Your Map of the ICD-9 to ICD-10 PCS Conversion

Your Map of the ICD-9 to ICD-10 PCS Conversion

Table of Contents Disclaimer 3 Endoscopy 4 Interventional Cardiology 20 Neuromodulation 34 Peripheral Interventions 35 Rhythm Management and Electrophysiology 61 Urology 71 Women s Health 74 2

Disclaimers Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA approved label. CPT copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Advantage, Advantage Fit, Capio, Capio SLIM, Lynx, Obtryx, Obtryx II, Polyform, Solyx, Uphold and Xenform are registered trademarks of Boston Scientific Corporation or its affiliates. All other trademarks are property of their respective owners. Accordingly for mesh for stress urinary incontinence: CAUTION: Federal Law (USA) restricts this device to sale by or on the order of a physician trained in use of mesh for the repair of stress urinary incontinence. Accordingly for mesh for transvaginal repair of pelvic organ prolapse: CAUTION: Federal Law (USA) restricts this device to sale by or on the order of a physician trained in use of surgical mesh for transvaginal repair of pelvic organ prolapse. Repliform Tissue Regeneration Matrix complies with U.S. Regulations in 21 CFR part 1270 and 1271 Human Tissue Intended for Transplantation. Coaptite is manufactured by Merz Aesthetics, Inc. and distributed by Boston Scientific. Caution: Federal Law (USA) restricts the Coaptite Implant device to sale by or on the order of a physician trained in diagnostic and therapeutic cystoscopy. Please refer to package insert provided with the product for complete Indications for Use, Contraindications, Warnings, Precautions, Adverse Events and Instructions prior to using this product. This crosswalk is not a comprehensive list of all relevant ICD-10 PCS codes, rather it is a one-way mapping (ICD-9 CM > ICD-10 PCS) based on the most frequent and most relevant ICD-9 codes used in relation to Boston Scientific devices. Please refer to your coding guidelines for the most appropriate codes to reflect the services performed. Accordingly for medical devices: CAUTION: Federal Law (USA) restricts these devices to sale by or on the order of a physician. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 3

Endoscopy 51.10 Endoscopic retrograde cholangio- pancreatography (ERCP) BF110ZZ BF111ZZ BF11YZZ Fluoroscopy of Biliary and Pancreatic Ducts using High Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Low Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Other Contrast 51.11 Endoscopic retrograde cholangiography (ERC) BF100ZZ BF101ZZ BF10YZZ Fluoroscopy of Bile Ducts using High Osmolar Contrast Fluoroscopy of Bile Ducts using Low Osmolar Contrast Fluoroscopy of Bile Ducts using Other Contrast 0F954ZX Drainage of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F957ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F958ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F964ZX Drainage of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F967ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F968ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F984ZX Drainage of Cystic Duct, Percutaneous Endoscopic, Diagnostic 0F987ZX Drainage of Cystic Duct, Via Natural or Artificial Opening, Diagnostic 0F988ZX Drainage of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F994ZX Drainage of Common Bile Duct, Percutaneous Endoscopic, Diagnostic 0F997ZX Drainage of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic 51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 0F998ZX 0F9C4ZX 0F9C7ZX Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic Drainage of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 0F9C8ZX Drainage of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB44ZX Excision of Gallbladder, Percutaneous Endoscopic, Diagnostic 0FB54ZX Excision of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB57ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB58ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB64ZX Excision of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB67ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB68ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB84ZX Excision of Cystic Duct, Percutaneous Endoscopic, Diagnostic 0FB87ZX Excision of Cystic Duct, Via Natural or Artificial Opening, Diagnostic 0FB88ZX Excision of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 4

Endoscopy 0FB94ZX Excision of Common Bile Duct, Percutaneous Endoscopic, Diagnostic 51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 0FB97ZX 0FB98ZX 0FBC4ZX 0FBC7ZX Excision of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic Excision of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic Excision of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 0FBC8ZX Excision of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F753DZ Dilation of Right Hepatic Duct with Intraluminal Device, Percutaneous 0F753ZZ Dilation of Right Hepatic Duct, Percutaneous 0F763DZ Dilation of Left Hepatic Duct with Intraluminal Device, Percutaneous 0F763ZZ Dilation of Left Hepatic Duct, Percutaneous 0F783DZ Dilation of Cystic Duct with Intraluminal Device, Percutaneous 0F783ZZ Dilation of Cystic Duct, Percutaneous 0F793DZ Dilation of Common Bile Duct with Intraluminal Device, Percutaneous 0F793ZZ Dilation of Common Bile Duct, Percutaneous 0F993ZZ Drainage of Common Bile Duct, Percutaneous 0F994ZZ Drainage of Common Bile Duct, Percutaneous Endoscopic 0F997ZZ Drainage of Common Bile Duct, Via Natural or Artificial Opening 0F998ZZ Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 0FC53ZZ Extirpation of Matter from Right Hepatic Duct, Percutaneous 51.98 Other percutaneous procedures on biliary tract 0FC57ZZ 0FC63ZZ Extirpation of Matter from Right Hepatic Duct, Via Natural or Artificial Opening Extirpation of Matter from Left Hepatic Duct, Percutaneous 0FC67ZZ Extirpation of Matter from Left Hepatic Duct, Via Natural or Artificial Opening 0FC83ZZ Extirpation of Matter from Cystic Duct, Percutaneous 0FC87ZZ Extirpation of Matter from Cystic Duct, Via Natural or Artificial Opening 0FL53CZ Occlusion of Right Hepatic Duct with Extraluminal Device, Percutaneous 0FL53DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Percutaneous 0FL53ZZ Occlusion of Right Hepatic Duct, Percutaneous 0FL54CZ Occlusion of Right Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FL54DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL54ZZ Occlusion of Right Hepatic Duct, Percutaneous Endoscopic 0FL57DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL57ZZ Occlusion of Right Hepatic Duct, Via Natural or Artificial Opening 0FL58DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL58ZZ Occlusion of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FL63CZ Occlusion of Left Hepatic Duct with Extraluminal Device, Percutaneous 51.98 Other percutaneous procedures on biliary tract 0FL63DZ 0FL63ZZ Occlusion of Left Hepatic Duct with Intraluminal Device, Percutaneous Occlusion of Left Hepatic Duct, Percutaneous 0FL64CZ Occlusion of Left Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 5

Endoscopy 0FL64DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL64ZZ Occlusion of Left Hepatic Duct, Percutaneous Endoscopic 0FL67DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL67ZZ Occlusion of Left Hepatic Duct, Via Natural or Artificial Opening 0FL68DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL68ZZ Occlusion of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FL83CZ Occlusion of Cystic Duct with Extraluminal Device, Percutaneous 0FL83DZ Occlusion of Cystic Duct with Intraluminal Device, Percutaneous 0FL83ZZ Occlusion of Cystic Duct, Percutaneous 0FL84CZ Occlusion of Cystic Duct with Extraluminal Device, Percutaneous Endoscopic 0FL84DZ Occlusion of Cystic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL84ZZ Occlusion of Cystic Duct, Percutaneous Endoscopic 0FL87DZ Occlusion of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL87ZZ Occlusion of Cystic Duct, Via Natural or Artificial Opening 0FL88DZ Occlusion of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL88ZZ Occlusion of Cystic Duct, Via Natural or Artificial Opening Endoscopic 0FL93CZ Occlusion of Common Bile Duct with Extraluminal Device, Percutaneous 0FL93DZ Occlusion of Common Bile Duct with Intraluminal Device, Percutaneous 0FL93ZZ Occlusion of Common Bile Duct, Percutaneous 0FL94CZ Occlusion of Common Bile Duct with Extraluminal Device, Percutaneous Endoscopic 0FL94DZ Occlusion of Common Bile Duct with Intraluminal Device, Percutaneous Endoscopic 0FL94ZZ Occlusion of Common Bile Duct, Percutaneous Endoscopic 0FL97DZ Occlusion of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL97ZZ Occlusion of Common Bile Duct, Via Natural or Artificial Opening 0FL98DZ Occlusion of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL98ZZ Occlusion of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 0FM44ZZ Reattachment of Gallbladder, Percutaneous Endoscopic 0FM54ZZ Reattachment of Right Hepatic Duct, Percutaneous Endoscopic 0FM64ZZ Reattachment of Left Hepatic Duct, Percutaneous Endoscopic 0FM84ZZ Reattachment of Cystic Duct, Percutaneous Endoscopic 0FM94ZZ Reattachment of Common Bile Duct, Percutaneous Endoscopic 0FV53CZ Restriction of Right Hepatic Duct with Extraluminal Device, Percutaneous 51.98 Other percutaneous procedures on biliary tract 0FV53DZ 0FV53ZZ 0FV54CZ Restriction of Right Hepatic Duct with Intraluminal Device, Percutaneous Restriction of Right Hepatic Duct, Percutaneous Restriction of Right Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV54DZ Restriction of Right Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV54ZZ Restriction of Right Hepatic Duct, Percutaneous Endoscopic 0FV57DZ Restriction of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 6

Endoscopy 0FV57ZZ Restriction of Right Hepatic Duct, Via Natural or Artificial Opening 0FV58DZ Restriction of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV58ZZ Restriction of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FV63CZ Restriction of Left Hepatic Duct with Extraluminal Device, Percutaneous 0FV63DZ Restriction of Left Hepatic Duct with Intraluminal Device, Percutaneous 0FV63ZZ Restriction of Left Hepatic Duct, Percutaneous 0FV64CZ Restriction of Left Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV64DZ Restriction of Left Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV64ZZ Restriction of Left Hepatic Duct, Percutaneous Endoscopic 0FV67DZ Restriction of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FV67ZZ Restriction of Left Hepatic Duct, Via Natural or Artificial Opening 0FV68DZ Restriction of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV68ZZ Restriction of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FV83CZ Restriction of Cystic Duct with Extraluminal Device, Percutaneous 0FV83DZ Restriction of Cystic Duct with Intraluminal Device, Percutaneous 0FV83ZZ Restriction of Cystic Duct, Percutaneous 0FV84CZ Restriction of Cystic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV84DZ Restriction of Cystic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV84ZZ Restriction of Cystic Duct, Percutaneous Endoscopic 0FV87DZ Restriction of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FV87ZZ Restriction of Cystic Duct, Via Natural or Artificial Opening 0FV88DZ Restriction of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV88ZZ Restriction of Cystic Duct, Via Natural or Artificial Opening Endoscopic 0FV93CZ Restriction of Common Bile Duct with Extraluminal Device, Percutaneous 0FV93DZ Restriction of Common Bile Duct with Intraluminal Device, Percutaneous 0FV93ZZ Restriction of Common Bile Duct, Percutaneous 0FV94CZ Restriction of Common Bile Duct with Extraluminal Device, Percutaneous Endoscopic 0FV94DZ Restriction of Common Bile Duct with Intraluminal Device, Percutaneous Endoscopic 0FV94ZZ Restriction of Common Bile Duct, Percutaneous Endoscopic 0FV97DZ Restriction of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening 51.98 Other percutaneous procedures on biliary tract 0FV97ZZ 0FV98DZ Restriction of Common Bile Duct, Via Natural or Artificial Opening Restriction of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV98ZZ Restriction of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 3E1J38X Irrigation of Biliary and Pancreatic Tract using Irrigating Substance, Percutaneous, Diagnostic 3E1J38Z Irrigation of Biliary and Pancreatic Tract using Irrigating Substance, Percutaneous 3E1R38X Irrigation of Spinal Canal using Irrigating Substance, Percutaneous, Diagnostic 3E1R38Z Irrigation of Spinal Canal using Irrigating Substance, Percutaneous 3E1S38X Irrigation of Epidural Space using Irrigating Substance, Percutaneous, Diagnostic 3E1S38Z Irrigation of Epidural Space using Irrigating Substance, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 7

Endoscopy 0B538ZZ Destruction of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B548ZZ Destruction of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 32.27 Bronchoscopic bronchial thermoplasty, ablation of airway smooth muscle 0B558ZZ 0B568ZZ 0B578ZZ 0B588ZZ Destruction of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Destruction of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Destruction of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic Destruction of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B598ZZ Destruction of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 0B5B8ZZ Destruction of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B534ZZ Destruction of Right Main Bronchus, Percutaneous Endoscopic 0B538ZZ Destruction of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B544ZZ Destruction of Right Upper Lobe Bronchus, Percutaneous Endoscopic 0B548ZZ Destruction of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B554ZZ Destruction of Right Middle Lobe Bronchus, Percutaneous Endoscopic 0B558ZZ Destruction of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B564ZZ Destruction of Right Lower Lobe Bronchus, Percutaneous Endoscopic 0B568ZZ Destruction of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B574ZZ Destruction of Left Main Bronchus, Percutaneous Endoscopic 0B578ZZ Destruction of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic 0B584ZZ Destruction of Left Upper Lobe Bronchus, Percutaneous Endoscopic 0B588ZZ Destruction of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0B594ZZ Destruction of Lingula Bronchus, Percutaneous Endoscopic 0B598ZZ Destruction of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 32.01 Endoscopic excision or destruction of lesion or tissue of bronchus 0B5B4ZZ 0B5B8ZZ 0BB34ZZ 0BB38ZZ Destruction of Left Lower Lobe Bronchus, Percutaneous Endoscopic Destruction of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Excision of Right Main Bronchus, Percutaneous Endoscopic Excision of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BB44ZZ Excision of Right Upper Lobe Bronchus, Percutaneous Endoscopic 0BB48ZZ Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB54ZZ Excision of Right Middle Lobe Bronchus, Percutaneous Endoscopic 0BB58ZZ Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB64ZZ Excision of Right Lower Lobe Bronchus, Percutaneous Endoscopic 0BB68ZZ Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB74ZZ Excision of Left Main Bronchus, Percutaneous Endoscopic 0BB78ZZ Excision of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BB84ZZ Excision of Left Upper Lobe Bronchus, Percutaneous Endoscopic 0BB88ZZ Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BB94ZZ Excision of Lingula Bronchus, Percutaneous Endoscopic 0BB98ZZ Excision of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 0BBB4ZZ Excision of Left Lower Lobe Bronchus, Percutaneous Endoscopic 0BBB8ZZ Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 8

Endoscopy 33.23 Other bronchoscopy 33.24 Closed [endoscopic] biopsy of bronchus 0BJ08ZZ 0BJK8ZZ 0BJL8ZZ 0B933ZX 0B934ZX 0B937ZX 0B938ZX 0B943ZX 0B944ZX 0B947ZX 0B948ZX 0B953ZX 0B954ZX 0B957ZX 0B958ZX 0B963ZX 0B964ZX 0B967ZX 0B968ZX 0B973ZX 0B974ZX 0B977ZX 0B978ZX 0B983ZX 0B984ZX 0B987ZX 0B988ZX 0B993ZX 0B994ZX 0B997ZX 0B998ZX 0B9B3ZX 0B9B4ZX 0B9B7ZX 0B9B8ZX 0BB33ZX 0BB34ZX 0BB37ZX 0BB38ZX 0BB43ZX 0BB44ZX 0BB47ZX 0BB48ZX 0BB53ZX Inspection of Tracheobronchial Tree, Via Natural or Artificial Opening Endoscopic Inspection of Right Lung, Via Natural or Artificial Opening Endoscopic Inspection of Left Lung, Via Natural or Artificial Opening Endoscopic Drainage of Right Main Bronchus, Percutaneous, Diagnostic Drainage of Right Main Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Main Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Upper Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Middle Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Middle Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Middle Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Lower Lobe Bronchus, Percutaneous, Diagnostic Drainage of Right Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Right Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Main Bronchus, Percutaneous, Diagnostic Drainage of Left Main Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Main Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Upper Lobe Bronchus, Percutaneous, Diagnostic Drainage of Left Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Lingula Bronchus, Percutaneous, Diagnostic Drainage of Lingula Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Lingula Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Lower Lobe Bronchus, Percutaneous, Diagnostic Drainage of Left Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Drainage of Left Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Drainage of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Main Bronchus, Percutaneous, Diagnostic Excision of Right Main Bronchus, Percutaneous Endoscopic, Diagnostic Excision of Right Main Bronchus, Via Natural or Artificial Opening, Diagnostic Excision of Right Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Upper Lobe Bronchus, Percutaneous, Diagnostic Excision of Right Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic Excision of Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Right Middle Lobe Bronchus, Percutaneous, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 9

Endoscopy 0BB54ZX Excision of Right Middle Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB57ZX Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB58ZX Excision of Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB63ZX Excision of Right Lower Lobe Bronchus, Percutaneous, Diagnostic 0BB64ZX Excision of Right Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB67ZX Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB68ZX Excision of Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB73ZX Excision of Left Main Bronchus, Percutaneous, Diagnostic 0BB74ZX Excision of Left Main Bronchus, Percutaneous Endoscopic, Diagnostic 0BB77ZX Excision of Left Main Bronchus, Via Natural or Artificial Opening, Diagnostic 33.24 Closed [endoscopic] biopsy of bronchus 0BB78ZX 0BB83ZX 0BB84ZX Excision of Left Main Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Left Upper Lobe Bronchus, Percutaneous, Diagnostic Excision of Left Upper Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BB87ZX Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB88ZX Excision of Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BB93ZX Excision of Lingula Bronchus, Percutaneous, Diagnostic 0BB94ZX Excision of Lingula Bronchus, Percutaneous Endoscopic, Diagnostic 0BB97ZX Excision of Lingula Bronchus, Via Natural or Artificial Opening, Diagnostic 0BB98ZX Excision of Lingula Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBB3ZX Excision of Left Lower Lobe Bronchus, Percutaneous, Diagnostic 0BBB4ZX Excision of Left Lower Lobe Bronchus, Percutaneous Endoscopic, Diagnostic 0BBB7ZX Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening, Diagnostic 0BBB8ZX Excision of Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9C8ZX Drainage of Right Upper Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 33.27 Closed endoscopic biopsy of lung 0B9D8ZX 0B9F8ZX 0B9G8ZX Drainage of Right Middle Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Right Lower Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Left Upper Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9H8ZX Drainage of Lung Lingula, Via Natural or Artificial Opening Endoscopic, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 10

Endoscopy 0B9J8ZX Drainage of Left Lower Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9K8ZX Drainage of Right Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9L8ZX Drainage of Left Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0B9M8ZX Drainage of Bilateral Lungs, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBC7ZX Excision of Right Upper Lung Lobe, Via Natural or Artificial Opening, Diagnostic 0BBC8ZX Excision of Right Upper Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBD7ZX Excision of Right Middle Lung Lobe, Via Natural or Artificial Opening, Diagnostic 0BBD8ZX Excision of Right Middle Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBF7ZX Excision of Right Lower Lung Lobe, Via Natural or Artificial Opening, Diagnostic 0BBF8ZX Excision of Right Lower Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 33.27 Closed endoscopic biopsy of lung 0BBG7ZX 0BBG8ZX 0BBH7ZX Excision of Left Upper Lung Lobe, Via Natural or Artificial Opening, Diagnostic Excision of Left Upper Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Lung Lingula, Via Natural or Artificial Opening, Diagnostic 0BBH8ZX Excision of Lung Lingula, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBJ7ZX Excision of Left Lower Lung Lobe, Via Natural or Artificial Opening, Diagnostic 0BBJ8ZX Excision of Left Lower Lung Lobe, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBK7ZX Excision of Right Lung, Via Natural or Artificial Opening, Diagnostic 0BBK8ZX Excision of Right Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBL7ZX Excision of Left Lung, Via Natural or Artificial Opening, Diagnostic 0BBL8ZX Excision of Left Lung, Via Natural or Artificial Opening Endoscopic, Diagnostic 0BBM4ZX Excision of Bilateral Lungs, Percutaneous Endoscopic, Diagnostic 0BBM7ZX Excision of Bilateral Lungs, Via Natural or Artificial Opening, Diagnostic 0BBM8ZX Excision of Bilateral Lungs, Via Natural or Artificial Opening Endoscopic, Diagnostic 0C7S0DZ Dilation of Larynx with Intraluminal Device, Open 0C7S3DZ Dilation of Larynx with Intraluminal Device, Percutaneous 0C7S4DZ Dilation of Larynx with Intraluminal Device, Percutaneous Endoscopic 31.93 Replacement of laryngeal or tracheal stent 0C7S7DZ 0C7S8DZ 0CPS0DZ Dilation of Larynx with Intraluminal Device, Via Natural or Artificial Opening Dilation of Larynx with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Larynx, Open 0CPS3DZ Removal of Intraluminal Device from Larynx, Percutaneous 0CPS7DZ Removal of Intraluminal Device from Larynx, Via Natural or Artificial Opening 0CPS8DZ Removal of Intraluminal Device from Larynx, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 11

Endoscopy 31.99 Other operations on trach 0B710DZ 0B710ZZ 0B713DZ 0B713ZZ 0B714DZ 0B714ZZ 0B717DZ 0B717ZZ 0B718DZ 0B718ZZ 0B720DZ 0B720ZZ 0B723DZ 0B723ZZ 0B724DZ 0B724ZZ 0B727DZ 0B727ZZ 0B728DZ 0B728ZZ 0BL10CZ 0BL10DZ 0BL10ZZ 0BL13CZ 0BL13DZ 0BL13ZZ 0BL14CZ 0BL14DZ 0BL14ZZ 0BL17DZ 0BL17ZZ 0BL18DZ 0BL18ZZ 0BL20CZ 0BL20DZ 0BL20ZZ 0BL23CZ 0BL23DZ 0BL23ZZ 0BL24CZ 0BL24DZ 0BL24ZZ 0BL27DZ 0BL27ZZ 0BL28DZ 0BL28ZZ Dilation of Trachea with Intraluminal Device, Open Dilation of Trachea, Open Dilation of Trachea with Intraluminal Device, Percutaneous Dilation of Trachea, Percutaneous Dilation of Trachea with Intraluminal Device, Percutaneous Endoscopic Dilation of Trachea, Percutaneous Endoscopic Dilation of Trachea with Intraluminal Device, Via Natural or Artificial Opening Dilation of Trachea, Via Natural or Artificial Opening Dilation of Trachea with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Trachea, Via Natural or Artificial Opening Endoscopic Dilation of Carina with Intraluminal Device, Open Dilation of Carina, Open Dilation of Carina with Intraluminal Device, Percutaneous Dilation of Carina, Percutaneous Dilation of Carina with Intraluminal Device, Percutaneous Endoscopic Dilation of Carina, Percutaneous Endoscopic Dilation of Carina with Intraluminal Device, Via Natural or Artificial Opening Dilation of Carina, Via Natural or Artificial Opening Dilation of Carina with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Carina, Via Natural or Artificial Opening Endoscopic Occlusion of Trachea with Extraluminal Device, Open Occlusion of Trachea with Intraluminal Device, Open Occlusion of Trachea, Open Occlusion of Trachea with Extraluminal Device, Percutaneous Occlusion of Trachea with Intraluminal Device, Percutaneous Occlusion of Trachea, Percutaneous Occlusion of Trachea with Extraluminal Device, Percutaneous Endoscopic Occlusion of Trachea with Intraluminal Device, Percutaneous Endoscopic Occlusion of Trachea, Percutaneous Endoscopic Occlusion of Trachea with Intraluminal Device, Via Natural or Artificial Opening Occlusion of Trachea, Via Natural or Artificial Opening Occlusion of Trachea with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Occlusion of Trachea, Via Natural or Artificial Opening Endoscopic Occlusion of Carina with Extraluminal Device, Open Occlusion of Carina with Intraluminal Device, Open Occlusion of Carina, Open Occlusion of Carina with Extraluminal Device, Percutaneous Occlusion of Carina with Intraluminal Device, Percutaneous Occlusion of Carina, Percutaneous Occlusion of Carina with Extraluminal Device, Percutaneous Endoscopic Occlusion of Carina with Intraluminal Device, Percutaneous Endoscopic Occlusion of Carina, Percutaneous Endoscopic Occlusion of Carina with Intraluminal Device, Via Natural or Artificial Opening Occlusion of Carina, Via Natural or Artificial Opening Occlusion of Carina with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Occlusion of Carina, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 12

Endoscopy 0BQ10ZZ Repair Trachea, Open 0BQ13ZZ Repair Trachea, Percutaneous 0BQ14ZZ Repair Trachea, Percutaneous Endoscopic 0BQ17ZZ Repair Trachea, Via Natural or Artificial Opening 0BQ18ZZ Repair Trachea, Via Natural or Artificial Opening Endoscopic 0BC17ZZ Extirpation of Matter from Trachea, Via Natural or Artificial Opening 0BC18ZZ Extirpation of Matter from Trachea, Via Natural or Artificial Opening Endoscopic 0BC27ZZ Extirpation of Matter from Carina, Via Natural or Artificial Opening 0BC28ZZ Extirpation of Matter from Carina, Via Natural or Artificial Opening Endoscopic 0BC37ZZ Extirpation of Matter from Right Main Bronchus, Via Natural or Artificial Opening 0BC38ZZ Extirpation of Matter from Right Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BC47ZZ Extirpation of Matter from Right Upper Lobe Bronchus, Via Natural or Artificial Opening 0BC48ZZ Extirpation of Matter from Right Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 98.15 Removal of intraluminal foreign body from trachea and bronchus without incision 0BC57ZZ 0BC58ZZ 0BC67ZZ 0BC68ZZ Extirpation of Matter from Right Middle Lobe Bronchus, Via Natural or Artificial Opening Extirpation of Matter from Right Middle Lobe Bronchus, Via Natural or Artificial Opening Endoscopic Extirpation of Matter from Right Lower Lobe Bronchus, Via Natural or Artificial Opening Extirpation of Matter from Right Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BC77ZZ Extirpation of Matter from Left Main Bronchus, Via Natural or Artificial Opening 0BC78ZZ Extirpation of Matter from Left Main Bronchus, Via Natural or Artificial Opening Endoscopic 0BC87ZZ Extirpation of Matter from Left Upper Lobe Bronchus, Via Natural or Artificial Opening 0BC88ZZ Extirpation of Matter from Left Upper Lobe Bronchus, Via Natural or Artificial Opening Endoscopic 0BC97ZZ Extirpation of Matter from Lingula Bronchus, Via Natural or Artificial Opening 0BC98ZZ Extirpation of Matter from Lingula Bronchus, Via Natural or Artificial Opening Endoscopic 0BCB7ZZ Extirpation of Matter from Left Lower Lobe Bronchus, Via Natural or Artificial Opening 0BCB8ZZ Extirpation of Matter from Left Lower Lobe Bronchus, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 13

Endoscopy 0DH50DZ Intraluminal Device into Esophagus, Open 0DH50UZ Feeding Device into Esophagus, Open 0DH53DZ Intraluminal Device into Esophagus, Percutaneous 0DH53UZ Feeding Device into Esophagus, Percutaneous 42.81 permanent tube into esophagus 0DH54DZ 0DH54UZ Intraluminal Device into Esophagus, Percutaneous Endoscopic Feeding Device into Esophagus, Percutaneous Endoscopic 0DH57DZ Intraluminal Device into Esophagus, Via Natural or Artificial Opening 0DH57UZ Feeding Device into Esophagus, Via Natural or Artificial Opening 0DH58DZ Intraluminal Device into Esophagus, Via Natural or Artificial Opening Endoscopic 0DH58UZ Feeding Device into Esophagus, Via Natural or Artificial Opening Endoscopic 0D788DZ Dilation of Small Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D798DZ Dilation of Duodenum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7A8DZ Dilation of Jejunum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7B8DZ Dilation of Ileum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7C8DZ Dilation of Ileocecal Valve with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7E8DZ Dilation of Large Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7F8DZ Dilation of Right Large Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7G8DZ Dilation of Left Large Intestine with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 46.86 Endoscopic insertion of colonic stent(s) 0D7H8DZ 0D7K8DZ 0D7L8DZ Dilation of Cecum with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Ascending Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Transverse Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7M8DZ Dilation of Descending Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0D7N8DZ Dilation of Sigmoid Colon with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0DH88DZ Intraluminal Device into Small Intestine, Via Natural or Artificial Opening Endoscopic 0DH98DZ Intraluminal Device into Duodenum, Via Natural or Artificial Opening Endoscopic 0DHA8DZ Intraluminal Device into Jejunum, Via Natural or Artificial Opening Endoscopic 0DHB8DZ Intraluminal Device into Ileum, Via Natural or Artificial Opening Endoscopic 0DHE8DZ Intraluminal Device into Large Intestine, Via Natural or Artificial Opening Endoscopic 0DHP8DZ Intraluminal Device into Rectum, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 14

Endoscopy 0F754DZ Dilation of Right Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0F758DZ Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F764DZ Dilation of Left Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0F768DZ Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 51.87 Endoscopic insertion of stent (tube) into bile duct 0F784DZ 0F788DZ Dilation of Cystic Duct with Intraluminal Device, Percutaneous Endoscopic Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F794DZ Dilation of Common Bile Duct with Intraluminal Device, Percutaneous Endoscopic 0F798DZ Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FHB4DZ Intraluminal Device into Hepatobiliary Duct, Percutaneous Endoscopic 0FHB8DZ Intraluminal Device into Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic 0F753DZ Dilation of Right Hepatic Duct with Intraluminal Device, Percutaneous 0F753ZZ Dilation of Right Hepatic Duct, Percutaneous 0F763DZ Dilation of Left Hepatic Duct with Intraluminal Device, Percutaneous 0F763ZZ Dilation of Left Hepatic Duct, Percutaneous 0F783DZ Dilation of Cystic Duct with Intraluminal Device, Percutaneous 0F783ZZ Dilation of Cystic Duct, Percutaneous 0F793DZ Dilation of Common Bile Duct with Intraluminal Device, Percutaneous 0F793ZZ Dilation of Common Bile Duct, Percutaneous 51.98 Other percutaneous procedures on biliary tract 0F993ZZ 0F994ZZ Drainage of Common Bile Duct, Percutaneous Drainage of Common Bile Duct, Percutaneous Endoscopic 0F997ZZ Drainage of Common Bile Duct, Via Natural or Artificial Opening 0F998ZZ Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 0FC53ZZ Extirpation of Matter from Right Hepatic Duct, Percutaneous 0FC57ZZ Extirpation of Matter from Right Hepatic Duct, Via Natural or Artificial Opening 0FC63ZZ Extirpation of Matter from Left Hepatic Duct, Percutaneous 0FC67ZZ Extirpation of Matter from Left Hepatic Duct, Via Natural or Artificial Opening 0FC83ZZ Extirpation of Matter from Cystic Duct, Percutaneous 0FC87ZZ Extirpation of Matter from Cystic Duct, Via Natural or Artificial Opening See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 15

Endoscopy 0FL53CZ Occlusion of Right Hepatic Duct with Extraluminal Device, Percutaneous 0FL53DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Percutaneous 0FL53ZZ Occlusion of Right Hepatic Duct, Percutaneous 0FL54CZ Occlusion of Right Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FL54DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL54ZZ Occlusion of Right Hepatic Duct, Percutaneous Endoscopic 0FL57DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL57ZZ Occlusion of Right Hepatic Duct, Via Natural or Artificial Opening 0FL58DZ Occlusion of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL58ZZ Occlusion of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FL63CZ Occlusion of Left Hepatic Duct with Extraluminal Device, Percutaneous 0FL63DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Percutaneous 0FL63ZZ Occlusion of Left Hepatic Duct, Percutaneous 0FL64CZ Occlusion of Left Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FL64DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL64ZZ Occlusion of Left Hepatic Duct, Percutaneous Endoscopic 0FL67DZ Occlusion of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL67ZZ Occlusion of Left Hepatic Duct, Via Natural or Artificial Opening 51.98 Other percutaneous procedures on biliary tract 0FL68DZ 0FL68ZZ Occlusion of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Occlusion of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FL83CZ Occlusion of Cystic Duct with Extraluminal Device, Percutaneous 0FL83DZ Occlusion of Cystic Duct with Intraluminal Device, Percutaneous 0FL83ZZ Occlusion of Cystic Duct, Percutaneous 0FL84CZ Occlusion of Cystic Duct with Extraluminal Device, Percutaneous Endoscopic 0FL84DZ Occlusion of Cystic Duct with Intraluminal Device, Percutaneous Endoscopic 0FL84ZZ Occlusion of Cystic Duct, Percutaneous Endoscopic 0FL87DZ Occlusion of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL87ZZ Occlusion of Cystic Duct, Via Natural or Artificial Opening 0FL88DZ Occlusion of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL88ZZ Occlusion of Cystic Duct, Via Natural or Artificial Opening Endoscopic 0FL93CZ Occlusion of Common Bile Duct with Extraluminal Device, Percutaneous 0FL93DZ Occlusion of Common Bile Duct with Intraluminal Device, Percutaneous 0FL93ZZ Occlusion of Common Bile Duct, Percutaneous 0FL94CZ Occlusion of Common Bile Duct with Extraluminal Device, Percutaneous Endoscopic 0FL94DZ Occlusion of Common Bile Duct with Intraluminal Device, Percutaneous Endoscopic 0FL94ZZ Occlusion of Common Bile Duct, Percutaneous Endoscopic 0FL97DZ Occlusion of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening 0FL97ZZ Occlusion of Common Bile Duct, Via Natural or Artificial Opening See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 16

Endoscopy 0FL98DZ Occlusion of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FL98ZZ Occlusion of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 0FM44ZZ Reattachment of Gallbladder, Percutaneous Endoscopic 0FM54ZZ Reattachment of Right Hepatic Duct, Percutaneous Endoscopic 0FM64ZZ Reattachment of Left Hepatic Duct, Percutaneous Endoscopic 0FM84ZZ Reattachment of Cystic Duct, Percutaneous Endoscopic 0FM94ZZ Reattachment of Common Bile Duct, Percutaneous Endoscopic 0FV53CZ Restriction of Right Hepatic Duct with Extraluminal Device, Percutaneous 0FV53DZ Restriction of Right Hepatic Duct with Intraluminal Device, Percutaneous 0FV53ZZ Restriction of Right Hepatic Duct, Percutaneous 0FV54CZ Restriction of Right Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV54DZ Restriction of Right Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV54ZZ Restriction of Right Hepatic Duct, Percutaneous Endoscopic 0FV57DZ Restriction of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FV57ZZ Restriction of Right Hepatic Duct, Via Natural or Artificial Opening 0FV58DZ Restriction of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV58ZZ Restriction of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic 51.98 Other percutaneous procedures on biliary tract 0FV63CZ 0FV63DZ Restriction of Left Hepatic Duct with Extraluminal Device, Percutaneous Restriction of Left Hepatic Duct with Intraluminal Device, Percutaneous 0FV63ZZ Restriction of Left Hepatic Duct, Percutaneous 0FV64CZ Restriction of Left Hepatic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV64DZ Restriction of Left Hepatic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV64ZZ Restriction of Left Hepatic Duct, Percutaneous Endoscopic 0FV67DZ Restriction of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FV67ZZ Restriction of Left Hepatic Duct, Via Natural or Artificial Opening 0FV68DZ Restriction of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV68ZZ Restriction of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic 0FV83CZ Restriction of Cystic Duct with Extraluminal Device, Percutaneous 0FV83DZ Restriction of Cystic Duct with Intraluminal Device, Percutaneous 0FV83ZZ Restriction of Cystic Duct, Percutaneous 0FV84CZ Restriction of Cystic Duct with Extraluminal Device, Percutaneous Endoscopic 0FV84DZ Restriction of Cystic Duct with Intraluminal Device, Percutaneous Endoscopic 0FV84ZZ Restriction of Cystic Duct, Percutaneous Endoscopic 0FV87DZ Restriction of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening 0FV87ZZ Restriction of Cystic Duct, Via Natural or Artificial Opening 0FV88DZ Restriction of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV88ZZ Restriction of Cystic Duct, Via Natural or Artificial Opening Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 17

Endoscopy 0FV93CZ Restriction of Common Bile Duct with Extraluminal Device, Percutaneous 0FV93DZ Restriction of Common Bile Duct with Intraluminal Device, Percutaneous 0FV93ZZ Restriction of Common Bile Duct, Percutaneous 0FV94CZ Restriction of Common Bile Duct with Extraluminal Device, Percutaneous Endoscopic 0FV94DZ Restriction of Common Bile Duct with Intraluminal Device, Percutaneous Endoscopic 0FV94ZZ Restriction of Common Bile Duct, Percutaneous Endoscopic 0FV97DZ Restriction of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening 51.98 Other percutaneous procedures on biliary tract 0FV97ZZ 0FV98DZ Restriction of Common Bile Duct, Via Natural or Artificial Opening Restriction of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0FV98ZZ Restriction of Common Bile Duct, Via Natural or Artificial Opening Endoscopic 3E1J38X Irrigation of Biliary and Pancreatic Tract using Irrigating Substance, Percutaneous, Diagnostic 3E1J38Z Irrigation of Biliary and Pancreatic Tract using Irrigating Substance, Percutaneous 3E1R38X Irrigation of Spinal Canal using Irrigating Substance, Percutaneous, Diagnostic 3E1R38Z Irrigation of Spinal Canal using Irrigating Substance, Percutaneous 3E1S38X Irrigation of Epidural Space using Irrigating Substance, Percutaneous, Diagnostic 3E1S38Z Irrigation of Epidural Space using Irrigating Substance, Percutaneous 0F758DZ Dilation of Right Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F767DZ Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening 97.05 Replacement of stent (tube) in biliary or pancreatic duct 0F768DZ 0F787DZ Dilation of Left Hepatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening 0F788DZ Dilation of Cystic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F797DZ Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening 0F798DZ Dilation of Common Bile Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 0F7D7DZ Dilation of Pancreatic Duct with Intraluminal Device, Via Natural or Artificial Opening 0F7D8DZ Dilation of Pancreatic Duct with Intraluminal Device, Via Natural or Artificial Opening Endoscopic 97.05 Replacement of stent (tube) in biliary or pancreatic duct 0FPB7DZ 0FPB8DZ 0FPBXDZ Removal of Intraluminal Device from Hepatobiliary Duct, Via Natural or Artificial Opening Removal of Intraluminal Device from Hepatobiliary Duct, Via Natural or Artificial Opening Endoscopic Removal of Intraluminal Device from Hepatobiliary Duct, External 0FPD7DZ Removal of Intraluminal Device from Pancreatic Duct, Via Natural or Artificial Opening 0FPD8DZ Removal of Intraluminal Device from Pancreatic Duct, Via Natural or Artificial Opening Endoscopic 0FPDXDZ Removal of Intraluminal Device from Pancreatic Duct, External See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 18

Endoscopy 51.10 Endoscopic retrograde cholangiopancreatography (ERCP) BF110ZZ BF111ZZ BF11YZZ Fluoroscopy of Biliary and Pancreatic Ducts using High Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Low Osmolar Contrast Fluoroscopy of Biliary and Pancreatic Ducts using Other Contrast 51.11 Endoscopic retrograde cholangiography (ERC) BF100ZZ BF101ZZ BF10YZZ Fluoroscopy of Bile Ducts using High Osmolar Contrast Fluoroscopy of Bile Ducts using Low Osmolar Contrast Fluoroscopy of Bile Ducts using Other Contrast 0F954ZX Drainage of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F957ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F958ZX Drainage of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F964ZX Drainage of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0F967ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0F968ZX Drainage of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F984ZX Drainage of Cystic Duct, Percutaneous Endoscopic, Diagnostic 51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 0F987ZX 0F988ZX 0F994ZX 0F997ZX Drainage of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Drainage of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Drainage of Common Bile Duct, Percutaneous Endoscopic, Diagnostic Drainage of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic 0F998ZX Drainage of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0F9C4ZX Drainage of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic 0F9C7ZX Drainage of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 0F9C8ZX Drainage of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB44ZX Excision of Gallbladder, Percutaneous Endoscopic, Diagnostic 0FB54ZX Excision of Right Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB57ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB58ZX Excision of Right Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB64ZX Excision of Left Hepatic Duct, Percutaneous Endoscopic, Diagnostic 0FB67ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening, Diagnostic 0FB68ZX Excision of Left Hepatic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FB84ZX Excision of Cystic Duct, Percutaneous Endoscopic, Diagnostic 51.14 Other closed (endoscopic) biopsy of biliary duct or sphincter of Oddi 0FB87ZX 0FB88ZX 0FB94ZX Excision of Cystic Duct, Via Natural or Artificial Opening, Diagnostic Excision of Cystic Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic Excision of Common Bile Duct, Percutaneous Endoscopic, Diagnostic 0FB97ZX Excision of Common Bile Duct, Via Natural or Artificial Opening, Diagnostic 0FB98ZX Excision of Common Bile Duct, Via Natural or Artificial Opening Endoscopic, Diagnostic 0FBC4ZX Excision of Ampulla of Vater, Percutaneous Endoscopic, Diagnostic 0FBC7ZX Excision of Ampulla of Vater, Via Natural or Artificial Opening, Diagnostic 0FBC8ZX Excision of Ampulla of Vater, Via Natural or Artificial Opening Endoscopic, Diagnostic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 19

Interventional Cardiology 37.21 37.22 37.23 00.40 00.41 Right heart cardiac catheterization Left heart cardiac catheterization Combined right and left heart cardiac catheterization Procedure on single Procedure on two s 4A0 4A020N6 4A023N6 4A0 4A020N7 4A023N7 4A0 4A020N8 4A023N8 Measurement / Physiological Systems Measurement of Cardiac Sampling and Pressure, Right Heart, Open Measurement of Cardiac Sampling and Pressure, Right Heart, Percutaneous Measurement / Physiological Systems Measurement of Cardiac Sampling and Pressure, Left Heart, Open Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Measurement / Physiological Systems Measurement of Cardiac Sampling and Pressure, Bilateral, Open Measurement of Cardiac Sampling and Pressure, Bilateral, Percutaneous 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 0270046 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Open 027004Z 02700D6 02700DZ 02700T6 02700TZ 02700Z6 02700ZZ Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, One Site with Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, Open Dilation of Coronary Artery, One Site, Open 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027034Z 02703D6 02703DZ 02703T6 02703TZ 02703Z6 02703ZZ 0270446 027044Z 02704D6 02704DZ 02704T6 02704TZ 02704Z6 02704ZZ 02C 02C0 02C03ZZ Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous Dilation of Coronary Artery, One Site, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Percutaneous Endoscopic Extirpation / Heart and Great Vessels Extirpation / Coronary Artery, One Site Extirpation of Matter from Coronary Artery, One Site, Percutaneous 027 Dilation / Heart and Great Vessels 0271 Dilation / Coronary Artery, Two Sites 0271046 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027104Z 02710D6 02710DZ 02710T6 Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Open See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 20

Interventional Cardiology 00.41 00.42 Procedure on two s Procedure on three s 02710TZ 02710Z6 02710ZZ Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, Open Dilation of Coronary Artery, Two Sites, Open 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027134Z 02713D6 02713DZ 02713T6 02713TZ 02713Z6 02713ZZ 0271446 027144Z 02714D6 02714DZ 02714T6 02714TZ 02714Z6 02714ZZ 02C 02C13ZZ Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Two Sites, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Percutaneous Endoscopic Extirpation / Heart and Great Vessels Extirpation of Matter from Coronary Artery, Two Sites, Percutaneous 027 Dilation / Heart and Great Vessels 0272 Dilation / Coronary Artery, Three Sites 0272046 Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027204Z 02720D6 02720DZ 02720T6 02720TZ 02720Z6 02720ZZ 0272346 027234Z 02723D6 02723DZ 02723T6 02723TZ 02723Z6 02723ZZ 0272446 027244Z 02724D6 02724DZ Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, Open Dilation of Coronary Artery, Three Sites, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Three Sites, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 21

Interventional Cardiology 00.42 00.43 00.44 Procedure on three s Procedure on four or more s Procedure on bifurcation 02724T6 02724TZ 02724Z6 02724ZZ 02C 02C23ZZ Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Percutaneous Endoscopic Extirpation / Heart and Great Vessels Extirpation of Matter from Coronary Artery, Three Sites, Percutaneous 027 Dilation / Heart and Great Vessels 0273 Dilation / Coronary Artery, Four or More Sites 0273046 Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027304Z 02730D6 02730DZ 02730T6 02730TZ 02730Z6 02730ZZ 0273346 027334Z 02733D6 02733DZ 02733T6 02733TZ 02733Z6 02733ZZ 0273446 027344Z 02734D6 02734DZ 02734T6 02734TZ 02734Z6 02734ZZ 02C 02C33ZZ Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, Open Dilation of Coronary Artery, Four or More Sites, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Four or More Sites, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Percutaneous Endoscopic Extirpation / Heart and Great Vessels Extirpation of Matter from Coronary Artery, Four or More Sites, Percutaneous 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 0270046 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Open 02700D6 02700T6 02700Z6 Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, Open 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 02703D6 02703T6 02703Z6 Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 22

Interventional Cardiology 00.44 Procedure on bifurcation 0270446 02704D6 02704T6 02704Z6 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous Endoscopic 0271 Dilation / Coronary Artery, Two Sites 0271046 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 02710D6 02710T6 02710Z6 Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, Open 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 02713D6 02713T6 02713Z6 0271446 02714D6 02714T6 02714Z6 Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Endoscopic 0272 Dilation / Coronary Artery, Three Sites 0272046 Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 02720D6 02720T6 02720Z6 0272346 02723D6 02723T6 02723Z6 0272446 02724D6 02724T6 02724Z6 Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Endoscopic 0273 Dilation / Coronary Artery, Four or More Sites 0273046 Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 02730D6 02730T6 02730Z6 0273346 02733D6 02733T6 02733Z6 0273446 02734D6 02734T6 02734Z6 Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 23

Interventional Cardiology 00.45 00.46 one vascular stent two vascular stents 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 0270046 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Open 027004Z 02700D6 02700DZ 02700T6 02700TZ Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, One Site with Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Open 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027034Z 02703D6 02703DZ 02703T6 02703TZ 0270446 027044Z 02704D6 02704DZ 02704T6 02704TZ Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Endoscopic 027 Dilation / Heart and Great Vessels 0271 Dilation / Coronary Artery, Two Sites 0271046 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027104Z 02710D6 02710DZ 02710T6 02710TZ Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Open 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027134Z 02713D6 02713DZ 02713T6 02713TZ 0271446 027144Z 02714D6 02714DZ 02714T6 02714TZ Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 24

Interventional Cardiology 00.47 00.48 three vascular stents four or more vascular stents 027 Dilation / Heart and Great Vessels 0272 Dilation / Coronary Artery, Three Sites 0272046 Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027204Z 02720D6 02720DZ 02720T6 02720TZ 0272346 027234Z 02723D6 02723DZ 02723T6 02723TZ 0272446 027244Z 02724D6 02724DZ 02724T6 02724TZ Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic 027 Dilation / Heart and Great Vessels 0273 Dilation / Coronary Artery, Four or More Sites 0273046 Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027304Z 02730D6 02730DZ 02730T6 02730TZ 0273346 027334Z 02733D6 02733DZ 02733T6 02733TZ 0273446 027344Z 02734D6 02734DZ 02734T6 02734TZ Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 25

Interventional Cardiology 17.55 36.06 Transluminal coronary atherectomy coronary artery stent(s) 02C 02C03ZZ 02C13ZZ 02C23ZZ 02C33ZZ Extirpation / Heart and Great Vessels Extirpation of Matter from Coronary Artery, One Site, Percutaneous Extirpation of Matter from Coronary Artery, Two Sites, Percutaneous Extirpation of Matter from Coronary Artery, Three Sites, Percutaneous Extirpation of Matter from Coronary Artery, Four or More Sites, Percutaneous 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 02700D6 02700DZ 02700T6 02700TZ 02703D6 02703DZ 02703T6 02703TZ 02704D6 02704DZ 02704T6 02704TZ Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, One Site with Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Endoscopic 0271 Dilation / Coronary Artery, Two Sites 02710D6 02710DZ 02710T6 02710TZ 02713D6 02713DZ 02713T6 02713TZ 02714D6 02714DZ 02714T6 02714TZ Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites with Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic 0272 Dilation / Coronary Artery, Three Sites 02720D6 02720DZ 02720T6 02720TZ 02723D6 02723DZ 02723T6 02723TZ 02724D6 Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 26

Interventional Cardiology 36.06 36.07 coronary artery stent(s) drugeluting coronary artery stent(s) 02724DZ 02724T6 02724TZ Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic 0273 Dilation / Coronary Artery, Four or More Sites 02730D6 02730DZ 02730T6 02730TZ 02733D6 02733DZ 02733T6 02733TZ 02734D6 02734DZ 02734T6 02734TZ Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 0270046 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Open 027004Z Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Open 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027034Z 0270446 027044Z Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 0271 Dilation / Coronary Artery, Two Sites 0271046 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027104Z Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Open 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027134Z 0271446 027144Z Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 0272 Dilation / Coronary Artery, Three Sites 0272046 Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027204Z 0272346 027234Z 0272446 027244Z Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 27

Interventional Cardiology 36.07 35.05 35.06 35.07 35.08 35.09 drugeluting coronary artery stent(s) Endovascular replacement of aortic valve Transapical replacement of aortic valve Endovascular replacement of pulmonary valve Transapical replacement of pulmonary valve Endovascular replacement of unspecified heart valve 0273 Dilation / Coronary Artery, Four or More Sites 0273046 Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Open 027304Z 0273346 027334Z 0273446 027344Z 02R 02RF37Z 02RF38Z 02RF3JZ 02RF3KZ 02R 02RF37H 02RF38H 02RF3JH 02RF3KH 02R 02RH37Z 02RH38Z 02RH3JZ 02RH3KZ 02R 02RH37H 02RH38H 02RH3JH 02RH3KH 02R 02RF 02RF37Z 02RF38Z 02RF3JZ 02RF3KZ 02RG 02RG37H 02RG37Z 02RG38H 02RG38Z 02RG3JH 02RG3JZ 02RG3KH 02RG3KZ 02RH 02RH37Z 02RH38Z 02RH3JZ 02RH3KZ Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Open Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Replacement / Heart and Great Vessels Replacement of Aortic Valve with Autologous Tissue Substitute, Percutaneous Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Replacement of Aortic Valve with Synthetic Substitute, Percutaneous Replacement of Aortic Valve with Nonautologous Tissue Substitute, Percutaneous Replacement / Heart and Great Vessels Replacement of Aortic Valve with Autologous Tissue Substitute, Transapical, Percutaneous Replacement of Aortic Valve with Zooplastic Tissue, Transapical, Percutaneous Replacement of Aortic Valve with Synthetic Substitute, Transapical, Percutaneous Replacement of Aortic Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Replacement / Heart and Great Vessels Replacement of Pulmonary Valve with Autologous Tissue Substitute, Percutaneous Replacement of Pulmonary Valve with Zooplastic Tissue, Percutaneous Replacement of Pulmonary Valve with Synthetic Substitute, Percutaneous Replacement of Pulmonary Valve with Nonautologous Tissue Substitute, Percutaneous Replacement / Heart and Great Vessels Replacement of Pulmonary Valve with Autologous Tissue Substitute, Transapical, Percutaneous Replacement of Pulmonary Valve with Zooplastic Tissue, Transapical, Percutaneous Replacement of Pulmonary Valve with Synthetic Substitute, Transapical, Percutaneous Replacement of Pulmonary Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Replacement / Heart and Great Vessels Replacement / Aortic Valve Replacement of Aortic Valve with Autologous Tissue Substitute, Percutaneous Replacement of Aortic Valve with Zooplastic Tissue, Percutaneous Replacement of Aortic Valve with Synthetic Substitute, Percutaneous Replacement of Aortic Valve with Nonautologous Tissue Substitute, Percutaneous Replacement / Mitral Valve Replacement of Mitral Valve with Autologous Tissue Substitute, Transapical, Percutaneous Replacement of Mitral Valve with Autologous Tissue Substitute, Percutaneous Replacement of Mitral Valve with Zooplastic Tissue, Transapical, Percutaneous Replacement of Mitral Valve with Zooplastic Tissue, Percutaneous Replacement of Mitral Valve with Synthetic Substitute, Transapical, Percutaneous Replacement of Mitral Valve with Synthetic Substitute, Percutaneous Replacement of Mitral Valve with Nonautologous Tissue Substitute, Transapical, Percutaneous Replacement of Mitral Valve with Nonautologous Tissue Substitute, Percutaneous Replacement / Pulmonary Valve Replacement of Pulmonary Valve with Autologous Tissue Substitute, Percutaneous Replacement of Pulmonary Valve with Zooplastic Tissue, Percutaneous Replacement of Pulmonary Valve with Synthetic Substitute, Percutaneous Replacement of Pulmonary Valve with Nonautologous Tissue Substitute, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 28

Interventional Cardiology 35.96 35.97 00.59 00.66 Percutaneous balloon valvuloplasty Percutaneous mitral valve repair with implant Intravascular pressure measurement of coronary arteries Percutaneous transluminal coronary angioplasty [PTCA] 027 Dilation / Heart and Great Vessels 027F Dilation / Aortic Valve 027F34Z Dilation of Aortic Valve with Drug-eluting Intraluminal Device, Percutaneous 027F3DZ Dilation of Aortic Valve with Intraluminal Device, Percutaneous 027F3ZZ Dilation of Aortic Valve, Percutaneous 027F44Z Dilation of Aortic Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027F4DZ Dilation of Aortic Valve with Intraluminal Device, Percutaneous Endoscopic 027F4ZZ Dilation of Aortic Valve, Percutaneous Endoscopic 027G Dilation / Mitral Valve 027G34Z Dilation of Mitral Valve with Drug-eluting Intraluminal Device, Percutaneous 027G3DZ Dilation of Mitral Valve with Intraluminal Device, Percutaneous 027G3ZZ Dilation of Mitral Valve, Percutaneous 027G44Z Dilation of Mitral Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027G4DZ Dilation of Mitral Valve with Intraluminal Device, Percutaneous Endoscopic 027G4ZZ Dilation of Mitral Valve, Percutaneous Endoscopic 027H Dilation / Pulmonary Valve 027H34Z Dilation of Pulmonary Valve with Drug-eluting Intraluminal Device, Percutaneous 027H3DZ Dilation of Pulmonary Valve with Intraluminal Device, Percutaneous 027H3ZZ Dilation of Pulmonary Valve, Percutaneous 027H44Z Dilation of Pulmonary Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027H4DZ Dilation of Pulmonary Valve with Intraluminal Device, Percutaneous Endoscopic 027H4ZZ Dilation of Pulmonary Valve, Percutaneous Endoscopic 027J Dilation / Tricuspid Valve 027J34Z Dilation of Tricuspid Valve with Drug-eluting Intraluminal Device, Percutaneous 027J3DZ Dilation of Tricuspid Valve with Intraluminal Device, Percutaneous 027J3ZZ Dilation of Tricuspid Valve, Percutaneous 027J44Z Dilation of Tricuspid Valve with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027J4DZ Dilation of Tricuspid Valve with Intraluminal Device, Percutaneous Endoscopic 027J4ZZ Dilation of Tricuspid Valve, Percutaneous Endoscopic 02U Supplement / Heart and Great Vessels 02UG3JZ Supplement Mitral Valve with Synthetic Substitute, Percutaneous 4A0 Measurement / Physiological Systems 4A030BC Measurement of Arterial Pressure, Coronary, Open 4A033BC Measurement of Arterial Pressure, Coronary, Percutaneous 4A1 Monitoring / Physiological Systems 4A130BC Monitoring of Arterial Pressure, Coronary, Open 4A133BC Monitoring of Arterial Pressure, Coronary, Percutaneous 027 Dilation / Heart and Great Vessels 0270 Dilation / Coronary Artery, One Site 0270346 Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027034Z Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous 02703D6 Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous 02703DZ Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous 02703T6 Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous 02703TZ Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous 02703Z6 Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous 02703ZZ Dilation of Coronary Artery, One Site, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 29

Interventional Cardiology 00.66 Percutaneous transluminal coronary angioplasty [PTCA] 0270446 027044Z 02704D6 02704DZ 02704T6 02704TZ 02704Z6 02704ZZ Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, One Site, Percutaneous Endoscopic 0271 Dilation / Coronary Artery, Two Sites 0271346 Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 027134Z 02713D6 02713DZ 02713T6 02713TZ 02713Z6 02713ZZ 0271446 027144Z 02714D6 02714DZ 02714T6 02714TZ 02714Z6 02714ZZ Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Two Sites, Percutaneous Dilation of Coronary Artery, Two Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Two Sites, Percutaneous Endoscopic 0272 Dilation / Coronary Artery, Three Sites 0272346 027234Z 02723D6 02723DZ 02723T6 02723TZ 02723Z6 02723ZZ 0272446 027244Z 02724D6 02724DZ 02724T6 02724TZ Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Three Sites, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 30

Interventional Cardiology 00.66 Percutaneous transluminal coronary angioplasty [PTCA] 02724Z6 02724ZZ Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Percutaneous Endoscopic 0273 Dilation / Coronary Artery, Four or More Sites 0273346 027334Z 02733D6 02733DZ 02724Z6 02724ZZ Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Three Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Three Sites, Percutaneous Endoscopic 0273 Dilation / Coronary Artery, Four or More Sites 0273346 027334Z 02733D6 02733DZ 02733T6 02733TZ 02733Z6 02733ZZ 0273446 027344Z 02734D6 02734DZ 02734T6 02734TZ 02734Z6 02734ZZ 02C 02C0 02C03ZZ 02C04ZZ 02C1 02C13ZZ 02C14ZZ 02C2 02C23ZZ 02C24ZZ 02C3 02C33ZZ 02C34ZZ Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Dilation of Coronary Artery, Four or More Sites, Percutaneous Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites with Radioactive Intraluminal Device, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Bifurcation, Percutaneous Endoscopic Dilation of Coronary Artery, Four or More Sites, Percutaneous Endoscopic Extirpation / Heart and Great Vessels Extirpation / Coronary Artery, One Site Extirpation of Matter from Coronary Artery, One Site, Percutaneous Extirpation of Matter from Coronary Artery, One Site, Percutaneous Endoscopic Extirpation / Coronary Artery, Two Sites Extirpation of Matter from Coronary Artery, Two Sites, Percutaneous Extirpation of Matter from Coronary Artery, Two Sites, Percutaneous Endoscopic Extirpation / Coronary Artery, Three Sites Extirpation of Matter from Coronary Artery, Three Sites, Percutaneous Extirpation of Matter from Coronary Artery, Three Sites, Percutaneous Endoscopic Extirpation / Coronary Artery, Four or More Sites Extirpation of Matter from Coronary Artery, Four or More Sites, Percutaneous Extirpation of Matter from Coronary Artery, Four or More Sites, Percutaneous Endoscopic See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 31

Interventional Cardiology 39.61 Extracorporeal circulation auxiliary to open heart surgery 5A1 5A1221Z Performance / Physiological Systems Performance of Cardiac Output, Continuous B24 Ultrasonography / Heart B240 Ultrasonography / Coronary Artery, Single B240ZZ3 Ultrasonography of Single Coronary Artery, Intravascular B241 Ultrasonography / Coronary Arteries, Multiple B241ZZ3 Ultrasonography of Multiple Coronary Arteries, Intravascular 00.24 Intravascular imaging of coronary s B244 B244ZZ3 B245 Ultrasonography / Heart, Right Ultrasonography of Right Heart, Intravascular Ultrasonography / Heart, Left B245ZZ3 Ultrasonography of Left Heart, Intravascular B246 Ultrasonography / Heart, Right and Left B246ZZ3 Ultrasonography of Right and Left Heart, Intravascular B24D Ultrasonography / Pediatric Heart B24DZZ3 Ultrasonography of Pediatric Heart, Intravascular B20 Plain Radiography / Heart B200 Plain Radiography / Coronary Artery, Single B2000ZZ Plain Radiography of Single Coronary Artery using High Osmolar Contrast B2001ZZ Plain Radiography of Single Coronary Artery using Low Osmolar Contrast B200YZZ Plain Radiography of Single Coronary Artery using Other Contrast B201 Plain Radiography / Coronary Arteries, Multiple B2010ZZ Plain Radiography of Multiple Coronary Arteries using High Osmolar Contrast B2011ZZ Plain Radiography of Multiple Coronary Arteries using Low Osmolar Contrast B201YZZ Plain Radiography of Multiple Coronary Arteries using Other Contrast B202 Plain Radiography / Coronary Artery Bypass Graft, Single B2020ZZ Plain Radiography of Single Coronary Artery Bypass Graft using High Osmolar Contrast B2021ZZ Plain Radiography of Single Coronary Artery Bypass Graft using Low Osmolar Contrast B202YZZ Plain Radiography of Single Coronary Artery Bypass Graft using Other Contrast B203 Plain Radiography / Coronary Artery Bypass Grafts, Multiple 88.50 Angio, not otherwise specified B2030ZZ B2031ZZ B203YZZ B206 Plain Radiography of Multiple Coronary Artery Bypass Grafts using High Osmolar Contrast Plain Radiography of Multiple Coronary Artery Bypass Grafts using Low Osmolar Contrast Plain Radiography of Multiple Coronary Artery Bypass Grafts using Other Contrast Plain Radiography / Heart, Right and Left B2060ZZ Plain Radiography of Right and Left Heart using High Osmolar Contrast B2061ZZ Plain Radiography of Right and Left Heart using Low Osmolar Contrast B206YZZ Plain Radiography of Right and Left Heart using Other Contrast B21 Fluoroscopy / Heart B210 Fluoroscopy / Coronary Artery, Single B2100ZZ Fluoroscopy of Single Coronary Artery using High Osmolar Contrast B2101ZZ Fluoroscopy of Single Coronary Artery using Low Osmolar Contrast B210YZZ Fluoroscopy of Single Coronary Artery using Other Contrast B211 Fluoroscopy / Coronary Arteries, Multiple B2110ZZ Fluoroscopy of Multiple Coronary Arteries using High Osmolar Contrast B2111ZZ Fluoroscopy of Multiple Coronary Arteries using Low Osmolar Contrast B211YZZ Fluoroscopy of Multiple Coronary Arteries using Other Contrast B212 Fluoroscopy / Coronary Artery Bypass Graft, Single B2120ZZ Fluoroscopy of Single Coronary Artery Bypass Graft using High Osmolar Contrast See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 32

Interventional Cardiology B2121ZZ Fluoroscopy of Single Coronary Artery Bypass Graft using Low Osmolar Contrast B212YZZ Fluoroscopy of Single Coronary Artery Bypass Graft using Other Contrast B213 Fluoroscopy / Coronary Artery Bypass Grafts, Multiple B2130ZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using High Osmolar Contrast B2131ZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using Low Osmolar Contrast B213YZZ Fluoroscopy of Multiple Coronary Artery Bypass Grafts using Other Contrast B216 Fluoroscopy / Heart, Right and Left B2160ZZ Fluoroscopy of Right and Left Heart using High Osmolar Contrast B2161ZZ Fluoroscopy of Right and Left Heart using Low Osmolar Contrast 88.50 Angio, not otherwise specified B216YZZ B217 B2170ZZ B2171ZZ Fluoroscopy of Right and Left Heart using Other Contrast Fluoroscopy / Internal Mammary Bypass Graft, Right Fluoroscopy of Right Internal Mammary Bypass Graft using High Osmolar Contrast Fluoroscopy of Right Internal Mammary Bypass Graft using Low Osmolar Contrast B217YZZ Fluoroscopy of Right Internal Mammary Bypass Graft using Other Contrast B218 Fluoroscopy / Internal Mammary Bypass Graft, Left B2180ZZ Fluoroscopy of Left Internal Mammary Bypass Graft using High Osmolar Contrast B2181ZZ Fluoroscopy of Left Internal Mammary Bypass Graft using Low Osmolar Contrast B218YZZ Fluoroscopy of Left Internal Mammary Bypass Graft using Other Contrast B21F Fluoroscopy / Bypass Graft, Other B21F0ZZ Fluoroscopy of Other Bypass Graft using High Osmolar Contrast B21F1ZZ Fluoroscopy of Other Bypass Graft using Low Osmolar Contrast B21FYZZ Fluoroscopy of Other Bypass Graft using Other Contrast B20 Plain Radiography / Heart B2050ZZ Plain Radiography of Left Heart using High Osmolar Contrast B2051ZZ Plain Radiography of Left Heart using Low Osmolar Contrast 88.53 Angio of left heart structures B205YZZ B21 Plain Radiography of Left Heart using Other Contrast Fluoroscopy / Heart B2150ZZ Fluoroscopy of Left Heart using High Osmolar Contrast B2151ZZ Fluoroscopy of Left Heart using Low Osmolar Contrast B215YZZ Fluoroscopy of Left Heart using Other Contrast See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 33

Neuromodulation 03.93 86.98 Implantation or Replacement of Spinal Neurostimulator Lead(s) Insertion or Replacement of Multiple Array (two or more) Rechargeable Neurostimulator Pulse Generator Insertion/Spinal Canal 00HU0MZ 00HU3MZ 00HU4MZ Neurostimulator Lead into Spinal Canal, Open Neurostimulator Lead into Spinal Canal, Percutaneous Neurostimulator Lead into Spinal Canal, Percutaneous Endoscopic Insertion/Subcutaneous Tissue and Fascia, Back 0JH70EZ 0JH73EZ Multiple Array Rechargeable Stimulator Generator into Back Subcutaneous Tissue and Fascia, Open Multiple Array Rechargeable Stimulator Generator into Back Subcutaneous Tissue and Fascia, Percutaneous See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 34

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 027P 027P04Z 027P0DZ Dilation / Pulmonary Trunk Dilation of Pulmonary Trunk with Drug-eluting Intraluminal Device, Open Dilation of Pulmonary Trunk with Intraluminal Device, Open 027P0DZ Dilation of Pulmonary Trunk with Intraluminal Device, Open 027P0ZZ Dilation of Pulmonary Trunk, Open 027P34Z Dilation of Pulmonary Trunk with Drug-eluting Intraluminal Device, Percutaneous 027P3DZ Dilation of Pulmonary Trunk with Intraluminal Device, Percutaneous 027P3ZZ Dilation of Pulmonary Trunk, Percutaneous 027P44Z Dilation of Pulmonary Trunk with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027P4DZ Dilation of Pulmonary Trunk with Intraluminal Device, Percutaneous Endoscopic 027P4ZZ Dilation of Pulmonary Trunk, Percutaneous Endoscopic 027Q Dilation / Pulmonary Artery, Right 027Q04Z Dilation of Right Pulmonary Artery with Drug-eluting Intraluminal Device, Open 027Q0DZ Dilation of Right Pulmonary Artery with Intraluminal Device, Open 027Q0ZZ Dilation of Right Pulmonary Artery, Open 027Q34Z Dilation of Right Pulmonary Artery with Drug-eluting Intraluminal Device, Percutaneous 027Q3DZ Dilation of Right Pulmonary Artery with Intraluminal Device, Percutaneous 027Q3ZZ 027Q44Z 027Q4DZ 027Q4ZZ 027R Dilation of Right Pulmonary Artery, Percutaneous Dilation of Right Pulmonary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Pulmonary Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Pulmonary Artery, Percutaneous Endoscopic Dilation / Pulmonary Artery, Left 027R04Z Dilation of Left Pulmonary Artery with Drug-eluting Intraluminal Device, Open 027R0DZ Dilation of Left Pulmonary Artery with Intraluminal Device, Open 027R0ZZ Dilation of Left Pulmonary Artery, Open 027R34Z Dilation of Left Pulmonary Artery with Drug-eluting Intraluminal Device, Percutaneous 027R3DZ Dilation of Left Pulmonary Artery with Intraluminal Device, Percutaneous 027R3ZZ Dilation of Left Pulmonary Artery, Percutaneous 027R44Z Dilation of Left Pulmonary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027R4DZ Dilation of Left Pulmonary Artery with Intraluminal Device, Percutaneous Endoscopic 027R4ZZ Dilation of Left Pulmonary Artery, Percutaneous Endoscopic 027S Dilation / Pulmonary Vein, Right 027S04Z Dilation of Right Pulmonary Vein with Drug-eluting Intraluminal Device, Open 027S0DZ Dilation of Right Pulmonary Vein with Intraluminal Device, Open 027S0ZZ Dilation of Right Pulmonary Vein, Open 027S34Z Dilation of Right Pulmonary Vein with Drug-eluting Intraluminal Device, Percutaneous 027S3DZ Dilation of Right Pulmonary Vein with Intraluminal Device, Percutaneous 027S3ZZ Dilation of Right Pulmonary Vein, Percutaneous 39.5 Angioplasty of other non-coronary (s) 027S44Z 027S4DZ 027S4ZZ 027T Dilation of Right Pulmonary Vein with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Pulmonary Vein with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Pulmonary Vein, Percutaneous Endoscopic Dilation / Pulmonary Vein, Left 027T04Z Dilation of Left Pulmonary Vein with Drug-eluting Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 35

Peripheral Interventions 027T0DZ Dilation of Left Pulmonary Vein with Intraluminal Device, Open 027T0ZZ Dilation of Left Pulmonary Vein, Open 027T34Z Dilation of Left Pulmonary Vein with Drug-eluting Intraluminal Device, Percutaneous 027T3DZ Dilation of Left Pulmonary Vein with Intraluminal Device, Percutaneous 027T3ZZ Dilation of Left Pulmonary Vein, Percutaneous 027T44Z Dilation of Left Pulmonary Vein with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027T4DZ Dilation of Left Pulmonary Vein with Intraluminal Device, Percutaneous Endoscopic 027T4ZZ Dilation of Left Pulmonary Vein, Percutaneous Endoscopic 027V Dilation / Superior Vena Cava 027V04Z Dilation of Superior Vena Cava with Drug-eluting Intraluminal Device, Open 027V0DZ Dilation of Superior Vena Cava with Intraluminal Device, Open 027V0ZZ Dilation of Superior Vena Cava, Open 027V34Z Dilation of Superior Vena Cava with Drug-eluting Intraluminal Device, Percutaneous 027V3DZ Dilation of Superior Vena Cava with Intraluminal Device, Percutaneous 027V3ZZ Dilation of Superior Vena Cava, Percutaneous 027V44Z Dilation of Superior Vena Cava with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027V4DZ Dilation of Superior Vena Cava with Intraluminal Device, Percutaneous Endoscopic 027V4ZZ 027W 027W04Z 027W0DZ Dilation of Superior Vena Cava, Percutaneous Endoscopic Dilation / Thoracic Aorta Dilation of Thoracic Aorta with Drug-eluting Intraluminal Device, Open Dilation of Thoracic Aorta with Intraluminal Device, Open 027W0ZZ Dilation of Thoracic Aorta, Open 027W34Z Dilation of Thoracic Aorta with Drug-eluting Intraluminal Device, Percutaneous 027W3DZ Dilation of Thoracic Aorta with Intraluminal Device, Percutaneous 027W3ZZ Dilation of Thoracic Aorta, Percutaneous 027W44Z Dilation of Thoracic Aorta with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 027W4DZ Dilation of Thoracic Aorta with Intraluminal Device, Percutaneous Endoscopic 027W4ZZ Dilation of Thoracic Aorta, Percutaneous Endoscopic 02C Extirpation / Heart and Great Vessels 02CP Extirpation / Pulmonary Trunk 02CP0ZZ Extirpation of Matter from Pulmonary Trunk, Open 02CP3ZZ Extirpation of Matter from Pulmonary Trunk, Percutaneous 02CP4ZZ Extirpation of Matter from Pulmonary Trunk, Percutaneous Endoscopic 02CQ Extirpation / Pulmonary Artery, Right 02CQ0ZZ Extirpation of Matter from Right Pulmonary Artery, Open 02CQ3ZZ Extirpation of Matter from Right Pulmonary Artery, Percutaneous 02CQ4ZZ Extirpation of Matter from Right Pulmonary Artery, Percutaneous Endoscopic 02CR Extirpation / Pulmonary Artery, Left 39.5 Angioplasty of other non-coronary (s) 02CR0ZZ 02CR3ZZ 02CR4ZZ Extirpation of Matter from Left Pulmonary Artery, Open Extirpation of Matter from Left Pulmonary Artery, Percutaneous Extirpation of Matter from Left Pulmonary Artery, Percutaneous Endoscopic 02CS Extirpation / Pulmonary Vein, Right 02CS0ZZ 02CS3ZZ 02CS4ZZ 02CT Extirpation of Matter from Right Pulmonary Vein, Open Extirpation of Matter from Right Pulmonary Vein, Percutaneous Extirpation of Matter from Right Pulmonary Vein, Percutaneous Endoscopic Extirpation / Pulmonary Vein, Left 02CT0ZZ Extirpation of Matter from Left Pulmonary Vein, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 36

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 02CT3ZZ 02CT4ZZ 02CV 02CV0ZZ 02CV3ZZ 02CV4ZZ 02CW 02CW0ZZ 02CW3ZZ 02CW4ZZ Extirpation of Matter from Left Pulmonary Vein, Percutaneous Extirpation of Matter from Left Pulmonary Vein, Percutaneous Endoscopic Extirpation / Superior Vena Cava Extirpation of Matter from Superior Vena Cava, Open Extirpation of Matter from Superior Vena Cava, Percutaneous Extirpation of Matter from Superior Vena Cava, Percutaneous Endoscopic Extirpation / Thoracic Aorta Extirpation of Matter from Thoracic Aorta, Open Extirpation of Matter from Thoracic Aorta, Percutaneous Extirpation of Matter from Thoracic Aorta, Percutaneous Endoscopic 037 Dilation / Upper Arteries 0370 Dilation / Internal Mammary Artery, Right 037004Z 03700DZ 03700ZZ 037034Z 03703DZ 03703ZZ 037044Z 03704DZ 03704ZZ Dilation of Right Internal Mammary Artery with Drug-eluting Intraluminal Device, Open Dilation of Right Internal Mammary Artery with Intraluminal Device, Open Dilation of Right Internal Mammary Artery, Open Dilation of Right Internal Mammary Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Right Internal Mammary Artery with Intraluminal Device, Percutaneous Dilation of Right Internal Mammary Artery, Percutaneous Dilation of Right Internal Mammary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Internal Mammary Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Internal Mammary Artery, Percutaneous Endoscopic 0371 Dilation / Internal Mammary Artery, Left 037104Z 03710DZ 03710ZZ 037134Z 03713DZ 03713ZZ 037144Z 03714DZ 03714ZZ Dilation of Left Internal Mammary Artery with Drug-eluting Intraluminal Device, Open Dilation of Left Internal Mammary Artery with Intraluminal Device, Open Dilation of Left Internal Mammary Artery, Open Dilation of Left Internal Mammary Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Internal Mammary Artery with Intraluminal Device, Percutaneous Dilation of Left Internal Mammary Artery, Percutaneous Dilation of Left Internal Mammary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Left Internal Mammary Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Left Internal Mammary Artery, Percutaneous Endoscopic 0372 Dilation / Innominate Artery 037204Z 03720DZ 03720ZZ 037234Z 03723DZ 03723ZZ 037244Z 03724DZ 03724ZZ Dilation of Innominate Artery with Drug-eluting Intraluminal Device, Open Dilation of Innominate Artery with Intraluminal Device, Open Dilation of Innominate Artery, Open Dilation of Innominate Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Innominate Artery with Intraluminal Device, Percutaneous Dilation of Innominate Artery, Percutaneous Dilation of Innominate Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Innominate Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Innominate Artery, Percutaneous Endoscopic 0373 Dilation / Subclavian Artery, Right 037304Z 03730DZ 03730ZZ 037334Z Dilation of Right Subclavian Artery with Drug-eluting Intraluminal Device, Open Dilation of Right Subclavian Artery with Intraluminal Device, Open Dilation of Right Subclavian Artery, Open Dilation of Right Subclavian Artery with Drug-eluting Intraluminal Device, Percutaneous Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 37

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 03733DZ Dilation of Right Subclavian Artery with Intraluminal Device, Percutaneous 03733ZZ Dilation of Right Subclavian Artery, Percutaneous 037344Z Dilation of Right Subclavian Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03734DZ Dilation of Right Subclavian Artery with Intraluminal Device, Percutaneous Endoscopic 03734ZZ Dilation of Right Subclavian Artery, Percutaneous Endoscopic 0374 Dilation / Subclavian Artery, Left 037404Z Dilation of Left Subclavian Artery with Drug-eluting Intraluminal Device, Open 03740DZ Dilation of Left Subclavian Artery with Intraluminal Device, Open 03740ZZ Dilation of Left Subclavian Artery, Open 037434Z Dilation of Left Subclavian Artery with Drug-eluting Intraluminal Device, Percutaneous 03743DZ Dilation of Left Subclavian Artery with Intraluminal Device, Percutaneous 03743ZZ Dilation of Left Subclavian Artery, Percutaneous 037444Z Dilation of Left Subclavian Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03744DZ Dilation of Left Subclavian Artery with Intraluminal Device, Percutaneous Endoscopic 03744ZZ Dilation of Left Subclavian Artery, Percutaneous Endoscopic 0375 Dilation / Axillary Artery, Right 037504Z Dilation of Right Axillary Artery with Drug-eluting Intraluminal Device, Open 03750DZ Dilation of Right Axillary Artery with Intraluminal Device, Open 03750ZZ Dilation of Right Axillary Artery, Open 037534Z Dilation of Right Axillary Artery with Drug-eluting Intraluminal Device, Percutaneous 03753DZ Dilation of Right Axillary Artery with Intraluminal Device, Percutaneous 03753ZZ Dilation of Right Axillary Artery, Percutaneous 037544Z Dilation of Right Axillary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03754DZ Dilation of Right Axillary Artery with Intraluminal Device, Percutaneous Endoscopic 03754ZZ Dilation of Right Axillary Artery, Percutaneous Endoscopic 0376 Dilation / Axillary Artery, Left 037604Z Dilation of Left Axillary Artery with Drug-eluting Intraluminal Device, Open 03760DZ Dilation of Left Axillary Artery with Intraluminal Device, Open 03760ZZ Dilation of Left Axillary Artery, Open 037634Z Dilation of Left Axillary Artery with Drug-eluting Intraluminal Device, Percutaneous 03763DZ Dilation of Left Axillary Artery with Intraluminal Device, Percutaneous 03763ZZ Dilation of Left Axillary Artery, Percutaneous 037644Z Dilation of Left Axillary Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03764DZ Dilation of Left Axillary Artery with Intraluminal Device, Percutaneous Endoscopic 03764ZZ Dilation of Left Axillary Artery, Percutaneous Endoscopic 0377 Dilation / Brachial Artery, Right 037704Z Dilation of Right Brachial Artery with Drug-eluting Intraluminal Device, Open 03770DZ Dilation of Right Brachial Artery with Intraluminal Device, Open 03770ZZ Dilation of Right Brachial Artery, Open 037734Z Dilation of Right Brachial Artery with Drug-eluting Intraluminal Device, Percutaneous 03773DZ Dilation of Right Brachial Artery with Intraluminal Device, Percutaneous 03773ZZ Dilation of Right Brachial Artery, Percutaneous 037744Z Dilation of Right Brachial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03774DZ Dilation of Right Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03774ZZ Dilation of Right Brachial Artery, Percutaneous Endoscopic 0378 Dilation / Brachial Artery, Left 037804Z Dilation of Left Brachial Artery with Drug-eluting Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 38

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 03780DZ Dilation of Left Brachial Artery with Intraluminal Device, Open 03780ZZ Dilation of Left Brachial Artery, Open 037834Z Dilation of Left Brachial Artery with Drug-eluting Intraluminal Device, Percutaneous 03783DZ Dilation of Left Brachial Artery with Intraluminal Device, Percutaneous 03783ZZ Dilation of Left Brachial Artery, Percutaneous 037844Z Dilation of Left Brachial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03784DZ Dilation of Left Brachial Artery with Intraluminal Device, Percutaneous Endoscopic 03784ZZ Dilation of Left Brachial Artery, Percutaneous Endoscopic 0379 Dilation / Ulnar Artery, Right 037904Z Dilation of Right Ulnar Artery with Drug-eluting Intraluminal Device, Open 03790DZ Dilation of Right Ulnar Artery with Intraluminal Device, Open 03790ZZ Dilation of Right Ulnar Artery, Open 037934Z Dilation of Right Ulnar Artery with Drug-eluting Intraluminal Device, Percutaneous 03793DZ Dilation of Right Ulnar Artery with Intraluminal Device, Percutaneous 03793ZZ Dilation of Right Ulnar Artery, Percutaneous 037944Z Dilation of Right Ulnar Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 03794DZ Dilation of Right Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 03794ZZ Dilation of Right Ulnar Artery, Percutaneous Endoscopic 037A Dilation / Ulnar Artery, Left 037A04Z Dilation of Left Ulnar Artery with Drug-eluting Intraluminal Device, Open 037A0DZ Dilation of Left Ulnar Artery with Intraluminal Device, Open 037A0ZZ Dilation of Left Ulnar Artery, Open 037A34Z Dilation of Left Ulnar Artery with Drug-eluting Intraluminal Device, Percutaneous 037A3DZ Dilation of Left Ulnar Artery with Intraluminal Device, Percutaneous 037A3ZZ Dilation of Left Ulnar Artery, Percutaneous 037A44Z Dilation of Left Ulnar Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037A4DZ Dilation of Left Ulnar Artery with Intraluminal Device, Percutaneous Endoscopic 037A4ZZ Dilation of Left Ulnar Artery, Percutaneous Endoscopic 037B Dilation / Radial Artery, Right 037B04Z Dilation of Right Radial Artery with Drug-eluting Intraluminal Device, Open 037B0DZ Dilation of Right Radial Artery with Intraluminal Device, Open 037B0ZZ Dilation of Right Radial Artery, Open 037B34Z Dilation of Right Radial Artery with Drug-eluting Intraluminal Device, Percutaneous 037B3DZ Dilation of Right Radial Artery with Intraluminal Device, Percutaneous 037B3ZZ Dilation of Right Radial Artery, Percutaneous 037B44Z Dilation of Right Radial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037B4DZ Dilation of Right Radial Artery with Intraluminal Device, Percutaneous Endoscopic 037B4ZZ Dilation of Right Radial Artery, Percutaneous Endoscopic 037C Dilation / Radial Artery, Left 037C04Z Dilation of Left Radial Artery with Drug-eluting Intraluminal Device, Open 037C0DZ Dilation of Left Radial Artery with Intraluminal Device, Open 037C0ZZ Dilation of Left Radial Artery, Open 037C34Z Dilation of Left Radial Artery with Drug-eluting Intraluminal Device, Percutaneous 037C3DZ Dilation of Left Radial Artery with Intraluminal Device, Percutaneous 037C3ZZ Dilation of Left Radial Artery, Percutaneous 037C44Z Dilation of Left Radial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037C4DZ Dilation of Left Radial Artery with Intraluminal Device, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 39

Peripheral Interventions 037C4ZZ Dilation of Left Radial Artery, Percutaneous Endoscopic 037D Dilation / Hand Artery, Right 037D04Z Dilation of Right Hand Artery with Drug-eluting Intraluminal Device, Open 037D0DZ Dilation of Right Hand Artery with Intraluminal Device, Open 037D0ZZ Dilation of Right Hand Artery, Open 037D34Z 037D3DZ 037D3ZZ 037D44Z 037D4DZ Dilation of Right Hand Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Right Hand Artery with Intraluminal Device, Percutaneous Dilation of Right Hand Artery, Percutaneous Dilation of Right Hand Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Hand Artery with Intraluminal Device, Percutaneous Endoscopic 037D4ZZ Dilation of Right Hand Artery, Percutaneous Endoscopic 037F Dilation / Hand Artery, Left 037F04Z Dilation of Left Hand Artery with Drug-eluting Intraluminal Device, Open 037F0DZ Dilation of Left Hand Artery with Intraluminal Device, Open 037F0ZZ Dilation of Left Hand Artery, Open 39.5 Angioplasty of other non-coronary (s) 037F34Z 037F3DZ 037F3ZZ Dilation of Left Hand Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Hand Artery with Intraluminal Device, Percutaneous Dilation of Left Hand Artery, Percutaneous 037F44Z Dilation of Left Hand Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037F4DZ Dilation of Left Hand Artery with Intraluminal Device, Percutaneous Endoscopic 037F4ZZ Dilation of Left Hand Artery, Percutaneous Endoscopic 037G Dilation / Intracranial Artery 037G04Z Dilation of Intracranial Artery with Drug-eluting Intraluminal Device, Open 037G0DZ Dilation of Intracranial Artery with Intraluminal Device, Open 037G0ZZ Dilation of Intracranial Artery, Open 037G3ZZ Dilation of Intracranial Artery, Percutaneous 037G4ZZ Dilation of Intracranial Artery, Percutaneous Endoscopic 037H Dilation / Common Carotid Artery, Right 037H04Z Dilation of Right Common Carotid Artery with Drug-eluting Intraluminal Device, Open 037H0DZ Dilation of Right Common Carotid Artery with Intraluminal Device, Open 037H0ZZ 037H3ZZ 037H4ZZ 037J 037J04Z Dilation of Right Common Carotid Artery, Open Dilation of Right Common Carotid Artery, Percutaneous Dilation of Right Common Carotid Artery, Percutaneous Endoscopic Dilation / Common Carotid Artery, Left Dilation of Left Common Carotid Artery with Drug-eluting Intraluminal Device, Open 037J0DZ Dilation of Left Common Carotid Artery with Intraluminal Device, Open 037J0ZZ Dilation of Left Common Carotid Artery, Open 037J3ZZ Dilation of Left Common Carotid Artery, Percutaneous 037J4ZZ Dilation of Left Common Carotid Artery, Percutaneous Endoscopic 037K Dilation / Internal Carotid Artery, Right 037K04Z Dilation of Right Internal Carotid Artery with Drug-eluting Intraluminal Device, Open 037K0DZ Dilation of Right Internal Carotid Artery with Intraluminal Device, Open 037K0ZZ Dilation of Right Internal Carotid Artery, Open 037K3ZZ Dilation of Right Internal Carotid Artery, Percutaneous 037K4ZZ Dilation of Right Internal Carotid Artery, Percutaneous Endoscopic 037L Dilation / Internal Carotid Artery, Left 037L04Z Dilation of Left Internal Carotid Artery with Drug-eluting Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 40

Peripheral Interventions 037L0DZ Dilation of Left Internal Carotid Artery with Intraluminal Device, Open 037L0ZZ Dilation of Left Internal Carotid Artery, Open 037L3ZZ Dilation of Left Internal Carotid Artery, Percutaneous 037L4ZZ Dilation of Left Internal Carotid Artery, Percutaneous Endoscopic 037M 037M04Z 037M0DZ 037M0ZZ Dilation / External Carotid Artery, Right Dilation of Right External Carotid Artery with Drug-eluting Intraluminal Device, Open Dilation of Right External Carotid Artery with Intraluminal Device, Open Dilation of Right External Carotid Artery, Open 037M3ZZ Dilation of Right External Carotid Artery, Percutaneous 037M4ZZ Dilation of Right External Carotid Artery, Percutaneous Endoscopic 037N Dilation / External Carotid Artery, Left 037N04Z Dilation of Left External Carotid Artery with Drug-eluting Intraluminal Device, Open 39.5 Angioplasty of other non-coronary (s) 037N0DZ 037N0ZZ 037N3ZZ Dilation of Left External Carotid Artery with Intraluminal Device, Open Dilation of Left External Carotid Artery, Open Dilation of Left External Carotid Artery, Percutaneous 037N4ZZ Dilation of Left External Carotid Artery, Percutaneous Endoscopic 037P Dilation / Vertebral Artery, Right 037P04Z Dilation of Right Vertebral Artery with Drug-eluting Intraluminal Device, Open 037P0DZ Dilation of Right Vertebral Artery with Intraluminal Device, Open 037P0ZZ Dilation of Right Vertebral Artery, Open 037P3ZZ Dilation of Right Vertebral Artery, Percutaneous 037P4ZZ Dilation of Right Vertebral Artery, Percutaneous Endoscopic 037Q Dilation / Vertebral Artery, Left 037Q04Z Dilation of Left Vertebral Artery with Drug-eluting Intraluminal Device, Open 037Q0DZ Dilation of Left Vertebral Artery with Intraluminal Device, Open 037Q0ZZ Dilation of Left Vertebral Artery, Open 037Q3ZZ Dilation of Left Vertebral Artery, Percutaneous 037Q4ZZ Dilation of Left Vertebral Artery, Percutaneous Endoscopic 037R Dilation / Face Artery 037R04Z 037R0DZ 037R0ZZ 037R34Z Dilation of Face Artery with Drug-eluting Intraluminal Device, Open Dilation of Face Artery with Intraluminal Device, Open Dilation of Face Artery, Open Dilation of Face Artery with Drug-eluting Intraluminal Device, Percutaneous 037R3DZ Dilation of Face Artery with Intraluminal Device, Percutaneous 037R3ZZ Dilation of Face Artery, Percutaneous 037R44Z Dilation of Face Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037R4DZ Dilation of Face Artery with Intraluminal Device, Percutaneous Endoscopic 037R4ZZ Dilation of Face Artery, Percutaneous Endoscopic 037S Dilation / Temporal Artery, Right 037S04Z Dilation of Right Temporal Artery with Drug-eluting Intraluminal Device, Open 037S0DZ Dilation of Right Temporal Artery with Intraluminal Device, Open 037S0ZZ Dilation of Right Temporal Artery, Open 037S34Z Dilation of Right Temporal Artery with Drug-eluting Intraluminal Device, Percutaneous 037S3DZ Dilation of Right Temporal Artery with Intraluminal Device, Percutaneous 037S3ZZ Dilation of Right Temporal Artery, Percutaneous 037S44Z Dilation of Right Temporal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037S4DZ Dilation of Right Temporal Artery with Intraluminal Device, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 41

Peripheral Interventions 037S4ZZ Dilation of Right Temporal Artery, Percutaneous Endoscopic 037T Dilation / Temporal Artery, Left 037T04Z Dilation of Left Temporal Artery with Drug-eluting Intraluminal Device, Open 037T0DZ Dilation of Left Temporal Artery with Intraluminal Device, Open 037T0ZZ 037T34Z 037T3DZ 037T3ZZ Dilation of Left Temporal Artery, Open Dilation of Left Temporal Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Temporal Artery with Intraluminal Device, Percutaneous Dilation of Left Temporal Artery, Percutaneous 037T44Z Dilation of Left Temporal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037T4DZ Dilation of Left Temporal Artery with Intraluminal Device, Percutaneous Endoscopic 037T4ZZ Dilation of Left Temporal Artery, Percutaneous Endoscopic 037U Dilation / Thyroid Artery, Right 39.5 Angioplasty of other non-coronary (s) 037U04Z 037U0DZ 037U0ZZ Dilation of Right Thyroid Artery with Drug-eluting Intraluminal Device, Open Dilation of Right Thyroid Artery with Intraluminal Device, Open Dilation of Right Thyroid Artery, Open 037U34Z Dilation of Right Thyroid Artery with Drug-eluting Intraluminal Device, Percutaneous 037U3DZ Dilation of Right Thyroid Artery with Intraluminal Device, Percutaneous 037U3ZZ Dilation of Right Thyroid Artery, Percutaneous 037U44Z Dilation of Right Thyroid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037U4DZ Dilation of Right Thyroid Artery with Intraluminal Device, Percutaneous Endoscopic 037U4ZZ Dilation of Right Thyroid Artery, Percutaneous Endoscopic 037V Dilation / Thyroid Artery, Left 037V04Z Dilation of Left Thyroid Artery with Drug-eluting Intraluminal Device, Open 037V0DZ Dilation of Left Thyroid Artery with Intraluminal Device, Open 037V0ZZ Dilation of Left Thyroid Artery, Open 037V34Z Dilation of Left Thyroid Artery with Drug-eluting Intraluminal Device, Percutaneous 037V3DZ Dilation of Left Thyroid Artery with Intraluminal Device, Percutaneous 037V3ZZ Dilation of Left Thyroid Artery, Percutaneous 037V44Z Dilation of Left Thyroid Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037V4DZ 037V4ZZ 037Y 037Y04Z Dilation of Left Thyroid Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Left Thyroid Artery, Percutaneous Endoscopic Dilation / Upper Artery Dilation of Upper Artery with Drug-eluting Intraluminal Device, Open 037Y0DZ Dilation of Upper Artery with Intraluminal Device, Open 037Y0ZZ Dilation of Upper Artery, Open 037Y34Z Dilation of Upper Artery with Drug-eluting Intraluminal Device, Percutaneous 037Y3DZ Dilation of Upper Artery with Intraluminal Device, Percutaneous 037Y3ZZ Dilation of Upper Artery, Percutaneous 037Y44Z Dilation of Upper Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 037Y4DZ Dilation of Upper Artery with Intraluminal Device, Percutaneous Endoscopic 037Y4ZZ Dilation of Upper Artery, Percutaneous Endoscopic 03C Extirpation / Upper Arteries 03C0 Extirpation / Internal Mammary Artery, Right 03C00ZZ Extirpation of Matter from Right Internal Mammary Artery, Open 03C03ZZ Extirpation of Matter from Right Internal Mammary Artery, Percutaneous 03C04ZZ Extirpation of Matter from Right Internal Mammary Artery, Percutaneous Endoscopic 03C1 Extirpation / Internal Mammary Artery, Left Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 42

Peripheral Interventions 03C10ZZ 03C13ZZ Extirpation of Matter from Left Internal Mammary Artery, Open Extirpation of Matter from Left Internal Mammary Artery, Percutaneous 03C14ZZ Extirpation of Matter from Left Internal Mammary Artery, Percutaneous Endoscopic 39.5 Angioplasty of other non-coronary (s) 03C2 03C20ZZ 03C23ZZ Extirpation / Innominate Artery Extirpation of Matter from Innominate Artery, Open Extirpation of Matter from Innominate Artery, Percutaneous 03C24ZZ Extirpation of Matter from Innominate Artery, Percutaneous Endoscopic 03C3 Extirpation / Subclavian Artery, Right 03C30ZZ Extirpation of Matter from Right Subclavian Artery, Open 03C33ZZ Extirpation of Matter from Right Subclavian Artery, Percutaneous 03C34ZZ Extirpation of Matter from Right Subclavian Artery, Percutaneous Endoscopic 03C4 Extirpation / Subclavian Artery, Left 03C40ZZ Extirpation of Matter from Left Subclavian Artery, Open 03C43ZZ Extirpation of Matter from Left Subclavian Artery, Percutaneous 03C44ZZ Extirpation of Matter from Left Subclavian Artery, Percutaneous Endoscopic 03C5 Extirpation / Axillary Artery, Right 03C50ZZ Extirpation of Matter from Right Axillary Artery, Open 03C53ZZ Extirpation of Matter from Right Axillary Artery, Percutaneous 03C54ZZ Extirpation of Matter from Right Axillary Artery, Percutaneous Endoscopic 03C6 Extirpation / Axillary Artery, Left 03C60ZZ Extirpation of Matter from Left Axillary Artery, Open 03C63ZZ Extirpation of Matter from Left Axillary Artery, Percutaneous 03C64ZZ Extirpation of Matter from Left Axillary Artery, Percutaneous Endoscopic 03C7 Extirpation / Brachial Artery, Right 03C70ZZ 03C73ZZ 03C74ZZ 03C8 Extirpation of Matter from Right Brachial Artery, Open Extirpation of Matter from Right Brachial Artery, Percutaneous Extirpation of Matter from Right Brachial Artery, Percutaneous Endoscopic Extirpation / Brachial Artery, Left 03C80ZZ Extirpation of Matter from Left Brachial Artery, Open 03C83ZZ Extirpation of Matter from Left Brachial Artery, Percutaneous 03C84ZZ Extirpation of Matter from Left Brachial Artery, Percutaneous Endoscopic 03C9 Extirpation / Ulnar Artery, Right 03C90ZZ Extirpation of Matter from Right Ulnar Artery, Open 03C93ZZ Extirpation of Matter from Right Ulnar Artery, Percutaneous 03C94ZZ Extirpation of Matter from Right Ulnar Artery, Percutaneous Endoscopic 03CA Extirpation / Ulnar Artery, Left 03CA0ZZ Extirpation of Matter from Left Ulnar Artery, Open 03CA3ZZ Extirpation of Matter from Left Ulnar Artery, Percutaneous 03CA4ZZ Extirpation of Matter from Left Ulnar Artery, Percutaneous Endoscopic 03CB Extirpation / Radial Artery, Right 03CB0ZZ Extirpation of Matter from Right Radial Artery, Open 03CB3ZZ Extirpation of Matter from Right Radial Artery, Percutaneous 03CB4ZZ Extirpation of Matter from Right Radial Artery, Percutaneous Endoscopic 03CC Extirpation / Radial Artery, Left 03CC0ZZ Extirpation of Matter from Left Radial Artery, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 43

Peripheral Interventions 03CC3ZZ Extirpation of Matter from Left Radial Artery, Percutaneous 03CC4ZZ Extirpation of Matter from Left Radial Artery, Percutaneous Endoscopic 03CD 03CD0ZZ 03CD3ZZ 03CD4ZZ 03CF Extirpation / Hand Artery, Right Extirpation of Matter from Right Hand Artery, Open Extirpation of Matter from Right Hand Artery, Percutaneous Extirpation of Matter from Right Hand Artery, Percutaneous Endoscopic Extirpation / Hand Artery, Left 03CF0ZZ Extirpation of Matter from Left Hand Artery, Open 03CF3ZZ Extirpation of Matter from Left Hand Artery, Percutaneous 03CF4ZZ Extirpation of Matter from Left Hand Artery, Percutaneous Endoscopic 03CG Extirpation / Intracranial Artery 03CG0ZZ Extirpation of Matter from Intracranial Artery, Open 39.5 Angioplasty of other non-coronary (s) 03CH 03CH0ZZ 03CJ 03CJ0ZZ Extirpation / Common Carotid Artery, Right Extirpation of Matter from Right Common Carotid Artery, Open Extirpation / Common Carotid Artery, Left Extirpation of Matter from Left Common Carotid Artery, Open 03CK Extirpation / Internal Carotid Artery, Right 03CK0ZZ Extirpation of Matter from Right Internal Carotid Artery, Open 03CL Extirpation / Internal Carotid Artery, Left 03CL0ZZ Extirpation of Matter from Left Internal Carotid Artery, Open 03CM Extirpation / External Carotid Artery, Right 03CM0ZZ Extirpation of Matter from Right External Carotid Artery, Open 03CN Extirpation / External Carotid Artery, Left 03CN0ZZ Extirpation of Matter from Left External Carotid Artery, Open 03CP Extirpation / Vertebral Artery, Right 03CP0ZZ Extirpation of Matter from Right Vertebral Artery, Open 03CQ Extirpation / Vertebral Artery, Left 03CQ0ZZ Extirpation of Matter from Left Vertebral Artery, Open 03CR Extirpation / Face Artery 03CR0ZZ Extirpation of Matter from Face Artery, Open 03CR3ZZ Extirpation of Matter from Face Artery, Percutaneous 03CR4ZZ 03CS 03CS0ZZ 03CS3ZZ Extirpation of Matter from Face Artery, Percutaneous Endoscopic Extirpation / Temporal Artery, Right Extirpation of Matter from Right Temporal Artery, Open Extirpation of Matter from Right Temporal Artery, Percutaneous 03CS4ZZ Extirpation of Matter from Right Temporal Artery, Percutaneous Endoscopic 03CT Extirpation / Temporal Artery, Left 03CT0ZZ Extirpation of Matter from Left Temporal Artery, Open 03CT3ZZ Extirpation of Matter from Left Temporal Artery, Percutaneous 03CT4ZZ Extirpation of Matter from Left Temporal Artery, Percutaneous Endoscopic 03CU Extirpation / Thyroid Artery, Right 03CU0ZZ Extirpation of Matter from Right Thyroid Artery, Open 03CU3ZZ Extirpation of Matter from Right Thyroid Artery, Percutaneous 03CU4ZZ Extirpation of Matter from Right Thyroid Artery, Percutaneous Endoscopic 03CV Extirpation / Thyroid Artery, Left 03CV0ZZ Extirpation of Matter from Left Thyroid Artery, Open 03CV3ZZ Extirpation of Matter from Left Thyroid Artery, Percutaneous Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 44

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 03CV4ZZ Extirpation of Matter from Left Thyroid Artery, Percutaneous Endoscopic 03CY Extirpation / Upper Artery 03CY0ZZ Extirpation of Matter from Upper Artery, Open 03CY3ZZ Extirpation of Matter from Upper Artery, Percutaneous 03CY4ZZ Extirpation of Matter from Upper Artery, Percutaneous Endoscopic 047 Dilation / Lower Arteries 0470 Dilation / Abdominal Aorta 047004Z Dilation of Abdominal Aorta with Drug-eluting Intraluminal Device, Open 04700DZ Dilation of Abdominal Aorta with Intraluminal Device, Open 04700ZZ Dilation of Abdominal Aorta, Open 047034Z Dilation of Abdominal Aorta with Drug-eluting Intraluminal Device, Percutaneous 04703DZ Dilation of Abdominal Aorta with Intraluminal Device, Percutaneous 04703ZZ Dilation of Abdominal Aorta, Percutaneous 047044Z Dilation of Abdominal Aorta with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04704DZ Dilation of Abdominal Aorta with Intraluminal Device, Percutaneous Endoscopic 04704ZZ Dilation of Abdominal Aorta, Percutaneous Endoscopic 0471 Dilation / Celiac Artery 047104Z Dilation of Celiac Artery with Drug-eluting Intraluminal Device, Open 04710DZ Dilation of Celiac Artery with Intraluminal Device, Open 04710ZZ Dilation of Celiac Artery, Open 047134Z Dilation of Celiac Artery with Drug-eluting Intraluminal Device, Percutaneous 04713DZ Dilation of Celiac Artery with Intraluminal Device, Percutaneous 04713ZZ Dilation of Celiac Artery, Percutaneous 047144Z Dilation of Celiac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04714DZ Dilation of Celiac Artery with Intraluminal Device, Percutaneous Endoscopic 04714ZZ Dilation of Celiac Artery, Percutaneous Endoscopic 0472 Dilation / Gastric Artery 047204Z Dilation of Gastric Artery with Drug-eluting Intraluminal Device, Open 04720DZ Dilation of Gastric Artery with Intraluminal Device, Open 04720ZZ Dilation of Gastric Artery, Open 047234Z Dilation of Gastric Artery with Drug-eluting Intraluminal Device, Percutaneous 04723DZ Dilation of Gastric Artery with Intraluminal Device, Percutaneous 04723ZZ Dilation of Gastric Artery, Percutaneous 047244Z Dilation of Gastric Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04724DZ Dilation of Gastric Artery with Intraluminal Device, Percutaneous Endoscopic 04724ZZ Dilation of Gastric Artery, Percutaneous Endoscopic 0473 Dilation / Hepatic Artery 047304Z Dilation of Hepatic Artery with Drug-eluting Intraluminal Device, Open 04730DZ Dilation of Hepatic Artery with Intraluminal Device, Open 04730ZZ Dilation of Hepatic Artery, Open 047334Z Dilation of Hepatic Artery with Drug-eluting Intraluminal Device, Percutaneous 04733DZ Dilation of Hepatic Artery with Intraluminal Device, Percutaneous 04733ZZ Dilation of Hepatic Artery, Percutaneous 047344Z Dilation of Hepatic Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04734DZ Dilation of Hepatic Artery with Intraluminal Device, Percutaneous Endoscopic 04734ZZ Dilation of Hepatic Artery, Percutaneous Endoscopic 0474 Dilation / Splenic Artery Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 45

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 047404Z Dilation of Splenic Artery with Drug-eluting Intraluminal Device, Open 04740DZ Dilation of Splenic Artery with Intraluminal Device, Open 04740ZZ Dilation of Splenic Artery, Open 047434Z Dilation of Splenic Artery with Drug-eluting Intraluminal Device, Percutaneous 04743DZ Dilation of Splenic Artery with Intraluminal Device, Percutaneous 04743ZZ Dilation of Splenic Artery, Percutaneous 047444Z Dilation of Splenic Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04744DZ Dilation of Splenic Artery with Intraluminal Device, Percutaneous Endoscopic 04744ZZ Dilation of Splenic Artery, Percutaneous Endoscopic 0475 Dilation / Superior Mesenteric Artery 047504Z Dilation of Superior Mesenteric Artery with Drug-eluting Intraluminal Device, Open 04750DZ Dilation of Superior Mesenteric Artery with Intraluminal Device, Open 04750ZZ Dilation of Superior Mesenteric Artery, Open 047534Z Dilation of Superior Mesenteric Artery with Drug-eluting Intraluminal Device, Percutaneous 04753DZ Dilation of Superior Mesenteric Artery with Intraluminal Device, Percutaneous 04753ZZ Dilation of Superior Mesenteric Artery, Percutaneous 047544Z Dilation of Superior Mesenteric Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04754DZ Dilation of Superior Mesenteric Artery with Intraluminal Device, Percutaneous Endoscopic 04754ZZ Dilation of Superior Mesenteric Artery, Percutaneous Endoscopic 0476 Dilation / Colic Artery, Right 047604Z Dilation of Right Colic Artery with Drug-eluting Intraluminal Device, Open 04760DZ Dilation of Right Colic Artery with Intraluminal Device, Open 04760ZZ Dilation of Right Colic Artery, Open 047634Z Dilation of Right Colic Artery with Drug-eluting Intraluminal Device, Percutaneous 04763DZ Dilation of Right Colic Artery with Intraluminal Device, Percutaneous 04763ZZ Dilation of Right Colic Artery, Percutaneous 047644Z Dilation of Right Colic Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04764DZ Dilation of Right Colic Artery with Intraluminal Device, Percutaneous Endoscopic 04764ZZ Dilation of Right Colic Artery, Percutaneous Endoscopic 0477 Dilation / Colic Artery, Left 047704Z Dilation of Left Colic Artery with Drug-eluting Intraluminal Device, Open 04770DZ Dilation of Left Colic Artery with Intraluminal Device, Open 04770ZZ Dilation of Left Colic Artery, Open 047734Z Dilation of Left Colic Artery with Drug-eluting Intraluminal Device, Percutaneous 04773DZ Dilation of Left Colic Artery with Intraluminal Device, Percutaneous 04773ZZ Dilation of Left Colic Artery, Percutaneous 047744Z Dilation of Left Colic Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04774DZ Dilation of Left Colic Artery with Intraluminal Device, Percutaneous Endoscopic 04774ZZ Dilation of Left Colic Artery, Percutaneous Endoscopic 0478 Dilation / Colic Artery, Middle 047804Z Dilation of Middle Colic Artery with Drug-eluting Intraluminal Device, Open 04780DZ Dilation of Middle Colic Artery with Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 46

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 04780ZZ Dilation of Middle Colic Artery, Open 047834Z Dilation of Middle Colic Artery with Drug-eluting Intraluminal Device, Percutaneous 04783DZ Dilation of Middle Colic Artery with Intraluminal Device, Percutaneous 04783ZZ Dilation of Middle Colic Artery, Percutaneous 047844Z Dilation of Middle Colic Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04784DZ Dilation of Middle Colic Artery with Intraluminal Device, Percutaneous Endoscopic 04784ZZ Dilation of Middle Colic Artery, Percutaneous Endoscopic 0479 Dilation / Renal Artery, Right 047904Z Dilation of Right Renal Artery with Drug-eluting Intraluminal Device, Open 04790DZ Dilation of Right Renal Artery with Intraluminal Device, Open 04790ZZ Dilation of Right Renal Artery, Open 047934Z Dilation of Right Renal Artery with Drug-eluting Intraluminal Device, Percutaneous 04793DZ Dilation of Right Renal Artery with Intraluminal Device, Percutaneous 04793ZZ Dilation of Right Renal Artery, Percutaneous 047944Z Dilation of Right Renal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 04794DZ Dilation of Right Renal Artery with Intraluminal Device, Percutaneous Endoscopic 04794ZZ Dilation of Right Renal Artery, Percutaneous Endoscopic 047A Dilation / Renal Artery, Left 047A04Z Dilation of Left Renal Artery with Drug-eluting Intraluminal Device, Open 047A0DZ Dilation of Left Renal Artery with Intraluminal Device, Open 047A0ZZ Dilation of Left Renal Artery, Open 047A34Z Dilation of Left Renal Artery with Drug-eluting Intraluminal Device, Percutaneous 047A3DZ Dilation of Left Renal Artery with Intraluminal Device, Percutaneous 047A3ZZ Dilation of Left Renal Artery, Percutaneous 047A44Z Dilation of Left Renal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047A4DZ Dilation of Left Renal Artery with Intraluminal Device, Percutaneous Endoscopic 047A4ZZ Dilation of Left Renal Artery, Percutaneous Endoscopic 047B Dilation / Inferior Mesenteric Artery 047B04Z Dilation of Inferior Mesenteric Artery with Drug-eluting Intraluminal Device, Open 047B0DZ Dilation of Inferior Mesenteric Artery with Intraluminal Device, Open 047B0ZZ Dilation of Inferior Mesenteric Artery, Open 047B34Z Dilation of Inferior Mesenteric Artery with Drug-eluting Intraluminal Device, Percutaneous 047B3DZ Dilation of Inferior Mesenteric Artery with Intraluminal Device, Percutaneous 047B3ZZ Dilation of Inferior Mesenteric Artery, Percutaneous 047B44Z Dilation of Inferior Mesenteric Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047B4DZ Dilation of Inferior Mesenteric Artery with Intraluminal Device, Percutaneous Endoscopic 047B4ZZ Dilation of Inferior Mesenteric Artery, Percutaneous Endoscopic 047C Dilation / Common Iliac Artery, Right 047C04Z Dilation of Right Common Iliac Artery with Drug-eluting Intraluminal Device, Open 047C0DZ Dilation of Right Common Iliac Artery with Intraluminal Device, Open 047C0ZZ Dilation of Right Common Iliac Artery, Open 047C34Z Dilation of Right Common Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous 047C3DZ Dilation of Right Common Iliac Artery with Intraluminal Device, Percutaneous 047C3ZZ Dilation of Right Common Iliac Artery, Percutaneous 047C44Z Dilation of Right Common Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047C4DZ Dilation of Right Common Iliac Artery with Intraluminal Device, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 47

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 047C4ZZ 047D 047D04Z Dilation of Right Common Iliac Artery, Percutaneous Endoscopic Dilation / Common Iliac Artery, Left Dilation of Left Common Iliac Artery with Drug-eluting Intraluminal Device, Open 047D0DZ Dilation of Left Common Iliac Artery with Intraluminal Device, Open 047D0ZZ Dilation of Left Common Iliac Artery, Open 047D34Z Dilation of Left Common Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous 047D3DZ Dilation of Left Common Iliac Artery with Intraluminal Device, Percutaneous 047D3ZZ Dilation of Left Common Iliac Artery, Percutaneous 047D44Z Dilation of Left Common Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047D4DZ Dilation of Left Common Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 047D4ZZ Dilation of Left Common Iliac Artery, Percutaneous Endoscopic 047E Dilation / Internal Iliac Artery, Right 047E04Z Dilation of Right Internal Iliac Artery with Drug-eluting Intraluminal Device, Open 047E0DZ Dilation of Right Internal Iliac Artery with Intraluminal Device, Open 047E0ZZ Dilation of Right Internal Iliac Artery, Open 047E34Z Dilation of Right Internal Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous 047E3DZ Dilation of Right Internal Iliac Artery with Intraluminal Device, Percutaneous 047E3ZZ Dilation of Right Internal Iliac Artery, Percutaneous 047E44Z Dilation of Right Internal Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047E4DZ Dilation of Right Internal Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 047E4ZZ Dilation of Right Internal Iliac Artery, Percutaneous Endoscopic 047F Dilation / Internal Iliac Artery, Left 047F04Z 047F0DZ 047F0ZZ 047F34Z Dilation of Left Internal Iliac Artery with Drug-eluting Intraluminal Device, Open Dilation of Left Internal Iliac Artery with Intraluminal Device, Open Dilation of Left Internal Iliac Artery, Open Dilation of Left Internal Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous 047F3DZ Dilation of Left Internal Iliac Artery with Intraluminal Device, Percutaneous 047F3ZZ Dilation of Left Internal Iliac Artery, Percutaneous 047F44Z Dilation of Left Internal Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047F4DZ Dilation of Left Internal Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 047F4ZZ Dilation of Left Internal Iliac Artery, Percutaneous Endoscopic 047H Dilation / External Iliac Artery, Right 047H04Z Dilation of Right External Iliac Artery with Drug-eluting Intraluminal Device, Open 047H0DZ Dilation of Right External Iliac Artery with Intraluminal Device, Open 047H0ZZ Dilation of Right External Iliac Artery, Open 047H34Z Dilation of Right External Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous 047H3DZ Dilation of Right External Iliac Artery with Intraluminal Device, Percutaneous 047H3ZZ Dilation of Right External Iliac Artery, Percutaneous 047H44Z Dilation of Right External Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047H4DZ Dilation of Right External Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 047H4ZZ Dilation of Right External Iliac Artery, Percutaneous Endoscopic 047J Dilation / External Iliac Artery, Left 047J04Z Dilation of Left External Iliac Artery with Drug-eluting Intraluminal Device, Open 047J0DZ Dilation of Left External Iliac Artery with Intraluminal Device, Open 047J0ZZ Dilation of Left External Iliac Artery, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 48

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 047J34Z 047J3DZ 047J3ZZ Dilation of Left External Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left External Iliac Artery with Intraluminal Device, Percutaneous Dilation of Left External Iliac Artery, Percutaneous 047J44Z Dilation of Left External Iliac Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047J4DZ Dilation of Left External Iliac Artery with Intraluminal Device, Percutaneous Endoscopic 047J4ZZ Dilation of Left External Iliac Artery, Percutaneous Endoscopic 047K Dilation / Femoral Artery, Right 047K04Z Dilation of Right Femoral Artery with Drug-eluting Intraluminal Device, Open 047K0DZ Dilation of Right Femoral Artery with Intraluminal Device, Open 047K0ZZ Dilation of Right Femoral Artery, Open 047K34Z Dilation of Right Femoral Artery with Drug-eluting Intraluminal Device, Percutaneous 047K3DZ Dilation of Right Femoral Artery with Intraluminal Device, Percutaneous 047K3ZZ Dilation of Right Femoral Artery, Percutaneous 047K44Z Dilation of Right Femoral Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047K4DZ Dilation of Right Femoral Artery with Intraluminal Device, Percutaneous Endoscopic 047K4ZZ 047L 047L04Z 047L0DZ 047L0ZZ Dilation of Right Femoral Artery, Percutaneous Endoscopic Dilation / Femoral Artery, Left Dilation of Left Femoral Artery with Drug-eluting Intraluminal Device, Open Dilation of Left Femoral Artery with Intraluminal Device, Open Dilation of Left Femoral Artery, Open 047L34Z Dilation of Left Femoral Artery with Drug-eluting Intraluminal Device, Percutaneous 047L3DZ Dilation of Left Femoral Artery with Intraluminal Device, Percutaneous 047L3ZZ Dilation of Left Femoral Artery, Percutaneous 047L44Z Dilation of Left Femoral Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047L4DZ Dilation of Left Femoral Artery with Intraluminal Device, Percutaneous Endoscopic 047L4ZZ Dilation of Left Femoral Artery, Percutaneous Endoscopic 047M Dilation / Popliteal Artery, Right 047M04Z Dilation of Right Popliteal Artery with Drug-eluting Intraluminal Device, Open 047M0DZ Dilation of Right Popliteal Artery with Intraluminal Device, Open 047M0ZZ Dilation of Right Popliteal Artery, Open 047M34Z Dilation of Right Popliteal Artery with Drug-eluting Intraluminal Device, Percutaneous 047M3DZ Dilation of Right Popliteal Artery with Intraluminal Device, Percutaneous 39.5 Angioplasty of other non-coronary (s) 047M3ZZ 047M44Z 047M4DZ Dilation of Right Popliteal Artery, Percutaneous Dilation of Right Popliteal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Popliteal Artery with Intraluminal Device, Percutaneous Endoscopic 047M4ZZ Dilation of Right Popliteal Artery, Percutaneous Endoscopic 047N Dilation / Popliteal Artery, Left 047N04Z 047N0DZ 047N0ZZ 047N34Z 047N3DZ Dilation of Left Popliteal Artery with Drug-eluting Intraluminal Device, Open Dilation of Left Popliteal Artery with Intraluminal Device, Open Dilation of Left Popliteal Artery, Open Dilation of Left Popliteal Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Popliteal Artery with Intraluminal Device, Percutaneous 047N3ZZ Dilation of Left Popliteal Artery, Percutaneous 047N44Z Dilation of Left Popliteal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 49

Peripheral Interventions 047N4DZ Dilation of Left Popliteal Artery with Intraluminal Device, Percutaneous Endoscopic 047N4ZZ Dilation of Left Popliteal Artery, Percutaneous Endoscopic 047P Dilation / Anterior Tibial Artery, Right 047P04Z Dilation of Right Anterior Tibial Artery with Drug-eluting Intraluminal Device, Open 047P0DZ Dilation of Right Anterior Tibial Artery with Intraluminal Device, Open 047P0ZZ Dilation of Right Anterior Tibial Artery, Open 047P34Z Dilation of Right Anterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous 047P3DZ Dilation of Right Anterior Tibial Artery with Intraluminal Device, Percutaneous 047P3ZZ Dilation of Right Anterior Tibial Artery, Percutaneous 047P44Z Dilation of Right Anterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047P4DZ Dilation of Right Anterior Tibial Artery with Intraluminal Device, Percutaneous Endoscopic 047P4ZZ Dilation of Right Anterior Tibial Artery, Percutaneous Endoscopic 047Q 047Q04Z 047Q0DZ 047Q0ZZ 047Q34Z Dilation / Anterior Tibial Artery, Left Dilation of Left Anterior Tibial Artery with Drug-eluting Intraluminal Device, Open Dilation of Left Anterior Tibial Artery with Intraluminal Device, Open Dilation of Left Anterior Tibial Artery, Open Dilation of Left Anterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous 047Q3DZ Dilation of Left Anterior Tibial Artery with Intraluminal Device, Percutaneous 047Q3ZZ Dilation of Left Anterior Tibial Artery, Percutaneous 047Q44Z Dilation of Left Anterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047Q4DZ Dilation of Left Anterior Tibial Artery with Intraluminal Device, Percutaneous Endoscopic 047Q4ZZ Dilation of Left Anterior Tibial Artery, Percutaneous Endoscopic 047R Dilation / Posterior Tibial Artery, Right 047R04Z Dilation of Right Posterior Tibial Artery with Drug-eluting Intraluminal Device, Open 047R0DZ Dilation of Right Posterior Tibial Artery with Intraluminal Device, Open 047R0ZZ Dilation of Right Posterior Tibial Artery, Open 047R34Z Dilation of Right Posterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous 047R3DZ Dilation of Right Posterior Tibial Artery with Intraluminal Device, Percutaneous 047R3ZZ Dilation of Right Posterior Tibial Artery, Percutaneous 39.5 Angioplasty of other non-coronary (s) 047R44Z 047R4DZ 047R4ZZ Dilation of Right Posterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Right Posterior Tibial Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Posterior Tibial Artery, Percutaneous Endoscopic 047S Dilation / Posterior Tibial Artery, Left 047S04Z Dilation of Left Posterior Tibial Artery with Drug-eluting Intraluminal Device, Open 047S0DZ Dilation of Left Posterior Tibial Artery with Intraluminal Device, Open 047S0ZZ Dilation of Left Posterior Tibial Artery, Open 047S34Z 047S3DZ 047S3ZZ 047S44Z 047S4DZ Dilation of Left Posterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Posterior Tibial Artery with Intraluminal Device, Percutaneous Dilation of Left Posterior Tibial Artery, Percutaneous Dilation of Left Posterior Tibial Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic Dilation of Left Posterior Tibial Artery with Intraluminal Device, Percutaneous Endoscopic 047S4ZZ Dilation of Left Posterior Tibial Artery, Percutaneous Endoscopic 047T Dilation / Peroneal Artery, Right 047T04Z Dilation of Right Peroneal Artery with Drug-eluting Intraluminal Device, Open 047T0DZ Dilation of Right Peroneal Artery with Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 50

Peripheral Interventions 047T0ZZ Dilation of Right Peroneal Artery, Open 047T34Z Dilation of Right Peroneal Artery with Drug-eluting Intraluminal Device, Percutaneous 047T3DZ Dilation of Right Peroneal Artery with Intraluminal Device, Percutaneous 047T3ZZ Dilation of Right Peroneal Artery, Percutaneous 047T44Z Dilation of Right Peroneal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047T4DZ Dilation of Right Peroneal Artery with Intraluminal Device, Percutaneous Endoscopic 047T4ZZ Dilation of Right Peroneal Artery, Percutaneous Endoscopic 047U Dilation / Peroneal Artery, Left 047U04Z Dilation of Left Peroneal Artery with Drug-eluting Intraluminal Device, Open 047U0DZ Dilation of Left Peroneal Artery with Intraluminal Device, Open 047U0ZZ 047U34Z 047U3DZ 047U3ZZ 047U44Z Dilation of Left Peroneal Artery, Open Dilation of Left Peroneal Artery with Drug-eluting Intraluminal Device, Percutaneous Dilation of Left Peroneal Artery with Intraluminal Device, Percutaneous Dilation of Left Peroneal Artery, Percutaneous Dilation of Left Peroneal Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047U4DZ Dilation of Left Peroneal Artery with Intraluminal Device, Percutaneous Endoscopic 047U4ZZ Dilation of Left Peroneal Artery, Percutaneous Endoscopic 047V Dilation / Foot Artery, Right 047V04Z Dilation of Right Foot Artery with Drug-eluting Intraluminal Device, Open 047V0DZ Dilation of Right Foot Artery with Intraluminal Device, Open 047V0ZZ Dilation of Right Foot Artery, Open 047V34Z Dilation of Right Foot Artery with Drug-eluting Intraluminal Device, Percutaneous 047V3DZ Dilation of Right Foot Artery with Intraluminal Device, Percutaneous 047V3ZZ Dilation of Right Foot Artery, Percutaneous 047V44Z Dilation of Right Foot Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 39.5 Angioplasty of other non-coronary (s) 047V4DZ 047V4ZZ 047W Dilation of Right Foot Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Foot Artery, Percutaneous Endoscopic Dilation / Foot Artery, Left 047W04Z Dilation of Left Foot Artery with Drug-eluting Intraluminal Device, Open 047W0DZ Dilation of Left Foot Artery with Intraluminal Device, Open 047W0ZZ Dilation of Left Foot Artery, Open 047W34Z Dilation of Left Foot Artery with Drug-eluting Intraluminal Device, Percutaneous 047W3DZ Dilation of Left Foot Artery with Intraluminal Device, Percutaneous 047W3ZZ Dilation of Left Foot Artery, Percutaneous 047W44Z Dilation of Left Foot Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047W4DZ 047W4ZZ 047Y 047Y04Z Dilation of Left Foot Artery with Intraluminal Device, Percutaneous Endoscopic Dilation of Left Foot Artery, Percutaneous Endoscopic Dilation / Lower Artery Dilation of Lower Artery with Drug-eluting Intraluminal Device, Open 047Y0DZ Dilation of Lower Artery with Intraluminal Device, Open 047Y0ZZ Dilation of Lower Artery, Open 047Y34Z Dilation of Lower Artery with Drug-eluting Intraluminal Device, Percutaneous 047Y3DZ Dilation of Lower Artery with Intraluminal Device, Percutaneous 047Y3ZZ Dilation of Lower Artery, Percutaneous 047Y44Z Dilation of Lower Artery with Drug-eluting Intraluminal Device, Percutaneous Endoscopic 047Y4DZ Dilation of Lower Artery with Intraluminal Device, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 51

Peripheral Interventions 047Y4ZZ Dilation of Lower Artery, Percutaneous Endoscopic 04C Extirpation / Lower Arteries 04C0 Extirpation / Abdominal Aorta 04C00ZZ Extirpation of Matter from Abdominal Aorta, Open 04C03ZZ Extirpation of Matter from Abdominal Aorta, Percutaneous 04C04ZZ Extirpation of Matter from Abdominal Aorta, Percutaneous Endoscopic 04C1 Extirpation / Celiac Artery 04C10ZZ Extirpation of Matter from Celiac Artery, Open 04C13ZZ Extirpation of Matter from Celiac Artery, Percutaneous 04C14ZZ Extirpation of Matter from Celiac Artery, Percutaneous Endoscopic 04C2 Extirpation / Gastric Artery 04C20ZZ Extirpation of Matter from Gastric Artery, Open 04C23ZZ Extirpation of Matter from Gastric Artery, Percutaneous 04C24ZZ Extirpation of Matter from Gastric Artery, Percutaneous Endoscopic 04C3 04C30ZZ 04C33ZZ 04C34ZZ 04C4 Extirpation / Hepatic Artery Extirpation of Matter from Hepatic Artery, Open Extirpation of Matter from Hepatic Artery, Percutaneous Extirpation of Matter from Hepatic Artery, Percutaneous Endoscopic Extirpation / Splenic Artery 04C40ZZ Extirpation of Matter from Splenic Artery, Open 04C43ZZ Extirpation of Matter from Splenic Artery, Percutaneous 04C44ZZ Extirpation of Matter from Splenic Artery, Percutaneous Endoscopic 04C5 Extirpation / Superior Mesenteric Artery 04C50ZZ Extirpation of Matter from Superior Mesenteric Artery, Open 04C53ZZ Extirpation of Matter from Superior Mesenteric Artery, Percutaneous 04C54ZZ Extirpation of Matter from Superior Mesenteric Artery, Percutaneous Endoscopic 04C6 Extirpation / Colic Artery, Right 04C60ZZ Extirpation of Matter from Right Colic Artery, Open 04C63ZZ Extirpation of Matter from Right Colic Artery, Percutaneous 04C64ZZ Extirpation of Matter from Right Colic Artery, Percutaneous Endoscopic 04C7 Extirpation / Colic Artery, Left 04C70ZZ Extirpation of Matter from Left Colic Artery, Open 04C73ZZ Extirpation of Matter from Left Colic Artery, Percutaneous 39.5 Angioplasty of other non-coronary (s) 04C74ZZ 04C8 04C80ZZ Extirpation of Matter from Left Colic Artery, Percutaneous Endoscopic Extirpation / Colic Artery, Middle Extirpation of Matter from Middle Colic Artery, Open 04C83ZZ Extirpation of Matter from Middle Colic Artery, Percutaneous 04C84ZZ Extirpation of Matter from Middle Colic Artery, Percutaneous Endoscopic 04C9 Extirpation / Renal Artery, Right 04C90ZZ 04C93ZZ 04C94ZZ 04CA 04CA0ZZ Extirpation of Matter from Right Renal Artery, Open Extirpation of Matter from Right Renal Artery, Percutaneous Extirpation of Matter from Right Renal Artery, Percutaneous Endoscopic Extirpation / Renal Artery, Left Extirpation of Matter from Left Renal Artery, Open 04CA3ZZ Extirpation of Matter from Left Renal Artery, Percutaneous 04CA4ZZ Extirpation of Matter from Left Renal Artery, Percutaneous Endoscopic 04CB Extirpation / Inferior Mesenteric Artery Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 52

Peripheral Interventions 04CB0ZZ Extirpation of Matter from Inferior Mesenteric Artery, Open 04CB3ZZ Extirpation of Matter from Inferior Mesenteric Artery, Percutaneous 04CB4ZZ Extirpation of Matter from Inferior Mesenteric Artery, Percutaneous Endoscopic 04CC Extirpation / Common Iliac Artery, Right 04CC0ZZ Extirpation of Matter from Right Common Iliac Artery, Open 04CC3ZZ Extirpation of Matter from Right Common Iliac Artery, Percutaneous 04CC4ZZ Extirpation of Matter from Right Common Iliac Artery, Percutaneous Endoscopic 04CD Extirpation / Common Iliac Artery, Left 04CD0ZZ 04CD3ZZ 04CD4ZZ 04CE 04CE0ZZ Extirpation of Matter from Left Common Iliac Artery, Open Extirpation of Matter from Left Common Iliac Artery, Percutaneous Extirpation of Matter from Left Common Iliac Artery, Percutaneous Endoscopic Extirpation / Internal Iliac Artery, Right Extirpation of Matter from Right Internal Iliac Artery, Open 04CE3ZZ Extirpation of Matter from Right Internal Iliac Artery, Percutaneous 04CE4ZZ Extirpation of Matter from Right Internal Iliac Artery, Percutaneous Endoscopic 04CF Extirpation / Internal Iliac Artery, Left 04CF0ZZ Extirpation of Matter from Left Internal Iliac Artery, Open 04CF3ZZ Extirpation of Matter from Left Internal Iliac Artery, Percutaneous 04CF4ZZ Extirpation of Matter from Left Internal Iliac Artery, Percutaneous Endoscopic 04CH Extirpation / External Iliac Artery, Right 04CH0ZZ Extirpation of Matter from Right External Iliac Artery, Open 39.5 Angioplasty of other non-coronary (s) 04CH3ZZ 04CH4ZZ 04CJ Extirpation of Matter from Right External Iliac Artery, Percutaneous Extirpation of Matter from Right External Iliac Artery, Percutaneous Endoscopic Extirpation / External Iliac Artery, Left 04CJ0ZZ Extirpation of Matter from Left External Iliac Artery, Open 04CJ3ZZ Extirpation of Matter from Left External Iliac Artery, Percutaneous 04CJ4ZZ Extirpation of Matter from Left External Iliac Artery, Percutaneous Endoscopic 04CK Extirpation / Femoral Artery, Right 04CK0ZZ Extirpation of Matter from Right Femoral Artery, Open 04CK3ZZ Extirpation of Matter from Right Femoral Artery, Percutaneous 04CK4ZZ Extirpation of Matter from Right Femoral Artery, Percutaneous Endoscopic 04CL Extirpation / Femoral Artery, Left 04CL0ZZ Extirpation of Matter from Left Femoral Artery, Open 04CL3ZZ 04CL4ZZ 04CM 04CM0ZZ 04CM3ZZ Extirpation of Matter from Left Femoral Artery, Percutaneous Extirpation of Matter from Left Femoral Artery, Percutaneous Endoscopic Extirpation / Popliteal Artery, Right Extirpation of Matter from Right Popliteal Artery, Open Extirpation of Matter from Right Popliteal Artery, Percutaneous 04CM4ZZ Extirpation of Matter from Right Popliteal Artery, Percutaneous Endoscopic 04CN Extirpation / Popliteal Artery, Left 04CN0ZZ Extirpation of Matter from Left Popliteal Artery, Open 04CN3ZZ Extirpation of Matter from Left Popliteal Artery, Percutaneous 04CN4ZZ Extirpation of Matter from Left Popliteal Artery, Percutaneous Endoscopic 04CP Extirpation / Anterior Tibial Artery, Right 04CP0ZZ Extirpation of Matter from Right Anterior Tibial Artery, Open 04CP3ZZ Extirpation of Matter from Right Anterior Tibial Artery, Percutaneous 04CP4ZZ Extirpation of Matter from Right Anterior Tibial Artery, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 53

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 04CQ Extirpation / Anterior Tibial Artery, Left 04CQ0ZZ Extirpation of Matter from Left Anterior Tibial Artery, Open 04CQ3ZZ Extirpation of Matter from Left Anterior Tibial Artery, Percutaneous 04CQ4ZZ Extirpation of Matter from Left Anterior Tibial Artery, Percutaneous Endoscopic 04CR Extirpation / Posterior Tibial Artery, Right 04CR0ZZ Extirpation of Matter from Right Posterior Tibial Artery, Open 04CR3ZZ Extirpation of Matter from Right Posterior Tibial Artery, Percutaneous 04CR4ZZ Extirpation of Matter from Right Posterior Tibial Artery, Percutaneous Endoscopic 04CR Extirpation / Posterior Tibial Artery, Right 04CR0ZZ Extirpation of Matter from Right Posterior Tibial Artery, Open 04CR3ZZ Extirpation of Matter from Right Posterior Tibial Artery, Percutaneous 04CR4ZZ Extirpation of Matter from Right Posterior Tibial Artery, Percutaneous Endoscopic 04CT Extirpation / Peroneal Artery, Right 04CT0ZZ Extirpation of Matter from Right Peroneal Artery, Open 04CT3ZZ Extirpation of Matter from Right Peroneal Artery, Percutaneous 04CT4ZZ Extirpation of Matter from Right Peroneal Artery, Percutaneous Endoscopic 04CU Extirpation / Peroneal Artery, Left 04CU0ZZ Extirpation of Matter from Left Peroneal Artery, Open 04CU3ZZ Extirpation of Matter from Left Peroneal Artery, Percutaneous 04CU4ZZ Extirpation of Matter from Left Peroneal Artery, Percutaneous Endoscopic 04CV Extirpation / Foot Artery, Right 04CV0ZZ Extirpation of Matter from Right Foot Artery, Open 04CV3ZZ Extirpation of Matter from Right Foot Artery, Percutaneous 04CV4ZZ Extirpation of Matter from Right Foot Artery, Percutaneous Endoscopic 04CW Extirpation / Foot Artery, Left 04CW0ZZ Extirpation of Matter from Left Foot Artery, Open 04CW3ZZ Extirpation of Matter from Left Foot Artery, Percutaneous 04CW4ZZ Extirpation of Matter from Left Foot Artery, Percutaneous Endoscopic 04CY Extirpation / Lower Artery 04CY0ZZ Extirpation of Matter from Lower Artery, Open 04CY3ZZ Extirpation of Matter from Lower Artery, Percutaneous 04CY4ZZ Extirpation of Matter from Lower Artery, Percutaneous Endoscopic 057 Dilation / Upper Veins 0579 Dilation / Brachial Vein, Right 05790DZ Dilation of Right Brachial Vein with Intraluminal Device, Open 05790ZZ Dilation of Right Brachial Vein, Open 05793DZ Dilation of Right Brachial Vein with Intraluminal Device, Percutaneous 05793ZZ Dilation of Right Brachial Vein, Percutaneous 05794DZ Dilation of Right Brachial Vein with Intraluminal Device, Percutaneous Endoscopic 05794ZZ Dilation of Right Brachial Vein, Percutaneous Endoscopic 057A Dilation / Brachial Vein, Left 057A0DZ Dilation of Left Brachial Vein with Intraluminal Device, Open 057A0ZZ Dilation of Left Brachial Vein, Open 057A3DZ Dilation of Left Brachial Vein with Intraluminal Device, Percutaneous 057A3ZZ Dilation of Left Brachial Vein, Percutaneous 057A4DZ Dilation of Left Brachial Vein with Intraluminal Device, Percutaneous Endoscopic 057A4ZZ Dilation of Left Brachial Vein, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 54

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 057B Dilation / Basilic Vein, Right 057B0DZ Dilation of Right Basilic Vein with Intraluminal Device, Open 057B0ZZ Dilation of Right Basilic Vein, Open 057B3DZ Dilation of Right Basilic Vein with Intraluminal Device, Percutaneous 057B3ZZ Dilation of Right Basilic Vein, Percutaneous 057B4DZ Dilation of Right Basilic Vein with Intraluminal Device, Percutaneous Endoscopic 057B4ZZ Dilation of Right Basilic Vein, Percutaneous Endoscopic 057C Dilation / Basilic Vein, Left 057C0DZ Dilation of Left Basilic Vein with Intraluminal Device, Open 057C0ZZ Dilation of Left Basilic Vein, Open 057C3DZ Dilation of Left Basilic Vein with Intraluminal Device, Percutaneous 057C3ZZ Dilation of Left Basilic Vein, Percutaneous 057C4DZ Dilation of Left Basilic Vein with Intraluminal Device, Percutaneous Endoscopic 057C4ZZ Dilation of Left Basilic Vein, Percutaneous Endoscopic 057D Dilation / Cephalic Vein, Right 057D0DZ Dilation of Right Cephalic Vein with Intraluminal Device, Open 057D0ZZ Dilation of Right Cephalic Vein, Open 057D3DZ Dilation of Right Cephalic Vein with Intraluminal Device, Percutaneous 057D3ZZ Dilation of Right Cephalic Vein, Percutaneous 057D4DZ Dilation of Right Cephalic Vein with Intraluminal Device, Percutaneous Endoscopic 057D4ZZ Dilation of Right Cephalic Vein, Percutaneous Endoscopic 057F Dilation / Cephalic Vein, Left 057F0DZ Dilation of Left Cephalic Vein with Intraluminal Device, Open 057F0ZZ Dilation of Left Cephalic Vein, Open 057F3DZ Dilation of Left Cephalic Vein with Intraluminal Device, Percutaneous 057F3ZZ Dilation of Left Cephalic Vein, Percutaneous 057F4DZ Dilation of Left Cephalic Vein with Intraluminal Device, Percutaneous Endoscopic 057F4ZZ Dilation of Left Cephalic Vein, Percutaneous Endoscopic 067 Dilation / Lower Veins 0670 Dilation / Inferior Vena Cava 06700DZ Dilation of Inferior Vena Cava with Intraluminal Device, Open 06700ZZ Dilation of Inferior Vena Cava, Open 06703DZ Dilation of Inferior Vena Cava with Intraluminal Device, Percutaneous 06703ZZ Dilation of Inferior Vena Cava, Percutaneous 06704DZ Dilation of Inferior Vena Cava with Intraluminal Device, Percutaneous Endoscopic 06704ZZ Dilation of Inferior Vena Cava, Percutaneous Endoscopic 0671 Dilation / Splenic Vein 06710DZ Dilation of Splenic Vein with Intraluminal Device, Open 06710ZZ Dilation of Splenic Vein, Open 06713DZ Dilation of Splenic Vein with Intraluminal Device, Percutaneous 06713ZZ Dilation of Splenic Vein, Percutaneous 06714DZ Dilation of Splenic Vein with Intraluminal Device, Percutaneous Endoscopic 06714ZZ Dilation of Splenic Vein, Percutaneous Endoscopic 0672 Dilation / Gastric Vein 06720DZ Dilation of Gastric Vein with Intraluminal Device, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 55

Peripheral Interventions 39.5 Angioplasty of other non-coronary (s) 06720ZZ Dilation of Gastric Vein, Open 06723DZ Dilation of Gastric Vein with Intraluminal Device, Percutaneous 06723ZZ Dilation of Gastric Vein, Percutaneous 06724DZ Dilation of Gastric Vein with Intraluminal Device, Percutaneous Endoscopic 06724ZZ Dilation of Gastric Vein, Percutaneous Endoscopic 0673 Dilation / Esophageal Vein 06730DZ Dilation of Esophageal Vein with Intraluminal Device, Open 06730ZZ Dilation of Esophageal Vein, Open 06733DZ Dilation of Esophageal Vein with Intraluminal Device, Percutaneous 06733ZZ Dilation of Esophageal Vein, Percutaneous 06734DZ Dilation of Esophageal Vein with Intraluminal Device, Percutaneous Endoscopic 06734ZZ Dilation of Esophageal Vein, Percutaneous Endoscopic 0679 Dilation / Renal Vein, Right 06790DZ Dilation of Right Renal Vein with Intraluminal Device, Open 06790ZZ Dilation of Right Renal Vein, Open 06793DZ Dilation of Right Renal Vein with Intraluminal Device, Percutaneous 06793ZZ Dilation of Right Renal Vein, Percutaneous 06794DZ Dilation of Right Renal Vein with Intraluminal Device, Percutaneous Endoscopic 06794ZZ Dilation of Right Renal Vein, Percutaneous Endoscopic 067B Dilation / Renal Vein, Left 067B0DZ Dilation of Left Renal Vein with Intraluminal Device, Open 067B0ZZ Dilation of Left Renal Vein, Open 067B3DZ Dilation of Left Renal Vein with Intraluminal Device, Percutaneous 067B3ZZ Dilation of Left Renal Vein, Percutaneous 067B4DZ Dilation of Left Renal Vein with Intraluminal Device, Percutaneous Endoscopic 067B4ZZ Dilation of Left Renal Vein, Percutaneous Endoscopic 067C Dilation / Common Iliac Vein, Right 067C0DZ Dilation of Right Common Iliac Vein with Intraluminal Device, Open 067C0ZZ Dilation of Right Common Iliac Vein, Open 067C3DZ Dilation of Right Common Iliac Vein with Intraluminal Device, Percutaneous 067C3ZZ Dilation of Right Common Iliac Vein, Percutaneous 067C4DZ Dilation of Right Common Iliac Vein with Intraluminal Device, Percutaneous Endoscopic 067C4ZZ Dilation of Right Common Iliac Vein, Percutaneous Endoscopic 067D Dilation / Common Iliac Vein, Left 067D0DZ Dilation of Left Common Iliac Vein with Intraluminal Device, Open 067D0ZZ Dilation of Left Common Iliac Vein, Open 067D3DZ Dilation of Left Common Iliac Vein with Intraluminal Device, Percutaneous 067D3ZZ Dilation of Left Common Iliac Vein, Percutaneous 067D4DZ Dilation of Left Common Iliac Vein with Intraluminal Device, Percutaneous Endoscopic 067D4ZZ Dilation of Left Common Iliac Vein, Percutaneous Endoscopic 067F Dilation / External Iliac Vein, Right 067F0DZ Dilation of Right External Iliac Vein with Intraluminal Device, Open 067F0ZZ Dilation of Right External Iliac Vein, Open 067F3DZ Dilation of Right External Iliac Vein with Intraluminal Device, Percutaneous 067F3ZZ Dilation of Right External Iliac Vein, Percutaneous 067F4DZ Dilation of Right External Iliac Vein with Intraluminal Device, Percutaneous Endoscopic 067F4ZZ Dilation of Right External Iliac Vein, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 56

Peripheral Interventions 067G Dilation / External Iliac Vein, Left 067G0DZ Dilation of Left External Iliac Vein with Intraluminal Device, Open 067G0ZZ Dilation of Left External Iliac Vein, Open 067G3DZ Dilation of Left External Iliac Vein with Intraluminal Device, Percutaneous 067G3ZZ Dilation of Left External Iliac Vein, Percutaneous 067G4DZ 067G4ZZ 067H 067H0DZ 067H0ZZ Dilation of Left External Iliac Vein with Intraluminal Device, Percutaneous Endoscopic Dilation of Left External Iliac Vein, Percutaneous Endoscopic Dilation / Hypogastric Vein, Right Dilation of Right Hypogastric Vein with Intraluminal Device, Open Dilation of Right Hypogastric Vein, Open 067H3DZ Dilation of Right Hypogastric Vein with Intraluminal Device, Percutaneous 067H3ZZ Dilation of Right Hypogastric Vein, Percutaneous 067H4DZ Dilation of Right Hypogastric Vein with Intraluminal Device, Percutaneous Endoscopic 067H4ZZ Dilation of Right Hypogastric Vein, Percutaneous Endoscopic 067J Dilation / Hypogastric Vein, Left 39.5 Angioplasty of other non-coronary (s) 067J0DZ 067J0ZZ 067J3DZ Dilation of Left Hypogastric Vein with Intraluminal Device, Open Dilation of Left Hypogastric Vein, Open Dilation of Left Hypogastric Vein with Intraluminal Device, Percutaneous 067J3ZZ Dilation of Left Hypogastric Vein, Percutaneous 067J4DZ Dilation of Left Hypogastric Vein with Intraluminal Device, Percutaneous Endoscopic 067J4ZZ Dilation of Left Hypogastric Vein, Percutaneous Endoscopic 067M Dilation / Femoral Vein, Right 067M0DZ Dilation of Right Femoral Vein with Intraluminal Device, Open 067M0ZZ 067M3DZ 067M3ZZ 067M4DZ 067M4ZZ Dilation of Right Femoral Vein, Open Dilation of Right Femoral Vein with Intraluminal Device, Percutaneous Dilation of Right Femoral Vein, Percutaneous Dilation of Right Femoral Vein with Intraluminal Device, Percutaneous Endoscopic Dilation of Right Femoral Vein, Percutaneous Endoscopic 067N Dilation / Femoral Vein, Left 067N0DZ Dilation of Left Femoral Vein with Intraluminal Device, Open 067N0ZZ Dilation of Left Femoral Vein, Open 067N3DZ Dilation of Left Femoral Vein with Intraluminal Device, Percutaneous 067N3ZZ Dilation of Left Femoral Vein, Percutaneous Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 57

Peripheral Interventions 067N4DZ Dilation of Left Femoral Vein with Intraluminal Device, Percutaneous Endoscopic 067N4ZZ Dilation of Left Femoral Vein, Percutaneous Endoscopic 067P Dilation / Greater Saphenous Vein, Right 067P0DZ Dilation of Right Greater Saphenous Vein with Intraluminal Device, Open 067P0ZZ Dilation of Right Greater Saphenous Vein, Open 067P3DZ Dilation of Right Greater Saphenous Vein with Intraluminal Device, Percutaneous 067P3ZZ Dilation of Right Greater Saphenous Vein, Percutaneous 067P4DZ Dilation of Right Greater Saphenous Vein with Intraluminal Device, Percutaneous Endoscopic 067P4ZZ Dilation of Right Greater Saphenous Vein, Percutaneous Endoscopic 067Q Dilation / Greater Saphenous Vein, Left 067Q0DZ Dilation of Left Greater Saphenous Vein with Intraluminal Device, Open 067Q0ZZ 067Q3DZ 067Q3ZZ 067Q4DZ 067Q4ZZ Dilation of Left Greater Saphenous Vein, Open Dilation of Left Greater Saphenous Vein with Intraluminal Device, Percutaneous Dilation of Left Greater Saphenous Vein, Percutaneous Dilation of Left Greater Saphenous Vein with Intraluminal Device, Percutaneous Endoscopic Dilation of Left Greater Saphenous Vein, Percutaneous Endoscopic 067R Dilation / Lesser Saphenous Vein, Right 067R0DZ Dilation of Right Lesser Saphenous Vein with Intraluminal Device, Open 067R0ZZ Dilation of Right Lesser Saphenous Vein, Open 067R3DZ Dilation of Right Lesser Saphenous Vein with Intraluminal Device, Percutaneous 067R3ZZ Dilation of Right Lesser Saphenous Vein, Percutaneous 067R4DZ Dilation of Right Lesser Saphenous Vein with Intraluminal Device, Percutaneous Endoscopic 067R4ZZ Dilation of Right Lesser Saphenous Vein, Percutaneous Endoscopic 067S Dilation / Lesser Saphenous Vein, Left 067S0DZ Dilation of Left Lesser Saphenous Vein with Intraluminal Device, Open 067S0ZZ Dilation of Left Lesser Saphenous Vein, Open 067S3DZ Dilation of Left Lesser Saphenous Vein with Intraluminal Device, Percutaneous 39.5 Angioplasty of other non-coronary (s) 067S3ZZ 067S4DZ 067S4ZZ Dilation of Left Lesser Saphenous Vein, Percutaneous Dilation of Left Lesser Saphenous Vein with Intraluminal Device, Percutaneous Endoscopic Dilation of Left Lesser Saphenous Vein, Percutaneous Endoscopic 067T Dilation / Foot Vein, Right 067T0DZ Dilation of Right Foot Vein with Intraluminal Device, Open 067T0ZZ Dilation of Right Foot Vein, Open 067T3DZ Dilation of Right Foot Vein with Intraluminal Device, Percutaneous 067T3ZZ Dilation of Right Foot Vein, Percutaneous 067T4DZ Dilation of Right Foot Vein with Intraluminal Device, Percutaneous Endoscopic 067T4ZZ 067V 067V0DZ 067V0ZZ 067V3DZ Dilation of Right Foot Vein, Percutaneous Endoscopic Dilation / Foot Vein, Left Dilation of Left Foot Vein with Intraluminal Device, Open Dilation of Left Foot Vein, Open Dilation of Left Foot Vein with Intraluminal Device, Percutaneous 067V3ZZ Dilation of Left Foot Vein, Percutaneous 067V4DZ Dilation of Left Foot Vein with Intraluminal Device, Percutaneous Endoscopic 067V4ZZ Dilation of Left Foot Vein, Percutaneous Endoscopic 067Y Dilation / Lower Vein 067Y0DZ Dilation of Lower Vein with Intraluminal Device, Open 067Y0ZZ Dilation of Lower Vein, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 58

Peripheral Interventions 067Y3DZ Dilation of Lower Vein with Intraluminal Device, Percutaneous 067Y3ZZ Dilation of Lower Vein, Percutaneous 067Y4DZ Dilation of Lower Vein with Intraluminal Device, Percutaneous Endoscopic 067Y4ZZ Dilation of Lower Vein, Percutaneous Endoscopic 06C Extirpation / Lower Veins 06C0 Extirpation / Inferior Vena Cava 06C00ZZ Extirpation of Matter from Inferior Vena Cava, Open 06C03ZZ Extirpation of Matter from Inferior Vena Cava, Percutaneous 06C04ZZ Extirpation of Matter from Inferior Vena Cava, Percutaneous Endoscopic 06C9 Extirpation / Renal Vein, Right 06C90ZZ Extirpation of Matter from Right Renal Vein, Open 06C93ZZ Extirpation of Matter from Right Renal Vein, Percutaneous 06C94ZZ 06CB 06CB0ZZ 06CB3ZZ 06CB4ZZ Extirpation of Matter from Right Renal Vein, Percutaneous Endoscopic Extirpation / Renal Vein, Left Extirpation of Matter from Left Renal Vein, Open Extirpation of Matter from Left Renal Vein, Percutaneous Extirpation of Matter from Left Renal Vein, Percutaneous Endoscopic 06CC Extirpation / Common Iliac Vein, Right 06CC0ZZ Extirpation of Matter from Right Common Iliac Vein, Open 06CC3ZZ Extirpation of Matter from Right Common Iliac Vein, Percutaneous 06CC4ZZ Extirpation of Matter from Right Common Iliac Vein, Percutaneous Endoscopic 06CD Extirpation / Common Iliac Vein, Left 06CD0ZZ Extirpation of Matter from Left Common Iliac Vein, Open 06CD3ZZ Extirpation of Matter from Left Common Iliac Vein, Percutaneous 06CD4ZZ Extirpation of Matter from Left Common Iliac Vein, Percutaneous Endoscopic 06CF Extirpation / External Iliac Vein, Right 06CF0ZZ Extirpation of Matter from Right External Iliac Vein, Open 06CF3ZZ Extirpation of Matter from Right External Iliac Vein, Percutaneous 06CF4ZZ Extirpation of Matter from Right External Iliac Vein, Percutaneous Endoscopic 39.5 Angioplasty of other non-coronary (s) 06CG 06CG0ZZ 06CG3ZZ Extirpation / External Iliac Vein, Left Extirpation of Matter from Left External Iliac Vein, Open Extirpation of Matter from Left External Iliac Vein, Percutaneous 06CG4ZZ Extirpation of Matter from Left External Iliac Vein, Percutaneous Endoscopic 06CM Extirpation / Femoral Vein, Right 06CM0ZZ Extirpation of Matter from Right Femoral Vein, Open 06CM3ZZ Extirpation of Matter from Right Femoral Vein, Percutaneous 06CM4ZZ Extirpation of Matter from Right Femoral Vein, Percutaneous Endoscopic 06CN 06CN0ZZ 06CN3ZZ 06CN4ZZ 06CP Extirpation / Femoral Vein, Left Extirpation of Matter from Left Femoral Vein, Open Extirpation of Matter from Left Femoral Vein, Percutaneous Extirpation of Matter from Left Femoral Vein, Percutaneous Endoscopic Extirpation / Greater Saphenous Vein, Right 06CP0ZZ Extirpation of Matter from Right Greater Saphenous Vein, Open 06CP3ZZ Extirpation of Matter from Right Greater Saphenous Vein, Percutaneous 06CP4ZZ Extirpation of Matter from Right Greater Saphenous Vein, Percutaneous Endoscopic 06CQ Extirpation / Greater Saphenous Vein, Left 06CQ0ZZ Extirpation of Matter from Left Greater Saphenous Vein, Open Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 59

Peripheral Interventions 06CQ3ZZ Extirpation of Matter from Left Greater Saphenous Vein, Percutaneous 06CQ4ZZ Extirpation of Matter from Left Greater Saphenous Vein, Percutaneous Endoscopic 06CR Extirpation / Lesser Saphenous Vein, Right 06CR0ZZ Extirpation of Matter from Right Lesser Saphenous Vein, Open 06CR3ZZ Extirpation of Matter from Right Lesser Saphenous Vein, Percutaneous peripheral (non-coronary) 06CR4ZZ 06CS 06CS0ZZ 06CS3ZZ Extirpation of Matter from Right Lesser Saphenous Vein, Percutaneous Endoscopic Extirpation / Lesser Saphenous Vein, Left Extirpation of Matter from Left Lesser Saphenous Vein, Open Extirpation of Matter from Left Lesser Saphenous Vein, Percutaneous 06CS4ZZ Extirpation of Matter from Left Lesser Saphenous Vein, Percutaneous Endoscopic 06CY Extirpation / Lower Vein 06CY0ZZ Extirpation of Matter from Lower Vein, Open 06CY3ZZ Extirpation of Matter from Lower Vein, Percutaneous 06CY4ZZ Extirpation of Matter from Lower Vein, Percutaneous Endoscopic Note: BSC has no stents FDA approved for use in the infrainguinal regions of the lower extremities. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 60

Rhythm Management and Electrophysiology Insertion CRT-P Generator 0JH607Z Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Chest Subcutaneous/Fascia, Open 0JH637Z Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Chest Subcutaneous/Fascia, Percutaneous 0JH807Z Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Abdomen Subcutaneous/Fascia, Open 0JH837Z Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Abdomen Subcutaneous/Fascia, Percutaneous Insertion Ventricular Lead 00.50 cardiac resynchronization pacemaker without mention of defibrillation, total system (CRT-P) 02HK0JZ 02HK3JZ 02HK4JZ 02HL0JZ 02HL3JZ Pacemaker Lead into Right Ventricle, Open Pacemaker Lead into Right Ventricle, Percutaneous Pacemaker Lead into Right Ventricle, Percutaneous Endoscopic Pacemaker Lead into Left Ventricle, Open Pacemaker Lead into Left Ventricle, Percutaneous 02HL4JZ Pacemaker Lead into Left Ventricle, Percutaneous Endoscopic Insertion Atrial Lead 02H60JZ Pacemaker Lead into Right Atrium, Open 02H63JZ Pacemaker Lead into Right Atrium, Percutaneous 02H64JZ Pacemaker Lead into Right Atrium, Percutaneous Endoscopic Insertion Coronary Vein Lead 02H40JZ Pacemaker Lead into Coronary Vein, Open 02H43JZ Pacemaker Lead into Coronary Vein, Percutaneous 02H44JZ Pacemaker Lead into Coronary Vein, Percutaneous Endoscopic Insertion CRT-D Generator 0JH609Z Insertion Cardiaciac Resynchronization Defibrillator Pulse Generator in Chest Subcutaneous/Fascia, Open 0JH639Z Insertion Cardiac Resynchronization Defibrillator Pulse Generator in Chest Subcutaneous/Fascia, Percutaneous 00.51 Implantation of cardiac resynchronization defibrillator, total system [CRT-D] 0JH809Z 0JH839Z 02HK0KZ Insertion Cardiac Resynchronization Defibrillator Pulse Generator in Abdomen Subcutaneous/Fascia, Open Insertion Cardiac Resynchronization Defibrillator Pulse Generator in Abdomen Subcutaneous/Fascia, Percutaneous Insertion Ventricle Lead Defibrillator Lead into Right Ventricle, Open 02HK3KZ Defibrillator Lead into Right Ventricle, Percutaneous 02HK4KZ Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic 02HL0KZ Defibrillator Lead into Left Ventricle, Open 02HL3KZ Defibrillator Lead into Left Ventricle, Percutaneous 02HL4KZ Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 61

Rhythm Management and Electrophysiology Insertion Atrial Lead 02H63KZ Defibrillator Lead into Right Atrium, Percutaneous 00.51 Implantation of cardiac resynchronization defibrillator, total system [CRT-D] 02H60KZ 02H64KZ 02H40KZ Defibrillator Lead into Right Atrium, Open Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Insertion Coronary Vein Lead Defibrillator Lead into Coronary Vein, Open 02H43KZ Defibrillator Lead into Coronary Vein, Percutaneous 02H44KZ Defibrillator Lead into Coronary Vein, Percutaneous Endoscopic Lead 02H43JZ Pacemaker Lead into Coronary Vein, Percutaneous 00.52 Implantation or replacement of transvenous lead [electrode] into left ventricular coronary venous system 02H43KZ 02H43MZ 02PA0MZ Defibrillator Lead into Coronary Vein, Percutaneous Cardiac Lead into Coronary Vein, Percutaneous Removal of Lead Removal of Cardiac Lead from Heart, Open 02PA3MZ Removal of Cardiac Lead from Heart,Percutaneous 02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic CRT-P 0.53 Implantation or replacement of cardiac resynchronization pacemaker pulse generator only [CRT-P] 0JH607Z 0JH637Z Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Chest Subcutaneous/Fascia, Open Insertion Cardiac Resynchronization Pacemaker Pulse Generator in Chest Subcutaneous/Fascia, Percutaneous Removal of CRT-P 0JPT0PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Open 0JPT3PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Percutaneous CRT-D 00.54 Implantation or replacement of cardiac resynchronization defibrillator pulse generator device only [CRT-D] 0JH609Z 0JH639Z Insertion Cardiac Resynchronization Defibrillator Pulse Generatorerator in Chest Subcutaneous/ Fascia, Open Insertion Cardiac Resynchronization Defibrillator Pulse Generatorerator in Chest Subcutaneous/ Fascia, Percutaneous Removal of CRT-D 0JPT0PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Open 0JPT3PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Percutaneous Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 62

Rhythm Management and Electrophysiology 37.26 Catheter based invasive electrophysiologic testing Electrophysiologic studies [EPS] 37.27 Cardiac mapping 37.28 37.29 37.34 37.70 Intracardiac echocardiography [ICE] Other diagnostic procedures on heart and pericardium Excision or destruction of other lesion or tissue of heart, endovascular approach Initial insertion of lead [electrode], not otherwise specified 4A023FZ 3E053KZ 3E063KZ 02K80ZZ 02K83ZZ 02K84ZZ B244YZZ B244ZZZ B245YZZ B245ZZZ B246YZZ B246ZZZ B24DYZZ B24DZZZ 02JA3ZZ 02JY3ZZ 0WJD0ZZ 0WJD3ZZ 02583ZZ 02B83ZZ 02T83ZZ 02H40JZ 02H40MZ 02H44JZ 02H44MZ 02H60JZ 02H60MZ 02H63JZ 02H64JZ 02H64MZ 02H70JZ 02H70MZ 02H73JZ 02H74JZ 02H74MZ 02HK0JZ 02HK0MZ Measurement of Rhythm Measurement of Cardiac Rhythm, Percutaneous Injection of Diagnostic Substance Introduction of Other Diagnostic Substance into Peripheral Artery, Percutaneous Introduction of Other Diagnostic Substance into Central Artery, Percutaneous Map Conduction Mechanism, Open Map Conduction Mechanism, Percutaneous Map Conduction Mechansim, Percustaneous Endoscopic Ultrasonography of Right Heart using Other Contrast Ultrasonography of Right Heart Ultrasonography of Left Heart using Other Contrast Ultrasonography of Left Heart Ultrasonography of Right and Left Heart using Other Contrast Ultrasonography of Right and Left Heart Ultrasonography of Pediatriac Heart using Other Contrast Ultrasonography of Pediatriac Heart Inspection of Heart, Percutaneous Inspection of Great Vessel, Percutaneous Inspection of Pericardial Cavity, Open Inspection of Pericardial Cavity, Percutaneous ***Not an All-Inclusive List*** Destruction of Conduction Mechanism, Percutaneous Excision of Conduction Mechanism, Percutaneous Recection of Conduction Mechanism, Percutaneous Pacemaker Lead into Coronary Vein, Open Cardiac Lead into Coronary Vein, Open Pacemaker Lead into Coronary Vein, Percutaneous Endoscopic Cardiac Lead into Coronary Vein, Percutaneous Endoscopic Pacemaker Lead into Right Atrium, Open Cardiac Lead into Right Atrium, Open Pacemaker Lead into Right Atrium, Percutaneous Pacemaker Lead into Right Atrium, Percutaneous Endoscopic Cardiac Lead into Right Atrium, Percutaneous Endoscopic Pacemaker Lead into Left Atrium, Open Cardiac Lead into Left Atrium, Open Pacemaker Lead into Left Atrium, Percutaneous Pacemaker Lead into Left Atrium, Percutaneous Endoscopic Cardiac Lead into Left Atrium, Percutaneous Endoscopic Pacemaker Lead into Right Ventricle, Open Cardiac Lead into Right Ventricle, Open Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 63

Rhythm Management and Electrophysiology 37.70 37.71 37.72 37.73 37.74 Initial insertion of lead [electrode], not otherwise specified Initial insertion of transvenous lead [electrode] into ventricle Initial insertion of transvenous leads [electrodes] into atrium and ventricle Initial insertion of transvenous lead [electrode] into atrium Insertion or replacement of epicardial lead [electrode] into epicardium 37.75 Revision of lead [electrode] 02HK3JZ 02HK4JZ 02HK4MZ 02HL0JZ 02HL0MZ 02HL3JZ 02HL4JZ 02HL4MZ 02HK3JZ 02HK3MZ 02HL3JZ 02HL3MZ 02HK3JZ 02HL3JZ 02H63JZ 02H73JZ 02H63JZ 02H73JZ 02HN0JZ 02HN0MZ 02HN3JZ 02HN3MZ 02HN4JZ 02HN4MZ 02WA0MZ 02WA3MZ 02WA4MZ Pacemaker Lead into Right Ventricle, Percutaneous Pacemaker Lead into Right Ventricle, Percutaneous Endoscopic Cardiac Lead into Right Ventricle, Percutaneous Endoscopic Pacemaker Lead into Left Ventricle, Open Cardiac Lead into Left Ventricle, Open Pacemaker Lead into Left Ventricle, Percutaneous Pacemaker Lead into Left Ventricle, Percutaneous Endoscopic Cardiac Lead into Left Ventricle, Percutaneous Endoscopic Pacemaker Lead into Right Ventricle, Percutaneous Cardiac Lead into Right Ventricle, Percutaneous Pacemaker Lead into Left Ventricle, Percutaneous Cardiac Lead into Left Ventricle, Percutaneous Lead into Ventricle Pacemaker Lead into Right Ventricle, Percutaneous Pacemaker Lead into Left Ventricle, Percutaneous Lead into Atrium Pacemaker Lead into Right Atrium, Percutaneous Pacemaker Lead into Left Atrium, Percutaneous Pacemaker Lead into Right Atrium, Percutaneous Pacemaker Lead into Left Atrium, Percutaneous Lead into Epicardium Pacemaker Lead into Pericardium, Open Cardiac Lead into Pericardium, Open Pacemaker Lead into Pericardium, Percutaneous Cardiac Lead into Pericardium, Percutaneous Pacemaker Lead into Pericardium, Percutaneous Endoscopic Cardiac Lead into Pericardium, Percutaneous Endoscopic Revision of Cardiac Lead in Heart, Open Revision of Cardiac Lead in Heart, Percutaneous Revision of Cardiac Lead in Heart, Percutaneous Endoscopic Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 64

Rhythm Management and Electrophysiology Lead 02H63JZ Pacemaker Lead into Right Atrium, Percutaneous 02H63MZ Cardiac Lead into Right Atrium, Percutaneous 02H73JZ Pacemaker Lead into Left Atrium, Percutaneous 37.76 Replacement of transvenous atrial and/or ventricular lead(s) [electrode] 02H73MZ 02HK3JZ 02HL3JZ Cardiac Lead into Left Atrium, Percutaneous Pacemaker Lead into Right Ventricle, Percutaneous Pacemaker Lead into Left Ventricle, Percutaneous Removal of Lead 02PA0MZ Removal of Cardiac Lead from Heart, Open 02PA3MZ Removal of Cardiac Lead from Heart,Percutaneous 02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic 02PAXMZ Removal of Cardiac Lead from Heart, External 37.77 Removal of lead(s) [electrode] without replacement 02PA0MZ 02PA3MZ 02PA4MZ 02PAXMZ Removal of Cardiac Lead from Heart, Open Removal of Cardiac Lead from Heart, Percutaneous Removal of Cardiac Lead from Heart,Percutaneous Endoscopic Removal of Cardiac Lead from Heart, External 37.79 Revision or relocation of cardiac device pocket 0JWT0PZ 0JWT3PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutansous Tissue and Fascia, Open Revision of Cardiac Rhythm Related Device in Trunk Subcutansous Tissue and Fascia, Percutaneous Pacemaker 0JH60PZ Cardiac Rhythm Related Device into Chest Subcutaneous Tissue and Fascia, Open 0JH63PZ Cardiac Rhythm Related Device into Chest Subcutaneous Tissue and Fascia, Percutaneous 37.80 permanent pacemaker, initial or replacement, type of device not specified 0JH80PZ 0JH83PZ Cardiac Rhythm Related Device into Abdomen Subcutaneous Tissue and Fascia, Open Cardiac Rhythm Related Device into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Removal of Pacemaker 0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open 0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous 0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open 0JH604Z Pacemaker, single Chamber into Chest Subcutaneous Tissue and Fascia, Open 37.81 Initial insertion of single- Chamber device; not specified as rate responsive 0JH634Z 0JH804Z Pacemaker, Single Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Pacemkaer, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Open 0JH834Z Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 65

Rhythm Management and Electrophysiology 0JH605Z Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Open 37.82 Initial insertion of single- Chamber device, rate responsive 0JH635Z 0JH805Z Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Percutaneous Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Open 0JH835Z Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Percutaneous 0JH606Z Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Open 37.83 Initial insertion of dual- Chamber device 0JH636Z 0JH806Z Pacemaker, Dual Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Open 0JH836Z Pacemaker, Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Insertion Single-Chamber Device, not specified as rate responsive 0JH604Z Pacemaker, Single Chamber in Chest Subcutaneous Tissue and Fascia, Open 0JH634Z Insertionof Pacemaker, Single Chamber into Chest Subcutaneous and Fascia, Percutaneous 37.85 Replacement of any type pacemaker device with single-chamber device, not specified as rate responsive 0JH804Z 0JH834Z Pacemaker, Single Chamber into Abdomen Subcutaneous Tissue and Fascia, Open Insertion Pacemaker, Single Chamber in Abdomen Subcutaneous/Fascia, Percutaneous Removal Single-Chamber Device 0JPT0PZ Removal of Related Cardiac Rhythm Device from Trunk Subcutaneous Tissue and Fascia, Open 0JPT3PZ Removal Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Insertion Single-Chamber Device, rate responsive 0JH605Z Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Open 0JH635Z Pacemaker, Single Chamber Rate Responsive into Chest Subcutaneous Tissue and Fascia, Percutaneous 37.86 Replacement of any type of pacemaker device with single-chamber device rate responsive 0JH805Z 0JH835Z Pacemaker, Single Chamber Rate Responsive into Abdomen Subcutaneous Tissue and Fascia, Open Pacemaker, Single Chamber Rate Responsive in Abdomen Subcutaneous Tissue and Fascia, Percutaneous Removal Single-Chamber Device 0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open 0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Dual Chamber Device 0JH606Z Pacemaker Dual Chamber into Chest Subcutaneous Tissue Fascia, Open 0JH636Z Pacemaker Dual Chamber into Chest Subcutaneous Tissue and Fascia, Percutaneous 37.87 Replacement of any type pacemaker device with dual-chamber device 0JH806Z 0JH836Z Pacemaker Dual Chamber iton Abdomen Subcutaneous Tissue and Fascia, Open Pacemaker Dual Chamber into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Removal of Device 0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneou Tissue and Fascia, Open 0JPT3PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 66

Rhythm Management and Electrophysiology 0JPT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Open 37.89 Revision or removal of pacemaker device 0JPT3PZ 0JWT0PZ Removal of Cardiac Rhythm Related Device from Trunk Subcutaneous Tissue and Fascia, Percutaneous Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fasci, Open 0JWT3PZ Revision of Cardiac Rhythm Related Device in Trunk Subcutaneous Tissue and Fasci, Percutaneous 37.90 left atrial appendage device 02L73DK Occlusion of Left Atrial Appendage with Intraluminal Device, Percutaneous Generator 0JH608Z Defibrillator Generator into Chest Subcutaneous/Fascia, Open 0JH638Z Defibrillator Generator into Chest Subcutaneous/Fascia, Percutaneous 0JH808Z Defibrillator Generator into Abdomen Subcutaneous/Fascia, Open 0JH838Z Defibrillator Generator into Abdomen Subcutaneous/Fascia, Percutaneous Atrial Lead 02H60KZ Lead 02H63KZ Defibrillator Lead into Right Atrium, Percutaneous 02H64KZ Defibrillator Lead into Right Atrium, Percutaneous Endoscopic 02H70KZ Defibrillator Lead into Left Atrium, Open 37.94 Implantation or replacement of automatic cardioverter/ defibrillator, total system [AICD] 02H73KZ 02H74KZ 02HK0KZ Defibrillator Lead into Left Atrium, Percutaneous Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Ventricular Lead Defibrillator Lead into Right Ventricle, Open 02HK3KZ Defibrillator Lead into Right Ventricle, Percutaneous 02HK4KZ Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic 02HL0KZ Defibrillator Lead into Left Ventricle, Open 02HL3KZ Defibrillator Lead into Left Ventricle, Percutaneous 02HL4KZ Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic Defibrillator into Chest or Abdomen 0JH608Z Defibrillator Generator into Chest Subcutaneous/Fascia, Open 0JH638Z Defibrillator Generator into Chest Subcutaneous/Fascia, Percutaneous 0JH808Z Defibrillator Generator into Abdomen Subcutaneous/Fascia, Open 0JH838Z Defibrillator Generator into Abdomen Subcutaneous/Fascia, Percutaneous Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 67

Rhythm Management and Electrophysiology Removal of Generator 0JPT0PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Open 0JPT3PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Percutaneous Removal of Lead 02PA0MZ Removal of Cardiac Lead from Heart, Open 02PA3MZ Removal of Cardiac Lead from Heart, Percutaneous 02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic 02PAXMZ Removal of Cardiac Lead from Heart, External Defibrillator Lead into Atrium 37.94 Implantation or replacement of automatic cardioverter/ defibrillator, total system [AICD] 02H60KZ 02H63KZ 02H64KZ 02H70KZ Defibrillator Lead into Right Atrium, Open Defibrillator Lead into Right Atrium, Percutaneous Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Defibrillator Lead into Left Atrium, Open 02H73KZ Defibrillator Lead into Left Atrium, Percutaneous 02H74KZ Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Defibrillator Lead into Ventricle 02HK0KZ Defibrillator Lead into Right Ventricle, Open 02HK3KZ Defibrillator Lead into Right Ventricle, Percutaneous 02HK4KZ Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic 02HL0KZ Defibrillator Lead into Left Ventricle, Open 02HL3KZ Defibrillator Lead into Left Ventricle, Percutaneous 02HL4KZ Defibrillator Lead into Left Ventricle,Percutaneous Endoscopic Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 68

Rhythm Management and Electrophysiology 02H40KZ Defibrillator Lead into Coronary Vein, Open 02H44KZ Defibrillator Lead into Coronary Vein, Percutaneous Endoscopic 02H60KZ Defibrillator Lead into Right Atrium, Open 02H63KZ Defibrillator Lead into Right Atrium, Percutaneous 02H64KZ Defibrillator Lead into Right Atrium, Percutaneous Endoscopic 37.95 Implantation of automatic cardioverter/defibrillator lead(s) only 02H70KZ 02H73KZ 02H74KZ 02HL0KZ Defibrillator Lead into Left Atrium, Open Defibrillator Lead into Left Atrium, Percutaneous Defibrillator Lead into Left Atrium, Percutaneous Endoscopic Defibrillator Lead into Left Ventricle, Open 02HL3KZ Defibrillator Lead into Left Ventricle, Percutaneous 02HL4KZ Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic 02HN0KZ Defibrillator Lead into Pericardium, Open 02HN3KZ Defibrillator Lead into Pericardium, Percutaneous 02HN4KZ Defibrillator Lead into Pericardium, Percutaneous Endoscopic 0JH608Z Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Open 37.96 Implantation of automatic cardioverter/defibrillator pulse generator only 0JH638Z 0JH808Z 0JH838Z Defibrillator Generator into Chest Subcutaneous Tissue and Fascia, Percutaneous Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Open Defibrillator Generator into Abdomen Subcutaneous Tissue and Fascia, Percutaneous Defibrillator Lead 02H40KZ Defibrillator Lead into Coronary Vein, Open 02H44KZ Defibrillator Lead into Coronary Vein, Percutaneous Endoscopic 37.97 Replacement of automatic cardioverter/defibrillator lead(s) only 02H60KZ 02H63KZ 02H64KZ 02H70KZ Defibrillator Lead into Right Atrium, Open Defibrillator Lead into Right Atrium, Percutaneous Defibrillator Lead into Right Atrium, Percutaneous Endoscopic Defibrillator Lead into Left Atrium, Open 02H73KZ Defibrillator Lead into Left Atrium, Percutaneous 02H74KZ Defibrillator Lead into Left Atrium, Percutaneous Endoscopic 02HK0KZ Defibrillator Lead into Right Ventricle, Open Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 69

Rhythm Management and Electrophysiology 02HK3KZ Defibrillator Lead into Right Ventricle, Percutaneous 02HK4KZ Defibrillator Lead into Right Ventricle, Percutaneous Endoscopic 02HL0KZ Defibrillator Lead into Left Ventricle, Open 02HL3KZ Defibrillator Lead into Left Ventricle, Percutaneous 02HL4KZ Defibrillator Lead into Left Ventricle, Percutaneous Endoscopic 37.97 Replacement of automatic cardioverter/defibrillator lead(s) only 02HN0KZ 02HN3KZ 02HN4KZ Defibrillator Lead into Pericardium, Open Defibrillator Lead into Pericardium, Percutaneous Defibrillator Lead into Pericardium, Percutaneous Endoscopic Removal of Lead 02PA0MZ Removal of Cardiac Lead from Heart, Open 02PA3MZ Removal of Cardiac Lead from Heart,Percutaneous 02PA4MZ Removal of Cardiac Lead from Heart, Percutaneous Endoscopic 02PAXMZ Removal of Cardiac Lead from Heart, External Generator 0JH608Z Defibrillator Generator into Chest Subcutaneous/Fascia, Open 37.98 Replacement of automatic cardioverter/defibrillator pulse generator only 0JH638Z 0JH808Z Defibrillator Generator into Chest Subcutaneous/Fascia, Percutaneous Defibrillator Generator into Abdomen Subcutaneous/Fascia, Open Removal of Device 0JPT0PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Open 0JPT3PZ Removal Cardiac Rhythm Device from Trunk Subcutaneous/Fascia, Percutaneous Note: No Boston Scientific products are approved for sale in the US for atrial fibrillation ablations. See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 70

Urology 40.30 Regional lymph node excision 40.53 Radical excision of iliac lymph nodes 40.59 Radical excision of other lymph nodes 55.03 Percutaneous nephrostomy without fragmentation 55.04 Percutaneous nephrostomy with fragmentation 07B30ZZ 07B34ZZ 07BC3ZZ 07BC0ZZ 07BC4ZZ 07BG4ZZ 07BG0ZZ 07BF0ZZ 07BF4ZZ 07BD4ZZ 07BD0ZZ 07BD3ZZ 07B00ZZ 07B04ZZ 07B40ZZ 07B44ZZ 07B70ZZ 07B74ZZ 07BB4ZZ 07BB0ZZ 07BC0ZZ 07TC4ZZ 07TC0ZZ 07B80ZZ 07B90ZZ 07T90ZZ 07T94ZZ 07T80ZZ 07T84ZZ 0T9030Z 0T9040Z 0T9130Z 0T9140Z 0TC03ZZ 0TC04ZZ 0TC13ZZ 0TC14ZZ 0TF33ZZ 0TF43ZZ 0TF44ZZ Excision of Right Upper Extremity Lymphatic, Open Excision of Right Upper Extremity Lymphatic, Percutaneous Endoscopic Excision of Pelvis Lymphatic, Percutaneous Excision of Pelvis Lymphatic, Open Excision of Pelvis Lymphatic, Percutaneous Endoscopic Excision of Left Lower Extremity Lymphatic, Percutaneous Endoscopic Excision of Left Lower Extremity Lymphatic, Open Excision of Right Lower Extremity Lymphatic, Open Excision of Right Lower Extremity Lymphatic, Percutaneous Endoscopic Excision of Aortic Lymphatic, Percutaneous Endoscopic Excision of Aortic Lymphatic, Open Excision of Aortic Lymphatic, Percutaneous Excision of Head Lymphatic, Open Excision of Head Lymphatic, Percutaneous Endoscopic Excision of Left Upper Extremity Lymphatic, Open Excision of Left Upper Extremity Lymphatic, Percutaneous Endoscopic Excision of Thorax Lymphatic, Open Excision of Thorax Lymphatic, Percutaneous Endoscopic Excision of Mesenteric Lymphatic, Percutaneous Endoscpic Excision of Mesenteric Lymphatic, Open Excision of Pelvis Lymphatic, Open Resection of Pelvis Lymphatic, Percutaneous Endoscopic Resection of Pelvis Lymphatic, Open Excision of Right Internal Mammary Lymphatic, Open Excision of Left Internal Mammary Lymphatic, Open Resection of Left Internal Mammary Lymphatic, Open Resection of Left Internal Mammary Lymphatic, Percutaneous Endoscopic Resection of Right Internal Mammary Lymphatic, Open Resection of Right Internal Mammary Lymphatic, Percutaneous Endoscopic Drainage of Right Kidney with Drainage Device, Perc Drainage of Right Kidney with Drain Dev, Perc Endo Drainage of Left Kidney with Drainage Device, Perc Drainage of Left Kidney with Drain Dev, Perc Endo Extirpation of Matter from Right Kidney, Perc Extirpation of Matter from Right Kidney, Perc Endo Extirpation of Matter from Left Kidney, Perc Extirpation of Matter from Left Kidney, Perc Endo Fragmentation in Right Kidney Pelvis, Percutaneous Fragmentation in Left Kidney Pelvis, Percutaneous Fragmentation in Left Kidney Pelvis, Perc Endo See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 71

Urology 56.0 Transurethral removal of obstruction from ureter and renal pelvis 57.0 Transuretheral clearance of bladder 59.95 Utrasonic Fragmentation of Urinary Stones 0TC37ZZ 0TC38ZZ 0TC47ZZ 0TC48ZZ 0TC67ZZ 0TC68ZZ 0TC77ZZ 0TC78ZZ 0T9B7ZZ 0T9B8ZZ 0TCB7ZZ 0TCB8ZZ 0TF30ZZ 0TF37ZZ 0TF38ZZ 0TF40ZZ 0TF47ZZ 0TF48ZZ 0TF60ZZ 0TF63ZZ 0TF64ZZ 0TF67ZZ 0TF68ZZ 0TF70ZZ 0TF73ZZ 0TF74ZZ 0TF77ZZ 0TF78ZZ 0TFB0ZZ 0TFB3ZZ 0TFB4ZZ 0TFB7ZZ 0TFB8ZZ 0TFC0ZZ 0TFC3ZZ 0TFC4ZZ 0TFC7ZZ 0TFC8ZZ 0TFD0ZZ 0TFD3ZZ 0TFD4ZZ 0TFD7ZZ 0TFD8ZZ 0WFR0ZZ 0WFR3ZZ 0WFR4ZZ 0WFR7ZZ Extirpation of Matter from Right Kidney Pelvis, Via Opening Extirpation of Matter from Right Kidney Pelvis, Endo Extirpation of Matter from Left Kidney Pelvis, Via Opening Extirpation of Matter from Left Kidney Pelvis, Endo Extirpation of Matter from Right Ureter, Via Opening Extirpation of Matter from Right Ureter, Endo Extirpation of Matter from Left Ureter, Via Opening Extirpation of Matter from Left Ureter, Endo Drainage of Bladder, Via Natural or Artificial Opening Drainage of Bladder, Endo Extirpation of Matter from Bladder, Via Opening Extirpation of Matter from Bladder, Endo Fragmentation in Right Kidney Pelvis, Open Fragmentation in Right Kidney Pelvis, Via Opening Fragmentation in Right Kidney Pelvis, Endo Fragmentation in Left Kidney Pelvis, Open Fragmentation in Left Kidney Pelvis, Via Opening Fragmentation in Left Kidney Pelvis, Endo Fragmentation in Left Kidney Pelvis, Endo Fragmentation in Right Ureter, Percutaneous Fragmentation in Right Ureter, Percutaneous Endoscopic Fragmentation in Right Ureter, Via Natural or Artificial Opening Fragmentation in Right Ureter, Via Natural or Artificial Opening Endoscopic Fragmentation in Right Ureter, Perc Endo Fragmentation in Left Ureter, Percutaneous Fragmentation in Left Ureter, Perc Endo Fragmentation in Left Ureter, Via Opening Fragmentation in Left Ureter, Endo Fragmentation in Bladder, Open Fragmentation in Bladder, Percutaneous Fragmentation in Bladder, Percutaneous Endoscopic Fragmentation in Bladder, Via Natural or Artificial Opening Fragmentation in Bladder, Endo Fragmentation in Bladder Neck, Open Fragmentation in Bladder Neck, Percutaneous Fragmentation in Bladder Neck, Perc Endo Fragmentation in Bladder Neck, Via Opening Fragmentation in Bladder Neck, Endo Fragmentation in Urethra, Open Fragmentation in Urethra, Percutaneous Fragmentation in Urethra, Percutaneous Endoscopic Fragmentation in Urethra, Via Natural or Artificial Opening Fragmentation in Urethra, Endo Fragmentation in Genitourinary Tract, Open Fragmentation in Genitourinary Tract, Percutaneous Fragmentation in Genitourinary Tract, Perc Endo Fragmentation in Genitourinary Tract, Via Opening See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 72

Urology 60.21 Transurethral guided laser induced prostatectomy 60.29 Other transurethral prostatectomy 0V508ZZ 0V507ZZ 0VT07ZZ 0VT08ZZ 0VB07ZZ 0VB08ZZ 0VB07ZZ 0VB08ZZ 0VT07ZZ 0VT08ZZ Desctruction of Prostate, Via Natural or Artificial Opening Endoscopic Desctruction of Prostate, Via Natural or Artificial Opening Resection of Prostate, Via Natural or Artificial Opening Resection of Prostate, Via Natural or Artificial Opening Endoscopic Excision of Prostate, Via Natural or Artificial Opening Excision of Prostate, Via Natural or Artificial Opening Endoscopic Excision of Prostate, Via Natural or Artificial Opening Excision of Prostate, Endo Resection of Prostate, Via Natural or Artificial Opening Resection of Prostate, Endo 60.30 Suprapubic prostatectomy; transvesical prostatectomy 0VT00ZZ Resection of Prostate, Open 60.40 Retropubic prostatecotmy 0VT00ZZ Resection of Prostate, Open 60.5 Radical postatectomy 60.93 Repair of prostate 98.51 Extracorporeal shockwave lithotripsy (ESWL) of the kidney, ureter and/or bladder 0VT00ZZ 0VT04ZZ 0VT07ZZ 0VT08ZZ 0VT30ZZ 0VT34ZZ 0VQ00ZZ 0VQ03ZZ 0VQ04ZZ 0VQ07ZZ 0VQ08ZZ 0VN07ZZ 0VN08ZZ 0VN03ZZ 0VN00ZZ Resection of Prostate, Open Resection of Prostate, Percutaneous Endoscopic Resection of Prostate, Via Natural or Artificial Opening Resection of Prostate, Endo Resection of Bilateral Seminal Vesicles, Open Resection of Bilateral Seminal Vesicles, Perc Endo Repair Prostate, Open Repair Prostate, Percutaneous Repair Prostate, Percutaneous Endoscopic Repair Prostate, Via Natural or Artificial Opening Repair Prostate, Endo Release Prosate, Via Natural or Artificial Opening Release Prostate, Via Natural or Artificial Opening Endoscopic Release Prostate, Percutaneous Release Prostate, Open 0VN04ZZ Release Prostate, Percutaneous Endoscopic 0TF3XZZ 0TF4XZZ 0TF6XZZ 0TF7XZZ 0TFBXZZ 0TFCXZZ 0WFRXZZ Fragmentation in Right Kidney Pelvis, External Fragmentation in Left Kidney Pelvis, External Fragmentation in Right Ureter, External Fragmentation in Left Ureter, External Fragmentation in Bladder, External Fragmentation in Bladder Neck, External Fragmentation in Genitourinary Tract, External See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 73

Women s Health 59.4 Suprpubic sling operation 59.71 Levator muscle operation for urethrovesical suspension 59.79 Other repairs of stress incontinence 59.79 Other repairs of stress incontinence 0TSC0ZZ 0TSC4ZZ 0TUC07Z 0TUC0KZ 0TUC47Z 0TUC4KZ 0TUC77Z 0TUC7KZ 0TUC87Z 0TUC8KZ 0TQD0ZZ 0TQD3ZZ 0TQD4ZZ 0TQD7ZZ 0TQD8ZZ 0TQDXZZ 0TUC0JZ 0TUC4JZ 0TUC7JZ 0TUC8JZ 0TQD0ZZ 0TQD3ZZ 0TQD4ZZ 0TQD7ZZ 0TQD8ZZ 0TQDXZZ 0TUC0JZ 0TUC4JZ 0TUC7JZ 0TUC8JZ Reposition Bladder Neck, Open Reposition Bladder Neck, Percutaneous Endoscopic Supplement Bladder Neck with Autol Sub, Open Supplement Bladder Neck with Autol Sub, Open Supplement Bladder Neck with Autol Sub, Perc Endo Supplement Bladder Neck with Nonaut Sub, Perc Endo Supplement Bladder Neck with Autol Sub, Via Opening Supplement Bladder Neck with Nonaut Sub, Via Opening Supplement Bladder Neck with Autol Sub, Endo Supplement Bladder Neck with Nonaut Sub, Endo Repair Urethra, Open Repair Urethra, Percutaneous Repair Urethra, Percutaneous Endoscopic Repair Urethra, Via Natural or Artificial Opening Repair Urethra, Via Natural or Artificial Opening Endoscopic Repair Urethra, External Supplement Bladder Neck with Synth Sub, Via Opening Supplement Bladder Neck with Synth Sub, Perc Endo Supplement Bladder Neck with Synth Sub, Via Opening Supplement Bladder Neck with Synthetic Substitute, Endo Repair Urethra, Open Repair Urethra, Percutaneous Repair Urethra, Percutaneous Endoscopic Repair Urethra, Via Natural or Artificial Opening Repair Urethra, Via Natural or Artificial Opening Endoscopic Repair Urethra, External Supplement Bladder Neck with Synth Sub, Via Opening Supplement Bladder Neck with Synth Sub, Perc Endo Supplement Bladder Neck with Synth Sub, Via Opening Supplement Bladder Neck with Synthetic Substitute, Endo 70.51 Repair of cystocele 0JQC3ZZ Repair Pelvic Subcu/Fascia, Perc 70.54 Repair of cystocele with graft or prosthesis (anterior colporrhaphy) 70.77 Vaginal suspension and fixation 70.78 Vaginal suspension and fixation with graft or prosthesis 0JUC0KZ 0USG0ZZ 0USG4ZZ 0USGXZZ 0UUG07Z 0UUG0JZ 0UUG0KZ 0UUG47Z 0UUG4JZ 0UUG4KZ 0UUG77Z 0UUG7JZ 0UUG7KZ 0UUG87Z 0UUG8JZ Supplement Pelvic Subcu/Fascia w Nonaut Sub, Open Reposition Vagina, Open Reposition Vagina, Percutaneous Endoscopic Reposition Vagina, External Supplement Vagina with Autol Sub, Open Supplement Vagina with Synthetic Substitute, Open Supplement Vagina with Nonaut Sub, Open Supplement Vagina with Autol Sub, Perc Endo Supplement Vagina with Synth Sub, Perc Endo Supplement Vagina with Nonaut Sub, Perc Endo Supplement Vagina with Autol Sub, Via Opening Supplement Vagina with Synthetic Substitute, Via Opening Supplement Vagina with Nonaut Sub, Via Opening Supplement Vagina with Autologous Tissue Substitute, Endo Supplement Vagina with Synthetic Substitute, Endo See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 74

Women s Health 70.95 synthetic graft or prosthesis 0UUG0JZ 0UUG7JZ 0UUG8JZ 0UUG4JZ 0UUGXJZ 0UUF0JZ 0UUF4JZ 0UUF8JZ 0UUF7JZ Supplement Vagina with Synthetic Substitute, Open Supplement Vagina with Synthetic Substitute, Via Opening Supplement Vagina with Synthetic Substitute, Endo Supplement Vagina with Synth Sub, Perc Endo Supplement Vagina with Synthetic Subsitute, External Supplement Cul-de-sac with Synthetic Subsitute, Open Supplement Cul-de-sac with Synthetic Subsitute, Percutaneous Endoscopic Supplement Cul-de-sac with Synthetic Subsitute, Via Natural or Artificial Opening Endoscopic Supplement Cul-de-sac with Synthetic Subsitute, Via Natural or Artificial Opening See page 3 for important information about the uses and limitations of this document. CORP-224204-AA SEP2014 75

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