Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0001F 0 N N N N N 1/1/2008 12/31/2078

0005F 0 N N N N N 1/1/2008 12/31/2078

00100 0 N N N N N 1/1/2008 12/31/2078

00102 0 N N N N N 1/1/2008 12/31/2078

00103 0 N N N N N 1/1/2008 12/31/2078

00104 0 N N N N N 1/1/2008 12/31/2078

00120 0 N N N N N 1/1/2008 12/31/2078

00124 0 N N N N N 1/1/2008 12/31/2078

00126 0 N N N N N 1/1/2008 12/31/2078

0012F 0 N N N N N 1/1/2008 12/31/2078

00140 0 N N N N N 1/1/2008 12/31/2078

00142 0 N N N N N 1/1/2008 12/31/2078

00144 0 N N N N N 1/1/2008 12/31/2078

00145 0 N N N N N 1/1/2008 12/31/2078

00147 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 1 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00148 0 N N N N N 1/1/2008 12/31/2078

0014F 0 N N N N N 1/1/2008 12/31/2078

0015F 0 N N N N N 1/1/2008 12/31/2078

00160 0 N N N N N 1/1/2008 12/31/2078

00162 0 N N N N N 1/1/2008 12/31/2078

00164 0 N N N N N 1/1/2008 12/31/2078

0016T 0 Y Y Y N N 1/1/2008 12/31/2010

00170 0 N N N N N 1/1/2008 12/31/2078

00172 0 N N N N N 1/1/2008 12/31/2078

00174 0 N N N N N 1/1/2008 12/31/2078

00176 0 N N N N N 1/1/2008 12/31/2078

0017T 0 Y Y Y N N 1/1/2008 12/31/2010

00190 0 N N N N N 1/1/2008 12/31/2078

00192 0 N N N N N 1/1/2008 12/31/2078

0019T 0 N N Y N N 1/1/2008 12/31/2016

09/08/2020 Global Surgery Rules.xls Page 2 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00210 0 N N N N N 1/1/2008 12/31/2078

00211 0 N N N N N 1/1/2009 12/31/2078

00212 0 N N N N N 1/1/2008 12/31/2078

00214 0 N N N N N 1/1/2008 12/31/2078

00215 0 N N N N N 1/1/2008 12/31/2078

00216 0 N N N N N 1/1/2008 12/31/2078

00218 0 N N N N N 1/1/2008 12/31/2078

00220 0 N N N N N 1/1/2008 12/31/2078

00222 0 N N N N N 1/1/2008 12/31/2078

0026T 0 N N Y N N 1/1/2008 12/31/2008

0027T 0 N N Y N N 1/1/2008 12/31/2008

0028T 0 N N Y N N 1/1/2008 12/31/2008

0029T 0 N N Y N N 1/1/2008 12/31/2008

00300 0 N N N N N 1/1/2008 12/31/2078

0030T 0 N N Y N N 1/1/2008 12/31/2012

09/08/2020 Global Surgery Rules.xls Page 3 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0031T 0 N N Y N N 1/1/2008 12/31/2008

00320 0 N N N N N 1/1/2008 12/31/2078

00322 0 N N N N N 1/1/2008 12/31/2078

00326 0 N N N N N 1/1/2008 12/31/2078

0032T 0 N N Y N N 1/1/2008 12/31/2008

00350 0 N N N N N 1/1/2008 12/31/2078

00352 0 N N N N N 1/1/2008 12/31/2078

00400 0 N N N N N 1/1/2008 12/31/2078

00402 0 N N N N N 1/1/2008 12/31/2078

00404 0 N N N N N 1/1/2008 12/31/2078

00406 0 N N N N N 1/1/2008 12/31/2078

00410 0 N N N N N 1/1/2008 12/31/2078

0041T 0 N N Y N N 1/1/2008 12/31/2008

0042T 0 N N Y N N 1/1/2008 12/31/2078

0043T 0 N N Y N N 1/1/2008 12/31/2008

09/08/2020 Global Surgery Rules.xls Page 4 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00450 0 N N N N N 1/1/2008 12/31/2078

00452 0 N N N N N 1/1/2008 12/31/2014

00452 0 N N N N N 1/1/2016 6/30/2016

00454 0 N N N N N 1/1/2008 12/31/2078

0046T 0 N N Y N N 1/1/2008 12/31/2008

00470 0 N N N N N 1/1/2008 12/31/2078

00472 0 N N N N N 1/1/2008 12/31/2078

00474 0 N N N N N 1/1/2008 12/31/2078

0047T 0 N N Y N N 1/1/2008 12/31/2008

0048T 0 N N Y N N 1/1/2008 12/31/2012

0049T 0 N N Y N N 1/1/2008 12/31/2008

00500 0 N N N N N 1/1/2008 12/31/2078

0050T 0 N N Y N N 1/1/2008 12/31/2012

0051T 0 N N Y N N 1/1/2008 12/31/2017

00520 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 5 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00522 0 N N N N N 1/1/2008 12/31/2078

00524 0 N N N N N 1/1/2008 12/31/2078

00528 0 N N N N N 1/1/2008 12/31/2078

00529 0 N N N N N 1/1/2008 12/31/2078

0052T 0 N N Y N N 1/1/2008 12/31/2017

00530 0 N N N N N 1/1/2008 12/31/2078

00532 0 N N N N N 1/1/2008 12/31/2078

00534 0 N N N N N 1/1/2008 12/31/2078

00537 0 N N N N N 1/1/2008 12/31/2078

00539 0 N N N N N 1/1/2008 12/31/2078

0053T 0 N N Y N N 1/1/2008 12/31/2017

00540 0 N N N N N 1/1/2008 12/31/2078

00541 0 N N N N N 1/1/2008 12/31/2078

00542 0 N N N N N 1/1/2008 12/31/2078

00546 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 6 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00548 0 N N N N N 1/1/2008 12/31/2078

0054T 0 N N Y N N 1/1/2009 12/31/2078

00550 0 N N N N N 1/1/2008 12/31/2078

0055T 0 N N Y N N 1/1/2009 12/31/2078

00560 0 N N N N N 1/1/2008 12/31/2078

00561 0 N N N N N 1/1/2008 12/31/2078

00562 0 N N N N N 1/1/2008 12/31/2078

00563 0 N N N N N 1/1/2008 12/31/2078

00566 0 N N N N N 1/1/2008 12/31/2078

00567 0 N N N N N 1/1/2009 12/31/2078

00580 0 N N N N N 1/1/2008 12/31/2078

0058T 0 N N Y N N 1/1/2008 12/31/2008

0058T 0 N N Y N N 1/1/2011 12/31/2078

0059T 0 N N Y N N 1/1/2008 12/31/2008

0059T 0 N N Y N N 1/1/2011 12/31/2014

09/08/2020 Global Surgery Rules.xls Page 7 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0059T 0 N N Y N N 1/1/2016 6/30/2016

00600 0 N N N N N 1/1/2008 12/31/2078

00604 0 N N N N N 1/1/2008 12/31/2078

0060T 0 N N Y N N 1/1/2008 12/31/2008

0061T 0 N N Y N N 1/1/2008 12/31/2008

00620 0 N N N N N 1/1/2008 12/31/2078

00622 0 N N N N N 1/1/2008 12/31/2014

00622 0 N N N N N 1/1/2016 6/30/2016

00625 0 N N N N N 1/1/2008 12/31/2078

00626 0 N N N N N 1/1/2008 12/31/2078

0062T 0 N N Y N N 1/1/2008 12/31/2009

00630 0 N N N N N 1/1/2008 12/31/2078

00632 0 N N N N N 1/1/2008 12/31/2078

00634 0 N N N N N 1/1/2008 12/31/2014

00634 0 N N N N N 1/1/2016 6/30/2016

09/08/2020 Global Surgery Rules.xls Page 8 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00635 0 N N N N N 1/1/2008 12/31/2078

0063T 0 N N Y N N 1/1/2008 12/31/2009

00640 0 N N N N N 1/1/2008 12/31/2078

0064T 0 N N Y N N 1/1/2008 12/31/2009

0066T 0 N N N N N 1/1/2008 12/31/2009

0066T 26 0 N N N N N 1/1/2008 12/31/2009

0066T TC 0 N N N N N 1/1/2008 12/31/2009

00670 0 N N N N N 1/1/2008 12/31/2078

0067T 0 N Y Y N N 1/1/2008 12/31/2009

0067T 26 0 N N Y N N 1/1/2008 12/31/2009

0067T TC 0 N Y Y N N 1/1/2008 12/31/2009

0068T 0 N N Y N N 1/1/2008 12/31/2009

0069T 0 N N Y N N 1/1/2008 12/31/2009

00700 0 N N N N N 1/1/2008 12/31/2078

00702 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 9 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0070T 0 N N Y N N 1/1/2008 12/31/2009

0071T 0 N N Y N N 1/1/2008 12/31/2078

0072T 0 N N Y N N 1/1/2008 12/31/2078

00730 0 N N N N N 1/1/2008 12/31/2078

00731 0 N N N N N 1/1/2018 12/31/2078

00732 0 N N N N N 1/1/2018 12/31/2078

0073T 0 N N Y N N 1/1/2008 12/31/2014

0073T 0 N N Y N N 1/1/2016 6/30/2016

00740 0 N N N N N 1/1/2008 12/31/2017

00750 0 N N N N N 1/1/2008 12/31/2078

00752 0 N N N N N 1/1/2008 12/31/2078

00754 0 N N N N N 1/1/2008 12/31/2078

00756 0 N N N N N 1/1/2008 12/31/2078

0075T 0 N N Y N N 1/1/2008 12/31/2078

0075T 26 0 N N Y N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 10 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0075T TC 0 N N Y N N 1/1/2008 12/31/2078

0076T 0 N N Y N N 1/1/2008 12/31/2078

0076T 26 0 N N Y N N 1/1/2008 12/31/2078

0076T TC 0 N N Y N N 1/1/2008 12/31/2078

00770 0 N N N N N 1/1/2008 12/31/2078

0077T 0 N N Y N N 1/1/2008 12/31/2009

0078T 0 N N Y N N 1/1/2008 12/31/2013

00790 0 N N N N N 1/1/2008 12/31/2078

00792 0 N N N N N 1/1/2008 12/31/2078

00794 0 N N N N N 1/1/2008 12/31/2078

00796 0 N N N N N 1/1/2008 12/31/2078

00797 0 N N N N N 1/1/2008 12/31/2078

0079T 0 N N Y N N 1/1/2008 12/31/2013

00800 0 N N N N N 1/1/2008 12/31/2078

00802 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 11 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0080T 0 N N Y N N 1/1/2008 12/31/2013

00810 0 N N N N N 1/1/2008 12/31/2017

00811 0 N N N N N 1/1/2018 12/31/2078

00812 0 N N N N N 1/1/2018 12/31/2078

00813 0 N N N N N 1/1/2018 12/31/2078

0081T 0 N N Y N N 1/1/2008 12/31/2013

00820 0 N N N N N 1/1/2008 12/31/2078

00830 0 N N N N N 1/1/2008 12/31/2078

00832 0 N N N N N 1/1/2008 12/31/2078

00834 0 N N N N N 1/1/2008 12/31/2078

00836 0 N N N N N 1/1/2008 12/31/2078

00840 0 N N N N N 1/1/2008 12/31/2078

00842 0 N N N N N 1/1/2008 12/31/2078

00844 0 N N N N N 1/1/2008 12/31/2078

00846 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 12 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00848 0 N N N N N 1/1/2008 12/31/2078

0084T 0 N N Y N N 1/1/2008 12/31/2009

00851 0 N N N N N 1/1/2008 12/31/2078

0085T 0 N N Y N N 1/1/2008 12/31/2009

0085T 0 N N N N N 1/1/2010 12/31/2078

00860 0 N N N N N 1/1/2008 12/31/2078

00862 0 N N N N N 1/1/2008 12/31/2078

00864 0 N N N N N 1/1/2008 12/31/2078

00865 0 N N N N N 1/1/2008 12/31/2078

00866 0 N N N N N 1/1/2008 12/31/2078

00868 0 N N N N N 1/1/2008 12/31/2078

0086T 0 N N Y N N 1/1/2008 12/31/2009

00870 0 N N N N N 1/1/2008 12/31/2078

00872 0 N N N N N 1/1/2008 12/31/2078

00873 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 13 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0087T 0 N N Y N N 1/1/2008 12/31/2009

00880 0 N N N N N 1/1/2008 12/31/2078

00882 0 N N N N N 1/1/2008 12/31/2078

0088T 0 N N Y N N 1/1/2008 12/31/2008

0089T 0 N N Y N N 1/1/2008 12/31/2008

00902 0 N N N N N 1/1/2008 12/31/2078

00904 0 N N N N N 1/1/2008 12/31/2078

00906 0 N N N N N 1/1/2008 12/31/2078

00908 0 N N N N N 1/1/2008 12/31/2078

0090T 0 N N Y N N 1/1/2008 12/31/2008

00910 0 N N N N N 1/1/2008 12/31/2078

00912 0 N N N N N 1/1/2008 12/31/2078

00914 0 N N N N N 1/1/2008 12/31/2078

00916 0 N N N N N 1/1/2008 12/31/2078

00918 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 14 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00920 0 N N N N N 1/1/2008 12/31/2078

00921 0 N N N N N 1/1/2008 12/31/2078

00922 0 N N N N N 1/1/2008 12/31/2078

00924 0 N N N N N 1/1/2008 12/31/2078

00926 0 N N N N N 1/1/2008 12/31/2078

00928 0 N N N N N 1/1/2008 12/31/2078

0092T 0 N N Y N N 1/1/2008 12/31/2014

0092T 0 N N Y N N 1/1/2016 6/30/2016

00930 0 N N N N N 1/1/2008 12/31/2078

00932 0 N N N N N 1/1/2008 12/31/2078

00934 0 N N N N N 1/1/2008 12/31/2078

00936 0 N N N N N 1/1/2008 12/31/2078

00938 0 N N N N N 1/1/2008 12/31/2078

0093T 0 N N Y N N 1/1/2008 12/31/2008

00940 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 15 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

00942 0 N N N N N 1/1/2008 12/31/2078

00944 0 N N N N N 1/1/2008 12/31/2078

00948 0 N N N N N 1/1/2008 12/31/2078

00950 0 N N N N N 1/1/2008 12/31/2078

00952 0 N N N N N 1/1/2008 12/31/2078

0095T 0 N N Y N N 1/1/2008 12/31/2078

0096T 0 N N Y N N 1/1/2008 12/31/2008

0098T 0 N N Y N N 1/1/2008 12/31/2078

0099T 0 N N Y N N 1/1/2008 12/31/2015

0100T 0 N N Y N N 1/1/2008 12/31/2078

0101T 0 N N Y N N 1/1/2008 12/31/2078

0102T 0 N N Y N N 1/1/2008 12/31/2078

0103T 0 N N Y N N 1/1/2008 12/31/2015

0104T 0 N N Y N N 1/1/2008 12/31/2010

0105T 0 N N Y N N 1/1/2008 12/31/2010

09/08/2020 Global Surgery Rules.xls Page 16 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0106T 0 N N Y N N 1/1/2008 12/31/2078

0107T 0 N N Y N N 1/1/2008 12/31/2078

0108T 0 N N Y N N 1/1/2008 12/31/2078

0109T 0 N N Y N N 1/1/2008 12/31/2078

0110T 0 N N Y N N 1/1/2008 12/31/2078

01112 0 N N N N N 1/1/2008 12/31/2078

0111T 0 N N Y N N 1/1/2008 12/31/2015

0111T 0 N N N N N 1/1/2016 12/31/2078

01120 0 N N N N N 1/1/2008 12/31/2078

01130 0 N N N N N 1/1/2008 12/31/2078

01140 0 N N N N N 1/1/2008 12/31/2078

01150 0 N N N N N 1/1/2008 12/31/2078

01160 0 N N N N N 1/1/2008 12/31/2078

01170 0 N N N N N 1/1/2008 12/31/2078

01173 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 17 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01180 0 N N N N N 1/1/2008 12/31/2017

01190 0 N N N N N 1/1/2008 12/31/2017

01200 0 N N N N N 1/1/2008 12/31/2078

01202 0 N N N N N 1/1/2008 12/31/2078

01210 0 N N N N N 1/1/2008 12/31/2078

01212 0 N N N N N 1/1/2008 12/31/2078

01214 0 N N N N N 1/1/2008 12/31/2078

01215 0 N N N N N 1/1/2008 12/31/2078

01220 0 N N N N N 1/1/2008 12/31/2078

01230 0 N N N N N 1/1/2008 12/31/2078

01232 0 N N N N N 1/1/2008 12/31/2078

01234 0 N N N N N 1/1/2008 12/31/2078

0123T 0 N N Y N N 1/1/2008 12/31/2015

0124T 0 N N Y N N 1/1/2008 12/31/2013

01250 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 18 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01260 0 N N N N N 1/1/2008 12/31/2078

0126T 0 N N Y N N 1/1/2008 12/31/2078

01270 0 N N N N N 1/1/2008 12/31/2078

01272 0 N N N N N 1/1/2008 12/31/2078

01274 0 N N N N N 1/1/2008 12/31/2078

0130T 0 N N Y N N 1/1/2008 12/31/2010

01320 0 N N N N N 1/1/2008 12/31/2078

01340 0 N N N N N 1/1/2008 12/31/2078

01360 0 N N N N N 1/1/2008 12/31/2078

0137T 0 N N Y N N 1/1/2008 12/31/2008

01380 0 N N N N N 1/1/2008 12/31/2078

01382 0 N N N N N 1/1/2008 12/31/2078

01390 0 N N N N N 1/1/2008 12/31/2078

01392 0 N N N N N 1/1/2008 12/31/2078

01400 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 19 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01402 0 N N N N N 1/1/2008 12/31/2078

01404 0 N N N N N 1/1/2008 12/31/2078

0140T 0 N N Y N N 1/1/2008 12/31/2010

0141T 0 N N N N N 1/1/2008 12/31/2011

01420 0 N N N N N 1/1/2008 12/31/2078

0142T 0 N N N N N 1/1/2008 12/31/2011

01430 0 N N N N N 1/1/2008 12/31/2078

01432 0 N N N N N 1/1/2008 12/31/2078

0143T 0 N N N N N 1/1/2008 12/31/2011

01440 0 N N N N N 1/1/2008 12/31/2078

01442 0 N N N N N 1/1/2008 12/31/2078

01444 0 N N N N N 1/1/2008 12/31/2078

0144T 0 N N Y N N 1/1/2008 12/31/2009

0144T 26 0 N N Y N N 1/1/2008 12/31/2009

0144T TC 0 N N Y N N 1/1/2008 12/31/2009

09/08/2020 Global Surgery Rules.xls Page 20 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0145T 0 N N Y N N 1/1/2008 12/31/2009

0145T 26 0 N N Y N N 1/1/2008 12/31/2009

0145T TC 0 N N Y N N 1/1/2008 12/31/2009

01462 0 N N N N N 1/1/2008 12/31/2078

01464 0 N N N N N 1/1/2008 12/31/2078

0146T 0 N N Y N N 1/1/2008 12/31/2009

0146T 26 0 N N Y N N 1/1/2008 12/31/2009

0146T TC 0 N N Y N N 1/1/2008 12/31/2009

01470 0 N N N N N 1/1/2008 12/31/2078

01472 0 N N N N N 1/1/2008 12/31/2078

01474 0 N N N N N 1/1/2008 12/31/2078

0147T 0 N N Y N N 1/1/2008 12/31/2009

0147T 26 0 N N Y N N 1/1/2008 12/31/2009

0147T TC 0 N N Y N N 1/1/2008 12/31/2009

01480 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 21 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01482 0 N N N N N 1/1/2008 12/31/2078

01484 0 N N N N N 1/1/2008 12/31/2078

01486 0 N N N N N 1/1/2008 12/31/2078

0148T 0 N N Y N N 1/1/2008 12/31/2009

0148T 26 0 N N Y N N 1/1/2008 12/31/2009

0148T TC 0 N N Y N N 1/1/2008 12/31/2009

01490 0 N N N N N 1/1/2008 12/31/2078

0149T 0 N N Y N N 1/1/2008 12/31/2009

0149T 26 0 N N Y N N 1/1/2008 12/31/2009

0149T TC 0 N N Y N N 1/1/2008 12/31/2009

01500 0 N N N N N 1/1/2008 12/31/2078

01502 0 N N N N N 1/1/2008 12/31/2078

0150T 0 N N Y N N 1/1/2008 12/31/2009

0150T 26 0 N N Y N N 1/1/2008 12/31/2009

0150T TC 0 N N Y N N 1/1/2008 12/31/2009

09/08/2020 Global Surgery Rules.xls Page 22 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0151T 0 N N Y N N 1/1/2008 12/31/2009

0151T 26 0 N N Y N N 1/1/2008 12/31/2009

0151T TC 0 N N Y N N 1/1/2008 12/31/2009

01520 0 N N N N N 1/1/2008 12/31/2078

01522 0 N N N N N 1/1/2008 12/31/2078

0155T 0 N N Y N N 1/1/2008 12/31/2011

0156T 0 N N Y N N 1/1/2008 12/31/2011

0157T 0 N N Y N N 1/1/2008 12/31/2011

0158T 0 N N Y N N 1/1/2008 12/31/2011

0159T 0 N N Y N N 1/1/2008 12/31/2018

0159T 26 0 N N Y N N 1/1/2008 12/31/2018

0159T TC 0 N N Y N N 1/1/2008 12/31/2018

0160T 0 N N Y N N 1/1/2008 12/31/2010

01610 0 N N N N N 1/1/2008 12/31/2078

0161T 0 N N Y N N 1/1/2008 12/31/2010

09/08/2020 Global Surgery Rules.xls Page 23 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01620 0 N N N N N 1/1/2008 12/31/2078

01622 0 N N N N N 1/1/2008 12/31/2078

0162T 0 N N Y N N 1/1/2008 12/31/2008

01630 0 N N N N N 1/1/2008 12/31/2078

01632 0 N N N N N 1/1/2008 12/31/2009

01634 0 N N N N N 1/1/2008 12/31/2078

01636 0 N N N N N 1/1/2008 12/31/2078

01638 0 N N N N N 1/1/2008 12/31/2078

0163T 0 N N Y N N 1/1/2008 12/31/2078

0164T 0 N N Y N N 1/1/2008 12/31/2078

01650 0 N N N N N 1/1/2008 12/31/2078

01652 0 N N N N N 1/1/2008 12/31/2078

01654 0 N N N N N 1/1/2008 12/31/2078

01656 0 N N N N N 1/1/2008 12/31/2078

0165T 0 N N Y N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 24 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0166T 0 N N Y N N 1/1/2008 12/31/2011

01670 0 N N N N N 1/1/2008 12/31/2078

0167T 0 N N Y N N 1/1/2008 12/31/2011

01680 0 N N N N N 1/1/2008 12/31/2078

01682 0 N N N N N 1/1/2008 12/31/2017

0168T 0 N N Y N N 1/1/2008 12/31/2011

0169T 0 N N Y N N 1/1/2008 12/31/2016

0170T 0 N N Y N N 1/1/2008 12/31/2009

01710 0 N N N N N 1/1/2008 12/31/2078

01712 0 N N N N N 1/1/2008 12/31/2078

01714 0 N N N N N 1/1/2008 12/31/2078

01716 0 N N N N N 1/1/2008 12/31/2078

0171T 0 N N Y N N 1/1/2008 12/31/2016

0172T 0 N N Y N N 1/1/2008 12/31/2016

01730 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 25 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01732 0 N N N N N 1/1/2008 12/31/2078

0173T 0 N N Y N N 1/1/2008 12/31/2012

01740 0 N N N N N 1/1/2008 12/31/2078

01742 0 N N N N N 1/1/2008 12/31/2078

01744 0 N N N N N 1/1/2008 12/31/2078

0174T 0 N N Y N N 1/1/2008 12/31/2078

01756 0 N N N N N 1/1/2008 12/31/2078

01758 0 N N N N N 1/1/2008 12/31/2078

0175T 0 N N Y N N 1/1/2008 12/31/2078

01760 0 N N N N N 1/1/2008 12/31/2078

0176T 0 N N Y N N 1/1/2008 12/31/2010

01770 0 N N N N N 1/1/2008 12/31/2078

01772 0 N N N N N 1/1/2008 12/31/2078

0177T 0 N N Y N N 1/1/2008 12/31/2010

01780 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 26 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01782 0 N N N N N 1/1/2008 12/31/2078

0178T 0 N N Y N N 1/1/2008 12/31/2017

0179T 0 N N Y N N 1/1/2008 12/31/2017

0180T 0 N N Y N N 1/1/2008 12/31/2017

01810 0 N N N N N 1/1/2008 12/31/2078

0181T 0 N N Y N N 1/1/2008 12/31/2014

0181T 0 N N Y N N 1/1/2016 6/30/2016

01820 0 N N N N N 1/1/2008 12/31/2078

01829 0 N N N N N 1/1/2008 12/31/2078

0182T 0 N N Y N N 1/1/2008 12/31/2015

0182T 26 0 N N Y N N 1/1/2010 12/31/2015

0182T TC 0 N N Y N N 1/1/2010 12/31/2015

01830 0 N N N N N 1/1/2008 12/31/2078

01832 0 N N N N N 1/1/2008 12/31/2078

0183T 0 N N Y N N 1/1/2008 12/31/2013

09/08/2020 Global Surgery Rules.xls Page 27 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01840 0 N N N N N 1/1/2008 12/31/2078

01842 0 N N N N N 1/1/2008 12/31/2078

01844 0 N N N N N 1/1/2008 12/31/2078

0184T 0 N N Y N N 1/1/2008 12/31/2078

01850 0 N N N N N 1/1/2008 12/31/2078

01852 0 N N N N N 1/1/2008 12/31/2078

0185T 0 N N Y N N 1/1/2008 12/31/2013

01860 0 N N N N N 1/1/2008 12/31/2078

0186T 0 N N Y N N 1/1/2008 12/31/2013

0187T 0 N N Y N N 1/1/2008 12/31/2010

0188T 0 N N N N N 1/1/2009 12/31/2018

0189T 0 N N N N N 1/1/2009 12/31/2018

0190T 0 N N Y N N 1/1/2009 12/31/2018

01916 0 N N N N N 1/1/2008 12/31/2078

0191T 0 N N Y N N 1/1/2009 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 28 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01920 0 N N N N N 1/1/2008 12/31/2078

01922 0 N N N N N 1/1/2008 12/31/2078

01924 0 N N N N N 1/1/2008 12/31/2078

01925 0 N N N N N 1/1/2008 12/31/2078

01926 0 N N N N N 1/1/2008 12/31/2078

0192T 0 N N Y N N 1/1/2009 12/31/2013

01930 0 N N N N N 1/1/2008 12/31/2078

01931 0 N N N N N 1/1/2008 12/31/2078

01932 0 N N N N N 1/1/2008 12/31/2078

01933 0 N N N N N 1/1/2008 12/31/2078

01935 0 N N N N N 1/1/2008 12/31/2078

01936 0 N N N N N 1/1/2008 12/31/2078

0193T 0 N N Y N N 1/1/2009 12/31/2011

0194T 0 N N Y N N 1/1/2009 12/31/2009

01951 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 29 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

01952 0 N N N N N 1/1/2008 12/31/2078

01953 0 N N N N N 1/1/2008 12/31/2078

01958 0 N N N N N 1/1/2008 12/31/2078

0195T 0 N N Y N N 1/1/2009 12/31/2018

01960 0 N N N N N 1/1/2008 12/31/2078

01961 0 N N N N N 1/1/2008 12/31/2078

01962 0 N N N N N 1/1/2008 12/31/2078

01963 0 N N N N N 1/1/2008 12/31/2078

01965 0 N N N N N 1/1/2008 12/31/2078

01966 0 N N N N N 1/1/2008 12/31/2078

01967 0 N N N N N 1/1/2008 12/31/2078

01968 0 N N N N N 1/1/2008 12/31/2078

01969 0 N N N N N 1/1/2008 12/31/2078

0196T 0 N N Y N N 1/1/2009 12/31/2018

0197T 0 N N Y N N 1/1/2009 12/31/2014

09/08/2020 Global Surgery Rules.xls Page 30 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0197T 0 N N Y N N 1/1/2016 6/30/2016

0198T 0 N N Y N N 1/1/2009 12/31/2078

01990 0 N N N N N 1/1/2008 12/31/2078

01991 0 N N N N N 1/1/2008 12/31/2078

01992 0 N N N N N 1/1/2008 12/31/2078

01996 0 N N N N N 1/1/2008 12/31/2078

01999 0 N N N N N 1/1/2008 12/31/2078

0199T 0 N N Y N N 1/1/2010 12/31/2014

0199T 0 N N Y N N 1/1/2016 6/30/2016

0200T 0 Y N Y N N 1/1/2010 12/31/2078

0201T 0 N N Y N N 1/1/2010 12/31/2078

0202T 0 N N Y N N 1/1/2010 12/31/2078

0203T 0 N N Y N N 1/1/2010 12/31/2010

0203T 26 0 N N Y N N 1/1/2010 12/31/2010

0203T TC 0 N N Y N N 1/1/2010 12/31/2010

09/08/2020 Global Surgery Rules.xls Page 31 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0204T 0 N N Y N N 1/1/2010 12/31/2010

0204T 26 0 N N Y N N 1/1/2010 12/31/2010

0204T TC 0 N N Y N N 1/1/2010 12/31/2010

0205T 0 N N Y N N 1/1/2010 12/31/2019

0206T 0 N N Y N N 1/1/2010 12/31/2019

0207T 0 N N Y N N 1/1/2010 12/31/2078

0208T 0 N N Y N N 1/1/2010 12/31/2078

0209T 0 N N Y N N 1/1/2010 12/31/2078

0210T 0 N N Y N N 1/1/2010 12/31/2078

0211T 0 N N Y N N 1/1/2010 12/31/2078

0212T 0 N N Y N N 1/1/2010 12/31/2078

0213T 0 Y N Y N N 1/1/2010 12/31/2078

0214T 0 Y N Y N N 1/1/2010 12/31/2078

0215T 0 Y N Y N N 1/1/2010 12/31/2078

0216T 0 Y N Y N N 1/1/2010 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 32 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0217T 0 Y N Y N N 1/1/2010 12/31/2078

0218T 0 Y N Y N N 1/1/2010 12/31/2078

0219T 0 N N Y N N 1/1/2010 12/31/2078

0220T 0 N N Y N N 1/1/2010 12/31/2078

0221T 0 N N Y N N 1/1/2010 12/31/2078

0222T 0 N N Y N N 1/1/2010 12/31/2078

0223T 0 N N Y N N 1/1/2011 12/31/2015

0224T 0 N N Y N N 1/1/2011 12/31/2015

0225T 0 N N Y N N 1/1/2011 12/31/2015

0226T 0 N N N N N 1/1/2011 12/31/2014

0226T 0 N N Y N N 1/1/2016 6/30/2016

0227T 0 N N N N N 1/1/2011 12/31/2014

0227T 0 N N Y N N 1/1/2016 6/30/2016

0228T 0 Y N N N N 1/1/2011 12/31/2078

0229T 0 Y N N N N 1/1/2011 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 33 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0230T 0 Y N N N N 1/1/2011 12/31/2078

0231T 0 Y N N N N 1/1/2011 12/31/2078

0232T 0 N N N N N 1/1/2011 12/31/2078

0233T 0 N N Y N N 1/1/2011 12/31/2015

0234T 0 N N Y N N 1/1/2011 12/31/2078

0235T 0 N N Y N N 1/1/2011 12/31/2078

0236T 0 N N Y N N 1/1/2011 12/31/2078

0237T 0 N N Y N N 1/1/2011 12/31/2078

0238T 0 N N Y N N 1/1/2011 12/31/2078

0239T 0 N N Y N N 1/1/2011 12/31/2014

0239T 0 N N Y N N 1/1/2016 6/30/2016

0240T 0 N N Y N N 1/1/2011 12/31/2015

0240T 26 0 N N Y N N 1/1/2011 12/31/2015

0240T TC 0 N N Y N N 1/1/2011 12/31/2015

0241T 0 N N Y N N 1/1/2011 12/31/2015

09/08/2020 Global Surgery Rules.xls Page 34 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0241T 26 0 N N Y N N 1/1/2011 12/31/2015

0241T TC 0 N N Y N N 1/1/2011 12/31/2015

0242T 0 N N Y N N 1/1/2011 12/31/2012

0242T 26 0 N N Y N N 1/1/2011 12/31/2012

0242T TC 0 N N Y N N 1/1/2011 12/31/2012

0243T 0 N N Y N N 1/1/2011 12/31/2015

0243T 26 0 N N Y N N 1/1/2011 12/31/2015

0243T TC 0 N N Y N N 1/1/2011 12/31/2015

0244T 0 N N Y N N 1/1/2011 12/31/2015

0244T 26 0 N N Y N N 1/1/2011 12/31/2015

0244T TC 0 N N Y N N 1/1/2011 12/31/2015

0245T 0 Y N Y N N 1/1/2011 12/31/2014

0245T 0 N N Y N N 1/1/2016 6/30/2016

0246T 0 Y N Y N N 1/1/2011 12/31/2014

0246T 0 N N Y N N 1/1/2016 6/30/2016

09/08/2020 Global Surgery Rules.xls Page 35 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0247T 0 Y N Y N N 1/1/2011 12/31/2014

0247T 0 N N Y N N 1/1/2016 6/30/2016

0248T 0 Y N Y N N 1/1/2011 12/31/2014

0248T 0 N N Y N N 1/1/2016 6/30/2016

0249T 0 N N Y N N 1/1/2011 12/31/2019

0250T 0 N N Y N N 1/1/2011 12/31/2012

0251T 0 N N Y N N 1/1/2011 12/31/2012

0252T 0 N N Y N N 1/1/2011 12/31/2012

0253T 0 N N Y N N 1/1/2011 12/31/2078

0254T 0 N N Y N N 1/1/2011 12/31/2019

0255T 0 N N Y N N 1/1/2011 12/31/2017

0255T 26 0 N N Y N N 1/1/2011 12/31/2017

0255T TC 0 N N Y N N 1/1/2011 12/31/2017

0256T 0 N N Y N N 1/1/2011 12/31/2011

0256T 0 N N Y Y Y 1/1/2012 12/31/2012

09/08/2020 Global Surgery Rules.xls Page 36 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0257T 0 N N Y N N 1/1/2011 12/31/2011

0257T 0 N N Y Y Y 1/1/2012 12/31/2012

0258T 0 N N Y N N 1/1/2011 12/31/2011

0258T 0 N N Y Y Y 1/1/2012 12/31/2012

0259T 0 N N Y N N 1/1/2011 12/31/2011

0259T 0 N N Y Y Y 1/1/2012 12/31/2012

0260T 0 N N Y N N 1/1/2011 12/31/2013

0261T 0 N N Y N N 1/1/2011 12/31/2013

0262T 0 N N Y N N 1/1/2012 12/31/2015

0263T 0 N N Y N N 1/1/2012 12/31/2078

0264T 0 N N Y N N 1/1/2012 12/31/2078

0265T 0 N N Y N N 1/1/2012 12/31/2078

0266T 0 N N Y N N 1/1/2012 12/31/2078

0267T 0 N N Y N N 1/1/2012 12/31/2078

0268T 0 N N Y N N 1/1/2012 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 37 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0269T 0 N N Y N N 1/1/2012 12/31/2078

0270T 0 N N Y N N 1/1/2012 12/31/2078

0271T 0 N N Y N N 1/1/2012 12/31/2078

0272T 0 N N Y N N 1/1/2012 12/31/2078

0273T 0 N N Y N N 1/1/2012 12/31/2078

0274T 0 N N Y N N 1/1/2012 12/31/2078

0275T 0 N N Y N N 1/1/2012 9/30/2014

0275T 0 N N N N N 10/1/2014 12/31/2078

0276T 0 N N Y N N 1/1/2012 12/31/2012

0277T 0 N N Y N N 1/1/2012 12/31/2012

0278T 0 N N Y N N 1/1/2012 12/31/2078

0279T 0 N N Y N N 1/1/2012 12/31/2012

0280T 0 N N Y N N 1/1/2012 12/31/2012

0281T 0 N N Y N N 1/1/2012 12/31/2016

0282T 0 Y N Y N N 1/1/2012 12/31/2016

09/08/2020 Global Surgery Rules.xls Page 38 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0283T 0 Y N Y N N 1/1/2012 12/31/2016

0284T 0 N N Y N N 1/1/2012 12/31/2016

0285T 0 N N Y N N 1/1/2012 12/31/2016

0286T 0 N N Y N N 1/1/2012 12/31/2016

0287T 0 N N Y N N 1/1/2012 12/31/2016

0288T 0 N N Y N N 1/1/2012 12/31/2016

0289T 0 N N Y N N 1/1/2012 12/31/2016

0290T 0 N N Y N N 1/1/2012 12/31/2078

0291T 0 N N Y N N 1/1/2012 12/31/2016

0292T 0 N N Y N N 1/1/2012 12/31/2016

0293T 0 N N Y N N 1/1/2012 12/31/2017

0294T 0 N N Y N N 1/1/2012 12/31/2017

0295T 0 N N Y N N 1/1/2012 12/31/2078

0296T 0 N N Y N N 1/1/2012 12/31/2078

0297T 0 N N Y N N 1/1/2012 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 39 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0298T 0 N N Y N N 1/1/2012 12/31/2078

0299T 0 N N Y N N 1/1/2012 12/31/2017

0300T 0 N N Y N N 1/1/2012 12/31/2017

0301T 0 N N Y N N 1/1/2012 12/31/2017

0302T 0 N Y N N Y 7/1/2012 12/31/2017

0303T 0 N Y N N N 7/1/2012 12/31/2017

0304T 0 N Y N N N 7/1/2012 12/31/2017

0305T 0 N N Y N N 7/1/2012 12/31/2017

0306T 0 N N Y N N 7/1/2012 12/31/2017

0307T 0 N Y N N N 7/1/2012 12/31/2017

0308T 0 Y Y N N N 7/1/2012 12/31/2078

0309T 0 N N Y N N 1/1/2013 12/31/2017

0310T 0 N N Y N N 1/1/2013 12/31/2017

0311T 0 N N Y N N 1/1/2013 12/31/2015

0312T 0 N N Y N N 1/1/2013 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 40 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0313T 0 N N Y N N 1/1/2013 12/31/2078

0314T 0 N N Y N N 1/1/2013 12/31/2078

0315T 0 N N Y N N 1/1/2013 12/31/2078

0316T 0 N N Y N N 1/1/2013 12/31/2078

0317T 0 N N Y N N 1/1/2013 12/31/2078

0318T 0 N Y Y Y Y 1/1/2013 12/31/2013

0319T 0 N N Y N N 1/1/2013 12/31/2014

0319T 0 N N Y N N 1/1/2016 6/30/2016

0320T 0 N N Y N N 1/1/2013 12/31/2014

0320T 0 N N Y N N 1/1/2016 6/30/2016

0321T 0 N N Y N N 1/1/2013 12/31/2014

0321T 0 N N Y N N 1/1/2016 6/30/2016

0322T 0 N N Y N N 1/1/2013 12/31/2014

0322T 0 N N Y N N 1/1/2016 6/30/2016

0323T 0 N N Y N N 1/1/2013 12/31/2014

09/08/2020 Global Surgery Rules.xls Page 41 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0323T 0 N N Y N N 1/1/2016 6/30/2016

0324T 0 N N Y N N 1/1/2013 12/31/2014

0324T 0 N N Y N N 1/1/2016 6/30/2016

0325T 0 N N Y N N 1/1/2013 12/31/2014

0325T 0 N N Y N N 1/1/2016 6/30/2016

0326T 0 N N Y N N 1/1/2013 12/31/2014

0326T 0 N N Y N N 1/1/2016 6/30/2016

0327T 0 N N Y N N 1/1/2013 12/31/2014

0327T 0 N N Y N N 1/1/2016 6/30/2016

0328T 0 N N Y N N 1/1/2013 12/31/2014

0328T 0 N N Y N N 1/1/2016 6/30/2016

0329T 0 N N N N N 1/1/2014 12/31/2078

0330T 0 N N N N N 1/1/2014 12/31/2078

0331T 0 N N N N N 1/1/2014 12/31/2078

0332T 0 N N N N N 1/1/2014 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 42 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0333T 0 N N N N N 1/1/2014 12/31/2078

0334T 0 N N N N N 1/1/2014 12/31/2014

0334T 0 N N Y N N 1/1/2016 6/30/2016

0335T 0 N N N N N 1/1/2014 12/31/2078

0336T 0 N N N N N 1/1/2014 12/31/2016

0337T 0 N N N N N 1/1/2014 12/31/2018

0338T 0 N N N N N 1/1/2014 12/31/2078

0339T 0 N N N N N 1/1/2014 12/31/2078

0340T 0 N N N N N 1/1/2014 12/31/2017

0341T 0 N N N N N 1/1/2014 12/31/2019

0342T 0 N N N N N 1/1/2014 12/31/2078

0343T 0 N N N N N 1/1/2014 12/31/2014

0343T 0 N N Y N N 1/1/2016 6/30/2016

0344T 0 N N N N N 1/1/2014 12/31/2014

0344T 0 N N Y N N 1/1/2016 6/30/2016

09/08/2020 Global Surgery Rules.xls Page 43 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0345T 0 N N N N N 1/1/2014 12/31/2078

0346T 0 N N N N N 1/1/2014 12/31/2018

0347T 0 N N N N N 7/1/2014 12/31/2078

0348T 0 N N N N N 7/1/2014 12/31/2078

0349T 0 N N N N N 7/1/2014 12/31/2078

0350T 0 N N N N N 7/1/2014 12/31/2078

0351T 0 N N N N N 7/1/2014 12/31/2078

0352T 0 N N N N N 7/1/2014 12/31/2078

0353T 0 N N N N N 7/1/2014 12/31/2078

0354T 0 N N N N N 7/1/2014 12/31/2078

0355T 0 N N N N N 7/1/2014 12/31/2078

0356T 0 N N N N N 7/1/2014 12/31/2078

0357T 0 N N Y N N 1/1/2015 12/31/2019

0358T 0 N N N N N 7/1/2014 12/31/2078

0359T 0 N N N N N 7/1/2014 12/31/2018

09/08/2020 Global Surgery Rules.xls Page 44 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0360T 0 N N N N N 7/1/2014 12/31/2018

0361T 0 N N N N N 7/1/2014 12/31/2018

0362T 0 N N N N N 7/1/2014 12/31/2078

0363T 0 N N N N N 7/1/2014 12/31/2018

0364T 0 N N N N N 7/1/2014 12/31/2018

0365T 0 N N N N N 7/1/2014 12/31/2018

0366T 0 N N N N N 7/1/2014 12/31/2018

0367T 0 N N N N N 7/1/2014 12/31/2018

0368T 0 N N N N N 7/1/2014 12/31/2018

0369T 0 N N N N N 7/1/2014 12/31/2018

0370T 0 N N N N N 7/1/2014 12/31/2018

0371T 0 N N N N N 7/1/2014 12/31/2018

0372T 0 N N N N N 7/1/2014 12/31/2018

0373T 0 N N N N N 7/1/2014 12/31/2078

0374T 0 N N N N N 7/1/2014 12/31/2018

09/08/2020 Global Surgery Rules.xls Page 45 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0375T 0 N N Y N N 1/1/2015 12/31/2019

0376T 0 N N Y N N 1/1/2015 12/31/2078

0377T 0 N N Y N N 1/1/2015 12/31/2019

0378T 0 N N Y N N 1/1/2015 12/31/2078

0379T 0 N N Y N N 1/1/2015 12/31/2078

0380T 0 N N Y N N 1/1/2015 12/31/2019

0381T 0 N N Y N N 1/1/2015 12/31/2078

0382T 0 N N Y N N 1/1/2015 12/31/2078

0383T 0 N N Y N N 1/1/2015 12/31/2078

0384T 0 N N Y N N 1/1/2015 12/31/2078

0385T 0 N N Y N N 1/1/2015 12/31/2078

0386T 0 N N Y N N 1/1/2015 12/31/2078

0387T 0 N N Y N N 1/1/2015 12/31/2018

0388T 0 N N Y N N 1/1/2015 12/31/2018

0389T 0 N N Y N N 1/1/2015 12/31/2018

09/08/2020 Global Surgery Rules.xls Page 46 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0390T 0 N N Y N N 1/1/2015 12/31/2018

0391T 0 N N Y N N 1/1/2015 12/31/2018

0392T 0 N N Y N N 7/1/2015 12/31/2016

0393T 0 N N Y N N 7/1/2015 12/31/2016

0394T 0 N N Y N N 1/1/2016 12/31/2078

0395T 0 N N Y N N 1/1/2016 12/31/2078

0396T 0 N N Y N N 1/1/2016 12/31/2078

0397T 0 N N Y N N 1/1/2016 12/31/2078

0398T 0 N N Y N N 1/1/2016 12/31/2078

0399T 0 N N Y N N 1/1/2016 12/31/2019

0400T 0 N N Y N N 1/1/2016 12/31/2078

0401T 0 N N Y N N 1/1/2016 12/31/2078

0402T 0 N N Y N N 1/1/2016 12/31/2078

0403T 0 N N Y N N 1/1/2016 12/31/2078

0404T 0 N N Y N N 1/1/2016 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 47 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0405T 0 N N Y N N 1/1/2016 12/31/2078

0406T 0 N N Y N N 1/1/2016 12/31/2018

0407T 0 N N Y N N 1/1/2016 12/31/2018

0408T 0 N N Y N N 1/1/2016 12/31/2078

0409T 0 N N Y N N 1/1/2016 12/31/2078

0410T 0 N N Y N N 1/1/2016 12/31/2078

0411T 0 N N Y N N 1/1/2016 12/31/2078

0412T 0 N N Y N N 1/1/2016 12/31/2078

0413T 0 N N Y N N 1/1/2016 12/31/2078

0414T 0 N N Y N N 1/1/2016 12/31/2078

0415T 0 N N Y N N 1/1/2016 12/31/2078

0416T 0 N N Y N N 1/1/2016 12/31/2078

0417T 0 N N Y N N 1/1/2016 12/31/2078

0418T 0 N N Y N N 1/1/2016 12/31/2078

0419T 0 N N Y N N 1/1/2016 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 48 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0420T 0 N N Y N N 1/1/2016 12/31/2078

0421T 0 N N Y N N 1/1/2016 12/31/2078

0422T 0 N N Y N N 1/1/2016 12/31/2078

0423T 0 N N N N N 1/1/2016 12/31/2078

0424T 0 N N Y N N 1/1/2016 12/31/2078

0425T 0 N N Y N N 1/1/2016 12/31/2078

0426T 0 N N Y N N 1/1/2016 12/31/2078

0427T 0 N N Y N N 1/1/2016 12/31/2078

0428T 0 N N Y N N 1/1/2016 12/31/2078

0429T 0 N N Y N N 1/1/2016 12/31/2078

0430T 0 N N Y N N 1/1/2016 12/31/2078

0431T 0 N N Y N N 1/1/2016 12/31/2078

0432T 0 N N Y N N 1/1/2016 12/31/2078

0433T 0 N N Y N N 1/1/2016 12/31/2078

0434T 0 N N Y N N 1/1/2016 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 49 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0435T 0 N N Y N N 1/1/2016 12/31/2078

0436T 0 N N Y N N 1/1/2016 12/31/2078

0437T 0 N N Y N N 7/1/2016 12/31/2078

0438T 0 N N Y N N 7/1/2016 12/31/2017

0439T 0 N N Y N N 7/1/2016 12/31/2078

0440T 0 N N Y N N 7/1/2016 12/31/2078

0441T 0 N N Y N N 7/1/2016 12/31/2078

0442T 0 N N Y N N 7/1/2016 12/31/2078

0443T 0 N N Y N N 7/1/2016 12/31/2078

0444T 0 N N Y N N 7/1/2016 12/31/2078

0445T 0 N N Y N N 7/1/2016 12/31/2078

0446T 0 N N N N N 1/1/2017 12/31/2078

0447T 0 N N N N N 1/1/2017 12/31/2078

0448T 0 N N N N N 1/1/2017 12/31/2078

0449T 0 N N N N N 1/1/2017 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 50 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0450T 0 N N N N N 1/1/2017 12/31/2078

0451T 0 N N N N N 1/1/2017 12/31/2078

0452T 0 N N N N N 1/1/2017 12/31/2078

0453T 0 N N N N N 1/1/2017 12/31/2078

0454T 0 N N N N N 1/1/2017 12/31/2078

0455T 0 N N N N N 1/1/2017 12/31/2078

0456T 0 N N N N N 1/1/2017 12/31/2078

0457T 0 N N N N N 1/1/2017 12/31/2078

0458T 0 N N N N N 1/1/2017 12/31/2078

0459T 0 N N N N N 1/1/2017 12/31/2078

0460T 0 N N N N N 1/1/2017 12/31/2078

0461T 0 N N N N N 1/1/2017 12/31/2078

0462T 0 N N N N N 1/1/2017 12/31/2078

0463T 0 N N N N N 1/1/2017 12/31/2078

0464T 0 N N N N N 1/1/2017 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 51 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0465T 0 N N N N N 1/1/2017 12/31/2078

0466T 0 N N N N N 1/1/2017 12/31/2078

0467T 0 N N N N N 1/1/2017 12/31/2078

0468T 0 N N N N N 1/1/2017 12/31/2078

0469T 0 N N N N N 7/1/2017 12/31/2078

0470T 0 N N N N N 7/1/2017 12/31/2078

0470T 26 0 N N N N N 7/1/2017 12/31/2078

0470T TC 0 N N N N N 7/1/2017 12/31/2078

0471T 0 N N N N N 7/1/2017 12/31/2078

0471T 26 0 N N N N N 7/1/2017 12/31/2078

0471T TC 0 N N N N N 7/1/2017 12/31/2078

0472T 0 N N N N N 7/1/2017 12/31/2078

0473T 0 N N N N N 7/1/2017 12/31/2078

0474T 0 N N N N N 7/1/2017 12/31/2078

0475T 0 N N N N N 7/1/2017 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 52 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0476T 0 N N N N N 7/1/2017 12/31/2078

0477T 0 N N N N N 7/1/2017 12/31/2078

0478T 0 N N N N N 7/1/2017 12/31/2078

0479T 0 N Y N N N 1/1/2018 12/31/2078

0480T 0 N N N N N 1/1/2018 12/31/2078

0481T 0 N N N N N 1/1/2018 12/31/2078

0482T 0 N N N N N 1/1/2018 12/31/2019

0482T 26 0 N N N N N 1/1/2018 12/31/2019

0482T TC 0 N N N N N 1/1/2018 12/31/2019

0483T 0 N Y Y Y Y 1/1/2018 12/31/2078

0484T 0 N Y Y Y Y 1/1/2018 12/31/2078

0485T 0 Y N N N N 1/1/2018 12/31/2078

0485T 26 0 Y N N N N 1/1/2018 12/31/2078

0485T TC 0 Y N N N N 1/1/2018 12/31/2078

0486T 0 N N N N N 1/1/2018 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 53 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0486T 26 0 N N N N N 1/1/2018 12/31/2078

0486T TC 0 N N N N N 1/1/2018 12/31/2078

0487T 0 N N N N N 1/1/2018 12/31/2078

0488T 0 N N N N N 1/1/2018 12/31/2078

0489T 0 N N N N N 1/1/2018 12/31/2078

0490T 0 N N N N N 1/1/2018 12/31/2078

0491T 0 N N N N N 1/1/2018 12/31/2078

0492T 0 N N N N N 1/1/2018 12/31/2078

0493T 0 N N N N N 1/1/2018 12/31/2078

0494T 0 N Y Y N Y 1/1/2018 12/31/2078

0495T 0 N N N N N 1/1/2018 12/31/2078

0496T 0 N N N N N 1/1/2018 12/31/2078

0497T 0 N N N N N 1/1/2018 12/31/2078

0498T 0 N N N N N 1/1/2018 12/31/2078

0499T 0 N Y N N N 1/1/2018 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 54 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0500F 0 N N N N N 1/1/2008 12/31/2078

0500T 0 N N N N N 1/1/2018 12/31/2078

0501F 0 N N N N N 1/1/2008 12/31/2078

0501T 0 N N N N N 1/1/2018 12/31/2078

0502F 0 N N N N N 1/1/2008 12/31/2078

0502T 0 N N N N N 1/1/2018 12/31/2078

0503F 0 N N N N N 1/1/2008 12/31/2078

0503T 0 N N N N N 1/1/2018 12/31/2078

0504T 0 N N N N N 1/1/2018 12/31/2078

0505F 0 N N N N N 1/1/2008 12/31/2078

0505T 0 N N Y N N 7/1/2018 12/31/2078

0506T 0 N N Y N N 7/1/2018 12/31/2078

0506T 26 0 N N Y N N 7/1/2018 12/31/2078

0506T TC 0 N N Y N N 7/1/2018 12/31/2078

0507F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 55 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0507T 0 N N Y N N 7/1/2018 12/31/2078

0507T 26 0 N N Y N N 7/1/2018 12/31/2078

0507T TC 0 N N Y N N 7/1/2018 12/31/2078

0508T 0 N N Y N N 7/1/2018 12/31/2078

0508T 26 0 N N Y N N 7/1/2018 12/31/2078

0508T TC 0 N N Y N N 7/1/2018 12/31/2078

0509F 0 N N N N N 1/1/2008 12/31/2078

0509T 0 N N Y N N 1/1/2019 12/31/2078

0509T 26 0 N N Y N N 1/1/2019 12/31/2078

0509T TC 0 N N Y N N 1/1/2019 12/31/2078

0510T 0 Y Y N N N 1/1/2019 12/31/2078

0511T 0 Y Y N N N 1/1/2019 12/31/2078

0512T 0 N N Y N N 1/1/2019 12/31/2078

0513F 0 N N N N N 1/1/2008 12/31/2078

0513T 0 N N Y N N 1/1/2019 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 56 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0514F 0 N N N N N 1/1/2008 12/31/2078

0514T 0 N N N N N 1/1/2019 12/31/2078

0515T 0 N Y N N N 1/1/2019 12/31/2078

0516F 0 N N N N N 1/1/2008 12/31/2078

0516T 0 N Y N N N 1/1/2019 12/31/2078

0517F 0 N N N N N 1/1/2008 12/31/2078

0517T 0 N Y N N N 1/1/2019 12/31/2078

0518F 0 N N N N N 1/1/2008 12/31/2078

0518T 0 N Y N N N 1/1/2019 12/31/2078

0519F 0 N N N N N 1/1/2008 12/31/2078

0519T 0 N Y N N N 1/1/2019 12/31/2078

0520F 0 N N N N N 1/1/2008 12/31/2078

0520T 0 N Y N N N 1/1/2019 12/31/2078

0521F 0 N N N N N 1/1/2008 12/31/2078

0521T 0 N N N N N 1/1/2019 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 57 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0521T 26 0 N N N N N 1/1/2019 12/31/2078

0521T TC 0 N N N N N 1/1/2019 12/31/2078

0522T 0 N N N N N 1/1/2019 12/31/2078

0522T 26 0 N N N N N 1/1/2019 12/31/2078

0522T TC 0 N N N N N 1/1/2019 12/31/2078

0523T 0 N N Y N N 1/1/2019 12/31/2078

0524T 0 Y Y N N N 1/1/2019 12/31/2078

0525F 0 N N N N N 1/1/2009 12/31/2078

0525T 0 N Y N N N 1/1/2019 12/31/2078

0526F 0 N N N N N 1/1/2009 12/31/2078

0526T 0 N Y N N N 1/1/2019 12/31/2078

0527T 0 N Y N N N 1/1/2019 12/31/2078

0528F 0 N N N N N 1/1/2009 12/31/2078

0528T 0 N N N N N 1/1/2019 12/31/2078

0528T 26 0 N N N N N 1/1/2019 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 58 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0528T TC 0 N N N N N 1/1/2019 12/31/2078

0529F 0 N N N N N 1/1/2009 12/31/2078

0529T 0 N N N N N 1/1/2019 12/31/2078

0529T 26 0 N N N N N 1/1/2019 12/31/2078

0529T TC 0 N N N N N 1/1/2019 12/31/2078

0530T 0 N Y N N N 1/1/2019 12/31/2078

0531T 0 N Y N N N 1/1/2019 12/31/2078

0532T 0 N Y N N N 1/1/2019 12/31/2078

0533T 0 N N N N N 1/1/2019 12/31/2078

0533T 26 0 N N N N N 1/1/2019 12/31/2078

0533T TC 0 N N N N N 1/1/2019 12/31/2078

0534T 0 N N N N N 1/1/2019 12/31/2078

0534T 26 0 N N N N N 1/1/2019 12/31/2078

0534T TC 0 N N N N N 1/1/2019 12/31/2078

0535F 0 N N N N N 1/1/2009 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 59 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0535T 0 N N N N N 1/1/2019 12/31/2078

0535T 26 0 N N N N N 1/1/2019 12/31/2078

0535T TC 0 N N N N N 1/1/2019 12/31/2078

0536T 0 N N N N N 1/1/2019 12/31/2078

0536T 26 0 N N N N N 1/1/2019 12/31/2078

0536T TC 0 N N N N N 1/1/2019 12/31/2078

0537T 0 N N N N N 1/1/2019 12/31/2078

0538T 0 N N N N N 1/1/2019 12/31/2078

0539T 0 N N N N N 1/1/2019 12/31/2078

0540F 0 N N N N N 1/1/2009 12/31/2078

0540T 0 N N N N N 1/1/2019 12/31/2078

0541T 0 N N N N N 1/1/2019 12/31/2078

0542T 0 N N N N N 1/1/2019 12/31/2078

0543T 0 N N Y N N 1/1/2020 12/31/2078

0544T 0 N N Y N N 1/1/2020 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 60 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0545F 0 N N N N N 1/1/2010 12/31/2078

0545T 0 N N Y N N 1/1/2020 12/31/2078

0546T 0 N N Y N N 1/1/2020 12/31/2078

0547T 0 N N Y N N 1/1/2020 12/31/2078

0548T 0 N N Y N N 1/1/2020 12/31/2078

0549T 0 N N Y N N 1/1/2020 12/31/2078

0550F 0 N N N N N 1/1/2012 12/31/2078

0550T 0 N N Y N N 1/1/2020 12/31/2078

0551F 0 N N N N N 1/1/2012 12/31/2078

0551T 0 N N Y N N 1/1/2020 12/31/2078

0552T 0 N N Y N N 1/1/2020 12/31/2078

0553T 0 N N Y N N 1/1/2020 12/31/2078

0554T 0 N N Y N N 1/1/2020 12/31/2078

0555F 0 N N N N N 1/1/2012 12/31/2078

0555T 0 N N Y N N 1/1/2020 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 61 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0556F 0 N N N N N 1/1/2012 12/31/2078

0556T 0 N N Y N N 1/1/2020 12/31/2078

0557F 0 N N N N N 1/1/2012 12/31/2078

0557T 0 N N Y N N 1/1/2020 12/31/2078

0558T 0 N N Y N N 1/1/2020 12/31/2078

0559T 0 N N Y N N 1/1/2020 12/31/2078

0560T 0 N N Y N N 1/1/2020 12/31/2078

0561T 0 N N Y N N 1/1/2020 12/31/2078

0562T 0 N N Y N N 1/1/2020 12/31/2078

0563T 0 N N Y N N 1/1/2020 12/31/2078

0564T 0 N N Y N N 1/1/2020 12/31/2078

0565T 0 N N Y N N 1/1/2020 12/31/2078

0566T 0 N N Y N N 1/1/2020 12/31/2078

0567T 0 N N Y N N 1/1/2020 12/31/2078

0568T 0 N N Y N N 1/1/2020 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 62 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0569T 0 N N Y N N 1/1/2020 12/31/2078

0570T 0 N N Y N N 1/1/2020 12/31/2078

0571T 0 N N Y N N 1/1/2020 12/31/2078

0572T 0 N N Y N N 1/1/2020 12/31/2078

0573T 0 N N Y N N 1/1/2020 12/31/2078

0574T 0 N N Y N N 1/1/2020 12/31/2078

0575F 0 N N N N N 1/1/2009 12/31/2078

0575T 0 N N Y N N 1/1/2020 12/31/2078

0576T 0 N N Y N N 1/1/2020 12/31/2078

0577T 0 N N Y N N 1/1/2020 12/31/2078

0578T 0 N N Y N N 1/1/2020 12/31/2078

0579T 0 N N Y N N 1/1/2020 12/31/2078

0580F 0 N N N N N 1/1/2013 12/31/2078

0580T 0 N N Y N N 1/1/2020 12/31/2078

0581F 0 N N N N N 1/1/2013 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 63 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0581T 0 N N Y N N 1/1/2020 12/31/2078

0582F 0 N N N N N 1/1/2013 12/31/2078

0582T 0 N N Y N N 1/1/2020 12/31/2078

0583F 0 N N N N N 1/1/2013 12/31/2078

0583T 0 N N Y N N 1/1/2020 12/31/2078

0584F 0 N N N N N 1/1/2013 12/31/2078

0584T 0 N N Y N N 1/1/2020 12/31/2078

0585T 0 N N Y N N 1/1/2020 12/31/2078

0586T 0 N N Y N N 1/1/2020 12/31/2078

0587T 0 N N Y N N 1/1/2020 12/31/2078

0588T 0 N N Y N N 1/1/2020 12/31/2078

0589T 0 N N Y N N 1/1/2020 12/31/2078

0590T 0 N N Y N N 1/1/2020 12/31/2078

0591T 0 N N Y N N 1/1/2020 12/31/2078

0592T 0 N N Y N N 1/1/2020 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 64 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

0593T 0 N N Y N N 1/1/2020 12/31/2078

10004 0 N N Y N N 1/1/2019 12/31/2078

10005 0 N Y Y N N 1/1/2019 12/31/2078

10006 0 N N Y N N 1/1/2019 12/31/2078

10007 0 N Y Y N N 1/1/2019 12/31/2078

10008 0 N N Y N N 1/1/2019 12/31/2078

10009 0 N Y Y N N 1/1/2019 12/31/2078

1000F 0 N N N N N 1/1/2008 12/31/2078

10010 0 N N Y N N 1/1/2019 12/31/2078

10011 0 N Y Y N N 1/1/2019 12/31/2078

10012 0 N N Y N N 1/1/2019 12/31/2078

10021 0 N N Y N N 1/1/2008 12/31/2018

10021 0 N Y Y N N 1/1/2019 12/31/2078

10022 0 N N Y N N 1/1/2008 12/31/2018

1002F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 65 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

10030 0 N Y Y N N 1/1/2014 12/31/2078

10035 0 Y Y Y N N 1/1/2016 12/31/2078

10036 0 N Y Y N N 1/1/2016 6/30/2016

10036 0 N N Y N N 7/1/2016 12/31/2078

1003F 0 N N N N N 1/1/2008 12/31/2078

10040 10 N Y N N N 1/1/2008 12/31/2078

1004F 0 N N N N N 1/1/2008 12/31/2078

1005F 0 N N N N N 1/1/2008 12/31/2078

10060 10 N Y N N N 1/1/2008 12/31/2078

10061 10 N Y N N N 1/1/2008 12/31/2078

1006F 0 N N N N N 1/1/2008 12/31/2078

1007F 0 N N N N N 1/1/2008 12/31/2078

10080 10 N Y N N N 1/1/2008 12/31/2078

10081 10 N Y N N N 1/1/2008 12/31/2078

1008F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 66 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

1010F 0 N N N N N 1/1/2012 12/31/2078

1011F 0 N N N N N 1/1/2012 12/31/2078

10120 10 N Y N N N 1/1/2008 12/31/2078

10121 10 N Y N N N 1/1/2008 12/31/2078

1012F 0 N N N N N 1/1/2012 12/31/2078

10140 10 N Y N N N 1/1/2008 12/31/2078

1015F 0 N N N N N 1/1/2008 12/31/2078

10160 10 N Y N N N 1/1/2008 12/31/2078

10180 10 N Y N N N 1/1/2008 12/31/2078

1018F 0 N N N N N 1/1/2008 12/31/2078

1019F 0 N N N N N 1/1/2008 12/31/2078

1022F 0 N N N N N 1/1/2008 12/31/2078

1026F 0 N N N N N 1/1/2008 12/31/2078

1030F 0 N N N N N 1/1/2008 12/31/2078

1031F 0 N N N N N 1/1/2012 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 67 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

1032F 0 N N N N N 1/1/2012 12/31/2078

1033F 0 N N N N N 1/1/2012 12/31/2078

1034F 0 N N N N N 1/1/2008 12/31/2078

1035F 0 N N N N N 1/1/2008 12/31/2078

1036F 0 N N N N N 1/1/2008 12/31/2078

1038F 0 N N N N N 1/1/2008 12/31/2078

1039F 0 N N N N N 1/1/2008 12/31/2078

1040F 0 N N N N N 1/1/2008 12/31/2078

1050F 0 N N N N N 1/1/2008 12/31/2078

1052F 0 N N N N N 1/1/2012 12/31/2078

1055F 0 N N N N N 1/1/2008 12/31/2078

1060F 0 N N N N N 1/1/2008 12/31/2078

1061F 0 N N N N N 1/1/2008 12/31/2078

1065F 0 N N N N N 1/1/2008 12/31/2078

1066F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 68 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

1070F 0 N N N N N 1/1/2008 12/31/2078

1071F 0 N N N N N 1/1/2008 12/31/2078

1090F 0 N N N N N 1/1/2008 12/31/2078

1091F 0 N N N N N 1/1/2008 12/31/2078

11000 0 N Y N N N 1/1/2008 12/31/2078

11001 0 N N N N N 1/1/2008 12/31/2078

11004 0 N Y N N N 1/1/2008 12/31/2078

11005 0 N N Y N N 1/1/2008 12/31/2078

11006 0 N Y N N N 1/1/2008 12/31/2078

11008 0 N N Y N N 1/1/2008 12/31/2078

1100F 0 N N N N N 1/1/2008 12/31/2078

11010 10 N Y N N N 1/1/2008 12/31/2078

11011 0 N Y N N N 1/1/2008 12/31/2078

11012 0 N Y N N N 1/1/2008 12/31/2078

1101F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 69 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

11040 0 N Y N N N 1/1/2008 12/31/2010

11041 0 N Y N N N 1/1/2008 12/31/2010

11042 0 N Y N N N 1/1/2008 12/31/2078

11043 10 N Y N N N 1/1/2008 12/31/2010

11043 0 N Y N N N 1/1/2011 12/31/2078

11044 10 N Y N N N 1/1/2008 12/31/2010

11044 0 N Y N N N 1/1/2011 12/31/2078

11045 0 N N Y N N 1/1/2011 12/31/2078

11046 0 N N Y N N 1/1/2011 12/31/2078

11047 0 N N Y N N 1/1/2011 12/31/2078

11055 0 N Y N N N 1/1/2008 12/31/2078

11056 0 N Y N N N 1/1/2008 12/31/2078

11057 0 N Y N N N 1/1/2008 12/31/2078

11100 0 N Y N N N 1/1/2008 12/31/2018

11101 0 N N N N N 1/1/2008 12/31/2018

09/08/2020 Global Surgery Rules.xls Page 70 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

11102 0 N Y N N N 1/1/2019 12/31/2078

11103 0 N N N N N 1/1/2019 12/31/2078

11104 0 N Y N N N 1/1/2019 12/31/2078

11105 0 N N N N N 1/1/2019 12/31/2078

11106 0 N Y N N N 1/1/2019 12/31/2078

11107 0 N N N N N 1/1/2019 12/31/2078

1110F 0 N N N N N 1/1/2008 12/31/2078

1111F 0 N N N N N 1/1/2008 12/31/2078

1116F 0 N N N N N 1/1/2008 12/31/2078

1118F 0 N N N N N 1/1/2008 12/31/2078

1119F 0 N N N N N 1/1/2008 12/31/2078

11200 10 N Y N N N 1/1/2008 12/31/2078

11201 0 N N N N N 1/1/2008 12/31/2078

1121F 0 N N N N N 1/1/2008 12/31/2078

1123F 0 N N N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 71 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

1124F 0 N N N N N 1/1/2008 12/31/2078

1125F 0 N N N N N 1/1/2008 12/31/2078

1126F 0 N N N N N 1/1/2008 12/31/2078

1127F 0 N N N N N 1/1/2008 12/31/2009

1127F 0 N N N N N 1/1/2012 12/31/2078

1128F 0 N N N N N 1/1/2008 12/31/2009

1128F 0 N N N N N 1/1/2012 12/31/2078

11300 0 N Y Y N N 1/1/2008 12/31/2078

11301 0 N Y Y N N 1/1/2008 12/31/2078

11302 0 N Y Y N N 1/1/2008 12/31/2078

11303 0 N Y Y N N 1/1/2008 12/31/2078

11305 0 N Y Y N N 1/1/2008 12/31/2078

11306 0 N Y Y N N 1/1/2008 12/31/2078

11307 0 N Y Y N N 1/1/2008 12/31/2078

11308 0 N Y Y N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 72 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

1130F 0 N N N N N 1/1/2009 12/31/2078

11310 0 N Y Y N N 1/1/2008 12/31/2078

11311 0 N Y Y N N 1/1/2008 12/31/2078

11312 0 N Y Y N N 1/1/2008 12/31/2078

11313 0 N Y Y N N 1/1/2008 12/31/2078

1134F 0 N N N N N 1/1/2009 12/31/2078

1135F 0 N N N N N 1/1/2009 12/31/2078

1136F 0 N N N N N 1/1/2009 12/31/2078

1137F 0 N N N N N 1/1/2009 12/31/2078

11400 10 N Y N N N 1/1/2008 12/31/2078

11401 10 N Y N N N 1/1/2008 12/31/2078

11402 10 N Y N N N 1/1/2008 12/31/2078

11403 10 N Y N N N 1/1/2008 12/31/2078

11404 10 N Y N N N 1/1/2008 12/31/2078

11406 10 N Y N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 73 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

11420 10 N Y N N N 1/1/2008 12/31/2078

11421 10 N Y N N N 1/1/2008 12/31/2078

11422 10 N Y N N N 1/1/2008 12/31/2078

11423 10 N Y N N N 1/1/2008 12/31/2078

11424 10 N Y N N N 1/1/2008 12/31/2078

11426 10 N Y N N N 1/1/2008 12/31/2078

11440 10 N Y N N N 1/1/2008 12/31/2078

11441 10 N Y N N N 1/1/2008 12/31/2078

11442 10 N Y N N N 1/1/2008 12/31/2078

11443 10 N Y N N N 1/1/2008 12/31/2078

11444 10 N Y N N N 1/1/2008 12/31/2078

11446 10 N Y N N N 1/1/2008 12/31/2078

11450 90 N Y N N N 1/1/2008 12/31/2012

11450 90 Y Y N N N 1/1/2013 12/31/2078

11451 90 N Y Y N N 1/1/2008 12/31/2012

09/08/2020 Global Surgery Rules.xls Page 74 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

11451 90 Y Y Y N N 1/1/2013 12/31/2078

11462 90 N Y Y N N 1/1/2008 12/31/2012

11462 90 Y Y Y N N 1/1/2013 12/31/2078

11463 90 N Y Y N N 1/1/2008 12/31/2012

11463 90 Y Y Y N N 1/1/2013 12/31/2078

11470 90 N Y N N N 1/1/2008 12/31/2078

11471 90 N Y Y N N 1/1/2008 12/31/2078

1150F 0 N N N N N 1/1/2009 12/31/2078

1151F 0 N N N N N 1/1/2009 12/31/2078

1152F 0 N N N N N 1/1/2009 12/31/2078

1153F 0 N N N N N 1/1/2009 12/31/2078

1157F 0 N N N N N 1/1/2009 12/31/2078

1158F 0 N N N N N 1/1/2009 12/31/2078

1159F 0 N N N N N 1/1/2009 12/31/2078

11600 10 N Y N N N 1/1/2008 12/31/2078

09/08/2020 Global Surgery Rules.xls Page 75 of 1403

MaineCare Fee Schedule

Service Code Modifier Global Days

Bilateral Multiple Assistant Team Co-surgeon Professional Fee

Rule ID Effective Date Termination Date

11601 10 N Y N N N 1/1/2008 12/31/2078

11602 10 N Y N N N 1/1/2008 12/31/2078

11603 10 N Y N N N 1/1/2008 12/31/2078

11604 10 N Y N N N 1/1/2008 12/31/2078

11606 10 N Y N N N 1/1/2008 12/31/2078

1160F 0 N N N N N 1/1/2009 12/31/2078

11620 10 N Y N N N 1/1/2008 12/31/2078

11621 10 N Y N N N 1/1/2008 12/31/2078

11622 10 N Y N N N 1/1/2008 12/31/2078

11623 10 N Y N N N 1/1/2008 12/31/2078

11624 10 N Y N N N 1/1/2008 12/31/2078

11626 10 N Y N N N