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

24 CPT EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, IN 5,120 PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE CPT EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE; 1,806 CPT EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE; 2,547 WITH OSTECTOMY CPT EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,668 CPT EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,947 WITH OSTECTOMY CPT EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR 3,569 MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; CPT EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR 3,680 MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY CPT UNLISTED PROCEDURE, EXCISION PRESSURE ULCER N/A CPT INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL 212 TREATMENT IS REQUIRED CPT DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, 250 INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA) CPT DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, 454 INITIAL OR SUBSEQUENT; MEDIUM (EG, WHOLE FACE OR WHOLE EXTREMITY, OR 5% TO 10% TOTAL BODY SURFACE AREA) CPT DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, 553 INITIAL OR SUBSEQUENT; LARGE (EG, MORE THAN ONE EXTREMITY, OR GREATER THAN 10% TOTAL BODY SURFACE AREA) CPT ESCHAROTOMY; INITIAL INCISION 682 CPT ESCHAROTOMY; EACH ADDITIONAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION CPT DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); SECOND THROUGH 14 LESIONS, EACH (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST LESION) CPT DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS CPT DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS THAN 10 SQ CM CPT DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); 10.0 TO 50.0 SQ CM CPT DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); OVER 50.0 SQ CM CPT DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; UP TO 14 LESIONS CPT DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), OF BENIGN LESIONS OTHER THAN SKIN TAGS OR CUTANEOUS VASCULAR PROLIFERATIVE LESIONS; 15 OR MORE LESIONS ,215 2,114 2, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 24 of 380

25 CPT CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (PROUD FLESH, 236 SINUS OR FISTULA) CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 299 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 469 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 566 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 623 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 2.1 TO 3.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 668 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 748 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 482 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 532 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 607 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 674 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2.1 TO 3.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 795 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 915 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 453 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 572 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 25 of 380

26 CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 664 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 796 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 922 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM CPT DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 1,149 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM CPT MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS 2,158 TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; FIRST STAGE, UP TO 5 TISSUE BLOCKS CPT MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS 1,298 TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), HEAD, NECK, HANDS, FEET, GENITALIA, OR ANY LOCATION WITH SURGERY DIRECTLY INVOLVING MUSCLE, CARTILAGE, BONE, TENDON, MAJOR NERVES, OR VESSELS; EACH ADDITIONAL STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS 1,971 TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; FIRST STAGE, UP TO 5 TISSUE BLOCKS CPT MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS 1,202 TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), OF THE TRUNK, ARMS, OR LEGS; EACH ADDITIONAL STAGE AFTER THE FIRST STAGE, UP TO 5 TISSUE BLOCKS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MOHS MICROGRAPHIC TECHNIQUE, INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND HISTOPATHOLOGIC PREPARATION INCLUDING ROUTINE STAIN(S) (EG, HEMATOXYLIN AND EOSIN, TOLUIDINE BLUE), EACH ADDITIONAL BLOCK AFTER THE FIRST 5 TISSUE BLOCKS, ANY STAGE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 256 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 26 of 380

27 CPT CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE 146 CPT CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) 422 CPT ELECTROLYSIS EPILATION, EACH 30 MINUTES 245 CPT UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS N/A TISSUE CPT PUNCTURE ASPIRATION OF CYST OF BREAST; 356 CPT PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST 90 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP 1,361 CPT INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR 539 GALACTOGRAM CPT BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING 441 GUIDANCE (SEPARATE PROCEDURE) CPT BIOPSY OF BREAST; OPEN, INCISIONAL 1,001 CPT BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING 706 GUIDANCE CPT BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR 1,773 ROTATING BIOPSY DEVICE, USING IMAGING GUIDANCE CPT ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING 6,356 ULTRASOUND GUIDANCE, EACH FIBROADENOMA CPT NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY 1,383 LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT CPT EXCISION OF LACTIFEROUS DUCT FISTULA 1,312 CPT EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT 1,467 TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, ONE OR MORE LESIONS CPT EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT 1,630 OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION CPT EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT 511 OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EXCISION OF CHEST WALL TUMOR INCLUDING RIBS 3,762 CPT EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC 5,075 RECONSTRUCTION; WITHOUT MEDIASTINAL LYMPHADENECTOMY CPT EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC 5,637 RECONSTRUCTION; WITH MEDIASTINAL LYMPHADENECTOMY CPT PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; 532 CPT PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, DURING BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY ,330 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 27 of 380

28 CPT PLACEMENT OF RADIOTHERAPY AFTERLOADING BALLOON CATHETER INTO 293 THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; CONCURRENT WITH PARTIAL MASTECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY 3,580 CATHETERS (MULTIPLE TUBE AND BUTTON TYPE) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING (AT THE TIME OF OR SUBSEQUENT TO) PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE CPT MASTECTOMY FOR GYNECOMASTIA 1,755 CPT MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, 1,940 QUADRANTECTOMY, SEGMENTECTOMY); CPT MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, 2,746 QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY CPT MASTECTOMY, SIMPLE, COMPLETE 3,001 CPT MASTECTOMY, SUBCUTANEOUS 1,735 CPT MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY 3,433 LYMPH NODES CPT MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY AND 3,606 INTERNAL MAMMARY LYMPH NODES (URBAN TYPE OPERATION) CPT MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, 3,631 WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE CPT MASTOPEXY 2,463 CPT REDUCTION MAMMAPLASTY 3,618 CPT MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT 1,505 CPT MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT 2,046 CPT REMOVAL OF INTACT MAMMARY IMPLANT 1,541 CPT REMOVAL OF MAMMARY IMPLANT MATERIAL 1,963 CPT IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, 1,282 MASTECTOMY OR IN RECONSTRUCTION CPT DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, 2,916 MASTECTOMY OR IN RECONSTRUCTION CPT NIPPLE/AREOLA RECONSTRUCTION 2,553 CPT CORRECTION OF INVERTED NIPPLES 2,102 CPT BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE 4,896 EXPANDER, INCLUDING SUBSEQUENT EXPANSION CPT BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT 5,399 PROSTHETIC IMPLANT CPT BREAST RECONSTRUCTION WITH FREE FLAP 8,912 CPT BREAST RECONSTRUCTION WITH OTHER TECHNIQUE 4,387 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 28 of 380

29 CPT BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 5,767 MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; CPT BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 7,198 MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING) CPT BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 6,527 MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE CPT OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST 2,148 CPT PERIPROSTHETIC CAPSULECTOMY, BREAST 2,483 CPT REVISION OF RECONSTRUCTED BREAST 2,424 CPT PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT 881 CPT UNLISTED PROCEDURE, BREAST N/A CPT INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 650 OSTEOMYELITIS); SUPERFICIAL CPT INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 966 OSTEOMYELITIS); DEEP OR COMPLICATED CPT EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK 1,903 CPT EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); CHEST 1,291 CPT EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 1,433 ABDOMEN/FLANK/BACK CPT EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 1,745 EXTREMITY CPT EXCISION OF EPIPHYSEAL BAR, WITH OR WITHOUT AUTOGENOUS SOFT 3,057 TISSUE GRAFT OBTAINED THROUGH SAME FASCIAL INCISION CPT BIOPSY, MUSCLE; SUPERFICIAL 601 CPT BIOPSY, MUSCLE; DEEP 819 CPT BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE 790 CPT BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, 511 SPINOUS PROCESS, RIBS) CPT BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, 1,773 FEMUR) CPT BIOPSY, BONE, OPEN; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS 718 PROCESS, RIBS, TROCHANTER OF FEMUR) CPT BIOPSY, BONE, OPEN; DEEP (EG, HUMERUS, ISCHIUM, FEMUR) 1,992 CPT BIOPSY, VERTEBRAL BODY, OPEN; THORACIC 1,234 CPT BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL 1,345 CPT INJECTION OF SINUS TRACT; THERAPEUTIC (SEPARATE PROCEDURE) 341 CPT INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM) 399 CPT REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; SIMPLE 590 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 29 of 380

30 CPT REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR 1,400 COMPLICATED CPT INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), 236 CARPAL TUNNEL CPT INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS 185 (EG, PLANTAR "FASCIA") CPT INJECTION(S); SINGLE TENDON ORIGIN/INSERTION 185 CPT INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO 162 MUSCLE(S) CPT INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE 179 MUSCLE(S) CPT PLACEMENT OF NEEDLES OR CATHETERS INTO MUSCLE AND/OR SOFT 1,083 TISSUE FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION (AT THE TIME OF OR SUBSEQUENT TO THE PROCEDURE) CPT ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL JOINT OR 176 BURSA (EG, FINGERS, TOES) CPT ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE 188 JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA) CPT ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR 247 BURSA (EG, SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) CPT ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 188 CPT ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST 655 CPT INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, 631 INCLUDING REMOVAL (SEPARATE PROCEDURE) CPT APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, 766 INCLUDING REMOVAL (SEPARATE PROCEDURE) CPT APPLICATION OF HALO, INCLUDING REMOVAL; CRANIAL 1,551 CPT APPLICATION OF HALO, INCLUDING REMOVAL; PELVIC 1,463 CPT APPLICATION OF HALO, INCLUDING REMOVAL; FEMORAL 1,437 CPT APPLICATION OF HALO, INCLUDING REMOVAL, CRANIAL, 6 OR MORE PINS 2,444 PLACED, FOR THIN SKULL OSTEOLOGY (EG, PEDIATRIC PATIENTS, HYDROCEPHALUS, OSTEOGENESIS IMPERFECTA), REQUIRING GENERAL ANESTHESIA CPT REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSICIAN 363 CPT REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) 1,091 (SEPARATE PROCEDURE) CPT REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL 1,837 BAND, NAIL, ROD OR PLATE) CPT APPLICATION OF A UNIPLANE (PINS OR WIRES IN ONE PLANE), 1,781 UNILATERAL, EXTERNAL FIXATION SYSTEM CPT APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN ONE 3,380 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE) CPT ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM REQUIRING 1,439 ANESTHESIA (EG, NEW PIN(S) OR WIRE(S) AND/OR NEW RING(S) OR BAR(S)) CPT REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM 1,286 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 30 of 380

31 CPT REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS THROUGH 7,470 ELBOW JOINT), COMPLETE AMPUTATION CPT REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL 9,311 CARPAL JOINT), COMPLETE AMPUTATION CPT REPLANTATION, HAND (INCLUDES HAND THROUGH 12,585 METACARPOPHALANGEAL JOINTS), COMPLETE AMPUTATION CPT REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES 6,625 METACARPOPHALANGEAL JOINT TO INSERTION OF FLEXOR SUBLIMIS TENDON), COMPLETE AMPUTATION CPT REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO 5,749 SUBLIMIS TENDON INSERTION), COMPLETE AMPUTATION CPT REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO MP 6,616 JOINT), COMPLETE AMPUTATION CPT REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT), COMPLETE 5,747 AMPUTATION CPT REPLANTATION, FOOT, COMPLETE AMPUTATION 7,263 CPT BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR 2,006 BUTTON) CPT BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE 1,920 CPT CARTILAGE GRAFT; COSTOCHONDRAL 1,345 CPT CARTILAGE GRAFT; NASAL SEPTUM 1,517 CPT FASCIA LATA GRAFT; BY STRIPPER 1,311 CPT FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR 1,900 SHEET CPT TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, 1,585 PLANTARIS) CPT TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) 1,393 CPT ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED (LIST SEPARATELY 406 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL (LIST SEPARATELY 367 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE 433 GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE 555 GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE 605 GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MONITORING OF INTERSTITIAL FLUID PRESSURE (INCLUDES INSERTION 716 OF DEVICE, EG, WICK CATHETER TECHNIQUE, NEEDLE MANOMETER TECHNIQUE) IN DETECTION OF MUSCLE COMPARTMENT SYNDROME CPT BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; FIBULA 7,988 CPT BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; ILIAC CREST 8,596 CPT BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; METATARSAL 8,218 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 31 of 380

32 CPT BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN 8,445 FIBULA, ILIAC CREST, OR METATARSAL CPT FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,940 OTHER THAN ILIAC CREST, METATARSAL, OR GREAT TOE CPT FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 9,037 ILIAC CREST CPT FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,111 METATARSAL CPT FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,391 GREAT TOE WITH WEB SPACE CPT ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE 215 (NONOPERATIVE) CPT ELECTRICAL STIMULATION TO AID BONE HEALING; INVASIVE 575 (OPERATIVE) CPT LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, 166 NONINVASIVE (NONOPERATIVE) CPT ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) 11,082 RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE CPT COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR 499 MUSCULOSKELETAL PROCEDURES; IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR 575 MUSCULOSKELETAL PROCEDURES; WITH IMAGE GUIDANCE BASED ON INTRAOPERATIVELY OBTAINED IMAGES (EG, FLUOROSCOPY, ULTRASOUND) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR 575 MUSCULOSKELETAL PROCEDURES; WITH IMAGE GUIDANCE BASED ON PREOPERATIVE IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL N/A CPT ARTHROTOMY, TEMPOROMANDIBULAR JOINT 2,303 CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 1,334 TISSUE OF FACE OR SCALP CPT EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); 3,139 MANDIBLE CPT EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); 1,884 FACIAL BONE(S) CPT REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE (EG, 2,361 FIBROUS DYSPLASIA) CPT EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA OR ZYGOMA BY 1,577 ENUCLEATION AND CURETTAGE CPT EXCISION OF TORUS MANDIBULARIS 1,215 CPT EXCISION OF MAXILLARY TORUS PALATINUS 1,232 CPT EXCISION OF MALIGNANT TUMOR OF MAXILLA OR ZYGOMA 4,132 CPT EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE, BY ENUCLEATION 1,578 AND/OR CURETTAGE CPT EXCISION OF MALIGNANT TUMOR OF MANDIBLE; 2,748 CPT EXCISION OF MALIGNANT TUMOR OF MANDIBLE; RADICAL RESECTION 3,831 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 32 of 380

33 CPT EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA- 3,440 ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING EXTRA- 4,050 ORAL OSTEOTOMY AND PARTIAL MANDIBULECTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA- 3,477 ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING EXTRA- 3,896 ORAL OSTEOTOMY AND PARTIAL MAXILLECTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 2,670 CPT MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT 2,453 (SEPARATE PROCEDURE) CPT CORONOIDECTOMY (SEPARATE PROCEDURE) 2,018 CPT MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, 1,165 REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE) CPT IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR 2,947 PROSTHESIS CPT IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS 7,136 CPT IMPRESSION AND CUSTOM PREPARATION; INTERIM OBTURATOR 4,964 PROSTHESIS CPT IMPRESSION AND CUSTOM PREPARATION; DEFINITIVE OBTURATOR 5,660 PROSTHESIS CPT IMPRESSION AND CUSTOM PREPARATION; MANDIBULAR RESECTION 5,170 PROSTHESIS CPT IMPRESSION AND CUSTOM PREPARATION; PALATAL AUGMENTATION 4,892 PROSTHESIS CPT IMPRESSION AND CUSTOM PREPARATION; PALATAL LIFT PROSTHESIS 4,665 CPT IMPRESSION AND CUSTOM PREPARATION; SPEECH AID PROSTHESIS 5,226 CPT IMPRESSION AND CUSTOM PREPARATION; ORAL SURGICAL SPLINT 2,163 CPT IMPRESSION AND CUSTOM PREPARATION; AURICULAR PROSTHESIS 5,224 CPT IMPRESSION AND CUSTOM PREPARATION; NASAL PROSTHESIS 5,208 CPT IMPRESSION AND CUSTOM PREPARATION; FACIAL PROSTHESIS N/A CPT UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE N/A CPT APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL FIXATION, 2,488 INCLUDES REMOVAL (SEPARATE PROCEDURE) CPT APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS 2,464 OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL CPT INJECTION PROCEDURE FOR TEMPOROMANDIBULAR JOINT 426 ARTHROGRAPHY CPT GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC 1,918 MATERIAL) CPT GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE 2,422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 33 of 380

34 CPT GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES 2,280 (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) CPT GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE 2,473 GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 9,500 CPT AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, 12,434 ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) CPT REDUCTION FOREHEAD; CONTOURING ONLY 2,376 CPT REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) CPT REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL CPT RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT CPT RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT CPT RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT CPT RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT) CPT RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES) CPT RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) CPT RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I CPT RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I CPT RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I CPT RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I CPT RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION (EG, PLAGIOCEPHALY, TRIGONOCEPHALY, BRACHYCEPHALY), WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 2,803 2,903 4,216 4,084 4,307 4,968 4,634 5,324 5,698 5,382 6,473 7,528 8,336 9,355 5,711 6,520 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 34 of 380

35 CPT RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 4,601 SUPRAORBITAL RIMS; WITH GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) CPT RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 5,280 SUPRAORBITAL RIMS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFTS) CPT RECONSTRUCTION BY CONTOURING OF BENIGN TUMOR OF CRANIAL 2,307 BONES (EG, FIBROUS DYSPLASIA), EXTRACRANIAL CPT RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID 6,360 COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING LESS THAN 40 SQ CM CPT RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID 7,461 COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 40 SQ CM BUT LESS THAN 80 SQ CM CPT RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID 7,532 COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA), WITH MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 80 SQ CM CPT RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) 5,075 AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR 3,865 L OSTEOTOMY; WITHOUT BONE GRAFT CPT RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR 4,493 L OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL 4,229 SPLIT; WITHOUT INTERNAL RIGID FIXATION CPT RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL 4,604 SPLIT; WITH INTERNAL RIGID FIXATION CPT OSTEOTOMY, MANDIBLE, SEGMENTAL; 3,626 CPT OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS 3,219 ADVANCEMENT CPT OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) 3,471 CPT OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, 5,717 ALLOGRAFT, OR PROSTHETIC IMPLANT) CPT OSTEOPLASTY, FACIAL BONES; REDUCTION 2,602 CPT GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES 7,073 OBTAINING GRAFT) CPT GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) 12,537 CPT GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR 2,438 (INCLUDES OBTAINING GRAFT) CPT GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES 2,270 OBTAINING GRAFT) CPT ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT 3,456 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT 3,163 CPT ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT 5,217 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 35 of 380

36 CPT RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL BONE 3,288 PLATE (EG, MANDIBULAR STAPLE BONE PLATE) CPT RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; 3,560 PARTIAL CPT RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; 2,713 COMPLETE CPT RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND 4,983 CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL MICROSOMIA) CPT RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, 3,360 BLADE, CYLINDER); PARTIAL CPT RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, 4,632 BLADE, CYLINDER); COMPLETE CPT RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH 4,352 BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS) CPT RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND 3,588 WITH BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, MICRO- OPHTHALMIA) CPT PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 3,986 GRAFTS; EXTRACRANIAL APPROACH CPT PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 6,540 GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH CPT PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 5,966 GRAFTS; WITH FOREHEAD ADVANCEMENT CPT ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, 4,809 WITH BONE GRAFTS; EXTRACRANIAL APPROACH CPT ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, 5,485 WITH BONE GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH CPT MALAR AUGMENTATION, PROSTHETIC MATERIAL 2,819 CPT SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION 2,529 CPT MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) 1,636 CPT LATERAL CANTHOPEXY 1,073 CPT REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF 529 BENIGN MASSETERIC HYPERTROPHY); EXTRAORAL APPROACH CPT REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF 1,314 BENIGN MASSETERIC HYPERTROPHY); INTRAORAL APPROACH CPT UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE N/A CPT CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION 331 CPT CLOSED TREATMENT OF NASAL BONE FRACTURE; WITHOUT 835 STABILIZATION CPT CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH STABILIZATION 798 CPT OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED 1,429 CPT OPEN TREATMENT OF NASAL FRACTURE; COMPLICATED, WITH INTERNAL AND/OR EXTERNAL SKELETAL FIXATION CPT OPEN TREATMENT OF NASAL FRACTURE; WITH CONCOMITANT OPEN TREATMENT OF FRACTURED SEPTUM CPT OPEN TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT STABILIZATION 1,745 2,282 1,986 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 36 of 380

37 CPT CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT 1,219 STABILIZATION CPT OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL 2,203 FIXATION CPT OPEN TREATMENT OF NASOETHMOID FRACTURE; WITH EXTERNAL 2,415 FIXATION CPT PERCUTANEOUS TREATMENT OF NASOETHMOID COMPLEX FRACTURE, 2,483 WITH SPLINT, WIRE OR HEADCAP FIXATION, INCLUDING REPAIR OF CANTHAL LIGAMENTS AND/OR THE NASOLACRIMAL APPARATUS CPT OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE 3,572 CPT OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING POSTERIOR WALL) FRONTAL SINUS FRACTURE, VIA CORONAL OR MULTIPLE APPROACHES CPT CLOSED TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE), WITH INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CPT OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH WIRING AND/OR LOCAL FIXATION CPT OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); REQUIRING MULTIPLE OPEN APPROACHES CPT OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) CPT PERCUTANEOUS TREATMENT OF FRACTURE OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD, WITH MANIPULATION CPT OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (EG, GILLIES APPROACH) CPT OPEN TREATMENT OF DEPRESSED MALAR FRACTURE, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD CPT OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES CPT OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) CPT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; TRANSANTRAL APPROACH (CALDWELL-LUC TYPE OPERATION) CPT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH CPT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH CPT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT CPT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION CPT OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT CPT OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH IMPLANT CPT OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) 4,639 2,553 2,936 3,345 3,883 1,330 1,528 1,657 3,438 3,958 2,211 2,069 2,332 2,389 3, ,383 1,677 1,984 2,713 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 37 of 380

38 CPT CLOSED TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I 2,391 TYPE), WITH INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CPT OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); 2,096 CPT OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); 2,439 COMPLICATED (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES CPT CLOSED TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) 2,428 USING INTERDENTAL WIRE FIXATION OF DENTURE OR SPLINT CPT OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 2,061 WITH WIRING AND/OR INTERNAL FIXATION CPT OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 5,168 COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE SURGICAL APPROACHES CPT OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 4,165 COMPLICATED, UTILIZING INTERNAL AND/OR EXTERNAL FIXATION TECHNIQUES (EG, HEAD CAP, HALO DEVICE, AND/OR INTERMAXILLARY FIXATION) CPT OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 5,822 COMPLICATED, MULTIPLE SURGICAL APPROACHES, INTERNAL FIXATION, WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) CPT CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE 1,728 FRACTURE (SEPARATE PROCEDURE) CPT OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE 2,405 FRACTURE (SEPARATE PROCEDURE) CPT CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITHOUT 1,811 MANIPULATION CPT CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 2,401 CPT PERCUTANEOUS TREATMENT OF MANDIBULAR FRACTURE, WITH EXTERNAL 1,837 FIXATION CPT CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL 2,762 FIXATION CPT OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION 1,725 CPT OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL 6,517 FIXATION CPT OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL 6,930 FIXATION CPT OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE 2,832 CPT OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE 3,699 SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS CPT CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL 275 OR SUBSEQUENT CPT CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; 2,163 COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT CPT OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION 2,871 CPT OPEN TREATMENT OF HYOID FRACTURE 2,201 CPT INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 2,162 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 38 of 380

39 CPT UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD N/A CPT INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES 1,366 OF NECK OR THORAX; CPT INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES 1,631 OF NECK OR THORAX; WITH PARTIAL RIB OSTECTOMY CPT INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR 1,468 OSTEOMYELITIS OR BONE ABSCESS), THORAX CPT BIOPSY, SOFT TISSUE OF NECK OR THORAX 830 CPT EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; SUBCUTANEOUS 1,353 CPT EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; DEEP, 1,311 SUBFASCIAL, INTRAMUSCULAR CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 1,825 TISSUE OF NECK OR THORAX CPT EXCISION OF RIB, PARTIAL 1,774 CPT COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE) 3,491 CPT EXCISION FIRST AND/OR CERVICAL RIB; 2,130 CPT EXCISION FIRST AND/OR CERVICAL RIB; WITH SYMPATHECTOMY 2,634 CPT OSTECTOMY OF STERNUM, PARTIAL 1,623 CPT STERNAL DEBRIDEMENT 1,730 CPT RADICAL RESECTION OF STERNUM; 4,022 CPT RADICAL RESECTION OF STERNUM; WITH MEDIASTINAL 3,977 LYMPHADENECTOMY CPT HYOID MYOTOMY AND SUSPENSION 3,111 CPT DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF CERVICAL 1,378 RIB CPT DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CERVICAL RIB 1,966 CPT DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN 1,351 OPERATION; WITHOUT CAST APPLICATION CPT DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN 1,694 OPERATION; WITH CAST APPLICATION CPT RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN 3,530 CPT RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; 3,236 MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY CPT RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; 4,291 MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY CPT CLOSURE OF MEDIAN STERNOTOMY SEPARATION WITH OR WITHOUT 2,303 DEBRIDEMENT (SEPARATE PROCEDURE) CPT CLOSED TREATMENT OF RIB FRACTURE, UNCOMPLICATED, EACH 305 CPT OPEN TREATMENT OF RIB FRACTURE WITHOUT FIXATION, EACH 811 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 39 of 380

40 CPT TREATMENT OF RIB FRACTURE REQUIRING EXTERNAL FIXATION (FLAIL 1,666 CHEST) CPT CLOSED TREATMENT OF STERNUM FRACTURE 415 CPT OPEN TREATMENT OF STERNUM FRACTURE WITH OR WITHOUT SKELETAL 1,779 FIXATION CPT UNLISTED PROCEDURE, NECK OR THORAX N/A CPT BIOPSY, SOFT TISSUE OF BACK OR FLANK; SUPERFICIAL 838 CPT BIOPSY, SOFT TISSUE OF BACK OR FLANK; DEEP 1,320 CPT EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK 1,481 CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK CPT INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC CPT INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL CPT PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL CPT PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; THORACIC CPT PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; LUMBAR CPT PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; CERVICAL CPT PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; THORACIC CPT PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; LUMBAR CPT PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); THORACIC CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 3,689 2,853 2,834 2,660 2,631 2, ,233 3,200 3, ,673 7,574 1,945 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 40 of 380

41 CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 5,683 VERTEBRAL SEGMENT; CERVICAL CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 4,669 VERTEBRAL SEGMENT; THORACIC CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 4,686 VERTEBRAL SEGMENT; LUMBAR CPT OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 1,213 VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 5,177 SINGLE VERTEBRAL SEGMENT; CERVICAL CPT OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 4,712 SINGLE VERTEBRAL SEGMENT; THORACIC CPT OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 5,025 SINGLE VERTEBRAL SEGMENT; LUMBAR CPT OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 1,208 SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) 581 CPT CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), WITHOUT 903 MANIPULATION, REQUIRING AND INCLUDING CASTING OR BRACING CPT CLOSED TREATMENT OF VERTEBRAL FRACTURE(S) AND/OR 2,726 DISLOCATION(S) REQUIRING CASTING OR BRACING, WITH AND INCLUDING CASTING AND/OR BRACING, WITH OR WITHOUT ANESTHESIA, BY MANIPULATION OR TRACTION CPT OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND 5,174 OR DISLOCATION(S) (INCLUDING OS ODONTOIDEUM), ANTERIOR APPROACH, INCLUDING PLACEMENT OF INTERNAL FIXATION; WITHOUT GRAFTING CPT OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND 5,621 OR DISLOCATION(S) (INCLUDING OS ODONTOIDEUM), ANTERIOR APPROACH, INCLUDING PLACEMENT OF INTERNAL FIXATION; WITH GRAFTING CPT OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) 4,487 AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRA OR DISLOCATED SEGMENT; LUMBAR CPT OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) 4,669 AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRA OR DISLOCATED SEGMENT; CERVICAL CPT OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) 4,638 AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRA OR DISLOCATED SEGMENT; THORACIC CPT OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) 918 AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRA OR DISLOCATED SEGMENT; EACH ADDITIONAL FRACTURED VERTEBRA OR DISLOCATED SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION 419 CPT PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC CPT PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR CPT PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 6,887 6, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 41 of 380

42 PROCEDURE) CPT PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY 1,963 CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); THORACIC CPT PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY 1,880 CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); LUMBAR CPT PERCUTANEOUS VERTEBRAL AUGMENTATION, INCLUDING CAVITY 878 CREATION (FRACTURE REDUCTION AND BONE BIOPSY INCLUDED WHEN PERFORMED) USING MECHANICAL DEVICE, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL CANNULATION (EG, KYPHOPLASTY); EACH ADDITIONAL THORACIC OR LUMBAR VERTEBRAL BODY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, 6,791 UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL CPT PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, 5,539 UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; ONE OR MORE ADDITIONAL LEVELS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 5,531 MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC CPT ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 5,204 MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR CPT ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 1,198 MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, 5,967 CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS CPT ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 4,109 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2 CPT ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 5,262 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC CPT ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 4,774 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR CPT ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 1,111 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) 4,963 CPT ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) 4,720 CPT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT 4,044 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 42 of 380

43 CPT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 3,956 LEVEL; THORACIC (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) CPT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 5,078 LEVEL; LUMBAR (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) CPT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 1,292 LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING 4,929 LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR CPT ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING 1,053 LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 4,307 CAST; UP TO 6 VERTEBRAL SEGMENTS CPT ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 6,807 CAST; 7 TO 12 VERTEBRAL SEGMENTS CPT ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 7,858 CAST; 13 OR MORE VERTEBRAL SEGMENTS CPT ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 5,827 CAST; 2 TO 3 VERTEBRAL SEGMENTS CPT ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 6,465 CAST; 4 TO 7 VERTEBRAL SEGMENTS CPT ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 7,135 CAST; 8 OR MORE VERTEBRAL SEGMENTS CPT KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION 7,209 OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); SINGLE OR 2 SEGMENTS CPT KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION 8,273 OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); 3 OR MORE SEGMENTS CPT EXPLORATION OF SPINAL FUSION 2,579 CPT POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS ONE INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXATION, SUBLAMINAR WIRING AT C1, FACET SCREW FIXATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 7 TO 12 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH MULTIPLE HOOKS AND SUBLAMINAR WIRES); 13 OR MORE VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 2,528 1,327 2,531 2,701 3,275 2,428 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 43 of 380

44 CPT ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST 2,519 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS (LIST 2,766 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION 1,193 TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REINSERTION OF SPINAL FIXATION DEVICE 4,172 CPT REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, 2,290 HARRINGTON ROD) CPT APPLICATION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, 1,350 SYNTHETIC CAGE(S), THREADED BONE DOWEL(S), METHYLMETHACRYLATE) TO VERTEBRAL DEFECT OR INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION 2,186 CPT REMOVAL OF ANTERIOR INSTRUMENTATION 3,583 CPT TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, 5,703 INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, SINGLE INTERSPACE CPT REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY 6,781 (ARTIFICIAL DISC) ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE CPT REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR 6,604 APPROACH, LUMBAR, SINGLE INTERSPACE CPT UNLISTED PROCEDURE, SPINE N/A CPT EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (EG, DESMOID) 1,314 CPT UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM N/A CPT REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN 1,632 CPT CAPSULAR CONTRACTURE RELEASE (EG, SEVER TYPE PROCEDURE) 2,173 CPT INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR 1,296 HEMATOMA CPT INCISION AND DRAINAGE, SHOULDER AREA; INFECTED BURSA 1,225 CPT INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), 2,136 SHOULDER AREA CPT ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, 2,263 DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, 1,792 INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT BIOPSY, SOFT TISSUE OF SHOULDER AREA; SUPERFICIAL 684 CPT BIOPSY, SOFT TISSUE OF SHOULDER AREA; DEEP 1,585 CPT EXCISION, SOFT TISSUE TUMOR, SHOULDER AREA; SUBCUTANEOUS 811 CPT EXCISION, SOFT TISSUE TUMOR, SHOULDER AREA; DEEP, SUBFASCIAL, OR INTRAMUSCULAR CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF SHOULDER AREA 1,789 3,779 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 44 of 380

45 CPT ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING BIOPSY 1,526 CPT ARTHROTOMY, ACROMIOCLAVICULAR JOINT OR STERNOCLAVICULAR 1,400 JOINT, INCLUDING BIOPSY AND/OR EXCISION OF TORN CARTILAGE CPT ARTHROTOMY; GLENOHUMERAL JOINT, WITH SYNOVECTOMY, WITH OR 1,998 WITHOUT BIOPSY CPT ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH SYNOVECTOMY, WITH 1,485 OR WITHOUT BIOPSY CPT ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH 2,076 OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT CLAVICULECTOMY; PARTIAL 1,753 CPT CLAVICULECTOMY; TOTAL 2,206 CPT ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT 1,889 CORACOACROMIAL LIGAMENT RELEASE CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 1,635 CLAVICLE OR SCAPULA; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,172 CLAVICLE OR SCAPULA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 1,916 CLAVICLE OR SCAPULA; WITH ALLOGRAFT CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,060 PROXIMAL HUMERUS; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,490 PROXIMAL HUMERUS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,112 PROXIMAL HUMERUS; WITH ALLOGRAFT CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 1,664 CLAVICLE CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 1,728 SCAPULA CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 2,357 HUMERAL HEAD TO SURGICAL NECK CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,107 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), CLAVICLE CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,047 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), SCAPULA CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,305 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS CPT OSTECTOMY OF SCAPULA, PARTIAL (EG, SUPERIOR MEDIAL ANGLE) 1,742 CPT RESECTION, HUMERAL HEAD 2,375 CPT RADICAL RESECTION FOR TUMOR; CLAVICLE 2,737 CPT RADICAL RESECTION FOR TUMOR; SCAPULA 2,895 CPT RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; 3,398 CPT RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH 4,039 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH 5,379 PROSTHETIC REPLACEMENT CPT REMOVAL OF FOREIGN BODY, SHOULDER; SUBCUTANEOUS 688 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 45 of 380

46 CPT REMOVAL OF FOREIGN BODY, SHOULDER; DEEP (EG, NEER 1,840 HEMIARTHROPLASTY REMOVAL) CPT REMOVAL OF FOREIGN BODY, SHOULDER; COMPLICATED (EG, TOTAL 2,798 SHOULDER) CPT INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED 477 CT/MRI SHOULDER ARTHROGRAPHY CPT MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; SINGLE 4,083 CPT MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; MULTIPLE 3,640 CPT SCAPULOPEXY (EG, SPRENGELS DEFORMITY OR FOR PARALYSIS) 3,093 CPT TENOTOMY, SHOULDER AREA; SINGLE TENDON 1,988 CPT TENOTOMY, SHOULDER AREA; MULTIPLE TENDONS THROUGH SAME 2,478 INCISION CPT REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) 2,842 OPEN; ACUTE CPT REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) 3,024 OPEN; CHRONIC CPT CORACOACROMIAL LIGAMENT RELEASE, WITH OR WITHOUT 2,318 ACROMIOPLASTY CPT RECONSTRUCTION OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, 3,370 CHRONIC (INCLUDES ACROMIOPLASTY) CPT TENODESIS OF LONG TENDON OF BICEPS 2,337 CPT RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS 2,409 CPT CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON 3,032 TYPE OPERATION CPT CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART 3,223 PROCEDURE) CPT CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK 3,489 CPT CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS 3,434 TRANSFER CPT CAPSULORRHAPHY, GLENOHUMERAL JOINT, POSTERIOR, WITH OR 3,578 WITHOUT BONE BLOCK CPT CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTI- 3,526 DIRECTIONAL INSTABILITY CPT ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY 3,885 CPT ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID 4,819 AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) CPT OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION; 2,601 CPT OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION; WITH 3,063 BONE GRAFT FOR NONUNION OR MALUNION (INCLUDES OBTAINING GRAFT AND/OR NECESSARY FIXATION) CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,550 WITH OR WITHOUT METHYLMETHACRYLATE; CLAVICLE CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 3,221 WITH OR WITHOUT METHYLMETHACRYLATE; PROXIMAL HUMERUS CPT CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT 638 MANIPULATION CPT CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITH MANIPULATION 1,052 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 46 of 380

47 CPT OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL 2,243 FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITHOUT 669 MANIPULATION CPT CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITH 1,044 MANIPULATION CPT OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR 1,747 CHRONIC; CPT OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR 1,948 CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT CLOSED TREATMENT OF ACROMIOCLAVICULAR DISLOCATION; WITHOUT 659 MANIPULATION CPT CLOSED TREATMENT OF ACROMIOCLAVICULAR DISLOCATION; WITH 932 MANIPULATION CPT OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR 1,796 CHRONIC; CPT OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR 2,066 CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION 682 CPT CLOSED TREATMENT OF SCAPULAR FRACTURE; WITH MANIPULATION, 1,170 WITH OR WITHOUT SKELETAL TRACTION (WITH OR WITHOUT SHOULDER JOINT INVOLVEMENT) CPT OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR 3,035 ACROMION) WITH OR WITHOUT INTERNAL FIXATION CPT CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 950 NECK) FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 1,404 NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 2,743 NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; CPT OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 4,071 NECK) FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TUBEROSITY(S), WHEN PERFORMED; WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT CPT CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; 789 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; 1,146 WITH MANIPULATION CPT OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, 2,395 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 884 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 1,193 REQUIRING ANESTHESIA CPT OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION 1,828 CPT CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH MANIPULATION CPT OPEN TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR ANATOMICAL NECK FRACTURE, WITH MANIPULATION 1,271 2,694 1,670 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 47 of 380

48 CPT OPEN TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR 2,893 ANATOMICAL NECK FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING 614 APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED) CPT ARTHRODESIS, GLENOHUMERAL JOINT; 3,249 CPT ARTHRODESIS, GLENOHUMERAL JOINT; WITH AUTOGENOUS GRAFT 4,040 (INCLUDES OBTAINING GRAFT) CPT INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER) 4,303 CPT DISARTICULATION OF SHOULDER; 3,489 CPT DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR SCAR 1,414 REVISION CPT UNLISTED PROCEDURE, SHOULDER N/A CPT INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS 1,053 OR HEMATOMA CPT INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA 811 CPT INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR 1,563 OSTEOMYELITIS OR BONE ABSCESS), HUMERUS OR ELBOW CPT ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, OR 1,473 REMOVAL OF FOREIGN BODY CPT ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR CAPSULAR 2,230 RELEASE (SEPARATE PROCEDURE) CPT BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; SUPERFICIAL 808 CPT BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP 1,803 (SUBFASCIAL OR INTRAMUSCULAR) CPT EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; 1,473 SUBCUTANEOUS CPT EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP 1,497 (SUBFASCIAL OR INTRAMUSCULAR) CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,585 TISSUE OF UPPER ARM OR ELBOW AREA CPT ARTHROTOMY, ELBOW; WITH SYNOVIAL BIOPSY ONLY 1,248 CPT ARTHROTOMY, ELBOW; WITH JOINT EXPLORATION, WITH OR WITHOUT 1,544 BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT ARTHROTOMY, ELBOW; WITH SYNOVECTOMY 1,924 CPT EXCISION, OLECRANON BURSA 1,045 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; 1,811 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; WITH ALLOGRAFT CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) 2,013 2,750 1,635 1,896 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 48 of 380

49 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR 1,972 NECK OF RADIUS OR OLECRANON PROCESS; WITH ALLOGRAFT CPT EXCISION, RADIAL HEAD 1,570 CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), SHAFT 2,347 OR DISTAL HUMERUS CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), RADIAL 1,943 HEAD OR NECK CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 2,034 OLECRANON PROCESS CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,205 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), HUMERUS CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,836 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), RADIAL HEAD OR NECK CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,922 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS CPT RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC 3,655 BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE) CPT RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; 3,087 CPT RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; WITH 3,572 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; 2,251 CPT RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; WITH 2,182 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT RESECTION OF ELBOW JOINT (ARTHRECTOMY) 2,683 CPT IMPLANT REMOVAL; ELBOW JOINT 1,890 CPT IMPLANT REMOVAL; RADIAL HEAD 1,544 CPT REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; 594 SUBCUTANEOUS CPT REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP 1,652 (SUBFASCIAL OR INTRAMUSCULAR) CPT INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY 509 CPT MANIPULATION, ELBOW, UNDER ANESTHESIA 1,217 CPT MUSCLE OR TENDON TRANSFER, ANY TYPE, UPPER ARM OR ELBOW, 2,360 SINGLE (EXCLUDING ) CPT TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON 1,802 CPT TENOTOMY, OPEN, ELBOW TO SHOULDER, EACH TENDON 1,475 CPT TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT FREE GRAFT, 2,455 ELBOW TO SHOULDER, SINGLE (SEDDON-BROOKES TYPE PROCEDURE) CPT FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE ADVANCEMENT); 2,254 CPT FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE ADVANCEMENT); WITH 2,462 EXTENSOR ADVANCEMENT CPT TENOLYSIS, TRICEPS 1,877 CPT TENODESIS OF BICEPS TENDON AT ELBOW (SEPARATE PROCEDURE) 1,923 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 49 of 380

50 CPT REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR 2,282 MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF) CPT REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH 2,475 OR WITHOUT TENDON GRAFT CPT REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE 2,191 CPT RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, WITH 3,436 TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) CPT REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE 2,186 CPT RECONSTRUCTION MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH 3,442 TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) CPT TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS 1,373 ELBOW, GOLFER'S ELBOW); PERCUTANEOUS CPT TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS 1,622 ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN CPT TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS 2,073 ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN WITH TENDON REPAIR OR REATTACHMENT CPT ARTHROPLASTY, ELBOW; WITH MEMBRANE (EG, FASCIAL) 2,823 CPT ARTHROPLASTY, ELBOW; WITH DISTAL HUMERAL PROSTHETIC 3,174 REPLACEMENT CPT ARTHROPLASTY, ELBOW; WITH IMPLANT AND FASCIA LATA LIGAMENT 2,961 RECONSTRUCTION CPT ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR 4,741 PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW) CPT ARTHROPLASTY, RADIAL HEAD; 2,000 CPT ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT 2,149 CPT OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXATION 2,595 CPT MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDULLARY ROD, HUMERAL SHAFT (SOFIELD TYPE PROCEDURE) CPT OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENING) (EXCLUDING 64876) CPT REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE) CPT REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT HEMIEPIPHYSEAL ARREST (EG, CUBITUS VARUS OR VALGUS, DISTAL HUMERUS) CPT DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL ARTERY EXPLORATION CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING), WITH OR WITHOUT METHYLMETHACRYLATE, HUMERAL SHAFT CPT CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE CPT TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS 3,372 3,054 3,338 3,378 2,007 2,000 2,756 1,037 1,507 2,774 2,737 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 50 of 380

51 CPT CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL 1,116 FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL 1,883 FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR 2,323 TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION CPT OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR 2,907 FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION CPT OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR 3,345 FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION CPT CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 933 LATERAL; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 1,574 LATERAL; WITH MANIPULATION CPT PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR 2,134 FRACTURE, MEDIAL OR LATERAL, WITH MANIPULATION CPT OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 2,312 LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 983 LATERAL; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 1,618 LATERAL; WITH MANIPULATION CPT OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 2,647 LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE, 2,460 MEDIAL OR LATERAL, WITH MANIPULATION CPT OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION 3,476 OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); CPT OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION 3,461 OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); WITH IMPLANT ARTHROPLASTY CPT TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 1,087 CPT TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA 1,422 CPT OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION 2,250 CPT CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), WITH MANIPULATION CPT OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION CPT CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION CPT OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; 1,715 2, ,304 2,031 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 51 of 380

52 CPT OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES 2,305 INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; WITH RADIAL HEAD PROSTHETIC REPLACEMENT CPT CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, 848 OLECRANON OR CORONOID PROCESS[ES]); WITHOUT MANIPULATION CPT CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, 1,382 OLECRANON OR CORONOID PROCESS[ES]); WITH MANIPULATION CPT OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON 2,045 OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT ARTHRODESIS, ELBOW JOINT; LOCAL 2,490 CPT ARTHRODESIS, ELBOW JOINT; WITH AUTOGENOUS GRAFT (INCLUDES 3,095 OBTAINING GRAFT) CPT AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOSURE 2,264 CPT AMPUTATION, ARM THROUGH HUMERUS; OPEN, CIRCULAR (GUILLOTINE) 2,224 CPT AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE OR SCAR 1,671 REVISION CPT AMPUTATION, ARM THROUGH HUMERUS; RE-AMPUTATION 2,341 CPT AMPUTATION, ARM THROUGH HUMERUS; WITH IMPLANT 2,555 CPT STUMP ELONGATION, UPPER EXTREMITY 3,638 CPT CINEPLASTY, UPPER EXTREMITY, COMPLETE PROCEDURE 3,397 CPT UNLISTED PROCEDURE, HUMERUS OR ELBOW N/A CPT INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DEQUERVAINS 1,003 DISEASE) CPT INCISION, FLEXOR TENDON SHEATH, WRIST (EG, FLEXOR CARPI 1,029 RADIALIS) CPT DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR 1,743 EXTENSOR COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR 3,406 EXTENSOR COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND 2,399 EXTENSOR COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND 3,687 EXTENSOR COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT INCISION AND DRAINAGE, FOREARM AND/OR WRIST; DEEP ABSCESS OR 1,549 HEMATOMA CPT INCISION AND DRAINAGE, FOREARM AND/OR WRIST; BURSA 1,044 CPT INCISION, DEEP, BONE CORTEX, FOREARM AND/OR WRIST (EG, 1,813 OSTEOMYELITIS OR BONE ABSCESS) CPT ARTHROTOMY, RADIOCARPAL OR MIDCARPAL JOINT, WITH EXPLORATION, 1,757 DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; SUPERFICIAL 816 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 52 of 380

53 CPT BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL 1,090 OR INTRAMUSCULAR) CPT EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA; 961 SUBCUTANEOUS CPT EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA; 1,236 DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,202 TISSUE OF FOREARM AND/OR WRIST AREA CPT CAPSULOTOMY, WRIST (EG, CONTRACTURE) 1,387 CPT ARTHROTOMY, WRIST JOINT; WITH BIOPSY 1,044 CPT ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR 1,238 WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT ARTHROTOMY, WRIST JOINT; WITH SYNOVECTOMY 1,486 CPT ARTHROTOMY, DISTAL RADIOULNAR JOINT INCLUDING REPAIR OF 1,854 TRIANGULAR CARTILAGE, COMPLEX CPT EXCISION OF TENDON, FOREARM AND/OR WRIST, FLEXOR OR EXTENSOR, 1,637 EACH CPT EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST 1,032 CPT EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY 955 CPT EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT 1,178 CPT RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); FLEXORS CPT RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, WITH OR WITHOUT TRANSPOSITION OF DORSAL RETINACULUM CPT SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; CPT SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); WITH ALLOGRAFT CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH ALLOGRAFT CPT SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), FOREARM AND/OR WRIST CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); ULNA 2,333 1,847 1,164 1,526 1,543 1,798 1,856 1,365 1,711 1,530 1,592 1,754 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 53 of 380

54 CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,812 DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); RADIUS CPT RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA 2,579 CPT CARPECTOMY; ONE BONE 1,502 CPT CARPECTOMY; ALL BONES OF PROXIMAL ROW 1,918 CPT RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE) 1,330 CPT EXCISION DISTAL ULNA PARTIAL OR COMPLETE (EG, DARRACH TYPE OR 1,321 MATCHED RESECTION) CPT INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY 537 CPT EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR 1,254 WRIST CPT REMOVAL OF WRIST PROSTHESIS; (SEPARATE PROCEDURE) 1,628 CPT REMOVAL OF WRIST PROSTHESIS; COMPLICATED, INCLUDING TOTAL 2,229 WRIST CPT MANIPULATION, WRIST, UNDER ANESTHESIA 1,213 CPT REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 1,945 PRIMARY, SINGLE, EACH TENDON OR MUSCLE CPT REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 1,910 SECONDARY, SINGLE, EACH TENDON OR MUSCLE CPT REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 2,333 SECONDARY, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE CPT REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 1,507 PRIMARY, SINGLE, EACH TENDON OR MUSCLE CPT REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 1,724 SECONDARY, SINGLE, EACH TENDON OR MUSCLE CPT REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 2,083 SECONDARY, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE CPT REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH 2,090 FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION) CPT LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TENDON, 1,752 FOREARM AND/OR WRIST, SINGLE, EACH TENDON CPT TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR 1,341 WRIST, SINGLE, EACH TENDON CPT TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, 1,623 SINGLE, EACH TENDON CPT TENODESIS AT WRIST; FLEXORS OF FINGERS 2,114 CPT TENODESIS AT WRIST; EXTENSORS OF FINGERS 2,007 CPT TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON CPT TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; WITH TENDON GRAFT(S) (INCLUDES OBTAINING GRAFT), EACH TENDON CPT FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PALSY, VOLKMANN CONTRACTURE), FOREARM AND/OR WRIST; 1,939 2,243 2,422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 54 of 380

55 CPT FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PALSY, VOLKMANN 2,810 CONTRACTURE), FOREARM AND/OR WRIST; WITH TENDON(S) TRANSFER CPT CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, 3,003 CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY CPT ARTHROPLASTY, WRIST, WITH OR WITHOUT INTERPOSITION, WITH OR 2,649 WITHOUT EXTERNAL OR INTERNAL FIXATION CPT CENTRALIZATION OF WRIST ON ULNA (EG, RADIAL CLUB HAND) 2,956 CPT RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR 2,728 DISTAL RADIOULNAR JOINT, SECONDARY BY SOFT TISSUE STABILIZATION (EG, TENDON TRANSFER, TENDON GRAFT OR WEAVE, OR TENODESIS) WITH OR WITHOUT OPEN REDUCTION OF DISTAL RADIOULNAR JOINT CPT OSTEOTOMY, RADIUS; DISTAL THIRD 2,112 CPT OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD 2,378 CPT OSTEOTOMY; ULNA 2,047 CPT OSTEOTOMY; RADIUS AND ULNA 2,908 CPT MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,175 (SOFIELD TYPE PROCEDURE); RADIUS OR ULNA CPT MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,027 (SOFIELD TYPE PROCEDURE); RADIUS AND ULNA CPT OSTEOPLASTY, RADIUS OR ULNA; SHORTENING 2,429 CPT OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTOGRAFT 3,150 CPT OSTEOPLASTY, RADIUS AND ULNA; SHORTENING (EXCLUDING 64876) 3,204 CPT OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUTOGRAFT 3,620 CPT OSTEOPLASTY, CARPAL BONE, SHORTENING 2,422 CPT REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITHOUT GRAFT 2,550 (EG, COMPRESSION TECHNIQUE) CPT REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH 3,288 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITHOUT 3,101 GRAFT (EG, COMPRESSION TECHNIQUE) CPT REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITH 3,705 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS OR ULNA 3,041 CPT REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS AND ULNA 3,531 CPT INSERTION OF VASCULAR PEDICLE INTO CARPAL BONE (EG, HORI PROCEDURE) CPT REPAIR OF NONUNION OF CARPAL BONE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)) (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION), EACH BONE CPT REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION) 2,250 2,494 2,402 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 55 of 380

56 CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS 2,937 CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL ULNA 2,519 CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID CARPAL 2,405 (NAVICULAR) CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE 2,572 CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM 2,266 CPT ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS AND 3,729 PARTIAL OR ENTIRE CARPUS (TOTAL WRIST) CPT ARTHROPLASTY, INTERPOSITION, INTERCARPAL OR CARPOMETACARPAL 2,571 JOINTS CPT REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, WRIST 3,270 JOINT CPT EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS 1,653 OR ULNA CPT EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS 2,187 AND ULNA CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,217 WITH OR WITHOUT METHYLMETHACRYLATE; RADIUS CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,318 WITH OR WITHOUT METHYLMETHACRYLATE; ULNA CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,896 WITH OR WITHOUT METHYLMETHACRYLATE; RADIUS AND ULNA CPT CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITHOUT 776 MANIPULATION CPT CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION 1,514 CPT OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL 2,102 FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF RADIAL SHAFT FRACTURE AND CLOSED 1,652 TREATMENT OF DISLOCATION OF DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION) CPT OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL 2,507 FIXATION, WHEN PERFORMED, AND CLOSED TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES PERCUTANEOUS SKELETAL FIXATION, WHEN PERFORMED CPT OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL 3,001 FIXATION, WHEN PERFORMED, AND OPEN TREATMENT OF DISTAL RADIOULNAR JOINT DISLOCATION (GALEAZZI FRACTURE/ DISLOCATION), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, INCLUDES REPAIR OF TRIANGULAR FIBROCARTILAGE COMPLEX CPT CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITHOUT 751 MANIPULATION CPT CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITH MANIPULATION 1,470 CPT OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION CPT OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA 1, ,579 2,064 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 56 of 380

57 CPT OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH 2,805 INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA CPT CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR 854 SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR 1,874 SMITH TYPE) OR EPIPHYSEAL SEPARATION, INCLUDES CLOSED TREATMENT OF FRACTURE OF ULNAR STYLOID, WHEN PERFORMED; WITH MANIPULATION CPT PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR 2,021 EPIPHYSEAL SEPARATION CPT OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR 2,254 EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION CPT OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR 2,580 EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS CPT OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR 3,292 EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS CPT CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; 881 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; 1,387 WITH MANIPULATION CPT OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, 2,231 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL 899 SCAPHOID (NAVICULAR)); WITHOUT MANIPULATION, EACH BONE CPT CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL 1,300 SCAPHOID (NAVICULAR)); WITH MANIPULATION, EACH BONE CPT OPEN TREATMENT OF CARPAL BONE FRACTURE (OTHER THAN CARPAL 1,770 SCAPHOID (NAVICULAR)), EACH BONE CPT CLOSED TREATMENT OF ULNAR STYLOID FRACTURE 933 CPT PERCUTANEOUS SKELETAL FIXATION OF ULNAR STYLOID FRACTURE 1,471 CPT OPEN TREATMENT OF ULNAR STYLOID FRACTURE 1,924 CPT CLOSED TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, 1,227 ONE OR MORE BONES, WITH MANIPULATION CPT OPEN TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE 1,898 OR MORE BONES CPT PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIOULNAR 1,618 DISLOCATION CPT CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH 1,270 MANIPULATION CPT OPEN TREATMENT OF DISTAL RADIOULNAR DISLOCATION, ACUTE OR 1,969 CHRONIC CPT CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE 1,416 DISLOCATION, WITH MANIPULATION CPT OPEN TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE 2,290 DISLOCATION CPT CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION 1,423 CPT OPEN TREATMENT OF LUNATE DISLOCATION 1,979 CPT ARTHRODESIS, WRIST; COMPLETE, WITHOUT BONE GRAFT (INCLUDES RADIOCARPAL AND/OR INTERCARPAL AND/OR CARPOMETACARPAL 2,305 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 57 of 380

58 JOINTS) CPT ARTHRODESIS, WRIST; WITH SLIDING GRAFT 2,653 CPT ARTHRODESIS, WRIST; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES 2,702 OBTAINING GRAFT) CPT ARTHRODESIS, WRIST; LIMITED, WITHOUT BONE GRAFT (EG, 1,906 INTERCARPAL OR RADIOCARPAL) CPT ARTHRODESIS, WRIST; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) 2,342 CPT ARTHRODESIS, DISTAL RADIOULNAR JOINT WITH SEGMENTAL RESECTION 2,873 OF ULNA, WITH OR WITHOUT BONE GRAFT (EG, SAUVE-KAPANDJI PROCEDURE) CPT AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; 2,202 CPT AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; OPEN, CIRCULAR 2,133 (GUILLOTINE) CPT AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECONDARY 1,869 CLOSURE OR SCAR REVISION CPT AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; RE-AMPUTATION 2,136 CPT KRUKENBERG PROCEDURE 3,310 CPT DISARTICULATION THROUGH WRIST; 2,122 CPT DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE OR SCAR 1,880 REVISION CPT DISARTICULATION THROUGH WRIST; RE-AMPUTATION 2,032 CPT TRANSMETACARPAL AMPUTATION; 2,380 CPT TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR SCAR 1,827 REVISION CPT TRANSMETACARPAL AMPUTATION; RE-AMPUTATION 2,191 CPT UNLISTED PROCEDURE, FOREARM OR WRIST N/A CPT DRAINAGE OF FINGER ABSCESS; SIMPLE 730 CPT DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON) 1,106 CPT DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH 1,314 CPT DRAINAGE OF PALMAR BURSA; SINGLE, BURSA 1,285 CPT DRAINAGE OF PALMAR BURSA; MULTIPLE BURSA 1,520 CPT INCISION, BONE CORTEX, HAND OR FINGER (EG, OSTEOMYELITIS OR 1,646 BONE ABSCESS) CPT DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJURY (EG, 2,610 GREASE GUN) CPT DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035) 1,776 CPT FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); PERCUTANEOUS CPT FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); OPEN, PARTIAL 945 1,439 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 58 of 380

59 CPT TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER) 1,570 CPT TENOTOMY, PERCUTANEOUS, SINGLE, EACH DIGIT 800 CPT ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 915 OR FOREIGN BODY; CARPOMETACARPAL JOINT CPT ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 972 OR FOREIGN BODY; METACARPOPHALANGEAL JOINT, EACH CPT ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 1,175 OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH CPT ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH 996 CPT ARTHROTOMY WITH BIOPSY; METACARPOPHALANGEAL JOINT, EACH 1,009 CPT ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL JOINT, EACH 970 CPT EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND 1,806 OR FINGER; SUBCUTANEOUS CPT EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND 1,480 OR FINGER; DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,022 TISSUE OF HAND OR FINGER CPT FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL 1,851 TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT) CPT FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT 2,552 INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z- PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); CPT FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT 902 INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z- PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SYNOVECTOMY, CARPOMETACARPAL JOINT 1,423 CPT SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING INTRINSIC 1,706 RELEASE AND EXTENSOR HOOD RECONSTRUCTION, EACH DIGIT CPT SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, INCLUDING 1,550 EXTENSOR RECONSTRUCTION, EACH INTERPHALANGEAL JOINT CPT SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), 1,578 FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON CPT EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, 1,635 MUCOUS CYST, OR GANGLION), HAND OR FINGER CPT EXCISION OF TENDON, PALM, FLEXOR OR EXTENSOR, SINGLE, EACH 1,243 TENDON CPT EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON 1,350 CPT SESAMOIDECTOMY, THUMB OR FINGER (SEPARATE PROCEDURE) 1,618 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; 1,384 1,871 1,351 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 59 of 380

60 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 1,721 PROXIMAL, MIDDLE, OR DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,553 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,528 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,354 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); DISTAL PHALANX OF FINGER CPT RADICAL RESECTION, METACARPAL (EG, TUMOR); 1,812 CPT RADICAL RESECTION, METACARPAL (EG, TUMOR); WITH AUTOGRAFT 2,867 (INCLUDES OBTAINING GRAFT) CPT RADICAL RESECTION, PROXIMAL OR MIDDLE PHALANX OF FINGER (EG, 1,708 TUMOR); CPT RADICAL RESECTION, PROXIMAL OR MIDDLE PHALANX OF FINGER (EG, 2,158 TUMOR); WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT RADICAL RESECTION, DISTAL PHALANX OF FINGER (EG, TUMOR) 1,428 CPT REMOVAL OF IMPLANT FROM FINGER OR HAND 1,057 CPT MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT 959 CPT REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR SECONDARY WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY, WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON CPT REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; SECONDARY WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; SECONDARY WITHOUT FREE GRAFT, EACH TENDON CPT EXCISION FLEXOR TENDON, WITH IMPLANTATION OF SYNTHETIC ROD FOR DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD CPT REMOVAL OF SYNTHETIC ROD AND INSERTION OF FLEXOR TENDON GRAFT, HAND OR FINGER (INCLUDES OBTAINING GRAFT), EACH ROD CPT REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 2,081 2,385 3,165 2,560 2,713 2,240 2,621 2,478 2,507 2,910 1,642 2,010 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 60 of 380

61 CPT EXCISION OF EXTENSOR TENDON, WITH IMPLANTATION OF SYNTHETIC 2,120 ROD FOR DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD CPT REMOVAL OF SYNTHETIC ROD AND INSERTION OF EXTENSOR TENDON 2,426 GRAFT (INCLUDES OBTAINING GRAFT), HAND OR FINGER, EACH ROD CPT REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; 1,655 WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITH 2,103 FREE GRAFT (INCLUDES OBTAINING GRAFT) EACH TENDON CPT REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, 1,545 BOUTONNIERE DEFORMITY); USING LOCAL TISSUE(S), INCLUDING LATERAL BAND(S), EACH FINGER CPT REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, 2,219 BOUTONNIERE DEFORMITY); WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH FINGER CPT CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR 1,447 WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER) CPT REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR 1,554 SECONDARY; WITHOUT GRAFT (EG, MALLET FINGER) CPT REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR 1,890 SECONDARY; WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) CPT REALIGNMENT OF EXTENSOR TENDON, HAND, EACH TENDON 1,836 CPT TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON 1,801 CPT TENOLYSIS, FLEXOR TENDON; PALM AND FINGER, EACH TENDON 2,835 CPT TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON 1,667 CPT TENOLYSIS, COMPLEX, EXTENSOR TENDON, FINGER, INCLUDING 2,099 FOREARM, EACH TENDON CPT TENOTOMY, FLEXOR, PALM, OPEN, EACH TENDON 1,194 CPT TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON 1,184 CPT TENOTOMY, EXTENSOR, HAND OR FINGER, OPEN, EACH TENDON 1,154 CPT TENODESIS; OF PROXIMAL INTERPHALANGEAL JOINT, EACH JOINT 1,821 CPT TENODESIS; OF DISTAL JOINT, EACH JOINT 1,730 CPT LENGTHENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON 1,685 CPT SHORTENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON 1,711 CPT LENGTHENING OF TENDON, FLEXOR, HAND OR FINGER, EACH TENDON 1,831 CPT SHORTENING OF TENDON, FLEXOR, HAND OR FINGER, EACH TENDON 1,820 CPT TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON CPT TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITHOUT FREE TENDON GRAFT, EACH TENDON CPT TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 2,196 2,498 2,392 2,747 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 61 of 380

62 CPT OPPONENSPLASTY; SUPERFICIALIS TENDON TRANSFER TYPE, EACH 2,337 TENDON CPT OPPONENSPLASTY; TENDON TRANSFER WITH GRAFT (INCLUDES 2,634 OBTAINING GRAFT), EACH TENDON CPT OPPONENSPLASTY; HYPOTHENAR MUSCLE TRANSFER 2,399 CPT OPPONENSPLASTY; OTHER METHODS 2,604 CPT TRANSFER OF TENDON TO RESTORE INTRINSIC FUNCTION; RING AND 2,591 SMALL FINGER CPT TRANSFER OF TENDON TO RESTORE INTRINSIC FUNCTION; ALL FOUR 3,504 FINGERS CPT CORRECTION CLAW FINGER, OTHER METHODS 2,424 CPT RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH LOCAL 1,846 TISSUES (SEPARATE PROCEDURE) CPT RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH TENDON OR 2,096 FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) (SEPARATE PROCEDURE) CPT RELEASE OF THENAR MUSCLE(S) (EG, THUMB CONTRACTURE) 1,869 CPT CROSS INTRINSIC TRANSFER, EACH TENDON 1,752 CPT CAPSULODESIS, METACARPOPHALANGEAL JOINT; SINGLE DIGIT 2,091 CPT CAPSULODESIS, METACARPOPHALANGEAL JOINT; TWO DIGITS 2,438 CPT CAPSULODESIS, METACARPOPHALANGEAL JOINT; THREE OR FOUR DIGITS 2,450 CPT CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, 1,891 EACH JOINT CPT CAPSULECTOMY OR CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH 1,899 JOINT CPT ARTHROPLASTY, METACARPOPHALANGEAL JOINT; EACH JOINT 1,662 CPT ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC 1,929 IMPLANT, EACH JOINT CPT ARTHROPLASTY, INTERPHALANGEAL JOINT; EACH JOINT 1,271 CPT ARTHROPLASTY, INTERPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, 2,095 EACH JOINT CPT REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR 1,956 INTERPHALANGEAL JOINT CPT RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL 2,402 JOINT, SINGLE; WITH TENDON OR FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL 2,021 JOINT, SINGLE; WITH LOCAL TISSUE (EG, ADDUCTOR ADVANCEMENT) CPT RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL JOINT, 2,076 SINGLE, INCLUDING GRAFT, EACH JOINT CPT REPAIR NON-UNION, METACARPAL OR PHALANX (INCLUDES OBTAINING 2,945 BONE GRAFT WITH OR WITHOUT EXTERNAL OR INTERNAL FIXATION) CPT REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE, 2,279 INTERPHALANGEAL JOINT CPT POLLICIZATION OF A DIGIT 4,852 CPT TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; GREAT TOE WRAP-AROUND WITH BONE GRAFT 9,236 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 62 of 380

63 CPT TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER 9,782 THAN GREAT TOE, SINGLE CPT TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER 12,837 THAN GREAT TOE, DOUBLE CPT TRANSFER, FINGER TO ANOTHER POSITION WITHOUT MICROVASCULAR 4,209 ANASTOMOSIS CPT TRANSFER, FREE TOE JOINT, WITH MICROVASCULAR ANASTOMOSIS 8,818 CPT REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN 1,627 FLAPS CPT REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN 2,761 FLAPS AND GRAFTS CPT REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; COMPLEX (EG, 3,450 INVOLVING BONE, NAILS) CPT OSTEOTOMY; METACARPAL, EACH 2,008 CPT OSTEOTOMY; PHALANX OF FINGER, EACH 2,018 CPT OSTEOPLASTY, LENGTHENING, METACARPAL OR PHALANX 2,686 CPT REPAIR CLEFT HAND 3,968 CPT RECONSTRUCTION OF POLYDACTYLOUS DIGIT, SOFT TISSUE AND BONE 3,009 CPT REPAIR MACRODACTYLIA, EACH DIGIT 4,244 CPT REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE 1,258 CPT RELEASE, INTRINSIC MUSCLES OF HAND, EACH MUSCLE 1,757 CPT EXCISION OF CONSTRICTING RING OF FINGER, WITH MULTIPLE Z- PLASTIES CPT CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITHOUT MANIPULATION, EACH BONE CPT CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE CPT CLOSED TREATMENT OF METACARPAL FRACTURE, WITH MANIPULATION, WITH EXTERNAL FIXATION, EACH BONE CPT PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE CPT OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE CPT CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION CPT CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION CPT PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION CPT OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT 2, ,404 1,452 1,735 1,062 1,227 1,387 1, ,351 1,520 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 63 of 380

64 CPT OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN 1,758 THUMB; INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH JOINT CPT OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN 1,935 THUMB; COMPLEX, MULTIPLE, OR DELAYED REDUCTION CPT CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 930 WITH MANIPULATION; WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 1,217 WITH MANIPULATION; REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL 1,346 DISLOCATION, SINGLE, WITH MANIPULATION CPT OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 1,734 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR 568 MIDDLE PHALANX, FINGER OR THUMB; WITHOUT MANIPULATION, EACH CPT CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR 1,008 MIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH CPT PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT 1,424 FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH CPT OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR 1,804 MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING 668 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITHOUT MANIPULATION, EACH CPT CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING 1,101 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITH MANIPULATION, EACH CPT OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING 2,227 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 529 THUMB; WITHOUT MANIPULATION, EACH CPT CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 921 THUMB; WITH MANIPULATION, EACH CPT PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, 1,262 FINGER OR THUMB, EACH CPT OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 1,489 THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, 787 WITH MANIPULATION; WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, 1,125 WITH MANIPULATION; REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT 1,337 DISLOCATION, SINGLE, WITH MANIPULATION CPT OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES 1,623 INTERNAL FIXATION, WHEN PERFORMED, SINGLE CPT FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT (INCLUDES 2,341 OBTAINING GRAFT) CPT ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT 2,159 INTERNAL FIXATION; CPT ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT 2,355 INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT ARTHRODESIS, CARPOMETACARPAL JOINT, DIGIT, OTHER THAN THUMB, EACH; 2,188 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 64 of 380

65 CPT ARTHRODESIS, CARPOMETACARPAL JOINT, DIGIT, OTHER THAN THUMB, 2,435 EACH; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT 2,059 INTERNAL FIXATION; CPT ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT 2,385 INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 1,640 FIXATION; CPT ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 341 FIXATION; EACH ADDITIONAL INTERPHALANGEAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 2,166 FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 758 FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT), EACH ADDITIONAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT AMPUTATION, METACARPAL, WITH FINGER OR THUMB (RAY AMPUTATION), 2,153 SINGLE, WITH OR WITHOUT INTEROSSEOUS TRANSFER CPT AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT 1,883 OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE CPT AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT 1,916 OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD) CPT UNLISTED PROCEDURE, HANDS OR FINGERS N/A CPT INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR 1,922 HEMATOMA CPT INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; INFECTED BURSA 2,102 CPT INCISION, BONE CORTEX, PELVIS AND/OR HIP JOINT (EG, 3,015 OSTEOMYELITIS OR BONE ABSCESS) CPT TENOTOMY, ADDUCTOR OF HIP, PERCUTANEOUS (SEPARATE PROCEDURE) 1,403 CPT TENOTOMY, ADDUCTOR OF HIP, OPEN 1,701 CPT TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN, WITH OBTURATOR 1,831 NEURECTOMY CPT TENOTOMY, HIP FLEXOR(S), OPEN (SEPARATE PROCEDURE) 2,288 CPT TENOTOMY, ABDUCTORS AND/OR EXTENSOR(S) OF HIP, OPEN (SEPARATE 2,322 PROCEDURE) CPT FASCIOTOMY, HIP OR THIGH, ANY TYPE 2,859 CPT ARTHROTOMY, HIP, WITH DRAINAGE (EG, INFECTION) 3,001 CPT ARTHROTOMY, HIP, INCLUDING EXPLORATION OR REMOVAL OF LOOSE OR 3,111 FOREIGN BODY CPT DENERVATION, HIP JOINT, INTRAPELVIC OR EXTRAPELVIC INTRA- 3,514 ARTICULAR BRANCHES OF SCIATIC, FEMORAL, OR OBTURATOR NERVES CPT CAPSULECTOMY OR CAPSULOTOMY, HIP, WITH OR WITHOUT EXCISION OF 3,193 HETEROTOPIC BONE, WITH RELEASE OF HIP FLEXOR MUSCLES (IE, GLUTEUS MEDIUS, GLUTEUS MINIMUS, TENSOR FASCIA LATAE, RECTUS FEMORIS, SARTORIUS, ILIOPSOAS) CPT BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; SUPERFICIAL 1,051 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 65 of 380

66 CPT BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; DEEP, SUBFASCIAL OR 2,159 INTRAMUSCULAR CPT EXCISION, TUMOR, PELVIS AND HIP AREA; SUBCUTANEOUS TISSUE 1,959 CPT EXCISION, TUMOR, PELVIS AND HIP AREA; DEEP, SUBFASCIAL, 1,506 INTRAMUSCULAR CPT RADICAL RESECTION OF TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA 3,202 (EG, MALIGNANT NEOPLASM) CPT ARTHROTOMY, WITH BIOPSY; SACROILIAC JOINT 1,039 CPT ARTHROTOMY, WITH BIOPSY; HIP JOINT 1,762 CPT ARTHROTOMY WITH SYNOVECTOMY, HIP JOINT 2,146 CPT EXCISION; ISCHIAL BURSA 1,378 CPT EXCISION; TROCHANTERIC BURSA OR CALCIFICATION 1,408 CPT EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL (WING OF 1,565 ILIUM, SYMPHYSIS PUBIS, OR GREATER TROCHANTER OF FEMUR) WITH OR WITHOUT AUTOGRAFT CPT EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP, WITH OR WITHOUT 2,555 AUTOGRAFT CPT EXCISION OF BONE CYST OR BENIGN TUMOR; WITH AUTOGRAFT 3,180 REQUIRING SEPARATE INCISION CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, 2,670 OSTEOMYELITIS OR BONE ABSCESS); SUPERFICIAL (EG, WING OF ILIUM, SYMPHYSIS PUBIS, OR GREATER TROCHANTER OF FEMUR) CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, 2,852 OSTEOMYELITIS OR BONE ABSCESS); DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT RADICAL RESECTION OF TUMOR OR INFECTION; WING OF ILIUM, ONE 7,373 PUBIC OR ISCHIAL RAMUS OR SYMPHYSIS PUBIS CPT RADICAL RESECTION OF TUMOR OR INFECTION; ILIUM, INCLUDING 5,134 ACETABULUM, BOTH PUBIC RAMI, OR ISCHIUM AND ACETABULUM CPT RADICAL RESECTION OF TUMOR OR INFECTION; INNOMINATE BONE, 8,638 TOTAL CPT RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY 3,221 AND GREATER TROCHANTER OF FEMUR CPT RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY 3,130 AND GREATER TROCHANTER OF FEMUR, WITH SKIN FLAPS CPT COCCYGECTOMY, PRIMARY 1,550 CPT REMOVAL OF FOREIGN BODY, PELVIS OR HIP; SUBCUTANEOUS TISSUE 730 CPT REMOVAL OF FOREIGN BODY, PELVIS OR HIP; DEEP (SUBFASCIAL OR 1,979 INTRAMUSCULAR) CPT REMOVAL OF HIP PROSTHESIS; (SEPARATE PROCEDURE) 2,634 CPT REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING TOTAL HIP 5,149 PROSTHESIS, METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER CPT INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA 576 CPT INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA 673 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 66 of 380

67 CPT INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/OR 503 ANESTHETIC/STEROID CPT RELEASE OR RECESSION, HAMSTRING, PROXIMAL 2,148 CPT TRANSFER, ADDUCTOR TO ISCHIUM 1,895 CPT TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREATER TROCHANTER 2,576 INCLUDING FASCIAL OR TENDON EXTENSION (GRAFT) CPT TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASCIAL OR TENDON 2,642 EXTENSION GRAFT) CPT TRANSFER ILIOPSOAS; TO GREATER TROCHANTER OF FEMUR 3,033 CPT TRANSFER ILIOPSOAS; TO FEMORAL NECK 2,829 CPT ACETABULOPLASTY; (EG, WHITMAN, COLONNA, HAYGROVES, OR CUP 4,154 TYPE) CPT ACETABULOPLASTY; RESECTION, FEMORAL HEAD (EG, GIRDLESTONE 3,525 PROCEDURE) CPT HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, 3,601 BIPOLAR ARTHROPLASTY) CPT ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC 4,643 REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, 5,408 WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR 6,264 WITHOUT AUTOGRAFT OR ALLOGRAFT CPT REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT 4,778 ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, 4,974 WITH OR WITHOUT ALLOGRAFT CPT OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER OF FEMUR 2,852 (SEPARATE PROCEDURE) CPT OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; 4,075 CPT OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH OPEN 4,716 REDUCTION OF HIP CPT OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 5,126 OSTEOTOMY CPT OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 5,534 OSTEOTOMY AND WITH OPEN REDUCTION OF HIP CPT OSTEOTOMY, PELVIS, BILATERAL (EG, CONGENITAL MALFORMATION) 4,478 CPT OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE) 3,908 CPT OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC INCLUDING INTERNAL OR EXTERNAL FIXATION AND/OR CAST CPT BONE GRAFT, FEMORAL HEAD, NECK, INTERTROCHANTERIC OR SUBTROCHANTERIC AREA (INCLUDES OBTAINING BONE GRAFT) CPT TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY TRACTION, WITHOUT REDUCTION CPT TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE OR MULTIPLE PINNING, IN SITU CPT OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGLE OR MULTIPLE PINNING OR BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; CLOSED MANIPULATION WITH SINGLE OR MULTIPLE PINNING 4,373 3,781 2,003 2,918 3,549 2,876 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 67 of 380

68 CPT OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOPLASTY OF 3,103 FEMORAL NECK (HEYMAN TYPE PROCEDURE) CPT OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOTOMY AND 3,434 INTERNAL FIXATION CPT EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, GREATER 2,356 TROCHANTER OF FEMUR CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 3,166 WITH OR WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR CPT CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 1,456 DIASTASIS OR SUBLUXATION; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 2,308 DIASTASIS OR SUBLUXATION; WITH MANIPULATION, REQUIRING MORE THAN LOCAL ANESTHESIA CPT CLOSED TREATMENT OF COCCYGEAL FRACTURE 532 CPT OPEN TREATMENT OF COCCYGEAL FRACTURE 1,664 CPT OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACTURE(S) (EG, PELVIC FRACTURE(S) WHICH DO NOT DISRUPT THE PELVIC RING), WITH INTERNAL FIXATION CPT PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC RING FRACTURE AND/OR DISLOCATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) CPT OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR DISLOCATION WITH INTERNAL FIXATION (INCLUDES PUBIC SYMPHYSIS AND/OR RAMI) CPT OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR DISLOCATION WITH INTERNAL FIXATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) CPT CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITHOUT MANIPULATION CPT CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR WALL FRACTURE, WITH INTERNAL FIXATION CPT OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR OR POSTERIOR (ONE) COLUMN, OR A FRACTURE RUNNING TRANSVERSELY ACROSS THE ACETABULUM, WITH INTERNAL FIXATION CPT OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR AND POSTERIOR (TWO) COLUMNS, INCLUDES T-FRACTURE AND BOTH COLUMN FRACTURE WITH COMPLETE ARTICULAR DETACHMENT, OR SINGLE COLUMN OR TRANSVERSE FRACTURE WITH ASSOCIATED ACETABULAR WALL FRACTURE, WITH INTERNAL FIXATION CPT CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK CPT OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT CPT CLOSED TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION 2,389 3,462 3,234 4,499 1,641 3,107 3,382 5,368 6,123 1,456 2,469 2,892 3,812 1,407 3,025 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 68 of 380

69 CPT TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR 3,710 SUBTROCHANTERIC FEMORAL FRACTURE; WITH PLATE/SCREW TYPE IMPLANT, WITH OR WITHOUT CERCLAGE CPT TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR 4,526 SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE CPT CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE, WITHOUT 1,191 MANIPULATION CPT OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE, INCLUDES 2,371 INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT 1,526 ANESTHESIA CPT CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING 2,400 ANESTHESIA CPT OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, WITHOUT INTERNAL 3,005 FIXATION CPT OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, WITH ACETABULAR 4,093 WALL AND FEMORAL HEAD FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION CPT TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, 910 INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITHOUT ANESTHESIA, WITHOUT MANIPULATION CPT TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, 1,079 INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITH MANIPULATION, REQUIRING ANESTHESIA CPT OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION 3,545 (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUDING TENOTOMY, ETC); CPT OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION 4,979 (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUDING TENOTOMY, ETC); WITH FEMORAL SHAFT SHORTENING CPT CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; 1,220 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; 1,821 REQUIRING REGIONAL OR GENERAL ANESTHESIA CPT CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 1,343 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 1,658 WITH MANIPULATION CPT OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD, 3,973 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA 570 CPT ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING GRAFT) 3,261 CPT ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING OBTAINING GRAFT) 2,688 CPT ARTHRODESIS, HIP JOINT (INCLUDING OBTAINING GRAFT); 5,141 CPT ARTHRODESIS, HIP JOINT (INCLUDING OBTAINING GRAFT); WITH 5,124 SUBTROCHANTERIC OSTEOTOMY CPT INTERPELVIABDOMINAL AMPUTATION (HINDQUARTER AMPUTATION) 5,025 CPT DISARTICULATION OF HIP 4,039 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 69 of 380

70 CPT UNLISTED PROCEDURE, PELVIS OR HIP JOINT N/A CPT INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH 2,002 OR KNEE REGION CPT INCISION, DEEP, WITH OPENING OF BONE CORTEX, FEMUR OR KNEE (EG, 2,006 OSTEOMYELITIS OR BONE ABSCESS) CPT FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN 1,482 CPT TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; SINGLE 1,207 TENDON (SEPARATE PROCEDURE) CPT TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; MULTIPLE 1,478 TENDONS CPT ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF 2,299 FOREIGN BODY (EG, INFECTION) CPT BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL 848 CPT BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; DEEP (SUBFASCIAL OR 1,198 INTRAMUSCULAR) CPT NEURECTOMY, HAMSTRING MUSCLE 1,657 CPT NEURECTOMY, POPLITEAL (GASTROCNEMIUS) 1,578 CPT EXCISION, TUMOR, THIGH OR KNEE AREA; SUBCUTANEOUS 1,409 CPT EXCISION, TUMOR, THIGH OR KNEE AREA; DEEP, SUBFASCIAL, OR 1,325 INTRAMUSCULAR CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 3,310 TISSUE OF THIGH OR KNEE AREA CPT ARTHROTOMY, KNEE; WITH SYNOVIAL BIOPSY ONLY 1,276 CPT ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR 1,478 REMOVAL OF LOOSE OR FOREIGN BODIES CPT ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE 2,000 (MENISCECTOMY) KNEE; MEDIAL OR LATERAL CPT ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE 1,810 (MENISCECTOMY) KNEE; MEDIAL AND LATERAL CPT ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR 2,141 CPT ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR 2,416 INCLUDING POPLITEAL AREA CPT EXCISION, PREPATELLAR BURSA 1,131 CPT EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (EG, BAKER'S CYST) 1,494 CPT EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), 1,613 KNEE CPT PATELLECTOMY OR HEMIPATELLECTOMY 2,039 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; 1,890 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH ALLOGRAFT CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH INTERNAL FIXATION (LIST IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 2,323 2, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 70 of 380

71 CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,672 DIAPHYSECTOMY) BONE, FEMUR, PROXIMAL TIBIA AND/OR FIBULA (EG, OSTEOMYELITIS OR BONE ABSCESS) CPT RADICAL RESECTION OF TUMOR, BONE, FEMUR OR KNEE 3,920 CPT INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY 508 CPT REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA 1,796 CPT SUTURE OF INFRAPATELLAR TENDON; PRIMARY 1,842 CPT SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTRUCTION, 2,517 INCLUDING FASCIAL OR TENDON GRAFT CPT SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY 1,972 CPT SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY 2,615 RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT CPT TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE TENDON 1,363 CPT TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE TENDONS, ONE 1,782 LEG CPT TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE TENDONS, 2,234 BILATERAL CPT LENGTHENING OF HAMSTRING TENDON; SINGLE TENDON 1,580 CPT LENGTHENING OF HAMSTRING TENDON; MULTIPLE TENDONS, ONE LEG 2,051 CPT LENGTHENING OF HAMSTRING TENDON; MULTIPLE TENDONS, BILATERAL 2,779 CPT TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE TENDON 1,914 CPT TRANSPLANT, HAMSTRING TENDON TO PATELLA; MULTIPLE TENDONS 2,849 CPT TRANSFER, TENDON OR MUSCLE, HAMSTRINGS TO FEMUR (EG, EGGER'S 2,143 TYPE PROCEDURE) CPT ARTHROTOMY WITH MENISCUS REPAIR, KNEE 2,011 CPT REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL 2,122 CPT REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; CRUCIATE 2,433 CPT REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL 3,030 AND CRUCIATE LIGAMENTS CPT AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE 5,355 CPT OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN 4,523 CPT OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) 3,110 (INCLUDES HARVESTING OF AUTOGRAFT[S]) CPT ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE) 2,633 CPT RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE) CPT RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE) 2,362 2,351 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 71 of 380

72 CPT RECONSTRUCTION OF DISLOCATING PATELLA; WITH PATELLECTOMY 2,357 CPT LATERAL RETINACULAR RELEASE, OPEN 1,369 CPT LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA- 2,265 ARTICULAR CPT LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA- 3,500 ARTICULAR (OPEN) CPT LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA- 3,928 ARTICULAR (OPEN) AND EXTRA-ARTICULAR CPT QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE) 2,338 CPT CAPSULOTOMY, POSTERIOR CAPSULAR RELEASE, KNEE 2,513 CPT ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS 2,076 CPT ARTHROPLASTY, PATELLA; WITH PROSTHESIS 2,672 CPT ARTHROPLASTY, KNEE, TIBIAL PLATEAU; 2,490 CPT ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH DEBRIDEMENT AND 2,601 PARTIAL SYNOVECTOMY CPT ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; 2,767 CPT ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; WITH 2,586 DEBRIDEMENT AND PARTIAL SYNOVECTOMY CPT ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG, WALLDIUS TYPE) 4,031 CPT ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL 3,569 COMPARTMENT CPT ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL 4,961 COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY) CPT OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITHOUT FIXATION 2,611 CPT OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION 3,239 CPT OSTEOTOMY, MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD, 4,132 FEMORAL SHAFT (EG, SOFIELD TYPE PROCEDURE) CPT OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR 2,995 OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); BEFORE EPIPHYSEAL CLOSURE CPT OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR 3,083 OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); AFTER EPIPHYSEAL CLOSURE CPT OSTEOPLASTY, FEMUR; SHORTENING (EXCLUDING 64876) 3,928 CPT OSTEOPLASTY, FEMUR; LENGTHENING 3,772 CPT OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING AND SHORTENING WITH FEMORAL SEGMENT TRANSFER CPT REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE) CPT REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; WITH ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) 4,317 3,767 4,064 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 72 of 380

73 CPT ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); DISTAL 2,061 FEMUR CPT ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND 2,312 FIBULA, PROXIMAL CPT ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); COMBINED 3,106 DISTAL FEMUR, PROXIMAL TIBIA AND FIBULA CPT ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL TIBIA OR FIBULA 2,110 (EG, GENU VARUS OR VALGUS) CPT REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT 4,521 ALLOGRAFT; ONE COMPONENT CPT REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT 5,700 ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT CPT REMOVAL OF PROSTHESIS, INCLUDING TOTAL KNEE PROSTHESIS, 3,826 METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER, KNEE CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) 3,614 WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR CPT DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 1,589 COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); CPT DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 1,742 COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 1,884 COMPARTMENTS; CPT DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 2,109 COMPARTMENTS; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITHOUT 1,584 MANIPULATION CPT CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL 1,558 FRACTURE WITH OR WITHOUT INTERCONDYLAR EXTENSION, WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH 2,503 MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL 2,542 FRACTURE WITH OR WITHOUT INTERCONDYLAR EXTENSION, WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, WITH OR WITHOUT 4,258 EXTERNAL FIXATION, WITH INSERTION OF INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS CPT OPEN TREATMENT OF FEMORAL SHAFT FRACTURE WITH PLATE/SCREWS, 3,140 WITH OR WITHOUT CERCLAGE CPT CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR 1,603 LATERAL CONDYLE, WITHOUT MANIPULATION CPT PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, DISTAL 2,001 END, MEDIAL OR LATERAL CONDYLE, OR SUPRACONDYLAR OR TRANSCONDYLAR, WITH OR WITHOUT INTERCONDYLAR EXTENSION, OR DISTAL FEMORAL EPIPHYSEAL SEPARATION CPT CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR 2,200 LATERAL CONDYLE, WITH MANIPULATION CPT OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR 3,204 FRACTURE WITHOUT INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR 4,026 FRACTURE WITH INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED 3,192 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 73 of 380

74 CPT CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; 1,507 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; 2,091 WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT OPEN TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION, 2,902 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF PATELLAR FRACTURE, WITHOUT MANIPULATION 944 CPT OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION 2,383 AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR CPT CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 1,188 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITH 1,899 OR WITHOUT MANIPULATION, WITH SKELETAL TRACTION CPT OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 2,861 UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 3,792 BICONDYLAR, WITH OR WITHOUT INTERNAL FIXATION CPT CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY 1,422 FRACTURE(S) OF KNEE, WITH OR WITHOUT MANIPULATION CPT OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY 2,621 FRACTURE(S) OF THE KNEE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF KNEE DISLOCATION; WITHOUT ANESTHESIA 1,486 CPT CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA 1,949 CPT OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 2,848 FIXATION, WHEN PERFORMED; WITHOUT PRIMARY LIGAMENTOUS REPAIR OR AUGMENTATION/RECONSTRUCTION CPT OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 3,422 FIXATION, WHEN PERFORMED; WITH PRIMARY LIGAMENTOUS REPAIR CPT OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 3,855 FIXATION, WHEN PERFORMED; WITH PRIMARY LIGAMENTOUS REPAIR, WITH AUGMENTATION/RECONSTRUCTION CPT CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 1,073 CPT CLOSED TREATMENT OF PATELLAR DISLOCATION; REQUIRING 1,436 ANESTHESIA CPT OPEN TREATMENT OF PATELLAR DISLOCATION, WITH OR WITHOUT 2,845 PARTIAL OR TOTAL PATELLECTOMY CPT MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES 463 APPLICATION OF TRACTION OR OTHER FIXATION DEVICES) CPT ARTHRODESIS, KNEE, ANY TECHNIQUE 4,590 CPT AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; 2,658 CPT AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMEDIATE FITTING 2,920 TECHNIQUE INCLUDING FIRST CAST CPT AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN, CIRCULAR 2,235 (GUILLOTINE) CPT AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECONDARY 1,626 CLOSURE OR SCAR REVISION CPT AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; RE-AMPUTATION 2,353 CPT DISARTICULATION AT KNEE 2,382 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 74 of 380

75 CPT UNLISTED PROCEDURE, FEMUR OR KNEE N/A CPT DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL 1,334 COMPARTMENTS ONLY CPT DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) ONLY 1,374 CPT DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND 1,648 POSTERIOR COMPARTMENT(S) CPT INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA 1,624 CPT INCISION AND DRAINAGE, LEG OR ANKLE; INFECTED BURSA 1,471 CPT TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE 1,064 PROCEDURE); LOCAL ANESTHESIA CPT TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE 940 PROCEDURE); GENERAL ANESTHESIA CPT INCISION (EG, OSTEOMYELITIS OR BONE ABSCESS), LEG OR ANKLE 1,953 CPT ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR 2,079 REMOVAL OF FOREIGN BODY CPT ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR 1,802 WITHOUT ACHILLES TENDON LENGTHENING CPT BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; SUPERFICIAL 792 CPT BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; DEEP (SUBFASCIAL OR 1,793 INTRAMUSCULAR) CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,775 TISSUE OF LEG OR ANKLE AREA CPT EXCISION, TUMOR, LEG OR ANKLE AREA; SUBCUTANEOUS TISSUE 1,548 CPT EXCISION, TUMOR, LEG OR ANKLE AREA; DEEP (SUBFASCIAL OR 2,482 INTRAMUSCULAR) CPT ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT 1,457 BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; 1,906 CPT ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING 2,044 TENOSYNOVECTOMY CPT EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR 1,709 GANGLION), LEG AND/OR ANKLE CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 1,869 FIBULA; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 2,358 FIBULA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 2,488 FIBULA; WITH ALLOGRAFT CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,701 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR EXOSTOSIS); TIBIA CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,175 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR EXOSTOSIS); FIBULA CPT RADICAL RESECTION OF TUMOR, BONE; TIBIA 3,265 CPT RADICAL RESECTION OF TUMOR, BONE; FIBULA 2,883 CPT RADICAL RESECTION OF TUMOR, BONE; TALUS OR CALCANEUS 2,662 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 75 of 380

76 CPT INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY 493 CPT REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 2,226 TENDON; CPT REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 2,366 TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT) CPT REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT 2,251 CPT REPAIR, FASCIAL DEFECT OF LEG 1,670 CPT REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH 1,222 TENDON CPT REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, 1,606 EACH TENDON CPT REPAIR, EXTENSOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH 1,168 TENDON CPT REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT 1,344 GRAFT, EACH TENDON CPT REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR 1,638 OSTEOTOMY CPT REPAIR, DISLOCATING PERONEAL TENDONS; WITH FIBULAR OSTEOTOMY 1,977 CPT TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; 1,369 SINGLE, EACH TENDON CPT TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; 1,658 MULTIPLE TENDONS (THROUGH SEPARATE INCISION(S)) CPT LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE 2,054 TENDON (SEPARATE PROCEDURE) CPT LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE 1,783 TENDONS (THROUGH SAME INCISION), EACH CPT GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE) 1,481 CPT TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE 1,971 REDIRECTION OR REROUTING); SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT) CPT TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE 2,338 REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT) CPT TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE 365 REDIRECTION OR REROUTING); EACH ADDITIONAL TENDON (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL 1,574 CPT REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL 1,888 LIGAMENTS CPT REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, 2,118 WATSON-JONES PROCEDURE) CPT ARTHROPLASTY, ANKLE; 2,020 CPT ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE) 3,185 CPT ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE 3,693 CPT REMOVAL OF ANKLE IMPLANT 1,835 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 76 of 380

77 CPT OSTEOTOMY; TIBIA 2,455 CPT OSTEOTOMY; FIBULA 1,248 CPT OSTEOTOMY; TIBIA AND FIBULA 3,652 CPT OSTEOTOMY; MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,474 (EG, SOFIELD TYPE PROCEDURE) CPT OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING OR SHORTENING 3,385 CPT REPAIR OF NONUNION OR MALUNION, TIBIA; WITHOUT GRAFT, (EG, 2,794 COMPRESSION TECHNIQUE) CPT REPAIR OF NONUNION OR MALUNION, TIBIA; WITH SLIDING GRAFT 2,801 CPT REPAIR OF NONUNION OR MALUNION, TIBIA; WITH ILIAC OR OTHER 4,108 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT REPAIR OF NONUNION OR MALUNION, TIBIA; BY SYNOSTOSIS, WITH 3,833 FIBULA, ANY METHOD CPT REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL 2,934 FIXATION CPT REPAIR OF CONGENITAL PSEUDARTHROSIS, TIBIA 3,297 CPT ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL TIBIA 1,841 CPT ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL FIBULA 1,297 CPT ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL TIBIA AND FIBULA CPT ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; CPT ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; AND DISTAL FEMUR CPT PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA CPT CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION CPT CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT PERCUTANEOUS SKELETAL FIXATION OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) (EG, PINS OR SCREWS) CPT OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE CPT TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE CPT CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH MANIPULATION 2,044 2,230 2,125 2,407 1,023 1,650 1,794 2,828 3, ,467 1, ,270 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 77 of 380

78 CPT OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES 2,206 INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; 881 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH 1,268 MANIPULATION CPT OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, INCLUDES 2,214 INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 933 MALLEOLUS); WITHOUT MANIPULATION CPT CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 1,287 MALLEOLUS); WITH MANIPULATION CPT OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), 2,225 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL 978 AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITHOUT MANIPULATION CPT CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL 1,438 AND MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI OR MEDIAL AND POSTERIOR MALLEOLI); WITH MANIPULATION CPT OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE (EG, LATERAL AND 2,462 MEDIAL MALLEOLI, OR LATERAL AND POSTERIOR MALLEOLI, OR MEDIAL AND POSTERIOR MALLEOLI), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITHOUT 928 MANIPULATION CPT CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH 1,485 MANIPULATION CPT OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES 2,663 INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP CPT OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES 3,043 INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP CPT CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 918 PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 1,686 PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION CPT OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 2,592 SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF FIBULA ONLY CPT OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 3,422 SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF TIBIA ONLY CPT OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR 4,103 SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH INTERNAL FIXATION, WHEN PERFORMED; OF BOTH TIBIA AND FIBULA CPT OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) 2,084 DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION; 1,067 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION; REQUIRING ANESTHESIA 1,184 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 78 of 380

79 CPT OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION, 2,249 INCLUDES INTERNAL FIXATION, WHEN PERFORMED, OR WITH EXCISION OF PROXIMAL FIBULA CPT CLOSED TREATMENT OF ANKLE DISLOCATION; WITHOUT ANESTHESIA 1,102 CPT CLOSED TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHESIA, 1,534 WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION CPT OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT 2,346 PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION CPT OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT 2,621 PERCUTANEOUS SKELETAL FIXATION; WITH REPAIR OR INTERNAL OR EXTERNAL FIXATION CPT MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (INCLUDES 558 APPLICATION OF TRACTION OR OTHER FIXATION APPARATUS) CPT ARTHRODESIS, ANKLE, OPEN 3,355 CPT ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL 2,209 CPT AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; 2,976 CPT AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; WITH IMMEDIATE 2,855 FITTING TECHNIQUE INCLUDING APPLICATION OF FIRST CAST CPT AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; OPEN, CIRCULAR 1,997 (GUILLOTINE) CPT AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE 1,884 OR SCAR REVISION CPT AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE-AMPUTATION 2,130 CPT AMPUTATION, ANKLE, THROUGH MALLEOLI OF TIBIA AND FIBULA (EG, 2,234 SYME, PIROGOFF TYPE PROCEDURES), WITH PLASTIC CLOSURE AND RESECTION OF NERVES CPT ANKLE DISARTICULATION 2,217 CPT DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL 1,764 COMPARTMENTS ONLY, WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) 1,763 ONLY, WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND 2,694 POSTERIOR COMPARTMENT(S), WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT UNLISTED PROCEDURE, LEG OR ANKLE N/A CPT INCISION AND DRAINAGE, BURSA, FOOT 891 CPT INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON 1,645 SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE CPT INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON 2,246 SHEATH INVOLVEMENT, FOOT; MULTIPLE AREAS CPT INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), FOOT 2,012 CPT FASCIOTOMY, FOOT AND/OR TOE 1,414 CPT TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON 769 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 79 of 380

80 CPT TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE TENDONS 1,079 CPT ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,655 LOOSE OR FOREIGN BODY; INTERTARSAL OR TARSOMETATARSAL JOINT CPT ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,544 LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT CPT ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,456 LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT CPT RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION) 1,651 CPT EXCISION, TUMOR, FOOT; SUBCUTANEOUS TISSUE 1,110 CPT EXCISION, TUMOR, FOOT; DEEP, SUBFASCIAL, INTRAMUSCULAR 1,564 CPT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,804 TISSUE OF FOOT CPT ARTHROTOMY WITH BIOPSY; INTERTARSAL OR TARSOMETATARSAL JOINT 1,491 CPT ARTHROTOMY WITH BIOPSY; METATARSOPHALANGEAL JOINT 1,360 CPT ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL JOINT 1,283 CPT NEURECTOMY, INTRINSIC MUSCULATURE OF FOOT 1,306 CPT FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE) 1,645 CPT FASCIECTOMY, PLANTAR FASCIA; RADICAL (SEPARATE PROCEDURE) 1,918 CPT SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT, EACH 1,667 CPT SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH 1,621 CPT EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH 1,609 CPT SYNOVECTOMY, TENDON SHEATH, FOOT; FLEXOR 1,694 CPT SYNOVECTOMY, TENDON SHEATH, FOOT; EXTENSOR 1,448 CPT EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT CPT EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ALLOGRAFT CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT 1,487 1,340 1,842 1,734 1,447 1,648 1,564 1,769 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 80 of 380

81 CPT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, PHALANGES 1,395 OF FOOT CPT OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD 1,460 (BUNIONETTE) (SEPARATE PROCEDURE) CPT OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD 1,614 CPT OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, 1,553 THIRD OR FOURTH) CPT OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD 1,872 CPT OSTECTOMY, COMPLETE EXCISION; ALL METATARSAL HEADS, WITH 3,326 PARTIAL PROXIMAL PHALANGECTOMY, EXCLUDING FIRST METATARSAL (EG, CLAYTON TYPE PROCEDURE) CPT OSTECTOMY, EXCISION OF TARSAL COALITION 2,444 CPT OSTECTOMY, CALCANEUS; 1,861 CPT OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR 1,682 FASCIAL RELEASE CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 1,825 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 2,141 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS CPT PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 1,543 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE CPT RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE 1,254 CPT TALECTOMY (ASTRAGALECTOMY) 2,104 CPT METATARSECTOMY 1,984 CPT PHALANGECTOMY, TOE, EACH TOE 1,388 CPT RESECTION, CONDYLE(S), DISTAL END OF PHALANX, EACH TOE 1,307 CPT HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, TOE, 1,332 PROXIMAL END OF PHALANX, EACH CPT RADICAL RESECTION OF TUMOR, BONE; TARSAL (EXCEPT TALUS OR 2,069 CALCANEUS) CPT RADICAL RESECTION OF TUMOR, BONE; METATARSAL 2,380 CPT RADICAL RESECTION OF TUMOR, BONE; PHALANX OF TOE 1,767 CPT REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS 781 CPT REMOVAL OF FOREIGN BODY, FOOT; DEEP 1,512 CPT REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED 1,744 CPT REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON CPT REPAIR, TENDON, FLEXOR, FOOT; SECONDARY WITH FREE GRAFT, EACH TENDON (INCLUDES OBTAINING GRAFT) 1,528 1,968 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 81 of 380

82 CPT REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH 1,472 TENDON CPT REPAIR, TENDON, EXTENSOR, FOOT; SECONDARY WITH FREE GRAFT, 1,869 EACH TENDON (INCLUDES OBTAINING GRAFT) CPT TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON 1,456 CPT TENOLYSIS, FLEXOR, FOOT; MULTIPLE TENDONS 1,672 CPT TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON 1,281 CPT TENOLYSIS, EXTENSOR, FOOT; MULTIPLE TENDONS 1,516 CPT TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE 1,397 TENDON(S) (SEPARATE PROCEDURE) CPT TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE 1,234 PROCEDURE) CPT TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON 1,280 CPT RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH 2,177 EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE) CPT TENOTOMY, LENGTHENING, OR RELEASE, ABDUCTOR HALLUCIS MUSCLE 1,427 CPT DIVISION OF PLANTAR FASCIA AND MUSCLE (EG, STEINDLER STRIPPING) 1,806 (SEPARATE PROCEDURE) CPT CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY (SEPARATE 2,224 PROCEDURE) CPT CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING 3,166 CPT CAPSULOTOMY, MIDFOOT; EXTENSIVE, INCLUDING POSTERIOR 4,424 TALOTIBIAL CAPSULOTOMY AND TENDON(S) LENGTHENING (EG, RESISTANT CLUBFOOT DEFORMITY) CPT CAPSULOTOMY, MIDTARSAL (EG, HEYMAN TYPE PROCEDURE) 2,818 CPT CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE) CPT CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH JOINT (SEPARATE PROCEDURE) CPT SYNDACTYLIZATION, TOES (EG, WEBBING OR KELIKIAN TYPE PROCEDURE) CPT CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY) CPT CORRECTION, COCK-UP FIFTH TOE, WITH PLASTIC SKIN CLOSURE (EG, RUIZ-MORA TYPE PROCEDURE) CPT OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD CPT HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; SIMPLE EXOSTECTOMY (EG, SILVER TYPE PROCEDURE) CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; KELLER, MCBRIDE, OR MAYO TYPE PROCEDURE CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; RESECTION OF JOINT WITH IMPLANT CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; WITH TENDON TRANSPLANTS (EG, JOPLIN TYPE 1,555 1,276 1,669 1,504 1,473 1,895 2,336 1,854 2,514 3,361 2,414 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 82 of 380

83 PROCEDURE) CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,527 SESAMOIDECTOMY; WITH METATARSAL OSTEOTOMY (EG, MITCHELL, CHEVRON, OR CONCENTRIC TYPE PROCEDURES) CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,655 SESAMOIDECTOMY; LAPIDUS-TYPE PROCEDURE CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,310 SESAMOIDECTOMY; BY PHALANX OSTEOTOMY CPT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,934 SESAMOIDECTOMY; BY DOUBLE OSTEOTOMY CPT OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), 2,163 WITH OR WITHOUT INTERNAL FIXATION CPT OSTEOTOMY; TALUS 2,171 CPT OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS; 2,532 CPT OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS; WITH 2,226 AUTOGRAFT (INCLUDES OBTAINING GRAFT) (EG, FOWLER TYPE) CPT OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 1,909 ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL CPT OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 2,085 ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL WITH AUTOGRAFT (OTHER THAN FIRST TOE) CPT OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 1,759 ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH CPT OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 2,983 ANGULAR CORRECTION, METATARSAL; MULTIPLE (EG, SWANSON TYPE CAVUS FOOT PROCEDURE) CPT OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; 1,728 PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE) CPT OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; 1,587 OTHER PHALANGES, ANY TOE CPT RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE 1,643 PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES) CPT SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE) 1,538 CPT REPAIR, NONUNION OR MALUNION; TARSAL BONES 2,060 CPT REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT 2,445 BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT RECONSTRUCTION, TOE, MACRODACTYLY; SOFT TISSUE RESECTION 2,011 CPT RECONSTRUCTION, TOE, MACRODACTYLY; REQUIRING BONE RESECTION 2,292 CPT RECONSTRUCTION, TOE(S); POLYDACTYLY 1,414 CPT RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH OR WITHOUT SKIN 1,812 GRAFT(S), EACH WEB CPT RECONSTRUCTION, CLEFT FOOT 2,934 CPT CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION 747 CPT CLOSED TREATMENT OF CALCANEAL FRACTURE; WITH MANIPULATION 1,232 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 83 of 380

84 CPT PERCUTANEOUS SKELETAL FIXATION OF CALCANEAL FRACTURE, WITH 1,650 MANIPULATION CPT OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL 3,635 FIXATION, WHEN PERFORMED; CPT OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL 3,823 FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION 701 CPT CLOSED TREATMENT OF TALUS FRACTURE; WITH MANIPULATION 1,005 CPT PERCUTANEOUS SKELETAL FIXATION OF TALUS FRACTURE, WITH 1,301 MANIPULATION CPT OPEN TREATMENT OF TALUS FRACTURE, INCLUDES INTERNAL FIXATION, 3,475 WHEN PERFORMED CPT OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING 3,815 GRAFT[S]) CPT TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 648 CALCANEUS); WITHOUT MANIPULATION, EACH CPT TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 922 CALCANEUS); WITH MANIPULATION, EACH CPT PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE FRACTURE 871 (EXCEPT TALUS AND CALCANEUS), WITH MANIPULATION, EACH CPT OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 1,990 CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT 640 MANIPULATION, EACH CPT CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, 823 EACH CPT PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH 1,048 MANIPULATION, EACH CPT OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL 1,720 FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; 421 WITHOUT MANIPULATION CPT CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; 538 WITH MANIPULATION CPT PERCUTANEOUS SKELETAL FIXATION OF FRACTURE GREAT TOE, PHALANX 1,280 OR PHALANGES, WITH MANIPULATION CPT OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, 2,051 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER 371 THAN GREAT TOE; WITHOUT MANIPULATION, EACH CPT CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER 490 THAN GREAT TOE; WITH MANIPULATION, EACH CPT OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN 1,770 GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT CLOSED TREATMENT OF SESAMOID FRACTURE 357 CPT OPEN TREATMENT OF SESAMOID FRACTURE, WITH OR WITHOUT INTERNAL FIXATION CPT CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL, WITH MANIPULATION 1, ,492 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 84 of 380

85 CPT OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL 2,686 FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITHOUT 556 ANESTHESIA CPT CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; REQUIRING 1,052 ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT 1,161 DISLOCATION, WITH MANIPULATION CPT OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES 2,988 INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION; 659 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION; 889 REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT 1,247 DISLOCATION, WITH MANIPULATION CPT OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES 2,504 INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; 474 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; 561 REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT 955 DISLOCATION, WITH MANIPULATION CPT OPEN TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION, 2,037 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; 337 WITHOUT ANESTHESIA CPT CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; 505 REQUIRING ANESTHESIA CPT PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT 619 DISLOCATION, WITH MANIPULATION CPT OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES 1,781 INTERNAL FIXATION, WHEN PERFORMED CPT ARTHRODESIS; PANTALAR 4,263 CPT ARTHRODESIS; TRIPLE 3,154 CPT ARTHRODESIS; SUBTALAR 2,600 CPT ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 2,728 TRANSVERSE; CPT ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 2,604 TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION) CPT ARTHRODESIS, WITH TENDON LENGTHENING AND ADVANCEMENT, 2,312 MIDTARSAL, TARSAL NAVICULAR-CUNEIFORM (EG, MILLER TYPE PROCEDURE) CPT ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT 2,665 CPT ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT 2,551 CPT ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT 1,598 CPT ARTHRODESIS, WITH EXTENSOR HALLUCIS LONGUS TRANSFER TO FIRST METATARSAL NECK, GREAT TOE, INTERPHALANGEAL JOINT (EG, JONES TYPE PROCEDURE) 2,499 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 85 of 380

86 CPT AMPUTATION, FOOT; MIDTARSAL (EG, CHOPART TYPE PROCEDURE) 1,864 CPT AMPUTATION, FOOT; TRANSMETATARSAL 2,470 CPT AMPUTATION, METATARSAL, WITH TOE, SINGLE 1,439 CPT AMPUTATION, TOE; METATARSOPHALANGEAL JOINT 1,655 CPT AMPUTATION, TOE; INTERPHALANGEAL JOINT 1,427 CPT EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A 1,049 PHYSICIAN, REQUIRING ANESTHESIA OTHER THAN LOCAL, INCLUDING ULTRASOUND GUIDANCE, INVOLVING THE PLANTAR FASCIA CPT UNLISTED PROCEDURE, FOOT OR TOES N/A CPT APPLICATION OF HALO TYPE BODY CAST (SEE FOR 839 INSERTION) CPT APPLICATION OF RISSER JACKET, LOCALIZER, BODY; ONLY 867 CPT APPLICATION OF RISSER JACKET, LOCALIZER, BODY; INCLUDING HEAD 792 CPT APPLICATION OF TURNBUCKLE JACKET, BODY; ONLY 780 CPT APPLICATION OF TURNBUCKLE JACKET, BODY; INCLUDING HEAD 865 CPT APPLICATION OF BODY CAST, SHOULDER TO HIPS; 723 CPT APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING HEAD, 737 MINERVA TYPE CPT APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING ONE 761 THIGH CPT APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING BOTH 921 THIGHS CPT APPLICATION, CAST; FIGURE-OF-EIGHT 269 CPT APPLICATION, CAST; SHOULDER SPICA 616 CPT APPLICATION, CAST; PLASTER VELPEAU 344 CPT APPLICATION, CAST; SHOULDER TO HAND (LONG ARM) 289 CPT APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM) 269 CPT APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET) 285 CPT APPLICATION, CAST; FINGER (EG, CONTRACTURE) 222 CPT APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 261 CPT APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 205 CPT APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); DYNAMIC 232 CPT APPLICATION OF FINGER SPLINT; STATIC 124 CPT APPLICATION OF FINGER SPLINT; DYNAMIC 147 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 86 of 380

87 CPT STRAPPING; THORAX 163 CPT STRAPPING; LOW BACK 167 CPT STRAPPING; SHOULDER (EG, VELPEAU) 182 CPT STRAPPING; ELBOW OR WRIST 159 CPT STRAPPING; HAND OR FINGER 152 CPT APPLICATION OF HIP SPICA CAST; ONE LEG 713 CPT APPLICATION OF HIP SPICA CAST; ONE AND ONE-HALF SPICA OR BOTH 761 LEGS CPT APPLICATION OF LONG LEG CAST (THIGH TO TOES); 415 CPT APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR 429 AMBULATORY TYPE CPT APPLICATION OF LONG LEG CAST BRACE 464 CPT APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) 372 CPT APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); 276 CPT APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR 299 AMBULATORY TYPE CPT APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST 366 CPT ADDING WALKER TO PREVIOUSLY APPLIED CAST 162 CPT APPLICATION OF RIGID TOTAL CONTACT LEG CAST 454 CPT APPLICATION OF CLUBFOOT CAST WITH MOLDING OR MANIPULATION, 495 LONG OR SHORT LEG CPT APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 231 CPT APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 224 CPT STRAPPING; HIP 154 CPT STRAPPING; KNEE 161 CPT STRAPPING; ANKLE AND/OR FOOT 140 CPT STRAPPING; TOES 137 CPT STRAPPING; UNNA BOOT 167 CPT DENIS-BROWNE SPLINT STRAPPING 181 CPT REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST 201 CPT REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 207 CPT REMOVAL OR BIVALVING; SHOULDER OR HIP SPICA, MINERVA, OR RISSER JACKET, ETC. 359 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 87 of 380

88 CPT REMOVAL OR BIVALVING; TURNBUCKLE JACKET 280 CPT REPAIR OF SPICA, BODY CAST OR JACKET 247 CPT WINDOWING OF CAST 202 CPT WEDGING OF CAST (EXCEPT CLUBFOOT CASTS) 293 CPT WEDGING OF CLUBFOOT CAST 319 CPT UNLISTED PROCEDURE, CASTING OR STRAPPING N/A CPT ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR 1,554 WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) CPT ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL 1,987 CPT ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,468 BIOPSY (SEPARATE PROCEDURE) CPT ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY 3,374 CPT ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION 3,285 CPT ARTHROSCOPY, SHOULDER, SURGICAL; WITH REMOVAL OF LOOSE BODY 1,841 OR FOREIGN BODY CPT ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL 1,701 CPT ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, COMPLETE 1,859 CPT ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED 1,806 CPT ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE 1,976 CPT ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY 2,112 INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE) CPT ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF 1,842 ADHESIONS, WITH OR WITHOUT MANIPULATION CPT ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF 2,112 SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH OR WITHOUT CORACOACROMIAL RELEASE CPT ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR 3,452 CPT ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS 2,939 CPT ARTHROSCOPY, ELBOW, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,419 BIOPSY (SEPARATE PROCEDURE) CPT ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR 1,544 FOREIGN BODY CPT ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, PARTIAL 1,589 CPT ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, COMPLETE 1,808 CPT ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, LIMITED 1,658 CPT ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE 1,854 CPT ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) 1,392 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 88 of 380

89 CPT ARTHROSCOPY, WRIST, SURGICAL; FOR INFECTION, LAVAGE AND 1,484 DRAINAGE CPT ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, PARTIAL 1,553 CPT ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE 1,783 CPT ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF 1,633 TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT CPT ARTHROSCOPY, WRIST, SURGICAL; INTERNAL FIXATION FOR FRACTURE 1,697 OR INSTABILITY CPT ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL 1,558 LIGAMENT CPT ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) 1,781 AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITHOUT INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) CPT ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) 2,976 AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH OR WITHOUT MANIPULATION; WITH INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) CPT ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL 2,483 (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY) CPT ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL 3,174 (PLATEAU); BICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY) CPT ARTHROSCOPY, HIP, DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY 2,071 (SEPARATE PROCEDURE) CPT ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL OF LOOSE BODY OR 2,258 FOREIGN BODY CPT ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDEMENT/SHAVING OF 2,537 ARTICULAR CARTILAGE (CHONDROPLASTY), ABRASION ARTHROPLASTY, AND/OR RESECTION OF LABRUM CPT ARTHROSCOPY, HIP, SURGICAL; WITH SYNOVECTOMY 2,502 CPT ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, 3,316 MOSAICPLASTY) (INCLUDES HARVESTING OF THE AUTOGRAFT[S]) CPT ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, 4,029 MOSAICPLASTY) CPT ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION 5,418 (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR LATERAL CPT ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,276 BIOPSY (SEPARATE PROCEDURE) CPT ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND 1,611 DRAINAGE CPT ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE 1,602 CPT ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION) CPT ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE) CPT ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL) CPT ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) 1,674 1,553 2,049 1,939 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 89 of 380

90 CPT ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES 2,071 CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE CPT ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND 2,164 LATERAL, INCLUDING ANY MENISCAL SHAVING) CPT ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR 2,018 LATERAL, INCLUDING ANY MENISCAL SHAVING) CPT ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR 2,191 LATERAL) CPT ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND 2,659 LATERAL) CPT ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR 1,933 WITHOUT MANIPULATION (SEPARATE PROCEDURE) CPT ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR OSTEOCHONDRITIS 2,346 DISSECANS WITH BONE GRAFTING, WITH OR WITHOUT INTERNAL FIXATION (INCLUDING DEBRIDEMENT OF BASE OF LESION) CPT ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT 1,973 OSTEOCHONDRITIS DISSECANS LESION CPT ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT 2,331 OSTEOCHONDRITIS DISSECANS LESION WITH INTERNAL FIXATION CPT ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT 3,125 REPAIR/AUGMENTATION OR RECONSTRUCTION CPT ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT 3,846 REPAIR/AUGMENTATION OR RECONSTRUCTION CPT ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL 2,203 DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT CPT ARTHROSCOPICALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS 2,249 DISSECANS LESION, TALAR DOME FRACTURE, OR TIBIAL PLAFOND FRACTURE, WITH OR WITHOUT INTERNAL FIXATION (INCLUDES ARTHROSCOPY) CPT ENDOSCOPIC PLANTAR FASCIOTOMY 1,957 CPT ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,652 SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY CPT ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,594 SURGICAL; SYNOVECTOMY, PARTIAL CPT ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,664 SURGICAL; DEBRIDEMENT, LIMITED CPT ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,875 SURGICAL; DEBRIDEMENT, EXTENSIVE CPT ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 3,377 SURGICAL; WITH ANKLE ARTHRODESIS CPT ARTHROSCOPY, METACARPOPHALANGEAL JOINT, DIAGNOSTIC, INCLUDES 1,428 SYNOVIAL BIOPSY CPT ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 1,587 DEBRIDEMENT CPT ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 1,617 REDUCTION OF DISPLACED ULNAR COLLATERAL LIGAMENT (EG, STENAR LESION) CPT ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH REMOVAL OF LOOSE 1,968 BODY OR FOREIGN BODY CPT ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SYNOVECTOMY 2,119 CPT ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT 2,232 CPT ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SUBTALAR ARTHRODESIS 2,740 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 90 of 380

91 CPT UNLISTED PROCEDURE, ARTHROSCOPY N/A CPT DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPROACH 703 CPT DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM 722 CPT BIOPSY, INTRANASAL 451 CPT EXCISION, NASAL POLYP(S), SIMPLE 716 CPT EXCISION, NASAL POLYP(S), EXTENSIVE 1,356 CPT EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; 2,722 INTERNAL APPROACH CPT EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; 2,410 EXTERNAL APPROACH (LATERAL RHINOTOMY) CPT EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR RHINOPHYMA 1,624 CPT EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, SUBCUTANEOUS 889 CPT EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE OR CARTILAGE 1,919 CPT EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD 1,178 CPT SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, 1,377 ANY METHOD CPT RHINECTOMY; PARTIAL 2,443 CPT RHINECTOMY; TOTAL 2,472 CPT INJECTION INTO TURBINATE(S), THERAPEUTIC 359 CPT DISPLACEMENT THERAPY (PROETZ TYPE) 465 CPT INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON) 944 CPT REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE 684 CPT REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERAL 635 ANESTHESIA CPT REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINOTOMY 1,423 CPT RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR 3,214 ELEVATION OF NASAL TIP CPT RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY 3,836 PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP CPT RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR 4,269 CPT RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK) CPT RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES) CPT RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) CPT RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP 2,766 3,662 4,814 2,361 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 91 of 380

92 ONLY CPT RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL 4,697 CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OSTEOTOMIES CPT REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, 3,063 LATERAL NASAL WALL RECONSTRUCTION) CPT SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT 1,933 CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT CPT REPAIR CHOANAL ATRESIA; INTRANASAL 2,143 CPT REPAIR CHOANAL ATRESIA; TRANSPALATINE 3,058 CPT LYSIS INTRANASAL SYNECHIA 838 CPT REPAIR FISTULA; OROMAXILLARY (COMBINE WITH IF ANTROTOMY 1,987 IS INCLUDED) CPT REPAIR FISTULA; ORONASAL 1,818 CPT SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT INCLUDE 1,923 OBTAINING GRAFT) CPT REPAIR NASAL SEPTAL PERFORATIONS 1,953 CPT CAUTERY AND/OR ABLATION, MUCOSA OF INFERIOR TURBINATES, 692 UNILATERAL OR BILATERAL, ANY METHOD; SUPERFICIAL CPT CAUTERY AND/OR ABLATION, MUCOSA OF INFERIOR TURBINATES, 905 UNILATERAL OR BILATERAL, ANY METHOD; INTRAMURAL CPT CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY 326 AND/OR PACKING) ANY METHOD CPT CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE 623 CAUTERY AND/OR PACKING) ANY METHOD CPT CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL 765 PACKS AND/OR CAUTERY, ANY METHOD; INITIAL CPT CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL 873 PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT CPT LIGATION ARTERIES; ETHMOIDAL 1,812 CPT LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRANSANTRAL 2,618 CPT FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC 382 CPT UNLISTED PROCEDURE, NOSE N/A CPT LAVAGE BY CANNULATION; MAXILLARY SINUS (ANTRUM PUNCTURE OR 563 NATURAL OSTIUM) CPT LAVAGE BY CANNULATION; SPHENOID SINUS 600 CPT SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL 1,496 CPT SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) 2,134 WITHOUT REMOVAL OF ANTROCHOANAL POLYPS CPT SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) 1,787 WITH REMOVAL OF ANTROCHOANAL POLYPS CPT PTERYGOMAXILLARY FOSSA SURGERY, ANY APPROACH 2,254 CPT SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; 1,549 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 92 of 380

93 CPT SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; WITH MUCOSAL 2,032 STRIPPING OR REMOVAL OF POLYP(S) CPT SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE (TREPHINE OPERATION) 1,370 CPT SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL (FOR MUCOCELE OR 2,451 OSTEOMA, LYNCH TYPE) CPT SINUSOTOMY FRONTAL; OBLITERATIVE WITHOUT OSTEOPLASTIC FLAP, 3,071 BROW INCISION (INCLUDES ABLATION) CPT SINUSOTOMY FRONTAL; OBLITERATIVE, WITHOUT OSTEOPLASTIC FLAP, 4,007 CORONAL INCISION (INCLUDES ABLATION) CPT SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTIC FLAP, BROW 3,627 INCISION CPT SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,978 CORONAL INCISION CPT SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,526 BROW INCISION CPT SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,458 CORONAL INCISION CPT SINUSOTOMY, UNILATERAL, THREE OR MORE PARANASAL SINUSES 3,175 (FRONTAL, MAXILLARY, ETHMOID, SPHENOID) CPT ETHMOIDECTOMY; INTRANASAL, ANTERIOR 1,606 CPT ETHMOIDECTOMY; INTRANASAL, TOTAL 2,304 CPT ETHMOIDECTOMY; EXTRANASAL, TOTAL 2,600 CPT MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION 5,781 CPT MAXILLECTOMY; WITH ORBITAL EXENTERATION (EN BLOC) 6,525 CPT NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE 602 PROCEDURE) CPT NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY SINUSOSCOPY 837 (VIA INFERIOR MEATUS OR CANINE FOSSA PUNCTURE) CPT NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SINUSOSCOPY 950 (VIA PUNCTURE OF SPHENOIDAL FACE OR CANNULATION OF OSTIUM) CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR 1,027 DEBRIDEMENT (SEPARATE PROCEDURE) CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL 1,052 HEMORRHAGE CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY 2,049 CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA 518 RESECTION CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, PARTIAL 884 (ANTERIOR) CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL 1,305 (ANTERIOR AND POSTERIOR) CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; 643 CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; 1,032 WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS CPT NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS 1,645 EXPLORATION, WITH OR WITHOUT REMOVAL OF TISSUE FROM FRONTAL SINUS CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; 753 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 93 of 380

94 CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH 873 REMOVAL OF TISSUE FROM THE SPHENOID SINUS CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL 3,643 FLUID LEAK; ETHMOID REGION CPT NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL 3,861 FLUID LEAK; SPHENOID REGION CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL OR INFERIOR 3,154 ORBITAL WALL DECOMPRESSION CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL ORBITAL WALL AND 3,440 INFERIOR ORBITAL WALL DECOMPRESSION CPT NASAL/SINUS ENDOSCOPY, SURGICAL; WITH OPTIC NERVE 3,952 DECOMPRESSION CPT UNLISTED PROCEDURE, ACCESSORY SINUSES N/A CPT LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMOVAL OF 3,961 TUMOR OR LARYNGOCELE, CORDECTOMY CPT LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); DIAGNOSTIC 2,042 CPT LARYNGECTOMY; TOTAL, WITHOUT RADICAL NECK DISSECTION 6,423 CPT LARYNGECTOMY; TOTAL, WITH RADICAL NECK DISSECTION 7,986 CPT LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITHOUT RADICAL NECK 6,864 DISSECTION CPT LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITH RADICAL NECK 7,636 DISSECTION CPT PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTAL 6,436 CPT PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVERTICAL 6,107 CPT PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVERTICAL 6,010 CPT PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO-LATERO- 6,623 VERTICAL CPT PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION; WITHOUT 8,861 RECONSTRUCTION CPT PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION; WITH 9,374 RECONSTRUCTION CPT ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROACH 3,122 CPT EPIGLOTTIDECTOMY 2,610 CPT INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 367 CPT TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA 114 TRACT CPT LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE) 263 CPT LARYNGOSCOPY, INDIRECT; WITH BIOPSY 668 CPT LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF FOREIGN BODY 665 CPT LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF LESION 657 CPT LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD INJECTION 422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 94 of 380

95 CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; FOR 646 ASPIRATION CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 499 DIAGNOSTIC, NEWBORN CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 791 DIAGNOSTIC, EXCEPT NEWBORN CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 507 DIAGNOSTIC, WITH OPERATING MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 620 INSERTION OF OBTURATOR CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 459 DILATION, INITIAL CPT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 522 DILATION, SUBSEQUENT CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; 644 CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; 687 WITH OPERATING MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; 611 CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING 680 MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR 781 STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR 853 STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR 1,156 TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH LOCAL TISSUE FLAP(S) CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH OPERATING MICROSCOPE OR 1,754 TELESCOPE, WITH SUBMUCOSAL REMOVAL OF NON-NEOPLASTIC LESION(S) OF VOCAL CORD; RECONSTRUCTION WITH GRAFT(S) (INCLUDES OBTAINING AUTOGRAFT) CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY; 1,011 CPT LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY; WITH 1,107 OPERATING MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 1,061 THERAPEUTIC; CPT LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 808 THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE CPT LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC 363 CPT LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH BIOPSY 708 CPT LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN 762 BODY CPT LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF LESION 889 CPT LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, WITH STROBOSCOPY 668 CPT LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH KEEL INSERTION AND REMOVAL CPT LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT OR CORE MOLD, INCLUDING TRACHEOTOMY 3,686 5,941 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 95 of 380

96 CPT LARYNGOPLASTY; WITH OPEN REDUCTION OF FRACTURE 4,701 CPT LARYNGOPLASTY, CRICOID SPLIT 3,112 CPT LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BURNS, 3,549 RECONSTRUCTION AFTER PARTIAL LARYNGECTOMY) CPT LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE 2,677 CPT SECTION RECURRENT LARYNGEAL NERVE, THERAPEUTIC (SEPARATE 2,401 PROCEDURE), UNILATERAL CPT UNLISTED PROCEDURE, LARYNX N/A CPT TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); 1,290 CPT TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); YOUNGER THAN 828 TWO YEARS CPT TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL 726 CPT TRACHEOSTOMY, EMERGENCY PROCEDURE; CRICOTHYROID MEMBRANE 602 CPT TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLAPS 2,241 CPT CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBSEQUENT 1,694 INSERTION OF AN ALARYNGEAL SPEECH PROSTHESIS (EG, VOICE BUTTON, BLOM-SINGER PROSTHESIS) CPT TRACHEAL PUNCTURE, PERCUTANEOUS WITH TRANSTRACHEAL 261 ASPIRATION AND/OR INJECTION CPT TRACHEOSTOMA REVISION; SIMPLE, WITHOUT FLAP ROTATION 1,408 CPT TRACHEOSTOMA REVISION; COMPLEX, WITH FLAP ROTATION 2,346 CPT TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCISION CPT ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE(S)) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; DIAGNOSTIC, WITH OR WITHOUT CELL WASHING (SEPARATE PROCEDURE) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRUSHING OR PROTECTED BRUSHINGS CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL ALVEOLAR LAVAGE CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRACHEAL/BRONCHIAL DILATION OR CLOSED REDUCTION OF FRACTURE CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH PLACEMENT OF TRACHEAL STENT(S) (INCLUDES TRACHEAL/BRONCHIAL DILATION AS REQUIRED) ,032 1,131 1,051 1,135 1,377 2, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 96 of 380

97 CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 260 GUIDANCE; WITH TRANSBRONCHIAL LUNG BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 310 GUIDANCE; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 1,146 GUIDANCE; WITH REMOVAL OF FOREIGN BODY CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 748 GUIDANCE; WITH PLACEMENT OF BRONCHIAL STENT(S) (INCLUDES TRACHEAL/BRONCHIAL DILATION AS REQUIRED), INITIAL BRONCHUS CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 266 GUIDANCE; EACH ADDITIONAL MAJOR BRONCHUS STENTED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 835 GUIDANCE; WITH REVISION OF TRACHEAL OR BRONCHIAL STENT INSERTED AT PREVIOUS SESSION (INCLUDES TRACHEAL/BRONCHIAL DILATION AS REQUIRED) CPT BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 871 GUIDANCE; WITH EXCISION OF TUMOR CPT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH DESTRUCTION OF TUMOR 863 OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY) CPT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH PLACEMENT OF 595 CATHETER(S) FOR INTRACAVITARY RADIOELEMENT APPLICATION CPT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION 1,011 OF TRACHEOBRONCHIAL TREE, INITIAL (EG, DRAINAGE OF LUNG ABSCESS) CPT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION 916 OF TRACHEOBRONCHIAL TREE, SUBSEQUENT CPT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH INJECTION OF CONTRAST 1,008 MATERIAL FOR SEGMENTAL BRONCHOGRAPHY (FIBERSCOPE ONLY) CPT TRANSTRACHEAL INJECTION FOR BRONCHOGRAPHY 179 CPT CATHETERIZATION WITH BRONCHIAL BRUSH BIOPSY 1,019 CPT CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL 176 CPT CATHETER ASPIRATION (SEPARATE PROCEDURE); TRACHEOBRONCHIAL 315 WITH FIBERSCOPE, BEDSIDE CPT TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDLE WIRE 3,625 DILATOR/STENT OR INDWELLING TUBE FOR OXYGEN THERAPY CPT TRACHEOPLASTY; CERVICAL 4,241 CPT TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULIZATION, EACH STAGE 5,346 CPT TRACHEOPLASTY; INTRATHORACIC 4,542 CPT CARINAL RECONSTRUCTION 6,017 CPT BRONCHOPLASTY; GRAFT REPAIR 4,387 CPT BRONCHOPLASTY; EXCISION STENOSIS AND ANASTOMOSIS 4,663 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 97 of 380

98 CPT EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICAL 3,794 CPT EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICOTHORACIC 4,618 CPT EXCISION OF TRACHEAL TUMOR OR CARCINOMA; CERVICAL 3,468 CPT EXCISION OF TRACHEAL TUMOR OR CARCINOMA; THORACIC 4,815 CPT SUTURE OF TRACHEAL WOUND OR INJURY; CERVICAL 2,211 CPT SUTURE OF TRACHEAL WOUND OR INJURY; INTRATHORACIC 2,692 CPT SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC 1,361 REPAIR CPT SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITH PLASTIC REPAIR 1,883 CPT REVISION OF TRACHEOSTOMY SCAR 1,373 CPT UNLISTED PROCEDURE, TRACHEA, BRONCHI N/A CPT THORACOSTOMY; WITH RIB RESECTION FOR EMPYEMA 2,334 CPT THORACOSTOMY; WITH OPEN FLAP DRAINAGE FOR EMPYEMA 2,509 CPT THORACOTOMY, LIMITED, FOR BIOPSY OF LUNG OR PLEURA 2,061 CPT THORACOTOMY, MAJOR; WITH EXPLORATION AND BIOPSY 3,188 CPT THORACOTOMY, MAJOR; WITH CONTROL OF TRAUMATIC HEMORRHAGE 4,814 AND/OR REPAIR OF LUNG TEAR CPT THORACOTOMY, MAJOR; FOR POSTOPERATIVE COMPLICATIONS 2,854 CPT THORACOTOMY, MAJOR; WITH OPEN INTRAPLEURAL PNEUMONOLYSIS 3,044 CPT THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL, WITH OR WITHOUT A 3,261 PLEURAL PROCEDURE CPT THORACOTOMY, MAJOR; WITH EXCISION-PLICATION OF BULLAE, WITH OR 4,946 WITHOUT ANY PLEURAL PROCEDURE CPT THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL FOREIGN 3,300 BODY OR FIBRIN DEPOSIT CPT THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPULMONARY FOREIGN 3,370 BODY CPT THORACOTOMY, MAJOR; WITH CARDIAC MASSAGE 2,538 CPT PNEUMONOSTOMY; WITH OPEN DRAINAGE OF ABSCESS OR CYST 3,699 CPT PNEUMONOSTOMY; WITH PERCUTANEOUS DRAINAGE OF ABSCESS OR 3,033 CYST CPT PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX 2,625 CPT DECORTICATION, PULMONARY (SEPARATE PROCEDURE); TOTAL 5,272 CPT DECORTICATION, PULMONARY (SEPARATE PROCEDURE); PARTIAL 3,292 CPT PLEURECTOMY, PARIETAL (SEPARATE PROCEDURE) 3,032 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 98 of 380

99 CPT DECORTICATION AND PARIETAL PLEURECTOMY 5,289 CPT BIOPSY, PLEURA; PERCUTANEOUS NEEDLE 504 CPT BIOPSY, PLEURA; OPEN 1,843 CPT BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE 343 CPT PNEUMOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION 378 CPT THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, 507 INITIAL OR SUBSEQUENT CPT THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL (EG, 653 FOR PNEUMOTHORAX), WHEN PERFORMED (SEPARATE PROCEDURE) CPT REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; 5,258 CPT REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; WITH RESECTION OF 9,938 SEGMENT OF TRACHEA FOLLOWED BY BRONCHO-TRACHEAL ANASTOMOSIS (SLEEVE PNEUMONECTOMY) CPT REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; EXTRAPLEURAL 11,343 CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE LOBE 4,959 (LOBECTOMY) CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; TWO LOBES 5,292 (BILOBECTOMY) CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE 4,771 SEGMENT (SEGMENTECTOMY) CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WITH 7,670 CIRCUMFERENTIAL RESECTION OF SEGMENT OF BRONCHUS FOLLOWED BY BRONCHO-BRONCHIAL ANASTOMOSIS (SLEEVE LOBECTOMY) CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; ALL 7,831 REMAINING LUNG FOLLOWING PREVIOUS REMOVAL OF A PORTION OF LUNG (COMPLETION PNEUMONECTOMY) CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; EXCISION- 4,847 PLICATION OF EMPHYSEMATOUS LUNG(S) (BULLOUS OR NON-BULLOUS) FOR LUNG VOLUME REDUCTION, STERNAL SPLIT OR TRANSTHORACIC APPROACH, WITH OR WITHOUT ANY PLEURAL PROCEDURE CPT REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WEDGE 4,784 RESECTION, SINGLE OR MULTIPLE CPT RESECTION AND REPAIR OF PORTION OF BRONCHUS (BRONCHOPLASTY) 839 WHEN PERFORMED AT TIME OF LOBECTOMY OR SEGMENTECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING 6,051 CHEST WALL RESECTION, RIB(S) RESECTION(S), NEUROVASCULAR DISSECTION, WHEN PERFORMED; WITHOUT CHEST WALL RECONSTRUCTION(S) CPT RESECTION OF APICAL LUNG TUMOR (EG, PANCOAST TUMOR), INCLUDING 6,920 CHEST WALL RESECTION, RIB(S) RESECTION(S), NEUROVASCULAR DISSECTION, WHEN PERFORMED; WITH CHEST WALL RECONSTRUCTION CPT EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY) 5,511 CPT INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF 2,462 CPT TUBE THORACOSTOMY, INCLUDES WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, EMPYEMA), WHEN PERFORMED (SEPARATE PROCEDURE) CPT CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT PNEUMOTHORAX) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 99 of 380

100 CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 1,047 PLEURAL SPACE, WITHOUT BIOPSY CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 1,137 PLEURAL SPACE, WITH BIOPSY CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); PERICARDIAL 1,470 SAC, WITHOUT BIOPSY CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); PERICARDIAL 1,645 SAC, WITH BIOPSY CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL 1,321 SPACE, WITHOUT BIOPSY CPT THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL 1,583 SPACE, WITH BIOPSY CPT THORACOSCOPY, SURGICAL; WITH PLEURODESIS (EG, MECHANICAL OR 2,214 CHEMICAL) CPT THORACOSCOPY, SURGICAL; WITH PARTIAL PULMONARY DECORTICATION 3,558 CPT THORACOSCOPY, SURGICAL; WITH TOTAL PULMONARY DECORTICATION, 5,396 INCLUDING INTRAPLEURAL PNEUMONOLYSIS CPT THORACOSCOPY, SURGICAL; WITH REMOVAL OF INTRAPLEURAL FOREIGN 3,453 BODY OR FIBRIN DEPOSIT CPT THORACOSCOPY, SURGICAL; WITH CONTROL OF TRAUMATIC 3,779 HEMORRHAGE CPT THORACOSCOPY, SURGICAL; WITH EXCISION-PLICATION OF BULLAE, 3,130 INCLUDING ANY PLEURAL PROCEDURE CPT THORACOSCOPY, SURGICAL; WITH PARIETAL PLEURECTOMY 2,648 CPT THORACOSCOPY, SURGICAL; WITH WEDGE RESECTION OF LUNG, SINGLE 2,620 OR MULTIPLE CPT THORACOSCOPY, SURGICAL; WITH REMOVAL OF CLOT OR FOREIGN BODY 2,372 FROM PERICARDIAL SAC CPT THORACOSCOPY, SURGICAL; WITH CREATION OF PERICARDIAL WINDOW 2,426 OR PARTIAL RESECTION OF PERICARDIAL SAC FOR DRAINAGE CPT THORACOSCOPY, SURGICAL; WITH TOTAL PERICARDIECTOMY 3,445 CPT THORACOSCOPY, SURGICAL; WITH EXCISION OF PERICARDIAL CYST, 2,674 TUMOR, OR MASS CPT THORACOSCOPY, SURGICAL; WITH EXCISION OF MEDIASTINAL CYST, 2,986 TUMOR, OR MASS CPT THORACOSCOPY, SURGICAL; WITH LOBECTOMY, TOTAL OR SEGMENTAL 4,618 CPT THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY 2,790 CPT THORACOSCOPY, SURGICAL; WITH ESOPHAGOMYOTOMY (HELLER TYPE) 4,050 CPT REPAIR LUNG HERNIA THROUGH CHEST WALL 3,085 CPT CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE FOR 2,989 EMPYEMA (CLAGETT TYPE PROCEDURE) CPT OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA 9,021 CPT MAJOR RECONSTRUCTION, CHEST WALL (POSTTRAUMATIC) 4,459 CPT DONOR PNEUMONECTOMY(S) (INCLUDING COLD PRESERVATION), FROM N/A CADAVER DONOR CPT LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOPULMONARY BYPASS 8,396 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 100 of 380

101 CPT LUNG TRANSPLANT, SINGLE; WITH CARDIOPULMONARY BYPASS 9,219 CPT LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 10,067 WITHOUT CARDIOPULMONARY BYPASS CPT LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 10,936 WITH CARDIOPULMONARY BYPASS CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR LUNG N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE PULMONARY VENOUS/ATRIAL CUFF, PULMONARY ARTERY, AND BRONCHUS; UNILATERAL CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR LUNG N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE PULMONARY VENOUS/ATRIAL CUFF, PULMONARY ARTERY, AND BRONCHUS; BILATERAL CPT RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES 4,556 CPT THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); 4,513 CPT THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); WITH 5,563 CLOSURE OF BRONCHOPLEURAL FISTULA CPT PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING OR PACKING 4,103 PROCEDURES CPT PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL INJECTION OF AIR 454 CPT TOTAL LUNG LAVAGE (UNILATERAL) 1,220 CPT ABLATION THERAPY FOR REDUCTION OR ERADICATION OF ONE OR MORE 9,603 PULMONARY TUMOR(S) INCLUDING PLEURA OR CHEST WALL WHEN INVOLVED BY TUMOR EXTENSION, PERCUTANEOUS, RADIOFREQUENCY, UNILATERAL CPT UNLISTED PROCEDURE, LUNGS AND PLEURA N/A CPT PERICARDIOCENTESIS; INITIAL 430 CPT PERICARDIOCENTESIS; SUBSEQUENT 443 CPT TUBE PERICARDIOSTOMY 1,793 CPT PERICARDIOTOMY FOR REMOVAL OF CLOT OR FOREIGN BODY (PRIMARY 2,900 PROCEDURE) CPT CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTION FOR 2,682 DRAINAGE CPT PERICARDIECTOMY, SUBTOTAL OR COMPLETE; WITHOUT 4,308 CARDIOPULMONARY BYPASS CPT PERICARDIECTOMY, SUBTOTAL OR COMPLETE; WITH CARDIOPULMONARY 4,785 BYPASS CPT EXCISION OF PERICARDIAL CYST OR TUMOR 3,319 CPT EXCISION OF INTRACARDIAC TUMOR, RESECTION WITH 5,236 CARDIOPULMONARY BYPASS CPT RESECTION OF EXTERNAL CARDIAC TUMOR 4,585 CPT TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; (SEPARATE PROCEDURE) CPT TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; PERFORMED AT THE TIME OF OTHER OPEN CARDIAC PROCEDURE(S) (LIST 5, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 101 of 380

102 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INSERTION OF EPICARDIAL ELECTRODE(S); OPEN INCISION (EG, 2,635 THORACOTOMY, MEDIAN STERNOTOMY, SUBXIPHOID APPROACH) CPT INSERTION OF EPICARDIAL ELECTRODE(S); ENDOSCOPIC APPROACH (EG, 2,698 THORACOSCOPY, PERICARDIOSCOPY) CPT INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,631 TRANSVENOUS ELECTRODE(S); ATRIAL CPT INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,739 TRANSVENOUS ELECTRODE(S); VENTRICULAR CPT INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,880 TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR CPT INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE 646 CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE) CPT INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS DUAL 653 CHAMBER PACING ELECTRODES (SEPARATE PROCEDURE) CPT INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; 1,214 SINGLE CHAMBER, ATRIAL OR VENTRICULAR CPT INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; 1,387 DUAL CHAMBER CPT UPGRADE OF IMPLANTED PACEMAKER SYSTEM, CONVERSION OF SINGLE 1,726 CHAMBER SYSTEM TO DUAL CHAMBER SYSTEM (INCLUDES REMOVAL OF PREVIOUSLY PLACED PULSE GENERATOR, TESTING OF EXISTING LEAD, INSERTION OF NEW LEAD, INSERTION OF NEW PULSE GENERATOR) CPT REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER 1,101 OR PACING CARDIOVERTER-DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE CPT INSERTION OF A TRANSVENOUS ELECTRODE; SINGLE CHAMBER (ONE 1,348 ELECTRODE) PERMANENT PACEMAKER OR SINGLE CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT INSERTION OF A TRANSVENOUS ELECTRODE; DUAL CHAMBER (TWO 1,334 ELECTRODES) PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT REPAIR OF SINGLE TRANSVENOUS ELECTRODE FOR A SINGLE CHAMBER, 1,404 PERMANENT PACEMAKER OR SINGLE CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR CPT REPAIR OF TWO TRANSVENOUS ELECTRODES FOR A DUAL CHAMBER 1,409 PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR CPT REVISION OR RELOCATION OF SKIN POCKET FOR PACEMAKER 1,224 CPT REVISION OF SKIN POCKET FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, WITH ATTACHMENT TO PREVIOUSLY PLACED PACEMAKER OR PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR (INCLUDING REVISION OF POCKET, REMOVAL, INSERTION, AND/OR REPLACEMENT OF GENERATOR) CPT INSERTION OF PACING ELECTRODE, CARDIAC VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF PACING CARDIOVERTER-DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (INCLUDING UPGRADE TO DUAL CHAMBER SYSTEM) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPOSITIONING OF PREVIOUSLY IMPLANTED CARDIAC VENOUS SYSTEM (LEFT VENTRICULAR) ELECTRODE (INCLUDING REMOVAL, INSERTION AND/OR REPLACEMENT OF GENERATOR) 1,487 1,823 1,652 1,763 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 102 of 380

103 CPT REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR 858 CPT REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR CPT REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD SYSTEM CPT REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR CPT REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; DUAL LEAD SYSTEM CPT REMOVAL OF PERMANENT TRANSVENOUS ELECTRODE(S) BY THORACOTOMY CPT INSERTION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR CPT SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR CPT REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY THORACOTOMY CPT REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION CPT INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR CPT OPERATIVE ABLATION OF SUPRAVENTRICULAR ARRHYTHMOGENIC FOCUS OR PATHWAY (EG, WOLFF-PARKINSON-WHITE, ATRIOVENTRICULAR NODE RE-ENTRY), TRACT(S) AND/OR FOCUS (FOCI); WITHOUT CARDIOPULMONARY BYPASS CPT OPERATIVE ABLATION OF SUPRAVENTRICULAR ARRHYTHMOGENIC FOCUS OR PATHWAY (EG, WOLFF-PARKINSON-WHITE, ATRIOVENTRICULAR NODE RE-ENTRY), TRACT(S) AND/OR FOCUS (FOCI); WITH CARDIOPULMONARY BYPASS CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED (EG, MODIFIED MAZE PROCEDURE) CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE); WITHOUT CARDIOPULMONARY BYPASS CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE); WITH CARDIOPULMONARY BYPASS CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), LIMITED (EG, MODIFIED MAZE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), EXTENSIVE (EG, MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, PERFORMED AT THE TIME OF OTHER CARDIAC PROCEDURE(S), EXTENSIVE (EG, MAZE PROCEDURE), WITH CARDIOPULMONARY BYPASS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPERATIVE ABLATION OF VENTRICULAR ARRHYTHMOGENIC FOCUS WITH CARDIOPULMONARY BYPASS CPT ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED (EG, MODIFIED MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS CPT ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE), 1,749 2,253 2,606 2,940 3,192 1, ,589 3,054 3,266 5,017 5,458 4,619 5,565 6,650 2,012 2,275 2,985 5,531 4,619 6,328 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 103 of 380

104 WITHOUT CARDIOPULMONARY BYPASS CPT IMPLANTATION OF PATIENT-ACTIVATED CARDIAC EVENT RECORDER 1,154 CPT REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT 825 RECORDER CPT REPAIR OF CARDIAC WOUND; WITHOUT BYPASS 7,880 CPT REPAIR OF CARDIAC WOUND; WITH CARDIOPULMONARY BYPASS 13,231 CPT CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY, 3,923 ATRIAL OR VENTRICULAR THROMBUS); WITHOUT BYPASS CPT CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY, 4,995 ATRIAL OR VENTRICULAR THROMBUS); WITH CARDIOPULMONARY BYPASS CPT SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITHOUT SHUNT OR 3,593 CARDIOPULMONARY BYPASS CPT SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH SHUNT BYPASS 4,027 CPT SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH 4,620 CARDIOPULMONARY BYPASS CPT INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITHOUT SHUNT, OR 4,718 CARDIOPULMONARY BYPASS CPT INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITH SHUNT BYPASS 4,650 CPT INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITH 6,363 CARDIOPULMONARY BYPASS CPT VALVULOPLASTY, AORTIC VALVE; OPEN, WITH CARDIOPULMONARY 7,559 BYPASS CPT VALVULOPLASTY, AORTIC VALVE; OPEN, WITH INFLOW OCCLUSION 4,815 CPT VALVULOPLASTY, AORTIC VALVE; USING TRANSVENTRICULAR DILATION, 5,219 WITH CARDIOPULMONARY BYPASS CPT CONSTRUCTION OF APICAL-AORTIC CONDUIT 5,991 CPT REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 7,758 PROSTHETIC VALVE OTHER THAN HOMOGRAFT OR STENTLESS VALVE CPT REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 9,615 ALLOGRAFT VALVE (FREEHAND) CPT REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 8,496 STENTLESS TISSUE VALVE CPT REPLACEMENT, AORTIC VALVE; WITH AORTIC ANNULUS ENLARGEMENT, 11,143 NONCORONARY CUSP CPT REPLACEMENT, AORTIC VALVE; WITH TRANSVENTRICULAR AORTIC 8,355 ANNULUS ENLARGEMENT (KONNO PROCEDURE) CPT REPLACEMENT, AORTIC VALVE; BY TRANSLOCATION OF AUTOLOGOUS 11,305 PULMONARY VALVE WITH ALLOGRAFT REPLACEMENT OF PULMONARY VALVE (ROSS PROCEDURE) CPT REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION BY PATCH 7,319 ENLARGEMENT OF THE OUTFLOW TRACT CPT RESECTION OR INCISION OF SUBVALVULAR TISSUE FOR DISCRETE 6,857 SUBVALVULAR AORTIC STENOSIS CPT VENTRICULOMYOTOMY (-MYECTOMY) FOR IDIOPATHIC HYPERTROPHIC 6,827 SUBAORTIC STENOSIS (EG, ASYMMETRIC SEPTAL HYPERTROPHY) CPT AORTOPLASTY (GUSSET) FOR SUPRAVALVULAR STENOSIS 5,661 CPT VALVOTOMY, MITRAL VALVE; CLOSED HEART 4,655 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 104 of 380

105 CPT VALVOTOMY, MITRAL VALVE; OPEN HEART, WITH CARDIOPULMONARY 5,652 BYPASS CPT VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 9,000 CPT VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 8,048 WITH PROSTHETIC RING CPT VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 8,369 RADICAL RECONSTRUCTION, WITH OR WITHOUT RING CPT REPLACEMENT, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS 9,367 CPT VALVECTOMY, TRICUSPID VALVE, WITH CARDIOPULMONARY BYPASS 7,903 CPT VALVULOPLASTY, TRICUSPID VALVE; WITHOUT RING INSERTION 10,138 CPT VALVULOPLASTY, TRICUSPID VALVE; WITH RING INSERTION 8,117 CPT REPLACEMENT, TRICUSPID VALVE, WITH CARDIOPULMONARY BYPASS 9,141 CPT TRICUSPID VALVE REPOSITIONING AND PLICATION FOR EBSTEIN 6,562 ANOMALY CPT VALVOTOMY, PULMONARY VALVE, CLOSED HEART; TRANSVENTRICULAR 3,811 CPT VALVOTOMY, PULMONARY VALVE, CLOSED HEART; VIA PULMONARY 4,760 ARTERY CPT VALVOTOMY, PULMONARY VALVE, OPEN HEART; WITH INFLOW 4,435 OCCLUSION CPT VALVOTOMY, PULMONARY VALVE, OPEN HEART; WITH CARDIOPULMONARY 6,978 BYPASS CPT REPLACEMENT, PULMONARY VALVE 7,837 CPT RIGHT VENTRICULAR RESECTION FOR INFUNDIBULAR STENOSIS, WITH OR WITHOUT COMMISSUROTOMY CPT OUTFLOW TRACT AUGMENTATION (GUSSET), WITH OR WITHOUT COMMISSUROTOMY OR INFUNDIBULAR RESECTION CPT REPAIR OF NON-STRUCTURAL PROSTHETIC VALVE DYSFUNCTION WITH CARDIOPULMONARY BYPASS (SEPARATE PROCEDURE) CPT REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; WITH CARDIOPULMONARY BYPASS CPT REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; WITHOUT CARDIOPULMONARY BYPASS CPT REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY LIGATION CPT REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY GRAFT, WITHOUT CARDIOPULMONARY BYPASS CPT REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY GRAFT, WITH CARDIOPULMONARY BYPASS CPT REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; WITH CONSTRUCTION OF INTRAPULMONARY ARTERY TUNNEL (TAKEUCHI PROCEDURE) CPT REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY TRANSLOCATION FROM PULMONARY ARTERY TO AORTA CPT REPAIR OF ANOMALOUS (EG, INTRAMURAL) AORTIC ORIGIN OF CORONARY ARTERY BY UNROOFING OR TRANSLOCATION CPT ENDOSCOPY, SURGICAL, INCLUDING VIDEO-ASSISTED HARVEST OF VEIN(S) FOR CORONARY ARTERY BYPASS PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 4,934 5,323 5,656 5,378 3,693 4,283 4,581 4,940 7,008 6,944 5, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 105 of 380

106 CPT CORONARY ARTERY BYPASS, VEIN ONLY; SINGLE CORONARY VENOUS 6,570 GRAFT CPT CORONARY ARTERY BYPASS, VEIN ONLY; TWO CORONARY VENOUS 7,182 GRAFTS CPT CORONARY ARTERY BYPASS, VEIN ONLY; THREE CORONARY VENOUS 8,117 GRAFTS CPT CORONARY ARTERY BYPASS, VEIN ONLY; FOUR CORONARY VENOUS 8,372 GRAFTS CPT CORONARY ARTERY BYPASS, VEIN ONLY; FIVE CORONARY VENOUS 8,823 GRAFTS CPT CORONARY ARTERY BYPASS, VEIN ONLY; SIX OR MORE CORONARY 9,157 VENOUS GRAFTS CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 639 GRAFT(S); SINGLE VEIN GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 1,388 GRAFT(S); TWO VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 1,846 GRAFT(S); THREE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 2,232 GRAFT(S); FOUR VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 2,537 GRAFT(S); FIVE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL 2,893 GRAFT(S); SIX OR MORE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REOPERATION, CORONARY ARTERY BYPASS PROCEDURE OR VALVE 1,757 PROCEDURE, MORE THAN ONE MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE 6,390 ARTERIAL GRAFT CPT CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); TWO CORONARY 7,454 ARTERIAL GRAFTS CPT CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); THREE 8,304 CORONARY ARTERIAL GRAFTS CPT CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR MORE 8,949 CORONARY ARTERIAL GRAFTS CPT MYOCARDIAL RESECTION (EG, VENTRICULAR ANEURYSMECTOMY) 8,730 CPT REPAIR OF POSTINFARCTION VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT MYOCARDIAL RESECTION CPT SURGICAL VENTRICULAR RESTORATION PROCEDURE, INCLUDES PROSTHETIC PATCH, WHEN PERFORMED (EG, VENTRICULAR REMODELING, SVR, SAVER, DOR PROCEDURES) CPT CORONARY ENDARTERECTOMY, OPEN, ANY METHOD, OF LEFT ANTERIOR DESCENDING, CIRCUMFLEX, OR RIGHT CORONARY ARTERY PERFORMED IN CONJUNCTION WITH CORONARY ARTERY BYPASS GRAFT PROCEDURE, EACH VESSEL (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT CLOSURE OF ATRIOVENTRICULAR VALVE (MITRAL OR TRICUSPID) BY SUTURE OR PATCH CPT CLOSURE OF SEMILUNAR VALVE (AORTIC OR PULMONARY) BY SUTURE OR PATCH 10,359 9, ,880 5,559 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 106 of 380

107 CPT ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE- 6,003 STANSEL PROCEDURE) CPT REPAIR OF COMPLEX CARDIAC ANOMALY OTHER THAN PULMONARY 6,207 ATRESIA WITH VENTRICULAR SEPTAL DEFECT BY CONSTRUCTION OR REPLACEMENT OF CONDUIT FROM RIGHT OR LEFT VENTRICLE TO PULMONARY ARTERY CPT REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE WITH 6,212 SUBAORTIC OBSTRUCTION) BY SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR 6,574 TUNNEL REPAIR; CPT REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR 7,062 TUNNEL REPAIR; WITH REPAIR OF RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION CPT REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, TRICUSPID ATRESIA) BY 6,781 CLOSURE OF ATRIAL SEPTAL DEFECT AND ANASTOMOSIS OF ATRIA OR VENA CAVA TO PULMONARY ARTERY (SIMPLE FONTAN PROCEDURE) CPT REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE) BY 7,373 MODIFIED FONTAN PROCEDURE CPT REPAIR OF SINGLE VENTRICLE WITH AORTIC OUTFLOW OBSTRUCTION 9,194 AND AORTIC ARCH HYPOPLASIA (HYPOPLASTIC LEFT HEART SYNDROME) (EG, NORWOOD PROCEDURE) CPT REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM, WITH CARDIOPULMONARY 5,490 BYPASS, WITH OR WITHOUT PATCH CPT DIRECT OR PATCH CLOSURE, SINUS VENOSUS, WITH OR WITHOUT 5,343 ANOMALOUS PULMONARY VENOUS DRAINAGE CPT REPAIR OF ATRIAL SEPTAL DEFECT AND VENTRICULAR SEPTAL DEFECT, 5,715 WITH DIRECT OR PATCH CLOSURE CPT REPAIR OF INCOMPLETE OR PARTIAL ATRIOVENTRICULAR CANAL (OSTIUM 6,050 PRIMUM ATRIAL SEPTAL DEFECT), WITH OR WITHOUT ATRIOVENTRICULAR VALVE REPAIR CPT REPAIR OF INTERMEDIATE OR TRANSITIONAL ATRIOVENTRICULAR CANAL, 6,411 WITH OR WITHOUT ATRIOVENTRICULAR VALVE REPAIR CPT REPAIR OF COMPLETE ATRIOVENTRICULAR CANAL, WITH OR WITHOUT 7,158 PROSTHETIC VALVE CPT CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; 7,121 CPT CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH 7,347 PULMONARY VALVOTOMY OR INFUNDIBULAR RESECTION (ACYANOTIC) CPT CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH REMOVAL 7,637 OF PULMONARY ARTERY BAND, WITH OR WITHOUT GUSSET CPT CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,230 PATCH; CPT CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,415 PATCH; WITH PULMONARY VALVOTOMY OR INFUNDIBULAR RESECTION (ACYANOTIC) CPT CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,423 PATCH; WITH REMOVAL OF PULMONARY ARTERY BAND, WITH OR WITHOUT GUSSET CPT BANDING OF PULMONARY ARTERY 3,878 CPT COMPLETE REPAIR TETRALOGY OF FALLOT WITHOUT PULMONARY ATRESIA; CPT COMPLETE REPAIR TETRALOGY OF FALLOT WITHOUT PULMONARY ATRESIA; WITH TRANSANNULAR PATCH CPT COMPLETE REPAIR TETRALOGY OF FALLOT WITH PULMONARY ATRESIA INCLUDING CONSTRUCTION OF CONDUIT FROM RIGHT VENTRICLE TO 6,992 6,396 7,367 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 107 of 380

108 PULMONARY ARTERY AND CLOSURE OF VENTRICULAR SEPTAL DEFECT CPT REPAIR SINUS OF VALSALVA FISTULA, WITH CARDIOPULMONARY BYPASS; 5,200 CPT REPAIR SINUS OF VALSALVA FISTULA, WITH CARDIOPULMONARY BYPASS; 5,786 WITH REPAIR OF VENTRICULAR SEPTAL DEFECT CPT REPAIR SINUS OF VALSALVA ANEURYSM, WITH CARDIOPULMONARY 5,243 BYPASS CPT CLOSURE OF AORTICO-LEFT VENTRICULAR TUNNEL 5,155 CPT REPAIR OF ISOLATED PARTIAL ANOMALOUS PULMONARY VENOUS RETURN 5,277 (EG, SCIMITAR SYNDROME) CPT REPAIR OF PULMONARY VENOUS STENOSIS 6,960 CPT COMPLETE REPAIR OF ANOMALOUS PULMONARY VENOUS RETURN 6,785 (SUPRACARDIAC, INTRACARDIAC, OR INFRACARDIAC TYPES) CPT REPAIR OF COR TRIATRIATUM OR SUPRAVALVULAR MITRAL RING BY 5,681 RESECTION OF LEFT ATRIAL MEMBRANE CPT ATRIAL SEPTECTOMY OR SEPTOSTOMY; CLOSED HEART (BLALOCK- 4,405 HANLON TYPE OPERATION) CPT ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART WITH 4,949 CARDIOPULMONARY BYPASS CPT ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART, WITH INFLOW 4,370 OCCLUSION CPT SHUNT; SUBCLAVIAN TO PULMONARY ARTERY (BLALOCK-TAUSSIG TYPE 4,109 OPERATION) CPT SHUNT; ASCENDING AORTA TO PULMONARY ARTERY (WATERSTON TYPE 4,216 OPERATION) CPT SHUNT; DESCENDING AORTA TO PULMONARY ARTERY (POTTS-SMITH TYPE 4,313 OPERATION) CPT SHUNT; CENTRAL, WITH PROSTHETIC GRAFT 4,329 CPT SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO ONE LUNG (CLASSICAL GLENN PROCEDURE) CPT SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO BOTH LUNGS (BIDIRECTIONAL GLENN PROCEDURE) CPT ANASTOMOSIS, CAVOPULMONARY, SECOND SUPERIOR VENA CAVA (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; WITHOUT SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; WITH SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; WITH REMOVAL OF PULMONARY BAND CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; WITH CLOSURE OF VENTRICULAR SEPTAL DEFECT CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; WITH REPAIR OF SUBPULMONIC OBSTRUCTION 4,479 4,716 1,388 7,134 7,470 6,112 6,032 6,277 6,214 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 108 of 380

109 CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 8,024 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,367 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH REMOVAL OF PULMONARY BAND CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,637 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH CLOSURE OF VENTRICULAR SEPTAL DEFECT CPT REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,584 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH REPAIR OF SUBPULMONIC OBSTRUCTION CPT TOTAL REPAIR, TRUNCUS ARTERIOSUS (RASTELLI TYPE OPERATION) 7,747 CPT REIMPLANTATION OF AN ANOMALOUS PULMONARY ARTERY 4,976 CPT AORTIC SUSPENSION (AORTOPEXY) FOR TRACHEAL DECOMPRESSION (EG, 3,336 FOR TRACHEOMALACIA) (SEPARATE PROCEDURE) CPT DIVISION OF ABERRANT VESSEL (VASCULAR RING); 3,582 CPT DIVISION OF ABERRANT VESSEL (VASCULAR RING); WITH 3,747 REANASTOMOSIS CPT OBLITERATION OF AORTOPULMONARY SEPTAL DEFECT; WITHOUT 4,176 CARDIOPULMONARY BYPASS CPT OBLITERATION OF AORTOPULMONARY SEPTAL DEFECT; WITH 5,119 CARDIOPULMONARY BYPASS CPT REPAIR OF PATENT DUCTUS ARTERIOSUS; BY LIGATION 3,262 CPT REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, YOUNGER THAN 3, YEARS CPT REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, 18 YEARS AND 3,958 OLDER CPT EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT ASSOCIATED 4,117 PATENT DUCTUS ARTERIOSUS; WITH DIRECT ANASTOMOSIS CPT EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT ASSOCIATED 4,453 PATENT DUCTUS ARTERIOSUS; WITH GRAFT CPT EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT ASSOCIATED 4,268 PATENT DUCTUS ARTERIOSUS; REPAIR USING EITHER LEFT SUBCLAVIAN ARTERY OR PROSTHETIC MATERIAL AS GUSSET FOR ENLARGEMENT CPT REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING 5,187 AUTOGENOUS OR PROSTHETIC MATERIAL; WITHOUT CARDIOPULMONARY BYPASS CPT REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING 6,178 AUTOGENOUS OR PROSTHETIC MATERIAL; WITH CARDIOPULMONARY BYPASS CPT ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 10,737 WITHOUT VALVE SUSPENSION; CPT ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 8,309 WITHOUT VALVE SUSPENSION; WITH CORONARY RECONSTRUCTION CPT ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 10,687 WITHOUT VALVE SUSPENSION; WITH AORTIC ROOT REPLACEMENT USING COMPOSITE PROSTHESIS AND CORONARY RECONSTRUCTION CPT ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS WITH 10,930 VALVE SUSPENSION, WITH CORONARY RECONSTRUCTION AND VALVE- SPARING AORTIC ANNULUS REMODELING (EG, DAVID PROCEDURE, YACOUB PROCEDURE) CPT TRANSVERSE ARCH GRAFT, WITH CARDIOPULMONARY BYPASS 8,664 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 109 of 380

110 CPT DESCENDING THORACIC AORTA GRAFT, WITH OR WITHOUT BYPASS 6,732 CPT REPAIR OF THORACOABDOMINAL AORTIC ANEURYSM WITH GRAFT, WITH 12,060 OR WITHOUT CARDIOPULMONARY BYPASS CPT ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, 6,061 ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDING THORACIC AORTIC EXTENSION(S), IF REQUIRED, TO LEVEL OF CELIAC ARTERY ORIGIN CPT ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, 5,221 ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); NOT INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDING THORACIC AORTIC EXTENSION(S), IF REQUIRED, TO LEVEL OF CELIAC ARTERY ORIGIN CPT PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR 3,818 REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); INITIAL EXTENSION CPT PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR 1,402 REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); EACH ADDITIONAL PROXIMAL EXTENSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) DELAYED AFTER 3,288 ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA CPT OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSPOSITION PERFORMED IN 2,779 CONJUNCTION WITH ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, BY NECK INCISION, UNILATERAL CPT BYPASS GRAFT, WITH OTHER THAN VEIN, TRANSCERVICAL 3,593 RETROPHARYNGEAL CAROTID-CAROTID, PERFORMED IN CONJUNCTION WITH ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, BY NECK INCISION CPT PULMONARY ARTERY EMBOLECTOMY; WITH CARDIOPULMONARY BYPASS 5,618 CPT PULMONARY ARTERY EMBOLECTOMY; WITHOUT CARDIOPULMONARY 4,454 BYPASS CPT PULMONARY ENDARTERECTOMY, WITH OR WITHOUT EMBOLECTOMY, WITH 5,387 CARDIOPULMONARY BYPASS CPT REPAIR OF PULMONARY ARTERY STENOSIS BY RECONSTRUCTION WITH 4,893 PATCH OR GRAFT CPT REPAIR OF PULMONARY ATRESIA WITH VENTRICULAR SEPTAL DEFECT, BY 5,844 CONSTRUCTION OR REPLACEMENT OF CONDUIT FROM RIGHT OR LEFT VENTRICLE TO PULMONARY ARTERY CPT TRANSECTION OF PULMONARY ARTERY WITH CARDIOPULMONARY BYPASS 4,712 CPT LIGATION AND TAKEDOWN OF A SYSTEMIC-TO-PULMONARY ARTERY SHUNT, PERFORMED IN CONJUNCTION WITH A CONGENITAL HEART PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY UNIFOCALIZATION; WITHOUT CARDIOPULMONARY BYPASS CPT REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY UNIFOCALIZATION; WITH CARDIOPULMONARY BYPASS 994 6,582 8,270 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 110 of 380

111 CPT DONOR CARDIECTOMY-PNEUMONECTOMY (INCLUDING COLD N/A PRESERVATION) CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR HEART/LUNG N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE AORTA, SUPERIOR VENA CAVA, INFERIOR VENA CAVA, AND TRACHEA FOR IMPLANTATION CPT HEART-LUNG TRANSPLANT WITH RECIPIENT CARDIECTOMY- 11,794 PNEUMONECTOMY CPT DONOR CARDIECTOMY (INCLUDING COLD PRESERVATION) N/A CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR HEART N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES TO PREPARE AORTA, SUPERIOR VENA CAVA, INFERIOR VENA CAVA, PULMONARY ARTERY, AND LEFT ATRIUM FOR IMPLA CPT HEART TRANSPLANT, WITH OR WITHOUT RECIPIENT CARDIECTOMY 15,826 CPT PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY 3,431 INSUFFICIENCY; INITIAL 24 HOURS CPT PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY 1,860 INSUFFICIENCY; EACH ADDITIONAL 24 HOURS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE, PERCUTANEOUS 956 CPT REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE, PERCUTANEOUS 122 CPT INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE 1,271 FEMORAL ARTERY, OPEN APPROACH CPT REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE INCLUDING REPAIR 2,412 OF FEMORAL ARTERY, WITH OR WITHOUT GRAFT CPT INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE 1,881 ASCENDING AORTA CPT REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE FROM THE 3,072 ASCENDING AORTA, INCLUDING REPAIR OF THE ASCENDING AORTA, WITH OR WITHOUT GRAFT CPT INSERTION OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, SINGLE 3,818 VENTRICLE CPT INSERTION OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, 4,266 BIVENTRICULAR CPT REMOVAL OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, SINGLE 4,065 VENTRICLE CPT REMOVAL OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, 4,562 BIVENTRICULAR CPT INSERTION OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 8,331 INTRACORPOREAL, SINGLE VENTRICLE CPT REMOVAL OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 12,151 INTRACORPOREAL, SINGLE VENTRICLE CPT UNLISTED PROCEDURE, CARDIAC SURGERY N/A CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; CAROTID, SUBCLAVIAN OR INNOMINATE ARTERY, BY NECK INCISION CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 3,272 3,343 2,084 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 111 of 380

112 CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 2,080 RADIAL OR ULNAR ARTERY, BY ARM INCISION CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 4,862 RENAL, CELIAC, MESENTERY, AORTOILIAC ARTERY, BY ABDOMINAL INCISION CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 3,446 FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG INCISION CPT EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 3,331 POPLITEAL-TIBIO-PERONEAL ARTERY, BY LEG INCISION CPT THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC VEIN, 4,881 BY ABDOMINAL INCISION CPT THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC, 2,522 FEMOROPOPLITEAL VEIN, BY LEG INCISION CPT THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC, 5,241 FEMOROPOPLITEAL VEIN, BY ABDOMINAL AND LEG INCISION CPT THROMBECTOMY, DIRECT OR WITH CATHETER; SUBCLAVIAN VEIN, BY 3,782 NECK INCISION CPT THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND 2,088 SUBCLAVIAN VEIN, BY ARM INCISION CPT VALVULOPLASTY, FEMORAL VEIN 3,212 CPT RECONSTRUCTION OF VENA CAVA, ANY METHOD 5,284 CPT VENOUS VALVE TRANSPOSITION, ANY VEIN DONOR 3,733 CPT CROSS-OVER VEIN GRAFT TO VENOUS SYSTEM 3,569 CPT SAPHENOPOPLITEAL VEIN ANASTOMOSIS 3,307 CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING AORTO-AORTIC TUBE PROSTHESIS CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING MODULAR BIFURCATED PROSTHESIS (ONE DOCKING LIMB) CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING MODULAR BIFURCATED PROSTHESIS (TWO DOCKING LIMBS) CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING UNIBODY BIFURCATED PROSTHESIS CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING AORTO-UNIILIAC OR AORTO-UNIFEMORAL PROSTHESIS CPT TRANSCATHETER PLACEMENT OF WIRELESS PHYSIOLOGIC SENSOR IN ANEURYSMAL SAC DURING ENDOVASCULAR REPAIR, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION, INSTRUMENT CALIBRATION, AND COLLECTION OF PRESSURE DATA CPT ENDOVASCULAR PLACEMENT OF ILIAC ARTERY OCCLUSION DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPEN FEMORAL ARTERY EXPOSURE FOR DELIVERY OF ENDOVASCULAR PROSTHESIS, BY GROIN INCISION, UNILATERAL CPT PLACEMENT OF FEMORAL-FEMORAL PROSTHETIC GRAFT DURING ENDOVASCULAR AORTIC ANEURYSM REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPEN ILIAC ARTERY EXPOSURE FOR DELIVERY OF ENDOVASCULAR PROSTHESIS OR ILIAC OCCLUSION DURING ENDOVASCULAR THERAPY, BY ABDOMINAL OR RETROPERITONEAL INCISION, UNILATERAL 3,923 4,307 4,376 4,289 4, , ,723 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 112 of 380

113 CPT PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR 2,410 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC OR ILIAC ANEURYSM, FALSE ANEURYSM, OR DISSECTION; INITIAL VESSEL CPT PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR 717 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC OR ILIAC ANEURYSM, FALSE ANEURYSM, OR DISSECTION; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, PLUS 6,292 REPAIR OF ASSOCIATED ARTERIAL TRAUMA, FOLLOWING UNSUCCESSFUL ENDOVASCULAR REPAIR; TUBE PROSTHESIS CPT OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, PLUS 6,799 REPAIR OF ASSOCIATED ARTERIAL TRAUMA, FOLLOWING UNSUCCESSFUL ENDOVASCULAR REPAIR; AORTO-BI-ILIAC PROSTHESIS CPT OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, PLUS 6,861 REPAIR OF ASSOCIATED ARTERIAL TRAUMA, FOLLOWING UNSUCCESSFUL ENDOVASCULAR REPAIR; AORTO-BIFEMORAL PROSTHESIS CPT OPEN ILIAC ARTERY EXPOSURE WITH CREATION OF CONDUIT FOR 2,136 DELIVERY OF AORTIC OR ILIAC ENDOVASCULAR PROSTHESIS, BY ABDOMINAL OR RETROPERITONEAL INCISION, UNILATERAL CPT OPEN BRACHIAL ARTERY EXPOSURE TO ASSIST IN THE DEPLOYMENT OF 965 AORTIC OR ILIAC ENDOVASCULAR PROSTHESIS BY ARM INCISION, UNILATERAL CPT ENDOVASCULAR GRAFT PLACEMENT FOR REPAIR OF ILIAC ARTERY (EG, 3,125 ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, TRAUMA) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 3,929 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, CAROTID, SUBCLAVIAN ARTERY, BY NECK INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,108 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, CAROTID, SUBCLAVIAN ARTERY, BY NECK INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 3,710 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, VERTEBRAL ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 3,442 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,275 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,207 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,956 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH 3,356 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 113 of 380

114 GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 6,053 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 7,571 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 6,355 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA INVOLVING VISCERAL VESSELS (MESENTERIC, CELIAC, RENAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 9,027 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA INVOLVING VISCERAL VESSELS (MESENTERIC, CELIAC, RENAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 6,564 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA INVOLVING ILIAC VESSELS (COMMON, HYPOGASTRIC, EXTERNAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 7,790 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA INVOLVING ILIAC VESSELS (COMMON, HYPOGASTRIC, EXTERNAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,801 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, SPLENIC ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 5,865 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, SPLENIC ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 5,750 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, HEPATIC, CELIAC, RENAL, OR MESENTERIC ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 6,800 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, HEPATIC, CELIAC, RENAL, OR MESENTERIC ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,874 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ILIAC ARTERY (COMMON, HYPOGASTRIC, EXTERNAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 5,919 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, ILIAC ARTERY (COMMON, HYPOGASTRIC, EXTERNAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, COMMON FEMORAL ARTERY (PROFUNDA FEMORIS, SUPERFICIAL FEMORAL) 3,860 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 114 of 380

115 CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,611 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, COMMON FEMORAL ARTERY (PROFUNDA FEMORIS, SUPERFICIAL FEMORAL) CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 4,342 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, POPLITEAL ARTERY CPT DIRECT REPAIR OF ANEURYSM, PSEUDOANEURYSM, OR EXCISION 5,067 (PARTIAL OR TOTAL) AND GRAFT INSERTION, WITH OR WITHOUT PATCH GRAFT; FOR RUPTURED ANEURYSM, POPLITEAL ARTERY CPT REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; HEAD AND NECK 2,803 CPT REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; THORAX AND ABDOMEN 5,888 CPT REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; EXTREMITIES 3,494 CPT REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; HEAD AND 2,957 NECK CPT REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; THORAX 5,606 AND ABDOMEN CPT REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; 2,563 EXTREMITIES CPT REPAIR BLOOD VESSEL, DIRECT; NECK 3,209 CPT REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY 2,634 CPT REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER 2,387 CPT REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, WITH BYPASS 4,710 CPT REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, WITHOUT BYPASS 6,633 CPT REPAIR BLOOD VESSEL, DIRECT; INTRA-ABDOMINAL 4,814 CPT REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY 2,900 CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; NECK 3,990 CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY 3,356 CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRATHORACIC, WITH 4,916 BYPASS CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRATHORACIC, WITHOUT 5,301 BYPASS CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRA-ABDOMINAL 5,717 CPT REPAIR BLOOD VESSEL WITH VEIN GRAFT; LOWER EXTREMITY 3,523 CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; NECK 3,583 CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; UPPER EXTREMITY CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; INTRATHORACIC, WITH BYPASS CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; INTRATHORACIC, WITHOUT BYPASS 2,935 4,701 4,908 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 115 of 380

116 CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; INTRA- 5,436 ABDOMINAL CPT REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; LOWER 3,237 EXTREMITY CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,637 CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,922 SUPERFICIAL FEMORAL ARTERY CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,309 POPLITEAL ARTERY CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,486 TIBIOPERONEAL TRUNK ARTERY CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,309 TIBIAL OR PERONEAL ARTERY, INITIAL VESSEL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 1,619 EACH ADDITIONAL TIBIAL OR PERONEAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,233 SUBCLAVIAN, INNOMINATE, BY THORACIC INCISION CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,088 AXILLARY-BRACHIAL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,067 ABDOMINAL AORTA CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,799 MESENTERIC, CELIAC, OR RENAL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,472 ILIAC CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,626 ILIOFEMORAL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,520 COMBINED AORTOILIAC CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,914 COMBINED AORTOILIOFEMORAL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 2,857 COMMON FEMORAL CPT THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,431 DEEP (PROFUNDA) FEMORAL CPT REOPERATION, CAROTID, THROMBOENDARTERECTOMY, MORE THAN ONE 562 MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ANGIOSCOPY (NON-CORONARY VESSELS OR GRAFTS) DURING 522 THERAPEUTIC INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; RENAL OR OTHER 1,796 VISCERAL ARTERY CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; AORTIC 1,246 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; ILIAC 1,090 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; FEMORAL-POPLITEAL 1,321 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; BRACHIOCEPHALIC 1,704 TRUNK OR BRANCHES, EACH VESSEL CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; TIBIOPERONEAL TRUNK 1,570 AND BRANCHES CPT TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; VENOUS 1,083 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 116 of 380

117 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; 8,873 TIBIOPERONEAL TRUNK OR BRANCHES, EACH VESSEL CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; RENAL OR 9,663 VISCERAL ARTERY CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; AORTIC 6,924 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; ILIAC 6,683 CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FEMORAL- 8,604 POPLITEAL CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; 7,399 BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; VENOUS 5,477 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; RENAL OR OTHER 2,063 VISCERAL ARTERY CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; AORTIC 1,422 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; ILIAC 1,200 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; FEMORAL-POPLITEAL 1,486 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; BRACHIOCEPHALIC 1,836 TRUNK OR BRANCHES, EACH VESSEL CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; TIBIOPERONEAL 1,724 TRUNK AND BRANCHES CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; RENAL OR 2,133 OTHER VISCERAL ARTERY CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; AORTIC 1,535 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; ILIAC 1,329 CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; FEMORAL- 1,588 POPLITEAL CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; 2,034 BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL CPT TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; 1,840 TIBIOPERONEAL TRUNK AND BRANCHES CPT HARVEST OF UPPER EXTREMITY VEIN, ONE SEGMENT, FOR LOWER 1,129 EXTREMITY OR CORONARY ARTERY BYPASS PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BYPASS GRAFT, WITH VEIN; COMMON CAROTID-IPSILATERAL INTERNAL 5,558 CAROTID CPT BYPASS GRAFT, WITH VEIN; CAROTID-SUBCLAVIAN OR SUBCLAVIAN- 4,584 CAROTID CPT BYPASS GRAFT, WITH VEIN; CAROTID-VERTEBRAL 4,725 CPT BYPASS GRAFT, WITH VEIN; CAROTID-CONTRALATERAL CAROTID 5,374 CPT BYPASS GRAFT, WITH VEIN; CAROTID-BRACHIAL 4,293 CPT BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-SUBCLAVIAN 4,114 CPT BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-BRACHIAL 4,202 CPT BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-VERTEBRAL 4,765 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 117 of 380

118 CPT BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-AXILLARY 4,268 CPT BYPASS GRAFT, WITH VEIN; AXILLARY-AXILLARY 4,144 CPT BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORAL 4,415 CPT BYPASS GRAFT, WITH VEIN; AXILLARY-BRACHIAL 4,099 CPT BYPASS GRAFT, WITH VEIN; BRACHIAL-ULNAR OR -RADIAL 4,450 CPT BYPASS GRAFT, WITH VEIN; BRACHIAL-BRACHIAL 3,870 CPT BYPASS GRAFT, WITH VEIN; AORTOSUBCLAVIAN OR CAROTID 6,185 CPT BYPASS GRAFT, WITH VEIN; AORTOCELIAC OR AORTOMESENTERIC 7,003 CPT BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORAL-FEMORAL 5,430 CPT BYPASS GRAFT, WITH VEIN; SPLENORENAL 6,007 CPT BYPASS GRAFT, WITH VEIN; AORTOILIAC 7,623 CPT BYPASS GRAFT, WITH VEIN; AORTOBI-ILIAC 8,516 CPT BYPASS GRAFT, WITH VEIN; AORTOFEMORAL 7,988 CPT BYPASS GRAFT, WITH VEIN; AORTOBIFEMORAL 8,909 CPT BYPASS GRAFT, WITH VEIN; AORTOILIOFEMORAL, UNILATERAL 4,190 CPT BYPASS GRAFT, WITH VEIN; AORTOILIOFEMORAL, BILATERAL 4,579 CPT BYPASS GRAFT, WITH VEIN; AORTOFEMORAL-POPLITEAL 5,141 CPT BYPASS GRAFT, WITH VEIN; FEMORAL-POPLITEAL 4,828 CPT BYPASS GRAFT, WITH VEIN; FEMORAL-FEMORAL 4,263 CPT BYPASS GRAFT, WITH VEIN; AORTORENAL 6,202 CPT BYPASS GRAFT, WITH VEIN; ILIOILIAC 4,832 CPT BYPASS GRAFT, WITH VEIN; ILIOFEMORAL 4,590 CPT BYPASS GRAFT, WITH VEIN; FEMORAL-ANTERIOR TIBIAL, POSTERIOR 5,777 TIBIAL, PERONEAL ARTERY OR OTHER DISTAL VESSELS CPT BYPASS GRAFT, WITH VEIN; POPLITEAL-TIBIAL, -PERONEAL ARTERY OR 4,645 OTHER DISTAL VESSELS CPT HARVEST OF FEMOROPOPLITEAL VEIN, ONE SEGMENT, FOR VASCULAR 1,223 RECONSTRUCTION PROCEDURE (EG, AORTIC, VENA CAVAL, CORONARY, PERIPHERAL ARTERY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT IN-SITU VEIN BYPASS; FEMORAL-POPLITEAL 4,963 CPT IN-SITU VEIN BYPASS; FEMORAL-ANTERIOR TIBIAL, POSTERIOR TIBIAL, OR PERONEAL ARTERY 5,834 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 118 of 380

119 CPT IN-SITU VEIN BYPASS; POPLITEAL-TIBIAL, PERONEAL 4,796 CPT HARVEST OF UPPER EXTREMITY ARTERY, ONE SEGMENT, FOR CORONARY 905 ARTERY BYPASS PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BYPASS GRAFT, WITH OTHER THAN VEIN; COMMON CAROTID- 5,178 IPSILATERAL INTERNAL CAROTID CPT BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-SUBCLAVIAN 4,073 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-SUBCLAVIAN 3,160 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-AXILLARY 3,910 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL 3,857 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-POPLITEAL OR - 4,744 TIBIAL CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOSUBCLAVIAN OR 5,465 CAROTID CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOCELIAC, 6,472 AORTOMESENTERIC, AORTORENAL CPT BYPASS GRAFT, WITH OTHER THAN VEIN; SPLENORENAL (SPLENIC TO 5,719 RENAL ARTERIAL ANASTOMOSIS) CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOILIAC 6,043 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOBI-ILIAC 6,139 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-VERTEBRAL 3,442 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-VERTEBRAL 3,627 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOBIFEMORAL 6,007 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL 5,446 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-AXILLARY 3,742 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL-POPLITEAL 4,788 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL-FEMORAL 4,790 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-POPLITEAL 3,779 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL 3,773 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOILIAC 4,381 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOFEMORAL 4,102 CPT BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-ANTERIOR TIBIAL, POSTERIOR TIBIAL, OR PERONEAL ARTERY CPT BYPASS GRAFT, WITH OTHER THAN VEIN; POPLITEAL-TIBIAL OR - PERONEAL ARTERY CPT BYPASS GRAFT; COMPOSITE, PROSTHETIC AND VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BYPASS GRAFT; AUTOGENOUS COMPOSITE, TWO SEGMENTS OF VEINS FROM TWO LOCATIONS (LIST SEPARATELY IN ADDITION TO CODE FOR 4,430 3, ,248 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 119 of 380

120 PRIMARY PROCEDURE) CPT BYPASS GRAFT; AUTOGENOUS COMPOSITE, THREE OR MORE SEGMENTS 1,466 OF VEIN FROM TWO OR MORE LOCATIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PLACEMENT OF VEIN PATCH OR CUFF AT DISTAL ANASTOMOSIS OF 702 BYPASS GRAFT, SYNTHETIC CONDUIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CREATION OF DISTAL ARTERIOVENOUS FISTULA DURING LOWER 586 EXTREMITY BYPASS SURGERY (NON-HEMODIALYSIS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO CAROTID 3,380 ARTERY CPT TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO SUBCLAVIAN 3,018 ARTERY CPT TRANSPOSITION AND/OR REIMPLANTATION; SUBCLAVIAN TO CAROTID 3,550 ARTERY CPT TRANSPOSITION AND/OR REIMPLANTATION; CAROTID TO SUBCLAVIAN 3,703 ARTERY CPT REIMPLANTATION, VISCERAL ARTERY TO INFRARENAL AORTIC 522 PROSTHESIS, EACH ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REOPERATION, FEMORAL-POPLITEAL OR FEMORAL (POPLITEAL)-ANTERIOR 539 TIBIAL, POSTERIOR TIBIAL, PERONEAL ARTERY, OR OTHER DISTAL VESSELS, MORE THAN ONE MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,831 WITHOUT LYSIS OF ARTERY; CAROTID ARTERY CPT EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,575 WITHOUT LYSIS OF ARTERY; FEMORAL ARTERY CPT EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,711 WITHOUT LYSIS OF ARTERY; POPLITEAL ARTERY CPT EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,262 WITHOUT LYSIS OF ARTERY; OTHER VESSELS CPT EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 1,622 INFECTION; NECK CPT EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 6,503 INFECTION; CHEST CPT EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 2,142 INFECTION; ABDOMEN CPT EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 1,369 INFECTION; EXTREMITY CPT REPAIR OF GRAFT-ENTERIC FISTULA 4,445 CPT THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA); CPT THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA); WITH REVISION OF ARTERIAL OR VENOUS GRAFT CPT REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH VEIN PATCH ANGIOPLASTY CPT REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH SEGMENTAL VEIN INTERPOSITION CPT REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS GRAFT IN GROIN, OPEN; WITH NONAUTOGENOUS PATCH GRAFT (EG, DACRON, EPTFE, BOVINE PERICARDIUM) 2,056 3,283 3,214 3,554 4,375 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 120 of 380

121 CPT REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS 4,647 GRAFT IN GROIN, OPEN; WITH AUTOGENOUS VEIN PATCH GRAFT CPT EXCISION OF INFECTED GRAFT; NECK 1,718 CPT EXCISION OF INFECTED GRAFT; EXTREMITY 1,930 CPT EXCISION OF INFECTED GRAFT; THORAX 6,103 CPT EXCISION OF INFECTED GRAFT; ABDOMEN 6,664 CPT INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN 81 CPT INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS 550 TREATMENT OF EXTREMITY PSEUDOANEURYSM CPT INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING 1,191 INTRODUCTION OF NEEDLE OR INTRACATHETER) CPT INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA 1,728 CPT SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER 2,900 BRANCH (EG, RENAL VEIN, JUGULAR VEIN) CPT SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR 3,020 MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS) CPT INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY 2,713 ARTERY CPT SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT PULMONARY ARTERY 2,790 CPT SELECTIVE CATHETER PLACEMENT, SEGMENTAL OR SUBSEGMENTAL 2,804 PULMONARY ARTERY CPT INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR VERTEBRAL 1,828 ARTERY CPT INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE BRACHIAL 1,429 ARTERY CPT INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY 1,593 CPT INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT 1,562 CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) CPT INTRODUCTION OF NEEDLE OR INTRACATHETER, AORTIC, TRANSLUMBAR 1,803 CPT INTRODUCTION OF CATHETER, AORTA 2,130 CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE) CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY 3,890 4,234 6, ,251 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 121 of 380

122 CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND 4,166 ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD 6,540 ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY CPT SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; ADDITIONAL 536 SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE FOR INITIAL SECOND OR THIRD ORDER VESSEL AS APPROPRIATE) CPT INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (EG, FOR 1,983 CHEMOTHERAPY OF LIVER) CPT REVISION OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 1,171 CPT REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 918 CPT UNLISTED PROCEDURE, VASCULAR INJECTION N/A CPT VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 86 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; FEMORAL OR JUGULAR VEIN CPT VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 76 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; SCALP VEIN CPT VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 55 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; OTHER VEIN CPT VENIPUNCTURE, AGE 3 YEARS OR OLDER, NECESSITATING PHYSICIAN'S 64 SKILL (SEPARATE PROCEDURE), FOR DIAGNOSTIC OR THERAPEUTIC PURPOSES (NOT TO BE USED FOR ROUTINE VENIPUNCTURE) CPT ROUTINE VENIPUNCTURE 11 CPT COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR 15 STICK) CPT VENIPUNCTURE, CUTDOWN; YOUNGER THAN AGE 1 YEAR 162 CPT VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER 129 CPT TRANSFUSION, BLOOD OR BLOOD COMPONENTS 125 CPT PUSH TRANSFUSION, BLOOD, 2 YEARS OR YOUNGER 173 CPT EXCHANGE TRANSFUSION, BLOOD; NEWBORN 404 CPT EXCHANGE TRANSFUSION, BLOOD; OTHER THAN NEWBORN 409 CPT TRANSFUSION, INTRAUTERINE, FETAL 1,155 CPT SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER N/A VEINS (TELANGIECTASIA); LIMB OR TRUNK CPT SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER N/A VEINS (TELANGIECTASIA); FACE CPT INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN 455 CPT INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG 547 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 122 of 380

123 CPT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 5,396 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED CPT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 1,220 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; SECOND AND SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 4,288 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED CPT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 1,248 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; SECOND AND SUBSEQUENT VEINS TREATED IN A SINGLE EXTREMITY, EACH THROUGH SEPARATE ACCESS SITES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY METHOD 1,244 CPT VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING 624 CPT CATHETERIZATION OF UMBILICAL VEIN FOR DIAGNOSIS OR THERAPY, 285 NEWBORN CPT THERAPEUTIC APHERESIS; FOR WHITE BLOOD CELLS 302 CPT THERAPEUTIC APHERESIS; FOR RED BLOOD CELLS 304 CPT THERAPEUTIC APHERESIS; FOR PLATELETS 309 CPT THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS 1,551 CPT THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL IMMUNOADSORPTION 5,957 AND PLASMA REINFUSION CPT THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL SELECTIVE 6,405 ADSORPTION OR SELECTIVE FILTRATION AND PLASMA REINFUSION CPT PHOTOPHERESIS, EXTRACORPOREAL 4,939 CPT INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; YOUNGER THAN 5 YEARS OF AGE CPT INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; YOUNGER THAN 5 YEARS OF AGE CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PUMP CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, ,616 2,546 3,544 3,631 3,796 3,034 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 123 of 380

124 TESIO TYPE CATHETER) CPT INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITH SUBCUTANEOUS PORT(S) CPT INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE CPT INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER CPT INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; YOUNGER THAN 5 YEARS OF AGE CPT INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER CPT REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT REPAIR OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS CPT REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PUMP, THROUGH SAME VENOUS ACCESS CPT REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS CPT REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP CPT REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION CPT COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE VENOUS ACCESS DEVICE CPT COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PERIPHERAL CATHETER, VENOUS, NOT OTHERWISE SPECIFIED CPT DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCESS DEVICE OR CATHETER CPT MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS CPT MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN 14, ,417 3, ,171 1, ,410 3,392 3, , , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 124 of 380

125 CPT REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER 417 UNDER FLUOROSCOPIC GUIDANCE CPT CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING 378 CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT CPT ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS 105 CPT ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, 172 MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS CPT ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, 361 MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); CUTDOWN CPT ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY 405 (CHEMOTHERAPY), CUTDOWN CPT CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR DIAGNOSIS OR 245 THERAPY CPT PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 200 CPT INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN CPT INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS, EXTERNAL (SCRIBNER TYPE) CPT INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE CPT ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION CPT ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION CPT ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION CPT ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE) CPT INSERTION OF CANNULA(S) FOR PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY INSUFFICIENCY (ECMO) (SEPARATE PROCEDURE) CPT INSERTION OF ARTERIAL AND VENOUS CANNULA(S) FOR ISOLATED EXTRACORPOREAL CIRCULATION INCLUDING REGIONAL CHEMOTHERAPY PERFUSION TO AN EXTREMITY, WITH OR WITHOUT HYPERTHERMIA, WITH REMOVAL OF CANNULA(S) AND REPAIR OF ARTERIOTOMY AND VENOTOMY SITES CPT CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT CPT CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT) CPT THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) CPT REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) CPT REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) ,290 2,702 2,716 1,802 1,264 4,323 1,961 2,239 1,546 1,974 2,230 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 125 of 380

126 CPT PLASTIC REPAIR OF ARTERIOVENOUS ANEURYSM (SEPARATE PROCEDURE) 2,102 CPT INSERTION OF THOMAS SHUNT (SEPARATE PROCEDURE) 1,529 CPT DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER 3,985 EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME) CPT EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT 689 BALLOON CATHETER CPT EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH 504 BALLOON CATHETER CPT THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, 5,826 AUTOGENOUS OR NONAUTOGENOUS GRAFT (INCLUDES MECHANICAL THROMBUS EXTRACTION AND INTRA-GRAFT THROMBOLYSIS) CPT VENOUS ANASTOMOSIS, OPEN; PORTOCAVAL 4,540 CPT VENOUS ANASTOMOSIS, OPEN; RENOPORTAL 5,015 CPT VENOUS ANASTOMOSIS, OPEN; CAVAL-MESENTERIC 4,264 CPT VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, PROXIMAL 4,878 CPT VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, DISTAL (SELECTIVE DECOMPRESSION OF ESOPHAGOGASTRIC VARICES, ANY TECHNIQUE) CPT INSERTION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S) (TIPS) (INCLUDES VENOUS ACCESS, HEPATIC AND PORTAL VEIN CATHETERIZATION, PORTOGRAPHY WITH HEMODYNAMIC EVALUATION, INTRAHEPATIC TRACT FORMATION/DILATATION, STENT PLACEMENT AND ALL ASSOCIATED IMAGING GUIDANCE AND DOCUMENTATION) CPT REVISION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S) (TIPS) (INCLUDES VENOUS ACCESS, HEPATIC AND PORTAL VEIN CATHETERIZATION, PORTOGRAPHY WITH HEMODYNAMIC EVALUATION, INTRAHEPATIC TRACT RECANULIZATION/DILATATION, STENT PLACEMENT AND ALL ASSOCIATED IMAGING GUIDANCE AND DOCUMENTATION) CPT PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL CPT PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); SECOND AND ALL SUBSEQUENT VESSEL(S) WITHIN THE SAME VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY MECHANICAL THROMBECTOMY PROCEDURE) CPT SECONDARY PERCUTANEOUS TRANSLUMINAL THROMBECTOMY (EG, NONPRIMARY MECHANICAL, SNARE BASKET, SUCTION TECHNIQUE), NONCORONARY, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS, PROVIDED IN CONJUNCTION WITH ANOTHER PERCUTANEOUS INTERVENTION OTHER THAN PRIMARY MECHANICAL THROMBECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE CPT PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC 5,098 3,058 1,453 7,448 2,502 5,057 7,150 6,085 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 126 of 380

127 INJECTIONS AND FLUOROSCOPIC GUIDANCE, REPEAT TREATMENT ON SUBSEQUENT DAY DURING COURSE OF THROMBOLYTIC THERAPY CPT THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION 1,033 CPT TRANSCATHETER BIOPSY 814 CPT TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER THAN 962 CORONARY CPT TRANSCATHETER THERAPY, INFUSION OTHER THAN FOR THROMBOLYSIS, 1,188 ANY TYPE (EG, SPASMOLYTIC, VASOCONSTRICTIVE) CPT TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR 4,462 FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER) CPT TRANSCATHETER OCCLUSION OR EMBOLIZATION (EG, FOR TUMOR 3,251 DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD, NON-CENTRAL NERVOUS SYSTEM, NON-HEAD OR NECK CPT TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT 14,808 CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS; INITIAL VESSEL CPT TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT 8,931 CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (NON- 1,487 CORONARY VESSEL), OPEN; INITIAL VESSEL CPT TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (NON- 719 CORONARY VESSEL), OPEN; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EXCHANGE OF A PREVIOUSLY PLACED INTRAVASCULAR CATHETER 401 DURING THROMBOLYTIC THERAPY CPT UTERINE FIBROID EMBOLIZATION (UFE, EMBOLIZATION OF THE UTERINE 11,895 ARTERIES TO TREAT UTERINE FIBROIDS, LEIOMYOMATA), PERCUTANEOUS APPROACH INCLUSIVE OF VASCULAR ACCESS, VESSEL SELECTION, EMBOLIZATION, AND ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE PROCEDURE CPT TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL 3,852 CAROTID ARTERY, PERCUTANEOUS; WITH DISTAL EMBOLIC PROTECTION CPT TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL 3,228 CAROTID ARTERY, PERCUTANEOUS; WITHOUT DISTAL EMBOLIC PROTECTION CPT INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING 387 DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL) DURING 288 DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR 2,319 VEINS, SUBFASCIAL (SEPS) CPT UNLISTED VASCULAR ENDOSCOPY PROCEDURE N/A CPT LIGATION, INTERNAL JUGULAR VEIN 2,321 CPT LIGATION; EXTERNAL CAROTID ARTERY 2,349 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 127 of 380

128 CPT LIGATION; INTERNAL OR COMMON CAROTID ARTERY 2,723 CPT LIGATION; INTERNAL OR COMMON CAROTID ARTERY, WITH GRADUAL 1,864 OCCLUSION, AS WITH SELVERSTONE OR CRUTCHFIELD CLAMP CPT LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA 1,267 CPT LIGATION OR BIOPSY, TEMPORAL ARTERY 954 CPT LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); NECK 1,572 CPT LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); CHEST 3,669 CPT LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); ABDOMEN 4,352 CPT LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY 1,257 CPT INTERRUPTION, PARTIAL OR COMPLETE, OF INFERIOR VENA CAVA BY 2,246 SUTURE, LIGATION, PLICATION, CLIP, EXTRAVASCULAR, INTRAVASCULAR (UMBRELLA DEVICE) CPT LIGATION OF FEMORAL VEIN 1,718 CPT LIGATION OF COMMON ILIAC VEIN 4,063 CPT LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT 840 SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS CPT LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN 1,343 CPT LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS 1,589 VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW CPT LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT 2,137 SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA CPT LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), 2,090 WITH OR WITHOUT SKIN GRAFT, OPEN CPT STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; STAB 1,470 INCISIONS CPT STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE THAN 1, INCISIONS CPT LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT 854 SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE) CPT LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1,174 ONE LEG CPT PENILE REVASCULARIZATION, ARTERY, WITH OR WITHOUT VEIN GRAFT 4,722 CPT PENILE VENOUS OCCLUSIVE PROCEDURE 1,776 CPT UNLISTED PROCEDURE, VASCULAR SURGERY N/A CPT SPLENECTOMY; TOTAL (SEPARATE PROCEDURE) 3,554 CPT SPLENECTOMY; PARTIAL (SEPARATE PROCEDURE) 3,579 CPT SPLENECTOMY; TOTAL, EN BLOC FOR EXTENSIVE DISEASE, IN CONJUNCTION WITH OTHER PROCEDURE (LIST IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 837 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 128 of 380

129 CPT REPAIR OF RUPTURED SPLEEN (SPLENORRHAPHY) WITH OR WITHOUT 3,943 PARTIAL SPLENECTOMY CPT LAPAROSCOPY, SURGICAL, SPLENECTOMY 3,291 CPT UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN N/A CPT INJECTION PROCEDURE FOR SPLENOPORTOGRAPHY 487 CPT MANAGEMENT OF RECIPIENT HEMATOPOIETIC PROGENITOR CELL DONOR 317 SEARCH AND CELL ACQUISITION CPT BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR 264 TRANSPLANTATION, PER COLLECTION; ALLOGENIC CPT BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR 266 TRANSPLANTATION, PER COLLECTION; AUTOLOGOUS CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 163 CRYOPRESERVATION AND STORAGE CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 104 THAWING OF PREVIOUSLY FROZEN HARVEST, WITHOUT WASHING CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 45 THAWING OF PREVIOUSLY FROZEN HARVEST, WITH WASHING CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 290 SPECIFIC CELL DEPLETION WITHIN HARVEST, T-CELL DEPLETION CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 261 TUMOR CELL DEPLETION CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; RED 173 BLOOD CELL REMOVAL CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 45 PLATELET DEPLETION CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 148 PLASMA (VOLUME) DEPLETION CPT TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 173 CELL CONCENTRATION IN PLASMA, MONONUCLEAR, OR BUFFY COAT LAYER CPT BONE MARROW; ASPIRATION ONLY 479 CPT BONE MARROW; BIOPSY, NEEDLE OR TROCAR 532 CPT BONE MARROW HARVESTING FOR TRANSPLANTATION 1,058 CPT BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 414 TRANSPLANTATION; ALLOGENIC CPT BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 414 TRANSPLANTATION; AUTOLOGOUS CPT BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 309 TRANSPLANTATION; ALLOGENEIC DONOR LYMPHOCYTE INFUSIONS CPT DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; SIMPLE 849 CPT DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; EXTENSIVE 1,463 CPT LYMPHANGIOTOMY OR OTHER OPERATIONS ON LYMPHATIC CHANNELS 1,399 CPT SUTURE AND/OR LIGATION OF THORACIC DUCT; CERVICAL APPROACH 1,779 CPT SUTURE AND/OR LIGATION OF THORACIC DUCT; THORACIC APPROACH 2,674 CPT SUTURE AND/OR LIGATION OF THORACIC DUCT; ABDOMINAL APPROACH 2,178 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 129 of 380

130 CPT BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL 1,006 CPT BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, 420 CERVICAL, INGUINAL, AXILLARY) CPT BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL 1,609 NODE(S) CPT BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL 1,452 NODE(S) WITH EXCISION SCALENE FAT PAD CPT BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S) 1,336 CPT BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INTERNAL MAMMARY 1,699 NODE(S) CPT DISSECTION, DEEP JUGULAR NODE(S) 1,340 CPT EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITHOUT DEEP 1,529 NEUROVASCULAR DISSECTION CPT EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITH DEEP 3,100 NEUROVASCULAR DISSECTION CPT LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE PROCEDURE); 2,251 PELVIC AND PARA-AORTIC CPT LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE PROCEDURE); 2,243 RETROPERITONEAL (AORTIC AND/OR SPLENIC) CPT LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE 1,818 SAMPLING (BIOPSY), SINGLE OR MULTIPLE CPT LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC 2,850 LYMPHADENECTOMY CPT LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC 3,110 LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE CPT UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM N/A CPT SUPRAHYOID LYMPHADENECTOMY 2,506 CPT CERVICAL LYMPHADENECTOMY (COMPLETE) 4,166 CPT CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION) 4,522 CPT AXILLARY LYMPHADENECTOMY; SUPERFICIAL 2,125 CPT AXILLARY LYMPHADENECTOMY; COMPLETE 2,706 CPT THORACIC LYMPHADENECTOMY, REGIONAL, INCLUDING MEDIASTINAL AND PERITRACHEAL NODES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ABDOMINAL LYMPHADENECTOMY, REGIONAL, INCLUDING CELIAC, GASTRIC, PORTAL, PERIPANCREATIC, WITH OR WITHOUT PARA-AORTIC AND VENA CAVAL NODES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUETS NODE (SEPARATE PROCEDURE) CPT INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, IN CONTINUITY WITH PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE) CPT PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE) CPT RETROPERITONEAL TRANSABDOMINAL LYMPHADENECTOMY, EXTENSIVE, INCLUDING PELVIC, AORTIC, AND RENAL NODES (SEPARATE PROCEDURE) ,659 4,104 2,781 3,453 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 130 of 380

131 CPT INJECTION PROCEDURE; LYMPHANGIOGRAPHY 273 CPT INJECTION PROCEDURE; FOR IDENTIFICATION OF SENTINEL NODE 134 CPT CANNULATION, THORACIC DUCT 1,008 CPT UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM N/A CPT MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, REMOVAL OF 1,592 FOREIGN BODY, OR BIOPSY; CERVICAL APPROACH CPT MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, REMOVAL OF 2,669 FOREIGN BODY, OR BIOPSY; TRANSTHORACIC APPROACH, INCLUDING EITHER TRANSTHORACIC OR MEDIAN STERNOTOMY CPT EXCISION OF MEDIASTINAL CYST 2,928 CPT EXCISION OF MEDIASTINAL TUMOR 3,767 CPT MEDIASTINOSCOPY, WITH OR WITHOUT BIOPSY 1,632 CPT UNLISTED PROCEDURE, MEDIASTINUM N/A CPT REPAIR, LACERATION OF DIAPHRAGM, ANY APPROACH 2,704 CPT REPAIR, PARAESOPHAGEAL HIATUS HERNIA, TRANSABDOMINAL, WITH OR 3,253 WITHOUT FUNDOPLASTY, VAGOTOMY, AND/OR PYLOROPLASTY, EXCEPT NEONATAL CPT REPAIR, NEONATAL DIAPHRAGMATIC HERNIA, WITH OR WITHOUT CHEST 18,510 TUBE INSERTION AND WITH OR WITHOUT CREATION OF VENTRAL HERNIA CPT REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); 3,231 TRANSTHORACIC CPT REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, 3,091 THORACOABDOMINAL CPT REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, 3,276 THORACOABDOMINAL, WITH DILATION OF STRICTURE (WITH OR WITHOUT GASTROPLASTY) CPT REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; 2,770 ACUTE CPT REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; 2,979 CHRONIC CPT IMBRICATION OF DIAPHRAGM FOR EVENTRATION, TRANSTHORACIC OR 2,939 TRANSABDOMINAL, PARALYTIC OR NONPARALYTIC CPT RESECTION, DIAPHRAGM; WITH SIMPLE REPAIR (EG, PRIMARY SUTURE) 2,527 CPT RESECTION, DIAPHRAGM; WITH COMPLEX REPAIR (EG, PROSTHETIC 3,967 MATERIAL, LOCAL MUSCLE FLAP) CPT UNLISTED PROCEDURE, DIAPHRAGM N/A CPT BIOPSY OF LIP 421 CPT VERMILIONECTOMY (LIP SHAVE), WITH MUCOSAL ADVANCEMENT 1,590 CPT EXCISION OF LIP; TRANSVERSE WEDGE EXCISION WITH PRIMARY 1,506 CLOSURE CPT EXCISION OF LIP; V-EXCISION WITH PRIMARY DIRECT LINEAR CLOSURE 1,539 CPT EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH LOCAL FLAP (EG, ESTLANDER OR FAN) 1,735 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 131 of 380

132 CPT EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH CROSS LIP 2,052 FLAP (ABBE-ESTLANDER) CPT RESECTION OF LIP, MORE THAN ONE-FOURTH, WITHOUT 1,710 RECONSTRUCTION CPT REPAIR LIP, FULL THICKNESS; VERMILION ONLY 1,266 CPT REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT 1,523 CPT REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR 1,769 COMPLEX CPT PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR 2,968 COMPLETE, UNILATERAL CPT PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 3,335 ONE STAGE PROCEDURE CPT PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 2,660 ONE OF TWO STAGES CPT PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY 3,256 RECREATION OF DEFECT AND RECLOSURE CPT PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; WITH CROSS LIP 3,388 PEDICLE FLAP (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND INSERTING OF PEDICLE CPT UNLISTED PROCEDURE, LIPS N/A CPT DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; 649 SIMPLE CPT DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; 976 COMPLICATED CPT REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; SIMPLE 649 CPT REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; 1,030 COMPLICATED CPT INCISION OF LABIAL FRENUM (FRENOTOMY) 349 CPT BIOPSY, VESTIBULE OF MOUTH 590 CPT EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 648 MOUTH; WITHOUT REPAIR CPT EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 899 MOUTH; WITH SIMPLE REPAIR CPT EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 1,202 MOUTH; WITH COMPLEX REPAIR CPT EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 1,259 MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE CPT EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT 1,102 CPT EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, 965 FRENULECTOMY, FRENECTOMY) CPT DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY 844 PHYSICAL METHODS (EG, LASER, THERMAL, CRYO, CHEMICAL) CPT CLOSURE OF LACERATION, VESTIBULE OF MOUTH; 2.5 CM OR LESS 756 CPT CLOSURE OF LACERATION, VESTIBULE OF MOUTH; OVER 2.5 CM OR 1,011 COMPLEX CPT VESTIBULOPLASTY; ANTERIOR 2,535 CPT VESTIBULOPLASTY; POSTERIOR, UNILATERAL 2,558 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 132 of 380

133 CPT VESTIBULOPLASTY; POSTERIOR, BILATERAL 3,190 CPT VESTIBULOPLASTY; ENTIRE ARCH 4,254 CPT VESTIBULOPLASTY; COMPLEX (INCLUDING RIDGE EXTENSION, MUSCLE 4,679 REPOSITIONING) CPT UNLISTED PROCEDURE, VESTIBULE OF MOUTH N/A CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 503 OF TONGUE OR FLOOR OF MOUTH; LINGUAL CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 721 OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, SUPERFICIAL CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,141 OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, DEEP, SUPRAMYLOHYOID CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,107 OF TONGUE OR FLOOR OF MOUTH; SUBMENTAL SPACE CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,175 OF TONGUE OR FLOOR OF MOUTH; SUBMANDIBULAR SPACE CPT INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,249 OF TONGUE OR FLOOR OF MOUTH; MASTICATOR SPACE CPT INCISION OF LINGUAL FRENUM (FRENOTOMY) 635 CPT EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,353 OF FLOOR OF MOUTH; SUBLINGUAL CPT EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,368 OF FLOOR OF MOUTH; SUBMENTAL CPT EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,385 OF FLOOR OF MOUTH; SUBMANDIBULAR CPT EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,583 OF FLOOR OF MOUTH; MASTICATOR SPACE CPT PLACEMENT OF NEEDLES, CATHETERS, OR OTHER DEVICE(S) INTO THE 1,599 HEAD AND/OR NECK REGION (PERCUTANEOUS, TRANSORAL, OR TRANSNASAL) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION CPT BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS 531 CPT BIOPSY OF TONGUE; POSTERIOR ONE-THIRD 534 CPT BIOPSY OF FLOOR OF MOUTH 464 CPT EXCISION OF LESION OF TONGUE WITHOUT CLOSURE 669 CPT EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO- 1,045 THIRDS CPT EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR ONE- 1,144 THIRD CPT EXCISION OF LESION OF TONGUE WITH CLOSURE; WITH LOCAL TONGUE 1,993 FLAP CPT EXCISION OF LINGUAL FRENUM (FRENECTOMY) 771 CPT EXCISION, LESION OF FLOOR OF MOUTH 1,039 CPT GLOSSECTOMY; LESS THAN ONE-HALF TONGUE 3,277 CPT GLOSSECTOMY; HEMIGLOSSECTOMY 4,069 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 133 of 380

134 CPT GLOSSECTOMY; PARTIAL, WITH UNILATERAL RADICAL NECK DISSECTION 6,745 CPT GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT 6,881 TRACHEOSTOMY, WITHOUT RADICAL NECK DISSECTION CPT GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT 8,681 TRACHEOSTOMY, WITH UNILATERAL RADICAL NECK DISSECTION CPT GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 6,862 MOUTH AND MANDIBULAR RESECTION, WITHOUT RADICAL NECK DISSECTION CPT GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 7,456 MOUTH, WITH SUPRAHYOID NECK DISSECTION CPT GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 9,304 MOUTH, MANDIBULAR RESECTION, AND RADICAL NECK DISSECTION (COMMANDO TYPE) CPT REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR 751 ANTERIOR TWO-THIRDS OF TONGUE CPT REPAIR OF LACERATION 2.5 CM OR LESS; POSTERIOR ONE-THIRD OF 755 TONGUE CPT REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR 991 COMPLEX CPT FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K-WIRE) 1,456 CPT SUTURE OF TONGUE TO LIP FOR MICROGNATHIA (DOUGLAS TYPE 1,275 PROCEDURE) CPT FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z-PLASTY) 1,113 CPT UNLISTED PROCEDURE, TONGUE, FLOOR OF MOUTH N/A CPT DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR 771 STRUCTURES CPT REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 761 STRUCTURES; SOFT TISSUES CPT REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 1,124 STRUCTURES; BONE CPT GINGIVECTOMY, EXCISION GINGIVA, EACH QUADRANT 788 CPT OPERCULECTOMY, EXCISION PERICORONAL TISSUES 177 CPT EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 938 CPT EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 1,329 CPT EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 653 DENTOALVEOLAR STRUCTURES; WITHOUT REPAIR CPT EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 974 DENTOALVEOLAR STRUCTURES; WITH SIMPLE REPAIR CPT EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 1,349 DENTOALVEOLAR STRUCTURES; WITH COMPLEX REPAIR CPT EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH QUADRANT 961 (SPECIFY) CPT ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR 1,234 SEQUESTRECTOMY CPT DESTRUCTION OF LESION (EXCEPT EXCISION), DENTOALVEOLAR 394 STRUCTURES CPT PERIODONTAL MUCOSAL GRAFTING 984 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 134 of 380

135 CPT GINGIVOPLASTY, EACH QUADRANT (SPECIFY) 1,164 CPT ALVEOLOPLASTY, EACH QUADRANT (SPECIFY) 1,164 CPT UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES N/A CPT DRAINAGE OF ABSCESS OF PALATE, UVULA 484 CPT BIOPSY OF PALATE, UVULA 469 CPT EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE 679 CPT EXCISION, LESION OF PALATE, UVULA; WITH SIMPLE PRIMARY CLOSURE 858 CPT EXCISION, LESION OF PALATE, UVULA; WITH LOCAL FLAP CLOSURE 1,442 CPT RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION 3,085 CPT UVULECTOMY, EXCISION OF UVULA 800 CPT PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, 2,236 UVULOPHARYNGOPLASTY) CPT DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR 726 CHEMICAL) CPT REPAIR, LACERATION OF PALATE; UP TO 2 CM 769 CPT REPAIR, LACERATION OF PALATE; OVER 2 CM OR COMPLEX 1,035 CPT PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY 2,808 CPT PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; 2,834 SOFT TISSUE ONLY CPT PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; 3,440 WITH BONE GRAFT TO ALVEOLAR RIDGE (INCLUDES OBTAINING GRAFT) CPT PALATOPLASTY FOR CLEFT PALATE; MAJOR REVISION 2,216 CPT PALATOPLASTY FOR CLEFT PALATE; SECONDARY LENGTHENING 1,890 PROCEDURE CPT PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP 2,866 CPT LENGTHENING OF PALATE, AND PHARYNGEAL FLAP 2,915 CPT LENGTHENING OF PALATE, WITH ISLAND FLAP 2,770 CPT REPAIR OF ANTERIOR PALATE, INCLUDING VOMER FLAP 2,390 CPT REPAIR OF NASOLABIAL FISTULA 2,655 CPT MAXILLARY IMPRESSION FOR PALATAL PROSTHESIS 500 CPT INSERTION OF PIN-RETAINED PALATAL PROSTHESIS 648 CPT UNLISTED PROCEDURE, PALATE, UVULA N/A CPT DRAINAGE OF ABSCESS; PAROTID, SIMPLE 660 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 135 of 380

136 CPT DRAINAGE OF ABSCESS; PAROTID, COMPLICATED 1,350 CPT DRAINAGE OF ABSCESS; SUBMAXILLARY OR SUBLINGUAL, INTRAORAL 503 CPT DRAINAGE OF ABSCESS; SUBMAXILLARY, EXTERNAL 795 CPT SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR 733 PAROTID, UNCOMPLICATED, INTRAORAL CPT SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), COMPLICATED, 1,184 INTRAORAL CPT SIALOLITHOTOMY; PAROTID, EXTRAORAL OR COMPLICATED INTRAORAL 1,481 CPT BIOPSY OF SALIVARY GLAND; NEEDLE 357 CPT BIOPSY OF SALIVARY GLAND; INCISIONAL 951 CPT EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) 1,441 CPT MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) 1,062 CPT EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, 1,981 WITHOUT NERVE DISSECTION CPT EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH 3,530 DISSECTION AND PRESERVATION OF FACIAL NERVE CPT EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH 4,040 DISSECTION AND PRESERVATION OF FACIAL NERVE CPT EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, EN BLOC 2,668 REMOVAL WITH SACRIFICE OF FACIAL NERVE CPT EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH 4,324 UNILATERAL RADICAL NECK DISSECTION CPT EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND 1,447 CPT EXCISION OF SUBLINGUAL GLAND 1,442 CPT PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR 1,368 SIMPLE CPT PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; SECONDARY 1,769 OR COMPLICATED CPT PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); 1,635 CPT PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 2,308 EXCISION OF ONE SUBMANDIBULAR GLAND CPT PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 2,706 EXCISION OF BOTH SUBMANDIBULAR GLANDS CPT PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 1,991 LIGATION OF BOTH SUBMANDIBULAR (WHARTON'S) DUCTS CPT INJECTION PROCEDURE FOR SIALOGRAPHY 453 CPT CLOSURE SALIVARY FISTULA 1,492 CPT DILATION SALIVARY DUCT 268 CPT DILATION AND CATHETERIZATION OF SALIVARY DUCT, WITH OR 337 WITHOUT INJECTION CPT LIGATION SALIVARY DUCT, INTRAORAL 981 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 136 of 380

137 CPT UNLISTED PROCEDURE, SALIVARY GLANDS OR DUCTS N/A CPT INCISION AND DRAINAGE ABSCESS; PERITONSILLAR 596 CPT INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR 1,441 PARAPHARYNGEAL, INTRAORAL APPROACH CPT INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR 2,552 PARAPHARYNGEAL, EXTERNAL APPROACH CPT BIOPSY; OROPHARYNX 502 CPT BIOPSY; HYPOPHARYNX 732 CPT BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE 623 CPT BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN PRIMARY LESION 699 CPT EXCISION OR DESTRUCTION OF LESION OF PHARYNX, ANY METHOD 721 CPT REMOVAL OF FOREIGN BODY FROM PHARYNX 531 CPT EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN AND 1,236 SUBCUTANEOUS TISSUES CPT EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, EXTENDING 1,774 BENEATH SUBCUTANEOUS TISSUES AND/OR INTO PHARYNX CPT TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE CPT TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER 962 CPT TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE CPT TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER 800 CPT ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE CPT ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER 708 CPT ADENOIDECTOMY, SECONDARY; YOUNGER THAN AGE CPT ADENOIDECTOMY, SECONDARY; AGE 12 OR OVER 770 CPT RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 3,119 RETROMOLAR TRIGONE; WITHOUT CLOSURE CPT RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 4,306 RETROMOLAR TRIGONE; CLOSURE WITH LOCAL FLAP (EG, TONGUE, BUCCAL) CPT RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 6,987 RETROMOLAR TRIGONE; CLOSURE WITH OTHER FLAP CPT EXCISION OF TONSIL TAGS 595 CPT EXCISION OR DESTRUCTION LINGUAL TONSIL, ANY METHOD (SEPARATE 1,836 PROCEDURE) CPT LIMITED PHARYNGECTOMY 4,434 CPT RESECTION OF LATERAL PHARYNGEAL WALL OR PYRIFORM SINUS, DIRECT CLOSURE BY ADVANCEMENT OF LATERAL AND POSTERIOR PHARYNGEAL WALLS 5,824 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 137 of 380

138 CPT RESECTION OF PHARYNGEAL WALL REQUIRING CLOSURE WITH 7,430 MYOCUTANEOUS FLAP CPT SUTURE PHARYNX FOR WOUND OR INJURY 1,097 CPT PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIVE OPERATION ON 2,512 PHARYNX) CPT PHARYNGOESOPHAGEAL REPAIR 3,020 CPT PHARYNGOSTOMY (FISTULIZATION OF PHARYNX, EXTERNAL FOR 2,370 FEEDING) CPT CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 536 POST-TONSILLECTOMY); SIMPLE CPT CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 1,337 POST-TONSILLECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION CPT CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 1,646 POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION CPT CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY 1,225 (EG, POSTADENOIDECTOMY); SIMPLE, WITH POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS AND/OR CAUTERY CPT CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY 1,455 (EG, POSTADENOIDECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION CPT CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY 1,653 (EG, POSTADENOIDECTOMY); WITH SECONDARY SURGICAL INTERVENTION CPT UNLISTED PROCEDURE, PHARYNX, ADENOIDS, OR TONSILS N/A CPT ESOPHAGOTOMY, CERVICAL APPROACH, WITH REMOVAL OF FOREIGN 1,710 BODY CPT CRICOPHARYNGEAL MYOTOMY 1,652 CPT ESOPHAGOTOMY, THORACIC APPROACH, WITH REMOVAL OF FOREIGN BODY CPT EXCISION OF LESION, ESOPHAGUS, WITH PRIMARY REPAIR; CERVICAL APPROACH CPT EXCISION OF LESION, ESOPHAGUS, WITH PRIMARY REPAIR; THORACIC OR ABDOMINAL APPROACH CPT TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY (TRANSHIATAL) CPT TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION AND ANASTOMOSIS(ES) CPT TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION, AND ANASTOMOSIS(ES) CPT PARTIAL ESOPHAGECTOMY, CERVICAL, WITH FREE INTESTINAL GRAFT, INCLUDING MICROVASCULAR ANASTOMOSIS, OBTAINING THE GRAFT AND INTESTINAL RECONSTRUCTION CPT PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY AND SEPARATE ABDOMINAL INCISION, WITH OR WITHOUT PROXIMAL GASTRECTOMY; WITH THORACIC ESOPHAGOGASTROSTOMY, WITH OR 4,229 1,974 3,333 8,241 14,000 8,823 13,801 15,882 8,039 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 138 of 380

139 WITHOUT PYLOROPLASTY (IVOR LEWIS) CPT PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY AND SEPARATE ABDOMINAL INCISION, WITH OR WITHOUT PROXIMAL GASTRECTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION, AND ANASTOMOSIS(ES) CPT PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY ONLY, WITH OR WITHOUT PROXIMAL GASTRECTOMY, WITH THORACIC ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, WITH OR WITHOUT PROXIMAL GASTRECTOMY; WITH ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, WITH OR WITHOUT PROXIMAL GASTRECTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION, AND ANASTOMOSIS(ES) CPT TOTAL OR PARTIAL ESOPHAGECTOMY, WITHOUT RECONSTRUCTION (ANY APPROACH), WITH CERVICAL ESOPHAGOSTOMY CPT DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; CERVICAL APPROACH CPT DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; THORACIC APPROACH CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL VARICES CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION OF ESOPHAGEAL VARICES CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF FOREIGN BODY CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF PLASTIC TUBE OR STENT CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION (LESS THAN 30 MM DIAMETER) CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OVER GUIDE WIRE CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION CPT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE 11,642 9,241 8,182 14,204 12,201 2,511 4, , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 139 of 380

140 ASPIRATION/BIOPSY(S) CPT UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION (EG, WITH SMALL DIAMETER FLEXIBLE ENDOSCOPE) (SEPARATE PROCEDURE) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), ESOPHAGUS (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR CATHETER PLACEMENT CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR GASTRIC VARICES CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BAND LIGATION OF ESOPHAGEAL AND/OR GASTRIC VARICES CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DILATION OF GASTRIC OUTLET FOR OBSTRUCTION (EG, BALLOON, GUIDE WIRE, BOUGIE) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE , ,009 1,151 1, , , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 140 of 380

141 CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 684 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF FOREIGN BODY CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 648 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OF ESOPHAGUS OVER GUIDE WIRE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 596 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 638 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 742 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 967 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 869 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 1,006 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DELIVERY OF THERMAL ENERGY TO THE MUSCLE OF LOWER ESOPHAGEAL SPHINCTER AND/OR GASTRIC CARDIA, FOR TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 911 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 1,035 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,188 DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,248 WITH BIOPSY, SINGLE OR MULTIPLE CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,466 WITH SPHINCTEROTOMY/PAPILLOTOMY CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,442 WITH PRESSURE MEASUREMENT OF SPHINCTER OF ODDI (PANCREATIC DUCT OR COMMON BILE DUCT) CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,759 WITH ENDOSCOPIC RETROGRADE REMOVAL OF CALCULUS/CALCULI FROM BILIARY AND/OR PANCREATIC DUCTS CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE DESTRUCTION, LITHOTRIPSY OF CALCULUS/CALCULI, ANY METHOD 1,978 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 141 of 380

142 CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,423 WITH ENDOSCOPIC RETROGRADE INSERTION OF NASOBILIARY OR NASOPANCREATIC DRAINAGE TUBE CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,486 WITH ENDOSCOPIC RETROGRADE INSERTION OF TUBE OR STENT INTO BILE OR PANCREATIC DUCT CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,623 WITH ENDOSCOPIC RETROGRADE REMOVAL OF FOREIGN BODY AND/OR CHANGE OF TUBE OR STENT CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,463 WITH ENDOSCOPIC RETROGRADE BALLOON DILATION OF AMPULLA, BILIARY AND/OR PANCREATIC DUCT(S) CPT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,472 WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, 3,390 NISSEN, TOUPET PROCEDURES) CPT UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS N/A CPT ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL 1,981 APPROACH; WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL 3,506 APPROACH; WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC 4,985 APPROACH; WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC 5,477 APPROACH; WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR 8,951 RECONSTRUCTION), THORACIC APPROACH; WITHOUT REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR 9,428 RECONSTRUCTION), THORACIC APPROACH; WITH REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA CPT ESOPHAGOGASTROSTOMY (CARDIOPLASTY), WITH OR WITHOUT 4,346 VAGOTOMY AND PYLOROPLASTY, TRANSABDOMINAL OR TRANSTHORACIC APPROACH CPT ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, BELSEY IV, HILL 4,275 PROCEDURES) CPT ESOPHAGOGASTRIC FUNDOPLASTY; WITH FUNDIC PATCH (THAL-NISSEN 4,211 PROCEDURE) CPT ESOPHAGOGASTRIC FUNDOPLASTY; WITH GASTROPLASTY (EG, COLLIS) 4,306 CPT ESOPHAGOMYOTOMY (HELLER TYPE); ABDOMINAL APPROACH 4,127 CPT ESOPHAGOMYOTOMY (HELLER TYPE); THORACIC APPROACH 4,493 CPT ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY); ABDOMINAL APPROACH CPT ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY); THORACIC APPROACH CPT ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; ABDOMINAL APPROACH CPT ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; THORACIC APPROACH CPT ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; CERVICAL APPROACH 4,355 4,616 3,711 4,431 3,485 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 142 of 380

143 CPT GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS ESOPHAGECTOMY, 7,523 FOR OBSTRUCTING ESOPHAGEAL LESION OR FISTULA, OR FOR PREVIOUS ESOPHAGEAL EXCLUSION; WITH STOMACH, WITH OR WITHOUT PYLOROPLASTY CPT GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS ESOPHAGECTOMY, 8,578 FOR OBSTRUCTING ESOPHAGEAL LESION OR FISTULA, OR FOR PREVIOUS ESOPHAGEAL EXCLUSION; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION, AND ANASTOMOSIS(ES) CPT LIGATION, DIRECT, ESOPHAGEAL VARICES 5,164 CPT TRANSECTION OF ESOPHAGUS WITH REPAIR, FOR ESOPHAGEAL VARICES 4,903 CPT LIGATION OR STAPLING AT GASTROESOPHAGEAL JUNCTION FOR PRE- 4,791 EXISTING ESOPHAGEAL PERFORATION CPT SUTURE OF ESOPHAGEAL WOUND OR INJURY; CERVICAL APPROACH 3,231 CPT SUTURE OF ESOPHAGEAL WOUND OR INJURY; TRANSTHORACIC OR 5,547 TRANSABDOMINAL APPROACH CPT CLOSURE OF ESOPHAGOSTOMY OR FISTULA; CERVICAL APPROACH 3,217 CPT CLOSURE OF ESOPHAGOSTOMY OR FISTULA; TRANSTHORACIC OR 4,833 TRANSABDOMINAL APPROACH CPT DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR 524 MULTIPLE PASSES CPT DILATION OF ESOPHAGUS, OVER GUIDE WIRE 998 CPT DILATION OF ESOPHAGUS, BY BALLOON OR DILATOR, RETROGRADE 1,987 CPT DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) 1,287 FOR ACHALASIA CPT ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON (SENGSTAAKEN TYPE) 737 CPT FREE JEJUNUM TRANSFER WITH MICROVASCULAR ANASTOMOSIS N/A CPT UNLISTED PROCEDURE, ESOPHAGUS N/A CPT GASTROTOMY; WITH EXPLORATION OR FOREIGN BODY REMOVAL 2,448 CPT GASTROTOMY; WITH SUTURE REPAIR OF BLEEDING ULCER 4,181 CPT GASTROTOMY; WITH SUTURE REPAIR OF PRE-EXISTING 4,736 ESOPHAGOGASTRIC LACERATION (EG, MALLORY-WEISS) CPT GASTROTOMY; WITH ESOPHAGEAL DILATION AND INSERTION OF 3,226 PERMANENT INTRALUMINAL TUBE (EG, CELESTIN OR MOUSSEAUX- BARBIN) CPT PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE (FREDET-RAMSTEDT 2,188 TYPE OPERATION) CPT BIOPSY OF STOMACH; BY CAPSULE, TUBE, PERORAL (ONE OR MORE 354 SPECIMENS) CPT BIOPSY OF STOMACH; BY LAPAROTOMY 2,590 CPT EXCISION, LOCAL; ULCER OR BENIGN TUMOR OF STOMACH 3,049 CPT EXCISION, LOCAL; MALIGNANT TUMOR OF STOMACH 3,788 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 143 of 380

144 CPT GASTRECTOMY, TOTAL; WITH ESOPHAGOENTEROSTOMY 6,163 CPT GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECONSTRUCTION 7,029 CPT GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, ANY 7,138 TYPE CPT GASTRECTOMY, PARTIAL, DISTAL; WITH GASTRODUODENOSTOMY 4,526 CPT GASTRECTOMY, PARTIAL, DISTAL; WITH GASTROJEJUNOSTOMY 6,202 CPT GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION 5,894 CPT GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL 6,498 POUCH CPT VAGOTOMY WHEN PERFORMED WITH PARTIAL DISTAL GASTRECTOMY 358 (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE) CPT VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 3,654 GASTROSTOMY; TRUNCAL OR SELECTIVE CPT VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 3,720 GASTROSTOMY; PARIETAL CELL (HIGHLY SELECTIVE) CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 5,350 GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 5,714 GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION CPT LAPAROSCOPY, SURGICAL; IMPLANTATION OR REPLACEMENT OF GASTRIC N/A NEUROSTIMULATOR ELECTRODES, ANTRUM CPT LAPAROSCOPY, SURGICAL; REVISION OR REMOVAL OF GASTRIC N/A NEUROSTIMULATOR ELECTRODES, ANTRUM CPT LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL 2,023 CPT LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, SELECTIVE 2,380 OR HIGHLY SELECTIVE CPT LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF 1,744 GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE) CPT UNLISTED LAPAROSCOPY PROCEDURE, STOMACH N/A CPT NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT) CPT CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE CPT REPOSITIONING OF THE GASTRIC FEEDING TUBE, THROUGH THE DUODENUM FOR ENTERIC NUTRITION CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL AND REPLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS ,453 3,942 2,964 3,940 2,981 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 144 of 380

145 PORT COMPONENTS CPT PYLOROPLASTY 2,893 CPT GASTRODUODENOSTOMY 3,131 CPT GASTROJEJUNOSTOMY; WITHOUT VAGOTOMY 4,093 CPT GASTROJEJUNOSTOMY; WITH VAGOTOMY, ANY TYPE 4,036 CPT GASTROSTOMY, OPEN; WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, 2,161 STAMM PROCEDURE) (SEPARATE PROCEDURE) CPT GASTROSTOMY, OPEN; NEONATAL, FOR FEEDING 1,804 CPT GASTROSTOMY, OPEN; WITH CONSTRUCTION OF GASTRIC TUBE (EG, 3,311 JANEWAY PROCEDURE) CPT GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR GASTRIC 4,142 ULCER, WOUND, OR INJURY CPT GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR 3,788 MORBID OBESITY; VERTICAL-BANDED GASTROPLASTY CPT GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR 3,951 MORBID OBESITY; OTHER THAN VERTICAL-BANDED GASTROPLASTY CPT GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, 6,302 PYLORUS-PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH) CPT GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID 5,085 OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY CPT GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID 5,560 OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION CPT REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID 6,011 OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE) CPT REVISION OF GASTRODUODENAL ANASTOMOSIS 5,063 (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT VAGOTOMY CPT REVISION OF GASTRODUODENAL ANASTOMOSIS 5,253 (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITH VAGOTOMY CPT REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) 5,104 WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITHOUT VAGOTOMY CPT REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) 5,307 WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITH VAGOTOMY CPT CLOSURE OF GASTROSTOMY, SURGICAL 2,212 CPT CLOSURE OF GASTROCOLIC FISTULA 4,984 CPT IMPLANTATION OR REPLACEMENT OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN CPT REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN CPT GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY N/A N/A 1,037 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 145 of 380

146 CPT GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS 983 PORT COMPONENT ONLY CPT GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT 1,390 OF SUBCUTANEOUS PORT COMPONENT ONLY CPT UNLISTED PROCEDURE, STOMACH N/A CPT ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE 3,413 PROCEDURE) CPT DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY 2,687 REMOVAL CPT TUBE OR NEEDLE CATHETER JEJUNOSTOMY FOR ENTERAL ALIMENTATION, 459 INTRAOPERATIVE, ANY METHOD (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR 3,022 EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL CPT ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR 3,052 DECOMPRESSION (EG, BAKER TUBE) CPT COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL 3,069 CPT REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY 2,911 LAPAROTOMY CPT CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR 4,648 REDUCTION OF MIDGUT VOLVULUS (EG, LADD PROCEDURE) CPT BIOPSY OF INTESTINE BY CAPSULE, TUBE, PERORAL (ONE OR MORE 388 SPECIMENS) CPT EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE 2,645 NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; SINGLE ENTEROTOMY CPT EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE 3,072 NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; MULTIPLE ENTEROTOMIES CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION 3,793 AND ANASTOMOSIS CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE; EACH ADDITIONAL 772 RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE; WITH ENTEROSTOMY 3,679 CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 7,592 ATRESIA, SINGLE RESECTION AND ANASTOMOSIS OF PROXIMAL SEGMENT OF INTESTINE; WITHOUT TAPERING CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 8,875 ATRESIA, SINGLE RESECTION AND ANASTOMOSIS OF PROXIMAL SEGMENT OF INTESTINE; WITH TAPERING CPT ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 789 ATRESIA, SINGLE RESECTION AND ANASTOMOSIS OF PROXIMAL SEGMENT OF INTESTINE; EACH ADDITIONAL RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT 4,007 CUTANEOUS ENTEROSTOMY (SEPARATE PROCEDURE) CPT DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; FROM N/A CADAVER DONOR CPT DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; N/A PARTIAL, FROM LIVING DONOR CPT INTESTINAL ALLOTRANSPLANTATION; FROM CADAVER DONOR N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 146 of 380

147 CPT INTESTINAL ALLOTRANSPLANTATION; FROM LIVING DONOR N/A CPT REMOVAL OF TRANSPLANTED INTESTINAL ALLOGRAFT, COMPLETE N/A CPT MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN 386 CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT COLECTOMY, PARTIAL; WITH ANASTOMOSIS 4,183 CPT COLECTOMY, PARTIAL; WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY 5,554 CPT COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL 5,156 SEGMENT (HARTMANN TYPE PROCEDURE) CPT COLECTOMY, PARTIAL; WITH RESECTION, WITH COLOSTOMY OR 5,442 ILEOSTOMY AND CREATION OF MUCOFISTULA CPT COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC 5,189 ANASTOMOSIS) CPT COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC 6,535 ANASTOMOSIS), WITH COLOSTOMY CPT COLECTOMY, PARTIAL; ABDOMINAL AND TRANSANAL APPROACH 5,904 CPT COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY; WITH 5,745 ILEOSTOMY OR ILEOPROCTOSTOMY CPT COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY; WITH 6,564 CONTINENT ILEOSTOMY CPT COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH ILEOSTOMY 6,415 CPT COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH 7,007 CONTINENT ILEOSTOMY CPT COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH ILEOANAL 7,114 ANASTOMOSIS, INCLUDES LOOP ILEOSTOMY, AND RECTAL MUCOSECTOMY, WHEN PERFORMED CPT COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH ILEOANAL 7,299 ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), INCLUDES LOOP ILEOSTOMY, AND RECTAL MUCOSECTOMY, WHEN PERFORMED CPT COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH 3,860 ILEOCOLOSTOMY CPT LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL 2,877 ADHESION) (SEPARATE PROCEDURE) CPT LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR 2,034 FEEDING) CPT LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 3,443 CPT LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY 3,791 CPT LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL 4,333 INTESTINE, SINGLE RESECTION AND ANASTOMOSIS CPT LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE 771 RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS 4,819 CPT LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOLOSTOMY CPT LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE) 4,206 5,484 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 147 of 380

148 CPT LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, 5,735 WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) CPT LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, 6,263 WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) WITH COLOSTOMY CPT LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITHOUT 5,599 PROCTECTOMY, WITH ILEOSTOMY OR ILEOPROCTOSTOMY CPT LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH 6,877 PROCTECTOMY, WITH ILEOANAL ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), WITH LOOP ILEOSTOMY, INCLUDES RECTAL MUCOSECTOMY, WHEN PERFORMED CPT LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH 6,444 PROCTECTOMY, WITH ILEOSTOMY CPT LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC 604 FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR SMALL 5,205 INTESTINE, WITH RESECTION AND ANASTOMOSIS CPT UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM) N/A CPT PLACEMENT, ENTEROSTOMY OR CECOSTOMY, TUBE OPEN (EG, FOR 2,619 FEEDING OR DECOMPRESSION) (SEPARATE PROCEDURE) CPT ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 3,257 CPT REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) 1,876 (SEPARATE PROCEDURE) CPT REVISION OF ILEOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) 3,164 (SEPARATE PROCEDURE) CPT CONTINENT ILEOSTOMY (KOCK PROCEDURE) (SEPARATE PROCEDURE) 4,370 CPT COLOSTOMY OR SKIN LEVEL CECOSTOMY; 3,727 CPT COLOSTOMY OR SKIN LEVEL CECOSTOMY; WITH MULTIPLE BIOPSIES (EG, FOR CONGENITAL MEGACOLON) (SEPARATE PROCEDURE) CPT REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE) CPT REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE PROCEDURE) CPT REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 2,995 1,894 3,266 3, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 148 of 380

149 CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 892 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 906 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 971 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 864 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 696 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONVERSION OF PERCUTANEOUS GASTROSTOMY TUBE TO PERCUTANEOUS JEJUNOSTOMY TUBE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,024 PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,092 PORTION OF DUODENUM, INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,412 PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,511 PORTION OF DUODENUM, INCLUDING ILEUM; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT 235 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE 280 CPT ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 599 PLACEMENT (INCLUDES PREDILATION) CPT ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR 864 PELVIC) POUCH; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR 1,129 PELVIC) POUCH; WITH BIOPSY, SINGLE OR MULTIPLE CPT COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT 1,158 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE 1,322 CPT COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY 1,570 CPT COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 1,710 1,450 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 149 of 380

150 CPT COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), 1,672 POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), 1,675 POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 912 PLACEMENT (INCLUDES PREDILATION) CPT INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) 86 (SEPARATE PROCEDURE) CPT SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 4,327 ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION CPT SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 4,961 ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; MULTIPLE PERFORATIONS CPT SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, 3,304 DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITHOUT COLOSTOMY CPT SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, 4,071 DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITH COLOSTOMY CPT INTESTINAL STRICTUROPLASTY (ENTEROTOMY AND ENTERORRHAPHY) 3,359 WITH OR WITHOUT DILATION, FOR INTESTINAL OBSTRUCTION CPT CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; 2,689 CPT CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH 3,173 RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL CPT CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH 5,032 RESECTION AND COLORECTAL ANASTOMOSIS (EG, CLOSURE OF HARTMANN TYPE PROCEDURE) CPT CLOSURE OF INTESTINAL CUTANEOUS FISTULA 4,395 CPT CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA 4,566 CPT CLOSURE OF ENTEROVESICAL FISTULA; WITHOUT INTESTINAL OR 4,497 BLADDER RESECTION CPT CLOSURE OF ENTEROVESICAL FISTULA; WITH INTESTINE AND/OR 4,969 BLADDER RESECTION CPT INTESTINAL PLICATION (SEPARATE PROCEDURE) 3,344 CPT EXCLUSION OF SMALL INTESTINE FROM PELVIS BY MESH OR OTHER 3,197 PROSTHESIS, OR NATIVE TISSUE (EG, BLADDER OR OMENTUM) CPT INTRAOPERATIVE COLONIC LAVAGE (LIST SEPARATELY IN ADDITION TO 532 CODE FOR PRIMARY PROCEDURE) CPT BACKBENCH STANDARD PREPARATION OF CADAVER OR LIVING DONOR N/A INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING MOBILIZATION AND FASHIONING OF THE SUPERIOR MESENTERIC ARTERY AND VEIN CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 835 INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 1,227 INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT UNLISTED PROCEDURE, INTESTINE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 150 of 380

151 CPT EXCISION OF MECKEL'S DIVERTICULUM (DIVERTICULECTOMY) OR 2,378 OMPHALOMESENTERIC DUCT CPT EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE) 2,615 CPT SUTURE OF MESENTERY (SEPARATE PROCEDURE) 2,319 CPT UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY N/A CPT INCISION AND DRAINAGE OF APPENDICEAL ABSCESS; OPEN 2,366 CPT INCISION AND DRAINAGE OF APPENDICEAL ABSCESS; PERCUTANEOUS 2,945 CPT APPENDECTOMY; 1,998 CPT APPENDECTOMY; WHEN DONE FOR INDICATED PURPOSE AT TIME OF 268 OTHER MAJOR PROCEDURE (NOT AS SEPARATE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT APPENDECTOMY; FOR RUPTURED APPENDIX WITH ABSCESS OR 2,696 GENERALIZED PERITONITIS CPT LAPAROSCOPY, SURGICAL, APPENDECTOMY 1,847 CPT UNLISTED LAPAROSCOPY PROCEDURE, APPENDIX N/A CPT TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 1,295 CPT INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM 785 CPT INCISION AND DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, OR 1,703 RETRORECTAL ABSCESS CPT BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL 907 MEGACOLON) CPT ANORECTAL MYOMECTOMY 1,098 CPT PROCTECTOMY; COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY CPT PROCTECTOMY; PARTIAL RESECTION OF RECTUM, TRANSABDOMINAL APPROACH CPT PROCTECTOMY, COMBINED ABDOMINOPERINEAL, PULL-THROUGH PROCEDURE (EG, COLO-ANAL ANASTOMOSIS) CPT PROCTECTOMY, PARTIAL, WITH RECTAL MUCOSECTOMY, ILEOANAL ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), WITH OR WITHOUT LOOP ILEOSTOMY CPT PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS; ABDOMINAL AND TRANSSACRAL APPROACH CPT PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS; TRANSSACRAL APPROACH ONLY (KRASKE TYPE) CPT PROCTECTOMY, COMBINED ABDOMINOPERINEAL PULL-THROUGH PROCEDURE (EG, COLO-ANAL ANASTOMOSIS), WITH CREATION OF COLONIC RESERVOIR (EG, J-POUCH), WITH DIVERTING ENTEROSTOMY WHEN PERFORMED CPT PROCTECTOMY, COMPLETE (FOR CONGENITAL MEGACOLON), ABDOMINAL AND PERINEAL APPROACH; WITH PULL-THROUGH PROCEDURE AND ANASTOMOSIS (EG, SWENSON, DUHAMEL, OR SOAVE TYPE OPERATION) CPT PROCTECTOMY, COMPLETE (FOR CONGENITAL MEGACOLON), ABDOMINAL AND PERINEAL APPROACH; WITH SUBTOTAL OR TOTAL COLECTOMY, WITH MULTIPLE BIOPSIES 5,763 3,393 5,889 6,063 5,574 5,046 6,073 4,835 5,314 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 151 of 380

152 CPT PROCTECTOMY, PARTIAL, WITHOUT ANASTOMOSIS, PERINEAL APPROACH 3,461 CPT PELVIC EXENTERATION FOR COLORECTAL MALIGNANCY, WITH 8,950 PROCTECTOMY (WITH OR WITHOUT COLOSTOMY), WITH REMOVAL OF BLADDER AND URETERAL TRANSPLANTATIONS, AND/OR HYSTERECTOMY, OR CERVICECTOMY, WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S), OR ANY COMBINATION THEREOF CPT EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; PERINEAL 3,378 APPROACH CPT EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; ABDOMINAL 4,168 AND PERINEAL APPROACH CPT EXCISION OF ILEOANAL RESERVOIR WITH ILEOSTOMY 5,715 CPT DIVISION OF STRICTURE OF RECTUM 1,223 CPT EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSSACRAL OR 3,057 TRANSCOCCYGEAL APPROACH CPT EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH 2,415 CPT DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, 2,132 ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH CPT PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT 352 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATION (EG, BALLOON, GUIDE 2,703 WIRE, BOUGIE) CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, SINGLE OR MULTIPLE 572 CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN BODY 636 CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 616 POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 660 POLYP, OR OTHER LESION BY SNARE TECHNIQUE CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, 726 POLYPS, OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, 694 INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATION OF TUMOR(S), 672 POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE (EG, LASER) CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPRESSION OF VOLVULUS 344 CPT PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT 386 PLACEMENT (INCLUDES PREDILATION) CPT SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT 448 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE 568 CPT SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY 942 CPT SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 957 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 152 of 380

153 CPT SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING (EG, 562 INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL 869 INJECTION(S), ANY SUBSTANCE CPT SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION OF VOLVULUS, ANY 480 METHOD CPT SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR 1,062 OTHER LESION(S) BY SNARE TECHNIQUE CPT SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), 1,149 OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR MORE 1,549 STRICTURES CPT SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND 536 EXAMINATION CPT SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND 820 GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) CPT SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT 585 PLACEMENT (INCLUDES PREDILATION) CPT COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, 685 SINGLE OR MULTIPLE CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, 1,306 WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WITH OR WITHOUT COLON DECOMPRESSION (SEPARATE PROCEDURE) CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,655 REMOVAL OF FOREIGN BODY CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,578 BIOPSY, SINGLE OR MULTIPLE CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,538 DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 2,070 CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,875 ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,544 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,774 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 2,181 DILATION BY BALLOON, 1 OR MORE STRICTURES CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,155 TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,020 ENDOSCOPIC ULTRASOUND EXAMINATION CPT COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,280 TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) CPT LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY 6,215 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 153 of 380

154 CPT LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMBINED 6,716 ABDOMINOPERINEAL PULL-THROUGH PROCEDURE (EG, COLO-ANAL ANASTOMOSIS), WITH CREATION OF COLONIC RESERVOIR (EG, J- POUCH), WITH DIVERTING ENTEROSTOMY, WHEN PERFORMED CPT LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE) 3,577 CPT LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID 4,775 RESECTION CPT UNLISTED LAPAROSCOPY PROCEDURE, RECTUM N/A CPT PROCTOPLASTY; FOR STENOSIS 1,617 CPT PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE 1,774 CPT PERIRECTAL INJECTION OF SCLEROSING SOLUTION FOR PROLAPSE 435 CPT PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL APPROACH 3,236 CPT PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH 2,877 CPT PROCTOPEXY (EG, FOR PROLAPSE); WITH SIGMOID RESECTION, 4,562 ABDOMINAL APPROACH CPT REPAIR OF RECTOCELE (SEPARATE PROCEDURE) 2,274 CPT EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL INJURY; 3,495 CPT EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL INJURY; 5,046 WITH COLOSTOMY CPT CLOSURE OF RECTOVESICAL FISTULA; 3,925 CPT CLOSURE OF RECTOVESICAL FISTULA; WITH COLOSTOMY 4,424 CPT CLOSURE OF RECTOURETHRAL FISTULA; 3,891 CPT CLOSURE OF RECTOURETHRAL FISTULA; WITH COLOSTOMY 4,506 CPT REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER 619 ANESTHESIA CPT DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER 527 ANESTHESIA OTHER THAN LOCAL CPT DILATION OF RECTAL STRICTURE (SEPARATE PROCEDURE) UNDER 625 ANESTHESIA OTHER THAN LOCAL CPT REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE 965 PROCEDURE) UNDER ANESTHESIA CPT ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, 338 SPINAL, OR EPIDURAL), DIAGNOSTIC CPT UNLISTED PROCEDURE, RECTUM N/A CPT PLACEMENT OF SETON 819 CPT REMOVAL OF ANAL SETON, OTHER MARKER 411 CPT INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE) CPT INCISION AND DRAINAGE OF INTRAMURAL, INTRAMUSCULAR, OR SUBMUCOSAL ABSCESS, TRANSANAL, UNDER ANESTHESIA 1,563 1,292 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 154 of 380

155 CPT INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL 572 CPT INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, 1,426 WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON CPT INCISION, ANAL SEPTUM (INFANT) 685 CPT SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE 738 PROCEDURE) CPT INCISION OF THROMBOSED HEMORRHOID, EXTERNAL 495 CPT FISSURECTOMY, WITH OR WITHOUT SPHINCTEROTOMY 1,278 CPT CRYPTECTOMY; SINGLE 1,116 CPT CRYPTECTOMY; MULTIPLE (SEPARATE PROCEDURE) 1,590 CPT PAPILLECTOMY OR EXCISION OF SINGLE TAG, ANUS (SEPARATE 600 PROCEDURE) CPT HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG, RUBBER BAND) 789 CPT EXCISION OF EXTERNAL HEMORRHOID TAGS AND/OR MULTIPLE PAPILLAE 805 CPT HEMORRHOIDECTOMY, EXTERNAL, COMPLETE 1,335 CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; 1,485 CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; WITH 1,280 FISSURECTOMY CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; WITH 1,374 FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,444 EXTENSIVE; CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,601 EXTENSIVE; WITH FISSURECTOMY CPT HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,672 EXTENSIVE; WITH FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY CPT SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,467 SUBCUTANEOUS CPT SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,568 SUBMUSCULAR CPT SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,411 COMPLEX OR MULTIPLE, WITH OR WITHOUT PLACEMENT OF SETON CPT SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,545 SECOND STAGE CPT CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP 1,655 CPT ENUCLEATION OR EXCISION OF EXTERNAL THROMBOTIC HEMORRHOID 529 CPT INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS 680 CPT CHEMODENERVATION OF INTERNAL ANAL SPHINCTER 824 CPT ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF 247 SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT ANOSCOPY; WITH DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE) 1,720 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 155 of 380

156 CPT ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE 650 CPT ANOSCOPY; WITH REMOVAL OF FOREIGN BODY 657 CPT ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION 658 BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION 505 BY SNARE TECHNIQUE CPT ANOSCOPY; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER 815 LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR 393 CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER 449 LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT 1,986 CPT ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; INFANT 1,548 CPT REPAIR OF ANAL FISTULA WITH FIBRIN GLUE 526 CPT REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 3,265 VAGINAL), POUCH ADVANCEMENT; TRANSPERINEAL APPROACH CPT REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 6,798 VAGINAL), POUCH ADVANCEMENT; COMBINED TRANSPERINEAL AND TRANSABDOMINAL APPROACH CPT REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL FISTULA (CUT- 1,538 BACK PROCEDURE) CPT REPAIR OF LOW IMPERFORATE ANUS; WITH TRANSPOSITION OF 3,564 ANOPERINEAL OR ANOVESTIBULAR FISTULA CPT REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; PERINEAL OR 5,681 SACROPERINEAL APPROACH CPT REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; COMBINED 6,783 TRANSABDOMINAL AND SACROPERINEAL APPROACHES CPT REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR 6,436 RECTOVAGINAL FISTULA; PERINEAL OR SACROPERINEAL APPROACH CPT REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR 7,126 RECTOVAGINAL FISTULA; COMBINED TRANSABDOMINAL AND SACROPERINEAL APPROACHES CPT REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 10,448 URETHROPLASTY, SACROPERINEAL APPROACH CPT REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 11,620 URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; CPT REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 12,000 URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; WITH VAGINAL LENGTHENING BY INTESTINAL GRAFT OR PEDICLE FLAPS CPT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT 2,377 CPT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; CHILD 1,906 CPT GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE 1,804 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 156 of 380

157 CPT REMOVAL OF THIERSCH WIRE OR SUTURE, ANAL CANAL 844 CPT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; MUSCLE 3,380 TRANSPLANT CPT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR 2,902 MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR) CPT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; IMPLANTATION 2,892 ARTIFICIAL SPHINCTER CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 722 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 748 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 725 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 1,369 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 785 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION CPT DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 1,588 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL 1,218 CPT DESTRUCTION OF HEMORRHOIDS, ANY METHOD; EXTERNAL 821 CPT DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL AND 1,293 EXTERNAL CPT CRYOSURGERY OF RECTAL TUMOR; BENIGN 786 CPT CRYOSURGERY OF RECTAL TUMOR; MALIGNANT 1,373 CPT CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF 680 ANAL SPHINCTER (SEPARATE PROCEDURE); INITIAL CPT CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF 634 ANAL SPHINCTER (SEPARATE PROCEDURE); SUBSEQUENT CPT LIGATION OF INTERNAL HEMORRHOIDS; SINGLE PROCEDURE 896 CPT LIGATION OF INTERNAL HEMORRHOIDS; MULTIPLE PROCEDURES 945 CPT HEMORRHOIDOPEXY (EG, FOR PROLAPSING INTERNAL HEMORRHOIDS) BY 1,176 STAPLING CPT UNLISTED PROCEDURE, ANUS N/A CPT BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS 1,219 CPT BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT HEPATOTOMY; FOR OPEN DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES CPT HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES CPT LAPAROTOMY, WITH ASPIRATION AND/OR INJECTION OF HEPATIC PARASITIC (EG, AMOEBIC OR ECHINOCOCCAL) CYST(S) OR ABSCESS(ES) 331 3, ,572 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 157 of 380

158 CPT BIOPSY OF LIVER, WEDGE 2,596 CPT HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY 7,245 CPT HEPATECTOMY, RESECTION OF LIVER; TRISEGMENTECTOMY 10,739 CPT HEPATECTOMY, RESECTION OF LIVER; TOTAL LEFT LOBECTOMY 9,636 CPT HEPATECTOMY, RESECTION OF LIVER; TOTAL RIGHT LOBECTOMY 10,338 CPT DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM N/A CADAVER DONOR CPT LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, PARTIAL OR WHOLE, FROM 15,231 CADAVER OR LIVING DONOR, ANY AGE CPT LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, FROM 13,013 CADAVER OR LIVING DONOR, ANY AGE CPT DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 10,829 DONOR; LEFT LATERAL SEGMENT ONLY (SEGMENTS II AND III) CPT DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 12,816 DONOR; TOTAL LEFT LOBECTOMY (SEGMENTS II, III AND IV) CPT DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 14,068 DONOR; TOTAL RIGHT LOBECTOMY (SEGMENTS V, VI, VII AND VIII) CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER N/A GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMM CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER N/A GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMM CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR WHOLE LIVER N/A GRAFT PRIOR TO ALLOTRANSPLANTATION, INCLUDING CHOLECYSTECTOMY, IF NECESSARY, AND DISSECTION AND REMOVAL OF SURROUNDING SOFT TISSUES TO PREPARE THE VENA CAVA, PORTAL VEIN, HEPATIC ARTERY, AND COMM CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 1,051 GRAFT PRIOR TO ALLOTRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 1,225 GRAFT PRIOR TO ALLOTRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT MARSUPIALIZATION OF CYST OR ABSCESS OF LIVER 3,492 CPT MANAGEMENT OF LIVER HEMORRHAGE; SIMPLE SUTURE OF LIVER WOUND OR INJURY CPT MANAGEMENT OF LIVER HEMORRHAGE; COMPLEX SUTURE OF LIVER WOUND OR INJURY, WITH OR WITHOUT HEPATIC ARTERY LIGATION CPT MANAGEMENT OF LIVER HEMORRHAGE; EXPLORATION OF HEPATIC WOUND, EXTENSIVE DEBRIDEMENT, COAGULATION AND/OR SUTURE, WITH OR WITHOUT PACKING OF LIVER CPT MANAGEMENT OF LIVER HEMORRHAGE; RE-EXPLORATION OF HEPATIC WOUND FOR REMOVAL OF PACKING CPT LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER TUMOR(S); RADIOFREQUENCY CPT LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER TUMOR(S); CRYOSURGICAL 4,245 5,766 9,533 4,434 3,893 3,924 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 158 of 380

159 CPT UNLISTED LAPAROSCOPIC PROCEDURE, LIVER N/A CPT ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); RADIOFREQUENCY 4,519 CPT ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); CRYOSURGICAL 4,643 CPT ABLATION, ONE OR MORE LIVER TUMOR(S), PERCUTANEOUS, 2,814 RADIOFREQUENCY CPT UNLISTED PROCEDURE, LIVER N/A CPT HEPATICOTOMY OR HEPATICOSTOMY WITH EXPLORATION, DRAINAGE, OR 6,586 REMOVAL OF CALCULUS CPT CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 4,166 DRAINAGE, OR REMOVAL OF CALCULUS, WITH OR WITHOUT CHOLECYSTOTOMY; WITHOUT TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY CPT CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 4,212 DRAINAGE, OR REMOVAL OF CALCULUS, WITH OR WITHOUT CHOLECYSTOTOMY; WITH TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY CPT TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, WITH OR 3,997 WITHOUT TRANSDUODENAL EXTRACTION OF CALCULUS (SEPARATE PROCEDURE) CPT CHOLECYSTOTOMY OR CHOLECYSTOSTOMY WITH EXPLORATION, 2,665 DRAINAGE, OR REMOVAL OF CALCULUS (SEPARATE PROCEDURE) CPT PERCUTANEOUS CHOLECYSTOSTOMY 1,734 CPT INJECTION PROCEDURE FOR PERCUTANEOUS TRANSHEPATIC 351 CHOLANGIOGRAPHY CPT INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN EXISTING 134 CATHETER (EG, PERCUTANEOUS TRANSHEPATIC OR T-TUBE) CPT INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER FOR 1,640 BILIARY DRAINAGE CPT INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR INTERNAL 2,065 AND EXTERNAL BILIARY DRAINAGE CPT CHANGE OF PERCUTANEOUS BILIARY DRAINAGE CATHETER 2,611 CPT REVISION AND/OR REINSERTION OF TRANSHEPATIC TUBE 4,648 CPT BILIARY ENDOSCOPY, INTRAOPERATIVE (CHOLEDOCHOSCOPY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING AND/OR WASHING (SEPARATE PROCEDURE) CPT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH BIOPSY, SINGLE OR MULTIPLE CPT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH REMOVAL OF CALCULUS/CALCULI CPT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH DILATION OF BILIARY DUCT STRICTURE(S) WITHOUT STENT CPT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH DILATION OF BILIARY DUCT STRICTURE(S) WITH STENT CPT LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT BIOPSY CPT LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY WITH BIOPSY 528 1,124 1,127 1,675 1,353 1, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 159 of 380

160 CPT LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY 2,310 CPT LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY 2,351 CPT LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF 2,708 COMMON DUCT CPT LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROSTOMY 2,414 CPT UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT N/A CPT CHOLECYSTECTOMY; 3,319 CPT CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY 3,051 CPT CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; 3,900 CPT CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH 3,938 CHOLEDOCHOENTEROSTOMY CPT CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH 4,265 TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, WITH OR WITHOUT CHOLANGIOGRAPHY CPT BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUBE TRACT, 1,881 BASKET, OR SNARE (EG, BURHENNE TECHNIQUE) CPT EXPLORATION FOR CONGENITAL ATRESIA OF BILE DUCTS, WITHOUT 3,243 REPAIR, WITH OR WITHOUT LIVER BIOPSY, WITH OR WITHOUT CHOLANGIOGRAPHY CPT PORTOENTEROSTOMY (EG, KASAI PROCEDURE) 5,406 CPT EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF 4,842 BILE DUCT; EXTRAHEPATIC CPT EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF 6,190 BILE DUCT; INTRAHEPATIC CPT EXCISION OF CHOLEDOCHAL CYST 4,093 CPT CHOLECYSTOENTEROSTOMY; DIRECT 3,528 CPT CHOLECYSTOENTEROSTOMY; WITH GASTROENTEROSTOMY 4,146 CPT CHOLECYSTOENTEROSTOMY; ROUX-EN-Y 4,010 CPT CHOLECYSTOENTEROSTOMY; ROUX-EN-Y WITH GASTROENTEROSTOMY 4,552 CPT ANASTOMOSIS, OF EXTRAHEPATIC BILIARY DUCTS AND 6,873 GASTROINTESTINAL TRACT CPT ANASTOMOSIS, OF INTRAHEPATIC DUCTS AND GASTROINTESTINAL TRACT 9,096 CPT ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC BILIARY DUCTS AND 7,523 GASTROINTESTINAL TRACT CPT ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC BILIARY DUCTS AND 9,814 GASTROINTESTINAL TRACT CPT RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC BILIARY DUCTS WITH 4,896 END-TO-END ANASTOMOSIS CPT PLACEMENT OF CHOLEDOCHAL STENT 3,407 CPT U-TUBE HEPATICOENTEROSTOMY 4,701 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 160 of 380

161 CPT SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR PRE-EXISTING INJURY 4,256 (SEPARATE PROCEDURE) CPT UNLISTED PROCEDURE, BILIARY TRACT N/A CPT PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; 5,811 CPT PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; 7,177 WITH CHOLECYSTOSTOMY, GASTROSTOMY, AND JEJUNOSTOMY CPT REMOVAL OF PANCREATIC CALCULUS 3,611 CPT BIOPSY OF PANCREAS, OPEN (EG, FINE NEEDLE ASPIRATION, NEEDLE 2,764 CORE BIOPSY, WEDGE BIOPSY) CPT BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE 1,835 CPT RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC 8,859 TISSUE FOR ACUTE NECROTIZING PANCREATITIS CPT EXCISION OF LESION OF PANCREAS (EG, CYST, ADENOMA) 3,434 CPT PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 4,858 SPLENECTOMY; WITHOUT PANCREATICOJEJUNOSTOMY CPT PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 5,034 SPLENECTOMY; WITH PANCREATICOJEJUNOSTOMY CPT PANCREATECTOMY, DISTAL, NEAR-TOTAL WITH PRESERVATION OF 5,772 DUODENUM (CHILD-TYPE PROCEDURE) CPT EXCISION OF AMPULLA OF VATER 3,873 CPT PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL DUODENECTOMY, 9,689 PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITH PANCREATOJEJUNOSTOMY CPT PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL DUODENECTOMY, 8,950 PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITHOUT PANCREATOJEJUNOSTOMY CPT PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 9,671 DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); WITH PANCREATOJEJUNOSTOMY CPT PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 9,013 DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); WITHOUT PANCREATOJEJUNOSTOMY CPT PANCREATECTOMY, TOTAL 5,602 CPT PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH AUTOLOGOUS 9,777 TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLET CELLS CPT INJECTION PROCEDURE FOR INTRAOPERATIVE PANCREATOGRAPHY (LIST 347 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MARSUPIALIZATION OF PANCREATIC CYST 3,490 CPT EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREAS; OPEN 3,335 CPT EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREAS; PERCUTANEOUS 3,075 CPT INTERNAL ANASTOMOSIS OF PANCREATIC CYST TO GASTROINTESTINAL TRACT; DIRECT 3,393 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 161 of 380

162 CPT INTERNAL ANASTOMOSIS OF PANCREATIC CYST TO GASTROINTESTINAL 4,061 TRACT; ROUX-EN-Y CPT PANCREATORRHAPHY FOR INJURY 4,141 CPT DUODENAL EXCLUSION WITH GASTROJEJUNOSTOMY FOR PANCREATIC 5,533 INJURY CPT PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANASTOMOSIS (PUESTOW- 5,177 TYPE OPERATION) CPT DONOR PANCREATECTOMY (INCLUDING COLD PRESERVATION), WITH OR N/A WITHOUT DUODENAL SEGMENT FOR TRANSPLANTATION CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR PANCREAS N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION OF ALLOGRAFT FROM SURROUNDING SOFT TISSUES, SPLENECTOMY, DUODENOTOMY, LIGATION OF BILE DUCT, LIGATION OF MESENTERIC VESSELS, AND Y-GRAFT ARTE CPT BACKBENCH RECONSTRUCTION OF CADAVER DONOR PANCREAS 723 ALLOGRAFT PRIOR TO TRANSPLANTATION, VENOUS ANASTOMOSIS, EACH CPT TRANSPLANTATION OF PANCREATIC ALLOGRAFT 7,772 CPT REMOVAL OF TRANSPLANTED PANCREATIC ALLOGRAFT 3,845 CPT UNLISTED PROCEDURE, PANCREAS N/A CPT EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR 2,412 WITHOUT BIOPSY(S) (SEPARATE PROCEDURE) CPT REOPENING OF RECENT LAPAROTOMY 3,185 CPT EXPLORATION, RETROPERITONEAL AREA WITH OR WITHOUT BIOPSY(S) 2,981 (SEPARATE PROCEDURE) CPT DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, 4,934 EXCLUSIVE OF APPENDICEAL ABSCESS; OPEN CPT DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, 2,922 EXCLUSIVE OF APPENDICEAL ABSCESS; PERCUTANEOUS CPT DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; OPEN 3,100 CPT DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; 3,041 PERCUTANEOUS CPT DRAINAGE OF RETROPERITONEAL ABSCESS; OPEN 3,451 CPT DRAINAGE OF RETROPERITONEAL ABSCESS; PERCUTANEOUS 2,979 CPT DRAINAGE OF EXTRAPERITONEAL LYMPHOCELE TO PERITONEAL CAVITY, OPEN CPT PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE (DIAGNOSTIC OR THERAPEUTIC); INITIAL CPT PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE (DIAGNOSTIC OR THERAPEUTIC); SUBSEQUENT CPT BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE CPT EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR 5 CM DIAMETER OR LESS CPT EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR CM DIAMETER 2, ,767 4,809 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 162 of 380

163 CPT EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS 5,506 OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR GREATER THAN 10.0 CM DIAMETER CPT EXCISION OF PRESACRAL OR SACROCOCCYGEAL TUMOR 6,888 CPT STAGING LAPAROTOMY FOR HODGKINS DISEASE OR LYMPHOMA 3,027 (INCLUDES SPLENECTOMY, NEEDLE OR OPEN BIOPSIES OF BOTH LIVER LOBES, POSSIBLY ALSO REMOVAL OF ABDOMINAL NODES, ABDOMINAL NODE AND/OR BONE MARROW BIOPSIES, OVARIAN REPOSITIONING) CPT UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE 1,806 PROCEDURE) CPT OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE 2,450 PROCEDURE) CPT LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, 1,029 WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) 1,088 CPT LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, 1,170 OVARIAN CYST) (SINGLE OR MULTIPLE) CPT LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF LYMPHOCELE TO 2,016 PERITONEAL CAVITY CPT LAPAROSCOPY, SURGICAL; WITH INSERTION OF INTRAPERITONEAL 1,232 CANNULA OR CATHETER, PERMANENT CPT LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED 1,326 INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED CPT LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING 611 PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND N/A OMENTUM CPT INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE 566 PROCEDURE) CPT REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY 2,662 CPT INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER, WITH 1,418 SUBCUTANEOUS RESERVOIR, PERMANENT (IE, TOTALLY IMPLANTABLE) CPT INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE 454 OR DIALYSIS; TEMPORARY CPT INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE 1,224 OR DIALYSIS; PERMANENT CPT REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR CATHETER 1,220 CPT EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE 1,843 CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE) CPT CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA 488 PREVIOUSLY PLACED DRAINAGE CATHETER OR TUBE (SEPARATE PROCEDURE) CPT INSERTION OF PERITONEAL-VENOUS SHUNT 2,386 CPT REVISION OF PERITONEAL-VENOUS SHUNT 2,035 CPT INJECTION PROCEDURE (EG, CONTRAST MEDIA) FOR EVALUATION OF PREVIOUSLY PLACED PERITONEAL-VENOUS SHUNT 161 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 163 of 380

164 CPT LIGATION OF PERITONEAL-VENOUS SHUNT 1,332 CPT REMOVAL OF PERITONEAL-VENOUS SHUNT 1,437 CPT INSERTION OF SUBCUTANEOUS EXTENSION TO INTRAPERITONEAL CANNULA OR CATHETER WITH REMOTE CHEST EXIT SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT OF INTRAPERITONEAL CANNULA OR CATHETER CPT INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT CONVERSION OF GASTROSTOMY TUBE TO GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT MECHANICAL REMOVAL OF OBSTRUCTIVE MATERIAL FROM GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO- JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, ANY METHOD, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IF PERFORMED, IMAGE DOCUMENTATION AND REPORT CPT CONTRAST INJECTION(S) FOR RADIOLOGICAL EVALUATION OF EXISTING GASTROSTOMY, DUODENOSTOMY, JEJUNOSTOMY, GASTRO- JEJUNOSTOMY, OR CECOSTOMY (OR OTHER COLONIC) TUBE, FROM A PERCUTANEOUS APPROACH INCLUDING IMAGE DOCUMENTATION AND REPORT CPT REPAIR, INITIAL INGUINAL HERNIA, PRETERM INFANT (YOUNGER THAN 37 WEEKS GESTATION AT BIRTH), PERFORMED FROM BIRTH UP TO 50 WEEKS POSTCONCEPTION AGE, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE CPT REPAIR, INITIAL INGUINAL HERNIA, PRETERM INFANT (YOUNGER THAN 37 WEEKS GESTATION AT BIRTH), PERFORMED FROM BIRTH UP TO 50 WEEKS POSTCONCEPTION AGE, WITH OR WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED CPT REPAIR, INITIAL INGUINAL HERNIA, FULL TERM INFANT YOUNGER THAN AGE 6 MONTHS, OR PRETERM INFANT OLDER THAN 50 WEEKS POSTCONCEPTION AGE AND YOUNGER THAN AGE 6 MONTHS AT THE TIME OF SURGERY, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE CPT REPAIR, INITIAL INGUINAL HERNIA, FULL TERM INFANT YOUNGER THAN AGE 6 MONTHS, OR PRETERM INFANT OLDER THAN 50 WEEKS POSTCONCEPTION AGE AND YOUNGER THAN AGE 6 MONTHS AT THE TIME OF SURGERY, WITH OR WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED ,742 4,429 3,612 3,684 2,569 2,726 3,341 2, ,321 2,940 1,252 1,867 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 164 of 380

165 CPT REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO YOUNGER THAN 5 1,273 YEARS, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE CPT REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO YOUNGER THAN 5 1,846 YEARS, WITH OR WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED CPT REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE 1,609 CPT REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; 1,974 INCARCERATED OR STRANGULATED CPT REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE 1,959 CPT REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR 2,382 STRANGULATED CPT REPAIR INGUINAL HERNIA, SLIDING, ANY AGE 1,774 CPT REPAIR LUMBAR HERNIA 2,090 CPT REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE 1,782 CPT REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR 1,950 STRANGULATED CPT REPAIR RECURRENT FEMORAL HERNIA; REDUCIBLE 1,851 CPT REPAIR RECURRENT FEMORAL HERNIA; INCARCERATED OR 2,245 STRANGULATED CPT REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE 2,295 CPT REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR 2,893 STRANGULATED CPT REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; REDUCIBLE 2,377 CPT REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; INCARCERATED 2,921 OR STRANGULATED CPT IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL OR 850 VENTRAL HERNIA REPAIR OR MESH FOR CLOSURE OF DEBRIDEMENT FOR NECROTIZING SOFT TISSUE INFECTION (LIST SEPARATELY IN ADDITION TO CODE FOR THE INCISIONAL OR VENTRAL HERNIA REPAIR) CPT REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); REDUCIBLE 1,271 (SEPARATE PROCEDURE) CPT REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); INCARCERATED 1,573 OR STRANGULATED CPT REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; REDUCIBLE 991 CPT REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; 1,462 INCARCERATED OR STRANGULATED CPT REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE 1,364 CPT REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR 1,612 STRANGULATED CPT REPAIR SPIGELIAN HERNIA 1,767 CPT REPAIR OF SMALL OMPHALOCELE, WITH PRIMARY CLOSURE 2,287 CPT REPAIR OF LARGE OMPHALOCELE OR GASTROSCHISIS; WITH OR WITHOUT PROSTHESIS CPT REPAIR OF LARGE OMPHALOCELE OR GASTROSCHISIS; WITH REMOVAL OF PROSTHESIS, FINAL REDUCTION AND CLOSURE, IN OPERATING ROOM 15,586 3,544 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 165 of 380

166 CPT REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); FIRST STAGE 2,163 CPT REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); SECOND STAGE 1,793 CPT LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA 1,331 CPT LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA 1,719 CPT UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, N/A HERNIOTOMY CPT SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION OR 2,538 DEHISCENCE CPT OMENTAL FLAP, EXTRA-ABDOMINAL (EG, FOR RECONSTRUCTION OF 4,625 STERNAL AND CHEST WALL DEFECTS) CPT OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO 1,130 CODE FOR PRIMARY PROCEDURE) CPT FREE OMENTAL FLAP WITH MICROVASCULAR ANASTOMOSIS N/A CPT UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM N/A CPT RENAL EXPLORATION, NOT NECESSITATING OTHER SPECIFIC 2,490 PROCEDURES CPT DRAINAGE OF PERIRENAL OR RENAL ABSCESS; OPEN 3,487 CPT DRAINAGE OF PERIRENAL OR RENAL ABSCESS; PERCUTANEOUS 3,106 CPT NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE 3,315 CPT NEPHROTOMY, WITH EXPLORATION 3,280 CPT NEPHROLITHOTOMY; REMOVAL OF CALCULUS 4,152 CPT NEPHROLITHOTOMY; SECONDARY SURGICAL OPERATION FOR CALCULUS 4,441 CPT NEPHROLITHOTOMY; COMPLICATED BY CONGENITAL KIDNEY 4,339 ABNORMALITY CPT NEPHROLITHOTOMY; REMOVAL OF LARGE STAGHORN CALCULUS FILLING 5,315 RENAL PELVIS AND CALYCES (INCLUDING ANATROPHIC PYELOLITHOTOMY) CPT PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, WITH 3,173 OR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; UP TO 2 CM CPT PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, WITH 4,662 OR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; OVER 2 CM CPT TRANSECTION OR REPOSITIONING OF ABERRANT RENAL VESSELS 3,258 (SEPARATE PROCEDURE) CPT PYELOTOMY; WITH EXPLORATION 3,447 CPT PYELOTOMY; WITH DRAINAGE, PYELOSTOMY 3,627 CPT PYELOTOMY; WITH REMOVAL OF CALCULUS (PYELOLITHOTOMY, 3,769 PELVIOLITHOTOMY, INCLUDING COAGULUM PYELOLITHOTOMY) CPT PYELOTOMY; COMPLICATED (EG, SECONDARY OPERATION, CONGENITAL 4,086 KIDNEY ABNORMALITY) CPT RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 500 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 166 of 380

167 CPT RENAL BIOPSY; BY SURGICAL EXPOSURE OF KIDNEY 2,391 CPT NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 3,700 APPROACH INCLUDING RIB RESECTION; CPT NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 4,311 APPROACH INCLUDING RIB RESECTION; COMPLICATED BECAUSE OF PREVIOUS SURGERY ON SAME KIDNEY CPT NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 4,642 APPROACH INCLUDING RIB RESECTION; RADICAL, WITH REGIONAL LYMPHADENECTOMY AND/OR VENA CAVAL THROMBECTOMY CPT NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; 4,723 THROUGH SAME INCISION CPT NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; 5,340 THROUGH SEPARATE INCISION CPT NEPHRECTOMY, PARTIAL 4,804 CPT ABLATION, OPEN, ONE OR MORE RENAL MASS LESION(S), 4,397 CRYOSURGICAL, INCLUDING INTRAOPERATIVE ULTRASOUND, IF PERFORMED CPT EXCISION OR UNROOFING OF CYST(S) OF KIDNEY 3,423 CPT EXCISION OF PERINEPHRIC CYST 3,165 CPT DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); FROM N/A CADAVER DONOR, UNILATERAL OR BILATERAL CPT DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); OPEN, FROM 4,650 LIVING DONOR CPT BACKBENCH STANDARD PREPARATION OF CADAVER DONOR RENAL N/A ALLOGRAFT PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION AND REMOVAL OF PERINEPHRIC FAT, DIAPHRAGMATIC AND RETROPERITONEAL ATTACHMENTS, EXCISION OF ADRENAL GLAND, AND PREPARATION OF URETER(S), RENAL VE CPT BACKBENCH STANDARD PREPARATION OF LIVING DONOR RENAL N/A ALLOGRAFT (OPEN OR LAPAROSCOPIC) PRIOR TO TRANSPLANTATION, INCLUDING DISSECTION AND REMOVAL OF PERINEPHRIC FAT AND PREPARATION OF URETER(S), RENAL VEIN(S), AND RENAL ARTERY(S), LIGATING BRANCHES, AS NEC CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 678 ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 596 ALLOGRAFT PRIOR TO TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 584 ALLOGRAFT PRIOR TO TRANSPLANTATION; URETERAL ANASTOMOSIS, EACH CPT RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) 2,935 CPT RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITHOUT 7,923 RECIPIENT NEPHRECTOMY CPT RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITH 8,751 RECIPIENT NEPHRECTOMY CPT REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 3,719 CPT RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY 6,089 CPT REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY DWELLING URETERAL STENT VIA PERCUTANEOUS APPROACH, INCLUDING 4,055 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 167 of 380

168 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL 3,271 STENT VIA PERCUTANEOUS APPROACH, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT REMOVAL (VIA SNARE/CAPTURE) AND REPLACEMENT OF INTERNALLY 4,449 DWELLING URETERAL STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL 2,879 STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT REMOVAL AND REPLACEMENT OF EXTERNALLY ACCESSIBLE 1,854 TRANSNEPHRIC URETERAL STENT (EG, EXTERNAL/INTERNAL STENT) REQUIRING FLUOROSCOPIC GUIDANCE, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC 988 GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT) CPT ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, 351 PERCUTANEOUS CPT INSTILLATION(S) OF THERAPEUTIC AGENT INTO RENAL PELVIS AND/OR 438 URETER THROUGH ESTABLISHED NEPHROSTOMY, PYELOSTOMY OR URETEROSTOMY TUBE (EG, ANTICARCINOGENIC OR ANTIFUNGAL AGENT) CPT INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS 640 FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS CPT INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER 780 THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS CPT INJECTION PROCEDURE FOR PYELOGRAPHY (AS NEPHROSTOGRAM, 337 PYELOSTOGRAM, ANTEGRADE PYELOURETEROGRAMS) THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, OR INDWELLING URETERAL CATHETER CPT INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER WITH 648 DILATION TO ESTABLISH NEPHROSTOMY TRACT, PERCUTANEOUS CPT MANOMETRIC STUDIES THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, 415 OR INDWELLING URETERAL CATHETER CPT CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE 1,686 CPT PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON RENAL 4,210 PELVIS, WITH OR WITHOUT PLASTIC OPERATION ON URETER, NEPHROPEXY, NEPHROSTOMY, PYELOSTOMY, OR URETERAL SPLINTING; SIMPLE CPT PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON RENAL 5,082 PELVIS, WITH OR WITHOUT PLASTIC OPERATION ON URETER, NEPHROPEXY, NEPHROSTOMY, PYELOSTOMY, OR URETERAL SPLINTING; COMPLICATED (CONGENITAL KIDNEY ABNORMALITY, SECONDARY PYELOPLASTY, SOLITARY KIDNEY, CALYCOPLASTY) CPT NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND OR INJURY 4,001 CPT CLOSURE OF NEPHROCUTANEOUS OR PYELOCUTANEOUS FISTULA 3,709 CPT CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), INCLUDING VISCERAL REPAIR; ABDOMINAL APPROACH CPT CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), INCLUDING VISCERAL REPAIR; THORACIC APPROACH CPT SYMPHYSIOTOMY FOR HORSESHOE KIDNEY WITH OR WITHOUT PYELOPLASTY AND/OR OTHER PLASTIC PROCEDURE, UNILATERAL OR 4,764 4,564 4,144 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 168 of 380

169 BILATERAL (ONE OPERATION) CPT LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS 3,346 CPT LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S) 4,248 CPT LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY 5,423 CPT LAPAROSCOPY, SURGICAL; PYELOPLASTY 4,567 CPT LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL 4,882 OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY) CPT LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL 4,348 URETERECTOMY CPT LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY (INCLUDING COLD 5,222 PRESERVATION), FROM LIVING DONOR CPT LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY 4,922 CPT UNLISTED LAPAROSCOPY PROCEDURE, RENAL N/A CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS CPT RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH RESECTION OF TUMOR CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH ENDOPYELOTOMY (INCLUDES 1,332 1,368 1,519 1,554 1,753 2,138 1,807 1,950 2,084 2,631 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 169 of 380

170 CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT) CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR 2,080 WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY CPT RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR 2,236 WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS CPT LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE 3,447 CPT ABLATION, ONE OR MORE RENAL TUMOR(S), PERCUTANEOUS, 10,408 UNILATERAL, RADIOFREQUENCY CPT ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, 15,643 CRYOTHERAPY CPT URETEROTOMY WITH EXPLORATION OR DRAINAGE (SEPARATE 3,358 PROCEDURE) CPT URETEROTOMY FOR INSERTION OF INDWELLING STENT, ALL TYPES 3,272 CPT URETEROLITHOTOMY; UPPER ONE-THIRD OF URETER 3,465 CPT URETEROLITHOTOMY; MIDDLE ONE-THIRD OF URETER 3,304 CPT URETEROLITHOTOMY; LOWER ONE-THIRD OF URETER 3,193 CPT URETERECTOMY, WITH BLADDER CUFF (SEPARATE PROCEDURE) 3,758 CPT URETERECTOMY, TOTAL, ECTOPIC URETER, COMBINATION ABDOMINAL, 4,151 VAGINAL AND/OR PERINEAL APPROACH CPT INJECTION PROCEDURE FOR URETEROGRAPHY OR URETEROPYELOGRAPHY 601 THROUGH URETEROSTOMY OR INDWELLING URETERAL CATHETER CPT MANOMETRIC STUDIES THROUGH URETEROSTOMY OR INDWELLING 493 URETERAL CATHETER CPT CHANGE OF URETEROSTOMY TUBE OR EXTERNALLY ACCESSIBLE 276 URETERAL STENT VIA ILEAL CONDUIT CPT INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR 337 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE CPT URETEROPLASTY, PLASTIC OPERATION ON URETER (EG, STRICTURE) 3,344 CPT URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR 3,923 RETROPERITONEAL FIBROSIS CPT URETEROLYSIS FOR OVARIAN VEIN SYNDROME 3,395 CPT URETEROLYSIS FOR RETROCAVAL URETER, WITH REANASTOMOSIS OF 3,825 UPPER URINARY TRACT OR VENA CAVA CPT REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 1,826 UROSTOMY); CPT REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 2,485 UROSTOMY); WITH REPAIR OF FASCIAL DEFECT AND HERNIA CPT URETEROPYELOSTOMY, ANASTOMOSIS OF URETER AND RENAL PELVIS 3,885 CPT URETEROCALYCOSTOMY, ANASTOMOSIS OF URETER TO RENAL CALYX 4,220 CPT URETEROURETEROSTOMY 3,948 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 170 of 380

171 CPT TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF URETER TO 4,204 CONTRALATERAL URETER CPT URETERONEOCYSTOSTOMY; ANASTOMOSIS OF SINGLE URETER TO 3,954 BLADDER CPT URETERONEOCYSTOSTOMY; ANASTOMOSIS OF DUPLICATED URETER TO 3,903 BLADDER CPT URETERONEOCYSTOSTOMY; WITH EXTENSIVE URETERAL TAILORING 4,107 CPT URETERONEOCYSTOSTOMY; WITH VESICO-PSOAS HITCH OR BLADDER 4,371 FLAP CPT URETEROENTEROSTOMY, DIRECT ANASTOMOSIS OF URETER TO 3,346 INTESTINE CPT URETEROSIGMOIDOSTOMY, WITH CREATION OF SIGMOID BLADDER AND 4,440 ESTABLISHMENT OF ABDOMINAL OR PERINEAL COLOSTOMY, INCLUDING INTESTINE ANASTOMOSIS CPT URETEROCOLON CONDUIT, INCLUDING INTESTINE ANASTOMOSIS 4,414 CPT URETEROILEAL CONDUIT (ILEAL BLADDER), INCLUDING INTESTINE 4,739 ANASTOMOSIS (BRICKER OPERATION) CPT CONTINENT DIVERSION, INCLUDING INTESTINE ANASTOMOSIS USING 5,975 ANY SEGMENT OF SMALL AND/OR LARGE INTESTINE (KOCK POUCH OR CAMEY ENTEROCYSTOPLASTY) CPT URINARY UNDIVERSION (EG, TAKING DOWN OF URETEROILEAL CONDUIT, 6,491 URETEROSIGMOIDOSTOMY OR URETEROENTEROSTOMY WITH URETEROURETEROSTOMY OR URETERONEOCYSTOSTOMY) CPT REPLACEMENT OF ALL OR PART OF URETER BY INTESTINE SEGMENT, 4,479 INCLUDING INTESTINE ANASTOMOSIS CPT CUTANEOUS APPENDICO-VESICOSTOMY 4,512 CPT URETEROSTOMY, TRANSPLANTATION OF URETER TO SKIN 3,453 CPT URETERORRHAPHY, SUTURE OF URETER (SEPARATE PROCEDURE) 3,023 CPT CLOSURE OF URETEROCUTANEOUS FISTULA 3,170 CPT CLOSURE OF URETEROVISCERAL FISTULA (INCLUDING VISCERAL REPAIR) 3,878 CPT DELIGATION OF URETER 3,125 CPT LAPAROSCOPY, SURGICAL; URETEROLITHOTOMY 3,589 CPT LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY 5,046 AND URETERAL STENT PLACEMENT CPT LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT 4,605 CYSTOSCOPY AND URETERAL STENT PLACEMENT CPT UNLISTED LAPAROSCOPY PROCEDURE, URETER N/A CPT URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER CPT URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY 1,392 1,458 1,557 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 171 of 380

172 CPT URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH 1,590 OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY CPT URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH 1,409 OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS CPT URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,370 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,311 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER CPT URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,708 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,704 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY CPT URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,314 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS CPT CYSTOTOMY OR CYSTOSTOMY; WITH FULGURATION AND/OR INSERTION 1,689 OF RADIOACTIVE MATERIAL CPT CYSTOTOMY OR CYSTOSTOMY; WITH CRYOSURGICAL DESTRUCTION OF 1,656 INTRAVESICAL LESION CPT CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE 1,061 CPT CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT 1,680 (SEPARATE PROCEDURE) CPT CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT 1,723 VESICAL NECK RESECTION CPT TRANSVESICAL URETEROLITHOTOMY 2,122 CPT CYSTOTOMY, WITH CALCULUS BASKET EXTRACTION AND/OR ULTRASONIC 2,102 OR ELECTROHYDRAULIC FRAGMENTATION OF URETERAL CALCULUS CPT DRAINAGE OF PERIVESICAL OR PREVESICAL SPACE ABSCESS 1,466 CPT ASPIRATION OF BLADDER; BY NEEDLE 220 CPT ASPIRATION OF BLADDER; BY TROCAR OR INTRACATHETER 444 CPT ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER 1,170 CPT EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL 2,229 HERNIA REPAIR CPT CYSTOTOMY; FOR SIMPLE EXCISION OF VESICAL NECK (SEPARATE 2,149 PROCEDURE) CPT CYSTOTOMY; FOR EXCISION OF BLADDER DIVERTICULUM, SINGLE OR 3,115 MULTIPLE (SEPARATE PROCEDURE) CPT CYSTOTOMY; FOR EXCISION OF BLADDER TUMOR 2,770 CPT CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE 2,816 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 172 of 380

173 CPT CYSTECTOMY, PARTIAL; SIMPLE 3,413 CPT CYSTECTOMY, PARTIAL; COMPLICATED (EG, POSTRADIATION, PREVIOUS 4,542 SURGERY, DIFFICULT LOCATION) CPT CYSTECTOMY, PARTIAL, WITH REIMPLANTATION OF URETER(S) INTO 4,688 BLADDER (URETERONEOCYSTOSTOMY) CPT CYSTECTOMY, COMPLETE; (SEPARATE PROCEDURE) 5,351 CPT CYSTECTOMY, COMPLETE; WITH BILATERAL PELVIC LYMPHADENECTOMY, 6,623 INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR 6,920 URETEROCUTANEOUS TRANSPLANTATIONS; CPT CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR 7,698 URETEROCUTANEOUS TRANSPLANTATIONS; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID 7,008 BLADDER, INCLUDING INTESTINE ANASTOMOSIS; CPT CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID 7,967 BLADDER, INCLUDING INTESTINE ANASTOMOSIS; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT CYSTECTOMY, COMPLETE, WITH CONTINENT DIVERSION, ANY OPEN 8,557 TECHNIQUE, USING ANY SEGMENT OF SMALL AND/OR LARGE INTESTINE TO CONSTRUCT NEOBLADDER CPT PELVIC EXENTERATION, COMPLETE, FOR VESICAL, PROSTATIC OR 8,259 URETHRAL MALIGNANCY, WITH REMOVAL OF BLADDER AND URETERAL TRANSPLANTATIONS, WITH OR WITHOUT HYSTERECTOMY AND/OR ABDOMINOPERINEAL RESECTION OF RECTUM AND COLON AND COLOSTOMY, OR ANY COMBINATION THEREOF CPT INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING 650 URETHROCYSTOGRAPHY CPT INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST 139 AND/OR CHAIN URETHROCYSTOGRAPHY CPT INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY 381 CPT BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION 307 CPT INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT 198 CATHETERIZATION FOR RESIDUAL URINE) CPT INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE 260 (EG, FOLEY) CPT INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; 482 COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON) CPT CHANGE OF CYSTOSTOMY TUBE; SIMPLE 392 CPT CHANGE OF CYSTOSTOMY TUBE; COMPLICATED 546 CPT ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL 1,061 TISSUES OF THE URETHRA AND/OR BLADDER NECK CPT BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING 410 RETENTION TIME) CPT SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) 742 CPT COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT) 1,132 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 173 of 380

174 CPT SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, 202 MECHANICAL UROFLOWMETER) CPT COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT) 317 CPT URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE 864 PRESSURE PROFILE), ANY TECHNIQUE CPT ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, 731 OTHER THAN NEEDLE, ANY TECHNIQUE CPT NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL 784 SPHINCTER, ANY TECHNIQUE CPT STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF 799 BULBOCAVERNOSUS REFLEX LATENCY TIME) CPT VOIDING PRESSURE STUDIES (VP); BLADDER VOIDING PRESSURE, ANY 1,066 TECHNIQUE CPT VOIDING PRESSURE STUDIES (VP); INTRA-ABDOMINAL VOIDING 429 PRESSURE (AP) (RECTAL, GASTRIC, INTRAPERITONEAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER 84 CAPACITY BY ULTRASOUND, NON-IMAGING CPT CYSTOPLASTY OR CYSTOURETHROPLASTY, PLASTIC OPERATION ON 3,748 BLADDER AND/OR VESICAL NECK (ANTERIOR Y-PLASTY, VESICAL FUNDUS RESECTION), ANY PROCEDURE, WITH OR WITHOUT WEDGE RESECTION OF POSTERIOR VESICAL NECK CPT CYSTOURETHROPLASTY WITH UNILATERAL OR BILATERAL 3,890 URETERONEOCYSTOSTOMY CPT ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL- 2,278 MARCHETTI-KRANTZ, BURCH); SIMPLE CPT ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL- 2,731 MARCHETTI-KRANTZ, BURCH); COMPLICATED (EG, SECONDARY REPAIR) CPT ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, WITH OR WITHOUT 2,108 ENDOSCOPIC CONTROL (EG, STAMEY, RAZ, MODIFIED PEREYRA) CPT CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; 2,565 SIMPLE CPT CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; 3,178 COMPLICATED CPT CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDURE) 1,669 CPT CLOSURE OF VESICOVAGINAL FISTULA, ABDOMINAL APPROACH 2,979 CPT CLOSURE OF VESICOUTERINE FISTULA; 2,829 CPT CLOSURE OF VESICOUTERINE FISTULA; WITH HYSTERECTOMY 4,003 CPT CLOSURE, EXSTROPHY OF BLADDER 5,583 CPT ENTEROCYSTOPLASTY, INCLUDING INTESTINAL ANASTOMOSIS 4,999 CPT CUTANEOUS VESICOSTOMY 2,563 CPT LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS 2,590 INCONTINENCE CPT LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS 2,855 INCONTINENCE (EG, FASCIA OR SYNTHETIC) CPT UNLISTED LAPAROSCOPY PROCEDURE, BLADDER N/A CPT CYSTOURETHROSCOPY (SEPARATE PROCEDURE) 758 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 174 of 380

175 CPT CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE 1,369 OBSTRUCTING CLOTS CPT CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR 1,040 WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR 1,755 WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS CPT CYSTOURETHROSCOPY, WITH EJACULATORY DUCT CATHETERIZATION, 1,423 WITH OR WITHOUT IRRIGATION, INSTILLATION, OR DUCT RADIOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE CPT CYSTOURETHROSCOPY, WITH BIOPSY(S) 1,393 CPT CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 3,001 OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS CPT CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 2,823 OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY CPT CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 908 OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 UP TO 2.0 CM) CPT CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 1,066 OR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM) CPT CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 1,855 OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S) CPT CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, 894 WITH OR WITHOUT BIOPSY OR FULGURATION CPT CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL 770 CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA CPT CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL 1,340 CYSTITIS; LOCAL ANESTHESIA CPT CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; FEMALE 1,336 CPT CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; MALE 1,802 CPT CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY 979 CPT CYSTOURETHROSCOPY, WITH RESECTION OF EXTERNAL SPHINCTER 1,195 (SPHINCTEROTOMY) CPT CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF 1,043 URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE CPT CYSTOURETHROSCOPY, WITH INSERTION OF URETHRAL STENT 1,233 CPT CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE 1,013 CPT CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL SYNDROME WITH ANY OR ALL OF THE FOLLOWING: URETHRAL MEATOTOMY, URETHRAL DILATION, INTERNAL URETHROTOMY, LYSIS OF URETHROVAGINAL SEPTAL FIBROSIS, LATERAL INCISIONS OF THE BLADDER NECK, AND FULGURATION OF POLYP(S) OF URETHRA, BLADDER NECK, AND/OR TRIGONE 1,030 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 175 of 380

176 CPT CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL OR 901 BILATERAL CPT CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF 1,037 ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL CPT CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ECTOPIC 1,087 URETEROCELE(S), UNILATERAL OR BILATERAL CPT CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF 1,028 BLADDER DIVERTICULUM, SINGLE OR MULTIPLE CPT CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, 882 OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE CPT CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, 1,535 OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED CPT LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY 3,053 MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM) CPT LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY 1,745 MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM) CPT CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 910 REMOVAL OF URETERAL CALCULUS CPT CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 1,179 FRAGMENTATION OF URETERAL CALCULUS (EG, ULTRASONIC OR ELECTRO-HYDRAULIC TECHNIQUE) CPT CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 955 SUBURETERIC INJECTION OF IMPLANT MATERIAL CPT CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 3,247 MANIPULATION, WITHOUT REMOVAL OF URETERAL CALCULUS CPT CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL 1,945 STENT (EG, GIBBONS OR DOUBLE-J TYPE) CPT CYSTOURETHROSCOPY WITH INSERTION OF URETERAL GUIDE WIRE 944 THROUGH KIDNEY TO ESTABLISH A PERCUTANEOUS NEPHROSTOMY, RETROGRADE CPT CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, 1,205 BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION 1,298 STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE 1,423 (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,543 URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,636 URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,825 INTRA-RENAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,159 DIAGNOSTIC CPT CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,361 WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED) CPT CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED) 1,564 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 176 of 380

177 CPT CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,446 WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION CPT CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,721 WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR CPT CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR RESECTION OF 2,030 CONGENITAL POSTERIOR URETHRAL VALVES, OR CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS CPT CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR INCISION 984 OF EJACULATORY DUCTS CPT TRANSURETHRAL INCISION OF PROSTATE 1,718 CPT TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE) 2,035 CPT TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, 3,075 INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) CPT TRANSURETHRAL FULGURATION FOR POSTOPERATIVE BLEEDING 1,874 OCCURRING AFTER THE USUAL FOLLOW-UP TIME CPT TRANSURETHRAL RESECTION OF PROSTATE; FIRST STAGE OF TWO-STAGE 1,952 RESECTION (PARTIAL RESECTION) CPT TRANSURETHRAL RESECTION OF PROSTATE; SECOND STAGE OF TWO- 1,719 STAGE RESECTION (RESECTION COMPLETED) CPT TRANSURETHRAL RESECTION; OF RESIDUAL OBSTRUCTIVE TISSUE AFTER 1, DAYS POSTOPERATIVE CPT TRANSURETHRAL RESECTION; OF REGROWTH OF OBSTRUCTIVE TISSUE 1,631 LONGER THAN ONE YEAR POSTOPERATIVE CPT TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK 1,481 CONTRACTURE CPT LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF 6,775 POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED IF PERFORMED) CPT LASER VAPORIZATION OF PROSTATE, INCLUDING CONTROL OF 6,958 POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED) CPT LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, 3,472 INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE INCLUDED IF PERFORMED) CPT TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS 1,607 CPT URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); 533 PENDULOUS URETHRA CPT URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); 1,059 PERINEAL URETHRA, EXTERNAL CPT MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE); EXCEPT 358 INFANT CPT MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE); INFANT 255 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 177 of 380

178 CPT DRAINAGE OF DEEP PERIURETHRAL ABSCESS 1,427 CPT DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST 631 CPT DRAINAGE OF PERINEAL URINARY EXTRAVASATION; UNCOMPLICATED 1,549 (SEPARATE PROCEDURE) CPT DRAINAGE OF PERINEAL URINARY EXTRAVASATION; COMPLICATED 2,061 CPT BIOPSY OF URETHRA 565 CPT URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; FEMALE 2,799 CPT URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; MALE 3,390 CPT EXCISION OR FULGURATION OF CARCINOMA OF URETHRA 1,636 CPT EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); 2,191 FEMALE CPT EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); MALE 2,328 CPT MARSUPIALIZATION OF URETHRAL DIVERTICULUM, MALE OR FEMALE 1,557 CPT EXCISION OF BULBOURETHRAL GLAND (COWPER'S GLAND) 1,421 CPT EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA 717 CPT EXCISION OR FULGURATION; URETHRAL CARUNCLE 795 CPT EXCISION OR FULGURATION; SKENE'S GLANDS 738 CPT EXCISION OR FULGURATION; URETHRAL PROLAPSE 960 CPT URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR 2,911 STRICTURE (EG, JOHANNSEN TYPE) CPT URETHROPLASTY; SECOND STAGE (FORMATION OF URETHRA), INCLUDING 3,184 URINARY DIVERSION CPT URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE ANTERIOR 3,570 URETHRA CPT URETHROPLASTY, TRANSPUBIC OR PERINEAL, ONE STAGE, FOR 4,105 RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA CPT URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 2,910 PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE CPT URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 3,407 PROSTATIC OR MEMBRANOUS URETHRA; SECOND STAGE CPT URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA 3,431 CPT URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA 4,206 AND/OR LOWER BLADDER FOR INCONTINENCE (EG, TENAGO, LEADBETTER PROCEDURE) CPT SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE 3,208 (EG, FASCIA OR SYNTHETIC) CPT REMOVAL OR REVISION OF SLING FOR MALE URINARY INCONTINENCE 2,828 (EG, FASCIA OR SYNTHETIC) CPT INSERTION OF TANDEM CUFF (DUAL CUFF) 2,897 CPT INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF 3,140 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 178 of 380

179 CPT REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 2,342 INCLUDING PUMP, RESERVOIR, AND CUFF CPT REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK 2,955 SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION CPT REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK 4,668 SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE CPT REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 2,230 INCLUDING PUMP, RESERVOIR, AND CUFF CPT URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT 1,491 CPT URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL 1,661 SEGMENT (RICHARDSON TYPE PROCEDURE) CPT URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN, INCLUDING 2,665 CYSTOURETHROSCOPY (EG, POSTSURGICAL OBSTRUCTION, SCARRING) CPT URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, FEMALE 1,747 CPT URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE 1,772 CPT URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL 2,316 CPT URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; 2,907 PROSTATOMEMBRANOUS CPT CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE 2,034 (SEPARATE PROCEDURE) CPT DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR 308 URETHRAL DILATOR, MALE; INITIAL CPT DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR 303 URETHRAL DILATOR, MALE; SUBSEQUENT CPT DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF 236 SOUND OR URETHRAL DILATOR, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA CPT DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND 431 FOLLOWER, MALE; INITIAL CPT DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND 410 FOLLOWER, MALE; SUBSEQUENT CPT DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR 261 INSTILLATION; INITIAL CPT DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR 259 INSTILLATION; SUBSEQUENT CPT DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) 137 ANESTHESIA CPT TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE 7,539 THERMOTHERAPY CPT TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY 7,268 RADIOFREQUENCY THERMOTHERAPY CPT TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY WATER- 4,406 INDUCED THERMOTHERAPY CPT UNLISTED PROCEDURE, URINARY SYSTEM N/A CPT SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); NEWBORN CPT SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 179 of 380

180 CPT INCISION AND DRAINAGE OF PENIS, DEEP 1,122 CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 432 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 412 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 464 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 500 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 650 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION CPT DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 738 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT BIOPSY OF PENIS; (SEPARATE PROCEDURE) 673 CPT BIOPSY OF PENIS; DEEP STRUCTURES 974 CPT EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); 2,294 CPT EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); WITH GRAFT TO 5 CM 2,930 IN LENGTH CPT EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); WITH GRAFT 3,429 GREATER THAN 5 CM IN LENGTH CPT REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE (EG, PLASTIC 1,637 IMPLANT) CPT AMPUTATION OF PENIS; PARTIAL 2,300 CPT AMPUTATION OF PENIS; COMPLETE 2,951 CPT AMPUTATION OF PENIS, RADICAL; WITH BILATERAL INGUINOFEMORAL 4,375 LYMPHADENECTOMY CPT AMPUTATION OF PENIS, RADICAL; IN CONTINUITY WITH BILATERAL 5,535 PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES CPT CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL 561 DORSAL PENILE OR RING BLOCK CPT CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR 816 DORSAL SLIT; NEONATE (28 DAYS OF AGE OR LESS) CPT CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR 719 DORSAL SLIT; OLDER THAN 28 DAYS OF AGE CPT LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS 942 CPT REPAIR INCOMPLETE CIRCUMCISION 796 CPT FRENULOTOMY OF PENIS 706 CPT INJECTION PROCEDURE FOR PEYRONIE DISEASE; 400 CPT INJECTION PROCEDURE FOR PEYRONIE DISEASE; WITH SURGICAL 1,945 EXPOSURE OF PLAQUE CPT IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM 743 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 180 of 380

181 CPT INJECTION PROCEDURE FOR CORPORA CAVERNOSOGRAPHY 356 CPT DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL INJECTION 524 OF VASOACTIVE DRUGS (EG, PAPAVERINE, PHENTOLAMINE) CPT INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) 334 (EG, PAPAVERINE, PHENTOLAMINE) CPT PENILE PLETHYSMOGRAPHY 376 CPT NOCTURNAL PENILE TUMESCENCE AND/OR RIGIDITY TEST 455 CPT PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA CPT PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR FIRST STAGE HYPOSPADIAS REPAIR WITH OR WITHOUT TRANSPLANTATION OF PREPUCE AND/OR SKIN FLAPS CPT URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); LESS THAN 3 CM CPT URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); GREATER THAN 3 CM CPT URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION) WITH FREE SKIN GRAFT OBTAINED FROM SITE OTHER THAN GENITALIA CPT URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE PENIS FROM SCROTUM (EG, THIRD STAGE CECIL REPAIR) CPT ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH SIMPLE MEATAL ADVANCEMENT (EG, MAGPI, V- FLAP) CPT ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS (EG, FLIP-FLAP, PREPUCIAL FLAP) CPT ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA CPT ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY WITH LOCAL SKIN FLAPS, SKIN GRAFT PATCH, AND/OR ISLAND FLAP CPT ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP CPT ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP CPT REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); BY CLOSURE, INCISION, OR EXCISION, SIMPLE CPT REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING MOBILIZATION OF SKIN FLAPS AND URETHROPLASTY WITH FLAP OR PATCH GRAFT CPT REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING EXTENSIVE DISSECTION AND URETHROPLASTY WITH FLAP, PATCH OR TUBED GRAFT (INCLUDES URINARY DIVERSION) CPT REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE DISSECTION AND EXCISION OF PREVIOUSLY CONSTRUCTED STRUCTURES INCLUDING RE-RELEASE OF CHORDEE AND RECONSTRUCTION OF URETHRA AND PENIS BY USE OF LOCAL SKIN AS GRAFTS AND ISLAND FLAPS AND SKIN BROUGHT IN AS FLAPS OR GRAFTS 2,332 2,747 2,276 3,080 3,656 2,328 2,858 3,560 3,416 3,423 3,713 3,896 2,085 3,523 3,716 5,311 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 181 of 380

182 CPT PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION 2,635 CPT PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 2,895 SPHINCTER; CPT PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 3,593 SPHINCTER; WITH INCONTINENCE CPT PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 3,971 SPHINCTER; WITH EXSTROPHY OF BLADDER CPT INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID) 1,948 CPT INSERTION OF PENILE PROSTHESIS; INFLATABLE (SELF-CONTAINED) 2,409 CPT INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, 2,952 INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR CPT REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE 2,670 PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS CPT REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE 2,879 PROSTHESIS CPT REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI- 3,389 COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION CPT REMOVAL AND REPLACEMENT OF ALL COMPONENTS OF A MULTI- 3,735 COMPONENT INFLATABLE PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE CPT REMOVAL OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF- 1,929 CONTAINED) PENILE PROSTHESIS, WITHOUT REPLACEMENT OF PROSTHESIS CPT REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR 2,585 INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION CPT REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR 3,277 INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS THROUGH AN INFECTED FIELD AT THE SAME OPERATIVE SESSION, INCLUDING IRRIGATION AND DEBRIDEMENT OF INFECTED TISSUE CPT CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (PRIAPISM OPERATION), 2,575 UNILATERAL OR BILATERAL CPT CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT (PRIAPISM 2,343 OPERATION), UNILATERAL OR BILATERAL CPT CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY 1,526 NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM CPT PLASTIC OPERATION OF PENIS FOR INJURY 1,961 CPT FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS 258 AND STRETCHING CPT BIOPSY OF TESTIS, NEEDLE (SEPARATE PROCEDURE) 273 CPT BIOPSY OF TESTIS, INCISIONAL (SEPARATE PROCEDURE) 777 CPT EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS 1,959 CPT ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT 1,191 TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH CPT ORCHIECTOMY, PARTIAL 2,093 CPT ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH 2,017 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 182 of 380

183 CPT ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION 2,633 CPT EXPLORATION FOR UNDESCENDED TESTIS (INGUINAL OR SCROTAL AREA) 1,776 CPT EXPLORATION FOR UNDESCENDED TESTIS WITH ABDOMINAL 2,484 EXPLORATION CPT REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT 1,656 FIXATION OF CONTRALATERAL TESTIS CPT FIXATION OF CONTRALATERAL TESTIS (SEPARATE PROCEDURE) 1,101 CPT ORCHIOPEXY, INGUINAL APPROACH, WITH OR WITHOUT HERNIA REPAIR 1,704 CPT ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL TESTIS 2,399 (EG, FOWLER-STEPHENS) CPT INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) 1,312 CPT SUTURE OR REPAIR OF TESTICULAR INJURY 1,489 CPT TRANSPLANTATION OF TESTIS(ES) TO THIGH (BECAUSE OF SCROTAL 2,866 DESTRUCTION) CPT LAPAROSCOPY, SURGICAL; ORCHIECTOMY 2,292 CPT LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR INTRA-ABDOMINAL TESTIS 2,832 CPT UNLISTED LAPAROSCOPY PROCEDURE, TESTIS N/A CPT INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL 766 SPACE (EG, ABSCESS OR HEMATOMA) CPT BIOPSY OF EPIDIDYMIS, NEEDLE 475 CPT EXCISION OF LOCAL LESION OF EPIDIDYMIS 1,353 CPT EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY 1,181 CPT EPIDIDYMECTOMY; UNILATERAL 1,531 CPT EPIDIDYMECTOMY; BILATERAL 2,070 CPT EXPLORATION OF EPIDIDYMIS, WITH OR WITHOUT BIOPSY 1,300 CPT EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 2,545 DEFERENS; UNILATERAL CPT EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 3,934 DEFERENS; BILATERAL CPT PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR 426 WITHOUT INJECTION OF MEDICATION CPT EXCISION OF HYDROCELE; UNILATERAL 1,231 CPT EXCISION OF HYDROCELE; BILATERAL 1,849 CPT REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE) 1,379 CPT DRAINAGE OF SCROTAL WALL ABSCESS 762 CPT SCROTAL EXPLORATION 1,402 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 183 of 380

184 CPT REMOVAL OF FOREIGN BODY IN SCROTUM 1,286 CPT RESECTION OF SCROTUM 1,764 CPT SCROTOPLASTY; SIMPLE 1,319 CPT SCROTOPLASTY; COMPLICATED 2,492 CPT VASOTOMY, CANNULIZATION WITH OR WITHOUT INCISION OF VAS, 1,616 UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) CPT VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), 1,434 INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S) CPT VASOTOMY FOR VASOGRAMS, SEMINAL VESICULOGRAMS, OR 692 EPIDIDYMOGRAMS, UNILATERAL OR BILATERAL CPT VASOVASOSTOMY, VASOVASORRHAPHY 1,835 CPT LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR 1,275 BILATERAL (SEPARATE PROCEDURE) CPT EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE 1,368 PROCEDURE) CPT EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE) 1,400 CPT EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,287 VARICOCELE; (SEPARATE PROCEDURE) CPT EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,559 VARICOCELE; ABDOMINAL APPROACH CPT EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,685 VARICOCELE; WITH HERNIA REPAIR CPT LAPAROSCOPY, SURGICAL, WITH LIGATION OF SPERMATIC VEINS FOR 1,538 VARICOCELE CPT UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD N/A CPT VESICULOTOMY; 1,564 CPT VESICULOTOMY; COMPLICATED 1,749 CPT VESICULECTOMY, ANY APPROACH 2,623 CPT EXCISION OF MULLERIAN DUCT CYST 1,257 CPT BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY 805 APPROACH CPT BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH 975 CPT PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY 1,700 APPROACH; SIMPLE CPT PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY 2,124 APPROACH; COMPLICATED CPT PROSTATECTOMY, PERINEAL, SUBTOTAL (INCLUDING CONTROL OF 3,939 POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY) CPT PROSTATECTOMY, PERINEAL RADICAL; 4,793 CPT PROSTATECTOMY, PERINEAL RADICAL; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT PROSTATECTOMY, PERINEAL RADICAL; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND 5,783 6,434 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 184 of 380

185 OBTURATOR NODES CPT PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, 3,185 VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY); SUPRAPUBIC, SUBTOTAL, ONE OR TWO STAGES CPT PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, 3,448 VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY); RETROPUBIC, SUBTOTAL CPT PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 4,877 SPARING; CPT PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 5,226 SPARING; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 5,967 SPARING; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 3,180 RADIOACTIVE SUBSTANCE; CPT EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 4,037 RADIOACTIVE SUBSTANCE; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 4,837 RADIOACTIVE SUBSTANCE; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES CPT LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, 6,341 INCLUDING NERVE SPARING CPT ELECTROEJACULATION 658 CPT CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC 4,143 GUIDANCE FOR INTERSTITIAL CRYOSURGICAL PROBE PLACEMENT) CPT TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO PROSTATE 2,774 FOR INTERSTITIAL RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY CPT PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY 513 GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE CPT UNLISTED PROCEDURE, MALE GENITAL SYSTEM N/A CPT PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR 1,514 GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION CPT INTERSEX SURGERY; MALE TO FEMALE N/A CPT INTERSEX SURGERY; FEMALE TO MALE N/A CPT INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS 353 CPT INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS 388 CPT MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST 599 CPT LYSIS OF LABIAL ADHESIONS 490 CPT HYMENOTOMY, SIMPLE INCISION 161 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 185 of 380

186 CPT DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, 422 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, 725 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); ONE LESION 271 CPT BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH 123 SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VULVECTOMY SIMPLE; PARTIAL 1,729 CPT VULVECTOMY SIMPLE; COMPLETE 1,935 CPT VULVECTOMY, RADICAL, PARTIAL; 2,824 CPT VULVECTOMY, RADICAL, PARTIAL; WITH UNILATERAL INGUINOFEMORAL 3,594 LYMPHADENECTOMY CPT VULVECTOMY, RADICAL, PARTIAL; WITH BILATERAL INGUINOFEMORAL 4,191 LYMPHADENECTOMY CPT VULVECTOMY, RADICAL, COMPLETE; 3,681 CPT VULVECTOMY, RADICAL, COMPLETE; WITH UNILATERAL INGUINOFEMORAL 3,881 LYMPHADENECTOMY CPT VULVECTOMY, RADICAL, COMPLETE; WITH BILATERAL INGUINOFEMORAL 4,592 LYMPHADENECTOMY CPT VULVECTOMY, RADICAL, COMPLETE, WITH INGUINOFEMORAL, ILIAC, AND 4,579 PELVIC LYMPHADENECTOMY CPT PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING 611 CPT EXCISION OF BARTHOLIN'S GLAND OR CYST 971 CPT PLASTIC REPAIR OF INTROITUS 792 CPT CLITOROPLASTY FOR INTERSEX STATE 3,724 CPT PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE 854 PROCEDURE) CPT COLPOSCOPY OF THE VULVA; 361 CPT COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) 482 CPT COLPOTOMY; WITH EXPLORATION 635 CPT COLPOTOMY; WITH DRAINAGE OF PELVIC ABSCESS 1,416 CPT COLPOCENTESIS (SEPARATE PROCEDURE) 308 CPT INCISION AND DRAINAGE OF VAGINAL HEMATOMA; 552 OBSTETRICAL/POSTPARTUM CPT INCISION AND DRAINAGE OF VAGINAL HEMATOMA; NON-OBSTETRICAL 1,017 (EG, POST-TRAUMA, SPONTANEOUS BLEEDING) CPT DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, 370 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, 625 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE) 288 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 186 of 380

187 CPT BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQUIRING SUTURE 440 (INCLUDING CYSTS) CPT VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; 1,554 CPT VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF 4,557 PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) CPT VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF 5,252 PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY) CPT VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; 2,934 CPT VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL 5,268 OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) CPT VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL 5,547 OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY) CPT COLPOCLEISIS (LE FORT TYPE) 1,670 CPT EXCISION OF VAGINAL SEPTUM 590 CPT EXCISION OF VAGINAL CYST OR TUMOR 631 CPT IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT FOR 151 TREATMENT OF BACTERIAL, PARASITIC, OR FUNGOID DISEASE CPT INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR 1,348 CLINICAL BRACHYTHERAPY CPT FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT 255 DEVICE CPT DIAPHRAGM OR CERVICAL CAP FITTING WITH INSTRUCTIONS 200 CPT INTRODUCTION OF ANY HEMOSTATIC AGENT OR PACK FOR SPONTANEOUS 459 OR TRAUMATIC NONOBSTETRICAL VAGINAL HEMORRHAGE (SEPARATE PROCEDURE) CPT COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) 980 CPT COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR 1,198 PERINEUM (NONOBSTETRICAL) CPT PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, 1,043 KELLY URETHRAL PLICATION) CPT PLASTIC REPAIR OF URETHROCELE 1,309 CPT ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT 2,206 REPAIR OF URETHROCELE CPT POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT 2,153 PERINEORRHAPHY CPT COMBINED ANTEROPOSTERIOR COLPORRHAPHY; 2,667 CPT COMBINED ANTEROPOSTERIOR COLPORRHAPHY; WITH ENTEROCELE 2,959 REPAIR CPT INSERTION OF MESH OR OTHER PROSTHESIS FOR REPAIR OF PELVIC 883 FLOOR DEFECT, EACH SITE (ANTERIOR, POSTERIOR COMPARTMENT), VAGINAL APPROACH (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE) 1,585 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 187 of 380

188 CPT REPAIR OF ENTEROCELE, ABDOMINAL APPROACH (SEPARATE PROCEDURE) 2,621 CPT COLPOPEXY, ABDOMINAL APPROACH 3,180 CPT COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, 1,681 ILIOCOCCYGEUS) CPT COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, 2,230 LEVATOR MYORRHAPHY) CPT PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF 2,725 PERFORMED); OPEN ABDOMINAL APPROACH CPT PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF 2,178 PERFORMED); VAGINAL APPROACH CPT REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, 2,358 FASCIA OR SYNTHETIC) CPT SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR 2,788 SYNTHETIC) CPT PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY 2,594 CPT CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT 1,808 CPT CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT 2,693 CPT REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; 1,603 VAGINAL APPROACH CPT REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN 3,122 ABDOMINAL APPROACH CPT CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL 1,748 APPROACH CPT CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH 2,916 CPT CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH, WITH 3,266 CONCOMITANT COLOSTOMY CPT CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH 2,086 PERINEAL BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION CPT CLOSURE OF URETHROVAGINAL FISTULA; 1,650 CPT CLOSURE OF URETHROVAGINAL FISTULA; WITH BULBOCAVERNOSUS 1,884 TRANSPLANT CPT CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH 1,856 CPT CLOSURE OF VESICOVAGINAL FISTULA; TRANSVESICAL AND VAGINAL 2,689 APPROACH CPT VAGINOPLASTY FOR INTERSEX STATE 3,728 CPT DILATION OF VAGINA UNDER ANESTHESIA 444 CPT PELVIC EXAMINATION UNDER ANESTHESIA 357 CPT REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) 524 UNDER ANESTHESIA CPT COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; 380 CPT COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX CPT PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF PERFORMED), LAPAROSCOPIC APPROACH 511 3,042 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 188 of 380

189 CPT LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX) 3,222 CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 359 CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 503 WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 469 WITH BIOPSY(S) OF THE CERVIX CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 444 WITH ENDOCERVICAL CURETTAGE CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 937 WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX CPT COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 1,058 WITH LOOP ELECTRODE CONIZATION OF THE CERVIX CPT BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF 420 LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE) CPT ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND 331 CURETTAGE) CPT CAUTERY OF CERVIX; ELECTRO OR THERMAL 431 CPT CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT 472 CPT CAUTERY OF CERVIX; LASER ABLATION 468 CPT CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR 998 WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER CPT CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR 855 WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION CPT TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE 1,116 PROCEDURE) CPT RADICAL TRACHELECTOMY, WITH BILATERAL TOTAL PELVIC 5,535 LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING BIOPSY, WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) CPT EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; 2,532 CPT EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; WITH PELVIC 2,673 FLOOR REPAIR CPT EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; 1,324 CPT EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; WITH ANTERIOR 1,973 AND/OR POSTERIOR REPAIR CPT EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; WITH REPAIR OF 1,861 ENTEROCELE CPT DILATION AND CURETTAGE OF CERVICAL STUMP 407 CPT CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL 995 CPT TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL 1,001 APPROACH CPT DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE PROCEDURE) 198 CPT ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE) 358 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 189 of 380

190 CPT ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH 158 COLPOSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC 834 (NONOBSTETRICAL) CPT MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 2,981 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; ABDOMINAL APPROACH CPT MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 1,763 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH CPT MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE 3,764 INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G, ABDOMINAL APPROACH CPT TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR 3,224 WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S); CPT TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR 4,058 WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S); WITH COLPO-URETHROCYSTOPEXY (EG, MARSHALL- MARCHETTI-KRANTZ, BURCH) CPT SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL 3,080 HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) CPT TOTAL ABDOMINAL HYSTERECTOMY, INCLUDING PARTIAL VAGINECTOMY, 4,241 WITH PARA-AORTIC AND PELVIC LYMPH NODE SAMPLING, WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) CPT RADICAL ABDOMINAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC 5,646 LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) CPT PELVIC EXENTERATION FOR GYNECOLOGIC MALIGNANCY, WITH TOTAL 8,922 ABDOMINAL HYSTERECTOMY OR CERVICECTOMY, WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S), WITH REMOVAL OF BLADDER AND URETERAL TRANSPLANTATIONS, AND/OR ABDOMINOPERINEAL RESECTION OF RECTUM AND COLON AND COLOSTOMY, OR ANY COMBINATION THEREOF CPT VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; 2,691 CPT VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL 3,000 OF TUBE(S), AND/OR OVARY(S) CPT VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL 3,233 OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE CPT VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH COLPO- 3,432 URETHROCYSTOPEXY (MARSHALL-MARCHETTI-KRANTZ TYPE, PEREYRA TYPE) WITH OR WITHOUT ENDOSCOPIC CONTROL CPT VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF 2,878 ENTEROCELE CPT VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; 3,200 CPT VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH 3,427 REPAIR OF ENTEROCELE CPT VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) 4,273 CPT VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; 3,753 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 190 of 380

191 CPT VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 4,066 REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 4,297 REMOVAL OF TUBE(S) AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE CPT VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 4,473 COLPO-URETHROCYSTOPEXY (MARSHALL-MARCHETTI-KRANTZ TYPE, PEREYRA TYPE) WITH OR WITHOUT ENDOSCOPIC CONTROL CPT VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 3,947 REPAIR OF ENTEROCELE CPT INSERTION OF INTRAUTERINE DEVICE (IUD) 221 CPT REMOVAL OF INTRAUTERINE DEVICE (IUD) 310 CPT ARTIFICIAL INSEMINATION; INTRA-CERVICAL 246 CPT ARTIFICIAL INSEMINATION; INTRA-UTERINE 284 CPT SPERM WASHING FOR ARTIFICIAL INSEMINATION 52 CPT CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST 392 MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY CPT TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR 905 DIAGNOSIS AND/OR RE-ESTABLISHING PATENCY (ANY METHOD), WITH OR WITHOUT HYSTEROSALPINGOGRAPHY CPT INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY 1,482 CPT CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS 314 CPT ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC 3,378 GUIDANCE CPT ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING 6,363 ENDOMETRIAL CURETTAGE, WHEN PERFORMED CPT UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND 1,468 LIGAMENTS, WITH OR WITHOUT SHORTENING OF SACROUTERINE LIGAMENTS; (SEPARATE PROCEDURE) CPT UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND 2,605 LIGAMENTS, WITH OR WITHOUT SHORTENING OF SACROUTERINE LIGAMENTS; WITH PRESACRAL SYMPATHECTOMY CPT HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL) 2,560 CPT HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) 2,964 CPT LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; CPT LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; CPT LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS CPT LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 G 2,816 3,116 3,169 3,428 2,907 3,675 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 191 of 380

192 CPT LAPAROSCOPY, SURGICAL, WITH RADICAL HYSTERECTOMY, WITH 5,971 BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), WITH REMOVAL OF TUBE(S) AND OVARY(S), IF PERFORMED CPT LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 2, G OR LESS; CPT LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 3, G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 3,695 GREATER THAN 250 G; CPT LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 4,216 GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) 816 CPT HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM 1,124 AND/OR POLYPECTOMY, WITH OR WITHOUT D & C CPT HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS 1,125 (ANY METHOD) CPT HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF 1,277 INTRAUTERINE SEPTUM (ANY METHOD) CPT HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA 1,801 CPT HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN 1,178 BODY CPT HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, 5,558 ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION) CPT HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE 6,323 CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS CPT LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3, G OR LESS; CPT LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3, G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3,759 GREATER THAN 250 G; CPT LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 4,239 GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT UNLISTED LAPAROSCOPY PROCEDURE, UTERUS N/A CPT UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS N/A CPT LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERAL OR BILATERAL CPT LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTUM, UNILATERAL OR BILATERAL, DURING SAME HOSPITALIZATION (SEPARATE PROCEDURE) CPT LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVERY OR INTRA-ABDOMINAL SURGERY (NOT A SEPARATE PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR SUPRAPUBIC APPROACH CPT LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE) CPT LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY) 1,188 1, ,193 2,093 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 192 of 380

193 CPT LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF 2,299 LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD CPT LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR 1,193 WITHOUT TRANSECTION) CPT LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE 1,193 (EG, BAND, CLIP, OR FALOPE RING) CPT LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY 2,424 CPT LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) 2,620 CPT UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY N/A CPT SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL 2,497 (SEPARATE PROCEDURE) CPT SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR 2,336 BILATERAL (SEPARATE PROCEDURE) CPT LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) 2,839 CPT TUBOTUBAL ANASTOMOSIS 2,952 CPT TUBOUTERINE IMPLANTATION 2,940 CPT FIMBRIOPLASTY 2,673 CPT SALPINGOSTOMY (SALPINGONEOSTOMY) 2,791 CPT DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE 1,029 PROCEDURE); VAGINAL APPROACH CPT DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE 1,326 PROCEDURE); ABDOMINAL APPROACH CPT DRAINAGE OF OVARIAN ABSCESS; VAGINAL APPROACH, OPEN 1,011 CPT DRAINAGE OF OVARIAN ABSCESS; ABDOMINAL APPROACH 2,269 CPT DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL OR TRANSRECTAL 2,971 APPROACH, PERCUTANEOUS (EG, OVARIAN, PERICOLIC) CPT TRANSPOSITION, OVARY(S) 2,248 CPT BIOPSY OF OVARY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) 1,353 CPT WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR BILATERAL 2,309 CPT OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL 2,390 CPT OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; 1,645 CPT OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; FOR OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY, WITH PARA- AORTIC AND PELVIC LYMPH NODE BIOPSIES, PERITONEAL WASHINGS, PERITONEAL BIOPSIES, DIAPHRAGMATIC ASSESSMENTS, WITH OR WITHOUT SALPINGECTOMY(S), WITH OR WITHOUT OMENTECTOMY CPT RESECTION (INITIAL) OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND OMENTECTOMY; CPT RESECTION (INITIAL) OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND 3,628 3,466 4,454 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 193 of 380

194 OMENTECTOMY; WITH TOTAL ABDOMINAL HYSTERECTOMY, PELVIC AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT RESECTION (INITIAL) OF OVARIAN, TUBAL OR PRIMARY PERITONEAL 5,034 MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND OMENTECTOMY; WITH RADICAL DISSECTION FOR DEBULKING (IE, RADICAL EXCISION OR DESTRUCTION, INTRA-ABDOMINAL OR RETROPERITONEAL TUMORS) CPT BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 6,223 ABDOMINAL HYSTERECTOMY AND RADICAL DISSECTION FOR DEBULKING; CPT BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 6,755 ABDOMINAL HYSTERECTOMY AND RADICAL DISSECTION FOR DEBULKING; WITH PELVIC LYMPHADENECTOMY AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT BILATERAL SALPINGO-OOPHORECTOMY WITH TOTAL OMENTECTOMY, 4,436 TOTAL ABDOMINAL HYSTERECTOMY FOR MALIGNANCY CPT RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, 4,856 PRIMARY PERITONEAL, UTERINE MALIGNANCY (INTRA-ABDOMINAL, RETROPERITONEAL TUMORS), WITH OMENTECTOMY, IF PERFORMED; CPT RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, 5,375 PRIMARY PERITONEAL, UTERINE MALIGNANCY (INTRA-ABDOMINAL, RETROPERITONEAL TUMORS), WITH OMENTECTOMY, IF PERFORMED; WITH PELVIC LYMPHADENECTOMY AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT LAPAROTOMY, FOR STAGING OR RESTAGING OF OVARIAN, TUBAL, OR 2,986 PRIMARY PERITONEAL MALIGNANCY (SECOND LOOK), WITH OR WITHOUT OMENTECTOMY, PERITONEAL WASHING, BIOPSY OF ABDOMINAL AND PELVIC PERITONEUM, DIAPHRAGMATIC ASSESSMENT WITH PELVIC AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD 730 CPT EMBRYO TRANSFER, INTRAUTERINE 483 CPT GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY METHOD 784 CPT UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL) N/A CPT AMNIOCENTESIS; DIAGNOSTIC 422 CPT AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION (INCLUDES 601 ULTRASOUND GUIDANCE) CPT CORDOCENTESIS (INTRAUTERINE), ANY METHOD 678 CPT CHORIONIC VILLUS SAMPLING, ANY METHOD 521 CPT FETAL CONTRACTION STRESS TEST 250 CPT FETAL NON-STRESS TEST 164 CPT FETAL SCALP BLOOD SAMPLING 367 CPT FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITTEN REPORT; SUPERVISION AND INTERPRETATION CPT FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITTEN REPORT; INTERPRETATION ONLY Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 194 of 380

195 CPT TRANSABDOMINAL AMNIOINFUSION, INCLUDING ULTRASOUND GUIDANCE 1,247 CPT FETAL UMBILICAL CORD OCCLUSION, INCLUDING ULTRASOUND 1,452 GUIDANCE CPT FETAL FLUID DRAINAGE (EG, VESICOCENTESIS, THORACOCENTESIS, 1,149 PARACENTESIS), INCLUDING ULTRASOUND GUIDANCE CPT FETAL SHUNT PLACEMENT, INCLUDING ULTRASOUND GUIDANCE 1,452 CPT HYSTEROTOMY, ABDOMINAL (EG, FOR HYDATIDIFORM MOLE, ABORTION) 2,738 CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, 2,604 REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, 2,615 WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; ABDOMINAL PREGNANCY 3,160 CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE 2,922 PREGNANCY REQUIRING TOTAL HYSTERECTOMY CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE 2,796 PREGNANCY WITH PARTIAL RESECTION OF UTERUS CPT SURGICAL TREATMENT OF ECTOPIC PREGNANCY; CERVICAL, WITH 1,315 EVACUATION CPT LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT 2,543 SALPINGECTOMY AND/OR OOPHORECTOMY CPT LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH 2,469 SALPINGECTOMY AND/OR OOPHORECTOMY CPT CURETTAGE, POSTPARTUM 674 CPT INSERTION OF CERVICAL DILATOR (EG, LAMINARIA, PROSTAGLANDIN) 241 (SEPARATE PROCEDURE) CPT EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING 650 PHYSICIAN CPT CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL 512 CPT CERCLAGE OF CERVIX, DURING PREGNANCY; ABDOMINAL 803 CPT HYSTERORRHAPHY OF RUPTURED UTERUS 921 CPT ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL 5,839 DELIVERY (WITH OR WITHOUT EPISIOTOMY, AND/OR FORCEPS) AND POSTPARTUM CARE CPT VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR 2,567 FORCEPS); CPT VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR 2,986 FORCEPS); INCLUDING POSTPARTUM CARE CPT EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS 346 CPT DELIVERY OF PLACENTA (SEPARATE PROCEDURE) 305 CPT ANTEPARTUM CARE ONLY; 4-6 VISITS 1,460 CPT ANTEPARTUM CARE ONLY; 7 OR MORE VISITS 2,619 CPT POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) 466 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 195 of 380

196 CPT ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN 6,616 DELIVERY, AND POSTPARTUM CARE CPT CESAREAN DELIVERY ONLY; 3,043 CPT CESAREAN DELIVERY ONLY; INCLUDING POSTPARTUM CARE 3,589 CPT SUBTOTAL OR TOTAL HYSTERECTOMY AFTER CESAREAN DELIVERY (LIST 1,602 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL 6,170 DELIVERY (WITH OR WITHOUT EPISIOTOMY, AND/OR FORCEPS) AND POSTPARTUM CARE, AFTER PREVIOUS CESAREAN DELIVERY CPT VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH 2,872 OR WITHOUT EPISIOTOMY AND/OR FORCEPS); CPT VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH 3,221 OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTUM CARE CPT ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN 6,892 DELIVERY, AND POSTPARTUM CARE, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY CPT CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY 3,314 AFTER PREVIOUS CESAREAN DELIVERY; CPT CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY 3,890 AFTER PREVIOUS CESAREAN DELIVERY; INCLUDING POSTPARTUM CARE CPT TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED 1,062 SURGICALLY CPT TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST 1,220 TRIMESTER CPT TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND 1,251 TRIMESTER CPT TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY 1,433 CPT INDUCED ABORTION, BY DILATION AND CURETTAGE 719 CPT INDUCED ABORTION, BY DILATION AND EVACUATION 1,249 CPT INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; CPT INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH DILATION AND CURETTAGE AND/OR EVACUATION CPT INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAILED INTRA-AMNIOTIC INJECTION) CPT INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; CPT INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH DILATION AND CURETTAGE AND/OR EVACUATION CPT INDUCED ABORTION, BY ONE OR MORE VAGINAL SUPPOSITORIES (EG, PROSTAGLANDIN) WITH OR WITHOUT CERVICAL DILATION (EG, 1,213 1,320 1,744 1,373 1,617 1,883 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 196 of 380

197 LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAILED MEDICAL EVACUATION) CPT MULTIFETAL PREGNANCY REDUCTION(S) (MPR) 782 CPT UTERINE EVACUATION AND CURETTAGE FOR HYDATIDIFORM MOLE 1,535 CPT REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN 445 LOCAL) CPT UNLISTED FETAL INVASIVE PROCEDURE, INCLUDING ULTRASOUND N/A GUIDANCE CPT UNLISTED LAPAROSCOPY PROCEDURE, MATERNITY CARE AND DELIVERY N/A CPT UNLISTED PROCEDURE, MATERNITY CARE AND DELIVERY N/A CPT INCISION AND DRAINAGE OF THYROGLOSSAL DUCT CYST, INFECTED 505 CPT BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE 375 CPT EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF 2,066 ISTHMUS CPT PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT 2,216 ISTHMUSECTOMY CPT PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL 3,174 SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY CPT TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT 2,426 ISTHMUSECTOMY CPT TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL 2,923 SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY CPT THYROIDECTOMY, TOTAL OR COMPLETE 3,076 CPT THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED 4,154 NECK DISSECTION CPT THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL 5,301 NECK DISSECTION CPT THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE 3,465 FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID CPT THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; STERNAL SPLIT OR 4,371 TRANSTHORACIC APPROACH CPT THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL 3,328 APPROACH CPT EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; 1,393 CPT EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT 1,857 CPT ASPIRATION AND/OR INJECTION, THYROID CYST 375 CPT PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); 3,217 CPT PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE- EXPLORATION CPT PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); WITH MEDIASTINAL EXPLORATION, STERNAL SPLIT OR TRANSTHORACIC APPROACH CPT PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 4,047 4, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 197 of 380

198 CPT THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH 3,307 (SEPARATE PROCEDURE) CPT THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC 3,783 APPROACH, WITHOUT RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) CPT THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC 4,562 APPROACH, WITH RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) CPT ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL 3,513 GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE); CPT ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL 4,008 GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE); WITH EXCISION OF ADJACENT RETROPERITONEAL TUMOR CPT EXCISION OF CAROTID BODY TUMOR; WITHOUT EXCISION OF CAROTID 4,533 ARTERY CPT EXCISION OF CAROTID BODY TUMOR; WITH EXCISION OF CAROTID 5,852 ARTERY CPT LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR 3,903 COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL CPT UNLISTED LAPAROSCOPY PROCEDURE, ENDOCRINE SYSTEM N/A CPT UNLISTED PROCEDURE, ENDOCRINE SYSTEM N/A CPT SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL 371 OR BILATERAL; INITIAL CPT SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL 343 OR BILATERAL; SUBSEQUENT TAPS CPT VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, 438 SUTURE, OR IMPLANTED VENTRICULAR CATHETER/RESERVOIR; WITHOUT INJECTION CPT VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, 417 SUTURE, OR IMPLANTED VENTRICULAR CATHETER/RESERVOIR; WITH INJECTION OF MEDICATION OR OTHER SUBSTANCE FOR DIAGNOSIS OR TREATMENT CPT CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITHOUT 348 INJECTION (SEPARATE PROCEDURE) CPT CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITH INJECTION 453 OF MEDICATION OR OTHER SUBSTANCE FOR DIAGNOSIS OR TREATMENT (EG, C1-C2) CPT PUNCTURE OF SHUNT TUBING OR RESERVOIR FOR ASPIRATION OR 279 INJECTION PROCEDURE CPT TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE 1,463 CPT TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR IMPLANTING VENTRICULAR CATHETER, PRESSURE RECORDING DEVICE, OR OTHER INTRACEREBRAL MONITORING DEVICE CPT TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA CPT BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING INJECTION OF GAS, CONTRAST MEDIA, DYE, OR RADIOACTIVE MATERIAL) CPT BURR HOLE(S) OR TREPHINE; WITH BIOPSY OF BRAIN OR INTRACRANIAL LESION 1,020 2,832 2,316 3,982 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 198 of 380

199 CPT BURR HOLE(S) OR TREPHINE; WITH DRAINAGE OF BRAIN ABSCESS OR 4,254 CYST CPT BURR HOLE(S) OR TREPHINE; WITH SUBSEQUENT TAPPING (ASPIRATION) 3,129 OF INTRACRANIAL ABSCESS OR CYST CPT BURR HOLE(S) WITH EVACUATION AND/OR DRAINAGE OF HEMATOMA, 4,022 EXTRADURAL OR SUBDURAL CPT BURR HOLE(S); WITH ASPIRATION OF HEMATOMA OR CYST, 3,942 INTRACEREBRAL CPT BURR HOLE(S); FOR IMPLANTING VENTRICULAR CATHETER, RESERVOIR, 1,193 EEG ELECTRODE(S), PRESSURE RECORDING DEVICE, OR OTHER CEREBRAL MONITORING DEVICE (SEPARATE PROCEDURE) CPT INSERTION OF SUBCUTANEOUS RESERVOIR, PUMP OR CONTINUOUS 1,570 INFUSION SYSTEM FOR CONNECTION TO VENTRICULAR CATHETER CPT BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL, EXPLORATORY, NOT 2,713 FOLLOWED BY OTHER SURGERY CPT BURR HOLE(S) OR TREPHINE, INFRATENTORIAL, UNILATERAL OR 2,960 BILATERAL CPT CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; SUPRATENTORIAL 5,221 CPT CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; INFRATENTORIAL 6,239 (POSTERIOR FOSSA) CPT CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,503 SUPRATENTORIAL; EXTRADURAL OR SUBDURAL CPT CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,263 SUPRATENTORIAL; INTRACEREBRAL CPT CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 5,815 INFRATENTORIAL; EXTRADURAL OR SUBDURAL CPT CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,569 INFRATENTORIAL; INTRACEREBELLAR CPT INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL BONE GRAFT 283 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; 6,065 SUPRATENTORIAL CPT CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; 6,747 INFRATENTORIAL CPT CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR WITHOUT 7,450 DURAPLASTY, FOR TREATMENT OF INTRACRANIAL HYPERTENSION, WITHOUT EVACUATION OF ASSOCIATED INTRAPARENCHYMAL HEMATOMA; WITHOUT LOBECTOMY CPT CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR WITHOUT 7,586 DURAPLASTY, FOR TREATMENT OF INTRACRANIAL HYPERTENSION, WITHOUT EVACUATION OF ASSOCIATED INTRAPARENCHYMAL HEMATOMA; WITH LOBECTOMY CPT DECOMPRESSION OF ORBIT ONLY, TRANSCRANIAL APPROACH 4,911 CPT EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH BIOPSY 5,826 CPT EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH REMOVAL OF LESION CPT EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH REMOVAL OF FOREIGN BODY CPT SUBTEMPORAL CRANIAL DECOMPRESSION (PSEUDOTUMOR CEREBRI, SLIT VENTRICLE SYNDROME) CPT CRANIECTOMY, SUBOCCIPITAL WITH CERVICAL LAMINECTOMY FOR DECOMPRESSION OF MEDULLA AND SPINAL CORD, WITH OR WITHOUT DURAL GRAFT (EG, ARNOLD-CHIARI MALFORMATION) 5,786 3,810 4,598 6,961 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 199 of 380

200 CPT OTHER CRANIAL DECOMPRESSION, POSTERIOR FOSSA 6,419 CPT CRANIOTOMY FOR SECTION OF TENTORIUM CEREBELLI (SEPARATE 6,376 PROCEDURE) CPT CRANIECTOMY, SUBTEMPORAL, FOR SECTION, COMPRESSION, OR 5,971 DECOMPRESSION OF SENSORY ROOT OF GASSERIAN GANGLION CPT CRANIECTOMY, SUBOCCIPITAL; FOR EXPLORATION OR DECOMPRESSION 6,372 OF CRANIAL NERVES CPT CRANIECTOMY, SUBOCCIPITAL; FOR SECTION OF ONE OR MORE CRANIAL 6,385 NERVES CPT CRANIECTOMY, SUBOCCIPITAL; FOR MEDULLARY TRACTOTOMY 5,976 CPT CRANIECTOMY, SUBOCCIPITAL; FOR MESENCEPHALIC TRACTOTOMY OR 5,389 PEDUNCULOTOMY CPT CRANIOTOMY FOR LOBOTOMY, INCLUDING CINGULOTOMY 6,075 CPT CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF 4,260 SKULL CPT CRANIECTOMY; FOR OSTEOMYELITIS 3,636 CPT CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN TUMOR, SUPRATENTORIAL, EXCEPT MENINGIOMA CPT CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF MENINGIOMA, SUPRATENTORIAL CPT CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN ABSCESS, SUPRATENTORIAL CPT CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OR FENESTRATION OF CYST, SUPRATENTORIAL CPT IMPLANTATION OF BRAIN INTRACAVITARY CHEMOTHERAPY AGENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; EXCEPT MENINGIOMA, CEREBELLOPONTINE ANGLE TUMOR, OR MIDLINE TUMOR AT BASE OF SKULL CPT CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MENINGIOMA CPT CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; CEREBELLOPONTINE ANGLE TUMOR CPT CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MIDLINE TUMOR AT BASE OF SKULL CPT CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OF BRAIN ABSCESS CPT CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OR FENESTRATION OF CYST CPT CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; CPT CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; COMBINED WITH MIDDLE/POSTERIOR FOSSA CRANIOTOMY/CRANIECTOMY CPT SUBDURAL IMPLANTATION OF STRIP ELECTRODES THROUGH ONE OR MORE BURR OR TREPHINE HOLE(S) FOR LONG-TERM SEIZURE MONITORING CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SUBDURAL IMPLANTATION OF AN ELECTRODE ARRAY, FOR LONG-TERM SEIZURE MONITORING CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF EPILEPTOGENIC FOCUS WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY 6,914 8,123 6,049 5, ,766 9,384 11,839 10,118 6,897 6,623 10,510 8,945 3,842 4,817 5,217 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 200 of 380

201 CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR REMOVAL OF 3,135 EPIDURAL OR SUBDURAL ELECTRODE ARRAY, WITHOUT EXCISION OF CEREBRAL TISSUE (SEPARATE PROCEDURE) CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF 8,223 CEREBRAL EPILEPTOGENIC FOCUS, WITH ELECTROCORTICOGRAPHY DURING SURGERY (INCLUDES REMOVAL OF ELECTRODE ARRAY) CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 7,593 TEMPORAL LOBE, WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 8,138 TEMPORAL LOBE, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, OTHER 7,464 THAN TEMPORAL LOBE, PARTIAL OR TOTAL, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, OTHER 7,038 THAN TEMPORAL LOBE, PARTIAL OR TOTAL, WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR TRANSECTION OF 6,734 CORPUS CALLOSUM CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR TOTAL 7,280 HEMISPHERECTOMY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR PARTIAL OR 6,620 SUBTOTAL (FUNCTIONAL) HEMISPHERECTOMY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OR 5,980 COAGULATION OF CHOROID PLEXUS CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF 10,030 CRANIOPHARYNGIOMA CPT CRANIOTOMY FOR HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, 7,265 INTRACRANIAL APPROACH CPT HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, TRANSNASAL OR 4,823 TRANSSEPTAL APPROACH, NONSTEREOTACTIC CPT CRANIECTOMY FOR CRANIOSYNOSTOSIS; SINGLE CRANIAL SUTURE 2,777 CPT CRANIECTOMY FOR CRANIOSYNOSTOSIS; MULTIPLE CRANIAL SUTURES 4,214 CPT CRANIOTOMY FOR CRANIOSYNOSTOSIS; FRONTAL OR PARIETAL BONE 5,278 FLAP CPT CRANIOTOMY FOR CRANIOSYNOSTOSIS; BIFRONTAL BONE FLAP 5,362 CPT EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE CRANIOSYNOSTOSIS (EG, CLOVERLEAF SKULL); NOT REQUIRING BONE GRAFTS CPT EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE CRANIOSYNOSTOSIS (EG, CLOVERLEAF SKULL); RECONTOURING WITH MULTIPLE OSTEOTOMIES AND BONE AUTOGRAFTS (EG, BARREL-STAVE PROCEDURE) (INCLUDES OBTAINING GRAFTS) CPT EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA); WITHOUT OPTIC NERVE DECOMPRESSION CPT EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA); WITH OPTIC NERVE DECOMPRESSION CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SELECTIVE AMYGDALOHIPPOCAMPECTOMY CPT CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR MULTIPLE SUBPIAL TRANSECTIONS, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT CRANIECTOMY OR CRANIOTOMY; WITH EXCISION OF FOREIGN BODY FROM BRAIN CPT CRANIECTOMY OR CRANIOTOMY; WITH TREATMENT OF PENETRATING WOUND OF BRAIN 5,338 7,641 5,866 7,713 7,037 7,860 5,825 6,258 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 201 of 380

202 CPT TRANSORAL APPROACH TO SKULL BASE, BRAIN STEM OR UPPER SPINAL 7,284 CORD FOR BIOPSY, DECOMPRESSION OR EXCISION OF LESION; CPT TRANSORAL APPROACH TO SKULL BASE, BRAIN STEM OR UPPER SPINAL 11,174 CORD FOR BIOPSY, DECOMPRESSION OR EXCISION OF LESION; REQUIRING SPLITTING OF TONGUE AND/OR MANDIBLE (INCLUDING TRACHEOSTOMY) CPT CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, 7,622 INCLUDING LATERAL RHINOTOMY, ETHMOIDECTOMY, SPHENOIDECTOMY, WITHOUT MAXILLECTOMY OR ORBITAL EXENTERATION CPT CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, 8,890 INCLUDING LATERAL RHINOTOMY, ORBITAL EXENTERATION, ETHMOIDECTOMY, SPHENOIDECTOMY AND/OR MAXILLECTOMY CPT CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, 9,140 INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OF FRONTAL LOBE(S), OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA CPT CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; INTRADURAL, 9,253 INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OR RESECTION OF FRONTAL LOBE, OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA CPT ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, EXTRADURAL, 9,041 INCLUDING SUPRAORBITAL RIDGE OSTEOTOMY AND ELEVATION OF FRONTAL AND/OR TEMPORAL LOBE(S); WITHOUT ORBITAL EXENTERATION CPT ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, EXTRADURAL, 9,392 INCLUDING SUPRAORBITAL RIDGE OSTEOTOMY AND ELEVATION OF FRONTAL AND/OR TEMPORAL LOBE(S); WITH ORBITAL EXENTERATION CPT BICORONAL, TRANSZYGOMATIC AND/OR LEFORT I OSTEOTOMY APPROACH 6,833 TO ANTERIOR CRANIAL FOSSA WITH OR WITHOUT INTERNAL FIXATION, WITHOUT BONE GRAFT CPT INFRATEMPORAL PRE-AURICULAR APPROACH TO MIDDLE CRANIAL FOSSA 9,690 (PARAPHARYNGEAL SPACE, INFRATEMPORAL AND MIDLINE SKULL BASE, NASOPHARYNX), WITH OR WITHOUT DISARTICULATION OF THE MANDIBLE, INCLUDING PAROTIDECTOMY, CRANIOTOMY, DECOMPRESSION AND/OR MOBILIZATION OF THE FACIAL NERVE AND/OR PETROUS CAROTID ARTERY CPT INFRATEMPORAL POST-AURICULAR APPROACH TO MIDDLE CRANIAL 9,708 FOSSA (INTERNAL AUDITORY MEATUS, PETROUS APEX, TENTORIUM, CAVERNOUS SINUS, PARASELLAR AREA, INFRATEMPORAL FOSSA) INCLUDING MASTOIDECTOMY, RESECTION OF SIGMOID SINUS, WITH OR WITHOUT DECOMPRESSION AND/OR MOBILIZATION OF CONTENTS OF AUDITORY CANAL OR PETROUS CAROTID ARTERY CPT ORBITOCRANIAL ZYGOMATIC APPROACH TO MIDDLE CRANIAL FOSSA 10,050 (CAVERNOUS SINUS AND CAROTID ARTERY, CLIVUS, BASILAR ARTERY OR PETROUS APEX) INCLUDING OSTEOTOMY OF ZYGOMA, CRANIOTOMY, EXTRA- OR INTRADURAL ELEVATION OF TEMPORAL LOBE CPT TRANSTEMPORAL APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR 7,387 FORAMEN OR MIDLINE SKULL BASE, INCLUDING MASTOIDECTOMY, DECOMPRESSION OF SIGMOID SINUS AND/OR FACIAL NERVE, WITH OR WITHOUT MOBILIZATION CPT TRANSCOCHLEAR APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR 8,012 FORAMEN OR MIDLINE SKULL BASE, INCLUDING LABYRINTHECTOMY, DECOMPRESSION, WITH OR WITHOUT MOBILIZATION OF FACIAL NERVE AND/OR PETROUS CAROTID ARTERY CPT TRANSCONDYLAR (FAR LATERAL) APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN OR MIDLINE SKULL BASE, INCLUDING OCCIPITAL CONDYLECTOMY, MASTOIDECTOMY, RESECTION OF C1-C3 VERTEBRAL BODY(S), DECOMPRESSION OF VERTEBRAL ARTERY, WITH OR WITHOUT MOBILIZATION 9,168 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 202 of 380

203 CPT TRANSPETROSAL APPROACH TO POSTERIOR CRANIAL FOSSA, CLIVUS OR 8,089 FORAMEN MAGNUM, INCLUDING LIGATION OF SUPERIOR PETROSAL SINUS AND/OR SIGMOID SINUS CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 6,720 LESION OF BASE OF ANTERIOR CRANIAL FOSSA; EXTRADURAL CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 7,558 LESION OF BASE OF ANTERIOR CRANIAL FOSSA; INTRADURAL, INCLUDING DURAL REPAIR, WITH OR WITHOUT GRAFT CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 6,888 LESION OF INFRATEMPORAL FOSSA, PARAPHARYNGEAL SPACE, PETROUS APEX; EXTRADURAL CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 9,399 LESION OF INFRATEMPORAL FOSSA, PARAPHARYNGEAL SPACE, PETROUS APEX; INTRADURAL, INCLUDING DURAL REPAIR, WITH OR WITHOUT GRAFT CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 8,649 LESION OF PARASELLAR AREA, CAVERNOUS SINUS, CLIVUS OR MIDLINE SKULL BASE; EXTRADURAL CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 10,386 LESION OF PARASELLAR AREA, CAVERNOUS SINUS, CLIVUS OR MIDLINE SKULL BASE; INTRADURAL, INCLUDING DURAL REPAIR, WITH OR WITHOUT GRAFT CPT TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS SINUS; 1,974 WITHOUT REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS SINUS; 6,088 WITH REPAIR BY ANASTOMOSIS OR GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSECTION OR LIGATION, CAROTID ARTERY IN PETROUS CANAL; 1,385 WITHOUT REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSECTION OR LIGATION, CAROTID ARTERY IN PETROUS CANAL; WITH 4,853 REPAIR BY ANASTOMOSIS OR GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OBLITERATION OF CAROTID ANEURYSM, ARTERIOVENOUS 10,162 MALFORMATION, OR CAROTID-CAVERNOUS FISTULA BY DISSECTION WITHIN CAVERNOUS SINUS CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 7,761 LESION OF BASE OF POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN, FORAMEN MAGNUM, OR C1-C3 VERTEBRAL BODIES; EXTRADURAL CPT RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 10,333 LESION OF BASE OF POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN, FORAMEN MAGNUM, OR C1-C3 VERTEBRAL BODIES; INTRADURAL, INCLUDING DURAL REPAIR, WITH OR WITHOUT GRAFT CPT SECONDARY REPAIR OF DURA FOR CEREBROSPINAL FLUID LEAK, 4,120 ANTERIOR, MIDDLE OR POSTERIOR CRANIAL FOSSA FOLLOWING SURGERY OF THE SKULL BASE; BY FREE TISSUE GRAFT (EG, PERICRANIUM, FASCIA, TENSOR FASCIA LATA, ADIPOSE TISSUE, HOMOLOGOUS OR SYNTHETIC GRAFTS) CPT SECONDARY REPAIR OF DURA FOR CEREBROSPINAL FLUID LEAK, 4,736 ANTERIOR, MIDDLE OR POSTERIOR CRANIAL FOSSA FOLLOWING SURGERY OF THE SKULL BASE; BY LOCAL OR REGIONALIZED VASCULARIZED PEDICLE FLAP OR MYOCUTANEOUS FLAP (INCLUDING GALEA, TEMPORALIS, FRONTALIS OR OCCIPITALIS MUSCLE) CPT ENDOVASCULAR TEMPORARY BALLOON ARTERIAL OCCLUSION, HEAD OR NECK (EXTRACRANIAL/INTRACRANIAL) INCLUDING SELECTIVE CATHETERIZATION OF VESSEL TO BE OCCLUDED, POSITIONING AND 1,852 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 203 of 380

204 INFLATION OF OCCLUSION BALLOON, CONCOMITANT NEUROLOGICAL MONITORING, AND RADIOLOGIC SUPERVISION AND INTERPRETATION OF ALL ANGIOGRAPHY REQUIRED FOR BALLOON OCCLUSION AND TO EXCLUDE VASCULAR INJURY POST OCCLUSION CPT TRANSCATHETER PERMANENT OCCLUSION OR EMBOLIZATION (EG, FOR 3,696 TUMOR DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD; CENTRAL NERVOUS SYSTEM (INTRACRANIAL, SPINAL CORD) CPT TRANSCATHETER PERMANENT OCCLUSION OR EMBOLIZATION (EG, FOR 2,996 TUMOR DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD; NON- CENTRAL NERVOUS SYSTEM, HEAD OR NECK (EXTRACRANIAL, BRACHIOCEPHALIC BRANCH) CPT BALLOON ANGIOPLASTY, INTRACRANIAL (EG, ATHEROSCLEROTIC 3,842 STENOSIS), PERCUTANEOUS CPT TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), 4,209 INTRACRANIAL (EG, ATHEROSCLEROTIC STENOSIS), INCLUDING BALLOON ANGIOPLASTY, IF PERFORMED CPT BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; 1,996 INITIAL VESSEL CPT BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; 702 EACH ADDITIONAL VESSEL IN SAME VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; 1,403 EACH ADDITIONAL VESSEL IN DIFFERENT VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 7,187 SUPRATENTORIAL, SIMPLE CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 13,436 SUPRATENTORIAL, COMPLEX CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 9,085 INFRATENTORIAL, SIMPLE CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 14,412 INFRATENTORIAL, COMPLEX CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, 6,877 SIMPLE CPT SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, 11,606 COMPLEX CPT SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 13,179 APPROACH; CAROTID CIRCULATION CPT SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 14,170 APPROACH; VERTEBROBASILAR CIRCULATION CPT SURGERY OF SIMPLE INTRACRANIAL ANEURYSM, INTRACRANIAL 11,012 APPROACH; CAROTID CIRCULATION CPT SURGERY OF SIMPLE INTRACRANIAL ANEURYSM, INTRACRANIAL 12,354 APPROACH; VERTEBROBASILAR CIRCULATION CPT SURGERY OF INTRACRANIAL ANEURYSM, CERVICAL APPROACH BY 4,131 APPLICATION OF OCCLUDING CLAMP TO CERVICAL CAROTID ARTERY (SELVERSTONE-CRUTCHFIELD TYPE) CPT SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- 8,201 CAVERNOUS FISTULA; BY INTRACRANIAL AND CERVICAL OCCLUSION OF CAROTID ARTERY CPT SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- 6,853 CAVERNOUS FISTULA; BY INTRACRANIAL ELECTROTHROMBOSIS CPT SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- CAVERNOUS FISTULA; BY INTRA-ARTERIAL EMBOLIZATION, INJECTION PROCEDURE, OR BALLOON CATHETER 6,230 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 204 of 380

205 CPT ANASTOMOSIS, ARTERIAL, EXTRACRANIAL-INTRACRANIAL (EG, MIDDLE 8,323 CEREBRAL/CORTICAL) ARTERIES CPT CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR 3,549 HOLE(S) AND LOCALIZING AND RECORDING TECHNIQUES, SINGLE OR MULTIPLE STAGES; GLOBUS PALLIDUS OR THALAMUS CPT CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR 4,294 HOLE(S) AND LOCALIZING AND RECORDING TECHNIQUES, SINGLE OR MULTIPLE STAGES; SUBCORTICAL STRUCTURE(S) OTHER THAN GLOBUS PALLIDUS OR THALAMUS CPT STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR 4,455 HOLE(S), FOR INTRACRANIAL LESION; CPT STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR 4,351 HOLE(S), FOR INTRACRANIAL LESION; WITH COMPUTED TOMOGRAPHY AND/OR MAGNETIC RESONANCE GUIDANCE CPT STEREOTACTIC IMPLANTATION OF DEPTH ELECTRODES INTO THE 4,999 CEREBRUM FOR LONG-TERM SEIZURE MONITORING CPT STEREOTACTIC LOCALIZATION, INCLUDING BURR HOLE(S), WITH 4,598 INSERTION OF CATHETER(S) OR PROBE(S) FOR PLACEMENT OF RADIATION SOURCE CPT CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY 2,771 NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); GASSERIAN GANGLION CPT CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY 3,388 NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); TRIGEMINAL MEDULLARY TRACT CPT STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY OR LINEAR 3,997 ACCELERATOR), ONE OR MORE SESSIONS CPT STEREOTACTIC COMPUTER-ASSISTED VOLUMETRIC (NAVIGATIONAL) 786 PROCEDURE, INTRACRANIAL, EXTRACRANIAL, OR SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF 3,067 NEUROSTIMULATOR ELECTRODES, CORTICAL CPT CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF 4,872 NEUROSTIMULATOR ELECTRODES, CEREBRAL, CORTICAL CPT TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY WITH 4,834 STEREOTACTIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG, THALAMUS, GLOBUS PALLIDUS, SUBTHALAMIC NUCLEUS, PERIVENTRICULAR, PERIAQUEDUCTAL GRAY), WITHOUT USE OF INTRAOPERATIVE MICROELECTRODE RECORDING; FIRST ARRAY CPT TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY WITH 1,460 STEREOTACTIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG, THALAMUS, GLOBUS PALLIDUS, SUBTHALAMIC NUCLEUS, PERIVENTRICULAR, PERIAQUEDUCTAL GRAY), WITHOUT USE OF INTRAOPERATIVE MICROELECTRODE RECORDING; EACH ADDITIONAL ARRAY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY WITH 6,882 STEREOTACTIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG, THALAMUS, GLOBUS PALLIDUS, SUBTHALAMIC NUCLEUS, PERIVENTRICULAR, PERIAQUEDUCTAL GRAY), WITH USE OF INTRAOPERATIVE MICROELECTRODE RECORDING; FIRST ARRAY CPT TWIST DRILL, BURR HOLE, CRANIOTOMY, OR CRANIECTOMY WITH STEREOTACTIC IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY IN SUBCORTICAL SITE (EG, THALAMUS, GLOBUS PALLIDUS, SUBTHALAMIC NUCLEUS, PERIVENTRICULAR, PERIAQUEDUCTAL GRAY), WITH USE OF INTRAOPERATIVE MICROELECTRODE RECORDING; EACH ADDITIONAL ARRAY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) 2,049 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 205 of 380

206 CPT CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 3,750 CEREBELLAR; CORTICAL CPT CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 3,101 CEREBELLAR; SUBCORTICAL CPT REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR 1,725 ELECTRODES CPT INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE 2,016 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO A SINGLE ELECTRODE ARRAY CPT INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE 2,545 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO TWO OR MORE ELECTRODE ARRAYS CPT REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE 1,258 GENERATOR OR RECEIVER CPT ELEVATION OF DEPRESSED SKULL FRACTURE; SIMPLE, EXTRADURAL 2,832 CPT ELEVATION OF DEPRESSED SKULL FRACTURE; COMPOUND OR 3,900 COMMINUTED, EXTRADURAL CPT ELEVATION OF DEPRESSED SKULL FRACTURE; WITH REPAIR OF DURA 4,814 AND/OR DEBRIDEMENT OF BRAIN CPT CRANIOTOMY FOR REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK, 5,076 INCLUDING SURGERY FOR RHINORRHEA/OTORRHEA CPT REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,300 NOT REQUIRING BONE GRAFTS OR CRANIOPLASTY CPT REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,583 WITH SIMPLE CRANIOPLASTY CPT REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,730 REQUIRING CRANIOTOMY AND RECONSTRUCTION WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFTS) CPT REPAIR OF ENCEPHALOCELE, SKULL VAULT, INCLUDING CRANIOPLASTY 5,628 CPT CRANIOTOMY FOR REPAIR OF ENCEPHALOCELE, SKULL BASE 5,203 CPT CRANIOPLASTY FOR SKULL DEFECT; UP TO 5 CM DIAMETER 3,343 CPT CRANIOPLASTY FOR SKULL DEFECT; LARGER THAN 5 CM DIAMETER 3,659 CPT REMOVAL OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 2,800 CPT REPLACEMENT OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 3,291 CPT CRANIOPLASTY FOR SKULL DEFECT WITH REPARATIVE BRAIN SURGERY 4,373 CPT CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); UP TO 5 CM DIAMETER CPT CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); LARGER THAN 5 CM DIAMETER CPT INCISION AND RETRIEVAL OF SUBCUTANEOUS CRANIAL BONE GRAFT FOR CRANIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT NEUROENDOSCOPY, INTRACRANIAL, FOR PLACEMENT OR REPLACEMENT OF VENTRICULAR CATHETER AND ATTACHMENT TO SHUNT SYSTEM OR EXTERNAL DRAINAGE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT NEUROENDOSCOPY, INTRACRANIAL; WITH DISSECTION OF ADHESIONS, FENESTRATION OF SEPTUM PELLUCIDUM OR INTRAVENTRICULAR CYSTS (INCLUDING PLACEMENT, REPLACEMENT, OR REMOVAL OF VENTRICULAR 3,816 4, ,838 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 206 of 380

207 CATHETER) CPT NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR EXCISION 5,944 OF COLLOID CYST, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE CPT NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY 3,733 CPT NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF BRAIN TUMOR, 6,366 INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE CPT NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY 4,769 TUMOR, TRANSNASAL OR TRANS-SPHENOIDAL APPROACH CPT VENTRICULOCISTERNOSTOMY (TORKILDSEN TYPE OPERATION) 5,009 CPT CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-ATRIAL, -JUGULAR, - 2,799 AURICULAR CPT CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-PERITONEAL, - 3,057 PLEURAL, OTHER TERMINUS CPT REPLACEMENT OR IRRIGATION, SUBARACHNOID/SUBDURAL CATHETER 1,225 CPT VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; 4,347 CPT VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; STEREOTACTIC, 3,766 NEUROENDOSCOPIC METHOD CPT CREATION OF SHUNT; VENTRICULO-ATRIAL, -JUGULAR, -AURICULAR 3,268 CPT CREATION OF SHUNT; VENTRICULO-PERITONEAL, -PLEURAL, OTHER 3,322 TERMINUS CPT REPLACEMENT OR IRRIGATION, VENTRICULAR CATHETER 1,633 CPT REPLACEMENT OR REVISION OF CEREBROSPINAL FLUID SHUNT, 2,677 OBSTRUCTED VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM CPT REPROGRAMMING OF PROGRAMMABLE CEREBROSPINAL SHUNT 342 CPT REMOVAL OF COMPLETE CEREBROSPINAL FLUID SHUNT SYSTEM; 1,877 WITHOUT REPLACEMENT CPT REMOVAL OF COMPLETE CEREBROSPINAL FLUID SHUNT SYSTEM; WITH 3,597 REPLACEMENT BY SIMILAR OR OTHER SHUNT AT SAME OPERATION CPT PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION 2,049 INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS CPT PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION 1,298 INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 1 DAY CPT PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX 1,492 CPT BIOPSY OF SPINAL CORD, PERCUTANEOUS NEEDLE 1,463 CPT SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC 484 CPT SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY NEEDLE OR CATHETER) 586 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 207 of 380

208 CPT INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH 497 CPT INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 951 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; SUBARACHNOID CPT INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 872 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC CPT INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 828 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL) CPT INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED 687 TOMOGRAPHY, SPINAL (OTHER THAN C1-C2 AND POSTERIOR FOSSA) CPT ASPIRATION OR DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF 1,731 NUCLEUS PULPOSUS OF INTERVERTEBRAL DISC, ANY METHOD, SINGLE OR MULTIPLE LEVELS, LUMBAR (EG, MANUAL OR AUTOMATED PERCUTANEOUS DISCECTOMY, PERCUTANEOUS LASER DISCECTOMY) CPT INJECTION PROCEDURE FOR DISCOGRAPHY, EACH LEVEL; LUMBAR 972 CPT INJECTION PROCEDURE FOR DISCOGRAPHY, EACH LEVEL; CERVICAL OR THORACIC CPT INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS, INCLUDING DISCOGRAPHY, INTERVERTEBRAL DISC, SINGLE OR MULTIPLE LEVELS, LUMBAR CPT INJECTION PROCEDURE, ARTERIAL, FOR OCCLUSION OF ARTERIOVENOUS MALFORMATION, SPINAL CPT INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC CPT INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), EPIDURAL OR SUBARACHNOID; LUMBAR, SACRAL (CAUDAL) CPT INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), EPIDURAL OR SUBARACHNOID; CERVICAL OR THORACIC CPT INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), EPIDURAL OR SUBARACHNOID; LUMBAR, SACRAL (CAUDAL) CPT IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY CPT IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE 932 1,614 2, ,642 2,698 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 208 of 380

209 RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY CPT REMOVAL OF PREVIOUSLY IMPLANTED INTRATHECAL OR EPIDURAL CATHETER CPT IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR CPT IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP CPT IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING CPT REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION CPT ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; CERVICAL CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; THORACIC CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), 1 OR 2 VERTEBRAL SEGMENTS; SACRAL CPT LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS WITH DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LUMBAR (GILL TYPE PROCEDURE) CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC CPT LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, FORAMINOTOMY OR DISCECTOMY (EG, SPINAL STENOSIS), MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; ONE INTERSPACE, CERVICAL 1, ,442 1,813 1, ,908 3,914 3,696 3,545 3,772 4,696 4,800 3,923 3,732 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 209 of 380

210 CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 3,101 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; ONE INTERSPACE, LUMBAR (INCLUDING OPEN OR ENDOSCOPICALLY-ASSISTED APPROACH) CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 645 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 4,517 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; CERVICAL CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 4,211 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; LUMBAR CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 1,881 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL CERVICAL INTERSPACE (LIST SEPARATELY IN ADDI CPT LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE 1,786 ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC, REEXPLORATION, SINGLE INTERSPACE; EACH ADDITIONAL LUMBAR INTERSPACE (LIST SEPARATELY IN ADDITI CPT LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR 4,046 BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; CERVICAL CPT LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR 3,835 BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; THORACIC CPT LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR 3,499 BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; LUMBAR CPT LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR 693 BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT[S], [EG, SPINAL OR LATERAL RECESS STENOSIS]), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT, CERVICAL, THORACIC, OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 4,829 TWO OR MORE VERTEBRAL SEGMENTS; CPT LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 5,428 TWO OR MORE VERTEBRAL SEGMENTS; WITH RECONSTRUCTION OF THE POSTERIOR BONY ELEMENTS (INCLUDING THE APPLICATION OF BRIDGING BONE GRAFT AND NON-SEGMENTAL FIXATION DEVICES (EG, WIRE, SUTURE, MINI-PLATES), WHEN PERFORMED) CPT TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, 5,180 EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC CPT TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL 4,766 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 210 of 380

211 DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC) CPT TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, 1,063 EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; EACH ADDITIONAL SEGMENT, THORACIC OR LUMBAR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD 5,666 OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), THORACIC; SINGLE SEGMENT CPT COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD 649 OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), THORACIC; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 4,419 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE CPT DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 820 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 4,760 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE CPT DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 648 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 5,666 COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 883 COMPLETE, ANTERIOR APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVICAL, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 5,962 COMPLETE, TRANSTHORACIC APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); THORACIC, SINGLE SEGMENT CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 623 COMPLETE, TRANSTHORACIC APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); THORACIC, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,583 COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; SINGLE SEGMENT CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 847 COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; SINGLE SEGMENT 6,216 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 211 of 380

212 CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 585 COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,133 COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); THORACIC, SINGLE SEGMENT CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,106 COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); LUMBAR, SINGLE SEGMENT CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 912 COMPLETE, LATERAL EXTRACAVITARY APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S) (EG, FOR TUMOR OR RETROPULSED BONE FRAGMENTS); THORACIC OR LUMBAR, EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT LAMINECTOMY WITH MYELOTOMY (EG, BISCHOF OR DREZ TYPE), 4,706 CERVICAL, THORACIC, OR THORACOLUMBAR CPT LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 4,433 SUBARACHNOID SPACE CPT LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 5,469 PERITONEAL OR PLEURAL SPACE CPT LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR 4,444 WITHOUT DURAL GRAFT, CERVICAL; ONE OR TWO SEGMENTS CPT LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR 4,429 WITHOUT DURAL GRAFT, CERVICAL; MORE THAN TWO SEGMENTS CPT LAMINECTOMY WITH RHIZOTOMY; ONE OR TWO SEGMENTS 3,645 CPT LAMINECTOMY WITH RHIZOTOMY; MORE THAN TWO SEGMENTS 3,978 CPT LAMINECTOMY WITH SECTION OF SPINAL ACCESSORY NERVE 3,681 CPT LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE 4,586 SPINOTHALAMIC TRACT, ONE STAGE; CERVICAL CPT LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE 4,848 SPINOTHALAMIC TRACT, ONE STAGE; THORACIC CPT LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH 5,627 SPINOTHALAMIC TRACTS, ONE STAGE; CERVICAL CPT LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH 4,632 SPINOTHALAMIC TRACTS, ONE STAGE; THORACIC CPT LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH 5,680 SPINOTHALAMIC TRACTS, TWO STAGES WITHIN 14 DAYS; CERVICAL CPT LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH 5,287 SPINOTHALAMIC TRACTS, TWO STAGES WITHIN 14 DAYS; THORACIC CPT LAMINECTOMY, WITH RELEASE OF TETHERED SPINAL CORD, LUMBAR 4,830 CPT LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; CERVICAL CPT LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACIC CPT LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACOLUMBAR CPT LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM, EXTRADURAL; CERVICAL 9,274 9,624 9,568 5,302 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 212 of 380

213 CPT LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 5,448 OTHER THAN NEOPLASM, EXTRADURAL; THORACIC CPT LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 4,384 OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR CPT LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 4,385 OTHER THAN NEOPLASM, EXTRADURAL; SACRAL CPT LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,528 NEOPLASM, INTRADURAL; CERVICAL CPT LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,549 NEOPLASM, INTRADURAL; THORACIC CPT LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,024 NEOPLASM, INTRADURAL; LUMBAR CPT LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 5,812 NEOPLASM, INTRADURAL; SACRAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,700 EXTRADURAL, CERVICAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,655 EXTRADURAL, THORACIC CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 4,961 EXTRADURAL, LUMBAR CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 4,842 EXTRADURAL, SACRAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,710 INTRADURAL, EXTRAMEDULLARY, CERVICAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,658 INTRADURAL, EXTRAMEDULLARY, THORACIC CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,267 INTRADURAL, EXTRAMEDULLARY, LUMBAR CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,987 INTRADURAL, SACRAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,207 INTRADURAL, INTRAMEDULLARY, CERVICAL CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,234 INTRADURAL, INTRAMEDULLARY, THORACIC CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,681 INTRADURAL, INTRAMEDULLARY, THORACOLUMBAR CPT LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,686 COMBINED EXTRADURAL-INTRADURAL LESION, ANY LEVEL CPT OSTEOPLASTIC RECONSTRUCTION OF DORSAL SPINAL ELEMENTS, 1,035 FOLLOWING PRIMARY INTRASPINAL PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 5,847 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, CERVICAL CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,424 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY TRANSTHORACIC APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,335 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY THORACOLUMBAR APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,684 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, CERVICAL 7,263 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 213 of 380

214 CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,402 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY TRANSTHORACIC APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,602 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY THORACOLUMBAR APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,810 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH CPT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 1,067 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODES FOR SINGLE SEGMENT) CPT CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, 2,589 PERCUTANEOUS, ANY MODALITY (INCLUDING STIMULATION AND/OR RECORDING) CPT STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, 2,961 SEPARATE PROCEDURE NOT FOLLOWED BY OTHER SURGERY CPT STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION OF LESION, SPINAL 3,599 CORD CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE 1,387 ARRAY, EPIDURAL CPT LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 2,706 PLATE/PADDLE, EPIDURAL CPT REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE 1,393 PERCUTANEOUS ARRAY(S) OR PLATE/PADDLE(S) CPT INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE 1,582 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING CPT REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE 1,324 GENERATOR OR RECEIVER CPT REPAIR OF MENINGOCELE; LESS THAN 5 CM DIAMETER 3,876 CPT REPAIR OF MENINGOCELE; LARGER THAN 5 CM DIAMETER 4,200 CPT REPAIR OF MYELOMENINGOCELE; LESS THAN 5 CM DIAMETER 4,842 CPT REPAIR OF MYELOMENINGOCELE; LARGER THAN 5 CM DIAMETER 5,752 CPT REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK, NOT REQUIRING 2,878 LAMINECTOMY CPT REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR 3,472 PSEUDOMENINGOCELE, WITH LAMINECTOMY CPT DURAL GRAFT, SPINAL 3,507 CPT CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, 2,985 OR OTHER; INCLUDING LAMINECTOMY CPT CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, 1,964 OR OTHER; PERCUTANEOUS, NOT REQUIRING LAMINECTOMY CPT REPLACEMENT, IRRIGATION OR REVISION OF LUMBOSUBARACHNOID 2,079 SHUNT CPT REMOVAL OF ENTIRE LUMBOSUBARACHNOID SHUNT SYSTEM WITHOUT 1,821 REPLACEMENT CPT INJECTION, ANESTHETIC AGENT; TRIGEMINAL NERVE, ANY DIVISION OR 327 BRANCH CPT INJECTION, ANESTHETIC AGENT; FACIAL NERVE 346 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 214 of 380

215 CPT INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE 322 CPT INJECTION, ANESTHETIC AGENT; VAGUS NERVE 372 CPT INJECTION, ANESTHETIC AGENT; PHRENIC NERVE 432 CPT INJECTION, ANESTHETIC AGENT; SPINAL ACCESSORY NERVE 426 CPT INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS 351 CPT INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE 375 CPT INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, CONTINUOUS 581 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT INJECTION, ANESTHETIC AGENT; AXILLARY NERVE 375 CPT INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE 412 CPT INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE 460 CPT INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, 672 REGIONAL BLOCK CPT INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC 399 NERVES CPT INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE 497 CPT INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE 454 CPT INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE 404 CPT INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS 539 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE 221 CPT INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS 494 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR 479 APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 337 CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 215 of 380

216 PRIMARY PROCEDURE) CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 764 EPIDURAL; CERVICAL OR THORACIC, SINGLE LEVEL CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 401 EPIDURAL; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 733 EPIDURAL; LUMBAR OR SACRAL, SINGLE LEVEL CPT INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 382 EPIDURAL; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION 326 CPT INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE 406 PROCEDURE) CPT INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL 401 SYMPATHETIC) CPT INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS 507 CPT INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL 503 SYMPATHETIC) CPT INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT 562 RADIOLOGIC MONITORING CPT APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR 49 CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 649 CRANIAL NERVE CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 662 PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 630 AUTONOMIC NERVE CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 3,422 SACRAL NERVE (TRANSFORAMINAL PLACEMENT) CPT PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 551 NEUROMUSCULAR CPT INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 1,876 CRANIAL NERVE CPT INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 886 PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) CPT INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 1,317 AUTONOMIC NERVE CPT INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 907 NEUROMUSCULAR CPT INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 2,743 SACRAL NERVE (TRANSFORAMINAL PLACEMENT) CPT REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODES 1,032 CPT INSERTION OR REPLACEMENT OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING CPT REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER CPT DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SUPRAORBITAL, INFRAORBITAL, MENTAL, OR INFERIOR ALVEOLAR BRANCH 1,135 1,056 1,161 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 216 of 380

217 CPT DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND 1,715 THIRD DIVISION BRANCHES AT FORAMEN OVALE CPT DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND 2,256 THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING CPT CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL 461 NERVE (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM) CPT CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S) (EG, FOR 435 SPASMODIC TORTICOLLIS, SPASMODIC DYSPHONIA) CPT CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S) AND/OR TRUNK 493 MUSCLE(S) (EG, FOR DYSTONIA, CEREBRAL PALSY, MULTIPLE SCLEROSIS) CPT DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE 800 CPT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 913 NERVE; LUMBAR OR SACRAL, SINGLE LEVEL CPT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 343 NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 1,102 NERVE; CERVICAL OR THORACIC, SINGLE LEVEL CPT DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 453 NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT DESTRUCTION BY NEUROLYTIC AGENT; PUDENDAL NERVE 755 CPT DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR 691 BRANCH CPT CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE 186 CPT CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, 215 FACE, NECK), PER DAY CPT DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC 889 MONITORING; CELIAC PLEXUS CPT DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC 1,117 MONITORING; SUPERIOR HYPOGASTRIC PLEXUS CPT NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME DIGIT 1,497 CPT NEUROPLASTY; NERVE OF HAND OR FOOT 1,069 CPT NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; OTHER THAN 1,432 SPECIFIED CPT NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; SCIATIC NERVE 1,675 CPT NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; BRACHIAL 2,412 PLEXUS CPT NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; LUMBAR PLEXUS 2,013 CPT NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY) 1,630 CPT NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW 1,801 CPT NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST 1,233 CPT NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL 1,293 TUNNEL CPT DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY) 1,034 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 217 of 380

218 CPT DECOMPRESSION; PLANTAR DIGITAL NERVE 950 CPT INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE 600 (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS) CPT TRANSECTION OR AVULSION OF; SUPRAORBITAL NERVE 1,189 CPT TRANSECTION OR AVULSION OF; INFRAORBITAL NERVE 1,356 CPT TRANSECTION OR AVULSION OF; MENTAL NERVE 1,179 CPT TRANSECTION OR AVULSION OF; INFERIOR ALVEOLAR NERVE BY 1,509 OSTEOTOMY CPT TRANSECTION OR AVULSION OF; LINGUAL NERVE 1,484 CPT TRANSECTION OR AVULSION OF; FACIAL NERVE, DIFFERENTIAL OR 1,480 COMPLETE CPT TRANSECTION OR AVULSION OF; GREATER OCCIPITAL NERVE 1,364 CPT TRANSECTION OR AVULSION OF; PHRENIC NERVE 1,402 CPT TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), 1,549 TRANSTHORACIC CPT TRANSECTION OR AVULSION OF; VAGUS NERVES LIMITED TO PROXIMAL 2,808 STOMACH (SELECTIVE PROXIMAL VAGOTOMY, PROXIMAL GASTRIC VAGOTOMY, PARIETAL CELL VAGOTOMY, SUPRA- OR HIGHLY SELECTIVE VAGOTOMY) CPT TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), 1,520 ABDOMINAL CPT TRANSECTION OR AVULSION OF; PUDENDAL NERVE 1,485 CPT TRANSECTION OR AVULSION OF OBTURATOR NERVE, EXTRAPELVIC, WITH 1,549 OR WITHOUT ADDUCTOR TENOTOMY CPT TRANSECTION OR AVULSION OF OBTURATOR NERVE, INTRAPELVIC, WITH 1,905 OR WITHOUT ADDUCTOR TENOTOMY CPT TRANSECTION OR AVULSION OF OTHER CRANIAL NERVE, EXTRADURAL 1,874 CPT TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL 1,794 CPT EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE 1,317 CPT EXCISION OF NEUROMA; DIGITAL NERVE, ONE OR BOTH, SAME DIGIT 1,259 CPT EXCISION OF NEUROMA; DIGITAL NERVE, EACH ADDITIONAL DIGIT (LIST 601 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EXCISION OF NEUROMA; HAND OR FOOT, EXCEPT DIGITAL NERVE 1,490 CPT EXCISION OF NEUROMA; HAND OR FOOT, EACH ADDITIONAL NERVE, 703 EXCEPT SAME DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT EXCISION OF NEUROMA; MAJOR PERIPHERAL NERVE, EXCEPT SCIATIC 2,300 CPT EXCISION OF NEUROMA; SCIATIC NERVE 3,419 CPT IMPLANTATION OF NERVE END INTO BONE OR MUSCLE (LIST SEPARATELY IN ADDITION TO NEUROMA EXCISION) 819 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 218 of 380

219 CPT EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; CUTANEOUS NERVE 1,249 CPT EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; MAJOR PERIPHERAL 2,650 NERVE CPT EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; EXTENSIVE 3,335 (INCLUDING MALIGNANT TYPE) CPT BIOPSY OF NERVE 624 CPT SYMPATHECTOMY, CERVICAL 1,893 CPT SYMPATHECTOMY, CERVICOTHORACIC 3,008 CPT SYMPATHECTOMY, THORACOLUMBAR 2,913 CPT SYMPATHECTOMY, LUMBAR 2,125 CPT SYMPATHECTOMY; DIGITAL ARTERIES, EACH DIGIT 2,400 CPT SYMPATHECTOMY; RADIAL ARTERY 2,136 CPT SYMPATHECTOMY; ULNAR ARTERY 2,129 CPT SYMPATHECTOMY; SUPERFICIAL PALMAR ARCH 2,371 CPT SUTURE OF DIGITAL NERVE, HAND OR FOOT; ONE NERVE 2,298 CPT SUTURE OF DIGITAL NERVE, HAND OR FOOT; EACH ADDITIONAL DIGITAL 1,110 NERVE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUTURE OF ONE NERVE; HAND OR FOOT, COMMON SENSORY NERVE 2,353 CPT SUTURE OF ONE NERVE; MEDIAN MOTOR THENAR 2,548 CPT SUTURE OF ONE NERVE; ULNAR MOTOR 2,561 CPT SUTURE OF EACH ADDITIONAL NERVE, HAND OR FOOT (LIST SEPARATELY 1,232 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUTURE OF POSTERIOR TIBIAL NERVE 2,864 CPT SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; 3,215 INCLUDING TRANSPOSITION CPT SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; 3,356 WITHOUT TRANSPOSITION CPT SUTURE OF SCIATIC NERVE 3,851 CPT SUTURE OF EACH ADDITIONAL MAJOR PERIPHERAL NERVE (LIST 839 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUTURE OF; BRACHIAL PLEXUS 4,385 CPT SUTURE OF; LUMBAR PLEXUS 4,455 CPT SUTURE OF FACIAL NERVE; EXTRACRANIAL 2,774 CPT SUTURE OF FACIAL NERVE; INFRATEMPORAL, WITH OR WITHOUT 3,648 GRAFTING CPT ANASTOMOSIS; FACIAL-SPINAL ACCESSORY 3,758 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 219 of 380

220 CPT ANASTOMOSIS; FACIAL-HYPOGLOSSAL 3,275 CPT ANASTOMOSIS; FACIAL-PHRENIC 3,311 CPT SUTURE OF NERVE; REQUIRING SECONDARY OR DELAYED SUTURE (LIST 385 SEPARATELY IN ADDITION TO CODE FOR PRIMARY NEURORRHAPHY) CPT SUTURE OF NERVE; REQUIRING EXTENSIVE MOBILIZATION, OR 586 TRANSPOSITION OF NERVE (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE SUTURE) CPT SUTURE OF NERVE; REQUIRING SHORTENING OF BONE OF EXTREMITY 663 (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE SUTURE) CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; UP TO 4 3,534 CM IN LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; MORE 4,177 THAN 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR 3,447 FOOT; UP TO 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR 3,589 FOOT; MORE THAN 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR 3,426 LEG; UP TO 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR 3,648 LEG; MORE THAN 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,264 (CABLE), HAND OR FOOT; UP TO 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,613 (CABLE), HAND OR FOOT; MORE THAN 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,065 (CABLE), ARM OR LEG; UP TO 4 CM LENGTH CPT NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,412 (CABLE), ARM OR LEG; MORE THAN 4 CM LENGTH CPT NERVE GRAFT, EACH ADDITIONAL NERVE; SINGLE STRAND (LIST 1,913 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT NERVE GRAFT, EACH ADDITIONAL NERVE; MULTIPLE STRANDS (CABLE) 2,268 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT NERVE PEDICLE TRANSFER; FIRST STAGE 3,019 CPT NERVE PEDICLE TRANSFER; SECOND STAGE 3,703 CPT NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, 2,216 NERVE TUBE), EACH NERVE CPT NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT (INCLUDES HARVEST OF 2,698 VEIN GRAFT), EACH NERVE CPT UNLISTED PROCEDURE, NERVOUS SYSTEM N/A CPT EVISCERATION OF OCULAR CONTENTS; WITHOUT IMPLANT 1,784 CPT EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT 1,769 CPT ENUCLEATION OF EYE; WITHOUT IMPLANT 2,065 CPT ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES NOT ATTACHED TO 2,156 IMPLANT CPT ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT 2,377 CPT EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL OF ORBITAL CONTENTS; ONLY 3,480 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 220 of 380

221 CPT EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL 4,126 OF ORBITAL CONTENTS; WITH THERAPEUTIC REMOVAL OF BONE CPT EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL 4,268 OF ORBITAL CONTENTS; WITH MUSCLE OR MYOCUTANEOUS FLAP CPT MODIFICATION OF OCULAR IMPLANT WITH PLACEMENT OR REPLACEMENT 1,268 OF PEGS (EG, DRILLING RECEPTACLE FOR PROSTHESIS APPENDAGE) (SEPARATE PROCEDURE) CPT INSERTION OF OCULAR IMPLANT SECONDARY; AFTER EVISCERATION, IN 2,045 SCLERAL SHELL CPT INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, 2,076 MUSCLES NOT ATTACHED TO IMPLANT CPT INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, 2,266 MUSCLES ATTACHED TO IMPLANT CPT REINSERTION OF OCULAR IMPLANT; WITH OR WITHOUT CONJUNCTIVAL 1,626 GRAFT CPT REINSERTION OF OCULAR IMPLANT; WITH USE OF FOREIGN MATERIAL 2,409 FOR REINFORCEMENT AND/OR ATTACHMENT OF MUSCLES TO IMPLANT CPT REMOVAL OF OCULAR IMPLANT 1,833 CPT REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL 164 SUPERFICIAL CPT REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED 200 (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING CPT REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT 169 LAMP CPT REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP 220 CPT REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM ANTERIOR CHAMBER 2,005 OF EYE OR LENS CPT REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR 2,718 SEGMENT, MAGNETIC EXTRACTION, ANTERIOR OR POSTERIOR ROUTE CPT REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR 3,054 SEGMENT, NONMAGNETIC EXTRACTION CPT REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT 733 NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE CPT REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND 1,382 REARRANGEMENT, WITHOUT HOSPITALIZATION CPT REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND 1,083 REARRANGEMENT, WITH HOSPITALIZATION CPT REPAIR OF LACERATION; CORNEA, NONPERFORATING, WITH OR WITHOUT 1,598 REMOVAL FOREIGN BODY CPT REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, NOT 1,898 INVOLVING UVEAL TISSUE CPT REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, WITH 2,952 REPOSITION OR RESECTION OF UVEAL TISSUE CPT REPAIR OF LACERATION; APPLICATION OF TISSUE GLUE, WOUNDS OF 1,940 CORNEA AND/OR SCLERA CPT REPAIR OF WOUND, EXTRAOCULAR MUSCLE, TENDON AND/OR TENON'S 1,395 CAPSULE CPT EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), 1,889 EXCEPT PTERYGIUM CPT BIOPSY OF CORNEA 402 CPT EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT 1,422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 221 of 380

222 CPT EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT 1,796 CPT SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE 331 CPT REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT 229 CHEMOCAUTERIZATION (ABRASION, CURETTAGE) CPT REMOVAL OF CORNEAL EPITHELIUM; WITH APPLICATION OF CHELATING 1,093 AGENT (EG, EDTA) CPT DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY, 903 PHOTOCOAGULATION OR THERMOCAUTERIZATION CPT MULTIPLE PUNCTURES OF ANTERIOR CORNEA (EG, FOR CORNEAL 1,091 EROSION, TATTOO) CPT KERATOPLASTY (CORNEAL TRANSPLANT); LAMELLAR 3,126 CPT KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN 3,480 APHAKIA) CPT KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA) 3,518 CPT KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN 3,499 PSEUDOPHAKIA) CPT KERATOMILEUSIS 4,248 CPT KERATOPHAKIA 4,929 CPT EPIKERATOPLASTY 4,589 CPT KERATOPROSTHESIS 4,019 CPT RADIAL KERATOTOMY 2,497 CPT CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY 1,259 INDUCED ASTIGMATISM CPT CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY INDUCED 1,549 ASTIGMATISM CPT OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE 2,492 TRANSPLANTATION CPT OCULAR SURFACE RECONSTRUCTION; LIMBAL STEM CELL ALLOGRAFT 3,757 (EG, CADAVERIC OR LIVING DONOR) CPT OCULAR SURFACE RECONSTRUCTION; LIMBAL CONJUNCTIVAL AUTOGRAFT 3,246 (INCLUDES OBTAINING GRAFT) CPT PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 426 WITH DIAGNOSTIC ASPIRATION OF AQUEOUS CPT PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 465 WITH THERAPEUTIC RELEASE OF AQUEOUS CPT PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 1,330 WITH REMOVAL OF VITREOUS AND/OR DISCISSION OF ANTERIOR HYALOID MEMBRANE, WITH OR WITHOUT AIR INJECTION CPT PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 1,763 WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION CPT GONIOTOMY 2,091 CPT TRABECULOTOMY AB EXTERNO 2,401 CPT TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE SESSIONS (DEFINED TREATMENT SERIES) 954 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 222 of 380

223 CPT SEVERING ADHESIONS OF ANTERIOR SEGMENT, LASER TECHNIQUE 881 (SEPARATE PROCEDURE) CPT SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,337 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE CPT SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,664 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); ANTERIOR SYNECHIAE, EXCEPT GONIOSYNECHIAE CPT SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,769 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); POSTERIOR SYNECHIAE CPT SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,864 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); CORNEOVITREAL ADHESIONS CPT REMOVAL OF EPITHELIAL DOWNGROWTH, ANTERIOR CHAMBER OF EYE 2,730 CPT REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE 2,216 CPT REMOVAL OF BLOOD CLOT, ANTERIOR SEGMENT OF EYE 1,810 CPT INJECTION, ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); AIR OR 517 LIQUID CPT INJECTION, ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 455 MEDICATION CPT EXCISION OF LESION, SCLERA 1,967 CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; TREPHINATION WITH 2,448 IRIDECTOMY CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; THERMOCAUTERIZATION 2,440 WITH IRIDECTOMY CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; SCLERECTOMY WITH PUNCH 2,770 OR SCISSORS, WITH IRIDECTOMY CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; IRIDENCLEISIS OR 2,399 IRIDOTASIS CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB 3,361 EXTERNO IN ABSENCE OF PREVIOUS SURGERY CPT FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB 4,233 EXTERNO WITH SCARRING FROM PREVIOUS OCULAR SURGERY OR TRAUMA (INCLUDES INJECTION OF ANTIFIBROTIC AGENTS) CPT AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR (EG, MOLTENO, 3,325 SCHOCKET, DENVER-KRUPIN) CPT REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR 2,113 CPT REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GRAFT 2,083 CPT REPAIR OF SCLERAL STAPHYLOMA; WITH GRAFT 2,648 CPT REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE CPT IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION CPT IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); WITH TRANSFIXION AS FOR IRIS BOMBE CPT IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; FOR REMOVAL OF LESION 2, ,086 2,337 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 223 of 380

224 CPT IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; WITH 3,047 CYCLECTOMY CPT IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; PERIPHERAL 1,215 FOR GLAUCOMA (SEPARATE PROCEDURE) CPT IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; SECTOR 1,604 FOR GLAUCOMA (SEPARATE PROCEDURE) CPT IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; OPTICAL 1,619 (SEPARATE PROCEDURE) CPT REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS) 1,456 CPT SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH 1,783 RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE) CPT CILIARY BODY DESTRUCTION; DIATHERMY 1,268 CPT CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, 1,244 TRANSSCLERAL CPT CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, ENDOSCOPIC 1,798 CPT CILIARY BODY DESTRUCTION; CRYOTHERAPY 1,320 CPT CILIARY BODY DESTRUCTION; CYCLODIALYSIS 1,236 CPT IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (ONE 1,270 OR MORE SESSIONS) CPT IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) (EG, 1,331 FOR IMPROVEMENT OF VISION, FOR WIDENING OF ANTERIOR CHAMBER ANGLE) CPT DESTRUCTION OF CYST OR LESION IRIS OR CILIARY BODY 1,481 (NONEXCISIONAL PROCEDURE) CPT DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED 1,100 POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); STAB INCISION TECHNIQUE (ZIEGLER OR WHEELER KNIFE) CPT DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED 912 POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (ONE OR MORE STAGES) CPT REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN 2,138 INCISION (SEPARATE PROCEDURE) CPT REMOVAL OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED 2,013 POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID) WITH CORNEO- SCLERAL SECTION, WITH OR WITHOUT IRIDECTOMY (IRIDOCAPSULOTOMY, IRIDOCAPSULECTOMY) CPT REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, ONE OR MORE 1,971 STAGES CPT REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE 2,244 (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION CPT REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR 2,397 WITHOUT VITRECTOMY CPT REMOVAL OF LENS MATERIAL; INTRACAPSULAR 2,141 CPT REMOVAL OF LENS MATERIAL; INTRACAPSULAR, FOR DISLOCATED LENS 2,431 CPT REMOVAL OF LENS MATERIAL; EXTRACAPSULAR (OTHER THAN 66840, 66850, 66852) CPT EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR MECHANICAL 2,211 3,072 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 224 of 380

225 TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUTINE CATARACT SURGERY (EG, IRIS EXPANSION DEVICE, SUTURE SUPPORT FOR INTRAOCULAR LENS, OR PRIMARY POSTERIOR CAPSULORRHEXIS) OR PERFORMED ON PATIENTS IN THE AMBLYOGENIC DEVELOPMENTAL STAGE CPT INTRACAPSULAR CATARACT EXTRACTION WITH INSERTION OF 2,120 INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE) CPT EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR 2,163 LENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) CPT INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), 2,166 NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL CPT EXCHANGE OF INTRAOCULAR LENS 2,631 CPT USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO 266 CODE FOR PRIMARY PROCEDURE) CPT UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE N/A CPT REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR 1,336 LIMBAL INCISION); PARTIAL REMOVAL CPT REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR 1,544 LIMBAL INCISION); SUBTOTAL REMOVAL WITH MECHANICAL VITRECTOMY CPT ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL 1,641 FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY) CPT INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA OR LIMBAL APPROACH 2,027 (FLUID-GAS EXCHANGE), WITH OR WITHOUT ASPIRATION (SEPARATE PROCEDURE) CPT IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM (EG, 2,434 GANCICLOVIR IMPLANT), INCLUDES CONCOMITANT REMOVAL OF VITREOUS CPT INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE 602 PROCEDURE) CPT DISCISSION OF VITREOUS STRANDS (WITHOUT REMOVAL), PARS PLANA 1,478 APPROACH CPT SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, SHEETS, 1,083 MEMBRANES OR OPACITIES, LASER SURGERY (ONE OR MORE STAGES) CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; 2,735 CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER) CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF INTERNAL LIMITING MEMBRANE OF RETINA (EG, FOR REPAIR OF MACULAR HOLE, DIABETIC MACULAR EDEMA), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) CPT VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANE (EG, CHOROIDAL NEOVASCULARIZATION), INCLUDES, IF PERFORMED, INTRAOCULAR TAMPONADE (IE, AIR, GAS OR SILICONE OIL) AND LASER PHOTOCOAGULATION CPT REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; CRYOTHERAPY OR DIATHERMY, WITH OR WITHOUT DRAINAGE OF SUBRETINAL FLUID 3,497 4,037 3,805 4,357 4,572 2,197 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 225 of 380

226 CPT REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; 2,030 PHOTOCOAGULATION, WITH OR WITHOUT DRAINAGE OF SUBRETINAL FLUID CPT REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS 3,452 LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), WITH OR WITHOUT IMPLANT, WITH OR WITHOUT CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID CPT REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, 4,586 WITH OR WITHOUT AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE CPT REPAIR OF RETINAL DETACHMENT; BY INJECTION OF AIR OR OTHER GAS 2,439 (EG, PNEUMATIC RETINOPEXY) CPT REPAIR OF RETINAL DETACHMENT; BY SCLERAL BUCKLING OR 3,793 VITRECTOMY, ON PATIENT HAVING PREVIOUS IPSILATERAL RETINAL DETACHMENT REPAIR(S) USING SCLERAL BUCKLING OR VITRECTOMY TECHNIQUES CPT REPAIR OF COMPLEX RETINAL DETACHMENT (EG, PROLIFERATIVE 5,019 VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGREES), WITH VITRECTOMY AND MEMBRANE PEELING, MAY INCLUDE AIR, GAS, OR SILICONE OIL TAMPONADE, CRYOTHERAPY, ENDOLASER PHOTOCOAGULATION, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS CPT RELEASE OF ENCIRCLING MATERIAL (POSTERIOR SEGMENT) 1,397 CPT REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; 1,832 EXTRAOCULAR CPT REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR 2,577 CPT PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY CPT PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON ARC) CPT DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY CPT DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; PHOTOCOAGULATION CPT DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; RADIATION BY IMPLANTATION OF SOURCE (INCLUDES REMOVAL OF SOURCE) CPT DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTOCOAGULATION (EG, LASER), ONE OR MORE SESSIONS CPT DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC THERAPY (INCLUDES INTRAVENOUS INFUSION) CPT DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC THERAPY, SECOND EYE, AT SINGLE SESSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY EYE TREATMENT) CPT DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), ONE OR MORE SESSIONS, CRYOTHERAPY, DIATHERMY 1,468 1,482 1,695 1,976 3,996 3, ,725 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 226 of 380

227 CPT TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE OR 3,511 MORE SESSIONS; (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION CPT TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE OR 3,301 MORE SESSIONS; PRETERM INFANT (LESS THAN 37 WEEKS GESTATION AT BIRTH), PERFORMED FROM BIRTH UP TO 1 YEAR OF AGE (EG, RETINOPATHY OF PREMATURITY), PHOTOCOAGULATION OR CRYOTHERAPY CPT SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITHOUT GRAFT 2,214 CPT SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT 2,371 CPT UNLISTED PROCEDURE, POSTERIOR SEGMENT N/A CPT STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE 1,694 HORIZONTAL MUSCLE CPT STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO 2,026 HORIZONTAL MUSCLES CPT STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE 1,904 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE) CPT STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO OR 2,283 MORE VERTICAL MUSCLES (EXCLUDING SUPERIOR OBLIQUE) CPT STRABISMUS SURGERY, ANY PROCEDURE, SUPERIOR OBLIQUE MUSCLE 1,993 CPT TRANSPOSITION PROCEDURE (EG, FOR PARETIC EXTRAOCULAR MUSCLE), 949 ANY EXTRAOCULAR MUSCLE (SPECIFY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT STRABISMUS SURGERY ON PATIENT WITH PREVIOUS EYE SURGERY OR 899 INJURY THAT DID NOT INVOLVE THE EXTRAOCULAR MUSCLES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT STRABISMUS SURGERY ON PATIENT WITH SCARRING OF EXTRAOCULAR 976 MUSCLES (EG, PRIOR OCULAR INJURY, STRABISMUS OR RETINAL DETACHMENT SURGERY) OR RESTRICTIVE MYOPATHY (EG, DYSTHYROID OPHTHALMOPATHY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT STRABISMUS SURGERY BY POSTERIOR FIXATION SUTURE TECHNIQUE, 887 WITH OR WITHOUT MUSCLE RECESSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PLACEMENT OF ADJUSTABLE SUTURE(S) DURING STRABISMUS SURGERY, 440 INCLUDING POSTOPERATIVE ADJUSTMENT(S) OF SUTURE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR SPECIFIC STRABISMUS SURGERY) CPT STRABISMUS SURGERY INVOLVING EXPLORATION AND/OR REPAIR OF 1,056 DETACHED EXTRAOCULAR MUSCLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT RELEASE OF EXTENSIVE SCAR TISSUE WITHOUT DETACHING 1,852 EXTRAOCULAR MUSCLE (SEPARATE PROCEDURE) CPT CHEMODENERVATION OF EXTRAOCULAR MUSCLE 669 CPT BIOPSY OF EXTRAOCULAR MUSCLE 584 CPT UNLISTED PROCEDURE, OCULAR MUSCLE N/A CPT ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY CPT ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH DRAINAGE ONLY CPT ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH REMOVAL OF LESION 2,636 2,237 2,414 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 227 of 380

228 CPT ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL 2,428 APPROACH); WITH REMOVAL OF FOREIGN BODY CPT ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL 3,784 APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION CPT FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS 310 CPT ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 4,658 KROENLEIN); WITH REMOVAL OF LESION CPT ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,489 KROENLEIN); WITH REMOVAL OF FOREIGN BODY CPT ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,416 KROENLEIN); WITH DRAINAGE CPT ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 4,027 KROENLEIN); WITH REMOVAL OF BONE FOR DECOMPRESSION CPT ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,535 KROENLEIN); FOR EXPLORATION, WITH OR WITHOUT BIOPSY CPT RETROBULBAR INJECTION; MEDICATION (SEPARATE PROCEDURE, DOES 259 NOT INCLUDE SUPPLY OF MEDICATION) CPT RETROBULBAR INJECTION; ALCOHOL 247 CPT INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S 276 CAPSULE CPT ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); INSERTION 2,777 CPT ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR 2,808 REVISION CPT OPTIC NERVE DECOMPRESSION (EG, INCISION OR FENESTRATION OF 3,260 OPTIC NERVE SHEATH) CPT UNLISTED PROCEDURE, ORBIT N/A CPT BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID 723 CPT SEVERING OF TARSORRHAPHY 602 CPT CANTHOTOMY (SEPARATE PROCEDURE) 645 CPT EXCISION OF CHALAZION; SINGLE 358 CPT EXCISION OF CHALAZION; MULTIPLE, SAME LID 459 CPT EXCISION OF CHALAZION; MULTIPLE, DIFFERENT LIDS 570 CPT EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR 1,040 REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE CPT BIOPSY OF EYELID 689 CPT CORRECTION OF TRICHIASIS; EPILATION, BY FORCEPS ONLY 148 CPT CORRECTION OF TRICHIASIS; EPILATION BY OTHER THAN FORCEPS (EG, 361 BY ELECTROSURGERY, CRYOTHERAPY, LASER SURGERY) CPT CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN 728 CPT CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE GRAFT CPT EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE 1, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 228 of 380

229 CPT DESTRUCTION OF LESION OF LID MARGIN (UP TO 1 CM) 638 CPT TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE) 478 CPT CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 1,271 TARSORRHAPHY, OR CANTHORRHAPHY; CPT CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 1,570 TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE CPT REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL 1,817 APPROACH) CPT REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH 2,139 SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA) CPT REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH 2,091 AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA) CPT REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR 1,701 ADVANCEMENT, INTERNAL APPROACH CPT REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR 2,065 ADVANCEMENT, EXTERNAL APPROACH CPT REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH 1,481 FASCIAL SLING (INCLUDES OBTAINING FASCIA) CPT REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE- 1,387 LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE) CPT REDUCTION OF OVERCORRECTION OF PTOSIS 1,504 CPT CORRECTION OF LID RETRACTION 1,603 CPT CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER 2,473 EYELID LID LOAD (EG, GOLD WEIGHT) CPT REPAIR OF ECTROPION; SUTURE 1,087 CPT REPAIR OF ECTROPION; THERMOCAUTERIZATION 967 CPT REPAIR OF ECTROPION; EXCISION TARSAL WEDGE 1,512 CPT REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS) 1,656 CPT REPAIR OF ENTROPION; SUTURE 1,033 CPT REPAIR OF ENTROPION; THERMOCAUTERIZATION 931 CPT REPAIR OF ENTROPION; EXCISION TARSAL WEDGE 1,596 CPT REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR 1,642 CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION) CPT SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, 1,029 AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; PARTIAL THICKNESS CPT SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, 1,689 AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS CPT REMOVAL OF EMBEDDED FOREIGN BODY, EYELID 659 CPT CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) 1,623 CPT EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE 1,622 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 229 of 380

230 TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN CPT EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, 2,171 CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN CPT RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 2,086 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, ONE STAGE OR FIRST STAGE CPT RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 2,696 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, ONE STAGE OR FIRST STAGE CPT RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 2,689 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, UPPER, ONE STAGE OR FIRST STAGE CPT RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 1,969 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE CPT UNLISTED PROCEDURE, EYELIDS N/A CPT INCISION OF CONJUNCTIVA, DRAINAGE OF CYST 338 CPT EXPRESSION OF CONJUNCTIVAL FOLLICLES (EG, FOR TRACHOMA) 187 CPT BIOPSY OF CONJUNCTIVA 475 CPT EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM 623 CPT EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM 859 CPT EXCISION OF LESION, CONJUNCTIVA; WITH ADJACENT SCLERA 1,494 CPT DESTRUCTION OF LESION, CONJUNCTIVA 444 CPT SUBCONJUNCTIVAL INJECTION 120 CPT CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE 1,997 REARRANGEMENT CPT CONJUNCTIVOPLASTY; WITH BUCCAL MUCOUS MEMBRANE GRAFT 1,884 (INCLUDES OBTAINING GRAFT) CPT CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC; WITH 1,823 CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT CPT CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC; WITH BUCCAL 2,035 MUCOUS MEMBRANE GRAFT (INCLUDES OBTAINING GRAFT) CPT REPAIR OF SYMBLEPHARON; CONJUNCTIVOPLASTY, WITHOUT GRAFT 1,671 CPT REPAIR OF SYMBLEPHARON; WITH FREE GRAFT CONJUNCTIVA OR BUCCAL 1,830 MUCOUS MEMBRANE (INCLUDES OBTAINING GRAFT) CPT REPAIR OF SYMBLEPHARON; DIVISION OF SYMBLEPHARON, WITH OR 1,500 WITHOUT INSERTION OF CONFORMER OR CONTACT LENS CPT CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL (SEPARATE PROCEDURE) 1,471 CPT CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDERSON THIN FLAP OR PURSE 1,855 STRING FLAP) CPT HARVESTING CONJUNCTIVAL ALLOGRAFT, LIVING DONOR 1,191 CPT UNLISTED PROCEDURE, CONJUNCTIVA N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 230 of 380

231 CPT INCISION, DRAINAGE OF LACRIMAL GLAND 781 CPT INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR 883 DACRYOCYSTOSTOMY) CPT SNIP INCISION OF LACRIMAL PUNCTUM 284 CPT EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 2,840 TUMOR; TOTAL CPT EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 2,752 TUMOR; PARTIAL CPT BIOPSY OF LACRIMAL GLAND 1,263 CPT EXCISION OF LACRIMAL SAC (DACRYOCYSTECTOMY) 1,943 CPT BIOPSY OF LACRIMAL SAC 781 CPT REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES 1,189 CPT EXCISION OF LACRIMAL GLAND TUMOR; FRONTAL APPROACH 2,635 CPT EXCISION OF LACRIMAL GLAND TUMOR; INVOLVING OSTEOTOMY 3,189 CPT PLASTIC REPAIR OF CANALICULI 1,705 CPT CORRECTION OF EVERTED PUNCTUM, CAUTERY 655 CPT DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL 2,152 CAVITY) CPT CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL 2,164 CAVITY); WITHOUT TUBE CPT CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL 2,231 CAVITY); WITH INSERTION OF TUBE OR STENT CPT CLOSURE OF THE LACRIMAL PUNCTUM; BY THERMOCAUTERIZATION, 557 LIGATION, OR LASER SURGERY CPT CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH 411 CPT CLOSURE OF LACRIMAL FISTULA (SEPARATE PROCEDURE) 1,786 CPT DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION 349 CPT PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 770 CPT PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 584 REQUIRING GENERAL ANESTHESIA CPT PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 1,237 WITH INSERTION OF TUBE OR STENT CPT PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 2,002 WITH TRANSLUMINAL BALLOON CATHETER DILATION CPT PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION 357 CPT INJECTION OF CONTRAST MEDIUM FOR DACRYOCYSTOGRAPHY 196 CPT UNLISTED PROCEDURE, LACRIMAL SYSTEM N/A CPT DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; SIMPLE 563 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 231 of 380

232 CPT DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED 665 CPT DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS 718 CPT EAR PIERCING 98 CPT BIOPSY EXTERNAL EAR 338 CPT BIOPSY EXTERNAL AUDITORY CANAL 448 CPT EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR 1,461 CPT EXCISION EXTERNAL EAR; COMPLETE AMPUTATION 1,236 CPT EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL 2,757 CPT EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY CANAL 1,244 CPT RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; WITHOUT NECK 3,294 DISSECTION CPT RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; WITH NECK 5,285 DISSECTION CPT REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT 375 GENERAL ANESTHESIA CPT REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH 319 GENERAL ANESTHESIA CPT REMOVAL IMPACTED CERUMEN (SEPARATE PROCEDURE), ONE OR BOTH 156 EARS CPT DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG, ROUTINE 435 CLEANING) CPT DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH 693 ANESTHESIA OR MORE THAN ROUTINE CLEANING) CPT OTOPLASTY, PROTRUDING EAR, WITH OR WITHOUT SIZE REDUCTION 2,282 CPT RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, 3,423 FOR STENOSIS DUE TO INJURY, INFECTION) (SEPARATE PROCEDURE) CPT RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL 4,842 ATRESIA, SINGLE STAGE CPT UNLISTED PROCEDURE, EXTERNAL EAR N/A CPT EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITH CATHETERIZATION 468 CPT EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITHOUT 278 CATHETERIZATION CPT EUSTACHIAN TUBE CATHETERIZATION, TRANSTYMPANIC 820 CPT MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE 601 INFLATION CPT MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE 472 INFLATION REQUIRING GENERAL ANESTHESIA CPT VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA 410 CPT TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), LOCAL OR TOPICAL ANESTHESIA CPT TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 232 of 380

233 CPT MIDDLE EAR EXPLORATION THROUGH POSTAURICULAR OR EAR CANAL 2,183 INCISION CPT TYMPANOLYSIS, TRANSCANAL 1,721 CPT TRANSMASTOID ANTROTOMY (SIMPLE MASTOIDECTOMY) 2,329 CPT MASTOIDECTOMY; COMPLETE 3,082 CPT MASTOIDECTOMY; MODIFIED RADICAL 3,807 CPT MASTOIDECTOMY; RADICAL 3,903 CPT PETROUS APICECTOMY INCLUDING RADICAL MASTOIDECTOMY 5,217 CPT RESECTION TEMPORAL BONE, EXTERNAL APPROACH 8,430 CPT EXCISION AURAL POLYP 657 CPT EXCISION AURAL GLOMUS TUMOR; TRANSCANAL 3,299 CPT EXCISION AURAL GLOMUS TUMOR; TRANSMASTOID 4,969 CPT EXCISION AURAL GLOMUS TUMOR; EXTENDED (EXTRATEMPORAL) 7,884 CPT REVISION MASTOIDECTOMY; RESULTING IN COMPLETE MASTOIDECTOMY 3,311 CPT REVISION MASTOIDECTOMY; RESULTING IN MODIFIED RADICAL 3,467 MASTOIDECTOMY CPT REVISION MASTOIDECTOMY; RESULTING IN RADICAL MASTOIDECTOMY 3,986 CPT REVISION MASTOIDECTOMY; RESULTING IN TYMPANOPLASTY 3,525 CPT REVISION MASTOIDECTOMY; WITH APICECTOMY 4,952 CPT TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF 1,222 PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH CPT MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR AREA) 2,182 CPT TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION) CPT TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP), TOTAL OSSICULAR REPLACEMENT PROSTHESIS (TORP)) CPT TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC 2,801 3,419 3,302 3,873 4,371 4,345 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 233 of 380

234 MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP), TOTAL OSSICULAR REPLACEMENT PROSTHESIS (TORP)) CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 3,307 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,255 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 3,884 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,683 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,595 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,885 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITH OSSICULAR CHAIN RECONSTRUCTION CPT STAPES MOBILIZATION 2,521 CPT STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF 2,946 OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; CPT STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF 3,844 OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; WITH FOOTPLATE DRILL OUT CPT REVISION OF STAPEDECTOMY OR STAPEDOTOMY 3,681 CPT REPAIR OVAL WINDOW FISTULA 2,567 CPT REPAIR ROUND WINDOW FISTULA 2,572 CPT MASTOID OBLITERATION (SEPARATE PROCEDURE) 2,995 CPT TYMPANIC NEURECTOMY 2,644 CPT CLOSURE POSTAURICULAR FISTULA, MASTOID (SEPARATE PROCEDURE) 2,219 CPT IMPLANTATION OR REPLACEMENT OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN TEMPORAL BONE CPT REMOVAL OR REPAIR OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN TEMPORAL BONE CPT IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY CPT IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY CPT REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY N/A 2,737 3,428 4,231 3,544 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 234 of 380

235 CPT REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), 4,492 OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY CPT DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; LATERAL TO 3,745 GENICULATE GANGLION CPT DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; INCLUDING MEDIAL 6,032 TO GENICULATE GANGLION CPT SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR 3,655 DECOMPRESSION; LATERAL TO GENICULATE GANGLION CPT SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR 3,523 DECOMPRESSION; INCLUDING MEDIAL TO GENICULATE GANGLION CPT UNLISTED PROCEDURE, MIDDLE EAR N/A CPT LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER 2,382 NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); TRANSCANAL CPT LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER 3,312 NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); WITH MASTOIDECTOMY CPT ENDOLYMPHATIC SAC OPERATION; WITHOUT SHUNT 3,344 CPT ENDOLYMPHATIC SAC OPERATION; WITH SHUNT 3,010 CPT FENESTRATION SEMICIRCULAR CANAL 2,713 CPT REVISION FENESTRATION OPERATION 2,830 CPT LABYRINTHECTOMY; TRANSCANAL 2,906 CPT LABYRINTHECTOMY; WITH MASTOIDECTOMY 3,242 CPT VESTIBULAR NERVE SECTION, TRANSLABYRINTHINE APPROACH 4,931 CPT COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY 4,037 CPT UNLISTED PROCEDURE, INNER EAR N/A CPT VESTIBULAR NERVE SECTION, TRANSCRANIAL APPROACH 5,864 CPT TOTAL FACIAL NERVE DECOMPRESSION AND/OR REPAIR (MAY INCLUDE 6,434 GRAFT) CPT DECOMPRESSION INTERNAL AUDITORY CANAL 6,207 CPT REMOVAL OF TUMOR, TEMPORAL BONE 6,818 CPT UNLISTED PROCEDURE, TEMPORAL BONE, MIDDLE FOSSA APPROACH N/A CPT MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 235 of 380

236 CPT RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY 55 CPT RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR 57 VIEWS CPT RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF FOUR 76 VIEWS CPT RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS PER 63 SIDE CPT RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE 107 VIEWS PER SIDE CPT RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE 91 CPT RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS 53 CPT RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 80 THREE VIEWS CPT RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 62 THREE VIEWS CPT DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL 99 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION; OPTIC FORAMINA 67 CPT RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR 83 VIEWS CPT RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE 55 VIEWS CPT RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM 71 OF THREE VIEWS CPT RADIOLOGIC EXAMINATION, SELLA TURCICA 57 CPT RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS 68 CPT RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR 89 VIEWS CPT RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW 25 CPT RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, LESS THAN 69 FULL MOUTH CPT RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH 92 CPT RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 57 CLOSED MOUTH; UNILATERAL CPT RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 90 CLOSED MOUTH; BILATERAL CPT TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL 147 SUPERVISION AND INTERPRETATION CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR 990 JOINT(S) CPT CEPHALOGRAM, ORTHODONTIC 35 CPT ORTHOPANTOGRAM 37 CPT RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE 52 CPT RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR MAGNIFICATION TECHNIQUE 141 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 236 of 380

237 CPT COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR 171 VIDEO RECORDING CPT LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND 148 INTERPRETATION CPT RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS 71 CPT SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 196 CPT COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL CPT COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) CPT COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL CPT COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S) CPT COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL CPT COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) CPT COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL CPT COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) CPT COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES ,350 1,360 1,106 1,207 1,513 1,224 1,216 1,834 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 237 of 380

238 CPT MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 1,220 MATERIAL(S) CPT MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST 1,279 MATERIAL(S) CPT MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 1,835 MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,147 BRAIN STEM); WITHOUT CONTRAST MATERIAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,256 BRAIN STEM); WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,513 BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; INCLUDING 1,277 TEST SELECTION AND ADMINISTRATION OF REPETITIVE BODY PART MOVEMENT AND/OR VISUAL STIMULATION, NOT REQUIRING PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION CPT MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; REQUIRING 1,459 PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 2,580 BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 2,840 BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 2,865 BRAIN STEM AND SKULL BASE), DURING OPEN INTRACRANIAL PROCEDURE (EG, TO ASSESS FOR RESIDUAL TUMOR OR RESIDUAL VASCULAR MALFORMATION); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) A CPT RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL 44 CPT RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL 56 CPT RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; 57 CPT RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE CPT RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS CPT RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY CPT RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; CPT RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY CPT RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) CPT BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 238 of 380

239 CPT INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, 187 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS 61 CPT RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING 75 POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS CPT RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS 75 CPT RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING 100 POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS CPT RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS 60 CPT RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, 70 MINIMUM OF THREE VIEWS CPT COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL 551 CPT COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) 668 CPT COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, 826 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH 980 CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 1,269 EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 1,403 EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 1,773 EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING 1,231 MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) CPT RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, 135 ANTEROPOSTERIOR AND LATERAL CPT RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL 44 CPT RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VIEWS 70 CPT RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS 100 CPT RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING 126 OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES CPT RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING 69 (SCOLIOSIS) CPT RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS 62 CPT RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS 72 CPT RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR VIEWS 85 CPT RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEWS 67 CPT RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING SUPINE AND ERECT STUDIES 91 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 239 of 380

240 CPT RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THREE 74 VIEWS CPT RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF FOUR 105 VIEWS CPT RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, 138 INCLUDING BENDING VIEWS CPT RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS 94 ONLY, MINIMUM OF FOUR VIEWS CPT COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST 552 MATERIAL CPT COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL 667 CPT COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST 819 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST 552 MATERIAL CPT COMPUTED TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL 667 CPT COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST 814 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST 550 MATERIAL CPT COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL 665 CPT COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST 817 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,018 CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,268 CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,023 CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,127 CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,010 CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,251 CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,507 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,398 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,486 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR CPT MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, 1,191 WITH OR WITHOUT CONTRAST MATERIAL(S) CPT RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 48 CPT RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE VIEWS 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 240 of 380

241 CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITH CONTRAST 942 MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL 518 CPT COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) 630 CPT COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, 818 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 1,135 CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH 1,236 CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 1,540 CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT 1,215 CONTRAST MATERIAL(S) CPT RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE 54 VIEWS CPT RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE VIEWS 67 CPT RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO 55 VIEWS CPT MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND 261 INTERPRETATION CPT MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND 235 INTERPRETATION CPT MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND 250 INTERPRETATION CPT MYELOGRAPHY, TWO OR MORE REGIONS (EG, LUMBAR/THORACIC, 394 CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 190 CPT DISCOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION 214 AND INTERPRETATION CPT RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 571 VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION, PER VERTEBRAL BODY; UNDER FLUOROSCOPIC GUIDANCE CPT RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 589 VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION, PER VERTEBRAL BODY; UNDER CT GUIDANCE CPT DISCOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND 190 INTERPRETATION CPT RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE 51 CPT RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE 53 CPT RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW 42 CPT RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS CPT RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 241 of 380

242 CPT RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS 55 CPT RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS 50 CPT RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE 67 VIEWS CPT RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL 174 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS 51 CPT RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 52 TWO VIEWS CPT RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS 55 CPT RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE 67 VIEWS CPT RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL 206 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, HAND; TWO VIEWS 51 CPT RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS 59 CPT RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF TWO VIEWS 57 CPT COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST 539 MATERIAL CPT COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST 653 MATERIAL(S) CPT COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST 844 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITH 915 CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 1,138 OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 1,216 OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 1,533 OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER 1,063 EXTREMITY; WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER 1,140 EXTREMITY; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER 1,430 EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR 1,181 WITHOUT CONTRAST MATERIAL(S) CPT RADIOLOGIC EXAMINATION, HIP, UNILATERAL; ONE VIEW 47 CPT RADIOLOGIC EXAMINATION, HIP, UNILATERAL; COMPLETE, MINIMUM OF TWO VIEWS CPT RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF PELVIS Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 242 of 380

243 CPT RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL 174 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE 65 CPT RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, 73 MINIMUM OF TWO VIEWS CPT RADIOLOGICAL EXAMINATION, SACROILIAC JOINT ARTHROGRAPHY, 129 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS 52 CPT RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS 53 CPT RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS 66 CPT RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE VIEWS 78 CPT RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, 58 ANTEROPOSTERIOR CPT RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL 226 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS 51 CPT RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 52 TWO VIEWS CPT RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS 51 CPT RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE 60 VIEWS CPT RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL 185 SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS 48 CPT RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE 58 VIEWS CPT RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS 51 CPT RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF TWO VIEWS 55 CPT COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL CPT COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) CPT COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL ,018 1,112 1,216 1,529 1,085 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 243 of 380

244 CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER 1,152 EXTREMITY; WITH CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER 1,429 EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR 1,219 WITHOUT CONTRAST MATERIAL(S) CPT RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW 46 CPT RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND 73 ADDITIONAL OBLIQUE AND CONE VIEWS CPT RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING 78 DECUBITUS AND/OR ERECT VIEWS CPT RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN 94 SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, SINGLE VIEW CHEST CPT COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL 526 CPT COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) 727 CPT COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, 974 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITH CONTRAST 1,013 MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT 998 CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH 1,368 CONTRAST MATERIAL(S) CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT 1,542 CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT 1,215 CONTRAST MATERIAL(S) CPT PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), 144 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL ESOPHAGUS 152 CPT RADIOLOGIC EXAMINATION; ESOPHAGUS 176 CPT SWALLOWING FUNCTION, WITH CINERADIOGRAPHY/VIDEORADIOGRAPHY 177 CPT REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB CPT RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB CPT RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH SMALL INTESTINE, INCLUDES MULTIPLE SERIAL FILMS CPT RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB CPT RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT DELAYED Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 244 of 380

245 FILMS, WITH KUB CPT RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR 376 CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH SMALL INTESTINE FOLLOW- THROUGH CPT RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 210 SERIAL FILMS; CPT RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 748 SERIAL FILMS; VIA ENTEROCLYSIS TUBE CPT DUODENOGRAPHY, HYPOTONIC 616 CPT RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA, WITH OR WITHOUT 305 KUB CPT RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH 422 DENSITY BARIUM, WITH OR WITHOUT GLUCAGON CPT THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF 397 INTUSSUSCEPTION OR OTHER INTRALUMINAL OBSTRUCTION (EG, MECONIUM ILEUS) CPT CHOLECYSTOGRAPHY, ORAL CONTRAST; 135 CPT CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT 123 EXAMINATION OR MULTIPLE DAY EXAMINATION CPT CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, 100 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; ADDITIONAL SET 58 INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; THROUGH EXISTING 101 CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL 198 SUPERVISION AND INTERPRETATION CPT POSTOPERATIVE BILIARY DUCT CALCULUS REMOVAL, PERCUTANEOUS VIA 263 T-TUBE TRACT, BASKET, OR SNARE (EG, BURHENNE TECHNIQUE), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, 311 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, 196 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND 324 PANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER- 250 ABBOTT), INCLUDING MULTIPLE FLUOROSCOPIES AND FILMS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL 272 SUPERVISION AND INTERPRETATION CPT INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, 299 ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS TRANSHEPATIC DILATION OF BILIARY DUCT STRICTURE 244 WITH OR WITHOUT PLACEMENT OF STENT, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, 222 WITH OR WITHOUT TOMOGRAPHY CPT UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 228 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 245 of 380

246 CPT UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 269 WITH NEPHROTOMOGRAPHY CPT UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB 238 CPT UROGRAPHY, ANTEGRADE (PYELOSTOGRAM, NEPHROSTOGRAM, 132 LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CYSTOGRAPHY, MINIMUM OF 3 VIEWS, RADIOLOGICAL SUPERVISION AND 163 INTERPRETATION CPT VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL 178 SUPERVISION AND INTERPRETATION CPT CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND 198 INTERPRETATION CPT URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION 143 AND INTERPRETATION CPT URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND 182 INTERPRETATION CPT RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, 144 CONTRAST VISUALIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS 200 FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER 201 THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL 207 SUPERVISION AND INTERPRETATION CPT PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION 73 CPT HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH FLOW/VELOCITY QUANTIFICATION CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH FLOW/VELOCITY QUANTIFICATION AND STRESS CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH FLOW/VELOCITY QUANTIFICATION CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING CPT CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH FLOW/VELOCITY QUANTIFICATION AND STRESS ,009 1,111 1,465 1,442 1,360 1,430 1,681 1,681 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 246 of 380

247 CPT AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, RADIOLOGICAL 524 SUPERVISION AND INTERPRETATION CPT AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, RADIOLOGICAL 372 SUPERVISION AND INTERPRETATION CPT AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL 359 SUPERVISION AND INTERPRETATION CPT AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER 439 EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND 1,096 BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL 397 ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION 398 AND INTERPRETATION CPT ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, 408 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, 510 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL 425 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL 517 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL 408 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL 483 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, 408 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND 493 INTERPRETATION CPT ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION 402 AND INTERPRETATION CPT ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION 480 AND INTERPRETATION CPT ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH 392 AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH 506 AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR 388 WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 411 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 517 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL 395 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, RADIOLOGICAL 359 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, RADIOLOGICAL 410 SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY, PULMONARY, BY NONSELECTIVE CATHETER OR VENOUS INJECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION 370 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 247 of 380

248 CPT ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND 426 INTERPRETATION CPT ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER 244 BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), 354 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, RADIOLOGICAL 469 SUPERVISION AND INTERPRETATION CPT LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, RADIOLOGICAL 512 SUPERVISION AND INTERPRETATION CPT LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, RADIOLOGICAL 526 SUPERVISION AND INTERPRETATION CPT LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL 563 SUPERVISION AND INTERPRETATION CPT SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING 187 NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT, INDWELLING INFUSION PUMP), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND 998 INTERPRETATION CPT VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION 262 AND INTERPRETATION CPT VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND 302 INTERPRETATION CPT VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL 331 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL 331 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 338 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 408 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 333 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 412 SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) 361 OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION 354 AND INTERPRETATION CPT VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND 413 INTERPRETATION CPT VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND 276 INTERPRETATION CPT PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH HEMODYNAMIC 368 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC 385 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC 339 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC 339 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT VENOUS SAMPLING THROUGH CATHETER, WITH OR WITHOUT ANGIOGRAPHY (EG, FOR PARATHYROID HORMONE, RENIN), 281 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 248 of 380

249 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ANGIOGRAPHY THROUGH EXISTING CATHETER FOR FOLLOW-UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR INFUSION CPT EXCHANGE OF A PREVIOUSLY PLACED INTRAVASCULAR CATHETER DURING THROMBOLYTIC THERAPY WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS, RADIOLOGIC SUPERVISION AND INTERPRETATION CPT MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN, RADIOLOGIC SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL VESSEL CPT INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NON-CORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF INFRARENAL AORTIC OR ILIAC ARTERY ANEURYSM, PSEUDOANEURYSM, OR DISSECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ENDOVASCULAR REPAIR OF ILIAC ARTERY ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, OR TRAUMA, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDING THORA CPT ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); NOT INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDING T CPT PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (EG, ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) (DELAYED) AFTER ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, AS NEEDED, TO LEVEL OF CELIAC ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S) (EXCEPT CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS AND/OR OPEN, RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH VESSEL 1,827 1, , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 249 of 380

250 CPT TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR 667 FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, 338 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL 219 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL 440 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL VISCERAL 222 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND 901 INTERPRETATION CPT TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN 322 STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST 537 MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT PERCUTANEOUS PLACEMENT OF DRAINAGE CATHETER FOR COMBINED 609 INTERNAL AND EXTERNAL BILIARY DRAINAGE OR OF A DRAINAGE STENT FOR INTERNAL BILIARY DRAINAGE IN PATIENTS WITH AN INOPERABLE MECHANICAL BILIARY OBSTRUCTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT CHANGE OF PERCUTANEOUS TUBE OR DRAINAGE CATHETER WITH 219 CONTRAST MONITORING (EG, GENITOURINARY SYSTEM, ABSCESS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGICAL GUIDANCE (IE, FLUOROSCOPY, ULTRASOUND, OR 252 COMPUTED TOMOGRAPHY), FOR PERCUTANEOUS DRAINAGE (EG, ABSCESS, SPECIMEN COLLECTION), WITH PLACEMENT OF CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL 1,363 SUPERVISION AND INTERPRETATION CPT TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL ARTERY, 891 RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION 1,314 AND INTERPRETATION CPT TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION 1,279 AND INTERPRETATION CPT TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL VISCERAL ARTERY, 350 RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN TIME, 209 OTHER THAN OR (EG, CARDIAC FLUOROSCOPY) CPT FLUOROSCOPY, PHYSICIAN TIME MORE THAN 1 HOUR, ASSISTING A 266 NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, TRANSBRONCHIAL BIOPSY) CPT RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, 51 SINGLE VIEW, CHILD CPT RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, 118 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT RADIOLOGICAL EXAMINATION, SURGICAL SPECIMEN 35 CPT RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, TOMOGRAPHY), OTHER THAN WITH UROGRAPHY 292 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 250 of 380

251 CPT RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) 426 BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; UNILATERAL CPT RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) 579 BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; BILATERAL CPT CINERADIOGRAPHY/VIDEORADIOGRAPHY, EXCEPT WHERE SPECIFICALLY 161 INCLUDED CPT XERORADIOGRAPHY 48 CPT D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED 118 TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; NOT REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION CPT D RENDERING WITH INTERPRETATION AND REPORTING OF COMPUTED 178 TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY; REQUIRING IMAGE POSTPROCESSING ON AN INDEPENDENT WORKSTATION CPT COMPUTED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY 409 CPT MAGNETIC RESONANCE SPECTROSCOPY 795 CPT UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT UNLISTED MAGNETIC RESONANCE PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE N/A CPT ECHOENCEPHALOGRAPHY, REAL TIME WITH IMAGE DOCUMENTATION 244 (GRAY SCALE) (FOR DETERMINATION OF VENTRICULAR SIZE, DELINEATION OF CEREBRAL CONTENTS, AND DETECTION OF FLUID MASSES OR OTHER INTRACRANIAL ABNORMALITIES), INCLUDING A-MODE ENCEPHALOGRAPHY AS SECONDARY COMPONENT WHERE INDICATED CPT OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE A- 269 SCAN PERFORMED DURING THE SAME PATIENT ENCOUNTER CPT OPHTHALMIC ULTRASOUND, DIAGNOSTIC; QUANTITATIVE A-SCAN ONLY 165 CPT OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN (WITH OR WITHOUT 153 SUPERIMPOSED NON-QUANTITATIVE A-SCAN) CPT OPHTHALMIC ULTRASOUND, DIAGNOSTIC; ANTERIOR SEGMENT 158 ULTRASOUND, IMMERSION (WATER BATH) B-SCAN OR HIGH RESOLUTION BIOMICROSCOPY CPT OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, 24 UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS) CPT OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; 122 CPT OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH 132 INTRAOCULAR LENS POWER CALCULATION CPT OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 125 CPT ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION CPT ULTRASOUND, CHEST (INCLUDES MEDIASTINUM), REAL TIME WITH IMAGE DOCUMENTATION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 251 of 380

252 CPT ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), REAL TIME WITH 189 IMAGE DOCUMENTATION CPT ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; 275 COMPLETE CPT ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; 211 LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP) CPT ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL 263 TIME WITH IMAGE DOCUMENTATION; COMPLETE CPT ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL 215 TIME WITH IMAGE DOCUMENTATION; LIMITED CPT ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER 299 WITH IMAGE DOCUMENTATION CPT ULTRASOUND, SPINAL CANAL AND CONTENTS 246 CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, FIRST TRIMESTER (< 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS DETAILED FETAL ANATOMIC EXAMINATION, TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS DETAILED FETAL ANATOMIC EXAMINATION, TRANSABDOMINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; EACH ADDITIONAL GESTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, LIMITED (EG, FETAL HEART BEAT, PLACENTAL LOCATION, FETAL POSITION AND/OR QUALITATIVE AMNIOTIC FLUID VOLUME), ONE OR MORE FETUSES CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 252 of 380

253 VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS CPT ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE 197 DOCUMENTATION, TRANSVAGINAL CPT FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 236 CPT FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING 174 CPT DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY 83 CPT DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY 188 CPT ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME 430 WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; CPT ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME 253 WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR REPEAT STUDY CPT DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR 123 CONTINUOUS WAVE WITH SPECTRAL DISPLAY; COMPLETE CPT DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR 89 CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR REPEAT STUDY CPT ULTRASOUND, TRANSVAGINAL 247 CPT SALINE INFUSION SONOHYSTEROGRAPHY (SIS), INCLUDING COLOR FLOW 248 DOPPLER, WHEN PERFORMED CPT ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE 250 DOCUMENTATION; COMPLETE CPT ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE 204 DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES) CPT ULTRASOUND, SCROTUM AND CONTENTS 249 CPT ULTRASOUND, TRANSRECTAL; 293 CPT ULTRASOUND, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY TREATMENT PLANNING (SEPARATE PROCEDURE) CPT ULTRASOUND, EXTREMITY, NONVASCULAR, REAL TIME WITH IMAGE DOCUMENTATION CPT ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; DYNAMIC (REQUIRING PHYSICIAN MANIPULATION) CPT ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC (NOT REQUIRING PHYSICIAN MANIPULATION) CPT ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, IMAGING SUPERVISION AND INTERPRETATION CPT ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE (INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION AND IMAGING) CPT ULTRASOUND GUIDANCE FOR VASCULAR ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NEEDLE ENTRY, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 253 of 380

254 WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ULTRASOUND GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL 333 TISSUE ABLATION CPT ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR 238 CORDOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, 387 ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR CHORIONIC VILLUS SAMPLING, IMAGING 177 SUPERVISION AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING SUPERVISION 65 AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, IMAGING 65 SUPERVISION AND INTERPRETATION CPT ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 130 CPT ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION 201 CPT ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 170 CPT GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, SUPERVISION AND 194 INTERPRETATION CPT ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, 14 PERIPHERAL SITE(S), ANY METHOD CPT ULTRASONIC GUIDANCE, INTRAOPERATIVE 120 CPT UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT FLUOROSCOPIC GUIDANCE FOR CENTRAL VENOUS ACCESS DEVICE 222 PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY NECESSARY CONTRAST INJECTIONS THROUGH ACCESS SITE OR CATHETER WITH RELATED VENOGRAPHY RADIOLOGIC SUPERVISION AND INTERPRETATION, AND RADIOGRAPHIC DOCUMENTATION OF FINAL CATHETER POSITION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, 128 ASPIRATION, INJECTION, LOCALIZATION DEVICE) CPT FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER 100 TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL, TRANSFORAMINAL EPIDURAL, SUBARACHNOID, PARAVERTEBRAL FACET JOINT, PARAVERTEBRAL FACET JOINT NERVE, OR SACROILIAC JOINT), INCLUDING NEUROLYTIC AGENT DESTRUCTION CPT COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION 1,520 CPT COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT COMPUTED TOMOGRAPHY GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION CPT COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS CPT MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY, NEEDLE ASPIRATION, INJECTION, OR PLACEMENT OF LOCALIZATION DEVICE) RADIOLOGICAL SUPERVISION AND 273 1, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 254 of 380

255 INTERPRETATION CPT MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, 1,337 PARENCHYMAL TISSUE ABLATION CPT STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR 271 NEEDLE PLACEMENT (EG, FOR WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR 102 WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 19 DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; DIAGNOSTIC MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT COMPUTER-AIDED DETECTION (COMPUTER ALGORITHM ANALYSIS OF 19 DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER PHYSICIAN REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; SCREENING MAMMOGRAPHY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL 121 SUPERVISION AND INTERPRETATION CPT MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 161 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT MAMMOGRAPHY; UNILATERAL 168 CPT MAMMOGRAPHY; BILATERAL 216 CPT SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH 154 BREAST) CPT MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH 1,679 CONTRAST MATERIAL(S); UNILATERAL CPT MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH 1,697 CONTRAST MATERIAL(S); BILATERAL CPT MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT 85 RADIOGRAPHY, INCLUDING CONTRALATERAL JOINT IF INDICATED CPT BONE AGE STUDIES 44 CPT BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) 68 CPT RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR 136 METASTASES) CPT RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND 202 APPENDICULAR SKELETON) CPT RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT 201 CPT JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) 72 CPT COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) CPT COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) CPT DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 255 of 380

256 CPT DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 51 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) CPT DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 52 OR MORE SITES; VERTEBRAL FRACTURE ASSESSMENT CPT RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, 43 RADIOGRAMMETRY), 1 OR MORE SITES CPT MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD 1,095 SUPPLY CPT THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE 134 CPT THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE 201 CPT THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX 299 CPT THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE 370 CPT THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 651 INTERMEDIATE CPT THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX 1,067 CPT THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; DIMENSIONAL CPT UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY CLINICAL TREATMENT N/A PLANNING CPT BASIC RADIATION DOSIMETRY CALCULATION, CENTRAL AXIS DEPTH DOSE 131 CALCULATION, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, CALCULATION OF NON-IONIZING RADIATION SURFACE AND DEPTH DOSE, AS REQUIRED DURING COURSE OF TREATMENT, ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN CPT INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME 4,662 HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS CPT TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER 121 CALCULATED); SIMPLE (ONE OR TWO PARALLEL OPPOSED UNMODIFIED PORTS DIRECTED TO A SINGLE AREA OF INTEREST) CPT TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER 170 CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS DIRECTED TO A SINGLE AREA OF INTEREST) CPT TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER 266 CALCULATED); COMPLEX (MANTLE OR INVERTED Y, TANGENTIAL PORTS, THE USE OF WEDGES, COMPENSATORS, COMPLEX BLOCKING, ROTATIONAL BEAM, OR SPECIAL BEAM CONSIDERATIONS) CPT SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMIBODY, TOTAL BODY 188 CPT BRACHYTHERAPY ISODOSE PLAN; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, ONE TO FOUR SOURCES/RIBBON APPLICATION, REMOTE AFTERLOADING BRACHYTHERAPY, 1 TO 8 SOURCES) CPT BRACHYTHERAPY ISODOSE PLAN; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING 5 TO 10 SOURCES/RIBBONS, REMOTE AFTERLOADING BRACHYTHERAPY, 9 TO 12 SOURCES) CPT BRACHYTHERAPY ISODOSE PLAN; COMPLEX (MULTIPLANE ISODOSE PLAN, VOLUME IMPLANT CALCULATIONS, OVER 10 SOURCES/RIBBONS USED, SPECIAL SPATIAL RECONSTRUCTION, REMOTE AFTERLOADING BRACHYTHERAPY, OVER 12 SOURCES) CPT SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 256 of 380

257 CPT TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE 151 BLOCK, SIMPLE BOLUS) CPT TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE 104 (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) CPT TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX 289 (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, MOLDS OR CASTS) CPT CONTINUING MEDICAL PHYSICS CONSULTATION, INCLUDING 89 ASSESSMENT OF TREATMENT PARAMETERS, QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION IN SUPPORT OF THE RADIATION ONCOLOGIST, REPORTED PER WEEK OF THERAPY CPT SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION 223 CPT RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED CPT RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED CPT STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS CPT UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES, AND SPECIAL SERVICES CPT RADIATION TREATMENT DELIVERY, SUPERFICIAL AND/OR ORTHO VOLTAGE CPT RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; UP TO 5 MEV CPT RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 6-10 MEV CPT RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; MEV CPT RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 20 MEV OR GREATER CPT RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; UP TO 5 MEV CPT RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; 6-10 MEV CPT RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; MEV CPT RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; 20 MEV OR GREATER CPT RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; UP TO 5 MEV CPT RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 6-10 MEV 2,093 1,588 2,962 N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 257 of 380

258 CPT RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE 543 TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; MEV CPT RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE 543 TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 20 MEV OR GREATER CPT THERAPEUTIC RADIOLOGY PORT FILM(S) 27 CPT INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE 920 FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION CPT STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME 200 FOR THE DELIVERY OF RADIATION THERAPY CPT HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; SINGLE 380 TREATMENT AREA USING A SINGLE PORT OR PARALLEL-OPPOSED PORTS WITH NO BLOCKS OR SIMPLE BLOCKING CPT HIGH ENERGY NEUTRON RADIATION TREATMENT DELIVERY; 1 OR MORE 525 ISOCENTER(S) WITH COPLANAR OR NON-COPLANAR GEOMETRY WITH BLOCKING AND/OR WEDGE, AND/OR COMPENSATOR(S) CPT RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS 364 CPT RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF THERAPY 185 CONSISTING OF ONE OR TWO FRACTIONS ONLY CPT STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CRANIAL 755 LESION(S) (COMPLETE COURSE OF TREATMENT CONSISTING OF ONE SESSION) CPT STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, 1,275 PER TREATMENT COURSE, TO ONE OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS CPT SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, 325 HEMIBODY RADIATION, PER ORAL, ENDOCAVITARY OR INTRAOPERATIVE CONE IRRADIATION) CPT UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY TREATMENT N/A MANAGEMENT CPT PROTON TREATMENT DELIVERY; SIMPLE, WITHOUT COMPENSATION N/A CPT PROTON TREATMENT DELIVERY; SIMPLE, WITH COMPENSATION N/A CPT PROTON TREATMENT DELIVERY; INTERMEDIATE N/A CPT PROTON TREATMENT DELIVERY; COMPLEX N/A CPT HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (IE, HEATING TO 833 A DEPTH OF 4 CM OR LESS) CPT HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING TO DEPTHS 1,449 GREATER THAN 4 CM) CPT HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER 1,366 INTERSTITIAL APPLICATORS CPT HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 1,962 INTERSTITIAL APPLICATORS CPT HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) 859 CPT INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES MONTHS FOLLOW-UP CARE) CPT INTRACAVITARY RADIATION SOURCE APPLICATION; SIMPLE 726 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 258 of 380

259 CPT INTRACAVITARY RADIATION SOURCE APPLICATION; INTERMEDIATE 958 CPT INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX 1,357 CPT INTERSTITIAL RADIATION SOURCE APPLICATION; SIMPLE 878 CPT INTERSTITIAL RADIATION SOURCE APPLICATION; INTERMEDIATE 1,108 CPT INTERSTITIAL RADIATION SOURCE APPLICATION; COMPLEX 1,619 CPT REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE 467 POSITIONS OR CATHETERS CPT REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE 1,082 POSITIONS OR CATHETERS CPT REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE 1,988 POSITIONS OR CATHETERS CPT REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 3,614 SOURCE POSITIONS OR CATHETERS CPT SURFACE APPLICATION OF RADIATION SOURCE 223 CPT SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE 178 CPT UNLISTED PROCEDURE, CLINICAL BRACHYTHERAPY N/A CPT THYROID UPTAKE; SINGLE DETERMINATION 145 CPT THYROID UPTAKE; MULTIPLE DETERMINATIONS 183 CPT THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT 161 INCLUDING INITIAL UPTAKE STUDIES) CPT THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION 475 CPT THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS 257 CPT THYROID IMAGING; ONLY 325 CPT THYROID IMAGING; WITH VASCULAR FLOW 356 CPT THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, NECK 427 AND CHEST ONLY) CPT THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL 662 STUDIES (EG, URINARY RECOVERY) CPT THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY 631 CPT THYROID CARCINOMA METASTASES UPTAKE (LIST SEPARATELY IN 177 ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PARATHYROID IMAGING 308 CPT ADRENAL IMAGING, CORTEX AND/OR MEDULLA 878 CPT UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A CPT BONE MARROW IMAGING; LIMITED AREA 336 CPT BONE MARROW IMAGING; MULTIPLE AREAS 442 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 259 of 380

260 CPT BONE MARROW IMAGING; WHOLE BODY 503 CPT PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 165 TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING CPT PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 173 TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS CPT RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE 169 SAMPLING CPT RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE 184 SAMPLINGS CPT WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE 204 MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIOPHARMACEUTICAL VOLUME-DILUTION TECHNIQUE) CPT RED CELL SURVIVAL STUDY; 295 CPT RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS (EG, 664 SPLENIC AND/OR HEPATIC SEQUESTRATION) CPT LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE (EG, 262 SPLENIC AND/OR HEPATIC) CPT SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW 397 CPT KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT 681 DIFFERENTIAL ORGAN/TISSUE LOCALIZATION CPT PLATELET SURVIVAL STUDY 313 CPT LYMPHATICS AND LYMPH NODES IMAGING 704 CPT UNLISTED HEMATOPOIETIC, RETICULOENDOTHELIAL AND LYMPHATIC N/A PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE CPT LIVER IMAGING; STATIC ONLY 359 CPT LIVER IMAGING; WITH VASCULAR FLOW 416 CPT LIVER IMAGING (SPECT); 437 CPT LIVER IMAGING (SPECT); WITH VASCULAR FLOW 672 CPT LIVER AND SPLEEN IMAGING; STATIC ONLY 378 CPT LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW 250 CPT LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL 261 IMAGES CPT HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, 662 WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, WITH OR WITHOUT QUANTITATIVE MEASUREMENT OF GALLBLADDER FUNCTION CPT SALIVARY GLAND IMAGING; 330 CPT SALIVARY GLAND IMAGING; WITH SERIAL IMAGES 243 CPT SALIVARY GLAND FUNCTION STUDY 238 CPT ESOPHAGEAL MOTILITY 444 CPT GASTRIC MUCOSA IMAGING 480 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 260 of 380

261 CPT GASTROESOPHAGEAL REFLUX STUDY 476 CPT GASTRIC EMPTYING STUDY 566 CPT UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION FOR ANALYSIS 40 CPT UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS 346 CPT VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT 156 INTRINSIC FACTOR CPT VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH 151 INTRINSIC FACTOR CPT VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT 170 INTRINSIC FACTOR CPT ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING 684 CPT GASTROINTESTINAL PROTEIN LOSS 148 CPT INTESTINE IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S 649 LOCALIZATION, VOLVULUS) CPT PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, DENVER 500 SHUNT) CPT UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT BONE AND/OR JOINT IMAGING; LIMITED AREA 347 CPT BONE AND/OR JOINT IMAGING; MULTIPLE AREAS 452 CPT BONE AND/OR JOINT IMAGING; WHOLE BODY 497 CPT BONE AND/OR JOINT IMAGING; THREE PHASE STUDY 685 CPT BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) 466 CPT BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; 54 SINGLE PHOTON ABSORPTIOMETRY CPT BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; 25 DUAL PHOTON ABSORPTIOMETRY, ONE OR MORE SITES CPT UNLISTED MUSCULOSKELETAL PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT DETERMINATION OF CENTRAL C-V HEMODYNAMICS (NON-IMAGING) (EG, 149 EJECTION FRACTION WITH PROBE TECHNIQUE) WITH OR WITHOUT PHARMACOLOGIC INTERVENTION OR EXERCISE, SINGLE OR MULTIPLE DETERMINATIONS CPT CARDIAC SHUNT DETECTION 429 CPT NON-CARDIAC VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, 353 VENOGRAPHY) CPT ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE 701 CPT VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL 387 CPT VENOUS THROMBOSIS IMAGING, VENOGRAM; BILATERAL 391 CPT MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), METABOLIC EVALUATION 2,127 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 261 of 380

262 CPT MYOCARDIAL PERFUSION IMAGING; (PLANAR) SINGLE STUDY, AT REST 393 OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT QUANTIFICATION CPT MYOCARDIAL PERFUSION IMAGING; MULTIPLE STUDIES (PLANAR), AT 387 REST AND/OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), AND REDISTRIBUTION AND/OR REST INJECTION, WITH OR WITHOUT QUANTIFICATION CPT MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), SINGLE 509 STUDY (INCLUDING ATTENUATION CORRECTION WHEN PERFORMED), AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT QUANTIFICATION CPT MYOCARDIAL PERFUSION IMAGING; TOMOGRAPHIC (SPECT), MULTIPLE 940 STUDIES (INCLUDING ATTENUATION CORRECTION WHEN PERFORMED), AT REST AND/OR STRESS (EXERCISE AND/OR PHARMACOLOGIC) AND REDISTRIBUTION AND/OR REST INJECTION, WITH OR WITHOUT QUANTIFICATION CPT MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR 376 QUANTITATIVE CPT MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION 477 FRACTION BY FIRST PASS TECHNIQUE CPT MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT 520 WITH OR WITHOUT QUANTIFICATION CPT CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; PLANAR, SINGLE 508 STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT ADDITIONAL QUANTITATIVE PROCESSING CPT CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM; MULTIPLE 672 STUDIES, WALL MOTION STUDY PLUS EJECTION FRACTION, AT REST AND STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT ADDITIONAL QUANTIFICATION CPT MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR 97 QUANTITATIVE STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST 77 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; 440 SINGLE STUDY, AT REST OR WITH STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION CPT CARDIAC BLOOD POOL IMAGING (PLANAR), FIRST PASS TECHNIQUE; 608 MULTIPLE STUDIES, AT REST AND WITH STRESS (EXERCISE AND/ OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTIFICATION CPT MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 2,166 PERFUSION; SINGLE STUDY AT REST OR STRESS CPT MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 2,700 PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS CPT CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, 537 WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTITATIVE PROCESSING CPT CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SINGLE STUDY, 117 AT REST, WITH RIGHT VENTRICULAR EJECTION FRACTION BY FIRST PASS TECHNIQUE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 262 of 380

263 CPT PULMONARY PERFUSION IMAGING, PARTICULATE 420 CPT PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; 292 SINGLE BREATH CPT PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; 696 REBREATHING AND WASHOUT, WITH OR WITHOUT SINGLE BREATH CPT PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION 327 CPT PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE PROJECTIONS 421 (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) CPT PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION 690 IMAGING, AEROSOL, ONE OR MULTIPLE PROJECTIONS CPT PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, SINGLE 327 PROJECTION CPT PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND 381 WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE PROJECTION CPT PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND 421 WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) CPT PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION 717 (VENTILATION/PERFUSION) STUDY CPT UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A CPT BRAIN IMAGING, LESS THAN 4 STATIC VIEWS; 345 CPT BRAIN IMAGING, LESS THAN 4 STATIC VIEWS; WITH VASCULAR FLOW 421 CPT BRAIN IMAGING, MINIMUM 4 STATIC VIEWS; 386 CPT BRAIN IMAGING, MINIMUM 4 STATIC VIEWS; WITH VASCULAR FLOW 651 CPT BRAIN IMAGING, TOMOGRAPHIC (SPECT) 710 CPT BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC 3,929 EVALUATION CPT BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION 3,446 EVALUATION CPT BRAIN IMAGING, VASCULAR FLOW ONLY 336 CPT CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 667 OF MATERIAL); CISTERNOGRAPHY CPT CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 662 OF MATERIAL); VENTRICULOGRAPHY CPT CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 640 OF MATERIAL); SHUNT EVALUATION CPT CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 677 OF MATERIAL); TOMOGRAPHIC (SPECT) CPT CEREBROSPINAL FLUID LEAKAGE DETECTION AND LOCALIZATION 653 CPT RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY 341 CPT UNLISTED NERVOUS SYSTEM PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT KIDNEY IMAGING MORPHOLOGY; 347 CPT KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW 420 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 263 of 380

264 CPT KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW AND FUNCTION, 464 SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION CPT KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW AND FUNCTION, 343 SINGLE STUDY, WITH PHARMACOLOGICAL INTERVENTION (EG, ANGIOTENSIN CONVERTING ENZYME INHIBITOR AND/OR DIURETIC) CPT KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW AND FUNCTION, 732 MULTIPLE STUDIES, WITH AND WITHOUT PHARMACOLOGICAL INTERVENTION (EG, ANGIOTENSIN CONVERTING ENZYME INHIBITOR AND/OR DIURETIC) CPT KIDNEY IMAGING MORPHOLOGY; TOMOGRAPHIC (SPECT) 434 CPT KIDNEY FUNCTION STUDY, NON-IMAGING RADIOISOTOPIC STUDY 197 CPT URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDITION TO 154 CODE FOR PRIMARY PROCEDURE) CPT URETERAL REFLUX STUDY (RADIOPHARMACEUTICAL VOIDING 440 CYSTOGRAM) CPT TESTICULAR IMAGING WITH VASCULAR FLOW 413 CPT UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 361 RADIOPHARMACEUTICAL AGENT(S); LIMITED AREA CPT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 492 RADIOPHARMACEUTICAL AGENT(S); MULTIPLE AREAS CPT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 646 RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, SINGLE DAY IMAGING CPT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 694 RADIOPHARMACEUTICAL AGENT(S); TOMOGRAPHIC (SPECT) CPT RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 1,125 RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING TWO OR MORE DAYS IMAGING CPT RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 357 LIMITED AREA CPT RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 664 WHOLE BODY CPT RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 691 TOMOGRAPHIC (SPECT) CPT POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, 2,971 CHEST, HEAD/NECK) CPT POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID- 3,668 THIGH CPT POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY 3,817 CPT POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK) CPT POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH CPT POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY CPT GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONAL 4,170 4,609 4, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 264 of 380

265 PERSONNEL; SIMPLE MANIPULATIONS AND INTERPRETATION, NOT TO EXCEED 30 MINUTES CPT GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING 77 NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONAL PERSONNEL; COMPLEX MANIPULATIONS AND INTERPRETATION, EXCEEDING 30 MINUTES CPT UNLISTED MISCELLANEOUS PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION 267 CPT RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTRATION 300 CPT RADIOPHARMACEUTICAL THERAPY, BY INTRACAVITARY ADMINISTRATION 306 CPT RADIOPHARMACEUTICAL THERAPY, BY INTERSTITIAL RADIOACTIVE 266 COLLOID ADMINISTRATION CPT RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL 374 ANTIBODY BY INTRAVENOUS INFUSION CPT RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTICULAR 279 ADMINISTRATION CPT RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE 426 ADMINISTRATION CPT RADIOPHARMACEUTICAL THERAPY, UNLISTED PROCEDURE N/A CPT BASIC METABOLIC PANEL (CALCIUM, IONIZED) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM, IONIZED (82330) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) CPT BASIC METABOLIC PANEL (CALCIUM, TOTAL) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM (82310) CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) CPT GENERAL HEALTH PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: COMPREHENSIVE METABOLIC PANEL (80053) BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED DIFFERENTIAL WBC COUNT (85025 OR AND 85004) OR BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND CPT ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) CPT COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520) CPT OBSTETRIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED DIFFERENTIAL WBC COUNT (85025 OR AND 85004) OR BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND APPROPRIATE MANUAL DIFFERENTIAL WBC COUNT ( CPT LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 265 of 380

266 CPT RENAL FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 207 ALBUMIN (82040) CALCIUM (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHORUS INORGANIC (PHOSPHATE) (84100) POTASSIUM (84132) SODIUM (84295) UREA NITROGEN (BUN) (84520) CPT ACUTE HEPATITIS PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 239 HEPATITIS A ANTIBODY (HAAB), IGM ANTIBODY (86709) HEPATITIS B CORE ANTIBODY (HBCAB), IGM ANTIBODY (86705) HEPATITIS B SURFACE ANTIGEN (HBSAG) (87340) HEPATITIS C ANTIBODY (86803) CPT HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 172 ALBUMIN (82040) BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE (84075) PROTEIN, TOTAL (84155) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) CPT DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES 75 CHROMATOGRAPHIC METHOD, EACH PROCEDURE CPT DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS METHOD (EG, 71 IMMUNOASSAY, ENZYME ASSAY), EACH DRUG CLASS CPT DRUG CONFIRMATION, EACH PROCEDURE 68 CPT TISSUE PREPARATION FOR DRUG ANALYSIS 78 CPT AMIKACIN 77 CPT AMITRIPTYLINE 92 CPT BENZODIAZEPINES 95 CPT CARBAMAZEPINE; TOTAL 75 CPT CARBAMAZEPINE; FREE 68 CPT CYCLOSPORINE 93 CPT DESIPRAMINE 88 CPT DIGOXIN 68 CPT DIPROPYLACETIC ACID (VALPROIC ACID) 70 CPT DOXEPIN 80 CPT ETHOSUXIMIDE 84 CPT GENTAMICIN 84 CPT GOLD 84 CPT HALOPERIDOL 75 CPT IMIPRAMINE 88 CPT LIDOCAINE 75 CPT LITHIUM 34 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 266 of 380

267 CPT NORTRIPTYLINE 70 CPT PHENOBARBITAL 59 CPT PHENYTOIN; TOTAL 68 CPT PHENYTOIN; FREE 71 CPT PRIMIDONE 85 CPT PROCAINAMIDE; 86 CPT PROCAINAMIDE; WITH METABOLITES (EG, N-ACETYL PROCAINAMIDE) 86 CPT QUINIDINE 75 CPT SIROLIMUS 70 CPT SALICYLATE 36 CPT TACROLIMUS 70 CPT THEOPHYLLINE 73 CPT TOBRAMYCIN 83 CPT TOPIRAMATE 61 CPT VANCOMYCIN 70 CPT QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED 70 CPT ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) CPT ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 17 HYDROXYPROGESTERONE (83498 X 2) CPT ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 17 HYDROXYPREGNENOLONE (84143 X 2) CPT ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION) THIS PANEL MUST INCLUDE THE FOLLOWING: ALDOSTERONE (82088 X 2) RENIN (84244 X 2) CPT CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCITONIN (82308 X 3) CPT CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 6) ADRENOCORTICOTROPIC HORMONE (ACTH) (82024 X 6) CPT CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: TESTOSTERONE (84403 X 2 ON THREE POOLED BLOOD SAMPLES) CPT CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: ESTRADIOL (82670 X 2 ON THREE POOLED BLOOD SAMPLES) CPT RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS PANEL MUST INCLUDE THE FOLLOWING: RENIN (84244 X 6) , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 267 of 380

268 CPT PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS 224 PANEL MUST INCLUDE THE FOLLOWING: RENIN (84244 X 2) CPT COMBINED RAPID ANTERIOR PITUITARY EVALUATION PANEL THIS PANEL 2,949 MUST INCLUDE THE FOLLOWING: ADRENOCORTICOTROPIC HORMONE (ACTH) (82024 X 4) LUTEINIZING HORMONE (LH) (83002 X 4) FOLLICLE STIMULATING HORMONE (FSH) (83001 X 4) PROLACTIN (84146 X 4) HUMAN GROWTH HORMONE (HGH) (83003 X 4) CORTISOL (82533 X 4) THYROID STIMULATING HORMONE (TSH) (84443 X 4) CPT DEXAMETHASONE SUPPRESSION PANEL, 48 HOUR THIS PANEL MUST 366 INCLUDE THE FOLLOWING: FREE CORTISOL, URINE (82530 X 2) CORTISOL (82533 X 2) VOLUME MEASUREMENT FOR TIMED COLLECTION (81050 X 2) CPT GLUCAGON TOLERANCE PANEL; FOR INSULINOMA THIS PANEL MUST 234 INCLUDE THE FOLLOWING: GLUCOSE (82947 X 3) INSULIN (83525 X 3) CPT GLUCAGON TOLERANCE PANEL; FOR PHEOCHROMOCYTOMA THIS PANEL 251 MUST INCLUDE THE FOLLOWING: CATECHOLAMINES, FRACTIONATED (82384 X 2) CPT GONADOTROPIN RELEASING HORMONE STIMULATION PANEL THIS PANEL 756 MUST INCLUDE THE FOLLOWING: FOLLICLE STIMULATING HORMONE (FSH) (83001 X 4) LUTEINIZING HORMONE (LH) (83002 X 4) CPT GROWTH HORMONE STIMULATION PANEL (EG, ARGININE INFUSION, L- 340 DOPA ADMINISTRATION) THIS PANEL MUST INCLUDE THE FOLLOWING: HUMAN GROWTH HORMONE (HGH) (83003 X 4) CPT GROWTH HORMONE SUPPRESSION PANEL (GLUCOSE ADMINISTRATION) 400 THIS PANEL MUST INCLUDE THE FOLLOWING: GLUCOSE (82947 X 3) HUMAN GROWTH HORMONE (HGH) (83003 X 4) CPT INSULIN-INDUCED C-PEPTIDE SUPPRESSION PANEL THIS PANEL MUST 662 INCLUDE THE FOLLOWING: INSULIN (83525) C-PEPTIDE (84681 X 5) GLUCOSE (82947 X 5) CPT INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY THIS PANEL MUST 514 INCLUDE THE FOLLOWING: CORTISOL (82533 X 5) GLUCOSE (82947 X 5) CPT INSULIN TOLERANCE PANEL; FOR GROWTH HORMONE DEFICIENCY THIS 525 PANEL MUST INCLUDE THE FOLLOWING: GLUCOSE (82947 X 5) HUMAN GROWTH HORMONE (HGH) (83003 X 5) CPT METYRAPONE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 455 CORTISOL (82533 X 2) 11 DEOXYCORTISOL (82634 X 2) CPT THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE 257 HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID STIMULATING HORMONE (TSH) (84443 X 3) CPT THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO 344 HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID STIMULATING HORMONE (TSH) (84443 X 4) CPT THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR 298 HYPERPROLACTINEMIA THIS PANEL MUST INCLUDE THE FOLLOWING: PROLACTIN (84146 X 3) CPT CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF 73 PATIENT'S HISTORY AND MEDICAL RECORDS CPT CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX 211 DIAGNOSTIC PROBLEM, WITH REVIEW OF PATIENT'S HISTORY AND MEDICAL RECORDS CPT URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, 16 GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITH MICROSCOPY CPT URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITH MICROSCOPY 16 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 268 of 380

269 CPT URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, 13 GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; NON-AUTOMATED, WITHOUT MICROSCOPY CPT URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, 12 GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE CONSTITUENTS; AUTOMATED, WITHOUT MICROSCOPY CPT URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT 12 IMMUNOASSAYS CPT URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK 13 CPT URINALYSIS; MICROSCOPIC ONLY 16 CPT URINALYSIS; TWO OR THREE GLASS TEST 19 CPT URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 33 CPT VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 15 CPT UNLISTED URINALYSIS PROCEDURE N/A CPT ACETALDEHYDE, BLOOD 64 CPT ACETAMINOPHEN 104 CPT ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE 23 CPT ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE 42 CPT ACETYLCHOLINESTERASE 57 CPT ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 71 CPT ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 87 CPT ADRENOCORTICOTROPIC HORMONE (ACTH) 198 CPT ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP) 132 CPT ALBUMIN; SERUM 25 CPT ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, EACH SPECIMEN 27 CPT ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 30 CPT ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT 24 STRIP ASSAY) CPT ALBUMIN; ISCHEMIA MODIFIED 174 CPT ALCOHOL (ETHANOL); ANY SPECIMEN EXCEPT BREATH 55 CPT ALCOHOL (ETHANOL); BREATH 62 CPT ALDOLASE 50 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 269 of 380

270 CPT ALDOSTERONE 209 CPT ALKALOIDS, URINE, QUANTITATIVE 154 CPT ALPHA-1-ANTITRYPSIN; TOTAL 69 CPT ALPHA-1-ANTITRYPSIN; PHENOTYPE 74 CPT ALPHA-FETOPROTEIN (AFP); SERUM 86 CPT ALPHA-FETOPROTEIN (AFP); AMNIOTIC FLUID 86 CPT ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP 330 (INCLUDING RATIO) CPT ALUMINUM 131 CPT AMINES, VAGINAL FLUID, QUALITATIVE 19 CPT AMINO ACIDS; SINGLE, QUALITATIVE, EACH SPECIMEN 71 CPT AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN 71 CPT AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN 87 CPT AMINOLEVULINIC ACID, DELTA (ALA) 85 CPT AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN 87 CPT AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH 87 SPECIMEN CPT AMMONIA 75 CPT AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 35 CPT AMPHETAMINE OR METHAMPHETAMINE 80 CPT AMYLASE 33 CPT ANDROSTANEDIOL GLUCURONIDE 148 CPT ANDROSTENEDIONE 150 CPT ANDROSTERONE 128 CPT ANGIOTENSIN II 105 CPT ANGIOTENSIN I - CONVERTING ENZYME (ACE) 75 CPT APOLIPOPROTEIN, EACH 80 CPT ARSENIC 97 CPT ASCORBIC ACID (VITAMIN C), BLOOD 164 CPT ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE 77 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 270 of 380

271 CPT BARBITURATES, NOT ELSEWHERE SPECIFIED 59 CPT BETA-2 MICROGLOBULIN 83 CPT BILE ACIDS; TOTAL 88 CPT BILE ACIDS; CHOLYLGLYCINE 136 CPT BILIRUBIN; TOTAL 26 CPT BILIRUBIN; DIRECT 26 CPT BILIRUBIN; FECES, QUALITATIVE 23 CPT BIOTINIDASE, EACH SPECIMEN 87 CPT BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; 17 FECES, CONSECUTIVE COLLECTED SPECIMENS WITH SINGLE DETERMINATION, FOR COLORECTAL NEOPLASM SCREENING (IE, PATIENT WAS PROVIDED 3 CARDS OR SINGLE TRIPLE CARD FOR CONSECUTIVE COLLECTION) CPT BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; 17 OTHER SOURCES CPT BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, 17 FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING CPT BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY 82 IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS CPT BRADYKININ 35 CPT CADMIUM 119 CPT CALCIFEDIOL (25-OH VITAMIN D-3) 152 CPT CALCIFEROL (VITAMIN D) 165 CPT CALCITONIN 137 CPT CALCIUM; TOTAL 26 CPT CALCIUM; IONIZED 70 CPT CALCIUM; AFTER CALCIUM INFUSION TEST 27 CPT CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 31 CPT CALCULUS; QUALITATIVE ANALYSIS 59 CPT CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 66 CPT CALCULUS; INFRARED SPECTROSCOPY 66 CPT CALCULUS; X-RAY DIFFRACTION 64 CPT CARBOHYDRATE DEFICIENT TRANSFERRIN 93 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 271 of 380

272 CPT CARBON DIOXIDE (BICARBONATE) 25 CPT CARBON MONOXIDE (CARBOXYHEMOGLOBIN); QUANTITATIVE 63 CPT CARBON MONOXIDE (CARBOXYHEMOGLOBIN); QUALITATIVE 31 CPT CARCINOEMBRYONIC ANTIGEN (CEA) 97 CPT CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN 87 CPT CAROTENE 47 CPT CATECHOLAMINES; TOTAL URINE 88 CPT CATECHOLAMINES; BLOOD 129 CPT CATECHOLAMINES; FRACTIONATED 130 CPT CATHEPSIN-D 107 CPT CERULOPLASMIN 55 CPT CHEMILUMINESCENT ASSAY 73 CPT CHLORAMPHENICOL 65 CPT CHLORIDE; BLOOD 24 CPT CHLORIDE; URINE 26 CPT CHLORIDE; OTHER SOURCE 25 CPT CHLORINATED HYDROCARBONS, SCREEN 31 CPT CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 22 CPT CHOLINESTERASE; SERUM 40 CPT CHOLINESTERASE; RBC 39 CPT CHONDROITIN B SULFATE, QUANTITATIVE 106 CPT CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR HPLC), 93 ANALYTE NOT ELSEWHERE SPECIFIED CPT CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE NOT 82 ELSEWHERE SPECIFIED CPT CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE NOT 110 ELSEWHERE SPECIFIED CPT CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT 95 ELSEWHERE SPECIFIED CPT CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); 93 SINGLE ANALYTE NOT ELSEWHERE SPECIFIED, SINGLE STATIONARY AND MOBILE PHASE CPT CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); 93 MULTIPLE ANALYTES, SINGLE STATIONARY AND MOBILE PHASE CPT CHROMIUM 104 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 272 of 380

273 CPT CITRATE 143 CPT COCAINE OR METABOLITE 78 CPT COLLAGEN CROSS LINKS, ANY METHOD 96 CPT COPPER 64 CPT CORTICOSTERONE 116 CPT CORTISOL; FREE 86 CPT CORTISOL; TOTAL 84 CPT CREATINE 24 CPT COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; STABLE ISOTOPE DILUTION, SINGLE ANALYTE, QUANTITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; STABLE ISOTOPE DILUTION, MULTIPLE ANALYTES, QUANTITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT CREATINE KINASE (CK), (CPK); TOTAL 33 CPT CREATINE KINASE (CK), (CPK); ISOENZYMES 69 CPT CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 59 CPT CREATINE KINASE (CK), (CPK); ISOFORMS 61 CPT CREATININE; BLOOD 26 CPT CREATININE; OTHER SOURCE 27 CPT CREATININE; CLEARANCE 49 CPT CRYOFIBRINOGEN 44 CPT CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, CRYOCRIT) 33 CPT CYANIDE 100 CPT CYANOCOBALAMIN (VITAMIN B-12); 77 CPT CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY 74 CPT CYSTATIN C 70 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 273 of 380

274 CPT CYSTINE AND HOMOCYSTINE, URINE, QUALITATIVE 42 CPT DEHYDROEPIANDROSTERONE (DHEA) 130 CPT DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 114 CPT DESOXYCORTICOSTERONE, CPT DEOXYCORTISOL, CPT DIBUCAINE NUMBER 63 CPT DIHYDROCODEINONE 106 CPT DIHYDROMORPHINONE 132 CPT DIHYDROTESTOSTERONE (DHT) 132 CPT DIHYDROXYVITAMIN D, 1, CPT DIMETHADIONE 71 CPT ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI- 59 QUANTITATIVE CPT ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT 93 ELSEWHERE SPECIFIED; NONRADIOACTIVE SUBSTRATE, EACH SPECIMEN CPT ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT 93 ELSEWHERE SPECIFIED; RADIOACTIVE SUBSTRATE, EACH SPECIMEN CPT ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE SPECIFIED 176 CPT EPIANDROSTERONE 110 CPT ERYTHROPOIETIN 96 CPT ESTRADIOL 143 CPT ESTROGENS; FRACTIONATED 166 CPT ESTROGENS; TOTAL 111 CPT ESTRIOL 124 CPT ESTRONE 128 CPT ETHCHLORVYNOL 89 CPT ETHYLENE GLYCOL 77 CPT ETIOCHOLANOLONE 121 CPT FAT OR LIPIDS, FECES; QUALITATIVE 26 CPT FAT OR LIPIDS, FECES; QUANTITATIVE 86 CPT FAT DIFFERENTIAL, FECES, QUANTITATIVE 88 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 274 of 380

275 CPT FATTY ACIDS, NONESTERIFIED 68 CPT VERY LONG CHAIN FATTY ACIDS 93 CPT FERRITIN 70 CPT FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI- 330 QUANTITATIVE CPT FLUORIDE 95 CPT FLURAZEPAM 102 CPT FOLIC ACID; SERUM 75 CPT FOLIC ACID; RBC 89 CPT FRUCTOSE, SEMEN 89 CPT GALACTOKINASE, RBC 110 CPT GALACTOSE 57 CPT GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; QUANTITATIVE 108 CPT GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; SCREEN 43 CPT GAMMAGLOBULIN; IGA, IGD, IGG, IGM, EACH 48 CPT GAMMAGLOBULIN; IGE 85 CPT GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES (IGG1, 2, 3, OR 4), 41 EACH CPT GASES, BLOOD, PH ONLY 43 CPT GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 99 (INCLUDING CALCULATED O2 SATURATION); CPT GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 146 (INCLUDING CALCULATED O2 SATURATION); WITH O2 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULSE OXIMETRY CPT GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, 45 EXCEPT PULSE OXIMETRY CPT HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN 51 SATURATION WITH OXYGEN) CPT GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 28 CPT GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 34 CPT GASTRIN AFTER SECRETIN STIMULATION 91 CPT GASTRIN 91 CPT GLUCAGON 73 CPT GLUCOSE, BODY FLUID, OTHER THAN BLOOD 20 CPT GLUCAGON TOLERANCE TEST 77 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 275 of 380

276 CPT GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP) 20 CPT GLUCOSE; BLOOD, REAGENT STRIP 16 CPT GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 24 CPT GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES 66 GLUCOSE) CPT GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE 20 SPECIMENS CPT GLUCOSE; TOLBUTAMIDE TOLERANCE TEST 78 CPT GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); QUANTITATIVE 50 CPT GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); SCREEN 31 CPT GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE 12 FDA SPECIFICALLY FOR HOME USE CPT GLUCOSIDASE, BETA 110 CPT GLUTAMATE DEHYDROGENASE 40 CPT GLUTAMINE (GLUTAMIC ACID AMIDE) 81 CPT GLUTAMYLTRANSFERASE, GAMMA (GGT) 37 CPT GLUTATHIONE 73 CPT GLUTATHIONE REDUCTASE, RBC 35 CPT GLUTETHIMIDE 94 CPT GLYCATED PROTEIN 77 CPT GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 95 CPT GONADOTROPIN; LUTEINIZING HORMONE (LH) 95 CPT GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN) 86 CPT GUANOSINE MONOPHOSPHATE (GMP), CYCLIC 86 CPT HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE ACTIVITY, 346 NON-RADIOACTIVE ISOTOPE (EG, C-13) CPT HAPTOGLOBIN; QUANTITATIVE 65 CPT HAPTOGLOBIN; PHENOTYPES 88 CPT HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, 346 NON-RADIOACTIVE ISOTOPE (EG, C-13) CPT HELICOBACTER PYLORI; DRUG ADMINISTRATION 40 CPT HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN CPT HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTITATIVE, EACH Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 276 of 380

277 CPT HEMOGLOBIN FRACTIONATION AND QUANTITATION; ELECTROPHORESIS 66 (EG, A2, S, C, AND/OR F) CPT HEMOGLOBIN FRACTIONATION AND QUANTITATION; CHROMATOGRAPHY 93 (EG, A2, S, C, AND/OR F) CPT HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED 12 CPT HEMOGLOBIN; F (FETAL), CHEMICAL 42 CPT HEMOGLOBIN; F (FETAL), QUALITATIVE 31 CPT HEMOGLOBIN; GLYCOSYLATED (A1C) 50 CPT HEMOGLOBIN; GLYCOSYLATED (A1C) BY DEVICE CLEARED BY FDA FOR 50 HOME USE CPT HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE 25 CPT HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE 38 CPT HEMOGLOBIN; PLASMA 38 CPT HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE 25 CPT HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 42 CPT HEMOGLOBIN; THERMOLABILE 35 CPT HEMOGLOBIN; UNSTABLE, SCREEN 43 CPT HEMOGLOBIN; URINE 20 CPT HEMOSIDERIN; QUALITATIVE 24 CPT HEMOSIDERIN; QUANTITATIVE 35 CPT B-HEXOSAMINIDASE, EACH ASSAY 87 CPT HISTAMINE 152 CPT HOMOCYSTEINE 87 CPT HOMOVANILLIC ACID (HVA) 99 CPT HYDROXYCORTICOSTEROIDS, 17- (17-OHCS) 90 CPT HYDROXYINDOLACETIC ACID, 5-(HIAA) 66 CPT HYDROXYPROGESTERONE, 17-D 139 CPT HYDROXYPROGESTERONE, CPT HYDROXYPROLINE; FREE 116 CPT HYDROXYPROLINE; TOTAL 125 CPT IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP METHOD 59 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 277 of 380

278 CPT IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY 44 OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE; SINGLE STEP METHOD (EG, REAGENT STRIP) CPT IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY RADIOPHARMACEUTICAL 69 TECHNIQUE (EG, RIA) CPT IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE SPECIFIED 66 CPT INSULIN; TOTAL 59 CPT INSULIN; FREE 66 CPT INTRINSIC FACTOR 82 CPT IRON 33 CPT IRON BINDING CAPACITY 45 CPT ISOCITRIC DEHYDROGENASE (IDH) 45 CPT KETOGENIC STEROIDS, FRACTIONATION 289 CPT KETOSTEROIDS, 17- (17-KS); TOTAL 66 CPT KETOSTEROIDS, 17- (17-KS); FRACTIONATION 135 CPT LACTATE (LACTIC ACID) 55 CPT LACTATE DEHYDROGENASE (LD), (LDH); 31 CPT LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND 66 QUANTITATION CPT LACTOFERRIN, FECAL; QUALITATIVE 101 CPT LACTOFERRIN, FECAL; QUANTITATIVE 101 CPT LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC 104 SOMATOMAMMOTROPIN CPT LACTOSE, URINE; QUALITATIVE 28 CPT LACTOSE, URINE; QUANTITATIVE 59 CPT LEAD 62 CPT FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN (L/S) 113 RATIO CPT FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST 97 CPT FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE POLARIZATION 97 CPT FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY 97 CPT LEUCINE AMINOPEPTIDASE (LAP) 47 CPT LIPASE 35 CPT LIPOPROTEIN (A) 66 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 278 of 380

279 CPT LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 (LP-PLA2) 174 CPT LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND 58 QUANTITATION CPT LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND 127 QUANTITATION OF LIPOPROTEINS INCLUDING LIPOPROTEIN SUBCLASSES WHEN PERFORMED (EG, ELECTROPHORESIS, ULTRACENTRIFUGATION) CPT LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE 162 NUMBERS AND LIPOPROTEIN PARTICLE SUBCLASSES (EG, BY NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY) CPT LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL 42 (HDL CHOLESTEROL) CPT LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL 60 CPT LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL 49 CPT LUTEINIZING RELEASING FACTOR (LRH) 88 CPT MAGNESIUM 34 CPT MALATE DEHYDROGENASE 38 CPT MANGANESE 126 CPT MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), 93 ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, EACH SPECIMEN CPT MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), 93 ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, EACH SPECIMEN CPT MEPROBAMATE 90 CPT MERCURY, QUANTITATIVE 83 CPT METANEPHRINES 87 CPT METHADONE 84 CPT METHEMALBUMIN 55 CPT METHSUXIMIDE 76 CPT MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE 102 CPT MUCOPOLYSACCHARIDES, ACID; SCREEN 51 CPT MUCIN, SYNOVIAL FLUID (ROPES TEST) 30 CPT MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID 88 CPT MYOGLOBIN 66 CPT NATRIURETIC PEPTIDE 174 CPT NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE SPECIFIED 70 CPT NICKEL 126 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 279 of 380

280 CPT NICOTINE 122 CPT MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION 21 CPT MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY 21 PURIFIED NUCLEIC ACID CPT MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 21 CPT MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION 21 CPT MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, 21 AGAROSE, POLYACRYLAMIDE) CPT MOLECULAR DIAGNOSTICS; NUCLEIC ACID PROBE, EACH 21 CPT MOLECULAR DIAGNOSTICS; NUCLEIC ACID TRANSFER (EG, SOUTHERN, 21 NORTHERN) CPT MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, EACH NUCLEIC 86 ACID SEQUENCE CPT MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, MULTIPLEX, FIRST 172 TWO NUCLEIC ACID SEQUENCES CPT MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, MULTIPLEX, EACH 86 ADDITIONAL NUCLEIC ACID SEQUENCE BEYOND 2 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION 73 CPT MOLECULAR DIAGNOSTICS; MUTATION SCANNING, BY PHYSICAL 86 PROPERTIES (EG, SINGLE STRAND CONFORMATIONAL POLYMORPHISMS (SSCP), HETERODUPLEX, DENATURING GRADIENT GEL ELECTROPHORESIS (DGGE), RNA'ASE A), SINGLE SEGMENT, EACH CPT MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY SEQUENCING, 86 SINGLE SEGMENT, EACH SEGMENT CPT MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 86 SPECIFIC TRANSCRIPTION, SINGLE SEGMENT, EACH SEGMENT CPT MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 86 SPECIFIC TRANSLATION, SINGLE SEGMENT, EACH SEGMENT CPT MOLECULAR DIAGNOSTICS; LYSIS OF CELLS PRIOR TO NUCLEIC ACID 69 EXTRACTION (EG, STOOL SPECIMENS, PARAFFIN EMBEDDED TISSUE) CPT MOLECULAR DIAGNOSTICS; AMPLIFICATION, SIGNAL, EACH NUCLEIC 86 ACID SEQUENCE CPT MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY HIGH 86 RESOLUTION TECHNIQUE (EG, CAPILLARY ELECTROPHORESIS) CPT MOLECULAR DIAGNOSTICS; INTERPRETATION AND REPORT 21 CPT MOLECULAR DIAGNOSTICS; RNA STABILIZATION 69 CPT MUTATION IDENTIFICATION BY ENZYMATIC LIGATION OR PRIMER 86 EXTENSION, SINGLE SEGMENT, EACH SEGMENT (EG, OLIGONUCLEOTIDE LIGATION ASSAY (OLA), SINGLE BASE CHAIN EXTENSION (SBCE), OR ALLELE-SPECIFIC PRIMER EXTENSION (ASPE)) CPT NUCLEOTIDASE 5'- 57 CPT OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS) 103 CPT ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN 85 CPT ORGANIC ACIDS; QUALITATIVE, EACH SPECIMEN 85 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 280 of 380

281 CPT ORGANIC ACID, SINGLE, QUANTITATIVE 85 CPT OPIATES (EG, MORPHINE, MEPERIDINE) 100 CPT OSMOLALITY; BLOOD 34 CPT OSMOLALITY; URINE 35 CPT OSTEOCALCIN (BONE G1A PROTEIN) 153 CPT OXALATE 66 CPT ONCOPROTEIN, HER-2/NEU 330 CPT PARATHORMONE (PARATHYROID HORMONE) 212 CPT PH, BODY FLUID, EXCEPT BLOOD 18 CPT PHENCYCLIDINE (PCP) 75 CPT CALPROTECTIN, FECAL 101 CPT PHENOTHIAZINE 80 CPT PHENYLALANINE (PKU), BLOOD 28 CPT PHENYLKETONES, QUALITATIVE 19 CPT PHOSPHATASE, ACID; TOTAL 38 CPT PHOSPHATASE, ACID; FORENSIC EXAMINATION 41 CPT PHOSPHATASE, ACID; PROSTATIC 50 CPT PHOSPHATASE, ALKALINE; 27 CPT PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED) 38 CPT PHOSPHATASE, ALKALINE; ISOENZYMES 76 CPT PHOSPHATIDYLGLYCEROL 85 CPT PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 35 CPT PHOSPHOHEXOSE ISOMERASE 53 CPT PHOSPHORUS INORGANIC (PHOSPHATE); 24 CPT PHOSPHORUS INORGANIC (PHOSPHATE); URINE 27 CPT PORPHOBILINOGEN, URINE; QUALITATIVE 22 CPT PORPHOBILINOGEN, URINE; QUANTITATIVE 43 CPT PORPHYRINS, URINE; QUALITATIVE 44 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 281 of 380

282 CPT PORPHYRINS, URINE; QUANTITATION AND FRACTIONATION 253 CPT PORPHYRINS, FECES; QUANTITATIVE 131 CPT PORPHYRINS, FECES; QUALITATIVE 60 CPT POTASSIUM; SERUM 24 CPT POTASSIUM; URINE 22 CPT PREALBUMIN 75 CPT PREGNANEDIOL 98 CPT PREGNANETRIOL 97 CPT PREGNENOLONE 106 CPT HYDROXYPREGNENOLONE 117 CPT PROGESTERONE 107 CPT PROLACTIN 99 CPT PROSTAGLANDIN, EACH 128 CPT PROSTATE SPECIFIC ANTIGEN (PSA); COMPLEXED (DIRECT 94 MEASUREMENT) CPT PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 94 CPT PROSTATE SPECIFIC ANTIGEN (PSA); FREE 94 CPT PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM 19 CPT PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE 19 CPT PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, 19 SYNOVIAL FLUID, CEREBROSPINAL FLUID) CPT PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 27 CPT PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A) 77 CPT PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 55 SERUM CPT PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 92 OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF) CPT PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD 87 OR OTHER BODY FLUID CPT PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD 92 OR OTHER BODY FLUID, IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH CPT PROTOPORPHYRIN, RBC; QUANTITATIVE 74 CPT PROTOPORPHYRIN, RBC; SCREEN 44 CPT PROINSULIN 91 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 282 of 380

283 CPT PYRIDOXAL PHOSPHATE (VITAMIN B-6) 144 CPT PYRUVATE 56 CPT PYRUVATE KINASE 48 CPT QUININE 60 CPT RECEPTOR ASSAY; ESTROGEN 330 CPT RECEPTOR ASSAY; PROGESTERONE 333 CPT RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR 269 PROGESTERONE (SPECIFY HORMONE) CPT RECEPTOR ASSAY; NON-ENDOCRINE (SPECIFY RECEPTOR) 188 CPT RENIN 113 CPT RIBOFLAVIN (VITAMIN B-2) 104 CPT SELENIUM 131 CPT SEROTONIN 159 CPT SEX HORMONE BINDING GLOBULIN (SHBG) 112 CPT SIALIC ACID 69 CPT SILICA 121 CPT SODIUM; SERUM 25 CPT SODIUM; URINE 25 CPT SODIUM; OTHER SOURCE 25 CPT SOMATOMEDIN 109 CPT SOMATOSTATIN 94 CPT SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED 36 CPT SPECIFIC GRAVITY (EXCEPT URINE) 13 CPT SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY 101 CPT SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, 28 EACH SPECIMEN CPT SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 28 QUALITATIVE, EACH SPECIMEN CPT SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE 59 QUANTITATIVE, EACH SPECIMEN CPT SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 59 QUANTITATIVE, EACH SPECIMEN CPT SULFATE, URINE 24 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 283 of 380

284 CPT TESTOSTERONE; FREE 131 CPT TESTOSTERONE; TOTAL 133 CPT THIAMINE (VITAMIN B-1) 109 CPT THIOCYANATE 60 CPT THYROGLOBULIN 82 CPT THYROXINE; TOTAL 35 CPT THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 33 CPT THYROXINE; FREE 46 CPT THYROXINE BINDING GLOBULIN (TBG) 76 CPT THYROID STIMULATING HORMONE (TSH) 86 CPT THYROID STIMULATING IMMUNE GLOBULINS (TSI) 261 CPT TOCOPHEROL ALPHA (VITAMIN E) 73 CPT TRANSCORTIN (CORTISOL BINDING GLOBULIN) 92 CPT TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 27 CPT TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 27 CPT TRANSFERRIN 66 CPT TRIGLYCERIDES 30 CPT THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING 33 RATIO (THBR) CPT TRIIODOTHYRONINE T3; TOTAL (TT-3) 73 CPT TRIIODOTHYRONINE T3; FREE 87 CPT TRIIODOTHYRONINE T3; REVERSE 81 CPT TROPONIN, QUANTITATIVE 51 CPT TRYPSIN; DUODENAL FLUID 39 CPT TRYPSIN; FECES, QUALITATIVE 38 CPT TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION 39 CPT TYROSINE 53 CPT TROPONIN, QUALITATIVE 40 CPT UREA NITROGEN; QUANTITATIVE 20 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 284 of 380

285 CPT UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST) 19 CPT UREA NITROGEN, URINE 24 CPT UREA NITROGEN, CLEARANCE 34 CPT URIC ACID; BLOOD 23 CPT URIC ACID; OTHER SOURCE 24 CPT UROBILINOGEN, FECES, QUANTITATIVE 64 CPT UROBILINOGEN, URINE; QUALITATIVE 17 CPT UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN 36 CPT UROBILINOGEN, URINE; SEMIQUANTITATIVE 26 CPT VANILLYLMANDELIC ACID (VMA), URINE 80 CPT VASOACTIVE INTESTINAL PEPTIDE (VIP) 181 CPT VASOPRESSIN (ANTIDIURETIC HORMONE, ADH) 174 CPT VITAMIN A 60 CPT VITAMIN, NOT OTHERWISE SPECIFIED 60 CPT VITAMIN K 70 CPT VOLATILES (EG, ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, 82 DICHLOROETHANE, DICHLOROMETHANE, DIETHYLETHER, ISOPROPYL ALCOHOL, METHANOL) CPT XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 61 CPT ZINC 58 CPT C-PEPTIDE 107 CPT GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 77 CPT GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 39 CPT GONADOTROPIN, CHORIONIC (HCG); FREE BETA CHAIN 77 CPT OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR 52 HUMAN LUTEINIZING HORMONE CPT UNLISTED CHEMISTRY PROCEDURE N/A CPT BLEEDING TIME 23 CPT BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 33 CPT BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT CPT BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITHOUT MANUAL DIFFERENTIAL WBC COUNT Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 285 of 380

286 CPT BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT 19 CPT BLOOD COUNT; SPUN MICROHEMATOCRIT 12 CPT BLOOD COUNT; HEMATOCRIT (HCT) 12 CPT BLOOD COUNT; HEMOGLOBIN (HGB) 12 CPT BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND 40 PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT CPT BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND 33 PLATELET COUNT) CPT BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR 22 PLATELET) EACH CPT BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 15 CPT BLOOD COUNT; RETICULOCYTE, MANUAL 22 CPT BLOOD COUNT; RETICULOCYTE, AUTOMATED 21 CPT BLOOD COUNT; RETICULOCYTES, AUTOMATED, INCLUDING ONE OR MORE 29 CELLULAR PARAMETERS (EG, RETICULOCYTE HEMOGLOBIN CONTENT (CHR), IMMATURE RETICULOCYTE FRACTION (IRF), RETICULOCYTE VOLUME (MRV), RNA CONTENT), DIRECT MEASUREMENT CPT BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 13 CPT BLOOD COUNT; PLATELET, AUTOMATED 23 CPT RETICULATED PLATELET ASSAY 137 CPT BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH 76 WRITTEN REPORT CPT BONE MARROW, SMEAR INTERPRETATION 280 CPT CHROMOGENIC SUBSTRATE ASSAY 61 CPT CLOT RETRACTION 19 CPT CLOT LYSIS TIME, WHOLE BLOOD DILUTION 23 CPT CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC 67 CPT CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR 91 CPT CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR) 92 CPT CLOTTING; FACTOR VIII (AHG), ONE STAGE 92 CPT CLOTTING; FACTOR VIII RELATED ANTIGEN 105 CPT CLOTTING; FACTOR VIII, VW FACTOR, RISTOCETIN COFACTOR 118 CPT CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN 118 CPT CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR, MULTIMETRIC ANALYSIS 118 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 286 of 380

287 CPT CLOTTING; FACTOR IX (PTC OR CHRISTMAS) 98 CPT CLOTTING; FACTOR X (STUART-PROWER) 92 CPT CLOTTING; FACTOR XI (PTA) 92 CPT CLOTTING; FACTOR XII (HAGEMAN) 99 CPT CLOTTING; FACTOR XIII (FIBRIN STABILIZING) 84 CPT CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY 46 CPT CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY) 97 CPT CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY (FITZGERALD 97 FACTOR ASSAY) CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 61 ACTIVITY CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 56 ANTIGEN ASSAY CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN 62 CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY 71 CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL 60 CPT CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE 79 CPT ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 79 CPT FACTOR INHIBITOR TEST 66 CPT THROMBOMODULIN 54 CPT COAGULATION TIME; LEE AND WHITE 22 CPT COAGULATION TIME; ACTIVATED 22 CPT COAGULATION TIME; OTHER METHODS 19 CPT EUGLOBULIN LYSIS 43 CPT FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 35 AGGLUTINATION SLIDE, SEMIQUANTITATIVE CPT FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 44 PARACOAGULATION CPT FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 58 QUANTITATIVE CPT FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR 37 SEMIQUANTITATIVE CPT FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE 52 CPT FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR 52 EVALUATION FOR VENOUS THROMBOEMBOLISM), QUALITATIVE OR SEMIQUANTITATIVE CPT FIBRINOGEN; ACTIVITY 44 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 287 of 380

288 CPT FIBRINOGEN; ANTIGEN 44 CPT FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND 27 REPORT CPT COAGULATION/FIBRINOLYSIS ASSAY, WHOLE BLOOD (EG, VISCOELASTIC 64 CLOT ASSESSMENT), INCLUDING USE OF ANY PHARMACOLOGIC ADDITIVE(S), AS INDICATED, INCLUDING INTERPRETATION AND WRITTEN REPORT, PER DAY CPT FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 45 CPT FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN 40 CPT FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR 88 CPT FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT 34 ANTIGENIC ASSAY CPT FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC 52 ASSAY CPT HEINZ BODIES; DIRECT 22 CPT HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE 35 CPT HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 40 DIFFERENTIAL LYSIS (KLEIHAUER-BETKE) CPT HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 34 ROSETTE CPT HEMOLYSIN, ACID 46 CPT HEPARIN ASSAY 67 CPT HEPARIN NEUTRALIZATION 61 CPT HEPARIN-PROTAMINE TOLERANCE TEST 73 CPT IRON STAIN, PERIPHERAL BLOOD 33 CPT LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT 44 CPT MECHANICAL FRAGILITY, RBC 44 CPT MURAMIDASE 96 CPT OSMOTIC FRAGILITY, RBC; UNINCUBATED 34 CPT OSMOTIC FRAGILITY, RBC; INCUBATED 69 CPT PLATELET, AGGREGATION (IN VITRO), EACH AGENT 110 CPT PLATELET NEUTRALIZATION 92 CPT PROTHROMBIN TIME; 20 CPT PROTHROMBIN TIME; SUBSTITUTION, PLASMA FRACTIONS, EACH 20 CPT RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED 49 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 288 of 380

289 CPT RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED 49 CPT REPTILASE TEST 51 CPT SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED 18 CPT SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED 14 CPT SICKLING OF RBC, REDUCTION 28 CPT THROMBIN TIME; PLASMA 30 CPT THROMBIN TIME; TITER 35 CPT THROMBOPLASTIN INHIBITION, TISSUE 49 CPT THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD 31 CPT THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA 33 FRACTIONS, EACH CPT VISCOSITY 60 CPT UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE N/A CPT AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, 36 Q FEVER, ROCKY MOUNTAIN SPOTTED FEVER, SCRUB TYPHUS), EACH ANTIGEN CPT ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH 27 ALLERGEN CPT ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH 27 ALLERGEN CPT ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN 41 (DIPSTICK, PADDLE, OR DISK) CPT ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES 77 CPT ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 291 CPT ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED IMMUNOGLOBULIN 64 ASSAY CPT ANTINUCLEAR ANTIBODIES (ANA); 62 CPT ANTINUCLEAR ANTIBODIES (ANA); TITER 57 CPT ANTISTREPTOLYSIN 0; TITER 38 CPT ANTISTREPTOLYSIN 0; SCREEN 30 CPT BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS MATCH AND/OR EVALUATION OF IRREGULAR ANTIBODY(S), INTERPRETATION AND WRITTEN REPORT CPT BLOOD BANK PHYSICIAN SERVICES; INVESTIGATION OF TRANSFUSION REACTION INCLUDING SUSPICION OF TRANSMISSIBLE DISEASE, INTERPRETATION AND WRITTEN REPORT CPT BLOOD BANK PHYSICIAN SERVICES; AUTHORIZATION FOR DEVIATION FROM STANDARD BLOOD BANKING PROCEDURES (EG, USE OF OUTDATED BLOOD, TRANSFUSION OF RH INCOMPATIBLE UNITS), WITH WRITTEN REPORT Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 289 of 380

290 CPT C-REACTIVE PROTEIN; 27 CPT C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 66 CPT BETA 2 GLYCOPROTEIN I ANTIBODY, EACH 131 CPT CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS 131 CPT ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY 82 CPT CHEMOTAXIS ASSAY, SPECIFY METHOD 82 CPT COLD AGGLUTININ; SCREEN 34 CPT COLD AGGLUTININ; TITER 41 CPT COMPLEMENT; ANTIGEN, EACH COMPONENT 62 CPT COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT 62 CPT COMPLEMENT; TOTAL HEMOLYTIC (CH50) 104 CPT COMPLEMENT FIXATION TESTS, EACH ANTIGEN 51 CPT COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN 46 CPT CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 66 CPT DEOXYRIBONUCLEASE, ANTIBODY 68 CPT DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE OR DOUBLE 71 STRANDED CPT DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE STRANDED 62 CPT EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, 92 NRNP, SS-A, SS-B, SM, RNP, SC170, J01), EACH ANTIBODY CPT FC RECEPTOR 105 CPT FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; SCREEN, EACH 62 ANTIBODY CPT FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; TITER, EACH 62 ANTIBODY CPT GROWTH HORMONE, HUMAN (HGH), ANTIBODY 81 CPT HEMAGGLUTINATION INHIBITION TEST (HAI) 42 CPT IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR 101 SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN) CPT IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29) 107 CPT IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA CPT IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA CPT HETEROPHILE ANTIBODIES; SCREENING 27 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 290 of 380

291 CPT HETEROPHILE ANTIBODIES; TITER 33 CPT HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF 38 CELLS AND GUINEA PIG KIDNEY CPT IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE 107 (EG, CA 50, 72-4, 549), EACH CPT IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUANTITATIVE, NOT 77 OTHERWISE SPECIFIED CPT IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUALITATIVE OR 66 SEMIQUANTITATIVE, SINGLE STEP METHOD (EG, REAGENT STRIP) CPT IMMUNOELECTROPHORESIS; SERUM 115 CPT IMMUNOELECTROPHORESIS; OTHER FLUIDS (EG, URINE, CEREBROSPINAL 115 FLUID) WITH CONCENTRATION CPT IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY) 116 CPT IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 72 CPT IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), 62 EACH ANTIGEN OR ANTIBODY CPT IMMUNE COMPLEX ASSAY 125 CPT IMMUNOFIXATION ELECTROPHORESIS; SERUM 115 CPT IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH 151 CONCENTRATION (EG, URINE, CSF) CPT INHIBIN A 80 CPT INSULIN ANTIBODIES 110 CPT INTRINSIC FACTOR ANTIBODIES 77 CPT ISLET CELL ANTIBODY 102 CPT LEUKOCYTE HISTAMINE RELEASE TEST (LHR) 64 CPT LEUKOCYTE PHAGOCYTOSIS 282 CPT LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR 252 ANTIGEN INDUCED BLASTOGENESIS CPT B CELLS, TOTAL COUNT 194 CPT MONONUCLEAR CELL ANTIGEN, QUANTITATIVE (EG, FLOW CYTOMETRY), 137 NOT OTHERWISE SPECIFIED, EACH ANTIGEN CPT NATURAL KILLER (NK) CELLS, TOTAL COUNT 194 CPT T CELLS; TOTAL COUNT 194 CPT T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO 241 CPT T CELLS; ABSOLUTE CD4 COUNT 137 CPT STEM CELLS (IE, CD34), TOTAL COUNT 194 CPT MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 291 of 380

292 CPT MIGRATION INHIBITORY FACTOR TEST (MIF) 101 CPT NEUTRALIZATION TEST, VIRAL 87 CPT NITROBLUE TETRAZOLIUM DYE TEST (NTD) 336 CPT PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY 52 CPT PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 55 CPT RHEUMATOID FACTOR; QUALITATIVE 29 CPT RHEUMATOID FACTOR; QUANTITATIVE 29 CPT TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF 318 GAMMA INTERFERON ANTIGEN RESPONSE CPT SKIN TEST; CANDIDA 44 CPT SKIN TEST; UNLISTED ANTIGEN, EACH 18 CPT SKIN TEST; COCCIDIOIDOMYCOSIS 18 CPT SKIN TEST; HISTOPLASMOSIS 18 CPT SKIN TEST; TUBERCULOSIS, INTRADERMAL 22 CPT STREPTOKINASE, ANTIBODY 57 CPT SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 22 CPT SYPHILIS TEST; QUANTITATIVE 23 CPT ANTIBODY; ACTINOMYCES 52 CPT ANTIBODY; ADENOVIRUS 66 CPT ANTIBODY; ASPERGILLUS 77 CPT ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED 66 CPT ANTIBODY; BARTONELLA 52 CPT ANTIBODY; BLASTOMYCES 66 CPT ANTIBODY; BORDETELLA 68 CPT ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY 80 TEST (EG, WESTERN BLOT OR IMMUNOBLOT) CPT ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) 87 CPT ANTIBODY; BORRELIA (RELAPSING FEVER) 69 CPT ANTIBODY; BRUCELLA 46 CPT ANTIBODY; CAMPYLOBACTER 67 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 292 of 380

293 CPT ANTIBODY; CANDIDA 326 CPT ANTIBODY; CHLAMYDIA 61 CPT ANTIBODY; CHLAMYDIA, IGM 65 CPT ANTIBODY; COCCIDIOIDES 59 CPT ANTIBODY; COXIELLA BURNETII (Q FEVER) 62 CPT ANTIBODY; CRYPTOCOCCUS 74 CPT ANTIBODY; CYTOMEGALOVIRUS (CMV) 72 CPT ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM 86 CPT ANTIBODY; DIPHTHERIA 78 CPT ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 68 CPT ANTIBODY; ENCEPHALITIS, EASTERN EQUINE 68 CPT ANTIBODY; ENCEPHALITIS, ST. LOUIS 68 CPT ANTIBODY; ENCEPHALITIS, WESTERN EQUINE 68 CPT ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO) 67 CPT ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA) 67 CPT ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA) 79 CPT ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA) 93 CPT ANTIBODY; EHRLICHIA 333 CPT ANTIBODY; FRANCISELLA TULARENSIS 53 CPT ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 63 CPT ANTIBODY; GIARDIA LAMBLIA 76 CPT ANTIBODY; HELICOBACTER PYLORI 75 CPT ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED 67 CPT ANTIBODY; HAEMOPHILUS INFLUENZA 81 CPT ANTIBODY; HTLV-I 43 CPT ANTIBODY; HTLV-II 72 CPT ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, WESTERN 99 BLOT) CPT ANTIBODY; HEPATITIS, DELTA AGENT 88 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 293 of 380

294 CPT ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST 74 CPT ANTIBODY; HERPES SIMPLEX, TYPE 1 68 CPT ANTIBODY; HERPES SIMPLEX, TYPE 2 99 CPT ANTIBODY; HISTOPLASMA 64 CPT ANTIBODY; HIV-1 46 CPT ANTIBODY; HIV-2 69 CPT ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY 63 CPT HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 61 CPT HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 60 CPT HEPATITIS B SURFACE ANTIBODY (HBSAB) 55 CPT HEPATITIS BE ANTIBODY (HBEAB) 59 CPT HEPATITIS A ANTIBODY (HAAB); TOTAL 64 CPT HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY 58 CPT ANTIBODY; INFLUENZA VIRUS 70 CPT ANTIBODY; LEGIONELLA 289 CPT ANTIBODY; LEISHMANIA 63 CPT ANTIBODY; LEPTOSPIRA 68 CPT ANTIBODY; LISTERIA MONOCYTOGENES 68 CPT ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS 66 CPT ANTIBODY; LYMPHOGRANULOMA VENEREUM 61 CPT ANTIBODY; MUCORMYCOSIS 68 CPT ANTIBODY; MUMPS 67 CPT ANTIBODY; MYCOPLASMA 68 CPT ANTIBODY; NEISSERIA MENINGITIDIS 68 CPT ANTIBODY; NOCARDIA 68 CPT ANTIBODY; PARVOVIRUS 77 CPT ANTIBODY; PLASMODIUM (MALARIA) 68 CPT ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED 64 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 294 of 380

295 CPT ANTIBODY; RESPIRATORY SYNCYTIAL VIRUS 66 CPT ANTIBODY; RICKETTSIA 99 CPT ANTIBODY; ROTAVIRUS 68 CPT ANTIBODY; RUBELLA 74 CPT ANTIBODY; RUBEOLA 66 CPT ANTIBODY; SALMONELLA 68 CPT ANTIBODY; SHIGELLA 68 CPT ANTIBODY; TETANUS 76 CPT ANTIBODY; TOXOPLASMA 74 CPT ANTIBODY; TOXOPLASMA, IGM 74 CPT ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) 68 CPT ANTIBODY; TRICHINELLA 64 CPT ANTIBODY; VARICELLA-ZOSTER 66 CPT ANTIBODY; WEST NILE VIRUS, IGM 86 CPT ANTIBODY; WEST NILE VIRUS 74 CPT ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED 66 CPT ANTIBODY; YERSINIA 68 CPT THYROGLOBULIN ANTIBODY 82 CPT HEPATITIS C ANTIBODY; 65 CPT HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, IMMUNOBLOT) 80 CPT LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH TITRATION 268 CPT LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT 244 TITRATION CPT SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY (PRA); 203 STANDARD METHOD CPT SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY (PRA); 152 QUICK METHOD CPT HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN 132 CPT HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS 298 CPT HLA TYPING; DR/DQ, SINGLE ANTIGEN 143 CPT HLA TYPING; DR/DQ, MULTIPLE ANTIGENS 330 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 295 of 380

296 CPT HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 290 CPT HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC) 188 CPT UNLISTED IMMUNOLOGY PROCEDURE N/A CPT ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE 54 CPT ANTIBODY ELUTION (RBC), EACH ELUTION 65 CPT ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH 101 SERUM TECHNIQUE CPT ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM 28 CPT ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, 29 EACH REAGENT RED CELL CPT ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY 27 TITER CPT AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND 218 STORAGE; PREDEPOSITED CPT AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND 340 STORAGE; INTRA- OR POSTOPERATIVE SALVAGE CPT BLOOD TYPING; ABO 15 CPT BLOOD TYPING; RH (D) 15 CPT BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT 48 USING REAGENT SERUM, PER UNIT SCREENED CPT BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING 49 PATIENT SERUM, PER UNIT SCREENED CPT BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH 20 CPT BLOOD TYPING; RH PHENOTYPING, COMPLETE 40 CPT BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH AND 60 MN CPT BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH 52 ADDITIONAL ANTIGEN SYSTEM CPT COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 89 CPT COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE 73 CPT COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE 82 CPT COMPATIBILITY TEST EACH UNIT; ELECTRONIC 65 CPT FRESH FROZEN PLASMA, THAWING, EACH UNIT 35 CPT FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) 272 CPT FROZEN BLOOD, EACH UNIT; THAWING 204 CPT FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) AND 272 THAWING CPT HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH 42 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 296 of 380

297 CPT HEMOLYSINS AND AGGLUTININS; INCUBATED 62 CPT IRRADIATION OF BLOOD PRODUCT, EACH UNIT 75 CPT LEUKOCYTE TRANSFUSION 169 CPT VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED BLOOD 75 CELLS OR PLATELETS), EACH UNIT CPT POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS 68 CPT PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 54 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH CHEMICAL AGENTS OR DRUGS, EACH CPT PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 54 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH ENZYMES, EACH CPT PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 87 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; BY DENSITY GRADIENT SEPARATION CPT PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 73 INCUBATION WITH DRUGS, EACH CPT PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 82 BY DILUTION CPT PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 73 INCUBATION WITH INHIBITORS, EACH CPT PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 73 BY DIFFERENTIAL RED CELL ABSORPTION USING PATIENT RBCS OR RBCS OF KNOWN PHENOTYPE, EACH ABSORPTION CPT SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH UNIT 54 CPT UNLISTED TRANSFUSION MEDICINE PROCEDURE N/A CPT ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION 68 CPT ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND 86 DISSECTION CPT CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS 34 CPT CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) CPT CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES CPT CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE CPT CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT URINE, BLOOD OR STOOL CPT CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT URINE, BLOOD OR STOOL Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 297 of 380

298 CPT CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH 49 ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS 42 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE CPT CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS 42 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE CPT CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 34 CPT CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 44 WITH COLONY ESTIMATION FROM DENSITY CHART CPT CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE 42 CPT CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE 42 IDENTIFICATION OF EACH ISOLATE, URINE CPT CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 40 IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL CPT CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 43 IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD) CPT CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 46 IDENTIFICATION OF ISOLATES; BLOOD CPT CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST 53 CPT CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; MOLD 53 CPT CULTURE, MYCOPLASMA, ANY SOURCE 79 CPT CULTURE, CHLAMYDIA, ANY SOURCE 101 CPT CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, 55 MYCOBACTERIA) ANY SOURCE, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE 56 CPT CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM 29 CPT CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY (GLC) OR HIGH 64 PRESSURE LIQUID CHROMATOGRAPHY (HPLC) METHOD CPT CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER THAN 27 IMMUNOFLUORESENCE (EG, AGGLUTINATION GROUPING), PER ANTISERUM CPT CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE 103 CPT CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD GEL TYPING 27 CPT CULTURE, TYPING; OTHER METHODS 27 CPT DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, 55 SKIN); INCLUDES SPECIMEN COLLECTION CPT DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, 58 SKIN); WITHOUT COLLECTION CPT MACROSCOPIC EXAMINATION; ARTHROPOD 22 CPT MACROSCOPIC EXAMINATION; PARASITE 22 CPT PINWORM EXAM (EG, CELLOPHANE TAPE PREP) 22 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 298 of 380

299 CPT HOMOGENIZATION, TISSUE, FOR CULTURE 30 CPT OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND 46 IDENTIFICATION CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION 24 METHOD, PER AGENT (EG, ANTIBIOTIC GRADIENT STRIP) CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER 35 PLATE (12 OR FEWER AGENTS) CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME DETECTION 24 (EG, BETA LACTAMASE), PER ENZYME CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR 44 AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION (MIC) OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR 53 AGAR DILUTION, MINIMUM LETHAL CONCENTRATION (MLC), EACH PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH 34 DILUTION METHOD, EACH AGENT CPT SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, 29 PROPORTION METHOD, EACH AGENT CPT SERUM BACTERICIDAL TITER (SCHLICTER TEST) 77 CPT SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES CPT SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES CPT SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES) CPT SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES CPT SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS) CPT TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES) CPT TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN) CPT VIRUS ISOLATION; INOCULATION OF EMBRYONATED EGGS, OR SMALL ANIMAL, INCLUDES OBSERVATION AND DISSECTION CPT VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENTIFICATION BY CYTOPATHIC EFFECT CPT VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE IDENTIFICATION (EG, HEMABSORPTION, NEUTRALIZATION, IMMUNOFLUORESENCE STAIN), EACH ISOLATE CPT VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL VIAL) TECHNIQUE, INCLUDES IDENTIFICATION WITH IMMUNOFLUORESCENCE STAIN, EACH VIRUS CPT VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN BY CYTOPATHIC EFFECT (EG, VIRUS SPECIFIC ENZYMATIC ACTIVITY) CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ADENOVIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; BORDETELLA PERTUSSIS/PARAPERTUSSIS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ENTEROVIRUS, DIRECT FLUORESCENT ANTIBODY (DFA) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 299 of 380

300 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; GIARDIA CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CHLAMYDIA TRACHOMATIS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CYTOMEGALOVIRUS, DIRECT FLUORESCENT ANTIBODY (DFA) CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CRYPTOSPORIDIUM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 2 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 1 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; INFLUENZA B VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; INFLUENZA A VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; LEGIONELLA MICDADEI CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; LEGIONELLA PNEUMOPHILA CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; PARAINFLUENZA VIRUS, EACH TYPE CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; RESPIRATORY SYNCYTIAL VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; PNEUMOCYSTIS CARINII CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; RUBEOLA CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; TREPONEMA PALLIDUM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; VARICELLA ZOSTER VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE, POLYVALENT FOR MULTIPLE ORGANISMS, EACH POLYVALENT ANTISERUM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ADENOVIRUS ENTERIC TYPES 40/41 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ASPERGILLUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CHLAMYDIA TRACHOMATIS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CLOSTRIDIUM DIFFICILE TOXIN(S) CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CRYPTOCOCCUS NEOFORMANS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CRYPTOSPORIDIUM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP 62 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 300 of 380

301 METHOD; GIARDIA CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CYTOMEGALOVIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ESCHERICHIA COLI 0157 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ENTAMOEBA HISTOLYTICA DISPAR GROUP CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ENTAMOEBA HISTOLYTICA GROUP CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HELICOBACTER PYLORI, STOOL CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HELICOBACTER PYLORI CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS B SURFACE ANTIGEN (HBSAG) CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS B SURFACE ANTIGEN (HBSAG) NEUTRALIZATION CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS BE ANTIGEN (HBEAG) CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS, DELTA AGENT CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HISTOPLASMA CAPSULATUM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HIV-1 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HIV-2 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; INFLUENZA, A OR B, EACH CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; RESPIRATORY SYNCYTIAL VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ROTAVIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; SHIGA-LIKE TOXIN CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; STREPTOCOCCUS, GROUP A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 301 of 380

302 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP METHOD, NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 49 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; SINGLE STEP METHOD, NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 49 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP METHOD, POLYVALENT FOR MULTIPLE ORGANISMS, EACH POLYVALENT ANTISERUM CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 BORRELIA BURGDORFERI, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 BORRELIA BURGDORFERI, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CANDIDA SPECIES, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CANDIDA SPECIES, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 CANDIDA SPECIES, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 CHLAMYDIA PNEUMONIAE, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 179 CHLAMYDIA TRACHOMATIS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CYTOMEGALOVIRUS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CYTOMEGALOVIRUS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 CYTOMEGALOVIRUS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 ENTEROVIRUS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 VANCOMYCIN RESISTANCE (EG, ENTEROCOCCUS SPECIES VAN A, VAN B), AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 GARDNERELLA VAGINALIS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); GARDNERELLA VAGINALIS, AMPLIFIED PROBE TECHNIQUE 180 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 302 of 380

303 CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 GARDNERELLA VAGINALIS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS B VIRUS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 HEPATITIS B VIRUS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS C, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS C, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 HEPATITIS C, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS G, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS G, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 HEPATITIS G, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 103 SIMPLEX VIRUS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 180 SIMPLEX VIRUS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 220 SIMPLEX VIRUS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 103 VIRUS-6, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 180 VIRUS-6, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 214 VIRUS-6, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 103 DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 180 AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 437 QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 103 DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 180 AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 220 QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 LEGIONELLA PNEUMOPHILA, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 LEGIONELLA PNEUMOPHILA, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 LEGIONELLA PNEUMOPHILA, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA SPECIES, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA SPECIES, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); MYCOBACTERIA SPECIES, QUANTIFICATION 220 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 303 of 380

304 CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA TUBERCULOSIS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA TUBERCULOSIS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 MYCOBACTERIA TUBERCULOSIS, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA AVIUM-INTRACELLULARE, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA AVIUM-INTRACELLULARE, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 MYCOBACTERIA AVIUM-INTRACELLULARE, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOPLASMA PNEUMONIAE, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 MYCOPLASMA PNEUMONIAE, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 NEISSERIA GONORRHOEAE, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 NEISSERIA GONORRHOEAE, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 PAPILLOMAVIRUS, HUMAN, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 PAPILLOMAVIRUS, HUMAN, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 PAPILLOMAVIRUS, HUMAN, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STAPHYLOCOCCUS AUREUS, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 STREPTOCOCCUS, GROUP A, QUANTIFICATION CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 TRICHOMONAS VAGINALIS, DIRECT PROBE TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 103 OTHERWISE SPECIFIED; DIRECT PROBE TECHNIQUE, EACH ORGANISM CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 180 OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 220 OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 206 MULTIPLE ORGANISMS; DIRECT PROBE(S) TECHNIQUE CPT INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 360 MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; STREPTOCOCCUS, GROUP B 62 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 304 of 380

305 CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; CLOSTRIDIUM DIFFICILE TOXIN A CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; INFLUENZA CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; RESPIRATORY SYNCYTIAL VIRUS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; TRICHOMONAS VAGINALIS CPT INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; ADENOVIRUS CPT INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; CHLAMYDIA TRACHOMATIS CPT INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; NEISSERIA GONORRHOEAE CPT INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; STREPTOCOCCUS, GROUP A CPT INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; NOT OTHERWISE SPECIFIED CPT INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION 669 USING REGULARLY UPDATED GENOTYPIC BIOINFORMATICS CPT INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 1,321 RNA); HIV 1, REVERSE TRANSCRIPTASE AND PROTEASE CPT INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 1,321 RNA); HEPATITIS C VIRUS CPT INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 2,507 RNA) WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; FIRST THROUGH 10 DRUGS TESTED CPT INFECTIOUS AGENT PHENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 134 RNA) WITH DRUG RESISTANCE TISSUE CULTURE ANALYSIS, HIV 1; EACH ADDITIONAL DRUG TESTED (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT UNLISTED MICROBIOLOGY PROCEDURE N/A CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITHOUT CNS 674 CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITH BRAIN 775 CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITH BRAIN AND 843 SPINAL CORD CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; INFANT WITH BRAIN 606 CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; STILLBORN OR 606 NEWBORN WITH BRAIN CPT NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; MACERATED 775 STILLBORN CPT NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITHOUT CNS 1,045 CPT NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITH BRAIN 1,146 CPT NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITH BRAIN AND 1,248 SPINAL CORD CPT NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; INFANT WITH BRAIN 606 CPT NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; STILLBORN OR NEWBORN WITH BRAIN CPT NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; REGIONAL Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 305 of 380

306 CPT NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; SINGLE 269 ORGAN CPT NECROPSY (AUTOPSY); FORENSIC EXAMINATION 1,686 CPT NECROPSY (AUTOPSY); CORONER'S CALL 169 CPT UNLISTED NECROPSY (AUTOPSY) PROCEDURE N/A CPT CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 225 OR VAGINAL; SMEARS WITH INTERPRETATION CPT CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 266 OR VAGINAL; SIMPLE FILTER METHOD WITH INTERPRETATION CPT CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 353 OR VAGINAL; SMEARS AND SIMPLE FILTER PREPARATION WITH INTERPRETATION CPT CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS AND 260 INTERPRETATION (EG, SACCOMANNO TECHNIQUE) CPT CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH 338 INTERPRETATION (EG, LIQUID BASED SLIDE PREPARATION METHOD), EXCEPT CERVICAL OR VAGINAL CPT CYTOPATHOLOGY, FORENSIC (EG, SPERM) 61 CPT SEX CHROMATIN IDENTIFICATION; BARR BODIES 77 CPT SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, POLYMORPHONUCLEAR DRUMSTICKS CPT CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRETATION BY PHYSICIAN CPT CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM WITH MANUAL RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL SELECTION AND REVIEW UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL, DEFINITIVE HORMONAL EVALUATION (EG, MATURATION INDEX, KARYOPYKNOTIC INDEX, ESTROGENIC INDEX) (LIST SEPARATELY IN ADDITION TO CODE(S) FOR OTHER TECHNICAL AND INTERPRETATION SERVICES) CPT CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 306 of 380

307 CPT CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, 201 SCREENING AND INTERPRETATION CPT CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY 300 INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL SELECTION AND REVIEW UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE 182 CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY OF SPECIMEN(S) CPT CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; 161 INTERPRETATION AND REPORT CPT CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), 110 COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; SCREENING BY AUTOMATED SYSTEM, UNDER PHYSICIAN SUPERVISION CPT CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), 136 COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; WITH SCREENING BY AUTOMATED SYSTEM AND MANUAL RESCREENING OR REVIEW, UNDER PHYSICIAN SUPERVISION CPT FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 359 CPT FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, 313 TECHNICAL COMPONENT ONLY; FIRST MARKER CPT FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, 191 TECHNICAL COMPONENT ONLY; EACH ADDITIONAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR FIRST MARKER) CPT FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS 222 CPT FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS 269 CPT FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE MARKERS 341 CPT UNLISTED CYTOPATHOLOGY PROCEDURE N/A CPT TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE 598 CPT TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR OTHER 722 SOLID TISSUE BIOPSY CPT TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC FLUID 756 OR CHORIONIC VILLUS CELLS CPT TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, BLOOD 648 CELLS CPT TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR 757 CPT CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS, EACH CELL 52 LINE CPT THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT 52 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 307 of 380

308 CPT CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER 764 CHROMATID EXCHANGE (SCE), CELLS CPT CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE 889 BREAKAGE, SCORE CELLS, COUNT 20 CELLS, 2 KARYOTYPES (EG, FOR ATAXIA TELANGIECTASIA, FANCONI ANEMIA, FRAGILE X) CPT CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, 889 CLASTOGEN STRESS (EG, DIEPOXYBUTANE, MITOMYCIN C, IONIZING RADIATION, UV RADIATION) CPT CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING 907 CPT CHROMOSOME ANALYSIS; COUNT CELLS, 2 KARYOTYPES, WITH 639 BANDING CPT CHROMOSOME ANALYSIS; COUNT 45 CELLS FOR MOSAICISM, KARYOTYPES, WITH BANDING CPT CHROMOSOME ANALYSIS; ANALYZE CELLS 639 CPT CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, 922 COUNT 15 CELLS, 1 KARYOTYPE, WITH BANDING CPT CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT 853 CELLS FROM 6-12 COLONIES, 1 KARYOTYPE, WITH BANDING CPT MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) 110 CPT MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, 137 ANALYZE 3-5 CELLS (EG, FOR DERIVATIVES AND MARKERS) CPT MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, 165 ANALYZE CELLS (EG, FOR MICRODELETIONS) CPT MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 179 ANALYZE CELLS CPT MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 206 ANALYZE CELLS CPT CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY 129 CPT CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING 352 TECHNIQUE (EG, NOR, C-BANDING) CPT CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY 98 CPT CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY 177 CPT CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION AND 101 REPORT CPT UNLISTED CYTOGENETIC STUDY N/A CPT UNLISTED CYTOGENETIC STUDY N/A CPT LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY 83 CPT LEVEL II - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION APPENDIX, INCIDENTAL FALLOPIAN TUBE, STERILIZATION FINGERS/TOES, AMPUTATION, TRAUMATIC FORESKIN, NEWBORN HERNIA SAC, ANY LOCATION HYDROCELE SAC NERVE SKIN, PLASTIC REPAIR SYMPATHETIC GANGLION TESTIS, CASTRATION VAGINAL MUCOSA, INCIDENTAL VAS DEFERENS, STERILIZATION CPT LEVEL III - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION, INDUCED ABSCESS ANEURYSM - ARTERIAL/VENTRICULAR ANUS, TAG APPENDIX, OTHER THAN INCIDENTAL ARTERY, ATHEROMATOUS PLAQUE BARTHOLIN'S GLAND CYST BONE FRAGMENT(S), OTHER THAN PATHOLOGIC FRACTURE BURSA/SYNOVIAL Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 308 of 380

309 CYST CARPAL TUNNEL TISSUE CARTILAGE, SHAVINGS CHOLESTEATOMA COLON, COLOSTOMY STOMA CONJUNCTIVA - BIOPSY/PTERYGIUM CORNEA DIVERTICULUM - ESOPHAGUS/SMALL INTESTINE DUPUYTREN'S CONTRACTURE TISSUE FEMORAL HEAD, OTHER THAN FRACTURE FISSURE/FISTULA FORESKIN, OTHER THAN NEWBORN GALLBLADDER GANGLION CYST HEMATOMA HEMORRHOIDS HYDATID OF MORGAGNI INTERVERTEBRAL DISC JOINT, LOOSE BODY MENISCUS MUCOCELE, SALIVARY NEUROMA - MORTON'S/TRAUMATIC PILONIDAL CYST/SINUS POLYPS, INFLAMMATORY - NASAL/SINUSOIDAL SKIN - CYST/TAG/DEBRIDEMENT SOFT TISSUE, DEBRIDEMENT SOFT TISSUE, LIPOMA SPERMATOCELE TENDON/TENDON SHEATH TESTICULAR APPENDAGE THROMBUS OR EMBOLUS TONSIL AND/OR ADENOIDS VARICOCELE VAS DEFERENS, OTHER THAN STERILIZATION VEIN, VARICOSITY CPT LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC 361 EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTERY, BIOPSY BONE MARROW, BIOPSY BONE EXOSTOSIS BRAIN/MENINGES, OTHER THAN FOR TUMOR RESECTION BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, REDUCTION MAMMOPLASTY BRONCHUS, BIOPSY CELL BLOCK, ANY SOURCE CERVIX, BIOPSY COLON, BIOPSY DUODENUM, BIOPSY ENDOCERVIX, CURETTINGS/BIOPSY ENDOMETRIUM, CURETTINGS/BIOPSY ESOPHAGUS, BIOPSY EXTREMITY, AMPUTATION, TRAUMATIC FALLOPIAN TUBE, BIOPSY FALLOPIAN TUBE, ECTOPIC PREGNANCY FEMORAL HEAD, FRACTURE FINGERS/TOES, AMPUTATION, NON-TRAUMATIC GINGIVA/ORAL MUCOSA, BIOPSY HEART VALVE JOINT, RESECTION KIDNEY, BIOPSY LARYNX, BIOPSY LEIOMYOMA(S), UTERINE MYOMECTOMY - WITHOUT UTERUS LIP, BIOPSY/WEDGE RESECTION LUNG, TRANSBRONCHIAL BIOPSY LYMPH NODE, BIOPSY MUSCLE, BIOPSY NASAL MUCOSA, BIOPSY NASOPHARYNX/OROPHARYNX, BIOPSY NERVE, BIOPSY ODONTOGENIC/DENTAL CYST OMENTUM, BIOPSY OVARY WITH OR WITHOUT TUBE, NON-NEOPLASTIC OVARY, BIOPSY/WEDGE RESECTION PARATHYROID GLAND PERITONEUM, BIOPSY PITUITARY TUMOR PLACENTA, OTHER THAN THIRD TRIMESTER PLEURA/PERICARDIUM - BIOPSY/TISSUE POLYP, CERVICAL/ENDOMETRIAL POLYP, COLORECTAL POLYP, STOMACH/SMALL INTESTINE PROSTATE, NEEDLE BIOPSY PROSTATE, TUR SALIVARY GLAND, BIOPSY SINUS, PARANASAL BIOPSY SKIN, OTHER THAN CYST/TAG/DEBRIDEMENT/PLASTIC REPAIR SMALL INTESTINE, BIOPSY SOFT TISSUE, OTHER THAN TUMOR/MASS/LIPOMA/DEBRIDEMENT SPLEEN STOMACH, BIOPSY SYNOVIUM TESTIS, OTHER THAN TUMOR/BIOPSY/CASTRATION THYROGLOSSAL DUCT/BRACHIAL CLEFT CYST TONGUE, BIOPSY TONSIL, BIOPSY TRACHEA, BIOPSY URETER, BIOPSY URETHRA, BIOPSY URINARY BLADDER, BIOPSY UTERUS, WITH OR WITHOUT TUBES AND OVARIES, FOR PROLAPSE VAGINA, BIOPSY VULVA/LABIA, BIOPSY CPT LEVEL V - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ADRENAL, RESECTION BONE - BIOPSY/CURETTINGS BONE FRAGMENT(S), PATHOLOGIC FRACTURE BRAIN, BIOPSY BRAIN/MENINGES, TUMOR RESECTION BREAST, EXCISION OF LESION, REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, MASTECTOMY - PARTIAL/SIMPLE CERVIX, CONIZATION COLON, SEGMENTAL RESECTION, OTHER THAN FOR TUMOR EXTREMITY, AMPUTATION, NON-TRAUMATIC EYE, ENUCLEATION KIDNEY, PARTIAL/TOTAL NEPHRECTOMY LARYNX, PARTIAL/TOTAL RESECTION LIVER, BIOPSY - NEEDLE/WEDGE LIVER, PARTIAL RESECTION LUNG, WEDGE BIOPSY LYMPH NODES, REGIONAL RESECTION MEDIASTINUM, MASS MYOCARDIUM, BIOPSY ODONTOGENIC TUMOR OVARY WITH OR 770 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 309 of 380

310 WITHOUT TUBE, NEOPLASTIC PANCREAS, BIOPSY PLACENTA, THIRD TRIMESTER PROSTATE, EXCEPT RADICAL RESECTION SALIVARY GLAND SENTINEL LYMPH NODE SMALL INTESTINE, RESECTION, OTHER THAN FOR TUMOR SOFT TISSUE MASS (EXCEPT LIPOMA) - BIOPSY/SIMPLE EXCISION STOMACH - SUBTOTAL/TOTAL RESECTION, OTHER THAN FOR TUMOR TESTIS, BIOPSY THYMUS, TUMOR THYROID, TOTAL/LOBE URETER, RESECTION URINARY BLADDER, TUR UTERUS, WITH OR WITHOUT TUBES AND OVARIES, OTHER THAN NEOPLASTIC/PROLAPSE CPT LEVEL VI - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC 1,146 EXAMINATION BONE RESECTION BREAST, MASTECTOMY - WITH REGIONAL LYMPH NODES COLON, SEGMENTAL RESECTION FOR TUMOR COLON, TOTAL RESECTION ESOPHAGUS, PARTIAL/TOTAL RESECTION EXTREMITY, DISARTICULATION FETUS, WITH DISSECTION LARYNX, PARTIAL/TOTAL RESECTION - WITH REGIONAL LYMPH NODES LUNG - TOTAL/LOBE/SEGMENT RESECTION PANCREAS, TOTAL/SUBTOTAL RESECTION PROSTATE, RADICAL RESECTION SMALL INTESTINE, RESECTION FOR TUMOR SOFT TISSUE TUMOR, EXTENSIVE RESECTION STOMACH - SUBTOTAL/TOTAL RESECTION FOR TUMOR TESTIS, TUMOR TONGUE/TONSIL -RESECTION FOR TUMOR URINARY BLADDER, PARTIAL/TOTAL RESECTION UTERUS, WITH OR WITHOUT TUBES AND OVARIES, NEOPLASTIC VULVA, TOTAL/SUBTOTAL RESECTION CPT DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE 62 FOR SURGICAL PATHOLOGY EXAMINATION) CPT SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 361 SERVICE); GROUP I FOR MICROORGANISMS (EG, GRIDLEY, ACID FAST, METHENAMINE SILVER), EACH CPT SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 278 SERVICE); GROUP II, ALL OTHER (EG, IRON, TRICHROME), EXCEPT IMMUNOCYTOCHEMISTRY AND IMMUNOPEROXIDASE STAINS, EACH CPT SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 308 SERVICE); HISTOCHEMICAL STAINING WITH FROZEN SECTION(S) CPT DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS 427 (EG, COPPER, ZINC) CPT DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY 478 ENZYME CONSTITUENTS, EACH CPT CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED 300 ELSEWHERE CPT CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING 517 PREPARATION OF SLIDES CPT CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND 625 SPECIMENS, WITH REPORT ON REFERRED MATERIAL CPT PATHOLOGY CONSULTATION DURING SURGERY; 59 CPT PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, 312 WITH FROZEN SECTION(S), SINGLE SPECIMEN CPT PATHOLOGY CONSULTATION DURING SURGERY; EACH ADDITIONAL 139 TISSUE BLOCK WITH FROZEN SECTION(S) CPT PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 327 EXAMINATION (EG, TOUCH PREP, SQUASH PREP), INITIAL SITE CPT PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 195 EXAMINATION (EG, TOUCH PREP, SQUASH PREP), EACH ADDITIONAL SITE CPT IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), 365 EACH ANTIBODY CPT IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD 354 CPT IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD 279 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 310 of 380

311 CPT ELECTRON MICROSCOPY; DIAGNOSTIC 2,504 CPT ELECTRON MICROSCOPY; SCANNING 1,290 CPT MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE 654 CPT MORPHOMETRIC ANALYSIS; NERVE 1,078 CPT MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY) 279 CPT MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER /NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; MANUAL CPT MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER /NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; USING COMPUTER-ASSISTED TECHNOLOGY CPT NERVE TEASING PREPARATIONS 921 CPT IN SITU HYBRIDIZATION (EG, FISH), EACH PROBE 577 CPT MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR 828 SEMI-QUANTITATIVE) EACH PROBE; USING COMPUTER-ASSISTED TECHNOLOGY CPT MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR 816 SEMI-QUANTITATIVE) EACH PROBE; MANUAL CPT PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 114 INTERPRETATION AND REPORT; CPT PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 117 INTERPRETATION AND REPORT; IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH CPT MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY 548 IDENTIFIED TARGET); LASER CAPTURE CPT MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY 721 IDENTIFIED TARGET); MANUAL CPT ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 11 1,196 THROUGH 50 PROBES CPT ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 2,161 THROUGH 250 PROBES CPT ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 2,202 THROUGH 500 PROBES CPT UNLISTED SURGICAL PATHOLOGY PROCEDURE N/A CPT BILIRUBIN, TOTAL, TRANSCUTANEOUS 26 CPT CAFFEINE HALOTHANE CONTRACTURE TEST (CHCT) FOR MALIGNANT 631 HYPERTHERMIA SUSCEPTIBILITY, INCLUDING INTERPRETATION AND REPORT CPT CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, 24 JOINT FLUID), EXCEPT BLOOD; CPT CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, 28 JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT CPT LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR SEMIQUANTITATIVE 22 CPT CRYSTAL IDENTIFICATION BY LIGHT MICROSCOPY WITH OR WITHOUT POLARIZING LENS ANALYSIS, TISSUE OR ANY BODY FLUID (EXCEPT URINE) 37 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 311 of 380

312 CPT DUODENAL INTUBATION AND ASPIRATION; SINGLE SPECIMEN (EG, 616 SIMPLE BILE STUDY OR AFFERENT LOOP CULTURE) PLUS APPROPRIATE TEST PROCEDURE CPT DUODENAL INTUBATION AND ASPIRATION; COLLECTION OF MULTIPLE 1,053 FRACTIONAL SPECIMENS WITH PANCREATIC OR GALLBLADDER STIMULATION, SINGLE OR DOUBLE LUMEN TUBE CPT FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS 22 CPT GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, 518 FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; CPT GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, 584 FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; AFTER STIMULATION CPT GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 692 GASTRIC SECRETORY STUDY); ONE HOUR CPT GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 457 GASTRIC SECRETORY STUDY); 2 HOURS CPT GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 906 GASTRIC SECRETORY STUDY); 2 HOURS INCLUDING GASTRIC STIMULATION (EG, HISTALOG, PENTAGASTRIN) CPT GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 911 GASTRIC SECRETORY STUDY); 3 HOURS, INCLUDING GASTRIC STIMULATION CPT MEAT FIBERS, FECES 19 CPT NASAL SMEAR FOR EOSINOPHILS 24 CPT SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE 49 (SEPARATE PROCEDURE) CPT STARCH GRANULES, FECES 17 CPT SWEAT COLLECTION BY IONTOPHORESIS 11 CPT WATER LOAD TEST 28 CPT UNLISTED MISCELLANEOUS PATHOLOGY TEST N/A CPT CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; 5,876 CPT CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; WITH CO- 6,111 CULTURE OF OOCYTE(S)/EMBRYOS CPT ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) N/A CPT OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID N/A CPT PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) N/A CPT SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL N/A FLUID) CPT CRYOPRESERVATION; EMBRYO(S) N/A CPT CRYOPRESERVATION; SPERM N/A CPT SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS CPT SPERM ISOLATION; COMPLEX PREP (EG, PERCOLL GRADIENT, ALBUMIN GRADIENT) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS 20 N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 312 of 380

313 CPT SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR N/A CRYOPRESERVED CPT INSEMINATION OF OOCYTES N/A CPT EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS N/A CPT ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; LESS THAN OR N/A EQUAL TO 10 OOCYTES CPT ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; GREATER THAN 10 N/A OOCYTES CPT BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, N/A MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS CPT BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, N/A MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS CPT SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM INCLUDING 46 HUHNER TEST (POST COITAL) CPT SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) 44 CPT SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL 62 CPT SEMEN ANALYSIS; SPERM PRESENCE AND MOTILITY OF SPERM, IF 62 PERFORMED CPT SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL USING 80 STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) CPT SPERM ANTIBODIES 55 CPT SPERM EVALUATION; HAMSTER PENETRATION TEST 108 CPT SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR 51 WITHOUT SPINNBARKEIT TEST CPT SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE (SPERM 101 CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS INDICATED) CPT CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR N/A CPT STORAGE (PER YEAR); EMBRYO(S) N/A CPT STORAGE (PER YEAR); SPERM/SEMEN N/A CPT STORAGE (PER YEAR); REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN N/A CPT STORAGE (PER YEAR); OOCYTE(S) N/A CPT THAWING OF CRYOPRESERVED; EMBRYO(S) N/A CPT THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT N/A CPT THAWING OF CRYOPRESERVED; REPRODUCTIVE TISSUE, N/A TESTICULAR/OVARIAN CPT THAWING OF CRYOPRESERVED; OOCYTES, EACH ALIQUOT N/A CPT IMMUNIZATION ADMINISTRATION YOUNGER THAN 8 YEARS OF AGE (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS) WHEN THE PHYSICIAN COUNSELS THE PATIENT/FAMILY; FIRST INJECTION (SINGLE OR COMBINATION VACCINE/TOXOID), PER DAY 28 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 313 of 380

314 CPT IMMUNIZATION ADMINISTRATION YOUNGER THAN 8 YEARS OF AGE 13 (INCLUDES PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS) WHEN THE PHYSICIAN COUNSELS THE PATIENT/FAMILY; EACH ADDITIONAL INJECTION (SINGLE OR COMBINATION VACCINE/TOXOID), PER DAY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 8 YEARS 16 (INCLUDES INTRANASAL OR ORAL ROUTES OF ADMINISTRATION) WHEN THE PHYSICIAN COUNSELS THE PATIENT/FAMILY; FIRST ADMINISTRATION (SINGLE OR COMBINATION VACCINE/TOXOID), PER DAY CPT IMMUNIZATION ADMINISTRATION YOUNGER THAN AGE 8 YEARS 12 (INCLUDES INTRANASAL OR ORAL ROUTES OF ADMINISTRATION) WHEN THE PHYSICIAN COUNSELS THE PATIENT/FAMILY; EACH ADDITIONAL ADMINISTRATION (SINGLE OR COMBINATION VACCINE/TOXOID), PER DAY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, 28 INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); ONE VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) CPT IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, 13 INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); EACH ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; ONE 16 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) CPT IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; EACH 11 ADDITIONAL VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR 71 CPT INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR CPT INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION, UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO ONE HOUR, INCLUDING PUMP SET-UP AND ESTABLISHMENT OF SUBCUTANEOUS INFUSION SITE(S) CPT SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL PUMP SET-UP WITH ESTABLISHMENT OF NEW SUBCUTANEOUS INFUSION SITE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR CPT THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRA-ARTERIAL Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 314 of 380

315 CPT THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 20 SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG CPT THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 20 SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF A NEW SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 20 SUBSTANCE OR DRUG); EACH ADDITIONAL SEQUENTIAL INTRAVENOUS PUSH OF THE SAME SUBSTANCE/DRUG PROVIDED IN A FACILITY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT UNLISTED THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INTRAVENOUS 20 OR INTRA-ARTERIAL INJECTION OR INFUSION CPT PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION 547 CPT INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF COMMUNICATION CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR MODIFYING AND/OR SUPPORTIVE, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 315 of 380

316 CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 378 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 474 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 518 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN OFFICE OR OUTPATIENT FACILITY, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 202 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 225 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 298 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 322 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 439 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INSIGHT ORIENTED, BEHAVIOR 465 MODIFYING AND/OR SUPPORTIVE, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 219 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 242 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 20 TO 30 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 316 of 380

317 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 338 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 45 TO 50 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 455 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; CPT INDIVIDUAL PSYCHOTHERAPY, INTERACTIVE, USING PLAY EQUIPMENT, 479 PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF NON-VERBAL COMMUNICATION, IN AN INPATIENT HOSPITAL, PARTIAL HOSPITAL OR RESIDENTIAL CARE SETTING, APPROXIMATELY 75 TO 80 MINUTES FACE-TO-FACE WITH THE PATIENT; WITH MEDICAL EVALUATION AND MANAGEMENT SERVICES CPT PSYCHOANALYSIS 279 CPT FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 299 CPT FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT 377 PRESENT) CPT MULTIPLE-FAMILY GROUP PSYCHOTHERAPY 118 CPT GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP) 108 CPT INTERACTIVE GROUP PSYCHOTHERAPY 128 CPT PHARMACOLOGIC MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND 200 REVIEW OF MEDICATION WITH NO MORE THAN MINIMAL MEDICAL PSYCHOTHERAPY CPT NARCOSYNTHESIS FOR PSYCHIATRIC DIAGNOSTIC AND THERAPEUTIC 5,195 PURPOSES (EG, SODIUM AMOBARBITAL (AMYTAL) INTERVIEW) CPT ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY MONITORING) 483 CPT INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING 222 BIOFEEDBACK TRAINING BY ANY MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED, BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); APPROXIMATELY MINUTES CPT INDIVIDUAL PSYCHOPHYSIOLOGICAL THERAPY INCORPORATING 329 BIOFEEDBACK TRAINING BY ANY MODALITY (FACE-TO-FACE WITH THE PATIENT), WITH PSYCHOTHERAPY (EG, INSIGHT ORIENTED, BEHAVIOR MODIFYING OR SUPPORTIVE PSYCHOTHERAPY); APPROXIMATELY MINUTES CPT HYPNOTHERAPY 354 CPT ENVIRONMENTAL INTERVENTION FOR MEDICAL MANAGEMENT PURPOSES ON A PSYCHIATRIC PATIENT'S BEHALF WITH AGENCIES, EMPLOYERS, OR INSTITUTIONS CPT PSYCHIATRIC EVALUATION OF HOSPITAL RECORDS, OTHER PSYCHIATRIC REPORTS, PSYCHOMETRIC AND/OR PROJECTIVE TESTS, AND OTHER ACCUMULATED DATA FOR MEDICAL DIAGNOSTIC PURPOSES Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 317 of 380

318 CPT INTERPRETATION OR EXPLANATION OF RESULTS OF PSYCHIATRIC, OTHER 268 MEDICAL EXAMINATIONS AND PROCEDURES, OR OTHER ACCUMULATED DATA TO FAMILY OR OTHER RESPONSIBLE PERSONS, OR ADVISING THEM HOW TO ASSIST PATIENT CPT PREPARATION OF REPORT OF PATIENT'S PSYCHIATRIC STATUS, HISTORY, 272 TREATMENT, OR PROGRESS (OTHER THAN FOR LEGAL OR CONSULTATIVE PURPOSES) FOR OTHER PHYSICIANS, AGENCIES, OR INSURANCE CARRIERS CPT UNLISTED PSYCHIATRIC SERVICE OR PROCEDURE N/A CPT BIOFEEDBACK TRAINING BY ANY MODALITY 39 CPT BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL 105 SPHINCTER, INCLUDING EMG AND/OR MANOMETRY CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 2,041 MONTH; FOR PATIENTS YOUNGER THAN TWO YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 1,491 MONTH; FOR PATIENTS BETWEEN TWO AND ELEVEN YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 1,287 MONTH; FOR PATIENTS BETWEEN TWELVE AND NINETEEN YEARS OF AGE TO INCLUDE MONITORING FOR THE ADEQUACY OF NUTRITION, ASSESSMENT OF GROWTH AND DEVELOPMENT, AND COUNSELING OF PARENTS CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 794 MONTH; FOR PATIENTS TWENTY YEARS OF AGE AND OLDER CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 67 MONTH), PER DAY; FOR PATIENTS YOUNGER THAN TWO YEARS OF AGE CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 49 MONTH), PER DAY; FOR PATIENTS BETWEEN TWO AND ELEVEN YEARS OF AGE CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 42 MONTH), PER DAY; FOR PATIENTS BETWEEN TWELVE AND NINETEEN YEARS OF AGE CPT END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 26 MONTH), PER DAY; FOR PATIENTS TWENTY YEARS OF AGE AND OLDER CPT HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION 226 CPT HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION CPT HEMODIALYSIS ACCESS FLOW STUDY TO DETERMINE BLOOD FLOW IN GRAFTS AND ARTERIOVENOUS FISTULAE BY AN INDICATOR METHOD CPT DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL DIALYSIS, HEMOFILTRATION, OR OTHER CONTINUOUS RENAL REPLACEMENT THERAPIES), WITH SINGLE PHYSICIAN EVALUATION CPT DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL DIALYSIS, HEMOFILTRATION, OR OTHER CONTINUOUS RENAL REPLACEMENT THERAPIES) REQUIRING REPEATED PHYSICIAN EVALUATIONS, WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION CPT DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COMPLETED COURSE CPT DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COURSE NOT COMPLETED, PER TRAINING SESSION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 318 of 380

319 CPT HEMOPERFUSION (EG, WITH ACTIVATED CHARCOAL OR RESIN) 302 CPT UNLISTED DIALYSIS PROCEDURE, INPATIENT OR OUTPATIENT N/A CPT ESOPHAGEAL INTUBATION AND COLLECTION OF WASHINGS FOR 365 CYTOLOGY, INCLUDING PREPARATION OF SPECIMENS (SEPARATE PROCEDURE) CPT ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 634 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; CPT ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 882 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; WITH MECHOLYL OR SIMILAR STIMULANT CPT ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 884 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; WITH ACID PERFUSION STUDIES CPT GASTRIC MOTILITY (MANOMETRIC) STUDIES 804 CPT DUODENAL MOTILITY (MANOMETRIC) STUDY 592 CPT ESOPHAGUS, ACID PERFUSION (BERNSTEIN) TEST FOR ESOPHAGITIS 487 CPT ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER 659 PH ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION CPT ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL 1,648 ATTACHED TELEMETRY PH ELECTRODE PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION CPT ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH 573 NASAL CATHETER INTRALUMINAL IMPEDANCE ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION; CPT ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH 507 NASAL CATHETER INTRALUMINAL IMPEDANCE ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION; PROLONGED (GREATER THAN 1 HOUR, UP TO 24 HOURS) CPT ESOPHAGEAL BALLOON DISTENSION PROVOCATION STUDY 1,110 CPT GASTRIC ANALYSIS TEST WITH INJECTION OF STIMULANT OF GASTRIC 473 SECRETION (EG, HISTAMINE, INSULIN, PENTAGASTRIN, CALCIUM AND SECRETIN) CPT GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES FOR 451 CYTOLOGY (SEPARATE PROCEDURE) CPT BREATH HYDROGEN TEST (EG, FOR DETECTION OF LACTASE DEFICIENCY, 197 FRUCTOSE INTOLERANCE, BACTERIAL OVERGROWTH, OR ORO-CECAL GASTROINTESTINAL TRANSIT) CPT INTESTINAL BLEEDING TUBE, PASSAGE, POSITIONING AND MONITORING 414 CPT GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR TREATMENT (EG, FOR INGESTED POISONS) CPT GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT CPT GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT CPT RECTAL SENSATION, TONE, AND COMPLIANCE TEST (IE, RESPONSE TO GRADED BALLOON DISTENTION) 260 3,078 2,503 1,254 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 319 of 380

320 CPT ANORECTAL MANOMETRY 791 CPT PULSED IRRIGATION OF FECAL IMPACTION N/A CPT ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; 147 CPT ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; WITH 187 PROVOCATIVE TESTING CPT UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE N/A CPT OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 83 EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, NEW PATIENT CPT OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 155 EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, NEW PATIENT, ONE OR MORE VISITS CPT OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 87 EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT CPT OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 127 EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS CPT DETERMINATION OF REFRACTIVE STATE 22 CPT OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER GENERAL 431 ANESTHESIA, WITH OR WITHOUT MANIPULATION OF GLOBE FOR PASSIVE RANGE OF MOTION OR OTHER MANIPULATION TO FACILITATE DIAGNOSTIC EXAMINATION; COMPLETE CPT OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER GENERAL 212 ANESTHESIA, WITH OR WITHOUT MANIPULATION OF GLOBE FOR PASSIVE RANGE OF MOTION OR OTHER MANIPULATION TO FACILITATE DIAGNOSTIC EXAMINATION; LIMITED CPT GONIOSCOPY (SEPARATE PROCEDURE) 28 CPT COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT CPT SENSORIMOTOR EXAMINATION WITH MULTIPLE MEASUREMENTS OF OCULAR DEVIATION (EG, RESTRICTIVE OR PARETIC MUSCLE WITH DIPLOPIA) WITH INTERPRETATION AND REPORT (SEPARATE PROCEDURE) CPT ORTHOPTIC AND/OR PLEOPTIC TRAINING, WITH CONTINUING MEDICAL DIRECTION AND EVALUATION CPT FITTING OF CONTACT LENS FOR TREATMENT OF DISEASE, INCLUDING SUPPLY OF LENS CPT VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; LIMITED EXAMINATION (EG, TANGENT SCREEN, AUTOPLOT, ARC PERIMETER, OR SINGLE STIMULUS LEVEL AUTOMATED TEST, SUCH AS OCTOPUS 3 OR 7 EQUIVALENT) CPT VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; INTERMEDIATE EXAMINATION (EG, AT LEAST 2 ISOPTERS ON GOLDMANN PERIMETER, OR SEMIQUANTITATIVE, AUTOMATED SUPRATHRESHOLD SCREENING PROGRAM, HUMPHREY SUPRATHRESHOLD AUTOMATIC DIAGNOSTIC TEST, OCTOPUS PROGRAM 33) CPT VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 320 of 380

321 STATIC DETERMINATION WITHIN THE CENTRAL 30, OR QUANTITATIVE, AUTOMATED THRESHOLD PERIMETRY, OCTOPUS PROGRAM G-1, 32 OR 42, HUMPHREY VISUAL FIELD ANALYZER FULL THRESHOLD PROGRAMS 30-2, 24-2, OR 30/60-2) CPT SERIAL TONOMETRY (SEPARATE PROCEDURE) WITH MULTIPLE 274 MEASUREMENTS OF INTRAOCULAR PRESSURE OVER AN EXTENDED TIME PERIOD WITH INTERPRETATION AND REPORT, SAME DAY (EG, DIURNAL CURVE OR MEDICAL TREATMENT OF ACUTE ELEVATION OF INTRAOCULAR PRESSURE) CPT TONOGRAPHY WITH INTERPRETATION AND REPORT, RECORDING 226 INDENTATION TONOMETER METHOD OR PERILIMBAL SUCTION METHOD CPT TONOGRAPHY WITH WATER PROVOCATION 252 CPT SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, 146 POSTERIOR SEGMENT, (EG, SCANNING LASER) WITH INTERPRETATION AND REPORT, UNILATERAL CPT OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH 256 INTRAOCULAR LENS POWER CALCULATION CPT PROVOCATIVE TESTS FOR GLAUCOMA, WITH INTERPRETATION AND 176 REPORT, WITHOUT TONOGRAPHY CPT OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR 28 RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; INITIAL CPT OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR 26 RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; SUBSEQUENT CPT FLUORESCEIN ANGIOSCOPY WITH INTERPRETATION AND REPORT 163 CPT FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH 396 INTERPRETATION AND REPORT CPT INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) 701 WITH INTERPRETATION AND REPORT CPT FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT 221 CPT OPHTHALMODYNAMOMETRY 20 CPT NEEDLE OCULOELECTROMYOGRAPHY, ONE OR MORE EXTRAOCULAR 235 MUSCLES, ONE OR BOTH EYES, WITH INTERPRETATION AND REPORT CPT ELECTRO-OCULOGRAPHY WITH INTERPRETATION AND REPORT 274 CPT ELECTRORETINOGRAPHY WITH INTERPRETATION AND REPORT 438 CPT COLOR VISION EXAMINATION, EXTENDED, EG, ANOMALOSCOPE OR 148 EQUIVALENT CPT DARK ADAPTATION EXAMINATION WITH INTERPRETATION AND REPORT 174 CPT EXTERNAL OCULAR PHOTOGRAPHY WITH INTERPRETATION AND REPORT FOR DOCUMENTATION OF MEDICAL PROGRESS (EG, CLOSE-UP PHOTOGRAPHY, SLIT LAMP PHOTOGRAPHY, GONIOPHOTOGRAPHY, STEREO-PHOTOGRAPHY) CPT SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH SPECULAR ENDOTHELIAL MICROSCOPY AND CELL COUNT CPT SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH FLUORESCEIN ANGIOGRAPHY CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEAL LENS, BOTH EYES, EXCEPT FOR APHAKIA Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 321 of 380

322 CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND 108 FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEAL LENS FOR APHAKIA, ONE EYE CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND 124 FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEAL LENS FOR APHAKIA, BOTH EYES CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND 107 FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEOSCLERAL LENS CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF 83 CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION AND DIRECTION OF FITTING BY INDEPENDENT TECHNICIAN; CORNEAL LENS, BOTH EYES EXCEPT FOR APHAKIA CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF 80 CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION AND DIRECTION OF FITTING BY INDEPENDENT TECHNICIAN; CORNEAL LENS FOR APHAKIA, ONE EYE CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF 105 CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION AND DIRECTION OF FITTING BY INDEPENDENT TECHNICIAN; CORNEAL LENS FOR APHAKIA, BOTH EYES CPT PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF 80 CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION AND DIRECTION OF FITTING BY INDEPENDENT TECHNICIAN; CORNEOSCLERAL LENS CPT MODIFICATION OF CONTACT LENS (SEPARATE PROCEDURE), WITH 105 MEDICAL SUPERVISION OF ADAPTATION CPT REPLACEMENT OF CONTACT LENS 36 CPT FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; MONOFOCAL 37 CPT FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; BIFOCAL 42 CPT FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; MULTIFOCAL, OTHER 46 THAN BIFOCAL CPT FITTING OF SPECTACLE PROSTHESIS FOR APHAKIA; MONOFOCAL 42 CPT FITTING OF SPECTACLE PROSTHESIS FOR APHAKIA; MULTIFOCAL 50 CPT FITTING OF SPECTACLE MOUNTED LOW VISION AID; SINGLE ELEMENT 17 SYSTEM CPT FITTING OF SPECTACLE MOUNTED LOW VISION AID; TELESCOPIC OR 20 OTHER COMPOUND LENS SYSTEM CPT PROSTHESIS SERVICE FOR APHAKIA, TEMPORARY (DISPOSABLE OR LOAN, 36 INCLUDING MATERIALS) CPT REPAIR AND REFITTING SPECTACLES; EXCEPT FOR APHAKIA 33 CPT REPAIR AND REFITTING SPECTACLES; SPECTACLE PROSTHESIS FOR 32 APHAKIA CPT UNLISTED OPHTHALMOLOGICAL SERVICE OR PROCEDURE N/A CPT OTOLARYNGOLOGIC EXAMINATION UNDER GENERAL ANESTHESIA 309 CPT BINOCULAR MICROSCOPY (SEPARATE DIAGNOSTIC PROCEDURE) 36 CPT EVALUATION OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR AUDITORY PROCESSING 199 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 322 of 380

323 CPT TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR 80 AUDITORY PROCESSING DISORDER; INDIVIDUAL CPT TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR 37 AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS CPT NASOPHARYNGOSCOPY WITH ENDOSCOPE (SEPARATE PROCEDURE) 181 CPT NASAL FUNCTION STUDIES (EG, RHINOMANOMETRY) 71 CPT FACIAL NERVE FUNCTION STUDIES (EG, ELECTRONEURONOGRAPHY) 76 CPT LARYNGEAL FUNCTION STUDIES (IE, AERODYNAMIC TESTING AND 215 ACOUSTIC TESTING) CPT TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION 103 FOR FEEDING CPT SPONTANEOUS NYSTAGMUS, INCLUDING GAZE 98 CPT POSITIONAL NYSTAGMUS TEST 88 CPT CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL 141 STIMULATION CONSTITUTES FOUR TESTS) CPT OPTOKINETIC NYSTAGMUS TEST 75 CPT SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION 200 NYSTAGMUS, WITH RECORDING CPT POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH 207 RECORDING CPT CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL 96 STIMULATION CONSTITUTES FOUR TESTS), WITH RECORDING CPT OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR 166 PERIPHERAL STIMULATION, WITH RECORDING CPT OSCILLATING TRACKING TEST, WITH RECORDING 158 CPT SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING 268 CPT USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN ADDITION TO CODE 21 FOR PRIMARY PROCEDURE) CPT COMPUTERIZED DYNAMIC POSTUROGRAPHY 295 CPT SCREENING TEST, PURE TONE, AIR ONLY 32 CPT PURE TONE AUDIOMETRY (THRESHOLD); AIR ONLY 81 CPT PURE TONE AUDIOMETRY (THRESHOLD); AIR AND BONE 104 CPT SPEECH AUDIOMETRY THRESHOLD; 56 CPT SPEECH AUDIOMETRY THRESHOLD; WITH SPEECH RECOGNITION 26 CPT COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION AND SPEECH 127 RECOGNITION (92553 AND COMBINED) CPT AUDIOMETRIC TESTING OF GROUPS 91 CPT BEKESY AUDIOMETRY; SCREENING 54 CPT BEKESY AUDIOMETRY; DIAGNOSTIC 95 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 323 of 380

324 CPT LOUDNESS BALANCE TEST, ALTERNATE BINAURAL OR MONAURAL 83 CPT TONE DECAY TEST 74 CPT SHORT INCREMENT SENSITIVITY INDEX (SISI) 66 CPT STENGER TEST, PURE TONE 36 CPT TYMPANOMETRY (IMPEDANCE TESTING) 49 CPT ACOUSTIC REFLEX TESTING; THRESHOLD 19 CPT ACOUSTIC REFLEX TESTING; DECAY 39 CPT FILTERED SPEECH TEST 60 CPT STAGGERED SPONDAIC WORD TEST 75 CPT SENSORINEURAL ACUITY LEVEL TEST 147 CPT SYNTHETIC SENTENCE IDENTIFICATION TEST 28 CPT STENGER TEST, SPEECH 41 CPT VISUAL REINFORCEMENT AUDIOMETRY (VRA) 139 CPT CONDITIONING PLAY AUDIOMETRY 154 CPT SELECT PICTURE AUDIOMETRY 101 CPT ELECTROCOCHLEOGRAPHY 197 CPT AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY 348 AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; COMPREHENSIVE CPT AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY 195 AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED CPT EVOKED OTOACOUSTIC EMISSIONS; LIMITED (SINGLE STIMULUS LEVEL, 113 EITHER TRANSIENT OR DISTORTION PRODUCTS) CPT EVOKED OTOACOUSTIC EMISSIONS; COMPREHENSIVE OR DIAGNOSTIC 203 EVALUATION (COMPARISON OF TRANSIENT AND/OR DISTORTION PRODUCT OTOACOUSTIC EMISSIONS AT MULTIPLE LEVELS AND FREQUENCIES) CPT HEARING AID EXAMINATION AND SELECTION; MONAURAL 165 CPT HEARING AID EXAMINATION AND SELECTION; BINAURAL 210 CPT HEARING AID CHECK; MONAURAL 65 CPT HEARING AID CHECK; BINAURAL 108 CPT ELECTROACOUSTIC EVALUATION FOR HEARING AID; MONAURAL 63 CPT ELECTROACOUSTIC EVALUATION FOR HEARING AID; BINAURAL 135 CPT EAR PROTECTOR ATTENUATION MEASUREMENTS 135 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 324 of 380

325 CPT EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC DEVICE 130 TO SUPPLEMENT ORAL SPEECH CPT DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT YOUNGER THAN YEARS OF AGE; WITH PROGRAMMING CPT DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT YOUNGER THAN YEARS OF AGE; SUBSEQUENT REPROGRAMMING CPT DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR OLDER; 441 WITH PROGRAMMING CPT DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR OLDER; 264 SUBSEQUENT REPROGRAMMING CPT EVALUATION FOR PRESCRIPTION OF NON-SPEECH-GENERATING N/A AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE CPT THERAPEUTIC SERVICE(S) FOR THE USE OF NON-SPEECH-GENERATING N/A DEVICE, INCLUDING PROGRAMMING AND MODIFICATION CPT EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING 212 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO- FACE WITH THE PATIENT; FIRST HOUR CPT EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING 117 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO- FACE WITH THE PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, 313 INCLUDING PROGRAMMING AND MODIFICATION CPT EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 224 CPT MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY 255 CINE OR VIDEO RECORDING CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY 538 CINE OR VIDEO RECORDING; CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY 125 CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY 469 TESTING BY CINE OR VIDEO RECORDING; CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY 112 TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND 641 LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; CPT FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND 138 LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; INITIAL MINUTES CPT EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; EACH 62 ADDITIONAL 15 MINUTES CPT ASSESSMENT OF TINNITUS (INCLUDES PITCH, LOUDNESS MATCHING, 251 AND MASKING) CPT EVALUATION OF AUDITORY REHABILITATION STATUS; FIRST HOUR 260 CPT EVALUATION OF AUDITORY REHABILITATION STATUS; EACH ADDITIONAL MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS N/A CPT AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 325 of 380

326 CPT DIAGNOSTIC ANALYSIS WITH PROGRAMMING OF AUDITORY BRAINSTEM 169 IMPLANT, PER HOUR CPT UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE N/A CPT CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST) 921 CPT TEMPORARY TRANSCUTANEOUS PACING 40 CPT CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; 842 EXTERNAL CPT CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; 920 INTERNAL (SEPARATE PROCEDURE) CPT CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; INTERNAL 645 CPT CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; EXTERNAL 367 CPT PERCUTANEOUS TRANSLUMINAL CORONARY THROMBECTOMY (LIST 663 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSCATHETER PLACEMENT OF RADIATION DELIVERY DEVICE FOR 607 SUBSEQUENT CORONARY INTRAVASCULAR BRACHYTHERAPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT THROMBOLYSIS, CORONARY; BY INTRACORONARY INFUSION, INCLUDING 1,457 SELECTIVE CORONARY ANGIOGRAPHY CPT THROMBOLYSIS, CORONARY; BY INTRAVENOUS INFUSION 275 CPT INTRAVASCULAR ULTRASOUND (CORONARY VESSEL OR GRAFT) DURING 340 DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRAVASCULAR ULTRASOUND (CORONARY VESSEL OR GRAFT) DURING 208 DIAGNOSTIC EVALUATION AND/OR THERAPEUTIC INTERVENTION INCLUDING IMAGING SUPERVISION, INTERPRETATION AND REPORT; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), 3,018 PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL CPT TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), 840 PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; 2,237 SINGLE VESSEL CPT PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; 599 EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS BALLOON VALVULOPLASTY; AORTIC VALVE 4,978 CPT PERCUTANEOUS BALLOON VALVULOPLASTY; MITRAL VALVE 5,164 CPT PERCUTANEOUS BALLOON VALVULOPLASTY; PULMONARY VALVE 3,859 CPT ATRIAL SEPTECTOMY OR SEPTOSTOMY; TRANSVENOUS METHOD, BALLOON (EG, RASHKIND TYPE) (INCLUDES CARDIAC CATHETERIZATION) CPT ATRIAL SEPTECTOMY OR SEPTOSTOMY; BLADE METHOD (PARK SEPTOSTOMY) (INCLUDES CARDIAC CATHETERIZATION) 1, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 326 of 380

327 CPT PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY 2,462 MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY; SINGLE VESSEL CPT PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY 644 MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 2,264 ANGIOPLASTY; SINGLE VESSEL CPT PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 1,166 ANGIOPLASTY; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH 69 INTERPRETATION AND REPORT CPT ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 37 TRACING ONLY, WITHOUT INTERPRETATION AND REPORT CPT ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 31 INTERPRETATION AND REPORT ONLY CPT TELEPHONIC TRANSMISSION OF POST-SYMPTOM ELECTROCARDIOGRAM 547 RHYTHM STRIP(S), 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; TRACING ONLY CPT TELEPHONIC TRANSMISSION OF POST-SYMPTOM ELECTROCARDIOGRAM 95 RHYTHM STRIP(S), 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; PHYSICIAN REVIEW WITH INTERPRETATION AND REPORT ONLY CPT CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 352 TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; WITH PHYSICIAN SUPERVISION, WITH INTERPRETATION AND REPORT CPT CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 86 TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; PHYSICIAN SUPERVISION ONLY, WITHOUT INTERPRETATION AND REPORT CPT CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 207 TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; TRACING ONLY, WITHOUT INTERPRETATION AND REPORT CPT CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 57 TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; INTERPRETATION AND REPORT ONLY CPT ERGONOVINE PROVOCATION TEST 464 CPT MICROVOLT T-WAVE ALTERNANS FOR ASSESSMENT OF VENTRICULAR ARRHYTHMIAS CPT RHYTHM ECG, ONE TO THREE LEADS; WITH INTERPRETATION AND REPORT CPT RHYTHM ECG, ONE TO THREE LEADS; TRACING ONLY WITHOUT INTERPRETATION AND REPORT CPT RHYTHM ECG, ONE TO THREE LEADS; INTERPRETATION AND REPORT ONLY CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; INCLUDES RECORDING, SCANNING ANALYSIS WITH REPORT, PHYSICIAN REVIEW AND INTERPRETATION Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 327 of 380

328 CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 117 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; RECORDING (INCLUDES HOOK-UP, RECORDING, AND DISCONNECTION) CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 167 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; SCANNING ANALYSIS WITH REPORT CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 101 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; PHYSICIAN REVIEW AND INTERPRETATION CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 387 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE WITHOUT SUPERIMPOSITION SCANNING UTILIZING A DEVICE CAPABLE OF PRODUCING A FULL MINIATURIZED PRINTOUT; INCLUDES RECORDING, MICROPROCESSOR-BASED ANALYSIS WITH REPORT, PHYSICIAN REVIEW AND INTERPRETATION CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 104 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE WITHOUT SUPERIMPOSITION SCANNING UTILIZING A DEVICE CAPABLE OF PRODUCING A FULL MINIATURIZED PRINTOUT; RECORDING (INCLUDES HOOK-UP, RECORDING, AND DISCONNECTION) CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 186 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE WITHOUT SUPERIMPOSITION SCANNING UTILIZING A DEVICE CAPABLE OF PRODUCING A FULL MINIATURIZED PRINTOUT; MICROPROCESSOR-BASED ANALYSIS WITH REPORT CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 96 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE WITHOUT SUPERIMPOSITION SCANNING UTILIZING A DEVICE CAPABLE OF PRODUCING A FULL MINIATURIZED PRINTOUT; PHYSICIAN REVIEW AND INTERPRETATION CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 374 COMPUTERIZED MONITORING AND NON-CONTINUOUS RECORDING, AND REAL-TIME DATA ANALYSIS UTILIZING A DEVICE CAPABLE OF PRODUCING INTERMITTENT FULL-SIZED WAVEFORM TRACINGS, POSSIBLY PATIENT ACTIVATED; INC CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 298 COMPUTERIZED MONITORING AND NON-CONTINUOUS RECORDING, AND REAL-TIME DATA ANALYSIS UTILIZING A DEVICE CAPABLE OF PRODUCING INTERMITTENT FULL-SIZED WAVEFORM TRACINGS, POSSIBLY PATIENT ACTIVATED; MON CPT ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 86 COMPUTERIZED MONITORING AND NON-CONTINUOUS RECORDING, AND REAL-TIME DATA ANALYSIS UTILIZING A DEVICE CAPABLE OF PRODUCING INTERMITTENT FULL-SIZED WAVEFORM TRACINGS, POSSIBLY PATIENT ACTIVATED; PHYSICIAN REVIEW AND INTERPRETATION CPT PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH 829 PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; INCLUDES TRANSMISSION, PHYSICIAN REVIEW AND INTERPRETATION CPT PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH 46 PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; RECORDING (INCLUDES HOOK-UP, RECORDING, AND DISCONNECTION) CPT PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; MONITORING, RECEIPT OF TRANSMISSIONS, AND 687 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 328 of 380

329 ANALYSIS CPT PATIENT DEMAND SINGLE OR MULTIPLE EVENT RECORDING WITH 95 PRESYMPTOM MEMORY LOOP, 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; PHYSICIAN REVIEW AND INTERPRETATION ONLY CPT SIGNAL-AVERAGED ELECTROCARDIOGRAPHY (SAECG), WITH OR WITHOUT 124 ECG CPT TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 764 ANOMALIES; COMPLETE CPT TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 503 ANOMALIES; FOLLOW-UP OR LIMITED STUDY CPT ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE 618 DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE CPT ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE 415 DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY CPT ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE 1,253 DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT CPT ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE 142 DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY CPT ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE 1,107 DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY CPT TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 1,014 ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT CPT TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 158 ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY CPT TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 634 ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY CPT ECHOCARDIOGRAPHY, TRANSESOPHAGEAL (TEE) FOR MONITORING 757 PURPOSES, INCLUDING PROBE PLACEMENT, REAL TIME 2-DIMENSIONAL IMAGE ACQUISITION AND INTERPRETATION LEADING TO ONGOING (CONTINUOUS) ASSESSMENT OF (DYNAMICALLY CHANGING) CARDIAC PUMPING FUNCTION AND TO T CPT DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS 274 WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE CPT DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS 106 WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING) CPT DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST 119 SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) CPT ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE 849 DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING, DURING REST AND CARDIOVASCULAR STRESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR PHARMACOLOGICALLY INDUCED STRESS, WITH INTERPRETATION AND REPORT CPT RIGHT HEART CATHETERIZATION 2,912 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 329 of 380

330 CPT INSERTION AND PLACEMENT OF FLOW DIRECTED CATHETER (EG, SWAN- 391 GANZ) FOR MONITORING PURPOSES CPT ENDOMYOCARDIAL BIOPSY 3,241 CPT CATHETER PLACEMENT IN CORONARY ARTERY(S), ARTERIAL CORONARY 4,280 CONDUIT(S), AND/OR VENOUS CORONARY BYPASS GRAFT(S) FOR CORONARY ANGIOGRAPHY WITHOUT CONCOMITANT LEFT HEART CATHETERIZATION CPT LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL 4,433 ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; PERCUTANEOUS CPT LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL 2,051 ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; BY CUTDOWN CPT LEFT HEART CATHETERIZATION BY LEFT VENTRICULAR PUNCTURE 2,116 CPT COMBINED TRANSSEPTAL AND RETROGRADE LEFT HEART 2,821 CATHETERIZATION CPT COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT 5,627 HEART CATHETERIZATION CPT COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT 2,781 HEART CATHETERIZATION THROUGH INTACT SEPTUM (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT COMBINED RIGHT HEART CATHETERIZATION WITH LEFT VENTRICULAR 2,902 PUNCTURE (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT COMBINED RIGHT HEART CATHETERIZATION AND LEFT HEART 2,557 CATHETERIZATION THROUGH EXISTING SEPTAL OPENING (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 1,084 CPT COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES CPT COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH INTACT SEPTUM WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES CPT COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH EXISTING SEPTAL OPENING, WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF ARTERIAL CONDUITS (EG, INTERNAL MAMMARY), WHETHER NATIVE OR USED FOR BYPASS CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF AORTOCORONARY VENOUS BYPASS GRAFTS, ONE OR MORE CORONARY ARTERIES CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR PULMONARY ANGIOGRAPHY CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE RIGHT VENTRICULAR OR RIGHT ATRIAL ANGIOGRAPHY CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE LEFT VENTRICULAR OR LEFT ATRIAL ANGIOGRAPHY CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR AORTOGRAPHY CPT INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE CORONARY ANGIOGRAPHY (INJECTION OF RADIOPAQUE MATERIAL MAY BE BY HAND) 2,752 2,801 2, Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 330 of 380

331 CPT IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR INJECTION 224 PROCEDURE(S) DURING CARDIAC CATHETERIZATION; VENTRICULAR AND/OR ATRIAL ANGIOGRAPHY CPT IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR INJECTION 283 PROCEDURE(S) DURING CARDIAC CATHETERIZATION; PULMONARY ANGIOGRAPHY, AORTOGRAPHY, AND/OR SELECTIVE CORONARY ANGIOGRAPHY INCLUDING VENOUS BYPASS GRAFTS AND ARTERIAL CONDUITS (WHETHER NATIVE OR USED IN BYPASS) CPT INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, 156 INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; WITH CARDIAC OUTPUT MEASUREMENT (SEPARATE PROCEDURE) CPT INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, 24 INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; SUBSEQUENT MEASUREMENT OF CARDIAC OUTPUT CPT INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED 964 CORONARY FLOW RESERVE MEASUREMENT (CORONARY VESSEL OR GRAFT) DURING CORONARY ANGIOGRAPHY INCLUDING PHARMACOLOGICALLY INDUCED STRESS; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PRO CPT INTRAVASCULAR DOPPLER VELOCITY AND/OR PRESSURE DERIVED 562 CORONARY FLOW RESERVE MEASUREMENT (CORONARY VESSEL OR GRAFT) DURING CORONARY ANGIOGRAPHY INCLUDING PHARMACOLOGICALLY INDUCED STRESS; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRI CPT PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL 3,603 COMMUNICATION (IE, FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT CPT PERCUTANEOUS TRANSCATHETER CLOSURE OF A CONGENITAL 4,741 VENTRICULAR SEPTAL DEFECT WITH IMPLANT CPT BUNDLE OF HIS RECORDING 679 CPT INTRA-ATRIAL RECORDING 197 CPT RIGHT VENTRICULAR RECORDING 643 CPT INTRAVENTRICULAR AND/OR INTRA-ATRIAL MAPPING OF TACHYCARDIA 133 SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT INTRA-ATRIAL PACING 766 CPT INTRAVENTRICULAR PACING 796 CPT INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING (LIST 1,405 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT 226 VENTRICULAR ELECTROGRAM(S); CPT ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT 323 VENTRICULAR ELECTROGRAM(S); WITH PACING CPT INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING 1,367 CPT COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OR ATTEMPTED INDUCTI 2,505 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 331 of 380

332 CPT COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING 2,990 INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUND CPT COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING 538 INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT ATRIAL PACING AND RECORDING FROM CORONARY SINUS OR LEFT ATRIUM (LIST SEPARATEL CPT COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING 790 INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH LEFT VENTRICULAR PACING AND RECORDING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIM CPT PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG 730 INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTROPHYSIOLOGIC FOLLOW-UP STUDY WITH PACING AND RECORDING 1,214 TO TEST EFFECTIVENESS OF THERAPY, INCLUDING INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA CPT INTRA-OPERATIVE EPICARDIAL AND ENDOCARDIAL PACING AND MAPPING 1,898 TO LOCALIZE THE SITE OF TACHYCARDIA OR ZONE OF SLOW CONDUCTION FOR SURGICAL CORRECTION CPT ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER 1,679 PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANT CPT ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER 2,146 PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANT CPT ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER 1,613 PACING CARDIOVERTER-DEFIBRILLATOR (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING OF SENSING OR THERAPEUTIC PARAMETERS) CPT INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE 2,142 FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT CPT INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; FOR 3,258 TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAYS, ACCESSORY ATRIOVENTRICULAR CONNECTIONS OR OTHER ATRIAL FOCI, SINGLY OR IN COMBINATION CPT INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; FOR 3,553 TREATMENT OF VENTRICULAR TACHYCARDIA CPT EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE 626 EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION CPT INTRACARDIAC ECHOCARDIOGRAPHY DURING THERAPEUTIC/DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND 701 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 332 of 380

333 INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT PERIPHERAL ARTERIAL DISEASE (PAD) REHABILITATION, PER SESSION 19 CPT BIOIMPEDANCE, THORACIC, ELECTRICAL 112 CPT PLETHYSMOGRAPHY, TOTAL BODY; WITH INTERPRETATION AND REPORT 177 CPT PLETHYSMOGRAPHY, TOTAL BODY; TRACING ONLY, WITHOUT 149 INTERPRETATION AND REPORT CPT PLETHYSMOGRAPHY, TOTAL BODY; INTERPRETATION AND REPORT ONLY 27 CPT ELECTRONIC ANALYSIS OF ANTITACHYCARDIA PACEMAKER SYSTEM 1,069 (INCLUDES ELECTROCARDIOGRAPHIC RECORDING, PROGRAMMING OF DEVICE, INDUCTION AND TERMINATION OF TACHYCARDIA VIA IMPLANTED PACEMAKER, AND INTERPRETATION OF RECORDINGS) CPT ELECTRONIC ANALYSIS OF IMPLANTABLE LOOP RECORDER (ILR) SYSTEM 148 (INCLUDES RETRIEVAL OF RECORDED AND STORED ECG DATA, PHYSICIAN REVIEW AND INTERPRETATION OF RETRIEVED ECG DATA AND REPROGRAMMING) CPT ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM 162 (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF DUAL-CHAMBER PACEMAKER SYSTEM 269 (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); WITH REPROGRAMMING CPT ELECTRONIC ANALYSIS OF DUAL CHAMBER INTERNAL PACEMAKER 147 SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, AND/OR TESTING OF SENSORY FUNCTION OF PACEMAKER), TELEPHONIC ANALYSIS CPT ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER SYSTEM 138 (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF SINGLE CHAMBER PACEMAKER SYSTEM 221 (INCLUDES EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); WITH REPROGRAMMING CPT ELECTRONIC ANALYSIS OF SINGLE CHAMBER INTERNAL PACEMAKER 142 SYSTEM (MAY INCLUDE RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, AND/OR TESTING OF SENSORY FUNCTION OF PACEMAKER), TELEPHONIC ANALYSIS CPT TEMPERATURE GRADIENT STUDIES 27 CPT ELECTRONIC ANALYSIS OF PACING CARDIOVERTER-DEFIBRILLATOR (INCLUDES INTERROGATION, EVALUATION OF PULSE GENERATOR STATUS, EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND 237 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 333 of 380

334 DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); SINGLE CHAMBER OR WEARABLE CARDIOVERTER- DEFIBRILLATOR SYSTEM, WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF PACING CARDIOVERTER-DEFIBRILLATOR 268 (INCLUDES INTERROGATION, EVALUATION OF PULSE GENERATOR STATUS, EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); SINGLE CHAMBER OR WEARABLE CARDIOVERTER- DEFIBRILLATOR SYSTEM, WITH REPROGRAMMING CPT ELECTRONIC ANALYSIS OF PACING CARDIOVERTER-DEFIBRILLATOR 288 (INCLUDES INTERROGATION, EVALUATION OF PULSE GENERATOR STATUS, EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); DUAL CHAMBER, WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF PACING CARDIOVERTER-DEFIBRILLATOR 328 (INCLUDES INTERROGATION, EVALUATION OF PULSE GENERATOR STATUS, EVALUATION OF PROGRAMMABLE PARAMETERS AT REST AND DURING ACTIVITY WHERE APPLICABLE, USING ELECTROCARDIOGRAPHIC RECORDING AND INTERPRETATION OF RECORDINGS AT REST AND DURING EXERCISE, ANALYSIS OF EVENT MARKERS AND DEVICE RESPONSE); DUAL CHAMBER, WITH REPROGRAMMING CPT INITIAL SET-UP AND PROGRAMMING BY A PHYSICIAN OF WEARABLE N/A CARDIOVERTER-DEFIBRILLATOR INCLUDES INITIAL PROGRAMMING OF SYSTEM, ESTABLISHING BASELINE ELECTRONIC ECG, TRANSMISSION OF DATA TO DATA REPOSITORY, PATIENT INSTRUCTION IN WEARING SYSTEM AND PATIENT R CPT THERMOGRAM; CEPHALIC 171 CPT THERMOGRAM; PERIPHERAL 189 CPT DETERMINATION OF VENOUS PRESSURE 27 CPT AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM 226 SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR LONGER; INCLUDING RECORDING, SCANNING ANALYSIS, INTERPRETATION AND REPORT CPT AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM 103 SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR LONGER; RECORDING ONLY CPT AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM 57 SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR LONGER; SCANNING ANALYSIS WITH REPORT CPT AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM 65 SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR LONGER; PHYSICIAN REVIEW WITH INTERPRETATION AND REPORT CPT PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; 23 WITHOUT CONTINUOUS ECG MONITORING (PER SESSION) CPT PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; WITH 33 CONTINUOUS ECG MONITORING (PER SESSION) CPT UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 334 of 380

335 CPT NONINVASIVE PHYSIOLOGIC STUDIES OF EXTRACRANIAL ARTERIES, 363 COMPLETE BILATERAL STUDY (EG, PERIORBITAL FLOW DIRECTION WITH ARTERIAL COMPRESSION, OCULAR PNEUMOPLETHYSMOGRAPHY, DOPPLER ULTRASOUND SPECTRAL ANALYSIS) CPT DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 899 CPT DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED STUDY CPT TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; COMPLETE STUDY CPT TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; LIMITED STUDY CPT TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; VASOREACTIVITY STUDY CPT TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITHOUT INTRAVENOUS MICROBUBBLE INJECTION CPT TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITH INTRAVENOUS MICROBUBBLE INJECTION CPT NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, SINGLE LEVEL, BILATERAL (EG, ANKLE/BRACHIAL INDICES, DOPPLER WAVEFORM ANALYSIS, VOLUME PLETHYSMOGRAPHY, TRANSCUTANEOUS OXYGEN TENSION MEASUREMENT) CPT NONINVASIVE PHYSIOLOGIC STUDIES OF UPPER OR LOWER EXTREMITY ARTERIES, MULTIPLE LEVELS OR WITH PROVOCATIVE FUNCTIONAL MANEUVERS, COMPLETE BILATERAL STUDY (EG, SEGMENTAL BLOOD PRESSURE MEASUREMENTS, SEGMENTAL DOPPLER WAVEFORM ANALYSIS, SEGMENTAL VOLUME PLETHYSMOGRAPHY, SEGMENTAL TRANSCUTANEOUS OXYGEN TENSION MEASUREMENTS, MEASUREMENTS WITH POSTURAL PROVOCATIVE TESTS, MEASUREMENTS WITH REACTIVE HYPEREMIA) CPT NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ARTERIES, AT REST AND FOLLOWING TREADMILL STRESS TESTING, COMPLETE BILATERAL STUDY CPT DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY CPT DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY CPT DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY) CPT DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY CPT DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY CPT DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY CPT DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY CPT DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY 601 1, ,063 1, , , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 335 of 380

336 CPT DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR 612 BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE 648 VESSELS; COMPLETE STUDY CPT DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE 454 VESSELS; FOLLOW-UP OR LIMITED STUDY CPT NONINVASIVE PHYSIOLOGIC STUDY OF IMPLANTED WIRELESS PRESSURE 139 SENSOR IN ANEURYSMAL SAC FOLLOWING ENDOVASCULAR REPAIR, COMPLETE STUDY INCLUDING RECORDING, ANALYSIS OF PRESSURE AND WAVEFORM TRACINGS, INTERPRETATION AND REPORT CPT DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, 721 BODY OF ACCESS AND VENOUS OUTFLOW) CPT VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 305 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; HOSPITAL INPATIENT/OBSERVATION, INITIAL DAY CPT VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 220 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; HOSPITAL INPATIENT/OBSERVATION, EACH SUBSEQUENT DAY CPT VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 159 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; NURSING FACILITY, PER DAY CPT HOME VENTILATOR MANAGEMENT CARE PLAN OVERSIGHT OF A PATIENT 284 (PATIENT NOT PRESENT) IN HOME, DOMICILIARY OR REST HOME (EG, ASSISTED LIVING) REQUIRING REVIEW OF STATUS, REVIEW OF LABORATORIES AND OTHER STUDIES AND REVISION OF ORDERS AND RESPIRATORY CARE PLAN (AS APPROPRIATE), WITHIN A CALENDAR MONTH, 30 MINUTES OR MORE CPT SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL 118 CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION CPT PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF 171 TIME; INCLUDES REINFORCED EDUCATION, TRANSMISSION OF SPIROMETRIC TRACING, DATA CAPTURE, ANALYSIS OF TRANSMITTED DATA, PERIODIC RECALIBRATION AND PHYSICIAN REVIEW AND INTERPRETATION CPT PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF 85 TIME; RECORDING (INCLUDES HOOK-UP, REINFORCED EDUCATION, DATA TRANSMISSION, DATA CAPTURE, TREND ANALYSIS, AND PERIODIC RECALIBRATION) CPT PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF 85 TIME; PHYSICIAN REVIEW AND INTERPRETATION ONLY CPT BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- 213 AND POST-BRONCHODILATOR ADMINISTRATION CPT BRONCHOSPASM PROVOCATION EVALUATION, MULTIPLE SPIROMETRIC 217 DETERMINATIONS AS IN 94010, WITH ADMINISTERED AGENTS (EG, ANTIGEN[S], COLD AIR, METHACHOLINE) CPT VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE) 26 CPT MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION 81 CPT FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME: HELIUM 143 METHOD, NITROGEN OPEN CIRCUIT METHOD, OR OTHER METHOD CPT EXPIRED GAS COLLECTION, QUANTITATIVE, SINGLE PROCEDURE 29 (SEPARATE PROCEDURE) CPT THORACIC GAS VOLUME 118 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 336 of 380

337 CPT DETERMINATION OF MALDISTRIBUTION OF INSPIRED GAS: MULTIPLE 115 BREATH NITROGEN WASHOUT CURVE INCLUDING ALVEOLAR NITROGEN OR HELIUM EQUILIBRATION TIME CPT DETERMINATION OF RESISTANCE TO AIRFLOW, OSCILLATORY OR 161 PLETHYSMOGRAPHIC METHODS CPT DETERMINATION OF AIRWAY CLOSING VOLUME, SINGLE BREATH TESTS 112 CPT RESPIRATORY FLOW VOLUME LOOP 134 CPT BREATHING RESPONSE TO CO2 (CO2 RESPONSE CURVE) 191 CPT BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) 182 CPT HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN INTERPRETATION AND REPORT; CPT HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN INTERPRETATION AND REPORT; WITH SUPPLEMENTAL OXYGEN TITRATION CPT INTRAPULMONARY SURFACTANT ADMINISTRATION BY A PHYSICIAN THROUGH ENDOTRACHEAL TUBE CPT PULMONARY STRESS TESTING; SIMPLE (EG, 6-MINUTE WALK TEST, PROLONGED EXERCISE TEST FOR BRONCHOSPASM WITH PRE- AND POST- SPIROMETRY AND OXIMETRY) CPT PULMONARY STRESS TESTING; COMPLEX (INCLUDING MEASUREMENTS OF CO2 PRODUCTION, O2 UPTAKE, AND ELECTROCARDIOGRAPHIC RECORDINGS) CPT PRESSURIZED OR NONPRESSURIZED INHALATION TREATMENT FOR ACUTE AIRWAY OBSTRUCTION OR FOR SPUTUM INDUCTION FOR DIAGNOSTIC PURPOSES (EG, WITH AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR INTERMITTENT POSITIVE PRESSURE BREATHING [IPPB] DEVICE) CPT AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII PNEUMONIA TREATMENT OR PROPHYLAXIS CPT CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; FIRST HOUR CPT CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT CPT CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION AND MANAGEMENT CPT DEMONSTRATION AND/OR EVALUATION OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR IPPB DEVICE CPT MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL DEMONSTRATION AND/OR EVALUATION CPT MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT CPT OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST AND EXERCISE, DIRECT, SIMPLE CPT OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; INCLUDING CO2 OUTPUT, PERCENTAGE OXYGEN EXTRACTED CPT OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST, INDIRECT (SEPARATE PROCEDURE) CPT CARBON MONOXIDE DIFFUSING CAPACITY (EG, SINGLE BREATH, STEADY STATE) Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 337 of 380

338 CPT MEMBRANE DIFFUSION CAPACITY 172 CPT PULMONARY COMPLIANCE STUDY (EG, PLETHYSMOGRAPHY, VOLUME AND 258 PRESSURE MEASUREMENTS) CPT NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 10 SINGLE DETERMINATION CPT NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 21 MULTIPLE DETERMINATIONS (EG, DURING EXERCISE) CPT NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY 118 CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE) CPT CARBON DIOXIDE, EXPIRED GAS DETERMINATION BY INFRARED 130 ANALYZER CPT CIRCADIAN RESPIRATORY PATTERN RECORDING (PEDIATRIC N/A PNEUMOGRAM), HOUR CONTINUOUS RECORDING, INFANT CPT PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING N/A RESPIRATORY RATE, PATTERN AND HEART RATE PER 30-DAY PERIOD OF TIME; INCLUDES MONITOR ATTACHMENT, DOWNLOAD OF DATA, PHYSICIAN REVIEW, INTERPRETATION, AND PREPARATION OF A REPORT CPT PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING N/A RESPIRATORY RATE, PATTERN AND HEART RATE PER 30-DAY PERIOD OF TIME; MONITOR ATTACHMENT ONLY (INCLUDES HOOK-UP, INITIATION OF RECORDING AND DISCONNECTION) CPT PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING N/A RESPIRATORY RATE, PATTERN AND HEART RATE PER 30-DAY PERIOD OF TIME; MONITORING, DOWNLOAD OF INFORMATION, RECEIPT OF TRANSMISSION(S) AND ANALYSES BY COMPUTER ONLY CPT PEDIATRIC HOME APNEA MONITORING EVENT RECORDING INCLUDING N/A RESPIRATORY RATE, PATTERN AND HEART RATE PER 30-DAY PERIOD OF TIME; PHYSICIAN REVIEW, INTERPRETATION AND PREPARATION OF REPORT ONLY CPT UNLISTED PULMONARY SERVICE OR PROCEDURE N/A CPT PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) WITH ALLERGENIC 21 EXTRACTS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS CPT PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) SEQUENTIAL AND 21 INCREMENTAL, WITH DRUGS, BIOLOGICALS OR VENOMS, IMMEDIATE TYPE REACTION, SPECIFY NUMBER OF TESTS CPT NITRIC OXIDE EXPIRED GAS DETERMINATION 62 CPT INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND 46 INCREMENTAL, WITH DRUGS, BIOLOGICALS, OR VENOMS, IMMEDIATE TYPE REACTION, SPECIFY NUMBER OF TESTS CPT INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, 23 IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS CPT INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND 15 INCREMENTAL, WITH ALLERGENIC EXTRACTS FOR AIRBORNE ALLERGENS, IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS CPT INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, 14 DELAYED TYPE REACTION, INCLUDING READING, SPECIFY NUMBER OF TESTS CPT PATCH OR APPLICATION TEST(S) (SPECIFY NUMBER OF TESTS) 20 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 338 of 380

339 CPT PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS) 21 CPT PHOTO TESTS 158 CPT OPHTHALMIC MUCOUS MEMBRANE TESTS 94 CPT DIRECT NASAL MUCOUS MEMBRANE TEST 32 CPT INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH HISTAMINE, METHACHOLINE, OR SIMILAR COMPOUNDS CPT INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH ANTIGENS OR GASES, SPECIFY CPT INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD, DRUG OR OTHER SUBSTANCE SUCH AS METABISULFITE) CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; TWO OR MORE INJECTIONS CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE INJECTION CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; TWO OR MORE INJECTIONS CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE STINGING INSECT VENOM CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; TWO STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; THREE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; FOUR STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; FIVE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY, SINGLE DOSE VIAL(S) (SPECIFY NUMBER OF VIALS) CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); SINGLE STINGING INSECT VENOM CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); TWO SINGLE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); THREE SINGLE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 339 of 380

340 NUMBER OF DOSES); FOUR SINGLE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND 20 PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); FIVE SINGLE STINGING INSECT VENOMS CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND 15 PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; SINGLE OR MULTIPLE ANTIGENS (SPECIFY NUMBER OF DOSES) CPT PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND 12 PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; WHOLE BODY EXTRACT OF BITING INSECT OR OTHER ARTHROPOD (SPECIFY NUMBER OF DOSES) CPT RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, INSULIN, 466 PENICILLIN, EQUINE SERUM) CPT UNLISTED ALLERGY/CLINICAL IMMUNOLOGIC SERVICE OR PROCEDURE N/A CPT AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL 441 TISSUE FLUID VIA A SUBCUTANEOUS SENSOR FOR UP TO 72 HOURS; SENSOR PLACEMENT, HOOK-UP, CALIBRATION OF MONITOR, PATIENT TRAINING, REMOVAL OF SENSOR, AND PRINTOUT OF RECORDING CPT AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL 142 TISSUE FLUID VIA A SUBCUTANEOUS SENSOR FOR UP TO 72 HOURS; PHYSICIAN INTERPRETATION AND REPORT CPT MULTIPLE SLEEP LATENCY OR MAINTENANCE OF WAKEFULNESS TESTING, 1,174 RECORDING, ANALYSIS AND INTERPRETATION OF PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING MULTIPLE TRIALS TO ASSESS SLEEPINESS CPT SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, 752 RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, UNATTENDED BY A TECHNOLOGIST CPT SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, 1,821 RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, ATTENDED BY A TECHNOLOGIST CPT POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL 2,386 PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST CPT POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL 2,745 PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST CPT POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL 3,033 PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BILEVEL VENTILATION, ATTENDED BY A TECHNOLOGIST CPT ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; MINUTES CPT ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; GREATER 1,063 THAN ONE HOUR CPT ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING AWAKE AND 820 DROWSY CPT ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING AWAKE AND 334 ASLEEP CPT ELECTROENCEPHALOGRAM (EEG); RECORDING IN COMA OR SLEEP ONLY 854 CPT ELECTROENCEPHALOGRAM (EEG); CEREBRAL DEATH EVALUATION ONLY 336 CPT ELECTROENCEPHALOGRAM (EEG); ALL NIGHT RECORDING 1,612 CPT ELECTROCORTICOGRAM AT SURGERY (SEPARATE PROCEDURE) 3,961 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 340 of 380

341 CPT INSERTION BY PHYSICIAN OF SPHENOIDAL ELECTRODES FOR 216 ELECTROENCEPHALOGRAPHIC (EEG) RECORDING CPT MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 86 EXTREMITY (EXCLUDING HAND) OR TRUNK CPT MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 85 HAND, WITH OR WITHOUT COMPARISON WITH NORMAL SIDE CPT MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 45 TOTAL EVALUATION OF BODY, EXCLUDING HANDS CPT MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 147 TOTAL EVALUATION OF BODY, INCLUDING HANDS CPT RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 19 PROCEDURE); EACH EXTREMITY (EXCLUDING HAND) OR EACH TRUNK SECTION (SPINE) CPT RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 16 PROCEDURE); HAND, WITH OR WITHOUT COMPARISON WITH NORMAL SIDE CPT TENSILON TEST FOR MYASTHENIA GRAVIS 142 CPT NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH OR WITHOUT 275 RELATED PARASPINAL AREAS CPT NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES WITH OR WITHOUT 419 RELATED PARASPINAL AREAS CPT NEEDLE ELECTROMYOGRAPHY; THREE EXTREMITIES WITH OR WITHOUT 495 RELATED PARASPINAL AREAS CPT NEEDLE ELECTROMYOGRAPHY; FOUR EXTREMITIES WITH OR WITHOUT 546 RELATED PARASPINAL AREAS CPT NEEDLE ELECTROMYOGRAPHY; LARYNX 386 CPT NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM 336 CPT NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL CPT NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL CPT NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12) CPT NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY OF MUSCLES IN ONE EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS CPT NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED CPT ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ISCHEMIC LIMB EXERCISE TEST WITH SERIAL SPECIMEN(S) ACQUISITION FOR MUSCLE(S) METABOLITE(S) CPT NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITHOUT F-WAVE STUDY CPT NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITH F-WAVE STUDY CPT NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 341 of 380

342 CPT INTRAOPERATIVE NEUROPHYSIOLOGY TESTING, PER HOUR (LIST 511 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; CARDIOVAGAL 266 INNERVATION (PARASYMPATHETIC FUNCTION), INCLUDING TWO OR MORE OF THE FOLLOWING: HEART RATE RESPONSE TO DEEP BREATHING WITH RECORDED R-R INTERVAL, VALSALVA RATIO, AND 30:15 RATIO CPT TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; VASOMOTOR 332 ADRENERGIC INNERVATION (SYMPATHETIC ADRENERGIC FUNCTION), INCLUDING BEAT-TO-BEAT BLOOD PRESSURE AND R-R INTERVAL CHANGES DURING VALSALVA MANEUVER AND AT LEAST FIVE MINUTES OF PASSIVE TILT CPT TESTING OF AUTONOMIC NERVOUS SYSTEM FUNCTION; SUDOMOTOR, 415 INCLUDING ONE OR MORE OF THE FOLLOWING: QUANTITATIVE SUDOMOTOR AXON REFLEX TEST (QSART), SILASTIC SWEAT IMPRINT, THERMOREGULATORY SWEAT TEST, AND CHANGES IN SYMPATHETIC SKIN POTENTIAL CPT SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 466 STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER LIMBS CPT SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 456 STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN LOWER LIMBS CPT SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, 474 STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN THE TRUNK OR HEAD CPT CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL MOTOR 696 STIMULATION); UPPER LIMBS CPT CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL MOTOR 736 STIMULATION); LOWER LIMBS CPT VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS SYSTEM, 380 CHECKERBOARD OR FLASH CPT ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC TESTING 226 CPT H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD GASTROCNEMIUS/SOLEUS MUSCLE CPT H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS MUSCLE CPT NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY ONE METHOD CPT MONITORING FOR IDENTIFICATION AND LATERALIZATION OF CEREBRAL SEIZURE FOCUS, ELECTROENCEPHALOGRAPHIC (EG, 8 CHANNEL EEG) RECORDING AND INTERPRETATION, EACH 24 HOURS CPT MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY CABLE OR RADIO, 16 OR MORE CHANNEL TELEMETRY, COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND INTERPRETATION (EG, FOR PRESURGICAL LOCALIZATION), EACH 24 HOURS CPT MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY COMPUTERIZED PORTABLE 16 OR MORE CHANNEL EEG, ELECTROENCEPHALOGRAPHIC (EEG) RECORDING AND INTERPRETATION, EACH 24 HOURS CPT PHARMACOLOGICAL OR PHYSICAL ACTIVATION REQUIRING PHYSICIAN ATTENDANCE DURING EEG RECORDING OF ACTIVATION PHASE (EG, THIOPENTAL ACTIVATION TEST) CPT ELECTROENCEPHALOGRAM (EEG) DURING NONINTRACRANIAL SURGERY (EG, CAROTID SURGERY) , Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 342 of 380

343 CPT MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY 2,513 CABLE OR RADIO, 16 OR MORE CHANNEL TELEMETRY, ELECTROENCEPHALOGRAPHIC (EEG) RECORDING AND INTERPRETATION, EACH 24 HOURS CPT DIGITAL ANALYSIS OF ELECTROENCEPHALOGRAM (EEG) (EG, FOR 1,014 EPILEPTIC SPIKE ANALYSIS) CPT WADA ACTIVATION TEST FOR HEMISPHERIC FUNCTION, INCLUDING 1,419 ELECTROENCEPHALOGRAPHIC (EEG) MONITORING CPT FUNCTIONAL CORTICAL AND SUBCORTICAL MAPPING BY STIMULATION 826 AND/OR RECORDING OF ELECTRODES ON BRAIN SURFACE, OR OF DEPTH ELECTRODES, TO PROVOKE SEIZURES OR IDENTIFY VITAL BRAIN STRUCTURES; INITIAL HOUR OF PHYSICIAN ATTENDANCE CPT FUNCTIONAL CORTICAL AND SUBCORTICAL MAPPING BY STIMULATION 731 AND/OR RECORDING OF ELECTRODES ON BRAIN SURFACE, OR OF DEPTH ELECTRODES, TO PROVOKE SEIZURES OR IDENTIFY VITAL BRAIN STRUCTURES; EACH ADDITIONAL HOUR OF PHYSICIAN ATTENDANCE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR 2,501 SPONTANEOUS BRAIN MAGNETIC ACTIVITY (EG, EPILEPTIC CEREBRAL CORTEX LOCALIZATION) CPT MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR 1,239 EVOKED MAGNETIC FIELDS, SINGLE MODALITY (EG, SENSORY, MOTOR, LANGUAGE, OR VISUAL CORTEX LOCALIZATION) CPT MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR 1,043 EVOKED MAGNETIC FIELDS, EACH ADDITIONAL MODALITY (EG, SENSORY, MOTOR, LANGUAGE, OR VISUAL CORTEX LOCALIZATION) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 62 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); SIMPLE OR COMPLEX BRAIN, SPINAL CORD, OR PERIPHERAL (IE, CRANIAL NERVE, PERIPHERAL NERVE, AUTONOMIC NERVE, NEUROMUSCULAR) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 179 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); SIMPLE SPINAL CORD, OR PERIPHERAL (IE, PERIPHERAL NERVE, AUTONOMIC NERVE, NEUROMUSCULAR) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 351 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); COMPLEX SPINAL CORD, OR PERIPHERAL (EXCEPT CRANIAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING, FIRST HOUR CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); COMPLEX SPINAL CORD, OR 186 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 343 of 380

344 PERIPHERAL (EXCEPT CRANIAL NERVE) NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING, EACH ADDITIONAL 30 MINUTES AFTER FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 579 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); COMPLEX CRANIAL NERVE NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING, WITH OR WITHOUT NERVE INTERFACE TESTING, FIRST HOUR CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 320 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS); COMPLEX CRANIAL NERVE NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INTRAOPERATIVE OR SUBSEQUENT PROGRAMMING, EACH ADDITIONAL 30 MINUTES AFTER FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 697 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, BATTERY STATUS, ELECTRODE SELECTABILITY AND POLARITY, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS), COMPLEX DEEP BRAIN NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INITIAL OR SUBSEQUENT PROGRAMMING; FIRST HOUR CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 307 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, BATTERY STATUS, ELECTRODE SELECTABILITY AND POLARITY, IMPEDANCE AND PATIENT COMPLIANCE MEASUREMENTS), COMPLEX DEEP BRAIN NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER, WITH INITIAL OR SUBSEQUENT PROGRAMMING; EACH ADDITIONAL 30 MINUTES AFTER FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 140 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; INTRAOPERATIVE, WITH PROGRAMMING CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 95 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUENT, WITHOUT REPROGRAMMING CPT ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE 147 GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE AND DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATION, CYCLING, IMPEDANCE AND PATIENT MEASUREMENTS) GASTRIC NEUROSTIMULATOR PULSE GENERATOR/TRANSMITTER; SUBSEQUENT, WITH REPROGRAMMING CPT REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR); 211 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 344 of 380

345 CPT REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR 111 FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR); ADMINISTERED BY PHYSICIAN CPT UNLISTED NEUROLOGICAL OR NEUROMUSCULAR DIAGNOSTIC N/A PROCEDURE CPT COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO-TAPING 295 AND 3-D KINEMATICS; CPT COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO-TAPING 353 AND 3-D KINEMATICS; WITH DYNAMIC PLANTAR PRESSURE MEASUREMENTS DURING WALKING CPT DYNAMIC SURFACE ELECTROMYOGRAPHY, DURING WALKING OR OTHER 66 FUNCTIONAL ACTIVITIES, 1-12 MUSCLES CPT DYNAMIC FINE WIRE ELECTROMYOGRAPHY, DURING WALKING OR OTHER 60 FUNCTIONAL ACTIVITIES, 1 MUSCLE CPT PHYSICIAN REVIEW AND INTERPRETATION OF COMPREHENSIVE 365 COMPUTER-BASED MOTION ANALYSIS, DYNAMIC PLANTAR PRESSURE MEASUREMENTS, DYNAMIC SURFACE ELECTROMYOGRAPHY DURING WALKING OR OTHER FUNCTIONAL ACTIVITIES, AND DYNAMIC FINE WIRE ELECTROMYOGRAPHY, WITH WRITTEN REPORT CPT NEUROFUNCTIONAL TESTING SELECTION AND ADMINISTRATION DURING 587 NONINVASIVE IMAGING FUNCTIONAL BRAIN MAPPING, WITH TEST ADMINISTERED ENTIRELY BY A PHYSICIAN OR PSYCHOLOGIST, WITH REVIEW OF TEST RESULTS AND REPORT CPT MEDICAL GENETICS AND GENETIC COUNSELING SERVICES, EACH MINUTES FACE-TO-FACE WITH PATIENT/FAMILY CPT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT 284 OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT CPT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT 202 OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI AND WAIS), WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE CPT PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT 182 OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI), ADMINISTERED BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT CPT ASSESSMENT OF APHASIA (INCLUDES ASSESSMENT OF EXPRESSIVE AND 231 RECEPTIVE SPEECH AND LANGUAGE FUNCTION, LANGUAGE COMPREHENSION, SPEECH PRODUCTION ABILITY, READING, SPELLING, WRITING, EG, BY BOSTON DIAGNOSTIC APHASIA EXAMINATION) WITH INTERPRETATION AND REPORT, PER HOUR CPT DEVELOPMENTAL TESTING; LIMITED (EG, DEVELOPMENTAL SCREENING 46 TEST II, EARLY LANGUAGE MILESTONE SCREEN), WITH INTERPRETATION AND REPORT CPT DEVELOPMENTAL TESTING; EXTENDED (INCLUDES ASSESSMENT OF 436 MOTOR, LANGUAGE, SOCIAL, ADAPTIVE AND/OR COGNITIVE FUNCTIONING BY STANDARDIZED DEVELOPMENTAL INSTRUMENTS) WITH INTERPRETATION AND REPORT CPT NEUROBEHAVIORAL STATUS EXAM (CLINICAL ASSESSMENT OF THINKING, REASONING AND JUDGMENT, EG, ACQUIRED KNOWLEDGE, ATTENTION, LANGUAGE, MEMORY, PLANNING AND PROBLEM SOLVING, AND VISUAL SPATIAL ABILITIES), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME WITH THE PATIENT AND TIME 323 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 345 of 380

346 INTERPRETING TEST RESULTS AND PREPARING THE REPORT CPT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT CPT NEUROPSYCHOLOGICAL TESTING (EG, HALSTEAD-REITAN NEUROPSYCHOLOGICAL BATTERY, WECHSLER MEMORY SCALES AND WISCONSIN CARD SORTING TEST), WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT, ADMINISTERED BY TECHNICIAN, PER HOUR OF TECHNICIAN TIME, FACE-TO-FACE CPT NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST), ADMINISTERED BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT CPT STANDARDIZED COGNITIVE PERFORMANCE TESTING (EG, ROSS INFORMATION PROCESSING ASSESSMENT) PER HOUR OF A QUALIFIED HEALTH CARE PROFESSIONAL'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TESTS TO THE PATIENT AND TIME INTERPRETING THESE TEST RESULTS AND PREPARING THE REPORT CPT HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; INITIAL ASSESSMENT CPT HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; RE-ASSESSMENT CPT HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; INDIVIDUAL CPT HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; GROUP (2 OR MORE PATIENTS) CPT HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; FAMILY (WITH THE PATIENT PRESENT) CPT HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; FAMILY (WITHOUT THE PATIENT PRESENT) CPT CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; NON-HORMONAL ANTI-NEOPLASTIC CPT CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC CPT CHEMOTHERAPY ADMINISTRATION; INTRALESIONAL, UP TO AND INCLUDING 7 LESIONS CPT CHEMOTHERAPY ADMINISTRATION; INTRALESIONAL, MORE THAN 7 LESIONS CPT CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH TECHNIQUE, SINGLE OR INITIAL SUBSTANCE/DRUG CPT CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH TECHNIQUE, EACH ADDITIONAL SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; UP TO 1 HOUR, SINGLE OR INITIAL SUBSTANCE/DRUG CPT CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 346 of 380

347 HOURS), REQUIRING USE OF A PORTABLE OR IMPLANTABLE PUMP CPT CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; 252 EACH ADDITIONAL SEQUENTIAL INFUSION (DIFFERENT SUBSTANCE/DRUG), UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; PUSH TECHNIQUE 381 CPT CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION 597 TECHNIQUE, UP TO ONE HOUR CPT CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION 274 TECHNIQUE, EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION 619 TECHNIQUE, INITIATION OF PROLONGED INFUSION (MORE THAN 8 HOURS), REQUIRING THE USE OF A PORTABLE OR IMPLANTABLE PUMP CPT CHEMOTHERAPY ADMINISTRATION INTO PLEURAL CAVITY, REQUIRING 1,019 AND INCLUDING THORACENTESIS CPT CHEMOTHERAPY ADMINISTRATION INTO PERITONEAL CAVITY, REQUIRING 351 AND INCLUDING PERITONEOCENTESIS CPT CHEMOTHERAPY ADMINISTRATION, INTO CNS (EG, INTRATHECAL), 300 REQUIRING AND INCLUDING SPINAL PUNCTURE CPT REFILLING AND MAINTENANCE OF PORTABLE PUMP 431 CPT REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR 383 FOR DRUG DELIVERY, SYSTEMIC (EG, INTRAVENOUS, INTRA-ARTERIAL) CPT IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG 31 DELIVERY SYSTEMS CPT CHEMOTHERAPY INJECTION, SUBARACHNOID OR INTRAVENTRICULAR VIA 198 SUBCUTANEOUS RESERVOIR, SINGLE OR MULTIPLE AGENTS CPT UNLISTED CHEMOTHERAPY PROCEDURE N/A CPT PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO 475 DESTROY PREMALIGNANT AND/OR MALIGNANT LESIONS OF THE SKIN AND ADJACENT MUCOSA (EG, LIP) BY ACTIVATION OF PHOTOSENSITIVE DRUG(S), EACH PHOTOTHERAPY EXPOSURE SESSION CPT PHOTODYNAMIC THERAPY BY ENDOSCOPIC APPLICATION OF LIGHT TO 202 ABLATE ABNORMAL TISSUE VIA ACTIVATION OF PHOTOSENSITIVE DRUG(S); FIRST 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR ENDOSCOPY OR BRONCHOSCOPY PROCEDURES OF LUNG AND ESOPHAGUS) CPT PHOTODYNAMIC THERAPY BY ENDOSCOPIC APPLICATION OF LIGHT TO 96 ABLATE ABNORMAL TISSUE VIA ACTIVATION OF PHOTOSENSITIVE DRUG(S); EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR ENDOSCOPY OR BRONCHOSCOPY PROCEDURES OF LUNG AND ESOPHAGUS) CPT ACTINOTHERAPY (ULTRAVIOLET LIGHT) 27 CPT MICROSCOPIC EXAMINATION OF HAIRS PLUCKED OR CLIPPED BY THE EXAMINER (EXCLUDING HAIR COLLECTED BY THE PATIENT) TO DETERMINE TELOGEN AND ANAGEN COUNTS, OR STRUCTURAL HAIR SHAFT ABNORMALITY CPT WHOLE BODY INTEGUMENTARY PHOTOGRAPHY, FOR MONITORING OF HIGH RISK PATIENTS WITH DYSPLASTIC NEVUS SYNDROME OR A HISTORY OF DYSPLASTIC NEVI, OR PATIENTS WITH A PERSONAL OR FAMILIAL HISTORY OF MELANOMA Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 347 of 380

348 CPT PHOTOCHEMOTHERAPY; TAR AND ULTRAVIOLET B (GOECKERMAN 258 TREATMENT) OR PETROLATUM AND ULTRAVIOLET B CPT PHOTOCHEMOTHERAPY; PSORALENS AND ULTRAVIOLET A (PUVA) 331 CPT PHOTOCHEMOTHERAPY (GOECKERMAN AND/OR PUVA) FOR SEVERE 449 PHOTORESPONSIVE DERMATOSES REQUIRING AT LEAST FOUR TO EIGHT HOURS OF CARE UNDER DIRECT SUPERVISION OF THE PHYSICIAN (INCLUDES APPLICATION OF MEDICATION AND DRESSINGS) CPT LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 215 TOTAL AREA LESS THAN 250 SQ CM CPT LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); SQ CM TO 500 SQ CM CPT LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 853 OVER 500 SQ CM CPT UNLISTED SPECIAL DERMATOLOGICAL SERVICE OR PROCEDURE N/A CPT PHYSICAL THERAPY EVALUATION 86 CPT PHYSICAL THERAPY RE-EVALUATION 46 CPT OCCUPATIONAL THERAPY EVALUATION 91 CPT OCCUPATIONAL THERAPY RE-EVALUATION 146 CPT ATHLETIC TRAINING EVALUATION 199 CPT ATHLETIC TRAINING RE-EVALUATION 99 CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD 17 PACKS CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, 18 MECHANICAL CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL 17 STIMULATION (UNATTENDED) CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC 19 DEVICES CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH 11 CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL 23 CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (EG, 18 MICROWAVE) CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED 17 CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET 21 CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES CPT APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH 15 MINUTES Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 348 of 380

349 CPT UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT N/A ATTENDANCE) CPT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 36 THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY CPT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 36 NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES CPT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 44 AQUATIC THERAPY WITH THERAPEUTIC EXERCISES CPT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 31 GAIT TRAINING (INCLUDES STAIR CLIMBING) CPT THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 28 MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) CPT UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) N/A CPT MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, 33 MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES CPT THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) 22 CPT THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY 37 THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES CPT DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, 30 PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, EACH 15 MINUTES CPT SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY 32 PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, EACH 15 MINUTES CPT SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY 104 LIVING (ADL) AND COMPENSATORY TRAINING, MEAL PREPARATION, SAFETY PROCEDURES, AND INSTRUCTIONS IN USE OF ASSISTIVE TECHNOLOGY DEVICES/ADAPTIVE EQUIPMENT) DIRECT ONE-ON-ONE CONTACT BY PROVIDER, EACH 15 MINUTES CPT COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, 33 TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES AND/OR WORK ENVIRONMENT/MODIFICATION ANALYSIS, WORK TASK ANALYSIS, USE OF ASSISTIVE TECHNOLOGY DEVICE/ADAPTIVE EQUIPMENT), DIRECT ONE-ON-ONE CONTACT BY PROVIDER, EACH 15 MINUTES CPT WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), 34 EACH 15 MINUTES CPT WORK HARDENING/CONDITIONING; INITIAL 2 HOURS 401 CPT WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), WITH OR WITHOUT TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, MAY INCLUDE USE OF A WHIRLPOOL, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 20 SQUARE Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 349 of 380

350 CENTIMETERS CPT REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, HIGH PRESSURE WATERJET WITH/WITHOUT SUCTION, SHARP SELECTIVE DEBRIDEMENT WITH SCISSORS, SCALPEL AND FORCEPS), WITH OR WITHOUT TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, MAY INCLUDE USE OF A WHIRLPOOL, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 20 SQUARE CENTIMETERS CPT REMOVAL OF DEVITALIZED TISSUE FROM WOUND(S), NON-SELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA (EG, WET-TO-MOIST DRESSINGS, ENZYMATIC, ABRASION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION CPT NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS CPT NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS CPT PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES CPT ASSISTIVE TECHNOLOGY ASSESSMENT (EG, TO RESTORE, AUGMENT OR COMPENSATE FOR EXISTING FUNCTION, OPTIMIZE FUNCTIONAL TASKS AND/OR MAXIMIZE ENVIRONMENTAL ACCESSIBILITY), DIRECT ONE-ON- ONE CONTACT BY PROVIDER, WITH WRITTEN REPORT, EACH 15 MINUTES CPT ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT AND FITTING WHEN NOT OTHERWISE REPORTED), UPPER EXTREMITY(S), LOWER EXTREMITY(S) AND/OR TRUNK, EACH 15 MINUTES CPT PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES CPT CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED PATIENT, EACH 15 MINUTES CPT UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE CPT MEDICAL NUTRITION THERAPY; INITIAL ASSESSMENT AND INTERVENTION, INDIVIDUAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES CPT MEDICAL NUTRITION THERAPY; RE-ASSESSMENT AND INTERVENTION, INDIVIDUAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES CPT MEDICAL NUTRITION THERAPY; GROUP (2 OR MORE INDIVIDUAL(S)), EACH 30 MINUTES CPT ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT CPT ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON- ONE CONTACT WITH THE PATIENT, WITH RE-INSERTION OF NEEDLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT ACUPUNCTURE, 1 OR MORE NEEDLES; WITH ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 350 of 380

351 CPT ACUPUNCTURE, 1 OR MORE NEEDLES; WITH ELECTRICAL STIMULATION, 35 EACH ADDITIONAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT, WITH RE-INSERTION OF NEEDLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); ONE TO TWO BODY 34 REGIONS INVOLVED CPT OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); THREE TO FOUR BODY 48 REGIONS INVOLVED CPT OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); FIVE TO SIX BODY 61 REGIONS INVOLVED CPT OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); SEVEN TO EIGHT BODY 71 REGIONS INVOLVED CPT OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); NINE TO TEN BODY 82 REGIONS INVOLVED CPT CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, ONE TO TWO 30 REGIONS CPT CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, THREE TO 42 FOUR REGIONS CPT CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, FIVE REGIONS 55 CPT CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, ONE OR MORE REGIONS CPT EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A QUALIFIED, NONPHYSICIAN HEALTH CARE PROFESSIONAL USING A STANDARDIZED CURRICULUM, FACE-TO-FACE WITH THE PATIENT (COULD INCLUDE CAREGIVER/FAMILY) EACH 30 MINUTES; INDIVIDUAL PATIENT CPT EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A QUALIFIED, NONPHYSICIAN HEALTH CARE PROFESSIONAL USING A STANDARDIZED CURRICULUM, FACE-TO-FACE WITH THE PATIENT (COULD INCLUDE CAREGIVER/FAMILY) EACH 30 MINUTES; 2-4 PATIENTS CPT EDUCATION AND TRAINING FOR PATIENT SELF-MANAGEMENT BY A QUALIFIED, NONPHYSICIAN HEALTH CARE PROFESSIONAL USING A STANDARDIZED CURRICULUM, FACE-TO-FACE WITH THE PATIENT (COULD INCLUDE CAREGIVER/FAMILY) EACH 30 MINUTES; 5-8 PATIENTS CPT TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION CPT TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; MINUTES OF MEDICAL DISCUSSION CPT TELEPHONE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIOUS SEVEN DAYS NOR LEADING TO AN ASSESSMENT AND MANAGEMENT SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; MINUTES OF MEDICAL Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 351 of 380

352 DISCUSSION CPT ONLINE ASSESSMENT AND MANAGEMENT SERVICE PROVIDED BY A N/A QUALIFIED NONPHYSICIAN HEALTH CARE PROFESSIONAL TO AN ESTABLISHED PATIENT, GUARDIAN, OR HEALTH CARE PROVIDER NOT ORIGINATING FROM A RELATED ASSESSMENT AND MANAGEMENT SERVICE PROVIDED WITHIN THE PREVIO CPT HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE 2 PHYSICIAN'S OFFICE TO A LABORATORY CPT HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE 3 PATIENT IN OTHER THAN A PHYSICIAN'S OFFICE TO A LABORATORY (DISTANCE MAY BE INDICATED) CPT HANDLING, CONVEYANCE, AND/OR ANY OTHER SERVICE IN CONNECTION 3 WITH THE IMPLEMENTATION OF AN ORDER INVOLVING DEVICES (EG, DESIGNING, FITTING, PACKAGING, HANDLING, DELIVERY OR MAILING) WHEN DEVICES SUCH AS ORTHOTICS, PROTECTIVES, PROSTHETICS ARE FABRICATED B CPT POSTOPERATIVE FOLLOW-UP VISIT, NORMALLY INCLUDED IN THE N/A SURGICAL PACKAGE, TO INDICATE THAT AN EVALUATION AND MANAGEMENT SERVICE WAS PERFORMED DURING A POSTOPERATIVE PERIOD FOR A REASON(S) RELATED TO THE ORIGINAL PROCEDURE CPT HOSPITAL MANDATED ON CALL SERVICE; IN-HOSPITAL, EACH HOUR N/A CPT HOSPITAL MANDATED ON CALL SERVICE; OUT-OF-HOSPITAL, EACH HOUR N/A CPT SERVICES PROVIDED IN THE OFFICE AT TIMES OTHER THAN REGULARLY 24 SCHEDULED OFFICE HOURS, OR DAYS WHEN THE OFFICE IS NORMALLY CLOSED (EG, HOLIDAYS, SATURDAY OR SUNDAY), IN ADDITION TO BASIC SERVICE CPT SERVICE(S) PROVIDED IN THE OFFICE DURING REGULARLY SCHEDULED N/A EVENING, WEEKEND, OR HOLIDAY OFFICE HOURS, IN ADDITION TO BASIC SERVICE CPT SERVICE(S) PROVIDED BETWEEN 10:00 PM AND 8:00 AM AT 24-HOUR N/A FACILITY, IN ADDITION TO BASIC SERVICE CPT SERVICE(S) TYPICALLY PROVIDED IN THE OFFICE, PROVIDED OUT OF THE N/A OFFICE AT REQUEST OF PATIENT, IN ADDITION TO BASIC SERVICE CPT SERVICE(S) PROVIDED ON AN EMERGENCY BASIS IN THE OFFICE, WHICH 28 DISRUPTS OTHER SCHEDULED OFFICE SERVICES, IN ADDITION TO BASIC SERVICE CPT SERVICE(S) PROVIDED ON AN EMERGENCY BASIS, OUT OF THE OFFICE, 32 WHICH DISRUPTS OTHER SCHEDULED OFFICE SERVICES, IN ADDITION TO BASIC SERVICE CPT SUPPLIES AND MATERIALS (EXCEPT SPECTACLES), PROVIDED BY THE N/A PHYSICIAN OVER AND ABOVE THOSE USUALLY INCLUDED WITH THE OFFICE VISIT OR OTHER SERVICES RENDERED (LIST DRUGS, TRAYS, SUPPLIES, OR MATERIALS PROVIDED) CPT EDUCATIONAL SUPPLIES, SUCH AS BOOKS, TAPES, AND PAMPHLETS, N/A PROVIDED BY THE PHYSICIAN FOR THE PATIENT'S EDUCATION AT COST TO PHYSICIAN CPT MEDICAL TESTIMONY N/A CPT PHYSICIAN EDUCATIONAL SERVICES RENDERED TO PATIENTS IN A GROUP SETTING (EG, PRENATAL, OBESITY, OR DIABETIC INSTRUCTIONS) CPT SPECIAL REPORTS SUCH AS INSURANCE FORMS, MORE THAN THE INFORMATION CONVEYED IN THE USUAL MEDICAL COMMUNICATIONS OR STANDARD REPORTING FORM N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 352 of 380

353 CPT UNUSUAL TRAVEL (EG, TRANSPORTATION AND ESCORT OF PATIENT) N/A CPT ANALYSIS OF CLINICAL DATA STORED IN COMPUTERS (EG, ECGS, BLOOD N/A PRESSURES, HEMATOLOGIC DATA) CPT COLLECTION AND INTERPRETATION OF PHYSIOLOGIC DATA (EG, ECG, 177 BLOOD PRESSURE, GLUCOSE MONITORING) DIGITALLY STORED AND/OR TRANSMITTED BY THE PATIENT AND/OR CAREGIVER TO THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, REQUIRING A MINIMUM OF 30 MINUTES OF TIME CPT ANOGENITAL EXAMINATION WITH COLPOSCOPIC MAGNIFICATION IN 469 CHILDHOOD FOR SUSPECTED TRAUMA CPT OCULAR FUNCTION SCREENING, AUTOMATED OR SEMI-AUTOMATED 63 BILATERAL QUANTITATIVE DETERMINATION OF VISUAL ACUITY, OCULAR ALIGNMENT, COLOR VISION BY PSEUDOISOCHROMATIC PLATES, AND FIELD OF VISION (MAY INCLUDE ALL OR SOME SCREENING OF THE DETERMINATION[S] FOR C CPT SCREENING TEST OF VISUAL ACUITY, QUANTITATIVE, BILATERAL 15 CPT OCULAR PHOTOSCREENING WITH INTERPRETATION AND REPORT, 49 BILATERAL CPT IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND 20 CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON CPT PHYSICIAN ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN 228 THERAPY, PER SESSION CPT HYPOTHERMIA; REGIONAL 190 CPT HYPOTHERMIA; TOTAL BODY 428 CPT ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 564 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); EACH HOUR CPT ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 395 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); 45 MINUTES CPT ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 282 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); 30 MINUTES CPT PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE) 115 CPT UNLISTED SPECIAL SERVICE, PROCEDURE OR REPORT N/A CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 10 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 353 of 380

354 CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 20 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 114 MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 175 MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 45 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 220 MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 60 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 24 MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALLY, 5 MINUTES ARE SPENT PERFORMING OR SUPERVISING THESE SERVICES. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 46 MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 10 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 354 of 380

355 PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 15 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 113 MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 25 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND 153 MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 40 MINUTES FACE-TO- FACE WITH THE PATIENT AND/OR FAMILY. CPT OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE 82 UTILIZED BY THE PHYSICIAN TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM "OBSERVATION STATUS" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF "OBSERVATION STATUS." TO REPORT SERVICES TO A PATIENT DESIGNATED AS "OBSERVATION STATUS" OR "INPATIENT STATUS" AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, AS APPROPRIATE.]) CPT INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND 77 MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO "OBSERVATION STATUS" ARE OF LOW SEVERITY. CPT INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND 127 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO "OBSERVATION STATUS" ARE OF MODERATE SEVERITY. CPT INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE 177 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 355 of 380

356 PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION TO "OBSERVATION STATUS" ARE OF HIGH SEVERITY. CPT INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 111 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 151 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 50 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 223 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 70 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 46 MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING OR IMPROVING. PHYSICIANS TYPICALLY SPEND 15 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 82 MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. PHYSICIANS TYPICALLY SPEND 25 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 356 of 380

357 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS UNSTABLE OR HAS DEVELOPED A SIGNIFICANT COMPLICATION OR A SIGNIFICANT NEW PROBLEM. PHYSICIANS TYPICALLY SPEND 35 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND 155 MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY THE PRESENTING PROBLEM(S) REQUIRING ADMISSION ARE OF LOW SEVERITY. CPT OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND 203 MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY THE PRESENTING PROBLEM(S) REQUIRING ADMISSION ARE OF MODERATE SEVERITY. CPT OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND 253 MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY THE PRESENTING PROBLEM(S) REQUIRING ADMISSION ARE OF HIGH SEVERITY. CPT HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 81 CPT HOSPITAL DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES 118 CPT OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 15 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 357 of 380

358 PROBLEM(S) ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 153 REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 40 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 226 REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 60 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT OFFICE CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 279 REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 80 MINUTES FACE-TO- FACE WITH THE PATIENT AND/OR FAMILY. CPT INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 61 REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 20 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 93 REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 40 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 55 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. 142 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 358 of 380

359 CPT INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 206 REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 80 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT INPATIENT CONSULTATION FOR A NEW OR ESTABLISHED PATIENT, WHICH 249 REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 110 MINUTES AT THE BEDSIDE AND ON THE PATIENT'S HOSPITAL FLOOR OR UNIT. CPT EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT 25 OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. CPT EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT 48 OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. CPT EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT 76 OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. CPT EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT 142 OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY, AND REQUIRE URGENT EVALUATION BY THE PHYSICIAN BUT DO NOT POSE AN IMMEDIATE SIGNIFICANT THREAT TO LIFE OR PHYSIOLOGIC FUNCTION. CPT EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS WITHIN THE 211 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 359 of 380

360 CONSTRAINTS IMPOSED BY THE URGENCY OF THE PATIENT'S CLINICAL CONDITION AND/OR MENTAL STATUS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY AND POSE AN IMMEDIATE SIGNIFICANT THREAT TO LIFE OR PHYSIOLOGIC FUNCTION. CPT PHYSICIAN DIRECTION OF EMERGENCY MEDICAL SYSTEMS (EMS) N/A EMERGENCY CARE, ADVANCED LIFE SUPPORT CPT CRITICAL CARE SERVICES DELIVERED BY A PHYSICIAN, FACE-TO-FACE, 281 DURING AN INTERFACILITY TRANSPORT OF CRITICALLY ILL OR CRITICALLY INJURED PEDIATRIC PATIENT, 24 MONTHS OF AGE OR LESS; FIRST MINUTES OF HANDS ON CARE DURING TRANSPORT CPT CRITICAL CARE SERVICES DELIVERED BY A PHYSICIAN, FACE-TO-FACE, 151 DURING AN INTERFACILITY TRANSPORT OF CRITICALLY ILL OR CRITICALLY INJURED PEDIATRIC PATIENT, 24 MONTHS OF AGE OR LESS; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) CPT CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL 319 OR CRITICALLY INJURED PATIENT; FIRST MINUTES CPT CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL 144 OR CRITICALLY INJURED PATIENT; EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) CPT INITIAL INPATIENT PEDIATRIC CRITICAL CARE, PER DAY, FOR THE 934 EVALUATION AND MANAGEMENT OF A CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE CPT SUBSEQUENT INPATIENT PEDIATRIC CRITICAL CARE, PER DAY, FOR THE 452 EVALUATION AND MANAGEMENT OF A CRITICALLY ILL INFANT OR YOUNG CHILD, 29 DAYS THROUGH 24 MONTHS OF AGE CPT INITIAL INPATIENT NEONATAL CRITICAL CARE, PER DAY, FOR THE 1,082 EVALUATION AND MANAGEMENT OF A CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS CPT SUBSEQUENT INPATIENT NEONATAL CRITICAL CARE, PER DAY, FOR THE 464 EVALUATION AND MANAGEMENT OF A CRITICALLY ILL NEONATE, 28 DAYS OF AGE OR LESS CPT SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 161 MANAGEMENT OF THE RECOVERING VERY LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT LESS THAN 1500 G) CPT SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 145 MANAGEMENT OF THE RECOVERING LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF G) CPT SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 146 MANAGEMENT OF THE RECOVERING INFANT (PRESENT BODY WEIGHT OF G) CPT INITIAL NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 25 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. 100 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 360 of 380

361 CPT INITIAL NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND 139 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 35 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT INITIAL NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND 179 MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PROBLEM(S) REQUIRING ADMISSION ARE OF HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 45 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION 49 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. PHYSICIANS TYPICALLY SPEND 10 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION 75 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS RESPONDING INADEQUATELY TO THERAPY OR HAS DEVELOPED A MINOR COMPLICATION. PHYSICIANS TYPICALLY SPEND 15 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION 99 AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT HAS DEVELOPED A SIGNIFICANT COMPLICATION OR A SIGNIFICANT NEW PROBLEM. PHYSICIANS TYPICALLY SPEND 25 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT SUBSEQUENT NURSING FACILITY CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE 148 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 361 of 380

362 NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. THE PATIENT MAY BE UNSTABLE OR MAY HAVE DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. PHYSICIANS TYPICALLY SPEND 35 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT NURSING FACILITY DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 71 CPT NURSING FACILITY DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES CPT EVALUATION AND MANAGEMENT OF A PATIENT INVOLVING AN ANNUAL NURSING FACILITY ASSESSMENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS OF LOW TO MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS STABLE, RECOVERING, OR IMPROVING. PHYSICIANS TYPICALLY SPEND 30 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 20 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 45 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 60 MINUTES WITH THE PATIENT AND/OR Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 362 of 380

363 FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS UNSTABLE OR HAS DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. PHYSICIANS TYPICALLY SPEND 75 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF-LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 15 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 25 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 40 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT DOMICILIARY OR REST HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE TO HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. THE PATIENT MAY BE UNSTABLE OR MAY HAVE DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. PHYSICIANS TYPICALLY SPEND 60 MINUTES WITH THE PATIENT AND/OR FAMILY OR CAREGIVER. CPT INDIVIDUAL PHYSICIAN SUPERVISION OF A PATIENT (PATIENT NOT PRESENT) IN HOME, DOMICILIARY OR REST HOME (EG, ASSISTED LIVING Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 363 of 380

364 FACILITY) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; MINUTES CPT INDIVIDUAL PHYSICIAN SUPERVISION OF A PATIENT (PATIENT NOT 118 PRESENT) IN HOME, DOMICILIARY OR REST HOME (EG, ASSISTED LIVING FACILITY) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; 30 MINUTES OR MORE CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 68 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 20 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 157 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 45 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES 206 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 364 of 380

365 ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 60 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 248 PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PATIENT IS UNSTABLE OR HAS DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. PHYSICIANS TYPICALLY SPEND 75 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 65 ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED INTERVAL HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE SELF LIMITED OR MINOR. PHYSICIANS TYPICALLY SPEND 15 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 98 ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED INTERVAL HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION; MEDICAL DECISION MAKING OF LOW COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 25 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN 143 ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED INTERVAL HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE MODERATE TO HIGH SEVERITY. PHYSICIANS TYPICALLY SPEND 40 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT HOME VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE INTERVAL HISTORY; A COMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKING OF MODERATE TO HIGH COMPLEXITY. COUNSELING AND/OR COORDINATION OF CARE WITH OTHER PROVIDERS OR AGENCIES ARE PROVIDED CONSISTENT WITH THE NATURE OF THE PROBLEM(S) AND THE PATIENT'S AND/OR FAMILY'S NEEDS. USUALLY, THE PRESENTING PROBLEM(S) ARE OF MODERATE TO HIGH SEVERITY. THE PATIENT MAY BE UNSTABLE OR MAY HAVE DEVELOPED A SIGNIFICANT NEW PROBLEM REQUIRING IMMEDIATE PHYSICIAN ATTENTION. PHYSICIANS TYPICALLY SPEND 60 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. 201 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 365 of 380

366 CPT PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER OUTPATIENT 114 SETTING REQUIRING DIRECT (FACE-TO-FACE) PATIENT CONTACT BEYOND THE USUAL SERVICE (EG, PROLONGED CARE AND TREATMENT OF AN ACUTE ASTHMATIC PATIENT IN AN OUTPATIENT SETTING); FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR OFFICE OR OTHER OUTPATIENT EVALUATION AND MANAGEMENT SERVICE) CPT PROLONGED PHYSICIAN SERVICE IN THE OFFICE OR OTHER OUTPATIENT 113 SETTING REQUIRING DIRECT (FACE-TO-FACE) PATIENT CONTACT BEYOND THE USUAL SERVICE (EG, PROLONGED CARE AND TREATMENT OF AN ACUTE ASTHMATIC PATIENT IN AN OUTPATIENT SETTING); EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PROLONGED PHYSICIAN SERVICE) CPT PROLONGED PHYSICIAN SERVICE IN THE INPATIENT SETTING, REQUIRING 102 DIRECT (FACE-TO-FACE) PATIENT CONTACT BEYOND THE USUAL SERVICE (EG, MATERNAL FETAL MONITORING FOR HIGH RISK DELIVERY OR OTHER PHYSIOLOGICAL MONITORING, PROLONGED CARE OF AN ACUTELY ILL INPATIENT); FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR INPATIENT EVALUATION AND MANAGEMENT SERVICE) CPT PROLONGED PHYSICIAN SERVICE IN THE INPATIENT SETTING, REQUIRING 102 DIRECT (FACE-TO-FACE) PATIENT CONTACT BEYOND THE USUAL SERVICE (EG, MATERNAL FETAL MONITORING FOR HIGH RISK DELIVERY OR OTHER PHYSIOLOGICAL MONITORING, PROLONGED CARE OF AN ACUTELY ILL INPATIENT); EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PROLONGED PHYSICIAN SERVICE) CPT PROLONGED EVALUATION AND MANAGEMENT SERVICE BEFORE AND/OR 121 AFTER DIRECT (FACE-TO-FACE) PATIENT CARE (EG, REVIEW OF EXTENSIVE RECORDS AND TESTS, COMMUNICATION WITH OTHER PROFESSIONALS AND/OR THE PATIENT/FAMILY); FIRST HOUR (LIST SEPARATELY IN ADDITION TO CODE(S) FOR OTHER PHYSICIAN SERVICE(S) AND/OR INPATIENT OR OUTPATIENT EVALUATION AND MANAGEMENT SERVICE) CPT PROLONGED EVALUATION AND MANAGEMENT SERVICE BEFORE AND/OR 58 AFTER DIRECT (FACE-TO-FACE) PATIENT CARE (EG, REVIEW OF EXTENSIVE RECORDS AND TESTS, COMMUNICATION WITH OTHER PROFESSIONALS AND/OR THE PATIENT/FAMILY); EACH ADDITIONAL 30 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PROLONGED PHYSICIAN SERVICE) CPT PHYSICIAN STANDBY SERVICE, REQUIRING PROLONGED PHYSICIAN 68 ATTENDANCE, EACH 30 MINUTES (EG, OPERATIVE STANDBY, STANDBY FOR FROZEN SECTION, FOR CESAREAN/HIGH RISK DELIVERY, FOR MONITORING EEG) CPT ANTICOAGULANT MANAGEMENT FOR AN OUTPATIENT TAKING WARFARIN, 135 PHYSICIAN REVIEW AND INTERPRETATION OF INTERNATIONAL NORMALIZED RATIO (INR) TESTING, PATIENT INSTRUCTIONS, DOSAGE ADJUSTMENT (AS NEEDED), AND ORDERING OF ADDITIONAL TESTS; INITIAL 90 DAYS OF THERAPY (MUST INCLUDE A MINIMUM OF 8 INR MEASUREMENTS) CPT ANTICOAGULANT MANAGEMENT FOR AN OUTPATIENT TAKING WARFARIN, 47 PHYSICIAN REVIEW AND INTERPRETATION OF INTERNATIONAL NORMALIZED RATIO (INR) TESTING, PATIENT INSTRUCTIONS, DOSAGE ADJUSTMENT (AS NEEDED), AND ORDERING OF ADDITIONAL TESTS; EACH SUBSEQUENT 90 DAYS OF THERAPY (MUST INCLUDE A MINIMUM OF 3 INR MEASUREMENTS) CPT MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH CARE PROFESSIONALS, FACE-TO-FACE WITH PATIENT AND/OR FAMILY, 30 MINUTES OR MORE, PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL 48 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 366 of 380

367 CPT MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH 63 CARE PROFESSIONALS, PATIENT AND/OR FAMILY NOT PRESENT, 30 MINUTES OR MORE; PARTICIPATION BY PHYSICIAN CPT MEDICAL TEAM CONFERENCE WITH INTERDISCIPLINARY TEAM OF HEALTH 41 CARE PROFESSIONALS, PATIENT AND/OR FAMILY NOT PRESENT, 30 MINUTES OR MORE; PARTICIPATION BY NONPHYSICIAN QUALIFIED HEALTH CARE PROFESSIONAL CPT PHYSICIAN SUPERVISION OF A PATIENT UNDER CARE OF HOME HEALTH 79 AGENCY (PATIENT NOT PRESENT) IN HOME, DOMICILIARY OR EQUIVALENT ENVIRONMENT (EG, ALZHEIMER'S FACILITY) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; MINUTES CPT PHYSICIAN SUPERVISION OF A PATIENT UNDER CARE OF HOME HEALTH 132 AGENCY (PATIENT NOT PRESENT) IN HOME, DOMICILIARY OR EQUIVALENT ENVIRONMENT (EG, ALZHEIMER'S FACILITY) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; 30 MINUTES OR MORE CPT PHYSICIAN SUPERVISION OF A HOSPICE PATIENT (PATIENT NOT 76 PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; MINUTES CPT PHYSICIAN SUPERVISION OF A HOSPICE PATIENT (PATIENT NOT PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; 30 MINUTES OR MORE 114 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 367 of 380

368 CPT PHYSICIAN SUPERVISION OF A NURSING FACILITY PATIENT (PATIENT NOT 75 PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; MINUTES CPT PHYSICIAN SUPERVISION OF A NURSING FACILITY PATIENT (PATIENT NOT 113 PRESENT) REQUIRING COMPLEX AND MULTIDISCIPLINARY CARE MODALITIES INVOLVING REGULAR PHYSICIAN DEVELOPMENT AND/OR REVISION OF CARE PLANS, REVIEW OF SUBSEQUENT REPORTS OF PATIENT STATUS, REVIEW OF RELATED LABORATORY AND OTHER STUDIES, COMMUNICATION (INCLUDING TELEPHONE CALLS) FOR PURPOSES OF ASSESSMENT OR CARE DECISIONS WITH HEALTH CARE PROFESSIONAL(S), FAMILY MEMBER(S), SURROGATE DECISION MAKER(S) (EG, LEGAL GUARDIAN) AND/OR KEY CAREGIVER(S) INVOLVED IN PATIENT'S CARE, INTEGRATION OF NEW INFORMATION INTO THE MEDICAL TREATMENT PLAN AND/OR ADJUSTMENT OF MEDICAL THERAPY, WITHIN A CALENDAR MONTH; 30 MINUTES OR MORE CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND 111 MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; INFANT (AGE YOUNGER THAN 1 YEAR) CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND 121 MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; EARLY CHILDHOOD (AGE 1 THROUGH 4 YEARS) CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND 119 MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; LATE CHILDHOOD (AGE 5 THROUGH 11 YEARS) CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND 130 MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; ADOLESCENT (AGE 12 THROUGH 17 YEARS) CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), 130 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 368 of 380

369 LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; YEARS CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; YEARS CPT INITIAL COMPREHENSIVE PREVENTIVE MEDICINE EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; 65 YEARS AND OLDER CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; INFANT (AGE YOUNGER THAN 1 YEAR) CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; EARLY CHILDHOOD (AGE 1 THROUGH 4 YEARS) CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; LATE CHILDHOOD (AGE 5 THROUGH 11 YEARS) CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; ADOLESCENT (AGE 12 THROUGH 17 YEARS) CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; YEARS CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; YEARS Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 369 of 380

370 CPT PERIODIC COMPREHENSIVE PREVENTIVE MEDICINE RE-EVALUATION AND 135 MANAGEMENT OF AN INDIVIDUAL INCLUDING AN AGE AND GENDER APPROPRIATE HISTORY, EXAMINATION, COUNSELLING/ANTICIPATORY GUIDANCE/RISK FACTOR REDUCTION INTERVENTIONS, AND THE ORDERING OF APPROPRIATE IMMUNIZATION(S), LABORATORY/DIAGNOSTIC PROCEDURES, ESTABLISHED PATIENT; 65 YEARS AND OLDER CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 44 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 15 MINUTES CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 75 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 30 MINUTES CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 105 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 45 MINUTES CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 135 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 60 MINUTES CPT SMOKING AND TOBACCO USE CESSATION COUNSELLING VISIT; 16 INTERMEDIATE, GREATER THAN 3 MINUTES UP TO 10 MINUTES CPT SMOKING AND TOBACCO USE CESSATION COUNSELLING VISIT; 31 INTENSIVE, GREATER THAN 10 MINUTES CPT ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE 38 STRUCTURED SCREENING (EG, AUDIT, DAST), AND BRIEF INTERVENTION (SBI) SERVICES; 15 TO 30 MINUTES CPT ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE 75 STRUCTURED SCREENING (E.G., AUDIT, DAST), AND BRIEF INTERVENTION (SBI) SERVICES; GREATER THAN 30 MINUTES CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 16 INTERVENTION(S) PROVIDED TO INDIVIDUALS IN A GROUP SETTING (SEPARATE PROCEDURE); APPROXIMATELY 30 MINUTES CPT PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 23 INTERVENTION(S) PROVIDED TO INDIVIDUALS IN A GROUP SETTING (SEPARATE PROCEDURE); APPROXIMATELY 60 MINUTES CPT ADMINISTRATION AND INTERPRETATION OF HEALTH RISK ASSESSMENT 10 INSTRUMENT (E.G., HEALTH HAZARD APPRAISAL) CPT UNLISTED PREVENTIVE MEDICINE SERVICE 22 CPT HISTORY AND EXAMINATION OF THE NORMAL NEW-BORN INFANT, INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAMS AND PREPARATION OF HOSPITAL RECORDS. (THIS CODE SHOULD ALSO BE USED FOR BIRTHING ROOM DELIVERIES.) CPT NORMAL NEW-BORN CARE IN OTHER THAN HOSPITAL OR BIRTHING ROOM SETTING, INCLUDING PHYSICAL EXAMINATION OF BABY AND CONFERENCE(S) WITH PARENT(S) CPT SUBSEQUENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A NORMAL NEW-BORN, PER DAY CPT HISTORY AND EXAMINATION OF THE NORMAL NEW-BORN INFANT, INCLUDING THE PREPARATION OF MEDICAL RECORDS. (THIS CODE SHOULD ONLY BE USED FOR NEW-BORNS ASSESSED AND DISCHARGED FROM THE HOSPITAL OR BIRTHING ROOM ON THE SAME DATE.) CPT ATTENDANCE AT DELIVERY (WHEN REQUESTED BY DELIVERING PHYSICIAN) AND INITIAL STABILIZATION OF NEW-BORN CPT NEW-BORN RESUSCITATION: PROVISION OF POSITIVE PRESSURE VENTILATION AND/OR CHEST COMPRESSIONS IN THE PRESENCE OF ACUTE INADEQUATE VENTILATION AND/OR CARDIAC OUTPUT Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 370 of 380

371 CPT TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A 16 PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; 5-10 MINUTES OF MEDICAL DISCUSSION CPT TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A 30 PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; MINUTES OF MEDICAL DISCUSSION CPT TELEPHONE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A 44 PHYSICIAN TO AN ESTABLISHED PATIENT, PARENT, OR GUARDIAN NOT ORIGINATING FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS NOR LEADING TO AN E/M SERVICE OR PROCEDURE WITHIN THE NEXT 24 HOURS OR SOONEST AVAILABLE APPOINTMENT; MINUTES OF MEDICAL DISCUSSION CPT ONLINE EVALUATION AND MANAGEMENT SERVICE PROVIDED BY A N/A PHYSICIAN TO AN ESTABLISHED PATIENT, GUARDIAN, OR HEALTH CARE PROVIDER NOT ORIGINATING FROM A RELATED E/M SERVICE PROVIDED WITHIN THE PREVIOUS 7 DAYS, USING THE INTERNET OR SIMILAR ELECTRONIC COMMUNIC CPT BASIC LIFE AND/OR DISABILITY EXAMINATION THAT INCLUDES: N/A MEASUREMENT OF HEIGHT, WEIGHT, AND BLOOD PRESSURE; COMPLETION OF A MEDICAL HISTORY FOLLOWING A LIFE INSURANCE PRO FORMA; COLLECTION OF BLOOD SAMPLE AND/OR URINALYSIS COMPLYING WITH "CHAIN OF CUSTODY" CPT WORK RELATED OR MEDICAL DISABILITY EXAMINATION BY THE TREATING N/A PHYSICIAN THAT INCLUDES: COMPLETION OF A MEDICAL HISTORY COMMENSURATE WITH THE PATIENT'S CONDITION; PERFORMANCE OF AN EXAMINATION COMMENSURATE WITH THE PATIENT'S CONDITION; FORMULATION OF A DI CPT WORK RELATED OR MEDICAL DISABILITY EXAMINATION BY OTHER THAN N/A THE TREATING PHYSICIAN THAT INCLUDES: COMPLETION OF A MEDICAL HISTORY COMMENSURATE WITH THE PATIENT'S CONDITION; PERFORMANCE OF AN EXAMINATION COMMENSURATE WITH THE PATIENT'S CONDITION; FORMULATE CPT INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND 416 MANAGEMENT OF THE NEONATE, 28 DAYS OF AGE OR LESS, WHO REQUIRES INTENSIVE OBSERVATION, FREQUENT INTERVENTIONS, AND OTHER INTENSIVE CARE SERVICES CPT HOME VISIT FOR PRENATAL MONITORING AND ASSESSMENT TO INCLUDE N/A FETAL HEART RATE, NON-STRESS TEST, UTERINE MONITORING, AND GESTATIONAL DIABETES MONITORING CPT HOME VISIT FOR POSTNATAL ASSESSMENT AND FOLLOW-UP CARE N/A CPT HOME VISIT FOR NEW-BORN CARE AND ASSESSMENT N/A CPT HOME VISIT FOR RESPIRATORY THERAPY CARE (E.G., BRONCHODILATOR, N/A OXYGEN THERAPY, RESPIRATORY ASSESSMENT, APNEA EVALUATION) CPT HOME VISIT FOR MECHANICAL VENTILATION CARE N/A CPT HOME VISIT FOR STOMA CARE AND MAINTENANCE INCLUDING N/A COLOSTOMY AND CYSTOSTOMY CPT HOME VISIT FOR INTRAMUSCULAR INJECTIONS N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 371 of 380

372 CPT HOME VISIT FOR CARE AND MAINTENANCE OF CATHETER(S) (E.G., N/A URINARY, DRAINAGE, AND ENTERAL) CPT HOME VISIT FOR ASSISTANCE WITH ACTIVITIES OF DAILY LIVING AND N/A PERSONAL CARE CPT HOME VISIT FOR INDIVIDUAL, FAMILY, OR MARRIAGE COUNSELLING N/A CPT HOME VISIT FOR FAECAL IMPACTION MANAGEMENT AND ENEMA N/A ADMINISTRATION CPT HOME VISIT FOR HAEMODIALYSIS N/A CPT UNLISTED HOME VISIT SERVICE OR PROCEDURE N/A CPT HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); CPT HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE-TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; INITIAL 15 MINUTES, NEW PATIENT CPT MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE-TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; INITIAL 15 MINUTES, ESTABLISHED PATIENT CPT MEDICATION THERAPY MANAGEMENT SERVICE(S) PROVIDED BY A PHARMACIST, INDIVIDUAL, FACE-TO-FACE WITH PATIENT, WITH ASSESSMENT AND INTERVENTION IF PROVIDED; EACH ADDITIONAL 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE) N/A N/A N/A N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 372 of 380

373 Price List for Anesthesia Services CODE DESCRIPTION PRICE (IN AED) ANESTHESIA CONSULTATION 154 ANESTHETISTS ROUNDS CHARGES 83 GENERAL ANESTHESIA - 1/2 HOUR 360 GENERAL ANESTHESIA FOR 1 HOURS 683 LOCAL ANESTHESIA - 1/2 HOUR 323 LOCAL ANESTHESIA 1 HOUR 641 REGIONAL ANESTHESIA -1/2 HOUR 581 REGIONAL ANESTHESIA -1 HOUR 803 REGIONAL ANESTHESIA SUBSEQUENT HR 443 EPIDURAL ANESTHESIA 600 MONITOR ANESTHESIA SEDATION FIRST 1/2 HR 383 MONITOR ANESTHESIA CARE/ SEDATION 1 HR 544 CHARGEABLE ANESTHESIA CONSUMABLES ACTUALS Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 373 of 380

374 Price List for Healthcare Common Procedure Coding System HCPCS A0225 AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAY 600 HCPCS A0420 AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR 50 INCREMENTS HCPCS A0425 GROUND MILEAGE, PER STATUTE MILE 5 HCPCS A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS1-EMERGENCY) 495 HCPCS A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY) 420 HCPCS A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) 705 HCPCS A0434 SPECIALTY CARE TRANSPORT (SCT) 825 HCPCS P9010 BLOOD (WHOLE), FOR TRANSFUSION, PER UNIT 825 HCPCS P9012 CRYOPRECIPITATE, EACH UNIT 250 HCPCS P9017 FRESH FROZEN PLASMA (SINGLE DONOR), FROZEN WITHIN 8 HOURS OF COLLECTION, EACH UNIT HCPCS P9019 PLATELETS, EACH UNIT 150 HCPCS P9021 RED BLOOD CELLS, EACH UNIT 825 HCPCS P9034 PLATELETS, PHERESIS, EACH UNIT 750 HCPCS A9500 TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES HCPCS A9502 TECHNETIUM TC-99M TETROFOSMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES HCPCS A9503 TECHNETIUM TC-99M MEDRONATE, DIAGNOSTIC, PER STUDY DOSE, UP N/A TO 30 MILLICURIES HCPCS A9505 THALLIUM TL-201 THALLOUS CHLORIDE, DIAGNOSTIC, PER MILLICURIE N/A HCPCS A9510 TECHNETIUM TC-99M DISOFENIN, DIAGNOSTIC, PER STUDY DOSE, UP N/A TO 15 MILLICURIES HCPCS A9512 TECHNETIUM TC-99M PERTECHNETATE, DIAGNOSTIC, PER MILLICURIE N/A HCPCS A9521 TECHNETIUM TC-99M EXAMETAZIME, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES 450 N/A N/A N/A HCPCS A9528 IODINE I-131 SODIUM IODIDE CAPSULE(S), DIAGNOSTIC, PER MILLICURIE HCPCS A9537 TECHNETIUM TC-99M MEBROFENIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES HCPCS A9538 TECHNETIUM TC-99M PYROPHOSPHATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES HCPCS A9539 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES HCPCS A9540 TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES N/A N/A N/A N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 374 of 380

375 HCPCS A9541 TECHNETIUM TC-99M SULFUR COLLOID, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES N/A HCPCS A9550 TECHNETIUM TC-99M SODIUM GLUCEPTATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIE N/A HCPCS A9551 TECHNETIUM TC-99M SUCCIMER, DIAGNOSTIC, PER STUDY DOSE, UP N/A TO 10 MILLICURIES HCPCS A9556 GALLIUM GA-67 CITRATE, DIAGNOSTIC, PER MILLICURIE N/A HCPCS A9557 TECHNETIUM TC-99M BICISATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES HCPCS A9560 TECHNETIUM TC-99M LABELED RED BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES HCPCS A9561 TECHNETIUM TC-99M OXIDRONATE, DIAGNOSTIC, PER STUDY DOSE, N/A UP TO 30 MILLICURIES HCPCS A9562 TECHNETIUM TC-99M MERTIATIDE, DIAGNOSTIC, PER STUDY DOSE, UP N/A TO 15 MILLICURIES HCPCS A9565 INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER MILLICURIE N/A HCPCS A9566 TECHNETIUM TC-99M FANOLESOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES HCPCS A9999 MISCELLANEOUS DME SUPPLY OR ACCESSORY, NOT OTHERWISE N/A SPECIFIED HCPCS C1713 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO- N/A BONE (IMPLANTABLE) HCPCS C1721 CARDIOVERTER-DEFIBRILLATOR, DUAL CHAMBER (IMPLANTABLE) N/A HCPCS C1722 CARDIOVERTER-DEFIBRILLATOR, SINGLE CHAMBER (IMPLANTABLE) N/A HCPCS C1760 CLOSURE DEVICE, VASCULAR (IMPLANTABLE/INSERTABLE) N/A HCPCS C1762 CONNECTIVE TISSUE, HUMAN (INCLUDES FASCIA LATA) N/A HCPCS C1768 GRAFT, VASCULAR N/A HCPCS C1776 JOINT DEVICE (IMPLANTABLE) N/A HCPCS C1777 LEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL SINGLE COIL N/A (IMPLANTABLE) HCPCS C1781 MESH (IMPLANTABLE) N/A HCPCS C1785 PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE) N/A HCPCS C1786 PACEMAKER, SINGLE CHAMBER, RATE-RESPONSIVE (IMPLANTABLE) N/A HCPCS C1874 STENT, COATED/COVERED, WITH DELIVERY SYSTEM N/A HCPCS C1875 STENT, COATED/COVERED, WITHOUT DELIVERY SYSTEM N/A HCPCS C1876 STENT, NON-COATED/NON-COVERED, WITH DELIVERY SYSTEM N/A HCPCS C1877 STENT, NON-COATED/NON-COVERED, WITHOUT DELIVERY SYSTEM N/A HCPCS C1882 CARDIOVERTER-DEFIBRILLATOR, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE) HCPCS C1895 LEAD, CARDIOVERTER-DEFIBRILLATOR, ENDOCARDIAL DUAL COIL (IMPLANTABLE) HCPCS C1896 LEAD, CARDIOVERTER-DEFIBRILLATOR, OTHER THAN ENDOCARDIAL SINGLE OR DUAL COIL (IMPLANTABLE) HCPCS C2619 PACEMAKER, DUAL CHAMBER, NON RATE-RESPONSIVE (IMPLANTABLE) N/A HCPCS C2620 PACEMAKER, SINGLE CHAMBER, NON RATE-RESPONSIVE N/A (IMPLANTABLE) HCPCS C2621 PACEMAKER, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE) N/A N/A N/A N/A N/A N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 375 of 380

376 HCPCS Q1003 NEW TECHNOLOGY INTRAOCULAR LENS CATEGORY 3 (REDUCED N/A SPHERICAL ABERRATION) HCPCS V2630 ANTERIOR CHAMBER INTRAOCULAR LENS N/A HCPCS V2632 POSTERIOR CHAMBER INTRAOCULAR LENS N/A HCPCS V2788 PRESBYOPIA CORRECTING FUNCTION OF INTRAOCULAR LENS N/A HCPCS A4616 TUBING (OXYGEN), PER FOOT N/A HCPCS A4649 SURGICAL SUPPLY; MISCELLANEOUS N/A HCPCS C1714 CATHETER, TRANSLUMINAL ATHERECTOMY, DIRECTIONAL N/A HCPCS C1725 CATHETER, TRANSLUMINAL ANGIOPLASTY, NON-LASER (MAY INCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY) HCPCS C1727 CATHETER, BALLOON TISSUE DISSECTOR, NON-VASCULAR N/A (INSERTABLE) HCPCS C1757 CATHETER, THROMBECTOMY/EMBOLECTOMY N/A HCPCS C1765 ADHESION BARRIER N/A HCPCS C1771 REPAIR DEVICE, URINARY, INCONTINENCE, WITH SLING GRAFT N/A HCPCS C1785 PACEMAKER, DUAL CHAMBER, RATE-RESPONSIVE (IMPLANTABLE) N/A HCPCS C1880 VENA CAVA FILTER N/A HCPCS C1887 CATHETER, GUIDING (MAY INCLUDE INFUSION/PERFUSION N/A CAPABILITY) HCPCS D5982 SURGICAL STENT N/A HCPCS L8612 AQUEOUS SHUNT N/A HCPCS L8699 PROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIED N/A HCPCS A9501 TECHNETIUM TC-99M TEBOROXIME, DIAGNOSTIC, PER STUDY DOSE N/A HCPCS A9504 TECHNETIUM TC-99M APCITIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES N/A N/A HCPCS A9507 INDIUM IN-111 CAPROMAB PENDETIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES N/A HCPCS A9508 IODINE I-131 IOBENGUANE SULFATE, DIAGNOSTIC, PER 0.5 N/A MILLICURIE HCPCS A9509 IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER MILLICURIE N/A HCPCS A9511 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC 99M, DEPREOTIDE, PER MCI N/A HCPCS A9513 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M MEBROFENIN, PER MCI HCPCS A9514 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M PYROPHOSPHATE, PER MCI HCPCS A9515 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M PENTETATE, PER MCI HCPCS A9516 IODINE I-123 SODIUM IODIDE, DIAGNOSTIC, PER 100 MICROCURIES, UP TO 999 MICROCURIES HCPCS A9517 IODINE I-131 SODIUM IODIDE CAPSULE(S), THERAPEUTIC, PER MILLICURIE HCPCS A9519 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M MACROAGGREGATED ALBUMIN, PER MCI N/A N/A N/A N/A N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 376 of 380

377 HCPCS A9520 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, TECHNETIUM TC-99M SULFUR COLLOID, PER MCI N/A HCPCS A9522 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, INDIUM-111 IBRITUMOMAB TIUXETAN, PER MCI HCPCS A9523 SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, YTTRIUM 90 IBRITUMOMAB TIUXETAN, PER MCI HCPCS A9524 IODINE I-131 IODINATED SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES HCPCS A9525 SUPPLY OF LOW OR ISO-OSMOLAR CONTRAST MATERIAL, 10 MG OF IODINE HCPCS A9526 NITROGEN N-13 AMMONIA, DIAGNOSTIC, PER STUDY DOSE, UP TO 40 MILLICURIES HCPCS A9527 IODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE HCPCS A9529 IODINE I-131 SODIUM IODIDE SOLUTION, DIAGNOSTIC, PER MILLICURIE HCPCS A9530 IODINE I-131 SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE HCPCS A9531 IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER MICROCURIE (UP TO 100 MICROCURIES) N/A N/A N/A N/A N/A N/A N/A N/A N/A HCPCS A9532 IODINE I-125 SERUM ALBUMIN, DIAGNOSTIC, PER 5 MICROCURIES N/A HCPCS A9533 SUPPLY OF RADIOPHARMACEUTICAL DIAGNOSTIC IMAGING AGENT, I- 131 TOSITUMOMAB, PER MILLICURIE N/A HCPCS A9534 SUPPLY OF RADIOPHARMACEUTICAL THERAPEUTIC IMAGING AGENT, I- 131 TOSITUMOMAB, PER MILLICURIE N/A HCPCS A9535 INJECTION, METHYLENE BLUE, 1 ML N/A HCPCS A9536 TECHNETIUM TC-99M DEPREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 35 MILLICURIES N/A HCPCS A9542 INDIUM IN-111 IBRITUMOMAB TIUXETAN, DIAGNOSTIC, PER STUDY DOSE, UP TO 5 MILLICURIES HCPCS A9543 YTTRIUM Y-90 IBRITUMOMAB TIUXETAN, THERAPEUTIC, PER TREATMENT DOSE, UP TO 40 MILLICURIES N/A N/A HCPCS A9544 IODINE I-131 TOSITUMOMAB, DIAGNOSTIC, PER STUDY DOSE N/A HCPCS A9545 IODINE I-131 TOSITUMOMAB, THERAPEUTIC, PER TREATMENT DOSE N/A HCPCS A9546 COBALT CO-57/58, CYANOCOBALAMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE HCPCS A9547 INDIUM IN-111 OXYQUINOLINE, DIAGNOSTIC, PER 0.5 MILLICURIE N/A HCPCS A9548 INDIUM IN-111 PENTETATE, DIAGNOSTIC, PER 0.5 MILLICURIE N/A HCPCS A9549 TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 25 MILLICURIES N/A N/A HCPCS A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES HCPCS A9553 CHROMIUM CR-51 SODIUM CHROMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 250 MICROCURIES N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 377 of 380

378 HCPCS A9554 IODINE I-125 SODIUM IOTHALAMATE, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MICROCURIES N/A HCPCS A9555 RUBIDIUM RB-82, DIAGNOSTIC, PER STUDY DOSE, UP TO 60 N/A MILLICURIES HCPCS A9558 XENON XE-133 GAS, DIAGNOSTIC, PER 10 MILLICURIES N/A HCPCS A9559 COBALT CO-57 CYANOCOBALAMIN, ORAL, DIAGNOSTIC, PER STUDY DOSE, UP TO 1 MICROCURIE HCPCS A9563 SODIUM PHOSPHATE P-32, THERAPEUTIC, PER MILLICURIE N/A HCPCS A9564 CHROMIC PHOSPHATE P-32 SUSPENSION, THERAPEUTIC, PER MILLICURIE HCPCS A9567 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, AEROSOL, PER STUDY DOSE, UP TO 75 MILLICURIES N/A N/A N/A HCPCS A9568 TECHNETIUM TC-99M ARCITUMOMAB, DIAGNOSTIC, PER STUDY DOSE, UP TO 45 MILLICURIES HCPCS A9569 TECHNETIUM TC-99M EXAMETAZIME LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE HCPCS A9570 INDIUM IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE HCPCS A9571 INDIUM IN-111 LABELED AUTOLOGOUS PLATELETS, DIAGNOSTIC, PER STUDY DOSE HCPCS A9572 INDIUM IN-111 PENTETREOTIDE, DIAGNOSTIC, PER STUDY DOSE, UP TO 6 MILLICURIES N/A N/A N/A N/A N/A HCPCS A9576 INJECTION, GADOTERIDOL, (PROHANCE MULTIPACK), PER ML N/A HCPCS A9577 INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE), PER ML N/A HCPCS A9578 INJECTION, GADOBENATE DIMEGLUMINE (MULTIHANCE MULTIPACK), PER ML HCPCS A9579 INJECTION, GADOLINIUM-BASED MAGNETIC RESONANCE CONTRAST AGENT, NOT OTHERWISE SPECIFIED (NOS), PER ML HCPCS A9600 STRONTIUM SR-89 CHLORIDE, THERAPEUTIC, PER MILLICURIE N/A HCPCS A9605 SAMARIUM SM-153 LEXIDRONAMM, THERAPEUTIC, PER 50 MILLICURIES HCPCS A9698 NON-RADIOACTIVE CONTRAST IMAGING MATERIAL, NOT OTHERWISE CLASSIFIED, PER STUDY HCPCS A9699 RADIOPHARMACEUTICAL, THERAPEUTIC, NOT OTHERWISE CLASSIFIED N/A HCPCS A9700 SUPPLY OF INJECTABLE CONTRAST MATERIAL FOR USE IN ECHOCARDIOGRAPHY, PER STUDY HCPCS C1821 INTERSPINOUS PROCESS DISTRACTION DEVICE (IMPLANTABLE) N/A HCPCS E0615 PACEMAKER MONITOR, SELF CONTAINED, CHECKS BATTERY DEPLETION AND OTHER PACEMAKER COMPONENTS, INCLUDES DIGITAL/VISIBLE CHECK SYSTEMS HCPCS C1883 ADAPTOR/EXTENSION, PACING LEAD OR NEUROSTIMULATOR LEAD (IMPLANTABLE) HCPCS C1884 EMBOLIZATION PROTECTIVE SYSTEM N/A HCPCS C1900 LEAD, LEFT VENTRICULAR CORONARY VENOUS SYSTEM N/A N/A N/A N/A N/A N/A N/A N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 378 of 380

379 HCPCS C1817 SEPTAL DEFECT IMPLANT SYSTEM, INTRACARDIAC N/A HCPCS C1763 CONNECTIVE TISSUE, NON-HUMAN (INCLUDES SYNTHETIC) N/A HCPCS L8612 AQUEOUS SHUNT N/A HCPCS A4300 IMPLANTABLE ACCESS CATHETER, (E,G., VENOUS, ARTERIAL, EPIDURAL SUBARACHNOID, OR PERITONEAL, ETC.) EXTERNAL ACCESS HCPCS C1788 PORT, INDWELLING (IMPLANTABLE) N/A HCPCS L8603 INJECTABLE BULKING AGENT, COLLAGEN IMPLANT, URINARY TRACT, 2.5 ML SYRINGE, INCLUDES SHIPPING AND NECESSARY SUPPLIES N/A N/A HCPCS L8606 INJECTABLE BULKING AGENT, SYNTHETIC IMPLANT, URINARY TRACT, 1 ML SYRINGE, INCLUDES SHIPPING AND NECESSARY SUPPLIES N/A HCPCS S8490 INSULIN SYRINGES (100 SYRINGES, ANY SIZE) N/A HCPCS A4215 NEEDLE, STERILE, ANY SIZE, EACH N/A HCPCS S5561 INSULIN DELIVERY DEVICE, REUSABLE PEN; 3 ML SIZE N/A HCPCS A4245 ALCOHOL WIPES, PER BOX N/A HCPCS L8699 PROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIED N/A HCPCS L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE OR EQUAL N/A HCPCS L8039 BREAST PROSTHESIS, NOT OTHERWISE SPECIFIED N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: Page No(s): 379 of 380

380 Contact Us In case of any enquiry, kindly contact us on: Toll Free: DAMAN (32626) Fax: P.O. Box , Abu Dhabi, UAE Disclaimer: Daman does not directly or indirectly practice medicine or dispense medication; hence Daman assumes no liability for the data contained herein. While every effort is made to ensure the accuracy of the content, we cannot be held accountable for any typographical errors, errors of fact, or any other error or inconsistency found in this price list. Please refer to this list before you opt for a medical treatment at any Non-Network Provider. Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 1 Date of Issue: Page No(s).: 380 of 380