EEG MONITORING/COMPUTER 683.31 645.5795953 TC EEG MONITORING/COMPUTER 438.28 408.9495953 26 EEG MONITORING/COMPUTER 245.04 236.6295955 EEG DURING SURG 279.78 263.6495955 TC EEG DURING SURG 201.41 187.9295955 26 EEG DURING SURG 78.37 75.7295956 EEG MONITORING, CABLE/RADIO 1,700.99 1,596.6995956 TC EEG MONITORING, CABLE/RADIO 1,425.05 1,329.8995956 26 EEG MONITORING, CABLE/RADIO 275.95 266.7995957 EEG DIGITAL ANALYSIS 565.05 532.3195957 TC EEG DIGITAL ANALYSIS 408.70 381.2995957 26 EEG DIGITAL ANALYSIS 156.33 151.0295961 ELECTRODE STIMULATION, BRAIN 407.15 387.5995961 TC ELECTRODE STIMULATION, BRAIN 169.96 158.5995961 26 ELECTRODE STIMULATION, BRAIN 237.19 228.9995962 ELECTRODE STIM, BRAIN, ADDED 362.26 346.3095962 TC ELECTRODE STIM, BRAIN, ADDED 108.83 101.5595962 26 ELECTRODE STIM, BRAIN, ADDED 253.44 244.7595970 ANALYZE NEUROSTIM, NO PROG 97.12 91.8395971 ANALYZE NEUROSTIM, SIMPLE 92.71 88.6395972 ANALYZE NEUROSTIM, COMPLEX 170.16 162.8895973 ANALYZE NEUROSTIM, COMPLEX 95.10 91.2395981 IO ANAL GAST N-STIM SUBSEQ 49.98 47.4595991 SPIN/BRAIN PUMP REFILL & MAIN 174.44 164.7795992 CANALITH REPOSITIONING PROC 66.86 64.3896000 MOTION ANALYSIS, VIDEO/3D 141.90 137.1596002 DYNAMIC SURFACE EMG 32.84 31.7596004 PHYS REVIEW MOTION TESTS 174.11 168.1396101 PSYCHO TESTING BY PSYCH/PHYS 171.94 166.8396102 PSYCHO TESTING BY TECHNICIAN 110.20 104.1296103 PSYCHO TESTING ADMIN BY COMP 92.07 87.2496105 ASSESS APHASIA 169.49 162.5396111 DEVELOPMENTAL TEST, EXTEND 194.42 188.2696116 NEUROBEHAVIORAL STATUS EXAM 163.28 157.9796118 NEUROPSYCH TEST BY PSYCH/PHYS 175.60 169.3296119 NEUROPSYCH TESTING BY TEC 116.36 109.92

11:3-29.6 APPENDIX B - REGULATIONS96120 NEUROPSYCH TEST ADMIN W/COMP 136.91 129.0696125 COGNITIVE TEST BY HC PRO 147.55 142.0496150 ASSESS HEALTH/BEHAVE, INIT 32.30 31.3996151 ASSESS HEALTH/BEHAVE, SUBSEQ 31.28 30.3896152 INTERVENE HEALTH/BEHAVE, INDIV 29.69 28.8596153 INTERVENE HEALTH/BEHAVE, GROUP 7.35 7.1396154 INTERVENE HEALTH/BEHAVE, FAM

W/PT 29.17 28.3596360 HYDRATION IV INFUSION, INIT 96.36 90.4196361 HYDRATE IV INFUSION, ADDED 25.47 24.0296365 THER/PROPHY/DIAG IV INF, INIT 119.94 112.5196366 THER/PROPHY/DIAG IV INF ADDED 35.85 33.9296367 THER/PROPHY/DIAG ADDED SEQ IV

INF 55.00 51.8096368 THER/DIAG CONCURRENT INF 31.86 30.1796370 SC THER INFUSION, ADDED HR 24.80 23.6096372 THER/PROPHY/DIAG INJ, SC/IM 38.26 36.1496373 THER/PROPHY/DIAG INJ, IA 31.28 29.6396374 THER/PROPHY/DIAG INJ, IV PUSH 93.96 88.1996375 TX/PRO/DIAG INJECT NEW DRUG

ADDED 38.20 35.9196409 CHEMO IV PUSH, SINGLE DRUG 191.22 179.1396446 CHEMOTHERAPY ADM PERITONEAL

CAV 300.18 281.1696523 IRRIG DRUG DELIVERY DEVICE 43.31 40.5396900 ULTRAVIOLET LIGHT THERAPY 35.46 33.1196912 PHOTOCHEMOTHERAPY W/UV-A 152.50 142.2997001 PHYSICAL THERAPY EVAL 114.74 110.1397002 PHYSICAL THERAPY RE-EVAL 64.03 61.3197003 OT EVAL 127.54 122.0997004 OT RE-EVAL 78.59 74.8897010 APPLIC MODAL 1/> AREAS;

HOT/COLD PACKS 0.00 0.0097012 MECHANICAL TRACTION THERAPY 28.01 26.8797016 VASOPNEUMATIC DEVICE THERAPY 28.29 26.8697014 APPLICATION MODALITY TO 1 OR

MORE AREAS; E-STIM 0.00 0.0097018 PARAFFIN BATH THERAPY 15.79 14.9197022 WHIRLPOOL THERAPY 33.61 31.7997024 DIATHERMY EG, MICROWAVE 9.98 9.4897026 INFRARED THERAPY 8.81 8.4097028 ULTRAVIOLET THERAPY 10.98 10.4797032 ELECTRICAL STIMULATION 28.35 27.0997033 ELECTRIC CURRENT THERAPY 46.33 43.8897034 CONTRAST BATH THERAPY 26.32 25.1097035 ULTRASOUND THERAPY 27.40 26.3697036 HYDROTHERAPY 47.92 45.4297039 PHYSICAL THERAPY TREAT 20.42 19.7197110 THERAPEUTIC EXERCISES 50.87 48.6797112 NEUROMUSCULAR REEDUCATION 53.36 51.0197113 AQUATIC THERAPY/EXERCISES 67.87 64.5197116 GAIT TRAINING THERAPY 48.21 46.1497124 MASSAGE THERAPY 38.67 36.9597139 PHYSICAL MEDICINE PROCEDURE 27.64 26.6797140 MANUAL THERAPY 44.47 42.5697150 GROUP THERAPEUTIC PROCEDURES 30.52 29.1797530 THERAPEUTIC ACTIVITIES 59.96 57.2197532 COGNITIVE SKILLS DEVELOPMENT 61.13 58.7297533 SENSORY INTEGRATION 43.81 41.9897535 SELF CARE MANAGEMENT TRAINING51.88 49.5497537 COMMUNITY/WORK REINTEGRATION44.91 43.0297542 WHEELCHAIR MANAGEMENT

TRAINING 45.49 43.5697597 ACTIVE WOUND CARE/20 CM OR < 119.31 112.7297598 ACTIVE WOUND CARE > 20 CM 39.36 37.4097605 NEG PRESS WOUND TX, < 50 CM 62.93 60.3297606 NEG PRESS WOUND TX, > 50 CM 67.09 64.4097750 PHYSICAL PERFORMANCE TEST 55.79 53.3897755 ASSISTIVE TECHNOLOGY ASSESS 53.99 51.9897760 ORTHOTIC MGMT & TRAINING 56.42 53.8397761 PROSTHETIC TRAINING 49.44 47.3297762 C/O FOR ORTHOTIC/PROSTH USE 67.36 63.48

UCJF 11:3-29.697802 MEDICAL NUTRITION, INDIV, IN 50.58 48.5997810 ACUPUNCT 1/> NDLES W/O E-STIM;

INIT 15 MIN 1-1 43.74 32.0797811 ACUPUNCT 1 /> NDLES W/O E-STIM;

EA ADD 15 MIN 1-1 37.49 27.4997813 ACUPUNCT 1/> NDLES WITH E-STIM;

INIT 15 MIN 1-1 47.91 35.1297814 ACUPUNCT 1/> NDLES WITH E-STIM;

EA ADD 15 MIN 1-1 41.66 30.5498925 OSTEOPATHIC MANIPULATION 1-2

REGIONS 55.70 53.3498926 OSTEOPATHIC MANIPULATION 3-4



REGIONS 97.37 93.5298940 CHIROPRACTIC MANIPULATION 1-2

REGIONS 39.44 37.9098941 CHIROPRACTIC MANIPULATION 3-4

REGIONS 54.40 52.4198942 CHIROPRACTIC MANIPULATION 5

REGIONS 69.90 67.3998943 CHIROPRACTIC MANIP TX;

XTRASPINAL 1/MORE REGIONS 37.14 36.0199070 SUPPLIES & MATERIALS: ADDL TO

USUAL FOR OFFICE VISIT 0.00 0.0099071 EDUCATION SUPPLIES; S/A BOOKS,

TAPES & PAMPHLETS FOR PATIENTEDUCATION 0.00 0.00

99080 SPECIAL REPORTS 0.00 0.0099082 UNUSUAL PHYSICIAN TRAVEL 0.00 0.0099143 MOD SEDATION SAME PHYS, < 5 YRS 44.74 43.7099144 MOD SEDATION BY SAME PHYS,

5 YRS + 64.49 62.2499145 MOD SEDATION BY SAME PHYS,

ADDED 22.24 21.4499148 MOD SEDATION DIFF PHYS < 5 YRS 125.97 121.5899149 MOD SEDATION DIFF PHYS 5 YRS + 125.97 121.5899150 MOD SEDATION DIFF PHYS, ADDED 47.38 45.6999175 INDUCTION VOMITING 41.87 39.0899183 HYPERBARIC OXYGEN THERAPY 518.83 494.1699195 PHLEBOTOMY 227.07 212.0999201 OFFICE/OUTPAT VISIT, NEW PAT 10

MINS 51.25 48.8199202 OFFICE/OUTPAT VISIT, NEW PAT 20




MINS 240.25 230.7999211 OFFICE/OUTPAT VISIT, EST PAT 5





MINS 168.59 161.6199217 OBSERVATION CARE DISCHARGE 108.71 104.8299218 OBSERVATION CARE LOW SEVERITY 99.97 96.6699219 OBSERVATION CARE MODERATE

SEVERITY 167.12 161.6199220 OBSERVATION CARE HIGH

SEVERITY 233.75 226.0599221 INITIAL HOSPITAL CARE 30 MINS 151.05 146.2299222 INITIAL HOSPITAL CARE 50 MINS 205.62 198.9499223 INITIAL HOSPITAL CARE 70 MINS 301.80 291.96

11:3-29.6 APPENDIX B - REGULATIONS99224 SUBSEQ OBSERVATION CARE 15

MINS 43.46 41.9999225 SUBSEQ OBSERVATION CARE 25

MINS 76.94 74.2999226 SUBSEQ OBSERVATION CARE 35

MINS 115.08 111.1699231 SUBSEQUENT HOSPITAL CARE 15



MINS 154.90 149.8099234 OBSERVE/HOSP SAME DATE LOW

SEVERITY 204.82 198.0899235 OBSERVE/HOSP SAME DATE MOD

SEVERITY 268.27 259.3999236 OBSERVE/HOSP SAME DATE HIGH

SEVERITY 333.16 322.2099238 HOSPITAL DISCHARGE DAY 30

MINS/LESS 108.19 104.2999239 HOSPITAL DISCHARGE DAY > 30

MINS 158.62 152.9999241 OFFICE CONSULTATION 15 MINS 94.26 81.7299242 OFFICE CONSULTATION 30 MINS 120.18 104.1999243 OFFICE CONSULTATION 40 MINS 153.17 132.7999244 OFFICE CONSULTATION 60 MINS 200.30 173.6699245 OFFICE CONSULTATION 80 MINS 252.93 219.2899251 INPATIENT CONSULTATION 20 MINS 94.26 81.7299252 INPATIENT CONSULTATION 40 MINS 142.96 123.9499253 INPATIENT CONSULTATION 55 MINS 175.95 152.5499254 INPATIENT CONSULTATION 80 MINS 219.94 190.8899255 INPATIENT CONSULTATION 110 MINS276.50 239.7199281 EMERGENCY DEPT VISIT SELF

LIMIT/MINOR 122.92 119.3299282 EMERGENCY DEPT VISIT

LOW/MODERATE 203.58 197.7399283 EMERGENCY DEPT VISIT MODERATE206.43 200.5199284 EMERGENCY DEPT VISIT HIGH

SEVERITY 375.38 365.0099285 EMERGENCY DEPT VISIT HIGH

SEVERITY 519.35 505.1499291 CRITICAL CARE, FIRST HOUR 417.23 401.3899292 CRITICAL CARE, ADDED 30 MIN 185.85 179.4899304 NURSING FACILITY CARE, INIT 137.67 132.9199305 NURSING FACILITY CARE, INIT 193.13 186.5999306 NURSING FACILITY CARE, INIT 245.26 237.0899307 NURSING FACILITY CARE, SUBSEQ 66.27 63.8199308 NURSING FACILITY CARE, SUBSEQ 102.10 98.3299309 NURSING FACILITY CARE, SUBSEQ 134.06 129.1299310 NURSING FACILITY CARE, SUBSEQ 198.16 191.0899315 NURSING FACILITY DISCHARGE DAY 96.51 93.0299316 NURSING FACILITY DISCHARGE DAY125.11 120.6599334 DOMICILE/REST HOME VISIT EST PAT 91.72 88.4199341 HOME VISIT, NEW PATIENT 20 MINS 85.75 82.7199342 HOME VISIT, NEW PATIENT-30 MINS 124.20 119.9599343 HOME VISIT, NEW PATIENT 45 MINS 202.38 195.6099344 HOME VISIT, NEW PATIENT 60 MINS 272.05 262.8099345 HOME VISIT, NEW PATIENT 75 MINS 326.47 315.4499347 HOME VISIT, EST PATIENT 15 MINS 85.25 82.2199348 HOME VISIT, EST PATIENT 25 MINS 128.62 124.1599349 HOME VISIT, EST PATIENT 40 MINS 190.15 183.5699350 HOME VISIT, EST PATIENT 60 MINS 264.65 255.6599354 PROLONGED SERVICE, OFFICE 149.70 144.3599355 PROLONGED SERVICE, OFFICE 147.95 142.7299356 PROLONGED SERVICE, INPATIENT 136.17 131.5899357 PROLONGED SERVICE, INPATIENT 136.75 132.1399406 BEHAVIOR CHANGE SMOKING 3-10

MIN 21.43 20.6299407 BEHAVIOR CHANGE SMOKING > 10

MIN 41.50 40.0399471 PEDIATRIC CRITICAL CARE, INITIAL1,202.04 1,163.3899472 PEDIATRIC CRITICAL CARE, SUBSEQ605.11 585.66

UCJF 11:3-29.699475 PEDIATRIC CRIT CARE AGE 2-5, INIT 848.53 822.0299476 PEDIATRIC CRIT CARE AGE 2-5,

SUBSEQ 514.56 498.3099478 IC, LBW INF < 1500 GM SUBSEQ 213.55 206.55N1 = ASC Packaged Procedure no separate paymentX = ASC codes Not Subject to Multiple Procedure Reductions

Exhibit 2Dental Fee Schedule

CDT Description NORTH SOUTHD0120 periodic oral evaluation - established patient 59 52D0140 limited oral evaluation - problem focused 91 80D0150 comprehensive oral evaluation - new or established patient 104 92D0160 detailed and extensive oral evaluation - problem focused, by report 190 168D0170 re-evaluation - limited, problem focused (established patient; not

post-operative visit) 85 75D0180 comprehensive periodontal evaluation - new or established patient 113 100D0210 intraoral - complete series (including bitewings) 153 135D0220 intraoral - periapical first film 34 30D0230 intraoral - periapical each additional film 28 25D0240 intraoral - occlusal film 51 45D0250 extraoral - first film 80 71D0260 extraoral - each additional film 68 60D0270 bitewing - single film 34 30D0272 bitewings - two films 53 47D0273 bitewings - three films 67 59D0274 bitewings - four films 78 69D0277 vertical bitewings - 7 to 8 films 119 105D0290 posterior-anterior or lateral skull and facial bone survey film 164 145D0320 temporomandibular joint arthrogram, including injection 714 632D0321 other temporomandibular joint films, by report 248 219D0330 panoramic film 130 115D0340 cephalometric film 147 130D0350 oral/facial photographic images 88 78D0360 cone beam ct - craniofacial data capture 691 611D0362 cone beam - two-dimensional image reconstruction using

existing data, includes multiple images 448 397D0363 cone beam - three-dimensional image reconstruction using

existing data, includes multiple images 482 427D0460 pulp vitality tests 67 59D0470 diagnostic casts 135 119D1110 prophylaxis - adult 108 95D1120 prophylaxis - child 79 70D1351 sealant - per tooth 65 57D1510 space maintainer - fixed-unilateral 374 330D1515 space maintainer - fixed - bilateral 509 451D1520 space maintainer - removable - unilateral 457 405D1525 space maintainer - removable - bilateral 578 512D1550 re-cementation of space maintainer 101 89D1555 removal of fixed space maintainer 93 82D2140 amalgam - one surface, primary or permanent 169 149D2150 amalgam - two surfaces, primary or permanent 213 188D2160 amalgam - three surfaces, primary or permanent 256 226D2161 amalgam - four or more surfaces, primary or permanent 305 269D2330 resin-based composite - one surface, anterior 190 168D2331 resin-based composite - two surfaces, anterior 238 210D2332 resin-based composite - three surfaces, anterior 298 263D2335 resin-based composite - four or more surfaces or involving incisal

angle (anterior) 374 330D2390 resin-based composite crown, anterior 549 486


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

UCJF 11:3-29.6

D2960 labial veneer (resin laminate) - chairside 797 705D2961 labial veneer (resin laminate) - laboratory 1160 1027D2962 labial veneer (porcelain laminate) - laboratory 1360 1203D2970 temporary crown (fractured tooth) 453 401D2971 additional procedures to construct new crown under existing partial

denture framework 246 217D2975 coping 717 634D2980 crown repair, by report 351 310D3310 endodontic therapy, anterior tooth (excluding final restoration) 865 765D3320 endodontic therapy, bicuspid tooth (excluding final restoration) 996 881D3330 endodontic therapy, molar (excluding final restoration) 1198 1060D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant 764 676D4249 clinical crown lengthening - hard tissue 912 807D4260 osseous surgery (including flap entry and closure) - four or more

contiguous teeth or tooth bounded spaces per quadrant 1272 1126D4261 osseous surgery (including flap entry and closure) - one to three

contiguous teeth or tooth bounded spaces per quadrant 1075 951D4263 bone replacement graft - first site in quadrant 851 753D4341 periodontal scaling and root planing - four or more teeth per quadrant 300 265D4355 full mouth debridement to enable comprehensive evaluation and

diagnosis 217 192D4381 localized delivery of antimicrobial agents via a controlled release

vehicle into diseased crevicular tissue, per tooth, by report 180 159D4910 periodontal maintenance 166 147D5110 complete denture-maxillary 2038 1803D5120 complete denture - mandibular 2042 1807D5130 immediate denture-maxillary 2207 1953D5140 immediate denture-mandibular 2207 1953D5211 maxillary partial denture - resin base (including any conventional

clasps, rests and teeth) 1613 1427D5212 mandibular partial denture - resin base (including any conventional

clasps, rests and teeth) 1613 1427D5213 maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth) 2126 1881D5214 mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth) 2126 1881D5510 repair broken complete denture base 252 223D5520 replace missing or broken teeth - complete denture (each tooth) 223 197D5610 repair resin denture base 242 214D5620 repair cast framework 345 305D5630 repair or replace broken clasp 316 279D5640 replace broken teeth - per tooth 218 193D5650 add tooth to existing partial denture 267 236D5660 add clasp to existing partial denture 323 285D5670 replace all teeth and acrylic on cast metal framework (maxillary) 890 787D5671 replace all teeth and acrylic on cast metal framework (mandibular) 901 797D5710 rebase complete maxillary denture 692 612D5711 rebase complete mandibular denture 686 607D5720 rebase maxillary partial denture 668 591D5721 rebase mandibular partial denture 668 591D5730 reline complete maxillary denture (chairside) 441 391D5731 reline complete mandibular denture (chairside) 440 390D5740 reline maxillary partial denture (chairside) 432 383D5741 reline mandibular partial denture (chairside) 440 390D5750 reline complete maxillary denture (laboratory) 565 500D5751 reline complete mandibular denture (laboratory) 566 501D5760 reline maxillary partial denture (laboratory) 560 496D5761 reline mandibular partial denture (laboratory) 560 496


D5810 interim complete denture (maxillary) 1029 910D5811 interim complete denture (mandibular) 1043 922D5820 interim partial denture (maxillary) 834 738D5821 interim partial denture (mandibular) 834 738D5850 tissue conditioning, maxillary 249 220D5851 tissue conditioning, mandibular 249 220D5860 overdenture - complete, by report 2537 2244D5861 overdenture - partial, by report 2477 2191D5862 precision attachment, by report 849 751D5867 replacement of replaceable part of semi-precision or precision

attachment (male or female component) 462 409D5875 modification of removable prosthesis following implant surgery 466 413D5937 trismus appliance (not for TMD treatment) 882 780D5951 feeding aid 1031 912D5982 surgical stent 529 468D5988 surgical splint 902 799D6010 surgical placement of implant body: endosteal implant 2377 2103D6012 surgical placement of interim implant body for transitional

prosthesis: endosteal implant 1872 1656D6040 surgical placement: eposteal implant 9819 8687D6050 surgical placement: transosteal implant 6885 6091D6053 implant/abutment supported removable denture for completely

edentulous arch 3386 2995D6054 implant/abutment supported removable denture for partially

edentulous arch 3321 2938D6055 connecting bar - implant supported or abutment supported 3506 3102D6056 prefabricated abutment - includes placement 962 851D6057 custom abutment - includes placement 1132 1002D6058 abutment supported porcelain/ceramic crown 1727 1528D6059 abutment supported porcelain fused to metal crown (high noble metal)1734 1534D6060 abutment supported porcelain fused to metal crown (predominantly

base metal) 1626 1438D6061 abutment supported porcelain fused to metal crown (noble metal) 1622 1435D6062 abutment supported cast metal crown (high noble metal) 1698 1502D6063 abutment supported cast metal crown (predominantly base metal) 1586 1403D6064 abutment supported cast metal crown (noble metal) 1623 1436D6065 implant supported porcelain/ceramic crown 1824 1613D6066 implant supported porcelain fused to metal crown (titanium,

titanium alloy, high noble metal) 1838 1626D6067 implant supported metal crown (titanium, titanium alloy, high noble

metal) 1855 1641D6068 abutment supported retainer for porcelain/ceramic FPD 1731 1531D6069 abutment supported retainer for porcelain fused to metal FPD (high

noble metal) 1729 1529D6070 abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal) 1641 1452D6071 abutment supported retainer for porcelain fused to metal FPD (noble

metal) 1643 1453D6072 abutment supported retainer for cast metal FPD (high noble metal) 1741 1540D6073 abutment supported retainer for cast metal FPD (predominantly base

metal) 1635 1446D6074 abutment supported retainer for cast metal FPD (noble metal) 1603 1418D6075 implant supported retainer for ceramic FPD 1813 1604D6076 implant supported retainer for porcelain fused to metal FPD

(titanium, titanium alloy, or high noble metal) 1854 1640D6077 implant supported retainer for cast metal FPD (titanium, titanium

alloy, or high noble metal) 1870 1654D6078 implant/abutment supported fixed denture for completely edentulous

arch 6621 5858

UCJF 11:3-29.6

D6079 implantlabutment supported fixed denture for partially edentulousarch 4784 4232

D6080 implant maintenance procedures, including removal ofprosthesis, cleansing of prosthesis and abutments and reinsertion ofprosthesis 375 331

D6090 repair implant supported prosthesis, by report 889 786D6091 replacement of semi-precision or precision attachment (male or

female component) of implant/abutment supported prosthesis, perattachment 752 665

D6092 recement implant/abutment supported crown 189 167D6093 recement implant/abutment supported fixed partial denture 216 191D6094 abutment supported crown - (titanium) 1590 1407D6095 repair implant abutment, by report 863 763D6100 implant removal, by report 904 800D6190 radiographic/surgical implant index, by report 509 451D6194 abutment supported retainer crown for FPD - (titanium) 1721 1522D6205 pontic - indirect resin based composite 1156 1023D6210 pontic - cast high noble metal 1296 1147D6211 pontic - cast predominantly base metal 1201 1063D6212 pontic - cast noble metal 1233 1091D6214 pontic-titanium 1292 1143D6240 pontic - porcelain fused to high noble metal 1319 1167D6241 pontic - porcelain fused to predominantly base metal 1215 1075D6242 pontic - porcelain fused to noble metal 1245 1102D6245 pontic - porcelain/ceramic 1358 1202D6250 pontic - resin with high noble metal 1255 1111D6251 pontic - resin with predominantly base metal 1244 1101D6252 pontic - resin with noble metal 1228 1087D6253 provisional pontic 910 805D6545 retainer - cast metal for resin bonded fixed prosthesis 1019 901D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis 1122 992D6710 crown - indirect resin based composite 1192 1055D6720 crown - resin with high noble metal 1253 1109D6721 crown - resin with predominantly base metal 1242 1099D6722 crown - resin with noble metal 1245 1102D6740 crown - porcelain/ceramic 1364 1207D6750 crown - porcelain fused to high noble metal 1330 1177D6751 crown - porcelain fused to predominantly base metal 1217 1077D6752 crown - porcelain fused to noble metal 1245 1102D6780 crown - 3/4 cast high noble metal 1271 1125D6781 crown - 3/4 cast predominantly base metal 1218 1078D6782 crown - 3/4 cast noble metal 1245 1102D6783 crown - 3/4 porcelain/ceramic 1296 1147D6790 crown - full cast high noble metal 1298 1149D6791 crown - full cast predominantly base metal 1201 1063D6792 crown - full cast noble metal 1233 1091D6793 provisional retainer crown 661 585D6794 crown - titanium 1250 1106D6920 connector bar 1182 1046D6930 recement fixed partial denture 205 181D6940 stress breaker 528 467D6950 precision attachment 789 698D6970 post and core in addition to fixed partial denture retainer, indirectly

fabricated 517 458D6972 prefabricated post and core in addition to fixed partial denture retainer406 360D6973 core build up for retainer, including any pins 323 285D6975 coping-metal 832 736D6976 each additional indirectly fabricated post - same tooth 343 303D6977 each additional prefabricated post - same tooth 246 217


D6980 fixed partial denture repair, by report 455 403D6985 pediatric partial denture, fixed 1073 949D7110 single tooth (extraction) n/a n/aD7111 extraction, coronal remnants - deciduous tooth 161 142D7120 each add tooth (extraction) n/a n/aD7140 extraction, erupted tooth or exposed root (elevation and/or forceps

removal) 209 185D7210 surgical removal of erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flap ifindicated 328 290

D7250 surgical removal of residual tooth roots (cutting procedure) 370 327D7290 surgical repositioning of teeth 625 553D7560 maxillary sinusotomy for removal of tooth fragment or foreign body 1681 1487D7610 maxilla - open reduction (teeth immobilized, if present) 5162 4567D7620 maxilla - closed reduction (teeth immobilized, if present) 4180 3699D7630 mandible - open reduction (teeth immobilized, if present) 5349 4732D7640 mandible - closed reduction (teeth immobilized, if present) 4157 3678D7650 malar and/or zygomatic arch - open reduction 4631 4097D7660 malar and/or zygomatic arch - closed reduction 3862 3417D7670 alveolus closed reduction may include stabilization of teeth 2257 1997D7671 alveolus, open reduction may include stabilization of teeth 1512 1338D7680 facial bones - complicated reduction with fixation and multiple

surgical approaches 7759 6864D7710 maxilla open reduction 5260 4654D7720 maxilla - closed reduction 4133 3656D7730 mandible - open reduction 5746 5084D7740 mandible - closed reduction 4273 3781D7750 malar and/or zygomatic arch - open reduction 5014 4436D7760 malar and/or zygomatic arch - closed reduction 7186 6358D7770 alveolus - open reduction stabilization of teeth 3294 2914D7771 alveolus, closed reduction stabilization of teeth 2287 2023D7780 facial bones - complicated reduction with fixation and multiple

surgical approaches 10128 8960D7810 open reduction of dislocation 5014 4436D7820 closed reduction of dislocation 763 675D7830 manipulation under anesthesia 1166 1032D7840 condylectomy 6424 5684D7850 surgical discectomy, with/without implant 6210 5494D7852 disc repair 6609 5847D7854 synovectomy 6140 5432D7856 myotomy 4188 3706D7880 occlusal orthotic device, by report 1453 1376D7910 suture of recent small wounds up to 5 cm 368 325D7911 complicated suture - up to 5 cm 610 540D7912 complicated suture - greater than 5 cm 961 850D7920 skin graft (identify defect covered, location and type of graft) 3110 2751D7955 repair of maxillofacial soft and/or hard tissue defect 4554 3941D7960 frenulectomy - also known as frenectomy or frenotomy -

separate procedure not incidental to another procedure 538 476D7990 emergency tracheotomy 1715 1517D8210 removable appliance therapy 1034 914D8220 fixed appliance therapy 1174 1039D8691 repair of orthodontic appliance 255 225D8692 replacement of lost or broken retainer 405 359D8693 rebonding or recementing; and/or repair, as required, of fixed

retainers 408 361D9110 palliative (emergency) treatment of dental pain - minor procedure 154 136D9210 local anesthesia not in conjunction with operative or surgical

procedures 91 80

UCJF 11:3-29.6

D9211 regional block anesthesia 113 100D9212 trigeminal division block anesthesia 317 280D9215 local anesthesia in conjunction with operative or surgical procedures 79 70D9220 deep sedation/general anesthesia - first 30 minutes 480 425D9221 deep sedation/general anesthesia - each additional 15 minutes 205 181D9230 inhalation of nitrous oxide / anxiolysis, analgesia 96 85D9241 intravenous conscious sedation/analgesia - first 30 minutes 509 451D9242 intravenous conscious sedation/analgesia - each additional 15 minutes200 177D9248 non-intravenous conscious sedation 400 354D9310 consultation - diagnostic service provided by dentist or physician

other than requesting dentist or physician 158 140D9410 house/extended care facility call 301 266D9420 hospital or ambulatory surgical center call 357 315D9430 office visit for observation (during regularly scheduled hours) - no

other services performed 94 83D9610 therapeutic parenteral drug, single administration 131 116D9612 therapeutic parenteral drugs, two or more administrations,

different medications 226 200D9630 other drugs and/or medicaments, by report 63 56D9940 occlusal guard, by report 727 643D9950 occlusion analysis - mounted case 418 370D9951 occlusal adjus ment - limited 223 197D9952 occlusal adjustment - complete 846 748

Exhibit 3Home Care Fees

ServicePRIVATE NURSING CARE(PER HOUR) HSPCS CODE FEERegistered nurse S9123 70.00Licensed practical nurse S9124 65.00Home health aide S9122 24.00Live-in attendant (per 24-hr shift) S5126 180.00HOME HEALTH VISITS(PER VISIT) HSPCS CODE FEERegistered nurse T1030 125.00Physical therapist S9131 135.00Speech therapist S9128 145.00Occupational therapist S9129 135.00Medical social worker S9127 195.00

Exhibit 4Ambulance Services Fee Schedule

HCPCS Description North SouthA0425 GROUND MILEAGE, PER STATUTE MILEA0426 AMBULANCE SERVICE, ALS, NON-EMERGENCY TRANSPORT,

LEVEL 1 8.93 8.93A0427 AMBULANCE SERVICE, ALS, EMERGENCY TRANSPORT,

LEVEL I 386.84 363.02A0428 AMBULANCE SERVICE, BLS, NON-EMERGENCY TRANSPORT 612.49 574.78A0429 AMBULANCE SERVICE, BLS, EMERGENCY TRANSPORT 322.36 302.52A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES 515.78 484.02

TRANSPORT ONE WAY (ROTARY WING) 4,790.49 4,571.17A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) 886.50 831.92A0434 SPECIALTY CARE TRANSPORT (SCT) 1,047.68 983.17A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE 27.99 27.99


Exhibit 5Durable Medical Equipment, Prosthetics, Orthotics & Supplies

HCPCS Mod Mod2 CATG Fee DescriptionA4216 OS $.047 Sterile water/saline, 10mlA4217 SU $3.29 Sterile water/saline, 500 mlA4217 AU OS $3.29 Sterile water/saline, 500 mlA4221 SU $23.77 Maint drug infus cath per wkA4222 SU $49.07 Infusion supplies with pumpA4233 NU IN $0.84 Alkalin batt for glucose monA4233 NU KL IN $0.72 Alkalin batt for glucose monA4234 NU IN $3.81 J-cell batt for glucose monA4234 NU KL IN $3.29 J-cell batt for glucose monA4235 NU IN $2.46 Lithium batt for glucose monA4235 NU KL IN $2.12 Lithium batt for glucose monA4236 NU IN $1.76 Silvr oxide batt glucose monA4236 NU KL IN $1.52 Silvr oxide batt glucose monA4253 NU IN $38.79 Blood glucose/reagent stripsA4253 NU KL IN $33.43 Blood glucose/reagent stripsA4255 SU $4.11 Glucose monitor platformsA4256 SU $10.21 Calibrator solution/chipsA4256 KL SU $8.80 Calibrator solution/chipsA4257 SU $13.39 Replace Lensshield CartridgeA4258 SU $18.95 Lancet device eachA4258 KL SU $16.34 Lancet device eachA4259 SU $12.66 Lancets per boxA4259 KL SU $10.91 Lancets per boxA4265 SU $3.56 ParaffinA4280 PO $5.55 Brst prsths adhsv attchmntA4310 OS $7.50 Insert tray w/o bag/cathA4311 OS $13.24 Catheter w/o bag 2-way latexA4312 OS $16.10 Cath w/o bag 2-way siliconeA4313 OS $19.06 Catheter w/bag 3-wayA4314 OS $25.21 Cath w/drainage 2-way latexA4315 OS $27.09 Cath w/drainage 2-way silcneA4316 OS $28.30 Cath w/drainage 3-wayA4320 OS $5.29 Irrigation trayA4321 OS $0.00 Cath therapeutic irrig agentA4322 OS $3.09 Irrigation syringeA4326 OS $11.33 Male external catheterA4327 OS $44.38 Fem urinary collect dev cupA4328 OS $10.97 Fem urinary collect pouchA4330 OS $7.51 Stool collection pouchA4331 OS $3.34 Extension drainage tubingA4332 OS $0.13 Lube sterile packetA4333 OS $2.31 Urinary cath anchor deviceA4334 OS $5.18 Urinary Bath leg strapA4336 OS $1.51 Urethral insertA4338 OS $11.09 Indwelling catheter latexA4340 OS $33.34 Indwelling catheter specialA4344 OS $14.30 Cath indw foley 2 way silicnA4346 OS $17.90 Cath indw foley 3 wayA4349 OS $2.12 Disposable male external catA4351 OS $1.83 Straight tip urine catheterA4352 OS $6.74 Coude tip urinary catheterA4353 OS $7.34 Intermittent urinary cathA4354 OS $12.29 Cath insertion tray w/bagA4355 OS $9.36 Bladder irrigation tubingA4356 OS $47.91 Ext ureth clmp or compr dvcA4357 OS $9.65 Bedside drainage bagA4358 OS $6.96 Urinary leg or abdomen bagA4360 OS $0.51 Disposable ext urethral devA4361 OS $19.17 Ostomy face plateA4362 OS $3.63 Solid skin barrierA4363 OS $2.48 Ostomy clamp, replacementA4364 OS $3.08 Adhesive, liquid or equalA4366 OS $1.37 Ostomy ventA4367 OS $7.72 Ostomy belt

UCJF 11:3-29.6

A4368 OS $0.27 Ostomy filterA4369 OS $2.54 Skin barrier liquid per ozA4371 OS $3.83 Skin barrier powder per ozA4372 OS $4.39 Skin barrier solid 4x4 equivA4373 OS $6.59 Skin barrier with flangeA4375 OS $18.04 Drainable plastic pch w fcplA4376 OS $49.96 Drainable rubber pch w fcpltA4377 OS $4.50 Drainable plstic pch w/o fpA4378 OS $32.29 Drainable rubber pch w/o fpA4379 OS $15.77 Urinary plastic pouch w fcplA4380 OS $39.20 Urinary rubber pouch w fcpltA4381 OS $4.84 Urinary plastic pouch w/o fpA4382 OS $25.85 Urinary hvy plstc pch w/o fpA4383 OS $29.60 Urinary rubber pouch w/o fpA4384 OS $10.10 Ostomy faceplt/silicone ringA4385 OS $5.36 Ost skn barrier sld ext wearA4387 OS $0.00 Ost clsd pouch w att st barrA4388 OS $4.58 Drainable pch w ex wear barrA4389 OS $6.53 Drainable pch w st wear barrA4390 OS $10.09 Drainable pch ex wear convexA4391 OS $7.42 Urinary pouch w ex wear barrA4392 OS $8.59 Urinary pouch w st wear barrA4393 OS $9.49 Urine pch w ex wear bar convA4394 OS $2.71 Ostomy pouch liq deodorantA4395 OS $0.05 Ostomy pouch solid deodorantA4396 OS $42.50 Peristomal hernia supprt bltA4397 OS $5.03 Irrigation supply sleeveA4398 OS $14.50 Ostomy irrigation bagA4399 OS $12.87 Ostomy irrig cone/cath w brsA4400 OS $51.31 Ostomy irrigation setA4402 OS $1.46 Lubricant per ounceA4404 OS $1.62 Ostomy ring eachA4405 OS $3.57 Nonpectin based ostomy pasteA4406 OS $6.03 Pectin based ostomy pasteA4407 OS $9.20 Ext wear ost skn barr <=4sq"A4408 OS $10.36 Ext wear ost skn barr >4sq"A4409 OS $6.53 Ost skn barr convex <=4 sq iA4410 OS $9.49 Ost skn barr extnd >4 sqA4411 OS $5.36 Ost skn barr extnd =4sqA4412 OS $2.84 Ost pouch drain high outputA4413 OS $5.78 2 pc drainable ost pouchA4414 OS $5.18 Ost sknbar w/o conv<=4 sq inA4415 OS $6.30 Ost skn barn w/o conv >4 sqiA4416 OS $2.89 Ost pch clsd w barrier/filtrA4417 OS $3.91 Ost pch w bar/bltinconv/fltrA4418 OS $1.90 Ost pch clsd w/o bar w filtrA4419 OS $1.83 Ost pch for bar w flange/fltA4420 OS $0.00 Ost pch clsd for bar w lk flA4422 OS $0.13 Ost pouch absorbent materialA4423 OS $1.95 Ost pch for bar w lk fl/fltrA4424 OS $4.99 Ost pch drain w bar & filterA4425 OS $3.76 Ost pch drain for barrier flA4426 OS $2.87 Ost pch drain 2 piece systemA4427 OS $2.92 Ost pch drain/barr lk flng/fA4428 OS $6.84 Urine ost pouch w faucet/tapA4429 OS $8.66 Urine ost pouch w bltinconvA4430 OS $8.95 Ost urine pch w b/bltin conyA4431 OS $6.53 Ost pch urine w barrier/tapvA4432 OS $3.77 Os pch urine w bar/fange/tapA4433 OS $3.51 Urine ost pch bar w lock flnA4434 OS $3.95 Ost pch urine w lock flng/ftA4450 AU OS $0.09 Non-waterproof tapeA4450 AV OS $0.09 Non-waterproof tapeA4450 AW OS $0.12 Non-waterproof tapeA4452 AU OS $0.38 Waterproof tapeA4452 AV OS $0.38 Waterproof tapeA4452 AW OS $0.42 Waterproof tapeA4455 OS $1.47 Adhesive remover per ounce


A4456 OS $0.26 Adhesive remover, wipesA4461 SD $3.45 Surgicl dress hold non-reuseA4463 SD $13.98 Surgical dress holder reuseA4481 OS $0.39 Tracheostoma filterA4483 OS $0.00 Moisture exchangerA4556 SU $12.75 Electrodes, pairA4557 SU $18.84 Lead wires, pairA4558 SU $5.72 Conductive gel or pasteA4559 SU $0.11 Coupling gel or pasteA4561 PO $20.95 Pessary rubber, any typeA4562 PO $52.16 Pessary, non rubber,any typeA4595 SU $30.25 TENS suppl 2 lead per monthA4604 NU IN $60.46 Tubing with heating elementA4605 NU IN $17.22 Trach suction cath close sysA4608 OX $52.63 Transtracheal oxygen cathA4611 NU IN $206.27 Heavy duty batteryA4611 RR IN $21.39 Heavy duty batteryA4611 UE IN $154.71 Heavy duty batteryA4612 NU IN $71.34 Battery cablesA4612 RR IN $7.27 Battery cablesA4612 UE IN $54.40 Battery cablesA4613 NU IN $151.42 Battery chargerA4613 RR IN $15.15 Battery chargerA4613 UE IN $109.50 Battery chargerA4614 IN $24.97 Hand-held PEFR meterA4615 SU $0.75 Cannula nasalA4616 SU $0.07 Tubing (oxygen) per footA4617 SU $3.25 Mouth pieceA4618 NU IN $9.33 Breathing circuitsA4618 RR IN $1.07 Breathing circuitsA4618 UE IN $7.00 Breathing circuitsA4619 OX $1.27 Face tentA4620 SU $0.62 Variable concentration maskA4623 OS $6.88 Tracheostomy inner cannulaA4624 NU IN $2.47 Tracheal suction tubeA4625 OS $7.28 Trach care kit for new trachA4626 OS $3.35 Tracheostomy cleaning brushA4628 NU TN $3.85 Oropharyngeal suction cathA4629 OS $4.86 Tracheostomy care kitA4630 NU IN $5.97 Repl bat t.e.n.s. own by ptA4633 NU TN $43.09 Uvl replacement bulbA4635 NU IN $5.38 Underarm crutch padA4635 RR IN $0.72 Underarm crutch padA4635 UE IN $3.56 Underarm crutch padA4636 NU IN $3.24 Handgrip for cane etcA4636 NU KE TN $3.76 Handgrip for cane etcA4636 RR IN $0.39 Handgrip for cane etcA4636 RR KE IN $0.45 Handgrip for cane etcA4636 UE IN $2.36 Handgrip for cane etcA4636 UE KE IN $2.74 Handgrip for cane etcA4637 NU IN $1.93 Repl tip cane/crutch/walkerA4637 NU KE IN $2.24 Repl tip cane/crutch/walkerA4637 RR IN $0.27 Repl tip cane/crutch/walkerA4637 RR KE TN $0.32 Repl tip cane/crutch/walkerA4637 UE IN $1.46 Repl tip cane/crutch/walkerA4637 UE KE IN $1.69 Rcpl tip cane/crutch/walkerA4638 NU IN $0.00 Repl batt pulse gen sysA4638 RR IN $0.00 Repl batt pulse gen sysA4638 UE IN $0.00 Repl batt pulse gen sysA4639 NU IN $301.57 Infrared ht sys replcmnt padA4640 NU IN $62.79 Alternating pressure padA4640 RR IN $6.28 Alternating pressure padA4640 UE IN $47.10 Alternating pressure padA5051 OS $2.17 Pouch clsd w barr attachedA5052 OS $1.56 Clsd ostomy pouch w/o barrA5053 OS $1.83 Clsd ostomy pouch faceplateA5054 OS $1.88 Clsd ostomy pouch w/flangeA5055 OS $1.49 Stoma cap

UCJF 11:3-29.6

A5061 OS $3.70 Pouch drainable w barrier atA5062 OS $2.33 Drnble ostomy pouch w/o barrA5063 OS $2.84 Drain ostomy pouch w/flangeA5071 OS $6.31 Urinary pouch w/barrierA5072 OS $3.70 Urinary pouch w/o barrierA5073 OS $3.34 Urinary pouch on barn w/flngA5081 OS $3.47 Continent stoma plugA5082 OS $12.48 Continent stoma catheterA5083 OS $0.66 Stoma absorptive coverA5093 OS $2.04 Ostomy accessory convex inseA5102 OS $23.54 Bedside drain btl w/wo tubeA5105 OS $42.80 Urinary suspensoryA5112 OS $30.90 Urinary leg bagA5113 OS $4.94 Latex leg strapA5114 OS $9.39 Foam/fabric leg strapA5120 AU OS $0.26 Skin barrier, wipe or swabA5120 AV PO $0.25 Skin barrier, wipe or swabA5121 OS $6.87 Solid skin barrier 6x6A5122 OS $11.47 Solid skin barrier 8x8A5126 OS $1.39 Disk/foam pad +or- adhesiveA5131 OS $16.65 Appliance cleanerA5200 OS $11.87 Percutaneous catheter anchorA5500 TS $66.76 Diab shoe for density insertA5501 TS $200.25 Diabetic custom molded shoeA5503 TS $29.69 Diabetic shoe w/roller/rockrA5504 TS $29.69 Diabetic shoe with wedgeA5505 TS $29.69 Diab shoe w/metatarsal barA5506 TS $29.69 Diabetic shoe w/off set heelA5507 TS $29.69 Modification diabetic shoeA5512 TS $27.24 Multi den insert direct formA5513 TS $40.65 Multi den insert custom moldA6010 SD $32.51 Collagen based wound fillerA6011 SD $2.39 Collagen gel/paste wound filA6021 SD $22.07 Collagen dressing <=16 sq inA6022 SD $22.07 Collagen drsg>16<=48 sq inA6023 SD $199.82 Collagen dressing >48 sq inA6024 SD $6.50 Collagen dsg wound fillerA6154 SD $15.10 Wound pouch eachA6196 SD $7.72 Alginate dressing <=16 sq inA6197 SD $17.26 Alginate drsg >16 <=48 sq inA6199 SD $5.55 Alginate drsg wound fillerA6203 SD $3.52 Composite drsg <= 16 sq inA6204 SD $6.54 Composite drsg >1 6<=48 sq inA6207 SD $7.71. Contact layer >16<= 48 sq inA6209 SD $7.85 Foam drsg <=16 sq in w/o bdrA6210 SD $20.92 Foam drg >16<=48 sq in w/o bA6211 SD $30.84 Foam drg > 48 sq in w/o brdrA6212 SD $10.19 Foam drg <=16 sq in w/borderA6214 SD $10.80 Foam drg > 48 sq in w/borderA6216 SD $0.05 Non-sterile gauze<=16 sq inA6217 SD $0.00 Non-sterile gauze>16<=48 sqA6219 SD $1.00 Gauze <= 16 sq in w/borderA6220 SD $2.71 Gauze >16 <=48 sq in w/bordrA6222 SD $2.24 Gauze <=16 in no w/sal w/o bA6223 SD $2.54 Gauze >16<=48 no w/sal w/o bA6224 SD $3.79 Gauze > 48 in no w/sal w/o bA6229 SD $3.79 Gauze >16<=48 sq in watr/salA6231 SD $4.89 Hydrogel dsg<=16 sq inA6232 SD $7.22 Hydrogel dsg>16<=48 sq inA6233 SD $20.15 Hydrogel dressing >48 sq inA6234 SD $6.87 Hydrocolld drg <=16 w/o bdrA6235 SD $17.66 Hydrocoil d drg >16<=48 w/o bA6236 SD $28.61 Hydrocolld drg > 48 in w/o bA6237 SD $8.31 Hydrocolld drg <=16 in w/bdrA6238 SD $23.93 Hydrocolld drg >16<=48 w/bdrA6240 SD $12.85 Hydrocolld drg filler pasteA6241 SD $2.70 Hydrocolloid drg filler dryA6242 SD $6.37 Hydrogel drg <=16 in w/o bdr


A6243 SD $12.93 Hydrogel drg >16<=48 w/o bdrA6244 SD $41.24 Hydrogel drg >48 in w/o bdrA6245 SD $7.63 Hydrogel drg <= 16 in w/bdrA6246 SD $10.42 Hydrogel drg >16<=48 in w/bA6247 SD $24.97 Hydrogel dig > 48 sq in w/bA6248 SD $17.05 Hydrogel drsg gel fillerA6251 SD $2.09 Absorpt drg <=16 sq in w/o bA6252 SD $3.41 Absorpt drg >16 <=48 w/o bdrA6253 SD $6.66 Absorpt drg > 48 sq in w/o bA6254 SD $1.27 Absorpt drg <=16 sq in w/bdrA6255 SD $3.18 Absorpt drg >16<=48 in w/bdrA6257 SD $1.61 Transparent film <= 16 sq inA6258 SD $4.52 Transparent film >16<=48 inA6259 SD $11.49 Transparent film > 48 sq inA6266 SD $2.02 Impreg gauze no h20/sal/yardA6402 SD $0.13 Sterile gauze <= 16 sq inA6403 SD $0.45 Sterile gauze>16 <= 48 sq inA6407 SD $1.97 Packing strips, non-impregA6410 SD $0.41 Sterile eye padA6411 SD $0.00 Non-sterile eye padA6441 SD $0.70 Pad band w>=3" <5"/ydA6442 SD $0.18 Conform band n/s w<3"/ydA6443 SD $0.30 Conform band n/s w>=3"<5"/ydA6444 SD $0.59 Conform band n/s w>=5"/ydA6445 SD $0.34 Conform band s w <3"/ydA6446 SD $0.43 Conform band s w>=3" <5"/ydA6447 SD $0.70 Confom band s w >=5"/ydA6448 SD $1.22 Lt compres band <3"/ydA6449 SD $1.84 Lt compres band >=3" <5"/ydA6450 SD $0.00 Lt compres band >=5"/ydA6451 SD $0.00 Mod compres band w>=3"<5"/ydA6452 SD $6.21 High compres band w>=3"<5"ydA6453 SD $0.64 Self-adher band w <3"/ydA6454 SD $0.81 Self-adher band w>=3" <5"/ydA6455 SD $1.46 Self-adher band >=5"/ydA6456 SD $1.34 Zinc paste band w >=3"<5"/ydA6457 SD $1.20 Tubular dressingA6501 SD $0.00 Compres burngarment bodysuitA6502 SD $0.00 Compres burngarment chinstrpA6503 SD $0.00 Compres burngarment facehoodA6504 SD $0.00 Cmprsburngarment glove-wristA6505 SD $0.00 Cmprsburngarment glove-elbowA6506 SD $0.00 Cmprsbumgrmt glove-axillaA6507 SD $0.00 Cmprs burngarment foot-kneeA6508 SD $0.00 Cmprs burngarment foot-thighA6509 SD $0.00 Compres bum garment jacketA6510 SD $0.00 Compres bum garment leotardA6511 SD $0.00 Compres burn garment pantyA6513 SD $0.00 Compress bum mask face/neckA6531 AW SD $45.43 Compression stocking BK30-40A6532 AW SD $64.01 Compression stocking BK40-50A6545 SD $0.00 Grad comp non-elastic BKA6545 AW SD $89.45 Grad comp non-elastic BKA6550 SU $24.82 Neg pres wound ther drsg setA7000 NU IN $7.54 Disposable canister for pumpA7000 NU KE IN $8.75 Disposable canister for pumpA7001 NU IN $31.32 Nondisposable pump canisterA7002 NU IN $3.63 Tubing used w suction pumpA7003 NU IN $2.87 Nebulizer administration setA7004 NU IN $1.61 Disposable nebulizer sml volA7005 NU IN $29.18 Nondisposable nebulizer setA7006 NU IN $8.55 Filtered nebulizer admin setA7007 NU IN $4.17 Lg vol nebulizer disposableA7008 NU IN $11.55 Disposable nebulizer prefillA7009 NU IN $39.80 Nebulizer reservoir bottleA7010 NU IN $24.48 Disposable corrugated tubingA7012 NU IN $3.76 Nebulizer water collec devicA7013 NU IN $0.79 Disposable compressor filter

UCJF 11:3-29.6

A7014 NU IN $4.24 Compressor nondispos filterA7015 NU IN $1.73 Aerosol mask used w nebulizerA7016 NU IN $6.85 Nebulizer dome & mouthpieceA7017 NU IN $140.74 Nebulizer not used w oxygenA7017 RR IN $14.07 Nebulizer not used w oxygenA7017 UE IN $105.55 Nebulizer not used w oxygenA7018 SU $0.40 Water distilled w/nebulizerA7025 NU IN $456,69 Replace chest compress vestA7026 NU IN $30.19 Replace chst cmprss sys hoseA7027 NU IN $188.32 Combination oral/nasal maskA7028 NU IN $52.02 Repl oral cushion combo maskA7029 NU IN $21.25 Repl nasal pillow comb maskA7030 NU IN $170.72 CPAP full face maskA7031 NU IN $63.14 Replacement facemask interfaA7032 NU IN $36.68 Replacement nasal cushionA7033 NU IN $25.71 Replacement nasal pillowsA7034 NU IN $106.46 Nasal application deviceA7035 NU IN $32.06 Pos airway press headgearA7036 NU IN $16.47 Pos airway press chinstrapA7037 NU IN $35.49 Pos airway pressure tubingA7038 NU IN $4.15 Pos airway pressure filterA7039 NU IN $13.87 Filter, non disposable w papA7040 PO $41.45 One way chest drain valveA7041 PO $77.90 Water seal drain containerA7042 PO $173.36 Implanted pleural catheterA7043 PO $29.52 Vacuum drainagebottle/tubingA7044 NU IN $109.42 PAP oral interfaceA7045 NU IN $17.62 Repl exhalation port for PAPA7045 RR IN $1.76 Repl exhalation port for PAPA7045 UE IN $13.21 Repl exhalation port for PAPA7046 NU IN $17.66 Repl water chamber, PAP devA7501 OS $110.28 Tracheostoma valve w diaphraA7502 OS $52.41 Replacement diaphragm/fplateA7503 OS $11.90 HMES filter holder or capA7504 OS $0.70 Tracheostoma HMES filterA7505 OS $4.91 HMES or trach valve housingA7506 OS $0.35 HMES/trachvalve adhesivediskA7507 OS $2.61 Integrated filter & holderA7508 OS $3.01 Housing & Integrated AdhesivA7509 OS $1.48 Heat & moisture exchange sysA7520 OS $49.85 Trach/laryn tube non-cuffedA7521 OS $49.40 Trach/laryn tube cuffedA7522 OS $47.42 Trach/laryn tube stainlessA7524 OS $81.27 Tracheostoma stent/stud/bttnA7525 OS $2.17 Tracheostomy maskA7526 OS $3.54 Tracheostomy tube collarA7527 OS $3.76 Trach/laryn tube plug/stopA8000 NU IN $161.02 Soft protect helmet prefabA8000 RR IN $16.10 Soft protect helmet prefabA8000 UE IN $120.78 Soft protect helmet prefabA8001 NU IN $161.02 Hard protect helmet prefabA8001 RR IN $16.10 Hard protect helmet prefabA8001 UE IN $120.78 Hard protect helmet prefabA8002 NU IN $0.00 Soft protect helmet customA8002 RR IN $0.00 Soft protect helmet customA8002 UE IN $0.00 Soft protect helmet customA8003 NU IN $0.00 Hard protect helmet customA8003 RR IN $0.00 Hard protect helmet customA8003 UE IN $0.00 Hard protect helmet customA8004 NU IN $0.00 Repl soft interface, helmetA8004 RR IN $0.00 Repl soft interface, helmetA8004 UE IN $0.00 Repl soft interface, helmetE0100 NU IN $19.69 Cane adjust/fixed with tipE0100 RR IN $5.30 Cane adjust/fixed with tipE0100 UE IN $15.25 Cane adjust/fixed with tipE0105 NU IN $51.57 Cane adjust/fixed quad/3 proE0105 RR IN $7.91 Cane adjust/fixed quad/3 proE0105 UE IN $38.05 Cane adjust/fixed quad/3 pro


E0110 NU IN $76.20 Crutch forearm pairE0110 RR IN $14.27 Crutch forearm pairE0110 UE IN $57.14 Crutch foreann pairE0111 NU IN $55.92 Crutch forearm eachE0111 RR IN $8.75 Crutch forearm eachE0111 UE IN $43.16 Crutch foreariu eachE0112 NU IN $38.85 Crutch underarm pair woodE0112 RR IN $8.87 Crutch underarm pair woodE0112 UE IN $29.64 Crutch underarm pair woodE0113 NU IN $22.19 Crutch underarm each woodE0113 RR IN $5.41 Crutch underarm each woodE0113 UE IN $16.65 Crutch underarm each woodE0114 NU IN $49.55 Crutch underarm pair no woodE0114 RR IN $9.00 Crutch underarm pair no woodE0114 UE IN $37.45 Crutch underarm pair no woodE0116 NU IN $24.98 Crutch underarm each no woodE0116 RR IN $5.67 Crutch underann each no woodE0116 UE IN $18.73 Crutch underamn each no woodE0117 NU IN $202.35 Underarm springassist crutchE0117 RR IN $20.22 Underarm springassist crutchE0117 UE IN $151.78 Underarm springassist crutchE0130 NU IN $63.42 Walker rigid adjust/fixed htE0130 RR IN $15.22 Walker rigid adjust/fixed htE0130 UE IN $47.52 Walker rigid adjust/fixed htE0135 NU IN $67.40 Walker folding adjust/fixedE0135 RR IN $15.62 Walker folding adjust/fixedE0135 UE IN $49.48 Walker folding adjust/fixedE0140 NU IN $326.44 Walker w trunk supportE0140 RR IN $32.65 Walker w trunk supportE0140 UE IN $244.84 Walker w trunk supportE0141 NU IN $104.34 Rigid wheeled walker adj/fixE0141 RR IN $20.24 Rigid wheeled walker adj/fixE0141 UE IN $78.26 Rigid wheeled walker adj/fixE0143 NU IN $108.81 Walker folding wheeled w/o sE0143 RR IN $19.54 Walker folding wheeled w/o sE0143 UE IN $81.43 Walker folding wheeled w/o sE0144 NU IN $288.20 Enclosed walker w rear seatE0144 RR IN $24.51 Enclosed walker w rear seatE0144 UE IN $183.72 Enclosed walker w rear seatE0147 NU IN $520.20 Walker variable wheel resistE0147 RR IN $52.02 Walker variable wheel resistE0147 UE IN $390.17 Walker variable wheel resistE0148 NU IN $114.98 Heavyduty walker no wheelsE0148 RR IN $11.51 Heavyduty walker no wheelsE0148 UE IN $86.23 Heavyduty walker no wheelsE0149 NU IN $202.00 Heavy duty wheeled walkerE0149 RR IN $20.20 Heavy duty wheeled walkerE0149 UE IN $151.49 Heavy duty wheeled walkerE0153 NU IN $72.85 Forearm crutch platform attaE0153 RR IN $8.23 Forearm crutch platform attaE0153 UE IN $54.63 Forearm crutch platform attaE0154 NU IN $63.81 Walker platform attachmentE0154 RR IN $7.75 Walker platform attachmentE0154 UE IN $48.48 Walker platform attachmentE0155 NU IN $28.56 Walker wheel attachment,pairE0155 RR IN $3.48 Walker wheel attachment,pairE0155 UE IN $21.77 Walker wheel attachment,pairE0156 NU IN $23.92 Walker seat attachmentE0156 RR IN $3.06 Walker seat attachmentE0156 UE IN $17.96 Walker seat attachmentE0157 NU IN $63.02 Walker crutch attachmentE0157 RR IN $8.14 Walker crutch attachmentE0157 UE IN $47.2 Walker crutch attachmentE0158 NU IN $29.12 Walker leg extenders set of4E0158 RR IN $3.21 Walker leg extenders set of4E0158 UE IN $21.98 Walker leg extenders set of4E0159 NU IN $16.12 Brake for wheeled walkerE0159 RR IN $1.63 Brake for wheeled walker

UCJF 11:3-29.6

E0159 UE IN $12.11 Brake for wheeled walkerE0160 NU IN $29.50 Sitz type bath or equipmentE0160 RR IN $4.55 Sitz type bath or equipmentE0160 UE IN $22.11 Sitz type bath or equipmentE0161 NU IN $27.54 Sitz bath/equipment w/faucetE0161 RR IN $3.75 Sitz bath/equipment w/faucetE0161 UE IN $20.62 Sitz bath/equipment w/faucetE0162 NU IN $152.99 Sitz bath chairE0162 RR IN $16.05 Sitz bath chairE0162 UE IN $118.65 Sitz bath chairE0163 NU IN $115.80 Commode chair with fixed armE0163 RR IN $25.65 Commode chair with fixed armE0163 UE IN $80.80 Commode chair with fixed armE0165 RR CR $19.13 Commode chair with detacharmE0167 NU IN $12.60 Commode chair pail or panE0167 RR IN $1.32 Commode chair pail or panE0167 UE IN $9.49 Comninode chair pail or panE0168 NU IN $158.47 Heavyduty/wide commode chairE0168 RR IN $15.93 Heavyduty/wide commode chairE0168 UE IN $118.84 Heavyduty/wide commode chairE0170 RR CR $168.76 Commode chair electricE0171 RR CR $30.37 Commode chair non-electricE0175 NU IN $69.54 Commode chair foot restE0175 RR IN $5.91 Commode chair foot restE0175 UE IN $43.50 Commode chair foot restE0181 RR CR $27.36 Press pad alternating w/ pumE0182 RR CR $27.49 Replace pump, alt press padE0184 NU IN $173.77 Dry pressure mattressE0184 RR IN $25.80 Dry pressure mattressE0184 UE IN $133.27 Dry pressure mattressE0185 NU IIN $285.47 Gel pressure mattress padE0185 RR IN $47.19 Gel pressure mattress padE0185 UE IN $219.09 Gel pressure mattress padE0186 RR CR $21.32 Air pressure mattressE0187 RR CR $23.70 Water pressure mattressE0188 NU IN $27.75 Synthetic sheepskin padE0188 RR IN $3.26 Synthetic sheepskin padE0188 UE IN $20.84 Synthetic sheepskin padE0189 NU IN $46.38 Lambswool sheepskin padE0189 RR IN $5.91 Lambswool sheepskin padE0189 UE IN $34.79 Lambswool sheepskin padE0191 NU IN $10.49 Protector heel or elbowE0191 RR IN $1.07 Protector heel or elbowE0191 UE IN $7.83 Protector heel or elbowE0193 RR CR $786.82 Powered air flotation bedE0194 RR CR $3,307.35 Air fluidized bedE0196 RR CR $28.99 Gel pressure mattressE0197 NU IN $197.76 Air pressure pad for mattresE0197 RR IN $32.10 Air pressure pad for mattresE0197 UE IN $173.71 Air pressure pad for mattresE0198 NU IN $197.76 Water pressure pad for mattrE0198 RR IN $24.10 Water pressure pad for mattrE0198 UE IN $150.07 Water pressure pad for mattrE0199 NU IN $33.65 Dry pressure pad for mattresE0199 RR IN $3.35 Dry pressure pad for mattresE0199 UE IN $25.24 Dry pressure pad for mattresE0200 NU IN $70.75 Heat lamp without standE0200 RR IN $11.30 Heat lamp without standE0200 UE IN $53.09 Heat lamp without standE0202 RR CR $65.74 Phototherapy light w/ photomE0205 NU IN $173.20 Heat lamp with standE0205 RR IN $20.84 Heat lamp with standE0205 UE IN $129.90 Heat lamp with standE0210 NU IN $34.27 Electric heat pad standardE0210 RR IN $3.22 Electric heat pad standardE0210 UE IN $25.70 Electric heat pad standardE0215 NU IN $63.22 Electric heat pad moistE0215 RR IN $6.95 Electric heat pad moist


E0215 UE IN $47.43 Electric heat pad moistE0217 NU IN $443.10 Water circ heat pad w pumpE0217 RR IN $49.33 Water circ heat pad w pumpE0217 UE IN $332.30 Water circ heat pad w pumpE0220 NU IN $7.56 Hot water bottleE0220 RR IN $0.79 Hot water bottleE0220 UE IN $5.65 Hot water bottleE0225 NU IN $346.87 Hydrocollator unitE0225 RR IN $34.20 Hydrocollator unitE0225 UE IN $260.14 Hydrocollator unitE0230 NU IN $7.57 Ice cap or collarE0230 RR IN $0.85 Ice cap or collarE0230 UE IN $5.66 Ice cap or collarE0235 RR CR $18.12 Paraffin bath unit portableE0236 RR CR $40.19 Pump for water circulating pE0238 NU IN $28.38 Heat pad non-electric moistE0238 RR IN $2.86 Heat pad non-electric moistE0238 UE IN $20.87 Heat pad non-electric moistE0239 NU IN $472.32 Hydrocollator unit portableE0239 RR IN $47.24 Hydrocollator unit portableE0239 UE IN $354.26 Hydrocollator unit portableE0249 NU IN $104.58 Pad water circulating heat uE0249 RR IN $11.50 Pad water circulating heat uE0249 UE IN $78.44 Pad water circulating heat uE0250 RR CR $84.09 Hosp bed fixed ht w/ mattresE0251 RR CR $61.24 Hosp bed fixd ht w/o mattresE0255 RR CR $91.93 Hospital bed var ht w/ mattrE0256 RR CR $64.12 Hospital bed var ht w/o mattE0260 RR CR $127.12 Hosp bed semi-electr w/ mattE0261 RR CR $105.34 Hosp bed semi-electr w/o matE0265 RR CR $173.87 Hosp bed total electr w/ matE0266 RR CR $160.72 Hosp bed total elec w/o mattE0271 NU IN $191.13 Mattress innerspringE0271 RR IN $20.87 Mattress innerspringE0271 UE IN $143.32 Mattress innerspringE0272 NU IN $176.39 Mattress foam rubberE0272 RR IN $19.12 Mattress foam rubberE0272 UE IN $132.29 Mattress foam rubberE0275 NU IN $16.08 Bed pan standardE0275 RR IN $1.68 Bed pan standardE0275 UE IN $12.05 Bed pan standardE0276 NU IN $13.97 Bed pan fractureE0276 RR IN $1.65 Bed pan fractureE0276 UE IN $11.05 Bed pan fractureE0277 RR CR $584.14 Powered pres-redu air mattrsE0280 NU IN $33.49 Bed cradleE0280 RR IN $3.72 Bed cradleE0280 UE IN $25.11 Bed cradleE0290 RR CR $57.49 Hosp bed fx ht w/o rails w/mE0291 RR CR $41.77 Hosp bed fx ht w/o rail w/oE0292 RR CR $64.65 Hosp bed var ht w/o rail w/oE0293 RR CR $62.16 Hosp bed var ht w/o rail w/E0294 RR CR $100.88 Hosp bed semi-elect w/ mattE0295 RR CR $100.88 Hosp bed semi-elect w/o mattE0296 RR CR $127.56 Hosp bed total elect w/ mattE0297 RR CR $127.31 Hosp bed total elect w/o matE0300 NU IN $2,568.95 Enclosed ped crib hosp gradeE0300 RR IN $256.89 Enclosed ped crib hosp gradeE0300 UE IN $1,926.71 Enclosed ped crib hosp gradeE0301 RR CR $228.58 HD hosp bed, 350-600 lbsE0302 RR CR $647.47 Ex hd hosp bed > 600 lbsE0303 RR CR $258.68 Hosp bed hvy dty xtra wideE0304 RR CR $697.46 Hosp bed xtra hvy dty x wideE0305 RR CR $13.69 Rails bed side half lengthE0310 NU IN $175.70 Rails bed side full lengthE0310 RR IN $20.60 Rails bed side full lengthE0310 UE IN $132.95 Rails bed side full lengthE0316 RR CR $191.21 Bed safety enclosure

UCJF 11:3-29.6

E0325 NU IN $9.03 Urinal male jug-typeE0325 RR IN $1.59 Urinal male jug-typeE0325 UE IN $6.48 Urinal male jug-typeE0326 NU IN $11.03 Urinal female jug-typeE0326 RR IN $1.25 Urinal female jug-typeE0326 UE IN $8.26 Urinal female jug-typeE0371 RR CR $377.47 Nonpower mattress overlayE0372 RR CR $458.01 Powered air mattress overlayE0373 RR CR $524.67 Nonpowered pressure mattressE0424 RR OX $173.17 Stationary compressed gas 02E0431 RR OX $28.77 Portable gaseous 02E0433 RR OX $51.63 Portable liquid oxygen sysE0434 RR OX $28.77 Portable liquid 02E0439 RR OX $173.17 Stationary liquid 02E0441 OX $77.45 Stationary 02 contents, gasE0442 OX $77.45 Stationary 02 contents, liqE0443 OX $77,45 Portable 02 contents, gasE0444 OX $77.45 Portable 02 contents, liquidE0450 RR FS $1,002.25 Vol control vent invasiv intE0457 NU IN $645.24 Chest shellE0457 RR IN $64.52 Chest shellE0457 UE IN $483.89 Chest shellE0459 RR CR $53.43 Chest wrapE0460 RR FS $654.71 Neg press vent portabl/statnE0461 RR FS $1,002.25 Vol control vent noninv intE0462 RR CR $305.97 Rocking bed w/ or w/o side rE0463 RR FS $1,476.70 Press supp vent invasive intE0464 RR FS $1,476.70 Press supp vent noninv intE0470 RR CR $197.39 RAD w/o backup non-inv intfcE0471 RR CR $493.99 RAD w/backup non inv mineE0472 RR CR $493.99 RAD w backup invasive intrfcE0480 RR CR $46.14 Percussor elect/pneum home mE0482 RR CR $423.71 Cough stimulating deviceE0483 RR CR $1,116.29 Chest compression gen systemE0484 NU IN $38.77 Non-elec oscillatory pep dvcE0484 RR IN $3.87 Non-elec oscillatory pep dvcE0484 UE IN $29.09 Non-elec oscillatory pep dvcE0485 NU IN $0.00 Oral device/appliance prefabE0485 RR IN $0.00 Oral device/appliance prefabE0485 UE IN $0.00 Oral device/appliance prefabE0486 NU IN $0.00 Oral device/appliance cusfabE0486 RR IN $0.00 Oral device/appliance cusfabE0486 UE IN $0.00 Oral device/appliance cusfabE0500 RR FS $115.26 Ippb all typesE0550 RR CR $52.64 Humidif extens supple w ippbE0560 NU IN $131.95 Humidifier supplemental w/ iE0560 RR IN $15.46 Humidifier supplemental w/ iE0560 UE IN $98.96 Humidifier supplemental w/ iE0561 NU IN $96.84 Humidifier nonheated w PAPE0561 RR IN $9.67 Humidifier nonheated w PAPE0561 UE IN $72.62 Humidifier nonheated w PAPE0562 NU IN $272.60 Humidifier heated used w PAPE0562 RR IN $27.25 Humidifier heated used w PAPE0562 UE IN $204.45 Humidifier heated used w PAPE0565 RR CR $54.45 Compressor air power sourceE0570 RR CR $16.91 Nebulizer with compressionE0571 RR CR $29.69 Aerosol compressor for svnebE0572 RR CR $37.73 Aerosol compressor adjust prE0574 RR CR $39.87 Ultrasonic generator w svnebE0575 RR FS $107.92 Nebulizer ultrasonicE0580 NU IN $121.31 Nebulizer for use w/regulatE0580 RR IN $12.13 Nebulizer for use w/regulatE0580 UE IN $90.97 Nebulizer for use w/ regulatE0585 RR CR $36.82 Nebulizer w/ compressor & heE0600 RR CR $46.23 Suction pump portab hom modlE0601 RR CR $90.59 Cont airway pressure deviceE0602 NU IN $31.00 Manual breast pumpE0602 RR IN $3.11 Manual breast pump


E0602 UE IN $23.25 Manual breast pumpE0605 NU IN $27.75 Vaporizer room typeE0605 RR IN $3.22 Vaporizer room typeE0605 UE IN $22.86 Vaporizer room typeE0606 RR CR $20.48 Drainage board posturalE0607 NU IN $70.16 Blood glucose monitor homeE0607 RR IN $7.01 Blood glucose monitor homeE0607 UE IN $52.61 Blood glucose monitor homeE0610 NU IN $249.75 Pacemaker monitr audible/visE0610 RR IN $26.34 Pacemaker monitr audible/visE0610 UE IN $187.34 Pacemaker monitr audible/visE0615 NU IN $442.62 Pacemaker monitr digital/visE0615 RR IN $61.43 Pacemaker monitr digital/visE0615 UE IN $331.97 Pacemaker monitr digital/visE0617 RR CR $319.25 Automatic ext defibrillatorE0617 RR KF CR $354.45 Automatic ext defibrillatorE0618 RR CR $257.49 Apnea monitorE0619 RR CR $0.00 Apnea monitor w recorderE0620 NU IN $918.11 Cap bld skin piercing laserE0620 RR IN $91.80 Cap bld skin piercing laserE0620 UE IN $688.58 Cap bld skin piercing laserE0621 NU IN $85.67 Patient lift sling or seatE0621 RR IN $9.71 Patient lift sling or seatE0621 UE IN $64.58 Patient lift sling or seatE0627 NU IN $347.25 Seat lift incorp lift-chairE0627 RR IN $34.73 Seat lift incorp lift-chairE0627 UE IN $260.41 Seat lift incorp lift-chairE0628 NU IN $347.25 Seat lift for pt furn-electrE0628 RR IN $34.73 Seat lift for pt furn-electrE0628 UE IN $260.41 Seat lift for pt furn-electrE0629 NU IN $347.25 Seat lift for pt furn-non-elE0629 RR IN $34.73 Seat lift for pt furn-non-elE0629 UE IN $260.41 Seat lift for pt furn-non-elE0630 RR CR $101.67 Patient lift hydraulicE0635 RR CR $109.21 Patient lift electricE0636 RR CR $1,107.29 PT support & positioning sysE0650 NU IN $686.85 Pneuma compresor non-segmentE0650 RR IN $93.31 Pneuma compresor non-segmentE0650 UE IN $515.15 Pneuma compresor non-segmentE0651 NU IN $964.34 Pneum compressor segmentalE0651 RR IN $96.44 Pneum compressor segmentalE0651 UE IN $723.26 Pneum compressor segmentalE0652 NU IN $4,731.54 Pneum compres w/cal pressureE0652 RR IN $467.63 Pneum compres w/cal pressureE0652 UE IN $4,126.23 Pneum compres w/cal pressureE0655 NU IN $109.78 Pneumatic appliance half armE0655 RR IN $13.31 Pneumatic appliance half armE0655 UE IN $82.31 Pneumatic appliance half armE0656 NU IN $606.60 Segmental pneumatic trunkE0656 RR IN $60.59 Segmental pneumatic trunkE0656 UE IN $455.01 Segmental pneumatic trunkE0657 NU IN $569.88 Segmental pneumatic chestE0657 RR IN $56.89 Segmental pneumatic chestE0657 UE IN $427.44 Segmental pneumatic chestE0660 NU IN $167.74 Pneumatic appliance full legE0660 RR IN $17.46 Pneumatic appliance full legE0660 UE IN $115.91 Pneumatic appliance full legE0665 NU IN $122.26 Pneumatic appliance full ainlE0665 RR IN $14.77 Pneumatic appliance full armB0665 UE IN $91.82 Pneumatic appliance full aimE0666 NU IN $144.98 Pneumatic appliance half legE0666 RR IN $14.94 Pneumatic appliance half legE0666 UE IN $108.77 Pneumatic appliance half legE0667 NU IN $339.96 Seg pneumatic appl full legE0667 RR IN $34.00 Seg pneumatic appl full legE0667 UE IN $254.96 Seg pneumatic appl full legE0668 NU IN $394.37 Seg pneumatic appl full armE0668 RR IN $38.92 Seg pneumatic appl full arm

UCJF 11:3-29.6

E0668 UE IN $295.79 Seg pneumatic appl full armE0669 NU IN $182.76 Seg pneumatic appli half legE0669 RR IN $18.28 Seg pneumatic appli half legE0669 UE IN '$137.09 Seg pneumatic appli half legE0671 NU IN $436.12 Pressure pneum appl full legE0671 RR IN $43.62 Pressure pneum appl full legE0671 UE IN $327.08 Pressure pneum appl full legE0672 NU IN $338.87 Pressure pneum appl full armE0672 RR IN $33.89 Pressure pneum appl full armE0672 UE IN $254.16 Pressure pneum appl full armE0673 NU IN $281.58 Pressure pneum appl half legE0673 RR IN $28.16 Pressure pneum appl half legE0673 UE IN $211.21 Pressure pneLun appl half legE0675 RR CR $403.78 Pneumatic compression deviceE0691 NU IN $943.52 Uvl pnl 2 sq ft or lessE0691 RR IN $94.35 Uvl pnl 2 sq ft or lessE0691 UE IN $707.64 Uvl pnl 2 sq ft or lessE0692 NU IN $1,184.79 Uvl sys panel 4 ftE0692 RR IN $118.47 Uvl sys panel 4 ftE0692 UE IN $888.60 Uv1 sys panel 4 ftE0693 NU IN $1,460.53 Uvl sys panel 6 ftE0693 RR IN $146.06 Uvl sys panel 6 ftE0693 UE IN $1,095.40 Uvl sys panel 6 ftE0694 NU IN $4,648.71 Uvl and cabinet sys 6 ftE0694 RR IN $464.87 Uvl and cabinet sys 6 ftE0694 UE IN $3,486.56 Uvl and cabinet sys 6 ftE0705 NU IN $49.59 Transfer deviceE0705 RR IN $5.01 Transfer deviceE0705 UE IN $37.21 Transfer deviceE0720 NU TE $95.00 Tens two leadE0730 NU TE $100.00 Tens four leadE0731 NU IN $374.52 Conductive garment for tens/E0740 NU IN $549.01 Incontinence treatment systmE0740 RR IN $54.90 Incontinence treatment systmE0740 UE IN $411.79 Incontinence treatment systmE0744 RR CR $96.15 Neuromuscular stim for scoliE0745 NU IN $200.00 Neuromuscular stim for shockE0745 RR CR $20.00 Neuromuscular stim for shockE0747 NU KF IN $3,963.48 Elec osteogen stim not spineE0747 RR KF IN $396.32 Elec osteogen stim not spineE0747 UE KF IN $2,972.60 Elec osteogen stim not spineE0748 NU KF IN $4,085.24 Elec osteogen stim spinalE0748 RR KF IN $408.52 Elec osteogen stim spinalE0748 UE KF IN $3,063.94 Elec osteogen stim spinalE0749 RR KF CR $298.59 Elec osteogen stim implantedE0760 NU KF IN $3,394.76 Osteogen ultrasound stimltorE0760 RR KF IN $339.49 Osteogen ultrasound stimltorE0760 UE KF IN $2,546.07 Osteogen ultrasound stimltorE0762 NU IN $1,154.54 Trans elec jt stim dev sysE0762 RR IN $115.46 Trans elec jt stim dev sysE0762 UE IN $865.88 Trans elec jt stim dev sysE0764 NU KF IN $11,620.16 Functional neuromuscularstim.E0764 RR KF IN $1,162.00 Functional neuromuscularstimE0764 UE KF IN $8,715.13 Functional neuromuscularstimE0765 NU IN $88.34 Nerve stimulator for tx n&vE0765 RR IN $8.85 Nerve stimulator for tx n&vE0765 UE IN $66.28 Nerve stimulator for tx n&vE0776 NU IN $127.77 Iv poleE0776 RR IN $19.58 Iv poleE0776 UE IN $94.01 Iv poleE0779 RR CR $17.57 Amb infusion pump mechanicalE0780 NU IN $10.89 Mech amb infusion pump <8hrsE0781 RR CR $236.39 External ambulatory infus puE0782 NU KF IN $4,508.08 Non-programble infusion pumpE0782 RR KF IN $450.83 Non-programble infusion pumpE0782 UE KF IN $3,381.07 Non-programble infusion pumpE0783 NU KF IN $8,202.34 Programmable infusion pumpE0783 RR KF IN $820.25 Programmable infusion pump


E0783 UE KF IN $6,151.77 Programmable infusion pumpE0784 RR CR $438.45 Ext amb infusn pump insulinE0785 KF IN $421.71 Replacement impl pump cachetE0786 NU KF IN $8,082.48 Implantable pump replacementE0786 RR KF IN $808.25 Implantable pump replacementE0786 UE KF IN $6,061.88 Implantable pump replacementE0791 RR CR $282.21 Parenteral infusion pump staE0840 NU IN $65.40 Tract frame attach headboardE0840 RR IN $14.57 Tract frame attach headboardE0840 UE IN $49.03 Tract frame attach headboardE0849 NU IN $541.08 Cervical pneum trac equipE0849 RR IN $54.11 Cervical pneurn trac equipE0849 UE IN $405.78 Cervical pneum trac equipE0850 NU IN $93.76 Traction stand free standingE0850 RR IN $12.88 Traction stand free standingE0850 UE IN $70.33 Traction stand free standingE0855 NU IN $527.76 Cervical traction equipmentE0855 RR IN $52.77 Cervical traction equipmentE0855 UE IN $395.81 Cervical traction equipmentE0856 NU IN $161.73 Cervic collar w air bladderE0856 RR IN $16.19 Cervic collar w air bladderE0856 UE IN $121.31 Cervic collar w air bladderE0860 NU IN $35.74 Tract equip cervical tractE0860 RR IN $6.84 Tract equip cervical tractE0860 UE IN $26.81 Tract equip cervical tractE0870 NU IN $110.31 Tract frame attach footboardE0870 RR IN $13.88 Tract frame attach footboardE0870 UE IN $82.74 Tract frame attach footboardE0880 NU IN $112.05 Trac stand free stand extremeE0880 RR IN $20.70 Trac stand free stand extremeE0880 UE IN $84.80 Trac stand free stand extremeE0890 NU IN $107.47 Traction frame attach pelvicE0890 RR IN $34.47 Traction frame attach pelvicE0890 UE IN $86.56 Traction frame attach pelvicE0900 NU IN $114.35 Trac stand free stand pelvicE0900 RR IN $29.00 Trac stand free stand pelvicE0900 UE IN $85.79 Trac stand free stand pelvicE0910 RR CR $17.70 Trapeze bar attached to bedE0911 RR CR $45.11 HD trapeze bar attach to bedE0912 RR CR $103.60 HD trapeze bar free standingE0920 RR CR $41.67 Fracture frame attached to bE0930 RR CR $41.67 Fracture frame free standingE0935 RR FS $23.87 Cont pas motion exercise devE0940 RR CR $28.67 Trapeze bar free standingE0941 RR CR $40.67 Gravity assisted traction deE0942 NU IN $20.84 Cervical head harness/halterE0942 RR IN $2.46 Cervical head harness/halterE0942 UE IN $15.62 Cervical head harness/halterE0944 NU IN $43.08 Pelvic belt/harness/bootE0944 RR IN $4.83 Pelvic belt/harness/bootE0944 UE IN $32.32 Pelvic belt/haniess/bootE0945 NU IN $46.54 Belt/harness extremityE0945 RR IN $4.66 Belt/harness extremityE0945 UE IN $36.03 Belt/harness extremityE0946 RR CR $62.12 Fracture frame dual w crossE0947 NU IN $636.78 Fracture frame attachmnts peE0947 RR IN $66.03 Fracture frame attachmnts peE0947 UE IN $477.58 Fracture frame attachmnts peE0948 NU IN $615.92 Fracture frame attachmnts ccE0948 RR IN $61.57 Fracture frame attachmnts ccE0948 UE IN $434.39 Fracture frame attachmnts ccE0950 NU IN $94.07 TrayE0950 NU KE IN $109.15 TrayE0950 RR IN $9.42 TrayE0950 RR KE IN $10.93 TrayE0950 UE IN $70.56 TrayE0950 UE KE IN $81.87 TrayE0951 NU IN $17.18 Loop heel

UCJF 11:3-29.6

E0951 NU KE IN $19.93 Loop heelE0951 RR IN $1.72 Loop heelE0951 RR KE IN $2.00 Loop heelE0951 UE IN $12.87 Loop heelE0951 UE KE IN $14.93 Loop heelE0952 NU IN $17.04 Toe loop/holder, eachE0952 NU KE IN $19.77 Toe loop/holder, eachE0952 RR IN $1.71 Toe loop/holder, eachE0952 RR KE IN $1.98 Toe loop/holder, eachE0952 UE IN $12.79 Toe loop/holder, eachE0952 UE KE IN $14.84 Toe loop/holder, eachE0955 NU IN $182.97 Cushioned headrestE0955 NIT KE IN $212.29 Cushioned headrestE0955 RR IN $18.31 Cushioned headrestE0955 RR KE IN $21.24 Cushioned headrestE0955 UE IN $137.23 Cushioned headrestE0955 UE KE IN $159.21 Cushioned headrestE0956 NU IN $89.21 W/c lateral trunk/hip supporE0956 NU KE IN $103.51 W/c lateral trunk/hip supporE0956 RR IN $8.93 W/C lateral trunk/hip supporE0956 RR KE IN $10.36 W/c lateral trunk/hip supporE0956 UE IN $66.91 W/c lateral trunk/hip supporE0956 UE KE IN $77.63 W/c lateral trunk/hip supporE0957 NU IN $124.83 W/c medial thigh supportE0957 NU KE IN $144.83 W/c medial thigh supportE0957 RR IN $12.48 W/c medial thigh supportE0957 RR KE IN $14.48 W/c medial thigh supportE0957 UE IN $93.62 W/c medial thigh supportE0957 UE KE TN $108.62 W/c medial thigh supportE0958 RR CR $44.53 Whlchr att- cony 1 arm driveE0959 NU IN $46.42 Amputee adapterE0959 RR IN $4.67 Amputee adapterE0959 UE IN $35.13 Amputee adapterE0960 NU IN $82.34 W/c shoulder harness/strapsE0960 NU KE IN $95.53 W/c shoulder harness/strapsE0960 RR IN $8.24 W/c shoulder harness/strapsE0960 RR KE IN $9.56 W/c shoulder harness/strapsE0960 UE IN $61.76 W/c shoulder harness/strapsE0960 UE KE IN $71.65 W/c shoulder harness/strapsE0961 NU IN $26.55 Wheelchair brake extensionE0961 RR IN $2.77 Wheelchair brake extensionE0961 UE IN $13.26 Wheelchair brake extensionE0966 NU IN $67.97 Wheelchair head rest extensiE0966 RR IN $6.79 Wheelchair head rest extensiE0966 UE IN $50.98 Wheelchair head rest extensiE0967 NU IN $68.94 Manual we hand rim w projectE0967 RR IN $6.89 Manual we hand rim w projectE0967 UE IN $51.71 Manual we hand rim w projectE0968 RR CR $18.83 Wheelchair commode seatE0969 NU IN $153.50 Wheelchair narrowing deviceE0969 RR IN $15.36 Wheelchair narrowing deviceE0969 UE IN $115.12 Wheelchair narrowing deviceE0971 NU IN $45.56 Wheelchair anti-tipping deviE0971 RR IN $4.56 Wheelchair anti-tipping deviE0971 UE TN $34.19 Wheelchair anti-tipping deviE0973 NU IN $104.05 W/Ch access det adj armrestE0973 NU KE IN $120.72 W/Ch access det adj armrestE0973 RR IN $9.91 W/Ch access det adj armrestE0973 RR KE TN $11.50 W/Ch access det adj armrestE0973 UE IN $78.04 W/Ch access det adj armrestE0973 UE KE IN $90.54 W/Ch access det adj armrestE0974 NU IN $82.33 W/Ch access anti-rollbackE0974 RR IN $8.73 W/Ch access anti-rollbackE0974 UE IN $62.21 W/Ch access anti-rollbackE0978 NU IN $38.64 W/C acc,saf belt pelv strapE0978 NU KE IN $44.84 W/C acc,saf belt pelv strapE0978 RR IN $3.87 W/C acc,saf belt pelv strapE0978 RR KE IN $4.49 W/C acc,saf belt pelv strap


E0978 UE IN $28.65 W/C acc,saf belt pelv strapE0978 UE IN $33.24 W/C acc,saf belt pelv strapE0980 NU IN $34.71 Wheelchair safety vestE0980 RR IN $3.47 Wheelchair safety vestB0980 UE I N $25.89 Wheelchair safety vestE0981 NU IN $42.67 Seat upholstery, replacementE0981 NU KE IN $49.51 Seat upholstery, replacementE0981 RR IN $4.34 Seat upholstery, replacementE0981 RR KE IN $5.04 Seat upholstery, replacementE0981 UE IN $32.31 Seat upholstery, replacementE0981 UE KE IN $37.49 Seat upholstery, replacementE0982 NU IN $46.63 Back upholstery, replacementE0982 NU KE IN $54.11 Back upholstery, replacementE0982 RR IN $4.66 Back upholstery, replacementE0982 RR KE IN $5.41 Back upholstery, replacementB0982 UE IN $34.97 Back upholstery, replacementE0982 UE KE IN $40.57 Back upholstery, replacementE0983 RR CR $246.77 Add pwr joystickE0984 NU IN $1,705.19 Add pwr tillerE0984 RR IN $158.56 Add pwr tillerE0984 UE IN $1,315.78 Add pwr tillerE0985 NU IN $212.99 W/c seat lift mechanismE0985 RR IN $21.32 W/c seat lift mechanismE0985 UE IN $159.73 W/c seat lift mechanismE0986 NU IN $5,107.45 Man w/c push-rim pow assistE0986 RR IN $510.75 Man w/c push-rim pow assistE0986 UE IN $3,830.61 Man w/c push-rim pow assistE0990 NU IN $90.33 Wheelchair elevating leg resE0990 NU KE IN $104.81 Wheelchair elevating leg resE0990 RR IN $11.96 Wheelchair elevating leg resE0990 RR KE IN $13.88 Wheelchair elevating leg resE0990 UE IN $70.58 Wheelchair elevating leg resE0990 UE KE IN $81.89 Wheelchair elevating leg resE0992 NU IN $84.92 Wheelchair. solid seat insertE0992 RR IN $8.25 Wheelchair solid seat insertE0992 UE IN $63.70 Wheelchair solid seat insertE0994 NU IN $17.65 Wheelchair arm restE0994 RR IN $1.76 Wheelchair arm restE0994 UE IN $13.25 Wheelchair arm restE0995 NU IN $23.92 Wheelchair calf restE0995 NU KE IN $27.75 Wheelchair calf restE0995 RR IN $2.40 Wheelchair calf restE0995 RR KE IN $2.78 Wheelchair calf restE0995 UE IN $17.96 Wheelchair calf restE0995 UE KE IN $20.84 Wheelchair calf restE1002 NU IN $3,668.16 Pwr seat tiltE1002 NU KE IN $4,255.87 Pwr seat tiltE1002 RR IN $366.81 Pwr seat tiltE1002 RR KE IN $425.59 Pwr seat tiltE1002 UE IN $2,751.11 Pwr seat tiltE1002 UE KE IN $3,191.90 Pwr seat tiltE1003 NU IN $3,974.13 Pwr seat reclineE1003 NU KE IN $4,610.87 Pwr seat reclineE1003 RR IN $397.42 Pwr seat reclineE1003 RR KE IN $461.10 Pwr seat reclineE1003 UE IN $2,980.60 Pwr seat reclineE1003 UE KE IN $3,458.15 Pwr seat reclineE1004 NU IN $4,406.49 Pwr seat recline mechE1004 NU KE IN $5,112.50 Pwr seat recline mechE1004 RR IN $440.64 Pwr seat recline mechE1004 RR KE IN $511.25 Pwr seat recline mechE1004 UE IN $3,304.85 Pwr seat recline mechE1004 UE KE IN $3,834.36 Pwr seat recline mechE1005 NU IN $4,769.68 Pwr seat recline pwrE1005 NU KE IN $5,533.88 Pwr seat recline pwrE1005 RR IN $476.96 Pwr seat recline pwrE1005 RR KE IN $553.38 Pwr seat recline pwrE1005 UE IN $3,577.27 Pwr seat recline pwr

UCJF 11:3-29.6

E1005 UE KE IN $4,150.42 Pwr seat recline pwrE1006 NU IN $5,842.41 Pwr seat combo w/o shearE1006 NU KE IN $6,778.49 Pwr seat combo w/o shearE1006 RR IN $584.22 Pwr seat combo w/o shearE1006 RR KE IN $677.83 Pwr seat combo w/o shearE1006 UE IN $4,381.81 Pwr seat combo w/o shearE1006 UE KE IN $5,083.87 Pwr seat combo w/o shearB1007 NU IN $7,910.85 Pwr seat combo w/shearE1007 NU KE IN $9,178.33 Pwr seat combo w/shearE1007 RR IN $791.09 Pwr seat combo w/shearE1007 RR IN $917.84 Pwr seat combo w/shearE1007 UE IN $5,933.13 Pwr seat combo w/shearE1007 UE KE IN $6,883.74 Pwr seat combo w/shearE1008 NU IN $7,911.56 Pwr seat combo pwr shearE1008 NU KE IN $9,179.15 Pwr seat combo pwr shearE1008 RR IN $791.15 Pwr seat combo pwr shearE1008 RR KE IN $917.91 Pwr seat combo pwr shearE1008 UE IN $5,933.68 Pwr seat combo pwr shearE1008 UE KE IN $6,884.38 Pwr seat combo pwr shearE1009 NU IN $0.00 Add mech leg elevationE1009 RR IN $0.00 Add mech leg elevationE1009 UE IN $0.00 Add mech leg elevationE1010 NU IN $1,035.13 Add pwr leg elevationE1010 NU KE IN $1,200.98 Add pwr leg elevationE1010 RR IN $103.51 Add pwr leg elevationE1010 RR KE IN $120.10 Add pwr leg elevationE1010 UE IN $776.36 Add pwr leg elevationE1010 UE KE IN $900.75 Add pwr leg elevationE1011 NU IN $0.00 Ped wc modify width adjustmE101 l RR IN $0.00 Ped wc modify width adjustmE1011 UE IN $0.00 Ped wc modify width adjustE1014 NU IN $383.40 Reclining back add ped w/cE1014 RR IN $38.35 Reclining back add ped w/cE1014 UE IN $287.54 Reclining back add ped w/cE1015 NU IN $120.44 Shock absorber for man w/cE1015 RR IN $12.03 Shock absorber for man w/cE1015 UE IN $90.32 Shock absorber for man w/cE1016 NU IN $118.84 Shock absorber for power w/cE1016 NU KE IN $137.88 Shock absorber for power w/cE1016 RR IN $11.89 Shock absorber for power w/cE1016 RR KE IN $13.80 Shock absorber for power w/cE1016 UE IN $89.12 Shock absorber for power w/cE1016 UE KE IN $103.40 Shock absorber for power w/cE1017 NU IN $0.00 HD shck absrbr for hd man wcE1017 RR IN $0.00 HD shck absrbr for hd man wcE1017 UE IN $0.00 HD shck absrbr for hd man wcE1018 NU IN $0.00 HD slick absrber for hd powwcE1018 RR IN $0.00 HD shck absrber for hd powwcE1018 UE IN $0.00 HD sgck absrber for hd powwcE1020 NU IN $220.29 Residual limb support systemE1020 NU KE IN $255.58 Residual limb support systemE1020 RR IN $22.01 Residual limb support systemE1020 RR KB IN $25.54 Residual limb support systemE1020 UE IN $165.21 Residual limb support systemE1020 UE KE IN $191.68 Residual limb support systemE1028 NU IN $186.92 W/c manual swingawayE1028 NU KE IN $216.87 W/c manual swingawayE1028 RR IN $18.69 W/c manual swingawayE1028 RR KE IN $21.68 W/c manual swingawayE1028 UE IN $140.18 W/c manual swingawayE1028 UE KE IN $162.63 W/c manual swingawayB1029 NU IN $334.43 W/c vent tray fixedE1029 NU KE IN $388.02 W/c vent tray fixedE1029 RR IN $33.44 W/c vent tray fixedE1029 RR KE IN $38.80 W/c vent tray fixedE1029 UE IN $250.82 W/c vent tray fixedE1029 UE KE IN $291.01 W/c vent tray fixedE1030 NU IN $1,054.57 W/c vent tray gimbaled


E1030 NU KE IN $1,223.53 W/o vent tray gimbaledE1030 RR IN $105.46 W/c vent tray gimbaledE1030 RR KE IN $122.36 W/c vent tray gimbaledE1030 UE IN $790.93 W/c vent tray gimbaledE1030 UE KE IN $917.66 W/c vent tray gimbaledE1031 RR CR $53.04 Rollabout chair with castersE1035 RR CR $643.86 Patient transfer system <300E1036 RR CR $902.63 Patient transfer system >300E1037 RR CR $113.91 Transport chair, ped sizeE1038 RR CR $18.93 Transport chair pt wt<=3001bE1039 RR CR $35.91 Transport chair pt wt >3001bE1050 RR CR $106.93 Whelchr fxd full length armsE1060 RR CR $118.97 Wheelchair detachable armsE1070 RR CR $115.01 Wheelchair detachable foot rE1083 RR CR $75.78 Hemi-wheelchair fixed armsE1084 RR CR $103.01 Hemi-wheelchair detachable aE1087 RR CR $121.80 Wheelchair lightwt fixed armE1088 RR CR $158.31 Wheelchair lightweight det aE1092 RR CR $134.94 Wheelchair wide w/ leg restsE1093 RR CR $116.05 Wheelchair wide w/ foot restE1100 RR CR $109.00 Whchr s-recl fxd arm leg resE1110 RR CR $106.74 Wheelchair semi-reel detachE1150 RR CR $82.07 Wheelchair standard w/ leg rE1160 RR CR $64.53 Wheelchair fixed armsE1161 NU IN $2,484.39 Manual adult we w tiltinspacE1161 RR IN $248.44 Manual adult we w tiltinspacE1161 UE IN $1,863.30 Manual adult we w tiltinspacE1170 RR CR $90.63 Whlchr ampu fxd arm leg restE1171 RR CR $72.10 Wheelchair amputee w/o leg rE1172 RR CR $92.72 Wheelchair amputee detach arE1180 RR CR $99.11 Wheelchair amputee w/ foot rE1190 RR CR $114.51 Wheelchair amputee w/ leg reE1195 RR CR $112.12 Wheelchair amputee heavy dutE1200 RR CR $85.27 Wheelchair amputee fixed armE1221 RR CR $44.02 Wheelchair spec size w footE1222 RR CR $71.18 Wheelchair spec size w/ legE1223 RR CR $77.72 Wheelchair spec size w footE1224 RR CR $85.21 Wheelchair spec size w/ legE1225 RR CR $47.46 Manual semi-reclining backE1226 NU IN $572.93 Manual fully reclining backE1226 RR IN $58.97 Manual fully reclining backE1226 UE IN $429.66 Manual fully reclining backE1227 NU IN $291.38 Wheelchair spec sz spec ht aE1227 RR IN $28.67 Wheelchair spec sz spec ht aE1227 UE IN $218.56 Wheelchair spec sz spec ht aE1228 RR CR $25.01 Wheelchair spec sz spec ht bE1230 NU IN $2,136.81 Power operated vehicleE1230 RR IN $233.57 Power operated vehicleE1230 UE IN $1,596.51 Power operated vehicleE1231 NU IN $0.00 Rigid ped w/c tilt-in-spaceE1231 RR IN $0.00 Rigid ped w/c tilt-in-spaceE1231 UE IN $0.00 Rigid ped w/c tilt-in-spaceE1232 NU IN $2,245.33 Folding ped wc tilt-in-spaceE1232 RR IN $224.54 Folding ped wc tilt-in-spaceE1232 UE IN $1,684.01 Folding ped wc tilt-in-spaceE1233 NU IN $2,326.52 Rig ped wc tltnspc w/o seatE1233 RR IN $232.65 Rig ped wc tltnspc w/o seatE1233 UE IN $1,744.88 Rig ped wc tltnspc w/o seatE1234 NU IN $2,025.40 Fld ped wc tltnspc w/o seatE1234 RR IN $202.56 Fld ped wc tltnspc w/o seatE1234 UE IN $1,519.04 Fld ped wc tltnspc w/o seatE1235 NU IN $1,950.30 Rigid ped wc adjustableE1235 RR IN $195.04 Rigid ped wc adjustableE1235 UE IN $1,462.72 Rigid ped wc adjustableE1236 NU IN $1,720.67 Folding ped wc adjustableE1236 RR IN $172.06 Folding ped wc adjustableE1236 UE IN $1,290.50 Folding ped wc adjustableE1237 NU IN $1,735.70 Rgd ped wc adjstabl w/o seat

UCJF 11:3-29.6

E1237 RR IN $173.57 Rgd ped wc adjstabl w/o seatE1237 UE IN $1,301.79 Rgd ped wc adjstabl w/o seatE1238 NU IN $1,720.67 Fld ped wc adjstabl w/o seatE1238 RR IN $172.06 Fld ped wc adjstabl w/o seatE1238 UE IN $1,290.50 Fld ped wc adjstabl w/o seatE1240 RR CR $108.17 Whchr litwt det arm leg restE1270 RR CR $80.68 Wheelchair lightweight leg rE1280 RR CR $128.96 Whchr h-duty det arm leg resE1295 RR CR $124.10 Wheelchair heavy duty fixedE1296 NU IN $438.81 Wheelchair special seat heigE1296 RR IN $44.57 Wheelchair special seat heigE1296 UE IN $329.11 Wheelchair special seat heigE1297 NU IN $93.36 Wheelchair special seat deptE1297 RR IN $10.37 Wheelchair special seat deptE1297 UE IN $70.01 Wheelchair special seat deptE1298 NU IN $401.01 Wheelchair spec seat depth/wE1298 RR IN $40.11 Wheelchair spec seat depth/wE1298 UE IN $300.75 Wheelchair spec seat depth/wE1310 NU IN $2,254.77 Whirlpool non-portableE1310 RR IN $192.85 Whirlpool non-portableE1310 UE IN $1,691.08 Whirlpool non-portableE1353 OX $29.75 Oxygen supplies regulatorE1355 OX $22.40 Oxygen supplies stand/rackE1372 NU IN $171.18 Oxy suppl heater for nebulizE1372 RR IN $24.87 Oxy suppl heater for nebulizE1372 UE IN $107.70 Oxy suppl heater for nebulizE1390 RR OX $173.17 Oxygen concentratorE1391 RR OX $173.17 Oxygen concentrator, dualE1392 RR OX $51.63 Portable oxygen concentratorE1405 RR OX $209.99 O2/water vapor enrich wheatE1406 RR OX $190.08 O2/water vapor enrich w/o heE1700 NU IN $307.77 Jaw motion rehab systemE1700 RR IN $30.18 Jaw motion rehab systemE1700 UE IN $230.83 Jaw motion rehab systemE1701 SU $10.89 Repl cushions for jaw motionE1702 SU $21.85 Repl measr scales jaw motionE1800 RR CR $109.34 Adjust elbow ext/flex deviceE1801 RR CR $127.14 SPS elbow deviceE1802 RR CR $343.14 Adjst forearm pro/sup deviceE1805 RR CR $118.01 Adjust wrist ext/flex deviceE1806 RR CR $104.34 SPS wrist deviceE1810 RR CR $118.01 Adjust knee ext/flex deviceE1811 RR CR $132.16 SPS knee deviceE1812 RR CR $90.29 Knee ext/flex w act res ctrlE1815 RR CR $118.01 Adjust ankle ext/flex deviceE1816 RR CR $134.24 SPS ankle deviceE1818 RR CR $137.05 SPS forearm deviceE1820 NU IN $85.83 Soft interface materialE1820 RR IN $8.58 Soft interface materialE1820 UE IN $64.38 Soft interface materialE1821 NU IN $110.51 Replacement interface SPSDE1821 RR IN $11.04 Replacement interface SPSDE1821 UE IN $82.90 Replacement interface SPSDE1825 RR CR $118.01 Adjust finger ext/flex devcE1830 RR CR $118.01 Adjust toe ext/flex deviceE1840 RR CR $390.41 Adj shoulder ext/flex deviceE1841 RR CR $475.65 Static str shldr dev rom adjE2000 RR CR $51.05 Gastric suction pump hme mdlE2100 NU IN $666.03 Bld glucose monitor w voiceE2100 RR IN $66.60 Bld glucose monitor w voiceE2100 UE IN $499.54 Bld glucose monitor w voiceE2101 NU IN $197.99 Bld glucose monitor w lanceE2101 RR IN $19.80 Bld glucose monitor w lanceE2101 UE IN $148.49 Bld glucose monitor w lanceE2120 RR CR $297.70 Pulse gen sys tx endolymp flE2201 NU IN $391.76 Man w/ch acc seat w>=20"<24"E2201 RR IN $39.18 Man w/ch ace seat w>=20"<24"E2201 UE IN $293.82 Man w/ch ace seat w>=20"<24"


E2202 NU IN $497.68 Seat width 24-27 inE2202 RR IN $49.77 Seat width 24-27 inE2202 UE IN $373.28 Seat width 24-27 inE2203 NU IN $503.00 F rame depth less than 22 inE2203 RR IN $50.28 Frame depth less than 22 inE2203 UE IN $377.24 Frame depth less than 22 inE2204 NU IN $854.07 Frame depth 22 to 25 inE2204 RR IN $85.42 Frame depth 22 to 25 inE2204 UE IN $640.55 Frame depth 22 to 25 inE2205 NU IN $34.30 Manual we accessory, handrimE2205 RR IN $3.41 Manual we accessory, handrimE2205 UE IN $25.73 Manual we accessory, handrimE2206 NU IN $42.71 Complete wheel lock assemblyE2206 RR IN $4.26 Complete wheel lock assemblyE2206 UE IN $32.03 Complete wheel lock assemblyE2207 NU IN $45.52 Crutch and cane holderE2207 RR IN $4.56 Crutch and cane holderE2207 UE IN $34.14 Crutch and cane holderE2208 NU IN $107.50 Cylinder tank carrierE2208 NU KE IN $124.72 Cylinder tank carrierE2208 RR IN $10.74 Cylinder tank carrierE2208 RR KE IN $12.46 Cylinder tank carrierE2208 UE IN $80.63 Cylinder tank carrierE2208 UE KE IN $93.54 Cylinder tank carrierE2209 NU IN $96.98 Arm trough eachE2209 NU KE IN $112.52 Arm trough eachE2209 RR IN $9.72 Arm trough eachE2209 RR KE IN $11.28 Arm trough eachE2209 UE IN $72.74 Arm trough eachE2209 UE KE IN $84.40 Arm trough eachE2210 NU IN $5.93 Wheelchair bearingsE2210 NU KE IN $6.88 Wheelchair bearingsE2210 RR IN $0.51 Wheelchair bearingsE2210 RR KE IN $0.59 Wheelchair bearingsE2210 UE IN $4.45 Wheelchair bearingsE2210 UE KE IN $5.17 Wheelchair bearingsE2211 NU IN $42.96 Pneumatic propulsion tireE2211 RR IN $4.21 Pneumatic propulsion tireE2211 UE IN $30.77 Pneumatic propulsion tireE2212 NU IN $6.17 Pneumatic prop tire tubeE2212 RR IN $0.64 Pneumatic prop tire tubeE2212 UE IN $4.64 Pneumatic prop tire tubeE2213 NU IN $31.92 Pneumatic prop tire insertE2213 RR IN $3.20 Pneumatic prop tire insertE2213 UE IN $23.92 Pneumatic prop tire insertE2214 NU IN $37.80 Pneumatic caster tire eachE2214 RR IN $4.16 Pneumatic caster tire eachE2214 UE IN $28.34 Pneumatic caster tire eachE2215 NU IN $10.08 Pneumatic caster tire tubeE2215 RR IN $1.00 Pneumatic caster tire tubeE2215 UE IN $7.54 Pneumatic caster tire tubeE2216 NU IN $0.00 Foam filled propulsion tireE2216 RR IN $0.00 Foam filled propulsion tireE2216 UE IN $0.00 Foam filled propulsion tireE2217 NU IN $0.00 Foam filled caster tire eachE2217 RR IN $0.00 Foam filled caster tire eachE2217 UE IN $0.00 Foam filled caster tire eachE2218 NU IN $0.00 Foam propulsion tire eachE2218 RR IN $0.00 Foam propulsion tire eachE2218 UE IN $0.00 Foam propulsion tire eachE2219 NU IN $43.94 Foam caster tire any size eaE2219 RR IN $4.96 Foam caster tire any size eaE2219 UE IN $32.96 Foam caster tire any size eaE2220 NU IN $29.95 Solid propulsion tire eachE2220 RR IN $2.89 Solid propulsion tire eachE2220 UE IN $22.80 Solid propulsion tire eachE2221 NU IN $26.83 Solid caster tire eachE2221 RR IN $2.71 Solid caster tire each

UCJF 11:3-29.6

E2221 UE IN $20.14 Solid caster tire eachE2222 NU IN $22.11 Solid caster integrated whlE2222 RR IN $2.19 Solid caster integrated whlE2222 UE IN $16.60 Solid caster integrated whlE2224 NU IN $102.96 Propulsion whl excludes tireE2224 RR IN $10.80 Propulsion whl excludes tireE2224 UE IN $77.23 Propulsion whl excludes tireE2225 NU IN $18.27 Caster wheel excludes tireE2225 RR IN $1.83 Caster wheel excludes tireE2225 UE IN $13.69 Caster wheel excludes tireE2226 NU IN $39.84 Caster fork replacement onlyE2226 RR IN $3.98 Caster fork replacement onlyE2226 UE IN $29.88 Caster fork replacement onlyE2227 NU IN $1,888.65 Gear reduction drive wheelE2227 RR IN $188.85 Gear reduction drive wheelE2227 UE IN $1,416.48 Gear reduction drive wheelE2228 NU IN $983.07 Mwc acc, wheelchair brakeE2228 RR IN $98.30 Mwc acc, wheelchair brakeE2228 UE IN $737.33 Mwc acc, wheelchair brakeE2231 NU IN $161.36 Solid seat support baseE2231 RR IN $16.14 Solid seat support baseE2231 UE IN $121.01 Solid seat support baseE2310 NU IN $1,059.07 Electro connect btvv controlE2310 NU KE IN $1,228.75 Electro connect btw controlE2310 RR IN $105.90 Electro connect btw controlE2310 RR KE IN $122.87 Electro connect btw controlE2310 UE IN $794.30 Electro connect btw controlE2310 UE KE IN $921.56 Electro connect btw controlE2311 NU IN $2,144.13 Electro connect btw 2 sysE2311 NU KE IN $2,487.66 Electro connect btw 2 sysE2311 RR IN $214.42 Electro connect btw 2 sysE2311 RR KE IN $248.78 Electro connect btw 2 sysE2311 UE IN $1,608.09 Electro connect btw 2 sysE2311 UE KE IN $1,865.75 Electro connect btw 2 sysE2312 NU IN $2,036.14 Mini-prop remote joystickE2312 NU KC IN $2,596.84 Mini-prop remote joystickE2312 RR IN $203.62 Mini-prop remote joystickE2312 RR KC IN $259.69 Mini-prop remote joystickE2312 UE IN $1,527.08 Mini-prop remote joystickE2312 UE KC IN $1,947.62 Mini-prop remote joystickE2313 NU IN $323.33 PWC harness, expand controlE2313 RR IN $32.35 PWC harness, expand controlE23 13 UE IN $242.50 PWC harness, expand controlE2321 NU IN $1,438.14 Hand interface joystickE2321 NU KC IN $2,342.55 Hand interface joystickE2321 NU KE IN $1,668.56 Hand interface joystickE2321 RR IN $143.82 Hand interface joystickE2321 RR KC IN $234.26 Hand interface joystickE2321 RR KE IN $166.87 Hand interface joystickE2321 UE IN $1,078.62 Hand interface joystickE2321 UE KC IN $1,756.91 Hand interface joystickE2321 UE KE IN $1,251.43 Hand interface joystickE2322 NU IN $1,276.38 Mult mech switchesE2322 NU KC IN $2,480.72 Mult mech switchesE2322 NU KE IN $1,480.88 Mult mech switchesE2322 RR IN $127.63 Mult mech switchesE2322 RR KC IN $248.07 Mult mech switchesE2322 RR KE IN $148.08 Mult mech switchesB2322 UE IN $957.29 Mult mech switchesE2322 UE KC IN $1,860.54 Mult mech switchesE2322 UE KE IN $1,110.67 Mult mech switchesE2323 NU IN $62.59 Special joystick handleE2323 NU KE IN $72.62 Special joystick handleE2323 RR IN $6.26 Special joystick handleE2323 RR KE IN $7.27 Special joystick handleE2323 UE IN $46.94 Special joystick handleE2323 UE KE IN $54.46 Special joystick handleE2324 NU IN $39.66 Chin cup interface


E2324 NU KE IN $46.01 Chin cup interfaceE2324 RR IN $3.95 Chin cup interfaceE2324 RR KE IN $4.59 Chin cup interfaceE2324 UE IN $29.75 Chin cup interfaceE2324 UE KE IN $34.51 Chin cup interfaceE2325 NU IN $1,218.88 Sip and puff interfaceE2325 NU KE IN $1,414.17 Sip and puff interfaceE2325 RR IN $121.90 Sip and puff interfaceE2325 RR KE IN $141.44 Sip and puff interfaceE2325 UE IN $914.17 Sip and puff interfaceE2325 UE KE IN $1,060.64 Sip and puff interfaceE2326 NU IN $314.16 Breath tube kitE2326 NU KE IN $364.50 Breath tube kitE2326 RR IN $31.43 Breath tube kitE2326 RR KE IN $36.47 Breath tube kitE2326 UE IN $235.61 Breath tube kitE2326 UE KE IN $273.36 Breath tube kitE2327 NU IN $2,364.20 Head control interface mechE2327 NU KC IN $3,591.81 Head control interface mechE2327 NU KE IN $2,743.00 Head control interface mechE2327 RR IN $236.42 Head control interface mechE2327 RR KC IN $359.18 Head control interface mechE2327 RR KE IN $274.30 Head control interface mechE2327 UE IN $1,773.15 Head control interface mechE2327 UE KC IN $2,693.85 Head control interface mechE2327 UE KE IN $2,057.24 Head control interface mechE2328 NU IN $4,484.56 Head/extremity control interE2328 NU KE IN $5,203.09 Head/extremity control interE2328 RR IN $448.45 Head/extremity control interE2328 RR KE IN $520.30 Head/extremity control interE2328 UE IN $3,363.43 Head/extremity control interE2328 UE KE IN $3,902.33 Head/extremity control interE2329 NU IN $1,598.35 Head control nonproportionalE2329 NU KE IN $1,854.44 Head control nonproportionalE2329 RR IN $159.83 Head control nonproportionalE2329 RR KE IN $185.44 Head control nonproportionalE2329 UE IN $1,198.76 Head control nonproportionalE2329 UE KE IN $1,390.83 Head control nonproportionalE2330 NU IN $3,096.99 Head control proximity switcE2330 NU KE IN $3,593.19 Head control proximity switcE2330 RR IN $309.69 Head control proximity switcE2330 RR KE IN $359.31 Head control proximity switcE2330 UE IN $2,322.75 Head control proximity switcE2330 UE KE IN $2,694.91 Head control proximity switcE2340 NU IN $376.28 W/c wdth 20-23 in seat frameE2340 RR IN $37.64 W/c wdth 20-23 in seat frameE2340 UE IN $282.23 W/c wdth 20-23 in seat frameE2341 NU IN $564.46 W/o wdth 24-27 in seat frameE2341 RR IN $56.45 W/c wdth 24-27 in seat frameE2341 UE IN $423.35 W/c wdth 24-27 in seat frameE2342 NU IN $470.38 W/c dpth 20-21 in seat frameE2342 RR IN $47.04 W/c dpth 20-21 in seat frameE2342 UE IN $352.79 W/c dpth 20-21 in seat frameE2343 NU IN $752.62 W/c dpth 22-25 in seat frameE2343 RR IN $75.25 W/c dpth 22-25 in seat frameE2343 UE IN $564.46 W/c dpth 22-25 in seat frameE2351 NU IN $632.26 Electronic SGD interfaceE2351 NU KE IN $733.56 Electronic SGD interfaceE2351 RR IN $63.24 Electronic SGD interfaceE2351 RR KE IN $73.37 Electronic SGD interfaceE2351 UE IN $474.18 Electronic SGD interfaceE2351 UE KE IN $550.16 Electronic SGD interfaceE2360 NU IN $117.96 22nf nonsealed leadacidE2360 RR IN $11.85 22nf nonsealed leadacidE2360 UE IN $88.47 22nf nonsealed leadacidE2361 NU IN $126.22 22nf sealed leadacid batteryE2361 NU KE IN $146.44 22nf sealed leadacid batteryE2361 RR IN $12.62 22nf sealed leadacid battery

UCJF 11:3-29.6

E2361 RR KE IN $14.65 22nf sealed leadacid batteryE2361 UE IN $94.68 22nf sealed leadacid batteryE2361 UE KE IN $109.85 22nf sealed leadacid batteryE2362 NU IN $96.58 Gr24 nonsealed leadacidE2362 RR IN $9.66 Gr24 nonsealed leadacidE2362 UE IN $72.43 Gr24 nonsealed leadacidE2363 NU IN $168.33 Gr24 sealed leadacid batteryE2363 NU KE IN $195.30 Gr24 sealed leadacid batteryE2363 RR IN $16.84 Gr24 sealed leadacid batteryE2363 RR KE IN $19.54 Gr24 sealed leadacid batteryE2363 UE IN $126.25 Gr24 sealed leadacid batteryE2363 UE KE IN $146.48 Gr24 sealed leadacid batteryE2364 NU IN $117.96 Ulnonsealed leadacid batteryE2364 RR IN $11.85 U1 nonsealed leadacid batteryE2364 UE IN $88.47 U1 nonsealed leadacid batteryE2365 NU IN $101.51 U1 sealed leadacid batteryE2365 NU KE IN $117.78 U 1 sealed leadacid batteryE2365 RR IN $10.15 U1 sealed leadacid batteryE2365 RR KE IN $11.78 Ul sealed leadacid batteryE2365 UE IN $76.16 U1 sealed leadacid batteryE2365 UE KE IN $88.36 U1 sealed leadacid batteryE2366 NU IN $238.58 Battery charger, single modeE2366 NU KE IN $276.80 Battery charger, single modeE2366 RR IN $23.92 Battery charger, single modeE2366 RR KE IN $27.75 Battery charger, single modeE2366 UE IN $178.94 Battery charger, single modeE2366 UE KE IN $207.61 Battery charger, single mode E2367 NU IN $379.27 Battery charger, dual modeE2367 NU KE IN $440.03 Battery charger, dual modeE2367 RR IN $37.93 Battery charger, dual modeE2367 RR KE IN $44.01 Battery charger, dual modeE2367 UE IN $$284.45 Battery charger, dual modeE2367 UE KE IN $330.03 Battery charger, dual modeE2368 NU IN $467.50 Power we motor replacementE2368 NU KE IN $542.40 Power we motor replacementE2368 RR IN $46.76 Power we motor replacementE2368 RR KE IN $54.25 Power we motor replacementE2368 UE IN $350.63 Power we motor replacementE2368 UE KE IN $406.81 Power we motor replacementE2369 NU IN $407.20 Pwr we gear box replacementE2369 NU KE IN $472.44 Pwr we gear box replacementE2369 RR IN $40.73 Pwr we gear box replacementE2369 RR KE IN $47.25 Pwr we gear box replacementE2369 UE IN $305.39 Pwr we gear box replacement E2369 UE KE IN $354.32 Pwr we gear box replacementE2370 NU IN $726.57 Pwr we motor/gear box comboE2370 NU KE IN $842.98 Pwr we motor/gear box comboE2370 RR IN $72.66 Pwr we motor/gear box comboE2370 RR KE IN $84.30 Pwr we motor/gear box comboE2370 UE IN $544.92 Pwr we motor/gear box comboE2370 UE KE IN $632.23 Pwr we motor/gear box comboE2371 NU IN $136.42 Gr27 sealed leadacid batteryE2371 NU KE IN $158.28 Gr27 sealed leadacid batteryE2371 RR IN $13.65 Gr27 sealed leadacid batteryE2371 RR KE IN $15.83 Gr27 sealed leadacid batteryE2371 UE IN $102.32 Gr27 sealed leadacid batteryE2371 UE KE IN $118.71 Gr27 sealed leadacid batteryE2372 NU IN $0.00 Gr27 non-sealed leadacidE2372 RR IN $0.00 Gr27 non-sealed leadacidE2372 UE IN $0.00 Gr27 non-sealed leadacidE2373 NU IN $709.72 Hand/chin ctrl spec joystickE2373 NU KC IN $1,094.99 Hand/chin ctrl spec joystickE2373 NU KE IN $709.72 Hand/chin ctrl spec joystickE2373 RR IN $70.99 Hand/chin ctrl spec joystickE2373 RR KC IN $109.51 Hand/chin ctrl spec joystickE2373 RR KE IN $70.99 Hand/chin ctrl spec joystickE2373 UE IN $532.31 Hand/chin ctrl spec joystickE2373 UE KC IN $821.26 Hand/chin ctrl spec joystick


E2373 UE KE IN $532.31 Hand/chin ctrl spec joystickE2374 NU IN $483.29 Hand/chin ctrl std j oystickE2374 NU KE IN $560.72 Hand/chin ctrl std joystickE2374 RR IN $48.33 Hand/chin ctrl std joystickE2374 RR KE IN $56.07 Hand/chin ctrl std joystickE2374 UE IN $362.48 Hand/chin ctrl std joystickE2374 UE KE IN $420.56 Hand/chin ctrl std joystickE2375 NU IN $775.19 Non-expandable controllerE2375 NU KE IN $899.39 Non-expandable controllerE2375 RR IN $77.51 Non-expandable controllerE2375 RR KE IN $89.93 Non-expandable controllerE2375 UE IN $581.37 Non-expandable controllerE2375 UE KE IN $674.52 Non-expandable controllerE2376 NU IN $1,214.75 Expandable controller, replE2376 NU KE IN $1,409.38 Expandable controller, replE2376 RR IN $121.48 Expandable controller, replE2376 RR KE IN $140.94 Expandable controller, replE2376 UE IN $911.08 Expandable controller, replE2376 UE KE IN $1,057.06 Expandable controller, replE2377 NU IN $439.57 Expandable controller, initlE2377 NU KE IN $510.00 Expandable controller, initlE2377 RR IN $43.95 Expandable controller, initlE2377 RR KE IN $50.99 Expandable controller, initlE2377 UE IN $329.69 Expandable controller, initlE2377 UE KE IN $382.52 Expandable controller, initlE2381 NU IN $68.94 Pneum drive wheel tireE2381 NU KE IN $79.99 Pneum drive wheel tireE2381 RR IN $6.91 Pneurn drive wheel tireE2381 RR KE IN $8.01 Pneum drive wheel tireE2381 UE IN $51.71 Pneum drive wheel tireE2381 UE KE IN $60.00 Pneuin drive wheel tireE2382 NU IN $18.80 Tube, pneurn wheel drive tireE2382 NU KE IN $21.81 Tube, pneum wheel drive tireE2382 RR IN $1.87 Tube, pneum wheel drive tireE2382 RR KE IN $2.17 Tube, pneum wheel drive tireE2382 UE IN $14.09 Tube, pneum wheel drive tireE2382 UE KE IN $16.35 Tube, pneum wheel drive tireE2383 NU IN $137.45 Insert, pneum wheel driveE2383 NU KE IN $159.47 Insert, pneum wheel driveE2383 RR IN $13.75 I nsert, pneum wheel driveE2383 RR KE IN $15.95 Insert, pneum wheel driveE2383 UE IN $103.09 Insert, pneum wheel driveE2383 UE KE IN $119.61 Insert, pneum wheel driveE2384 NU IN $73.22 Pneumatic caster tireE2384 NU KE IN $84.96 Pneumatic caster tireE2384 RR IN $7.34 Pneumatic caster tireE2384 RR KE IN $8.52 Pneumatic caster tireE2384 UE IN $54.92 Pneumatic caster tireE2384 UE KE IN $63.71 Pneumatic caster tireE2385 NU IN $44.80 Tube, pneumatic caster tireE2385 NU KE IN $51.98 Tube, pneumatic caster tireE2385 RR IN $4.49 Tube, pneumatic caster tireE2385 RR KE IN $5.21 Tube, pneumatic caster tireE2385 UE IN $33.58 Tube, pneumatic caster tireE2385 UE KE IN $38.97 Tube, pneumatic caster tireE2386 NU IN $136.21 Foam filled drive wheel tireE2386 NU KE IN $158.04 Foam filled drive wheel tireE2386 RR IN $13.62 Foam filled drive wheel tireE2386 RR KE IN $15.80 Foam filled drive wheel tireE2386 UE IN $102.15 Foam filled drive wheel tireE2386 UE KE IN $118.51 Foam filled drive wheel tireE2387 NU IN $61.08 Foam filled caster tireE2387 NU KE IN $70.86 Foam filled caster tireE2387 RR IN $6.11 Foam filled caster tireE2387 RR KE IN $7.09 Foam filled caster tireE2387 UE IN $45.84 Foam filled caster tireE2387 UE KE IN $53.18 Foam filled caster tireE2388 NU IN $45.60 Foam drive wheel tire

UCJF 11:3-29.6

E2388 NU KE IN $52.91 Foam drive wheel tireE2388 RR IN $4.56 Foam drive wheel tireE2388 RR KE IN $5.29 Foam drive wheel tireE2388 UE IN $34.21 Foam drive wheel tireE2388 UE KE IN $39.69 Foam drive wheel tireE2389 NU IN $24.76 Foam caster tireE2389 NU KE IN $28.73 Foam caster tireE2389 RR IN $2.48 Foam caster tireE2389 RR KE IN $2.88 Foam caster tireE2389 UE IN $18.56 Foam caster tireE2389 UE KE IN $21.54 Foam caster tireE2390 NU IN $38.72 Solid drive wheel tireE2390 NU KE IN $44.93 Solid drive wheel tireE2390 RR IN $3.87 Solid drive wheel tireE2390 RR KE IN $4.49 Solid drive wheel tireE2390 UE IN $29.02 Solid drive wheel tireE2390 UE KE IN $33.67 Solid drive wheel tireE2391 NU IN $18.55 Solid caster tireE2391 NU KE IN $21.53 Solid caster tireE2391 RR IN $1.86 Solid caster tireE2391 RR KE IN $2.15 Solid caster tireE2391 UE IN $13.92 Solid caster tireE2391 UE KE IN $16.15 Solid caster tireE2392 NU IN $48.76 Solid caster tire, integrateE2392 NU KE IN $56.57 Solid caster tire, integrateE2392 RR IN $4.89 Solid caster tire, integrateE2392 RR KE IN $5.67 Solid caster tire, integrateE2392 UE IN $36.57 Solid caster tire, integrateE2392 UE KE IN $42.43 Solid caster tire, integrateE2394 NU IN $69.46 Drive wheel excludes tireE2394 NU KE IN $80.59 Drive wheel excludes tireE2394 RR IN $6.96 Drive wheel excludes tireE2394 RR KE IN $8.07 Drive wheel excludes tireE2394 UE IN $52.10 Drive wheel excludes tireE2394 UE KE IN $60.45 Drive wheel excludes tireE2395 NU IN $49.37 Caster wheel excludes tireE2395 NU KE IN $57.28 Caster wheel excludes tireE2395 RR IN $4.94 Caster wheel excludes tireE2395 RR KE IN $5,73 Caster wheel excludes tireE2395 UE IN $37.04 Caster wheel excludes tireE2395 UE KE IN $42.98 Caster wheel excludes tireE2396 NU IN $60.19 Caster forkE2396 NU KE IN $69.84 Caster forkE2396 RR IN $6.45 Caster forkE2396 RR KE IN $7.49 Caster forkE2396 UE IN $45.15 Caster forkE2396 UE KE IN $52.38 Caster forkE2397 NU IN $434.84 Pwc ace, lith-based batteryE2397 RR IN $43.48 Pwc ace, lith-based batteryE2397 UE IN $326.12 Pwc ace, lith-based batteryE2402 RR CR $1,553.40 Neg press wound therapy pumpE2500 NU IN $410.61 SGD digitized pre-rec <=8minE2500 RR IN $41.07 SGD digitized pre-rec <=8minE2500 UE IN $307.95 SGD digitized pre-rec <=8minE2502 NU IN $1,255.59 SGD prerec msg >8min <=20minE2502 RR IN $125.57 SGD prerec msg >8min <=20minE2502 UE IN $941.70 SGD prerec msg >8min <=20minE2504 NU IN $1,656.29 SGD prerec msg>20min <=40minE2504 RR IN $165.65 SGD prerec msg>20min <=40minE2504 UE IN $1,242.20 SGD prerec msg>20min <=40minE2506 NU IN $2,428.61 SGD prerec msg > 40 minE2506 RR IN $242.85 SGD prerec msg > 40 minE2506 UE IN $1,821.42 SGD prerec msg > 40 minB2508 NU IN $3,755.44 SGD spelling phys contactE2508 RR IN $375.55 SGD spelling phys contactE2508 UE IN $2,816.59 SGD spelling phys contactE2510 NU IN $7,106.66 SGD w multi methods msg/accsE2510 RR IN $710.66 SGD w multi methods msg/accs


E2510 UE IN $5,329.99 OD w multi methods msg/accsE2511 NU IN $0.00 SGD sftwre prgrm for PC/PDAE2511 RR IN $0.00 SGD sftwre prgrm for PC/PDAE2511 UE IN $0.00 SGD sftwre prgrm for PC/PDAE2512 NU IN $0.00 SGD accessory, mounting sysE2512 RR IN $0.00 SGD accessory, mounting sysE2512 UE IN $0.00 SGD accessory, mounting sysE2601 NU IN $55,35 Gen w/c cushion wdth < 22 inE2601 NU KE IN $64.22 Gen w/c cushion wdth < 22 inE2601 RR IN $5.55 Gen w/c cushion wdth < 22 inE2601 RR KE IN $6.44 Gen w/c cushion wdth < 22 inE2601 UE IN $41.51 Gen w/c cushion wdth < 22 inE2601 TIE KE IN $48.16 Gen w/c cushion wdth < 22 inE2602 NU IN $108.06 Gen w/c cushion wdth >=22 inE2602 NU KE IN $125.37 Gen w/c cushion wdth >=22 inE2602 RR IN $10.81 Gen w/c cushion wdth >=22 inE2602 RR KE IN $12.54 Gen w/c cushion wdth >=22 inE2602 UE IN $81.04 Gen w/c cushion wdth >=22 inE2602 UE KE IN $94.03 Gen w/c cushion wdth >=22 inE2603 NU IN $137.19 Skin protect we cus wd <22inE2603 NU KE IN $159.17 Skin protect we cus wd <22inE2603 RR IN $13.73 Skin protect wc cus wd <22inE2603 RR KE IN $15.93 Skin protect wc cus wd <22inE2603 UE IN $102.89 Skin protect wc cus wd <22inE2603 UE KE IN $119.37 Skin protect wc cus wd <22inE2604 NU IN $170.51 Skin protect wc cus wd>=22inE2604 NU KE IN $197.83 Skin protect wc cus wd>=22inE2604 RR IN $17.04 Skin protect wc cus wd>=22inE2604 RR KE IN $19.77 Skin protect wc cus wd>=22inE2604 UE IN $127.90 Skin protect wc cus wd>=22inE2604 UE KE IN $148.40 Skin protect wc cus wd>=22inE2605 NU IN $243.60 Position wc cush wdth <22 inE2605 NU KE IN $282.63 Position wc cush wdth <22 inE2605 RR IN $24.37 Position wc cush wdth <22 inE2605 RR KE IN $28.28 Position wc cush wdth <22 inE2605 UE IN $182.73 Position wc cush wdth <22 inE2605 UE KE IN $212.01 Position wc cush wdth <22 inE2606 NU IN $380.04 Position wc cush wdth>=22 inE2606 NU KE IN $440.93 Position wc cush wdth>=22 inE2606 RR IN $38.02 Position wc cush wdth>=22 inE2606 RR KE IN $44.11 Position wc cush wdth>=22 inE2606 UE IN $285.02 Position wc cush wdth>=22 inE2606 UE KE IN $330.69 Position wc cush wdth>=22 inE2607 NU IN $262.31 Skin pro/pos wc cus wd <22inE2607 NU KE IN $304.34 Skin pro/pos wc cus wd <22inE2607 RR IN $26.24 Skin pro/pos wc cus wd <22inE2607 RR KE IN $30.44 Skin pro/pos wc cus wd <22inE2607 UE IN $196.74 Skin pro/pos wc cus wd <22inE2607 UE KE IN $228.26 Skin pro/pos wc cus wd <22inE2608 NU IN $315.02 Skin pro/pos wc cus wd>=22inE2608 NU KE IN $365.49 Skin pro/pos wc cus wd>=22inE2608 RR IN $31.49 Skin pro/pos wc cus wd>=22inE2608 RR KE IN $36.54 Skin pro/pos wc cus wd>=22inE2608 UE IN $236.27 Skin pro/pos wc cus wd>=22inE2608 UE KE IN $274.12 Skin pro/pos wc cus wd>=22inE2611 NU IN $282.68 Gen use back cush wdth <22inE2611 NU KE IN $327.97 Gen use back cush wdth <22inE2611 RR IN $28.26 Gen use back cush wdth <22inE2611 RR KE IN $32.79 Gen use back cush wdth <22inE2611 UE IN $212.03 Gen use back cush wdth <22inE2611 UE KE IN $246.00 Gen use back cush wdth <22inE2612 NU IN $382.40 Gen use back cush wdth>=22inE2612 NU KE IN $443.67 Gen use back cush wdth>=22inE2612 RR IN $38.24 Gen use back cush wdth>=22inE2612 RR KE IN $44.36 Gen use back cush wdth>=22inE2612 UE IN $286.79 Gen use back cush wdth>=22inE2612 UE KE IN $332.73 Gen use back cush wdth>=22inE2613 NU IN $355.70 Position back cush wd <22in

UCJF 11:3-29.6

E2613 NU KE IN $412.69 Position back cush wd <22inE2613 RR IN $35.58 Position back cush wd <22inE2613 RR KE IN $41.28 Position back cush wd <22inE2613 UE IN $266.78 Position back cush wd <22inE2613 UE KE IN $309.52 Position back cush wd <22inE2614 NU IN $492.26 Position back cush wd>=22inE2614 NU KE IN $571.13 Position back cush wd>=22inE2614 RR IN $49.23 Position back cush wd>=22inE2614 RR KE IN $57.12 Position back cush wd>=22inE2614 UE IN $369.21 Position back cush wd>=22inE2614 UE KE IN $428.37 Position back cush wd>=22inE2615 NU IN $409.35 Pos back post/lat wdth <22inE2615 NU KE IN $474.94 Pos back post/lat wdth <22inE2615 RR IN $40.94 Pos back post/lat wdth <22inE2615 RR KE IN $47.50 Pos back post/lat wdth <22inE2615 UE IN $307.00 Pos back post/lat wdth <22inE2615 UE KE IN $356.19 Pos back post/lat wdth <22inE2616 NU IN $550.76 Pos back post/lat wdth>=22inE2616 NU KE IN $639.01 Pos back post/lat wdth>=22inE2616 RR IN $55.08 Pos back post/lat wdth>=22inE2616 RR KE IN $63.90 Pos back post/lat wdth>=22inE2616 UE IN $413.09 Pos back post/lat wdth>=22inE2616 UE KE IN $479.27 Pos back post/lat wdth>=22inE2619 NU IN $46.44 Replace cover w/c seat cushE2619 NU KE IN $53.89 Replace cover w/c seat cushE2619 RR IN $4.64 Replace cover w/c seat cushE2619 RR KE IN $5.39 Replace cover w/c seat cushE2619 UE IN $34.85 Replace cover w/c seat cushE2619 UE KE IN $40.44 Replace cover w/c seat cushE2620 NU IN $495.67 WC planar back cush wd <22inE2620 NU KE IN $575.09 WC planar back cush wd <22inE2620 RR IN $49.57 WC planar back cush wd <22inE2620 RR KE IN $57.51 WC planar back cush wd <22inE2620 UE IN $371.76 WC planar back cush wd <22inE2620 UE KE IN $431.33 WC planar back cush wd <22inE2621 NU IN $520.16 WC planar back cush wd>=22inE2621 NU KE IN $603.50 WC planar back cush wd>=22inE2621 RR IN $52.01 WC planar back cush wd>=22inE2621 RR KE IN $60.34 WC planar back cush wd>=22inE2621 UE IN $390.13 WC planar back cush wd>=22inE2621 UE KE IN $452.63 WC planar back cush wd>=22inK0001 RR CR $55.10 Standard wheelchairK0002 RR CR $85.92 Stnd hemi (low seat) whlchrK0003 RR CR $94.07 Lightweight wheelchairK0004 RR CR $119.83 High strength ltwt whlchrK0005 NU IN $1,941.20 Ultralightweight wheelchairK0005 RR IN $194.10 Ultralightweight wheelchairK0005 UE IN $1,455.88 Ultralightweight wheelchairK0006 RR CR $128.51 Heavy duty wheelchairK0007 RR CR $178.30 Extra heavy duty wheelchairK0010 RR CR $380.20 Stnd wt frame power whlchrK0011 RR CR $521.87 Stnd wt pwr whlchr w controlK0011 RR KF CR $579.42 Stnd wt pwr whlchr w controlK0012 RR CR $320.12 Ltwt portbl power whlchrK0015 NU IN $164.44 Detach non-adjus hght armrstK0015 NU KE IN $190.79 Detach non-adjus hght armrstK0015 RR IN $16.45 Detach non-adjus hght armrstK0015 RR KE IN $19.09 Detach non-adjus hght armrstK0015 UE IN $123.32 Detach non-adjus hght armrstK0015 UE KE IN $143.08 Detach non-adjus hght armrestK0017 NU IN $46.25 Detach adjust armrest baseK0017 NU KE IN $53.67 Detach adjust armrest baseK0017 RR IN $4.62 Detach adjust armrest baseK0017 RR KE IN $5.37 Detach adjust armrest baseK0017 UE IN $34.69 Detach adjust armrest baseK0017 UE KE IN $40.25 Detach adjust armrest baseK0018 NU IN $25.84 Detach adjust armrst upperK0018 NU KE IN $29.98 Detach adjust armrst upper


K0018 RR IN $2.57 Detach adjust armrst upperK0018 RR KE IN $2.98 Detach adjust armrst upperK0018 UE IN $19.39 Detach adjust armrst upperK0018 UE KE IN $22.50 Detach adjust armrst upperK0019 NU IN $14.80 Arm pad eachK0019 NU KE IN $17.17 Arm pad eachK0019 RR IN $1.48 Arm pad eachK0019 RR KE IN $1.72 Arm pad eachK0019 UE IN $11.09 Arm pad eachK0019 UE KE IN $12.86 Arm pad eachK0020 NU IN $42.05 Fixed adjust armrest pairK0020 NU KE IN $48.78 Fixed adjust armrest pairK0020 RR IN $4.21 Fixed adjust armrest pairK0020 RR KE IN $4.88 Fixed adjust armrest pairK0020 UE IN $31.52 Fixed adjust armrest pairK0020 UE KE IN $36.57 Fixed adjust armrest pairK0037 NU IN $43.58 High mount flip-up footrestK0037 NU KE IN $50.57 High mount flip-up footrestK0037 RR IN $3.89 High mount flip-up footrestK0037 RR KE IN $4.52 High mount flip-up footrestK0037 UE IN $32.70 High mount flip-up footrestK0037 UE KE IN $37.94 High mount flip-up footrestK0038 NU IN $21.96 Leg strap eachK0038 NU KE IN $25.47 Leg strap eachK0038 RR IN $2.20 Leg strap eachK0038 RR KE IN $2.55 Leg strap eachK0038 UE IN $16.47 Leg strap eachK0038 UE KE IN $19.11 Leg strap eachK0039 NU IN $48.76 Leg strap h style eachK0039 NU KE IN $56.57 Leg strap h style eachK0039 RR IN $4.89 Leg strap h style eachK0039 RR KE IN $5.67 Leg strap h style eachK0039 UE IN $36.57 Leg strap h style eachK0039 UE KE IN $42.43 Leg strap h style eachK0040 NU IN $67.58 Adjustable angle footplateK0040 NU KE IN $78.40 Adjustable angle footplateK0040 RR IN $6.74 Adjustable angle footplateK0040 RR KE IN $7.82 Adjustable angle footplateK0040 UE IN $50.67 Adjustable angle footplateK0040 UE KE IN $58.79 Adjustable angle footplateK0041 NU IN $47.89 Large size footplate eachK0041 NU KE IN $55.57 Large size footplate eachK0041 RR IN $4.81 Large size footplate eachK0041 RR KE IN $5.58 Large size footplate eachK0041 UE IN $35.92 Large size footplate eachK0041 UE KE IN $41.67 Large size footplate eachK0042 NU IN $32.97 Standard size footplate eachK0042 NU KE IN $38.25 Standard size footplate eachK0042 RR IN $3.29 Standard size footplate eachK0042 RR KE IN $3.81 Standard size footplate eachK0042 UE IN $24.72 Standard size footplate eachK0042 UE KE IN $28.69 Standard size footplate eachK0043 NU IN $17.67 Ftrst lower extension tubeK0043 NU KE IN $20.51 Ftrst lower extension tubeK0043 RR IN $1.76 Ftrst lower extension tubeK0043 RR KE IN $2.05 Ftrst lower extension tubeK0043 UE IN $13.27 Ftrst lower extension tubeK0043 UE KE IN $15.39 Ftrst lower extension tubeK0044 NU IN $15.06 Ftrst upper hanger bracketK0044 NU KE IN $17.47 Ftrst upper hanger bracketK0044 RR IN $1.51 Ftrst upper hanger bracketK0044 RR KE IN $1.75 Ftrst upper hanger bracketK0044 UE IN $11.29 Ftrst upper hanger bracketK0044 UE KE IN $13.10 Ftrst upper hanger bracketK0045 NU IN $51.24 Footrest complete assemblyK0045 NU KE IN $59.45 Footrest complete assemblyK0045 RR IN $5.13 Footrest complete assemblyK0045 RR KE IN $5.95 Footrest complete assembly

UCJF 11:3-29.6

K0045 UE IN $38.44 Footrest complete assemblyK0045 UE KE IN $44.59 Footrest complete assemblyK0046 NU IN $17.67 Elevat legrst low extensionK0046 NU KE IN $20.51 Elevat legrst low extensionK0046 RR IN $1.76 Elevat legrst low extensionK0046 RR KE IN $2.05 Elevat legrst low extensionK0046 UE IN $13.27 Elevat legrst low extensionK0046 UE KE IN $15.39 Elevat legrst low extensionK0047 NU IN $69.21 Elevat legrst up hangr brackK0047 NU KE IN $80.30 Elevat legrst up hangr brackK0047 RR IN $6.94 Elevat legrst up hangr brackK0047 RR KE IN $8.05 Elevat legrst up hangr brackK0047 UE IN $51.89 Elevat legrst up hangr brackK0047 UE KE IN $60.21 Elevat legrst up hangr brackK0050 NU IN $29.41 Ratchet assemblyK0050 NU KE IN $34.13 Ratchet assemblyK0050 RR IN $2.93 Ratchet assemblyK0050 RR KE IN $3.40 Ratchet assemblyK0050 UE IN $22.07 Ratchet assemblyK0050 UE KE IN $25.61 Ratchet assemblyK0051 NU IN $47.61 Cam relese assem ftrst/lgrstK0051 NU KE IN $55.24 Cam relese assem ftrst/lgrstK0051 RR IN $4.79 Cam relese assem ftrst/lgrstK0051 RR KE IN $5.55 Cam relese assem ftrst/lgrstK0051 UE IN $35.69 Cam relese assem ftrst/lgrstK0051 UE KE IN $41.41 Cam relese assem ftrst/lgrstK0052 NU IN $83.66 Swingaway detach footrestK0052 NU KE IN $97.06 Swingaway detach footrestK0052 RR IN $8.36 Swingaway detach footrestK0052 RR KE IN $9.70 Swingaway detach footrestK0052 UE IN $62.73 Swingaway detach footrestK0052 UE KE IN $72.79 Swingaway detach footrestK0053 NU IN $92.32 Elevate footrest articulateK0053 NU KE IN $107.11 Elevate footrest articulateK0053 RR IN $9.22 Elevate footrest articulateK0053 RR KE IN $10.70 Elevate footrest articulateK0053 UE IN $69.24 Elevate footrest articulateK0053 UE KE IN $80.34 Elevate footrest articulateK0056 NU IN $99.86 Seat ht <17 or >=21 ltwt wcK0056 RR IN $9.99 Seat ht <17 or >=21 ltwt wcK0056 UE IN $74.91 Seat ht <17 or >=21 ltwt wcK0065 NU IN $46.68 Spoke protectorsK0065 RR IN $4.67 Spoke protectorsK0065 UE IN $35.01 Spoke protectorsK0069 NU IN $104.92 Rear whl complete solid tireK0069 RR IN $10.49 Rear whl complete solid tireK0069 UE IN $78.69 Rear whl complete solid tireK0070 NU IN $192.32 Rear whl compl pneum tireK0070 RR IN $19.25 Rear whl compl pneum tireK0070 UE IN $144.24 Rear whl compl pneum tireK0071 NU IN $114.71 Front castr compl pneum tireK0071 RR IN $11.48 Front castr compl pneum tireK0071 UE IN $86.02 Front castr compl pneum tireK0072 NU IN $69.05 Frnt cstr cmpl sem-pneum tirK0072 RR IN $6.90 Frnt cstr cmpl sem-pneum tirK0072 UE IN $51.79 Frnt cstr cmpl sem-pneum tirK0073 NU IN $36.54 Caster pin lock eachK0073 RR IN $3.65 Caster pin lock eachK0073 UE IN $27.41 Caster pin lock eachK0077 NU IN $61.79 Front caster assem completeK0077 RR IN $6.17 Front caster assem completeK0077 UE IN $46.34 Front caster assem completeK0098 NU IN $24.63 Drive belt power wheelchairK0098 NU KE IN $28.57 Drive belt power wheelchairK0098 RR IN $2.46 Drive belt power wheelchairK0098 RR KE IN $2.86 Drive belt power wheelchairK0098 UE IN $18.45 Drive belt power wheelchairK0098 UE KE IN $21.41 Drive belt power wheelchair


K0105 NU IN $104.40 Iv hangerK0105 RR IN $10.43 Iv hangerK0105 UE IN $78.30 Iv hangerK0195 RR CR $16.21 Elevating whlchair leg restsK0195 RR KE CR $18.80 Elevating whlchair leg restsK0455 RR FS $236.39 Pump uninterrupted infusionK0552 SU $2.78 Supply/ext inf pump syr typeK0601 NU IN $1.16 Repl batt silver oxide 1.5 vK0602 NU IN $6.68 Repl batt silver oxide 3 vK0603 NU IN $0.60 Repl batt alkaline 1.5 vK0604 NU IN $6.39 Repl batt lithium 3.6 vK0605 NU IN $15.33 Repl batt lithium 4.5 vK0606 RR KF CR $2,644.18 AED garment w elec analysisK0607 NU IN $203.94 Repl batt for AEDK0607 NU KF IN $226.42 Repl batt for AEDK0607 RR IN $20.40 Repl batt for AEDK0607 RR KF IN $22.65 Repl batt for AEDK0607 UE IN $152.95 Repl batt for AEDK0607 UE KF IN $169.82 Repl batt for AEDK0608 NU IN $127.27 Repl garment for AEDK0608 NU KF IN $141.31 Repl garment for AEDK0608 RR IN $12.75 Repl garment for AEDK0608 RR KF IN $14.14 Repl garment for AEDK0608 UE IN $95.46 Repl garment for AEDK0608 UE KF IN $105.98 Repl garment for AEDK0609 SU $846.39 Repl electrode for AEDK0609 KF SU $939.71 Repl electrode for AEDK0672 PO $74.92 Removable soft interface LEK0730 NU IN $1,810.22 Ctrl dose inh drug deliv sysK0730 RR IN $181.02 Ctrl dose inh drug deliv sysK0730 UE IN $1,357.66 Ctrl dose inh drug deliv sysK0733 NU IN $27.34 12-24hr sealed lead acidK0733 NU KE IN $31.72 12-24hr sealed lead acidK0733 RR IN $2.75 12-24hr sealed lead acid K0733 RR KE IN $3.19 12-24hr sealed lead acidK0733 UE IN $20.52 12-24hr sealed lead acidK0733 UE KE IN $23.80 12-24hr sealed lead acidK0734 NU IN $299.98 Adj skin pro w/c cus wd<22inK0734 NU KE IN $348.04 Adj skin pro w/c cus wd<22inK0734 RR IN $30.00 Adj skin pro w/c cus wd<22inK0734 RR KE IN $34.81 Adj skin pro w/c cus wd<22inK0734 UE IN $224.98 Adj skin pro w/c cus wd<22inK0734 UE KE IN $261.03 Adj skin pro w/c cus wd<22inK0735 NU IN $381.71 Adj skin pro wc cus wd>=22inK0735 NU KE IN $442.87 Adj skin pro wc cus wd>=22inK0735 RR IN $38.18 Adj skin pro wc cus wd>=22inK0735 RR KE IN $44.30 Adj skin pro wc cus wd>=22inK0735 UE IN $286.28 Adj skin pro wc cus wd>=22inK0735 UE KE IN $332.15 Adj skin pro wc cus wd>=22inK0736 NU IN $302.44 Adj skin pro/pos wc cus<22inK0736 NU KE IN $350.90 Adj skin pro/pos wc cus<22inK0736 RR IN $30.25 Adj skin pro/pos wc cus<22inK0736 RR KE IN $35.09 Adj skin pro/pos wc cus<22inK0736 UE IN $226.85 Adj skin pro/pos wc cus<22inK0736 UE KE IN $263.19 Adj skin pro/pos wc cus<22inK0737 NU IN $382.87 Adj skin pro/pos wc cus>=22”K0737 NU KE IN $444.21 Adj skin pro/pos wc cus>=22”K0737 RR IN $38.28 Adj skin pro/pos wc cus>=22”K0737 RR KE IN $44.42 Adj skin pro/pos wc cus>=22”K0737 UE IN $287.15 Adj skin pro/pos wc cus>=22”K0737 UE KE IN $333.15 Adj skin pro/pos wc cus>=22”K0738 RR OX $51.63 Portable gas oxygen systemK0800 NU IN $1,169.96 POV group 1 std up to 300lbsK0800 RR IN $117.00 POV group 1 std up to 300lbsK0800 UE IN $877.47 POV group 1 std up to 300lbsK0801 NU IN $1,886.22 POV group 1 hd 301-450 lbsK0801 RR IN $188.60 POV group 1 hd 301-450 lbsK0801 UE IN $1,414.65 POV group 1 hd 301-450 lbs

UCJF 11:3-29.6

K0802 NU IN $2,134.59 POV group 1 vhd 451-600 lbsK0802 RR IN $213.45 POV group 1 vhd 451-600 lbsK0802 UE IN $1,600.95 POV group 1 vhd 451-600 lbsK0806 NU IN $1,415.34 POV group 2 std up to 300lbsK0806 RR IN $141.53 POV group 2 std up to 300lbsK0806 UE IN $1,061.50 POV group 2 std up to 300lbsK0807 NU IN $2,147.61 POV group 2 hd 301-450 lbsK0807 RR IN $214.76 POV group 2 hd 301-450 lbsK0807 UE IN $1,610.72 POV group 2 hd 301-450 lbsK0808 NU IN $3,322.80 POV group 2 vhd 451-600 lbsK0808 RR IN $332.27 POV group 2 vhd 451-600 lbsK0808 UE IN $2,492.09 POV group 2 vhd 451-600 lbsK0813 RR CR $218.32 PWC gp 1 std port seat/backK0814 RR CR $279.45 PWC gp 1 std port cap chairK0815 RR CR $318.23 PWC gp 1 std seat/backK0816 RR CR $304.75 PWC gp 1 std cap chairK0820 RR CR $233.18 PWC gp 2 std port seat/backK0821 RR CR $299.35 PWC gp 2 std port cap chairK0822 RR CR $361.77 PWC gp 2 std seat/backK0823 RR CR $364.14 PWC gp 2 std cap chairK0824 RR CR $438.26 PWC gp 2 hd seat/backK0825 RR CR $401.20 PWC gp 2 hd cap chairK0826 RR CR $567.37 PWC gp 2 vhd seat/backK0827 RR CR $482.45 PWC gp vhd cap chairK0828 RR CR $625.19 PWC gp 2 xtra hd seat/backK0829 RR CR $574.10 PWC gp 2 xtra hd cap chairK0835 RR CR $367.19 PWC gp2 std sing pow opt s/bK0836 RR CR $380.78 PWC gp2 std sing pow opt capK0837 RR CR $438.26 PWC gp 2 hd sing pow opt s/bK0838 RR CR $392.07 PWC gp 2 hd sing pow opt capK0839 RR CR $567.37 PWC gp2 vhd sing pow opt s/bK0840 RR CR $859.60 PWC gp2 xhd sing pow opt s/bK0841 RR CR $390.83 PWC gp2 std mult pow opt s/bK0842 RR CR $390.83 PWC gp2 std mult pow opt capK0843 RR CR $470.56 PWC gp2 hd mult pow opt s/bK0848 RR CR $478.24 PWC gp 3 std seat/backK0849 RR CR $459.80 PWC gp 3 std cap chairK0850 RR CR $554.75 PWC gp 3 hd seat/backK0851 RR CR $533.38 PWC gp 3 hd cap chairK0852 RR CR $640.98 PWC gp 3 vhd seat/backK0853 RR CR $658.44 PWC gp 3 vhd cap chairK0854 RR CR $872.29 PWC gp 3 xhd seat/backK0855 RR CR $824.01 PWC gp 3 xhd cap chairK0856 RR CR $513.34 PWC gp3 std sing pow opt s/bK0857 RR CR $523.63 PWC gp3 std sing pow opt capK0858 RR CR $636.90 PWC gp3 hd sing pow opt s/bK0859 RR CR $607.41 PWC gp3 hd sing pow opt capK0860 RR CR $909.90 PWC gp3 vhd sing pow opt s/bK0861 RR CR $514.17 PWC gp3 std mult pow opt s/bK0861 RR KF CR $662.31 PWC gp3 std mult pow opt s/bK0862 RR CR $636.90 PWC gp3 hd mult pow opt s/bK0863 RR CR $909.90 PWC gp3 vhd mult pow opt s/bK0864 RR CR $1,082.79 PWC gp3 xhd mult pow opt s/bL0112 PO $1,236.93 Cranial cervical orthosisL0113 PO $252.02 Cranial cervical torticollisL0120 PO $22.46 Cerv flexible non-adjustableL0130 PO $184.17 Flex thermoplastic collar moL0140 PO $54.20 Cervical semi-rigid adjustabL0150 PO $104.69 Cerv semi-rig adj molded chnL0160 PO $141.88 Cerv semi-rig wire occ/mandL0170 PO $546.01 Cervical collar molded to ptL0172 PO $123.90 Cerv col thermplas foam 2 piL0174 PO $232.58 Cerv col foam 2 piece w thorL0180 PO $343.37 Cer post col occ/man sup adjL0190 PO $459.91 Cerv collar supp adj cerv baL0200 PO $442.87 Cerv col supp adj bar & thorL0220 PO $130.69 Thor rib belt custom fabricaL0430 PO $1,258.46 Dewall posture protector


L0450 PO $172.35 TLSO flex prefab thoracicL0452 PO $0.00 tlso flex custom fab thoraciL0454 PO $306.51 TLSO flex prefab sacrococ-T9L0456 PO $878.98 TLSO flex prefabL0458 PO $788.16 TLSO 2Mod symphis-xipho preL0460 PO $887.12 TLSO2Mod symphysis-stern preL0462 PO $1,103.45 TLSO 3Mod sacro-scap preL0464 PO $1,313.63 TLSO 4Mod sacro-scap preL0466 PO $316.31 TLSO rigid frame pre soft apL0468 PO $388.08 TLSO rigid frame prefab pelvL0470 PO $629.34 TLSO rigid frame pre subclavL0472 PO $409.96 TLSO rigid frame hyperex preL0480 PO $1,455.56 TLSO rigid plastic custom faL0482 PO $1,622.12 TLSO rigid lined custom fabL0484 PO $1,611.53 TLSO rigid plastic cust fabL0486 PO $1,713.40 TLSO rigidlined cust fab twoL0488 PO $887.12 TLSO rigid lined pre one pieL0490 PO $250.01 TLSO rigid plastic pre oneL0491 PO $678.74 TLSO 2 piece rigid shellL0492 PO $445.87 TLSO 3 piece rigid shellL0621 PO $81.90 SIO flex pelvisacral prefabL0622 PO $218.72 SIO flex pelvisacral customL0623 PO $0.00 SIO panel prefabL0624 PO $0.00 SIO panel customL0625 PO $48.67 LO flexibl L1-below L5 preL0626 PO $68.88 LO sag stays/panels pre-fabL0627 PO $363.27 LO sagitt rigid panel prefabL0628 PO $74.14 LO flex w/o rigid stays preL0629 PO $0.00 LSO flex w/rigid stays custL0630 PO $143.13 LSO post rigid panel preL0631 PO $907.25 LSO sag-coro rigid frame preL0632 PO $0.00 LSO sag rigid frame custL0633 PO $253.42 LSO flexion control prefabL0634 PO $0.00 LSO flexion control customL0635 PO $861.51 LSO sagit rigid panel prefabL0636 PO $1,277.69 LSO sagittal rigid panel cusL0637 PO $949.40 LSO sag-coronal panel prefabL0638 PO $1,165.59 LSO sag-coronal panel customL0639 PO $949.40 LSO s/c shell/panel prefabL0640 PO $924.76 LSO s/c shell/panel customL0700 PO $1,711.65 Ctlso a-p-l control moldedL0710 PO $1,776.81 Ctlso a-p-l control w/ interL0810 PO $2,217.73 Halo cervical into jckt vestL0820 PO $1,828.81 Halo cervical into body jackL0830 PO $2,654.88 Halo cerv into milwaukee typL0859 PO $1,031.40 MRI compatible systemL0861 PO $190.48 Halo repl liner/interfaceL0970 PO $100.15 Tlso corset frontL0972 PO $96.54 Lso corset frontL0974 PO $151.58 Tlso full corsetL0976 PO $135.38 Lso full corsetL0978 PO $162.97 Axillary crutch extensionL0980 PO $14.78 Peroneal straps pairL0982 PO $13.78 Stocking supp grips set of fL0984 PO $55.43 Protective body sock eachL1000 PO $1,718.88 Ctlso milwauke initial modelL1001 PO $0.00 CTLSO infant immobilizerL1005 PO $2,828.58 Tension based scoliosis orthL1010 PO $56.82 Ctlso axilla slingL1020 PO $73.18 Kyphosis padL1025 PO $140.77 Kyphosis pad floatingL1030 PO $53.86 Lumbar bolster padL1040 PO $66.05 Lumbar or lumbar rib padL1050 PO $70.49 Sternal padL1060 PO $80.97 Thoracic padL1070 PO $76.18 Trapezius slingL1080 PO $46.86 OutriggerL1085 PO $130.32 Outrigger bil w/ vert extens

UCJF 11:3-29.6

L1090 PO $85.17 LumbarL1100 PO $138.22 Ring flange plastic/leatherL1110 PO $216.23 Ring flange plas/leather molL1120 PO $33.62 Covers for upright eachL1200 PO $1,326.54 Furnsh initial orthosis onlyL1210 PO $295.37 Lateral thoracic extensionL1220 PO $250.09 Anterior thoracic extensionL1230 PO $641.70 Milwaukee type superstructurL1240 PO $66.35 Lumbar derotation padL1250 PO $61.17 Anterior asis padL1260 PO $64.05 Anterior thoracic derotationL1270 PO $65.60 Abdominal padL1280 PO $78.46 Rib gusset (elastic) eachL1290 PO $66.54 Lateral trochanteric padL1300 PO $1,885.67 Body jacket mold to patientL1310 PO $1,878.10 Post-operative body jacketL1500 PO $1,608.16 Thkao mobility frameL1510 PO $1,356.53 Thkao standing frameL1520 PO $2,516.64 Thkao swivel walkerL1600 PO $109.10 Abduct hip flex frejka w cvrL1610 PO $40.61 Abduct hip flex frejka covrL1620 PO $125.53 Abduct hip flex pavlik harneL1630 PO $143.46 Abduct control hip semi-flexL1640 PO $456.47 Pelv band/spread bar thigh cL1650 PO $196.02 HO abduction hip adjustableL1652 PO $315.03 HO bi thighcuffs w sprdr barL1660 PO $144.89 HO abduction static plasticL1680 PO $1,031.57 Pelvic & hip control thigh cL1685 PO $1,007.06 Post-op hip abduct custom faL1686 PO $1,029.73 HO post-op hip abductionL1690 PO $1,708.96 Combination bilateral HOL1700 PO $1,292.91 Leg perthes orth toronto typL1710 PO $1,513.50 Legg perthes orth newingtonL1720 PO $1,115.63 Legg perthes orthosis trilatL1730 PO $983.88 Legg perthes orth scottish rL1755 PO $1,379.70 Legg perthes patten bottom tL1810 PO $90.95 Ko elastic with jointsL1820 PO $124.61 Ko elas w/ condyle pads & joL1830 PO $87.80 Ko immobilizer canvas longitL1831 PO $260.10 Knee orth pos locking joinL1832 PO $686.31 KO adj jnt pos rigid supportL1834 PO $744.08 Ko w/0 joint rigid molded toL1836 PO $117.92 Rigid KO wo jointsL1840 PO $876.12 Ko derot ant cruciate customL1843 PO $792.96 KO single upright custom fitL1844 PO $1,384.28 Ko w/adj jt rot cntrl moldedL1845 PO $869.76 Ko w/ adj flex/ext rotat cusL1846 PO $1,141.23 Ko w adj flex/ext rotat moldL1847 PO $508.31 KO adjustable w air chambersL1850 PO $267.60 Ko swedish typeL1860 PO $1,106.55 Ko supracondylar socket moldL1900 PO $228.40 Afo sprng wir drsflx calf bdL1902 PO $88.45 Afo ankle gauntletL1904 PO $411.73 Afo molded ankle gauntletL1906 PO $102.82 Afo multiligamentus ankle suL1907 PO $497.28 AFO supramalleolar customL1910 PO $281.66 Afo sing bar clasp attach shL1920 PO $316.64 Afo sing upright w/ adjust sL1930 PO $200.28 Afo plasticL1932 PO $788.63 Afo rig ant tib prefab TCF/=L1940 PO $531.48 Afo molded to patient plastiL1945 PO $783.73 Afo molded plas rig ant tibL1950 PO $840.82 Afo spiral molded to pt plasL1951 PO $742.21 AFO spiral prefabricatedL1960 PO $625.71 Afo pos solid ank plastic moL1970 PO $799.03 Afo plastic molded w/ankle jL1971 PO $414.24 AFO w/ankle joint, prefabL1980 PO $348.77 Afo sing solid stirrup calf


L1990 PO $450.06 Afo doub solid stirrup calfL2000 PO $968.33 Kafo sing fre stirr thi/calfL2005 PO $3,621.39 KAFO sng/dbl mechanical actL2010 PO $1,043.76 Kafo sng solid stirrup w/o jL2020 PO $1,074.01 Kafo dbl solid stirrup band/L2030 PO $1,101.22 Kafo dbl solid stirrup w/o jL2034 PO $1,842.24 KAFO pla sin up w/wo k/a cusL2035 PO $155.72 KAFO plastic pediatric sizeL2036 PO $2,094.38 Kafo plas doub free knee molL2037 PO $1,853.19 Kafo plas sing free knee molL2038 PO $1,590.19 Kafo w/o joint multi-axis anL2040 PO $150.31 Hkafo torsion bil rot strapsL2050 PO $413.47 Hkafo torsion cable hip pelvL2060 PO $520.42 Hkafo torsion ball bearing jL2070 PO $114.59 Hkafo torsion unilat rot strL2080 PO $323.11 Hkafo unilat torsion cableL2090 PO $371.24 Hkafo unilat torsion ball brL2106 PO $738.57 Afo tib fx cast plaster moldL2108 PO $1,097.86 Afo tib fx cast molded to ptL2112 PO $501.71 Afo tibial fracture softL2114 PO $654.70 Afo tib fx semi-rigidL2116 PO $720.29 Afo tibial fracture rigidL2126 PO $1,351.75 Kafo fem fx cast thermoplasL2128 PO $1,749.02 Kafo fem fx cast molded to pL2132 PO $910.62 Kafo femoral fx cast softL2134 PO $1,091.80 Kafo fem fx cast semi-rigidL2136 PO $1,334.99 Kafo femoral fx cast rigidL2180 PO $99.15 Plas shoe insert w ank jointL2182 PO $77.60 Drop lock kneeL2184 PO $104.88 Limited motion knee jointL2186 PO $140.15 Adj motion knee jnt lerman tL2188 PO $338.08 Quadrilateral brimL2190 PO $79.61 Waist beltL2192 PO $385.26 Pelvic band & belt thigh flaL2200 PO $41.70 Limited ankle motion ea jntL2210 PO $62.19 Dorsiflexion assist each joiL2220 PO $78.65 Dorsi & plantar flex ass/resL2230 PO $64.96 Split flat caliper stirr & pL2232 PO $87.95 Rocker bottom, contact AFOL2240 PO $70.80 Round caliper and plate attaL2250 PO $300.84 Foot plate molded stirrup atL2260 PO $226.29 Reinforced solid stirrupL2265 PO $99.70 Long tongue stirrupL2270 PO $46.48 Varus/valgus strap padded/liL2275 PO $106.72 Plastic mod low ext pad/lineL2280 PO $442.02 Molded inner bootL2300 PO $303.93 Abduction bar jointed adjustL2310 PO $104.15 Abduction bar-straightL2320 PO $208.49 Non-molded lacerL2330 PO $443.25 Lacer molded to patient modeL2335 PO $192.33 Anterior swing bandL2340 PO $411.27 Pre-tibial shell molded to pL2350 PO $1,002.62 Prosthetic type socket moldeL2360 PO $58.41 Extended steel shankL2370 PO $289.79 Patten bottomL2375 PO $95.66 Torsion ank & half solid stiL2380 PO $104.23 Torsion straight knee jointL2385 PO $113.40 Straight knee joint heavy duL2387 PO $140.12 Add LE poly knee custom KAFOL2390 PO $98.79 Offset knee joint eachL2395 PO $132.46 Offset knee joint heavy dutyL2397 PO $99.93 Suspension sleeve lower extL2405 PO $77.05 Knee joint drop lock ea jntL2415 PO $107.33 Knee joint cam lock each joiL2425 PO $126.68 Knee disc/dial lock/adj flexL2430 PO $126.68 Knee jnt ratchet lock ea jntL2492 PO $98.36 Knee lift loop drop lock rinL2500 PO $267.09 Thi/glut/ischia wgt bearing

UCJF 11:3-29.6

L2510 PO $715.81 Th/wght bear quad-lat brim mL2520 PO $480.56 Th/wght bear quad-lat brim cL2525 PO $1,187.84 Th/wght bear nar m-l brim moL2526 PO $579.90 Th/wght bear nar m-l brim cuL2530 PO $259.22 Thigh/wght bear lacer non-moL2540 PO $365.67 Thigh/wght bear lacer moldedL2550 PO $295.50 Thigh/wght bear high roll cuL2570 PO $403.26 Hip clevis type 2 posit jntL2580 PO $450.84 Pelvic control pelvic slingL2600 PO $173.88 Hip clevis/thrust bearing frL2610 PO $239.94 Hip clevis/thrust bearing loL2620 PO $301.83 Pelvic control hip heavy dutL2622 PO $259.63 Hip joint adjustable flexionL2624 PO $300.21 Hip adj flex ext abduct contL2627 PO $1,765.80 Plastic mold recipro hip & cL2628 PO $1,823.23 Metal frame recipro hip & caL2630 PO $255.33 Pelvic control band & belt uL2640 PO $379.36 Pelvic control band & belt bL2650 PO $104.32 Pelv & thor control glutealL2660 PO $157.80 Thoracic control thoracic baL2670 PO $178.37 Thorac cont paraspinal uprigL2680 PO $165.80 Thorac cont lat support upriL2750 PO $83.30 Plating chrome/nickel pr barL2755 PO $115.44 Carbon graphite laminationL2760 PO $63.27 Extension per extension perL2768 PO $115.14 Ortho sidebar disconnectL2780 PO $68.99 Non-corrosive finishL2785 PO $31.59 Drop lock retainer eachL2795 PO $80.83 Knee control full kneecapL2800 PO $90.31 Knee cap medial or lateral pL2810 PO $66.13 Knee control condylar padL2820 PO $84.45 Soft interface below knee seL2830 PO $97.94 Soft interface above knee seL2840 PO $43.76 Tibial length sock fx or equL2850 PO $56.28 Femoral lgth sock fx or equaL3000 PO $277.61 Ft insert ucb berkeley shellL3001 PO $116.89 Foot insert remov molded speL3002 PO $142.73 Foot insert plastazote or eqL3003 PO $154.00 Foot insert silicone gel eacL3010 PO $154.00 Foot longitudinal arch suppoL3020 PO $175.35 Foot longitud/metatarsal supL3030 PO $67.45 Foot arch support remov premL3031 PO $0.00 Foot lamin/prepreg compositeL3040 PO $41.58 Ft arch suprt premold longitL3050 PO $41.58 Foot arch supp premold metatL3060 PO $65.19 Foot arch supp longitud/metaL3070 PO $28.07 Arch suprt att to sho longitL3080 PO $28.07 Arch supp att to shoe metataL3090 PO $35.98 Arch supp att to shoe long/mL3100 PO $38.21 Hallus-valgus nght dynamic sL3140 PO $78.69 Abduction rotation bar shoeL3150 PO $71.94 Abduct rotation bar w/o shoeL3170 PO $44.98 Foot plastic heel stabilizerL3224 PO $54.83 Woman’s shoe oxford braceL3225 PO $61.58 Man’s shoe oxford braceL3300 PO $46.07 Sho lift taper to metatarsalL3310 PO $71.94 Shoe lift elev heel/sole neoL3330 PO $500.16 Lifts elevation metal extensL3332 PO $65.19 Shoe lifts tapered to one-haL3334 PO $33.72 Shoe lifts elevation heel /iL3340 PO $75.32 Shoe wedge sachL3350 PO $20.24 Shoe heel wedgeL3360 PO $31.47 Shoe sole wedge outside soleL3370 PO $43.81 Shoe sole wedge between soleL3380 PO $43.81 Shoe clubfoot wedgeL3390 PO $43.81 Shoe outflare wedgeL3400 PO $35.98 Shoe metatarsal bar wedge roL3410 PO $82.04 Shoe metatarsal bar between


L3420 PO $48.33 Full sole/heel wedge betweenL3430 PO $141.62 Sho heel count plast reinforL3440 PO $67.45 Heel leather reinforcedL3450 PO $93.29 Shoe heel sach cushion typeL3455 PO $35.98 Shoe heel new leather standaL3460 PO $30.33 Shoe heel new rubber standarL3465 PO $51.71 Shoe heel thomas with wedgeL3470 PO $55.07 Shoe heel thomas extend to bL3480 PO $55.07 Shoe heel pad & depress forL3500 PO $25.85 Ortho shoe add leather insolL3510 PO $25.85 Orthopedic shoe add rub inslL3520 PO $28.07 O shoe add felt w leath inslL3530 PO $28.07 Ortho shoe add half soleL3540 PO $44.98 Ortho shoe add full soleL3550 PO $7.85 O shoe add standard toe tapL3560 PO $20.24 O shoe add horseshoe toe tapL3570 PO $75.32 O shoe add instep extensionL3580 PO $57.32 O shoe add instep velcro cloL3590 PO $47.20 O shoe convert to sof counteL3595 PO $37.09 Ortho shoe add march barL3600 PO $67.45 Trans shoe calip plate existL3610 PO $88.78 Trans shoe caliper plate newL3620 PO $67.45 Trans shoe solid stirrup exiL3630 PO $88.78 Trans shoe solid stirrup newL3640 PO $38.21 Shoe dennis browne splint boL3650 PO $56.44 Shlder fig 8 abduct restrainL3660 PO $87.15 Abduct restrainer canvas&webL3670 PO $111.07 Acromio/clavicular canvas&weL3671 PO $724.74 SO cap design w/o jnts CFL3672 PO $901.26 SO airplane w/o jnts CFL3673 PO $982.26 SO airplane w/joint CFL3675 PO $141.14 Canvas vest SOL3702 PO $232.24 EO w/o joints CFL3710 PO $106.90 Elbow elastic with metal joiL3720 PO $722.52 Forearm/arm cuffs free motioL3730 PO $974.00 Forearm/arm cuffs ext/flex aL3740 PO $1,092.33 Cuffs adj lock w/ active conL3760 PO $402.22 EO withjoint, PrefabricatedL3762 PO $86.49 Rigid EO wo jointsL3763 PO $619.76 EWHO rigid w/o jnts CFL3764 PO $779.98 EWHO w/joint(s) CFL3765 PO $1,031.30 EWHFO rigid w/o jnts CFL3766 PO $1,092.07 EWHFO w/joint(s) CFL3806 PO $365.35 WHFO w/joint(s) custom fabL3807 PO $201.12 WHFO,no joint, prefabricatedL3808 PO $326.34 WHFO, rigid w/o jointsL3900 PO $1,072.01 Hinge extension/flex wrist/fL3901 PO $1,472.96 Hinge ext/flex wrist fingerL3904 PO $2,426.16 Whfo electric custom fittedL3905 PO $797.64 WHO w/nontorsion jnt(s) CFL3906 PO $338.28 WHO w/o joints CFL3908 PO $66.19 Wrist cock-up non-moldedL3912 PO $78.57 Flex glove w/elastic fingerL3913 PO $217.84 HFO w/o joints CFL3915 PO $427.53 WHO w nontor jnt(s) prefabL3917 PO $84.97 Prefab metacarpl fx orthosisL3919 PO $217.84 HO w/o joints CFL3921 PO $258.36 HFO w/joint(s) CFL3923 PO $72.07 HFO w/o joints PFL3925 PO $40.89 FO pip/dip with joint/springL3927 PO $28.10 FO pip/dip w/o joint/springL3929 PO $64.76 HFO nontorsion joint, prefabL3931 PO $158.21 WHFO nontorsion joint prefabL3933 PO $171.61 FO w/o joints CFL3935 PO $177.68 FO nontorsion joint CFL3956 PO $0.00 Add joint upper ext orthosisL3960 PO $624.54 Sewho airplan desig abdu posL3961 PO $1,351.31 SEWHO cap design w/o jnts CF

UCJF 11:3-29.6

L3962 PO $594.43 Sewho erbs palsey design abdL3964 NU IN $652.17 Seo mobile arm sup att to wcL3964 RR IN $65.21 Seo mobile arm sup att to wcL3964 UE IN $489.09 Seo mobile arm sup att to wcL3965 NU IN $1,040.67 Arm supp att to wc rancho tyL3965 RR IN $104.09 Arm supp att to wc rancho tyL3965 UE IN $780.50 Arm supp att to wc rancho tyL3966 NU IN $783.97 Mobile arm supports recliningL3966 RR IN $78.40 Mobile arm supports recliningL3966 UE IN $587.98 Mobile arm supports reclininL3967 PO $1,595.45 SEWHO airplane w/o jnts CFL3968 NU IN $992.10 Friction dampening arm suppL3968 RR IN $99.20 Friction dampening arm suppL3968 UE IN $744.08 Friction dampening arm supL3969 NU IN $675.03 Monosuspension arm/hand suppL3969 RR IN $67.52 Monosuspension arm/hand suppL3969 UE IN $506.29 Monosuspension arm/hand suppL3970 NU IN $277.53 Elevat proximal arm supportL3970 RR IN $27.75 Elevat proximal arm supportL3970 UE IN $208.14 Elevat proximal arm supportL3971 PO $1,514.45 SEWHO cap design w/jnt(s) CFL3972 NU IN $176.47 Offset/lat rocker arm w/ elaL3972 RR IN $17.65 Offset/lat rocker arm w/ elaL3972 UE IN $132.35 Offset/lat rocker arm w/ elaL3973 PO $1,595.45 SEWHO airplane w/jnt(s) CFL3974 NU IN $149.68 Mobile arm support supinatorL3974 RR IN $14.98 Mobile arm support supinatorL3974 UE IN $112.26 Mobile arm support supinatorL3975 PO $1,351.31 SEWHFO cap design w/o jnt CFL3976 PO $1,351.31 SEWHFO airplane w/o jnts CFL3977 PO $1,514.45 SEWHFO cap desgn w/jnt(s) CFL3978 PO $1,595.45 SEWHFO airplane w/jnt(s) CFL3980 PO $292.85 Upp ext fx orthosis humeralL3982 PO $412.38 Upper ext fx orthosis rad/ulL3984 PO $305.04 Upper ext fx orthosis wristL3995 PO $36.12 Sock fracture or equal eachL4000 PO $1,079.50 Repl girdle milwaukee orthL4002 PO $0.00 Replace strap, any orthosisL4010 PO $670.03 Replace trilateral socket brL4020 PO $930.03 Replace quadlat socket brimL4030 PO $569.94 Replace socket brim cust fitL4040 PO $408.64 Replace molded thigh lacerL4045 PO $277.72 Replace non-molded thigh lacL4050 PO $466.04 Replace molded calf lacerL4055 PO $226.33 Replace non-molded calf laceL4060 PO $269.06 Replace high roll cuffL4070 PO $238.27 Replace prox & dist uprightL4080 PO $87.52 Repl met band kafo-afo proxL4090 PO $91.00 Repl met band kafo-afo calf/L4100 PO $109.71 Repl leath cuff kafo prox thL4110 PO $94.65 Repl leath cuff kafo-afo calL4130 PO $420.05 Replace pretibial shellL4350 PO $75.68 Ankle control orthosi prefabL4360 PO $243.20 Pneumati walking boot prefabL4370 PO $159.83 Pneumatic full leg splintL4380 PO $112.46 Pneumatic knee splintL4386 PO $140.12 Non-pneum walk boot prefabL4392 PO $20.80 Replace AFO soft interfaceL4394 PO $15.17 Replace foot drop spintL4396 PO $148.29 Static AFOL4398 PO $68.28 Foot drop splint recumbentL5000 PO $455.74 Sho insert w arch toe fillerL5010 PO $1,393.98 Mold socket ank hgt w/ toe fL5020 PO $1,787.52 Tibial tubercle hgt w/ toe fL5050 PO $2,206.49 Ank symes mold sckt sach ftL5060 PO $3,321.74 Symes met fr leath socket arL5100 PO $2,286.02 Molded socket shin sach footL5105 PO $3,818.81 Plast socket jts/thgh lacer


L5150 PO $3,518.16 Mold sckt ext knee shin sachL5160 PO $3,445.23 Mold socket bent knee shin sL5200 PO $2,981.01 Kne sing axis fric shin sachL5210 PO $2,918.33 No knee/ankle joints w/ ft bL5220 PO $2,663.70 No knee joint with artic aliL5230 PO $3,431.32 Fem focal defic constant friL5250 PO $4,998.89 Hip canad sing axi cons fricL5270 PO $4,639.02 Tilt table locking hip singL5280 PO $4,592.63 Hemipelvect canad sing axisL5301 PO $2,071.00 BK mold socket SACH ft endoL5311 PO $3,026.74 Knee disart, SACH ft, endoL5321 PO $2,964.57 AK open end SACHL5331 PO $4,194.98 Hip disart canadian SACH ftL5341 PO $4,592.78 Hemipelvectomy canadian SACHL5400 PO $1,085.58 Postop dress & 1 cast chg bkL5410 PO $376.87 Postop dsg bk ea add cast chL5420 PO $1,371.04 Postop dsg & 1 cast chg ak/dL5430 PO $605.19 Postop dsg ak ea add cast chL5450 PO $408.79 Postop app non-wgt bear dsgL5460 PO $491.84 Postop app non-wgt bear dsgL5500 PO $1,158.45 Init bk ptb plaster directL5505 PO $1,568.85 Init ak ischal plstr directL5510 PO $1,313.18 Prep BK ptb plaster moldedL5520 PO $1,584.72 Perp BK ptb thermopls directL5530 PO $1,557.95 Prep BK ptb thermopls moldedL5535 PO $1,710.89 Prep BK ptb open end socketL5540 PO $1,632.56 Prep BK ptb laminated socketL5560 PO $2,048.48 Prep AK ischial plast moldedL5570 PO $2,063.30 Prep AK ischial direct formL5580 PO $2,338.67 Prep AK ischial thermo moldL5585 PO $2,307.80 Prep AK ischial open endL5590 PO $2,406.26 Prep AK ischial laminatedL5595 PO $4,009.37 Hip disartic sach thermoplsL5600 PO $4,435.46 Hip disart sach laminat moldL5610 PO $1,867.47 Above knee hydracadenceL5611 PO $1,453.26 Ak 4 bar link w/fric swingL5613 PO $2,210.50 Ak 4 bar ling w/hydraul swigL5614 PO $1,494.20 4-bar link above knee w/swngL5616 PO $1,225.04 Ak univ multiplex sys frictL5617 PO $505.39 AK/BK self-aligning unit eaL5618 PO $267.34 Test socket symesL5620 PO $296.69 Test socket below kneeL5622 PO $435.99 Test socket knee disarticulaL5624 PO $378.87 Test socket above kneeL5626 PO $430.06 Test socket hip disarticulateL5628 PO $449.66 Test socket hemipelvectomyL5629 PO $382.20 Below knee acrylic socketL5630 PO $408.92 Syme typ expandabl wall scktL5631 PO $528.42 Ak/knee disartic acrylic socL5632 PO $218.16 Symes type ptb brim design sL5634 PO $321.65 Symes type poster opening soL5636 PO $306.44 Symes type medial opening soL5637 PO $332.45 Below knee total contactL5638 PO $528.12 Below knee leather socketL5639 PO $1,288.34 Below knee wood socketL5640 PO $769.02 Knee disarticulat leather soL5642 PO $666.91 Above knee leather socketL5643 PO $1,403.89 Hip flex inner socket ext frL5644 PO $532.75 Above knee wood socketL5645 PO $719.69 Bk flex inner socket ext fraL5646 PO $523.31 Below knee cushion socketL5647 PO $751.02 Below knee suction socketL5648 PO $659.98 Above knee cushion socketL5649 PO $1,717.33 Isch containmt/narrow m-l soL5650 PO $587.11 Tot contact ak/knee disart sL5651 PO $1,083.21 Ak flex inner socket ext fraL5652 PO $393.25 Suction susp ak/knee disartL5653 PO $524.95 Knee disart expand wall sock

UCJF 11:3-29.6

L5654 PO $316.80 Socket insert symesL5655 PO $307.80 Socket insert below kneeL5656 PO $437.29 Socket insert knee articulatL5658 PO $353.07 Socket insert above kneeL5661 PO $550.50 Multi-durometer symesL5665 PO $461.84 Multi-durometer below kneeL5666 PO $70.93 Below knee cuff suspensionL5668 PO $94.93 Socket insert w/o lock lowerL5670 PO $253.22 Bk molded supracondylar suspL5671 PO $448.66 BK/AK locking mechanismL5672 PO $268.96 Bk removable medial brim susL5673 PO $602.72 Socket insert w lock mechL5676 PO $326.85 Bk knee joints single axis pL5677 PO $444.73 Bk knee joints polycentric pL5678 PO $35.81 Bk joint covers pairL5679 PO $502.25 Socket insert w/o lock mechL5680 PO $351.57 Bk thigh lacer non-moldedL5681 PO $1,164.74 Intl custm cong/latyp insertL5682 PO $588.04 Bk thigh lacer glut/ischia mL5683 PO $1,164.74 Initial custom socket insertL5684 PO $44.57 Bk fork strapL5685 PO $113.41 Below knee sus/seal sleeveL5686 PO $61.44 Bk back checkL5688 PO $73.46 Bk waist belt webbingL5690 PO $93.38 Bk waist belt padded and linL5692 PO $119.86 Ak pelvic control belt lightL5694 PO $163.63 Ak pelvic control belt pad/lL5695 PO $171.09 Ak sleeve susp neoprene/equaL5696 PO $181.28 Ak/knee disartic pelvic joinL5697 PO $72.41 Ak/knee disartic pelvic bandL5698 PO $118.13 Ak/knee disartic silesian baL5699 PO $171.57 Shoulder harnessL5700 PO $2,516.16 Replace socket below kneeL5701 PO $3,121.51 Replace socket above kneeL5702 PO $3,934.19 Replace socket hipL5703 PO $2,098.10 Symes ankle w/o (SACH) footL5704 PO $513.04 Custom shape cover BKL5705 PO $940.57 Custom shape cover AKL5706 PO $917.40 Custom shape cvr knee disartL5707 PO $1,232.53 Custom shape cvr hip disartL5710 PO $341.39 Kne-shin exo sng axi mnl locL5711 PO $512.58 Knee-shin exo mnl lock ultraL5712 PO $444.22 Knee-shin exo frict swg & stL5714 PO $391.36 Knee-shin exo variable frictL5716 PO $657.41 Knee-shin exo mech stance phL5718 PO $821.69 Knee-shin exo frct swg & staL5722 PO $814.38 Knee-shin pneum swg frct exoL5724 PO $1,695.67 Knee-shin exo fluid swing phL5726 PO $1,569.07 Knee-shin ext jnts fld swg eL5728 PO $2,388.06 Knee-shin fluid swg & stanceL5780 PO $1,032.69 Knee-shin pneum/hydra pneumL5781 PO $3,542.95 Lower limb pros vacuum pumpL5782 PO $3,735.08 HD low limb pros vacuum pumpL5785 PO $468.63 Exoskeletal bk ultralt materL5790 PO $648.55 Exoskeletal ak ultra-light mL5795 PO $968.46 Exoskel hip ultra-light mateL5810 PO $453.75 Endoskel knee-shin mnl lockL5811 PO $657.83 Endo knee-shin mnl lck ultraL5812 PO $509.89 Endo knee-shin frct swg & stL5814 PO $3,288.54 Endo knee-shin hydral swg phL5816 PO $767.09 Endo knee-shin polyc mch staL5818 PO $928.33 Endo knee-shin frct swg & stL5822 PO $1,904.52 Endo knee-shin pneum swg frcL5824 PO $1,712.64 Endo knee-shin fluid swing pL5826 PO $2,812.31 Miniature knee jointL5828 PO $3,112.56 Endo knee-shin fluid swg/staL5830 PO $1,836.77 Endo knee-shin pneum/swg phaL5840 PO $3,198.98 Multi-axial knee/shin system


L5845 PO $1,587.11 Knee-shin sys stance flexionL5848 PO $952.18 Knee-shin sys hydraul stanceL5850 PO $120.91 Endo ak/hip knee extens assiL5855 PO $278.56 Mech hip extension assistL5856 PO $21,353.09 Elec knee-shin swing/stanceL5857 PO $7,639.05 Elec knee-shin swing onlyL5858 PO $16,456.85 Stance phase onlyL5910 PO $357.37 Endo below knee alignable syL5920 PO $478.58 Endo ak/hip alignable systemL5925 PO $303.07 Above knee manual lockL5930 PO $3,040.28 High activity knee frameL5940 PO $491.52 Endo bk ultra-light materialL5950 PO $796.83 Endo ak ultra-light materialL5960 PO $1,154.32 Endo hip ultra-light materialL5962 PO $530.18 Below knee flex cover systemL5964 PO $919.55 Above knee flex cover systemL5966 PO $1,184.53 Hip flexible cover systemL5968 PO $3,217.78 Multiaxial ankle w dorsiflexL5970 PO $183.19 Foot external keel sach footL5971 PO $183.19 SACH foot, replacementL5972 PO $317.89 Flexible keel footL5973 PO $15,410.73 Ank-foot sys dors-plant flexL5974 PO $210.19 Foot single axis ankle/footL5975 PO $410.50 Combo ankle/foot prosthesisL5976 PO $637.40 Energy storing footL5978 PO $263.23 Ft prosth multiaxial ankl/ftL5979 PO $2,058.12 Multi-axial ankle/ft prosthL5980 PO $4,391.63 Flex foot systemL5981 PO $2,799.03 Flex-walk sys low ext prosthL5982 PO $521.45 Exoskeletal axial rotation uL5984 PO $513.84 Endoskeletal axial rotationL5985 PO $255.06 Lwr ext dynamic prosth pylonL5986 PO $571.58 Multi-axial rotation unitL5987 PO $6,369.90 Shank ft w vert load pylonL5988 PO $1,768.94 Vertical shock reducing pyloL5990 PO $1,606.45 User adjustable heel heightL6000 PO $1,225.74 Par hand robin-aids thum remL6010 PO $1,400.35 Hand robin-aids little/ringL6020 PO $1,243.46 Part hand robin-aids no fingL6025 PO $7,085.97 Part hand disart myoelectricL6050 PO $1,998.97 Wrst MLd sck flx hng tri padL6055 PO $2,604.97 Wrst mold sock w/exp interfaL6100 PO $2,314.64 Elb mold sock flex hinge padL6110 PO $2,455.06 Elbow mold sock suspension tL6120 PO $2,667.06 Elbow mold doub splt soc steL6130 PO $2,886.40 Elbow stump activated lock hL6200 PO $2,460.70 Elbow mold outsid lock hingeL6205 PO $3,692.89 Elbow molded w/ expand interL6250 PO $2,552.59 Elbow inter loc elbow forarmL6300 PO $4,078.78 Shlder disart int lock elbowL6310 PO $2,912.39 Shoulder passive restor compL6320 PO $1,541.44 Shoulder passive restor capL6350 PO $4,710.70 Thoracic intern lock elbowL6360 PO $2,873.00 Thoracic passive restor compL6370 PO $2,442.68 Thoracic passive restor capL6380 PO $1,248.88 Postop dsg cast chg wrst/elbL6382 PO $1,780.73 Postop dsg cast chg elb dis/L6384 PO $2,292.98 Postop dsg cast chg shlder/tL6386 PO $482.97 Postop ea cast chg & realignL6388 PO $396.54 Postop applicat rigid dsg onL6400 PO $2,436.00 Below elbow prosth tiss shapL6450 PO $2,798.60 Elb disart prosth tiss shapL6500 PO $2,883.85 Above elbow prosth tiss shapL6550 PO $3,439.51 Shldr disar prosth tiss shapL6570 PO $4,204.05 Scap thorac prosth tiss shapL6580 PO $1,413.43 Wrist/elbow bowden cable molL6582 PO $1,248.88 Wrist/elbow bowden cbl dir fL6584 PO $1,895.51 Elbow fair lead cable molded

UCJF 11:3-29.6

L6586 PO $1,698.83 Elbow fair lead cable dir foL6588 PO $2,602.47 Shdr fair lead cable moldedL6590 PO $2,423.98 Shdr fair lead cable directL6600 PO $225.59 Polycentric hinge pairL6605 PO $222.75 Single pivot hinge pairL6610 PO $150.17 Flexible metal hinge pairL6611 PO $364.58 Additional switch, ext powerL6615 PO $165.77 Disconnect locking wrist uniL6616 PO $68.22 Disconnect insert locking wrL6620 PO $273.49 Flexion/extension wrist unitL6621 PO $2,025.37 Flex/ext wrist w/wo frictionL6623 PO $578.59 Spring-ass rot wrst w/ latchL6624 PO $3,334.81 Flex/ext/rotation wrist unitL6625 PO $479.73 Rotation wrst w/ cable lockL6628 PO $432.10 Quick disconn hook adapter oL6629 PO $158.07 Lamination collar w/ couplinL6630 PO $194.40 Stainless steel any wristL6632 PO $58.60 Latex suspension sleeve eachL6635 PO $182.27 Lift assist for elbowL6637 PO $331.20 Nudge control elbow lockL6638 PO $2,214.36 Elec lock on manual pw elbowL6640 PO $336.88 Shoulder abduction joint paiL6641 PO $192.94 Excursion amplifier pulley tL6642 PO $261.51 Excursion amplifier lever tyL6645 PO $291.09 Shoulder flexion-abduction jL6646 PO $2,792.80 Multipo locking shoulder jntL6647 PO $459.77 Shoulder lock actuatorL6648 PO $2,880.38 Ext pwrd shlder lock/unlockL6650 PO $349.67 Shoulder universal jointL6655 PO $72.10 Standard control cable extraL6660 PO $82.79 Heavy duty control cableL6665 PO $48.11 Teflon or equal cable liningL6670 PO $53.31 Hook to hand cable adapterL6672 PO $184.88 Harness chest/shlder saddleL6675 PO $122.61 Harness figure of 8 sing conL6676 PO $131.59 Harness figure of 8 dual conL6677 PO $262.67 UE triple control harnessL6680 PO $263.73 Test sock wrist disart/bel eL6682 PO $282.84 Test sock elbw disart/aboveL6684 PO $401.49 Test socket shldr disart/thoL6686 PO $540.30 Suction socketL6687 PO $529.49 Frame typ socket bel elbow/wL6688 PO $491.68 Frame typ sock above elb/disL6689 PO $810.35 Frame typ socket shoulder diL6690 PO $697.00 Frame typ sock interscap-thoL6691 PO $332.43 Removable insert eachL6692 PO $511.61 Silicone gel insert or equalL6693 PO $2,513.89 Lockingelbow forearm cntrbalL6694 PO $602.72 Elbow socket ins use w/lockL6695 PO $502.25 Elbow socket ins use w/o lckL6696 PO $1,164.74 Cus elbo skt in for con/atypL6697 PO $1,164.74 Cus elbo skt in not con/atypL6698 PO $448.66 Below/above elbow lock mechL6703 PO $390.97 Term dev, passive hand mittL6704 PO $529.24 Term dev, sport/rec/work attL6706 PO $314.73 Term dev mech hook vol openL6707 PO $1,236.49 Term dev mech hook vol closeL6708 PO $828.61 Term dev mech hand vol openL6709 PO $1,109.29 Term dev mech hand vol closeL6711 PO $595.31 Ped term dev, hook, vol openL6712 PO $1,096.10 Ped term dev, hook, vol closL6713 PO $1,383.40 Ped term dev, hand, vol openL6714 PO $1,171.72 Ped term dev, hand, vol closL6721 PO $2,082.62 Hook/hand, hvy dty, vol openL6722 PO $1,795.38 Hook/hand, hvy dty, vol closL6805 PO $360.23 Term dev modifier wrist unitL6810 PO $168.25 Term dev precision pinch devL6881 PO $3,620.07 Term dev auto grasp feature


L6882 PO $2,745.98 Microprocessor control uplmbL6883 PO $1,908.47 Replc sockt below e/w disaL6884 PO $2,098.76 Replc sockt above elbow disaL6885 PO $2,873.00 Replc sockt shldr dis/intercL6890 PO $204.56 Prefab glove for term deviceL6895 PO $503.66 Custom glove for term deviceL6900 PO $1,601.01 Hand restorat thumb/1 fingerL6905 PO $1,581.91 Hand restoration multiple fiL6910 PO $1,644.79 Hand restoration no fingersL6915 PO $564.67 Hand restoration replacmnt gL6920 PO $6,019.63 Wrist disarticul switch ctrlL6925 PO $6,949.58 Wrist disart myoelectronic cL6930 PO $6,056.96 Below elbow switch controlL6935 PO $7,079.68 Below elbow myoelectronic ctL6940 PO $8,389.82 Elbow disarticulation switchL6945 PO $9,406.38 Elbow disart myoelectronic cL6950 PO $8,995.16 Above elbow switch controlL6955 PO $10,772.93 Above elbow myoelectronic ctL6960 PO $10,865.31 Shldr disartic switch controL6965 PO $12,783.55 Shldr disartic myoelectronicL6970 PO $13,155.45 Interscapular-thor switch ctL6975 PO $14,414.20 Interscap-thor myoelectronicL7007 PO $3,535.52 Adult electric handL7008 PO $5,543.02 Pediatric electric handL7009 PO $3,354.86 Adult electric hookL7040 PO $2,752.06 Prehensile actuatorL7045 PO $1,457.92 Pediatric electric hookL7170 PO $5,288.82 Electronic elbow hosmer switL7180 PO $32,424.45 Electronic elbow sequentialL7181 PO $35,479.56 Electronic elbo simultaneousL7185 PO $6,467.88 Electron elbow adolescent swL7186 PO $9,853.56 Electron elbow child switchL7190 PO $9,085.38 Elbow adolescent myoelectronL7191 PO $10,187.64 Elbow child myoelectronic ctL7260 PO $1,775.14 Electron wrist rotator ottoL7261 PO $3,231.43 Electron wrist rotator utahL7266 PO $893.04 Servo control steeper or equL7272 PO $2,007.51 Analogue control unb or equaL7274 PO $5,662.80 Proportional ctl 12 volt utaL7360 PO $273.48 Six volt bat otto bock/eq eaL7362 PO $252.04 Battery chrgr six volt ottoL7364 PO $479.23 Twelve volt battery utah/equL7366 PO $645.54 Battery chrgr 12 volt utah/eL7367 PO $344.74 Replacemnt lithium ionbatterL7368 PO $446.90 Lithium ion battery chargerL7400 PO $271.39 Add UE prost be/wd, ultliteL7401 PO $303.82 Add UE prost a/e ultlite matL7402 PO $328.10 Add UE prost s/d ultlite matL7403 PO $326.09 Add UE prost b/e acrylicL7404 PO $492.16 Add UE prost a/e acrylicL7405 PO $643.68 Add UE prost s/d acrylicL7900 PO $465.26 Male vacuum erection systemL8000 PO $33.23 Mastectomy braL8001 PO $111.06 Breast prosthesis bra & formL8002 PO $146.08 Brst prsth bra & bilat formL8015 PO $53.08 Ext breastprosthesis garmentL8020 PO $216.32 Mastectomy formL8030 PO $291.72 Breast prosthes w/o adhesiveL8031 PO $291.72 Breast prosthesis w adhesiveL8032 PO $34.69 Reusable nipple prosthesisL8035 PO $3,244.08 Custom breast prosthesisL8040 PO $2,461.37 Nasal prosthesisL8040 KM PO $2,338.31 Nasal prosthesisL8040 KN PO $984.54 Nasal prosthesisL8041 PO $2,966.74 Midfacial prosthesisL8041 KM PO $2,818.41 Midfacial prosthesisL8041 KN PO $1,186.69 Midfacial prosthesisL8042 PO $3,333.44 Orbital prosthesis

UCJF 11:3-29.6

L8042 KM PO $3,166.75 Orbital prosthesisL8042 KN PO $1,333.37 Orbital prosthesisL8043 PO $3,733.45 Upper facial prosthesisL8043 KM PO $3,546.76 Upper facial prosthesisL8043 KN PO $1,493.37 Upper facial prosthesisL8044 PO $4,133.46 Hemi-facial prosthesisL8044 KM PO $3,926.79 Hemi-facial prosthesisL8044 KN PO $1,653.38 Hemi-facial prosthesisL8045 PO $2,598.34 Auricular prosthesisL8045 KM PO $2,468.43 Auricular prosthesisL8045 KN PO $1,039.33 Auricular prosthesisL8046 PO $2,666.74 Partial facial prosthesisL8046 KM PO $2,533.42 Partial facial prosthesisL8046 KN PO $1,066.70 Partial facial prosthesisL8047 PO $1,366.71 Nasal septal prosthesisL8047 KM PO $1,298.39 Nasal septal prosthesisL8047 KN PO $546.68 Nasal septal prosthesisL8300 PO $76.08 Truss single w/ standard padL8310 PO $159.29 Truss double w/ standard padL8320 PO $48.22 Truss addition to std pad waL8330 PO $44.53 Truss add to std pad scrotalL8400 PO $18.93 Sheath below kneeL8410 PO $22.92 Sheath above kneeL8415 PO $21.68 Sheath upper limbL8417 PO $66.49 Pros sheath/sock w gel cushnL8420 PO $20.33 Prosthetic sock multi ply BKL8430 PO $23.50 Prosthetic sock multi ply AKL8435 PO $19.82 Pros sock multi ply upper lmL8440 PO $48.81 Shrinker below kneeL8460 PO $60.12 Shrinker above kneeL8465 PO $44.00 Shrinker upper limbL8470 PO $6.02 Pros sock single ply BKL8480 PO $8.30 Pros sock single ply AKL8485 PO $10.08 Pros sock single ply upper lL8500 PO $685.49 Artificial larynxL8501 PO $108.96 Tracheostomy speaking valveL8507 PO $37.10 Trach-esoph voice pros pt inL8509 PO $96.71 Trach-esoph voice pros md inL8510 PO $223.74 Voice amplifierL8511 PO $64.40 Indwelling trach insertL8512 PO $1.91 Gel cap for trach voice prosL8513 PO $4.60 Trach pros cleaning deviceL8514 PO $83.50 Repl trach puncture dilatorL8515 PO $55.89 Gel cap app device for trachL8600 PO $563.24 Implant breast silicone/eqL8603 PO $393.90 Collagen imp urinary 2.5 mlL8606 PO $193.99 Synthetic implnt urinary 1mlL8609 PO $5,769.31 Artificial corneaL8610 PO $625.30 Ocular implantL8612 PO $597.23 Aqueous shunt prosthesisL8613 PO $302.32 Ossicular implantL8614 PO $17,284.73 Cochlear deviceL8615 PO $399.36 Coch implant headset replaceL8616 PO $93.02 Coch implant microphone replL8617 PO $81.24 Coch implant trans coil replL8618 PO $23.22 Coch implant tran cable replL8619 PO $7,420.22 Coch imp ext proc/contr rplcL8621 PO $0.55 Repl zinc air batteryL8622 PO $0.29 Repl alkaline batteryL8623 PO $57.28 Lith ion batt CID,non-earlvlL8624 PO $142.80 Lith ion batt CID, ear levelL8627 PO $6,324.80 CID ext speech process replL8628 PO $1,095.43 CID ext controller replL8629 PO $158.55 CID transmit coil and cableL8630 PO $303.88 Metacarpophalangeal implantL8631 PO $1,957.77 MCP joint repl 2 pc or moreL8641 PO $315.74 Metatarsal joint implantL8642 PO $276.79 Hallux implant


L8658 PO $275.29 Interphalangeal joint spacerL8659 PO $1,708.71 Interphalangeal joint replL8670 PO $502.09 Vascular graft, syntheticL8680 PO $406.73 Implt neurostim elctr eachL8681 PO $1,297.42 Pt prgrm for implt neurostimL8682 PO $5,278.95 Implt neurostim radiofq recL8683 PO $4,646.68 Radiofq trsmtr for implt neuL8684 PO $614.20 Radiof trsmtr implt scrl neuL8685 PO $11,579.27 Implt nrostm pls gen sng recL8686 PO $7,388.47 Implt nrostm pls gen sng nonL8687 PO $15,069.25 Implt nrostm pls gen dua recL8688 PO $9,615.40 Implt nrostm pls gen dua nonL8689 PO $1,527.41 External recharg sys internL8690 PO $4,212.39 Aud osseo dev, int/ext compL8691 PO $2,361.18 Osseointegrated snd proc rplL8695 PO $14.74 External recharg sys externQ0480 PO $79,750.51 Driver pneumatic vad, repQ0481 PO $12,866.81 Microprcsr cu elec vad, repQ0482 PO $4,030.13 Microprcsr cu combo vad, repQ0483 PO $16,602.32 Monitor elec vad, repQ0484 PO $3,224.12 Monitor elec or comb vad repQ0485 PO $311.28 Monitor cable elec vad, repQ0486 PO $259.09 Mon cable elec/pneum vad repQ0487 PO $302.26 Leads any type vad, rep onlyQ0489 PO $14,393.32 Pwr pck base combo vad, repQ0490 PO $622.58 Emr pwr source elec vad, repQ0491 PO $978.78 Emr pwr source combo vad repQ0492 PO $78.84 Emr pwr cbl elec vad, repQ0493 PO $224.53 Emr pwr cbl combo vad, repQ0494 PO $190.00 Emr hd pmp elec/combo, repQ0495 PO $3,698.71 Charger elec/combo vad, repQ0496 PO $1,327.53 Battery elec/combo vad, repQ0497 PO $414.53 Bat clps elec/comb vad, repQ0498 PO $454.83 Holster elec/combo vad, repQ0499 PO $147.78 Belt/vest elec/combo vad repQ0500 PO $27.04 Filters elec/combo vad, repQ0501 PO $452.21 Shwr cov elec/combo vad, repQ0502 PO $575.73 Mobility cart pneum vad, repQ0503 PO $1,151.46 Battery pneum vad replacemntQ0504 PO $607.60 Pwr adpt pneum vad, rep vehQ0506 PO $756.33 Lith-ion batt elec/pneum VADV2020 PO $56.55 Vision svcs frames purchasesV2100 PO $47.11 Lens spher single plano 4.00V2101 PO $49.64 Single visn sphere 4.12-7.00V2102 PO $57.49 Singl visn sphere 7.12-20.00V2103 PO $40.91 Spherocylindr 4.00d/12-2.00dV2104 PO $45.30 Spherocylindr 4.00d/2.12-4dV2105 PO $49.32 Spherocylinder 4.00d/4.25-6dV2106 PO $54.46 Spherocylinder 4.00d/>6.00dV2107 PO $52.05 Spherocylinder 4.25d/12-2dV2108 PO $51.82 Spherocylinder 4.25d/2.12-4dV2109 PO $57.62 Spherocylinder 4.25d/4.25-6dV2110 PO $58.84 Spherocylinder 4.25d/over 6dV2111 PO $61.34 Spherocylindr 7.25d/.25-2.25V2112 PO $66.96 Spherocylindr 7.25d/2.25-4dV2113 PO $73.58 Spherocylindr 7.25d/4.25-6dV2114 PO $81.74 Spherocylinder over 12.00dV2115 PO $68.90 Lens lenticular bifocalV2118 PO $75.59 Lens aniseikonic singleV2121 PO $76.05 Lenticular lens, singleV2200 PO $61.66 Lens spher bifoc plano 4.00dV2201 PO $66.76 Lens sphere bifocal 4.12-7.0V2202 PO $75.75 Lens sphere bifocal 7.12-20.V2203 PO $62.20 Lens sphcyl bifocal 4.00d/.1V2204 PO $63.86 Lens sphcy bifocal 4.00d/2.1V2205 PO $69.62 Lens sphcy bifocal 4.00d/4.2V2206 PO $70.32 Lens sphcy bifocal 4.00d/oveV2207 PO $64.74 Lens sphcy bifocal 4.25-7d/.

UCJF 11:3-29.6

V2208 PO $66.85 Lens sphcy bifocal 4.25-7/2.V2209 PO $67.97 Lens sphcy bifocal 4.25-7/4.V2210 PO $72.61 Lens sphcy bifocal 4.25-7/ovV2211 PO $75.41 Lens sphcy bifo 7.25-12/.25-V2212 PO $76.61 Lens sphcyl bifo 7.25-12/2.2V2213 PO $79.47 Lens sphcyl bifo 7.25-12/4.2V2214 PO $96.83 Lens sphcyl bifocal over 12.V2215 PO $90.00 Lens lenticular bifocalV2218 PO $117.06 Lens aniseikonic bifocalV2219 PO $50.39 Lens bifocal seg width overV2220 PO $43.43 Lens bifocal add over 3.25dV2221 PO $87.23 Lenticular lens, bifocalV2300 PO $76.06 Lens sphere trifocal 4.00dV2301 PO $73.45 Lens sphere trifocal 4.12-7.V2302 PO $74.50 Lens sphere trifocal 7.12-20V2303 PO $72.61 Lens sphcy trifocal 4.0/.12-V2304 PO $78.29 Lens sphcy trifocal 4.0/2.25V2305 PO $80.77 Lens sphcy trifocal 4.0/4.25V2306 PO $82.90 Lens sphcyl trifocal 4.00/>6V2307 PO $79.89 Lens sphcy trifocal 4.25-7/.V2308 PO $80.01 Lens sphc trifocal 4.25-7/2.V2309 PO $82.31 Lens sphc trifocal 4.25-7/4.V2310 PO $83.69 Lens sphc trifocal 4.25-7/>6V2311 PO $80.66 Lens sphc trifo 7.25-12/.25-V2312 PO $81.17 Lens sphc trifo 7.25-12/2.25V2313 PO $91.43 Lens sphc trifo 7.25-12/4.25V2314 PO $104.24 Lens sphcyl trifocal over 12V2315 PO $129.87 Lens lenticular trifocalV2318 PO $176.41 Lens aniseikonic trifocalV2319 PO $51.33 Lens trifocal seg width > 28V2320 PO $63.01 Lens trifocal add over 3.25dV2321 PO $128.30 Lenticular lens, trifocalV2410 PO $99.73 Lens variab asphericity singV2430 PO $129.96 Lens variable asphericity biV2500 PO $97.75 Contact lens pmma sphericalV2501 PO $148.90 Cntct lens pmma-toric/prismV2502 PO $183.43 Contact lens pmma bifocalV2503 PO $168.94 Cntct lens pmma color visionV2510 PO $113.95 Cntct gas permeable sphericlV2511 PO $191.73 Cntct toric prism ballastV2512 PO $226.56 Cntct lens gas permbl bifoclV2513 PO $190.21 Contact lens extended wearV2520 PO $125.43 Contact lens hydrophilicV2521 PO $218.37 Cntct lens hydrophilic toricV2522 PO $212.51 Cntct lens hydrophil bifoclV2523 PO $169.30 Cntct lens hydrophil extendV2530 PO $201.17 Contact lens gas impermeableV2531 PO $489.09 Contact lens gas permeableV2623 PO $1,045.38 Plastic eye prosth customV2624 PO $54.91 Polishing artifical eyeV2625 PO $333.85 Enlargemnt of eye prosthesisV2626 PO $179.96 Reduction of eye prosthesisV2627 PO $1,426.01 Scleral cover shellV2628 PO $278.76 Fabrication & fittingV2700 PO $45.54 Balance lensV2710 PO $77.11 Glass/plastic slab off prismV2715 PO $13.98 Prism lens/esV2718 PO $31.89 Fresnell prism press-on lensV2730 PO $19.02 Special base curveV2744 PO $14.98 Tint photochromatic lens/esV2745 PO $12.02 Tint, any color/solid/gradV2750 PO $18.47 Anti-reflective coatingV2755 PO $14.99 UV lens/esV2760 PO $15.31 Scratch resistant coatingV2762 PO $52.77 Polarization, any lensV2770 PO $22.59 Occluder lens/esV2780 PO $11.30 Oversize lens/esV2782 PO $57.00 Lens, 1.54-1.65 p/1.60-1.79g


V2783 PO $64.27 Lens, >= 1.66 p/>=1.80 gV2784 PO $41.80 Lens polycarb or equalV2786 PO $0.00 Occupational multifocal lensModifiers: NU Purchased, New(MOD) RR Rented

UE Purchased, UsedKM Replacement of Facial Prosthesis including new impression/moulageKN Replacement of Facial Prosthesis using previous master moldAU Urological, ostomy or trach itemAV Item with prosthetic/orthotic deviceAW Item with a surgical dressingKE Bid Under Round I of the DMEPOS Competitive Bid Program ForUse WithNonCompetitive Bid Base Equipment KF--Class III deviceKL DMEPOS Item Delivered Via MailKC Replacement of Special Power Wheelchair Interface

Categories: IN Inexpensive and Other Routinely Purchased Items(CATG) FS Frequently Serviced Items

CR Capped Rental ItemsOX Oxygen and Oxygen EquipmentOS Ostomy, Tracheostomy & Urological ItemsSD Surgical DressingsPO Prosthetics & OrthoticsSU SuppliesTE Transcutaneous Electrical Nerve StimulatorsTS Therapeutic Shoes

Exhibit 6Codes Subject to the Daily Maximum

CPT*/HCPSC Description*Current Procedural Terminology (CPT) is copyright 2010 American Medical Association (AIvIA). All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. the AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restric-tions apply to government use. CPT® is a trademark of the American Medical Association.29200 STRAP CHEST29240 STRAP SHOULDER29260 STRAP ELBOW OR WRIST29280 STRAP HAND OR FINGER29520 STRAP HIP29530 STRAP KNEE29540 STRAP ANKLE AND/OR FT29550 STRAP TOES29580 APPLY PASTE BOOT29581 APPLY MULTILAY COMPRESS LWR

LEG29590 APPLY FOOT SPLINT29799 CAST/STRAP PROCEDURE97012 MECHANICAL TRACTION THERAPY SUPERVISED includes treatment

MODALITY with VAX-D,DRX and similarmachines

G0283 ELECTRICAL STIMULATION,(UNATTENDED), TO ONE OR MOREAREAS

97016 VASOPNEUMATIC DEVICE THERAPY SUPERVISEDMODALITY

97018 PARAFFIN BATH THERAPY SUPERVISEDMODALITY

97022 WHIRLPOOL THERAPY SUPERVISEDMODALITY

97024 DIATHERMY EG, MICROWAVE SUPERVISEDMODALITY

97026 INFRARED THERAPY SUPERVISEDMODALITY

97028 ULTRAVIOLET THERAPY SUPERVISED

UCJF 11:3-29.6

MODALITY97032 APPLICATION OF A MODALITY TO DIRECT ONE-

ONE OR MORE AREAS; ELECTRICAL ON-ONESTIMULATION (MANUAL), EACH 15 PATIENTMINUTES CONTACT

REQUIRED97033 IONTOPHORESIS, EACH 15 MINUTES DIRECT ONE-

ON-ONEPATIENTCONTACTREQUIRED

97034 CONTRAST BATHS, EACH 15 MINUTES DIRECT ONE-ON-ONEPATIENTCONTACTREQUIRED

97035 ULTRASOUND, EACH 15 MINUTES DIRECT ONE-ON-ONEPATIENTCONTACTREQUIRED

97036 HUBBARD TANK, EACH 15 MINUTES DIRECT ONE-ON-ONEPATIENTCONTACTREQUIRED

97039 UNLISTED PHYSICAL MEDICINE &REHAB MODALITY

97110 THERAPEUTIC PROCEDURE, 1 OR DIRECT ONE-MORE AREAS, EACH 15 MINUTES; ON-ONETHERAPEUTIC EXERCISES TO PATIENTDEVELOP STRENGTH AND ENDURANCE, CONTACTRANGE OF MOTION AND FLEXIBILITY REQUIRED

97112 NEUROMUSCULAR REEDUCATION OF DIRECT ONE-MOVEMENT, BALANCE COORDINATION, ON-ONEKINESTHETIC SENSE, POSTURE, AND/OR PATIENTPROPRIOCEPTION FOR SITTING OR CONTACTSTANDING ACTIVITIES REQUIRED

97113 AQUATIC THERAPY WITHTHERAPEUTIC EXERCISES

97124 MASSAGE THERAPY DIRECT ONE-ON-ONEPATIENTCONTACTREQUIRED

97139 UNLISTED PHYSICAL MEDICINEPROCEDURE

97140 MANUAL THERAPY TECHNIQUES (eg DIRECT ONE-MOBILIZATION/IvIANIPULATION, ON-ONEMANUAL LYMPHATIC DRAINAGE, PATIENTMANUAL TRACTION, 1 OR CONTACTMORE REGIONS, EACH 15 MINUTES REQUIRED

97150 GROUP THERAPEUTIC PROCEDURES, CONSTANT(2 OR MORE INDIVIDUALS) ATTENDANCE

OF PROVIDERREQUIRED

97530 THERAPEUTIC ACTIVITIES, (USE OF DIRECT ONE-DYNAMIC ACTIVITIES TO IMPROVE ON-ONEFUNCTIONAL PERFORMANCE) PATIENT

CONTACTREQUIRED

97535 SELF CARE MANAGEMENT TRAINING DIRECT ONE-


97810 ACUPUNCTURE, 1 OR MORE NEEDLES, ON-ONEWITHOUT ELECTRICAL STIMULATION, PATIENTINITIAL 15 MINUTES CONTACT

REQUIRED97811 ACUPUNCTURE, 1 OR MORE NEEDLES, DIRECT ONE-

WITHOUT ELECTRICAL STIMULATION, ON-ONEEACH ADDITIONAL 15 MINUTES, PATIENTWITH REINSERTION OF NEEDLES CONTACT


WITH ELECTRICAL STIMULATION, ON-ONEINITIAL 15 MINUTES PATIENT CONTACT


WITH ELECTRICAL STIMULATION, ON-ONEEACH ADDITIONAL 15 MINUTES, WITH PATIENTREINSERTION OF NEEDLES CONTACT

REQUIRED98925 OSTEOPATHIC MANIPULATION 1-2

REGIONS98926 OSTEOPATHIC MANIPULATION 3-4




REGIONS98940 CHIROPRACTIC MANIPULATION 1-2

REGIONS98941 CHIROPRACTIC MANIPULATION 3-4

REGIONS98942 CHIROPRACTIC MANIPULATION 5

REGIONS98943 CHIROPRACTIC MANIPULATION

EXTRASPINAL, 1 OR MORE REGIONSNOTE: FOR CHIROPRACTIC MANIPULATIVE TREATMENT, THE 5 SPINAL REGIONS RE-FERRED TO ARE: CERVICAL REGION (INCLUDES ATLANTO-OCCIPITAL JOINT); THO-RACIC REGION (INCLUDES COSTOVERTEBRAL AND COSTOTRANSVERSE JOINTS); LUMBAR REGION; SACRAL REGION; AND PELVIC (SACRO-ILIAC JOINT) REGION. THE FIVE EXTRA-SPINAL REGIONS REFERRED TO ARE: HEAD (INCLUDING TEMPOROMAN-DIBULAR JOINT, EXCLUDING ATLANTO-OCCIPITAL) (EXCLUDING COSTOTRANSVERSE AND COSTOVERTEBRAL JOINTS AND ABDOMEN)NOTE: FOR OSTEOMANIPULATIVE TREATMENT, THE BODY REGIONS REFERRED TO ARE: HEAD REGION; CERVICAL REGION; THORACIC REGION; LUMBAR REGION; SAC-RAL REGION; PELVIC REGION; LOWER EXTREMITIES; UPPER EXTREMITIES; RIB CAGE REGION; ABDOMEN AND VISCERA REGIONNOTE: FOR STRAPPING, THIS IS A REPLACEMENT PROCEDURE USED DURING OR AF-TER THE PERIOD OF FOLLOW-UP CARE OR WHEN THE APPLICATION IS AN INITIAL SER-VICE PERFORMED WITHOUT A RESTORATIVE TREATMENT TO STABILIZE OR PROTECT A FRACTURE, INJURY OR DISLOCATION AND/OR TO AFFORD COMFORT TO A PATIENT.

Exhibit 7Hospital Outpatient Surgical Facility (HOSF) Fees

Ancil-lary

Serv-CPT* DESCRIPTION Hospital Hospital Not ices

Outpatient Outpatient Subject Packaged Separ-Surgical Surgical to Multiple Item; No ateFacility Facility Procedure Separate Pay-

Fees North Fees South Reductions Payment ment0232T NJX PLATELET PLASMA 182.27 156.22 AS

UCJF 11:3-29.6

G0289 ARTHRO, LOOSE BODY +CHONDRO X N1

10060 DRAIN SKIN ABSCESS 404.79 346.9410061 DRAIN SKIN ABSCESS 404.79 346.9410120 REMOVE FOREIGN BODY 741.84 635.8310121 REMOVE FOREIGN BODY 4,909.21 4,207.6810140 DRAIN HEMATOMA/FLUID 3,533.67 3,028.7110160 PUNCTURE DRAIN LESION 404.79 346.9410180 COMPLEX DRAIN WOUND 5,485.22 4,701.3811000 DEBRIDE INFECTED SKIN 741.84 635.8311001 DEBRIDE INFECTED SKIN,

ADDED 247.20 211.8811010 DEBRIDE SKIN, FX 1,381.84 1,184.3811011 DEBRIDE SKIN/MUSCLE, FX 1,381.84 1,184.3811012 DEBRIDE SKIN/MUSCLE/BONE,

FX 1,381.84 1,184.3811042 DEBRIDE SKIN/TISSUE 741.84 635.8311043 DEBRIDE TISSUE/MUSCLE 741.84 635.8311044 DEBRIDE TISSUE/MUSCLE

BONE 2,306.26 1,976.7011045 DEBRIDE SUBQ TISSUE

ADD-ON 741.84 635.8311046 DEBRIDE MUSCLE/FASCIA

ADD-ON 741.84 635.8311047 DEBRIDE BONE ADD-ON 2,306.26 1,976.7011055 TRIM SKIN LESION 247.20 211.8811056 TRIM SKIN LESIONS, 2 TO 4 247.20 211.8811057 TRIM SKIN LESIONS, OVER 4 247.20 211.8811100 BIOPSY SKIN LESION 406.64 348.5311101 BIOPSY SKIN, ADDED 247.20 211.8811200 REMOVE SKIN TAGS 247.20 211.8811300 SHAVE SKIN LESION 247.20 211.8811301 SHAVE SKIN LESION 247.20 211.8811302 SHAVE SKIN LESION 247.20 211.8811305 SHAVE SKIN LESION 247.20 211.8811306 SHAVE SKIN LESION 247.20 211.8811310 SHAVE SKIN LESION 247.20 211.8811311 SHAVE SKIN LESION 247.20 211.8811400 EXCISE TRT-EXT BENIGN+

MARG 0.5 < CM 1,381.84 1,184.3811401 EXCISE TRT-EXT BENIGN+

MARG 0.6-1 CM 1,381.84 1,184.3811402 EXCISE TRT-EXT BENIGN+




MARG > 4.0 CM 4,909.21 4,042.5711420 EXCISE H-F-NECK-SP

BENIGN+MARG 0.5 < 2,306.26 1,976.7011421 EXCISE H-F-NECK-SP

BENIGN+MARG 0.6-1 2,306.26 1,976.7011422 EXCISE H-F-NECK-SP




BENIGN+MARG > 4 CM 6,489.68 5,562.30


11440 EXCISE FACE-MMBENIGN+MARG 0.5 < CM 1,381.84 1,184.38

11441 EXCISE FACE-MMBENIGN+MARG 0.6-1 CM 1,381.84 1,184.38




11719 TRIM NAIL(S) 117.49 100.7011720 DEBRIDE NAIL, 1-5 247.20 211.8811721 DEBRIDE NAIL, 6 OR MORE 247.20 211.8811730 REMOVE NAIL PLATE 247.20 211.8811732 REMOVE NAIL PLATE, ADDED 247.20 211.8811740 DRAIN BLOOD UNDER NAIL 117.49 100.7011750 REMOVE NAIL BED 1,381.84 1,184.3811752 REMOVE NAIL BED/FINGER

TIP 6,489.68 5,562.3011760 REPAIR NAIL BED 361.97 310.2411762 RECONSTRUCT NAIL BED 4,673.83 4,005.9411765 EXCISE NAIL FOLD, TOE 247.20 211.8811900 INJECTION INTO SKIN

LESIONS 247.20 211.8811901 ADDED SKIN LESIONS

INJECTION 247.20 211.8811950 THERAPY FOR CONTOUR

DEFECTS 361.97 310.2411951 THERAPY FOR CONTOUR

DEFECTS 361.97 310.2411960 INSERT TISSUE

EXPANDER(S) 6,050.71 5,186.0611981 INSERT DRUG IMPLANT

DEVICE 182.27 156.22 AS11982 REMOVE DRUG IMPLANT

DEVICE 182.27 156.22 AS12001 REPAIR SUPERFICIAL

WOUND(S) 361.97 310.2412002 REPAIR SUPERFICIAL











WOUND(S) 361.97 310.2412020 CLOSE SPLIT WOUND 1,260.61 1,080.4712021 CLOSE SPLIT WOUND 858.58 735.89

UCJF 11:3-29.6

12031 INTERMED WOUND REPAIRS/TRT/EXT 361.97 310.24






12041 INTERMED WOUND REPAIRN-HF/GENITAL 361.97 310.24

12042 INTERMED WOUND REPAIRN-HG/GENITAL 361.97 310.24





12051 INTERMED WOUND REPAIRFACE/MM 858.58 735.89







13100 REPAIR WOUND OR LESION 1,260.61 1,080.4713101 REPAIR WOUND OR LESION 1,260.61 1,080.4713102 REPAIR WOUND/LESION,

ADDED 1,260.61 1,080.4713120 REPAIR WOUND OR LESION 858.58 735.8913121 REPAIR WOUND OR LESION 858.58 735.8913122 REPAIR WOUND/LESION,

ADDED 361.97 310.2413131 REPAIR WOUND OR LESION 858.58 735.8913132 REPAIR WOUND OR LESION 1,260.61 1,080.4713133 REPAIR WOUND/LESION,

ADDED 858.58 735.8913150 REPAIR WOUND OR LESION 1,260.61 1,080.4713151 REPAIR WOUND OR LESION 1,260.61 1,080.4713152 REPAIR WOUND OR LESION 1,260.61 1,080.4713153 REPAIR WOUND/LESION,

ADDED 858.58 735.8913160 LATE CLOSE WOUND 6,050.71 5,186.0614000 SKIN TISSUE

REARRANGEMENT 4,673.83 4,005.9414001 SKIN TISSUE

REARRANGEMENT 4,673.83 4,005.9414020 SKIN TISSUE

REARRANGEMENT 4,673.83 4,005.94


14021 SKIN TISSUEREARRANGEMENT 4,673.83 4,005.94






14302 SKIN TISSUE REARRANGEADDED 6,050.71 5,186.06

15002 WOUND PREP,TRUNK/ARM/LEG 1,260.61 1,080.47

15003 WOUND PREP, ADDED 100CM 1,260.61 1,080.47

15004 WOUND PREP, F/N/HF/G 1,260.61 1,080.4715005 WOUND PREP, F/N/HF/G,

ADDED CM 1,260.61 1,080.4715050 SKIN PINCH GRAFT 1,260.61 1,080.4715100 SKIN SPLIT GRAFT,

TRUNK/ARM/LEG 6,050.71 5,186.0615101 SKIN SPLIT GRAFT T/A/L,

ADDED 6,050.71 5,186.0615120 SKIN SPLIT A-GRAFT

FAC/NECK/HF/G 6,050.71 5,186.0615121 SKIN SPLIT A-GRAFT

F/N/HF/G ADDED 6,050.71 5,186.0615130 DERM AUTOGRAFT,

TRUNK/ARM/LEG 4,673.83 4,005.9415170 ACELLULAR GRAFT

TRUNK/ARMS/LEGS 1,260.61 1,080.4715171 ACELLULAR GRAFT

T/ARM/LEG, ADDED 858.58 735.8915175 ACELLULAR GRAFT, F/N/HF/G1,260.61 1,080.4715220 SKIN FULL GRAFT

SCALP/ARM/LEG 4,673.83 4,005.9415221 SKIN FULL GRAFT, ADDED 1,260.61 1,080.4715240 SKIN FULL GRAFT

FACE/GENITAL/HF 4,673.83 4,005.9415241 SKIN FULL GRAFT, ADDED 1,260.61 1,080.4715260 SKIN FULL GRAFT EEN &

LIPS 4,673.83 4,005.9415330 APPLY ACELLULAR

ALLOGRAFT T/ARM/LEG 1,260.61 1,080.4715331 APPLY ACELLULAR GRAFT

T/A/L, ADDED 1,260.61 1,080.4715340 APPLY CULT SKIN

SUBSTITUTE 858.58 735.8915341 APPLY CULT SKIN SUB,

ADDED 858.58 735.8915365 APPLY CULT DERM SUB

F/N/HF/G 858.58 735.8915366 APPLY CULT DERM F/HF/G

ADDED 858.58 735.8915430 APPLY ACELLULAR

XENOGRAFT 1,260.61 1,080.4715431 APPLY ACELLULAR

XENOGRAFT ADDED 1,260.61 1,080.4715570 FORM SKIN PEDICLE FLAP 6,050.71 5,186.06

UCJF 11:3-29.6

15572 FORM SKIN PEDICLE FLAP 6,050.71 5,186.0615574 FORM SKIN PEDICLE FLAP 6,050.71 5,186.0615576 FORM SKIN PEDICLE FLAP 6,050.71 5,186.0615620 SKIN GRAFT 6,050.71 5,186.0615732 MUSCLE-SKIN GRAFT,

HEAD/NECK 6,050.71 5,186.0615734 MUSCLE-SKIN GRAFT,

TRUNK 6,050.71 5,186.0615736 MUSCLE-SKIN GRAFT, ARM 6,050.71 5,186.0615738 MUSCLE-SKIN GRAFT, LEG 6,050.71 5,186.0615770 DERMA-FAT-FASCIA GRAFT 6,050.71 5,186.0615780 ABRASION TREAT SKIN 6,489.68 5,562.3015781 ABRASION TREAT SKIN 1,381.84 1,184.3815782 ABRASION TREAT SKIN 1,381.84 1,184.3815786 ABRASION, LESION, SING 247.20 211.8815787 ABRASION, LESIONS, ADDED 247.20 211.8815823 REVISE UPPER EYELID 6,050.71 5,186.0615830 EXCISE SKIN ABD 6,489.68 5,562.3015832 EXCISE EXCESSIVE SKIN

TISSUE 6,489.68 5,562.3015851 REMOVE SUTURES 741.84 635.8315852 DRESSING CHANGE NOT FOR

BURN 182.27 156.22 AS15940 REMOVE HIP PRESSURE SORE6,489.68 5,562.3015941 REMOVE HIP PRESSURE SORE6,489.68 5,562.3015944 REMOVE HIP PRESSURE SORE6,050.71 5,186.0615945 REMOVE HIP PRESSURE SORE6,050.71 5,186.0615946 REMOVE HIP PRESSURE SORE6,050.71 5,186.0615950 REMOVE THIGH PRESSURE

SORE 6,489.68 5,562.3015951 REMOVE THIGH PRESSURE





SORE 4,673.83 4,005.9416000 INITIAL TREAT BURN(S) 247.20 211.8816020 DRESS/DEBRIDE P-THICK

BURN, S 406.64 348.5316025 DRESS/DEBRIDE P-THICK

BURN, M 406.64 348.5316030 DRESS/DEBRIDE P-THICK

BURN, L 406.64 348.5317000 DESTROY PREMALIG LESION 247.20 211.8817003 DESTROY PREMALIG LES, 2-14 117.49 100.7017004 DESTROY PREMALIG LESIONS

15+ 741.84 635.8317106 DESTROY SKIN LESIONS 741.84 635.8317107 DESTROY SKIN LESIONS 741.84 635.8317108 DESTROY SKIN LESIONS 741.84 635.8317110 DESTROY B9 LESION, 1-14 247.20 211.8817111 DSTRJ B9 SK TGS/CUTAN VASC

15/> 406.64 348.5317250 CHEM CAUT GRANLTJ TISS

PROUD FLESH SINUS/FSTL 406.64 348.5317261 DESTROY SKIN LESIONS 406.64 348.5317262 DESTROY SKIN LESIONS 406.64 348.5319000 DRAIN BREAST LESION 1,244.88 1,066.98


19120 REMOVE BREAST LESION 6,949.27 5,956.2119125 EXCISE BREAST LESION 6,949.27 5,956.2119290 PLACE NEEDLE WIRE,

BREAST N120100 EXPLORE WOUND, NECK 2,150.53 1,843.2220101 EXPLORE WOUND, CHEST 6,050.71 5,186.0620102 EXPLORE WOUND,

ABDOMEN 6,050.71 5,186.0620103 EXPLORE WOUND,

EXTREMITY 3,533.67 3,028.7120520 REMOVE FOREIGN BODY 6,238.69 5,347.1820525 REMOVE FOREIGN BODY 6,489.68 5,562.3020526 THERAPEUTIC INJECTION,

CARP TUNNEL 724.57 621.0320550 INJECT TENDON

SHEATH/LIGAMENT 724.57 621.0320551 INJECT TENDON

ORIGIN/INSERT 724.57 621.0320552 INJECT TRIGGER POINT, 1/2

MUSCLE 724.57 621.0320553 INJECT TRIGGER POINTS, =/>

3 724.57 621.0320600 DRAIN/INJ, JOINT/BURSA 724.57 621.0320605 DRAIN/INJ, JOINT/BURSA 724.57 621.0320610 DRAIN/INJ, JOINT/BURSA 724.57 621.0320612 ASPIRATE/INJECT GANGLION

CYST 724.57 621.0320615 TREAT BONE CYST 1,244.88 1,066.9820650 INSERT & REMOVE BONE

PIN 6,238.69 5,347.1820660 APPLY, REM FIXATION

DEVICE 1,494.88 1,281.2620662 APPLY PELVIS BRACE 6,238.69 5,347.1820663 APPLY THIGH BRACE 6,238.69 5,347.1820665 REMOVE FIXATION DEVICE 182.27 156.22 AS20670 REMOVE SUPPORT IMPLANT 4,909.21 4,207.6820680 REMOVE SUPPORT IMPLANT 6,489.68 5,562.3020690 APPLY BONE FIXATION

DEVICE 8,755.84 7,504.6320692 APPLY BONE FIXATION

DEVICE 8,755.84 7,504.6320693 ADJUST BONE FIXATION

DEVICE 6,238.69 5,347.1820694 REMOVE BONE FIXATION

DEVICE 6,238.69 5,347.1820696 COMP MULTIPLANE EXT

FIXATION 8,755.84 7,504.6320697 COMP EXT FIXATE STRUT

CHANGE 5,657.91 4,849.3920900 REMOVE BONE FOR GRAFT 8,755.84 7,504.6320902 REMOVE BONE FOR GRAFT 8,755.84 7,504.6320910 REMOVE CARTILAGE FOR

GRAFT 6,050.71 5,186.0620912 REMOVE CARTILAGE FOR

GRAFT 6,050.71 5,186.0620920 REMOVE FASCIA FOR GRAFT 4,673.83 4,005.9420922 REMOVE FASCIA FOR GRAFT 4,673.83 4,005.9420924 REMOVE TENDON FOR

GRAFT 8,755.84 7,504.6320926 REMOVE TISSUE FOR GRAFT 1,260.61 1,080.4720950 FLUID PRESSURE, MUSCLE 404.79 346.9420975 ELECTRICAL BONE

UCJF 11:3-29.6

STIMULATION N120979 US BONE STIMULATION 182.27 156.22 AS20985 COMPUTER-ASSIST DIR MS

PX N121060 REMOVE JAW JOINT

CARTILAGE 12,135.56 10,401.3821070 REMOVE CORONOID

PROCESS 12,135.56 10,401.3821073 MANIPULATE TMJ

W/ANESTH 2,150.53 1,843.2221085 PREPARE FACE/ORAL

PROSTHESIS 4,708.37 4,035.5421110 INTERDENTAL FIXATION 2,150.53 1,843.2221116 INJECTION, JAW JOINT

X-RAY N121209 REDUCE FACIAL BONES 12,135.56 10,401.3821210 FACE BONE GRAFT 12,135.56 10,401.3821240 RECONSTRUCT JAW JOINT 12,135.56 10,401.3821242 RECONSTRUCT JAW JOINT 12,135.56 10,401.3821243 RECONSTRUCT JAW JOINT 12,135.56 10,401.3821244 RECONSTRUCT LOWER JAW 12,135.56 10,401.3821245 RECONSTRUCT JAW 12,135.56 10,401.3821246 RECONSTRUCT JAW 12,135.56 10,401.3821248 RECONSTRUCT JAW 12,135.56 10,401.3821249 RECONSTRUCT JAW 12,135.56 10,401.3821310 TREAT NOSE FX 307.68 263.7121315 TREAT NOSE FX 4,708.37 4,035.5421320 TREAT NOSE FX 4,708.37 4,035.5421325 TREAT NOSE FX 6,964.52 5,969.2921330 TREAT NOSE FX 6,964.52 5,969.2921335 TREAT NOSE FX 6,964.52 5,969.2921356 TREAT CHEEK BONE FX 6,964.52 5,969.2921360 TREAT CHEEK BONE FX 6,964.52 5,969.2921365 TREAT CHEEK BONE FX 12,135.56 10,401.3821385 TREAT EYE SOCKET FX 12,135.56 10,401.3821386 TREAT EYE SOCKET FX 12,135.56 10,401.3821390 TREAT EYE SOCKET FX 12,135.56 10,401.3821395 TREAT EYE SOCKET FX 12,135.56 10,401.3821400 TREAT EYE SOCKET FX 2,150.53 1,843.2221401 TREAT EYE SOCKET FX 4,708.37 4,035.5421406 TREAT EYE SOCKET FX 12,135.56 10,401.3821407 TREAT EYE SOCKET FX 12,135.56 10,401.3821408 TREAT EYE SOCKET FX 12,135.56 10,401.3821450 TREAT LOWER JAW FX 965.03 827.1321451 TREAT LOWER JAW FX 2,150.53 1,843.2221452 TREAT LOWER JAW FX 4,708.37 4,035.5421453 TREAT LOWER JAW FX 12,135.56 10,401.3821454 TREAT LOWER JAW FX 6,964.52 5,969.2921461 TREAT LOWER JAW FX 12,135.56 10,401.3821462 TREAT LOWER JAW FX 12,135.56 10,401.3821465 TREAT LOWER JAW FX 12,135.56 10,401.3821470 TREAT LOWER JAW FX 12,135.56 10,401.3821800 TREAT RIB FX 428.68 367.4221820 TREAT STERNUM FX 428.68 367.4222222 REVISE THORAX SPINE 13,940.72 11,948.5822305 TREAT SPINE PROCESS FX 428.68 367.4222310 TREAT SPINE FX 1,494.88 1,281.2622315 TREAT SPINE FX 5,657.91 4,849.3922505 MANIPULATE SPINE 4,222.92 3,619.4622520 PERCUT VERTEBROPLASTY

THORACIC 8,755.84 7,504.6322521 PERCUT VERTEBROPLASTY


LUMBAR 8,755.84 7,504.6322522 PERCUT VERTEBROPLASTY

ADDED 8,755.84 7,504.6322612 LUMBAR SPINE FUSION 13,940.72 11,948.5822614 SPINE FUSION, EXTRA

SEGMENT 13,940.72 11,948.5822851 APPLY SPINE PROSTH

DEVICE 6,238.69 5,347.1823120 PARTIAL REMOVE COLLAR

BONE 8,755.84 7,504.6323125 REMOVE COLLAR BONE 8,755.84 7,504.6323130 REMOVE SHOULDER BONE,

PART 12,850.12 11,013.8323331 REMOVE SHOULDER

FOREIGN BODY 6,489.68 5,562.3023350 INJECTION FOR SHOULDER

X-RAY N123405 TX SHO AREA 1 TDN 8,755.84 7,504.6323406 TX SHO AREA MLT TDN

THRU SM INC 8,755.84 7,504.6323410 OPEN REPAIR OF ROTATOR

CUFF, RECENT 12,850.12 11,013.8323412 OPEN REPAIR OF ROTATOR

CUFF, OLD 12,850.12 11,013.8323415 CORACOACROMIAL LIGM

RLS +-ACROMP 12,850.12 11,013.8323420 RECONSTRUCTION ROTATOR

CUFF, OLD 12,850.12 11,013.8323430 TENODIS LONG TDN BICEPS 12,850.12 11,013.8323440 RESCJ/TRNSPLJ LONG TDN

BICEPS 12,850.12 11,013.8323470 RECONSTRUCT SHOULDER

JOINT 19,460.64 17,581.9923480 REVISE COLLAR BONE 12,850.12 11,013.8323485 REVISE COLLAR BONE 24,164.43 20,711.3223500 TREAT CLAVICLE FX 428.68 367.4223505 TREAT CLAVICLE FX 5,657.91 4,849.3923515 TREAT CLAVICLE FX 18,168.29 15,572.0323520 TREAT CLAVICLE

DISLOCATION 1,494.88 1,281.2623525 TREAT CLAVICLE



DISLOCATION 428.68 367.4223545 TREAT CLAVICLE



DISLOCATION 13,070.23 11,202.4923570 TREAT SHOULDER BLADE

FX 428.68 367.4223600 TREAT HUMERUS FX 428.68 367.4223605 TREAT HUMERUS FX 5,657.91 4,849.3923615 TREAT HUMERUS FX 18,168.29 15,572.0323616 TREAT HUMERUS FX 18,168.29 15,572.0323620 TREAT HUMERUS FX 428.68 367.4223625 TREAT HUMERUS FX 5,657.91 4,849.3923630 TREAT HUMERUS FX 18,168.29 15,572.0323650 TREAT SHOULDER

UCJF 11:3-29.6

DISLOCATION 428.68 367.4223655 TREAT SHOULDER

DISLOCATION 4,222.92 3,619.4623700 FIXATE SHOULDER 4,222.92 3,619.4624220 INJECTION FOR ELBOW

X-RAY N124300 MANIPULATE ELBOW

W/ANESTH 4,222.92 3,619.4624305 ARM TENDON

LENGTHENING 8,755.84 7,504.6324340 REPAIR BICEPS TENDON 12,850.12 11,013.8324341 REPAIR ARM

TENDON/MUSCLE 12,850.12 11,013.8324342 REPAIR RUPTURED

TENDON 12,850.12 11,013.8324343 REPAIR ELBOW LAT

LIGAMENT W/TISS 8,755.84 7,504.6324500 TREAT HUMERUS FX 428.68 367.4224505 TREAT HUMERUS FX 428.68 367.4224515 TREAT HUMERUS FX 18,168.29 15,572.0324516 TREAT HUMERUS FX 18,168.29 15,572.0324530 TREAT HUMERUS FX 428.68 367.4224535 TREAT HUMERUS FX 1,494.88 1,281.2624545 TREAT HUMERUS FX 18,168.29 15,572.0324546 TREAT HUMERUS FX 18,168.29 15,572.0324560 TREAT HUMERUS FX 428.68 367.4224565 TREAT HUMERUS FX 428.68 367.4224575 TREAT HUMERUS FX 18,168.29 15,572.0324576 TREAT HUMERUS FX 428.68 367.4224577 TREAT HUMERUS FX 428.68 367.4224579 TREAT HUMERUS FX 18,168.29 15,572.0325000 INCISE TENDON SHEATH 6,238.69 5,347.1825001 INCISE FLEXOR CARPI

RADIALIS 6,238.69 5,347.1825020 DECOMPRESS FOREARM 1

SPACE 8,755.84 7,504.6325023 DECOMPRESS FOREARM 1

SPACE 8,755.84 7,504.6325024 DECOMPRESS FOREARM 2

SPACES 8,755.84 7,504.6325025 DECOMPRESS FOREARM 2

SPACES 8,755.84 7,504.6325118 EXCISE WRIST TENDON

SHEATH 8,755.84 7,504.6325215 REMOVE WRIST BONES 8,755.84 7,504.6325246 INJECTION FOR WRIST

X-RAY N125259 MANIPULATE WRIST

W/ANESTH 5,657.91 4,849.3925260 REPAIR FOREARM

TENDON/MUSCLE 8,755.84 7,504.6325263 REPAIR FOREARM





TENDON/MUSCLE 8,755.84 7,504.6325295 RELEASE WRIST/FOREARM


TENDON 6,238.69 5,347.1825500 TREAT FX RADIUS 428.68 367.4225505 TREAT FX RADIUS 1,494.88 1,281.2625515 TREAT FX RADIUS 13,070.23 11,202.4925525 TREAT FX RADIUS 13,070.23 11,202.4925526 TREAT FX RADIUS 13,070.23 11,202.4925530 TREAT FX ULNA 428.68 367.4225535 TREAT FX ULNA 428.68 367.4225545 TREAT FX ULNA 13,070.23 11,202.4925560 TREAT FX RADIUS & ULNA 428.68 367.4225565 TREAT FX RADIUS & ULNA 1,494.88 1,281.2625574 TREAT FX RADIUS & ULNA 18,168.29 15,572.0325575 TREAT FX RADIUS/ULNA 18,168.29 15,572.0325600 TREAT FX RADIUS/ULNA 428.68 367.4225605 TREAT FX RADIUS/ULNA 1,494.88 1,281.2625606 TREAT FX DISTAL RADIAL 7,210.82 6,180.3925607 TREAT FX RADIAL

EXTRA-ARTICULAR 18,168.29 15,572.0325608 TREAT FX RADIAL

INTRA-ARTICULAR 18,168.29 15,572.0325609 TREAT FX RADIAL 3+ FRAG 18,168.29 15,572.0325622 TREAT WRIST BONE FX 428.68 367.4225624 TREAT WRIST BONE FX 1,494.88 1,281.2625628 TREAT WRIST BONE FX 13,070.23 11,202.4925630 TREAT WRIST BONE FX 428.68 367.4225635 TREAT WRIST BONE FX 428.68 367.4225645 TREAT WRIST BONE FX 13,070.23 11,202.4925650 TREAT WRIST BONE FX 428.68 367.4225652 TREAT FX ULNAR STYLOID 13,070.23 11,202.4925670 TREAT FX ULNAR STYLOID 7,210.82 6,180.3925671 TREAT FX ULNAR STYLOID 7,210.82 6,180.3925676 TREAT WRIST DISLOCATION 7,210.82 6,180.3925680 TREAT WRIST FX 428.68 367.4225685 TREAT WRIST FX 7,210.82 6,180.3926055 INCISE FINGER TENDON

SHEATH 4,660.94 3,994.8926116 EXCISE HAND TUMOR DEEP

< 1.5 CM 4,909.21 4,207.6826140 REVISE FINGER JOINT, EACH 4,660.94 3,994.8926145 TENDON EXCISE

PALM/FINGER 4,660.94 3,994.8926340 MANIPULATE FINGER

W/ANESTH 1,494.88 1,281.2626410 REPAIR HAND TENDON 4,660.94 3,994.8926418 REPAIR FINGER TENDON 4,660.94 3,994.8926445 RELEASE HAND/FINGER

TENDON 4,660.94 3,994.8926480 TRANSPLANT HAND

TENDON 8,083.67 6,928.5126525 RELEASE FINGER

CONTRACTURE 4,660.94 3,994.8926540 REPAIR HAND JOINT 4,660.94 3,994.8926600 TREAT METACARPAL FX 428.68 367.4226605 TREAT METACARPAL FX 428.68 367.4226607 TREAT METACARPAL FX 5,657.91 4,849.3926608 TREAT METACARPAL FX 7,210.82 6,180.3926615 TREAT METACARPAL FX 13,070.23 11,202.4926720 TREAT FINGER FX, EACH 428.68 367.4226725 TREAT FINGER FX, EACH 428.68 367.4226727 TREAT FINGER FX, EACH 7,210.82 6,180.3926735 TREAT FINGER FX, EACH 7,210.82 6,180.3926740 TREAT FINGER FX, EACH 428.68 367.42

UCJF 11:3-29.6

26742 TREAT FINGER FX, EACH 428.68 367.4226746 TREAT FINGER FX, EACH 7,210.82 6,180.3926750 TREAT FINGER FX, EACH 428.68 367.4226755 TREAT FINGER FX, EACH 428.68 367.4227093 INJECTION FOR HIP X-RAY N127095 INJECTION FOR HIP X-RAY N127193 TREAT PELVIC RING FX 428.68 367.4227194 TREAT PELVIC RING FX 4,222.92 3,619.4627275 MANIPULATE HIP JOINT 4,222.92 3,619.4627403 REPAIR KNEE CARTILAGE 8,755.84 7,504.6327405 REPAIR KNEE LIGAMENT 12,850.12 11,013.8327420 REVISE UNSTABLE

KNEECAP 12,850.12 11,013.8327422 REVISE UNSTABLE

KNEECAP 12,850.12 11,013.8327424 REVISION/REMOVE

KNEECAP 12,850.12 11,013.8327500 TREAT THIGH FX 1,494.88 1,281.2627501 TREAT THIGH FX 428.68 367.4227502 TREAT THIGH FX 5,657.91 4,849.3927503 TREAT THIGH FX 428.68 367.4227508 TREAT THIGH FX 428.68 367.4227509 TREAT THIGH FX 7,210.82 6,180.3927510 TREAT THIGH FX 1,494.88 1,281.2627520 TREAT KNEECAP FX 428.68 367.4227524 TREAT KNEECAP FX 13,070.23 11,202.4927530 TREAT KNEE FX 428.68 367.4227532 TREAT KNEE FX 5,657.91 4,849.3927538 TREAT KNEE FX(S) 428.68 367.4227570 FIXATE KNEE JOINT 4,222.92 3,619.4627685 REVISE LOWER LEG

TENDON 8,755.84 7,504.6327686 REVISE LOWER LEG

TENDONS 8,755.84 7,504.6327690 REVISE LOWER LEG

TENDON 12,850.12 11,013.8327691 REVISE LOWER LEG

TENDON 12,850.12 11,013.8327692 REVISE ADDEDITIONAL

LEG TENDON 12,850.12 11,013.8327695 REPAIR ANKLE LIGAMENT 8,755.84 7,504.6327696 REPAIR ANKLE LIGAMENTS 8,755.84 7,504.6327698 REPAIR ANKLE LIGAMENT 8,755.84 7,504.6327750 TREAT TIBIA FX 428.68 367.4227752 TREAT TIBIA FX 5,657.91 4,849.3927758 TREAT TIBIA FX 13,070.23 11,202.4927759 TREAT TIBIA FX 18,168.29 15,572.0327760 CLOSED TREAT MEDIAL

ANKLE FX 428.68 367.4227762 CLOSED TREAT MED

ANKLE FX W/MANIP 5,657.91 4,849.3927766 OPEN TREAT MEDIAL

ANKLE FX 13,070.23 11,202.4927786 TREAT ANKLE FX 428.68 367.4227788 TREAT ANKLE FX 428.68 367.4227792 TREAT ANKLE FX 13,070.23 11,202.4927808 TREAT ANKLE FX 428.68 367.4227810 TREAT ANKLE FX 428.68 367.4227814 TREAT ANKLE FX 13,070.23 11,202.4927816 TREAT ANKLE FX 428.68 367.4227818 TREAT ANKLE FX 1,494.88 1,281.2627822 TREAT ANKLE FX 13,070.23 11,202.49


27823 TREAT ANKLE FX 18,168.29 15,572.0327824 TREAT LOWER LEG FX 428.68 367.4227825 TREAT LOWER LEG FX 5,657.91 4,849.3927826 TREAT LOWER LEG FX 13,070.23 11,202.4927827 TREAT LOWER LEG FX 18,168.29 15,572.0327828 TREAT LOWER LEG FX 18,168.29 15,572.0327829 TREAT LOWER LEG JOINT 13,070.23 11,202.4927840 TREAT ANKLE

DISLOCATION 428.68 367.4227842 TREAT ANKLE

DISLOCATION 4,222.92 3,619.4627846 TREAT ANKLE

DISLOCATION 13,070.23 11,202.4927848 TREAT ANKLE

DISLOCATION 13,070.23 11,202.4927860 FIXATE ANKLE JOINT 4,222.92 3,619.4628120 PART REMOVE ANKLE/HEEL 6,135.71 5,258.9128122 PARTIAL REMOVE FOOT

BONE 6,135.71 5,258.9128400 TREAT HEEL FX 428.68 367.4228405 TREAT HEEL FX 5,657.91 4,849.3928415 TREAT HEEL FX 18,168.29 15,572.0328420 TREAT/GRAFT HEEL FX 13,070.23 11,202.4928430 TREAT ANKLE FX 428.68 367.4228435 TREAT ANKLE FX 428.68 367.4228436 TREAT ANKLE FX 7,210.82 6,180.3928445 TREAT ANKLE FX 13,070.23 11,202.4928470 TREAT METATARSAL FX 428.68 367.4228475 TREAT METATARSAL FX 428.68 367.4228476 TREAT METATARSAL FX 7,210.82 6,180.3928485 TREAT METATARSAL FX 13,070.23 11,202.4928725 FUSE FOOT BONES 15,005.30 12,861.0328730 FUSE FOOT BONES 15,005.30 12,861.0328740 FUSE FOOT BONES 15,005.30 12,861.0328750 FUSE BIG TOE JOINT 15,005.30 12,861.0329065 APPLY LONG ARM CAST 691.49 592.68 X29075 APPLY FOREARM CAST 691.49 592.68 X29085 APPLY HAND/WRIST CAST 304.17 260.71 X29086 APPLY FINGER CAST 304.17 260.71 X29105 APPLY LONG ARM SPLINT 304.17 260.71 X29125 APPLY FOREARM SPLINT 304.17 260.71 X29126 APPLY FOREARM SPLINT 304.17 260.71 X29130 APPLY FINGER SPLINT 304.17 260.71 X29131 APPLY FINGER SPLINT 304.17 260.71 X29200 STRAP CHEST 304.17 260.71 X29240 STRAP SHOULDER 304.17 260.71 X29260 STRAP ELBOW OR WRIST 304.17 260.71 X29280 STRAP HAND OR FINGER 304.17 260.71 X29345 APPLY LONG LEG CAST 691.49 592.68 X29355 APPLY LONG LEG CAST 691.49 592.68 X29365 APPLY LONG LEG CAST 691.49 592.68 X29405 APPLY SHORT LEG CAST 691.49 592.68 X29425 APPLY SHORT LEG CAST 691.49 592.68 X29450 APPLY LEG CAST 304.17 260.71 X29505 APPLY LONG LEG SPLINT 304.17 260.71 X29515 APPLY LOWER LEG SPLINT 304.17 260.71 X29520 STRAP HIP 304.17 260.71 X29530 STRAP KNEE 304.17 260.71 X29540 STRAP ANKLE AND/OR FT 304.17 260.71 X29550 STRAP TOES 304.17 260.71 X29580 APPLY PASTE BOOT 304.17 260.71 X29581 APPLY MULTILAY COMPRESS

UCJF 11:3-29.6

LWR LEG 304.17 260.71 X29590 APPLY FOOT SPLINT 304.17 260.71 X29700 REMOVE/REVISE CAST 304.17 260.71 X29705 REMOVE/REVISE CAST 304.17 260.71 X29710 REMOVE/REVISE CAST 691.49 592.68 X29740 WEDGE CAST 304.17 260.71 X29800 JAW ARTHROSCOPY/SURG 8,137.61 6,974.7429804 JAW ARTHROSCOPY/SURG 8,137.61 6,974.7429805 SHOULDER ARTHROSCOPY,

DIAG 8,137.61 6,974.7429806 SHOULDER

ARTHROSCOPY/SURG 13,154.68 11,274.8729807 SHOULDER



ARTHROSCOPY/SURG 13,154.68 11,274.8729821

SHOULDERARTHROSCOPY/SURG 13,154.68 11,274.87

29822 SHOULDERARTHROSCOPY/SURG 8,137.61 6,974.74





29827 ARTHROSCOPY ROTATORCUFF REPAIR 13,154.68 11,274.87

29828 ARTHROSCOPY BICEPSTENODESIS 13,154.68 11,274.87

29830 ELBOW ARTHROSCOPY 8,137.61 6,974.7429834 ELBOW

ARTHROSCOPY/SURG 8,137.61 6,974.7429835 ELBOW

ARTHROSCOPY/SURG 8,137.61 6,974.7429837 ELBOW

ARTHROSCOPY/SURG 8,137.61 6,974.7429840 WRIST ARTHROSCOPY 8,137.61 6,974.7429844 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.7429845 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.7429846 WRIST ARTHROSCOPY/SURG 8,137.61 6,974.7429847 WRIST ARTHROSCOPY/SURG13,154.68 11,274.8729848 WRIST ENDOSCOPY/SURG 8,137.61 6,974.7429850 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429855 TIBIAL ARTHROSCOPY/SURG13,154.68 11,274.8729860 HIP ARTHROSCOPY, DIAG 13,154.68 11,274.8729861 HIP ARTHROSCOPY/SURG 13,154.68 11,274.8729862 HIP ARTHROSCOPY/SURG 13,154.68 11,274.8729863 HIP ARTHROSCOPY/SURG 13,154.68 11,274.8729870 KNEE ARTHROSCOPY, DIAG 8,137.61 6,974.7429871 KNEE ARTHROSCOPY/DRAIN 8,137.61 6,974.7429873 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429874 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429875 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429876 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429877 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429879 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.74


29880 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429881 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429882 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429883 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429884 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429886 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429887 KNEE ARTHROSCOPY/SURG 8,137.61 6,974.7429888 KNEE ARTHROSCOPY/SURG 24,164.43 20,711.3229889 KNEE ARTHROSCOPY/SURG 24,164.43 20,711.3229891 ANKLE

ARTHROSCOPY/SURG 13,154.68 11,274.8729894 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.7429895 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.7429897 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.7429898 ANKLE ARTHROSCOPY/SURG8,137.61 6,974.7429899 ANKLE ARTHROSCOPY/SURG13,154.68 11,274.8730100 INTRANASAL BIOPSY 2,150.53 1,843.2230130 EXCISE INFERIOR

TURBINATE 4,708.37 4,035.5430140 RESECT INFERIOR

TURBINATE 6,964.52 5,969.2930200 INJECTION TREAT NOSE 2,150.53 1,843.2230300 REMOVE NASAL FOREIGN

BODY 182.27 156.22 AS30310 REMOVE NASAL FOREIGN

BODY 4,708.37 4,035.5430520 REPAIR NASAL SEPTUM 6,964.52 5,969.2930802 ABLATE INF TURBINATE

SUBMUCOSAL 4,708.37 4,035.5430901 CONTROL NOSEBLEED 307.68 263.7130903 CONTROL NOSEBLEED 307.68 263.7130905 CONTROL NOSEBLEED 307.68 263.7130930 THERAPEUTIC FX, NASAL

INF TURB 4,708.37 4,035.5431000 IRRIGATE MAXILLARY SINUS 965.03 827.1331020 EXPLORE MAXILLARY SINUS6,964.52 5,969.2931231 NASAL ENDOSCOPY, DIAG 546.21 468.1531237 NASAL/SINUS ENDOSCOPY,

SURG 5,959.12 5,107.5631238 NASAL/SINUS ENDOSCOPY,

SURG 5,959.12 5,107.5631255 REMOVE ETHMOID SINUS 8,403.49 7,202.6331256 EXPLORE MAXILLARY SINUS8,403.49 7,202.6331267 ENDOSCOPY, MAXILLARY

SINUS 8,403.49 7,202.6331500 INSERT EMERGENCY

AIRWAY 642.80 550.94 X31505 DIAGNOSTIC LARYNGOSCOPY 252.44 216.3731515 LARYNGOSCOPY FOR

ASPIRATION 5,959.12 5,107.5631525 DIAG LARYNGOSCOPY EXCL

NB 5,959.12 5,107.5631575 DIAGNOSTIC LARYNGOSCOPY 546.21 468.1531579 DIAGNOSTIC LARYNGOSCOPY1,147.30 983.3531600 INCISE WINDPIPE 6,964.52 5,969.2931605 INCISE WINDPIPE 2,150.53 1,843.2231622 DIAG BRONCHOSCOPE/WASH2,851.45 2,443.9731624 DIAG BRONCHOSCOPE/LAVAGE2,851.45 2,443.9731645 BRONCHOSCOPY, CLEAR

AIRWAYS 2,851.45 2,443.9731646 BRONCHOSCOPY, RECLEAR

AIRWAY 2,851.45 2,443.97

UCJF 11:3-29.6

32405 BIOPSY LUNG ORMEDIASTINUM 2,643.63 2,265.85

32551 INSERT CHEST TUBE 1,510.65 1,294.7732601 THORACOSCOPY,

DIAGNOSTIC 9,461.41 8,109.3733210 INSERT HEART ELECTRODE 9,299.39 8,275.5833212 INSERT PULSE GENERATOR 12,451.20 11,516.4236000 PLACE NEEDLE IN VEIN N136005 INJECTION EXT

VENOGRAPHY N136010 PLACE CATHETER IN VEIN N136011 PLACE CATHETER IN VEIN N136013 PLACE CATHETER IN ARTERY N136014 PLACE CATHETER IN ARTERY N136140 ESTABLISH ACCESS TO

ARTERY N136200 PLACE CATHETER IN AORTA N136215 PLACE CATHETER IN ARTERY N136216 PLACE CATHETER IN ARTERY N136217 PLACE CATHETER IN ARTERY N136218 PLACE CATHETER IN ARTERY N136245 PLACE CATHETER IN ARTERY N136246 PLACE CATHETER IN ARTERY N136247 PLACE CATHETER IN ARTERY N136248 PLACE CATHETER IN ARTERY N136400 BLOOD DRAW < 3 YRS

FEM/JUGULAR N136406 BLOOD DRAW < 3 YRS OTHER

VEIN N136410 NON-ROUTINE BL DRAW > 3

YRS N136425 VEIN ACCESS CUTDOWN > 1

YR 72.62 62.24 AS36430 BLOOD TRANSFUSION

SERVICE 921.03 789.41 X36471 INJECTION THERAPY VEINS 247.20 211.8836513 APHERESIS PLATELETS 3,363.75 2,883.07 X36514 APHERESIS PLASMA 3,363.75 2,883.07 X36515 APHERESIS,

ADSORP/REINFUSE 8,540.97 7,320.46 X36555 INSERT NON-TUNNEL CV

CATH 3,087.37 2,646.1836556 INSERT NON-TUNNEL CV

CATH 3,087.37 2,646.1836558 INSERT TUNNELED CV

CATH 5,241.41 4,907.6836569 INSERT PICC CATH 3,087.37 2,646.1836571 INSERT PICVAD CATH 5,241.41 4,907.6836576 REPAIR TUNNELED CV

CATH 3,087.37 2,646.1836578 REPLACE TUNNELED CV

CATH 5,241.41 4,907.6836580 REPLACE CVAD CATH 3,087.37 2,646.1836584 REPLACE PICC CATH 3,087.37 2,646.1836589 REMOVE TUNNELED CV

CATH 1,718.86 1,473.2336592 COLLECT BLOOD PICC 171.82 147.2736593 DECLOT VASCULAR DEVICE 637.44 546.3536598 INJECT W/FLUOR, EVAL CV

DEVICE 637.44 546.3536600 WITHDRAW ARTERIAL

BLOOD 72.62 62.24


36620 INSERT CATHETER, ARTERY N136625 INSERT CATHETER, ARTERY N136800 INSERT CANNULA 8,505.69 7,354.1236810 INSERT CANNULA 8,505.69 7,354.1236815 INSERT CANNULA 8,505.69 7,354.1236818 AV FUSE, UPPER ARM,

CEPHALIC 11,329.30 9,710.3336833 AV FISTULA REVISION 11,329.30 9,710.3336860 EXTERNAL CANNULA

DECLOTTING 637.44 546.3537204 TRANSCATHETER

OCCLUSION 19,232.98 16,856.3937609 TEMPORAL ARTERY

PROCEDURE 4,909.21 4,207.6837620 REVISE MAJOR VEIN 11,946.47 10,239.3137650 REVISE MAJOR VEIN 7,454.87 6,389.5638200 INJECTION FOR SPLEEN

X-RAY N143235 UPPER GI ENDOSCOPY,

DIAGNOSIS 2,411.81 2,067.1643236 UPPER GI SCOPE

W/SUBMUCOSA INJECT 2,411.81 2,067.1643239 UPPER GI ENDOSCOPY,

BIOPSY 2,411.81 2,067.1643246 PLACE GASTROSTOMY

TUBE 2,411.81 2,067.1643248 UPPER GI ENDOSCOPY/GUIDE

WIRE 2,411.81 2,067.1643249 ESOPH ENDOSCOPY,

DILATION 2,411.81 2,067.1643255 OPERATIVE UPPER GI

ENDOSCOPY 2,411.81 2,067.1643259 ENDOSCOPIC ULTRASOUND

EXAM 2,411.81 2,067.1643260 ENDO CHOLANGIOPANCRE-

ATOGRAPHY 6,309.66 5,408.0043450 DILATE ESOPHAGUS 1,782.37 1,527.6743760 CHANGE GASTROSTOMY

TUBE 637.44 546.3543830 PLACE GASTROSTOMY

TUBE 4,529.06 3,881.8644500 INTRODUCE

GASTROINTESTINAL TUBE 1,718.86 1,473.2346040 INCISE RECTAL ABSCESS 6,610.91 5,666.2146600 DIAGNOSTIC ANOSCOPY 182.27 156.22 AS47000 NEEDLE BIOPSY LIVER 2,643.63 2,265.8549080 PUNCTURE, PERITONEAL

CAVITY 1,510.65 1,294.7749320 DIAG LAP SEPARATE PROC 10,495.79 8,995.9449421 INSERT ABDOM DRAIN,

PERM 7,481.94 6,471.3149505 PART RPR I/HERNIA INIT

REDUCE >5 YR 8,982.66 7,699.0350392 INSERT KIDNEY DRAIN 4,772.16 4,090.2250394 INJECTION FOR KIDNEY

X-RAY N151600 INJECTION FOR BLADDER

X-RAY N151610 INJECTION FOR BLADDER

X-RAY N151700 IRRIGATION BLADDER 553.11 474.0751701 INSERT BLADDER CATHETER 182.27 156.22 AS

UCJF 11:3-29.6

51702 INSERT TEMP BLADDERCATH 182.27 156.22 AS

51703 INSERT BLADDER CATH,COMPLEX 301.69 258.58

51705 CHANGE BLADDER TUBE 553.11 474.0751720 TREAT BLADDER LESION 872.10 747.4851725 SIMPLE CYSTOMETROGRAM 872.10 747.4851726 COMPLEX

CYSTOMETROGRAM 872.10 747.4851741 ELECTRO-UROFLOWMETRY,

FIRST 301.69 258.5851784 ANAL/URINARY MUSCLE

STUDY 301.69 258.5851797 INTRAABDOMINAL PRESSURE

TEST 553.11 474.0751798 US URINE CAPACITY

MEASURE 182.27 156.22 AS52000 CYSTOSCOPY 2,020.50 1,731.7752005 CYSTOSCOPY & URETER

CATHETER 7,150.85 6,128.9952204 CYSTOSCOPY W/BIOPSY(S) 7,150.85 6,128.9952281 CYSTOSCOPY & TREAT 4,772.16 4,090.2252310 CYSTOSCOPY & TREAT 4,772.16 4,090.2252332 CYSTOSCOPY & TREAT 7,150.85 6,128.9952351 CYSTOURETERO & OR

PYELOSCOPE 7,150.85 6,128.9953600 DILATE URETHRA

STRICTURE 874.07 749.1753601 DILATE URETHRA

STRICTURE 301.69 258.5853660 DILATE URETHRA 301.69 258.5853661 DILATE URETHRA 301.69 258.5854235 PENILE INJECTION 872.10 747.4857452 EXAM CERVIX W/SCOPE 443.98 380.5357500 BIOPSY CERVIX 1,783.00 1,528.2157511 CRYOCAUTERY CERVIX 443.98 380.5358340 CATHETER FOR

HYSTERORRHAPHY N158558 HYSTEROSCOPY, BIOPSY 6,268.18 5,372.4559000 AMNIOCENTESIS,

DIAGNOSTIC 983.13 842.6459025 FETAL NON-STRESS TEST 443.98 380.5359841 ABORTION 5,615.09 4,812.6961790 TREAT TRIGEMINAL NERVE 5,195.44 4,453.0162263 EPIDURAL LYSIS MULT

SESSIONS 2,060.68 1,766.2162264 EPIDURAL LYSIS ON SINGLE

DAY 3,474.53 2,978.0262270 SPINAL FLUID TAP,

DIAGNOSTIC 1,054.25 903.6062273 INJECT EPIDURAL PATCH 2,060.68 1,766.2162280 TREAT SPINAL CORD L

ESION 2,060.68 1,766.2162281 TREAT SPINAL CORD

LESION 2,060.68 1,766.2162282 TREAT SPINAL CANAL

LESION 2,060.68 1,766.2162284 INJECTION FOR

MYELOGRAM N162287 PERCUTANEOUS

DISKECTOMY 10,121.96 8,675.5262290 INJECT FOR SPINE DISK


X-RAY N162291 INJECT FOR SPINE DISK

X-RAY N162292 INJECTION INTO DISK

LESION 2,060.68 1,766.2162310 INJECT SPINE C/T 2,060.68 1,766.2162311 INJECT SPINE L/S (CD) 2,060.68 1,766.2162318 INJECT SPINE W/CATH, C/T 2,060.68 1,766.2162319 INJECT SPINE W/CATH L/S

(CD) 3,474.53 2,978.0262350 IMPLANT SPINAL CANAL

CATH 11,382.48 9,755.9262355 REMOVE SPINAL CANAL

CATHETER 3,474.53 2,978.0262360 INSERT SPINE INFUSION

DEVICE 11,382.48 9,755.9262362 IMPLANT SPINE INFUSION

PUMP 22,227.97 20,941.6362365 REMOVE SPINE INFUSION

DEVICE 10,121.96 8,675.5262367 ANALYZE SPINE INFUSION

PUMP 657.70 563.72 X62368 ANALYZE SPINE INFUSION

PUMP 657.70 563.72 X63020 NECK SPINE DISK SURG 13,940.72 11,948.5863030 LOW BACK DISK SURG 13,940.72 11,948.5863035 SPINAL DISK SURG, ADDED 13,940.72 11,948.5863040 LAMINOTOMY, SINGLE

CERV 13,940.72 11,948.5863042 LAMINOTOMY, SINGLE

LUMBAR 13,940.72 11,948.5863045 REMOVE SPINAL LAMINA 13,940.72 11,948.5863046 REMOVE SPINAL LAMINA 13,940.72 11,948.5863047 REMOVE SPINAL LAMINA 13,940.72 11,948.5863048 REMOVE SPINAL LAMINA,

ADDED 13,940.72 11,948.5863056 DECOMPRESS SPINAL CORD13,940.72 11,948.5863057 DECOMPRESS SPINE CORD,

ADDED 13,940.72 11,948.5863075 NECK SPINE DISK SURG 13,940.72 11,948.5863076 NECK SPINE DISK SURG 13,940.72 11,948.5863650 IMPLANT

NEUROELECTRODES 17,950.74 9,545.51 X63655 IMPLANT

NEUROELECTRODES 13,352.79 12,138.59 X63685 INSERT/REDO SPINE N

GENERATOR 23,191.56 22,061.87 X63688 REVISE/REMOVE

NEURORECEIVER 7,898.33 6,769.6564400 NERVE BLOCK INJ,

TRIGEMINAL 724.57 621.0364402 NERVE BLOCK INJ, FACIAL 724.57 621.0364405 NERVE BLOCK INJ, OCCIPITAL1,054.25 903.6064412 NERVE BLOCK INJ, SPINAL

ACCESSORY 2,060.68 1,766.2164413 NERVE BLOCK INJ, CERV

PLEXUS 1,054.25 903.6064415 NERVE BLOCK INJ,

BRACHIAL PLEXUS 1,054.25 903.6064416 NERVE BLOCK CONT INFUSE,

B PLEX 2,060.68 1,766.2164417 NERVE BLOCK INJ,

UCJF 11:3-29.6

AXILLARY 1,054.25 903.6064418 NERVE BLOCK INJ,

SUPRASCAPULAR 1,054.25 903.6064420 NERVE BLOCK INJ,

INTERCOSTAL, SING 1,054.25 903.6064421 NERVE BLOCK INJ,

INTERCOSTAL, MULT 2,060.68 1,766.2164425 NERVE BLOCK INJ,

ILIO-ING/HYPOGI 1,054.25 903.6064430 NERVE BLOCK INJ,

PUDENDAL 2,060.68 1,766.2164435 NERVE BLOCK INJ,

PARACERV 1,054.25 903.6064445 NERVE BLOCK INJ, SCIATIC,

SING 2,060.68 1,766.2164446 NERVE BLOCK INJ, SCIATIC,

CONT INF 2,060.68 1,766.2164447 NERVE BLOCK INJ, FEM, SING1,054.25 903.6064448 NERVE BLOCK INJ, FEM,

CONT INF 2,060.68 1,766.2164449 NERVE BLOCK INJ, LUMBAR

PLEXUS 2,060.68 1,766.2164450 NERVE BLOCK, OTHER

PERIPHERAL 1,054.25 903.6064455 NERVE BLOCK INJ, PLANTAR

DIGIT 724.57 621.0364479 INJECT FORAMEN EPIDURAL

C/T 2,060.68 1,766.2164480 INJECT FORAMEN EPIDURAL,

ADDED 1,054.25 903.6064483 INJECT FORAMEN EPIDURAL

L/S 2,060.68 1,766.2164484 INJECT FORAMEN EPIDURAL,

ADDED 1,054.25 903.6064490 INJECT PARAVERT F JNT C/T

1 LEV 2,060.68 1,766.2164491 INJECT PARAVERT F JNT C/T

2 LEV 724.57 621.0364492 INJECT PARAVERT F JNT C/T

3 LEV 724.57 621.0364493 INJECT PARAVERT F JNT L/S

1 LEV 2,060.68 1,766.2164494 INJECT PARAVERT F JNT L/S

2 LEV 724.57 621.0364495 INJECT PARAVERT F JNT L/S

3 LEV 724.57 621.0364505 NERVE BLOCK

SPHENOPALATINE GANGLIA 724.57 621.0364510 NERVE BLOCK STELLATE

GANGLION 2,060.68 1,766.2164517 NERVE BLOCK INJ, HYPOGAS

PLXS 2,060.68 1,766.2164520 NERVE BLOCK

LUMBAR/THORACIC 2,060.68 1,766.2164555 IMPLANT



NEUROELECTRODES 10,600.82 9,545.51 X64600 INJECTION TREAT NERVE 3,474.53 2,978.0264605 INJECTION TREAT NERVE 5,195.44 4,453.01


64610 INJECTION TREAT NERVE 5,195.44 4,453.0164612 DESTROY NERVE, FACE

MUSCLE 724.57 621.0364613 DESTROY NERVE, NECK

MUSCLE 1,054.25 903.6064614 DESTROY NERVE,

EXTREMITY MUSC 1,054.25 903.6064620 INJECTION TREAT NERVE 2,060.68 1,766.2164622 DESTROY PARAVERTEBRAL

NERVE L/S 3,474.53 2,978.0264623 DESTROY PARAVERT NERVE,

ADDED 2,060.68 1,766.2164626 DESTROY PARAVERTEBRAL

NERVE C/T 2,060.68 1,766.2164627 DESTROY PARAVERT NERVE,

ADDED 724.57 621.0364640 INJECTION TREAT NERVE 2,060.68 1,766.2164680 INJECTION TREAT NERVE 2,060.68 1,766.2164702 REVISE FINGER/TOE NERVE 5,195.44 4,453.0164704 REVISE HAND/FOOT NERVE 5,195.44 4,453.0164708 REVISE ARM/LEG NERVE 5,195.44 4,453.0164712 REVISE SCIATIC NERVE 5,195.44 4,453.0164713 REVISE ARM NERVE(S) 5,195.44 4,453.0164714 REVISE LOW BACK NERVE(S) 5,195.44 4,453.0164716 REVISE CRANIAL NERVE 5,195.44 4,453.0164718 REVISE ULNAR NERVE AT

ELBOW 5,195.44 4,453.0164719 REVISE ULNAR NERVE AT

WRIST 5,195.44 4,453.0164721 CARPAL TUNNEL SURG 5,195.44 4,453.0165205 REMOVE FOREIGN BODY EYE 263.33 225.70 X65210 REMOVE FOREIGN BODY EYE 263.33 225.70 X65220 REMOVE FOREIGN BODY EYE 263.33 225.70 X65222 REMOVE FOREIGN BODY EYE 263.33 225.70 X65265 REMOVE FOREIGN BODY EYE6,362.61 5,453.3967412 EXPLORE/TREAT EYE

SOCKET 5,433.49 4,657.0469210 REMOVE IMPACTED EAR

WAX 182.27 156.22 AS69310 REBUILD OUTER EAR

CANAL 12,135.56 10,401.3869320 REBUILD OUTER EAR

CANAL 12,135.56 10,401.3869666 REPAIR MIDDLE EAR

STRUCTURES 12,135.56 10,401.3869667 REPAIR MIDDLE EAR

STRUCTURES 12,135.56 10,401.3869990 MICROSURG, ADDED N170030 X-RAY EYE FOR FOREIGN

BODY 177.57 152.20 AS70100 X-RAY JAW < 4 VIEWS 177.57 152.20 AS70110 X-RAY JAW MINIMUM 4

VIEWS 177.57 152.20 AS70120 X-RAY MASTOIDS < 3

VIEWS/SIDE 177.57 152.20 AS70130 X-RAY MASTOIDS MINIMUM

3 VIEWS/SIDE 177.57 152.20 AS70140 X-RAY FACIAL BONES < 3

VIEWS 177.57 152.20 AS70150 X-RAY FACIAL BONES

MINIMUM 3 VIEWS 177.57 152.20 AS70160 X-RAY NASAL BONES

UCJF 11:3-29.6

MINIMUM 3 VIEWS 177.57 152.20 AS70190 X-RAY OPTIC FORAMINA 177.57 152.20 AS70200 X-RAY ORBITS, MINIMUM 4

VIEWS 177.57 152.20 AS70210 X-RAY SINUSES < 3 VIEWS 177.57 152.20 AS70220 X-RAY SINUSES MINIMUM 3

VIEWS 177.57 152.20 AS70250 X-RAY SKULL < 4 VIEWS 177.57 152.20 AS70260 X-RAY SKULL MINIMUM 4

VIEWS 299.09 256.35 AS70300 X-RAY TEETH SINGLE VIEW 120.17 103.00 AS70310 X-RAY TEETH < FULL MOUTH 120.17 103.00 AS70320 X-RAY TEETH FULL MOUTH 120.17 103.00 AS70328 X-RAY TMJ UNILATERAL 177.57 152.20 AS70330 X-RAY TMJ BILATERAL 177.57 152.20 AS70332 TMJ ARTHOGRAPHY; RAD

SUPER & INTERP 1,084.37 929.4270336 MRI TMJ 1,352.04 1,158.8370350 CEPHALOGRAM,

ORTHODONTIC 177.57 152.20 AS70355 ORTHOPANTOGRAM 120.17 103.00 AS70360 X-RAY NECK SOFT TISSUE 177.57 152.20 AS70450 CT HEAD/BRAIN W/O DYE 764.27 655.0670460 CT HEAD/BRAIN W/DYE 1,182.03 1,013.1270470 CT HEAD/BRAIN W/O &

W/DYE 1,317.77 1,129.4670480 CT ORBIT/EAR/FOSSA W/O

DYE 764.27 655.0670481 CT ORBIT/EAR/FOSSA W/DYE 1,182.03 1,013.1270482 CT ORBIT/EAR/FOSSA W/O &

W/DYE 1,317.77 1,129.4670486 CT MAXILLOFACIAL W/O

DYE 764.27 655.0670487 CT MAXILLOFACIAL W/DYE 1,182.03 1,013.1270488 CT MAXILLOFACIAL W/O &

W/DYE 1,317.77 1,129.4670490 CT SOFT TISSUE NECK W/O

DYE 764.27 655.0670491 CT SOFT TISSUE NECK

W/DYE 1,182.03 1,013.1270492 CT SOFT TISSUE NECK W/O

& W/DYE 1,317.77 1,129.4670496 CT ANGIOGRAPHY, HEAD 1,334.69 1,143.9670498 CT ANGIOGRAPHY, NECK 1,334.69 1,143.9670540 MRI ORBIT/FACE/NECK W/O

DYE 1,352.04 1,158.8370542 MRI ORBIT/FACE/NECK

W/DYE 1,722.84 1,476.6470543 MRI ORBIT/FACE/NECK W/O

& W/DYE 2,103.77 1,803.1470544 MR ANGIOGRAPHY HEAD

W/O DYE 1,352.04 1,158.8370545 MR ANGIOGRAPHY HEAD

W/DYE 1,722.84 1,476.6470546 MR ANGIOGRAPH HEAD W/O

& W/DYE 2,103.77 1,803.1470547 MR ANGIOGRAPHY NECK

W/O DYE 1,352.04 1,158.8370548 MR ANGIOGRAPHY NECK

W/DYE 1,722.84 1,476.6470549 MR ANGIOGRAPH NECK W/O

& W/DYE 2,103.77 1,803.14


70551 MRI BRAIN W/O DYE 1,352.04 1,158.8370552 MRI BRAIN W/DYE 1,722.84 1,476.6470553 MRI BRAIN W/O & W/DYE 2,103.77 1,803.1470554 FMRI BRAIN BY TECH 1,352.04 1,158.8370555 FMRI BRAIN BY PHYS/PSYCH 1,352.04 1,158.83 X71010 CHEST X-RAY SINGLE VIEW

FRONTAL 177.57 152.2071020 CHEST X-RAY 2 VIEWS

FRONTAL & LATERAL 177.57 152.2071021 CHEST X-RAY 2 VIEWS

W/APICAL LORD PROC 177.57 152.20 AS71022 CHEST X-RAY 2 VIEWS

W/OBLIQUE PROJ 177.57 152.20 AS71030 CHEST X-RAY MINIMUM 4

VIEWS 177.57 152.20 AS71035 CHEST X-RAY SPECIAL VIEWS 177.57 152.20 AS71040 CONTRAST X-RAY BRONCHI

UNILATERAL 906.64 777.0871090 X-RAY & PACEMAKER INSERT N171100 X-RAY RIBS 2 VIEWS 177.57 152.20 AS71101 X-RAY RIBS/CHEST MINIMUM

3 VIEWS 177.57 152.20 AS71110 X-RAY RIBS BILATERAL 3

VIEWS 177.57 152.20 AS71111 X-RAY RIBS/CHEST MINIMUM

4 VIEWS 299.09 256.35 AS71120 X-RAY STERNUM MINIMUM

2 VIEWS 177.57 152.20 AS71130 X-RAY STERNOCLAV JOINT

MINIMUM 3 VIEWS 177.57 152.20 AS71250 CT THORAX W/O DYE 764.27 655.0671260 CT THORAX W/DYE 1,182.03 1,013.1271270 CT THORAX W/O & W/DYE 1,317.77 1,129.4671275 CT ANGIOGRAPHY, CHEST 1,334.69 1,143.9671550 MRI CHEST W/O DYE 1,352.04 1,158.8371552 MRI CHEST W/O & W/DYE 2,103.77 1,803.1472010 X-RAY SPINE ANTEROPOST

& LATERAL 299.09 256.35 AS72020 X-RAY SPINE SINGLE VIEW

SPECIFY LEVEL 177.57 152.20 AS72040 X-RAY NECK SPINE CERV 2/3

VIEWS 177.57 152.20 AS72050 X-RAY NECK SPINE CERV

MINIMUM 4 VIEWS 299.09 256.35 AS72052 X-RAY NECK SPINE

COMPLETE 299.09 256.35 AS72069 X-RAY TRUNK SPINE

STANDING 177.57 152.20 AS72070 X-RAY THORACIC SPINE 2

VIEWS 177.57 152.20 AS72072 X-RAY THORACIC SPINE 3

VIEWS 177.57 152.20 AS72074 X-RAY THORACIC SPINE

MINIMUM 4 VIEWS 177.57 152.20 AS72080 X-RAY TRUNK SPINE 2 VIEWS 177.57 152.20 AS72090 X-RAY TRUNK SPINE

SCOLIOSIS STUDY 299.09 256.35 AS72100 X-RAY LOWER SPINE 2/3

VIEWS 177.57 152.20 AS72110 X-RAY LOWER SPINE

MINIMUM 4 VIEWS 299.09 256.35 AS72114 X-RAY LOWER SPINE

UCJF 11:3-29.6

COMPLETE 299.09 256.35 AS72120 X-RAY LOWER SPINE

BENDING MINIMUM 4 VIEWS 177.57 152.20 AS72125 CT NECK SPINE W/O DYE 764.27 655.0672126 CT NECK SPINE W/DYE 1,182.03 1,013.1272127 CT NECK SPINE W/O &

W/DYE 1,317.77 1,129.4672128 CT CHEST SPINE W/O DYE 764.27 655.0672129 CT CHEST SPINE W/DYE 1,182.03 1,013.1272130 CT CHEST SPINE W/O &

W/DYE 1,317.77 1,129.4672131 CT LUMBAR SPINE W/O DYE 764.27 655.0672132 CT LUMBAR SPINE W/DYE 1,182.03 1,013.1272133 CT LUMBAR SPINE W/O &

W/DYE 1,317.77 1,129.4672141 MRI NECK SPINE W/O DYE 1,352.04 1,158.8372142 MRI NECK SPINE W/DYE 1,722.84 1,476.6472146 MRI CHEST SPINE W/O DYE 1,352.04 1,158.8372147 MRI CHEST SPINE W/DYE 1,722.84 1,476.6472148 MRI LUMBAR SPINE W/O

DYE 1,352.04 1,158.8372149 MRI LUMBAR SPINE W/DYE 1,722.84 1,476.6472156 MRI NECK SPINE W/O &

W/DYE 2,103.77 1,803.1472157 MRI CHEST SPINE W/O &

W/DYE 2,103.77 1,803.1472158 MRI LUMBAR SPINE W/O &

W/DYE 2,103.77 1,803.1472170 X-RAY PELVIS 1/2 VIEWS 177.57 152.20 AS72190 X-RAY PELVIS MINIMUM 3

VIEWS 177.57 152.20 AS72191 CT ANGIOGRAPH PELVIS W/O

& W/DYE 1,334.69 1,143.9672192 CT PELVIS W/O DYE 764.27 655.0672193 CT PELVIS W/DYE 1,182.03 1,013.1272194 CT PELVIS W/O & W/DYE 1,317.77 1,129.4672195 MRI PELVIS W/O DYE 1,352.04 1,158.8372196 MRI PELVIS W/DYE 1,722.84 1,476.6472197 MRI PELVIS W/O & W/DYE 2,103.77 1,803.1472200 X-RAY EXAM SACROILIAC

JOINTS 177.57 152.20 AS72202 X-RAY EXAM SACROILIAC

JOINTS 177.57 152.20 AS72220 X-RAY TAILBONE 177.57 152.20 AS72240 CONTRAST X-RAY NECK

SPINE 1,967.75 1,686.5672255 CONTRAST X-RAY THORAX

SPINE 1,967.75 1,686.5672265 CONTRAST X-RAY LOWER

SPINE 1,967.75 1,686.5672270 CONTRAST X-RAY SPINE 1,967.75 1,686.5672275 EPIDUROGRAPHY N172285 X-RAY C/T SPINE DISK 6,593.09 5,650.9372291 PERCUT

VERT/SACROPLASTY, FLUOR N172295 X-RAY LOWER SPINE DISK 6,593.09 5,650.9373000 X-RAY COLLAR BONE 177.57 152.20 AS73010 X-RAY SHOULDER BLADE 177.57 152.20 AS73020 X-RAY SHOULDER 1 VIEW 177.57 152.20 AS73030 X-RAY SHOULDER MINIMUM

2 VIEWS 177.57 152.20 AS73040 CONTRAST X-RAY


SHOULDER 1,084.37 929.4273050 X-RAY SHOULDERS 177.57 152.20 AS73060 X-RAY HUMERUS MINIMUM 2

VIEWS 177.57 152.20 AS73070 X-RAY ELBOW 2 VIEWS 177.57 152.20 AS73080 X-RAY ELBOW MINIMUM 3

VIEWS 177.57 152.20 AS73090 X-RAY FOREARM 177.57 152.20 AS73092 X-RAY ARM, INFANT 177.57 152.20 AS73100 X-RAY WRIST 2 VIEWS 177.57 152.20 AS73110 X-RAY WRIST MINIMUM 3

VIEWS 177.57 152.20 AS73115 CONTRAST X-RAY WRIST 1,084.37 929.4273120 X-RAY HAND 2 VIEWS 177.57 152.20 AS73130 X-RAY HAND MINIMUM 3

VIEWS 177.57 152.20 AS73140 X-RAY FINGER(S) MINIMUM 2

VIEWS 177.57 152.20 AS73200 CT UPPER EXTREMITY W/O

DYE 764.27 655.0673201 CT UPPER EXTREMITY

W/DYE 1,182.03 1,013.1273202 CT UPPER EXTREMITY W/O

& W/DYE 1,317.77 1,129.4673206 CT ANGIO UPR EXTREMITY

W/O & W/DYE 1,334.69 1,143.9673218 MRI UPPER EXTREMITY

W/O DYE 1,352.04 1,158.8373219 MRI UPPER EXTREMITY

W/DYE 1,722.84 1,476.6473220 MRI UPPER EXTREMITY W/O

& W/DYE 2,103.77 1,803.1473221 MRI JOINT UPPER

EXTREMITY W/O DYE 1,352.04 1,158.8373222 MRI JOINT UPPER

EXTREMITY W/DYE 1,722.84 1,476.6473223 MRI JOINT UPPER

EXTREMITY W/O & W/DYE 2,103.77 1,803.1473500 X-RAY HIP UNILATERAL

1 VIEW 177.57 152.20 AS73510 X-RAY HIP COMPLETE

MINIMUM 2 VIEWS 177.57 152.20 AS73520 X-RAY HIPS MINIMUM 2

VIEWS 177.57 152.20 AS73525 X-RAY HIP ARTHROGRAPHY 1,084.37 929.4273530 X-RAY HIP DURING

OPERATIVE PROCEDURE N173540 X-RAY PELVIS & HIPS

MINIMUM 2 VIEWS 177.57 152.20 AS73542 X-RAY EXAM, SACROILIAC

JOINT 1,084.37 929.4273550 X-RAY THIGH 2 VIEWS 177.57 152.20 AS73560 X-RAY KNEE 1/2 VIEWS 177.57 152.20 AS73562 X-RAY KNEE 3 VIEWS 177.57 152.20 AS73564 X-RAY KNEE, COMPLETE

4/MORE VIEWS 177.57 152.20 AS73565 X-RAY KNEES STANDING

ANTEROPOST 177.57 152.20 AS73580 X-RAY KNEE ARTHOGRAPHY 1,084.37 929.4273590 X-RAY TIBIA & FIBULA 2

VIEWS 177.57 152.20 AS73592 X-RAY LEG, INFANT MINIMUM

UCJF 11:3-29.6

2 VIEWS 177.57 152.20 AS73600 X-RAY ANKLE 2 VIEWS 177.57 152.20 AS73610 X-RAY ANKLE MINIMUM 3

VIEWS 177.57 152.20 AS73615 CONTRAST X-RAY ANKLE 1,084.37 929.4273620 X-RAY FOOT 2 VIEWS 177.57 152.20 AS73630 X-RAY FOOT MINIMUM 3

VIEWS 177.57 152.20 AS73650 X-RAY HEEL 177.57 152.20 AS73660 X-RAY TOE(S) 177.57 152.20 AS73700 CT LOWER EXTREMITY W/O

DYE 764.27 655.0673701 CT LOWER EXTREMITY

W/DYE 1,182.03 1,013.1273706 CT ANGIO LWR EXTREMITY

W/O & W/DYE 1,334.69 1,143.9673718 MRI LOWER EXTREMITY

W/O DYE 1,352.04 1,158.8373719 MRI LOWER EXTREMITY

W/DYE 1,722.84 1,476.6473720 MRI LOWER EXTREMITY

W/O & W/DYE 2,103.77 1,803.1473721 MRI JOINT LOWER

EXTREMITY W/O DYE 1,352.04 1,158.8373722 MRI JOINT LOWER

EXTREMITY W/DYE 1,722.84 1,476.6473723 MRI JOINT LWR EXTREMITY

W/O & W/DYE 2,103.77 1,803.1474000 X-RAY ABDOMEN SINGLE

ANTEROPOST 177.57 152.20 AS74010 X-RAY ABDOMEN

ANTEROPOST & ADDED VW 177.57 152.20 AS74020 X-RAY ABDOMEN COMPLETE 177.57 152.20 AS74022 X-RAY EXAM SERIES,

ABDOMEN 299.09 256.35 AS74150 CT ABDOMEN W/O DYE 764.27 655.0674160 CT ABDOMEN W/DYE 1,182.03 1,013.1274170 CT ABDOMEN W/O & W/DYE 1,317.77 1,129.4674175 CT ANGIO ABDOM W/O &

W/DYE 1,334.69 1,143.9674176 CT ANGIO ABDOM & PELVIS 764.27 655.0674177 CT ANGIO ABDOM & PELVIS

W/CONTRAST 1,182.03 1,013.1274178 CT ANGIO ABDOM & PELVIS

1+ REGNS 1,317.77 1,129.4674181 MRI ABDOMEN W/O DYE 1,352.04 1,158.8374183 MRI ABDOMEN W/O & W/DYE2,103.77 1,803.1474220 CONTRAST X-RAY,

ESOPHAGUS 341.90 293.04 X74230 CINE/VIDEO X-RAY,

THROAT/ESOPH 341.90 293.04 X74241 X-RAY EXAM, UPPER GI

TRACT W/KUB 341.90 293.04 X74246 CONTRAST X-RAY UGI TRACT

W/O KUB 341.90 293.04 X74280 CONTRAST X-RAY COLON

W/WO GLUCOGEN 559.77 479.78 X74290 CONTRAST X-RAY,

GALLBLADDER 341.90 293.04 X74330 X-RAY BILE/PANCREAS

ENDOSCOPY N174400 CONTRAST X-RAY URINARY


TRACT 694.37 595.14 X74410 CONTRAST X-RAY URINARY




TRACT 694.37 595.1474430 CONTRAST X-RAY BLADDER 694.37 595.1474450 X-RAY URETHRA/BLADDER 694.37 595.1474455 X-RAY URETHRA/BLADDER 694.37 595.1474475 X-RAY CONTROL, CATH

INSERT 4,772.16 4,090.2274480 X-RAY CONTROL, CATH

INSERT 4,772.16 4,090.2274485 X-RAY GUIDE, GU DILATION 4,772.16 4,090.2275561 CARDIAC MRI FOR MORPH

W/DYE 2,103.77 1,803.1475572 CT HEART W/3D IMAGE 1,012.70 867.98 X75574 CT ANGIO HEART W/3D

IMAGE 1,012.70 867.98 X75605 CONTRAST X-RAY AORTA 7,990.03 6,848.2575625 CONTRAST X-RAY AORTA 7,990.03 6,848.2575630 X-RAY AORTA, LEG

ARTERIES 7,990.03 6,848.2575635 CT ANGIO ABDOMINAL

ARTERIES 1,334.69 1,143.9675650 ARTERY X-RAYS HEAD &

NECK 12,970.25 11,116.7975665 ARTERY X-RAYS HEAD &

NECK 7,990.03 6,848.2575671 ARTERY X-RAYS HEAD & NECK 12,970.25 11,116.7975676 ARTERY X-RAYS NECK

UNILATERAL 7,990.03 6,848.2575680 ARTERY X-RAYS NECK

BILATERAL 7,990.03 6,848.2575685 ARTERY X-RAYS SPINE 7,990.03 6,848.2575705 ARTERY X-RAYS SPINE 7,990.03 6,848.2575710 ARTERY X-RAYS ARM/LEG 7,990.03 6,848.2575716 ARTERY X-RAYS ARMS/LEGS 7,990.03 6,848.2575722 ARTERY X-RAYS KIDNEY 7,990.03 6,848.2575724 ARTERY X-RAYS KIDNEYS 7,990.03 6,848.2575726 ARTERY X-RAYS ABDOMEN 7,990.03 6,848.2575736 ARTERY X-RAYS PELVIS 7,990.03 6,848.2575743 ARTERY X-RAYS LUNGS 7,990.03 6,848.2575774 ARTERY X-RAY, EACH VESSEL N175809 NONVASCULAR SHUNT, X-RAY 299.09 256.3575820 VEIN X-RAY ARM/LEG 2,833.55 2,428.6375822 VEIN X-RAY ARMS/LEGS 2,833.55 2,428.6375825 VEIN X-RAY TRUNK 7,990.03 6,848.2575894 X-RAYS, TRANSCATH

THERAPY N175898 F/U ANGIOGRAPHY 299.09 256.3575940 X-RAY PLACE VEIN FILTER N175960 TRANSCATH IV STENT RS & I N175961 RETRIEVE BROKEN CATHETER N175962 REPAIR ARTERIAL BLOCKAGE12,095.18 10,542.3775964 REPAIR ARTERY BLOCKAGE, EACH N175978 REPAIR VENOUS BLOCKAGE 8,317.24 7,228.1775984 X-RAY CONTROL CATHETER

CHANGE N1

UCJF 11:3-29.6

75989 ABSCESS DRAIN UNDER X-RAY N176000 FLUOROSCOPE EXAM 329.21 282.1676001 FLUOROSCOPE EXAM,

EXTENSIVE N176010 X-RAY NOSE TO RECTUM 177.57 152.20 AS76080 X-RAY FISTULA 906.64 777.0876098 X-RAY EXAM, BREAST

SPECIMEN 1,605.07 1,375.7176100 X-RAY BODY SECTION 299.09 256.35 AS76102 COMPLEX BODY SECTION

X-RAYS 906.64 777.08 AS76120 CINE/VIDEO X-RAYS 329.21 282.16 AS76125 CINE/VIDEO X-RAYS, ADDED N176376 3D RENDER W/O POST PROCESS N176377 3D RENDERING W/POST PROCESS N176380 CAT SCAN F/U STUDY 447.45 383.51 X76506 ECHO EXAM HEAD 245.43 210.36 X76510 OPHTHALMIC US, B & QUANT

A 691.93 593.0576511 OPHTHALMIC US, QUANT A

ONLY 379.59 325.35 X76512 OPHTHALMIC US, B

W/NON-QUANT A 379.59 325.35 X76514 ECHO EXAM EYE, THICKNESS 72.62 62.24 AS76516 ECHO EXAM EYE 245.43 210.36 X76519 ECHO EXAM EYE 379.59 325.35 X76536 US EXAM HEAD & NECK 379.59 325.35 X76604 US EXAM, CHEST 245.43 210.3676645 US EXAM, BREAST(S) 245.43 210.36 X76700 US EXAM, ABDOM, COMPLETE 379.59 325.3576705 ECHO EXAM ABDOMEN 379.59 325.3576770 US EXAM ABDOM BACK

WALL, COMP 379.59 325.3576775 US EXAM ABDOM BACK WALL,

LIM 379.59 325.3576776 US EXAM K TRANSPLANT

W/DOPPLER 379.59 325.3576800 US EXAM, SPINAL CANAL 379.59 325.35 X76801 OBSTET US < 14 WKS, SINGLE

FETUS 379.59 325.35 X76805 OBSTET US >/= 14 WKS, SINGLE

FETUS 379.59 325.35 X76810 OBSTET US >/= 14 WKS, ADDED

FETUS 379.59 325.35 X76811 OBSTET US, DETAILED, SINGLE

FETUS 603.18 516.98 X76814 OBSTET US NUCHAL MEAS,

ADDED 245.43 210.36 X76815 OBSTET US, LIMITED,

FETUS(S) 245.43 210.36 X76816 OBSTET US, F/U, PER FETUS 245.43 210.36 X76817 TRANSVAGINAL US,

OBSTETRIC 245.43 210.36 X76818 FETAL BIOPHYS PROFILE

W/NST 379.59 325.35 X76819 FETAL BIOPHYS PROFILE W/O

NST 379.59 325.35 X76820 UMBILICAL ARTERY ECHO 245.43 210.36 X76821 MIDDLE CEREBRAL ARTERY

ECHO 245.43 210.36 X76826 ECHO EXAM FETAL HEART 1,586.46 1,359.76 X76827 ECHO EXAM FETAL HEART 245.43 210.36 X


76828 ECHO EXAM FETAL HEART 245.43 210.36 X76830 TRANSVAGINAL US, NON-OB 379.59 325.35 X76856 US EXAM, PELVIC, COMPLETE 379.59 325.3576857 US EXAM, PELVIC, LIMITED 245.43 210.3676870 US EXAM, SCROTUM 379.59 325.3576872 US, TRANSRECTAL 379.59 325.35 X76881 US XTR NON-VASC COMPLETE 379.59 325.35 X76882 US XTR NON-VASC LMTD 245.43 210.36 X76937 US GUIDE VASCULAR ACCESS N176942 ECHO GUIDE FOR BIOPSY N176998 US GUIDE, INTRAOP N177001 FLUOROGUIDE FOR VEIN

DEVICE N177002 NEEDLE LOCALIZATION BY

X-RAY N177003 FLUOROGUIDE FOR SPINE

INJECT N177011 CT SCAN FOR LOCALIZATION N177012 CT SCAN FOR NEEDLE BIOPSY N177032 GUIDANCE FOR NEEDLE,

BREAST N177072 X-RAYS FOR BONE AGE 177.57 152.20 AS77073 X-RAYS, BONE LENGTH

STUDIES 177.57 152.20 AS77074 X-RAYS, BONE SURVEY,

LIMITED 299.09 256.35 AS77075 X-RAYS, BONE SURVEY

COMPLETE 299.09 256.35 AS77076 X-RAYS, BONE SURVEY,

INFANT 299.09 256.35 AS77077 JOINT SURVEY, SINGLE VIEW 177.57 152.20 AS77080 DIAG BONE DENSITY, AXIAL 278.03 238.30 X77081 DIAG BONE

DENSITY/PERIPHERAL 126.60 108.51 X77082 DIAG BONE DENSITY,

VERTEBRAL FX 177.57 152.20 X77280 SET RADIATION THERAPY

FIELD 411.92 353.06 AS77285 SET RADIATION THERAPY

FIELD 1,070.85 917.82 AS77290 SET RADIATION THERAPY

FIELD 1,070.85 917.82 AS77295 SET RADIATION THERAPY

FIELD 3,653.77 3,131.64 AS77300 RADIATION THERAPY DOSE

PLAN 411.92 353.06 AS77305 TELETX ISODOSE PLAN

SIMPLE 411.92 353.06 AS77310 TELETX ISODOSE PLAN

INTERMED 411.92 353.06 AS77315 TELETX ISODOSE PLAN

COMPLEX 1,070.85 917.82 AS77321 SPECIAL TELETX PORT

PLAN 1,070.85 917.82 AS77331 SPECIAL RADIATION

DOSIMETRY 411.92 353.06 AS77332 RADIATION TREAT AID(S) 787.38 674.86 AS77333 RADIATION TREAT AID(S) 787.38 674.86 AS77334 RADIATION TREAT AID(S) 787.38 674.86 AS77336 RADIATION PHYSICS

CONSULT 411.92 353.06 AS77371 SRS, MULTISOURCE 30,204.85 25,888.56 X

UCJF 11:3-29.6

77403 RADIATION TX SING AREA6-10MEV 385.67 330.55 X

77413 RADIATION TX 3/MORE AREA 6-10MEV 632.95 542.50 X

77414 RADIATION TX 3/MORE AREA 11-19MEV 632.95 542.50 X

77417 RADIOLOGY PORT FILM(S) N177470 SPECIAL RADIATION TREAT 1,532.02 1,313.09 X78006 THYROID IMAGING

W/UPTAKE 865.36 741.70 X78007 THYROID IMAGE, MULT

UPTAKES 865.36 741.70 X78102 BONE MARROW IMAGING,

LTD 1,013.33 868.52 X78103 BONE MARROW IMAGING,

MULT 1,013.33 868.52 X78215 LIVER & SPLEEN IMAGING 1,045.30 895.93 X78220 LIVER FUNCTION STUDY 1,045.30 895.93 X78223 HEPATOBILIARY IMAGING 1,045.30 895.93 X78232 SALIVARY GLAND FUNCTION

EXAM 943.46 808.64 X78300 BONE IMAGING, LIMITED

AREA 964.75 826.89 X78305 BONE IMAGING, MULTIPLE

AREAS 964.75 826.89 X78306 BONE IMAGING, WHOLE BODY 964.75 826.89 X78315 BONE IMAGING, 3 PHASE 964.75 826.89 X78320 BONE IMAGING (3D) 964.75 826.89 X78445 VASCULAR FLOW IMAGING 789.90 677.02 X78451 HEART MUSCLE IMAGE SPECT,

SING 2,995.98 2,567.85 X78452 HEART MUSCLE IMAGE SPECT,

MULT 2,995.98 2,567.85 X78469 HEART INFARCT IMAGE (3D) 1,148.83 984.67 X78472 GATED HEART, PLANAR,

SING 1,148.83 984.67 X78481 HEART FIRST PASS, SING 1,148.83 984.67 X78494 HEART IMAGE, SPECT 1,148.83 984.67 X78580 LUNG PERFUSION IMAGING 776.02 665.13 X78584 LUNG V/Q IMAGE SINGLE

BREATH 1,261.32 1,081.07 X78585 LUNG V/Q IMAGING 1,261.32 1,081.07 X78588 PERFUSION LUNG IMAGE 1,261.32 1,081.07 X78594 VENT IMAGE, MULT PROJ,

GAS 776.02 665.13 X78596 LUNG DIFFERENTIAL

FUNCTION 1,261.32 1,081.07 X78607 BRAIN IMAGING (3D) 2,350.85 2,014.92 X78707 KID FLOW/FUNCT IMAGE W/O

DRUG 1,267.39 1,086.28 X78708 KID FLOW/FUNCT IMAGE

W/DRUG 1,267.39 1,086.28 X78709 KIDNEY IMG MORPHOLOGY

VASCULAR FLOW MULTIPLE 1,267.39 1,086.28 X78802 TUMOR IMAGING, WHOLE

BODY 1,872.66 1,605.05 X78803 TUMOR IMAGING (3D) 1,872.66 1,605.05 X78805 ABSCESS IMAGING, LTD

AREA 1,872.66 1,605.05 X78806 ABSCESS IMAGING, WHOLE

BODY 1,872.66 1,605.05 X78815 PET IMAGE W/CT,


SKULL-THIGH 4,108.15 3,521.09 X79101 NUCLEAR RX, IV ADMIN 883.62 757.35 X88141 CYTOPATH, C/V, INTERPRET N192070 FIT CONTACT LENS N192504 EAR MICROSCOPY EXAM N192547 SUPPLEMENTAL ELECTRICAL

TEST N192621 AUDITORY FUNCTION, + 15

MIN N193314 ECHO TRANSESOPHAGEAL N193320 DOPPLER ECHO EXAM,

HEART N193321 DOPPLER ECHO EXAM,

HEART N193325 DOPPLER COLOR FLOW,

ADDED N193463 DRUG ADMIN & HEMODYNMIC

MEAS N193464 EXERCISE W/HEMODYNAMIC

MEAS N193563 INJECT CONGENITAL CARD

CATH N193564 INJECT HEART CONGNTL

ART/GRAFT N193565 INJECT L VENTR/ATRIAL ANGIO N193566 INJECT R VENTR/ATRIAL ANGIO N193567 INJECT SUPRVLV AORTOGRAPHY N193568 INJECT PULM ART HEART CATH N193609 MAP TACHYCARDIA, ADDED N193623 STIMULATION, PACING HEART N193641 ELECTROPHYSIOLOGY EVAL N194760 MEASURE BLOOD OXYGEN LEVEL N194761 MEASURE BLOOD OXYGEN LEVEL N195873 GUIDE NERVE DESTROY, ELECT

STIM N195874 GUIDE NERVE DESTROY, NEEDLE

EMG N195920 INTRAOP NERVE TEST, ADDED N195955 EEG DURING SURG N195957 EEG DIGITAL ANALYSIS N196368 THER/DIAG CONCURRENT INF N199143 MOD SEDATION SAME PHYS, < 5

YRS N199144 MOD SEDATION BY SAME PHYS, 5

YRS + N199145 MOD SEDATION BY SAME PHYS,

ADDED N199148 MOD SEDATION DIFF PHYS < 5

YRS N199149 MOD SEDATION DIFF PHYS 5 YRS + N199150 MOD SEDATION DIFF PHYS, ADDED N199175 INDUCTION VOMITING N199292 CRITICAL CARE, ADDED 30 MIN N199354 PROLONGED SERVICE, OFFICE N199355 PROLONGED SERVICE, OFFICE N1 New Rule. R.2001 d.253, effective July 16, 2001; R.2002 d.59, effective March 4, 2002; R.2003 d.143,effective April 7, 2003; R.2004 d.481, effective December 20, 2004; R.2007 d.305, effective October1, 2007; R.2009 d.194, effective June 15, 2009; R.2009 d.209, effective July 6, 2009. Repeal and NewRule. R.2012 d.187, effective November 5, 2012 (operative January 4, 2013). Amended. R.2014 d.004,effective January 6, 2014.

MOTOR VEHICLE SELF-INSURANCE 11:3-30

SUBCHAPTER 30. MOTOR VEHICLE SELF-INSURANCESection11:3-30.1. Purpose.11:3-30.2. Scope.11:3-30.3. Definitions.11:3-30.4. General requirements.11:3-30.5. Certificate of self-insurance.11:3-30.6. Renewals.11:3-30.7. Surety bond requirement.11:3-30.8. Audits and examinations.11:3-30.9. Public entities.11:3-30.10. Cancellation of certificate of self-insurance.

11:3-30.1. Purpose. This subchapter sets forth the filing requirements for mo-tor vehicle self-insurers pursuant to N.J.S.A. 39:6-50.1, and 39:6-52 to 39:6-54.

11:3-30.2. Scope. The provisions of this subchapter apply to any person seek-ing to qualify as a motor vehicle self-insurer in New Jersey, except public entitiespursuant to N.J.S.A. 39:6-54.


“Applicant” means a person applying for a certificate of self-insurance whodoes not currently possess a valid certificate.

“Association” means the New Jersey Automobile Full Insurance UnderwritingAssociation created pursuant to N.J.S.A. 17:30E-1 et seq.

“Certificate” means certificate of self-insurance. “Certificate holder” means a person who currently possesses a valid certificate

of self-insurance. “Certified public accountant” means an independent certified public accoun-

tant or accounting firm in good standing with the American Institute of CertifiedPublic Accountants and in all states in which they are licensed to do business.

“Commissioner” means the Commissioner of Banking and Insurance. “Motorized bicycle” means a pedal bicycle having a helper motor character-

ized in that either the maximum piston displacement is less than 50 cubic centime-ters (cc.) or said motor is rated at no more than 1.5 brake horsepower and said bi-cycle is capable of a maximum speed of no more than 25 miles per hour on a flatsurface.

“Motor vehicle” means all vehicles propelled otherwise than by muscular pow-er, excepting such vehicles as run upon rails or tracks and motorized bicycles.

“Person” means a natural person, firm, co-partnership, association or corpora-tion.

“Public entity” means this State, any political subdivision of this State or anymunicipality therein.

Amended. R. 2001 d. 44, effective February 5, 2001.

11:3-30.4. General requirements. (a) Any person in whose name more than25 motor vehicles are registered or in whose name more than 25 motor vehicles


are leased may qualify as a self-insurer by obtaining a certificate of self-insuranceissued at the discretion of the Commissioner as provided in this subchapter.

(b) All filings for certificates of self-insurance, renewals, and any other filingsdeemed necessary by the Commissioner pursuant to this subchapter shall be sentto:

New Jersey Department of Banking and Insurance Financial Exams Division 20 West State Street PO Box 325 Trenton, New Jersey 08625-0325 Attention: Self-insurersAmended. R. 2001 d. 44, effective February 5, 2001.

11:3-30.5. Certificate of self-insurance. (a) Any person applying for a certif-icate of self-insurance shall submit the following to the Commissioner:

1. A completed application form on forms to be provided by the Commission-er;

2. The most current financial statement and financial statements for the twoyears immediately preceding the date of such current financial statement:

i. All financial statements shall be certified by a Certified Public Accountant:ii. If the applicant is a subsidiary of a corporation, the applicant shall also sub-

mit the financial statements of the subsidiary’s ultimate parent corporation;iii. If the applicant is a corporation, the Commissioner may also include the

name of any subsidiary corporation under the control of that corporation in thecertificate of self-insurance if the ultimate parent corporation guarantees that itwill discharge the subsidiary’s liability as evidenced by the filing of an indemnityagreement. If the ultimate parent corporation does not provide such a guarantee,the subsidiary shall make a separate application and receive independent qualifi-cation as a self-insurer. If the name of the subsidiary is included in the certificateof self-insurance of the ultimate parent corporation and ownership of the ultimateparent or subsidiary corporation changes, the ultimate parent or subsidiary shallreapply for a certificate of self-insurance within 30 days of the ownership change;and

3. A 51,000 filing fee.(b) After the submission of an application, the Commissioner may require an

additional fee to cover the costs of further examinations which may include a cred-it report to be prepared by a credit agency acceptable to the Commissioner.

(c) If an application is approved and the Commissioner receives notificationfrom the Association that the applicant has paid any applicable policy constant orRMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 et seq., respectively, theCommissioner shall issue a certificate of self-insurance to the applicant. (d) Allcertificates of self-insurance are valid from the date of issuance until June 30 im-mediately following and may be renewed thereafter, pursuant to N.J.A.C. 11:3-30.6, for a one year period beginning July 1 and ending June 30 the following year.

11:3-30.6. Renewals. (a) Any certificate holder applying for renewal shall sub-mit the following so that it is received by the Commissioner not later than June lof the year of the expiration date of such certificate:

1. An accident and claim activity report on forms to be provided by the Com-missioner;

2. A financial statement for the calendar year immediately preceding the expi-ration date of the certificate of self-insurance certified by a Certified Public Ac-countant;

INSURANCE ELIGIBILITY 11:3-34

3. An updated vehicle listing which shall include a listing of the vehicles sub-ject to any applicable policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1and 17:30E-1 et seq., respectively;

4. A $1,000 renewal fee; and5. Any other information that is substantially different from the information

provided in the original application form or from the information provided in thelast renewal period.

(b) After the submission of an application for renewal, the Commissioner mayrequire an additional fee to cover the costs of further examinations which may in-clude a credit report to be prepared by a credit agency acceptable to the Commis-sioner.

(c) If an application for renewal is approved and the Commissioner receivesnotification from the Association that the certificate holder has paid any applica-ble policy constant or RMEC pursuant to N.J.S.A. 17:29A-37.1 and 17:30E-1 etseq., respectively, the Commissioner shall issue a new certificate of self-insur-ance.

11:3-30.7. Surety bond requirement. (a) The Commissioner may require thefurnishing of a surety bond and for evidence of excess insurance.

(b) If the applicant or certificate holder is required to furnish a surety bond, thesurety bond shall be in an amount of not less than 5300.000, with an additional510,000 for each vehicle registered or leased in the applicant’s or certificate hold-er’s name over the minimum required to qualify as self-insurer under this sub-chapter. up to a maximum amount of 51,000,000.

11:3-30.8. Audits and examinations. (a) The Commissioner may make orcause to be made audits or examinations as may be necessary to determine theability of the applicant or the certificate holder to discharge its financial obliga-tions as a self-insurer.

(b) The applicant or certificate holder shall pay the reasonable expenses of theaudit or examination.

11:3-30.9. Public entities. (a) This subchapter does not apply to any motor ve-hicle owned by the United States, this State, any political subdivision of this Stateor any municipality therein; nor to any motor vehicle which is subject to the re-quirements of law requiring insurance or other security on certain types of vehi-cles, other than the requirements of N.J.S.A. 39:6A-1 et seq. or N.J.S.A. 39:6B-1et seq.

(b) Notwithstanding the provisions in (a) to the contrary, any public entity thatcurrently has or will establish in the future a self-insurance program or plans todiscontinue a self-insurance program currently in effect, shall notify the Commis-sioner in writing that it currently has, will establish or discontinue such a program.

11:3-30.10. Cancellation of certificate of self-insurance. After a hearing con-ducted pursuant to the Administrative Procedure Act, N.J.S.A. 52:148-1 et seq.,and the Uniform Administrative Procedure Rules, N.J.A.C. 1:1, upon not less thanfive days’ notice, the Commissioner may cancel a certificate of self-insuranceupon reasonable grounds including, but not limited to, failure to pay any judgmentwithin 30 days after such judgment has become final.

SUBCHAPTER 34. ELIGIBLE PERSONS QUALIFICATIONS AND AUTOMOBILE INSURANCE ELIGIBILITY POINTS SCHEDULE

Section11:3-34.1. Purpose.11:3-34.2. Scope.


11:3-34.3. Definitions.11:3-34.4. Eligible person qualifications.11:3-34.5. Automobile insurance eligibility points.APPENDIX Schedule of Automobile Insurance Eligibility Points

11:3-34.1. Purpose. The purpose of this subchapter is to set forth the require-ments for determining who can qualify as an “eligible person”, and to provide theschedule for “automobile insurance eligibility points” pursuant to N.J.S.A.17:33B-13 and 14.Amended. R. 1996 d. 58, effective February 5, 1996.

11:3-34.2. Scope. (a) The provisions of this subchapter apply to all insurerswhich write personal private passenger automobile insurance and all persons whoare required to procure automobile insurance coverage in this State.

(b) Except to the extent that the definition of eligible and ineligible persons atN.J.A.C. 11:3-34.4 is utilized for nonrenewals pursuant to N.J.A.C. 11:3-8, thissubchapter shall become inoperative on and after January 1, 2009, unless and untilthe Commissioner by Order makes the requirements of N.J.S.A. 17:33B-15a andb operative pursuant to the limited circumstances set forth in N.J.S.A. 17:33B-15d(3), upon a determination made after a hearing conducted pursuant to the Ad-ministrative Procedure Act, N.J.S.A. 52:14B-1 et seq., and Uniform Administra-tive Procedure Rules, N.J.A.C. 1:1, that a competitive market does not existamong insurers authorized to write private passenger automobile insurance in thisState, or the Commissioner certifies by Order that the Personal Automobile Insur-ance Plan is insuring 10 percent or more of the aggregate number of private pas-senger automobile non-fleet exposures being written in this State. A notice of theissuance by the Commissioner of such an Order shall be published in the New Jer-sey Register.Amended. R. 2008 d. 380, effective December 15, 2008 (operative January 1, 2009); R.2011 d.242,effective September 19, 2011.

11:3-34.3. Definitions. The following words and terms, as used in this sub-chapter, shall have the following meanings, unless the context clearly indicatesotherwise.

“At-fault accident” is any accident involving a driver insured under the policy:1. Where a driver is proportionately responsible based on the number of vehi-

cles involved. A driver is proportionately responsible if 50 percent responsible foran accident involving two drivers; if 33 1/3 percent responsible for an accident in-volving three drivers, etc.; and

2. Which results in a total payment by the insurer of at least $500.00 for an ac-cident occurring before June 9, 2003; or at least $1,000 for an accident occurringon or after June 9, 2003. The $1,000 dollar amount may be adjusted in $100.00 or$250.00 increments by Order of the Commissioner not more frequently than every36 months. The Order shall reflect the cumulative increases or decreases in thecomponents of the Consumer Price Index, All Urban Consumers (CPI-U) for theNortheast Region, and the adjusted amount shall apply to automobile accidentsoccurring at least 120 days after the effective date of the adjustment. The adjust-ment shall be reflected in this definition through a notice of administrative changepublished in the New Jersey Register.

An at-fault accident shall not include the following:1. Involvement in an accident in which the motor vehicle owned or operated by

the insured or other driver insured under the policy was lawfully parked;

INSURANCE ELIGIBILITY 11:3-34.4

2. Involvement in an accident in which the motor vehicle was struck by a hitand run driver, if such accident was reported to the proper authorities within 24hours;

3. Involvement in an accident in connection with which neither the named in-sured nor any other driver insured under the policy was convicted of a movingtraffic violation and the owner or operator of another vehicle involved in such ac-cident was so convicted;

4. For physical damage losses other than collision; 5. For an accident in which the motor vehicle was struck in the rear by another

vehicle and a driver insured under the policy has not been convicted of a movingviolation in connection with the accident; or

6. For an accident occurring as a result of operation of any motor vehicle in re-sponse to an emergency if the operator at the time of the accident was respondingto the call to duty as a paid or volunteer member of any police or fire department,first aid squad or any law enforcement agency.

“Automobile” means an automobile as defined in N.J.S.A. 39:6A-2. “Automobile insurance” means insurance for an automobile including any or

all of the following coverages: bodily injury liability, and property damage liabil-ity, comprehensive and collision coverages, uninsured and underinsured motoristcoverage, personal injury protection coverage, additional personal injury protec-tion coverage and any other automobile insurance required by law.

“Automobile insurance eligibility points” means points calculated under theschedule promulgated by the Commissioner pursuant to this subchapter.

“Commissioner” means the Commissioner of Banking and Insurance of theState of New Jersey.


“State” means the State of New Jersey.Amended. R. 2001 d. 44, effective February 5, 2001; R. 2003 d.469, effective December 1, 2003.

11:3-34.4. Eligible person qualifications. (a) An “eligible person” is a personwho is an owner or registrant of an automobile registered and principally garagedin this State or who is a resident and holds a valid New Jersey driver's license tooperate an automobile, but does not include any person:

1. Who, during the three-year period immediately preceding application for, orrenewal of, an automobile insurance policy has been convicted pursuant toN.J.S.A. 39:4-50 or N.J.S.A. 39:4-50.4a or for an offense of a substantially similarnature committed in another jurisdiction;

2. Who has been convicted of a crime of the first, second or third degree result-ing from the use of a motor vehicle; or has been convicted of theft of a motor ve-hicle;

3. Whose driver's license to operate an automobile is under suspension or revo-cation;

4. Who has been convicted, within the five-year period immediately precedingapplication for or renewal of a policy of automobile insurance, of fraud or intentto defraud involving an insurance claim or an application for insurance;

5. Who has been successfully denied, with the immediately preceding fiveyears' payment by an insurer of a claim in excess of $1,000 under an automobileinsurance policy, if there was evidence of fraud or intent to defraud involving theautomobile insurance claim or application. For the purpose of this section:

i. If the claim has been subject to litigation between the insurer and the insuredin which the insurer defended against payment of the claim in whole or in part on


grounds of fraud, it shall be conclusively presumed that the claim was successfullydenied if judgment was entered for the insurer in the litigation; and conclusivelypresumed that the claim was not successfully denied if judgment was entered forthe insured;

ii. If the claim has not been subject to litigation between the insurer and the in-sured, but the insurer denied the claim without payment by reason of fraud, it shallbe presumed that the claim was successfully denied. This presumption may beovercome in an administrative proceeding pursuant to N.J.A.C. 11:3-33;

iii. If the incident was not reported to the New Jersey Office of Insurance FraudProsecutor pursuant to N.J.S.A. 17:33A-9 it shall be presumed that there was noevidence of fraud or intent to defraud;

6. Whose automobile insurance policy has been cancelled for nonpayment ofpremiums or financed premium with a lapse of coverage of at least 30 days, withinthe immediately preceding two-year period, unless the premium due on a policyfor which application has been made is paid in full before issuance or renewal ofthe policy. For the purpose of this section, “paid in full” shall not include anytransaction in which a lender obtains authority from an insured to cancel the policyand receive a refund from the insurer in the event the insured defaults on a loanused to pay the premium;

7. Who fails to obtain or maintain membership or qualification for membershipin a club, group, or organization, if membership is a uniform requirement of theinsurer as a condition of providing insurance, and if the dues or charges, if any, orother conditions for membership or qualifications for membership are applied uni-formly throughout this State, are not expressed as a percentage of the insurancepremium, and do not vary with respect to the rating classification of the memberor potential member except for the purpose of offering a membership fee to familyunits. Membership fees, if applicable, may vary in accordance with the amount ortype of coverage if the purchase of additional coverage, either as to type oramount, is not a condition for reduction of dues or fees;

8. Whose driving record for the three year period immediately preceding theapplication for or renewal of a policy of automobile insurance has an accumula-tion of seven or more automobile insurance eligibility points as determined inN.J.A.C. 11:3-34.5;

9. Who, during the three-year period immediately preceding application for, orrenewal of, an automobile insurance policy, has knowingly provided materiallyfalse or misleading information in connection with an application for insurance,renewal of insurance or claim for benefits under an insurance policy;

10. Who is a named insured or who is insured under the same policy as a personwhose driver's license is suspended or revoked and either:

i. The suspended or revoked driver has been convicted of a violation ofN.J.S.A. 39:6B-2 within the previous three years; or

ii. With the exception of a conviction for violating N.J.S.A. 39:3-40i, other ev-idence exists indicating that the suspended or revoked driver has been operating avehicle during the period of suspension or revocation;or

11. Who, for the purposes of nonrenewals under N.J.A.C. 11:3-8 only, does notsatisfy the insurer’s acceptance criteria as set forth in N.J.A.C. 11:3-8.12.

(b) An “eligible person” includes a person who is an owner or registrant of anautomobile registered in this State or who holds a valid New Jersey driver's licenseto operate an automobile and is domiciled in this State who is temporarily residingout-of-State and whose car may be principally garaged in another state while the


person either is a full time student or is in the military service and is stationed out-of-State.Amended: R. 1992, d. 481; R. 1996 d.246, effective June 3, 1996; R. 2001 d. 44, effective February5, 2001; R. 2003 d. 469, effective December 1, 2003; R.2007 d.373, effective December 3, 2007;R.2011 d.242, effective September 19, 2011.

11:3-34.5. Automobile insurance eligibility points. (a) Automobile insur-ance eligibility points shall be accumulated as a result of convictions, suspensions,revocations and determinations of responsibility for civil infractions in accor-dance with the schedule set forth in the Appendix to this subchapter herein incor-porated by reference.

(b) Automobile eligibility points are cumulative and accrue for all violationsand occurrences set forth on Schedules 1 and 2. Automobile insurance eligibilitypoints shall be deemed to accrue as follows:

1. Points for an at-fault accident shall accrue on the date that total payment bythe insurer equals or exceeds $1,000 or such other amount as may be prescribedby Order of the Commissioner issued pursuant to N.J.S.A. 17:33B-14. Theamount under such Order shall be reflected in this paragraph through a notice ofadministrative change published in the New Jersey Register. An insurer may, at itsoption, use the date of the accident or date of first payment provided, however, thatthe insurer shall not underwrite or rate any policy based on the accident until totalpayment by the insurer equals or exceeds $1,00; and further provided that the in-surer shall use the optional date consistently in all cases.

2. Points for conviction of motor vehicle violations and other events that are setforth on an abstract of drivers license records available from the New Jersey Mo-tor Vehicle Commission, or a comparable agency of another state, shall accruewhen the event is recorded in the agency's records as evidenced by an abstract.

3. When an eligible person is involved in an at-fault accident and has not ac-crued any eligibility points during the three-year period immediately precedingthe date of that accident, no eligibility points for a two- or three-point violation, asset forth in Schedule 2 of the Appendix, shall accrue along with the points as-sessed in accordance with Schedule 1 for the at-fault accident, when the violationarises out of the same incident which results in 1the assessment of points for theat-fault accident. However, violations that arise out of the same incident may beconsidered by insurers for purposes of tier placement pursuant to N.J.A.C. 11:3-19A.

4. Points for each full year of court-imposed driver's license suspension withinthe preceding three years and points for each full year within the immediately pre-ceding three years that a person has not held a driver's license shall accrue on thedate of application for insurance. However, in accordance with Schedule 1, eligi-bility points assessed for failure to hold a drivers’ license in the previous threeyears are not cumulative to points assessed for the suspension of a drivers license.

(c) Automobile insurance eligibility points set forth on Schedule 2 of the Ap-pendix represent motor vehicle points established by the New Jersey Motor Vehi-cle Commission by rule, N.J.A.C. 13:19-10.1, which is hereby incorporated byreference. Any additions, deletions or modifications to N.J.A.C. 13:19-10.1 shalllikewise be incorporated as of the effective date of amendment. Schedule 2 is in-cluded in the Appendix for convenience.

(d) The reference in Appendix Schedule 1 and Schedule 2 to provisions of theNew Jersey Statutes Annotated is meant for convenience to assist in the quickidentification of the nature of the event. If the event takes place in a state or prov-


ince other than New Jersey, Schedule 1 and 2 should be consulted for identifica-tion of the specific misconduct committed and the assessment of the appropriatenumber of insurance eligibility points to be assessed.

(e) In addition to the motor vehicle violation and insurance eligibility pointsspecifically enumerated on Schedule 2 of the Appendix pertaining to the New Jer-sey Turnpike, Atlantic City Expressway, and the Garden State Parkway, for anyother motor vehicle violations that occur on the New Jersey Turnpike (N.J.A.C.19:9), the Atlantic City Expressway (N.J.A.C. 19:2-2.1), the Garden State Park-way (N.J.A.C. 19:8) or for any other moving violation at any location, Schedules1 and 2 shall be consulted for identification of the specific misconduct committedand the determination of the appropriate number of insurance eligibility points tobe assessed.Amended. R.2001 d.44, effective February 5, 2001; R.2002 d.330, effective October 7, 2002; R.2003d.469, effective December 1, 2003; R.2006 d.243, effective July 3, 2006; R.2007 d.373, effective De-cember 3, 2007.

APPENDIXSchedule of Automobile Insurance Eligibility Points

Schedule 1N.J.S.A. DMVSection EventNumber Event Identifier(s)If applicableDescription If applicable Points39:4-50 Operating a motor vehicle under the

influence of alcohol or drugs 0450; 3261 939:4-50.4 Refusal to submit to a chemical test 4504 92C:11-2 Vehicular homicide C115 939:3-40 Operating a motor vehicle while drivinga through privilege is suspended 0340 9h and j39:6B-2 Operating a motor vehicle without liability insurance06B2 939:6A-15 Misrepresentation of insurance coverage 6A15 9

Each at fault accident 5*For each full year of a court imposed driver’s license suspensionwithin the preceding 3 years 3*For each full year within the immediately preceding 3 years thata person has not held a driver’s license 1Involved in a fatal accident EFTL 4

NFTL 239:3-37 Obtaining a driver’s license or registration

through deception 0337; 0312; 05D5;1312; MSNJ;MSOS 5

39:3-38 Make or use counterfeit plate or platesother than issued 0338 5

39:3-38.1 Make, alter or counterfeit driver’s licenseor registration 3381 5Failure to verify insurance involved in anautomobile accident FVIA 2

* Points for failure to hold a driver’s license in the previous three years are notcumulative to points for driver’s license suspension.


Schedule 2N.J.S.A.SectionNumber Offense Points27:23-29 Moving against traffic-New Jersey Turnpike, Garden

State Parkway, and Atlantic City Expressway 227:23-29 Improper passing-New Jersey Turnpike, Garden State

Parkway, and Atlantic City Expressway 427:23-29 Unlawful use of median strip-New Jersey Turnpike,

Garden State Parkway, and Atlantic City Expressway 239:3-20 Operating constructor vehicle in excess of 30 mph 339:4-14.3 Operating motorized bicycle on a restricted highway 239:4-14.3d More than one person on a motorized bike 239:4-35 Failure to yield to pedestrian in crosswalk 239:4-36 Failure to yield to pedestrian in crosswalk; passing a

vehicle yielding to pedestrian in crosswalk 239:4-41 Driving through a safety zone 239:4-52 &39:5C-1 Racing on highway 539:4-55 Improper action or omission on grades and curves 239:4-57 Failure to observe direction of officer 239:4-66 Failure to stop vehicle before crossing sidewalk 239:4-66.1 Failure to yield to pedestrians or vehicles while entering

or leaving highway 239:4-71 Operating a motor vehicle on a sidewalk 239:4-80 Failure to obey direction of officer 239:4-81 Failure to observe traffic signals 239:4-82 Failure to keep right 239:4-82.1 Improper operating of vehicle on divided highway or

divider 239:4-83 Failure to keep right at intersection 239:4-84 Failure to pass to right of vehicle proceeding in opposite

direction 539:4-85 Improper passing on right or off roadway 439:4-85.1 Wrong way on a one-way street 239:4-86 Improper passing in no passing zone 439:4-87 Failure to yield to overtaking vehicle 239:4-88 Failure to observe traffic lanes 239:4-89 Tailgating 539:4-90 Failure to yield at intersection 239:4-90.1 Failure to use proper entrances to limited access high-

ways 239:4-91 &39:4-92 Failure to yield to emergency vehicles 239:4-96 Reckless driving 539:4-97 Careless driving 239:4-97a Destruction of agricultural or recreational property 239:4-97.1 Slow speed blocking traffic 239:4-98 &39:4-99 Exceeding maximum speed 1-14 mph over limit 2

Exceeding maximum speed 15-29 mph over limit 4Exceeding maximum speed 30 mph or more over limit 5


39:4-105 Failure to stop for traffic light 239:4-115 Improper turn at traffic light 339:4-119 Failure to stop at flashing red signal 239:4-122 Failure to stop for police whistle 239:4-123 Improper right or left turn 339:4-124 Improper turn from approved turning course 339:4-125 Improper “U” turn 339:4-126 Failure to give proper signal 239:4-127 Improper backing or turning in street 239:4-127.1 Improper crossing of railroad grade crossing 239:4-127.2 Improper crossing of bridge 239:4-128 Improper crossing of railroad grade crossing by certain

vehicles 239:4-128.1 Improper passing of school bus 539:4-128.4 Improper passing of a frozen -dessert truck 439:4-129 Leaving the scene of an accident

No personal injury 2Personal injury 8

39:4-144 Failure to observe “stop” or “yield” signs 239:5D-4 Moving violation out-of-state 2Amended. R. 1996 d. 58, effective February 5, 1996; R.2007 d.373, effective December 3, 2007.

SUBCHAPTER 37. ORDER OF BENEFIT DETERMINATION BETWEEN AUTOMOBILE PERSONAL INJURY PROTECTION AND HEALTH

INSURANCESection11:3-37.1. Purpose and scope.11:3-37.2. Definitions.11:3-37.3. Health benefits providers.11:3-37.4. Application of the PIP-as-secondary coverage option.11:3-37.5. Health benefit plan standards and the PIP premium reduction.11:3-37.6. Order of benefits determination when PIP is secondary coverage. 11:3-37.7. Determination of PIP medical benefits payable when PIP is

secondary coverage.11:3-37.8. Health benefits plan coverage ineligibility.11:3-37.9. Determination of benefits when PIP is primary coverage.11:3-37.10. Explanation of benefits.11:3-37.11. Dispute as to primacy of coverage.11:3-37.12. Eligibility under two or more automobile policies.11:3-37.13. Penalties.11:3-37.14. Severability.

11:3-37.1. Purpose and scope. The purpose of this subchapter is to establishguidelines for the order of benefit determination between a plan of health insur-ance and personal injury protection provided through an automobile policy pursu-ant to N.J.S.A. 39:6A-4, when a named insured elects to have his or her personalinjury protection become secondary coverage for the provision of benefits formedical expenses incurred due to injuries sustained in an automobile accident.This subchapter also sets forth the requirements for the order of benefit determi-nation between a plan of health insurance and personal injury protection providedpursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, when personal injury protection is pri-mary coverage. The provisions of this subchapter shall apply to all automobile

BENEFIT DETERMINATION: PIP - HEALTH 11:3-37.2

policies, as that term is defined at N.J.S.A. 39:6A-2a, issued to New Jersey resi-dents, or renewed on or after January 1. 1991, and to all health benefits planswhich have been or will be delivered or issued for delivery in this State.

Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).


“Actual benefits” means those benefits determined to be payable for allowableexpenses.

“Allowable expense” means a medically necessary, reasonable and customaryitem of expense covered by an insured's health benefits plan(s) or PIP plan as aneligible expense, at least in part. When a plan provides benefits in the form of ser-vices, the reasonable monetary value of each such service shall be considered asboth an allowable expense and a paid benefit.

“Benefits” means the provision of the following in consideration of payment ofpremiums or fees on a prepaid or postpaid basis:

1. Services, including supplies; 2. Payment of expenses incurred; 3. A combination of 1 and 2 above; or 4. An indemnification. “Eligible expense” means: 1. In the case of health benefits plans, that portion of the medical expenses in-

curred for treatment of an injury which is covered under the terms and conditionsof the plan, without application of the deductible(s) and copayment(s), if any.

2. In the case of PIP plans, that portion of the medical expenses incurred fortreatment of an injury which, without considering any deductible and copayment,shall not exceed:

i. The percent or dollar amounts specified on the medical fee schedules, or theactual billed expense, whichever is less; or

ii. The reasonable amount, as determined by the automobile insurer, consider-ing the medical fee schedules for similar services or equipment in the regionwhere the service or equipment was provided, when an incurred medical expenseis not included on the medical fee schedules.

“Health benefits provider” means any person, whether subject to the regulationof the New Jersey Department of Banking and Insurance, Department of Healthand Senior Services, or both, or not otherwise subject to such regulation, who con-tracts to provide health services, provide reimbursement for the cost of health ser-vices in whole or in part, or to provide for indemnity in the event health servicesare used, in return for a prepaid or postpaid premium or fee or other consideration,including, but not limited to:

1. Insurers, as defined at N.J.S.A. 17B:17-2; 2. Hospital service corporations, as defined at N.J.S.A. 17:48-1; 3. Medical service corporations, as defined at N.J.S.A. 17:48A-1; 4. Health service corporations, as defined at N.J.S.A. 17:48E-1; 5. Health maintenance organizations, as defined at N.J.S.A. 26:2J-2; 6. Dental service corporations, as defined at N.J.S.A. 17:48C-2; 7. Dental plan organizations, as defined at N.J.S.A. 17:48D-2; 8. Medicare; 9. Medicaid; 10. State Employees Health Benefits Plan; 11. CHAMPUS; 12. Self-insured programs; and


13. An entity organized under the laws of any other state or jurisdiction whichdelivers certificates to residents of New Jersey evidencing coverage under a con-tract issued and delivered in a state or jurisdiction other than New Jersey.

“Hospital expenses,” when used by the automobile insurance PIP plan, meansthose expenses defined at N.J.S.A. 39:6A-2f.

“Injury” means bodily injury sustained by an insured as a result of an accidentwhile occupying, entering into, alighting from or using an automobile, or as a pe-destrian, caused by an automobile or by an object propelled by or from an auto-mobile.

“Insured” means a person eligible for coverage, at least in part, for medical ex-penses incurred for treatment of injuries, under an automobile policy PIP medicalexpense provision, and who meets the definition of a named insured or familymember.

1. Named insured means the person or persons identified as the insured in theautomobile policy and if an individual, that person's spouse, if the spouse is a res-ident of the same household, except that if the spouse ceases to be a resident of thehousehold of the named insured, coverage for that spouse shall continue until theexpiration of full term of any policy period in effect at the time of the cessation ofresidency.

2. Family member means any relative of the named insured or the named in-sured's spouse who:

i. Is related to the named insured or named insured's spouse by blood, marriage,adoption or guardianship;

ii. Resides in the household of the named insured or spouse of the named in-sured; and

iii. Is not a named insured under another automobile policy. “Medical expenses” is as defined in N.J.A.C. 11:3-4.2. “Medical fee schedule” means that list of services, procedures and supplies to

which have been assigned a maximum fee or percentage of a fee payable by anautomobile insurer for expenses incurred as a result of the rendering to an insuredany of those specific services, procedures or supplies for injuries, which list is setforth at N.J.A.C. 11:3-29.

“Out-of-State automobile insurance coverage” or “OSAIC” means any cover-age for medical expenses under an automobile insurance policy other than PIP, asPIP is defined herein, including automobile insurance policies issued in anotherstate or jurisdiction.

“PIP” means personal injury protection coverage provided as part of an auto-mobile insurance policy pursuant to N.J.S.A. 39:6A-4 or 39:6A-3.1, issued inNew Jersey, specifically those provisions for medical expenses coverage.

“Plan” means any policy, contract, certificate, booklet, evidence of enrollment,program, or other such term which evidences the existence of a relationship be-tween a health benefits provider or PIP carrier and an insured with respect to theprovisions of hospital, medical, surgical, dental and/or other health care relatedbenefits, at least in part.

“Primary coverage” means coverage by any plan which determines its actualbenefits payable on allowable expenses incurred by an insured for treatment of in-juries without taking into consideration the existence of any coverage for whichthe insured may be eligible provided secondary in accordance with this subchap-ter. There may be more than one plan providing the insured primary coverage.


“Secondary coverage” means coverage by any plan which determines its actualbenefits payable on all allowable expenses incurred by an insured for treatment ofinjuries after all plans providing primary coverage have considered expenses in-curred and paid actual benefits.

Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999); R. 2001 d.44, effective February 5, 2001.

11:3-37.3. Health benefits providers. (a) Nothing in this subchapter shall beconstrued as requiring any health benefits provider to offer, provide, or continuecoverage to or for any individual or group, except as may be set forth by other lawsof this State, or of the Federal government.

(b) Nothing in this subchapter shall be construed as requiring any health bene-fits provider to provide coverage for any treatment or service not otherwise cov-ered under the terms of the applicable health benefits plan.

(c) No health benefits contract or policy delivered or issued for delivery in thisState, or renewed, continued or converted on or after January 1. 1991, shall con-tain any provision, rider, waiver of endorsement or other instrument which re-stricts, limits or excludes coverage, directly or indirectly, of services or expensesotherwise eligible under the policy or contract on the grounds that such expensesor services would be covered under an automobile policy PIP provision for whichthe insured would be eligible had the named insured on the automobile policy notselected the PIP-as-secondary coverage option.

(d) No health benefits contract or policy delivered or issued for delivery in thisState, or renewed, continued or converted on or after January 1. 1991, shall con-tain any provision, rider, waiver or endorsement, or other instrument which re-stricts, limits or excludes coverage, directly or indirectly, of services or expensesotherwise eligible under the policy or contract on the grounds that:

1. Such expenses arise from an automobile-related injury;2. Such expenses are covered or paid by PIP; or3. Such expenses are covered or paid by OSAIC except for reductions in ben-

efits when the health benefits contract provides secondary coverage as defined inand permitted by this rule.

(e) A health benefits contract or policy may provide that it is always primary toOSAIC, or may provide that it will determine its benefits as if it were secondaryto any OSAIC. If the health benefits contract or policy provides that it will deter-mine its benefits as if it were secondary to OSAIC and the OSAIC either containsa provision that it is always excess or secondary, or refuses to cooperate in deter-mining the amount of benefits payable by the health benefits plan as secondarycoverage provider, the health benefits plan shall provide primary coverage.

11:3-37.4. Application of the PIP-as-secondary coverage option. (a) Whena named insured elects the PIP option, whereby the named insured intends thatmedical expenses incurred for treatment of an injury are to be covered by a healthbenefits provider or providers, as evidenced on the Coverage Selection Form, thenthe medical expense provisions of the PIP coverage shall be considered to be sec-ondary coverage for the purposes of the order of benefit determination, and allhealth benefits plans of an insured subject to the PIP option elected shall be con-sidered to be primary coverage.

(b) The election by the named insured to make PIP medical expense provisionssecondary coverage shall apply to only the named insured and family members ofthe named insured who reside in the named insured’s household and are not namedinsureds under other automobile policies.

(c) The election by the named insured to make PIP medical expense provisionssecondary coverage shall continue in force as to subsequent renewal or replace-


ment policies until the automobile policy insurer or its authorized representativereceives a properly executed written request revoking the selection of this option.

(d) In the event that an insured is ineligible for health plan coverage of medicalexpenses, or is eligible for coverage under a dental expense or dental service planonly when an injury occurs, despite the selection of the PIP-as-secondary cover-age option by the named insured, benefits shall be provided to the insured throughPIP coverage in accordance with N.J.A.C. 11:3-37.8.

11:3-37.5. Health benefit plan standards and the PIP premium reduction.(a) An automobile insurer may eliminate the premium reduction on the base rateapplicable to the amount of medical expense benefit chosen in conjunction withthe PIP-as-secondary coverage option election if the automobile insurer complieswith (b) below, and verifies that the coverage specified by the named insured:

1. Excludes the provision of benefits for treatment of injuries of an eligible in-sured when expenses incurred in relation to treatment of those injuRes are eligibleexpenses under an automobile policy’s PIP provisions; or

2. Provides that it is always secondary, or otherwise will not be a primary pro-vider of benefits;

3. Provides benefits only for dental expenses or dental services; or4. Provides benefits only for prescription drugs.(b) An automobile carrier shall notify a named insured if the automobile insurer

determines that the health benefits plan(s) specified by the named insured containexclusionary or restrictive coverage provisions as set forth in (a) above, or if theautomobile insurer determines that one or more of the insureds covered under theautomobile insurance policy is not provided coverage by at least one of the healthbenefit plan(s) specified by the named insured, and, therefore, the named insured’spremium reduction for PIP medical expense benefits will be eliminated.

1. The notice shall be in writing and shall specify the reasons why the automo-bile insurer believes the named insured’s health plan coverage is not in compliancewith this subchapter.

2. The automobile insurer may include in the notice a demand for payment ofthe premium reduction difference with an explanation that failure to pay the indi-cated premium reduction difference may result in early cancellation of the auto-mobile policy in accordance with (c) below.

3. The notice shall be sent no later than 30 days prior to the date of cancellationas calculated in accordance with (c) below. A notice which is sent 30 days prior tothe date of cancellation shall either contain a statement that it is a notice of can-cellation, or be attached to a notice of cancellation, setting forth the effective dateof cancellation.

(c) The effective date of the cancellation of a policy for nonpayment of premi-um shall not be earlier than 10 days prior to the last full day of which premiumreceived by the company, prior to the date of preparation of the cancellation no-tice, would pay for coverage on a pro rata basis. In calculating the effective dateof the cancellation, the premium applicable to the coverage provided by the policyand the premium received by the company at or prior to the time the cancellationnotice was prepared shall be the premium used for the calculation and determina-tion of such effective date.

1. No cancellation in accordance with (c) above shall be effective unless priorthereto, the automobile insurer shall have notified the named insured that the pre-mium reduction difference had to be paid to avoid cancellation, as specified in(b)2 above.

2. No cancellation notice shall be mailed prior to 30 days in advance of its ef-fective date.

(d) If the insured provides payment of the full premium amount and subse-quently provides proof that coverage is not restricted in the manner set forth in ac-


cordance with (a) above, or that all insureds under the automobile policy were pro-vided coverage by a health benefits plan at the time notification of noncoveragewas sent, and that such coverage continues and is not restricted in the manner setforth in accordance with (a) above, the automobile insurer shall refund the moniespaid in excess of the full reduction, or shall credit any excess paid on the reducedpremium to the extent any premium payment is still unpaid on the policy.

11:3-37.6. Order of benefits determination when PIP is secondary cover-age. (a) When the named insured of an automobile policy has selected the PIP-as-secondary coverage option, all health benefits plans for which the insured is eligi-ble shall provide coverage for the allowable expenses incurred by the insured dueto an automobile-related injury prior to any benefits for medical expenses beingpaid by a PIP plan.

(b) If the insured is eligible for coverage under more than one group health ben-efits plan, the group health benefits plans shall coordinate benefits with one anoth-er in accordance with the rules set forth for such plans at N.J.A.C. 11:4-28.

(c) The PIP plan shall provide benefits for allowable expenses remaining un-covered after all health benefits plans for which the insured is eligible have paidbenefits towards those allowable expenses.

(d) The PIP plan shall continue to be liable for expenses related to the same oc-currence as the expenses are incurred, whether or not the health benefits plan(s) inforce at the time of the accident terminate(s) coverage, or benefits provided underthe health benefits plan(s) are exhausted subsequent to the occurrence of the acci-dent, up to the maximum PIP benefits available to the insured under the terms ofthe automobile policy.

(e) Total benefits paid by an insured’s health benefits and PIP plans shall notexceed the amount of total allowable expenses.

11:3-37.7. Determination of PIP medical benefits payable when PIP is sec-ondary coverage. (a) In calculating the actual benefits to be paid by the automo-bile insurer when the PIP-as-secondary coverage option has been selected, the au-tomobile insurer shall first determine the amount of eligible expenses whichwould have been paid after application of the deductible and copayment limita-tions had the PIP-as-secondary coverage option not been selected.

1. In the event the remaining allowable expenses are less than the benefits cal-culated pursuant to (a) above, the automobile insurer shall pay actual benefitsequal to the remaining allowable expenses, without reducing the remaining allow-able expenses by its deductible or copayments.

2. In the event the remaining allowable expenses are greater than the benefitscalculated pursuant to (a) above, the actual benefits paid by the automobile insurershall be the benefits calculated pursuant to (a) above, without reducing the remain-ing allowable expenses by its deductible or copayments.

(b) In paying actual benefits, the automobile insurer shall not:1. Reduce its actual benefits payable on account of any deductibles or copay-

ments of the health benefits plans which have provided benefits ahead of the PIPplan due to the selection of the PIP-as-secondary coverage option: or

2. Reduce its actual benefits payable for any allowable expense remaining un-covered which item of expense otherwise would not be an eligible expense underthe PIP plan, except as set forth by (c) below.

(c) In determining remaining uncovered allowable expenses, the automobileinsurer shall not consider any amount for items of expense which exceed the dollaror percent amounts recognized by the medical fee schedules promulgated pursu-ant to N.J.S.A. 39:6A-4.6.


(d) The total amount of benefits to be provided through the PIP medical ex-pense provisions for each insured per accident or occurrence shall not exceed themaximum PIP benefits as provided for by the terms of the policy.

11:3-37.8. Health benefits plan coverage ineligibility. (a) When, subsequentto the selection of the PIP-as-secondary coverage option by a named insured, it isdetermined that an insured did not have health coverage in effect at the time of aninjury, or had health coverage in effect at the time of any injury which is such thatthe PIP-as-secondary coverage option selection could have been invalidated bythe automobile insurer and elimination of the premium reduction amount effectedin accordance with N.J.A.C. 11:3-37.5(a), but was not, then the insured shall beprovided benefits for incurred medical expenses through the PIP medical expenseprovision.

1. Benefits payable shall be subject to a per accident deductible equalling thetotal of $750.00 plus the PIP deductible selected by the named insured of the pol-icy.

2. Benefits payable shall be subject to a 20 percent copayment for amounts lessthan $5,000 after the deductible has been satisfied.

3. Determination of the amount of benefits payable shall be made in accordancewith medical fee schedules promulgated pursuant to N.J.S.A. 39:6A-4.6 and setforth at N.J.A.C. 11:3-29, or on a reasonable basis, as determined by the automo-bile insurer, considering the medical fee schedules for similar services or equip-ment in the region where the service or equipment was provided, when an item ofexpense is not included on the medical fee schedules.

4. Total benefits paid for each insured eligible for benefits in any one accidentshall not exceed the maximum PIP benefits provided for by the terms of the policy.

(b) All items of medical expense incurred by the insured for treatment of an in-jury shall be eligible expense to the extent the treatment or procedure from whichthe expenses arose is recognized on the medical fee schedules, or are reasonablemedical expenses in accordance with N.J.S.A. 39:6A-4.

(c) The automobile insurer shall be entitled to recover, for the contract periodin which the automobile-related injury occurred, the difference between the re-duced premiums paid on the policy and the amount of premium which would havebeen due on the policy had the named insured not selected the PIP-as-secondarycoverage option, and no premium reduction shall be provided on that policy forthe PIP-as-secondary coverage option during the remainder of that current con-tract period.

11:3-37.9. Determination of benefits when PIP is primary coverage. (a)When no election has been made by a named insured to make his or her healthbenefits plan(s) primary coverage provider(s), so that the PIP plan will provideprimary coverage for medical expenses incurred for treatment of injuries, the PIPplan shall provide benefits to the insured without consideration of any benefits forwhich the insured may be eligible under any health benefits plan.

(b) Actual benefits paid by the PIP plan shall be medical expenses, subject tothe policy limits and supplication of any deductible and copayment provided forby the terms of the automobile policy, approved by the Commissioner pursuant toN.J.S.A. 39:6A-4 or 39:6A-3.1, and any rules promulgated thereunder.

(c) Actual benefits payable by a health benefits plan, when the PIP plan is pro-viding primary coverage for medical expenses incurred for treatment of injuries,shall be the lesser of the remaining uncovered allowable expenses or the actualbenefits that would have been payable had the health benefits plan been providingcoverage primary to the PIP plan.

1. Actual benefits payable may be reduced by the deductible(s) and copaymentrequirements applicable by the terms of the health benefits plan, and shall not ex-


ceed the amount of actual benefits that would have been payable had the healthbenefits plan been providing coverage primary to the PIP plan.

2. Allowable expenses remaining uncovered, which the health benefits plan(s)shall consider when the PIP plan is providing primary coverage, include:

i. Any PIP deductible(s);ii. Any PIP copayment amounts;iii. Any expenses which exceed the medical expense coverage limits of the PIP

plan per person per accident, as set forth by the terms of the automobile policy;and

iv. Any expenses not covered by the PIP plan when such expense was deter-mined to be in excess of the reasonable charge for an item of expense not listed onthe medical fee schedules, but for which the automobile insurer determined a rea-sonable charge based on the medical fee schedule for a similar item of expense inthe region where the service or equipment was provided.

(d) When a health benefits plan provides hospital expense or service benefitsonly, or medical expense or service benefits only, and is not otherwise a part of abasic health benefits package, all allowable expenses remaining uncovered shallbe considered by that health benefits plan for the provision of benefits, without re-gard as to whether the expenses are hospital-related or medical-related expenses.Actual benefits paid by that health benefits plan for the allowable expenses re-maining uncovered shall not exceed the total actual benefits which would havebeen payable had the health benefits plan been providing coverage primary to thePIP plan.

(e) When there is one health benefits plan providing insureds hospital expenseor service benefits and another health benefits plan providing insureds medical ex-pense or service benefits as two separate parts of one basic health benefits planpackage, the hospital benefits plan and the medical benefits plan shall both con-sider all allowable expenses remaining uncovered and shall apportion such allow-able expenses between the two plans on a pro-rata basis without regard as towhether the expenses are hospital-related or medical-related expenses. Actualbenefits paid by each plan of the health benefits plan package shall not exceed thetotal actual benefits which would have been payable by each plan had the healthbenefits plan package been providing primary coverage.

(f) No insured shall be liable to a health care provider for any fees for servicesor supplies which exceed the dollar or percentage amounts recognized for thoseservices or supplies on the medical fee schedules.

(g) No health benefits plan shall seek repayment from or withhold payment toan insured for amounts paid to the insured in consideration of charges which werein excess of the amounts set forth in the medical fee schedules.

(h) If there is more than one group health benefits plan providing secondarycoverage to an insured, these plans may coordinate their benefits with one anotherin accordance with N.J.A.C. 11:4-28.

Amended. R. 1998 d. 591, effective December 21, 1998 (operative March 22, 1999).

11:3-37.10. Explanation of benefits. (a) Automobile insurers shall developand utilize an explanation of benefits form to be provided with the payment ofbenefits for expenses incurred for treatment of injuries which clearly identifiesand explains the following:

1. Each procedure for which a claim has been made;2. Eligible expense related to each procedure with an indication of whether the

eligible expense is based on the medical fee schedules or is the reasonable chargeas determined by the automobile insurer;

3. Actual benefits paid;4. Any deductible or copayment applied;


5. A concise explanation why any item of expense is considered an ineligibleexpense, when this occurs; and

6. A statement to insureds that no health care provider may demand or requestany payment from any person in excess of those permitted by N.J.A.C. 11:3-29,and that no person is liable to any health care provider for any amount of moneywhich results from the charging of fees in excess of those permitted by N.J.A.C.11:3-29, pursuant to N.J.S.A. 39:6A-4.6.Amended by R. 1994 d. 564, effective November 21, 1994 (operative January 1, 1995).

11:3-37.11. Dispute as to primacy of coverage. (a) If, subsequent to the se-lection of the PIP-as-secondary coverage option by the named insured, injuries aresustained by an insured eligible for health benefits plan coverage, but a dispute ex-ists between the health benefits provider and the automobile insurer, then thehealth benefits provider shall provide benefit as if it were the primary coverageprovider and no PIP benefits were available to the insured. In no event shall theprovision of benefits be unreasonably delayed by either a health benefits provideror an automobile insurer.

(b) If the health benefits provider asserts that it is not subject to N.J.A.C. 11:3-37.3, and thus, will not act as the primary coverage provider then the automobileinsurer shall assume the role of primary coverage provider, and provide its bene-fits in accordance with N.J.A.C. 11:3-37.8. The automobile insurer shall be enti-tled to recover premium reductions in accordance with N.J.A.C. 11:3-37.8(c).

11:3-37.12. Eligibility under two or more automobile policies. (a) If an in-sured is eligible for coverage of medical expenses under more than one automo-bile policy, the determination as to which automobile policy will assume coverageresponsibility for that insured shall be as follows:

1. A named insured shall receive benefits for medical expenses under the termsof the automobile policy on which he or she, or his or her spouse, is identified asthe named insured.

2. A family member who is a child of a named insured or the named insured’sspouse shall receive benefits for medical expenses under the automobile policy ofthe named insured, subject to the following:

i. If the child is a child of more than one named insured or of more than onespouse of a named insured, the child shall receive benefits under the terms of theautomobile policy of the named insured who has legal custody of that child orwhose spouse has legal custody of that child.

ii. If the child is a child of more than one named insured or of more than onenamed insured’s spouse, and legal custody of that child has either never beenawarded, or has been awarded jointly, then the child shall receive benefits underthe terms of the automobile policy of the named insured whose birthday occursearliest in the calendar year.

iii. If the child is a named insured or the spouse of a named insured, (a)1 aboveshall apply.

3. If neither (a)1 nor (a)2 above apply to an adult or child family member, thenthat family member shall receive benefits for medical expenses under the terms ofthe automobile policy of the named insured whose birthday occurs earliest in thecalendar year.

4. If an automobile policy identifies more than one person as a named insuredon the automobile policy, the birthday of the named insured whose birthday occursearliest in the calendar year shall be considered the determinant birthday on thatautomobile policy.

(b) An insured shall not receive benefits for medical expenses under more thanone automobile policy.


(c) If an automobile policy PIP plan provides benefits for medical expenses foran insured who is eligible for medical expense benefits under more than one auto-mobile policy PIP plan, the automobile insurer of the paying PIP plan may seekequitable pro rata contributions from the other automobile policy PIP plan(s) forthe benefits actually paid by the paying PIP plan.

11:3-37.13. Penalties. Each automobile policy or health benefits plan subjectto the terms of this subchapter which fails to comply with the terms herein shallbe in violation of this subchapter. Failure to comply with the terms of this sub-chapter may result in the assessment of any and all penalties in accordance withthe laws of this State.

11:3-37.14. Severability. If any provision of this subchapter or applicationthereof to any person or circumstance is held invalid, the remainder of the sub-chapter and the application of such provision to other persons or circumstancesshall not be affected thereby.