Daman Published Rates

Transcription

1 Daman Published Rates Non-Network Services Price List Daman Published Rates as applicable for covered Health Services in Non-Network Providers

2 TABLE OF CONTENTS WELCOME... 3 HOW TO READ THE PRICE LIST?... 3 SPECIFIC CONDITIONS... 4 HOW TO OBTAIN NON-NETWORK BENEFITS?... 4 DAMAN PUBLISHED RATES... 6 PRICE LIST FOR SERVICE CODES... 7 PRICE LIST FOR CURRENT PROCEDURAL TERMINOLOGY PRICE LIST FOR ANESTHESIA SERVICES PRICE LIST FOR HEALTHCARE COMMON PROCEDURE CODING SYSTEM CONTACT US Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 2 of 380

3 Welcome Daman Published Rates (Price List) is an integral part and shall be read and interpreted along with the Letter of Acceptance and the Schedule of Benefits detailing the prices as applicable for covered Health Services availed in Non-Network Providers. Content of this document shall be read and interpreted in conjunction with the applicable Policy terms and conditions. How to read the Price List? Following are the listed fields used across the Price List, alongwith their description for your easy reference: Field Type Description Code type: SERVICE = Service Codes (used for Consultations, Room and Boarding) CPT = Current Procedural Terminology (used for Inpatient and Outpatient Procedures) HCPCS = Healthcare Common Procedure Coding System Code Code Description Price Unique Alpha-numeric or Numeric code Short description of the code Maximum amount in AED (Dirhams) for listed services Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 3 of 380

4 Specific Conditions Pharmaceuticals: These benefits will be payable on Actuals, as per the Policy terms and conditions All benefits and services with an undefined price list will be examined on case to case basis, according to Policy terms and conditions. Whereever Co-insurance/Deductible applies to Non-Network Benefits; the amount of Coinsurance/Deductible will be deducted from the amount reimbursable to the Eligible Person. For covered health services in Non-Network Providers, Daman will pay the lower of Claimed Amount or Benefit Payable under the terms of the Policy. This has been illustrated below, for a case where 50% co-insurance applies for all covered services in Non-Network Provider: Original Amount After applying coinsurance Maximum Benefit Payable Daman Published Rates: for tonsillectomy services AED 1000 AED 500 AED 500 Scenario 1: Claimed Amount AED 1428 AED 714 AED 500 Scenario 2 : Claimed Amount AED 285 AED 142 AED 142 Prices contained herein are subject to change by Daman. Any change to the Price List will be issued as an amendment and/or endorsement and will be communicated to the Policyholder. The Policyholder shall ensure that such amendments are communicated to the Daman members under the Policyholder s Policy. No agent has the authority to change the Policy or waive any of its provisions. How to obtain non-network benefits? In case of Health Services that have been availed at Non-Network Provider, you will have to pay for the services provided. However, if such services are covered in your plan, you can apply for reimbursement. All reimbursement claims, for Health Services availed at any Non-Network Provider within and/or outside the UAE, should be reported to Daman within 120 days from the date of service taken, and should be submitted with the following required documents: Original itemized invoices with dates Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 4 of 380

5 Medical Report/Discharge Summary signed and stamped by the treating doctor (for inpatient services only) Original drug prescription with a detailed pharmacy bill (itemized) Diagnostic (lab/radiology) investigation reports and invoices (if any), report of the results only if single investigation cost is more than AED 1,000 Copy of Daman card Reimbursement claims submission can be applied online through Daman s web portal ( or through Daman s interfaces, either in branches or service points. Reimbursement forms are available on Daman s website. Reimbursement of claims shall be subject to submission of all required documents, and will be settled as per Daman Published Rates and Policy terms and conditions within 15 working days from the date of receipt of the claim, and a cheque will be issued in the Policyholder s/principal s name along with a detailed settlement report. Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 5 of 380

6 Daman Published Rates Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 6 of 380

7 Price List for Service Codes SERVICE ROOM AND BOARD: SUITE 1,200 SERVICE ROOM AND BOARD: VIP ROOM 1,000 SERVICE ROOM AND BOARD: FIRST CLASS ROOM 750 SERVICE ROOM AND BOARD: SHARED ROOM 550 SERVICE ROOM AND BOARD: WARD 450 SERVICE ROOM AND BOARD: ROYAL SUITE 2,000 SERVICE ROOM AND BOARD: ISOLATION ROOM 700 SERVICE 29 SPECIAL CARE UNIT (SCU) OR ADULT SPECIAL-CARE UNIT (ASCU) 800 SERVICE 30 SPECIAL CARE BABY UNIT (SCBU) 900 SERVICE 32 NURSERY - GENERAL CLASSIFICATION 150 SERVICE 27 INTENSIVE CARE UNIT (ICU) 1,200 SERVICE CORONARY CARE UNIT (CCU) 1,200 SERVICE 28 NEONATAL INTENSIVE CARE UNIT (NICU) 2,500 SERVICE 31 PAEDIATRIC INTENSIVE CARE UNIT (PICU) 1,500 SERVICE EMERGENCY ROOM - HOURLY RATE 35 SERVICE OBSERVATION OR TREATMENT ROOM - HOURLY RATE 50 SERVICE RECOVERY ROOM - HOURLY RATE 150 SERVICE OBSERVATION OR TREATMENT ROOM - DAILY RATE 200 SERVICE DAY STAY (DAY CARE) ROOM - DAILY RATE 300 SERVICE 1 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 1 TO 3) 1,300 SERVICE 2 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 4 TO 8) 1,000 SERVICE 3 PERDIEM - WARD OR SHARED ROOM - DAILY RATE (DAY 8 AND 800 MORE) SERVICE 3-01 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND 700 MORE ) - SUITE SERVICE 3-02 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND 500 MORE ) - VIP ROOM SERVICE 3-03 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND 250 MORE ) - FIRST CLASS ROOM SERVICE 3-06 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND 1,500 MORE ) - ROYAL SUITE SERVICE 3-10 PERDIEM - ROOM RATE DIFFERENCE - DAILY RATE (DAY 1 AND 200 MORE ) - ISOLATION ROOM SERVICE 4 PERDIEM - ICU/CCU - DAILY RATE (DAY 1 TO 7) 2,100 SERVICE 5 PERDIEM - NICU - DAILY RATE (DAY 1 TO 7) 4,000 SERVICE 6 PERDIEM - NICU - DAILY RATE (DAY 8 TO 14) 3,600 SERVICE 7 PERDIEM - NICU - DAILY RATE (DAY 15 TO 21) 3,200 SERVICE 8 PERDIEM - NICU - DAILY RATE (DAY 22 AND MORE) 2,800 SERVICE PERDIEM - PICU - DAILY RATE (DAY 1 TO 7) 2,500 SERVICE SERVICE PERDIEM - PICU - DAILY RATE (DAY 8 TO 14) 2,250 PERDIEM - PICU - DAILY RATE (DAY 15 TO 21) 2,000 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 7 of 380

8 SERVICE 17- PERDIEM - PICU - DAILY RATE (DAY 22 AND MORE) 1, SERVICE 4-01 PERDIEM - ICU/CCU - DAILY RATE (DAY 8 TO 14) 1,900 SERVICE 4-02 PERDIEM - ICU/CCU - DAILY RATE (DAY 15 TO 21) 1,700 SERVICE 4-03 PERDIEM - ICU/CCU - DAILY RATE (DAY 22 AND MORE) 1,500 SERVICE PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 1 TO 3) 550 SERVICE PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 9 AND MORE) SERVICE 17- PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 4 TO 8) SERVICE 19 PERDIEM - SCBU - DAILY RATE (DAY 1 TO 3) 1,375 SERVICE 18 PERDIEM - SCU - DAILY RATE (DAY 1 TO 3) 1,400 SERVICE PERDIEM - SCU - DAILY RATE (DAY 4 TO 8) 1,250 SERVICE PERDIEM - SCU - DAILY RATE (DAY 9 AND MORE) 1,100 SERVICE PERDIEM - SCBU - DAILY RATE (DAY 4 TO 8) 990 SERVICE PERDIEM - SCBU - DAILY RATE (DAY 9 AND MORE) 1,200 SERVICE PERDIEM - LONG TERM STAY - DAILY RATE - SIMPLE CASES 750 SERVICE PERDIEM - LONG TERM STAY - DAILY RATE - INTERMEDIATE CASES 1,000 SERVICE PERDIEM - LONG TERM STAY - DAILY RATE - INTENSIVE CASES 1,250 SERVICE PERDIEM - LONG TERM STAY - DAILY RATE - SEVERE CASES 3,300 SERVICE 15 PERDIEM - TREATMENT OR OBSERVATION ROOM - NOT INCLUSIVE OF LABORATORY AND RADIOLOGY SERVICE 16 PERDIEM - DAY STAY (DAY CARE) ROOM - NOT INCLUSIVE OF 550 LABORATORY AND RADIOLOGY SERVICE 24 PERDIEM - TREATMENT OR OBSERVATION ROOM - INCLUSIVE. 375 SERVICE 25 PERDIEM - DAY STAY (DAY CARE) - INCLUSIVE. 750 SERVICE PERDIEM - HAEMODIALYSIS (HD) 1,500 SERVICE 9 CONSULTATION - GP 100 SERVICE 9.1 CONSULTATION - GP - FOLLOW UP WITHIN ONE WEEK 0 SERVICE 10 CONSULTATION - SPECIALIST 100 SERVICE 10.1 CONSULTATION - SPECIALIST - FOLLOW UP WITHIN ONE WEEK 0 SERVICE 11 CONSULTATION - CONSULTANT 100 SERVICE 11.1 CONSULTATION - CONSULTANT - FOLLOW UP WITHIN ONE WEEK 0 SERVICE 20 OPERATING ROOM SERVICES - GENERAL CLASSIFICATION 2,050 SERVICE OPERATING ROOM SERVICES - MINOR SURGERY 500 SERVICE OPERATING ROOM SERVICES - FIRST HOUR 1,600 SERVICE OPERATING ROOM SERVICES - EVERY ADDITIONAL 1/2 HR. 450 SERVICE CATHETERIZATION LAB 1,600 SERVICE DELIVERY ROOM 1,300 SERVICE PERDIEM - NON- MEDICAL ESCORT ACCOMMODATION - DAILY RATE 100 SERVICE 26 PERDIEM COMPANION ACCOMMODATION 100 SERVICE COMPREHENSIVE SCREENING EVALUATION AND MANAGEMENT BY CLINICIAN OF AN INDIVIDUAL, INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, QUESTIONNAIRE FILLING, EXAMINATION, AND ORDERING OF LABORATORY/DIAGNOSTIC PROCEDURES, NEW OR ESTABLISHED PATIENT; MINUTES Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 8 of 380

9 SERVICE COMPREHENSIVE SCREENING BY A NON-PHYSICIAN CLINICIAN OF AN INDIVIDUAL, INCLUDING VITAL SIGNS, AN AGE AND GENDER APPROPRIATE HISTORY, COORDINATION FOR ORDERING OF LABORATORY/DIAGNOSTIC PROCEDURES AND QUESTIONNAIRE FILLING, NEW OR ESTABLISHED PATIENT; MINUTES. SERVICE 99 OUTLIER PAYMENT USED FOR OUTLIER BILLING ONLY 66 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 9 of 380

10 Price List for Current Procedural Terminology CPT 0073T COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF 1,674 INVERSE PLANNED TREATMENT USING THREE OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION CPT FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE 446 CPT FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE 440 CPT ACNE SURGERY (E.G., MARSUPIALIZATION, OPENING OR REMOVAL OF 323 MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) CPT INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE 354 HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE CPT INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE 597 HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE CPT INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 500 CPT INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED 780 CPT INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; 415 SIMPLE CPT INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; 824 COMPLICATED CPT INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION 503 CPT PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST 404 CPT INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION 738 CPT DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE CPT DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM CPT DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE CPT DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA, PERINEUM AND ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE CPT REMOVAL OF PROSTHETIC MATERIAL OR MESH, ABDOMINAL WALL FOR INFECTION (E.G., FOR CHRONIC OR RECURRENT MESH INFECTION OR NECROTIZING SOFT TISSUE INFECTION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES ,847 2,389 2, ,467 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 10 of 380

11 CPT DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED 1,601 WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE CPT DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED 2,144 WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE CPT DEBRIDEMENT; SKIN, PARTIAL THICKNESS 156 CPT DEBRIDEMENT; SKIN, FULL THICKNESS 178 CPT DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE 236 CPT DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE 864 CPT DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE 1,180 CPT PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); SINGLE LESION CPT PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); 2 TO 4 LESIONS CPT PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); MORE THAN 4 LESIONS CPT BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE LESION CPT BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; EACH SEPARATE/ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS CPT REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 11 of 380

12 CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, 400 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM CPT SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, 492 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 353 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 445 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 497 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 571 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 648 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 922 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 367 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 477 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 534 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 616 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 713 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM CPT EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 1,015 (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 390 TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 504 TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 572 TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 682 TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM 853 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 12 of 380

13 CPT EXCISION, OTHER BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN 1,168 TAG (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,083 AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,417 AXILLARY; WITH COMPLEX REPAIR CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,078 INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,437 INGUINAL; WITH COMPLEX REPAIR CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,199 PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR CPT EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,497 PERIANAL, PERINEAL, OR UMBILICAL; WITH COMPLEX REPAIR CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 556 LEGS; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 702 LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 779 LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 878 LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 964 LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 1,363 LEGS; EXCISED DIAMETER OVER 4.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 570 HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 712 HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 805 HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 928 HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 1,040 HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 1,254 HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 602 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 745 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 855 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 995 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 1,224 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM CPT EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 1,602 EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM CPT TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER 71 CPT DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE 104 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 13 of 380

14 CPT DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE 146 CPT AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE 323 CPT AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH 149 ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EVACUATION OF SUBUNGUAL HEMATOMA 152 CPT EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., 702 INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL; CPT EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., 993 INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL; WITH AMPUTATION OF TUFT OF DISTAL PHALANX CPT BIOPSY OF NAIL UNIT (E.G., PLATE, BED, MATRIX, HYPONYCHIUM, 438 PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE PROCEDURE) CPT REPAIR OF NAIL BED 655 CPT RECONSTRUCTION OF NAIL BED WITH GRAFT 877 CPT WEDGE EXCISION OF SKIN OF NAIL FOLD (E.G., FOR INGROWN TOENAIL) 435 CPT EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE 808 CPT EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE 1,681 CPT EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED 2,034 CPT INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS 183 CPT INJECTION, INTRALESIONAL; MORE THAN 7 LESIONS 231 CPT TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE 528 PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ. CM OR LESS CPT TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE 614 PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ. CM CPT TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE 186 PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); CC OR LESS CPT SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); TO 5.0 CC CPT SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); TO 10.0 CC CPT SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 489 OVER 10.0 CC CPT INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, 2,882 INCLUDING SUBSEQUENT EXPANSION CPT REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS 1,898 CPT REMOVAL OF TISSUE EXPANDER(S) WITHOUT INSERTION OF PROSTHESIS 1,375 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 14 of 380

15 CPT INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 401 CPT REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES 468 CPT REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 711 CPT SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF 337 ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN) CPT INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 440 CPT REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 499 CPT REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY 776 IMPLANT CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 453 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 484 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 572 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 713 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 892 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, 999 EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 484 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 536 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 629 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 791 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 941 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 844 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM CPT SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 1,019 NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM CPT TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 834 CPT TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 497 CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 15 of 380

16 CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 1,149 EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 1,261 EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM CPT LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 1,426 EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 811 GENITALIA; 2.5 CM OR LESS CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 935 GENITALIA; 2.6 CM TO 7.5 CM CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,112 GENITALIA; 7.6 CM TO 12.5 CM CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,144 GENITALIA; 12.6 CM TO 20.0 CM CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,316 GENITALIA; 20.1 CM TO 30.0 CM CPT LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,477 GENITALIA; OVER 30.0 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 855 AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 988 AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,102 AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,158 AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,371 AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,562 AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM CPT LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,798 AND/OR MUCOUS MEMBRANES; OVER 30.0 CM CPT REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM 984 CPT REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM 1,276 CPT REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST 342 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM 1,027 CPT REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM 1,426 CPT REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM 372 OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 1,141 GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM CPT REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 1,849 GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM CPT REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 534 GENITALIA, HANDS AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.0 CM OR LESS 1,117 CPT REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.1 CM TO 2.5 CM 1,295 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 16 of 380

17 CPT REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM 1,797 CPT REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ. CM OR LESS CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ. CM OR LESS CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ. CM OR LESS CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ. CM OR LESS CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ. CM, UNUSUAL OR COMPLICATED, ANY AREA CPT FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE CPT SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ. CM OR LESS CPT PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL ULCER, TIP OF DIGIT, OR OTHER MINIMAL OPEN AREA (EXCEPT ON FACE), UP TO DEFECT 587 2,567 2,060 2,698 2,308 3,078 2,424 3,395 2,446 3,684 3,518 2,399 1, , ,708 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 17 of 380

18 SIZE 2 CM DIAMETER CPT SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) CPT SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) CPT SPLIT-THICKNESS AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT DERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25 SQ. CM OR LESS CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; ADDITIONAL 1 SQ. CM TO 75 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR 2, , , , , , , ,361 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 18 of 380

19 MULTIPLE DIGITS; FIRST 25 SQ. CM OR LESS CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; ADDITIONAL 1 SQ. CM TO 75 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ACELLULAR DERMAL REPLACEMENT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ. CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ. CM OR LESS CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ. CM OR LESS CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ. CM OR LESS CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ. CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS CPT FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, , , , , , , , ,223 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 19 of 380

20 AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, 302 EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM 1,004 OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, 1,053 EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT ACELLULAR DERMAL ALLOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, 298 EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR 989 LESS CPT TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; EACH ADDITIONAL SQ CM CPT TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, TRUNK, ARMS, 1,159 LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, TRUNK, ARMS, 225 LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, 1,118 EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT TISSUE CULTURED ALLOGENEIC DERMAL SUBSTITUTE, FACE, SCALP, 288 EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, TRUNK, 1,239 ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT XENOGRAFT, SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, TRUNK, 270 ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, 1,364 SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT XENOGRAFT SKIN (DERMAL), FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, 361 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 20 of 380

21 AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR 1% OF 1,661 BODY AREA OF INFANTS AND CHILDREN CPT ACELLULAR XENOGRAFT IMPLANT; EACH ADDITIONAL 100 SQ CM, OR 755 EACH ADDITIONAL 1% OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,697 TRANSFER; TRUNK CPT FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,634 TRANSFER; SCALP, ARMS, OR LEGS CPT FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,803 TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET CPT FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,489 TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL CPT DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 949 TRUNK CPT DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,054 SCALP, ARMS, OR LEGS CPT DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,314 FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET CPT DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,431 EYELIDS, NOSE, EARS, OR LIPS CPT TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO 1,553 WRIST, WALKING TUBE), ANY LOCATION CPT FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL 3,436 PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP) CPT MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK 4,576 (EG, TEMPORALIS, MASSETER MUSCLE, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE) CPT MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK 4,775 CPT MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; UPPER 4,126 EXTREMITY CPT MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER 4,450 EXTREMITY CPT FLAP; ISLAND PEDICLE 3,244 CPT FLAP; NEUROVASCULAR PEDICLE 2,896 CPT FREE MUSCLE OR MYOCUTANEOUS FLAP WITH MICROVASCULAR 7,543 ANASTOMOSIS CPT FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS 7,391 CPT FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS 7,365 CPT GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL 2,636 ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA CPT GRAFT; DERMA-FAT-FASCIA 2,066 CPT PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS 925 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 21 of 380

22 CPT PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS 1,397 CPT DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE 2,569 WRINKLING, RHYTIDS, GENERAL KERATOSIS) CPT DERMABRASION; SEGMENTAL, FACE 1,753 CPT DERMABRASION; REGIONAL, OTHER THAN FACE 1,689 CPT DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL) 1,577 CPT ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) 762 CPT ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY 151 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHEMICAL PEEL, FACIAL; EPIDERMAL 1,468 CPT CHEMICAL PEEL, FACIAL; DERMAL 1,830 CPT CHEMICAL PEEL, NONFACIAL; EPIDERMAL 1,380 CPT CHEMICAL PEEL, NONFACIAL; DERMAL 1,524 CPT CERVICOPLASTY 2,278 CPT BLEPHAROPLASTY, LOWER EYELID; 1,621 CPT BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD 1,721 CPT BLEPHAROPLASTY, UPPER EYELID; 1,272 CPT BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING 2,015 DOWN LID CPT RHYTIDECTOMY; FOREHEAD 3,441 CPT RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, 3,871 P-FLAP) CPT RHYTIDECTOMY; GLABELLAR FROWN LINES 2,795 CPT RHYTIDECTOMY; CHEEK, CHIN, AND NECK 7,312 CPT RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); FOREARM OR HAND 8,172 3,732 2,843 2,604 2,736 2,800 2,338 2,420 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 22 of 380

23 CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 1,774 LIPECTOMY); SUBMENTAL FAT PAD CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 2,681 LIPECTOMY); OTHER AREA CPT GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING 3,148 OBTAINING FASCIA) CPT GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING 5,258 OBTAINING GRAFT) CPT GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE FLAP BY 8,371 MICROSURGICAL TECHNIQUE CPT GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER 2,921 CPT EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 1,506 LIPECTOMY), ABDOMEN (EG, ABDOMINOPLASTY) (INCLUDES UMBILICAL TRANSPOSITION AND FASCIAL PLICATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), SAME 255 SURGEON CPT REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), OTHER 283 SURGEON CPT DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA 151 (OTHER THAN LOCAL) CPT INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST 359 VASCULAR FLOW IN FLAP OR GRAFT CPT SUCTION ASSISTED LIPECTOMY; HEAD AND NECK N/A CPT SUCTION ASSISTED LIPECTOMY; TRUNK N/A CPT SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY N/A CPT SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY N/A CPT EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH 1,830 PRIMARY SUTURE CPT EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH 2,368 FLAP CLOSURE CPT EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,110 CPT EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH 2,571 OSTECTOMY CPT EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,902 CPT EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH 3,380 OSTECTOMY CPT EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 2,798 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; CPT EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 3,273 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY CPT EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,168 CPT EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH 2,810 OSTECTOMY (ISCHIECTOMY) CPT EXCISION, ISCHIAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,776 CPT EXCISION, ISCHIAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH OSTECTOMY 3,049 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 23 of 380