On July 1 , 2009 , CMS proposed changes to policies and payment rates for services to be furnished under the 2010 physician fee schedule . Under the proposed provisions , EBITDA would be reduced by approximately $ 23 million . However , we currently estimate the impact to 2010 EBITDA of actual changes to CMS policies and payment rates will be between $ 5- $ 10 million . The most significant difference between the potential and estimated impact reflects our expectation that Congress , as in previous years , will enact legislation to avert a 21.5 % Sustainable Growth Rate reduction . The final rule is expected to be issued on or around November 1 , 2009 .