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Revised 03-11-08 Page 1
Physician Fee Schedule Key
COLUMN HEADING
COLUMN DESCRIPTION
HCPCS CPT–4 or HCPCS Procedure Code Note Special billing information applies to the code.
A Professional and Technical components are each reimbursed at 50% of the state maximum. To bill quantities: Number of tests performed on a single date of service should be billed using the days/units field. When the quantity exceeds 5, the claim must be submitted on paper and must be accompanied by supporting documentation.
B Professional and technical components are each reimbursed at 50% of the state maximum, rounded to the nearest cent. To bill quantities: For bilateral, submit the procedure code, use modifier 50, and show quantity “1” in days/units field. For multiples that are not bilateral, claims must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field, and attaching documentation of all tests performed.
C Reimbursement for professional and technical components split at a rate other than 50%. To bill quantities: Claims for multiple quantities must be submitted on paper. Submit the procedure code on one service section, and in the next service section submit the unlisted procedure code for any quantity beyond the first, listing total # and name of additional tests in the description field and attaching documentation of all test performed.
D Code is billable by encounter rate clinic only. E Vaccine is supplied through the Vaccines For Children
(VFC) program. The department reimburses for the administration of the vaccine only.
F Vaccine is not available the VFC; the department reimburses for the vaccine when it is medically necessary.
G Vaccine is supplied for children but not adults through the VFC. The department reimburses for the administration (as shown in the Unit Price column) for children, and for adults (as shown in the State Max column) when medically necessary.
Revised 03-11-08 Page 2
H CLIA “A” rage for the full test. I CLIA “W” rate for the waived test J Covered only for blood lead draws as a Healthy Kids
service for client ages 0-20 years and must be billed with the U1 modifier as documentation that the service meets this description.
K Prior approval required for surgeon and assistant surgeon. Anesthesia services for these codes must be billed using the anesthesia five-digit procedure code.
L Number of eyes tested should be billed using the days/units field; maximum quantity is 2.
M Age restricted to 9-26 years. Vaccine is supplied through the VFC Program for ages 9-20 years. The department reimburses VFC-enrolled providers for administration as shown in the unit price column. The department reimburses for adults, ages 21-26 years, and ages 9-26 years for non-VFC providers as shown in the State Max column. Additional information is provided at http://www.hfs.illinois.gov/physicians/ .
Prog Cov Program Coverage
02-Title XIX coverage only (limited Transitional Assistance coverage) 04-Medicaid covered services 09–Qualified Medicare Beneficiary (QMB) coverage only.
Eff Date Effective Date
Effective date of codes added on or after 01/01/07.
HP Hand Price Indicator
If “Y”, special pricing methodology is applied. Anesthesia: Claims may be submitted electronically or on paper following the billing guidelines posted on our website at http://www.hfs.illinois.gov/assets/101006_physician.pdf Medical/surgical procedure: Claims must be submitted on paper. The name of the procedure and total number of times performed must be submitted in the description field and the procedure note must be attached. To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field. Drugs: May be submitted electronically or on paper. The claim must contain the name of the drug, strength of the drug, and the amount given in the description/note field and must be billed according to NDC billing guidelines available on our website at http://www.hfs.illinois.gov/assets/ncd_112107.pdf To bill quantities: The number listed in the days/units field must be “1” and the actual quantity must be included in the description/note field.
Revised 03-11-08 Page 3
APL Ambulatory Procedure Listing
“Y” indicates the procedure is on the APL listing. APL rates are listed in a separate fee schedule on our website at http://www.hfs.illinois.gov/reimbursement/apl.html . Hospital claims billed fee-for-service will be rejected.
NDC Ind NDC Indicator
If “Y”, must be billed according to NDC billing guidelines available on our website at http://www.hfs.illinois.gov/assets/ncd_112107.pdf
Surg Ind Surgery Indicator
If “M”, reimbursement for procedure includes 30-day postoperative care.
M1(26) Modifier 1 (26)
Rate paid for the professional component of the code.
M2 (TC) Modifier 2 (TC)
Rate paid for the technical component of the code.
Unit Price Price for each unit when multiple quantities are billable. Max Qty Maximum
Quantity The maximum quantity payable for the code.
State Max State Maximum
The maximum allowable reimbursement (reflects combined professional and technical components where applicable).
Surg Add-on
Surgical Add-on
The additional amount paid beyond the state maximum when the procedure is performed in the practitioner’s office.
MODIFIERS RECOGNIZED IN PROCESSING ILLINOIS HEALTHCARE AND FAMILY SERVICE CLAIMS
MODIFIER DESCRIPTION HOW PAYMENT IS AFFECTED
26 Professional componentPays professional component only (*see physician fee schedule, Notes A, B, C)
50 Bilateral procedure
Bill procedure code one time with modifier and quantity "1" to indicate bilaterals performed (*see physician fee schedule, Note B)
51 Multiple proceduresApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)
52 Reduced services Goes to hand pricing, requires attachment of additional information
53 Discontinued procedure Not payable; bill only for services completed59 Distinct procedural service Applies to Medicare crossovers only62 Two surgeons Each surgeon is paid at 50% state maximum73 Discontinued outpatient procedure prior to anesthesia administration Not payable; bill only for services completed74 Discontinued outpatient procedure after anesthesia administration Not payable; bill only for services completed
76 Repeat procedure by same physicianApplies only to billing multiple NDCs (**see Informational Notice to Physicians dated 12-21-07)
80 Assistant surgeon Payment is based on minutes billed81 Minimum assistant surgeon Payment is based on minutes billed82 Assistant surgeon when qualified resident surgeon not available Payment is based on minutes billed90 Reference (outside) laboratory Not payable for APL or inpatient procedures91 Repeat clinical diagnostic laboratory test Applies to Medicare crossovers onlyAH Clinical psychologist Billable only by FQHC and RHCAJ Clinical social worker Billable only by FQHC and RHC
ASPhysician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Payment is based on minutes billed
AT Acute Treatment Sterilization permit not required when procedure performed for acute reason and not for sterilization purposes
E1 Upper left eyelidProcesses separately from same CPT with different eyelid modifier
E2 Lower left eyelidProcesses separately from same CPT with different eyelid modifier
E3 Upper right eyelidProcesses separately from same CPT with different eyelid modifier
E4 Lower right eyelidProcesses separately from same CPT with different eyelid modifier
EPService provided as part of medicaid early periodic screening diagnosis and treatment (EPSDT) program Service is processed as a Healthy Kids service
F1 Left hand, second digit Processes separately from same CPT with different digit modifier
F2 Left hand, third digit Processes separately from same CPT with different digit modifier
F3 Left hand, fourth digit Processes separately from same CPT with different digit modifier
F4 Left hand, fifth digit Processes separately from same CPT with different digit modifier
F5 Right hand, thumb Processes separately from same CPT with different digit modifier
F6 Right hand, second digit Processes separately from same CPT with different digit modifier
F7 Right hand, third digit Processes separately from same CPT with different digit modifier
F8 Right hand, fourth digit Processes separately from same CPT with different digit modifier
F9 Right hand, fifth digit Processes separately from same CPT with different digit modifier
FA Left hand, thumb Processes separately from same CPT with different digit modifierFP Service provided as part of family planning program Service is processed as a family planning serviceGN Outpatient speech therapy See Therapists Provider Notice dated 061605GO Outpatient occupational therapy See Therapists Provider Notice dated 061605GP Outpatient physical therapy See Therapists Provider Notice dated 061605GZ Item or service expected to be denied as not reasonable and necessary Not payable HD Pregnant/parenting women's program Service is processed as a postpartum depression screening
HE Mental health program
Inpatient/outpatient psychiatric consultation or inpatient psychiatric subsequent care rate (**see Physician Provider Notice dated 102903)
HO Masters degree level; added 060108 effective 10/22/07 Billable only by FQHC and RHC
LC Left circumflex coronary arteryProcesses separately from same CPT with different coronary artery modifier
LD Left anterior descending coronary arteryProcesses separately from same CPT with different coronary artery modifier
LT Left side Processes separately from same CPT with RT modifierNU New equipment Processes as PurchaseP1 Normal, healthy patient Anesthesia converts to modifying units "0"P2 Patient with mild systemic disease Anesthesia converts to modifying units "1"P3 Patient with severe systemic disease Anesthesia converts to modifying units "2"P4 Patient with severe systemic disease that is a constant threat to life Anesthesia converts to modifying units "3"P5 Moribund patient not expected to survive without the operation Anesthesia converts to modifying units "4"
P6Declared brain-dead patient whose organs are being removed for donor purposes Anesthesia converts to modifying units "0"
QL Patient pronounced dead after ambulance called Not payableQM Ambulance service provided under arrangement by a provider of services Not payable
QW CLIA waived testProcesses at the waived CLIA rate (*see physician fee schedule, Note I)
RC Right coronary arteryProcesses separately from same CPT with different coronary artery modifier
RR Rental Processes as rentalRT Right side Processes separately from same CPT with LT modifier
SL State supplied vaccineProcesses HPV vaccine to Obstetricians not enrolled with VFC (**see Physician Provider Notice dated 061507)
T1 Left foot, second digit Processes separately from same CPT with different digit modifier
T2 Left foot, third digit Processes separately from same CPT with different digit modifier
T3 Left foot, fourth digit Processes separately from same CPT with different digit modifier
T4 Left foot, fifth digit Processes separately from same CPT with different digit modifier
T5 Right foot, great toe Processes separately from same CPT with different digit modifier
T6 Right foot, second digit Processes separately from same CPT with different digit modifier
T7 Right foot, third digit Processes separately from same CPT with different digit modifier
T8 Right foot, fourth digit Processes separately from same CPT with different digit modifier
T9 Right foot, fifth digit Processes separately from same CPT with different digit modifier
TA Left foot, great toe Processes separately from same CPT with different digit modifier
TC Technical componentPays technical component only (*see physician fee schedule, Notes A, B, C)
TT Individualized service provided to more than one patient in same settingProcesses as coincident visit Long Term care(**see Physician Provider Notice dated 102903)
U1 Local modifier-Blood lead drawBlood specimen drawn for lead analysis as part of Healthy Kids program (***see Chapter HK-200 Section 202.1)
U2 Local modifier-Home Health nursing assessment visitProcesses as assessment visit only (***see Home Health Handbook Section R-203.1)
U4 Local modifier-Pregnancy resulting from rape Claim requires abortion payment application HFS form 2390
U6 Local modifier-Service provided within 60 days of hospital dischargeProcesses as therapy visit within 60 days of hospital discharge(***see Therapy Providers Handbook Section J-211)
U7 Local modifier-Pregnancy resulting from incest Claim requires abortion payment application HFS form 2390U8 Local modifier-Pregnancy threatening the mother's life Claim requires abortion payment application HFS form 2390
* Physician Fee Schedule is posted on our website at http://www.hfs.illinois.gov/feeschedule/**Provider Informational Notices are posted on our website at http://www.hfs.illinois.gov/releases/***Provider Handbooks are posted on our website at http://www.hfs.illinois.gov/handbooks/
2008 HCPCS Codes HealthCare and Family Services Updated 6/1/2008
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00102 04 MY
00103 04 MY
00104 02 N 44.40N
00120 04 MY
00124 04 IY
00126 04 IY
00140 04 MY
00142 04 MY
00144 04 MY
00145 04 MY
00147 04 MY
00148 04 IY
00160 04 MY
00162 04 MY
00164 04 IY
00170 04 IY
00172 04 MY
00174 04 MY
Wednesday, June 18, 2008 Page 1 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00176 04 MY
0017T 04 MYY
00190 04 MY
00192 04 MY
0019T 04 IYY
00210 04 MY
00212 04 MY
00214 04 MY
00215 04 MY
00216 04 MY
00218 04 MY
00220 04 MY
00222 04 MY
0026T B 04 NY
0027T 04 M 444.30YN
0028T B 04 N 49.05 49.05 98.10YN
0029T 04 NYY
00300 04 MY
0030T 04 NY
0031T 04 I 37.40N
00320 04 MY
Wednesday, June 18, 2008 Page 2 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00322 04 MY
00326 04 MY
00350 04 MY
00352 04 MY
00400 04 IY
00402 04 MY
00404 04 MY
00406 04 MY
00410 04 I 112.40N
0041T 04 NY
0042T B 04 N 141.22 141.22 282.45YN
0043T 04 NY
00450 04 MY
00452 04 MY
00454 04 IY
00470 04 MY
00472 04 MY
00474 04 MY
0048T 04 MY
00500 04 MY
0051T 04 MY
Wednesday, June 18, 2008 Page 3 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00520 04 MY
00522 04 IY
00524 04 MY
00528 04 MY
00529 04 NY
0052T 04 MY
00530 04 MY
00532 04 IY
00534 04 MY
00537 04 IY
00539 04 MY
0053T 04 MY
00540 04 MY
00541 04 MY
00542 04 MY
00546 04 MY
00548 04 MY
00550 04 MY
00560 04 MY
00561 04 MY
00562 04 MY
Wednesday, June 18, 2008 Page 4 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00563 04 MY
00566 04 MY
00580 04 MY
00600 04 MY
00604 04 MY
0060T 04 NYY
0061T 04 MYY
00620 04 MY
00622 04 MY
00625 04 1/1/2007 MY
00626 04 1/1/2007 NY
0062T 04 M 509.95YN
00630 04 MY
00632 04 MY
00634 04 MY
00635 04 IY
0063T 04 MYY
00640 04 MY
00670 04 MY
00700 04 MY
00702 04 IY
Wednesday, June 18, 2008 Page 5 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00730 04 MY
0073T 04 N 364.51YN
00740 04 MY
00750 04 MY
00752 04 MY
00754 04 MY
00756 04 MY
0075T 04 I 83.00YN
0076T 04 I 83.00YN
00770 04 MY
0077T 04 M 449.50YN
0078T 04 M 1,148.60N
00790 04 MY
00792 04 MY
00794 04 MY
00796 04 MY
00797 04 MY
0079T 04 MY
00800 04 MY
00802 04 MY
0080T 04 NY
Wednesday, June 18, 2008 Page 6 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00810 04 MY
0081T 04 MYY
00820 04 MY
00830 04 MY
00832 04 MY
00834 04 MY
00836 04 MY
00840 04 MY
00842 04 IY
00844 04 MY
00846 04 MY
00848 04 MY
0084T 04 I 118.20YN
00851 04 MY
00860 04 MY
00862 04 MY
00864 04 MY
00865 04 MY
00866 04 MY
00868 04 MY
00870 04 MY
Wednesday, June 18, 2008 Page 7 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00872 04 MY
00873 04 MY
00880 04 MY
00882 04 MY
00902 04 MY
00904 04 MY
00906 04 MY
00908 04 MY
0090T 04 MYY
00910 04 MY
00912 04 MY
00914 04 MY
00916 04 MY
00918 04 MY
00920 04 MY
00921 04 MY
00922 04 MY
00924 04 MY
00926 04 MY
00928 04 MY
00930 04 MY
Wednesday, June 18, 2008 Page 8 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
00932 04 MY
00934 04 MY
00936 04 MY
00938 04 MY
0093T 04 MYY
00940 04 IY
00942 04 MY
00944 04 MY
00948 04 IY
00950 04 IY
00952 04 IY
0095T 04 MYY
0096T 04 MYY
0101T 04 MYY
0102T 04 MYY
01112 04 IY
01120 04 MY
01130 04 IY
01140 04 MY
01150 04 MY
01160 04 MY
Wednesday, June 18, 2008 Page 9 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01170 04 MY
01173 04 MY
01180 04 MY
01190 04 MY
01200 04 MY
01202 04 MY
01210 04 MY
01212 04 MY
01214 04 MY
01215 04 IY
01220 04 MY
01230 04 MY
01232 04 MY
01234 04 MY
0123T 04 MYY
0124T 04 MYY
01250 04 MY
01260 04 MY
01270 04 MY
01272 04 MY
01274 04 MY
Wednesday, June 18, 2008 Page 10 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01320 04 MY
01340 04 MY
01360 04 MY
0137T 04 IYY
01380 04 MY
01382 04 MY
01390 04 MY
01392 04 MY
01400 04 MY
01402 04 MY
01404 04 MY
01420 04 IY
01430 04 MY
01432 04 MY
0143T 04 NY
01440 04 MY
01442 04 MY
01444 04 MY
01462 04 MY
01464 04 MY
01470 04 MY
Wednesday, June 18, 2008 Page 11 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01472 04 MY
01474 04 MY
0147T C 04 N 21.37 88.48 109.85N
01480 04 MY
01482 04 MY
01484 04 MY
01486 04 MY
01490 04 IY
01500 04 MY
01502 04 MY
01520 04 MY
01522 04 MY
01610 04 MY
01620 04 MY
01622 04 MY
01630 04 MY
01632 04 MY
01634 04 MY
01636 04 MY
01638 04 MY
01650 04 MY
Wednesday, June 18, 2008 Page 12 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01652 04 MY
01654 04 MY
01656 04 MY
01670 04 MY
01680 04 IY
01682 04 IY
01710 04 MY
01712 04 MY
01714 04 MY
01716 04 MY
01730 04 MY
01732 04 MY
01740 04 MY
01742 04 MY
01744 04 MY
01756 04 MY
01758 04 MY
01760 04 MY
01770 04 MY
01772 04 MY
01780 04 MY
Wednesday, June 18, 2008 Page 13 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01782 04 MY
01810 04 MY
01820 04 MY
01829 04 M 356.10N
01830 04 MY
01832 04 MY
01840 04 MY
01842 04 MY
01844 04 MY
01850 04 MY
01852 04 MY
01860 04 MY
01916 04 IY
01920 04 MY
01922 04 IY
01924 04 MY
01925 04 MY
01926 04 IY
01930 04 MY
01931 04 MY
01932 04 MY
Wednesday, June 18, 2008 Page 14 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
01933 04 MY
01935 04 1/1/2008 MY
01936 04 1/1/2008 MY
01951 04 IY
01952 04 IY
01953 04 IY
01958 04 MY
01960 09 MY
01961 04 MY
01962 04 MY
01963 04 MY
01965 04 MY
01967 04 MY
01968 04 MY
01969 04 MY
01991 04 IY
01992 04 IY
01996 04 I 14.25N
01999 04 MY
0500F 04 B 44.10N
0502F 04 B 44.10N
Wednesday, June 18, 2008 Page 15 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
0503F 04 B 50.15N
10021 04 I 49.80YN
10022 04 I 56.70YN
10040 04 I 35.20YN
10060 04 I 36.00YN
10061 04 I 66.50YN
10080 04 I 70.65.YN
10081 04 I 131.80YN
10120 04 I 39.05YN
10121 04 I 77.60YN
10140 04 I 41.50YN
10160 04 I 35.95YN
10180 04 I 130.55YN
11000 04 I 77.70YN
11001 04 I 20.85YN
11004 04 M 154.43YN
11005 04 M 154.43YN
11006 04 M 154.43YN
11008 04 M 154.43YN
11010 04 I 127.60YN
11011 04 I 157.90YN
Wednesday, June 18, 2008 Page 16 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
11012 04 I 218.40YN
11040 04 I 34.10YN
11041 04 I 51.90YN
11042 04 I 70.55YN
11043 04 M 170.55YN
11044 04 M 219.35YN
11055 04 I 22.15YN
11056 04 IYY
11057 04 IYY
11100 04 I 50.20 17.00YN
11101 04 I 22.15YN
11200 04 I 35.65 17.00YN
11201 04 I 15.20YN
11300 04 I 21.10YN
11301 04 I 29.20YN
11302 04 I 37.50YN
11303 04 I 45.70YN
11305 04 I 22.25YN
11306 04 I 31.25YN
11307 04 I 37.50YN
11308 04 I 45.70YN
Wednesday, June 18, 2008 Page 17 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
11310 04 I 32.40YN
11311 04 I 40.55YN
11312 04 I 48.80YN
11313 04 I 57.10YN
11400 04 I 39.05 17.00YN
11401 04 I 50.20 17.00YN
11402 04 I 64.80 17.00YN
11403 04 I 77.90 17.00YN
11404 04 I 92.40 17.00YN
11406 04 I 108.00 17.00YN
11420 04 I 38.30 17.00YN
11421 04 I 50.85 17.00YN
11422 04 I 64.80 17.00YN
11423 04 I 77.90 17.00YN
11424 04 I 92.40 17.00YN
11426 04 I 127.48 17.00YN
11440 04 I 54.15 17.00YN
11441 04 I 75.30 17.00YN
11442 04 I 96.40 17.00YN
11443 04 I 111.00 17.00YN
11444 04 I 117.55 17.00YN
Wednesday, June 18, 2008 Page 18 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
11446 04 I 146.37 17.00YN
11450 04 M 215.40 34.00YN
11451 04 M 244.10 34.00YN
11462 04 M 215.40 34.00YN
11463 04 M 232.20YN
11470 04 M 291.30YN
11471 04 M 297.00N
11600 04 I 54.15 17.00N
11601 04 I 75.30 17.00N
11602 04 I 96.40 17.00N
11603 04 I 117.55 17.00YN
11604 04 I 138.75 17.00YN
11606 04 M 185.52 17.00YN
11620 04 I 54.15 17.00N
11621 04 I 75.30 17.00N
11622 04 I 96.40 17.00YN
11623 04 I 117.55 17.00YN
11624 04 I 138.75 17.00YN
11626 04 M 185.52 17.00YN
11640 04 I 107.00 17.00YN
11641 04 I 149.25 17.00YN
Wednesday, June 18, 2008 Page 19 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
11642 04 M 192.95 17.00YN
11643 04 M 235.20 17.00YN
11644 04 M 278.80 17.00YN
11646 04 M 294.77 17.00YN
11719 04 I 15.90N
11720 04 I 15.90N
11721 04 I 18.10N
11730 04 I 34.30 17.00N
11732 04 I 14.45N
11740 04 I 36.00N
11750 04 I 61.85 34.00N
11752 04 M 167.40 34.00YN
11755 04 I 38.80N
11760 04 I 60.80 17.00YN
11762 04 I 87.75 17.00YN
11765 04 I 38.40N
11770 04 M 215.40 34.00YN
11771 04 M 291.30YN
11772 04 M 341.25YN
11900 04 I 21.10 17.00N
11901 04 IY
Wednesday, June 18, 2008 Page 20 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
11920 09 MY
11921 04 I 63.57N
11922 04 I 16.13N
11950 09 MY
11951 09 MY
11952 09 MY
11954 09 MY
11960 04 M 350.05YN
11970 04 M 475.70YN
11971 04 I 135.00YN
11975 04 I 108.00YN
11976 04 I 108.00YN
11977 04 I 108.00YN
11980 04 M 108.00YN
11981 04 I 72.30YN
11982 04 I 87.00YN
11983 04 I 108.00YN
12001 04 I 53.10 17.00YN
12002 04 I 58.40 17.00YN
12004 04 I 69.70 17.00YN
12005 04 I 100.40 17.00YN
Wednesday, June 18, 2008 Page 21 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
12006 04 I 145.80 17.00YN
12007 04 MYY
12011 04 I 56.40 17.00YN
12013 04 I 64.00 17.00YN
12014 04 I 112.90 17.00YN
12015 04 I 125.50 17.00YN
12016 04 I 200.75 17.00YN
12017 04 M 259.20 17.00YN
12018 04 M 272.63YN
12020 04 I 139.30 17.00YN
12021 04 I 88.70 17.00YN
12031 04 I 64.70 17.00YN
12032 04 I 81.60 17.00YN
12034 04 I 106.65 17.00YN
12035 04 I 144.30 17.00YN
12036 04 M 194.50 17.00YN
12037 04 M 261.12YN
12041 04 I 72.10 17.00YN
12042 04 I 94.10 17.00YN
12044 04 I 119.20 17.00YN
12045 04 I 156.85 17.00YN
Wednesday, June 18, 2008 Page 22 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
12046 04 M 207.10 17.00YN
12047 04 M 270.45YN
12051 04 I 74.70 17.00YN
12052 04 I 94.10 17.00YN
12053 04 I 112.90 17.00YN
12054 04 I 131.80 17.00YN
12055 04 I 169.40 17.00YN
12056 04 M 219.60 17.00YN
12057 04 M 305.68YN
13100 04 I 110.04YN
13101 04 I 127.57YN
13102 04 IY
13120 04 I 114.98YN
13121 04 I 138.55YN
13122 04 IY
13131 04 I 127.85YN
13132 04 I 178.18YN
13133 04 IYY
13150 04 I 150.67YN
13151 04 I 160.83YN
13152 04 I 205.55YN
Wednesday, June 18, 2008 Page 23 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
13153 04 IY
13160 04 M 295.88YN
14000 04 M 224.25YN
14001 04 M 291.69YN
14020 04 M 244.40YN
14021 04 M 328.07YN
14040 04 M 277.07YN
14041 04 M 375.10YN
14060 04 M 299.29YN
14061 04 M 405.20YN
14300 04 M 389.59YN
14350 04 M 270.20YN
15002 04 1/1/2007 MYY
15003 04 1/1/2007 MYY
15004 04 1/1/2007 MYY
15005 04 1/1/2007 MYY
15040 04 M 71.01YN
15050 04 M 131.80YN
15100 04 M 263.55YN
15101 04 MYY
15110 04 M 71.01YN
Wednesday, June 18, 2008 Page 24 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15111 04 M 71.00YN
15115 04 M 382.21YN
15116 04 M 84.01YN
15120 04 M 307.90YN
15121 04 MYY
15130 04 M 297.44YN
15131 04 M 50.11YN
15135 04 M 414.03YN
15136 04 M 50.41YN
15150 04 M 330.87YN
15151 04 M 66.75YN
15152 04 M 83.39YN
15155 04 M 354.66YN
15156 04 M 92.48YN
15157 04 M 100.77YN
15170 04 M 167.63YN
15171 04 M 50.29YN
15175 04 M 249.07YN
15176 04 M 79.42YN
15200 04 M 318.60YN
15201 04 MYY
Wednesday, June 18, 2008 Page 25 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15220 04 M 307.90YN
15221 04 MYY
15240 04 M 308.96YN
15241 04 MYY
15260 04 M 332.72YN
15261 04 MYY
15300 04 M 141.69YN
15301 04 M 32.90YN
15320 04 M 165.11YN
15321 04 M 49.16YN
15330 04 M 141.50YN
15331 04 M 32.90YN
15335 04 M 158.29YN
15336 04 M 47.01YN
15340 04 M 143.60YN
15341 04 M 16.19YN
15360 04 M 153.62YN
15361 04 M 37.29YN
15365 04 M 162.56YN
15366 04 M 46.85YN
15400 04 M 165.30YN
Wednesday, June 18, 2008 Page 26 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15401 04 MYY
15420 04 M 183.07YN
15421 04 M 49.73YN
15430 04 M 267.39YN
15431 04 MYY
15570 04 M 298.24YN
15572 04 M 292.34YN
15574 04 M 466.61YN
15576 04 M 296.30YN
15600 04 M 259.81YN
15610 04 M 97.47YN
15620 04 M 158.26YN
15630 04 M 310.61YN
15650 04 M 168.27YN
15731 04 1/1/2007 M 168.27YN
15732 04 M 536.60YN
15734 04 M 569.25YN
15736 04 M 512.70YN
15738 04 M 520.25YN
15740 04 M 321.69YN
15750 04 M 339.54YN
Wednesday, June 18, 2008 Page 27 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15756 04 M 1,306.65YN
15757 04 M 1,306.65YN
15758 04 M 1,306.65YN
15760 04 M 300.05YN
15770 04 M 307.90YN
15775 09 MY
15776 09 MY
15780 09 MY
15781 09 MY
15782 09 MY
15783 09 MY
15786 09 IY
15787 09 MY
15819 04 M 274.36YN
15820 04 M 651.10YN
15821 04 M 651.10YN
15822 04 M 651.10YN
15823 04 M 651.10YN
15830 04 1/1/2007 MYY
15832 04 M 340.15YN
15833 04 M 306.75YN
Wednesday, June 18, 2008 Page 28 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15834 04 M 308.30YN
15835 04 M 319.10YN
15836 04 M 265.30YN
15837 04 M 255.00YN
15838 04 M 219.35YN
15839 04 M 237.80YN
15840 04 M 891.10YN
15841 04 M 663.96YN
15842 04 M 1,063.03YN
15845 04 M 355.83YN
15847 04 1/1/2007 MYY
15850 04 I 31.40YN
15851 04 I 48.60YN
15852 04 I 31.95YN
15860 04 I 55.50N
15876 04 MYY
15877 04 MYY
15878 04 MYY
15879 04 MY
15920 04 M 374.55YN
15922 04 M 449.50YN
Wednesday, June 18, 2008 Page 29 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
15931 04 M 449.50YN
15933 04 M 674.20YN
15934 04 M 749.20YN
15935 04 M 749.20YN
15936 04 M 749.20YN
15937 04 M 749.20YN
15940 04 M 449.50YN
15941 04 M 524.40YN
15944 04 M 524.40YN
15945 04 M 600.00YN
15946 04 M 674.20YN
15950 04 M 449.50YN
15951 04 M 524.40YN
15952 04 M 524.40YN
15953 04 M 599.35YN
15956 04 M 727.40YN
15958 04 M 727.40YN
15962 04 MY
15963 04 MY
15999 04 MYY
16000 04 I 45.80N
Wednesday, June 18, 2008 Page 30 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
16020 04 I 24.90 17.00YN
16025 04 I 49.50 34.00YN
16030 04 I 61.65 34.00YN
16035 04 M 92.79 34.00YN
16036 04 M 36.74YN
17000 04 I 52.70N
17003 04 I 8.85 13 115.05N
17004 04 I 86.59N
17106 04 I 125.35YN
17107 04 M 238.80YN
17108 04 M 372.30YN
17110 04 I 74.90N
17111 04 I 43.05N
17250 04 I 18.90N
17260 04 I 40.60YN
17261 04 I 60.70YN
17262 04 I 80.85YN
17263 04 I 100.90YN
17264 04 I 117.55YN
17266 04 M 162.00YN
17270 04 I 45.25YN
Wednesday, June 18, 2008 Page 31 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
17271 04 I 64.50YN
17272 04 I 85.60YN
17273 04 I 106.75YN
17274 04 I 117.20YN
17276 04 M 162.00YN
17280 04 I 96.20YN
17281 04 I 127.70YN
17282 04 M 171.30YN
17283 04 M 213.60YN
17284 04 M 257.10YN
17286 04 IYY
17311 04 1/1/2007 M 216.00YN
17312 04 1/1/2007 MYY
17313 04 1/1/2007 MYY
17314 04 1/1/2007 MYY
17315 04 1/1/2007 MYY
17340 04 I 26.20N
17360 04 I 38.65N
17380 04 IY
17999 04 MY
19000 04 I 37.40N
Wednesday, June 18, 2008 Page 32 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
19001 04 I 17.80N
19020 04 I 135.90YN
19030 04 I 102.50YN
19100 04 I 59.60YN
19101 04 M 192.85 34.00YN
19102 04 M 164.85 34.00YN
19103 04 M 324.90 34.00YN
19105 04 1/1/2007 MYY
19110 04 M 240.00 34.00YN
19112 04 M 240.00YN
19120 04 M 240.00 34.00YN
19125 04 M 240.00YN
19126 04 M 74.45YN
19260 04 M 430.64N
19271 04 M 534.45YN
19272 04 M 598.34YN
19290 04 I 59.40N
19291 04 I 27.00N
19295 04 I 63.10N
19296 04 I 109.01YN
19297 04 I 109.01YN
Wednesday, June 18, 2008 Page 33 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
19298 04 I 109.01YN
19300 04 1/1/2007 M 374.55YN
19301 04 1/1/2007 M 310.80YN
19302 04 1/1/2007 M 601.45YN
19303 04 1/1/2007 M 461.95YN
19304 04 1/1/2007 M 574.35YN
19305 04 1/1/2007 M 787.95YN
19306 04 1/1/2007 M 948.90YN
19307 04 1/1/2007 M 738.10YN
19316 04 M 567.10YN
19318 04 M 374.60YN
19324 04 M 567.10YN
19325 04 M 567.10YN
19328 04 M 240.00YN
19330 04 M 240.00YN
19340 04 M 310.80YN
19342 04 M 354.20YN
19350 04 M 310.55YN
19355 04 M 275.00YN
19357 04 M 532.30YN
19361 04 M 609.80N
Wednesday, June 18, 2008 Page 34 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
19364 04 M 558.15N
19366 04 M 558.15N
19367 04 M 755.20N
19368 04 M 1,306.65N
19369 04 M 852.25N
19370 04 M 242.70YN
19371 04 M 297.00YN
19380 04 M 280.40YN
19396 04 M 136.88N
19499 04 MYY
20000 04 I 59.80 17.00YN
20005 04 I 125.50 17.00YN
20100 04 M 372.65YN
20101 04 M 599.35YN
20102 04 M 480.00YN
20103 04 M 189.37 34.00N
20150 04 MYY
20200 04 I 113.60 17.00YN
20205 04 M 252.35 17.00YN
20206 04 I 53.50 17.00YN
20220 04 I 90.10YN
Wednesday, June 18, 2008 Page 35 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
20225 04 I 187.30 34.00YN
20240 04 M 220.55YN
20245 04 M 289.90YN
20250 04 M 163.05YN
20251 04 M 277.50YN
20500 04 I 61.40YN
20501 04 I 105.90YN
20520 04 M 107.00 17.00YN
20525 04 M 167.80YN
20526 04 I 31.35N
20550 04 I 31.75N
20551 04 I 31.75N
20552 04 I 31.75N
20553 04 I 31.75N
20555 04 1/1/2008 I 176.10N
20600 04 I 30.40 17.00N
20605 04 I 33.00 17.00N
20610 04 I 31.80 17.00YN
20612 04 I 31.80N
20615 04 I 73.35YN
20650 04 I 141.50YN
Wednesday, June 18, 2008 Page 36 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
20660 04 M 192.85YN
20661 04 M 192.85YN
20662 04 I 203.85YN
20663 04 I 170.05YN
20664 04 M 271.45YN
20665 04 I 134.60YN
20670 04 I 134.60YN
20680 04 M 233.00YN
20690 04 I 172.80YN
20692 04 I 297.00YN
20693 04 I 243.00YN
20694 04 I 152.95YN
20802 04 MY
20805 04 MY
20808 04 MY
20816 04 MY
20822 04 MY
20824 04 MY
20827 04 MY
20838 04 MY
20900 04 M 224.70YN
Wednesday, June 18, 2008 Page 37 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
20902 04 M 374.55YN
20910 04 MYY
20912 04 MYY
20920 04 M 168.10YN
20922 04 M 231.10YN
20924 04 M 212.90YN
20926 04 MYY
20930 09 MY
20931 09 MYY
20936 09 MY
20937 09 MY
20938 09 MY
20950 04 I 44.80YN
20955 04 MY
20956 04 MYY
20957 04 MYY
20962 04 MYY
20969 04 MYY
20970 04 MYY
20972 04 MYY
20973 04 MYY
Wednesday, June 18, 2008 Page 38 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
20974 09 MY
20975 04 I 82.90YN
20979 04 I 176.70N
20982 04 M 220.57YN
20985 04 1/1/2008 M 83.23YN
20986 04 1/1/2008 MYY
20987 04 1/1/2008 MYY
20999 04 MY
21010 04 M 374.55YN
21015 04 M 224.36YN
21025 04 M 299.70YN
21026 04 M 299.70YN
21029 04 MYY
21030 04 M 299.70YN
21031 04 M 299.70YN
21032 04 M 299.70YN
21034 04 M 421.10YN
21040 04 M 299.70YN
21044 04 M 350.55YN
21045 04 M 1,678.65YN
21046 04 M 397.20YN
Wednesday, June 18, 2008 Page 39 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21047 04 MYY
21048 04 MYY
21049 04 MYY
21050 04 M 524.40YN
21060 04 M 524.40YN
21070 04 M 299.70YN
21073 04 1/1/2008 M 188.93YN
21076 04 IY
21077 04 IY
21079 04 IY
21080 04 IY
21081 04 IY
21082 04 IY
21083 04 IY
21084 04 IY
21085 04 IY
21086 04 IY
21087 04 IY
21088 04 IY
21089 04 IY
21100 04 M 192.85YN
Wednesday, June 18, 2008 Page 40 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21110 04 M 176.70YN
21116 04 I 73.20YN
21120 04 M 1,198.70YN
21121 04 M 1,198.70YN
21122 04 M 1,414.70YN
21123 04 M 1,522.70YN
21125 04 M 1,198.70YN
21127 04 M 1,306.65YN
21137 04 M 958.60YN
21138 04 M 1,198.70YN
21139 04 M 1,522.70YN
21141 04 M 1,198.70YN
21142 04 M 1,306.65YN
21143 04 M 1,414.70YN
21145 04 M 1,306.65YN
21146 04 M 1,522.70YN
21147 04 M 1,522.70YN
21150 04 M 1,306.65YN
21151 04 M 1,522.70YN
21154 04 M 1,306.65YN
21155 04 M 1,522.70YN
Wednesday, June 18, 2008 Page 41 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21159 04 M 1,522.70YN
21160 04 M 1,522.70YN
21172 04 M 1,522.70YN
21175 04 M 1,522.70YN
21179 04 M 1,414.70YN
21180 04 M 1,522.70YN
21181 04 M 958.60YN
21182 04 M 1,522.70YN
21183 04 M 1,522.70YN
21184 04 M 1,630.70YN
21188 04 M 1,306.65YN
21193 04 M 1,198.70YN
21194 04 M 1,414.70YN
21195 04 M 1,198.70YN
21196 04 M 1,198.70YN
21198 04 M 958.60YN
21199 04 M 700.70YN
21206 04 M 1,198.70YN
21208 04 M 1,198.70YN
21209 04 M 1,198.70YN
21210 04 M 636.80YN
Wednesday, June 18, 2008 Page 42 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21215 04 M 1,048.85YN
21230 04 M 957.25YN
21235 04 M 449.50YN
21240 04 M 599.35YN
21242 04 M 599.35YN
21243 04 M 1,198.70YN
21244 04 M 1,198.70YN
21245 04 M 1,198.70YN
21246 04 M 1,198.70YN
21247 04 M 1,306.65YN
21248 04 M 1,198.70YN
21249 04 M 1,198.70YN
21255 04 M 1,306.65YN
21256 04 M 1,306.65YN
21260 04 M 1,306.65YN
21261 04 M 1,522.70YN
21263 04 M 1,522.70YN
21267 04 M 1,306.65YN
21268 04 M 1,522.70YN
21270 04 M 1,048.85YN
21275 04 M 1,048.85YN
Wednesday, June 18, 2008 Page 43 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21280 04 M 359.30YN
21282 04 M 359.30YN
21295 04 M 449.50YN
21296 04 M 449.50YN
21299 04 MYY
21310 04 I 138.75YN
21315 04 M 176.20YN
21320 04 M 280.25YN
21325 04 M 337.10YN
21330 04 M 424.45YN
21335 04 M 571.60YN
21336 04 M 337.10YN
21337 04 M 224.70YN
21338 04 M 334.40YN
21339 04 M 457.70YN
21340 04 M 749.20YN
21343 04 M 898.95YN
21344 04 M 1,048.85YN
21345 04 M 749.20YN
21346 04 M 749.20YN
21347 04 M 766.90YN
Wednesday, June 18, 2008 Page 44 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21348 04 M 954.20YN
21355 04 M 149.80YN
21356 04 M 539.65YN
21360 04 M 539.65YN
21365 04 M 689.50YN
21366 04 M 954.20YN
21385 04 M 599.35YN
21386 04 M 599.35YN
21387 04 M 749.20YN
21390 04 M 861.50YN
21395 04 M 861.50YN
21400 04 I 149.80YN
21401 04 M 224.70YN
21406 04 M 599.35YN
21407 04 M 749.20YN
21408 04 M 749.20YN
21421 04 M 457.70YN
21422 04 M 678.40YN
21423 04 M 828.20YN
21431 04 M 524.40YN
21432 04 M 749.20YN
Wednesday, June 18, 2008 Page 45 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21433 04 M 898.95YN
21435 04 M 1,048.85YN
21436 04 M 1,048.85YN
21440 04 M 374.55YN
21445 04 M 599.35YN
21450 04 I 117.60YN
21451 04 M 498.10YN
21452 04 I 112.40YN
21453 04 M 498.10YN
21454 04 M 498.10YN
21461 04 M 706.15YN
21462 04 M 706.15YN
21465 04 M 498.10YN
21470 04 M 885.20YN
21480 04 M 240.00YN
21485 04 M 240.00YN
21490 04 M 749.20YN
21495 04 M 449.50YN
21497 04 M 149.80YN
21499 04 MYY
21501 04 I 115.30 17.00YN
Wednesday, June 18, 2008 Page 46 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21502 04 M 224.70YN
21510 04 M 224.70YN
21550 04 I 99.10 17.00YN
21555 04 I 124.00 17.00YN
21556 04 I 158.50YN
21557 04 MYY
21600 04 M 299.70YN
21610 04 M 399.50YN
21615 04 M 449.50YN
21616 04 M 599.35YN
21620 04 M 250.40YN
21627 04 MYY
21630 04 M 749.20YN
21632 04 M 749.20YN
21685 04 M 491.50YN
21700 04 M 374.55YN
21705 04 M 449.50YN
21720 04 M 577.10YN
21725 04 M 599.35YN
21740 04 M 898.95YN
21742 04 M 898.95YN
Wednesday, June 18, 2008 Page 47 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
21743 04 M 898.95YN
21750 04 M 368.20YN
21800 04 I 52.70YN
21805 04 I 111.00YN
21810 04 M 242.40YN
21820 04 I 74.90YN
21825 04 M 374.55YN
21899 04 MYY
21920 04 I 113.50 17.00YN
21925 04 M 180.20 17.00YN
21930 04 M 149.80YN
21935 04 MYY
22010 04 M 453.30YN
22015 04 M 449.25YN
22100 04 M 311.40YN
22101 04 M 315.50YN
22102 04 M 299.70YN
22103 04 MYY
22110 04 M 718.70YN
22112 04 M 718.70YN
22114 04 M 718.70YN
Wednesday, June 18, 2008 Page 48 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
22116 04 MYY
22206 04 1/1/2008 M 1270.13YN
22207 04 1/1/2008 M 1253.30YN
22208 04 1/1/2008 M 325.80YN
22210 04 M 973.90YN
22212 04 M 973.90YN
22214 04 M 973.90YN
22216 04 MYY
22220 04 M 973.90YN
22222 04 M 973.90YN
22224 04 M 973.90YN
22226 04 MYY
22305 04 M 259.40YN
22310 04 I 98.80YN
22315 04 M 276.20YN
22318 04 M 1,417.20YN
22319 04 M 1,558.90YN
22325 04 M 599.35YN
22326 04 M 627.30YN
22327 04 M 608.50YN
22328 04 MYY
Wednesday, June 18, 2008 Page 49 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
22505 04 I 149.80YN
22520 04 M 353.85YN
22521 04 M 331.90YN
22522 04 M 116.00N
22523 04 M 343.13N
22524 04 M 328.66N
22525 04 M 158.82N
22526 04 1/1/2007 M 509.95YN
22527 04 1/1/2007 MYY
22532 04 M 876.68YN
22533 04 M 816.43YN
22534 04 M 208.02YN
22548 04 M 1,642.15YN
22554 04 M 1,642.65YN
22556 04 M 1,642.65YN
22558 04 M 1,642.65YN
22585 04 MYY
22590 04 M 1,198.70YN
22595 04 M 1,198.70YN
22600 04 M 1,198.70YN
22610 04 M 1,198.70YN
Wednesday, June 18, 2008 Page 50 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
22612 04 M 1,198.70YN
22614 04 MYY
22630 04 M 1,198.70YN
22632 04 MYY
22800 04 M 1,086.30YN
22802 04 M 1,086.30YN
22804 04 M 1,782.30YN
22808 04 M 1,086.30YN
22810 04 M 1,086.30YN
22812 04 M 1,086.30YN
22818 04 M 1,610.65YN
22819 04 M 1,610.65YN
22830 04 MYY
22840 04 M 1,872.90YN
22841 04 M 1,872.90YN
22842 04 M 1,872.90YN
22843 04 M 1,872.90YN
22844 04 M 1,872.90YN
22845 04 M 1,872.90YN
22846 04 M 1,872.90YN
22847 04 M 1,872.90YN
Wednesday, June 18, 2008 Page 51 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
22848 04 M 351.00YN
22849 04 M 1,134.10YN
22850 04 M 449.50YN
22851 04 M 750.70YN
22852 04 M 449.50YN
22855 04 M 449.50YN
22857 04 1/1/2007 MYY
22862 04 1/1/2007 MYY
22865 04 1/1/2007 MYY
22899 04 MYY
22900 04 M 224.70YN
22999 04 MYY
23000 04 M 359.30YN
23020 04 M 299.70YN
23030 04 I 125.50 17.00YN
23031 04 I 99.10 17.00YN
23035 04 M 317.40YN
23040 04 M 599.35YN
23044 04 M 599.35YN
23065 04 I 113.60 17.00YN
23066 04 I 149.25 17.00YN
Wednesday, June 18, 2008 Page 52 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
23075 04 M 224.70YN
23076 04 M 449.50YN
23077 04 MYY
23100 04 M 374.55YN
23101 04 M 599.35YN
23105 04 M 599.35YN
23106 04 M 599.35YN
23107 04 M 473.50YN
23120 04 M 362.00YN
23125 04 M 718.70YN
23130 04 M 362.00YN
23140 04 M 264.90YN
23145 04 M 480.00YN
23146 04 M 480.00YN
23150 04 M 275.80YN
23155 04 M 480.00YN
23156 04 M 480.00YN
23170 04 M 240.00YN
23172 04 M 240.00YN
23174 04 M 480.00YN
23180 04 M 299.70YN
Wednesday, June 18, 2008 Page 53 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
23182 04 M 480.00YN
23184 04 M 480.00YN
23190 04 M 480.00YN
23195 04 M 599.35YN
23200 04 M 718.70YN
23210 04 M 718.70YN
23220 04 M 718.70YN
23221 04 M 839.35YN
23222 04 M 1,048.85YN
23330 04 I 17.00 107.00YN
23331 04 M 233.00YN
23332 04 MYY
23350 04 I 88.30YN
23395 04 M 501.35YN
23397 04 M 599.35YN
23400 04 M 839.35YN
23405 04 M 299.70YN
23406 04 M 449.50YN
23410 04 M 779.70YN
23412 04 M 779.70YN
23415 04 M 674.20YN
Wednesday, June 18, 2008 Page 54 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
23420 04 M 674.20YN
23430 04 M 449.50YN
23440 04 M 449.50YN
23450 04 M 839.35YN
23455 04 M 839.35YN
23460 04 M 839.35YN
23462 04 M 839.35YN
23465 04 M 733.85YN
23466 04 M 584.40YN
23470 04 M 839.35YN
23472 04 M 1,498.30YN
23480 04 M 480.00YN
23485 04 M 486.90YN
23490 04 M 379.40YN
23491 04 M 464.45YN
23500 04 I 112.40YN
23505 04 M 187.30YN
23515 04 M 419.00YN
23520 04 I 112.40YN
23525 04 M 162.30YN
23530 04 M 720.00YN
Wednesday, June 18, 2008 Page 55 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
23532 04 I 786.60YN
23540 04 I 112.40YN
23545 04 M 228.90YN
23550 04 M 503.60YN
23552 04 M 561.85YN
23570 04 I 79.60YN
23575 04 M 241.35YN
23585 04 M 449.50YN
23600 04 M 194.20YN
23605 04 M 277.50YN
23615 04 M 545.25YN
23616 04 M 975.25YN
23620 04 I 111.00YN
23625 04 M 163.70YN
23630 04 M 524.40YN
23650 04 M 178.90YN
23655 04 M 255.20YN
23660 04 M 419.00YN
23665 04 M 206.70YN
23670 04 M 842.10YN
23675 04 M 299.70YN
Wednesday, June 18, 2008 Page 56 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
23680 04 M 599.35YN
23700 04 M 194.20YN
23800 04 M 839.35YN
23802 04 M 839.35YN
23900 04 M 1198.70YN
23920 04 M 1048.85YN
23921 04 M 224.70YN
23929 04 MYY
23930 04 M 179.70 17.00YN
23931 04 I 141.30 17.00YN
23935 04 M 240.00YN
24000 04 M 299.70YN
24006 04 M 380.15YN
24065 04 I 113.60 17.00YN
24066 04 M 264.25 17.00YN
24075 04 M 149.80YN
24076 04 M 224.70YN
24077 04 MYY
24100 04 M 299.70YN
24101 04 M 480.00YN
24102 04 M 524.40YN
Wednesday, June 18, 2008 Page 57 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
24105 04 M 380.15YN
24110 04 M 527.20YN
24115 04 M 749.20YN
24116 04 M 749.20YN
24120 04 M 449.50YN
24125 04 M 749.20YN
24126 04 M 749.20YN
24130 04 M 492.55YN
24134 04 M 351.00YN
24136 04 M 262.80YN
24138 04 M 254.80YN
24140 04 M 480.00YN
24145 04 M 480.00YN
24147 04 M 480.00YN
24149 04 MYY
24150 04 M 1198.70YN
24151 04 M 1198.70YN
24152 04 M 958.60YN
24153 04 M 1048.85YN
24155 04 M 749.20YN
24160 04 M 299.70YN
Wednesday, June 18, 2008 Page 58 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
24164 04 M 492.55YN
24200 04 M 169.30YN
24201 04 M 245.55YN
24220 04 I 105.15YN
24300 04 I 66.70YN
24301 04 M 453.70YN
24305 04 M 359.30YN
24310 04 M 188.70YN
24320 04 M 599.35YN
24330 04 M 599.35YN
24331 04 M 599.35YN
24332 04 M 326.30YN
24340 04 M 299.70YN
24341 04 M 274.20YN
24342 04 M 535.45YN
24343 04 M 430.15YN
24344 04 M 651.95YN
24345 04 M 430.15YN
24346 04 M 651.95YN
24357 04 1/1/2008 M 233.94YN
24358 04 1/1/2008 M 275.71YN
Wednesday, June 18, 2008 Page 59 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
24359 04 1/1/2008 M 341.04YN
24360 04 M 718.70YN
24361 04 M 1123.70YN
24362 04 M 1123.70YN
24363 04 M 1123.70YN
24365 04 M 1123.70YN
24366 04 M 1123.70YN
24400 04 M 541.05YN
24410 04 M 481.65YN
24420 04 M 898.95YN
24430 04 M 636.80YN
24435 04 M 958.60YN
24470 04 M 374.55YN
24495 04 M 299.70YN
24498 04 M 491.50YN
24500 04 M 153.95YN
24505 04 M 295.50YN
24515 04 M 624.30YN
24516 04 M 624.30YN
24530 04 M 299.70YN
24535 04 M 334.40YN
Wednesday, June 18, 2008 Page 60 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
24538 04 M 405.10YN
24545 04 M 718.70YN
24546 04 M 718.70YN
24560 04 M 199.75YN
24565 04 M 242.80YN
24566 04 M 257.30YN
24575 04 M 718.70YN
24576 04 M 188.70YN
24577 04 M 245.55YN
24579 04 M 718.70YN
24582 04 M 405.10YN
24586 04 M 480.65YN
24587 04 M 1123.70YN
24600 04 M 208.05YN
24605 04 M 242.80YN
24615 04 M 419.00YN
24620 04 M 259.40YN
24635 04 M 482.80YN
24640 04 M 180.30YN
24650 04 I 142.90YN
24655 04 M 208.05YN
Wednesday, June 18, 2008 Page 61 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
24665 04 M 400.90YN
24666 04 M 449.50YN
24670 04 M 181.65YN
24675 04 M 206.70YN
24685 04 M 556.35YN
24800 04 M 718.70YN
24802 04 M 839.35YN
24900 04 M 313.50YN
24920 04 M 595.20YN
24925 04 M 262.20YN
24930 04 M 595.20YN
24931 04 M 674.20YN
24935 04 M 599.35YN
24940 04 M 621.10YN
24999 04 MYY
25000 04 M 351.00YN
25001 04 M 207.95YN
25020 04 M 388.50YN
25023 04 M 394.80YN
25024 04 M 458.20YN
25025 04 M 588.15YN
Wednesday, June 18, 2008 Page 62 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25028 04 I 179.25 17.00YN
25031 04 M 232.55 17.00YN
25035 04 M 287.60YN
25040 04 M 480.00YN
25065 04 I 113.60 17.00YN
25066 04 I 149.25 17.00YN
25075 04 M 149.80YN
25076 04 M 262.20YN
25077 04 MYY
25085 04 M 262.20YN
25100 04 M 419.00YN
25101 04 M 480.00YN
25105 04 M 480.00YN
25107 04 M 480.00YN
25109 04 1/1/2007 M 240.00YN
25110 04 M 217.80YN
25111 04 M 214.00 34.00YN
25112 04 M 214.00 34.00YN
25115 04 M 599.35YN
25116 04 M 599.35YN
25118 04 M 480.00YN
Wednesday, June 18, 2008 Page 63 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25119 04 M 659.00YN
25120 04 M 599.35YN
25125 04 M 674.20YN
25126 04 M 674.20YN
25130 04 M 299.70YN
25135 04 M 449.50YN
25136 04 M 449.50YN
25145 04 M 359.30YN
25150 04 M 359.30YN
25151 04 M 359.30YN
25170 04 MYY
25210 04 M 480.00YN
25215 04 M 480.00YN
25230 04 M 299.70YN
25240 04 M 359.30YN
25246 04 I 96.90YN
25248 04 M 181.25YN
25250 04 M 224.70YN
25251 04 M 339.50YN
25259 04 M 230.15YN
25260 04 M 283.50YN
Wednesday, June 18, 2008 Page 64 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25263 04 M 302.60YN
25265 04 M 484.20YN
25270 04 M 369.05YN
25272 04 M 256.85YN
25274 04 M 359.30YN
25275 04 M 442.50YN
25280 04 M 359.30YN
25290 04 M 302.40YN
25295 04 M 277.50YN
25300 04 M 359.30YN
25301 04 M 359.30YN
25310 04 M 480.00YN
25312 04 M 524.40YN
25315 04 M 480.00YN
25316 04 M 524.40YN
25320 04 M 449.50YN
25332 04 M 749.20YN
25335 04 M 749.20YN
25337 04 M 718.70YN
25350 04 M 374.55YN
25355 04 M 480.00YN
Wednesday, June 18, 2008 Page 65 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25360 04 M 316.10YN
25365 04 M 561.85YN
25370 04 M 480.00YN
25375 04 M 524.40YN
25390 04 M 599.35YN
25391 40 M 898.95YN
25392 04 M 898.95YN
25393 04 M 898.95YN
25394 04 M 514.80YN
25400 04 M 524.40YN
25405 04 M 599.35YN
25415 04 M 488.00YN
25420 04 M 839.35YN
25425 04 M 599.35YN
25426 04 M 749.20YN
25430 04 M 451.90YN
25431 04 M 449.10YN
25440 04 M 599.35YN
25441 04 M 659.00YN
25442 04 M 659.00YN
25443 04 M 749.20YN
Wednesday, June 18, 2008 Page 66 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25444 04 M 749.20YN
25445 04 M 749.20YN
25446 04 M 898.95YN
25447 04 MYY
25449 04 M 659.00YN
25450 04 M 299.70YN
25455 04 M 449.50YN
25490 04 M 356.50YN
25491 04 M 365.60YN
25492 04 M 459.05YN
25500 04 I 112.40YN
25505 04 M 210.90YN
25515 04 M 554.90YN
25520 04 M 267.80YN
25525 04 M 443.95YN
25526 04 M 592.40YN
25530 04 M 199.75YN
25535 04 M 240.00YN
25545 04 M 538.20YN
25560 04 M 176.20YN
25565 04 M 292.60YN
Wednesday, June 18, 2008 Page 67 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25574 04 M 538.20YN
25575 04 M 592.40YN
25600 04 M 155.35YN
25605 04 M 294.10YN
25606 04 1/1/2007 M 301.00YN
25607 04 1/1/2007 M 443.95YN
25608 04 1/1/2007 M 443.95YN
25609 04 1/1/2007 M 443.95YN
25622 04 I 147.10YN
25624 04 I 181.10YN
25628 04 M 335.70YN
25630 04 M 201.10YN
25635 04 I 174.60YN
25645 04 M 335.70YN
25650 04 I 126.90YN
25651 04 M 271.25YN
25652 04 M 374.00YN
25660 04 I 139.00YN
25670 04 M 266.70YN
25671 04 M 205.30YN
25675 04 I 168.25YN
Wednesday, June 18, 2008 Page 68 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25676 04 M 270.40YN
25680 04 M 240.00YN
25685 04 M 449.50YN
25690 04 I 188.65YN
25695 04 M 276.50YN
25800 04 M 718.70YN
25805 04 M 786.60YN
25810 04 M 839.35YN
25820 04 M 664.25YN
25825 04 M 718.70YN
25830 04 M 786.60YN
25900 04 M 359.30YN
25905 04 M 359.30YN
25907 04 M 290.30YN
25909 04 M 359.30YN
25915 04 M 1198.70YN
25920 04 M 359.30YN
25922 04 M 244.50YN
25924 04 M 359.30YN
25927 04 M 302.60YN
25929 04 M 236.30YN
Wednesday, June 18, 2008 Page 69 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
25931 04 M 285.80YN
25999 04 MYY
26010 04 I 76.25YN
26011 04 I 97.40YN
26020 04 M 191.80YN
26025 04 M 201.60YN
26030 04 M 237.15YN
26034 04 M 240.00YN
26035 04 M 321.65YN
26037 04 M 265.20YN
26040 04 M 264.90YN
26045 04 M 449.50YN
26055 04 M 235.80YN
26060 04 I 107.90YN
26070 04 M 224.70YN
26075 04 M 224.70YN
26080 04 M 187.30YN
26100 04 M 299.70YN
26105 04 M 262.20YN
26110 04 M 187.30YN
26115 04 M 149.80YN
Wednesday, June 18, 2008 Page 70 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26116 04 M 224.70YN
26117 04 MYY
26121 04 M 449.50YN
26123 04 M 524.40YN
26125 04 MYY
26130 04 M 374.55YN
26135 04 M 270.60YN
26140 04 M 245.35YN
26145 04 M 252.80YN
26160 04 M 210.10 34.00YN
26170 04 M 240.00YN
26180 04 M 240.00YN
26185 04 MYY
26200 04 M 299.70YN
26205 04 M 374.55YN
26210 04 M 224.70YN
26215 04 M 314.95YN
26230 04 M 299.70YN
26235 04 M 224.70YN
26236 04 M 204.05YN
26250 04 M 449.50YN
Wednesday, June 18, 2008 Page 71 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26255 04 M 524.40YN
26260 04 M 374.55YN
26261 04 M 449.50YN
26262 04 M 299.70YN
26320 04 M 233.00YN
26340 04 I 139.70YN
26350 04 M 274.40YN
26352 04 M 480.00YN
26356 04 M 359.30YN
26357 04 M 359.30YN
26358 04 M 599.35YN
26370 04 M 307.20YN
26372 04 M 480.00YN
26373 04 M 480.00YN
26390 04 M 480.00YN
26392 04 M 480.00YN
26410 04 M 222.00YN
26412 04 M 299.70YN
26415 04 M 306.95YN
26416 04 M 414.90YN
26418 04 M 201.65YN
Wednesday, June 18, 2008 Page 72 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26420 04 M 299.70YN
26426 04 M 480.00YN
26428 04 M 599.35YN
26432 04 M 359.30YN
26433 04 M 222.00YN
26434 04 M 359.30YN
26437 04 M 225.10YN
26440 04 M 417.60YN
26442 04 M 627.05YN
26445 04 M 240.00YN
26449 04 M 359.30YN
26450 04 M 240.00YN
26455 04 M 240.00YN
26460 04 M 240.00YN
26471 04 M 299.70YN
26474 04 M 359.30YN
26476 04 M 359.30YN
26477 04 M 359.30YN
26478 04 M 359.30YN
26479 04 M 359.30YN
26480 04 M 480.00YN
Wednesday, June 18, 2008 Page 73 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26483 04 M 480.00YN
26485 04 M 480.00YN
26489 04 M 561.85YN
26490 04 M 356.60YN
26492 04 M 449.50YN
26494 04 M 356.60YN
26496 04 MYY
26497 04 M 374.55YN
26498 04 M 693.70YN
26499 04 M 374.55YN
26500 04 M 226.50YN
26502 04 M 419.00YN
26508 04 M 232.55YN
26510 04 M 442.90YN
26514 04 IY
26516 04 M 255.00YN
26517 04 M 374.55YN
26518 04 M 416.20YN
26520 04 M 262.20YN
26525 04 M 262.20YN
26530 04 M 289.30YN
Wednesday, June 18, 2008 Page 74 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26531 04 M 337.10YN
26535 04 M 524.40YN
26536 04 M 524.40YN
26540 04 M 346.75YN
26541 04 M 374.55YN
26542 04 M 374.55YN
26545 04 M 299.70YN
26546 04 MYY
26548 04 M 299.70YN
26550 04 M 680.50YN
26551 04 MYY
26553 04 MYY
26554 04 MYY
26555 04 M 571.10YN
26556 04 MYY
26560 04 M 584.05YYN
26561 04 M 639.60YN
26562 04 M 898.95YN
26565 04 M 359.30YN
26567 04 M 359.30YN
26568 04 M 415.85YN
Wednesday, June 18, 2008 Page 75 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26580 04 M 579.05YN
26587 04 M 259.20YN
26590 04 M 587.40YN
26591 04 M 237.60YN
26593 04 M 259.20YN
26596 04 MYY
26600 04 I 93.70YN
26605 04 I 138.75YN
26607 04 M 299.70YN
26608 04 M 299.70YN
26615 04 M 299.70YN
26641 04 M 166.40YN
26645 04 M 166.40YN
26650 04 M 240.00YN
26665 04 M 374.55YN
26670 04 I 134.25YN
26675 04 I 181.55YN
26676 04 M 262.20YN
26685 04 M 233.30YN
26686 04 M 280.80YN
26700 04 I 107.00YN
Wednesday, June 18, 2008 Page 76 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26705 04 M 166.40YN
26706 04 M 237.85YN
26715 04 M 274.65YN
26720 04 I 97.05YN
26725 04 I 130.35YN
26727 04 M 171.00YN
26735 04 M 263.55YN
26740 04 I 97.05YN
26742 04 I 150.50YN
26746 04 M 263.55YN
26750 04 I 97.05YN
26755 04 I 104.10YN
26756 04 M 224.70YN
26765 04 M 285.80YN
26770 04 I 92.50YN
26775 04 I 132.45YN
26776 04 M 224.70YN
26785 04 I 148.60YN
26820 04 M 310.10YN
26841 04 M 299.70YN
26842 04 M 374.55YN
Wednesday, June 18, 2008 Page 77 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
26843 04 M 299.70YN
26844 04 M 374.55YN
26850 04 M 262.20YN
26852 04 M 301.70YN
26860 04 M 200.65YN
26861 04 M 90.10YN
26862 04 M 274.60YN
26863 04 M 119.25YN
26910 04 M 271.90YN
26951 04 M 271.90YN
26952 04 M 259.40YN
26989 04 MYY
26990 04 I 262.45 17.00YN
26991 04 I 215.80 17.00YN
26992 04 M 418.80YN
27000 04 M 197.00YN
27001 04 M 202.20YN
27003 04 M 299.70YN
27005 04 M 274.65YN
27006 04 M 289.20YN
27025 04 M 374.55YN
Wednesday, June 18, 2008 Page 78 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27030 04 M 524.40YN
27033 04 M 599.35YN
27035 04 M 599.35YN
27036 04 MYY
27040 04 I 113.60 17.00YN
27041 04 I 258.20 17.00YN
27047 04 M 224.70YN
27048 04 M 374.55YN
27049 04 MYY
27050 04 M 524.40YN
27052 04 M 524.40YN
27054 04 M 749.20YN
27060 04 M 277.50YN
27062 04 M 374.55YN
27065 04 M 599.35YN
27066 04 M 674.20YN
27067 04 M 749.20YN
27070 04 M 419.00YN
27071 04 M 480.00YN
27075 04 M 599.35YN
27076 04 M 681.10YN
Wednesday, June 18, 2008 Page 79 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27077 04 M 723.20YN
27078 04 M 599.35YN
27079 04 M 599.35YN
27080 04 M 359.30YN
27086 04 I 107.00 17.00YN
27087 04 M 247.20 17.00YN
27090 04 M 412.00YN
27091 04 M 694.45YN
27093 04 I 106.70YN
27095 04 I 111.70YN
27096 04 I 172.50YN
27097 04 M 290.25YN
27098 04 M 345.70YN
27100 04 M 561.85YN
27105 04 M 636.80YN
27110 04 M 674.20YN
27111 04 M 674.20YN
27120 04 M 898.95YN
27122 04 M 954.50YN
27125 04 M 1026.65YN
27130 04 M 1749.50YN
Wednesday, June 18, 2008 Page 80 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27132 04 M 1798.05YN
27134 04 M 1048.85YN
27137 04 M 1048.85YN
27138 04 M 1048.85YN
27140 04 M 718.70YN
27146 04 M 718.70YN
27147 04 M 839.35YN
27151 04 M 1011.40YN
27156 04 M 1123.70YN
27158 04 M 583.00YN
27161 04 M 749.20YN
27165 04 M 898.95YN
27170 04 M 898.95YN
27175 04 M 599.35YN
27176 04 M 599.35YN
27177 04 M 958.60YN
27178 04 M 958.60YN
27179 04 M 839.35YN
27181 04 M 958.60YN
27185 04 M 779.70YN
27187 04 M 950.50YN
Wednesday, June 18, 2008 Page 81 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27193 04 I 170.80YN
27194 04 I 272.40YN
27200 04 M 149.80YN
27202 04 M 374.55YN
27215 04 M 674.20YN
27216 04 M 550.90YN
27217 04 M 599.35YN
27218 04 M 599.35YN
27220 04 M 412.00YN
27222 04 M 412.00YN
27226 04 M 930.90YN
27227 04 M 930.90YN
27228 04 M 1198.70YN
27230 04 I 179.15YN
27232 04 M 449.50YN
27235 04 M 674.20YN
27236 04 M 1019.70YN
27238 04 I 183.80YN
27240 04 M 449.50YN
27244 04 M 933.80YN
27245 04 M 933.80YN
Wednesday, June 18, 2008 Page 82 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27246 04 I 167.00YN
27248 04 M 779.70YN
27250 04 M 242.80YN
27252 04 M 284.90YN
27253 04 M 599.35YN
27254 04 M 606.30YN
27256 04 M 208.05YN
27257 04 M 277.50YN
27258 04 M 733.85YN
27259 04 M 958.60YN
27265 04 M 242.80YN
27266 04 M 283.00YN
27267 04 1/1/2008 M 220.82YN
27268 04 1/1/2008 M 273.08YN
27269 04 1/1/2008 M 655.58YN
27275 04 M 240.00YN
27280 04 M 958.60YN
27282 04 M 958.60YN
27284 04 M 898.95YN
27286 04 M 1033.50YN
27290 04 M 1678.65YN
Wednesday, June 18, 2008 Page 83 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27295 04 M 1198.70YN
27299 04 MYY
27301 04 M 242.10YN
27303 04 M 298.20YN
27305 04 M 374.55YN
27306 04 M 374.55YN
27307 04 M 561.85YN
27310 04 M 486.90YN
27323 04 I 113.60 17.00YN
27324 04 M 264.25 17.00YN
27325 04 1/1/2007 M 412.00YN
27326 04 1/1/2007 M 412.00YN
27327 04 I 156.30YN
27328 04 M 295.50YN
27329 04 MYY
27330 04 M 374.55YN
27331 04 M 599.35YN
27332 04 M 621.50YN
27333 04 M 621.50YN
27334 04 M 621.50YN
27335 04 M 621.50YN
Wednesday, June 18, 2008 Page 84 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27340 04 M 240.00YN
27345 04 M 381.50YN
27347 04 M 381.50YN
27350 04 M 636.80YN
27355 04 M 599.35YN
27356 04 M 674.20YN
27357 04 M 674.20YN
27358 04 M 674.20YN
27360 04 M 480.00YN
27365 04 M 898.95YN
27370 04 I 101.10YN
27372 04 M 174.10YN
27380 04 M 412.00YN
27381 04 M 524.40YN
27385 04 M 419.00YN
27386 04 M 524.40YN
27390 04 M 359.30YN
27391 04 M 458.40YN
27392 04 M 661.15YN
27393 04 M 359.30YN
27394 04 M 458.40YN
Wednesday, June 18, 2008 Page 85 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27395 04 M 661.15YN
27396 04 M 599.35YN
27397 04 M 550.90YN
27400 04 M 599.35YN
27403 04 M 621.50YN
27405 04 M 524.40YN
27407 04 M 524.40YN
27409 04 M 674.20YN
27412 04 M 621.50YN
27415 04 M 621.50YN
27416 04 1/1/2008 M 513.32YN
27418 04 M 486.10YN
27420 04 M 620.10YN
27422 04 M 620.10YN
27424 04 M 636.80YN
27425 04 M 561.85YN
27427 04 M 524.40YN
27428 04 M 621.10YN
27429 04 M 674.20YN
27430 04 M 561.85YN
27435 04 M 524.40YN
Wednesday, June 18, 2008 Page 86 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27437 04 M 599.35YN
27438 04 M 958.60YN
27440 04 M 599.35YN
27441 04 M 599.35YN
27442 04 M 881.00YN
27443 04 M 881.00YN
27445 04 M 1473.35YN
27446 04 M 1473.35YN
27447 04 M 1473.35YN
27448 04 M 599.35YN
27450 04 M 689.50YN
27454 04 M 749.20YN
27455 04 M 524.40YN
27457 04 M 524.40YN
27465 04 M 749.20YN
27466 04 M 898.95YN
27468 04 M 1198.70YN
27470 04 M 839.35YN
27472 04 M 958.60YN
27475 04 M 659.00YN
27477 04 M 659.00YN
Wednesday, June 18, 2008 Page 87 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27479 04 M 958.60YN
27485 04 M 561.85YN
27486 04 M 736.60YN
27487 04 M 1473.30YN
27488 04 M 524.65YN
27495 04 MYY
27496 04 M 374.55YN
27497 04 M 374.55YN
27498 04 M 383.45YN
27499 04 M 383.45YN
27500 04 M 257.40YN
27501 04 M 263.20YN
27502 04 M 338.50YN
27503 04 M 338.50YN
27506 04 M 910.10YN
27507 04 M 910.10YN
27508 04 M 209.00YN
27509 04 M 524.40YN
27510 04 M 524.40YN
27511 04 M 836.55YN
27513 04 M 826.30YN
Wednesday, June 18, 2008 Page 88 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27514 04 M 836.55YN
27516 04 M 599.35YN
27517 04 M 599.35YN
27519 04 M 836.55YN
27520 04 M 191.50YN
27524 04 M 629.90YN
27530 04 M 288.50YN
27532 04 M 321.90YN
27535 04 M 839.35YN
27536 04 M 839.35YN
27538 04 M 213.65YN
27540 04 M 958.60YN
27550 04 M 194.25YN
27552 04 M 227.40YN
27556 04 M 656.20YN
27557 04 M 749.20YN
27558 04 M 749.20YN
27560 04 I 149.80YN
27562 04 M 187.80YN
27566 04 M 383.25YN
27570 04 I 66.70YN
Wednesday, June 18, 2008 Page 89 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27580 04 M 1384.60YN
27590 04 M 649.25YN
27591 04 M 749.20YN
27592 04 M 574.35YN
27594 04 M 224.70YN
27596 04 M 574.35YN
27598 04 M 480.00YN
27599 04 MYY
27600 04 M 189.80YN
27601 04 M 190.20YN
27602 04 M 262.20YN
27603 04 M 211.60 17.00YN
27604 04 I 156.50 17.00YN
27605 04 M 359.30YN
27606 04 M 359.30YN
27607 04 M 292.30YN
27610 04 M 480.00YN
27612 04 M 374.55YN
27613 04 I 113.60 17.00YN
27614 04 I 264.25 17.00YN
27615 04 M 521.56YN
Wednesday, June 18, 2008 Page 90 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27618 04 I 186.90YN
27619 04 M 268.40YN
27620 04 M 480.00YN
27625 04 M 480.00YN
27626 04 M 480.00YN
27630 04 M 188.65YN
27635 04 M 374.55YN
27637 04 M 599.35YN
27638 04 M 599.35YN
27640 04 M 407.80YN
27641 04 M 335.00YN
27645 04 M 599.35YN
27646 04 M 599.35YN
27647 04 M 449.50YN
27648 04 I 82.75YN
27650 04 M 359.30YN
27652 04 M 480.00YN
27654 04 M 449.50YN
27656 04 M 299.70YN
27658 04 M 224.70YN
27659 04 M 416.20YN
Wednesday, June 18, 2008 Page 91 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27664 04 M 182.50YN
27665 04 M 302.40YN
27675 04 M 239.30YN
27676 04 M 313.20YN
27680 04 M 381.50YN
27681 04 M 231.00YN
27685 04 M 262.20YN
27686 04 M 257.00YN
27687 04 M 262.20YN
27690 04 M 299.70YN
27691 04 M 524.40YN
27692 04 M 149.80YN
27695 04 M 374.55YN
27696 04 M 561.85YN
27698 04 M 453.70YN
27700 04 M 718.70YN
27702 04 M 749.20YN
27703 04 MYY
27704 04 M 249.35YN
27705 04 M 412.00YN
27707 04 M 359.30YN
Wednesday, June 18, 2008 Page 92 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27709 04 M 524.40YN
27712 04 M 674.20YN
27715 04 M 749.20YN
27720 04 M 629.90YN
27722 04 M 733.85YN
27724 04 M 840.75YN
27725 04 M 840.75YN
27726 04 1/1/2008 M 478.66YN
27727 04 M 648.10YN
27730 04 M 412.00YN
27732 04 M 314.95YN
27734 04 M 599.35YN
27740 04 M 839.35YN
27742 04 M 839.35YN
27745 04 M 378.05YN
27750 04 M 208.05YN
27752 04 M 320.45YN
27756 04 M 738.10YN
27758 04 M 839.35YN
27759 04 M 839.35YN
27760 04 M 166.40YN
Wednesday, June 18, 2008 Page 93 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27762 04 M 235.80YN
27766 04 M 535.45YN
27767 04 1/1/2008 M 131.63YN
27768 04 1/1/2008 M 208.32YN
27769 04 1/1/2008 M 362.81YN
27780 04 M 152.60YN
27781 04 M 217.80YN
27784 04 M 416.20YN
27786 04 M 152.60YN
27788 04 M 222.00YN
27792 04 M 299.70YN
27808 04 M 208.05YN
27810 04 M 305.15YN
27814 04 M 610.45YN
27816 04 M 224.70YN
27818 04 M 369.05YN
27822 04 M 599.35YN
27823 04 M 599.35YN
27824 04 M 232.20YN
27825 04 M 286.20YN
27826 04 M 515.70YN
Wednesday, June 18, 2008 Page 94 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27827 04 M 638.00YN
27828 04 M 696.90YN
27829 04 M 412.00YN
27830 04 M 153.75YN
27831 04 M 224.70YN
27832 04 M 599.35YN
27840 04 M 138.20YN
27842 04 M 208.05YN
27846 04 M 378.70YN
27848 04 M 481.90YN
27860 04 I 77.10YN
27870 04 M 659.00YN
27871 04 M 659.00YN
27880 04 M 613.20YN
27881 04 M 674.20YN
27882 04 M 588.20YN
27884 04 M 252.65YN
27886 04 M 374.55YN
27888 04 M 599.35YN
27889 04 M 374.55YN
27892 04 M 220.40YN
Wednesday, June 18, 2008 Page 95 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
27893 04 M 212.80YN
27894 04 M 293.20YN
27899 04 MY
28001 04 M 136.05 17.00YN
28002 04 M 143.95YN
28003 04 M 246.85YN
28005 04 M 270.50YN
28008 04 I 147.95YN
28010 04 I 123.35YN
28011 04 MYY
28020 04 M 224.70YN
28022 04 M 153.65YN
28024 04 I 146.15YN
28035 04 M 524.40YN
28043 04 M 149.80YN
28045 04 M 224.70YN
28046 04 MYY
28050 04 M 299.70YN
28052 04 M 299.70YN
28054 04 M 224.70YN
28055 04 1/1/2007 M 302.40YN
Wednesday, June 18, 2008 Page 96 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28060 04 M 224.70YN
28062 04 MYY
28070 04 M 224.70YN
28072 04 M 161.90YN
28080 04 M 180.30YN
28086 04 M 184.50YN
28088 04 M 184.50YN
28090 04 M 175.75 34.00YN
28092 04 M 211.35 34.00YN
28100 04 M 224.70YN
28102 04 M 718.70YN
28103 04 M 718.70YN
28104 04 M 259.40YN
28106 04 M 449.50YN
28107 04 M 449.50YN
28108 04 M 259.40YN
28110 04 M 359.30YN
28111 04 M 359.30YN
28112 04 M 314.95YN
28113 04 M 314.95YN
28114 04 M 943.40YN
Wednesday, June 18, 2008 Page 97 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28116 04 M 346.75YN
28118 04 M 346.75YN
28119 04 M 264.90YN
28120 04 M 259.40YN
28122 04 M 253.90YN
28124 04 M 259.40YN
28126 04 M 209.40YN
28130 04 M 412.00YN
28140 04 M 394.00YN
28150 04 M 209.40YN
28153 04 M 144.70YN
28160 04 M 224.70YN
28171 04 MYY
28173 04 MYY
28175 04 MYY
28190 04 I 107.00 17.00YN
28192 04 M 159.80 17.00YN
28193 04 M 180.30YN
28200 04 M 353.75YN
28202 04 M 480.00YN
28208 04 M 299.70YN
Wednesday, June 18, 2008 Page 98 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28210 04 M 378.05YN
28220 04 M 212.30YN
28222 04 MYY
28225 04 M 212.30YN
28226 04 MYY
28230 04 M 173.40YN
28232 04 I 121.10YN
28234 04 I 121.05YN
28238 04 M 299.70YN
28240 04 M 140.75YN
28250 04 M 359.30YN
28260 04 M 299.70YN
28261 04 M 363.45YN
28262 04 M 524.40YN
28264 04 M 449.50YN
28270 04 M 299.70YN
28272 04 M 224.70YN
28280 04 M 162.35YN
28285 04 M 270.50YN
28286 04 M 337.10YN
28288 04 M 299.70YN
Wednesday, June 18, 2008 Page 99 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28289 04 M 359.30YN
28290 04 M 424.45YN
28292 04 M 359.30YN
28293 04 M 359.30YN
28294 04 M 359.30YN
28296 04 M 419.00YN
28297 04 M 419.00YN
28298 04 M 359.30YN
28299 04 M 384.89YN
28300 04 M 374.55YN
28302 04 M 337.90YN
28304 04 M 283.60YN
28305 04 M 373.70YN
28306 04 M 262.20YN
28307 04 M 299.70YN
28308 04 M 202.50YN
28309 04 M 358.05YN
28310 04 M 262.20YN
28312 04 M 169.85YN
28313 04 M 167.10YN
28315 04 M 224.70YN
Wednesday, June 18, 2008 Page 100 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28320 04 M 378.05YN
28322 04 M 244.90YN
28340 04 M 270.00YN
28341 04 M 307.90YN
28344 04 M 172.80YN
28345 04 M 216.00YN
28360 04 MYY
28400 04 I 114.20YN
28405 04 M 228.90YN
28406 04 M 231.65YN
28415 04 M 642.45YN
28420 04 M 671.85YN
28430 04 M 109.00YN
28435 04 M 215.05YN
28436 04 M 318.60YN
28445 04 M 718.70YN
28446 04 1/1/2008 M 626.74YN
28450 04 M 98.00YN
28455 04 M 277.50YN
28456 04 M 313.20YN
28465 04 M 599.35YN
Wednesday, June 18, 2008 Page 101 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28470 04 I 97.05YN
28475 04 M 173.40YN
28476 04 M 237.85YN
28485 04 M 301.00YN
28490 04 I 55.40YN
28495 04 I 69.30YN
28496 04 M 113.60YN
28505 04 M 230.80YN
28510 04 I 41.60YN
28515 04 I 97.05YN
28525 04 I 202.90YN
28530 04 I 57.30YN
28531 04 M 224.70YN
28540 04 I 138.75YN
28545 04 I 152.60YN
28546 04 I 134.60YN
28555 04 M 480.00YN
28570 04 I 113.65YN
28575 04 M 151.15YN
28576 04 M 262.20YN
28585 04 M 427.20YN
Wednesday, June 18, 2008 Page 102 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28600 04 M 299.70YN
28605 04 M 299.70YN
28606 04 M 299.70YN
28615 04 M 368.45YN
28630 04 I 112.40YN
28635 04 M 262.20YN
28636 04 M 262.20YN
28645 04 M 240.00YN
28660 04 I 104.10YN
28665 04 I 117.85YN
28666 04 M 133.35YN
28675 04 M 241.35YN
28705 04 M 599.35YN
28715 04 M 599.35YN
28725 04 M 480.00YN
28730 04 M 480.00YN
28735 04 M 599.35YN
28737 04 M 599.35YN
28740 04 M 337.10YN
28750 04 M 262.20YN
28755 04 M 169.10YN
Wednesday, June 18, 2008 Page 103 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
28760 04 M 239.10YN
28800 04 M 485.50YN
28805 04 M 482.80YN
28810 04 M 419.00YN
28820 04 I 167.10YN
28825 04 I 145.60YN
28890 04 M 121.80YN
28899 04 MYY
29000 04 I 156.80YN
29010 04 I 141.50YN
29015 04 I 188.70YN
29020 04 I 205.30YN
29025 04 I 227.50YN
29035 04 I 152.60YN
29040 04 I 181.65YN
29044 04 I 173.40YN
29046 04 I 187.30YN
29049 04 I 66.10 34.00N
29055 04 I 115.80 34.00N
29058 04 I 79.30 34.00N
29065 04 I 59.45 34.00N
Wednesday, June 18, 2008 Page 104 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29075 04 I 59.45 34.00N
29085 04 I 49.30 17.00N
29086 04 I 30.70N
29105 04 I 42.10 17.00N
29125 04 I 32.15 17.00YN
29126 04 I 39.30 17.00YN
29130 04 I 23.00 17.00N
29131 04 I 23.50 17.00N
29200 04 I 24.25N
29220 04 I 23.00N
29240 04 I 37.40N
29260 04 I 19.95N
29280 04 I 19.30N
29305 04 I 166.40N
29325 04 I 194.20N
29345 04 I 79.30 34.00N
29355 04 I 92.40 34.00N
29358 04 I 174.40 34.00N
29365 04 I 79.30 34.00N
29405 04 I 70.00 34.00N
29425 04 I 75.30 34.00N
Wednesday, June 18, 2008 Page 105 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29435 04 I 79.30 34.00N
29440 04 I 29.80N
29445 04 I 91.65N
29450 04 I 43.50 17.00N
29505 04 I 43.50 17.00N
29515 04 I 35.85 17.00N
29520 04 I 21.40N
29530 04 I 21.80N
29540 04 I 15.40N
29550 04 I 14.20N
29580 04 I 27.00 17.00N
29590 04 I 22.15N
29700 04 I 24.15N
29705 04 I 25.60N
29710 04 I 56.80N
29715 04 I 94.30N
29720 04 I 59.60N
29730 04 I 36.00N
29740 04 I 46.55N
29750 04 I 44.30N
29799 04 IY
Wednesday, June 18, 2008 Page 106 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29800 04 M 374.55YN
29804 04 M 355.80YN
29805 04 M 325.20YN
29806 04 M 673.30YN
29807 04 M 673.30YN
29819 04 M 480.00YN
29820 04 M 480.00YN
29821 04 M 480.00YN
29822 04 M 480.00YN
29823 04 M 480.00YN
29824 04 M 526.45YN
29825 04 M 480.00YN
29826 04 M 480.00YN
29827 04 M 674.20YN
29828 04 1/1/2008 M 484.90YN
29830 04 M 394.50YN
29834 04 M 480.00YN
29835 04 M 480.00YN
29836 04 M 480.00YN
29837 04 M 480.00YN
29838 04 M 480.00YN
Wednesday, June 18, 2008 Page 107 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29840 04 M 356.10YN
29843 04 M 356.10YN
29844 04 M 480.00YN
29845 04 M 480.00YN
29846 04 M 356.10YN
29847 04 M 480.00YN
29848 04 M 456.00YN
29850 04 M 675.10YN
29851 04 M 958.60YN
29855 04 M 629.90YN
29856 04 M 839.35YN
29860 04 M 374.55YN
29861 04 M 486.90YN
29862 04 M 599.35YN
29863 04 M 599.35YN
29866 04 MYY
29867 04 MYY
29868 04 MYY
29870 04 M 374.55YN
29871 04 M 374.55YN
29873 04 M 374.55YN
Wednesday, June 18, 2008 Page 108 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29874 04 M 486.90YN
29875 04 M 599.35YN
29876 04 M 599.35YN
29877 04 M 599.35YN
29879 04 M 599.35YN
29880 04 M 621.50YN
29881 04 M 621.50YN
29882 04 M 621.50YN
29883 04 M 599.35YN
29884 04 M 599.35YN
29885 04 M 621.50YN
29886 04 M 599.35YN
29887 04 M 599.35YN
29888 04 M 621.50YN
29889 04 M 621.50YN
29891 04 M 480.00YN
29892 04 M 480.00YN
29893 04 M 171.90YN
29894 04 M 480.00YN
29895 04 M 480.00YN
29897 04 M 480.00YN
Wednesday, June 18, 2008 Page 109 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
29898 04 M 480.00YN
29899 04 M 659.00YN
29900 04 M 288.60YN
29901 04 M 318.80YN
29902 04 M 342.55YN
29904 04 1/1/2008 M 323.37YN
29905 04 1/1/2008 M 347.96YN
29906 04 1/1/2008 M 366.46YN
29907 04 1/1/2008 M 451.20YN
29999 04 MYY
30000 04 I 46.70 17.00YN
30020 04 I 47.80 17.00N
30100 04 I 55.40 17.00YN
30110 04 I 57.10 17.00YN
30115 04 M 156.80YN
30117 04 I 109.30YN
30118 04 I 299.35YN
30120 04 M 480.00YN
30124 04 I 89.10 17.00YN
30125 04 I 218.95YN
30130 04 M 180.30YN
Wednesday, June 18, 2008 Page 110 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
30140 04 M 180.30YN
30150 04 MYY
30160 04 MYY
30200 04 I 24.90YN
30210 04 I 34.80YN
30220 04 I 56.00YN
30300 04 I 39.05N
30310 04 I 74.90YN
30320 04 I 152.60YN
30400 04 M 749.20YN
30410 04 M 749.20YN
30420 04 M 980.85YN
30430 04 M 374.55YN
30435 04 MYY
30450 04 M 599.35YN
30460 04 M 599.35YN
30462 04 M 815.50YN
30465 04 M 547.60YN
30520 04 M 417.60YN
30540 04 M 524.40YN
30545 04 M 674.20YN
Wednesday, June 18, 2008 Page 111 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
30560 04 I 42.00YN
30580 04 M 374.55YN
30600 04 M 374.55YN
30620 04 M 524.40YN
30630 04 M 524.40YN
30801 04 I 50.05YN
30802 04 I 71.15YN
30901 04 I 74.90YN
30903 04 I 71.40 17.00YN
30905 04 I 80.75 17.00YN
30906 04 I 85.70 17.00YN
30915 04 M 359.30YN
30920 04 M 359.30YN
30930 04 I 90.10YN
30999 04 MYY
31000 04 I 39.35YN
31002 04 I 51.50YN
31020 04 M 180.30YN
31030 04 M 480.00YN
31032 04 M 718.70YN
31040 04 M 359.30YN
Wednesday, June 18, 2008 Page 112 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31050 04 M 412.00YN
31051 04 M 412.00YN
31070 04 M 180.30YN
31075 04 M 599.35YN
31080 04 M 898.95YN
31081 04 M 898.95YN
31084 04 M 898.95YN
31085 04 M 898.95YN
31086 04 M 898.95YN
31087 04 M 898.95YN
31090 04 M 718.70YN
31200 04 M 262.20YN
31201 04 M 449.50YN
31205 04 M 449.50YN
31225 04 M 898.95YN
31230 04 M 1,198.70YN
31231 04 I 107.00YN
31233 04 I 112.40YN
31235 04 I 107.00YN
31237 04 I 102.55YN
31238 04 I 113.10YN
Wednesday, June 18, 2008 Page 113 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31239 04 MYY
31240 04 M 221.90YN
31254 04 M 262.20YN
31255 04 M 449.50YN
31256 04 M 180.30YN
31267 04 M 224.70YN
31276 04 M 253.30YN
31287 04 M 205.95YN
31288 04 M 412.00YN
31290 04 MYY
31291 04 MYY
31292 04 M 451.50YN
31293 04 M 492.15YN
31294 04 M 581.00YN
31299 04 MYY
31300 04 M 524.40YN
31320 04 M 299.70YN
31360 04 M 1,198.70YN
31365 04 M 1,537.15YN
31367 04 M 958.60YN
31368 04 M 1,537.15YN
Wednesday, June 18, 2008 Page 114 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31370 04 M 958.60YN
31375 04 M 958.60YN
31380 04 M 958.60YN
31382 04 M 958.60YN
31390 04 M 1,537.15YN
31395 04 M 1,728.25YN
31400 04 M 749.20YN
31420 04 M 524.40YN
31500 04 I 55.50N
31502 04 I 28.50N
31505 04 I 37.40YN
31510 04 I 74.90YN
31511 04 I 202.50YN
31512 04 M 202.50YN
31513 04 M 235.80YN
31515 04 I 107.00 17.00YN
31520 04 I 112.40YN
31525 04 I 107.00 17.00YN
31526 04 I 192.95 17.00YN
31527 04 M 192.95 17.00YN
31528 04 I 192.95 17.00YN
Wednesday, June 18, 2008 Page 115 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31529 04 I 192.95 17.00YN
31530 04 M 192.95 34.00YN
31531 04 M 224.60 34.00YN
31535 04 I 224.60 34.00YN
31536 04 I 224.60 34.00YN
31540 04 M 268.20 34.00YN
31541 04 M 268.20 34.00YN
31545 04 M 268.20YN
31546 04 M 577.16YN
31560 04 M 499.45 34.00YN
31561 04 M 499.45 34.00YN
31570 04 M 224.60 34.00YN
31571 04 M 224.60 34.00YN
31575 04 I 107.00 34.00YN
31576 04 I 224.60 34.00YN
31577 04 M 192.95 34.00YN
31578 04 M 268.20 34.00YN
31579 04 I 192.95YN
31580 04 M 524.35YN
31582 04 M 686.80YN
31584 04 M 591.60YN
Wednesday, June 18, 2008 Page 116 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31587 04 M 524.35YN
31588 04 MYY
31590 04 M 839.35YN
31595 04 M 360.70YN
31599 04 MYY
31600 04 I 266.40YN
31601 04 I 284.40YN
31603 04 I 266.40YN
31605 04 I 266.40YN
31610 04 I 289.40YN
31611 04 M 374.60YN
31612 04 I 149.80YN
31613 04 M 208.05YN
31614 04 MYY
31615 04 I 107.00 17.00YN
31620 04 I 56.70YY
31622 04 I 235.20 56.70YN
31623 04 I 235.20YN
31624 04 I 270.50YN
31625 04 I 235.20 56.70YN
31628 04 I 246.95YN
Wednesday, June 18, 2008 Page 117 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31629 04 I 235.20YN
31630 04 M 251.10YN
31631 04 M 251.10YN
31632 04 I 30.94YN
31633 04 I 38.51YN
31635 04 M 239.15 56.70YN
31636 04 M 251.10YN
31637 04 M 251.10YN
31638 04 M 251.10YN
31640 04 M 251.10YN
31641 04 M 251.10YN
31643 04 I 235.95YN
31645 04 I 219.35 56.70YN
31646 04 I 219.35 56.70YN
31656 04 I 270.50YN
31715 04 I 74.90YN
31717 04 I 230.25YN
31720 04 I 224.70N
31725 04 I 224.70N
31730 04 I 88.90YN
31750 04 M 713.50YN
Wednesday, June 18, 2008 Page 118 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
31755 04 M 527.50YN
31760 04 M 1,123.70YN
31766 04 M 1,198.70YN
31770 04 M 1,048.85YN
31775 04 M 1,123.70YN
31780 04 M 749.20YN
31781 04 M 1,123.70YN
31785 04 M 1,198.70YN
31786 04 M 1,198.70YN
31800 04 M 524.40YN
31805 04 M 749.20YN
31820 04 M 214.00 34.00YN
31825 04 M 374.55YN
31830 04 M 166.75YN
31899 04 MY
32035 04 M 524.40YN
32036 04 M 331.15YN
32095 04 M 419.00YN
32100 04 M 811.50YN
32110 04 M 811.50YN
32120 04 M 599.35YN
Wednesday, June 18, 2008 Page 119 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
32124 04 M 599.35YN
32140 04 M 599.35YN
32141 04 M 599.35YN
32150 04 M 599.35YN
32151 04 M 599.35YN
32160 04 M 374.55YN
32200 04 M 480.00YN
32201 04 M 434.45YN
32215 04 M 599.35YN
32220 04 M 749.20YN
32225 04 M 599.35YN
32310 04 M 958.60YN
32320 04 M 1,198.70YN
32400 04 I 71.40 34.00YN
32402 04 M 524.40YN
32405 04 I 107.00 34.00YN
32420 04 I 107.00 34.00YN
32421 04 1/1/2008 I 87.98YN
32422 04 1/1/2008 I 108.51YN
32440 04 M 1,198.70N
32442 04 M 1,414.70N
Wednesday, June 18, 2008 Page 120 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
32445 04 M 1,198.70N
32480 04 M 1,213.95N
32482 04 M 1,213.95N
32484 04 M 1,213.95N
32486 04 M 1,350.15N
32488 04 M 1,213.95N
32491 04 M 1,213.95N
32500 04 M 718.70N
32501 04 M 324.05N
32503 04 M 1,050.34YN
32504 04 M 1,203.13YN
32540 04 M 958.60YN
32550 04 1/1/2008 M 127.01 318.46YN
32551 04 1/1/2008 M 101.27YN
32560 04 1/1/2008 I 165.83YN
32601 04 I 167.20YN
32602 04 I 181.35YN
32603 04 I 302.40YN
32604 04 I 302.40YN
32605 04 I 314.95YN
32606 04 I 314.95YN
Wednesday, June 18, 2008 Page 121 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
32650 04 M 349.85YN
32651 04 M 426.10YN
32652 04 M 591.40YN
32653 04 M 418.50YN
32654 04 M 400.80YN
32655 04 M 838.95YN
32656 04 M 523.85YN
32657 04 M 523.85YN
32658 04 M 415.90YN
32659 04 M 415.55YN
32660 04 M 648.10YN
32661 04 M 523.85YN
32662 04 M 598.40YN
32663 04 M 1,213.85YN
32664 04 M 749.20YN
32665 04 M 1,082.10YN
32800 04 MYY
32810 04 M 398.40YN
32815 04 MYY
32820 04 MYY
32850 04 M 1,134.10N
Wednesday, June 18, 2008 Page 122 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
32851 04 M 2,106.30N
32852 04 M 2,397.40N
32853 04 M 3,402.50N
32854 04 M 3,834.55N
32900 04 M 564.90YN
32905 04 M 749.20YN
32906 04 M 772.90YN
32940 04 M 571.55N
32960 04 I 299.70YN
32997 04 M 246.40YN
32998 04 1/1/2007 M 214.24YN
32999 04 MY
33010 04 I 61.25YN
33011 04 I 57.55YN
33015 04 I 204.05YN
33020 04 M 733.85YN
33025 04 M 839.35YN
33030 04 M 839.35N
33031 04 M 2,397.40N
33050 04 M 1,048.85N
33120 04 M 2,397.40N
Wednesday, June 18, 2008 Page 123 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33130 04 M 749.20N
33140 04 MYY
33141 04 MYY
33202 04 1/1/2007 M 861.50YN
33203 04 1/1/2007 M 349.85YN
33206 04 M 861.50YN
33207 04 M 861.50YN
33208 04 M 861.50YN
33210 04 I 240.00YN
33211 04 I 240.00YN
33212 04 I 240.00YN
33213 04 I 240.00YN
33214 04 M 299.70YN
33215 04 M 299.70YN
33216 04 M 299.70YN
33217 04 M 299.70YN
33218 04 M 299.70YN
33220 04 M 245.65YN
33222 04 M 299.70YN
33223 04 M 299.70YN
33224 04 M 299.70YN
Wednesday, June 18, 2008 Page 124 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33225 04 M 299.70YN
33226 04 M 299.70YN
33233 04 M 167.40YN
33234 04 M 351.00YN
33235 04 M 351.00YN
33236 04 M 419.00YN
33237 04 M 433.95YN
33238 04 M 452.80YN
33240 04 IYY
33241 04 IYY
33243 04 MYY
33244 04 IYY
33249 04 M 642.60YN
33250 04 M 1,798.10N
33251 04 M 2,397.40YN
33254 04 1/1/2007 M 2,397.40YN
33255 04 1/1/2007 M 2,397.40YN
33256 04 1/1/2007 M 2,397.40YN
33257 04 1/1/2008 M 327.74N
33258 04 1/1/2008 M 371.27N
33259 04 1/1/2008 M 489.48N
Wednesday, June 18, 2008 Page 125 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33261 04 M 2,397.40N
33265 04 1/1/2007 M 2,397.40YN
33266 04 1/1/2007 M 2,397.40YN
33282 04 M 584.80YN
33284 04 M 444.05YN
33300 04 M 629.90N
33305 04 M 2,397.40N
33310 04 M 1,048.85YN
33315 04 M 2,397.40N
33320 04 M 749.20YN
33321 04 M 1,798.05N
33322 04 M 2,397.40N
33330 04 M 1,198.70N
33332 04 M 2,397.40N
33335 04 M 2,397.40N
33400 04 M 2,397.40N
33401 04 M 2,397.40N
33403 04 M 2,397.40N
33404 04 MY
33405 04 M 2,397.40N
33406 04 M 2,397.40N
Wednesday, June 18, 2008 Page 126 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33410 04 M 2,397.40N
33411 04 M 2,397.40N
33412 04 M 2,397.40N
33413 04 M 2,397.40N
33414 04 MY
33415 04 M 1,198.70N
33416 04 M 2,397.40N
33417 04 MY
33420 04 M 1,048.85N
33422 04 M 2,397.40N
33425 04 M 2,397.40N
33426 04 M 2,397.40N
33427 04 M 2,397.40N
33430 04 M 2,397.40N
33460 04 M 2,397.40N
33463 04 M 2,397.40N
33464 04 M 2,397.40N
33465 04 M 2,397.40N
33468 04 M 2,397.40N
33470 04 M 749.20N
33471 04 M 1,198.70N
Wednesday, June 18, 2008 Page 127 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33472 04 M 1,198.70N
33474 04 M 2,397.40N
33475 04 M 2,397.40N
33476 04 M 1,198.70N
33478 04 M 2,277.50N
33496 04 M 2,397.40N
33500 04 M 2,397.40N
33501 04 M 1,198.70N
33502 04 M 749.20YN
33503 04 M 2,397.40YN
33504 04 M 2,397.40N
33505 04 MY
33506 04 MY
33507 04 M 1,014.99YN
33508 04 M 17.04YN
33510 04 M 2,397.40N
33511 04 M 2,397.40N
33512 04 M 2,397.40N
33513 04 M 2,397.40N
33514 04 M 2,397.40N
33516 04 M 2,397.40N
Wednesday, June 18, 2008 Page 128 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33517 04 M 2,397.40N
33518 04 M 2,397.40N
33519 04 M 2,397.40N
33521 04 M 2,397.40N
33522 04 M 2,397.40N
33523 04 M 2,397.40N
33530 04 M 2,397.40N
33533 04 M 2,397.40N
33534 04 M 2,397.40N
33535 04 M 2,397.40N
33536 04 M 2,397.40N
33542 04 M 1,198.70N
33545 04 M 2,397.40N
33548 04 M 1,333.12YN
33572 04 M 2,397.40N
33600 04 MY
33602 04 MY
33606 04 MY
33608 04 MY
33610 04 MY
33611 04 MY
Wednesday, June 18, 2008 Page 129 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33612 04 MY
33615 04 M 2,397.40N
33617 04 M 2,397.40N
33619 04 M 2,397.40N
33641 04 M 2,397.40N
33645 04 M 2,397.40N
33647 04 M 2,397.40N
33660 04 M 2,397.40N
33665 04 M 2,397.40N
33670 04 M 2,397.40N
33675 04 1/1/2007 M 2,397.40YN
33676 04 1/1/2007 M 2,397.40YN
33677 04 1/1/2007 M 2,397.40YN
33681 04 M 2,397.40N
33684 04 M 2,397.40N
33688 04 M 2,397.40N
33690 04 M 958.60N
33692 04 M 2,397.40N
33694 04 M 2,397.40N
33697 04 M 2,996.80N
33702 04 M 2,397.40N
Wednesday, June 18, 2008 Page 130 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33710 04 M 2,397.40N
33720 04 M 2,397.40N
33722 04 MY
33724 04 1/1/2007 M 2,397.40YN
33726 04 1/1/2007 M 2,721.45YN
33730 04 M 2,721.45N
33732 04 M 2,397.40N
33735 04 M 1,198.70N
33736 04 M 2,397.40N
33737 04 M 2,397.40N
33750 04 M 1,079.30N
33755 04 M 1,079.30N
33762 04 M 1,079.30N
33764 04 M 1,198.70N
33766 04 M 1,079.30N
33767 04 M 2,397.40N
33768 04 M 255.00YN
33770 04 M 2,996.80N
33771 04 M 2,996.80N
33774 04 M 2,397.40N
33775 04 M 2,397.40N
Wednesday, June 18, 2008 Page 131 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33776 04 M 2,996.60N
33777 04 M 2,996.60N
33778 04 M 2,397.40N
33779 04 M 2,397.40N
33780 04 M 2,996.60N
33781 04 M 2,996.60N
33786 04 M 2,397.40N
33788 04 M 2,057.80N
33800 04 M 1,123.70N
33802 04 M 1,123.70N
33803 04 M 1,501.75N
33813 04 M 1,797.95N
33814 04 M 2,397.40N
33820 04 M 839.35N
33822 04 M 839.35N
33824 04 M 1,079.30N
33840 04 M 1,198.70N
33845 04 M 1,198.70N
33851 04 M 1,198.70N
33852 04 M 2,397.40N
33853 04 M 2,397.40N
Wednesday, June 18, 2008 Page 132 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33860 04 M 2,397.40N
33861 04 M 2,397.40N
33863 04 M 2,397.40N
33864 04 1/1/2008 M 1794.48N
33870 04 M 2,397.40N
33875 04 MY
33877 04 MY
33880 04 M 1,042.97YN
33881 04 M 894.71YN
33883 04 M 662.83YN
33884 04 M 249.09YN
33886 04 M 571.51YN
33889 04 M 499.99YN
33891 04 M 636.67YN
33910 04 M 2,397.40N
33915 04 MY
33916 04 M 2,397.40N
33917 04 M 2,397.40N
33920 04 M 2,397.40N
33922 04 M 2,397.40N
33924 04 M 324.05N
Wednesday, June 18, 2008 Page 133 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
33925 04 M 1,037.68YN
33926 04 M 1,407.80YN
33930 04 M 1,306.65N
33935 04 M 4,104.60N
33940 04 M 1,198.70N
33945 04 M 2,894.30N
33960 04 I 453.70N
33961 04 I 295.60N
33967 04 I 230.20YN
33968 04 M 162.00YN
33970 04 M 689.50YN
33971 04 M 334.80YN
33973 04 M 689.50YN
33974 04 M 419.25YN
33975 04 M 1,350.15YN
33976 04 M 1,674.20YN
33977 04 M 1,215.15N
33978 04 M 1,458.20N
33979 04 M 730.85N
33980 04 M 787.90N
33999 04 MY
Wednesday, June 18, 2008 Page 134 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
34001 04 M 718.70YN
34051 04 M 718.70YN
34101 04 M 718.70YN
34111 04 M 718.70YN
34151 04 M 718.70YN
34201 04 M 718.70YN
34203 04 M 718.70YN
34401 04 M 718.70YN
34421 04 M 718.70YN
34451 04 M 898.95YN
34471 04 M 599.35YN
34490 04 M 599.35YN
34501 04 M 480.00YN
34502 04 MYY
34510 04 M 480.00YN
34520 04 M 480.00YN
34530 04 M 599.35YN
34800 04 M 819.60YN
34802 04 M 904.75YN
34803 04 M 1,148.60YN
34804 04 M 904.75YN
Wednesday, June 18, 2008 Page 135 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
34805 04 M 669.46YN
34806 04 1/1/2008 M 59.78YN
34808 04 M 156.10YN
34812 04 M 255.70YN
34813 04 M 181.55YN
34820 04 M 369.05YN
34825 04 M 488.60YN
34826 04 M 156.10YN
34830 04 M 1,276.30YN
34831 04 M 1,379.95YN
34832 04 M 1,379.95YN
34833 04 M 488.60YN
34834 04 M 369.05YN
34900 04 M 488.60YN
35001 04 M 1,123.70YN
35002 04 M 1,306.65YN
35005 04 M 1,414.70YN
35011 04 M 898.95YN
35013 04 M 1,198.70YN
35021 04 M 1,198.70YN
35022 04 M 1,414.70YN
Wednesday, June 18, 2008 Page 136 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35045 04 M 599.35YN
35081 04 M 1,198.70YN
35082 04 M 1,630.70YN
35091 04 M 1,198.70YN
35092 04 M 1,630.70YN
35102 04 M 1,198.70YN
35103 04 M 1,630.70YN
35111 04 M 1,198.70YN
35112 04 M 1,630.70YN
35121 04 M 1198.70YN
35122 04 M 1630.70YN
35131 04 M 958.60YN
35132 04 M 1,198.70YN
35141 04 M 958.60YN
35142 04 M 1,198.70YN
35151 04 M 958.60YN
35152 04 M 1,198.70YN
35180 04 M 1,198.70YN
35182 04 M 952.10YN
35184 04 M 599.35YN
35188 04 M 1,198.70YN
Wednesday, June 18, 2008 Page 137 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35189 04 M 952.10YN
35190 04 M 599.35YN
35201 04 M 1,198.70YN
35206 04 M 599.35YN
35207 04 M 341.20YN
35211 04 M 1,498.30YN
35216 04 M 1,198.70YN
35221 04 M 1,198.70YN
35226 04 M 599.35YN
35231 04 M 599.35YN
35236 04 M 599.35YN
35241 04 M 1498.30YN
35246 04 M 1,198.70YN
35251 04 M 1198.70YN
35256 04 M 599.35YN
35261 04 M 599.35YN
35266 04 M 599.35YN
35271 04 M 1498.30YN
35276 04 M 1198.70YN
35281 04 M 1198.70YN
35286 04 M 599.35YN
Wednesday, June 18, 2008 Page 138 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35301 04 M 1101.60YN
35302 04 1/1/2007 M 958.60YN
35303 04 1/1/2007 M 958.60YN
35304 04 1/1/2007 M 958.60YN
35305 04 1/1/2007 M 958.60YN
35306 04 1/1/2007 M 958.60YN
35311 04 M 749.20YN
35321 04 M 749.20YN
35331 04 M 1198.70YN
35341 04 M 958.60YN
35351 04 M 958.60YN
35355 04 M 958.60YN
35361 04 M 1,198.70YN
35363 04 M 1,198.70YN
35371 04 M 958.60YN
35372 04 M 1,021.15YN
35390 04 MYY
35400 04 IYY
35450 04 M 682.80YN
35452 04 M 682.80YN
35454 04 M 682.80YN
Wednesday, June 18, 2008 Page 139 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35456 04 M 479.00YN
35458 04 M 479.00YN
35459 04 M 479.00YN
35460 04 M 479.00YN
35470 04 M 479.00YN
35471 04 M 479.00YN
35472 04 M 479.00YN
35473 04 M 479.00YN
35474 04 M 479.00YN
35475 04 M 479.00YN
35476 04 M 479.00YN
35480 04 M 1,101.20YN
35481 04 M 1,198.70YN
35482 04 M 958.60YN
35483 04 M 958.60YN
35484 04 M 749.20YN
35485 04 M 958.60YN
35490 04 M 1,024.15YN
35491 04 M 1,024.15YN
35492 04 M 1,024.15YN
35493 04 M 718.50YN
Wednesday, June 18, 2008 Page 140 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35494 04 M 718.50YN
35495 04 M 718.50YN
35500 04 M 209.75YN
35501 04 M 839.35YN
35506 04 M 958.60YN
35508 04 M 958.60YN
35509 04 M 958.60YN
35510 04 M 708.05YN
35511 04 M 958.60YN
35512 04 M 694.72YN
35515 04 M 958.60YN
35516 04 M 958.60YN
35518 04 M 958.60YN
35521 04 M 1,198.70YN
35522 04 M 674.99YN
35523 04 1/1/2008 M 726.14YN
35525 04 M 644.91YN
35526 04 M 958.60YN
35531 04 M 958.60YN
35533 04 M 1,198.70YN
35536 04 M 958.60YN
Wednesday, June 18, 2008 Page 141 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35537 04 1/1/2007 M 1,198.70YN
35538 04 1/1/2007 M 1,198.70YN
35539 04 1/1/2007 M 839.35YN
35540 04 1/1/2007 M 839.35YN
35548 04 M 839.35YN
35549 04 M 1,198.70YN
35551 04 M 1,198.70YN
35556 04 M 958.60YN
35558 04 M 1,079.30YN
35560 04 M 1,198.70YN
35563 04 M 1,198.70YN
35565 04 M 1,198.70YN
35566 04 M 958.60YN
35571 04 M 958.60YN
35572 04 M 209.75YN
35583 04 M 958.60YN
35585 04 M 958.60YN
35587 04 M 958.60YN
35600 04 M 192.75YN
35601 04 M 839.35YN
35606 04 M 958.60YN
Wednesday, June 18, 2008 Page 142 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35612 04 M 958.60YN
35616 04 M 958.60YN
35621 04 M 1,198.70YN
35623 04 M 1,306.65YN
35626 04 M 958.60N
35631 04 M 1,198.70N
35636 04 M 1,079.30N
35637 04 1/1/2007 M 1,198.70YN
35638 04 1/1/2007 M 1,198.70YN
35642 04 M 958.60N
35645 04 M 958.60N
35646 04 M 1,198.70N
35647 04 M 1,053.80N
35650 04 M 1,079.30N
35651 04 M 1,198.70N
35654 04 M 1,198.70N
35656 04 M 958.60N
35661 04 M 1,079.30N
35663 04 M 1,198.70N
35665 04 M 1,198.70N
35666 04 M 958.60N
Wednesday, June 18, 2008 Page 143 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35671 04 M 958.60N
35681 04 MY
35682 04 M 314.60N
35683 04 M 314.60N
35685 04 I 146.50N
35686 04 I 129.25N
35691 04 M 1,198.70YN
35693 04 M 1,198.70YN
35694 04 M 1,198.70YN
35695 04 M 1,198.70YN
35697 04 M 90.02YN
35700 04 MYY
35701 04 M 374.55YN
35721 04 M 299.70YN
35741 04 M 299.70YN
35761 04 MYY
35800 04 M 374.55YN
35820 04 M 524.40YN
35840 04 M 480.00N
35860 04 M 449.50YN
35870 04 MYY
Wednesday, June 18, 2008 Page 144 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
35875 04 M 449.50YN
35876 04 M 455.15YN
35879 04 M 599.35YN
35881 04 M 789.80YN
35883 04 1/1/2007 M 599.35YN
35884 04 1/1/2007 M 599.35YN
35901 04 M 599.35YN
35903 04 M 449.50YN
35905 04 M 811.50YN
35907 04 M 599.35YN
36000 09 IY
36002 04 IYY
36005 04 I 136.65YN
36010 04 I 224.70YN
36011 04 I 249.35YN
36012 04 I 264.80YN
36013 04 I 213.50YN
36014 04 I 213.50YN
36015 04 I 249.35YN
36100 04 I 213.65YN
36120 04 I 233.00YN
Wednesday, June 18, 2008 Page 145 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
36140 04 I 188.70YN
36145 04 I 188.70YN
36160 04 I 202.50YN
36200 04 I 224.70YN
36215 04 I 198.90YN
36216 04 I 264.80YN
36217 04 I 281.00YN
36218 04 I 281.00YN
36245 04 I 213.50YN
36246 04 I 264.80YN
36247 04 I 281.00YN
36248 04 I 281.00YN
36260 04 MYY
36261 04 MYY
36262 04 MYY
36299 04 IYY
36400 04 I 16.65YN
36405 04 I 16.65YN
36406 04 I 16.65N
36410 04 I 16.65N
36415 J 04 I 4.10 1 4.10N
Wednesday, June 18, 2008 Page 146 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
36416 09 IY
36420 04 I 37.40YN
36425 04 I 37.40YN
36430 04 I 16.65YN
36440 04 I 28.80YN
36450 04 I 308.00YN
36455 04 I 338.50YN
36460 04 I 176.90YN
36470 04 I 17.00Y
36471 04 I 17.00Y
36475 04 M 213.52YN
36476 04 M 104.57YN
36478 04 M 213.52YN
36479 04 M 104.57YN
36481 04 I 264.80YN
36500 04 I 71.05N
36510 04 I 25.20N
36511 04 IYY
36512 04 IYY
36513 04 IYY
36514 04 IYY
Wednesday, June 18, 2008 Page 147 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
36515 04 IYY
36516 04 IYY
36522 04 M 599.30YN
36555 04 I 74.38YN
36556 04 I 67.13YN
36557 04 I 166.18YN
36558 04 I 158.02YN
36560 04 I 196.66YN
36561 04 I 190.09YN
36563 04 I 197.81YN
36565 04 I 190.09YN
36566 04 I 203.24YN
36568 04 I 55.01YN
36569 04 I 51.61YN
36570 04 I 171.97YN
36571 04 I 171.37YN
36575 04 I 33.10YN
36576 04 I 112.21YN
36578 04 I 126.75YN
36580 04 I 38.25YN
36581 04 I 118.78YN
Wednesday, June 18, 2008 Page 148 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
36582 04 I 171.77YN
36583 04 I 173.17YN
36584 04 I 38.64YN
36585 04 I 161.21YN
36589 04 I 78.73YN
36590 04 I 107.54YN
36593 04 1/1/2008 I 22.14YN
36595 04 I 107.23YN
36596 04 I 25.85YN
36597 04 I 34.37YN
36598 04 I 67.51YN
36600 09 IY
36620 04 I 37.40N
36625 04 I 52.70YN
36640 04 I 74.90YN
36660 04 I 37.40YN
36680 04 I 90.10YN
36800 04 M 424.45YN
36810 04 M 424.45YN
36815 04 I 112.40YN
36818 04 M 850.30YN
Wednesday, June 18, 2008 Page 149 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
36819 04 M 850.30YN
36820 04 M 541.15YN
36821 04 M 578.55YN
36822 04 M 599.30YN
36823 04 M 578.55YN
36825 04 M 578.55YN
36830 04 M 578.55YN
36831 04 M 578.55YN
36832 04 M 578.55YN
36833 04 M 578.55YN
36834 04 M 599.35YN
36835 04 M 578.55YN
36838 04 M 666.71YN
36860 04 I 112.40YN
36861 04 I 419.00YN
36870 04 M 884.80YN
37140 04 M 1198.70YN
37145 04 M 1079.30YN
37160 04 M 1079.30YN
37180 04 M 1079.30YN
37181 04 M 1079.30YN
Wednesday, June 18, 2008 Page 150 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
37182 04 M 910.70YN
37183 04 I 429.07YN
37184 04 M 265.81YN
37185 04 I 97.64YN
37186 04 M 146.50YN
37187 04 M 247.12YN
37188 04 I 178.38YN
37195 04 M 472.40YN
37200 04 I 189.00YN
37201 04 I 472.40YN
37202 04 I 189.00YN
37203 04 M 682.80YN
37204 04 M 682.80YN
37205 04 M 910.70YN
37206 04 MYY
37207 04 M 910.70YN
37208 04 MYY
37209 04 M 213.50YN
37210 04 1/1/2007 M 682.80YN
37215 04 M 910.70YN
37216 04 M 910.70YN
Wednesday, June 18, 2008 Page 151 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
37250 04 I 89.10YN
37251 04 I 57.65YN
37500 04 I 299.70YN
37501 04 IYY
37565 04 M 374.55YN
37600 04 M 374.55YN
37605 04 M 449.50YN
37606 04 M 449.50YN
37607 04 M 262.20YN
37609 04 I 112.40YN
37615 04 M 374.55YN
37616 04 M 524.40YN
37617 04 M 524.40YN
37618 04 M 262.20YN
37620 04 M 449.50YN
37650 04 M 374.55YN
37660 04 M 449.50YN
37700 04 M 203.95YN
37718 04 I 227.39YN
37722 04 I 275.02YN
37735 04 M 419.00YN
Wednesday, June 18, 2008 Page 152 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
37760 04 M 299.70YN
37765 04 M 245.90YN
37766 04 M 298.81YN
37780 04 M 149.80YN
37785 04 I 131.25YN
37788 04 MYY
37790 04 MYY
37799 04 MYY
38100 04 M 770.00N
38101 04 M 770.00N
38102 04 MY
38115 04 M 770.00N
38120 04 M 770.00YN
38129 04 MYY
38200 04 I 66.50YN
38204 09 IY
38205 04 IY
38206 04 IY
38207 09 IY
38208 09 IY
38209 09 IY
Wednesday, June 18, 2008 Page 153 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
38210 09 IY
38211 09 IY
38212 09 IY
38213 09 IY
38214 09 IY
38215 09 IY
38220 04 I 50.15YN
38221 04 I 78.45YN
38230 04 M 660.65YN
38240 04 M 220.20N
38241 04 M 220.20N
38242 04 I 80.55N
38300 04 I 71.40 17.00YN
38305 04 I 156.95 17.00YN
38308 04 MYY
38380 04 M 556.25YN
38381 04 M 811.60YN
38382 04 M 612.15YN
38500 04 I 85.70 17.00YN
38505 04 I 106.80 17.00YN
38510 04 I 127.70YN
Wednesday, June 18, 2008 Page 154 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
38520 04 I 157.90YN
38525 04 I 135.60YN
38530 04 I 189.25YN
38542 04 I 185.45YN
38550 04 M 224.70YN
38555 04 M 656.60YN
38562 04 M 480.00YN
38564 04 M 599.35YN
38570 04 M 302.40YN
38571 04 M 599.35YN
38572 04 M 599.35YN
38589 04 MYY
38700 04 M 786.60YN
38720 04 M 861.50YN
38724 04 M 645.45YN
38740 04 M 524.40YN
38745 04 M 524.40YN
38746 04 MYY
38747 04 MYY
38760 04 M 299.70YN
38765 04 M 918.40YN
Wednesday, June 18, 2008 Page 155 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
38770 04 M 918.40YN
38780 04 M 998.80YN
38790 04 I 220.85YN
38792 04 I 105.40YN
38794 04 MYY
38999 04 MYY
39000 04 M 718.70YN
39010 04 M 718.70YN
39200 04 M 749.20YN
39220 04 M 749.20YN
39400 04 I 314.95YN
39499 04 MYY
39501 04 M 648.60YN
39502 04 M 826.50YN
39503 04 M 960.55N
39520 04 M 682.60N
39530 04 M 682.60N
39531 04 M 735.45N
39540 04 M 682.60N
39541 04 M 682.60N
39545 04 M 682.60N
Wednesday, June 18, 2008 Page 156 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
39560 04 M 708.60N
39561 04 M 803.05N
39599 04 MYY
40490 04 I 46.25 17.00N
40500 04 M 165.10YN
40510 04 I 170.45YN
40520 04 M 524.40YN
40525 04 M 629.90YN
40527 04 M 718.70YN
40530 04 M 524.35YN
40650 04 M 629.90YN
40652 04 M 629.90YN
40654 04 M 629.90YN
40700 04 M 718.70YN
40701 04 M 958.60YN
40702 04 M 958.60YN
40720 04 M 718.70YN
40761 04 M 802.00YN
40799 04 MYY
40800 04 I 39.90 17.00YN
40801 04 I 76.15YN
Wednesday, June 18, 2008 Page 157 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
40804 04 I 44.10 17.00YN
40805 04 I 89.10YN
40806 04 I 35.65 17.00YN
40808 04 I 50.20 17.00YN
40810 04 I 50.95 17.00YN
40812 04 I 73.70 17.00YN
40814 04 I 117.65YN
40816 04 I 142.70 34.00YN
40818 04 I 113.40YN
40819 04 M 149.80YN
40820 04 I 142.70 17.00YN
40830 04 I 107.00 17.00YN
40831 04 I 132.75 17.00YN
40840 04 M 252.00YN
40842 04 M 251.05YN
40843 04 M 347.20YN
40844 04 M 496.90YN
40845 04 M 629.10YN
40899 04 MYY
41000 04 I 44.65 17.00YN
41005 04 I 41.70 17.00YN
Wednesday, June 18, 2008 Page 158 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
41006 04 I 93.60YN
41007 04 I 102.95 17.00YN
41008 04 I 92.70 17.00YN
41009 04 I 116.50YN
41010 04 I 42.45 17.00YN
41015 04 I 106.45 17.00YN
41016 04 I 130.40 17.00YN
41017 04 I 113.10 17.00YN
41018 04 I 154.95YN
41019 04 1/1/2008 I 259.65YN
41100 04 I 88.50 17.00YN
41105 04 I 181.00 17.00YN
41108 04 I 88.50 17.00YN
41110 04 M 214.00 17.00YN
41112 04 M 299.70YN
41113 04 M 299.70YN
41114 04 M 249.70YN
41115 04 M 224.70YN
41116 04 M 224.70YN
41120 04 M 524.40YN
41130 04 M 524.40YN
Wednesday, June 18, 2008 Page 159 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
41135 04 M 861.50N
41140 04 M 735.65N
41145 04 M 1048.85N
41150 04 M 1498.30N
41153 04 M 1498.30N
41155 04 M 1798.05N
41250 04 I 71.40 34.00YN
41251 04 I 74.10 34.00YN
41252 04 I 95.25 34.00YN
41500 04 I 121.70YN
41510 04 M 374.55YN
41520 04 I 92.70YN
41599 04 MYY
41800 04 I 39.70 17.00YN
41805 04 I 42.30 17.00YN
41806 04 I 90.10YN
41820 04 I 99.05YN
41821 04 I 71.60YN
41822 04 I 90.10YN
41823 04 M 169.40YN
41825 04 I 76.95YN
Wednesday, June 18, 2008 Page 160 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
41826 04 M 224.70YN
41827 04 M 299.70YN
41828 04 I 110.35YN
41830 04 M 224.70YN
41850 04 I 41.25YN
41870 04 M 169.40YN
41872 04 M 169.40YN
41874 04 M 169.40YN
41899 04 MYY
42000 04 I 43.05 17.00YN
42100 04 I 50.20 34.00YN
42104 04 I 79.30 34.00YN
42106 04 M 480.00YN
42107 04 M 506.40YN
42120 04 M 647.90YN
42140 04 M 184.50YN
42145 04 M 359.30YN
42160 04 I 64.10 17.00YN
42180 04 M 149.80YN
42182 04 M 215.90YN
42200 04 M 718.70YN
Wednesday, June 18, 2008 Page 161 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
42205 04 M 718.70YN
42210 04 M 850.80YN
42215 04 M 491.50YN
42220 04 M 718.70YN
42225 04 M 986.35YN
42226 04 M 784.75YN
42227 04 M 784.75YN
42235 04 M 374.55YN
42260 04 M 718.70YN
42280 04 I 53.85N
42281 04 I 58.45YN
42299 04 MYY
42300 04 I 79.30 17.00YN
42305 04 I 164.90YN
42310 04 I 79.30 17.00YN
42320 04 I 113.60 17.00YN
42330 04 I 113.60 34.00YN
42335 04 M 240.00YN
42340 04 M 240.00YN
42400 04 I 113.60 17.00YN
42405 04 I 113.60 34.00YN
Wednesday, June 18, 2008 Page 162 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
42408 04 I 137.80 34.00YN
42409 04 I 113.60 34.00YN
42410 04 M 749.20YN
42415 04 M 754.65YN
42420 04 M 867.10YN
42425 04 M 892.00YN
42426 04 M 1079.30N
42440 04 M 480.00YN
42450 04 M 480.00YN
42500 04 M 359.30YN
42505 04 M 359.30YN
42507 04 M 767.60YN
42508 04 M 839.35YN
42509 04 M 1079.30YN
42510 04 M 839.35YN
42550 04 I 109.95YN
42600 04 M 359.30YN
42650 04 I 30.40 17.00YN
42660 04 I 34.30 17.00YN
42665 04 I 160.20YN
42699 04 MYY
Wednesday, June 18, 2008 Page 163 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
42700 04 I 79.30 34.00YN
42720 04 I 157.30YN
42725 04 I 291.90YN
42800 04 I 79.30 34.00YN
42802 04 I 79.30 34.00YN
42804 04 I 79.30 34.00YN
42806 04 I 79.30 34.00YN
42808 04 M 192.95 34.00YN
42809 04 M 202.50 34.00YN
42810 04 M 374.55YN
42815 04 M 431.40YN
42820 04 M 194.20YN
42821 04 M 202.50YN
42825 04 M 194.20YN
42826 04 M 202.50YN
42830 04 M 142.90YN
42831 04 M 142.90YN
42835 04 M 142.90YN
42836 04 M 142.90YN
42842 04 M 702.10YN
42844 04 M 810.10YN
Wednesday, June 18, 2008 Page 164 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
42845 04 M 918.15YN
42860 04 I 119.25 34.00YN
42870 04 I 156.65 34.00YN
42890 04 M 958.60YN
42892 04 M 912.80YN
42894 04 M 1188.20YN
42900 04 M 34.00YY
42950 04 M 939.50YN
42953 04 MYY
42955 04 M 266.40YN
42960 04 I 74.90 34.00YN
42961 04 M 150.80YN
42962 04 M 220.10YN
42970 04 I 131.20 34.00YN
42971 04 M 173.40YN
42972 04 M 206.40YN
42999 04 MYY
43020 04 M 480.00YN
43030 04 M 819.10YN
43045 04 M 839.35YN
43100 04 M 749.20YN
Wednesday, June 18, 2008 Page 165 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43101 04 M 749.20YN
43107 04 M 1467.80N
43108 04 M 1782.30N
43112 04 M 1467.80N
43113 04 M 1782.30N
43116 04 M 2106.30N
43117 04 M 1467.80N
43118 04 M 1782.30N
43121 04 M 1467.80N
43122 04 M 1467.80N
43123 04 M 1782.30N
43124 04 MY
43130 04 M 718.70N
43135 04 M 718.70N
43200 04 I 186.20 56.70YN
43201 04 I 113.55YN
43202 04 I 199.50 56.70YN
43204 04 M 256.60YN
43205 04 M 256.60YN
43215 04 I 244.50 56.70YN
43216 04 I 244.50YN
Wednesday, June 18, 2008 Page 166 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43217 04 I 244.50 56.70YN
43219 04 I 244.50 56.70YN
43220 04 I 142.70 56.70YN
43226 04 M 224.60 56.70YN
43227 04 I 235.20 56.70YN
43228 04 M 235.20 56.70YN
43231 04 I 158.20YN
43232 04 I 183.70YN
43234 04 I 159.35 56.70YN
43235 04 I 239.15 56.70YN
43236 04 I 239.15YN
43237 04 I 117.67YN
43238 04 I 145.34YN
43239 04 I 249.70 56.70YN
43240 04 I 201.55YN
43241 04 I 249.70 56.70YN
43242 04 I 201.55YN
43243 04 M 256.60YN
43244 04 M 256.60YN
43245 04 I 249.70 56.70YN
43246 04 I 249.70 56.70YN
Wednesday, June 18, 2008 Page 167 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43247 04 M 249.70 56.70YN
43248 04 I 295.95YN
43249 04 I 113.40YN
43250 04 I 249.70YN
43251 04 I 249.70 56.70YN
43255 04 I 249.70 56.70YN
43256 04 M 159.35YN
43257 04 IYY
43258 04 M 249.70YN
43259 04 I 240.30YN
43260 04 I 264.25 56.70YN
43261 04 I 264.25YN
43262 04 M 390.10 56.70YN
43263 04 I 264.25 56.70YN
43264 04 M 390.10 56.70YN
43265 04 M 390.10YN
43267 04 I 264.25 56.70YN
43268 04 M 358.60 56.70YN
43269 04 M 358.60YN
43271 04 M 358.60 56.70YN
43272 04 M 390.10 56.70YN
Wednesday, June 18, 2008 Page 168 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43280 04 M 682.60YN
43289 04 MYY
43300 04 M 786.60N
43305 04 M 1258.35N
43310 04 M 839.35N
43312 04 M 1258.35N
43313 04 M 1188.50N
43314 04 M 1564.90N
43320 04 M 958.60N
43324 04 M 682.60N
43325 04 M 749.20N
43326 04 M 749.20N
43330 04 M 1082.10YN
43331 04 M 1082.10YN
43340 04 M 1198.70YN
43341 04 M 1082.10YN
43350 04 M 839.35YN
43351 04 M 839.35YN
43352 04 M 839.35YN
43360 04 M 1467.80YN
43361 04 M 1782.30YN
Wednesday, June 18, 2008 Page 169 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43400 04 M 480.00YN
43401 04 M 822.80YN
43405 04 MYY
43410 04 M 480.00YN
43415 04 M 839.35YN
43420 04 M 480.00YN
43425 04 M 839.35YN
43450 04 I 74.90YN
43453 04 I 74.90YN
43456 04 I 112.40YN
43458 04 I 142.70YN
43460 04 I 93.05YN
43496 04 M 1778.60YN
43499 04 MY
43500 04 M 599.35YN
43501 04 M 599.35YN
43502 04 M 658.90YN
43510 04 M 599.35YN
43520 04 M 599.35YN
43600 04 I 108.20YN
43605 04 M 599.35YN
Wednesday, June 18, 2008 Page 170 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43610 04 M 718.70YN
43611 04 MYY
43620 04 M 1011.40YN
43621 04 M 1011.40YN
43622 04 M 1173.40YN
43631 04 M 915.65YN
43632 04 M 915.65YN
43633 04 M 915.65YN
43634 04 M 1077.70YN
43635 04 M 1026.65YN
43640 04 M 812.90YN
43641 04 M 812.90YN
43644 K 04 M 942.28YN
43645 K 04 M 1017.05YN
43647 04 1/1/2007 M 399.59YN
43648 04 1/1/2007 M 399.50YN
43651 04 M 524.40YN
43652 04 M 524.40YN
43653 04 M 399.50N
43659 04 MY
43752 04 I 35.05YN
Wednesday, June 18, 2008 Page 171 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43760 04 I 35.65 17.00YN
43761 04 I 48.50YN
43770 K 04 I 565.47YN
43771 K 04 I 652.01YN
43772 K 04 I 497.20YN
43773 K 04 I 652.27YN
43774 K 04 I 497.78YN
43800 04 M 699.20YN
43810 04 M 718.70YN
43820 04 M 718.70YN
43825 04 M 898.95YN
43830 04 M 399.50YN
43831 04 M 399.50YN
43832 04 M 399.50YN
43840 04 M 678.40YN
43842 K 04 M 718.70YN
43843 K 04 M 718.70YN
43845 K 04 M 982.18N
43846 K 04 M 770.00N
43847 K 04 M 986.00N
43848 K 04 M 770.00N
Wednesday, June 18, 2008 Page 172 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
43850 04 M 718.70N
43855 04 M 793.60N
43860 04 M 718.70N
43865 04 M 793.60N
43870 04 M 240.00YN
43880 04 M 958.60YN
43881 04 1/1/2007 M 599.35YN
43882 04 1/1/2007 M 599.35YN
43886 04 I 152.73YN
43887 04 I 151.56YN
43888 04 I 215.38YN
43999 04 MY
44005 04 M 643.65YN
44010 04 M 599.35YN
44015 04 M 399.50YN
44020 04 M 599.35YN
44021 04 M 599.35YN
44025 04 M 599.35YN
44050 04 M 599.35YN
44055 04 M 599.35YN
44100 04 I 108.20YN
Wednesday, June 18, 2008 Page 173 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44110 04 M 599.35YN
44111 04 M 599.35YN
44120 04 M 806.10N
44121 04 M 403.05N
44125 04 M 733.85N
44126 04 M 1039.70N
44127 04 M 1195.80N
44128 04 M 175.20N
44130 04 M 718.70N
44132 04 MY
44133 04 MY
44135 04 MY
44136 04 MY
44137 04 M 806.10N
44139 04 M 108.00N
44140 04 M 951.80N
44141 04 M 951.80N
44143 04 M 951.80N
44144 04 M 951.80N
44145 04 M 958.60N
44146 04 M 951.80N
Wednesday, June 18, 2008 Page 174 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44147 04 M 1198.70N
44150 04 M 1079.30N
44151 04 M 1079.10N
44155 04 M 1198.70N
44156 04 M 1198.70N
44157 04 1/1/2007 M 1198.70N
44158 04 1/1/2007 M 1198.70N
44160 04 M 1198.70N
44180 04 I 479.20YN
44186 04 I 335.80YN
44187 04 I 553.18YN
44188 04 I 607.88YN
44202 04 M 806.10YN
44203 04 M 191.80YN
44204 04 M 973.80YN
44205 04 M 861.80YN
44206 04 M 951.80YN
44207 04 M 958.60YN
44208 04 M 951.80YN
44210 04 M 1255.88YN
44211 04 M 1079.30YN
Wednesday, June 18, 2008 Page 175 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44212 04 M 1198.70YN
44213 04 I 110.46YN
44227 04 I 864.06YN
44238 04 MYY
44300 04 M 599.35YN
44310 04 M 629.90YN
44312 04 M 374.55YN
44314 04 M 599.35YN
44316 04 M 535.45YN
44320 04 M 535.45YN
44322 04 M 535.45YN
44340 04 M 299.70YN
44345 04 M 480.00YN
44346 04 M 951.80YN
44360 04 I 264.25 56.70YN
44361 04 I 285.40 56.70YN
44363 04 M 285.40 56.70YN
44364 04 M 356.70 56.70YN
44365 04 M 356.70YN
44366 04 M 285.40 56.70YN
44369 04 M 285.40 56.70YN
Wednesday, June 18, 2008 Page 176 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44370 04 M 158.30YN
44372 04 M 285.40YN
44373 04 M 356.70YN
44376 04 I 318.30YN
44377 04 I 318.30YN
44378 04 M 318.30YN
44379 04 M 258.55YN
44380 04 I 182.30 56.70YN
44382 04 I 218.00 56.70YN
44383 04 I 88.30YN
44385 04 I 182.30 56.70YN
44386 04 I 182.30 56.70YN
44388 04 I 192.85 56.70YN
44389 04 I 192.85 56.70YN
44390 04 I 192.85 56.70YN
44391 04 I 283.40 56.70YN
44392 04 M 230.80 56.70YN
44393 04 M 230.80 56.70YN
44394 04 M 318.30YN
44397 04 M 165.00YN
44500 04 I 99.10N
Wednesday, June 18, 2008 Page 177 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44602 04 M 599.35YN
44603 04 M 674.20YN
44604 04 M 599.35YN
44605 04 M 718.70YN
44615 04 M 599.35YN
44620 04 M 359.30YN
44625 04 M 729.70YN
44626 04 M 729.70YN
44640 04 M 480.00YN
44650 04 M 629.90YN
44660 04 M 958.60YN
44661 04 M 958.60YN
44680 04 M 599.35YN
44700 04 M 480.00YN
44701 04 I 72.34N
44799 04 MY
44800 04 M 480.00YN
44820 04 M 599.35YN
44850 04 M 480.00YN
44899 04 MYY
44900 04 M 310.80YN
Wednesday, June 18, 2008 Page 178 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
44901 04 M 310.80YN
44950 04 M 374.55YN
44955 04 M 374.55N
44960 04 M 480.00YN
44970 04 M 374.55YN
44979 04 MYY
45000 04 M 170.65YN
45005 04 I 107.00 34.00YN
45020 04 I 134.00YN
45100 04 I 118.00YN
45108 04 M 262.20YN
45110 04 M 1079.30N
45111 04 M 1079.30N
45112 04 M 1079.30N
45113 04 M 1631.05N
45114 04 M 1138.70N
45116 04 M 1079.30N
45119 04 M 1630.70N
45120 04 M 1198.70N
45121 04 M 1450.40N
45123 04 MY
Wednesday, June 18, 2008 Page 179 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
45126 04 MY
45130 04 M 383.70YN
45135 04 M 524.40YN
45136 04 M 1028.70YN
45150 04 IYY
45160 04 M 1138.70YN
45170 04 M 257.70YN
45190 04 I 240.00YN
45300 04 I 42.30 17.00YN
45303 04 I 42.30 17.00YN
45305 04 I 72.60 17.00YN
45307 04 M 72.60 17.00YN
45308 04 I 125.50YN
45309 04 I 125.50YN
45315 04 I 107.00 17.00YN
45317 04 I 76.85 17.00YN
45320 04 M 201.30 56.70YN
45321 04 I 125.50 17.00YN
45327 04 I 61.65YN
45330 04 I 107.00 34.00YN
45331 04 I 142.70 34.00YN
Wednesday, June 18, 2008 Page 180 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
45332 04 I 125.50 34.00YN
45333 04 M 161.20 34.00YN
45334 04 I 142.70 34.00YN
45335 04 I 68.14N
45337 04 I 125.50 34.00YN
45338 04 M 161.20YN
45339 04 M 201.30YN
45340 04 I 42.30YN
45341 04 I 137.30YN
45342 04 I 158.60YN
45345 04 M 106.05YN
45355 04 I 112.40 56.70YN
45378 04 I 214.00 56.70YN
45379 04 M 214.00 56.70YN
45380 04 I 214.00 56.70YN
45381 04 I 184.28YN
45382 04 M 283.40 56.70YN
45383 04 M 285.40 56.70YN
45384 04 M 285.40YN
45385 04 M 285.40 56.70YN
45386 04 I 108.86YN
Wednesday, June 18, 2008 Page 181 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
45387 04 M 215.35YN
45391 04 M 204.00YN
45392 04 I 214.00YN
45395 04 I 1015.28YN
45397 04 I 1103.45YN
45400 04 I 592.90YN
45402 04 I 805.75YN
45499 04 IYY
45500 04 M 419.00YN
45505 04 M 419.00YN
45520 04 I 74.90YN
45540 04 M 599.35YN
45541 04 M 599.35YN
45550 04 M 749.20YN
45560 04 M 227.70YN
45562 04 MYY
45563 04 MYY
45800 04 M 599.35YN
45805 04 M 674.20YN
45820 04 M 599.35YN
45825 04 M 674.20YN
Wednesday, June 18, 2008 Page 182 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
45900 04 I 44.40YN
45905 04 I 58.05YN
45910 04 I 73.40YN
45915 04 I 77.60YN
45990 04 I 58.42YN
45999 04 MYY
46020 04 I 140.75YN
46030 04 I 71.40 34.00YN
46040 04 M 149.80YN
46045 04 M 149.80YN
46050 04 I 71.40 34.00YN
46060 04 M 471.70YN
46070 04 I 81.20YN
46080 04 I 119.25YN
46083 04 I 64.10 17.00YN
46200 04 M 262.20YN
46210 04 I 93.50 17.00YN
46211 04 I 129.45 17.00YN
46220 04 I 71.40 17.00YN
46221 04 I 107.00 17.00N
46230 04 I 84.65 17.00YN
Wednesday, June 18, 2008 Page 183 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
46250 04 M 248.30 34.00YN
46255 04 M 342.65YN
46257 04 M 417.60YN
46258 04 M 471.70YN
46260 04 M 449.50YN
46261 04 M 524.40YN
46262 04 M 578.55YN
46270 04 M 471.70YN
46275 04 M 471.70YN
46280 04 M 471.70YN
46285 04 M 471.70YN
46288 04 M 471.70YN
46320 04 I 62.90 17.00YN
46500 04 I 51.50 17.00YN
46505 04 I 102.99YN
46600 04 I 19.80 17.00N
46604 04 I 34.10 17.00YN
46606 04 I 24.20 17.00YN
46608 04 I 49.85 17.00YN
46610 04 I 71.40 17.00YN
46611 04 I 71.40YN
Wednesday, June 18, 2008 Page 184 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
46612 04 I 89.85 17.00YN
46614 04 I 62.00 17.00YN
46615 04 IYY
46700 04 M 299.70YN
46705 04 M 299.70YN
46706 04 I 62.32YN
46710 04 I 530.10YN
46712 04 I 1118.22YN
46715 04 M 449.50YN
46716 04 M 449.50YN
46730 04 M 571.25YN
46735 04 M 1079.30YN
46740 04 M 788.65YN
46742 04 M 1079.30YN
46744 04 M 918.15YN
46746 04 M 1139.40YN
46748 04 M 1139.40YN
46750 04 M 419.00YN
46751 04 M 419.00YN
46753 04 I 187.90YN
46754 04 I 134.60YN
Wednesday, June 18, 2008 Page 185 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
46760 04 M 524.40YN
46761 04 M 524.40YN
46762 04 M 739.90YN
46900 04 I 62.70 17.00N
46910 04 I 108.30 17.00YN
46916 04 I 108.30 34.00YN
46917 04 I 108.30 34.00YN
46922 04 I 108.30 17.00YN
46924 04 M 181.00 17.00YN
46934 04 I 127.20 34.00YN
46935 04 I 107.00 34.00YN
46936 04 M 178.30 34.00YN
46937 04 I 96.95 34.00YN
46938 04 I 148.20 34.00YN
46940 04 I 68.50 17.00YN
46942 04 I 61.15 17.00YN
46945 04 I 72.45 17.00YN
46946 04 I 112.40YN
46947 04 M 342.65YN
46999 04 MYY
47000 04 I 106.80YN
Wednesday, June 18, 2008 Page 186 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
47001 04 I 65.90YN
47010 04 M 599.35YN
47011 04 M 599.35YN
47015 04 M 480.00YN
47100 04 M 480.00YN
47120 04 M 682.60N
47122 04 M 1048.85N
47125 04 M 1048.85N
47130 04 M 1048.85N
47133 04 M 1048.85N
47135 04 M 3299.30N
47136 04 M 3299.30N
47140 04 M 1660.18YN
47141 04 M 2001.23YN
47142 04 M 2201.17YN
47300 04 M 718.70YN
47350 04 M 659.00YN
47360 04 M 697.90N
47361 04 M 810.10YN
47362 04 M 523.85YN
47370 04 M 761.10YN
Wednesday, June 18, 2008 Page 187 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
47371 04 M 761.10YN
47379 04 MYY
47380 04 M 892.80YN
47381 04 M 892.80YN
47382 04 M 474.20YN
47399 04 MYY
47400 04 M 718.70YN
47420 04 M 647.90YN
47425 04 M 682.60YN
47460 04 M 463.80YN
47480 04 M 647.90YN
47490 04 M 599.35YN
47500 04 I 50.75YN
47505 04 I 127.50YN
47510 04 M 230.75YN
47511 04 M 284.60YN
47525 04 I 129.90YN
47530 04 M 199.80YN
47550 04 M 94.30YN
47552 04 I 135.70YN
47553 04 I 155.75YN
Wednesday, June 18, 2008 Page 188 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
47554 04 I 220.30YN
47555 04 I 169.10YN
47556 04 I 187.90YN
47560 04 M 299.70YN
47561 04 M 317.60YN
47562 04 M 647.90YN
47563 04 M 699.20YN
47564 04 M 801.90YN
47570 04 M 685.40YN
47579 04 MYY
47600 04 M 647.90YN
47605 04 M 699.20YN
47610 04 M 801.90YN
47612 04 M 801.90YN
47620 04 M 801.90YN
47630 04 M 299.70YN
47700 04 M 449.50YN
47701 04 M 685.40YN
47711 04 M 801.90YN
47712 04 M 1198.70YN
47715 04 M 862.30YN
Wednesday, June 18, 2008 Page 189 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
47720 04 M 685.40YN
47721 04 M 1044.70YN
47740 04 M 685.40YN
47741 04 M 1044.70YN
47760 04 M 685.40YN
47765 04 M 1438.70YN
47780 04 M 770.00YN
47785 04 M 1438.70YN
47800 04 M 770.00YN
47801 04 M 621.95YN
47802 04 M 948.90YN
47900 04 M 621.95YN
47999 04 MYY
48000 04 M 718.70YN
48001 04 M 801.90YN
48020 04 M 839.35YN
48100 04 M 480.00YN
48102 04 I 154.90YN
48105 04 1/1/2007 M 810.10YN
48120 04 M 599.35YN
48140 04 M 839.35YN
Wednesday, June 18, 2008 Page 190 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
48145 04 M 1438.70YN
48146 04 M 1438.70YN
48148 04 M 859.00YN
48150 04 M 1438.70YN
48152 04 M 1438.70YN
48153 04 M 1438.70YN
48154 04 M 1438.70YN
48155 04 M 1438.70YN
48160 04 M 2397.40N
48400 04 I 47.30YN
48500 04 M 839.35YN
48510 04 M 839.35YN
48511 04 M 839.35YN
48520 04 M 839.35YN
48540 04 M 839.35YN
48545 04 M 599.35YN
48547 04 M 718.70YN
48548 04 1/1/2007 M 958.60YN
48550 04 M 599.35YN
48554 04 M 2397.40N
48556 04 M 599.35N
Wednesday, June 18, 2008 Page 191 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
48999 04 MY
49000 04 M 480.00YN
49002 04 M 480.00YN
49010 04 M 480.00YN
49020 04 M 480.00YN
49021 04 M 314.60YN
49040 04 M 480.00YN
49041 04 M 480.00YN
49060 04 M 480.00YN
49061 04 M 480.00YN
49062 04 M 480.00YN
49080 04 I 71.40 34.00YN
49081 04 I 71.40 34.00YN
49180 04 I 106.80YN
49203 04 1/1/2008 M 617.99YN
49204 04 1/1/2008 M 789.45YN
49205 04 1/1/2008 M 904.11YN
49215 04 M 766.90YN
49220 04 M 998.80YN
49250 04 M 374.55YN
49255 04 M 599.35YN
Wednesday, June 18, 2008 Page 192 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
49320 04 M 302.40YN
49321 04 M 302.40YN
49322 04 MYY
49323 04 M 480.00YN
49324 04 1/1/2007 M 480.00YN
49325 04 1/1/2007 M 480.00YN
49326 04 1/1/2007 M 480.00YN
49329 04 MYY
49400 04 I 47.00YN
49402 04 1/1/2007 MYY
49419 04 M 180.46YN
49420 04 I 74.90YN
49421 04 M 299.70YN
49422 04 M 240.00YN
49423 04 M 262.20YN
49424 04 I 20.95YN
49425 04 M 718.70YN
49426 04 MYY
49427 04 I 37.40YN
49428 04 MYY
49429 04 MYY
Wednesday, June 18, 2008 Page 193 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
49435 04 1/1/2007 M 60.90YN
49436 04 1/1/2007 M 88.75YN
49440 04 1/1/2008 I 133.76 465.96YN
49441 04 1/1/2008 I 144.19 563.56YN
49442 04 1/1/2008 I 119.66 457.55YN
49446 04 1/1/2008 I 94.47 493.61YN
49450 04 1/1/2008 I 38.43 371.36YN
49451 04 1/1/2008 I 52.85 382.19YN
49452 04 1/1/2008 I 82.55 451.13YN
49460 04 1/1/2008 I 27.00 406.44YN
49465 04 1/1/2008 I 17.80 73.55YN
49491 04 M 433.70YN
49492 04 M 535.00YN
49495 04 M 362.00YN
49496 04 M 362.00YN
49500 04 M 362.00YN
49501 04 M 387.05YN
49505 04 M 387.05YN
49507 04 M 387.05YN
49520 04 M 409.20YN
49521 04 M 387.05YN
Wednesday, June 18, 2008 Page 194 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
49525 04 M 464.80YN
49540 04 M 337.10YN
49550 04 M 409.20YN
49553 04 M 409.20YN
49555 04 M 460.60YN
49557 04 M 460.60YN
49560 04 M 503.60YN
49561 04 M 503.60YN
49565 04 M 546.65YN
49566 04 M 572.50YN
49568 04 M 460.60YN
49570 04 M 345.50YN
49572 04 M 345.50YN
49580 04 M 342.65YN
49582 04 M 374.55YN
49585 04 M 374.55YN
49587 04 M 374.55YN
49590 04 M 374.55YN
49600 04 M 275.80YN
49605 04 M 573.10YN
49606 04 MYY
Wednesday, June 18, 2008 Page 195 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
49610 04 M 599.35YN
49611 04 M 449.50YN
49650 04 M 387.05YN
49651 04 M 409.20YN
49659 04 MYY
49900 04 M 307.05YN
49904 04 M 617.40YN
49905 04 M 442.90YN
49906 04 M 1306.65YN
49999 04 MYY
50010 04 M 480.00YN
50020 04 M 398.35YN
50021 04 M 299.70YN
50040 04 M 775.60YN
50045 04 M 718.70YN
50060 04 M 718.70N
50065 04 M 599.35N
50070 04 M 749.20N
50075 04 M 749.20N
50080 04 M 434.20YN
50081 04 M 600.55YN
Wednesday, June 18, 2008 Page 196 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50100 04 M 767.20N
50120 04 M 839.35N
50125 04 M 839.35YN
50130 04 M 837.90YN
50135 04 MY
50200 04 I 112.40YN
50205 04 M 480.00YN
50220 04 M 933.80N
50225 04 M 933.80N
50230 04 M 1057.20N
50234 04 M 933.80N
50236 04 MY
50240 04 M 749.20N
50250 04 M 373.74N
50280 04 M 718.70YN
50290 04 M 718.70YN
50300 04 MY
50320 04 M 933.80N
50323 09 MY
50328 09 MY
50340 04 M 933.80N
Wednesday, June 18, 2008 Page 197 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50360 04 M 1366.60N
50365 04 M 1833.45N
50370 04 M 933.80N
50380 04 MY
50382 04 I 163.58YN
50384 04 I 148.92YN
50385 04 1/1/2008 M 137.81 572.99YN
50386 04 1/1/2008 M 104.23 356.14YN
50387 04 I 59.20YN
50389 04 I 32.75YN
50390 04 I 119.25YN
50391 04 I 117.95YN
50392 04 I 119.25YN
50393 04 I 119.25YN
50394 04 I 117.35YN
50395 04 I 119.25YN
50396 04 I 50.20 34.00YN
50398 04 I 36.70 34.00YN
50400 04 M 958.60YN
50405 04 M 958.60YN
50500 04 M 718.70YN
Wednesday, June 18, 2008 Page 198 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50520 04 M 480.00YN
50525 04 M 674.20YN
50526 04 M 674.20YN
50540 04 M 1198.70YN
50541 04 M 718.70YN
50542 04 M 718.70YN
50543 04 M 749.20YN
50544 04 M 958.60YN
50545 04 M 906.40YN
50546 04 M 933.80YN
50547 04 M 933.80N
50548 04 M 933.80YN
50549 04 MYY
50551 04 I 151.00 56.70YN
50553 04 I 245.35 56.70YN
50555 04 I 250.35 56.70YN
50557 04 I 294.80 56.70YN
50561 04 I 301.85 56.70YN
50562 04 M 301.95YN
50570 04 I 204.70YN
50572 04 I 268.20YN
Wednesday, June 18, 2008 Page 199 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50574 04 I 281.05YN
50575 04 I 365.15YN
50576 04 I 294.80YN
50580 04 I 269.70YN
50590 04 M 749.20YN
50592 04 I 214.22YN
50593 04 1/1/2008 M 267.81 2228.0YN
50600 04 M 718.70YN
50605 04 M 738.10YN
50610 04 M 738.10YN
50620 04 M 738.10YN
50630 04 M 738.10YN
50650 04 M 599.35YN
50660 04 M 599.35YN
50684 04 I 120.00 17.00YN
50686 04 I 64.10 34.00YN
50688 04 I 37.40 34.00YN
50690 04 I 129.70 17.00YN
50700 04 M 958.60YN
50715 04 M 749.20YN
50722 04 M 749.20YN
Wednesday, June 18, 2008 Page 200 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50725 04 M 958.60YN
50727 04 M 455.80YN
50728 04 M 567.10YN
50740 04 M 958.60YN
50750 04 M 958.60YN
50760 04 M 958.60YN
50770 04 M 958.60YN
50780 04 M 958.60YN
50782 04 M 945.15YN
50783 04 M 945.15YN
50785 04 M 958.60YN
50800 04 M 718.70YN
50810 04 M 718.70YN
50815 04 M 718.70YN
50820 04 M 718.70YN
50825 04 M 1438.70YN
50830 04 MYY
50840 04 M 718.70YN
50845 04 MYY
50860 04 M 958.60YN
50900 04 M 958.60YN
Wednesday, June 18, 2008 Page 201 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
50920 04 M 480.00YN
50930 04 M 629.90YN
50940 04 M 934.70YN
50945 04 M 738.10YN
50947 04 M 973.55YN
50948 04 M 890.50YN
50949 04 MYY
50951 04 I 152.60 56.70YN
50953 04 I 251.25 56.70YN
50955 04 I 235.50 56.70YN
50957 04 I 236.20 56.70YN
50961 04 M 297.95 56.70YN
50970 04 I 187.70YN
50972 04 I 152.10YN
50974 04 I 243.40YN
50976 04 I 236.20YN
50980 04 M 262.20YN
51020 04 M 524.40YN
51030 04 M 524.40YN
51040 04 M 449.50YN
51045 04 M 449.50YN
Wednesday, June 18, 2008 Page 202 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
51050 04 M 599.35YN
51060 04 M 738.10YN
51065 04 M 738.10YN
51080 04 M 599.35YN
51100 04 1/1/2008 I 22.55 13.02YN
51101 04 1/1/2008 I 30.11 41.49YN
51102 04 1/1/2008 I 141.08 47.69YN
51500 04 M 599.35YN
51520 04 M 480.00YN
51525 04 M 718.70YN
51530 04 M 599.35YN
51535 04 M 599.35YN
51550 04 M 599.35YN
51555 04 M 599.35YN
51565 04 M 958.60YN
51570 04 M 749.20YN
51575 04 M 1198.70YN
51580 04 M 1438.70YN
51585 04 M 1438.70YN
51590 04 M 1438.70YN
51595 04 M 1498.30YN
Wednesday, June 18, 2008 Page 203 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
51596 04 M 1438.70YN
51597 04 M 1498.30N
51600 04 I 121.35 17.00YN
51605 04 I 121.35 17.00YN
51610 04 I 130.80 17.00YN
51700 04 I 44.60N
51701 04 I 24.02N
51702 04 I 24.02N
51703 04 I 26.18N
51705 04 I 38.85 17.00YN
51710 04 I 66.85 17.00YN
51715 04 I 295.95YN
51720 04 I 66.85 17.00YN
51725 04 I 44.40YN
51726 04 I 50.05YN
51736 04 I 17.30YN
51741 04 I 52.70YN
51772 04 I 45.00YN
51784 04 I 52.70YN
51785 04 I 52.70YN
51792 04 I 74.90YN
Wednesday, June 18, 2008 Page 204 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
51795 04 I 51.50YN
51797 04 I 45.00YN
51798 A 04 I 8.78 8.78 17.56YN
51800 04 M 599.35YN
51820 04 M 839.35YN
51840 04 M 631.25YN
51841 04 M 631.25YN
51845 04 M 631.25YN
51860 04 M 599.35YN
51865 04 M 599.35YN
51880 04 M 216.65YN
51900 04 M 958.60YN
51920 04 M 958.60YN
51925 04 M 958.60YN
51940 04 M 839.35YN
51960 04 M 1105.80YN
51980 04 M 449.50YN
51990 04 M 631.25YN
51992 04 M 631.25YN
51999 04 MYY
52000 04 I 85.90 56.70YN
Wednesday, June 18, 2008 Page 205 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
52001 04 I 90.40YN
52005 04 I 118.90 56.70YN
52007 04 M 154.60 56.70YN
52010 04 I 118.90 56.70YN
52204 04 I 163.90 56.70N
52214 04 M 178.30 56.70YN
52224 04 M 295.95 56.70YN
52234 04 M 374.55YN
52235 04 M 374.55YN
52240 04 M 524.40YN
52250 04 I 141.30 56.70YN
52260 04 I 149.80YN
52265 04 I 142.70 56.70YN
52270 04 M 180.30YN
52275 04 M 194.20YN
52276 04 M 209.40YN
52277 04 M 180.30YN
52281 04 I 134.80 56.70YN
52282 04 I 204.10 56.70YN
52283 04 I 149.80YN
52285 04 I 135.70YN
Wednesday, June 18, 2008 Page 206 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
52290 04 M 184.50YN
52300 04 M 240.00YN
52301 04 M 240.00YN
52305 04 M 297.00YN
52310 04 I 180.30 56.70YN
52315 04 M 239.00 56.70YN
52317 04 M 342.15 56.70YN
52318 04 M 339.25 56.70YN
52320 04 M 249.70 56.70YN
52325 04 M 379.40YN
52327 04 I 295.95YN
52330 04 M 260.80 56.70YN
52332 04 I 138.90YN
52334 04 M 308.35YN
52341 04 M 224.45YN
52342 04 M 242.90YN
52343 04 M 269.10YN
52344 04 M 287.60YN
52345 04 M 306.60YN
52346 04 M 344.90YN
52351 04 I 178.30YN
Wednesday, June 18, 2008 Page 207 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
52352 04 M 293.75YN
52353 04 M 262.20YN
52354 04 M 249.70YN
52355 04 M 337.00YN
52400 04 M 398.85YN
52402 04 M 537.15YN
52450 04 M 249.00YN
52500 04 M 480.00YN
52601 04 M 775.60YN
52606 04 M 374.55YN
52612 04 M 621.50YN
52614 04 M 430.05YN
52620 04 M 202.55YN
52630 04 M 599.35YN
52640 04 M 486.90YN
52647 04 M 599.35YN
52648 04 M 599.35YN
52649 04 1/1/2008 M 562.42YN
52700 04 M 314.95YN
53000 04 M 240.00YN
53010 04 M 314.95YN
Wednesday, June 18, 2008 Page 208 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
53020 04 I 67.80 17.00YN
53025 04 I 58.60 17.00YN
53040 04 I 197.80 17.00YN
53060 04 I 95.30 17.00YN
53080 04 M 17.00YY
53085 04 MYY
53200 04 I 92.70 17.00YN
53210 04 M 449.50YN
53215 04 M 524.40YN
53220 04 M 449.50YN
53230 04 M 599.35YN
53235 04 M 599.35YN
53240 04 M 449.50YN
53250 04 M 34.00YY
53260 04 I 113.60 34.00YN
53265 04 I 115.00 34.00YN
53270 04 I 113.60 34.00YN
53275 04 I 122.20 34.00YN
53400 04 M 599.35YN
53405 04 M 599.35YN
53410 04 M 599.35YN
Wednesday, June 18, 2008 Page 209 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
53415 04 M 745.30YN
53420 04 M 599.35YN
53425 04 M 449.50YN
53430 04 M 517.40YN
53431 04 M 709.95YN
53440 04 M 599.35YN
53442 04 M 449.50YN
53444 04 M 540.40YN
53445 04 MYY
53446 04 M 494.90YN
53447 04 M 449.50YN
53448 04 M 842.25YN
53449 04 MYY
53450 04 M 164.30YN
53460 04 M 224.70YN
53500 04 M 386.25YN
53502 04 MYY
53505 04 MYY
53510 04 MYY
53515 04 MYY
53520 04 M 314.95YN
Wednesday, June 18, 2008 Page 210 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
53600 04 I 52.80YN
53601 04 I 47.80YN
53605 04 I 47.80YN
53620 04 I 75.10YN
53621 04 I 69.55YN
53660 04 I 41.80YN
53661 04 I 42.10YN
53665 04 I 36.00YN
53850 04 M 576.80YN
53852 04 M 576.80YN
53853 04 M 229.10YN
53899 04 MYY
54000 04 I 74.90 17.00YN
54001 04 I 87.85 17.00YN
54015 04 I 156.75 17.00YN
54050 04 I 52.70 17.00N
54055 04 I 72.10 17.00N
54056 04 I 71.40 17.00N
54057 04 I 71.40 17.00YN
54060 04 I 88.50 17.00YN
54065 04 I 107.00 34.00YN
Wednesday, June 18, 2008 Page 211 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
54100 04 I 88.50 17.00YN
54105 04 I 114.25 17.00YN
54110 04 M 321.45YN
54111 04 M 585.75YN
54112 04 M 717.90YN
54115 04 MYY
54120 04 M 285.10YN
54125 04 M 449.50N
54130 04 M 749.20N
54135 04 M 749.20N
54150 04 I 77.50YN
54160 04 I 99.80YN
54161 04 I 146.70 34.00YN
54162 04 I 97.25YN
54163 04 I 137.40YN
54164 04 I 120.30YN
54200 04 I 38.60YN
54205 04 IYY
54220 04 M 299.70YN
54230 04 I 38.20YN
54231 04 I 118.80N
Wednesday, June 18, 2008 Page 212 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
54235 04 I 37.40YN
54240 09 IY
54250 04 I 54.55N
54300 04 M 425.80YN
54304 04 M 670.10YN
54308 04 M 599.35YN
54312 04 M 670.10YN
54316 04 M 670.10YN
54318 04 M 670.10YN
54322 04 M 480.00YN
54324 04 M 538.00YN
54326 04 M 670.10YN
54328 04 M 958.60YN
54332 04 M 670.10YN
54336 04 M 958.60YN
54340 04 M 538.00YN
54344 04 M 670.10YN
54348 04 M 958.60YN
54352 04 MYY
54360 04 M 690.78YN
54380 04 M 386.30YN
Wednesday, June 18, 2008 Page 213 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
54385 04 M 446.00YN
54390 04 M 600.70YN
54400 09 MY
54401 09 MY
54405 09 MY
54406 09 MY
54408 09 MY
54410 09 MY
54411 09 MY
54415 09 MY
54416 09 MY
54417 09 MY
54420 04 M 409.20YN
54430 04 M 409.20YN
54435 04 M 405.10YN
54440 04 M 224.70YN
54450 04 I 37.45N
54500 04 I 68.20 17.00YN
54505 04 I 113.60 17.00YN
54512 04 M 356.05YN
54520 04 M 351.00YN
Wednesday, June 18, 2008 Page 214 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
54522 04 M 404.20YN
54530 04 M 958.60YN
54535 04 M 958.60YN
54550 04 M 359.30YN
54560 04 M 480.00YN
54600 04 M 359.30YN
54620 04 M 299.70YN
54640 04 M 504.90YN
54650 04 M 480.00YN
54660 09 MY
54670 04 MYY
54680 04 MYY
54690 04 M 351.00YN
54692 04 M 504.90YN
54699 04 MYY
54700 04 I 128.30 17.00YN
54800 04 I 119.25YN
54830 04 M 299.70YN
54840 04 M 299.70YN
54860 04 M 359.30YN
54861 04 M 480.00YN
Wednesday, June 18, 2008 Page 215 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
54865 04 1/1/2007 M 179.47YN
54900 04 M 480.00YN
54901 04 M 599.35YN
55000 04 I 42.35 17.00YN
55040 04 M 299.70YN
55041 04 M 449.50YN
55060 04 M 259.40YN
55100 04 I 110.90 17.00YN
55110 04 MYY
55120 04 I 129.30 17.00YN
55150 04 I 206.10YN
55175 04 MYY
55180 04 MYY
55200 04 I 147.95 56.70YN
55250 04 I 147.95 56.70YN
55300 04 I 112.40YN
55400 04 MYY
55450 04 M 150.40 56.70YN
55500 04 M 359.30YN
55520 04 M 240.00YN
55530 04 M 359.30YN
Wednesday, June 18, 2008 Page 216 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
55535 04 M 359.30YN
55540 04 M 480.00YN
55550 04 M 359.30YN
55559 04 MYY
55600 04 I 178.30YN
55605 04 M 223.60YN
55650 04 M 958.60YN
55680 04 I 299.70YN
55700 04 I 113.60 17.00YN
55705 04 M 187.30YN
55720 04 M 359.30YN
55725 04 M 359.30YN
55801 04 M 839.35YN
55810 04 M 1198.70YN
55812 04 M 1678.65YN
55815 04 M 1809.25YN
55821 04 M 958.60YN
55831 04 M 958.60YN
55840 04 M 1198.70YN
55842 04 M 1285.40YN
55845 04 M 1438.70N
Wednesday, June 18, 2008 Page 217 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
55860 04 MYY
55862 04 MYY
55865 04 MYY
55866 04 MYY
55870 09 IY
55873 04 M 739.15YN
55875 04 1/1/2007 M 359.30YN
55876 04 1/1/2007 M 59.34YN
55899 04 MYY
55920 04 1/1/2008 M 246.06N
56405 04 I 95.05YN
56420 04 I 103.05 17.00YN
56440 04 M 202.50YN
56441 04 I 127.90YN
56442 04 1/1/2007 I 68.65YN
56501 04 I 52.70 17.00YN
56515 04 M 181.00 34.00YN
56605 04 I 108.30YN
56606 04 I 35.65YN
56620 04 M 335.70YN
56625 04 M 480.00YN
Wednesday, June 18, 2008 Page 218 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
56630 04 M 524.40YN
56631 04 M 511.20YN
56632 04 M 599.65YN
56633 04 M 524.40YN
56634 04 M 599.35YN
56637 04 M 749.20YN
56640 04 M 749.20YN
56700 04 I 113.60N
56740 04 M 226.10YN
56800 04 I 119.25YN
56805 04 M 496.90YN
56810 04 M 190.00YN
56820 04 I 37.40N
56821 04 I 50.20N
57000 04 M 202.55YN
57010 04 M 224.70YN
57020 04 I 79.30 17.00YN
57022 04 I 109.50YN
57023 04 I 109.50YN
57061 04 I 45.40 17.00YN
57065 04 I 91.35YN
Wednesday, June 18, 2008 Page 219 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
57100 04 I 107.00 17.00N
57105 04 I 107.00 17.00YN
57106 04 M 299.70YN
57107 04 M 544.50YN
57109 04 M 782.80YN
57110 04 M 374.30YN
57111 04 M 782.80YN
57112 04 M 1022.80YN
57120 04 M 299.70YN
57130 04 M 180.30YN
57135 04 I 121.55 17.00YN
57150 04 I 18.25N
57155 04 I 257.40N
57160 04 I 27.65N
57170 04 I 28.60N
57180 04 I 48.75 17.00N
57200 04 M 188.90 34.00YN
57210 04 M 206.05 34.00YN
57220 04 M 355.10YN
57230 04 M 517.40YN
57240 04 M 355.10YN
Wednesday, June 18, 2008 Page 220 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
57250 04 M 314.95YN
57260 04 M 525.80YN
57265 04 M 532.80YN
57267 04 M 167.79YN
57268 04 M 532.80YN
57270 04 M 480.00YN
57280 04 M 599.35YN
57282 04 M 480.00YN
57283 04 M 599.35YN
57284 04 M 532.80YN
57285 04 1/1/2008 M 352.36YN
57287 04 M 467.50YN
57288 04 M 631.25YN
57289 04 M 674.20YN
57291 04 MYY
57292 04 MYY
57295 04 M 269.31YN
57296 04 1/1/2007 M 481.19YN
57300 04 M 466.15YN
57305 04 M 1127.90YN
57307 04 M 1127.90YN
Wednesday, June 18, 2008 Page 221 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
57308 04 M 728.35YN
57310 04 M 718.70YN
57311 04 M 799.70YN
57320 04 M 597.90YN
57330 04 M 524.40YN
57335 04 M 466.15YN
57400 04 I 111.00YN
57410 04 I 53.30YN
57415 04 I 111.00YN
57420 04 I 37.40N
57421 04 I 50.20N
57423 04 1/1/2008 M 497.75YN
57425 04 M 487.77YN
57452 04 I 37.40N
57454 04 I 50.20 34.00YN
57455 04 I 50.20YN
57456 04 I 50.20YN
57460 04 I 77.00 34.00YN
57461 04 I 172.05YN
57500 04 I 142.70 17.00N
57505 04 I 48.55YN
Wednesday, June 18, 2008 Page 222 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
57510 04 I 60.60YN
57511 04 I 58.10YN
57513 04 I 131.10YN
57520 04 M 321.90YN
57522 04 M 305.80 34.00YN
57530 04 M 308.00YN
57531 04 M 1030.80YN
57540 04 M 599.35YN
57545 04 M 599.35YN
57550 04 M 599.35YN
57555 04 M 674.20YN
57556 04 M 674.20YN
57558 04 1/1/2007 I 149.80YN
57700 04 M 313.50YN
57720 04 M 559.30YN
57800 04 I 119.25YN
58100 04 I 52.90 34.00YN
58110 04 M 24.90YN
58120 04 M 206.85YN
58140 04 M 718.70YN
58145 04 M 718.70YN
Wednesday, June 18, 2008 Page 223 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
58146 04 M 718.70YN
58150 04 M 772.70YN
58152 04 M 1096.05YN
58180 04 M 652.05YN
58200 04 M 772.70YN
58210 04 M 1030.80YN
58240 04 M 1423.45YN
58260 04 M 725.60YN
58262 04 M 725.60YN
58263 04 M 725.60YN
58267 04 M 856.00YN
58270 04 M 856.00YN
58275 04 M 875.40YN
58280 04 M 800.50YN
58285 04 M 950.30N
58290 04 M 725.60YN
58291 04 M 725.60YN
58292 04 M 725.60YN
58293 04 M 856.00YN
58294 04 M 856.00YN
58300 04 I 44.00N
Wednesday, June 18, 2008 Page 224 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
58301 04 I 37.40N
58340 04 I 93.40N
58346 04 I 274.00YN
58350 04 I 37.50N
58353 04 I 150.60YN
58356 04 M 201.30YN
58400 04 M 449.50YN
58410 04 M 449.50YN
58520 04 M 480.00YN
58540 04 MYY
58541 04 1/1/2007 M 433.94YN
58542 04 1/1/2007 M 479.33YN
58543 04 1/1/2007 M 487.55YN
58544 04 1/1/2007 M 528.11YN
58545 04 M 480.00YN
58546 04 M 480.00YN
58548 04 1/1/2007 M 924.56YN
58550 04 M 725.60YN
58552 04 M 725.00YN
58553 04 M 725.00YN
58554 04 M 725.00YN
Wednesday, June 18, 2008 Page 225 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
58555 04 I 95.75YN
58558 04 I 145.80YN
58559 04 I 160.80YN
58560 04 I 160.80YN
58561 04 M 361.85YN
58562 04 M 361.85YN
58563 04 I 300.43YN
58565 04 M 327.45YN
58570 04 1/1/2008 M 496.17YN
58571 04 1/1/2008 M 542.05YN
58572 04 1/1/2008 M 617.19YN
58573 04 1/1/2008 M 693.59YN
58578 04 MYY
58579 04 MYY
58600 04 M 327.45YN
58605 04 M 327.45YN
58611 04 M 97.30N
58615 04 M 327.45YN
58660 04 M 302.40YN
58661 04 M 480.00YN
58662 04 M 302.40YN
Wednesday, June 18, 2008 Page 226 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
58670 04 M 363.45YN
58671 04 M 363.45YN
58672 09 MY
58673 04 M 480.00YN
58679 04 MYY
58700 04 M 481.90YN
58720 04 M 525.85YN
58740 04 M 480.00YN
58752 09 MY
58770 04 M 480.00YN
58800 04 M 359.30YN
58805 04 M 480.00YN
58820 04 M 240.00YN
58822 04 M 480.00YN
58823 04 M 302.90YN
58825 04 MYY
58900 04 M 480.00YN
58920 04 M 529.95YN
58925 04 M 524.40YN
58940 04 M 554.90YN
58943 04 M 958.60YN
Wednesday, June 18, 2008 Page 227 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
58950 04 M 704.70YN
58951 04 M 898.95N
58952 04 M 958.60N
58953 04 M 1241.75YN
58954 04 M 1350.35N
58956 04 M 1241.75YN
58957 04 1/1/2007 M 749.43YN
58958 04 1/1/2007 M 830.11YN
58960 04 M 599.35YN
58999 04 MY
59000 04 I 58.35 34.00YN
59001 04 B 89.80YN
59012 04 I 115.00YN
59015 04 IYY
59020 C 04 I 7.90 25.80 33.70YN
59025 C 04 I 7.90 25.80 33.70YN
59030 04 I 79.00YN
59050 04 I 25.40N
59051 09 NY
59070 04 I 158.55YN
59074 04 I 158.55YN
Wednesday, June 18, 2008 Page 228 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
59076 04 M 257.88YN
59100 04 M 540.00YN
59120 04 M 540.00YN
59121 04 M 540.00YN
59130 04 M 540.00YN
59135 04 M 696.15YN
59136 04 M 540.00YN
59140 04 M 540.00YN
59150 04 M 540.00YN
59151 04 M 540.00YN
59160 04 M 199.95YN
59200 04 B 27.80N
59300 04 B 74.95N
59320 04 M 282.45YN
59325 04 M 540.10YN
59350 04 M 540.00YN
59409 04 B 535.20N
59410 04 B 535.20N
59412 04 B 72.95YN
59414 04 B 67.50N
59430 04 B 50.15N
Wednesday, June 18, 2008 Page 229 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
59510 09 NY
59514 04 B 681.20N
59515 04 B 681.20N
59525 04 M 299.30N
59610 09 NY
59612 04 B 535.20N
59614 04 B 535.20N
59618 09 BY
59620 04 B 681.20N
59622 04 B 681.20N
59812 04 M 298.70YN
59820 04 M 199.95YN
59821 04 M 298.70YN
59830 04 M 223.70YN
59840 04 M 199.95YN
59841 04 B 199.95YN
59850 04 M 199.95YN
59851 04 M 199.95N
59855 04 M 199.95N
59856 04 M 199.95YN
59857 04 M 199.95YN
Wednesday, June 18, 2008 Page 230 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
59866 09 MY
59870 04 M 389.25YN
59871 04 I 66.95YN
59897 04 MYY
59898 09 BY
59899 04 BY
60000 04 I 113.60 17.00YN
60100 04 I 50.20 17.00YN
60200 04 M 360.70YN
60210 04 M 550.90YN
60212 04 M 718.70YN
60220 04 M 703.30YN
60225 04 M 703.30YN
60240 04 M 718.70YN
60252 04 M 1198.70YN
60254 04 M 1198.70YN
60260 04 M 718.70YN
60270 04 M 839.35YN
60271 04 M 749.20YN
60280 04 M 718.70YN
60281 04 M 718.70YN
Wednesday, June 18, 2008 Page 231 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
60300 04 1/1/2008 I 27.75 27.05YN
60500 04 M 839.35YN
60502 04 M 839.35YN
60505 04 M 839.35YN
60512 04 M 135.00YN
60520 04 M 749.20YN
60521 04 M 839.35YN
60522 04 M 1198.70YN
60540 04 M 839.35YN
60545 04 M 958.60YN
60600 04 M 839.35YN
60605 04 M 839.35YN
60650 04 M 839.35YN
60659 04 MYY
60699 04 MYY
61000 04 I 112.40YN
61020 04 I 112.40YN
61026 04 M 62.15YN
61050 04 I 112.40YN
61055 04 M 157.50YN
61070 04 I 112.40YN
Wednesday, June 18, 2008 Page 232 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61105 04 M 359.30YN
61107 04 M 359.30YN
61108 04 M 599.35YN
61120 04 M 359.30YN
61140 04 M 510.30YN
61150 04 M 958.60YN
61151 04 I 330.80YN
61154 04 M 599.35YN
61156 04 M 599.35YN
61210 04 M 449.50YN
61215 04 M 449.50YN
61250 04 M 449.50YN
61253 04 M 449.50YN
61304 04 M 749.20N
61305 04 M 886.90N
61312 04 M 861.50N
61313 04 M 861.50N
61314 04 M 861.50N
61315 04 M 1198.70N
61316 04 MY
61320 04 M 1123.70N
Wednesday, June 18, 2008 Page 233 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61321 04 M 1123.70N
61322 04 M 1123.70N
61323 04 M 1123.70N
61330 04 M 973.90N
61332 04 M 973.90YN
61333 04 M 1198.70YN
61334 04 M 1198.70YN
61340 04 M 839.35YN
61343 04 M 1738.80N
61345 04 M 1198.70N
61440 04 M 839.35N
61450 04 M 839.35N
61458 04 M 893.25YN
61460 04 M 891.30N
61470 04 M 958.60N
61480 04 M 958.60N
61490 04 M 1198.70N
61500 04 M 1198.70YN
61501 04 M 1198.70YN
61510 04 M 1198.70N
61512 04 M 1198.70N
Wednesday, June 18, 2008 Page 234 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61514 04 M 1198.70N
61516 04 M 1198.70N
61517 04 I 49.85N
61518 04 M 1198.70N
61519 04 M 1271.10N
61520 04 M 1604.85N
61521 04 M 1351.20N
61522 04 M 1198.70N
61524 04 M 1198.70N
61526 04 M 1499.10N
61530 04 M 1327.00N
61531 04 M 1138.70YN
61533 04 M 1138.70YN
61534 04 M 1198.70YN
61535 04 MYY
61536 04 M 1198.70N
61537 04 M 939.13N
61538 04 M 1198.70N
61539 04 M 1198.70N
61540 04 M 1134.13N
61541 04 M 1701.95N
Wednesday, June 18, 2008 Page 235 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61542 04 M 1198.70N
61543 04 M 1198.70N
61544 04 M 1198.70N
61545 04 M 1283.15N
61546 04 M 1198.70N
61548 04 M 1198.70N
61550 04 M 898.95N
61552 04 M 1198.70N
61556 04 M 1144.65N
61557 04 M 1690.50N
61558 04 M 1689.90N
61559 04 M 1689.90N
61563 04 MYY
61564 04 MYY
61566 04 M 1116.28N
61567 04 M 1270.28N
61570 04 M 1198.70N
61571 04 M 1198.70N
61575 04 M 1198.70YN
61576 04 M 1630.70YN
61580 04 M 1198.70YN
Wednesday, June 18, 2008 Page 236 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61581 04 M 1630.70YN
61582 04 M 1198.70N
61583 04 M 1306.65N
61584 04 M 1306.65N
61585 04 M 1630.70N
61586 04 M 1306.65N
61590 04 M 1630.70N
61591 04 M 1630.70N
61592 04 M 1630.70N
61595 04 M 1414.70N
61596 04 M 1630.70N
61597 04 M 1630.70N
61598 04 M 1522.70N
61600 04 M 1198.70N
61601 04 M 1198.70N
61605 04 M 1138.70N
61606 04 M 1198.70N
61607 04 M 1198.70N
61608 04 M 1274.80N
61609 04 M 1198.70YN
61610 04 M 1306.65YN
Wednesday, June 18, 2008 Page 237 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61611 04 M 1198.70YN
61612 04 M 1306.65YN
61613 04 M 1244.80YN
61615 04 M 1198.70YN
61616 04 M 1306.65YN
61618 04 M 958.60YN
61619 04 MYY
61623 04 I 241.20YN
61624 04 M 682.80YN
61626 04 M 682.80YN
61630 04 MYY
61635 04 MYY
61640 04 MYY
61641 04 MYY
61642 04 MYY
61680 04 M 1048.85N
61682 04 M 1784.20N
61684 04 M 1231.20N
61686 04 M 1871.15N
61690 04 M 973.90N
61692 04 M 1480.90N
Wednesday, June 18, 2008 Page 238 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61697 04 M 2267.10N
61698 04 M 2182.15N
61700 04 M 1498.85N
61702 04 M 1481.20N
61703 04 M 718.70N
61705 04 M 1198.70N
61708 04 M 1198.70N
61710 04 M 787.40N
61711 04 M 1158.10N
61720 04 M 1198.70N
61735 04 M 1198.70N
61750 04 M 1306.65YN
61751 04 M 1198.70YN
61760 04 M 1138.70YN
61770 04 M 749.20YN
61790 04 M 749.20YN
61791 04 M 1198.70YN
61793 04 M 1198.70YN
61795 04 M 230.30N
61850 04 M 749.20YN
61860 04 M 1198.70YN
Wednesday, June 18, 2008 Page 239 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
61863 04 M 574.19YN
61867 04 M 843.83YN
61870 04 M 958.60YN
61875 04 M 958.60YN
61880 04 M 749.20YN
61885 04 M 749.20YN
61886 04 M 749.20YN
61888 04 M 749.20YN
62000 04 M 789.30N
62005 04 M 1347.10N
62010 04 M 1347.10N
62100 04 M 1198.70N
62115 04 M 1296.20N
62116 04 M 1458.20N
62117 04 M 1458.20N
62120 04 M 698.40N
62121 04 M 1198.70N
62140 04 M 749.20YN
62141 04 M 1048.85YN
62142 04 M 749.20YN
62143 04 M 1048.85YN
Wednesday, June 18, 2008 Page 240 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
62145 04 M 1198.70N
62146 04 M 1350.15YN
62147 04 M 1458.20YN
62148 04 M 105.00N
62160 04 M 156.52YN
62161 04 M 985.60YN
62162 04 M 1036.85YN
62163 04 M 861.50YN
62164 04 M 1198.70YN
62165 04 M 1198.70YN
62180 04 M 839.35YN
62190 04 M 839.35YN
62192 04 M 761.60YN
62194 04 M 599.35YN
62200 04 M 839.35YN
62201 04 M 1048.85YN
62220 04 M 839.35YN
62223 04 M 761.60YN
62225 04 M 374.55YN
62230 04 M 374.55YN
62252 04 I 54.20YN
Wednesday, June 18, 2008 Page 241 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
62256 04 M 225.80YN
62258 04 M 599.35YN
62263 04 M 193.60YN
62264 04 M 193.60YN
62268 04 M 449.50YN
62269 04 M 449.50YN
62270 04 I 53.70YN
62272 04 I 59.10YN
62273 04 I 74.90YN
62280 04 I 158.20YN
62281 04 I 81.10YN
62282 04 I 158.20YN
62284 04 I 158.20N
62287 04 M 481.80YN
62290 04 I 158.20YN
62291 04 I 158.20YN
62292 04 M 852.05YN
62294 04 M 852.05YN
62310 04 I 85.90YN
62311 04 I 86.00YN
62318 04 MYY
Wednesday, June 18, 2008 Page 242 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
62319 04 MYY
62350 04 M 545.10YN
62351 04 M 839.35YN
62355 04 M 180.30YN
62360 04 M 545.10YN
62361 04 M 545.10YN
62362 04 M 545.10YN
62365 04 M 162.00YN
62367 04 I 27.55N
62368 04 I 40.45N
63001 04 M 1102.95YN
63003 04 M 1102.95YN
63005 04 M 1102.95YN
63011 04 M 881.00YN
63012 04 M 1404.20YN
63015 04 M 1161.20YN
63016 04 M 1161.20YN
63017 04 M 1161.20YN
63020 04 MYY
63030 04 M 1129.30YN
63035 04 MYY
Wednesday, June 18, 2008 Page 243 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
63040 04 M 1129.30YN
63042 04 M 1129.30YN
63043 04 MYY
63044 04 MYY
63045 04 M 1129.30YN
63046 04 M 1129.30YN
63047 04 M 1129.30YN
63048 04 MYY
63050 04 M 843.88YN
63051 04 M 947.11YN
63055 04 M 1291.70YN
63056 04 M 1291.70YN
63057 04 MY
63064 04 M 1198.70YN
63066 04 MY
63075 04 M 1198.70YN
63076 04 M 1198.70N
63077 04 M 1198.70YN
63078 04 M 1198.70N
63081 04 M 1291.70YN
63082 04 MYY
Wednesday, June 18, 2008 Page 244 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
63085 04 M 1291.70YN
63086 04 MYY
63087 04 M 1291.70YN
63088 04 MYY
63090 04 M 1291.70YN
63091 04 MYY
63101 04 M 1153.57YN
63102 04 M 1153.57YN
63103 04 MYY
63170 04 M 1291.70YN
63172 04 M 1198.70YN
63173 04 M 1393.75YN
63180 04 M 1198.70YN
63182 04 M 1198.70YN
63185 04 M 839.35N
63190 04 M 1079.30N
63191 04 MYY
63194 04 M 958.60N
63195 04 M 958.60N
63196 04 M 958.60N
63197 04 M 958.60N
Wednesday, June 18, 2008 Page 245 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
63198 04 M 1291.70N
63199 04 MY
63200 04 M 1198.70YN
63250 04 M 1198.70YN
63251 04 M 1198.70YN
63252 04 M 1224.30YN
63265 04 M 1198.70YN
63266 04 M 1198.70YN
63267 04 M 1198.70YN
63268 04 M 1198.70YN
63270 04 M 1198.70YN
63271 04 M 1198.70YN
63272 04 M 1198.70YN
63273 04 M 1198.70YN
63275 04 M 1198.70YN
63276 04 M 1198.70YN
63277 04 M 1198.70YN
63278 04 M 1198.70YN
63280 04 M 1198.70YN
63281 04 M 1198.70YN
63282 04 M 1198.70YN
Wednesday, June 18, 2008 Page 246 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
63283 04 M 1198.70YN
63285 04 M 1198.70YN
63286 04 M 1198.70YN
63287 04 M 1198.70YN
63290 04 M 1198.70YN
63295 04 M 190.18YN
63300 04 M 1606.30YN
63301 04 M 1615.70YN
63302 04 M 1291.70YN
63303 04 M 1291.70YN
63304 04 M 1291.70YN
63305 04 M 1291.70YN
63306 04 M 1291.70YN
63307 04 M 1291.70YN
63308 04 MYY
63600 04 M 898.95YN
63610 04 M 599.35YN
63615 04 M 898.95YN
63650 04 M 524.40YN
63655 04 M 733.85YN
63660 04 M 374.55YN
Wednesday, June 18, 2008 Page 247 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
63685 04 M 599.35YN
63688 04 M 374.55YN
63700 04 M 599.35YN
63702 04 M 599.35N
63704 04 M 630.10YN
63706 04 M 689.00N
63707 04 M 1198.70YN
63709 04 M 1198.70YN
63710 04 M 1102.95YN
63740 04 M 839.35YN
63741 04 M 324.05YN
63744 04 M 374.55YN
63746 04 M 194.05YN
64400 04 I 74.90YN
64402 04 I 74.90YN
64405 04 I 74.90YN
64408 04 I 52.40YN
64410 04 I 49.40YN
64412 04 I 46.65YN
64413 04 I 52.70YN
64415 04 I 52.70YN
Wednesday, June 18, 2008 Page 248 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64416 04 I 74.90YN
64417 04 I 48.40YN
64418 04 I 47.15YN
64420 04 I 43.25YN
64421 04 I 56.40YN
64425 04 I 52.65YN
64430 04 I 51.10YN
64435 04 I 50.55YN
64445 04 I 53.20YN
64446 04 I 74.90YN
64447 04 I 53.20YN
64448 04 I 74.90YN
64449 04 I 81.40YN
64450 04 I 38.95YN
64470 04 I 88.05YN
64472 04 I 74.90YN
64475 04 I 77.90YN
64476 04 I 74.90YN
64479 04 I 95.90YN
64480 04 I 85.75YN
64483 04 I 88.25YN
Wednesday, June 18, 2008 Page 249 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64484 04 I 83.20YN
64505 04 I 59.60YN
64508 04 I 59.60YN
64510 04 I 59.60YN
64517 04 I 64.40YN
64520 04 I 56.20YN
64530 04 I 58.70YN
64550 04 I 22.15N
64553 04 I 149.80YN
64555 04 I 60.80YN
64560 04 I 97.20YN
64561 04 M 171.50YN
64565 04 IYY
64573 04 M 599.35YN
64575 04 M 599.35YN
64577 04 M 599.35YN
64580 04 M 599.35YN
64581 04 M 332.00YN
64585 04 I 149.80YN
64590 04 M 599.35YN
64595 04 M 149.80YN
Wednesday, June 18, 2008 Page 250 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64600 04 I 100.00YN
64605 04 I 140.65YN
64610 04 I 233.00YN
64612 04 I 71.15YN
64613 04 I 71.15YN
64614 04 I 27.10YN
64620 04 I 80.90YN
64622 04 I 99.70YN
64623 04 I 48.20YN
64626 04 I 113.40YN
64627 04 I 66.50YN
64630 04 I 88.50YN
64640 04 I 90.50YN
64650 04 I 22.42YN
64653 04 I 28.36YN
64680 04 M 224.70YN
64681 04 I 116.11YN
64702 04 M 524.40YN
64704 04 M 524.40YN
64708 04 M 524.40YN
64712 04 M 524.40YN
Wednesday, June 18, 2008 Page 251 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64713 04 M 647.90YN
64714 04 M 647.90YN
64716 04 MYY
64718 04 M 524.40YN
64719 04 M 524.40YN
64721 04 M 524.40YN
64722 04 M 524.40YN
64726 04 M 524.40YN
64727 04 M 524.40YN
64732 04 I 148.20YN
64734 04 M 158.30YN
64736 04 M 224.70YN
64738 04 M 374.55YN
64740 04 M 224.70YN
64742 04 M 224.70YN
64744 04 M 607.60YN
64746 04 I 181.05YN
64752 04 M 524.40YN
64755 04 M 524.40YN
64760 04 M 524.40YN
64761 04 M 299.70YN
Wednesday, June 18, 2008 Page 252 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64763 04 M 224.70YN
64766 04 M 374.55YN
64771 04 M 374.55YN
64772 04 M 374.55YN
64774 04 I 144.55 34.00YN
64776 04 M 180.30YN
64778 04 MYY
64782 04 M 240.00YN
64783 04 M 120.60YN
64784 04 M 359.30YN
64786 04 M 470.15YN
64787 04 M 124.70N
64788 04 I 139.60 34.00YN
64790 04 M 359.30YN
64792 04 MYY
64795 04 I 112.40YN
64802 04 M 480.00YN
64804 04 M 599.35YN
64809 04 M 749.20YN
64818 04 M 653.40YN
64820 04 MYY
Wednesday, June 18, 2008 Page 253 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64821 04 M 407.40YN
64822 04 M 407.40YN
64823 04 M 471.00YN
64831 04 M 252.45YN
64832 04 M 139.00YN
64834 04 M 299.70YN
64835 04 M 599.35YN
64836 04 M 599.35YN
64837 04 M 299.70YN
64840 04 M 449.50YN
64856 04 M 449.50YN
64857 04 M 449.50YN
64858 04 M 599.35YN
64859 04 M 229.70YN
64861 04 M 718.70YN
64862 04 M 718.70YN
64864 04 M 599.35YN
64865 04 M 861.50YN
64866 04 M 599.35YN
64868 04 M 599.35YN
64870 04 M 599.35YN
Wednesday, June 18, 2008 Page 254 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
64872 04 M 449.50YN
64874 04 M 749.20YN
64876 04 M 524.40YN
64885 04 M 507.15YN
64886 04 M 600.65YN
64890 04 M 455.90YN
64891 04 M 457.30YN
64892 04 M 557.45YN
64893 04 M 557.45YN
64895 04 M 551.10YN
64896 04 M 619.50YN
64897 04 M 665.50YN
64898 04 M 665.50YN
64901 04 M 316.55YN
64902 04 M 359.70YN
64905 04 MYY
64907 04 MYY
64910 04 1/1/2007 MYY
64911 04 1/1/2007 MYY
64999 04 MYY
65091 04 M 359.30YN
Wednesday, June 18, 2008 Page 255 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
65093 04 M 480.00YN
65101 04 M 359.30YN
65103 04 M 480.00YN
65105 04 M 599.35YN
65110 04 M 898.95YN
65112 04 M 973.90YN
65114 04 M 1048.85YN
65125 04 MYY
65130 04 M 749.20YN
65135 04 M 449.50YN
65140 04 M 599.35YN
65150 04 M 524.40YN
65155 04 M 475.25YN
65175 04 M 236.70YN
65205 04 I 58.15N
65210 04 I 62.60N
65220 04 I 73.50N
65222 04 I 64.60N
65235 04 M 480.00YN
65260 04 M 480.00YN
65265 04 M 480.00YN
Wednesday, June 18, 2008 Page 256 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
65270 04 M 107.00 17.00YN
65272 04 M 142.70 17.00YN
65273 04 M 224.70YN
65275 04 M 359.30YN
65280 04 M 599.35YN
65285 04 M 599.35YN
65286 04 M 359.30YN
65290 04 M 449.50YN
65400 04 M 323.30YN
65410 04 I 51.40 17.00YN
65420 04 M 273.30YN
65426 04 M 348.15YN
65430 04 I 78.50 17.00YN
65435 04 I 48.55YN
65436 04 I 125.25YN
65450 04 I 135.40YN
65600 04 M 240.00YN
65710 04 M 839.25YN
65730 04 M 1317.95YN
65750 04 M 1317.95YN
65755 04 M 1317.95YN
Wednesday, June 18, 2008 Page 257 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
65760 04 M 1560.80YN
65765 04 M 1560.80YN
65767 04 M 1560.80YN
65770 04 MYY
65772 04 M 1252.00YN
65775 04 M 648.10YN
65780 04 M 403.90YN
65781 04 M 617.78YN
65782 04 M 532.61YN
65800 04 M 240.00YN
65805 04 M 299.70YN
65810 04 M 299.70YN
65815 04 M 480.00YN
65820 04 M 599.35YN
65850 04 M 599.35YN
65855 04 M 599.35YN
65860 04 M 299.70YN
65865 04 M 299.70YN
65870 04 M 297.00YN
65875 04 M 324.05YN
65880 04 M 299.70YN
Wednesday, June 18, 2008 Page 258 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
65900 04 M 378.05YN
65920 04 MYY
65930 04 M 480.00YN
66020 04 M 180.30YN
66030 04 M 180.30YN
66130 04 M 273.30YN
66150 04 M 718.70YN
66155 04 M 718.70YN
66160 04 M 718.70YN
66165 04 M 599.35YN
66170 04 M 718.70YN
66172 04 M 810.10YN
66180 04 M 799.70YN
66185 04 M 351.00YN
66220 04 M 550.90YN
66225 04 M 675.10YN
66250 04 MYY
66500 04 M 149.80YN
66505 04 M 240.00YN
66600 04 M 581.30YN
66605 04 M 581.30YN
Wednesday, June 18, 2008 Page 259 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
66625 04 M 581.30YN
66630 04 M 581.30YN
66635 04 M 581.30YN
66680 04 M 471.70YN
66682 04 M 471.70YN
66700 04 M 341.30YN
66710 04 M 341.30YN
66711 04 M 341.30YN
66720 04 M 341.30YN
66740 04 M 569.30YN
66761 04 M 449.50YN
66762 04 M 449.50YN
66770 04 M 374.55YN
66820 04 M 299.70YN
66821 04 M 299.70YN
66825 04 M 299.70YN
66830 04 M 374.55YN
66840 04 M 751.90YN
66850 04 M 751.90YN
66852 04 M 751.90YN
66920 04 M 751.90YN
Wednesday, June 18, 2008 Page 260 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
66930 04 M 751.90YN
66940 04 M 751.90YN
66982 04 M 587.60YN
66983 04 M 1051.60YN
66984 04 M 1051.60YN
66985 04 M 574.75YN
66986 04 M 546.00YN
66990 09 NY
66999 04 MYY
67005 04 M 749.20YN
67010 04 M 749.20YN
67015 04 M 861.50YN
67025 04 M 818.45YN
67027 04 M 524.35YN
67028 04 M 287.10YN
67030 04 M 818.45YN
67031 04 M 818.45YN
67036 04 M 1086.30YN
67039 04 M 1086.30YN
67040 04 M 1086.30YN
67041 04 1/1/2008 M 613.65YN
Wednesday, June 18, 2008 Page 261 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
67042 04 1/1/2008 M 703.00YN
67043 04 1/1/2008 M 737.55YN
67101 04 M 434.30YN
67105 04 M 457.20YN
67107 04 M 980.85YN
67108 04 M 1086.30YN
67110 04 M 434.30YN
67112 04 MYY
67113 04 1/1/2008 M 809.66N
67115 04 M 735.60YN
67120 04 M 958.60YN
67121 04 MYY
67141 04 M 443.95YN
67145 04 M 443.95YN
67208 04 M 443.95YN
67210 04 M 443.95YN
67218 04 M 486.10YN
67220 04 M 443.95YN
67221 04 M 225.30YN
67225 04 I 42.55YN
67227 04 M 443.95YN
Wednesday, June 18, 2008 Page 262 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
67228 04 M 466.15YN
67229 04 1/1/2008 M 532.19YN
67250 04 M 749.20YN
67255 04 M 898.95YN
67299 04 MYY
67311 04 M 511.90YN
67312 04 M 511.90YN
67314 04 M 511.90YN
67316 04 M 511.90YN
67318 04 M 550.90YN
67320 04 M 647.20YN
67331 04 M 374.55YN
67332 04 M 511.90YN
67334 04 M 511.90YN
67335 09 NY
67340 04 M 405.10YN
67343 04 M 399.60YN
67345 04 M 100.00YN
67346 04 1/1/2007 I 107.00YN
67399 04 MYY
67400 04 M 681.10YN
Wednesday, June 18, 2008 Page 263 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
67405 04 M 524.40YN
67412 04 M 839.35YN
67413 04 M 839.35YN
67414 04 M 797.40YN
67415 04 I 56.80 17.00YN
67420 04 M 1079.30YN
67430 04 M 1079.30YN
67440 04 M 681.10YN
67445 04 M 1025.40YN
67450 04 M 681.10YN
67500 04 I 78.20YN
67505 04 M 74.90YN
67515 04 I 74.90YN
67550 04 M 415.85YN
67560 04 M 340.90YN
67570 04 M 797.40YN
67599 04 MYY
67700 04 I 73.50YN
67710 04 M 224.70YN
67715 04 I 59.60YN
67800 04 I 77.20 17.00YN
Wednesday, June 18, 2008 Page 264 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
67801 04 I 91.85 17.00YN
67805 04 M 99.05 17.00YN
67808 04 I 112.80YN
67810 04 I 68.10 17.00YN
67820 04 I 30.50N
67825 04 I 88.50N
67830 04 I 112.60N
67835 04 M 187.30YN
67840 04 I 93.30 17.00YN
67850 04 I 90.20YN
67875 04 M 187.30YN
67880 04 M 187.30YN
67882 04 M 231.50YN
67900 04 M 216.00YN
67901 04 M 685.40YN
67902 04 M 685.40YN
67903 04 M 685.40YN
67904 04 M 685.40YN
67906 04 M 749.20YN
67908 04 M 749.20YN
67909 04 M 749.20YN
Wednesday, June 18, 2008 Page 265 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
67911 04 M 749.20YN
67912 04 M 221.64YN
67914 04 M 359.30YN
67915 04 I 133.90YN
67916 04 M 299.70YN
67917 04 M 359.30YN
67921 04 M 359.30YN
67922 04 I 130.70YN
67923 04 M 299.70YN
67924 04 M 359.30YN
67930 04 M 189.00 17.00YN
67935 04 M 244.50 17.00YN
67938 04 I 80.90 17.00YN
67950 04 M 359.30YN
67961 04 M 324.05YN
67966 04 M 345.70YN
67971 04 M 449.50YN
67973 04 M 449.50YN
67974 04 M 449.50YN
67975 04 M 449.50YN
67999 04 MYY
Wednesday, June 18, 2008 Page 266 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
68020 04 I 72.55 17.00YN
68040 04 I 71.40 17.00YN
68100 04 I 77.60 17.00YN
68110 04 M 180.30YN
68115 04 M 180.30YN
68130 04 M 224.70YN
68135 04 M 224.70YN
68200 04 I 56.60N
68320 04 M 449.50YN
68325 04 M 531.30YN
68326 04 M 531.30YN
68328 04 M 531.30YN
68330 04 M 299.70YN
68335 04 M 524.40YN
68340 04 M 299.70YN
68360 04 M 240.00YN
68362 04 M 359.30YN
68371 04 M 191.25YN
68399 04 MYY
68400 04 I 103.60 17.00YN
68420 04 I 117.70 17.00YN
Wednesday, June 18, 2008 Page 267 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
68440 04 I 66.90 17.00YN
68500 04 M 599.35YN
68505 04 M 336.45YN
68510 04 I 191.40 17.00YN
68520 04 M 599.35YN
68525 04 I 124.50 17.00YN
68530 04 I 174.60 17.00YN
68540 04 M 599.35YN
68550 04 M 648.10YN
68700 04 M 359.30YN
68705 04 I 93.60YN
68720 04 M 839.35YN
68745 04 M 839.35YN
68750 04 M 858.70YN
68760 04 I 84.10YN
68761 04 I 75.50YN
68770 04 MYY
68801 04 I 71.70YN
68810 04 I 103.50YN
68811 04 I 115.10YN
68815 04 I 143.40YN
Wednesday, June 18, 2008 Page 268 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
68816 04 1/1/2008 I 115.00 205.23YN
68840 04 I 83.30YN
68850 04 I 116.35YN
68899 04 MYY
69000 04 I 42.40 17.00YN
69005 04 I 64.10 17.00YN
69020 04 I 44.60 17.00YN
69100 04 I 31.15 17.00YN
69105 04 I 50.20 17.00YN
69110 04 M 209.40YN
69120 04 M 240.00YN
69140 04 M 480.00YN
69145 04 I 90.10YN
69150 04 M 718.70YN
69155 04 M 1198.70N
69200 04 I 26.60N
69205 04 I 74.90YN
69210 04 I 21.40N
69220 04 I 28.50YN
69222 04 I 57.30YN
69300 09 MY
Wednesday, June 18, 2008 Page 269 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
69310 04 M 694.40YN
69320 04 M 958.60YN
69399 04 MYY
69400 04 I 28.15YN
69401 04 I 22.15YN
69405 04 I 115.10YN
69420 04 I 43.80 17.00YN
69421 04 I 56.60YN
69424 04 I 30.35YN
69433 04 I 76.60 34.00YN
69436 04 I 80.50YN
69440 04 M 599.35YN
69450 04 I 191.10YN
69501 04 M 692.20YN
69502 04 M 692.20YN
69505 04 M 749.20YN
69511 04 M 839.35YN
69530 04 M 1198.70YN
69535 04 M 1198.70YN
69540 04 I 50.20 17.00YN
69550 04 I 363.60 17.00YN
Wednesday, June 18, 2008 Page 270 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
69552 04 M 674.20YN
69554 04 M 954.95YN
69601 04 M 695.05YN
69602 04 M 695.05YN
69603 04 M 695.05YN
69604 04 M 695.05YN
69605 04 M 695.05YN
69610 04 MYY
69620 04 MYY
69631 04 M 749.20YN
69632 04 M 749.20YN
69633 04 M 861.50YN
69635 04 M 749.20YN
69636 04 M 749.20YN
69637 04 M 861.50YN
69641 04 M 1048.85YN
69642 04 M 1048.85YN
69643 04 M 1048.85YN
69644 04 M 1048.85YN
69645 04 M 1048.85YN
69646 04 M 1048.85YN
Wednesday, June 18, 2008 Page 271 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
69650 04 M 743.65YN
69660 04 M 749.20YN
69661 04 M 749.20YN
69662 04 M 749.20YN
69666 04 M 749.20YN
69667 04 M 749.20YN
69670 04 M 1079.30YN
69676 04 M 834.50YN
69700 04 M 299.70YN
69710 04 M 918.15YN
69711 04 M 550.90YN
69714 04 M 604.65YN
69715 04 M 765.85YN
69717 04 M 623.25YN
69718 04 M 775.20YN
69720 04 M 749.20YN
69725 04 M 749.20YN
69740 04 M 599.35YN
69745 04 M 947.20YN
69799 04 MYY
69801 04 M 749.20YN
Wednesday, June 18, 2008 Page 272 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
69802 04 M 749.20YN
69805 04 M 749.20YN
69806 04 M 749.20YN
69820 04 M 749.20YN
69840 04 M 749.20YN
69905 04 M 1198.70YN
69910 04 M 1198.70YN
69915 04 M 1198.70YN
69930 04 M 1296.20YN
69949 04 MYY
69950 04 M 1079.30YN
69955 04 M 1079.30YN
69960 04 M 1198.70YN
69970 04 M 1188.20YN
69979 04 MYY
69990 09 NY
70010 04 I 28.70YN
70015 04 I 39.20YN
70030 A 04 N 10.75 10.75 21.50N
70100 A 04 N 11.40 11.40 22.80N
70110 A 04 N 15.65 15.65 31.30N
Wednesday, June 18, 2008 Page 273 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
70120 A 04 N 11.40 11.40 22.80N
70130 A 04 N 15.65 15.65 31.30N
70134 A 04 N 20.25 20.25 40.50N
70140 A 04 N 14.35 14.35 28.70N
70150 A 04 N 17.62 15.62 35.25N
70160 A 04 N 10.47 10.47 20.95N
70170 04 I 18.30N
70190 A 04 N 11.40 11.40 22.80N
70200 A 04 N 17.62 17.62 35.25N
70210 A 04 N 11.10 11.10 22.20N
70220 A 04 N 14.35 14.35 28.70N
70240 A 04 N 11.40 11.40 22.80N
70250 A 04 N 10.75 10.75 21.50N
70260 A 04 N 17.62 17.62 35.25N
70300 A 04 N 5.90 5.90 11.80N
70310 A 04 N 7.17 7.17 14.35N
70320 A 04 N 14.35 14.35 28.70N
70328 A 04 N 14.35 14.35 28.70N
70330 A 04 N 14.35 14.35 28.70N
70332 04 I 23.30N
70336 B 04 N 148.30 148.30 296.60YN
Wednesday, June 18, 2008 Page 274 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
70350 A 04 N 7.17 7.17 14.35N
70355 A 04 N 14.35 14.35 28.70N
70360 A 04 N 7.17 7.17 14.35N
70370 A 04 N 13.07 13.07 26.15N
70371 A 04 N 12.70 12.70 25.40YN
70373 04 I 20.20N
70380 A 04 N 11.10 11.10 22.20N
70390 04 I 22.20YN
70450 B 04 N 123.58 123.58 247.15YN
70460 B 04 N 141.23 141.22 282.45YN
70470 B 04 N 141.22 141.22 282.45YN
70480 B 04 N 31.35 31.35 62.70YN
70481 B 04 N 37.95 37.95 75.90YN
70482 B 04 N 54.92 54.92 109.95YN
70486 B 04 N 31.35 31.35 62.70YN
70487 B 04 N 37.95 37.95 75.90YN
70488 B 04 N 54.92 54.92 109.85YN
70490 B 04 N 31.35 31.35 62.70YN
70491 B 04 N 37.95 37.95 75.90YN
70492 B 04 N 54.92 54.92 109.85YN
70496 B 04 N 123.52 123.52 247.05YN
Wednesday, June 18, 2008 Page 275 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
70498 B 04 N 123.52 123.52 247.05YN
70540 B 04 N 148.30 148.30 296.60YN
70542 B 04 N 148.30 148.30 296.60YN
70543 B 04 N 223.93 223.92 447.85YN
70544 B 04 N 148.30 148.30 296.60YN
70545 B 04 N 148.30 148.30 296.60YN
70546 B 04 N 204.77 204.78 409.55YN
70547 B 04 N 148.30 148.30 296.60YN
70548 B 04 N 148.30 148.30 296.60YN
70549 B 04 N 204.77 204.78 409.55YN
70551 B 04 N 148.30 148.30 296.60YN
70552 B 04 N 148.30 148.30 296.60YN
70553 B 04 N 148.30 148.30 296.60YN
70554 C 04 1/1/2007 N 50.42 246.18 1 296.60YN
70555 04 1/1/2007 N 64.32YN
70557 04 M 79.06YN
70558 04 M 87.53YN
70559 04 N 88.02YN
71010 A 04 N 8.50 8.50 17.00N
71015 A 04 N 10.75 10.75 21.50N
71020 A 04 N 10.75 10.75 21.50N
Wednesday, June 18, 2008 Page 276 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
71021 A 04 N 10.75 10.75 21.50N
71022 A 04 N 10.75 10.75 21.50N
71023 A 04 N 10.75 10.75 21.50N
71030 A 04 N 14.35 14.35 28.70N
71034 A 04 N 14.35 14.35 28.70N
71035 A 04 N 14.35 14.35 28.70N
71040 04 I 32.70YN
71060 04 I 52.30YN
71090 04 I 103.30YN
71100 A 04 N 10.75 10.75 21.50N
71101 A 04 N 12.40 12.40 24.80N
71110 A 04 N 13.07 13.08 26.15N
71111 A 04 N 14.35 14.35 28.70N
71120 A 04 N 10.75 10.75 21.50N
71130 A 04 N 14.35 14.35 28.70N
71250 B 04 N 31.35 31.35 62.70YN
71260 B 04 N 37.95 37.95 75.90YN
71270 B 04 N 54.93 54.92 109.85YN
71275 B 04 N 132.50 132.50 265.00YN
71550 B 04 N 148.30 148.30 296.60YN
71551 B 04 N 148.30 148.30 296.60YN
Wednesday, June 18, 2008 Page 277 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
71552 B 04 N 224.03 224.02 448.05YN
71555 B 04 N 148.30 148.30 296.60YN
72010 A 04 N 35.95 35.95 71.90N
72020 A 04 N 12.07 12.08 24.15N
72040 A 04 N 12.07 12.08 24.15N
72050 A 04 N 17.63 17.62 35.25N
72052 A 04 N 18.25 18.25 36.50N
72069 A 04 N 11.40 11.40 22.80N
72070 A 04 N 11.40 11.40 22.80N
72072 A 04 N 10.47 10.48 20.95N
72074 A 04 N 10.75 10.75 21.50N
72080 A 04 N 12.70 12.70 25.40N
72090 A 04 N 29.45 29.45 58.90N
72100 A 04 N 14.35 14.35 28.70N
72110 A 04 N 18.95 18.95 37.90N
72114 A 04 N 18.95 18.95 37.90N
72120 A 04 N 18.95 18.95 37.90N
72125 B 04 N 31.35 31.35 62.70YN
72126 B 04 N 37.95 37.95 75.90YN
72127 B 04 N 54.93 54.92 109.85YN
72128 B 04 N 31.35 31.35 62.70YN
Wednesday, June 18, 2008 Page 278 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
72129 B 04 N 37.95 37.95 75.90YN
72130 B 04 N 54.93 54.92 109.85YN
72131 B 04 N 31.35 31.35 62.70YN
72132 B 04 N 37.95 37.95 75.90YN
72133 B 04 N 54.93 54.92 109.85YN
72141 B 04 N 148.30 148.30 296.60YN
72142 B 04 N 148.30 148.30 296.60YN
72146 B 04 N 148.30 148.30 296.60YN
72147 B 04 N 148.30 148.30 296.60YN
72148 B 04 N 148.30 148.30 296.60YN
72149 B 04 N 148.30 148.30 296.60YN
72156 B 04 N 148.30 148.30 296.60YN
72157 B 04 N 148.30 148.30 296.60YN
72158 B 04 N 148.30 148.30 296.60YN
72159 B 04 N 148.30 148.30 296.60YN
72170 A 04 N 7.85 7.85 15.70N
72190 A 04 N 17.63 17.62 35.25N
72191 B 04 N 128.30 128.30 256.60YN
72192 B 04 N 31.35 31.35 62.70YN
72193 B 04 N 37.95 37.95 75.90YN
72194 B 04 N 54.93 54.92 109.85YN
Wednesday, June 18, 2008 Page 279 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
72195 B 04 N 148.30 148.30 296.60YN
72196 B 04 N 148.30 148.30 296.60YN
72197 B 04 N 226.15 226.15 452.30YN
72198 B 04 N 148.30 148.30 296.60YN
72200 A 04 N 10.75 10.75 21.50YN
72202 A 04 N 11.40 11.40 22.80YN
72220 A 04 N 10.75 10.75 21.50N
72240 04 I 65.35YN
72255 04 I 52.30YN
72265 04 N 52.30YN
72270 04 N 99.35YN
72275 04 I 57.45YN
72285 04 I 52.30N
72291 04 1/1/2007 I 78.05N
72292 04 1/1/2007 I 62.50N
72295 04 I 45.80N
73000 A 04 N 7.50 7.50 15.00N
73010 A 04 N 10.75 10.75 21.50N
73020 A 04 N 10.75 10.75 21.50N
73030 A 04 N 11.10 11.10 22.20N
73040 C 04 I 6.03 17.47 23.50YN
Wednesday, June 18, 2008 Page 280 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
73050 A 04 N 10.07 10.08 20.15YN
73060 A 04 N 7.85 7.85 15.70N
73070 A 04 N 9.80 9.80 19.60N
73080 A 04 N 10.75 10.75 21.50N
73085 04 I 22.20YN
73090 A 04 N 9.15 9.15 18.30N
73092 A 04 N 7.17 7.18 14.35N
73100 A 04 N 10.75 10.75 21.50N
73110 A 04 N 11.10 11.10 22.20N
73115 04 I 30.10YN
73120 A 04 N 8.50 8.50 17.00N
73130 A 04 N 9.15 9.15 18.30N
73140 A 04 N 7.17 7.18 14.35N
73200 B 04 N 31.35 31.35 62.70YN
73201 B 04 N 37.95 37.95 75.90YN
73202 B 04 N 54.93 54.92 109.85YN
73206 B 04 N 115.55 115.55 231.10YN
73218 B 04 N 148.30 148.30 296.60YN
73219 B 04 N 148.30 148.30 296.60YN
73220 B 04 N 148.30 148.30 296.60YN
73221 B 04 N 148.30 148.30 296.60YN
Wednesday, June 18, 2008 Page 281 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
73222 B 04 N 148.30 148.30 296.60YN
73223 B 04 N 223.92 223.92 447.85YN
73225 B 04 N 148.30 148.30 296.60YN
73500 A 04 N 10.75 10.75 21.50N
73510 A 04 N 14.35 14.35 28.70N
73520 A 04 N 19.60 19.60 39.20N
73525 C 04 I 14.02 38.28 52.30YN
73530 A 04 N 24.85 24.85 49.70N
73540 A 04 N 17.00 17.00 34.00N
73542 04 I 120.90YN
73550 A 04 N 10.75 10.75 21.50N
73560 A 04 N 9.80 9.80 19.60N
73562 A 04 N 10.10 10.10 20.20N
73564 A 04 N 11.10 11.10 22.20N
73565 A 04 N 16.70 16.70 33.40N
73580 04 I 37.90YN
73590 A 04 N 10.75 10.75 21.50N
73592 A 04 N 10.75 10.75 21.50N
73600 A 04 N 10.75 10.75 21.50N
73610 A 04 N 14.35 14.35 28.70N
73615 04 I 26.15N
Wednesday, June 18, 2008 Page 282 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
73620 A 04 N 8.50 8.50 17.00N
73630 A 04 N 10.75 10.75 21.50N
73650 A 04 N 8.50 8.50 17.00N
73660 A 04 N 7.17 7.17 14.35N
73700 B 04 N 31.35 31.35 62.70YN
73701 B 04 N 37.95 37.95 75.90YN
73702 B 04 N 54.92 54.92 109.85YN
73706 B 04 N 115.55 115.55 231.10YN
73718 B 04 N 148.30 148.30 296.60YN
73719 B 04 N 148.30 148.30 296.60YN
73720 B 04 N 148.30 148.30 296.60YN
73721 B 04 N 148.30 148.30 296.60YN
73722 B 04 N 148.30 148.30 296.60YN
73723 B 04 N 223.92 223.92 447.85YN
73725 B 04 N 148.30 148.30 296.60YN
74000 A 04 N 10.75 10.75 21.50N
74010 A 04 N 12.70 12.70 25.40N
74020 A 04 N 12.70 12.70 25.40N
74022 A 04 N 20.95 20.95 41.90N
74150 B 04 N 31.35 31.35 62.70YN
74160 B 04 N 37.95 37.95 75.90YN
Wednesday, June 18, 2008 Page 283 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
74170 B 04 N 54.92 54.92 109.85YN
74175 B 04 N 128.32 128.32 256.65YN
74181 B 04 N 148.30 148.30 296.60YN
74182 B 04 N 148.30 148.30 296.60YN
74183 B 04 N 226.15 226.15 452.30YN
74185 B 04 N 148.30 148.30 296.60YN
74190 04 I 21.50YN
74210 A 04 N 14.35 14.35 28.70N
74220 A 04 N 14.35 14.35 28.70N
74230 A 04 N 12.70 12.70 25.40N
74235 04 I 122.40YN
74240 B 04 N 24.85 24.85 49.70N
74241 B 04 N 25.50 25.50 51.00N
74245 B 04 N 32.02 32.02 64.05N
74246 B 04 N 26.15 26.15 52.30N
74247 B 04 N 26.80 26.80 53.60N
74249 B 04 N 32.02 32.02 64.05N
74250 B 04 N 21.57 21.57 43.15N
74251 B 04 N 29.45 29.45 58.90N
74260 B 04 N 18.25 18.25 36.50N
74270 B 04 N 24.85 24.85 49.70N
Wednesday, June 18, 2008 Page 284 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
74280 B 04 N 29.45 29.45 58.90N
74283 B 04 N 29.45 29.45 58.90N
74290 B 04 N 17.62 17.62 35.25YN
74291 B 04 N 17.62 17.62 35.25YN
74300 04 I 35.25YN
74301 04 IY
74305 04 I 35.25YN
74320 04 I 57.55YN
74327 04 I 168.65YN
74328 04 I 64.05YN
74329 04 I 92.80YN
74330 04 I 100.65YN
74340 04 I 51.00YN
74355 04 I 118.60YN
74360 04 I 44.90YN
74363 04 I 170.00YN
74400 B 04 N 24.85 24.85 49.70YN
74410 B 04 N 28.77 28.77 57.55YN
74415 B 04 N 28.77 28.77 57.55YN
74420 B 04 N 14.35 14.35 28.70YN
74425 04 I 28.70YN
Wednesday, June 18, 2008 Page 285 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
74430 04 I 23.50YN
74440 04 I 32.70YN
74445 04 I 28.70YN
74450 04 I 26.15YN
74455 04 I 26.15YN
74470 04 I 18.30YN
74475 04 I 14.35YN
74480 04 I 71.90YN
74485 04 I 28.50YN
74710 B 04 N 22.90 22.90 45.80YN
74740 C 04 I 10.65 28.55 39.20YN
74742 04 I 39.20YN
74775 04 N 71.20YN
75557 C 04 1/1/2008 N 68.87 230.81 299.68YY
75558 04 1/1/2008 NYY
75559 C 04 1/1/2008 N 87.60 344.24 431.84YY
75560 04 1/1/2008 NYY
75561 C 04 1/1/2008 N 76.18 325.65 401.83YN
75562 04 1/1/2008 NYY
75563 C 04 1/1/2008 N 90.99 404.09 495.08YY
75564 04 1/1/2008 NYY
Wednesday, June 18, 2008 Page 286 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
75600 04 I 109.85YN
75605 04 I 77.20YN
75625 04 I 98.10YN
75630 04 I 130.80YN
75635 C 04 I 51.14 230.26 281.40YN
75650 04 I 163.40YN
75658 04 I 78.45YN
75660 04 I 84.90YN
75662 04 I 130.80YN
75665 04 I 98.10YN
75671 04 I 130.80YN
75676 04 I 78.45YN
75680 04 I 104.60YN
75685 04 I 78.45YN
75705 04 I 98.10YN
75710 04 I 78.45YN
75716 04 I 111.10YN
75722 04 I 78.45YN
75724 04 I 111.10YN
75726 04 I 91.45YN
75731 04 I 91.45YN
Wednesday, June 18, 2008 Page 287 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
75733 04 I 115.10YN
75736 04 I 91.45YN
75741 04 I 91.45YN
75743 04 I 117.60YN
75746 04 I 65.35YN
75756 04 I 39.20YN
75774 04 I 25.10YN
75790 04 I 84.90YN
75801 04 I 35.25YN
75803 04 I 75.90YN
75805 04 I 77.20YN
75807 04 I 91.45YN
75809 04 I 77.20YN
75810 04 I 91.45YN
75820 04 I 45.80YN
75822 04 I 65.35YN
75825 04 I 78.45YN
75827 04 I 100.65YN
75831 04 I 91.45YN
75833 04 I 111.10YN
75840 04 I 57.55YN
Wednesday, June 18, 2008 Page 288 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
75842 04 I 91.45YN
75860 04 I 78.45YN
75870 04 I 52.30YN
75872 04 I 130.80YN
75880 04 I 28.70YN
75885 04 I 64.30YN
75887 04 I 54.60YN
75889 04 I 128.20YN
75891 04 I 93.40YN
75893 04 I 98.10N
75894 04 I 64.05YN
75896 04 I 64.05YN
75898 04 I 56.20YN
75900 04 I 201.20YN
75901 04 I 66.60YN
75902 04 I 66.60YN
75940 04 I 66.60YN
75945 04 I 64.05YN
75946 04 I 49.40YN
75952 04 I 162.85YN
75953 04 I 68.30YN
Wednesday, June 18, 2008 Page 289 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
75954 04 I 83.00YN
75956 04 M 221.10N
75957 04 M 189.42N
75958 04 M 126.26N
75959 04 M 110.52N
75960 04 I 83.00YN
75961 04 I 62.15YN
75962 04 I 83.00YN
75964 04 I 83.00YN
75966 04 I 83.00YN
75968 04 I 83.00YN
75970 04 I 78.90YN
75978 04 I 65.35YN
75980 04 I 83.00YN
75982 04 I 41.90YN
75984 04 I 53.60YN
75989 04 I 84.90YN
75992 04 I 83.00YN
75993 04 IYY
75994 04 I 83.00YN
75995 04 I 83.00YN
Wednesday, June 18, 2008 Page 290 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
75996 04 IYY
76000 04 I 32.70N
76001 04 I 56.45N
76010 A 04 N 16.20 16.20 32.40N
76080 04 I 26.15N
76098 A 04 N 6.20 6.20 12.40N
76100 A 04 N 24.85 24.85 49.70N
76101 A 04 N 17.62 17.62 35.25N
76102 A 04 N 24.85 24.85 49.70N
76120 A 04 N 10.47 10.47 20.95N
76125 A 04 N 24.85 24.85 49.70N
76140 04 N 19.60N
76150 B 04 NY
76350 B 04 NY
76376 C 04 I 6.18 66.99 1 73.17YN
76377 C 04 I 24.33 72.94 1 97.27YN
76380 04 N 59.55YN
76390 B 04 I 148.30 148.30 296.60YN
76496 A 04 IYY
76497 B 04 IYY
76498 B 04 IYY
Wednesday, June 18, 2008 Page 291 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
76499 04 NY
76506 B 04 N 32.02 32.02 64.05YN
76510 A 04 N 32.67 32.67 65.35N
76511 A 04 N 24.85 24.85 49.70YN
76512 A 04 N 32.67 32.67 65.35YN
76513 A 04 N 32.67 32.67 65.35YN
76514 C 04 N 5.20 1.37 1 6.57YN
76516 A 04 N 24.85 24.85 49.70YN
76519 A 04 N 24.90 24.90 49.80YN
76529 A 04 N 32.67 32.67 65.35YN
76536 B 04 N 34.00 34.00 68.00YN
76604 B 04 N 31.35 31.35 62.70YN
76645 B 04 N 31.35 31.35 62.70YN
76700 B 04 N 37.95 37.95 75.90YN
76705 B 04 N 31.35 31.35 62.70YN
76770 B 04 N 37.95 37.95 75.90YN
76775 B 04 N 31.35 31.35 62.70YN
76776 C 04 1/1/2007 N 53.13 22.77 1 75.90YN
76800 B 04 N 37.95 37.95 75.90YN
76801 B 04 N 35.95 35.95 71.90YN
76802 B 04 N 22.52 22.52 45.05YN
Wednesday, June 18, 2008 Page 292 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
76805 B 04 N 35.95 35.95 71.90YN
76810 B 04 N 22.52 22.52 45.05YN
76811 B 04 N 35.95 35.95 71.90YN
76812 B 04 N 22.52 22.52 45.05YN
76813 C 04 1/1/2007 N 32.36 39.54 1 71.90YN
76814 C 04 1/1/2007 N 25.23 19.82 1 45.05YN
76815 B 04 N 35.95 35.95 71.90YN
76816 B 04 N 35.95 35.95 71.90YN
76817 B 04 N 35.95 35.95 71.90YN
76818 B 04 N 31.97 31.97 63.95YN
76819 B 04 N 15.55 15.55 31.10YN
76820 B 04 N 35.95 35.95 71.90YN
76821 B 04 N 35.95 35.95 71.90YN
76825 B 04 N 35.95 35.95 71.90YN
76826 B 04 N 35.95 35.95 71.90YN
76827 B 04 N 35.95 35.95 71.90YN
76828 B 04 N 35.95 35.95 71.90YN
76830 B 04 N 35.95 35.95 71.90YN
76831 B 04 N 35.95 35.90 71.90YN
76856 B 04 N 35.95 35.95 71.90YN
76857 B 04 N 35.95 35.95 71.90YN
Wednesday, June 18, 2008 Page 293 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
76870 B 04 N 24.85 24.85 49.70YN
76872 B 04 N 35.95 35.95 71.90YN
76873 B 04 N 71.35 71.35 142.70YN
76880 B 04 N 24.85 24.85 49.70YN
76885 B 04 N 35.95 35.95 71.90YN
76886 B 04 N 35.95 35.95 71.90YN
76930 04 I 56.20YN
76932 04 I 65.35YN
76936 04 I 56.20YN
76937 C 04 I 9.21 9.60 1 18.81YN
76940 C 04 I 55.84 35.48 1 91.32YN
76941 04 I 56.20YN
76942 04 I 60.10YN
76945 04 I 49.70YN
76946 04 I 51.00YN
76950 B 04 N 31.35 31.35 62.70YN
76965 B 04 N 24.85 24.85 49.70YN
76970 A 04 NYY
76975 04 I 51.00YN
76977 B 04 N 17.25 17.25 34.50YN
76998 04 1/1/2007 N 33.37YN
Wednesday, June 18, 2008 Page 294 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
76999 04 NY
77001 C 04 1/1/2007 N 8.75 29.29 1 38.04N
77002 C 04 1/1/2007 N 13.27 24.63 1 37.90N
77003 C 04 1/1/2007 N 20.40 31.90 1 52.30N
77011 C 04 1/1/2007 N 7.31 48.89 1 56.20YN
77012 C 04 1/1/2007 N 10.12 46.08 1 56.20N
77013 04 N 233.70YN
77014 C 04 1/1/2007 N 14.05 42.15 1 56.20YN
77021 C 04 1/1/2007 N 53.61 281.44 1 335.05N
77022 C 04 1/1/2007 N 53.61 281.44 1 335.05YN
77031 C 04 1/1/2007 N 26.08 9.17 1 35.25N
77032 C 04 1/1/2007 N 13.75 21.50 1 35.25N
77051 C 04 1/1/2007 N 1.89 8.07 1 9.96N
77052 C 04 1/1/2007 N 1.89 8.07 1 9.96N
77053 C 04 1/1/2007 N 9.18 41.82 1 51.00N
77054 C 04 1/1/2007 N 11.44 60.06 1 71.50N
77055 C 04 1/1/2007 N 17.64 21.56 1 39.20N
77056 C 04 1/1/2007 N 31.64 40.26 1 71.90N
77057 C 04 1/1/2007 N 30.20 41.70 1 71.90N
77058 C 04 1/1/2007 N 29.66 266.94 1 296.60YN
77059 C 04 1/1/2007 N 23.73 272.87 1 296.60YN
Wednesday, June 18, 2008 Page 295 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
77071 04 1/1/2007 N 15.53N
77072 C 04 1/1/2007 N 8.81 12.69 1 21.50N
77073 C 04 1/1/2007 N 9.18 19.52 1 28.70N
77074 C 04 1/1/2007 N 20.72 36.83 1 57.55N
77075 C 04 1/1/2007 N 30.41 67.69 1 98.10N
77076 C 04 1/1/2007 N 16.92 18.33 1 35.25N
77077 C 04 1/1/2007 N 12.57 29.33 1 41.90YN
77078 C 04 1/1/2007 N 3.20 32.40 1 35.60YN
77079 C 04 1/1/2007 N 3.92 31.68 1 35.60YN
77080 C 04 1/1/2007 N 9.81 88.29 1 98.10YN
77081 C 04 1/1/2007 N 28.45 69.65 1 98.10YN
77082 C 04 1/1/2007 N 24.53 73.57 1 98.10YN
77083 C 04 1/1/2007 N 30.10 73.70 1 103.80YN
77084 C 04 1/1/2007 N 48.83 238.43 1 287.26YN
77261 09 NY
77262 09 NY
77263 09 IY
77280 09 NY
77285 09 NY
77290 09 NY
77295 09 NY
Wednesday, June 18, 2008 Page 296 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
77299 09 NY
77300 09 NY
77301 09 NY
77305 09 NY
77310 09 NY
77315 09 NY
77321 09 NY
77326 09 NY
77327 09 NY
77328 09 NY
77331 09 NY
77332 09 NY
77333 09 NY
77334 09 NY
77336 09 NY
77370 09 NY
77371 04 1/1/2007 N 574.13YN
77372 04 1/1/2007 N 435.96YN
77373 04 1/1/2007 N 812.27YN
77399 09 N 1Y
77401 B 04 N 12.07 12.07 24.15YN
Wednesday, June 18, 2008 Page 297 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
77402 B 04 N 12.07 12.07 24.15YN
77403 B 04 N 13.00 13.00 26.00YN
77404 B 04 N 13.85 13.85 27.70YN
77406 B 04 N 15.05 15.05 30.10YN
77407 B 04 N 19.47 19.47 38.95YN
77408 B 04 N 21.00 21.00 42.00YN
77409 B 04 N 22.90 22.90 45.80YN
77411 B 04 N 23.70 23.70 47.40YN
77412 B 04 N 21.00 21.00 42.00YN
77413 B 04 N 21.80 21.80 43.60YN
77414 B 04 N 22.90 22.90 45.80YN
77416 B 04 N 24.55 24.55 49.10YN
77417 09 NY
77418 B 04 N 123.25 123.25 246.50YN
77421 C 04 I 11.99 69.33 81.32YN
77422 04 I 35.73YN
77423 04 I 46.14YN
77427 04 N 70.85N
77431 04 N 35.65N
77432 04 I 254.60N
77435 04 1/1/2007 N 350.19N
Wednesday, June 18, 2008 Page 298 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
77470 04 N 240.10N
77499 04 NY
77520 B 04 N 35.42 35.42 70.85YN
77522 04 NYY
77523 B 04 N 44.87 44.87 89.75YN
77525 04 NYY
77600 04 N 21.30YN
77605 04 N 28.45YN
77610 04 N 58.80YN
77615 B 04 N 35.30 35.30 70.60YN
77620 04 N 74.10YN
77750 04 N 141.30YN
77761 04 I 256.30YN
77762 04 I 256.30YN
77763 04 I 256.30YN
77776 04 I 156.85YN
77777 04 I 183.10YN
77778 04 I 209.25YN
77781 04 NYY
77782 04 NYY
77783 04 NYY
Wednesday, June 18, 2008 Page 299 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
77784 04 NYY
77789 04 N 96.70YN
77790 04 NY
77799 04 NY
78000 B 04 N 10.75 10.75 21.50YN
78001 B 04 N 14.35 14.35 28.70YN
78003 B 04 N 15.05 15.05 30.10YN
78006 B 04 N 32.67 32.67 65.35YN
78007 B 04 N 32.67 32.67 65.35YN
78010 B 04 N 32.67 32.67 65.35YN
78011 B 04 N 35.30 35.30 70.60YN
78015 B 04 N 39.22 39.22 78.45YN
78016 B 04 N 49.05 49.05 98.10YN
78018 04 N 84.90YN
78020 04 N 78.45YN
78070 B 04 N 29.45 29.45 58.90YN
78075 B 04 N 32.67 32.67 65.35YN
78099 04 NYY
78102 B 04 N 42.45 42.45 84.90YN
78103 B 04 N 58.80 58.80 117.60YN
78104 B 04 N 58.80 58.80 117.60YN
Wednesday, June 18, 2008 Page 300 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78110 B 04 N 10.47 10.47 20.95YN
78111 B 04 N 16.35 16.35 32.70YN
78120 B 04 N 16.35 16.35 32.70YN
78121 B 04 N 28.77 28.77 57.55YN
78122 A 04 N 28.77 28.77 57.55YN
78130 B 04 N 32.67 32.67 65.35YN
78135 B 04 N 39.22 39.22 78.45YN
78140 B 04 N 21.57 21.57 43.15YN
78185 B 04 N 49.05 49.05 98.10YN
78190 04 NYY
78191 04 N 18.65YN
78195 B 04 N 49.05 49.05 98.10YN
78199 04 NYY
78201 B 04 N 65.40 65.40 130.80YN
78202 B 04 N 65.40 65.40 130.80YN
78205 B 04 N 65.40 65.40 130.80YN
78206 B 04 N 65.40 65.40 130.80YN
78215 B 04 N 65.40 65.40 130.80YN
78216 B 04 N 65.40 65.40 130.80YN
78220 B 04 N 32.67 32.67 65.35YN
78223 B 04 N 35.30 35.30 70.60YN
Wednesday, June 18, 2008 Page 301 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78230 B 04 N 16.35 16.35 32.70YN
78231 04 N 28.70YN
78232 04 N 14.25YN
78258 B 04 N 35.30 35.30 70.60YN
78261 04 N 28.70YN
78262 04 N 28.70YN
78264 04 N 41.90YN
78267 04 NYY
78268 B 04 N 30.58 30.58 61.17YN
78270 B 04 N 16.35 16.35 32.70YN
78271 B 04 N 16.35 16.35 32.70YN
78272 B 04 N 16.35 16.35 32.70YN
78278 C 04 N 9.64 32.26 41.90YN
78282 B 04 N 22.90 22.90 45.80YN
78290 B 04 N 49.05 49.05 98.10YN
78291 B 04 N 12.45 12.45 24.90YN
78299 04 NYY
78300 B 04 N 39.22 39.22 78.45YN
78305 B 04 N 58.80 58.80 117.60YN
78306 B 04 N 58.80 58.80 117.60YN
78315 B 04 N 17.62 17.62 35.25YN
Wednesday, June 18, 2008 Page 302 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78320 B 04 N 33.67 33.67 67.35YN
78350 B 04 N 62.25 62.25 124.50YN
78351 B 04 N 74.75 74.75 149.50YN
78399 04 NYY
78414 04 N 49.70YN
78428 04 N 49.70YN
78445 B 04 N 24.85 24.85 49.70YN
78456 B 04 N 70.85 70.85 141.70YN
78457 04 N 60.10YN
78458 04 N 84.90YN
78459 B 04 N 65.40 65.40 130.80YN
78460 B 04 N 24.85 24.85 49.70YN
78461 B 04 N 32.67 32.67 65.35YN
78464 B 04 N 65.40 65.40 130.80YN
78465 B 04 N 65.40 65.40 130.80YN
78466 B 04 N 24.85 24.85 49.70YN
78468 B 04 N 24.85 24.85 49.70YN
78469 B 04 N 65.40 65.40 130.80YN
78472 B 04 N 32.67 32.67 65.35YN
78473 B 04 N 37.20 37.20 74.40YN
78478 B 04 N 23.60 23.60 47.20YN
Wednesday, June 18, 2008 Page 303 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78480 B 04 N 23.60 23.60 47.20YN
78481 B 04 N 24.85 24.85 49.70YN
78483 B 04 N 31.07 31.07 62.15YN
78491 B 04 I 65.40 65.40 130.80YN
78492 B 04 I 65.40 65.40 130.80YN
78494 B 04 N 31.07 31.07 62.15YN
78496 B 04 N 31.07 31.07 62.15YN
78499 04 NYY
78580 B 04 N 32.67 32.67 65.35YN
78584 B 04 N 35.30 35.30 70.60YN
78585 B 04 N 35.30 35.30 70.60YN
78586 B 04 N 32.67 32.67 65.35YN
78587 B 04 N 32.67 32.67 65.35YN
78588 B 04 N 32.67 32.67 65.35YN
78591 B 04 N 32.67 32.67 65.35YN
78593 B 04 N 32.67 32.67 65.35YN
78594 B 04 N 35.95 35.95 71.90YN
78596 B 04 N 35.95 35.95 71.90YN
78599 A 04 NYY
78600 B 04 N 49.05 49.05 98.10YN
78601 B 04 N 65.40 65.40 130.80YN
Wednesday, June 18, 2008 Page 304 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78605 B 04 N 49.05 49.05 98.10YN
78606 B 04 N 65.40 65.40 130.80YN
78607 B 04 N 65.40 65.40 130.80YN
78608 B 04 N 65.40 65.40 130.80YN
78609 B 04 N 65.40 65.40 130.80YN
78610 B 04 N 65.40 65.40 130.80YN
78630 B 04 N 49.05 49.05 98.10YN
78635 B 04 N 49.05 49.05 98.10YN
78645 B 04 N 20.95 20.95 41.90YN
78647 B 04 N 24.85 24.85 49.70YN
78650 B 04 N 20.95 20.95 41.90YN
78660 B 04 N 16.35 16.35 32.70YN
78699 04 NYY
78700 B 04 N 39.22 39.22 78.45YN
78701 B 04 N 39.22 39.22 78.45YN
78707 B 04 N 42.45 42.45 84.90YN
78708 B 04 N 47.20 47.20 94.40YN
78709 B 04 N 47.20 47.20 94.40YN
78710 B 04 N 39.22 39.22 78.45YN
78725 B 04 N 39.22 39.22 78.45YN
78730 04 N 28.70YN
Wednesday, June 18, 2008 Page 305 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
78740 B 04 N 17.62 17.62 35.25YN
78761 B 04 N 24.85 24.85 49.70YN
78799 04 NYY
78800 B 04 N 32.02 32.02 64.05YN
78801 B 04 N 35.95 35.95 71.90YN
78802 B 04 N 42.45 42.45 84.90YN
78803 B 04 N 32.02 32.02 64.05YN
78804 C 04 N 29.65 86.89 116.54YN
78805 B 04 N 32.02 32.02 64.05YN
78806 B 04 N 42.45 42.45 84.90YN
78807 B 04 N 32.02 32.02 64.05YN
78811 B 04 N 65.40 65.40 130.80YN
78812 B 04 N 65.40 65.40 130.80YN
78813 B 04 N 65.40 65.40 130.80YN
78814 B 04 N 65.40 65.40 130.80YN
78815 B 04 N 65.40 65.40 130.80YN
78816 B 04 N 65.40 65.40 130.80YN
78890 B 04 N 10.47 10.47 20.95N
78891 B 04 N 10.47 10.47 20.95YN
78999 04 NYY
79005 04 N 52.50YN
Wednesday, June 18, 2008 Page 306 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
79101 04 N 57.30YN
79200 C 04 N 61.51 56.11 117.62YN
79300 B 04 N 70.60 70.60 141.20YN
79403 C 04 N 65.05 82.93 147.98YN
79440 B 04 N 52.95 52.95 105.90YN
79445 04 NYY
79999 04 NYY
80047 04 1/1/2008 N 18.31N
80048 B 04 N 5.52 5.52 11.05N
80051 A 04 N 4.57 4.57 9.15N
80053 B 04 N 6.90 6.90 13.80N
80055 B 04 N 20.95 20.95 41.90N
80061 B 04 N 4.15 4.15 8.30N
80069 B 04 N 5.67 5.67 11.35N
80074 B 04 N 25.65 25.65 51.30N
80076 B 04 N 5.32 5.32 10.65N
80100 09 NY
80101 B 04 N 8.95 8.95 17.90N
80102 09 NY
80103 A 09 NY
80150 A 04 N 3.60 3.60 7.20N
Wednesday, June 18, 2008 Page 307 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
80152 A 04 N 7.00 7.00 14.00N
80154 A 04 N 5.00 5.00 10.00N
80156 A 04 N 5.90 5.90 11.80N
80157 A 04 N 5.20 5.20 10.40N
80158 A 04 N 8.42 8.42 16.85N
80160 A 04 N 5.27 5.27 10.55N
80162 A 04 N 8.65 8.65 17.30N
80164 A 04 N 5.90 5.90 11.80N
80166 A 04 N 8.95 8.95 17.90N
80168 A 04 N 7.55 7.55 15.10N
80170 A 04 N 3.92 3.92 7.85N
80172 A 04 N 6.42 6.42 12.85N
80173 A 04 N 7.60 7.60 15.20N
80174 A 04 N 7.00 7.00 14.00N
80176 A 04 N 1.15 1.15 2.30N
80178 A 04 N 4.30 4.30 8.60N
80182 A 04 N 5.90 5.90 11.80N
80184 A 04 N 5.90 5.90 11.80N
80185 A 04 N 8.65 8.65 17.30N
80186 A 04 N 9.00 9.00 18.00N
80188 A 04 N 7.30 7.30 14.60N
Wednesday, June 18, 2008 Page 308 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
80190 A 04 N 6.15 6.15 12.30N
80192 A 04 N 6.15 6.15 12.30N
80194 A 04 N 7.00 7.00 14.00N
80195 04 N 11.50N
80196 A 04 N 3.60 3.60 7.20N
80197 A 04 N 7.00 7.00 14.00N
80198 A 04 N 6.15 6.15 12.30N
80200 A 04 N 5.85 5.85 11.70N
80201 A 04 N 7.55 7.55 15.10N
80202 A 04 N 8.85 8.85 17.70N
80299 A 04 NY
80400 B 04 N 17.97 17.97 35.95N
80402 B 04 N 29.72 29.72 59.45N
80406 B 04 N 30.30 30.30 60.60N
80408 B 04 N 81.90 81.90 163.80N
80410 B 04 N 16.80 16.80 33.60N
80412 B 04 N 107.85 107.85 215.70N
80414 B 04 N 33.70 33.70 67.40N
80415 B 04 N 13.60 13.60 27.20N
80416 B 04 N 86.15 86.15 172.30N
80417 B 04 N 28.72 28.72 57.45N
Wednesday, June 18, 2008 Page 309 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
80418 B 04 NY
80420 B 04 N 39.35 39.35 78.70N
80422 B 04 N 26.65 26.65 53.30N
80424 B 04 N 20.20 20.20 40.40N
80426 B 04 N 80.15 80.15 160.30N
80428 B 04 N 23.52 23.52 47.05N
80430 B 04 N 32.52 32.52 65.05N
80432 B 04 N 63.62 63.62 127.25N
80434 B 04 N 59.95 59.95 119.90N
80435 B 04 N 44.40 44.40 88.80N
80436 B 04 N 38.70 38.70 77.40N
80438 B 04 N 32.90 32.90 65.80N
80439 B 04 N 43.85 43.85 87.70N
80440 B 04 N 26.97 26.97 53.95N
80500 04 N 12.40N
80502 04 N 49.80N
81000 A 04 N 1.75 1.75 3.50N
81001 A 04 N 1.90 1.90 3.80N
81002 A 04 N 1.30 1.30 2.60N
81003 A 04 N 1.45 1.45 2.90N
81005 A 04 N 1.15 1.15 2.30N
Wednesday, June 18, 2008 Page 310 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
81007 A 04 N 1.67 1.67 3.35N
81015 A 04 N 1.75 1.75 3.50N
81020 A 04 N 1.85 1.85 3.70N
81025 A 04 N 1.72 1.72 3.45N
81050 A 04 N 1.70 1.70 3.40N
81099 A 04 NY
82000 A 04 N 5.27 5.27 10.55N
82003 A 04 N 5.27 5.27 10.55N
82009 A 04 N 1.15 1.15 2.30N
82010 A 04 N 1.15 1.15 2.30N
82013 A 04 N 3.60 3.60 7.20N
82016 A 04 N 3.40 3.40 6.80N
82017 A 04 N 7.75 7.75 15.50N
82024 A 04 N 8.95 8.95 17.90N
82030 B 04 N 5.90 5.90 11.80N
82040 A 04 N 3.00 3.00 6.00N
82042 A 04 N 3.00 3.00 6.00N
82043 A 04 N 2.62 2.62 5.25N
82044 A 04 N 2.62 2.62 5.25N
82045 A 04 NY
82055 A 04 N 5.75 5.75 11.50N
Wednesday, June 18, 2008 Page 311 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82075 A 04 N 3.35 3.35 6.70N
82085 B 04 N 4.20 4.20 8.40N
82088 A 04 N 26.60 26.60 53.20N
82101 A 04 N 11.80 11.80 23.60N
82103 B 04 N 5.90 5.90 11.80N
82104 B 04 N 4.77 4.77 9.55N
82105 B 04 N 10.95 10.95 21.90N
82106 B 04 N 4.15 4.15 8.30N
82107 B 04 N 19.62 19.62 39.24N
82108 A 04 N 3.35 3.35 6.70N
82120 A 04 N 2.45 2.45 4.90N
82127 A 04 N 3.40 3.40 6.80N
82128 A 04 N 3.40 3.40 6.80N
82131 A 04 N 7.75 7.75 15.50N
82135 B 04 N 5.90 5.90 11.80N
82136 A 04 N 7.75 7.75 15.50N
82139 A 04 N 7.75 7.75 15.50N
82140 A 04 N 4.77 4.77 9.55N
82143 A 04 N 4.47 4.77 8.95N
82145 A 04 N 7.00 7.00 14.00N
82150 A 04 N 4.25 4.25 8.50N
Wednesday, June 18, 2008 Page 312 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82154 B 04 N 11.20 11.20 22.40N
82157 B 04 N 11.20 11.20 22.40N
82160 A 04 N 3.60 3.60 7.20N
82163 B 04 N 5.00 5.00 10.00N
82164 B 04 N 4.77 4.77 9.55N
82172 A 04 N 8.00 8.00 16.00N
82175 A 04 N 5.90 5.90 11.80N
82180 B 04 N 3.35 3.35 6.70N
82190 A 04 N 9.75 9.75 19.50N
82205 A 04 N 5.90 5.90 11.80N
82232 A 04 N 5.27 5.27 10.55N
82239 B 04 N 11.17 11.17 22.35N
82240 B 04 N 8.50 8.50 17.00N
82247 A 04 N 3.10 3.10 6.20N
82248 A 04 N 3.10 3.10 6.20N
82252 A 04 N 1.75 1.75 3.50N
82261 B 04 N 11.00 11.00 22.00N
82270 A 04 N 1.65 1.65 3.30N
82271 A 04 N 1.36 1.36 2.72N
82272 A 04 N 1.36 1.36 2.72N
82274 A 04 N 6.66 6.66 13.33N
Wednesday, June 18, 2008 Page 313 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82286 A 04 N 2.67 2.67 5.35N
82300 A 04 N 4.45 4.45 8.90N
82306 04 N 11.80N
82307 04 N 23.60N
82308 A 04 N 4.20 4.20 8.40N
82310 A 04 N 3.10 3.10 6.20N
82330 A 04 N 8.90 8.90 17.80N
82331 A 04 N 2.77 2.77 5.55N
82340 A 04 N 3.60 3.60 7.20N
82355 A 04 N 3.10 3.10 6.20N
82360 A 04 N 6.05 6.05 12.10N
82365 A 04 N 3.10 3.10 6.20N
82370 A 04 N 3.10 3.10 6.20N
82373 A 04 N 3.75 3.75 7.50N
82374 A 04 N 3.20 3.20 6.40N
82375 A 04 N 3.10 3.10 6.20N
82376 A 04 N 3.10 3.10 6.20N
82378 B 04 N 8.95 8.95 17.90N
82379 A 04 N 7.75 7.75 15.50N
82380 A 04 N 3.10 3.10 6.20N
82382 B 04 N 10.10 10.10 20.20N
Wednesday, June 18, 2008 Page 314 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82383 B 04 N 10.10 10.10 20.20N
82384 B 04 N 10.10 10.10 20.20N
82387 B 04 N 7.65 7.65 15.30N
82390 B 04 N 5.90 5.90 11.80N
82397 A 04 N 9.22 9.22 18.45N
82415 A 04 N 5.90 5.90 11.80N
82435 A 04 N 3.00 3.00 6.00N
82436 A 04 N 3.10 3.10 6.20N
82438 A 04 N 3.20 3.20 6.40N
82441 A 04 N 2.85 2.85 5.70N
82465 A 04 N 2.82 2.82 5.65N
82480 A 04 N 4.77 4.77 9.55N
82482 A 04 N 1.75 1.75 3.50N
82485 A 04 N 6.72 6.72 13.45N
82486 B 04 N 4.77 4.77 9.55N
82487 B 04 N 5.62 5.62 11.25N
82488 B 04 N 8.55 8.55 17.10N
82489 B 04 N 2.25 2.25 4.50N
82491 B 04 N 8.12 8.12 16.25N
82492 B 04 N 8.12 8.12 16.25N
82495 A 04 N 8.95 8.95 17.90N
Wednesday, June 18, 2008 Page 315 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82507 A 04 N 3.60 3.60 7.20N
82520 A 04 N 4.77 4.77 9.55N
82523 09 NY
82525 A 04 N 7.40 7.40 14.80N
82528 B 04 N 11.80 11.80 23.60N
82530 A 04 N 8.95 8.95 17.90N
82533 A 04 N 8.95 8.95 17.90N
82540 A 04 N 3.00 3.00 6.00N
82541 B 04 N 4.77 4.77 9.55N
82542 B 04 N 8.12 8.12 16.25N
82543 B 04 N 8.12 8.12 16.25N
82544 B 04 N 8.12 8.12 16.25N
82550 A 04 N 4.05 4.05 8.10N
82552 A 04 N 4.20 4.20 8.40N
82553 A 04 N 4.95 4.95 9.90N
82554 A 04 N 4.10 4.10 8.20N
82565 A 04 N 3.10 3.10 6.20N
82570 A 04 N 3.10 3.10 6.20N
82575 B 04 N 6.15 6.15 12.30N
82585 B 04 N 5.60 5.60 11.20N
82595 B 04 N 3.10 3.10 6.20N
Wednesday, June 18, 2008 Page 316 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82600 A 04 N 4.45 4.45 8.90N
82607 B 04 N 8.01 8.01 16.02N
82608 B 04 N 8.01 8.01 16.02N
82610 04 1/1/2008 N 11.40N
82615 A 04 N 4.20 4.20 8.40N
82626 B 04 N 5.90 5.90 11.80N
82627 B 04 N 5.30 5.30 10.60N
82633 B 04 N 6.72 6.72 13.45N
82634 A 04 N 10.35 10.35 20.70N
82638 A 04 N 4.77 4.77 9.55N
82646 A 04 N 2.35 2.35 4.70N
82649 A 04 N 5.90 5.90 11.80N
82651 B 04 N 13.45 13.45 26.90N
82652 04 N 21.40N
82654 B 04 N 2.25 2.25 4.50N
82656 A 04 N 4.83 4.83 9.67N
82657 A 04 N 8.12 8.12 16.25N
82658 A 04 N 8.12 8.12 16.25N
82664 B 04 N 18.03 18.03 36.07N
82666 B 04 N 5.90 5.90 11.80N
82668 B 04 N 6.95 6.95 13.90N
Wednesday, June 18, 2008 Page 317 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82670 A 04 N 6.75 6.75 13.50N
82671 B 04 N 11.80 11.80 23.60N
82672 B 04 N 11.80 11.80 23.60N
82677 B 04 N 6.75 6.75 13.50N
82679 B 04 N 6.75 6.75 13.50N
82690 A 04 N 5.62 5.62 11.25N
82693 A 04 N 9.75 9.75 19.50N
82696 B 04 N 6.72 6.72 13.45N
82705 A 04 N 1.70 1.70 3.40N
82710 A 04 N 2.05 2.05 4.10N
82715 A 04 N 2.15 2.15 4.30N
82725 A 04 N 1.75 1.75 3.50N
82726 B 04 N 8.12 8.12 16.25N
82728 A 04 N 4.77 4.77 9.55N
82731 B 04 N 24.52 24.52 49.05N
82735 A 04 N 4.77 4.77 9.55N
82742 A 04 N 4.77 4.77 9.55N
82746 B 04 N 7.64 7.64 15.29N
82747 B 04 N 8.85 8.85 17.70N
82757 A 04 N 5.30 5.30 10.60N
82759 A 04 N 3.10 3.10 6.20N
Wednesday, June 18, 2008 Page 318 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82760 A 04 N 3.10 3.10 6.20N
82775 A 04 N 8.95 8.95 17.90N
82776 A 04 N 3.35 3.35 6.70N
82784 A 04 N 6.05 6.05 12.10N
82785 A 04 N 4.77 4.77 9.55N
82787 A 04 N 5.25 5.25 10.50N
82800 A 04 N 3.10 3.10 6.20N
82803 A 04 N 7.25 7.25 14.50N
82805 A 04 N 7.25 7.25 14.50N
82810 A 04 N 3.80 3.80 7.60N
82820 A 04 N 6.52 6.52 13.05N
82926 A 04 N 3.55 3.55 7.10N
82928 A 04 N 2.35 2.35 4.70N
82938 04 N 22.40N
82941 B 04 N 5.27 5.27 10.55N
82943 A 04 N 4.67 4.67 9.35N
82945 A 04 N 2.05 2.05 4.10N
82946 B 04 N 7.00 7.00 14.00N
82947 A 04 N 2.55 2.55 5.10N
82948 A 04 N 1.15 1.15 2.30N
82950 A 04 N 3.10 3.10 6.20N
Wednesday, June 18, 2008 Page 319 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
82951 B 04 N 8.40 8.40 16.80N
82952 A 04 N 2.55 2.55 5.10N
82953 A 04 N 3.10 3.10 6.20N
82955 A 04 N 5.75 5.75 11.50N
82960 A 04 N 3.95 3.95 7.90N
82962 A 04 N 1.12 1.12 2.25N
82963 B 04 N 8.42 8.42 16.85N
82965 A 04 N 4.77 4.77 9.55N
82975 B 04 N 3.60 3.60 7.20N
82977 A 04 N 3.60 3.60 7.20N
82978 A 04 N 6.40 6.40 12.80N
82979 A 04 N 2.35 2.35 4.70N
82980 A 04 N 4.10 4.10 8.20N
82985 B 04 N 8.95 8.95 17.90N
83001 A 04 N 12.12 12.12 24.25N
83002 A 04 N 5.90 5.90 11.80N
83003 A 04 N 5.90 5.90 11.80N
83008 A 04 N 7.50 7.50 15.00N
83009 A 04 N 28.23 28.23 56.47N
83010 A 04 N 5.90 5.90 11.80N
83012 A 04 N 4.45 4.45 8.90N
Wednesday, June 18, 2008 Page 320 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83013 B 04 N 5.75 5.75 11.50N
83014 B 04 N 5.10 5.10 10.20N
83015 B 04 N 12.30 12.30 24.60N
83018 A 04 N 3.10 3.10 6.20N
83020 B 04 N 5.75 5.75 11.50N
83021 B 04 N 8.12 8.12 16.25N
83026 A 04 N 1.52 1.52 3.05N
83030 A 04 N 2.15 2.15 4.30N
83033 A 04 N 3.90 3.90 7.80N
83036 B 04 N 4.20 4.20 8.40N
83037 04 N 1.96N
83045 A 04 N 3.10 3.10 6.20N
83050 A 04 N 2.00 2.00 4.00N
83051 A 04 N 2.15 2.15 4.30N
83055 A 04 N 2.15 2.15 4.30N
83060 A 04 N 2.15 2.15 4.30N
83065 A 04 N 2.15 2.15 4.30N
83068 A 04 N 2.15 2.15 4.30N
83069 A 04 N 1.02 1.02 2.05N
83070 A 04 N 1.75 1.75 3.50N
83071 A 04 N 2.15 2.15 4.30N
Wednesday, June 18, 2008 Page 321 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83080 B 04 N 7.75 7.75 15.50N
83088 04 N 23.60N
83090 04 N 17.60N
83150 B 04 N 7.30 7.30 14.60N
83491 B 04 N 4.77 4.72 9.55N
83497 B 04 N 8.42 8.42 16.85N
83498 B 04 N 5.90 5.90 11.80N
83499 B 04 N 10.70 10.70 21.40N
83500 B 04 N 9.52 9.52 19.05N
83505 B 04 N 11.80 11.80 23.60N
83516 A 04 N 5.85 5.85 11.70N
83518 A 04 N 5.52 5.52 11.05N
83519 A 04 N 8.80 8.80 17.60N
83520 A 04 N 8.45 8.45 16.90N
83525 A 04 N 5.90 5.90 11.80N
83527 A 04 N 5.90 5.90 11.80N
83528 A 04 N 5.30 5.30 10.60N
83540 A 04 N 4.25 4.25 8.50N
83550 A 04 N 5.70 5.70 11.40N
83570 A 04 N 4.77 4.77 9.55N
83582 B 04 N 8.12 8.12 16.25N
Wednesday, June 18, 2008 Page 322 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83586 B 04 N 4.37 4.37 8.75N
83593 B 04 N 10.35 10.35 20.70N
83605 A 04 N 5.90 5.90 11.80N
83615 A 04 N 3.95 3.95 7.90N
83625 B 04 N 6.95 6.95 13.90N
83630 04 N 9.62N
83631 B 04 I 8.22 8.22 16.45N
83632 B 04 N 5.90 5.90 11.80N
83633 A 04 N 3.60 3.60 7.20N
83634 A 04 N 3.95 3.95 7.90N
83655 B 04 N 7.90 7.90 15.80N
83661 B 04 N 8.95 8.95 17.90N
83662 B 04 N 8.27 8.27 16.55N
83663 B 04 N 4.90 4.90 9.80N
83664 B 04 N 2.47 2.47 4.95N
83670 B 04 N 4.20 4.20 8.40N
83690 A 04 N 4.47 4.47 8.95N
83695 B 04 N 5.42 5.42 10.85N
83698 04 N 11.89 11.89 23.78N
83700 04 I 4.71 4.71 9.43N
83701 04 N 10.40 10.40 20.80N
Wednesday, June 18, 2008 Page 323 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83704 04 I 13.22 13.22 26.44N
83718 B 04 N 5.35 5.35 10.70N
83719 B 04 N 7.60 7.60 15.20N
83721 B 04 N 6.22 6.22 12.45N
83727 A 04 N 5.90 5.90 11.80N
83735 A 04 N 4.37 4.37 8.75N
83775 A 04 N 3.70 3.70 7.40N
83785 A 04 N 0.85 0.85 1.70N
83788 A 04 N 4.77 4.77 9.55N
83789 A 04 N 4.77 4.77 9.55N
83805 A 04 N 4.70 4.70 9.40N
83825 A 04 N 5.27 5.27 10.55N
83835 B 04 N 8.95 8.95 17.90N
83840 A 04 N 5.90 5.90 11.80N
83857 A 04 N 1.75 1.75 3.50N
83858 A 04 N 5.27 5.27 10.55N
83864 B 04 N 7.00 7.00 14.00N
83866 B 04 N 5.95 5.95 11.90N
83872 A 04 N 1.75 1.75 3.50N
83873 B 04 N 6.42 6.42 12.85N
83874 B 04 N 8.42 8.42 16.85N
Wednesday, June 18, 2008 Page 324 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83880 B 04 N 9.91 9.91 19.82N
83883 A 04 N 6.96 6.96 13.93N
83885 A 04 N 5.27 5.27 10.55N
83887 A 04 N 4.45 4.45 8.90N
83890 B 04 N 2.62 2.62 5.25N
83891 B 04 N 2.62 2.62 5.25N
83892 B 04 N 2.52 2.52 5.05N
83893 B 04 N 2.62 2.62 5.25N
83894 B 04 N 2.52 2.52 5.05N
83896 B 04 N 2.62 2.62 5.25N
83897 B 04 N 2.62 2.62 5.25N
83898 B 04 N 10.95 10.95 21.90N
83900 B 04 N 14.05 14.05 28.10N
83901 B 04 N 10.95 10.95 21.90N
83902 B 04 N 9.25 9.25 18.50N
83903 B 04 N 10.95 10.95 21.90N
83904 B 04 N 10.95 10.95 21.90N
83905 B 04 N 10.95 10.95 21.90N
83906 B 04 N 10.95 10.95 21.90N
83907 B 04 N 5.59 5.59 11.19N
83908 B 04 N 7.02 7.02 14.05N
Wednesday, June 18, 2008 Page 325 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
83909 B 04 N 7.02 7.02 14.05N
83912 B 04 N 2.62 2.62 5.25N
83913 B 04 1/1/2007 N 5.60 5.60 11.20N
83914 B 04 N 7.02 7.02 14.05N
83915 B 04 N 3.60 3.60 7.20N
83916 B 04 N 4.45 4.45 8.90N
83918 B 04 N 10.75 10.75 21.50N
83919 B 04 N 10.75 10.75 21.50N
83921 B 04 N 8.60 8.60 17.20N
83925 A 04 N 11.30 11.30 22.60N
83930 A 04 N 3.10 3.10 6.20N
83935 A 04 N 3.10 3.10 6.20N
83937 04 N 17.90N
83945 A 04 N 2.05 2.05 4.10N
83950 B 04 N 30.55 30.55 61.10N
83970 B 04 N 20.75 20.75 41.50N
83986 A 04 N 2.35 2.35 4.70N
83992 A 04 N 3.10 3.10 6.20N
83993 04 1/1/2008 N 16.45N
84022 A 04 N 3.60 3.60 7.20N
84030 A 04 N 3.50 3.50 7.00N
Wednesday, June 18, 2008 Page 326 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84035 A 04 N 1.15 1.15 2.30N
84060 A 04 N 4.77 4.77 9.55N
84061 A 04 N 4.20 4.20 8.40N
84066 A 04 N 2.05 2.05 4.10N
84075 A 04 N 3.35 3.35 6.70N
84078 A 04 N 4.77 4.77 9.55N
84080 A 04 N 5.90 5.90 11.80N
84081 A 04 N 1.67 1.67 3.35N
84085 A 04 N 2.35 2.35 4.70N
84087 A 04 N 3.70 3.70 7.40N
84100 A 04 N 3.10 3.10 6.20N
84105 A 04 N 1.50 1.50 3.00N
84106 A 04 N 2.80 2.80 5.60N
84110 A 04 N 3.10 3.10 6.20N
84119 B 04 N 5.62 5.62 11.25N
84120 B 04 N 8.95 8.95 17.90N
84126 B 04 N 14.60 14.60 29.20N
84127 B 04 N 7.30 7.30 14.60N
84132 A 04 N 3.00 3.00 6.00N
84133 A 04 N 2.80 2.80 5.60N
84134 A 04 N 3.72 3.72 7.45N
Wednesday, June 18, 2008 Page 327 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84135 B 04 N 5.27 5.27 10.55N
84138 B 04 N 5.90 5.90 11.80N
84140 04 N 11.80N
84143 04 N 12.30N
84144 A 04 N 6.15 6.15 12.30N
84146 A 04 N 8.95 8.95 17.90N
84150 A 04 N 2.35 2.35 4.70N
84152 B 40 N 9.60 9.60 19.20N
84153 B 04 N 8.80 8.80 17.60N
84154 B 04 N 8.80 8.80 17.60N
84155 A 04 N 2.40 2.40 4.80N
84156 B 04 N 1.53 1.53 3.07N
84157 B 04 N 1.53 1.53 3.07N
84160 A 04 N 1.75 1.75 3.50N
84163 04 N 12.78N
84165 B 04 N 7.00 7.00 14.00N
84166 04 N 14.95N
84181 B 04 N 11.10 11.10 22.21N
84182 B 04 N 11.73 11.73 23.47N
84202 A 04 N 2.35 2.35 4.70N
84203 A 04 N 1.75 1.75 3.50N
Wednesday, June 18, 2008 Page 328 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84206 B 04 N 4.77 4.77 9.55N
84207 B 04 N 8.00 8.00 16.00N
84210 A 04 N 4.77 4.77 9.55N
84220 A 04 N 3.10 3.10 6.20N
84228 A 04 N 7.00 7.00 14.00N
84233 B 04 N 22.00 22.00 44.00N
84234 B 04 N 3.60 3.60 7.20N
84235 A 04 N 3.60 3.60 7.20N
84238 B 04 N 13.35 13.35 26.70N
84244 A 04 N 14.35 14.35 28.70N
84252 B 04 N 1.75 1.75 3.50N
84255 A 04 N 3.20 3.20 6.40N
84260 A 04 N 3.35 3.35 6.70N
84270 B 04 N 10.92 10.92 21.85N
84275 A 04 N 2.35 2.35 4.70N
84285 A 04 N 2.40 2.40 4.80N
84295 A 04 N 3.10 3.10 6.20N
84300 A 04 N 2.82 2.82 5.65N
84302 B 04 N 1.70 1.70 3.40N
84305 B 04 N 10.05 10.05 20.10N
84307 B 04 N 10.05 10.05 20.10N
Wednesday, June 18, 2008 Page 329 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84311 A 04 N 4.58 4.58 9.16N
84315 A 04 N 1.62 1.62 3.25N
84375 A 04 N 3.10 3.10 6.20N
84376 A 04 N 3.60 3.60 7.20N
84377 A 04 N 3.60 3.60 7.20N
84378 A 04 N 3.95 3.95 7.90N
84379 A 04 N 3.95 3.95 7.90N
84392 A 04 N 3.10 3.10 6.20N
84402 A 04 N 12.22 12.22 24.45N
84403 A 04 N 16.85 16.85 33.70N
84425 B 04 N 8.55 8.55 17.10N
84430 B 04 N 4.77 4.77 9.55N
84432 B 04 N 10.47 10.47 20.95N
84436 B 04 N 4.47 4.47 8.95N
84437 B 04 N 4.25 4.25 8.50N
84439 B 04 N 5.90 5.90 11.80N
84442 B 04 N 5.90 5.90 11.80N
84443 B 04 N 10.95 10.95 21.90N
84445 B 04 N 17.97 17.97 35.95N
84446 B 04 N 5.90 5.90 11.80N
84449 04 N 17.90N
Wednesday, June 18, 2008 Page 330 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84450 A 04 N 3.35 3.35 6.70N
84460 A 04 N 3.45 3.45 6.90N
84466 A 04 N 5.85 5.85 11.70N
84478 B 04 N 3.60 3.60 7.20N
84479 B 04 N 8.50N
84480 B 04 N 6.37 6.37 12.75N
84481 B 04 N 6.75 6.75 13.50N
84482 B 04 N 4.55 4.55 9.10N
84484 A 04 N 4.95 4.95 9.90N
84485 A 04 N 3.60 3.60 7.20N
84488 B 04 N 3.60 3.60 7.20N
84490 B 04 N 3.60 3.60 7.20N
84510 B 04 N 6.80 6.80 13.60N
84512 A 04 N 4.95 4.95 9.90N
84520 A 04 N 2.57 2.57 5.15N
84525 A 04 N 1.15 1.15 2.30N
84540 A 04 N 2.35 2.35 4.70N
84545 A 04 N 2.67 2.67 5.35N
84550 A 04 N 2.95 2.95 5.90N
84560 A 04 N 1.75 1.75 3.50N
84577 A 04 N 3.60 3.60 7.20N
Wednesday, June 18, 2008 Page 331 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
84578 A 04 N 1.15 1.15 2.30N
84580 A 04 N 2.67 2.67 5.35N
84583 A 04 N 1.75 1.75 3.50N
84585 B 04 N 10.10 10.10 20.20N
84586 B 04 N 4.65 4.65 9.30N
84588 B 04 N 3.10 3.10 6.20N
84590 B 04 N 3.10 3.10 6.20N
84591 B 04 N 6.05 6.05 12.10N
84597 B 04 N 3.35 3.35 6.70N
84600 A 04 N 2.35 2.35 4.70N
84620 A 04 N 5.00 5.00 10.00N
84630 B 04 N 6.72 6.72 13.45N
84681 B 04 N 8.55 8.55 17.10N
84702 B 04 N 5.90 5.90 11.80N
84703 B 04 N 4.77 4.77 9.55N
84704 04 1/1/2008 N 12.62N
84999 A 04 NY
85002 A 04 N 1.15 1.15 2.30N
85004 A 04 N 2.26 2.26 4.52N
85007 A 04 N 1.75 1.75 3.50N
85008 A 04 N 2.25 2.25 4.50N
Wednesday, June 18, 2008 Page 332 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
85009 A 04 N 1.75 1.75 3.50N
85013 A 04 N 1.55 1.55 3.10N
85014 A 04 N 1.55 1.55 3.10N
85018 A 04 N 1.55 1.55 3.10N
85025 A 04 N 3.82 3.82 7.65N
85027 A 04 N 3.82 3.82 7.65N
85032 A 04 N 1.50 1.50 3.01N
85041 A 04 N 1.15 1.15 2.30N
85044 A 04 N 1.75 1.75 3.50N
85045 A 04 N 1.75 1.75 3.50N
85046 A 04 N 3.65 3.65 7.30N
85048 A 04 N 1.15 1.15 2.30N
85049 A 04 N 1.56 1.56 3.13N
85055 A 04 N 5.66 5.66 11.32N
85060 04 N 4.50N
85097 04 N 22.40N
85130 B 04 N 7.75 7.75 15.50N
85170 A 04 N 1.15 1.15 2.30N
85175 A 04 N 2.97 2.97 5.95N
85210 B 04 N 5.90 5.90 11.80N
85220 B 04 N 5.90 5.90 11.80N
Wednesday, June 18, 2008 Page 333 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
85230 B 04 N 5.90 5.90 11.80N
85240 B 04 N 5.90 5.90 11.80N
85244 B 04 N 4.77 4.77 9.55N
85245 B 04 N 4.80 4.80 9.60N
85246 B 04 N 4.80 4.80 9.60N
85247 B 04 N 9.25 9.25 18.50N
85250 B 04 N 5.90 5.90 11.80N
85260 B 04 N 5.90 5.90 11.80N
85270 B 04 N 5.90 5.90 11.80N
85280 B 04 N 5.90 5.90 11.80N
85290 B 04 N 5.90 5.90 11.80N
85291 B 04 N 5.80 5.80 11.60N
85292 B 04 N 7.50 7.50 15.00N
85293 B 04 N 7.50 7.50 15.00N
85300 B 04 N 5.90 5.90 11.80N
85301 B 04 N 7.05 7.05 14.10N
85302 B 04 N 7.85 7.85 15.70N
85303 B 04 N 7.80 7.80 15.60N
85305 B 04 N 7.55 7.55 15.10N
85306 B 04 N 7.80 7.80 15.60N
85307 B 04 N 8.00 8.00 16.00N
Wednesday, June 18, 2008 Page 334 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
85335 A 04 N 7.05 7.05 14.10N
85337 A 04 N 6.80 6.80 13.60N
85345 A 04 N 2.00 2.00 4.00N
85347 A 04 N 1.75 1.75 3.50N
85348 A 04 N 2.45 2.45 4.90N
85360 A 04 N 3.95 3.95 7.90N
85362 A 04 N 1.75 1.75 3.50N
85366 A 04 N 3.65 3.65 7.30N
85370 A 04 N 3.65 3.65 7.30N
85378 B 04 N 4.65 4.65 9.30N
85379 B 04 N 5.00 5.00 10.00N
85380 B 04 N 3.55 3.55 7.11N
85384 A 04 N 3.50 3.50 7.00N
85385 A 04 N 3.50 3.50 7.00N
85390 A 04 N 1.62 1.62 3.25N
85396 A 04 N 5.84 5.84 11.69N
85400 A 04 N 3.10 3.10 6.20N
85410 A 04 N 3.10 3.10 6.20N
85415 A 04 N 5.75 5.75 11.50N
85420 A 04 N 3.10 3.10 6.20N
85421 A 04 N 4.30 4.30 8.60N
Wednesday, June 18, 2008 Page 335 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
85441 A 04 N 2.72 2.72 5.45N
85445 A 04 N 1.15 1.15 2.30N
85460 A 04 N 2.15 2.15 4.30N
85461 A 04 N 2.10 2.10 4.20N
85475 A 04 N 5.80 5.80 11.60N
85520 B 04 N 4.20 4.20 8.40N
85525 B 04 N 7.17 7.17 14.35N
85530 B 04 N 4.20 4.20 8.40N
85536 A 04 N 3.37 3.37 6.75N
85540 A 04 N 2.35 2.35 4.70N
85547 A 04 N 1.52 1.52 3.05N
85549 A 04 N 4.77 4.77 9.55N
85555 A 04 N 3.10 3.10 6.20N
85557 A 04 N 3.10 3.10 6.20N
85576 A 04 N 3.40 3.40 6.80N
85597 A 04 N 3.65 3.65 7.30N
85610 A 04 N 2.55 2.55 5.10N
85611 A 04 N 2.57 2.57 5.15N
85612 B 04 N 3.70 3.70 7.40N
85613 B 04 N 4.67 4.67 9.35N
85635 B 04 N 1.75 1.75 3.50N
Wednesday, June 18, 2008 Page 336 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
85651 A 04 N 2.30 2.30 4.60N
85652 A 04 N 1.75 1.75 3.50N
85660 A 04 N 3.10 3.10 6.20N
85670 A 04 N 3.10 3.10 6.20N
85675 A 04 N 4.25 4.25 8.50N
85705 A 04 N 5.80 5.80 11.60N
85730 A 04 N 3.92 3.92 7.85N
85732 A 04 N 4.25 4.25 8.50N
85810 A 04 N 3.60 3.60 7.20N
85999 A 04 NY
86000 A 04 N 3.70 3.70 7.40N
86001 A 04 N 2.72 2.72 5.45N
86003 A 04 N 0.57 0.57 1.15N
86005 A 04 N 5.20 5.20 10.40N
86021 A 04 N 3.10 3.10 6.20N
86022 A 04 N 9.52 9.52 19.05N
86023 B 04 N 4.70 4.70 9.40N
86038 B 04 N 7.90 7.90 15.80N
86039 B 04 N 5.35 5.35 10.70N
86060 B 04 N 4.30 4.30 8.60N
86063 B 04 N 3.77 3.77 7.55N
Wednesday, June 18, 2008 Page 337 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86077 04 N 39.30N
86078 04 N 16.85N
86079 04 N 20.35N
86140 B 04 N 2.35 2.35 4.70N
86141 B 04 N 8.45 8.45 16.90N
86146 B 04 N 13.30 13.30 26.60N
86147 B 04 N 6.35 6.35 12.70N
86148 B 04 N 6.35 6.35 12.70N
86155 A 04 N 4.30 4.30 8.60N
86156 B 04 N 2.62 2.62 5.25N
86157 B 04 N 3.30 3.30 6.60N
86160 A 04 N 4.62 4.62 9.25N
86161 A 04 N 5.15 5.15 10.30N
86162 B 04 N 8.95 8.95 17.90N
86171 09 NY
86185 04 N 4.20 4.20 8.40N
86200 04 N 5.42 5.42 10.85N
86215 B 04 N 5.90 5.90 11.80N
86225 B 04 N 5.90 5.90 11.80N
86226 B 04 N 6.67 6.67 13.35N
86235 A 04 N 5.90 5.90 11.80N
Wednesday, June 18, 2008 Page 338 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86243 A 04 N 5.90 5.90 11.80N
86255 A 04 N 3.60 3.60 7.20N
86256 A 04 N 5.90 5.90 11.80N
86277 A 04 N 10.27 10.27 20.55N
86280 A 04 N 4.10 4.10 8.20N
86294 A 04 NY
86300 B 04 N 10.85 10.85 21.70N
86301 B 04 N 10.85 10.85 21.70N
86304 B 04 N 10.85 10.85 21.70N
86308 B 04 N 2.40 2.40 4.80N
86309 B 04 N 4.25 4.25 8.50N
86310 B 04 N 4.82 4.82 9.65N
86316 A 04 N 5.05 5.05 10.10N
86317 09 Y
86318 A 04 N 8.45 8.45 16.90N
86320 B 04 N 10.65 10.65 21.30N
86325 B 04 N 5.90 5.90 11.80N
86327 B 04 N 7.00 7.00 14.00N
86329 A 04 N 9.15 9.15 18.30N
86331 A 04 N 5.90 5.90 11.80N
86332 B 04 N 9.40 9.40 18.80N
Wednesday, June 18, 2008 Page 339 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86334 B 04 N 13.95 13.95 27.90N
86335 A 04 N 12.30 12.30 24.60N
86336 B 04 N 10.87 10.87 21.75N
86337 B 04 N 5.90 5.90 11.80N
86340 A 04 N 5.90 5.90 11.80N
86341 04 N 11.80N
86343 B 04 N 8.07 8.07 16.15N
86344 A 04 N 1.15 1.15 2.30N
86353 B 04 N 5.90 5.90 11.80N
86355 04 N 15.81 15.81 31.62N
86356 04 1/1/2008 N 11.33N
86357 04 N 15.81 15.81 31.62N
86359 B 04 N 3.82 3.82 7.65N
86360 B 04 N 4.85 4.85 9.70N
86361 B 04 N 4.85 4.85 9.70N
86367 04 N 15.81 15.81 31.62N
86376 A 04 N 4.20 4.20 8.40N
86378 B 04 N 6.95 6.95 13.90N
86382 A 04 N 3.60 3.60 7.20N
86384 A 04 N 2.35 2.35 4.70N
86403 A 04 N 3.00 3.00 6.00N
Wednesday, June 18, 2008 Page 340 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86406 A 04 N 5.90 5.90 11.80N
86430 B 04 N 3.10 3.10 6.20N
86431 B 04 N 3.62 3.62 7.25N
86480 04 N 25.97 25.97 51.95N
86485 B 04 N 2.00 2.00 4.00N
86486 04 1/1/2008 NY
86490 B 04 N 2.57 2.57 5.15N
86510 B 04 N 2.57 2.57 5.15N
86580 04 N 4.00N
86590 B 04 N 5.90 5.90 11.80N
86592 B 04 N 2.00 2.00 4.00N
86593 B 04 N 2.00 2.00 4.00N
86602 B 04 N 5.10 5.10 10.20N
86603 A 04 N 7.40 7.40 14.80N
86606 B 04 N 5.10 5.10 10.20N
86609 B 04 N 5.12 5.12 10.25N
86611 B 04 N 5.30 5.30 10.60N
86612 B 04 N 5.10 5.10 10.20N
86615 B 04 N 5.95 5.95 11.90N
86617 B 04 N 10.10 10.10 20.20N
86618 B 04 N 11.10 11.10 22.20N
Wednesday, June 18, 2008 Page 341 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86619 B 04 N 5.10 5.10 10.20N
86622 B 04 N 5.10 5.10 10.20N
86625 B 04 N 4.85 4.85 9.70N
86628 B 04 N 5.10 5.10 10.20N
86631 B 04 N 7.70 7.70 15.40N
86632 B 04 N 8.27 8.27 16.55N
86635 B 04 N 5.10 5.10 10.20N
86638 B 04 N 5.10 5.10 10.20N
86641 B 04 N 5.10 5.10 10.20N
86644 B 04 N 6.67 6.67 13.35N
86645 B 04 N 9.12 9.12 18.25N
86648 B 04 N 9.60 9.60 19.20N
86651 B 04 N 8.00 8.00 16.00N
86652 B 04 N 8.00 8.00 16.00N
86653 B 04 N 7.80 7.80 15.60N
86654 B 04 N 8.00 8.00 16.00N
86658 B 04 N 8.50 8.50 17.00N
86663 B 04 N 8.57 8.57 17.15N
86664 B 04 N 8.80 8.80 17.60N
86665 B 04 N 9.60 9.60 19.20N
86666 B 04 N 5.30 5.30 10.60N
Wednesday, June 18, 2008 Page 342 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86668 B 04 N 5.10 5.10 10.20N
86671 B 04 N 8.01 8.01 16.02N
86674 B 04 N 5.10 5.10 10.20N
86677 B 04 N 7.50 7.50 15.00N
86682 B 04 NY
86684 B 04 N 9.60 9.60 19.20N
86687 B 04 N 5.10 5.10 10.20N
86688 B 04 N 6.72 6.72 13.45N
86689 B 04 N 11.19 11.19 22.39N
86692 B 04 N 5.05 5.05 10.10N
86694 B 04 N 6.67 6.67 13.35N
86695 B 04 N 7.65 7.65 15.30N
86696 B 04 N 10.10 10.10 20.20N
86698 B 04 N 8.15 8.15 16.30N
86701 B 04 N 5.80 5.80 11.60N
86702 B 04 N 5.10 5.10 10.20N
86703 B 04 N 8.95 8.95 17.90N
86704 B 04 N 7.85 7.85 15.70N
86705 B 04 N 7.70 7.70 15.40N
86706 B 04 N 7.00 7.00 14.00N
86707 B 04 N 4.77 4.77 9.55N
Wednesday, June 18, 2008 Page 343 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86708 B 04 N 4.77 4.77 9.55N
86709 B 04 N 2.77 2.77 5.55N
86710 B 04 N 8.85 8.85 17.70N
86713 B 04 N 2.62 2.62 5.25N
86717 B 04 N 5.10 5.10 10.20N
86720 B 04 N 5.10 5.10 10.20N
86723 B 04 N 8.32 8.32 16.65N
86727 B 04 N 7.80 7.80 15.60N
86729 B 04 N 7.65 7.65 15.30N
86732 B 04 N 5.10 5.10 10.20N
86735 B 04 N 6.35 6.35 12.70N
86738 B 04 N 5.10 5.10 10.20N
86741 B 04 N 5.10 5.10 10.20N
86744 B 04 N 5.10 5.10 10.20N
86747 B 04 N 9.80 9.80 19.60N
86750 B 04 N 5.10 5.10 10.20N
86753 B 04 N 8.08 8.08 16.17N
86756 B 04 N 8.42 8.42 16.85N
86757 B 04 N 10.10 10.10 20.20N
86759 B 04 N 8.40 8.40 16.80N
86762 B 04 N 4.10 4.10 8.20N
Wednesday, June 18, 2008 Page 344 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86765 B 04 N 4.10 4.10 8.20N
86768 B 04 N 5.10 5.10 10.20N
86771 B 04 N 5.10 5.10 10.20N
86774 B 04 N 9.65 9.65 19.30N
86777 B 04 N 6.35 6.35 12.70N
86778 B 04 N 9.40 9.40 18.80N
86781 B 04 N 8.64 8.64 17.29N
86784 B 04 N 5.10 5.10 10.20N
86787 B 04 N 7.50 7.50 15.00N
86788 B 04 1/1/2007 N 7.06 7.06 14.12N
86789 B 04 1/1/2007 N 6.03 6.03 12.07N
86790 B 04 N 8.42 8.42 16.85N
86793 B 04 N 5.10 5.10 10.20N
86800 B 04 N 5.90 5.90 11.80N
86803 B 04 N 8.42 8.42 16.85N
86804 B 04 N 6.20 6.20 12.40N
86805 B 04 N 23.90 23.90 47.80N
86806 B 04 N 21.72 21.72 43.45N
86807 B 04 N 18.05 18.05 36.10N
86808 B 04 N 13.55 13.55 27.10N
86812 B 04 N 3.10 3.10 6.20N
Wednesday, June 18, 2008 Page 345 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86813 B 04 N 8.42 8.42 16.85N
86816 B 04 N 7.50 7.50 15.00N
86817 B 04 N 14.00 14.00 28.00N
86821 B 04 N 28.05 28.05 56.10N
86822 B 04 N 13.35 13.35 26.70N
86849 A 04 NY
86850 A 04 N 2.82 2.82 5.65N
86860 A 04 N 5.95 5.95 11.90N
86870 A 04 N 7.17 7.17 14.35N
86880 A 04 N 2.90 2.90 5.80N
86885 A 04 N 3.05 3.05 6.10N
86886 A 04 N 3.10 3.10 6.20N
86890 04 N 40.40N
86891 04 N 101.80N
86900 A 04 N 1.75 1.75 3.50N
86901 A 04 N 2.35 2.35 4.70N
86903 A 04 N 6.15 6.15 12.30N
86904 A 04 N 6.20 6.20 12.40N
86905 A 04 N 2.47 2.47 4.95N
86906 A 04 N 2.30 2.30 4.60N
86910 A 04 N 12.02 12.02 24.05N
Wednesday, June 18, 2008 Page 346 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86911 A 04 N 3.40 3.40 6.80N
86920 A 04 N 2.35 2.35 4.70N
86921 A 04 N 4.70 4.70 9.40N
86922 A 04 N 4.70 4.70 9.40N
86927 09 NY
86930 09 NY
86931 09 NY
86932 09 NY
86940 A 04 N 2.77 2.77 5.55N
86941 A 04 N 2.35 2.35 4.70N
86945 04 N 6.60N
86950 04 N 25.70YN
86965 04 N 5.05N
86970 04 N 10.10N
86971 04 N 8.20N
86972 04 N 8.20N
86975 04 N 8.20N
86976 04 N 8.20N
86977 04 N 8.20N
86978 04 N 10.10N
86985 A 04 N 4.10 4.10 8.20N
Wednesday, June 18, 2008 Page 347 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
86999 A 04 NY
87001 B 04 N 8.60 8.60 17.20N
87003 B 04 N 8.95 8.95 17.90N
87015 A 04 N 3.60 3.60 7.20N
87040 B 04 N 6.75 6.75 13.50N
87045 B 04 N 6.15 6.15 12.30N
87046 B 04 N 1.20 1.20 2.40N
87070 B 04 N 3.10 3.10 6.20N
87071 09 NY
87073 09 NY
87075 B 04 N 6.17 6.17 12.35N
87076 09 NY
87077 09 NY
87081 B 04 N 2.90 2.90 5.80N
87084 B 04 N 3.00 3.00 6.00N
87086 B 04 N 5.25 5.25 10.50N
87088 09 Y 6.20N
87101 B 04 N 3.10 3.10 6.20N
87102 B 04 N 3.10 3.10 6.20N
87103 B 04 N 3.10 3.10 6.20N
87106 09 NY
Wednesday, June 18, 2008 Page 348 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87107 09 NY
87109 B 04 N 4.77 4.77 9.55N
87110 B 04 N 8.42 8.42 16.85N
87116 B 04 N 5.85 5.85 11.70N
87118 09 NY
87140 B 04 N 0.57 0.57 1.15N
87143 B 04 N 3.60 3.60 7.20N
87147 B 04 N 1.60 1.60 3.20N
87149 09 NY
87152 09 NY
87158 B 04 N 0.57 0.57 1.15N
87164 04 N 14.00N
87166 04 N 14.75N
87168 B 04 N 2.25 2.25 4.50N
87169 B 04 N 2.25 2.25 4.50N
87172 A 04 N 2.25 2.25 4.50N
87176 A 04 N 3.85 3.85 7.70N
87177 A 04 N 3.60 3.60 7.20N
87181 B 04 6.20N
87184 B 04 N 4.50 4.50 9.00N
87185 A 04 N 2.47 2.47 4.95N
Wednesday, June 18, 2008 Page 349 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87186 B 04 N 5.65 5.65 11.30N
87187 B 04 N 4.30 4.30 8.60N
87188 B 04 N 4.32 4.32 8.65N
87190 04 N 7.40N
87197 B 04 N 6.40 6.40 12.80N
87205 B 04 N 1.75 1.75 3.50N
87206 B 04 N 2.10 2.10 4.20N
87207 B 04 N 1.75 1.75 3.50N
87209 B 04 N 7.53 7.53 15.06N
87210 B 04 N 2.35 2.35 4.70N
87220 B 04 N 2.35 2.35 4.70N
87230 B 04 N 7.50 7.50 15.00N
87250 04 N 12.80N
87252 B 04 N 6.40 6.40 12.80N
87253 B 04 N 7.50 7.50 15.00N
87254 A 04 N 3.20 3.20 6.40N
87255 A 04 N 11.83 11.83 23.66N
87260 B 04 N 7.85 7.85 15.70N
87265 B 04 N 7.85 7.85 15.70N
87267 B 04 N 4.19 4.19 8.38N
87269 B 04 N 5.02 5.02 10.05N
Wednesday, June 18, 2008 Page 350 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87270 B 04 N 7.85 7.85 15.70N
87271 B 04 N 4.19 4.19 8.38N
87272 B 04 N 7.85 7.85 15.70N
87273 B 04 N 6.25 6.25 12.50N
87274 B 04 N 7.85 7.85 15.70N
87275 B 04 N 6.25 6.25 12.50N
87276 B 04 N 7.85 7.85 15.70N
87277 B 04 N 6.25 6.25 12.50N
87278 B 04 N 7.85 7.85 15.70N
87279 A 04 N 6.25 6.25 12.50N
87280 B 04 N 7.85 7.85 15.70N
87281 B 04 N 6.25 6.25 12.50N
87283 B 04 N 6.25 6.25 12.50N
87285 B 04 N 7.85 7.85 15.70N
87290 B 04 N 7.85 7.85 15.70N
87299 A 04 NY
87300 A 04 N 3.10 3.10 6.20N
87301 B 04 N 7.85 7.85 15.70N
87305 B 04 N 7.85 7.85 15.70N
87320 B 04 N 7.85 7.85 15.70N
87324 B 04 N 7.85 7.85 15.70N
Wednesday, June 18, 2008 Page 351 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87327 B 04 N 6.25 6.25 12.50N
87328 B 04 N 7.85 7.85 15.70N
87329 B 04 N 5.02 5.02 10.05N
87332 B 04 N 7.85 7.85 15.70N
87335 B 04 N 7.85 7.85 15.70N
87336 B 04 N 6.25 6.25 12.50N
87337 B 04 N 6.25 6.25 12.50N
87338 B 04 N 9.40 9.40 18.80N
87339 B 04 N 6.25 6.25 12.50N
87340 B 04 N 6.75 6.75 13.50N
87341 B 04 N 5.40 5.40 10.80N
87350 B 04 N 7.52 7.52 15.05N
87380 B 04 N 10.70 10.70 21.40N
87385 B 04 N 7.85 7.85 15.70N
87390 B 04 N 11.50 11.50 23.00N
87391 B 04 N 11.50 11.50 23.00N
87400 B 04 N 3.10 3.10 6.20N
87420 B 04 N 7.85 7.85 15.70N
87425 B 04 N 7.85 7.85 15.70N
87427 B 04 N 6.25 6.25 12.50N
87430 B 04 N 7.85 7.85 15.70N
Wednesday, June 18, 2008 Page 352 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87449 A 04 N 7.84 7.84 15.68N
87450 A 04 NY
87451 B 04 N 5.00 5.00 10.00N
87470 B 04 N 13.10 13.10 26.20N
87471 B 04 N 22.90 22.90 45.80N
87472 B 04 N 27.95 27.95 55.91N
87475 B 04 N 13.10 13.10 26.20N
87476 B 04 N 22.90 22.90 45.80N
87477 B 04 N 27.95 27.95 55.91N
87480 B 04 N 13.10 13.10 26.20N
87481 B 04 N 22.90 22.90 45.80N
87482 B 04 N 27.25 27.25 54.50N
87485 B 04 N 13.10 13.10 26.20N
87486 B 04 N 22.90 22.90 45.80N
87487 B 04 N 27.95 27.95 55.91N
87490 B 04 N 13.10 13.10 26.20N
87491 B 04 N 22.90 22.90 45.80N
87492 B 04 N 22.81 22.81 45.63N
87495 B 04 N 13.10 13.10 26.20N
87496 B 04 N 22.90 22.90 45.80N
87497 B 04 N 22.81 22.81 45.63N
Wednesday, June 18, 2008 Page 353 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87498 B 04 N 22.91 22.91 45.83N
87500 04 1/1/2008 N 29.42N
87510 B 04 N 13.10 13.10 26.20N
87511 B 04 N 22.90 22.90 45.80N
87512 B 04 NY
87515 B 04 N 13.10 13.10 26.20N
87516 B 04 N 22.90 22.90 45.80N
87517 B 04 N 27.95 27.95 55.90N
87520 B 04 N 13.10 13.10 26.20N
87521 B 04 N 22.90 22.90 45.80N
87522 B 04 N 27.95 27.95 55.90N
87525 B 04 N 13.10 13.10 26.20N
87526 B 04 N 22.90 22.90 45.80N
87527 B 04 NY
87528 B 04 N 13.10 13.10 26.20N
87529 B 04 N 22.90 22.90 45.80N
87530 B 04 NY
87531 B 04 N 13.10 13.10 26.20N
87532 B 04 N 22.90 22.90 45.80N
87533 B 04 NY
87534 B 04 N 13.10 13.10 26.20N
Wednesday, June 18, 2008 Page 354 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87535 B 04 N 22.90 22.90 45.80N
87536 B 04 N 43.45 43.45 86.90N
87537 B 04 N 13.10 13.10 26.20N
87538 B 04 N 22.90 22.90 45.80N
87539 B 04 NY
87540 B 04 N 13.10 13.10 26.20N
87541 B 04 N 22.90 22.90 45.80N
87542 B 04 NY
87550 B 04 N 13.10 13.10 26.20N
87551 B 04 N 22.90 22.90 45.80N
87552 B 04 NY
87555 B 04 N 13.10 13.10 26.20N
87556 B 04 N 22.90 22.90 45.80N
87557 B 04 NY
87560 B 04 N 13.10 13.10 26.20N
87561 B 04 N 22.90 22.90 45.80N
87562 B 04 NY
87580 B 04 N 13.10 13.10 26.20N
87581 B 04 N 22.90 22.90 45.80N
87582 B 04 NY
87590 B 04 N 13.10 13.10 26.20N
Wednesday, June 18, 2008 Page 355 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87591 B 04 N 22.90 22.90 45.80N
87592 B 04 NY
87620 B 04 N 13.10 13.10 26.20N
87621 B 04 N 22.90 22.90 45.80N
87622 B 04 NY
87640 B 04 N 22.91 22.91 45.83N
87641 B 04 N 22.91 22.91 45.83N
87650 B 04 N 13.10 13.10 26.20N
87651 B 04 N 22.90 22.90 45.80N
87652 04 NY
87653 B 04 N 22.91 22.92 45.83N
87660 B 04 N 8.40 8.40 16.81N
87797 A 04 N 13.10 13.10 26.20N
87798 A 04 N 22.91 22.91 45.83N
87799 A 04 N 25.94 25.94 51.89N
87800 B 04 N 10.47 10.47 20.95N
87801 B 04 N 18.30 18.30 36.60N
87802 B 04 N 7.82 7.82 15.65N
87803 B 04 N 7.82 7.82 15.65N
87804 B 04 N 7.82 7.82 15.65N
87807 04 N 10.06N
Wednesday, June 18, 2008 Page 356 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
87808 04 N 7.82 7.82 15.65N
87809 04 1/1/2008 N 10.06N
87810 B 04 N 7.85 7.85 15.70N
87850 B 04 N 7.85 7.85 15.70N
87880 04 N 4.20N
87880 H 04 N 7.85 7.85 15.70N
87899 A 04 NY
87900 04 N 162.20N
87901 04 N 168.05N
87902 B 04 N 84.02 84.02 168.05N
87903 04 N 682.72N
87904 04 N 32.44 9 291.96N
87999 A 04 NY
88104 B 04 N 5.90 5.90 11.80N
88106 B 04 N 5.90 5.90 11.80N
88107 B 04 N 5.90 5.90 11.80N
88108 B 04 N 4.45 4.45 8.90N
88112 C 04 N 29.33 23.68 63.61N
88125 B 04 N 1.67 1.67 3.35N
88130 B 04 N 7.00 7.00 14.00N
88140 B 04 N 4.77 4.77 9.55N
Wednesday, June 18, 2008 Page 357 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
88141 04 N 3.50N
88142 04 N 3.35N
88143 04 N 3.50N
88147 04 N 3.50N
88148 04 N 3.50N
88150 04 N 1 3.50N
88152 04 N 3.50N
88153 04 N 3.50N
88154 04 N 3.50N
88155 04 N 1 4.10N
88160 B 04 N 5.90 5.90 11.80N
88161 B 04 N 5.62 5.62 11.25N
88162 B 04 N 11.80 11.80 23.60N
88164 04 N 3.50N
88165 04 N 3.50N
88166 04 N 3.50N
88167 04 N 3.50N
88172 04 N 16.85N
88173 B 04 N 14.00 14.00 28.00N
88174 B 04 N 7.46 7.46 14.93N
88175 B 04 N 9.20 9.20 18.41N
Wednesday, June 18, 2008 Page 358 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
88182 B 04 N 15.25 15.25 30.50N
88184 04 N 2.10N
88185 04 N 1.05 24 25.20N
88187 04 N 40.11N
88188 04 N 50.00N
88189 04 N 65.85N
88199 A 04 NY
88230 B 04 N 45.40 45.40 90..80N
88233 B 04 N 58.77 58.77 117.55N
88235 B 04 N 66.80 66.80 133.60N
88237 B 04 N 53.47 53.47 106.95N
88239 B 04 N 66.80 66.80 133.60N
88240 A 09 NY
88241 A 09 NY
88245 B 04 N 43.82 43.82 87.65N
88248 B 04 N 44.12 44.12 88.25N
88249 B 04 N 43.77 43.77 87.55N
88261 B 04 N 58.90 58.90 117.80N
88262 B 04 N 81.37 81.37 162.75N
88263 B 04 N 94.37 94.37 188.75N
88264 B 04 N 81.37 81.37 162.75N
Wednesday, June 18, 2008 Page 359 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
88267 B 04 N 44.30 44.30 88.60N
88269 B 04 N 38.17 38.17 76.35N
88271 B 04 N 9.45 9.45 18.90N
88272 B 04 N 16.52 16.52 33.05N
88273 B 04 N 20.95 20.95 41.90N
88274 B 04 N 22.70 22.70 45.40N
88275 B 04 N 26.20 26.20 52.40N
88280 B 04 N 16.35 16.35 32.70N
88283 B 04 N 12.27 12.27 24.55N
88285 B 04 N 12.40 12.40 24.80N
88289 B 04 N 8.55 8.55 17.10N
88291 B 04 N 2.62 2.62 5.25N
88299 A 04 NY
88300 A 04 N 6.52 6.52 13.05N
88302 A 04 N 10.47 10.47 20.95N
88304 A 04 N 18.67 18.67 37.35N
88305 A 04 N 20.55 20.55 41.10N
88307 A 04 N 21.80 21.80 43.60N
88309 A 04 N 23.70 23.70 47.40N
88311 B 04 N 5.75 5.75 11.50N
88312 A 04 N 5.90 5.90 11.80N
Wednesday, June 18, 2008 Page 360 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
88313 A 04 N 3.35 3.35 6.70N
88314 B 04 N 3.10 3.10 6.20N
88318 B 04 N 20.90 20.90 41.80N
88319 B 04 N 11.20 11.20 22.40N
88321 04 N 6.20N
88323 04 N 17.90N
88325 04 N 19.90N
88329 04 N 48.55N
88331 04 N 48.55N
88332 04 N 19.90N
88333 04 N 50.86N
88334 04 N 26.40N
88342 A 04 N 6.72 6.72 13.45N
88346 A 04 N 8.42 8.42 16.85N
88347 A 04 N 8.42 8.42 16.85N
88348 B 04 N 23.60 23.60 47.20N
88349 B 04 N 35.35 35.35 70.70N
88355 B 04 N 54.30 54.30 108.60N
88356 B 04 N 54.30 54.30 108.60N
88358 B 04 N 54.30 54.30 108.60N
88360 A 04 N 30.91 30.91 61.83N
Wednesday, June 18, 2008 Page 361 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
88361 C 04 N 24.79 35.80 72.70N
88362 A 04 NY
88365 04 N 40.81N
88367 A 04 N 57.57 57.57 115.15N
88368 04 N 105.20N
88371 B 04 N 14.22 14.22 28.45N
88372 B 04 N 14.85 14.85 29.70N
88380 B 04 NY
88381 C 04 1/1/2008 N 31.82 83.72 115.54N
88384 04 NY
88385 04 N 46.41N
88386 04 N 58.39N
88399 A 04 NY
88400 A 04 N 1.30 1.30 2.60N
89049 B 04 N 18.52 18.52 37.05N
89050 B 04 N 1.75 1.75 3.50N
89051 B 04 N 3.10 3.10 6.20N
89055 A 04 N 1.49 1.49 2.98N
89060 B 04 N 4.67 4.67 9.35N
89100 B 04 N 3.10 3.10 6.20N
89105 B 04 N 29.75 29.75 59.50N
Wednesday, June 18, 2008 Page 362 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
89125 B 04 N 1.67 1.67 3.35N
89130 A 04 I 14.60 14.60 29.20N
89132 A 04 NY
89135 B 04 N 14.60 14.60 29.20N
89136 B 04 NY
89140 B 04 N 23.60 23.60 47.20N
89141 A 04 N 14.00 14.00 28.00N
89160 B 04 N 0.67 0.67 1.35N
89190 B 04 N 1.67 1.67 3.35N
89225 B 04 N 1.40 1.40 2.80N
89235 B 04 N 2.30 2.30 4.61N
89240 A 04 NY
89250 09 NY
89310 B 04 N 3.35 3.35 6.70N
89321 09 NY
89322 04 1/1/2008 N 11.36N
90375 04 Y NY
90376 04 Y NY
90378 04 Y NY
90379 04 Y NY
90384 04 Y N 107.70N
Wednesday, June 18, 2008 Page 363 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90385 04 Y N 37.70N
90386 04 Y NY
90393 04 Y NY
90399 04 Y NY
90471 09 NY
90472 09 NY
90473 09 NY
90474 09 NY
90476 F 04 NY
90477 F 04 NY
90581 F 04 NY
90585 F 04 NY
90586 F 04 NY
90632 G 04 N 6.40 56.15N
90633 E 04 N 6.40N
90634 E 04 N 28.05N
90636 G 04 N 6.40 111.18N
90645 E 04 N 6.40N
90646 E 04 N 6.40N
90647 E 04 N 6.40N
90648 E 04 N 6.40N
Wednesday, June 18, 2008 Page 364 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90649 M 04 N 6.40 149.33Y
90650 04 1/1/2008 NY
90655 E 04 N 6.40N
90656 G 04 N 6.40N
90657 E 04 N 6.40N
90658 G 04 N 6.40 5.65N
90660 G 04 N 6.40 22.37N
90665 09 Y NY
90669 E 04 N 6.40N
90675 F 04 NY
90676 F 04 NY
90680 E 04 N 6.40N
90681 04 1/1/2008 Y
90690 09 NY
90691 09 NY
90692 09 NY
90693 09 Y
90696 04 1/1/2008 NY
90700 E 04 N 6.40N
90701 E 04 N 6.40N
90702 E 04 N 2.70N
Wednesday, June 18, 2008 Page 365 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90703 F 04 N 1.85N
90704 F 04 NY
90705 F 04 NY
90706 F 04 NY
90707 G 04 N 6.40 39.70N
90708 F 04 NY
90710 E 04 N 6.40N
90712 F 04 N 14.00N
90713 E 04 N 6.40N
90714 G 04 N 6.40 18.92N
90715 G 04 N 6.40 38.28N
90716 G 04 N 6.40 46.60N
90717 09 NY
90718 G 04 N 6.40 2.70N
90719 F 04 N 3.40N
90721 F 04 N 35.25N
90723 E 04 N 6.40N
90725 09 NY
90727 09 NY
90732 G 04 N 6.40 1 14.60N
90733 F 04 N 85.00N
Wednesday, June 18, 2008 Page 366 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90734 E 04 N 6.40N
90735 F 04 N 243.80N
90736 F 04 N 190.02N
90740 G 04 NY
90743 G 04 NY
90744 E 04 N 6.40N
90746 G 04 N 6.40 74.38N
90747 G 04 NY
90748 E 04 N 6.40N
90749 04 NY
90760 04 N 19.11YN
90761 04 I 19.11 8 152.90YN
90765 04 I 19.11YN
90766 04 I 19.11 8 152.90YN
90767 04 I 19.11YN
90768 04 I 19.11YN
90769 04 1/1/2008 I 84.51YN
90770 04 1/1/2008 I 9.15YN
90771 04 1/1/2008 I 36.95YN
90772 04 I 9.81N
90773 04 I 10.26YN
Wednesday, June 18, 2008 Page 367 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90774 04 I 29.55YN
90775 04 I 13.99 2 27.98YN
90776 04 1/1/2008 NYY
90779 04 IYY
90801 02 N 67.50N
90802 02 N 27.55N
90804 02 N 27.55N
90805 02 N 30.90N
90806 02 N 47.50N
90807 02 N 47.50N
90808 02 N 64.80N
90809 02 N 67.50N
90810 02 N 31.70N
90811 02 N 34.85N
90812 02 N 47.50N
90813 02 N 47.50N
90814 02 N 63.45N
90815 02 N 66.30N
90816 02 N 31.65N
90817 02 N 31.65N
90818 02 N 47.50N
Wednesday, June 18, 2008 Page 368 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90819 02 N 47.50N
90821 02 N 65.90N
90822 02 N 68.30N
90823 02 N 33.30N
90824 02 N 35.95N
90826 02 N 47.50N
90827 02 N 48.65N
90828 02 N 65.05N
90829 02 N 66.90N
90845 D 04 NN
90846 09 NY
90847 02 N 61.20N
90849 02 N 61.20N
90853 02 N 33.70N
90857 09 NY
90862 04 N 22.45N
90865 02 N 63.40N
90870 04 I 44.40YN
90875 02 N 28.70N
90876 02 N 47.50N
90880 09 NY
Wednesday, June 18, 2008 Page 369 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90885 09 NY
90887 09 NY
90889 09 NY
90899 02 NY
90901 09 IY
90911 09 IY
90918 04 I 252.35N
90919 04 I 213.65N
90920 04 I 213.65N
90921 04 I 213.65N
90922 04 I 8.30N
90923 04 I 7.10N
90924 04 I 7.10N
90925 04 I 7.10N
90935 04 I 35.75YN
90937 04 I 61.70YN
90940 04 IYY
90945 04 I 36.50YN
90947 04 N 60.90YN
90989 09 IY
90993 09 IY
Wednesday, June 18, 2008 Page 370 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
90997 04 NYY
90999 04 IYY
91000 04 I 20.80YN
91010 04 I 52.70YN
91011 04 I 60.60YN
91012 04 I 74.90YN
91020 04 I 74.90YN
91022 C 04 N 42.72 75.37 1 118.09N
91030 04 I 74.90YN
91034 C 04 I 31.17 99.11 1 130.28YN
91035 04 I 255.62YN
91037 04 I 84.00YN
91038 C 04 I 32.73 40.00 72.73YN
91040 04 I 248.27YN
91052 04 I 25.65YN
91055 04 I 27.85YN
91065 04 I 29.65YN
91100 04 I 99.10YN
91105 04 I 40.85YN
91110 C 04 I 140.95 563.92 704.90YN
91111 C 04 N 28.37 343.76 372.13YN
Wednesday, June 18, 2008 Page 371 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
91120 04 I 245.00YN
91122 04 I 57.20YN
91123 04 I 194.20N
91132 04 IYY
91133 04 IYY
91299 04 IY
92002 04 N 27.55N
92004 04 N 46.45N
92012 04 N 23.30N
92014 04 N 44.45N
92015 04 I 18.45N
92018 04 I 152.60YN
92019 04 I 152.60YN
92020 04 I 19.50N
92025 C 04 I 9.04 6.29 15.33N
92060 04 I 24.90N
92065 04 I 22.15N
92070 09 NY
92081 04 I 20.45N
92082 04 I 30.50N
92083 04 I 37.40N
Wednesday, June 18, 2008 Page 372 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92100 04 I 23.80N
92120 04 I 22.30N
92130 04 I 24.55N
92135 L 04 I 26.35 26.35 52.70N
92136 04 I 50.05N
92140 04 I 22.15N
92225 04 I 30.50N
92226 04 I 30.50N
92230 B 04 I 22.20 22.20 44.40N
92235 B 04 I 26.35 26.35 52.70N
92240 B 04 I 28.25 28.25 56.50N
92250 B 04 I 22.20 22.20 44.40N
92260 B 04 I 26.35 26.35 52.70N
92265 04 I 74.90YN
92270 04 I 52.70N
92275 B 04 I 26.35 26.35 52.70N
92283 04 I 22.15N
92284 B 04 I 7.60 7.60 15.20N
92285 04 I 30.50N
92286 04 I 52.70N
92287 04 I 69.30N
Wednesday, June 18, 2008 Page 373 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92310 04 NY
92311 09 NY
92312 09 NY
92313 09 NY
92314 09 NY
92315 09 NY
92316 09 NY
92317 09 NY
92325 09 NY
92326 09 NY
92340 04 N 30.09N
92341 09 NY
92342 09 NY
92352 09 NY
92353 09 NY
92354 09 NY
92355 09 NY
92358 09 NY
92370 04 N 4.76N
92371 09 NY
92499 04 IY
Wednesday, June 18, 2008 Page 374 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92502 04 I 52.70YN
92504 04 I 37.40N
92506 04 I 37.40N
92507 04 I 19.85N
92508 09 IY
92511 04 I 112.40YN
92512 04 I 20.05N
92516 04 I 15.90YN
92520 04 I 30.50YN
92526 04 IY
92531 04 I 30.50N
92532 04 I 30.50N
92533 04 I 22.15N
92534 04 I 22.15N
92541 04 I 22.15N
92542 04 I 22.15N
92543 04 I 22.15N
92544 04 I 22.15N
92545 04 I 22.15N
92546 04 I 22.15N
92547 04 I 22.15N
Wednesday, June 18, 2008 Page 375 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92548 04 I 39.35N
92551 04 N 15.20 1 15.20N
92552 04 I 15.20N
92553 04 I 15.20N
92555 04 I 15.20N
92556 04 I 15.20N
92557 04 I 37.40N
92559 09 NY
92560 04 I 15.20N
92561 04 I 26.35N
92562 04 N 7.60N
92563 04 N 15.20N
92564 04 N 15.20N
92565 04 N 15.20N
92567 04 N 15.20N
92568 04 N 13.70N
92569 04 N 14.68N
92571 04 N 15.20N
92572 04 N 15.20N
92575 04 N 15.20N
92576 04 N 15.20N
Wednesday, June 18, 2008 Page 376 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92577 04 N 12.20N
92579 04 N 22.15N
92582 04 N 22.15N
92583 04 N 15.15YN
92584 04 I 74.90YN
92585 04 I 53.75YN
92586 04 I 47.80YN
92587 04 I 52.70YN
92588 04 I 61.00YN
92590 04 I 37.40N
92591 04 I 37.40N
92592 04 I 15.20N
92593 04 I 15.20N
92594 04 I 15.20N
92595 04 I 15.20N
92596 04 I 15.20N
92597 04 I 43.18N
92601 04 I 55.01N
92602 04 I 38.72N
92603 04 I 37.18N
92604 04 I 25.49N
Wednesday, June 18, 2008 Page 377 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92605 04 I 24.90N
92606 04 I 24.90YN
92607 04 I 45.85N
92608 04 N 9.25N
92609 04 I 24.90N
92610 04 I 18.00N
92611 04 I 19.55YN
92612 04 I 30.25YN
92613 04 I 30.25YN
92614 04 I 30.25YN
92615 04 I 30.25N
92616 04 I 44.00YN
92617 04 I 44.00N
92620 04 I 24.46YN
92621 04 I 6.63N
92625 04 I 24.06YN
92626 09 NY
92627 09 NY
92630 09 NY
92633 09 NY
92640 04 N 26.67N
Wednesday, June 18, 2008 Page 378 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92700 04 IYY
92950 04 I 112.50N
92953 04 IYY
92960 04 I 112.40YN
92961 04 I 112.40YN
92970 04 IYY
92971 04 IYY
92973 04 I 156.50YN
92974 04 I 183.90YN
92975 04 MYY
92977 04 MYY
92978 04 I 120.70YN
92979 04 I 74.20YN
92980 04 M 910.70YN
92981 04 MYY
92982 04 M 718.70YN
92984 04 MYY
92986 04 M 682.80YN
92987 04 M 682.80YN
92990 04 M 682.80YN
92992 04 M 898.75YN
Wednesday, June 18, 2008 Page 379 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
92993 04 M 958.60YN
92995 04 M 898.75YN
92996 04 MYY
92997 04 M 718.70YN
92998 04 MYY
93000 A 04 I 11.08 11.07 22.15N
93005 04 I 11.05N
93010 04 I 11.05 5 55.25N
93012 04 I 39.50N
93014 04 I 13.90N
93015 04 I 67.90YN
93016 04 I 21.60N
93017 04 I 27.90YN
93018 04 I 22.15N
93024 04 I 59.60N
93025 04 I 168.20YN
93040 A 04 I 3.80 3.80 7.60N
93041 04 I 3.80N
93042 04 I 4.20N
93224 04 I 180.30YN
93225 04 I 135.90YN
Wednesday, June 18, 2008 Page 380 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93226 04 I 44.40YN
93227 04 I 44.40N
93230 04 I 158.70YN
93231 04 I 135.90YN
93232 04 I 44.40YN
93233 04 I 44.40N
93235 04 I 180.30YN
93236 04 I 44.40YN
93237 04 I 44.40YN
93268 04 I 73.70N
93270 04 I 21.60YN
93271 04 I 39.50YN
93272 04 I 21.60N
93278 04 I 27.00N
93303 B 04 I 49.05 49.05 98.10YN
93304 B 04 I 26.50 26.50 53.00YN
93307 B 04 I 45.50 45.50 91.00YN
93308 B 04 I 26.35 26.35 52.70YN
93312 B 04 I 81.85 81.85 163.70YN
93313 B 04 I 55.50 55.50 111.00YN
93314 B 04 I 47.15 47.15 94.30N
Wednesday, June 18, 2008 Page 381 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93315 B 04 I 81.85 81.85 163.70YN
93316 B 04 I 55.50 55.50 111.00YN
93317 B 04 I 53.13 53.12 106.25N
93318 B 04 I 81.85 81.85 163.70YN
93320 B 04 I 19.90 19.90 39.80YN
93321 B 04 I 12.95 12.95 25.90YN
93325 B 04 I 25.17 25.17 50.35YN
93350 B 04 I 81.85 81.85 163.70YN
93501 04 I 371.00YN
93503 04 I 149.80YN
93505 04 I 154.80YN
93508 04 I 318.80YN
93510 04 I 727.50YN
93511 04 I 723.20YN
93514 04 I 783.70YN
93524 04 I 963.70YN
93526 04 I 969.95YN
93527 04 I 991.50YN
93528 04 I 1008.05YN
93529 04 I 899.70YN
93530 04 I 399.90YN
Wednesday, June 18, 2008 Page 382 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93531 04 I 1021.95YN
93532 04 I 1050.75YN
93533 04 I 940.30YN
93539 04 I 74.90YN
93540 04 I 74.90YN
93541 04 I 74.90YN
93542 04 I 74.90YN
93543 04 I 74.90YN
93544 04 I 74.90YN
93545 04 I 299.70YN
93555 04 I 121.00N
93556 04 I 181.35N
93561 04 I 109.20YN
93562 04 I 149.80YN
93571 B 04 I 57.82 57.82 115.65YN
93572 B 04 I 52.75 52.75 105.50YN
93580 04 MYY
93581 04 MYY
93600 04 I 224.70YN
93602 04 I 224.70YN
93603 04 I 224.70YN
Wednesday, June 18, 2008 Page 383 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93609 04 I 282.40YN
93610 04 I 224.70YN
93612 04 I 224.70YN
93613 04 I 252.15YN
93615 04 I 224.70YN
93616 04 I 374.60YN
93618 04 I 374.60YN
93619 04 I 343.70YN
93620 04 I 489.60YN
93621 04 I 374.60YN
93622 04 I 374.60YN
93623 04 I 374.60YN
93624 04 I 224.70YN
93631 04 I 310.95YN
93640 04 I 222.35YN
93641 04 I 293.55YN
93642 04 I 262.25YN
93650 04 M 550.90YN
93651 04 M 550.90YN
93652 04 M 550.90YN
93660 04 I 69.30YN
Wednesday, June 18, 2008 Page 384 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93662 04 I 205.00YN
93668 04 N 28.35N
93701 04 I 30.10YN
93720 04 I 74.90YN
93721 04 I 44.40YN
93722 04 I 22.15N
93724 04 I 224.70N
93727 04 I 31.35N
93731 04 I 31.35N
93732 04 I 31.35N
93733 04 I 22.15N
93734 04 I 31.35N
93735 04 I 31.35N
93736 04 I 22.15N
93740 04 I 7.60N
93741 04 I 29.75N
93742 04 I 36.90N
93743 04 I 33.85N
93744 04 I 42.00N
93745 04 I 36.90YN
93760 04 I 37.40YN
Wednesday, June 18, 2008 Page 385 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93762 04 I 37.40YN
93770 04 I 16.65N
93784 04 I 180.30YN
93786 04 I 134.60YN
93788 04 I 44.40N
93790 04 I 44.40N
93797 04 N 21.10N
93798 04 I 43.35N
93799 04 IYY
93875 A 04 I 25.03 25.02 50.05YN
93880 A 04 I 39.40 39.40 78.80YN
93882 A 04 I 26.20 26.20 52.40YN
93886 A 04 I 47.15 47.15 94.30YN
93888 A 04 I 31.53 31.52 63.05YN
93890 A 04 I 84.30 84.30 168.60YN
93892 A 04 I 70.87 70.86 141.73YN
93893 A 04 I 69.56 69.56 139.12YN
93922 A 04 I 25.03 25.02 50.05YN
93923 A 04 I 25.47 25.47 50.95YN
93924 A 04 I 28.00 28.00 56.00YN
93925 A 04 I 39.40 39.40 78.80YN
Wednesday, June 18, 2008 Page 386 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
93926 A 04 I 26.35 26.35 52.70YN
93930 A 04 I 40.07 40.08 80.15YN
93931 A 04 I 26.60 26.60 53.20YN
93965 A 04 I 25.03 25.02 50.05YN
93970 B 04 I 17.38 70.17 87.55YN
93971 A 04 I 10.77 47.48 58.25YN
93975 A 04 I 59.60 59.60 119.20YN
93976 A 04 I 39.85 39.85 79.70YN
93978 A 04 I 41.15 41.15 82.30YN
93979 A 04 I 27.40 27.40 54.80YN
93980 A 04 I 45.83 45.82 91.65YN
93981 A 04 I 33.65 33.65 67.30YN
93982 04 1/1/2008 N 22.25N
93990 A 04 I 40.93 40.92 81.85YN
94002 04 I 46.34N
94003 04 I 33.61N
94004 04 I 24.47N
94010 C 04 I 7.65 29.75 37.40N
94014 04 I 52.90N
94015 04 I 29.90N
94016 04 I 23.00N
Wednesday, June 18, 2008 Page 387 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
94060 C 04 I 12.50 40.20 52.70N
94070 C 04 I 15.25 37.45 52.70N
94150 C 04 I 1.60 6.00 7.60N
94200 C 04 I 1.55 15.10 16.65N
94240 C 04 I 4.50 26.00 30.50N
94250 C 04 I 3.20 4.40 7.60N
94260 C 04 I 4.45 10.75 15.20N
94350 C 04 I 1.60 51.10 52.70YN
94360 C 04 I 1.60 21.20 22.80YN
94370 C 04 I 4.45 10.75 15.20N
94375 C 04 I 7.70 36.70 44.40N
94400 C 04 I 4.45 17.70 22.15N
94450 C 04 I 4.45 17.70 22.15N
94452 A 04 I 14.29 14.28 28.57YN
94453 A 04 I 20.21 20.21 40.42YN
94610 04 N 35.06N
94620 C 04 I 12.30 29.80 42.10YN
94621 04 I 59.00YN
94640 04 N 14.50N
94642 04 N 22.05N
94644 04 N 17.87N
Wednesday, June 18, 2008 Page 388 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
94645 04 N 6.92YN
94660 09 IY
94662 04 IYY
94664 04 N 15.20N
94667 04 N 15.20N
94668 04 N 8.20N
94680 C 04 I 7.65 29.75 37.40YN
94681 C 04 I 7.70 36.70 44.40YN
94690 C 04 I 4.50 26.00 30.50YN
94720 C 04 I 9.40 28.00 37.40YN
94725 C 04 I 3.40 34.00 37.40YN
94750 C 04 I 4.45 17.70 22.15YN
94760 C 04 I 1.50 2.90 4.40N
94761 C 04 I 4.45 10.75 15.20N
94762 C 04 I 7.55 14.60 22.15N
94770 C 04 I 1.60 13.60 15.20YN
94772 04 IYY
94774 04 I 52.90N
94777 04 N 23.00N
94799 04 IY
95004 04 N 1.70 65 110.50N
Wednesday, June 18, 2008 Page 389 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95010 04 N 6.60 65 429.00N
95012 04 I 9.31N
95015 04 N 6.95 80 556.00N
95024 04 N 2.50 40 100.00N
95027 04 N 4.10 40 164.00N
95028 04 N 3.85 40 154.00N
95044 04 N 3.40 65 221.00N
95052 04 N 4.10 200 820.00N
95056 04 N 2.90 1 2.90N
95060 04 N 7.20N
95065 04 N 7.20N
95070 04 N 105.40YN
95071 04 N 59.04YN
95075 04 N 38.84N
95115 04 I 6.50N
95117 04 I 8.30N
95120 04 I 6.50N
95125 04 I 8.30N
95130 04 I 4.20N
95131 04 I 8.60N
95132 04 I 12.75N
Wednesday, June 18, 2008 Page 390 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95133 04 I 17.00N
95134 04 I 21.30N
95144 04 I 14.30N
95145 04 I 21.60N
95146 04 I 32.40N
95147 04 I 37.80N
95148 04 I 43.25N
95149 04 I 48.60N
95165 04 I 36.00N
95170 04 I 12.30N
95180 04 N 47.50YN
95199 04 IY
95250 04 NY
95251 04 N 15.40N
95805 A 04 I 76.05 76.05 152.10YN
95806 A 04 I 55.27 55.28 110.55YN
95807 A 04 I 77.35 77.35 154.70YN
95808 A 04 I 96.65 96.65 193.30YN
95810 A 04 I 130.80 130.80 261.60YN
95811 A 04 I 136.15 136.15 272.30YN
95812 A 04 I 29.40 29.40 58.80YN
Wednesday, June 18, 2008 Page 391 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95813 A 04 I 40.90 40.90 81.80YN
95816 A 04 I 28.55 28.55 57.10YN
95819 A 04 I 26.35 26.35 52.70YN
95822 A 04 I 27.65 27.65 55.30YN
95824 A 04 I 26.35 26.35 52.70N
95827 A 04 I 33.40 33.40 66.80YN
95829 04 I 163.50N
95830 04 I 79.10N
95831 04 I 25.60YN
95832 04 I 22.15YN
95833 04 I 52.70YN
95834 04 I 52.70YN
95851 04 I 30.50YN
95852 04 I 30.50YN
95857 04 I 25.60YN
95860 04 I 37.40YN
95861 04 I 56.80YN
95863 04 I 65.70YN
95864 04 I 85.30YN
95865 C 04 I 50.72 13.65 64.37YN
95866 C 04 I 39.54 4.56 44.10YN
Wednesday, June 18, 2008 Page 392 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95867 04 I 30.70YN
95868 04 I 46.30YN
95869 04 I 52.70YN
95870 04 I 52.70YN
95872 04 I 56.80YN
95873 C 04 I 11.58 4.30 15.88YN
95874 C 04 N 11.76 4.30 16.06YN
95875 04 I 36.60YN
95900 04 IYY
95903 04 IYY
95904 04 IYY
95920 04 MY
95921 04 I 44.50YN
95922 04 I 44.50YN
95923 04 I 44.80YN
95925 04 I 74.90YN
95926 04 I 74.90YN
95927 04 I 74.90YN
95928 04 I 97.05YN
95929 04 I 100.85YN
95930 04 I 52.70YN
Wednesday, June 18, 2008 Page 393 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95933 04 I 30.50YN
95934 04 I 37.40YN
95936 04 I 37.40YN
95937 04 I 37.40YN
95950 C 04 I 61.31 118.99 180.30YN
95951 C 04 I 71.18 284.72 355.90YN
95953 C 04 I 77.53 102.77 180.30YN
95954 C 04 I 119.09 106.61 1 224.70YN
95955 04 I 62.05YN
95956 C 04 I 100.41 294.32 394.73YN
95957 C 04 I 65.03 37.30 102.33YN
95958 04 I 142.05YN
95961 04 I 180.30YN
95962 04 IYY
95965 A 04 I 138.25 138.25 276.50YN
95966 A 04 I 93.83 93.82 187.65YN
95967 A 04 I 82.35 82.35 164.70N
95970 04 I 41.90N
95971 04 I 41.90N
95972 04 I 41.90N
95973 04 I 41.90N
Wednesday, June 18, 2008 Page 394 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
95974 04 I 68.50YN
95975 04 I 41.90YN
95978 04 I 110.51N
95979 04 I 53.28N
95980 04 1/1/2008 I 22.92N
95981 04 1/1/2008 I 8.89 6.41N
95982 04 1/1/2008 I 18.00 5.81N
95990 04 I 29.41N
95991 04 I 29.41N
95999 04 IYY
96000 04 I 82.00YN
96001 04 N 97.80YN
96002 04 I 19.20YN
96003 04 I 17.90YN
96004 04 I 67.50N
96020 04 I 85.31N
96105 04 I 52.70N
96110 04 N 16.07 2 32.15N
96111 04 N 16.07 2 32.15N
96116 09 IYY
96118 09 IY
Wednesday, June 18, 2008 Page 395 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
96119 09 NY
96120 09 NY
96125 09 1/1/2008 N 46.07 7.81N
96150 04 NY
96151 04 NY
96152 04 NY
96153 04 NY
96154 04 NY
96155 04 NY
96401 04 I 22.15N
96402 04 I 18.39N
96405 04 IY
96406 04 IY
96409 04 I 62.22N
96411 04 I 36.36N
96413 04 I 25.40N
96415 04 I 19.11 8 152.90N
96416 04 I 22.15N
96417 04 I 25.40N
96420 04 I 37.40N
96422 04 I 37.40N
Wednesday, June 18, 2008 Page 396 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
96423 04 I 14.17 8 113.40N
96425 04 I 33.80N
96440 04 I 102.00N
96445 04 I 101.30N
96450 04 I 83.20N
96521 04 I 32.90N
96522 04 I 34.70N
96523 09 NY
96542 04 IY
96549 04 IY
96567 04 IYY
96570 04 IYY
96571 04 IYY
96900 04 I 6.60N
96902 04 N 10.50N
96910 04 I 9.55N
96912 04 I 10.95N
96913 04 I 30.05N
96920 04 IY
96921 04 IY
96922 04 IY
Wednesday, June 18, 2008 Page 397 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
96999 04 IYY
97001 09 IYY
97002 09 IYY
97003 09 IY
97004 09 IY
97005 04 NYY
97006 04 NYY
97010 04 I 4.40YN
97012 04 I 7.70YN
97014 04 I 6.50YN
97016 04 I 7.00YN
97018 04 I 5.95YN
97022 04 I 6.50YN
97024 04 I 4.50YN
97026 04 I 4.40YN
97028 04 I 4.70YN
97032 04 I 7.40YN
97033 04 I 7.70YN
97034 04 I 6.40YN
97035 04 I 5.50YN
97036 04 I 8.95YN
Wednesday, June 18, 2008 Page 398 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
97039 04 IYY
97110 04 N 10.40YN
97112 04 I 10.90YN
97113 04 N 11.50YN
97116 04 I 9.75YN
97124 04 I 8.90N
97139 04 IY
97140 04 I 11.80N
97150 04 I 8.40N
97530 04 I 22.15YN
97532 09 IY
97533 04 I 18.75YN
97535 04 I 11.20YN
97537 04 I 11.00YN
97542 04 I 7.55YN
97545 04 I 27.00YN
97546 09 IY
97597 04 I 27.78YN
97598 04 I 35.97YN
97602 04 I 28.35YN
97605 04 IYY
Wednesday, June 18, 2008 Page 399 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
97606 04 IYY
97750 04 I 22.15YN
97760 09 NYY
97761 09 NYY
97762 09 NYY
97799 04 IYY
97802 09 NY
97803 09 NY
97804 09 NY
98925 04 I 12.55N
98926 04 I 17.60N
98927 04 I 22.05N
98928 04 I 25.50N
98929 04 I 28.60N
98940 09 NY
98941 02 NY
98942 09 NY
98943 09 NY
99000 09 NY
99001 09 NY
99002 09 NY
Wednesday, June 18, 2008 Page 400 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99056 04 N 14.35N
99058 04 N 14.35N
99070 04 NY
99071 09 NY
99075 09 NY
99078 09 NY
99082 04 NY
99090 09 NY
99091 09 NY
99100 09 NY
99116 09 NY
99135 09 NY
99140 09 NY
99143 04 I 76.70N
99144 04 I 76.70N
99145 04 I 38.35 2 76.70N
99148 04 I 38.35N
99149 04 I 38.35N
99150 04 I 19.17 2 38.35N
99170 04 I 58.90N
99172 04 IY
Wednesday, June 18, 2008 Page 401 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99173 04 N 7.45 1 7.45N
99175 09 NY
99183 04 I 60.50YN
99185 04 IY
99186 04 IY
99190 04 IY
99191 04 IY
99192 04 IY
99195 04 I 33.25N
99199 04 IY
99201 04 N 27.95 1 27.95N
99202 04 N 32.00 1 32.00N
99203 04 N 41.60 1 41.60N
99204 04 N 66.40 1 66.40N
99205 04 N 70.85 1 70.85N
99211 04 N 12.30 1 12.30N
99212 04 N 24.25 1 24.25N
99213 04 N 28.35 1 28.35N
99214 04 N 42.50 1 42.50N
99215 04 N 48.00 1 48.00N
99217 09 NY
Wednesday, June 18, 2008 Page 402 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99218 04 N 69.55N
99219 04 N 69.55N
99220 04 N 69.55N
99221 04 N 33.90N
99222 04 N 51.40N
99223 04 N 69.00N
99231 04 N 16.40N
99232 04 N 24.90N
99233 04 N 35.05N
99234 04 N 69.55N
99235 04 N 76.65N
99236 04 N 94.20N
99238 04 N 29.65N
99239 04 N 39.05N
99241 04 N 32.15N
99242 04 N 40.20N
99243 04 N 51.30N
99244 04 N 71.40N
99245 04 N 92.80N
99251 04 N 32.15N
99252 04 N 33.95N
Wednesday, June 18, 2008 Page 403 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99253 04 N 46.45N
99254 04 N 66.40N
99255 04 N 87.10N
99281 04 N 14.35N
99282 04 N 24.20N
99283 04 N 32.20N
99284 04 N 44.00N
99285 04 N 69.25N
99288 09 NY
99289 04 IY
99290 04 IY
99291 04 N 84.90N
99292 04 N 42.35N
99293 04 N 497.21N
99294 04 N 245.39N
99295 04 N 416.90N
99296 04 N 206.90N
99298 04 N 86.56N
99299 04 N 81.22N
99300 04 N 75.88N
99304 04 N 27.55N
Wednesday, June 18, 2008 Page 404 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99305 04 N 36.10N
99306 04 N 47.70N
99307 04 N 14.80N
99308 04 N 18.91N
99309 04 N 23.40N
99310 04 N 32.05N
99315 04 N 26.55N
99316 04 N 34.00N
99318 04 N 23.10N
99324 04 N 18.60N
99325 04 N 26.70N
99326 04 N 34.85N
99327 04 N 42.95N
99328 04 N 51.05N
99334 04 N 16.00N
99335 04 N 21.00N
99336 04 N 26.05N
99337 04 N 31.05N
99341 04 N 27.95N
99342 04 N 37.40N
99343 04 N 54.90N
Wednesday, June 18, 2008 Page 405 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99344 04 N 70.55N
99345 04 N 85.55N
99347 04 N 24.25N
99348 04 N 31.30N
99349 04 N 47.50N
99350 04 N 68.85N
99354 04 IY
99355 04 IY
99356 04 IY
99357 04 IY
99358 09 IY
99359 09 IY
99360 09 IY
99374 09 NY
99377 09 NY
99379 09 NY
99380 09 NY
99381 04 N 32.15 1 32.15N
99382 04 N 32.15 1 32.15N
99383 04 N 32.15 1 32.15N
99384 04 N 32.15 1 32.15N
Wednesday, June 18, 2008 Page 406 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99385 04 N 32.15 1 32.15N
99386 09 NY
99387 09 NY
99391 04 N 32.15 1 32.15N
99392 04 N 32.15 1 32.15N
99393 04 N 32.15 1 32.15N
99394 04 N 32.15 1 32.15N
99395 04 N 32.15 1 32.15N
99396 09 NY
99397 09 NY
99420 04 N 15.45 1 15.45N
99431 04 N 38.75N
99432 09 NY
99433 04 9/1/2007 N 16.40N
99435 04 N 42.55N
99436 04 N 83.70N
99440 04 N 94.50N
99450 09 NY
99455 09 NY
99456 09 NY
99477 04 1/1/2008 N 189.20N
Wednesday, June 18, 2008 Page 407 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
99499 04 NY
99500 04 NY
99501 04 NY
99502 04 NY
99503 04 NY
99504 04 NY
99505 04 NY
99506 04 NY
99507 04 NY
99509 04 NY
99510 04 N 24.25N
99511 04 NY
99512 04 NY
99600 04 NY
99999 04 NY
A4206 04 N 0.13 5 0.65N
A4207 04 N 0.05 5 0.25N
A4208 04 N 0.27 5 1.35N
A4209 04 N 0.26 5 1.30N
A4212 04 N 2.53 1 2.53N
A4213 04 N 0.32 5 1.60N
Wednesday, June 18, 2008 Page 408 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
A4215 04 N 0.05 5 0.25N
A4261 04 N 61.17N
A4267 04 N 0.45 30 13.62N
A4268 04 N 1.12 30 33.82N
A4269 04 Y NY
A9502 09 NY
A9503 09 NY
A9507 09 NY
A9526 09 NY
A9527 04 1/1/2007 NY
A9528 09 NY
A9529 09 NY
A9530 09 NY
A9531 09 NY
A9532 09 NY
A9543 04 Y NY
A9545 04 Y NY
A9563 04 NY
A9564 04 NY
A9605 09 NY
D1203 04 N 26.00N
Wednesday, June 18, 2008 Page 409 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
E0720 09 Y
G0008 04 N 3.70N
G0009 04 N 3.70N
G0010 04 N 3.70N
G0101 04 I 32.86N
G0102 04 I 28.35N
G0103 B 04 N 8.80 8.80 17.60N
G0104 04 IYY
G0105 04 I 214.00YN
G0108 09 NY
G0109 09 NY
G0111 09 NY
G0117 04 IY
G0118 04 IY
G0121 04 IYY
G0123 04 N 3.50N
G0124 04 N 11.45N
G0125 04 N 920.70YN
G0127 04 N 14.35N
G0128 09 NY
G0130 B 04 N 48.52 48.52 97.05N
Wednesday, June 18, 2008 Page 410 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G0141 04 N 11.45N
G0143 04 N 3.45N
G0144 04 N 3.45N
G0145 04 N 3.45N
G0147 04 N 3.45N
G0148 04 N 3.45N
G0159 04 M 449.50N
G0166 04 I 66.70N
G0168 04 I 22.55N
G0169 04 IY
G0170 04 MY
G0173 04 MY
G0175 09 NY
G0179 09 NY
G0180 09 NY
G0181 09 NY
G0182 09 NY
G0186 04 IY
G0202 B 04 N 35.95 35.95 71.90N
G0204 B 04 N 35.95 35.95 71.90N
G0206 B 04 N 19.60 19.60 39.20N
Wednesday, June 18, 2008 Page 411 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G0219 B 04 N 35.25 35.25 70.50N
G0237 04 IY
G0238 04 IY
G0239 04 IY
G0245 09 NY
G0246 09 NY
G0247 09 NY
G0248 09 NY
G0249 09 NY
G0250 09 NY
G0251 04 NY
G0252 04 N 35.25 35.25 70.50YN
G0255 04 IY
G0256 04 I 256.30N
G0257 04 I 35.75N
G0259 04 I 172.50N
G0260 04 I 31.80N
G0261 04 I 256.30N
G0265 09 NY
G0266 09 NY
G0268 04 I 21.40N
Wednesday, June 18, 2008 Page 412 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G0269 04 IY
G0270 09 NY
G0271 09 NY
G0275 04 I 78.45N
G0278 04 I 78.45N
G0281 04 IY
G0282 04 IY
G0283 04 IY
G0288 B 04 IY
G0289 04 MY
G0290 04 MYY
G0291 04 N MYY
G0293 09 MY
G0294 09 IY
G0295 09 IY
G0297 04 M 256.00YN
G0300 04 M 470.00YN
G0306 A 04 N 2.69 2.69 5.39N
G0307 A 04 N 3.21 3.21 6.42N
G0328 A 04 N 6.66 6.66 13.33N
G0329 04 I 9.05N
Wednesday, June 18, 2008 Page 413 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G0339 B 04 NYY
G0340 B 04 NYY
G0365 A 04 I 25.03 25.02 50.05YN
G0377 04 1/1/2007 N 9.81N
G0380 04 1/1/2007 N 14.35N
G0381 04 1/1/2007 N 24.20N
G0382 04 1/1/2007 N 32.20N
G0383 04 1/1/2007 N 44.00N
G0384 04 1/1/2007 N 69.25N
G0392 04 1/1/2007 M 479.00YN
G0393 04 1/1/2007 M 479.00YN
G0394 04 1/1/2007 N 2.72N
G3001 04 Y NY
G9001 09 NY
G9002 09 NY
G9003 09 NY
G9004 09 NY
G9005 09 NY
G9006 09 NY
G9007 09 NY
G9008 04 NY
Wednesday, June 18, 2008 Page 414 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G9009 09 NY
G9010 09 NY
G9011 09 NY
G9012 09 NY
G9016 09 NY
G9021 09 NY
G9022 09 NY
G9023 09 NY
G9024 09 NY
G9025 09 NY
G9026 09 NY
G9027 09 NY
G9028 09 NY
G9029 09 NY
G9030 09 NY
G9031 09 NY
G9032 09 NY
G9033 09 Y NY
G9034 09 NY
G9050 09 NY
G9051 09 NY
Wednesday, June 18, 2008 Page 415 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G9052 09 NY
G9053 09 NY
G9054 09 NY
G9055 09 NY
G9056 09 NY
G9057 09 NY
G9058 09 NY
G9059 09 NY
G9060 09 NY
G9061 09 NY
G9062 09 NY
G9063 09 NY
G9064 09 NY
G9065 09 NY
G9066 09 NY
G9067 09 NY
G9068 09 NY
G9069 09 NY
G9070 09 NY
G9071 09 NY
G9072 09 NY
Wednesday, June 18, 2008 Page 416 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G9073 09 NY
G9074 09 NY
G9075 09 NY
G9077 09 NY
G9078 09 NY
G9079 09 NY
G9080 09 NY
G9083 09 NY
G9084 09 NY
G9085 09 NY
G9086 09 NY
G9087 09 NY
G9088 09 NY
G9089 09 NY
G9090 09 NY
G9091 09 NY
G9092 09 NY
G9093 09 NY
G9094 09 NY
G9095 09 NY
G9096 09 NY
Wednesday, June 18, 2008 Page 417 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G9097 09 NY
G9098 09 NY
G9099 09 NY
G9100 09 NY
G9101 09 NY
G9102 09 NY
G9103 09 NY
G9104 09 NY
G9105 09 NY
G9106 09 NY
G9107 09 NY
G9108 09 NY
G9109 09 NY
G9110 09 NY
G9111 09 NY
G9112 09 NY
G9113 09 NY
G9114 09 NY
G9115 09 NY
G9116 09 NY
G9117 09 NY
Wednesday, June 18, 2008 Page 418 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
G9123 09 NY
G9124 09 NY
G9125 09 NY
G9126 09 NY
G9128 09 NY
G9129 09 NY
G9130 09 NY
H0033 04 N 118.10 1 118.10N
H1000 04 N 14.60N
J0120 04 Y N 5.49 1 5.49N
J0128 04 Y N 80.66 10 806.60N
J0129 04 1/1/2007 Y NY
J0132 04 Y N 0.32 2 0.64N
J0133 04 Y N 0.14 10 1.40N
J0135 04 Y N 862.86 8 6902.88N
J0150 04 Y 39.55 5 197.75N
J0152 04 Y N 87.14 3 261.42N
J0170 04 Y N 0.14 24 3.36N
J0180 04 Y N 149.52 14 2093.28N
J0190 04 Y NY
J0200 04 Y NY
Wednesday, June 18, 2008 Page 419 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J0205 04 Y N 44.74 8 357.92N
J0207 04 Y N 540.07 2 1080.14N
J0210 04 N 0.83 16 13.28N
J0215 K 04 Y NY
J0220 04 1/1/2008 YY
J0256 04 Y N 2.94 600 1764.00N
J0278 04 Y N 1.37 3 4.11N
J0280 04 N 0.67 6 4.02N
J0282 04 Y N 0.77 5 3.85N
J0285 04 Y N 17.36 6 104.16N
J0287 04 Y N 23.92 50 1196.00N
J0288 04 Y N 15.94 40 637.60N
J0289 04 Y N 39.12 50 1956.00N
J0290 04 Y N 3.39 4 13.56N
J0295 04 Y N 9.39 8 75.12N
J0300 04 NY
J0348 04 1/1/2007 Y NY
J0350 04 Y NY
J0360 04 Y N 15.92 12 191.04N
J0364 04 1/1/2007 Y NY
J0365 04 Y N 2.82 1 2.82N
Wednesday, June 18, 2008 Page 420 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J0370 04 Y N 1.85N
J0380 04 N 13.31 10 133.10N
J0390 04 Y N 3.50N
J0395 04 Y N 191.39 1 191.39N
J0400 04 1/1/2008 Y 2.61 120 313.20N
J0456 04 Y N 30.58 1 30.58N
J0460 04 N 0.61 10 6.10N
J0470 04 N 28.55 5 142.75N
J0475 04 Y N 257.19 12 3086.28N
J0476 04 Y N 83.73 1 83.73N
J0480 04 Y N 1,765.65 1 1765.65N
J0500 04 N 17.81 4 71.24N
J0515 04 Y N 4.10 8 32.80N
J0520 04 Y N 5.42 2 10.84N
J0530 04 Y N 4.05 4 16.20N
J0540 04 Y N 8.10 2 16.20N
J0550 04 Y N 16.20 1 16.20N
J0560 04 Y N 16.36 4 65.44N
J0570 04 Y N 33.25 2 66.50N
J0580 04 Y N 53.78 1 53.78N
J0583 04 Y N 1.81 10 18.10N
Wednesday, June 18, 2008 Page 421 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J0585 K 04 Y NY
J0587 09 N NY
J0592 04 Y N 1.24 6 7.44N
J0594 04 1/1/2007 Y NY
J0595 04 Y N 3.17 2 6.34N
J0600 04 Y N 48.14 2 96.28N
J0610 04 N 0.55 10 5.50N
J0620 04 Y N 12.49 6 74.94N
J0630 04 Y N 45.30 2 90.60N
J0636 04 Y N 1.11 40 44.40N
J0637 04 Y N 41.05 14 574.70N
J0640 04 Y N 3.73 30 111.90N
J0690 04 Y N 1.83 4 7.32N
J0692 04 Y N 9.49 8 75.92N
J0694 04 Y N 9.54 12 114.48N
J0695 04 YY
J0696 04 Y N 16.42 16 262.72N
J0697 04 Y N 5.43 4 21.72N
J0698 04 Y N 8.49 10 84.90N
J0702 04 Y N 3.02 4 12.08N
J0704 04 Y N 4.03 3 12.09N
Wednesday, June 18, 2008 Page 422 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J0706 04 Y N 4.05 4 16.20N
J0710 04 Y N 1.63 2 3.26N
J0713 04 Y N 7.08 12 84.96N
J0715 04 Y N 5.90 12 70.80N
J0720 04 Y N 6.71 7 46.97N
J0725 04 Y NY
J0735 04 Y N 74.44 2 148.88N
J0740 04 Y N 885.21 2 1770.42N
J0743 04 Y N 18.88 6 113.28N
J0744 04 Y N 15.55 5 77.75N
J0745 04 Y N 0.55 12 6.60N
J0760 04 Y N 7.72 2 15.44N
J0770 04 Y N 29.73 4 118.92N
J0780 04 Y N 7.90 10 79.00N
J0785 04 NY
J0795 04 Y N 5.15 10 51.50N
J0800 04 N 129.26 2 258.52N
J0835 04 Y N 88.55 1 88.55N
J0878 04 Y N 0.35 500 175.00N
J0881 04 Y N 5.54 500 2770.00N
J0882 04 Y N 5.54 500 2770.00N
Wednesday, June 18, 2008 Page 423 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J0885 04 Y N 15.16 80 1212.80N
J0886 04 Y N 15.16 80 1212.80N
J0894 04 1/1/2007 Y NY
J0895 04 Y N 15.36 6 92.16N
J0900 04 NY
J0945 04 Y N 0.77 10 7.70N
J0950 04 Y N 8.10N
J0970 04 Y N 34.14 1 34.14N
J1000 04 Y N 6.35 1 6.35N
J1015 04 Y N 18.63N
J1020 04 Y N 2.20 8 17.60N
J1030 04 Y N 4.93 4 19.72N
J1040 04 Y N 9.87 4 39.48N
J1051 04 Y N 20.56 9 185.04N
J1055 04 Y N 61.69 1 61.69N
J1056 04 Y N 26.90 1 26.90N
J1060 04 Y NY
J1070 04 Y N 6.18 3 18.54N
J1080 04 Y N 11.80 2 23.60N
J1094 04 Y N 0.86 32 27.52N
J1100 04 Y N 0.10 40 4.00N
Wednesday, June 18, 2008 Page 424 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1110 04 N 50.87 3 152.61N
J1120 04 N 22.42 2 44.84N
J1160 04 Y N 2.53 3 7.59N
J1162 04 Y N 755.86 80 60648.80N
J1165 04 Y N 0.40 20 8.00N
J1170 04 Y N 1.78 2 3.56N
J1180 04 NY
J1190 04 Y N 255.72 4 1022.88N
J1200 04 Y N 0.79 2 1.58N
J1205 04 Y N 10.99 1 10.99N
J1212 04 N 50.97 1 50.97N
J1230 04 N 3.62 6 21.72N
J1240 04 N 0.27 8 2.16N
J1245 04 Y N 5.09 6 30.54N
J1250 04 Y N 3.99 1 3.99N
J1260 04 Y N 4.85 20 97.00N
J1265 04 Y N 0.06 7 0.42N
J1270 04 Y N 6.00 4 24.00N
J1300 04 1/1/2008 Y 207.34 90 18660.60N
J1320 04 N 2.62 15 39.30N
J1324 04 1/1/2007 Y NY
Wednesday, June 18, 2008 Page 425 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1325 04 Y N 22.18 3 66.54N
J1327 04 Y N 24.32 5 121.60N
J1330 04 NY
J1335 04 Y N 23.76 2 47.52N
J1364 04 Y NY
J1380 04 Y N 0.55 4 2.20N
J1390 04 Y N 1.12 2 2.24N
J1405 04 Y N 10.00N
J1410 04 Y N 68.03 4 272.12N
J1430 04 Y N 41.74 1 41.74N
J1435 04 Y N 0.19 5 0.95N
J1436 04 Y NY
J1438 04 Y N 186.86 4 747.44N
J1440 04 Y N 197.17 2 394.34N
J1441 04 Y N 363.48 1 363.48N
J1450 04 Y N 103.11 2 206.22N
J1451 04 Y N 13.79 1 13.79N
J1452 04 Y NY
J1455 04 Y N 88.16 2 176.32N
J1457 04 Y NY
J1458 04 1/1/2007 Y NY
Wednesday, June 18, 2008 Page 426 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1460 04 Y N 14.21 156 2216.76N
J1470 04 Y NY
J1480 04 Y NY
J1490 04 Y NY
J1500 04 Y NY
J1510 04 Y NY
J1520 04 Y NY
J1530 04 Y NY
J1540 04 Y NY
J1550 04 Y NY
J1560 04 Y NY
J1561 04 1/1/2008 Y NY
J1562 04 1/1/2007 Y NY
J1565 04 Y N 19.00 4 76.00N
J1566 04 Y NY
J1567 04 Y NY
J1568 04 1/1/2008 Y NY
J1569 04 1/1/2008 Y NY
J1571 04 1/1/2008 Y NY
J1572 04 1/1/2008 Y NY
J1573 04 1/1/2008 Y NY
Wednesday, June 18, 2008 Page 427 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1580 04 Y N 0.70 5 3.50N
J1590 04 Y NY
J1595 04 Y NY
J1600 04 N 10.80 1 10.80N
J1626 04 Y N 19.45 20 389.00N
J1630 04 N 2.37 40 94.80N
J1631 04 Y N 23.86 6 143.16N
J1640 04 Y N 7.65 1 7.65N
J1642 04 Y N 0.03 5 0.15N
J1644 04 Y N 1.18 10 11.80N
J1645 04 Y NY
J1650 04 Y N 7.40 84 621.60N
J1652 04 Y N 43.36 20 867.20N
J1655 04 Y N 4.51 20 90.20N
J1670 04 N 107.66 1 107.66N
J1675 04 Y NY
J1700 04 Y NY
J1710 04 Y N 5.83 5 29.15N
J1720 04 Y N 2.26 10 22.60N
J1730 04 NY
J1740 04 1/1/2007 Y N 167.69 3 503.07N
Wednesday, June 18, 2008 Page 428 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1742 04 Y N 302.88 1 302.88N
J1743 04 1/1/2008 Y NY
J1745 04 Y N 68.94 100 6894.00N
J1751 04 Y N 16.00 40 640.00N
J1752 04 Y N 16.00 2 32.00N
J1756 04 Y N 0.67 100 67.00N
J1785 04 Y N 4.61 400 1844.00N
J1790 04 Y N 4.23 1 4.23N
J1800 04 Y N 8.22 3 24.66N
J1810 04 Y NY
J1815 04 Y N 0.23 20 4.60N
J1817 04 Y N 2.17 2 4.34N
J1825 04 Y NY
J1835 04 Y N 44.31 8 354.48N
J1840 04 N 2.93 3 8.79N
J1850 04 N 0.43 14 6.02N
J1885 04 Y N 1.05 8 8.40N
J1931 04 Y NY
J1940 04 Y N 0.45 10 4.50N
J1945 04 Y N 179.93 1 179.93N
J1950 04 Y N 591.46 2 1182.92N
Wednesday, June 18, 2008 Page 429 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J1955 04 Y NY
J1956 04 Y N 22.65 2 45.30N
J1960 04 Y N 3.94 2 7.88N
J1980 04 N 10.99 8 87.92N
J1990 04 Y N 26.22 3 78.66N
J2001 04 Y N 0.06 20 1.20N
J2010 04 Y N 3.52 4 14.08N
J2020 04 Y N 42.60 6 255.60N
J2060 04 Y N 1.18 4 4.72N
J2150 04 Y N 1.01 8 8.08N
J2175 04 Y N 0.87 6 5.22N
J2180 04 Y NY
J2185 04 Y N 6.15 10 61.50N
J2210 04 NY
J2248 04 1/1/2007 Y N 2.32 150 348.00N
J2250 04 Y N 0.62 10 6.20N
J2260 04 Y N 35.45 1 35.45N
J2270 04 Y N 0.78 10 7.80N
J2271 04 Y N 1.81 3 5.43N
J2275 04 Y N 2.49 10 24.90N
J2278 04 Y N 7.58 50 379.00N
Wednesday, June 18, 2008 Page 430 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J2280 04 Y NY
J2300 04 Y N 0.66 16 10.56N
J2310 04 N NY
J2315 04 1/1/2007 Y NY
J2320 04 N 4.02 4 16.08N
J2321 04 N 8.04 2 16.08N
J2322 04 N 16.94 1 16.94N
J2323 04 1/1/2008 Y NY
J2325 04 Y N 31.68 5 158.40N
J2353 04 Y NY
J2354 04 Y NY
J2355 04 Y N 305.04 1 305.04N
J2357 04 Y NY
J2360 04 N 20.43 1 20.43N
J2370 04 N 2.65 1 2.65N
J2400 04 Y NY
J2405 04 Y N 6.38 40 255.20N
J2410 04 Y N 3.23 10 32.30N
J2425 04 Y NY
J2430 04 Y N 237.76 3 713.28N
J2440 04 N 2.96 3 8.88N
Wednesday, June 18, 2008 Page 431 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J2460 04 Y N 0.71 10 7.10N
J2469 04 Y N 35.64 10 356.40N
J2501 04 Y N 5.82 20 116.40N
J2503 04 Y NY
J2504 04 Y N 195.38 1 195.38N
J2505 04 Y N 3243.53 1 3243.53N
J2510 04 Y N 10.86 1 10.86N
J2513 04 N 76.09 1 76.09N
J2515 04 N 5.24 4 20.96N
J2540 04 Y N 2.92 1 2.92N
J2543 04 Y N 12.38 12 148.56N
J2545 04 Y N 40.10 1 40.10N
J2550 04 Y N 0.48 1 0.48N
J2560 04 N 1.85 5 9.25N
J2590 04 NY
J2597 04 Y N 3.61 4 14.44N
J2650 04 NY
J2670 04 NY
J2675 04 Y N 3.28 3 9.84N
J2680 04 Y N 21.30 4 85.20N
J2690 04 Y N 2.96 1 2.96N
Wednesday, June 18, 2008 Page 432 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J2700 04 Y N 1.26 20 25.20N
J2710 04 Y N 1.56 8 12.48N
J2720 04 Y N 0.79 5 3.95N
J2724 04 1/1/2008 Y NY
J2730 04 Y N 108.03 3 324.09N
J2760 04 NY
J2765 04 Y N 0.40 14 5.60N
J2770 04 N N 110.30 4 441.20N
J2778 04 1/1/2008 Y NY
J2780 04 Y N 1.50 2 3.00N
J2783 04 Y N 133.87 3 401.61N
J2788 04 Y N 33.03 6 198.18N
J2790 04 Y N 99.92 1 99.92N
J2791 04 1/1/2008 Y NY
J2792 04 Y N 23.58 340 8017.20N
J2794 04 Y NY
J2795 04 N N 0.36 2 0.72N
J2800 04 N 15.49 3 46.47N
J2810 04 Y NY
J2820 04 Y NY
J2910 04 Y N 16.70 1 16.70N
Wednesday, June 18, 2008 Page 433 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J2916 04 Y N 8.56 10 85.60N
J2920 04 Y N 1.73 3 5.19N
J2930 04 Y N 2.88 4 11.52N
J2940 04 Y N 52.69 2 105.38N
J2941 04 Y N 35.68 20 713.60N
J2993 04 N N 1,503.32 2 3006.64N
J2994 04 Y NY
J2995 04 Y NY
J2996 04 Y N 280.60N
J2997 04 Y N 40.41 4 161.64N
J3000 04 Y N 9.06 2 18.12N
J3010 04 Y N 0.29 20 5.80N
J3030 04 Y N 65.71 1 65.71N
J3070 04 N 2.49 12 29.88N
J3100 04 Y N 2,908.32 1 2908.32N
J3105 04 Y N 19.09 3 57.27N
J3110 04 Y NY
J3120 04 N 8.46 4 33.84N
J3130 04 N 16.93 2 33.86N
J3140 04 Y N 0.41 4 1.64N
J3150 04 N 0.83 4 3.32N
Wednesday, June 18, 2008 Page 434 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J3230 04 Y N 12.86 8 102.88N
J3240 04 Y N 822.41 1 822.41N
J3243 04 1/1/2007 NY
J3246 04 Y N 105.80 1 105.80N
J3250 04 Y N 5.46 4 21.84N
J3260 04 Y N 7.73 5 38.65N
J3265 04 Y N 2.03 10 20.30N
J3280 04 Y NY
J3285 04 Y N 64.79 2 129.58N
J3301 04 N N 1.78 8 14.24N
J3302 04 Y N 0.54 32 17.28N
J3305 04 Y N 175.99 5 879.95N
J3310 04 Y N 1.75N
J3315 04 Y N 604.34 3 1813.02N
J3320 04 Y N 35.36 1 35.36N
J3350 04 NY
J3360 04 Y N 0.14 6 0.84N
J3364 04 Y N 56.42 2 112.84N
J3365 04 Y N 538.08 2 1076.16N
J3370 04 Y N 3.34 4 13.36N
J3396 04 Y N 11.20 150 1680.00N
Wednesday, June 18, 2008 Page 435 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J3400 04 Y N 3.80N
J3410 04 Y N 0.27 4 1.08N
J3411 04 Y N 0.84 2 1.68N
J3415 04 Y N 0.61 5 3.05N
J3420 04 Y N 0.18 1 0.18N
J3430 04 Y N 0.19 25 4.87N
J3465 04 Y N 5.72 60 343.20N
J3470 04 N 24.92 1 24.92N
J3471 04 Y N 0.13 999 129.87N
J3472 04 Y N 0.13 1,000 130.00N
J3473 04 1/1/2007 Y NY
J3475 04 Y N 0.07 20 1.40N
J3480 04 Y N 0.13 20 2.60N
J3485 04 Y N 1.21 50 60.50N
J3486 04 Y N 23.84 4 95.36N
J3487 04 Y N 237.65 4 950.60N
J3488 04 1/1/2008 Y NY
J3490 04 Y NY
J3520 04 Y N 1.40 20 28.00N
J3530 04 NY
J3590 04 Y NY
Wednesday, June 18, 2008 Page 436 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7030 04 Y N 1.30 2 2.60N
J7040 04 Y N 1.17 2 2.34N
J7042 04 Y N 1.52 2 3.04N
J7050 04 Y N 3.64 2 7.28N
J7060 04 Y N 4.24 2 8.48N
J7070 04 Y N 1.43 2 2.86N
J7100 04 NY
J7110 04 NY
J7120 04 Y N 1.61 2 3.22N
J7130 04 NY
J7187 04 1/1/2007 Y NY
J7189 04 Y N 1.15 1,000 1150.00N
J7190 04 Y N 0.75 1250 937.50N
J7191 04 Y N 2.18 550 1199.00N
J7192 04 Y N 0.67 2000 1340.00N
J7193 04 Y N 0.91 812 738.92N
J7194 04 Y N 0.47 1000 470.00N
J7195 04 Y N 1.03 1000 1030.00N
J7198 04 Y N 1.15 615 707.25N
J7199 04 Y NY
J7300 04 Y N 423.10N
Wednesday, June 18, 2008 Page 437 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7302 04 Y N 470.39 1 470.39N
J7303 04 Y N 43.80 3 131.40N
J7304 04 Y N 15.67 9 141.03N
J7306 04 Y NY
J7307 04 1/1/2008 Y N 651.69 1 651.69N
J7308 04 Y N 105.91 1 105.91N
J7310 04 Y N 4,984.32 1 4984.32N
J7311 04 1/1/2007 Y NY
J7318 04 N 4.92 25 123.00N
J7319 ^ 04 Y NY
J7321 04 1/1/2008 Y NY
J7322 04 1/1/2008 Y NY
J7323 04 1/1/2008 Y NY
J7324 04 1/1/2008 Y NY
J7330 04 NY
J7340 04 MY
J7341 04 NY
J7342 04 Y NY
J7343 04 NY
J7344 04 NY
J7346 04 1/1/2007 Y NY
Wednesday, June 18, 2008 Page 438 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7347 04 1/1/2008 NY
J7348 04 1/1/2008 NY
J7349 04 1/1/2008 NY
J7500 09 N NY
J7501 04 N N 72.21 5 361.05N
J7502 04 Y N 6.70 15 100.50N
J7504 04 Y N 359.26 12 4311.12N
J7505 04 Y N 980.75 1 980.75N
J7506 04 Y N 0.02 20 0.40N
J7507 04 Y N 4.12 20 82.40N
J7509 04 Y N 0.31 12 3.72N
J7510 04 Y N 0.11 40 4.40N
J7511 04 N N 429.89 1 429.89N
J7513 04 Y N 512.28 4 2049.12N
J7515 04 Y N 1.67 20 33.40N
J7516 04 Y N 24.77 3 74.31N
J7517 04 Y N 3.21 8 25.68N
J7518 04 Y NY
J7520 04 Y N 8.31 6 49.86N
J7525 04 Y N 164.48 1 164.48N
J7599 04 Y NY
Wednesday, June 18, 2008 Page 439 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7602 04 1/1/2008 Y NY
J7603 04 1/1/2008 Y NY
J7604 04 1/1/2008 Y N 5.53 1 5.53N
J7605 04 1/1/2008 Y N 5.73 1 5.73N
J7607 04 1/1/2007 Y NY
J7608 04 Y N 3.28 4 13.12N
J7609 04 1/1/2007 Y NY
J7610 04 1/1/2007 Y NY
J7611 04 4/1/2008 Y 0.03 5 0.15N
J7612 04 4/1/2008 Y 1.15 5 5.75N
J7613 04 4/1/2008 Y 0.06 5 0.15N
J7614 04 4/1/2008 Y 2.11 5 10.55N
J7615 04 1/1/2007 Y NY
J7620 04 Y NY
J7625 04 Y N 1.10N
J7626 04 Y N 4.91 4 19.64N
J7627 04 Y N 0.09 4 0.36N
J7628 04 Y NY
J7629 04 Y NY
J7630 04 Y N 1.10N
J7631 04 Y N 0.33 2 0.66N
Wednesday, June 18, 2008 Page 440 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7632 04 1/1/2008 Y N 0.33 2 0.66N
J7633 04 Y N 5.16 2 10.32N
J7634 04 1/1/2007 Y NY
J7635 04 Y N 0.40 2 0.80N
J7636 04 Y NY
J7637 04 Y N 11.21 1 11.21N
J7638 04 Y NY
J7639 04 Y N 22.56 2 45.12N
J7640 04 Y N 1.85 5 9.25N
J7642 04 Y NY
J7644 04 Y N 0.40 5 2.00N
J7645 04 1/1/2007 Y NY
J7647 04 1/1/2007 Y NY
J7648 04 Y NY
J7649 04 Y NY
J7650 04 1/1/2007 Y NY
J7657 04 1/1/2007 Y NY
J7658 04 Y NY
J7659 04 Y NY
J7660 04 1/1/2007 Y NY
J7665 04 Y N 2.15N
Wednesday, June 18, 2008 Page 441 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J7667 04 1/1/2007 Y NY
J7668 04 Y NY
J7669 04 Y N 0.54 1 0.54N
J7670 04 1/1/2007 Y NY
J7674 04 Y N 0.47 2 0.94N
J7676 04 1/1/2008 Y NY
J7680 04 Y NY
J7681 04 Y NY
J7682 04 Y N 63.79 1 63.79N
J7683 04 Y NY
J7684 04 Y NY
J7685 04 1/1/2007 Y NY
J7699 04 Y NY
J7799 04 Y NY
J8499 04 Y NY
J8501 04 Y NY
J8510 04 Y NY
J8520 04 Y N 3.91 100 391.00N
J8521 04 Y N 13.07 200 2614.00N
J8530 04 Y N 1.91 60 114.60N
J8560 04 Y N 63.56 4 254.24N
Wednesday, June 18, 2008 Page 442 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J8565 04 Y N 70.68 1 70.68N
J8600 04 Y N 5.39 3 16.17N
J8610 04 Y N 0.36 12 4.32N
J8700 04 Y N 8.84 50 442.00N
J8999 04 Y NY
J9000 04 Y N 11.67 20 233.40N
J9001 04 Y N 459.35 10 4593.50N
J9010 04 N N 637.29 3 1911.87N
J9015 04 Y N 891.57 1 891.57N
J9017 04 Y N 39.87 15 598.05N
J9020 04 Y N 65.70 2 131.40N
J9025 04 Y N 4.93 185 912.05N
J9027 04 Y NY
J9031 04 Y N 190.89 1 190.89N
J9035 04 Y N 68.53 100 6853.00N
J9040 04 Y N 248.46 3 745.38N
J9041 04 Y N 36.12 35 1264.20N
J9045 04 Y N 28.98 20 579.60N
J9050 04 Y N 169.76 8 1358.08N
J9055 04 Y N 59.81 100 5981.00N
J9060 04 Y N 40.78 30 1223.40N
Wednesday, June 18, 2008 Page 443 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J9062 04 Y N 203.90 4 815.60N
J9065 04 Y N 47.78 10 477.80N
J9070 04 Y N 2.87 20 57.40N
J9080 04 Y N 5.74 10 57.46N
J9090 04 Y N 13.49 4 53.96N
J9091 04 Y N 28.78 2 57.56N
J9092 04 Y N 44.59 1 44.59N
J9093 04 Y N 2.87 20 57.40N
J9094 04 Y N 9.99 4 39.96N
J9095 04 Y N 13.49 4 53.96N
J9096 04 Y N 28.78 2 57.56N
J9097 04 Y N 44.59 2 89.18N
J9098 04 Y N 454.56 5 2272.80N
J9100 04 Y N 3.18 60 190.80N
J9110 04 Y N 9.01 4 36.04N
J9120 04 Y N 14.54 3 43.62N
J9130 04 Y N 11.76 10 117.60N
J9140 04 Y N 19.65 5 98.25N
J9150 04 Y N 32.68 6 196.08N
J9151 04 Y N 67.74 8 541.92N
J9160 04 Y N 1,694.66 6 10167.96N
Wednesday, June 18, 2008 Page 444 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J9165 04 Y NY
J9170 04 Y N 386.82 13 5028.66N
J9175 04 Y NY
J9178 04 Y N 29.87 100 2987.00N
J9181 04 Y N 13.38 45 602.10N
J9182 04 Y N 133.93 3 401.79N
J9185 04 Y N 292.33 1 292.33N
J9190 04 Y N 3.18 12 38.16N
J9200 04 Y N 127.44 1 127.44N
J9201 04 Y N 142.20 10 1422.00N
J9202 04 Y N 468.51 3 1405.53N
J9206 04 Y N 152.95 44 6729.80N
J9208 04 N N 134.50 5 672.50N
J9209 04 N N 35.75 25 893.75N
J9211 04 Y N 417.26 10 4172.60N
J9212 04 Y N 14.16 90 1274.40N
J9213 04 Y N 42.02 1 42.02N
J9214 04 Y N 14.16 90 1274.40N
J9215 04 Y N 8.23 20 164.60N
J9216 04 Y N 379.81 2 759.62N
J9217 04 Y N 736.43 6 4418.58N
Wednesday, June 18, 2008 Page 445 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J9218 04 Y N 154.69 12 1856.28N
J9219 04 Y N 5,666.17 1 5666.17N
J9225 04 Y N 5,500.00 1 5,500.00N
J9226 04 1/1/2008 Y N 15,400.00 1 15,400.00N
J9230 04 Y N 12.59 3 37.77N
J9245 04 Y NY
J9250 04 Y N 0.21 20 4.20N
J9260 04 Y N 2.24 600 1344.00N
J9261 04 1/1/2007 Y NY
J9263 04 Y N 10.30 400 4120.00N
J9264 04 Y N 9.91 450 4459.50N
J9265 04 Y N 146.69 15 2200.35N
J9266 04 Y N 1,894.04 5 9470.20N
J9268 04 Y N 2,354.63 1 2354.63N
J9270 04 Y N 98.41 1 98.41N
J9280 04 Y N 92.36 8 738.88N
J9290 04 Y N 369.46 2 738.92N
J9291 04 Y N 895.77 1 895.77N
J9293 04 Y N 411.65 5 2058.25N
J9300 04 Y N 2,751.34 3 8254.02N
J9303 04 1/1/2008 Y NY
Wednesday, June 18, 2008 Page 446 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
J9305 04 Y N 49.80 100 4980.00N
J9310 04 Y N 546.80 10 5468.00N
J9320 04 Y N 185.66 1 185.66N
J9340 04 Y N 104.60 3 313.80N
J9350 04 Y N 972.24 3 2916.72N
J9355 04 Y N 66.34 50 3317.00N
J9357 04 Y N 552.65 1 552.65N
J9360 04 Y N 1.01 20 20.20N
J9370 04 Y N 15.97 4 63.88N
J9375 04 Y N 31.94 1 31.94N
J9380 04 Y N 79.86 1 79.86N
J9390 04 Y N 119.14 8 953.12N
J9395 04 Y N 196.11 10 1961.10N
J9600 04 Y N 3,005.31 2 6010.62N
J9999 04 NY
M0064 02 N 10.00N
M0075 04 NY
M0076 04 NY
P3000 04 N 3.55N
P3001 04 N 11.45N
P7001 A 04 N 6.40 6.40 12.80N
Wednesday, June 18, 2008 Page 447 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
P9041 09 NY
P9043 09 NY
P9045 09 NY
P9046 09 NY
P9047 09 NY
P9048 09 NY
P9050 04 NY
P9604 04 N 2.90N
P9612 09 NY
P9615 09 NY
Q0044 02 N 7.60N
Q0081 04 IY
Q0083 04 I 19.00N
Q0084 04 I 19.00N
Q0085 04 I 19.00N
Q0111 B 04 N 2.40 2.40 4.80N
Q0112 B 04 N 2.40 2.40 4.80N
Q0113 B 04 N 2.40 2.40 4.80N
Q0114 B 04 N 2.40 2.40 4.80N
Q0163 04 Y N 0.09 2 0.18N
Q0164 04 Y N 0.44 10 4.40N
Wednesday, June 18, 2008 Page 448 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
Q0165 04 Y N 0.64 5 3.20N
Q0166 04 Y N 46.88 2 93.76N
Q0168 04 Y N 10.47 2 20.94N
Q0169 04 Y N 0.28 4 1.12N
Q0170 04 Y N 0.57 2 1.14N
Q0171 04 Y N 0.27 5 1.35N
Q0172 04 Y N 0.41 16 6.56N
Q0173 04 Y N 0.28 4 1.12N
Q0174 04 Y N 0.60 6 3.60N
Q0175 04 Y N 0.79 6 4.74N
Q0176 04 Y N 0.96 3 2.88N
Q0177 04 Y N 0.09 16 1.44N
Q0178 04 Y N 0.11 8 0.88N
Q0179 04 Y N 28.80 4 115.20N
Q0180 04 Y N 75.99 1 75.99N
Q0181 04 Y NY
Q0515 04 Y NY
Q2004 04 Y NY
Q2009 04 Y N 7.30 40 292.00N
Q2017 04 Y N 320.97 6 1925.82N
Q3014 09 NY
Wednesday, June 18, 2008 Page 449 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
Q3025 04 Y NY
Q3026 04 Y N 55.40N
Q3031 04 NY
Q4001 09 NY
Q4002 09 NY
Q4003 09 NY
Q4004 09 NY
Q4005 09 NY
Q4011 09 NY
Q4013 09 NY
Q4014 09 NY
Q4015 09 NY
Q4016 09 NY
Q4018 09 NY
Q4019 09 NY
Q4020 09 NY
Q4024 09 NY
Q4025 09 NY
Q4026 09 NY
Q4027 09 NY
Q4028 09 NY
Wednesday, June 18, 2008 Page 450 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
Q4029 09 NY
Q4031 09 NY
Q4033 09 NY
Q4035 09 NY
Q4036 09 NY
Q4037 09 NY
Q4041 09 NY
Q4044 09 NY
Q4045 09 NY
Q4046 09 NY
Q4047 09 NY
Q4048 09 NY
Q4049 09 NY
Q4050 09 NY
Q4051 09 NY
Q4080 04 Y NY
Q4081 04 1/1/2007 Y N 1.56 800 1248.00N
Q4083 04 1/1/2007 Y N 145.54 2 291.08N
Q4084 04 1/1/2007 Y N 244.63 2 489.26N
Q4085 04 1/1/2007 Y N 123.87 2 247.74N
Q4086 04 1/1/2007 N 260.53 2 521.06N
Wednesday, June 18, 2008 Page 451 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
Q4087 04 7/1/2007 Y
Q4088 04 7/1/2007 Y
Q4089 04 7/1/2007 Y
Q4090 04 7/1/2007 Y
Q4091 04 Y
Q4092 04 Y
Q4096 04 4/1/2008 Y
Q4097 04 4/1/2008 Y
Q4098 04 4/1/2008 Y
Q4099 04 4/1/2008 Y
R0070 04 N 4.10N
R0075 04 N 4.10N
R0076 09 NY
S0017 04 Y N 1.01 6 6.06N
S0021 04 Y NY
S0023 04 Y N 1.04 4 4.16N
S0028 04 Y N 1.24 2 2.48N
S0030 04 Y N 27.61 3 82.83N
S0032 04 Y N 6.58 3 19.74N
S0034 04 Y N 27.50 2 55.00N
S0039 04 Y N 5.86 12 70.32N
Wednesday, June 18, 2008 Page 452 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
S0040 04 Y N 15.64 10 156.40N
S0073 04 Y N 14.90 16 238.40N
S0074 04 Y N 7.28 12 87.36N
S0077 04 Y N 2.74 6 16.44N
S0078 04 Y N 109.50 2 219.00N
S0080 04 Y N 40.10 1 40.10N
S0081 04 Y N 2.16 12 25.92N
S0088 04 Y N 25.42 6 152.52N
S0092 04 Y N 97.36 1 97.36N
S0093 04 Y N 9.05 1 9.05N
S0142 04 Y NY
S0145 04 Y NY
S0146 04 Y NY
S0155 04 Y NY
S0162 04 N 341.92N
S0166 04 Y N 6.07 4 24.28N
S0190 04 Y N 306.10N
S0191 04 Y N 2.40N
S0195 04 N 72.27N
S0630 04 I 24.35N
S1015 04 NY
Wednesday, June 18, 2008 Page 453 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
S1016 04 NY
S2066 04 1/1/2008 MY
S2067 04 1/1/2008 MY
S2068 04 MY
S2070 04 I 198.98YN
S2075 04 MYY
S2076 04 MYY
S2077 04 MYY
S2079 04 MYY
S2080 04 M 388.70N
S2083 04 N 10.00N
S2135 04 I 90.50YN
S2225 04 I 43.80 17.00YN
S2325 04 MY
S3626 04 NY
S3628 04 4/1/2008
S4981 04 IY
S4989 04 NY
S4990 09 NY
S4993 04 Y N 1.35 91 122.85N
S9123 09 NY
Wednesday, June 18, 2008 Page 454 of 455
Hcpcs code Note ProgCov Effective Date NDC Ind SurgInd M1 (26) M2 (TC) Unit price MaxQty StateMax SurgAddonAPLHP
S9124 09 NY
S9125 09 NY
S9127 09 NY
S9460 09 NY
S9474 09 NY
S9480 04 NN
T1015 D 04 N 0.0000 1Y
T1029 04 N 41.30N
Wednesday, June 18, 2008 Page 455 of 455