Code Description 00640 Anesthesia, Manipulation, Spine, Closed Proc, Cervical/Thoracic/Lumbar 11920 Tattooing To Correct Color Defects; 6.0 Sq Cm/< 11921 Tattooing To Correct Color Defects; 6.1-20.0 Sq Cm 11922 Tattooing To Correct Color Defects; Add'l 20.0 Sq Cm 11950 Subq Injection, Filling Matl; 1 Cc/< 11951 Subq Injection, Filling Matl; 1.1 To 5.0 Cc 11952 Subq Injection, Filling Matl; 5.1 To 10.0 Cc 11954 Subq Injection, Filling Matl; > 10.0 Cc 11960 Insertion, Tissue Expander(S), Other Than Breast, W/Subsequent Expansion 15271 App Skn Sub Grft T/A/L Area/<100Scm /<1St 25 Scm 15272 App Skn Sub Grft T/A/L Area/<100Scm Ea Adl 25Scm 15273 App Skn Sub Grft T/A/L Area/>100Scm 1St 100Scm 15274 App Skn Sub Grft T/A/L Area/>100Scm Adl 100Scm 15275 Sub Grft F/S/N/H/F/G/M/D /<100Scm /<1St 25 Scm 15276 Sub Grft F/S/N/H/F/G/M/D /<100Scm Ea Adl 25Scm 15277 Sub Grft F/S/N/H/F/G/M/D />100Scm 1St 100Scm 15278 Sub Grft F/S/N/H/F/G/M/D />100Scm Adl 100Scm 15775 Punch Graft, Hair Transplant; 1-15 Punch Grafts 15776 Punch Graft, Hair Transplant; > 15 Punch Grafts 15780 Dermabrasion; Total Face 15781 Dermabrasion; Segmental, Face 15782 Dermabrasion; Regional, Other Than Face 15783 Dermabrasion; Superficial, Any Site 15786 Abrasion; Single Lesion 15787 Abrasion; Add'l 4 Lesions/< 15788 Chemical Peel, Facial; Epidermal 15789 Chemical Peel, Facial; Dermal 15792 Chemical Peel, Nonfacial; Epidermal 15793 Chemical Peel, Nonfacial; Dermal 15819 Cervicoplasty 15820 Blepharoplasty, Lower Eyelid 15821 Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad 15822 Blepharoplasty, Upper Eyelid 15823 Blepharoplasty, Upper Eyelid; W/Excessive Skin Weighting Down Lid 15824 Rhytidectomy; Forehead 15825 Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap) 15826 Rhytidectomy; Glabellar Frown Lines 15828 Rhytidectomy; Cheek, Chin, & Neck 15829 Rhytidectomy; Superficial Musculoaponeurotic System (Smas) Flap 15830 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy); Abdomen, Infraumbilical Panniculectomy 15832 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Thigh 15833 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Leg 15834 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Hip 15835 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Buttock 15836 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Arm 15837 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Forearm/Hand 15838 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Submental Fat Pad 15839 Excision, Excessive Skin & Subq Tissue (W/Lipectomy); Other Area 15847 Excision, Excessive Skin and Subcutaneous Tissue (Includes Lipectomy), Abdomen 15876 Suction Assisted Lipectomy; Head & Neck 15877 Suction Assisted Lipectomy; Trunk 15878 Suction Assisted Lipectomy; Upper Extremity 15879 Suction Assisted Lipectomy; Lower Extremity 17106 Destruction, Cutaneous Vascular Proliferative Lesions; < 10 Sq Cm 17107 Destruction, Cutaneous Vascular Proliferative Lesions; 10.0-50.0 Sq Cm 17108 Destruction, Cutaneous Vascular Proliferative Lesions; > 50.0 Sq Cm 17380 Electrolysis Epilation, Each One Half Hour

Page 1 of 40 Code Description 17999 Unlisted Proc, Skin, Mucous Membrane & Subq Tissue 19105 Ablation, Cryosurgical, of Fibroadenoma, including Ultrasound Guidance, Each Fibroadenoma 19300 REMOVAL OF BREAST TISSUE 19316 Mastopexy 19318 Reduction Mammaplasty 19324 Mammaplasty, Augmentation; W/O Prosthetic Implant 19325 Mammaplasty, Augmentation; W/Prosthetic Implant 19328 Removal, Intact Mammary Implant 19340 Immediate Insertion, Breast Prosthesis Following Mastopexy, Mastectomy/In Reconstruction 19342 Delayed Insertion, Breast Prosthesis Following Mastopexy, Mastectomy/In Reconstruction 19350 Nipple/Areola Reconstruction 19355 Correction, Inverted Nipples 19357 Breast Reconstruction W/Tissue Expander, Immediate/Delayed, W/Subseq Expansion 19361 Breast Reconstruction W/Latissimus Dorsi Flap, W/Wo Prosthetic Implant 19364 Breast Reconstruction W/Free Flap 19366 Breast Reconstruction W/Other Technique 19367 Breast Reconstruction W/Myocutaneous (Tram) Flap, Single Pedicle W/Closure Donor Site; 19368 Breast Reconstruction W/Myocutan (Tram) Flap, Single Pedicle W/Closure Donor Site; W/Microvasc Anast 19369 Breast Reconstruction W/Myocutaneous (Tram) Flap, Double Pedicle W/Closure Donor Site 19370 Open Periprosthetic Capsulotomy, Breast 19371 Periprosthetic Capsulectomy, Breast 19380 Revision, Reconstructed Breast 19396 Preparation, Moulage, Custom Breast Implant 20610 Arthrocentesis Aspir&/Inj Major Jt/Bursa W/O Us 20930 Allograft For Spine Surgery Only Morselized 20931 Allograft For Spine Surgery Only Structural 20936 Autograft, Spine Surgery Only; Local, Same Incision 20937 Autograft, Spine Surgery Only; Morselized, Sep Incision 20938 Autograft, Spine Surgery Only; Structural/Bicortical/Tricortical, Sep Incision 20974 Electrical Stimulation To Aid Bone Healing; Noninvasive (Nonoperative) 20975 Electrical Stimulation To Aid Bone Healing; Invasive (Operative) 20979 Low Intensity Ultrasound Stimulation To Aid Bone Healing; Noninvasive 20982 Ablation Bone Tumor Rf Perq W/Img Gdn When Done 20983 Ablatj Bone Tumor Cryo Perq W/Img Gdn When Prfmd 20999 Unlisted Proc, Musculoskeletal System, General 21010 Arthrotomy, Temporomandibular Joint 21050 Condylectomy, Temporomandibular Joint (Sep Proc) 21060 Meniscectomy, Partial/Complete, Temporomandibular Joint (Sep Proc)

21073 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored 21083 Impression & Custom Preparation; Palatal Lift Prosthesis 21087 Impression & Custom Preparation; Nasal Prosthesis 21116 Injection Proc, Temporomandibular Joint Arthrography 21120 Genioplasty; Augmentation (Autograft, Allograft, Prosthetic Matl) 21121 Genioplasty; Sliding Osteotomy, Single Piece 21122 Genioplasty; Sliding Osteotomies, 2+ Osteotomies 21123 Genioplasty; Sliding, Augmentation W/Interpositional Bone Grafts W/Obtaining Autograft 21125 Augmentation, Mandibular Body/Angle; Prosthetic Matl 21127 Augmentation, Mandibular Body/Angle; W/Bone Graft/Onlay/Interpositional W/Obtaining Autograft 21137 Reduction Forehead; Contouring Only 21138 Reduction Forehead; Contouring/Prosthesis/Bone Graft W/Obtaining Autograft 21139 Reduction Forehead; Contouring & Setback, Anterior Frontal Sinus Wall 21141 Reconstruction Midface, Lefort I; 1 Piece, W/O Bone Graft 21142 Reconstruction Midface, Lefort I; 2 Pieces, W/O Bone Graft 21143 Reconstruction Midface, Lefort I; 3+ Pieces, W/O Bone Graft 21145 Reconstruction Midface, Lefort I; 1 Piece, W/Bone Grafts 21146 Reconstruction Midface, Lefort I; 2 Pieces, W/Bone Grafts

Page 2 of 40 Code Description 21147 Reconstruction Midface, Lefort I; 3+ Pieces, W/Bone Grafts 21150 Reconstruction Midface, Lefort Ii; Anterior Intrusion 21151 Reconstruction Midface, Lefort Ii; W/Bone Grafts 21154 Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/O Lefort I 21155 Reconstruction Midface, Lefort Iii, W/Bone Grafts; W/Lefort I 21172 Reconstruction Superior-Lateral Orbital Rim & Lower Forehead 21175 Reconstruction, Bifrontal,Superior-Lateral Orbital Rims & Lower Forehead 21179 Reconstruction, Majority, Forehead & Supraorbital Rims; W/Grafts (Allograft/Prosthetic) 21180 Reconstruction, Majority, Forehead & Supraorbital Rims; W/Autograft 21181 Reconstruction, Contouring, Benign Tumor, Cranial Bones, Extracranial 21182 Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft < 40 Sq Cm 21183 Reconstruction, Orbit/Forehead/Nasoethmiod, Following Excision, Benign Tumor, Graft 40-80 Sq Cm 21184 Reconstruction, Orbit/Forehead/Nasoethmoid, Following Excision, Benign Tumor, Graft > 80 Sq Cm 21188 Reconstruction, Midface, Osteotomies (Non-Lefort Type), W/Grafts, W/Obtaining Autografts 21193 Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/O Bone Graft 21194 Reconstruction, Mandibular Rami, Horizontal, Vertical, "C"/"L" Osteotomy; W/Bone Graft 21195 Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/O Int Rigid Fixation 21196 Reconstruction, Mandibular Rami &/Or Body, Sagittal Split; W/Int Rigid Fixation 21198 Osteotomy, Mandible, Segmental 21199 Osteotomy, Mandible, Segmental; W/Genioglossus Advancement 21206 Osteotomy, Maxilla, Segmental 21208 Osteoplasty, Facial Bones; Augmentation (Autograft, Allograft/Prosthetic Implant) 21209 Osteoplasty, Facial Bones; Reduction 21210 Graft, Bone; Nasal, Maxillary/Malar Areas (Includes Obtaining Graft) 21215 Graft, Bone; Mandible (Includes Obtaining Graft) 21230 Graft; Rib Cartilage, Autogenous, Face/Chin/Nose/Ear (Includes Obtaining Graft) 21235 Graft; Ear Cartilage, Autogenous, Nose/Ear (Includes Obtaining Graft) 21240 Arthroplasty, Temporomandibular Joint, W/Wo Autograft (Includes Obtaining Graft) 21242 Arthroplasty, Temporomandibular Joint, W/Allograft 21243 Arthroplasty, Temporomandibular Joint, W/Prosthetic Joint Replacement 21244 Reconstruction, Mandible, Extraoral, W/Transosteal Bone Plate 21245 Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Partial 21246 Reconstruction, Mandible/Maxilla, Subperiosteal Implant; Complete 21247 Reconstruction, Mandibular Condyle W/Bone & Cartilage Autografts 21256 Reconstruction, Orbit W/Osteotomies & Bone Grafts (Includes Obtaining Autografts) 21260 Periorbital Osteotomies, Orbital Hypertelorism, W/Bone Grafts; Extracranial Approach 21261 Periorbital Osteotomies, Orbital Hypertelorism, W/Bone Grafts; Intra & Extracranial Approach 21263 Periorbital Osteotomies, Orbital Hypertelorism, W/Bone Grafts; W/Forehead Advancement 21267 Orbital Repositioning, Periorbital Osteotomies, Unilat W/Bone Grafts; Extracranial Approach 21268 Orbital Repositioning, Periorbital Osteotomies, Unilat W/Bone Graft; Intra & Extracranial Approach 21270 Malar Augmentation, Prosthetic Matl 21275 Secondary Revision, Orbitocraniofacial Reconstruction 21280 Medial Canthopexy (Sep Proc) 21282 Lateral Canthopexy 21295 Reduction, Masseter Muscle/Bone; Extraoral Approach 21685 Hyoid Myotomy and Suspension 21740 Reconstructive Repair, Pectus Excavatum/Carinatum; Open 21742 Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/O Thoracoscopy 21743 Reconstructive Repair, Pectus Excavatum/Carinatum; Minimal Invasive Approach, W/Thoracoscopy 22100 Partial Excision, Posterior Vertebral Component, Intrinisic Bony Lesion Single Segment; Cervical 22101 Partial Excision, Posterior Vertebral Component, Intrinisic Bony Lesion Single Segment; Thoracic 22102 Partial Excision, Posterior Vertebral Component, Intrinisic Bony Lesion Single Segment; Lumbar 22103 Partial Excision, Post Vertebral Component, Intrinisic Bony Lesion Single Segment; Add'l Segment 22110 Part Excis, Vertebral Body, Bony Lesion, W/O Spinal Cord/Nerve Root Decompress, Single; Cervical 22112 Part Excis, Vertebral Body, Bony Lesion, W/O Spinal Cord/Nerve Root Decompress, Single; Thoracic 22114 Part Excis, Vertebral Body, Bony Lesion, W/O Spinal Cord/Nerve Root Decompress, Single; Lumbar 22116 Part Excis, Vertebral Body, Bony Lesion, W/O Spinal Cord/Nerve Root Decompress, Single; Add'l Segmen

Page 3 of 40 Code Description 22206 Osteotomy Spine Scoliosis Transthor 22207 Osteotomy-Spine,1+,Scol;txabd/Retro 22208 OSTEOTOMY SPINE POSTERIOR 3 COLUMN EA ADDL SGM 22210 Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Cervical 22212 Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Thoracic 22214 Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Lumbar 22220 Osteotomy, Spine, W/Diskectomy, Anterior Approach, Single Segment; Cervical 22224 Osteotomy, Spine, W/Diskectomy, Anterior Approach, Single Segment; Lumbar 22226 Osteotomy, Spine, W/Diskectomy, Anterior Approach, Single Segment; Add'l Segment 22505 Manipulation, Spine, Requiring Anesthesia, Any Region 22510 Perq Vertebroplasty Uni/Bi Injx Cervicothoracic 22511 Perq Vertebroplasty Uni/Bi Injection Lumbosacral 22512 Vertebroplasty Each Addl Cervicothor/Lumbosacral 22513 Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulation 22514 Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Lmbr 22515 Perq Vert Agmntj Cavity Crtj Uni/Bi Cannulj Each 22532 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Thoracic 22533 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy To Prepare Interspace; Lumbar

22534 Arthrodesis, Lateral Extracavitary Technique, Including Minimal Diskectomy; Thoracic or Lumbar, Each Additional Segment 22548 Arthrodesis, Anterior Transoral/Extraoral, Atlas-Axis, W/Wo Excision Odontoid Process 22551 Arthrd Ant Interbody Decompress Cervical Belw C2 22552 Arthrd Ant Interdy Cervcl Belw C2 Ea Addl Ntrspc 22554 Arthrodesis, Anterior Interbody, W/Mininmal Diskectomy; Cervical Below C2 22556 Arthrodesis, Anterior Interbody, W/Mininmal Diskectomy; Thoracic 22558 Arthrodesis, Anterior Interbody, W/Mininmal Diskectomy; Lumbar 22585 Arthrodesis, Anterior Interbody, W/Mininmal Diskectomy; Add'l Interspace 22586 Arthrodesis Presacral Intrbdy W/Instrument L5/S1 22590 Arthrodesis, Posterior Technique, Craniocervical 22595 Arthrodesis, Posterior Technique, Atlas-Axis 22600 Arthrodesis, Posterior/Posterolateral Technique, Single Level; Cervical Below C2 22610 Arthrodesis, Posterior/Posterolateral Technique, Single Level; Thoracic 22612 Arthrodesis, Posterior/Posterolateral Technique, Single Level; Lumbar 22614 Arthrodesis, Posterior/Posterolateral Technique, Single Level; Add'l Segment 22630 Arthrodesis, Post Interbody W/Laminectomy &/Or Diskect, Prep Interspace, Single Interspace; Lumbar 22632 Arthrodesis, Post Interbody W/Laminect &/Or Diskect, Prep Interspace, Sngl Intrspc; Add'l Interspc 22633 Arthdsis Post/Posterolatrl/Postinterbody Lumbar 22634 Arthdsis Post/Posterlatrl/Postintrbdyadl Spc/Seg 22800 Arthrodesis, Posterior, Spinal Deformity, W/Wo Cast; Up To 6 Vertebral Segments 22802 Arthrodesis, Posterior, Spinal Deformity, W/Wo Cast; 7 To 12 Vertebral Segments 22804 Arthrodesis, Posterior, Spinal Deformity, W/Wo Cast; 13+ Vertebral Segments 22808 Arthrodesis, Anterior, Spinal Deformity, W/Wo Cast; 2 To 3 Vertebral Segments 22810 Arthrodesis, Anterior, Spinal Deformity, W/Wo Cast; 4 To 7 Vertebral Segments 22812 Spinal Fixation, Wiring, Spinous Processes 22818 Kyphectomy, Exposure Of Spine & Resection Vertebral Segments; 1-2 Segs 22819 Kyphectomy, Exposure Of Spine & Resection Vertebral Segments; 3 / More 22830 Exploration of Spinal Fusion 22840 Pos.Instrumnt;e.g. Harringtn Rod 22841 Internal Spinal Fixation by Wiring of Spinous Processes 22842 Posterior Segmental Instrumentation; 3-6 Vertebral Segments 22843 Posterior Segmental Instrumentation; 7-12 Vertebral Segments 22844 Posterior Segmental Instrumentation; 13+ Vertebral Segments 22845 Anterior Instrumentation; 2 To 3 Vertebral Segments 22846 Anterior Instrumentation; 4 To 7 Vertebral Segments 22847 Anterior Instrumentation; 8+ Vertebral Segments 22848 Pelvic Fixation, Non-Sacrum 22849 Reinsertion, Spinal Fixation Device

Page 4 of 40 Code Description 22851 Application Intervertebral Biomechanical Device 22853 Insj Biomchn Dev Intervertebral Dsc Spc W/Arthrd 22854 Insj Biomchn Dev Vrt Corpectomy Defect W/Arthrd 22856 Tot Disc Arthrp Art Disc Ant Appro 1 Ntrspc Crv 22857 Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Including Discectomy, Lumbar, Single Interspace 22858 Tot Disc Arthrp Ant Appr Disc 2Nd Level Cervical 22859 Insj Biomchn Dev Ntrvrt Disc Space W/O Arthrd 22861 Revj Rplcmt Disc Arthroplasty Ant 1 Ntrspc Crv 22862 Revision Including Replacement of Total Disc Arthroplasty (Artificial Disc) Anterior Approach, Lumbar, Single Interspace 22864 Rmvl Disc Arthroplasty Ant 1 Interspace Cervical 22865 Removal of Total Disc Arthroplasty (Artificial Disc), Anterior Approach, Lumbar, Single Interspace 22867 Insj Stablj Dev W/Dcmprn Lumbar Single Level 22868 Insj Stablj Dev W/Dcmprn Lumbar Second Level 22869 Insj Stablj Dev W/O Dcmprn Lumbar Single Level 22870 Insj Stablj Dev W/O Dcmprn Lumbar Second Level 22899 Unlisted Proc, Spine 22999 Unlisted Proc, Abdomen, Musculoskeletal System 23470 Arthroplasty, Glenohumeral Joint; Hemiarthroplasty 23472 Arthroplasty, Glenohumeral Joint; Total Shoulder 23473 Revis Shoulder Arthrplsty Humeral/Glenoid Compnt 23474 Revis Shoulder Arthrplsty Humeral&Glenoid Compnt 24300 Manipulation, Elbow, Under Anesthesia 24360 Arthroplasty, Elbow; W/Membrane 24361 Arthroplasty, Elbow; W/Distal Humeral Prosthetic Replacement 24362 Arthroplasty, Elbow; W/Implant & Fascia Lata Ligament Reconstruction 24363 Arthroplasty, Elbow; W/Distal Humerus/Proximal Ulnar Prosthetic Replacement 24370 DRevis Elbow Arthrplsty Humeral/Ulna Compnt 24371 Revis Elbow Arthrplsty Humeral&Ulna Compnt 25259 Manipulation, Wrist, Under Anesthesia 26340 Manipulation, Finger Joint, Under Anesthesia, Each Joint 27120 Acetabuloplasty; 27122 Acetabuloplasty; Resection, Femoral Head 27125 Hemiarthroplasty, Hip, Partial 27130 Arthroplasty, Acetabular/Proximal Femoral Prosthetic Replacement, W/Wo Autograft/Allograft 27132 Conversion, Previous Hip Surgery To Total Hip Arthroplasty, W/Wo Autograft/Allograft 27134 Revision, Total Hip Arthroplasty; Both Components, W/Wo Autograft/Allograft 27137 Revision, Total Hip Arthroplasty; Acetabular Component Only, W/Wo Autograft/Allograft 27138 Revision, Total Hip Arthroplasty; Femoral Component Only, W/Wo Allograft 27275 Manipulation, Hip Joint, Requiring General Anesthesia 27279 Arthrodesis Sacroiliac Joint Percutaneous 27280 Arthrodesis Sacroiliac Joint W/Obtaining Graft 27412 Autologous Chondrocyte Implantation, Knee 27415 Osteochondral Allograft, Knee, Open 27416 OSTEOCHONDRAL AUTOGRAFT KNEE OPEN MOSAICPLASTY 27445 Arthroplasty, Knee, Hinge Prosthesis 27446 Arthroplasty, Knee, Condyle & Plateau; Medial/Lateral Compartment 27447 Arthroplasty, Knee, Condyle & Plateau; Medial & Lateral Compartments, W/Wo Patella Resurfacing 27486 Revision, Total Knee Arthroplasty, W/Wo Allograft; 1 Component 27487 Revision, Total Knee Arthroplasty; Femoral & Entire Tibial Component 27570 Manipulation, Knee Joint Under General Anesthesia 27860 Manipulation, Ankle Under General Anesthesia 28344 Reconstruction, Toe(S); Polydactyly 28890 Eswt Hi Nrg Phys/Qhp W/Us Gdn Invg Plntar Fascia 28899 Unlisted Proc, Foot/Toes 29800 Arthroscopy, Temporomandibular Joint, Dx W/Wo Synovial Bx (Sep Proc) 29804 Arthroscopy, Temporomandibular Joint, Surgical 29866 Arthroscopy, Knee, Surgical; Osteochondral Autograft(S) (Eg, Mosaicplasty) (Includes Harvesting Of The Autograft)

Page 5 of 40 Code Description 29867 Arthroscopy, Knee, Surgical; Osteochondral Allograft (Eg, Mosaicplasty) 29868 Arthroscopy, Knee, Surgical; Meniscal Transplantation (Includes Arthrotomy For Meniscal Insertion), Medial Or Lateral 29877 Arthroscopy, Knee, Surgical; Debridement/Shaving, Articular Cartilage (Chondroplasty) 29892 Arthroscopically Aided Repair, Osteochondritis/Talar Dome Fx/Tibial Plafond Fx 29999 Unlisted Proc, Arthroscopy 30120 Excision/Surgical Planing, Skin, Nose, Rhinophyma 30400 Rhinoplasty, Primary; Lateral & Alar Cartilages &/Or Elevation, Nasal Tip 30410 Rhinoplasty, Primary; Complete, Ext Parts W/Bony Pyramid, Lat & Alar Cartilages &/Or Elev Nasal Tip 30420 Rhinoplasty, Primary; W/Major Septal Repair 30430 Rhinoplasty, Secondary; Minor Revision (Small Amount, Nasal Tip Work) 30435 Rhinoplasty, Secondary; Intermediate Revision (Bony Work W/Osteotomies) 30450 Rhinoplasty, Secondary; Major Revision (Nasal Tip Work & Osteotomies) 30460 Rhinoplasty, Nasal Deformity Secondary To Cong Cleft Lip/Palate, W/Columellar Lengthening; Tip Only 30462 Rhinoplasty, Nasal Deform Sec To Cong Cleft Lip/Palat, W/Columellar Lengthen; Tip/Septum/Osteotomies 30540 Repair Choanal Atresia; Intranasal 30545 Repair Choanal Atresia; Transpalatine 30560 Lysis Intranasal Synechia 30620 Septal/Other Intranasal Dermatoplasty (Does Not Include Obtaining Graft) 30801 Abltj Sof Tiss Inf Turbs Uni/Bi Supfc 30802 Abltj Sof Tiss Inf Turbs Uni/Bi Supfc Intramural 31237 Nasal/Sinus Endoscopy, Surgical; W/Bx, Polypectomy/Debridement (Sep Proc) 31253 Nasal/Sinus Ndsc Tot W/Frnt Sins Expl Tiss Rmvl 31254 Nasal/Sinus Ndsc W/Partial Ethmoidectomy 31255 Nasal/Sinus Ndsc W/Total Ethoidectomy 31256 Nasal/Sinus Endoscopy, Surgical, W/Maxillary Antrostomy; 31257 Nasal/Sinus Ndsc Total With Sphenoidotomy 31259 Nasal/Sinus Ndsc Tot W/Sphendt W/Sphen Tiss Rmvl 31267 Nasal/Sinus Endoscopy, Surgical, W/Maxillary Antrostomy; W/Maxillary Tissue Removal 31276 Nasal/Sinus Ndsc W/Rmvl Tiss From Frontal Sinus 31287 Nasal/Sinus Endoscopy, Surgical, W/Sphenoidotomy; 31288 Nasal/Sinus Endoscopy, Surgical, W/Sphenoidotomy; W/Tissue Removal, Sphenoid Sinus 31295 Nsl/Sinus Ndsc Surg W/Dilat Maxillary Sinus 31296 Nsl/Sinus Ndsc Surg W/Dilat Frontal Sinus 31297 Nsl/Sinus Ndsc Surg W/Dilat Sphenoid Sinus 31298 Nasal/Sinus Ndsc W/Frontal & Sphen Sins Dilation 31660 Bronchoscopic Thermoplasty One Lobe 31661 Bronchoscopic Thermoplasty 2/> Lobes 32664 Thoracoscopy, Surgical; W/Thoracic Sympathectomy 32994 Ablation Ther 1+ Pulm Tumors Perq 33216 Insj 1 Transvns Eltrd Perm Pacemaker/Impltbl Dfb 33217 Insj 2 Transvns Eltrd Perm Pacemaker/Impltbl Dfb 33271 Insj Of Subq Implantable Defibrillator Electrode 33340 Perq Clsr Tcat L Atr Apndge W/Endocardial Implnt 33927 Impltj Total Rplcmt Heart Sys W/Rcp Cardiectomy 33928 Removal & Rplcmt Total Rplcmt Heart Sys 33929 Removal Total Rplcmt Heart Sys For Heart Trnspl 33975 Insertion, Ventricular Assist Device; Extracorporeal, Single Ventricle 33976 Insertion, Ventricular Assist Device; Extracorporeal, Biventricular 33979 Insertion, Ventricular Assist Device, Implantable Intracorporeal, Single Ventricle 33981 Rplcmt Xtrcorp Vad 1/Biventr Pump 1/Ea Pump 33982 Rplcmt Vad Pmp Impltbl Icorp 1 Vntr W/O Card Byp 33983 Rplcmt Vad Pmp Impltbl Icorp 1 Vntr W/Card Byp 33990 Insj Perq Vad W/Imaging Artery Access Only 33991 Insj Perq Vad Trnsptal W/Image Art&Venous Access 33993 Reposition Vad W/Imaging Different Session 36260 Insertion, Implantable Intra-Arterial Infusion Pump 36261 Revision, Implanted Intra-Arterial Infusion Pump

Page 6 of 40 Code Description 36468 Injections Sclerosant For Spider Veins Lim/Trnk 36470 Injection Sclerosant Single Incmptnt Vein 36471 Injection Sclerosant Multiple Incmptnt Veins 36473 Endoven Abltj Incmptnt Vein Mchnchem 1St Vein 36474 Endoven Abltj Incmptnt Vein Mchnchem Sbsq Veins 36475 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Radiofrequency; First Vein Treated 36476 Endoven Abltj Incmptnt Vein Xtr Rf 2Nd+ Veins 36478 Endovenous Ablation Therapy Of Incompetent Vein, Extremity, Percutaneous, Laser; First Vein Treated 36479 Endoven Abltj Incmptnt Vein Xtr Laser 2Nd+ Veins 36514 Therapeutic Apheresis; Plasma Pheresis 36563 Insertion of Tunneled Centrally Inserted Central Venous Access Device with Subcutaneous Pump 37700 Ligation & Division, Long Saphenous Vein, Saphenofemoral Junction/Distal Interruptions 37718 Ligation, division, and stripping, short saphenous vein 37722 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 37780 Ligation & Division, Short Saphenous Vein, Saphenopopliteal Junction 37788 Penile revascularization, artery, with or without vein graft 37790 Penile venous occlusive procedure 40500 Vermilionectomy (Lip Shave), W/Mucosal Advancement 41512 Tongue Base Suspension Permanent Suture Tq 41530 Submucosal Abltj Tongue Rf 1/> Sites Pr Session 42145 Palatopharyngoplasty 42299 Unlisted Proc, Palate, Uvula 42820 Tonsillectomy & Adenoidectomy; < Age 12 42825 Tonsillectomy, Primary/Secondary; < Age 12 43192 ESOPHAGOSCOPY RIGID TRANSORAL INJ SUBMUCOSAL 43201 ESOPHAGOSCOPY FLEXIBLE TRANSORAL W SUBMUCOUS INJ 43210 Egd Partial/Compl Esophagogastric Fundoplasty 43228 Esphgsc Rgd/Flx Abltj Tum Xcp Hot Bx/Caut/Snare 43236 ESOPHAGOGASTRODUODENOSCOPY SUBMUCOSAL INJECTION 43257 EGD DELIVER THERMAL ENERGY SPHNCTR/CARDIA GERD 43258 Upr Gi Ndsc Abltj Les X Rmvl Forceps/Caut/Snare 43632 Gastrectomy, Partial, Distal; W/Gastrojejunostomy Laparoscopy, Surg, Gastric Restrictive Procedure; W Gastric Bypass And Roux-En-Y Gastroenterostomy (Roux Limb <= 150 43644 Cm) 43645 Laparoscopy, Surgical, Gastric Restrictive Procedure; With Gastric Bypass And Small Intestine Reconstruction 43647 Laparoscopy, Surgical; Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum 43648 Laparoscopy, Surgical; Revision or Removal of Gastric Neurostimulator Electrodes, Antrum 43659 Unlisted Proc, Laparoscopy, Stomach 43770 Laparoscopy, surg, gastric restrictive procedure; placement of adjustable gastric band 43771 Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric band component only 43772 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric band component only

43773 Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric band component only

43774 Laparoscopy, surg, gastric restrictive procedure; removal of adjustable gastric band and subcutaneous port components 43775 Laps Gstrc Rstrictiv Px Longitudinal Gastrectomy 43842 Gastric Restrictive Proc, W/O Gastric Bypass, Morbid Obesity; Vertical-Banded Gastroplasty 43843 Gastric Restrictve Proc, W/O Gastric Bypass, Morbid Obesity; Non-Vertical-Banded Gastroplasty 43845 Gastric Stapling Morbid Obesity 43846 Gastric Restrictve Procedre, W/Gastric Bypass, Morbd Obsty; W/Short Limb Roux-En-Y Gastroenterostmy 43847 Gastric Restrictive Proc, W/Gastric Bypass, Morbid Obesity; W/Small Bowel Reconstruction 43848 Revision, Gastric Restrictive Proc, Morbid Obesity (Sep Proc) 43860 Revision, Gastrojejunal Anastomosis W/Reconstruction W/Wo Part Gastrect/Bowel Resect; W/O Vagotomy 43865 Revision, Gastrojejunal Anastomosis W/Reconstruction W/Wo Part Gastrect/Bowel Resect; W/Vagotomy 43881 Implantation or Replacement of Gastric Neurostimulator Electrodes, Antrum, Open 43882 Revision or Removal of Gastric Neurostimulator Electrodes, Antrum, Open 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only

Page 7 of 40 Code Description 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only 46505 Chemodenervation of internal anal sphincter 46707 Rpr Anorectal Fistula W/ Plug 47370 Laparoscopy, Surgical, Ablation 1+ Liver Tumor(S); Radiofrequency 47371 Laparoscopy, Surgical, Ablation 1+ Liver Tumor(S); Cryosurgical 47380 Ablation, Open, 1+ Liver Tumor(S); Radiofrequency 47381 Ablation, Open, 1+ Liver Tumor(S); Cryosurgical 47382 Ablation, Open, 1+ Liver Tumor(S), Percutaneous, Radiofrequency 50250 Open Ablation Renal Mass Cryosurg Ultrasound 50593 Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy 51785 Needle Electromyography Studies, Anal &/Or Urethral Sphincter, Any Technique 51792 Stimulus Evoked Response 52441 Cysto Insertion Transprostatic Implant Single 52442 Cysto Insertion Transprostatic Implant Ea Addl 52647 Non-Contact Laser Coagulation, , W/Control Postop Bleed, Complete 52648 Contact Laser Vapor, W/Wo Transurethral Resection Prostate, W/Control Postop Bleed, Complete

52649 Laser enucleation of the prostate with morcellation including control of postoperative bleeding, complete (, me 53850 Transurethral Destruction, Prostate Tissue; Microwave Thermotherapy 53852 Transurethral Destruction, Prostate Tissue; Radiofrequency Thermotherapy 53854 Trurl Dstrj Prst8 Tiss Rf Wv Thermotherapy 54125 Amputation, Penis; Complete 54230 Injection Proc, Corpora Cavernosography 54231 Dynamic Cavernosometry W/Injection Vasoactive Drugs 54235 Injection, Corpora Cavernosa W/Pharmacologic Agent(S) 54240 Penile Plethysmography 54250 Nocturnal Penile Tumescence &/Or Rigidity Test 54360 Plastic Operation, Penis To Correct Angulation 54400 Insertion, Penile Prosthesis; Non-Inflatable (Semi-Rigid) 54401 Insertion, Penile Prosthesis; Inflatable (Self-Contained) 54405 Insertion, (Multi-Component) Inflatable Penile Prosthesis 54408 Repair Component(S) Multi-Component, Inflatable Penile Prosthesis 54410 Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Same Session 54411 Removal & Replacement, Multi-Component Inflatable Penile Prosthesis, Infected, W/ Irrig & Debride 54416 Removal & Replacement, Non-Inflatable (Semi-Rigid)/Inflatable (Self-Contained) Penile Prosthesis 54417 Removal & Replace, Non-Inflatable/Inflatable Penile Prosthesis Infect, W/Irrig & Debride 54440 Plastic Operation, Penis, Injury 54520 , Simple, W/Wo Prosthesis, Scrotal/Inguinal Approach 54660 Insertion, Testicular Prosthesis (Sep Proc) 54690 Laparoscopy, Surgical; Orchiectomy 55180 Scrotoplasty; Complicated 55866 Laps Prstect Retropubic Rad W/Nrv Sparing Robot 55870 Electroejaculation 55873 Cryosurg Ablation Prostate Us & Monitoring 55899 Unlisted Proc, Male Genital System 56625 Vulvectomy Simple; Complete 56800 Plastic Repair, Introitus 56805 Clitoroplasty, Intersex State 56810 Perineoplasty, Repair, Perineum, Nonobstetrical (Sep Proc) 57110 Vaginectomy, Complete Removal, Vaginal Wall 57291 Construction, Artificial ; W/O Graft 57292 Construction, Artificial Vagina; W/Graft 57295 Revision (including removal) of prosthetic vaginal graft, vaginal approach 57296 Revision (including Removal) of Prosthetic Vaginal Graft; Open Abdominal Approach 57335 Vaginoplasty, Intersex State 58150 Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S)

Page 8 of 40 Code Description 58152 Total Abdominal Hysterectomy W/Wo Removal Tube(S)/Ovary(S); W/Colpo-Urethrocystopexy 58180 Supracervical Abdominal Hysterectomy, W/Wo Removal Tube(S)/Ovary(S) 58200 Total Abdominal Hysterectomy, W/Partial Vaginect, W/Pelvic Node Sample, W/Wo Rem Tubes/Ovaries 58210 Radical Abdominal Hysterectomy W/Bilat Pelvic Lymphadenectomy 58240 Pelvic Exenteration, Gynecologic Malignancy 58260 Vaginal Hysterectomy, Uterus 250 Gms/< 58262 Vaginal Hysterectomy, Uterus 250 Gms/<; W/Removal, Tube(S) & Ovary(S) 58263 Vaginal Hysterectomy, Uterus 250 Gms/<; W/Removal, Tube(S) & Ovary(S), W/Repair Of Enterocele 58267 Vaginal Hysterectomy, Uterus 250 Gms/<; W/Colpo-Urethrocystopexy W/Wo Endoscopic Control 58270 Vaginal Hysterectomy, Uterus 250 Gms/<; W/ Repair Of Enterocele 58275 Vaginal Hysterectomy, W/Total/Partial Vaginectomy 58280 Vaginal Hysterectomy; W/Total/Partial Vaginectomy; W/Repair, Enterocele 58285 Vaginal Hysterectomy; Radical 58290 Vaginal Hysterectomy, Uterus >250 Gms; 58291 Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) 58292 Vaginal Hysterectomy, Uterus >250 Gms; W/Removal, Tube(S) &/Or Ovary(S) W/Repair Of Enterocele 58293 Vaginal Hysterectomy, Uterus >250 Gms; W/Colpo-Urethrocystopexy W/Wo Endoscopic Control 58294 Vaginal Hysterectomy, Uterus >250 Gms; W/Repair Of Enterocele 58321 Artificial Insemination; Intra-Cervical 58322 Artificial Insemination; Intra-Uterine 58323 Sperm Washing, Artificial Insemination 58345 Transcervical Introduction, Fallopian Tube Catheter, W/Wo Hysterosalpingography 58350 Chromotubation, Oviduct, W/Matls 58541 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 g or Less; 58542 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus 250 g or Less; with Removal of Tube(s) and/or Ovary(s) 58543 Laparoscopy, Surgical, Supracervical Hysterectomy, for Uterus Greater Than 250 g 58544 Laparoscopy, Surg, Supracerv Hysterectomy, Uterus > 250 g; with Removal of Tube(s) and/or Ovary(s) Laparoscopy, Surg, w Rad Hysterectomy, w Bilat Totl Pelv Lymphadenectmy & Lymph Node Sampling, w Removl Tubes & 58548 Ovaries 58550 Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/< 58552 Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus 250gms/<; W/Removal, Tube(S) &/Or Ovary(S) 58553 Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms 58554 Laparoscopy, Surg, W/Vaginal Hysterectomy, Uterus >250gms; W/Remove Tube(S) &/Or Ovary(S) 58570 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less 58571 Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58572 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g 58573 Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 58578 Unlisted Proc, Laparoscopy, Uterus 58752 Tubouterine Implantation 58760 Fimbrioplasty 58953 Bilat Salpingo-Oophorect W/Omentect, Total Abdom Hyster & Radical Dissect Debulk 58954 Bilat Salping-Oophorec W/Omentec, Tl Abd Hyst & Radcl Dissec, Debul; W/Pelv & Ltd Paraaortic Lymp 58956 Bilateral Salpingo-Oophorectomy With Total Omentectomy, Total Abdominal Hysterectomy For Malignancy 58970 Follicle Puncture, Oocyte Retrieval, Any Method 58974 Embryo Transfer, Intrauterine 58976 Gamete, Zygote/Embryo Intrafallopian Transfer, Any Method 59525 Subtotal/Total Hysterectomy After Cesarean Delivery 61215 Insertion, Subq Reservoir/Pump/Infusion System, Ventricular Catheter 61630 Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous 61635 Transcatheter placement of intravascular stent(s), intracranial, including balloon angioplasty, if performed 61640 Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel 61641 Perq Balo Dila Ic Vspsm Ea Vsl Sm Vasc Ter 61642 Perq Balo Dila Ic Vspsm Ea Vsl Diff Vasc Ter

61863 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; First Array

61864 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, wo Intraop Microelectrode Recording; ea addl Array

Page 9 of 40 Code Description

61867 Burr Hole Craniotomy with Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; First Array

61868 Burr Hole Craniotomy w Implantation of Subcortical Electrode Array, w Intraop Microelectrode Recording; ea addl Array 61870 Craniectomy, Implantation, Neurostimulator Electrodes, Cerebellar; Cortical 61875 Crnec Impltj Nstim Eltrd Cerebellar Subcortical 61885 Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection Sngle Electrod Array 61886 Subq Placement Cranial Neurostimulator Pulse Generator/Receiver; W/Connection 2+ Electrode Arrays 62263 Lysis, Perq, Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 2 Days/> 62264 Lysis, Perq Epidural Adhesions, Solution Injection/Mechanical W/Radiologic Localization; 1 Day 62287 Dcmprn Perq Nucleus Pulposus 1/> Levels Lumbar 62290 Injection, Diskography, Each Level; Lumbar 62291 Injection, Diskography, Each Level; Cervical/Thoracic 62292 Injection, Chemonucleolysis, W/Diskography, Lumbar 62320 Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/O Img Gdn 62321 Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn 62322 Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn 62323 Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn 62324 Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/O Img Gdn 62325 Njx Dx/Ther Sbst Intrlmnr Crv/Thrc W/Img Gdn 62326 Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/O Img Gdn 62327 Njx Dx/Ther Sbst Intrlmnr Lmbr/Sac W/Img Gdn 62350 Implant/Revisn/Reposition Intrathecal/Epidural Catheter, Externl Reservor/Infusion Pump; W/O Laminct 62351 Implant/Revisn/Reposition Intrathecal/Epidural Catheter, Externl Reservor/Infusion Pump; W/Laminect 62360 Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Subq Reservoir 62361 Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Non-Programmable Pump 62362 Implantation/Replace, Device, Intrathecal/Epidural Drug Infusion; Programmable Pump 63001 Laminectomy, W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Cervical 63003 Laminectomy, W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Thoracic 63005 Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Lumbar 63011 Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Sacral 63012 Laminectomy W/Removal, Abnormal Facets, Lumbar 63015 Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; Cervical 63016 Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; Thoracic 63017 Laminectomy W/O Facetectomy/Foraminotomy/Diskectomy, > 2 Segments; Lumbar 63020 Laminotomy W/Partial Facetectomy/Foraminotomy/Herniated Diskectomy; 1 Interspace, Cervical 63030 Laminotomy W/Partial Facetectomy/Foraminotomy/Herniated Diskectomy; 1 Interspace, Lumbar 63035 Laminotomy W/Partial Facetectomy/Foraminotomy/Herniated Diskectmy; Add'l Interspace, Cervical/Lumbar 63040 Laminotomy W/Partl Facetectmy/Foramnotmy/Herniated Diskect, Re-Exploratn, Sngle Interspc; Cervical 63042 Laminotomy W/Partl Facetectomy/Foraminotomy/Herniated Diskect, Re-Explor, Sngle Interspc; Lumbar 63043 Lamot Prtl Ffd Hrna8 Reexpl 1 Ntrspc Ea Crv 63044 Lamot W/Prtl Ffd Hrna8 Reexpl 1 Ntrspc Ea Lmbr 63045 Laminectomy, Facetectomy & Foraminotomy, 1 Segment; Cervical 63046 Laminectomy, Facetectomy & Foraminotomy, 1 Segment; Thoracic 63047 Laminectomy. Facetectomy & Foraminotomy, 1 Segment; Lumbar 63048 Laminectomy, Facetectomy & Foraminotomy; Add'l Segment, Cervical/Thoracic/Lumbar 63050 Laminoplasty, Cervical, With Decompression Of The Spinal Cord, Two Or More Vertebral Segments; 63055 Transpedicular Approach, 1 Segment; Thoracic 63056 Transpedicular Approach, 1 Segment; Lumbar (Transfacet/Lateral Extraforaminal) 63057 Transpedicular Approach, Add'l Segment; Thoracic/Lumbar 63064 Costovertebral Approach, Thoracic; 1 Segment 63066 Costovertebral Approach, Thoracic; Add'l Segment 63075 Diskectomy, Anterior; Cervical, 1 Interspace 63076 Diskectomy, Anterior; Cervical, Add'l Interspace 63077 Diskectomy, Anterior; Thoracic, 1 Interspace 63078 Diskectomy, Anterior; Thoracic, Add'l Interspace 63081 Vertebral Corpectomy, Anterior; Cervical, 1 Segment

Page 10 of 40 Code Description 63082 Vertebral Corpectomy, Anterior; Cervical, Add'l Segment 63085 Vertebral Corpectomy, Transthoracic; Thoracic, 1 Segment 63086 Vertebral Corpectomy, Transthoracic; Thoracic, Add'l Segment 63087 Vertebral Corpectomy, Thoracolumbar, Lower Thoracic/Lumbar; 1 Segment 63088 Vertebral Corpectomy, Thoracolumbar, Lower Thoracic/Lumbar; Add'l Segment 63090 Vertebral Corpectomy, Transperitoneal/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; 1 Segment 63091 Vertebral Corpectomy, Trans/Retroperitoneal, Lower Thoracic/Lumbar/Sacral; Add'l Segment

63101 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Thoracic, Sgl Segment

63102 Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression of Spinal Cord/Nerve Roots; Lumbar, Sgl Segment Vertebral Corpectomy, Lateral Extracavitary Approach w Decompression Spinal Cord/Nerve Rts; Thoracic/Lumbar, ea addl 63103 Seg 63170 Laminectomy W/Myelotomy, Cervical, Thoracic/Thoracolumbar 63172 Laminectomy W/Drainage, Intramedullary Cyst/Syrinx; To Subarachnoid Space 63173 Laminectomy W/Drainage, Intramedullary Cyst/Syrinx; To Peritoneal Space 63180 Laminectomy/Section, Dentate Ligaments, Cervical; 1/2 Segments 63182 Laminectomy/Section, Dentate Ligaments, Cervical; > 2 Segments 63185 Laminectomy W/Rhizotomy; 1/2 Segments 63190 Laminectomy W/Rhizotomy; > 2 Segments 63191 Laminectomy W/Section, Spinal Accessory Nerve 63194 Laminectomy W/Cordotomy, W/Section, One Spinothalamic Tract, 1 Stage; Cervical 63195 Laminectomy W/Cordotomy, W/Section, One Spinothalamic Tract, 1 Stage; Thoracic 63196 Laminectomy W/Cordotomy, W/Section, Both Spinothalamic Tracts, 1 Stage; Cervical 63198 Laminectomy W/Cordotomy, W/Section, Both Spinothalamic Tracts, 2 Stages Within 14 Days; Cervical 63199 Laminectomy W/Cordotomy, W/Section, Both Spinothalamic Tracts, 2 Stages Within 14 Days; Thoracic 63200 Laminectomy, W/Release, Tethered Spinal Cord, Lumbar 63250 Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Cervical 63251 Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Thoracic 63252 Laminectomy, Excision/Occlusion, Avm, Spinal Cord; Thoracolumbar 63265 Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Cervical 63267 Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Lumbar 63268 Laminectomy, Excision, Non-Neoplastic Lesion, Extradural; Sacral 63270 Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Cervical 63271 Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Thoracic 63272 Laminectomy, Excision, Intraspinal Lesion Other Than Neoplasm, Intradural; Lumbar 63286 Laminectomy, Bx/Excision, Intraspinal Neoplasm; Intradural, Intramedullary, Thoracic 63300 Vertebral Corpectomy, 1 Segment; Extradural, Cervical 63301 Vertebral Corpectomy, 1 Segment; Extradural, Thoracic, Transthoracic Approach 63302 Vertebral Corpectomy, 1 Segment; Extradural, Thoracic, Thoracolumbar Approach 63303 Vertebral Corpectomy, 1 Segment; Extradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach 63304 Vertebral Corpectomy, 1 Segment; Intradural, Cervical 63305 Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Transthoracic Approach 63306 Vertebral Corpectomy, 1 Segment; Intradural, Thoracic, Thoracolumbar Approach 63307 Vertebral Corpectomy, 1 Segment; Intradural, Lumbar/Sacral, Transperitoneal/Retroperitoneal Approach 63308 Vertebral Corpectomy, Add'l Segment 63650 Percutaneous Implantation, Neurostimulator Electrode Array, Epidural 63655 Laminectomy, Implantation, Neurostimulator Electrodes, Plate/Paddle, Epidural 63685 Incision/Placement, Spinal Neurostimulator Pulse Generator/Receiver 64479 Njx Anes&/Strd W/Img Tfrml Edrl Crv/Thrc 1 Lvl 64480 Njx Anes&/Strd W/Img Tfrml Edrl Crv/Thrc Ea Lvl 64483 Njx Anes&/Strd W/Img Tfrml Edrl Lmbr/Sac 1 Lvl 64484 Njx Anes&/Strd W/Img Tfrml Edrl Lmbr/Sac Ea Lvl 64490 Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 1 Level 64491 Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 2Nd Level 64492 Njx Dx/Ther Agt Pvrt Facet Jt Crv/Thrc 3+ Level 64493 Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 1 Level

Page 11 of 40 Code Description 64494 Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 2Nd Level 64495 Njx Dx/Ther Agt Pvrt Facet Jt Lmbr/Sac 3+ Level 64553 Percutaneous Implantation, Neurostimulator Electrodes; Cranial Nerve 64555 Percutaneous Implantation, Neurostimulator Electrodes; Peripheral Nerve, W/O Sacral Nerve 64561 Prq Impltj Neurostim Eltrd Sacral Nrve W/Imaging 64566 Post Tib Neurostimulation Prq Needle Electrode 64568 Inc Impltj Crnl Nrv Nstim Eltrds & Pulse Gener 64569 Revision/Replmt Nstim Crnl Eltrds 64575 Incision, Implantation, Neurostimulator Electrodes; Peripheral Nerve 64580 Incision, Implantation, Neurostimulator Electrodes; Neuromuscular 64581 Incision, Implantation, Neurostimulator Electrodes; Sacral Nerve (Transforaminal Placement) 64585 Revision/Removal, Peripheral Neurostimulator Electrodes 64590 Incision & Subq Placement, Peripheral Neurostimulator Pulse Generator/Receiver 64595 Revision/Removal, Peripheral Neurostimulator Pulse Generator/Receiver 64600 Destruction, Neurolytic, Trigeminal Nerve; Supraorbital/Infraorbital/Mental/Inferior Alveolar 64633 Dstr Nrolytc Agnt Parverteb Fct Sngl Crvcl/Thora 64634 Dstr Nrolytc Agnt Parverteb Fct Addl Crvcl/Thora 64635 Dstr Nrolytc Agnt Parverteb Fct Sngl Lmbr/Sacral 64636 Dstr Nrolytc Agnt Parverteb Fct Addl Lmbr/Sacral 64640 Destruction, Neurolytic; Other Peripheral Nerve/Branch 64642 CHEMODENERVATION ONE EXTREMITY 1-4 MUSCLE 64643 CHEMODENERVATION 1 EXTREMITY EA ADDL 1-4 MUSCLE 64644 CHEMODENERVATION 1 EXTREMITY 5 OR MORE MUSCLES 64645 CHEMODENERVATION 1 EXTREMITY EA ADDL 5/> MUSCLES 64646 CHEMODENERVATION OF TRUNK MUSCLE 1-5 MUSCLES 64647 CHEMODENERVATION OF TRUNK 6 OR MORE MUSCLES 64650 Chemodenervation of eccrine glands; both axillae 64653 Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 64716 Neuroplasty &/Or Transposition; Cranial Nerve (Specify) 64722 Decompression; Unspecified Nerve(S) (Specify) 64732 Transection/Avulsion; Supraorbital Nerve 64734 Transection/Avulsion; Infraorbital Nerve 64736 Transection/Avulsion; Mental Nerve 64738 Transection/Avulsion; Inferior Alveolar Nerve, Osteotomy 64740 Transection/Avulsion; Lingual Nerve 64742 Transection/Avulsion; Facial Nerve, Differential/Complete 64864 Suture, Facial Nerve; Extracranial 64865 Suture, Facial Nerve; Infratemporal, W/Wo Grafting 64866 Anastomosis; Facial-Spinal Accessory 64868 Anastomosis; Facial-Hypoglossal 64870 Anastomosis Facial-Phrenic 64999 Unlisted Proc, Nervous System 65765 Keratophakia 65767 Epikeratoplasty 66174 Trluml Dilat Aqueous Canal W/O Dev/Stnt 66175 Trluml Dilat Aqueous Canal W/Dev/Stnt 66180 Aqueous Shunt Extraoc Equat Plate Rsvr W/Graft 66183 INSERT ANTER DRAINAGE DEV W/O EXTRAOC RESERVOIR 67220 Destruction, Localized Lesion, Choroid; Photocoagulation, 1+ Sessions 67900 Repair, Brow Ptosis, (Supraciliary/Mid-Forehead/Coronal Approach) 67901 Repair, Blepharoptosis; Frontalis Muscle Technique W/Suture/Other Material 67902 Repair, Blepharoptosis; Frontalis Muscle W/Fascial Sling 67903 Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Int Approach 67904 Repair, Blepharoptosis; (Tarso) Levator Resection/Advancement, Ext Approach 67906 Repair, Blepharoptosis; Superior Rectus W/Fascial Sling 67908 Repair, Blepharoptosis; Conjunctivo-Tarso-Muller's Muscle-Levator Resection 67909 Reduction, Overcorrection, Ptosis

Page 12 of 40 Code Description 67911 Correction, Lid Retraction 67912 Correction of Lagophthalmos, with Implantation of Upper Eyelid Lid Load (Eg, Gold Weight) 67914 Repair, Ectropion; Suture 67915 Repair, Ectropion; Thermocauterization 67916 Repair, Ectropion; Excision Tarsal Wedge 67917 Repair, Ectropion; Extensive 67921 Repair, Entropion; Suture 67922 Repair, Entropion; Thermocauterization 67923 Repair, Entropion; Blepharoplasty, Excision Tarsal Wedge 67924 Repair, Entropion; Blepharoplasty, Extensive 67950 Canthoplasty (Reconstruction, Canthus) 67961 Excision/Repair, Eyelid; Up T0 One Quarter, Lid Margin 67966 Excision/Repair, Eyelid; > One Quarter, Lid Margin 69090 Ear Piercing 69300 Otoplasty, Protruding Ear, W/Wo Size Reduction 69710 Implantation/Replacement, Electromagnetic Bone Conduction Hearing Device, Temporal Bone 69711 Removal/Repair, Electromagnetic Bone Conduction Hearing Device, Temporal Bone 69714 Implantation, Osseointegrated Implant Temporal Bone; W/O Mastoidectomy 69715 Implantation, Osseointegrated Implant, Temporal Bone; W/Mastoidectomy 69717 Replacement, Osseointegrated Implant, Temporal Bone; W/O Mastoidectomy 69718 Replacement, Osseointegrated Implant, Temporal Bone; W/Mastoidectomy 69930 Cochlear Device Implantation, W/Wo Mastoidectomy 72295 Diskography, Lumbar, Radiological S&I 76948 Us Guidance, Aspiration, Ova, Imaging S&I 81162 Brca 81163 Brca1 Brca2 Gene Analysis Full Sequence Analysis 81164 Brca1 Brca2 Gene Analysis Full Dup/Del Analysis 81165 Brca1 Gene Analysis Full Sequence Analysis 81166 Brca1 Gene Analysis Full Dup/Del Analysis 81167 Brca2 Gene Analysis Full Dup/Del Analysis 81171 Aff2 Gene Analysis Eval Detect Abnormal Alleles 81172 Aff2 Gene Analysis Characterization Of Alleles 81173 Ar Gene Analysis Full Gene Sequence 81174 Ar Gene Analysis Known Familial Variant 81177 Atn1 Gene Analysis Eval Detect Abnormal Alleles 81178 Atxn1 Gene Analysis Eval Detect Abnormal Alleles 81179 Atxn2 Gene Analysis Eval Detect Abnormal Alleles 81180 Atxn3 Gene Analysis Eval Detect Abnormal Alleles 81181 Atxn7 Gene Analysis Eval Detect Abnormal Alleles 81182 Atxn8Os Gene Analysis Eval Detect Abnor Alleles 81183 Atxn10 Gene Analysis Eval Detc Abnormal Alleles 81184 Cacna1A Gene Analysis Eval Detect Abnor Alleles 81185 Cacna1A Gene Analysis Full Gene Sequence 81186 Cacna1A Gene Analysis Known Familial Variant 81187 Cnbp Gene Analysis Eval Detect Abnormal Alleles 81188 Cstb Gene Analysis Eval Detect Abnormal Alleles 81189 Cstb Gene Analysis Full Gene Sequence 81190 Cstb Gene Analysis Known Familial Variants 81200 Aspa Gene Analysis Common Variants 81201 Apc Gene Analysis Full Gene Sequence 81202 Apc Gene Analysis Known Familial Variants 81203 Apc Gene Analysis Duplication/Deletion Variants 81204 Ar Gene Analysis Characterization Of Alleles 81209 Blm Gene Analysis 2281Del6Ins7 Variant 81211 Brca1&Brca2 Full Seq Analys/Comm Dup/Del Brca 81212 Brca1 Brca 2 Gen Alys 185Delag 5385Insc 6174Delt 81213 Brca1&Brca2 Anal Uncommon Dup/Del Variants

Page 13 of 40 Code Description 81214 Brca1 Full Seq Anal&Common Dup/Del Variants 81215 Brca1 Gene Analysis Known Familial Variant 81216 Brca2 Gene Analysis Full Sequence Analysis 81217 Brca2 Gene Analysis Known Familial Variant 81220 Cftr Gene Analysis Common Variants 81224 Cftr Gene Analysis Intron 8 Poly-T Analysis 81225 Cyp2C19 Gene Analysis Common Variants 81226 Cyp2D6 Gene Analysis Common Variants 81233 Btk Gene Analysis Common Variants 81234 Dmpk Gene Analysis Eval Detect Abnormal Alleles 81236 Ezh2 Gene Analysis Full Gene Sequence 81237 Ezh2 Gene Analysis Common Variants 81239 Dmpk Gene Analysis Characterization Of Alleles 81241 F5 Coagulation Factor V Anal Leiden Variant 81242 Fancc Gene Analysis Common Variant 81251 Gba Glucosidase/Beta/Acid Anal Comm Variants 81252 Gjb2 Gene Analysis Full Gene Sequence 81253 Gjb2 Gene Analysis Known Familial Variants 81254 Gjb6 Gene Analysis Common Variants 81255 Hexa Gene Analysis Common Variants 81256 Hfe Hemochromatosis Gene Anal Common Variants 81257 Hba1/Hba2 Gene Analysis Common Deletions/Variant 81260 Ikbkap Gene Analysis Common Variants 81271 Htt Gene Analysis Detect Abnormal Alleles 81274 Htt Gene Analysis Characterization Alleles 81284 Fxn Gene Analysis Eval Detect Abnormal Alleles 81285 Fxn Gene Analysis Characterization Alleles 81286 Fxn Gene Analysis Full Gene Sequence 81288 Mlh1 Gene Analysis Promoter Methylation Analysis 81289 Fxn Gene Analysis Known Familial Variants 81290 Mcoln1 Mucolipin1 Gene Analysis Common Variants 81292 Mlh1 Gene Analysis Full Sequence Analysis 81293 Mlh1 Gene Analysis Known Familial Variants 81294 Mlh1 Gene Analysis Duplication/Deletion Variants 81295 Msh2 Gene Analysis Full Sequence Analysis 81296 Msh2 Gene Analysis Known Familial Variants 81297 Msh2 Gene Analysis Duplication/Deletion Variants 81298 Msh6 Gene Analysis Full Sequence Analysis 81299 Msh6 Gene Analysis Known Familial Variants 81300 Msh6 Gene Analysis Duplication/Deletion Varia 81305 Myd88 Gene Analysis P.Leu265 (L265P) Variant 81306 Nudt15 Gene Analysis Common Variants 81312 Pabpn1 Gene Analysis Eval Detc Abnormal Alleles 81317 Pms2 Gene Analysis Full Sequence 81318 Pms2 Gene Analysis Known Familial Variants 81319 Pms2 Gene Analysis Duplication/Deletion Variants 81320 Plcg2 Gene Analysis Common Variants 81321 Pten Gene Analysis Full Sequence Analysis 81322 Pten Gene Analysis Known Familial Variant 81323 Pten Gene Analysis Duplication/Deletion Variant 81324 Pmp22 Gene Anal Duplication/Deletion Analysis 81325 Pmp22 Gene Analysis Full Sequence Analysis 81326 Pmp22 Gene Analysis Known Familial Variant 81329 Smn1 Gene Analysis Dosage/Delet Alys W/Smn2 Alys 81330 Smpd1 Gene Analysis Common Variants 81333 Tgfbi Gene Analysis Common Variants 81336 Smn1 Gene Analysis Full Gene Sequence

Page 14 of 40 Code Description 81337 Smn1 Gene Analysis Known Familial Seq Variants 81343 Ppp2R2B Gene Analysis Eval Detc Abnormal Alleles 81344 Tbp Gene Analysis Eval Detect Abnormal Alleles 81345 Tert Gene Analysis Targeted Sequence Analysis 81381 Hla I Typing High Resolution 1 Allele/Allele Grp 81401 Molecular Pathology Procedure Level 2 81402 Molecular Pathology Procedure Level 3 81403 Molecular Pathology Procedure Level 4 81404 Molecular Pathology Procedure Level 5 81405 Molecular Pathology Procedure Level 6 81406 Molecular Pathology Procedure Level 7 81412 Ashkenazi Jewish Assoc Dsrdrs Gen Seq Anal 9 Gen 81413 Car Ion Chnnlpath Genomic Seq Alys Inc 10 Gns 81414 Car Ion Chnnlpath Dup/Del Gn Alys Panel 2 Genes 81443 Genetic Testing For Severe Inherited Conditions 81448 Hereditary Peripheral Neuropathy Gen Seq Pnl 81479 Unlisted Molelcular Pathology Procedure 81490 Autoimmune Rheumatoid Arthrts Analys 12 Biomrkrs 81493 Cor Art Disease Mrna Gene Expression 23 Genes 81503 Ova1, multimarker serum test for ovarian cancer 81518 Oncology Breast Mrna Gene Expression 11 Genes 81519 Oncology Breast Mrna Gene Expression 21 Genes 81520 Onc Breast Mrna Gene Xprsn Prfl Hybrd 58 Genes 81521 Onc Breast Mrna Microra Gene Xprsn Prfl 70 Genes 81525 Oncology Colon Mrna Gene Expression 12 Genes 81538 Oncology Lung Ms 8-Protein Signature 81596 Nfct Ds Chrnc Hcv 6 Biochem Assay Srm Alg Lvr 81599 Unlisted Multianalyte Assay Algorithmic Analysis 82642 Dihydrotestosterone (Dht) 83722 Dir Meas Lipoprotein Small Dense Ldl Cholesterol 84999 Unlisted Chemistry Proc 88380 Microdissection (Mechanical, Laser Capture) 88381 MICRODISSECTION PREP IDENTIFIED TARGET MANUAL 89240 Unlisted Miscellaneous Pathology Test 89250 Culture, Oocyte(S) 89251 Culture & Fertilization, Oocyte(S); W/Co-Culture 89253 Assisted Embryo Hatching, Microtechniques (Any Method) 89254 Oocyte Identification, Follicular Fluid 89255 Preparation, Embryo, Transfer (Any Method) 89257 Sperm Identification, Aspiration (Other Than Seminal Fluid) 89258 Cryopreservation; Embryo 89259 Cryopreservation; Sperm 89260 Sperm Isolation; Simple Prep, For Insemination/Diagnosis W/ 89261 Sperm Isolation; Complex Prep, For Insemination/Diagnosis W/Semen Analysis 89264 Sperm Identification, Testis Tissue, Fresh/Cryopreserved 89268 Insemination of Oocytes 89272 Extended Culture of Oocyte(s)/Embryo(s), 4-7 Days 89280 Assisted Oocyte Fertilization, Microtechnique; Less Than or Equal To 10 Oocytes 89281 Assisted Oocyte Fertilization, Microtechnique; Greater Than 10 Oocytes 89290 Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Less Than or Equal To 5 Embryos 89291 Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Greater Than 5 Embryos 89335 Cryopreservation, Reproductive Tissue, Testicular 89337 Cryopreservation Mature Oocyte(S) 89342 Storage, (Per Year); Embryo(s) 89343 Storage, (Per Year); Sperm/Semen 89344 Storage, (Per Year); Reproductive Tissue, Testicular/Ovarian 89346 Storage, (Per Year); Oocyte

Page 15 of 40 Code Description 89354 Thawing of Cryopreserved; Reproductive Tissue, Testicular/Ovarian 91110 Gi Imag Intraluminal Esophagus-Ileum W/I&R 91111 Gastrointestinal Tract Imaging Esophagus W/I&R 92970 Cardioassist-Method, Circulatory Assist; Internal 92971 Cardioassist-Method, Circulatory Assist; External 93228 Xtrnl Mobile Cv Telemetry W/I&Report 30 Days 93229 Xtrnl Mobile Cv Telemetry W/Technical Support 93580 Perc Transcatheter Closure, Congenital Interatrial Communication W/Implant 93583 PERCUTANEOUS TRANSCATHETER SEPTAL REDUCTION THER 93600 Bundle Of His Recording 93602 Intra-Atrial Recording 93603 Right Ventricular Recording 93609 Intraventricular &/Or Intra-Atrial Mapping, Tachycardia Site(S) W/Catheter Manipulation 93613 Intracardiac Electrophysiologic 3-Dimensional Mapping 93618 Induction, Arrhythmia, Electrical Pacing 93619 Electrophys Eval, W/Right Atrial/Ventricular Pace/Recording, Insertion Cath, W/O Arrhyth Induction 93620 Electrophys Eval, Insert Cath, W/Arrhyth Induction; W/Right Atrial/Ventricular Pace/Record 93621 Electrophys Eval, Insert Cath, W/Arrhyth Induction; W/Lt Atrial Pace/Record 93622 Electrophys Eval, Insert Cath, W/Arrythmia Induction; W/Lt Vent Pace/Record 93623 Programmed Stimulation & Pacing After Iv Drug 93624 Electrophys, Follow-Up Study W/Pacing & Recording W/Arrhyth Induction 93640 Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace 93641 Electrophys Eval, Single/Dual Pacing Cardio/Defib Leads, Initial Implant/Replace; W/Pulse Generator 93642 Ephys Eval Pacg Cvdfb Prgrmg/Reprgrmg Parameters 93650 Intracardiac Catheter Ablation, Atrioventricular Node Function/Conduction 93653 Ephys Eval W/ Ablation Supravent Arrhythmia 93654 EPHYS EVAL W/ABLATION VENTRICULAR TACHYCARDIA 93655 Icar Catheter Ablation Arrhythmia Add On 93656 EPHYS EVL TRNSPTL TX ATRIAL FIB ISOLAT PULM VEIN 93657 Ablate L/R Atrial Fibril W/ Isolated Pulm Vein 93702 Bis Extracellular Fluid Alys Lymphedema Assmnt 93750 Interrogation Vad In Prson W/Phys/Qhp Analysis 95076 Ingestion Challenge Test Initial 120 Minutes 95079 Ingestion Challenge Test Each Addl 60 Minutes 95165 Profes Svc, Supervis, Prepara, Provision, Antigens, Allergen Immunotherapy; Single/Multiple Antigens 95250 Cont Gluc Mntr Physician/Qhp Provided Equiptment 95251 Continuous Glucose Monitoring Analysis I&R 95803 Actigraphy Testing Recording Analysis I&R 95860 Emg, Needle; 1 Extremity W/Wo Related Paraspinal Areas 95861 Emg, Needle; 2 Extremities W/Wo Related Paraspinal Areas 95863 Emg, Needle; 3 Extremities W/Wo Related Paraspinal Areas 95864 Emg, Needle; 4 Extremities W/Wo Related Paraspinal Areas 95867 Emg, Needle; Cranial Nerve Supplied Muscle(S), Unilat 95868 Emg, Needle; Cranial Nerve Supplied Muscles, Bilat 95869 Emg, Needle; Thoracic Paraspinal Muscles, Excluding T1/T12 95870 Emg, Needle; 1 Extremity/Non-Limb (Unilat/Bilat), Non-Thoracic Paraspinal/Cranial Muscles/Sphincters 95872 Emg, Needle, 1 Fiber Electrode W/Quantitative Measurement, Jitter 95921 Testing, Autonomic Nervous System; Cardiovagal Innervation Parasympathetic 95922 Testing, Autonomic Nervous System; Sympathetic Adrenergic Function 95923 Testing, Autonomic Nervous System; Sudomotor 95925 Short-Latency Somatosensory Evoked Potential Study; Upper Limbs 95926 Short-Latency Somatosensory Evoked Potential Study; Lower Limbs 95927 Short-Latency Somatosensory Evoked Potential Study; Trunk/Head 95928 Central Motor Evoked Potential Study (Transcranial Motor Stimulation); Upper Limbs 95929 Central Motor Evoked Potential Study (Transcranial Motor Stimulation); Lower Limbs 95933 Orbicularis Oculi Reflex, By Electrodx Testing 95965 Magnetoencephalography (Meg), Record & Analysis; For Spontaneous Brain Magnetic Activity

Page 16 of 40 Code Description 95966 Magnetoencephalography (Meg), Record & Analysis; For Evoked Magnetic Fields, Single Modality 95967 Magnetoencephalography (Meg), Record & Analysis; For Evoked Magnetic Fields, Ea Add'l Modality 95978 Elec Alys Nstim Pls Gen Cplx Dp Brn 1St Hr 95980 ELEC ALYS NSTIM PLS GEN GASTRIC INTRAOP W/PRGRMG 95981 ELEC ALYS NSTIM GEN GASTRIC SBSQ W/O REPRGRMG 95982 ELEC ALYS NSTIM PLS GEN GASTRIC SBSQ W/REPRGRMG 96002 Dynamic Surface Electromyography, Walking/Functional Activities, 1-12 Muscles 96121 Neurobehavioral Status Xm Phys/Qhp Ea Addl Hour 96130 Psychological Tst Eval Svc Phys/Qhp First Hour 96131 Psychological Tst Eval Svc Phys/Qhp Ea Addl Hour 96132 Neuropsychological Tst Eval Phys/Qhp 1St Hour 96133 Neuropsychological Tst Eval Phys/Qhp Ea Addl Hr 96136 Psyl/Nrpsycl Tst Phys/Qhp 2+ Tst 1St 30 Min 96137 Psycl/Nrpsycl Tst Phys/Qhp 2+ Tst Ea Addl 30 Min 96138 Psycl/Nrpsycl Tst Tech 2+ Tst 1St 30 Min 96139 Psycl/Nrpsycl Tst Tech 2+ Tst Ea Addl 30 Min 96146 Psycl/Nrpsycl Tst Elec Platform Auto Result 97151 Behavior Id Assessment By Phys/Qhp Ea 15 Min 97152 Behavior Id Support Assmt By 1 Tech Ea 15 Min 97153 Adaptive Behavior Tx By Protocol Tech Ea 15 Min 97154 Group Adaptive Bhv Tx By Protocol Tech Ea 15 Min 97155 Adapt Bhv Tx Prtcl Modificaj Phys/Qhp Ea 15 Min 97156 Family Adapt Bhv Tx Gdn Phys/Qhp Ea 15 Min 97157 Multiple Fam Group Bhv Tx Gdn Phys/Qhp Ea 15 Min 97158 Grp Adapt Bhv Prtcl Modifcaj Phys/Qhp Ea 15 Min 99183 Phys/Qhp Attn&Supvj Hyprbaric Oxygen Tx /Session A4210 Nonneedle Injection Device A4257 Replacement lens shield cartridge for use with laser skin piercing device, each A4556 Electrodes, Pair A4557 Lead Wires, Pair A4563 Rectal Cntrl Sys Vag Insrt Lt Use Any Type Ea A4575 Hyperbaric O2 Chamber Disps A4618RR Breathing Circuits A4630 Repl Bat T.E.N.S. Own By Pt A4635RR Underarm Crutch Pad A4636RR Handgrip For Cane Etc A4637RR Repl Tip Cane/Crutch/Walker A4638RR Replacement battery for patient-owned ear pulse ge A4639RR Replacement Pad For Infrared Heating Pad System, E A4640RR Alternating Pressure Pad A5514 Diab Only Mx Den Insrt Direct Carv Custom Fab Ea A6000 Non-contact wound warming wound cover for use with the non-contact wound warming device and warming card A6550 Dressing set for negative pressure wound therapy electrical pump, stationary or portable, each A7017RR Nebulizer Not Used W Oxygen A7025 High Frequency Chest Wall Oscillation System Vest, Replacement For Use A8000RR Helmet Protectve Soft Prefab Component Accssries A8001RR Helmet Protectve Hard Prefab Component Accssries A8002 Soft protect helmet custom A8003 Hard protect helmet custom A8004RR Soft Interface For Helmet Replacement Only A9272 WND SUCT DISPBL DSG ALL ACC & CMPNT ANY TYP EA A9280 Alert or alarm device, not otherwise classified B9002 Enteral Nutrition Infusion Pump Any Type B9004 Parenteral Infus Pump Portab B9006 Parenteral Infus Pump Statio C1721 Cardioverter-defibrillator, dual chamber (implantable) C1722 Cardioverter-defibrillator, single chamber (implantable)

Page 17 of 40 Code Description C1767 Generator, neurostimulator (implantable) C1772 Infusion pump, programmable ( implantable) C1777 Lead, cardioverter-defibrillator, endocardial single coil (implantable) C1778 Lead, neurostimulator (implantable) C1816 Receiver and/or transmitter, neurostimulator (implantable) C1820 Gen Neurostim W/Rechrg Battery & Charging System C1821 Interspinous implant C1822 Gen Neurostim High Freq Recharg Batt & Charg Sys C1823 Generatr Neurostim Non-Rechrgabl Tv S&Stim Leads C1882 Cardioverter-defibrillator, other than single or dual chamber (implantable) C1883 Adaptor/ extension, pacing lead or neurostimulator lead (implantable) C1891 Infusion pump, non-programmable, permanent (implantable) C1895 Lead, cardioverter-defibrillator, endocardial dual coil (implantable) C1896 Lead cardioverter- defibrillator, other than endocardial single or dual coil (implantable) C1897 Lead, neurostimulator test kit (implantable) C2626 Infusion pump, non-programmable, temporary (implantable) C9752 Destruc Io Basiverteb Nerv 1St 2 Vert B Lumb/Sac C9753 Destruc Io Basiverteb Nerv Ea Add Vert Body L/S C9754 Creation Av Fistula Percutaneous; Dirct Any Site D7995 Synthetic Graft - Mandible Or Facial Bones, By Report D7996 Implant-Mandible For Augmentation Purposes (Excluding Alveolar Ridge), By Report E0100RR Cane Adjust/Fixed With Tip E0105RR Cane Adjust/Fixed Quad/3 Pro E0110RR Crutch Forearm Pair E0111RR Crutch Forearm Each E0112RR Crutch Underarm Pair Wood E0113RR Crutch Underarm Each Wood E0114RR Crutch Underarm Pair No Wood E0116RR Crutch Underarm Each No Wood E0117RR Crutch, Underarm, Articulating, Spring Assisted, E E0130RR Walker Rigid Adjust/Fixed Ht E0135RR Walker Folding Adjust/Fixed E0140RR Walker, with trunk support, adjustable or fixed he E0141RR Rigid Walker Wheeled Wo Seat E0143RR Walker Folding Wheeled W/O S E0144RR Enclosed Walker W Rear Seat E0147RR Walker Variable Wheel Resist E0148RR Heavyduty Walker No Wheels E0149RR Heavy Duty Wheeled Walker E0153RR Forearm Crutch Platform Atta E0154RR Walker Platform Attachment E0155RR Walker Wheel Attachment,Pair E0156RR Walker Seat Attachment E0157RR Walker Crutch Attachment E0158RR Walker Leg Extenders Set Of4 E0159RR Brake For Wheeled Walker E0160RR Sitz Type Bath Or Equipment E0161RR Sitz Bath/Equipment W/Faucet E0162RR Sitz Bath Chair E0163RR Commode Chair Stationry Fxd E0165RR Commode Chair Stationry Det E0167RR Commode Chair Pail Or Pan E0168RR Heavyduty/Wide Commode Chair E0170RR Commode Chair Intgr Seat Lift Mech Elec Any Type E0171RR Commode Chair Intgr Seat Lift Mech Nonelec Any E0175RR Commode Chair Foot Rest E0181RR Press Pad Alternating W/ Pum

Page 18 of 40 Code Description E0182RR Pressure Pad Alternating Pum E0184RR Dry Pressure Mattress E0185RR Gel Pressure Mattress Pad E0186RR Air Pressure Mattress E0187RR Water Pressure Mattress E0188RR Synthetic Sheepskin Pad E0189RR Lambswool Sheepskin Pad E0191RR Protector Heel Or Elbow E0193 Powered Air Flotation Bed E0194RR Air Fluidized Bed E0196RR Gel Pressure Mattress E0197RR Air Pressure Pad For Mattres E0198RR Water Pressure Pad For Mattr E0199RR Dry Pressure Pad For Mattres E0200RR Heat Lamp Without Stand E0202RR Phototherapy Light W/ Photom E0205RR Heat Lamp With Stand E0210RR Electric Heat Pad Standard E0215RR Electric Heat Pad Moist E0217RR Water Circ Heat Pad W Pump E0225RR Hydrocollator Unit Non-contact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and E0231 wou E0235RR Paraffin Bath Unit Portable E0236RR Pump For Water Circulating P E0239RR Hydrocollator Unit Portable E0249RR Pad Water Circulating Heat Unit Replacement Only E0250RR Hosp Bed Fixed Ht W/ Mattres E0251RR Hosp Bed Fixd Ht W/O Mattres E0255RR Hospital Bed Var Ht W/ Mattr E0256 Hospital Bed Var Ht W/O Matt E0260RR Hosp Bed Semi-Electr W/ Matt E0261 Hosp Bed Semi-Electr W/O Mat E0265RR Hosp Bed Total Electr W/ Mat E0266 Hosp Bed Total Elec W/O Matt E0271RR Mattress Innerspring E0272RR Mattress Foam Rubber E0275RR Bed Pan Standard E0276RR Bed Pan Fracture E0277 Powered Pres-Redu Air Mattrs E0280RR Bed Cradle E0290RR Hosp Bed Fx Ht W/O Rails W/M E0291RR Hosp Bed Fx Ht W/O Rail W/O E0292RR Hosp Bed Var Ht W/O Rail W/O E0293RR Hosp Bed Var Ht W/O Rail W/ E0294RR Hosp Bed Semi-Elect W/ Mattr E0295RR Hosp Bed Semi-Elect W/O Matt E0296RR Hosp Bed Total Elect W/ Matt E0297RR Hosp Bed Total Elect W/O Mat E0300RR Ped Crib Hos Grade Fully Enc W/Wo Top Enc E0301 Hospital bed, heavy duty, extra wide, with weight capacity 350-600 lbs w/rails w/o mattress E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs w/rails w/o mattress E0303RR Hospital bed, heavy duty, extra wide, with weight E0304RR Hospital bed, extra heavy duty, extra wide, with w E0305RR Rails Bed Side Half Length E0310RR Rails Bed Side Full Length E0316RR Safety enclosure frame/canopy for use with hospita

Page 19 of 40 Code Description E0325RR Urinal Male Jug-Type E0326RR Urinal Female Jug-Type E0328 HOSPITAL BED PEDIATRIC MANUAL INCLUDES MATTRESS E0371 Nonpower Mattress Overlay E0372 Powered Air Mattress Overlay E0373RR Nonpowered Pressure Mattress E0424RR Stationary Compressed Gas 02 E0431RR Portable Gaseous 02 E0433RR Portabl Liquid Oxygen Sys Rental; Home Liquefier E0434RR Portable Liquid 02 E0439RR Stationary Liquid 02 E0445RR Oximeter Device For Measuring Blood Oxygen Levels E0446 Topical Oxygen Delivery System Nos Incl Supplies E0447 Prtb O C Lqd 1 Mo Spl=1 U Prsc Amt R/N Excd 4Lpm E0462RR Rocking Bed W/ Or W/O Side R E0465 Home Ventilator Any Type Used W/Invasive Intf E0466 Home Ventilator Any Type Used W/Non-Invasv Intf E0467 Home Ventilator Multi-Function Respiratory Devc E0472RR Respiratory assist device, bi-level pressure capab E0480 Percussor Elect/Pneum Home M E0481RR Intrapulmonary percussive ventilation system and r E0482RR Cough stimulating device, alternating positive and E0483 High Frequency Chest Wall Oscillation System Ea E0484RR Oscillatory Positive Expiratory Pressure Device, N E0485RR Orl Devc/Appl Rduc Up Arway Collapsibility Prfab E0486RR Orl Devc/Appl Rduc Up Airway Collapsibility Cstm E0500 Ippb All Types E0550RR Humidif Extens Supple W Ippb E0560RR Humidifier Supplemental W/ I E0565 Compressor Air Power Source E0570RR Nebulizer With Compression E0572RR Aerosol Compressor Adjust Pr E0574RR Ultrasonic Generator W Svneb E0575 Nebulizer Ultrasonic E0580RR Nebulizer For Use W/ Regulat E0585RR Nebulizer W/ Compressor & He E0600RR Suction Pump Portab Hom Modl E0602RR Breast Pump E0604RR Breast pump, heavy duty, hospital grade,piston ope E0605RR Vaporizer Room Type E0606RR Drainage Board Postural E0607RR Blood Glucose Monitor Home E0610RR Pacemaker Monitr Audible/Vis E0615RR Pacemaker Monitr Digital/Vis E0617RR Automatic Ext Defibrillator E0618RR Apnea Monitor, Without Recording Feature E0619RR Apnea Monitor, With Recording Feature E0620 Skin piercing device for collection of capillary blood, laser, each E0621RR Patient Lift Sling Or Seat E0627RR Seat Lift Mechanism Electric Any Type E0629RR Seat Lift Mechanism Non-Electric Any Type E0630 Patient Lift Hydraulic E0635RR Patient Lift Electric E0636RR Multipositional Patient Support System, With Integ E0637 Comb Sit Stand Frame/Table Sys Seatlift Feature E0638 Standing Frame/Table Sys One Position Any Sz E0639RR Moveable patient lift system

Page 20 of 40 Code Description E0640RR Fixed patient lift system E0641 Standing Frame/Table Sys Multi-Position Any Sz E0650 Pneuma Compresor Non-Segment E0651RR Pneum Compressor Segmental E0652RR Pneum Compres W/Cal Pressure E0655RR Pneumatic Appliance Half Arm E0656RR Seg Pneumat Appliance Use W/Pneumat Comprs Trunk E0657RR Seg Pneumat Appliance Use W/Pneumat Comprs Chest E0660RR Pneumatic Appliance Full Leg E0665RR Pneumatic Appliance Full Arm E0666RR Pneumatic Appliance Half Leg E0667RR Seg Pneumatic Appl Full Leg E0668RR Seg Pneumatic Appl Full Arm E0669RR Seg Pneumatic Appli Half Leg E0670RR Seg Pneu Applinc Pneu Comprs In 2 Full Legs Trnk E0671RR Pressure Pneum Appl Full Leg E0672RR Pressure Pneum Appl Full Arm E0673RR Pressure Pneum Appl Half Leg E0675RR Pneumatic compression device, high pressure, rapid E0691RR Uv Light Tx Sys Bulb/Lamp Timer; Tx 2 Sq Ft/Less E0692RR Ultraviolet Light Therapy System Panel, Includes B E0693RR Ultraviolet Light Therapy System Panel, Includes B E0694RR Ultraviolet Multidirectional Light Therapy System E0705RR Transer Device Any Type Each E0730 Tens Four Lead E0740RR Non-Impl Pelv Flr Electrical Stimulator Cmpl Sys E0744RR Neuromuscular Stim For Scoli E0745RR Neuromuscular Stim For Shock E0747 Elec Osteogen Stim Not Spine E0748 Elec Osteogen Stim Spinal E0749 Elec Osteogen Stim Implanted E0760 Osteogen Ultrasound Stimltor E0762RR Transcut Elec Joint Stim Devc Sys Incl All Accss E0764RR Func Neuromusc Stim Musc Ambul Cmpt Cntrl Sc Inj E0765RR Nerve Stimulator For Tx N&V E0776RR Iv Pole E0779RR Amb Infusion Pump Mechanical E0781 External Ambulatory Infus Pu E0782 Non-Programble Infusion Pump E0783 Programmable Infusion Pump E0786RR Implantable Pump Replacement E0791 Parenteral Infusion Pump Sta E0840RR Tract Frame Attach Headboard E0849 Cervical pneum trac equip E0850RR Traction Stand Free Standing E0855 Cervical Traction Equipment E0856RR Cervical Traction Device Inflatable Air Bladder E0860RR Tract Equip Cervical Tract E0870RR Tract Frame Attach Footboard E0880RR Trac Stand Free Stand Extrem E0890RR Traction Frame Attach Pelvic E0900RR Trac Stand Free Stand Pelvic E0910RR Trapeze Bar Attached To Bed E0911 HD trapeze bar attach to bed E0912 HD trapeze bar free standing E0920RR Fracture Frame Attached To B E0930RR Fracture Frame Free Standing

Page 21 of 40 Code Description E0935RR Exercise Device Passive Moti E0940RR Trapeze Bar Free Standing E0941RR Gravity Assisted Traction De E0942RR Cervical Head Harness/Halter E0944RR Pelvic Belt/Harness/Boot E0945RR Belt/Harness Extremity E0946 Fracture Frame Dual W Cross E0947RR Fracture Frame Attachmnts Pe E0948RR Fracture Frame Attachmnts Ce E0950 Tray E0951RR Loop Heel E0952RR Loop Tie E0953 Wheelchair Ac Lat Thigh/Knee Supp Any Type Ea E0954 Wheelchair Accessory Foot Box Any Type Each Foot E0955 Wheelchair accessory, headrest, cushioned, prefabricated, including fixed mounting hardware, each E0956 Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mounting hardware, each E0957 Wheelchair accessory, medial thigh support, prefabricated, including fixed mounting hardware, each E0958RR Whlchr Att- Conv 1 Arm Drive E0959RR Amputee Adapter E0960RR Wheelchair accessory, shoulder harness/straps or c E0961RR Wheelchair Brake Extension E0966RR Wheelchair Head Rest Extensi E0967RR Mnl Whlchr Ac Hnd Rim Proj Any Typ Repl Only Ea E0968RR Wheelchair Commode Seat E0969RR Wheelchair Narrowing Device E0971RR Wheelchair Anti-Tipping Devi E0973RR Wheelchair Adjustabl Height E0974RR Wheelchair Grade-Aid E0978RR Wheelchair Belt W/Airplane B E0980RR Wheelchair Safety Vest E0981RR Wheelchair accessory, seat upholstery, replacement E0982RR Wheelchair accessory, back upholstery, replacement E0983RR Manual wheelchair accessory, power add-on to conve E0984RR Manual wheelchair accessory, power add-on to conve E0985RR Wheelchair accessory, seat lift mechanism E0986RR Mnl Wheelchair Acss Push-Rim Act Pwr Assist Sys E0988RR Manual Wc Accessory Levr-Activatd Whl Drive Pair E0990 Wheelchair Elevating Leg Res E0992 Wheelchair Solid Seat Insert E0994RR Wheelchair Arm Rest E0995RR Wheelchair Accessory Calf Rest/Pad Repl Only Ea E1002 Wheelchair accessory, power seating system, tilt only E1003 Wheelchair accessory, power seating system, recline only, without shear E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear E1005 Wheelchair accessory, power seatng system, recline only, with power shear E1006 Wheelchair accessory, power seating system, combination tilt and recline, w/o shear reduction E1007 Wheelchair accessory, power seating system, combination tilt and recline, with manual shear reduction E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg E1010 Wheelchair accessory, addition to power seating system, power leg elevation E1011RR Modification To Pediatric Wheelchair, Width Adjust E1012 Wc Accss Pwr Seat Sys Cntr Mnt Pwr Elev Leg Ea E1014 Reclining Back, Addition To Pediatric Wheelchair E1015RR Shock Absorber For Manual Wheelchair, Each E1016RR Shock Absorber For Power Wheelchair, Each E1017RR Heavy Duty Shock Absorber For Heavy Duty Or Extra E1018RR Heavy Duty Shock Absorber For Heavy Duty Or Extra

Page 22 of 40 Code Description E1020 Residual Limb Support System Wheelchair Any Type E1028RR Wheelchair accessory, manual swingaway, retractabl E1029RR Wheelchair accessory, ventilator tray, fixed E1030RR Wheelchair accessory, ventilator tray, gimbaled E1031RR Rollabout Chair With Casters E1035RR Multi-Pstn Pt Trnsf Sys W/Seat Pt Wt 300 Lbs E1037RR Transport Chair, Pediatric Size E1038RR Transport Chair, Adult Size E1039RR Transport chair pt wt>=250lb E1050RR Whelchr Fxd Full Length Arms E1060RR Wheelchair Detachable Arms E1070RR Wheelchair Detachable Foot R E1083RR Hemi-W/C; Fixed Full-Len Arms Detachble Legrest E1084RR Hemi-Wheelchair Detachable A E1087RR Wheelchair Lightwt Fixed Arm E1088RR Wheelchair Lightweight Det A E1092RR Wheelchair Wide W/ Leg Rests E1093RR Wheelchair Wide W/ Foot Rest E1100RR Whchr S-Recl Fxd Arm Leg Res E1110RR Wheelchair Semi-Recl Detach E1150RR Wheelchair Standard W/ Leg R E1160RR Wheelchair Fixed Arms E1161 Manual Adult Size Wheelchair, Includes Tilt In Space E1170RR Whlchr Ampu Fxd Arm Leg Rest E1171RR Wheelchair Amputee W/O Leg R E1172RR Wheelchair Amputee Detach Ar E1180RR Wheelchair Amputee W/ Foot R E1190RR Wheelchair Amputee W/ Leg Re E1195RR Wheelchair Amputee Heavy Dut E1200RR Wheelchair Amputee Fixed Arm E1221RR Wheelchair Spec Size W Foot E1222RR Wheelchair Spec Size W/ Leg E1223RR Wheelchair Spec Size W Foot E1224RR Wheelchair Spec Size W/ Leg E1225RR Wheelchair Spec Sz Semi-Recl E1226 Wheelchair Spec Sz Full-Recl E1227RR Wheelchair Spec Sz Spec Ht A E1228 Wheelchair Spec Sz Spec Ht B E1229 Pediatric wheelchair NOS E1230RR Power Operated Vehicle E1231RR Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, E1232RR Wheelchair, Pediatric Size, Tilt-In-Space, Folding E1233 Wheelchair, Pediatric Size, Tilt-In-Space, Rigid, Adj, Wo Seating E1234 Wheelchair, Pediatric Size, Tilt-In-Space, Folding, Adj, Wo Seating E1235RR Wheelchair, Pediatric Size, Rigid, Adjustable, Wit E1236 Wheelchair, Pediatric Size, Folding, Adjustable, With Seating System E1237RR Wheelchair, Pediatric Size, Rigid, Adjustable, Wit E1238RR Wheelchair, Pediatric Size, Folding, Adjustable, W E1240RR Whchr Litwt Det Arm Leg Rest E1270RR Wheelchair Lightweight Leg R E1280RR Whchr H-Duty Det Arm Leg Res E1295RR Wheelchair Heavy Duty Fixed E1296RR Wheelchair Special Seat Heig E1297RR Wheelchair Special Seat Dept E1298 Wheelchair Spec Seat Depth/W E1310RR Whirlpool Non-Portable

Page 23 of 40 Code Description E1372RR Oxy Suppl Heater For Nebuliz E1390RR Oxygen Concentrator E1391RR Oxygen concentrator, dual delivery port, capable o E1392RR Portable oxygen concentrator E1405RR O2/Water Vapor Enrich W/Heat E1406RR O2/Water Vapor Enrich W/O He E1700RR Jaw Motion Rehab System E1800RR Adjust Elbow Ext/Flex Device E1801RR Bi-directional static progressive stretch elbow de E1802RR Dynamic Adjustable Forearm Pronation/Supination De E1805RR Adjust Wrist Ext/Flex Device E1806RR Bi-directional static progressive stretch wrist de E1810RR Adjust Knee Ext/Flex Device E1811RR Bi-directional progressive stretch knee device wit E1812RR Dyn Knee Ext/Flex Devc W/Actv Resistance Control E1815RR Adjust Ankle Ext/Flex Device E1816RR Bi-directional static progressive stretch ankle de E1818RR Bi-directional static progressive stretch forearm E1820RR Soft Interface Material E1821RR Replacement soft interface material/cuffs for bi-d E1825RR Adjust Finger Ext/Flex Devc E1830RR Adjust Toe Ext/Flex Device E1831 Static Progressive Stretch Toe Device E1840RR Dynamic adjustable shoulder flexion/abduction/rota E1841RR Static str shldr dev rom adj E2000RR Gastric suction pump, home model, portable or stat E2100 Blood glucose monitor with integrated voice synthesizer E2101RR Blood glucose monitor with integrated lancing/bloo E2120RR Pulse generator system for tympanic treatment of i E2201 Manual wheelchair accessory, nonstandard seat frame, width 20-24 in. E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20-22 in. E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches E2205 Manual wc accessory, handrim E2206RR Manual Wheelchair Ac Wl Asm Cmpl Repl Only Ea E2207RR Wheelchair Accessory Crutch And Cane Holder Each E2208RR Wheelchair Accessory Cylinder Tank Carrier Each E2209RR Arm Trough With Or Without Hand Support Each E2210RR Wheelchair Access Bearings Any Type Repl Only Ea E2211RR Mnl Whlchair Acss Pneumat Propulsion Tire Any Sz E2212RR Mnl Wc Acess Tube Pneumat Propulsion Tire Any Sz E2213RR Mnl Wc Acss Insrt Pneumat Propulsion Tire Any Sz E2214RR Mnl Whlchair Access Pneumat Caster Tire Any Size E2215RR Mnl Whlchair Acss Tube Pneumat Castr Tire Any Sz E2216RR Mnl Wc Acess Foam Fill Propulsion Tire Any Sz E2217RR Mnl Whlchair Accss Foam Fill Castr Tire Any Size E2218RR Mnl Whlchair Accss Foam Propulsion Tire Any Size E2219RR Mnl Whlchair Access Foam Caster Tire Any Size Ea E2220RR Mnl Wc Acss Sold Propulsion Tire Sz Repl Only Ea E2221RR Mnl Wc Ac Solid Caster Tire Any Sz Repl Only Ea E2222RR Mnl Wc Ac Sld C Tire I Whl Sz Rpl E E2224RR Mnl Wc Acss Prop Whl Excld Tire Sz Repl Only Ea E2225RR Mnl Wc Caster Whl Excld Tire Any Sz Repl Only Ea E2226RR Mnl Whlchair Acss Castr Fork Any Sz Repl Only Ea E2227RR Manual Wc Access Gear Reduction Drive Wheel Each E2228RR Mnl Wc Access Wheel Braking Sys&Lock Complete Ea E2231 Mnl Wc Access Solid Seat Supp Base Incl Hardware

Page 24 of 40 Code Description E2291 Planar back for ped size wc E2292 Planar seat for ped size wc E2300 WHEELCHAIR ACC PWR SEAT ELEVATION SYS ANY TYPE E2310RR Power wheelchair accessory, electronic connection E2311RR Power wheelchair accessory, electronic connection E2312 POWER WC ACCESS HAND OR CHIN CONTROL INTERFACE E2313RR Power Wc Access Harness Upgrade Exp Controllr Ea E2321RR Power wheelchair accessory, hand control interface E2322RR Power wheelchair accessory, hand control interface E2323RR Power wheelchair accessory, specialty joystick han E2324RR Power wheelchair accessory, chin cup for chin cont E2325 Power wheelchair accessory, sip and puff interface, nonproportional E2326RR Power wheelchair accessory, breath tube kit for si E2327 Power wheelchair accessory, head control interface, mechanical, proportional E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional E2340 Power wheelchair accessory, nonstandard seat frame width, 20-23 inches E2341RR Power wheelchair accessory, nonstandard seat frame E2342RR Power wheelchair accessory, nonstandard seat frame E2343RR Power wheelchair accessory, nonstandard seat frame E2351RR Power wheelchair accessory, electronic interface t E2359RR Pwr Wc Accessory Grp 34 Sealed Lead Acid Batt Ea E2360RR Power wheelchair accessory, 22 nf non-sealed lead E2361RR Power wheelchair accessory, 22nf sealed lead acid E2362RR Power wheelchair accessory, group 24 non-sealed le E2363RR Power wheelchair accessory, group 24 sealed lead a E2364RR Power wheelchair accessory, u-1 non-sealed lead ac E2365RR Power wheelchair accessory, u-1 sealed lead acid b E2366RR Power wheelchair accessory, battery charger, singl E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type E2368RR Power Wheelchair Cmpnt Motor Replacement Only E2369RR Power Wc Cmpnnt Drive Wheel Gear Box Repl Only E2370RR Pwr Wc Comp Int Dr Whl Mtr&Gr Box Comb Repl Only E2371RR Power Wc Acss Grp 27 Sealed Lead Acid Battery Ea E2372RR Pwr Wc Acss Grp 27 Nonsealed Lead Acid Battry Ea E2373 Hand/chin ctrl spec joystick E2374 Hand/chin ctrl std joystick E2375 Non-expandable controller E2376 Expandable controller, repl E2377 Expandable controller, initl E2378RR Power Wheelchair Component Actuator Replace Only E2381RR Pwr Wc Pneumatic Drive Wheel Tire Repl Only Each E2382RR Pwr Wc Tube Pneumatic Drive Wheel Tire Repl Each E2383RR Pwr Wc Insert Pneumatic Wheel Tire Repl Only Ea E2384RR Pwr Wc Pneumatic Caster Tire Repl Only Each E2385RR Pwr Wc Tube Pneumatic Caster Tire Repl Only Each E2386RR Pwr Wc Foam Filled Drive Wheel Tire Repl Only Ea E2387RR Pwr Wc Foam Filled Caster Tire Repl Only Each E2388RR Pwr Wc Foam Drive Wheel Tire Repl Only Each E2389RR Pwr Wc Foam Caster Tire Replacement Only Each E2390RR Pwr Wc Solid Drive Wheel Tire Repl Only Each E2391RR Pwr Wc Solid Caster Tire Replacement Only Each E2392RR Pwr Wc Solid Caster Tire Integrted Wheel Repl Ea E2394RR Pwr Wc Drive Wheel Excludes Tire Repl Only Each E2395RR Pwr Wc Caster Wheel Excludes Tire Repl Only Each E2396RR Pwr Wc Caster Fork Replacement Only Each

Page 25 of 40 Code Description E2397RR Power Whlchair Accessory Lithium-Based Battry Ea E2402 Negative pressure wound therapy electrical pump, stationary or portable E2500 Speech generating device, digitized speech, using pre-recorded messages, 8 min. or less E2502 Speech generating device, digitized speech, using pre-recorded messages, 8-20 min. E2504 Speech generating device, digitized speech, using pre-recorded messages, 20-40 min. E2506 Speech generating device, digitized speech, using pre-recorded messages, over 40 min. E2508 Speech generating device, synthesized speech, requiring message formulation by spelling E2510 Speech generating device, synthesized speech, permitting multiple methods E2511RR Speech generating software program, for personal c E2512RR Accessory for speech generating device, mounting s E2601RR Gen w/c cushion wdth < 22 in E2602 Gen w/c cushion wdth >=22 in E2603 Skin protect wc cus wd <22in E2604 Skin protect wc cus wd>=22in E2605 Position wc cush wdth <22 in E2606 Position wc cush wdth>=22 in E2607 Skin pro/pos wc cus wd <22in E2608 Skin pro/pos wc cus wd>=22in E2609 Custom fabricate w/c cushion E2611 Gen use back cush wdth <22in E2612 Gen use back cush wdth>=22in E2613 Position back cush wd <22in E2614 Position back cush wd>=22in E2615 Pos back post/lat wdth <22in E2616 Pos back post/lat wdth>=22in E2617 Custom fab w/c back cushion E2619RR Replace cover w/c seat cush E2620 WC planar back cush wd <22in E2621 WC planar back cush wd>=22in E2622 Skin Protect Wc Seat Cush Width <22 In Any Depth E2623 Skin Protct Wc Seat Cush Width 22 In/> Any Depth E2624 Skin Protect & Positioning Wc Cush Width < 22 In E2625 Skin Protect & Positioning Wc Cush Width 22 In/> E2626 Wc Access Shldr Elb Mobil Arm Supp Wc Adjustble E2627 Wc Access Shldr Elb M Arm Supp Adjustbl Rancho E2628 Wc Access Shldr Elb Mobil Arm Supp Wc Reclining E2629 Wc Access Shldr Elb M Arm Supp Friction Arm Supp E2630 Wc Access Shldr Elb Mobil Monosusp Arm Hand Supp E2631 Wc Access Add Mobile Arm Support Elev Prox Arm E2632 Wc Access Add Mobil Arm Supp Offset/Lat Rckr Arm E2633 Wc Access Add Mobile Arm Support Supinator

G0237 Therapeutic procedures to increase strength or endurance of respiratory muscles, face to face, one on one, each 15 minut G0238 Therapeutic procedures to improve respiratory function , other than described by G0237, one on one, face to face, per G0277 Hpo Und Press Full Body Chmbr Per 30 Min Int G0448 Ins/Rpl Prm Cv-Dfib Tv Leads Insrt Pace Elctrode G0460 AUTOLOGOUS PLATELET-RICH PLASMA K0001RR Standard Wheelchair K0002 Stnd Hemi (Low Seat) Whlchr K0003 Lightweight Wheelchair K0004 High Strength Ltwt Whlchr K0005 Ultralightweight Wheelchair K0006 Heavy Duty Wheelchair K0007 Extra Heavy Duty Wheelchair K0009 Other Manual Wheelchair/Base K0010RR Stnd Wt Frame Power Whlchr K0011RR Stnd Wt Pwr Whlchr W Control

Page 26 of 40 Code Description K0012RR Ltwt Portbl Power Whlchr K0015RR Detach Non-Adjus Hght Armrst K0017RR Detachable Adjust Ht Armrest Base Repl Only Ea K0018RR Dtachble Adjust Ht Armrest Up Prtn Repl Only Ea K0019RR Arm Pad Replacement Only Each K0020RR Fixed Adjust Armrest Pair K0037RR High Mount Flip-Up Footrest Each K0038RR Leg Strap Each K0039RR Leg Strap H Style Each K0040RR Adjustable Angle Footplate K0041RR Large Size Footplate Each K0042RR Standard Size Footplate Replacement Only Each K0043RR Footrest Lower Extension Tube Replacemnt Only Ea K0044RR Footrest Upper Hanger Bracket Repl Only Each K0045RR Footrest Complete Assembly Replacement Only Each K0046RR Elevating Legrest Lwr Extensn Tube Repl Only Ea K0047RR Elevating Legrest Upr Hanger Brackt Repl Only Ea K0050RR Ratchet Assembly Replacement Only K0051RR Cam Rls Assem Footrest/Legrest Repl Only Each K0052RR Swingaway Detachable Footrests Repl Only Each K0053RR Elevate Footrest Articulate K0056RR Seat Ht <17 Or >=21 Ltwt Wc K0065RR Spoke Protectors K0069RR Rear Whl Asm Cmpl Sld Tire Spke/Mld Repl Only Ea K0070RR Rear Whl Asm Comp Pneum Tire Spks/Mld Rpl Only E K0071RR Front Caster Assem Complete Pn Tire Repl Only Ea K0072RR Front C Assembly Compl Semipneu Tire Repl Only E K0073RR Caster Pin Lock Each K0077RR Front Caster Assembly Compl Sld Tire Repl Only E K0098RR Drive Belt For Power Wheelchair Replacemnt Only K0105RR Iv Hanger K0195RR Elevating Whlchair Leg Rests K0455RR Infusion Pump Uninterrupted Parenteral Admin Med K0552 Spl Ext Non-Ins Rx Infus Pmp Syr T Cart Sterl Ea K0554RR Receiver Dedicated Tx Gcm Sys K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type K0607RR Repl Battry Auto Ext Defib Garmnt Type Only Ea K0608RR Replacement Garment Use W/Auto External Defib Ea K0730RR Controlled Dose Inhalation Drug Delivery System K0733RR Pwr Wc 12-24 Amp Hr Sealed Lead Acid Battery Ea K0738RR Portable gas oxygen system K0743 Suction Pump Home Model Portable For Use Wounds K0744 Absorb Wd Dr Hom Mdl Prtble Pad Sz 16 Sq In/Less K0745 Absrb Wd Dr Hom Mdl Prt Pad>16 Sq In 48 Sq In K0800 POV group 1 std up to 300 lbs K0801 POV group 1 hd 301-450 lbs K0802 POV group 1 vhd 451-600 lbs K0806 POV group 2 std up to 300lbs K0807 POV group 2 hd 301-450 lbs K0808 POV group 2 vhd 451-600 lbs K0812 Power operated vehicle NOC K0813 PWC gp 1 std port seat/back K0814 PWC gp 1 std port cap chair K0815 PWC gp 1 std seat/back K0816 PWC gp 1 std cap chair K0820 PWC gp 2 std port seat/back

Page 27 of 40 Code Description K0821 PWC gp 2 std port cap chair K0822 PWC gp 2 std seat/back K0823 PWC gp 2 std cap chair K0824 PWC gp 2 hd seat/back K0825 PWC gp 2 hd cap chair K0826 PWC gp2 vhd seat/back K0827 PWC gp 2 vhd cap chair K0828 PWC gp 2 xtra hd seat/back K0829 PWC gp 2 xtra hd cap chair K0835 PWC gp2 std sing pow opt s/b K0836 PWC gp2 std sing pow opt cap K0837 PWC gp 2 hd sing pow opt s/b K0838 PWC gp 2 hd sing pow opt cap K0839 PWC gp2 vhd sing pow opt s/b K0840 PWC gp2 xhd sing pow opt s/b K0841 PWC gp2 std mult pow opt s/b K0842 PWC gp2 std mult pow opt cap K0843 PWC gp2 hd mult pow opt s/b K0848 PWC gp 3 std seat/back K0849 PWC gp 3 std cap chair K0850 PWC gp 3 hd seat/back K0851 PWC gp 3 hd cap chair K0852 PWC gp 3 vhd seat/back K0853 PWC gp 3 vhd cap chair K0854 PWC gp 3 xhd seat/back K0855 PWC gp 3 xhd cap chair K0856 PWC gp3 std sing pow opt s/b K0857 PWC gp3 std sing pow opt cap K0858 PWC gp3 hd sing pow opt s/b K0859 PWC gp3 hd sing pow opt cap K0860 PWC gp3 vhd sing pow opt s/b K0861 PWC gp3 std mult pow opt s/b K0862 PWC gp3 hd mult pow opt s/b K0863 PWC gp3 vhd mult pow opt s/b K0864 PWC gp3 xhd mult pow opt s/b K0868 PWC gp 4 std seat/back K0869 PWC gp 4 std cap chair K0870 PWC gp 4 hd seat/back K0871 PWC gp 4 vhd seat/back K0877 PWC gp4 std sing pow opt s/b K0878 PWC gp4 std sing pow opt cap K0879 PWC gp4 hd sing pow opt s/b K0880 PWC gp4 vhd sing pow opt s/b K0884 PWc gp4 std mult pow opt s/b K0885 PWC gp4 std mult pow opt cap K0886 PWC gp4 hd mult pow s/b K0890 PWC gp5 ped sing pow opt s/b K0891 PWC gp5 ped mult pow opt s/b K0898 Power wheelchair NOC L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft material L0170 Cervical Collar Molded To Pt L0456 TLSO FLEXIBLE SC JUNCT SCAP SPINE PREFAB CUSTOM L0457 TLSO FLX SC JUNC TERM INF TO SCAP SPINE PREFAB L0458 TLSO, Triplanar Control, Modular Segmented Spinal System, Two Rigid Pl L0460 TLSO TRIPLANAR 2 SHELL ANT TO STERNL NOTCH PRFAB L0462 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Three Rigid Pl L0464 TLSO, Triplanar Control, Modular Segmented Spinal Syst, Four Rigid Pla

Page 28 of 40 Code Description L0470 Tlso Triplanar Post Frme&Ant Apron W/Strap Prfab L0480 TLSO, Triplanar Control, One Piece Rigid Plastic Shell Wo Interface Li L0482 TLSO, Triplanar Control, One Piece Rigid Plastic Shell W Interface Lin L0484 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell Wo Interface Li L0486 TLSO, Triplanar Control, Two Piece Rigid Plastic Shell W Interface Lin L0488 TLSO, Triplanar Control, One Piece Rigid Plastic Shell W Interface Lin L0491 TLSO 2 piece rigid shell L0492 TLSO 3 piece rigid shell L0631 LUMB-SACRAL ORTHOS SAGIT CNTRL RIGID A&P PREFAB L0632 LSO sag rigid frame cust L0634 LSO flexion control custom L0635 LSO sagit rigid panel prefab L0636 LSO sagittal rigid panel cus L0637 LUMB-SACRAL ORTHOS SAG-COR CNTRL RIGD A&P PREFAB L0638 LSO sag-coronal panel custom L0639 LUMB-SAC ORTHOS SAG-COR CNTRL RIGID SHELL PREFAB L0640 LSO s/c shell/panel custom L0648 LSO SAGITTAL CONTROL RIGD ANT POST PANELS PREFAB L0650 LSO SAGITTAL-CORONAL CONTRL RIGD ANT POST PANELS L0651 LSO SAGITTAL-CORONAL CONTROL RIGD SHELLS/PANELS L0700 Ctlso A-P-L Control Molded L0710 Ctlso A-P-L Control W/ Inter L0810 Halo Cervical Into Jckt Vest L0820 Halo Cervical Into Body Jack L0830 Halo Cerv Into Milwaukee Typ L1000 Ctlso Milwauke Initial Model L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment L1200 Furnsh Initial Orthosis Only L1230 Milwaukee Type Superstructur L1300 Body Jacket Mold To Patient L1310 Post-Operative Body Jacket L1640 Pelv Band/Spread Bar Thigh C L1680 Pelvic & Hip Control Thigh C L1685 Post-Op Hip Abduct Custom Fa L1686 Ho Post-Op Hip Abduction L1690 Combination Bilateral Ho L1700 Leg Perthes Orth Toronto Typ L1710 Legg Perthes Orth Newington L1720 Legg Perthes Orthosis Trilat L1730 Legg Perthes Orth Scottish R L1755 Legg Perthes Patten Bottom T L1832 KNEE ORTHOSIS IMMOBLIZER ADJUSTABLE JOINT PREFAB L1833 KNEE ORTHOSIS ADJUSTABLE JOINT RIGD SUPP PREFAB L1834 Ko W/0 Joint Rigid Molded To L1840 Ko Derot Ant Cruciate Custom L1843 KNEE ORTHOSIS SINGLE UPRIGHT THIGH & CALF PREFAB L1844 Ko W/Adj Jt Rot Cntrl Molded L1845 KNEE ORTHOSIS DOUBLE UPRIGHT THIGH & CALF PREFAB L1846 Ko W Adj Flex/Ext Rotat Mold L1847 KNEE ORTHOSIS DOUBLE UPRIGHT AIR PREFAB CUSTOM L1848 KNEE ORTHOSIS ADJUSTABLE JOINT AIR SUPP PREFAB L1860 Ko Supracondylar Socket Mold L1907 ANKLE ORTHOSIS SUPRAMALLEOLAR WITH STRAPS CUSTOM L1932 Afo rig ant tib prefab TCF/= L1940 Afo Molded To Patient Plasti L1945 Afo Molded Plas Rig Ant Tib L1950 Afo Spiral Molded To Pt Plas

Page 29 of 40 Code Description L1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), prefabricated L1960 Afo Pos Solid Ank Plastic Mo L1970 Afo Plastic Molded W/Ankle J L2000 Kafo Sing Fre Stirr Thi/Calf L2005 Kafo Any Matl Auto Lock&Swng Rlse W/Ank Jnt Cstm L2010 Kafo Sng Solid Stirrup W/O J L2020 Kafo Dbl Solid Stirrup Band/ L2030 Kafo Dbl Solid Stirrup W/O J L2034 KAFO pla sin up w/wo k/a cus L2036 Kafo Plas Doub Free Knee Mol L2037 Kafo Plas Sing Free Knee Mol L2038 Kafo W/O Joint Multi-Axis An L2106 Afo Tib Fx Cast Plaster Mold L2108 Afo Tib Fx Cast Molded To Pt L2112 Afo Tibial Fracture Soft L2114 Afo Tib Fx Semi-Rigid L2116 Afo Tibial Fracture Rigid L2126 Kafo Fem Fx Cast Thermoplas L2128 Kafo Fem Fx Cast Molded To P L2132 Kafo Femoral Fx Cast Soft L2134 Kafo Fem Fx Cast Semi-Rigid L2136 Kafo Femoral Fx Cast Rigid L2330 Lacer Molded To Patient Mode L2350 Prosthetic Type Socket Molde L2510 Th/Wght Bear Quad-Lat Brim M L2520 Th/Wght Bear Quad-Lat Brim C L2525 Th/Wght Bear Nar M-L Brim Mo L2526 Th/Wght Bear Nar M-L Brim Cu L2580 Pelvic Control Pelvic Sling L2627 Plastic Mold Recipro Hip & C L2628 Metal Frame Recipro Hip & Ca L2640 Pelvic Control Band & Belt B L2999 Lower Extremity Orthosis Nos L3250 Custom Mold Shoe Remov Prost L3330 Lifts Elevation Metal Extens L3671 Shldr Orthotic Shldr Jnt Desn W/O Jnts Cstm Fab L3674 Shldr Orthosic Abduct Pstn Th Comp Supp Bar Cstm L3720 Forearm/Arm Cuffs Free Motio L3730 Forearm/Arm Cuffs Ext/Flex A L3740 Cuffs Adj Lock W/ Active Con L3763 EWHO rigid w/o jnts CF L3764 EWHO w/joint(s) CF L3765 EWHFO rigid w/o jnts CF L3766 EWHFO w/joint(s) CF L3900 Hinge Extension/Flex Wrist/F L3901 Hinge Ext/Flex Wrist Finger L3905 WHO w/nontorsion jnt(s) CF L3915 WRIST HAND ORTHOSIS 1/>NONTORSION JNT PRFAB CSTM L3960 Sewho Airplan Desig Abdu Pos L3961 SEWHO cap design w/o jnts CF L3962 Sewho Erbs Palsey Design Abd L3967 SEWHO airplane w/o jnts CF L3971 SEWHO cap design w/jnt(s) CF L3973 SEWHO airplane w/jnt(s) CF L3975 SEWHFO cap design w/o jnt CF L3976 SEWHFO airplane w/o jnts CF L3977 SEWHFO cap desgn w/jnt(s) CF

Page 30 of 40 Code Description L3978 SEWHFO airplane w/jnt(s) CF L3982 Upper Ext Fx Orthosis Rad/Ul L3999 Upper Limb Orthosis Nos L4000 Repl Girdle Milwaukee Orth L4010 Replace Trilateral Socket Br L4020 Replace Quadlat Socket Brim L4030 Replace Socket Brim Cust Fit L4040 Replace Molded Thigh Lacer L4050 Replace Molded Calf Lacer L4631 Afo Walk Boot Typ Rockr Bottm Ant Tib Shell Cstm L5010 Mold Socket Ank Hgt W/ Toe F L5020 Tibial Tubercle Hgt W/ Toe F L5050 Ank Symes Mold Sckt Sach Ft L5100 Molded Socket Shin Sach Foot L5105 Plast Socket Jts/Thgh Lacer L5150 Mold Sckt Ext Knee Shin Sach L5160 Mold Socket Bent Knee Shin S L5200 Kne Sing Axis Fric Shin Sach L5210 No Knee/Ankle Joints W/ Ft B L5220 No Knee Joint With Artic Ali L5230 Fem Focal Defic Constant Fri L5250 Hip Canad Sing Axi Cons Fric L5270 Tilt Table Locking Hip Sing L5280 Hemipelvect Canad Sing Axis L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system L5312 Knee Disartic Mold Socket 1 Axis Knee Sach Foot L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot L5400 Postop Dress & 1 Cast Chg Bk L5420 Postop Dsg & 1 Cast Chg Ak/D L5450 Postop App Non-Wgt Bear Dsg L5460 Postop App Non-Wgt Bear Dsg L5500 Init Bk Ptb Plaster Direct L5505 Init Ak Ischal Plstr Direct L5510 Prep Bk Ptb Plaster Molded L5520 Perp Bk Ptb Thermopls Direct L5530 Prep Bk Ptb Thermopls Molded L5535 Prep Below Knee Ptb Non-Align Prfab Adj Open End L5540 Prep Bk Ptb Laminated Socket L5560 Prep Ak Ischial Plast Molded L5570 Prep Ak Ischial Direct Form L5580 Prep Ak Ischial Thermo Mold L5585 Prep Ak Ischial Open End L5590 Prep Ak Ischial Laminated L5595 Hip Disartic Sach Thermopls L5600 Hip Disart Sach Laminat Mold L5610 Above Knee Hydracadence L5611 Ak 4 Bar Link W/Fric Swing L5613 Ak 4 Bar Ling W/Hydraul Swig L5614 4-Bar Link Above Knee W/Swng L5628 Test Socket Hemipelvectomy L5631 Ak/Knee Disartic Acrylic Soc L5634 Symes Type Poster Opening So L5638 Below Knee Leather Socket L5639 Below Knee Wood Socket L5640 Knee Disarticulat Leather So

Page 31 of 40 Code Description L5642 Above Knee Leather Socket L5643 Hip Flex Inner Socket Ext Fr L5644 Above Knee Wood Socket L5645 Ak Flexibl Inner Socket Ext L5646 Below Knee Air Cushion Socke L5647 Below Knee Suction Socket L5648 Above Knee Air Cushion Socke L5649 Isch Containmt/Narrow M-L So L5650 Tot Contact Ak/Knee Disart S L5651 Ak Flex Inner Socket Ext Fra L5661 Multi-Durometer Symes L5665 Multi-Durometer Below Knee

L5671 Addition lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), includes socke L5673 Addition to lower extremity, below knee/above knee, custom fabricated L5679 Addition to lower extremity, below knee/above knee, custom fabricated L5681 Addition to lower extremity, below knee/above knee, custom fabricated socket insert L5682 Bk Thigh Lacer Glut/Ischia M L5683 Addition to lower extremity, below knee/above knee, custom fabricated socket insert L5700 Replace Socket Below Knee L5701 Replace Socket Above Knee L5702 Replace Socket Hip L5703 Symes ankle w/o (SACH) foot L5704 Custom Shape Covr Below Knee L5705 Custm Shape Cover Above Knee L5706 Custm Shape Cvr Knee Disart L5707 Custm Shape Cover Hip Disart L5722 Knee-Shin Pneum Swg Frct Exo L5724 Knee-Shin Exo Fluid Swing Ph L5726 Knee-Shin Ext Jnts Fld Swg E L5728 Knee-Shin Fluid Swg & Stance L5780 Knee-Shin Pneum/Hydra Pneum L5781 Addition To Lower Limb Prosthesis, Vacuum Pump, Residual Limb Volume M L5790 Exoskeletal Ak Ultra-Light M L5795 Exoskel Hip Ultra-Light Mate L5814 Endo Knee-Shin Hydral Swg Ph L5816 Endo Knee-Shin Polyc Mch Sta L5818 Endo Knee-Shin Frct Swg & St L5822 Endo Knee-Shin Pneum Swg Frc L5824 Endo Knee-Shin Fluid Swing P L5826 Miniature Knee Joint L5828 Endo Knee-Shin Fluid Swg/Sta L5830 Endo Knee-Shin Pneum/Swg Pha L5840 Multi-Axial Knee/Shin System L5845 Knee-Shin Sys Stance Flexion L5930 High Activity Knee Frame L5940 Endo Bk Ultra-Light Material L5950 Endo Ak Ultra-Light Material L5960 Endo Hip Ultra-Light Materia L5962 Below Knee Flex Cover System L5964 Above Knee Flex Cover System L5966 Hip Flexible Cover System L5968 Multiaxial Ankle W Dorsiflex L5975 Combo Ankle/Foot Prosthesis L5976 Energy Storing Foot L5979 Multi-Axial Ankle/Ft Prosth L5980 Flex Foot System

Page 32 of 40 Code Description L5981 Flex-Walk Sys Low Ext Prosth L5984 Endoskeletal Axial Rotation L5987 Shank Ft W Vert Load Pylon L5988 Vertical Shock Reducing Pylo L5990 Addition to lower extremity prosthesis, user adjustable heel height L6000 Partial Hand Thumb Remaining L6010 Partial Hand Little & Or Ring Finger Remaining L6020 Partial Hand No Finger Remaining L6026 Transcarpal/Mc/Part Hand Disarticulation Pros L6050 Wrst Mld Sck Flx Hng Tri Pad L6055 Wrst Mold Sock W/Exp Interfa L6100 Elb Mold Sock Flex Hinge Pad L6110 Elbow Mold Sock Suspension T L6120 Elbow Mold Doub Splt Soc Ste L6130 Elbow Stump Activated Lock H L6200 Elbow Mold Outsid Lock Hinge L6205 Elbow Molded W/ Expand Inter L6250 Elbow Inter Loc Elbow Forarm L6300 Shlder Disart Int Lock Elbow L6310 Shoulder Passive Restor Comp L6320 Shoulder Passive Restor Cap L6350 Thoracic Intern Lock Elbow L6360 Thoracic Passive Restor Comp L6370 Thoracic Passive Restor Cap L6380 Postop Dsg Cast Chg Wrst/Elb L6382 Postop Dsg Cast Chg Elb Dis/ L6384 Postop Dsg Cast Chg Shlder/T L6388 Postop Applicat Rigid Dsg On L6400 Below Elbow Prosth Tiss Shap L6450 Elb Disart Prosth Tiss Shap L6500 Above Elbow Prosth Tiss Shap L6550 Shldr Disar Prosth Tiss Shap L6570 Scap Thorac Prosth Tiss Shap L6580 Wrist/Elbow Bowden Cable Mol L6582 Wrist/Elbow Bowden Cbl Dir F L6584 Elbow Fair Lead Cable Molded L6586 Elbow Fair Lead Cable Dir Fo L6588 Shdr Fair Lead Cable Molded L6590 Shdr Fair Lead Cable Direct L6621 Flex/ext wrist w/wo friction L6624 Flex/ext/rotation wrist unit L6638 Upper Extremity Addition To Prosthesis, Electric Locking Feature, Only L6646 Upper Extremity Addition, Shoulder Joint, Multipositional Locking, Fle L6686 Suction Socket L6687 Frame Typ Socket Bel Elbow/W L6688 Frame Typ Sock Above Elb/Dis L6689 Frame Typ Socket Shoulder Di L6690 Frame Typ Sock Interscap-Tho L6692 Silicone Gel Insert Or Equal L6693 Lockingelbow Forearm Cntrbal L6694 Elbow socket ins use w/lock L6695 Elbow socket ins use w/o lck L6703 Term dev, passive hand mitt L6707 Term dev mech hook vol close L6708 Term dev mech hand vol open L6709 Term dev mech hand vol close L6881 Automatic grasp feature, additional to upper limb prosthetic terminal device.

Page 33 of 40 Code Description L6882 Microprocessor control feature, addition to upper limb prosthesis terminal device L6883 Replc sockt below e/w disa L6884 Replc sockt above elbow disa L6885 Replc sockt shldr dis/interc L6900 Hand Restorat Thumb/1 Finger L6905 Hand Restoration Multiple Fi L6910 Hand Restoration No Fingers L7007 Adult electric hand L7008 Pediatric electric hand L7009 Adult electric hook L7186 Electron Elbow Child Switch L7364 Twelve Volt Battery Utah/Equ L7366 Battery Chrgr 12 Volt Utah/E L7368 Lithium Ion Battery Charger Replacement Only L7900 Vacuum System L8500 Artificial Larynx L8600 Implant Breast Silicone/Eq L8614 Cochlear implant system L8679 IMPLANTABLE NEUROSTIMULATOR PULSE GENERATOR ANY L8680 IMPLANTABLE NEUROSTIMULATOR ELECTRODE EACH L8681 Pt prgrm for implt neurostim L8682 Implt neurostim radiofq rec L8683 Radiofq trsmtr for implt neu L8684 Radiof trsmtr implt scrl neu L8685 Implt nrostm pls gen sng rec L8686 Implt nrostm pls gen sng non L8687 Implt nrostm pls gen dua rec L8688 Implt nrostm pls gen dua non L8690 Auditory osseointegrated device, includes all internal and external components L8691 Aud Oi Devc Ext Sp Excl Trnsducr/Actuatr Repl Ea L8692 Auditory Osseointegrated Dev Ext Sound Body Worn L8695 External recharg sys extern L8701 Pwr Ue Rom Ast Dvc Elb Wr Hand 1/Dbl Up Cus Fab L8702 Pwr Ue Rom Ast Dvc Elbo Wr H Finger 1/Dbl Up Cus Q0478 Power Adapter Electric/Pneumat Vad Vehicle Type Q0495 Charger elec/combo vad, rep Q0496 Battery Not Lithium-Ion Elec/Pneumat Vad Repl Q0509 MISC SPL/ACSS IMPL VAD NO PAYMENT MEDICARE PRT A Q2026 Injection Radiesse 0.1Ml Q4100 Skin Substitute Not Otherwise Specified Q4101 Apligraf Per Sq Cm Q4102 Oasis Wound Matrix Per Sq Cm Q4103 Oasis Burn Matrix Per Sq Cm Q4104 Integra Bilayer Matrix Wound Dressing Per Sq Cm Q4105 Integra Drt/Integra Omnigr Drml Rgn Mtx P Sq Cm Q4106 Dermagraft Per Sq Cm Q4107 Graftjacket Per Sq Cm Q4108 Integra Matrix Per Sq Cm Q4110 Primatrix Per Sq Cm Q4111 Gammagraft Per Sq Cm Q4112 Cymetra Injectable 1 Cc Q4113 Graftjacket Xpress Injectable 1 Cc Q4114 Integra Flowable Wound Matrix Injectable 1 Cc Q4115 Alloskin Per Sq Cm Q4116 Alloderm Per Sq Cm Q4117 Hyalomatrix Per Sq Cm Q4118 Matristem Micromatrix 1 Mg

Page 34 of 40 Code Description Q4119 Matristem Wound Matrix Per Square Centimeter Q4120 Matristem Burn Matrix Per Sq Cm Q4121 Theraskin Per Sq Cm Q4122 Dermacell Per Sq Cm Q4123 Alloskin Rt Per Sq Cm Q4124 Oasis Ultra Tri-Layer Wound Matrix Per Sq Cm Q4125 Arthroflex Per Sq Cm Q4126 Memoderm Dermaspan Tranzgrft/Integuply Per Sq Cm Q4127 Talymed Per Sq Cm Q4128 Flexhd Allopatchhd Or Matrix Hd Per Sq Cm Q4129 Unite Biomatrix Per Sq Cm Q4130 Strattice Per Sq Cm Q4131 Epifix Or Epicord Per Sq Cm Q4132 Grafix Core And Grafixpl Core Per Square Cm Q4133 Grafix Prm Grafixpl Prm Stravix & Stravixpl P Sc Q4134 Hmatrix Per Square Centimeter Q4135 Mediskin Per Square Centimeter Q4136 E-Z Derm Per Square Centimeter Q4137 Amnioexcel Amnioexcel Plus/Biodexcel Per Sq Cm Q4138 BIODFENCE DRYFLEX PER SQ CM Q4139 AMNIOMATRIX OR BIODMATRIX INJECTABLE 1 CC Q4140 BIODFENCE PER SQ CM Q4141 ALLOSKIN AC PER SQ CM Q4142 XCM BIOLOGIC TISSUE MATRIX PER SQ CM Q4143 REPRIZA PER SQ CM Q4145 EPIFIX INJECTABLE 1 MG Q4146 TENSIX PER SQ CM Q4147 Architect Extracellular Matrix Per Sq Cm Q4148 Neox Cord 1K Neox Cord Rt/Clarix Cord 1K-Sq Cm Q4149 EXCELLAGEN 0.1 CC Q4150 Allowrap Ds Or Dry Per Square Centimeter Q4151 Amnioband Or Guardian Per Square Centimeter Q4152 Dermapure Per Square Centimeter Q4153 Dermavest And Plurivest Per Sq Cm Q4154 Biovance Per Square Centimeter Q4155 Neoxflo Or Clarixflo 1 Mg Q4156 Neox 100 Or Clarix 100 Per Square Cm Q4157 Revitalon Per Square Centimeter Q4158 Kerecis Omega3 Per Square Cm Q4159 Affinity Per Square Centimeter Q4160 Nushield Per Square Centimeter Q4161 Bio-Connekt Wound Matrix Per Square Centimeter Q4162 Woundex Flow Bioskin Flow 0.5 Cc Q4163 Woundex Bioskin Per Square Cm Q4164 Helicoll Per Square Centimeter Q4165 Keramatrix Per Square Centimeter Q4166 Cytal Per Sq Cm Q4167 Truskin Per Sq Cm Q4168 Amnioband 1 Mg Q4169 Artacent Wound Per Sq Cm Q4170 Cygnus Per Sq Cm Q4171 Interfyl 1 Mg Q4172 Puraply Or Puraply Am Per Sq Cm Q4173 Palingen Or Palingen Xplus Per Sq Cm Q4174 Palingen Or Promatrx 0.36 Mg Per 0.25 Cc Q4175 Miroderm Per Sq Cm Q4176 Neopatch Per Square Cm

Page 35 of 40 Code Description Q4177 Floweramnioflo 0.1 Cc Q4178 Floweramniopatch Per Square Cm Q4179 Flowerderm Per Square Cm Q4180 Revita Per Square Cm Q4181 Amnio Wound Per Square Cm Q4182 Transcyte Per Square Cm Q4183 Surgigraft Per Sq Cm Q4184 Cellesta Per Sq Cm Q4185 Cellesta Flowable Amnion; Per 0.5 Cc Q4186 Epifix Per Sq Cm Q4187 Epicord Per Sq Cm Q4188 Amnioarmor Per Sq Cm Q4189 Artacent Ac 1 Mg Q4190 Artacent Ac Per Sq Cm Q4191 Restorigin Per Sq Cm Q4192 Restorigin 1 Cc Q4193 Coll-E-Derm Per Sq Cm Q4194 Novachor Per Sq Cm Q4195 Puraply Per Sq Cm Q4196 Puraply Am Per Sq Cm Q4197 Puraply Xt Per Sq Cm Q4198 Genesis Amniotic Membrane Per Sq Cm Q4200 Skinte Per Sq Cm Q4201 Matrion Per Sq Cm Q4202 Keroxx (2.5G/Cc) 1Cc Q4203 Derma-Gide Per Sq Cm Q4204 Xwrap Per Sq Cm S0810 Photorefractive Keratectomy S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor S1040 Cranial Remodeling Orthosis, Rigid W/Soft Interface Material S2102 Islet Cell Tissue Transplant S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

S2342 Nasal endoscopy for post-operative debridement following functional endoscopic sinus surgery, nasal and/or sinus cavity( S3652 Saliva Test, Hormone Level S3840 DNA analysis for germline mutations of the ret proto-oncogene S3841 Genetic testing for retinoblastoma S3842 Genetic testing for von hippel-lindau disease S3844 DNA analysis of the connexin 26 gene (gjb2) for susceptibility to congenital, profound deafness S3845 Genetic testing for alpha-thalassemia S3846 Genetic testing for hemoglobin e beta-thalassemia S3849 Genetic testing for niemann-pick disease S3853 Genetic testing for myotonic muscular dystrophy S3854 Gene Expression Profiling Panl Mgmt Breast Ca Tx S3861 GENETIC TESTING SCN5A & VARIANTS FOR SUSPCTED BS S4011 In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with S4013 Complete Cycle, Gamete Intrafallopian Transfer (Gift), Case Rate S4014 Complete Cycle, Zygote Intrafallopian Transfer (Zift), Case Rate S4015 Complete in vitro fertilization cycle, case rate S4016 Frozen in vitro fertilization cycle, case rate S4022 Assisted oocyte fertilization, case rate S4023 Donor Egg Cycle, Incomplete, Case Rate S4025 Donor services for in vitro fertilization (sperm or embryo), case rate S4026 Procurement of donor sperm from sperm bank S4028 Microsurgical epididymal sperm aspiration (mesa)

Page 36 of 40 Code Description S4030 Sperm procurement and cryopreservation services; initial visit S4031 Sperm procurement and cryopreservation services; subsequent visit S4035 Stimulated Intrauterine Insemination (Iui), Case Rate S4037 Cryopreserved Embryo Transfer, Case Rate S5125 Attendant Care Services, Per 15 Minutes S5126 Attendant Care Services, Per Diem S5130 Homemaker Service, NOS, Per 15 Minutes S5165 Home Modifications, Per Service S5185 Medication Reminder Services, No Face To Face, Per Month S8262 Mandibular Orthopedic Repositioning Device Each S9110 Telemonitoring Pt Home All Nec Equip; Per Month S9122 Home health aide or certified nurse assistant, providing care in the home; per hour S9123 Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT cod S9124 Nursing care, in the home; by licensed practical nurse, per hour S9127 Social work visit, in the home, per diem S9128 Speech therapy, in the home, per diem S9129 Occupational therapy, in the home, per diem S9131 Physical therapy, in the home, per diem S9988 Serv part of phase 1 trial S9990 Services Provided As Part Of S9991 Services Provided As Part Of T1001 Nursing assessment/evaluation T1002 RN services, up to 15 minutes T1003 LPN/LVN services, up to 15 minutes T1019 Personal Care Services, Per 15 Minutes, Not For An Inpatient Or Reside T1020 Personal Care Services, Per Diem, Not For An Inpatient Or Resident Of T1028 Assessment Of Home, Physical And Family Environment, To Determine Suit T1030 Nursing Care, In The Home, By Registered Nurse, Per Diem T1031 Nursing Care, In The Home, By Licensed Practical Nurse, Per Diem T1505 Electronic Medication Compliance Manage Devc Nos T2024 Service assessment/plan of care development, waiver T5001 Positioning seat for persons with special orthopedic needs, for use in vehicles V5040 Body-Worn Hearing Aid Bone V5050 Hearing Aid Monaural In Ear V5060 Behind Ear Hearing Aid V5171 Hearing Aid Contralat Rout Device Monaural Ite V5172 Hearing Aid Contralat Rout Device Monaural Ict V5181 Hearing Aid Contralateral Rout Dvc Monaural Bte V5211 Hearing Aid Contralat Rout Sys Binaural Ite/Ite V5212 Hearing Aid Contralat Rout Sys Binaural Ite/Itc V5213 Hearing Aid Contralat Rout Sys Binaural Ite/Bte V5214 Hearing Aid Contralat Rout Sys Binaural Itc/Itc V5215 Hearing Aid Contralat Rout Sys Binaural Itc/Bte V5220 Hearing Aid Bicros Behind The Ear V5221 Hearing Aid Contralat Rout Sys Binaural Bte/Bte V5253 Hearing aid, digitally programmable binaural, BTE V5256 Hearing aid, digital, monaural, ITE V5257 Hearing aid, digital, monaural, BTE V5260 Hearing aid, digital, binaural, ITE V5261 Hearing aid, digital, binaural, BTE 0263T Im B1 Mrw Cel Ther Cmpl 0275T Perc Lamino-/Laminectomy Indir Imag Guide Lumbar 0346T ULTRASOUND ELASTOGRAPHY 0449T Insj Aqueous Drain Dev W/O Eo Rsvr Initial Dev 10040 Acne Surgery 19301 PARTIAL MASTECTOMY 19303 MAST SIMPLE COMPLETE

Page 37 of 40 Code Description 28345 Reconstruction, Toe(S); Syndactyly, W/Wo Skin Graft(S), Each Web 30465 Repair, Nasal Vestibular Stenosis (Spreader Grafting, Lateral Nasal Wall Reconstruction) 30520 Septoplasty/Submucous Resection W/Wo Cartilage Scoring/Contouring/Graft 37220 Revascularization Iliac Artery Angiop 1St Vsl 37221 Revsc Opn/Prq Iliac Art W/Stnt Plmt & Angiop Uni 37223 Revsc Opn/Prq Iliac Art W/Stnt & Angiop Ipsi Vsl 37225 Revsc Opn/Prq Fem/Pop W/Athrc/Angiop Sm Vsl 37226 Revsc Opn/Prq Fem/Pop W/Stnt/Angiop Sm Vsl 37227 Revsc Opn/Prq Fem/Pop W/Stnt/Athrc/Angiop Sm Vsl 37228 Revsc Opn/Prq Tib/Pero W/Angioplasty Uni 37229 Revsc Opn/Prq Tib/Pero W/Athrc/Angiop Sm Vsl 41899 Unlisted Proc, Dentoalveolar Structures 49568 Implantation, Mesh/Prosthesis, Incisional/Ventral Hernia Repair 49585 Repair, Umbilical Hernia, Age 5+; Reducible 49652 Laps Repair Hernia Except Incal/Ingun Reducible 54300 Plastic Operation, Penis, Straightening, Chordee, W/Wo Mobilization, Urethra 58661 Laparoscopy, Surgical; W/Removal, Adnexal Structures 58670 Laparoscopy, Surgical; W/Fulguration Of Oviducts W/Wo Transection 58671 Laparoscopy, Surgical; W/Occlusion, Oviducts By Device 58940 Oophorectomy, Partial/Total, Unilat/Bilat 59320 Cerclage, Cervix, During Pregnancy; Vaginal 81229 Cytogenom Const Microarray Copy Number&Snp Var 81240 F2 Gene Analysis 20210G >A Variant 81243 Fmr1 Analysis Eval To Detect Abnormal Alleles 94760 Noninvasive Ear/Pulse Oximetry, Oxygen Saturation; Single Determination 94799 Unlisted Pulmonary Service/Proc A4550 Surgical Trays A4648 Tissue marker, implantable, any type, each C1725 Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/ perfusion capability) C1726 Catheter, balloon dilatation, non-vascular C1732 Catheter, electrophysiology, diagnostic/ ablation, 3D or vector mapping C1813 Prothesis, penile, inflatable C1874 Stent, coated/covered, with delivery system C2625 Stent, non-coronary, temporary, with delivery sytem D0210 Intraoral - Complete Series (Including Bitewings) D1120 Prophylaxis - Child D1510 Space Maintainer - Fixed - Unilateral D2140 Amalgam - One Surface, Permanent D2150 Amalgam - Two Surfaces, Permanent D2330 Resin - One Surface, Anterior D2331 Resin - Two Surfaces, Anterior D2332 Resin - Three Surfaces, Anterior D2335 Resin - Four Or More Surfaces Or Involving Incisal Angle (Anterior) D2390 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Surface, Posterior D2392 Resin-Based Composite - Two Surfaces, Posterior D2930 Prefabricated Stainless Steel Crown - Primary Tooth D3220 Therapeutic Pulpotomy (Excluding Final Restoration) D3910 Surgical Procedure For Isolation Of Tooth With Rubber Dam D4263 Bone Replacement Graft - First Site In Quadrant D7140 Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Re Surgical Removal Of Erupted Tooth Requiring Elevation Of Mucoperiosteal Flap And Removal Of Bone And/Or Section Of D7210 Tooth D7220 Removal Of Impacted Tooth - Soft Tissue D7230 Removal Of Impacted Tooth - Partially Bony D7240 Removal Of Impacted Tooth - Completely Bony

Page 38 of 40 Code Description

D7950 Osseous, Osteoperiosteal, Or Cartilage Graft Of The Mandible Or Facial Bones - Autogenous Or Nonautogenous, By Report D9223 Procedure code not valid. S2900 Robotic surgical system 11575 Punch graft for hair transplant; 1 to 15 punch grafts 11576 Punch graft for hair transplant; more than 15 punch grafts 65760 Keratomileusis 65771 Radial keratotomy S0800 Laser in situ keratomileusis S0812 Phototherapeutic keratectomy 55250 Vasectomy, Unilat/Bilat, W/Postoperative Semen Exam (Sep Proc) Hysteroscopy, Surgical; With Bilateral Fallopian Tube Cannulation To Induce Occlusion By Placement Of Permanent 58565 Implants 58600 Ligation/Transection, Fallopian Tube, Abd/Vaginal Approach, Unilat/Bilat 58605 Ligation/Transection, Fallopian Tube, Abd/Vaginal Approach, Postpartum (Sep Proc) 58611 Ligation/Transection, Fallopian Tube W/C-Section/Surgery 58615 Occlusion, Fallopian Tube By Device, Vaginal/Suprapubic Approach 96152TJ Hlth&Behavior Ivntj Ea 15 Min Indiv 90832TJ Psychotherapy W/Patient 30 Minutes 97124TJ Therapeutic Proc, 1+ Areas, Each 15 Min; Massage 86003 Allergen Spec Ige Crude Allergen Extract Each 15769 Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less 15771 injectate Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 15772 cc injectate, or part thereof (List separately in addition to code for primary procedure) Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, 15773 and/or feet; 25 cc or less injectate Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, 15774 and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy 64451 or computed tomography) 64454 Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or computed 64625 tomography) 80145 Adalimumab 80187 Posaconazole 80230 Infliximab 80235 Lacosamide 80280 Vedolizumab 80285 Voriconazole Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of- 81277 heterozygosity variants for chromosomal abnormalities 81307 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence 81308 PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene 81309 analysis, targeted sequence analysis (eg, exons 7, 9, 20) Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin- 81522 fixed paraffin-embedded tissue, algorithm reported as recurrence risk score Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin- 81542 embedded tissue, algorithm reported as metastasis risk score Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 81552 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis 87563 Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique Supplies for maintenance of insulin infusion pump with dosage rate adjustment using therapeutic continuous glucose A4226 sensing, per week

Page 39 of 40 Code Description B4187 Omegaven, 10 g lipids C1734 Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable) C1824 Generator, cardiac contractility modulation (implantable) C1839 Iris prosthesis C1982 Catheter, pressure generating, one-way valve, intermittently occlusive C2596 Probe, image guided, robotic, waterjet ablation E0787 External ambulatory infusion pump, insulin, dosage rate adjustment using therapeutic continuous glucose sensing E2398RR Wheelchair accessory, dynamic positioning hardware for back K1001 Standard Wheelchair K1002 Stnd Hemi (Low Seat) Whlchr K1003 Lightweight Wheelchair K1004 High Strength Ltwt Whlchr K1005RR Ultralightweight Wheelchair L2006 Kaf Dvc Any Material Adjustability Custom Fab L8033 Nipple Prosth Cstm Fab Reusabl Any Matl Any T Ea P9099 Blood Component Or Product Noc

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and C9757 excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar

Blinded procedure for NYHA Class III/IV heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, transesophageal echocardiography (TEE)/intracardiac echocardiography (ICE), and all C9758 imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (IDE) study

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