FEE SCHEDULE - ATTACHMENT 1 A. FEE FOR SERVICE RATE - Base year October 1, 2008 through September 30, 2009 Required Services Unit Unit Cost 1. New Patient - Focused Visit (CPT 99201) Per visit _________ 2. New Patient - Expanded Focus Visit (CPT 99020) Per visit _________ 3. New Patient - Intermediate Visit (CPT 99203) Per visit _________ 4. New Patient - Extended Visit (CPT 99204) Per visit _________ 5. Established Patient - Focused Visit (CPT 99211) Per visit _________ 6. Established Patient - Limited Visit (CPT 99212) Per visit _________ 7. Established Patient - Intermediate Visit (CPT 99213) Per visit _________ 8. Established Patient - Extended Visit (CPT 99214) Per visit _________ 9. Established Patient - Comprehensive Visit (CPT 99215) Per visit _________ Optional Services Unit Unit Cost 10. Vitamin B-12 Per Injection _________ 11. Pneumovax Vaccine Per Injection _________ 12. Testosterone Shots Per Injection _________ 13. Tetanus-Diptheria Booster Per Injection _________ 14. Influenza Vaccine Per Injection _________ VA-241-08-RP-0272 FEE SCHEDULE A. FEE FOR SERVICE RATE - Option 1: October 1, 2009 through September 30, 2010 Required Services Unit Unit Cost 1. New Patient - Focused Visit (CPT 99201) Per visit _________ 2. New Patient - Expanded Focus Visit (CPT 99020) Per visit _________ 3. New Patient - Intermediate Visit (CPT 99203) Per visit _________ 4. New Patient - Extended Visit (CPT 99204) Per visit _________ 5. Established Patient - Focused Visit (CPT 99211) Per visit _________ 6. Established Patient - Limited Visit (CPT 99212) Per visit _________ 7. Established Patient - Intermediate Visit (CPT 99213) Per visit _________ 8. Established Patient - Extended Visit (CPT 99214) Per visit _________ 9. Established Patient - Comprehensive Visit (CPT 99215) Per visit _________ Optional Services Unit Unit Cost 10. Vitamin B-12 Per Injection _________ 11. Pneumovax Vaccine Per Injection _________ 12. Testosterone Shots Per Injection _________ 13. Tetanus-Diptheria Booster Per Injection _________ 14. Influenza Vaccine Per Injection _________ VA-241-08-RP-0272 FEE SCHEDULE A. FEE FOR SERVICE RATE - Option 2: October 1, 2010 through September 30, 2011 Required Services Unit Unit Cost 1. New Patient - Focused Visit (CPT 99201) Per visit _________ 2. New Patient - Expanded Focus Visit (CPT 99020) Per visit _________ 3. New Patient - Intermediate Visit (CPT 99203) Per visit _________ 4. New Patient - Extended Visit (CPT 99204) Per visit _________ 5. Established Patient - Focused Visit (CPT 99211) Per visit _________ 6. Established Patient - Limited Visit (CPT 99212) Per visit _________ 7. Established Patient - Intermediate Visit (CPT 99213) Per visit _________ 8. Established Patient - Extended Visit (CPT 99214) Per visit _________ 9. Established Patient - Comprehensive Visit (CPT 99215) Per visit _________ Optional Services Unit Unit Cost 10. Vitamin B-12 Per Injection _________ 11. Pneumovax Vaccine Per Injection _________ 12. Testosterone Shots Per Injection _________ 13. Tetanus-Diptheria Booster Per Injection _________ 14. Influenza Vaccine Per Injection _________ VA-241-08-RP-0272 FEE SCHEDULE A. FEE FOR SERVICE RATE - Option 2: October 1, 2011 through September 30, 2012 Required Services Unit Unit Cost 1. New Patient - Focused Visit (CPT 99201) Per visit _________ 2. New Patient - Expanded Focus Visit (CPT 99020) Per visit _________ 3. New Patient - Intermediate Visit (CPT 99203) Per visit _________ 4. New Patient - Extended Visit (CPT 99204) Per visit _________ 5. Established Patient - Focused Visit (CPT 99211) Per visit _________ 6. Established Patient - Limited Visit (CPT 99212) Per visit _________ 7. Established Patient - Intermediate Visit (CPT 99213) Per visit _________ 8. Established Patient - Extended Visit (CPT 99214) Per visit _________ 9. Established Patient - Comprehensive Visit (CPT 99215) Per visit _________ Optional Services Unit Unit Cost 10. Vitamin B-12 Per Injection _________ 11. Pneumovax Vaccine Per Injection _________ 12. Testosterone Shots Per Injection _________ 13. Tetanus-Diptheria Booster Per Injection _________ 14. Influenza Vaccine Per Injection _________ VA-241-08-RP-0272

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