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SCHEDULE B <br />First Choice Health Network <br />Physician, Nurse Practitioner and Physician Assistant <br />Fee Schedule <br />Effective January 1, 2017 <br />CONFIDENTIAL AND PROPRIETARY <br />2016 RBRVS1, 2 <br />RVU's without Geographic (GPCI) Adjustment <br />Code Series <br />Code Range <br />Conversion Factor3 <br />E&M/Medical <br />90281-91299 <br />92025-99607 <br />$47.50 <br />Surgical/Specialty <br />10021-69990 <br />$47.50 <br />Radiology <br />70010-79999 <br />$47.50 <br />Routine Vision <br />92002-92020 <br />$40.00 <br />Lab4/Path/HCPCS5 <br />80047-89398 <br />A0021 -V5364 <br />$47.50 <br />Anesthesia <br />00100-01999 <br />$51.00ASA on a four unit hour <br />Facility and Non -Facility Site of Service payment rules will apply. <br />2FCHN reserves the right to assign fair and reasonable reimbursement values to services for <br />which there is not yet a specific code available or for which the specific code does not yet have <br />an assigned relative value. These services may be billed using "99" (nonspecific) codes. In <br />such circumstances FCHN reserves the right to require specific descriptor language for payment <br />purposes be included in the billing communication as well as reserves the right to assign <br />reimbursement values to those services. <br />3Fees for most other codes without Medicare RVU's are calculated using RVU's from the 2016 <br />OPTUM "The Complete RBRVS", otherwise, a 40% default discount will apply. For newer CPT <br />codes, the RVU from the first year the CPT code was issued and the above conversion factor will <br />be used. All final fee payments will be the lessor of the fee schedule amount or 90% of billed <br />charges. <br />4Fees for Clinical Lab Codes are reimbursed at 90% of the Washington 2016 Medicare Part B <br />Clinical Lab Fee Schedule. <br />5HCPC Codes- J -Codes (excluding codes J900049999) shall be reimbursed at 115% of the <br />current Average Sale Price. J -Codes J9000 to J9999 shall be reimbursed at 135% of Average <br />Sale Price. J -Code reimbursement will be updated four times a year, on March 1st, June 1st, <br />September 1st and December 1st. All Durable Medical Equipment (DME) codes, excluding V <br />Codes, shall be reimbursed at 90% of the 2016 Medicare Part B Durable Medical Equipment Fee <br />Schedule. Vision Hardware shall be reimbursed at 80% of billed charges. Hearing Aids will be <br />reimbursed at 100% of billed charges. <br />FCHN-PRO-102013 <br />Sch B - RBRVS <br />