Daman Published Rates

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

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... 10 PRICE LIST FOR ANESTHESIA SERVICES... 373 PRICE LIST FOR HEALTHCARE COMMON PROCEDURE CODING SYSTEM... 374 CONTACT US... 380 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 2 of 380

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: 01.03.2015 Page No(s): 3 of 380

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: 01.03.2015 Page No(s): 4 of 380

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 (www.damanhealth.ae) 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: 01.03.2015 Page No(s): 5 of 380

Daman Published Rates Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 6 of 380

Price List for Service Codes SERVICE 17-01 ROOM AND BOARD: SUITE 1,200 SERVICE 17-02 ROOM AND BOARD: VIP ROOM 1,000 SERVICE 17-03 ROOM AND BOARD: FIRST CLASS ROOM 750 SERVICE 17-04 ROOM AND BOARD: SHARED ROOM 550 SERVICE 17-05 ROOM AND BOARD: WARD 450 SERVICE 17-06 ROOM AND BOARD: ROYAL SUITE 2,000 SERVICE 17-10 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 27-01 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 17-21 EMERGENCY ROOM - HOURLY RATE 35 SERVICE 17-22 OBSERVATION OR TREATMENT ROOM - HOURLY RATE 50 SERVICE 17-23 RECOVERY ROOM - HOURLY RATE 150 SERVICE 17-24 OBSERVATION OR TREATMENT ROOM - DAILY RATE 200 SERVICE 17-25 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 17-07 PERDIEM - PICU - DAILY RATE (DAY 1 TO 7) 2,500 SERVICE 17-07-01 SERVICE 17-07-02 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: 01.03.2015 Page No(s): 7 of 380

SERVICE 17- PERDIEM - PICU - DAILY RATE (DAY 22 AND MORE) 1,800 07-03 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 17-12 PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 1 TO 3) 550 SERVICE 17-12 PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 9 AND MORE) 450-02 SERVICE 17- PERDIEM - NEW-BORN NURSERY - DAILY RATE (DAY 4 TO 8) 500 12-01 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 18-01 PERDIEM - SCU - DAILY RATE (DAY 4 TO 8) 1,250 SERVICE 18-02 PERDIEM - SCU - DAILY RATE (DAY 9 AND MORE) 1,100 SERVICE 19-01 PERDIEM - SCBU - DAILY RATE (DAY 4 TO 8) 990 SERVICE 19-02 PERDIEM - SCBU - DAILY RATE (DAY 9 AND MORE) 1,200 SERVICE 17-13 PERDIEM - LONG TERM STAY - DAILY RATE - SIMPLE CASES 750 SERVICE 17-14 PERDIEM - LONG TERM STAY - DAILY RATE - INTERMEDIATE CASES 1,000 SERVICE 17-15 PERDIEM - LONG TERM STAY - DAILY RATE - INTENSIVE CASES 1,250 SERVICE 17-16 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 14-01 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 20-01 OPERATING ROOM SERVICES - MINOR SURGERY 500 SERVICE 20-02 OPERATING ROOM SERVICES - FIRST HOUR 1,600 SERVICE 20-03 OPERATING ROOM SERVICES - EVERY ADDITIONAL 1/2 HR. 450 SERVICE 20-04 CATHETERIZATION LAB 1,600 SERVICE 20-05 DELIVERY ROOM 1,300 SERVICE 17-11 PERDIEM - NON- MEDICAL ESCORT ACCOMMODATION - DAILY RATE 100 SERVICE 26 PERDIEM COMPANION ACCOMMODATION 100 SERVICE 50-01 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; 30-40 MINUTES. 275 120 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 8 of 380

SERVICE 50-02 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; 30-40 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: 01.03.2015 Page No(s): 9 of 380

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 10021 FINE NEEDLE ASPIRATION; WITHOUT IMAGING GUIDANCE 446 CPT 10022 FINE NEEDLE ASPIRATION; WITH IMAGING GUIDANCE 440 CPT 10040 ACNE SURGERY (E.G., MARSUPIALIZATION, OPENING OR REMOVAL OF 323 MULTIPLE MILIA, COMEDONES, CYSTS, PUSTULES) CPT 10060 INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE 354 HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE CPT 10061 INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE 597 HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE CPT 10080 INCISION AND DRAINAGE OF PILONIDAL CYST; SIMPLE 500 CPT 10081 INCISION AND DRAINAGE OF PILONIDAL CYST; COMPLICATED 780 CPT 10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; 415 SIMPLE CPT 10121 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES; 824 COMPLICATED CPT 10140 INCISION AND DRAINAGE OF HEMATOMA, SEROMA OR FLUID COLLECTION 503 CPT 10160 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST 404 CPT 10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION 738 CPT 11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; UP TO 10% OF BODY SURFACE CPT 11001 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 11004 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; EXTERNAL GENITALIA AND PERINEUM CPT 11005 DEBRIDEMENT OF SKIN, SUBCUTANEOUS TISSUE, MUSCLE AND FASCIA FOR NECROTIZING SOFT TISSUE INFECTION; ABDOMINAL WALL, WITH OR WITHOUT FASCIAL CLOSURE CPT 11006 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 11008 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 11010 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES 174 71 1,847 2,389 2,308 868 1,467 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 10 of 380

CPT 11011 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 11012 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 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS 156 CPT 11041 DEBRIDEMENT; SKIN, FULL THICKNESS 178 CPT 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE 236 CPT 11043 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE 864 CPT 11044 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE 1,180 CPT 11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); SINGLE LESION CPT 11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); 2 TO 4 LESIONS CPT 11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (E.G., CORN OR CALLUS); MORE THAN 4 LESIONS CPT 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE LESION CPT 11101 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 11200 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND INCLUDING 15 LESIONS CPT 11201 REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL 10 LESIONS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS CPT 11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM CPT 11302 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM CPT 11303 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM CPT 11305 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS CPT 11306 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM CPT 11307 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM CPT 11308 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM CPT 11310 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS CPT 11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 162 196 236 342 105 259 59 217 302 359 420 227 313 366 409 270 344 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 11 of 380

CPT 11312 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 11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, 492 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM CPT 11400 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 353 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS CPT 11401 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 11402 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 11403 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 11404 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 11406 EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG 922 (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM CPT 11420 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 11421 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 11422 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 11423 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 11424 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 11426 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 11440 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 11441 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 11442 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 11443 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 11444 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: 01.03.2015 Page No(s): 12 of 380

CPT 11446 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 11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,083 AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR CPT 11451 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,417 AXILLARY; WITH COMPLEX REPAIR CPT 11462 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,078 INGUINAL; WITH SIMPLE OR INTERMEDIATE REPAIR CPT 11463 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,437 INGUINAL; WITH COMPLEX REPAIR CPT 11470 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,199 PERIANAL, PERINEAL, OR UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR CPT 11471 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, 1,497 PERIANAL, PERINEAL, OR UMBILICAL; WITH COMPLEX REPAIR CPT 11600 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 556 LEGS; EXCISED DIAMETER 0.5 CM OR LESS CPT 11601 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 702 LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM CPT 11602 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 779 LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM CPT 11603 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 878 LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM CPT 11604 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 964 LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM CPT 11606 EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR 1,363 LEGS; EXCISED DIAMETER OVER 4.0 CM CPT 11620 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 570 HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS CPT 11621 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 712 HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM CPT 11622 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 805 HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM CPT 11623 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 928 HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM CPT 11624 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 1,040 HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM CPT 11626 EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, 1,254 HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM CPT 11640 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 602 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.5 CM OR LESS CPT 11641 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 745 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 0.6 TO 1.0 CM CPT 11642 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 855 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 1.1 TO 2.0 CM CPT 11643 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 995 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 2.1 TO 3.0 CM CPT 11644 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 1,224 EYELIDS, NOSE, LIPS; EXCISED DIAMETER 3.1 TO 4.0 CM CPT 11646 EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, 1,602 EYELIDS, NOSE, LIPS; EXCISED DIAMETER OVER 4.0 CM CPT 11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER 71 CPT 11720 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: 01.03.2015 Page No(s): 13 of 380

CPT 11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE 146 CPT 11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; SINGLE 323 CPT 11732 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH 149 ADDITIONAL NAIL PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 11740 EVACUATION OF SUBUNGUAL HEMATOMA 152 CPT 11750 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., 702 INGROWN OR DEFORMED NAIL), FOR PERMANENT REMOVAL; CPT 11752 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 11755 BIOPSY OF NAIL UNIT (E.G., PLATE, BED, MATRIX, HYPONYCHIUM, 438 PROXIMAL AND LATERAL NAIL FOLDS) (SEPARATE PROCEDURE) CPT 11760 REPAIR OF NAIL BED 655 CPT 11762 RECONSTRUCTION OF NAIL BED WITH GRAFT 877 CPT 11765 WEDGE EXCISION OF SKIN OF NAIL FOLD (E.G., FOR INGROWN TOENAIL) 435 CPT 11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE 808 CPT 11771 EXCISION OF PILONIDAL CYST OR SINUS; EXTENSIVE 1,681 CPT 11772 EXCISION OF PILONIDAL CYST OR SINUS; COMPLICATED 2,034 CPT 11900 INJECTION, INTRALESIONAL; UP TO AND INCLUDING 7 LESIONS 183 CPT 11901 INJECTION, INTRALESIONAL; MORE THAN 7 LESIONS 231 CPT 11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE 528 PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ. CM OR LESS CPT 11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE 614 PIGMENTS TO CORRECT COLOUR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ. CM CPT 11922 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 11950 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 1 224 CC OR LESS CPT 11951 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 1.1 276 TO 5.0 CC CPT 11952 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 5.1 438 TO 10.0 CC CPT 11954 SUBCUTANEOUS INJECTION OF FILLING MATERIAL (E.G., COLLAGEN); 489 OVER 10.0 CC CPT 11960 INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, 2,882 INCLUDING SUBSEQUENT EXPANSION CPT 11970 REPLACEMENT OF TISSUE EXPANDER WITH PERMANENT PROSTHESIS 1,898 CPT 11971 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: 01.03.2015 Page No(s): 14 of 380

CPT 11975 INSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 401 CPT 11976 REMOVAL, IMPLANTABLE CONTRACEPTIVE CAPSULES 468 CPT 11977 REMOVAL WITH REINSERTION, IMPLANTABLE CONTRACEPTIVE CAPSULES 711 CPT 11980 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF 337 ESTRADIOL AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN) CPT 11981 INSERTION, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 440 CPT 11982 REMOVAL, NON-BIODEGRADABLE DRUG DELIVERY IMPLANT 499 CPT 11983 REMOVAL WITH REINSERTION, NON-BIODEGRADABLE DRUG DELIVERY 776 IMPLANT CPT 12001 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 12002 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 12004 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 12005 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 12006 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 12007 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 12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 484 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS CPT 12013 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 536 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM CPT 12014 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 629 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM CPT 12015 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 791 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM CPT 12016 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 941 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM CPT 12017 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 844 NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM CPT 12018 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, 1,019 NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM CPT 12020 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; SIMPLE CLOSURE 834 CPT 12021 TREATMENT OF SUPERFICIAL WOUND DEHISCENCE; WITH PACKING 497 CPT 12031 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS CPT 12032 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM CPT 12034 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM 785 990 981 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 15 of 380

CPT 12035 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 12036 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 12037 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR 1,426 EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM CPT 12041 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 811 GENITALIA; 2.5 CM OR LESS CPT 12042 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 935 GENITALIA; 2.6 CM TO 7.5 CM CPT 12044 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,112 GENITALIA; 7.6 CM TO 12.5 CM CPT 12045 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,144 GENITALIA; 12.6 CM TO 20.0 CM CPT 12046 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,316 GENITALIA; 20.1 CM TO 30.0 CM CPT 12047 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL 1,477 GENITALIA; OVER 30.0 CM CPT 12051 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 855 AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS CPT 12052 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 988 AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM CPT 12053 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,102 AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM CPT 12054 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,158 AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM CPT 12055 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,371 AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM CPT 12056 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,562 AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM CPT 12057 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS 1,798 AND/OR MUCOUS MEMBRANES; OVER 30.0 CM CPT 13100 REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM 984 CPT 13101 REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM 1,276 CPT 13102 REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST 342 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 13120 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 1.1 CM TO 2.5 CM 1,027 CPT 13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 2.6 CM TO 7.5 CM 1,426 CPT 13122 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM 372 OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 13131 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 1,141 GENITALIA, HANDS AND/OR FEET; 1.1 CM TO 2.5 CM CPT 13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 1,849 GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM CPT 13133 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 13150 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 1.0 CM OR LESS 1,117 CPT 13151 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: 01.03.2015 Page No(s): 16 of 380

CPT 13152 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; 2.6 CM TO 7.5 CM 1,797 CPT 13153 REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 13160 SECONDARY CLOSURE OF SURGICAL WOUND OR DEHISCENCE, EXTENSIVE OR COMPLICATED CPT 14000 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ. CM OR LESS CPT 14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT 14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ. CM OR LESS CPT 14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT 14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ. CM OR LESS CPT 14041 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 14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ. CM OR LESS CPT 14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ. CM TO 30.0 SQ. CM CPT 14300 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ. CM, UNUSUAL OR COMPLICATED, ANY AREA CPT 14350 FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE CPT 15002 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 15003 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 15004 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 15005 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 15040 HARVEST OF SKIN FOR TISSUE CULTURED SKIN AUTOGRAFT, 100 SQ. CM OR LESS CPT 15050 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 1,052 227 1,268 385 777 1,708 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 17 of 380

SIZE 2 CM DIAMETER CPT 15100 SPLIT-THICKNESS AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) CPT 15101 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 15110 EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT 15111 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 15115 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 15116 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 15120 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 15121 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 15130 DERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT 15131 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 15135 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 15136 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 15150 TISSUE CULTURED EPIDERMAL AUTOGRAFT, TRUNK, ARMS, LEGS; FIRST 25 SQ. CM OR LESS CPT 15151 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 15152 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 15155 TISSUE CULTURED EPIDERMAL AUTOGRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR 2,616 557 2,635 375 2,715 505 2,954 814 2,056 298 2,722 297 2,201 397 490 2,361 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 18 of 380

MULTIPLE DIGITS; FIRST 25 SQ. CM OR LESS CPT 15156 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 15157 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 15170 ACELLULAR DERMAL REPLACEMENT, TRUNK, ARMS, LEGS; FIRST 100 SQ. CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT 15171 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 15175 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 15176 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 15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ. CM OR LESS CPT 15201 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 15220 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ. CM OR LESS CPT 15221 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 15240 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 15241 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 15260 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS CPT 15261 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 15300 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 15301 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 15320 ALLOGRAFT SKIN FOR TEMPORARY WOUND CLOSURE, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, 536 595 1,327 294 1,671 475 2,499 444 2,424 421 2,908 582 3,159 682 1,079 201 1,223 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 19 of 380

AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT 15321 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 15330 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM 1,004 OR LESS, OR 1% OF BODY AREA OF INFANTS AND CHILDREN CPT 15331 ACELLULAR DERMAL ALLOGRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 205 100 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 15335 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 15336 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 15340 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; FIRST 25 SQ CM OR 989 LESS CPT 15341 TISSUE CULTURED ALLOGENEIC SKIN SUBSTITUTE; EACH ADDITIONAL 25 151 SQ CM CPT 15360 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 15361 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 15365 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 15366 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 15400 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 15401 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 15420 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 15421 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: 01.03.2015 Page No(s): 20 of 380

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 15430 ACELLULAR XENOGRAFT IMPLANT; FIRST 100 SQ CM OR LESS, OR 1% OF 1,661 BODY AREA OF INFANTS AND CHILDREN CPT 15431 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 15570 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,697 TRANSFER; TRUNK CPT 15572 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,634 TRANSFER; SCALP, ARMS, OR LEGS CPT 15574 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,803 TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET CPT 15576 FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT 2,489 TRANSFER; EYELIDS, NOSE, EARS, LIPS, OR INTRAORAL CPT 15600 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 949 TRUNK CPT 15610 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,054 SCALP, ARMS, OR LEGS CPT 15620 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,314 FOREHEAD, CHEEKS, CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET CPT 15630 DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT 1,431 EYELIDS, NOSE, EARS, OR LIPS CPT 15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO 1,553 WRIST, WALKING TUBE), ANY LOCATION CPT 15731 FOREHEAD FLAP WITH PRESERVATION OF VASCULAR PEDICLE (EG, AXIAL 3,436 PATTERN FLAP, PARAMEDIAN FOREHEAD FLAP) CPT 15732 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK 4,576 (EG, TEMPORALIS, MASSETER MUSCLE, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE) CPT 15734 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK 4,775 CPT 15736 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; UPPER 4,126 EXTREMITY CPT 15738 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER 4,450 EXTREMITY CPT 15740 FLAP; ISLAND PEDICLE 3,244 CPT 15750 FLAP; NEUROVASCULAR PEDICLE 2,896 CPT 15756 FREE MUSCLE OR MYOCUTANEOUS FLAP WITH MICROVASCULAR 7,543 ANASTOMOSIS CPT 15757 FREE SKIN FLAP WITH MICROVASCULAR ANASTOMOSIS 7,391 CPT 15758 FREE FASCIAL FLAP WITH MICROVASCULAR ANASTOMOSIS 7,365 CPT 15760 GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL 2,636 ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA CPT 15770 GRAFT; DERMA-FAT-FASCIA 2,066 CPT 15775 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: 01.03.2015 Page No(s): 21 of 380

CPT 15776 PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS 1,397 CPT 15780 DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE 2,569 WRINKLING, RHYTIDS, GENERAL KERATOSIS) CPT 15781 DERMABRASION; SEGMENTAL, FACE 1,753 CPT 15782 DERMABRASION; REGIONAL, OTHER THAN FACE 1,689 CPT 15783 DERMABRASION; SUPERFICIAL, ANY SITE (EG, TATTOO REMOVAL) 1,577 CPT 15786 ABRASION; SINGLE LESION (EG, KERATOSIS, SCAR) 762 CPT 15787 ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY 151 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 15788 CHEMICAL PEEL, FACIAL; EPIDERMAL 1,468 CPT 15789 CHEMICAL PEEL, FACIAL; DERMAL 1,830 CPT 15792 CHEMICAL PEEL, NONFACIAL; EPIDERMAL 1,380 CPT 15793 CHEMICAL PEEL, NONFACIAL; DERMAL 1,524 CPT 15819 CERVICOPLASTY 2,278 CPT 15820 BLEPHAROPLASTY, LOWER EYELID; 1,621 CPT 15821 BLEPHAROPLASTY, LOWER EYELID; WITH EXTENSIVE HERNIATED FAT PAD 1,721 CPT 15822 BLEPHAROPLASTY, UPPER EYELID; 1,272 CPT 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING 2,015 DOWN LID CPT 15824 RHYTIDECTOMY; FOREHEAD 3,441 CPT 15825 RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING (PLATYSMAL FLAP, 3,871 P-FLAP) CPT 15826 RHYTIDECTOMY; GLABELLAR FROWN LINES 2,795 CPT 15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK 7,312 CPT 15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP CPT 15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY CPT 15832 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); THIGH CPT 15833 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); LEG CPT 15834 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); HIP CPT 15835 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); BUTTOCK CPT 15836 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ARM CPT 15837 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: 01.03.2015 Page No(s): 22 of 380

CPT 15838 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 1,774 LIPECTOMY); SUBMENTAL FAT PAD CPT 15839 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES 2,681 LIPECTOMY); OTHER AREA CPT 15840 GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING 3,148 OBTAINING FASCIA) CPT 15841 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING 5,258 OBTAINING GRAFT) CPT 15842 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE FLAP BY 8,371 MICROSURGICAL TECHNIQUE CPT 15845 GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER 2,921 CPT 15847 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 15850 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), SAME 255 SURGEON CPT 15851 REMOVAL OF SUTURES UNDER ANESTHESIA (OTHER THAN LOCAL), OTHER 283 SURGEON CPT 15852 DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA 151 (OTHER THAN LOCAL) CPT 15860 INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST 359 VASCULAR FLOW IN FLAP OR GRAFT CPT 15876 SUCTION ASSISTED LIPECTOMY; HEAD AND NECK N/A CPT 15877 SUCTION ASSISTED LIPECTOMY; TRUNK N/A CPT 15878 SUCTION ASSISTED LIPECTOMY; UPPER EXTREMITY N/A CPT 15879 SUCTION ASSISTED LIPECTOMY; LOWER EXTREMITY N/A CPT 15920 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH 1,830 PRIMARY SUTURE CPT 15922 EXCISION, COCCYGEAL PRESSURE ULCER, WITH COCCYGECTOMY; WITH 2,368 FLAP CLOSURE CPT 15931 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,110 CPT 15933 EXCISION, SACRAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH 2,571 OSTECTOMY CPT 15934 EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,902 CPT 15935 EXCISION, SACRAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; WITH 3,380 OSTECTOMY CPT 15936 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 2,798 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; CPT 15937 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 3,273 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY CPT 15940 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; 2,168 CPT 15941 EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH 2,810 OSTECTOMY (ISCHIECTOMY) CPT 15944 EXCISION, ISCHIAL PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,776 CPT 15945 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: 01.03.2015 Page No(s): 23 of 380

CPT 15946 EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, IN 5,120 PREPARATION FOR MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE CPT 15950 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE; 1,806 CPT 15951 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH PRIMARY SUTURE; 2,547 WITH OSTECTOMY CPT 15952 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,668 CPT 15953 EXCISION, TROCHANTERIC PRESSURE ULCER, WITH SKIN FLAP CLOSURE; 2,947 WITH OSTECTOMY CPT 15956 EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR 3,569 MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; CPT 15958 EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR 3,680 MUSCLE OR MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY CPT 15999 UNLISTED PROCEDURE, EXCISION PRESSURE ULCER N/A CPT 16000 INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL 212 TREATMENT IS REQUIRED CPT 16020 DRESSINGS AND/OR DEBRIDEMENT OF PARTIAL-THICKNESS BURNS, 250 INITIAL OR SUBSEQUENT; SMALL (LESS THAN 5% TOTAL BODY SURFACE AREA) CPT 16025 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 16030 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 16035 ESCHAROTOMY; INITIAL INCISION 682 CPT 16036 ESCHAROTOMY; EACH ADDITIONAL INCISION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 17000 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES); FIRST LESION CPT 17003 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 17004 DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES), 15 OR MORE LESIONS CPT 17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); LESS THAN 10 SQ CM CPT 17107 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); 10.0 TO 50.0 SQ CM CPT 17108 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, LASER TECHNIQUE); OVER 50.0 SQ CM CPT 17110 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 17111 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 271 259 22 550 1,215 2,114 2,848 315 407 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 24 of 380

CPT 17250 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (PROUD FLESH, 236 SINUS OR FISTULA) CPT 17260 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 299 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS CPT 17261 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 17262 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 17263 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 17264 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 17266 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 748 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM CPT 17270 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 17271 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 17272 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 17273 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 17274 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 17276 DESTRUCTION, MALIGNANT LESION (EG, LASER SURGERY, 915 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM CPT 17280 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 17281 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: 01.03.2015 Page No(s): 25 of 380

CPT 17282 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 17283 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 17284 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 17286 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 17311 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 17312 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 17313 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 17314 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 17315 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: 01.03.2015 Page No(s): 26 of 380

CPT 17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR ACNE 146 CPT 17360 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE PASTE, ACID) 422 CPT 17380 ELECTROLYSIS EPILATION, EACH 30 MINUTES 245 CPT 17999 UNLISTED PROCEDURE, SKIN, MUCOUS MEMBRANE AND SUBCUTANEOUS N/A TISSUE CPT 19000 PUNCTURE ASPIRATION OF CYST OF BREAST; 356 CPT 19001 PUNCTURE ASPIRATION OF CYST OF BREAST; EACH ADDITIONAL CYST 90 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 19020 MASTOTOMY WITH EXPLORATION OR DRAINAGE OF ABSCESS, DEEP 1,361 CPT 19030 INJECTION PROCEDURE ONLY FOR MAMMARY DUCTOGRAM OR 539 GALACTOGRAM CPT 19100 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING 441 GUIDANCE (SEPARATE PROCEDURE) CPT 19101 BIOPSY OF BREAST; OPEN, INCISIONAL 1,001 CPT 19102 BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, USING IMAGING 706 GUIDANCE CPT 19103 BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR 1,773 ROTATING BIOPSY DEVICE, USING IMAGING GUIDANCE CPT 19105 ABLATION, CRYOSURGICAL, OF FIBROADENOMA, INCLUDING 6,356 ULTRASOUND GUIDANCE, EACH FIBROADENOMA CPT 19110 NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY 1,383 LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT CPT 19112 EXCISION OF LACTIFEROUS DUCT FISTULA 1,312 CPT 19120 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 19125 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT 1,630 OF RADIOLOGICAL MARKER, OPEN; SINGLE LESION CPT 19126 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 19260 EXCISION OF CHEST WALL TUMOR INCLUDING RIBS 3,762 CPT 19271 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC 5,075 RECONSTRUCTION; WITHOUT MEDIASTINAL LYMPHADENECTOMY CPT 19272 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC 5,637 RECONSTRUCTION; WITH MEDIASTINAL LYMPHADENECTOMY CPT 19290 PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; 532 CPT 19291 PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; EACH ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 19295 IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, DURING BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 19296 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 227 288 11,330 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 27 of 380

CPT 19297 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 19298 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 19300 MASTECTOMY FOR GYNECOMASTIA 1,755 CPT 19301 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, 1,940 QUADRANTECTOMY, SEGMENTECTOMY); CPT 19302 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, 2,746 QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY CPT 19303 MASTECTOMY, SIMPLE, COMPLETE 3,001 CPT 19304 MASTECTOMY, SUBCUTANEOUS 1,735 CPT 19305 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY 3,433 LYMPH NODES CPT 19306 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY AND 3,606 INTERNAL MAMMARY LYMPH NODES (URBAN TYPE OPERATION) CPT 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, 3,631 WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE CPT 19316 MASTOPEXY 2,463 CPT 19318 REDUCTION MAMMAPLASTY 3,618 CPT 19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT 1,505 CPT 19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT 2,046 CPT 19328 REMOVAL OF INTACT MAMMARY IMPLANT 1,541 CPT 19330 REMOVAL OF MAMMARY IMPLANT MATERIAL 1,963 CPT 19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, 1,282 MASTECTOMY OR IN RECONSTRUCTION CPT 19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, 2,916 MASTECTOMY OR IN RECONSTRUCTION CPT 19350 NIPPLE/AREOLA RECONSTRUCTION 2,553 CPT 19355 CORRECTION OF INVERTED NIPPLES 2,102 CPT 19357 BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE 4,896 EXPANDER, INCLUDING SUBSEQUENT EXPANSION CPT 19361 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT 5,399 PROSTHETIC IMPLANT CPT 19364 BREAST RECONSTRUCTION WITH FREE FLAP 8,912 CPT 19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE 4,387 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 28 of 380

CPT 19367 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 5,767 MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; CPT 19368 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 7,198 MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING) CPT 19369 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS 6,527 MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE CPT 19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST 2,148 CPT 19371 PERIPROSTHETIC CAPSULECTOMY, BREAST 2,483 CPT 19380 REVISION OF RECONSTRUCTED BREAST 2,424 CPT 19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT 881 CPT 19499 UNLISTED PROCEDURE, BREAST N/A CPT 20000 INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 650 OSTEOMYELITIS); SUPERFICIAL CPT 20005 INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO 966 OSTEOMYELITIS); DEEP OR COMPLICATED CPT 20100 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); NECK 1,903 CPT 20101 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); CHEST 1,291 CPT 20102 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 1,433 ABDOMEN/FLANK/BACK CPT 20103 EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 1,745 EXTREMITY CPT 20150 EXCISION OF EPIPHYSEAL BAR, WITH OR WITHOUT AUTOGENOUS SOFT 3,057 TISSUE GRAFT OBTAINED THROUGH SAME FASCIAL INCISION CPT 20200 BIOPSY, MUSCLE; SUPERFICIAL 601 CPT 20205 BIOPSY, MUSCLE; DEEP 819 CPT 20206 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE 790 CPT 20220 BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, 511 SPINOUS PROCESS, RIBS) CPT 20225 BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, VERTEBRAL BODY, 1,773 FEMUR) CPT 20240 BIOPSY, BONE, OPEN; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS 718 PROCESS, RIBS, TROCHANTER OF FEMUR) CPT 20245 BIOPSY, BONE, OPEN; DEEP (EG, HUMERUS, ISCHIUM, FEMUR) 1,992 CPT 20250 BIOPSY, VERTEBRAL BODY, OPEN; THORACIC 1,234 CPT 20251 BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL 1,345 CPT 20500 INJECTION OF SINUS TRACT; THERAPEUTIC (SEPARATE PROCEDURE) 341 CPT 20501 INJECTION OF SINUS TRACT; DIAGNOSTIC (SINOGRAM) 399 CPT 20520 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: 01.03.2015 Page No(s): 29 of 380

CPT 20525 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH; DEEP OR 1,400 COMPLICATED CPT 20526 INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), 236 CARPAL TUNNEL CPT 20550 INJECTION(S); SINGLE TENDON SHEATH, OR LIGAMENT, APONEUROSIS 185 (EG, PLANTAR "FASCIA") CPT 20551 INJECTION(S); SINGLE TENDON ORIGIN/INSERTION 185 CPT 20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), ONE OR TWO 162 MUSCLE(S) CPT 20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), THREE OR MORE 179 MUSCLE(S) CPT 20555 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 20600 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL JOINT OR 176 BURSA (EG, FINGERS, TOES) CPT 20605 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE 188 JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA) CPT 20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR 247 BURSA (EG, SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) CPT 20612 ASPIRATION AND/OR INJECTION OF GANGLION CYST(S) ANY LOCATION 188 CPT 20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST 655 CPT 20650 INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, 631 INCLUDING REMOVAL (SEPARATE PROCEDURE) CPT 20660 APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, 766 INCLUDING REMOVAL (SEPARATE PROCEDURE) CPT 20661 APPLICATION OF HALO, INCLUDING REMOVAL; CRANIAL 1,551 CPT 20662 APPLICATION OF HALO, INCLUDING REMOVAL; PELVIC 1,463 CPT 20663 APPLICATION OF HALO, INCLUDING REMOVAL; FEMORAL 1,437 CPT 20664 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 20665 REMOVAL OF TONGS OR HALO APPLIED BY ANOTHER PHYSICIAN 363 CPT 20670 REMOVAL OF IMPLANT; SUPERFICIAL (EG, BURIED WIRE, PIN OR ROD) 1,091 (SEPARATE PROCEDURE) CPT 20680 REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL 1,837 BAND, NAIL, ROD OR PLATE) CPT 20690 APPLICATION OF A UNIPLANE (PINS OR WIRES IN ONE PLANE), 1,781 UNILATERAL, EXTERNAL FIXATION SYSTEM CPT 20692 APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN ONE 3,380 PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE) CPT 20693 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 20694 REMOVAL, UNDER ANESTHESIA, OF EXTERNAL FIXATION SYSTEM 1,286 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 30 of 380

CPT 20802 REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS THROUGH 7,470 ELBOW JOINT), COMPLETE AMPUTATION CPT 20805 REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL 9,311 CARPAL JOINT), COMPLETE AMPUTATION CPT 20808 REPLANTATION, HAND (INCLUDES HAND THROUGH 12,585 METACARPOPHALANGEAL JOINTS), COMPLETE AMPUTATION CPT 20816 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES 6,625 METACARPOPHALANGEAL JOINT TO INSERTION OF FLEXOR SUBLIMIS TENDON), COMPLETE AMPUTATION CPT 20822 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO 5,749 SUBLIMIS TENDON INSERTION), COMPLETE AMPUTATION CPT 20824 REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO MP 6,616 JOINT), COMPLETE AMPUTATION CPT 20827 REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT), COMPLETE 5,747 AMPUTATION CPT 20838 REPLANTATION, FOOT, COMPLETE AMPUTATION 7,263 CPT 20900 BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (EG, DOWEL OR 2,006 BUTTON) CPT 20902 BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE 1,920 CPT 20910 CARTILAGE GRAFT; COSTOCHONDRAL 1,345 CPT 20912 CARTILAGE GRAFT; NASAL SEPTUM 1,517 CPT 20920 FASCIA LATA GRAFT; BY STRIPPER 1,311 CPT 20922 FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR 1,900 SHEET CPT 20924 TENDON GRAFT, FROM A DISTANCE (EG, PALMARIS, TOE EXTENSOR, 1,585 PLANTARIS) CPT 20926 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, DERMIS) 1,393 CPT 20930 ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED (LIST SEPARATELY 406 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 20931 ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL (LIST SEPARATELY 367 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 20936 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 20937 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 20938 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 20950 MONITORING OF INTERSTITIAL FLUID PRESSURE (INCLUDES INSERTION 716 OF DEVICE, EG, WICK CATHETER TECHNIQUE, NEEDLE MANOMETER TECHNIQUE) IN DETECTION OF MUSCLE COMPARTMENT SYNDROME CPT 20955 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; FIBULA 7,988 CPT 20956 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; ILIAC CREST 8,596 CPT 20957 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; METATARSAL 8,218 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 31 of 380

CPT 20962 BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN 8,445 FIBULA, ILIAC CREST, OR METATARSAL CPT 20969 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,940 OTHER THAN ILIAC CREST, METATARSAL, OR GREAT TOE CPT 20970 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 9,037 ILIAC CREST CPT 20972 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,111 METATARSAL CPT 20973 FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; 8,391 GREAT TOE WITH WEB SPACE CPT 20974 ELECTRICAL STIMULATION TO AID BONE HEALING; NONINVASIVE 215 (NONOPERATIVE) CPT 20975 ELECTRICAL STIMULATION TO AID BONE HEALING; INVASIVE 575 (OPERATIVE) CPT 20979 LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, 166 NONINVASIVE (NONOPERATIVE) CPT 20982 ABLATION, BONE TUMOR(S) (EG, OSTEOID OSTEOMA, METASTASIS) 11,082 RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE CPT 20985 COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR 499 MUSCULOSKELETAL PROCEDURES; IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 20986 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 20987 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 20999 UNLISTED PROCEDURE, MUSCULOSKELETAL SYSTEM, GENERAL N/A CPT 21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT 2,303 CPT 21015 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 1,334 TISSUE OF FACE OR SCALP CPT 21025 EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); 3,139 MANDIBLE CPT 21026 EXCISION OF BONE (EG, FOR OSTEOMYELITIS OR BONE ABSCESS); 1,884 FACIAL BONE(S) CPT 21029 REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE (EG, 2,361 FIBROUS DYSPLASIA) CPT 21030 EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA OR ZYGOMA BY 1,577 ENUCLEATION AND CURETTAGE CPT 21031 EXCISION OF TORUS MANDIBULARIS 1,215 CPT 21032 EXCISION OF MAXILLARY TORUS PALATINUS 1,232 CPT 21034 EXCISION OF MALIGNANT TUMOR OF MAXILLA OR ZYGOMA 4,132 CPT 21040 EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE, BY ENUCLEATION 1,578 AND/OR CURETTAGE CPT 21044 EXCISION OF MALIGNANT TUMOR OF MANDIBLE; 2,748 CPT 21045 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: 01.03.2015 Page No(s): 32 of 380

CPT 21046 EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA- 3,440 ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT 21047 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 21048 EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA- 3,477 ORAL OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) CPT 21049 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 21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) 2,670 CPT 21060 MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT 2,453 (SEPARATE PROCEDURE) CPT 21070 CORONOIDECTOMY (SEPARATE PROCEDURE) 2,018 CPT 21073 MANIPULATION OF TEMPOROMANDIBULAR JOINT(S) (TMJ), THERAPEUTIC, 1,165 REQUIRING AN ANESTHESIA SERVICE (IE, GENERAL OR MONITORED ANESTHESIA CARE) CPT 21076 IMPRESSION AND CUSTOM PREPARATION; SURGICAL OBTURATOR 2,947 PROSTHESIS CPT 21077 IMPRESSION AND CUSTOM PREPARATION; ORBITAL PROSTHESIS 7,136 CPT 21079 IMPRESSION AND CUSTOM PREPARATION; INTERIM OBTURATOR 4,964 PROSTHESIS CPT 21080 IMPRESSION AND CUSTOM PREPARATION; DEFINITIVE OBTURATOR 5,660 PROSTHESIS CPT 21081 IMPRESSION AND CUSTOM PREPARATION; MANDIBULAR RESECTION 5,170 PROSTHESIS CPT 21082 IMPRESSION AND CUSTOM PREPARATION; PALATAL AUGMENTATION 4,892 PROSTHESIS CPT 21083 IMPRESSION AND CUSTOM PREPARATION; PALATAL LIFT PROSTHESIS 4,665 CPT 21084 IMPRESSION AND CUSTOM PREPARATION; SPEECH AID PROSTHESIS 5,226 CPT 21085 IMPRESSION AND CUSTOM PREPARATION; ORAL SURGICAL SPLINT 2,163 CPT 21086 IMPRESSION AND CUSTOM PREPARATION; AURICULAR PROSTHESIS 5,224 CPT 21087 IMPRESSION AND CUSTOM PREPARATION; NASAL PROSTHESIS 5,208 CPT 21088 IMPRESSION AND CUSTOM PREPARATION; FACIAL PROSTHESIS N/A CPT 21089 UNLISTED MAXILLOFACIAL PROSTHETIC PROCEDURE N/A CPT 21100 APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL FIXATION, 2,488 INCLUDES REMOVAL (SEPARATE PROCEDURE) CPT 21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS 2,464 OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL CPT 21116 INJECTION PROCEDURE FOR TEMPOROMANDIBULAR JOINT 426 ARTHROGRAPHY CPT 21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC 1,918 MATERIAL) CPT 21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE 2,422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 33 of 380

CPT 21122 GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES 2,280 (EG, WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) CPT 21123 GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE 2,473 GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT 21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 9,500 CPT 21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, 12,434 ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) CPT 21137 REDUCTION FOREHEAD; CONTOURING ONLY 2,376 CPT 21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) CPT 21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL CPT 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT CPT 21142 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT CPT 21143 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT CPT 21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT 21146 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT) CPT 21147 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 21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) CPT 21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT 21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I CPT 21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I CPT 21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I CPT 21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I CPT 21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT 21175 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: 01.03.2015 Page No(s): 34 of 380

CPT 21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 4,601 SUPRAORBITAL RIMS; WITH GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) CPT 21180 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR 5,280 SUPRAORBITAL RIMS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFTS) CPT 21181 RECONSTRUCTION BY CONTOURING OF BENIGN TUMOR OF CRANIAL 2,307 BONES (EG, FIBROUS DYSPLASIA), EXTRACRANIAL CPT 21182 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 21183 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 21184 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 21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) 5,075 AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) CPT 21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR 3,865 L OSTEOTOMY; WITHOUT BONE GRAFT CPT 21194 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR 4,493 L OSTEOTOMY; WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT 21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL 4,229 SPLIT; WITHOUT INTERNAL RIGID FIXATION CPT 21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL 4,604 SPLIT; WITH INTERNAL RIGID FIXATION CPT 21198 OSTEOTOMY, MANDIBLE, SEGMENTAL; 3,626 CPT 21199 OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH GENIOGLOSSUS 3,219 ADVANCEMENT CPT 21206 OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) 3,471 CPT 21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, 5,717 ALLOGRAFT, OR PROSTHETIC IMPLANT) CPT 21209 OSTEOPLASTY, FACIAL BONES; REDUCTION 2,602 CPT 21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES 7,073 OBTAINING GRAFT) CPT 21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) 12,537 CPT 21230 GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR 2,438 (INCLUDES OBTAINING GRAFT) CPT 21235 GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES 2,270 OBTAINING GRAFT) CPT 21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT 3,456 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT 3,163 CPT 21243 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT 5,217 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 35 of 380

CPT 21244 RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL BONE 3,288 PLATE (EG, MANDIBULAR STAPLE BONE PLATE) CPT 21245 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; 3,560 PARTIAL CPT 21246 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; 2,713 COMPLETE CPT 21247 RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND 4,983 CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL MICROSOMIA) CPT 21248 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, 3,360 BLADE, CYLINDER); PARTIAL CPT 21249 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, 4,632 BLADE, CYLINDER); COMPLETE CPT 21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH 4,352 BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS) CPT 21256 RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND 3,588 WITH BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, MICRO- OPHTHALMIA) CPT 21260 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 3,986 GRAFTS; EXTRACRANIAL APPROACH CPT 21261 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 6,540 GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH CPT 21263 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE 5,966 GRAFTS; WITH FOREHEAD ADVANCEMENT CPT 21267 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, 4,809 WITH BONE GRAFTS; EXTRACRANIAL APPROACH CPT 21268 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, 5,485 WITH BONE GRAFTS; COMBINED INTRA- AND EXTRACRANIAL APPROACH CPT 21270 MALAR AUGMENTATION, PROSTHETIC MATERIAL 2,819 CPT 21275 SECONDARY REVISION OF ORBITOCRANIOFACIAL RECONSTRUCTION 2,529 CPT 21280 MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) 1,636 CPT 21282 LATERAL CANTHOPEXY 1,073 CPT 21295 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF 529 BENIGN MASSETERIC HYPERTROPHY); EXTRAORAL APPROACH CPT 21296 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF 1,314 BENIGN MASSETERIC HYPERTROPHY); INTRAORAL APPROACH CPT 21299 UNLISTED CRANIOFACIAL AND MAXILLOFACIAL PROCEDURE N/A CPT 21310 CLOSED TREATMENT OF NASAL BONE FRACTURE WITHOUT MANIPULATION 331 CPT 21315 CLOSED TREATMENT OF NASAL BONE FRACTURE; WITHOUT 835 STABILIZATION CPT 21320 CLOSED TREATMENT OF NASAL BONE FRACTURE; WITH STABILIZATION 798 CPT 21325 OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED 1,429 CPT 21330 OPEN TREATMENT OF NASAL FRACTURE; COMPLICATED, WITH INTERNAL AND/OR EXTERNAL SKELETAL FIXATION CPT 21335 OPEN TREATMENT OF NASAL FRACTURE; WITH CONCOMITANT OPEN TREATMENT OF FRACTURED SEPTUM CPT 21336 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: 01.03.2015 Page No(s): 36 of 380

CPT 21337 CLOSED TREATMENT OF NASAL SEPTAL FRACTURE, WITH OR WITHOUT 1,219 STABILIZATION CPT 21338 OPEN TREATMENT OF NASOETHMOID FRACTURE; WITHOUT EXTERNAL 2,203 FIXATION CPT 21339 OPEN TREATMENT OF NASOETHMOID FRACTURE; WITH EXTERNAL 2,415 FIXATION CPT 21340 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 21343 OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE 3,572 CPT 21344 OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING POSTERIOR WALL) FRONTAL SINUS FRACTURE, VIA CORONAL OR MULTIPLE APPROACHES CPT 21345 CLOSED TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE), WITH INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CPT 21346 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH WIRING AND/OR LOCAL FIXATION CPT 21347 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); REQUIRING MULTIPLE OPEN APPROACHES CPT 21348 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) CPT 21355 PERCUTANEOUS TREATMENT OF FRACTURE OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD, WITH MANIPULATION CPT 21356 OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (EG, GILLIES APPROACH) CPT 21360 OPEN TREATMENT OF DEPRESSED MALAR FRACTURE, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD CPT 21365 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 21366 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 21385 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; TRANSANTRAL APPROACH (CALDWELL-LUC TYPE OPERATION) CPT 21386 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH CPT 21387 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; COMBINED APPROACH CPT 21390 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT CPT 21395 OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT 21400 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT MANIPULATION CPT 21401 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH MANIPULATION CPT 21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITHOUT IMPLANT CPT 21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT BLOWOUT; WITH IMPLANT CPT 21408 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 3,071 541 1,383 1,677 1,984 2,713 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 37 of 380

CPT 21421 CLOSED TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I 2,391 TYPE), WITH INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CPT 21422 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); 2,096 CPT 21423 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); 2,439 COMPLICATED (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES CPT 21431 CLOSED TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) 2,428 USING INTERDENTAL WIRE FIXATION OF DENTURE OR SPLINT CPT 21432 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 2,061 WITH WIRING AND/OR INTERNAL FIXATION CPT 21433 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 5,168 COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE SURGICAL APPROACHES CPT 21435 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 21436 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); 5,822 COMPLICATED, MULTIPLE SURGICAL APPROACHES, INTERNAL FIXATION, WITH BONE GRAFTING (INCLUDES OBTAINING GRAFT) CPT 21440 CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE 1,728 FRACTURE (SEPARATE PROCEDURE) CPT 21445 OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE 2,405 FRACTURE (SEPARATE PROCEDURE) CPT 21450 CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITHOUT 1,811 MANIPULATION CPT 21451 CLOSED TREATMENT OF MANDIBULAR FRACTURE; WITH MANIPULATION 2,401 CPT 21452 PERCUTANEOUS TREATMENT OF MANDIBULAR FRACTURE, WITH EXTERNAL 1,837 FIXATION CPT 21453 CLOSED TREATMENT OF MANDIBULAR FRACTURE WITH INTERDENTAL 2,762 FIXATION CPT 21454 OPEN TREATMENT OF MANDIBULAR FRACTURE WITH EXTERNAL FIXATION 1,725 CPT 21461 OPEN TREATMENT OF MANDIBULAR FRACTURE; WITHOUT INTERDENTAL 6,517 FIXATION CPT 21462 OPEN TREATMENT OF MANDIBULAR FRACTURE; WITH INTERDENTAL 6,930 FIXATION CPT 21465 OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE 2,832 CPT 21470 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 21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL 275 OR SUBSEQUENT CPT 21485 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; 2,163 COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT CPT 21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION 2,871 CPT 21495 OPEN TREATMENT OF HYOID FRACTURE 2,201 CPT 21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 2,162 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 38 of 380

CPT 21499 UNLISTED MUSCULOSKELETAL PROCEDURE, HEAD N/A CPT 21501 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES 1,366 OF NECK OR THORAX; CPT 21502 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES 1,631 OF NECK OR THORAX; WITH PARTIAL RIB OSTECTOMY CPT 21510 INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR 1,468 OSTEOMYELITIS OR BONE ABSCESS), THORAX CPT 21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX 830 CPT 21555 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; SUBCUTANEOUS 1,353 CPT 21556 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; DEEP, 1,311 SUBFASCIAL, INTRAMUSCULAR CPT 21557 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 1,825 TISSUE OF NECK OR THORAX CPT 21600 EXCISION OF RIB, PARTIAL 1,774 CPT 21610 COSTOTRANSVERSECTOMY (SEPARATE PROCEDURE) 3,491 CPT 21615 EXCISION FIRST AND/OR CERVICAL RIB; 2,130 CPT 21616 EXCISION FIRST AND/OR CERVICAL RIB; WITH SYMPATHECTOMY 2,634 CPT 21620 OSTECTOMY OF STERNUM, PARTIAL 1,623 CPT 21627 STERNAL DEBRIDEMENT 1,730 CPT 21630 RADICAL RESECTION OF STERNUM; 4,022 CPT 21632 RADICAL RESECTION OF STERNUM; WITH MEDIASTINAL 3,977 LYMPHADENECTOMY CPT 21685 HYOID MYOTOMY AND SUSPENSION 3,111 CPT 21700 DIVISION OF SCALENUS ANTICUS; WITHOUT RESECTION OF CERVICAL 1,378 RIB CPT 21705 DIVISION OF SCALENUS ANTICUS; WITH RESECTION OF CERVICAL RIB 1,966 CPT 21720 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN 1,351 OPERATION; WITHOUT CAST APPLICATION CPT 21725 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN 1,694 OPERATION; WITH CAST APPLICATION CPT 21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; OPEN 3,530 CPT 21742 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; 3,236 MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY CPT 21743 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; 4,291 MINIMALLY INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY CPT 21750 CLOSURE OF MEDIAN STERNOTOMY SEPARATION WITH OR WITHOUT 2,303 DEBRIDEMENT (SEPARATE PROCEDURE) CPT 21800 CLOSED TREATMENT OF RIB FRACTURE, UNCOMPLICATED, EACH 305 CPT 21805 OPEN TREATMENT OF RIB FRACTURE WITHOUT FIXATION, EACH 811 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 39 of 380

CPT 21810 TREATMENT OF RIB FRACTURE REQUIRING EXTERNAL FIXATION (FLAIL 1,666 CHEST) CPT 21820 CLOSED TREATMENT OF STERNUM FRACTURE 415 CPT 21825 OPEN TREATMENT OF STERNUM FRACTURE WITH OR WITHOUT SKELETAL 1,779 FIXATION CPT 21899 UNLISTED PROCEDURE, NECK OR THORAX N/A CPT 21920 BIOPSY, SOFT TISSUE OF BACK OR FLANK; SUPERFICIAL 838 CPT 21925 BIOPSY, SOFT TISSUE OF BACK OR FLANK; DEEP 1,320 CPT 21930 EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK 1,481 CPT 21935 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK CPT 22010 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; CERVICAL, THORACIC, OR CERVICOTHORACIC CPT 22015 INCISION AND DRAINAGE, OPEN, OF DEEP ABSCESS (SUBFASCIAL), POSTERIOR SPINE; LUMBAR, SACRAL, OR LUMBOSACRAL CPT 22100 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL CPT 22101 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; THORACIC CPT 22102 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; LUMBAR CPT 22103 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 22110 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; CERVICAL CPT 22112 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; THORACIC CPT 22114 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; LUMBAR CPT 22116 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 22206 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); THORACIC CPT 22207 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, THREE COLUMNS, ONE VERTEBRAL SEGMENT (EG, PEDICLE/VERTEBRAL BODY SUBTRACTION); LUMBAR CPT 22208 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 2,604 463 3,233 3,200 3,212 466 7,673 7,574 1,945 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 40 of 380

CPT 22210 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 5,683 VERTEBRAL SEGMENT; CERVICAL CPT 22212 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 4,669 VERTEBRAL SEGMENT; THORACIC CPT 22214 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 4,686 VERTEBRAL SEGMENT; LUMBAR CPT 22216 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE 1,213 VERTEBRAL SEGMENT; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT 22220 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 5,177 SINGLE VERTEBRAL SEGMENT; CERVICAL CPT 22222 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 4,712 SINGLE VERTEBRAL SEGMENT; THORACIC CPT 22224 OSTEOTOMY OF SPINE, INCLUDING DISCECTOMY, ANTERIOR APPROACH, 5,025 SINGLE VERTEBRAL SEGMENT; LUMBAR CPT 22226 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 22305 CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) 581 CPT 22310 CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), WITHOUT 903 MANIPULATION, REQUIRING AND INCLUDING CASTING OR BRACING CPT 22315 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 22318 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 22319 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 22325 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 22326 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 22327 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 22328 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 22505 MANIPULATION OF SPINE REQUIRING ANESTHESIA, ANY REGION 419 CPT 22520 PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; THORACIC CPT 22521 PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL INJECTION; LUMBAR CPT 22522 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 6,949 834 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 41 of 380

PROCEDURE) CPT 22523 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 22524 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 22525 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 22526 PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY, 6,791 UNILATERAL OR BILATERAL INCLUDING FLUOROSCOPIC GUIDANCE; SINGLE LEVEL CPT 22527 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 22532 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 5,531 MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC CPT 22533 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING 5,204 MINIMAL DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR CPT 22534 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 22548 ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, 5,967 CLIVUS-C1-C2 (ATLAS-AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS CPT 22554 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 4,109 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2 CPT 22556 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 5,262 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC CPT 22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 4,774 DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR CPT 22585 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 22590 ARTHRODESIS, POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) 4,963 CPT 22595 ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) 4,720 CPT 22600 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: 01.03.2015 Page No(s): 42 of 380

CPT 22610 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 3,956 LEVEL; THORACIC (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) CPT 22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 5,078 LEVEL; LUMBAR (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) CPT 22614 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE 1,292 LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING 4,929 LAMINECTOMY AND/OR DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), SINGLE INTERSPACE; LUMBAR CPT 22632 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 22800 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 4,307 CAST; UP TO 6 VERTEBRAL SEGMENTS CPT 22802 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 6,807 CAST; 7 TO 12 VERTEBRAL SEGMENTS CPT 22804 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 7,858 CAST; 13 OR MORE VERTEBRAL SEGMENTS CPT 22808 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 5,827 CAST; 2 TO 3 VERTEBRAL SEGMENTS CPT 22810 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 6,465 CAST; 4 TO 7 VERTEBRAL SEGMENTS CPT 22812 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT 7,135 CAST; 8 OR MORE VERTEBRAL SEGMENTS CPT 22818 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION 7,209 OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); SINGLE OR 2 SEGMENTS CPT 22819 KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION 8,273 OF VERTEBRAL SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); 3 OR MORE SEGMENTS CPT 22830 EXPLORATION OF SPINAL FUSION 2,579 CPT 22840 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 22841 INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 22842 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 22843 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 22844 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 22845 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: 01.03.2015 Page No(s): 43 of 380

CPT 22846 ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS (LIST 2,519 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 22847 ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS (LIST 2,766 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 22848 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 22849 REINSERTION OF SPINAL FIXATION DEVICE 4,172 CPT 22850 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (EG, 2,290 HARRINGTON ROD) CPT 22851 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 22852 REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION 2,186 CPT 22855 REMOVAL OF ANTERIOR INSTRUMENTATION 3,583 CPT 22857 TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR APPROACH, 5,703 INCLUDING DISCECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION), LUMBAR, SINGLE INTERSPACE CPT 22862 REVISION INCLUDING REPLACEMENT OF TOTAL DISC ARTHROPLASTY 6,781 (ARTIFICIAL DISC) ANTERIOR APPROACH, LUMBAR, SINGLE INTERSPACE CPT 22865 REMOVAL OF TOTAL DISC ARTHROPLASTY (ARTIFICIAL DISC), ANTERIOR 6,604 APPROACH, LUMBAR, SINGLE INTERSPACE CPT 22899 UNLISTED PROCEDURE, SPINE N/A CPT 22900 EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (EG, DESMOID) 1,314 CPT 22999 UNLISTED PROCEDURE, ABDOMEN, MUSCULOSKELETAL SYSTEM N/A CPT 23000 REMOVAL OF SUBDELTOID CALCAREOUS DEPOSITS, OPEN 1,632 CPT 23020 CAPSULAR CONTRACTURE RELEASE (EG, SEVER TYPE PROCEDURE) 2,173 CPT 23030 INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR 1,296 HEMATOMA CPT 23031 INCISION AND DRAINAGE, SHOULDER AREA; INFECTED BURSA 1,225 CPT 23035 INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), 2,136 SHOULDER AREA CPT 23040 ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, 2,263 DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT 23044 ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, 1,792 INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT 23065 BIOPSY, SOFT TISSUE OF SHOULDER AREA; SUPERFICIAL 684 CPT 23066 BIOPSY, SOFT TISSUE OF SHOULDER AREA; DEEP 1,585 CPT 23075 EXCISION, SOFT TISSUE TUMOR, SHOULDER AREA; SUBCUTANEOUS 811 CPT 23076 EXCISION, SOFT TISSUE TUMOR, SHOULDER AREA; DEEP, SUBFASCIAL, OR INTRAMUSCULAR CPT 23077 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: 01.03.2015 Page No(s): 44 of 380

CPT 23100 ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING BIOPSY 1,526 CPT 23101 ARTHROTOMY, ACROMIOCLAVICULAR JOINT OR STERNOCLAVICULAR 1,400 JOINT, INCLUDING BIOPSY AND/OR EXCISION OF TORN CARTILAGE CPT 23105 ARTHROTOMY; GLENOHUMERAL JOINT, WITH SYNOVECTOMY, WITH OR 1,998 WITHOUT BIOPSY CPT 23106 ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH SYNOVECTOMY, WITH 1,485 OR WITHOUT BIOPSY CPT 23107 ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH 2,076 OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT 23120 CLAVICULECTOMY; PARTIAL 1,753 CPT 23125 CLAVICULECTOMY; TOTAL 2,206 CPT 23130 ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT 1,889 CORACOACROMIAL LIGAMENT RELEASE CPT 23140 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 1,635 CLAVICLE OR SCAPULA; CPT 23145 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,172 CLAVICLE OR SCAPULA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 23146 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 1,916 CLAVICLE OR SCAPULA; WITH ALLOGRAFT CPT 23150 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,060 PROXIMAL HUMERUS; CPT 23155 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,490 PROXIMAL HUMERUS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 23156 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF 2,112 PROXIMAL HUMERUS; WITH ALLOGRAFT CPT 23170 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 1,664 CLAVICLE CPT 23172 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 1,728 SCAPULA CPT 23174 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 2,357 HUMERAL HEAD TO SURGICAL NECK CPT 23180 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,107 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), CLAVICLE CPT 23182 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,047 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), SCAPULA CPT 23184 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,305 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), PROXIMAL HUMERUS CPT 23190 OSTECTOMY OF SCAPULA, PARTIAL (EG, SUPERIOR MEDIAL ANGLE) 1,742 CPT 23195 RESECTION, HUMERAL HEAD 2,375 CPT 23200 RADICAL RESECTION FOR TUMOR; CLAVICLE 2,737 CPT 23210 RADICAL RESECTION FOR TUMOR; SCAPULA 2,895 CPT 23220 RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; 3,398 CPT 23221 RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH 4,039 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 23222 RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH 5,379 PROSTHETIC REPLACEMENT CPT 23330 REMOVAL OF FOREIGN BODY, SHOULDER; SUBCUTANEOUS 688 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 45 of 380

CPT 23331 REMOVAL OF FOREIGN BODY, SHOULDER; DEEP (EG, NEER 1,840 HEMIARTHROPLASTY REMOVAL) CPT 23332 REMOVAL OF FOREIGN BODY, SHOULDER; COMPLICATED (EG, TOTAL 2,798 SHOULDER) CPT 23350 INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED 477 CT/MRI SHOULDER ARTHROGRAPHY CPT 23395 MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; SINGLE 4,083 CPT 23397 MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; MULTIPLE 3,640 CPT 23400 SCAPULOPEXY (EG, SPRENGELS DEFORMITY OR FOR PARALYSIS) 3,093 CPT 23405 TENOTOMY, SHOULDER AREA; SINGLE TENDON 1,988 CPT 23406 TENOTOMY, SHOULDER AREA; MULTIPLE TENDONS THROUGH SAME 2,478 INCISION CPT 23410 REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) 2,842 OPEN; ACUTE CPT 23412 REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (EG, ROTATOR CUFF) 3,024 OPEN; CHRONIC CPT 23415 CORACOACROMIAL LIGAMENT RELEASE, WITH OR WITHOUT 2,318 ACROMIOPLASTY CPT 23420 RECONSTRUCTION OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, 3,370 CHRONIC (INCLUDES ACROMIOPLASTY) CPT 23430 TENODESIS OF LONG TENDON OF BICEPS 2,337 CPT 23440 RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS 2,409 CPT 23450 CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON 3,032 TYPE OPERATION CPT 23455 CAPSULORRHAPHY, ANTERIOR; WITH LABRAL REPAIR (EG, BANKART 3,223 PROCEDURE) CPT 23460 CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH BONE BLOCK 3,489 CPT 23462 CAPSULORRHAPHY, ANTERIOR, ANY TYPE; WITH CORACOID PROCESS 3,434 TRANSFER CPT 23465 CAPSULORRHAPHY, GLENOHUMERAL JOINT, POSTERIOR, WITH OR 3,578 WITHOUT BONE BLOCK CPT 23466 CAPSULORRHAPHY, GLENOHUMERAL JOINT, ANY TYPE MULTI- 3,526 DIRECTIONAL INSTABILITY CPT 23470 ARTHROPLASTY, GLENOHUMERAL JOINT; HEMIARTHROPLASTY 3,885 CPT 23472 ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID 4,819 AND PROXIMAL HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) CPT 23480 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION; 2,601 CPT 23485 OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION; WITH 3,063 BONE GRAFT FOR NONUNION OR MALUNION (INCLUDES OBTAINING GRAFT AND/OR NECESSARY FIXATION) CPT 23490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,550 WITH OR WITHOUT METHYLMETHACRYLATE; CLAVICLE CPT 23491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 3,221 WITH OR WITHOUT METHYLMETHACRYLATE; PROXIMAL HUMERUS CPT 23500 CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITHOUT 638 MANIPULATION CPT 23505 CLOSED TREATMENT OF CLAVICULAR FRACTURE; WITH MANIPULATION 1,052 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 46 of 380

CPT 23515 OPEN TREATMENT OF CLAVICULAR FRACTURE, INCLUDES INTERNAL 2,243 FIXATION, WHEN PERFORMED CPT 23520 CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITHOUT 669 MANIPULATION CPT 23525 CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION; WITH 1,044 MANIPULATION CPT 23530 OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR 1,747 CHRONIC; CPT 23532 OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR 1,948 CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT 23540 CLOSED TREATMENT OF ACROMIOCLAVICULAR DISLOCATION; WITHOUT 659 MANIPULATION CPT 23545 CLOSED TREATMENT OF ACROMIOCLAVICULAR DISLOCATION; WITH 932 MANIPULATION CPT 23550 OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR 1,796 CHRONIC; CPT 23552 OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR 2,066 CHRONIC; WITH FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT 23570 CLOSED TREATMENT OF SCAPULAR FRACTURE; WITHOUT MANIPULATION 682 CPT 23575 CLOSED TREATMENT OF SCAPULAR FRACTURE; WITH MANIPULATION, 1,170 WITH OR WITHOUT SKELETAL TRACTION (WITH OR WITHOUT SHOULDER JOINT INVOLVEMENT) CPT 23585 OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR 3,035 ACROMION) WITH OR WITHOUT INTERNAL FIXATION CPT 23600 CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 950 NECK) FRACTURE; WITHOUT MANIPULATION CPT 23605 CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL 1,404 NECK) FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT 23615 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 23616 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 23620 CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; 789 WITHOUT MANIPULATION CPT 23625 CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; 1,146 WITH MANIPULATION CPT 23630 OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, 2,395 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 23650 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 884 WITHOUT ANESTHESIA CPT 23655 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 1,193 REQUIRING ANESTHESIA CPT 23660 OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION 1,828 CPT 23665 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, WITH MANIPULATION CPT 23670 OPEN TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL TUBEROSITY, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 23675 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: 01.03.2015 Page No(s): 47 of 380

CPT 23680 OPEN TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR 2,893 ANATOMICAL NECK FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING 614 APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED) CPT 23800 ARTHRODESIS, GLENOHUMERAL JOINT; 3,249 CPT 23802 ARTHRODESIS, GLENOHUMERAL JOINT; WITH AUTOGENOUS GRAFT 4,040 (INCLUDES OBTAINING GRAFT) CPT 23900 INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER) 4,303 CPT 23920 DISARTICULATION OF SHOULDER; 3,489 CPT 23921 DISARTICULATION OF SHOULDER; SECONDARY CLOSURE OR SCAR 1,414 REVISION CPT 23929 UNLISTED PROCEDURE, SHOULDER N/A CPT 23930 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS 1,053 OR HEMATOMA CPT 23931 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; BURSA 811 CPT 23935 INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR 1,563 OSTEOMYELITIS OR BONE ABSCESS), HUMERUS OR ELBOW CPT 24000 ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, OR 1,473 REMOVAL OF FOREIGN BODY CPT 24006 ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR CAPSULAR 2,230 RELEASE (SEPARATE PROCEDURE) CPT 24065 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; SUPERFICIAL 808 CPT 24066 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP 1,803 (SUBFASCIAL OR INTRAMUSCULAR) CPT 24075 EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; 1,473 SUBCUTANEOUS CPT 24076 EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP 1,497 (SUBFASCIAL OR INTRAMUSCULAR) CPT 24077 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,585 TISSUE OF UPPER ARM OR ELBOW AREA CPT 24100 ARTHROTOMY, ELBOW; WITH SYNOVIAL BIOPSY ONLY 1,248 CPT 24101 ARTHROTOMY, ELBOW; WITH JOINT EXPLORATION, WITH OR WITHOUT 1,544 BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT 24102 ARTHROTOMY, ELBOW; WITH SYNOVECTOMY 1,924 CPT 24105 EXCISION, OLECRANON BURSA 1,045 CPT 24110 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; 1,811 CPT 24115 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 24116 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; WITH ALLOGRAFT CPT 24120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; CPT 24125 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: 01.03.2015 Page No(s): 48 of 380

CPT 24126 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR 1,972 NECK OF RADIUS OR OLECRANON PROCESS; WITH ALLOGRAFT CPT 24130 EXCISION, RADIAL HEAD 1,570 CPT 24134 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), SHAFT 2,347 OR DISTAL HUMERUS CPT 24136 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), RADIAL 1,943 HEAD OR NECK CPT 24138 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), 2,034 OLECRANON PROCESS CPT 24140 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,205 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), HUMERUS CPT 24145 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,836 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), RADIAL HEAD OR NECK CPT 24147 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,922 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS), OLECRANON PROCESS CPT 24149 RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC 3,655 BONE, ELBOW, WITH CONTRACTURE RELEASE (SEPARATE PROCEDURE) CPT 24150 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; 3,087 CPT 24151 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; WITH 3,572 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 24152 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; 2,251 CPT 24153 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; WITH 2,182 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 24155 RESECTION OF ELBOW JOINT (ARTHRECTOMY) 2,683 CPT 24160 IMPLANT REMOVAL; ELBOW JOINT 1,890 CPT 24164 IMPLANT REMOVAL; RADIAL HEAD 1,544 CPT 24200 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; 594 SUBCUTANEOUS CPT 24201 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP 1,652 (SUBFASCIAL OR INTRAMUSCULAR) CPT 24220 INJECTION PROCEDURE FOR ELBOW ARTHROGRAPHY 509 CPT 24300 MANIPULATION, ELBOW, UNDER ANESTHESIA 1,217 CPT 24301 MUSCLE OR TENDON TRANSFER, ANY TYPE, UPPER ARM OR ELBOW, 2,360 SINGLE (EXCLUDING 24320-24331) CPT 24305 TENDON LENGTHENING, UPPER ARM OR ELBOW, EACH TENDON 1,802 CPT 24310 TENOTOMY, OPEN, ELBOW TO SHOULDER, EACH TENDON 1,475 CPT 24320 TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT FREE GRAFT, 2,455 ELBOW TO SHOULDER, SINGLE (SEDDON-BROOKES TYPE PROCEDURE) CPT 24330 FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE ADVANCEMENT); 2,254 CPT 24331 FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE ADVANCEMENT); WITH 2,462 EXTENSOR ADVANCEMENT CPT 24332 TENOLYSIS, TRICEPS 1,877 CPT 24340 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: 01.03.2015 Page No(s): 49 of 380

CPT 24341 REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR 2,282 MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF) CPT 24342 REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH 2,475 OR WITHOUT TENDON GRAFT CPT 24343 REPAIR LATERAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE 2,191 CPT 24344 RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, WITH 3,436 TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) CPT 24345 REPAIR MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH LOCAL TISSUE 2,186 CPT 24346 RECONSTRUCTION MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH 3,442 TENDON GRAFT (INCLUDES HARVESTING OF GRAFT) CPT 24357 TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS 1,373 ELBOW, GOLFER'S ELBOW); PERCUTANEOUS CPT 24358 TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS 1,622 ELBOW, GOLFER'S ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN CPT 24359 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 24360 ARTHROPLASTY, ELBOW; WITH MEMBRANE (EG, FASCIAL) 2,823 CPT 24361 ARTHROPLASTY, ELBOW; WITH DISTAL HUMERAL PROSTHETIC 3,174 REPLACEMENT CPT 24362 ARTHROPLASTY, ELBOW; WITH IMPLANT AND FASCIA LATA LIGAMENT 2,961 RECONSTRUCTION CPT 24363 ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR 4,741 PROSTHETIC REPLACEMENT (EG, TOTAL ELBOW) CPT 24365 ARTHROPLASTY, RADIAL HEAD; 2,000 CPT 24366 ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT 2,149 CPT 24400 OSTEOTOMY, HUMERUS, WITH OR WITHOUT INTERNAL FIXATION 2,595 CPT 24410 MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDULLARY ROD, HUMERAL SHAFT (SOFIELD TYPE PROCEDURE) CPT 24420 OSTEOPLASTY, HUMERUS (EG, SHORTENING OR LENGTHENING) (EXCLUDING 64876) CPT 24430 REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE) CPT 24435 REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 24470 HEMIEPIPHYSEAL ARREST (EG, CUBITUS VARUS OR VALGUS, DISTAL HUMERUS) CPT 24495 DECOMPRESSION FASCIOTOMY, FOREARM, WITH BRACHIAL ARTERY EXPLORATION CPT 24498 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING), WITH OR WITHOUT METHYLMETHACRYLATE, HUMERAL SHAFT CPT 24500 CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITHOUT MANIPULATION CPT 24505 CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT 24515 OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE CPT 24516 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: 01.03.2015 Page No(s): 50 of 380

CPT 24530 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL 1,116 FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; WITHOUT MANIPULATION CPT 24535 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 24538 PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR 2,323 TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION CPT 24545 OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR 2,907 FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITHOUT INTERCONDYLAR EXTENSION CPT 24546 OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR 3,345 FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED; WITH INTERCONDYLAR EXTENSION CPT 24560 CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 933 LATERAL; WITHOUT MANIPULATION CPT 24565 CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 1,574 LATERAL; WITH MANIPULATION CPT 24566 PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR 2,134 FRACTURE, MEDIAL OR LATERAL, WITH MANIPULATION CPT 24575 OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 2,312 LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 24576 CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 983 LATERAL; WITHOUT MANIPULATION CPT 24577 CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 1,618 LATERAL; WITH MANIPULATION CPT 24579 OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 2,647 LATERAL, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 24582 PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE, 2,460 MEDIAL OR LATERAL, WITH MANIPULATION CPT 24586 OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION 3,476 OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); CPT 24587 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 24600 TREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 1,087 CPT 24605 TREATMENT OF CLOSED ELBOW DISLOCATION; REQUIRING ANESTHESIA 1,422 CPT 24615 OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION 2,250 CPT 24620 CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH DISLOCATION OF RADIAL HEAD), WITH MANIPULATION CPT 24635 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 24640 CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, WITH MANIPULATION CPT 24650 CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITHOUT MANIPULATION CPT 24655 CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE; WITH MANIPULATION CPT 24665 OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, INCLUDES INTERNAL FIXATION OR RADIAL HEAD EXCISION, WHEN PERFORMED; 1,715 2,200 361 755 1,304 2,031 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 51 of 380

CPT 24666 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 24670 CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, 848 OLECRANON OR CORONOID PROCESS[ES]); WITHOUT MANIPULATION CPT 24675 CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, 1,382 OLECRANON OR CORONOID PROCESS[ES]); WITH MANIPULATION CPT 24685 OPEN TREATMENT OF ULNAR FRACTURE, PROXIMAL END (EG, OLECRANON 2,045 OR CORONOID PROCESS[ES]), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 24800 ARTHRODESIS, ELBOW JOINT; LOCAL 2,490 CPT 24802 ARTHRODESIS, ELBOW JOINT; WITH AUTOGENOUS GRAFT (INCLUDES 3,095 OBTAINING GRAFT) CPT 24900 AMPUTATION, ARM THROUGH HUMERUS; WITH PRIMARY CLOSURE 2,264 CPT 24920 AMPUTATION, ARM THROUGH HUMERUS; OPEN, CIRCULAR (GUILLOTINE) 2,224 CPT 24925 AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE OR SCAR 1,671 REVISION CPT 24930 AMPUTATION, ARM THROUGH HUMERUS; RE-AMPUTATION 2,341 CPT 24931 AMPUTATION, ARM THROUGH HUMERUS; WITH IMPLANT 2,555 CPT 24935 STUMP ELONGATION, UPPER EXTREMITY 3,638 CPT 24940 CINEPLASTY, UPPER EXTREMITY, COMPLETE PROCEDURE 3,397 CPT 24999 UNLISTED PROCEDURE, HUMERUS OR ELBOW N/A CPT 25000 INCISION, EXTENSOR TENDON SHEATH, WRIST (EG, DEQUERVAINS 1,003 DISEASE) CPT 25001 INCISION, FLEXOR TENDON SHEATH, WRIST (EG, FLEXOR CARPI 1,029 RADIALIS) CPT 25020 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR 1,743 EXTENSOR COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 25023 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR 3,406 EXTENSOR COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 25024 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND 2,399 EXTENSOR COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 25025 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND 3,687 EXTENSOR COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 25028 INCISION AND DRAINAGE, FOREARM AND/OR WRIST; DEEP ABSCESS OR 1,549 HEMATOMA CPT 25031 INCISION AND DRAINAGE, FOREARM AND/OR WRIST; BURSA 1,044 CPT 25035 INCISION, DEEP, BONE CORTEX, FOREARM AND/OR WRIST (EG, 1,813 OSTEOMYELITIS OR BONE ABSCESS) CPT 25040 ARTHROTOMY, RADIOCARPAL OR MIDCARPAL JOINT, WITH EXPLORATION, 1,757 DRAINAGE, OR REMOVAL OF FOREIGN BODY CPT 25065 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: 01.03.2015 Page No(s): 52 of 380

CPT 25066 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL 1,090 OR INTRAMUSCULAR) CPT 25075 EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA; 961 SUBCUTANEOUS CPT 25076 EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA; 1,236 DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT 25077 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,202 TISSUE OF FOREARM AND/OR WRIST AREA CPT 25085 CAPSULOTOMY, WRIST (EG, CONTRACTURE) 1,387 CPT 25100 ARTHROTOMY, WRIST JOINT; WITH BIOPSY 1,044 CPT 25101 ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR 1,238 WITHOUT BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT 25105 ARTHROTOMY, WRIST JOINT; WITH SYNOVECTOMY 1,486 CPT 25107 ARTHROTOMY, DISTAL RADIOULNAR JOINT INCLUDING REPAIR OF 1,854 TRIANGULAR CARTILAGE, COMPLEX CPT 25109 EXCISION OF TENDON, FOREARM AND/OR WRIST, FLEXOR OR EXTENSOR, 1,637 EACH CPT 25110 EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST 1,032 CPT 25111 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); PRIMARY 955 CPT 25112 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR); RECURRENT 1,178 CPT 25115 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); FLEXORS CPT 25116 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 25118 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; CPT 25119 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH RESECTION OF DISTAL ULNA CPT 25120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); CPT 25125 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 25126 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 25130 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; CPT 25135 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 25136 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH ALLOGRAFT CPT 25145 SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), FOREARM AND/OR WRIST CPT 25150 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: 01.03.2015 Page No(s): 53 of 380

CPT 25151 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,812 DIAPHYSECTOMY) OF BONE (EG, FOR OSTEOMYELITIS); RADIUS CPT 25170 RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA 2,579 CPT 25210 CARPECTOMY; ONE BONE 1,502 CPT 25215 CARPECTOMY; ALL BONES OF PROXIMAL ROW 1,918 CPT 25230 RADIAL STYLOIDECTOMY (SEPARATE PROCEDURE) 1,330 CPT 25240 EXCISION DISTAL ULNA PARTIAL OR COMPLETE (EG, DARRACH TYPE OR 1,321 MATCHED RESECTION) CPT 25246 INJECTION PROCEDURE FOR WRIST ARTHROGRAPHY 537 CPT 25248 EXPLORATION WITH REMOVAL OF DEEP FOREIGN BODY, FOREARM OR 1,254 WRIST CPT 25250 REMOVAL OF WRIST PROSTHESIS; (SEPARATE PROCEDURE) 1,628 CPT 25251 REMOVAL OF WRIST PROSTHESIS; COMPLICATED, INCLUDING TOTAL 2,229 WRIST CPT 25259 MANIPULATION, WRIST, UNDER ANESTHESIA 1,213 CPT 25260 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 1,945 PRIMARY, SINGLE, EACH TENDON OR MUSCLE CPT 25263 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 1,910 SECONDARY, SINGLE, EACH TENDON OR MUSCLE CPT 25265 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; 2,333 SECONDARY, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE CPT 25270 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 1,507 PRIMARY, SINGLE, EACH TENDON OR MUSCLE CPT 25272 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 1,724 SECONDARY, SINGLE, EACH TENDON OR MUSCLE CPT 25274 REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; 2,083 SECONDARY, WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE CPT 25275 REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH 2,090 FREE GRAFT (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION) CPT 25280 LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TENDON, 1,752 FOREARM AND/OR WRIST, SINGLE, EACH TENDON CPT 25290 TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR 1,341 WRIST, SINGLE, EACH TENDON CPT 25295 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, 1,623 SINGLE, EACH TENDON CPT 25300 TENODESIS AT WRIST; FLEXORS OF FINGERS 2,114 CPT 25301 TENODESIS AT WRIST; EXTENSORS OF FINGERS 2,007 CPT 25310 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON CPT 25312 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; WITH TENDON GRAFT(S) (INCLUDES OBTAINING GRAFT), EACH TENDON CPT 25315 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: 01.03.2015 Page No(s): 54 of 380

CPT 25316 FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PALSY, VOLKMANN 2,810 CONTRACTURE), FOREARM AND/OR WRIST; WITH TENDON(S) TRANSFER CPT 25320 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 25332 ARTHROPLASTY, WRIST, WITH OR WITHOUT INTERPOSITION, WITH OR 2,649 WITHOUT EXTERNAL OR INTERNAL FIXATION CPT 25335 CENTRALIZATION OF WRIST ON ULNA (EG, RADIAL CLUB HAND) 2,956 CPT 25337 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 25350 OSTEOTOMY, RADIUS; DISTAL THIRD 2,112 CPT 25355 OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD 2,378 CPT 25360 OSTEOTOMY; ULNA 2,047 CPT 25365 OSTEOTOMY; RADIUS AND ULNA 2,908 CPT 25370 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,175 (SOFIELD TYPE PROCEDURE); RADIUS OR ULNA CPT 25375 MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,027 (SOFIELD TYPE PROCEDURE); RADIUS AND ULNA CPT 25390 OSTEOPLASTY, RADIUS OR ULNA; SHORTENING 2,429 CPT 25391 OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING WITH AUTOGRAFT 3,150 CPT 25392 OSTEOPLASTY, RADIUS AND ULNA; SHORTENING (EXCLUDING 64876) 3,204 CPT 25393 OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING WITH AUTOGRAFT 3,620 CPT 25394 OSTEOPLASTY, CARPAL BONE, SHORTENING 2,422 CPT 25400 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITHOUT GRAFT 2,550 (EG, COMPRESSION TECHNIQUE) CPT 25405 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH 3,288 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 25415 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITHOUT 3,101 GRAFT (EG, COMPRESSION TECHNIQUE) CPT 25420 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITH 3,705 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 25425 REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS OR ULNA 3,041 CPT 25426 REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS AND ULNA 3,531 CPT 25430 INSERTION OF VASCULAR PEDICLE INTO CARPAL BONE (EG, HORI PROCEDURE) CPT 25431 REPAIR OF NONUNION OF CARPAL BONE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)) (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION), EACH BONE CPT 25440 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: 01.03.2015 Page No(s): 55 of 380

CPT 25441 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS 2,937 CPT 25442 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL ULNA 2,519 CPT 25443 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID CARPAL 2,405 (NAVICULAR) CPT 25444 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; LUNATE 2,572 CPT 25445 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; TRAPEZIUM 2,266 CPT 25446 ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS AND 3,729 PARTIAL OR ENTIRE CARPUS (TOTAL WRIST) CPT 25447 ARTHROPLASTY, INTERPOSITION, INTERCARPAL OR CARPOMETACARPAL 2,571 JOINTS CPT 25449 REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, WRIST 3,270 JOINT CPT 25450 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS 1,653 OR ULNA CPT 25455 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS 2,187 AND ULNA CPT 25490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,217 WITH OR WITHOUT METHYLMETHACRYLATE; RADIUS CPT 25491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,318 WITH OR WITHOUT METHYLMETHACRYLATE; ULNA CPT 25492 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 2,896 WITH OR WITHOUT METHYLMETHACRYLATE; RADIUS AND ULNA CPT 25500 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITHOUT 776 MANIPULATION CPT 25505 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE; WITH MANIPULATION 1,514 CPT 25515 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, INCLUDES INTERNAL 2,102 FIXATION, WHEN PERFORMED CPT 25520 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE AND CLOSED 1,652 TREATMENT OF DISLOCATION OF DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION) CPT 25525 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 25526 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 25530 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITHOUT 751 MANIPULATION CPT 25535 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE; WITH MANIPULATION 1,470 CPT 25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 25560 CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITHOUT MANIPULATION CPT 25565 CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH MANIPULATION CPT 25574 OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS OR ULNA 1,956 782 1,579 2,064 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 56 of 380

CPT 25575 OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH 2,805 INTERNAL FIXATION, WHEN PERFORMED; OF RADIUS AND ULNA CPT 25600 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 25605 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 25606 PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE OR 2,021 EPIPHYSEAL SEPARATION CPT 25607 OPEN TREATMENT OF DISTAL RADIAL EXTRA-ARTICULAR FRACTURE OR 2,254 EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION CPT 25608 OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR 2,580 EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS CPT 25609 OPEN TREATMENT OF DISTAL RADIAL INTRA-ARTICULAR FRACTURE OR 3,292 EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS CPT 25622 CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; 881 WITHOUT MANIPULATION CPT 25624 CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE; 1,387 WITH MANIPULATION CPT 25628 OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, 2,231 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 25630 CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL 899 SCAPHOID (NAVICULAR)); WITHOUT MANIPULATION, EACH BONE CPT 25635 CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL 1,300 SCAPHOID (NAVICULAR)); WITH MANIPULATION, EACH BONE CPT 25645 OPEN TREATMENT OF CARPAL BONE FRACTURE (OTHER THAN CARPAL 1,770 SCAPHOID (NAVICULAR)), EACH BONE CPT 25650 CLOSED TREATMENT OF ULNAR STYLOID FRACTURE 933 CPT 25651 PERCUTANEOUS SKELETAL FIXATION OF ULNAR STYLOID FRACTURE 1,471 CPT 25652 OPEN TREATMENT OF ULNAR STYLOID FRACTURE 1,924 CPT 25660 CLOSED TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, 1,227 ONE OR MORE BONES, WITH MANIPULATION CPT 25670 OPEN TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE 1,898 OR MORE BONES CPT 25671 PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIOULNAR 1,618 DISLOCATION CPT 25675 CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION WITH 1,270 MANIPULATION CPT 25676 OPEN TREATMENT OF DISTAL RADIOULNAR DISLOCATION, ACUTE OR 1,969 CHRONIC CPT 25680 CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE 1,416 DISLOCATION, WITH MANIPULATION CPT 25685 OPEN TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE 2,290 DISLOCATION CPT 25690 CLOSED TREATMENT OF LUNATE DISLOCATION, WITH MANIPULATION 1,423 CPT 25695 OPEN TREATMENT OF LUNATE DISLOCATION 1,979 CPT 25800 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: 01.03.2015 Page No(s): 57 of 380

JOINTS) CPT 25805 ARTHRODESIS, WRIST; WITH SLIDING GRAFT 2,653 CPT 25810 ARTHRODESIS, WRIST; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES 2,702 OBTAINING GRAFT) CPT 25820 ARTHRODESIS, WRIST; LIMITED, WITHOUT BONE GRAFT (EG, 1,906 INTERCARPAL OR RADIOCARPAL) CPT 25825 ARTHRODESIS, WRIST; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) 2,342 CPT 25830 ARTHRODESIS, DISTAL RADIOULNAR JOINT WITH SEGMENTAL RESECTION 2,873 OF ULNA, WITH OR WITHOUT BONE GRAFT (EG, SAUVE-KAPANDJI PROCEDURE) CPT 25900 AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; 2,202 CPT 25905 AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; OPEN, CIRCULAR 2,133 (GUILLOTINE) CPT 25907 AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECONDARY 1,869 CLOSURE OR SCAR REVISION CPT 25909 AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; RE-AMPUTATION 2,136 CPT 25915 KRUKENBERG PROCEDURE 3,310 CPT 25920 DISARTICULATION THROUGH WRIST; 2,122 CPT 25922 DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE OR SCAR 1,880 REVISION CPT 25924 DISARTICULATION THROUGH WRIST; RE-AMPUTATION 2,032 CPT 25927 TRANSMETACARPAL AMPUTATION; 2,380 CPT 25929 TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR SCAR 1,827 REVISION CPT 25931 TRANSMETACARPAL AMPUTATION; RE-AMPUTATION 2,191 CPT 25999 UNLISTED PROCEDURE, FOREARM OR WRIST N/A CPT 26010 DRAINAGE OF FINGER ABSCESS; SIMPLE 730 CPT 26011 DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON) 1,106 CPT 26020 DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH 1,314 CPT 26025 DRAINAGE OF PALMAR BURSA; SINGLE, BURSA 1,285 CPT 26030 DRAINAGE OF PALMAR BURSA; MULTIPLE BURSA 1,520 CPT 26034 INCISION, BONE CORTEX, HAND OR FINGER (EG, OSTEOMYELITIS OR 1,646 BONE ABSCESS) CPT 26035 DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJURY (EG, 2,610 GREASE GUN) CPT 26037 DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035) 1,776 CPT 26040 FASCIOTOMY, PALMAR (EG, DUPUYTREN'S CONTRACTURE); PERCUTANEOUS CPT 26045 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: 01.03.2015 Page No(s): 58 of 380

CPT 26055 TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER) 1,570 CPT 26060 TENOTOMY, PERCUTANEOUS, SINGLE, EACH DIGIT 800 CPT 26070 ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 915 OR FOREIGN BODY; CARPOMETACARPAL JOINT CPT 26075 ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 972 OR FOREIGN BODY; METACARPOPHALANGEAL JOINT, EACH CPT 26080 ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE 1,175 OR FOREIGN BODY; INTERPHALANGEAL JOINT, EACH CPT 26100 ARTHROTOMY WITH BIOPSY; CARPOMETACARPAL JOINT, EACH 996 CPT 26105 ARTHROTOMY WITH BIOPSY; METACARPOPHALANGEAL JOINT, EACH 1,009 CPT 26110 ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL JOINT, EACH 970 CPT 26115 EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND 1,806 OR FINGER; SUBCUTANEOUS CPT 26116 EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND 1,480 OR FINGER; DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT 26117 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,022 TISSUE OF HAND OR FINGER CPT 26121 FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL 1,851 TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT) CPT 26123 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 26125 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 26130 SYNOVECTOMY, CARPOMETACARPAL JOINT 1,423 CPT 26135 SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING INTRINSIC 1,706 RELEASE AND EXTENSOR HOOD RECONSTRUCTION, EACH DIGIT CPT 26140 SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, INCLUDING 1,550 EXTENSOR RECONSTRUCTION, EACH INTERPHALANGEAL JOINT CPT 26145 SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), 1,578 FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDON CPT 26160 EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, 1,635 MUCOUS CYST, OR GANGLION), HAND OR FINGER CPT 26170 EXCISION OF TENDON, PALM, FLEXOR OR EXTENSOR, SINGLE, EACH 1,243 TENDON CPT 26180 EXCISION OF TENDON, FINGER, FLEXOR OR EXTENSOR, EACH TENDON 1,350 CPT 26185 SESAMOIDECTOMY, THUMB OR FINGER (SEPARATE PROCEDURE) 1,618 CPT 26200 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; CPT 26205 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26210 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: 01.03.2015 Page No(s): 59 of 380

CPT 26215 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 26230 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,553 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); METACARPAL CPT 26235 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,528 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER CPT 26236 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 1,354 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); DISTAL PHALANX OF FINGER CPT 26250 RADICAL RESECTION, METACARPAL (EG, TUMOR); 1,812 CPT 26255 RADICAL RESECTION, METACARPAL (EG, TUMOR); WITH AUTOGRAFT 2,867 (INCLUDES OBTAINING GRAFT) CPT 26260 RADICAL RESECTION, PROXIMAL OR MIDDLE PHALANX OF FINGER (EG, 1,708 TUMOR); CPT 26261 RADICAL RESECTION, PROXIMAL OR MIDDLE PHALANX OF FINGER (EG, 2,158 TUMOR); WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26262 RADICAL RESECTION, DISTAL PHALANX OF FINGER (EG, TUMOR) 1,428 CPT 26320 REMOVAL OF IMPLANT FROM FINGER OR HAND 1,057 CPT 26340 MANIPULATION, FINGER JOINT, UNDER ANESTHESIA, EACH JOINT 959 CPT 26350 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 26352 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 26356 REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, WITHOUT FREE GRAFT, EACH TENDON CPT 26357 REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY, WITHOUT FREE GRAFT, EACH TENDON CPT 26358 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 26370 REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; PRIMARY, EACH TENDON CPT 26372 REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; SECONDARY WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT 26373 REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; SECONDARY WITHOUT FREE GRAFT, EACH TENDON CPT 26390 EXCISION FLEXOR TENDON, WITH IMPLANTATION OF SYNTHETIC ROD FOR DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD CPT 26392 REMOVAL OF SYNTHETIC ROD AND INSERTION OF FLEXOR TENDON GRAFT, HAND OR FINGER (INCLUDES OBTAINING GRAFT), EACH ROD CPT 26410 REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH TENDON CPT 26412 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: 01.03.2015 Page No(s): 60 of 380

CPT 26415 EXCISION OF EXTENSOR TENDON, WITH IMPLANTATION OF SYNTHETIC 2,120 ROD FOR DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD CPT 26416 REMOVAL OF SYNTHETIC ROD AND INSERTION OF EXTENSOR TENDON 2,426 GRAFT (INCLUDES OBTAINING GRAFT), HAND OR FINGER, EACH ROD CPT 26418 REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; 1,655 WITHOUT FREE GRAFT, EACH TENDON CPT 26420 REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITH 2,103 FREE GRAFT (INCLUDES OBTAINING GRAFT) EACH TENDON CPT 26426 REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, 1,545 BOUTONNIERE DEFORMITY); USING LOCAL TISSUE(S), INCLUDING LATERAL BAND(S), EACH FINGER CPT 26428 REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, 2,219 BOUTONNIERE DEFORMITY); WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH FINGER CPT 26432 CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR 1,447 WITHOUT PERCUTANEOUS PINNING (EG, MALLET FINGER) CPT 26433 REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR 1,554 SECONDARY; WITHOUT GRAFT (EG, MALLET FINGER) CPT 26434 REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR 1,890 SECONDARY; WITH FREE GRAFT (INCLUDES OBTAINING GRAFT) CPT 26437 REALIGNMENT OF EXTENSOR TENDON, HAND, EACH TENDON 1,836 CPT 26440 TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, EACH TENDON 1,801 CPT 26442 TENOLYSIS, FLEXOR TENDON; PALM AND FINGER, EACH TENDON 2,835 CPT 26445 TENOLYSIS, EXTENSOR TENDON, HAND OR FINGER, EACH TENDON 1,667 CPT 26449 TENOLYSIS, COMPLEX, EXTENSOR TENDON, FINGER, INCLUDING 2,099 FOREARM, EACH TENDON CPT 26450 TENOTOMY, FLEXOR, PALM, OPEN, EACH TENDON 1,194 CPT 26455 TENOTOMY, FLEXOR, FINGER, OPEN, EACH TENDON 1,184 CPT 26460 TENOTOMY, EXTENSOR, HAND OR FINGER, OPEN, EACH TENDON 1,154 CPT 26471 TENODESIS; OF PROXIMAL INTERPHALANGEAL JOINT, EACH JOINT 1,821 CPT 26474 TENODESIS; OF DISTAL JOINT, EACH JOINT 1,730 CPT 26476 LENGTHENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON 1,685 CPT 26477 SHORTENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON 1,711 CPT 26478 LENGTHENING OF TENDON, FLEXOR, HAND OR FINGER, EACH TENDON 1,831 CPT 26479 SHORTENING OF TENDON, FLEXOR, HAND OR FINGER, EACH TENDON 1,820 CPT 26480 TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON CPT 26483 TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON CPT 26485 TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITHOUT FREE TENDON GRAFT, EACH TENDON CPT 26489 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: 01.03.2015 Page No(s): 61 of 380

CPT 26490 OPPONENSPLASTY; SUPERFICIALIS TENDON TRANSFER TYPE, EACH 2,337 TENDON CPT 26492 OPPONENSPLASTY; TENDON TRANSFER WITH GRAFT (INCLUDES 2,634 OBTAINING GRAFT), EACH TENDON CPT 26494 OPPONENSPLASTY; HYPOTHENAR MUSCLE TRANSFER 2,399 CPT 26496 OPPONENSPLASTY; OTHER METHODS 2,604 CPT 26497 TRANSFER OF TENDON TO RESTORE INTRINSIC FUNCTION; RING AND 2,591 SMALL FINGER CPT 26498 TRANSFER OF TENDON TO RESTORE INTRINSIC FUNCTION; ALL FOUR 3,504 FINGERS CPT 26499 CORRECTION CLAW FINGER, OTHER METHODS 2,424 CPT 26500 RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH LOCAL 1,846 TISSUES (SEPARATE PROCEDURE) CPT 26502 RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH TENDON OR 2,096 FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) (SEPARATE PROCEDURE) CPT 26508 RELEASE OF THENAR MUSCLE(S) (EG, THUMB CONTRACTURE) 1,869 CPT 26510 CROSS INTRINSIC TRANSFER, EACH TENDON 1,752 CPT 26516 CAPSULODESIS, METACARPOPHALANGEAL JOINT; SINGLE DIGIT 2,091 CPT 26517 CAPSULODESIS, METACARPOPHALANGEAL JOINT; TWO DIGITS 2,438 CPT 26518 CAPSULODESIS, METACARPOPHALANGEAL JOINT; THREE OR FOUR DIGITS 2,450 CPT 26520 CAPSULECTOMY OR CAPSULOTOMY; METACARPOPHALANGEAL JOINT, 1,891 EACH JOINT CPT 26525 CAPSULECTOMY OR CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH 1,899 JOINT CPT 26530 ARTHROPLASTY, METACARPOPHALANGEAL JOINT; EACH JOINT 1,662 CPT 26531 ARTHROPLASTY, METACARPOPHALANGEAL JOINT; WITH PROSTHETIC 1,929 IMPLANT, EACH JOINT CPT 26535 ARTHROPLASTY, INTERPHALANGEAL JOINT; EACH JOINT 1,271 CPT 26536 ARTHROPLASTY, INTERPHALANGEAL JOINT; WITH PROSTHETIC IMPLANT, 2,095 EACH JOINT CPT 26540 REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR 1,956 INTERPHALANGEAL JOINT CPT 26541 RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL 2,402 JOINT, SINGLE; WITH TENDON OR FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) CPT 26542 RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL 2,021 JOINT, SINGLE; WITH LOCAL TISSUE (EG, ADDUCTOR ADVANCEMENT) CPT 26545 RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL JOINT, 2,076 SINGLE, INCLUDING GRAFT, EACH JOINT CPT 26546 REPAIR NON-UNION, METACARPAL OR PHALANX (INCLUDES OBTAINING 2,945 BONE GRAFT WITH OR WITHOUT EXTERNAL OR INTERNAL FIXATION) CPT 26548 REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE, 2,279 INTERPHALANGEAL JOINT CPT 26550 POLLICIZATION OF A DIGIT 4,852 CPT 26551 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: 01.03.2015 Page No(s): 62 of 380

CPT 26553 TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER 9,782 THAN GREAT TOE, SINGLE CPT 26554 TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER 12,837 THAN GREAT TOE, DOUBLE CPT 26555 TRANSFER, FINGER TO ANOTHER POSITION WITHOUT MICROVASCULAR 4,209 ANASTOMOSIS CPT 26556 TRANSFER, FREE TOE JOINT, WITH MICROVASCULAR ANASTOMOSIS 8,818 CPT 26560 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN 1,627 FLAPS CPT 26561 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; WITH SKIN 2,761 FLAPS AND GRAFTS CPT 26562 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; COMPLEX (EG, 3,450 INVOLVING BONE, NAILS) CPT 26565 OSTEOTOMY; METACARPAL, EACH 2,008 CPT 26567 OSTEOTOMY; PHALANX OF FINGER, EACH 2,018 CPT 26568 OSTEOPLASTY, LENGTHENING, METACARPAL OR PHALANX 2,686 CPT 26580 REPAIR CLEFT HAND 3,968 CPT 26587 RECONSTRUCTION OF POLYDACTYLOUS DIGIT, SOFT TISSUE AND BONE 3,009 CPT 26590 REPAIR MACRODACTYLIA, EACH DIGIT 4,244 CPT 26591 REPAIR, INTRINSIC MUSCLES OF HAND, EACH MUSCLE 1,258 CPT 26593 RELEASE, INTRINSIC MUSCLES OF HAND, EACH MUSCLE 1,757 CPT 26596 EXCISION OF CONSTRICTING RING OF FINGER, WITH MULTIPLE Z- PLASTIES CPT 26600 CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITHOUT MANIPULATION, EACH BONE CPT 26605 CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, EACH BONE CPT 26607 CLOSED TREATMENT OF METACARPAL FRACTURE, WITH MANIPULATION, WITH EXTERNAL FIXATION, EACH BONE CPT 26608 PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE CPT 26615 OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH BONE CPT 26641 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB, WITH MANIPULATION CPT 26645 CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION CPT 26650 PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH MANIPULATION CPT 26665 OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 26670 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA CPT 26675 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT; REQUIRING ANESTHESIA CPT 26676 PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH MANIPULATION, EACH JOINT 2,258 833 944 1,404 1,452 1,735 1,062 1,227 1,387 1,888 975 1,351 1,520 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 63 of 380

CPT 26685 OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN 1,758 THUMB; INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH JOINT CPT 26686 OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN 1,935 THUMB; COMPLEX, MULTIPLE, OR DELAYED REDUCTION CPT 26700 CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 930 WITH MANIPULATION; WITHOUT ANESTHESIA CPT 26705 CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 1,217 WITH MANIPULATION; REQUIRING ANESTHESIA CPT 26706 PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL 1,346 DISLOCATION, SINGLE, WITH MANIPULATION CPT 26715 OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, 1,734 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 26720 CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR 568 MIDDLE PHALANX, FINGER OR THUMB; WITHOUT MANIPULATION, EACH CPT 26725 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 26727 PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT 1,424 FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH CPT 26735 OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR 1,804 MIDDLE PHALANX, FINGER OR THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT 26740 CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING 668 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITHOUT MANIPULATION, EACH CPT 26742 CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING 1,101 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT; WITH MANIPULATION, EACH CPT 26746 OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING 2,227 METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT 26750 CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 529 THUMB; WITHOUT MANIPULATION, EACH CPT 26755 CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 921 THUMB; WITH MANIPULATION, EACH CPT 26756 PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, 1,262 FINGER OR THUMB, EACH CPT 26765 OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR 1,489 THUMB, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT 26770 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, 787 WITH MANIPULATION; WITHOUT ANESTHESIA CPT 26775 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, 1,125 WITH MANIPULATION; REQUIRING ANESTHESIA CPT 26776 PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT 1,337 DISLOCATION, SINGLE, WITH MANIPULATION CPT 26785 OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES 1,623 INTERNAL FIXATION, WHEN PERFORMED, SINGLE CPT 26820 FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT (INCLUDES 2,341 OBTAINING GRAFT) CPT 26841 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT 2,159 INTERNAL FIXATION; CPT 26842 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT 2,355 INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26843 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: 01.03.2015 Page No(s): 64 of 380

CPT 26844 ARTHRODESIS, CARPOMETACARPAL JOINT, DIGIT, OTHER THAN THUMB, 2,435 EACH; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26850 ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT 2,059 INTERNAL FIXATION; CPT 26852 ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT 2,385 INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26860 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 1,640 FIXATION; CPT 26861 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 341 FIXATION; EACH ADDITIONAL INTERPHALANGEAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 26862 ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL 2,166 FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 26863 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 26910 AMPUTATION, METACARPAL, WITH FINGER OR THUMB (RAY AMPUTATION), 2,153 SINGLE, WITH OR WITHOUT INTEROSSEOUS TRANSFER CPT 26951 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT 1,883 OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE CPT 26952 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT 1,916 OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD) CPT 26989 UNLISTED PROCEDURE, HANDS OR FINGERS N/A CPT 26990 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR 1,922 HEMATOMA CPT 26991 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; INFECTED BURSA 2,102 CPT 26992 INCISION, BONE CORTEX, PELVIS AND/OR HIP JOINT (EG, 3,015 OSTEOMYELITIS OR BONE ABSCESS) CPT 27000 TENOTOMY, ADDUCTOR OF HIP, PERCUTANEOUS (SEPARATE PROCEDURE) 1,403 CPT 27001 TENOTOMY, ADDUCTOR OF HIP, OPEN 1,701 CPT 27003 TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN, WITH OBTURATOR 1,831 NEURECTOMY CPT 27005 TENOTOMY, HIP FLEXOR(S), OPEN (SEPARATE PROCEDURE) 2,288 CPT 27006 TENOTOMY, ABDUCTORS AND/OR EXTENSOR(S) OF HIP, OPEN (SEPARATE 2,322 PROCEDURE) CPT 27025 FASCIOTOMY, HIP OR THIGH, ANY TYPE 2,859 CPT 27030 ARTHROTOMY, HIP, WITH DRAINAGE (EG, INFECTION) 3,001 CPT 27033 ARTHROTOMY, HIP, INCLUDING EXPLORATION OR REMOVAL OF LOOSE OR 3,111 FOREIGN BODY CPT 27035 DENERVATION, HIP JOINT, INTRAPELVIC OR EXTRAPELVIC INTRA- 3,514 ARTICULAR BRANCHES OF SCIATIC, FEMORAL, OR OBTURATOR NERVES CPT 27036 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 27040 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: 01.03.2015 Page No(s): 65 of 380

CPT 27041 BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; DEEP, SUBFASCIAL OR 2,159 INTRAMUSCULAR CPT 27047 EXCISION, TUMOR, PELVIS AND HIP AREA; SUBCUTANEOUS TISSUE 1,959 CPT 27048 EXCISION, TUMOR, PELVIS AND HIP AREA; DEEP, SUBFASCIAL, 1,506 INTRAMUSCULAR CPT 27049 RADICAL RESECTION OF TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA 3,202 (EG, MALIGNANT NEOPLASM) CPT 27050 ARTHROTOMY, WITH BIOPSY; SACROILIAC JOINT 1,039 CPT 27052 ARTHROTOMY, WITH BIOPSY; HIP JOINT 1,762 CPT 27054 ARTHROTOMY WITH SYNOVECTOMY, HIP JOINT 2,146 CPT 27060 EXCISION; ISCHIAL BURSA 1,378 CPT 27062 EXCISION; TROCHANTERIC BURSA OR CALCIFICATION 1,408 CPT 27065 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 27066 EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP, WITH OR WITHOUT 2,555 AUTOGRAFT CPT 27067 EXCISION OF BONE CYST OR BENIGN TUMOR; WITH AUTOGRAFT 3,180 REQUIRING SEPARATE INCISION CPT 27070 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, 2,670 OSTEOMYELITIS OR BONE ABSCESS); SUPERFICIAL (EG, WING OF ILIUM, SYMPHYSIS PUBIS, OR GREATER TROCHANTER OF FEMUR) CPT 27071 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, 2,852 OSTEOMYELITIS OR BONE ABSCESS); DEEP (SUBFASCIAL OR INTRAMUSCULAR) CPT 27075 RADICAL RESECTION OF TUMOR OR INFECTION; WING OF ILIUM, ONE 7,373 PUBIC OR ISCHIAL RAMUS OR SYMPHYSIS PUBIS CPT 27076 RADICAL RESECTION OF TUMOR OR INFECTION; ILIUM, INCLUDING 5,134 ACETABULUM, BOTH PUBIC RAMI, OR ISCHIUM AND ACETABULUM CPT 27077 RADICAL RESECTION OF TUMOR OR INFECTION; INNOMINATE BONE, 8,638 TOTAL CPT 27078 RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY 3,221 AND GREATER TROCHANTER OF FEMUR CPT 27079 RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY 3,130 AND GREATER TROCHANTER OF FEMUR, WITH SKIN FLAPS CPT 27080 COCCYGECTOMY, PRIMARY 1,550 CPT 27086 REMOVAL OF FOREIGN BODY, PELVIS OR HIP; SUBCUTANEOUS TISSUE 730 CPT 27087 REMOVAL OF FOREIGN BODY, PELVIS OR HIP; DEEP (SUBFASCIAL OR 1,979 INTRAMUSCULAR) CPT 27090 REMOVAL OF HIP PROSTHESIS; (SEPARATE PROCEDURE) 2,634 CPT 27091 REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING TOTAL HIP 5,149 PROSTHESIS, METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER CPT 27093 INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITHOUT ANESTHESIA 576 CPT 27095 INJECTION PROCEDURE FOR HIP ARTHROGRAPHY; WITH ANESTHESIA 673 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 66 of 380

CPT 27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, ARTHROGRAPHY AND/OR 503 ANESTHETIC/STEROID CPT 27097 RELEASE OR RECESSION, HAMSTRING, PROXIMAL 2,148 CPT 27098 TRANSFER, ADDUCTOR TO ISCHIUM 1,895 CPT 27100 TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREATER TROCHANTER 2,576 INCLUDING FASCIAL OR TENDON EXTENSION (GRAFT) CPT 27105 TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASCIAL OR TENDON 2,642 EXTENSION GRAFT) CPT 27110 TRANSFER ILIOPSOAS; TO GREATER TROCHANTER OF FEMUR 3,033 CPT 27111 TRANSFER ILIOPSOAS; TO FEMORAL NECK 2,829 CPT 27120 ACETABULOPLASTY; (EG, WHITMAN, COLONNA, HAYGROVES, OR CUP 4,154 TYPE) CPT 27122 ACETABULOPLASTY; RESECTION, FEMORAL HEAD (EG, GIRDLESTONE 3,525 PROCEDURE) CPT 27125 HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, 3,601 BIPOLAR ARTHROPLASTY) CPT 27130 ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC 4,643 REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT 27132 CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, 5,408 WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT 27134 REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR 6,264 WITHOUT AUTOGRAFT OR ALLOGRAFT CPT 27137 REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT 4,778 ONLY, WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT CPT 27138 REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, 4,974 WITH OR WITHOUT ALLOGRAFT CPT 27140 OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER OF FEMUR 2,852 (SEPARATE PROCEDURE) CPT 27146 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; 4,075 CPT 27147 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH OPEN 4,716 REDUCTION OF HIP CPT 27151 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 5,126 OSTEOTOMY CPT 27156 OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 5,534 OSTEOTOMY AND WITH OPEN REDUCTION OF HIP CPT 27158 OSTEOTOMY, PELVIS, BILATERAL (EG, CONGENITAL MALFORMATION) 4,478 CPT 27161 OSTEOTOMY, FEMORAL NECK (SEPARATE PROCEDURE) 3,908 CPT 27165 OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC INCLUDING INTERNAL OR EXTERNAL FIXATION AND/OR CAST CPT 27170 BONE GRAFT, FEMORAL HEAD, NECK, INTERTROCHANTERIC OR SUBTROCHANTERIC AREA (INCLUDES OBTAINING BONE GRAFT) CPT 27175 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY TRACTION, WITHOUT REDUCTION CPT 27176 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE OR MULTIPLE PINNING, IN SITU CPT 27177 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGLE OR MULTIPLE PINNING OR BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT 27178 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: 01.03.2015 Page No(s): 67 of 380

CPT 27179 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOPLASTY OF 3,103 FEMORAL NECK (HEYMAN TYPE PROCEDURE) CPT 27181 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOTOMY AND 3,434 INTERNAL FIXATION CPT 27185 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, GREATER 2,356 TROCHANTER OF FEMUR CPT 27187 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) 3,166 WITH OR WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR CPT 27193 CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 1,456 DIASTASIS OR SUBLUXATION; WITHOUT MANIPULATION CPT 27194 CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, 2,308 DIASTASIS OR SUBLUXATION; WITH MANIPULATION, REQUIRING MORE THAN LOCAL ANESTHESIA CPT 27200 CLOSED TREATMENT OF COCCYGEAL FRACTURE 532 CPT 27202 OPEN TREATMENT OF COCCYGEAL FRACTURE 1,664 CPT 27215 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 27216 PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC RING FRACTURE AND/OR DISLOCATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) CPT 27217 OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR DISLOCATION WITH INTERNAL FIXATION (INCLUDES PUBIC SYMPHYSIS AND/OR RAMI) CPT 27218 OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR DISLOCATION WITH INTERNAL FIXATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) CPT 27220 CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITHOUT MANIPULATION CPT 27222 CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT 27226 OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR WALL FRACTURE, WITH INTERNAL FIXATION CPT 27227 OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR OR POSTERIOR (ONE) COLUMN, OR A FRACTURE RUNNING TRANSVERSELY ACROSS THE ACETABULUM, WITH INTERNAL FIXATION CPT 27228 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 27230 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITHOUT MANIPULATION CPT 27232 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT 27235 PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK CPT 27236 OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT CPT 27238 CLOSED TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITHOUT MANIPULATION CPT 27240 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: 01.03.2015 Page No(s): 68 of 380

CPT 27244 TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR 3,710 SUBTROCHANTERIC FEMORAL FRACTURE; WITH PLATE/SCREW TYPE IMPLANT, WITH OR WITHOUT CERCLAGE CPT 27245 TREATMENT OF INTERTROCHANTERIC, PERITROCHANTERIC, OR 4,526 SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE CPT 27246 CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE, WITHOUT 1,191 MANIPULATION CPT 27248 OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE, INCLUDES 2,371 INTERNAL FIXATION, WHEN PERFORMED CPT 27250 CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; WITHOUT 1,526 ANESTHESIA CPT 27252 CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC; REQUIRING 2,400 ANESTHESIA CPT 27253 OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, WITHOUT INTERNAL 3,005 FIXATION CPT 27254 OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, WITH ACETABULAR 4,093 WALL AND FEMORAL HEAD FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION CPT 27256 TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, 910 INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITHOUT ANESTHESIA, WITHOUT MANIPULATION CPT 27257 TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, 1,079 INCLUDING CONGENITAL OR PATHOLOGICAL), BY ABDUCTION, SPLINT OR TRACTION; WITH MANIPULATION, REQUIRING ANESTHESIA CPT 27258 OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION 3,545 (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUDING TENOTOMY, ETC); CPT 27259 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 27265 CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; 1,220 WITHOUT ANESTHESIA CPT 27266 CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; 1,821 REQUIRING REGIONAL OR GENERAL ANESTHESIA CPT 27267 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 1,343 WITHOUT MANIPULATION CPT 27268 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD; 1,658 WITH MANIPULATION CPT 27269 OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, HEAD, 3,973 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27275 MANIPULATION, HIP JOINT, REQUIRING GENERAL ANESTHESIA 570 CPT 27280 ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING GRAFT) 3,261 CPT 27282 ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING OBTAINING GRAFT) 2,688 CPT 27284 ARTHRODESIS, HIP JOINT (INCLUDING OBTAINING GRAFT); 5,141 CPT 27286 ARTHRODESIS, HIP JOINT (INCLUDING OBTAINING GRAFT); WITH 5,124 SUBTROCHANTERIC OSTEOTOMY CPT 27290 INTERPELVIABDOMINAL AMPUTATION (HINDQUARTER AMPUTATION) 5,025 CPT 27295 DISARTICULATION OF HIP 4,039 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 69 of 380

CPT 27299 UNLISTED PROCEDURE, PELVIS OR HIP JOINT N/A CPT 27301 INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH 2,002 OR KNEE REGION CPT 27303 INCISION, DEEP, WITH OPENING OF BONE CORTEX, FEMUR OR KNEE (EG, 2,006 OSTEOMYELITIS OR BONE ABSCESS) CPT 27305 FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN 1,482 CPT 27306 TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; SINGLE 1,207 TENDON (SEPARATE PROCEDURE) CPT 27307 TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; MULTIPLE 1,478 TENDONS CPT 27310 ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF 2,299 FOREIGN BODY (EG, INFECTION) CPT 27323 BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; SUPERFICIAL 848 CPT 27324 BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; DEEP (SUBFASCIAL OR 1,198 INTRAMUSCULAR) CPT 27325 NEURECTOMY, HAMSTRING MUSCLE 1,657 CPT 27326 NEURECTOMY, POPLITEAL (GASTROCNEMIUS) 1,578 CPT 27327 EXCISION, TUMOR, THIGH OR KNEE AREA; SUBCUTANEOUS 1,409 CPT 27328 EXCISION, TUMOR, THIGH OR KNEE AREA; DEEP, SUBFASCIAL, OR 1,325 INTRAMUSCULAR CPT 27329 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 3,310 TISSUE OF THIGH OR KNEE AREA CPT 27330 ARTHROTOMY, KNEE; WITH SYNOVIAL BIOPSY ONLY 1,276 CPT 27331 ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR 1,478 REMOVAL OF LOOSE OR FOREIGN BODIES CPT 27332 ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE 2,000 (MENISCECTOMY) KNEE; MEDIAL OR LATERAL CPT 27333 ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE 1,810 (MENISCECTOMY) KNEE; MEDIAL AND LATERAL CPT 27334 ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR OR POSTERIOR 2,141 CPT 27335 ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR 2,416 INCLUDING POPLITEAL AREA CPT 27340 EXCISION, PREPATELLAR BURSA 1,131 CPT 27345 EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (EG, BAKER'S CYST) 1,494 CPT 27347 EXCISION OF LESION OF MENISCUS OR CAPSULE (EG, CYST, GANGLION), 1,613 KNEE CPT 27350 PATELLECTOMY OR HEMIPATELLECTOMY 2,039 CPT 27355 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; 1,890 CPT 27356 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH ALLOGRAFT CPT 27357 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 27358 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH INTERNAL FIXATION (LIST IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 2,323 2,575 926 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 70 of 380

CPT 27360 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,672 DIAPHYSECTOMY) BONE, FEMUR, PROXIMAL TIBIA AND/OR FIBULA (EG, OSTEOMYELITIS OR BONE ABSCESS) CPT 27365 RADICAL RESECTION OF TUMOR, BONE, FEMUR OR KNEE 3,920 CPT 27370 INJECTION PROCEDURE FOR KNEE ARTHROGRAPHY 508 CPT 27372 REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA 1,796 CPT 27380 SUTURE OF INFRAPATELLAR TENDON; PRIMARY 1,842 CPT 27381 SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTRUCTION, 2,517 INCLUDING FASCIAL OR TENDON GRAFT CPT 27385 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY 1,972 CPT 27386 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY 2,615 RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT CPT 27390 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE TENDON 1,363 CPT 27391 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE TENDONS, ONE 1,782 LEG CPT 27392 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE TENDONS, 2,234 BILATERAL CPT 27393 LENGTHENING OF HAMSTRING TENDON; SINGLE TENDON 1,580 CPT 27394 LENGTHENING OF HAMSTRING TENDON; MULTIPLE TENDONS, ONE LEG 2,051 CPT 27395 LENGTHENING OF HAMSTRING TENDON; MULTIPLE TENDONS, BILATERAL 2,779 CPT 27396 TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE TENDON 1,914 CPT 27397 TRANSPLANT, HAMSTRING TENDON TO PATELLA; MULTIPLE TENDONS 2,849 CPT 27400 TRANSFER, TENDON OR MUSCLE, HAMSTRINGS TO FEMUR (EG, EGGER'S 2,143 TYPE PROCEDURE) CPT 27403 ARTHROTOMY WITH MENISCUS REPAIR, KNEE 2,011 CPT 27405 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL 2,122 CPT 27407 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; CRUCIATE 2,433 CPT 27409 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL 3,030 AND CRUCIATE LIGAMENTS CPT 27412 AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE 5,355 CPT 27415 OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN 4,523 CPT 27416 OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) 3,110 (INCLUDES HARVESTING OF AUTOGRAFT[S]) CPT 27418 ANTERIOR TIBIAL TUBERCLEPLASTY (EG, MAQUET TYPE PROCEDURE) 2,633 CPT 27420 RECONSTRUCTION OF DISLOCATING PATELLA; (EG, HAUSER TYPE PROCEDURE) CPT 27422 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: 01.03.2015 Page No(s): 71 of 380

CPT 27424 RECONSTRUCTION OF DISLOCATING PATELLA; WITH PATELLECTOMY 2,357 CPT 27425 LATERAL RETINACULAR RELEASE, OPEN 1,369 CPT 27427 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA- 2,265 ARTICULAR CPT 27428 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA- 3,500 ARTICULAR (OPEN) CPT 27429 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA- 3,928 ARTICULAR (OPEN) AND EXTRA-ARTICULAR CPT 27430 QUADRICEPSPLASTY (EG, BENNETT OR THOMPSON TYPE) 2,338 CPT 27435 CAPSULOTOMY, POSTERIOR CAPSULAR RELEASE, KNEE 2,513 CPT 27437 ARTHROPLASTY, PATELLA; WITHOUT PROSTHESIS 2,076 CPT 27438 ARTHROPLASTY, PATELLA; WITH PROSTHESIS 2,672 CPT 27440 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; 2,490 CPT 27441 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH DEBRIDEMENT AND 2,601 PARTIAL SYNOVECTOMY CPT 27442 ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; 2,767 CPT 27443 ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; WITH 2,586 DEBRIDEMENT AND PARTIAL SYNOVECTOMY CPT 27445 ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG, WALLDIUS TYPE) 4,031 CPT 27446 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL 3,569 COMPARTMENT CPT 27447 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL 4,961 COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY) CPT 27448 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITHOUT FIXATION 2,611 CPT 27450 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; WITH FIXATION 3,239 CPT 27454 OSTEOTOMY, MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD, 4,132 FEMORAL SHAFT (EG, SOFIELD TYPE PROCEDURE) CPT 27455 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 27457 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 27465 OSTEOPLASTY, FEMUR; SHORTENING (EXCLUDING 64876) 3,928 CPT 27466 OSTEOPLASTY, FEMUR; LENGTHENING 3,772 CPT 27468 OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING AND SHORTENING WITH FEMORAL SEGMENT TRANSFER CPT 27470 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; WITHOUT GRAFT (EG, COMPRESSION TECHNIQUE) CPT 27472 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: 01.03.2015 Page No(s): 72 of 380

CPT 27475 ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); DISTAL 2,061 FEMUR CPT 27477 ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND 2,312 FIBULA, PROXIMAL CPT 27479 ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); COMBINED 3,106 DISTAL FEMUR, PROXIMAL TIBIA AND FIBULA CPT 27485 ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL TIBIA OR FIBULA 2,110 (EG, GENU VARUS OR VALGUS) CPT 27486 REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT 4,521 ALLOGRAFT; ONE COMPONENT CPT 27487 REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT 5,700 ALLOGRAFT; FEMORAL AND ENTIRE TIBIAL COMPONENT CPT 27488 REMOVAL OF PROSTHESIS, INCLUDING TOTAL KNEE PROSTHESIS, 3,826 METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER, KNEE CPT 27495 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) 3,614 WITH OR WITHOUT METHYLMETHACRYLATE, FEMUR CPT 27496 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 1,589 COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); CPT 27497 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE 1,742 COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 27498 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 1,884 COMPARTMENTS; CPT 27499 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE 2,109 COMPARTMENTS; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 27500 CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITHOUT 1,584 MANIPULATION CPT 27501 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL 1,558 FRACTURE WITH OR WITHOUT INTERCONDYLAR EXTENSION, WITHOUT MANIPULATION CPT 27502 CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH 2,503 MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT 27503 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 27506 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 27507 OPEN TREATMENT OF FEMORAL SHAFT FRACTURE WITH PLATE/SCREWS, 3,140 WITH OR WITHOUT CERCLAGE CPT 27508 CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR 1,603 LATERAL CONDYLE, WITHOUT MANIPULATION CPT 27509 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 27510 CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR 2,200 LATERAL CONDYLE, WITH MANIPULATION CPT 27511 OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR 3,204 FRACTURE WITHOUT INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27513 OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR 4,026 FRACTURE WITH INTERCONDYLAR EXTENSION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27514 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: 01.03.2015 Page No(s): 73 of 380

CPT 27516 CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; 1,507 WITHOUT MANIPULATION CPT 27517 CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; 2,091 WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT 27519 OPEN TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION, 2,902 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27520 CLOSED TREATMENT OF PATELLAR FRACTURE, WITHOUT MANIPULATION 944 CPT 27524 OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION 2,383 AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR CPT 27530 CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 1,188 WITHOUT MANIPULATION CPT 27532 CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITH 1,899 OR WITHOUT MANIPULATION, WITH SKELETAL TRACTION CPT 27535 OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 2,861 UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27536 OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); 3,792 BICONDYLAR, WITH OR WITHOUT INTERNAL FIXATION CPT 27538 CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY 1,422 FRACTURE(S) OF KNEE, WITH OR WITHOUT MANIPULATION CPT 27540 OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY 2,621 FRACTURE(S) OF THE KNEE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27550 CLOSED TREATMENT OF KNEE DISLOCATION; WITHOUT ANESTHESIA 1,486 CPT 27552 CLOSED TREATMENT OF KNEE DISLOCATION; REQUIRING ANESTHESIA 1,949 CPT 27556 OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 2,848 FIXATION, WHEN PERFORMED; WITHOUT PRIMARY LIGAMENTOUS REPAIR OR AUGMENTATION/RECONSTRUCTION CPT 27557 OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 3,422 FIXATION, WHEN PERFORMED; WITH PRIMARY LIGAMENTOUS REPAIR CPT 27558 OPEN TREATMENT OF KNEE DISLOCATION, INCLUDES INTERNAL 3,855 FIXATION, WHEN PERFORMED; WITH PRIMARY LIGAMENTOUS REPAIR, WITH AUGMENTATION/RECONSTRUCTION CPT 27560 CLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 1,073 CPT 27562 CLOSED TREATMENT OF PATELLAR DISLOCATION; REQUIRING 1,436 ANESTHESIA CPT 27566 OPEN TREATMENT OF PATELLAR DISLOCATION, WITH OR WITHOUT 2,845 PARTIAL OR TOTAL PATELLECTOMY CPT 27570 MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES 463 APPLICATION OF TRACTION OR OTHER FIXATION DEVICES) CPT 27580 ARTHRODESIS, KNEE, ANY TECHNIQUE 4,590 CPT 27590 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; 2,658 CPT 27591 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMEDIATE FITTING 2,920 TECHNIQUE INCLUDING FIRST CAST CPT 27592 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN, CIRCULAR 2,235 (GUILLOTINE) CPT 27594 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECONDARY 1,626 CLOSURE OR SCAR REVISION CPT 27596 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; RE-AMPUTATION 2,353 CPT 27598 DISARTICULATION AT KNEE 2,382 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 74 of 380

CPT 27599 UNLISTED PROCEDURE, FEMUR OR KNEE N/A CPT 27600 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL 1,334 COMPARTMENTS ONLY CPT 27601 DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) ONLY 1,374 CPT 27602 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND 1,648 POSTERIOR COMPARTMENT(S) CPT 27603 INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA 1,624 CPT 27604 INCISION AND DRAINAGE, LEG OR ANKLE; INFECTED BURSA 1,471 CPT 27605 TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE 1,064 PROCEDURE); LOCAL ANESTHESIA CPT 27606 TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE 940 PROCEDURE); GENERAL ANESTHESIA CPT 27607 INCISION (EG, OSTEOMYELITIS OR BONE ABSCESS), LEG OR ANKLE 1,953 CPT 27610 ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR 2,079 REMOVAL OF FOREIGN BODY CPT 27612 ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR 1,802 WITHOUT ACHILLES TENDON LENGTHENING CPT 27613 BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; SUPERFICIAL 792 CPT 27614 BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; DEEP (SUBFASCIAL OR 1,793 INTRAMUSCULAR) CPT 27615 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,775 TISSUE OF LEG OR ANKLE AREA CPT 27618 EXCISION, TUMOR, LEG OR ANKLE AREA; SUBCUTANEOUS TISSUE 1,548 CPT 27619 EXCISION, TUMOR, LEG OR ANKLE AREA; DEEP (SUBFASCIAL OR 2,482 INTRAMUSCULAR) CPT 27620 ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT 1,457 BIOPSY, WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY CPT 27625 ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; 1,906 CPT 27626 ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; INCLUDING 2,044 TENOSYNOVECTOMY CPT 27630 EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR 1,709 GANGLION), LEG AND/OR ANKLE CPT 27635 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 1,869 FIBULA; CPT 27637 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 2,358 FIBULA; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 27638 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR 2,488 FIBULA; WITH ALLOGRAFT CPT 27640 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,701 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR EXOSTOSIS); TIBIA CPT 27641 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR 2,175 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR EXOSTOSIS); FIBULA CPT 27645 RADICAL RESECTION OF TUMOR, BONE; TIBIA 3,265 CPT 27646 RADICAL RESECTION OF TUMOR, BONE; FIBULA 2,883 CPT 27647 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: 01.03.2015 Page No(s): 75 of 380

CPT 27648 INJECTION PROCEDURE FOR ANKLE ARTHROGRAPHY 493 CPT 27650 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 2,226 TENDON; CPT 27652 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES 2,366 TENDON; WITH GRAFT (INCLUDES OBTAINING GRAFT) CPT 27654 REPAIR, SECONDARY, ACHILLES TENDON, WITH OR WITHOUT GRAFT 2,251 CPT 27656 REPAIR, FASCIAL DEFECT OF LEG 1,670 CPT 27658 REPAIR, FLEXOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH 1,222 TENDON CPT 27659 REPAIR, FLEXOR TENDON, LEG; SECONDARY, WITH OR WITHOUT GRAFT, 1,606 EACH TENDON CPT 27664 REPAIR, EXTENSOR TENDON, LEG; PRIMARY, WITHOUT GRAFT, EACH 1,168 TENDON CPT 27665 REPAIR, EXTENSOR TENDON, LEG; SECONDARY, WITH OR WITHOUT 1,344 GRAFT, EACH TENDON CPT 27675 REPAIR, DISLOCATING PERONEAL TENDONS; WITHOUT FIBULAR 1,638 OSTEOTOMY CPT 27676 REPAIR, DISLOCATING PERONEAL TENDONS; WITH FIBULAR OSTEOTOMY 1,977 CPT 27680 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; 1,369 SINGLE, EACH TENDON CPT 27681 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; 1,658 MULTIPLE TENDONS (THROUGH SEPARATE INCISION(S)) CPT 27685 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE 2,054 TENDON (SEPARATE PROCEDURE) CPT 27686 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE 1,783 TENDONS (THROUGH SAME INCISION), EACH CPT 27687 GASTROCNEMIUS RECESSION (EG, STRAYER PROCEDURE) 1,481 CPT 27690 TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE 1,971 REDIRECTION OR REROUTING); SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT) CPT 27691 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 27692 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 27695 REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; COLLATERAL 1,574 CPT 27696 REPAIR, PRIMARY, DISRUPTED LIGAMENT, ANKLE; BOTH COLLATERAL 1,888 LIGAMENTS CPT 27698 REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, 2,118 WATSON-JONES PROCEDURE) CPT 27700 ARTHROPLASTY, ANKLE; 2,020 CPT 27702 ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE) 3,185 CPT 27703 ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE 3,693 CPT 27704 REMOVAL OF ANKLE IMPLANT 1,835 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 76 of 380

CPT 27705 OSTEOTOMY; TIBIA 2,455 CPT 27707 OSTEOTOMY; FIBULA 1,248 CPT 27709 OSTEOTOMY; TIBIA AND FIBULA 3,652 CPT 27712 OSTEOTOMY; MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD 3,474 (EG, SOFIELD TYPE PROCEDURE) CPT 27715 OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING OR SHORTENING 3,385 CPT 27720 REPAIR OF NONUNION OR MALUNION, TIBIA; WITHOUT GRAFT, (EG, 2,794 COMPRESSION TECHNIQUE) CPT 27722 REPAIR OF NONUNION OR MALUNION, TIBIA; WITH SLIDING GRAFT 2,801 CPT 27724 REPAIR OF NONUNION OR MALUNION, TIBIA; WITH ILIAC OR OTHER 4,108 AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 27725 REPAIR OF NONUNION OR MALUNION, TIBIA; BY SYNOSTOSIS, WITH 3,833 FIBULA, ANY METHOD CPT 27726 REPAIR OF FIBULA NONUNION AND/OR MALUNION WITH INTERNAL 2,934 FIXATION CPT 27727 REPAIR OF CONGENITAL PSEUDARTHROSIS, TIBIA 3,297 CPT 27730 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL TIBIA 1,841 CPT 27732 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL FIBULA 1,297 CPT 27734 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; DISTAL TIBIA AND FIBULA CPT 27740 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; CPT 27742 ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; AND DISTAL FEMUR CPT 27745 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR WITHOUT METHYLMETHACRYLATE, TIBIA CPT 27750 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITHOUT MANIPULATION CPT 27752 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CPT 27756 PERCUTANEOUS SKELETAL FIXATION OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) (EG, PINS OR SCREWS) CPT 27758 OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE), WITH PLATE/SCREWS, WITH OR WITHOUT CERCLAGE CPT 27759 TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE CPT 27760 CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITHOUT MANIPULATION CPT 27762 CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CPT 27766 OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27767 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITHOUT MANIPULATION CPT 27768 CLOSED TREATMENT OF POSTERIOR MALLEOLUS FRACTURE; WITH MANIPULATION 2,044 2,230 2,125 2,407 1,023 1,650 1,794 2,828 3,193 988 1,467 1,925 808 1,270 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 77 of 380

CPT 27769 OPEN TREATMENT OF POSTERIOR MALLEOLUS FRACTURE, INCLUDES 2,206 INTERNAL FIXATION, WHEN PERFORMED CPT 27780 CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; 881 WITHOUT MANIPULATION CPT 27781 CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE; WITH 1,268 MANIPULATION CPT 27784 OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, INCLUDES 2,214 INTERNAL FIXATION, WHEN PERFORMED CPT 27786 CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 933 MALLEOLUS); WITHOUT MANIPULATION CPT 27788 CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL 1,287 MALLEOLUS); WITH MANIPULATION CPT 27792 OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), 2,225 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27808 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 27810 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 27814 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 27816 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITHOUT 928 MANIPULATION CPT 27818 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH 1,485 MANIPULATION CPT 27822 OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES 2,663 INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP CPT 27823 OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, INCLUDES 3,043 INTERNAL FIXATION, WHEN PERFORMED, MEDIAL AND/OR LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP CPT 27824 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 27825 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 27826 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 27827 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 27828 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 27829 OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) 2,084 DISRUPTION, INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 27830 CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION; 1,067 WITHOUT ANESTHESIA CPT 27831 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: 01.03.2015 Page No(s): 78 of 380

CPT 27832 OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION, 2,249 INCLUDES INTERNAL FIXATION, WHEN PERFORMED, OR WITH EXCISION OF PROXIMAL FIBULA CPT 27840 CLOSED TREATMENT OF ANKLE DISLOCATION; WITHOUT ANESTHESIA 1,102 CPT 27842 CLOSED TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHESIA, 1,534 WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION CPT 27846 OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT 2,346 PERCUTANEOUS SKELETAL FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION CPT 27848 OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT 2,621 PERCUTANEOUS SKELETAL FIXATION; WITH REPAIR OR INTERNAL OR EXTERNAL FIXATION CPT 27860 MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (INCLUDES 558 APPLICATION OF TRACTION OR OTHER FIXATION APPARATUS) CPT 27870 ARTHRODESIS, ANKLE, OPEN 3,355 CPT 27871 ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL 2,209 CPT 27880 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; 2,976 CPT 27881 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; WITH IMMEDIATE 2,855 FITTING TECHNIQUE INCLUDING APPLICATION OF FIRST CAST CPT 27882 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; OPEN, CIRCULAR 1,997 (GUILLOTINE) CPT 27884 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE 1,884 OR SCAR REVISION CPT 27886 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE-AMPUTATION 2,130 CPT 27888 AMPUTATION, ANKLE, THROUGH MALLEOLI OF TIBIA AND FIBULA (EG, 2,234 SYME, PIROGOFF TYPE PROCEDURES), WITH PLASTIC CLOSURE AND RESECTION OF NERVES CPT 27889 ANKLE DISARTICULATION 2,217 CPT 27892 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL 1,764 COMPARTMENTS ONLY, WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 27893 DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) 1,763 ONLY, WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 27894 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND 2,694 POSTERIOR COMPARTMENT(S), WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE CPT 27899 UNLISTED PROCEDURE, LEG OR ANKLE N/A CPT 28001 INCISION AND DRAINAGE, BURSA, FOOT 891 CPT 28002 INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON 1,645 SHEATH INVOLVEMENT, FOOT; SINGLE BURSAL SPACE CPT 28003 INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON 2,246 SHEATH INVOLVEMENT, FOOT; MULTIPLE AREAS CPT 28005 INCISION, BONE CORTEX (EG, OSTEOMYELITIS OR BONE ABSCESS), FOOT 2,012 CPT 28008 FASCIOTOMY, FOOT AND/OR TOE 1,414 CPT 28010 TENOTOMY, PERCUTANEOUS, TOE; SINGLE TENDON 769 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 79 of 380

CPT 28011 TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE TENDONS 1,079 CPT 28020 ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,655 LOOSE OR FOREIGN BODY; INTERTARSAL OR TARSOMETATARSAL JOINT CPT 28022 ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,544 LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT CPT 28024 ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 1,456 LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT CPT 28035 RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL NERVE DECOMPRESSION) 1,651 CPT 28043 EXCISION, TUMOR, FOOT; SUBCUTANEOUS TISSUE 1,110 CPT 28045 EXCISION, TUMOR, FOOT; DEEP, SUBFASCIAL, INTRAMUSCULAR 1,564 CPT 28046 RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT 2,804 TISSUE OF FOOT CPT 28050 ARTHROTOMY WITH BIOPSY; INTERTARSAL OR TARSOMETATARSAL JOINT 1,491 CPT 28052 ARTHROTOMY WITH BIOPSY; METATARSOPHALANGEAL JOINT 1,360 CPT 28054 ARTHROTOMY WITH BIOPSY; INTERPHALANGEAL JOINT 1,283 CPT 28055 NEURECTOMY, INTRINSIC MUSCULATURE OF FOOT 1,306 CPT 28060 FASCIECTOMY, PLANTAR FASCIA; PARTIAL (SEPARATE PROCEDURE) 1,645 CPT 28062 FASCIECTOMY, PLANTAR FASCIA; RADICAL (SEPARATE PROCEDURE) 1,918 CPT 28070 SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT, EACH 1,667 CPT 28072 SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH 1,621 CPT 28080 EXCISION, INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH 1,609 CPT 28086 SYNOVECTOMY, TENDON SHEATH, FOOT; FLEXOR 1,694 CPT 28088 SYNOVECTOMY, TENDON SHEATH, FOOT; EXTENSOR 1,448 CPT 28090 EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT CPT 28092 EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH CPT 28100 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; CPT 28102 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) CPT 28103 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH ALLOGRAFT CPT 28104 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; CPT 28106 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 28107 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: 01.03.2015 Page No(s): 80 of 380

CPT 28108 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, PHALANGES 1,395 OF FOOT CPT 28110 OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD 1,460 (BUNIONETTE) (SEPARATE PROCEDURE) CPT 28111 OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD 1,614 CPT 28112 OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, 1,553 THIRD OR FOURTH) CPT 28113 OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD 1,872 CPT 28114 OSTECTOMY, COMPLETE EXCISION; ALL METATARSAL HEADS, WITH 3,326 PARTIAL PROXIMAL PHALANGECTOMY, EXCLUDING FIRST METATARSAL (EG, CLAYTON TYPE PROCEDURE) CPT 28116 OSTECTOMY, EXCISION OF TARSAL COALITION 2,444 CPT 28118 OSTECTOMY, CALCANEUS; 1,861 CPT 28119 OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR WITHOUT PLANTAR 1,682 FASCIAL RELEASE CPT 28120 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 1,825 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS CPT 28122 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 2,141 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS CPT 28124 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, 1,543 SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE CPT 28126 RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, EACH TOE 1,254 CPT 28130 TALECTOMY (ASTRAGALECTOMY) 2,104 CPT 28140 METATARSECTOMY 1,984 CPT 28150 PHALANGECTOMY, TOE, EACH TOE 1,388 CPT 28153 RESECTION, CONDYLE(S), DISTAL END OF PHALANX, EACH TOE 1,307 CPT 28160 HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, TOE, 1,332 PROXIMAL END OF PHALANX, EACH CPT 28171 RADICAL RESECTION OF TUMOR, BONE; TARSAL (EXCEPT TALUS OR 2,069 CALCANEUS) CPT 28173 RADICAL RESECTION OF TUMOR, BONE; METATARSAL 2,380 CPT 28175 RADICAL RESECTION OF TUMOR, BONE; PHALANX OF TOE 1,767 CPT 28190 REMOVAL OF FOREIGN BODY, FOOT; SUBCUTANEOUS 781 CPT 28192 REMOVAL OF FOREIGN BODY, FOOT; DEEP 1,512 CPT 28193 REMOVAL OF FOREIGN BODY, FOOT; COMPLICATED 1,744 CPT 28200 REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH TENDON CPT 28202 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: 01.03.2015 Page No(s): 81 of 380

CPT 28208 REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY OR SECONDARY, EACH 1,472 TENDON CPT 28210 REPAIR, TENDON, EXTENSOR, FOOT; SECONDARY WITH FREE GRAFT, 1,869 EACH TENDON (INCLUDES OBTAINING GRAFT) CPT 28220 TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON 1,456 CPT 28222 TENOLYSIS, FLEXOR, FOOT; MULTIPLE TENDONS 1,672 CPT 28225 TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON 1,281 CPT 28226 TENOLYSIS, EXTENSOR, FOOT; MULTIPLE TENDONS 1,516 CPT 28230 TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE 1,397 TENDON(S) (SEPARATE PROCEDURE) CPT 28232 TENOTOMY, OPEN, TENDON FLEXOR; TOE, SINGLE TENDON (SEPARATE 1,234 PROCEDURE) CPT 28234 TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, EACH TENDON 1,280 CPT 28238 RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH 2,177 EXCISION OF ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE) CPT 28240 TENOTOMY, LENGTHENING, OR RELEASE, ABDUCTOR HALLUCIS MUSCLE 1,427 CPT 28250 DIVISION OF PLANTAR FASCIA AND MUSCLE (EG, STEINDLER STRIPPING) 1,806 (SEPARATE PROCEDURE) CPT 28260 CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY (SEPARATE 2,224 PROCEDURE) CPT 28261 CAPSULOTOMY, MIDFOOT; WITH TENDON LENGTHENING 3,166 CPT 28262 CAPSULOTOMY, MIDFOOT; EXTENSIVE, INCLUDING POSTERIOR 4,424 TALOTIBIAL CAPSULOTOMY AND TENDON(S) LENGTHENING (EG, RESISTANT CLUBFOOT DEFORMITY) CPT 28264 CAPSULOTOMY, MIDTARSAL (EG, HEYMAN TYPE PROCEDURE) 2,818 CPT 28270 CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE) CPT 28272 CAPSULOTOMY; INTERPHALANGEAL JOINT, EACH JOINT (SEPARATE PROCEDURE) CPT 28280 SYNDACTYLIZATION, TOES (EG, WEBBING OR KELIKIAN TYPE PROCEDURE) CPT 28285 CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR TOTAL PHALANGECTOMY) CPT 28286 CORRECTION, COCK-UP FIFTH TOE, WITH PLASTIC SKIN CLOSURE (EG, RUIZ-MORA TYPE PROCEDURE) CPT 28288 OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD CPT 28289 HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT CPT 28290 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; SIMPLE EXOSTECTOMY (EG, SILVER TYPE PROCEDURE) CPT 28292 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; KELLER, MCBRIDE, OR MAYO TYPE PROCEDURE CPT 28293 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; RESECTION OF JOINT WITH IMPLANT CPT 28294 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: 01.03.2015 Page No(s): 82 of 380

PROCEDURE) CPT 28296 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,527 SESAMOIDECTOMY; WITH METATARSAL OSTEOTOMY (EG, MITCHELL, CHEVRON, OR CONCENTRIC TYPE PROCEDURES) CPT 28297 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,655 SESAMOIDECTOMY; LAPIDUS-TYPE PROCEDURE CPT 28298 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,310 SESAMOIDECTOMY; BY PHALANX OSTEOTOMY CPT 28299 CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT 2,934 SESAMOIDECTOMY; BY DOUBLE OSTEOTOMY CPT 28300 OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), 2,163 WITH OR WITHOUT INTERNAL FIXATION CPT 28302 OSTEOTOMY; TALUS 2,171 CPT 28304 OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS; 2,532 CPT 28305 OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS; WITH 2,226 AUTOGRAFT (INCLUDES OBTAINING GRAFT) (EG, FOWLER TYPE) CPT 28306 OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 1,909 ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL CPT 28307 OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 2,085 ANGULAR CORRECTION, METATARSAL; FIRST METATARSAL WITH AUTOGRAFT (OTHER THAN FIRST TOE) CPT 28308 OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 1,759 ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH CPT 28309 OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR 2,983 ANGULAR CORRECTION, METATARSAL; MULTIPLE (EG, SWANSON TYPE CAVUS FOOT PROCEDURE) CPT 28310 OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; 1,728 PROXIMAL PHALANX, FIRST TOE (SEPARATE PROCEDURE) CPT 28312 OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; 1,587 OTHER PHALANGES, ANY TOE CPT 28313 RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE 1,643 PROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES) CPT 28315 SESAMOIDECTOMY, FIRST TOE (SEPARATE PROCEDURE) 1,538 CPT 28320 REPAIR, NONUNION OR MALUNION; TARSAL BONES 2,060 CPT 28322 REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT 2,445 BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT 28340 RECONSTRUCTION, TOE, MACRODACTYLY; SOFT TISSUE RESECTION 2,011 CPT 28341 RECONSTRUCTION, TOE, MACRODACTYLY; REQUIRING BONE RESECTION 2,292 CPT 28344 RECONSTRUCTION, TOE(S); POLYDACTYLY 1,414 CPT 28345 RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH OR WITHOUT SKIN 1,812 GRAFT(S), EACH WEB CPT 28360 RECONSTRUCTION, CLEFT FOOT 2,934 CPT 28400 CLOSED TREATMENT OF CALCANEAL FRACTURE; WITHOUT MANIPULATION 747 CPT 28405 CLOSED TREATMENT OF CALCANEAL FRACTURE; WITH MANIPULATION 1,232 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 83 of 380

CPT 28406 PERCUTANEOUS SKELETAL FIXATION OF CALCANEAL FRACTURE, WITH 1,650 MANIPULATION CPT 28415 OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL 3,635 FIXATION, WHEN PERFORMED; CPT 28420 OPEN TREATMENT OF CALCANEAL FRACTURE, INCLUDES INTERNAL 3,823 FIXATION, WHEN PERFORMED; WITH PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) CPT 28430 CLOSED TREATMENT OF TALUS FRACTURE; WITHOUT MANIPULATION 701 CPT 28435 CLOSED TREATMENT OF TALUS FRACTURE; WITH MANIPULATION 1,005 CPT 28436 PERCUTANEOUS SKELETAL FIXATION OF TALUS FRACTURE, WITH 1,301 MANIPULATION CPT 28445 OPEN TREATMENT OF TALUS FRACTURE, INCLUDES INTERNAL FIXATION, 3,475 WHEN PERFORMED CPT 28446 OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING 3,815 GRAFT[S]) CPT 28450 TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 648 CALCANEUS); WITHOUT MANIPULATION, EACH CPT 28455 TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 922 CALCANEUS); WITH MANIPULATION, EACH CPT 28456 PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE FRACTURE 871 (EXCEPT TALUS AND CALCANEUS), WITH MANIPULATION, EACH CPT 28465 OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 1,990 CALCANEUS), INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT 28470 CLOSED TREATMENT OF METATARSAL FRACTURE; WITHOUT 640 MANIPULATION, EACH CPT 28475 CLOSED TREATMENT OF METATARSAL FRACTURE; WITH MANIPULATION, 823 EACH CPT 28476 PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH 1,048 MANIPULATION, EACH CPT 28485 OPEN TREATMENT OF METATARSAL FRACTURE, INCLUDES INTERNAL 1,720 FIXATION, WHEN PERFORMED, EACH CPT 28490 CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; 421 WITHOUT MANIPULATION CPT 28495 CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; 538 WITH MANIPULATION CPT 28496 PERCUTANEOUS SKELETAL FIXATION OF FRACTURE GREAT TOE, PHALANX 1,280 OR PHALANGES, WITH MANIPULATION CPT 28505 OPEN TREATMENT OF FRACTURE, GREAT TOE, PHALANX OR PHALANGES, 2,051 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 28510 CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER 371 THAN GREAT TOE; WITHOUT MANIPULATION, EACH CPT 28515 CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER 490 THAN GREAT TOE; WITH MANIPULATION, EACH CPT 28525 OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN 1,770 GREAT TOE, INCLUDES INTERNAL FIXATION, WHEN PERFORMED, EACH CPT 28530 CLOSED TREATMENT OF SESAMOID FRACTURE 357 CPT 28531 OPEN TREATMENT OF SESAMOID FRACTURE, WITH OR WITHOUT INTERNAL FIXATION CPT 28540 CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; WITHOUT ANESTHESIA CPT 28545 CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; REQUIRING ANESTHESIA CPT 28546 PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL, WITH MANIPULATION 1,183 643 794 1,492 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 84 of 380

CPT 28555 OPEN TREATMENT OF TARSAL BONE DISLOCATION, INCLUDES INTERNAL 2,686 FIXATION, WHEN PERFORMED CPT 28570 CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; WITHOUT 556 ANESTHESIA CPT 28575 CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION; REQUIRING 1,052 ANESTHESIA CPT 28576 PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT 1,161 DISLOCATION, WITH MANIPULATION CPT 28585 OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, INCLUDES 2,988 INTERNAL FIXATION, WHEN PERFORMED CPT 28600 CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION; 659 WITHOUT ANESTHESIA CPT 28605 CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION; 889 REQUIRING ANESTHESIA CPT 28606 PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT 1,247 DISLOCATION, WITH MANIPULATION CPT 28615 OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, INCLUDES 2,504 INTERNAL FIXATION, WHEN PERFORMED CPT 28630 CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; 474 WITHOUT ANESTHESIA CPT 28635 CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; 561 REQUIRING ANESTHESIA CPT 28636 PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT 955 DISLOCATION, WITH MANIPULATION CPT 28645 OPEN TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION, 2,037 INCLUDES INTERNAL FIXATION, WHEN PERFORMED CPT 28660 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; 337 WITHOUT ANESTHESIA CPT 28665 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION; 505 REQUIRING ANESTHESIA CPT 28666 PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT 619 DISLOCATION, WITH MANIPULATION CPT 28675 OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, INCLUDES 1,781 INTERNAL FIXATION, WHEN PERFORMED CPT 28705 ARTHRODESIS; PANTALAR 4,263 CPT 28715 ARTHRODESIS; TRIPLE 3,154 CPT 28725 ARTHRODESIS; SUBTALAR 2,600 CPT 28730 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 2,728 TRANSVERSE; CPT 28735 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 2,604 TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION) CPT 28737 ARTHRODESIS, WITH TENDON LENGTHENING AND ADVANCEMENT, 2,312 MIDTARSAL, TARSAL NAVICULAR-CUNEIFORM (EG, MILLER TYPE PROCEDURE) CPT 28740 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT 2,665 CPT 28750 ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT 2,551 CPT 28755 ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT 1,598 CPT 28760 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: 01.03.2015 Page No(s): 85 of 380

CPT 28800 AMPUTATION, FOOT; MIDTARSAL (EG, CHOPART TYPE PROCEDURE) 1,864 CPT 28805 AMPUTATION, FOOT; TRANSMETATARSAL 2,470 CPT 28810 AMPUTATION, METATARSAL, WITH TOE, SINGLE 1,439 CPT 28820 AMPUTATION, TOE; METATARSOPHALANGEAL JOINT 1,655 CPT 28825 AMPUTATION, TOE; INTERPHALANGEAL JOINT 1,427 CPT 28890 EXTRACORPOREAL SHOCK WAVE, HIGH ENERGY, PERFORMED BY A 1,049 PHYSICIAN, REQUIRING ANESTHESIA OTHER THAN LOCAL, INCLUDING ULTRASOUND GUIDANCE, INVOLVING THE PLANTAR FASCIA CPT 28899 UNLISTED PROCEDURE, FOOT OR TOES N/A CPT 29000 APPLICATION OF HALO TYPE BODY CAST (SEE 20661-20663 FOR 839 INSERTION) CPT 29010 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; ONLY 867 CPT 29015 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; INCLUDING HEAD 792 CPT 29020 APPLICATION OF TURNBUCKLE JACKET, BODY; ONLY 780 CPT 29025 APPLICATION OF TURNBUCKLE JACKET, BODY; INCLUDING HEAD 865 CPT 29035 APPLICATION OF BODY CAST, SHOULDER TO HIPS; 723 CPT 29040 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING HEAD, 737 MINERVA TYPE CPT 29044 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING ONE 761 THIGH CPT 29046 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING BOTH 921 THIGHS CPT 29049 APPLICATION, CAST; FIGURE-OF-EIGHT 269 CPT 29055 APPLICATION, CAST; SHOULDER SPICA 616 CPT 29058 APPLICATION, CAST; PLASTER VELPEAU 344 CPT 29065 APPLICATION, CAST; SHOULDER TO HAND (LONG ARM) 289 CPT 29075 APPLICATION, CAST; ELBOW TO FINGER (SHORT ARM) 269 CPT 29085 APPLICATION, CAST; HAND AND LOWER FOREARM (GAUNTLET) 285 CPT 29086 APPLICATION, CAST; FINGER (EG, CONTRACTURE) 222 CPT 29105 APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 261 CPT 29125 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 205 CPT 29126 APPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); DYNAMIC 232 CPT 29130 APPLICATION OF FINGER SPLINT; STATIC 124 CPT 29131 APPLICATION OF FINGER SPLINT; DYNAMIC 147 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 86 of 380

CPT 29200 STRAPPING; THORAX 163 CPT 29220 STRAPPING; LOW BACK 167 CPT 29240 STRAPPING; SHOULDER (EG, VELPEAU) 182 CPT 29260 STRAPPING; ELBOW OR WRIST 159 CPT 29280 STRAPPING; HAND OR FINGER 152 CPT 29305 APPLICATION OF HIP SPICA CAST; ONE LEG 713 CPT 29325 APPLICATION OF HIP SPICA CAST; ONE AND ONE-HALF SPICA OR BOTH 761 LEGS CPT 29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES); 415 CPT 29355 APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR 429 AMBULATORY TYPE CPT 29358 APPLICATION OF LONG LEG CAST BRACE 464 CPT 29365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) 372 CPT 29405 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); 276 CPT 29425 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR 299 AMBULATORY TYPE CPT 29435 APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST 366 CPT 29440 ADDING WALKER TO PREVIOUSLY APPLIED CAST 162 CPT 29445 APPLICATION OF RIGID TOTAL CONTACT LEG CAST 454 CPT 29450 APPLICATION OF CLUBFOOT CAST WITH MOLDING OR MANIPULATION, 495 LONG OR SHORT LEG CPT 29505 APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 231 CPT 29515 APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 224 CPT 29520 STRAPPING; HIP 154 CPT 29530 STRAPPING; KNEE 161 CPT 29540 STRAPPING; ANKLE AND/OR FOOT 140 CPT 29550 STRAPPING; TOES 137 CPT 29580 STRAPPING; UNNA BOOT 167 CPT 29590 DENIS-BROWNE SPLINT STRAPPING 181 CPT 29700 REMOVAL OR BIVALVING; GAUNTLET, BOOT OR BODY CAST 201 CPT 29705 REMOVAL OR BIVALVING; FULL ARM OR FULL LEG CAST 207 CPT 29710 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: 01.03.2015 Page No(s): 87 of 380

CPT 29715 REMOVAL OR BIVALVING; TURNBUCKLE JACKET 280 CPT 29720 REPAIR OF SPICA, BODY CAST OR JACKET 247 CPT 29730 WINDOWING OF CAST 202 CPT 29740 WEDGING OF CAST (EXCEPT CLUBFOOT CASTS) 293 CPT 29750 WEDGING OF CLUBFOOT CAST 319 CPT 29799 UNLISTED PROCEDURE, CASTING OR STRAPPING N/A CPT 29800 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR 1,554 WITHOUT SYNOVIAL BIOPSY (SEPARATE PROCEDURE) CPT 29804 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL 1,987 CPT 29805 ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,468 BIOPSY (SEPARATE PROCEDURE) CPT 29806 ARTHROSCOPY, SHOULDER, SURGICAL; CAPSULORRHAPHY 3,374 CPT 29807 ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR OF SLAP LESION 3,285 CPT 29819 ARTHROSCOPY, SHOULDER, SURGICAL; WITH REMOVAL OF LOOSE BODY 1,841 OR FOREIGN BODY CPT 29820 ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL 1,701 CPT 29821 ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, COMPLETE 1,859 CPT 29822 ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED 1,806 CPT 29823 ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE 1,976 CPT 29824 ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY 2,112 INCLUDING DISTAL ARTICULAR SURFACE (MUMFORD PROCEDURE) CPT 29825 ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF 1,842 ADHESIONS, WITH OR WITHOUT MANIPULATION CPT 29826 ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF 2,112 SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITH OR WITHOUT CORACOACROMIAL RELEASE CPT 29827 ARTHROSCOPY, SHOULDER, SURGICAL; WITH ROTATOR CUFF REPAIR 3,452 CPT 29828 ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS TENODESIS 2,939 CPT 29830 ARTHROSCOPY, ELBOW, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,419 BIOPSY (SEPARATE PROCEDURE) CPT 29834 ARTHROSCOPY, ELBOW, SURGICAL; WITH REMOVAL OF LOOSE BODY OR 1,544 FOREIGN BODY CPT 29835 ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, PARTIAL 1,589 CPT 29836 ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, COMPLETE 1,808 CPT 29837 ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, LIMITED 1,658 CPT 29838 ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE 1,854 CPT 29840 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: 01.03.2015 Page No(s): 88 of 380

CPT 29843 ARTHROSCOPY, WRIST, SURGICAL; FOR INFECTION, LAVAGE AND 1,484 DRAINAGE CPT 29844 ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, PARTIAL 1,553 CPT 29845 ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE 1,783 CPT 29846 ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF 1,633 TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT CPT 29847 ARTHROSCOPY, WRIST, SURGICAL; INTERNAL FIXATION FOR FRACTURE 1,697 OR INSTABILITY CPT 29848 ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE OF TRANSVERSE CARPAL 1,558 LIGAMENT CPT 29850 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 29851 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 29855 ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL 2,483 (PLATEAU); UNICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY) CPT 29856 ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL 3,174 (PLATEAU); BICONDYLAR, INCLUDES INTERNAL FIXATION, WHEN PERFORMED (INCLUDES ARTHROSCOPY) CPT 29860 ARTHROSCOPY, HIP, DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY 2,071 (SEPARATE PROCEDURE) CPT 29861 ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL OF LOOSE BODY OR 2,258 FOREIGN BODY CPT 29862 ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDEMENT/SHAVING OF 2,537 ARTICULAR CARTILAGE (CHONDROPLASTY), ABRASION ARTHROPLASTY, AND/OR RESECTION OF LABRUM CPT 29863 ARTHROSCOPY, HIP, SURGICAL; WITH SYNOVECTOMY 2,502 CPT 29866 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, 3,316 MOSAICPLASTY) (INCLUDES HARVESTING OF THE AUTOGRAFT[S]) CPT 29867 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, 4,029 MOSAICPLASTY) CPT 29868 ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION 5,418 (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR LATERAL CPT 29870 ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 1,276 BIOPSY (SEPARATE PROCEDURE) CPT 29871 ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND 1,611 DRAINAGE CPT 29873 ARTHROSCOPY, KNEE, SURGICAL; WITH LATERAL RELEASE 1,602 CPT 29874 ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION) CPT 29875 ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF RESECTION) (SEPARATE PROCEDURE) CPT 29876 ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL) CPT 29877 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: 01.03.2015 Page No(s): 89 of 380

CPT 29879 ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES 2,071 CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE CPT 29880 ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND 2,164 LATERAL, INCLUDING ANY MENISCAL SHAVING) CPT 29881 ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR 2,018 LATERAL, INCLUDING ANY MENISCAL SHAVING) CPT 29882 ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL OR 2,191 LATERAL) CPT 29883 ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCUS REPAIR (MEDIAL AND 2,659 LATERAL) CPT 29884 ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR 1,933 WITHOUT MANIPULATION (SEPARATE PROCEDURE) CPT 29885 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR OSTEOCHONDRITIS 2,346 DISSECANS WITH BONE GRAFTING, WITH OR WITHOUT INTERNAL FIXATION (INCLUDING DEBRIDEMENT OF BASE OF LESION) CPT 29886 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT 1,973 OSTEOCHONDRITIS DISSECANS LESION CPT 29887 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT 2,331 OSTEOCHONDRITIS DISSECANS LESION WITH INTERNAL FIXATION CPT 29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT 3,125 REPAIR/AUGMENTATION OR RECONSTRUCTION CPT 29889 ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT 3,846 REPAIR/AUGMENTATION OR RECONSTRUCTION CPT 29891 ARTHROSCOPY, ANKLE, SURGICAL, EXCISION OF OSTEOCHONDRAL 2,203 DEFECT OF TALUS AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT CPT 29892 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 29893 ENDOSCOPIC PLANTAR FASCIOTOMY 1,957 CPT 29894 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,652 SURGICAL; WITH REMOVAL OF LOOSE BODY OR FOREIGN BODY CPT 29895 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,594 SURGICAL; SYNOVECTOMY, PARTIAL CPT 29897 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,664 SURGICAL; DEBRIDEMENT, LIMITED CPT 29898 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 1,875 SURGICAL; DEBRIDEMENT, EXTENSIVE CPT 29899 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 3,377 SURGICAL; WITH ANKLE ARTHRODESIS CPT 29900 ARTHROSCOPY, METACARPOPHALANGEAL JOINT, DIAGNOSTIC, INCLUDES 1,428 SYNOVIAL BIOPSY CPT 29901 ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 1,587 DEBRIDEMENT CPT 29902 ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH 1,617 REDUCTION OF DISPLACED ULNAR COLLATERAL LIGAMENT (EG, STENAR LESION) CPT 29904 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH REMOVAL OF LOOSE 1,968 BODY OR FOREIGN BODY CPT 29905 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SYNOVECTOMY 2,119 CPT 29906 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH DEBRIDEMENT 2,232 CPT 29907 ARTHROSCOPY, SUBTALAR JOINT, SURGICAL; WITH SUBTALAR ARTHRODESIS 2,740 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 90 of 380

CPT 29999 UNLISTED PROCEDURE, ARTHROSCOPY N/A CPT 30000 DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPROACH 703 CPT 30020 DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM 722 CPT 30100 BIOPSY, INTRANASAL 451 CPT 30110 EXCISION, NASAL POLYP(S), SIMPLE 716 CPT 30115 EXCISION, NASAL POLYP(S), EXTENSIVE 1,356 CPT 30117 EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; 2,722 INTERNAL APPROACH CPT 30118 EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; 2,410 EXTERNAL APPROACH (LATERAL RHINOTOMY) CPT 30120 EXCISION OR SURGICAL PLANING OF SKIN OF NOSE FOR RHINOPHYMA 1,624 CPT 30124 EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, SUBCUTANEOUS 889 CPT 30125 EXCISION DERMOID CYST, NOSE; COMPLEX, UNDER BONE OR CARTILAGE 1,919 CPT 30130 EXCISION INFERIOR TURBINATE, PARTIAL OR COMPLETE, ANY METHOD 1,178 CPT 30140 SUBMUCOUS RESECTION INFERIOR TURBINATE, PARTIAL OR COMPLETE, 1,377 ANY METHOD CPT 30150 RHINECTOMY; PARTIAL 2,443 CPT 30160 RHINECTOMY; TOTAL 2,472 CPT 30200 INJECTION INTO TURBINATE(S), THERAPEUTIC 359 CPT 30210 DISPLACEMENT THERAPY (PROETZ TYPE) 465 CPT 30220 INSERTION, NASAL SEPTAL PROSTHESIS (BUTTON) 944 CPT 30300 REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE 684 CPT 30310 REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERAL 635 ANESTHESIA CPT 30320 REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINOTOMY 1,423 CPT 30400 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR 3,214 ELEVATION OF NASAL TIP CPT 30410 RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY 3,836 PYRAMID, LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP CPT 30420 RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR 4,269 CPT 30430 RHINOPLASTY, SECONDARY; MINOR REVISION (SMALL AMOUNT OF NASAL TIP WORK) CPT 30435 RHINOPLASTY, SECONDARY; INTERMEDIATE REVISION (BONY WORK WITH OSTEOTOMIES) CPT 30450 RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES) CPT 30460 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: 01.03.2015 Page No(s): 91 of 380

ONLY CPT 30462 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL 4,697 CLEFT LIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OSTEOTOMIES CPT 30465 REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, 3,063 LATERAL NASAL WALL RECONSTRUCTION) CPT 30520 SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT 1,933 CARTILAGE SCORING, CONTOURING OR REPLACEMENT WITH GRAFT CPT 30540 REPAIR CHOANAL ATRESIA; INTRANASAL 2,143 CPT 30545 REPAIR CHOANAL ATRESIA; TRANSPALATINE 3,058 CPT 30560 LYSIS INTRANASAL SYNECHIA 838 CPT 30580 REPAIR FISTULA; OROMAXILLARY (COMBINE WITH 31030 IF ANTROTOMY 1,987 IS INCLUDED) CPT 30600 REPAIR FISTULA; ORONASAL 1,818 CPT 30620 SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT INCLUDE 1,923 OBTAINING GRAFT) CPT 30630 REPAIR NASAL SEPTAL PERFORATIONS 1,953 CPT 30801 CAUTERY AND/OR ABLATION, MUCOSA OF INFERIOR TURBINATES, 692 UNILATERAL OR BILATERAL, ANY METHOD; SUPERFICIAL CPT 30802 CAUTERY AND/OR ABLATION, MUCOSA OF INFERIOR TURBINATES, 905 UNILATERAL OR BILATERAL, ANY METHOD; INTRAMURAL CPT 30901 CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY 326 AND/OR PACKING) ANY METHOD CPT 30903 CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE 623 CAUTERY AND/OR PACKING) ANY METHOD CPT 30905 CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL 765 PACKS AND/OR CAUTERY, ANY METHOD; INITIAL CPT 30906 CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL 873 PACKS AND/OR CAUTERY, ANY METHOD; SUBSEQUENT CPT 30915 LIGATION ARTERIES; ETHMOIDAL 1,812 CPT 30920 LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRANSANTRAL 2,618 CPT 30930 FRACTURE NASAL INFERIOR TURBINATE(S), THERAPEUTIC 382 CPT 30999 UNLISTED PROCEDURE, NOSE N/A CPT 31000 LAVAGE BY CANNULATION; MAXILLARY SINUS (ANTRUM PUNCTURE OR 563 NATURAL OSTIUM) CPT 31002 LAVAGE BY CANNULATION; SPHENOID SINUS 600 CPT 31020 SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL 1,496 CPT 31030 SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) 2,134 WITHOUT REMOVAL OF ANTROCHOANAL POLYPS CPT 31032 SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) 1,787 WITH REMOVAL OF ANTROCHOANAL POLYPS CPT 31040 PTERYGOMAXILLARY FOSSA SURGERY, ANY APPROACH 2,254 CPT 31050 SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; 1,549 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 92 of 380

CPT 31051 SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; WITH MUCOSAL 2,032 STRIPPING OR REMOVAL OF POLYP(S) CPT 31070 SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE (TREPHINE OPERATION) 1,370 CPT 31075 SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL (FOR MUCOCELE OR 2,451 OSTEOMA, LYNCH TYPE) CPT 31080 SINUSOTOMY FRONTAL; OBLITERATIVE WITHOUT OSTEOPLASTIC FLAP, 3,071 BROW INCISION (INCLUDES ABLATION) CPT 31081 SINUSOTOMY FRONTAL; OBLITERATIVE, WITHOUT OSTEOPLASTIC FLAP, 4,007 CORONAL INCISION (INCLUDES ABLATION) CPT 31084 SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTIC FLAP, BROW 3,627 INCISION CPT 31085 SINUSOTOMY FRONTAL; OBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,978 CORONAL INCISION CPT 31086 SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,526 BROW INCISION CPT 31087 SINUSOTOMY FRONTAL; NONOBLITERATIVE, WITH OSTEOPLASTIC FLAP, 3,458 CORONAL INCISION CPT 31090 SINUSOTOMY, UNILATERAL, THREE OR MORE PARANASAL SINUSES 3,175 (FRONTAL, MAXILLARY, ETHMOID, SPHENOID) CPT 31200 ETHMOIDECTOMY; INTRANASAL, ANTERIOR 1,606 CPT 31201 ETHMOIDECTOMY; INTRANASAL, TOTAL 2,304 CPT 31205 ETHMOIDECTOMY; EXTRANASAL, TOTAL 2,600 CPT 31225 MAXILLECTOMY; WITHOUT ORBITAL EXENTERATION 5,781 CPT 31230 MAXILLECTOMY; WITH ORBITAL EXENTERATION (EN BLOC) 6,525 CPT 31231 NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL (SEPARATE 602 PROCEDURE) CPT 31233 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY SINUSOSCOPY 837 (VIA INFERIOR MEATUS OR CANINE FOSSA PUNCTURE) CPT 31235 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SINUSOSCOPY 950 (VIA PUNCTURE OF SPHENOIDAL FACE OR CANNULATION OF OSTIUM) CPT 31237 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR 1,027 DEBRIDEMENT (SEPARATE PROCEDURE) CPT 31238 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONTROL OF NASAL 1,052 HEMORRHAGE CPT 31239 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DACRYOCYSTORHINOSTOMY 2,049 CPT 31240 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH CONCHA BULLOSA 518 RESECTION CPT 31254 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, PARTIAL 884 (ANTERIOR) CPT 31255 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL 1,305 (ANTERIOR AND POSTERIOR) CPT 31256 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; 643 CPT 31267 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; 1,032 WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS CPT 31276 NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS 1,645 EXPLORATION, WITH OR WITHOUT REMOVAL OF TISSUE FROM FRONTAL SINUS CPT 31287 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; 753 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 93 of 380

CPT 31288 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH 873 REMOVAL OF TISSUE FROM THE SPHENOID SINUS CPT 31290 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL 3,643 FLUID LEAK; ETHMOID REGION CPT 31291 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL 3,861 FLUID LEAK; SPHENOID REGION CPT 31292 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL OR INFERIOR 3,154 ORBITAL WALL DECOMPRESSION CPT 31293 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL ORBITAL WALL AND 3,440 INFERIOR ORBITAL WALL DECOMPRESSION CPT 31294 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH OPTIC NERVE 3,952 DECOMPRESSION CPT 31299 UNLISTED PROCEDURE, ACCESSORY SINUSES N/A CPT 31300 LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMOVAL OF 3,961 TUMOR OR LARYNGOCELE, CORDECTOMY CPT 31320 LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); DIAGNOSTIC 2,042 CPT 31360 LARYNGECTOMY; TOTAL, WITHOUT RADICAL NECK DISSECTION 6,423 CPT 31365 LARYNGECTOMY; TOTAL, WITH RADICAL NECK DISSECTION 7,986 CPT 31367 LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITHOUT RADICAL NECK 6,864 DISSECTION CPT 31368 LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, WITH RADICAL NECK 7,636 DISSECTION CPT 31370 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTAL 6,436 CPT 31375 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVERTICAL 6,107 CPT 31380 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVERTICAL 6,010 CPT 31382 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO-LATERO- 6,623 VERTICAL CPT 31390 PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION; WITHOUT 8,861 RECONSTRUCTION CPT 31395 PHARYNGOLARYNGECTOMY, WITH RADICAL NECK DISSECTION; WITH 9,374 RECONSTRUCTION CPT 31400 ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROACH 3,122 CPT 31420 EPIGLOTTIDECTOMY 2,610 CPT 31500 INTUBATION, ENDOTRACHEAL, EMERGENCY PROCEDURE 367 CPT 31502 TRACHEOTOMY TUBE CHANGE PRIOR TO ESTABLISHMENT OF FISTULA 114 TRACT CPT 31505 LARYNGOSCOPY, INDIRECT; DIAGNOSTIC (SEPARATE PROCEDURE) 263 CPT 31510 LARYNGOSCOPY, INDIRECT; WITH BIOPSY 668 CPT 31511 LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF FOREIGN BODY 665 CPT 31512 LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF LESION 657 CPT 31513 LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD INJECTION 422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 94 of 380

CPT 31515 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; FOR 646 ASPIRATION CPT 31520 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 499 DIAGNOSTIC, NEWBORN CPT 31525 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 791 DIAGNOSTIC, EXCEPT NEWBORN CPT 31526 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; 507 DIAGNOSTIC, WITH OPERATING MICROSCOPE OR TELESCOPE CPT 31527 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 620 INSERTION OF OBTURATOR CPT 31528 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 459 DILATION, INITIAL CPT 31529 LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH 522 DILATION, SUBSEQUENT CPT 31530 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; 644 CPT 31531 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; 687 WITH OPERATING MICROSCOPE OR TELESCOPE CPT 31535 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; 611 CPT 31536 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH BIOPSY; WITH OPERATING 680 MICROSCOPE OR TELESCOPE CPT 31540 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR 781 STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; CPT 31541 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR 853 STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE OR TELESCOPE CPT 31545 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 31546 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 31560 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY; 1,011 CPT 31561 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY; WITH 1,107 OPERATING MICROSCOPE OR TELESCOPE CPT 31570 LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 1,061 THERAPEUTIC; CPT 31571 LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), 808 THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE CPT 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC 363 CPT 31576 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH BIOPSY 708 CPT 31577 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF FOREIGN 762 BODY CPT 31578 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH REMOVAL OF LESION 889 CPT 31579 LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, WITH STROBOSCOPY 668 CPT 31580 LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, WITH KEEL INSERTION AND REMOVAL CPT 31582 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: 01.03.2015 Page No(s): 95 of 380

CPT 31584 LARYNGOPLASTY; WITH OPEN REDUCTION OF FRACTURE 4,701 CPT 31587 LARYNGOPLASTY, CRICOID SPLIT 3,112 CPT 31588 LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BURNS, 3,549 RECONSTRUCTION AFTER PARTIAL LARYNGECTOMY) CPT 31590 LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE 2,677 CPT 31595 SECTION RECURRENT LARYNGEAL NERVE, THERAPEUTIC (SEPARATE 2,401 PROCEDURE), UNILATERAL CPT 31599 UNLISTED PROCEDURE, LARYNX N/A CPT 31600 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); 1,290 CPT 31601 TRACHEOSTOMY, PLANNED (SEPARATE PROCEDURE); YOUNGER THAN 828 TWO YEARS CPT 31603 TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL 726 CPT 31605 TRACHEOSTOMY, EMERGENCY PROCEDURE; CRICOTHYROID MEMBRANE 602 CPT 31610 TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLAPS 2,241 CPT 31611 CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBSEQUENT 1,694 INSERTION OF AN ALARYNGEAL SPEECH PROSTHESIS (EG, VOICE BUTTON, BLOM-SINGER PROSTHESIS) CPT 31612 TRACHEAL PUNCTURE, PERCUTANEOUS WITH TRANSTRACHEAL 261 ASPIRATION AND/OR INJECTION CPT 31613 TRACHEOSTOMA REVISION; SIMPLE, WITHOUT FLAP ROTATION 1,408 CPT 31614 TRACHEOSTOMA REVISION; COMPLEX, WITH FLAP ROTATION 2,346 CPT 31615 TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCISION CPT 31620 ENDOBRONCHIAL ULTRASOUND (EBUS) DURING BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE(S)) CPT 31622 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; DIAGNOSTIC, WITH OR WITHOUT CELL WASHING (SEPARATE PROCEDURE) CPT 31623 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRUSHING OR PROTECTED BRUSHINGS CPT 31624 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL ALVEOLAR LAVAGE CPT 31625 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES CPT 31628 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE CPT 31629 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I) CPT 31630 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH TRACHEAL/BRONCHIAL DILATION OR CLOSED REDUCTION OF FRACTURE CPT 31631 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC GUIDANCE; WITH PLACEMENT OF TRACHEAL STENT(S) (INCLUDES TRACHEAL/BRONCHIAL DILATION AS REQUIRED) 582 947 1,032 1,131 1,051 1,135 1,377 2,046 679 770 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 96 of 380

CPT 31632 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 31633 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 31635 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 1,146 GUIDANCE; WITH REMOVAL OF FOREIGN BODY CPT 31636 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 31637 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 31638 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 31640 BRONCHOSCOPY, RIGID OR FLEXIBLE, WITH OR WITHOUT FLUOROSCOPIC 871 GUIDANCE; WITH EXCISION OF TUMOR CPT 31641 BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH DESTRUCTION OF TUMOR 863 OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (EG, LASER THERAPY, CRYOTHERAPY) CPT 31643 BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH PLACEMENT OF 595 CATHETER(S) FOR INTRACAVITARY RADIOELEMENT APPLICATION CPT 31645 BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION 1,011 OF TRACHEOBRONCHIAL TREE, INITIAL (EG, DRAINAGE OF LUNG ABSCESS) CPT 31646 BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION 916 OF TRACHEOBRONCHIAL TREE, SUBSEQUENT CPT 31656 BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH INJECTION OF CONTRAST 1,008 MATERIAL FOR SEGMENTAL BRONCHOGRAPHY (FIBERSCOPE ONLY) CPT 31715 TRANSTRACHEAL INJECTION FOR BRONCHOGRAPHY 179 CPT 31717 CATHETERIZATION WITH BRONCHIAL BRUSH BIOPSY 1,019 CPT 31720 CATHETER ASPIRATION (SEPARATE PROCEDURE); NASOTRACHEAL 176 CPT 31725 CATHETER ASPIRATION (SEPARATE PROCEDURE); TRACHEOBRONCHIAL 315 WITH FIBERSCOPE, BEDSIDE CPT 31730 TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDLE WIRE 3,625 DILATOR/STENT OR INDWELLING TUBE FOR OXYGEN THERAPY CPT 31750 TRACHEOPLASTY; CERVICAL 4,241 CPT 31755 TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULIZATION, EACH STAGE 5,346 CPT 31760 TRACHEOPLASTY; INTRATHORACIC 4,542 CPT 31766 CARINAL RECONSTRUCTION 6,017 CPT 31770 BRONCHOPLASTY; GRAFT REPAIR 4,387 CPT 31775 BRONCHOPLASTY; EXCISION STENOSIS AND ANASTOMOSIS 4,663 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 97 of 380

CPT 31780 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICAL 3,794 CPT 31781 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICOTHORACIC 4,618 CPT 31785 EXCISION OF TRACHEAL TUMOR OR CARCINOMA; CERVICAL 3,468 CPT 31786 EXCISION OF TRACHEAL TUMOR OR CARCINOMA; THORACIC 4,815 CPT 31800 SUTURE OF TRACHEAL WOUND OR INJURY; CERVICAL 2,211 CPT 31805 SUTURE OF TRACHEAL WOUND OR INJURY; INTRATHORACIC 2,692 CPT 31820 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITHOUT PLASTIC 1,361 REPAIR CPT 31825 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA; WITH PLASTIC REPAIR 1,883 CPT 31830 REVISION OF TRACHEOSTOMY SCAR 1,373 CPT 31899 UNLISTED PROCEDURE, TRACHEA, BRONCHI N/A CPT 32035 THORACOSTOMY; WITH RIB RESECTION FOR EMPYEMA 2,334 CPT 32036 THORACOSTOMY; WITH OPEN FLAP DRAINAGE FOR EMPYEMA 2,509 CPT 32095 THORACOTOMY, LIMITED, FOR BIOPSY OF LUNG OR PLEURA 2,061 CPT 32100 THORACOTOMY, MAJOR; WITH EXPLORATION AND BIOPSY 3,188 CPT 32110 THORACOTOMY, MAJOR; WITH CONTROL OF TRAUMATIC HEMORRHAGE 4,814 AND/OR REPAIR OF LUNG TEAR CPT 32120 THORACOTOMY, MAJOR; FOR POSTOPERATIVE COMPLICATIONS 2,854 CPT 32124 THORACOTOMY, MAJOR; WITH OPEN INTRAPLEURAL PNEUMONOLYSIS 3,044 CPT 32140 THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL, WITH OR WITHOUT A 3,261 PLEURAL PROCEDURE CPT 32141 THORACOTOMY, MAJOR; WITH EXCISION-PLICATION OF BULLAE, WITH OR 4,946 WITHOUT ANY PLEURAL PROCEDURE CPT 32150 THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL FOREIGN 3,300 BODY OR FIBRIN DEPOSIT CPT 32151 THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPULMONARY FOREIGN 3,370 BODY CPT 32160 THORACOTOMY, MAJOR; WITH CARDIAC MASSAGE 2,538 CPT 32200 PNEUMONOSTOMY; WITH OPEN DRAINAGE OF ABSCESS OR CYST 3,699 CPT 32201 PNEUMONOSTOMY; WITH PERCUTANEOUS DRAINAGE OF ABSCESS OR 3,033 CYST CPT 32215 PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX 2,625 CPT 32220 DECORTICATION, PULMONARY (SEPARATE PROCEDURE); TOTAL 5,272 CPT 32225 DECORTICATION, PULMONARY (SEPARATE PROCEDURE); PARTIAL 3,292 CPT 32310 PLEURECTOMY, PARIETAL (SEPARATE PROCEDURE) 3,032 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 98 of 380

CPT 32320 DECORTICATION AND PARIETAL PLEURECTOMY 5,289 CPT 32400 BIOPSY, PLEURA; PERCUTANEOUS NEEDLE 504 CPT 32402 BIOPSY, PLEURA; OPEN 1,843 CPT 32405 BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE 343 CPT 32420 PNEUMOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION 378 CPT 32421 THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, 507 INITIAL OR SUBSEQUENT CPT 32422 THORACENTESIS WITH INSERTION OF TUBE, INCLUDES WATER SEAL (EG, 653 FOR PNEUMOTHORAX), WHEN PERFORMED (SEPARATE PROCEDURE) CPT 32440 REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; 5,258 CPT 32442 REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; WITH RESECTION OF 9,938 SEGMENT OF TRACHEA FOLLOWED BY BRONCHO-TRACHEAL ANASTOMOSIS (SLEEVE PNEUMONECTOMY) CPT 32445 REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; EXTRAPLEURAL 11,343 CPT 32480 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE LOBE 4,959 (LOBECTOMY) CPT 32482 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; TWO LOBES 5,292 (BILOBECTOMY) CPT 32484 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE 4,771 SEGMENT (SEGMENTECTOMY) CPT 32486 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WITH 7,670 CIRCUMFERENTIAL RESECTION OF SEGMENT OF BRONCHUS FOLLOWED BY BRONCHO-BRONCHIAL ANASTOMOSIS (SLEEVE LOBECTOMY) CPT 32488 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; ALL 7,831 REMAINING LUNG FOLLOWING PREVIOUS REMOVAL OF A PORTION OF LUNG (COMPLETION PNEUMONECTOMY) CPT 32491 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 32500 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WEDGE 4,784 RESECTION, SINGLE OR MULTIPLE CPT 32501 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 32503 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 32504 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 32540 EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY) 5,511 CPT 32550 INSERTION OF INDWELLING TUNNELED PLEURAL CATHETER WITH CUFF 2,462 CPT 32551 TUBE THORACOSTOMY, INCLUDES WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, EMPYEMA), WHEN PERFORMED (SEPARATE PROCEDURE) CPT 32560 CHEMICAL PLEURODESIS (EG, FOR RECURRENT OR PERSISTENT PNEUMOTHORAX) 590 941 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 99 of 380

CPT 32601 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 1,047 PLEURAL SPACE, WITHOUT BIOPSY CPT 32602 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND 1,137 PLEURAL SPACE, WITH BIOPSY CPT 32603 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); PERICARDIAL 1,470 SAC, WITHOUT BIOPSY CPT 32604 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); PERICARDIAL 1,645 SAC, WITH BIOPSY CPT 32605 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL 1,321 SPACE, WITHOUT BIOPSY CPT 32606 THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL 1,583 SPACE, WITH BIOPSY CPT 32650 THORACOSCOPY, SURGICAL; WITH PLEURODESIS (EG, MECHANICAL OR 2,214 CHEMICAL) CPT 32651 THORACOSCOPY, SURGICAL; WITH PARTIAL PULMONARY DECORTICATION 3,558 CPT 32652 THORACOSCOPY, SURGICAL; WITH TOTAL PULMONARY DECORTICATION, 5,396 INCLUDING INTRAPLEURAL PNEUMONOLYSIS CPT 32653 THORACOSCOPY, SURGICAL; WITH REMOVAL OF INTRAPLEURAL FOREIGN 3,453 BODY OR FIBRIN DEPOSIT CPT 32654 THORACOSCOPY, SURGICAL; WITH CONTROL OF TRAUMATIC 3,779 HEMORRHAGE CPT 32655 THORACOSCOPY, SURGICAL; WITH EXCISION-PLICATION OF BULLAE, 3,130 INCLUDING ANY PLEURAL PROCEDURE CPT 32656 THORACOSCOPY, SURGICAL; WITH PARIETAL PLEURECTOMY 2,648 CPT 32657 THORACOSCOPY, SURGICAL; WITH WEDGE RESECTION OF LUNG, SINGLE 2,620 OR MULTIPLE CPT 32658 THORACOSCOPY, SURGICAL; WITH REMOVAL OF CLOT OR FOREIGN BODY 2,372 FROM PERICARDIAL SAC CPT 32659 THORACOSCOPY, SURGICAL; WITH CREATION OF PERICARDIAL WINDOW 2,426 OR PARTIAL RESECTION OF PERICARDIAL SAC FOR DRAINAGE CPT 32660 THORACOSCOPY, SURGICAL; WITH TOTAL PERICARDIECTOMY 3,445 CPT 32661 THORACOSCOPY, SURGICAL; WITH EXCISION OF PERICARDIAL CYST, 2,674 TUMOR, OR MASS CPT 32662 THORACOSCOPY, SURGICAL; WITH EXCISION OF MEDIASTINAL CYST, 2,986 TUMOR, OR MASS CPT 32663 THORACOSCOPY, SURGICAL; WITH LOBECTOMY, TOTAL OR SEGMENTAL 4,618 CPT 32664 THORACOSCOPY, SURGICAL; WITH THORACIC SYMPATHECTOMY 2,790 CPT 32665 THORACOSCOPY, SURGICAL; WITH ESOPHAGOMYOTOMY (HELLER TYPE) 4,050 CPT 32800 REPAIR LUNG HERNIA THROUGH CHEST WALL 3,085 CPT 32810 CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE FOR 2,989 EMPYEMA (CLAGETT TYPE PROCEDURE) CPT 32815 OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA 9,021 CPT 32820 MAJOR RECONSTRUCTION, CHEST WALL (POSTTRAUMATIC) 4,459 CPT 32850 DONOR PNEUMONECTOMY(S) (INCLUDING COLD PRESERVATION), FROM N/A CADAVER DONOR CPT 32851 LUNG TRANSPLANT, SINGLE; WITHOUT CARDIOPULMONARY BYPASS 8,396 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 100 of 380

CPT 32852 LUNG TRANSPLANT, SINGLE; WITH CARDIOPULMONARY BYPASS 9,219 CPT 32853 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 10,067 WITHOUT CARDIOPULMONARY BYPASS CPT 32854 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); 10,936 WITH CARDIOPULMONARY BYPASS CPT 32855 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 32856 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 32900 RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES 4,556 CPT 32905 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); 4,513 CPT 32906 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); WITH 5,563 CLOSURE OF BRONCHOPLEURAL FISTULA CPT 32940 PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING OR PACKING 4,103 PROCEDURES CPT 32960 PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL INJECTION OF AIR 454 CPT 32997 TOTAL LUNG LAVAGE (UNILATERAL) 1,220 CPT 32998 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 32999 UNLISTED PROCEDURE, LUNGS AND PLEURA N/A CPT 33010 PERICARDIOCENTESIS; INITIAL 430 CPT 33011 PERICARDIOCENTESIS; SUBSEQUENT 443 CPT 33015 TUBE PERICARDIOSTOMY 1,793 CPT 33020 PERICARDIOTOMY FOR REMOVAL OF CLOT OR FOREIGN BODY (PRIMARY 2,900 PROCEDURE) CPT 33025 CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTION FOR 2,682 DRAINAGE CPT 33030 PERICARDIECTOMY, SUBTOTAL OR COMPLETE; WITHOUT 4,308 CARDIOPULMONARY BYPASS CPT 33031 PERICARDIECTOMY, SUBTOTAL OR COMPLETE; WITH CARDIOPULMONARY 4,785 BYPASS CPT 33050 EXCISION OF PERICARDIAL CYST OR TUMOR 3,319 CPT 33120 EXCISION OF INTRACARDIAC TUMOR, RESECTION WITH 5,236 CARDIOPULMONARY BYPASS CPT 33130 RESECTION OF EXTERNAL CARDIAC TUMOR 4,585 CPT 33140 TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; (SEPARATE PROCEDURE) CPT 33141 TRANSMYOCARDIAL LASER REVASCULARIZATION, BY THORACOTOMY; PERFORMED AT THE TIME OF OTHER OPEN CARDIAC PROCEDURE(S) (LIST 5,214 504 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 101 of 380

SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 33202 INSERTION OF EPICARDIAL ELECTRODE(S); OPEN INCISION (EG, 2,635 THORACOTOMY, MEDIAN STERNOTOMY, SUBXIPHOID APPROACH) CPT 33203 INSERTION OF EPICARDIAL ELECTRODE(S); ENDOSCOPIC APPROACH (EG, 2,698 THORACOSCOPY, PERICARDIOSCOPY) CPT 33206 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,631 TRANSVENOUS ELECTRODE(S); ATRIAL CPT 33207 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,739 TRANSVENOUS ELECTRODE(S); VENTRICULAR CPT 33208 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER WITH 1,880 TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR CPT 33210 INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS SINGLE 646 CHAMBER CARDIAC ELECTRODE OR PACEMAKER CATHETER (SEPARATE PROCEDURE) CPT 33211 INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS DUAL 653 CHAMBER PACING ELECTRODES (SEPARATE PROCEDURE) CPT 33212 INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; 1,214 SINGLE CHAMBER, ATRIAL OR VENTRICULAR CPT 33213 INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; 1,387 DUAL CHAMBER CPT 33214 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 33215 REPOSITIONING OF PREVIOUSLY IMPLANTED TRANSVENOUS PACEMAKER 1,101 OR PACING CARDIOVERTER-DEFIBRILLATOR (RIGHT ATRIAL OR RIGHT VENTRICULAR) ELECTRODE CPT 33216 INSERTION OF A TRANSVENOUS ELECTRODE; SINGLE CHAMBER (ONE 1,348 ELECTRODE) PERMANENT PACEMAKER OR SINGLE CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT 33217 INSERTION OF A TRANSVENOUS ELECTRODE; DUAL CHAMBER (TWO 1,334 ELECTRODES) PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT 33218 REPAIR OF SINGLE TRANSVENOUS ELECTRODE FOR A SINGLE CHAMBER, 1,404 PERMANENT PACEMAKER OR SINGLE CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR CPT 33220 REPAIR OF TWO TRANSVENOUS ELECTRODES FOR A DUAL CHAMBER 1,409 PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR CPT 33222 REVISION OR RELOCATION OF SKIN POCKET FOR PACEMAKER 1,224 CPT 33223 REVISION OF SKIN POCKET FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR CPT 33224 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 33225 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 33226 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: 01.03.2015 Page No(s): 102 of 380

CPT 33233 REMOVAL OF PERMANENT PACEMAKER PULSE GENERATOR 858 CPT 33234 REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR CPT 33235 REMOVAL OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD SYSTEM CPT 33236 REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR CPT 33237 REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; DUAL LEAD SYSTEM CPT 33238 REMOVAL OF PERMANENT TRANSVENOUS ELECTRODE(S) BY THORACOTOMY CPT 33240 INSERTION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR CPT 33241 SUBCUTANEOUS REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR CPT 33243 REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY THORACOTOMY CPT 33244 REMOVAL OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- DEFIBRILLATOR ELECTRODE(S); BY TRANSVENOUS EXTRACTION CPT 33249 INSERTION OR REPOSITIONING OF ELECTRODE LEAD(S) FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR AND INSERTION OF PULSE GENERATOR CPT 33250 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 33251 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 33254 OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED (EG, MODIFIED MAZE PROCEDURE) CPT 33255 OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE); WITHOUT CARDIOPULMONARY BYPASS CPT 33256 OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE); WITH CARDIOPULMONARY BYPASS CPT 33257 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 33258 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 33259 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 33261 OPERATIVE ABLATION OF VENTRICULAR ARRHYTHMOGENIC FOCUS WITH CARDIOPULMONARY BYPASS CPT 33265 ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, LIMITED (EG, MODIFIED MAZE PROCEDURE), WITHOUT CARDIOPULMONARY BYPASS CPT 33266 ENDOSCOPY, SURGICAL; OPERATIVE TISSUE ABLATION AND RECONSTRUCTION OF ATRIA, EXTENSIVE (EG, MAZE PROCEDURE), 1,749 2,253 2,606 2,940 3,192 1,670 810 4,589 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: 01.03.2015 Page No(s): 103 of 380

WITHOUT CARDIOPULMONARY BYPASS CPT 33282 IMPLANTATION OF PATIENT-ACTIVATED CARDIAC EVENT RECORDER 1,154 CPT 33284 REMOVAL OF AN IMPLANTABLE, PATIENT-ACTIVATED CARDIAC EVENT 825 RECORDER CPT 33300 REPAIR OF CARDIAC WOUND; WITHOUT BYPASS 7,880 CPT 33305 REPAIR OF CARDIAC WOUND; WITH CARDIOPULMONARY BYPASS 13,231 CPT 33310 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY, 3,923 ATRIAL OR VENTRICULAR THROMBUS); WITHOUT BYPASS CPT 33315 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY, 4,995 ATRIAL OR VENTRICULAR THROMBUS); WITH CARDIOPULMONARY BYPASS CPT 33320 SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITHOUT SHUNT OR 3,593 CARDIOPULMONARY BYPASS CPT 33321 SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH SHUNT BYPASS 4,027 CPT 33322 SUTURE REPAIR OF AORTA OR GREAT VESSELS; WITH 4,620 CARDIOPULMONARY BYPASS CPT 33330 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITHOUT SHUNT, OR 4,718 CARDIOPULMONARY BYPASS CPT 33332 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITH SHUNT BYPASS 4,650 CPT 33335 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; WITH 6,363 CARDIOPULMONARY BYPASS CPT 33400 VALVULOPLASTY, AORTIC VALVE; OPEN, WITH CARDIOPULMONARY 7,559 BYPASS CPT 33401 VALVULOPLASTY, AORTIC VALVE; OPEN, WITH INFLOW OCCLUSION 4,815 CPT 33403 VALVULOPLASTY, AORTIC VALVE; USING TRANSVENTRICULAR DILATION, 5,219 WITH CARDIOPULMONARY BYPASS CPT 33404 CONSTRUCTION OF APICAL-AORTIC CONDUIT 5,991 CPT 33405 REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 7,758 PROSTHETIC VALVE OTHER THAN HOMOGRAFT OR STENTLESS VALVE CPT 33406 REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 9,615 ALLOGRAFT VALVE (FREEHAND) CPT 33410 REPLACEMENT, AORTIC VALVE, WITH CARDIOPULMONARY BYPASS; WITH 8,496 STENTLESS TISSUE VALVE CPT 33411 REPLACEMENT, AORTIC VALVE; WITH AORTIC ANNULUS ENLARGEMENT, 11,143 NONCORONARY CUSP CPT 33412 REPLACEMENT, AORTIC VALVE; WITH TRANSVENTRICULAR AORTIC 8,355 ANNULUS ENLARGEMENT (KONNO PROCEDURE) CPT 33413 REPLACEMENT, AORTIC VALVE; BY TRANSLOCATION OF AUTOLOGOUS 11,305 PULMONARY VALVE WITH ALLOGRAFT REPLACEMENT OF PULMONARY VALVE (ROSS PROCEDURE) CPT 33414 REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION BY PATCH 7,319 ENLARGEMENT OF THE OUTFLOW TRACT CPT 33415 RESECTION OR INCISION OF SUBVALVULAR TISSUE FOR DISCRETE 6,857 SUBVALVULAR AORTIC STENOSIS CPT 33416 VENTRICULOMYOTOMY (-MYECTOMY) FOR IDIOPATHIC HYPERTROPHIC 6,827 SUBAORTIC STENOSIS (EG, ASYMMETRIC SEPTAL HYPERTROPHY) CPT 33417 AORTOPLASTY (GUSSET) FOR SUPRAVALVULAR STENOSIS 5,661 CPT 33420 VALVOTOMY, MITRAL VALVE; CLOSED HEART 4,655 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 104 of 380

CPT 33422 VALVOTOMY, MITRAL VALVE; OPEN HEART, WITH CARDIOPULMONARY 5,652 BYPASS CPT 33425 VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 9,000 CPT 33426 VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 8,048 WITH PROSTHETIC RING CPT 33427 VALVULOPLASTY, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS; 8,369 RADICAL RECONSTRUCTION, WITH OR WITHOUT RING CPT 33430 REPLACEMENT, MITRAL VALVE, WITH CARDIOPULMONARY BYPASS 9,367 CPT 33460 VALVECTOMY, TRICUSPID VALVE, WITH CARDIOPULMONARY BYPASS 7,903 CPT 33463 VALVULOPLASTY, TRICUSPID VALVE; WITHOUT RING INSERTION 10,138 CPT 33464 VALVULOPLASTY, TRICUSPID VALVE; WITH RING INSERTION 8,117 CPT 33465 REPLACEMENT, TRICUSPID VALVE, WITH CARDIOPULMONARY BYPASS 9,141 CPT 33468 TRICUSPID VALVE REPOSITIONING AND PLICATION FOR EBSTEIN 6,562 ANOMALY CPT 33470 VALVOTOMY, PULMONARY VALVE, CLOSED HEART; TRANSVENTRICULAR 3,811 CPT 33471 VALVOTOMY, PULMONARY VALVE, CLOSED HEART; VIA PULMONARY 4,760 ARTERY CPT 33472 VALVOTOMY, PULMONARY VALVE, OPEN HEART; WITH INFLOW 4,435 OCCLUSION CPT 33474 VALVOTOMY, PULMONARY VALVE, OPEN HEART; WITH CARDIOPULMONARY 6,978 BYPASS CPT 33475 REPLACEMENT, PULMONARY VALVE 7,837 CPT 33476 RIGHT VENTRICULAR RESECTION FOR INFUNDIBULAR STENOSIS, WITH OR WITHOUT COMMISSUROTOMY CPT 33478 OUTFLOW TRACT AUGMENTATION (GUSSET), WITH OR WITHOUT COMMISSUROTOMY OR INFUNDIBULAR RESECTION CPT 33496 REPAIR OF NON-STRUCTURAL PROSTHETIC VALVE DYSFUNCTION WITH CARDIOPULMONARY BYPASS (SEPARATE PROCEDURE) CPT 33500 REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; WITH CARDIOPULMONARY BYPASS CPT 33501 REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; WITHOUT CARDIOPULMONARY BYPASS CPT 33502 REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY LIGATION CPT 33503 REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY GRAFT, WITHOUT CARDIOPULMONARY BYPASS CPT 33504 REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY GRAFT, WITH CARDIOPULMONARY BYPASS CPT 33505 REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; WITH CONSTRUCTION OF INTRAPULMONARY ARTERY TUNNEL (TAKEUCHI PROCEDURE) CPT 33506 REPAIR OF ANOMALOUS CORONARY ARTERY FROM PULMONARY ARTERY ORIGIN; BY TRANSLOCATION FROM PULMONARY ARTERY TO AORTA CPT 33507 REPAIR OF ANOMALOUS (EG, INTRAMURAL) AORTIC ORIGIN OF CORONARY ARTERY BY UNROOFING OR TRANSLOCATION CPT 33508 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 5,854 55 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 105 of 380

CPT 33510 CORONARY ARTERY BYPASS, VEIN ONLY; SINGLE CORONARY VENOUS 6,570 GRAFT CPT 33511 CORONARY ARTERY BYPASS, VEIN ONLY; TWO CORONARY VENOUS 7,182 GRAFTS CPT 33512 CORONARY ARTERY BYPASS, VEIN ONLY; THREE CORONARY VENOUS 8,117 GRAFTS CPT 33513 CORONARY ARTERY BYPASS, VEIN ONLY; FOUR CORONARY VENOUS 8,372 GRAFTS CPT 33514 CORONARY ARTERY BYPASS, VEIN ONLY; FIVE CORONARY VENOUS 8,823 GRAFTS CPT 33516 CORONARY ARTERY BYPASS, VEIN ONLY; SIX OR MORE CORONARY 9,157 VENOUS GRAFTS CPT 33517 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 33518 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 33519 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 33521 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 33522 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 33523 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 33530 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 33533 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE 6,390 ARTERIAL GRAFT CPT 33534 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); TWO CORONARY 7,454 ARTERIAL GRAFTS CPT 33535 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); THREE 8,304 CORONARY ARTERIAL GRAFTS CPT 33536 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR MORE 8,949 CORONARY ARTERIAL GRAFTS CPT 33542 MYOCARDIAL RESECTION (EG, VENTRICULAR ANEURYSMECTOMY) 8,730 CPT 33545 REPAIR OF POSTINFARCTION VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT MYOCARDIAL RESECTION CPT 33548 SURGICAL VENTRICULAR RESTORATION PROCEDURE, INCLUDES PROSTHETIC PATCH, WHEN PERFORMED (EG, VENTRICULAR REMODELING, SVR, SAVER, DOR PROCEDURES) CPT 33572 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 33600 CLOSURE OF ATRIOVENTRICULAR VALVE (MITRAL OR TRICUSPID) BY SUTURE OR PATCH CPT 33602 CLOSURE OF SEMILUNAR VALVE (AORTIC OR PULMONARY) BY SUTURE OR PATCH 10,359 9,923 805 5,880 5,559 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 106 of 380

CPT 33606 ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE- 6,003 STANSEL PROCEDURE) CPT 33608 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 33610 REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE WITH 6,212 SUBAORTIC OBSTRUCTION) BY SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT 33611 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR 6,574 TUNNEL REPAIR; CPT 33612 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR 7,062 TUNNEL REPAIR; WITH REPAIR OF RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION CPT 33615 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 33617 REPAIR OF COMPLEX CARDIAC ANOMALIES (EG, SINGLE VENTRICLE) BY 7,373 MODIFIED FONTAN PROCEDURE CPT 33619 REPAIR OF SINGLE VENTRICLE WITH AORTIC OUTFLOW OBSTRUCTION 9,194 AND AORTIC ARCH HYPOPLASIA (HYPOPLASTIC LEFT HEART SYNDROME) (EG, NORWOOD PROCEDURE) CPT 33641 REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM, WITH CARDIOPULMONARY 5,490 BYPASS, WITH OR WITHOUT PATCH CPT 33645 DIRECT OR PATCH CLOSURE, SINUS VENOSUS, WITH OR WITHOUT 5,343 ANOMALOUS PULMONARY VENOUS DRAINAGE CPT 33647 REPAIR OF ATRIAL SEPTAL DEFECT AND VENTRICULAR SEPTAL DEFECT, 5,715 WITH DIRECT OR PATCH CLOSURE CPT 33660 REPAIR OF INCOMPLETE OR PARTIAL ATRIOVENTRICULAR CANAL (OSTIUM 6,050 PRIMUM ATRIAL SEPTAL DEFECT), WITH OR WITHOUT ATRIOVENTRICULAR VALVE REPAIR CPT 33665 REPAIR OF INTERMEDIATE OR TRANSITIONAL ATRIOVENTRICULAR CANAL, 6,411 WITH OR WITHOUT ATRIOVENTRICULAR VALVE REPAIR CPT 33670 REPAIR OF COMPLETE ATRIOVENTRICULAR CANAL, WITH OR WITHOUT 7,158 PROSTHETIC VALVE CPT 33675 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; 7,121 CPT 33676 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH 7,347 PULMONARY VALVOTOMY OR INFUNDIBULAR RESECTION (ACYANOTIC) CPT 33677 CLOSURE OF MULTIPLE VENTRICULAR SEPTAL DEFECTS; WITH REMOVAL 7,637 OF PULMONARY ARTERY BAND, WITH OR WITHOUT GUSSET CPT 33681 CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,230 PATCH; CPT 33684 CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,415 PATCH; WITH PULMONARY VALVOTOMY OR INFUNDIBULAR RESECTION (ACYANOTIC) CPT 33688 CLOSURE OF SINGLE VENTRICULAR SEPTAL DEFECT, WITH OR WITHOUT 6,423 PATCH; WITH REMOVAL OF PULMONARY ARTERY BAND, WITH OR WITHOUT GUSSET CPT 33690 BANDING OF PULMONARY ARTERY 3,878 CPT 33692 COMPLETE REPAIR TETRALOGY OF FALLOT WITHOUT PULMONARY ATRESIA; CPT 33694 COMPLETE REPAIR TETRALOGY OF FALLOT WITHOUT PULMONARY ATRESIA; WITH TRANSANNULAR PATCH CPT 33697 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: 01.03.2015 Page No(s): 107 of 380

PULMONARY ARTERY AND CLOSURE OF VENTRICULAR SEPTAL DEFECT CPT 33702 REPAIR SINUS OF VALSALVA FISTULA, WITH CARDIOPULMONARY BYPASS; 5,200 CPT 33710 REPAIR SINUS OF VALSALVA FISTULA, WITH CARDIOPULMONARY BYPASS; 5,786 WITH REPAIR OF VENTRICULAR SEPTAL DEFECT CPT 33720 REPAIR SINUS OF VALSALVA ANEURYSM, WITH CARDIOPULMONARY 5,243 BYPASS CPT 33722 CLOSURE OF AORTICO-LEFT VENTRICULAR TUNNEL 5,155 CPT 33724 REPAIR OF ISOLATED PARTIAL ANOMALOUS PULMONARY VENOUS RETURN 5,277 (EG, SCIMITAR SYNDROME) CPT 33726 REPAIR OF PULMONARY VENOUS STENOSIS 6,960 CPT 33730 COMPLETE REPAIR OF ANOMALOUS PULMONARY VENOUS RETURN 6,785 (SUPRACARDIAC, INTRACARDIAC, OR INFRACARDIAC TYPES) CPT 33732 REPAIR OF COR TRIATRIATUM OR SUPRAVALVULAR MITRAL RING BY 5,681 RESECTION OF LEFT ATRIAL MEMBRANE CPT 33735 ATRIAL SEPTECTOMY OR SEPTOSTOMY; CLOSED HEART (BLALOCK- 4,405 HANLON TYPE OPERATION) CPT 33736 ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART WITH 4,949 CARDIOPULMONARY BYPASS CPT 33737 ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART, WITH INFLOW 4,370 OCCLUSION CPT 33750 SHUNT; SUBCLAVIAN TO PULMONARY ARTERY (BLALOCK-TAUSSIG TYPE 4,109 OPERATION) CPT 33755 SHUNT; ASCENDING AORTA TO PULMONARY ARTERY (WATERSTON TYPE 4,216 OPERATION) CPT 33762 SHUNT; DESCENDING AORTA TO PULMONARY ARTERY (POTTS-SMITH TYPE 4,313 OPERATION) CPT 33764 SHUNT; CENTRAL, WITH PROSTHETIC GRAFT 4,329 CPT 33766 SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO ONE LUNG (CLASSICAL GLENN PROCEDURE) CPT 33767 SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO BOTH LUNGS (BIDIRECTIONAL GLENN PROCEDURE) CPT 33768 ANASTOMOSIS, CAVOPULMONARY, SECOND SUPERIOR VENA CAVA (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT 33770 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; WITHOUT SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT 33771 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES WITH VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; WITH SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT CPT 33774 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; CPT 33775 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (EG, MUSTARD OR SENNING TYPE) WITH CARDIOPULMONARY BYPASS; WITH REMOVAL OF PULMONARY BAND CPT 33776 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 33777 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: 01.03.2015 Page No(s): 108 of 380

CPT 33778 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 8,024 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); CPT 33779 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,367 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH REMOVAL OF PULMONARY BAND CPT 33780 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,637 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH CLOSURE OF VENTRICULAR SEPTAL DEFECT CPT 33781 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC 7,584 PULMONARY ARTERY RECONSTRUCTION (EG, JATENE TYPE); WITH REPAIR OF SUBPULMONIC OBSTRUCTION CPT 33786 TOTAL REPAIR, TRUNCUS ARTERIOSUS (RASTELLI TYPE OPERATION) 7,747 CPT 33788 REIMPLANTATION OF AN ANOMALOUS PULMONARY ARTERY 4,976 CPT 33800 AORTIC SUSPENSION (AORTOPEXY) FOR TRACHEAL DECOMPRESSION (EG, 3,336 FOR TRACHEOMALACIA) (SEPARATE PROCEDURE) CPT 33802 DIVISION OF ABERRANT VESSEL (VASCULAR RING); 3,582 CPT 33803 DIVISION OF ABERRANT VESSEL (VASCULAR RING); WITH 3,747 REANASTOMOSIS CPT 33813 OBLITERATION OF AORTOPULMONARY SEPTAL DEFECT; WITHOUT 4,176 CARDIOPULMONARY BYPASS CPT 33814 OBLITERATION OF AORTOPULMONARY SEPTAL DEFECT; WITH 5,119 CARDIOPULMONARY BYPASS CPT 33820 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY LIGATION 3,262 CPT 33822 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, YOUNGER THAN 3,304 18 YEARS CPT 33824 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, 18 YEARS AND 3,958 OLDER CPT 33840 EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT ASSOCIATED 4,117 PATENT DUCTUS ARTERIOSUS; WITH DIRECT ANASTOMOSIS CPT 33845 EXCISION OF COARCTATION OF AORTA, WITH OR WITHOUT ASSOCIATED 4,453 PATENT DUCTUS ARTERIOSUS; WITH GRAFT CPT 33851 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 33852 REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING 5,187 AUTOGENOUS OR PROSTHETIC MATERIAL; WITHOUT CARDIOPULMONARY BYPASS CPT 33853 REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING 6,178 AUTOGENOUS OR PROSTHETIC MATERIAL; WITH CARDIOPULMONARY BYPASS CPT 33860 ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 10,737 WITHOUT VALVE SUSPENSION; CPT 33861 ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 8,309 WITHOUT VALVE SUSPENSION; WITH CORONARY RECONSTRUCTION CPT 33863 ASCENDING AORTA GRAFT, WITH CARDIOPULMONARY BYPASS, WITH OR 10,687 WITHOUT VALVE SUSPENSION; WITH AORTIC ROOT REPLACEMENT USING COMPOSITE PROSTHESIS AND CORONARY RECONSTRUCTION CPT 33864 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 33870 TRANSVERSE ARCH GRAFT, WITH CARDIOPULMONARY BYPASS 8,664 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 109 of 380

CPT 33875 DESCENDING THORACIC AORTA GRAFT, WITH OR WITHOUT BYPASS 6,732 CPT 33877 REPAIR OF THORACOABDOMINAL AORTIC ANEURYSM WITH GRAFT, WITH 12,060 OR WITHOUT CARDIOPULMONARY BYPASS CPT 33880 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 33881 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 33883 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 33884 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 33886 PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) DELAYED AFTER 3,288 ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA CPT 33889 OPEN SUBCLAVIAN TO CAROTID ARTERY TRANSPOSITION PERFORMED IN 2,779 CONJUNCTION WITH ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, BY NECK INCISION, UNILATERAL CPT 33891 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 33910 PULMONARY ARTERY EMBOLECTOMY; WITH CARDIOPULMONARY BYPASS 5,618 CPT 33915 PULMONARY ARTERY EMBOLECTOMY; WITHOUT CARDIOPULMONARY 4,454 BYPASS CPT 33916 PULMONARY ENDARTERECTOMY, WITH OR WITHOUT EMBOLECTOMY, WITH 5,387 CARDIOPULMONARY BYPASS CPT 33917 REPAIR OF PULMONARY ARTERY STENOSIS BY RECONSTRUCTION WITH 4,893 PATCH OR GRAFT CPT 33920 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 33922 TRANSECTION OF PULMONARY ARTERY WITH CARDIOPULMONARY BYPASS 4,712 CPT 33924 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 33925 REPAIR OF PULMONARY ARTERY ARBORIZATION ANOMALIES BY UNIFOCALIZATION; WITHOUT CARDIOPULMONARY BYPASS CPT 33926 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: 01.03.2015 Page No(s): 110 of 380

CPT 33930 DONOR CARDIECTOMY-PNEUMONECTOMY (INCLUDING COLD N/A PRESERVATION) CPT 33933 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 33935 HEART-LUNG TRANSPLANT WITH RECIPIENT CARDIECTOMY- 11,794 PNEUMONECTOMY CPT 33940 DONOR CARDIECTOMY (INCLUDING COLD PRESERVATION) N/A CPT 33944 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 33945 HEART TRANSPLANT, WITH OR WITHOUT RECIPIENT CARDIECTOMY 15,826 CPT 33960 PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY 3,431 INSUFFICIENCY; INITIAL 24 HOURS CPT 33961 PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY 1,860 INSUFFICIENCY; EACH ADDITIONAL 24 HOURS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 33967 INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE, PERCUTANEOUS 956 CPT 33968 REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE, PERCUTANEOUS 122 CPT 33970 INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE 1,271 FEMORAL ARTERY, OPEN APPROACH CPT 33971 REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE INCLUDING REPAIR 2,412 OF FEMORAL ARTERY, WITH OR WITHOUT GRAFT CPT 33973 INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE 1,881 ASCENDING AORTA CPT 33974 REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE FROM THE 3,072 ASCENDING AORTA, INCLUDING REPAIR OF THE ASCENDING AORTA, WITH OR WITHOUT GRAFT CPT 33975 INSERTION OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, SINGLE 3,818 VENTRICLE CPT 33976 INSERTION OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, 4,266 BIVENTRICULAR CPT 33977 REMOVAL OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, SINGLE 4,065 VENTRICLE CPT 33978 REMOVAL OF VENTRICULAR ASSIST DEVICE; EXTRACORPOREAL, 4,562 BIVENTRICULAR CPT 33979 INSERTION OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 8,331 INTRACORPOREAL, SINGLE VENTRICLE CPT 33980 REMOVAL OF VENTRICULAR ASSIST DEVICE, IMPLANTABLE 12,151 INTRACORPOREAL, SINGLE VENTRICLE CPT 33999 UNLISTED PROCEDURE, CARDIAC SURGERY N/A CPT 34001 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; CAROTID, SUBCLAVIAN OR INNOMINATE ARTERY, BY NECK INCISION CPT 34051 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION CPT 34101 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: 01.03.2015 Page No(s): 111 of 380

CPT 34111 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 2,080 RADIAL OR ULNAR ARTERY, BY ARM INCISION CPT 34151 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 4,862 RENAL, CELIAC, MESENTERY, AORTOILIAC ARTERY, BY ABDOMINAL INCISION CPT 34201 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 3,446 FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG INCISION CPT 34203 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; 3,331 POPLITEAL-TIBIO-PERONEAL ARTERY, BY LEG INCISION CPT 34401 THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC VEIN, 4,881 BY ABDOMINAL INCISION CPT 34421 THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC, 2,522 FEMOROPOPLITEAL VEIN, BY LEG INCISION CPT 34451 THROMBECTOMY, DIRECT OR WITH CATHETER; VENA CAVA, ILIAC, 5,241 FEMOROPOPLITEAL VEIN, BY ABDOMINAL AND LEG INCISION CPT 34471 THROMBECTOMY, DIRECT OR WITH CATHETER; SUBCLAVIAN VEIN, BY 3,782 NECK INCISION CPT 34490 THROMBECTOMY, DIRECT OR WITH CATHETER; AXILLARY AND 2,088 SUBCLAVIAN VEIN, BY ARM INCISION CPT 34501 VALVULOPLASTY, FEMORAL VEIN 3,212 CPT 34502 RECONSTRUCTION OF VENA CAVA, ANY METHOD 5,284 CPT 34510 VENOUS VALVE TRANSPOSITION, ANY VEIN DONOR 3,733 CPT 34520 CROSS-OVER VEIN GRAFT TO VENOUS SYSTEM 3,569 CPT 34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS 3,307 CPT 34800 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING AORTO-AORTIC TUBE PROSTHESIS CPT 34802 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING MODULAR BIFURCATED PROSTHESIS (ONE DOCKING LIMB) CPT 34803 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING MODULAR BIFURCATED PROSTHESIS (TWO DOCKING LIMBS) CPT 34804 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING UNIBODY BIFURCATED PROSTHESIS CPT 34805 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION; USING AORTO-UNIILIAC OR AORTO-UNIFEMORAL PROSTHESIS CPT 34806 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 34808 ENDOVASCULAR PLACEMENT OF ILIAC ARTERY OCCLUSION DEVICE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 34812 OPEN FEMORAL ARTERY EXPOSURE FOR DELIVERY OF ENDOVASCULAR PROSTHESIS, BY GROIN INCISION, UNILATERAL CPT 34813 PLACEMENT OF FEMORAL-FEMORAL PROSTHETIC GRAFT DURING ENDOVASCULAR AORTIC ANEURYSM REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 34820 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 4,011 361 725 1,207 833 1,723 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 112 of 380

CPT 34825 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 34826 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 34830 OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, PLUS 6,292 REPAIR OF ASSOCIATED ARTERIAL TRAUMA, FOLLOWING UNSUCCESSFUL ENDOVASCULAR REPAIR; TUBE PROSTHESIS CPT 34831 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 34832 OPEN REPAIR OF INFRARENAL AORTIC ANEURYSM OR DISSECTION, PLUS 6,861 REPAIR OF ASSOCIATED ARTERIAL TRAUMA, FOLLOWING UNSUCCESSFUL ENDOVASCULAR REPAIR; AORTO-BIFEMORAL PROSTHESIS CPT 34833 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 34834 OPEN BRACHIAL ARTERY EXPOSURE TO ASSIST IN THE DEPLOYMENT OF 965 AORTIC OR ILIAC ENDOVASCULAR PROSTHESIS BY ARM INCISION, UNILATERAL CPT 34900 ENDOVASCULAR GRAFT PLACEMENT FOR REPAIR OF ILIAC ARTERY (EG, 3,125 ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, TRAUMA) CPT 35001 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 35002 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 35005 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 35011 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 35013 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 35021 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 35022 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 35045 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: 01.03.2015 Page No(s): 113 of 380

GRAFT; FOR ANEURYSM, PSEUDOANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY CPT 35081 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 35082 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 35091 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 35092 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 35102 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 35103 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 35111 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 35112 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 35121 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 35122 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 35131 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 35132 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 35141 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: 01.03.2015 Page No(s): 114 of 380

CPT 35142 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 35151 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 35152 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 35180 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; HEAD AND NECK 2,803 CPT 35182 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; THORAX AND ABDOMEN 5,888 CPT 35184 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; EXTREMITIES 3,494 CPT 35188 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; HEAD AND 2,957 NECK CPT 35189 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; THORAX 5,606 AND ABDOMEN CPT 35190 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; 2,563 EXTREMITIES CPT 35201 REPAIR BLOOD VESSEL, DIRECT; NECK 3,209 CPT 35206 REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY 2,634 CPT 35207 REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER 2,387 CPT 35211 REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, WITH BYPASS 4,710 CPT 35216 REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, WITHOUT BYPASS 6,633 CPT 35221 REPAIR BLOOD VESSEL, DIRECT; INTRA-ABDOMINAL 4,814 CPT 35226 REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY 2,900 CPT 35231 REPAIR BLOOD VESSEL WITH VEIN GRAFT; NECK 3,990 CPT 35236 REPAIR BLOOD VESSEL WITH VEIN GRAFT; UPPER EXTREMITY 3,356 CPT 35241 REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRATHORACIC, WITH 4,916 BYPASS CPT 35246 REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRATHORACIC, WITHOUT 5,301 BYPASS CPT 35251 REPAIR BLOOD VESSEL WITH VEIN GRAFT; INTRA-ABDOMINAL 5,717 CPT 35256 REPAIR BLOOD VESSEL WITH VEIN GRAFT; LOWER EXTREMITY 3,523 CPT 35261 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; NECK 3,583 CPT 35266 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; UPPER EXTREMITY CPT 35271 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; INTRATHORACIC, WITH BYPASS CPT 35276 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: 01.03.2015 Page No(s): 115 of 380

CPT 35281 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; INTRA- 5,436 ABDOMINAL CPT 35286 REPAIR BLOOD VESSEL WITH GRAFT OTHER THAN VEIN; LOWER 3,237 EXTREMITY CPT 35301 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,637 CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION CPT 35302 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,922 SUPERFICIAL FEMORAL ARTERY CPT 35303 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,309 POPLITEAL ARTERY CPT 35304 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,486 TIBIOPERONEAL TRUNK ARTERY CPT 35305 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,309 TIBIAL OR PERONEAL ARTERY, INITIAL VESSEL CPT 35306 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 1,619 EACH ADDITIONAL TIBIAL OR PERONEAL ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35311 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,233 SUBCLAVIAN, INNOMINATE, BY THORACIC INCISION CPT 35321 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,088 AXILLARY-BRACHIAL CPT 35331 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,067 ABDOMINAL AORTA CPT 35341 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,799 MESENTERIC, CELIAC, OR RENAL CPT 35351 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 4,472 ILIAC CPT 35355 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,626 ILIOFEMORAL CPT 35361 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,520 COMBINED AORTOILIAC CPT 35363 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 5,914 COMBINED AORTOILIOFEMORAL CPT 35371 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 2,857 COMMON FEMORAL CPT 35372 THROMBOENDARTERECTOMY, INCLUDING PATCH GRAFT, IF PERFORMED; 3,431 DEEP (PROFUNDA) FEMORAL CPT 35390 REOPERATION, CAROTID, THROMBOENDARTERECTOMY, MORE THAN ONE 562 MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35400 ANGIOSCOPY (NON-CORONARY VESSELS OR GRAFTS) DURING 522 THERAPEUTIC INTERVENTION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35450 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; RENAL OR OTHER 1,796 VISCERAL ARTERY CPT 35452 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; AORTIC 1,246 CPT 35454 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; ILIAC 1,090 CPT 35456 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; FEMORAL-POPLITEAL 1,321 CPT 35458 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; BRACHIOCEPHALIC 1,704 TRUNK OR BRANCHES, EACH VESSEL CPT 35459 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; TIBIOPERONEAL TRUNK 1,570 AND BRANCHES CPT 35460 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; VENOUS 1,083 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 116 of 380

CPT 35470 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; 8,873 TIBIOPERONEAL TRUNK OR BRANCHES, EACH VESSEL CPT 35471 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; RENAL OR 9,663 VISCERAL ARTERY CPT 35472 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; AORTIC 6,924 CPT 35473 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; ILIAC 6,683 CPT 35474 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FEMORAL- 8,604 POPLITEAL CPT 35475 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; 7,399 BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL CPT 35476 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; VENOUS 5,477 CPT 35480 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; RENAL OR OTHER 2,063 VISCERAL ARTERY CPT 35481 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; AORTIC 1,422 CPT 35482 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; ILIAC 1,200 CPT 35483 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; FEMORAL-POPLITEAL 1,486 CPT 35484 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; BRACHIOCEPHALIC 1,836 TRUNK OR BRANCHES, EACH VESSEL CPT 35485 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; TIBIOPERONEAL 1,724 TRUNK AND BRANCHES CPT 35490 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; RENAL OR 2,133 OTHER VISCERAL ARTERY CPT 35491 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; AORTIC 1,535 CPT 35492 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; ILIAC 1,329 CPT 35493 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; FEMORAL- 1,588 POPLITEAL CPT 35494 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; 2,034 BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL CPT 35495 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; 1,840 TIBIOPERONEAL TRUNK AND BRANCHES CPT 35500 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 35501 BYPASS GRAFT, WITH VEIN; COMMON CAROTID-IPSILATERAL INTERNAL 5,558 CAROTID CPT 35506 BYPASS GRAFT, WITH VEIN; CAROTID-SUBCLAVIAN OR SUBCLAVIAN- 4,584 CAROTID CPT 35508 BYPASS GRAFT, WITH VEIN; CAROTID-VERTEBRAL 4,725 CPT 35509 BYPASS GRAFT, WITH VEIN; CAROTID-CONTRALATERAL CAROTID 5,374 CPT 35510 BYPASS GRAFT, WITH VEIN; CAROTID-BRACHIAL 4,293 CPT 35511 BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-SUBCLAVIAN 4,114 CPT 35512 BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-BRACHIAL 4,202 CPT 35515 BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-VERTEBRAL 4,765 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 117 of 380

CPT 35516 BYPASS GRAFT, WITH VEIN; SUBCLAVIAN-AXILLARY 4,268 CPT 35518 BYPASS GRAFT, WITH VEIN; AXILLARY-AXILLARY 4,144 CPT 35521 BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORAL 4,415 CPT 35522 BYPASS GRAFT, WITH VEIN; AXILLARY-BRACHIAL 4,099 CPT 35523 BYPASS GRAFT, WITH VEIN; BRACHIAL-ULNAR OR -RADIAL 4,450 CPT 35525 BYPASS GRAFT, WITH VEIN; BRACHIAL-BRACHIAL 3,870 CPT 35526 BYPASS GRAFT, WITH VEIN; AORTOSUBCLAVIAN OR CAROTID 6,185 CPT 35531 BYPASS GRAFT, WITH VEIN; AORTOCELIAC OR AORTOMESENTERIC 7,003 CPT 35533 BYPASS GRAFT, WITH VEIN; AXILLARY-FEMORAL-FEMORAL 5,430 CPT 35536 BYPASS GRAFT, WITH VEIN; SPLENORENAL 6,007 CPT 35537 BYPASS GRAFT, WITH VEIN; AORTOILIAC 7,623 CPT 35538 BYPASS GRAFT, WITH VEIN; AORTOBI-ILIAC 8,516 CPT 35539 BYPASS GRAFT, WITH VEIN; AORTOFEMORAL 7,988 CPT 35540 BYPASS GRAFT, WITH VEIN; AORTOBIFEMORAL 8,909 CPT 35548 BYPASS GRAFT, WITH VEIN; AORTOILIOFEMORAL, UNILATERAL 4,190 CPT 35549 BYPASS GRAFT, WITH VEIN; AORTOILIOFEMORAL, BILATERAL 4,579 CPT 35551 BYPASS GRAFT, WITH VEIN; AORTOFEMORAL-POPLITEAL 5,141 CPT 35556 BYPASS GRAFT, WITH VEIN; FEMORAL-POPLITEAL 4,828 CPT 35558 BYPASS GRAFT, WITH VEIN; FEMORAL-FEMORAL 4,263 CPT 35560 BYPASS GRAFT, WITH VEIN; AORTORENAL 6,202 CPT 35563 BYPASS GRAFT, WITH VEIN; ILIOILIAC 4,832 CPT 35565 BYPASS GRAFT, WITH VEIN; ILIOFEMORAL 4,590 CPT 35566 BYPASS GRAFT, WITH VEIN; FEMORAL-ANTERIOR TIBIAL, POSTERIOR 5,777 TIBIAL, PERONEAL ARTERY OR OTHER DISTAL VESSELS CPT 35571 BYPASS GRAFT, WITH VEIN; POPLITEAL-TIBIAL, -PERONEAL ARTERY OR 4,645 OTHER DISTAL VESSELS CPT 35572 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 35583 IN-SITU VEIN BYPASS; FEMORAL-POPLITEAL 4,963 CPT 35585 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: 01.03.2015 Page No(s): 118 of 380

CPT 35587 IN-SITU VEIN BYPASS; POPLITEAL-TIBIAL, PERONEAL 4,796 CPT 35600 HARVEST OF UPPER EXTREMITY ARTERY, ONE SEGMENT, FOR CORONARY 905 ARTERY BYPASS PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35601 BYPASS GRAFT, WITH OTHER THAN VEIN; COMMON CAROTID- 5,178 IPSILATERAL INTERNAL CAROTID CPT 35606 BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-SUBCLAVIAN 4,073 CPT 35612 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-SUBCLAVIAN 3,160 CPT 35616 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-AXILLARY 3,910 CPT 35621 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL 3,857 CPT 35623 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-POPLITEAL OR - 4,744 TIBIAL CPT 35626 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOSUBCLAVIAN OR 5,465 CAROTID CPT 35631 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOCELIAC, 6,472 AORTOMESENTERIC, AORTORENAL CPT 35636 BYPASS GRAFT, WITH OTHER THAN VEIN; SPLENORENAL (SPLENIC TO 5,719 RENAL ARTERIAL ANASTOMOSIS) CPT 35637 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOILIAC 6,043 CPT 35638 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOBI-ILIAC 6,139 CPT 35642 BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-VERTEBRAL 3,442 CPT 35645 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-VERTEBRAL 3,627 CPT 35646 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOBIFEMORAL 6,007 CPT 35647 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL 5,446 CPT 35650 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-AXILLARY 3,742 CPT 35651 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL-POPLITEAL 4,788 CPT 35654 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL-FEMORAL 4,790 CPT 35656 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-POPLITEAL 3,779 CPT 35661 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL 3,773 CPT 35663 BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOILIAC 4,381 CPT 35665 BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOFEMORAL 4,102 CPT 35666 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-ANTERIOR TIBIAL, POSTERIOR TIBIAL, OR PERONEAL ARTERY CPT 35671 BYPASS GRAFT, WITH OTHER THAN VEIN; POPLITEAL-TIBIAL OR - PERONEAL ARTERY CPT 35681 BYPASS GRAFT; COMPOSITE, PROSTHETIC AND VEIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35682 BYPASS GRAFT; AUTOGENOUS COMPOSITE, TWO SEGMENTS OF VEINS FROM TWO LOCATIONS (LIST SEPARATELY IN ADDITION TO CODE FOR 4,430 3,908 280 1,248 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 119 of 380

PRIMARY PROCEDURE) CPT 35683 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 35685 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 35686 CREATION OF DISTAL ARTERIOVENOUS FISTULA DURING LOWER 586 EXTREMITY BYPASS SURGERY (NON-HEMODIALYSIS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35691 TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO CAROTID 3,380 ARTERY CPT 35693 TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO SUBCLAVIAN 3,018 ARTERY CPT 35694 TRANSPOSITION AND/OR REIMPLANTATION; SUBCLAVIAN TO CAROTID 3,550 ARTERY CPT 35695 TRANSPOSITION AND/OR REIMPLANTATION; CAROTID TO SUBCLAVIAN 3,703 ARTERY CPT 35697 REIMPLANTATION, VISCERAL ARTERY TO INFRARENAL AORTIC 522 PROSTHESIS, EACH ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 35700 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 35701 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,831 WITHOUT LYSIS OF ARTERY; CAROTID ARTERY CPT 35721 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,575 WITHOUT LYSIS OF ARTERY; FEMORAL ARTERY CPT 35741 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,711 WITHOUT LYSIS OF ARTERY; POPLITEAL ARTERY CPT 35761 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), WITH OR 1,262 WITHOUT LYSIS OF ARTERY; OTHER VESSELS CPT 35800 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 1,622 INFECTION; NECK CPT 35820 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 6,503 INFECTION; CHEST CPT 35840 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 2,142 INFECTION; ABDOMEN CPT 35860 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR 1,369 INFECTION; EXTREMITY CPT 35870 REPAIR OF GRAFT-ENTERIC FISTULA 4,445 CPT 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA); CPT 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR FISTULA); WITH REVISION OF ARTERIAL OR VENOUS GRAFT CPT 35879 REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH VEIN PATCH ANGIOPLASTY CPT 35881 REVISION, LOWER EXTREMITY ARTERIAL BYPASS, WITHOUT THROMBECTOMY, OPEN; WITH SEGMENTAL VEIN INTERPOSITION CPT 35883 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: 01.03.2015 Page No(s): 120 of 380

CPT 35884 REVISION, FEMORAL ANASTOMOSIS OF SYNTHETIC ARTERIAL BYPASS 4,647 GRAFT IN GROIN, OPEN; WITH AUTOGENOUS VEIN PATCH GRAFT CPT 35901 EXCISION OF INFECTED GRAFT; NECK 1,718 CPT 35903 EXCISION OF INFECTED GRAFT; EXTREMITY 1,930 CPT 35905 EXCISION OF INFECTED GRAFT; THORAX 6,103 CPT 35907 EXCISION OF INFECTED GRAFT; ABDOMEN 6,664 CPT 36000 INTRODUCTION OF NEEDLE OR INTRACATHETER, VEIN 81 CPT 36002 INJECTION PROCEDURES (EG, THROMBIN) FOR PERCUTANEOUS 550 TREATMENT OF EXTREMITY PSEUDOANEURYSM CPT 36005 INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY (INCLUDING 1,191 INTRODUCTION OF NEEDLE OR INTRACATHETER) CPT 36010 INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA 1,728 CPT 36011 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER 2,900 BRANCH (EG, RENAL VEIN, JUGULAR VEIN) CPT 36012 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR 3,020 MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS) CPT 36013 INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY 2,713 ARTERY CPT 36014 SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT PULMONARY ARTERY 2,790 CPT 36015 SELECTIVE CATHETER PLACEMENT, SEGMENTAL OR SUBSEGMENTAL 2,804 PULMONARY ARTERY CPT 36100 INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR VERTEBRAL 1,828 ARTERY CPT 36120 INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE BRACHIAL 1,429 ARTERY CPT 36140 INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY 1,593 CPT 36145 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT 1,562 CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) CPT 36160 INTRODUCTION OF NEEDLE OR INTRACATHETER, AORTIC, TRANSLUMBAR 1,803 CPT 36200 INTRODUCTION OF CATHETER, AORTA 2,130 CPT 36215 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT 36216 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT 36217 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, WITHIN A VASCULAR FAMILY CPT 36218 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 36245 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY 3,890 4,234 6,625 610 4,251 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 121 of 380

CPT 36246 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND 4,166 ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY CPT 36247 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 36248 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 36260 INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (EG, FOR 1,983 CHEMOTHERAPY OF LIVER) CPT 36261 REVISION OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 1,171 CPT 36262 REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 918 CPT 36299 UNLISTED PROCEDURE, VASCULAR INJECTION N/A CPT 36400 VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 86 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; FEMORAL OR JUGULAR VEIN CPT 36405 VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 76 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; SCALP VEIN CPT 36406 VENIPUNCTURE, YOUNGER THAN AGE 3 YEARS, NECESSITATING 55 PHYSICIAN'S SKILL, NOT TO BE USED FOR ROUTINE VENIPUNCTURE; OTHER VEIN CPT 36410 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 36415 ROUTINE VENIPUNCTURE 11 CPT 36416 COLLECTION OF CAPILLARY BLOOD SPECIMEN (EG, FINGER, HEEL, EAR 15 STICK) CPT 36420 VENIPUNCTURE, CUTDOWN; YOUNGER THAN AGE 1 YEAR 162 CPT 36425 VENIPUNCTURE, CUTDOWN; AGE 1 OR OVER 129 CPT 36430 TRANSFUSION, BLOOD OR BLOOD COMPONENTS 125 CPT 36440 PUSH TRANSFUSION, BLOOD, 2 YEARS OR YOUNGER 173 CPT 36450 EXCHANGE TRANSFUSION, BLOOD; NEWBORN 404 CPT 36455 EXCHANGE TRANSFUSION, BLOOD; OTHER THAN NEWBORN 409 CPT 36460 TRANSFUSION, INTRAUTERINE, FETAL 1,155 CPT 36468 SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER N/A VEINS (TELANGIECTASIA); LIMB OR TRUNK CPT 36469 SINGLE OR MULTIPLE INJECTIONS OF SCLEROSING SOLUTIONS, SPIDER N/A VEINS (TELANGIECTASIA); FACE CPT 36470 INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN 455 CPT 36471 INJECTION OF SCLEROSING SOLUTION; MULTIPLE VEINS, SAME LEG 547 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 122 of 380

CPT 36475 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 5,396 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED CPT 36476 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 36478 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, 4,288 INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED CPT 36479 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 36481 PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY METHOD 1,244 CPT 36500 VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING 624 CPT 36510 CATHETERIZATION OF UMBILICAL VEIN FOR DIAGNOSIS OR THERAPY, 285 NEWBORN CPT 36511 THERAPEUTIC APHERESIS; FOR WHITE BLOOD CELLS 302 CPT 36512 THERAPEUTIC APHERESIS; FOR RED BLOOD CELLS 304 CPT 36513 THERAPEUTIC APHERESIS; FOR PLATELETS 309 CPT 36514 THERAPEUTIC APHERESIS; FOR PLASMA PHERESIS 1,551 CPT 36515 THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL IMMUNOADSORPTION 5,957 AND PLASMA REINFUSION CPT 36516 THERAPEUTIC APHERESIS; WITH EXTRACORPOREAL SELECTIVE 6,405 ADSORPTION OR SELECTIVE FILTRATION AND PLASMA REINFUSION CPT 36522 PHOTOPHERESIS, EXTRACORPOREAL 4,939 CPT 36555 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; YOUNGER THAN 5 YEARS OF AGE CPT 36556 INSERTION OF NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER CPT 36557 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE CPT 36558 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER CPT 36560 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; YOUNGER THAN 5 YEARS OF AGE CPT 36561 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER CPT 36563 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PUMP CPT 36565 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITHOUT SUBCUTANEOUS PORT OR PUMP (EG, 830 698 2,616 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: 01.03.2015 Page No(s): 123 of 380

TESIO TYPE CATHETER) CPT 36566 INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, REQUIRING TWO CATHETERS VIA TWO SEPARATE VENOUS ACCESS SITES; WITH SUBCUTANEOUS PORT(S) CPT 36568 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; YOUNGER THAN 5 YEARS OF AGE CPT 36569 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER CPT 36570 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; YOUNGER THAN 5 YEARS OF AGE CPT 36571 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER CPT 36575 REPAIR OF TUNNELED OR NON-TUNNELED CENTRAL VENOUS ACCESS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT 36576 REPAIR OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT 36578 REPLACEMENT, CATHETER ONLY, OF CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION SITE CPT 36580 REPLACEMENT, COMPLETE, OF A NON-TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT 36581 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT 36582 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS CPT 36583 REPLACEMENT, COMPLETE, OF A TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PUMP, THROUGH SAME VENOUS ACCESS CPT 36584 REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP, THROUGH SAME VENOUS ACCESS CPT 36585 REPLACEMENT, COMPLETE, OF A PERIPHERALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT, THROUGH SAME VENOUS ACCESS CPT 36589 REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP CPT 36590 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT OR PUMP, CENTRAL OR PERIPHERAL INSERTION CPT 36591 COLLECTION OF BLOOD SPECIMEN FROM A COMPLETELY IMPLANTABLE VENOUS ACCESS DEVICE CPT 36592 COLLECTION OF BLOOD SPECIMEN USING ESTABLISHED CENTRAL OR PERIPHERAL CATHETER, VENOUS, NOT OTHERWISE SPECIFIED CPT 36593 DECLOTTING BY THROMBOLYTIC AGENT OF IMPLANTED VASCULAR ACCESS DEVICE OR CATHETER CPT 36595 MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS CPT 36596 MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN 14,982 995 815 3,417 3,827 526 1,171 1,621 687 2,410 3,392 3,404 674 3,470 550 928 69 85 149 1,842 425 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 124 of 380

CPT 36597 REPOSITIONING OF PREVIOUSLY PLACED CENTRAL VENOUS CATHETER 417 UNDER FLUOROSCOPIC GUIDANCE CPT 36598 CONTRAST INJECTION(S) FOR RADIOLOGIC EVALUATION OF EXISTING 378 CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT CPT 36600 ARTERIAL PUNCTURE, WITHDRAWAL OF BLOOD FOR DIAGNOSIS 105 CPT 36620 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, 172 MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); PERCUTANEOUS CPT 36625 ARTERIAL CATHETERIZATION OR CANNULATION FOR SAMPLING, 361 MONITORING OR TRANSFUSION (SEPARATE PROCEDURE); CUTDOWN CPT 36640 ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY 405 (CHEMOTHERAPY), CUTDOWN CPT 36660 CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR DIAGNOSIS OR 245 THERAPY CPT 36680 PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 200 CPT 36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN TO VEIN CPT 36810 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS, EXTERNAL (SCRIBNER TYPE) CPT 36815 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE CPT 36818 ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM CEPHALIC VEIN TRANSPOSITION CPT 36819 ARTERIOVENOUS ANASTOMOSIS, OPEN; BY UPPER ARM BASILIC VEIN TRANSPOSITION CPT 36820 ARTERIOVENOUS ANASTOMOSIS, OPEN; BY FOREARM VEIN TRANSPOSITION CPT 36821 ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE PROCEDURE) CPT 36822 INSERTION OF CANNULA(S) FOR PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY INSUFFICIENCY (ECMO) (SEPARATE PROCEDURE) CPT 36823 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 36825 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT CPT 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT) CPT 36831 THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) CPT 36832 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) CPT 36833 REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) 529 721 504 2,290 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: 01.03.2015 Page No(s): 125 of 380

CPT 36834 PLASTIC REPAIR OF ARTERIOVENOUS ANEURYSM (SEPARATE PROCEDURE) 2,102 CPT 36835 INSERTION OF THOMAS SHUNT (SEPARATE PROCEDURE) 1,529 CPT 36838 DISTAL REVASCULARIZATION AND INTERVAL LIGATION (DRIL), UPPER 3,985 EXTREMITY HEMODIALYSIS ACCESS (STEAL SYNDROME) CPT 36860 EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITHOUT 689 BALLOON CATHETER CPT 36861 EXTERNAL CANNULA DECLOTTING (SEPARATE PROCEDURE); WITH 504 BALLOON CATHETER CPT 36870 THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, 5,826 AUTOGENOUS OR NONAUTOGENOUS GRAFT (INCLUDES MECHANICAL THROMBUS EXTRACTION AND INTRA-GRAFT THROMBOLYSIS) CPT 37140 VENOUS ANASTOMOSIS, OPEN; PORTOCAVAL 4,540 CPT 37145 VENOUS ANASTOMOSIS, OPEN; RENOPORTAL 5,015 CPT 37160 VENOUS ANASTOMOSIS, OPEN; CAVAL-MESENTERIC 4,264 CPT 37180 VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, PROXIMAL 4,878 CPT 37181 VENOUS ANASTOMOSIS, OPEN; SPLENORENAL, DISTAL (SELECTIVE DECOMPRESSION OF ESOPHAGOGASTRIC VARICES, ANY TECHNIQUE) CPT 37182 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 37183 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 37184 PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NONCORONARY, ARTERIAL OR ARTERIAL BYPASS GRAFT, INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTION(S); INITIAL VESSEL CPT 37185 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 37186 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 37187 PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEIN(S), INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE CPT 37188 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: 01.03.2015 Page No(s): 126 of 380

INJECTIONS AND FLUOROSCOPIC GUIDANCE, REPEAT TREATMENT ON SUBSEQUENT DAY DURING COURSE OF THROMBOLYTIC THERAPY CPT 37195 THROMBOLYSIS, CEREBRAL, BY INTRAVENOUS INFUSION 1,033 CPT 37200 TRANSCATHETER BIOPSY 814 CPT 37201 TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER THAN 962 CORONARY CPT 37202 TRANSCATHETER THERAPY, INFUSION OTHER THAN FOR THROMBOLYSIS, 1,188 ANY TYPE (EG, SPASMOLYTIC, VASOCONSTRICTIVE) CPT 37203 TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR 4,462 FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER) CPT 37204 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 37205 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (EXCEPT 14,808 CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS; INITIAL VESSEL CPT 37206 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 37207 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S) (NON- 1,487 CORONARY VESSEL), OPEN; INITIAL VESSEL CPT 37208 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 37209 EXCHANGE OF A PREVIOUSLY PLACED INTRAVASCULAR CATHETER 401 DURING THROMBOLYTIC THERAPY CPT 37210 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 37215 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL 3,852 CAROTID ARTERY, PERCUTANEOUS; WITH DISTAL EMBOLIC PROTECTION CPT 37216 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), CERVICAL 3,228 CAROTID ARTERY, PERCUTANEOUS; WITHOUT DISTAL EMBOLIC PROTECTION CPT 37250 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 37251 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 37500 VASCULAR ENDOSCOPY, SURGICAL, WITH LIGATION OF PERFORATOR 2,319 VEINS, SUBFASCIAL (SEPS) CPT 37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE N/A CPT 37565 LIGATION, INTERNAL JUGULAR VEIN 2,321 CPT 37600 LIGATION; EXTERNAL CAROTID ARTERY 2,349 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 127 of 380

CPT 37605 LIGATION; INTERNAL OR COMMON CAROTID ARTERY 2,723 CPT 37606 LIGATION; INTERNAL OR COMMON CAROTID ARTERY, WITH GRADUAL 1,864 OCCLUSION, AS WITH SELVERSTONE OR CRUTCHFIELD CLAMP CPT 37607 LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA 1,267 CPT 37609 LIGATION OR BIOPSY, TEMPORAL ARTERY 954 CPT 37615 LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); NECK 1,572 CPT 37616 LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); CHEST 3,669 CPT 37617 LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); ABDOMEN 4,352 CPT 37618 LIGATION, MAJOR ARTERY (EG, POST-TRAUMATIC, RUPTURE); EXTREMITY 1,257 CPT 37620 INTERRUPTION, PARTIAL OR COMPLETE, OF INFERIOR VENA CAVA BY 2,246 SUTURE, LIGATION, PLICATION, CLIP, EXTRAVASCULAR, INTRAVASCULAR (UMBRELLA DEVICE) CPT 37650 LIGATION OF FEMORAL VEIN 1,718 CPT 37660 LIGATION OF COMMON ILIAC VEIN 4,063 CPT 37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT 840 SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS CPT 37718 LIGATION, DIVISION, AND STRIPPING, SHORT SAPHENOUS VEIN 1,343 CPT 37722 LIGATION, DIVISION, AND STRIPPING, LONG (GREATER) SAPHENOUS 1,589 VEINS FROM SAPHENOFEMORAL JUNCTION TO KNEE OR BELOW CPT 37735 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 37760 LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), 2,090 WITH OR WITHOUT SKIN GRAFT, OPEN CPT 37765 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; 10-20 STAB 1,470 INCISIONS CPT 37766 STAB PHLEBECTOMY OF VARICOSE VEINS, ONE EXTREMITY; MORE THAN 1,786 20 INCISIONS CPT 37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT 854 SAPHENOPOPLITEAL JUNCTION (SEPARATE PROCEDURE) CPT 37785 LIGATION, DIVISION, AND/OR EXCISION OF VARICOSE VEIN CLUSTER(S), 1,174 ONE LEG CPT 37788 PENILE REVASCULARIZATION, ARTERY, WITH OR WITHOUT VEIN GRAFT 4,722 CPT 37790 PENILE VENOUS OCCLUSIVE PROCEDURE 1,776 CPT 37799 UNLISTED PROCEDURE, VASCULAR SURGERY N/A CPT 38100 SPLENECTOMY; TOTAL (SEPARATE PROCEDURE) 3,554 CPT 38101 SPLENECTOMY; PARTIAL (SEPARATE PROCEDURE) 3,579 CPT 38102 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: 01.03.2015 Page No(s): 128 of 380

CPT 38115 REPAIR OF RUPTURED SPLEEN (SPLENORRHAPHY) WITH OR WITHOUT 3,943 PARTIAL SPLENECTOMY CPT 38120 LAPAROSCOPY, SURGICAL, SPLENECTOMY 3,291 CPT 38129 UNLISTED LAPAROSCOPY PROCEDURE, SPLEEN N/A CPT 38200 INJECTION PROCEDURE FOR SPLENOPORTOGRAPHY 487 CPT 38204 MANAGEMENT OF RECIPIENT HEMATOPOIETIC PROGENITOR CELL DONOR 317 SEARCH AND CELL ACQUISITION CPT 38205 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR 264 TRANSPLANTATION, PER COLLECTION; ALLOGENIC CPT 38206 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR 266 TRANSPLANTATION, PER COLLECTION; AUTOLOGOUS CPT 38207 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 163 CRYOPRESERVATION AND STORAGE CPT 38208 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 104 THAWING OF PREVIOUSLY FROZEN HARVEST, WITHOUT WASHING CPT 38209 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 45 THAWING OF PREVIOUSLY FROZEN HARVEST, WITH WASHING CPT 38210 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 290 SPECIFIC CELL DEPLETION WITHIN HARVEST, T-CELL DEPLETION CPT 38211 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 261 TUMOR CELL DEPLETION CPT 38212 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; RED 173 BLOOD CELL REMOVAL CPT 38213 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 45 PLATELET DEPLETION CPT 38214 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 148 PLASMA (VOLUME) DEPLETION CPT 38215 TRANSPLANT PREPARATION OF HEMATOPOIETIC PROGENITOR CELLS; 173 CELL CONCENTRATION IN PLASMA, MONONUCLEAR, OR BUFFY COAT LAYER CPT 38220 BONE MARROW; ASPIRATION ONLY 479 CPT 38221 BONE MARROW; BIOPSY, NEEDLE OR TROCAR 532 CPT 38230 BONE MARROW HARVESTING FOR TRANSPLANTATION 1,058 CPT 38240 BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 414 TRANSPLANTATION; ALLOGENIC CPT 38241 BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 414 TRANSPLANTATION; AUTOLOGOUS CPT 38242 BONE MARROW OR BLOOD-DERIVED PERIPHERAL STEM CELL 309 TRANSPLANTATION; ALLOGENEIC DONOR LYMPHOCYTE INFUSIONS CPT 38300 DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; SIMPLE 849 CPT 38305 DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS; EXTENSIVE 1,463 CPT 38308 LYMPHANGIOTOMY OR OTHER OPERATIONS ON LYMPHATIC CHANNELS 1,399 CPT 38380 SUTURE AND/OR LIGATION OF THORACIC DUCT; CERVICAL APPROACH 1,779 CPT 38381 SUTURE AND/OR LIGATION OF THORACIC DUCT; THORACIC APPROACH 2,674 CPT 38382 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: 01.03.2015 Page No(s): 129 of 380

CPT 38500 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, SUPERFICIAL 1,006 CPT 38505 BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, 420 CERVICAL, INGUINAL, AXILLARY) CPT 38510 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL 1,609 NODE(S) CPT 38520 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL 1,452 NODE(S) WITH EXCISION SCALENE FAT PAD CPT 38525 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP AXILLARY NODE(S) 1,336 CPT 38530 BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, INTERNAL MAMMARY 1,699 NODE(S) CPT 38542 DISSECTION, DEEP JUGULAR NODE(S) 1,340 CPT 38550 EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITHOUT DEEP 1,529 NEUROVASCULAR DISSECTION CPT 38555 EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITH DEEP 3,100 NEUROVASCULAR DISSECTION CPT 38562 LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE PROCEDURE); 2,251 PELVIC AND PARA-AORTIC CPT 38564 LIMITED LYMPHADENECTOMY FOR STAGING (SEPARATE PROCEDURE); 2,243 RETROPERITONEAL (AORTIC AND/OR SPLENIC) CPT 38570 LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE 1,818 SAMPLING (BIOPSY), SINGLE OR MULTIPLE CPT 38571 LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC 2,850 LYMPHADENECTOMY CPT 38572 LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC 3,110 LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE CPT 38589 UNLISTED LAPAROSCOPY PROCEDURE, LYMPHATIC SYSTEM N/A CPT 38700 SUPRAHYOID LYMPHADENECTOMY 2,506 CPT 38720 CERVICAL LYMPHADENECTOMY (COMPLETE) 4,166 CPT 38724 CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION) 4,522 CPT 38740 AXILLARY LYMPHADENECTOMY; SUPERFICIAL 2,125 CPT 38745 AXILLARY LYMPHADENECTOMY; COMPLETE 2,706 CPT 38746 THORACIC LYMPHADENECTOMY, REGIONAL, INCLUDING MEDIASTINAL AND PERITRACHEAL NODES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 38747 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 38760 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUETS NODE (SEPARATE PROCEDURE) CPT 38765 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, IN CONTINUITY WITH PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE) CPT 38770 PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES (SEPARATE PROCEDURE) CPT 38780 RETROPERITONEAL TRANSABDOMINAL LYMPHADENECTOMY, EXTENSIVE, INCLUDING PELVIC, AORTIC, AND RENAL NODES (SEPARATE PROCEDURE) 883 854 2,659 4,104 2,781 3,453 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 130 of 380

CPT 38790 INJECTION PROCEDURE; LYMPHANGIOGRAPHY 273 CPT 38792 INJECTION PROCEDURE; FOR IDENTIFICATION OF SENTINEL NODE 134 CPT 38794 CANNULATION, THORACIC DUCT 1,008 CPT 38999 UNLISTED PROCEDURE, HEMIC OR LYMPHATIC SYSTEM N/A CPT 39000 MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, REMOVAL OF 1,592 FOREIGN BODY, OR BIOPSY; CERVICAL APPROACH CPT 39010 MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, REMOVAL OF 2,669 FOREIGN BODY, OR BIOPSY; TRANSTHORACIC APPROACH, INCLUDING EITHER TRANSTHORACIC OR MEDIAN STERNOTOMY CPT 39200 EXCISION OF MEDIASTINAL CYST 2,928 CPT 39220 EXCISION OF MEDIASTINAL TUMOR 3,767 CPT 39400 MEDIASTINOSCOPY, WITH OR WITHOUT BIOPSY 1,632 CPT 39499 UNLISTED PROCEDURE, MEDIASTINUM N/A CPT 39501 REPAIR, LACERATION OF DIAPHRAGM, ANY APPROACH 2,704 CPT 39502 REPAIR, PARAESOPHAGEAL HIATUS HERNIA, TRANSABDOMINAL, WITH OR 3,253 WITHOUT FUNDOPLASTY, VAGOTOMY, AND/OR PYLOROPLASTY, EXCEPT NEONATAL CPT 39503 REPAIR, NEONATAL DIAPHRAGMATIC HERNIA, WITH OR WITHOUT CHEST 18,510 TUBE INSERTION AND WITH OR WITHOUT CREATION OF VENTRAL HERNIA CPT 39520 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); 3,231 TRANSTHORACIC CPT 39530 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, 3,091 THORACOABDOMINAL CPT 39531 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, 3,276 THORACOABDOMINAL, WITH DILATION OF STRICTURE (WITH OR WITHOUT GASTROPLASTY) CPT 39540 REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; 2,770 ACUTE CPT 39541 REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; 2,979 CHRONIC CPT 39545 IMBRICATION OF DIAPHRAGM FOR EVENTRATION, TRANSTHORACIC OR 2,939 TRANSABDOMINAL, PARALYTIC OR NONPARALYTIC CPT 39560 RESECTION, DIAPHRAGM; WITH SIMPLE REPAIR (EG, PRIMARY SUTURE) 2,527 CPT 39561 RESECTION, DIAPHRAGM; WITH COMPLEX REPAIR (EG, PROSTHETIC 3,967 MATERIAL, LOCAL MUSCLE FLAP) CPT 39599 UNLISTED PROCEDURE, DIAPHRAGM N/A CPT 40490 BIOPSY OF LIP 421 CPT 40500 VERMILIONECTOMY (LIP SHAVE), WITH MUCOSAL ADVANCEMENT 1,590 CPT 40510 EXCISION OF LIP; TRANSVERSE WEDGE EXCISION WITH PRIMARY 1,506 CLOSURE CPT 40520 EXCISION OF LIP; V-EXCISION WITH PRIMARY DIRECT LINEAR CLOSURE 1,539 CPT 40525 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: 01.03.2015 Page No(s): 131 of 380

CPT 40527 EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH CROSS LIP 2,052 FLAP (ABBE-ESTLANDER) CPT 40530 RESECTION OF LIP, MORE THAN ONE-FOURTH, WITHOUT 1,710 RECONSTRUCTION CPT 40650 REPAIR LIP, FULL THICKNESS; VERMILION ONLY 1,266 CPT 40652 REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT 1,523 CPT 40654 REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR 1,769 COMPLEX CPT 40700 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR 2,968 COMPLETE, UNILATERAL CPT 40701 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 3,335 ONE STAGE PROCEDURE CPT 40702 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, 2,660 ONE OF TWO STAGES CPT 40720 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY 3,256 RECREATION OF DEFECT AND RECLOSURE CPT 40761 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; WITH CROSS LIP 3,388 PEDICLE FLAP (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND INSERTING OF PEDICLE CPT 40799 UNLISTED PROCEDURE, LIPS N/A CPT 40800 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; 649 SIMPLE CPT 40801 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH; 976 COMPLICATED CPT 40804 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; SIMPLE 649 CPT 40805 REMOVAL OF EMBEDDED FOREIGN BODY, VESTIBULE OF MOUTH; 1,030 COMPLICATED CPT 40806 INCISION OF LABIAL FRENUM (FRENOTOMY) 349 CPT 40808 BIOPSY, VESTIBULE OF MOUTH 590 CPT 40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 648 MOUTH; WITHOUT REPAIR CPT 40812 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 899 MOUTH; WITH SIMPLE REPAIR CPT 40814 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 1,202 MOUTH; WITH COMPLEX REPAIR CPT 40816 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF 1,259 MOUTH; COMPLEX, WITH EXCISION OF UNDERLYING MUSCLE CPT 40818 EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT 1,102 CPT 40819 EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, 965 FRENULECTOMY, FRENECTOMY) CPT 40820 DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY 844 PHYSICAL METHODS (EG, LASER, THERMAL, CRYO, CHEMICAL) CPT 40830 CLOSURE OF LACERATION, VESTIBULE OF MOUTH; 2.5 CM OR LESS 756 CPT 40831 CLOSURE OF LACERATION, VESTIBULE OF MOUTH; OVER 2.5 CM OR 1,011 COMPLEX CPT 40840 VESTIBULOPLASTY; ANTERIOR 2,535 CPT 40842 VESTIBULOPLASTY; POSTERIOR, UNILATERAL 2,558 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 132 of 380

CPT 40843 VESTIBULOPLASTY; POSTERIOR, BILATERAL 3,190 CPT 40844 VESTIBULOPLASTY; ENTIRE ARCH 4,254 CPT 40845 VESTIBULOPLASTY; COMPLEX (INCLUDING RIDGE EXTENSION, MUSCLE 4,679 REPOSITIONING) CPT 40899 UNLISTED PROCEDURE, VESTIBULE OF MOUTH N/A CPT 41000 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 503 OF TONGUE OR FLOOR OF MOUTH; LINGUAL CPT 41005 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 721 OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, SUPERFICIAL CPT 41006 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,141 OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, DEEP, SUPRAMYLOHYOID CPT 41007 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,107 OF TONGUE OR FLOOR OF MOUTH; SUBMENTAL SPACE CPT 41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,175 OF TONGUE OR FLOOR OF MOUTH; SUBMANDIBULAR SPACE CPT 41009 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,249 OF TONGUE OR FLOOR OF MOUTH; MASTICATOR SPACE CPT 41010 INCISION OF LINGUAL FRENUM (FRENOTOMY) 635 CPT 41015 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,353 OF FLOOR OF MOUTH; SUBLINGUAL CPT 41016 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,368 OF FLOOR OF MOUTH; SUBMENTAL CPT 41017 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,385 OF FLOOR OF MOUTH; SUBMANDIBULAR CPT 41018 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA 1,583 OF FLOOR OF MOUTH; MASTICATOR SPACE CPT 41019 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 41100 BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS 531 CPT 41105 BIOPSY OF TONGUE; POSTERIOR ONE-THIRD 534 CPT 41108 BIOPSY OF FLOOR OF MOUTH 464 CPT 41110 EXCISION OF LESION OF TONGUE WITHOUT CLOSURE 669 CPT 41112 EXCISION OF LESION OF TONGUE WITH CLOSURE; ANTERIOR TWO- 1,045 THIRDS CPT 41113 EXCISION OF LESION OF TONGUE WITH CLOSURE; POSTERIOR ONE- 1,144 THIRD CPT 41114 EXCISION OF LESION OF TONGUE WITH CLOSURE; WITH LOCAL TONGUE 1,993 FLAP CPT 41115 EXCISION OF LINGUAL FRENUM (FRENECTOMY) 771 CPT 41116 EXCISION, LESION OF FLOOR OF MOUTH 1,039 CPT 41120 GLOSSECTOMY; LESS THAN ONE-HALF TONGUE 3,277 CPT 41130 GLOSSECTOMY; HEMIGLOSSECTOMY 4,069 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 133 of 380

CPT 41135 GLOSSECTOMY; PARTIAL, WITH UNILATERAL RADICAL NECK DISSECTION 6,745 CPT 41140 GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT 6,881 TRACHEOSTOMY, WITHOUT RADICAL NECK DISSECTION CPT 41145 GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT 8,681 TRACHEOSTOMY, WITH UNILATERAL RADICAL NECK DISSECTION CPT 41150 GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 6,862 MOUTH AND MANDIBULAR RESECTION, WITHOUT RADICAL NECK DISSECTION CPT 41153 GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 7,456 MOUTH, WITH SUPRAHYOID NECK DISSECTION CPT 41155 GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF 9,304 MOUTH, MANDIBULAR RESECTION, AND RADICAL NECK DISSECTION (COMMANDO TYPE) CPT 41250 REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR 751 ANTERIOR TWO-THIRDS OF TONGUE CPT 41251 REPAIR OF LACERATION 2.5 CM OR LESS; POSTERIOR ONE-THIRD OF 755 TONGUE CPT 41252 REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR 991 COMPLEX CPT 41500 FIXATION OF TONGUE, MECHANICAL, OTHER THAN SUTURE (EG, K-WIRE) 1,456 CPT 41510 SUTURE OF TONGUE TO LIP FOR MICROGNATHIA (DOUGLAS TYPE 1,275 PROCEDURE) CPT 41520 FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, WITH Z-PLASTY) 1,113 CPT 41599 UNLISTED PROCEDURE, TONGUE, FLOOR OF MOUTH N/A CPT 41800 DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR 771 STRUCTURES CPT 41805 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 761 STRUCTURES; SOFT TISSUES CPT 41806 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR 1,124 STRUCTURES; BONE CPT 41820 GINGIVECTOMY, EXCISION GINGIVA, EACH QUADRANT 788 CPT 41821 OPERCULECTOMY, EXCISION PERICORONAL TISSUES 177 CPT 41822 EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 938 CPT 41823 EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 1,329 CPT 41825 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 653 DENTOALVEOLAR STRUCTURES; WITHOUT REPAIR CPT 41826 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 974 DENTOALVEOLAR STRUCTURES; WITH SIMPLE REPAIR CPT 41827 EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), 1,349 DENTOALVEOLAR STRUCTURES; WITH COMPLEX REPAIR CPT 41828 EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA, EACH QUADRANT 961 (SPECIFY) CPT 41830 ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR 1,234 SEQUESTRECTOMY CPT 41850 DESTRUCTION OF LESION (EXCEPT EXCISION), DENTOALVEOLAR 394 STRUCTURES CPT 41870 PERIODONTAL MUCOSAL GRAFTING 984 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 134 of 380

CPT 41872 GINGIVOPLASTY, EACH QUADRANT (SPECIFY) 1,164 CPT 41874 ALVEOLOPLASTY, EACH QUADRANT (SPECIFY) 1,164 CPT 41899 UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES N/A CPT 42000 DRAINAGE OF ABSCESS OF PALATE, UVULA 484 CPT 42100 BIOPSY OF PALATE, UVULA 469 CPT 42104 EXCISION, LESION OF PALATE, UVULA; WITHOUT CLOSURE 679 CPT 42106 EXCISION, LESION OF PALATE, UVULA; WITH SIMPLE PRIMARY CLOSURE 858 CPT 42107 EXCISION, LESION OF PALATE, UVULA; WITH LOCAL FLAP CLOSURE 1,442 CPT 42120 RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION 3,085 CPT 42140 UVULECTOMY, EXCISION OF UVULA 800 CPT 42145 PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, 2,236 UVULOPHARYNGOPLASTY) CPT 42160 DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR 726 CHEMICAL) CPT 42180 REPAIR, LACERATION OF PALATE; UP TO 2 CM 769 CPT 42182 REPAIR, LACERATION OF PALATE; OVER 2 CM OR COMPLEX 1,035 CPT 42200 PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY 2,808 CPT 42205 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; 2,834 SOFT TISSUE ONLY CPT 42210 PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; 3,440 WITH BONE GRAFT TO ALVEOLAR RIDGE (INCLUDES OBTAINING GRAFT) CPT 42215 PALATOPLASTY FOR CLEFT PALATE; MAJOR REVISION 2,216 CPT 42220 PALATOPLASTY FOR CLEFT PALATE; SECONDARY LENGTHENING 1,890 PROCEDURE CPT 42225 PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP 2,866 CPT 42226 LENGTHENING OF PALATE, AND PHARYNGEAL FLAP 2,915 CPT 42227 LENGTHENING OF PALATE, WITH ISLAND FLAP 2,770 CPT 42235 REPAIR OF ANTERIOR PALATE, INCLUDING VOMER FLAP 2,390 CPT 42260 REPAIR OF NASOLABIAL FISTULA 2,655 CPT 42280 MAXILLARY IMPRESSION FOR PALATAL PROSTHESIS 500 CPT 42281 INSERTION OF PIN-RETAINED PALATAL PROSTHESIS 648 CPT 42299 UNLISTED PROCEDURE, PALATE, UVULA N/A CPT 42300 DRAINAGE OF ABSCESS; PAROTID, SIMPLE 660 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 135 of 380

CPT 42305 DRAINAGE OF ABSCESS; PAROTID, COMPLICATED 1,350 CPT 42310 DRAINAGE OF ABSCESS; SUBMAXILLARY OR SUBLINGUAL, INTRAORAL 503 CPT 42320 DRAINAGE OF ABSCESS; SUBMAXILLARY, EXTERNAL 795 CPT 42330 SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR 733 PAROTID, UNCOMPLICATED, INTRAORAL CPT 42335 SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), COMPLICATED, 1,184 INTRAORAL CPT 42340 SIALOLITHOTOMY; PAROTID, EXTRAORAL OR COMPLICATED INTRAORAL 1,481 CPT 42400 BIOPSY OF SALIVARY GLAND; NEEDLE 357 CPT 42405 BIOPSY OF SALIVARY GLAND; INCISIONAL 951 CPT 42408 EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) 1,441 CPT 42409 MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) 1,062 CPT 42410 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, 1,981 WITHOUT NERVE DISSECTION CPT 42415 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH 3,530 DISSECTION AND PRESERVATION OF FACIAL NERVE CPT 42420 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH 4,040 DISSECTION AND PRESERVATION OF FACIAL NERVE CPT 42425 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, EN BLOC 2,668 REMOVAL WITH SACRIFICE OF FACIAL NERVE CPT 42426 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH 4,324 UNILATERAL RADICAL NECK DISSECTION CPT 42440 EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND 1,447 CPT 42450 EXCISION OF SUBLINGUAL GLAND 1,442 CPT 42500 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR 1,368 SIMPLE CPT 42505 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; SECONDARY 1,769 OR COMPLICATED CPT 42507 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); 1,635 CPT 42508 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 2,308 EXCISION OF ONE SUBMANDIBULAR GLAND CPT 42509 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 2,706 EXCISION OF BOTH SUBMANDIBULAR GLANDS CPT 42510 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH 1,991 LIGATION OF BOTH SUBMANDIBULAR (WHARTON'S) DUCTS CPT 42550 INJECTION PROCEDURE FOR SIALOGRAPHY 453 CPT 42600 CLOSURE SALIVARY FISTULA 1,492 CPT 42650 DILATION SALIVARY DUCT 268 CPT 42660 DILATION AND CATHETERIZATION OF SALIVARY DUCT, WITH OR 337 WITHOUT INJECTION CPT 42665 LIGATION SALIVARY DUCT, INTRAORAL 981 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 136 of 380

CPT 42699 UNLISTED PROCEDURE, SALIVARY GLANDS OR DUCTS N/A CPT 42700 INCISION AND DRAINAGE ABSCESS; PERITONSILLAR 596 CPT 42720 INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR 1,441 PARAPHARYNGEAL, INTRAORAL APPROACH CPT 42725 INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR 2,552 PARAPHARYNGEAL, EXTERNAL APPROACH CPT 42800 BIOPSY; OROPHARYNX 502 CPT 42802 BIOPSY; HYPOPHARYNX 732 CPT 42804 BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE 623 CPT 42806 BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN PRIMARY LESION 699 CPT 42808 EXCISION OR DESTRUCTION OF LESION OF PHARYNX, ANY METHOD 721 CPT 42809 REMOVAL OF FOREIGN BODY FROM PHARYNX 531 CPT 42810 EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN AND 1,236 SUBCUTANEOUS TISSUES CPT 42815 EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, EXTENDING 1,774 BENEATH SUBCUTANEOUS TISSUES AND/OR INTO PHARYNX CPT 42820 TONSILLECTOMY AND ADENOIDECTOMY; YOUNGER THAN AGE 12 922 CPT 42821 TONSILLECTOMY AND ADENOIDECTOMY; AGE 12 OR OVER 962 CPT 42825 TONSILLECTOMY, PRIMARY OR SECONDARY; YOUNGER THAN AGE 12 830 CPT 42826 TONSILLECTOMY, PRIMARY OR SECONDARY; AGE 12 OR OVER 800 CPT 42830 ADENOIDECTOMY, PRIMARY; YOUNGER THAN AGE 12 658 CPT 42831 ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER 708 CPT 42835 ADENOIDECTOMY, SECONDARY; YOUNGER THAN AGE 12 543 CPT 42836 ADENOIDECTOMY, SECONDARY; AGE 12 OR OVER 770 CPT 42842 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 3,119 RETROMOLAR TRIGONE; WITHOUT CLOSURE CPT 42844 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 4,306 RETROMOLAR TRIGONE; CLOSURE WITH LOCAL FLAP (EG, TONGUE, BUCCAL) CPT 42845 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR 6,987 RETROMOLAR TRIGONE; CLOSURE WITH OTHER FLAP CPT 42860 EXCISION OF TONSIL TAGS 595 CPT 42870 EXCISION OR DESTRUCTION LINGUAL TONSIL, ANY METHOD (SEPARATE 1,836 PROCEDURE) CPT 42890 LIMITED PHARYNGECTOMY 4,434 CPT 42892 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: 01.03.2015 Page No(s): 137 of 380

CPT 42894 RESECTION OF PHARYNGEAL WALL REQUIRING CLOSURE WITH 7,430 MYOCUTANEOUS FLAP CPT 42900 SUTURE PHARYNX FOR WOUND OR INJURY 1,097 CPT 42950 PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIVE OPERATION ON 2,512 PHARYNX) CPT 42953 PHARYNGOESOPHAGEAL REPAIR 3,020 CPT 42955 PHARYNGOSTOMY (FISTULIZATION OF PHARYNX, EXTERNAL FOR 2,370 FEEDING) CPT 42960 CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 536 POST-TONSILLECTOMY); SIMPLE CPT 42961 CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 1,337 POST-TONSILLECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION CPT 42962 CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 1,646 POST-TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION CPT 42970 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 42971 CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY 1,455 (EG, POSTADENOIDECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION CPT 42972 CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY 1,653 (EG, POSTADENOIDECTOMY); WITH SECONDARY SURGICAL INTERVENTION CPT 42999 UNLISTED PROCEDURE, PHARYNX, ADENOIDS, OR TONSILS N/A CPT 43020 ESOPHAGOTOMY, CERVICAL APPROACH, WITH REMOVAL OF FOREIGN 1,710 BODY CPT 43030 CRICOPHARYNGEAL MYOTOMY 1,652 CPT 43045 ESOPHAGOTOMY, THORACIC APPROACH, WITH REMOVAL OF FOREIGN BODY CPT 43100 EXCISION OF LESION, ESOPHAGUS, WITH PRIMARY REPAIR; CERVICAL APPROACH CPT 43101 EXCISION OF LESION, ESOPHAGUS, WITH PRIMARY REPAIR; THORACIC OR ABDOMINAL APPROACH CPT 43107 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY (TRANSHIATAL) CPT 43108 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION AND ANASTOMOSIS(ES) CPT 43112 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT 43113 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PREPARATION, AND ANASTOMOSIS(ES) CPT 43116 PARTIAL ESOPHAGECTOMY, CERVICAL, WITH FREE INTESTINAL GRAFT, INCLUDING MICROVASCULAR ANASTOMOSIS, OBTAINING THE GRAFT AND INTESTINAL RECONSTRUCTION CPT 43117 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: 01.03.2015 Page No(s): 138 of 380

WITHOUT PYLOROPLASTY (IVOR LEWIS) CPT 43118 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 43121 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, WITH THORACOTOMY ONLY, WITH OR WITHOUT PROXIMAL GASTRECTOMY, WITH THORACIC ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT 43122 PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, WITH OR WITHOUT PROXIMAL GASTRECTOMY; WITH ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY CPT 43123 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 43124 TOTAL OR PARTIAL ESOPHAGECTOMY, WITHOUT RECONSTRUCTION (ANY APPROACH), WITH CERVICAL ESOPHAGOSTOMY CPT 43130 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; CERVICAL APPROACH CPT 43135 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; THORACIC APPROACH CPT 43200 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 43201 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT 43202 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE CPT 43204 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL VARICES CPT 43205 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BAND LIGATION OF ESOPHAGEAL VARICES CPT 43215 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF FOREIGN BODY CPT 43216 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT 43217 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT 43219 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF PLASTIC TUBE OR STENT CPT 43220 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION (LESS THAN 30 MM DIAMETER) CPT 43226 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OVER GUIDE WIRE CPT 43227 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT 43228 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 43231 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION CPT 43232 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 4,828 685 990 907 764 770 517 714 1,225 577 427 480 709 753 652 906 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 139 of 380

ASPIRATION/BIOPSY(S) CPT 43234 UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION (EG, WITH SMALL DIAMETER FLEXIBLE ENDOSCOPE) (SEPARATE PROCEDURE) CPT 43235 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 43236 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT 43237 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS CPT 43238 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 43239 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE CPT 43240 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST CPT 43241 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR CATHETER PLACEMENT CPT 43242 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 43243 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 43244 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 43245 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 43246 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE 901 990 1,239 826 1,009 1,151 1,346 528 1,448 912 1,014 638 852 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 140 of 380

CPT 43247 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 684 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH REMOVAL OF FOREIGN BODY CPT 43248 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 43249 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 43250 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 43251 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 43255 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 967 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD CPT 43256 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, 869 STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT 43257 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 43258 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 43259 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 43260 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,188 DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 43261 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,248 WITH BIOPSY, SINGLE OR MULTIPLE CPT 43262 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,466 WITH SPHINCTEROTOMY/PAPILLOTOMY CPT 43263 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,442 WITH PRESSURE MEASUREMENT OF SPHINCTER OF ODDI (PANCREATIC DUCT OR COMMON BILE DUCT) CPT 43264 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,759 WITH ENDOSCOPIC RETROGRADE REMOVAL OF CALCULUS/CALCULI FROM BILIARY AND/OR PANCREATIC DUCTS CPT 43265 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: 01.03.2015 Page No(s): 141 of 380

CPT 43267 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,423 WITH ENDOSCOPIC RETROGRADE INSERTION OF NASOBILIARY OR NASOPANCREATIC DRAINAGE TUBE CPT 43268 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,486 WITH ENDOSCOPIC RETROGRADE INSERTION OF TUBE OR STENT INTO BILE OR PANCREATIC DUCT CPT 43269 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,623 WITH ENDOSCOPIC RETROGRADE REMOVAL OF FOREIGN BODY AND/OR CHANGE OF TUBE OR STENT CPT 43271 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); 1,463 WITH ENDOSCOPIC RETROGRADE BALLOON DILATION OF AMPULLA, BILIARY AND/OR PANCREATIC DUCT(S) CPT 43272 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 43280 LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, 3,390 NISSEN, TOUPET PROCEDURES) CPT 43289 UNLISTED LAPAROSCOPY PROCEDURE, ESOPHAGUS N/A CPT 43300 ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL 1,981 APPROACH; WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT 43305 ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL 3,506 APPROACH; WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT 43310 ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC 4,985 APPROACH; WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT 43312 ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC 5,477 APPROACH; WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA CPT 43313 ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR 8,951 RECONSTRUCTION), THORACIC APPROACH; WITHOUT REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA CPT 43314 ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR 9,428 RECONSTRUCTION), THORACIC APPROACH; WITH REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA CPT 43320 ESOPHAGOGASTROSTOMY (CARDIOPLASTY), WITH OR WITHOUT 4,346 VAGOTOMY AND PYLOROPLASTY, TRANSABDOMINAL OR TRANSTHORACIC APPROACH CPT 43324 ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, BELSEY IV, HILL 4,275 PROCEDURES) CPT 43325 ESOPHAGOGASTRIC FUNDOPLASTY; WITH FUNDIC PATCH (THAL-NISSEN 4,211 PROCEDURE) CPT 43326 ESOPHAGOGASTRIC FUNDOPLASTY; WITH GASTROPLASTY (EG, COLLIS) 4,306 CPT 43330 ESOPHAGOMYOTOMY (HELLER TYPE); ABDOMINAL APPROACH 4,127 CPT 43331 ESOPHAGOMYOTOMY (HELLER TYPE); THORACIC APPROACH 4,493 CPT 43340 ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY); ABDOMINAL APPROACH CPT 43341 ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL GASTRECTOMY); THORACIC APPROACH CPT 43350 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; ABDOMINAL APPROACH CPT 43351 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; THORACIC APPROACH CPT 43352 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: 01.03.2015 Page No(s): 142 of 380

CPT 43360 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 43361 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 43400 LIGATION, DIRECT, ESOPHAGEAL VARICES 5,164 CPT 43401 TRANSECTION OF ESOPHAGUS WITH REPAIR, FOR ESOPHAGEAL VARICES 4,903 CPT 43405 LIGATION OR STAPLING AT GASTROESOPHAGEAL JUNCTION FOR PRE- 4,791 EXISTING ESOPHAGEAL PERFORATION CPT 43410 SUTURE OF ESOPHAGEAL WOUND OR INJURY; CERVICAL APPROACH 3,231 CPT 43415 SUTURE OF ESOPHAGEAL WOUND OR INJURY; TRANSTHORACIC OR 5,547 TRANSABDOMINAL APPROACH CPT 43420 CLOSURE OF ESOPHAGOSTOMY OR FISTULA; CERVICAL APPROACH 3,217 CPT 43425 CLOSURE OF ESOPHAGOSTOMY OR FISTULA; TRANSTHORACIC OR 4,833 TRANSABDOMINAL APPROACH CPT 43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR 524 MULTIPLE PASSES CPT 43453 DILATION OF ESOPHAGUS, OVER GUIDE WIRE 998 CPT 43456 DILATION OF ESOPHAGUS, BY BALLOON OR DILATOR, RETROGRADE 1,987 CPT 43458 DILATION OF ESOPHAGUS WITH BALLOON (30 MM DIAMETER OR LARGER) 1,287 FOR ACHALASIA CPT 43460 ESOPHAGOGASTRIC TAMPONADE, WITH BALLOON (SENGSTAAKEN TYPE) 737 CPT 43496 FREE JEJUNUM TRANSFER WITH MICROVASCULAR ANASTOMOSIS N/A CPT 43499 UNLISTED PROCEDURE, ESOPHAGUS N/A CPT 43500 GASTROTOMY; WITH EXPLORATION OR FOREIGN BODY REMOVAL 2,448 CPT 43501 GASTROTOMY; WITH SUTURE REPAIR OF BLEEDING ULCER 4,181 CPT 43502 GASTROTOMY; WITH SUTURE REPAIR OF PRE-EXISTING 4,736 ESOPHAGOGASTRIC LACERATION (EG, MALLORY-WEISS) CPT 43510 GASTROTOMY; WITH ESOPHAGEAL DILATION AND INSERTION OF 3,226 PERMANENT INTRALUMINAL TUBE (EG, CELESTIN OR MOUSSEAUX- BARBIN) CPT 43520 PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE (FREDET-RAMSTEDT 2,188 TYPE OPERATION) CPT 43600 BIOPSY OF STOMACH; BY CAPSULE, TUBE, PERORAL (ONE OR MORE 354 SPECIMENS) CPT 43605 BIOPSY OF STOMACH; BY LAPAROTOMY 2,590 CPT 43610 EXCISION, LOCAL; ULCER OR BENIGN TUMOR OF STOMACH 3,049 CPT 43611 EXCISION, LOCAL; MALIGNANT TUMOR OF STOMACH 3,788 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 143 of 380

CPT 43620 GASTRECTOMY, TOTAL; WITH ESOPHAGOENTEROSTOMY 6,163 CPT 43621 GASTRECTOMY, TOTAL; WITH ROUX-EN-Y RECONSTRUCTION 7,029 CPT 43622 GASTRECTOMY, TOTAL; WITH FORMATION OF INTESTINAL POUCH, ANY 7,138 TYPE CPT 43631 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTRODUODENOSTOMY 4,526 CPT 43632 GASTRECTOMY, PARTIAL, DISTAL; WITH GASTROJEJUNOSTOMY 6,202 CPT 43633 GASTRECTOMY, PARTIAL, DISTAL; WITH ROUX-EN-Y RECONSTRUCTION 5,894 CPT 43634 GASTRECTOMY, PARTIAL, DISTAL; WITH FORMATION OF INTESTINAL 6,498 POUCH CPT 43635 VAGOTOMY WHEN PERFORMED WITH PARTIAL DISTAL GASTRECTOMY 358 (LIST SEPARATELY IN ADDITION TO CODE(S) FOR PRIMARY PROCEDURE) CPT 43640 VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 3,654 GASTROSTOMY; TRUNCAL OR SELECTIVE CPT 43641 VAGOTOMY INCLUDING PYLOROPLASTY, WITH OR WITHOUT 3,720 GASTROSTOMY; PARIETAL CELL (HIGHLY SELECTIVE) CPT 43644 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 5,350 GASTRIC BYPASS AND ROUX-EN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) CPT 43645 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH 5,714 GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION CPT 43647 LAPAROSCOPY, SURGICAL; IMPLANTATION OR REPLACEMENT OF GASTRIC N/A NEUROSTIMULATOR ELECTRODES, ANTRUM CPT 43648 LAPAROSCOPY, SURGICAL; REVISION OR REMOVAL OF GASTRIC N/A NEUROSTIMULATOR ELECTRODES, ANTRUM CPT 43651 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL 2,023 CPT 43652 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, SELECTIVE 2,380 OR HIGHLY SELECTIVE CPT 43653 LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF 1,744 GASTRIC TUBE (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE) CPT 43659 UNLISTED LAPAROSCOPY PROCEDURE, STOMACH N/A CPT 43752 NASO- OR ORO-GASTRIC TUBE PLACEMENT, REQUIRING PHYSICIAN'S SKILL AND FLUOROSCOPIC GUIDANCE (INCLUDES FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT) CPT 43760 CHANGE OF GASTROSTOMY TUBE, PERCUTANEOUS, WITHOUT IMAGING OR ENDOSCOPIC GUIDANCE CPT 43761 REPOSITIONING OF THE GASTRIC FEEDING TUBE, THROUGH THE DUODENUM FOR ENTERIC NUTRITION CPT 43770 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) CPT 43771 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REVISION OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT 43772 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT 43773 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL AND REPLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY CPT 43774 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS 138 878 400 3,453 3,942 2,964 3,940 2,981 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 144 of 380

PORT COMPONENTS CPT 43800 PYLOROPLASTY 2,893 CPT 43810 GASTRODUODENOSTOMY 3,131 CPT 43820 GASTROJEJUNOSTOMY; WITHOUT VAGOTOMY 4,093 CPT 43825 GASTROJEJUNOSTOMY; WITH VAGOTOMY, ANY TYPE 4,036 CPT 43830 GASTROSTOMY, OPEN; WITHOUT CONSTRUCTION OF GASTRIC TUBE (EG, 2,161 STAMM PROCEDURE) (SEPARATE PROCEDURE) CPT 43831 GASTROSTOMY, OPEN; NEONATAL, FOR FEEDING 1,804 CPT 43832 GASTROSTOMY, OPEN; WITH CONSTRUCTION OF GASTRIC TUBE (EG, 3,311 JANEWAY PROCEDURE) CPT 43840 GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR GASTRIC 4,142 ULCER, WOUND, OR INJURY CPT 43842 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR 3,788 MORBID OBESITY; VERTICAL-BANDED GASTROPLASTY CPT 43843 GASTRIC RESTRICTIVE PROCEDURE, WITHOUT GASTRIC BYPASS, FOR 3,951 MORBID OBESITY; OTHER THAN VERTICAL-BANDED GASTROPLASTY CPT 43845 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 43846 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID 5,085 OBESITY; WITH SHORT LIMB (150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY CPT 43847 GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID 5,560 OBESITY; WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION CPT 43848 REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID 6,011 OBESITY, OTHER THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE) CPT 43850 REVISION OF GASTRODUODENAL ANASTOMOSIS 5,063 (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITHOUT VAGOTOMY CPT 43855 REVISION OF GASTRODUODENAL ANASTOMOSIS 5,253 (GASTRODUODENOSTOMY) WITH RECONSTRUCTION; WITH VAGOTOMY CPT 43860 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) 5,104 WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITHOUT VAGOTOMY CPT 43865 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) 5,307 WITH RECONSTRUCTION, WITH OR WITHOUT PARTIAL GASTRECTOMY OR INTESTINE RESECTION; WITH VAGOTOMY CPT 43870 CLOSURE OF GASTROSTOMY, SURGICAL 2,212 CPT 43880 CLOSURE OF GASTROCOLIC FISTULA 4,984 CPT 43881 IMPLANTATION OR REPLACEMENT OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN CPT 43882 REVISION OR REMOVAL OF GASTRIC NEUROSTIMULATOR ELECTRODES, ANTRUM, OPEN CPT 43886 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: 01.03.2015 Page No(s): 145 of 380

CPT 43887 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL OF SUBCUTANEOUS 983 PORT COMPONENT ONLY CPT 43888 GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT 1,390 OF SUBCUTANEOUS PORT COMPONENT ONLY CPT 43999 UNLISTED PROCEDURE, STOMACH N/A CPT 44005 ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) (SEPARATE 3,413 PROCEDURE) CPT 44010 DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY 2,687 REMOVAL CPT 44015 TUBE OR NEEDLE CATHETER JEJUNOSTOMY FOR ENTERAL ALIMENTATION, 459 INTRAOPERATIVE, ANY METHOD (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT 44020 ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR 3,022 EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL CPT 44021 ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR 3,052 DECOMPRESSION (EG, BAKER TUBE) CPT 44025 COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL 3,069 CPT 44050 REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY 2,911 LAPAROTOMY CPT 44055 CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR 4,648 REDUCTION OF MIDGUT VOLVULUS (EG, LADD PROCEDURE) CPT 44100 BIOPSY OF INTESTINE BY CAPSULE, TUBE, PERORAL (ONE OR MORE 388 SPECIMENS) CPT 44110 EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE 2,645 NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; SINGLE ENTEROTOMY CPT 44111 EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE 3,072 NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; MULTIPLE ENTEROTOMIES CPT 44120 ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION 3,793 AND ANASTOMOSIS CPT 44121 ENTERECTOMY, RESECTION OF SMALL INTESTINE; EACH ADDITIONAL 772 RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 44125 ENTERECTOMY, RESECTION OF SMALL INTESTINE; WITH ENTEROSTOMY 3,679 CPT 44126 ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 7,592 ATRESIA, SINGLE RESECTION AND ANASTOMOSIS OF PROXIMAL SEGMENT OF INTESTINE; WITHOUT TAPERING CPT 44127 ENTERECTOMY, RESECTION OF SMALL INTESTINE FOR CONGENITAL 8,875 ATRESIA, SINGLE RESECTION AND ANASTOMOSIS OF PROXIMAL SEGMENT OF INTESTINE; WITH TAPERING CPT 44128 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 44130 ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, WITH OR WITHOUT 4,007 CUTANEOUS ENTEROSTOMY (SEPARATE PROCEDURE) CPT 44132 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; FROM N/A CADAVER DONOR CPT 44133 DONOR ENTERECTOMY (INCLUDING COLD PRESERVATION), OPEN; N/A PARTIAL, FROM LIVING DONOR CPT 44135 INTESTINAL ALLOTRANSPLANTATION; FROM CADAVER DONOR N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 146 of 380

CPT 44136 INTESTINAL ALLOTRANSPLANTATION; FROM LIVING DONOR N/A CPT 44137 REMOVAL OF TRANSPLANTED INTESTINAL ALLOGRAFT, COMPLETE N/A CPT 44139 MOBILIZATION (TAKE-DOWN) OF SPLENIC FLEXURE PERFORMED IN 386 CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT 44140 COLECTOMY, PARTIAL; WITH ANASTOMOSIS 4,183 CPT 44141 COLECTOMY, PARTIAL; WITH SKIN LEVEL CECOSTOMY OR COLOSTOMY 5,554 CPT 44143 COLECTOMY, PARTIAL; WITH END COLOSTOMY AND CLOSURE OF DISTAL 5,156 SEGMENT (HARTMANN TYPE PROCEDURE) CPT 44144 COLECTOMY, PARTIAL; WITH RESECTION, WITH COLOSTOMY OR 5,442 ILEOSTOMY AND CREATION OF MUCOFISTULA CPT 44145 COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC 5,189 ANASTOMOSIS) CPT 44146 COLECTOMY, PARTIAL; WITH COLOPROCTOSTOMY (LOW PELVIC 6,535 ANASTOMOSIS), WITH COLOSTOMY CPT 44147 COLECTOMY, PARTIAL; ABDOMINAL AND TRANSANAL APPROACH 5,904 CPT 44150 COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY; WITH 5,745 ILEOSTOMY OR ILEOPROCTOSTOMY CPT 44151 COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY; WITH 6,564 CONTINENT ILEOSTOMY CPT 44155 COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH ILEOSTOMY 6,415 CPT 44156 COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH 7,007 CONTINENT ILEOSTOMY CPT 44157 COLECTOMY, TOTAL, ABDOMINAL, WITH PROCTECTOMY; WITH ILEOANAL 7,114 ANASTOMOSIS, INCLUDES LOOP ILEOSTOMY, AND RECTAL MUCOSECTOMY, WHEN PERFORMED CPT 44158 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 44160 COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH 3,860 ILEOCOLOSTOMY CPT 44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL 2,877 ADHESION) (SEPARATE PROCEDURE) CPT 44186 LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, FOR DECOMPRESSION OR 2,034 FEEDING) CPT 44187 LAPAROSCOPY, SURGICAL; ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 3,443 CPT 44188 LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY 3,791 CPT 44202 LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL 4,333 INTESTINE, SINGLE RESECTION AND ANASTOMOSIS CPT 44203 LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE 771 RESECTION AND ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 44204 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS 4,819 CPT 44205 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOLOSTOMY CPT 44206 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: 01.03.2015 Page No(s): 147 of 380

CPT 44207 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, 5,735 WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) CPT 44208 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, 6,263 WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) WITH COLOSTOMY CPT 44210 LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITHOUT 5,599 PROCTECTOMY, WITH ILEOSTOMY OR ILEOPROCTOSTOMY CPT 44211 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 44212 LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH 6,444 PROCTECTOMY, WITH ILEOSTOMY CPT 44213 LAPAROSCOPY, SURGICAL, MOBILIZATION (TAKE-DOWN) OF SPLENIC 604 FLEXURE PERFORMED IN CONJUNCTION WITH PARTIAL COLECTOMY (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) CPT 44227 LAPAROSCOPY, SURGICAL, CLOSURE OF ENTEROSTOMY, LARGE OR SMALL 5,205 INTESTINE, WITH RESECTION AND ANASTOMOSIS CPT 44238 UNLISTED LAPAROSCOPY PROCEDURE, INTESTINE (EXCEPT RECTUM) N/A CPT 44300 PLACEMENT, ENTEROSTOMY OR CECOSTOMY, TUBE OPEN (EG, FOR 2,619 FEEDING OR DECOMPRESSION) (SEPARATE PROCEDURE) CPT 44310 ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 3,257 CPT 44312 REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) 1,876 (SEPARATE PROCEDURE) CPT 44314 REVISION OF ILEOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) 3,164 (SEPARATE PROCEDURE) CPT 44316 CONTINENT ILEOSTOMY (KOCK PROCEDURE) (SEPARATE PROCEDURE) 4,370 CPT 44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY; 3,727 CPT 44322 COLOSTOMY OR SKIN LEVEL CECOSTOMY; WITH MULTIPLE BIOPSIES (EG, FOR CONGENITAL MEGACOLON) (SEPARATE PROCEDURE) CPT 44340 REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE) CPT 44345 REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE PROCEDURE) CPT 44346 REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE PROCEDURE) CPT 44360 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 44361 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE CPT 44363 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY CPT 44364 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 44365 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 3,666 538 592 706 752 665 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 148 of 380

CPT 44366 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 44369 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 44370 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 971 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT 44372 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 864 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE CPT 44373 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 696 PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONVERSION OF PERCUTANEOUS GASTROSTOMY TUBE TO PERCUTANEOUS JEJUNOSTOMY TUBE CPT 44376 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 44377 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,092 PORTION OF DUODENUM, INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE CPT 44378 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 44379 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND 1,511 PORTION OF DUODENUM, INCLUDING ILEUM; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT 44380 ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT 235 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 44382 ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE 280 CPT 44383 ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 599 PLACEMENT (INCLUDES PREDILATION) CPT 44385 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 44386 ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR 1,129 PELVIC) POUCH; WITH BIOPSY, SINGLE OR MULTIPLE CPT 44388 COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT 1,158 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 44389 COLONOSCOPY THROUGH STOMA; WITH BIOPSY, SINGLE OR MULTIPLE 1,322 CPT 44390 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF FOREIGN BODY 1,570 CPT 44391 COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT 44392 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: 01.03.2015 Page No(s): 149 of 380

CPT 44393 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 44394 COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), 1,675 POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT 44397 COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC STENT 912 PLACEMENT (INCLUDES PREDILATION) CPT 44500 INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) 86 (SEPARATE PROCEDURE) CPT 44602 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 4,327 ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION CPT 44603 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED 4,961 ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; MULTIPLE PERFORATIONS CPT 44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, 3,304 DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITHOUT COLOSTOMY CPT 44605 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, 4,071 DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITH COLOSTOMY CPT 44615 INTESTINAL STRICTUROPLASTY (ENTEROTOMY AND ENTERORRHAPHY) 3,359 WITH OR WITHOUT DILATION, FOR INTESTINAL OBSTRUCTION CPT 44620 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; 2,689 CPT 44625 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH 3,173 RESECTION AND ANASTOMOSIS OTHER THAN COLORECTAL CPT 44626 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH 5,032 RESECTION AND COLORECTAL ANASTOMOSIS (EG, CLOSURE OF HARTMANN TYPE PROCEDURE) CPT 44640 CLOSURE OF INTESTINAL CUTANEOUS FISTULA 4,395 CPT 44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA 4,566 CPT 44660 CLOSURE OF ENTEROVESICAL FISTULA; WITHOUT INTESTINAL OR 4,497 BLADDER RESECTION CPT 44661 CLOSURE OF ENTEROVESICAL FISTULA; WITH INTESTINE AND/OR 4,969 BLADDER RESECTION CPT 44680 INTESTINAL PLICATION (SEPARATE PROCEDURE) 3,344 CPT 44700 EXCLUSION OF SMALL INTESTINE FROM PELVIS BY MESH OR OTHER 3,197 PROSTHESIS, OR NATIVE TISSUE (EG, BLADDER OR OMENTUM) CPT 44701 INTRAOPERATIVE COLONIC LAVAGE (LIST SEPARATELY IN ADDITION TO 532 CODE FOR PRIMARY PROCEDURE) CPT 44715 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 44720 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 835 INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT 44721 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR 1,227 INTESTINE ALLOGRAFT PRIOR TO TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT 44799 UNLISTED PROCEDURE, INTESTINE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 150 of 380

CPT 44800 EXCISION OF MECKEL'S DIVERTICULUM (DIVERTICULECTOMY) OR 2,378 OMPHALOMESENTERIC DUCT CPT 44820 EXCISION OF LESION OF MESENTERY (SEPARATE PROCEDURE) 2,615 CPT 44850 SUTURE OF MESENTERY (SEPARATE PROCEDURE) 2,319 CPT 44899 UNLISTED PROCEDURE, MECKEL'S DIVERTICULUM AND THE MESENTERY N/A CPT 44900 INCISION AND DRAINAGE OF APPENDICEAL ABSCESS; OPEN 2,366 CPT 44901 INCISION AND DRAINAGE OF APPENDICEAL ABSCESS; PERCUTANEOUS 2,945 CPT 44950 APPENDECTOMY; 1,998 CPT 44955 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 44960 APPENDECTOMY; FOR RUPTURED APPENDIX WITH ABSCESS OR 2,696 GENERALIZED PERITONITIS CPT 44970 LAPAROSCOPY, SURGICAL, APPENDECTOMY 1,847 CPT 44979 UNLISTED LAPAROSCOPY PROCEDURE, APPENDIX N/A CPT 45000 TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 1,295 CPT 45005 INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM 785 CPT 45020 INCISION AND DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, OR 1,703 RETRORECTAL ABSCESS CPT 45100 BIOPSY OF ANORECTAL WALL, ANAL APPROACH (EG, CONGENITAL 907 MEGACOLON) CPT 45108 ANORECTAL MYOMECTOMY 1,098 CPT 45110 PROCTECTOMY; COMPLETE, COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY CPT 45111 PROCTECTOMY; PARTIAL RESECTION OF RECTUM, TRANSABDOMINAL APPROACH CPT 45112 PROCTECTOMY, COMBINED ABDOMINOPERINEAL, PULL-THROUGH PROCEDURE (EG, COLO-ANAL ANASTOMOSIS) CPT 45113 PROCTECTOMY, PARTIAL, WITH RECTAL MUCOSECTOMY, ILEOANAL ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), WITH OR WITHOUT LOOP ILEOSTOMY CPT 45114 PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS; ABDOMINAL AND TRANSSACRAL APPROACH CPT 45116 PROCTECTOMY, PARTIAL, WITH ANASTOMOSIS; TRANSSACRAL APPROACH ONLY (KRASKE TYPE) CPT 45119 PROCTECTOMY, COMBINED ABDOMINOPERINEAL PULL-THROUGH PROCEDURE (EG, COLO-ANAL ANASTOMOSIS), WITH CREATION OF COLONIC RESERVOIR (EG, J-POUCH), WITH DIVERTING ENTEROSTOMY WHEN PERFORMED CPT 45120 PROCTECTOMY, COMPLETE (FOR CONGENITAL MEGACOLON), ABDOMINAL AND PERINEAL APPROACH; WITH PULL-THROUGH PROCEDURE AND ANASTOMOSIS (EG, SWENSON, DUHAMEL, OR SOAVE TYPE OPERATION) CPT 45121 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: 01.03.2015 Page No(s): 151 of 380

CPT 45123 PROCTECTOMY, PARTIAL, WITHOUT ANASTOMOSIS, PERINEAL APPROACH 3,461 CPT 45126 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 45130 EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; PERINEAL 3,378 APPROACH CPT 45135 EXCISION OF RECTAL PROCIDENTIA, WITH ANASTOMOSIS; ABDOMINAL 4,168 AND PERINEAL APPROACH CPT 45136 EXCISION OF ILEOANAL RESERVOIR WITH ILEOSTOMY 5,715 CPT 45150 DIVISION OF STRICTURE OF RECTUM 1,223 CPT 45160 EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSSACRAL OR 3,057 TRANSCOCCYGEAL APPROACH CPT 45170 EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH 2,415 CPT 45190 DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESICCATION, 2,132 ELECTROSURGERY, LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH CPT 45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT 352 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 45303 PROCTOSIGMOIDOSCOPY, RIGID; WITH DILATION (EG, BALLOON, GUIDE 2,703 WIRE, BOUGIE) CPT 45305 PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, SINGLE OR MULTIPLE 572 CPT 45307 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF FOREIGN BODY 636 CPT 45308 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 616 POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT 45309 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, 660 POLYP, OR OTHER LESION BY SNARE TECHNIQUE CPT 45315 PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, 726 POLYPS, OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT 45317 PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, 694 INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT 45320 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 45321 PROCTOSIGMOIDOSCOPY, RIGID; WITH DECOMPRESSION OF VOLVULUS 344 CPT 45327 PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT 386 PLACEMENT (INCLUDES PREDILATION) CPT 45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT 448 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 45331 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE 568 CPT 45332 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF FOREIGN BODY 942 CPT 45333 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: 01.03.2015 Page No(s): 152 of 380

CPT 45334 SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING (EG, 562 INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT 45335 SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED SUBMUCOSAL 869 INJECTION(S), ANY SUBSTANCE CPT 45337 SIGMOIDOSCOPY, FLEXIBLE; WITH DECOMPRESSION OF VOLVULUS, ANY 480 METHOD CPT 45338 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR 1,062 OTHER LESION(S) BY SNARE TECHNIQUE CPT 45339 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 45340 SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY BALLOON, 1 OR MORE 1,549 STRICTURES CPT 45341 SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC ULTRASOUND 536 EXAMINATION CPT 45342 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND 820 GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) CPT 45345 SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT 585 PLACEMENT (INCLUDES PREDILATION) CPT 45355 COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, 685 SINGLE OR MULTIPLE CPT 45378 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 45379 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,655 REMOVAL OF FOREIGN BODY CPT 45380 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,578 BIOPSY, SINGLE OR MULTIPLE CPT 45381 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,538 DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE CPT 45382 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 45383 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 45384 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 45385 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,774 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE CPT 45386 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 2,181 DILATION BY BALLOON, 1 OR MORE STRICTURES CPT 45387 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,155 TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) CPT 45391 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,020 ENDOSCOPIC ULTRASOUND EXAMINATION CPT 45392 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH 1,280 TRANSENDOSCOPIC ULTRASOUND GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) CPT 45395 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: 01.03.2015 Page No(s): 153 of 380

CPT 45397 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 45400 LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE) 3,577 CPT 45402 LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID 4,775 RESECTION CPT 45499 UNLISTED LAPAROSCOPY PROCEDURE, RECTUM N/A CPT 45500 PROCTOPLASTY; FOR STENOSIS 1,617 CPT 45505 PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE 1,774 CPT 45520 PERIRECTAL INJECTION OF SCLEROSING SOLUTION FOR PROLAPSE 435 CPT 45540 PROCTOPEXY (EG, FOR PROLAPSE); ABDOMINAL APPROACH 3,236 CPT 45541 PROCTOPEXY (EG, FOR PROLAPSE); PERINEAL APPROACH 2,877 CPT 45550 PROCTOPEXY (EG, FOR PROLAPSE); WITH SIGMOID RESECTION, 4,562 ABDOMINAL APPROACH CPT 45560 REPAIR OF RECTOCELE (SEPARATE PROCEDURE) 2,274 CPT 45562 EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL INJURY; 3,495 CPT 45563 EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL INJURY; 5,046 WITH COLOSTOMY CPT 45800 CLOSURE OF RECTOVESICAL FISTULA; 3,925 CPT 45805 CLOSURE OF RECTOVESICAL FISTULA; WITH COLOSTOMY 4,424 CPT 45820 CLOSURE OF RECTOURETHRAL FISTULA; 3,891 CPT 45825 CLOSURE OF RECTOURETHRAL FISTULA; WITH COLOSTOMY 4,506 CPT 45900 REDUCTION OF PROCIDENTIA (SEPARATE PROCEDURE) UNDER 619 ANESTHESIA CPT 45905 DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER 527 ANESTHESIA OTHER THAN LOCAL CPT 45910 DILATION OF RECTAL STRICTURE (SEPARATE PROCEDURE) UNDER 625 ANESTHESIA OTHER THAN LOCAL CPT 45915 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE 965 PROCEDURE) UNDER ANESTHESIA CPT 45990 ANORECTAL EXAM, SURGICAL, REQUIRING ANESTHESIA (GENERAL, 338 SPINAL, OR EPIDURAL), DIAGNOSTIC CPT 45999 UNLISTED PROCEDURE, RECTUM N/A CPT 46020 PLACEMENT OF SETON 819 CPT 46030 REMOVAL OF ANAL SETON, OTHER MARKER 411 CPT 46040 INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE PROCEDURE) CPT 46045 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: 01.03.2015 Page No(s): 154 of 380

CPT 46050 INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL 572 CPT 46060 INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, 1,426 WITH FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON CPT 46070 INCISION, ANAL SEPTUM (INFANT) 685 CPT 46080 SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER (SEPARATE 738 PROCEDURE) CPT 46083 INCISION OF THROMBOSED HEMORRHOID, EXTERNAL 495 CPT 46200 FISSURECTOMY, WITH OR WITHOUT SPHINCTEROTOMY 1,278 CPT 46210 CRYPTECTOMY; SINGLE 1,116 CPT 46211 CRYPTECTOMY; MULTIPLE (SEPARATE PROCEDURE) 1,590 CPT 46220 PAPILLECTOMY OR EXCISION OF SINGLE TAG, ANUS (SEPARATE 600 PROCEDURE) CPT 46221 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (EG, RUBBER BAND) 789 CPT 46230 EXCISION OF EXTERNAL HEMORRHOID TAGS AND/OR MULTIPLE PAPILLAE 805 CPT 46250 HEMORRHOIDECTOMY, EXTERNAL, COMPLETE 1,335 CPT 46255 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; 1,485 CPT 46257 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; WITH 1,280 FISSURECTOMY CPT 46258 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; WITH 1,374 FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY CPT 46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,444 EXTENSIVE; CPT 46261 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,601 EXTENSIVE; WITH FISSURECTOMY CPT 46262 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR 1,672 EXTENSIVE; WITH FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY CPT 46270 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,467 SUBCUTANEOUS CPT 46275 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,568 SUBMUSCULAR CPT 46280 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,411 COMPLEX OR MULTIPLE, WITH OR WITHOUT PLACEMENT OF SETON CPT 46285 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 1,545 SECOND STAGE CPT 46288 CLOSURE OF ANAL FISTULA WITH RECTAL ADVANCEMENT FLAP 1,655 CPT 46320 ENUCLEATION OR EXCISION OF EXTERNAL THROMBOTIC HEMORRHOID 529 CPT 46500 INJECTION OF SCLEROSING SOLUTION, HEMORRHOIDS 680 CPT 46505 CHEMODENERVATION OF INTERNAL ANAL SPHINCTER 824 CPT 46600 ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF 247 SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 46604 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: 01.03.2015 Page No(s): 155 of 380

CPT 46606 ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE 650 CPT 46608 ANOSCOPY; WITH REMOVAL OF FOREIGN BODY 657 CPT 46610 ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION 658 BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY CPT 46611 ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION 505 BY SNARE TECHNIQUE CPT 46612 ANOSCOPY; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER 815 LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE CPT 46614 ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR 393 CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) CPT 46615 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 46700 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT 1,986 CPT 46705 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; INFANT 1,548 CPT 46706 REPAIR OF ANAL FISTULA WITH FIBRIN GLUE 526 CPT 46710 REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 3,265 VAGINAL), POUCH ADVANCEMENT; TRANSPERINEAL APPROACH CPT 46712 REPAIR OF ILEOANAL POUCH FISTULA/SINUS (EG, PERINEAL OR 6,798 VAGINAL), POUCH ADVANCEMENT; COMBINED TRANSPERINEAL AND TRANSABDOMINAL APPROACH CPT 46715 REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL FISTULA (CUT- 1,538 BACK PROCEDURE) CPT 46716 REPAIR OF LOW IMPERFORATE ANUS; WITH TRANSPOSITION OF 3,564 ANOPERINEAL OR ANOVESTIBULAR FISTULA CPT 46730 REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; PERINEAL OR 5,681 SACROPERINEAL APPROACH CPT 46735 REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; COMBINED 6,783 TRANSABDOMINAL AND SACROPERINEAL APPROACHES CPT 46740 REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR 6,436 RECTOVAGINAL FISTULA; PERINEAL OR SACROPERINEAL APPROACH CPT 46742 REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR 7,126 RECTOVAGINAL FISTULA; COMBINED TRANSABDOMINAL AND SACROPERINEAL APPROACHES CPT 46744 REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 10,448 URETHROPLASTY, SACROPERINEAL APPROACH CPT 46746 REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 11,620 URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; CPT 46748 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 46750 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT 2,377 CPT 46751 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; CHILD 1,906 CPT 46753 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: 01.03.2015 Page No(s): 156 of 380

CPT 46754 REMOVAL OF THIERSCH WIRE OR SUTURE, ANAL CANAL 844 CPT 46760 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; MUSCLE 3,380 TRANSPLANT CPT 46761 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR 2,902 MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR) CPT 46762 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; IMPLANTATION 2,892 ARTIFICIAL SPHINCTER CPT 46900 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 722 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL CPT 46910 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 748 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION CPT 46916 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 725 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY CPT 46917 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 1,369 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY CPT 46922 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 785 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION CPT 46924 DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, 1,588 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 46934 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL 1,218 CPT 46935 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; EXTERNAL 821 CPT 46936 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL AND 1,293 EXTERNAL CPT 46937 CRYOSURGERY OF RECTAL TUMOR; BENIGN 786 CPT 46938 CRYOSURGERY OF RECTAL TUMOR; MALIGNANT 1,373 CPT 46940 CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF 680 ANAL SPHINCTER (SEPARATE PROCEDURE); INITIAL CPT 46942 CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF 634 ANAL SPHINCTER (SEPARATE PROCEDURE); SUBSEQUENT CPT 46945 LIGATION OF INTERNAL HEMORRHOIDS; SINGLE PROCEDURE 896 CPT 46946 LIGATION OF INTERNAL HEMORRHOIDS; MULTIPLE PROCEDURES 945 CPT 46947 HEMORRHOIDOPEXY (EG, FOR PROLAPSING INTERNAL HEMORRHOIDS) BY 1,176 STAPLING CPT 46999 UNLISTED PROCEDURE, ANUS N/A CPT 47000 BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS 1,219 CPT 47001 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 47010 HEPATOTOMY; FOR OPEN DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES CPT 47011 HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES CPT 47015 LAPAROTOMY, WITH ASPIRATION AND/OR INJECTION OF HEPATIC PARASITIC (EG, AMOEBIC OR ECHINOCOCCAL) CYST(S) OR ABSCESS(ES) 331 3,700 658 3,572 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 157 of 380

CPT 47100 BIOPSY OF LIVER, WEDGE 2,596 CPT 47120 HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY 7,245 CPT 47122 HEPATECTOMY, RESECTION OF LIVER; TRISEGMENTECTOMY 10,739 CPT 47125 HEPATECTOMY, RESECTION OF LIVER; TOTAL LEFT LOBECTOMY 9,636 CPT 47130 HEPATECTOMY, RESECTION OF LIVER; TOTAL RIGHT LOBECTOMY 10,338 CPT 47133 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM N/A CADAVER DONOR CPT 47135 LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, PARTIAL OR WHOLE, FROM 15,231 CADAVER OR LIVING DONOR, ANY AGE CPT 47136 LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, FROM 13,013 CADAVER OR LIVING DONOR, ANY AGE CPT 47140 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 10,829 DONOR; LEFT LATERAL SEGMENT ONLY (SEGMENTS II AND III) CPT 47141 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 12,816 DONOR; TOTAL LEFT LOBECTOMY (SEGMENTS II, III AND IV) CPT 47142 DONOR HEPATECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING 14,068 DONOR; TOTAL RIGHT LOBECTOMY (SEGMENTS V, VI, VII AND VIII) CPT 47143 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 47144 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 47145 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 47146 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 1,051 GRAFT PRIOR TO ALLOTRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT 47147 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR LIVER 1,225 GRAFT PRIOR TO ALLOTRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT 47300 MARSUPIALIZATION OF CYST OR ABSCESS OF LIVER 3,492 CPT 47350 MANAGEMENT OF LIVER HEMORRHAGE; SIMPLE SUTURE OF LIVER WOUND OR INJURY CPT 47360 MANAGEMENT OF LIVER HEMORRHAGE; COMPLEX SUTURE OF LIVER WOUND OR INJURY, WITH OR WITHOUT HEPATIC ARTERY LIGATION CPT 47361 MANAGEMENT OF LIVER HEMORRHAGE; EXPLORATION OF HEPATIC WOUND, EXTENSIVE DEBRIDEMENT, COAGULATION AND/OR SUTURE, WITH OR WITHOUT PACKING OF LIVER CPT 47362 MANAGEMENT OF LIVER HEMORRHAGE; RE-EXPLORATION OF HEPATIC WOUND FOR REMOVAL OF PACKING CPT 47370 LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER TUMOR(S); RADIOFREQUENCY CPT 47371 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: 01.03.2015 Page No(s): 158 of 380

CPT 47379 UNLISTED LAPAROSCOPIC PROCEDURE, LIVER N/A CPT 47380 ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); RADIOFREQUENCY 4,519 CPT 47381 ABLATION, OPEN, OF ONE OR MORE LIVER TUMOR(S); CRYOSURGICAL 4,643 CPT 47382 ABLATION, ONE OR MORE LIVER TUMOR(S), PERCUTANEOUS, 2,814 RADIOFREQUENCY CPT 47399 UNLISTED PROCEDURE, LIVER N/A CPT 47400 HEPATICOTOMY OR HEPATICOSTOMY WITH EXPLORATION, DRAINAGE, OR 6,586 REMOVAL OF CALCULUS CPT 47420 CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 4,166 DRAINAGE, OR REMOVAL OF CALCULUS, WITH OR WITHOUT CHOLECYSTOTOMY; WITHOUT TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY CPT 47425 CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY WITH EXPLORATION, 4,212 DRAINAGE, OR REMOVAL OF CALCULUS, WITH OR WITHOUT CHOLECYSTOTOMY; WITH TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY CPT 47460 TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, WITH OR 3,997 WITHOUT TRANSDUODENAL EXTRACTION OF CALCULUS (SEPARATE PROCEDURE) CPT 47480 CHOLECYSTOTOMY OR CHOLECYSTOSTOMY WITH EXPLORATION, 2,665 DRAINAGE, OR REMOVAL OF CALCULUS (SEPARATE PROCEDURE) CPT 47490 PERCUTANEOUS CHOLECYSTOSTOMY 1,734 CPT 47500 INJECTION PROCEDURE FOR PERCUTANEOUS TRANSHEPATIC 351 CHOLANGIOGRAPHY CPT 47505 INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN EXISTING 134 CATHETER (EG, PERCUTANEOUS TRANSHEPATIC OR T-TUBE) CPT 47510 INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER FOR 1,640 BILIARY DRAINAGE CPT 47511 INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR INTERNAL 2,065 AND EXTERNAL BILIARY DRAINAGE CPT 47525 CHANGE OF PERCUTANEOUS BILIARY DRAINAGE CATHETER 2,611 CPT 47530 REVISION AND/OR REINSERTION OF TRANSHEPATIC TUBE 4,648 CPT 47550 BILIARY ENDOSCOPY, INTRAOPERATIVE (CHOLEDOCHOSCOPY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 47552 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 47553 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH BIOPSY, SINGLE OR MULTIPLE CPT 47554 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH REMOVAL OF CALCULUS/CALCULI CPT 47555 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH DILATION OF BILIARY DUCT STRICTURE(S) WITHOUT STENT CPT 47556 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T-TUBE OR OTHER TRACT; WITH DILATION OF BILIARY DUCT STRICTURE(S) WITH STENT CPT 47560 LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT BIOPSY CPT 47561 LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY WITH BIOPSY 528 1,124 1,127 1,675 1,353 1,528 852 932 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 159 of 380

CPT 47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY 2,310 CPT 47563 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY 2,351 CPT 47564 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF 2,708 COMMON DUCT CPT 47570 LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROSTOMY 2,414 CPT 47579 UNLISTED LAPAROSCOPY PROCEDURE, BILIARY TRACT N/A CPT 47600 CHOLECYSTECTOMY; 3,319 CPT 47605 CHOLECYSTECTOMY; WITH CHOLANGIOGRAPHY 3,051 CPT 47610 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; 3,900 CPT 47612 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH 3,938 CHOLEDOCHOENTEROSTOMY CPT 47620 CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH 4,265 TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, WITH OR WITHOUT CHOLANGIOGRAPHY CPT 47630 BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUBE TRACT, 1,881 BASKET, OR SNARE (EG, BURHENNE TECHNIQUE) CPT 47700 EXPLORATION FOR CONGENITAL ATRESIA OF BILE DUCTS, WITHOUT 3,243 REPAIR, WITH OR WITHOUT LIVER BIOPSY, WITH OR WITHOUT CHOLANGIOGRAPHY CPT 47701 PORTOENTEROSTOMY (EG, KASAI PROCEDURE) 5,406 CPT 47711 EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF 4,842 BILE DUCT; EXTRAHEPATIC CPT 47712 EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF 6,190 BILE DUCT; INTRAHEPATIC CPT 47715 EXCISION OF CHOLEDOCHAL CYST 4,093 CPT 47720 CHOLECYSTOENTEROSTOMY; DIRECT 3,528 CPT 47721 CHOLECYSTOENTEROSTOMY; WITH GASTROENTEROSTOMY 4,146 CPT 47740 CHOLECYSTOENTEROSTOMY; ROUX-EN-Y 4,010 CPT 47741 CHOLECYSTOENTEROSTOMY; ROUX-EN-Y WITH GASTROENTEROSTOMY 4,552 CPT 47760 ANASTOMOSIS, OF EXTRAHEPATIC BILIARY DUCTS AND 6,873 GASTROINTESTINAL TRACT CPT 47765 ANASTOMOSIS, OF INTRAHEPATIC DUCTS AND GASTROINTESTINAL TRACT 9,096 CPT 47780 ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC BILIARY DUCTS AND 7,523 GASTROINTESTINAL TRACT CPT 47785 ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC BILIARY DUCTS AND 9,814 GASTROINTESTINAL TRACT CPT 47800 RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC BILIARY DUCTS WITH 4,896 END-TO-END ANASTOMOSIS CPT 47801 PLACEMENT OF CHOLEDOCHAL STENT 3,407 CPT 47802 U-TUBE HEPATICOENTEROSTOMY 4,701 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 160 of 380

CPT 47900 SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR PRE-EXISTING INJURY 4,256 (SEPARATE PROCEDURE) CPT 47999 UNLISTED PROCEDURE, BILIARY TRACT N/A CPT 48000 PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; 5,811 CPT 48001 PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; 7,177 WITH CHOLECYSTOSTOMY, GASTROSTOMY, AND JEJUNOSTOMY CPT 48020 REMOVAL OF PANCREATIC CALCULUS 3,611 CPT 48100 BIOPSY OF PANCREAS, OPEN (EG, FINE NEEDLE ASPIRATION, NEEDLE 2,764 CORE BIOPSY, WEDGE BIOPSY) CPT 48102 BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE 1,835 CPT 48105 RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC 8,859 TISSUE FOR ACUTE NECROTIZING PANCREATITIS CPT 48120 EXCISION OF LESION OF PANCREAS (EG, CYST, ADENOMA) 3,434 CPT 48140 PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 4,858 SPLENECTOMY; WITHOUT PANCREATICOJEJUNOSTOMY CPT 48145 PANCREATECTOMY, DISTAL SUBTOTAL, WITH OR WITHOUT 5,034 SPLENECTOMY; WITH PANCREATICOJEJUNOSTOMY CPT 48146 PANCREATECTOMY, DISTAL, NEAR-TOTAL WITH PRESERVATION OF 5,772 DUODENUM (CHILD-TYPE PROCEDURE) CPT 48148 EXCISION OF AMPULLA OF VATER 3,873 CPT 48150 PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL DUODENECTOMY, 9,689 PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITH PANCREATOJEJUNOSTOMY CPT 48152 PANCREATECTOMY, PROXIMAL SUBTOTAL WITH TOTAL DUODENECTOMY, 8,950 PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); WITHOUT PANCREATOJEJUNOSTOMY CPT 48153 PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 9,671 DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); WITH PANCREATOJEJUNOSTOMY CPT 48154 PANCREATECTOMY, PROXIMAL SUBTOTAL WITH NEAR-TOTAL 9,013 DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); WITHOUT PANCREATOJEJUNOSTOMY CPT 48155 PANCREATECTOMY, TOTAL 5,602 CPT 48160 PANCREATECTOMY, TOTAL OR SUBTOTAL, WITH AUTOLOGOUS 9,777 TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLET CELLS CPT 48400 INJECTION PROCEDURE FOR INTRAOPERATIVE PANCREATOGRAPHY (LIST 347 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 48500 MARSUPIALIZATION OF PANCREATIC CYST 3,490 CPT 48510 EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREAS; OPEN 3,335 CPT 48511 EXTERNAL DRAINAGE, PSEUDOCYST OF PANCREAS; PERCUTANEOUS 3,075 CPT 48520 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: 01.03.2015 Page No(s): 161 of 380

CPT 48540 INTERNAL ANASTOMOSIS OF PANCREATIC CYST TO GASTROINTESTINAL 4,061 TRACT; ROUX-EN-Y CPT 48545 PANCREATORRHAPHY FOR INJURY 4,141 CPT 48547 DUODENAL EXCLUSION WITH GASTROJEJUNOSTOMY FOR PANCREATIC 5,533 INJURY CPT 48548 PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANASTOMOSIS (PUESTOW- 5,177 TYPE OPERATION) CPT 48550 DONOR PANCREATECTOMY (INCLUDING COLD PRESERVATION), WITH OR N/A WITHOUT DUODENAL SEGMENT FOR TRANSPLANTATION CPT 48551 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 48552 BACKBENCH RECONSTRUCTION OF CADAVER DONOR PANCREAS 723 ALLOGRAFT PRIOR TO TRANSPLANTATION, VENOUS ANASTOMOSIS, EACH CPT 48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT 7,772 CPT 48556 REMOVAL OF TRANSPLANTED PANCREATIC ALLOGRAFT 3,845 CPT 48999 UNLISTED PROCEDURE, PANCREAS N/A CPT 49000 EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR 2,412 WITHOUT BIOPSY(S) (SEPARATE PROCEDURE) CPT 49002 REOPENING OF RECENT LAPAROTOMY 3,185 CPT 49010 EXPLORATION, RETROPERITONEAL AREA WITH OR WITHOUT BIOPSY(S) 2,981 (SEPARATE PROCEDURE) CPT 49020 DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, 4,934 EXCLUSIVE OF APPENDICEAL ABSCESS; OPEN CPT 49021 DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, 2,922 EXCLUSIVE OF APPENDICEAL ABSCESS; PERCUTANEOUS CPT 49040 DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; OPEN 3,100 CPT 49041 DRAINAGE OF SUBDIAPHRAGMATIC OR SUBPHRENIC ABSCESS; 3,041 PERCUTANEOUS CPT 49060 DRAINAGE OF RETROPERITONEAL ABSCESS; OPEN 3,451 CPT 49061 DRAINAGE OF RETROPERITONEAL ABSCESS; PERCUTANEOUS 2,979 CPT 49062 DRAINAGE OF EXTRAPERITONEAL LYMPHOCELE TO PERITONEAL CAVITY, OPEN CPT 49080 PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE (DIAGNOSTIC OR THERAPEUTIC); INITIAL CPT 49081 PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE (DIAGNOSTIC OR THERAPEUTIC); SUBSEQUENT CPT 49180 BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE CPT 49203 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 49204 EXCISION OR DESTRUCTION, OPEN, INTRA-ABDOMINAL TUMORS, CYSTS OR ENDOMETRIOMAS, 1 OR MORE PERITONEAL, MESENTERIC, OR RETROPERITONEAL PRIMARY OR SECONDARY TUMORS; LARGEST TUMOR 5.1-10.0 CM DIAMETER 2,344 523 539 542 3,767 4,809 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 162 of 380

CPT 49205 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 49215 EXCISION OF PRESACRAL OR SACROCOCCYGEAL TUMOR 6,888 CPT 49220 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 49250 UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS (SEPARATE 1,806 PROCEDURE) CPT 49255 OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM (SEPARATE 2,450 PROCEDURE) CPT 49320 LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, 1,029 WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) CPT 49321 LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) 1,088 CPT 49322 LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, 1,170 OVARIAN CYST) (SINGLE OR MULTIPLE) CPT 49323 LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF LYMPHOCELE TO 2,016 PERITONEAL CAVITY CPT 49324 LAPAROSCOPY, SURGICAL; WITH INSERTION OF INTRAPERITONEAL 1,232 CANNULA OR CATHETER, PERMANENT CPT 49325 LAPAROSCOPY, SURGICAL; WITH REVISION OF PREVIOUSLY PLACED 1,326 INTRAPERITONEAL CANNULA OR CATHETER, WITH REMOVAL OF INTRALUMINAL OBSTRUCTIVE MATERIAL IF PERFORMED CPT 49326 LAPAROSCOPY, SURGICAL; WITH OMENTOPEXY (OMENTAL TACKING 611 PROCEDURE) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 49329 UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND N/A OMENTUM CPT 49400 INJECTION OF AIR OR CONTRAST INTO PERITONEAL CAVITY (SEPARATE 566 PROCEDURE) CPT 49402 REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY 2,662 CPT 49419 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER, WITH 1,418 SUBCUTANEOUS RESERVOIR, PERMANENT (IE, TOTALLY IMPLANTABLE) CPT 49420 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE 454 OR DIALYSIS; TEMPORARY CPT 49421 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE 1,224 OR DIALYSIS; PERMANENT CPT 49422 REMOVAL OF PERMANENT INTRAPERITONEAL CANNULA OR CATHETER 1,220 CPT 49423 EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE 1,843 CATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE) CPT 49424 CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA 488 PREVIOUSLY PLACED DRAINAGE CATHETER OR TUBE (SEPARATE PROCEDURE) CPT 49425 INSERTION OF PERITONEAL-VENOUS SHUNT 2,386 CPT 49426 REVISION OF PERITONEAL-VENOUS SHUNT 2,035 CPT 49427 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: 01.03.2015 Page No(s): 163 of 380

CPT 49428 LIGATION OF PERITONEAL-VENOUS SHUNT 1,332 CPT 49429 REMOVAL OF PERITONEAL-VENOUS SHUNT 1,437 CPT 49435 INSERTION OF SUBCUTANEOUS EXTENSION TO INTRAPERITONEAL CANNULA OR CATHETER WITH REMOTE CHEST EXIT SITE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 49436 DELAYED CREATION OF EXIT SITE FROM EMBEDDED SUBCUTANEOUS SEGMENT OF INTRAPERITONEAL CANNULA OR CATHETER CPT 49440 INSERTION OF GASTROSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49441 INSERTION OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49442 INSERTION OF CECOSTOMY OR OTHER COLONIC TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49446 CONVERSION OF GASTROSTOMY TUBE TO GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49450 REPLACEMENT OF GASTROSTOMY OR CECOSTOMY (OR OTHER COLONIC) TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49451 REPLACEMENT OF DUODENOSTOMY OR JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49452 REPLACEMENT OF GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS, UNDER FLUOROSCOPIC GUIDANCE INCLUDING CONTRAST INJECTION(S), IMAGE DOCUMENTATION AND REPORT CPT 49460 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 49465 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 49491 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 49492 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 49495 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 49496 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 396 582 3,742 4,429 3,612 3,684 2,569 2,726 3,341 2,718 571 2,321 2,940 1,252 1,867 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 164 of 380

CPT 49500 REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO YOUNGER THAN 5 1,273 YEARS, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE CPT 49501 REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO YOUNGER THAN 5 1,846 YEARS, WITH OR WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED CPT 49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE 1,609 CPT 49507 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OLDER; 1,974 INCARCERATED OR STRANGULATED CPT 49520 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE 1,959 CPT 49521 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED OR 2,382 STRANGULATED CPT 49525 REPAIR INGUINAL HERNIA, SLIDING, ANY AGE 1,774 CPT 49540 REPAIR LUMBAR HERNIA 2,090 CPT 49550 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE 1,782 CPT 49553 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED OR 1,950 STRANGULATED CPT 49555 REPAIR RECURRENT FEMORAL HERNIA; REDUCIBLE 1,851 CPT 49557 REPAIR RECURRENT FEMORAL HERNIA; INCARCERATED OR 2,245 STRANGULATED CPT 49560 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; REDUCIBLE 2,295 CPT 49561 REPAIR INITIAL INCISIONAL OR VENTRAL HERNIA; INCARCERATED OR 2,893 STRANGULATED CPT 49565 REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; REDUCIBLE 2,377 CPT 49566 REPAIR RECURRENT INCISIONAL OR VENTRAL HERNIA; INCARCERATED 2,921 OR STRANGULATED CPT 49568 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 49570 REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); REDUCIBLE 1,271 (SEPARATE PROCEDURE) CPT 49572 REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); INCARCERATED 1,573 OR STRANGULATED CPT 49580 REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; REDUCIBLE 991 CPT 49582 REPAIR UMBILICAL HERNIA, YOUNGER THAN AGE 5 YEARS; 1,462 INCARCERATED OR STRANGULATED CPT 49585 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; REDUCIBLE 1,364 CPT 49587 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OLDER; INCARCERATED OR 1,612 STRANGULATED CPT 49590 REPAIR SPIGELIAN HERNIA 1,767 CPT 49600 REPAIR OF SMALL OMPHALOCELE, WITH PRIMARY CLOSURE 2,287 CPT 49605 REPAIR OF LARGE OMPHALOCELE OR GASTROSCHISIS; WITH OR WITHOUT PROSTHESIS CPT 49606 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: 01.03.2015 Page No(s): 165 of 380

CPT 49610 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); FIRST STAGE 2,163 CPT 49611 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); SECOND STAGE 1,793 CPT 49650 LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA 1,331 CPT 49651 LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA 1,719 CPT 49659 UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, N/A HERNIOTOMY CPT 49900 SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION OR 2,538 DEHISCENCE CPT 49904 OMENTAL FLAP, EXTRA-ABDOMINAL (EG, FOR RECONSTRUCTION OF 4,625 STERNAL AND CHEST WALL DEFECTS) CPT 49905 OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO 1,130 CODE FOR PRIMARY PROCEDURE) CPT 49906 FREE OMENTAL FLAP WITH MICROVASCULAR ANASTOMOSIS N/A CPT 49999 UNLISTED PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM N/A CPT 50010 RENAL EXPLORATION, NOT NECESSITATING OTHER SPECIFIC 2,490 PROCEDURES CPT 50020 DRAINAGE OF PERIRENAL OR RENAL ABSCESS; OPEN 3,487 CPT 50021 DRAINAGE OF PERIRENAL OR RENAL ABSCESS; PERCUTANEOUS 3,106 CPT 50040 NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE 3,315 CPT 50045 NEPHROTOMY, WITH EXPLORATION 3,280 CPT 50060 NEPHROLITHOTOMY; REMOVAL OF CALCULUS 4,152 CPT 50065 NEPHROLITHOTOMY; SECONDARY SURGICAL OPERATION FOR CALCULUS 4,441 CPT 50070 NEPHROLITHOTOMY; COMPLICATED BY CONGENITAL KIDNEY 4,339 ABNORMALITY CPT 50075 NEPHROLITHOTOMY; REMOVAL OF LARGE STAGHORN CALCULUS FILLING 5,315 RENAL PELVIS AND CALYCES (INCLUDING ANATROPHIC PYELOLITHOTOMY) CPT 50080 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, WITH 3,173 OR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; UP TO 2 CM CPT 50081 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, WITH 4,662 OR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; OVER 2 CM CPT 50100 TRANSECTION OR REPOSITIONING OF ABERRANT RENAL VESSELS 3,258 (SEPARATE PROCEDURE) CPT 50120 PYELOTOMY; WITH EXPLORATION 3,447 CPT 50125 PYELOTOMY; WITH DRAINAGE, PYELOSTOMY 3,627 CPT 50130 PYELOTOMY; WITH REMOVAL OF CALCULUS (PYELOLITHOTOMY, 3,769 PELVIOLITHOTOMY, INCLUDING COAGULUM PYELOLITHOTOMY) CPT 50135 PYELOTOMY; COMPLICATED (EG, SECONDARY OPERATION, CONGENITAL 4,086 KIDNEY ABNORMALITY) CPT 50200 RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 500 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 166 of 380

CPT 50205 RENAL BIOPSY; BY SURGICAL EXPOSURE OF KIDNEY 2,391 CPT 50220 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 3,700 APPROACH INCLUDING RIB RESECTION; CPT 50225 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 4,311 APPROACH INCLUDING RIB RESECTION; COMPLICATED BECAUSE OF PREVIOUS SURGERY ON SAME KIDNEY CPT 50230 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY OPEN 4,642 APPROACH INCLUDING RIB RESECTION; RADICAL, WITH REGIONAL LYMPHADENECTOMY AND/OR VENA CAVAL THROMBECTOMY CPT 50234 NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; 4,723 THROUGH SAME INCISION CPT 50236 NEPHRECTOMY WITH TOTAL URETERECTOMY AND BLADDER CUFF; 5,340 THROUGH SEPARATE INCISION CPT 50240 NEPHRECTOMY, PARTIAL 4,804 CPT 50250 ABLATION, OPEN, ONE OR MORE RENAL MASS LESION(S), 4,397 CRYOSURGICAL, INCLUDING INTRAOPERATIVE ULTRASOUND, IF PERFORMED CPT 50280 EXCISION OR UNROOFING OF CYST(S) OF KIDNEY 3,423 CPT 50290 EXCISION OF PERINEPHRIC CYST 3,165 CPT 50300 DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); FROM N/A CADAVER DONOR, UNILATERAL OR BILATERAL CPT 50320 DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION); OPEN, FROM 4,650 LIVING DONOR CPT 50323 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 50325 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 50327 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 678 ALLOGRAFT PRIOR TO TRANSPLANTATION; VENOUS ANASTOMOSIS, EACH CPT 50328 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 596 ALLOGRAFT PRIOR TO TRANSPLANTATION; ARTERIAL ANASTOMOSIS, EACH CPT 50329 BACKBENCH RECONSTRUCTION OF CADAVER OR LIVING DONOR RENAL 584 ALLOGRAFT PRIOR TO TRANSPLANTATION; URETERAL ANASTOMOSIS, EACH CPT 50340 RECIPIENT NEPHRECTOMY (SEPARATE PROCEDURE) 2,935 CPT 50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITHOUT 7,923 RECIPIENT NEPHRECTOMY CPT 50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; WITH 8,751 RECIPIENT NEPHRECTOMY CPT 50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 3,719 CPT 50380 RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY 6,089 CPT 50382 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: 01.03.2015 Page No(s): 167 of 380

RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 50384 REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL 3,271 STENT VIA PERCUTANEOUS APPROACH, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 50385 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 50386 REMOVAL (VIA SNARE/CAPTURE) OF INTERNALLY DWELLING URETERAL 2,879 STENT VIA TRANSURETHRAL APPROACH, WITHOUT USE OF CYSTOSCOPY, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 50387 REMOVAL AND REPLACEMENT OF EXTERNALLY ACCESSIBLE 1,854 TRANSNEPHRIC URETERAL STENT (EG, EXTERNAL/INTERNAL STENT) REQUIRING FLUOROSCOPIC GUIDANCE, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 50389 REMOVAL OF NEPHROSTOMY TUBE, REQUIRING FLUOROSCOPIC 988 GUIDANCE (EG, WITH CONCURRENT INDWELLING URETERAL STENT) CPT 50390 ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, 351 PERCUTANEOUS CPT 50391 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 50392 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS 640 FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS CPT 50393 INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER 780 THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS CPT 50394 INJECTION PROCEDURE FOR PYELOGRAPHY (AS NEPHROSTOGRAM, 337 PYELOSTOGRAM, ANTEGRADE PYELOURETEROGRAMS) THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, OR INDWELLING URETERAL CATHETER CPT 50395 INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER WITH 648 DILATION TO ESTABLISH NEPHROSTOMY TRACT, PERCUTANEOUS CPT 50396 MANOMETRIC STUDIES THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, 415 OR INDWELLING URETERAL CATHETER CPT 50398 CHANGE OF NEPHROSTOMY OR PYELOSTOMY TUBE 1,686 CPT 50400 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 50405 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 50500 NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND OR INJURY 4,001 CPT 50520 CLOSURE OF NEPHROCUTANEOUS OR PYELOCUTANEOUS FISTULA 3,709 CPT 50525 CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), INCLUDING VISCERAL REPAIR; ABDOMINAL APPROACH CPT 50526 CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), INCLUDING VISCERAL REPAIR; THORACIC APPROACH CPT 50540 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: 01.03.2015 Page No(s): 168 of 380

BILATERAL (ONE OPERATION) CPT 50541 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS 3,346 CPT 50542 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S) 4,248 CPT 50543 LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY 5,423 CPT 50544 LAPAROSCOPY, SURGICAL; PYELOPLASTY 4,567 CPT 50545 LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL 4,882 OF GEROTA'S FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES, AND ADRENALECTOMY) CPT 50546 LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL 4,348 URETERECTOMY CPT 50547 LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY (INCLUDING COLD 5,222 PRESERVATION), FROM LIVING DONOR CPT 50548 LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY 4,922 CPT 50549 UNLISTED LAPAROSCOPY PROCEDURE, RENAL N/A CPT 50551 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT 50553 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 50555 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT 50557 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 50561 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 50562 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH RESECTION OF TUMOR CPT 50570 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT 50572 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 50574 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT 50575 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: 01.03.2015 Page No(s): 169 of 380

CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF URETERAL PELVIC JUNCTION AND INSERTION OF ENDOPYELOTOMY STENT) CPT 50576 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 50580 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 50590 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE 3,447 CPT 50592 ABLATION, ONE OR MORE RENAL TUMOR(S), PERCUTANEOUS, 10,408 UNILATERAL, RADIOFREQUENCY CPT 50593 ABLATION, RENAL TUMOR(S), UNILATERAL, PERCUTANEOUS, 15,643 CRYOTHERAPY CPT 50600 URETEROTOMY WITH EXPLORATION OR DRAINAGE (SEPARATE 3,358 PROCEDURE) CPT 50605 URETEROTOMY FOR INSERTION OF INDWELLING STENT, ALL TYPES 3,272 CPT 50610 URETEROLITHOTOMY; UPPER ONE-THIRD OF URETER 3,465 CPT 50620 URETEROLITHOTOMY; MIDDLE ONE-THIRD OF URETER 3,304 CPT 50630 URETEROLITHOTOMY; LOWER ONE-THIRD OF URETER 3,193 CPT 50650 URETERECTOMY, WITH BLADDER CUFF (SEPARATE PROCEDURE) 3,758 CPT 50660 URETERECTOMY, TOTAL, ECTOPIC URETER, COMBINATION ABDOMINAL, 4,151 VAGINAL AND/OR PERINEAL APPROACH CPT 50684 INJECTION PROCEDURE FOR URETEROGRAPHY OR URETEROPYELOGRAPHY 601 THROUGH URETEROSTOMY OR INDWELLING URETERAL CATHETER CPT 50686 MANOMETRIC STUDIES THROUGH URETEROSTOMY OR INDWELLING 493 URETERAL CATHETER CPT 50688 CHANGE OF URETEROSTOMY TUBE OR EXTERNALLY ACCESSIBLE 276 URETERAL STENT VIA ILEAL CONDUIT CPT 50690 INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR 337 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE CPT 50700 URETEROPLASTY, PLASTIC OPERATION ON URETER (EG, STRICTURE) 3,344 CPT 50715 URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR 3,923 RETROPERITONEAL FIBROSIS CPT 50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME 3,395 CPT 50725 URETEROLYSIS FOR RETROCAVAL URETER, WITH REANASTOMOSIS OF 3,825 UPPER URINARY TRACT OR VENA CAVA CPT 50727 REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 1,826 UROSTOMY); CPT 50728 REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE 2,485 UROSTOMY); WITH REPAIR OF FASCIAL DEFECT AND HERNIA CPT 50740 URETEROPYELOSTOMY, ANASTOMOSIS OF URETER AND RENAL PELVIS 3,885 CPT 50750 URETEROCALYCOSTOMY, ANASTOMOSIS OF URETER TO RENAL CALYX 4,220 CPT 50760 URETEROURETEROSTOMY 3,948 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 170 of 380

CPT 50770 TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF URETER TO 4,204 CONTRALATERAL URETER CPT 50780 URETERONEOCYSTOSTOMY; ANASTOMOSIS OF SINGLE URETER TO 3,954 BLADDER CPT 50782 URETERONEOCYSTOSTOMY; ANASTOMOSIS OF DUPLICATED URETER TO 3,903 BLADDER CPT 50783 URETERONEOCYSTOSTOMY; WITH EXTENSIVE URETERAL TAILORING 4,107 CPT 50785 URETERONEOCYSTOSTOMY; WITH VESICO-PSOAS HITCH OR BLADDER 4,371 FLAP CPT 50800 URETEROENTEROSTOMY, DIRECT ANASTOMOSIS OF URETER TO 3,346 INTESTINE CPT 50810 URETEROSIGMOIDOSTOMY, WITH CREATION OF SIGMOID BLADDER AND 4,440 ESTABLISHMENT OF ABDOMINAL OR PERINEAL COLOSTOMY, INCLUDING INTESTINE ANASTOMOSIS CPT 50815 URETEROCOLON CONDUIT, INCLUDING INTESTINE ANASTOMOSIS 4,414 CPT 50820 URETEROILEAL CONDUIT (ILEAL BLADDER), INCLUDING INTESTINE 4,739 ANASTOMOSIS (BRICKER OPERATION) CPT 50825 CONTINENT DIVERSION, INCLUDING INTESTINE ANASTOMOSIS USING 5,975 ANY SEGMENT OF SMALL AND/OR LARGE INTESTINE (KOCK POUCH OR CAMEY ENTEROCYSTOPLASTY) CPT 50830 URINARY UNDIVERSION (EG, TAKING DOWN OF URETEROILEAL CONDUIT, 6,491 URETEROSIGMOIDOSTOMY OR URETEROENTEROSTOMY WITH URETEROURETEROSTOMY OR URETERONEOCYSTOSTOMY) CPT 50840 REPLACEMENT OF ALL OR PART OF URETER BY INTESTINE SEGMENT, 4,479 INCLUDING INTESTINE ANASTOMOSIS CPT 50845 CUTANEOUS APPENDICO-VESICOSTOMY 4,512 CPT 50860 URETEROSTOMY, TRANSPLANTATION OF URETER TO SKIN 3,453 CPT 50900 URETERORRHAPHY, SUTURE OF URETER (SEPARATE PROCEDURE) 3,023 CPT 50920 CLOSURE OF URETEROCUTANEOUS FISTULA 3,170 CPT 50930 CLOSURE OF URETEROVISCERAL FISTULA (INCLUDING VISCERAL REPAIR) 3,878 CPT 50940 DELIGATION OF URETER 3,125 CPT 50945 LAPAROSCOPY, SURGICAL; URETEROLITHOTOMY 3,589 CPT 50947 LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY 5,046 AND URETERAL STENT PLACEMENT CPT 50948 LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT 4,605 CYSTOSCOPY AND URETERAL STENT PLACEMENT CPT 50949 UNLISTED LAPAROSCOPY PROCEDURE, URETER N/A CPT 50951 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT 50953 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 50955 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: 01.03.2015 Page No(s): 171 of 380

CPT 50957 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 50961 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 50970 URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,370 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT 50972 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 50974 URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT 1,708 IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY CPT 50976 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 50980 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 51020 CYSTOTOMY OR CYSTOSTOMY; WITH FULGURATION AND/OR INSERTION 1,689 OF RADIOACTIVE MATERIAL CPT 51030 CYSTOTOMY OR CYSTOSTOMY; WITH CRYOSURGICAL DESTRUCTION OF 1,656 INTRAVESICAL LESION CPT 51040 CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE 1,061 CPT 51045 CYSTOTOMY, WITH INSERTION OF URETERAL CATHETER OR STENT 1,680 (SEPARATE PROCEDURE) CPT 51050 CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT 1,723 VESICAL NECK RESECTION CPT 51060 TRANSVESICAL URETEROLITHOTOMY 2,122 CPT 51065 CYSTOTOMY, WITH CALCULUS BASKET EXTRACTION AND/OR ULTRASONIC 2,102 OR ELECTROHYDRAULIC FRAGMENTATION OF URETERAL CALCULUS CPT 51080 DRAINAGE OF PERIVESICAL OR PREVESICAL SPACE ABSCESS 1,466 CPT 51100 ASPIRATION OF BLADDER; BY NEEDLE 220 CPT 51101 ASPIRATION OF BLADDER; BY TROCAR OR INTRACATHETER 444 CPT 51102 ASPIRATION OF BLADDER; WITH INSERTION OF SUPRAPUBIC CATHETER 1,170 CPT 51500 EXCISION OF URACHAL CYST OR SINUS, WITH OR WITHOUT UMBILICAL 2,229 HERNIA REPAIR CPT 51520 CYSTOTOMY; FOR SIMPLE EXCISION OF VESICAL NECK (SEPARATE 2,149 PROCEDURE) CPT 51525 CYSTOTOMY; FOR EXCISION OF BLADDER DIVERTICULUM, SINGLE OR 3,115 MULTIPLE (SEPARATE PROCEDURE) CPT 51530 CYSTOTOMY; FOR EXCISION OF BLADDER TUMOR 2,770 CPT 51535 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: 01.03.2015 Page No(s): 172 of 380

CPT 51550 CYSTECTOMY, PARTIAL; SIMPLE 3,413 CPT 51555 CYSTECTOMY, PARTIAL; COMPLICATED (EG, POSTRADIATION, PREVIOUS 4,542 SURGERY, DIFFICULT LOCATION) CPT 51565 CYSTECTOMY, PARTIAL, WITH REIMPLANTATION OF URETER(S) INTO 4,688 BLADDER (URETERONEOCYSTOSTOMY) CPT 51570 CYSTECTOMY, COMPLETE; (SEPARATE PROCEDURE) 5,351 CPT 51575 CYSTECTOMY, COMPLETE; WITH BILATERAL PELVIC LYMPHADENECTOMY, 6,623 INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT 51580 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR 6,920 URETEROCUTANEOUS TRANSPLANTATIONS; CPT 51585 CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR 7,698 URETEROCUTANEOUS TRANSPLANTATIONS; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT 51590 CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID 7,008 BLADDER, INCLUDING INTESTINE ANASTOMOSIS; CPT 51595 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 51596 CYSTECTOMY, COMPLETE, WITH CONTINENT DIVERSION, ANY OPEN 8,557 TECHNIQUE, USING ANY SEGMENT OF SMALL AND/OR LARGE INTESTINE TO CONSTRUCT NEOBLADDER CPT 51597 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 51600 INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING 650 URETHROCYSTOGRAPHY CPT 51605 INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST 139 AND/OR CHAIN URETHROCYSTOGRAPHY CPT 51610 INJECTION PROCEDURE FOR RETROGRADE URETHROCYSTOGRAPHY 381 CPT 51700 BLADDER IRRIGATION, SIMPLE, LAVAGE AND/OR INSTILLATION 307 CPT 51701 INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT 198 CATHETERIZATION FOR RESIDUAL URINE) CPT 51702 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; SIMPLE 260 (EG, FOLEY) CPT 51703 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; 482 COMPLICATED (EG, ALTERED ANATOMY, FRACTURED CATHETER/BALLOON) CPT 51705 CHANGE OF CYSTOSTOMY TUBE; SIMPLE 392 CPT 51710 CHANGE OF CYSTOSTOMY TUBE; COMPLICATED 546 CPT 51715 ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL 1,061 TISSUES OF THE URETHRA AND/OR BLADDER NECK CPT 51720 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING 410 RETENTION TIME) CPT 51725 SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL MANOMETER) 742 CPT 51726 COMPLEX CYSTOMETROGRAM (EG, CALIBRATED ELECTRONIC EQUIPMENT) 1,132 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 173 of 380

CPT 51736 SIMPLE UROFLOWMETRY (UFR) (EG, STOP-WATCH FLOW RATE, 202 MECHANICAL UROFLOWMETER) CPT 51741 COMPLEX UROFLOWMETRY (EG, CALIBRATED ELECTRONIC EQUIPMENT) 317 CPT 51772 URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE 864 PRESSURE PROFILE), ANY TECHNIQUE CPT 51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, 731 OTHER THAN NEEDLE, ANY TECHNIQUE CPT 51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL 784 SPHINCTER, ANY TECHNIQUE CPT 51792 STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF 799 BULBOCAVERNOSUS REFLEX LATENCY TIME) CPT 51795 VOIDING PRESSURE STUDIES (VP); BLADDER VOIDING PRESSURE, ANY 1,066 TECHNIQUE CPT 51797 VOIDING PRESSURE STUDIES (VP); INTRA-ABDOMINAL VOIDING 429 PRESSURE (AP) (RECTAL, GASTRIC, INTRAPERITONEAL) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 51798 MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER 84 CAPACITY BY ULTRASOUND, NON-IMAGING CPT 51800 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 51820 CYSTOURETHROPLASTY WITH UNILATERAL OR BILATERAL 3,890 URETERONEOCYSTOSTOMY CPT 51840 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL- 2,278 MARCHETTI-KRANTZ, BURCH); SIMPLE CPT 51841 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL- 2,731 MARCHETTI-KRANTZ, BURCH); COMPLICATED (EG, SECONDARY REPAIR) CPT 51845 ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, WITH OR WITHOUT 2,108 ENDOSCOPIC CONTROL (EG, STAMEY, RAZ, MODIFIED PEREYRA) CPT 51860 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; 2,565 SIMPLE CPT 51865 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE; 3,178 COMPLICATED CPT 51880 CLOSURE OF CYSTOSTOMY (SEPARATE PROCEDURE) 1,669 CPT 51900 CLOSURE OF VESICOVAGINAL FISTULA, ABDOMINAL APPROACH 2,979 CPT 51920 CLOSURE OF VESICOUTERINE FISTULA; 2,829 CPT 51925 CLOSURE OF VESICOUTERINE FISTULA; WITH HYSTERECTOMY 4,003 CPT 51940 CLOSURE, EXSTROPHY OF BLADDER 5,583 CPT 51960 ENTEROCYSTOPLASTY, INCLUDING INTESTINAL ANASTOMOSIS 4,999 CPT 51980 CUTANEOUS VESICOSTOMY 2,563 CPT 51990 LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS 2,590 INCONTINENCE CPT 51992 LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS 2,855 INCONTINENCE (EG, FASCIA OR SYNTHETIC) CPT 51999 UNLISTED LAPAROSCOPY PROCEDURE, BLADDER N/A CPT 52000 CYSTOURETHROSCOPY (SEPARATE PROCEDURE) 758 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 174 of 380

CPT 52001 CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE 1,369 OBSTRUCTING CLOTS CPT 52005 CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR 1,040 WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; CPT 52007 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 52010 CYSTOURETHROSCOPY, WITH EJACULATORY DUCT CATHETERIZATION, 1,423 WITH OR WITHOUT IRRIGATION, INSTILLATION, OR DUCT RADIOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE CPT 52204 CYSTOURETHROSCOPY, WITH BIOPSY(S) 1,393 CPT 52214 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 3,001 OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS CPT 52224 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 52234 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 52235 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 52240 CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY 1,855 OR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S) CPT 52250 CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, 894 WITH OR WITHOUT BIOPSY OR FULGURATION CPT 52260 CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL 770 CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA CPT 52265 CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL 1,340 CYSTITIS; LOCAL ANESTHESIA CPT 52270 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; FEMALE 1,336 CPT 52275 CYSTOURETHROSCOPY, WITH INTERNAL URETHROTOMY; MALE 1,802 CPT 52276 CYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY 979 CPT 52277 CYSTOURETHROSCOPY, WITH RESECTION OF EXTERNAL SPHINCTER 1,195 (SPHINCTEROTOMY) CPT 52281 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 52282 CYSTOURETHROSCOPY, WITH INSERTION OF URETHRAL STENT 1,233 CPT 52283 CYSTOURETHROSCOPY, WITH STEROID INJECTION INTO STRICTURE 1,013 CPT 52285 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: 01.03.2015 Page No(s): 175 of 380

CPT 52290 CYSTOURETHROSCOPY; WITH URETERAL MEATOTOMY, UNILATERAL OR 901 BILATERAL CPT 52300 CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF 1,037 ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL CPT 52301 CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ECTOPIC 1,087 URETEROCELE(S), UNILATERAL OR BILATERAL CPT 52305 CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF 1,028 BLADDER DIVERTICULUM, SINGLE OR MULTIPLE CPT 52310 CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, 882 OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE CPT 52315 CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, 1,535 OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED CPT 52317 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 52318 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 52320 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 910 REMOVAL OF URETERAL CALCULUS CPT 52325 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 1,179 FRAGMENTATION OF URETERAL CALCULUS (EG, ULTRASONIC OR ELECTRO-HYDRAULIC TECHNIQUE) CPT 52327 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 955 SUBURETERIC INJECTION OF IMPLANT MATERIAL CPT 52330 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 3,247 MANIPULATION, WITHOUT REMOVAL OF URETERAL CALCULUS CPT 52332 CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL 1,945 STENT (EG, GIBBONS OR DOUBLE-J TYPE) CPT 52334 CYSTOURETHROSCOPY WITH INSERTION OF URETERAL GUIDE WIRE 944 THROUGH KIDNEY TO ESTABLISH A PERCUTANEOUS NEPHROSTOMY, RETROGRADE CPT 52341 CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, 1,205 BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52342 CYSTOURETHROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION 1,298 STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52343 CYSTOURETHROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE 1,423 (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52344 CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,543 URETERAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52345 CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,636 URETEROPELVIC JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52346 CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF 1,825 INTRA-RENAL STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CPT 52351 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,159 DIAGNOSTIC CPT 52352 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,361 WITH REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED) CPT 52353 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: 01.03.2015 Page No(s): 176 of 380

CPT 52354 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,446 WITH BIOPSY AND/OR FULGURATION OF URETERAL OR RENAL PELVIC LESION CPT 52355 CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; 1,721 WITH RESECTION OF URETERAL OR RENAL PELVIC TUMOR CPT 52400 CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR RESECTION OF 2,030 CONGENITAL POSTERIOR URETHRAL VALVES, OR CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS CPT 52402 CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR INCISION 984 OF EJACULATORY DUCTS CPT 52450 TRANSURETHRAL INCISION OF PROSTATE 1,718 CPT 52500 TRANSURETHRAL RESECTION OF BLADDER NECK (SEPARATE PROCEDURE) 2,035 CPT 52601 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 52606 TRANSURETHRAL FULGURATION FOR POSTOPERATIVE BLEEDING 1,874 OCCURRING AFTER THE USUAL FOLLOW-UP TIME CPT 52612 TRANSURETHRAL RESECTION OF PROSTATE; FIRST STAGE OF TWO-STAGE 1,952 RESECTION (PARTIAL RESECTION) CPT 52614 TRANSURETHRAL RESECTION OF PROSTATE; SECOND STAGE OF TWO- 1,719 STAGE RESECTION (RESECTION COMPLETED) CPT 52620 TRANSURETHRAL RESECTION; OF RESIDUAL OBSTRUCTIVE TISSUE AFTER 1,544 90 DAYS POSTOPERATIVE CPT 52630 TRANSURETHRAL RESECTION; OF REGROWTH OF OBSTRUCTIVE TISSUE 1,631 LONGER THAN ONE YEAR POSTOPERATIVE CPT 52640 TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK 1,481 CONTRACTURE CPT 52647 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 52648 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 52649 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 52700 TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS 1,607 CPT 53000 URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); 533 PENDULOUS URETHRA CPT 53010 URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); 1,059 PERINEAL URETHRA, EXTERNAL CPT 53020 MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE); EXCEPT 358 INFANT CPT 53025 MEATOTOMY, CUTTING OF MEATUS (SEPARATE PROCEDURE); INFANT 255 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 177 of 380

CPT 53040 DRAINAGE OF DEEP PERIURETHRAL ABSCESS 1,427 CPT 53060 DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST 631 CPT 53080 DRAINAGE OF PERINEAL URINARY EXTRAVASATION; UNCOMPLICATED 1,549 (SEPARATE PROCEDURE) CPT 53085 DRAINAGE OF PERINEAL URINARY EXTRAVASATION; COMPLICATED 2,061 CPT 53200 BIOPSY OF URETHRA 565 CPT 53210 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; FEMALE 2,799 CPT 53215 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; MALE 3,390 CPT 53220 EXCISION OR FULGURATION OF CARCINOMA OF URETHRA 1,636 CPT 53230 EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); 2,191 FEMALE CPT 53235 EXCISION OF URETHRAL DIVERTICULUM (SEPARATE PROCEDURE); MALE 2,328 CPT 53240 MARSUPIALIZATION OF URETHRAL DIVERTICULUM, MALE OR FEMALE 1,557 CPT 53250 EXCISION OF BULBOURETHRAL GLAND (COWPER'S GLAND) 1,421 CPT 53260 EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA 717 CPT 53265 EXCISION OR FULGURATION; URETHRAL CARUNCLE 795 CPT 53270 EXCISION OR FULGURATION; SKENE'S GLANDS 738 CPT 53275 EXCISION OR FULGURATION; URETHRAL PROLAPSE 960 CPT 53400 URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR 2,911 STRICTURE (EG, JOHANNSEN TYPE) CPT 53405 URETHROPLASTY; SECOND STAGE (FORMATION OF URETHRA), INCLUDING 3,184 URINARY DIVERSION CPT 53410 URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE ANTERIOR 3,570 URETHRA CPT 53415 URETHROPLASTY, TRANSPUBIC OR PERINEAL, ONE STAGE, FOR 4,105 RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA CPT 53420 URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 2,910 PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE CPT 53425 URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF 3,407 PROSTATIC OR MEMBRANOUS URETHRA; SECOND STAGE CPT 53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA 3,431 CPT 53431 URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA 4,206 AND/OR LOWER BLADDER FOR INCONTINENCE (EG, TENAGO, LEADBETTER PROCEDURE) CPT 53440 SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE 3,208 (EG, FASCIA OR SYNTHETIC) CPT 53442 REMOVAL OR REVISION OF SLING FOR MALE URINARY INCONTINENCE 2,828 (EG, FASCIA OR SYNTHETIC) CPT 53444 INSERTION OF TANDEM CUFF (DUAL CUFF) 2,897 CPT 53445 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: 01.03.2015 Page No(s): 178 of 380

CPT 53446 REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 2,342 INCLUDING PUMP, RESERVOIR, AND CUFF CPT 53447 REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK 2,955 SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION CPT 53448 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 53449 REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 2,230 INCLUDING PUMP, RESERVOIR, AND CUFF CPT 53450 URETHROMEATOPLASTY, WITH MUCOSAL ADVANCEMENT 1,491 CPT 53460 URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL 1,661 SEGMENT (RICHARDSON TYPE PROCEDURE) CPT 53500 URETHROLYSIS, TRANSVAGINAL, SECONDARY, OPEN, INCLUDING 2,665 CYSTOURETHROSCOPY (EG, POSTSURGICAL OBSTRUCTION, SCARRING) CPT 53502 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, FEMALE 1,747 CPT 53505 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE 1,772 CPT 53510 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL 2,316 CPT 53515 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; 2,907 PROSTATOMEMBRANOUS CPT 53520 CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE 2,034 (SEPARATE PROCEDURE) CPT 53600 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR 308 URETHRAL DILATOR, MALE; INITIAL CPT 53601 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR 303 URETHRAL DILATOR, MALE; SUBSEQUENT CPT 53605 DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF 236 SOUND OR URETHRAL DILATOR, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA CPT 53620 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND 431 FOLLOWER, MALE; INITIAL CPT 53621 DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND 410 FOLLOWER, MALE; SUBSEQUENT CPT 53660 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR 261 INSTILLATION; INITIAL CPT 53661 DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR 259 INSTILLATION; SUBSEQUENT CPT 53665 DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) 137 ANESTHESIA CPT 53850 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE 7,539 THERMOTHERAPY CPT 53852 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY 7,268 RADIOFREQUENCY THERMOTHERAPY CPT 53853 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY WATER- 4,406 INDUCED THERMOTHERAPY CPT 53899 UNLISTED PROCEDURE, URINARY SYSTEM N/A CPT 54000 SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); NEWBORN CPT 54001 SLITTING OF PREPUCE, DORSAL OR LATERAL (SEPARATE PROCEDURE); EXCEPT NEWBORN 550 682 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 179 of 380

CPT 54015 INCISION AND DRAINAGE OF PENIS, DEEP 1,122 CPT 54050 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 432 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL CPT 54055 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 412 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION CPT 54056 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 464 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY CPT 54057 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 500 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY CPT 54060 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 650 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION CPT 54065 DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, 738 MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 54100 BIOPSY OF PENIS; (SEPARATE PROCEDURE) 673 CPT 54105 BIOPSY OF PENIS; DEEP STRUCTURES 974 CPT 54110 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); 2,294 CPT 54111 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); WITH GRAFT TO 5 CM 2,930 IN LENGTH CPT 54112 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); WITH GRAFT 3,429 GREATER THAN 5 CM IN LENGTH CPT 54115 REMOVAL FOREIGN BODY FROM DEEP PENILE TISSUE (EG, PLASTIC 1,637 IMPLANT) CPT 54120 AMPUTATION OF PENIS; PARTIAL 2,300 CPT 54125 AMPUTATION OF PENIS; COMPLETE 2,951 CPT 54130 AMPUTATION OF PENIS, RADICAL; WITH BILATERAL INGUINOFEMORAL 4,375 LYMPHADENECTOMY CPT 54135 AMPUTATION OF PENIS, RADICAL; IN CONTINUITY WITH BILATERAL 5,535 PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES CPT 54150 CIRCUMCISION, USING CLAMP OR OTHER DEVICE WITH REGIONAL 561 DORSAL PENILE OR RING BLOCK CPT 54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR 816 DORSAL SLIT; NEONATE (28 DAYS OF AGE OR LESS) CPT 54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE, OR 719 DORSAL SLIT; OLDER THAN 28 DAYS OF AGE CPT 54162 LYSIS OR EXCISION OF PENILE POST-CIRCUMCISION ADHESIONS 942 CPT 54163 REPAIR INCOMPLETE CIRCUMCISION 796 CPT 54164 FRENULOTOMY OF PENIS 706 CPT 54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE; 400 CPT 54205 INJECTION PROCEDURE FOR PEYRONIE DISEASE; WITH SURGICAL 1,945 EXPOSURE OF PLAQUE CPT 54220 IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM 743 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 180 of 380

CPT 54230 INJECTION PROCEDURE FOR CORPORA CAVERNOSOGRAPHY 356 CPT 54231 DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL INJECTION 524 OF VASOACTIVE DRUGS (EG, PAPAVERINE, PHENTOLAMINE) CPT 54235 INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) 334 (EG, PAPAVERINE, PHENTOLAMINE) CPT 54240 PENILE PLETHYSMOGRAPHY 376 CPT 54250 NOCTURNAL PENILE TUMESCENCE AND/OR RIGIDITY TEST 455 CPT 54300 PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA CPT 54304 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 54308 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); LESS THAN 3 CM CPT 54312 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); GREATER THAN 3 CM CPT 54316 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION) WITH FREE SKIN GRAFT OBTAINED FROM SITE OTHER THAN GENITALIA CPT 54318 URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE PENIS FROM SCROTUM (EG, THIRD STAGE CECIL REPAIR) CPT 54322 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH SIMPLE MEATAL ADVANCEMENT (EG, MAGPI, V- FLAP) CPT 54324 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS (EG, FLIP-FLAP, PREPUCIAL FLAP) CPT 54326 ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA CPT 54328 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 54332 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 54336 ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP CPT 54340 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); BY CLOSURE, INCISION, OR EXCISION, SIMPLE CPT 54344 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING MOBILIZATION OF SKIN FLAPS AND URETHROPLASTY WITH FLAP OR PATCH GRAFT CPT 54348 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING EXTENSIVE DISSECTION AND URETHROPLASTY WITH FLAP, PATCH OR TUBED GRAFT (INCLUDES URINARY DIVERSION) CPT 54352 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: 01.03.2015 Page No(s): 181 of 380

CPT 54360 PLASTIC OPERATION ON PENIS TO CORRECT ANGULATION 2,635 CPT 54380 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 2,895 SPHINCTER; CPT 54385 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 3,593 SPHINCTER; WITH INCONTINENCE CPT 54390 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL 3,971 SPHINCTER; WITH EXSTROPHY OF BLADDER CPT 54400 INSERTION OF PENILE PROSTHESIS; NON-INFLATABLE (SEMI-RIGID) 1,948 CPT 54401 INSERTION OF PENILE PROSTHESIS; INFLATABLE (SELF-CONTAINED) 2,409 CPT 54405 INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, 2,952 INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR CPT 54406 REMOVAL OF ALL COMPONENTS OF A MULTI-COMPONENT, INFLATABLE 2,670 PENILE PROSTHESIS WITHOUT REPLACEMENT OF PROSTHESIS CPT 54408 REPAIR OF COMPONENT(S) OF A MULTI-COMPONENT, INFLATABLE PENILE 2,879 PROSTHESIS CPT 54410 REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI- 3,389 COMPONENT, INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION CPT 54411 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 54415 REMOVAL OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF- 1,929 CONTAINED) PENILE PROSTHESIS, WITHOUT REPLACEMENT OF PROSTHESIS CPT 54416 REMOVAL AND REPLACEMENT OF NON-INFLATABLE (SEMI-RIGID) OR 2,585 INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION CPT 54417 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 54420 CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (PRIAPISM OPERATION), 2,575 UNILATERAL OR BILATERAL CPT 54430 CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT (PRIAPISM 2,343 OPERATION), UNILATERAL OR BILATERAL CPT 54435 CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY 1,526 NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM CPT 54440 PLASTIC OPERATION OF PENIS FOR INJURY 1,961 CPT 54450 FORESKIN MANIPULATION INCLUDING LYSIS OF PREPUTIAL ADHESIONS 258 AND STRETCHING CPT 54500 BIOPSY OF TESTIS, NEEDLE (SEPARATE PROCEDURE) 273 CPT 54505 BIOPSY OF TESTIS, INCISIONAL (SEPARATE PROCEDURE) 777 CPT 54512 EXCISION OF EXTRAPARENCHYMAL LESION OF TESTIS 1,959 CPT 54520 ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT 1,191 TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH CPT 54522 ORCHIECTOMY, PARTIAL 2,093 CPT 54530 ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH 2,017 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 182 of 380

CPT 54535 ORCHIECTOMY, RADICAL, FOR TUMOR; WITH ABDOMINAL EXPLORATION 2,633 CPT 54550 EXPLORATION FOR UNDESCENDED TESTIS (INGUINAL OR SCROTAL AREA) 1,776 CPT 54560 EXPLORATION FOR UNDESCENDED TESTIS WITH ABDOMINAL 2,484 EXPLORATION CPT 54600 REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT 1,656 FIXATION OF CONTRALATERAL TESTIS CPT 54620 FIXATION OF CONTRALATERAL TESTIS (SEPARATE PROCEDURE) 1,101 CPT 54640 ORCHIOPEXY, INGUINAL APPROACH, WITH OR WITHOUT HERNIA REPAIR 1,704 CPT 54650 ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL TESTIS 2,399 (EG, FOWLER-STEPHENS) CPT 54660 INSERTION OF TESTICULAR PROSTHESIS (SEPARATE PROCEDURE) 1,312 CPT 54670 SUTURE OR REPAIR OF TESTICULAR INJURY 1,489 CPT 54680 TRANSPLANTATION OF TESTIS(ES) TO THIGH (BECAUSE OF SCROTAL 2,866 DESTRUCTION) CPT 54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY 2,292 CPT 54692 LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR INTRA-ABDOMINAL TESTIS 2,832 CPT 54699 UNLISTED LAPAROSCOPY PROCEDURE, TESTIS N/A CPT 54700 INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL 766 SPACE (EG, ABSCESS OR HEMATOMA) CPT 54800 BIOPSY OF EPIDIDYMIS, NEEDLE 475 CPT 54830 EXCISION OF LOCAL LESION OF EPIDIDYMIS 1,353 CPT 54840 EXCISION OF SPERMATOCELE, WITH OR WITHOUT EPIDIDYMECTOMY 1,181 CPT 54860 EPIDIDYMECTOMY; UNILATERAL 1,531 CPT 54861 EPIDIDYMECTOMY; BILATERAL 2,070 CPT 54865 EXPLORATION OF EPIDIDYMIS, WITH OR WITHOUT BIOPSY 1,300 CPT 54900 EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 2,545 DEFERENS; UNILATERAL CPT 54901 EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS 3,934 DEFERENS; BILATERAL CPT 55000 PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR 426 WITHOUT INJECTION OF MEDICATION CPT 55040 EXCISION OF HYDROCELE; UNILATERAL 1,231 CPT 55041 EXCISION OF HYDROCELE; BILATERAL 1,849 CPT 55060 REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE) 1,379 CPT 55100 DRAINAGE OF SCROTAL WALL ABSCESS 762 CPT 55110 SCROTAL EXPLORATION 1,402 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 183 of 380

CPT 55120 REMOVAL OF FOREIGN BODY IN SCROTUM 1,286 CPT 55150 RESECTION OF SCROTUM 1,764 CPT 55175 SCROTOPLASTY; SIMPLE 1,319 CPT 55180 SCROTOPLASTY; COMPLICATED 2,492 CPT 55200 VASOTOMY, CANNULIZATION WITH OR WITHOUT INCISION OF VAS, 1,616 UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) CPT 55250 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), 1,434 INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S) CPT 55300 VASOTOMY FOR VASOGRAMS, SEMINAL VESICULOGRAMS, OR 692 EPIDIDYMOGRAMS, UNILATERAL OR BILATERAL CPT 55400 VASOVASOSTOMY, VASOVASORRHAPHY 1,835 CPT 55450 LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR 1,275 BILATERAL (SEPARATE PROCEDURE) CPT 55500 EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL (SEPARATE 1,368 PROCEDURE) CPT 55520 EXCISION OF LESION OF SPERMATIC CORD (SEPARATE PROCEDURE) 1,400 CPT 55530 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,287 VARICOCELE; (SEPARATE PROCEDURE) CPT 55535 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,559 VARICOCELE; ABDOMINAL APPROACH CPT 55540 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR 1,685 VARICOCELE; WITH HERNIA REPAIR CPT 55550 LAPAROSCOPY, SURGICAL, WITH LIGATION OF SPERMATIC VEINS FOR 1,538 VARICOCELE CPT 55559 UNLISTED LAPAROSCOPY PROCEDURE, SPERMATIC CORD N/A CPT 55600 VESICULOTOMY; 1,564 CPT 55605 VESICULOTOMY; COMPLICATED 1,749 CPT 55650 VESICULECTOMY, ANY APPROACH 2,623 CPT 55680 EXCISION OF MULLERIAN DUCT CYST 1,257 CPT 55700 BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY 805 APPROACH CPT 55705 BIOPSY, PROSTATE; INCISIONAL, ANY APPROACH 975 CPT 55720 PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY 1,700 APPROACH; SIMPLE CPT 55725 PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY 2,124 APPROACH; COMPLICATED CPT 55801 PROSTATECTOMY, PERINEAL, SUBTOTAL (INCLUDING CONTROL OF 3,939 POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY) CPT 55810 PROSTATECTOMY, PERINEAL RADICAL; 4,793 CPT 55812 PROSTATECTOMY, PERINEAL RADICAL; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT 55815 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: 01.03.2015 Page No(s): 184 of 380

OBTURATOR NODES CPT 55821 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 55831 PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, 3,448 VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY); RETROPUBIC, SUBTOTAL CPT 55840 PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 4,877 SPARING; CPT 55842 PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 5,226 SPARING; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT 55845 PROSTATECTOMY, RETROPUBIC RADICAL, WITH OR WITHOUT NERVE 5,967 SPARING; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CPT 55860 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 3,180 RADIOACTIVE SUBSTANCE; CPT 55862 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 4,037 RADIOACTIVE SUBSTANCE; WITH LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) CPT 55865 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF 4,837 RADIOACTIVE SUBSTANCE; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES CPT 55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, 6,341 INCLUDING NERVE SPARING CPT 55870 ELECTROEJACULATION 658 CPT 55873 CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC 4,143 GUIDANCE FOR INTERSTITIAL CRYOSURGICAL PROBE PLACEMENT) CPT 55875 TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO PROSTATE 2,774 FOR INTERSTITIAL RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY CPT 55876 PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY 513 GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE CPT 55899 UNLISTED PROCEDURE, MALE GENITAL SYSTEM N/A CPT 55920 PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR 1,514 GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION CPT 55970 INTERSEX SURGERY; MALE TO FEMALE N/A CPT 55980 INTERSEX SURGERY; FEMALE TO MALE N/A CPT 56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS 353 CPT 56420 INCISION AND DRAINAGE OF BARTHOLIN'S GLAND ABSCESS 388 CPT 56440 MARSUPIALIZATION OF BARTHOLIN'S GLAND CYST 599 CPT 56441 LYSIS OF LABIAL ADHESIONS 490 CPT 56442 HYMENOTOMY, SIMPLE INCISION 161 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 185 of 380

CPT 56501 DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, 422 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 56515 DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, 725 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 56605 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); ONE LESION 271 CPT 56606 BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH 123 SEPARATE ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 56620 VULVECTOMY SIMPLE; PARTIAL 1,729 CPT 56625 VULVECTOMY SIMPLE; COMPLETE 1,935 CPT 56630 VULVECTOMY, RADICAL, PARTIAL; 2,824 CPT 56631 VULVECTOMY, RADICAL, PARTIAL; WITH UNILATERAL INGUINOFEMORAL 3,594 LYMPHADENECTOMY CPT 56632 VULVECTOMY, RADICAL, PARTIAL; WITH BILATERAL INGUINOFEMORAL 4,191 LYMPHADENECTOMY CPT 56633 VULVECTOMY, RADICAL, COMPLETE; 3,681 CPT 56634 VULVECTOMY, RADICAL, COMPLETE; WITH UNILATERAL INGUINOFEMORAL 3,881 LYMPHADENECTOMY CPT 56637 VULVECTOMY, RADICAL, COMPLETE; WITH BILATERAL INGUINOFEMORAL 4,592 LYMPHADENECTOMY CPT 56640 VULVECTOMY, RADICAL, COMPLETE, WITH INGUINOFEMORAL, ILIAC, AND 4,579 PELVIC LYMPHADENECTOMY CPT 56700 PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING 611 CPT 56740 EXCISION OF BARTHOLIN'S GLAND OR CYST 971 CPT 56800 PLASTIC REPAIR OF INTROITUS 792 CPT 56805 CLITOROPLASTY FOR INTERSEX STATE 3,724 CPT 56810 PERINEOPLASTY, REPAIR OF PERINEUM, NONOBSTETRICAL (SEPARATE 854 PROCEDURE) CPT 56820 COLPOSCOPY OF THE VULVA; 361 CPT 56821 COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) 482 CPT 57000 COLPOTOMY; WITH EXPLORATION 635 CPT 57010 COLPOTOMY; WITH DRAINAGE OF PELVIC ABSCESS 1,416 CPT 57020 COLPOCENTESIS (SEPARATE PROCEDURE) 308 CPT 57022 INCISION AND DRAINAGE OF VAGINAL HEMATOMA; 552 OBSTETRICAL/POSTPARTUM CPT 57023 INCISION AND DRAINAGE OF VAGINAL HEMATOMA; NON-OBSTETRICAL 1,017 (EG, POST-TRAUMA, SPONTANEOUS BLEEDING) CPT 57061 DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, 370 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 57065 DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, 625 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) CPT 57100 BIOPSY OF VAGINAL MUCOSA; SIMPLE (SEPARATE PROCEDURE) 288 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 186 of 380

CPT 57105 BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, REQUIRING SUTURE 440 (INCLUDING CYSTS) CPT 57106 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; 1,554 CPT 57107 VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF 4,557 PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) CPT 57109 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 57110 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; 2,934 CPT 57111 VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL 5,268 OF PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) CPT 57112 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 57120 COLPOCLEISIS (LE FORT TYPE) 1,670 CPT 57130 EXCISION OF VAGINAL SEPTUM 590 CPT 57135 EXCISION OF VAGINAL CYST OR TUMOR 631 CPT 57150 IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT FOR 151 TREATMENT OF BACTERIAL, PARASITIC, OR FUNGOID DISEASE CPT 57155 INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR 1,348 CLINICAL BRACHYTHERAPY CPT 57160 FITTING AND INSERTION OF PESSARY OR OTHER INTRAVAGINAL SUPPORT 255 DEVICE CPT 57170 DIAPHRAGM OR CERVICAL CAP FITTING WITH INSTRUCTIONS 200 CPT 57180 INTRODUCTION OF ANY HEMOSTATIC AGENT OR PACK FOR SPONTANEOUS 459 OR TRAUMATIC NONOBSTETRICAL VAGINAL HEMORRHAGE (SEPARATE PROCEDURE) CPT 57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) 980 CPT 57210 COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR 1,198 PERINEUM (NONOBSTETRICAL) CPT 57220 PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, 1,043 KELLY URETHRAL PLICATION) CPT 57230 PLASTIC REPAIR OF URETHROCELE 1,309 CPT 57240 ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT 2,206 REPAIR OF URETHROCELE CPT 57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT 2,153 PERINEORRHAPHY CPT 57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; 2,667 CPT 57265 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; WITH ENTEROCELE 2,959 REPAIR CPT 57267 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 57268 REPAIR OF ENTEROCELE, VAGINAL APPROACH (SEPARATE PROCEDURE) 1,585 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 187 of 380

CPT 57270 REPAIR OF ENTEROCELE, ABDOMINAL APPROACH (SEPARATE PROCEDURE) 2,621 CPT 57280 COLPOPEXY, ABDOMINAL APPROACH 3,180 CPT 57282 COLPOPEXY, VAGINAL; EXTRA-PERITONEAL APPROACH (SACROSPINOUS, 1,681 ILIOCOCCYGEUS) CPT 57283 COLPOPEXY, VAGINAL; INTRA-PERITONEAL APPROACH (UTEROSACRAL, 2,230 LEVATOR MYORRHAPHY) CPT 57284 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF 2,725 PERFORMED); OPEN ABDOMINAL APPROACH CPT 57285 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, IF 2,178 PERFORMED); VAGINAL APPROACH CPT 57287 REMOVAL OR REVISION OF SLING FOR STRESS INCONTINENCE (EG, 2,358 FASCIA OR SYNTHETIC) CPT 57288 SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR 2,788 SYNTHETIC) CPT 57289 PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY 2,594 CPT 57291 CONSTRUCTION OF ARTIFICIAL VAGINA; WITHOUT GRAFT 1,808 CPT 57292 CONSTRUCTION OF ARTIFICIAL VAGINA; WITH GRAFT 2,693 CPT 57295 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; 1,603 VAGINAL APPROACH CPT 57296 REVISION (INCLUDING REMOVAL) OF PROSTHETIC VAGINAL GRAFT; OPEN 3,122 ABDOMINAL APPROACH CPT 57300 CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL 1,748 APPROACH CPT 57305 CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH 2,916 CPT 57307 CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH, WITH 3,266 CONCOMITANT COLOSTOMY CPT 57308 CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH 2,086 PERINEAL BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION CPT 57310 CLOSURE OF URETHROVAGINAL FISTULA; 1,650 CPT 57311 CLOSURE OF URETHROVAGINAL FISTULA; WITH BULBOCAVERNOSUS 1,884 TRANSPLANT CPT 57320 CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH 1,856 CPT 57330 CLOSURE OF VESICOVAGINAL FISTULA; TRANSVESICAL AND VAGINAL 2,689 APPROACH CPT 57335 VAGINOPLASTY FOR INTERSEX STATE 3,728 CPT 57400 DILATION OF VAGINA UNDER ANESTHESIA 444 CPT 57410 PELVIC EXAMINATION UNDER ANESTHESIA 357 CPT 57415 REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) 524 UNDER ANESTHESIA CPT 57420 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; 380 CPT 57421 COLPOSCOPY OF THE ENTIRE VAGINA, WITH CERVIX IF PRESENT; WITH BIOPSY(S) OF VAGINA/CERVIX CPT 57423 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: 01.03.2015 Page No(s): 188 of 380

CPT 57425 LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX) 3,222 CPT 57452 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 359 CPT 57454 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 503 WITH BIOPSY(S) OF THE CERVIX AND ENDOCERVICAL CURETTAGE CPT 57455 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 469 WITH BIOPSY(S) OF THE CERVIX CPT 57456 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 444 WITH ENDOCERVICAL CURETTAGE CPT 57460 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 937 WITH LOOP ELECTRODE BIOPSY(S) OF THE CERVIX CPT 57461 COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; 1,058 WITH LOOP ELECTRODE CONIZATION OF THE CERVIX CPT 57500 BIOPSY OF CERVIX, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF 420 LESION, WITH OR WITHOUT FULGURATION (SEPARATE PROCEDURE) CPT 57505 ENDOCERVICAL CURETTAGE (NOT DONE AS PART OF A DILATION AND 331 CURETTAGE) CPT 57510 CAUTERY OF CERVIX; ELECTRO OR THERMAL 431 CPT 57511 CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL OR REPEAT 472 CPT 57513 CAUTERY OF CERVIX; LASER ABLATION 468 CPT 57520 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR 998 WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER CPT 57522 CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR 855 WITHOUT DILATION AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION CPT 57530 TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE 1,116 PROCEDURE) CPT 57531 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 57540 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; 2,532 CPT 57545 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; WITH PELVIC 2,673 FLOOR REPAIR CPT 57550 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; 1,324 CPT 57555 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; WITH ANTERIOR 1,973 AND/OR POSTERIOR REPAIR CPT 57556 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; WITH REPAIR OF 1,861 ENTEROCELE CPT 57558 DILATION AND CURETTAGE OF CERVICAL STUMP 407 CPT 57700 CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL 995 CPT 57720 TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL 1,001 APPROACH CPT 57800 DILATION OF CERVICAL CANAL, INSTRUMENTAL (SEPARATE PROCEDURE) 198 CPT 58100 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: 01.03.2015 Page No(s): 189 of 380

CPT 58110 ENDOMETRIAL SAMPLING (BIOPSY) PERFORMED IN CONJUNCTION WITH 158 COLPOSCOPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 58120 DILATION AND CURETTAGE, DIAGNOSTIC AND/OR THERAPEUTIC 834 (NONOBSTETRICAL) CPT 58140 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 58145 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 58146 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 58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR 3,224 WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S); CPT 58152 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 58180 SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL 3,080 HYSTERECTOMY), WITH OR WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) CPT 58200 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 58210 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 58240 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 58260 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; 2,691 CPT 58262 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL 3,000 OF TUBE(S), AND/OR OVARY(S) CPT 58263 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL 3,233 OF TUBE(S), AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE CPT 58267 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 58270 VAGINAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REPAIR OF 2,878 ENTEROCELE CPT 58275 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; 3,200 CPT 58280 VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH 3,427 REPAIR OF ENTEROCELE CPT 58285 VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) 4,273 CPT 58290 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: 01.03.2015 Page No(s): 190 of 380

CPT 58291 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 4,066 REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58292 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 4,297 REMOVAL OF TUBE(S) AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE CPT 58293 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 58294 VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH 3,947 REPAIR OF ENTEROCELE CPT 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) 221 CPT 58301 REMOVAL OF INTRAUTERINE DEVICE (IUD) 310 CPT 58321 ARTIFICIAL INSEMINATION; INTRA-CERVICAL 246 CPT 58322 ARTIFICIAL INSEMINATION; INTRA-UTERINE 284 CPT 58323 SPERM WASHING FOR ARTIFICIAL INSEMINATION 52 CPT 58340 CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST 392 MATERIAL FOR SALINE INFUSION SONOHYSTEROGRAPHY (SIS) OR HYSTEROSALPINGOGRAPHY CPT 58345 TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR 905 DIAGNOSIS AND/OR RE-ESTABLISHING PATENCY (ANY METHOD), WITH OR WITHOUT HYSTEROSALPINGOGRAPHY CPT 58346 INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY 1,482 CPT 58350 CHROMOTUBATION OF OVIDUCT, INCLUDING MATERIALS 314 CPT 58353 ENDOMETRIAL ABLATION, THERMAL, WITHOUT HYSTEROSCOPIC 3,378 GUIDANCE CPT 58356 ENDOMETRIAL CRYOABLATION WITH ULTRASONIC GUIDANCE, INCLUDING 6,363 ENDOMETRIAL CURETTAGE, WHEN PERFORMED CPT 58400 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND 1,468 LIGAMENTS, WITH OR WITHOUT SHORTENING OF SACROUTERINE LIGAMENTS; (SEPARATE PROCEDURE) CPT 58410 UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND 2,605 LIGAMENTS, WITH OR WITHOUT SHORTENING OF SACROUTERINE LIGAMENTS; WITH PRESACRAL SYMPATHECTOMY CPT 58520 HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL) 2,560 CPT 58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) 2,964 CPT 58541 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; CPT 58542 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58543 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; CPT 58544 LAPAROSCOPY, SURGICAL, SUPRACERVICAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58545 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH TOTAL WEIGHT OF 250 G OR LESS AND/OR REMOVAL OF SURFACE MYOMAS CPT 58546 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: 01.03.2015 Page No(s): 191 of 380

CPT 58548 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 58550 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 2,873 250 G OR LESS; CPT 58552 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 3,155 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58553 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 3,695 GREATER THAN 250 G; CPT 58554 LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 4,216 GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE) 816 CPT 58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM 1,124 AND/OR POLYPECTOMY, WITH OR WITHOUT D & C CPT 58559 HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS 1,125 (ANY METHOD) CPT 58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF 1,277 INTRAUTERINE SEPTUM (ANY METHOD) CPT 58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA 1,801 CPT 58562 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN 1,178 BODY CPT 58563 HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, 5,558 ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION) CPT 58565 HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE 6,323 CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS CPT 58570 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3,024 250 G OR LESS; CPT 58571 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3,312 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58572 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 3,759 GREATER THAN 250 G; CPT 58573 LAPAROSCOPY, SURGICAL, WITH TOTAL HYSTERECTOMY, FOR UTERUS 4,239 GREATER THAN 250 G; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) CPT 58578 UNLISTED LAPAROSCOPY PROCEDURE, UTERUS N/A CPT 58579 UNLISTED HYSTEROSCOPY PROCEDURE, UTERUS N/A CPT 58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERAL OR BILATERAL CPT 58605 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, POSTPARTUM, UNILATERAL OR BILATERAL, DURING SAME HOSPITALIZATION (SEPARATE PROCEDURE) CPT 58611 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 58615 OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR SUPRAPUBIC APPROACH CPT 58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE) CPT 58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY) 1,188 1,076 255 808 2,193 2,093 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 192 of 380

CPT 58662 LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF 2,299 LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD CPT 58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR 1,193 WITHOUT TRANSECTION) CPT 58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE 1,193 (EG, BAND, CLIP, OR FALOPE RING) CPT 58672 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY 2,424 CPT 58673 LAPAROSCOPY, SURGICAL; WITH SALPINGOSTOMY (SALPINGONEOSTOMY) 2,620 CPT 58679 UNLISTED LAPAROSCOPY PROCEDURE, OVIDUCT, OVARY N/A CPT 58700 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL 2,497 (SEPARATE PROCEDURE) CPT 58720 SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR 2,336 BILATERAL (SEPARATE PROCEDURE) CPT 58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) 2,839 CPT 58750 TUBOTUBAL ANASTOMOSIS 2,952 CPT 58752 TUBOUTERINE IMPLANTATION 2,940 CPT 58760 FIMBRIOPLASTY 2,673 CPT 58770 SALPINGOSTOMY (SALPINGONEOSTOMY) 2,791 CPT 58800 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE 1,029 PROCEDURE); VAGINAL APPROACH CPT 58805 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL (SEPARATE 1,326 PROCEDURE); ABDOMINAL APPROACH CPT 58820 DRAINAGE OF OVARIAN ABSCESS; VAGINAL APPROACH, OPEN 1,011 CPT 58822 DRAINAGE OF OVARIAN ABSCESS; ABDOMINAL APPROACH 2,269 CPT 58823 DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL OR TRANSRECTAL 2,971 APPROACH, PERCUTANEOUS (EG, OVARIAN, PERICOLIC) CPT 58825 TRANSPOSITION, OVARY(S) 2,248 CPT 58900 BIOPSY OF OVARY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE) 1,353 CPT 58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR BILATERAL 2,309 CPT 58925 OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL 2,390 CPT 58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; 1,645 CPT 58943 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 58950 RESECTION (INITIAL) OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND OMENTECTOMY; CPT 58951 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: 01.03.2015 Page No(s): 193 of 380

OMENTECTOMY; WITH TOTAL ABDOMINAL HYSTERECTOMY, PELVIC AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT 58952 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 58953 BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 6,223 ABDOMINAL HYSTERECTOMY AND RADICAL DISSECTION FOR DEBULKING; CPT 58954 BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL 6,755 ABDOMINAL HYSTERECTOMY AND RADICAL DISSECTION FOR DEBULKING; WITH PELVIC LYMPHADENECTOMY AND LIMITED PARA-AORTIC LYMPHADENECTOMY CPT 58956 BILATERAL SALPINGO-OOPHORECTOMY WITH TOTAL OMENTECTOMY, 4,436 TOTAL ABDOMINAL HYSTERECTOMY FOR MALIGNANCY CPT 58957 RESECTION (TUMOR DEBULKING) OF RECURRENT OVARIAN, TUBAL, 4,856 PRIMARY PERITONEAL, UTERINE MALIGNANCY (INTRA-ABDOMINAL, RETROPERITONEAL TUMORS), WITH OMENTECTOMY, IF PERFORMED; CPT 58958 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 58960 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 58970 FOLLICLE PUNCTURE FOR OOCYTE RETRIEVAL, ANY METHOD 730 CPT 58974 EMBRYO TRANSFER, INTRAUTERINE 483 CPT 58976 GAMETE, ZYGOTE, OR EMBRYO INTRAFALLOPIAN TRANSFER, ANY METHOD 784 CPT 58999 UNLISTED PROCEDURE, FEMALE GENITAL SYSTEM (NONOBSTETRICAL) N/A CPT 59000 AMNIOCENTESIS; DIAGNOSTIC 422 CPT 59001 AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION (INCLUDES 601 ULTRASOUND GUIDANCE) CPT 59012 CORDOCENTESIS (INTRAUTERINE), ANY METHOD 678 CPT 59015 CHORIONIC VILLUS SAMPLING, ANY METHOD 521 CPT 59020 FETAL CONTRACTION STRESS TEST 250 CPT 59025 FETAL NON-STRESS TEST 164 CPT 59030 FETAL SCALP BLOOD SAMPLING 367 CPT 59050 FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITTEN REPORT; SUPERVISION AND INTERPRETATION CPT 59051 FETAL MONITORING DURING LABOR BY CONSULTING PHYSICIAN (IE, NON-ATTENDING PHYSICIAN) WITH WRITTEN REPORT; INTERPRETATION ONLY 172 139 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 194 of 380

CPT 59070 TRANSABDOMINAL AMNIOINFUSION, INCLUDING ULTRASOUND GUIDANCE 1,247 CPT 59072 FETAL UMBILICAL CORD OCCLUSION, INCLUDING ULTRASOUND 1,452 GUIDANCE CPT 59074 FETAL FLUID DRAINAGE (EG, VESICOCENTESIS, THORACOCENTESIS, 1,149 PARACENTESIS), INCLUDING ULTRASOUND GUIDANCE CPT 59076 FETAL SHUNT PLACEMENT, INCLUDING ULTRASOUND GUIDANCE 1,452 CPT 59100 HYSTEROTOMY, ABDOMINAL (EG, FOR HYDATIDIFORM MOLE, ABORTION) 2,738 CPT 59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, 2,604 REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH CPT 59121 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, 2,615 WITHOUT SALPINGECTOMY AND/OR OOPHORECTOMY CPT 59130 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; ABDOMINAL PREGNANCY 3,160 CPT 59135 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE 2,922 PREGNANCY REQUIRING TOTAL HYSTERECTOMY CPT 59136 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE 2,796 PREGNANCY WITH PARTIAL RESECTION OF UTERUS CPT 59140 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; CERVICAL, WITH 1,315 EVACUATION CPT 59150 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITHOUT 2,543 SALPINGECTOMY AND/OR OOPHORECTOMY CPT 59151 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; WITH 2,469 SALPINGECTOMY AND/OR OOPHORECTOMY CPT 59160 CURETTAGE, POSTPARTUM 674 CPT 59200 INSERTION OF CERVICAL DILATOR (EG, LAMINARIA, PROSTAGLANDIN) 241 (SEPARATE PROCEDURE) CPT 59300 EPISIOTOMY OR VAGINAL REPAIR, BY OTHER THAN ATTENDING 650 PHYSICIAN CPT 59320 CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL 512 CPT 59325 CERCLAGE OF CERVIX, DURING PREGNANCY; ABDOMINAL 803 CPT 59350 HYSTERORRHAPHY OF RUPTURED UTERUS 921 CPT 59400 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL 5,839 DELIVERY (WITH OR WITHOUT EPISIOTOMY, AND/OR FORCEPS) AND POSTPARTUM CARE CPT 59409 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR 2,567 FORCEPS); CPT 59410 VAGINAL DELIVERY ONLY (WITH OR WITHOUT EPISIOTOMY AND/OR 2,986 FORCEPS); INCLUDING POSTPARTUM CARE CPT 59412 EXTERNAL CEPHALIC VERSION, WITH OR WITHOUT TOCOLYSIS 346 CPT 59414 DELIVERY OF PLACENTA (SEPARATE PROCEDURE) 305 CPT 59425 ANTEPARTUM CARE ONLY; 4-6 VISITS 1,460 CPT 59426 ANTEPARTUM CARE ONLY; 7 OR MORE VISITS 2,619 CPT 59430 POSTPARTUM CARE ONLY (SEPARATE PROCEDURE) 466 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 195 of 380

CPT 59510 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN 6,616 DELIVERY, AND POSTPARTUM CARE CPT 59514 CESAREAN DELIVERY ONLY; 3,043 CPT 59515 CESAREAN DELIVERY ONLY; INCLUDING POSTPARTUM CARE 3,589 CPT 59525 SUBTOTAL OR TOTAL HYSTERECTOMY AFTER CESAREAN DELIVERY (LIST 1,602 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 59610 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 59612 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH 2,872 OR WITHOUT EPISIOTOMY AND/OR FORCEPS); CPT 59614 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (WITH 3,221 OR WITHOUT EPISIOTOMY AND/OR FORCEPS); INCLUDING POSTPARTUM CARE CPT 59618 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, CESAREAN 6,892 DELIVERY, AND POSTPARTUM CARE, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY CPT 59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY 3,314 AFTER PREVIOUS CESAREAN DELIVERY; CPT 59622 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY 3,890 AFTER PREVIOUS CESAREAN DELIVERY; INCLUDING POSTPARTUM CARE CPT 59812 TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED 1,062 SURGICALLY CPT 59820 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST 1,220 TRIMESTER CPT 59821 TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND 1,251 TRIMESTER CPT 59830 TREATMENT OF SEPTIC ABORTION, COMPLETED SURGICALLY 1,433 CPT 59840 INDUCED ABORTION, BY DILATION AND CURETTAGE 719 CPT 59841 INDUCED ABORTION, BY DILATION AND EVACUATION 1,249 CPT 59850 INDUCED ABORTION, BY ONE OR MORE INTRA-AMNIOTIC INJECTIONS (AMNIOCENTESIS-INJECTIONS), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; CPT 59851 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 59852 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 59855 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 59856 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 59857 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: 01.03.2015 Page No(s): 196 of 380

LAMINARIA), INCLUDING HOSPITAL ADMISSION AND VISITS, DELIVERY OF FETUS AND SECUNDINES; WITH HYSTEROTOMY (FAILED MEDICAL EVACUATION) CPT 59866 MULTIFETAL PREGNANCY REDUCTION(S) (MPR) 782 CPT 59870 UTERINE EVACUATION AND CURETTAGE FOR HYDATIDIFORM MOLE 1,535 CPT 59871 REMOVAL OF CERCLAGE SUTURE UNDER ANESTHESIA (OTHER THAN 445 LOCAL) CPT 59897 UNLISTED FETAL INVASIVE PROCEDURE, INCLUDING ULTRASOUND N/A GUIDANCE CPT 59898 UNLISTED LAPAROSCOPY PROCEDURE, MATERNITY CARE AND DELIVERY N/A CPT 59899 UNLISTED PROCEDURE, MATERNITY CARE AND DELIVERY N/A CPT 60000 INCISION AND DRAINAGE OF THYROGLOSSAL DUCT CYST, INFECTED 505 CPT 60100 BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE 375 CPT 60200 EXCISION OF CYST OR ADENOMA OF THYROID, OR TRANSECTION OF 2,066 ISTHMUS CPT 60210 PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT 2,216 ISTHMUSECTOMY CPT 60212 PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL 3,174 SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY CPT 60220 TOTAL THYROID LOBECTOMY, UNILATERAL; WITH OR WITHOUT 2,426 ISTHMUSECTOMY CPT 60225 TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL 2,923 SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY CPT 60240 THYROIDECTOMY, TOTAL OR COMPLETE 3,076 CPT 60252 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED 4,154 NECK DISSECTION CPT 60254 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL 5,301 NECK DISSECTION CPT 60260 THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE 3,465 FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID CPT 60270 THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; STERNAL SPLIT OR 4,371 TRANSTHORACIC APPROACH CPT 60271 THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; CERVICAL 3,328 APPROACH CPT 60280 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; 1,393 CPT 60281 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT 1,857 CPT 60300 ASPIRATION AND/OR INJECTION, THYROID CYST 375 CPT 60500 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); 3,217 CPT 60502 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE- EXPLORATION CPT 60505 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); WITH MEDIASTINAL EXPLORATION, STERNAL SPLIT OR TRANSTHORACIC APPROACH CPT 60512 PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 4,047 4,399 777 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 197 of 380

CPT 60520 THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH 3,307 (SEPARATE PROCEDURE) CPT 60521 THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC 3,783 APPROACH, WITHOUT RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) CPT 60522 THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC 4,562 APPROACH, WITH RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) CPT 60540 ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL 3,513 GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE); CPT 60545 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 60600 EXCISION OF CAROTID BODY TUMOR; WITHOUT EXCISION OF CAROTID 4,533 ARTERY CPT 60605 EXCISION OF CAROTID BODY TUMOR; WITH EXCISION OF CAROTID 5,852 ARTERY CPT 60650 LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR 3,903 COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL CPT 60659 UNLISTED LAPAROSCOPY PROCEDURE, ENDOCRINE SYSTEM N/A CPT 60699 UNLISTED PROCEDURE, ENDOCRINE SYSTEM N/A CPT 61000 SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL 371 OR BILATERAL; INITIAL CPT 61001 SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL 343 OR BILATERAL; SUBSEQUENT TAPS CPT 61020 VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, 438 SUTURE, OR IMPLANTED VENTRICULAR CATHETER/RESERVOIR; WITHOUT INJECTION CPT 61026 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 61050 CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITHOUT 348 INJECTION (SEPARATE PROCEDURE) CPT 61055 CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITH INJECTION 453 OF MEDICATION OR OTHER SUBSTANCE FOR DIAGNOSIS OR TREATMENT (EG, C1-C2) CPT 61070 PUNCTURE OF SHUNT TUBING OR RESERVOIR FOR ASPIRATION OR 279 INJECTION PROCEDURE CPT 61105 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE 1,463 CPT 61107 TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR IMPLANTING VENTRICULAR CATHETER, PRESSURE RECORDING DEVICE, OR OTHER INTRACEREBRAL MONITORING DEVICE CPT 61108 TWIST DRILL HOLE(S) FOR SUBDURAL, INTRACEREBRAL, OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA CPT 61120 BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING INJECTION OF GAS, CONTRAST MEDIA, DYE, OR RADIOACTIVE MATERIAL) CPT 61140 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: 01.03.2015 Page No(s): 198 of 380

CPT 61150 BURR HOLE(S) OR TREPHINE; WITH DRAINAGE OF BRAIN ABSCESS OR 4,254 CYST CPT 61151 BURR HOLE(S) OR TREPHINE; WITH SUBSEQUENT TAPPING (ASPIRATION) 3,129 OF INTRACRANIAL ABSCESS OR CYST CPT 61154 BURR HOLE(S) WITH EVACUATION AND/OR DRAINAGE OF HEMATOMA, 4,022 EXTRADURAL OR SUBDURAL CPT 61156 BURR HOLE(S); WITH ASPIRATION OF HEMATOMA OR CYST, 3,942 INTRACEREBRAL CPT 61210 BURR HOLE(S); FOR IMPLANTING VENTRICULAR CATHETER, RESERVOIR, 1,193 EEG ELECTRODE(S), PRESSURE RECORDING DEVICE, OR OTHER CEREBRAL MONITORING DEVICE (SEPARATE PROCEDURE) CPT 61215 INSERTION OF SUBCUTANEOUS RESERVOIR, PUMP OR CONTINUOUS 1,570 INFUSION SYSTEM FOR CONNECTION TO VENTRICULAR CATHETER CPT 61250 BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL, EXPLORATORY, NOT 2,713 FOLLOWED BY OTHER SURGERY CPT 61253 BURR HOLE(S) OR TREPHINE, INFRATENTORIAL, UNILATERAL OR 2,960 BILATERAL CPT 61304 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; SUPRATENTORIAL 5,221 CPT 61305 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; INFRATENTORIAL 6,239 (POSTERIOR FOSSA) CPT 61312 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,503 SUPRATENTORIAL; EXTRADURAL OR SUBDURAL CPT 61313 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,263 SUPRATENTORIAL; INTRACEREBRAL CPT 61314 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 5,815 INFRATENTORIAL; EXTRADURAL OR SUBDURAL CPT 61315 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, 6,569 INFRATENTORIAL; INTRACEREBELLAR CPT 61316 INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL BONE GRAFT 283 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61320 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; 6,065 SUPRATENTORIAL CPT 61321 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; 6,747 INFRATENTORIAL CPT 61322 CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR WITHOUT 7,450 DURAPLASTY, FOR TREATMENT OF INTRACRANIAL HYPERTENSION, WITHOUT EVACUATION OF ASSOCIATED INTRAPARENCHYMAL HEMATOMA; WITHOUT LOBECTOMY CPT 61323 CRANIECTOMY OR CRANIOTOMY, DECOMPRESSIVE, WITH OR WITHOUT 7,586 DURAPLASTY, FOR TREATMENT OF INTRACRANIAL HYPERTENSION, WITHOUT EVACUATION OF ASSOCIATED INTRAPARENCHYMAL HEMATOMA; WITH LOBECTOMY CPT 61330 DECOMPRESSION OF ORBIT ONLY, TRANSCRANIAL APPROACH 4,911 CPT 61332 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH BIOPSY 5,826 CPT 61333 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH REMOVAL OF LESION CPT 61334 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); WITH REMOVAL OF FOREIGN BODY CPT 61340 SUBTEMPORAL CRANIAL DECOMPRESSION (PSEUDOTUMOR CEREBRI, SLIT VENTRICLE SYNDROME) CPT 61343 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: 01.03.2015 Page No(s): 199 of 380

CPT 61345 OTHER CRANIAL DECOMPRESSION, POSTERIOR FOSSA 6,419 CPT 61440 CRANIOTOMY FOR SECTION OF TENTORIUM CEREBELLI (SEPARATE 6,376 PROCEDURE) CPT 61450 CRANIECTOMY, SUBTEMPORAL, FOR SECTION, COMPRESSION, OR 5,971 DECOMPRESSION OF SENSORY ROOT OF GASSERIAN GANGLION CPT 61458 CRANIECTOMY, SUBOCCIPITAL; FOR EXPLORATION OR DECOMPRESSION 6,372 OF CRANIAL NERVES CPT 61460 CRANIECTOMY, SUBOCCIPITAL; FOR SECTION OF ONE OR MORE CRANIAL 6,385 NERVES CPT 61470 CRANIECTOMY, SUBOCCIPITAL; FOR MEDULLARY TRACTOTOMY 5,976 CPT 61480 CRANIECTOMY, SUBOCCIPITAL; FOR MESENCEPHALIC TRACTOTOMY OR 5,389 PEDUNCULOTOMY CPT 61490 CRANIOTOMY FOR LOBOTOMY, INCLUDING CINGULOTOMY 6,075 CPT 61500 CRANIECTOMY; WITH EXCISION OF TUMOR OR OTHER BONE LESION OF 4,260 SKULL CPT 61501 CRANIECTOMY; FOR OSTEOMYELITIS 3,636 CPT 61510 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN TUMOR, SUPRATENTORIAL, EXCEPT MENINGIOMA CPT 61512 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF MENINGIOMA, SUPRATENTORIAL CPT 61514 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN ABSCESS, SUPRATENTORIAL CPT 61516 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OR FENESTRATION OF CYST, SUPRATENTORIAL CPT 61517 IMPLANTATION OF BRAIN INTRACAVITARY CHEMOTHERAPY AGENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61518 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; EXCEPT MENINGIOMA, CEREBELLOPONTINE ANGLE TUMOR, OR MIDLINE TUMOR AT BASE OF SKULL CPT 61519 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MENINGIOMA CPT 61520 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; CEREBELLOPONTINE ANGLE TUMOR CPT 61521 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MIDLINE TUMOR AT BASE OF SKULL CPT 61522 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OF BRAIN ABSCESS CPT 61524 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OR FENESTRATION OF CYST CPT 61526 CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; CPT 61530 CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; COMBINED WITH MIDDLE/POSTERIOR FOSSA CRANIOTOMY/CRANIECTOMY CPT 61531 SUBDURAL IMPLANTATION OF STRIP ELECTRODES THROUGH ONE OR MORE BURR OR TREPHINE HOLE(S) FOR LONG-TERM SEIZURE MONITORING CPT 61533 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SUBDURAL IMPLANTATION OF AN ELECTRODE ARRAY, FOR LONG-TERM SEIZURE MONITORING CPT 61534 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF EPILEPTOGENIC FOCUS WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY 6,914 8,123 6,049 5,898 281 8,766 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: 01.03.2015 Page No(s): 200 of 380

CPT 61535 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR REMOVAL OF 3,135 EPIDURAL OR SUBDURAL ELECTRODE ARRAY, WITHOUT EXCISION OF CEREBRAL TISSUE (SEPARATE PROCEDURE) CPT 61536 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF 8,223 CEREBRAL EPILEPTOGENIC FOCUS, WITH ELECTROCORTICOGRAPHY DURING SURGERY (INCLUDES REMOVAL OF ELECTRODE ARRAY) CPT 61537 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 7,593 TEMPORAL LOBE, WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY CPT 61538 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, 8,138 TEMPORAL LOBE, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT 61539 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, OTHER 7,464 THAN TEMPORAL LOBE, PARTIAL OR TOTAL, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT 61540 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR LOBECTOMY, OTHER 7,038 THAN TEMPORAL LOBE, PARTIAL OR TOTAL, WITHOUT ELECTROCORTICOGRAPHY DURING SURGERY CPT 61541 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR TRANSECTION OF 6,734 CORPUS CALLOSUM CPT 61542 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR TOTAL 7,280 HEMISPHERECTOMY CPT 61543 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR PARTIAL OR 6,620 SUBTOTAL (FUNCTIONAL) HEMISPHERECTOMY CPT 61544 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OR 5,980 COAGULATION OF CHOROID PLEXUS CPT 61545 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR EXCISION OF 10,030 CRANIOPHARYNGIOMA CPT 61546 CRANIOTOMY FOR HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, 7,265 INTRACRANIAL APPROACH CPT 61548 HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, TRANSNASAL OR 4,823 TRANSSEPTAL APPROACH, NONSTEREOTACTIC CPT 61550 CRANIECTOMY FOR CRANIOSYNOSTOSIS; SINGLE CRANIAL SUTURE 2,777 CPT 61552 CRANIECTOMY FOR CRANIOSYNOSTOSIS; MULTIPLE CRANIAL SUTURES 4,214 CPT 61556 CRANIOTOMY FOR CRANIOSYNOSTOSIS; FRONTAL OR PARIETAL BONE 5,278 FLAP CPT 61557 CRANIOTOMY FOR CRANIOSYNOSTOSIS; BIFRONTAL BONE FLAP 5,362 CPT 61558 EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE CRANIOSYNOSTOSIS (EG, CLOVERLEAF SKULL); NOT REQUIRING BONE GRAFTS CPT 61559 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 61563 EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA); WITHOUT OPTIC NERVE DECOMPRESSION CPT 61564 EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (EG, FIBROUS DYSPLASIA); WITH OPTIC NERVE DECOMPRESSION CPT 61566 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR SELECTIVE AMYGDALOHIPPOCAMPECTOMY CPT 61567 CRANIOTOMY WITH ELEVATION OF BONE FLAP; FOR MULTIPLE SUBPIAL TRANSECTIONS, WITH ELECTROCORTICOGRAPHY DURING SURGERY CPT 61570 CRANIECTOMY OR CRANIOTOMY; WITH EXCISION OF FOREIGN BODY FROM BRAIN CPT 61571 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: 01.03.2015 Page No(s): 201 of 380

CPT 61575 TRANSORAL APPROACH TO SKULL BASE, BRAIN STEM OR UPPER SPINAL 7,284 CORD FOR BIOPSY, DECOMPRESSION OR EXCISION OF LESION; CPT 61576 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 61580 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, 7,622 INCLUDING LATERAL RHINOTOMY, ETHMOIDECTOMY, SPHENOIDECTOMY, WITHOUT MAXILLECTOMY OR ORBITAL EXENTERATION CPT 61581 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, 8,890 INCLUDING LATERAL RHINOTOMY, ORBITAL EXENTERATION, ETHMOIDECTOMY, SPHENOIDECTOMY AND/OR MAXILLECTOMY CPT 61582 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 61583 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 61584 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 61585 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 61586 BICORONAL, TRANSZYGOMATIC AND/OR LEFORT I OSTEOTOMY APPROACH 6,833 TO ANTERIOR CRANIAL FOSSA WITH OR WITHOUT INTERNAL FIXATION, WITHOUT BONE GRAFT CPT 61590 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 61591 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 61592 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 61595 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 61596 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 61597 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: 01.03.2015 Page No(s): 202 of 380

CPT 61598 TRANSPETROSAL APPROACH TO POSTERIOR CRANIAL FOSSA, CLIVUS OR 8,089 FORAMEN MAGNUM, INCLUDING LIGATION OF SUPERIOR PETROSAL SINUS AND/OR SIGMOID SINUS CPT 61600 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 6,720 LESION OF BASE OF ANTERIOR CRANIAL FOSSA; EXTRADURAL CPT 61601 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 61605 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 6,888 LESION OF INFRATEMPORAL FOSSA, PARAPHARYNGEAL SPACE, PETROUS APEX; EXTRADURAL CPT 61606 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 61607 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS 8,649 LESION OF PARASELLAR AREA, CAVERNOUS SINUS, CLIVUS OR MIDLINE SKULL BASE; EXTRADURAL CPT 61608 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 61609 TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS SINUS; 1,974 WITHOUT REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61610 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 61611 TRANSECTION OR LIGATION, CAROTID ARTERY IN PETROUS CANAL; 1,385 WITHOUT REPAIR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61612 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 61613 OBLITERATION OF CAROTID ANEURYSM, ARTERIOVENOUS 10,162 MALFORMATION, OR CAROTID-CAVERNOUS FISTULA BY DISSECTION WITHIN CAVERNOUS SINUS CPT 61615 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 61616 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 61618 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 61619 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 61623 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: 01.03.2015 Page No(s): 203 of 380

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 61624 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 61626 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 61630 BALLOON ANGIOPLASTY, INTRACRANIAL (EG, ATHEROSCLEROTIC 3,842 STENOSIS), PERCUTANEOUS CPT 61635 TRANSCATHETER PLACEMENT OF INTRAVASCULAR STENT(S), 4,209 INTRACRANIAL (EG, ATHEROSCLEROTIC STENOSIS), INCLUDING BALLOON ANGIOPLASTY, IF PERFORMED CPT 61640 BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; 1,996 INITIAL VESSEL CPT 61641 BALLOON DILATATION OF INTRACRANIAL VASOSPASM, PERCUTANEOUS; 702 EACH ADDITIONAL VESSEL IN SAME VASCULAR FAMILY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61642 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 61680 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 7,187 SUPRATENTORIAL, SIMPLE CPT 61682 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 13,436 SUPRATENTORIAL, COMPLEX CPT 61684 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 9,085 INFRATENTORIAL, SIMPLE CPT 61686 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; 14,412 INFRATENTORIAL, COMPLEX CPT 61690 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, 6,877 SIMPLE CPT 61692 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, 11,606 COMPLEX CPT 61697 SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 13,179 APPROACH; CAROTID CIRCULATION CPT 61698 SURGERY OF COMPLEX INTRACRANIAL ANEURYSM, INTRACRANIAL 14,170 APPROACH; VERTEBROBASILAR CIRCULATION CPT 61700 SURGERY OF SIMPLE INTRACRANIAL ANEURYSM, INTRACRANIAL 11,012 APPROACH; CAROTID CIRCULATION CPT 61702 SURGERY OF SIMPLE INTRACRANIAL ANEURYSM, INTRACRANIAL 12,354 APPROACH; VERTEBROBASILAR CIRCULATION CPT 61703 SURGERY OF INTRACRANIAL ANEURYSM, CERVICAL APPROACH BY 4,131 APPLICATION OF OCCLUDING CLAMP TO CERVICAL CAROTID ARTERY (SELVERSTONE-CRUTCHFIELD TYPE) CPT 61705 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- 8,201 CAVERNOUS FISTULA; BY INTRACRANIAL AND CERVICAL OCCLUSION OF CAROTID ARTERY CPT 61708 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- 6,853 CAVERNOUS FISTULA; BY INTRACRANIAL ELECTROTHROMBOSIS CPT 61710 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: 01.03.2015 Page No(s): 204 of 380

CPT 61711 ANASTOMOSIS, ARTERIAL, EXTRACRANIAL-INTRACRANIAL (EG, MIDDLE 8,323 CEREBRAL/CORTICAL) ARTERIES CPT 61720 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 61735 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 61750 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR 4,455 HOLE(S), FOR INTRACRANIAL LESION; CPT 61751 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION, INCLUDING BURR 4,351 HOLE(S), FOR INTRACRANIAL LESION; WITH COMPUTED TOMOGRAPHY AND/OR MAGNETIC RESONANCE GUIDANCE CPT 61760 STEREOTACTIC IMPLANTATION OF DEPTH ELECTRODES INTO THE 4,999 CEREBRUM FOR LONG-TERM SEIZURE MONITORING CPT 61770 STEREOTACTIC LOCALIZATION, INCLUDING BURR HOLE(S), WITH 4,598 INSERTION OF CATHETER(S) OR PROBE(S) FOR PLACEMENT OF RADIATION SOURCE CPT 61790 CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY 2,771 NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); GASSERIAN GANGLION CPT 61791 CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY 3,388 NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); TRIGEMINAL MEDULLARY TRACT CPT 61793 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY OR LINEAR 3,997 ACCELERATOR), ONE OR MORE SESSIONS CPT 61795 STEREOTACTIC COMPUTER-ASSISTED VOLUMETRIC (NAVIGATIONAL) 786 PROCEDURE, INTRACRANIAL, EXTRACRANIAL, OR SPINAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 61850 TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF 3,067 NEUROSTIMULATOR ELECTRODES, CORTICAL CPT 61860 CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF 4,872 NEUROSTIMULATOR ELECTRODES, CEREBRAL, CORTICAL CPT 61863 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 61864 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 61867 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 61868 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: 01.03.2015 Page No(s): 205 of 380

CPT 61870 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 3,750 CEREBELLAR; CORTICAL CPT 61875 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 3,101 CEREBELLAR; SUBCORTICAL CPT 61880 REVISION OR REMOVAL OF INTRACRANIAL NEUROSTIMULATOR 1,725 ELECTRODES CPT 61885 INSERTION OR REPLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE 2,016 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING; WITH CONNECTION TO A SINGLE ELECTRODE ARRAY CPT 61886 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 61888 REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE 1,258 GENERATOR OR RECEIVER CPT 62000 ELEVATION OF DEPRESSED SKULL FRACTURE; SIMPLE, EXTRADURAL 2,832 CPT 62005 ELEVATION OF DEPRESSED SKULL FRACTURE; COMPOUND OR 3,900 COMMINUTED, EXTRADURAL CPT 62010 ELEVATION OF DEPRESSED SKULL FRACTURE; WITH REPAIR OF DURA 4,814 AND/OR DEBRIDEMENT OF BRAIN CPT 62100 CRANIOTOMY FOR REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK, 5,076 INCLUDING SURGERY FOR RHINORRHEA/OTORRHEA CPT 62115 REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,300 NOT REQUIRING BONE GRAFTS OR CRANIOPLASTY CPT 62116 REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,583 WITH SIMPLE CRANIOPLASTY CPT 62117 REDUCTION OF CRANIOMEGALIC SKULL (EG, TREATED HYDROCEPHALUS); 5,730 REQUIRING CRANIOTOMY AND RECONSTRUCTION WITH OR WITHOUT BONE GRAFT (INCLUDES OBTAINING GRAFTS) CPT 62120 REPAIR OF ENCEPHALOCELE, SKULL VAULT, INCLUDING CRANIOPLASTY 5,628 CPT 62121 CRANIOTOMY FOR REPAIR OF ENCEPHALOCELE, SKULL BASE 5,203 CPT 62140 CRANIOPLASTY FOR SKULL DEFECT; UP TO 5 CM DIAMETER 3,343 CPT 62141 CRANIOPLASTY FOR SKULL DEFECT; LARGER THAN 5 CM DIAMETER 3,659 CPT 62142 REMOVAL OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 2,800 CPT 62143 REPLACEMENT OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 3,291 CPT 62145 CRANIOPLASTY FOR SKULL DEFECT WITH REPARATIVE BRAIN SURGERY 4,373 CPT 62146 CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); UP TO 5 CM DIAMETER CPT 62147 CRANIOPLASTY WITH AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); LARGER THAN 5 CM DIAMETER CPT 62148 INCISION AND RETRIEVAL OF SUBCUTANEOUS CRANIAL BONE GRAFT FOR CRANIOPLASTY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 62160 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 62161 NEUROENDOSCOPY, INTRACRANIAL; WITH DISSECTION OF ADHESIONS, FENESTRATION OF SEPTUM PELLUCIDUM OR INTRAVENTRICULAR CYSTS (INCLUDING PLACEMENT, REPLACEMENT, OR REMOVAL OF VENTRICULAR 3,816 4,517 405 614 4,838 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 206 of 380

CATHETER) CPT 62162 NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR EXCISION 5,944 OF COLLOID CYST, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE CPT 62163 NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY 3,733 CPT 62164 NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF BRAIN TUMOR, 6,366 INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE CPT 62165 NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY 4,769 TUMOR, TRANSNASAL OR TRANS-SPHENOIDAL APPROACH CPT 62180 VENTRICULOCISTERNOSTOMY (TORKILDSEN TYPE OPERATION) 5,009 CPT 62190 CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-ATRIAL, -JUGULAR, - 2,799 AURICULAR CPT 62192 CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-PERITONEAL, - 3,057 PLEURAL, OTHER TERMINUS CPT 62194 REPLACEMENT OR IRRIGATION, SUBARACHNOID/SUBDURAL CATHETER 1,225 CPT 62200 VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; 4,347 CPT 62201 VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; STEREOTACTIC, 3,766 NEUROENDOSCOPIC METHOD CPT 62220 CREATION OF SHUNT; VENTRICULO-ATRIAL, -JUGULAR, -AURICULAR 3,268 CPT 62223 CREATION OF SHUNT; VENTRICULO-PERITONEAL, -PLEURAL, OTHER 3,322 TERMINUS CPT 62225 REPLACEMENT OR IRRIGATION, VENTRICULAR CATHETER 1,633 CPT 62230 REPLACEMENT OR REVISION OF CEREBROSPINAL FLUID SHUNT, 2,677 OBSTRUCTED VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM CPT 62252 REPROGRAMMING OF PROGRAMMABLE CEREBROSPINAL SHUNT 342 CPT 62256 REMOVAL OF COMPLETE CEREBROSPINAL FLUID SHUNT SYSTEM; 1,877 WITHOUT REPLACEMENT CPT 62258 REMOVAL OF COMPLETE CEREBROSPINAL FLUID SHUNT SYSTEM; WITH 3,597 REPLACEMENT BY SIMILAR OR OTHER SHUNT AT SAME OPERATION CPT 62263 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 62264 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 62268 PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX 1,492 CPT 62269 BIOPSY OF SPINAL CORD, PERCUTANEOUS NEEDLE 1,463 CPT 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC 484 CPT 62272 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: 01.03.2015 Page No(s): 207 of 380

CPT 62273 INJECTION, EPIDURAL, OF BLOOD OR CLOT PATCH 497 CPT 62280 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 951 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; SUBARACHNOID CPT 62281 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 872 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC CPT 62282 INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, 828 PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL) CPT 62284 INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED 687 TOMOGRAPHY, SPINAL (OTHER THAN C1-C2 AND POSTERIOR FOSSA) CPT 62287 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 62290 INJECTION PROCEDURE FOR DISCOGRAPHY, EACH LEVEL; LUMBAR 972 CPT 62291 INJECTION PROCEDURE FOR DISCOGRAPHY, EACH LEVEL; CERVICAL OR THORACIC CPT 62292 INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS, INCLUDING DISCOGRAPHY, INTERVERTEBRAL DISC, SINGLE OR MULTIPLE LEVELS, LUMBAR CPT 62294 INJECTION PROCEDURE, ARTERIAL, FOR OCCLUSION OF ARTERIOVENOUS MALFORMATION, SPINAL CPT 62310 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 62311 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 62318 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 62319 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 62350 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 62351 IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE 932 1,614 2,580 633 539 660 601 1,642 2,698 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 208 of 380

RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY CPT 62355 REMOVAL OF PREVIOUSLY IMPLANTED INTRATHECAL OR EPIDURAL CATHETER CPT 62360 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR CPT 62361 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NONPROGRAMMABLE PUMP CPT 62362 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING CPT 62365 REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR INTRATHECAL OR EPIDURAL INFUSION CPT 62367 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 62368 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 63001 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 63003 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 63005 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 63011 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 63012 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 63015 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 63016 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 63017 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 63020 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; ONE INTERSPACE, CERVICAL 1,363 905 1,442 1,813 1,402 117 174 3,908 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: 01.03.2015 Page No(s): 209 of 380

CPT 63030 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 63035 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 63040 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 63042 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 63043 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 63044 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 63045 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 63046 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 63047 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 63048 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 63050 LAMINOPLASTY, CERVICAL, WITH DECOMPRESSION OF THE SPINAL CORD, 4,829 TWO OR MORE VERTEBRAL SEGMENTS; CPT 63051 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 63055 TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, 5,180 EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), SINGLE SEGMENT; THORACIC CPT 63056 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: 01.03.2015 Page No(s): 210 of 380

DISC), SINGLE SEGMENT; LUMBAR (INCLUDING TRANSFACET, OR LATERAL EXTRAFORAMINAL APPROACH) (EG, FAR LATERAL HERNIATED INTERVERTEBRAL DISC) CPT 63057 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 63064 COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD 5,666 OR NERVE ROOT(S) (EG, HERNIATED INTERVERTEBRAL DISC), THORACIC; SINGLE SEGMENT CPT 63066 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 63075 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 4,419 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE CPT 63076 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 63077 DISCECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD 4,760 AND/OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE CPT 63078 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 63081 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 63082 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 63085 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 63086 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 63087 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 63088 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 63090 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: 01.03.2015 Page No(s): 211 of 380

CPT 63091 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 63101 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 63102 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 63103 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 63170 LAMINECTOMY WITH MYELOTOMY (EG, BISCHOF OR DREZ TYPE), 4,706 CERVICAL, THORACIC, OR THORACOLUMBAR CPT 63172 LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 4,433 SUBARACHNOID SPACE CPT 63173 LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 5,469 PERITONEAL OR PLEURAL SPACE CPT 63180 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR 4,444 WITHOUT DURAL GRAFT, CERVICAL; ONE OR TWO SEGMENTS CPT 63182 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR 4,429 WITHOUT DURAL GRAFT, CERVICAL; MORE THAN TWO SEGMENTS CPT 63185 LAMINECTOMY WITH RHIZOTOMY; ONE OR TWO SEGMENTS 3,645 CPT 63190 LAMINECTOMY WITH RHIZOTOMY; MORE THAN TWO SEGMENTS 3,978 CPT 63191 LAMINECTOMY WITH SECTION OF SPINAL ACCESSORY NERVE 3,681 CPT 63194 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE 4,586 SPINOTHALAMIC TRACT, ONE STAGE; CERVICAL CPT 63195 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE 4,848 SPINOTHALAMIC TRACT, ONE STAGE; THORACIC CPT 63196 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH 5,627 SPINOTHALAMIC TRACTS, ONE STAGE; CERVICAL CPT 63197 LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH 4,632 SPINOTHALAMIC TRACTS, ONE STAGE; THORACIC CPT 63198 LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH 5,680 SPINOTHALAMIC TRACTS, TWO STAGES WITHIN 14 DAYS; CERVICAL CPT 63199 LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH 5,287 SPINOTHALAMIC TRACTS, TWO STAGES WITHIN 14 DAYS; THORACIC CPT 63200 LAMINECTOMY, WITH RELEASE OF TETHERED SPINAL CORD, LUMBAR 4,830 CPT 63250 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; CERVICAL CPT 63251 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACIC CPT 63252 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACOLUMBAR CPT 63265 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: 01.03.2015 Page No(s): 212 of 380

CPT 63266 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 5,448 OTHER THAN NEOPLASM, EXTRADURAL; THORACIC CPT 63267 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 4,384 OTHER THAN NEOPLASM, EXTRADURAL; LUMBAR CPT 63268 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION 4,385 OTHER THAN NEOPLASM, EXTRADURAL; SACRAL CPT 63270 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,528 NEOPLASM, INTRADURAL; CERVICAL CPT 63271 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,549 NEOPLASM, INTRADURAL; THORACIC CPT 63272 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 6,024 NEOPLASM, INTRADURAL; LUMBAR CPT 63273 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN 5,812 NEOPLASM, INTRADURAL; SACRAL CPT 63275 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,700 EXTRADURAL, CERVICAL CPT 63276 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,655 EXTRADURAL, THORACIC CPT 63277 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 4,961 EXTRADURAL, LUMBAR CPT 63278 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 4,842 EXTRADURAL, SACRAL CPT 63280 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,710 INTRADURAL, EXTRAMEDULLARY, CERVICAL CPT 63281 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,658 INTRADURAL, EXTRAMEDULLARY, THORACIC CPT 63282 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 6,267 INTRADURAL, EXTRAMEDULLARY, LUMBAR CPT 63283 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 5,987 INTRADURAL, SACRAL CPT 63285 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,207 INTRADURAL, INTRAMEDULLARY, CERVICAL CPT 63286 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,234 INTRADURAL, INTRAMEDULLARY, THORACIC CPT 63287 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,681 INTRADURAL, INTRAMEDULLARY, THORACOLUMBAR CPT 63290 LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; 8,686 COMBINED EXTRADURAL-INTRADURAL LESION, ANY LEVEL CPT 63295 OSTEOPLASTIC RECONSTRUCTION OF DORSAL SPINAL ELEMENTS, 1,035 FOLLOWING PRIMARY INTRASPINAL PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 63300 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 5,847 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, CERVICAL CPT 63301 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,424 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY TRANSTHORACIC APPROACH CPT 63302 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 6,335 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY THORACOLUMBAR APPROACH CPT 63303 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 63304 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: 01.03.2015 Page No(s): 213 of 380

CPT 63305 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,402 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY TRANSTHORACIC APPROACH CPT 63306 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR 7,602 COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY THORACOLUMBAR APPROACH CPT 63307 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 63308 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 63600 CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, 2,589 PERCUTANEOUS, ANY MODALITY (INCLUDING STIMULATION AND/OR RECORDING) CPT 63610 STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, 2,961 SEPARATE PROCEDURE NOT FOLLOWED BY OTHER SURGERY CPT 63615 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION OF LESION, SPINAL 3,599 CORD CPT 63650 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE 1,387 ARRAY, EPIDURAL CPT 63655 LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 2,706 PLATE/PADDLE, EPIDURAL CPT 63660 REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE 1,393 PERCUTANEOUS ARRAY(S) OR PLATE/PADDLE(S) CPT 63685 INSERTION OR REPLACEMENT OF SPINAL NEUROSTIMULATOR PULSE 1,582 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING CPT 63688 REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE 1,324 GENERATOR OR RECEIVER CPT 63700 REPAIR OF MENINGOCELE; LESS THAN 5 CM DIAMETER 3,876 CPT 63702 REPAIR OF MENINGOCELE; LARGER THAN 5 CM DIAMETER 4,200 CPT 63704 REPAIR OF MYELOMENINGOCELE; LESS THAN 5 CM DIAMETER 4,842 CPT 63706 REPAIR OF MYELOMENINGOCELE; LARGER THAN 5 CM DIAMETER 5,752 CPT 63707 REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK, NOT REQUIRING 2,878 LAMINECTOMY CPT 63709 REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR 3,472 PSEUDOMENINGOCELE, WITH LAMINECTOMY CPT 63710 DURAL GRAFT, SPINAL 3,507 CPT 63740 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, 2,985 OR OTHER; INCLUDING LAMINECTOMY CPT 63741 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, 1,964 OR OTHER; PERCUTANEOUS, NOT REQUIRING LAMINECTOMY CPT 63744 REPLACEMENT, IRRIGATION OR REVISION OF LUMBOSUBARACHNOID 2,079 SHUNT CPT 63746 REMOVAL OF ENTIRE LUMBOSUBARACHNOID SHUNT SYSTEM WITHOUT 1,821 REPLACEMENT CPT 64400 INJECTION, ANESTHETIC AGENT; TRIGEMINAL NERVE, ANY DIVISION OR 327 BRANCH CPT 64402 INJECTION, ANESTHETIC AGENT; FACIAL NERVE 346 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 214 of 380

CPT 64405 INJECTION, ANESTHETIC AGENT; GREATER OCCIPITAL NERVE 322 CPT 64408 INJECTION, ANESTHETIC AGENT; VAGUS NERVE 372 CPT 64410 INJECTION, ANESTHETIC AGENT; PHRENIC NERVE 432 CPT 64412 INJECTION, ANESTHETIC AGENT; SPINAL ACCESSORY NERVE 426 CPT 64413 INJECTION, ANESTHETIC AGENT; CERVICAL PLEXUS 351 CPT 64415 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, SINGLE 375 CPT 64416 INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, CONTINUOUS 581 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT 64417 INJECTION, ANESTHETIC AGENT; AXILLARY NERVE 375 CPT 64418 INJECTION, ANESTHETIC AGENT; SUPRASCAPULAR NERVE 412 CPT 64420 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVE, SINGLE 460 CPT 64421 INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, 672 REGIONAL BLOCK CPT 64425 INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, ILIOHYPOGASTRIC 399 NERVES CPT 64430 INJECTION, ANESTHETIC AGENT; PUDENDAL NERVE 497 CPT 64435 INJECTION, ANESTHETIC AGENT; PARACERVICAL (UTERINE) NERVE 454 CPT 64445 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, SINGLE 404 CPT 64446 INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS 539 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT), INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT 64447 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, SINGLE 221 CPT 64448 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS 494 INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT 64449 INJECTION, ANESTHETIC AGENT; LUMBAR PLEXUS, POSTERIOR 479 APPROACH, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) INCLUDING DAILY MANAGEMENT FOR ANESTHETIC AGENT ADMINISTRATION CPT 64450 INJECTION, ANESTHETIC AGENT; OTHER PERIPHERAL NERVE OR BRANCH 337 CPT 64470 INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL CPT 64472 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 64475 INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL CPT 64476 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 728 326 648 270 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 215 of 380

PRIMARY PROCEDURE) CPT 64479 INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 764 EPIDURAL; CERVICAL OR THORACIC, SINGLE LEVEL CPT 64480 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 64483 INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL 733 EPIDURAL; LUMBAR OR SACRAL, SINGLE LEVEL CPT 64484 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 64505 INJECTION, ANESTHETIC AGENT; SPHENOPALATINE GANGLION 326 CPT 64508 INJECTION, ANESTHETIC AGENT; CAROTID SINUS (SEPARATE 406 PROCEDURE) CPT 64510 INJECTION, ANESTHETIC AGENT; STELLATE GANGLION (CERVICAL 401 SYMPATHETIC) CPT 64517 INJECTION, ANESTHETIC AGENT; SUPERIOR HYPOGASTRIC PLEXUS 507 CPT 64520 INJECTION, ANESTHETIC AGENT; LUMBAR OR THORACIC (PARAVERTEBRAL 503 SYMPATHETIC) CPT 64530 INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT 562 RADIOLOGIC MONITORING CPT 64550 APPLICATION OF SURFACE (TRANSCUTANEOUS) NEUROSTIMULATOR 49 CPT 64553 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 649 CRANIAL NERVE CPT 64555 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 662 PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) CPT 64560 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 630 AUTONOMIC NERVE CPT 64561 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 3,422 SACRAL NERVE (TRANSFORAMINAL PLACEMENT) CPT 64565 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 551 NEUROMUSCULAR CPT 64573 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 1,876 CRANIAL NERVE CPT 64575 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 886 PERIPHERAL NERVE (EXCLUDES SACRAL NERVE) CPT 64577 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 1,317 AUTONOMIC NERVE CPT 64580 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 907 NEUROMUSCULAR CPT 64581 INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 2,743 SACRAL NERVE (TRANSFORAMINAL PLACEMENT) CPT 64585 REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR ELECTRODES 1,032 CPT 64590 INSERTION OR REPLACEMENT OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING CPT 64595 REVISION OR REMOVAL OF PERIPHERAL OR GASTRIC NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER CPT 64600 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: 01.03.2015 Page No(s): 216 of 380

CPT 64605 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND 1,715 THIRD DIVISION BRANCHES AT FORAMEN OVALE CPT 64610 DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND 2,256 THIRD DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING CPT 64612 CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL 461 NERVE (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM) CPT 64613 CHEMODENERVATION OF MUSCLE(S); NECK MUSCLE(S) (EG, FOR 435 SPASMODIC TORTICOLLIS, SPASMODIC DYSPHONIA) CPT 64614 CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S) AND/OR TRUNK 493 MUSCLE(S) (EG, FOR DYSTONIA, CEREBRAL PALSY, MULTIPLE SCLEROSIS) CPT 64620 DESTRUCTION BY NEUROLYTIC AGENT, INTERCOSTAL NERVE 800 CPT 64622 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 913 NERVE; LUMBAR OR SACRAL, SINGLE LEVEL CPT 64623 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 64626 DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT 1,102 NERVE; CERVICAL OR THORACIC, SINGLE LEVEL CPT 64627 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 64630 DESTRUCTION BY NEUROLYTIC AGENT; PUDENDAL NERVE 755 CPT 64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER PERIPHERAL NERVE OR 691 BRANCH CPT 64650 CHEMODENERVATION OF ECCRINE GLANDS; BOTH AXILLAE 186 CPT 64653 CHEMODENERVATION OF ECCRINE GLANDS; OTHER AREA(S) (EG, SCALP, 215 FACE, NECK), PER DAY CPT 64680 DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC 889 MONITORING; CELIAC PLEXUS CPT 64681 DESTRUCTION BY NEUROLYTIC AGENT, WITH OR WITHOUT RADIOLOGIC 1,117 MONITORING; SUPERIOR HYPOGASTRIC PLEXUS CPT 64702 NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME DIGIT 1,497 CPT 64704 NEUROPLASTY; NERVE OF HAND OR FOOT 1,069 CPT 64708 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; OTHER THAN 1,432 SPECIFIED CPT 64712 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; SCIATIC NERVE 1,675 CPT 64713 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; BRACHIAL 2,412 PLEXUS CPT 64714 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; LUMBAR PLEXUS 2,013 CPT 64716 NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY) 1,630 CPT 64718 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW 1,801 CPT 64719 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST 1,233 CPT 64721 NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL 1,293 TUNNEL CPT 64722 DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY) 1,034 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 217 of 380

CPT 64726 DECOMPRESSION; PLANTAR DIGITAL NERVE 950 CPT 64727 INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE 600 (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS) CPT 64732 TRANSECTION OR AVULSION OF; SUPRAORBITAL NERVE 1,189 CPT 64734 TRANSECTION OR AVULSION OF; INFRAORBITAL NERVE 1,356 CPT 64736 TRANSECTION OR AVULSION OF; MENTAL NERVE 1,179 CPT 64738 TRANSECTION OR AVULSION OF; INFERIOR ALVEOLAR NERVE BY 1,509 OSTEOTOMY CPT 64740 TRANSECTION OR AVULSION OF; LINGUAL NERVE 1,484 CPT 64742 TRANSECTION OR AVULSION OF; FACIAL NERVE, DIFFERENTIAL OR 1,480 COMPLETE CPT 64744 TRANSECTION OR AVULSION OF; GREATER OCCIPITAL NERVE 1,364 CPT 64746 TRANSECTION OR AVULSION OF; PHRENIC NERVE 1,402 CPT 64752 TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), 1,549 TRANSTHORACIC CPT 64755 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 64760 TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), 1,520 ABDOMINAL CPT 64761 TRANSECTION OR AVULSION OF; PUDENDAL NERVE 1,485 CPT 64763 TRANSECTION OR AVULSION OF OBTURATOR NERVE, EXTRAPELVIC, WITH 1,549 OR WITHOUT ADDUCTOR TENOTOMY CPT 64766 TRANSECTION OR AVULSION OF OBTURATOR NERVE, INTRAPELVIC, WITH 1,905 OR WITHOUT ADDUCTOR TENOTOMY CPT 64771 TRANSECTION OR AVULSION OF OTHER CRANIAL NERVE, EXTRADURAL 1,874 CPT 64772 TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL 1,794 CPT 64774 EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE 1,317 CPT 64776 EXCISION OF NEUROMA; DIGITAL NERVE, ONE OR BOTH, SAME DIGIT 1,259 CPT 64778 EXCISION OF NEUROMA; DIGITAL NERVE, EACH ADDITIONAL DIGIT (LIST 601 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64782 EXCISION OF NEUROMA; HAND OR FOOT, EXCEPT DIGITAL NERVE 1,490 CPT 64783 EXCISION OF NEUROMA; HAND OR FOOT, EACH ADDITIONAL NERVE, 703 EXCEPT SAME DIGIT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64784 EXCISION OF NEUROMA; MAJOR PERIPHERAL NERVE, EXCEPT SCIATIC 2,300 CPT 64786 EXCISION OF NEUROMA; SCIATIC NERVE 3,419 CPT 64787 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: 01.03.2015 Page No(s): 218 of 380

CPT 64788 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; CUTANEOUS NERVE 1,249 CPT 64790 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; MAJOR PERIPHERAL 2,650 NERVE CPT 64792 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; EXTENSIVE 3,335 (INCLUDING MALIGNANT TYPE) CPT 64795 BIOPSY OF NERVE 624 CPT 64802 SYMPATHECTOMY, CERVICAL 1,893 CPT 64804 SYMPATHECTOMY, CERVICOTHORACIC 3,008 CPT 64809 SYMPATHECTOMY, THORACOLUMBAR 2,913 CPT 64818 SYMPATHECTOMY, LUMBAR 2,125 CPT 64820 SYMPATHECTOMY; DIGITAL ARTERIES, EACH DIGIT 2,400 CPT 64821 SYMPATHECTOMY; RADIAL ARTERY 2,136 CPT 64822 SYMPATHECTOMY; ULNAR ARTERY 2,129 CPT 64823 SYMPATHECTOMY; SUPERFICIAL PALMAR ARCH 2,371 CPT 64831 SUTURE OF DIGITAL NERVE, HAND OR FOOT; ONE NERVE 2,298 CPT 64832 SUTURE OF DIGITAL NERVE, HAND OR FOOT; EACH ADDITIONAL DIGITAL 1,110 NERVE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64834 SUTURE OF ONE NERVE; HAND OR FOOT, COMMON SENSORY NERVE 2,353 CPT 64835 SUTURE OF ONE NERVE; MEDIAN MOTOR THENAR 2,548 CPT 64836 SUTURE OF ONE NERVE; ULNAR MOTOR 2,561 CPT 64837 SUTURE OF EACH ADDITIONAL NERVE, HAND OR FOOT (LIST SEPARATELY 1,232 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64840 SUTURE OF POSTERIOR TIBIAL NERVE 2,864 CPT 64856 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; 3,215 INCLUDING TRANSPOSITION CPT 64857 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; 3,356 WITHOUT TRANSPOSITION CPT 64858 SUTURE OF SCIATIC NERVE 3,851 CPT 64859 SUTURE OF EACH ADDITIONAL MAJOR PERIPHERAL NERVE (LIST 839 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64861 SUTURE OF; BRACHIAL PLEXUS 4,385 CPT 64862 SUTURE OF; LUMBAR PLEXUS 4,455 CPT 64864 SUTURE OF FACIAL NERVE; EXTRACRANIAL 2,774 CPT 64865 SUTURE OF FACIAL NERVE; INFRATEMPORAL, WITH OR WITHOUT 3,648 GRAFTING CPT 64866 ANASTOMOSIS; FACIAL-SPINAL ACCESSORY 3,758 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 219 of 380

CPT 64868 ANASTOMOSIS; FACIAL-HYPOGLOSSAL 3,275 CPT 64870 ANASTOMOSIS; FACIAL-PHRENIC 3,311 CPT 64872 SUTURE OF NERVE; REQUIRING SECONDARY OR DELAYED SUTURE (LIST 385 SEPARATELY IN ADDITION TO CODE FOR PRIMARY NEURORRHAPHY) CPT 64874 SUTURE OF NERVE; REQUIRING EXTENSIVE MOBILIZATION, OR 586 TRANSPOSITION OF NERVE (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE SUTURE) CPT 64876 SUTURE OF NERVE; REQUIRING SHORTENING OF BONE OF EXTREMITY 663 (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE SUTURE) CPT 64885 NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; UP TO 4 3,534 CM IN LENGTH CPT 64886 NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; MORE 4,177 THAN 4 CM LENGTH CPT 64890 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR 3,447 FOOT; UP TO 4 CM LENGTH CPT 64891 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR 3,589 FOOT; MORE THAN 4 CM LENGTH CPT 64892 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR 3,426 LEG; UP TO 4 CM LENGTH CPT 64893 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR 3,648 LEG; MORE THAN 4 CM LENGTH CPT 64895 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,264 (CABLE), HAND OR FOOT; UP TO 4 CM LENGTH CPT 64896 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,613 (CABLE), HAND OR FOOT; MORE THAN 4 CM LENGTH CPT 64897 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,065 (CABLE), ARM OR LEG; UP TO 4 CM LENGTH CPT 64898 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS 4,412 (CABLE), ARM OR LEG; MORE THAN 4 CM LENGTH CPT 64901 NERVE GRAFT, EACH ADDITIONAL NERVE; SINGLE STRAND (LIST 1,913 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64902 NERVE GRAFT, EACH ADDITIONAL NERVE; MULTIPLE STRANDS (CABLE) 2,268 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 64905 NERVE PEDICLE TRANSFER; FIRST STAGE 3,019 CPT 64907 NERVE PEDICLE TRANSFER; SECOND STAGE 3,703 CPT 64910 NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, 2,216 NERVE TUBE), EACH NERVE CPT 64911 NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT (INCLUDES HARVEST OF 2,698 VEIN GRAFT), EACH NERVE CPT 64999 UNLISTED PROCEDURE, NERVOUS SYSTEM N/A CPT 65091 EVISCERATION OF OCULAR CONTENTS; WITHOUT IMPLANT 1,784 CPT 65093 EVISCERATION OF OCULAR CONTENTS; WITH IMPLANT 1,769 CPT 65101 ENUCLEATION OF EYE; WITHOUT IMPLANT 2,065 CPT 65103 ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES NOT ATTACHED TO 2,156 IMPLANT CPT 65105 ENUCLEATION OF EYE; WITH IMPLANT, MUSCLES ATTACHED TO IMPLANT 2,377 CPT 65110 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: 01.03.2015 Page No(s): 220 of 380

CPT 65112 EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL 4,126 OF ORBITAL CONTENTS; WITH THERAPEUTIC REMOVAL OF BONE CPT 65114 EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL 4,268 OF ORBITAL CONTENTS; WITH MUSCLE OR MYOCUTANEOUS FLAP CPT 65125 MODIFICATION OF OCULAR IMPLANT WITH PLACEMENT OR REPLACEMENT 1,268 OF PEGS (EG, DRILLING RECEPTACLE FOR PROSTHESIS APPENDAGE) (SEPARATE PROCEDURE) CPT 65130 INSERTION OF OCULAR IMPLANT SECONDARY; AFTER EVISCERATION, IN 2,045 SCLERAL SHELL CPT 65135 INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, 2,076 MUSCLES NOT ATTACHED TO IMPLANT CPT 65140 INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, 2,266 MUSCLES ATTACHED TO IMPLANT CPT 65150 REINSERTION OF OCULAR IMPLANT; WITH OR WITHOUT CONJUNCTIVAL 1,626 GRAFT CPT 65155 REINSERTION OF OCULAR IMPLANT; WITH USE OF FOREIGN MATERIAL 2,409 FOR REINFORCEMENT AND/OR ATTACHMENT OF MUSCLES TO IMPLANT CPT 65175 REMOVAL OF OCULAR IMPLANT 1,833 CPT 65205 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL 164 SUPERFICIAL CPT 65210 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED 200 (INCLUDES CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING CPT 65220 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT SLIT 169 LAMP CPT 65222 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITH SLIT LAMP 220 CPT 65235 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM ANTERIOR CHAMBER 2,005 OF EYE OR LENS CPT 65260 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR 2,718 SEGMENT, MAGNETIC EXTRACTION, ANTERIOR OR POSTERIOR ROUTE CPT 65265 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR 3,054 SEGMENT, NONMAGNETIC EXTRACTION CPT 65270 REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT 733 NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE CPT 65272 REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND 1,382 REARRANGEMENT, WITHOUT HOSPITALIZATION CPT 65273 REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND 1,083 REARRANGEMENT, WITH HOSPITALIZATION CPT 65275 REPAIR OF LACERATION; CORNEA, NONPERFORATING, WITH OR WITHOUT 1,598 REMOVAL FOREIGN BODY CPT 65280 REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, NOT 1,898 INVOLVING UVEAL TISSUE CPT 65285 REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, WITH 2,952 REPOSITION OR RESECTION OF UVEAL TISSUE CPT 65286 REPAIR OF LACERATION; APPLICATION OF TISSUE GLUE, WOUNDS OF 1,940 CORNEA AND/OR SCLERA CPT 65290 REPAIR OF WOUND, EXTRAOCULAR MUSCLE, TENDON AND/OR TENON'S 1,395 CAPSULE CPT 65400 EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), 1,889 EXCEPT PTERYGIUM CPT 65410 BIOPSY OF CORNEA 402 CPT 65420 EXCISION OR TRANSPOSITION OF PTERYGIUM; WITHOUT GRAFT 1,422 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 221 of 380

CPT 65426 EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT 1,796 CPT 65430 SCRAPING OF CORNEA, DIAGNOSTIC, FOR SMEAR AND/OR CULTURE 331 CPT 65435 REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT 229 CHEMOCAUTERIZATION (ABRASION, CURETTAGE) CPT 65436 REMOVAL OF CORNEAL EPITHELIUM; WITH APPLICATION OF CHELATING 1,093 AGENT (EG, EDTA) CPT 65450 DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY, 903 PHOTOCOAGULATION OR THERMOCAUTERIZATION CPT 65600 MULTIPLE PUNCTURES OF ANTERIOR CORNEA (EG, FOR CORNEAL 1,091 EROSION, TATTOO) CPT 65710 KERATOPLASTY (CORNEAL TRANSPLANT); LAMELLAR 3,126 CPT 65730 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN 3,480 APHAKIA) CPT 65750 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA) 3,518 CPT 65755 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN 3,499 PSEUDOPHAKIA) CPT 65760 KERATOMILEUSIS 4,248 CPT 65765 KERATOPHAKIA 4,929 CPT 65767 EPIKERATOPLASTY 4,589 CPT 65770 KERATOPROSTHESIS 4,019 CPT 65771 RADIAL KERATOTOMY 2,497 CPT 65772 CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY 1,259 INDUCED ASTIGMATISM CPT 65775 CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY INDUCED 1,549 ASTIGMATISM CPT 65780 OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE 2,492 TRANSPLANTATION CPT 65781 OCULAR SURFACE RECONSTRUCTION; LIMBAL STEM CELL ALLOGRAFT 3,757 (EG, CADAVERIC OR LIVING DONOR) CPT 65782 OCULAR SURFACE RECONSTRUCTION; LIMBAL CONJUNCTIVAL AUTOGRAFT 3,246 (INCLUDES OBTAINING GRAFT) CPT 65800 PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 426 WITH DIAGNOSTIC ASPIRATION OF AQUEOUS CPT 65805 PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 465 WITH THERAPEUTIC RELEASE OF AQUEOUS CPT 65810 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 65815 PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 1,763 WITH REMOVAL OF BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION CPT 65820 GONIOTOMY 2,091 CPT 65850 TRABECULOTOMY AB EXTERNO 2,401 CPT 65855 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: 01.03.2015 Page No(s): 222 of 380

CPT 65860 SEVERING ADHESIONS OF ANTERIOR SEGMENT, LASER TECHNIQUE 881 (SEPARATE PROCEDURE) CPT 65865 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,337 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE CPT 65870 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 65875 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,769 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); POSTERIOR SYNECHIAE CPT 65880 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL 1,864 TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); CORNEOVITREAL ADHESIONS CPT 65900 REMOVAL OF EPITHELIAL DOWNGROWTH, ANTERIOR CHAMBER OF EYE 2,730 CPT 65920 REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT OF EYE 2,216 CPT 65930 REMOVAL OF BLOOD CLOT, ANTERIOR SEGMENT OF EYE 1,810 CPT 66020 INJECTION, ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); AIR OR 517 LIQUID CPT 66030 INJECTION, ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); 455 MEDICATION CPT 66130 EXCISION OF LESION, SCLERA 1,967 CPT 66150 FISTULIZATION OF SCLERA FOR GLAUCOMA; TREPHINATION WITH 2,448 IRIDECTOMY CPT 66155 FISTULIZATION OF SCLERA FOR GLAUCOMA; THERMOCAUTERIZATION 2,440 WITH IRIDECTOMY CPT 66160 FISTULIZATION OF SCLERA FOR GLAUCOMA; SCLERECTOMY WITH PUNCH 2,770 OR SCISSORS, WITH IRIDECTOMY CPT 66165 FISTULIZATION OF SCLERA FOR GLAUCOMA; IRIDENCLEISIS OR 2,399 IRIDOTASIS CPT 66170 FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB 3,361 EXTERNO IN ABSENCE OF PREVIOUS SURGERY CPT 66172 FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB 4,233 EXTERNO WITH SCARRING FROM PREVIOUS OCULAR SURGERY OR TRAUMA (INCLUDES INJECTION OF ANTIFIBROTIC AGENTS) CPT 66180 AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR (EG, MOLTENO, 3,325 SCHOCKET, DENVER-KRUPIN) CPT 66185 REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR 2,113 CPT 66220 REPAIR OF SCLERAL STAPHYLOMA; WITHOUT GRAFT 2,083 CPT 66225 REPAIR OF SCLERAL STAPHYLOMA; WITH GRAFT 2,648 CPT 66250 REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE CPT 66500 IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); EXCEPT TRANSFIXION CPT 66505 IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); WITH TRANSFIXION AS FOR IRIS BOMBE CPT 66600 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; FOR REMOVAL OF LESION 2,071 991 1,086 2,337 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 223 of 380

CPT 66605 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; WITH 3,047 CYCLECTOMY CPT 66625 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; PERIPHERAL 1,215 FOR GLAUCOMA (SEPARATE PROCEDURE) CPT 66630 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; SECTOR 1,604 FOR GLAUCOMA (SEPARATE PROCEDURE) CPT 66635 IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; OPTICAL 1,619 (SEPARATE PROCEDURE) CPT 66680 REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS) 1,456 CPT 66682 SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH 1,783 RETRIEVAL OF SUTURE THROUGH SMALL INCISION (EG, MCCANNEL SUTURE) CPT 66700 CILIARY BODY DESTRUCTION; DIATHERMY 1,268 CPT 66710 CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, 1,244 TRANSSCLERAL CPT 66711 CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION, ENDOSCOPIC 1,798 CPT 66720 CILIARY BODY DESTRUCTION; CRYOTHERAPY 1,320 CPT 66740 CILIARY BODY DESTRUCTION; CYCLODIALYSIS 1,236 CPT 66761 IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (EG, FOR GLAUCOMA) (ONE 1,270 OR MORE SESSIONS) CPT 66762 IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) (EG, 1,331 FOR IMPROVEMENT OF VISION, FOR WIDENING OF ANTERIOR CHAMBER ANGLE) CPT 66770 DESTRUCTION OF CYST OR LESION IRIS OR CILIARY BODY 1,481 (NONEXCISIONAL PROCEDURE) CPT 66820 DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED 1,100 POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); STAB INCISION TECHNIQUE (ZIEGLER OR WHEELER KNIFE) CPT 66821 DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED 912 POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (ONE OR MORE STAGES) CPT 66825 REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN 2,138 INCISION (SEPARATE PROCEDURE) CPT 66830 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 66840 REMOVAL OF LENS MATERIAL; ASPIRATION TECHNIQUE, ONE OR MORE 1,971 STAGES CPT 66850 REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE 2,244 (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION CPT 66852 REMOVAL OF LENS MATERIAL; PARS PLANA APPROACH, WITH OR 2,397 WITHOUT VITRECTOMY CPT 66920 REMOVAL OF LENS MATERIAL; INTRACAPSULAR 2,141 CPT 66930 REMOVAL OF LENS MATERIAL; INTRACAPSULAR, FOR DISLOCATED LENS 2,431 CPT 66940 REMOVAL OF LENS MATERIAL; EXTRACAPSULAR (OTHER THAN 66840, 66850, 66852) CPT 66982 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: 01.03.2015 Page No(s): 224 of 380

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 66983 INTRACAPSULAR CATARACT EXTRACTION WITH INSERTION OF 2,120 INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE) CPT 66984 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 66985 INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), 2,166 NOT ASSOCIATED WITH CONCURRENT CATARACT REMOVAL CPT 66986 EXCHANGE OF INTRAOCULAR LENS 2,631 CPT 66990 USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO 266 CODE FOR PRIMARY PROCEDURE) CPT 66999 UNLISTED PROCEDURE, ANTERIOR SEGMENT OF EYE N/A CPT 67005 REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR 1,336 LIMBAL INCISION); PARTIAL REMOVAL CPT 67010 REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR 1,544 LIMBAL INCISION); SUBTOTAL REMOVAL WITH MECHANICAL VITRECTOMY CPT 67015 ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL 1,641 FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY) CPT 67025 INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA OR LIMBAL APPROACH 2,027 (FLUID-GAS EXCHANGE), WITH OR WITHOUT ASPIRATION (SEPARATE PROCEDURE) CPT 67027 IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM (EG, 2,434 GANCICLOVIR IMPLANT), INCLUDES CONCOMITANT REMOVAL OF VITREOUS CPT 67028 INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE 602 PROCEDURE) CPT 67030 DISCISSION OF VITREOUS STRANDS (WITHOUT REMOVAL), PARS PLANA 1,478 APPROACH CPT 67031 SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, SHEETS, 1,083 MEMBRANES OR OPACITIES, LASER SURGERY (ONE OR MORE STAGES) CPT 67036 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; 2,735 CPT 67039 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER PHOTOCOAGULATION CPT 67040 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION CPT 67041 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF PRERETINAL CELLULAR MEMBRANE (EG, MACULAR PUCKER) CPT 67042 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 67043 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 67101 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: 01.03.2015 Page No(s): 225 of 380

CPT 67105 REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; 2,030 PHOTOCOAGULATION, WITH OR WITHOUT DRAINAGE OF SUBRETINAL FLUID CPT 67107 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 67108 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 67110 REPAIR OF RETINAL DETACHMENT; BY INJECTION OF AIR OR OTHER GAS 2,439 (EG, PNEUMATIC RETINOPEXY) CPT 67112 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 67113 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 67115 RELEASE OF ENCIRCLING MATERIAL (POSTERIOR SEGMENT) 1,397 CPT 67120 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; 1,832 EXTRAOCULAR CPT 67121 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR 2,577 CPT 67141 PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY CPT 67145 PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) WITHOUT DRAINAGE, ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON ARC) CPT 67208 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY CPT 67210 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; PHOTOCOAGULATION CPT 67218 DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; RADIATION BY IMPLANTATION OF SOURCE (INCLUDES REMOVAL OF SOURCE) CPT 67220 DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTOCOAGULATION (EG, LASER), ONE OR MORE SESSIONS CPT 67221 DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC THERAPY (INCLUDES INTRAVENOUS INFUSION) CPT 67225 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 67227 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 3,028 826 89 1,725 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 226 of 380

CPT 67228 TREATMENT OF EXTENSIVE OR PROGRESSIVE RETINOPATHY, ONE OR 3,511 MORE SESSIONS; (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION CPT 67229 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 67250 SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITHOUT GRAFT 2,214 CPT 67255 SCLERAL REINFORCEMENT (SEPARATE PROCEDURE); WITH GRAFT 2,371 CPT 67299 UNLISTED PROCEDURE, POSTERIOR SEGMENT N/A CPT 67311 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE 1,694 HORIZONTAL MUSCLE CPT 67312 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO 2,026 HORIZONTAL MUSCLES CPT 67314 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE 1,904 VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE) CPT 67316 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO OR 2,283 MORE VERTICAL MUSCLES (EXCLUDING SUPERIOR OBLIQUE) CPT 67318 STRABISMUS SURGERY, ANY PROCEDURE, SUPERIOR OBLIQUE MUSCLE 1,993 CPT 67320 TRANSPOSITION PROCEDURE (EG, FOR PARETIC EXTRAOCULAR MUSCLE), 949 ANY EXTRAOCULAR MUSCLE (SPECIFY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 67331 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 67332 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 67334 STRABISMUS SURGERY BY POSTERIOR FIXATION SUTURE TECHNIQUE, 887 WITH OR WITHOUT MUSCLE RECESSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 67335 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 67340 STRABISMUS SURGERY INVOLVING EXPLORATION AND/OR REPAIR OF 1,056 DETACHED EXTRAOCULAR MUSCLE(S) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 67343 RELEASE OF EXTENSIVE SCAR TISSUE WITHOUT DETACHING 1,852 EXTRAOCULAR MUSCLE (SEPARATE PROCEDURE) CPT 67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE 669 CPT 67346 BIOPSY OF EXTRAOCULAR MUSCLE 584 CPT 67399 UNLISTED PROCEDURE, OCULAR MUSCLE N/A CPT 67400 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, WITH OR WITHOUT BIOPSY CPT 67405 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH DRAINAGE ONLY CPT 67412 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: 01.03.2015 Page No(s): 227 of 380

CPT 67413 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL 2,428 APPROACH); WITH REMOVAL OF FOREIGN BODY CPT 67414 ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL 3,784 APPROACH); WITH REMOVAL OF BONE FOR DECOMPRESSION CPT 67415 FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS 310 CPT 67420 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 4,658 KROENLEIN); WITH REMOVAL OF LESION CPT 67430 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,489 KROENLEIN); WITH REMOVAL OF FOREIGN BODY CPT 67440 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,416 KROENLEIN); WITH DRAINAGE CPT 67445 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 4,027 KROENLEIN); WITH REMOVAL OF BONE FOR DECOMPRESSION CPT 67450 ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, 3,535 KROENLEIN); FOR EXPLORATION, WITH OR WITHOUT BIOPSY CPT 67500 RETROBULBAR INJECTION; MEDICATION (SEPARATE PROCEDURE, DOES 259 NOT INCLUDE SUPPLY OF MEDICATION) CPT 67505 RETROBULBAR INJECTION; ALCOHOL 247 CPT 67515 INJECTION OF MEDICATION OR OTHER SUBSTANCE INTO TENON'S 276 CAPSULE CPT 67550 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); INSERTION 2,777 CPT 67560 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR 2,808 REVISION CPT 67570 OPTIC NERVE DECOMPRESSION (EG, INCISION OR FENESTRATION OF 3,260 OPTIC NERVE SHEATH) CPT 67599 UNLISTED PROCEDURE, ORBIT N/A CPT 67700 BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID 723 CPT 67710 SEVERING OF TARSORRHAPHY 602 CPT 67715 CANTHOTOMY (SEPARATE PROCEDURE) 645 CPT 67800 EXCISION OF CHALAZION; SINGLE 358 CPT 67801 EXCISION OF CHALAZION; MULTIPLE, SAME LID 459 CPT 67805 EXCISION OF CHALAZION; MULTIPLE, DIFFERENT LIDS 570 CPT 67808 EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR 1,040 REQUIRING HOSPITALIZATION, SINGLE OR MULTIPLE CPT 67810 BIOPSY OF EYELID 689 CPT 67820 CORRECTION OF TRICHIASIS; EPILATION, BY FORCEPS ONLY 148 CPT 67825 CORRECTION OF TRICHIASIS; EPILATION BY OTHER THAN FORCEPS (EG, 361 BY ELECTROSURGERY, CRYOTHERAPY, LASER SURGERY) CPT 67830 CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN 728 CPT 67835 CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE GRAFT CPT 67840 EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE 1,259 762 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 228 of 380

CPT 67850 DESTRUCTION OF LESION OF LID MARGIN (UP TO 1 CM) 638 CPT 67875 TEMPORARY CLOSURE OF EYELIDS BY SUTURE (EG, FROST SUTURE) 478 CPT 67880 CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 1,271 TARSORRHAPHY, OR CANTHORRHAPHY; CPT 67882 CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN 1,570 TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE CPT 67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MID-FOREHEAD OR CORONAL 1,817 APPROACH) CPT 67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH 2,139 SUTURE OR OTHER MATERIAL (EG, BANKED FASCIA) CPT 67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH 2,091 AUTOLOGOUS FASCIAL SLING (INCLUDES OBTAINING FASCIA) CPT 67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR 1,701 ADVANCEMENT, INTERNAL APPROACH CPT 67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR 2,065 ADVANCEMENT, EXTERNAL APPROACH CPT 67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH 1,481 FASCIAL SLING (INCLUDES OBTAINING FASCIA) CPT 67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLER'S MUSCLE- 1,387 LEVATOR RESECTION (EG, FASANELLA-SERVAT TYPE) CPT 67909 REDUCTION OF OVERCORRECTION OF PTOSIS 1,504 CPT 67911 CORRECTION OF LID RETRACTION 1,603 CPT 67912 CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER 2,473 EYELID LID LOAD (EG, GOLD WEIGHT) CPT 67914 REPAIR OF ECTROPION; SUTURE 1,087 CPT 67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION 967 CPT 67916 REPAIR OF ECTROPION; EXCISION TARSAL WEDGE 1,512 CPT 67917 REPAIR OF ECTROPION; EXTENSIVE (EG, TARSAL STRIP OPERATIONS) 1,656 CPT 67921 REPAIR OF ENTROPION; SUTURE 1,033 CPT 67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION 931 CPT 67923 REPAIR OF ENTROPION; EXCISION TARSAL WEDGE 1,596 CPT 67924 REPAIR OF ENTROPION; EXTENSIVE (EG, TARSAL STRIP OR 1,642 CAPSULOPALPEBRAL FASCIA REPAIRS OPERATION) CPT 67930 SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, 1,029 AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; PARTIAL THICKNESS CPT 67935 SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, 1,689 AND/OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS CPT 67938 REMOVAL OF EMBEDDED FOREIGN BODY, EYELID 659 CPT 67950 CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) 1,623 CPT 67961 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: 01.03.2015 Page No(s): 229 of 380

TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN CPT 67966 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 67971 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 67973 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 2,696 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, ONE STAGE OR FIRST STAGE CPT 67974 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 2,689 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, UPPER, ONE STAGE OR FIRST STAGE CPT 67975 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF 1,969 TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE CPT 67999 UNLISTED PROCEDURE, EYELIDS N/A CPT 68020 INCISION OF CONJUNCTIVA, DRAINAGE OF CYST 338 CPT 68040 EXPRESSION OF CONJUNCTIVAL FOLLICLES (EG, FOR TRACHOMA) 187 CPT 68100 BIOPSY OF CONJUNCTIVA 475 CPT 68110 EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM 623 CPT 68115 EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM 859 CPT 68130 EXCISION OF LESION, CONJUNCTIVA; WITH ADJACENT SCLERA 1,494 CPT 68135 DESTRUCTION OF LESION, CONJUNCTIVA 444 CPT 68200 SUBCONJUNCTIVAL INJECTION 120 CPT 68320 CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE 1,997 REARRANGEMENT CPT 68325 CONJUNCTIVOPLASTY; WITH BUCCAL MUCOUS MEMBRANE GRAFT 1,884 (INCLUDES OBTAINING GRAFT) CPT 68326 CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC; WITH 1,823 CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT CPT 68328 CONJUNCTIVOPLASTY, RECONSTRUCTION CUL-DE-SAC; WITH BUCCAL 2,035 MUCOUS MEMBRANE GRAFT (INCLUDES OBTAINING GRAFT) CPT 68330 REPAIR OF SYMBLEPHARON; CONJUNCTIVOPLASTY, WITHOUT GRAFT 1,671 CPT 68335 REPAIR OF SYMBLEPHARON; WITH FREE GRAFT CONJUNCTIVA OR BUCCAL 1,830 MUCOUS MEMBRANE (INCLUDES OBTAINING GRAFT) CPT 68340 REPAIR OF SYMBLEPHARON; DIVISION OF SYMBLEPHARON, WITH OR 1,500 WITHOUT INSERTION OF CONFORMER OR CONTACT LENS CPT 68360 CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL (SEPARATE PROCEDURE) 1,471 CPT 68362 CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDERSON THIN FLAP OR PURSE 1,855 STRING FLAP) CPT 68371 HARVESTING CONJUNCTIVAL ALLOGRAFT, LIVING DONOR 1,191 CPT 68399 UNLISTED PROCEDURE, CONJUNCTIVA N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 230 of 380

CPT 68400 INCISION, DRAINAGE OF LACRIMAL GLAND 781 CPT 68420 INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR 883 DACRYOCYSTOSTOMY) CPT 68440 SNIP INCISION OF LACRIMAL PUNCTUM 284 CPT 68500 EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 2,840 TUMOR; TOTAL CPT 68505 EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR 2,752 TUMOR; PARTIAL CPT 68510 BIOPSY OF LACRIMAL GLAND 1,263 CPT 68520 EXCISION OF LACRIMAL SAC (DACRYOCYSTECTOMY) 1,943 CPT 68525 BIOPSY OF LACRIMAL SAC 781 CPT 68530 REMOVAL OF FOREIGN BODY OR DACRYOLITH, LACRIMAL PASSAGES 1,189 CPT 68540 EXCISION OF LACRIMAL GLAND TUMOR; FRONTAL APPROACH 2,635 CPT 68550 EXCISION OF LACRIMAL GLAND TUMOR; INVOLVING OSTEOTOMY 3,189 CPT 68700 PLASTIC REPAIR OF CANALICULI 1,705 CPT 68705 CORRECTION OF EVERTED PUNCTUM, CAUTERY 655 CPT 68720 DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL 2,152 CAVITY) CPT 68745 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL 2,164 CAVITY); WITHOUT TUBE CPT 68750 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL 2,231 CAVITY); WITH INSERTION OF TUBE OR STENT CPT 68760 CLOSURE OF THE LACRIMAL PUNCTUM; BY THERMOCAUTERIZATION, 557 LIGATION, OR LASER SURGERY CPT 68761 CLOSURE OF THE LACRIMAL PUNCTUM; BY PLUG, EACH 411 CPT 68770 CLOSURE OF LACRIMAL FISTULA (SEPARATE PROCEDURE) 1,786 CPT 68801 DILATION OF LACRIMAL PUNCTUM, WITH OR WITHOUT IRRIGATION 349 CPT 68810 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 770 CPT 68811 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 584 REQUIRING GENERAL ANESTHESIA CPT 68815 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 1,237 WITH INSERTION OF TUBE OR STENT CPT 68816 PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; 2,002 WITH TRANSLUMINAL BALLOON CATHETER DILATION CPT 68840 PROBING OF LACRIMAL CANALICULI, WITH OR WITHOUT IRRIGATION 357 CPT 68850 INJECTION OF CONTRAST MEDIUM FOR DACRYOCYSTOGRAPHY 196 CPT 68899 UNLISTED PROCEDURE, LACRIMAL SYSTEM N/A CPT 69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; SIMPLE 563 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 231 of 380

CPT 69005 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA; COMPLICATED 665 CPT 69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS 718 CPT 69090 EAR PIERCING 98 CPT 69100 BIOPSY EXTERNAL EAR 338 CPT 69105 BIOPSY EXTERNAL AUDITORY CANAL 448 CPT 69110 EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR 1,461 CPT 69120 EXCISION EXTERNAL EAR; COMPLETE AMPUTATION 1,236 CPT 69140 EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL 2,757 CPT 69145 EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY CANAL 1,244 CPT 69150 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; WITHOUT NECK 3,294 DISSECTION CPT 69155 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; WITH NECK 5,285 DISSECTION CPT 69200 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT 375 GENERAL ANESTHESIA CPT 69205 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITH 319 GENERAL ANESTHESIA CPT 69210 REMOVAL IMPACTED CERUMEN (SEPARATE PROCEDURE), ONE OR BOTH 156 EARS CPT 69220 DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (EG, ROUTINE 435 CLEANING) CPT 69222 DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH 693 ANESTHESIA OR MORE THAN ROUTINE CLEANING) CPT 69300 OTOPLASTY, PROTRUDING EAR, WITH OR WITHOUT SIZE REDUCTION 2,282 CPT 69310 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, 3,423 FOR STENOSIS DUE TO INJURY, INFECTION) (SEPARATE PROCEDURE) CPT 69320 RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL 4,842 ATRESIA, SINGLE STAGE CPT 69399 UNLISTED PROCEDURE, EXTERNAL EAR N/A CPT 69400 EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITH CATHETERIZATION 468 CPT 69401 EUSTACHIAN TUBE INFLATION, TRANSNASAL; WITHOUT 278 CATHETERIZATION CPT 69405 EUSTACHIAN TUBE CATHETERIZATION, TRANSTYMPANIC 820 CPT 69420 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE 601 INFLATION CPT 69421 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE 472 INFLATION REQUIRING GENERAL ANESTHESIA CPT 69424 VENTILATING TUBE REMOVAL REQUIRING GENERAL ANESTHESIA 410 CPT 69433 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), LOCAL OR TOPICAL ANESTHESIA CPT 69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), GENERAL ANESTHESIA 628 512 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 232 of 380

CPT 69440 MIDDLE EAR EXPLORATION THROUGH POSTAURICULAR OR EAR CANAL 2,183 INCISION CPT 69450 TYMPANOLYSIS, TRANSCANAL 1,721 CPT 69501 TRANSMASTOID ANTROTOMY (SIMPLE MASTOIDECTOMY) 2,329 CPT 69502 MASTOIDECTOMY; COMPLETE 3,082 CPT 69505 MASTOIDECTOMY; MODIFIED RADICAL 3,807 CPT 69511 MASTOIDECTOMY; RADICAL 3,903 CPT 69530 PETROUS APICECTOMY INCLUDING RADICAL MASTOIDECTOMY 5,217 CPT 69535 RESECTION TEMPORAL BONE, EXTERNAL APPROACH 8,430 CPT 69540 EXCISION AURAL POLYP 657 CPT 69550 EXCISION AURAL GLOMUS TUMOR; TRANSCANAL 3,299 CPT 69552 EXCISION AURAL GLOMUS TUMOR; TRANSMASTOID 4,969 CPT 69554 EXCISION AURAL GLOMUS TUMOR; EXTENDED (EXTRATEMPORAL) 7,884 CPT 69601 REVISION MASTOIDECTOMY; RESULTING IN COMPLETE MASTOIDECTOMY 3,311 CPT 69602 REVISION MASTOIDECTOMY; RESULTING IN MODIFIED RADICAL 3,467 MASTOIDECTOMY CPT 69603 REVISION MASTOIDECTOMY; RESULTING IN RADICAL MASTOIDECTOMY 3,986 CPT 69604 REVISION MASTOIDECTOMY; RESULTING IN TYMPANOPLASTY 3,525 CPT 69605 REVISION MASTOIDECTOMY; WITH APICECTOMY 4,952 CPT 69610 TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OF 1,222 PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH CPT 69620 MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR AREA) 2,182 CPT 69631 TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT 69632 TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION) CPT 69633 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 69635 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT 69636 TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION CPT 69637 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: 01.03.2015 Page No(s): 233 of 380

MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP), TOTAL OSSICULAR REPLACEMENT PROSTHESIS (TORP)) CPT 69641 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 3,307 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT 69642 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,255 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION CPT 69643 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 3,884 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT 69644 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,683 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION CPT 69645 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,595 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITHOUT OSSICULAR CHAIN RECONSTRUCTION CPT 69646 TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, 4,885 MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, WITH OSSICULAR CHAIN RECONSTRUCTION CPT 69650 STAPES MOBILIZATION 2,521 CPT 69660 STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF 2,946 OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; CPT 69661 STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF 3,844 OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; WITH FOOTPLATE DRILL OUT CPT 69662 REVISION OF STAPEDECTOMY OR STAPEDOTOMY 3,681 CPT 69666 REPAIR OVAL WINDOW FISTULA 2,567 CPT 69667 REPAIR ROUND WINDOW FISTULA 2,572 CPT 69670 MASTOID OBLITERATION (SEPARATE PROCEDURE) 2,995 CPT 69676 TYMPANIC NEURECTOMY 2,644 CPT 69700 CLOSURE POSTAURICULAR FISTULA, MASTOID (SEPARATE PROCEDURE) 2,219 CPT 69710 IMPLANTATION OR REPLACEMENT OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN TEMPORAL BONE CPT 69711 REMOVAL OR REPAIR OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN TEMPORAL BONE CPT 69714 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY CPT 69715 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY CPT 69717 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: 01.03.2015 Page No(s): 234 of 380

CPT 69718 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), 4,492 OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY CPT 69720 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; LATERAL TO 3,745 GENICULATE GANGLION CPT 69725 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; INCLUDING MEDIAL 6,032 TO GENICULATE GANGLION CPT 69740 SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR 3,655 DECOMPRESSION; LATERAL TO GENICULATE GANGLION CPT 69745 SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR 3,523 DECOMPRESSION; INCLUDING MEDIAL TO GENICULATE GANGLION CPT 69799 UNLISTED PROCEDURE, MIDDLE EAR N/A CPT 69801 LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER 2,382 NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); TRANSCANAL CPT 69802 LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER 3,312 NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); WITH MASTOIDECTOMY CPT 69805 ENDOLYMPHATIC SAC OPERATION; WITHOUT SHUNT 3,344 CPT 69806 ENDOLYMPHATIC SAC OPERATION; WITH SHUNT 3,010 CPT 69820 FENESTRATION SEMICIRCULAR CANAL 2,713 CPT 69840 REVISION FENESTRATION OPERATION 2,830 CPT 69905 LABYRINTHECTOMY; TRANSCANAL 2,906 CPT 69910 LABYRINTHECTOMY; WITH MASTOIDECTOMY 3,242 CPT 69915 VESTIBULAR NERVE SECTION, TRANSLABYRINTHINE APPROACH 4,931 CPT 69930 COCHLEAR DEVICE IMPLANTATION, WITH OR WITHOUT MASTOIDECTOMY 4,037 CPT 69949 UNLISTED PROCEDURE, INNER EAR N/A CPT 69950 VESTIBULAR NERVE SECTION, TRANSCRANIAL APPROACH 5,864 CPT 69955 TOTAL FACIAL NERVE DECOMPRESSION AND/OR REPAIR (MAY INCLUDE 6,434 GRAFT) CPT 69960 DECOMPRESSION INTERNAL AUDITORY CANAL 6,207 CPT 69970 REMOVAL OF TUMOR, TEMPORAL BONE 6,818 CPT 69979 UNLISTED PROCEDURE, TEMPORAL BONE, MIDDLE FOSSA APPROACH N/A CPT 69990 MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 70010 MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 70015 CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND INTERPRETATION 707 295 295 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 235 of 380

CPT 70030 RADIOLOGIC EXAMINATION, EYE, FOR DETECTION OF FOREIGN BODY 55 CPT 70100 RADIOLOGIC EXAMINATION, MANDIBLE; PARTIAL, LESS THAN FOUR 57 VIEWS CPT 70110 RADIOLOGIC EXAMINATION, MANDIBLE; COMPLETE, MINIMUM OF FOUR 76 VIEWS CPT 70120 RADIOLOGIC EXAMINATION, MASTOIDS; LESS THAN THREE VIEWS PER 63 SIDE CPT 70130 RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE 107 VIEWS PER SIDE CPT 70134 RADIOLOGIC EXAMINATION, INTERNAL AUDITORY MEATI, COMPLETE 91 CPT 70140 RADIOLOGIC EXAMINATION, FACIAL BONES; LESS THAN THREE VIEWS 53 CPT 70150 RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 80 THREE VIEWS CPT 70160 RADIOLOGIC EXAMINATION, NASAL BONES, COMPLETE, MINIMUM OF 62 THREE VIEWS CPT 70170 DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL 99 SUPERVISION AND INTERPRETATION CPT 70190 RADIOLOGIC EXAMINATION; OPTIC FORAMINA 67 CPT 70200 RADIOLOGIC EXAMINATION; ORBITS, COMPLETE, MINIMUM OF FOUR 83 VIEWS CPT 70210 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, LESS THAN THREE 55 VIEWS CPT 70220 RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM 71 OF THREE VIEWS CPT 70240 RADIOLOGIC EXAMINATION, SELLA TURCICA 57 CPT 70250 RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS 68 CPT 70260 RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR 89 VIEWS CPT 70300 RADIOLOGIC EXAMINATION, TEETH; SINGLE VIEW 25 CPT 70310 RADIOLOGIC EXAMINATION, TEETH; PARTIAL EXAMINATION, LESS THAN 69 FULL MOUTH CPT 70320 RADIOLOGIC EXAMINATION, TEETH; COMPLETE, FULL MOUTH 92 CPT 70328 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 57 CLOSED MOUTH; UNILATERAL CPT 70330 RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 90 CLOSED MOUTH; BILATERAL CPT 70332 TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL 147 SUPERVISION AND INTERPRETATION CPT 70336 MAGNETIC RESONANCE (EG, PROTON) IMAGING, TEMPOROMANDIBULAR 990 JOINT(S) CPT 70350 CEPHALOGRAM, ORTHODONTIC 35 CPT 70355 ORTHOPANTOGRAM 37 CPT 70360 RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE 52 CPT 70370 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: 01.03.2015 Page No(s): 236 of 380

CPT 70371 COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EVALUATION BY CINE OR 171 VIDEO RECORDING CPT 70373 LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL SUPERVISION AND 148 INTERPRETATION CPT 70380 RADIOLOGIC EXAMINATION, SALIVARY GLAND FOR CALCULUS 71 CPT 70390 SIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 196 CPT 70450 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL CPT 70460 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITH CONTRAST MATERIAL(S) CPT 70470 COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 70480 COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL CPT 70481 COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S) CPT 70482 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 70486 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL CPT 70487 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITH CONTRAST MATERIAL(S) CPT 70488 COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 70490 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL CPT 70491 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITH CONTRAST MATERIAL(S) CPT 70492 COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 70496 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 70498 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 70540 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S) CPT 70542 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITH CONTRAST MATERIAL(S) CPT 70543 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND/OR NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S) CPT 70545 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITH CONTRAST MATERIAL(S) CPT 70546 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 419 552 667 697 811 919 570 692 847 559 677 825 1,350 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: 01.03.2015 Page No(s): 237 of 380

CPT 70547 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 1,220 MATERIAL(S) CPT 70548 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITH CONTRAST 1,279 MATERIAL(S) CPT 70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST 1,835 MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 70551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,147 BRAIN STEM); WITHOUT CONTRAST MATERIAL CPT 70552 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,256 BRAIN STEM); WITH CONTRAST MATERIAL(S) CPT 70553 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING 1,513 BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 70554 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 70555 MAGNETIC RESONANCE IMAGING, BRAIN, FUNCTIONAL MRI; REQUIRING 1,459 PHYSICIAN OR PSYCHOLOGIST ADMINISTRATION OF ENTIRE NEUROFUNCTIONAL TESTING CPT 70557 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 70558 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 70559 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 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VIEW, FRONTAL 44 CPT 71015 RADIOLOGIC EXAMINATION, CHEST; STEREO, FRONTAL 56 CPT 71020 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; 57 CPT 71021 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH APICAL LORDOTIC PROCEDURE CPT 71022 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE PROJECTIONS CPT 71023 RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH FLUOROSCOPY CPT 71030 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; CPT 71034 RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH FLUOROSCOPY CPT 71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY STUDIES) CPT 71040 BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 71060 BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 71 87 136 89 185 68 190 277 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 238 of 380

CPT 71090 INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, 187 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 71100 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; TWO VIEWS 61 CPT 71101 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING 75 POSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS CPT 71110 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; THREE VIEWS 75 CPT 71111 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING 100 POSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS CPT 71120 RADIOLOGIC EXAMINATION; STERNUM, MINIMUM OF TWO VIEWS 60 CPT 71130 RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, 70 MINIMUM OF THREE VIEWS CPT 71250 COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL 551 CPT 71260 COMPUTED TOMOGRAPHY, THORAX; WITH CONTRAST MATERIAL(S) 668 CPT 71270 COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, 826 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 71275 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST (NONCORONARY), WITH 980 CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 71550 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 1,269 EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S) CPT 71551 MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR 1,403 EVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S) CPT 71552 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 71555 MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING 1,231 MYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) CPT 72010 RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, 135 ANTEROPOSTERIOR AND LATERAL CPT 72020 RADIOLOGIC EXAMINATION, SPINE, SINGLE VIEW, SPECIFY LEVEL 44 CPT 72040 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; TWO OR THREE VIEWS 70 CPT 72050 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; MINIMUM OF FOUR VIEWS 100 CPT 72052 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING 126 OBLIQUE AND FLEXION AND/OR EXTENSION STUDIES CPT 72069 RADIOLOGIC EXAMINATION, SPINE, THORACOLUMBAR, STANDING 69 (SCOLIOSIS) CPT 72070 RADIOLOGIC EXAMINATION, SPINE; THORACIC, TWO VIEWS 62 CPT 72072 RADIOLOGIC EXAMINATION, SPINE; THORACIC, THREE VIEWS 72 CPT 72074 RADIOLOGIC EXAMINATION, SPINE; THORACIC, MINIMUM OF FOUR VIEWS 85 CPT 72080 RADIOLOGIC EXAMINATION, SPINE; THORACOLUMBAR, TWO VIEWS 67 CPT 72090 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: 01.03.2015 Page No(s): 239 of 380

CPT 72100 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; TWO OR THREE 74 VIEWS CPT 72110 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; MINIMUM OF FOUR 105 VIEWS CPT 72114 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, 138 INCLUDING BENDING VIEWS CPT 72120 RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS 94 ONLY, MINIMUM OF FOUR VIEWS CPT 72125 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST 552 MATERIAL CPT 72126 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITH CONTRAST MATERIAL 667 CPT 72127 COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST 819 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 72128 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST 552 MATERIAL CPT 72129 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITH CONTRAST MATERIAL 667 CPT 72130 COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST 814 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 72131 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST 550 MATERIAL CPT 72132 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITH CONTRAST MATERIAL 665 CPT 72133 COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST 817 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 72141 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,018 CONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL CPT 72142 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,268 CONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) CPT 72146 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,023 CONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL CPT 72147 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,127 CONTENTS, THORACIC; WITH CONTRAST MATERIAL(S) CPT 72148 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,010 CONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL CPT 72149 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,251 CONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) CPT 72156 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,507 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL CPT 72157 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,398 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC CPT 72158 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND 1,486 CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR CPT 72159 MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, 1,191 WITH OR WITHOUT CONTRAST MATERIAL(S) CPT 72170 RADIOLOGIC EXAMINATION, PELVIS; ONE OR TWO VIEWS 48 CPT 72190 RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, MINIMUM OF THREE VIEWS 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 240 of 380

CPT 72191 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITH CONTRAST 942 MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 72192 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL 518 CPT 72193 COMPUTED TOMOGRAPHY, PELVIS; WITH CONTRAST MATERIAL(S) 630 CPT 72194 COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, 818 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 72195 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 1,135 CONTRAST MATERIAL(S) CPT 72196 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITH 1,236 CONTRAST MATERIAL(S) CPT 72197 MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT 1,540 CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 72198 MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, WITH OR WITHOUT 1,215 CONTRAST MATERIAL(S) CPT 72200 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; LESS THAN THREE 54 VIEWS CPT 72202 RADIOLOGIC EXAMINATION, SACROILIAC JOINTS; THREE OR MORE VIEWS 67 CPT 72220 RADIOLOGIC EXAMINATION, SACRUM AND COCCYX, MINIMUM OF TWO 55 VIEWS CPT 72240 MYELOGRAPHY, CERVICAL, RADIOLOGICAL SUPERVISION AND 261 INTERPRETATION CPT 72255 MYELOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND 235 INTERPRETATION CPT 72265 MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND 250 INTERPRETATION CPT 72270 MYELOGRAPHY, TWO OR MORE REGIONS (EG, LUMBAR/THORACIC, 394 CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 72275 EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 190 CPT 72285 DISCOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION 214 AND INTERPRETATION CPT 72291 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 571 VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION, PER VERTEBRAL BODY; UNDER FLUOROSCOPIC GUIDANCE CPT 72292 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 589 VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION, PER VERTEBRAL BODY; UNDER CT GUIDANCE CPT 72295 DISCOGRAPHY, LUMBAR, RADIOLOGICAL SUPERVISION AND 190 INTERPRETATION CPT 73000 RADIOLOGIC EXAMINATION; CLAVICLE, COMPLETE 51 CPT 73010 RADIOLOGIC EXAMINATION; SCAPULA, COMPLETE 53 CPT 73020 RADIOLOGIC EXAMINATION, SHOULDER; ONE VIEW 42 CPT 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLETE, MINIMUM OF TWO VIEWS CPT 73040 RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 73050 RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, WITH OR WITHOUT WEIGHTED DISTRACTION 55 202 68 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 241 of 380

CPT 73060 RADIOLOGIC EXAMINATION; HUMERUS, MINIMUM OF TWO VIEWS 55 CPT 73070 RADIOLOGIC EXAMINATION, ELBOW; TWO VIEWS 50 CPT 73080 RADIOLOGIC EXAMINATION, ELBOW; COMPLETE, MINIMUM OF THREE 67 VIEWS CPT 73085 RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL 174 SUPERVISION AND INTERPRETATION CPT 73090 RADIOLOGIC EXAMINATION; FOREARM, TWO VIEWS 51 CPT 73092 RADIOLOGIC EXAMINATION; UPPER EXTREMITY, INFANT, MINIMUM OF 52 TWO VIEWS CPT 73100 RADIOLOGIC EXAMINATION, WRIST; TWO VIEWS 55 CPT 73110 RADIOLOGIC EXAMINATION, WRIST; COMPLETE, MINIMUM OF THREE 67 VIEWS CPT 73115 RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL 206 SUPERVISION AND INTERPRETATION CPT 73120 RADIOLOGIC EXAMINATION, HAND; TWO VIEWS 51 CPT 73130 RADIOLOGIC EXAMINATION, HAND; MINIMUM OF THREE VIEWS 59 CPT 73140 RADIOLOGIC EXAMINATION, FINGER(S), MINIMUM OF TWO VIEWS 57 CPT 73200 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST 539 MATERIAL CPT 73201 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITH CONTRAST 653 MATERIAL(S) CPT 73202 COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST 844 MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 73206 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITH 915 CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 73218 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 1,138 OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) CPT 73219 MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, 1,216 OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) CPT 73220 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 73221 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER 1,063 EXTREMITY; WITHOUT CONTRAST MATERIAL(S) CPT 73222 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER 1,140 EXTREMITY; WITH CONTRAST MATERIAL(S) CPT 73223 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 73225 MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR 1,181 WITHOUT CONTRAST MATERIAL(S) CPT 73500 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; ONE VIEW 47 CPT 73510 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; COMPLETE, MINIMUM OF TWO VIEWS CPT 73520 RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIOR VIEW OF PELVIS 70 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 242 of 380

CPT 73525 RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL 174 SUPERVISION AND INTERPRETATION CPT 73530 RADIOLOGIC EXAMINATION, HIP, DURING OPERATIVE PROCEDURE 65 CPT 73540 RADIOLOGIC EXAMINATION, PELVIS AND HIPS, INFANT OR CHILD, 73 MINIMUM OF TWO VIEWS CPT 73542 RADIOLOGICAL EXAMINATION, SACROILIAC JOINT ARTHROGRAPHY, 129 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 73550 RADIOLOGIC EXAMINATION, FEMUR, TWO VIEWS 52 CPT 73560 RADIOLOGIC EXAMINATION, KNEE; ONE OR TWO VIEWS 53 CPT 73562 RADIOLOGIC EXAMINATION, KNEE; THREE VIEWS 66 CPT 73564 RADIOLOGIC EXAMINATION, KNEE; COMPLETE, FOUR OR MORE VIEWS 78 CPT 73565 RADIOLOGIC EXAMINATION, KNEE; BOTH KNEES, STANDING, 58 ANTEROPOSTERIOR CPT 73580 RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL 226 SUPERVISION AND INTERPRETATION CPT 73590 RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, TWO VIEWS 51 CPT 73592 RADIOLOGIC EXAMINATION; LOWER EXTREMITY, INFANT, MINIMUM OF 52 TWO VIEWS CPT 73600 RADIOLOGIC EXAMINATION, ANKLE; TWO VIEWS 51 CPT 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, MINIMUM OF THREE 60 VIEWS CPT 73615 RADIOLOGIC EXAMINATION, ANKLE, ARTHROGRAPHY, RADIOLOGICAL 185 SUPERVISION AND INTERPRETATION CPT 73620 RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS 48 CPT 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, MINIMUM OF THREE 58 VIEWS CPT 73650 RADIOLOGIC EXAMINATION; CALCANEUS, MINIMUM OF TWO VIEWS 51 CPT 73660 RADIOLOGIC EXAMINATION; TOE(S), MINIMUM OF TWO VIEWS 55 CPT 73700 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL CPT 73701 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) CPT 73702 COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 73706 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 73718 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) CPT 73719 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH CONTRAST MATERIAL(S) CPT 73720 MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 73721 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL 539 657 857 1,018 1,112 1,216 1,529 1,085 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 243 of 380

CPT 73722 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER 1,152 EXTREMITY; WITH CONTRAST MATERIAL(S) CPT 73723 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 73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR 1,219 WITHOUT CONTRAST MATERIAL(S) CPT 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE ANTEROPOSTERIOR VIEW 46 CPT 74010 RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND 73 ADDITIONAL OBLIQUE AND CONE VIEWS CPT 74020 RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING 78 DECUBITUS AND/OR ERECT VIEWS CPT 74022 RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN 94 SERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, SINGLE VIEW CHEST CPT 74150 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL 526 CPT 74160 COMPUTED TOMOGRAPHY, ABDOMEN; WITH CONTRAST MATERIAL(S) 727 CPT 74170 COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, 974 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS CPT 74175 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITH CONTRAST 1,013 MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING CPT 74181 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT 998 CONTRAST MATERIAL(S) CPT 74182 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITH 1,368 CONTRAST MATERIAL(S) CPT 74183 MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT 1,542 CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES CPT 74185 MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT 1,215 CONTRAST MATERIAL(S) CPT 74190 PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), 144 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74210 RADIOLOGIC EXAMINATION; PHARYNX AND/OR CERVICAL ESOPHAGUS 152 CPT 74220 RADIOLOGIC EXAMINATION; ESOPHAGUS 176 CPT 74230 SWALLOWING FUNCTION, WITH CINERADIOGRAPHY/VIDEORADIOGRAPHY 177 CPT 74235 REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74240 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITHOUT KUB CPT 74241 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED FILMS, WITH KUB CPT 74245 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH SMALL INTESTINE, INCLUDES MULTIPLE SERIAL FILMS CPT 74246 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 74247 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT DELAYED 334 214 233 348 250 279 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 244 of 380

FILMS, WITH KUB CPT 74249 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 74250 RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 210 SERIAL FILMS; CPT 74251 RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE 748 SERIAL FILMS; VIA ENTEROCLYSIS TUBE CPT 74260 DUODENOGRAPHY, HYPOTONIC 616 CPT 74270 RADIOLOGIC EXAMINATION, COLON; BARIUM ENEMA, WITH OR WITHOUT 305 KUB CPT 74280 RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH 422 DENSITY BARIUM, WITH OR WITHOUT GLUCAGON CPT 74283 THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF 397 INTUSSUSCEPTION OR OTHER INTRALUMINAL OBSTRUCTION (EG, MECONIUM ILEUS) CPT 74290 CHOLECYSTOGRAPHY, ORAL CONTRAST; 135 CPT 74291 CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT 123 EXAMINATION OR MULTIPLE DAY EXAMINATION CPT 74300 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, 100 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74301 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; ADDITIONAL SET 58 INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 74305 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; THROUGH EXISTING 101 CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74320 CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL 198 SUPERVISION AND INTERPRETATION CPT 74327 POSTOPERATIVE BILIARY DUCT CALCULUS REMOVAL, PERCUTANEOUS VIA 263 T-TUBE TRACT, BASKET, OR SNARE (EG, BURHENNE TECHNIQUE), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74328 ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, 311 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74329 ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, 196 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74330 COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND 324 PANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74340 INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER- 250 ABBOTT), INCLUDING MULTIPLE FLUOROSCOPIES AND FILMS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74355 PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL 272 SUPERVISION AND INTERPRETATION CPT 74360 INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS (EG, 299 ESOPHAGUS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74363 PERCUTANEOUS TRANSHEPATIC DILATION OF BILIARY DUCT STRICTURE 244 WITH OR WITHOUT PLACEMENT OF STENT, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74400 UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, 222 WITH OR WITHOUT TOMOGRAPHY CPT 74410 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 228 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 245 of 380

CPT 74415 UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 269 WITH NEPHROTOMOGRAPHY CPT 74420 UROGRAPHY, RETROGRADE, WITH OR WITHOUT KUB 238 CPT 74425 UROGRAPHY, ANTEGRADE (PYELOSTOGRAM, NEPHROSTOGRAM, 132 LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74430 CYSTOGRAPHY, MINIMUM OF 3 VIEWS, RADIOLOGICAL SUPERVISION AND 163 INTERPRETATION CPT 74440 VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL 178 SUPERVISION AND INTERPRETATION CPT 74445 CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL SUPERVISION AND 198 INTERPRETATION CPT 74450 URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION 143 AND INTERPRETATION CPT 74455 URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND 182 INTERPRETATION CPT 74470 RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, 144 CONTRAST VISUALIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS 200 FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74480 INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER 201 THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74485 DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL 207 SUPERVISION AND INTERPRETATION CPT 74710 PELVIMETRY, WITH OR WITHOUT PLACENTAL LOCALIZATION 73 CPT 74740 HYSTEROSALPINGOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 74742 TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75557 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; CPT 75558 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH FLOW/VELOCITY QUANTIFICATION CPT 75559 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH STRESS IMAGING CPT 75560 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL; WITH FLOW/VELOCITY QUANTIFICATION AND STRESS CPT 75561 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CPT 75562 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 75563 CARDIAC MAGNETIC RESONANCE IMAGING FOR MORPHOLOGY AND FUNCTION WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; WITH STRESS IMAGING CPT 75564 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 154 168 1,009 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: 01.03.2015 Page No(s): 246 of 380

CPT 75600 AORTOGRAPHY, THORACIC, WITHOUT SERIALOGRAPHY, RADIOLOGICAL 524 SUPERVISION AND INTERPRETATION CPT 75605 AORTOGRAPHY, THORACIC, BY SERIALOGRAPHY, RADIOLOGICAL 372 SUPERVISION AND INTERPRETATION CPT 75625 AORTOGRAPHY, ABDOMINAL, BY SERIALOGRAPHY, RADIOLOGICAL 359 SUPERVISION AND INTERPRETATION CPT 75630 AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER 439 EXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75635 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 75650 ANGIOGRAPHY, CERVICOCEREBRAL, CATHETER, INCLUDING VESSEL 397 ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75658 ANGIOGRAPHY, BRACHIAL, RETROGRADE, RADIOLOGICAL SUPERVISION 398 AND INTERPRETATION CPT 75660 ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, 408 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75662 ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, 510 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75665 ANGIOGRAPHY, CAROTID, CEREBRAL, UNILATERAL, RADIOLOGICAL 425 SUPERVISION AND INTERPRETATION CPT 75671 ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL 517 SUPERVISION AND INTERPRETATION CPT 75676 ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL 408 SUPERVISION AND INTERPRETATION CPT 75680 ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL 483 SUPERVISION AND INTERPRETATION CPT 75685 ANGIOGRAPHY, VERTEBRAL, CERVICAL, AND/OR INTRACRANIAL, 408 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75705 ANGIOGRAPHY, SPINAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND 493 INTERPRETATION CPT 75710 ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION 402 AND INTERPRETATION CPT 75716 ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION 480 AND INTERPRETATION CPT 75722 ANGIOGRAPHY, RENAL, UNILATERAL, SELECTIVE (INCLUDING FLUSH 392 AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75724 ANGIOGRAPHY, RENAL, BILATERAL, SELECTIVE (INCLUDING FLUSH 506 AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75726 ANGIOGRAPHY, VISCERAL, SELECTIVE OR SUPRASELECTIVE (WITH OR 388 WITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75731 ANGIOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 411 SUPERVISION AND INTERPRETATION CPT 75733 ANGIOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 517 SUPERVISION AND INTERPRETATION CPT 75736 ANGIOGRAPHY, PELVIC, SELECTIVE OR SUPRASELECTIVE, RADIOLOGICAL 395 SUPERVISION AND INTERPRETATION CPT 75741 ANGIOGRAPHY, PULMONARY, UNILATERAL, SELECTIVE, RADIOLOGICAL 359 SUPERVISION AND INTERPRETATION CPT 75743 ANGIOGRAPHY, PULMONARY, BILATERAL, SELECTIVE, RADIOLOGICAL 410 SUPERVISION AND INTERPRETATION CPT 75746 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: 01.03.2015 Page No(s): 247 of 380

CPT 75756 ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND 426 INTERPRETATION CPT 75774 ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL VESSEL STUDIED AFTER 244 BASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (EG, DIALYSIS PATIENT), 354 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75801 LYMPHANGIOGRAPHY, EXTREMITY ONLY, UNILATERAL, RADIOLOGICAL 469 SUPERVISION AND INTERPRETATION CPT 75803 LYMPHANGIOGRAPHY, EXTREMITY ONLY, BILATERAL, RADIOLOGICAL 512 SUPERVISION AND INTERPRETATION CPT 75805 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL, RADIOLOGICAL 526 SUPERVISION AND INTERPRETATION CPT 75807 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL 563 SUPERVISION AND INTERPRETATION CPT 75809 SHUNTOGRAM FOR INVESTIGATION OF PREVIOUSLY PLACED INDWELLING 187 NONVASCULAR SHUNT (EG, LEVEEN SHUNT, VENTRICULOPERITONEAL SHUNT, INDWELLING INFUSION PUMP), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75810 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND 998 INTERPRETATION CPT 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION 262 AND INTERPRETATION CPT 75822 VENOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND 302 INTERPRETATION CPT 75825 VENOGRAPHY, CAVAL, INFERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL 331 SUPERVISION AND INTERPRETATION CPT 75827 VENOGRAPHY, CAVAL, SUPERIOR, WITH SERIALOGRAPHY, RADIOLOGICAL 331 SUPERVISION AND INTERPRETATION CPT 75831 VENOGRAPHY, RENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 338 SUPERVISION AND INTERPRETATION CPT 75833 VENOGRAPHY, RENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 408 SUPERVISION AND INTERPRETATION CPT 75840 VENOGRAPHY, ADRENAL, UNILATERAL, SELECTIVE, RADIOLOGICAL 333 SUPERVISION AND INTERPRETATION CPT 75842 VENOGRAPHY, ADRENAL, BILATERAL, SELECTIVE, RADIOLOGICAL 412 SUPERVISION AND INTERPRETATION CPT 75860 VENOGRAPHY, VENOUS SINUS (EG, PETROSAL AND INFERIOR SAGITTAL) 361 OR JUGULAR, CATHETER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75870 VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION 354 AND INTERPRETATION CPT 75872 VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND 413 INTERPRETATION CPT 75880 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND 276 INTERPRETATION CPT 75885 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITH HEMODYNAMIC 368 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75887 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY WITHOUT HEMODYNAMIC 385 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75889 HEPATIC VENOGRAPHY, WEDGED OR FREE, WITH HEMODYNAMIC 339 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75891 HEPATIC VENOGRAPHY, WEDGED OR FREE, WITHOUT HEMODYNAMIC 339 EVALUATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75893 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: 01.03.2015 Page No(s): 248 of 380

RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75894 TRANSCATHETER THERAPY, EMBOLIZATION, ANY METHOD, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75896 TRANSCATHETER THERAPY, INFUSION, ANY METHOD (EG, THROMBOLYSIS OTHER THAN CORONARY), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75898 ANGIOGRAPHY THROUGH EXISTING CATHETER FOR FOLLOW-UP STUDY FOR TRANSCATHETER THERAPY, EMBOLIZATION OR INFUSION CPT 75900 EXCHANGE OF A PREVIOUSLY PLACED INTRAVASCULAR CATHETER DURING THROMBOLYTIC THERAPY WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75901 MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (EG, FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS, RADIOLOGIC SUPERVISION AND INTERPRETATION CPT 75902 MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN, RADIOLOGIC SUPERVISION AND INTERPRETATION CPT 75940 PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75945 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL VESSEL CPT 75946 INTRAVASCULAR ULTRASOUND (NON-CORONARY VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; EACH ADDITIONAL NON-CORONARY VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 75952 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75953 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 75954 ENDOVASCULAR REPAIR OF ILIAC ARTERY ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, OR TRAUMA, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75956 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 75957 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 75958 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 75959 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 75960 TRANSCATHETER INTRODUCTION OF INTRAVASCULAR STENT(S) (EXCEPT CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS AND/OR OPEN, RADIOLOGICAL SUPERVISION AND INTERPRETATION, EACH VESSEL 1,827 1,607 241 317 380 198 1,062 368 368 441 133 217 697 598 398 348 300 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 249 of 380

CPT 75961 TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR 667 FOREIGN BODY (EG, FRACTURED VENOUS OR ARTERIAL CATHETER), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, 338 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75964 TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL PERIPHERAL 219 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 75966 TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL 440 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75968 TRANSLUMINAL BALLOON ANGIOPLASTY, EACH ADDITIONAL VISCERAL 222 ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 75970 TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND 901 INTERPRETATION CPT 75978 TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (EG, SUBCLAVIAN 322 STENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75980 PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST 537 MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75982 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 75984 CHANGE OF PERCUTANEOUS TUBE OR DRAINAGE CATHETER WITH 219 CONTRAST MONITORING (EG, GENITOURINARY SYSTEM, ABSCESS), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 75989 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 75992 TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL 1,363 SUPERVISION AND INTERPRETATION CPT 75993 TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL PERIPHERAL ARTERY, 891 RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 75994 TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION 1,314 AND INTERPRETATION CPT 75995 TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION 1,279 AND INTERPRETATION CPT 75996 TRANSLUMINAL ATHERECTOMY, EACH ADDITIONAL VISCERAL ARTERY, 350 RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 76000 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN TIME, 209 OTHER THAN 71023 OR 71034 (EG, CARDIAC FLUOROSCOPY) CPT 76001 FLUOROSCOPY, PHYSICIAN TIME MORE THAN 1 HOUR, ASSISTING A 266 NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, TRANSBRONCHIAL BIOPSY) CPT 76010 RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, 51 SINGLE VIEW, CHILD CPT 76080 RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, 118 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 76098 RADIOLOGICAL EXAMINATION, SURGICAL SPECIMEN 35 CPT 76100 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: 01.03.2015 Page No(s): 250 of 380

CPT 76101 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) 426 BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; UNILATERAL CPT 76102 RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) 579 BODY SECTION (EG, MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; BILATERAL CPT 76120 CINERADIOGRAPHY/VIDEORADIOGRAPHY, EXCEPT WHERE SPECIFICALLY 161 INCLUDED CPT 76150 XERORADIOGRAPHY 48 CPT 76376 3D 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 76377 3D 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 76380 COMPUTED TOMOGRAPHY, LIMITED OR LOCALIZED FOLLOW-UP STUDY 409 CPT 76390 MAGNETIC RESONANCE SPECTROSCOPY 795 CPT 76496 UNLISTED FLUOROSCOPIC PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT 76497 UNLISTED COMPUTED TOMOGRAPHY PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT 76498 UNLISTED MAGNETIC RESONANCE PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT 76499 UNLISTED DIAGNOSTIC RADIOGRAPHIC PROCEDURE N/A CPT 76506 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 76510 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN AND QUANTITATIVE A- 269 SCAN PERFORMED DURING THE SAME PATIENT ENCOUNTER CPT 76511 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; QUANTITATIVE A-SCAN ONLY 165 CPT 76512 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; B-SCAN (WITH OR WITHOUT 153 SUPERIMPOSED NON-QUANTITATIVE A-SCAN) CPT 76513 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; ANTERIOR SEGMENT 158 ULTRASOUND, IMMERSION (WATER BATH) B-SCAN OR HIGH RESOLUTION BIOMICROSCOPY CPT 76514 OPHTHALMIC ULTRASOUND, DIAGNOSTIC; CORNEAL PACHYMETRY, 24 UNILATERAL OR BILATERAL (DETERMINATION OF CORNEAL THICKNESS) CPT 76516 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; 122 CPT 76519 OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH 132 INTRAOCULAR LENS POWER CALCULATION CPT 76529 OPHTHALMIC ULTRASONIC FOREIGN BODY LOCALIZATION 125 CPT 76536 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), REAL TIME WITH IMAGE DOCUMENTATION CPT 76604 ULTRASOUND, CHEST (INCLUDES MEDIASTINUM), REAL TIME WITH IMAGE DOCUMENTATION 231 170 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 251 of 380

CPT 76645 ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), REAL TIME WITH 189 IMAGE DOCUMENTATION CPT 76700 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; 275 COMPLETE CPT 76705 ULTRASOUND, ABDOMINAL, REAL TIME WITH IMAGE DOCUMENTATION; 211 LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP) CPT 76770 ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL 263 TIME WITH IMAGE DOCUMENTATION; COMPLETE CPT 76775 ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), REAL 215 TIME WITH IMAGE DOCUMENTATION; LIMITED CPT 76776 ULTRASOUND, TRANSPLANTED KIDNEY, REAL TIME AND DUPLEX DOPPLER 299 WITH IMAGE DOCUMENTATION CPT 76800 ULTRASOUND, SPINAL CANAL AND CONTENTS 246 CPT 76801 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 76802 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 76805 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 76810 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 76811 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND MATERNAL EVALUATION PLUS DETAILED FETAL ANATOMIC EXAMINATION, TRANSABDOMINAL APPROACH; SINGLE OR FIRST GESTATION CPT 76812 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 76813 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINAL APPROACH; SINGLE OR FIRST GESTATION CPT 76814 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 76815 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 76816 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FOLLOW-UP (EG, RE-EVALUATION OF FETAL SIZE BY MEASURING STANDARD GROWTH PARAMETERS AND AMNIOTIC FLUID 249 135 290 199 378 432 247 161 177 230 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 252 of 380

VOLUME, RE-EVALUATION OF ORGAN SYSTEM(S) SUSPECTED OR CONFIRMED TO BE ABNORMAL ON A PREVIOUS SCAN), TRANSABDOMINAL APPROACH, PER FETUS CPT 76817 ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE 197 DOCUMENTATION, TRANSVAGINAL CPT 76818 FETAL BIOPHYSICAL PROFILE; WITH NON-STRESS TESTING 236 CPT 76819 FETAL BIOPHYSICAL PROFILE; WITHOUT NON-STRESS TESTING 174 CPT 76820 DOPPLER VELOCIMETRY, FETAL; UMBILICAL ARTERY 83 CPT 76821 DOPPLER VELOCIMETRY, FETAL; MIDDLE CEREBRAL ARTERY 188 CPT 76825 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME 430 WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; CPT 76826 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR SYSTEM, REAL TIME 253 WITH IMAGE DOCUMENTATION (2D), WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR REPEAT STUDY CPT 76827 DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR 123 CONTINUOUS WAVE WITH SPECTRAL DISPLAY; COMPLETE CPT 76828 DOPPLER ECHOCARDIOGRAPHY, FETAL, PULSED WAVE AND/OR 89 CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR REPEAT STUDY CPT 76830 ULTRASOUND, TRANSVAGINAL 247 CPT 76831 SALINE INFUSION SONOHYSTEROGRAPHY (SIS), INCLUDING COLOR FLOW 248 DOPPLER, WHEN PERFORMED CPT 76856 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE 250 DOCUMENTATION; COMPLETE CPT 76857 ULTRASOUND, PELVIC (NONOBSTETRIC), REAL TIME WITH IMAGE 204 DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES) CPT 76870 ULTRASOUND, SCROTUM AND CONTENTS 249 CPT 76872 ULTRASOUND, TRANSRECTAL; 293 CPT 76873 ULTRASOUND, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY TREATMENT PLANNING (SEPARATE PROCEDURE) CPT 76880 ULTRASOUND, EXTREMITY, NONVASCULAR, REAL TIME WITH IMAGE DOCUMENTATION CPT 76885 ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; DYNAMIC (REQUIRING PHYSICIAN MANIPULATION) CPT 76886 ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC (NOT REQUIRING PHYSICIAN MANIPULATION) CPT 76930 ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION CPT 76932 ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, IMAGING SUPERVISION AND INTERPRETATION CPT 76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE (INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION AND IMAGING) CPT 76937 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, 359 268 285 207 198 187 594 72 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 253 of 380

WITH PERMANENT RECORDING AND REPORTING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 76940 ULTRASOUND GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL 333 TISSUE ABLATION CPT 76941 ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR 238 CORDOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION CPT 76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, 387 ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION CPT 76945 ULTRASONIC GUIDANCE FOR CHORIONIC VILLUS SAMPLING, IMAGING 177 SUPERVISION AND INTERPRETATION CPT 76946 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, IMAGING SUPERVISION 65 AND INTERPRETATION CPT 76948 ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, IMAGING 65 SUPERVISION AND INTERPRETATION CPT 76950 ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS 130 CPT 76965 ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION 201 CPT 76970 ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 170 CPT 76975 GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, SUPERVISION AND 194 INTERPRETATION CPT 76977 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, 14 PERIPHERAL SITE(S), ANY METHOD CPT 76998 ULTRASONIC GUIDANCE, INTRAOPERATIVE 120 CPT 76999 UNLISTED ULTRASOUND PROCEDURE (EG, DIAGNOSTIC, N/A INTERVENTIONAL) CPT 77001 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 77002 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, 128 ASPIRATION, INJECTION, LOCALIZATION DEVICE) CPT 77003 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 77011 COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION 1,520 CPT 77012 COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 77013 COMPUTED TOMOGRAPHY GUIDANCE FOR, AND MONITORING OF, PARENCHYMAL TISSUE ABLATION CPT 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS CPT 77021 MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY, NEEDLE ASPIRATION, INJECTION, OR PLACEMENT OF LOCALIZATION DEVICE) RADIOLOGICAL SUPERVISION AND 273 1,074 382 820 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 254 of 380

INTERPRETATION CPT 77022 MAGNETIC RESONANCE GUIDANCE FOR, AND MONITORING OF, 1,337 PARENCHYMAL TISSUE ABLATION CPT 77031 STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR 271 NEEDLE PLACEMENT (EG, FOR WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 77032 MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR 102 WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 77051 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 77052 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 77053 MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL 121 SUPERVISION AND INTERPRETATION CPT 77054 MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, 161 RADIOLOGICAL SUPERVISION AND INTERPRETATION CPT 77055 MAMMOGRAPHY; UNILATERAL 168 CPT 77056 MAMMOGRAPHY; BILATERAL 216 CPT 77057 SCREENING MAMMOGRAPHY, BILATERAL (2-VIEW FILM STUDY OF EACH 154 BREAST) CPT 77058 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH 1,679 CONTRAST MATERIAL(S); UNILATERAL CPT 77059 MAGNETIC RESONANCE IMAGING, BREAST, WITHOUT AND/OR WITH 1,697 CONTRAST MATERIAL(S); BILATERAL CPT 77071 MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT 85 RADIOGRAPHY, INCLUDING CONTRALATERAL JOINT IF INDICATED CPT 77072 BONE AGE STUDIES 44 CPT 77073 BONE LENGTH STUDIES (ORTHOROENTGENOGRAM, SCANOGRAM) 68 CPT 77074 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; LIMITED (EG, FOR 136 METASTASES) CPT 77075 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; COMPLETE (AXIAL AND 202 APPENDICULAR SKELETON) CPT 77076 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY, INFANT 201 CPT 77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS (SPECIFY) 72 CPT 77078 COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) CPT 77079 COMPUTED TOMOGRAPHY, BONE MINERAL DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) CPT 77080 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) 357 76 102 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 255 of 380

CPT 77081 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 51 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) CPT 77082 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), BONE DENSITY STUDY, 1 52 OR MORE SITES; VERTEBRAL FRACTURE ASSESSMENT CPT 77083 RADIOGRAPHIC ABSORPTIOMETRY (EG, PHOTODENSITOMETRY, 43 RADIOGRAMMETRY), 1 OR MORE SITES CPT 77084 MAGNETIC RESONANCE (EG, PROTON) IMAGING, BONE MARROW BLOOD 1,095 SUPPLY CPT 77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE 134 CPT 77262 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE 201 CPT 77263 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX 299 CPT 77280 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE 370 CPT 77285 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 651 INTERMEDIATE CPT 77290 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX 1,067 CPT 77295 THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 3-950 DIMENSIONAL CPT 77299 UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY CLINICAL TREATMENT N/A PLANNING CPT 77300 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 77301 INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME 4,662 HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS CPT 77305 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 77310 TELETHERAPY, ISODOSE PLAN (WHETHER HAND OR COMPUTER 170 CALCULATED); INTERMEDIATE (THREE OR MORE TREATMENT PORTS DIRECTED TO A SINGLE AREA OF INTEREST) CPT 77315 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 77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, HEMIBODY, TOTAL BODY 188 CPT 77326 BRACHYTHERAPY ISODOSE PLAN; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, ONE TO FOUR SOURCES/RIBBON APPLICATION, REMOTE AFTERLOADING BRACHYTHERAPY, 1 TO 8 SOURCES) CPT 77327 BRACHYTHERAPY ISODOSE PLAN; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING 5 TO 10 SOURCES/RIBBONS, REMOTE AFTERLOADING BRACHYTHERAPY, 9 TO 12 SOURCES) CPT 77328 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 77331 SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN 282 396 533 120 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 256 of 380

CPT 77332 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; SIMPLE (SIMPLE 151 BLOCK, SIMPLE BOLUS) CPT 77333 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; INTERMEDIATE 104 (MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) CPT 77334 TREATMENT DEVICES, DESIGN AND CONSTRUCTION; COMPLEX 289 (IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS, WEDGES, MOLDS OR CASTS) CPT 77336 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 77370 SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION 223 CPT 77371 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED CPT 77372 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED CPT 77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS CPT 77399 UNLISTED PROCEDURE, MEDICAL RADIATION PHYSICS, DOSIMETRY AND TREATMENT DEVICES, AND SPECIAL SERVICES CPT 77401 RADIATION TREATMENT DELIVERY, SUPERFICIAL AND/OR ORTHO VOLTAGE CPT 77402 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; UP TO 5 MEV CPT 77403 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 6-10 MEV CPT 77404 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 11-19 MEV CPT 77406 RADIATION TREATMENT DELIVERY, SINGLE TREATMENT AREA, SINGLE PORT OR PARALLEL OPPOSED PORTS, SIMPLE BLOCKS OR NO BLOCKS; 20 MEV OR GREATER CPT 77407 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 77408 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; 6-10 MEV CPT 77409 RADIATION TREATMENT DELIVERY, TWO SEPARATE TREATMENT AREAS, THREE OR MORE PORTS ON A SINGLE TREATMENT AREA, USE OF MULTIPLE BLOCKS; 11-19 MEV CPT 77411 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 77412 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; UP TO 5 MEV CPT 77413 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 40 308 267 298 300 408 367 407 405 479 483 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 257 of 380

CPT 77414 RADIATION TREATMENT DELIVERY, THREE OR MORE SEPARATE 543 TREATMENT AREAS, CUSTOM BLOCKING, TANGENTIAL PORTS, WEDGES, ROTATIONAL BEAM, COMPENSATORS, ELECTRON BEAM; 11-19 MEV CPT 77416 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 77417 THERAPEUTIC RADIOLOGY PORT FILM(S) 27 CPT 77418 INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE 920 FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION CPT 77421 STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME 200 FOR THE DELIVERY OF RADIATION THERAPY CPT 77422 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 77423 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 77427 RADIATION TREATMENT MANAGEMENT, FIVE TREATMENTS 364 CPT 77431 RADIATION THERAPY MANAGEMENT WITH COMPLETE COURSE OF THERAPY 185 CONSISTING OF ONE OR TWO FRACTIONS ONLY CPT 77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CRANIAL 755 LESION(S) (COMPLETE COURSE OF TREATMENT CONSISTING OF ONE SESSION) CPT 77435 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 77470 SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, 325 HEMIBODY RADIATION, PER ORAL, ENDOCAVITARY OR INTRAOPERATIVE CONE IRRADIATION) CPT 77499 UNLISTED PROCEDURE, THERAPEUTIC RADIOLOGY TREATMENT N/A MANAGEMENT CPT 77520 PROTON TREATMENT DELIVERY; SIMPLE, WITHOUT COMPENSATION N/A CPT 77522 PROTON TREATMENT DELIVERY; SIMPLE, WITH COMPENSATION N/A CPT 77523 PROTON TREATMENT DELIVERY; INTERMEDIATE N/A CPT 77525 PROTON TREATMENT DELIVERY; COMPLEX N/A CPT 77600 HYPERTHERMIA, EXTERNALLY GENERATED; SUPERFICIAL (IE, HEATING TO 833 A DEPTH OF 4 CM OR LESS) CPT 77605 HYPERTHERMIA, EXTERNALLY GENERATED; DEEP (IE, HEATING TO DEPTHS 1,449 GREATER THAN 4 CM) CPT 77610 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); 5 OR FEWER 1,366 INTERSTITIAL APPLICATORS CPT 77615 HYPERTHERMIA GENERATED BY INTERSTITIAL PROBE(S); MORE THAN 5 1,962 INTERSTITIAL APPLICATORS CPT 77620 HYPERTHERMIA GENERATED BY INTRACAVITARY PROBE(S) 859 CPT 77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES 3 678 MONTHS FOLLOW-UP CARE) CPT 77761 INTRACAVITARY RADIATION SOURCE APPLICATION; SIMPLE 726 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 258 of 380

CPT 77762 INTRACAVITARY RADIATION SOURCE APPLICATION; INTERMEDIATE 958 CPT 77763 INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX 1,357 CPT 77776 INTERSTITIAL RADIATION SOURCE APPLICATION; SIMPLE 878 CPT 77777 INTERSTITIAL RADIATION SOURCE APPLICATION; INTERMEDIATE 1,108 CPT 77778 INTERSTITIAL RADIATION SOURCE APPLICATION; COMPLEX 1,619 CPT 77781 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 1-4 SOURCE 467 POSITIONS OR CATHETERS CPT 77782 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 5-8 SOURCE 1,082 POSITIONS OR CATHETERS CPT 77783 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; 9-12 SOURCE 1,988 POSITIONS OR CATHETERS CPT 77784 REMOTE AFTERLOADING HIGH INTENSITY BRACHYTHERAPY; OVER 12 3,614 SOURCE POSITIONS OR CATHETERS CPT 77789 SURFACE APPLICATION OF RADIATION SOURCE 223 CPT 77790 SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE 178 CPT 77799 UNLISTED PROCEDURE, CLINICAL BRACHYTHERAPY N/A CPT 78000 THYROID UPTAKE; SINGLE DETERMINATION 145 CPT 78001 THYROID UPTAKE; MULTIPLE DETERMINATIONS 183 CPT 78003 THYROID UPTAKE; STIMULATION, SUPPRESSION OR DISCHARGE (NOT 161 INCLUDING INITIAL UPTAKE STUDIES) CPT 78006 THYROID IMAGING, WITH UPTAKE; SINGLE DETERMINATION 475 CPT 78007 THYROID IMAGING, WITH UPTAKE; MULTIPLE DETERMINATIONS 257 CPT 78010 THYROID IMAGING; ONLY 325 CPT 78011 THYROID IMAGING; WITH VASCULAR FLOW 356 CPT 78015 THYROID CARCINOMA METASTASES IMAGING; LIMITED AREA (EG, NECK 427 AND CHEST ONLY) CPT 78016 THYROID CARCINOMA METASTASES IMAGING; WITH ADDITIONAL 662 STUDIES (EG, URINARY RECOVERY) CPT 78018 THYROID CARCINOMA METASTASES IMAGING; WHOLE BODY 631 CPT 78020 THYROID CARCINOMA METASTASES UPTAKE (LIST SEPARATELY IN 177 ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 78070 PARATHYROID IMAGING 308 CPT 78075 ADRENAL IMAGING, CORTEX AND/OR MEDULLA 878 CPT 78099 UNLISTED ENDOCRINE PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A CPT 78102 BONE MARROW IMAGING; LIMITED AREA 336 CPT 78103 BONE MARROW IMAGING; MULTIPLE AREAS 442 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 259 of 380

CPT 78104 BONE MARROW IMAGING; WHOLE BODY 503 CPT 78110 PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 165 TECHNIQUE (SEPARATE PROCEDURE); SINGLE SAMPLING CPT 78111 PLASMA VOLUME, RADIOPHARMACEUTICAL VOLUME-DILUTION 173 TECHNIQUE (SEPARATE PROCEDURE); MULTIPLE SAMPLINGS CPT 78120 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); SINGLE 169 SAMPLING CPT 78121 RED CELL VOLUME DETERMINATION (SEPARATE PROCEDURE); MULTIPLE 184 SAMPLINGS CPT 78122 WHOLE BLOOD VOLUME DETERMINATION, INCLUDING SEPARATE 204 MEASUREMENT OF PLASMA VOLUME AND RED CELL VOLUME (RADIOPHARMACEUTICAL VOLUME-DILUTION TECHNIQUE) CPT 78130 RED CELL SURVIVAL STUDY; 295 CPT 78135 RED CELL SURVIVAL STUDY; DIFFERENTIAL ORGAN/TISSUE KINETICS (EG, 664 SPLENIC AND/OR HEPATIC SEQUESTRATION) CPT 78140 LABELED RED CELL SEQUESTRATION, DIFFERENTIAL ORGAN/TISSUE (EG, 262 SPLENIC AND/OR HEPATIC) CPT 78185 SPLEEN IMAGING ONLY, WITH OR WITHOUT VASCULAR FLOW 397 CPT 78190 KINETICS, STUDY OF PLATELET SURVIVAL, WITH OR WITHOUT 681 DIFFERENTIAL ORGAN/TISSUE LOCALIZATION CPT 78191 PLATELET SURVIVAL STUDY 313 CPT 78195 LYMPHATICS AND LYMPH NODES IMAGING 704 CPT 78199 UNLISTED HEMATOPOIETIC, RETICULOENDOTHELIAL AND LYMPHATIC N/A PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE CPT 78201 LIVER IMAGING; STATIC ONLY 359 CPT 78202 LIVER IMAGING; WITH VASCULAR FLOW 416 CPT 78205 LIVER IMAGING (SPECT); 437 CPT 78206 LIVER IMAGING (SPECT); WITH VASCULAR FLOW 672 CPT 78215 LIVER AND SPLEEN IMAGING; STATIC ONLY 378 CPT 78216 LIVER AND SPLEEN IMAGING; WITH VASCULAR FLOW 250 CPT 78220 LIVER FUNCTION STUDY WITH HEPATOBILIARY AGENTS, WITH SERIAL 261 IMAGES CPT 78223 HEPATOBILIARY DUCTAL SYSTEM IMAGING, INCLUDING GALLBLADDER, 662 WITH OR WITHOUT PHARMACOLOGIC INTERVENTION, WITH OR WITHOUT QUANTITATIVE MEASUREMENT OF GALLBLADDER FUNCTION CPT 78230 SALIVARY GLAND IMAGING; 330 CPT 78231 SALIVARY GLAND IMAGING; WITH SERIAL IMAGES 243 CPT 78232 SALIVARY GLAND FUNCTION STUDY 238 CPT 78258 ESOPHAGEAL MOTILITY 444 CPT 78261 GASTRIC MUCOSA IMAGING 480 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 260 of 380

CPT 78262 GASTROESOPHAGEAL REFLUX STUDY 476 CPT 78264 GASTRIC EMPTYING STUDY 566 CPT 78267 UREA BREATH TEST, C-14 (ISOTOPIC); ACQUISITION FOR ANALYSIS 40 CPT 78268 UREA BREATH TEST, C-14 (ISOTOPIC); ANALYSIS 346 CPT 78270 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITHOUT 156 INTRINSIC FACTOR CPT 78271 VITAMIN B-12 ABSORPTION STUDY (EG, SCHILLING TEST); WITH 151 INTRINSIC FACTOR CPT 78272 VITAMIN B-12 ABSORPTION STUDIES COMBINED, WITH AND WITHOUT 170 INTRINSIC FACTOR CPT 78278 ACUTE GASTROINTESTINAL BLOOD LOSS IMAGING 684 CPT 78282 GASTROINTESTINAL PROTEIN LOSS 148 CPT 78290 INTESTINE IMAGING (EG, ECTOPIC GASTRIC MUCOSA, MECKEL'S 649 LOCALIZATION, VOLVULUS) CPT 78291 PERITONEAL-VENOUS SHUNT PATENCY TEST (EG, FOR LEVEEN, DENVER 500 SHUNT) CPT 78299 UNLISTED GASTROINTESTINAL PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT 78300 BONE AND/OR JOINT IMAGING; LIMITED AREA 347 CPT 78305 BONE AND/OR JOINT IMAGING; MULTIPLE AREAS 452 CPT 78306 BONE AND/OR JOINT IMAGING; WHOLE BODY 497 CPT 78315 BONE AND/OR JOINT IMAGING; THREE PHASE STUDY 685 CPT 78320 BONE AND/OR JOINT IMAGING; TOMOGRAPHIC (SPECT) 466 CPT 78350 BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; 54 SINGLE PHOTON ABSORPTIOMETRY CPT 78351 BONE DENSITY (BONE MINERAL CONTENT) STUDY, ONE OR MORE SITES; 25 DUAL PHOTON ABSORPTIOMETRY, ONE OR MORE SITES CPT 78399 UNLISTED MUSCULOSKELETAL PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT 78414 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 78428 CARDIAC SHUNT DETECTION 429 CPT 78445 NON-CARDIAC VASCULAR FLOW IMAGING (IE, ANGIOGRAPHY, 353 VENOGRAPHY) CPT 78456 ACUTE VENOUS THROMBOSIS IMAGING, PEPTIDE 701 CPT 78457 VENOUS THROMBOSIS IMAGING, VENOGRAM; UNILATERAL 387 CPT 78458 VENOUS THROMBOSIS IMAGING, VENOGRAM; BILATERAL 391 CPT 78459 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: 01.03.2015 Page No(s): 261 of 380

CPT 78460 MYOCARDIAL PERFUSION IMAGING; (PLANAR) SINGLE STUDY, AT REST 393 OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WITH OR WITHOUT QUANTIFICATION CPT 78461 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 78464 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 78465 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 78466 MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; QUALITATIVE OR 376 QUANTITATIVE CPT 78468 MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; WITH EJECTION 477 FRACTION BY FIRST PASS TECHNIQUE CPT 78469 MYOCARDIAL IMAGING, INFARCT AVID, PLANAR; TOMOGRAPHIC SPECT 520 WITH OR WITHOUT QUANTIFICATION CPT 78472 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 78473 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 78478 MYOCARDIAL PERFUSION STUDY WITH WALL MOTION, QUALITATIVE OR 97 QUANTITATIVE STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 78480 MYOCARDIAL PERFUSION STUDY WITH EJECTION FRACTION (LIST 77 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 78481 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 78483 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 78491 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 2,166 PERFUSION; SINGLE STUDY AT REST OR STRESS CPT 78492 MYOCARDIAL IMAGING, POSITRON EMISSION TOMOGRAPHY (PET), 2,700 PERFUSION; MULTIPLE STUDIES AT REST AND/OR STRESS CPT 78494 CARDIAC BLOOD POOL IMAGING, GATED EQUILIBRIUM, SPECT, AT REST, 537 WALL MOTION STUDY PLUS EJECTION FRACTION, WITH OR WITHOUT QUANTITATIVE PROCESSING CPT 78496 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 78499 UNLISTED CARDIOVASCULAR PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 262 of 380

CPT 78580 PULMONARY PERFUSION IMAGING, PARTICULATE 420 CPT 78584 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; 292 SINGLE BREATH CPT 78585 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION; 696 REBREATHING AND WASHOUT, WITH OR WITHOUT SINGLE BREATH CPT 78586 PULMONARY VENTILATION IMAGING, AEROSOL; SINGLE PROJECTION 327 CPT 78587 PULMONARY VENTILATION IMAGING, AEROSOL; MULTIPLE PROJECTIONS 421 (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) CPT 78588 PULMONARY PERFUSION IMAGING, PARTICULATE, WITH VENTILATION 690 IMAGING, AEROSOL, ONE OR MULTIPLE PROJECTIONS CPT 78591 PULMONARY VENTILATION IMAGING, GASEOUS, SINGLE BREATH, SINGLE 327 PROJECTION CPT 78593 PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND 381 WASHOUT WITH OR WITHOUT SINGLE BREATH; SINGLE PROJECTION CPT 78594 PULMONARY VENTILATION IMAGING, GASEOUS, WITH REBREATHING AND 421 WASHOUT WITH OR WITHOUT SINGLE BREATH; MULTIPLE PROJECTIONS (EG, ANTERIOR, POSTERIOR, LATERAL VIEWS) CPT 78596 PULMONARY QUANTITATIVE DIFFERENTIAL FUNCTION 717 (VENTILATION/PERFUSION) STUDY CPT 78599 UNLISTED RESPIRATORY PROCEDURE, DIAGNOSTIC NUCLEAR MEDICINE N/A CPT 78600 BRAIN IMAGING, LESS THAN 4 STATIC VIEWS; 345 CPT 78601 BRAIN IMAGING, LESS THAN 4 STATIC VIEWS; WITH VASCULAR FLOW 421 CPT 78605 BRAIN IMAGING, MINIMUM 4 STATIC VIEWS; 386 CPT 78606 BRAIN IMAGING, MINIMUM 4 STATIC VIEWS; WITH VASCULAR FLOW 651 CPT 78607 BRAIN IMAGING, TOMOGRAPHIC (SPECT) 710 CPT 78608 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); METABOLIC 3,929 EVALUATION CPT 78609 BRAIN IMAGING, POSITRON EMISSION TOMOGRAPHY (PET); PERFUSION 3,446 EVALUATION CPT 78610 BRAIN IMAGING, VASCULAR FLOW ONLY 336 CPT 78630 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 667 OF MATERIAL); CISTERNOGRAPHY CPT 78635 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 662 OF MATERIAL); VENTRICULOGRAPHY CPT 78645 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 640 OF MATERIAL); SHUNT EVALUATION CPT 78647 CEREBROSPINAL FLUID FLOW, IMAGING (NOT INCLUDING INTRODUCTION 677 OF MATERIAL); TOMOGRAPHIC (SPECT) CPT 78650 CEREBROSPINAL FLUID LEAKAGE DETECTION AND LOCALIZATION 653 CPT 78660 RADIOPHARMACEUTICAL DACRYOCYSTOGRAPHY 341 CPT 78699 UNLISTED NERVOUS SYSTEM PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT 78700 KIDNEY IMAGING MORPHOLOGY; 347 CPT 78701 KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW 420 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 263 of 380

CPT 78707 KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW AND FUNCTION, 464 SINGLE STUDY WITHOUT PHARMACOLOGICAL INTERVENTION CPT 78708 KIDNEY IMAGING MORPHOLOGY; WITH VASCULAR FLOW AND FUNCTION, 343 SINGLE STUDY, WITH PHARMACOLOGICAL INTERVENTION (EG, ANGIOTENSIN CONVERTING ENZYME INHIBITOR AND/OR DIURETIC) CPT 78709 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 78710 KIDNEY IMAGING MORPHOLOGY; TOMOGRAPHIC (SPECT) 434 CPT 78725 KIDNEY FUNCTION STUDY, NON-IMAGING RADIOISOTOPIC STUDY 197 CPT 78730 URINARY BLADDER RESIDUAL STUDY (LIST SEPARATELY IN ADDITION TO 154 CODE FOR PRIMARY PROCEDURE) CPT 78740 URETERAL REFLUX STUDY (RADIOPHARMACEUTICAL VOIDING 440 CYSTOGRAM) CPT 78761 TESTICULAR IMAGING WITH VASCULAR FLOW 413 CPT 78799 UNLISTED GENITOURINARY PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT 78800 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 361 RADIOPHARMACEUTICAL AGENT(S); LIMITED AREA CPT 78801 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 492 RADIOPHARMACEUTICAL AGENT(S); MULTIPLE AREAS CPT 78802 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 646 RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, SINGLE DAY IMAGING CPT 78803 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 694 RADIOPHARMACEUTICAL AGENT(S); TOMOGRAPHIC (SPECT) CPT 78804 RADIOPHARMACEUTICAL LOCALIZATION OF TUMOR OR DISTRIBUTION OF 1,125 RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING TWO OR MORE DAYS IMAGING CPT 78805 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 357 LIMITED AREA CPT 78806 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 664 WHOLE BODY CPT 78807 RADIOPHARMACEUTICAL LOCALIZATION OF INFLAMMATORY PROCESS; 691 TOMOGRAPHIC (SPECT) CPT 78811 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; LIMITED AREA (EG, 2,971 CHEST, HEAD/NECK) CPT 78812 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; SKULL BASE TO MID- 3,668 THIGH CPT 78813 POSITRON EMISSION TOMOGRAPHY (PET) IMAGING; WHOLE BODY 3,817 CPT 78814 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; LIMITED AREA (EG, CHEST, HEAD/NECK) CPT 78815 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; SKULL BASE TO MID-THIGH CPT 78816 POSITRON EMISSION TOMOGRAPHY (PET) WITH CONCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ATTENUATION CORRECTION AND ANATOMICAL LOCALIZATION IMAGING; WHOLE BODY CPT 78890 GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONAL 4,170 4,609 4,734 35 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 264 of 380

PERSONNEL; SIMPLE MANIPULATIONS AND INTERPRETATION, NOT TO EXCEED 30 MINUTES CPT 78891 GENERATION OF AUTOMATED DATA: INTERACTIVE PROCESS INVOLVING 77 NUCLEAR PHYSICIAN AND/OR ALLIED HEALTH PROFESSIONAL PERSONNEL; COMPLEX MANIPULATIONS AND INTERPRETATION, EXCEEDING 30 MINUTES CPT 78999 UNLISTED MISCELLANEOUS PROCEDURE, DIAGNOSTIC NUCLEAR N/A MEDICINE CPT 79005 RADIOPHARMACEUTICAL THERAPY, BY ORAL ADMINISTRATION 267 CPT 79101 RADIOPHARMACEUTICAL THERAPY, BY INTRAVENOUS ADMINISTRATION 300 CPT 79200 RADIOPHARMACEUTICAL THERAPY, BY INTRACAVITARY ADMINISTRATION 306 CPT 79300 RADIOPHARMACEUTICAL THERAPY, BY INTERSTITIAL RADIOACTIVE 266 COLLOID ADMINISTRATION CPT 79403 RADIOPHARMACEUTICAL THERAPY, RADIOLABELED MONOCLONAL 374 ANTIBODY BY INTRAVENOUS INFUSION CPT 79440 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTICULAR 279 ADMINISTRATION CPT 79445 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE 426 ADMINISTRATION CPT 79999 RADIOPHARMACEUTICAL THERAPY, UNLISTED PROCEDURE N/A CPT 80047 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 80048 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 80050 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 85027 AND 85004) OR BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND CPT 80051 ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) CPT 80053 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 80055 OBSTETRIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: BLOOD COUNT, COMPLETE (CBC), AUTOMATED AND AUTOMATED DIFFERENTIAL WBC COUNT (85025 OR 85027 AND 85004) OR BLOOD COUNT, COMPLETE (CBC), AUTOMATED (85027) AND APPROPRIATE MANUAL DIFFERENTIAL WBC COUNT ( CPT 80061 LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) TRIGLYCERIDES (84478) 105 250 143 36 193 209 67 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 265 of 380

CPT 80069 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 80074 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 80076 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 80100 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES 75 CHROMATOGRAPHIC METHOD, EACH PROCEDURE CPT 80101 DRUG SCREEN, QUALITATIVE; SINGLE DRUG CLASS METHOD (EG, 71 IMMUNOASSAY, ENZYME ASSAY), EACH DRUG CLASS CPT 80102 DRUG CONFIRMATION, EACH PROCEDURE 68 CPT 80103 TISSUE PREPARATION FOR DRUG ANALYSIS 78 CPT 80150 AMIKACIN 77 CPT 80152 AMITRIPTYLINE 92 CPT 80154 BENZODIAZEPINES 95 CPT 80156 CARBAMAZEPINE; TOTAL 75 CPT 80157 CARBAMAZEPINE; FREE 68 CPT 80158 CYCLOSPORINE 93 CPT 80160 DESIPRAMINE 88 CPT 80162 DIGOXIN 68 CPT 80164 DIPROPYLACETIC ACID (VALPROIC ACID) 70 CPT 80166 DOXEPIN 80 CPT 80168 ETHOSUXIMIDE 84 CPT 80170 GENTAMICIN 84 CPT 80172 GOLD 84 CPT 80173 HALOPERIDOL 75 CPT 80174 IMIPRAMINE 88 CPT 80176 LIDOCAINE 75 CPT 80178 LITHIUM 34 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 266 of 380

CPT 80182 NORTRIPTYLINE 70 CPT 80184 PHENOBARBITAL 59 CPT 80185 PHENYTOIN; TOTAL 68 CPT 80186 PHENYTOIN; FREE 71 CPT 80188 PRIMIDONE 85 CPT 80190 PROCAINAMIDE; 86 CPT 80192 PROCAINAMIDE; WITH METABOLITES (EG, N-ACETYL PROCAINAMIDE) 86 CPT 80194 QUINIDINE 75 CPT 80195 SIROLIMUS 70 CPT 80196 SALICYLATE 36 CPT 80197 TACROLIMUS 70 CPT 80198 THEOPHYLLINE 73 CPT 80200 TOBRAMYCIN 83 CPT 80201 TOPIRAMATE 61 CPT 80202 VANCOMYCIN 70 CPT 80299 QUANTITATION OF DRUG, NOT ELSEWHERE SPECIFIED 70 CPT 80400 ACTH STIMULATION PANEL; FOR ADRENAL INSUFFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) CPT 80402 ACTH STIMULATION PANEL; FOR 21 HYDROXYLASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 17 HYDROXYPROGESTERONE (83498 X 2) CPT 80406 ACTH STIMULATION PANEL; FOR 3 BETA-HYDROXYDEHYDROGENASE DEFICIENCY THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 2) 17 HYDROXYPREGNENOLONE (84143 X 2) CPT 80408 ALDOSTERONE SUPPRESSION EVALUATION PANEL (EG, SALINE INFUSION) THIS PANEL MUST INCLUDE THE FOLLOWING: ALDOSTERONE (82088 X 2) RENIN (84244 X 2) CPT 80410 CALCITONIN STIMULATION PANEL (EG, CALCIUM, PENTAGASTRIN) THIS PANEL MUST INCLUDE THE FOLLOWING: CALCITONIN (82308 X 3) CPT 80412 CORTICOTROPIC RELEASING HORMONE (CRH) STIMULATION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CORTISOL (82533 X 6) ADRENOCORTICOTROPIC HORMONE (ACTH) (82024 X 6) CPT 80414 CHORIONIC GONADOTROPIN STIMULATION PANEL; TESTOSTERONE RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: TESTOSTERONE (84403 X 2 ON THREE POOLED BLOOD SAMPLES) CPT 80415 CHORIONIC GONADOTROPIN STIMULATION PANEL; ESTRADIOL RESPONSE THIS PANEL MUST INCLUDE THE FOLLOWING: ESTRADIOL (82670 X 2 ON THREE POOLED BLOOD SAMPLES) CPT 80416 RENAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS PANEL MUST INCLUDE THE FOLLOWING: RENIN (84244 X 6) 166 438 381 638 402 1,667 262 283 673 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 267 of 380

CPT 80417 PERIPHERAL VEIN RENIN STIMULATION PANEL (EG, CAPTOPRIL) THIS 224 PANEL MUST INCLUDE THE FOLLOWING: RENIN (84244 X 2) CPT 80418 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 80420 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 80422 GLUCAGON TOLERANCE PANEL; FOR INSULINOMA THIS PANEL MUST 234 INCLUDE THE FOLLOWING: GLUCOSE (82947 X 3) INSULIN (83525 X 3) CPT 80424 GLUCAGON TOLERANCE PANEL; FOR PHEOCHROMOCYTOMA THIS PANEL 251 MUST INCLUDE THE FOLLOWING: CATECHOLAMINES, FRACTIONATED (82384 X 2) CPT 80426 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 80428 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 80430 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 80432 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 80434 INSULIN TOLERANCE PANEL; FOR ACTH INSUFFICIENCY THIS PANEL MUST 514 INCLUDE THE FOLLOWING: CORTISOL (82533 X 5) GLUCOSE (82947 X 5) CPT 80435 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 80436 METYRAPONE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 455 CORTISOL (82533 X 2) 11 DEOXYCORTISOL (82634 X 2) CPT 80438 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; ONE 257 HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID STIMULATING HORMONE (TSH) (84443 X 3) CPT 80439 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; TWO 344 HOUR THIS PANEL MUST INCLUDE THE FOLLOWING: THYROID STIMULATING HORMONE (TSH) (84443 X 4) CPT 80440 THYROTROPIN RELEASING HORMONE (TRH) STIMULATION PANEL; FOR 298 HYPERPROLACTINEMIA THIS PANEL MUST INCLUDE THE FOLLOWING: PROLACTIN (84146 X 3) CPT 80500 CLINICAL PATHOLOGY CONSULTATION; LIMITED, WITHOUT REVIEW OF 73 PATIENT'S HISTORY AND MEDICAL RECORDS CPT 80502 CLINICAL PATHOLOGY CONSULTATION; COMPREHENSIVE, FOR A COMPLEX 211 DIAGNOSTIC PROBLEM, WITH REVIEW OF PATIENT'S HISTORY AND MEDICAL RECORDS CPT 81000 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 81001 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: 01.03.2015 Page No(s): 268 of 380

CPT 81002 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 81003 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 81005 URINALYSIS; QUALITATIVE OR SEMIQUANTITATIVE, EXCEPT 12 IMMUNOASSAYS CPT 81007 URINALYSIS; BACTERIURIA SCREEN, EXCEPT BY CULTURE OR DIPSTICK 13 CPT 81015 URINALYSIS; MICROSCOPIC ONLY 16 CPT 81020 URINALYSIS; TWO OR THREE GLASS TEST 19 CPT 81025 URINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 33 CPT 81050 VOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 15 CPT 81099 UNLISTED URINALYSIS PROCEDURE N/A CPT 82000 ACETALDEHYDE, BLOOD 64 CPT 82003 ACETAMINOPHEN 104 CPT 82009 ACETONE OR OTHER KETONE BODIES, SERUM; QUALITATIVE 23 CPT 82010 ACETONE OR OTHER KETONE BODIES, SERUM; QUANTITATIVE 42 CPT 82013 ACETYLCHOLINESTERASE 57 CPT 82016 ACYLCARNITINES; QUALITATIVE, EACH SPECIMEN 71 CPT 82017 ACYLCARNITINES; QUANTITATIVE, EACH SPECIMEN 87 CPT 82024 ADRENOCORTICOTROPIC HORMONE (ACTH) 198 CPT 82030 ADENOSINE, 5-MONOPHOSPHATE, CYCLIC (CYCLIC AMP) 132 CPT 82040 ALBUMIN; SERUM 25 CPT 82042 ALBUMIN; URINE OR OTHER SOURCE, QUANTITATIVE, EACH SPECIMEN 27 CPT 82043 ALBUMIN; URINE, MICROALBUMIN, QUANTITATIVE 30 CPT 82044 ALBUMIN; URINE, MICROALBUMIN, SEMIQUANTITATIVE (EG, REAGENT 24 STRIP ASSAY) CPT 82045 ALBUMIN; ISCHEMIA MODIFIED 174 CPT 82055 ALCOHOL (ETHANOL); ANY SPECIMEN EXCEPT BREATH 55 CPT 82075 ALCOHOL (ETHANOL); BREATH 62 CPT 82085 ALDOLASE 50 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 269 of 380

CPT 82088 ALDOSTERONE 209 CPT 82101 ALKALOIDS, URINE, QUANTITATIVE 154 CPT 82103 ALPHA-1-ANTITRYPSIN; TOTAL 69 CPT 82104 ALPHA-1-ANTITRYPSIN; PHENOTYPE 74 CPT 82105 ALPHA-FETOPROTEIN (AFP); SERUM 86 CPT 82106 ALPHA-FETOPROTEIN (AFP); AMNIOTIC FLUID 86 CPT 82107 ALPHA-FETOPROTEIN (AFP); AFP-L3 FRACTION ISOFORM AND TOTAL AFP 330 (INCLUDING RATIO) CPT 82108 ALUMINUM 131 CPT 82120 AMINES, VAGINAL FLUID, QUALITATIVE 19 CPT 82127 AMINO ACIDS; SINGLE, QUALITATIVE, EACH SPECIMEN 71 CPT 82128 AMINO ACIDS; MULTIPLE, QUALITATIVE, EACH SPECIMEN 71 CPT 82131 AMINO ACIDS; SINGLE, QUANTITATIVE, EACH SPECIMEN 87 CPT 82135 AMINOLEVULINIC ACID, DELTA (ALA) 85 CPT 82136 AMINO ACIDS, 2 TO 5 AMINO ACIDS, QUANTITATIVE, EACH SPECIMEN 87 CPT 82139 AMINO ACIDS, 6 OR MORE AMINO ACIDS, QUANTITATIVE, EACH 87 SPECIMEN CPT 82140 AMMONIA 75 CPT 82143 AMNIOTIC FLUID SCAN (SPECTROPHOTOMETRIC) 35 CPT 82145 AMPHETAMINE OR METHAMPHETAMINE 80 CPT 82150 AMYLASE 33 CPT 82154 ANDROSTANEDIOL GLUCURONIDE 148 CPT 82157 ANDROSTENEDIONE 150 CPT 82160 ANDROSTERONE 128 CPT 82163 ANGIOTENSIN II 105 CPT 82164 ANGIOTENSIN I - CONVERTING ENZYME (ACE) 75 CPT 82172 APOLIPOPROTEIN, EACH 80 CPT 82175 ARSENIC 97 CPT 82180 ASCORBIC ACID (VITAMIN C), BLOOD 164 CPT 82190 ATOMIC ABSORPTION SPECTROSCOPY, EACH ANALYTE 77 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 270 of 380

CPT 82205 BARBITURATES, NOT ELSEWHERE SPECIFIED 59 CPT 82232 BETA-2 MICROGLOBULIN 83 CPT 82239 BILE ACIDS; TOTAL 88 CPT 82240 BILE ACIDS; CHOLYLGLYCINE 136 CPT 82247 BILIRUBIN; TOTAL 26 CPT 82248 BILIRUBIN; DIRECT 26 CPT 82252 BILIRUBIN; FECES, QUALITATIVE 23 CPT 82261 BIOTINIDASE, EACH SPECIMEN 87 CPT 82270 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 82271 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE; 17 OTHER SOURCES CPT 82272 BLOOD, OCCULT, BY PEROXIDASE ACTIVITY (EG, GUAIAC), QUALITATIVE, 17 FECES, 1-3 SIMULTANEOUS DETERMINATIONS, PERFORMED FOR OTHER THAN COLORECTAL NEOPLASM SCREENING CPT 82274 BLOOD, OCCULT, BY FECAL HEMOGLOBIN DETERMINATION BY 82 IMMUNOASSAY, QUALITATIVE, FECES, 1-3 SIMULTANEOUS DETERMINATIONS CPT 82286 BRADYKININ 35 CPT 82300 CADMIUM 119 CPT 82306 CALCIFEDIOL (25-OH VITAMIN D-3) 152 CPT 82307 CALCIFEROL (VITAMIN D) 165 CPT 82308 CALCITONIN 137 CPT 82310 CALCIUM; TOTAL 26 CPT 82330 CALCIUM; IONIZED 70 CPT 82331 CALCIUM; AFTER CALCIUM INFUSION TEST 27 CPT 82340 CALCIUM; URINE QUANTITATIVE, TIMED SPECIMEN 31 CPT 82355 CALCULUS; QUALITATIVE ANALYSIS 59 CPT 82360 CALCULUS; QUANTITATIVE ANALYSIS, CHEMICAL 66 CPT 82365 CALCULUS; INFRARED SPECTROSCOPY 66 CPT 82370 CALCULUS; X-RAY DIFFRACTION 64 CPT 82373 CARBOHYDRATE DEFICIENT TRANSFERRIN 93 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 271 of 380

CPT 82374 CARBON DIOXIDE (BICARBONATE) 25 CPT 82375 CARBON MONOXIDE (CARBOXYHEMOGLOBIN); QUANTITATIVE 63 CPT 82376 CARBON MONOXIDE (CARBOXYHEMOGLOBIN); QUALITATIVE 31 CPT 82378 CARCINOEMBRYONIC ANTIGEN (CEA) 97 CPT 82379 CARNITINE (TOTAL AND FREE), QUANTITATIVE, EACH SPECIMEN 87 CPT 82380 CAROTENE 47 CPT 82382 CATECHOLAMINES; TOTAL URINE 88 CPT 82383 CATECHOLAMINES; BLOOD 129 CPT 82384 CATECHOLAMINES; FRACTIONATED 130 CPT 82387 CATHEPSIN-D 107 CPT 82390 CERULOPLASMIN 55 CPT 82397 CHEMILUMINESCENT ASSAY 73 CPT 82415 CHLORAMPHENICOL 65 CPT 82435 CHLORIDE; BLOOD 24 CPT 82436 CHLORIDE; URINE 26 CPT 82438 CHLORIDE; OTHER SOURCE 25 CPT 82441 CHLORINATED HYDROCARBONS, SCREEN 31 CPT 82465 CHOLESTEROL, SERUM OR WHOLE BLOOD, TOTAL 22 CPT 82480 CHOLINESTERASE; SERUM 40 CPT 82482 CHOLINESTERASE; RBC 39 CPT 82485 CHONDROITIN B SULFATE, QUANTITATIVE 106 CPT 82486 CHROMATOGRAPHY, QUALITATIVE; COLUMN (EG, GAS LIQUID OR HPLC), 93 ANALYTE NOT ELSEWHERE SPECIFIED CPT 82487 CHROMATOGRAPHY, QUALITATIVE; PAPER, 1-DIMENSIONAL, ANALYTE NOT 82 ELSEWHERE SPECIFIED CPT 82488 CHROMATOGRAPHY, QUALITATIVE; PAPER, 2-DIMENSIONAL, ANALYTE NOT 110 ELSEWHERE SPECIFIED CPT 82489 CHROMATOGRAPHY, QUALITATIVE; THIN LAYER, ANALYTE NOT 95 ELSEWHERE SPECIFIED CPT 82491 CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); 93 SINGLE ANALYTE NOT ELSEWHERE SPECIFIED, SINGLE STATIONARY AND MOBILE PHASE CPT 82492 CHROMATOGRAPHY, QUANTITATIVE, COLUMN (EG, GAS LIQUID OR HPLC); 93 MULTIPLE ANALYTES, SINGLE STATIONARY AND MOBILE PHASE CPT 82495 CHROMIUM 104 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 272 of 380

CPT 82507 CITRATE 143 CPT 82520 COCAINE OR METABOLITE 78 CPT 82523 COLLAGEN CROSS LINKS, ANY METHOD 96 CPT 82525 COPPER 64 CPT 82528 CORTICOSTERONE 116 CPT 82530 CORTISOL; FREE 86 CPT 82533 CORTISOL; TOTAL 84 CPT 82540 CREATINE 24 CPT 82541 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT 82542 COLUMN CHROMATOGRAPHY/MASS SPECTROMETRY (EG, GC/MS, OR 93 HPLC/MS), ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, SINGLE STATIONARY AND MOBILE PHASE CPT 82543 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 82544 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 82550 CREATINE KINASE (CK), (CPK); TOTAL 33 CPT 82552 CREATINE KINASE (CK), (CPK); ISOENZYMES 69 CPT 82553 CREATINE KINASE (CK), (CPK); MB FRACTION ONLY 59 CPT 82554 CREATINE KINASE (CK), (CPK); ISOFORMS 61 CPT 82565 CREATININE; BLOOD 26 CPT 82570 CREATININE; OTHER SOURCE 27 CPT 82575 CREATININE; CLEARANCE 49 CPT 82585 CRYOFIBRINOGEN 44 CPT 82595 CRYOGLOBULIN, QUALITATIVE OR SEMI-QUANTITATIVE (EG, CRYOCRIT) 33 CPT 82600 CYANIDE 100 CPT 82607 CYANOCOBALAMIN (VITAMIN B-12); 77 CPT 82608 CYANOCOBALAMIN (VITAMIN B-12); UNSATURATED BINDING CAPACITY 74 CPT 82610 CYSTATIN C 70 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 273 of 380

CPT 82615 CYSTINE AND HOMOCYSTINE, URINE, QUALITATIVE 42 CPT 82626 DEHYDROEPIANDROSTERONE (DHEA) 130 CPT 82627 DEHYDROEPIANDROSTERONE-SULFATE (DHEA-S) 114 CPT 82633 DESOXYCORTICOSTERONE, 11-159 CPT 82634 DEOXYCORTISOL, 11-150 CPT 82638 DIBUCAINE NUMBER 63 CPT 82646 DIHYDROCODEINONE 106 CPT 82649 DIHYDROMORPHINONE 132 CPT 82651 DIHYDROTESTOSTERONE (DHT) 132 CPT 82652 DIHYDROXYVITAMIN D, 1,25-198 CPT 82654 DIMETHADIONE 71 CPT 82656 ELASTASE, PANCREATIC (EL-1), FECAL, QUALITATIVE OR SEMI- 59 QUANTITATIVE CPT 82657 ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT 93 ELSEWHERE SPECIFIED; NONRADIOACTIVE SUBSTRATE, EACH SPECIMEN CPT 82658 ENZYME ACTIVITY IN BLOOD CELLS, CULTURED CELLS, OR TISSUE, NOT 93 ELSEWHERE SPECIFIED; RADIOACTIVE SUBSTRATE, EACH SPECIMEN CPT 82664 ELECTROPHORETIC TECHNIQUE, NOT ELSEWHERE SPECIFIED 176 CPT 82666 EPIANDROSTERONE 110 CPT 82668 ERYTHROPOIETIN 96 CPT 82670 ESTRADIOL 143 CPT 82671 ESTROGENS; FRACTIONATED 166 CPT 82672 ESTROGENS; TOTAL 111 CPT 82677 ESTRIOL 124 CPT 82679 ESTRONE 128 CPT 82690 ETHCHLORVYNOL 89 CPT 82693 ETHYLENE GLYCOL 77 CPT 82696 ETIOCHOLANOLONE 121 CPT 82705 FAT OR LIPIDS, FECES; QUALITATIVE 26 CPT 82710 FAT OR LIPIDS, FECES; QUANTITATIVE 86 CPT 82715 FAT DIFFERENTIAL, FECES, QUANTITATIVE 88 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 274 of 380

CPT 82725 FATTY ACIDS, NONESTERIFIED 68 CPT 82726 VERY LONG CHAIN FATTY ACIDS 93 CPT 82728 FERRITIN 70 CPT 82731 FETAL FIBRONECTIN, CERVICOVAGINAL SECRETIONS, SEMI- 330 QUANTITATIVE CPT 82735 FLUORIDE 95 CPT 82742 FLURAZEPAM 102 CPT 82746 FOLIC ACID; SERUM 75 CPT 82747 FOLIC ACID; RBC 89 CPT 82757 FRUCTOSE, SEMEN 89 CPT 82759 GALACTOKINASE, RBC 110 CPT 82760 GALACTOSE 57 CPT 82775 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; QUANTITATIVE 108 CPT 82776 GALACTOSE-1-PHOSPHATE URIDYL TRANSFERASE; SCREEN 43 CPT 82784 GAMMAGLOBULIN; IGA, IGD, IGG, IGM, EACH 48 CPT 82785 GAMMAGLOBULIN; IGE 85 CPT 82787 GAMMAGLOBULIN; IMMUNOGLOBULIN SUBCLASSES (IGG1, 2, 3, OR 4), 41 EACH CPT 82800 GASES, BLOOD, PH ONLY 43 CPT 82803 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 99 (INCLUDING CALCULATED O2 SATURATION); CPT 82805 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 82810 GASES, BLOOD, O2 SATURATION ONLY, BY DIRECT MEASUREMENT, 45 EXCEPT PULSE OXIMETRY CPT 82820 HEMOGLOBIN-OXYGEN AFFINITY (PO2 FOR 50% HEMOGLOBIN 51 SATURATION WITH OXYGEN) CPT 82926 GASTRIC ACID, FREE AND TOTAL, EACH SPECIMEN 28 CPT 82928 GASTRIC ACID, FREE OR TOTAL, EACH SPECIMEN 34 CPT 82938 GASTRIN AFTER SECRETIN STIMULATION 91 CPT 82941 GASTRIN 91 CPT 82943 GLUCAGON 73 CPT 82945 GLUCOSE, BODY FLUID, OTHER THAN BLOOD 20 CPT 82946 GLUCAGON TOLERANCE TEST 77 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 275 of 380

CPT 82947 GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT REAGENT STRIP) 20 CPT 82948 GLUCOSE; BLOOD, REAGENT STRIP 16 CPT 82950 GLUCOSE; POST GLUCOSE DOSE (INCLUDES GLUCOSE) 24 CPT 82951 GLUCOSE; TOLERANCE TEST (GTT), THREE SPECIMENS (INCLUDES 66 GLUCOSE) CPT 82952 GLUCOSE; TOLERANCE TEST, EACH ADDITIONAL BEYOND THREE 20 SPECIMENS CPT 82953 GLUCOSE; TOLBUTAMIDE TOLERANCE TEST 78 CPT 82955 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); QUANTITATIVE 50 CPT 82960 GLUCOSE-6-PHOSPHATE DEHYDROGENASE (G6PD); SCREEN 31 CPT 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE 12 FDA SPECIFICALLY FOR HOME USE CPT 82963 GLUCOSIDASE, BETA 110 CPT 82965 GLUTAMATE DEHYDROGENASE 40 CPT 82975 GLUTAMINE (GLUTAMIC ACID AMIDE) 81 CPT 82977 GLUTAMYLTRANSFERASE, GAMMA (GGT) 37 CPT 82978 GLUTATHIONE 73 CPT 82979 GLUTATHIONE REDUCTASE, RBC 35 CPT 82980 GLUTETHIMIDE 94 CPT 82985 GLYCATED PROTEIN 77 CPT 83001 GONADOTROPIN; FOLLICLE STIMULATING HORMONE (FSH) 95 CPT 83002 GONADOTROPIN; LUTEINIZING HORMONE (LH) 95 CPT 83003 GROWTH HORMONE, HUMAN (HGH) (SOMATOTROPIN) 86 CPT 83008 GUANOSINE MONOPHOSPHATE (GMP), CYCLIC 86 CPT 83009 HELICOBACTER PYLORI, BLOOD TEST ANALYSIS FOR UREASE ACTIVITY, 346 NON-RADIOACTIVE ISOTOPE (EG, C-13) CPT 83010 HAPTOGLOBIN; QUANTITATIVE 65 CPT 83012 HAPTOGLOBIN; PHENOTYPES 88 CPT 83013 HELICOBACTER PYLORI; BREATH TEST ANALYSIS FOR UREASE ACTIVITY, 346 NON-RADIOACTIVE ISOTOPE (EG, C-13) CPT 83014 HELICOBACTER PYLORI; DRUG ADMINISTRATION 40 CPT 83015 HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN CPT 83018 HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTITATIVE, EACH 97 113 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 276 of 380

CPT 83020 HEMOGLOBIN FRACTIONATION AND QUANTITATION; ELECTROPHORESIS 66 (EG, A2, S, C, AND/OR F) CPT 83021 HEMOGLOBIN FRACTIONATION AND QUANTITATION; CHROMATOGRAPHY 93 (EG, A2, S, C, AND/OR F) CPT 83026 HEMOGLOBIN; BY COPPER SULFATE METHOD, NON-AUTOMATED 12 CPT 83030 HEMOGLOBIN; F (FETAL), CHEMICAL 42 CPT 83033 HEMOGLOBIN; F (FETAL), QUALITATIVE 31 CPT 83036 HEMOGLOBIN; GLYCOSYLATED (A1C) 50 CPT 83037 HEMOGLOBIN; GLYCOSYLATED (A1C) BY DEVICE CLEARED BY FDA FOR 50 HOME USE CPT 83045 HEMOGLOBIN; METHEMOGLOBIN, QUALITATIVE 25 CPT 83050 HEMOGLOBIN; METHEMOGLOBIN, QUANTITATIVE 38 CPT 83051 HEMOGLOBIN; PLASMA 38 CPT 83055 HEMOGLOBIN; SULFHEMOGLOBIN, QUALITATIVE 25 CPT 83060 HEMOGLOBIN; SULFHEMOGLOBIN, QUANTITATIVE 42 CPT 83065 HEMOGLOBIN; THERMOLABILE 35 CPT 83068 HEMOGLOBIN; UNSTABLE, SCREEN 43 CPT 83069 HEMOGLOBIN; URINE 20 CPT 83070 HEMOSIDERIN; QUALITATIVE 24 CPT 83071 HEMOSIDERIN; QUANTITATIVE 35 CPT 83080 B-HEXOSAMINIDASE, EACH ASSAY 87 CPT 83088 HISTAMINE 152 CPT 83090 HOMOCYSTEINE 87 CPT 83150 HOMOVANILLIC ACID (HVA) 99 CPT 83491 HYDROXYCORTICOSTEROIDS, 17- (17-OHCS) 90 CPT 83497 HYDROXYINDOLACETIC ACID, 5-(HIAA) 66 CPT 83498 HYDROXYPROGESTERONE, 17-D 139 CPT 83499 HYDROXYPROGESTERONE, 20-129 CPT 83500 HYDROXYPROLINE; FREE 116 CPT 83505 HYDROXYPROLINE; TOTAL 125 CPT 83516 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: 01.03.2015 Page No(s): 277 of 380

CPT 83518 IMMUNOASSAY FOR ANALYTE OTHER THAN INFECTIOUS AGENT ANTIBODY 44 OR INFECTIOUS AGENT ANTIGEN, QUALITATIVE OR SEMIQUANTITATIVE; SINGLE STEP METHOD (EG, REAGENT STRIP) CPT 83519 IMMUNOASSAY, ANALYTE, QUANTITATIVE; BY RADIOPHARMACEUTICAL 69 TECHNIQUE (EG, RIA) CPT 83520 IMMUNOASSAY, ANALYTE, QUANTITATIVE; NOT OTHERWISE SPECIFIED 66 CPT 83525 INSULIN; TOTAL 59 CPT 83527 INSULIN; FREE 66 CPT 83528 INTRINSIC FACTOR 82 CPT 83540 IRON 33 CPT 83550 IRON BINDING CAPACITY 45 CPT 83570 ISOCITRIC DEHYDROGENASE (IDH) 45 CPT 83582 KETOGENIC STEROIDS, FRACTIONATION 289 CPT 83586 KETOSTEROIDS, 17- (17-KS); TOTAL 66 CPT 83593 KETOSTEROIDS, 17- (17-KS); FRACTIONATION 135 CPT 83605 LACTATE (LACTIC ACID) 55 CPT 83615 LACTATE DEHYDROGENASE (LD), (LDH); 31 CPT 83625 LACTATE DEHYDROGENASE (LD), (LDH); ISOENZYMES, SEPARATION AND 66 QUANTITATION CPT 83630 LACTOFERRIN, FECAL; QUALITATIVE 101 CPT 83631 LACTOFERRIN, FECAL; QUANTITATIVE 101 CPT 83632 LACTOGEN, HUMAN PLACENTAL (HPL) HUMAN CHORIONIC 104 SOMATOMAMMOTROPIN CPT 83633 LACTOSE, URINE; QUALITATIVE 28 CPT 83634 LACTOSE, URINE; QUANTITATIVE 59 CPT 83655 LEAD 62 CPT 83661 FETAL LUNG MATURITY ASSESSMENT; LECITHIN SPHINGOMYELIN (L/S) 113 RATIO CPT 83662 FETAL LUNG MATURITY ASSESSMENT; FOAM STABILITY TEST 97 CPT 83663 FETAL LUNG MATURITY ASSESSMENT; FLUORESCENCE POLARIZATION 97 CPT 83664 FETAL LUNG MATURITY ASSESSMENT; LAMELLAR BODY DENSITY 97 CPT 83670 LEUCINE AMINOPEPTIDASE (LAP) 47 CPT 83690 LIPASE 35 CPT 83695 LIPOPROTEIN (A) 66 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 278 of 380

CPT 83698 LIPOPROTEIN-ASSOCIATED PHOSPHOLIPASE A2 (LP-PLA2) 174 CPT 83700 LIPOPROTEIN, BLOOD; ELECTROPHORETIC SEPARATION AND 58 QUANTITATION CPT 83701 LIPOPROTEIN, BLOOD; HIGH RESOLUTION FRACTIONATION AND 127 QUANTITATION OF LIPOPROTEINS INCLUDING LIPOPROTEIN SUBCLASSES WHEN PERFORMED (EG, ELECTROPHORESIS, ULTRACENTRIFUGATION) CPT 83704 LIPOPROTEIN, BLOOD; QUANTITATION OF LIPOPROTEIN PARTICLE 162 NUMBERS AND LIPOPROTEIN PARTICLE SUBCLASSES (EG, BY NUCLEAR MAGNETIC RESONANCE SPECTROSCOPY) CPT 83718 LIPOPROTEIN, DIRECT MEASUREMENT; HIGH DENSITY CHOLESTEROL 42 (HDL CHOLESTEROL) CPT 83719 LIPOPROTEIN, DIRECT MEASUREMENT; VLDL CHOLESTEROL 60 CPT 83721 LIPOPROTEIN, DIRECT MEASUREMENT; LDL CHOLESTEROL 49 CPT 83727 LUTEINIZING RELEASING FACTOR (LRH) 88 CPT 83735 MAGNESIUM 34 CPT 83775 MALATE DEHYDROGENASE 38 CPT 83785 MANGANESE 126 CPT 83788 MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), 93 ANALYTE NOT ELSEWHERE SPECIFIED; QUALITATIVE, EACH SPECIMEN CPT 83789 MASS SPECTROMETRY AND TANDEM MASS SPECTROMETRY (MS, MS/MS), 93 ANALYTE NOT ELSEWHERE SPECIFIED; QUANTITATIVE, EACH SPECIMEN CPT 83805 MEPROBAMATE 90 CPT 83825 MERCURY, QUANTITATIVE 83 CPT 83835 METANEPHRINES 87 CPT 83840 METHADONE 84 CPT 83857 METHEMALBUMIN 55 CPT 83858 METHSUXIMIDE 76 CPT 83864 MUCOPOLYSACCHARIDES, ACID; QUANTITATIVE 102 CPT 83866 MUCOPOLYSACCHARIDES, ACID; SCREEN 51 CPT 83872 MUCIN, SYNOVIAL FLUID (ROPES TEST) 30 CPT 83873 MYELIN BASIC PROTEIN, CEREBROSPINAL FLUID 88 CPT 83874 MYOGLOBIN 66 CPT 83880 NATRIURETIC PEPTIDE 174 CPT 83883 NEPHELOMETRY, EACH ANALYTE NOT ELSEWHERE SPECIFIED 70 CPT 83885 NICKEL 126 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 279 of 380

CPT 83887 NICOTINE 122 CPT 83890 MOLECULAR DIAGNOSTICS; MOLECULAR ISOLATION OR EXTRACTION 21 CPT 83891 MOLECULAR DIAGNOSTICS; ISOLATION OR EXTRACTION OF HIGHLY 21 PURIFIED NUCLEIC ACID CPT 83892 MOLECULAR DIAGNOSTICS; ENZYMATIC DIGESTION 21 CPT 83893 MOLECULAR DIAGNOSTICS; DOT/SLOT BLOT PRODUCTION 21 CPT 83894 MOLECULAR DIAGNOSTICS; SEPARATION BY GEL ELECTROPHORESIS (EG, 21 AGAROSE, POLYACRYLAMIDE) CPT 83896 MOLECULAR DIAGNOSTICS; NUCLEIC ACID PROBE, EACH 21 CPT 83897 MOLECULAR DIAGNOSTICS; NUCLEIC ACID TRANSFER (EG, SOUTHERN, 21 NORTHERN) CPT 83898 MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, EACH NUCLEIC 86 ACID SEQUENCE CPT 83900 MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, MULTIPLEX, FIRST 172 TWO NUCLEIC ACID SEQUENCES CPT 83901 MOLECULAR DIAGNOSTICS; AMPLIFICATION, TARGET, MULTIPLEX, EACH 86 ADDITIONAL NUCLEIC ACID SEQUENCE BEYOND 2 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 83902 MOLECULAR DIAGNOSTICS; REVERSE TRANSCRIPTION 73 CPT 83903 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 83904 MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY SEQUENCING, 86 SINGLE SEGMENT, EACH SEGMENT CPT 83905 MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 86 SPECIFIC TRANSCRIPTION, SINGLE SEGMENT, EACH SEGMENT CPT 83906 MOLECULAR DIAGNOSTICS; MUTATION IDENTIFICATION BY ALLELE 86 SPECIFIC TRANSLATION, SINGLE SEGMENT, EACH SEGMENT CPT 83907 MOLECULAR DIAGNOSTICS; LYSIS OF CELLS PRIOR TO NUCLEIC ACID 69 EXTRACTION (EG, STOOL SPECIMENS, PARAFFIN EMBEDDED TISSUE) CPT 83908 MOLECULAR DIAGNOSTICS; AMPLIFICATION, SIGNAL, EACH NUCLEIC 86 ACID SEQUENCE CPT 83909 MOLECULAR DIAGNOSTICS; SEPARATION AND IDENTIFICATION BY HIGH 86 RESOLUTION TECHNIQUE (EG, CAPILLARY ELECTROPHORESIS) CPT 83912 MOLECULAR DIAGNOSTICS; INTERPRETATION AND REPORT 21 CPT 83913 MOLECULAR DIAGNOSTICS; RNA STABILIZATION 69 CPT 83914 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 83915 NUCLEOTIDASE 5'- 57 CPT 83916 OLIGOCLONAL IMMUNE (OLIGOCLONAL BANDS) 103 CPT 83918 ORGANIC ACIDS; TOTAL, QUANTITATIVE, EACH SPECIMEN 85 CPT 83919 ORGANIC ACIDS; QUALITATIVE, EACH SPECIMEN 85 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 280 of 380

CPT 83921 ORGANIC ACID, SINGLE, QUANTITATIVE 85 CPT 83925 OPIATES (EG, MORPHINE, MEPERIDINE) 100 CPT 83930 OSMOLALITY; BLOOD 34 CPT 83935 OSMOLALITY; URINE 35 CPT 83937 OSTEOCALCIN (BONE G1A PROTEIN) 153 CPT 83945 OXALATE 66 CPT 83950 ONCOPROTEIN, HER-2/NEU 330 CPT 83970 PARATHORMONE (PARATHYROID HORMONE) 212 CPT 83986 PH, BODY FLUID, EXCEPT BLOOD 18 CPT 83992 PHENCYCLIDINE (PCP) 75 CPT 83993 CALPROTECTIN, FECAL 101 CPT 84022 PHENOTHIAZINE 80 CPT 84030 PHENYLALANINE (PKU), BLOOD 28 CPT 84035 PHENYLKETONES, QUALITATIVE 19 CPT 84060 PHOSPHATASE, ACID; TOTAL 38 CPT 84061 PHOSPHATASE, ACID; FORENSIC EXAMINATION 41 CPT 84066 PHOSPHATASE, ACID; PROSTATIC 50 CPT 84075 PHOSPHATASE, ALKALINE; 27 CPT 84078 PHOSPHATASE, ALKALINE; HEAT STABLE (TOTAL NOT INCLUDED) 38 CPT 84080 PHOSPHATASE, ALKALINE; ISOENZYMES 76 CPT 84081 PHOSPHATIDYLGLYCEROL 85 CPT 84085 PHOSPHOGLUCONATE, 6-, DEHYDROGENASE, RBC 35 CPT 84087 PHOSPHOHEXOSE ISOMERASE 53 CPT 84100 PHOSPHORUS INORGANIC (PHOSPHATE); 24 CPT 84105 PHOSPHORUS INORGANIC (PHOSPHATE); URINE 27 CPT 84106 PORPHOBILINOGEN, URINE; QUALITATIVE 22 CPT 84110 PORPHOBILINOGEN, URINE; QUANTITATIVE 43 CPT 84119 PORPHYRINS, URINE; QUALITATIVE 44 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 281 of 380

CPT 84120 PORPHYRINS, URINE; QUANTITATION AND FRACTIONATION 253 CPT 84126 PORPHYRINS, FECES; QUANTITATIVE 131 CPT 84127 PORPHYRINS, FECES; QUALITATIVE 60 CPT 84132 POTASSIUM; SERUM 24 CPT 84133 POTASSIUM; URINE 22 CPT 84134 PREALBUMIN 75 CPT 84135 PREGNANEDIOL 98 CPT 84138 PREGNANETRIOL 97 CPT 84140 PREGNENOLONE 106 CPT 84143 17-HYDROXYPREGNENOLONE 117 CPT 84144 PROGESTERONE 107 CPT 84146 PROLACTIN 99 CPT 84150 PROSTAGLANDIN, EACH 128 CPT 84152 PROSTATE SPECIFIC ANTIGEN (PSA); COMPLEXED (DIRECT 94 MEASUREMENT) CPT 84153 PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 94 CPT 84154 PROSTATE SPECIFIC ANTIGEN (PSA); FREE 94 CPT 84155 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM 19 CPT 84156 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; URINE 19 CPT 84157 PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; OTHER SOURCE (EG, 19 SYNOVIAL FLUID, CEREBROSPINAL FLUID) CPT 84160 PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE 27 CPT 84163 PREGNANCY-ASSOCIATED PLASMA PROTEIN-A (PAPP-A) 77 CPT 84165 PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 55 SERUM CPT 84166 PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, 92 OTHER FLUIDS WITH CONCENTRATION (EG, URINE, CSF) CPT 84181 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD 87 OR OTHER BODY FLUID CPT 84182 PROTEIN; WESTERN BLOT, WITH INTERPRETATION AND REPORT, BLOOD 92 OR OTHER BODY FLUID, IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH CPT 84202 PROTOPORPHYRIN, RBC; QUANTITATIVE 74 CPT 84203 PROTOPORPHYRIN, RBC; SCREEN 44 CPT 84206 PROINSULIN 91 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 282 of 380

CPT 84207 PYRIDOXAL PHOSPHATE (VITAMIN B-6) 144 CPT 84210 PYRUVATE 56 CPT 84220 PYRUVATE KINASE 48 CPT 84228 QUININE 60 CPT 84233 RECEPTOR ASSAY; ESTROGEN 330 CPT 84234 RECEPTOR ASSAY; PROGESTERONE 333 CPT 84235 RECEPTOR ASSAY; ENDOCRINE, OTHER THAN ESTROGEN OR 269 PROGESTERONE (SPECIFY HORMONE) CPT 84238 RECEPTOR ASSAY; NON-ENDOCRINE (SPECIFY RECEPTOR) 188 CPT 84244 RENIN 113 CPT 84252 RIBOFLAVIN (VITAMIN B-2) 104 CPT 84255 SELENIUM 131 CPT 84260 SEROTONIN 159 CPT 84270 SEX HORMONE BINDING GLOBULIN (SHBG) 112 CPT 84275 SIALIC ACID 69 CPT 84285 SILICA 121 CPT 84295 SODIUM; SERUM 25 CPT 84300 SODIUM; URINE 25 CPT 84302 SODIUM; OTHER SOURCE 25 CPT 84305 SOMATOMEDIN 109 CPT 84307 SOMATOSTATIN 94 CPT 84311 SPECTROPHOTOMETRY, ANALYTE NOT ELSEWHERE SPECIFIED 36 CPT 84315 SPECIFIC GRAVITY (EXCEPT URINE) 13 CPT 84375 SUGARS, CHROMATOGRAPHIC, TLC OR PAPER CHROMATOGRAPHY 101 CPT 84376 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE QUALITATIVE, 28 EACH SPECIMEN CPT 84377 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 28 QUALITATIVE, EACH SPECIMEN CPT 84378 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); SINGLE 59 QUANTITATIVE, EACH SPECIMEN CPT 84379 SUGARS (MONO-, DI-, AND OLIGOSACCHARIDES); MULTIPLE 59 QUANTITATIVE, EACH SPECIMEN CPT 84392 SULFATE, URINE 24 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 283 of 380

CPT 84402 TESTOSTERONE; FREE 131 CPT 84403 TESTOSTERONE; TOTAL 133 CPT 84425 THIAMINE (VITAMIN B-1) 109 CPT 84430 THIOCYANATE 60 CPT 84432 THYROGLOBULIN 82 CPT 84436 THYROXINE; TOTAL 35 CPT 84437 THYROXINE; REQUIRING ELUTION (EG, NEONATAL) 33 CPT 84439 THYROXINE; FREE 46 CPT 84442 THYROXINE BINDING GLOBULIN (TBG) 76 CPT 84443 THYROID STIMULATING HORMONE (TSH) 86 CPT 84445 THYROID STIMULATING IMMUNE GLOBULINS (TSI) 261 CPT 84446 TOCOPHEROL ALPHA (VITAMIN E) 73 CPT 84449 TRANSCORTIN (CORTISOL BINDING GLOBULIN) 92 CPT 84450 TRANSFERASE; ASPARTATE AMINO (AST) (SGOT) 27 CPT 84460 TRANSFERASE; ALANINE AMINO (ALT) (SGPT) 27 CPT 84466 TRANSFERRIN 66 CPT 84478 TRIGLYCERIDES 30 CPT 84479 THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING 33 RATIO (THBR) CPT 84480 TRIIODOTHYRONINE T3; TOTAL (TT-3) 73 CPT 84481 TRIIODOTHYRONINE T3; FREE 87 CPT 84482 TRIIODOTHYRONINE T3; REVERSE 81 CPT 84484 TROPONIN, QUANTITATIVE 51 CPT 84485 TRYPSIN; DUODENAL FLUID 39 CPT 84488 TRYPSIN; FECES, QUALITATIVE 38 CPT 84490 TRYPSIN; FECES, QUANTITATIVE, 24-HOUR COLLECTION 39 CPT 84510 TYROSINE 53 CPT 84512 TROPONIN, QUALITATIVE 40 CPT 84520 UREA NITROGEN; QUANTITATIVE 20 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 284 of 380

CPT 84525 UREA NITROGEN; SEMIQUANTITATIVE (EG, REAGENT STRIP TEST) 19 CPT 84540 UREA NITROGEN, URINE 24 CPT 84545 UREA NITROGEN, CLEARANCE 34 CPT 84550 URIC ACID; BLOOD 23 CPT 84560 URIC ACID; OTHER SOURCE 24 CPT 84577 UROBILINOGEN, FECES, QUANTITATIVE 64 CPT 84578 UROBILINOGEN, URINE; QUALITATIVE 17 CPT 84580 UROBILINOGEN, URINE; QUANTITATIVE, TIMED SPECIMEN 36 CPT 84583 UROBILINOGEN, URINE; SEMIQUANTITATIVE 26 CPT 84585 VANILLYLMANDELIC ACID (VMA), URINE 80 CPT 84586 VASOACTIVE INTESTINAL PEPTIDE (VIP) 181 CPT 84588 VASOPRESSIN (ANTIDIURETIC HORMONE, ADH) 174 CPT 84590 VITAMIN A 60 CPT 84591 VITAMIN, NOT OTHERWISE SPECIFIED 60 CPT 84597 VITAMIN K 70 CPT 84600 VOLATILES (EG, ACETIC ANHYDRIDE, CARBON TETRACHLORIDE, 82 DICHLOROETHANE, DICHLOROMETHANE, DIETHYLETHER, ISOPROPYL ALCOHOL, METHANOL) CPT 84620 XYLOSE ABSORPTION TEST, BLOOD AND/OR URINE 61 CPT 84630 ZINC 58 CPT 84681 C-PEPTIDE 107 CPT 84702 GONADOTROPIN, CHORIONIC (HCG); QUANTITATIVE 77 CPT 84703 GONADOTROPIN, CHORIONIC (HCG); QUALITATIVE 39 CPT 84704 GONADOTROPIN, CHORIONIC (HCG); FREE BETA CHAIN 77 CPT 84830 OVULATION TESTS, BY VISUAL COLOR COMPARISON METHODS FOR 52 HUMAN LUTEINIZING HORMONE CPT 84999 UNLISTED CHEMISTRY PROCEDURE N/A CPT 85002 BLEEDING TIME 23 CPT 85004 BLOOD COUNT; AUTOMATED DIFFERENTIAL WBC COUNT 33 CPT 85007 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL WBC COUNT CPT 85008 BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITHOUT MANUAL DIFFERENTIAL WBC COUNT 18 18 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 285 of 380

CPT 85009 BLOOD COUNT; MANUAL DIFFERENTIAL WBC COUNT, BUFFY COAT 19 CPT 85013 BLOOD COUNT; SPUN MICROHEMATOCRIT 12 CPT 85014 BLOOD COUNT; HEMATOCRIT (HCT) 12 CPT 85018 BLOOD COUNT; HEMOGLOBIN (HGB) 12 CPT 85025 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND 40 PLATELET COUNT) AND AUTOMATED DIFFERENTIAL WBC COUNT CPT 85027 BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND 33 PLATELET COUNT) CPT 85032 BLOOD COUNT; MANUAL CELL COUNT (ERYTHROCYTE, LEUKOCYTE, OR 22 PLATELET) EACH CPT 85041 BLOOD COUNT; RED BLOOD CELL (RBC), AUTOMATED 15 CPT 85044 BLOOD COUNT; RETICULOCYTE, MANUAL 22 CPT 85045 BLOOD COUNT; RETICULOCYTE, AUTOMATED 21 CPT 85046 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 85048 BLOOD COUNT; LEUKOCYTE (WBC), AUTOMATED 13 CPT 85049 BLOOD COUNT; PLATELET, AUTOMATED 23 CPT 85055 RETICULATED PLATELET ASSAY 137 CPT 85060 BLOOD SMEAR, PERIPHERAL, INTERPRETATION BY PHYSICIAN WITH 76 WRITTEN REPORT CPT 85097 BONE MARROW, SMEAR INTERPRETATION 280 CPT 85130 CHROMOGENIC SUBSTRATE ASSAY 61 CPT 85170 CLOT RETRACTION 19 CPT 85175 CLOT LYSIS TIME, WHOLE BLOOD DILUTION 23 CPT 85210 CLOTTING; FACTOR II, PROTHROMBIN, SPECIFIC 67 CPT 85220 CLOTTING; FACTOR V (ACG OR PROACCELERIN), LABILE FACTOR 91 CPT 85230 CLOTTING; FACTOR VII (PROCONVERTIN, STABLE FACTOR) 92 CPT 85240 CLOTTING; FACTOR VIII (AHG), ONE STAGE 92 CPT 85244 CLOTTING; FACTOR VIII RELATED ANTIGEN 105 CPT 85245 CLOTTING; FACTOR VIII, VW FACTOR, RISTOCETIN COFACTOR 118 CPT 85246 CLOTTING; FACTOR VIII, VW FACTOR ANTIGEN 118 CPT 85247 CLOTTING; FACTOR VIII, VON WILLEBRAND FACTOR, MULTIMETRIC ANALYSIS 118 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 286 of 380

CPT 85250 CLOTTING; FACTOR IX (PTC OR CHRISTMAS) 98 CPT 85260 CLOTTING; FACTOR X (STUART-PROWER) 92 CPT 85270 CLOTTING; FACTOR XI (PTA) 92 CPT 85280 CLOTTING; FACTOR XII (HAGEMAN) 99 CPT 85290 CLOTTING; FACTOR XIII (FIBRIN STABILIZING) 84 CPT 85291 CLOTTING; FACTOR XIII (FIBRIN STABILIZING), SCREEN SOLUBILITY 46 CPT 85292 CLOTTING; PREKALLIKREIN ASSAY (FLETCHER FACTOR ASSAY) 97 CPT 85293 CLOTTING; HIGH MOLECULAR WEIGHT KININOGEN ASSAY (FITZGERALD 97 FACTOR ASSAY) CPT 85300 CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 61 ACTIVITY CPT 85301 CLOTTING INHIBITORS OR ANTICOAGULANTS; ANTITHROMBIN III, 56 ANTIGEN ASSAY CPT 85302 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ANTIGEN 62 CPT 85303 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN C, ACTIVITY 71 CPT 85305 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, TOTAL 60 CPT 85306 CLOTTING INHIBITORS OR ANTICOAGULANTS; PROTEIN S, FREE 79 CPT 85307 ACTIVATED PROTEIN C (APC) RESISTANCE ASSAY 79 CPT 85335 FACTOR INHIBITOR TEST 66 CPT 85337 THROMBOMODULIN 54 CPT 85345 COAGULATION TIME; LEE AND WHITE 22 CPT 85347 COAGULATION TIME; ACTIVATED 22 CPT 85348 COAGULATION TIME; OTHER METHODS 19 CPT 85360 EUGLOBULIN LYSIS 43 CPT 85362 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 35 AGGLUTINATION SLIDE, SEMIQUANTITATIVE CPT 85366 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 44 PARACOAGULATION CPT 85370 FIBRIN(OGEN) DEGRADATION (SPLIT) PRODUCTS (FDP) (FSP); 58 QUANTITATIVE CPT 85378 FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUALITATIVE OR 37 SEMIQUANTITATIVE CPT 85379 FIBRIN DEGRADATION PRODUCTS, D-DIMER; QUANTITATIVE 52 CPT 85380 FIBRIN DEGRADATION PRODUCTS, D-DIMER; ULTRASENSITIVE (EG, FOR 52 EVALUATION FOR VENOUS THROMBOEMBOLISM), QUALITATIVE OR SEMIQUANTITATIVE CPT 85384 FIBRINOGEN; ACTIVITY 44 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 287 of 380

CPT 85385 FIBRINOGEN; ANTIGEN 44 CPT 85390 FIBRINOLYSINS OR COAGULOPATHY SCREEN, INTERPRETATION AND 27 REPORT CPT 85396 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 85400 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMIN 45 CPT 85410 FIBRINOLYTIC FACTORS AND INHIBITORS; ALPHA-2 ANTIPLASMIN 40 CPT 85415 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN ACTIVATOR 88 CPT 85420 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, EXCEPT 34 ANTIGENIC ASSAY CPT 85421 FIBRINOLYTIC FACTORS AND INHIBITORS; PLASMINOGEN, ANTIGENIC 52 ASSAY CPT 85441 HEINZ BODIES; DIRECT 22 CPT 85445 HEINZ BODIES; INDUCED, ACETYL PHENYLHYDRAZINE 35 CPT 85460 HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 40 DIFFERENTIAL LYSIS (KLEIHAUER-BETKE) CPT 85461 HEMOGLOBIN OR RBCS, FETAL, FOR FETOMATERNAL HEMORRHAGE; 34 ROSETTE CPT 85475 HEMOLYSIN, ACID 46 CPT 85520 HEPARIN ASSAY 67 CPT 85525 HEPARIN NEUTRALIZATION 61 CPT 85530 HEPARIN-PROTAMINE TOLERANCE TEST 73 CPT 85536 IRON STAIN, PERIPHERAL BLOOD 33 CPT 85540 LEUKOCYTE ALKALINE PHOSPHATASE WITH COUNT 44 CPT 85547 MECHANICAL FRAGILITY, RBC 44 CPT 85549 MURAMIDASE 96 CPT 85555 OSMOTIC FRAGILITY, RBC; UNINCUBATED 34 CPT 85557 OSMOTIC FRAGILITY, RBC; INCUBATED 69 CPT 85576 PLATELET, AGGREGATION (IN VITRO), EACH AGENT 110 CPT 85597 PLATELET NEUTRALIZATION 92 CPT 85610 PROTHROMBIN TIME; 20 CPT 85611 PROTHROMBIN TIME; SUBSTITUTION, PLASMA FRACTIONS, EACH 20 CPT 85612 RUSSELL VIPER VENOM TIME (INCLUDES VENOM); UNDILUTED 49 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 288 of 380

CPT 85613 RUSSELL VIPER VENOM TIME (INCLUDES VENOM); DILUTED 49 CPT 85635 REPTILASE TEST 51 CPT 85651 SEDIMENTATION RATE, ERYTHROCYTE; NON-AUTOMATED 18 CPT 85652 SEDIMENTATION RATE, ERYTHROCYTE; AUTOMATED 14 CPT 85660 SICKLING OF RBC, REDUCTION 28 CPT 85670 THROMBIN TIME; PLASMA 30 CPT 85675 THROMBIN TIME; TITER 35 CPT 85705 THROMBOPLASTIN INHIBITION, TISSUE 49 CPT 85730 THROMBOPLASTIN TIME, PARTIAL (PTT); PLASMA OR WHOLE BLOOD 31 CPT 85732 THROMBOPLASTIN TIME, PARTIAL (PTT); SUBSTITUTION, PLASMA 33 FRACTIONS, EACH CPT 85810 VISCOSITY 60 CPT 85999 UNLISTED HEMATOLOGY AND COAGULATION PROCEDURE N/A CPT 86000 AGGLUTININS, FEBRILE (EG, BRUCELLA, FRANCISELLA, MURINE TYPHUS, 36 Q FEVER, ROCKY MOUNTAIN SPOTTED FEVER, SCRUB TYPHUS), EACH ANTIGEN CPT 86001 ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH 27 ALLERGEN CPT 86003 ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH 27 ALLERGEN CPT 86005 ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN 41 (DIPSTICK, PADDLE, OR DISK) CPT 86021 ANTIBODY IDENTIFICATION; LEUKOCYTE ANTIBODIES 77 CPT 86022 ANTIBODY IDENTIFICATION; PLATELET ANTIBODIES 291 CPT 86023 ANTIBODY IDENTIFICATION; PLATELET ASSOCIATED IMMUNOGLOBULIN 64 ASSAY CPT 86038 ANTINUCLEAR ANTIBODIES (ANA); 62 CPT 86039 ANTINUCLEAR ANTIBODIES (ANA); TITER 57 CPT 86060 ANTISTREPTOLYSIN 0; TITER 38 CPT 86063 ANTISTREPTOLYSIN 0; SCREEN 30 CPT 86077 BLOOD BANK PHYSICIAN SERVICES; DIFFICULT CROSS MATCH AND/OR EVALUATION OF IRREGULAR ANTIBODY(S), INTERPRETATION AND WRITTEN REPORT CPT 86078 BLOOD BANK PHYSICIAN SERVICES; INVESTIGATION OF TRANSFUSION REACTION INCLUDING SUSPICION OF TRANSMISSIBLE DISEASE, INTERPRETATION AND WRITTEN REPORT CPT 86079 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 169 169 171 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 289 of 380

CPT 86140 C-REACTIVE PROTEIN; 27 CPT 86141 C-REACTIVE PROTEIN; HIGH SENSITIVITY (HSCRP) 66 CPT 86146 BETA 2 GLYCOPROTEIN I ANTIBODY, EACH 131 CPT 86147 CARDIOLIPIN (PHOSPHOLIPID) ANTIBODY, EACH IG CLASS 131 CPT 86148 ANTI-PHOSPHATIDYLSERINE (PHOSPHOLIPID) ANTIBODY 82 CPT 86155 CHEMOTAXIS ASSAY, SPECIFY METHOD 82 CPT 86156 COLD AGGLUTININ; SCREEN 34 CPT 86157 COLD AGGLUTININ; TITER 41 CPT 86160 COMPLEMENT; ANTIGEN, EACH COMPONENT 62 CPT 86161 COMPLEMENT; FUNCTIONAL ACTIVITY, EACH COMPONENT 62 CPT 86162 COMPLEMENT; TOTAL HEMOLYTIC (CH50) 104 CPT 86171 COMPLEMENT FIXATION TESTS, EACH ANTIGEN 51 CPT 86185 COUNTERIMMUNOELECTROPHORESIS, EACH ANTIGEN 46 CPT 86200 CYCLIC CITRULLINATED PEPTIDE (CCP), ANTIBODY 66 CPT 86215 DEOXYRIBONUCLEASE, ANTIBODY 68 CPT 86225 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; NATIVE OR DOUBLE 71 STRANDED CPT 86226 DEOXYRIBONUCLEIC ACID (DNA) ANTIBODY; SINGLE STRANDED 62 CPT 86235 EXTRACTABLE NUCLEAR ANTIGEN, ANTIBODY TO, ANY METHOD (EG, 92 NRNP, SS-A, SS-B, SM, RNP, SC170, J01), EACH ANTIBODY CPT 86243 FC RECEPTOR 105 CPT 86255 FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; SCREEN, EACH 62 ANTIBODY CPT 86256 FLUORESCENT NONINFECTIOUS AGENT ANTIBODY; TITER, EACH 62 ANTIBODY CPT 86277 GROWTH HORMONE, HUMAN (HGH), ANTIBODY 81 CPT 86280 HEMAGGLUTINATION INHIBITION TEST (HAI) 42 CPT 86294 IMMUNOASSAY FOR TUMOR ANTIGEN, QUALITATIVE OR 101 SEMIQUANTITATIVE (EG, BLADDER TUMOR ANTIGEN) CPT 86300 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 15-3 (27.29) 107 CPT 86301 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 19-9 107 CPT 86304 IMMUNOASSAY FOR TUMOR ANTIGEN, QUANTITATIVE; CA 125 107 CPT 86308 HETEROPHILE ANTIBODIES; SCREENING 27 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 290 of 380

CPT 86309 HETEROPHILE ANTIBODIES; TITER 33 CPT 86310 HETEROPHILE ANTIBODIES; TITERS AFTER ABSORPTION WITH BEEF 38 CELLS AND GUINEA PIG KIDNEY CPT 86316 IMMUNOASSAY FOR TUMOR ANTIGEN, OTHER ANTIGEN, QUANTITATIVE 107 (EG, CA 50, 72-4, 549), EACH CPT 86317 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUANTITATIVE, NOT 77 OTHERWISE SPECIFIED CPT 86318 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUALITATIVE OR 66 SEMIQUANTITATIVE, SINGLE STEP METHOD (EG, REAGENT STRIP) CPT 86320 IMMUNOELECTROPHORESIS; SERUM 115 CPT 86325 IMMUNOELECTROPHORESIS; OTHER FLUIDS (EG, URINE, CEREBROSPINAL 115 FLUID) WITH CONCENTRATION CPT 86327 IMMUNOELECTROPHORESIS; CROSSED (2-DIMENSIONAL ASSAY) 116 CPT 86329 IMMUNODIFFUSION; NOT ELSEWHERE SPECIFIED 72 CPT 86331 IMMUNODIFFUSION; GEL DIFFUSION, QUALITATIVE (OUCHTERLONY), 62 EACH ANTIGEN OR ANTIBODY CPT 86332 IMMUNE COMPLEX ASSAY 125 CPT 86334 IMMUNOFIXATION ELECTROPHORESIS; SERUM 115 CPT 86335 IMMUNOFIXATION ELECTROPHORESIS; OTHER FLUIDS WITH 151 CONCENTRATION (EG, URINE, CSF) CPT 86336 INHIBIN A 80 CPT 86337 INSULIN ANTIBODIES 110 CPT 86340 INTRINSIC FACTOR ANTIBODIES 77 CPT 86341 ISLET CELL ANTIBODY 102 CPT 86343 LEUKOCYTE HISTAMINE RELEASE TEST (LHR) 64 CPT 86344 LEUKOCYTE PHAGOCYTOSIS 282 CPT 86353 LYMPHOCYTE TRANSFORMATION, MITOGEN (PHYTOMITOGEN) OR 252 ANTIGEN INDUCED BLASTOGENESIS CPT 86355 B CELLS, TOTAL COUNT 194 CPT 86356 MONONUCLEAR CELL ANTIGEN, QUANTITATIVE (EG, FLOW CYTOMETRY), 137 NOT OTHERWISE SPECIFIED, EACH ANTIGEN CPT 86357 NATURAL KILLER (NK) CELLS, TOTAL COUNT 194 CPT 86359 T CELLS; TOTAL COUNT 194 CPT 86360 T CELLS; ABSOLUTE CD4 AND CD8 COUNT, INCLUDING RATIO 241 CPT 86361 T CELLS; ABSOLUTE CD4 COUNT 137 CPT 86367 STEM CELLS (IE, CD34), TOTAL COUNT 194 CPT 86376 MICROSOMAL ANTIBODIES (EG, THYROID OR LIVER-KIDNEY), EACH 75 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 291 of 380

CPT 86378 MIGRATION INHIBITORY FACTOR TEST (MIF) 101 CPT 86382 NEUTRALIZATION TEST, VIRAL 87 CPT 86384 NITROBLUE TETRAZOLIUM DYE TEST (NTD) 336 CPT 86403 PARTICLE AGGLUTINATION; SCREEN, EACH ANTIBODY 52 CPT 86406 PARTICLE AGGLUTINATION; TITER, EACH ANTIBODY 55 CPT 86430 RHEUMATOID FACTOR; QUALITATIVE 29 CPT 86431 RHEUMATOID FACTOR; QUANTITATIVE 29 CPT 86480 TUBERCULOSIS TEST, CELL MEDIATED IMMUNITY MEASUREMENT OF 318 GAMMA INTERFERON ANTIGEN RESPONSE CPT 86485 SKIN TEST; CANDIDA 44 CPT 86486 SKIN TEST; UNLISTED ANTIGEN, EACH 18 CPT 86490 SKIN TEST; COCCIDIOIDOMYCOSIS 18 CPT 86510 SKIN TEST; HISTOPLASMOSIS 18 CPT 86580 SKIN TEST; TUBERCULOSIS, INTRADERMAL 22 CPT 86590 STREPTOKINASE, ANTIBODY 57 CPT 86592 SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, ART) 22 CPT 86593 SYPHILIS TEST; QUANTITATIVE 23 CPT 86602 ANTIBODY; ACTINOMYCES 52 CPT 86603 ANTIBODY; ADENOVIRUS 66 CPT 86606 ANTIBODY; ASPERGILLUS 77 CPT 86609 ANTIBODY; BACTERIUM, NOT ELSEWHERE SPECIFIED 66 CPT 86611 ANTIBODY; BARTONELLA 52 CPT 86612 ANTIBODY; BLASTOMYCES 66 CPT 86615 ANTIBODY; BORDETELLA 68 CPT 86617 ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) CONFIRMATORY 80 TEST (EG, WESTERN BLOT OR IMMUNOBLOT) CPT 86618 ANTIBODY; BORRELIA BURGDORFERI (LYME DISEASE) 87 CPT 86619 ANTIBODY; BORRELIA (RELAPSING FEVER) 69 CPT 86622 ANTIBODY; BRUCELLA 46 CPT 86625 ANTIBODY; CAMPYLOBACTER 67 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 292 of 380

CPT 86628 ANTIBODY; CANDIDA 326 CPT 86631 ANTIBODY; CHLAMYDIA 61 CPT 86632 ANTIBODY; CHLAMYDIA, IGM 65 CPT 86635 ANTIBODY; COCCIDIOIDES 59 CPT 86638 ANTIBODY; COXIELLA BURNETII (Q FEVER) 62 CPT 86641 ANTIBODY; CRYPTOCOCCUS 74 CPT 86644 ANTIBODY; CYTOMEGALOVIRUS (CMV) 72 CPT 86645 ANTIBODY; CYTOMEGALOVIRUS (CMV), IGM 86 CPT 86648 ANTIBODY; DIPHTHERIA 78 CPT 86651 ANTIBODY; ENCEPHALITIS, CALIFORNIA (LA CROSSE) 68 CPT 86652 ANTIBODY; ENCEPHALITIS, EASTERN EQUINE 68 CPT 86653 ANTIBODY; ENCEPHALITIS, ST. LOUIS 68 CPT 86654 ANTIBODY; ENCEPHALITIS, WESTERN EQUINE 68 CPT 86658 ANTIBODY; ENTEROVIRUS (EG, COXSACKIE, ECHO, POLIO) 67 CPT 86663 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, EARLY ANTIGEN (EA) 67 CPT 86664 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, NUCLEAR ANTIGEN (EBNA) 79 CPT 86665 ANTIBODY; EPSTEIN-BARR (EB) VIRUS, VIRAL CAPSID (VCA) 93 CPT 86666 ANTIBODY; EHRLICHIA 333 CPT 86668 ANTIBODY; FRANCISELLA TULARENSIS 53 CPT 86671 ANTIBODY; FUNGUS, NOT ELSEWHERE SPECIFIED 63 CPT 86674 ANTIBODY; GIARDIA LAMBLIA 76 CPT 86677 ANTIBODY; HELICOBACTER PYLORI 75 CPT 86682 ANTIBODY; HELMINTH, NOT ELSEWHERE SPECIFIED 67 CPT 86684 ANTIBODY; HAEMOPHILUS INFLUENZA 81 CPT 86687 ANTIBODY; HTLV-I 43 CPT 86688 ANTIBODY; HTLV-II 72 CPT 86689 ANTIBODY; HTLV OR HIV ANTIBODY, CONFIRMATORY TEST (EG, WESTERN 99 BLOT) CPT 86692 ANTIBODY; HEPATITIS, DELTA AGENT 88 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 293 of 380

CPT 86694 ANTIBODY; HERPES SIMPLEX, NON-SPECIFIC TYPE TEST 74 CPT 86695 ANTIBODY; HERPES SIMPLEX, TYPE 1 68 CPT 86696 ANTIBODY; HERPES SIMPLEX, TYPE 2 99 CPT 86698 ANTIBODY; HISTOPLASMA 64 CPT 86701 ANTIBODY; HIV-1 46 CPT 86702 ANTIBODY; HIV-2 69 CPT 86703 ANTIBODY; HIV-1 AND HIV-2, SINGLE ASSAY 63 CPT 86704 HEPATITIS B CORE ANTIBODY (HBCAB); TOTAL 61 CPT 86705 HEPATITIS B CORE ANTIBODY (HBCAB); IGM ANTIBODY 60 CPT 86706 HEPATITIS B SURFACE ANTIBODY (HBSAB) 55 CPT 86707 HEPATITIS BE ANTIBODY (HBEAB) 59 CPT 86708 HEPATITIS A ANTIBODY (HAAB); TOTAL 64 CPT 86709 HEPATITIS A ANTIBODY (HAAB); IGM ANTIBODY 58 CPT 86710 ANTIBODY; INFLUENZA VIRUS 70 CPT 86713 ANTIBODY; LEGIONELLA 289 CPT 86717 ANTIBODY; LEISHMANIA 63 CPT 86720 ANTIBODY; LEPTOSPIRA 68 CPT 86723 ANTIBODY; LISTERIA MONOCYTOGENES 68 CPT 86727 ANTIBODY; LYMPHOCYTIC CHORIOMENINGITIS 66 CPT 86729 ANTIBODY; LYMPHOGRANULOMA VENEREUM 61 CPT 86732 ANTIBODY; MUCORMYCOSIS 68 CPT 86735 ANTIBODY; MUMPS 67 CPT 86738 ANTIBODY; MYCOPLASMA 68 CPT 86741 ANTIBODY; NEISSERIA MENINGITIDIS 68 CPT 86744 ANTIBODY; NOCARDIA 68 CPT 86747 ANTIBODY; PARVOVIRUS 77 CPT 86750 ANTIBODY; PLASMODIUM (MALARIA) 68 CPT 86753 ANTIBODY; PROTOZOA, NOT ELSEWHERE SPECIFIED 64 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 294 of 380

CPT 86756 ANTIBODY; RESPIRATORY SYNCYTIAL VIRUS 66 CPT 86757 ANTIBODY; RICKETTSIA 99 CPT 86759 ANTIBODY; ROTAVIRUS 68 CPT 86762 ANTIBODY; RUBELLA 74 CPT 86765 ANTIBODY; RUBEOLA 66 CPT 86768 ANTIBODY; SALMONELLA 68 CPT 86771 ANTIBODY; SHIGELLA 68 CPT 86774 ANTIBODY; TETANUS 76 CPT 86777 ANTIBODY; TOXOPLASMA 74 CPT 86778 ANTIBODY; TOXOPLASMA, IGM 74 CPT 86781 ANTIBODY; TREPONEMA PALLIDUM, CONFIRMATORY TEST (EG, FTA-ABS) 68 CPT 86784 ANTIBODY; TRICHINELLA 64 CPT 86787 ANTIBODY; VARICELLA-ZOSTER 66 CPT 86788 ANTIBODY; WEST NILE VIRUS, IGM 86 CPT 86789 ANTIBODY; WEST NILE VIRUS 74 CPT 86790 ANTIBODY; VIRUS, NOT ELSEWHERE SPECIFIED 66 CPT 86793 ANTIBODY; YERSINIA 68 CPT 86800 THYROGLOBULIN ANTIBODY 82 CPT 86803 HEPATITIS C ANTIBODY; 65 CPT 86804 HEPATITIS C ANTIBODY; CONFIRMATORY TEST (EG, IMMUNOBLOT) 80 CPT 86805 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITH TITRATION 268 CPT 86806 LYMPHOCYTOTOXICITY ASSAY, VISUAL CROSSMATCH; WITHOUT 244 TITRATION CPT 86807 SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY (PRA); 203 STANDARD METHOD CPT 86808 SERUM SCREENING FOR CYTOTOXIC PERCENT REACTIVE ANTIBODY (PRA); 152 QUICK METHOD CPT 86812 HLA TYPING; A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN 132 CPT 86813 HLA TYPING; A, B, OR C, MULTIPLE ANTIGENS 298 CPT 86816 HLA TYPING; DR/DQ, SINGLE ANTIGEN 143 CPT 86817 HLA TYPING; DR/DQ, MULTIPLE ANTIGENS 330 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 295 of 380

CPT 86821 HLA TYPING; LYMPHOCYTE CULTURE, MIXED (MLC) 290 CPT 86822 HLA TYPING; LYMPHOCYTE CULTURE, PRIMED (PLC) 188 CPT 86849 UNLISTED IMMUNOLOGY PROCEDURE N/A CPT 86850 ANTIBODY SCREEN, RBC, EACH SERUM TECHNIQUE 54 CPT 86860 ANTIBODY ELUTION (RBC), EACH ELUTION 65 CPT 86870 ANTIBODY IDENTIFICATION, RBC ANTIBODIES, EACH PANEL FOR EACH 101 SERUM TECHNIQUE CPT 86880 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); DIRECT, EACH ANTISERUM 28 CPT 86885 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, QUALITATIVE, 29 EACH REAGENT RED CELL CPT 86886 ANTIHUMAN GLOBULIN TEST (COOMBS TEST); INDIRECT, EACH ANTIBODY 27 TITER CPT 86890 AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND 218 STORAGE; PREDEPOSITED CPT 86891 AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND 340 STORAGE; INTRA- OR POSTOPERATIVE SALVAGE CPT 86900 BLOOD TYPING; ABO 15 CPT 86901 BLOOD TYPING; RH (D) 15 CPT 86903 BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE BLOOD UNIT 48 USING REAGENT SERUM, PER UNIT SCREENED CPT 86904 BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING 49 PATIENT SERUM, PER UNIT SCREENED CPT 86905 BLOOD TYPING; RBC ANTIGENS, OTHER THAN ABO OR RH (D), EACH 20 CPT 86906 BLOOD TYPING; RH PHENOTYPING, COMPLETE 40 CPT 86910 BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; ABO, RH AND 60 MN CPT 86911 BLOOD TYPING, FOR PATERNITY TESTING, PER INDIVIDUAL; EACH 52 ADDITIONAL ANTIGEN SYSTEM CPT 86920 COMPATIBILITY TEST EACH UNIT; IMMEDIATE SPIN TECHNIQUE 89 CPT 86921 COMPATIBILITY TEST EACH UNIT; INCUBATION TECHNIQUE 73 CPT 86922 COMPATIBILITY TEST EACH UNIT; ANTIGLOBULIN TECHNIQUE 82 CPT 86923 COMPATIBILITY TEST EACH UNIT; ELECTRONIC 65 CPT 86927 FRESH FROZEN PLASMA, THAWING, EACH UNIT 35 CPT 86930 FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) 272 CPT 86931 FROZEN BLOOD, EACH UNIT; THAWING 204 CPT 86932 FROZEN BLOOD, EACH UNIT; FREEZING (INCLUDES PREPARATION) AND 272 THAWING CPT 86940 HEMOLYSINS AND AGGLUTININS; AUTO, SCREEN, EACH 42 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 296 of 380

CPT 86941 HEMOLYSINS AND AGGLUTININS; INCUBATED 62 CPT 86945 IRRADIATION OF BLOOD PRODUCT, EACH UNIT 75 CPT 86950 LEUKOCYTE TRANSFUSION 169 CPT 86960 VOLUME REDUCTION OF BLOOD OR BLOOD PRODUCT (EG, RED BLOOD 75 CELLS OR PLATELETS), EACH UNIT CPT 86965 POOLING OF PLATELETS OR OTHER BLOOD PRODUCTS 68 CPT 86970 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 54 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH CHEMICAL AGENTS OR DRUGS, EACH CPT 86971 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 54 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; INCUBATION WITH ENZYMES, EACH CPT 86972 PRETREATMENT OF RBCS FOR USE IN RBC ANTIBODY DETECTION, 87 IDENTIFICATION, AND/OR COMPATIBILITY TESTING; BY DENSITY GRADIENT SEPARATION CPT 86975 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 73 INCUBATION WITH DRUGS, EACH CPT 86976 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 82 BY DILUTION CPT 86977 PRETREATMENT OF SERUM FOR USE IN RBC ANTIBODY IDENTIFICATION; 73 INCUBATION WITH INHIBITORS, EACH CPT 86978 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 86985 SPLITTING OF BLOOD OR BLOOD PRODUCTS, EACH UNIT 54 CPT 86999 UNLISTED TRANSFUSION MEDICINE PROCEDURE N/A CPT 87001 ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION 68 CPT 87003 ANIMAL INOCULATION, SMALL ANIMAL; WITH OBSERVATION AND 86 DISSECTION CPT 87015 CONCENTRATION (ANY TYPE), FOR INFECTIOUS AGENTS 34 CPT 87040 CULTURE, BACTERIAL; BLOOD, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) CPT 87045 CULTURE, BACTERIAL; STOOL, AEROBIC, WITH ISOLATION AND PRELIMINARY EXAMINATION (EG, KIA, LIA), SALMONELLA AND SHIGELLA SPECIES CPT 87046 CULTURE, BACTERIAL; STOOL, AEROBIC, ADDITIONAL PATHOGENS, ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, EACH PLATE CPT 87070 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, AEROBIC, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT 87071 CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT URINE, BLOOD OR STOOL CPT 87073 CULTURE, BACTERIAL; QUANTITATIVE, ANAEROBIC WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT URINE, BLOOD OR STOOL 53 48 48 44 48 48 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 297 of 380

CPT 87075 CULTURE, BACTERIAL; ANY SOURCE, EXCEPT BLOOD, ANAEROBIC WITH 49 ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT 87076 CULTURE, BACTERIAL; ANAEROBIC ISOLATE, ADDITIONAL METHODS 42 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE CPT 87077 CULTURE, BACTERIAL; AEROBIC ISOLATE, ADDITIONAL METHODS 42 REQUIRED FOR DEFINITIVE IDENTIFICATION, EACH ISOLATE CPT 87081 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 34 CPT 87084 CULTURE, PRESUMPTIVE, PATHOGENIC ORGANISMS, SCREENING ONLY; 44 WITH COLONY ESTIMATION FROM DENSITY CHART CPT 87086 CULTURE, BACTERIAL; QUANTITATIVE COLONY COUNT, URINE 42 CPT 87088 CULTURE, BACTERIAL; WITH ISOLATION AND PRESUMPTIVE 42 IDENTIFICATION OF EACH ISOLATE, URINE CPT 87101 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 40 IDENTIFICATION OF ISOLATES; SKIN, HAIR, OR NAIL CPT 87102 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 43 IDENTIFICATION OF ISOLATES; OTHER SOURCE (EXCEPT BLOOD) CPT 87103 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE 46 IDENTIFICATION OF ISOLATES; BLOOD CPT 87106 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; YEAST 53 CPT 87107 CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH ORGANISM; MOLD 53 CPT 87109 CULTURE, MYCOPLASMA, ANY SOURCE 79 CPT 87110 CULTURE, CHLAMYDIA, ANY SOURCE 101 CPT 87116 CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, 55 MYCOBACTERIA) ANY SOURCE, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES CPT 87118 CULTURE, MYCOBACTERIAL, DEFINITIVE IDENTIFICATION, EACH ISOLATE 56 CPT 87140 CULTURE, TYPING; IMMUNOFLUORESCENT METHOD, EACH ANTISERUM 29 CPT 87143 CULTURE, TYPING; GAS LIQUID CHROMATOGRAPHY (GLC) OR HIGH 64 PRESSURE LIQUID CHROMATOGRAPHY (HPLC) METHOD CPT 87147 CULTURE, TYPING; IMMUNOLOGIC METHOD, OTHER THAN 27 IMMUNOFLUORESENCE (EG, AGGLUTINATION GROUPING), PER ANTISERUM CPT 87149 CULTURE, TYPING; IDENTIFICATION BY NUCLEIC ACID PROBE 103 CPT 87152 CULTURE, TYPING; IDENTIFICATION BY PULSE FIELD GEL TYPING 27 CPT 87158 CULTURE, TYPING; OTHER METHODS 27 CPT 87164 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, 55 SKIN); INCLUDES SPECIMEN COLLECTION CPT 87166 DARK FIELD EXAMINATION, ANY SOURCE (EG, PENILE, VAGINAL, ORAL, 58 SKIN); WITHOUT COLLECTION CPT 87168 MACROSCOPIC EXAMINATION; ARTHROPOD 22 CPT 87169 MACROSCOPIC EXAMINATION; PARASITE 22 CPT 87172 PINWORM EXAM (EG, CELLOPHANE TAPE PREP) 22 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 298 of 380

CPT 87176 HOMOGENIZATION, TISSUE, FOR CULTURE 30 CPT 87177 OVA AND PARASITES, DIRECT SMEARS, CONCENTRATION AND 46 IDENTIFICATION CPT 87181 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; AGAR DILUTION 24 METHOD, PER AGENT (EG, ANTIBIOTIC GRADIENT STRIP) CPT 87184 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; DISK METHOD, PER 35 PLATE (12 OR FEWER AGENTS) CPT 87185 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; ENZYME DETECTION 24 (EG, BETA LACTAMASE), PER ENZYME CPT 87186 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MICRODILUTION OR 44 AGAR DILUTION (MINIMUM INHIBITORY CONCENTRATION (MIC) OR BREAKPOINT), EACH MULTI-ANTIMICROBIAL, PER PLATE CPT 87187 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 87188 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MACROBROTH 34 DILUTION METHOD, EACH AGENT CPT 87190 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT; MYCOBACTERIA, 29 PROPORTION METHOD, EACH AGENT CPT 87197 SERUM BACTERICIDAL TITER (SCHLICTER TEST) 77 CPT 87205 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; GRAM OR GIEMSA STAIN FOR BACTERIA, FUNGI, OR CELL TYPES CPT 87206 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; FLUORESCENT AND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, PARASITES, VIRUSES OR CELL TYPES CPT 87207 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; SPECIAL STAIN FOR INCLUSION BODIES OR PARASITES (EG, MALARIA, COCCIDIA, MICROSPORIDIA, TRYPANOSOMES, HERPES VIRUSES) CPT 87209 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; COMPLEX SPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) FOR OVA AND PARASITES CPT 87210 SMEAR, PRIMARY SOURCE WITH INTERPRETATION; WET MOUNT FOR INFECTIOUS AGENTS (EG, SALINE, INDIA INK, KOH PREPS) CPT 87220 TISSUE EXAMINATION BY KOH SLIDE OF SAMPLES FROM SKIN, HAIR, OR NAILS FOR FUNGI OR ECTOPARASITE OVA OR MITES (EG, SCABIES) CPT 87230 TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE (EG, CLOSTRIDIUM DIFFICILE TOXIN) CPT 87250 VIRUS ISOLATION; INOCULATION OF EMBRYONATED EGGS, OR SMALL ANIMAL, INCLUDES OBSERVATION AND DISSECTION CPT 87252 VIRUS ISOLATION; TISSUE CULTURE INOCULATION, OBSERVATION, AND PRESUMPTIVE IDENTIFICATION BY CYTOPATHIC EFFECT CPT 87253 VIRUS ISOLATION; TISSUE CULTURE, ADDITIONAL STUDIES OR DEFINITIVE IDENTIFICATION (EG, HEMABSORPTION, NEUTRALIZATION, IMMUNOFLUORESENCE STAIN), EACH ISOLATE CPT 87254 VIRUS ISOLATION; CENTRIFUGE ENHANCED (SHELL VIAL) TECHNIQUE, INCLUDES IDENTIFICATION WITH IMMUNOFLUORESCENCE STAIN, EACH VIRUS CPT 87255 VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN BY CYTOPATHIC EFFECT (EG, VIRUS SPECIFIC ENZYMATIC ACTIVITY) CPT 87260 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ADENOVIRUS CPT 87265 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; BORDETELLA PERTUSSIS/PARAPERTUSSIS CPT 87267 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT TECHNIQUE; ENTEROVIRUS, DIRECT FLUORESCENT ANTIBODY (DFA) 22 28 31 92 22 92 101 100 134 104 100 174 62 62 62 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 299 of 380

CPT 87269 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; GIARDIA CPT 87270 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CHLAMYDIA TRACHOMATIS CPT 87271 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CYTOMEGALOVIRUS, DIRECT FLUORESCENT ANTIBODY (DFA) CPT 87272 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; CRYPTOSPORIDIUM CPT 87273 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 2 CPT 87274 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; HERPES SIMPLEX VIRUS TYPE 1 CPT 87275 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; INFLUENZA B VIRUS CPT 87276 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; INFLUENZA A VIRUS CPT 87277 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; LEGIONELLA MICDADEI CPT 87278 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; LEGIONELLA PNEUMOPHILA CPT 87279 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; PARAINFLUENZA VIRUS, EACH TYPE CPT 87280 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; RESPIRATORY SYNCYTIAL VIRUS CPT 87281 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; PNEUMOCYSTIS CARINII CPT 87283 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; RUBEOLA CPT 87285 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; TREPONEMA PALLIDUM CPT 87290 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; VARICELLA ZOSTER VIRUS CPT 87299 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE; NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT 87300 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOFLUORESCENT 62 TECHNIQUE, POLYVALENT FOR MULTIPLE ORGANISMS, EACH POLYVALENT ANTISERUM CPT 87301 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ADENOVIRUS ENTERIC TYPES 40/41 CPT 87305 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ASPERGILLUS CPT 87320 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CHLAMYDIA TRACHOMATIS CPT 87324 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CLOSTRIDIUM DIFFICILE TOXIN(S) CPT 87327 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CRYPTOCOCCUS NEOFORMANS CPT 87328 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CRYPTOSPORIDIUM CPT 87329 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: 01.03.2015 Page No(s): 300 of 380

METHOD; GIARDIA CPT 87332 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; CYTOMEGALOVIRUS CPT 87335 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ESCHERICHIA COLI 0157 CPT 87336 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ENTAMOEBA HISTOLYTICA DISPAR GROUP CPT 87337 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ENTAMOEBA HISTOLYTICA GROUP CPT 87338 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HELICOBACTER PYLORI, STOOL CPT 87339 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HELICOBACTER PYLORI CPT 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS B SURFACE ANTIGEN (HBSAG) CPT 87341 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS B SURFACE ANTIGEN (HBSAG) NEUTRALIZATION CPT 87350 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS BE ANTIGEN (HBEAG) CPT 87380 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HEPATITIS, DELTA AGENT CPT 87385 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HISTOPLASMA CAPSULATUM CPT 87390 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HIV-1 CPT 87391 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; HIV-2 CPT 87400 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; INFLUENZA, A OR B, EACH CPT 87420 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; RESPIRATORY SYNCYTIAL VIRUS CPT 87425 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; ROTAVIRUS CPT 87427 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; SHIGA-LIKE TOXIN CPT 87430 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, MULTIPLE-STEP METHOD; STREPTOCOCCUS, GROUP A 62 62 62 62 74 62 48 53 59 84 62 91 91 62 62 62 62 62 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 301 of 380

CPT 87449 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 62 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP METHOD, NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT 87450 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 49 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; SINGLE STEP METHOD, NOT OTHERWISE SPECIFIED, EACH ORGANISM CPT 87451 INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY 49 TECHNIQUE QUALITATIVE OR SEMIQUANTITATIVE; MULTIPLE STEP METHOD, POLYVALENT FOR MULTIPLE ORGANISMS, EACH POLYVALENT ANTISERUM CPT 87470 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, DIRECT PROBE TECHNIQUE CPT 87471 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, AMPLIFIED PROBE TECHNIQUE CPT 87472 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 BARTONELLA HENSELAE AND BARTONELLA QUINTANA, QUANTIFICATION CPT 87475 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 BORRELIA BURGDORFERI, DIRECT PROBE TECHNIQUE CPT 87476 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNIQUE CPT 87477 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 BORRELIA BURGDORFERI, QUANTIFICATION CPT 87480 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CANDIDA SPECIES, DIRECT PROBE TECHNIQUE CPT 87481 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CANDIDA SPECIES, AMPLIFIED PROBE TECHNIQUE CPT 87482 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 CANDIDA SPECIES, QUANTIFICATION CPT 87485 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CHLAMYDIA PNEUMONIAE, DIRECT PROBE TECHNIQUE CPT 87486 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE CPT 87487 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 CHLAMYDIA PNEUMONIAE, QUANTIFICATION CPT 87490 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQUE CPT 87491 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHNIQUE CPT 87492 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 179 CHLAMYDIA TRACHOMATIS, QUANTIFICATION CPT 87495 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 CYTOMEGALOVIRUS, DIRECT PROBE TECHNIQUE CPT 87496 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 CYTOMEGALOVIRUS, AMPLIFIED PROBE TECHNIQUE CPT 87497 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 CYTOMEGALOVIRUS, QUANTIFICATION CPT 87498 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 ENTEROVIRUS, AMPLIFIED PROBE TECHNIQUE CPT 87500 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 VANCOMYCIN RESISTANCE (EG, ENTEROCOCCUS SPECIES VAN A, VAN B), AMPLIFIED PROBE TECHNIQUE CPT 87510 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 GARDNERELLA VAGINALIS, DIRECT PROBE TECHNIQUE CPT 87511 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: 01.03.2015 Page No(s): 302 of 380

CPT 87512 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 GARDNERELLA VAGINALIS, QUANTIFICATION CPT 87515 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS B VIRUS, DIRECT PROBE TECHNIQUE CPT 87516 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE CPT 87517 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 HEPATITIS B VIRUS, QUANTIFICATION CPT 87520 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS C, DIRECT PROBE TECHNIQUE CPT 87521 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS C, AMPLIFIED PROBE TECHNIQUE CPT 87522 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 HEPATITIS C, QUANTIFICATION CPT 87525 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 HEPATITIS G, DIRECT PROBE TECHNIQUE CPT 87526 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 HEPATITIS G, AMPLIFIED PROBE TECHNIQUE CPT 87527 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 HEPATITIS G, QUANTIFICATION CPT 87528 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 103 SIMPLEX VIRUS, DIRECT PROBE TECHNIQUE CPT 87529 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 180 SIMPLEX VIRUS, AMPLIFIED PROBE TECHNIQUE CPT 87530 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 220 SIMPLEX VIRUS, QUANTIFICATION CPT 87531 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 103 VIRUS-6, DIRECT PROBE TECHNIQUE CPT 87532 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 180 VIRUS-6, AMPLIFIED PROBE TECHNIQUE CPT 87533 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HERPES 214 VIRUS-6, QUANTIFICATION CPT 87534 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 103 DIRECT PROBE TECHNIQUE CPT 87535 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 180 AMPLIFIED PROBE TECHNIQUE CPT 87536 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-1, 437 QUANTIFICATION CPT 87537 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 103 DIRECT PROBE TECHNIQUE CPT 87538 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 180 AMPLIFIED PROBE TECHNIQUE CPT 87539 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); HIV-2, 220 QUANTIFICATION CPT 87540 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 LEGIONELLA PNEUMOPHILA, DIRECT PROBE TECHNIQUE CPT 87541 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 LEGIONELLA PNEUMOPHILA, AMPLIFIED PROBE TECHNIQUE CPT 87542 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 LEGIONELLA PNEUMOPHILA, QUANTIFICATION CPT 87550 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA SPECIES, DIRECT PROBE TECHNIQUE CPT 87551 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA SPECIES, AMPLIFIED PROBE TECHNIQUE CPT 87552 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: 01.03.2015 Page No(s): 303 of 380

CPT 87555 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA TUBERCULOSIS, DIRECT PROBE TECHNIQUE CPT 87556 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA TUBERCULOSIS, AMPLIFIED PROBE TECHNIQUE CPT 87557 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 MYCOBACTERIA TUBERCULOSIS, QUANTIFICATION CPT 87560 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOBACTERIA AVIUM-INTRACELLULARE, DIRECT PROBE TECHNIQUE CPT 87561 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOBACTERIA AVIUM-INTRACELLULARE, AMPLIFIED PROBE TECHNIQUE CPT 87562 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 MYCOBACTERIA AVIUM-INTRACELLULARE, QUANTIFICATION CPT 87580 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 MYCOPLASMA PNEUMONIAE, DIRECT PROBE TECHNIQUE CPT 87581 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHNIQUE CPT 87582 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 MYCOPLASMA PNEUMONIAE, QUANTIFICATION CPT 87590 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 NEISSERIA GONORRHOEAE, DIRECT PROBE TECHNIQUE CPT 87591 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHNIQUE CPT 87592 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 220 NEISSERIA GONORRHOEAE, QUANTIFICATION CPT 87620 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 PAPILLOMAVIRUS, HUMAN, DIRECT PROBE TECHNIQUE CPT 87621 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 PAPILLOMAVIRUS, HUMAN, AMPLIFIED PROBE TECHNIQUE CPT 87622 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 PAPILLOMAVIRUS, HUMAN, QUANTIFICATION CPT 87640 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STAPHYLOCOCCUS AUREUS, AMPLIFIED PROBE TECHNIQUE CPT 87641 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTANT, AMPLIFIED PROBE TECHNIQUE CPT 87650 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 STREPTOCOCCUS, GROUP A, DIRECT PROBE TECHNIQUE CPT 87651 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STREPTOCOCCUS, GROUP A, AMPLIFIED PROBE TECHNIQUE CPT 87652 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 214 STREPTOCOCCUS, GROUP A, QUANTIFICATION CPT 87653 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 180 STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TECHNIQUE CPT 87660 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 103 TRICHOMONAS VAGINALIS, DIRECT PROBE TECHNIQUE CPT 87797 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 103 OTHERWISE SPECIFIED; DIRECT PROBE TECHNIQUE, EACH ORGANISM CPT 87798 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 180 OTHERWISE SPECIFIED; AMPLIFIED PROBE TECHNIQUE, EACH ORGANISM CPT 87799 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), NOT 220 OTHERWISE SPECIFIED; QUANTIFICATION, EACH ORGANISM CPT 87800 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 206 MULTIPLE ORGANISMS; DIRECT PROBE(S) TECHNIQUE CPT 87801 INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA), 360 MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE CPT 87802 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: 01.03.2015 Page No(s): 304 of 380

CPT 87803 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; CLOSTRIDIUM DIFFICILE TOXIN A CPT 87804 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; INFLUENZA CPT 87807 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; RESPIRATORY SYNCYTIAL VIRUS CPT 87808 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; TRICHOMONAS VAGINALIS CPT 87809 INFECTIOUS AGENT ANTIGEN DETECTION BY IMMUNOASSAY WITH DIRECT 62 OPTICAL OBSERVATION; ADENOVIRUS CPT 87810 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; CHLAMYDIA TRACHOMATIS CPT 87850 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; NEISSERIA GONORRHOEAE CPT 87880 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; STREPTOCOCCUS, GROUP A CPT 87899 INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT OPTICAL 62 OBSERVATION; NOT OTHERWISE SPECIFIED CPT 87900 INFECTIOUS AGENT DRUG SUSCEPTIBILITY PHENOTYPE PREDICTION 669 USING REGULARLY UPDATED GENOTYPIC BIOINFORMATICS CPT 87901 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 1,321 RNA); HIV 1, REVERSE TRANSCRIPTASE AND PROTEASE CPT 87902 INFECTIOUS AGENT GENOTYPE ANALYSIS BY NUCLEIC ACID (DNA OR 1,321 RNA); HEPATITIS C VIRUS CPT 87903 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 87904 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 87999 UNLISTED MICROBIOLOGY PROCEDURE N/A CPT 88000 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITHOUT CNS 674 CPT 88005 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITH BRAIN 775 CPT 88007 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; WITH BRAIN AND 843 SPINAL CORD CPT 88012 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; INFANT WITH BRAIN 606 CPT 88014 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; STILLBORN OR 606 NEWBORN WITH BRAIN CPT 88016 NECROPSY (AUTOPSY), GROSS EXAMINATION ONLY; MACERATED 775 STILLBORN CPT 88020 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITHOUT CNS 1,045 CPT 88025 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITH BRAIN 1,146 CPT 88027 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; WITH BRAIN AND 1,248 SPINAL CORD CPT 88028 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; INFANT WITH BRAIN 606 CPT 88029 NECROPSY (AUTOPSY), GROSS AND MICROSCOPIC; STILLBORN OR NEWBORN WITH BRAIN CPT 88036 NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; REGIONAL 606 337 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 305 of 380

CPT 88037 NECROPSY (AUTOPSY), LIMITED, GROSS AND/OR MICROSCOPIC; SINGLE 269 ORGAN CPT 88040 NECROPSY (AUTOPSY); FORENSIC EXAMINATION 1,686 CPT 88045 NECROPSY (AUTOPSY); CORONER'S CALL 169 CPT 88099 UNLISTED NECROPSY (AUTOPSY) PROCEDURE N/A CPT 88104 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 225 OR VAGINAL; SMEARS WITH INTERPRETATION CPT 88106 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 266 OR VAGINAL; SIMPLE FILTER METHOD WITH INTERPRETATION CPT 88107 CYTOPATHOLOGY, FLUIDS, WASHINGS OR BRUSHINGS, EXCEPT CERVICAL 353 OR VAGINAL; SMEARS AND SIMPLE FILTER PREPARATION WITH INTERPRETATION CPT 88108 CYTOPATHOLOGY, CONCENTRATION TECHNIQUE, SMEARS AND 260 INTERPRETATION (EG, SACCOMANNO TECHNIQUE) CPT 88112 CYTOPATHOLOGY, SELECTIVE CELLULAR ENHANCEMENT TECHNIQUE WITH 338 INTERPRETATION (EG, LIQUID BASED SLIDE PREPARATION METHOD), EXCEPT CERVICAL OR VAGINAL CPT 88125 CYTOPATHOLOGY, FORENSIC (EG, SPERM) 61 CPT 88130 SEX CHROMATIN IDENTIFICATION; BARR BODIES 77 CPT 88140 SEX CHROMATIN IDENTIFICATION; PERIPHERAL BLOOD SMEAR, POLYMORPHONUCLEAR DRUMSTICKS CPT 88141 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), REQUIRING INTERPRETATION BY PHYSICIAN CPT 88142 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT 88143 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88147 CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM UNDER PHYSICIAN SUPERVISION CPT 88148 CYTOPATHOLOGY SMEARS, CERVICAL OR VAGINAL; SCREENING BY AUTOMATED SYSTEM WITH MANUAL RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88150 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT 88152 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88153 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88154 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL; WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING USING CELL SELECTION AND REVIEW UNDER PHYSICIAN SUPERVISION CPT 88155 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 88160 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; SCREENING AND INTERPRETATION 41 103 104 104 58 78 54 54 54 54 31 182 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 306 of 380

CPT 88161 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; PREPARATION, 201 SCREENING AND INTERPRETATION CPT 88162 CYTOPATHOLOGY, SMEARS, ANY OTHER SOURCE; EXTENDED STUDY 300 INVOLVING OVER 5 SLIDES AND/OR MULTIPLE STAINS CPT 88164 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); MANUAL SCREENING UNDER PHYSICIAN SUPERVISION CPT 88165 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); WITH MANUAL SCREENING AND RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88166 CYTOPATHOLOGY, SLIDES, CERVICAL OR VAGINAL (THE BETHESDA 54 SYSTEM); WITH MANUAL SCREENING AND COMPUTER-ASSISTED RESCREENING UNDER PHYSICIAN SUPERVISION CPT 88167 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 88172 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; IMMEDIATE 182 CYTOHISTOLOGIC STUDY TO DETERMINE ADEQUACY OF SPECIMEN(S) CPT 88173 CYTOPATHOLOGY, EVALUATION OF FINE NEEDLE ASPIRATE; 161 INTERPRETATION AND REPORT CPT 88174 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY REPORTING SYSTEM), 110 COLLECTED IN PRESERVATIVE FLUID, AUTOMATED THIN LAYER PREPARATION; SCREENING BY AUTOMATED SYSTEM, UNDER PHYSICIAN SUPERVISION CPT 88175 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 88182 FLOW CYTOMETRY, CELL CYCLE OR DNA ANALYSIS 359 CPT 88184 FLOW CYTOMETRY, CELL SURFACE, CYTOPLASMIC, OR NUCLEAR MARKER, 313 TECHNICAL COMPONENT ONLY; FIRST MARKER CPT 88185 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 88187 FLOW CYTOMETRY, INTERPRETATION; 2 TO 8 MARKERS 222 CPT 88188 FLOW CYTOMETRY, INTERPRETATION; 9 TO 15 MARKERS 269 CPT 88189 FLOW CYTOMETRY, INTERPRETATION; 16 OR MORE MARKERS 341 CPT 88199 UNLISTED CYTOPATHOLOGY PROCEDURE N/A CPT 88230 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; LYMPHOCYTE 598 CPT 88233 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; SKIN OR OTHER 722 SOLID TISSUE BIOPSY CPT 88235 TISSUE CULTURE FOR NON-NEOPLASTIC DISORDERS; AMNIOTIC FLUID 756 OR CHORIONIC VILLUS CELLS CPT 88237 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; BONE MARROW, BLOOD 648 CELLS CPT 88239 TISSUE CULTURE FOR NEOPLASTIC DISORDERS; SOLID TUMOR 757 CPT 88240 CRYOPRESERVATION, FREEZING AND STORAGE OF CELLS, EACH CELL 52 LINE CPT 88241 THAWING AND EXPANSION OF FROZEN CELLS, EACH ALIQUOT 52 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 307 of 380

CPT 88245 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE SISTER 764 CHROMATID EXCHANGE (SCE), 20-25 CELLS CPT 88248 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; BASELINE 889 BREAKAGE, SCORE 50-100 CELLS, COUNT 20 CELLS, 2 KARYOTYPES (EG, FOR ATAXIA TELANGIECTASIA, FANCONI ANEMIA, FRAGILE X) CPT 88249 CHROMOSOME ANALYSIS FOR BREAKAGE SYNDROMES; SCORE 100 CELLS, 889 CLASTOGEN STRESS (EG, DIEPOXYBUTANE, MITOMYCIN C, IONIZING RADIATION, UV RADIATION) CPT 88261 CHROMOSOME ANALYSIS; COUNT 5 CELLS, 1 KARYOTYPE, WITH BANDING 907 CPT 88262 CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 KARYOTYPES, WITH 639 BANDING CPT 88263 CHROMOSOME ANALYSIS; COUNT 45 CELLS FOR MOSAICISM, 2 771 KARYOTYPES, WITH BANDING CPT 88264 CHROMOSOME ANALYSIS; ANALYZE 20-25 CELLS 639 CPT 88267 CHROMOSOME ANALYSIS, AMNIOTIC FLUID OR CHORIONIC VILLUS, 922 COUNT 15 CELLS, 1 KARYOTYPE, WITH BANDING CPT 88269 CHROMOSOME ANALYSIS, IN SITU FOR AMNIOTIC FLUID CELLS, COUNT 853 CELLS FROM 6-12 COLONIES, 1 KARYOTYPE, WITH BANDING CPT 88271 MOLECULAR CYTOGENETICS; DNA PROBE, EACH (EG, FISH) 110 CPT 88272 MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, 137 ANALYZE 3-5 CELLS (EG, FOR DERIVATIVES AND MARKERS) CPT 88273 MOLECULAR CYTOGENETICS; CHROMOSOMAL IN SITU HYBRIDIZATION, 165 ANALYZE 10-30 CELLS (EG, FOR MICRODELETIONS) CPT 88274 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 179 ANALYZE 25-99 CELLS CPT 88275 MOLECULAR CYTOGENETICS; INTERPHASE IN SITU HYBRIDIZATION, 206 ANALYZE 100-300 CELLS CPT 88280 CHROMOSOME ANALYSIS; ADDITIONAL KARYOTYPES, EACH STUDY 129 CPT 88283 CHROMOSOME ANALYSIS; ADDITIONAL SPECIALIZED BANDING 352 TECHNIQUE (EG, NOR, C-BANDING) CPT 88285 CHROMOSOME ANALYSIS; ADDITIONAL CELLS COUNTED, EACH STUDY 98 CPT 88289 CHROMOSOME ANALYSIS; ADDITIONAL HIGH RESOLUTION STUDY 177 CPT 88291 CYTOGENETICS AND MOLECULAR CYTOGENETICS, INTERPRETATION AND 101 REPORT CPT 88299 UNLISTED CYTOGENETIC STUDY N/A CPT 88299 UNLISTED CYTOGENETIC STUDY N/A CPT 88300 LEVEL I - SURGICAL PATHOLOGY, GROSS EXAMINATION ONLY 83 CPT 88302 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 88304 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 182 217 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 308 of 380

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 88305 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 88307 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: 01.03.2015 Page No(s): 309 of 380

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 88309 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 88311 DECALCIFICATION PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE 62 FOR SURGICAL PATHOLOGY EXAMINATION) CPT 88312 SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 361 SERVICE); GROUP I FOR MICROORGANISMS (EG, GRIDLEY, ACID FAST, METHENAMINE SILVER), EACH CPT 88313 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 88314 SPECIAL STAINS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 308 SERVICE); HISTOCHEMICAL STAINING WITH FROZEN SECTION(S) CPT 88318 DETERMINATIVE HISTOCHEMISTRY TO IDENTIFY CHEMICAL COMPONENTS 427 (EG, COPPER, ZINC) CPT 88319 DETERMINATIVE HISTOCHEMISTRY OR CYTOCHEMISTRY TO IDENTIFY 478 ENZYME CONSTITUENTS, EACH CPT 88321 CONSULTATION AND REPORT ON REFERRED SLIDES PREPARED 300 ELSEWHERE CPT 88323 CONSULTATION AND REPORT ON REFERRED MATERIAL REQUIRING 517 PREPARATION OF SLIDES CPT 88325 CONSULTATION, COMPREHENSIVE, WITH REVIEW OF RECORDS AND 625 SPECIMENS, WITH REPORT ON REFERRED MATERIAL CPT 88329 PATHOLOGY CONSULTATION DURING SURGERY; 59 CPT 88331 PATHOLOGY CONSULTATION DURING SURGERY; FIRST TISSUE BLOCK, 312 WITH FROZEN SECTION(S), SINGLE SPECIMEN CPT 88332 PATHOLOGY CONSULTATION DURING SURGERY; EACH ADDITIONAL 139 TISSUE BLOCK WITH FROZEN SECTION(S) CPT 88333 PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 327 EXAMINATION (EG, TOUCH PREP, SQUASH PREP), INITIAL SITE CPT 88334 PATHOLOGY CONSULTATION DURING SURGERY; CYTOLOGIC 195 EXAMINATION (EG, TOUCH PREP, SQUASH PREP), EACH ADDITIONAL SITE CPT 88342 IMMUNOHISTOCHEMISTRY (INCLUDING TISSUE IMMUNOPEROXIDASE), 365 EACH ANTIBODY CPT 88346 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; DIRECT METHOD 354 CPT 88347 IMMUNOFLUORESCENT STUDY, EACH ANTIBODY; INDIRECT METHOD 279 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 310 of 380

CPT 88348 ELECTRON MICROSCOPY; DIAGNOSTIC 2,504 CPT 88349 ELECTRON MICROSCOPY; SCANNING 1,290 CPT 88355 MORPHOMETRIC ANALYSIS; SKELETAL MUSCLE 654 CPT 88356 MORPHOMETRIC ANALYSIS; NERVE 1,078 CPT 88358 MORPHOMETRIC ANALYSIS; TUMOR (EG, DNA PLOIDY) 279 CPT 88360 MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER- 427 2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; MANUAL CPT 88361 MORPHOMETRIC ANALYSIS, TUMOR IMMUNOHISTOCHEMISTRY (EG, HER- 522 2/NEU, ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR), QUANTITATIVE OR SEMIQUANTITATIVE, EACH ANTIBODY; USING COMPUTER-ASSISTED TECHNOLOGY CPT 88362 NERVE TEASING PREPARATIONS 921 CPT 88365 IN SITU HYBRIDIZATION (EG, FISH), EACH PROBE 577 CPT 88367 MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR 828 SEMI-QUANTITATIVE) EACH PROBE; USING COMPUTER-ASSISTED TECHNOLOGY CPT 88368 MORPHOMETRIC ANALYSIS, IN SITU HYBRIDIZATION (QUANTITATIVE OR 816 SEMI-QUANTITATIVE) EACH PROBE; MANUAL CPT 88371 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 114 INTERPRETATION AND REPORT; CPT 88372 PROTEIN ANALYSIS OF TISSUE BY WESTERN BLOT, WITH 117 INTERPRETATION AND REPORT; IMMUNOLOGICAL PROBE FOR BAND IDENTIFICATION, EACH CPT 88380 MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY 548 IDENTIFIED TARGET); LASER CAPTURE CPT 88381 MICRODISSECTION (IE, SAMPLE PREPARATION OF MICROSCOPICALLY 721 IDENTIFIED TARGET); MANUAL CPT 88384 ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 11 1,196 THROUGH 50 PROBES CPT 88385 ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 51 2,161 THROUGH 250 PROBES CPT 88386 ARRAY-BASED EVALUATION OF MULTIPLE MOLECULAR PROBES; 251 2,202 THROUGH 500 PROBES CPT 88399 UNLISTED SURGICAL PATHOLOGY PROCEDURE N/A CPT 88400 BILIRUBIN, TOTAL, TRANSCUTANEOUS 26 CPT 89049 CAFFEINE HALOTHANE CONTRACTURE TEST (CHCT) FOR MALIGNANT 631 HYPERTHERMIA SUSCEPTIBILITY, INCLUDING INTERPRETATION AND REPORT CPT 89050 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, 24 JOINT FLUID), EXCEPT BLOOD; CPT 89051 CELL COUNT, MISCELLANEOUS BODY FLUIDS (EG, CEREBROSPINAL FLUID, 28 JOINT FLUID), EXCEPT BLOOD; WITH DIFFERENTIAL COUNT CPT 89055 LEUKOCYTE ASSESSMENT, FECAL, QUALITATIVE OR SEMIQUANTITATIVE 22 CPT 89060 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: 01.03.2015 Page No(s): 311 of 380

CPT 89100 DUODENAL INTUBATION AND ASPIRATION; SINGLE SPECIMEN (EG, 616 SIMPLE BILE STUDY OR AFFERENT LOOP CULTURE) PLUS APPROPRIATE TEST PROCEDURE CPT 89105 DUODENAL INTUBATION AND ASPIRATION; COLLECTION OF MULTIPLE 1,053 FRACTIONAL SPECIMENS WITH PANCREATIC OR GALLBLADDER STIMULATION, SINGLE OR DOUBLE LUMEN TUBE CPT 89125 FAT STAIN, FECES, URINE, OR RESPIRATORY SECRETIONS 22 CPT 89130 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, 518 FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; CPT 89132 GASTRIC INTUBATION AND ASPIRATION, DIAGNOSTIC, EACH SPECIMEN, 584 FOR CHEMICAL ANALYSES OR CYTOPATHOLOGY; AFTER STIMULATION CPT 89135 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 692 GASTRIC SECRETORY STUDY); ONE HOUR CPT 89136 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 457 GASTRIC SECRETORY STUDY); 2 HOURS CPT 89140 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 906 GASTRIC SECRETORY STUDY); 2 HOURS INCLUDING GASTRIC STIMULATION (EG, HISTALOG, PENTAGASTRIN) CPT 89141 GASTRIC INTUBATION, ASPIRATION, AND FRACTIONAL COLLECTIONS (EG, 911 GASTRIC SECRETORY STUDY); 3 HOURS, INCLUDING GASTRIC STIMULATION CPT 89160 MEAT FIBERS, FECES 19 CPT 89190 NASAL SMEAR FOR EOSINOPHILS 24 CPT 89220 SPUTUM, OBTAINING SPECIMEN, AEROSOL INDUCED TECHNIQUE 49 (SEPARATE PROCEDURE) CPT 89225 STARCH GRANULES, FECES 17 CPT 89230 SWEAT COLLECTION BY IONTOPHORESIS 11 CPT 89235 WATER LOAD TEST 28 CPT 89240 UNLISTED MISCELLANEOUS PATHOLOGY TEST N/A CPT 89250 CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; 5,876 CPT 89251 CULTURE OF OOCYTE(S)/EMBRYO(S), LESS THAN 4 DAYS; WITH CO- 6,111 CULTURE OF OOCYTE(S)/EMBRYOS CPT 89253 ASSISTED EMBRYO HATCHING, MICROTECHNIQUES (ANY METHOD) N/A CPT 89254 OOCYTE IDENTIFICATION FROM FOLLICULAR FLUID N/A CPT 89255 PREPARATION OF EMBRYO FOR TRANSFER (ANY METHOD) N/A CPT 89257 SPERM IDENTIFICATION FROM ASPIRATION (OTHER THAN SEMINAL N/A FLUID) CPT 89258 CRYOPRESERVATION; EMBRYO(S) N/A CPT 89259 CRYOPRESERVATION; SPERM N/A CPT 89260 SPERM ISOLATION; SIMPLE PREP (EG, SPERM WASH AND SWIM-UP) FOR INSEMINATION OR DIAGNOSIS WITH SEMEN ANALYSIS CPT 89261 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: 01.03.2015 Page No(s): 312 of 380

CPT 89264 SPERM IDENTIFICATION FROM TESTIS TISSUE, FRESH OR N/A CRYOPRESERVED CPT 89268 INSEMINATION OF OOCYTES N/A CPT 89272 EXTENDED CULTURE OF OOCYTE(S)/EMBRYO(S), 4-7 DAYS N/A CPT 89280 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; LESS THAN OR N/A EQUAL TO 10 OOCYTES CPT 89281 ASSISTED OOCYTE FERTILIZATION, MICROTECHNIQUE; GREATER THAN 10 N/A OOCYTES CPT 89290 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, N/A MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); LESS THAN OR EQUAL TO 5 EMBRYOS CPT 89291 BIOPSY, OOCYTE POLAR BODY OR EMBRYO BLASTOMERE, N/A MICROTECHNIQUE (FOR PRE-IMPLANTATION GENETIC DIAGNOSIS); GREATER THAN 5 EMBRYOS CPT 89300 SEMEN ANALYSIS; PRESENCE AND/OR MOTILITY OF SPERM INCLUDING 46 HUHNER TEST (POST COITAL) CPT 89310 SEMEN ANALYSIS; MOTILITY AND COUNT (NOT INCLUDING HUHNER TEST) 44 CPT 89320 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL 62 CPT 89321 SEMEN ANALYSIS; SPERM PRESENCE AND MOTILITY OF SPERM, IF 62 PERFORMED CPT 89322 SEMEN ANALYSIS; VOLUME, COUNT, MOTILITY, AND DIFFERENTIAL USING 80 STRICT MORPHOLOGIC CRITERIA (EG, KRUGER) CPT 89325 SPERM ANTIBODIES 55 CPT 89329 SPERM EVALUATION; HAMSTER PENETRATION TEST 108 CPT 89330 SPERM EVALUATION; CERVICAL MUCUS PENETRATION TEST, WITH OR 51 WITHOUT SPINNBARKEIT TEST CPT 89331 SPERM EVALUATION, FOR RETROGRADE EJACULATION, URINE (SPERM 101 CONCENTRATION, MOTILITY, AND MORPHOLOGY, AS INDICATED) CPT 89335 CRYOPRESERVATION, REPRODUCTIVE TISSUE, TESTICULAR N/A CPT 89342 STORAGE (PER YEAR); EMBRYO(S) N/A CPT 89343 STORAGE (PER YEAR); SPERM/SEMEN N/A CPT 89344 STORAGE (PER YEAR); REPRODUCTIVE TISSUE, TESTICULAR/OVARIAN N/A CPT 89346 STORAGE (PER YEAR); OOCYTE(S) N/A CPT 89352 THAWING OF CRYOPRESERVED; EMBRYO(S) N/A CPT 89353 THAWING OF CRYOPRESERVED; SPERM/SEMEN, EACH ALIQUOT N/A CPT 89354 THAWING OF CRYOPRESERVED; REPRODUCTIVE TISSUE, N/A TESTICULAR/OVARIAN CPT 89356 THAWING OF CRYOPRESERVED; OOCYTES, EACH ALIQUOT N/A CPT 90465 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: 01.03.2015 Page No(s): 313 of 380

CPT 90466 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 90467 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 90468 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 90471 IMMUNIZATION ADMINISTRATION (INCLUDES PERCUTANEOUS, 28 INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); ONE VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) CPT 90472 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 90473 IMMUNIZATION ADMINISTRATION BY INTRANASAL OR ORAL ROUTE; ONE 16 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) CPT 90474 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 90760 INTRAVENOUS INFUSION, HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR 71 CPT 90761 INTRAVENOUS INFUSION, HYDRATION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 90765 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); INITIAL, UP TO 1 HOUR CPT 90766 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 90767 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 90768 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); CONCURRENT INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 90769 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 90770 SUBCUTANEOUS INFUSION FOR THERAPY OR PROPHYLAXIS (SPECIFY SUBSTANCE OR DRUG); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 90771 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 90772 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); SUBCUTANEOUS OR INTRAMUSCULAR CPT 90773 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY SUBSTANCE OR DRUG); INTRA-ARTERIAL 20 86 27 41 24 190 20 85 28 22 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 314 of 380

CPT 90774 THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INJECTION (SPECIFY 20 SUBSTANCE OR DRUG); INTRAVENOUS PUSH, SINGLE OR INITIAL SUBSTANCE/DRUG CPT 90775 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 90776 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 90779 UNLISTED THERAPEUTIC, PROPHYLACTIC OR DIAGNOSTIC INTRAVENOUS 20 OR INTRA-ARTERIAL INJECTION OR INFUSION CPT 90801 PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION 547 CPT 90802 INTERACTIVE PSYCHIATRIC DIAGNOSTIC INTERVIEW EXAMINATION USING PLAY EQUIPMENT, PHYSICAL DEVICES, LANGUAGE INTERPRETER, OR OTHER MECHANISMS OF COMMUNICATION CPT 90804 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 90805 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 90806 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 90807 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 90808 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 90809 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 90810 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 90811 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 90812 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; 581 226 251 305 348 445 488 239 281 334 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 315 of 380

CPT 90813 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 90814 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 90815 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 90816 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 90817 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 90818 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 90819 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 90821 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 90822 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 90823 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 90824 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 90826 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 50 317 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 316 of 380

MINUTES FACE-TO-FACE WITH THE PATIENT; CPT 90827 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 90828 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 90829 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 90845 PSYCHOANALYSIS 279 CPT 90846 FAMILY PSYCHOTHERAPY (WITHOUT THE PATIENT PRESENT) 299 CPT 90847 FAMILY PSYCHOTHERAPY (CONJOINT PSYCHOTHERAPY) (WITH PATIENT 377 PRESENT) CPT 90849 MULTIPLE-FAMILY GROUP PSYCHOTHERAPY 118 CPT 90853 GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE-FAMILY GROUP) 108 CPT 90857 INTERACTIVE GROUP PSYCHOTHERAPY 128 CPT 90862 PHARMACOLOGIC MANAGEMENT, INCLUDING PRESCRIPTION, USE, AND 200 REVIEW OF MEDICATION WITH NO MORE THAN MINIMAL MEDICAL PSYCHOTHERAPY CPT 90865 NARCOSYNTHESIS FOR PSYCHIATRIC DIAGNOSTIC AND THERAPEUTIC 5,195 PURPOSES (EG, SODIUM AMOBARBITAL (AMYTAL) INTERVIEW) CPT 90870 ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY MONITORING) 483 CPT 90875 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 20-30 MINUTES CPT 90876 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 45-50 MINUTES CPT 90880 HYPNOTHERAPY 354 CPT 90882 ENVIRONMENTAL INTERVENTION FOR MEDICAL MANAGEMENT PURPOSES ON A PSYCHIATRIC PATIENT'S BEHALF WITH AGENCIES, EMPLOYERS, OR INSTITUTIONS CPT 90885 PSYCHIATRIC EVALUATION OF HOSPITAL RECORDS, OTHER PSYCHIATRIC REPORTS, PSYCHOMETRIC AND/OR PROJECTIVE TESTS, AND OTHER ACCUMULATED DATA FOR MEDICAL DIAGNOSTIC PURPOSES 316 152 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 317 of 380

CPT 90887 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 90889 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 90899 UNLISTED PSYCHIATRIC SERVICE OR PROCEDURE N/A CPT 90901 BIOFEEDBACK TRAINING BY ANY MODALITY 39 CPT 90911 BIOFEEDBACK TRAINING, PERINEAL MUSCLES, ANORECTAL OR URETHRAL 105 SPHINCTER, INCLUDING EMG AND/OR MANOMETRY CPT 90918 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 90919 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 90920 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 90921 END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES PER FULL 794 MONTH; FOR PATIENTS TWENTY YEARS OF AGE AND OLDER CPT 90922 END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 67 MONTH), PER DAY; FOR PATIENTS YOUNGER THAN TWO YEARS OF AGE CPT 90923 END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 49 MONTH), PER DAY; FOR PATIENTS BETWEEN TWO AND ELEVEN YEARS OF AGE CPT 90924 END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 42 MONTH), PER DAY; FOR PATIENTS BETWEEN TWELVE AND NINETEEN YEARS OF AGE CPT 90925 END-STAGE RENAL DISEASE (ESRD) RELATED SERVICES (LESS THAN FULL 26 MONTH), PER DAY; FOR PATIENTS TWENTY YEARS OF AGE AND OLDER CPT 90935 HEMODIALYSIS PROCEDURE WITH SINGLE PHYSICIAN EVALUATION 226 CPT 90937 HEMODIALYSIS PROCEDURE REQUIRING REPEATED EVALUATION(S) WITH OR WITHOUT SUBSTANTIAL REVISION OF DIALYSIS PRESCRIPTION CPT 90940 HEMODIALYSIS ACCESS FLOW STUDY TO DETERMINE BLOOD FLOW IN GRAFTS AND ARTERIOVENOUS FISTULAE BY AN INDICATOR METHOD CPT 90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (EG, PERITONEAL DIALYSIS, HEMOFILTRATION, OR OTHER CONTINUOUS RENAL REPLACEMENT THERAPIES), WITH SINGLE PHYSICIAN EVALUATION CPT 90947 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 90989 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COMPLETED COURSE CPT 90993 DIALYSIS TRAINING, PATIENT, INCLUDING HELPER WHERE APPLICABLE, ANY MODE, COURSE NOT COMPLETED, PER TRAINING SESSION 371 211 235 380 506 249 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 318 of 380

CPT 90997 HEMOPERFUSION (EG, WITH ACTIVATED CHARCOAL OR RESIN) 302 CPT 90999 UNLISTED DIALYSIS PROCEDURE, INPATIENT OR OUTPATIENT N/A CPT 91000 ESOPHAGEAL INTUBATION AND COLLECTION OF WASHINGS FOR 365 CYTOLOGY, INCLUDING PREPARATION OF SPECIMENS (SEPARATE PROCEDURE) CPT 91010 ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 634 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; CPT 91011 ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 882 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; WITH MECHOLYL OR SIMILAR STIMULANT CPT 91012 ESOPHAGEAL MOTILITY (MANOMETRIC STUDY OF THE ESOPHAGUS 884 AND/OR GASTROESOPHAGEAL JUNCTION) STUDY; WITH ACID PERFUSION STUDIES CPT 91020 GASTRIC MOTILITY (MANOMETRIC) STUDIES 804 CPT 91022 DUODENAL MOTILITY (MANOMETRIC) STUDY 592 CPT 91030 ESOPHAGUS, ACID PERFUSION (BERNSTEIN) TEST FOR ESOPHAGITIS 487 CPT 91034 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER 659 PH ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION CPT 91035 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH MUCOSAL 1,648 ATTACHED TELEMETRY PH ELECTRODE PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION CPT 91037 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH 573 NASAL CATHETER INTRALUMINAL IMPEDANCE ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION; CPT 91038 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 91040 ESOPHAGEAL BALLOON DISTENSION PROVOCATION STUDY 1,110 CPT 91052 GASTRIC ANALYSIS TEST WITH INJECTION OF STIMULANT OF GASTRIC 473 SECRETION (EG, HISTAMINE, INSULIN, PENTAGASTRIN, CALCIUM AND SECRETIN) CPT 91055 GASTRIC INTUBATION, WASHINGS, AND PREPARING SLIDES FOR 451 CYTOLOGY (SEPARATE PROCEDURE) CPT 91065 BREATH HYDROGEN TEST (EG, FOR DETECTION OF LACTASE DEFICIENCY, 197 FRUCTOSE INTOLERANCE, BACTERIAL OVERGROWTH, OR ORO-CECAL GASTROINTESTINAL TRANSIT) CPT 91100 INTESTINAL BLEEDING TUBE, PASSAGE, POSITIONING AND MONITORING 414 CPT 91105 GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR TREATMENT (EG, FOR INGESTED POISONS) CPT 91110 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT CPT 91111 GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS WITH PHYSICIAN INTERPRETATION AND REPORT CPT 91120 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: 01.03.2015 Page No(s): 319 of 380

CPT 91122 ANORECTAL MANOMETRY 791 CPT 91123 PULSED IRRIGATION OF FECAL IMPACTION N/A CPT 91132 ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; 147 CPT 91133 ELECTROGASTROGRAPHY, DIAGNOSTIC, TRANSCUTANEOUS; WITH 187 PROVOCATIVE TESTING CPT 91299 UNLISTED DIAGNOSTIC GASTROENTEROLOGY PROCEDURE N/A CPT 92002 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 83 EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, NEW PATIENT CPT 92004 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 155 EVALUATION WITH INITIATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, NEW PATIENT, ONE OR MORE VISITS CPT 92012 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 87 EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; INTERMEDIATE, ESTABLISHED PATIENT CPT 92014 OPHTHALMOLOGICAL SERVICES: MEDICAL EXAMINATION AND 127 EVALUATION, WITH INITIATION OR CONTINUATION OF DIAGNOSTIC AND TREATMENT PROGRAM; COMPREHENSIVE, ESTABLISHED PATIENT, ONE OR MORE VISITS CPT 92015 DETERMINATION OF REFRACTIVE STATE 22 CPT 92018 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 92019 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 92020 GONIOSCOPY (SEPARATE PROCEDURE) 28 CPT 92025 COMPUTERIZED CORNEAL TOPOGRAPHY, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT CPT 92060 SENSORIMOTOR EXAMINATION WITH MULTIPLE MEASUREMENTS OF OCULAR DEVIATION (EG, RESTRICTIVE OR PARETIC MUSCLE WITH DIPLOPIA) WITH INTERPRETATION AND REPORT (SEPARATE PROCEDURE) CPT 92065 ORTHOPTIC AND/OR PLEOPTIC TRAINING, WITH CONTINUING MEDICAL DIRECTION AND EVALUATION CPT 92070 FITTING OF CONTACT LENS FOR TREATMENT OF DISEASE, INCLUDING SUPPLY OF LENS CPT 92081 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 92082 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 92083 VISUAL FIELD EXAMINATION, UNILATERAL OR BILATERAL, WITH INTERPRETATION AND REPORT; EXTENDED EXAMINATION (EG, GOLDMANN VISUAL FIELDS WITH AT LEAST 3 ISOPTERS PLOTTED AND 108 186 157 203 167 224 255 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 320 of 380

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 92100 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 92120 TONOGRAPHY WITH INTERPRETATION AND REPORT, RECORDING 226 INDENTATION TONOMETER METHOD OR PERILIMBAL SUCTION METHOD CPT 92130 TONOGRAPHY WITH WATER PROVOCATION 252 CPT 92135 SCANNING COMPUTERIZED OPHTHALMIC DIAGNOSTIC IMAGING, 146 POSTERIOR SEGMENT, (EG, SCANNING LASER) WITH INTERPRETATION AND REPORT, UNILATERAL CPT 92136 OPHTHALMIC BIOMETRY BY PARTIAL COHERENCE INTERFEROMETRY WITH 256 INTRAOCULAR LENS POWER CALCULATION CPT 92140 PROVOCATIVE TESTS FOR GLAUCOMA, WITH INTERPRETATION AND 176 REPORT, WITHOUT TONOGRAPHY CPT 92225 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR 28 RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; INITIAL CPT 92226 OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR 26 RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; SUBSEQUENT CPT 92230 FLUORESCEIN ANGIOSCOPY WITH INTERPRETATION AND REPORT 163 CPT 92235 FLUORESCEIN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) WITH 396 INTERPRETATION AND REPORT CPT 92240 INDOCYANINE-GREEN ANGIOGRAPHY (INCLUDES MULTIFRAME IMAGING) 701 WITH INTERPRETATION AND REPORT CPT 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT 221 CPT 92260 OPHTHALMODYNAMOMETRY 20 CPT 92265 NEEDLE OCULOELECTROMYOGRAPHY, ONE OR MORE EXTRAOCULAR 235 MUSCLES, ONE OR BOTH EYES, WITH INTERPRETATION AND REPORT CPT 92270 ELECTRO-OCULOGRAPHY WITH INTERPRETATION AND REPORT 274 CPT 92275 ELECTRORETINOGRAPHY WITH INTERPRETATION AND REPORT 438 CPT 92283 COLOR VISION EXAMINATION, EXTENDED, EG, ANOMALOSCOPE OR 148 EQUIVALENT CPT 92284 DARK ADAPTATION EXAMINATION WITH INTERPRETATION AND REPORT 174 CPT 92285 EXTERNAL OCULAR PHOTOGRAPHY WITH INTERPRETATION AND REPORT FOR DOCUMENTATION OF MEDICAL PROGRESS (EG, CLOSE-UP PHOTOGRAPHY, SLIT LAMP PHOTOGRAPHY, GONIOPHOTOGRAPHY, STEREO-PHOTOGRAPHY) CPT 92286 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH SPECULAR ENDOTHELIAL MICROSCOPY AND CELL COUNT CPT 92287 SPECIAL ANTERIOR SEGMENT PHOTOGRAPHY WITH INTERPRETATION AND REPORT; WITH FLUORESCEIN ANGIOGRAPHY CPT 92310 PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEAL LENS, BOTH EYES, EXCEPT FOR APHAKIA 128 351 343 103 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 321 of 380

CPT 92311 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 92312 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 92313 PRESCRIPTION OF OPTICAL AND PHYSICAL CHARACTERISTICS OF AND 107 FITTING OF CONTACT LENS, WITH MEDICAL SUPERVISION OF ADAPTATION; CORNEOSCLERAL LENS CPT 92314 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 92315 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 92316 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 92317 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 92325 MODIFICATION OF CONTACT LENS (SEPARATE PROCEDURE), WITH 105 MEDICAL SUPERVISION OF ADAPTATION CPT 92326 REPLACEMENT OF CONTACT LENS 36 CPT 92340 FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; MONOFOCAL 37 CPT 92341 FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; BIFOCAL 42 CPT 92342 FITTING OF SPECTACLES, EXCEPT FOR APHAKIA; MULTIFOCAL, OTHER 46 THAN BIFOCAL CPT 92352 FITTING OF SPECTACLE PROSTHESIS FOR APHAKIA; MONOFOCAL 42 CPT 92353 FITTING OF SPECTACLE PROSTHESIS FOR APHAKIA; MULTIFOCAL 50 CPT 92354 FITTING OF SPECTACLE MOUNTED LOW VISION AID; SINGLE ELEMENT 17 SYSTEM CPT 92355 FITTING OF SPECTACLE MOUNTED LOW VISION AID; TELESCOPIC OR 20 OTHER COMPOUND LENS SYSTEM CPT 92358 PROSTHESIS SERVICE FOR APHAKIA, TEMPORARY (DISPOSABLE OR LOAN, 36 INCLUDING MATERIALS) CPT 92370 REPAIR AND REFITTING SPECTACLES; EXCEPT FOR APHAKIA 33 CPT 92371 REPAIR AND REFITTING SPECTACLES; SPECTACLE PROSTHESIS FOR 32 APHAKIA CPT 92499 UNLISTED OPHTHALMOLOGICAL SERVICE OR PROCEDURE N/A CPT 92502 OTOLARYNGOLOGIC EXAMINATION UNDER GENERAL ANESTHESIA 309 CPT 92504 BINOCULAR MICROSCOPY (SEPARATE DIAGNOSTIC PROCEDURE) 36 CPT 92506 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: 01.03.2015 Page No(s): 322 of 380

CPT 92507 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR 80 AUDITORY PROCESSING DISORDER; INDIVIDUAL CPT 92508 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION, AND/OR 37 AUDITORY PROCESSING DISORDER; GROUP, 2 OR MORE INDIVIDUALS CPT 92511 NASOPHARYNGOSCOPY WITH ENDOSCOPE (SEPARATE PROCEDURE) 181 CPT 92512 NASAL FUNCTION STUDIES (EG, RHINOMANOMETRY) 71 CPT 92516 FACIAL NERVE FUNCTION STUDIES (EG, ELECTRONEURONOGRAPHY) 76 CPT 92520 LARYNGEAL FUNCTION STUDIES (IE, AERODYNAMIC TESTING AND 215 ACOUSTIC TESTING) CPT 92526 TREATMENT OF SWALLOWING DYSFUNCTION AND/OR ORAL FUNCTION 103 FOR FEEDING CPT 92531 SPONTANEOUS NYSTAGMUS, INCLUDING GAZE 98 CPT 92532 POSITIONAL NYSTAGMUS TEST 88 CPT 92533 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL 141 STIMULATION CONSTITUTES FOUR TESTS) CPT 92534 OPTOKINETIC NYSTAGMUS TEST 75 CPT 92541 SPONTANEOUS NYSTAGMUS TEST, INCLUDING GAZE AND FIXATION 200 NYSTAGMUS, WITH RECORDING CPT 92542 POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH 207 RECORDING CPT 92543 CALORIC VESTIBULAR TEST, EACH IRRIGATION (BINAURAL, BITHERMAL 96 STIMULATION CONSTITUTES FOUR TESTS), WITH RECORDING CPT 92544 OPTOKINETIC NYSTAGMUS TEST, BIDIRECTIONAL, FOVEAL OR 166 PERIPHERAL STIMULATION, WITH RECORDING CPT 92545 OSCILLATING TRACKING TEST, WITH RECORDING 158 CPT 92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING 268 CPT 92547 USE OF VERTICAL ELECTRODES (LIST SEPARATELY IN ADDITION TO CODE 21 FOR PRIMARY PROCEDURE) CPT 92548 COMPUTERIZED DYNAMIC POSTUROGRAPHY 295 CPT 92551 SCREENING TEST, PURE TONE, AIR ONLY 32 CPT 92552 PURE TONE AUDIOMETRY (THRESHOLD); AIR ONLY 81 CPT 92553 PURE TONE AUDIOMETRY (THRESHOLD); AIR AND BONE 104 CPT 92555 SPEECH AUDIOMETRY THRESHOLD; 56 CPT 92556 SPEECH AUDIOMETRY THRESHOLD; WITH SPEECH RECOGNITION 26 CPT 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD EVALUATION AND SPEECH 127 RECOGNITION (92553 AND 92556 COMBINED) CPT 92559 AUDIOMETRIC TESTING OF GROUPS 91 CPT 92560 BEKESY AUDIOMETRY; SCREENING 54 CPT 92561 BEKESY AUDIOMETRY; DIAGNOSTIC 95 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 323 of 380

CPT 92562 LOUDNESS BALANCE TEST, ALTERNATE BINAURAL OR MONAURAL 83 CPT 92563 TONE DECAY TEST 74 CPT 92564 SHORT INCREMENT SENSITIVITY INDEX (SISI) 66 CPT 92565 STENGER TEST, PURE TONE 36 CPT 92567 TYMPANOMETRY (IMPEDANCE TESTING) 49 CPT 92568 ACOUSTIC REFLEX TESTING; THRESHOLD 19 CPT 92569 ACOUSTIC REFLEX TESTING; DECAY 39 CPT 92571 FILTERED SPEECH TEST 60 CPT 92572 STAGGERED SPONDAIC WORD TEST 75 CPT 92575 SENSORINEURAL ACUITY LEVEL TEST 147 CPT 92576 SYNTHETIC SENTENCE IDENTIFICATION TEST 28 CPT 92577 STENGER TEST, SPEECH 41 CPT 92579 VISUAL REINFORCEMENT AUDIOMETRY (VRA) 139 CPT 92582 CONDITIONING PLAY AUDIOMETRY 154 CPT 92583 SELECT PICTURE AUDIOMETRY 101 CPT 92584 ELECTROCOCHLEOGRAPHY 197 CPT 92585 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY 348 AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; COMPREHENSIVE CPT 92586 AUDITORY EVOKED POTENTIALS FOR EVOKED RESPONSE AUDIOMETRY 195 AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED CPT 92587 EVOKED OTOACOUSTIC EMISSIONS; LIMITED (SINGLE STIMULUS LEVEL, 113 EITHER TRANSIENT OR DISTORTION PRODUCTS) CPT 92588 EVOKED OTOACOUSTIC EMISSIONS; COMPREHENSIVE OR DIAGNOSTIC 203 EVALUATION (COMPARISON OF TRANSIENT AND/OR DISTORTION PRODUCT OTOACOUSTIC EMISSIONS AT MULTIPLE LEVELS AND FREQUENCIES) CPT 92590 HEARING AID EXAMINATION AND SELECTION; MONAURAL 165 CPT 92591 HEARING AID EXAMINATION AND SELECTION; BINAURAL 210 CPT 92592 HEARING AID CHECK; MONAURAL 65 CPT 92593 HEARING AID CHECK; BINAURAL 108 CPT 92594 ELECTROACOUSTIC EVALUATION FOR HEARING AID; MONAURAL 63 CPT 92595 ELECTROACOUSTIC EVALUATION FOR HEARING AID; BINAURAL 135 CPT 92596 EAR PROTECTOR ATTENUATION MEASUREMENTS 135 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 324 of 380

CPT 92597 EVALUATION FOR USE AND/OR FITTING OF VOICE PROSTHETIC DEVICE 130 TO SUPPLEMENT ORAL SPEECH CPT 92601 DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT YOUNGER THAN 435 7 YEARS OF AGE; WITH PROGRAMMING CPT 92602 DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT YOUNGER THAN 278 7 YEARS OF AGE; SUBSEQUENT REPROGRAMMING CPT 92603 DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR OLDER; 441 WITH PROGRAMMING CPT 92604 DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, AGE 7 YEARS OR OLDER; 264 SUBSEQUENT REPROGRAMMING CPT 92605 EVALUATION FOR PRESCRIPTION OF NON-SPEECH-GENERATING N/A AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE CPT 92606 THERAPEUTIC SERVICE(S) FOR THE USE OF NON-SPEECH-GENERATING N/A DEVICE, INCLUDING PROGRAMMING AND MODIFICATION CPT 92607 EVALUATION FOR PRESCRIPTION FOR SPEECH-GENERATING 212 AUGMENTATIVE AND ALTERNATIVE COMMUNICATION DEVICE, FACE-TO- FACE WITH THE PATIENT; FIRST HOUR CPT 92608 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 92609 THERAPEUTIC SERVICES FOR THE USE OF SPEECH-GENERATING DEVICE, 313 INCLUDING PROGRAMMING AND MODIFICATION CPT 92610 EVALUATION OF ORAL AND PHARYNGEAL SWALLOWING FUNCTION 224 CPT 92611 MOTION FLUOROSCOPIC EVALUATION OF SWALLOWING FUNCTION BY 255 CINE OR VIDEO RECORDING CPT 92612 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY 538 CINE OR VIDEO RECORDING; CPT 92613 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING BY 125 CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT 92614 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY 469 TESTING BY CINE OR VIDEO RECORDING; CPT 92615 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION, LARYNGEAL SENSORY 112 TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT 92616 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND 641 LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; CPT 92617 FLEXIBLE FIBEROPTIC ENDOSCOPIC EVALUATION OF SWALLOWING AND 138 LARYNGEAL SENSORY TESTING BY CINE OR VIDEO RECORDING; PHYSICIAN INTERPRETATION AND REPORT ONLY CPT 92620 EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; INITIAL 250 60 MINUTES CPT 92621 EVALUATION OF CENTRAL AUDITORY FUNCTION, WITH REPORT; EACH 62 ADDITIONAL 15 MINUTES CPT 92625 ASSESSMENT OF TINNITUS (INCLUDES PITCH, LOUDNESS MATCHING, 251 AND MASKING) CPT 92626 EVALUATION OF AUDITORY REHABILITATION STATUS; FIRST HOUR 260 CPT 92627 EVALUATION OF AUDITORY REHABILITATION STATUS; EACH ADDITIONAL 22 15 MINUTES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 92630 AUDITORY REHABILITATION; PRELINGUAL HEARING LOSS N/A CPT 92633 AUDITORY REHABILITATION; POSTLINGUAL HEARING LOSS N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 325 of 380

CPT 92640 DIAGNOSTIC ANALYSIS WITH PROGRAMMING OF AUDITORY BRAINSTEM 169 IMPLANT, PER HOUR CPT 92700 UNLISTED OTORHINOLARYNGOLOGICAL SERVICE OR PROCEDURE N/A CPT 92950 CARDIOPULMONARY RESUSCITATION (EG, IN CARDIAC ARREST) 921 CPT 92953 TEMPORARY TRANSCUTANEOUS PACING 40 CPT 92960 CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; 842 EXTERNAL CPT 92961 CARDIOVERSION, ELECTIVE, ELECTRICAL CONVERSION OF ARRHYTHMIA; 920 INTERNAL (SEPARATE PROCEDURE) CPT 92970 CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; INTERNAL 645 CPT 92971 CARDIOASSIST-METHOD OF CIRCULATORY ASSIST; EXTERNAL 367 CPT 92973 PERCUTANEOUS TRANSLUMINAL CORONARY THROMBECTOMY (LIST 663 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 92974 TRANSCATHETER PLACEMENT OF RADIATION DELIVERY DEVICE FOR 607 SUBSEQUENT CORONARY INTRAVASCULAR BRACHYTHERAPY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 92975 THROMBOLYSIS, CORONARY; BY INTRACORONARY INFUSION, INCLUDING 1,457 SELECTIVE CORONARY ANGIOGRAPHY CPT 92977 THROMBOLYSIS, CORONARY; BY INTRAVENOUS INFUSION 275 CPT 92978 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 92979 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 92980 TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), 3,018 PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTION, ANY METHOD; SINGLE VESSEL CPT 92981 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 92982 PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; 2,237 SINGLE VESSEL CPT 92984 PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY; 599 EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 92986 PERCUTANEOUS BALLOON VALVULOPLASTY; AORTIC VALVE 4,978 CPT 92987 PERCUTANEOUS BALLOON VALVULOPLASTY; MITRAL VALVE 5,164 CPT 92990 PERCUTANEOUS BALLOON VALVULOPLASTY; PULMONARY VALVE 3,859 CPT 92992 ATRIAL SEPTECTOMY OR SEPTOSTOMY; TRANSVENOUS METHOD, BALLOON (EG, RASHKIND TYPE) (INCLUDES CARDIAC CATHETERIZATION) CPT 92993 ATRIAL SEPTECTOMY OR SEPTOSTOMY; BLADE METHOD (PARK SEPTOSTOMY) (INCLUDES CARDIAC CATHETERIZATION) 1,220 965 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 326 of 380

CPT 92995 PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY 2,462 MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY; SINGLE VESSEL CPT 92996 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 92997 PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 2,264 ANGIOPLASTY; SINGLE VESSEL CPT 92998 PERCUTANEOUS TRANSLUMINAL PULMONARY ARTERY BALLOON 1,166 ANGIOPLASTY; EACH ADDITIONAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 93000 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; WITH 69 INTERPRETATION AND REPORT CPT 93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 37 TRACING ONLY, WITHOUT INTERPRETATION AND REPORT CPT 93010 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12 LEADS; 31 INTERPRETATION AND REPORT ONLY CPT 93012 TELEPHONIC TRANSMISSION OF POST-SYMPTOM ELECTROCARDIOGRAM 547 RHYTHM STRIP(S), 24-HOUR ATTENDED MONITORING, PER 30 DAY PERIOD OF TIME; TRACING ONLY CPT 93014 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 93015 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 93016 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 93017 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 93018 CARDIOVASCULAR STRESS TEST USING MAXIMAL OR SUBMAXIMAL 57 TREADMILL OR BICYCLE EXERCISE, CONTINUOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL STRESS; INTERPRETATION AND REPORT ONLY CPT 93024 ERGONOVINE PROVOCATION TEST 464 CPT 93025 MICROVOLT T-WAVE ALTERNANS FOR ASSESSMENT OF VENTRICULAR ARRHYTHMIAS CPT 93040 RHYTHM ECG, ONE TO THREE LEADS; WITH INTERPRETATION AND REPORT CPT 93041 RHYTHM ECG, ONE TO THREE LEADS; TRACING ONLY WITHOUT INTERPRETATION AND REPORT CPT 93042 RHYTHM ECG, ONE TO THREE LEADS; INTERPRETATION AND REPORT ONLY CPT 93224 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 606 46 18 27 386 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 327 of 380

CPT 93225 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 93226 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 167 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; SCANNING ANALYSIS WITH REPORT CPT 93227 ELECTROCARDIOGRAPHIC MONITORING FOR 24 HOURS BY CONTINUOUS 101 ORIGINAL ECG WAVEFORM RECORDING AND STORAGE, WITH VISUAL SUPERIMPOSITION SCANNING; PHYSICIAN REVIEW AND INTERPRETATION CPT 93230 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 93231 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 93232 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 93233 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 93235 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 93236 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 93237 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 93268 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 93270 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 93271 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: 01.03.2015 Page No(s): 328 of 380

ANALYSIS CPT 93272 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 93278 SIGNAL-AVERAGED ELECTROCARDIOGRAPHY (SAECG), WITH OR WITHOUT 124 ECG CPT 93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 764 ANOMALIES; COMPLETE CPT 93304 TRANSTHORACIC ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 503 ANOMALIES; FOLLOW-UP OR LIMITED STUDY CPT 93307 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE 618 DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; COMPLETE CPT 93308 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL-TIME WITH IMAGE 415 DOCUMENTATION (2D) WITH OR WITHOUT M-MODE RECORDING; FOLLOW-UP OR LIMITED STUDY CPT 93312 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 93313 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE 142 DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY CPT 93314 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, REAL TIME WITH IMAGE 1,107 DOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY CPT 93315 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 1,014 ANOMALIES; INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION AND REPORT CPT 93316 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 158 ANOMALIES; PLACEMENT OF TRANSESOPHAGEAL PROBE ONLY CPT 93317 TRANSESOPHAGEAL ECHOCARDIOGRAPHY FOR CONGENITAL CARDIAC 634 ANOMALIES; IMAGE ACQUISITION, INTERPRETATION AND REPORT ONLY CPT 93318 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 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE AND/OR CONTINUOUS 274 WAVE WITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE CPT 93321 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 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW VELOCITY MAPPING (LIST 119 SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) CPT 93350 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 93501 RIGHT HEART CATHETERIZATION 2,912 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 329 of 380

CPT 93503 INSERTION AND PLACEMENT OF FLOW DIRECTED CATHETER (EG, SWAN- 391 GANZ) FOR MONITORING PURPOSES CPT 93505 ENDOMYOCARDIAL BIOPSY 3,241 CPT 93508 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 93510 LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL 4,433 ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; PERCUTANEOUS CPT 93511 LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL 2,051 ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; BY CUTDOWN CPT 93514 LEFT HEART CATHETERIZATION BY LEFT VENTRICULAR PUNCTURE 2,116 CPT 93524 COMBINED TRANSSEPTAL AND RETROGRADE LEFT HEART 2,821 CATHETERIZATION CPT 93526 COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT 5,627 HEART CATHETERIZATION CPT 93527 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT 2,781 HEART CATHETERIZATION THROUGH INTACT SEPTUM (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT 93528 COMBINED RIGHT HEART CATHETERIZATION WITH LEFT VENTRICULAR 2,902 PUNCTURE (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT 93529 COMBINED RIGHT HEART CATHETERIZATION AND LEFT HEART 2,557 CATHETERIZATION THROUGH EXISTING SEPTAL OPENING (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) CPT 93530 RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 1,084 CPT 93531 COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES CPT 93532 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH INTACT SEPTUM WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES CPT 93533 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 93539 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF ARTERIAL CONDUITS (EG, INTERNAL MAMMARY), WHETHER NATIVE OR USED FOR BYPASS CPT 93540 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF AORTOCORONARY VENOUS BYPASS GRAFTS, ONE OR MORE CORONARY ARTERIES CPT 93541 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR PULMONARY ANGIOGRAPHY CPT 93542 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE RIGHT VENTRICULAR OR RIGHT ATRIAL ANGIOGRAPHY CPT 93543 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE LEFT VENTRICULAR OR LEFT ATRIAL ANGIOGRAPHY CPT 93544 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR AORTOGRAPHY CPT 93545 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE CORONARY ANGIOGRAPHY (INJECTION OF RADIOPAQUE MATERIAL MAY BE BY HAND) 2,752 2,801 2,791 130 410 56 249 132 95 284 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 330 of 380

CPT 93555 IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR INJECTION 224 PROCEDURE(S) DURING CARDIAC CATHETERIZATION; VENTRICULAR AND/OR ATRIAL ANGIOGRAPHY CPT 93556 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 93561 INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, 156 INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; WITH CARDIAC OUTPUT MEASUREMENT (SEPARATE PROCEDURE) CPT 93562 INDICATOR DILUTION STUDIES SUCH AS DYE OR THERMAL DILUTION, 24 INCLUDING ARTERIAL AND/OR VENOUS CATHETERIZATION; SUBSEQUENT MEASUREMENT OF CARDIAC OUTPUT CPT 93571 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 93572 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 93580 PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL 3,603 COMMUNICATION (IE, FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT CPT 93581 PERCUTANEOUS TRANSCATHETER CLOSURE OF A CONGENITAL 4,741 VENTRICULAR SEPTAL DEFECT WITH IMPLANT CPT 93600 BUNDLE OF HIS RECORDING 679 CPT 93602 INTRA-ATRIAL RECORDING 197 CPT 93603 RIGHT VENTRICULAR RECORDING 643 CPT 93609 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 93610 INTRA-ATRIAL PACING 766 CPT 93612 INTRAVENTRICULAR PACING 796 CPT 93613 INTRACARDIAC ELECTROPHYSIOLOGIC 3-DIMENSIONAL MAPPING (LIST 1,405 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 93615 ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT 226 VENTRICULAR ELECTROGRAM(S); CPT 93616 ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT 323 VENTRICULAR ELECTROGRAM(S); WITH PACING CPT 93618 INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING 1,367 CPT 93619 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: 01.03.2015 Page No(s): 331 of 380

CPT 93620 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 93621 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 93622 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 93623 PROGRAMMED STIMULATION AND PACING AFTER INTRAVENOUS DRUG 730 INFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 93624 ELECTROPHYSIOLOGIC FOLLOW-UP STUDY WITH PACING AND RECORDING 1,214 TO TEST EFFECTIVENESS OF THERAPY, INCLUDING INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA CPT 93631 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 93640 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 93641 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 93642 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 93650 INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE 2,142 FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT CPT 93651 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 93652 INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; FOR 3,553 TREATMENT OF VENTRICULAR TACHYCARDIA CPT 93660 EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE 626 EVALUATION, WITH CONTINUOUS ECG MONITORING AND INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION CPT 93662 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: 01.03.2015 Page No(s): 332 of 380

INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 93668 PERIPHERAL ARTERIAL DISEASE (PAD) REHABILITATION, PER SESSION 19 CPT 93701 BIOIMPEDANCE, THORACIC, ELECTRICAL 112 CPT 93720 PLETHYSMOGRAPHY, TOTAL BODY; WITH INTERPRETATION AND REPORT 177 CPT 93721 PLETHYSMOGRAPHY, TOTAL BODY; TRACING ONLY, WITHOUT 149 INTERPRETATION AND REPORT CPT 93722 PLETHYSMOGRAPHY, TOTAL BODY; INTERPRETATION AND REPORT ONLY 27 CPT 93724 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 93727 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 93731 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 93732 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 93733 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 93734 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 93735 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 93736 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 93740 TEMPERATURE GRADIENT STUDIES 27 CPT 93741 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: 01.03.2015 Page No(s): 333 of 380

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 93742 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 93743 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 93744 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 93745 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 93760 THERMOGRAM; CEPHALIC 171 CPT 93762 THERMOGRAM; PERIPHERAL 189 CPT 93770 DETERMINATION OF VENOUS PRESSURE 27 CPT 93784 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 93786 AMBULATORY BLOOD PRESSURE MONITORING, UTILIZING A SYSTEM 103 SUCH AS MAGNETIC TAPE AND/OR COMPUTER DISK, FOR 24 HOURS OR LONGER; RECORDING ONLY CPT 93788 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 93790 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 93797 PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; 23 WITHOUT CONTINUOUS ECG MONITORING (PER SESSION) CPT 93798 PHYSICIAN SERVICES FOR OUTPATIENT CARDIAC REHABILITATION; WITH 33 CONTINUOUS ECG MONITORING (PER SESSION) CPT 93799 UNLISTED CARDIOVASCULAR SERVICE OR PROCEDURE N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 334 of 380

CPT 93875 NONINVASIVE PHYSIOLOGIC STUDIES OF EXTRACRANIAL ARTERIES, 363 COMPLETE BILATERAL STUDY (EG, PERIORBITAL FLOW DIRECTION WITH ARTERIAL COMPRESSION, OCULAR PNEUMOPLETHYSMOGRAPHY, DOPPLER ULTRASOUND SPECTRAL ANALYSIS) CPT 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; COMPLETE BILATERAL STUDY 899 CPT 93882 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; UNILATERAL OR LIMITED STUDY CPT 93886 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; COMPLETE STUDY CPT 93888 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; LIMITED STUDY CPT 93890 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; VASOREACTIVITY STUDY CPT 93892 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITHOUT INTRAVENOUS MICROBUBBLE INJECTION CPT 93893 TRANSCRANIAL DOPPLER STUDY OF THE INTRACRANIAL ARTERIES; EMBOLI DETECTION WITH INTRAVENOUS MICROBUBBLE INJECTION CPT 93922 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 93923 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 93924 NONINVASIVE PHYSIOLOGIC STUDIES OF LOWER EXTREMITY ARTERIES, AT REST AND FOLLOWING TREADMILL STRESS TESTING, COMPLETE BILATERAL STUDY CPT 93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY CPT 93926 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT 93930 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; COMPLETE BILATERAL STUDY CPT 93931 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES OR ARTERIAL BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT 93965 NONINVASIVE PHYSIOLOGIC STUDIES OF EXTREMITY VEINS, COMPLETE BILATERAL STUDY (EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, PHLEBORHEOGRAPHY, IMPEDANCE PLETHYSMOGRAPHY) CPT 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; COMPLETE BILATERAL STUDY CPT 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY CPT 93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY CPT 93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY CPT 93978 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY 601 1,059 737 993 1,063 1,082 441 678 848 1,131 730 896 599 440 332 606 1,361 772 894 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 335 of 380

CPT 93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR 612 BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY CPT 93980 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE 648 VESSELS; COMPLETE STUDY CPT 93981 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE 454 VESSELS; FOLLOW-UP OR LIMITED STUDY CPT 93982 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 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS (INCLUDING ARTERIAL INFLOW, 721 BODY OF ACCESS AND VENOUS OUTFLOW) CPT 94002 VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 305 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; HOSPITAL INPATIENT/OBSERVATION, INITIAL DAY CPT 94003 VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 220 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; HOSPITAL INPATIENT/OBSERVATION, EACH SUBSEQUENT DAY CPT 94004 VENTILATION ASSIST AND MANAGEMENT, INITIATION OF PRESSURE OR 159 VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; NURSING FACILITY, PER DAY CPT 94005 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 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, TOTAL AND TIMED VITAL 118 CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION CPT 94014 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 94015 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 94016 PATIENT-INITIATED SPIROMETRIC RECORDING PER 30-DAY PERIOD OF 85 TIME; PHYSICIAN REVIEW AND INTERPRETATION ONLY CPT 94060 BRONCHODILATION RESPONSIVENESS, SPIROMETRY AS IN 94010, PRE- 213 AND POST-BRONCHODILATOR ADMINISTRATION CPT 94070 BRONCHOSPASM PROVOCATION EVALUATION, MULTIPLE SPIROMETRIC 217 DETERMINATIONS AS IN 94010, WITH ADMINISTERED AGENTS (EG, ANTIGEN[S], COLD AIR, METHACHOLINE) CPT 94150 VITAL CAPACITY, TOTAL (SEPARATE PROCEDURE) 26 CPT 94200 MAXIMUM BREATHING CAPACITY, MAXIMAL VOLUNTARY VENTILATION 81 CPT 94240 FUNCTIONAL RESIDUAL CAPACITY OR RESIDUAL VOLUME: HELIUM 143 METHOD, NITROGEN OPEN CIRCUIT METHOD, OR OTHER METHOD CPT 94250 EXPIRED GAS COLLECTION, QUANTITATIVE, SINGLE PROCEDURE 29 (SEPARATE PROCEDURE) CPT 94260 THORACIC GAS VOLUME 118 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 336 of 380

CPT 94350 DETERMINATION OF MALDISTRIBUTION OF INSPIRED GAS: MULTIPLE 115 BREATH NITROGEN WASHOUT CURVE INCLUDING ALVEOLAR NITROGEN OR HELIUM EQUILIBRATION TIME CPT 94360 DETERMINATION OF RESISTANCE TO AIRFLOW, OSCILLATORY OR 161 PLETHYSMOGRAPHIC METHODS CPT 94370 DETERMINATION OF AIRWAY CLOSING VOLUME, SINGLE BREATH TESTS 112 CPT 94375 RESPIRATORY FLOW VOLUME LOOP 134 CPT 94400 BREATHING RESPONSE TO CO2 (CO2 RESPONSE CURVE) 191 CPT 94450 BREATHING RESPONSE TO HYPOXIA (HYPOXIA RESPONSE CURVE) 182 CPT 94452 HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN INTERPRETATION AND REPORT; CPT 94453 HIGH ALTITUDE SIMULATION TEST (HAST), WITH PHYSICIAN INTERPRETATION AND REPORT; WITH SUPPLEMENTAL OXYGEN TITRATION CPT 94610 INTRAPULMONARY SURFACTANT ADMINISTRATION BY A PHYSICIAN THROUGH ENDOTRACHEAL TUBE CPT 94620 PULMONARY STRESS TESTING; SIMPLE (EG, 6-MINUTE WALK TEST, PROLONGED EXERCISE TEST FOR BRONCHOSPASM WITH PRE- AND POST- SPIROMETRY AND OXIMETRY) CPT 94621 PULMONARY STRESS TESTING; COMPLEX (INCLUDING MEASUREMENTS OF CO2 PRODUCTION, O2 UPTAKE, AND ELECTROCARDIOGRAPHIC RECORDINGS) CPT 94640 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 94642 AEROSOL INHALATION OF PENTAMIDINE FOR PNEUMOCYSTIS CARINII PNEUMONIA TREATMENT OR PROPHYLAXIS CPT 94644 CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; FIRST HOUR CPT 94645 CONTINUOUS INHALATION TREATMENT WITH AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 94660 CONTINUOUS POSITIVE AIRWAY PRESSURE VENTILATION (CPAP), INITIATION AND MANAGEMENT CPT 94662 CONTINUOUS NEGATIVE PRESSURE VENTILATION (CNP), INITIATION AND MANAGEMENT CPT 94664 DEMONSTRATION AND/OR EVALUATION OF PATIENT UTILIZATION OF AN AEROSOL GENERATOR, NEBULIZER, METERED DOSE INHALER OR IPPB DEVICE CPT 94667 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; INITIAL DEMONSTRATION AND/OR EVALUATION CPT 94668 MANIPULATION CHEST WALL, SUCH AS CUPPING, PERCUSSING, AND VIBRATION TO FACILITATE LUNG FUNCTION; SUBSEQUENT CPT 94680 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST AND EXERCISE, DIRECT, SIMPLE CPT 94681 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; INCLUDING CO2 OUTPUT, PERCENTAGE OXYGEN EXTRACTED CPT 94690 OXYGEN UPTAKE, EXPIRED GAS ANALYSIS; REST, INDIRECT (SEPARATE PROCEDURE) CPT 94720 CARBON MONOXIDE DIFFUSING CAPACITY (EG, SINGLE BREATH, STEADY STATE) 203 268 221 196 599 18 146 123 46 202 124 20 27 66 174 176 146 186 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 337 of 380

CPT 94725 MEMBRANE DIFFUSION CAPACITY 172 CPT 94750 PULMONARY COMPLIANCE STUDY (EG, PLETHYSMOGRAPHY, VOLUME AND 258 PRESSURE MEASUREMENTS) CPT 94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 10 SINGLE DETERMINATION CPT 94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; 21 MULTIPLE DETERMINATIONS (EG, DURING EXERCISE) CPT 94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR OXYGEN SATURATION; BY 118 CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE) CPT 94770 CARBON DIOXIDE, EXPIRED GAS DETERMINATION BY INFRARED 130 ANALYZER CPT 94772 CIRCADIAN RESPIRATORY PATTERN RECORDING (PEDIATRIC N/A PNEUMOGRAM), 12-24 HOUR CONTINUOUS RECORDING, INFANT CPT 94774 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 94775 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 94776 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 94777 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 94799 UNLISTED PULMONARY SERVICE OR PROCEDURE N/A CPT 95004 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 95010 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, PRICK) SEQUENTIAL AND 21 INCREMENTAL, WITH DRUGS, BIOLOGICALS OR VENOMS, IMMEDIATE TYPE REACTION, SPECIFY NUMBER OF TESTS CPT 95012 NITRIC OXIDE EXPIRED GAS DETERMINATION 62 CPT 95015 INTRACUTANEOUS (INTRADERMAL) TESTS, SEQUENTIAL AND 46 INCREMENTAL, WITH DRUGS, BIOLOGICALS, OR VENOMS, IMMEDIATE TYPE REACTION, SPECIFY NUMBER OF TESTS CPT 95024 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, 23 IMMEDIATE TYPE REACTION, INCLUDING TEST INTERPRETATION AND REPORT BY A PHYSICIAN, SPECIFY NUMBER OF TESTS CPT 95027 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 95028 INTRACUTANEOUS (INTRADERMAL) TESTS WITH ALLERGENIC EXTRACTS, 14 DELAYED TYPE REACTION, INCLUDING READING, SPECIFY NUMBER OF TESTS CPT 95044 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: 01.03.2015 Page No(s): 338 of 380

CPT 95052 PHOTO PATCH TEST(S) (SPECIFY NUMBER OF TESTS) 21 CPT 95056 PHOTO TESTS 158 CPT 95060 OPHTHALMIC MUCOUS MEMBRANE TESTS 94 CPT 95065 DIRECT NASAL MUCOUS MEMBRANE TEST 32 CPT 95070 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH HISTAMINE, METHACHOLINE, OR SIMILAR COMPOUNDS CPT 95071 INHALATION BRONCHIAL CHALLENGE TESTING (NOT INCLUDING NECESSARY PULMONARY FUNCTION TESTS); WITH ANTIGENS OR GASES, SPECIFY CPT 95075 INGESTION CHALLENGE TEST (SEQUENTIAL AND INCREMENTAL INGESTION OF TEST ITEMS, EG, FOOD, DRUG OR OTHER SUBSTANCE SUCH AS METABISULFITE) CPT 95115 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION CPT 95117 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY NOT INCLUDING PROVISION OF ALLERGENIC EXTRACTS; TWO OR MORE INJECTIONS CPT 95120 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE INJECTION CPT 95125 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; TWO OR MORE INJECTIONS CPT 95130 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; SINGLE STINGING INSECT VENOM CPT 95131 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; TWO STINGING INSECT VENOMS CPT 95132 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; THREE STINGING INSECT VENOMS CPT 95133 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; FOUR STINGING INSECT VENOMS CPT 95134 PROFESSIONAL SERVICES FOR ALLERGEN IMMUNOTHERAPY IN PRESCRIBING PHYSICIANS OFFICE OR INSTITUTION, INCLUDING PROVISION OF ALLERGENIC EXTRACT; FIVE STINGING INSECT VENOMS CPT 95144 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY, SINGLE DOSE VIAL(S) (SPECIFY NUMBER OF VIALS) CPT 95145 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); SINGLE STINGING INSECT VENOM CPT 95146 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); TWO SINGLE STINGING INSECT VENOMS CPT 95147 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY NUMBER OF DOSES); THREE SINGLE STINGING INSECT VENOMS CPT 95148 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY (SPECIFY 104 125 208 31 13 53 22 88 112 135 164 196 15 19 34 33 48 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 339 of 380

NUMBER OF DOSES); FOUR SINGLE STINGING INSECT VENOMS CPT 95149 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 95165 PROFESSIONAL SERVICES FOR THE SUPERVISION OF PREPARATION AND 15 PROVISION OF ANTIGENS FOR ALLERGEN IMMUNOTHERAPY; SINGLE OR MULTIPLE ANTIGENS (SPECIFY NUMBER OF DOSES) CPT 95170 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 95180 RAPID DESENSITIZATION PROCEDURE, EACH HOUR (EG, INSULIN, 466 PENICILLIN, EQUINE SERUM) CPT 95199 UNLISTED ALLERGY/CLINICAL IMMUNOLOGIC SERVICE OR PROCEDURE N/A CPT 95250 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 95251 AMBULATORY CONTINUOUS GLUCOSE MONITORING OF INTERSTITIAL 142 TISSUE FLUID VIA A SUBCUTANEOUS SENSOR FOR UP TO 72 HOURS; PHYSICIAN INTERPRETATION AND REPORT CPT 95805 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 95806 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, 752 RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, UNATTENDED BY A TECHNOLOGIST CPT 95807 SLEEP STUDY, SIMULTANEOUS RECORDING OF VENTILATION, 1,821 RESPIRATORY EFFORT, ECG OR HEART RATE, AND OXYGEN SATURATION, ATTENDED BY A TECHNOLOGIST CPT 95808 POLYSOMNOGRAPHY; SLEEP STAGING WITH 1-3 ADDITIONAL 2,386 PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST CPT 95810 POLYSOMNOGRAPHY; SLEEP STAGING WITH 4 OR MORE ADDITIONAL 2,745 PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST CPT 95811 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 95812 ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; 41-60 899 MINUTES CPT 95813 ELECTROENCEPHALOGRAM (EEG) EXTENDED MONITORING; GREATER 1,063 THAN ONE HOUR CPT 95816 ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING AWAKE AND 820 DROWSY CPT 95819 ELECTROENCEPHALOGRAM (EEG); INCLUDING RECORDING AWAKE AND 334 ASLEEP CPT 95822 ELECTROENCEPHALOGRAM (EEG); RECORDING IN COMA OR SLEEP ONLY 854 CPT 95824 ELECTROENCEPHALOGRAM (EEG); CEREBRAL DEATH EVALUATION ONLY 336 CPT 95827 ELECTROENCEPHALOGRAM (EEG); ALL NIGHT RECORDING 1,612 CPT 95829 ELECTROCORTICOGRAM AT SURGERY (SEPARATE PROCEDURE) 3,961 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 340 of 380

CPT 95830 INSERTION BY PHYSICIAN OF SPHENOIDAL ELECTRODES FOR 216 ELECTROENCEPHALOGRAPHIC (EEG) RECORDING CPT 95831 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 86 EXTREMITY (EXCLUDING HAND) OR TRUNK CPT 95832 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 85 HAND, WITH OR WITHOUT COMPARISON WITH NORMAL SIDE CPT 95833 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 45 TOTAL EVALUATION OF BODY, EXCLUDING HANDS CPT 95834 MUSCLE TESTING, MANUAL (SEPARATE PROCEDURE) WITH REPORT; 147 TOTAL EVALUATION OF BODY, INCLUDING HANDS CPT 95851 RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 19 PROCEDURE); EACH EXTREMITY (EXCLUDING HAND) OR EACH TRUNK SECTION (SPINE) CPT 95852 RANGE OF MOTION MEASUREMENTS AND REPORT (SEPARATE 16 PROCEDURE); HAND, WITH OR WITHOUT COMPARISON WITH NORMAL SIDE CPT 95857 TENSILON TEST FOR MYASTHENIA GRAVIS 142 CPT 95860 NEEDLE ELECTROMYOGRAPHY; ONE EXTREMITY WITH OR WITHOUT 275 RELATED PARASPINAL AREAS CPT 95861 NEEDLE ELECTROMYOGRAPHY; TWO EXTREMITIES WITH OR WITHOUT 419 RELATED PARASPINAL AREAS CPT 95863 NEEDLE ELECTROMYOGRAPHY; THREE EXTREMITIES WITH OR WITHOUT 495 RELATED PARASPINAL AREAS CPT 95864 NEEDLE ELECTROMYOGRAPHY; FOUR EXTREMITIES WITH OR WITHOUT 546 RELATED PARASPINAL AREAS CPT 95865 NEEDLE ELECTROMYOGRAPHY; LARYNX 386 CPT 95866 NEEDLE ELECTROMYOGRAPHY; HEMIDIAPHRAGM 336 CPT 95867 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLE(S), UNILATERAL CPT 95868 NEEDLE ELECTROMYOGRAPHY; CRANIAL NERVE SUPPLIED MUSCLES, BILATERAL CPT 95869 NEEDLE ELECTROMYOGRAPHY; THORACIC PARASPINAL MUSCLES (EXCLUDING T1 OR T12) CPT 95870 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 95872 NEEDLE ELECTROMYOGRAPHY USING SINGLE FIBER ELECTRODE, WITH QUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED CPT 95873 ELECTRICAL STIMULATION FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 95874 NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 95875 ISCHEMIC LIMB EXERCISE TEST WITH SERIAL SPECIMEN(S) ACQUISITION FOR MUSCLE(S) METABOLITE(S) CPT 95900 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITHOUT F-WAVE STUDY CPT 95903 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; MOTOR, WITH F-WAVE STUDY CPT 95904 NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY, EACH NERVE; SENSORY 252 346 181 176 585 179 171 338 173 207 153 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 341 of 380

CPT 95920 INTRAOPERATIVE NEUROPHYSIOLOGY TESTING, PER HOUR (LIST 511 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 95921 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 95922 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 95923 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 95925 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 95926 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 95927 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 95928 CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL MOTOR 696 STIMULATION); UPPER LIMBS CPT 95929 CENTRAL MOTOR EVOKED POTENTIAL STUDY (TRANSCRANIAL MOTOR 736 STIMULATION); LOWER LIMBS CPT 95930 VISUAL EVOKED POTENTIAL (VEP) TESTING CENTRAL NERVOUS SYSTEM, 380 CHECKERBOARD OR FLASH CPT 95933 ORBICULARIS OCULI (BLINK) REFLEX, BY ELECTRODIAGNOSTIC TESTING 226 CPT 95934 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD GASTROCNEMIUS/SOLEUS MUSCLE CPT 95936 H-REFLEX, AMPLITUDE AND LATENCY STUDY; RECORD MUSCLE OTHER THAN GASTROCNEMIUS/SOLEUS MUSCLE CPT 95937 NEUROMUSCULAR JUNCTION TESTING (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY ONE METHOD CPT 95950 MONITORING FOR IDENTIFICATION AND LATERALIZATION OF CEREBRAL SEIZURE FOCUS, ELECTROENCEPHALOGRAPHIC (EG, 8 CHANNEL EEG) RECORDING AND INTERPRETATION, EACH 24 HOURS CPT 95951 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 95953 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS BY COMPUTERIZED PORTABLE 16 OR MORE CHANNEL EEG, ELECTROENCEPHALOGRAPHIC (EEG) RECORDING AND INTERPRETATION, EACH 24 HOURS CPT 95954 PHARMACOLOGICAL OR PHYSICAL ACTIVATION REQUIRING PHYSICIAN ATTENDANCE DURING EEG RECORDING OF ACTIVATION PHASE (EG, THIOPENTAL ACTIVATION TEST) CPT 95955 ELECTROENCEPHALOGRAM (EEG) DURING NONINTRACRANIAL SURGERY (EG, CAROTID SURGERY) 176 149 210 874 928 1,399 883 502 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 342 of 380

CPT 95956 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 95957 DIGITAL ANALYSIS OF ELECTROENCEPHALOGRAM (EEG) (EG, FOR 1,014 EPILEPTIC SPIKE ANALYSIS) CPT 95958 WADA ACTIVATION TEST FOR HEMISPHERIC FUNCTION, INCLUDING 1,419 ELECTROENCEPHALOGRAPHIC (EEG) MONITORING CPT 95961 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 95962 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 95965 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR 2,501 SPONTANEOUS BRAIN MAGNETIC ACTIVITY (EG, EPILEPTIC CEREBRAL CORTEX LOCALIZATION) CPT 95966 MAGNETOENCEPHALOGRAPHY (MEG), RECORDING AND ANALYSIS; FOR 1,239 EVOKED MAGNETIC FIELDS, SINGLE MODALITY (EG, SENSORY, MOTOR, LANGUAGE, OR VISUAL CORTEX LOCALIZATION) CPT 95967 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 95970 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 95971 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 95972 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 95973 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: 01.03.2015 Page No(s): 343 of 380

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 95974 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 95975 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 95978 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 95979 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 95980 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 95981 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 95982 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 95990 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: 01.03.2015 Page No(s): 344 of 380

CPT 95991 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR 111 FOR DRUG DELIVERY, SPINAL (INTRATHECAL, EPIDURAL) OR BRAIN (INTRAVENTRICULAR); ADMINISTERED BY PHYSICIAN CPT 95999 UNLISTED NEUROLOGICAL OR NEUROMUSCULAR DIAGNOSTIC N/A PROCEDURE CPT 96000 COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO-TAPING 295 AND 3-D KINEMATICS; CPT 96001 COMPREHENSIVE COMPUTER-BASED MOTION ANALYSIS BY VIDEO-TAPING 353 AND 3-D KINEMATICS; WITH DYNAMIC PLANTAR PRESSURE MEASUREMENTS DURING WALKING CPT 96002 DYNAMIC SURFACE ELECTROMYOGRAPHY, DURING WALKING OR OTHER 66 FUNCTIONAL ACTIVITIES, 1-12 MUSCLES CPT 96003 DYNAMIC FINE WIRE ELECTROMYOGRAPHY, DURING WALKING OR OTHER 60 FUNCTIONAL ACTIVITIES, 1 MUSCLE CPT 96004 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 96020 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 96040 MEDICAL GENETICS AND GENETIC COUNSELING SERVICES, EACH 30 124 MINUTES FACE-TO-FACE WITH PATIENT/FAMILY CPT 96101 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 96102 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 96103 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 96105 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 96110 DEVELOPMENTAL TESTING; LIMITED (EG, DEVELOPMENTAL SCREENING 46 TEST II, EARLY LANGUAGE MILESTONE SCREEN), WITH INTERPRETATION AND REPORT CPT 96111 DEVELOPMENTAL TESTING; EXTENDED (INCLUDES ASSESSMENT OF 436 MOTOR, LANGUAGE, SOCIAL, ADAPTIVE AND/OR COGNITIVE FUNCTIONING BY STANDARDIZED DEVELOPMENTAL INSTRUMENTS) WITH INTERPRETATION AND REPORT CPT 96116 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: 01.03.2015 Page No(s): 345 of 380

INTERPRETING TEST RESULTS AND PREPARING THE REPORT CPT 96118 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 96119 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 96120 NEUROPSYCHOLOGICAL TESTING (EG, WISCONSIN CARD SORTING TEST), ADMINISTERED BY A COMPUTER, WITH QUALIFIED HEALTH CARE PROFESSIONAL INTERPRETATION AND REPORT CPT 96125 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 96150 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 96151 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 96152 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; INDIVIDUAL CPT 96153 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; GROUP (2 OR MORE PATIENTS) CPT 96154 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; FAMILY (WITH THE PATIENT PRESENT) CPT 96155 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO- FACE; FAMILY (WITHOUT THE PATIENT PRESENT) CPT 96401 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; NON-HORMONAL ANTI-NEOPLASTIC CPT 96402 CHEMOTHERAPY ADMINISTRATION, SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC CPT 96405 CHEMOTHERAPY ADMINISTRATION; INTRALESIONAL, UP TO AND INCLUDING 7 LESIONS CPT 96406 CHEMOTHERAPY ADMINISTRATION; INTRALESIONAL, MORE THAN 7 LESIONS CPT 96409 CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH TECHNIQUE, SINGLE OR INITIAL SUBSTANCE/DRUG CPT 96411 CHEMOTHERAPY ADMINISTRATION; INTRAVENOUS, PUSH TECHNIQUE, EACH ADDITIONAL SUBSTANCE/DRUG (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 96413 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; UP TO 1 HOUR, SINGLE OR INITIAL SUBSTANCE/DRUG CPT 96415 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 96416 CHEMOTHERAPY ADMINISTRATION, INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN 8 362 284 279 329 76 74 70 16 69 70 261 123 192 202 390 221 503 115 551 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 346 of 380

HOURS), REQUIRING USE OF A PORTABLE OR IMPLANTABLE PUMP CPT 96417 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 96420 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; PUSH TECHNIQUE 381 CPT 96422 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION 597 TECHNIQUE, UP TO ONE HOUR CPT 96423 CHEMOTHERAPY ADMINISTRATION, INTRA-ARTERIAL; INFUSION 274 TECHNIQUE, EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 96425 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 96440 CHEMOTHERAPY ADMINISTRATION INTO PLEURAL CAVITY, REQUIRING 1,019 AND INCLUDING THORACENTESIS CPT 96445 CHEMOTHERAPY ADMINISTRATION INTO PERITONEAL CAVITY, REQUIRING 351 AND INCLUDING PERITONEOCENTESIS CPT 96450 CHEMOTHERAPY ADMINISTRATION, INTO CNS (EG, INTRATHECAL), 300 REQUIRING AND INCLUDING SPINAL PUNCTURE CPT 96521 REFILLING AND MAINTENANCE OF PORTABLE PUMP 431 CPT 96522 REFILLING AND MAINTENANCE OF IMPLANTABLE PUMP OR RESERVOIR 383 FOR DRUG DELIVERY, SYSTEMIC (EG, INTRAVENOUS, INTRA-ARTERIAL) CPT 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS DEVICE FOR DRUG 31 DELIVERY SYSTEMS CPT 96542 CHEMOTHERAPY INJECTION, SUBARACHNOID OR INTRAVENTRICULAR VIA 198 SUBCUTANEOUS RESERVOIR, SINGLE OR MULTIPLE AGENTS CPT 96549 UNLISTED CHEMOTHERAPY PROCEDURE N/A CPT 96567 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 96570 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 96571 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 96900 ACTINOTHERAPY (ULTRAVIOLET LIGHT) 27 CPT 96902 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 96904 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 66 240 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 347 of 380

CPT 96910 PHOTOCHEMOTHERAPY; TAR AND ULTRAVIOLET B (GOECKERMAN 258 TREATMENT) OR PETROLATUM AND ULTRAVIOLET B CPT 96912 PHOTOCHEMOTHERAPY; PSORALENS AND ULTRAVIOLET A (PUVA) 331 CPT 96913 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 96920 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 215 TOTAL AREA LESS THAN 250 SQ CM CPT 96921 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 250 570 SQ CM TO 500 SQ CM CPT 96922 LASER TREATMENT FOR INFLAMMATORY SKIN DISEASE (PSORIASIS); 853 OVER 500 SQ CM CPT 96999 UNLISTED SPECIAL DERMATOLOGICAL SERVICE OR PROCEDURE N/A CPT 97001 PHYSICAL THERAPY EVALUATION 86 CPT 97002 PHYSICAL THERAPY RE-EVALUATION 46 CPT 97003 OCCUPATIONAL THERAPY EVALUATION 91 CPT 97004 OCCUPATIONAL THERAPY RE-EVALUATION 146 CPT 97005 ATHLETIC TRAINING EVALUATION 199 CPT 97006 ATHLETIC TRAINING RE-EVALUATION 99 CPT 97010 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HOT OR COLD 17 PACKS CPT 97012 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; TRACTION, 18 MECHANICAL CPT 97014 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL 17 STIMULATION (UNATTENDED) CPT 97016 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; VASOPNEUMATIC 19 DEVICES CPT 97018 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; PARAFFIN BATH 11 CPT 97022 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; WHIRLPOOL 23 CPT 97024 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; DIATHERMY (EG, 18 MICROWAVE) CPT 97026 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; INFRARED 17 CPT 97028 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRAVIOLET 21 CPT 97032 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES CPT 97033 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES CPT 97034 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES CPT 97035 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES CPT 97036 APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH 15 MINUTES 21 32 19 14 33 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 348 of 380

CPT 97039 UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT N/A ATTENDANCE) CPT 97110 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 36 THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY CPT 97112 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 97113 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 44 AQUATIC THERAPY WITH THERAPEUTIC EXERCISES CPT 97116 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 31 GAIT TRAINING (INCLUDES STAIR CLIMBING) CPT 97124 THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; 28 MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION) CPT 97139 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) N/A CPT 97140 MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, 33 MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES CPT 97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) 22 CPT 97530 THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY 37 THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES CPT 97532 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 97533 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 97535 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 97537 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 97542 WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), 34 EACH 15 MINUTES CPT 97545 WORK HARDENING/CONDITIONING; INITIAL 2 HOURS 401 CPT 97546 WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 97597 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 56 78 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 349 of 380

CENTIMETERS CPT 97598 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 97602 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 97605 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 97606 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 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES CPT 97755 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 97760 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 97761 PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES CPT 97762 CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED PATIENT, EACH 15 MINUTES CPT 97799 UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE CPT 97802 MEDICAL NUTRITION THERAPY; INITIAL ASSESSMENT AND INTERVENTION, INDIVIDUAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES CPT 97803 MEDICAL NUTRITION THERAPY; RE-ASSESSMENT AND INTERVENTION, INDIVIDUAL, FACE-TO-FACE WITH THE PATIENT, EACH 15 MINUTES CPT 97804 MEDICAL NUTRITION THERAPY; GROUP (2 OR MORE INDIVIDUAL(S)), EACH 30 MINUTES CPT 97810 ACUPUNCTURE, 1 OR MORE NEEDLES; WITHOUT ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT CPT 97811 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 97813 ACUPUNCTURE, 1 OR MORE NEEDLES; WITH ELECTRICAL STIMULATION, INITIAL 15 MINUTES OF PERSONAL ONE-ON-ONE CONTACT WITH THE PATIENT 96 42 44 47 36 114 113 36 45 N/A 27 22 15 40 31 119 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 350 of 380

CPT 97814 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 98925 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); ONE TO TWO BODY 34 REGIONS INVOLVED CPT 98926 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); THREE TO FOUR BODY 48 REGIONS INVOLVED CPT 98927 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); FIVE TO SIX BODY 61 REGIONS INVOLVED CPT 98928 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); SEVEN TO EIGHT BODY 71 REGIONS INVOLVED CPT 98929 OSTEOPATHIC MANIPULATIVE TREATMENT (OMT); NINE TO TEN BODY 82 REGIONS INVOLVED CPT 98940 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, ONE TO TWO 30 REGIONS CPT 98941 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, THREE TO 42 FOUR REGIONS CPT 98942 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); SPINAL, FIVE REGIONS 55 CPT 98943 CHIROPRACTIC MANIPULATIVE TREATMENT (CMT); EXTRASPINAL, ONE OR MORE REGIONS CPT 98960 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 98961 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 98962 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 98966 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 98967 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; 11-20 MINUTES OF MEDICAL DISCUSSION CPT 98968 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; 21-30 MINUTES OF MEDICAL 26 27 36 26 16 30 44 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 351 of 380

DISCUSSION CPT 98969 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 99000 HANDLING AND/OR CONVEYANCE OF SPECIMEN FOR TRANSFER FROM THE 2 PHYSICIAN'S OFFICE TO A LABORATORY CPT 99001 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 99002 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 99024 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 99026 HOSPITAL MANDATED ON CALL SERVICE; IN-HOSPITAL, EACH HOUR N/A CPT 99027 HOSPITAL MANDATED ON CALL SERVICE; OUT-OF-HOSPITAL, EACH HOUR N/A CPT 99050 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 99051 SERVICE(S) PROVIDED IN THE OFFICE DURING REGULARLY SCHEDULED N/A EVENING, WEEKEND, OR HOLIDAY OFFICE HOURS, IN ADDITION TO BASIC SERVICE CPT 99053 SERVICE(S) PROVIDED BETWEEN 10:00 PM AND 8:00 AM AT 24-HOUR N/A FACILITY, IN ADDITION TO BASIC SERVICE CPT 99056 SERVICE(S) TYPICALLY PROVIDED IN THE OFFICE, PROVIDED OUT OF THE N/A OFFICE AT REQUEST OF PATIENT, IN ADDITION TO BASIC SERVICE CPT 99058 SERVICE(S) PROVIDED ON AN EMERGENCY BASIS IN THE OFFICE, WHICH 28 DISRUPTS OTHER SCHEDULED OFFICE SERVICES, IN ADDITION TO BASIC SERVICE CPT 99060 SERVICE(S) PROVIDED ON AN EMERGENCY BASIS, OUT OF THE OFFICE, 32 WHICH DISRUPTS OTHER SCHEDULED OFFICE SERVICES, IN ADDITION TO BASIC SERVICE CPT 99070 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 99071 EDUCATIONAL SUPPLIES, SUCH AS BOOKS, TAPES, AND PAMPHLETS, N/A PROVIDED BY THE PHYSICIAN FOR THE PATIENT'S EDUCATION AT COST TO PHYSICIAN CPT 99075 MEDICAL TESTIMONY N/A CPT 99078 PHYSICIAN EDUCATIONAL SERVICES RENDERED TO PATIENTS IN A GROUP SETTING (EG, PRENATAL, OBESITY, OR DIABETIC INSTRUCTIONS) CPT 99080 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: 01.03.2015 Page No(s): 352 of 380

CPT 99082 UNUSUAL TRAVEL (EG, TRANSPORTATION AND ESCORT OF PATIENT) N/A CPT 99090 ANALYSIS OF CLINICAL DATA STORED IN COMPUTERS (EG, ECGS, BLOOD N/A PRESSURES, HEMATOLOGIC DATA) CPT 99091 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 99170 ANOGENITAL EXAMINATION WITH COLPOSCOPIC MAGNIFICATION IN 469 CHILDHOOD FOR SUSPECTED TRAUMA CPT 99172 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 99173 SCREENING TEST OF VISUAL ACUITY, QUANTITATIVE, BILATERAL 15 CPT 99174 OCULAR PHOTOSCREENING WITH INTERPRETATION AND REPORT, 49 BILATERAL CPT 99175 IPECAC OR SIMILAR ADMINISTRATION FOR INDIVIDUAL EMESIS AND 20 CONTINUED OBSERVATION UNTIL STOMACH ADEQUATELY EMPTIED OF POISON CPT 99183 PHYSICIAN ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN 228 THERAPY, PER SESSION CPT 99185 HYPOTHERMIA; REGIONAL 190 CPT 99186 HYPOTHERMIA; TOTAL BODY 428 CPT 99190 ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 564 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); EACH HOUR CPT 99191 ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 395 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); 45 MINUTES CPT 99192 ASSEMBLY AND OPERATION OF PUMP WITH OXYGENATOR OR HEAT 282 EXCHANGER (WITH OR WITHOUT ECG AND/OR PRESSURE MONITORING); 30 MINUTES CPT 99195 PHLEBOTOMY, THERAPEUTIC (SEPARATE PROCEDURE) 115 CPT 99199 UNLISTED SPECIAL SERVICE, PROCEDURE OR REPORT N/A CPT 99201 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 99202 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 45 78 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 353 of 380

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 99203 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 99204 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 99205 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 99211 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 99212 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 99213 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: 01.03.2015 Page No(s): 354 of 380

PROBLEM(S) ARE OF LOW TO MODERATE SEVERITY. PHYSICIANS TYPICALLY SPEND 15 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT 99214 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 99215 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 99217 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, 99234-99236 AS APPROPRIATE.]) CPT 99218 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 99219 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 99220 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: 01.03.2015 Page No(s): 355 of 380

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 99221 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 99222 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 99223 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 99231 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 99232 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 99233 SUBSEQUENT HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 118 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 356 of 380

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 99234 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 99235 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 99236 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 99238 HOSPITAL DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 81 CPT 99239 HOSPITAL DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES 118 CPT 99241 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 99242 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 60 112 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 357 of 380

PROBLEM(S) ARE OF LOW SEVERITY. PHYSICIANS TYPICALLY SPEND 30 MINUTES FACE-TO-FACE WITH THE PATIENT AND/OR FAMILY. CPT 99243 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 99244 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 99245 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 99251 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 99252 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 99253 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: 01.03.2015 Page No(s): 358 of 380

CPT 99254 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 99255 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 99281 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 99282 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 99283 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 99284 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 99285 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: 01.03.2015 Page No(s): 359 of 380

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 99288 PHYSICIAN DIRECTION OF EMERGENCY MEDICAL SYSTEMS (EMS) N/A EMERGENCY CARE, ADVANCED LIFE SUPPORT CPT 99289 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 30-74 MINUTES OF HANDS ON CARE DURING TRANSPORT CPT 99290 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 99291 CRITICAL CARE, EVALUATION AND MANAGEMENT OF THE CRITICALLY ILL 319 OR CRITICALLY INJURED PATIENT; FIRST 30-74 MINUTES CPT 99292 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 99293 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 99294 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 99295 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 99296 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 99298 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 99299 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 145 MANAGEMENT OF THE RECOVERING LOW BIRTH WEIGHT INFANT (PRESENT BODY WEIGHT OF 1500-2500 G) CPT 99300 SUBSEQUENT INTENSIVE CARE, PER DAY, FOR THE EVALUATION AND 146 MANAGEMENT OF THE RECOVERING INFANT (PRESENT BODY WEIGHT OF 2501-5000 G) CPT 99304 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: 01.03.2015 Page No(s): 360 of 380

CPT 99305 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 99306 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 99307 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 99308 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 99309 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 99310 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: 01.03.2015 Page No(s): 361 of 380

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 99315 NURSING FACILITY DISCHARGE DAY MANAGEMENT; 30 MINUTES OR LESS 71 CPT 99316 NURSING FACILITY DISCHARGE DAY MANAGEMENT; MORE THAN 30 MINUTES CPT 99318 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 99324 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 99325 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 99326 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 99327 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 92 104 66 96 159 206 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 362 of 380

FAMILY OR CAREGIVER. CPT 99328 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 99334 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 99335 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 99336 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 99337 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 99339 INDIVIDUAL PHYSICIAN SUPERVISION OF A PATIENT (PATIENT NOT PRESENT) IN HOME, DOMICILIARY OR REST HOME (EG, ASSISTED LIVING 242 69 106 148 212 84 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 363 of 380

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; 15-29 MINUTES CPT 99340 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 99341 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 99342 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 99343 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 99344 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: 01.03.2015 Page No(s): 364 of 380

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 99345 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 99347 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 99348 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 99349 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 99350 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: 01.03.2015 Page No(s): 365 of 380

CPT 99354 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 99355 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 99356 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 99357 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 99358 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 99359 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 99360 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 99363 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 99364 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 99366 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: 01.03.2015 Page No(s): 366 of 380

CPT 99367 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 99368 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 99374 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; 15-29 MINUTES CPT 99375 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 99377 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; 15-29 MINUTES CPT 99378 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: 01.03.2015 Page No(s): 367 of 380

CPT 99379 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; 15-29 MINUTES CPT 99380 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 99381 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 99382 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 99383 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 99384 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 99385 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: 01.03.2015 Page No(s): 368 of 380

LABORATORY/DIAGNOSTIC PROCEDURES, NEW PATIENT; 18-39 YEARS CPT 99386 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; 40-64 YEARS CPT 99387 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 99391 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 99392 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 99393 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 99394 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 99395 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; 18-39 YEARS CPT 99396 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; 40-64 YEARS 152 166 90 100 99 109 110 121 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 369 of 380

CPT 99397 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 99401 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 44 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 15 MINUTES CPT 99402 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 75 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 30 MINUTES CPT 99403 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 105 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 45 MINUTES CPT 99404 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 135 INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 60 MINUTES CPT 99406 SMOKING AND TOBACCO USE CESSATION COUNSELLING VISIT; 16 INTERMEDIATE, GREATER THAN 3 MINUTES UP TO 10 MINUTES CPT 99407 SMOKING AND TOBACCO USE CESSATION COUNSELLING VISIT; 31 INTENSIVE, GREATER THAN 10 MINUTES CPT 99408 ALCOHOL AND/OR SUBSTANCE (OTHER THAN TOBACCO) ABUSE 38 STRUCTURED SCREENING (EG, AUDIT, DAST), AND BRIEF INTERVENTION (SBI) SERVICES; 15 TO 30 MINUTES CPT 99409 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 99411 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 16 INTERVENTION(S) PROVIDED TO INDIVIDUALS IN A GROUP SETTING (SEPARATE PROCEDURE); APPROXIMATELY 30 MINUTES CPT 99412 PREVENTIVE MEDICINE COUNSELLING AND/OR RISK FACTOR REDUCTION 23 INTERVENTION(S) PROVIDED TO INDIVIDUALS IN A GROUP SETTING (SEPARATE PROCEDURE); APPROXIMATELY 60 MINUTES CPT 99420 ADMINISTRATION AND INTERPRETATION OF HEALTH RISK ASSESSMENT 10 INSTRUMENT (E.G., HEALTH HAZARD APPRAISAL) CPT 99429 UNLISTED PREVENTIVE MEDICINE SERVICE 22 CPT 99431 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 99432 NORMAL NEW-BORN CARE IN OTHER THAN HOSPITAL OR BIRTHING ROOM SETTING, INCLUDING PHYSICAL EXAMINATION OF BABY AND CONFERENCE(S) WITH PARENT(S) CPT 99433 SUBSEQUENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A NORMAL NEW-BORN, PER DAY CPT 99435 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 99436 ATTENDANCE AT DELIVERY (WHEN REQUESTED BY DELIVERING PHYSICIAN) AND INITIAL STABILIZATION OF NEW-BORN CPT 99440 NEW-BORN RESUSCITATION: PROVISION OF POSITIVE PRESSURE VENTILATION AND/OR CHEST COMPRESSIONS IN THE PRESENCE OF ACUTE INADEQUATE VENTILATION AND/OR CARDIAC OUTPUT 66 105 36 92 84 474 Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 370 of 380

CPT 99441 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 99442 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; 11-20 MINUTES OF MEDICAL DISCUSSION CPT 99443 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; 21-30 MINUTES OF MEDICAL DISCUSSION CPT 99444 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 99450 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 99455 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 99456 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 99477 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 99500 HOME VISIT FOR PRENATAL MONITORING AND ASSESSMENT TO INCLUDE N/A FETAL HEART RATE, NON-STRESS TEST, UTERINE MONITORING, AND GESTATIONAL DIABETES MONITORING CPT 99501 HOME VISIT FOR POSTNATAL ASSESSMENT AND FOLLOW-UP CARE N/A CPT 99502 HOME VISIT FOR NEW-BORN CARE AND ASSESSMENT N/A CPT 99503 HOME VISIT FOR RESPIRATORY THERAPY CARE (E.G., BRONCHODILATOR, N/A OXYGEN THERAPY, RESPIRATORY ASSESSMENT, APNEA EVALUATION) CPT 99504 HOME VISIT FOR MECHANICAL VENTILATION CARE N/A CPT 99505 HOME VISIT FOR STOMA CARE AND MAINTENANCE INCLUDING N/A COLOSTOMY AND CYSTOSTOMY CPT 99506 HOME VISIT FOR INTRAMUSCULAR INJECTIONS N/A Doc Ctrl No.: EXH/PM-033 Version No.: 1 Revision No.: 2 Date of Issue: 01.03.2015 Page No(s): 371 of 380

CPT 99507 HOME VISIT FOR CARE AND MAINTENANCE OF CATHETER(S) (E.G., N/A URINARY, DRAINAGE, AND ENTERAL) CPT 99509 HOME VISIT FOR ASSISTANCE WITH ACTIVITIES OF DAILY LIVING AND N/A PERSONAL CARE CPT 99510 HOME VISIT FOR INDIVIDUAL, FAMILY, OR MARRIAGE COUNSELLING N/A CPT 99511 HOME VISIT FOR FAECAL IMPACTION MANAGEMENT AND ENEMA N/A ADMINISTRATION CPT 99512 HOME VISIT FOR HAEMODIALYSIS N/A CPT 99600 UNLISTED HOME VISIT SERVICE OR PROCEDURE N/A CPT 99601 HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); CPT 99602 HOME INFUSION/SPECIALTY DRUG ADMINISTRATION, PER VISIT (UP TO 2 HOURS); EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) CPT 99605 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 99606 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 99607 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: 01.03.2015 Page No(s): 372 of 380

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: 01.03.2015 Page No(s): 373 of 380

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: 01.03.2015 Page No(s): 374 of 380

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: 01.03.2015 Page No(s): 375 of 380

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: 01.03.2015 Page No(s): 376 of 380

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: 01.03.2015 Page No(s): 377 of 380

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: 01.03.2015 Page No(s): 378 of 380

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: 01.03.2015 Page No(s): 379 of 380

Contact Us In case of any enquiry, kindly contact us on: Toll Free: 800 4 DAMAN (32626) Fax: +971 2 614 9775 P.O. Box 128888, 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: 01.03.2015 Page No(s).: 380 of 380