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Home , Coccygectomy

OUTPATIENT SURGERY FEE SCHEDULE

PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 10021 FINE NEEDLE ASPIRATION;W/O IMAGING GUIDE $27.11 $27.11 $27.11 10022 FINE NEEDLE ASPIREATION;W/IMAGING GUIDE $36.34 $36.34 $36.34 10040 ACNE SURG(E.G.MARSUPIALIZATION)OPN-REMOV $822.23 $822.23 $822.23 10060 INCIS&DRAIN ABCESS/CYST, SIMPLE/SINGLE $822.23 $822.23 $822.23 10061 INCIS&DRAIN CYST/ABSESS COMPLICA/MULTIPL $822.23 $822.23 $822.23 10080 I&D PILONIDAL CYST SIMPLE $822.23 $822.23 $822.23 10081 I&D PILONIDAL CYST COMPLICATED $822.23 $822.23 $822.23 10120 INC REMOVAL FOREIGN BODY SURG SIMPLE $822.23 $822.23 $822.23 10121 INC REMOVAL FOREIGN BODY SURG COMPLICAT $822.23 $822.23 $822.23 10140 I&D HEMATOMA, SEROMA OR FLUID COLLECTION $822.23 $822.23 $822.23 10160 PUNCT ASPLE ABSCESS HEMATOMA BULLA CYST $125.00 $125.00 $125.00 10180 INCISION/DRAINAGE,COMPLEX,POSTOP WOUND. $822.23 $822.23 $822.23 11000 DEBRI EXTEN ECZEMA OR INFECT SKIN 10% $570.00 $570.00 $570.00 11004 DEBRI SKIN,SUBCUT TIS,EXT GENTALIA&PERIN $822.23 $822.23 $822.23 11005 DEBRIDE SKIN,SUBCUTAN TIS,ABDOMINAL WALL $822.23 $822.23 $822.23 11006 DEBR SKN,SUBCUT TIS,EXT GENTAL,PERIN&ABD $822.23 $822.23 $822.23 11008 REMV PROSTH MATR'L/MESH,ABD WALL/ADD-ON $125.00 $125.00 $125.00 11010 DEBRID/OPEN FRACT-DISLOC;SKIN&SUBCU TISS $822.23 $822.23 $822.23 11011 DEBRID/OPN FRA&DISL;SKN,SUBCU,MUSCLE FAS $822.23 $822.23 $822.23 11012 DEBRID/OPN FRA&DISL;SKN,SUBC,MUS FAS,BON $822.23 $822.23 $822.23 11040 DEBRIDEMENT SKIN PARTIAL THICKNESS $1,339.05 D D 11041 DEBRIDEMENT SKIN FULL THICKNESS $1,339.05 D D 11042 DEBRIDEMENT SKIN AND SUBCUTANEOUS TISSUE $1,339.05 $1,339.05 $1,339.05 11043 DEBRIDEMENT SKIN SUBCUTAN TISSU MUSCLE $1,339.05 $1,339.05 $1,339.05 11044 DEBRIDEMENT SKIN SUBCUTAN TISS MUSC $1,339.05 $1,339.05 $1,339.05 11045 DEBRIDEMNT,SUBCUT TISSUE;EA ADD 20 SQ Not Valid $1,339.05 $1,339.05 11046 DEBRID,MUSCL/FASC (EPID,DERMIS,SUBCU Not Valid $1,339.05 $1,339.05 11047 DEBRIDEMENT, BONE; EACH ADD'L 20 SQ CM Not Valid $1,339.05 $1,339.05 11055 PARING/CUT BEN HYPERKERATOTIC LESI;SINGL $822.23 $822.23 $822.23 11056 PARING/CUT BEN HYPERKERATOTIC LESI; 20R4 $822.23 $822.23 $822.23 11057 PARING/CUT BEN HYPERKERATOTIC LESINOS;4+ $822.23 $822.23 $822.23 11100 BIOPSY SKN SQ TSSUE MUCOS MEMBRANE 1 LES $822.23 $822.23 $822.23 11200 REMOV SKN TAGS MULT FIBROCUT 15 OR < LES $822.23 $822.23 $822.23 11300 SHVG EPID/DERML LESION SGL TK/AM/LG .5C< $822.23 $822.23 $822.23 11301 SHAVE SKIN LESION, DIA 6.5 TO 1.0 CM $822.23 $822.23 $822.23 11302 SHVG EPID/DRM LESION SGL TK/AM/LG 1.1-2C $822.23 $822.23 $822.23 11303 SHVG EPID/DERM LESION SGL TK/AM/LG 2.0>C $822.23 $822.23 $822.23 11305 SHV EPD/DRL LSN SGL SCL/NK/HD/FT/GT .5C< $822.23 $822.23 $822.23 11306 SHV EPD/DRM LSN SGL SCL/NK/HD/FT/G .6-1C $822.23 $822.23 $822.23 11307 SHV EPD/DRM LSN SGL SCL/NK/HD/F/G 1.1-2G $822.23 $822.23 $822.23 11308 SHV EPD/DRL LSN SGL SCL/NK/HD/FT/G 2.0C> $822.23 $822.23 $822.23 11310 SHV EPD/DRM LESION SGL F/E/E/N/L/MM .5C< $822.23 $822.23 $822.23 11311 SHV EPD/DRM LESN SGL F/E/E/N/L/MM .6-1C $822.23 $822.23 $822.23 11312 SHV EPD/DRM LSN SGL F/E/E/N/L/MM 1.1-2CM $822.23 $822.23 $822.23 11313 SHV EPD/DRM LSN SGL F/E/E/N/L/MM DIA 2C> $822.23 $822.23 $822.23 11400 EXC BENGN LES INCL MARG,T-A-L,<= 0.5 CM $822.23 $822.23 $822.23

07/27/12 Page 1 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 11401 EXC BENGN LES INCL MARGIN,T-A-L,0.6-1 CM $822.23 $822.23 $822.23 11402 EXC BENGN LES INCL MARGIN,T-A-L,1.1-2 CM $822.23 $822.23 $822.23 11403 EXC BENGN LES INCL MARGIN,T-A-L,2.1-3 CM $822.23 $822.23 $822.23 11404 EXC BENGN LES INCL MARGIN,T-A-L,3.1-4 CM $822.23 $822.23 $822.23 11406 EXC BENGN LES INCL MARGIN,T-A-L, > 4.0CM $822.23 $822.23 $822.23 11420 EXC BENGN LES INCL MARG H-F-NK-SP 0.5 < $822.23 $822.23 $822.23 11421 EXC BENGN LES INCL MARG H-F-NK-SP 0.6-1 $822.23 $822.23 $822.23 11422 EXC BENGN LES INCL MARG H-F-NK-SP 1.1-2 $822.23 $822.23 $822.23 11423 EXC BENGN LES INCL MARG H-F-NK-SP 2.1-3 $822.23 $822.23 $822.23 11424 EXC BENGN LES INCL MARG H-F-NK-SP 3.1-4 $822.23 $822.23 $822.23 11426 EXC BENGN LES INCL MARG H-F-NK-SP > 4 CM $822.23 $822.23 $822.23 11440 EXC BEGN LES INCL MARG FACE 0.5 < CM $822.23 $822.23 $822.23 11441 EXC BEGN LES INCL MARG FACE 0.6-1 CM $822.23 $822.23 $822.23 11442 EXC BEGN LES INCL MARG FACE 1.1-2 CM $822.23 $822.23 $822.23 11443 EXC BEGN LES INCL MARG FACE 2.1-3 CM $822.23 $822.23 $822.23 11444 EXC BEGN LES INCL MARG FACE 3.1-4 CM $822.23 $822.23 $822.23 11446 EXC BEGN LES INCL MARG FACE > 4 CM $822.23 $822.23 $822.23 11450 EXC SKN SUBQ HIDRADENITIS AX SIM/INT REP $822.23 $822.23 $822.23 11451 EXC SKN SUBQ HIDRADENITIS AX COMPLEX REP $822.23 $822.23 $822.23 11462 EXC SKN SUBQ HIDRADENITIS ING SIM/INT RE $822.23 $822.23 $822.23 11463 EXC SKN SUBQ HIDRADENITIS ING COMPLEX RE $822.23 $822.23 $822.23 11470 EXCIS SKIN-SUBQ HIDRADENTIS PERI/NAL/NEA $822.23 $822.23 $822.23 11471 EXCIS SKIN-SUBQ HIDRADENITIS PERI/NAL/NE $822.23 $822.23 $822.23 11600 EXC MALGN LES INC MARG,TRNK-ARM-LG .5 4CM $822.23 $822.23 $822.23 11620 EXC,MAL LES INC MAR,HND-FT-NK-SP 0.5 < $822.23 $822.23 $822.23 11621 EXC,MAL LES INC MAR,HND-FT-NK-SP 0.6-1 $822.23 $822.23 $822.23 11622 EXC,MAL LES INC MAR,HND-FT-NK-SP 1.1-2 $822.23 $822.23 $822.23 11623 EXC,MAL LES INC MAR,HND-FT-NK-SP 2.1-3 $822.23 $822.23 $822.23 11624 EXC,MAL LES INC MAR,HND-FT-NK-SP 3.1-4 $822.23 $822.23 $822.23 11626 EXC,MAL LES INC MAR,HND-FT-NK-SP > 4 CM $822.23 $822.23 $822.23 11640 EXCISE,MALIG LESION INCL MARG,FACE 0.5 < $822.23 $822.23 $822.23 11641 EXCISE,MALG LESION INCL MARG, FACE 0.6-1 $822.23 $822.23 $822.23 11642 EXCISE,MALG LESION INCL MARG, FACE 1.1-2 $822.23 $822.23 $822.23 11643 EXCISE,MALG LESION INCL MARG, FACE 2.1-3 $822.23 $822.23 $822.23 11644 EXCISE,MALG LESION INCL MARG, FACE 3.1-4 $822.23 $822.23 $822.23 11646 EXCISE,MALG LESION INCL MARG,FACE > 4 CM $822.23 $822.23 $822.23 11720 DEBRID NAILS/ANY METHOD(S);ONE TO FIVE $293.65 $293.65 $293.65 11721 DEBRID NAILS BY ANY METHOD(S); 6 OR MORE $293.65 $293.65 $293.65 11730 EXC AVULSIO NAIL PLAPART COM SIMP SINGLE $822.23 $822.23 $822.23 11740 EVACUATION SUBUNGWAL HEMATOMA $822.23 $822.23 $822.23 11750 EXC OF NAIL & NAIL MATRIX $822.23 $822.23 $822.23 11752 EXCIS NAIL/MATX PART/COMP W AMPU DIST TU $822.23 $822.23 $822.23 11755 BIOPSY OF NAIL UNIT (SEPARATE PROCEDURE) $822.23 $822.23 $822.23

07/27/12 Page 2 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 11760 RECONSTRUCTION NAIL BEO SIMPLE $822.23 $822.23 $822.23 11762 RECONSTRUCTION NAIL BED COMPLICATED $822.23 $822.23 $822.23 11765 WEDGE EXCIS OF SKIN OF NAIL FOLD(IN-GROW $822.23 $822.23 $822.23 11770 EXC PILONIDAL CYST OR SINUS SIMPLE $1,339.05 $1,339.05 $1,339.05 11771 EXC PILONIDAL CYST OR SINUS EXTENSIVE $1,339.05 $1,339.05 $1,339.05 11772 EXC PILONIDAL CYST OR SINUS COMPLICATED $1,339.05 $1,339.05 $1,339.05 11900 INJECT INTRALESIONAL UP TO 7 LESIONS $822.23 $822.23 $822.23 11901 INJECT INTRALESIONAL MO THAN 7 LESIONS $822.23 $822.23 $822.23 11960 INSERTION OF TISSUE EXPANDERS $293.65 $293.65 $293.65 11970 REPLACE TISSUE EXPANDER WITH PERM PROSTH $822.23 $822.23 $822.23 11971 REMOV TISSU EXPANDER(S) WO INSERT PROSTH $293.65 $293.65 $293.65 11981 INSERT NON-BIODEGRADE DRUG DELIV IMPLANT $822.23 $822.23 $822.23 11982 REMOVE NON-BIODEGRADE DRUG DELIV IMPLANT $822.23 $822.23 $822.23 11983 RMOVE/REINSRT NON-BIO DRUG DELIV IMPLANT $822.23 $822.23 $822.23 12001 SIMPLE REPAIR (AREA) 2.5 OR LESS $293.65 $293.65 $293.65 12002 SIMPLE REPAIR (AREA) 2.6 TO 7.5 CM $293.65 $293.65 $293.65 12004 SIMPLE REPAIR (AREA) 7.6 TO 12.5 CM $125.00 $125.00 $125.00 12005 SIMPLE REPAIR (AREA) 12.6 TO 20.0 CM $822.23 $822.23 $822.23 12006 SIMPLE REPAIR (AREA) 20.1 TO 30.0 CM $822.23 $822.23 $822.23 12007 SIMPLE REPAIR WD SCALP ETC OVER 30CM $822.23 $822.23 $822.23 12011 SIMPLE REPAIR (AREA) 2.5 OR LESS $293.65 $293.65 $293.65 12013 SIMPLE REPAIR (AREA) 2.6 TO 5.0 CM $293.65 $293.65 $293.65 12014 SIMPLE REPAIR (AREA) 5.1 TO 7.5 CM $293.65 $293.65 $293.65 12015 SIMPLE REPAIR (AREA) 7.6 TO 12.5 CM $293.65 $293.65 $293.65 12016 SIMPLE REPAIR (AREA) 12.6 TO 20.0 CM $293.65 $293.65 $293.65 12017 SIMPLE REPAIR (AREA) 20.1 TO 30.0 CM $293.65 $293.65 $293.65 12018 SIMPLE REPAIR WD FACE ETC OVER 30CM $293.65 $293.65 $293.65 12020 TREATMENT SUPERFICIAL WOUND DEHISCENCE $293.65 $293.65 $293.65 12021 TREAT SUPERFICIAL WOUND DEHIS CF W/PACKI $293.65 $293.65 $293.65 12031 LAYER CLOSUR(AREA) 2.5 CM OR LESS $293.65 $293.65 $293.65 12032 LAYER CLOSURE(AREA) 2.6 CM TO 7.5 CM $293.65 $293.65 $293.65 12034 LAYER CLOSURE(AREA) 7.6 CM TO 12.5 CM $822.23 $822.23 $822.23 12035 LAYER CLOSURE(AREA) 12.6 CM TO 20.0 CM $822.23 $822.23 $822.23 12036 LAYER CLOSURE(AREA) 20.1 CM TO 30.0 CM $822.23 $822.23 $822.23 12037 LAYER CLOS SCALP/AX/TRUNK/EXTREM OVER 30 $822.23 $822.23 $822.23 12041 LAYER CLOSURE(AREA) 2.5 CM OR LESS $822.23 $822.23 $822.23 12042 LAYER CLOSURE (AREA) 2.6 CM TO 7.5 CM 75 $822.23 $822.23 $822.23 12044 LAYER CLOS (AREA) 7.6 CM TO 12.5 CM $822.23 $822.23 $822.23 12045 LAYER CLOS (AREA) 12.6 CM TO 20.0 CM $822.23 $822.23 $822.23 12046 LAYER CLOSURE (AREA) 20.1 CM TO 30.00 CM $822.23 $822.23 $822.23 12047 LAYER CLOS NEK/HAN/FET/EX GENIT OVER 30C $822.23 $822.23 $822.23 12051 LAYER CLOSURE (AREA) 2.5 CM OR LESS $293.65 $293.65 $293.65 12052 LAYER CLOSURE(AREA) 2.6 CM TO 5.0 CM $293.65 $293.65 $293.65 12053 LAYER CLOSURE(AREA) 7.6 CM TO 12.5 CM $293.65 $293.65 $293.65 12054 LAYER CLOS (AREA) 7.6 CM TO 12.5 CM $822.23 $822.23 $822.23 12055 LAYER CLOS (AREA) 12.6 CM TO 20.0 CM $822.23 $822.23 $822.23 12056 LAYER CLOS(AREA) 20.1 CM TO 30.0 CM $822.23 $822.23 $822.23 12057 LAY CLOS FAC/EAR/EYE/NOS/LIP/MM OVR 30CM $822.23 $822.23 $822.23

07/27/12 Page 3 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 13100 REPAIR COMPLEX TRUNK 1.1 TO 2.5 CM $822.23 $822.23 $822.23 13101 REPAIR COMPLEX TRUNK 2.6 TO 7.5 CM $1,339.05 $1,339.05 $1,339.05 13120 REPAIR COMPLEX (AREA) 1.1 TO 2.5 CM $822.23 $822.23 $822.23 13121 REPAIR COMPLX (AREA) 2.6 TO 7.5 CM $1,339.05 $1,339.05 $1,339.05 13131 REPAIR COMPLEX (AREA) 1.1 TO 2.5 CM $822.23 $822.23 $822.23 13132 REPAIR COMPLEX (AREA)2.6 TO 7.5 CM $1,339.05 $1,339.05 $1,339.05 13150 REPAIR COMPLX LID-NOS-EAR-LIP 1.2CM LESS $1,339.05 $1,339.05 $1,339.05 13151 REPAIR COMPLX LID-NOS-EAR-LIP 1.1-2.5SQ $1,339.05 $1,339.05 $1,339.05 13152 REPAIR COMPLX LID-NOS-EAR-LIP 2.6-7.5SQ $1,339.05 $1,339.05 $1,339.05 13160 SECONDARY CLOS SURGI WOUND, DEHISC COMPL $822.23 $822.23 $822.23 14000 ADJ TIS TRANS/REARR (AREA) SQ CM R LESS $822.23 $822.23 $822.23 14001 ADJ TISS TRANS/REAA (AREA)10.1-30 SQ CM $822.23 $822.23 $822.23 14020 ADJ TISS TRANS/REARR (AREA)10 SQ CM LESS $822.23 $822.23 $822.23 14021 ADJ TISS TRANS/REARR (AREA)10.1-30 SQ CM $822.23 $822.23 $822.23 14040 ADJ TISS TRANS/REARR(AREA)10 SQ CM LESS $822.23 $822.23 $822.23 14041 ADJA TISS TRAN/REARR(AREA)10.1-30SQ CM $822.23 $822.23 $822.23 14060 ADJ TSSUE TRANS-REARR(AREA)10 SQ OR LESS $822.23 $822.23 $822.23 14061 ADJ TSSUE TRNSF LID-NOS-ER-LP 10.1-30SQ $822.23 $822.23 $822.23 14301 $822.23 $822.23 $822.23 14302 $822.23 $822.23 $822.23 14350 FILLET FINGER TOE FLAP PREP SITE $1,339.05 $1,339.05 $1,339.05 15040 SKN HARV/TISS CULTURED AUTOGR,<=100SQ CM $822.23 $822.23 $822.23 15050 PINCH GRAFT SINGLE OR MTPLE $822.23 $822.23 $822.23 15100 SPLT-THICK AUTOGRF(TRUNK,ARM,LEG)1%BODY $822.23 $822.23 $822.23 15110 EPIDRM AUTOGR,TR-ARM-LEG;<=100SQ CM;INIT $822.23 $822.23 $822.23 15115 EPID AUTOGR(AREAS);1ST 100SQ CM,1%,INF&C $1,339.05 $1,339.05 $1,339.05 15120 SPLIT-THICK AUTOGRAFT(FACE,SCALP,ETC) 1% $822.23 $822.23 $822.23 15130 DERM AUTOGR(AREA);1ST 100SQ CM,1%,INF&CH $1,339.05 $1,339.05 $1,339.05 15135 DERM AUTOGR(AREA);1ST 100SQ CM,1%,INF&CH $1,339.05 $1,339.05 $1,339.05 15150 TISS CULT EPIDERM AUTO(AREA)1ST 25 SQ CM Not Valid Not Valid $570.00 15151 TISS CUL AUTOGRAFT $570.00 $570.00 15152 TISS CUL AUTOGRAFT $570.00 $570.00 15155 TISS CULT EPIDRM AUTO(AREA);1ST 25 SQ CM $1,339.05 $1,339.05 $1,339.05 15156 TISS CUL AUTOGRAFT $570.00 $570.00 15157 TISS CUL AUTOGRAFT $1,339.05 $1,339.05 15170 ACELL DERM REPL(AREA);1ST100SQ CM;INF/CH $1,339.05 $1,339.05 D 15175 ACELL DERM REPL(AREA);1ST100SQ CM;INF/CH $1,339.05 $1,339.05 D 15200 FULL THICK GRAFT DIR CLO TRUNK 20SQ LESS $1,339.05 $1,339.05 $1,339.05 15220 FULL THCKNSS GF SCALP ETC -20 SQCM $1,339.05 $1,339.05 $1,339.05 15240 FULL THCK GRAFT(AREA) 20SQCM OR LESS $1,339.05 $1,339.05 $1,339.05 15260 FULL THCKNSS GF NOSE ETC -20SQCM LESS $1,339.05 $1,339.05 $1,339.05 15271 SKIN SUB GRAFT TRNK/ARM/LEG TO 100SQ CM Not Valid Not Valid $1,339.05 15272 SKIN SUB GRAFT TRNK/ARM/LEG ADD-ON Not Valid Not Valid $1,339.05 15273 SKIN SUB GRAFT TRNK/ARM/LEG > 100 SQ CM Not Valid Not Valid $1,339.05 15274 SKIN SUB GRAFT TRNK/ARM/LEG>100SQ CM ADD Not Valid Not Valid $1,339.05 15275 SKIN SUB GRFT FACE/SCLP/ETC TO 100 SQ CM Not Valid Not Valid $1,339.05 15276 SKIN SUB GRFT FACE/SCLP/ETC, ADD-ON Not Valid Not Valid $1,339.05 15277 SKIN SUB GRFT FACE/SCLP/ETC,CHILDREN Not Valid Not Valid $1,339.05

07/27/12 Page 4 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 15278 SKIN SUB GRFT FACE/SCLP/ETC, ADD-ON Not Valid Not Valid $1,339.05 15300 ALLOGR SKN,TMP WND CLOS,100SQ CM,INF/CHD $822.23 $822.23 D 15320 ALLOGR SKN,TMP WND CLOS,100SQ CM,INF/CHD $822.23 $822.23 D 15330 ACELL DERM ALLOGR,1ST 100 SQ CM, INF&CHD $822.23 $822.23 D 15335 ACELL DERM ALLOGR;1ST 100 SQ CM, INF&CHD $822.23 $822.23 D 15340 TISS CULTUR ALLOGENEIC SKN SUB;=25SQ CM $822.23 $822.23 D 15360 TIS CUL ALLOG DERM SUB;=<100SQ CM,INF&CH $822.23 $822.23 D 15365 TIS CUL ALLOG DERM SUB;<=100 SQ CM/INF&C $822.23 $822.23 D 15400 XENOGRAFT,SKIN,TEMP WOUND CLOSURE,1%BODY $822.23 $822.23 D 15420 XENOGR SKN,TMP WND CLOS;<=100SQ CM,INF&C $822.23 $822.23 D 15430 ACELLUAR XENOGR IMPL;<100SQ CM,INF&CHD $822.23 $822.23 D 15570 FORM DIR-TUBED PED TRUNK $1,339.05 $1,339.05 $1,339.05 15572 FORM DIR-TUBED PED SCALP ARM LEG $1,339.05 $1,339.05 $1,339.05 15574 FORM DIR-TUBED PED FOREHEAD NECK HAND $1,339.05 $1,339.05 $1,339.05 15576 FORM DIR-TUBED PED EYELID NOSE INTRADRAL $1,339.05 $1,339.05 $1,339.05 15600 DELAY FLAP SECT FLAP AT TRUNK $1,339.05 $1,339.05 $1,339.05 15610 INTERMED DELAY ANY FLAP TO SCALP ETC $1,339.05 $1,339.05 $1,339.05 15620 INTERMED DELAY ANY FLAP TO CHEEK ETC $1,339.05 $1,339.05 $1,339.05 15630 INTERMED DELAY ANY FLAP NOSE ETC $1,339.05 $1,339.05 $1,339.05 15650 TRNSF INTERMED ANY PED FLAP ANY LOCATION $1,339.05 $1,339.05 $1,339.05 15732 MUSCL,MYO/FASCIOCUTANEOUS FLAP; HEAD&NCK $1,339.05 $1,339.05 $1,339.05 15734 FLAP,MUSCLE MYO/FASCIOCUTAN TRUNK $1,339.05 $1,339.05 $1,339.05 15736 FLAP MUSCLE MYO/FASCIOCUTAN UPPER EXTREM $1,339.05 $1,339.05 $1,339.05 15738 FLAP MUSCLE MYO/FASCIOCUTAN LOWER EXTREM $1,339.05 $1,339.05 $1,339.05 15740 FLAP ISLAND PEDICLE $1,339.05 $1,339.05 $1,339.05 15750 NEUROVASCULAR PEDICLE $1,339.05 $1,339.05 $1,339.05 15756 FREE MUSCLE FLAP W/SKIN MICROVASCUL ANAS $1,339.05 $1,339.05 $1,339.05 15757 FREE SKIN FLAP W/MICROVASCULAR ANASTOMOS $1,339.05 $1,339.05 $1,339.05 15758 FREE FACIAL FLAP W/MICROVASCULAR ANASTOM $1,339.05 $1,339.05 $1,339.05 15760 GRAFT COMPOS FULL THICK EAR-ALA DON AREA $822.23 $822.23 $822.23 15770 GRAFT DERMA FATFASCIA $822.23 $822.23 $822.23 15777 ACELLULAR DERMAL MATRIX IMPLANT/SOFT TIS Not Valid Not Valid $1,339.05 15823 BLEPHAROPLASTY,UP LID SKIN WT DOWN LID $822.23 $822.23 $822.23 15830 EXCISION,EXCESS SKIN&SUBCUT TISS,ABDOMEN $350.00 $350.00 $350.00 15840 GRF FACIAL NERVE PARALYSIS FASCIA GRAFT $822.23 $822.23 $822.23 15841 GRFT FACE NERVE PARALYSIS MSCLE GFT $822.23 $822.23 $822.23 15842 GRAF FAC NERV PARAL;FRE MUS FLAP-MICROSU $822.23 $822.23 $822.23 15845 GRFT FACE NERVE PARALYSIS REANIMATION $822.23 $822.23 $822.23 15850 REMOV SUTURES UNDER ANESTH(NO LOC)SAMEMD $293.65 $293.65 $293.65 15851 REMOVAL SUTURES UNDER ANESTH, OTH SURGEO $293.65 $293.65 $293.65 15852 DRESS CHANG(NO BURN)UNDER ANEST(NO LOC) $293.65 $293.65 $293.65 15860 IV INJ/AGENT TEST VASCULAR FLOW IN FLAP $822.23 $822.23 $822.23 15920 COCCYGECTOMY PRIMARY SUTURE $1,339.05 $1,339.05 $1,339.05 15922 COCCYGECTOMY WITH FLAP CLOSURE $1,339.05 $1,339.05 $1,339.05 15931 EXCIS SACRAL DECUB ULCER W/PRIM SUTURE $1,339.05 $1,339.05 $1,339.05 15933 EXC SACRAL DECUB ULCER OSECTOMY PRIM CLO $1,339.05 $1,339.05 $1,339.05 15934 EXCISION SACRAL PRESSURE ULCER $1,339.05 $1,339.05 $1,339.05 15935 EXCIS ULCER SACRAL W/FLAP... W/ $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 5 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 15936 EXV SAC PRE ULCER W MUS-MYOCUT FLAP CLOS $1,339.05 $1,339.05 $1,339.05 15937 EXCIS SACRAL ULCER W/FLAP CLOS W/OSTECTO $1,339.05 $1,339.05 $1,339.05 15940 EXC ISCHIAL DECUB ULCER DIRECT SUTURE $1,339.05 $1,339.05 $1,339.05 15941 EXC ISCHIAL DECUB ULCER W OSTECTOMY $1,339.05 $1,339.05 $1,339.05 15944 EXC ISCH PRE ULCER W SKIN FLAP CLOSURE $1,339.05 $1,339.05 $1,339.05 15945 EXCIS ISCHIAL ULCER LOCAL REGI FLAP/OSTE $1,339.05 $1,339.05 $1,339.05 15946 EXCIS,ISCHIAL ULCER,OSTEC,W/MUSCL MYOCUT $1,339.05 $1,339.05 $1,339.05 15950 EXC TROCHANTERIC DECUB ULCER DIREC SUTRE $1,339.05 $1,339.05 $1,339.05 15951 EXC TRONCHAN DECU ULCER W OSTECTOMY $1,339.05 $1,339.05 $1,339.05 15952 EXC TROCH PR UL W SK FP CLOSURE $1,339.05 $1,339.05 $1,339.05 15953 EXC TRONCHAN DECUB ULCER S FLAP OSTECTOM $1,339.05 $1,339.05 $1,339.05 15956 EXCIS TROCHANT ULCER W/MUSCL/MYOCUT FLAP $1,339.05 $1,339.05 $1,339.05 15958 EXCIS TROCAN ULCER W/MUSCL/MYOCUT W/OSTE $1,339.05 $1,339.05 $1,339.05 15999 UNLISTED PROCEDURE EXCISION PRESSURE ULC $1,339.05 $1,339.05 $1,339.05 16020 DRESS/DEBRID PARTIAL-THICK BURNS, SMALL $822.23 $822.23 $822.23 16025 DRESS/DEBRID PARTIAL-THICK BURNS,MEDIUM $822.23 $822.23 $822.23 16030 DSG DEBRID WO ANESTH LARGE $822.23 $822.23 $822.23 16035 ESCHAROTOMY; INITIAL INCISION $822.23 $822.23 $822.23 17000 DESTROY BENIGN/PREMALIGNANT LESIONS; 1ST $822.23 $822.23 $822.23 17004 DESTRUC OTHER THAN SKIN TAGS;15+LESIONS $822.23 $822.23 $822.23 17106 DESTRUCT MULT CUTANIOUS LESIONS:-10SQ CM $822.23 $822.23 $822.23 17107 DESTRUCT CUTANIOUS LESIONS;10-50SQ CM $822.23 $822.23 $822.23 17108 DESTRUCT CUTANIOUS LESIONS;ABOVE 50SQ CM $822.23 $822.23 $822.23 17110 DESTR BENIGN LES,MOLLUSCUM;0-14 LESIONS $822.23 $822.23 $822.23 17111 DEST FLAT WARTS,MOLL CONTAG,MILIA;15+LES $822.23 $822.23 $822.23 17250 CHEM CAUT GRAN TISSUPRD FLESH/SINUS/FIST $822.23 $822.23 $822.23 17260 DESTR MALIGN LES,TRUNK,ARM,LEG;DIA<=.5CM $822.23 $822.23 $822.23 17261 DEST MAL LESION .6-01 CM TRUNK ARM LEG $822.23 $822.23 $822.23 17262 DEST MAL LESION 1.1 2.0 CM TRUN ARM LEG $822.23 $822.23 $822.23 17263 DEST MAL LESION 2.1 3.0 CM TRUN ARM LEG $822.23 $822.23 $822.23 17264 DEST MAL LESION 3.1 4.0 CM TRUN ARM LEG $822.23 $822.23 $822.23 17266 DEST MAL LESION OVER 4.0CM TRUN ARM LEG $822.23 $822.23 $822.23 17270 DEST,MAL LES,SC,NCK,HND,FT,GEN;DIA<=.5CM $822.23 $822.23 $822.23 17271 DEST MAL LESION .6 1.CM SCA NE HA FT GEN $822.23 $822.23 $822.23 17272 DEST MAL LES 1.1 2.0CM SCA NE HA FT GEN $822.23 $822.23 $822.23 17273 DEST MAL LES 2.1 3.0CM SCA NE HA FT GEN $822.23 $822.23 $822.23 17274 DEST MAL LES 3.1 4.0CM SCA NE HA FT GEN $822.23 $822.23 $822.23 17276 DEST MAL LES >4.0 CM SCA NE HA FT GEN $822.23 $822.23 $822.23 17280 DESTR,MAL LES,FACE,EARS,EYELID;DIA<=.5CM $822.23 $822.23 $822.23 17281 DEST MAL LES .6 1CM FA EA EYELID NOSE $822.23 $822.23 $822.23 17282 DEST MAL LES 1.1 2CM FA EA EYELID NOSE $822.23 $822.23 $822.23 17283 DEST MAL LES 2.1 3CM FA EA EYELID NOSE $822.23 $822.23 $822.23 17284 DEST MAL LES 3.1 4CM FA EA EYELID NOSE $822.23 $822.23 $822.23 17286 DEST MAL LES >4CM FA EA EYELID NOSE $822.23 $822.23 $822.23 17340 CRYOTHERAPY (CO2 SLUSH, LIQUID N2) ACNE $822.23 $822.23 $822.23 17999 UNLISTED PROCEDURES KN & SUBQ TISSUE $822.23 $822.23 $822.23 19000 PUNCTURE ASPIRATION OF CYST $293.65 $293.65 $293.65 19020 MASTOTOMY W EXPLORATION $822.23 $822.23 $822.23

07/27/12 Page 6 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 19100 BIO BREAST PERCUT,NEDL CORE NO IMAG GUID $822.23 $822.23 $822.23 19101 BIOPSY OF BREAST; OPEN INCISIONAL $1,339.05 $1,339.05 $1,339.05 19102 BIOPSY-BREAST;PERCUT,NEEDLE COR,IMAG GUI $822.23 $822.23 $822.23 19103 BIOPSY-BREAST;PERC,AUTO VACUM AST/ROT BI $822.23 $822.23 $822.23 19110 NIPPLE EXPLOR W/WO EXCISION OF DUCTS $822.23 $822.23 $822.23 19112 EXCISION LACTIFEROUS DUCT FISTULA $822.23 $822.23 $822.23 19120 EXCIS CYST,FIBROADERMA,TUMOR BREAST 1 + $822.23 $822.23 $822.23 19125 EXC BREAST LES PREOP PL RADI MRK OPN SNG $822.23 $822.23 $822.23 19260 EXC CHEST WALL TUMOR INCLUDING RIBS $822.23 $822.23 $822.23 19271 EXC CHEST WALL TUMOR WO LYMPHADENECTOMY $822.23 $822.23 $822.23 19272 EXC CHEST WALL TUMOR W LYMPHADENECTOMY $822.23 $822.23 $822.23 19290 PREOP PLACE NEEDLE LOCALIZTN WIRE/BREAST $822.23 $822.23 $822.23 19296 BALL CATH/BRST RADIO ELE APPL POST MASTE $822.23 $822.23 $822.23 19297 PL BALL CATH/BRST RADIO EL APP W/MAST/AD $293.65 $293.65 $293.65 19298 PL BRAC CTH/BRST/RADIO EL APP W/POST MAS $822.23 $822.23 $822.23 19300 GYNECOMASTIA MASTECTOMY (REM BREAST TIS) $822.23 $822.23 $822.23 19301 PARTIAL MASTECTOMY $822.23 $822.23 $822.23 19302 PARTL MASTECTOMY W/AXIL LYMPHADENECTOMY $1,339.05 $1,339.05 $1,339.05 19303 MASTECTOMY, SIMPLE, COMPLETE $1,339.05 $1,339.05 $1,339.05 19304 MASTECTOMY, SUBCUTANEOUS $1,339.05 $1,339.05 $1,339.05 19305 MASTECTOMY, RADICAL,INC PECTORAL MUSCLES $1,585.73 $1,585.73 $1,585.73 19307 MASTECTOMY, MODIFIED RADICAL $1,339.05 $1,339.05 $1,339.05 19316 MASTOPEXY, REPAIR AND RECONSTRUCT $822.23 $822.23 $822.23 19318 REDUCTION MAMMAPLASTY $822.23 $822.23 $822.23 19328 REMOVAL INTACT MAMMARY IMPLANT $822.23 $822.23 $822.23 19330 REMOVAL MAMMARY IMPLANT MATERIAL UNILATE $822.23 $822.23 $822.23 19340 IMMED INSRT BREAST PROSTHES FOLLW MAST $822.23 $822.23 $822.23 19342 DELAYED INSERT BREAST IMPLANT AFTER MAST $822.23 $822.23 $822.23 19350 NIPPLE/AREOLA RECONSTRUCTION $822.23 $822.23 $822.23 19355 CORRECTION OF INVERTED NIPPLE $822.23 $822.23 $822.23 19357 BREAST RECON TIS EXP INC SUBSEQ EXP $2,572.41 $2,572.41 $2,572.41 19361 BREAST RECON LATI DOR FLAP W/PROS IMPLA $822.23 $822.23 $822.23 19364 BREAST RECON W/FREE FLAP $822.23 $822.23 $822.23 19366 BREAST RECON W OTHER TECHNIQUE $822.23 $822.23 $822.23 19367 BREAST RECONS W/TRAV RECTUS ABDOM MYOCUT $1,339.05 $1,339.05 $1,339.05 19368 BREAST RECONS W/TRAM SING PEDI W/MICROVA $1,339.05 $1,339.05 $1,339.05 19369 BREAST RECONS W/TRAM DOUBLE PEDICLE INC $1,339.05 $1,339.05 $1,339.05 19370 OPEN PERIPROSTHETIC CAPSULOTOMY - BREAST $822.23 $822.23 $822.23 19371 PERIPROSTHETIC CAPSULECTOMY - BREAST $822.23 $822.23 $822.23 19380 REVISION OF RECONSTR BREAST $822.23 $822.23 $822.23 19499 UNLISTED PROCEDURE BREAST $293.65 $293.65 $293.65 20000 INCIS SOFT TIS ABCES SECD OSTEOMYE SUPER $293.65 D D 20005 INCIS SOFT TIS ABCES SEC OSTEO DEEP-COMP $293.65 $293.65 $293.65 20100 EXPLOR PENETRATING WOUND; NECK (SEP PROC $1,339.05 $1,339.05 $1,339.05 20101 EXPLOR PENETRATING WOUND (SEP PROC); CHE $822.23 $822.23 $822.23 20102 EXPLOR PENETRATING WOUND (SEP PROC); ABD $1,339.05 $1,339.05 $1,339.05 20103 EXPLOR PENETRATING WOUND (SEP PROC); EXT $822.23 $822.23 $822.23 20200 BIOPSY MUSCLE SUPERFICIAL $822.23 $822.23 $822.23

07/27/12 Page 7 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 20205 BIOPSY MUSCLE DEEP $822.23 $822.23 $822.23 20206 BIOPSY MUSCLE PERCUTANEOUS NEEDLE $822.23 $822.23 $822.23 20220 BIOPSY BONE TROC-NEED SUPERFI (EG RIBS) $822.23 $822.23 $822.23 20225 BIOPSY,BONE,TROCAR,OR NEEDLE;DEEP $822.23 $822.23 $822.23 20240 BIOPSY,BONE,EXCIS;SUPERFIC(EG,ILIU;RIBS) $822.23 $822.23 $822.23 20245 BIOPSY EXCIS DEEP (HUMER,ISCH,FEMUR) $822.23 $822.23 $822.23 20250 BIOPSY VERTEBRAL BODY OPEN THORACIC $822.23 $822.23 $822.23 20251 BIOPSY VERTE BODY OPEN LUMBAR OR CERICAL $822.23 $822.23 $822.23 20500 INJECT OF SINUS TRACT THERA (SEPAR PROC) $293.65 $293.65 $293.65 20520 REMOV FB IN MUSCLE/TEND SHEART, SIMPLE $822.23 $822.23 $822.23 20525 REMOV FB MUSCL/TEND SHEATH DEEP OR COMPL $822.23 $822.23 $822.23 20526 INJECTION,THERAPY,CARPAL TUNNEL $98.05 $98.05 $98.05 20527 INJ, DUPUTREN'S CORD WITH ENZYME Not Valid Not Valid $98.05 20550 INJ TENDON SHEATH/LIGAMENT $293.65 $293.65 $293.65 20551 INJECTION;TENDON ORIGIN/INSERTION $293.65 $293.65 $293.65 20552 INJECT TRIGGER POINT(S), 1 OR 2 MUSCLE $293.65 $293.65 $293.65 20553 INJECT TRIGGER POINTS, =/> 3 MUSCLES $293.65 $293.65 $293.65 20555 PLAC NEEDLE IN MUSC/TISS RADIOELEMNT APP $822.23 $822.23 $822.23 20600 DRAIN/INJ SM JOINT/BURSA $293.65 $293.65 $293.65 20605 ARTHROCENTES DRAIN/INJ INTMED JNT/BURSA $293.65 $293.65 $293.65 20610 ARTHROCENTESIS MAJOR JT BURSA $293.65 $293.65 $293.65 20612 ASPIRATION &/OR INJECTN OF GANGLION CYST $293.65 $293.65 $293.65 20615 ASPIRATION ND INJECTION TREAT BONE DISEA $1,339.05 $1,339.05 $1,339.05 20650 INSERT WIRE-PIN SKELET TRAC INC REMOVAL $822.23 $822.23 $822.23 20660 APPLI CRANIAL TONGS,CALIPER,STERO REMOVA $822.23 $822.23 $822.23 20664 APP HALO,INC REM,CRAN,6+PINS,THN SK OSTE $822.23 $822.23 $822.23 20665 REMOVAL OF TONGS-HALO APPLI BY ANOT PHYS $822.23 $822.23 $822.23 20670 REMOVAL IMPLAN SUPER(EG WIRE,PIN-) SEPAR $822.23 $822.23 $822.23 20680 REMOV IMPLANT DEEP (EG SCREW,ROD,OR PLA) $822.23 $822.23 $822.23 20690 COMPUTER COMPUTATION MULTIPLANE EXT FIX $1,339.05 $1,339.05 $1,339.05 20692 COMPUTR AD,MULTIPL EXT FIX/EA STRUT CHG $1,339.05 $1,339.05 $1,339.05 20693 ADJUST/REVISE EXTERN FIX SYS; REQ ANESTH $1,339.05 $1,339.05 $1,339.05 20694 REMOVE,U ANESTH,EXTERN FIXATION SYSTEM $822.23 $822.23 $822.23 20696 COMPUTER COMPUTATION MULTIPLANE EXT FIX $1,339.05 $1,339.05 $1,339.05 20697 COMPUTR ADJ,MULTIPL EXT FIX/EA STRUT CHG $1,339.05 $1,339.05 $1,339.05 20900 BONE GRAFT ANY DONOR AREA(MINOR,SMALL) $822.23 $822.23 $822.23 20902 BONE GRAFT ANY DONOR AREA MAJOR OR LARGE $822.23 $822.23 $822.23 20910 GRAFT COSTOCHONDRAL $822.23 $822.23 $822.23 20912 CARTILAGE GRAFT NASAL SEPTRUM $822.23 $822.23 $822.23 20920 FASCIA LATA GRFT BY STRIPPER $1,339.05 $1,339.05 $1,339.05 20922 FASCIA LATA GRAFT BY INCIS EXPOS COM-SHE $1,339.05 $1,339.05 $1,339.05 20924 TENDON GRAFT FRM DIST (EG PALMA TOE EXT- $1,339.05 $1,339.05 $1,339.05 20926 TISSUE GRAFTS OTHER (EG PARATE,FAT,DERM) $822.23 $822.23 $822.23 20930 ALLOGRAFT FOR SPINE SURG ONLY; MORSELIZE $350.00 $350.00 $350.00 20931 ALLOGRAFT FOR SPINE SURG ONLY; STRUCTURA $822.23 $822.23 $822.23 20936 AUTOGRAFT SPINE SURG(INCL GRAFT HARV) LO $822.23 $822.23 $822.23 20937 AUTOGRAFT SPINE SURG(INCL GRAFT HARV) MO $822.23 $822.23 $822.23 20938 AUTOGRAFT SPINE SURG(INCL GRAFT HARV) ST $822.23 $822.23 $822.23

07/27/12 Page 8 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 20950 MONITORING INTERSTITIAL FLUID PRESS SEC- $293.65 $293.65 $293.65 20970 FREE OSTEOCUT FLP W/MICR ANAS;ILIAC CRST $822.23 $822.23 $822.23 20972 FREE OSTEOCUTAN FLAP W/MICRO ANAST METAT $822.23 $822.23 $822.23 20973 FREE OSTEOCUTAN FLAP W/MICRO ANAST TOE/W $822.23 $822.23 $822.23 20975 ELECT STIM AID BONE HEAL INVASIVE (OPERA $822.23 $822.23 $822.23 20982 ABLATION,BONE TUMOR(S) RADIOFREQ,PERCUTA $822.23 $822.23 $822.23 20999 UNLISTED PROCEDURE MUSCLOSKEL SYS GENERA $822.23 $822.23 $822.23 21010 TEMPOROMANDIB JOINT $822.23 $822.23 $822.23 21011 $822.23 $822.23 $822.23 21012 $1,339.05 $1,339.05 $1,339.05 21013 $822.23 $822.23 $822.23 21014 $822.23 $822.23 $822.23 21015 RAD RESECT MALIGN TUMOR,SFT TISS FACE/SC $1,339.05 $1,339.05 $1,339.05 21016 $1,339.05 $1,339.05 $1,339.05 21025 EXCISION BONE MANDIBLE (EG OSTEOMYELITIS $822.23 $822.23 $822.23 21026 EXCISION FACIAL BONE(S) (EG OSTEOMYLITIS $822.23 $822.23 $822.23 21029 REMOVE BENIGN TUMOR FACIAL BONE CONTOUR $1,339.05 $1,339.05 $1,339.05 21030 EXCISION BENIGN TUM-CYST FACI BONE OTHER $1,339.05 $1,339.05 $1,339.05 21031 EXC TORUS MANDIBULARIS $1,339.05 $1,339.05 $1,339.05 21032 ECIS OF MAXILLARY TORUS PALATINUS $822.23 $822.23 $822.23 21034 EXCISE MAXILLA/ZYGOMA MALIGNANT TUMOR $1,339.05 $1,339.05 $1,339.05 21040 EXCISIN BENIGN CYST-TUM MANDIB SIMPLE $1,339.05 $1,339.05 $1,339.05 21044 EXCISIN MALIGNANT TUMOR MANDIBLE $1,339.05 $1,339.05 $1,339.05 21046 EXCISN TUMOR/CYST MANDIBLE;INTRA-ORAL OS $1,339.05 $1,339.05 $1,339.05 21047 EXCISN CYST; EXTRA-ORAL/MANDIBULECTOMY $1,339.05 $1,339.05 $1,339.05 21048 EXCIS MAXILLA CYST;INTRA-ORAL $1,339.05 $1,339.05 $1,339.05 21049 EXCIS CYST;EXTRA-ORAL OSTEO/MAXILLECTOMY $1,339.05 $1,339.05 $1,339.05 21050 CONDYLECTOMY, TMJ (SEPARATE PROCEDURE) $1,585.73 $1,585.73 $1,585.73 21060 MENISCETOMY,TMJ,PART-COMPLETE(SEP PROCED $1,585.73 $1,585.73 $1,585.73 21070 CORONOIDECTOMY (SEPARATE PROCED) $822.23 $822.23 $822.23 21110 APPLI INTERDENT FIX DEVICE OTH THEN FX $822.23 $822.23 $822.23 21172 RECONSTR SUPER-LAT ORBIT RIM&LOW FOREHEA $350.00 $350.00 $350.00 21181 REMVE BY CONTOUR,CRANIAL BNE BENGN TUMOR $1,339.05 $1,339.05 $1,339.05 21206 OSTEOTOMY, MAXILLA, SEGMENTAL (WASSMUND) $822.23 $822.23 $822.23 21208 OSTEOPLASTY,FACIAL AUGMENT(IMPLANT $1,585.73 $1,585.73 $1,585.73 21209 OSTEOPLASTY,FACIAL BONES REDUCTION $822.23 $822.23 $822.23 21210 GRAFT BONE NASAL MAXI-MALAR(INC GRAF)SEE $1,585.73 $1,585.73 $1,585.73 21215 GRAFT BONE MANDIBLE (INC OBTAIN GRAFT $1,585.73 $1,585.73 $1,585.73 21230 GRAFT;RIB CART,AUTOG,FACE/CHIN/NOSE/EAR $1,339.05 $1,339.05 $1,339.05 21235 GRAFT EAR CART;AUTOG, TO NOSE OR EAR $822.23 $822.23 $822.23 21240 TEMPROMAND JOINT W/WO AUTOG $1,585.73 $1,585.73 $1,585.73 21242 ARTHROPLASTY TMJ W/WO AUTOGRAFT $1,585.73 $1,585.73 $1,585.73 21243 ARTHROPLASTY TMJWITH PROSTHETIC JOINT $1,585.73 $1,585.73 $1,585.73 21244 RECONSTRUC MANDIB EXTRAORAL W TRANS BONE $1,339.05 $1,339.05 $1,339.05 21245 RECONSTRUC MANDI-MAXI SUBPERIOS PARTIAL $1,339.05 $1,339.05 $1,339.05 21246 RECONSTRU MAND/MAXIL IMPLANT COMPLETE $1,339.05 $1,339.05 $1,339.05 21248 RECONSTRUC MANDI-MAXI SUBPERIOS COMPLETE $1,339.05 $1,339.05 $1,339.05 21249 RECONSTRU MANDI-MAXIENDO IMPLANT COMPLE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 9 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 21260 ORBIT HYPER CORR(PERIOR) EXCRAN APPROACH $822.23 $822.23 $822.23 21261 PERIOR OSTOMY FR HYPERT INTRA A EXTRACR $822.23 $822.23 $822.23 21263 ORBIT HYPER (PERIOB) WITH FOREHEA ADVANC $822.23 $822.23 $822.23 21267 ORBIT REPOS PERI OST UNILAT W GRFT EXTRC $822.23 $822.23 $822.23 21270 MALAR AUGMENT, PROSTHETIC MATERIAL $1,339.05 $1,339.05 $1,339.05 21275 SECNRY REVIS ORBITOCRAINIOFACL RECNSRUCT $822.23 $822.23 $822.23 21280 MEDIAL CANTHOPEXY (SEP PROC) $1,339.05 $1,339.05 $1,339.05 21282 LATERAL CANTHOPEXY $1,339.05 $1,339.05 $1,339.05 21295 REDUCT MASSETER MUSCLE/BONE ESTRAORAL AP $1,339.05 $1,339.05 $1,339.05 21296 REDUCT MASSETER MUSCLE/BONE INTRAORAL AP $1,339.05 $1,339.05 $1,339.05 21299 UNLISTED CRANIOFACIAL& MAXILLFAC PROCED $822.23 $822.23 $822.23 21310 CLOSED TREAT NASAL BONE FRACT W/O MANIPU $822.23 $822.23 $822.23 21315 CLOSED TREAT NASAL BONE FRACT W/O STABIL $822.23 $822.23 $822.23 21320 MANIPULATION INSTRUMENTAL COMPLI NASA FX $822.23 $822.23 $822.23 21325 OPN TREAT NASAL FX UNCMPLICATED $822.23 $822.23 $822.23 21330 OPN TREAT NASAL FX COMP INTER EXTER SKEL $822.23 $822.23 $822.23 21335 OPN TREAT NASAL FX CONCOM OPN FX SEPTUM $822.23 $822.23 $822.23 21336 OPN TREAT NASAL SEPT FX W/WO STABILIZATI $822.23 $822.23 $822.23 21337 CLOSED TREAT NASAL SEPTAL FRAC W/WO STAB $822.23 $822.23 $822.23 21338 OPEN TREAT NASOETHMOID FX W0 EXTER FIXAT $822.23 $822.23 $822.23 21339 OPEN TREAT NASOETHMO FX WITH EXT FIXAT $822.23 $822.23 $822.23 21340 PERCUTANEOUS TREAT NASOET COMPLX FX W SP $822.23 $822.23 $822.23 21343 OPEN TREAT DEPRESSED FRONTAL SINUS FRACT $1,339.05 $1,339.05 $1,339.05 21345 CLOSED TREAT NASOMAXCOMPLX FRACT LEFORT $1,339.05 $1,339.05 $1,339.05 21355 PERCUTANEOUS TREAT FX MALAR AREA W MANIP $1,339.05 $1,339.05 $1,339.05 21356 OPN TREAT DEPRESSED ZYGOMATIC ARCH FRACT $1,585.73 $1,585.73 $1,585.73 21360 OPEN TREAT DEPRES MALAR FX INC ZYG/MA TR $1,585.73 $1,585.73 $1,585.73 21365 OPN TREAT COMPLI FX MALAR W INT FIX/SURG $1,585.73 $1,585.73 $1,585.73 21385 OPEN TRT ORBITAL FL BLOWOUT FRAC TRAN AP $1,339.05 $1,339.05 $1,339.05 21386 OPN TREAT ORBIT(BLOWOUT)FX PERIORB APPRO $1,339.05 $1,339.05 $1,339.05 21387 OPN TREAT ORBIT(BLOWOUT)FX COMBIN APPROA $570.00 $570.00 $570.00 21390 OPN TREAT ORBIT(BLOWOUT) FX ALLOPLA-IMPL $1,339.05 $1,339.05 $1,339.05 21400 CLOSED TREAT FX ORB EXCPT BLOWOUT W/O MA $822.23 $822.23 $822.23 21401 OP TR FX ORB EXCPT BLOWOUT WITH MANIPULA $822.23 $822.23 $822.23 21406 OPN TREA FX EXCPT BLOWOUT W/O IMPLANT $1,339.05 $1,339.05 $1,339.05 21407 OPN TREA FX EXCPT BLOWOUT WITH IMPLANT $1,339.05 $1,339.05 $1,339.05 21421 CLOS TRT PALATAL OR MAXILLARY FX LEFORTI $1,339.05 $1,339.05 $1,339.05 21431 CLOS TRT CRANIOFACIAL SEP LEFORT III $1,339.05 $1,339.05 $1,339.05 21440 CLOS TRT MAN/MAXIL ALVEO RIDGE FX SEP PR $1,339.05 $1,339.05 $1,339.05 21445 OPN TRT MAND/MAXIL ALVEO RIDGE FX SEP PR $1,339.05 $1,339.05 $1,339.05 21450 CLOSED TRT MANDIBULAR FX W/O MANIPULAT $1,339.05 $1,339.05 $1,339.05 21451 CLOSED TRT MANDIBULAR FRAC W MANIPULAT $1,339.05 $1,339.05 $1,339.05 21452 PERCUTANEOUS TRT MANDIBULAR FX W EXT FIX $1,339.05 $1,339.05 $1,339.05 21453 CLOS TRT MANDIBULAR FX W INTERDENTAL FIX $1,339.05 $1,339.05 $1,339.05 21454 OPN TRT MANDIBULAR FRACTURE W EXTER FIXA $1,339.05 $1,339.05 $1,339.05 21461 OPEN TRT MANDIBULAR FX W/O INTERDENT FIX $1,339.05 $1,339.05 $1,339.05 21462 OPN TREAT CLO-OPN MANDIB FX WITH INT FIX $1,339.05 $1,339.05 $1,339.05 21465 OPEN TREAT MANDIB CONDYLAR FRACTURE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 10 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 21470 OPN TRT COMPLI MANDIBULAR MULTI SURG APP $1,339.05 $1,339.05 $1,339.05 21480 CLOSED TRT TEMPOROMANDIBUL DISLO INI/SUB $822.23 $822.23 $822.23 21485 CLOSED TRT TEMPOROMAN DISLO INI/SUB COMP $822.23 $822.23 $822.23 21490 OPEN TREAT TEMPOROMANDIBULAR DIS SE21462 $1,339.05 $1,339.05 $1,339.05 21499 UNLISTED PROCEDURE HEAD $822.23 $822.23 $822.23 21501 INCISION DRAINAGE DEEP ABCESS OR HEMATOM $293.65 $293.65 $293.65 21502 INCIS DRAIN DEEP ABCES W/PART RIBOSTECT $293.65 $293.65 $293.65 21550 BIOPSY SOFT TISSUE OF NECK OR THORAX $822.23 $822.23 $822.23 21552 $822.23 $822.23 $822.23 21554 $1,339.05 $1,339.05 $1,339.05 21555 EXCIS TUMOR SOFT TISS NECK-THORAX SUB-Q $822.23 $822.23 $822.23 21556 EXCIS TUMOR SOFT TISS NECK-THORAX DEEP $1,339.05 $1,339.05 $1,339.05 21557 RADI RESEC TUMOR(MALIG)SOFT TISS NECK-TH $1,339.05 $1,339.05 $1,339.05 21558 $1,339.05 $1,339.05 $1,339.05 21600 EXCISION OF RIB PARTIAL $1,339.05 $1,339.05 $1,339.05 21610 COSTOTRANSVERSECTOMY(SEPARATE PROCEDURE $1,339.05 $1,339.05 $1,339.05 21615 EXCISION FIRST AND/OR CERVICAL RIB $1,339.05 $1,339.05 $1,339.05 21620 OSTECTOMY OF STERNUM PART $1,339.05 $1,339.05 $1,339.05 21630 RADICAL RESECTION OF STERNUM $1,339.05 $1,339.05 $1,339.05 21685 HYOID MYOTOMY AND SUSPENSION $822.23 $822.23 $822.23 21700 DIVISION SCAL ANTICUS W/O RESEC CERV RIB $822.23 $822.23 $822.23 21705 DIVISION SCAL ANTICUS W/RESECTI CERV RIB $822.23 $822.23 $822.23 21720 DIVIS STERNOCLEIDOM TORTI OPN OP W/O CA $822.23 $822.23 $822.23 21740 RECONSTR PECTUS EXCAVATM/CARINATM; OPEN $822.23 $822.23 $822.23 21742 REPAIR/PECTUS EXCAVATUM/CARINA W/O SCOPE $822.23 $822.23 $822.23 21743 REPAIR/PECTUS EXCAVATUM/CARINATU W/SCOPE $822.23 $822.23 $822.23 21800 CLOSED TREATMENT RIB FRACTURE UNCOMPL EA $822.23 $822.23 $822.23 21805 OPEN TREATMENT RIB FRACTURE W/O FIXAT EA $822.23 $822.23 $822.23 21820 CLOSED TREATMENT OF STERNUM FRACTURE $822.23 $822.23 $822.23 21899 UNLISTED PROCEDURE NECK OR THORAX $822.23 $822.23 $822.23 21920 BIOPSY SOFT TISS BACK OR FLANK SUPERFICI $822.23 $822.23 $822.23 21925 BIOPSY SOFT TISSUE BACK OR FLANK DEEP $822.23 $822.23 $822.23 21930 EXCISION TUMOR SOFT TISSUE BACK OR FLANK $822.23 $822.23 $822.23 21931 $822.23 $822.23 $822.23 21932 $822.23 $822.23 $822.23 21933 $822.23 $822.23 $822.23 21935 RADI RESECT TUMOR(MALIG)SOFT TISS BACK-F $1,339.05 $1,339.05 $1,339.05 21936 $1,339.05 $1,339.05 $1,339.05 22010 INC/DRAIN,OPN,SUBFASC,POS SPINE,CERV,THO $822.23 $822.23 $822.23 22015 INC/DRAIN,OPN,SUBFASC,POS SPINE,LUMBR,SA $822.23 $822.23 $822.23 22100 PART EXCIS POST VERTEBRAL COMP SING VERT $822.23 $822.23 $822.23 22101 PAR RESEC VERTE COMP SPIN-PROC THORACIC $822.23 $822.23 $822.23 22102 PAR RESEC VERTE COMP SPIN PROC LUMBAR $822.23 $822.23 $822.23 22210 OSTEOTOMY SPINE POST/POSTEROLAT ONE VERT $1,339.05 $1,339.05 $1,339.05 22505 MANIPULATION OF SPINE ANY REGION/ANESTHE $293.65 $293.65 $293.65 22520 PERC VERTEBROPLAS,1 VER,UNI/BIL INJ;THOR Not Valid Not Valid $125.00 22521 PERC VERTEBROPLAS,1 VER,UNI/BIL INJ;LUMB Not Valid Not Valid $125.00 22522 VERBRAL BOBY MBO/INJ $125.00

07/27/12 Page 11 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 22523 PERCUT VERTEBRAL AUGM;1 VERT BDY;THORACI $822.23 $822.23 $822.23 22524 PERCUT VERTEBRAL AUGM;1 VERT BODY;LUMBAR $822.23 $822.23 $822.23 22551 $822.23 $822.23 22552 ARTHRODESIS $822.23 $822.23 22610 THORACIC W/LATERAL TRAN TECHING $822.23 22612 ARTHRODESIS POST/POSTEROLAT SI LEV LUMBA Not Valid Not Valid $822.23 22614 ARTHRODESIS POST-POSTEROLAT TECH,SING LE $822.23 $822.23 $822.23 22633 ANTHRODESIS $822.23 22634 ANTHRODESIS $822.23 22800 ARTHRODESIS POST SPINE DEF W/WO CAST 6

07/27/12 Page 12 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 23130 /ACROMIONECTOMY PARTIAL $1,339.05 $1,339.05 $1,339.05 23140 EXCISION OR CURETTAGE BON CYST BENIGN TU $822.23 $822.23 $822.23 23145 EXCIS CURETT CYST-TUM CLAV/SCAPU GRAFT I $822.23 $822.23 $822.23 23146 EXCIS CURRETT CYST TUM CLAV-SCAPULA GRAF $822.23 $822.23 $822.23 23150 EXCISION CURETT BONE CYST BENIGN PROXHUM $1,339.05 $1,339.05 $1,339.05 23155 EXCIS CURRETT CYST BENIGN TUM BUME GRAFT $1,339.05 $1,339.05 $1,339.05 23156 EXCIS CURETT CYST HUMERUS W/HOMO-NON GRA $1,339.05 $1,339.05 $1,339.05 23170 SEQUESTRECTOMY OSTEOMYO BONE ABCESS CLAV $1,339.05 $1,339.05 $1,339.05 23172 SEQUESTRE OSTEOMY ABCESS SCAPULA $1,339.05 $1,339.05 $1,339.05 23174 SEQUESTRE OSTEOMY ABCESS HUM-HEAD SURGI- $1,339.05 $1,339.05 $1,339.05 23180 PART EXCIS(CRAT,SAUCER,DIAPHY) CLAV $822.23 $822.23 $822.23 23182 PART EXCIS BONE(CRAT,SAUC,DIAP) SCAPULA $822.23 $822.23 $822.23 23184 PART EXCIS BONE(CRAT,SAUC,DIAP)PROX HUME $1,339.05 $1,339.05 $1,339.05 23190 OSTECTOMY SCAPULA PARTIAL(EG SUP MED ANG $1,339.05 $1,339.05 $1,339.05 23195 RESECTION HUMERAL HEAD SEE 23470 $822.23 $822.23 $822.23 23200 RADICAL RESECTION TUMOR CLAVICLE $1,339.05 $1,339.05 $1,339.05 23210 RADICAL RESECTION TUMOR SCAPULA $1,339.05 $1,339.05 $1,339.05 23330 REMOVAL FOREIGN BODY SHOULDER SUBCUTANEO $822.23 $822.23 $822.23 23331 REMOVAL FOREIGN BODY SHOULDER DEEP(NEER $1,339.05 $1,339.05 $1,339.05 23395 MUSCLE TRANS ANY TYP SHOU OR UP ARM SING $1,339.05 $1,339.05 $1,339.05 23397 MUSCLE TRANS ANY PRARA MULT SHOUL-UP ARM $1,339.05 $1,339.05 $1,339.05 23400 SCAPULOPEXY (EG SPRENGEL'S DEFORM PARAL) $822.23 $822.23 $822.23 23405 TENOTOMY,SHOULDER AREA;SINGLE TENDON $1,339.05 $1,339.05 $1,339.05 23406 TENOTOMY,SHOU AR;MULTI TENDONS/SAME INCI $1,339.05 $1,339.05 $1,339.05 23410 REPAIR RUPTURED ROTATOR CUFF OPEN,ACUTE $1,339.05 $1,339.05 $1,339.05 23412 REPAIR RUPTURED ROTATOR CUFF, CHRONIC $1,339.05 $1,339.05 $1,339.05 23415 CORACO LIG REL C ACROLOPLSTY $1,339.05 $1,339.05 $1,339.05 23420 REPAIR COMP SHOU CUFF AVUL CHRON(INC ACR $1,339.05 $1,339.05 $1,339.05 23430 TENODESIS OF LONG TENDON OF BICEPS $1,339.05 $1,339.05 $1,339.05 23440 RESEC OR TRANSPLAN LONG TENDON OF BICEPS $1,585.73 $1,585.73 $1,585.73 23450 CAPSULORRHAPHY ANT PUTTI-PL OR MAG TY OP $1,585.73 $1,585.73 $1,585.73 23455 CAPSULOR,ANTERI;W/LABRAL REPAIR(BANKART) $1,585.73 $1,585.73 $1,585.73 23460 CAPSULORRHAPHY ANT ANY TYP W/BONE BLOCK $1,585.73 $1,585.73 $1,585.73 23462 CAPSUL RECURR DISLO ANT ANY W/CORACOID P $1,585.73 $1,585.73 $1,585.73 23465 CAPSULOR,GLENOHU JT,POSTER,W-W/O BON BLK $1,585.73 $1,585.73 $1,585.73 23466 CAPSULOR,GLENOHU JT,ANY MULTI-DIR INSTAB $1,585.73 $1,585.73 $1,585.73 23470 ARTHROPLASTY,GLENOHU JNT;HEMIARTHROPLAST $1,585.73 $1,585.73 $1,585.73 23480 OSTEOT CLAVI W/WO $1,585.73 $1,585.73 $1,585.73 23485 OSTEO CLAV W/WO INT FIXA W/GRAFT NONUNIO $1,585.73 $1,585.73 $1,585.73 23490 PHOPHY RX(NAIL-PIN-PLAT-WIR)METHYL M CLA $822.23 $822.23 $822.23 23491 PROPHY RX(NAIL-PIN-WIR-PLAT)W/WO MM HUME $822.23 $822.23 $822.23 23500 CLOSED TREAT CLAVICULAR FX W/O MANIPULAT $822.23 $822.23 $822.23 23505 TREATMENT CLOS CLAVI FX WITH MANIPULATIO $822.23 $822.23 $822.23 23515 OPEN TRT CLAVICULAR FX W/WO INT/EXT FIXA $1,339.05 $1,339.05 $1,339.05 23520 CLOSED TRT STERNOCLAVICULAR DISL WO MANI $822.23 $822.23 $822.23 23525 TKT CLOS STERNOCLAVICULAR DISLO MANIPULA $822.23 $822.23 $822.23 23530 OPEN TRT STERNOCLAVICULAR DISL ACUTE/CHR $1,339.05 $1,339.05 $1,339.05 23532 OPN TREA CLO/OPN STERNOCLAV DIS W/GRAFT $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 13 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 23540 CLOSED TRT ACROMIOCLAVICULAR DISL WO MAN $1,339.05 $1,339.05 $1,339.05 23545 TREAT CLOS ACROMIOCLAV DISLO W/MANIPULAT $822.23 $822.23 $822.23 23550 OPN TREAT ACROMIO DIS ACUTE OR CHRONIC $1,339.05 $1,339.05 $1,339.05 23552 OPN TREAT CLO/OPN A/C DISLO ACU/CHRO GRF $1,585.73 $1,585.73 $1,585.73 23570 CLOSED TRT OF SCAPULAR FX W/O MANIPULATI $822.23 $822.23 $822.23 23575 CLO TRT SCAPU FX W/MANIP W/WO SKEL TRACT $1,339.05 $1,339.05 $1,339.05 23585 OPN TRT SCAPU FX(BDY,GLENO) W/WO INT FIX $822.23 $822.23 $822.23 23600 CLO TRT PROX HUMERAL(SURG/NECK)FX W/OMAN $822.23 $822.23 $822.23 23605 TREAT CLOS HUM(SURGI/NECK)FX WITH MANIPU $1,339.05 $1,339.05 $1,339.05 23615 OPN TREAT HUMERAL SURG/NECK FX W/WO FIXA $1,339.05 $1,339.05 $1,339.05 23616 OPN TRT PROX HUMERAL W/PROSTHETIC REPLAC $1,585.73 $1,585.73 $1,585.73 23620 CLOSED TREAT GREAT HUMER TUBR FRA W/O MA $822.23 $822.23 $822.23 23625 TREAT CLOS GREAT TUBER FX WITH MANIPULAT $822.23 $822.23 $822.23 23630 OPEN TREAT GREAT HUMER TUBR FRA,W-W/O FX $1,339.05 $1,339.05 $1,339.05 23650 CLOSED TREAT SHOULD DISLO W/MANIP W/O AN $822.23 $822.23 $822.23 23655 TREAT CLOS SHOULD DISLO W/MANIP W/ANESTH $822.23 $822.23 $822.23 23660 OPEN TREATMENT ACUTE SHOULDER DISLOCATIO $1,339.05 $1,339.05 $1,339.05 23665 CLOS TRT SHOULD DISL W FX GREA HUM TUBER $822.23 $822.23 $822.23 23670 OPN TRT SHOULD DISLO W/FX GRT HUM TUBERO $1,339.05 $1,339.05 $1,339.05 23675 CLOSE TRT SHOULD DISLO W/SUR/NEC FX W MA $822.23 $822.23 $822.23 23680 OPN TRT SHOULD DISLO SUR/NEC FX W/WO FIX $1,339.05 $1,339.05 $1,339.05 23700 MANIPULATION ANESTHES INC APPLY APPARATU $822.23 $822.23 $822.23 23800 ARTHRODESIS, GLENOHUMERAL JOINT $1,339.05 $1,339.05 $1,339.05 23802 ARTHRODESIS,GLENOHU JNT;W/AUTOGENO GRAFT $1,339.05 $1,339.05 $1,339.05 23921 DISARTICULATION OF SHOUL SEC CLOS/SCAR R $1,339.05 $1,339.05 $1,339.05 23929 UNLISTED PROCEDURE SHOULDER $822.23 $822.23 $822.23 23930 INCISION DRAINAGE DEEP ABCESS HEMATOMA $293.65 $293.65 $293.65 23931 INCISION-DRAIN,UPP ARM/ELBOW AREA; BURSA $822.23 $822.23 $822.23 23935 INCISION DEEP OPN CORTEX OSTEOMY OR ABCE $1,339.05 $1,339.05 $1,339.05 24000 ARTHROTOMY,ELBOW,W/EXPL,DRAIN,RMVL FOR B $1,339.05 $1,339.05 $1,339.05 24006 ARTHROTOMY ELBOW CAPSULAR EXC SEPAR PROC $1,339.05 $1,339.05 $1,339.05 24065 BIOPSY SOFT TISSUES SUPERFICIAL $822.23 $822.23 $822.23 24066 BIOPSY,SOFT TISS UPP ARM/ELBOW AREA;DEEP $822.23 $822.23 $822.23 24071 $822.23 $822.23 $822.23 24073 $822.23 $822.23 $822.23 24075 EXCIS,TUMOR,SOFT TISS UP ARM/ELB;SUBCUTA $822.23 $822.23 $822.23 24076 EXCISION BENIGN TUMOR DEEP SUBFAC OR INT $1,339.05 $1,339.05 $1,339.05 24077 RADI RESECT TUMOR(MALIG)UP ARM-ELBOW ARE $1,339.05 $1,339.05 $1,339.05 24079 $1,339.05 $1,339.05 $1,339.05 24100 ARTHROTOMY ELBOW W/SYNOVIAL BIOPSY ONLY $293.65 $293.65 $293.65 24101 ARTHROT ELBO EXPLOR W/WO BIOP W/WO FB RE $1,339.05 $1,339.05 $1,339.05 24102 ARTHROTOMY ELBOW WITH SYNOVECTOMY $1,339.05 $1,339.05 $1,339.05 24105 EXCISION OLECRANON BURSA $1,339.05 $1,339.05 $1,339.05 24110 EXCISION CURRETT CYST BENIGN TUMOR HUMER $1,339.05 $1,339.05 $1,339.05 24115 EXCIS/CURR CYST BENIGN TUMOR HUMER GRAFT $1,339.05 $1,339.05 $1,339.05 24116 EXCIS/CURR CYST/TUMOR HUMER HOMO/AUT GRA $1,339.05 $1,339.05 $1,339.05 24120 EXCISION OR CURRETT BONE CYST BENIGN TUM $1,339.05 $1,339.05 $1,339.05 24125 EXCIS/CURETT CYST/TUMOR OLECR PRI GRFT I $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 14 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 24126 EXCIS/CURETT CYST/TUMOR OLECR W/HOMO GRF $1,339.05 $1,339.05 $1,339.05 24130 EXCISION RADIAL HEAD SEE 24366 $1,339.05 $1,339.05 $1,339.05 24134 SEQUEST FOR OSTEOMY/ABCESS SHAFT/DIST HU $1,339.05 $1,339.05 $1,339.05 24136 SEQUEST OSTEO/ABCESS RADI HEAD/NECK $1,339.05 $1,339.05 $1,339.05 24138 SEQUEST OSTEOMY/ABCESS OLECRAN PROCESS $1,339.05 $1,339.05 $1,339.05 24140 PART EXCIS BONE(CRATER,SAUC,DIAPHY) HUME $1,339.05 $1,339.05 $1,339.05 24145 PART EXCIS BONE(CRAT,SAUC,DIAP)OSTEO RAD $1,339.05 $1,339.05 $1,339.05 24147 PART EXCIS BONE FOR OSTEOMY OLECRANON PR $1,339.05 $1,339.05 $1,339.05 24149 RADI RESEC CAPSULE,W/CONTR REL(SEP PROC) $1,339.05 $1,339.05 $1,339.05 24150 RADIAL RESECTION TUMOR SHAFT DISTAL HUME $822.23 $822.23 $822.23 24152 RADICAL RESECT TUMOR RADIAL HEAD OR NECK $1,339.05 $1,339.05 $1,339.05 24155 RESECTION OF ELBOW JOINT (ARTHRECTOMY) $1,339.05 $1,339.05 $1,339.05 24160 IMPLANT REMOVAL ELBOW JOINT $822.23 $822.23 $822.23 24164 IMPLANT REMOVAL RADIAL HEAD $822.23 $822.23 $822.23 24200 REMOVAL FOREIGN BODY SUBCUTANEOUS $293.65 $293.65 $293.65 24201 REMOVAL FOREIGN BODY,UPPER ARM/ELBOW;DEE $293.65 $293.65 $293.65 24300 MANIPULATION ELBOW W/ANESTHESIA $293.65 $293.65 $293.65 24301 MUSCLE/TENDON TRANS ANY TYPE(EX 24320-31 $1,585.73 $1,585.73 $1,585.73 24305 TENDON LENGTHENING,UPPER ARM/ELBOW,EACH $1,339.05 $1,339.05 $1,339.05 24310 TENOTOMY OPN ELBOW TO SHOULD SING EACH $1,339.05 $1,339.05 $1,339.05 24320 TENOPLASTY W/MUSCLE TRANS W/WO FREE GRAF $1,339.05 $1,339.05 $1,339.05 24330 FLEXOR-PLASTY ELBOW(EG STEINDLER) ADVANC $1,339.05 $1,339.05 $1,339.05 24331 FLEXOR-PLASTY ELBOW(EG STEINDLER) ADVANC $1,339.05 $1,339.05 $1,339.05 24332 TENOLYSIS,TRICEPS $1,339.05 $1,339.05 $1,339.05 24340 TENODESIS OF BICEP TEND ELBO (SEP PROC) $1,339.05 $1,339.05 $1,339.05 24341 REPAIR TENDON/MUSC,ARM/ELB,EA(NO ROT CUF $1,339.05 $1,339.05 $1,339.05 24342 REINSER RUPT BI/TRICEP TEND,DIST,TEN GRA $1,339.05 $1,339.05 $1,339.05 24343 REPAIR COL/LATRL LIGMT,ELBOW W LOCL TISS $1,339.05 $1,339.05 $1,339.05 24344 RECNSTRCT LIGMT ELBOW W/ TENDON GRAFT $1,339.05 $1,339.05 $1,339.05 24345 REPR ELBW MEDIAL LIGAMENT W/LOCAL TISSUE $1,339.05 $1,339.05 $1,339.05 24346 RECNSTR MED LIGMT ELBOW W/TENDON GRAFT $1,339.05 $1,339.05 $1,339.05 24357 TENOTOMY,ELBOW,LATERAL/MEDIAL,PERCUTANEO $1,339.95 $1,339.95 $1,339.95 24358 TENOTOMY,ELBOW,LATERAL/MED,DEBRIDMT,OPEN $1,339.95 $1,339.95 $1,339.95 24359 TENOTOMY,ELBW,LAT/MED,DEBRID,OPEN-REATCH $1,339.95 $1,339.95 $1,339.95 24360 ARTHROPLASTY ELBOW WITH MEMBRANE $1,339.05 $1,339.05 $1,339.05 24361 ARTHROPLASTY ELBOW MEMBRANE HUM PROSTHET $1,339.05 $1,339.05 $1,339.05 24362 ARTHROPLASTY ELBOW IMPLANT FASCIA LATA L $1,339.05 $1,339.05 $1,339.05 24363 ARTHROPL ELBOW HUM/ULNAR PROSTHETIC REPL $1,585.73 $1,585.73 $1,585.73 24365 ARTHROPLASTY RADIAL HEAD $1,339.05 $1,339.05 $1,339.05 24366 ARTHROPLASTY RADIAL HEAD WITH IMPLANT $1,339.05 $1,339.05 $1,339.05 24400 OSTEOTOMY HUMERUS W/WO INTERNAL FIXATION $1,339.05 $1,339.05 $1,339.05 24410 MULTI REALIGN INTRAMED(SOFIE $1,339.05 $1,339.05 $1,339.05 24420 OSTEOPLASTY HUMERUS SHORT-LENG(EX 64876) $1,339.05 $1,339.05 $1,339.05 24430 REPAIR NONUNION/MALUNION HUM WITH GRAFT $822.23 $822.23 $822.23 24435 REPAIR NONUNION/MALUNION HUM W/BONE GRAF $822.23 $822.23 $822.23 24470 HEMIEPIPHYSEAL ARREST(EG,CUBITUS VAR VAL $1,339.05 $1,339.05 $1,339.05 24495 DECOMPRESSION FASCIOTOMY FOREARM BRACHIA $1,339.05 $1,339.05 $1,339.05 24498 PROPHY RX(NAIL-PIN-WIR-PLAT) W/WO MM HUM $822.23 $822.23 $822.23

07/27/12 Page 15 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 24505 CLOSE TRT HUMERAL SHAFT W/MANIP W/WO TRA $822.23 $822.23 $822.23 24515 OPN TRT HUMERAL SHAFT FX W/WO CERCLAGE $1,339.05 $1,339.05 $1,339.05 24516 TX HUMERUS SHAFT FRACT,W/INTRAMED IMPLAN $1,339.05 $1,339.05 $1,339.05 24530 CLO TRT SUPRA/TRANS FX W/WO EXT W/O MANI $822.23 $822.23 $822.23 24535 CLO TRT SUPRA/TRANS FX W/WO EXT W/MANIPU $822.23 $822.23 $822.23 24538 PERCUTAN SKEL FIX SUPRA/TRANS FX W/WO EX $1,339.05 $1,339.05 $1,339.05 24545 OPN TREAT HUM SUPRA/TRANS FX WO/EXT $1,339.05 $1,339.05 $1,339.05 24546 OPN TREAT HUM SUPRA/TRANS FX W/EXT $1,339.05 $1,339.05 $1,339.05 24560 TREAT CLOS EPICON FX MED/LAT W/OMANIPULA $822.23 $822.23 $822.23 24565 TREAT CLOS EPICON FX MED OR LAT WITH MAN $822.23 $822.23 $822.23 24566 PERCUT SKEL FX HUM EPICON FX MED/LAT W/M $1,339.05 $1,339.05 $1,339.05 24575 OPN TREAT HUM EPICON FX MED/LAT W/FIX $1,339.05 $1,339.05 $1,339.05 24576 TREAT CLOS CONDY FX MED/LAT W/O MANIPULA $822.23 $822.23 $822.23 24577 TREAT CLOS CONDY FX MED/LAT WITH MANIPUL $822.23 $822.23 $822.23 24579 OPN TREAT HUM CONDY FX MED/LAT W/FIX $1,339.05 $1,339.05 $1,339.05 24582 PERCUT SKEL FX HUM CONDY FX MED/LAT W/MA $1,339.05 $1,339.05 $1,339.05 24586 OPN TREAT CLO/OPN COMMIN ELBO W/EL RESEC $1,339.05 $1,339.05 $1,339.05 24587 OPN TREA CLO/OPN COMMIN EL FX W/WO FIXAT $1,339.05 $1,339.05 $1,339.05 24600 TREAT CLOS ELBOW DISLO W/O ANESTHESIA $822.23 $822.23 $822.23 24605 TREAT CLOS ELBO DISLO WITH ANESTHESIA $822.23 $822.23 $822.23 24615 OPN TREAT OF CLOSED OR OPN ELBOW DISLOCA $822.23 $822.23 $822.23 24620 TREAT CLOS MONTEGGIA FX DISLOCAT AT ELBO $1,339.05 $1,339.05 $1,339.05 24635 OPN TREAT MONTEGGIA FX ELBO W/FIX $1,339.05 $1,339.05 $1,339.05 24640 TREAT RADIAL HEAD SUBLUX CHILD NURSEMAID $822.23 $822.23 $822.23 24650 TREAT CLOS RAD HEAD/NECK FX W/O MANIPULA $822.23 $822.23 $822.23 24655 TREAT CLOS RAD HEAD NECK FX WITH MANIPUL $822.23 $822.23 $822.23 24665 OPN TREAT RAD HEAD/NECK FX INT/RAD $570.00 $570.00 $570.00 24666 OPN TX RAD HEAD/NECK FX W/FIX OR EXCIS $1,339.05 $1,339.05 $1,339.05 24670 TREAT CLO ULNAR FX PROXI END OLE W/O MAN $822.23 $822.23 $822.23 24675 TREAT CLO ULNA FX PROX OLECRA W/MANIPULA $822.23 $822.23 $822.23 24685 OPN TRT ULNAR FX PROX OLE W INT FIXAT $1,339.05 $1,339.05 $1,339.05 24800 ARTHRODESIS, ELBOW JOINT; LOCAL $1,339.05 $1,339.05 $1,339.05 24802 ARTHRODESIS,ELBOW JNT;W/AUTOGENOUS GRFT $1,339.05 $1,339.05 $1,339.05 24900 AMPUTA ARM THROU HUMERUS WITH PRI CLOSUR $1,339.05 $1,339.05 $1,339.05 24925 AMPUTA ARM THROU HUMER SECOND CLO/SCAR R $1,339.05 $1,339.05 $1,339.05 24935 STUMP ELONGATION $1,339.05 $1,339.05 $1,339.05 24999 UNLISTED PROCEDURE HUMERUS OR ELBOW $822.23 $822.23 $822.23 25000 INCISION,EXTENSOR TENDON SHEATH, WRIST $1,339.05 $1,339.05 $1,339.05 25001 INCISION FLEXOR TENDON SHEATH,WRIST $1,339.05 $1,339.05 $1,339.05 25020 DECOMP FASCI FOREARM AND/OR WRI FLEX/EXT $1,339.05 $1,339.05 $1,339.05 25023 DECOMP FASCI FLEX AND/OR EXTEN W/DEBRIDE $1,339.05 $1,339.05 $1,339.05 25024 DECMPR FASCI FLEX/EXT CMPT W/O DEBRIDE $1,339.05 $1,339.05 $1,339.05 25025 DECMPR FASCI ARM/WRST FLEX/EXT W/DEBRIDE $1,339.05 $1,339.05 $1,339.05 25028 INCIS DRAIN DEEP ABCESS OR HEMATOMA $293.65 $293.65 $293.65 25031 INCISION & DRAINAGE,FOREARM-WRIST; BURSA $293.65 $293.65 $293.65 25035 INCIS,DEEP,BONE CORTEX,FROEARM-WRIST(ABS $1,339.05 $1,339.05 $1,339.05 25040 ARTHROTOMY RADIO-MEDIPCARP EXPLOR, DRAIN $1,339.05 $1,339.05 $1,339.05 25065 BIOPSY SOFT TISSUES SUPERFICIAL $822.23 $822.23 $822.23

07/27/12 Page 16 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 25066 BIOPSY,SOFT TISSUE FOREARM-WRIST; DEEP $822.23 $822.23 $822.23 25071 $822.23 $822.23 $822.23 25073 $822.23 $822.23 $822.23 25075 EXCIS,TUMOR,FOREARM &/OR WRIST; SUBCUTAN $822.23 $822.23 $822.23 25076 EXC,TUMOR,FOREARM/WRIST; SUBCUT/INTRAMUS $1,339.05 $1,339.05 $1,339.05 25077 RADI RESECT TUNOR(MALIG)FORE ARM,WRIST $1,339.05 $1,339.05 $1,339.05 25078 $1,339.05 $1,339.05 $1,339.05 25085 CAPSULOTOMY WRIST (EG FOR CONTRACTURE) $1,339.05 $1,339.05 $1,339.05 25100 ARTHROTOMY WRIST JOINT WITH BIOPSY $822.23 $822.23 $822.23 25101 ARTHROTOMY EXPLOR W/WO BIOP OR REMOV FB $1,339.05 $1,339.05 $1,339.05 25105 ARTHROTOMY WRIST JOINT WITH SYNOVECTOMY $1,339.05 $1,339.05 $1,339.05 25107 ARTHROTOMY DISTAL RADIOULNAR COMPLEX $1,339.05 $1,339.05 $1,339.05 25110 EXCISION LESION OF TENDON SHEATH $1,339.05 $1,339.05 $1,339.05 25111 EXCISION GANGLION WRIST(DORS/VOLDR) PRIM $1,339.05 $1,339.05 $1,339.05 25112 EXCISION GANGL WRIST(DOR/VOLAR) RECURREN $1,339.05 $1,339.05 $1,339.05 25115 RADIAL EXCIS BURSA SYNOV WRIST TEND FLEX $1,339.05 $1,339.05 $1,339.05 25116 RADIAL EXCIS BURSA SYNON WRIST/TEND EXTE $1,339.05 $1,339.05 $1,339.05 25118 SYNOVECT EXTEN TEND SHEATH WRIST SING CO $1,339.05 $1,339.05 $1,339.05 25119 SYNOVECT EXTEN TEND SHEATH WRIST RESECT- $1,339.05 $1,339.05 $1,339.05 25120 EXCIS OR CURETT BONE CYST BENIGN TUM ULN $1,339.05 $1,339.05 $1,339.05 25125 EXCIS/CURETT CYST BENIGN TUM ULNA W/GRAF $1,339.05 $1,339.05 $1,339.05 25126 EXCIS/CURETT CYST BENIGN TUM ULNA HOMOGR $1,339.05 $1,339.05 $1,339.05 25130 EXCIS/CURETT CYST BENIGN TUMOR CARPAL BO $822.23 $822.23 $822.23 25135 EXCIS/CURETT CYST BENIGN TUM CARPAL GRAF $822.23 $822.23 $822.23 25136 EXCI CUR BN CYST BEN TUM CAR BN NAU GRAF $822.23 $822.23 $822.23 25145 SEQUESTRECTOMY OSTEOMY/BONE ABCESS $1,339.05 $1,339.05 $1,339.05 25150 PART EXCIS BONE (CRAT,SAUC,DIAP)OSTE ULN $1,339.05 $1,339.05 $1,339.05 25151 PART EXCIS BONE(CRAT,SAUC,DIAP)OSTE RADI $1,339.05 $1,339.05 $1,339.05 25170 RADICAL RESECT TUMOR RADIUS OR ULNA $1,339.05 $1,339.05 $1,339.05 25210 CARPECTOMY ONE BONE SEE 25441-25445 IMP $1,339.05 $1,339.05 $1,339.05 25215 CARPECTOMY ALL BONES OR PROXIMAL ROW $1,339.05 $1,339.05 $1,339.05 25230 RADIAL STYLOIDECTOMY(SEPARATE PROCEDURE) $1,339.05 $1,339.05 $1,339.05 25240 EXCISION DISTAL ULNA(DARRACH PROC) OTHER $1,339.05 $1,339.05 $1,339.05 25248 EXPLOR W/REMOV DEEP FOREIGN BODY FORARM $1,339.05 $1,339.05 $1,339.05 25250 REMOVAL WRIST PROSTHESIS (SEP PROC) $822.23 $822.23 $822.23 25251 REMOVAL WRIST PROSTHESIS COMPLI INC TOTL $822.23 $822.23 $822.23 25259 MANIPULATION WRIST W/ANESTHESIA $822.23 $822.23 $822.23 25260 REPAIR TENDON MUSCLE FLEX PRI,SING EACH $1,339.05 $1,339.05 $1,339.05 25263 REPAIR TEND MUS FLEX SECONDARY SING,EACH $1,339.05 $1,339.05 $1,339.05 25265 REPAIR MUSCLE/TEN FLEX SECOND GRAFT EACH $1,339.05 $1,339.05 $1,339.05 25270 REPAIR TEND/MUSCLE EXTEN PRI SING EACH - $1,339.05 $1,339.05 $1,339.05 25272 REPAIR TEND/MUSC EXTEN SECOND EA TEND/MU $1,339.05 $1,339.05 $1,339.05 25274 REPAIR TEN/MUS,EXT,FO/WR;SECOND,GRAFT,EA $1,339.05 $1,339.05 $1,339.05 25275 REPR TNDN SHTH EXT ARM/WRST W/GRAFT $1,339.05 $1,339.05 $1,339.05 25280 LENGTH SHORT FLEX EXTEN TENDON EACH TEND $1,339.05 $1,339.05 $1,339.05 25290 TENOTOMY OPN SING FLEX/EXTEN TENDON EACH $1,339.05 $1,339.05 $1,339.05 25295 TENOLYSIS SING FLEXOR EXTENSOR TEND EACH $1,339.05 $1,339.05 $1,339.05 25300 TENODESIS AT WRIST OF FINGERS $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 17 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 25301 TENODESIS AT WRIST EXTENSORS OF FINGERS $1,339.05 $1,339.05 $1,339.05 25310 TENDON TRANSPLANT/TRANSFER FLEX/EXTEN EA $1,585.73 $1,585.73 $1,585.73 25312 TEND TRANSPL/TRANSFER FLEX/EXTEN INC GRA $1,585.73 $1,585.73 $1,585.73 25315 FLEXOR ORIG SLID FOR CERE PALSY/OTH ARM $1,339.05 $1,339.05 $1,339.05 25316 FLEXOR ORIGIN SLIDE CERE-PALSY W/TEN TRA $1,339.05 $1,339.05 $1,339.05 25320 REPAIR/REVISE WRIST JOINT $1,339.05 $1,339.05 $1,339.05 25332 ARTHROPLA,WRST,W W/O INTRPOS,INT,EXT FIX $1,339.05 $1,339.05 $1,339.05 25335 CENTRALIZATION WRIST ON ULNA $1,339.05 $1,339.05 $1,339.05 25337 RECON STABIL UNSTAB DISTAL ULNA W/WO RED $1,585.73 $1,585.73 $1,585.73 25350 OSTEOTOMY RADIAS DISTAL THIRD $1,585.73 $1,585.73 $1,585.73 25355 OSTEOTOMY RADIUS MIDDLE OR PROXIMA THIRD $1,585.73 $1,585.73 $1,585.73 25360 OSTEOTOMY ULNA $1,585.73 $1,585.73 $1,585.73 25365 OSTEOTOMY RADIUS AND ULNA $1,585.73 $1,585.73 $1,585.73 25370 MULTI OSTEOT W/REALIG INTRA ROD RADI/ULN $1,339.05 $1,339.05 $1,339.05 25375 MULTI OSTEO W/REALI ON ROD RADI AND ULNA $1,339.05 $1,339.05 $1,339.05 25390 OSTEOPLA RADIUS OR ULNA SHORTENING $1,585.73 $1,585.73 $1,585.73 25391 OSTEOPL RADI OR ULNA LENGTH W/AUTO GRAFT $1,585.73 $1,585.73 $1,585.73 25392 OSTEOPLASTY RAD+ULNA SHORTENING(EX-64876 $1,585.73 $1,585.73 $1,585.73 25393 OSTEOPLASTY RAD+ULNA LENGTH W/AUTO GRAFT $1,585.73 $1,585.73 $1,585.73 25400 REPAIR NONUNION/MALUNION RADI/ULNA WO/GR $822.23 $822.23 $822.23 25405 REPAIR NON/MALUNION,RADIUS/ULNA;W/AUTOGR $1,339.05 $1,339.05 $1,339.05 25415 REPAIR NON/MALUNION RADI AND ULNA WO/GRA $822.23 $822.23 $822.23 25420 REPAIR NON/MALUNION,RADIUS&ULNA;W/AUTOGR $1,339.05 $1,339.05 $1,339.05 25425 REPAIR OF DEFECT W/AUTO GRAFT RADI OR UL $1,339.05 $1,339.05 $1,339.05 25426 REPAIR DEFEC W/AUTO GRAFT RADIUS AND ULN $1,339.05 $1,339.05 $1,339.05 25430 INSERT VASCULAR PEDICLE INTO CARPAL BONE $822.23 $822.23 $822.23 25431 REPAIR NON-UNION CARPAL BONE,EACH BONE $822.23 $822.23 $822.23 25440 REPA NONUNION,SCAPHI CARP BON W/WO STYLO $822.23 $822.23 $822.23 25441 ARTHROPLASTY W/PROSTH REPLACE DIST RADIU $1,339.05 $1,339.05 $1,339.05 25442 ARTHROPLASTY W/PROSTH REPLACE DISTAL ULN $1,339.05 $1,339.05 $1,339.05 25443 ARTHROPLAS W/PROSTH REPLACE;SCAPHOID CAR $1,339.05 $1,339.05 $1,339.05 25444 ARTHROPLASTY W/PROSTH REPLACE LUNATE $1,339.05 $1,339.05 $1,339.05 25445 ARTHOPLASTY W/PROSTH REPLACEMENT TRAPEZI $1,339.05 $1,339.05 $1,339.05 25446 ARTHROPLASTY W/PROSTH REPLACE PART/TOTAL $1,339.05 $1,339.05 $1,339.05 25447 INTERPOSIT ARTHROPLAS INTER/CARPOM JOINT $1,339.05 $1,339.05 $1,339.05 25449 REVIS ARTHOPLAS INC REMOVAL IMPLANT $1,339.05 $1,339.05 $1,339.05 25450 EPIPHYSEAL ARREST EPIPHY STRAP RADI OR U $1,339.05 $1,339.05 $1,339.05 25455 EPIPHY ARREST EPIPHY STRAP RADI AND ULNA $1,339.05 $1,339.05 $1,339.05 25490 PROPHY RX(NAIL-PIN-PLAT-WIR)W/WO MM RADI $1,339.05 $1,339.05 $1,339.05 25491 PROPHY RX(NAIL-PIN-WIR-PLAT)W/WO MM ULNA $1,339.05 $1,339.05 $1,339.05 25492 PROPHY RX(NAIL-PIN-PLAT-WIR)W/WO MM RAD/ $1,339.05 $1,339.05 $1,339.05 25500 CLO TRT RADI SHAFT FX W/O MANIPULATION $822.23 $822.23 $822.23 25505 TREAT CLOS RADI SHAFT FX WITH MANIPULATI $822.23 $822.23 $822.23 25515 OPN TRT RADI SHAFT FX W INT FIXAT $1,339.05 $1,339.05 $1,339.05 25520 CLOS TRT RADIAL FX W/DISTAL RADIOUL JOIN $822.23 $822.23 $822.23 25525 OPN TRT RADIAL FX W PERCUT SKEL FIX $1,339.05 $1,339.05 $1,339.05 25526 OPN TRT RADIAL FX INC REPAIR TRIANG CART $1,339.05 $1,339.05 $1,339.05 25530 CLOS TRT ULNAR SHAFT FX W/O MANIPULATION $822.23 $822.23 $822.23

07/27/12 Page 18 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 25535 TREAT CLOS ULNA FX WITH MANIPULATION $822.23 $822.23 $822.23 25545 OPN TRT ULNAR SHAFT FX W INT FIXA $1,339.05 $1,339.05 $1,339.05 25560 CLOS TRT RADI/ULNAR SHAFT FX W/O MANIPUL $822.23 $822.23 $822.23 25565 TREAT CLOS RADI/ULNA FX WITH MANIPULATIO $822.23 $822.23 $822.23 25574 OPN TRT RADIAL/ULNAR FRAC W INT FIX $1,339.05 $1,339.05 $1,339.05 25575 OPN TRT RADI/ULNA SHAFT W INT FIXATION $1,339.05 $1,339.05 $1,339.05 25600 CLOS TRT DIS RAD FX(COLLES,SMITH)W/O MAN $822.23 $822.23 $822.23 25605 TREAT CLOS RAD FX(COLLES,SMITH) W/MANIPU $1,339.05 $1,339.05 $1,339.05 25606 PRECUT SKELETAL FIX DISTAL RADIAL FRACTU $570.00 $570.00 $570.00 25607 TX DIST RADIAL EXTRA-ARTICULAR FRACTURE $570.00 $570.00 $570.00 25608 TREAT RAD INTRA-ARTICULAR FRACT, 2+FRAG $570.00 $570.00 $570.00 25609 TX DIST RAD INTR-ARTICULAR FRACT, 3+FRAG $570.00 $570.00 $570.00 25622 CLOS TRT CARPAL SCAPHOID FX W/O MANIPULA $822.23 $822.23 $822.23 25624 TREAT CLOS CARPAL SCAPHOID FX WITH MANIP $822.23 $822.23 $822.23 25628 OPN TRT CARPAL SCAPHOID FX W IN FIX $1,339.05 $1,339.05 $1,339.05 25630 CLOS TRT CARPAL FX (EXCLU SCAP W/O MANIP $822.23 $822.23 $822.23 25635 TREAT CLO CARP FX(EXCLUD SCAP) W/MANI EA $822.23 $822.23 $822.23 25645 OPN TRT CARPAL BON FX(EX CAR SCAPHO)EACH $1,339.05 $1,339.05 $1,339.05 25650 CLOS TRT ULNAR STYLOID FRACTURE $1,339.05 $1,339.05 $1,339.05 25651 PERCUT SKEL FIX ULNAR STYLOID FRAC $1,339.05 $1,339.05 $1,339.05 25652 OPEN TX OF ULNAR STYLOID FRAC $1,339.05 $1,339.05 $1,339.05 25660 CLOS TRT RADIO/INTERCARP DISLO 1 OR MORE $822.23 $822.23 $822.23 25670 OPN TRT RADIO/INTERCARP DISLO 1 OR MORE $822.23 $822.23 $822.23 25671 PERCUT SKEL FIX DISTAL RADIOULNAR DISLOC $822.23 $822.23 $822.23 25675 CLOS TRT DISTAL RADIOULNAR DISLO W/MANIP $822.23 $822.23 $822.23 25676 OPN TRT RADIOULNAR DISLO ACUTE OR CHRONI $1,339.05 $1,339.05 $1,339.05 25680 CLO TRT TRANS-SCAPH FX DISLO W/MANIPULAT $1,339.05 $1,339.05 $1,339.05 25685 CLO TRT TRANS-SCAPHOPERILUNAR FX DISLOCA $1,339.05 $1,339.05 $1,339.05 25690 CLOS TRT LUNATE DISLOCATION W/MANIPULATI $822.23 $822.23 $822.23 25695 OPN TREAT OF LUNATE DISLOCATION $1,339.05 $1,339.05 $1,339.05 25800 ARTHRODESIS,WRIST;COMPLETE W/O BONE GRFT $822.23 $822.23 $822.23 25805 ARTHRODESIS WRIST JOINT W/SLIDING GRAFT $822.23 $822.23 $822.23 25810 ARTHRODESIS WRIST JOINT W/ILI AUTO INCGR $822.23 $822.23 $822.23 25820 ARTHRODESIS,WRIST;LIMITED W/O BONE GRAFT $1,339.05 $1,339.05 $1,339.05 25825 INTERCARPAL FUSION AUTO BONE GRAFT(INC $1,339.05 $1,339.05 $1,339.05 25830 DISTAL RADIOULNAR JT ARTHROD-SEC RES ULN $1,339.05 $1,339.05 $1,339.05 25907 AMPUT FOREARM RAD/ULNA SECOND CLO/SCAR R $1,339.05 $1,339.05 $1,339.05 25909 AMPUT FOREARM RAD/ULNA REAMPUTATION $1,339.05 $1,339.05 $1,339.05 25922 DISARTICULATION THRO WRIST SECOND CLO/SC $1,339.05 $1,339.05 $1,339.05 25924 DISARTICU THROUG WRIST REAMPUTATION $1,339.05 $1,339.05 $1,339.05 25927 TRANSMETACARPAL AMPUTATION $1,339.05 $1,339.05 $1,339.05 25929 TRANSMETACARPAL AMPUT SECOND CLOS/SCAR R $1,339.05 $1,339.05 $1,339.05 25931 TRANSMETACARPAL AMPUTATION REAMPUTATION $1,339.05 $1,339.05 $1,339.05 25999 UNLISTED PROCEDURE FOREARM OR WRIST $822.23 $822.23 $822.23 26010 DRAINAGE OF FINGER ABCESS SIMPLE $293.65 $293.65 $293.65 26011 DRAINAGE OF FINGER ABSCESS,COMPLICATED $293.65 $293.65 $293.65 26020 DRAINAGE OF TENDON SHEATH,DIGIT-PALM,EA. $822.23 $822.23 $822.23 26025 DRAINAGE OF PALMAR BURSA; SINGLE, BURSA $822.23 $822.23 $822.23

07/27/12 Page 19 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 26030 DRAINAGE OF PALMAR BURSA; MULTIPLE BURSA $822.23 $822.23 $822.23 26034 INCIS,BONE CORTEX,HAND-FINGER(OSTEO-ABSC $1,339.05 $1,339.05 $1,339.05 26035 DECOMPRESS FINGERS AND/OR HAND INJECT IN $822.23 $822.23 $822.23 26037 DECOMPRESSION FACIOTOMY HAND(EXCL 26035) $1,339.05 $1,339.05 $1,339.05 26040 FASCIOTOMY,PALMAR(DUPUYTREN CONTR)PERCUT $1,339.05 $1,339.05 $1,339.05 26045 FASCIO PALM(DUPUYTREN CONTRA) OPN PARTIA $1,339.05 $1,339.05 $1,339.05 26055 TENDON SHEATH INCISION FOR TRIGGER FINGE $1,339.05 $1,339.05 $1,339.05 26060 TENOTOMY,PERCUTANEOUS, SINGLE, EACH DIGT $1,339.05 $1,339.05 $1,339.05 26070 ARTHROT EXPLOR DRAIN FB REMOV CARPOMETAC $822.23 $822.23 $822.23 26075 ARTHROTOMY,EXPL-DRAIN-FB;METACAR JNT;EA. $822.23 $822.23 $822.23 26080 ARTHROT EXPLOR DRAIN REM FB INTERPHALANG $822.23 $822.23 $822.23 26100 ARTHROTOMY W/BIOPSY; CARPOMETAC JNT;EACH $822.23 $822.23 $822.23 26105 ARTHOTOMY W/BIOPSY; METACARPOPHA JNT;EA. $822.23 $822.23 $822.23 26110 ARTHRO SYNOV BIOPSY INTERPHALANG JOIN EA $822.23 $822.23 $822.23 26111 $822.23 $822.23 $822.23 26113 $822.23 $822.23 $822.23 26115 EXC,TUMOR/VASCUL MALFORM,HND/FING;SUBCUT $822.23 $822.23 $822.23 26116 EXC,TUMOR/VASCULR MALFORM,HAND/FNGR;DEEP $822.23 $822.23 $822.23 26117 RADI RESECT TUMOR(MALIG)SOF TISS HAND,FI $822.23 $822.23 $822.23 26118 $822.23 $822.23 $822.23 26121 FASCIECTMY,PALM,W/WO Z-PLASTY,TISS REARR $1,339.05 $1,339.05 $1,339.05 26123 FASCIECTMY,PART PALMAR W/REL SNGL DGT/JN $1,339.05 $1,339.05 $1,339.05 26130 SYNOVECTOMY CARPOMETACARPAL JOINT $1,339.05 $1,339.05 $1,339.05 26135 SYNOVECTOMY METACARPPH INC RELEAS/RECONS $1,339.05 $1,339.05 $1,339.05 26140 SYNOVECT PROXI INC EXTEN RECONSTRU EA JO $1,339.05 $1,339.05 $1,339.05 26145 SYNOVECT,TEND SHEATH,RAD,FLEX,PAL-FIN;EA $1,339.05 $1,339.05 $1,339.05 26160 EXCIS LESN TEND SHEATH/JOIN-CAP HAN FING $1,339.05 $1,339.05 $1,339.05 26170 EXCIS TENDON PALM FLEXOR,SINGLE(SEPAR)EA $1,339.05 $1,339.05 $1,339.05 26180 EXCISION TENDON,FINGER,FLEXOR(SEP PR)EA. $1,339.05 $1,339.05 $1,339.05 26185 SESAMOIDECTOMY,THUMB OR FINGER(SEP PROC) $1,339.05 $1,339.05 $1,339.05 26200 EXCISION OR CURETTAGE BONE CYST/BENIGN T $822.23 $822.23 $822.23 26205 EXCIS/CURETT CYST/BENIGN TUMOR METACARPA $822.23 $822.23 $822.23 26210 EXCIS/CURETT CYST/BENIGN TUM MIDDLE/DIST $822.23 $822.23 $822.23 26215 EXCIS/CURETT CYST/TUMOR MID/DIS PHAL W/G $822.23 $822.23 $822.23 26230 PART EXCIS BONE OSTEOMY METACARPAL $1,339.05 $1,339.05 $1,339.05 26235 PART EXCIS BONE OSTEOMY PROXI MIDDLE PHA $1,339.05 $1,339.05 $1,339.05 26236 PART EXCIS BONE OSTEOMY DISTAL PHALANX $1,339.05 $1,339.05 $1,339.05 26250 RADICAL RESECTION,METACARPAL(EG. TUMOR) $1,339.05 $1,339.05 $1,339.05 26260 RADICAL RESECT TUMOR PROXI MIDDLE PHALAN $822.23 $822.23 $822.23 26262 RADICAL RESECTION,DISTAL PHAL-FING(TUMOR $822.23 $822.23 $822.23 26320 REMOVAL IMPLANT FROM FINGER OR HAND $822.23 $822.23 $822.23 26340 MANIP FINGER JOINT UNDER ANES EACH JOINT $822.23 $822.23 $822.23 26341 MANIPULATION,PALMAR FASICAL CORD,SINGLE Not Valid Not Valid $822.23 26350 REPAIR/ADVANCE,FLEX TEND,NOT DIGITAL,EA. $1,339.05 $1,339.05 $1,339.05 26352 FLEXOR TENDON REPAIR/ADVANC SECOND W/GRA $1,339.05 $1,339.05 $1,339.05 26356 REPAIR/ADVAN,FLEX TEND,2 DIG,PRIM/SEC,EA $1,339.05 $1,339.05 $1,339.05 26357 FLEXOR TEND REPAIR/ADVANCE SECONDARY EA $1,339.05 $1,339.05 $1,339.05 26358 FLEX TEND REPAI/ADVANC SING SECOND GRAFT $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 20 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 26370 REPAIR/ADVANC PROFUND,W/INT SUPERF,PR,EA $1,339.05 $1,339.05 $1,339.05 26372 REPAIR/ADVANC PROFUND,W/FR GRAFT, SEC,EA $1,339.05 $1,339.05 $1,339.05 26373 REPAIR/ADVANC PROFUND,W/O FREE GRFT,EA. $1,339.05 $1,339.05 $1,339.05 26390 EXCIS FLEX TEND,IMPL SYNTH ROD,HND-FI,EA $1,339.05 $1,339.05 $1,339.05 26392 REM SYNTH ROD&INS FLEX TEN GRF,HA-FIN EA $1,339.05 $1,339.05 $1,339.05 26410 CROSS INTRINSIC TRANSFER;EACH TENDON $1,339.05 $1,339.05 $1,339.05 26412 EXTEN TEND DORSUM HAND SING,PRI,SEC INCG $1,339.05 $1,339.05 $1,339.05 26415 EXCIS EXTEN TEND,IMPLNT SYNTH ROD,HND-FI $1,339.05 $1,339.05 $1,339.05 26416 REMOV SYNTH ROD&INS EXT TENDN GFT,H F,EA $1,339.05 $1,339.05 $1,339.05 26418 REPAIR,EXTENS TEND,FIN,PRI-SEC;W-O GFT,E $1,339.05 $1,339.05 $1,339.05 26420 EXTEN TEND REPAIR DORSUM FING SING-INCGR $1,339.05 $1,339.05 $1,339.05 26426 REPAIR EXT TEN,CEN SLP,SEC,W/LAT BAN,EA. $1,339.05 $1,339.05 $1,339.05 26428 REPAIR EXT TEND,CEN SLP,SEC W/GRAFT,EACH $1,339.05 $1,339.05 $1,339.05 26432 CLOSED TREAT DISTAL EXTENSOR TENDON INSE $1,339.05 $1,339.05 $1,339.05 26433 REPAIR EXTEN TENDON,DISTAL INS,PRIM-SEC $1,339.05 $1,339.05 $1,339.05 26434 EXTENSOR TEND REPAIR OPN 1ST/2ND WO GRAF $1,339.05 $1,339.05 $1,339.05 26437 REALIGNMENT EXTENSOR TENDON, HAND, EACH $1,339.05 $1,339.05 $1,339.05 26440 TENOLYSIS SIMP FLEX TEN PALM OR FING EAC $1,339.05 $1,339.05 $1,339.05 26442 TENOLY FLEX TEN PALM AND FING EA TENDON $1,339.05 $1,339.05 $1,339.05 26445 TENOLYSIS,EXTENSOR TENDON,HAND/FING;EACH $1,339.05 $1,339.05 $1,339.05 26449 TENOLYSIS,COMPL,EXT TEND,FING,FOREARM,EA $1,339.05 $1,339.05 $1,339.05 26450 TENOTOMY FLEXOR SING PALM OPEN EACH $1,339.05 $1,339.05 $1,339.05 26455 TENOTOMY FLEXOR SING,FING,OPN,EACH $1,339.05 $1,339.05 $1,339.05 26460 TENOTOMY EXTENSOR HAND/FING SING OPN ECH $1,339.05 $1,339.05 $1,339.05 26471 TENODESIS; PROXIMAL INTERPHALA JOINT,EA. $1,339.05 $1,339.05 $1,339.05 26474 TENODESIS; DISTAL JOINT, EACH JOINT $1,339.05 $1,339.05 $1,339.05 26476 LENGTH OF TENDON,EXTENSO HAND/FINGER,EA. $822.23 $822.23 $822.23 26477 SHORTEN TENDON,EXTENSOR,HAND/FINGER,EACH $822.23 $822.23 $822.23 26478 TENDON LENGTH FLEXOR HAND,FING.SINGLE EA $822.23 $822.23 $822.23 26479 TENDON SHORTEN FLEXOR HAND,FING,SING EA $822.23 $822.23 $822.23 26480 TENDON TRANSFER/TRANSPLANT CARPOMET W/OG $1,339.05 $1,339.05 $1,339.05 26483 TENDON TRANS/TRANSP CARPOMET W/FREE TEND $1,339.05 $1,339.05 $1,339.05 26485 TEND TRANS/TRANSPL PALM SING EA TEND W/O $1,339.05 $1,339.05 $1,339.05 26489 TEND TRANSF/TRANSPL PAL,SING,EA W/GRAFT $1,339.05 $1,339.05 $1,339.05 26490 OPPONENSPLASTY;SUPERFICI TEND TRANS,EACH $1,339.05 $1,339.05 $1,339.05 26492 OPPONENSPLASTY;TENDON TRANS W/GRAFT,EACH $1,339.05 $1,339.05 $1,339.05 26494 OPPENS PLASTY HYPOTHENAR MUSCLE TRANSFER $1,339.05 $1,339.05 $1,339.05 26496 OPPENS PLASTY OTHER METHODS $1,339.05 $1,339.05 $1,339.05 26497 TENDON TRANS RESTOR FUNCT RING/SM FINGER $1,339.05 $1,339.05 $1,339.05 26498 TENDON TRANS RESTOR FUNCT FOUR FINGERS $1,585.73 $1,585.73 $1,585.73 26499 CORRECTION CLAW FING OTHER METHODS $1,339.05 $1,339.05 $1,339.05 26500 RECONSTR TENDON PULLEY,EACH,W/LOCAL TISU $1,339.05 $1,339.05 $1,339.05 26502 TENDON PULLY RECON W/TEN FASC INC GRAFT $1,339.05 $1,339.05 $1,339.05 26508 THENAR MUSCLE RELEASE THUMB CONTRACTURE $822.23 $822.23 $822.23 26510 CROSS INTRINSIC TRANSFER, EACH TENDON $1,339.05 $1,339.05 $1,339.05 26516 CAPSULODESIS,METACARPOPH JOINT,SNGL DIGT $822.23 $822.23 $822.23 26517 CAPSULODESIS M-P JOINT STABILIZA TWO DIG $1,339.05 $1,339.05 $1,339.05 26518 CAPSULODESIS M-P JOINT STAB THRE/FOUR DI $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 21 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 26520 CAPSULECTOMY/OTOMY;METACARPOPH JOINT,EA. $822.23 $822.23 $822.23 26525 CAPSULECTOMY/OTOMY,INTERPHALAN JOINT,EA. $822.23 $822.23 $822.23 26530 ARTHROPL METACARPOPHAL JOINT SING EACH $822.23 $822.23 $822.23 26531 ARTHROPL METACARPOPHAL JOINT W/IMPLAN EA $1,339.05 $1,339.05 $1,339.05 26535 ARTHROPL INTERPHAL JOINT SINGLE EACH $822.23 $822.23 $822.23 26536 ARTHROPL INTERPHAL JOIN W/PROSTH IMPL EA $1,339.05 $1,339.05 $1,339.05 26540 REPAIR COL LIGMNT,METACARP/INTRPHAL JNT $822.23 $822.23 $822.23 26541 RECONSTR COLL LIG,METACAR J,SIN,TEN/FA G $822.23 $822.23 $822.23 26542 PRIM REP LIG METACARPOPHAL JOINT,LOC TIS $822.23 $822.23 $822.23 26545 RECON COLL LIGA INTERPHAL JOIN SING INC- $822.23 $822.23 $822.23 26546 REP NON-UN,META/PHAL,(BO GR W/WO EX/IN F $822.23 $822.23 $822.23 26548 REPAIR/RECONSTRUCT FING VOLAR PLATE EA $822.23 $822.23 $822.23 26550 POLLICIZATION OF A DIGIT $1,339.05 $1,339.05 $1,339.05 26555 TR,FING/ANOTH POS W/O MICROVASCUL ANASTO $1,585.73 $1,585.73 $1,585.73 26560 REPAIR SYNDACTYLY EA WEB SPAC W/SKIN FLA $822.23 $822.23 $822.23 26561 REPAIR SYNDACTYLY EA WEB SPA W/FLAP/GRAF $822.23 $822.23 $822.23 26562 REPAIR SYNDACT EA WEB SPA COMPLEX BON/NA $822.23 $822.23 $822.23 26565 OSTEOTOMY; METACARPOPAL, EACH $1,585.73 $1,585.73 $1,585.73 26567 OSTEOTOMY; PHALANX OR FINGER, EACH $1,585.73 $1,585.73 $1,585.73 26568 OSTEOPLASTY LENGTH METACARP OR PHALANX $293.65 $293.65 $293.65 26580 REPAIR CLEFT HAND $822.23 $822.23 $822.23 26587 RECONSTUC POLYDACTYL DIGT,SOFT TIS&BONE $822.23 $822.23 $822.23 26590 REPAIR MACRDACTYLIA; EACH DIGIT $1,339.05 $1,339.05 $1,339.05 26591 REPAIR, INTRINSIC MUSCLES OF HAND, EACH $1,339.05 $1,339.05 $1,339.05 26593 RELEASE,INTRINSIC MUSCLES OF HAND, EACH $1,339.05 $1,339.05 $1,339.05 26596 EXCIS CONSTRICT RING MULTI Z-PLASTIES $1,339.05 $1,339.05 $1,339.05 26600 CLO TRT METACARP FX SINGLE W/O MANIPULAT $822.23 $822.23 $822.23 26605 RX METACARPAL EX W MANIPULATION $822.23 $822.23 $822.23 26607 CLO TRT METACARP FX W/MANIP W/EXT FIX;EA $822.23 $822.23 $822.23 26608 PERCUTAN SKELTL FIX METACARPAL FX EA BON $822.23 $822.23 $822.23 26615 OPN TRT METACARP FX SING W IN FIX $1,339.05 $1,339.05 $1,339.05 26641 CLOS TRT CARPOMETACARP DISLO THUMB W/MAN $822.23 $822.23 $822.23 26645 CLO TRT CARPOMETACARP FX DIS THUMB W/MAN $822.23 $822.23 $822.23 26650 PERC SK FIX CARPOMETAC FX DIS TH W MANIP $822.23 $822.23 $822.23 26665 OPN TRT CARPOMETACARP FX DIS W IN FIX $1,339.05 $1,339.05 $1,339.05 26670 CLO TRT CARPOMET FX DIS O/T THUMBWO ANES $822.23 $822.23 $822.23 26675 TRT CLO CARP DISL SIN MAN REQUIR ANESTHE $822.23 $822.23 $822.23 26676 PERC SK FIX CARPOM DIS O/T THUMB,EA JNT $822.23 $822.23 $822.23 26685 OPN TRT CARPOMET DISLO O/T THUMB; EA JNT $1,339.05 $1,339.05 $1,339.05 26686 OPEN RX CARPMETACARP DSLOC REDUCTION $1,339.05 $1,339.05 $1,339.05 26700 CLO TRT METACARPHALANG DIS SING W/O ANES $822.23 $822.23 $822.23 26705 RX METACARPHALANG DSLOC REQUIRING ANESTH $822.23 $822.23 $822.23 26706 PERC SK FIX METOCARPHALANG DIS SI W/MANI $822.23 $822.23 $822.23 26715 OPN TRT METOCARPHALANG DIS W FIXATION $1,339.05 $1,339.05 $1,339.05 26720 CL TRT PHALANG SH FXPROX/MID W/O MANI EA $822.23 $822.23 $822.23 26725 CL TRT PHALANG SH FXPROX/MID W/MANI EACH $1,339.05 $1,339.05 $1,339.05 26727 PERC SK FIX UNSTAB PHALANG SH FX W/MANIP $822.23 $822.23 $822.23 26735 OPN TX PHALANG SH FX PROX/MID W FIXATION $822.23 $822.23 $822.23

07/27/12 Page 22 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 26740 CLO TRT ARTICULAR FXINV METACARP/PROX IN $822.23 $822.23 $822.23 26742 RX ARTICULAR FX W MANIPULATION EA $1,339.05 $1,339.05 $1,339.05 26746 OPN TX ARTICULAR FX INV METACARP W FIX $1,339.05 $1,339.05 $1,339.05 26750 CLS TRT DIST PHALANGEAL FX FING/TH WO MA $822.23 $822.23 $822.23 26755 RX DISTAL PHALANGS FX W MANIPULATION EA $822.23 $822.23 $822.23 26756 PERC SK FIX DIST PHALANG FX FIN/THUMB EA $822.23 $822.23 $822.23 26765 OPN TRT DIST PHALANGFX W INT FIXATION $1,339.05 $1,339.05 $1,339.05 26770 CL TRT INTERPHALANG JT DIS SI W/O ANESTH $822.23 $822.23 $822.23 26775 RX INTEPHALAN JT DSLOC W MAN REQ ANESTH $822.23 $822.23 $822.23 26776 PERC SK FIX INTERPHAL JT DIS SI W/MANIPU $822.23 $822.23 $822.23 26785 OPN TRT INTERPHALANGJT DIS W IN FIXATION $1,339.05 $1,339.05 $1,339.05 26820 FUSION IN OPPOSITION THUMB AUTOGEN GRAFT $1,339.05 $1,339.05 $1,339.05 26841 ARTHRODESIS W WO INT FIXATION $1,339.05 $1,339.05 $1,339.05 26842 ARTHRODESIS W WO FIXATION W AUTOG GRAFT $1,339.05 $1,339.05 $1,339.05 26843 ARTHRODES,CARPOMET JNT,DIG,NOT THUMB,EA. $1,339.05 $1,339.05 $1,339.05 26844 ARTHODESIS DIGITS NOT THUMB W AUTOGEN 6F $1,339.05 $1,339.05 $1,339.05 26850 ARTHODESIS JT W WO FIXATION $1,339.05 $1,339.05 $1,339.05 26852 ARTHODESIS JT W WO FIXATION W AUTOGEN 6F $1,339.05 $1,339.05 $1,339.05 26860 ARTHODESIS INTEPHALAN JT W WO FIXATION $1,339.05 $1,339.05 $1,339.05 26862 ARTHRODESIS INTEPHALAN W AUTOGEN GRAFT $1,339.05 $1,339.05 $1,339.05 26910 AMPUTAT FINGER THUMBW WO INTEROSSEUS TSE $1,339.05 $1,339.05 $1,339.05 26951 AMPUTAT FINGER THUMB W DIRECT CLOSURE $1,339.05 $1,339.05 $1,339.05 26952 AMPUTAT FINGER THUMB W LOCAL ADV ELAPS $1,339.05 $1,339.05 $1,339.05 26989 UNLISTED PROCEDURE HANDS OR FINGERS $822.23 $822.23 $822.23 26990 I&O DEEP ABSCESS OR HEMATOMA $293.65 $293.65 $293.65 26991 I&O INFECTED BURSA $293.65 $293.65 $293.65 27000 TENOTOMY,ADDUCTOR OF HIP,PERCUTANEOUS $822.23 $822.23 $822.23 27001 TENOTOMY, ADDUCTOR OF HIP, OPEN $822.23 $822.23 $822.23 27003 TENOTOMY OPN ADDUCTOR W OBTURA NEURECT $822.23 $822.23 $822.23 27005 TENOTOMY, HIP FLEXOR(S),OPEN (SEP PROC) $1,339.05 $1,339.05 $1,339.05 27006 TENOTOMY,ABDUCTORS/EXTENS OPEN(SEP PROC) $1,339.05 $1,339.05 $1,339.05 27025 PELVIC DECOMPRESS FASCIOTOMY,UNILATERAL $1,339.05 $1,339.05 $1,339.05 27027 PELVIC DECOMPRESS FASCIOTOMY,UNILATERAL $1,339.05 $1,339.05 $1,339.05 27033 ARTHROTOMY HIP W/EXPLOR OR REMOV FOREIGN $1,339.05 $1,339.05 $1,339.05 27035 DENERV,HIP JNT,SCIATIC,FEMOR,OBTUR NERVE $1,339.05 $1,339.05 $1,339.05 27036 CAPSULE/CAPSULO HIP,W/RELEASE HIP FLX MU $822.23 $822.23 $822.23 27040 BIOPSY SOFT TISSUES SUPERFICIAL $822.23 $822.23 $822.23 27041 BIOPSY,SOFT TISSUE-PELVIS/HIP AREA; DEEP $822.23 $822.23 $822.23 27043 $1,339.05 $1,339.05 $1,339.05 27045 $1,339.05 $1,339.05 $1,339.05 27047 EXCIS TUMOR PELVIS-HIP AREA SUB-Q $822.23 $822.23 $822.23 27048 EXCIS TUMOR PELVIS-HIP AREA DEEP SUBFASC $1,339.05 $1,339.05 $1,339.05 27049 RADI RESECT TUMOR(MALIG)PELVIS-HIP AREA $1,339.05 $1,339.05 $1,339.05 27050 ARTHROTOMY WITH BIOPSY SACROILIAC JOINT $822.23 $822.23 $822.23 27052 ARTHROTOMY FOR BIOPSY HIP JOINT $1,339.05 $1,339.05 $1,339.05 27057 PELVIC DECOMP FASCIOTOMY W/DEBRIDM,UNILA $1,339.05 $1,339.05 $1,339.05 27059 $1,339.05 $1,339.05 $1,339.05 27060 EXC ISCHIAL BURSA $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 23 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27062 EXC TROCHANTERIC BURSA OR CALCIF $1,339.05 $1,339.05 $1,339.05 27065 EXC BONE CYST BEN TUMOR SUPERFICIAL $1,339.05 $1,339.05 $1,339.05 27066 EXC BONE CYST BEN TUMOR DEEP $1,339.05 $1,339.05 $1,339.05 27067 EXC BONE CYST BEN TUMOR W BONE 6F $1,339.05 $1,339.05 $1,339.05 27070 PARTIAL EXC BONE SUPERFICIAL $1,339.05 $1,339.05 $1,339.05 27071 PARTIAL EXC BONE DEEP $1,339.05 $1,339.05 $1,339.05 27080 COCCYGECTOMY PRIMARY $1,339.05 $1,339.05 $1,339.05 27086 REMOVAL FOREIGN BODY SUBQ TISSUE $293.65 $293.65 $293.65 27087 REMOVAL FOREIGN BODY,PELVIS-HIP; DEEP $822.23 $822.23 $822.23 27096 INJ, SACROILIAC JOINT $293.65 27097 RELEASE OR RECESSION,HAMSTRING,PROXIMAL $1,339.05 $1,339.05 $1,339.05 27098 ADDUCTOR TRANSFER TO ISCHIUM $1,339.05 $1,339.05 $1,339.05 27100 TRANSF EXT OBLIYUE MUSCLE TO TROCHANTER $1,339.05 $1,339.05 $1,339.05 27105 TRANSF PARASPINAL MUSCLE TO HIP $1,339.05 $1,339.05 $1,339.05 27110 TRANSFER ILIOPSOAS;> TROCHANTER OF FEMUR $1,339.05 $1,339.05 $1,339.05 27111 TRANSF ILIOPSOAS TO FEMORAL NECK $1,339.05 $1,339.05 $1,339.05 27146 OSTEOTOMY ILIAC & ACETABULAR $1,585.73 $1,585.73 $1,585.73 27151 OSTEOTOMY I&A W FEMORAL OSTEOTOMY $1,585.73 $1,585.73 $1,585.73 27170 BONE GRA FEM HE NC INT-SUBTROC AREA $822.23 $822.23 $822.23 27176 RX SLIPPED FEMORAL EPIPHYSIS BY PINNING $1,339.05 $1,339.05 $1,339.05 27177 OPN RX SLIP FEM EPIPY BY PINNING BN 6FT $1,585.73 $1,585.73 $1,585.73 27178 OPN RX SLIP FEM EPIPY CLOS MANI W PINNIN $1,585.73 $1,585.73 $1,585.73 27187 PROPHY RX(NAIL-PIN-WIR-PLAT)W/WO MM FEMU $1,585.73 $1,585.73 $1,585.73 27193 CLOSD TRT PELVIC RING FX W/O MANIPULATIO $822.23 $822.23 $822.23 27194 CLOSD TRT PELVIC RING FX W/MANIPULATION $1,339.05 $1,339.05 $1,339.05 27200 CLS TRT COCCYGEAL FRACTURE $822.23 $822.23 $822.23 27202 OPN TRT COCCYGEAL FRACTURE $822.23 $822.23 $822.23 27216 PERC SKEL FIX POST PELV RING FRAC/DISLOC $822.23 $822.23 $822.23 27220 CLS TRT ACETABULUM(HIP SOCKET)FX W/O MAN $822.23 $822.23 $822.23 27222 RX CLOS ACETABULUM FX W MAN W/WO TRACT $822.23 $822.23 $822.23 27230 CLS TRT FEMORAL FX PROX END NECK W/O MAN $822.23 $822.23 $822.23 27232 CLS TRT FEMORAL FX PROX END W/MAN W/WOTR $1,339.05 $1,339.05 $1,339.05 27235 PERC SKEL FIX FERMORAL FX,PROX END,NECK $1,339.05 $1,339.05 $1,339.05 27238 CL TRT INTERTROCHANT PETRO FEM FX W/O MA $822.23 $822.23 $822.23 27240 CL TRT INTERTROCHANTFEMORAL FXW/WO SK TR $1,339.05 $1,339.05 $1,339.05 27245 OPN RX INT-PERT-SUBTRO FEM FX W/INTRA IM $1,585.73 $1,585.73 $1,585.73 27246 CLS TRT GREATER TROCHANT FX W/O MANIPULA $822.23 $822.23 $822.23 27250 CLS TRT HIP DISLOCATION TRAUM W/O ANESTH $1,339.05 $1,339.05 $1,339.05 27252 RX CLOS HIP DSLOC REY ANESTH $1,339.05 $1,339.05 $1,339.05 27257 RX CONGENITAL HIP DSLOC W MAN REY ANESTH $1,339.05 $1,339.05 $1,339.05 27258 OPN TR SPONT HIP DISREPL FEM HEAD IN ACE $1,339.05 $1,339.05 $1,339.05 27265 CL TRT POST HIP ARTHROPLAS DIS W/O ANEST $822.23 $822.23 $822.23 27266 CL TRT POST HIP ARTHROPLAS DIS W/ANESTHE $822.23 $822.23 $822.23 27267 CLOS TX-THIGH FX,PROXIML,HEAD;W-O MANIPL $822.23 $822.23 $822.23 27268 CLOS TX-THIGH FX,PROXIML,HEAD;W MANIPUL $1,339.95 $1,339.95 $1,339.95 27275 MANIPULATION HIP JT GEN ANESTH $822.23 $822.23 $822.23 27299 UNLISTED PROCED PELVIS HIP JOINT $822.23 $822.23 $822.23 27301 I&D DEEP ABSCESS INFECT BURSA HEMATOMA $822.23 $822.23 $822.23

07/27/12 Page 24 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27303 INCIS,DEEP,W/OPEN BONE CORTEX,FEMUR-KNEE $1,339.05 $1,339.05 $1,339.05 27305 FASCIOTOMY ILIOTIBIAL OPN $1,339.05 $1,339.05 $1,339.05 27306 TENOTOMY,PERCUTANEOUS,ADDUCT/HAMST,SINGL $1,339.05 $1,339.05 $1,339.05 27307 TENOTOMY,PERCUTANEOUS,ADD/HAMST;MULTIPLE $1,339.05 $1,339.05 $1,339.05 27310 ARTHRO KNEE INFEC EXPLOR-DRAIN-REMOV-FOB $1,339.05 $1,339.05 $1,339.05 27323 BIOPSY SOFT TISSUES SUPERFICIAL $822.23 $822.23 $822.23 27324 BIOPSY,SOFT TISSUE-THIGH-KNEE AREA; DEEP $822.23 $822.23 $822.23 27327 EXCISE TUMOR THIGH-KNEE AREA SUB-Q $822.23 $822.23 $822.23 27328 EXC BENIGH TUMOR DEEP SUBFASCIAL INTRAMU $1,339.05 $1,339.05 $1,339.05 27329 RADI RESECT TUMOR(MALIG)THIGH,KNEE AREA $1,339.05 $1,339.05 $1,339.05 27330 ARTHROTOMY KNEE W/SYNOVIAL BIOPSY ONLY $822.23 $822.23 $822.23 27331 ARTHROT KNEE EXPLOR W/WO BIOP, REMOV FB $1,339.05 $1,339.05 $1,339.05 27332 ARTHROTOMY,EXCIS SEMILUN CART KN;MED-LAT $1,585.73 $1,585.73 $1,585.73 27333 ARTHROTOMY KNEE MINISECTOMY MEDIA & LAT $1,585.73 $1,585.73 $1,585.73 27334 ARTHROTOMY KNEE W/SYNOVECTOMY ANT OR POS $1,585.73 $1,585.73 $1,585.73 27335 ARTHROTOMY KNEE FOR SYNOVECTOMY A&P POPL $1,585.73 $1,585.73 $1,585.73 27337 $822.23 $822.23 $822.23 27339 $1,339.05 $1,339.05 $1,339.05 27340 EXC PREPATELLAR BURSA $1,339.05 $1,339.05 $1,339.05 27345 EXC SYNOVIAL CYST OF POPLITEAL AREA $1,339.05 $1,339.05 $1,339.05 27347 EXC-LESION OF MENISCUS-CARSULE;KNEE $1,339.05 $1,339.05 $1,339.05 27350 PATELLECTOMY OR HEMIPATELLECTOMY $1,339.05 $1,339.05 $1,339.05 27355 EXC BN CYST BEN TUMOR OF FEMUR $1,339.05 $1,339.05 $1,339.05 27356 EXC BN CYST BEN TUMOR FEMUR W HOMOGEN GF $1,339.05 $1,339.05 $1,339.05 27357 EXC BN CYST BEN TUMOR FEMUR W AUTOGEN GF $1,339.05 $1,339.05 $1,339.05 27360 PART EXCIS BONE,FEMUR,PROXIMAL TIBIA-FIB $1,339.05 $1,339.05 $1,339.05 27364 $1,339.05 $1,339.05 $1,339.05 27365 RADIC RESEC OF TUMOR BONE FEMUR OR KNEE $1,339.05 $1,339.05 $1,339.05 27372 REMOVAL FOREIGN BODY DEEP $293.65 $293.65 $293.65 27380 SUTURE INFRAPATELLAR TENDON PRIMARY $1,339.05 $1,339.05 $1,339.05 27381 SUTURE INFRAPATELLAR TENDON SECONDARY $1,339.05 $1,339.05 $1,339.05 27385 SUTURE QUADRICEPS HAMSTRING MUS RUPT PRI $1,339.05 $1,339.05 $1,339.05 27386 SUTURE QUADRICEP HAMSTRING MUSCLE SECOND $1,339.05 $1,339.05 $1,339.05 27390 TENOTOMY,OPEN HAMSTR,KNEE TO HIP; SINGLE $1,339.05 $1,339.05 $1,339.05 27391 TENOTOMY,OPN HAMSTR,KN-HIP;MUL TEN,1 LEG $1,339.05 $1,339.05 $1,339.05 27392 TENOTOMY,OPN HAMSTR,KN-HIP,MULTIPL,BILAT $1,339.05 $1,339.05 $1,339.05 27393 LENGTHENING HAMSTRING TENDON SINGLE $1,339.05 $1,339.05 $1,339.05 27394 LENGTHENING HAMSTRING TENDON MULTP 1 LEG $1,339.05 $1,339.05 $1,339.05 27395 LENGTHENING HAMSTRING TENDON MULTP BILAT $1,339.05 $1,339.05 $1,339.05 27396 TRASPLANT HAMSTRING TEND TO PATELLA SGLE $1,585.73 $1,585.73 $1,585.73 27397 TRANSPLANT HAMSTRING TEND TO PATELA MLTP $1,585.73 $1,585.73 $1,585.73 27400 TENDON MUSCLE TRNSF HAMSTRING TO FEMUR $1,585.73 $1,585.73 $1,585.73 27403 ARTHROTOMY W/MENISCUS REPAIR , KNEE $822.23 $822.23 $822.23 27405 REPAIR PRIM TORN LIGAMENT/OR CAP KNE COL $1,339.05 $1,339.05 $1,339.05 27407 REPAIR PRIM TORN LIG +/OR CAPSUL KNE CRU $1,339.05 $1,339.05 $1,339.05 27409 SUTURE LIGAMENT KNEE COLL CRUCIATE LIG $1,339.05 $1,339.05 $1,339.05 27418 ANTERIOR TIBIAL TUBERCLEPLASTY(MAQUET PR $1,339.05 $1,339.05 $1,339.05 27420 RECONSTRUCT DISLOCATING PATELLA(HAUSER P $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 25 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27422 RESTRUCTION RECUR DSLOC PATELA REALIGN $1,339.05 $1,339.05 $1,339.05 27424 RECONSTRUCTION RECUR DSLOC PATELLECTOMY $1,339.05 $1,339.05 $1,339.05 27425 LATERAL RETINACULAR RELEASE OPEN $1,339.05 $1,339.05 $1,339.05 27427 RECONSTRUCT(AUGMEN)KNEE EXTRA-ARTICULAR $822.23 $822.23 $822.23 27428 RECONSTRUCT(AUGMEN)KNEE INTRA-ARTIC OPEN $822.23 $822.23 $822.23 27429 RECONSTRUC(AUGMEN)KNE INTRA-EXT ART OPEN $822.23 $822.23 $822.23 27430 QUADRICEPSPLASTY (BENNETT OR THOMPSON TY $1,585.73 $1,585.73 $1,585.73 27435 CAPSULOTOMY KNEE POSTERIOR CAP RELEASE $1,339.05 $1,339.05 $1,339.05 27437 ARTHROPLASTY PATELLA W/O PROSTHESIS $822.23 $822.23 $822.23 27438 ARTHROPLASTY PATELLA PROSTHETIC $822.23 $822.23 $822.23 27440 ARTHOPLASTY KNEE TIBIAL PLATEAU $822.23 $822.23 $822.23 27441 ARTHROPLAST KNEE ETC W DEBRID & PART SYN $822.23 $822.23 $822.23 27442 ARTHROPLASTY KNEE FEMORAL CONDYLES TIBIA $822.23 $822.23 $822.23 27443 ARTHROPLASTY W DEBRIDEMENT & PART SYNOVE $822.23 $822.23 $822.23 27446 ARTHROPLASTY KNEE TOTAL MEDIAL LAT CPART $1,339.05 $1,339.05 $1,339.05 27450 OSTEOTOMY FEMUR SHAFT/SUPRACONDYL FIXAT $1,585.73 $1,585.73 $1,585.73 27465 OSTEOPLASTY FEMUR SHORTEN(EXCL 64876) $1,585.73 $1,585.73 $1,585.73 27475 ARREST,EPIPHYSEAL,ANY METHOD,DISTAL FEMU $1,585.73 $1,585.73 $1,585.73 27477 EPIPYSEAL ARREST TIBIA & FIBULA PROXIMAL $1,585.73 $1,585.73 $1,585.73 27479 EPIPYSEAL ARREST COMBINED FEMUR TIB FIB $1,585.73 $1,585.73 $1,585.73 27485 ARREST HEMIEPIPYSEAL DISTAL FEMUR LEG $1,585.73 $1,585.73 $1,585.73 27486 REVIS TOTAL KNEE ARTHROPLAST ONE COMPONE $1,339.05 $1,339.05 $1,339.05 27487 REVIS TOTAL KNEE ARTHOPLAST ALL COMPONEN $1,339.05 $1,339.05 $1,339.05 27495 PROPHY RX(NAIL-PIN-PLAT-WIR)W/WO MM FEMU $1,585.73 $1,585.73 $1,585.73 27496 DECOMP FASCIO THIGH/KNEE ONE COMP (FLEX $1,339.05 $1,339.05 $1,339.05 27497 DECOMP FASCIO THIGH/KNEE W/DEBRID NONVIA $1,339.05 $1,339.05 $1,339.05 27498 DECOMP FASCIO THIGH/KNEE MULTI COMPARTME $1,339.05 $1,339.05 $1,339.05 27499 DECOMP FASCIO THIGH/KNEE W/DEBRID NONVIA $1,339.05 $1,339.05 $1,339.05 27500 CLOS TRT FEMORAL SHAFT FX W/O FIXATION $822.23 $822.23 $822.23 27502 CL TRT FEMO SH FX W/MAN W/WO SKIN/SK TRA $1,339.05 $1,339.05 $1,339.05 27503 CLOS RX SUPRA/TRANS FEM FX W MANI W/WO S $1,339.05 $1,339.05 $1,339.05 27506 OPN TR FEMO SH FX W/WO EX FIX W/INS IMPL $1,585.73 $1,585.73 $1,585.73 27508 CL TR FEMO FX DISTALEND MED/LAT CONDYLE $822.23 $822.23 $822.23 27509 PERCU SKEL FIX SUPRA/TRANS FEM FX W/WO I $1,339.05 $1,339.05 $1,339.05 27510 CL TR FEMO FX DIST/MED/LAT CON W/MANIPUL $1,339.05 $1,339.05 $1,339.05 27511 OPN RX FEM SUPRA/TRANS FX WO EX W FIX $1,585.73 $1,585.73 $1,585.73 27513 OPN RX FEM SUPRA/TRANS FX W EXT W FIXA $1,585.73 $1,585.73 $1,585.73 27514 OP TR FEMO FX DIS/MED/LAT CON W FIXATION $1,585.73 $1,585.73 $1,585.73 27516 CLS TR DIST FEMO EPIPHY SEP W/MANIPULATI $822.23 $822.23 $822.23 27517 CLS TR DIST FEMO EPIPHY W/MAN W/WO TRACT $1,339.05 $1,339.05 $1,339.05 27519 OPN TR DIST FEMO EPIPHY SEP W I/E FIX $1,585.73 $1,585.73 $1,585.73 27520 CLS TRT PATELLAR FX W/O MANIPULATION $822.23 $822.23 $822.23 27524 OPN TR PATELLA FX W/INT FIX W/TISSUE REP $1,339.05 $1,339.05 $1,339.05 27530 CLS TR TIBIAL FX PROX(PLATEAU) W/MANIPUL $822.23 $822.23 $822.23 27532 CLS TR TIBIAL FX PROX W/WO MAN W/SK TRAC $1,339.05 $1,339.05 $1,339.05 27535 OPN RX TIBIAL FX PROX (PLATEAU) W FIXA $1,585.73 $1,585.73 $1,585.73 27536 OPN TR TIBIAL FX PROX BICONDY W/WO FIXAT $1,585.73 $1,585.73 $1,585.73 27538 CLS TR INTERCONDY SP/TUBEROSITY FX KNEE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 26 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27540 OPN TR INTCONDY SP/TUBER FX KNEE W FIXA $1,585.73 $1,585.73 $1,585.73 27550 CLS TRT KNEE DISLOCATION W/O ANESTHESIA $822.23 $822.23 $822.23 27552 RX OPN KNEE DSLOC REQ ANESTHESIA $822.23 $822.23 $822.23 27556 OP TR KNEE DSLOC W FIX W/O LIG REPAIR $1,585.73 $1,585.73 $1,585.73 27557 OPN RX KNEE DSLOC W PRIMARY LIGA REPAIR $1,585.73 $1,585.73 $1,585.73 27558 OPN RX KNEE DSLOC W/PRIM LIGA REP W/AUGM $1,585.73 $1,585.73 $1,585.73 27560 CLS TRT PATELLAR DSLOC W/O ANESTHESIA $822.23 $822.23 $822.23 27562 RX CLOS PATELLA DSLOC REQ ANESTHESIA $822.23 $822.23 $822.23 27566 OPN TRT PATELLAR DISW/WO PART/TOT PATELL $1,339.05 $1,339.05 $1,339.05 27570 MANIPULATION KNEE JOINT UNDER ANESTH $822.23 $822.23 $822.23 27590 AMPUTATION THIGH THRU FEMUR ANY LEVEL $1,339.05 $1,339.05 $1,339.05 27591 AMPUTATION THIGH IMMED FITTING TECH $1,585.73 $1,585.73 $1,585.73 27592 AMPUTATION THIGH FEMUR ANY LEV OPEN CIRC $1,585.73 $1,585.73 $1,585.73 27594 AMPUTATION THIGH SECONDARY CLOSURE $1,339.05 $1,339.05 $1,339.05 27596 AMPUTATION THIGH REAMPUTATION $1,339.05 $1,339.05 $1,339.05 27598 DISARTCULATION AT KNEE $1,339.05 $1,339.05 $1,339.05 27599 UNLISTED PROCEDURES FEMUR KNEE $822.23 $822.23 $822.23 27600 DECOMPRES FASCIOTOMY LEG ANT/LAT COMPART $1,339.05 $1,339.05 $1,339.05 27601 DECOMPRES FASCIOTOMY LEG POST COMP ONLY $1,339.05 $1,339.05 $1,339.05 27602 DECOMP FASCIOTOMY LEG ANT/LAT/POST COMPA $1,339.05 $1,339.05 $1,339.05 27603 INCISION & DRAINAGE DEEP ABSCESS HEMATOM $293.65 $293.65 $293.65 27604 INCISION & DRAIN DP ABS HEM INFECT BURSA $822.23 $822.23 $822.23 27605 TENOTOMY,PERCUTANEOUS,ACHILLE TEND,LOCAL $1,339.05 $1,339.05 $1,339.05 27606 TENOTOMY ACHILLES TEN SUBCUTAN GEN ANEST $1,339.05 $1,339.05 $1,339.05 27607 INCISION(OSTEOMYEL/BONE ABSC)LEG OR ANKL $1,339.05 $1,339.05 $1,339.05 27610 ARTHROT ANKLE W/EXPLOR DRAIN REMOVE FB $1,339.05 $1,339.05 $1,339.05 27612 ARTHROTOMY ANKLE POST CAPSULAR RELEASE $1,339.05 $1,339.05 $1,339.05 27613 BIOPSY SOFT TISSUES SUPERFICIAL LEG $822.23 $822.23 $822.23 27614 BIOP,SOF TISSU LEG-ANKL;DEEP(SUBFA-INTRA $822.23 $822.23 $822.23 27615 RADICAL RESECT TUMOR(MALIG)LEG, ANKLE $1,339.05 $1,339.05 $1,339.05 27616 $1,339.05 $1,339.05 $1,339.05 27618 EXCISION TUMOR LEG, ANKLE AREA SUB-Q $822.23 $822.23 $822.23 27619 EXISION BENGN TUM SUB DEEP SUBPAS INTRAM $1,339.05 $1,339.05 $1,339.05 27620 ARTHROT ANKLE EXPLOR W/WO BIOP OR REM FB $822.23 $822.23 $822.23 27625 ARTHROTOMY ANKLE FOR SYNOVECTOMY $1,585.73 $1,585.73 $1,585.73 27626 ARTHROT ANK FOR SYNOVECT INC TENOSYNOVEC $1,339.05 $1,339.05 $1,339.05 27630 EXCISION OF LESION TENDON SHEATH CAPSULE $1,339.05 $1,339.05 $1,339.05 27632 $822.23 $822.23 $822.23 27634 $1,339.05 $1,339.05 $1,339.05 27635 EXCIS CURET BN CYST BENGN TUMOR TIB FIBU $1,339.05 $1,339.05 $1,339.05 27637 EXCIS CUR BN CY BENG TM TB FB PR AUT GFT $1,339.05 $1,339.05 $1,339.05 27638 EXCIS CUR BN CY BENG TR TB PB FB PR HOMG $1,339.05 $1,339.05 $1,339.05 27640 PART EXCIS(CRATER-SAUCER) BONE TIBIA $1,339.05 $1,339.05 $1,339.05 27641 PART EXCIS(CRATER-SAUCER) BONE FIBULA $1,339.05 $1,339.05 $1,339.05 27645 RADICAL RESECTION OF TUMOR BONE TIBIA $1,339.05 $1,339.05 $1,339.05 27646 RESECTION FOR TUMOR RADICAL FIBULA $1,339.05 $1,339.05 $1,339.05 27647 RADIC RESEC OF TUMOR BONE TALUS CALCANEU $822.23 $822.23 $822.23 27650 REPAIR PRIM OPN PERCUT RUPT ACHILLES $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 27 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27652 REPAIR PRIM OPN/PERCUT RUPT ACHILL GRAFT $1,339.05 $1,339.05 $1,339.05 27654 REPAIR,SECOND,ACHILLES TEND,W-W/O GRAFT $1,339.05 $1,339.05 $1,339.05 27656 REPAIR FASCIAL DEFECT OF LEG $1,339.05 $1,339.05 $1,339.05 27658 REPAIR,FLEXDR TEN,LEG;PRIM,W/O GRAFT,EA. $1,339.05 $1,339.05 $1,339.05 27659 REPAIR,FLEXOR TENDON,LEG;SECONDARY, EACH $1,339.05 $1,339.05 $1,339.05 27664 REPAIR,EXTENSOR TEND,LEG;PRIM,W-O GRA,EA $1,339.05 $1,339.05 $1,339.05 27665 REPAIR,EXTEN TEND,LEG;2ND,W/WO GRAFT,EA. $1,339.05 $1,339.05 $1,339.05 27675 REPAIR,DISLOCAT PERONEAL TEN;W-O FIB OST $1,339.05 $1,339.05 $1,339.05 27676 SEE 27675 WITH FIBULAR OSTEOTOMY $1,339.05 $1,339.05 $1,339.05 27680 TENOLYSIS,FLEX-EXTENS TEN,LEG-ANK;SIN,EA $1,339.05 $1,339.05 $1,339.05 27681 TENOLYSIS,FLEX-EXT TEN,LEG-ANK;MULTI TEN $1,339.05 $1,339.05 $1,339.05 27685 LENGTH/SHORTEN TENDON,LEG-ANKLE;SINGL TE $1,339.05 $1,339.05 $1,339.05 27686 LENGTHEN/SHORTEN,LEG-ANKL;MULTI TEND,EA. $1,339.05 $1,339.05 $1,339.05 27687 GASTROCNEMIUS RECESSION (STRAYER PROCED) $1,339.05 $1,339.05 $1,339.05 27690 TRANS TRANP SING TEN SUPERFICIAL $1,585.73 $1,585.73 $1,585.73 27691 TRANS TRANP SING TEN ANTER/POSTER TIBIAL $1,585.73 $1,585.73 $1,585.73 27695 REPAIR,PRIMARY,DISRUPT LIGAMEN,ANKL,COLL $822.23 $822.23 $822.23 27696 SUTUR PRIM TORN,RUP,SEVER LIGA ANKL BOTH $822.23 $822.23 $822.23 27698 REPAIR,2ND DISRUPT LIGAMENT ANKL,COLLATE $822.23 $822.23 $822.23 27700 ARTHROPLASTY ANKLE $822.23 $822.23 $822.23 27703 ARTHROPLASTY,ANKLE;REVISION,TOTAL ANKLE $1,339.05 $1,339.05 $1,339.05 27704 REMOVAL ANKLE IMPLANT $822.23 $822.23 $822.23 27705 OSTEOTMY TIBIA $1,585.73 $1,585.73 $1,585.73 27707 OSTEOTOMY FIBULA $1,585.73 $1,585.73 $1,585.73 27709 OSTEOTOMY TIBIA AND FIBULA $1,585.73 $1,585.73 $1,585.73 27712 OSTEOTOMY MULTI REALIGN INTRMEDUL ROD $1,585.73 $1,585.73 $1,585.73 27715 OSTEOPLASTY,TIBIA-FIBULA,LENGTH/SHORTENI $1,585.73 $1,585.73 $1,585.73 27720 REPAIR NON/MAL UNION W/O GRAFT $1,339.05 $1,339.05 $1,339.05 27722 REPR NON/MAL UNION TIBIA W SLIDING GRAFT $1,339.05 $1,339.05 $1,339.05 27724 REPR NON/MAL UN TB W ILIAC AUTOGEN BN GT $1,339.05 $1,339.05 $1,339.05 27725 REPR NON/MAL TIB SYNOSTOSIS W FIB ANY MT $1,339.05 $1,339.05 $1,339.05 27726 REPAIR FIBULA NONUNION/MALUNION INTER FX $1,585.73 $1,585.73 $1,585.73 27727 REPAIR CONGENITAL PS EUDARTHROSIS TIBIA $1,339.05 $1,339.05 $1,339.05 27730 ARREST,DISTAL TIBIA EPIPHYSIS, OPEN $1,585.73 $1,585.73 $1,585.73 27732 EPIPHYSL ARREST EPIPHYSIOD STP DIST FIBU $1,585.73 $1,585.73 $1,585.73 27734 EPIPHS ARR EPIPHYDS STP DISTAL TIBI/FIBU $1,585.73 $1,585.73 $1,585.73 27740 ARREST,EPIPHY,ANY METH,COMB,PROX-DIS-TIB $1,585.73 $1,585.73 $1,585.73 27742 SEE 27740 AND DISTAL FEMUR $1,585.73 $1,585.73 $1,585.73 27745 PROPHY RX(NAIL-PIN-PLAT-WIR)W/WO MM TIBI $1,339.05 $1,339.05 $1,339.05 27750 CL TR TIBIAL SH FX W/WO FIB FX W/O MANIP $822.23 $822.23 $822.23 27752 CL TR TIBIAL SH FX W/WO FIB FX W/MANIPUL $822.23 $822.23 $822.23 27756 PERC SKEL FIX TIBIALSH FX W/WO FIB FX $1,339.05 $1,339.05 $1,339.05 27758 OP TR TIB SH FX W/PLATE/SCREWS W/WO CERC $1,585.73 $1,585.73 $1,585.73 27759 TREATMENT OF TIBIA SHAFT FRACTURE $1,585.73 $1,585.73 $1,585.73 27760 OP TX MEDIAL MALLEOUS FX,W/INTERNAL FIXA $822.23 $822.23 $822.23 27762 CL TR MEDIAL MALLEOLUS FX W/MAN W/WO TRA $822.23 $822.23 $822.23 27766 OPN TR MEDIAL MALLEOLUS FX W FIXATION $1,585.73 $1,585.73 $1,585.73 27767 CLOS TX POSTERIOR MALLEOLUS FX W/O MANIP $822.23 $822.23 $822.23

07/27/12 Page 28 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 27768 CLOS TX POSTERIOR MALLEOLUS FX W/ MANIPU $822.23 $822.23 $822.23 27769 OPN TX POSTERIOR MALLEOLUS FX,INTERN FIX $1,585.73 $1,585.73 $1,585.73 27780 CLS TRT PROX FIBULA SHFT FX W/MANIPULATI $822.23 $822.23 $822.23 27781 TRT CLS PROX FIBULA SHFT FRAC W MANIPULA $822.23 $822.23 $822.23 27784 OPN TRT PROX FIB SHF FX W FIXATION $1,585.73 $1,585.73 $1,585.73 27786 CLS TRT DIST FIB FX (LAT MALLEO) W/O MAN $822.23 $822.23 $822.23 27788 TRT CLOS DISTAL FX WITH MANIPULATION $822.23 $822.23 $822.23 27792 OPN TR DIST FIB FX (LAT MALLEO) W FIX $1,585.73 $1,585.73 $1,585.73 27808 CLS TRT BIMALLEOLAR ANKLE FX W/O MANIPUL $822.23 $822.23 $822.23 27810 CLSD BIMALLEOLAR ANKLE FX/W MANULATION $822.23 $822.23 $822.23 27814 OPN TR BIMALLEO ANKLE FX W FIXATION $1,585.73 $1,585.73 $1,585.73 27816 CLS TR TRIMALLEOLAR ANKLE FX W/O MANIPUL $822.23 $822.23 $822.23 27818 CLOSED TRIMALLEOR ANKLE FX W/ MANIPULATN $1,339.05 $1,339.05 $1,339.05 27822 OPN TR TRIMALLEO ANKLE FX W/O FIX POS LI $1,585.73 $1,585.73 $1,585.73 27823 OPN TR TRIMALLEO ANKLE FX W/FIX POST LIP $1,585.73 $1,585.73 $1,585.73 27824 CLSD TRT FX WT BEAR DIST TIBIA W/WO ANES $822.23 $822.23 $822.23 27825 CLSD TRT FX WT BEAR DIST TIBIA W/SKEL TR $1,339.05 $1,339.05 $1,339.05 27826 OPN TRT FX WT BEAR DIST TIBIA W/FIX FIBU $1,585.73 $1,585.73 $1,585.73 27827 OPN TRT FX TIBIA W/FIXATION TIB ONLY $1,585.73 $1,585.73 $1,585.73 27828 OPN TR FX DIS TIBIA W/FIX FIB/TIBIA&FIBU $1,585.73 $1,585.73 $1,585.73 27829 OPN TRT DIS TIBIOFIBULAR JNT DISR W/FIXA $1,339.05 $1,339.05 $1,339.05 27830 CLS TRT PROX TIBIOFIBULAR JT DIS W/O ANE $822.23 $822.23 $822.23 27831 PROX TIBIOFIBULAR JOINT DISLC W/ ANESTH $822.23 $822.23 $822.23 27832 OPN TR PROX TIBIOFIBJT DIS W/EXCIS PROX $1,339.05 $1,339.05 $1,339.05 27840 CLS TRT ANKLE DISLC W/O ANESTHESIA $822.23 $822.23 $822.23 27842 CLS TR ANKLE DIS REQANES W/WO PERC SK FI $822.23 $822.23 $822.23 27846 OPN TR ANKLE DIS W/WO PERC SK FIX W/O RE $1,339.05 $1,339.05 $1,339.05 27848 OPN TR ANKLE DIS W/WO PERC SK FIX W/REPA $1,339.05 $1,339.05 $1,339.05 27860 ANKLE MANIP UNDER GEN ANES $293.65 $293.65 $293.65 27870 ARTHRODESIS, ANKLE, OPEN $1,339.05 $1,339.05 $1,339.05 27871 ARTHRODESIS TIBIO FIBULAR JOINT PRO/DIST $1,339.05 $1,339.05 $1,339.05 27880 AMPUTATION LEG THROUGH TIBIA & FIBULA $1,585.73 $1,585.73 $1,585.73 27881 AMPUT LEG TIB/FIB W/ FIT TECH INC 1ST CS $1,585.73 $1,585.73 $1,585.73 27882 AMPUTAT LEG TIBIA/FIBIA OPEN CIRCULAR $1,585.73 $1,585.73 $1,585.73 27884 AMPUT LEG TIB/FIB SECOND CLSR/SCAR REVIS $1,339.05 $1,339.05 $1,339.05 27886 REAMPUTATION $1,339.05 $1,339.05 $1,339.05 27888 AMPUT ANKLE MALLEOLI TIB/FIB PLSTC CLSR $1,585.73 $1,585.73 $1,585.73 27892 DECOMP FASCIOTOMY,LEG ANT/LAT COMP W/DEB $1,339.05 $1,339.05 $1,339.05 27893 DECOMP FASCIOTOMY,LEG POST COMP W/DEBRID $1,339.05 $1,339.05 $1,339.05 27894 DECOMP FASCIOTOMY,LEG ANT/LAT/POST COMP $1,339.05 $1,339.05 $1,339.05 27899 UNLISTED PROCEDURE LEG ANKLE $822.23 $822.23 $822.23 28001 INCISION AND DRAINAGE, BURSA, FOOT $822.23 $822.23 $822.23 28002 INCIS/DRAIN BELOW FASCIA,FOOT;SIN BUR SP $822.23 $822.23 $822.23 28003 FT DP INFECT REG DP DISSECT MULTI AREAS $822.23 $822.23 $822.23 28005 INCISION,BONE CORTX(OSTEOM/BON ABS),FOOT $1,339.05 $1,339.05 $1,339.05 28008 INC,FASCIOTOMY,FOOT &/OR TOE $293.65 $293.65 $293.65 28010 TENOTOMY,PERCUTANEOUS,TOE; SINGLE TENDON $1,339.05 $1,339.05 $1,339.05 28011 TENOTOMY,PERCUTANEOUS,TOE;MULTIPLE TENDO $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 29 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 28020 ARTHRO,EXP-DRA-REM FOR BO;INTR-TARS JOIN $822.23 $822.23 $822.23 28022 FT ARTHROT METATARSOPHALANGEAL JT $822.23 $822.23 $822.23 28024 FT ARTHROT INTERPHLANGEAL JT $822.23 $822.23 $822.23 28035 RELEASE,TARSAL TUNNEL(POST TIB NER DECOM $1,339.05 $1,339.05 $1,339.05 28039 EXCISION (FOOT,TOE,SUBCUTANEOUS) >=1.5CM $822.23 $822.23 $822.23 28041 $1,339.05 $1,339.05 $1,339.05 28043 EXCISION TUMOR FOOT SUBCUTANEOUS $822.23 $822.23 $822.23 28045 FT EXCIS BENIGN TUMOR DP SUBFASC IM $1,339.05 $1,339.05 $1,339.05 28046 RADI RESECT TUMOR*MALIG)SOFT TISS FOOT $1,339.05 $1,339.05 $1,339.05 28047 $1,339.05 $1,339.05 $1,339.05 28050 ARTHROT W/BIOP;INTERTARSAL/TARSOME JOINT $822.23 $822.23 $822.23 28052 FT ARTHROT BIOPSY METATARSOPHALARG JT $822.23 $822.23 $822.23 28054 FT ARTHROT BIOPSY INTERPHALANG JT $822.23 $822.23 $822.23 28060 FASCIECTOMY,PLANTAR FACIA;PARTIAL(SEP PR $1,339.05 $1,339.05 $1,339.05 28062 FT FASCIECTOMY EXCISPLANTAR FASC RADICAL $1,339.05 $1,339.05 $1,339.05 28070 FT SYNOVECTOMY INTERTARS TARSOMETA JT $1,585.73 $1,585.73 $1,585.73 28072 FT SYNOVECTOMY METOTARSOPHALANGEAL JT $1,585.73 $1,585.73 $1,585.73 28080 EXCIS INTER DIGIT(MORTON) NEUROMA SING E $1,339.05 $1,339.05 $1,339.05 28086 FT SYNOVECTOMY TENDON SHEATH FLEXOR $1,339.05 $1,339.05 $1,339.05 28088 FT SYNOVECTOMY TENDON SHEATH EXTENSOR $1,339.05 $1,339.05 $1,339.05 28090 EXCIS LESION,TEND,TEND SHEATH/CAPSU;FOOT $1,339.05 $1,339.05 $1,339.05 28092 EXCIS LESION,TEND,SHEATH/CAPSUL;TOE;EACH $1,339.05 $1,339.05 $1,339.05 28100 EXC/CURETTAGE BONE CYST OR BENIGN TUMOR $822.23 $822.23 $822.23 28102 EXCIS/CURET BONE W/AUTO GRAFT $822.23 $822.23 $822.23 28103 EXCIS/CURET W/HOMO BONE GRAFT $822.23 $822.23 $822.23 28104 EXCIS/CURET OF BONE CYST OR BENIGN TUMOR $822.23 $822.23 $822.23 28106 W/ ILIAC/OTH AUTOG BWE GRFT-INE OBT GRFT $822.23 $822.23 $822.23 28107 W/ HOMOGENOUS BONE GRAFT $822.23 $822.23 $822.23 28110 FT OSTECTOMY PARTIALEXCIS FIFTH METAT HD $822.23 $822.23 $822.23 28111 OSTECT COMP EXCIS FIRST METATARSAL HEAD $822.23 $822.23 $822.23 28112 OSTECT COMP EXCIS OTH METAR HD(2-3-4TH $822.23 $822.23 $822.23 28113 OSTECT COMP EXCIS FITH METARSAL HEAD $822.23 $822.23 $822.23 28114 OSTECTOMY COMP EXCIS ALL METATARS HEADS $822.23 $822.23 $822.23 28116 OSTECTOMY CALCANEUS SPUR W/WO PLANT RELE $822.23 $822.23 $822.23 28118 OSTECTOMY CALCANEUS $1,339.05 $1,339.05 $1,339.05 28119 OSTECTOMY CALCANE SPUR W/WO PLANT RELEAS $822.23 $822.23 $822.23 28120 PARTEXCIS(SAUCER) OF BONE TALUS, CALCACU $822.23 $822.23 $822.23 28122 PART EXCIS(SAUCER)BONE TARSAL EXCPTTALUS $1,339.05 $1,339.05 $1,339.05 28124 PART EXCIS(SAUCER) PHALANX OF TOE $822.23 $822.23 $822.23 28126 RESEC PART/COMPLET PHALANG BASE SING TOE $822.23 $822.23 $822.23 28130 FT TALECTOMY $1,339.05 $1,339.05 $1,339.05 28140 FT METATARSECTOMY $1,339.05 $1,339.05 $1,339.05 28150 PHALANGECTOMY, TOE, EACH TOE $1,339.05 $1,339.05 $1,339.05 28153 RESECTION,CONDYLE(S),DISTAL END PHAL,EA. $822.23 $822.23 $822.23 28160 HEMIPHA/INTERPH JT EXC,TOE,PROX PHAL,EA. $1,339.05 $1,339.05 $1,339.05 28171 RADIC RESEC TUM BONE TARS NOT TAL OR CAL $822.23 $822.23 $822.23 28173 RADIC RESEC OF TUMOR BONE METATARSAL $822.23 $822.23 $822.23 28175 RADIC RESEC TUMOR BONE PHALANX OF TOE $822.23 $822.23 $822.23

07/27/12 Page 30 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 28190 FT REMOVE FOREIGN BODY SUBCU $822.23 $822.23 $822.23 28192 FT REMOVE FOREIGN BODY DEEP $293.65 $293.65 $293.65 28193 FT REMOVE FOREIGN BODY COMPLICATED $293.65 $293.65 $293.65 28200 REPAIR,TEND,FLEX,FOOT;PRI-SEC,W-O GRA/EA $1,339.05 $1,339.05 $1,339.05 28202 SECOND W/FREE GRFT, EA TEWS-INE OBT GRFT $1,339.05 $1,339.05 $1,339.05 28208 REPAIR,TENDON,EXTENSOR,FOOT;PRI-SEC,EACH $1,339.05 $1,339.05 $1,339.05 28210 SECOND W/FREE GRFT, EA TENO-INC OBT GRFT $1,339.05 $1,339.05 $1,339.05 28220 TENDLYSIS,FLEXOR,FOOT; SINGLE TENDON $1,339.05 $1,339.05 $1,339.05 28222 TENOLYSIS,FLEXOR,FOOT; MULTIPLE TENDONS $1,339.05 $1,339.05 $1,339.05 28225 FT TENOLYSIS EXTENSOR SINGLE $1,339.05 $1,339.05 $1,339.05 28226 TENOLYSIS,EXTENSOR, FOOT; MULTI TENDONS $1,339.05 $1,339.05 $1,339.05 28230 TENOTOMY,OPEN,TEND FLEX,SING-MULTI TEND $1,339.05 $1,339.05 $1,339.05 28232 TENOTOMY,OPEN,TEND FLEX;TOE,SING TEN(SEP $1,339.05 $1,339.05 $1,339.05 28234 TENOTOMY,OPEN,EXTENSOR,FOOT/TOE;EACH $1,339.05 $1,339.05 $1,339.05 28238 RECONST,POST TIB TEND W/EXC ACCES NAV BO $1,339.05 $1,339.05 $1,339.05 28240 TENOTOMY LENGTH OR RELEAS ABDUC HAILUCIS $822.23 $822.23 $822.23 28250 DIVISION PLANTAR FASCIA & MUSCLE(SEP PRO $1,339.05 $1,339.05 $1,339.05 28260 FT CAPSULOTOMY MIDFT MEDIAL RELEASE ONLY $1,339.05 $1,339.05 $1,339.05 28261 FT CAPSULOTOMY W TENDON LENGTHENING $1,339.05 $1,339.05 $1,339.05 28262 CAPSUL,MIDFOOT;EXT,POST TAL CAPS&TEN LEN $1,339.05 $1,339.05 $1,339.05 28264 CAPSULOTOMY MIDTARSAL (HEYMAN TYP PROC) $1,339.05 $1,339.05 $1,339.05 28270 CAPSULOTOMY MTP JOINT W/WO SING EA JOINT $822.23 $822.23 $822.23 28272 CAPSULOTOMY INTERPHALANGEAL EACH JOINT $822.23 $822.23 $822.23 28280 SYNDACTYLIZATION,TOES(WEBB-KELIKIAN PROC $822.23 $822.23 $822.23 28285 CORRECTION,HAMMERTOE(INTERPH FUS,PHALANG $822.23 $822.23 $822.23 28286 CX,COCK-UP 5TH TOE,W/PLASTIC SKIN CLOSUR $822.23 $822.23 $822.23 28288 OSTECTOMY,PART,EXOST/CONDYLEC,MET HEA,EA $822.23 $822.23 $822.23 28289 HALLUX RIGIDUS W/CHEILECTOMY DEBRIQEMENT $822.23 $822.23 $822.23 28290 CX,HALLUX VALGUS,SIMPLE EXOSTECTOMY $1,585.73 $1,585.73 $1,585.73 28292 FT KELLER MCBRIDE MAYO PROCEDURE $1,585.73 $1,585.73 $1,585.73 28293 RESECTION OF JOINT WITH IMPLANT $1,585.73 $1,585.73 $1,585.73 28294 CX,HALLUX VALGUS; W/TENDON TRANSPLANTS $1,585.73 $1,585.73 $1,585.73 28296 HALLUX VALGUS CORRECT METARSAL OSTEOTOMY $1,585.73 $1,585.73 $1,585.73 28297 LAPIDUS TYPE PROCEDURE $1,585.73 $1,585.73 $1,585.73 28298 LAPIDUS TYPE PROC BY PHALANX OSTEOTOMY $1,585.73 $1,585.73 $1,585.73 28299 CX,HALLUX VALGUS(BUNION);DOUBLE OSTEOTMY $1,585.73 $1,585.73 $1,585.73 28300 OSTEOTOMY;CALCANEUS(DWY-CHAMB)W-WO IN FX $1,585.73 $1,585.73 $1,585.73 28302 FT OSTEOTOMY TALUS $1,585.73 $1,585.73 $1,585.73 28304 OSTEOTOMY,TARSAL BONES,NOT CALCANE-TALUS $1,339.05 $1,339.05 $1,339.05 28305 OSTEOTOMY,TARSAL BONES,NOT CALC/TAL;AUTO $1,339.05 $1,339.05 $1,339.05 28306 OSTEOTOMY,W-WO LENG/SHOR/ANG CX,1ST META $1,339.05 $1,339.05 $1,339.05 28307 OSTEOT,W-WO LEN-SHOR-ANG CX,1ST MET W/AU $1,339.05 $1,339.05 $1,339.05 28308 OSTEO,W-WO LEN-SHO-ANG CX,NOT 1ST MET,EA $1,339.05 $1,339.05 $1,339.05 28309 OSTEO,W-WO LEN-SHO-ANG CX,METATARS,MULTI $1,585.73 $1,585.73 $1,585.73 28310 OSTEO,SHORT,ANGL,ROT CX,PROX PHAL,1ST TO $1,339.05 $1,339.05 $1,339.05 28312 FT OSTEOTOMY OTHER PHALANGES ANY TOE $1,339.05 $1,339.05 $1,339.05 28313 RECONSTRUC ANG DEFORM TOE SOFT TISS ONLY $822.23 $822.23 $822.23 28315 FT SESAMOITECTOMY FIRST TOE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 31 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 28320 REPAIR,NONUNION-MALFUNCTION;TARSAL BONES $822.23 $822.23 $822.23 28322 FT REPAIR NONUNION METATAR WITH BONE GFT $822.23 $822.23 $822.23 28340 RECONSTRUCT TOE MACRODACTYLSOFT TISS RES $293.65 $293.65 $293.65 28341 RECONSTRUC TOE MACRODACTYLY W/BONE RESEC $822.23 $822.23 $822.23 28344 RECONSTRUCTION TOE(S) POLYDACTYLY $822.23 $822.23 $822.23 28345 RECONSTRUCTOE(S)SYNDACTYLY W/NO GRAFT EA $822.23 $822.23 $822.23 28360 RECONSTRUCTION CLEFT FOOT $822.23 $822.23 $822.23 28400 CLS TRT CALCANEAL FX W/O MANIPULATION $822.23 $822.23 $822.23 28405 CLS TRT CALCANEAL FXW/MANIPULATION $1,339.05 $1,339.05 $1,339.05 28406 PERC SKL FIX CALCANEAL FX W/MANIPULATION $822.23 $822.23 $822.23 28415 OPN TRT CALCANEAL FX W INT FIXATION $1,339.05 $1,339.05 $1,339.05 28420 SEE 28415 W PRIMARY ILIAC AUTOG BONE GRF $1,339.05 $1,339.05 $1,339.05 28430 CLS TRT TALUS FX W/OMANIPULATION $822.23 $822.23 $822.23 28435 RX CLOSED TALUS FX C MANIPULATION $1,339.05 $1,339.05 $1,339.05 28436 PERC SKL FIX TALUS FX W/MANIPULATION $822.23 $822.23 $822.23 28445 OPN TRT TALUS FX W INT FIXATION $1,339.05 $1,339.05 $1,339.05 28455 RX CLOSD TARSAL BN FX C MANIPULATION $1,339.05 $1,339.05 $1,339.05 28456 PERC SKL FIX TARSAL BN FX EX TAL E CALCA $822.23 $822.23 $822.23 28465 OPN TRT TARSAL BN FXW W INT FIX EACH $1,339.05 $1,339.05 $1,339.05 28470 CLS TRT METATARSAL FX W/O MANIPUL EA $822.23 $822.23 $822.23 28475 RX CLOSD METATARAL FY C MANIPULATION $1,339.05 $1,339.05 $1,339.05 28476 PERC SKL FIX METATARSAL FX W/MANIPUL EA $822.23 $822.23 $822.23 28485 OPN RX METATARSAL FRACT, W INT FIX, EACH $1,339.05 $1,339.05 $1,339.05 28490 RX CLOSD FRACT GT TOE, PHLNX OR PHLNG WO $822.23 $822.23 $822.23 28495 RX CLSD FX GT TOE PHLNX R PHLNGES MANIP $822.23 $822.23 $822.23 28496 PERC SKEL FIX FRACT GT TOE, PHLNX OR PHA $822.23 $822.23 $822.23 28505 OPN RX OF FRACT GT TOE, PHLNX OR PHLNGS $822.23 $822.23 $822.23 28515 RX CLSD FX PHLNX PHLNGES C MANIP $822.23 $822.23 $822.23 28525 OPN RX OF FRACT, PHLNX OR PHLNGES OTH,EA $822.23 $822.23 $822.23 28530 TREATMENT OF CLOSED SESMOID FRACTURE $822.23 $822.23 $822.23 28531 OPN TREAT SESAMOID FRACTURE W/WO INT FIX $822.23 $822.23 $822.23 28540 TRTMENT CLSD TRSAL BWE DLSLCTN W/O ANEST $822.23 $822.23 $822.23 28545 TX CLOSE TARSAL BONE DISLOC REG ANES $822.23 $822.23 $822.23 28546 PERCUTANE SKTL FIXTARSAL BN DISL W/MANIP $822.23 $822.23 $822.23 28555 OPEN TX TARSAL BONE DISLOC, INC FIXATION $1,339.05 $1,339.05 $1,339.05 28570 RX CLSD TALOTARSAL DISLOC S ANESTHESIA $822.23 $822.23 $822.23 28575 SEE 28570 REQUIRING ANESTHESIA $822.23 $822.23 $822.23 28576 PERCU SKEL FIX TALOTARSAL JT DISL W/MANI $822.23 $822.23 $822.23 28585 OPEN TX TALOTARSAL JT DISLOC, INC FIXA $1,339.05 $1,339.05 $1,339.05 28600 TREAT CLOSED TARSOMETATARSAL JOI DIS W/O $822.23 $822.23 $822.23 28605 TREAT CLOS TARSOMETATAR DISLO W ANESTHES $822.23 $822.23 $822.23 28606 PERCUTANE SKTL FIX/TARSOMETA JT DIS W/MA $822.23 $822.23 $822.23 28615 OPN RX OF TARSOMETA JOINT DISLOC W FIXA $1,339.05 $1,339.05 $1,339.05 28630 TREA CLOS METATARSOPHANG DISL WITHOUT AN $822.23 $822.23 $822.23 28635 TREAT CLO METARSOPHALNG DISLO W ANESTHES $822.23 $822.23 $822.23 28636 PERC SKEL FIX METATARSOPHALA DISC W/MANI $822.23 $822.23 $822.23 28645 OPN RX OF METATARSOPHALNG JNT DISLOC W O $1,339.05 $1,339.05 $1,339.05 28660 TREA CLOS INTERPHALAN JOINT DIS WOUT ANE $822.23 $822.23 $822.23

07/27/12 Page 32 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 28665 TREAT CLOS INTERPHALANG DISLO W ANESTHES $822.23 $822.23 $822.23 28666 PERC SKEL FIX INTERPHALAN JT DISC W/MANI $822.23 $822.23 $822.23 28675 OPN RX OF INTERPHALANG JNT DISLOC W FIX $1,339.05 $1,339.05 $1,339.05 28705 PLANTALAR ARTHRODESIS $1,339.05 $1,339.05 $1,339.05 28715 TRIPLE/ARTHRODESIS $1,339.05 $1,339.05 $1,339.05 28725 SUBTALAR ARTHRODESIS $1,339.05 $1,339.05 $1,339.05 28730 ARTHRODESIS MIDTARSAL/TARSOMET MULTI TRA $1,339.05 $1,339.05 $1,339.05 28735 ARTHRODESIS MIDTAR/TARSOMET W/OSTEOTOMY $1,339.05 $1,339.05 $1,339.05 28737 ARTHRODESIS MIDTAR NAVIC/CUNEIFOR W/TENN $1,339.05 $1,339.05 $1,339.05 28740 ARTH/MDTRSL/TRSMTSL/SNGL JOINT $1,339.05 $1,339.05 $1,339.05 28750 ARTHRODESIS GREAT TOE METATARSPHALANGEAL $822.23 $822.23 $822.23 28755 SEE 28750 INTERPHALANGEAL JT $822.23 $822.23 $822.23 28760 ARTHRODESIS,W/EXTENSOR HALLUCIS JOINT $822.23 $822.23 $822.23 28800 AMPUTATION, FOOT;MIDTARSAL(CHOPART PROC) $1,585.73 $1,585.73 $1,585.73 28805 TRANSMETATARSAL $1,585.73 $1,585.73 $1,585.73 28810 AMPUTATION/METATARSAL/W TOE SINGLE $1,339.05 $1,339.05 $1,339.05 28820 AMPUTATION/TOE/METATARSO PHALANGEAL/JOIN $1,339.05 $1,339.05 $1,339.05 28825 INTERPHALANGEAL JOINT $1,339.05 $1,339.05 $1,339.05 28899 UNLISTED PROCEDURE FOOT OR TOES $822.23 $822.23 $822.23 29800 ,TEMPOROMANDIBULAR JOINT,DIAG $1,339.05 $1,339.05 $1,339.05 29804 ARTHROSCOPY, TEMP-MANDIBULAR JOINT SURG $1,339.05 $1,339.05 $1,339.05 29805 ARTHSCPY,SHOULDR,DIAG,W-W/O SYNOVIAL BIO $822.23 $822.23 $822.23 29806 ARTHSCPY,SHOULDR,SURGICAL;CAPSULORRHAPHY $1,339.05 $1,339.05 $1,339.05 29807 ARTHSCPY,SHOULDR,SURG;REPAIR SLAP LESION $1,585.73 $1,585.73 $1,585.73 29819 ARTHROSCOPY SHOULD SURGI REMOV LOSE FOB $1,339.05 $1,339.05 $1,339.05 29820 ARTHROSCOPY SHOULD SURGI SYNOVECT PARTIA $1,585.73 $1,585.73 $1,585.73 29821 ARTHROSCOPY SHOULD SURGI SYNOVECT COMPLE $1,585.73 $1,585.73 $1,585.73 29822 ARTHROSCOPY SHOULD SURGI DEBRIDE LIMITED $1,339.05 $1,339.05 $1,339.05 29823 ARTHROSCOPY SHOULD SURGI DEBRIDE EXTENSI $1,339.05 $1,339.05 $1,339.05 29824 ARTHSCPY SHOULDER SURG DIST CLAVLCTMY $1,339.05 $1,339.05 $1,339.05 29825 ARTHROSCOPY SHOULD SURGI LYSI RESEC W/WO $1,339.05 $1,339.05 $1,339.05 29826 ARTHROSCOPY DECOMP SUBACROM SPCE PART AC $1,585.73 $1,585.73 $1,585.73 29827 ARTHROSCPY,SHOULDR,SURG;ROTATOR CUFF REP $1,339.05 $1,339.05 $1,339.05 29828 ARTHROSCOPY,SHOULDER; BICEPS TENODESIS $1,339.95 $1,339.95 $1,339.95 29830 ARTHROSCOPY ELBOW DIAG W/WO SYNOV BIOPSY $822.23 $822.23 $822.23 29834 ARTHROSCOPY ELBOW SURGI REMOV LOSE FOB $1,339.05 $1,339.05 $1,339.05 29835 ARTHROSCOPY ELBOW SURGI SYNOVECT PARTIAL $1,339.05 $1,339.05 $1,339.05 29836 ARTHROSCOPY ELBOW SURGI SYNOVECT COMPLET $1,339.05 $1,339.05 $1,339.05 29837 ARTHROSCOPY ELBOW SURGI DEBRIDE LIMITED $1,339.05 $1,339.05 $1,339.05 29838 ARTHROSCOPY ELBOW SURGI DEBRIDE EXTENSIV $1,339.05 $1,339.05 $1,339.05 29840 ARTHROSCOPY WRIST DIAGW/WO SYNOV BIOPSY $822.23 $822.23 $822.23 29843 ARTHROSCOPY WRIST SURGI FOR INFECT DRAIN $1,339.05 $1,339.05 $1,339.05 29844 ARTHROSCOPY WRIST SYNOVECTOMY PARTIAL $1,339.05 $1,339.05 $1,339.05 29845 ARTHROSCOPY WRIST SURGI-SYNOV COMPLETE $1,339.05 $1,339.05 $1,339.05 29846 ARTHROSCOPY WRIST EXCIS FIBROCART-DEBRID $1,339.05 $1,339.05 $1,339.05 29847 ARTHROSCOPY WRIST INT FIX(FX-INSTABILITY $1,339.05 $1,339.05 $1,339.05 29848 ENDOSCOPY,WRIST,SURGICAL,W/REL TRAN CARP $1,339.05 $1,339.05 $1,339.05 29850 ARTHROSCOPI AIDED TREAT INTER SPINE&TUBE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 33 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 29851 ARTHOSC AIDED TRT OFKNEE W/WO MAN OR FIX $1,339.05 $1,339.05 $1,339.05 29855 ARTHROSCP AIDED TX TIBIAL FX UNI INC FIX $1,339.05 $1,339.05 $1,339.05 29856 ARTHROSCP AIDED TX TIBIAL FX BI INC FIX $1,339.05 $1,339.05 $1,339.05 29860 ARTHROSCOPY,HIP,DIAG,W-W/O SYN BIOP(SEP) $822.23 $822.23 $822.23 29861 ARTHROSCOPY,HIP,SURG;W/REM LO BDY/FOR BO $1,339.05 $1,339.05 $1,339.05 29862 ARTHOSC,HIP,SURG,W/DEBR/SH AR CA,ABR;RES $822.23 $822.23 $822.23 29863 ARTHROSCOPY,HIP,SURG;WITH SYNOVECTOMY $1,339.05 $1,339.05 $1,339.05 29868 ARTHROSC,KNE,SURG;MENISCAL TRANS,MEDIAL/ $1,585.73 $1,585.73 $1,585.73 29870 ARTHROSCOPY KNEE DIAG W/WO SYNOV BIOPSY $822.23 $822.23 $822.23 29871 ARTHROSCOPY KNEE SURGI IFECT LAVAGE/DRAI $1,339.05 $1,339.05 $1,339.05 29873 ARTHROSCPY,KNEE,SURGICAL;W/LATERAL RELEA $1,339.05 $1,339.05 $1,339.05 29874 ARTHROSCOPY KNE SURGI REMOV LOSE BODY/FO $1,339.05 $1,339.05 $1,339.05 29875 ARTHROSCOPY KNEE SYNOVECT,LIMITED(SEPARA $1,585.73 $1,585.73 $1,585.73 29876 ARTHROSCOPY KNE SURGI SYNOVEC MAJ 2/MORE $1,585.73 $1,585.73 $1,585.73 29877 ARTHROSCOPY KNE SURGI DEBRID/SHAV/ARTICU $822.23 $822.23 $822.23 29879 ARTHROSCOPY KNE SURGI ABRAS ARTHPLAS MUL $1,339.05 $1,339.05 $1,339.05 29880 ARTHROSCOPY KNEE W MENISCET MED/LAT SHAV $1,585.73 $1,585.73 $1,585.73 29881 ARTHROSCOPY KNE SURGI MENISC MEDI/LATERA $1,585.73 $1,585.73 $1,585.73 29882 ARTHROSCOPY KNE SURGI W/MENIS REP MED/LA $822.23 $822.23 $822.23 29883 ARTHROSCOPY KNEE W MENISCUS REPAIR(M&L) $822.23 $822.23 $822.23 29884 ARTHROSCOPY KNE SURGI W/LYSIS ADHES W/WO $1,339.05 $1,339.05 $1,339.05 29885 ARTHROSCOPY KNEE DRILL GRAFT W/WO FIXATI $1,339.05 $1,339.05 $1,339.05 29886 ARTHROSCOPY KNE SURGI DRILL INTAC LESION $1,339.05 $1,339.05 $1,339.05 29887 ARTHROSCOPY KNE SURGI DRIL LESION FIXATI $1,339.05 $1,339.05 $1,339.05 29888 ARTHROSCOPY AIDED ANT CRUCCIATE REPAIR- $1,339.05 $1,339.05 $1,339.05 29889 ARTHROSCOP AIDE POST CRUCIAT REP-AUG-REC $1,339.05 $1,339.05 $1,339.05 29891 ARTHR,ANKLE,SUR;EXC OSTE DEF TAL-TIB,DRL $1,339.05 $1,339.05 $1,339.05 29892 ARTHR AIDED REP LG OST DIS L,FRA/INT FIX $822.23 $822.23 $822.23 29893 ENDOSCOPIC PLANTAR FASCIOTOMY $1,339.05 $1,339.05 $1,339.05 29894 ARTHROSCOPY ANKL SURGI REMOV LOSE BOD/FO $1,339.05 $1,339.05 $1,339.05 29895 ARTHROSCOPY ANKL SURGI SYNOVECTOMY PARTI $1,585.73 $1,585.73 $1,585.73 29897 ARTHROSCOPY ANKL SURGI DEBRIDE LIMITED $1,339.05 $1,339.05 $1,339.05 29898 ARTHROSCOPY ANKL SURGI DEBRIDE EXTENSIVE $1,339.05 $1,339.05 $1,339.05 29899 ARTHROSCPY,ANKLE,SURG;DEBRIDEMENT,EXTENS $822.23 $822.23 $822.23 29900 ARTHSCPY METCARPPHALANG DIAG W/SYN BIOP $822.23 $822.23 $822.23 29901 ARTHSCPY METCARPPHALANG SURG W/DEBRIDE $1,339.05 $1,339.05 $1,339.05 29902 ARTHSCPY METCARPPHALANG SURG W/REDUCT $822.23 $822.23 $822.23 29904 ARTHROSCPY,SUBTALAR JNT;W/ RMVL LOOSE-FB $1,339.95 $1,339.95 $1,339.95 29905 ARTHROSCPY,SUBTALAR JOINT; W/SYNOVECTOMY $1,585.73 $1,585.73 $1,585.73 29906 ARTHROSCPY,SUBTALAR JOINT; W/DEBRIDEMENT $1,339.05 $1,339.05 $1,339.05 29907 ARTHROSCPY,SUBTALAR JOINT; W/ARTHRODESIS $822.23 $822.23 $822.23 29914 ARTHROSCOPY,HIP,SURG;W/FEMOROPLASTY Not Valid $1,339.05 $1,339.05 29915 ARTHROSCOPY,HIP,SURG; W/ACETABULOPLASTY Not Valid $1,339.05 $1,339.05 29916 ARTHROSCOPY,HIP,SURG; W/ LABRAL REPAIR Not Valid $1,339.05 $1,339.05 29999 UNLISTED PROCEDURE,ARTHROSCOPY $822.23 $822.23 $822.23 30000 DRG ABSCESS HEMOTOMA NASAL INT APPROACH $822.23 $822.23 $822.23 30020 DRG ABSCESS HEMATOMA NASAL SEPTUM $822.23 $822.23 $822.23 30100 BIOPSY INTRANASAL $293.65 $293.65 $293.65

07/27/12 Page 34 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 30110 EXCISION NASAL POLYP(S) SIMPLE $293.65 $293.65 $293.65 30115 EXCIS NASAL POLYP(S) EXTENSIVE $822.23 $822.23 $822.23 30117 EXCS/DESTR,INTRANASL LESN;INTRNL APROACH $822.23 $822.23 $822.23 30118 EXCIS INTRANASAL LESION EXT APPROACH $1,339.05 $1,339.05 $1,339.05 30124 EXCIS DERMOID CYST NOSE SIMPLE SUBCU $822.23 $822.23 $822.23 30125 EXCIS DERMOID CYST NOSE COMPLEX $822.23 $822.23 $822.23 30130 EXCISION TURBINATE PARTIAL OR COMPLETE $822.23 $822.23 $822.23 30140 SUBMUCOUS RESECT TURBIN,PART-COMPL,ANY M $822.23 $822.23 $822.23 30150 RHINECTOMY PARTIAL $822.23 $822.23 $822.23 30160 RHINECTOMY TOTAL $822.23 $822.23 $822.23 30210 DISPLACEMENT THERAPY $1,339.05 $1,339.05 $1,339.05 30220 INSERTION NASAL SEPTAL PROSTHESIS(BUTTON $1,339.05 $1,339.05 $1,339.05 30310 REMOVAL FOREIGN BODY $822.23 $822.23 $822.23 30320 REMOVAL FOREIGN BODY INTRANASAL RHINOTMY $822.23 $822.23 $822.23 30400 RHINOPLASTY PRIMARY LAT ALAR CART/ ELEVA $822.23 $822.23 $822.23 30410 RHINOPLASTY,COMPLETEPYRAMID,CARTLAGE,TIP $822.23 $822.23 $822.23 30420 RHINOPLASTY,PRIMARY W MAJOR SEPTL REPAIR $822.23 $822.23 $822.23 30430 RHINOPLASTY,SECONDARY,MINOR REVISION $822.23 $822.23 $822.23 30435 RHINOPLASTY SECOND INTERMEDIATE REVIS(BO $822.23 $822.23 $822.23 30450 RHINOPLASTY,SECONDARY , MAJOR REVISION $822.23 $822.23 $822.23 30460 RHINOPLASTY NAS DEF SEC CONG CLEFT/LIP/D $822.23 $822.23 $822.23 30462 RHINOPL NAS DEF SEC CONG CLEF INC COL LE $822.23 $822.23 $822.23 30465 REPAIR NASAL VESTIBULAR STENOSIS $1,339.05 $1,339.05 $1,339.05 30520 SEPTOPLAS/SUBMUCO RESECT W/WO CARTILAGE $822.23 $822.23 $822.23 30540 REPAIR CHOANAL ATRESIA INTRANASAL $822.23 $822.23 $822.23 30545 REPAIR CHOANAL ATRESIA TRANSPALATINE $822.23 $822.23 $822.23 30560 LYSIS INTRANASAL SYNECHIA $822.23 $822.23 $822.23 30580 REPAIR FISTULA ORAMAXILLARY $1,339.05 $1,339.05 $1,339.05 30600 REPAIR FISTULA ORONASAL $822.23 $822.23 $822.23 30620 SEPTAL OTHER INTRANASAL DERMOPLASTY $1,339.05 $1,339.05 $1,339.05 30630 REPAIR NASAL SEPT PERFORATIONS $1,339.05 $1,339.05 $1,339.05 30801 CAUTERY/ABLATION,MUCOSA-TURBIN,SUPERFICI $822.23 $822.23 $822.23 30802 CAUT MUCOSA TUR BILAT INTRAMURAL $822.23 $822.23 $822.23 30901 CONTROL NASAL HEMMOR ANTER SIMP(LIMITED) $822.23 $822.23 $822.23 30903 CONTROL NASAL HEMOR ANT COMPLX(EXTENS)AN $822.23 $822.23 $822.23 30905 CONTROL NASAL HEMOR POSTER ANY MET INITI $822.23 $822.23 $822.23 30906 CONTROLHEMORRHAGE NASAL POST SUBSEQ $822.23 $822.23 $822.23 30915 CONTROL HEMORRHAGE NASAL LIGATION ARTERI $1,339.05 $1,339.05 $1,339.05 30920 SEE CODE 30915 INT MAXILLARY ARTERY $822.23 $822.23 $822.23 30930 FRACT NASAL TURBINATE(S) THERAPEUTIC $822.23 $822.23 $822.23 30999 UNLISTED PROCEDURE NOSE $293.65 $293.65 $293.65 31000 LAVAGE CANNULATION MAXILLARY SINUS $293.65 $293.65 $293.65 31002 LAUAGE CANNULATON SHENOID $293.65 $293.65 $293.65 31020 SINUSOTOMY MAXILLARY INTRANASAL (ANTROP) $1,339.05 $1,339.05 $1,339.05 31030 SINUSOTOMY RADICAL W/O REMOVAL POLYPS $1,585.73 $1,585.73 $1,585.73 31032 EXPLORE SINUS, REMOVE POLYPS $1,585.73 $1,585.73 $1,585.73 31040 PTERYGOMAXILLARY FOSSA SURGERY ANY APPRO $822.23 $822.23 $822.23 31050 SINUSOTOMY SPHENOID W/WO BIOPSY $822.23 $822.23 $822.23

07/27/12 Page 35 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 31051 SINUSOTOMY SPHENOID W/WO BIOP,STRIP,POLY $1,339.05 $1,339.05 $1,339.05 31070 SINUSOTOMY FRONTAL EXT SIMPLE $822.23 $822.23 $822.23 31075 SINUSOSTOMY TRANSORBITAL UNILAT $1,339.05 $1,339.05 $1,339.05 31080 SINUSOTOMY OBLITERATIVE BROW INCIS $1,339.05 $1,339.05 $1,339.05 31081 SINUSOTOMY OBLITERATIVE CORONAL INCISION $1,339.05 $1,339.05 $1,339.05 31084 SINUSOTOMY OBLITERATIVE W OSTEOPLASTIC $1,339.05 $1,339.05 $1,339.05 31085 SINUSOTOMY OBLITERATIVE W OSTEOPLASTIC $1,339.05 $1,339.05 $1,339.05 31086 SINUSOTOMY FRONTAL NONOBLIT W/FLAP BOW I $822.23 $822.23 $822.23 31087 SINUSOTOMY FRONT NONOBLIT W/FLAP CORONAL $822.23 $822.23 $822.23 31090 SINUSOTOMY,UNILATERAL,3OR MORE PARAN SIN $1,339.05 $1,339.05 $1,339.05 31200 ETHMOIDECTOMY INTRANASAL ANTERIOR $1,585.73 $1,585.73 $1,585.73 31201 ETHOMIDECTOMY INTRANASAL TOTAL $1,585.73 $1,585.73 $1,585.73 31205 ETHMOIDECTOMY EXTRANASAL TOTAL $1,585.73 $1,585.73 $1,585.73 31225 MAXILLECTOMY WITHOUT ORBITAL EXENTERAT $1,339.05 $1,339.05 $1,339.05 31230 MAXLLECTOMY WITH ORBITAL EXENTERATION $1,339.05 $1,339.05 $1,339.05 31231 NASAL ENDOSCOPY DIAG UNIL/BIL (SEP PROC) $293.65 $293.65 $293.65 31233 NAS/SINUS ENDOSC DIAG W/MAXIL SINUSOSCOP $822.23 $822.23 $822.23 31235 NAS/SINUS ENDOSC DIAG W/SPHENOID SINUSOS $822.23 $822.23 $822.23 31237 NAS/SINUS ENDOSC SURG W/BIOP POLYP DEBRI $1,339.05 $1,339.05 $1,339.05 31238 NAS/SINUS ENDOSC,SURG,W/CONTR NAS HEMORG $822.23 $822.23 $822.23 31239 NAS/SINUS ENDOSC SURG W/DACRYOCYSTORHINO $1,339.05 $1,339.05 $1,339.05 31240 MAS/SINUS ENDOSC SURG W/CONCHA BULLO RES $822.23 $822.23 $822.23 31254 NASAL ENDOSCOPY SURG W ETHMMOIDECT,PARTI $1,585.73 $1,585.73 $1,585.73 31255 NASAL ENDOSCOPY W ETHMOIDECT ANTE-POST $1,585.73 $1,585.73 $1,585.73 31256 NASAL ENDOSCOPY SURGICAL W MAXIL ANTROST $1,339.05 $1,339.05 $1,339.05 31267 MAXIL SINUS ENDOSCOP SURG REM MM-POLYPS $1,339.05 $1,339.05 $1,339.05 31276 NAS/SIN ENDO SU W/ FR SIN EXP W/WO TISSU $822.23 $822.23 $822.23 31287 NAS/SIN ENDO SURG W/SPHENOIDOTOMY $822.23 $822.23 $822.23 31288 NAS/SIN ENDO SU W/SPHEN W/REM TISSUE SPH $1,339.05 $1,339.05 $1,339.05 31292 NAS/SIN ENDO SU W/MED OR INF ORB WALL DE $1,585.73 $1,585.73 $1,585.73 31293 NAS/SIN ENDO SU W/MED&INF ORB WALL DECOM $1,585.73 $1,585.73 $1,585.73 31294 NAS/SIN ENDO SURG W/OPTIC NERVE DECOMPRE $1,339.05 $1,339.05 $1,339.05 31295 NASAL/SINUS ENDO,DILATE MAXILLARY SINUS Not Valid $1,339.05 $1,339.05 31296 NASAL/SINUS ENDO,DILATE FRONTAL SINUS OS Not Valid $1,339.05 $1,339.05 31297 NASAL/SINUS ENDO,DILATE SPHENIOD SINUS O Not Valid $1,339.05 $1,339.05 31299 UNLISTED PROCEDURE ACCESSORY SINUSES $293.65 $293.65 $293.65 31300 LARYNGOTOMY W REMOVAL TUMORE LARYNGOCELE $1,339.05 $1,339.05 $1,339.05 31320 LARYNGOTOMY DIAGNOSTIC $1,339.05 $1,339.05 $1,339.05 31365 LARYNGECTOMY TOTAL W RAD NECK DISSECTION $1,339.05 $1,339.05 $1,339.05 31367 LARYNGECTOMY SUBTOTAL SUPRAGLOTTIC $1,339.05 $1,339.05 $1,339.05 31368 SUBTOTAL SUPRAGLOTTIO W RAD NECK DISSECT $1,339.05 $1,339.05 $1,339.05 31390 PHARYNGOLARYNGECTOMY W RAD NECK DISSECT $1,339.05 $1,339.05 $1,339.05 31395 SEE 31390 WTH RECONSTRUCTION $1,339.05 $1,339.05 $1,339.05 31400 ARTENOIDECTOMY ARTENOIDOPEXY EXT APPRO $1,339.05 $1,339.05 $1,339.05 31420 EPIGLOTTIDECTOMY $1,585.73 $1,585.73 $1,585.73 31502 TRACHE TUBE CHANGE BEFOR ESTAB FIST TRAC $32.01 $32.01 $32.01 31505 LARYNGOSCOPY INDIRECT DIAGNOSTIC $822.23 $822.23 $822.23 31510 LARYNGOSCOPY WITH BIOPSY $822.23 $822.23 $822.23

07/27/12 Page 36 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 31511 LARYNGOSCOPY W REMOVAL FOREIGN BODY $822.23 $822.23 $822.23 31512 LARYNGOSCOPY W REMOVAL LESION $822.23 $822.23 $822.23 31513 LARYNGOSCOPY INDIRECT W/CORD INJECTION $822.23 $822.23 $822.23 31515 LARYNGOSCOPY DIR W/WO TRACHEOS ASPIRATIO $822.23 $822.23 $822.23 31520 LARYNGOSCOPY DIAGNOSTIC NEWBORN $822.23 $822.23 $822.23 31525 LARYNGOSCOPY DIAGNOSTIC EXCEPT NEWBORN $822.23 $822.23 $822.23 31526 LARYNGOSCOPY DIAGNOSTIC W OPERATING MICR $822.23 $822.23 $822.23 31527 LARYNGOSCOPY DIRECT W/INSERTION OBTURATO $822.23 $822.23 $822.23 31528 LARYNGOSCOP DIRECT W/DILITATION INITIAL $822.23 $822.23 $822.23 31529 LARYNGOSCOPY DIRECT W DILITAT SUBSEQUENT $822.23 $822.23 $822.23 31530 LARYNGOSCOPY OP W FOREIGN BODY REMOVAL $822.23 $822.23 $822.23 31531 LARYNGSCOPY,FOREIGN BDY REMVL,W/OP SCOPE $822.23 $822.23 $822.23 31535 LARYNGOSCOPY DIRECT OP W BIOPSY $822.23 $822.23 $822.23 31536 LARYNGOSCOP DIR OPERAT W BIOP MICROSCOPE $822.23 $822.23 $822.23 31540 LARYNGOSCOPY OP W EXCIS TUMOR STRIPOING $822.23 $822.23 $822.23 31541 LARYNGOSCOP DIR OP W EX TUMOR MICROSCOPE $822.23 $822.23 $822.23 31545 LARYNSC,D,OP,REC VOC CRD W LOC TIS FLAP $293.65 $293.65 $293.65 31546 LARYNSC,D,OP,REM LES VOC CRD REC W/DRAF $822.23 $822.23 $822.23 31560 LARYNGOSCOPY DIR OP W ARYTENOIDECTOMY $1,339.05 $1,339.05 $1,339.05 31561 LARYNGOSCOPY W ATRYTMY W OP MICROSCOPE $1,339.05 $1,339.05 $1,339.05 31570 LARYNGOSCOPY W INJECT INTO VOCAL CORDS $822.23 $822.23 $822.23 31571 LARYNGOSCOP DIR W INJEC THERAP MICROSCOP $822.23 $822.23 $822.23 31575 LARYNGOSCOPY FLEXI FIBERSCOPIC DIAGNOSTI $822.23 $822.23 $822.23 31576 LARYNGOSCOPY FLEXI FIBER W/BIOPSY $822.23 $822.23 $822.23 31577 LARYNGOSCOPY FLEXI FIBERSCOP W/REM FOREI $822.23 $822.23 $822.23 31578 LARYNGOSCOPY FLEXI FIBERSCOP W/REM LESIO $822.23 $822.23 $822.23 31579 LARYNGOSCOPY FLEX/RIGID FIBEROPTIC W/STR $822.23 $822.23 $822.23 31580 LARYNGOPLASTY FOR LARYNGEAL WEB $822.23 $822.23 $822.23 31582 LARYNGOPLASTY FOR LARYNGEAL STENOSIS $822.23 $822.23 $822.23 31587 LARYNGOPLASTY CRICOID SPLIT $822.23 $822.23 $822.23 31588 LARYNGPLASTY NOS (EG FOR BURNS,RECONSTRU $822.23 $822.23 $822.23 31590 LARYNGEAL REINNERVATION BY NEUROMUSCULAR $822.23 $822.23 $822.23 31595 SECTION RECURRENT LARYNGEAL NERV UNILATE $822.23 $822.23 $822.23 31599 UNLISTED PROCEURE LARYNX $822.23 $822.23 $822.23 31600 TRACHEOSTOMY $1,339.05 $1,339.05 $1,339.05 31601 TRACHEOSTOMY UNDER TWO YEARS $1,339.05 $1,339.05 $1,339.05 31603 TRACHEOSTOMY EMERGENCY PROCED TRANSTRACH $1,339.05 $1,339.05 $1,339.05 31605 CRICOTHYROIDOSTOMY $1,339.05 $1,339.05 $1,339.05 31610 TRACHEOSTOMY FENESTRATION PROCEDURE $1,339.05 $1,339.05 $1,339.05 31611 CONSTRUCT TRAC-ESOPH FISTLA INSRT SP PRO $1,250.00 $1,250.00 $1,250.00 31612 TRACHEAL PUNCTURE PERCUTANEOUS $822.23 $822.23 $822.23 31613 TRACHEOSTOMA REVISION-SIMP W/O FLAP $822.23 $822.23 $822.23 31614 TRACHEOSTOMA REVISION COMPLX W/FLAP ROTA $822.23 $822.23 $822.23 31615 TRACHEOBRONCHOSCOPY THROUGH ESTAB INCISI $822.23 $822.23 $822.23 31620 ENDOBRONCH US W/BRONCHOSCPC INTERV;ADD $293.65 $293.65 $293.65 31622 BRONCHSCPY,DIAG,W W/O CEL WASH(SEP PROC) $822.23 $822.23 $822.23 31623 BRONCHOSCOPY;W/BRUSHING-PROTECTED BRUSHS $822.23 $822.23 $822.23 31624 BRONCHOSCOPY;W/BRONCHIAL ALVEOLAR LAVAGE $822.23 $822.23 $822.23

07/27/12 Page 37 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 31625 BRONCHOSCOPY W/BIOPSY(S) $822.23 $822.23 $822.23 31626 $822.23 $822.23 $822.23 31627 $822.23 $822.23 $822.23 31628 BRONCHOSCOPY/LUNG BIOSPY $822.23 $822.23 $822.23 31629 BRONCHOSCOPY/NEEDLE ASPIRATN BIOPSY, EA $822.23 $822.23 $822.23 31630 BRONCHOSCOPY DILATE/CLSED REDUC FRACTRE $822.23 $822.23 $822.23 31631 BRONCHOSCOPY W TRACH DILITAT/PLACE STENT $1,339.05 $1,339.05 $1,339.05 31634 BRONCHOSCOPY,INCL FLUPROSCOPIC GUIDANCE Not Valid Not Valid $1,339.05 31635 BRONCHOSCOPY W/FOREIGN BODY REMOVAL $822.23 $822.23 $822.23 31636 BRONCHOSC W/PLC OF BRONCH STNT;DIL;INIT $293.65 $293.65 $293.65 31637 BRONCHOSCOPY;EA. ADD'L MAJOR BRONCH STEN $293.65 $293.65 $293.65 31638 BRONCHOSC,RIG/FLEX,STENT REV PREV SESSIO $293.65 $293.65 $293.65 31640 BRONCHSCOPY WITH EXCISION OF TUMOR $1,339.05 $1,339.05 $1,339.05 31641 BRONCHOSCO DEST TUMOR-STEN(NO EXCIS)LASE $1,339.05 $1,339.05 $1,339.05 31643 BRONCHOSCOPY W/PLACEMENT OF CATHETER $822.23 $822.23 $822.23 31645 BRONCHOSCOPY THERA ASPIR TRACH INITIAL $822.23 $822.23 $822.23 31646 BRONCHOSCOP W THERAP ASPIRAT SUBSEQUENT $822.23 $822.23 $822.23 31717 CATHERIZATION WITH BRONIAL BRUSH BIOPSY $822.23 $822.23 $822.23 31720 CATHETER ASPIRATION (SEPARATE PROCEDURE) $822.23 $822.23 $822.23 31730 TRANSTRACHEAL (PERCU) NEEDLE WIRE DILATO $822.23 $822.23 $822.23 31750 TRACHEOPLASTY CERVICAL $1,339.05 $1,339.05 $1,339.05 31755 TRACHEOPHARYNGEAL FISTULIZATION EACH $2,936.54 $2,936.54 $2,936.54 31760 TRACHEOPLASTY INTRATHORAIC $1,339.05 $1,339.05 $1,339.05 31766 CARINAL RECONSTRUCTION $1,339.05 $1,339.05 $1,339.05 31770 BRONCHOPLASTY GRAFT REPAIR $822.23 $822.23 $822.23 31775 BRONCHOPLASTY EXCIS STENOSIS ANASTOMOSIS $822.23 $822.23 $822.23 31780 EXCIS TRACHEAL STENOSIS ANASTOM CERVICAL $1,339.05 $1,339.05 $1,339.05 31781 EXCIS TRACH STENOSIS ANASTOM CERVICOTHOR $1,339.05 $1,339.05 $1,339.05 31785 EXCIS TRACHEAL TUMOR OR CARCINOMA CERV $1,339.05 $1,339.05 $1,339.05 31786 EXCIS TRACH TUMOR CARCINOMA THORACIC $1,339.05 $1,339.05 $1,339.05 31800 SUTURE TRACHEAL WOUND/INJURY CERVICAL $822.23 $822.23 $822.23 31805 SUTURE EXT TRACH WOUND INJURY INTRATHOR $822.23 $822.23 $822.23 31820 SURG CLOSURE TRACH FISTULA W OUT PLASTIC $822.23 $822.23 $822.23 31825 SURGI CLOSE TRACH/FISTULA W/REPAIR $822.23 $822.23 $822.23 31830 REVISION TRACHEOSTOMY SCAR $822.23 $822.23 $822.23 31899 UNLISTERD PROCEDURE TRACHEA BRONCHI $293.65 $293.65 $293.65 32035 THORACOSTOMY W RIB RESECTION $1,585.73 $1,585.73 $1,585.73 32036 THORACOSTOMY W OPEN FLAP DRG $1,585.73 $1,585.73 $1,585.73 32095 THORACOTOMY LIMITED FOR BIOPSY $822.23 $822.23 D 32096 THORACOTOMY W/BIOPSY OF LUNG INFILTRATES $822.23 32097 THORACOTOMY W/BIOPSY OF LUNG NODULES $822.23 32098 THORACOTOMY W/BIOPSY OF PLEURA $822.23 32100 THORACOTOMY MAJOR W EXPLORAION BIOPSY $822.23 $822.23 $822.23 32110 INCISION W/CONTROL OF TRAUMATIC HEMOR $822.23 32120 INCISION FOR POSTOP COMP $822.23 32124 INCISION W/OPEN INTRAPLEURAL PNEUMON $822.23 32140 THORACOTOMY W CYST REMOVAL $822.23 $822.23 $822.23 32141 INCISION W/RESECT OF BULLAE $822.23

07/27/12 Page 38 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 32150 SEE 32100 W REMOVAL FOREIGN BODY RIBRIN $1,585.73 $1,585.73 $1,585.73 32151 SEE 32100 W REMOVAL INTRAPULM FOREIGN $1,339.05 $1,339.05 $1,339.05 32160 THORACOTOMY W CARDIAC MASSAGE $1,339.05 $1,339.05 $1,339.05 32200 PNEUMONOSTOMY W OPEN PRG ABSCESS CYST $1,339.05 $1,339.05 $1,339.05 32201 PNEUMONOSTOMY,W/PERCUT DRAIN ABSCES/CYST $1,585.73 $1,585.73 $1,585.73 32402 BIOPSY OPEN PLEURA $822.23 $822.23 D 32405 BIOSY LUNG MEDIASTINUMPERCUTANEOUS NEEDL $822.23 $822.23 $822.23 32420 PNEUMOCENTESIS PUNCTURE LUNG ASPIRATION $1,585.73 $1,585.73 $1,585.73 32421 THORACENTETESIS,PLEURAL CAVITY/ASPIRATIN $822.23 $822.23 $822.23 32422 THORACENTETESIS W/INSERTION OF TUBE $822.23 $822.23 $822.23 32440 REMOVAL OF LUNG $1,339.05 32442 REMOVAL OF LUNG W/ RESECT $1,339.05 32445 REMOVAL OF LUNG W/EXTRA PLEURAL $1,339.05 32480 REMOVAL OF LUNG SINGLE LOBE $1,339.05 32482 REMOVAL OF LUNG TWO LOBES $1,339.05 32484 REMOVAL OF LUNG SINGLE SEGMENT $1,339.05 32486 REMOVAL OF LUNG W/CIRCUM RESEC $1,339.05 32488 REMOVAL OF LUNG W/ALL REMIN LUNG $1,339.05 32491 REMOVE LUNG,NOT PNEUMON;LUNG VOL REDUCTI $1,339.05 $1,339.05 $1,339.05 32500 WEDGE RESECTION LUNG SINGLE OR MULTIPLE $822.23 $822.23 $822.23 32501 RESECT/REPAIR PORTION BRONCHUS PERF AT L $822.23 $822.23 $822.23 32505 THORACOTOMY W/THERAPEUTIC WEDGE RESEC $1,339.05 32506 THORACOTOMY W/THERAPEUTIC WEDGE RESEC $1,339.05 32507 HORACOTOMY W/DIAG WEDGE RESEC $1,339.05 32540 EXTRAPLEURAL ENUOLEATION EMPYEMA $1,585.73 $1,585.73 $1,585.73 32550 INSERT INDWELLING TUNNELED PLEURAL CATHR $293.65 $293.65 $293.65 32551 TUBE THORACOSTOMY,INCLUDES WATER SEAL $1,339.05 $1,339.05 $1,339.05 32522 $293.65 $293.65 $293.65 32553 $822.23 $822.23 $822.23 32601 THORACOSCOPY DIAG LUNG/PLEUR SP W/O BIOP $822.23 $822.23 $822.23 32602 THORACOSCOPY DIAG LUNG/PLEUR SP W/BIOPSY $822.23 $822.23 D 32603 THORACOSCOPY DIAG PERICARDIAL SAC W/O BI $822.23 $822.23 D 32604 THORACOSCOPY DIAG PERICARDIAL SAC W/BIOP $1,339.05 $1,339.05 $1,339.05 32605 THORACOSCOPY DIAG MEDIASTINAL SP W/O BIO $822.23 $822.23 D 32606 THORACOSCOPY DIAG MEDIASTINAL SP W/BIOPS $822.23 $822.23 $822.23 32607 THORACOSCOPY W/D BIOPSY LUNG INFIL,UNIL Not Valid Not Valid $822.23 32608 THORASCOPY;W/DX BIOPSY LUNG MODULE/MASS Not Valid Not Valid $822.23 32609 THORACOSCOPY;W/BIOPSY OF PLEURA Not Valid Not Valid $822.23 32653 THORACOS SURG W/REM INTRAPL FOREIGN BODY $1,585.73 $1,585.73 $1,585.73 32654 THORACOS SURG W/CONTROL OF TRAUM HEMORRH $1,585.73 $1,585.73 $1,585.73 32655 THOROCOSCOPY W/RESEC OF BULLAE $1,585.73 32657 THORACOS SURG W/WEDGE RESECT OF LUNG S/M $822.23 $822.23 D 32658 THORACOS SURG W/REM CLOT FOR BODY FR PER $2,936.54 $2,936.54 $2,936.54 32659 THORACOS SURG W/CREAOF PERICARDIAL WINDO $2,936.54 $2,936.54 $2,936.54 32662 THORACOS SURG W/EXC MEDI CYST,TUMOR,MASS $822.23 $822.23 $822.23 32663 THOROCOSCOPY W/LOBECTOMY $822.23 32664 THORACOSCOPY SURG W/THORACIC SYMPATHECTO $822.23 $822.23 $822.23 32665 THORACOSCOPY SURG W/ESOPHAGOMYOTOMY $1,585.73 $1,585.73 $1,585.73

07/27/12 Page 39 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 32666 THOROCOSCOPY W/THERAPEUTIC WEDGE RESECT $822.23 32667 THOROCOSCOPY W/THERAPEUTIC WEDGE RESECT $822.23 32668 THOROCOSCOPY W/DIAGNOSTIC WEDGE RESECT $822.23 32669 THOROCOSCOPY W/REMOVAL OF SINGLE LUNG $822.23 32670 THOROCOSCOPY W/REMOVAL OF TWO LULNGS $822.23 32671 THOROCOSCOPY W/REMOVAL OF LUNGS $822.23 32672 THOROCOSCOPY W/RESECTION $822.23 32673 THOROCOSCOPY W/RESECTION OF THYMUS $822.23 32674 THOROCOSCOPY W/MEDIASTINAL AND REG LYMPH $822.23 32800 REPAIR LUNG HERNIA THRW CHEST WALL $822.23 $822.23 $822.23 32820 MAJOR RECONSTRUCT CHEST WALL $822.23 $822.23 $822.23 32906 SEE 32905 W CLOSURE BRONCHOPLEURAL FIST $822.23 $822.23 $822.23 32960 PNEUMOTHORAX THERAP INTRAPLEURAL INJ $822.23 $822.23 $822.23 32997 TOTAL LUNG LAVAGE (UNILATERAL) $822.23 $822.23 $822.23 32999 UNLISTED PROCEDURE LUNGS PLEURA $293.65 $293.65 $293.65 33015 TUBE PERICARDIOSTOMY $2,936.54 $2,936.54 $2,936.54 33020 PERICARDIOTOMY REMOVAL CLOT FOREIGN BODY $2,936.54 $2,936.54 $2,936.54 33025 CREATION PERICARDIAL WINDOW $2,936.54 $2,936.54 $2,936.54 33050 PERICARDIUM RESECTION OF CYST $822.23 33120 EXCIS INTRACARDIAC TUMOR RESECT W BYPASS $2,936.54 $2,936.54 $2,936.54 33130 RESECTION EXT CARDIAC TUMOR $2,936.54 $2,936.54 $2,936.54 33206 INSERT PERM PACEMAK TRANSVENOUS ATRIAL $1,585.73 $1,585.73 $1,585.73 33207 INSERT PERM PACE W/ELECT VENTRICULAR $1,585.73 $1,585.73 $1,585.73 33208 INSERT PERM PACE W/ELECT; ART AND VENTRI $1,585.73 $1,585.73 $1,585.73 33210 INSERT TEMPORARY TRANSVENOUS PACEMAKER $1,339.05 $1,339.05 $1,339.05 33211 INSERT REPL OF TEMP TRANSVENOUS PACEMAKE $1,339.05 $1,339.05 $1,339.05 33212 INSERT REPLAC PACE PULSE GENERAT ONLY; S $1,339.05 $1,339.05 $1,339.05 33213 INSERT PACEMAKER PULSE GENERATOR ONLY $1,585.73 $1,585.73 $1,585.73 33214 UPGRADE IMPLANTED PACEMAKER SYS SING CHA $1,585.73 $1,585.73 $1,585.73 33215 REPOSITION IMPLANT TRANSVENOUS PACEMAKER $1,339.05 $1,339.05 $1,339.05 33216 INSERT TRANSVENOUS ELECTRODE;SNGL CHAMB $1,339.05 $1,339.05 $1,339.05 33217 INSERT TRANSVENOUS ELECTRODE;DUAL CHAMB $1,339.05 $1,339.05 $1,339.05 33218 REPAIR SINGL TRANSVEN ELECTRD;SING CHMBR $1,339.05 $1,339.05 $1,339.05 33220 REPAIR 2 TRANSVEN ELECTRODES;DUAL CHMBR $1,339.05 $1,339.05 $1,339.05 33221 INSERT PACEMKR PULSE GEN;W/EXIST LEADS Not Valid Not Valid $1,585.73 33222 REVIS RELOC SKIN POCKET FOR PACE/DEFIB $1,339.05 $1,339.05 $1,339.05 33223 REVISION OF SKIN POCKET SING/DUAL CHMBR $1,339.05 $1,339.05 $1,339.05 33224 INSERT PACING LEAD AND CONNECT $1,339.05 $1,339.05 $1,339.05 33225 INSECTION OF PACING ELECTRCORPOREAL $822.23 33226 REPOSITION LEFT VENTRICAL LEAD $1,585.73 $1,585.73 $1,585.73 33227 REMOV & REPLACE PLACEMAKER PULSE GEN;SNG Not Valid Not Valid $1,339.05 33228 REMOV&REPLACE PACEMARKER PULSE GEN;DUAL Not Valid Not Valid $1,585.73 33229 REMOV PERM PACEMAKER PULSE GEN;MULTI-LE Not Valid Not Valid $1,585.73 33230 INSERT CVD PULSE GEN W/DUAL LEADS Not Valid Not Valid $1,339.05 33231 INSERT CVD PULSE GEN;W/MULTI LEADS Not Valid Not Valid $1,339.05 33233 REMOVAL PERMANENT PACEMAKER PULSE GENER $1,339.05 $1,339.05 $1,339.05 33234 REM TRANS PACEM ELECT;SIN LD SYS,ATR/VEN $822.23 $822.23 $822.23 33235 REMOV TRANSVEN PACEM ELECT;DUAL LEAD SYS $822.23 $822.23 $822.23

07/27/12 Page 40 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 33236 REM PERN EPICARD PCMKR&ELECTR BY THORACO $1,339.05 $1,339.05 $1,339.05 33237 REM PERM EPIC PCMKR&ELECTR THORACO DUAL $1,339.05 $1,339.05 $1,339.05 33240 INSERT REPL OF IMPL CARDIO-DEFIB PUL GEN $1,339.05 $1,339.05 $1,339.05 33241 REM IMPLANTABLE CARDIO-DEFIB PULSE GEN $1,339.05 $1,339.05 $1,339.05 33243 REMOVAL CARDIO-DEFBR ELECTRO;BY THORACOT $1,339.05 $1,339.05 $1,339.05 33244 REM CARDIO-DEFBR ELECTR;BY TRANSVN EXTRC $1,339.05 $1,339.05 $1,339.05 33249 INSRT/REPOS ELECTRD LEAD PACING PUL GENE $1,585.73 $1,585.73 $1,585.73 33250 OPER/ABLATION SUPRAVENT ARRHYTH FOCUS $2,936.54 $2,936.54 $2,936.54 33251 OPER/ABLAT SUPRAVENT ARRHYTH FOCUS BYPAS $2,936.54 $2,936.54 $2,936.54 33261 OPER/ABLAT VENT ARRHYM FOCUS W/CARDIO BY $2,936.54 $2,936.54 $2,936.54 33262 REMOV/REPLAC CVD GENERATOR;SNGL LEAD SYS Not Valid Not Valid $2,572.41 33263 REMOV/REPLAC CVD GENERATOR;MULTI LEAD SY Not Valid Not Valid $2,572.41 33264 REMOV/REPLAC CVD GENERATOR;MULTI LEAD SY Not Valid Not Valid $2,572.41 33282 IMPLANT PT-ACT CARDAIC EVENT RECORDER $822.23 $822.23 $822.23 33284 REM IMPLANTABLE PT-ACT CARDIAC EVENT REC $822.23 $822.23 $822.23 33300 REPAIR CARDIAC WOUND WITHOUT BYPASS $6,342.91 $6,342.91 $6,342.91 33305 REPAIR CARDIAC WOUND W BYPASS $6,342.91 $6,342.91 $6,342.91 33310 CARDIOTOMY EXPL WITHOUT BYPASS $2,936.54 $2,936.54 $2,936.54 33315 CARDIOTOMY EXPL WITH BYPASS $2,936.54 $2,936.54 $2,936.54 33320 SUTURE REP AORTA GREAT VESSELS W/O SHUNT $1,339.05 $1,339.05 $1,339.05 33321 SUTURE REP AORTA GREAT VESSELS W/SHUNT B $1,339.05 $1,339.05 $1,339.05 33322 SUTURE REPAIR AORTA GREAT VESSEL W BYPAS $1,339.05 $1,339.05 $1,339.05 33330 INS GRAFT AORTA GREAT VESSELS W/O SHUNT $822.23 $822.23 $822.23 33332 INSERT GRAFT AORTA GREAT VESS W/SHUNT BY $822.23 $822.23 $822.23 33335 INSERTION GRAFT WITH BYPASS $822.23 $822.23 $822.23 33496 REPA NON-STR PROS VAL DYSFW/CARDIO BYPAS $1,339.05 $1,339.05 $1,339.05 33500 REP CORO ARTERIOVEN CH FIST W/CP BYPASS $1,339.05 $1,339.05 $1,339.05 33501 REP CORONARY ARTERIOVEN/CARD FIST W/OBYP $1,339.05 $1,339.05 $1,339.05 33502 ANOMALOUS CORONARY ARTERY BY LIGATION $1,339.05 $1,339.05 $1,339.05 33503 ANAMALOUS CORONARY ARTERY GRAFT $1,339.05 $1,339.05 $1,339.05 33504 ANOMALOUS CORONARY ARTERY GRAFT W BYPASS $1,339.05 $1,339.05 $1,339.05 33505 REPAIR ANOMALOUS CORONARY ARTERY W/CONST $1,339.05 $1,339.05 $1,339.05 33506 REPAIR ANOMALOUS CORONARY ARTERY BY TRAN $1,339.05 $1,339.05 $1,339.05 33615 REPAIR COMPLEX CARDIAC ANOMALIES TRICUSP $1,339.05 $1,339.05 $1,339.05 33617 REPAIR COMPLEX CARDIAC ANOMALIES BY MODI $1,339.05 $1,339.05 $1,339.05 33619 REPAIR SINGLE VENTRICLE W/AORTIC OUTFLOW $1,339.05 $1,339.05 $1,339.05 33620 APPLIC OF PULMO ART BAND $1,339.05 1339.05 33621 TRANSTHORACIC INSERT CATH $1,339.05 1339.05 33622 RECONSTRUCTION OF COMPLEX ANAMALY $1,339.05 1339.05 33641 REPAR ATRIAL-SEP DEFEC SECUND COL-BYPASS $1,585.73 $1,585.73 $1,585.73 33645 DIRECT OR PATCH CLOSURE SINUS VENOSUS $1,585.73 $1,585.73 $1,585.73 33647 REPAIR ATRIAL-SEP/VENT-SEP DEFECT W CLOS $1,585.73 $1,585.73 $1,585.73 33660 REPAIR OF ATRIOVENT CANAL, W/WO VALVE RE $1,585.73 $1,585.73 $1,585.73 33665 REPAIR OF INTER OR TRANS ARTIOVENT CANAL $1,585.73 $1,585.73 $1,585.73 33681 CLOSURE VENTRIC SEPTAL DEFECT W/WO PATCH $1,585.73 $1,585.73 $1,585.73 33684 SEE 33681 W PULM VALVOTOMY INFUND RESECT $1,585.73 $1,585.73 $1,585.73 33688 SEE 33681 W REMOVAL PULMONARY ARTERY BND $1,585.73 $1,585.73 $1,585.73 33690 BANDING PULMONARY ARTERY $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 41 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 33722 CLOSURE AORTICO-LEFT VENTRICULAR TUNNEL $1,339.05 $1,339.05 $1,339.05 33732 REPAIR COR TRIATRIATUM OR SUPRAVALVULAR $2,936.54 $2,936.54 $2,936.54 33764 SHUNT CENTRAL W PROSTHETIC GRAFT $1,339.05 $1,339.05 $1,339.05 33800 AORTIC SUSP (AORTOPEXY) TRACHEAL DECOMPR $822.23 $822.23 $822.23 33960 CARDIAC ASSIST, PROLONGED EXTRACOPOREAL 1339.05 33961 CARADIAC ASSIST, EACH ADDITIONAL DAY 1339.05 33967 INSERT INTRA-AORTIC PERCUT ASST DEVICE $1,339.05 $1,339.05 $1,339.05 33970 INTRA-AORTIC BALLOON THRU FEMORAL ART OP $1,339.05 $1,339.05 $1,339.05 33973 INTER-AORT BALLOON ASSIST DEVICE THROUGH $1,339.05 $1,339.05 $1,339.05 33975 INSRT VENTR AST DEV;XTRACORP;SNG VENTRIC $1,339.05 $1,339.05 $1,339.05 33976 IMSRT VENTR AST DEV;XTRACORP;BIVENTRICUL $1,339.05 $1,339.05 $1,339.05 33979 INSERT VENTR ASST IMPLNT SING VENTRICLE $1,339.05 $1,339.05 $1,339.05 33999 UNLISTED PROCEDURE CARDIAC SURGERY $1,339.05 $1,339.05 $1,339.05 34001 EMBOL-THROMBOLECTOMY W/WO CATH NEC INCIS $1,339.05 $1,339.05 $1,339.05 34051 SEE 34001 INNOMIRATE SUBCLAVIAN ARTERY $822.23 $822.23 $822.23 34101 EMBO/THROMBOECT AX,BRACH ECT ARM INCES $822.23 $822.23 $822.23 34111 EMBOL-THROMBOECT W/WO CATH RADIAL ULNER $1,339.05 $1,339.05 $1,339.05 34201 SEE 34001 FEMOROPOPLITIAL AORTOILIAC $293.65 $293.65 $293.65 34203 EMBOL-THROMBOECTOMY W/WO CATH POP-TIB-PE $293.65 $293.65 $293.65 34421 THROMBECTOMY BY LEG INCISION $1,339.05 $1,339.05 $1,339.05 34471 THROMBECTOMY BY NECK DISSECTION $822.23 $822.23 $822.23 34490 THROMBECTOMY BY ARM INCISION $1,339.05 $1,339.05 $1,339.05 34501 VALVULOPLASTY FEMORAL VEIN $822.23 $822.23 $822.23 34510 VENOUS VALVU TRANSPOSITION ANY DONO VEIN $822.23 $822.23 $822.23 34520 CROSS-OVER VEIN GRAFT TO VENOUS SYSTEM $1,339.05 $1,339.05 $1,339.05 34530 SAPENOPOPLITEAL VEIN ANASTOMOSIS $1,339.05 $1,339.05 $1,339.05 34830 OPN REPAIR-ANEURYSM/DISSECTION;TUBE PROS $1,339.05 $1,339.05 $1,339.05 34831 OPN REPAIR-ANEURY/DISECT;AORTO-BI-ILI PR $1,339.05 $1,339.05 $1,339.05 34832 OPN REPAIR-ANEUR/DISEC;AROTO-BIFEMOR PRO $1,339.05 $1,339.05 $1,339.05 35001 REPAIR ANEURYSM-PSEUDO-EXCI,NECK INCISIO $1,339.05 $1,339.05 $1,339.05 35005 REPAIR ANEUR-PSEUDO-EXCI,VERTEBRAL ARTER $1,339.05 $1,339.05 $1,339.05 35011 SEE 35001 AXILLARY BRACHIAL ART BY ARM $1,339.05 $1,339.05 $1,339.05 35013 DIRECT REP ANEURYSM AXIL/BRAC ARM INCISI $1,339.05 $1,339.05 $1,339.05 35045 REPAIR ANEU-PSEU-EXC,RADIAL/ULNAR ARTERY $1,339.05 $1,339.05 $1,339.05 35081 DIR REPAIR ANEU-PSEU-EXCI,ABDOMIN AORTA $1,339.05 $1,339.05 $1,339.05 35082 DIRECT REPIR RUPT ABDOMINAL AORTA $1,339.05 $1,339.05 $1,339.05 35091 REPAIR ANEU-PSE-EXC,ABD AORT W/VISCR VES $1,339.05 $1,339.05 $1,339.05 35092 DIRECT REP BD ORT INC VISCERAL VESSEL $1,339.05 $1,339.05 $1,339.05 35102 REPAIR ANEU-PSE-EXC,ABD AORT W/ILIAC VES $1,339.05 $1,339.05 $1,339.05 35103 DIR REP ANEURYSM RUPT ABD AORTA W/ILIAC $1,339.05 $1,339.05 $1,339.05 35141 REPAIR ANEUR-PSEU-EXCI,COMON FEMOR ARTER $822.23 $822.23 $822.23 35151 REPAIR ANEUR-PSEU-EXCI,POPLITERAL ARTERY $822.23 $822.23 $822.23 35180 REPAIR CONGENT ARTERIO FISTULA HEAD-NECK $1,339.05 $1,339.05 $1,339.05 35182 REPAIR CONG ARTERIO FISTULA THORAX-ABDOM $1,339.05 $1,339.05 $1,339.05 35184 REPAIR CONGEN ARTERIOVEN FISTULA EXTREMI $1,339.05 $1,339.05 $1,339.05 35188 REPAIR ACQUIRED-TRAUMA A-V FIST HEAD-NEC $1,339.05 $1,339.05 $1,339.05 35189 REPAIR ACQUIR-TRAUMA A-V FIST THOR-ABDOM $1,339.05 $1,339.05 $1,339.05 35190 REPAIR ACQUIRE-TRAUMA A-V FISTULA EXTREM $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 42 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 35201 REPAIR BLOOD VESSELS AV FISTULA DIRECT $822.23 $822.23 $822.23 35206 REPAIR BLOOD VESSEL DIR UPPER EXTREM $822.23 $822.23 $822.23 35207 REPAIR BLOOD VESSEL DIR HAND FINGER $822.23 $822.23 $822.23 35211 REPAIR BLOOD VESSEL DIR INTRATHOR BY-PAS $1,339.05 $1,339.05 $1,339.05 35216 REPAIR BLOOD VES INTRATHOR DIR WO BYPASS $1,339.05 $1,339.05 $1,339.05 35221 REPAIR BLOOD VESSEL DIR INTRA ABDOMINAL $1,339.05 $1,339.05 $1,339.05 35226 REPAIR BLOOD VESSEL DIR LOWER EXTREMITY $1,339.05 $1,339.05 $1,339.05 35231 REPAIR BLOOD VESSEL W VEIN GRAFT NECK $1,339.05 $1,339.05 $1,339.05 35236 REPAIR BLD VESSEL W VEIN GRAF UP EXTREMI $1,339.05 $1,339.05 $1,339.05 35241 REPAIR BLD VES W VEIN GRAF INTRATHOR BYP $1,339.05 $1,339.05 $1,339.05 35246 REP BLD VES W VEIN GRAF INTRATHOR WO BYP $1,339.05 $1,339.05 $1,339.05 35251 REP BLD VESSEL W VEIN GRAF INTRA ABDOMIN $1,339.05 $1,339.05 $1,339.05 35256 REP BLD VESSEL W VEIN GRAF LOW EXTREMITY $1,339.05 $1,339.05 $1,339.05 35261 REPAIR BLD VESSEL W GRAFT OTH VEIN NECK $1,339.05 $1,339.05 $1,339.05 35266 REPAIR BLD VESSEL W VEIN OTH GRAF UP EXT $1,339.05 $1,339.05 $1,339.05 35271 REPAIR VESS W GRAF OTH VEIN INTRATHOR WI $1,339.05 $1,339.05 $1,339.05 35276 REPAIR VESS W OTH VEIN GRAF THOR WO BYPA $1,339.05 $1,339.05 $1,339.05 35281 REPAIR VESS W OTH VEIN GRAF INTRA ABDOMI $1,339.05 $1,339.05 $1,339.05 35286 REPAIR VESSEL W OTH VEIN GRAF LOW EXTREM $1,339.05 $1,339.05 $1,339.05 35301 THROMBOENDARTERECTOMY CAROTID VERTEBRAL $822.23 $822.23 $822.23 35321 SEE 35301 AXILLARY BRACHIAL $822.23 $822.23 $822.23 35470 TRANSLUM BALLO ANGIOP PERCU TIB TR & BRA $1,339.05 Deleted D 35471 TRANSLUM ANGIOPL PERCU REN OR VISC ART $1,339.05 $1,339.05 $1,339.05 35472 TRANSLUM ANGIOPL PERCU AORTA $1,339.05 $1,339.05 $1,339.05 35473 TRANSLUM ANGIOPL PERCU ILIAC $1,339.05 Deleted D 35474 TRANSLUM ANGIOPL PERCU FEM-POPLITEAL $1,339.05 Deleted D 35475 TRANSLUM ANGIOPL PERCU BRACHIOCEPHALIC $1,339.05 $1,339.05 $1,339.05 35476 TRANSLUM ANGIOPL PERCU VENOUS $1,339.05 $1,339.05 $1,339.05 35516 BYPASS GRAFT W VEIN SUBCLAV-AXILLARY $1,339.05 $1,339.05 $1,339.05 35518 BYPASS GRAFT W VEIN AXILLARY-AXILLARY $1,339.05 $1,339.05 $1,339.05 35533 BYPASS GRAFT W VEIN AXILLARY-FEMOR-FEMOR $1,339.05 $1,339.05 $1,339.05 35556 BYPASS GRAFT W VEIN FEMORAL-POPLITEAL $1,339.05 $1,339.05 $1,339.05 35558 BYPASS GRAFT W VEIN FEMORAL-FEMORAL $1,339.05 $1,339.05 $1,339.05 35570 ARTR BYPAS GRF,TIB-TIB,PER-TIB,TIB/PERON $1,339.05 $1,339.05 $1,339.05 35571 BYPAS GR POP-TIB PERO ART $1,339.05 $1,339.05 $1,339.05 35583 IN-SITU VEIN BY-PASS FEMORAL-POPLITEAL $1,339.05 $1,339.05 $1,339.05 35585 IN-SITU VEIN BY-PASS FEMOR-ANT-POST-PERO $1,339.05 $1,339.05 $1,339.05 35587 ARTR BYPAS GRF,TIB-TIB,PER-TIB/PERON $1,339.05 $1,339.05 $1,339.05 35616 BYPASS GRAFT WOTV SUBCLAVIAN-AXILLIARY $1,339.05 $1,339.05 $1,339.05 35621 BYPASS GRAFT WOTV AXILLIARY-FEMORAL $1,339.05 $1,339.05 $1,339.05 35623 BYPASS GRAFT WOTV AXILLARY-POPLITEAL OR $1,339.05 $1,339.05 $1,339.05 35636 BYPASS GRAFT WOTV SPLENORENAL $1,585.73 $1,585.73 $1,585.73 35650 BYPASS GRAFT WOTV AXILLARY-AXILLARY $1,339.05 $1,339.05 $1,339.05 35654 BYPASS GRAFT WOTV AXILLIARY-FEMORAL-FEMO $1,339.05 $1,339.05 $1,339.05 35656 BYPASS GRAFT WOTV FEMORAL-POPLITEAL $1,339.05 $1,339.05 $1,339.05 35661 BYPASS GRAFT WOTV FEMORAL-FEMORAL $1,339.05 $1,339.05 $1,339.05 35666 BYPASS GRAFT WOTV FEMOR-ANT/POST TIB-PER $1,339.05 $1,339.05 $1,339.05 35671 BYPASS GRAFT OTH THEN VEIN POP-TIB-PERON $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 43 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 35701 EXPLORATION CAROTID ARTERY $1,339.05 $1,339.05 $1,339.05 35721 EXPLOR FEMORAL ARTERY W/WO LYSIS ARTERY $293.65 $293.65 $293.65 35741 EXPLOR POPLITEAL ART,W/WO LYSIS ARTERY $293.65 $293.65 $293.65 35761 EXPLOR OTHER VESSELS W/WO LYSIS $822.23 $822.23 $822.23 35800 EXPLOR FOR POS OP HEMM,THROMB,INFEC NECK $1,339.05 $1,339.05 $1,339.05 35820 EXPLOR POST OP HEMORR/THROMB/INFEC CHEST $1,339.05 $1,339.05 $1,339.05 35840 EXPLOR POST OP HEMOR/THROM/INFEC ABDOMEN $1,339.05 $1,339.05 $1,339.05 35860 EXPLOR POST OP HEMOR/THROM/INFEC EXTREMI $1,339.05 $1,339.05 $1,339.05 35870 REPAIR OF GRAFT-ENTERIC FISTULA $1,339.05 $1,339.05 $1,339.05 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT $1,339.05 $1,339.05 $1,339.05 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT $1,339.05 $1,339.05 $1,339.05 35879 REV LOW-EXT ARTERIAL BYPASS V-P ANGIO $1,339.05 $1,339.05 $1,339.05 35881 REV LOW-EXT ARTERIAL BYPASS S-V INTERPOS $1,339.05 $1,339.05 $1,339.05 35901 EXCISION INFECTED GRAFT; NECK $1,339.05 $1,339.05 $1,339.05 35903 EXCISION INFECTED GRAFT; EXTREMITY $1,339.05 $1,339.05 $1,339.05 35905 EXCISION INFECTED GRAFT; THORAX $1,339.05 $1,339.05 $1,339.05 35907 EXCISION INFECTED GRAFT; ABDOMEN $1,339.05 $1,339.05 $1,339.05 36000 VASCULAR INTROD NEEDLE INTRACATH $293.65 $293.65 $293.65 36002 INJEC PROC PERCUT EXTRMTY PSEUDOANEUR $289.28 $289.28 $289.28 36005 INJEC PROCEDURE FOR EXTREMITY VENOGRAPHY $293.65 $293.65 $293.65 36010 INTRO CATH SUP-INF VENA CAVA $293.65 $293.65 $293.65 36147 INTRO NEEDLE/CATH DIALYSIS,INIT,DOC&RPT $289.28 $289.28 $289.28 36200 INTRO CATH AORTA $293.65 $293.65 $293.65 36245 SELECT CATH PLACE ART SYS ABD PEL L EXT $293.65 $293.65 $293.65 36246 SELECT CATH REPLACEMENT, ARTERIAL SYS $293.65 36247 SEL CATH PLACE ART INI 3RD OR ABD PELV $293.65 $293.65 $293.65 36248 SELECT CATH PLAC, ADDITIONAL SEC ORDER $293.65 36251 INSERT CATHETER RENAL ARTERY,1ST,UNILAT Not Valid Not Valid $293.65 36252 INSERT CATHETER RENAL ARTERY,1ST,BILAT Not Valid Not Valid $293.65 36253 INSERT CATHETER RENAL ARTERY,2ND,UNILAT Not Valid Not Valid $293.65 36254 INSERT CATHETER RENAL ARTERY,2ND,BILAT Not Valid Not Valid $293.65 36260 INSERTION IMPLANT INFUSION PUMP(CHEMO TH $1,339.05 $1,339.05 $1,339.05 36261 REVISION IMPLANTED INFUSION PUMP $1,339.05 $1,339.05 $1,339.05 36262 REMOVAL OF IMPLANTED INFUSION PUMP $822.23 $822.23 $822.23 36299 UNLISTED PROCEDURE VASCULAR INJECT $293.65 $293.65 $293.65 36460 TRANSFUSION INTRAUTERINE FETAL $822.23 $822.23 $822.23 36515 THERAPEU APHERESIS,W/PLASMA REINFUSION 1441.89 1441.89 $1,441.89 36555 INSERT NON-TUNEL CNTRL VENOUS CATH;AGE<5 $822.23 $822.23 $822.23 36556 INSRT NON-TUNEL CNTRL VENOUS CATH;AGE>=5 $822.23 $822.23 $822.23 36557 INSRT TUNEL CV CATH,AGE<5W/O SUBCUT PORT $822.23 $822.23 $822.23 36558 INSRT TUNEL CV CATH,AGE>=5 W/O SUBCU POR $822.23 $822.23 $822.23 36560 INS TUNEL CV ACCESS DEV,AG<5,W/SUBC PORT $822.23 $822.23 $822.23 36561 INS TUNL CV ACES DEV,AG>=5,W/SUBCUT PORT $822.23 $822.23 $822.23 36563 INSERT TUNEL CV ACES DEV W/SUBCUTAN PUMP $822.23 $822.23 $822.23 36565 INS TUNEL CV ACS DEV,2CATH,W/O SUBCU POR $822.23 $822.23 $822.23 36566 INS TUNEL CV ACS DEV,2 CATH,W/SUBCU PORT $822.23 $822.23 $822.23 36568 PERIP INSRT CV CATH,W/O SUBCU PORT;AGE<5 $822.23 $822.23 $822.23 36569 PERIP INSRT CV CATH,W/O SUBCU PORT;AG>=5 $822.23 $822.23 $822.23

07/27/12 Page 44 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 36570 PERIP INS CV ACES DEV,W/SUBCUT PORT;AG<5 $822.23 $822.23 $822.23 36571 PERIP INS CV ACES DEV,W/SUBCU PORT;AG>=5 $822.23 $822.23 $822.23 36575 REPR(NON)TUNEL CV ACS CATH,W/O SUBCU PRT $822.23 $822.23 $822.23 36576 REPAIR CV ACCES DEVC,W/SUBCUTA PORT/PUMP $822.23 $822.23 $822.23 36578 REPLAC,CATH ONLY,CV ACS DEV,W/SUBCU PORT $822.23 $822.23 $822.23 36580 REPLAC,NON-TUNEL CV CATH,W/O SUBCUT PORT $822.23 $822.23 $822.23 36581 REPLACE,TUNEL CV CATH,W/O SUBCU PORT/PUM $822.23 $822.23 $822.23 36582 REPLACE,TUNEL CV ACCES DEVC,W/SUBCU PORT $822.23 $822.23 $822.23 36583 REPLACE,TUNEL CV ACCES DEVC,W/SUBCU PUMP $822.23 $822.23 $822.23 36584 REPLC,PERIP INS CV CATH,W/O SUBC PORT/PU $822.23 $822.23 $822.23 36585 REPLC,PERIP INS CV ACCES DEV,W/SUBC PORT $822.23 $822.23 $822.23 36589 REMOVE TUNEL CV CATH,W/O SUBCUT PORT/PUM $822.23 $822.23 $822.23 36590 REMV TUNEL CV ACCES DEVC,W/SUBCUT PORT/P $822.23 $822.23 $822.23 36592 COLLECT BLOOD FROM CNTRL/PERIPH CATH,NOS $822.23 $822.23 $822.23 36593 DECLOT THROMBOLYTIC AGNT OF VASCULAR DEV $822.23 $822.23 $822.23 36595 MECH REMOV PERICATH OBSTRU MAT'L/CV DEVC $822.23 $822.23 $822.23 36596 MECH REMOV INTRACATH OBSTRU MAT'L/CV DEV $822.23 $822.23 $822.23 36597 REPOSITION CV CATH/FLUOROSCOPIC GUIDANCE $822.23 $822.23 $822.23 36598 CONTRST INJ RADIOLOG EVAL EXIST CNTRL VE $822.23 $822.23 $822.23 36620 ARTERIAL CATHETERIZATION PERCUTANEOUS $293.65 $293.65 $293.65 36625 ARTERIAL CATHETERIZATION CUTDOWN $293.65 $293.65 $293.65 36640 ARTERIAL CATHETER PROLONG INFUSION THERA $293.65 $293.65 $293.65 36660 CATHETERIZATION UMBILICAL ARTERY NEWBORN $293.65 $293.65 $293.65 36680 PLACEMENT OF NEEDLE INTRAOSSEOUS INFUS $822.23 $822.23 $822.23 36800 INSERT CANNULA HEMODIALYSIS VEIN TO VEIN $1,339.05 $1,339.05 $1,339.05 36810 INSER CANNULA HEMO ARTERIOVENOUS EXTERN $1,339.05 $1,339.05 $1,339.05 36815 SEE 36800 ARTERIOVENOUS EXTERN REVISION $822.23 $822.23 $822.23 36818 ARTERIOVEN ANASTOMOSIS;OPN;VEIN TRANSPOS $822.23 $822.23 $822.23 36819 ARTERIOVEN ANASTO,OPN;UP ARM BAS VE TRAN $1,339.05 $1,339.05 $1,339.05 36820 ARTVEN ANASMSIS OPEN F-ARM VEN TRNSPSITN $1,339.05 $1,339.05 $1,339.05 36821 ARTERIOVEN ANASTOMOSIS,OPEN;DIR,ANY SITE $1,339.05 $1,339.05 $1,339.05 36825 CREATE AUTERIOVEN FISTULA AUTOGEN GRAFT $1,339.05 $1,339.05 $1,339.05 36830 CREATE ARTERIOVEN FISTUL NONAUTOGEN GRAF $1,339.05 $1,339.05 $1,339.05 36831 THROMBECTMY OPN ARTERIOVEN FISTU W/O REV $822.23 $822.23 $822.23 36832 REV OPN ARTERIOVENOUS FIST;W/O THROMBECT $822.23 $822.23 $822.23 36833 REVISION ARTERIOVENOUS FISTULA W/THROMB $822.23 $822.23 $822.23 36835 INSERTION OF THOMAS SHUNT SEPARATE PROC $1,339.05 $1,339.05 $1,339.05 36838 DISTL REVAS&INTRVL LIGAT,UP EXTR HEMODIA $822.23 $822.23 $822.23 36860 EXTERN CANNULA DECLOT;W-O BALLOON CATHET $1,339.05 $1,339.05 $1,339.05 36861 CANNULA DECLOTTING W BALLOON CATHETER $1,339.05 $1,339.05 $1,339.05 36870 THROMB,PERCUT,ARTERY FISTULA,GRAFT $1,339.05 $1,339.05 $1,339.05 37140 VENOUS ANASTOMOSIS, OPEN; PORTOCAVAL $1,585.73 $1,585.73 $1,585.73 37145 VENOUS ANASTOMOSIS RENOPORTAL $1,585.73 $1,585.73 $1,585.73 37160 VENOUS ANASTOMOSIS CAVAL-MESENTERIC $1,585.73 $1,585.73 $1,585.73 37180 VENOUS ANASTOMOSIS SPLENORENAL PROXIMAL $1,585.73 $1,585.73 $1,585.73 37181 ANASTOMOSIS SPLENORENAL DISTAL(SELECT DE $1,585.73 $1,585.73 $1,585.73 37182 INSERT HEPATIC SHUNT (TIPS) $822.23 $822.23 $822.23 37183 REMOVE HEPATIC SHUNT (TIPS) $822.23 $822.23 $822.23

07/27/12 Page 45 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 37184 PRIM PERCU TRANSLUM MECH THROMBECTMY;INT $350.00 $350.00 $350.00 37187 PERCU TRANSLUM MECH THROMBEC,INJ&FLUO GU $350.00 $350.00 $350.00 37188 PERCU TRANSLUM MECH THROM,INJ&FLUO GU,SU $822.23 $822.23 $822.23 37191 INSERT ENDOVASCULAR VENA CAVA FILTER Not Valid Not Valid $822.23 37192 REPOS ENDOVASCULAR VENA CAVA FILTER Not Valid Not Valid $822.23 37193 REMOVE ENDOVASCULAR VENA CAVA FILTER Not Valid Not Valid $822.23 37201 TRANCATH THER INF THROMBOLYSIS NOT CORON $293.65 $293.65 $293.65 37203 TRANCATH RETRIEVAL PERCUT OR INTRAVAS $822.23 $822.23 $822.23 37204 TRANCATH OCCLUSION PERCU NOT CNS HEA NEC $822.23 $822.23 $822.23 37205 TRANCATH PLMT INTRAVASC STENT(S) INITIAL $822.23 $822.23 $822.23 37206 TRANSCATH PLAC INTRAVASC STNT,PERCUT,ADD $822.23 $822.23 $822.23 37208 TRANSCATH PLAC INTRAVAS STENT,OPEN;ADD'L $822.23 $822.23 $822.23 37209 EXCH PREVIOUS PLACED ARTERIAL CATH DURIN $293.65 $293.65 $293.65 37210 UTERINE FIBROID EMBOLIZATION,PERCUTANEOU $822.23 $822.23 $822.23 37215 TRANSCAT/INTRAVAS STNT;W/DISTL EMBOL PRO $822.23 $822.23 $822.23 37216 TRANSCAT/INTRAVA STNT;W/O DISTL EMBOL PR $822.23 $822.23 $822.23 37220 REVASCULARIZATION ILIAC ARTER $822.23 822.23 37221 REVASCAL W/STENT/W ANTIOPL $822.23 822.23 37222 REVASCUL W/ANGIOPLASTY $822.23 822.23 37223 ENDOVASCULAR REVASCUL $822.23 822.23 37224 REVASCUL ENDOVASC $822.23 822.23 37225 REVASCUL ENDOVASC $822.23 822.23 37226 REVASCUL ENDOVASC $822.23 822.23 37227 REVASCUL ENDOVASC $822.23 822.23 37228 REVASCUL ENDOVASC $822.23 822.23 37229 REVASCUL ENDOVASC $822.23 822.23 37230 REVASCUL ENDOVASC $822.23 822.23 37231 REVASCUL ENDOVASC $822.23 822.23 37232 REVASCUL ENDOVASC $822.23 822.23 37233 REVASCUL ENDOVASC $822.23 822.23 37234 REVASCUL ENDOVASC $822.23 822.23 37235 REVASCUL ENDOVASC $822.23 822.23 37500 ENDOSCOPY, SURG,W/LIGATION OF PERF VEINS $822.23 $822.23 $822.23 37501 UNLISTED VASCULAR ENDOSCOPY PROCEDURE $822.23 $822.23 $822.23 37565 LIGATION INTERNAL JUGULAR VEIN $822.23 $822.23 $822.23 37600 LIGATION EXT CAROTID ARTERY $822.23 $822.23 $822.23 37605 LIGATION INTERNAL OR COMMON CAROTID ART $822.23 $822.23 $822.23 37606 LIGATION INTERNAL W GRADUAL OCCLUSION $822.23 $822.23 $822.23 37607 LIGATION OR BANDING OF ANGIOACCESS ARTER $822.23 $822.23 $822.23 37609 LIGATION BIOPSY TEMPORAL ARTERY $822.23 $822.23 $822.23 37615 LIGATION MAJOR ARTERY NECK $822.23 $822.23 $822.23 37616 LIGATION MAJOR ARTERY CHEST $1,339.05 $1,339.05 $1,339.05 37617 LIGATION MAJOR ARTERY ABDOMEN $1,339.05 $1,339.05 $1,339.05 37618 LIGATION MAJOR ARTERY EXTREMITY $822.23 $822.23 $822.23 37619 LIGATION OF INFERIOR VENA CAVA $822.23 37650 LIGATION OF FEMORAL VEIN $822.23 $822.23 $822.23 37660 LIGATION OF COMMON ILIAC VEIN $1,339.05 $1,339.05 $1,339.05 37700 LIGAT,DIVIS LONG SAPHENOUS VIEN AT JUNCT $822.23 $822.23 $822.23

07/27/12 Page 46 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 37718 LIGATION,DIV,STRIP,SHORT SAPHENOUS VEIN $822.23 $822.23 $822.23 37722 LIGATION,DIV,STRIP,LONG SAPHENOUS VEIN $822.23 $822.23 $822.23 37735 LIGAT,STRIP SAPHENOUS VNS W EXCIS ULCER/ $822.23 $822.23 $822.23 37760 LIGATION PERFORAT VEINS,SUBFASCIAL,RAD $822.23 $822.23 $822.23 37761 $822.23 $822.23 $822.23 37765 STAB PHLEBECTOMY/VARICOSE,EXTRM;10-20 IN $822.23 $822.23 $822.23 37766 STAB PHLEBECTOMY/VARICOSE,EXTRM;>20 INCI $822.23 $822.23 $822.23 37780 LIGAT,DIVIS SHRT SAPHENOUS VIEN AT JUCT $822.23 $822.23 $822.23 37785 LIGAT,DIVIS,&/OR EXCIS SEC VIENS 1 LEG $822.23 $822.23 $822.23 37788 PENILE REVAS ART W VEIN GRAFT $1,339.05 $1,339.05 $1,339.05 37799 UNLISTED PROCEDURE VASCULAR SURGERY $822.23 $822.23 $822.23 38100 SPLENECTOMY(SEPARATE PROCEDURE)TOTAL $1,339.05 $1,339.05 $1,339.05 38101 SPLENECTOMY(SEPARATE PROCEDURE)PARTIAL $1,339.05 $1,339.05 $1,339.05 38120 LAPAROSCOPY,SURGICAL SPLENECTOMY $1,339.05 $1,339.05 $1,339.05 38129 UNLISTED LAPAROSCOPY PROCEDURE SPLEEN $1,339.05 $1,339.05 $1,339.05 38200 INJECTION PROCEDURE FOR SPLENOPORTOGRAPH $1,339.05 $1,339.05 $1,339.05 38205 HARVEST ALLOGENIC STEM CELLS Not Valid $236.72 $236.72 38220 BONE MARROW ASPIRATION $293.65 $293.65 $293.65 38221 BONE MARROW BIOPSY NEEDLE OR TROCAR $293.65 $293.65 $293.65 38230 BONE MARROW HARVESTING FOR IMPLANTATION $293.65 $293.65 $293.65 38232 BONE MARROW HARVESTING FOR AUTOLOGOUS Not Valid Not Valid $236.72 38240 BONE MARR/BL DERIV PERIPH STEM CELL TRAN $93,968.98 $93,968.98 $93,968.98 38241 BONE MARROW TRANSPLANT, AUTOLOGOUS $93,968.98 $93,968.98 $93,968.98 38242 LYMPHOCYTE INFUSE TRANSPLANT $93,968.98 $93,968.98 $93,968.98 38300 DRG LYMPH NODE ABSCESS LYMPHADEN SIMPLE $822.23 $822.23 $822.23 38305 DRG LYMPH NODE ABSCESS EXTENSIVE $822.23 $822.23 $822.23 38308 LYMPHANGIOTOMY OTHER OP LYMPHATIC CHANN $1,339.05 $1,339.05 $1,339.05 38500 BIOP/EXCIS LYMPH NODE OPEN SUPERFICIAL $822.23 $822.23 $822.23 38505 BIOP OR EXCIS LYMPH NODE NEEDLE SUPERFIC $822.23 $822.23 $822.23 38510 BIO/EXCI LYMP NODE DP CERV NODE W/EX $1,339.05 $1,339.05 $1,339.05 38520 BIO/EXC LYMP NODE OPN DP CERV NODE W/EXC $1,339.05 $1,339.05 $1,339.05 38525 BIOP-EXCI LYMP NODE OPN DEP AXIL NODE(S) $1,339.05 $1,339.05 $1,339.05 38530 BIOP/EXCI LYMP NODE OPN INT MAMMARY NODE $1,339.05 $1,339.05 $1,339.05 38542 DISSECTION DEEP JUGULAR NODE(S) $1,339.05 $1,339.05 $1,339.05 38550 EXCIS CYSTIC HYGROMA W/O DEEP NEURO DIS $822.23 $822.23 $822.23 38555 EXCIS CYSTIC HYGROMA W DEEP NEURO DISSE $1,339.05 $1,339.05 $1,339.05 38562 LIMIT LYMPHADENECT FOR STAGE PELVIC-PARA $822.23 $822.23 $822.23 38564 LIMITED LYMPHODENECT FOR STAG RETROPERIT $822.23 $822.23 $822.23 38570 LAP SURGICAL RETRO LYMPH NODE SAMPLE S/M $822.23 $822.23 $822.23 38571 LAP SURGICAL BILTRL TTL PELVIC LYMPHCTMY $822.23 $822.23 $822.23 38572 LAP SURG BILTRL TTL PELVIC LYMPH P-AORTC $822.23 $822.23 $822.23 38589 UNLISTED LAPARO PROCEDURE LYMPHATIC SYST $822.23 $822.23 $822.23 38700 SUPRAHYOID LYMPHADENECTOMY $1,339.05 $1,339.05 $1,339.05 38720 CERVICAL LYMPHADENECTOMY COMPLETE $1,339.05 $1,339.05 $1,339.05 38724 CERVICAL LYMPHADENECTOMY (MODIFI RADICAL $1,339.05 $1,339.05 $1,339.05 38740 AXILLARY LYMPHADENECTOMY SUPERFICIAL $1,339.05 $1,339.05 $1,339.05 38745 AXILLARY LYMPHADENECTOMY COMPLETE $1,339.05 $1,339.05 $1,339.05 38760 INGUINOFEMORAL LYMPHADENECTOMY SUPERFIC $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 47 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 38765 INGUINOFEMOR LYMPHADENCTOMY INCLD OTH ND $1,585.73 $1,585.73 $1,585.73 38770 PELVIC LYMPHADENECTOMY (SEPART PROC) $1,585.73 $1,585.73 $1,585.73 38780 RETROPERI TRANS ABD LYMPH EXTEN PEL-AORT $1,585.73 $1,585.73 $1,585.73 38900 INTRAOPER ID $822.23 $822.23 38999 UNLISTED PROCEDURE HEMIC LYMPHATIC SYST $1,339.05 $1,339.05 $1,339.05 39000 MEDIASTINO EXP-DRAIN-REMOV FOB CERVICAL $1,339.05 $1,339.05 $1,339.05 39010 MEDIASTINO EXP-DRAIN-REMOV FOB TRANSTHOR $1,339.05 $1,339.05 $1,339.05 39200 EXCIS MEDIASTINAL CYST $822.23 $822.23 $822.23 39220 EXCIS MEDIASTINAL TUMOR $822.23 $822.23 $822.23 39400 MEDIASTINOSCOPY W ORW OUT BIOPSY $822.23 $822.23 $822.23 39499 UNLIST PROCEDURE MEDIASTINUM $822.23 $822.23 $822.23 39502 REPAIR HIATUS HERNIA TRANS ABD W/WO FUND $1,339.05 D D 39503 REPAIR NEONAT DIAPH HERNIA W/WO TUBE,VEN $1,339.05 $1,339.05 $1,339.05 39540 REPAIR DIAPHRAG HERNIA TRAUMATIC ACUTE $1,339.05 $1,339.05 $1,339.05 39541 REPAIR DIAPHRAG HERNIA CHRONIC $1,339.05 $1,339.05 $1,339.05 39599 REPAIR LACERATION OF DIAPHRAGM $822.23 $822.23 $822.23 40490 BIOPSY LIP $293.65 $293.65 $293.65 40500 VERMILIONECTOMY W MUCOSAL ADVANCEMENT $822.23 $822.23 $822.23 40510 EXCIS LIP TRANSVERSE WEDGE EXCIS $822.23 $822.23 $822.23 40520 EXCISION LIP V EXCIS $822.23 $822.23 $822.23 40525 EXCIS LIP FULL THICK RECONSTR W/LOC FLAP $822.23 $822.23 $822.23 40527 EXCIS LIP FULL THICK RECON W/CROSS FLAP $822.23 $822.23 $822.23 40530 RESECTION LIP $822.23 $822.23 $822.23 40650 REPAIR LIP FULL THICKNESS VERMILION ONLY $822.23 $822.23 $822.23 40652 REPAIR LIP UP TO HALF VERTICAL HEIGHT $822.23 $822.23 $822.23 40654 REPAIR LIP COMPLEX $822.23 $822.23 $822.23 40700 PLASTIC REPAIR CLEFT LIP/NASAL;PRIM UNIL $1,339.05 $1,339.05 $1,339.05 40701 REPAIR CLEFT LIP/NASAL PRIM,BILAT 1 STAG $1,339.05 $1,339.05 $1,339.05 40702 REP CLEFT LIP/NASA PRIM,BILA,1 OF2 STAGE $1,339.05 $1,339.05 $1,339.05 40720 CLEFT LIP,2' RECREATION DEFECT & CLOSURE $1,339.05 $1,339.05 $1,339.05 40761 SEE 40700 INCLUDE SECTION INSERT PEDICLE $1,339.05 $1,339.05 $1,339.05 40799 UNLISTED PROCEDURE LIP $822.23 $822.23 $822.23 40800 MOUTH DRAINAGE ABCESS HEMOTOMA SIMPLE $822.23 $822.23 $822.23 40801 MOUTH DRAINAGE OF ABCESS CYST HEMATO COM $822.23 $822.23 $822.23 40804 MOUTH REMOVAL EMBEDDED FB SIMPLE $822.23 $822.23 $822.23 40805 MOUTH REMOV FB EMBEDDED COMPLICATED $822.23 $822.23 $822.23 40806 INCISION LIBIAL FRENOTOMY $822.23 $822.23 $822.23 40808 BIOPSY VESTIBULE OF MOUTH $293.65 $293.65 $293.65 40810 EXCIS LESION MUCOSA SUBMUCOS COMPLX MUSC $822.23 $822.23 $822.23 40812 MOUTH EXCISION MUCOSA/SUB MUC W/O REPAIR $822.23 $822.23 $822.23 40814 EXISE LESION MUCOS/SUBMUCOS W COMPLX REP $822.23 $822.23 $822.23 40816 MOUTH LESION MUCOSA/SUBMUCOSA UNDER MUSC $822.23 $822.23 $822.23 40818 MOUTH EXCISION OF MUCOSA DONAR GRAFT $822.23 $822.23 $822.23 40819 EXCISION FRENUM LIBIAL OR BUCCAL $822.23 $822.23 $822.23 40820 DESTRUCT LESION-SCAR PHYSICAL METHODS $822.23 $822.23 $822.23 40830 CLOSURE LACERATION 2.5CM OR LESS $822.23 $822.23 $822.23 40831 CLOS LACERAT MOTH OVER 2.5 CM-OR COMPLX $822.23 $822.23 $822.23 40840 MOUTH VESTIBULOPLASTY ANTERIOR $822.23 $822.23 $822.23

07/27/12 Page 48 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 40842 VESTIBULOPASTY;POSTERIOR UNILATERAL $1,339.05 $1,339.05 $1,339.05 40843 MOUTH VESTIBULOPLASTY POSTERIOR BILATERA $1,339.05 $1,339.05 $1,339.05 40844 VESTIBULOPASTY ENTIRE ARCH $1,585.73 $1,585.73 $1,585.73 40845 VESTIBULOPLASTY COMPLEX ( INC EXTENSION, $1,585.73 $1,585.73 $1,585.73 40899 UNLISTED PROCEDURE VESTIBULE MOUTH $293.65 $293.65 $293.65 41000 INTRAORAL I&D TONGUE FLOOR MOUTH LINGUAL $293.65 $293.65 $293.65 41005 I AND D INTRAORAL ABCES/CYST TONGUE FLOO $293.65 $293.65 $293.65 41006 I AND D INTRAORAL ABCES/CYST DEEP TONGUE $822.23 $822.23 $822.23 41007 I AND INTRAORAL ABCESS/CYST (SUBMENTAL S $822.23 $822.23 $822.23 41008 I AND D INTRAORAL ABCES/CYST (SUBMANDIBU $822.23 $822.23 $822.23 41009 I AND D INTRAORAL ABCES/CYST(MASTICATOR $822.23 $822.23 $822.23 41010 INCISION LINGUAL FRENUM (FRENOTOMY) $822.23 $822.23 $822.23 41015 EXTRAORAL I&D FLOOR MOUTH SUBLINGUAL $822.23 $822.23 $822.23 41016 I AND D EXTRAORAL ABCES/CYST(SUBMENTAL $822.23 $822.23 $822.23 41017 I AND D EXTRAORAL ABCES/CYST (SUBMANDIBU $822.23 $822.23 $822.23 41018 I AND D EXTRAORAL ABCES/CYST (MASTICATOR $822.23 $822.23 $822.23 41019 PLACE NEEDLE,CATH HEAD/NECK RADIOELE APP $822.23 $822.23 $822.23 41100 BIOPSY TONGUE ANT TWO THIRDS $822.23 $822.23 $822.23 41105 BIOPSY TONGUE POST ONE THIRD $822.23 $822.23 $822.23 41108 BIOPSY FLOOR MOUTH $293.65 $293.65 $293.65 41110 EXCIS LESION TONGUE W OUT CLOSURE $822.23 $822.23 $822.23 41112 EXCIS LESION TONGUE W CLOSURE ANTERIOR $1,339.05 $1,339.05 $1,339.05 41113 EXCIS LESION TONGUE W CLOSURE POSTERIOR $1,339.05 $1,339.05 $1,339.05 41114 EXCIS LESION TONGUE W/CLOS W/LOCAL TONG $1,339.05 $1,339.05 $1,339.05 41115 EXCISION LINGUAL FRENUM $822.23 $822.23 $822.23 41116 EXCIS LESION FLOOR OF MOUTH $822.23 $822.23 $822.23 41120 GLOSSECTOMY LESS THAN ONE HALF TONGUE $822.23 $822.23 $822.23 41130 HEMIGLOSSECTOMY $822.23 $822.23 $822.23 41135 SEE 41120 PARTIAL W UNILAT RADICAL NECK $822.23 $822.23 $822.23 41140 SEE 41120 COMPLETE OR TOTAL $1,339.05 $1,339.05 $1,339.05 41145 SEE 41120 COMPLETE TOTAL W UNIL RAD NECK $1,339.05 $1,339.05 $1,339.05 41250 REPAIR LAC 2.5CM/LESS FLOR MOUTH TONGUE $822.23 $822.23 $822.23 41251 REPAIR LACERATION FLOOR MOUTH POST TONGU $822.23 $822.23 $822.23 41252 REPAIR LACER TONG FLOR MOUTH +2.6 COMPLX $822.23 $822.23 $822.23 41500 FIXATION TONGUE MECHANICAL $822.23 $822.23 $822.23 41520 FRENOPLASTY (SRG REV FRENUM W Z PLASTY) $822.23 $822.23 $822.23 41599 UNLISTED PROCEDURE TONGUE FLOOR MOUTH $293.65 $293.65 $293.65 41800 DRG ABSCESS CYST HEMATOMA $822.23 $822.23 $822.23 41805 REMOVAL EMBEDDED FOREIGN BODY SOFT TISSU $822.23 $822.23 $822.23 41806 REMOV FB FROM DENTOALVELAR STRUCTUR BONE $822.23 $822.23 $822.23 41825 EXCIS LESION TUMOR $822.23 $822.23 $822.23 41826 EXCIS LESION TUMOR W SIMPLE REPAIR $822.23 $822.23 $822.23 41827 EXCIS LESION TUMOR W COMPLEX REPAIR $822.23 $822.23 $822.23 41850 DESTRUCT LESION(EXCPT EXCIS)DENTOALVEOLA $822.23 $822.23 $822.23 41899 UNLISTED PROCEDURE DENTOALVEOLAR STRUCT $293.65 $293.65 $293.65 42000 DRG ABSCESS PALATE UVULA $822.23 $822.23 $822.23 42100 BIOPSY PALATE UVULA $822.23 $822.23 $822.23 42104 EXCIS LESION PALATE UVULA W/O CLOSURE $822.23 $822.23 $822.23

07/27/12 Page 49 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 42106 EXCISION LESION PALATE UVULA WITH CLOSUR $822.23 $822.23 $822.23 42107 EXCISION LESION PALATE UVULA W/O CLOSURE $822.23 $822.23 $822.23 42120 RESECTION PALATE OR EXTENS RESECT LESION $1,339.05 $1,339.05 $1,339.05 42140 UVULECTOMY EXCIS OF UVULA $822.23 $822.23 $822.23 42145 PALATOPHARYGOPLASTY(EG UVULOPALATOPHARY) $1,339.05 $1,339.05 $1,339.05 42160 DESTRUCT LESION PALATE UVULA $822.23 $822.23 $822.23 42180 REPAIR LACERATION PALATE UP TO 2 CM $1,339.05 $1,339.05 $1,339.05 42182 REPAIR LACERATION PALATE OVER 2 CM $1,339.05 $1,339.05 $1,339.05 42200 PALATOPLASTY CLEFT PALATE $1,585.73 $1,585.73 $1,585.73 42205 PALATOPLASTY CLOSURE ALVEOLAR RIDGE $1,585.73 $1,585.73 $1,585.73 42210 PALATOPLASTY(CLEFT PALAT)CLOS RIDGE GRAF $1,585.73 $1,585.73 $1,585.73 42215 PALATOPLASTY MAJOR REVISION $1,585.73 $1,585.73 $1,585.73 42220 PALATOPLASTY SECONDARY LENGTHEN PROCED $1,585.73 $1,585.73 $1,585.73 42225 PALATOPLASTY ATTACHMENT PHARYNGEAL FLAP $1,585.73 $1,585.73 $1,585.73 42226 LENGHTENING PALATE AND PHARYNGEAL FLAP $1,339.05 $1,339.05 $1,339.05 42227 LENGHTENING PALATE WITH ISLAND FLAP $1,339.05 $1,339.05 $1,339.05 42235 REPAIR ANT PALATE INCLUDE VOMER FLAP $1,339.05 $1,339.05 $1,339.05 42260 REPAIR NASOLABIAL FISTULA $822.23 $822.23 $822.23 42280 MAXILLARY IMPRESSION PALPTAL PROSTHESES $1,339.05 $1,339.05 $1,339.05 42281 INSERTION PIN-RETAINED PALATAL PROSTHESE $1,339.05 $1,339.05 $1,339.05 42299 UNLISTED PROCEDURE PALATE UVULA $822.23 $822.23 $822.23 42300 DRG ABSCESS PAROTID SIMPLE $822.23 $822.23 $822.23 42305 DRG ABSCESS PAROTID COMPLICATED $822.23 $822.23 $822.23 42310 DRG ABSCESS SUBMAXILLARY SUBLINGUAL $822.23 $822.23 $822.23 42320 DRG ABSCESS SUBMAXILLARY EXTERNAL $822.23 $822.23 $822.23 42330 SIALOLITHOTOMY UNCOMPLICATED $822.23 $822.23 $822.23 42335 SIALOLITHOT SUBMANDIB COMPLI INTRAORAL $822.23 $822.23 $822.23 42340 SIALOLITHOTOMY PAROTID EXTRAORAL INTRA $822.23 $822.23 $822.23 42400 BIOPSY SALIVARY GLAND NEEDLE $822.23 $822.23 $822.23 42405 BIOPSY SALIVARY GLAND INCISIONAL $822.23 $822.23 $822.23 42408 EXCIS SUBLINGUAL SALIVARY CYST $822.23 $822.23 $822.23 42409 MARSUPIALIZATION SUBLINGUAL SALIV CYST $1,339.05 $1,339.05 $1,339.05 42410 EXCIS PAROTID TUMOR GLAND LATERAL LOBE $1,339.05 $1,339.05 $1,339.05 42415 EXCIS PAROTID TUMOR LATERAL W DISSECTION $1,339.05 $1,339.05 $1,339.05 42420 EXCIS PAROTID TUMOR TOTAL W DISSECTION $1,585.73 $1,585.73 $1,585.73 42425 EXCIS PAROTID TUMOR TOTAL SACRIFIC NERVE $1,585.73 $1,585.73 $1,585.73 42426 EXCIS PAROTID TUMOR UNILAT NECK DISSECT $1,585.73 $1,585.73 $1,585.73 42440 EXCIS SUBMANDIBULAR GLAND $1,339.05 $1,339.05 $1,339.05 42450 EXCIS SUBLINGUAL GLAND $1,339.05 $1,339.05 $1,339.05 42500 SIALODOCHOPLASTY PRIMARY SIMPLE $822.23 $822.23 $822.23 42505 SIALODOCHOPLASTY SECONDARY COMPLICATED $822.23 $822.23 $822.23 42507 PAROTID DUCT DIVERSION BILATERAL $822.23 $822.23 $822.23 42508 PAROTID DUCT DIVERS BILAT EXCISE 1 GLAND $822.23 $822.23 $822.23 42509 PAROTID DUCT DIVER BILAT EXCISE 2 GLANDS $822.23 $822.23 $822.23 42510 PARATID DUCT DIVER BILAT W/LIG SUBMANDIB $822.23 $822.23 $822.23 42600 CLOSURE SALIVARY FISTULA $822.23 $822.23 $822.23 42650 DILATION SALIVARY DUCT $822.23 $822.23 $822.23 42660 DILATION CATHETERIZATION SALIVARY DUCT $822.23 $822.23 $822.23

07/27/12 Page 50 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 42665 LIGATION SALIVARY DUCT INTRAORAL $293.65 $293.65 $293.65 42699 UNLISTED PROCEDURE SALIVARY GLANDS DUCTS $293.65 $293.65 $293.65 42700 INCIS DRG ABSCESS PERITONSILLAR $1,339.05 $1,339.05 $1,339.05 42720 SEE 42700 RETRO PARAPHARYGEAL INTRAORAL $1,339.05 $1,339.05 $1,339.05 42725 SEE 42700 RETRO PARAPHARYNGEAL EXTERNAL $1,339.05 $1,339.05 $1,339.05 42800 BIOPSY OROPHARYNX $822.23 $822.23 $822.23 42802 BIOPSY HYPOPHARYNX $822.23 $822.23 $822.23 42804 BIOPSY NASOPHARYNX VISIBLE LESION SIMPLE $822.23 $822.23 $822.23 42806 BIOPSY NASOPHARYNX UNKNOWN PRIMARY LES $822.23 $822.23 $822.23 42808 EXCISS OR DESTRUCT LESION OF PHARYNZ $822.23 $822.23 $822.23 42809 REMOVAL FOREIGN BODY PHARYNX $293.65 $293.65 $293.65 42810 EXCIS BRANCH CLEFT SYST/VEST SKIN-SUBQ $1,339.05 $1,339.05 $1,339.05 42815 EXCIS BRANCH CLEFT CYST-VEST-FISTU INTO $1,339.05 $1,339.05 $1,339.05 42820 TONSILLECT ADENOIDECT UNDER AGE 12 $1,339.05 $1,339.05 $1,339.05 42821 TONSILECT ADENOIDECT AGE 12 OR OVER $1,339.05 $1,339.05 $1,339.05 42825 TONSILLECTOMY UNDER AGE 12 $1,339.05 $1,339.05 $1,339.05 42826 TONSILLECTOMY AGE 12 OR OVER $1,339.05 $1,339.05 $1,339.05 42830 ADENOIDECTOMY PRIMARY UNDER AGE 12 $1,339.05 $1,339.05 $1,339.05 42831 ADENOIDECTOMY PRIMARY AGE 12 OR OVER $1,339.05 $1,339.05 $1,339.05 42835 ADENOIDECTOMY SECONDARY UNDER AGE 12 $1,339.05 $1,339.05 $1,339.05 42836 ADENOIDECTOMY SECONDARY AGE 12 OR OVER $1,339.05 $1,339.05 $1,339.05 42842 RADICAL RESECT TONSIL-PILLAR-TRIGONE $1,339.05 $1,339.05 $1,339.05 42844 RADI RESECT TONSIL-PILLAR-TRIG W/LOC FLA $1,339.05 $1,339.05 $1,339.05 42845 RADI RESECT TONSIL-PILL-TRIGON W/CLOS OT $1,339.05 $1,339.05 $1,339.05 42860 EXCISION TONSIL TAGS $822.23 $822.23 $822.23 42870 EXCISION/DESTRUCTION LINGUAL TONSIL $822.23 $822.23 $822.23 42890 LIMITED PHARYNGECTOMY $1,339.05 $1,339.05 $1,339.05 42892 RESECT LAT PHARY WALL-SINUS-CLOS DIR ADV $1,339.05 $1,339.05 $1,339.05 42894 RESECT PHARY WALL CLOS W/MYCUTAN FLAP $1,339.05 $1,339.05 $1,339.05 42900 SUTURE PHARYNX FOR WOUND OR INJURY $1,339.05 $1,339.05 $1,339.05 42950 PHARYNGOPLASTY $822.23 $822.23 $822.23 42953 PHARYNGOESOPHAGEAL REPAIR $822.23 $822.23 $822.23 42955 PHARYNGOSTOMY $1,339.05 $1,339.05 $1,339.05 42960 CONTROL OROPHARYNGEAL HEMORRHAGE SIMPLE $822.23 $822.23 $822.23 42961 CONT OROPHAR HEMORR COMPLI REQ HOSPITAL $822.23 $822.23 $822.23 42962 CONT ORO PHARY HEMORR WITH SECOND SURGER $822.23 $822.23 $822.23 42970 CONTROL NASOPHARYNGEAL HEMORR POST PACKS $822.23 $822.23 $822.23 42972 SEE 42970 SECONDARY SURGICAL INTERVENT $822.23 $822.23 $822.23 42999 UNLISTED PROCED PHARYNX ADENOID TONSIL $822.23 $822.23 $822.23 43020 ESOPHAGOTOMY CERVICAL W REMOVAL $1,339.05 $1,339.05 $1,339.05 43030 CRICOPHARYNGEAL MYOTOMY $822.23 $822.23 $822.23 43045 ESOPHAGOTOMY THORACIC W REMOVAL FOREIGN $1,339.05 $1,339.05 $1,339.05 43100 EXCIS LESION ESOPHAGUS CERVICAL APPROACH $822.23 $822.23 $822.23 43101 EXCIS LESION ESOPHAGUS THORACIC APPROACH $822.23 $822.23 $822.23 43107 TOT/NEAR TOTAL ESOPHAGECTOMY W/O THORACO $1,339.05 $1,339.05 $1,339.05 43108 ESOPHAGECTOMY,WITHOUT THORACTOMY $1,339.05 $1,339.05 $1,339.05 43112 TOT/NEAR TOT ESOPHAG W/THORAC W/WO PYLOR $1,339.05 $1,339.05 $1,339.05 43113 ESOPHAGECTOMY, WITH THORACTOMY $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 51 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 43130 DIVERTICULECTOMY HYPOPHARYNX ESOPHAGUS $1,339.05 $1,339.05 $1,339.05 43135 SEE 43130 THORACIC APPROACH $1,339.05 $1,339.05 $1,339.05 43200 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNO $822.23 $822.23 $822.23 43201 ESOPHAGOSCOPY, W/DIRECTED SUBMUCOSAL INJ $822.23 $822.23 $822.23 43202 ESOPHAGOSCOPY, RIGID OR FLEX; W/BIOP SIN $822.23 $822.23 $822.23 43204 ESOPHAGOSCOPY, W/SCLEROSIS INJECTION $1,339.05 $1,339.05 $1,339.05 43205 ESOPHAGOSCOPY, RIGID OR FLEX; W/BAND LIT $1,339.05 $1,339.05 $1,339.05 43215 ESOPHAGOSCOPY W REMOVE FOREIGN BODY $822.23 $822.23 $822.23 43216 ESOPHAGOSCOPY, RIGID OR FLEX; W/REMOVAL $1,339.05 $1,339.05 $1,339.05 43217 ESOPHAGOSCOPY FIBEROPTIC REMOVAL POLYPOI $1,339.05 $1,339.05 $1,339.05 43219 ESOPHAGOSCOPY W INSERT PLASTIC TUBE $822.23 $822.23 $822.23 43220 EXOPHAGOSCOPY RIG-FLEX FIBER DILATION $822.23 $822.23 $822.23 43226 ESOPHAGOGASTROSCOPY INSERT WIRE DILATION $822.23 $822.23 $822.23 43227 ESOPHAGOSCOPY,W/CONTROL OF BLEEDING $1,339.05 $1,339.05 $1,339.05 43228 ESOPHAGO RIG-FLEXI FIBER ABLANTION TUMOR $1,339.05 $1,339.05 $1,339.05 43231 ESOPHAGOSCOPY;W/ENDOSCOPIC ULTRASND EXAM $822.23 $822.23 $822.23 43232 ESOPHAGOSCOPY;W/TRANSENDOSC ULTRASND BIO $822.23 $822.23 $822.23 43234 UPPER GI ENDOSCOP SIMPL-PRIMARY EXAMINAT $822.23 $822.23 $822.23 43235 UPPER GI ENDOSCOP W/WO SPECIMEN, BRUSH O $822.23 $822.23 $822.23 43236 UPPER GI SCOPE W/SUBMUCOSAL INJ $822.23 $822.23 $822.23 43237 UP GI ENDOSCOP/ULTRASOUND EXAM ESOPHAGUS $822.23 $822.23 $822.23 43238 UP GI ENDOS W/ULTRASND F N ASPR/BIOP,ESO $1,339.05 $1,339.05 $1,339.05 43239 UP GI ENDOSCOPY FOR BI &/OR COLL OF SPEC $1,339.05 $1,339.05 $1,339.05 43240 UPPGASTRO ENDOSC;W/TRANS DRAIN PSEUDOCY $1,339.05 $1,339.05 $1,339.05 43241 UPPER GI ENDO W/TRANS TUBE OR CATH PLACE $822.23 $822.23 $822.23 43242 UP GASTRO ENDOSC;W/TRA ULTRSND-GUID/BIOP $1,339.05 $1,339.05 $1,339.05 43243 UPPER GI ENDOSCOP W/INJ SCLEROSIS OF ESO $1,339.05 $1,339.05 $1,339.05 43244 UPPER GI ENDOSCOP INC ESOPHAGUS, STOMACH $1,339.05 $1,339.05 $1,339.05 43245 UPPR GI SCOPE W/DILATION GASTRIC OUTLET $1,339.05 $1,339.05 $1,339.05 43246 UP GI ENDOO FOR PLACE PERCUTAN GAST TUBE $822.23 $822.23 $822.23 43247 UPPER GI ENDOSCOP W/REMOVAL FOREIGN BODY $1,339.05 $1,339.05 $1,339.05 43248 UPPER GI ENDOSCOP INC ESOPH, STOMACH, WI $1,339.05 $1,339.05 $1,339.05 43249 UPPER GI ENDOSCOPY INC ESOPH STOMACH AND $1,339.05 $1,339.05 $1,339.05 43250 UPPER GI ENDOSCOP REMOVAL TUMORS, POLYPS $1,339.05 $1,339.05 $1,339.05 43251 UPPER GI ENDOSCOP REMOVAL POLYPOID LESIO $1,339.05 $1,339.05 $1,339.05 43255 UPPER GI ENDOSCOP W/CONT BLEEDING ANY ME $822.23 $822.23 $822.23 43256 UPPER GI INDOSCOPY W/TRANSENDSC STNT PLA $822.23 $822.23 $822.23 43258 UP-GI ENDOSCOP ABLAT TUMOR, BIOPOLAR CUT $1,339.05 $1,339.05 $1,339.05 43259 UPPER GI ENDOSCOP WITH ULTRASOUND EXAMIN $1,339.05 $1,339.05 $1,339.05 43261 ENDOSCOP RETRO CHOLANG W/BIOP, SINGLE OR $1,339.05 $1,339.05 $1,339.05 43279 LAPAROSCOPY,ESOPHAGOMYOTOMY(HELLER TYPE) $822.23 $822.23 $822.23 43280 LAPAROSCOPY,ESOPHAGOMYOTOMY(HELLER TYPE) $822.23 $822.23 $822.23 43281 $822.23 $822.23 $822.23 43282 $822.23 $822.23 $822.23 43283 LAPARASCOPY $822.23 $822.23 43289 UNLISTED LAPAROSCOPY PROCEDURE ESOPHAGUS $822.23 $822.23 $822.23 43300 ESOPHAGOPLASTY CERVICAL APPROACH $1,339.05 $1,339.05 $1,339.05 43305 ESOPHAGOPLASTY CERV APPROACH W/REP TRACH $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 52 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 43310 ESOPHAGOPLASTY THORACIC APPROACH $1,339.05 $1,339.05 $1,339.05 43312 ESOPHAGOPLAST THORAC APPRO W/REP TRACH F $1,339.05 $1,339.05 $1,339.05 43313 ESOPHAGOPLASTY/CONGENITAL DEFEC; THORAC $1,339.05 $1,339.05 $1,339.05 43314 ESPHPLSTY CONG DFCT THORAC W/TRACH FIST $1,339.05 $1,339.05 $1,339.05 43320 ESOPHAGOGAST W/WO VAGOTOMY & PYLOROPLAS $822.23 $822.23 $822.23 43324 ESOPHAGOGASTRIC FUNDOPLASTY $822.23 D D 43325 ESOPHAGOGASTRIC FUNDOPLASTY FUNDIC PATCH $822.23 $822.23 $822.23 43326 ESOPHOGAST FUNDOPOAST; W GASTROPLASTY $822.23 D D 43327 REPAIR ESOPHA $822.23 $822.23 43328 REPAIR ESOPHA $822.23 $822.23 43330 ESOPHAGOMYOTOMY ABDOMINAL APPROACH $1,585.73 $1,585.73 $1,585.73 43331 ESOPHAGOMYOTOMY THORACIC APPROACH $1,585.73 $1,585.73 $1,585.73 43332 REPAIR ESOPHA $822.23 $822.23 43333 REPAIR ESOPHA $822.23 $822.23 43334 REPAIR ESOPHA $822.23 $822.23 43335 REPAIR ESOPHA $822.23 $822.23 43336 REPAIR ESOPHA $822.23 $822.23 43337 REPAIR ESOPHA $822.23 $822.23 43338 REPAIR ESOPHA $822.23 $822.23 43340 ESOPHAGOJEJUNOSTOMY ABDOMINAL APPROACH $822.23 $822.23 $822.23 43341 ESOPHAGOJEJUNOSTOMY THORACIC APPROACH $822.23 $822.23 $822.23 43350 ESOPHAGOSTOMY FISTULIZATION ESOPHAGUS $822.23 $822.23 $822.23 43351 SEE 43350 THORACIC APPROACH $822.23 $822.23 $822.23 43352 SEE 43350 CERVICAL APPROACH $822.23 $822.23 $822.23 43400 LIGATION DIRECT ESOPHAGEAL VARICES $822.23 $822.23 $822.23 43405 LIGATION OR STAPLING GASTROESOPH JUNCTIO $1,339.05 $1,339.05 $1,339.05 43410 SUTURE ESOPHAGEAL WOUND CERVICAL $1,339.05 $1,339.05 $1,339.05 43415 SUTURE ESOPHAGEAL WOUND THORACIC $1,339.05 $1,339.05 $1,339.05 43420 CLOSURE ESOPHAGOSTOMY FISTULA CERVPCAL $822.23 $822.23 $822.23 43425 CLOS ESOPHAGOSTOMY TRANSTHORACIC APPROAC $822.23 $822.23 $822.23 43450 DILAT ESOPHAGUS, BY UNG SOUND, SING/MULT $822.23 $822.23 $822.23 43453 DILATION ESOPHAGUS OVER GUIDE WIRE $822.23 $822.23 $822.23 43456 DILAT ESOPH,BALLOON/DILATOR;FLUOR RETROG $822.23 $822.23 $822.23 43458 DILAT ESOPH W/BALLOON (30MM DIAM OR GREA $822.23 $822.23 $822.23 43499 UNLISTED PROCEDURE ESOPHAGUS $822.23 $822.23 $822.23 43500 GASTROTOMY W EXPLORATION OR REMOVAL $1,339.05 $1,339.05 $1,339.05 43501 GASTROTOMY W SUTURE REPAIR BLEED ULCER $822.23 $822.23 $822.23 43502 GASTROTOMY W SUTURE REPAIR PREEXIST ESOP $1,585.73 $1,585.73 $1,585.73 43510 GASTROTOMY W ESOPHAGEAL DILATION INSERT $822.23 $822.23 $822.23 43520 PYLOROMYOTOMY $822.23 $822.23 $822.23 43600 BIOPSY STOMACH BY CAPSULE TUBE PERORAL $822.23 D D 43605 BIOPSY STOMACH BY LAPAROTOMY $1,339.05 $1,339.05 $1,339.05 43610 EXCISION LOCAL ULCER TUMOR STOMACH $1,339.05 $1,339.05 $1,339.05 43611 EXCISION, LOCAL; MALIGNANT TUMOR OF STOM $1,339.05 $1,339.05 $1,339.05 43644 LAP,SURG,GASTR RESTRIC;W/BYPAS&ROUX-EN-Y $2,807.33 $2,807.33 $2,807.33 43651 LAP SURGICAL TRANSECTION VAG NERVE TRNCL $822.23 $822.23 $822.23 43652 LAP SURGICAL TRANS VAG NERVE SEL/HIGHSEL $822.23 $822.23 $822.23 43653 LAP SURGICAL GASTROSTOMY NO GASTRIC TUBE $822.23 $822.23 $822.23

07/27/12 Page 53 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 43659 UNLISTED LAPAROSCOPY PROCEDURE STOMACH $822.23 $822.23 $822.23 43753 GASTRIC INTUBATION&ASPIRATION THERAPEUTC Not Valid $822.23 $822.23 43754 GASTRIC INTUBATION&ASPIRATION DIAGNOSTIC Not Valid $822.23 $822.23 43755 GASTRIC INTUBATION&ASPIR,DIAG;MULTI SPEC Not Valid $822.23 $822.23 43756 DUODENAL INTUBATION&ASPIR,DIAG,IMAG GUID Not Valid $822.23 $822.23 43757 DUODENAL INTUBATION&ASPIR,DIAG,IMAG GUID Not Valid $822.23 $822.23 43760 CHANGE OF GASTROSTOMY TUBE W/O IMG ENDO $822.23 $822.23 $822.23 43761 REPOS GAS FEED TUB,THRU DUO ENTERIC NUTR $822.23 $822.23 $822.23 43770 LAP,SURG,GASTRC RESTRC PROC,PLC ADJ BAND $1,339.05 $1,339.05 $1,339.05 43771 LAP,SURG,GASTRC RESTRC PROC,REV ADJ BAND $1,339.05 $1,339.05 $1,339.05 43800 PYLOROPLASTY $822.23 $822.23 $822.23 43810 GASTRODUODENOSTOMY $1,339.05 $1,339.05 $1,339.05 43820 GASTROJEJUNOSTOMY; WITHOUT VAGOTOMY $1,339.05 $1,339.05 $1,339.05 43825 GASTROJEJUNOSTOMY W VAGOTOMY ANY TYPE $1,339.05 $1,339.05 $1,339.05 43830 GASTROSTMY,OPN;W/O CONSTRCT GASTRIC TUBE $822.23 $822.23 $822.23 43831 GASTROSTOMY NEONATAL FOR FEEDING $822.23 $822.23 $822.23 43832 GASTROSTOMY,OPN;W/CONSTUCT GASTRIC TUBE $822.23 $822.23 $822.23 43842 GASTRIC RESTRIC PROC,V-BAND GASTROPLASTY $1,339.05 $1,339.05 $1,339.05 43847 GASTRIC RESTRIC PROC,SM INTES RECONSTRUC $1,339.05 $1,339.05 $1,339.05 43870 CLOSURE GASTROSTOMY SURGICAL $1,339.05 $1,339.05 $1,339.05 43880 CLOSURE GASTROCOLIC FISTULA $1,585.73 $1,585.73 $1,585.73 43999 UNLISTED PROCEDURE STOMACH $822.23 $822.23 $822.23 44005 ENTEROLYSIS (SEPERATE PROCEDURE) $1,339.05 $1,339.05 $1,339.05 44050 REDUCTION VOLVWLUS BY LAPAROTOMY $1,339.05 $1,339.05 $1,339.05 44055 CORRECT MALROTAT LYSIS BANDS-REDUCT V0LV $1,339.05 $1,339.05 $1,339.05 44100 BIOPSY INTESTINE BY CAPSULE TUBE PERORAL $822.23 $822.23 $822.23 44110 EXCISION LESION BOWEL SINGLE ENTEROTOMY $1,339.05 $1,339.05 $1,339.05 44111 EXCISION LESION BOWEL MULTI ENTEROTOMIES $1,339.05 $1,339.05 $1,339.05 44120 ENTERECTOMY SG RESECTION AND ANASTOMOSIS $1,339.05 $1,339.05 $1,339.05 44125 ENTERECTOMY RESEC SM INTEST W ENTEROSTOM $1,339.05 $1,339.05 $1,339.05 44126 ENTERECTOMY,CONGENITAL ATRESIA,W/O TAPER $1,339.05 $1,339.05 $1,339.05 44127 ENTERECTOMY,CONGENITAL ATRESIA,W/TAPER $1,339.05 $1,339.05 $1,339.05 44130 ENTEROENTEROSOMY W/WO CUTANEOUS ENTEROST $822.23 $822.23 $822.23 44140 COLECTOMY PARTIAL W ANASTOMOSIS $1,339.05 $1,339.05 $1,339.05 44141 COLECTOMY SKIN LEVEL CECOSTOMY COLOSTOMY $1,339.05 $1,339.05 $1,339.05 44143 COLECTOMY W END COLOSTOMY $1,339.05 $1,339.05 $1,339.05 44144 COLECTOMY W RESECTION COLOSTOMY ILEOSTOM $1,339.05 $1,339.05 $1,339.05 44145 COLECTOMY W COLOPROCTOSTOMY $1,339.05 $1,339.05 $1,339.05 44146 COLECTOMY W COLOPROCTOSTOMY COLOSTOMY $1,339.05 $1,339.05 $1,339.05 44147 COLECTOMY PART ABD AND TRANS ANAL APPROA $1,339.05 $1,339.05 $1,339.05 44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS $1,339.05 $1,339.05 $1,339.05 44186 LAPAROSCOPY, SURGICAL; JEJUNOSTOMY $1,339.05 $1,339.05 $1,339.05 44187 LAP,SURG;ILEOSTOMY/JEJUNOSTOMY, NON-TUBE $1,339.05 $1,339.05 $1,339.05 44188 LAP,SURG,COLOSTOMY OR SKIN LVL CECOSTOMY $1,339.05 $1,339.05 $1,339.05 44202 LAP,SURG;ENTERECTOMY,SNGL RESEC & ANAST $1,339.05 $1,339.05 $1,339.05 44204 LAP SURG;PART COLCTMY W/ANASTOMOSIS $1,339.05 $1,339.05 $1,339.05 44206 LAPAROSCOPY,PARTIAL,COLECTOMY W/STOMA $1,339.05 $1,339.05 $1,339.05 44207 LAPAROSCOPY, COLECTOMY/COLOPROCTOSTOMY $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 54 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 44208 LAP, COLECTOMY/COLOPROCTOSTOMY,COLOSTOMY $1,339.05 $1,339.05 $1,339.05 44210 LAPAROSCOPY, TOTAL, PROCTOCOLECTOMY $822.23 $822.23 $822.23 44211 LAP,TOTAL,PROCTOCOLECTOMY,W/PROTECTOMY $822.23 $822.23 $822.23 44212 LAP,TOTAL,PROCTOCOLECTOMY,W/PROTECTOMY,I $822.23 $822.23 $822.23 44227 LAP,SURG,CLOS ENTEROSTOMY W/RESEC&ANASTO $822.23 $822.23 $822.23 44238 UNLISTED LAPARASCOPY PROC,INTESTINE $822.23 $822.23 $822.23 44300 PLACE ENTERO/CECOSTOMY TUBE(DECOMPR,FEED $1,339.05 $1,339.05 $1,339.05 44310 ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE $1,339.05 $1,339.05 $1,339.05 44312 REVISION ILEOSTOMY SIMPLE,SEP PROCEDURE $822.23 $822.23 $822.23 44314 REVISION ILEOSTOMY COMPLIC SEP PROCEDURE $1,585.73 $1,585.73 $1,585.73 44316 CONTINENT ILEOSTOMY, SEPARATE PROCEDURE $1,339.05 $1,339.05 $1,339.05 44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY(SP) $1,339.05 $1,339.05 $1,339.05 44322 COLOSTOMY SKIN LEV CECOSTOMY;MULTI BIOPS $1,339.05 $1,339.05 $1,339.05 44340 REVISION COLOSTOMY SIMPLE,SEPAR PROCEDUR $1,585.73 $1,585.73 $1,585.73 44345 REVISION COLOSTOMY COMPLICAT SEP PROCEDU $1,585.73 $1,585.73 $1,585.73 44346 CHOLOSTOMY REVIS W REPIR PARACOL HERN SP $350.00 $350.00 $350.00 44360 SMALL INTESTINAL ENDOSCOPY ENTEROSCOPY $822.23 $822.23 $822.23 44361 SMALL INTEST ENDOS W BIOPSY-COI SPEC $822.23 $822.23 $822.23 44363 SMALL INTEST ENDOS W REMOVAL FB $822.23 $822.23 $822.23 44364 SMALL INTEST ENDOS W REMOVAL POLYP LES $822.23 $822.23 $822.23 44365 SMALL INTEST ENDOSCOP W/REM OF TUMORS PO $822.23 $822.23 $822.23 44366 SM INTES ENDOSC,NOT W/ILEUM,CONTRL BLEED $822.23 $822.23 $822.23 44369 SMALL INTEST ENDOS W/ABLAT TUMOR, BIPOLA $822.23 $822.23 $822.23 44370 SM INTESTINE;ENDOSCOPY; INCLUDING ILEUM $822.23 $822.23 $822.23 44372 ENDOSCOPY W/PLACEMENT OF PERCUT JEJUNOST $822.23 $822.23 $822.23 44373 ENDOSCOPY W/CONV PERC GAST TO PERC JEJUN $822.23 $822.23 $822.23 44376 SMALL INTEST ENDOSCOP W/COLL OF SPECIMEN $822.23 $822.23 $822.23 44377 SMALL INTEST ENDOSCOP W/BIOP SINGLE/MULT $822.23 $822.23 $822.23 44378 SM INTEST ENDOSC,INCL ILEUM,CONTRL BLEED $822.23 $822.23 $822.23 44379 S BOWEL ENDOSCOPE W/STENT $822.23 $822.23 $822.23 44380 ILEOSCOPY, THROUGH STOMA; DIAG W/WO SPEC $822.23 $822.23 $822.23 44382 ILEOSCOPY, THROUGH STOMA; W/BIOP, SING/M $822.23 $822.23 $822.23 44383 ILEOSCOP,THR STOMA;W/TRANSENDOSC STENT P $822.23 $822.23 $822.23 44385 ENDOSCOP EVAL SMALL INTEST; DIAG; W/WO C $822.23 $822.23 $822.23 44386 ENDOSCOP EVAL SMALL INTEST; W/BIOP, SING $822.23 $822.23 $822.23 44388 COLONOSCOP THR STOMA; DIAG; W/WO SPECIME $822.23 $822.23 $822.23 44389 COLONOSCOP THR STOMA; W/BIOP, SING/MULTI $822.23 $822.23 $822.23 44390 FIBEROP SCOPE W REMOVAL FB $822.23 $822.23 $822.23 44391 COLONSCOPY THRU STOMA;W/CONTROL OF BLEED $1,339.05 $1,339.05 $1,339.05 44392 COLONOSCOPY THRU STOMA; W/REM OF TUMOR(S $1,339.05 $1,339.05 $1,339.05 44393 COLONOSCOPY THROUGH STOMA; W/ABLAT TUMOR $1,339.05 $1,339.05 $1,339.05 44394 COLONOSCOPY THROUGH STOMACH, W/REM TUMOR $1,339.05 $1,339.05 $1,339.05 44397 COLONOSCOPY W/TRANSENDOSCOPIC STENT PLAC $1,339.05 $1,339.05 $1,339.05 44602 SUTURE SMALL INTEST SINGLE PERFORATION $1,339.05 $1,339.05 $1,339.05 44603 SUTURE SMALL INTEST MULTIPLE PERFORATION $1,339.05 $1,339.05 $1,339.05 44604 SUTURE LARGE INTEST FOR PERFORATED ULCER $1,339.05 $1,339.05 $1,339.05 44605 SUTURE INTESTINE PERFORATED ULCER COLOST $1,339.05 $1,339.05 $1,339.05 44620 CLOSURE ENTEROSTOMY $822.23 $822.23 $822.23

07/27/12 Page 55 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 44625 CLOSURE OF ENTEROSTOMY W RESECT ANASTD $822.23 $822.23 $822.23 44640 CLOSURE OF INTESTINAL CUT ANEOUS FISTULA $1,339.05 $1,339.05 $1,339.05 44650 CLOSURE ENTEROENTERIC ENTEROCOLIC FISTUL $1,339.05 $1,339.05 $1,339.05 44680 INTESTINAL PLICATION COMPLETE(SEP PROC) $822.23 $822.23 $822.23 44799 UNLISTED PROCEDURE INTESTINE $822.23 $822.23 $822.23 44800 EXCIS MECKELS DIVERTICULUM $1,339.05 $1,339.05 $1,339.05 44820 EXCIS LESION OF MESENTERY $822.23 $822.23 $822.23 44850 SUTURE OF MESENTERY $1,339.05 $1,339.05 $1,339.05 44899 UNLISTED PROCEDURE MECKELS DIVERTICULUM $293.65 $293.65 $293.65 44900 INCIS DRAIN APPENDICEAL ABSCESS; OPEN $822.23 $822.23 $822.23 44901 INCISION&DRAIN APPENDICEAL ABSC;PERCUTAN $822.23 $822.23 $822.23 44950 APPENDECTOMY $1,585.73 $1,585.73 $1,585.73 44960 APPENDECTOMY FOR RUPTURED APPENDIX $1,585.73 $1,585.73 $1,585.73 44970 LAPAROSCOPY SURGICAL APPENDECTOMY $1,585.73 $1,585.73 $1,585.73 44979 UNLISTED LAPAROSCIOY PROCEDURE APPENDIX $293.65 $293.65 $293.65 45000 TRANSRECTAL DRG PELVIC ABSCESS $1,339.05 $1,339.05 $1,339.05 45005 INCIS/DRAIN SUBMUCO ABCESS RECTUM $1,339.05 $1,339.05 $1,339.05 45020 INCIS DRG SUPRALEVATOR PELVIRECTAL ABSC $1,339.05 $1,339.05 $1,339.05 45100 BIOPSY ANORECTAL WALL ANAL APPROACH $1,339.05 $1,339.05 $1,339.05 45108 ANORECTAL MYOMECTOMY $1,339.05 $1,339.05 $1,339.05 45111 PROCTECTOMY W PARTIAL RESECTION RECTUM $822.23 $822.23 $822.23 45112 PROCTECTOMY PULL THROUGH PROCEDURE $2,936.54 $2,936.54 $2,936.54 45113 PROCTECTOMY W PARTIAL RECTAL MUCOSECTOMY $2,936.54 $2,936.54 $2,936.54 45114 PROCTECTOMY PARTIAL W ANASTOMOSIS $822.23 $822.23 $822.23 45116 PROCTECTOMY PARTIAL TRANSACRAL APPROACH $1,339.05 $1,339.05 $1,339.05 45120 PROCTECTOMY COMP FOR MEGACOLON(SWENSON) $2,936.54 $2,936.54 $2,936.54 45123 PROCTECTOMY PARTIAL W/O ANASTOMOSIS PERI $822.23 $822.23 $822.23 45130 EXCIS RECTAL PROCIDENTIA PERINEAL APPR $1,339.05 $1,339.05 $1,339.05 45136 EXCISION ILEOANAL RESERVIOR W/ILEOSTOMY $1,339.05 $1,339.05 $1,339.05 45150 DIVISION STRICTURE OF RECTUM $822.23 $822.23 $822.23 45160 EXCIS RECTAL TUMOR BY PROCTOTOMY $822.23 $822.23 $822.23 45171 $822.23 $822.23 $822.23 45172 $822.23 $822.23 $822.23 45190 DESTRUCT RECTAL TUMOR ELECTRODESICCATION $822.23 $822.23 $822.23 45300 PROCTOSIGMOIDOSCOPY DIAGNOSTIC $822.23 $822.23 $822.23 45303 PROCTOSIGMOIDSCOPY,RIGID; W/ DIALATION $822.23 $822.23 $822.23 45305 PROCTOSIGMOIDOSCOPY,W/BIOPSY,SNGL OR MUL $293.65 $293.65 $293.65 45307 PROCTOSIGMOIDOSCOPY,W/FOREIGN BODY REMOV $822.23 $822.23 $822.23 45308 PROCTOSIGMOIDOSCOP,SNGL TUMOR,FORCEP/CAU $1,339.05 $1,339.05 $1,339.05 45309 PROCTOSIGMOIDOSCOPY REMOVAL SNARE TECHNI $1,339.05 $1,339.05 $1,339.05 45315 PROCTOSIGMOIDOSCOPY,REMOVE MULTI TUMORS $1,339.05 $1,339.05 $1,339.05 45317 PROCTOSIGMOID0SCOPY,W/CONTROL BLEEDING $1,339.05 $1,339.05 $1,339.05 45320 PROCTOSIGMOIDOSCOPY,W/ABLATION OF TUMORS $1,339.05 $1,339.05 $1,339.05 45321 PROCTOSIGMOIDOSCOPY,W/DECOMPRES VOLVULUS $822.23 $822.23 $822.23 45327 PROTOSIGIDOSCOPY;RIGID;TRANSENDSC STENT $1,339.05 $1,339.05 $1,339.05 45330 SIGMOIDOSCOPY, FLEX;DIAGNOST W/WO SPECIM $822.23 $822.23 $822.23 45331 SIGMOIDOSCOPY, FLEX;W/BIOP, SINGLE/MULTI $822.23 $822.23 $822.23 45332 SIGMOID FLEX W REMOVAL FB $822.23 $822.23 $822.23

07/27/12 Page 56 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 45333 SIGMOIDOSCOPY, FLEX; W/REMOV TUMORS LESI $1,339.05 $1,339.05 $1,339.05 45334 SIGMOIDSCOPY,FLEXIBL;W/CONTROL OF BLEEDI $1,339.05 $1,339.05 $1,339.05 45335 SIGMOIDOSCOPY, FLEX, W/SUBMUCOSOL INJECT $822.23 $822.23 $822.23 45337 SIGMOIDOSCOPY, FLEX; W/DECOMP OF VOLVULU $1,339.05 $1,339.05 $1,339.05 45338 SIGMOID FLEX W/REMOVAL OF TUMORS, POLYPS $1,339.05 $1,339.05 $1,339.05 45339 SIGMOID FLEX W/ABLATION OF TUMORS, POLYP $1,339.05 $1,339.05 $1,339.05 45340 SIGMOIDOSCOPY, FLEX, W/BALLOON DILATION $822.23 $822.23 $822.23 45341 SIGMOIDOSCOPY;FLEX;W/ENDOSCOPIC ULTRASND $822.23 $822.23 $822.23 45342 SIGMOIDOSCOPY,FLEX;W/TRANSENDOSC ULTRASN $822.23 $822.23 $822.23 45345 SIGMOIDOSCOPY,W/TRANSENDOSCOPIC STENT PL $822.23 $822.23 $822.23 45355 COLONOSCOPY, RIG/FLEX, TRANSABDOM VIA CO $822.23 $822.23 $822.23 45378 COLONOSCOPY, FLEX, DIAGNOS, W/WO SPECIME $822.23 $822.23 $822.23 45379 COLON FIBEROP W REMOVAL FB $822.23 $822.23 $822.23 45380 COLONOSCOPY, FLEX, W/BIOP, SINGLE/MULTIP $822.23 $822.23 $822.23 45381 COLONSCOPY, FLEX, SUBMUCCOSAL INJ $822.23 $822.23 $822.23 45382 COLONOSCOPY, FLEX, W/CONTROL BLEEDING AN $1,339.05 $1,339.05 $1,339.05 45383 COLONOSCOPY, FLEX, W/ABLATION TUMORS/LES $1,339.05 $1,339.05 $1,339.05 45384 COLON FLEX W/REMOVALOF TUMOR, POLYP, OR $1,339.05 $1,339.05 $1,339.05 45385 COLONOSCOPY, FLEX, W/REMOVAL TUMOR, LESI $1,339.05 $1,339.05 $1,339.05 45386 COLONSCOPY,BALLOON DIALATE, 1 + STRICTUR $822.23 $822.23 $822.23 45387 COLONOSCOPY,FLEX,PROXIMAL SPLENIC FLEXUR $1,339.05 $1,339.05 $1,339.05 45391 COLONOSCOPY,FLEX,W/ENDOSCOP ULTRSND EXAM $822.23 $822.23 $822.23 45392 COLONOSCOPY,FLEX,W/TRANSENDOSC U-SND EXA $822.23 $822.23 $822.23 45395 LAP,SURG;PROCTECTOMY,COMPL W/COLOSTOMY $822.23 $822.23 $822.23 45397 LAP;PROCTECTOMY,COMB ABDOMINOPERINEAL PU $822.23 $822.23 $822.23 45400 LAPAROSCOPY,SURG;PROCTOPEXY(FOR PROLAPSE $822.23 $822.23 $822.23 45402 LAPAROSCOPY,PROCTOPEXY,W/SIGMOID RESECTN $822.23 $822.23 $822.23 45499 UNLISTED LAPAROSCOPY PROCEDURE, RECTUM $293.65 $293.65 $293.65 45500 PROCTOPLASTY FOR STENOSIS $1,339.05 $1,339.05 $1,339.05 45505 PROCTOPLASTY FOR PROLAPSE $822.23 $822.23 $822.23 45540 PROCTOPEXY PROLAPSE ABDOMINAL APPROACH $1,339.05 $1,339.05 $1,339.05 45541 PROCTOPEXY PROLAPSE PERINEAL APPROACH $1,339.05 $1,339.05 $1,339.05 45550 PROCTOPEXY W SIGMOID RESECTION $1,339.05 $1,339.05 $1,339.05 45560 REPAIR OF RECTOCELE $822.23 $822.23 $822.23 45562 EXPLORATION REPAIR & PRESACRAL DRAINAGE $1,339.05 $1,339.05 $1,339.05 45563 EXPLOR REPAIR & PRESAC DRAIN W/COLOSTOMY $1,339.05 $1,339.05 $1,339.05 45820 CLOSURE RECTOURETHRAL FISTULA $1,339.05 $1,339.05 $1,339.05 45825 CLOSURE RECTOURETHRAL FISTULA COLOSTOMY $1,339.05 $1,339.05 $1,339.05 45900 REDUCTION OF PROCIDENTIA UNDER ANESTHES $293.65 $293.65 $293.65 45905 DILATION ANAL SPHINCTER $822.23 $822.23 $822.23 45910 DILATION RECTAL STRICTURE $822.23 $822.23 $822.23 45915 REMOVE FECAL IMPACTION UNDER ANES $822.23 $822.23 $822.23 45990 ANORECTAL EXAM,SURG,REQUIR ANES,DIAGNOST $822.23 $822.23 $822.23 45999 UNLISTED PROCEDURE RECTUM $822.23 $822.23 $822.23 46020 PLACEMENT OF SETON (I.E.ANAL) $1,339.05 $1,339.05 $1,339.05 46030 REMOVAL SETON OTHER MARKER $822.23 $822.23 $822.23 46040 INCIS DRG ISCHIORECTAL PERIRECTAL ABSC $822.23 $822.23 $822.23 46045 INCIS DRG ABSCESS TRANSANAL UNDER ANES $822.23 $822.23 $822.23

07/27/12 Page 57 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 46050 INCIS DRG PERIANAL ABSCESS SUPERFICIAL $822.23 $822.23 $822.23 46060 INCIS DRG ISCHIORECT INTRAMURAL ABSCESS $1,339.05 $1,339.05 $1,339.05 46070 INCIS ANAL SEPTUM INFANT $822.23 $822.23 $822.23 46080 SPHINCTEROTOMY ANAL $1,339.05 $1,339.05 $1,339.05 46083 INCISION THROMBOSED HEMORRHOID,EXTERNAL $822.23 $822.23 $822.23 46200 FISSURECTOMY $822.23 $822.23 $822.23 46220 PAPILLECTOMY/EXCISION OF SNGL TAG, ANUS $822.23 $822.23 $822.23 46221 HEMORRHOIDECTOMY BY SIMPLE LIGATURE $822.23 $822.23 $822.23 46230 EXCIS EXTER HEMORRHOID TAGS AN/OR PAPILL $1,339.05 $1,339.05 $1,339.05 46250 HEMORRHOIDECTOMY EXTERNAL COMPLETE $1,339.05 $1,339.05 $1,339.05 46255 HEMORRHOIDECTOMY INTER & EXTERN SIMPLE $1,339.05 $1,339.05 $1,339.05 46257 HEMORRHOIDECTOMY IN + EX SIM FISSURECTOM $1,339.05 $1,339.05 $1,339.05 46258 HEMORRHOIDECTOMY IN EX W FISTUL W/WO FIS $1,339.05 $1,339.05 $1,339.05 46260 HEMORRHOIDECTOMY W FISSURECTOMY EXTENS $1,339.05 $1,339.05 $1,339.05 46261 HEMORRHOIDECTOMY IN EX COMP EXTENS FISSU $1,339.05 $1,339.05 $1,339.05 46262 HEMORRHOIDECTOMY W FISTULECTOMY EXTENS $1,339.05 $1,339.05 $1,339.05 46270 SURG TREAT ANAL FISTULA SUBCUTANEOUS $1,339.05 $1,339.05 $1,339.05 46275 FISTULECTOMY SUBMUSCULAR $1,339.05 $1,339.05 $1,339.05 46280 SURG TREAT ANAL FISTULA; COMPLEX/MULTIPL $1,339.05 $1,339.05 $1,339.05 46285 FISTULECTOMY SECOND STAGE $1,339.05 $1,339.05 $1,339.05 46288 CLOSURE OF ANAL FISTULA W/ RECT ADV FLAP $1,339.05 $1,339.05 $1,339.05 46320 ENUCLEATION EXCIS EXT THROMBOTIC HEMORRH $822.23 $822.23 $822.23 46500 INJECTION SCLEROSING SOLUTION HEMORRHOID $293.65 $293.65 $293.65 46505 CHEMODENERVATION/INTERNAL ANAL SPHINCTER $822.23 $822.23 $822.23 46600 ANOSCOPY; DIAGNOSTIC(SEPARATE PROCEDURE) $293.65 $293.65 $293.65 46604 ANOSCOPY;W/DIALATION(EG,BALLOON,GUID WIR $293.65 $293.65 $293.65 46606 ANOSCOPY; W/BIOPSY, SINGLE OR MULTIPLE $822.23 $822.23 $822.23 46608 ANOSCOPY, W/REMOVAL OF FOREIGN BODY $822.23 $822.23 $822.23 46610 ANOSCOPY,REMOVE LESION/FORCEP OR CAUTERY $822.23 $822.23 $822.23 46611 ANOSCOPY W/REMOVAL OF SINGLE TUMOR, POL $822.23 $822.23 $822.23 46612 ANOSCOPY, REMOVE MULTIPLE LESIONS $822.23 $822.23 $822.23 46614 ANOSCOPY;W/CONTROL OF BLEED(EG INJ,BIPOL $822.23 $822.23 $822.23 46615 ANOSCOPY W/ABLATION OF TUMORS, POLYPS, O $822.23 $822.23 $822.23 46700 ANOPLASTY ADULT $822.23 $822.23 $822.23 46705 ANOPLASTY CHILD $822.23 $822.23 $822.23 46706 REPAIR OF ANAL FISTULA W/ FIBRIN GLUE $1,339.05 $1,339.05 $1,339.05 46707 $1,339.05 $1,339.05 $1,339.05 46710 REP ILEOANAL POUCH FISTULA/SINUS,PCH ADV $822.23 $822.23 $822.23 46712 REPAIR ILEOANAL POUCH FISTULA/SINUS,POUC $1,339.05 $1,339.05 $1,339.05 46715 REP LOW IMPERFOR ANUS;W/ANOPERINEAL FIS $1,339.05 $1,339.05 $1,339.05 46716 REP LOW IMPERFOR ANUS;W/TR ANTOPER/ANOV $1,339.05 $1,339.05 $1,339.05 46730 REPAIR HIGH IMPERFORATE ANUS; PERINEAL $822.23 $822.23 $822.23 46735 SEE 46730 COMBINED TRANSABDOMINAL&SACROP $822.23 $822.23 $822.23 46740 CONSTRUCTION ANUS W REPAIR URINARY FIST $822.23 $822.23 $822.23 46742 REPAIR HIGH IMPERF ANUS W/RECTOURETHRAL $822.23 $822.23 $822.23 46744 REPAIR CLOACAL ANOMALY, SACROPERINEAL AP $1,339.05 $1,339.05 $1,339.05 46746 REPAIR CLOACAL ANOMALY, COMB ABDOMIAL AN $1,339.05 $1,339.05 $1,339.05 46748 REPAIR CLOACAL ANOMALY, W/VAGINAL LENGTH $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 58 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 46750 SPINCTEROPLASTY ANAL ADULT $822.23 $822.23 $822.23 46751 SPINCTEROPLASTY CHILD $822.23 $822.23 $822.23 46753 GRAFT RECTAL INCONTINENCE PROLAPSE $822.23 $822.23 $822.23 46754 REMOVAL THIERSCH WIRE OR SUTURE $822.23 $822.23 $822.23 46760 SPHINCTEROPLASTY(ANAL)INCONTIN ADULT TRA $822.23 $822.23 $822.23 46761 SPINCTEROPLASTY ANAL INCONT LEVATOR MUSC $822.23 $822.23 $822.23 46762 SPINCTEROPLASTY ANAL ARTIFICAL SPHINCTER $1,585.73 $1,585.73 $1,585.73 46900 DESTR LESION(S)ANUS SIMPLE CHEMICAL $822.23 $822.23 $822.23 46910 DESTR LESION(S)ANUS SIMPLE ELECTRODESICC $822.23 $822.23 $822.23 46916 DESTRUC LESION(S) ANUS SIMPLE CRYOSURGEY $822.23 $822.23 $822.23 46917 DESTRU LESION(S)ANUS SIMPLE LASER SURGER $822.23 $822.23 $822.23 46922 DESTRU LESION(S)ANUS SIMPLE SURG EXCISE $822.23 $822.23 $822.23 46924 DESTRU LESION(S),ANUS ESTENSIVE(EG,LASER $822.23 $822.23 $822.23 46930 DESTROY INTERNL HEMORRHOIDS/THERMAL ENEG $822.23 $822.23 $822.23 46936 DESTROY INTERNL HEMORRHOIDS/THERMAL ENEG $822.23 $822.23 $822.23 46940 CURETTAGE OR CAUTERY ANAL FISSURE,INITI $822.23 $822.23 $822.23 46942 CURETTAGE CAUTERIZ ANAL FISSURE SUBSEG $822.23 $822.23 $822.23 46945 LIGATION INTERNAL HEMORRHOIDS SINGLE $822.23 $822.23 $822.23 46946 LIGATION INTERNAL HEMORRHOIDS MULTIPLE $822.23 $822.23 $822.23 46947 HEMORRHOIDOPEXY BY STAPLING $822.23 $822.23 $822.23 46999 UNLISTED PROCEDURE ANUS $293.65 $293.65 $293.65 47000 BIOPSY OF LIVER NEEDLE PERCUTANEOUS $1,339.05 $1,339.05 $1,339.05 47011 HEPATOTOMY;PERCUT DRAIN ABCS/CYST,1-2 ST $822.23 $822.23 $822.23 47015 LAPAROTOMY W ASPIR AND/OR INJ OF HEPATIC $822.23 $822.23 $822.23 47100 BIOPSY LIVER WEDGE $1,339.05 $1,339.05 $1,339.05 47120 HEPATECTOMY RESECTION PARTIAL LOBECTOMY $1,339.05 $1,339.05 $1,339.05 47122 HEPATECTOMY RESECTION LIVER TRISEGMENTEC $1,339.05 $1,339.05 $1,339.05 47350 MGT LIVER HEMORRHAGE SIMP SUTURE LIV WOU $1,585.73 $1,585.73 $1,585.73 47360 MGT LIV HEMORRH COMP SUT LIV W/WO HEP AR $1,585.73 $1,585.73 $1,585.73 47370 LAP,SURG ABLATN 1+ LIVR TUMRS,RADIOFREQ $1,339.05 $1,339.05 $1,339.05 47371 LAPARO,ABLATE LIVER TUMOR;CRYOSURGICAL $1,339.05 $1,339.05 $1,339.05 47379 UNLISTED LAPAROSCOPIC PROCEDURE, LIVER $1,339.05 $1,339.05 $1,339.05 47380 ABLATION OPEN 1+ LIVR TUMRS,RADIOFREQ $1,339.05 $1,339.05 $1,339.05 47381 ABLATION OPEN 1+ LIVR TUMRS,CRYOSURG $1,339.05 $1,339.05 $1,339.05 47382 ABLATN 1+ LIVR TUMRS,PERCUT,RADIOFREQ $1,339.05 $1,339.05 $1,339.05 47399 UNLISTED PROCEDURE LIVER $822.23 $822.23 $822.23 47400 HEPATICOTOMY HEPATICOSTOMY $1,339.05 $1,339.05 $1,339.05 47420 CHOLEDOCHOTOMY CHOLEDOCHOSTOMY $1,339.05 $1,339.05 $1,339.05 47425 CHOLEDOCHOTOMY/OSTOM W TRANS SPHINSTERO $1,339.05 $1,339.05 $1,339.05 47460 TRANSDUODENAL SPINCTEROTOMY $1,585.73 $1,585.73 $1,585.73 47480 CHOLECYSTOTOMY CHOLECYSTOSTOMY $293.65 $293.65 $293.65 47550 BILIARY ENDOSCOPY INTRAOPERATIVE(CHOLEDO $570.00 $570.00 $570.00 47552 BILIARY ENDOSCOP PERCU T-TUB/OTHER DIAG $822.23 $822.23 $822.23 47553 BILIARY ENDOS PERCUT W/BIOP, SINGLE/MULT $822.23 $822.23 $822.23 47554 BILIARY ENDOS,PERCUT;W/REMOVAL OF CALCUL $822.23 $822.23 $822.23 47560 LAP SURGICAL GUIDED TRANSHEP CHALANGRAPH $1,339.05 $1,339.05 $1,339.05 47561 LAP SURGICAL GUIDED TRANS CHOLANG W/ BIO $822.23 $822.23 $822.23 47562 LAPARLSCOPY SURGICAL CHOLECYSTECTOMY $822.23 $822.23 $822.23

07/27/12 Page 59 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 47563 LAP SURGICAL CHOLECYSTECTOMY W/CHOLANG $822.23 $822.23 $822.23 47564 LAP SURGICAL CHOLECYSTECTOMY EXP COM DCT $822.23 $822.23 $822.23 47570 LAP SURGICAL CHOLECYSTOENTEROSTOMY $1,339.05 $1,339.05 $1,339.05 47579 UNLISTED LAP PROCEDURE BILIARY TRACT $822.23 $822.23 $822.23 47600 CHOLECYSTECTOMY $822.23 $822.23 $822.23 47605 CHOLECYSTECTOMY W CHOLANGIOGRAPHY $822.23 $822.23 $822.23 47610 CHOLECYSTECTOMY EXPLORAT COMMON DUCT $822.23 $822.23 $822.23 47612 CHOLECYSTECTOMY EXPLOR DUCT W CHOLEODOCH $822.23 $822.23 $822.23 47620 CHOLECYSTECTOMY TRANSDUOD SPINCTEROTOMY $822.23 $822.23 $822.23 47700 EXPLORAT CONGENITAL ATRESIA BILE DUCT $1,339.05 $1,339.05 $1,339.05 47711 EXCIS OF BILE DUCT TUMOR W/WO REP EXTRAH $1,585.73 $1,585.73 $1,585.73 47712 EXCIS OF BILE DUCT TUMOR W/WO REP INTRAH $1,585.73 $1,585.73 $1,585.73 47720 CHOLECYSTOENTEROSTOMY DIRECT $1,339.05 $1,339.05 $1,339.05 47721 SEE 47720 W GASTROENTEROSTOMY $1,339.05 $1,339.05 $1,339.05 47740 ROUX EN Y $1,339.05 $1,339.05 $1,339.05 47741 CHOLECYSTOENTEROSTOMY ROUX EN Y W/GASTRO $1,339.05 $1,339.05 $1,339.05 47801 PLACEMENT OF CHOLEDOCHAL STENT $822.23 $822.23 $822.23 47999 UNLISTED PROCEDURE BILIARY TRACT $822.23 $822.23 $822.23 48000 PLACE OF DRAINS, PERIPANCREATIC FOR ACUT $1,339.05 $1,339.05 $1,339.05 48001 PLACE DRAINS, PERIPANCREATIC, ACUTE PANC $1,339.05 $1,339.05 $1,339.05 48120 EXCIS LESION PANCREAS $1,339.05 $1,339.05 $1,339.05 48500 MARSUPIALIZATION OF PANCREATIC CYST $1,585.73 $1,585.73 $1,585.73 48510 EXT DRAINAGE,PSEUDOCYST OF PANCREAS;OPEN $1,585.73 $1,585.73 $1,585.73 48511 EXT DRAIN,PSEUDOCYST OF PANCREAS;PERCUTA $1,585.73 $1,585.73 $1,585.73 48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT $7.05 $7.05 $7.05 48999 UNLISTED PROCEDURE PANCREAS $822.23 $822.23 $822.23 49000 EXPLOR LAP-CELIOT-W/WO BIOPSY (S) SEP PR $1,585.73 $1,585.73 $1,585.73 49002 REOPEN RECENT LAPAROTOMY $822.23 $822.23 $822.23 49010 EXPLOR RETROPERITONEAL W/WO BIOPSY (S) S $1,339.05 $1,339.05 $1,339.05 49020 DRG PERITON ABS/LOC PERI,EXCL APP ABS;OP $1,339.05 $1,339.05 $1,339.05 49021 DRAIN PERITON ABCES/LOCAL,NOT APPND;PERC $1,339.05 $1,339.05 $1,339.05 49040 DRG SUBDIAPHRAGMAT SUBPHRENIC ABSCES;OPN $1,339.05 $1,339.05 $1,339.05 49041 DRG SUBDIAPHRAGM SUBPHREN ABCES;PERCUTAN $1,339.05 $1,339.05 $1,339.05 49060 DRG RETROPERITONEAL ABSCESS; OPEN $1,339.05 $1,339.05 $1,339.05 49061 DRG RETROPERITONEAL ABCESS;PERCUTANEOUS $1,339.05 $1,339.05 $1,339.05 49062 DRG EXTRAPERIT LYMPHOC PERCUT CAVTY;OPEN $1,339.05 $1,339.05 $1,339.05 49080 PERITONEOCEN ABD PARACEN-PERIT-LAV INITI $1,339.05 $1,339.05 D 49081 PERITONEOCENT (ABD PARACENT LAVAG SUBSEQ $1,339.05 $1,339.05 D 49082 ABDOMINAL PARACENTESIS W/O IMAG GUIDANCE Not Valid Not Valid $1,339.05 49083 ABDOMINAL PARACENTESIS W/IMAGING GUIDAN Not Valid Not Valid $1,339.05 49084 PERITONEAL LAVAGE, W/IMAGING GUIDANCE Not Valid Not Valid $1,339.05 49180 BIOPSY RETROPERITONEAL MASS NEEDLE PERCU $822.23 $822.23 $822.23 49203 EXCISION,OPEN,ABDOM TUMOR,5 CM OR <,EACH $822.23 $822.23 $822.23 49204 EXCISION,OPEN,ABDOM TUMOR,5.1-10 CM,EACH $822.23 $822.23 $822.23 49215 EXCIS PRESACRAL OR SACROCOCCYGEAL TUMOR $822.23 $822.23 $822.23 49220 STAG LAPAROTOMY HODGKINS DIS OR LYMPHOMA $1,585.73 $1,585.73 $1,585.73 49250 UMBILECTOMY OMPHALEOTOMY $1,339.05 $1,339.05 $1,339.05 49255 OMENTECTOMY EPIPLOECTOMY $822.23 $822.23 $822.23

07/27/12 Page 60 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 49320 LAP ABDOM PERITONE OMENTUM DIAG/BRUSH/WA $1,339.05 $1,339.05 $1,339.05 49321 LAPAROSCOPY SURGICAL W/BIOPSY SING/MULTI $1,339.05 $1,339.05 $1,339.05 49322 LAP SURG ABD PERIT OMENT ASP OF CAV CYST $1,339.05 $1,339.05 $1,339.05 49323 LAP SURG ABD PERIT DMENT DRG LYMPH PERCV $1,339.05 $1,339.05 $1,339.05 49324 LAPAROSCOPY INSERT PERMANENT IP CATHETER $822.23 $822.23 $822.23 49327 LAPAROSCOPY $822.23 $822.23 49329 UNLISTED LAP PROC ABDOMEN PERITONEUM OMT $1,339.05 $1,339.05 $1,339.05 49411 $1,339.05 $1,339.05 $1,339.05 49412 DEVICE REPLACEMENT $822.23 $822.23 49418 INSERT TUNNELED INTRAPERITONEAL CATHETER Not Valid $1,339.05 $1,339.05 49419 INSERT ABDOMINAL CATHETER FOR CHEMOTX $822.23 $822.23 $822.23 49420 INSERT INTRAPERITONEAL CATH TEMPORARY $1,339.05 $1,339.05 D 49421 INSERT INTRAPERITONEAL CATH PERMANENT $1,339.05 $1,339.05 $1,339.05 49422 REMOVE PERM INTRAPERITONEAL CANNULA/CATH $1,339.05 $1,339.05 $1,339.05 49425 INSERTION PERITONEAL-VENOUS SHUNT $822.23 $822.23 $822.23 49426 REVISION PERITONEAL-VENOUS SHUNT $822.23 $822.23 $822.23 49428 LIGATION OF PERITONEAL-VENOUS SHUNT $1,339.05 $1,339.05 $1,339.05 49429 REMOVAL OF PERITONEAL-VENOUS SHUNT $1,339.05 $1,339.05 $1,339.05 49442 INSERT CECOSTOMY TUBE,PERCUTAN,DOC &REPT $822.23 $822.23 $822.23 49446 GASTROSTOMY TUBE CONVERT TO JEJUNSTOMY $822.23 $822.23 $822.23 49450 GASTROSTOMY TUBE REPLACE,IMG DOC & RPT $822.23 $822.23 $822.23 49451 DUODEN/JEJUNOSTOMY TUBE REPL,DOC & RPT $822.23 $822.23 $822.23 49452 GASTRO-JEJUNOSTOMY TUBE REPL,DOC & RPT $822.23 $822.23 $822.23 49460 REMOVE OBSTRUCTIVE MAT'L G/COLON TUBE $822.23 $822.23 $822.23 49465 FLUORO EXAM OF GASTO/COLON TUBE $822.23 $822.23 $822.23 49491 REPAIR,INIT INGUINL HERNIA,<50WK;REDUCBL $1,339.05 $1,339.05 $1,339.05 49492 REP INIT ING HERN INFNT <50 WKS;INCARCER $1,339.05 $1,339.05 $1,339.05 49495 REPAIR INGUINAL HERNIA, <6MTHS, REDUCIBL $1,339.05 $1,339.05 $1,339.05 49496 REPAIR INGUINAL HERNIA, <6MTHS, INCARCER $1,339.05 $1,339.05 $1,339.05 49500 REPAIR INGUINAL HERNIA, AGE 6 MTHS TO <5 $1,339.05 $1,339.05 $1,339.05 49501 REPAIR INGUINAL HERNIA AGE 6MTHS TO <5Y $1,339.05 $1,339.05 $1,339.05 49505 REPAIR,INIT INGUINL HERNIA,>=5 YRS,REDUC $1,339.05 $1,339.05 $1,339.05 49507 REP INIT INGUINL HERNIA,AG5>,INCAR/STRAN $1,339.05 $1,339.05 $1,339.05 49520 REPAR RECURRENT INGUINAL HERNI ANY AGE $1,339.05 $1,339.05 $1,339.05 49521 REPAIR RECURRENT ING HERNIA, ANY AGE INC $1,339.05 $1,339.05 $1,339.05 49525 REPAIR ANY AGE RECUR INGUIN HERNI SLIDIN $1,339.05 $1,339.05 $1,339.05 49540 REPAIR LUMBAR HERNIA $1,339.05 $1,339.05 $1,339.05 49550 REPAIR INITIAL FEMORAL HERNIA,ANY STAGE $1,339.05 $1,339.05 $1,339.05 49553 REPAIR INITIAL FEMORAL HERNIA ANY AGE IN $1,585.73 $1,585.73 $1,585.73 49555 REPAIR RECURRENT FEMORAL HERNIA; REDUCIB $1,339.05 $1,339.05 $1,339.05 49557 REPAIR RECURRENT FEMORAL HERNIA, INCARCE $1,339.05 $1,339.05 $1,339.05 49560 LAP,INCISIONAL HERNIA REPAIR,REDUCIBLE $1,339.05 $1,339.05 $1,339.05 49561 LAP,INCIS HERNIA REPAIR,RECURRENT,REDUCI $1,585.73 $1,585.73 $1,585.73 49565 REPAIR RECUR INCISION/VENTRI HERNIA;REDU $1,339.05 $1,339.05 $1,339.05 49566 REPAIR RECURRENT INCISIONAL HERNIA, INCA $1,585.73 $1,585.73 $1,585.73 49570 REPAIR EPIGASTRIC HERNIA REDUCIBLE (SEPA $1,339.05 $1,339.05 $1,339.05 49572 REPAIR EPIGASTRIC HERNIA INCAR OR STRANG $1,339.05 $1,339.05 $1,339.05 49580 REPAIR UMBILICAL HERNIA,< 5 YRS;REDUCBLE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 61 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 49582 REPAIR UMBILICAL HERNIA, , RED $1,339.05 $1,339.05 $1,339.05 49587 REPAIR UMBILICAL HERNIA, AGE 5 OR >, INC $1,339.05 $1,339.05 $1,339.05 49590 REPAIR SPIGELIAN HERNIA $1,339.05 $1,339.05 $1,339.05 49600 REPAIR SMALL OMPHALOCELE, W/PRIM CLOSURE $1,339.05 $1,339.05 $1,339.05 49605 REPAIR OMPHALOCELE LARGE OR GASTROSCHIS $1,339.05 $1,339.05 $1,339.05 49610 REPAIR OMPHALOCELE FIRST STAGE $1,339.05 $1,339.05 $1,339.05 49611 REPAIR OMPHALOCELE SECOND STAGE $1,339.05 $1,339.05 $1,339.05 49650 LAP,VENTRAL,UMBILICAL..HERNIA,REDUCIBLE $1,339.05 $1,339.05 $1,339.05 49651 LAP SURG REPAIR RECURRENT INGUINAL HERNI $1,339.05 $1,339.05 $1,339.05 49652 LAP,VENTRAL,UMBILICAL..HERNIA,REDUCIBLE $1,339.05 $1,339.05 $1,339.05 49653 LAP,VENTRL,UMBILICAL.,HERNIA,INCAR/STRAN $1,339.05 $1,339.05 $1,339.05 49654 LAP,INCISIONAL HERNIA REPAIR,REDUCIBLE $1,339.05 $1,339.05 $1,339.05 49655 LAP,INCISIONL HERNIA REPAIR,INCARC/STRAN $1,339.05 $1,339.05 $1,339.05 49656 LAP,INCIS HERNIA REPAIR,RECURRENT,REDUCI $1,585.73 $1,585.73 $1,585.73 49657 LAP,INCIS HERNIA,RECURRENT,INCARC/STRANG $1,585.73 $1,585.73 $1,585.73 49659 UNLISTED LAP PRO HERNPLSY HERNRPHY HTOMY $822.23 $822.23 $822.23 49900 SUTURE FOR EVISCERATION DEHISCENCE $822.23 $822.23 $822.23 49999 UNLISTED PROCEDURE ABDOMEN PERITONEUM $822.23 $822.23 $822.23 50010 RENAL EXPLORATION $1,585.73 $1,585.73 $1,585.73 50020 DRAIN PERIRENAL OR RENAL ABSCESS; OPEN $1,585.73 $1,585.73 $1,585.73 50021 DRAIN PERIRENAL/RENAL ABCESS; PERCUTANEO $822.23 $822.23 $822.23 50040 NEPHROSTOMY NEPHROTOMY W DRG $822.23 $822.23 $822.23 50045 NEPHROTOMY W EXPLORATION $1,585.73 $1,585.73 $1,585.73 50060 NEPHROLITHOTOMY REMOVAL CALCULUS $1,585.73 $1,585.73 $1,585.73 50065 NEPHROLITHOTOMY SECONDARY $1,585.73 $1,585.73 $1,585.73 50070 NEPHROLITHOTOMY COMPLICATED $1,585.73 $1,585.73 $1,585.73 50075 NEPHROLITHOTOMY REMOVAL LG(STAGHORN CALC $1,585.73 $1,585.73 $1,585.73 50120 PYELOTOMY W EXPLORATION $1,585.73 $1,585.73 $1,585.73 50125 PYELOTOMY W DRG PYELOSTOMY $1,339.05 $1,339.05 $1,339.05 50130 PYELOTOMY W/REMOV CALCULUS INC COAGULUM. $1,585.73 $1,585.73 $1,585.73 50135 PYELOTOMY COMPLICATED $1,585.73 $1,585.73 $1,585.73 50200 RENAL BIOPSY $822.23 $822.23 $822.23 50205 RENAL BIOPSY BY SURGICAL EXPOSURE $822.23 $822.23 $822.23 50220 NEPHRECTOMY PARTIAL URETERECTOMY $1,585.73 $1,585.73 $1,585.73 50225 NEPHRECTOMY COMPLICATED $1,585.73 $1,585.73 $1,585.73 50230 NEPHRECTOMY RADICAL W REG LYMPHADEC/THRO $1,585.73 $1,585.73 $1,585.73 50234 NEPHRECTOMY TOTAL URETERECTOMY SAME INCI $1,585.73 $1,585.73 $1,585.73 50236 SEE 50234 THROUGH SEPARATE INCISION $1,585.73 $1,585.73 $1,585.73 50240 NEPHRECTOMY PARTIAL $1,585.73 $1,585.73 $1,585.73 50250 ABLATION,OPN,1+ RENAL MASS LESION,CRYOSU $1,339.05 $1,339.05 $1,339.05 50280 EXCIS UNROOFING CYSTS OF KIDNEY $1,339.05 $1,339.05 $1,339.05 50290 EXCIS PERINEPHRIC CYST $822.23 $822.23 $822.23 50382 REMOV&REPL INTERNAL DWELL URETERAL STENT $822.23 $822.23 $822.23 50384 REMOV INTERNAL DWEL URETERAL STENT,SUP&I $293.65 $293.65 $293.65 50385 CHANGE STENT VIA TRANSURETHERAL APPROACH $822.23 $822.23 $822.23 50386 REMOVE STENT VIA TRANSURETHERAL APPROACH $293.65 $293.65 $293.65 50387 RMV&REPL EXT ACCES TRANSNEPHRC URET STEN $822.23 $822.23 $822.23

07/27/12 Page 62 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 50389 RMV NEPHROSTOMY TUBE,FLUOROSCOPIC GUIDAN $293.65 $293.65 $293.65 50390 $293.65 $293.65 $293.65 50391 INSTIL THERAP AG/RENAL PELVIS&/OR URETER $293.65 $293.65 $293.65 50392 $293.65 $293.65 $293.65 50393 $293.65 $293.65 $293.65 50398 CHANGE NEPHROSTOMY PYELOSTOMY TUBE $293.65 $293.65 $293.65 50525 CLOSURE NEPHROVISCERAL FISTULA ABD APPR $1,339.05 $1,339.05 $1,339.05 50526 SEE 50525 THORACIC APPROACH $1,339.05 $1,339.05 $1,339.05 50541 LAP SURG ABLATION OF RENAL CYSTS $1,339.05 $1,339.05 $1,339.05 50542 LAPAROSCOPY,SURG;ABLATION RENAL MASS LES $822.23 $822.23 $822.23 50543 LAPAROSCOPY,SURGICAL;PARTIAL NEPHRECTOMY $822.23 $822.23 $822.23 50544 LAPAROSCOPY SURGICAL PYELOPLASTY $822.23 $822.23 $822.23 50545 LAPAROSCOPY,SURGICAL;RADICAL NEPHRECTOMY $1,585.73 $1,585.73 $1,585.73 50546 LAP SURG NEPHRECTOMY W/PART URETERECTOMY $1,585.73 $1,585.73 $1,585.73 50547 LAP SURG DON NEPHCTOMY LIVE DON EX PREP $1,585.73 $1,585.73 $1,585.73 50548 LAP SURG;NEPHRECTOMY W/TOTL URETERECTOMY $1,585.73 $1,585.73 $1,585.73 50549 UNLISTED LAPAROSCOPY PROCEDURE RENAL $822.23 $822.23 $822.23 50551 RENAL ENDOSCOPY(NEPHROSTOMY)W/WO INSTILL $822.23 $822.23 $822.23 50553 RENAL ENDOS W/WO IRRUG, INSTAL, URETEROP $822.23 $822.23 $822.23 50555 RENAL ENDOSCOPY(OSTOMY)W/WO IRR W BIOPSY $822.23 $822.23 $822.23 50557 RENAL ENDOSCOP(OSTOMY) W FULGU W/WO BIOP $822.23 $822.23 $822.23 50561 RENAL ENDOSCOPW(OSTOMY) W/REMOV FB OR CA $1,339.05 $1,339.05 $1,339.05 50562 RENAL ENDOSCOPY W/TUMOR RESECTION $822.23 $822.23 $822.23 50570 ENDOSCOPY THRU NEPHROTOMY PYELOTOMY $822.23 $822.23 $822.23 50572 RENAL ENDOSCOP W DATH W/WO DUL T URETER $822.23 $822.23 $822.23 50574 SEE 50570 W BIOPSY $822.23 $822.23 $822.23 50575 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PY $1,585.73 $1,585.73 $1,585.73 50576 RENAL ENDOSCOP(OTOMY)W/WO RADIOACT,BIOP, $1,339.05 $1,339.05 $1,339.05 50580 SEE 50570 W REMOVAL FOREIGN BODY $1,339.05 $1,339.05 $1,339.05 50590 LITHOTRIPSY EXTRACORPOREAL SHOCK WAVE $6,342.91 $6,342.91 $6,342.91 50600 URETEROTOMY W DRG $1,339.05 $1,339.05 $1,339.05 50605 URETEROTOMY FOR INSERT INDWEL STENT ALL $1,339.05 $1,339.05 $1,339.05 50610 URETEROLITHOTOMY UPPER ONE THIRD $1,339.05 $1,339.05 $1,339.05 50620 URETEROLITHOTOMY MIDDLE ONE THIRD $1,339.05 $1,339.05 $1,339.05 50630 URETEROLITHOTOMY LOWER ONE THIRD $1,339.05 $1,339.05 $1,339.05 50650 URETERECTOMY W BLADDER CUFF $1,339.05 $1,339.05 $1,339.05 50660 URETERECTOMY TOTAL $1,339.05 $1,339.05 $1,339.05 50700 URETEROPLASTY $1,339.05 $1,339.05 $1,339.05 50715 URETEROLYSIS UNILATERAL $1,339.05 $1,339.05 $1,339.05 50722 URETEROLYSIS OVARIAN VIEW SYNDROME $1,339.05 $1,339.05 $1,339.05 50725 URETEROLYSIS RETROCAVAL URETER $1,339.05 $1,339.05 $1,339.05 50727 REV URINARY-CUTANEOUS ANASTOMOSIS $1,339.05 $1,339.05 $1,339.05 50728 REV URI-CUTA ANAST W/REP FISCIAL DEF&HER $1,339.05 $1,339.05 $1,339.05 50780 URETERONECYS,OR SURG CORRCT REFLUX,SINGL $1,339.05 $1,339.05 $1,339.05 50782 URETERONEOCYSTOSTOMYANAST DUP URET-BLADD $1,339.05 $1,339.05 $1,339.05 50783 URETERONEOCYSTOSTOMYW/EXTEN URETERAL TAI $1,339.05 $1,339.05 $1,339.05 50785 URETERONECYS;W/VESICO-PSOAS HTC/BLDR FLP $1,339.05 $1,339.05 $1,339.05 50820 URETEROILEAL CONDUIT,INCL INTEST ANASTOM $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 63 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 50825 CONTINENT DIVERSION,INCL INTEST ANASTOM $1,339.05 $1,339.05 $1,339.05 50830 URINARY UNDIVERSION $1,339.05 $1,339.05 $1,339.05 50840 REPLACE ALL/PART OF URETER BY INTEST SEG $1,339.05 $1,339.05 $1,339.05 50845 CUTANEOUS APPENDICO-VESICOSTOMY $1,585.73 $1,585.73 $1,585.73 50860 URETEROSTOMY,TRANSPLNT URETER TO SKIN $1,339.05 $1,339.05 $1,339.05 50930 CLOSURE URETEROVISCERAL FISTULA $1,339.05 $1,339.05 $1,339.05 50945 LAPAROSCOPY SURGICAL URETEROLITHOTOMY $1,339.05 $1,339.05 $1,339.05 50947 LAP,SURG;URETERONEOCYSTOTOMY W/CYSTOTURE $1,339.05 $1,339.05 $1,339.05 50948 LAP,SURG;URETERONEOCYSTOTOMY W/O CYSTURE $1,339.05 $1,339.05 $1,339.05 50949 UNLISTED LAPAROSCOPY PROCEDURE, URETER $822.23 $822.23 $822.23 50951 URETERAL ENDOSCOPY(OSTOMY)W/WO INSTILL.. $822.23 $822.23 $822.23 50953 URETER ENDOSCOP THROU ESTAB W/CATH W/WO $822.23 $822.23 $822.23 50955 URETERAL ENDOSCOP(OSTOMY) WITH BIOPSY $822.23 $822.23 $822.23 50957 URETERAL ENDOSCOP(OSTOMY)W/WO FULGUR,INC $1,339.05 $1,339.05 $1,339.05 50961 URETERAL ENDOSCOP(OSTOMY) REMOV FB/CALCU $1,339.05 $1,339.05 $1,339.05 50970 URETERAL ENDOSCOPY THRU URETEROTOMY $822.23 $822.23 $822.23 50972 URETER ENDOSCOP (URETEROTOMY) CATH W/WO $822.23 $822.23 $822.23 50974 SEE 50970 W BIOPSY $822.23 $822.23 $822.23 50976 URETERAL ENDOSCOP(OTOMY)W/WO IRRIG,BIOP $1,339.05 $1,339.05 $1,339.05 50980 ENDOSCOPY W REMOVAL FOREIGN BODY $1,339.05 $1,339.05 $1,339.05 51020 CYSTOTOMY CYSTOSTOMY $822.23 $822.23 $822.23 51030 SEE 51020 CRYOSURG DESTRUCT INTRAVES LES $822.23 $822.23 $822.23 51040 CYSTOSTOMY CYSTOTOMY W DRG $822.23 $822.23 $822.23 51045 CYSTOMY W/INSERT URETERAL CATH OR STENT $822.23 $822.23 $822.23 51050 CYSTOLITHOTOMY $822.23 $822.23 $822.23 51060 TRANSUESICAL URETEROLITHOTOMY $1,339.05 $1,339.05 $1,339.05 51065 CYSTOTOMY,W/CALCUL BASKT EXT/ULTRASON/EL $822.23 $822.23 $822.23 51080 DRG PERIVESICAL PREVESICAL SPACE ABSCESS $822.23 $822.23 $822.23 51100 ASPIRATION OF BLADDER; BY NEEDLE $822.23 $822.23 $822.23 51101 BLADDER ASPIRATION;BY TROCAR/INTRACATH $822.23 $822.23 $822.23 51102 BLADDER ASPIRATION;W/SUPRAPUBIC CATHETER $822.23 $822.23 $822.23 51500 EXCIS URACHAL CYST OR SINUS $1,339.05 $1,339.05 $1,339.05 51520 CYSTOTOMY SIMPLE EXCIS VESICAL NECK $822.23 $822.23 $822.23 51525 CYSTOTOMY EXCIS BLADDER DIVERTICULUM $822.23 $822.23 $822.23 51530 CYSTOTOMY EXCIS BLADDER TUMOR $822.23 $822.23 $822.23 51535 CYSTOTOMY EXCIS,INCIS,O REPAIR URETECELE $1,339.05 $1,339.05 $1,339.05 51550 CYSTECTOMY PARTIAL SIMPLE $822.23 $822.23 $822.23 51555 CYSTECTOMY COMPLICATED PARTIAL $822.23 $822.23 $822.23 51565 CYSTECTOMY PARTIAL REIMPLANT URETER $822.23 $822.23 $822.23 51570 CYSTECTOMY COMPLETE $822.23 $822.23 $822.23 51575 CYSTECTOMY COMPLETE BIL PELVIC LYMPHADEN $822.23 $822.23 $822.23 51580 CYSTECTOMY URETERSIGMOIDOSTOMY TRANSPLAN $822.23 $822.23 $822.23 51585 SEE 51580 BIL PELVIC LYMPHADENECTOMY $822.23 $822.23 $822.23 51590 CYSTOTOMY,W/URETEROIL CONDUIT/SIGMOID BL $822.23 $822.23 $822.23 51595 SEE 51590 INCLUD EXT ILIAC HYPOGAST NODE $822.23 $822.23 $822.23 51596 CYSTECT,COMP,CONT DIVER,SM/LG INT CONSTR $822.23 $822.23 $822.23 51703 INSERT TEMP INDWELL BLADER CATHET,COMPLX $125.00 $125.00 $125.00 51705 CHANGE CYSTOSTOMY TUBE $293.65 $293.65 $293.65

07/27/12 Page 64 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 51710 CHANGE CYSTOSTOMY TUBE COMPLICATED $822.23 $822.23 $822.23 51715 ENDOSCOPIC INJECTION OF IMPLANT MATERIAL $1,339.05 $1,339.05 $1,339.05 51720 BLADDER INSTILLATION ANTICARCINOGENIC $1,250.00 $1,250.00 $1,250.00 51725 SIMPLE CYSTOMETROGRAM(EG SPINAL MANOMET) $350.00 $350.00 $350.00 51727 $293.65 $293.65 $293.65 51728 $293.65 $293.65 $293.65 51729 $293.65 $293.65 $293.65 51800 CYSTOPLASTY CYSTOURETHROPLASTY $1,585.73 $1,585.73 $1,585.73 51820 CYTOURETHROPLASTY UNILAT BILAT URETERNEO $1,585.73 $1,585.73 $1,585.73 51840 ANT VESICOURETHROPEXY,OR URETHROPXY;SIMP $1,339.05 $1,339.05 $1,339.05 51841 ANT VESICOURETHROPEXY COMPLICATED $1,339.05 $1,339.05 $1,339.05 51845 ABDOMINO-VAG VESICAL NECK SUSPEN W/WO EN $1,339.05 $1,339.05 $1,339.05 51860 CYSTORRHAPHY SUTURE BLAD WOUND/INJ SIMPL $1,585.73 $1,585.73 $1,585.73 51865 CYSTORRHAPHY SUTURE BLAD WOUND/INJ COMPL $1,585.73 $1,585.73 $1,585.73 51880 CLOSURE CYSTOSTOMY $822.23 $822.23 $822.23 51900 CLOSURE VESICOVAGINAL FISTU ABD APPROACH $822.23 $822.23 $822.23 51920 CLOSURE VESICOUTERINE FISTULA $822.23 $822.23 $822.23 51940 CLOSURE,EXSTROPHY OF BLADDER $1,339.05 $1,339.05 $1,339.05 51960 ENTEROCYSTOPLASTY,W/INTESTINAL ANASTOMOS $1,339.05 $1,339.05 $1,339.05 51980 CUTANEOUS VESICOSTOMY $1,339.05 $1,339.05 $1,339.05 51990 LAP SURG URETHRAL SUSPENSION STRESS INCT $1,339.05 $1,339.05 $1,339.05 51992 LAP SURG SLING OPERATION STRESS INCONTCE $1,339.05 $1,339.05 $1,339.05 51999 UNLISTED LAPAROSCOPY PROCEDURE, BLADDER $293.65 $293.65 $293.65 52000 CYSTOURETHROSCOPY(SEP PROCEDURE) $822.23 $822.23 $822.23 52001 CYSTOURETHSCPY W/IRRIGATN & EVAC CLOTS $822.23 $822.23 $822.23 52005 CYSTO W/CATH W/WO INSTIL OR OGRAPHY $822.23 $822.23 $822.23 52007 CYSTO W/CATH W/WO INSTIL-IRR-URET BIOPSY $822.23 $822.23 $822.23 52204 CYSTOURETHROSCOPY WITH BIOPSY $822.23 $822.23 $822.23 52214 CYSTO FULG(INC CRYO-LASER)TRIGO NK FOSSA $822.23 $822.23 $822.23 52224 CYSTO FULG(INC CRYO-LASER)MINOR LESION(S $822.23 $822.23 $822.23 52234 CYSTO FULG(INC CRYO-LASER) SMALL TUMOR $822.23 $822.23 $822.23 52235 CYSTO FULG(INC CRYO-LASER-RESEC)MED TUMO $822.23 $822.23 $822.23 52240 CYSTO FULG(INC CRYO-LASER-RESEC)LG TUMOR $822.23 $822.23 $822.23 52250 CYSTOURETHROSCOPY INSERT RADIOACT SUBS $1,339.05 $1,339.05 $1,339.05 52260 CYSTOURETHROSCOPY DILATION BLADDER $1,339.05 $1,339.05 $1,339.05 52265 SEE 55260 LOCAL ANES $822.23 $822.23 $822.23 52270 CYSTOURETHROSCOPY INT URETHROTOMY FEMALE $822.23 $822.23 $822.23 52275 CYSTOURETHROSCOPY INT URETHROTOMY MALE $822.23 $822.23 $822.23 52276 CYSTOURETHROSCOPY W DIRECT VISION INT UR $822.23 $822.23 $822.23 52277 CYSTOURETHROSCOPY RESECT EXT SPHINCTER $1,339.05 $1,339.05 $1,339.05 52281 CYSTOURETHROSCOPY CALIB/DILAT STRICT/STE $822.23 $822.23 $822.23 52282 CYSTOURETHROSCOPY,W/INSERT URETHR STENT $293.65 $293.65 $293.65 52283 CYSTOURETHOSCOPY W/STEROID INJECTION $822.23 $822.23 $822.23 52285 CYSTOURETHROSCOPY FEMALE URETHRALSYNDROM $1,339.05 $1,339.05 $1,339.05 52290 CYSTOURETHROSCOPY URETERAL MEATOTOMY $822.23 $822.23 $822.23 52300 CYSTO;W/RESECT/FULG ORTH URETER,UNIL/BIL $1,339.05 $1,339.05 $1,339.05 52301 CYSTOUR;W/RESCT/FULG ECTOP URETER,UNI/BI $1,339.05 $1,339.05 $1,339.05 52305 CYSTUROSCOPY INCIS/RESEC ORFICE SING-MUL $822.23 $822.23 $822.23

07/27/12 Page 65 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 52310 CYSTOURETHROSCOPY REMOVAL FB, CALCU SIMP $822.23 $822.23 $822.23 52315 CYSTOURETHROSCOPY W REMOV FB,CALCU COMPL $822.23 $822.23 $822.23 52317 LITHOLAPAXY CRUSH/FRAG CALCULUS ANY SMAL $822.23 $822.23 $822.23 52318 LITHOLAPAXY COMPLICATED OR LARGE $822.23 $822.23 $822.23 52320 CYSTURETHROSCOPY INC CATH REMOV URET CAL $1,339.05 $1,339.05 $1,339.05 52325 CYSTOURETHROSCOPY W/FRAG URET CAL ULTRAS $1,585.73 $1,585.73 $1,585.73 52327 CYSTOURETHSCPY TRANSURETH RESECT $1,339.05 $1,339.05 $1,339.05 52330 CYSTOURETHROSCOPY W MANI W/O REM URE CAL $1,339.05 $1,339.05 $1,339.05 52332 CYSTOURETHROSCOPY W/INSERT INDWELL STENT $822.23 $822.23 $822.23 52334 CYSTOURETHROSCOPY INSERT WIRE-KIDNEY PER $1,585.73 $1,585.73 $1,585.73 52341 CYSTOURETHROSCPY,TREATMNT URETHERAL STRI $822.23 $822.23 $822.23 52342 CYSTOURETHROSCOPY;TREAT URETHEROPELVIC J $822.23 $822.23 $822.23 52343 CYSTOURETHROSCOPY;TREAT INTRA-RENAL STRI $1,339.05 $1,339.05 $1,339.05 52344 CYSTOURETHROSCOPY/URETRSCOPY;TX UR STRIC $822.23 $822.23 $822.23 52345 CYSTOURETHROSCOPY W/URET;TREAT URETEROPE $822.23 $822.23 $822.23 52346 CYSTOURETHROSCOPY W/URE;TREAT INTRA-RENA $1,339.05 $1,339.05 $1,339.05 52351 CYSTOURETHROSCPY,URETER/PYELOSCOPY;DIAGN $822.23 $822.23 $822.23 52352 CYSTOURETHROSCOPY,REMOV/MANIPUL CALCULUS $1,339.05 $1,339.05 $1,339.05 52353 CYSTOURETHROSCOPY,URE/PYEL;W/LITHOTRIPSY $1,339.05 $1,339.05 $1,339.05 52354 CYSTOURETHROSCOPY,W/BIOPSY &/OR FULGURAT $822.23 $822.23 $822.23 52355 CYSTOURETHRO,W/RESECT URET-RENL PEL TUMR $1,339.05 $1,339.05 $1,339.05 52400 CYSTOURETHROSCOPY;CONG POST URETHR VALVE $822.23 $822.23 $822.23 52402 CYSTOURETHROSCOP W/TRANSSURETH RESEC/INC $822.23 $822.23 $822.23 52450 TRANSURETHRAL INCISION OF PROSTATE $1,585.73 $1,585.73 $1,585.73 52500 TRANSURETHRAL RESECTION BLADDER NECK $822.23 $822.23 $822.23 52601 TRANSURETHRAL ELECTROSURG RESECT PROSTAT $1,585.73 $1,585.73 $1,585.73 52630 TUR REGROWTH OBSTRUCT TISSUE 1 YR POSTOP $1,339.05 $1,339.05 $1,339.05 52640 TUR POSTOP BLADDER NECK CONTRACTURE $1,339.05 $1,339.05 $1,339.05 52647 LASER COAGULAT OF PROSTATE CONTROL BLEED $1,339.05 $1,339.05 $1,339.05 52648 CONTACT LASER W/WO TRANSURET RESEC PROST $1,585.73 $1,585.73 $1,585.73 52649 PROSTATE LASER ENUCLEATIN W/MORCELLATION $1,585.73 $1,585.73 $1,585.73 52700 TRANSURETHRAL REMOVAL DRG PROSTATIC ABSC $1,339.05 $1,339.05 $1,339.05 53000 URETHROTOMY URETHROSTOMY PENDULOUS $1,339.05 $1,339.05 $1,339.05 53010 URETHROTOMY URETHROSTOMY PERINEAL $1,339.05 $1,339.05 $1,339.05 53020 MEATOTOMY CUTTING OF MEATUS EXCEPT INFAN $822.23 $822.23 $822.23 53025 MEATOTOMY CUTTING MEATUS INFANT $822.23 $822.23 $822.23 53040 DRG DEEP PERIURTHRAL ABSCESS $1,339.05 $1,339.05 $1,339.05 53060 DRG SKENES GLAND ABSCESS OR CYST $822.23 $822.23 $822.23 53080 DRG PERINEAL URINARY EXTRAVASATION $1,339.05 $1,339.05 $1,339.05 53085 DRG PERINEAL URINARY EXTRAVASATION COMPL $1,339.05 $1,339.05 $1,339.05 53200 BIOPSY URETHRA $822.23 $822.23 $822.23 53210 URETHRECTOMY TOTAL FEMALE $822.23 $822.23 $822.23 53215 URETHRECTOMY TOTAL MALE $822.23 $822.23 $822.23 53220 EXCIS FULGURATION CA URETHRA $822.23 $822.23 $822.23 53230 EXCIS URETHRAL DIVERTICULUM FEMALE $822.23 $822.23 $822.23 53235 EXCIS URETHRAL DIVERTICULUM MALE $822.23 $822.23 $822.23 53240 MARSUPIALIZATION URETHRAL DIVERTICULUM $822.23 $822.23 $822.23 53250 EXCIS BULBOURETHRAL GLAND $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 66 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 53260 EXCIS FULGURATION URETHRAL POLYPS $822.23 $822.23 $822.23 53265 EXCIS URETHRA CARUNCLE $822.23 $822.23 $822.23 53270 EXCIS SKENES GLAND $822.23 $822.23 $822.23 53275 EXCIS URETHRAL PROLAPSE $822.23 $822.23 $822.23 53400 URETHROPLASTY 1ST STAGE $1,339.05 $1,339.05 $1,339.05 53405 URETHROPLASTY 2ND STAGE $1,339.05 $1,339.05 $1,339.05 53410 URETHROPLASTY ONE STAGE RECONSTRUCT MALE $1,339.05 $1,339.05 $1,339.05 53415 URETHROPLAS ISTAQE REPAIR-RECON MEMBRANE $1,339.05 $1,339.05 $1,339.05 53420 URETHROPLASTY TWO STAGE RECONSTRUCT 1ST $1,339.05 $1,339.05 $1,339.05 53425 URETHROPLASTY SECOND STAGE MALE $1,339.05 $1,339.05 $1,339.05 53430 URETHROPLASTY FEMALE URETHRA $1,339.05 $1,339.05 $1,339.05 53431 URETHPLSTY,URETHRA/LWR BLADD TUBUL;INCON $1,339.05 $1,339.05 $1,339.05 53440 SLING OPERATION/CX MALE URINARY INCONTIN $1,339.05 $1,339.05 $1,339.05 53442 REMOVE/REVISE MALE SLING,INCONTINENCE $822.23 $822.23 $822.23 53444 INSERTION OF TANDEM CUFF (DUAL CUFF) $1,339.05 $1,339.05 $1,339.05 53445 INSERT INFLAT URETH/BLADDER NECK SPHINCT $822.23 $822.23 $822.23 53446 REMOV INFLATBL URETH/BLADD NECK SPHNCTR $822.23 $822.23 $822.23 53447 REMV/REPL INFLAT URETH/BLAD NECK SPHINCT $822.23 $822.23 $822.23 53448 REMV/RPLAC URETH/BLAD NECK SPHNCTR,INFCT $822.23 $822.23 $822.23 53449 REPAIR INFL URETHRAL/BLAD NECK SPHINCTER $822.23 $822.23 $822.23 53450 URETHRAL MEATOPLASTY $822.23 $822.23 $822.23 53460 URETHRAL MEATOPLASTY PARTIAL EXCIS $1,339.05 $1,339.05 $1,339.05 53500 URETHROLYSIS,TRANSVAG,W/CYSTOURETHROSCOP $822.23 $822.23 $822.23 53502 URETHRORRHAPHY FEMALE $1,339.05 $1,339.05 $1,339.05 53505 URETHRORRHAPHY PENILE $1,339.05 $1,339.05 $1,339.05 53510 URETHRORRHAPHY PERINEAL $1,339.05 $1,339.05 $1,339.05 53515 URETHRORRHAPHY PROSTATOMEMBRANOUS $1,339.05 $1,339.05 $1,339.05 53520 CLOSURE URETHROSTOMY MALE $1,339.05 $1,339.05 $1,339.05 53605 DILATION UREATH STRICT MALE ANESTHESIA $822.23 $822.23 $822.23 53660 DILATION FEMALE URETHRA INITIAL $822.23 $822.23 $822.23 53661 DILATION FEMALE URETHRA SUBSEQ $822.23 $822.23 $822.23 53665 DILATION FEMALE URETHRA ANESTHESIA $822.23 $822.23 $822.23 53850 TRANSURETHRAL DESTR PROSTR TIS;M/W THERM $1,468.26 $1,468.26 $1,468.26 53852 TRANSURETHRAL DESTR PROST TIS;RADIOF THE $1,468.26 $1,468.26 $1,468.26 53855 $293.65 $293.65 $293.65 53860 $822.23 $822.23 $822.23 53899 UNLISTED PROCEDURE URINARY SYSTEM $822.23 $822.23 $822.23 54000 SLITTING PREPUCE DORSAL/LAT(SEP PRO NEWB $822.23 $822.23 $822.23 54001 SLITTING PREPUCE DOR/LAT(SEP PRO) EXNEWB $822.23 $822.23 $822.23 54015 INCISION DRAIN PENIS DEEP $822.23 $822.23 $822.23 54050 DESTRUCT LESION(S)PENIS SIMPLE CHEMICAL $822.23 $822.23 $822.23 54055 DESTRUCT LESION(S)PENIS SIMPLE ELECTRO $822.23 $822.23 $822.23 54056 DESTRUCT LESION(S)PENIS SIMPLE CRYOSURG $822.23 $822.23 $822.23 54057 DESTRUCT LESION(S)PENIS SIMPLE LASER SUR $822.23 $822.23 $822.23 54060 DESTRUCT LESION(S)PENIS SIMPLE SURG EXCI $822.23 $822.23 $822.23 54065 DESTRUCT LESION(S),PENIS,EXTENSIVE $822.23 $822.23 $822.23 54100 BIOPSY OF PENIS; (SEPERATE PROCEDURE) $822.23 $822.23 $822.23 54105 BIOPSY PENIS DEEP STRUCTURES $822.23 $822.23 $822.23

07/27/12 Page 67 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 54110 EXCISION PENILE PLAQUE (PEYRONIE DISEAS) $822.23 $822.23 $822.23 54111 EXCISION PENILE PLAQUE W/GRAFT TO 5CM $822.23 $822.23 $822.23 54112 EXCISION PENILE PLAQUE W/GRAFT OVER 5CM $822.23 $822.23 $822.23 54115 REMOVAL FOREIGN BODY DEEP PEN/TISSU(IMPL $822.23 $822.23 $822.23 54120 AMPUTATIONS PENIS PARTIAL $1,339.05 $1,339.05 $1,339.05 54150 CIRCUMCIS CLAMP/OTHER DEVISE NEWBORN $822.23 $822.23 $822.23 54160 CIRCUMCIS SURG EXCIS NOT DOR SLIT NEWBRN $1,339.05 $1,339.05 $1,339.05 54161 CIRCUMCIS SURGI EXCIS NOT DOR SLIT EXC N $1,339.05 $1,339.05 $1,339.05 54162 LYSIS/EXCIS PENILE POST-CIRC ADHESIONS $1,339.05 $1,339.05 $1,339.05 54163 REPAIR INCOMPLETE CIRCUMCISION $1,339.05 $1,339.05 $1,339.05 54164 FRENULOTOMY OF PENIS $822.23 $822.23 $822.23 54205 INJECT PROCED PEYRONIE W/SURGI EXPOS PLA $822.23 $822.23 $822.23 54220 IRRIGAT CORPORA CAVERNOSA FOR PRIAPISM $822.23 $822.23 $822.23 54300 PLAST OPER PENI STRAIGHTEN CHORDEE W/WO $1,339.05 $1,339.05 $1,339.05 54304 PLASTIC OP PENIS CHORDEE 1 STAGE W/WO TR $1,339.05 $1,339.05 $1,339.05 54308 URETHROPLASTY 2 STAGE HYPOSPA REPAIR 3CM $1,339.05 $1,339.05 $1,339.05 54312 URETHROPLASTY 2 STAGE HYPOSPA MORE 3 CM $1,339.05 $1,339.05 $1,339.05 54316 URETHROPLASTY 2 STAG HYPOSPA SKIN GRAFT $1,339.05 $1,339.05 $1,339.05 54318 URETHROPLASTY 3 STAGE HYPOSPA PENIS/SCRO $1,339.05 $1,339.05 $1,339.05 54322 ONE STAGE HYPOSPAD SIMP MEATAL ADVANCEME $1,339.05 $1,339.05 $1,339.05 54324 ONE STAGE HYPOSPA REPAIR UROPLA LOCAL SK $1,339.05 $1,339.05 $1,339.05 54326 ONE STAGE HYPOSPAD REPAIR URETH MOBILIZA $1,339.05 $1,339.05 $1,339.05 54328 ONE STAGE HYPOSPAD REPAIR ETENSIV FLAPS $1,339.05 $1,339.05 $1,339.05 54332 ONE STAGE PENOSCROTAL HYPOSPA DISS GRAFT $1,339.05 $1,339.05 $1,339.05 54336 ONE STAGE PERINEAL HYPOSPA EXT DISS TUBE $1,339.05 $1,339.05 $1,339.05 54340 REPAIR HYPOSPAD COMPLICATIONS SIMPLE $1,339.05 $1,339.05 $1,339.05 54344 REPAIR HYPOSPAD COMPLI MOBIL FLAPS GRAFT $1,339.05 $1,339.05 $1,339.05 54348 REPAIR HYPOSPAD COMPLI EXTENSIV DISSECTI $1,339.05 $1,339.05 $1,339.05 54352 REPAIR HYPOSPAD CRIPPLE EXTEN DISS/EXCIS $1,339.05 $1,339.05 $1,339.05 54360 PLASTIC OPERAT PENIS TO CORRECT ANGULATI $822.23 $822.23 $822.23 54380 PLASTIC OPER PENIS EPISPAD DIST EXT SPHI $1,339.05 $1,339.05 $1,339.05 54385 PLAS OPER PENIS EPISPAD DIST SPHIN/INCON $1,339.05 $1,339.05 $1,339.05 54390 PLAS OPER PEN EPISPA DIS EXTER SPHI EXST $1,339.05 $1,339.05 $1,339.05 54400 INSERT PENILE PROSTH NON-INFLAT(SEMI-RIG $822.23 $822.23 $822.23 54401 INSERT PENILE PROSTH INFLAT SLF-CONT $822.23 $822.23 $822.23 54405 INSERT MULTI-COMPONEN,INFLAT PENILE PROS $822.23 $822.23 $822.23 54406 REMOV ALL,INFLTBL PENIL PROSTH,NO REPLAC $822.23 $822.23 $822.23 54408 REPAIR ALL COMPONTS,INFLTBL PENIL PROSTH $822.23 $822.23 $822.23 54410 REMOV/RPLAC ALL,INFLTBL PENIL PROSTH $822.23 $822.23 $822.23 54411 REMV/REPL PENIS PROS,IRR&DEBRID INF TISS $822.23 $822.23 $822.23 54415 REMOV NON-/INFLTBL PENIL PROSTH,NO RPLAC $822.23 $822.23 $822.23 54416 RMOV/RPLAC PENIL PROSTH SAME OPER SESS $822.23 $822.23 $822.23 54417 RMOV/RPLAC PENIL PROSTH W/ I&D FOR INFCT $822.23 $822.23 $822.23 54420 CORPORA CAVERNOSA-SAPH VEIN SHUNT UNI/BI $1,339.05 $1,339.05 $1,339.05 54430 CORPORA CAVERNOSA-CORPUSSPONGIOSU SHUNT $1,339.05 $1,339.05 $1,339.05 54435 CORPORA CAVENOSA-PENIS FISTULIZ(PRIAPISM $1,339.05 $1,339.05 $1,339.05 54440 PLASTIC OPER PENIS INJURY $1,339.05 $1,339.05 $1,339.05 54450 FORESKIN MANIP LYSIS PREPUT ADHES/STRETC $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 68 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 54500 BIOPSY NEEDLE(SEPARATE PROCED) $822.23 $822.23 $822.23 54505 BIOPSY TESTIS INCISION (SEPAR PROCED) $822.23 $822.23 $822.23 54512 EXCISION OF EXTRAPARENCHYMAL LESN TESTIS $1,339.05 $1,339.05 $1,339.05 54520 ORCHIECTOMY SIMP W/WO TESTICULAR PROSTHE $1,339.05 $1,339.05 $1,339.05 54522 ORCHIECTOMY, PARTIAL $1,339.05 $1,339.05 $1,339.05 54530 ORCHIECTOMY RADICAL TUMOR INGUI APPROACH $1,339.05 $1,339.05 $1,339.05 54535 ORCHIECTOMY RADICAL FOR TUMOR W/ABDM EXP $1,339.05 $1,339.05 $1,339.05 54550 EXPLOR UNDECEND TESTIS(INGU/SCRO) $822.23 $822.23 $822.23 54560 EXPLORATION UNDESC TESTIS & ABDOM EXPLO $1,585.73 $1,585.73 $1,585.73 54600 REDUCTION TORSION TESTIS SURGI W/WO FLEX $1,585.73 $1,585.73 $1,585.73 54620 FIXATION CONTRALAT TESTIS (SEP PROCEDUR) $1,585.73 $1,585.73 $1,585.73 54640 ORCHIOPEXY, INGUIN APPRCH, W/WO HERNIA $1,585.73 $1,585.73 $1,585.73 54650 ORCHIOPEXY, ABDOMINAL, FOR INTRA TESTIS $1,585.73 $1,585.73 $1,585.73 54670 SUTURE OR REPAIR TESTICULAR INJURY $822.23 $822.23 $822.23 54680 TRANSPLANT TESTIS(ES) TO THIGH(SCRO DEST $1,339.05 $1,339.05 $1,339.05 54690 LAPAROSCOPY SURGICAL ORCHIECTOMY $1,339.05 $1,339.05 $1,339.05 54692 LAP SURG ORCHIOPEXY INTR-ABDOMINL TESTIS $1,585.73 $1,585.73 $1,585.73 54699 UNLISTED LAPAROSCOPY PROCEDURE TESTIS $1,339.05 $1,339.05 $1,339.05 54700 INCIS DRAIN EPIDIDYMIS TESTIS AND/OR SCR $822.23 $822.23 $822.23 54800 BIOPSY EPIDIDYMIS NEEDLE $822.23 $822.23 $822.23 54830 EXCISION LOCAL LESION EPIDIDYMIS $1,339.05 $1,339.05 $1,339.05 54840 EXCISION SPERMATOCELE W/WO EPIDIDYMECTOM $1,585.73 $1,585.73 $1,585.73 54860 EPIDIDYMECTOMY UNILATERAL $1,339.05 $1,339.05 $1,339.05 54861 EPIDIDYMECTOMY BILATERAL $1,339.05 $1,339.05 $1,339.05 55000 PUNCT ASPIR HYDROCELE W/WO INJECT MEDICA $822.23 $822.23 $822.23 55040 EXCISION HYDROCELE UNILAT $1,585.73 $1,585.73 $1,585.73 55041 EXCIS HYDROCELE BILAT $1,585.73 $1,585.73 $1,585.73 55060 REPAIR HYPROCELE(BOTTLE TYPE) $1,585.73 $1,585.73 $1,585.73 55100 DRAINAGE SCROTAL WALL ABCESS $822.23 $822.23 $822.23 55110 SCROTAL EXPLORATION $822.23 $822.23 $822.23 55120 REMOVAL FOREIGN BODY IN SCROTUM $822.23 $822.23 $822.23 55150 RESECTION SCROTUM $822.23 $822.23 $822.23 55175 SCROTOPLASTY SIMPLE $822.23 $822.23 $822.23 55180 SCROTOPLASTY COMPLICATED $822.23 $822.23 $822.23 55200 VASOTOMY CANNULI W/WO INCIS VAS UNI/BILA $822.23 $822.23 $822.23 55250 VASECTOMY UNI/BIL (SEP PRO)INC POSTOP SE $822.23 $822.23 $822.23 55300 VASOTOMY VASOGRAM SEMINAL VESICUL/EP UNI $350.00 $350.00 $350.00 55450 LIGATION(PERCUTAN)VAS DEFERNS UNI/BILAT $822.23 $822.23 $822.23 55500 EXCISION HYDROCELE SPERMA CORD UNILAT(SE $1,585.73 $1,585.73 $1,585.73 55520 EXCISION LESION SPERMA CORD (SEPAR PROC) $1,585.73 $1,585.73 $1,585.73 55530 EXCIS VARICOCELE LIGATION SPERM VEIN VAR $1,585.73 $1,585.73 $1,585.73 55535 EXCISION OF VARICELE OR LIGAT VEINS ABDO $1,585.73 $1,585.73 $1,585.73 55540 EXCIS VARIOCELE LIGATE/VARIOC W/HERNIA R $1,585.73 $1,585.73 $1,585.73 55550 LAP SURG LIGATION SPERM VEINS VARICOCELE $1,585.73 $1,585.73 $1,585.73 55559 UNLISTED LAP PROCEDURE SPERMATIC CORD $822.23 $822.23 $822.23 55700 PROSTATE BIOPSY,SATURATION SAMPLING,IMAG $822.23 $822.23 $822.23 55705 BIOPSY PROSTRATE INCISIONAL ANY APPROACH $822.23 $822.23 $822.23 55706 PROSTATE BIOPSY,SATURATION SAMPLING,IMAG $822.23 $822.23 $822.23

07/27/12 Page 69 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 55720 PROSTATOTOM EXTERNAL DRAIN PROS/ABCESS A $1,585.73 $1,585.73 $1,585.73 55725 PROSTATOTOMY EX/DRAIN ABCESS COMPLICATED $1,585.73 $1,585.73 $1,585.73 55842 PROSTATECTOMY RETROPUB RADI W/BIOPSY(S) $1,339.05 $1,339.05 $1,339.05 55860 EXPOSURE PROSTATE ANY APPROA RADIOACTIVE $1,585.73 $1,585.73 $1,585.73 55862 EXPOSURE PROSTATE ANY APPRO BIOPSY (S) $1,585.73 $1,585.73 $1,585.73 55865 EXPOSURE PROSTATE ANY APPRO BILAT LYMPHA $1,585.73 $1,585.73 $1,585.73 55873 CYROSURGICAL ABLATION OF THE PROSTATE $1,585.73 $1,585.73 $1,585.73 55899 UNLISTED PROCEDURE MALE GENITAL SYSTEM $822.23 $822.23 $822.23 55920 NEEDLE/CATH PLACE/PELVIC RADIOELEMNT APP $822.23 $822.23 $822.23 56405 INCISION/DRAIN OF VULVA OR PERINEAL ABSC $822.23 $822.23 $822.23 56420 I&D BARTHOLIN GLAND ABSCESS $822.23 $822.23 $822.23 56440 MARSUPIALIZATION BARTHOLIN GLAND CYST $822.23 $822.23 $822.23 56441 LYSIS OF LABIAL ADHESIONS $822.23 $822.23 $822.23 56501 DESTROY, VULVA LESIONS, SIMPLE $822.23 $822.23 $822.23 56515 DESTRUCT LESION(S) VULVA+EXTEN ANY METHO $822.23 $822.23 $822.23 56605 BIOP VULVA OR PERINEUM SEP PROC 1 LESION $822.23 $822.23 $822.23 56620 VULVECTOMY SIMPLE; PARTIAL $1,339.05 $1,339.05 $1,339.05 56625 VULVECTOMY; COMPLETE $1,585.73 $1,585.73 $1,585.73 56700 HYMENECTOMY PART OR REPAIR HYMENAL RING $822.23 $822.23 $822.23 56740 EXC BARTHOLIN GLAND OR CYST $822.23 $822.23 $822.23 56800 PLASTIC REPAIR OF INTROITUS $822.23 $822.23 $822.23 56805 CLITOROPLASTY FOR INTERSEX STATE $822.23 $822.23 $822.23 56810 PERINEOPLASTY REP PERINEUM NON-OB SEP PR $822.23 $822.23 $822.23 56820 COLPOSCOPY OF THE VULVA $822.23 $822.23 $822.23 56821 COLPOSCOPY OF THE VULVA W/BIOPSY $822.23 $822.23 $822.23 57000 COLPOTOMY W EXPLORATION $822.23 $822.23 $822.23 57010 COLPOTOMY W DRAIN OF PELVIC ABSCESS $822.23 $822.23 $822.23 57020 COLPOCENTESIS $822.23 $822.23 $822.23 57022 INCIS&DRAIN OF VAG HEMATOMA;OBSTET/POSTP $822.23 $822.23 $822.23 57023 INCISE&DRAIN OF VAG HEMATOM;NON-OBSTETRI $822.23 $822.23 $822.23 57061 DESTRU VAG LES;SIMPL(LASER,ELECTRO,CYR $822.23 $822.23 $822.23 57065 DESTRU VAG LES;EXTEN(LASER,ELECTRO,CYR $822.23 $822.23 $822.23 57100 BIOPSY VAGINAL MUCOSA SIMPLE $822.23 $822.23 $822.23 57105 BIOPSY VAGINAL MUCOSA EXTEN REQ SUTURE $822.23 $822.23 $822.23 57106 VAGINECTOMY PARIAL REM OF VAG WALL $822.23 $822.23 $822.23 57107 VAGINECTOMY PART REM WALL W/REM OF TISSU $822.23 $822.23 $822.23 57109 VAGINECTOMY PART REM LYMPH NODE SAMPLE $822.23 $822.23 $822.23 57110 VAGINECTOMY,COMPLETE REMOVAL VAGINAL WAL $822.23 $822.23 $822.23 57111 VAGINECTOMY COMP REM OF WALL $822.23 $822.23 $822.23 57112 VAGINECTOMY COMP REM OF WALL LYME SAMPLE $822.23 $822.23 $822.23 57120 COLPOCLEISIS $822.23 $822.23 $822.23 57130 EXC OF VAGINAL SEPTUM $1,339.05 $1,339.05 $1,339.05 57135 EXC VAGINAL CYST OR TUMOR $1,339.05 $1,339.05 $1,339.05 57155 INSERT UTER TANDEM/VAG OVOID,BRACHTHRPY 257.15 $257.15 $257.15 57156 INSERT VAG RADIAT'N AFTERLOAD APP/BRACHY Not Valid $257.15 $257.15 57200 COLPORRHAPHY (NONOBSTETRICAL) $822.23 $822.23 $822.23 57210 COLPOPERINEORRHAPHY (NONOBSTETRICAL) $822.23 $822.23 $822.23 57220 PLASTC OPERAT URETHR SPHINCT,VAGIN APPRO $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 70 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 57230 PLASTIC REPAIR OF URETHROCELE $1,339.05 $1,339.05 $1,339.05 57240 ANTER COLPORRH,REPAR RECTOCELE W/WO PERI $1,339.05 $1,339.05 $1,339.05 57250 POST COLPORR REPAIR RECTOCE W PERINEORRH $822.23 $822.23 $822.23 57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY $1,339.05 $1,339.05 $1,339.05 57265 COMBINE A&P COLPORR W ENTEROCELE REPAIR $1,339.05 $1,339.05 $1,339.05 57267 INSRT MESH/OTH PROSTHES/REPAIR PELVIC FL $293.65 $293.65 $293.65 57268 REPAIR ENTEROCELE VAGINAL APPROA(SEP PRO $822.23 $822.23 $822.23 57270 REPAIR OF ENTEROCELE $822.23 $822.23 $822.23 57280 COLPOPEXY $1,339.05 $1,339.05 $1,339.05 57282 SACROSPINO LIGAME FIX PROLAPSE OF VIGINA $1,339.05 $1,339.05 $1,339.05 57283 COCLPOPEXY,VAG;INTRA-PERITONEAL APPROACH $822.23 $822.23 $822.23 57284 PARAVAGINAL DEFECT REPAIR (INC CYSTOCELE $1,339.05 $1,339.05 $1,339.05 57285 PARAVAGINAL DEFECT REPAIR,VAG APPROACH $1,339.05 $1,339.05 $1,339.05 57287 REMOV-REVIS OF SLING FOR STRESS INCONTIN $1,339.05 $1,339.05 $1,339.05 57288 SGLE OPERATION FOR STRESS INCONTINENCE $1,339.05 $1,339.05 $1,339.05 57289 PEREYRA PROC INCLU ANT COLPORRHAPHY $1,339.05 $1,339.05 $1,339.05 57291 CONSTRUCTION ARTIFICIAL VAGINA WITH GRAF $1,468.26 $1,468.26 $1,468.26 57295 REV OF PROSTH VAG GRAFT,VAGINAL APPROACH $822.23 $822.23 $822.23 57300 CLOS RECTOVAG FISTULA VAG-TRANSANAL APPR $822.23 $822.23 $822.23 57305 CLOSU RECTOVAG FISTULA ABD APPROACH $822.23 $822.23 $822.23 57308 CLOS RECTOVAG FISTULA;TRANSPER/PERI RECO $822.23 $822.23 $822.23 57310 CLOSU URETHROVAGINAL FISTULA $1,339.05 $1,339.05 $1,339.05 57320 CLOSU OF VESICOVAGINAL FISTULA VAG APP $822.23 $822.23 $822.23 57330 CLOSU VESICOVAGIAL FISTULA TRANSVESC APP $822.23 $822.23 $822.23 57400 DILATION OF VAGINA UNDER ANESTH $822.23 $822.23 $822.23 57410 PELVIC EXAM UNDER ANESTH $822.23 $822.23 $822.23 57415 REMOV IMP VAG FOREIGN BODY SEP PROC ANES $822.23 $822.23 $822.23 57420 COLPOSCOPY OF VAGINA,W/CERVIX IF PRESENT $822.23 $822.23 $822.23 57421 COLPOSCOPY OF VAGINA, W/CERVIX, W/BIOPSY $822.23 $822.23 $822.23 57423 PARAVAGINAL DEFECT REPAIR,LAPAROSCOPIC $1,339.05 $1,339.05 $1,339.05 57425 LAPAROSCOPY, SURGICAL, COLPOPEXY $822.23 $822.23 $822.23 57426 $822.23 $822.23 $822.23 57452 COLOPOSCOPY CERVIX INCL UPER/ADJ VAGINA $822.23 $822.23 $822.23 57454 COLPOSCOPY CERVIX; W/BIOPSY $822.23 $822.23 $822.23 57455 COLPOSCPY CERVIX & UP/ADJ VAGINA, W/BIOP $822.23 $822.23 $822.23 57456 SCPY CERVIX & VAGINA,ENDOCERV CURETTAGE $822.23 $822.23 $822.23 57460 COLPOSCOPY CERVIX;W/ENDOCERVIC CURETTAGE $822.23 $822.23 $822.23 57461 SCPY CERVIX&VAGINA,W/LOOP ELECTRO BIOPSY $822.23 $822.23 $822.23 57500 BIOPSY SGLE MTPLE W WO FULGURATION $822.23 $822.23 $822.23 57505 ENDOCERVICAL CURETTAGE (NOT PART OF D&C) $822.23 $822.23 $822.23 57510 CAUTERY OF CERVIS;ELECTRO OR THERMAL $822.23 $822.23 $822.23 57511 CAUTERIZ CERVIX CRYOCAUT INITIAL REPEAT $822.23 $822.23 $822.23 57513 CAUTERIZATION OF CERVIX,LASER ABLATION $822.23 $822.23 $822.23 57520 CERVIX CONIZAT,W/WO FULGUR/D&C/REPAIR $822.23 $822.23 $822.23 57522 CONIZAT CERVIX, LOOP ELECTRODE EXCISION $350.00 $350.00 $350.00 57530 TRACHELECTOMY $1,585.73 $1,585.73 $1,585.73 57531 RAD TRAC,W/BILA PELV LY&PA AORT LY/BIOPO $1,585.73 $1,585.73 $1,585.73 57540 EXC CX STUMP ABD APP $1,585.73 $1,585.73 $1,585.73

07/27/12 Page 71 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 57545 EXC CX STUMP W PELVIC FLOOR REPAIR $1,585.73 $1,585.73 $1,585.73 57550 EXC CX STUMP VAG APP $1,585.73 $1,585.73 $1,585.73 57555 EXC CX STUMP VAG APP W A&P REPAIR $1,585.73 $1,585.73 $1,585.73 57556 EXC CX STUMP VAG APP W REPAIR ENTEROCELE $1,585.73 $1,585.73 $1,585.73 57700 CERCLAGE UTERINE CERVIX,NON OBSTETRIC $822.23 $822.23 $822.23 57720 TRACHELORRHAPHY VAG APP $822.23 $822.23 $822.23 57800 DILATION OF CX CANAL INSTRUMENTAL $822.23 $822.23 $822.23 58100 ENDOMETRIAL W/WO ENDOCERV SMPL W/O CER $822.23 $822.23 $822.23 58120 D&C DX OR THERAPUETIC (NONOBSTETRICAL) $822.23 $822.23 $822.23 58140 MYOMECTOMY;EXC FIBROID TUMOR;ABDOM APRO $1,339.05 $1,339.05 $1,339.05 58145 MYOMECTOMY;EXC FIBR TUMOR;VAGNL APPROACH $1,339.05 $1,339.05 $1,339.05 58146 MYOMECTOMY, ABDOMINAL APPROACH, COMPLEX $1,339.05 $1,339.05 $1,339.05 58260 VAGINAL HYSTERECTOMY; UTERUS <=250 GRAMS $1,585.73 $1,585.73 $1,585.73 58262 VAGINAL HYSTER,REMOVE TUBES &/OR OVARYS $1,585.73 $1,585.73 $1,585.73 58263 VAG HYST,REMV TUB/OVAR&ENTEROCELE REPAIR $1,585.73 $1,585.73 $1,585.73 58270 VAG HYST W/ENTEROCELE REPAIR $675.00 $675.00 $675.00 58300 INSERTION OF INTRAUTERINE DEVICE $293.65 $293.65 $283.35 58301 REMOVAL OF INTRAUTERINE DEVICE $293.65 $293.65 $293.65 58340 CATH&INTRO SALINE OR CONTR MAT FOR HYSTE $350.00 $350.00 $350.00 58346 INSERT HEYMAN CAPSULES,BRACHYTHERAPY $644.09 $644.09 $644.09 58353 ENDOMETRIAL ABLAT,THERM W/OHYSTEROSC GUI $1,339.05 $1,339.05 $1,339.05 58356 ENDOMETRIAL CRYOABLATION W/U-SONIC GUIDA $822.23 $822.23 $822.23 58400 UTERINE SUSPENSION $1,389.05 $1,389.05 $1,389.05 58520 HYSTERORRHAPHY (NONOBSTETRICAL $822.23 $822.23 $822.23 58540 HYSTEROPLASTY $293.65 $293.65 $293.65 58541 LAPAROSCOPY,SUPRACERV HYSTERECTOMY,250G< $1,339.05 $1,339.05 $1,339.05 58542 LAP,SUPRACERV HYSTER,250G<,REMO TUBE/OVA $1,585.73 $1,585.73 $1,585.73 58543 LAPAROSCOPY,SUPRACERV HYSTERECTOMY,>250G $1,339.05 $1,339.05 $1,339.05 58544 LAP,SUPRACERV HYSTER,>250G,REMO TUBE/OVA $1,339.05 $1,339.05 $1,339.05 58545 LAPAROSCOPIC MYOMECTOMY $1,339.05 $1,339.05 $1,339.05 58546 LAPAROSCOPIC MYOMECTOMY, COMPLEX $1,339.05 $1,339.05 $1,339.05 58550 LAPROSCOPY SURGICAL,W/VAGINAL HYSTERECTM $1,585.73 $1,585.73 $1,585.73 58552 LAPAROSCOPY VAG HYSTERECTOMY/TUBES&OVARI $1,585.73 $1,585.73 $1,585.73 58553 LAPAROSCOPY VAG HYSTERECTOMY, COMPLEX $1,585.73 $1,585.73 $1,585.73 58554 LAP VAG HYSTERECTOMY,REMV TUB&OVA COMPLX $1,585.73 $1,585.73 $1,585.73 58555 HYSTEROSCOPY, DIAGNOSTIC $822.23 $822.23 $822.23 58558 HYSTEROSCOPY SURG SPL ENDOM POLYP,OP D&C $822.23 $822.23 $822.23 58559 HYSTEROSCOPY SURG LYSIS INTRAUT ADHESION $1,339.05 $1,339.05 $1,339.05 58560 HYSTEROSCOPY SURG DIV RES INTRAUTRIN MTH $1,339.05 $1,339.05 $1,339.05 58561 HYSTEROSCOPY SURGICAL REMOVE LEIOMYOMATA $1,339.05 $1,339.05 $1,339.05 58562 HYSTEROSCOPY SURG REMOVE IMP FOREIGN BDY $822.23 $822.23 $822.23 58563 HYSTEROSCOPY SURG ENDOMETRIAL ABLATION $1,339.05 $1,339.05 $1,339.05 58565 HYSTEROSCOP,SURG;W/BILAT FALLOP TUBE CAN $822.23 $822.23 $822.23 58570 LAP,SURG,W/TOTAL TLH,UTER<=250G HYSTEREC $1,339.05 $1,339.05 $1,339.05 58571 LAP,W/TOTAL HYST,UT=<250G HYST,TUBE REMV $1,585.73 $1,585.73 $1,585.73 58572 LAP,W/TOTAL HYSTERECTOMY, UTERUS > 250G $1,339.05 $1,339.05 $1,339.05 58573 LAP,W/TOT HYSTERECY,UT>250G;REM TUBE/OVA $1,585.73 $1,585.73 $1,585.73 58578 UNLISTED LAPAROSCOPY PROCEDURE UTERUS $1,585.73 $1,585.73 $1,585.73

07/27/12 Page 72 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 58579 UNLISTED HYSTEROSCOPY PROCEDURE UTERUS $822.23 $822.23 $822.23 58600 TRANSECT FALLOPIAN TUBE UNIL & BILAT $1,585.73 $1,585.73 $1,585.73 58605 TRANSECT FALLOPIAN TUBE POSTPART $1,585.73 $1,585.73 $1,585.73 58615 OCCLUSION FALLOP TUBE(S)BY DEVICE VAG/SU $1,585.73 $1,585.73 $1,585.73 58660 LAP SURG LYSIS ADHESIONS SALPING OVARIO $1,585.73 $1,585.73 $1,585.73 58661 LAP SURG REMV AXL STR P/T OOPHOR SALPING $1,339.05 $1,339.05 $1,339.05 58662 LAP SURG FULG EXCIS LES OVRY PV OR PERIT $1,585.73 $1,585.73 $1,585.73 58670 LAP SURG FULGURATION OVIDCT W/WOUT TRANS $1,585.73 $1,585.73 $1,585.73 58671 LAP SURG OCCL OVIDUCTS DEV EG BND CP FR $1,585.73 $1,585.73 $332.00 58673 LAP SURG SALPINGOSTOMY (SALPINGONEOSTOMY $822.23 $822.23 $822.23 58679 UNLISTED LAPAROSCOPY PROC OVIDUCT OVARY $1,585.73 $1,585.73 $1,585.73 58700 SALPINGECTOMY CPLTE PART UNIL BILAT $1,585.73 $1,585.73 $1,585.73 58720 SALPINGO-OOPHORECTOMY CPLTE PART UNIL BI $1,585.73 $1,585.73 $1,585.73 58740 LYSIS ADHESIONS(SALPINGOLYSIS,OVARIOLYSI $1,585.73 $1,585.73 $1,585.73 58800 DRAINAGE OF OVARIAN CYST(S) UNIL BILAT V $1,585.73 $1,585.73 $1,585.73 58805 DRAINAGE OVARIAN CYST(S) UNIL BILAT ABD $1,585.73 $1,585.73 $1,585.73 58820 DRAIN OVARIAN ABSCESS;VAGINAL APPRO;OPEN $1,339.05 $1,339.05 $1,339.05 58822 DRAINAGE OVARIAN ABSCESS ABD APP $1,585.73 $1,585.73 $1,585.73 58823 DRG PELVIC ABCES,TRANSVAG/TRANSREC,PERCU $822.23 $822.23 $822.23 58900 BIOPSY OVARY UNIL BILAT $1,339.05 $1,339.05 $1,339.05 58920 WEDGE RESECTION UNIL BILAT $1,339.05 $1,339.05 $1,339.05 58925 OVARIAN CYSTECTOMY UNIL BILAT $1,339.05 $1,339.05 $1,339.05 58940 OOPHORECTOMY PART TOTAL UNIL BILAT $1,339.05 $1,339.05 $1,339.05 58956 BIL SAL-OOPH W OMENT., ABD HYST F MALIGN $1,585.73 $1,585.73 $1,585.73 58999 UL PROC FEMALE GENITAL SYST NONOBSTET $822.23 $822.23 $822.23 59000 AMNIOCENTESIS;DIAGNOSTIC $125.00 $125.00 $125.00 59001 AMNIOCENT;THERAP AMNIO FLUID REDUCT $113.15 $113.15 $113.15 59012 CORDOCENTESIS(INTRAUTERINE)ANY METHOD $293.65 $293.65 $293.65 59015 CHORIONIC VILLUS SAMPLING-ANY METHOD $293.65 $293.65 $293.65 59020 FETAL CONTRATION STRESS TEST $125.00 $125.00 $125.00 59025 FETAL NON-STRESS TEST (OLD CODE M0070) $125.00 $125.00 $125.00 59030 FETAL SCALP BLOOD SAMPLING $822.23 $822.23 $822.23 59050 FETAL MONITOR LABOR CONSULT PHY REPT S&I $125.00 $125.00 $125.00 59051 FETAL MONITOR LABOR, CONSULT, INT ONLY $293.65 $293.65 $293.65 59070 TRANSABDOMINL AMNIOINFUSION,W/U-SND GUID $256.62 $256.62 $256.62 59072 FETAL UMBILICAL CORD OCCLUS,W/U-SND GUID $125.00 $125.00 $125.00 59074 FETAL FLU DRAIN(VESICOCENTHESIS..)U-SND $244.16 $244.16 $244.16 59076 FETAL SHUNT PLACEMENT,W/ULTRASOUND GUIDA $307.00 $307.00 $307.00 59100 HYSTEROTOMY, ABDOMINAL $1,339.05 $1,339.05 $1,339.05 59120 SURGI ECTOPIC TUBAL SALPING/OOPHOR ABD/V $1,585.73 $1,585.73 $1,585.73 59121 TUBAL/OVARIAN ECTOPIC SURG W/WO SALPING/ $822.23 $822.23 $822.23 59130 SURGI ECTOPIC ABDOMINAL $1,585.73 $1,585.73 $1,585.73 59136 EXCIS ECTOPIC,INTERS UTERINE W UTER RESC $1,585.73 $1,585.73 $1,585.73 59140 SURGI ECTOPIC CERVICAL W EVACUATION $1,585.73 $1,585.73 $1,585.73 59150 LAPAROSCOPIC TX ECTOPIC PREG;WO SALPINEC $822.23 $822.23 $822.23 59151 LAPARSCOP TX ETOPIC PG W SALPING&/O OOPH $1,585.73 $1,585.73 $1,585.73 59160 CURRETTAGE, POSTPARTUM $822.23 $822.23 $822.23 59200 INSERT CERVICAL DILATOR(EG.LAMINAR,PROST $822.23 $822.23 $822.23

07/27/12 Page 73 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 59300 EPISIOTOMY OR VAGI REP ONLY OTHER THN AT $293.65 $293.65 $293.65 59320 CERVIX CERCLAGE,DURING PREG, VAGINAL $822.23 $822.23 $822.23 59325 VERVIX CERCLAGE,DURING PREG,ABDOMINAL $1,339.05 $1,339.05 $1,339.05 59409 VAG DEL (W OR WO EPISIOTOMY &/OR FORCEPS $1,585.73 $1,585.73 $1,585.73 59412 EXTERNAL CEPHALIC VERSION W\WO TOCOLYSIS $293.65 $293.65 $293.65 59414 DELIVERY OF PLACENTA ONLY $293.65 $293.65 $293.65 59612 VAG DEL ONLY AFTER PREV CESAREAL DEL $1,585.73 $1,585.73 $1,585.73 59812 TX INCOMPLETE ABORT,ANY TRIMES,COMP SURG $822.23 $822.23 $822.23 59820 TREAT MISS ABORT,COMPLETE SURG 1ST TRIME $822.23 $822.23 $822.23 59821 TX MISSED ABORT, COMPLT SURG,2ND TRIMEST $822.23 $822.23 $822.23 59830 TREATMENT SEPTIC ABORTION COMPLETED SURG $822.23 $822.23 $822.23 59840 INDUCED ABORTION PER D&C $822.23 $822.23 $822.23 59841 INDUCE ABORT, DILATION & EVAC $1,585.73 $1,585.73 $1,585.73 59850 INDUCE ABORT,BY INJECT INCLD HOSP ADM,DV $822.23 $822.23 $822.23 59856 INDUCE ABORT VAG SUPPOS HOSP ADM W/D&C $822.23 $822.23 $822.23 59870 UTERINE EVAC&CURETTAGE FOR HYDATIDIFORM $822.23 $822.23 $822.23 59871 REMOV CERCLAGE SUTURE UND ANESTH(NOT LOC $1,339.05 $1,339.05 $1,339.05 59897 UNLISTED FETAL INVASIVE PROC,W/ULTRASOUN $350.00 $350.00 $350.00 59898 UNLISTED LAP PROC MATERNITY CARE DELIVRY $293.65 $293.65 $293.65 59899 UNLISTED PROCED MATERNITY CARE DELIVERY $293.65 $293.65 $293.65 60000 INCIS&DRAIN THYROGLOSSAL DUCT CYST,INFE $822.23 $822.23 $822.23 60100 BIOPSY THYROID PERCUTANEOUS CORE NEEDLE $293.65 $293.65 $293.65 60200 EXCIS CYST ADENOMA THYROID TRANSE ISTHMU $1,339.05 $1,339.05 $1,339.05 60210 PARTIAL THYROID LOB UNI W/WO ISTHMUSECT $1,339.05 $1,339.05 $1,339.05 60212 PARTIAL THRYOID LOBEC,INCL ISTHMUSETOMY $1,339.05 $1,339.05 $1,339.05 60220 TOTAL THYROID LOBECTOMY UNILAT W/WO ISTH $1,339.05 $1,339.05 $1,339.05 60225 TOTAL THYROID LOB UNI W/CONTRA SUB ISTHM $1,339.05 $1,339.05 $1,339.05 60240 THYROIDECT TOTAL OR COMPLETE $1,339.05 $1,339.05 $1,339.05 60252 THYROIDECT TOT/SUBTOTAL MALIG W/RADICAL $1,339.05 $1,339.05 $1,339.05 60254 THYROIDECTOMY TOT/SUB MALIG RAD NK DISSE $1,339.05 $1,339.05 $1,339.05 60260 THYROIDECTOMY REMOV ALL REMAIN THY TISSU $1,339.05 $1,339.05 $1,339.05 60270 THYROIDECT,SUBSTER THYR;STERN/SPLI THRAN $1,339.05 $1,339.05 $1,339.05 60271 THYROIDECT SUBSTERN THYR GLAND CERV APPR $1,339.05 $1,339.05 $1,339.05 60280 EXCISION THYROGLOSS DUCT CYST SINUS $1,339.05 $1,339.05 $1,339.05 60281 EXCIS THYROGLOS DUCT CYST/SINUS RECURREN $1,339.05 $1,339.05 $1,339.05 60300 ASPIRATION AND/OR INJECTION,THYROID CYST $293.65 $293.65 $293.65 60500 PARATHYROIDECT OR EXPLOR PARATHYROID (S) $1,585.73 $1,585.73 $1,585.73 60505 PARATHYROIDECT EXPLOR OF MEDIASTIN STERN $1,585.73 $1,585.73 $1,585.73 60520 THYMECTOMY PART/TOT TRANSCERV APP SEP PR $822.23 $822.23 $822.23 60540 ADRENALECTOMY PART/COMP EXPLOR W/WO BIO $1,339.05 $1,339.05 $1,339.05 60545 ADRENAL PART/COMP EXPLOR UNI W/EXCIS ADJ $1,339.05 $1,339.05 $1,339.05 60600 EXCIS CAROTID TUMOR W/O EXCIS CAROT ARTE $822.23 $822.23 $822.23 60605 EXCIS CAROTID TUMOR W/EXCIS CAROT ARTERY $822.23 $822.23 $822.23 60650 LAP SURG ADRENL P/C/EXP AD GLO BIO T/L/D $350.00 $350.00 $350.00 60659 UNLISTED LAPAROSCOPY PROC ENDOCRINE SYST $822.23 $822.23 $822.23 60699 UNLISTED PROCEDURE ENDOCRINE SYSTEM $822.23 $822.23 $822.23 61000 SUBDURAL TAP INFANT UNIL BILAT INITIAL $822.23 $822.23 $822.23 61001 SUBDURAL TAP INFANT UNIL BILAT SUBSQ TAP $822.23 $822.23 $822.23

07/27/12 Page 74 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 61020 VENTRIC PUNCT THRU PREV BURR HOLES ETC $822.23 $822.23 $822.23 61026 VENTRICULAR PUNCT BUR HOLE,CATH W INJECT $822.23 $822.23 $822.23 61050 CISTER-LAT CERV PUNC S INJ SEP PRO $822.23 $822.23 $822.23 61105 TWIST DRILL HOLE SUBDURAL/VENTRIC PUNCTU $822.23 $822.23 $822.23 61107 TWIST DRILL HOLE SUBDUR/VENT PUNCT IMPLA $822.23 $822.23 $822.23 61108 TWIST DRILL HOLE EVAC AN/OR DRAIN HEMATO $822.23 $822.23 $822.23 61120 BURR HOLE(S) VENTRICULAR,PUNCTURE $822.23 $822.23 $822.23 61140 BURR HOLE TREPH W/BIOP BRAIN-INTERCRA LE $1,339.05 $1,339.05 $1,339.05 61151 BURR HOLE TREPH W/ASPIR INTERCR ABCESS/C $1,339.05 $1,339.05 $1,339.05 61154 BURR HOLE EVAC-DRAIN HEMATOM EX-SUBDURAL $822.23 $822.23 $822.23 61210 BURR HOLE IMP VENTCATH-RES-ELEC SEP PRO $822.23 $822.23 $822.23 61215 INSERT SUBQ RESERVOIR/PUMP CONTINO INFUS $822.23 $822.23 $822.23 61250 BURR HOLE(S) EXPLOR NOT FOLLOW BY SURG $822.23 $822.23 $822.23 61253 BURR HOLE(S) INFRAENTORIAL UNIL BILAT $822.23 $822.23 $822.23 61304 CANI-ECTOMY-OTOMY SUPRATENTORIAL $822.23 $822.23 $822.23 61305 CRANI-ECTOMY-OTOMY INFRATENTORIAL $822.23 $822.23 $822.23 61312 CRANIECTOMY-OTOMY HEMATOMA EXTRA-SUBDURA $822.23 $822.23 $822.23 61314 CRANIECTOMY-OTOMY HEMATO INFRAN EXT-SUBD $822.23 $822.23 $822.23 61320 CRANI-ECTOMY-OTOMY DRAIN ABSCESS SUPRAT $1,339.05 $1,339.05 $1,339.05 61321 EXPLOR/DECOMPR ORBIT TRANS APP UNILATER $1,339.05 $1,339.05 $1,339.05 61330 DECOMPRESSION ORBIT ONLY TRANSCRANIAL AP $1,585.73 $1,585.73 $1,585.73 61332 EXPLOR ORBIT W BIOPSY $822.23 $822.23 $822.23 61333 EXPLOR ORBIT W REMOVAL OF LESION $1,339.05 $1,339.05 $1,339.05 61334 EXPLOR ORBIT W REMOVAL OF FOREIGN BODY $1,339.05 $1,339.05 $1,339.05 61340 SUBTEMPORAL CRANIAL DECOMPRESSION $822.23 $822.23 $822.23 61343 CRANIECTOMY SUBOCCIP W DECOMPRESS W/WO $1,585.73 $1,585.73 $1,585.73 61345 OTH CRANIAL DECOMPRESSION POST FOSSA $822.23 $822.23 $822.23 61440 CRANIOTOMY SECT OF TENTORIUM CEREBELLI $1,339.05 $1,339.05 $1,339.05 61450 CRANIECTOMY SUBTEMPPORAL SECTION COMPRES $1,339.05 $1,339.05 $1,339.05 61458 CRAINIECTOMY SUBOCCIPITAL EXPLOR/DECOMPR $1,339.05 $1,339.05 $1,339.05 61460 CRANIECTOMY FOR SECT ONE OR MORE CRAN NV $1,339.05 $1,339.05 $1,339.05 61500 CRAINIECTOMY EXCIS TUMOR OTH BONE LES SK $1,585.73 $1,585.73 $1,585.73 61501 CRAINIECTOMY FOR OSTEOMYLITIS $1,585.73 $1,585.73 $1,585.73 61510 CRANIECTOMY TREPH FLAP CRANI BRAIN TUMOR $1,339.05 $1,339.05 $1,339.05 61512 CRANIECTOMY FOR EXC MENINGLOMA SUPRAT $1,339.05 $1,339.05 $1,339.05 61514 CRANIECTOMY EXC BRAIN ABSCESS SUPRAT $1,339.05 $1,339.05 $1,339.05 61516 CRANIECTOMY EXC FENESTRATION CYST SUPRAT $1,339.05 $1,339.05 $1,339.05 61518 CRANIECTOMY EXCIS TUMOR INFRAT POSTFOSSA $1,339.05 $1,339.05 $1,339.05 61519 CRANIOECTOMY EXC BRAIN TUMOR MENINGLOMA $1,339.05 $1,339.05 $1,339.05 61520 CRANIECTOMY EXC BRAIN CEREBEL AGLE TUMOR $1,339.05 $1,339.05 $1,339.05 61521 CRANIECTOMY EXCIS TUMOR MIDLINE BASE-SKU $1,339.05 $1,339.05 $1,339.05 61522 CRANIECTOM INFRAT POST EXC BRAIN TUMOR $1,339.05 $1,339.05 $1,339.05 61524 CRANIECTOM INFRAT POST EXC FENEST CYST $1,339.05 $1,339.05 $1,339.05 61526 CRANIECTOMY TRANSTEMPORAL EXC CAT $1,339.05 $1,339.05 $1,339.05 61530 CRANIECTOMY BONE FLAP TRANSTEM W FOSSA $1,339.05 $1,339.05 $1,339.05 61531 SUBDURAL IMPLANT STRIP ELECTRODES $1,585.73 $1,585.73 $1,585.73 61533 CRANIOT W/BN FL ELEV/SUBDRL IMP/ELEC ARA $1,585.73 $1,585.73 $1,585.73 62284 INJECTION FOR MYELOGRAM AND/OR CT,SPINAL $822.23 $822.23 $822.23

07/27/12 Page 75 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 61534 CRANIECTOMY TREP EXCIS EPILEPTGEN FOCUS. $1,339.05 $1,339.05 $1,339.05 61535 CRANIEC-TREPH REM ELE ARRAY SEP PRO $822.23 $822.23 $822.23 61536 CRANIECTOMY TREPH EXCIS EPLLEP FOCUS REM $1,339.05 $1,339.05 $1,339.05 61550 CRANIECTOMY FOR CYSTENOSIS SGLE SUTURE $1,339.05 $1,339.05 $1,339.05 61552 CRANIOSTENOSIS MTPLE SUTURES ONE STAGE $1,339.05 $1,339.05 $1,339.05 61556 CRANIOTOMY CRANIOSYNOSTOSIS;FRONTAL/PARI $822.23 $822.23 $822.23 61557 CRANIOTOMY CRANIOSYNOS,BIFRONTAL BONE FL $822.23 $822.23 $822.23 61558 EXTNSIVE CRANIECTOMY MULTI CRANIA SUTURE $1,339.05 $1,339.05 $1,339.05 61559 RECONTOUR CRANIECTOMY MULT OSTEOTOMIES $1,339.05 $1,339.05 $1,339.05 61563 EXCISE, INTRA EXTRANCRANIAL BENIGH BONE $1,585.73 $1,585.73 $1,585.73 61564 EXCISE,INTRA&EXTRACRAN,BENIGN,OPTIC NERV $1,585.73 $1,585.73 $1,585.73 61571 CRAINIECTOMY/OTOMY FOR PENETRATING WOUND $822.23 $822.23 $822.23 61586 BICORONAL,TRANSZ/I OSTEO/ANTE CRAN FOSSA $822.23 $822.23 $822.23 61600 RESECT OR EXC NEOP, VASC OR INF, EXTRADU $1,339.05 $1,339.05 $1,339.05 61601 RESECT OR EXC NEOP, VASC OR INF, INTRADU $1,339.05 $1,339.05 $1,339.05 61605 RESECT OR EXC NEOP, INFRAT FOSSA, EXTRAD $1,339.05 $1,339.05 $1,339.05 61606 RESECT OR EXC NEOP, INFRAT FOSSA, INTRAD $1,339.05 $1,339.05 $1,339.05 61607 RESECT OR EXC NEOP, PARASELLAR, EXTRADUR $1,339.05 $1,339.05 $1,339.05 61608 RESECT OR EXC NEOP, PARASELLAR, INTRADUR $1,339.05 $1,339.05 $1,339.05 61615 RESECT OR EXC OF NEOP, VASC OR INFEC EXT $1,339.05 $1,339.05 $1,339.05 61616 RESECT OR EXC OF NEOP, VASC OR INFEC INT $1,339.05 $1,339.05 $1,339.05 61623 ENDOVASCULAR TEMP BALLOON ARTERIAL OCCLU $349.72 $349.72 $349.72 61690 SURG INTRACRAN ARTERIO MALFORM DURA SIMP $1,339.05 $1,339.05 $1,339.05 61692 SURG INTRACRAN ARTERI MALFORM DURA COMPL $1,339.05 $1,339.05 $1,339.05 63020 LAMINOT W DECOMPRES NERVE ROOT 1 CERVICA $1,585.73 $1,585.73 $1,585.73 61697 SURG.COMPLEX INTRACRAN ANEURY;CAROTID CI $1,339.05 $1,339.05 $1,339.05 61700 SURG SIMPL INTRACRAN ANEURY CAROTID CIRC $1,339.05 $1,339.05 $1,339.05 61702 SURG INTRACRANIAL ANEURYSM VETE-BASI CIR $1,339.05 $1,339.05 $1,339.05 61703 SURG INTRACRANIAL ANEURYSM CX APP $1,339.05 $1,339.05 $1,339.05 61705 SURG ANEURYSM $822.23 $822.23 $822.23 61708 SURG ANEURYSM BY INTRACRANIAL ELECTROTHR $822.23 $822.23 $822.23 61710 SURG ANEURYSM MALFORM/CAROTID FISTU OCCU $822.23 $822.23 $822.23 61781 $822.23 $822.23 $822.23 61782 $822.23 $822.23 $822.23 61783 $822.23 $822.00 $822.23 61790 STEREOTACTIC, COMP ASSIST,INTRACRAN PROC $1,339.05 $1,339.05 $1,339.05 61791 CREATE LESION STERO INC BUR PERCUT $1,339.05 $1,339.05 $1,339.05 61880 REVISION INTRACRANIAL NEUROSTIM ELECTROD $822.23 $822.23 $822.23 61885 INCIS&SUBCUT PLACEM CRANIAL NEUROSTIMULA $1,339.05 $1,339.05 $1,339.05 61886 CRANIAL NEUROSTM PUL GEN REC INCIS SUBCT $1,585.73 $1,585.73 $1,585.73 61888 REVISION INTRACRAN NEUROSTIM RECEIVER $1,339.05 $1,339.05 $1,339.05 62000 ELEV DEP SKULL FX SMPLE EXTRADURAL $1,339.05 $1,339.05 $1,339.05 62005 ELEV DEP SKULL FX CPD OR COMMINUTED $1,339.05 $1,339.05 $1,339.05 62010 ELEV DEP SKULL FX W REPAIR DURA-DEBRIDE $1,339.05 $1,339.05 $1,339.05 62100 CRANIOTMY REPAIR DURAL/CSF LEAK,INC SUR $1,339.05 $1,339.05 $1,339.05 62115 REDUCE CRANIOMEGLIC SKULL NO GRAFT O PLA $1,339.05 $1,339.05 $1,339.05 62116 REDUCE CRANIOMEGLIC SKUL W C-PLASTY $1,339.05 $1,339.05 $1,339.05 62117 REDUCE CRANIOMEGALY;CRANIOTOMY&RECONSTRU $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 76 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 62120 REPAIR ENCEPHALOC,SKULL VAULT,CRANIOPLAS $1,339.05 $1,339.05 $1,339.05 62121 CRANIOTOMY REPAIR ENCEPHALOCELE,BASE SKU $1,339.05 $1,339.05 $1,339.05 62140 CRANIOPLASTY SKULL DEFECT UP TO SCM $1,339.05 $1,339.05 $1,339.05 62141 CRANIOPLASTY SKULL DEFECT LARGER THN SCM $1,339.05 $1,339.05 $1,339.05 62142 REMOV BONE FLAP OR SKULL PLATE $1,339.05 $1,339.05 $1,339.05 62143 REPLACE BONE FLAP OR SKULL PLATE $1,339.05 $1,339.05 $1,339.05 62146 CRANIOPLASTY W AUTOGRAFT TO 5CM $1,339.05 $1,339.05 $1,339.05 62147 CRANIOPLASTY F DEFECT W AUTOGRAFT +5CM $1,339.05 $1,339.05 $1,339.05 62161 NEUROENDOSCOPY, DISSECT ADHESIONS $1,339.05 $1,339.05 $1,339.05 62162 NEUROENDOSCOPY, REMOVE COLLOID CYST $822.23 $822.23 $822.23 62165 NEUROENDOSC,INTRACRAN,REMV PITUITARY TUM $822.23 $822.23 $822.23 62180 VENTRICULOCISTERNOSTOMY $822.23 $822.23 $822.23 62192 CREATION SHUNT SUBARACH-SUBDUR-PERITONEA $1,339.05 $1,339.05 $1,339.05 62194 REPLACE-IRRIGATE SUBARACH-SUBDUR CATHETE $293.65 $293.65 $293.65 62200 VENTRICULOCISTERNOSTOMY THIRD VENTRICLE $822.23 $822.23 $822.23 62201 VENTRICULOCISTERNOST,3RD VENT,STERIO MET $822.23 $822.23 $822.23 62223 CREATION SHUNT VENTRICULO-PERITONEAL $1,339.05 $1,339.05 $1,339.05 62225 REPLACEMENT OR IRRIG VENTRICULAR CATHETE $293.65 $293.65 $293.65 62230 REPLAC/REVISION OF CSF SHUNT,OBSTR VALV $822.23 $822.23 $822.23 62256 REMOV COMPLETE CSF SHUNT SYST;W/O REPLA $1,339.05 $1,339.05 $1,339.05 62258 REMOVAL OF CPLTE SHUNT SYSTEM W REPLACE $822.23 $822.23 $822.23 62263 EPIDURAL LYSIS,MULTI ADHESIOLYSIS SESION $822.23 $822.23 $822.23 62264 PERCUTANEOUS LYSIS/EPIDURAL ADHES; 1 DAY $293.65 $293.65 $293.65 62267 INTERDISCAL PRECU ASPIRATION/DX PURPOSES $822.23 $822.23 $822.23 62268 PERCUTANEOUS ASPIRATION SPINAL CORD CYST $293.65 $293.65 $293.65 62269 INTERDISCAL PRECU ASPIRATION/DX PURPOSES $822.23 $822.23 $822.23 62270 SPINAL PUNCT LUMBAR DIAGNOSTIC $293.65 $293.65 $293.65 62272 SPINAL PUNCT,THERA,DRAIN CSF(NEEDLE/CATH $822.23 $822.23 $822.23 62273 INJECT, EPIDURAL, OF BLOOD OR CLOT PATCH $293.65 $293.65 $293.65 62280 INJ/INF NEUROLYTC SUBST-THERAPEUTIC SUBS $822.23 $822.23 $822.23 62281 INJ NEUROLYTIC EPIDURAL CERV-THORACIC $822.23 $822.23 $822.23 62282 INJ/INF NEUROLYTIC SUBST-OTH THERAP SUBS $822.23 $822.23 $822.23 62287 ASPRA/DECOMP PROC,PERCUTN,NUC PULPO DISK $1,585.73 $1,585.73 $1,585.73 62290 INJ PRO FOR DISKOGRAPY $822.23 $822.23 $822.23 62291 INJ PROC DISK,EA LEV; CERVICAL OR THORAC $822.23 $822.23 $822.23 62294 INJ ARTERIAL AM SPINAL $822.23 $822.23 $822.23 62310 INJECT SING DIAG THERPTC SUB CERVCL/THOR $293.65 $293.65 $293.65 62311 INJECT SING DIAG THERPTC SUB LUMB/SACRAL $293.65 $293.65 $293.65 62318 INJECT CATHETER PLACEMENT INCL CERV/THOR $293.65 $293.65 $293.65 62319 INJECT CATHETER PLACEMENT INCL LUMB/SCRL $293.65 $293.65 $293.65 62350 IMP,REV/REPOS TUN INTRATHCL OR EPIDUR CA $822.23 $822.23 $822.23 62351 IMP REV/REPOSIT INTRATH/EPID CATH W/LAMI $822.23 $822.23 $822.23 62355 REM PREV IMP INTRATHECAL/EPIDURAL CATHET $822.23 $822.23 $822.23 62360 IMP REPL DEV INTRATHECAL/EDID DRG INF;SU $1,339.05 $1,339.05 $1,339.05 62361 IMP REPL DEV INTRTHE/EPID DRG INF;NP PUM $1,339.05 $1,339.05 $1,339.05 62362 IMP/REP DEV INTRATH/EPID DRG INF; PROG $1,339.05 $1,339.05 $1,339.05 62365 REM SUBCUT RESERV/PUMP, PREV IMP INTRA/E $822.23 $822.23 $822.23 63001 LAMINECT EXPLOR/DECOMP 1 OR 2 VERT CERVI $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 77 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 63003 LAMINECT EXPLOR/DECOMP 1 TO 2 SEG THORAS $1,339.05 $1,339.05 $1,339.05 63005 LAMINECT DECOMP/EXPLOR 1-2 SEG LUMBAR $1,339.05 $1,339.05 $1,339.05 63011 LAMINECT EXPLOR/DECOMP 1-2 SEGS SACRAL $1,339.05 $1,339.05 $1,339.05 63012 REMOVE ABNORM FACETS, LUMBAR $1,585.73 $1,585.73 $1,585.73 63015 LAMINECT EXP-DECOMP MORE THAN 2 SEG CERV $1,585.73 $1,585.73 $1,585.73 63016 LAMINECT EXPLOR/DECOMPR 2+SEGS;THORASIC $1,585.73 $1,585.73 $1,585.73 63017 LAMINECTOMY DECOMP MO THAN 2 SEQ LUMBAR $1,585.73 $1,585.73 $1,585.73 63030 LAMINT(HEMILAMINCTMY),W/DECOMP NERV ROOT $1,585.73 $1,585.73 $1,585.73 63035 LAMINOT DECOMP EACH ADD INTRAS CERV/LUMB $1,585.73 $1,585.73 $1,585.73 63040 LAMINOT DECOM ROOT SINGL INTERSPACE;CERV $1,585.73 $1,585.73 $1,585.73 63042 LAMINECTOMY ANY LEVEL LUMBAR $1,585.73 $1,585.73 $1,585.73 63045 LAMINECT DECOMPRES CORD 1 SEGMENT CERVIC $1,585.73 $1,585.73 $1,585.73 63046 LAMINECT DECOMP UNI-BILAT COMPLETE THORA $1,585.73 $1,585.73 $1,585.73 63047 LAMINECT DECOMP UNI-BILAT COMPLET LUMBAR $1,585.73 $1,585.73 $1,585.73 63050 LAMINOPLAS,CERV,W/DECOMPR SPNAL CRD,2+SE $1,585.73 $1,585.73 $1,585.73 63051 LAMINOPL,CERV,W/DECOM SPIN CRD;W/RESONST $1,585.73 $1,585.73 $1,585.73 63055 TRANSPEDICULAR DECOMP CORD SING SEG THOR $1,585.73 $1,585.73 $1,585.73 63056 TRANSPEDICULR DECOM CORD,EQUNA/NERV ROOT $1,585.73 $1,585.73 $1,585.73 63064 COSTOVERTEBRAL DECOMP CORD THORAC SING S $1,585.73 $1,585.73 $1,585.73 63075 DISKECTOM ANTER DECOMPR CORD 1 INTRA CER $1,585.73 $1,585.73 $1,585.73 63077 DISKECTOMY ANTE DECOMP THOR SING INTERSP $1,585.73 $1,585.73 $1,585.73 63081 VERTE ANTE DECOMP CERVI SINGL $822.23 $822.23 $822.23 63085 VERTE CORPECTOMY TRANS THORAC SING SEGME $822.23 $822.23 $822.23 63087 VERTE CORPECTOMY THORACOLUMBAR SING SEGM $822.23 $822.23 $822.23 63090 VERTE CORPECT TRANSPER/RETROPER 1 SEGMEN $822.23 $822.23 $822.23 63170 LAMINECTOMY MYELOTOMY CERVI,THOR,THORACO $1,585.73 $1,585.73 $1,585.73 63172 LAMINECTOMY DRAIN INTRAMEDUL CYST SUBARC $1,585.73 $1,585.73 $1,585.73 63173 LAMINECTOMY DRAIN INTRAMEDUL CYST PERITO $1,585.73 $1,585.73 $1,585.73 63180 LAMINECTOMY W WO DURAL GFT CERV 1OR2 SEG $1,585.73 $1,585.73 $1,585.73 63182 LAMINECTOMY W WO DURAL CERV MO THAN2 SEG $1,585.73 $1,585.73 $1,585.73 63185 LAMINECTOMY WITH RHIZOTOM 1-2 SEGMENTS $1,339.05 $1,339.05 $1,339.05 63190 LAMINECTOMY RHIZOTOMY MO THAN TWO SEG $1,339.05 $1,339.05 $1,339.05 63191 LAMINECTOM W SECT SPINAL ASSESSORY NERVE $822.23 $822.23 $822.23 63194 LAMINECTOMY CORDOTOMY 1 STAGE CERVICAL $1,585.73 $1,585.73 $1,585.73 63195 LAMINECTOMY CORDOTOMY UNIL 1 STAGE THORX $1,585.73 $1,585.73 $1,585.73 63196 LAMINECTOMY CORDOT BTH TRACTS 1 STG CERV $1,585.73 $1,585.73 $1,585.73 63197 LAMINECTOMY CORDOTOMY BILAT 1 STGE THORX $1,585.73 $1,585.73 $1,585.73 63198 LAMINECTOMY CORDOTOMY 2 STGE WI 14DA CEV $1,585.73 $1,585.73 $1,585.73 63199 LAMINECTOMY CORDOTOMY 2 STGE WI 14DA THX $1,585.73 $1,585.73 $1,585.73 63200 LAMINECTOMY RELEASE TETHERED CORD LUMBAR $822.23 $822.23 $822.23 63295 OSTEOPLASTIC RECONSTR/DORSAL SPINAL ELEM $125.00 $125.00 $125.00 63600 STEROTACTIC LESION SPNL CORD ANY MODALIT $1,339.05 $1,339.05 $1,339.05 63610 STEREOTACT LESION SPNL CORD NO OTH SURG $822.23 $822.23 $822.23 63615 STEREO BIOPSY ASPIR EXCIS LESI SPIN CORD $1,339.05 $1,339.05 $1,339.05 63650 PERC IMPLANTATION NEUROSTIM ELECTRODES $1,339.05 $1,339.05 $1,339.05 63655 LAMINECTOMY IMPLANTATION NEUROSTIM ELECT $1,339.05 $1,339.05 $1,339.05 63661 $822.23 $822.23 $822.23 63662 $822.23 $822.23 $822.23

07/27/12 Page 78 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 63663 $822.23 $822.23 $822.23 63664 REV W/REPL,SPIN NEUROSTIM ELEC PLATE/PAD $822.23 $822.23 $822.23 63685 INCIS SUBCUTAN SPINAL NEUROSTIM GENERATO $1,339.05 $1,339.05 $1,339.05 63688 REV/REM SPINAL NEUROSTIM GEMERA/RECIEVER $822.23 $822.23 $822.23 63700 REPAIR MININGOCELE LESS THAN SCM $1,585.73 $1,585.73 $1,585.73 63702 REPAIR MENINGOCELE LARGER THAN 5CM $1,585.73 $1,585.73 $1,585.73 63707 REPAIR DURAL/CSF LEAK-NO LAMINECTOMY $1,585.73 $1,585.73 $1,585.73 63709 REPAIR DURAL/CSF LEAK PSEUDOMEN,W/LAMIN $1,585.73 $1,585.73 $1,585.73 63710 DURAL GRAFT SPINAL $1,585.73 $1,585.73 $1,585.73 63740 CREAT SHUNT LUMB,SUBARACH, INCL LAMENECT $822.23 $822.23 $822.23 63741 SHUNT CREATION LUMBAR,PERCUT,NO LAMENECT $822.23 $822.23 $822.23 63744 REPLACE/IRRIG/REV OF LUMB-SUBARACH SHUNT $822.23 $822.23 $822.23 63746 REM LUMB-SUBARACH SYST SHUNT WO REPLACE $293.65 $293.65 $293.65 64405 INJ ANESTH GREATER OCCIPITAL NERVE $293.65 $293.65 $293.65 64421 INTERCOSTAL NERVE MTPLE REG BLOCK $125.00 $125.00 $125.00 64450 INJ ANESTH OTH PERIPHERAL NERVE/BRANCH $293.65 $293.65 $293.65 64455 NERVE BLOCK INJEC,PLANTAR DIGITAL NERVE $293.65 $293.65 $293.65 64479 INJCT ANESTH AGT STER TRNS EP CER/THR SL $293.65 $293.65 $293.65 64483 INJCT ANESTH AGT STER TRNS EP LUM/SAC SL $293.65 $293.65 $293.65 64490 INJ,ZYGAPOPHYSEAL,CERVICAL/THORAC,SNG LV $293.65 $293.65 $293.65 64491 $293.65 $293.65 $293.65 64493 INJ,ZYGAPOPHYSEAL,LUMBAR/SACRAL,SNG LVL $293.65 $293.65 $293.65 64505 INJ ANESTH SPHENOPALATINE GANGLION $293.65 $293.65 $293.65 64508 INJ ANESTH CAROTID SINUS $822.23 $822.23 $822.23 64510 INJ ANESTH STELLATE GANGLION $293.65 $293.65 $293.65 64517 INJ,ANESTH AGNT;SUPRIOR HYPOGASTRIC PLEX $293.65 $293.65 $293.65 64520 INJ ANESTH LUMBAR/THORACIC $293.65 $293.65 $293.65 64530 INJ ANESTH CELIAC PLEXUS W WO RADIOL MON $293.65 $293.65 $293.65 64561 PERCUT IMPLNT NEURSTIM ELECT;SACRAL NERV $34,416.14 $34,416.14 $34,416.14 64568 $34,416.14 $34,416.14 64573 INCISION IMPLANT NEUROSTIM ELECTRO CRANI $34,416.14 $34,416.14 $34,416.14 64581 INCIS IMPLNT NEURSTIN ELECT;SACRAL NERV $34,416.14 $34,416.14 $34,416.14 64585 REV/REM PERIPHERAL NEUROSTIM ELECTRODES $6,342.91 $6,342.91 $6,342.91 64590 INC & SUB PLACEMENT PERIP NEUROST GEN $34,416.14 $34,416.14 $34,416.14 64595 REV/REM PERIPHER NEUROSTIM RECEIV/GENERA $6,342.91 $6,342.91 $6,342.91 64600 DESTRUCT BY NEUROLYTIC AGENT TRIGEM ET $822.23 $822.23 $822.23 64605 DESTRUCT NEUROLYT AGENT TRIGEM NV ETC $822.23 $822.23 $822.23 64610 DESTRUCT NEUROLYTIC AGENT TRIGEM NV ETC $822.23 $822.23 $822.23 64611 CHEMODENERVATION OF PAROTID/SUBMANDIBULR Not Valid $293.65 $293.65 64612 CHEMODENERVATION/MUSC;INNERVAT/FACIA NER $293.65 $293.65 $293.65 64613 DECHEMODENERVATION OF NECK MUSCLES $293.65 $293.65 $293.65 64614 CHEMODENERVATION-MUSCLE;EXTREMITY;TRUNK $293.65 $293.65 $293.65 64620 DESTRUCT NEUROLYT AGENT INTERCOSTAL NV $822.23 $822.23 $822.23 64622 DESTR-NEUROLY AG,PARVRT FACET JNT NRV-SI $822.23 $822.23 D 64626 DEST BY NEURO AGENT;CERV OR THOR,SING LV $822.23 $822.23 D 64630 DESTR BY NEUROLYTIC AGENT/PUDENDAL NERVE $822.23 $822.23 $822.23 64632 NEUROLYTIC AGNT DESTR;PLANTAR DIGIT NERV $293.65 $293.65 $293.65 64633 DESTROY CERVICAL/THORACIC,SNG FACET JNT Not Valid Not Valid $822.23

07/27/12 Page 79 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 64634 DESTROY CERVICAL/THORACIC,JNT,EA ADD'L Not Valid Not Valid $822.23 64635 DESTROY LUMBAR/SACRAL,SINGLE FACET JOINT Not Valid Not Valid $822.23 64636 DESTROY LUMBAR/SACRAL,EA ADD'L FACET JNT Not Valid Not Valid $822.23 64640 DESTRUCT NEUROLYT AGENT OTH PERIPHER NV $822.23 $822.23 $822.23 64680 NEUROLYTIC AGNT DESTR;PLANTAR DIGIT NERV $293.65 $293.65 $293.65 64680 NEUROLYTIC AGNT DESTR;PLANTAR DIGIT NERV $293.65 $293.65 $293.65 64681 DESTRUCT BY NEUROLYTIC AGNT;SUPRIOR HYPO $700.14 $700.14 $700.14 64702 NEUROPLASTY DIGIT ONE OR BOTH DIGIT $1,339.05 $1,339.05 $1,339.05 64704 NEUROPLASTY NERVE OF HAND OR FOOT $1,339.05 $1,339.05 $1,339.05 64708 NEUROPLASTY MAJ PERIP NERVE ARM-LEG OTS $1,339.05 $1,339.05 $1,339.05 64712 NEUROPLAST MAJ PERIF NERV ARM-LEG SCIATI $1,339.05 $1,339.05 $1,339.05 64713 NEUROPLAS MAJ PERIP NERV ARM-LEG BRACHIA $1,339.05 $1,339.05 $1,339.05 64714 NEUROLYSIS LUMBAR PLEXUS $1,339.05 $1,339.05 $1,339.05 64716 NEUROPLAS + OR TRANSPOSIT CRANIAL NERVE $1,339.05 $1,339.05 $1,339.05 64718 NEUROPLAS + OR TRANSPO ULNAR NERVE ELBOW $1,339.05 $1,339.05 $1,339.05 64719 NEUROPLAS AN/OR TRANSPO ULNAR AT WRIST $1,339.05 $1,339.05 $1,339.05 64721 NEUROPLAS AN/OR TRANSPO MEDI CARPAL TUNN $1,339.05 $1,339.05 $1,339.05 64722 DECOMPRESSION UNSPECIFIED NERVES SPECIFY $1,339.05 $1,339.05 $1,339.05 64726 DECOMPRESSION PLANTAR DIGITAL NERVE $1,339.05 $1,339.05 $1,339.05 64732 TRANSECTION AVULSION SUPRAORBITAL NV $1,339.05 $1,339.05 $1,339.05 64734 TRANSECT AVULSION INFRAORBITAL NV $1,339.05 $1,339.05 $1,339.05 64736 TRANSEC AVULSION MENTAL NV $1,339.05 $1,339.05 $1,339.05 64738 TRANSEC OR AVULSION INFERIOR ALVEOLAR NV $1,339.05 $1,339.05 $1,339.05 64740 TRANSEC OR AVULSION LINGUAL NV $1,339.05 $1,339.05 $1,339.05 64742 TRANSEC OR AVULSION FACIAL NV DIF/CPLTE $1,339.05 $1,339.05 $1,339.05 64744 TRANSEC OR AVULSION GREAT OCCIPITAL NV $1,339.05 $1,339.05 $1,339.05 64746 TRANSEC OR AVULSION PHRENIC NV $1,339.05 $1,339.05 $1,339.05 64752 TRANSEC OR AVULSION VAGUS NV TRANSTHORX $822.23 $822.23 $822.23 64760 TRANSEC OR AVULSION VAGUS NV ABDOMINAL $822.23 $822.23 $822.23 64761 TRANSEC OR AVULSION PUDENTAL NERVE $1,339.05 $1,339.05 $1,339.05 64763 TRANSEC/AVULS OBTURATOR NRV EXT PELVIC $1,339.05 $1,339.05 $1,339.05 64763 TRANSEC/AVULS OBTURATOR NRV EXT PELVIC $1,339.05 $1,339.05 $1,339.05 64766 TRANSEC/AVULSION OBURATOR NRV PELVIC $1,339.05 $1,339.05 $1,339.05 64771 TRANSECTION?AVULSION OTH CRAN NERV EXTRA $1,339.05 $1,339.05 $1,339.05 64772 TRANSEC OR AVULSION OF OTH SPINAL NV $1,339.05 $1,339.05 $1,339.05 64774 EXC NEUROMA CUTANEOUS NV SURG IDENTIFIAB $1,339.05 $1,339.05 $1,339.05 64776 EXC NEUROMA DIGITAL NV ONE OR BOTH SME D $1,339.05 $1,339.05 $1,339.05 64782 EXC NEUROMA HAND OR FOOT CEPT DIGIT NV $1,339.05 $1,339.05 $1,339.05 64784 EXC NEUROMA MAJ PERIPHERL NV CEPT SCIATC $1,339.05 $1,339.05 $1,339.05 64786 EXC NEUROMA SCIATIC NV $1,339.05 $1,339.05 $1,339.05 64788 EXC NEURO-FIBROMA-LEMMOMA CUTAN NV $1,339.05 $1,339.05 $1,339.05 64790 EXC NEURO-FIBROMA-LEMMOMA MAJ PER NV $1,339.05 $1,339.05 $1,339.05 64792 EXC NEURO-FIBROMA-LEMMOMA EXTENSIVE $1,339.05 $1,339.05 $1,339.05 64795 BIOPSY OF NERVE $822.23 $822.23 $822.23 64802 SYMPATHECTOMY CERVICAL $822.23 $822.23 $822.23 64809 SYMPATHECTOMY THORACULUMBAR $1,339.05 $1,339.05 $1,339.05 64818 SYMPATHECTOMY LUMBAR $1,339.05 $1,339.05 $1,339.05 64820 SYMPATHECTOMY;DIGITAL ARTERIES,EA.DIGI $822.23 $822.23 $822.23

07/27/12 Page 80 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 64821 SYMPATHECTOMY;RADIAL ARTERY $822.23 $822.23 $822.23 64822 SYMPATHECTOMY;ULNAR ARTERY $822.23 $822.23 $822.23 64823 SYMPATHECTOMY;SUPERFICIAL PALMAR ARCH $822.23 $822.23 $822.23 64831 SUTURE OF DIGITAL NV HAND FOOT ONE NV $1,339.05 $1,339.05 $1,339.05 64834 SUTURE ONE NV HAND FOOT COMMON SER NV $1,339.05 $1,339.05 $1,339.05 64835 SUTURE ONE NV HAND FOOT MEDIAN MOTOR THE $1,339.05 $1,339.05 $1,339.05 64836 SUTURE ONE NV HAND FOOT ULNAR MOTOR $1,339.05 $1,339.05 $1,339.05 64840 SUTURE POST TIBIAL NV $1,339.05 $1,339.05 $1,339.05 64856 SUTURE MAS PER NV ARM LEG W TRANSPOSITIO $1,339.05 $1,339.05 $1,339.05 64857 SUTURE MAJ PER NV ARM LEG WO TRANSPOSIT $1,339.05 $1,339.05 $1,339.05 64858 SUTURE SCIATIC NV $1,339.05 $1,339.05 $1,339.05 64861 SUTURE OF BRACHIAL PLEXUS $1,339.05 $1,339.05 $1,339.05 64862 SUTURE OF LUMBAR PLEXUS $1,339.05 $1,339.05 $1,339.05 64864 SUTURE FACIAL NV EXTRA CRANIAL $1,339.05 $1,339.05 $1,339.05 64865 SUTURE FACIAL NV INTRATEMPORAL W WO GFTN $1,339.05 $1,339.05 $1,339.05 64866 ANASTOMOSIS FACIAL-SPINAL ACESSORY $1,339.05 $1,339.05 $1,339.05 64868 ANASTOMOSIS FACIAL-HYPOGLOSSAL $1,339.05 $1,339.05 $1,339.05 64870 AMASTOMOSIS FACIAL-PHRENIC $1,339.05 $1,339.05 $1,339.05 64885 NERVE GRAFT <4CM HEAD NECK $1,339.05 $1,339.05 $1,339.05 64886 NERVE GRAFT >4CM HEAD NECK $1,339.05 $1,339.05 $1,339.05 64890 NERVE GRAFT UP TO 4CM $1,339.05 $1,339.05 $1,339.05 64891 NERVE GRAFT MORE THAN 4CM HAND/FOOT $1,339.05 $1,339.05 $1,339.05 64892 NERVE GRAFT UP TO 4CM ARM OR LEG $1,339.05 $1,339.05 $1,339.05 64893 NERVE GRAFT ARM OR LEG MORE THAN 4CM $1,339.05 $1,339.05 $1,339.05 64895 NERVE GRAFT MTPLE STRAND HAND FOOT TO4CM $1,339.05 $1,339.05 $1,339.05 64896 NERVE GRAFT MTPLE STRAND HAND FOOT 4CMT $1,339.05 $1,339.05 $1,339.05 64897 NERVE GRAFT MTPLE STRAND ARM LEG TO 4CM $1,339.05 $1,339.05 $1,339.05 64898 NERVE GRAFT MTPLE STRAND ARM LEG 4CMPLUS $1,339.05 $1,339.05 $1,339.05 64905 NERVE PEDICLE TRANSFER FIRST STAGE $1,339.05 $1,339.05 $1,339.05 64907 NERVE PEDICLE TRANSFER SECOND STAGE $1,339.05 $1,339.05 $1,339.05 64999 UNLISTED PROCEDURE NERVOUS SYSTEM $293.65 $293.65 $293.65 65091 EVISCERATION OCULAR CONT W/O IMPLANT $1,585.73 $1,585.73 $1,585.73 65093 EVISCERATION OCULAR CONT W/ IMPLANT $1,585.73 $1,585.73 $1,585.73 65101 ENUCLEATION EYE W/O IMPLANT $1,585.73 $1,585.73 $1,585.73 65103 ENULEATION EYE W/IMPLANT MUSCLES NOT ATT $1,585.73 $1,585.73 $1,585.73 65105 ENUCLEA EYE W/IMPLAN MUSCLE ATTACH IMPLA $1,585.73 $1,585.73 $1,585.73 65110 EXENTERATION ORBIT REMOV ORBIT CONT ONLY $1,585.73 $1,585.73 $1,585.73 65112 EXENTERATION ORBIT REMOV ORBIT CON W/BON $1,585.73 $1,585.73 $1,585.73 65114 EXENT ORB W MUS OR MYOCUT FLAP $1,585.73 $1,585.73 $1,585.73 65125 MOD OCULAR IMPLANT W PLAC/REPL PEG SEPAR $1,339.05 $1,339.05 $1,339.05 65130 INSERT OCULAR IMPLAN SECOND EVIS SCLE SH $1,585.73 $1,585.73 $1,585.73 65135 INSERT OCULA IMPL SECON ENUCLE MUS NOT A $1,585.73 $1,585.73 $1,585.73 65140 INSERT OCUL IMPL SECOND ENUCLE MUS ATTCH $1,585.73 $1,585.73 $1,585.73 65150 REINSERT OCUL IMPL W/WO CONJUNC GRAFT $1,339.05 $1,339.05 $1,339.05 65155 REINSER OCUL IMPL W/USE FOREI MAT REINFO $1,339.05 $1,339.05 $1,339.05 65175 REMOV OCULAR IMPLANT $1,339.05 $1,339.05 $1,339.05 65210 REMOV FB EXTER EYE CONJUN EMBED NONPERFO $822.23 $822.23 $822.23 65220 REMOV FB EXT EYE CORNEAL W/O SLIT LAMP $293.65 $293.65 $293.65

07/27/12 Page 81 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 65222 REMOV FB EXT EYE W/SLIT LAMP CORNEAL $293.65 $293.65 $293.65 65235 REMV FB,INTRACULR;ANTERIR CHAMB EYE/LE $822.23 $822.23 $822.23 65260 REMOV FB INTRAOCU POST SEG MAG EXTRA A/P $822.23 $822.23 $822.23 65265 REMOV FB INTRAOCU POST SEGMEN NONMAG EXT $822.23 $822.23 $822.23 65270 REPAIR LAC CONJ W/WO NONPERFO LAC SCLERA $350.00 $350.00 $350.00 65272 REP/LAC CONJUN MOBIL/REARRANG W/O HOSPIT $822.23 $822.23 $822.23 65275 REP/LAC CORNEA NONPERFORAT W/WO REMOV FB $1,339.05 $1,339.05 $1,339.05 65280 REP/LAC CORNEA AND/OR SCLERA PERFOR NO/U $1,339.05 $1,339.05 $1,339.05 65285 REP/LAC CORNEA AND/OR SCLERA PERF RESE/U $1,339.05 $1,339.05 $1,339.05 65286 REPAIR LACER APPLICAT GLUE CORNEA+SCLERA $1,339.05 $1,339.05 $1,339.05 65290 REPAIR WOUND EXTRAOCUL MUS,TEND, AN/OR C $1,585.73 $1,585.73 $1,585.73 65400 EXCISION LESION CORNEA EXCEPT PTERYGIUM $822.23 $822.23 $822.23 65410 BIOPSY CORNEA $822.23 $822.23 $822.23 65420 EXCIS/TRANSPOSITION PTERYGIUM W/O GRAFT $822.23 $822.23 $822.23 65426 EXCIS/TRANSPOSITION PTERYGIUM W/GRAFT $1,339.05 $1,339.05 $1,339.05 65430 SCRAP CORNEA DIAGNOS SMEAR AND/OR CULTUR $293.65 $293.65 $293.65 65435 REMOV CORNEA EPITHEL W/WO CHEMOCAUTER $822.23 $822.23 $822.23 65436 REMOV COREAL EPITHEL W/APPLI CHELAT AGEN $822.23 $822.23 $822.23 65450 DESTRUCT LESION CORNEA CRYO-PHOTO-THERMO $822.23 $822.23 $822.23 65710 KERATOPLASTY (CORNEAL TRANSP);LAMELLAR $2,936.54 $2,936.54 $2,936.54 65730 KERATOPLAS(COR TRANS)PENETRAT(EXC APHAK) $2,936.54 $2,936.54 $2,936.54 65750 KERATOPLAS(COR TRANS)PENETRAT(IN APHAKI) $2,936.54 $2,936.54 $2,936.54 65755 KERATOPLAS(CORNE TRANS)PENETRAT(IN PSEUD $2,936.54 $2,936.54 $2,936.54 65760 KERATOMELEUSIS $1,339.05 $1,339.05 $1,339.05 65765 KERATOPHAKIA $1,339.05 $1,339.05 $1,339.05 65767 EPIKERATOPLASTY $822.23 $822.23 $822.23 65770 KERATOPROSTHESIS $1,339.05 $1,339.05 $1,339.05 65772 CORNEAL RELAXING INCIS CORRECT SURG ASTI $1,339.05 $1,339.05 $1,339.05 65775 CORNEAL WEDGE RESECT SURG INDUCED ASTIGM $1,339.05 $1,339.05 $1,339.05 65778 PLAC AMNIOTIC MEMBRAN/OCULAR SURFC/WOUND Not Valid $1,339.05 $1,339.05 65779 PLAC AMNIOTIC MEMBRAN/OCULAR SURFC/WOUND Not Valid $1,339.05 $1,339.05 65780 OCULAR RECONST;AMNIOTIC MEMBRANE TRANSPL $1,167.73 $1,167.73 $1,167.73 65781 OCULAR RECONST;IIMBAL STEM CELL ALLOGRFT $1,795.04 $1,795.04 $1,795.04 65782 OCULAR RECONST;LIMBAL CONJUNCTVL AUTOGRA $1,545.15 $1,545.15 $1,545.15 65800 PARACENT ANTER CHAMBEYE(SEP PRO)W/ASPIRA $822.23 $822.23 $822.23 65805 PARACENT ANTER EYE(SEP PRO)W/THER REL AQ $1,339.05 $1,339.05 $1,339.05 65810 PARACEN ANTE EYE(SEP PRO)W/REM VIT W/WOA $1,339.05 $1,339.05 $1,339.05 65815 PARACEN ANT/EYE(SEP PRO)W/REM BLD W/WO I $1,339.05 $1,339.05 $1,339.05 65820 GONIOTOMY $822.23 $822.23 $822.23 65850 TRABECULOTOMY AB EXTERNO $1,339.05 $1,339.05 $1,339.05 65855 TRABECULOPLASTY LASER ONE/MORE SESSIONS $822.23 $822.23 $822.23 65860 SEVERING ADHESIONS ANT SEGMENT, LASER $1,339.05 $1,339.05 $1,339.05 65865 SEVERING ADHESIONS ANT EYE INCIS GONIOSY $1,585.73 $1,585.73 $1,585.73 65870 SEVER ADHES ANTE SEQ EYE(W/WO AIR)EX GON $1,339.05 $1,339.05 $1,339.05 65875 SEVER ADHES ANTE SEQ EYE POST SYNECHIAE $822.23 $822.23 $822.23 65880 SEVER ADHES ANTE SEQ EYE CORNEOVITRE ADH $1,339.05 $1,339.05 $1,339.05 65900 REMOV EPITHEL DOWNGROWTH ANTE CHAM EYE $822.23 $822.23 $822.23 65920 REMOV PLANT MATERL,ANTERIOR SEG OF EYE $822.23 $822.23 $822.23

07/27/12 Page 82 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 65930 REMOVE BLOOD CLOT,ANTERIOR SEG OF EYE $1,339.05 $1,339.05 $1,339.05 66020 INJ,ANTERIOR CHAMBR EYE,(SEP PROC)AIR/LQ $822.23 $822.23 $822.23 66030 INJECTION ANTE CHAM(SEP PRO) MEDICATION $822.23 $822.23 $822.23 66130 EXCISION LESION SCLERA $1,339.05 $1,339.05 $1,339.05 66150 FISTULIZATION SCLERA GLAUCO TREP W/IRIDE $1,339.05 $1,339.05 $1,339.05 66155 FISTULIZ SCLERA GLAUCOM THERMOCAU W/IRID $822.23 $822.23 $822.23 66160 FISTULI SCLERA GLAU SCLERE W/PUNCH/SCI W $1,585.73 $1,585.73 $1,585.73 66165 FISTULI SCLER GLAUCO IRIDENCLEISIS/IRIDO $1,339.05 $1,339.05 $1,339.05 66170 FISTULI SCLER GLAUCO TRABECULE AB EXTERN $1,339.05 $1,339.05 $1,339.05 66172 FISTULI SCLER GLAUCO TRAB AB EXT W/SCARR $1,339.05 $1,339.05 $1,339.05 66174 TRANSLUM DILAT AQUEOUS OUTFLO CANAL;W/O Not Valid $1,339.05 $1,339.05 66175 TRANSLUM DILAT AQUEOUS OUTFLO CANAL;W/ R Not Valid $1,339.05 $1,339.05 66180 AQUESOUS SHUNT EXTRAOCULAR RESERVOIR $1,585.73 $1,585.73 $1,585.73 66185 REVISION,AQUEOUS SHUNT TO EXTRAOC RESERV $1,339.05 $1,339.05 $1,339.05 66220 REPAIR SCLERAL STAPHYLOMA W/O GRAFT $822.23 $822.23 $822.23 66225 REPAIR SCLERAL STAPHYLOMA WITH GRAFT $1,339.05 $1,339.05 $1,339.05 66250 REVISION/REPAIR OP WOUND ANTE SEQ ANY TY $822.23 $822.23 $822.23 66500 TRIDOTOMY STAB INCIS(SEP PRO) EX TRANSFI $1,585.73 $1,585.73 $1,585.73 66505 IRIDOT STAB INCIS(SEP PRO)W/TRANSFIX BOM $1,585.73 $1,585.73 $1,585.73 66600 IRIDEC W/CORNEOSCL/SECT REMOV LESION $1,339.05 $1,339.05 $1,339.05 66605 IRIDEC W/CORNEOSCL/SECT REMOV LES W/CYCL $1,339.05 $1,339.05 $1,339.05 66625 IRIDEC W/CORNEOSCL/SECT PERIP GLAU(SEP P $1,585.73 $1,585.73 $1,585.73 66630 IRIDEC W/CORNEOSCL/SECT SECTOR GLAU(SEP $1,585.73 $1,585.73 $1,585.73 66635 IRIDEC W/CORNEOSCL/SECT (OPTICAL)(SEP PR $1,585.73 $1,585.73 $1,585.73 66680 REPAIR IRIS CILIARY BODY(AS FOR IRIDODI) $1,339.05 $1,339.05 $1,339.05 66682 SUTURE IRIS CILLIARY BOD(MCCANNELL SUTUR $1,339.05 $1,339.05 $1,339.05 66700 CILIARY BODY DESTRUCTION, DIATHERMY $1,339.05 $1,339.05 $1,339.05 66710 CILIARY BODY DEST CYCLOPHOTOCOAGULATION $1,339.05 $1,339.05 $1,339.05 66711 CILIARY BODY DESTR;CYCLEPHOTOCOAG,ENDOSC $1,339.05 $1,339.05 $1,339.05 66720 CILIARY BODY DESTRUCTION, CRYOTHERAPY $1,339.05 $1,339.05 $1,339.05 66740 CILIARY BODY DESTRUCTION, CYCLODIALYSIS $1,339.05 $1,339.05 $1,339.05 66761 IRIDOTOMY/IRIDECTOMY/LASER SURG/FOR GLAU $1,585.73 $1,585.73 $1,585.73 66762 COREOPLASTY(IRIDOTOMY) COOAGUL OTHER GLA $1,339.05 $1,339.05 $1,339.05 66770 DESTRUCT CYST/LES IRIS/CILIARY(NON EXCIS $1,339.05 $1,339.05 $1,339.05 66820 DISCIS 2ND MEMB CATAR(OPAC POST CAP/ANT $1,339.05 $1,339.05 $1,339.05 66821 DISCISS 2ND CATARCT LASER(YAG) 1+ STAGES $1,339.05 $1,339.05 $1,339.05 66825 REPOSITION INTRAOC LENS PROSTHES INCIS $1,339.05 $1,339.05 $1,339.05 66830 REMOV 2ND MEMB CATAR W CORNEO-SCLER SECT $1,585.73 $1,585.73 $1,585.73 66840 REM LENS MAT ASPIR TECH ONE OR MORE STAG $1,585.73 $1,585.73 $1,585.73 66850 REM LENS MAT PHACOFRAG TECH W/ASPIRATION $1,585.73 $1,585.73 $1,585.73 66852 CATARACT REMOVAL PARS PLANA APPROACH $1,585.73 $1,585.73 $1,585.73 66920 REMOVE LENS MATERIAL;INTRACAPSULAR $1,585.73 $1,585.73 $1,585.73 66930 EXTRACT LENS W/WO IRIDEC INTRACAP DISLO $1,585.73 $1,585.73 $1,585.73 66940 EXTRACT LENS EXTRACAPS;NOT OTHER DISCRIB $1,585.73 $1,585.73 $1,585.73 66982 EXTRACAPSULAR CATARACT REMOVAL, COMPLEX $2,936.54 $2,936.54 $2,936.54 66983 INTRACAP CATARACT EXTRA INSERT LENS 1 ST $2,936.54 $2,936.54 $2,936.54 66984 CATARACT SURG W/LENS INSERTION, 1 STAGE $2,936.54 $2,936.54 $2,936.54 66985 INSERT INTRAOC LEN PRO NOT W CAT REM $2,936.54 $2,936.54 $2,936.54

07/27/12 Page 83 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 66986 EXCHANGE OF INTRAOCULAR LENS $2,936.54 $2,936.54 $2,936.54 66999 UNLISTED PROCEDURE ANTERIOR SEGMEN EYE $293.65 $293.65 $293.65 67005 REM VITRE ANTE APPRO(OPN SKY/LIMBAL)PART $1,339.05 $1,339.05 $1,339.05 67010 REMOV VIT ANT SUBTOTAL W MECHAN VITREC $1,339.05 $1,339.05 $1,339.05 67015 ASPIR/RELEA VITRE SUBRET/CHORO PARS PLAN $822.23 $822.23 $822.23 67025 INJECT VIT SUBSTI PARS PLANA/LIMBAL APPR $822.23 $822.23 $822.23 67027 IMPL/REPL INTRAVIT DRUG DEL SYS/CONC VIT $293.65 $293.65 $293.65 67028 INTRAVITREAL INJECT;PHARMACOLOGIC AGENT $293.65 $293.65 $293.65 67030 DISCISSION VITRE STRAND(W/O REM)PARS PLA $1,339.05 $1,339.05 $1,339.05 67031 SEVER VITRE STRANDS-FAC ADHES LASER 1OR+ $293.65 $293.65 $293.65 67036 VITRECTOMY MECHANICAL PARS PLANA APPROAC $1,339.05 $1,339.05 $1,339.05 67039 VITRECTOMY, W FOCAL ENDOLASER PHOTOCOAGU $1,339.05 $1,339.05 $1,339.05 67040 VITERECTOMY MECHAN W ENDOLASER PHOTOCOAG $1,339.05 $1,339.05 $1,339.05 67041 VITRECTOMY,PARS PLANTA AP,MACULAR PUCKER $1,339.05 $1,339.05 $1,339.05 67042 VITRECTOMY,PARS PLANTA APPR,MACULAR HOLE $1,339.05 $1,339.05 $1,339.05 67043 VITRECTOMY,PARS PLANTA AP,CHOROID NEOVAS $1,339.05 $1,339.05 $1,339.05 67101 REPAIR RET DET(1 OR MOR)CRYO-DIATH W/WO $1,339.05 $1,339.05 $1,339.05 67105 REPAIR RET DETACH 1 OR + PHOTOCOAG 1-2 S $1,339.05 $1,339.05 $1,339.05 67107 REP RETINAL DET SCLERAL BUCK W/WO IMPLAN $1,339.05 $1,339.05 $1,339.05 67108 REP RET DETACH W VITREC W/WO AIR/GAS TAM $1,339.05 $1,339.05 $1,339.05 67110 REPAIR RETINAL DETACH, AIR/GAS INJECTION $1,339.05 $1,339.05 $1,339.05 67112 REP RET DETACH SCLERAL BUCK/VITREC PREV $1,339.05 $1,339.05 $1,339.05 67113 REPAIR RETINAL DETACHMENT,COMPLEX $1,339.05 $1,339.05 $1,339.05 67115 RELEASE OF ENCIRCLING MATERIAL(POST SEGM $1,339.05 $1,339.05 $1,339.05 67120 REMOVAL IMPLANTED MATERIAL POST SEGM EXT $1,339.05 $1,339.05 $1,339.05 67121 REMOV IMPLANT MATERIAL POST SEGM INTRAOC $1,339.05 $1,339.05 $1,339.05 67141 PROPHY RET DET WO DRAIN(1 OR MOR)CRYO-DI $1,339.05 $1,339.05 $1,339.05 67145 PROPHY RET DET WO DRAIN(1 OR MOR)PHOTO- $1,339.05 $1,339.05 $1,339.05 67208 DESTRUCT LESION RET(1 OR MOR)CRYO-DIATH $822.23 $822.23 $822.23 67210 DESTRUCT LESION(1 OR MOR)PHOTOCOAG $822.23 $822.23 $822.23 67218 DESTRUCT LESION(1-MORE) RADIAT IMPLANT $1,339.05 $1,339.05 $1,339.05 67220 DESTR LOC LESION OF CHOROID, 1 OR MORE $822.23 $822.23 $822.23 67221 DESTR LOC LESION/CHORD;PHOTODYNAMIC THER $822.23 $822.23 $822.23 67227 DESTRUCT EXTEN/PROGRES RETINOPATHY CRYO/ $822.23 $822.23 $822.23 67228 DESTRUCT EXTEN/PROGRES RETINOPATHY PHOTO $822.23 $822.23 $822.23 67229 TX EXTN/PROGR RETINOPATHY,PRETERM INFANT $822.23 $822.23 $822.23 67250 SCLERAL REINFORCE(SEP PRO) W/O GRAFT $822.23 $822.23 $822.23 67255 SCLERAL REINFORC(SEP PRO) W/GRAFT SEE BO $1,339.05 $1,339.05 $1,339.05 67299 UNLISTED PROCEDURE POST SEGMENT $293.65 $293.65 $293.65 67311 STRABIS SURG,RECES/RESECT PROC;1HOR MUSC $1,585.73 $1,585.73 $1,585.73 67312 STRABIS SURG(NO PREV SURG)2 HORZ MUSCLES $1,585.73 $1,585.73 $1,585.73 67314 STRADISMUS SURG,RECESS/RESECT,1VERT MUSC $1,585.73 $1,585.73 $1,585.73 67316 STRABISMUS SURG,RECESS/RESECT 2+MUSCLES $1,585.73 $1,585.73 $1,585.73 67318 STRABISMUS SURG,ANY PROCED,SUPERIOR OBLQ $1,585.73 $1,585.73 $1,585.73 67343 STRABISMUS,RELEASE ESTENSIVE SCAR TISSUE $1,585.73 $1,585.73 $1,585.73 67345 CHEMODENERVATION EXTRAOCULAR MUSCLE $1,585.73 $1,585.73 $1,585.73 67399 UNLISTED PROCED OCULAR MUSCLE $822.23 $822.23 $822.23 67400 ORBITOTOMY W/O BF EXPLO W/WO BONE BIO $1,585.73 $1,585.73 $1,585.73

07/27/12 Page 84 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 67405 ORBITOTOMY W/O BONE FLAP(FRONT) DRAIN ON $1,585.73 $1,585.73 $1,585.73 67412 ORBITOTOMY W/O BONE FLAP(FRONT)REM LESIO $1,339.05 $1,339.05 $1,339.05 67413 ORBITOTOMY W/O BONE FLAP(FRON) REMOV FB $1,339.05 $1,339.05 $1,339.05 67414 ORBITOTOMY WITHOUT BONE FLAP REM BONE $1,585.73 $1,585.73 $1,585.73 67415 FINE NEEDLE ASP ORBITAL CONTENTS $293.65 $293.65 $293.65 67420 ORBITOTOMY W BF-WINDOW W REM LESION $1,585.73 $1,585.73 $1,585.73 67430 ORBITOTOMY W/FLAP LAT(KROENL) REMOV FB $1,585.73 $1,585.73 $1,585.73 67440 ORBITOTOMY W BF-WINDOW W DRAINAGE $1,585.73 $1,585.73 $1,585.73 67445 ORBITOTOMY BONE FLAP-WINDOW REM BONE $1,585.73 $1,585.73 $1,585.73 67450 ORBITOTOMY W/FLAP LAT(KROENL) EXPLO W/WO $1,585.73 $1,585.73 $1,585.73 67500 RETRBULDAR INJ MEDICATION (SEPAR PROCED) $822.23 $822.23 $822.23 67505 RETROBULBAR INJ ALCOHOL $822.23 $822.23 $822.23 67515 INJ MEDICA/OTHER SUBSTAN IN TENSON CAPSU $1,585.73 $1,585.73 $1,585.73 67550 ORBITAL IMPLANT (OUTSIDE CONE) INSERTION $1,585.73 $1,585.73 $1,585.73 67560 ORBIT(IMPLA OUT MUS CON) REMOVAL OR REVI $1,339.05 $1,339.05 $1,339.05 67570 OPTIC NERV DECOMPRESSION $1,339.05 $1,339.05 $1,339.05 67599 UNLISTED PROCEDURE ORBIT $822.23 $822.23 $822.23 67700 BLEPHAROTOMY DRAINAGE ABCESS EYELID $822.23 $822.23 $822.23 67710 SEVERING TARSORRHAPHY $293.65 $293.65 $293.65 67715 CANTHOTOMY (SEPARATE PROCEDURE)67950,683 $293.65 $293.65 $293.65 67800 EXCISION CHALAZION SINGLE $822.23 $822.23 $822.23 67801 EXCISION CHALAZION MULTIPLE SAME LID $822.23 $822.23 $822.23 67805 EXCISION CHALAZION MULTIPLE DIFFER LIDS $822.23 $822.23 $822.23 67808 EXCISION CHALAZION ANESTH AN/OR HOS 1 OR $822.23 $822.23 $822.23 67810 BIOPSY EYELID $293.65 $293.65 $293.65 67825 CORRECT TRICHIASIS EPIL O/THAN FORCEPS $822.23 $822.23 $822.23 67830 CORRECT TRICHIAS INCISION LID MARGIN $822.23 $822.23 $822.23 67835 CORRECT TRICHIAS INCIS LID MARG FREE GRA $822.23 $822.23 $822.23 67840 EXCIS LESIO EYELID W/O CLOS W/SIMP DIR C $822.23 $822.23 $822.23 67850 DESTRUCT LESION LID MARGIN (UP TO ICM) $822.23 $822.23 $822.23 67875 TEMP CLOSURE EYELIDS BY SUTURE $822.23 $822.23 $822.23 67880 CONSTRUCT INTER ADHESION MEDIAN TARSOR/C $822.23 $822.23 $822.23 67882 CONSTRUCT ADHES TARSOR/CANTH W/TRANS TAR $822.23 $822.23 $822.23 67900 REPAIR BROW PTOSIS $822.23 $822.23 $822.23 67901 REPAIR BLEPHAR FRONT W/MUS SUT-OTH MATER $822.23 $822.23 $822.23 67902 REPAIR BLEPHAR FRONT MUS W/FAC SLING(INC $1,339.05 $1,339.05 $1,339.05 67903 REPA BLEPHAROP(TARSO)LEVATO RECT/ADV INT $1,339.05 $1,339.05 $1,339.05 67904 REPAI BLEPHARO(TARSO)LEVATOR RESC/AD EXT $1,339.05 $1,339.05 $1,339.05 67906 REPAIR BLEPHAROP SUPERIOR RECT W/SLING I $822.23 $822.23 $822.23 67908 CONJUNC-TARSO-MULLER-MUS-LEV RESE FAS-SE $822.23 $822.23 $822.23 67909 REDUCT OF OVERCORRE OF PTOSIS $822.23 $822.23 $822.23 67911 CORRECTION LID RETRACTION $822.23 $822.23 $822.23 67912 CX LAGOPHTHALMOS,UP EYELID LID LOAD IMPL $1,478.72 $1,478.72 $1,478.72 67914 REPAIR ECTROPION SUTURE $1,339.05 $1,339.05 $1,339.05 67915 REPAIR ECTROPION THE RMOCAUTERIZATION $1,339.05 $1,339.05 $1,339.05 67916 REPAIR ECTROPION BLEPHAROP EXCIS TAR WED $1,339.05 $1,339.05 $1,339.05 67917 BLEPHAROPLASTY EXTENSIVE $822.23 $822.23 $822.23 67921 REPAIR ENTROPION SUTURE $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 85 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 67922 REPAIR ENTROPION SUT THERMOCAUTER $1,339.05 $1,339.05 $1,339.05 67923 REPAIR ENTROP BLEPHAROP EXTENSIVE(WHEEL) $1,339.05 $1,339.05 $1,339.05 67924 REPAIR ENTROPION SUT BLEPHARO EXTENSIVE $822.23 $822.23 $822.23 67930 SUT RECENT WOUND EYELID INVOLLID,TARSUS, $822.23 $822.23 $822.23 67935 SUT RECNT WOUND EYELID LID,TARSUS,FUL TH $822.23 $822.23 $822.23 67938 REMOV EMBEDDED FB EYELID SEE OTHER NUMBE $822.23 $822.23 $822.23 67950 CANTHOPLASTY $1,339.05 $1,339.05 $1,339.05 67961 EXCIS/REPAIR EYELID FULL THICK 1/4 MARGI $822.23 $822.23 $822.23 67966 EXCISION AND REPAIR EYELID SEE BOOK OVER $822.23 $822.23 $822.23 67971 RECONSTRU EYELID FULL THICK BY TRANS SEE $822.23 $822.23 $822.23 67973 RECON EYELID FULL THICK TOTAL,LOW,1 STAG $822.23 $822.23 $822.23 67974 RECON EYELID FUL THICK TOT EYE,UP,1 STAG $822.23 $822.23 $822.23 67975 RECON EYE FUL THICK BY TRANS SECOND STAG $822.23 $822.23 $822.23 67999 UNLISTED PROCED EYELIDS $293.65 $293.65 $293.65 68020 INCIS CONJUNCT DRAINAGE CYST $822.23 $822.23 $822.23 68040 EXPRESSION CONJUNCT FOLLICLES(EG TRACHOM $822.23 $822.23 $822.23 68100 BIOPSY CONJUNCTIVIA $822.23 $822.23 $822.23 68110 EXCISION LESION CONJUNCTIVIA UP TO 1CM $822.23 $822.23 $822.23 68115 EXCISION LESION CONJUNCTIVIA OVER 1CM $822.23 $822.23 $822.23 68130 EXCISION LESION CONJUNCTIVIA W/ADJ SCLER $822.23 $822.23 $822.23 68135 DESTRUCTION LESION CONJUNCTIVIA $822.23 $822.23 $822.23 68200 SUBCONJUNCTIVAL INJECTION $822.23 $822.23 $822.23 68320 CONJUNCTIVOP W/CONJUNCT GRAF OR REARRANG $822.23 $822.23 $822.23 68325 CONJUNCTIVOP W/BUCCAL MUC MEMB GRAF INCL $822.23 $822.23 $822.23 68326 CONJUNTI RECON CUL-DE-SAC W/GRAF OR REAR $1,339.05 $1,339.05 $1,339.05 68328 CONJUN RECON CUL-DE-SAC W/BUCCAL GRAF IN $1,339.05 $1,339.05 $1,339.05 68330 REPAIR SYMBLEPHARON CONJUNCT W/O GRAFT $822.23 $822.23 $822.23 68335 REPAIR SYMBLEPHARON W/GRAF CONJ/BUCCAL M $822.23 $822.23 $822.23 68340 REPAIR SYMBLEPHARON DIVIS W/WO INSERT/LE $1,339.05 $1,339.05 $1,339.05 68360 CONJUN FLAP BRIDGE/PARTIAL (SEPAR PROCE) $822.23 $822.23 $822.23 68362 CONJUNCT FLAP TOTAL (EG GUNDERSON THIN) $822.23 $822.23 $822.23 68399 UNLISTED PROCEDURE CONJUNCTIVA $293.65 $293.65 $293.65 68400 INCISION DRAINAGE LACRIMAL GLAND $822.23 $822.23 $822.23 68420 INCISION DRAIN LACRIMAL SAC (DACRYOCYSTO $822.23 $822.23 $822.23 68440 SNIP INCISION LACRIMAL PUNCTUM $822.23 $822.23 $822.23 68500 EXCIS LACRIMAL GLAND EX FOR TUMOR TOTAL $822.23 $822.23 $822.23 68505 EXCIS LACRIMAL GLAND EX FOR TUMOR PARTIA $822.23 $822.23 $822.23 68510 BIOPSY LACRIMAL GLAND $293.65 $293.65 $293.65 68520 EXCISION LACRIMAL SAC(DACRYOCYSTECTOMY) $293.65 $293.65 $293.65 68525 BIOPSY LACRIMAL SAC $293.65 $293.65 $293.65 68530 REMOVAL FOREIGN BODY OR DACRYOLITH PASSA $1,339.05 $1,339.05 $1,339.05 68540 EXCIS LACRIMAL GLAND TUMOR FRONTAL APPRO $822.23 $822.23 $822.23 68550 EXCIS LAC GLAND TUMOR INVOLVING OSTEOTOM $822.23 $822.23 $822.23 68700 PLASTIC REPAIR CANALICULI $822.23 $822.23 $822.23 68705 CORRECTION EVERTED PUNCTUM CAUTERY $822.23 $822.23 $822.23 68720 DACRYOCYSTORHINOSTOMY(FISTTUL OF SAC/CAV $1,339.05 $1,339.05 $1,339.05 68745 CONJUNCT(FISTUL OF CONJUN TO NASAL CAVIT $1,339.05 $1,339.05 $1,339.05 68750 CONJUNCTIVORHINOSTOMY W/INSERT OF TUBE/S $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 86 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 68760 CLOSURE LACRIMAL PUNCTUM (THERMOCAUT/LIG $822.23 $822.23 $822.23 68761 CLOSURE OF THE LACRIMAL PUNCTUM PLUG, EA $822.23 $822.23 $822.23 68770 CLOSURE LACRIM FISTULA (SEPARATE PROCED) $822.23 $822.23 $822.23 68801 DILATION LACRIMAL PUNCTUM,W W/O IRRIGATI $822.23 $822.23 $822.23 68810 PROBING NASOLACRIMAL DUCT,W W/O IRRIGATI $1,339.05 $1,339.05 $1,339.05 68811 PROBING NASOLACRIM DUCT,REQ GEN ANESTHES $1,339.05 $1,339.05 $1,339.05 68815 PROBING NASOLACRIM DUCT,INSRT TUBE/STENT $822.23 $822.23 $822.23 68816 PROB NASOLACRIMAL DUCT,BALLOON CATH DILA $822.23 $822.23 $822.23 68840 PROB LACRIM CANALICULI W/WO IRRIGATION $822.23 $822.23 $822.23 68899 UNLISTED PROCEDURE LACRIMAL SYSTEM $293.65 $293.65 $293.65 69000 DRAINAGE EXTERNAL EAR ABCESS HEMATO SIMP $822.23 $822.23 $822.23 69005 DRAIN EXTERNAL EAR ABCESS HEMATO COMPLIC $822.23 $822.23 $822.23 69020 DRAINAGE EXTERN AUDITORY CANAL ABCESS $293.65 $293.65 $293.65 69100 BIOPSY EXTERNAL EAR $822.23 $822.23 $822.23 69105 BIOPSY EXT AUDITORY CANAL $822.23 $822.23 $822.23 69110 EXCISION EXTERN EAR PART/SIMPLE REPAIR $822.23 $822.23 $822.23 69120 EXCIS EXT EAR COMPLETE AMPUTATIONSE15102 $1,339.05 $1,339.05 $1,339.05 69140 EXCIS EXOSTOSIS(ES) EXT AUDITORY CANAL $822.23 $822.23 $822.23 69145 EXCIS SOFT TISSUE LESION EX AUDITO CANAL $822.23 $822.23 $822.23 69150 RAD EXCIS EX AUDIT CAN LESIO W/O NEC/DIS $1,339.05 $1,339.05 $1,339.05 69155 RAD EXCIS EX AUDIT CAN LESION W/NECK DIS $1,339.05 $1,339.05 $1,339.05 69205 REM FB EX AUDIT CAN W/GEN ANESTHESIA $293.65 $293.65 $293.65 69210 REM IMPACT CERUMEN(SEP PROCED)ONE/BOTH $293.65 $293.65 $293.65 69220 DEBRIDE MASTOID CAVITY SIMPLE $822.23 $822.23 $822.23 69222 DEBRIDE,MASTOIDECTOMY CAVITY COMPLEX $822.23 $822.23 $822.23 69300 OTOPLASTY,PROTRUDINGEAR; W/WO REDUCTION $822.23 $822.23 $822.23 69310 RECONSTRUCT EX AUDI CANAL(STEN/TRAUM/INF $1,339.05 $1,339.05 $1,339.05 69320 RECONSTRUCT EX/AUDIT CANAL CONJ ATRES SI $1,339.05 $1,339.05 $1,339.05 69399 UNLISTED PROCEDURE EXTERNAL EAR $822.23 $822.23 $822.23 69400 EUSTACHIAN TUBE INFLATION W/CATHETERIZAT $822.23 $822.23 $822.23 69401 EUSTACHIAN TUBE INFLATION W/O CATHERIZAT $822.23 $822.23 $822.23 69405 EUSTACHIAN TUBE CATHERIZATION TRANSTYMPA $822.23 $822.23 $822.23 69420 MYRINGOTOMY INC ASPIRATION AND/OR EUSTAC $822.23 $822.23 $822.23 69421 MYRINGOTOMY INC ASPIR-INFLAT GEN ANESTH $822.23 $822.23 $822.23 69424 REMOVE VENTILATING TUBE $822.23 $822.23 $822.23 69433 TYMPANOSTOMY(TUBE)LOCAL/TOP ANEST $822.23 $822.23 $822.23 69436 TYMPANOSTOMY(TUBE)GEN ANESTHESIA $822.23 $822.23 $822.23 69440 MIDDLE EAR EXPLOR POST AURICUL OR CANAL $1,339.05 $1,339.05 $1,339.05 69450 TYMPANOLYSIS TRANSCANAL $1,339.05 $1,339.05 $1,339.05 69501 TRANSMASTOID ANTROTOMY(SIMPLE MASTOIDECT $1,339.05 $1,339.05 $1,339.05 69502 MASTOIDECTOMY COMPLETE $1,339.05 $1,339.05 $1,339.05 69505 MASTOIDECTOMY MODIFIED RADICAL $1,339.05 $1,339.05 $1,339.05 69511 MASTOIDECTOMY RADICAL(SEE 15000 ET SEQ) $1,585.73 $1,585.73 $1,585.73 69530 PETROUS APICECTOMY INC RADICAL MASTOIDEC $1,585.73 $1,585.73 $1,585.73 69535 RESECTION TEMPORAL BONE EXTERNAL APPROAC $822.23 $822.23 $822.23 69540 EXCISION AURAL POLYP $822.23 $822.23 $822.23 69550 EXCISION AURAL GLOMUS TUMOR TRANSCANAL $822.23 $822.23 $822.23 69552 EXCISION AURAL GLOMUS TUMOR TRANSMASTOID $822.23 $822.23 $822.23

07/27/12 Page 87 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 69554 EXCISION AURAL GLOMUS TUMOR EXTENDED(TEM $822.23 $822.23 $822.23 69601 REVIS MASTOIDECTOMY RESULT COMP MASTOIDE $1,339.05 $1,339.05 $1,339.05 69602 REVIS MASTOIDECT RESULT MODIFI RAD MASTO $1,339.05 $1,339.05 $1,339.05 69603 REVIS MASTOID RESULT IN RADICAL MAST $1,585.73 $1,585.73 $1,585.73 69604 REVIS MASTOID RESULT IN TYMPANOPLASTY $1,339.05 $1,339.05 $1,339.05 69605 REVIS MASTOID W/APICECTOMY SEE 15120-21- $1,339.05 $1,339.05 $1,339.05 69610 TYMPANIC MEMB REPAIR W/WO PREP OR PATCH $1,585.73 $1,585.73 $1,585.73 69620 MYRINGOPLASTY (SURG CONFIN TO DRUM/DONOR $1,585.73 $1,585.73 $1,585.73 69631 TYMPANOPLASTY W/O MASTOIDECTOMY INI REVI $1,585.73 $1,585.73 $1,585.73 69632 TYMPANOPLASTY W/O MASTOID W OSSICULA CHN $1,585.73 $1,585.73 $1,585.73 69633 TYMPANOPLASTY W OSS CHAIN RECON & PROSTH $1,585.73 $1,585.73 $1,585.73 69635 TYMPANOPLASTY W ANTROTOMY OR MASTOIDOTOM $1,339.05 $1,339.05 $1,339.05 69636 TYMPANPLASTY SEE BOOK W/OSSICULAR CHAIN $1,585.73 $1,585.73 $1,585.73 69637 TYMPANOPLASTY W ANTROTOMY-MASTOID PROSTH $1,585.73 $1,585.73 $1,585.73 69641 TYMPANOPLASTY MASTOID W/O OSSIC CHAIN RE $1,339.05 $1,339.05 $1,339.05 69642 TYMPANOPLASTY W/MASTOIDECT W/OSSI CHAIN $1,585.73 $1,585.73 $1,585.73 69643 TYMPANOPLASTY W/MASTOID W/INTACT REONSTR $1,339.05 $1,339.05 $1,339.05 69644 TYMPANOPLASTY W/MASTOIDECT SEE BOOK $1,585.73 $1,585.73 $1,585.73 69645 TYMPANOPLASTY MASTOIDECT SEE BOOK $1,339.05 $1,339.05 $1,339.05 69646 TYMPANOPLASTY WITH MASTOIDECTO SEE BOOK $1,585.73 $1,585.73 $1,585.73 69650 STAPES MOBILIZATION $1,585.73 $1,585.73 $1,585.73 69660 SPANEDEC/STAPECT W REESTAB OSSI CONTIN $1,585.73 $1,585.73 $1,585.73 69661 STAPEDECTOMY W/OSSICU W/WO MATER W/FOOTP $1,585.73 $1,585.73 $1,585.73 69662 REVIS SPAPEDECT OR STAPDOTOMY $1,585.73 $1,585.73 $1,585.73 69666 REPAIR OVAL WINDOW FISTULA $822.23 $822.23 $822.23 69667 REPAIR ROUND WINDOW FISTULA $822.23 $822.23 $822.23 69670 MASTOID OBLITERATION (SEPARATE PROCED) $822.23 $822.23 $822.23 69676 TYMPANIC NEURECTOMY $1,339.05 $1,339.05 $1,339.05 69700 CLOS POST FIST MASTOID (SEPAR PROCED $822.23 $822.23 $822.23 69710 IMPLANT-REPLA BONE CONDUCT DEVICE TEMPOR $822.23 $822.23 $822.23 69711 REMOV-REPAIR BONE CONDUCT DEVICE TEMPORA $1,339.05 $1,339.05 $1,339.05 69714 IMPLANT,OSSEOINTEGRATE;W/O MASTOIDECTOMY $34,416.14 $34,416.14 $34,416.14 69715 IMPLANT,OSSEOINTEGRATE; W/MASTOIDECTOMY $34,416.14 $34,416.14 $34,416.14 69717 REPLACE,OSSEOINTEGR IMPL;W/O MASTOIDECTO $34,416.14 $34,416.14 $34,416.14 69718 REPLACE,OSSEOINTEGR IMPL; W/ MASTOIDECTO $34,416.14 $34,416.14 $34,416.14 69720 DECOMPRESS FACIAL NERVE INTRA GENIC GANG $1,339.05 $1,339.05 $1,339.05 69725 DECOMPRES FAC NERV INTRA INC MED GEN GAN $1,339.05 $1,339.05 $1,339.05 69740 SUT FAC NERV INTRA LAT TO GENIC GANGLION $1,339.05 $1,339.05 $1,339.05 69745 SUT FAC NERV INTRA INCLUD MEDI GENIC GAN $1,339.05 $1,339.05 $1,339.05 69799 UNLISTED PROCEDURE MIDDLE EAR $822.23 $822.23 $822.23 69801 LABYRINTHOTOMY W/WO CRYOSUR/OTHER DESTRU $822.23 $822.23 $822.23 69802 LYBRINTHOTOMY SEE BOOK W/MASTOIDECTOMY $1,339.05 $1,339.05 D 69805 ENDOLYMPHATIC SAC OPER W/O SHUNT $822.23 $822.23 $822.23 69806 ENDDOLYMPHATIC SAC OPERATION WITH SHUNT $1,585.73 $1,585.73 $1,585.73 69820 FENESTRATION SEMICIRCULAR CANAL $1,585.73 $1,585.73 $1,585.73 69840 REVISION FENESTRATION OPERATION $1,585.73 $1,585.73 $1,585.73 69905 LABYRINTHECTOMY TRANSCANAL $822.23 $822.23 $822.23 69910 LABYRINTHECTOMY WITH MASTOIDECTOMY $1,339.05 $1,339.05 $1,339.05

07/27/12 Page 88 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 69915 VESTIBULAR NERVE SECTION TRANSLABYRINTHI $1,585.73 $1,585.73 $1,585.73 69930 COCHLEAR DEVICE IMPLANT W/WO MASTOIDECTO $34,416.14 $34,416.14 $34,416.14 69949 UNLISTED PROCEDURE INNER EAR $822.23 $822.23 $822.23 69955 TOTAL FACIAL NERVE DECOMPRESS AND/OR REP $1,339.05 $1,339.05 $1,339.05 69960 DECOMPRESS INTER AUDITORY CANAL $822.23 $822.23 $822.23 69970 REMOVAL OF TUMOR $822.23 $822.23 $822.23 69979 UNLISTED PROCEDURE TEMPORAL BONE MID/FOS $1,339.05 $1,339.05 $1,339.05 92018 OPHTHAL EXAM W/ANEST W/WO MANIP.COMPLETE $293.65 $293.65 $293.65 92019 OPHTHAL EXAM W/ANEST W/WO MANIP..LIMITED $293.65 $293.65 $293.65 92502 OTOLARYNGOLOGIC EXAM GENERAL ANES $293.65 $293.65 $293.65 92511 NASOPHARYNGOSCOPY W ENDOSCOPY $293.65 $293.65 $293.65 92970 CARDIOASSIST METHOD CIRC ASSIST INTERNAL $1,339.05 $1,339.05 $1,339.05 92980 TRANSCATH PLACE INTRACORO STNT PERCUT SG $1,339.05 $1,339.05 $1,339.05 92982 PERCUTANEOUS TRANSLU CORO BAL ANGIO; SGL $1,339.05 $1,339.05 $1,339.05 92986 PERCUT BALLOON VALVULOPLASTY AORTIC VALV $2,936.54 $2,936.54 $2,936.54 92987 PERCUT BALLOON VALVULOPLASTY; MITRAL VAL $2,936.54 $2,936.54 $2,936.54 92990 PERCU BALLOON VALVULOPLASTY PULMONAR VAL $2,936.54 $2,936.54 $2,936.54 92995 PERCUT TRANSLUM COR ATHERECTOMY SNG VESS $1,339.05 $1,339.05 $1,339.05 92997 PERCU TRNSLUM PULM ART BALO ANGIO;SIN VE $1,339.05 $1,339.05 $1,339.05 93451 $2,936.54 $2,936.54 93452 $2,936.54 $2,936.54 93453 $2,936.54 $2,936.54 93454 $2,936.54 $2,936.54 93455 $2,936.54 $2,936.54 93456 $2,936.54 $2,936.54 93457 $2,936.54 $2,936.54 93458 $2,936.54 $2,936.54 93459 $2,936.54 $2,936.54 93460 $2,936.54 $2,936.54 93461 $2,936.54 $2,936.54 93462 $2,936.54 $2,936.54 93463 $2,936.54 $2,936.54 93464 $2,936.54 $2,936.54 93501 RT HEART CATHETERIZATION $2,936.54 D D 93503 CARD-CATH PLACEMENT FLOW DIRECT MONITOR $2,936.54 $2,936.54 $2,936.54 93505 ENDOMYOCARDIAL BIOPSY $2,936.54 $2,936.54 $2,936.54 93510 LFT HEART CATHETERIZATION RETROGRADE $2,936.54 D D 93511 LFT HEART CATHETERIZATION CUTDOWN $2,936.54 D D 93514 LFT HEART CATH BY LFT VEN PUNCTURE $2,936.54 D D 93524 COMBINED TRANSSEPTAL RETROGRADE LFT CATH $2,936.54 D D 93526 COMBINE RT HEART CATH RETROGRADE LFT $2,936.54 D D 93527 COMBIN R HEART CATH-TRANSSEPTAL L HEART $2,936.54 D D 93528 COMBINE RT HEART CATH LFT VENTRIC PUNCT $2,936.54 D D 93529 RIGHT & LEFT HEART CATHETERIZATION $2,936.54 D D 93530 RT HEART CATH FOR CONGENITAL ANOMALIES $2,936.54 $2,936.54 $2,936.54 93531 COMB R HRT CATH&RETROG L CATH-CON ANOMAL $2,936.54 $2,936.54 $2,936.54 93532 COMB R HRT CATH&TRNSEPT L H CAT-INTA SEP $2,936.54 $2,936.54 $2,936.54 93533 COMB R HRT CATH&TRNSEP L H CAT-EXST OPNG $2,936.54 $2,936.54 $2,936.54

07/27/12 Page 89 of 90 PROC DESCRIPTION 2010 Rate 2011 Rate 2012 Rate 93563 $2,936.54 $2,936.54 $2,936.54 93564 $2,936.54 $2,936.54 $2,936.54 93565 $2,936.54 $2,936.54 $2,936.54 93566 $2,936.54 $2,936.54 $2,936.54 93567 $2,936.54 $2,936.54 $2,936.54 93568 $2,936.54 $2,936.54 $2,936.54 93610 INTRA ATRIAL PACING $1,339.05 $1,339.05 $1,339.05 93612 INTRAVENTRICULAR PACING $1,339.05 $1,339.05 $1,339.05 93616 ESOPH RECORD ATRIAL ELECTOCARD W PACING $1,339.05 $1,339.05 $1,339.05 93618 INDUCTION OF ARRHYTHMIA BY ELECT PACING $1,339.05 $1,339.05 $1,339.05 93619 COMP ELECTROPHYS EVAL WO INDUC ARRHYTHMI $1,339.05 $1,339.05 $1,339.05 93620 COMPREHENSIVE ELECTROPHYSIOLOGY EVAL $1,339.05 $1,339.05 $1,339.05 93624 ELECTROPHY F/UP W PAC EFF THERPY INC.IND $1,339.05 $1,339.05 $1,339.05 93631 INTRA-OPERT EPICARD&ENDOCARD PAC & MAPPI $1,339.05 $1,339.05 $1,339.05 93640 ELECTROPHYS EVAL CARDIOVERT-DEFIB LEAD $1,339.05 $1,339.05 $1,339.05 93641 ELECTROPHYS EVAL TEST CARDIOV-DEFIBR GEN $1,339.05 $1,339.05 $1,339.05 93650 INTRACARDIAC CATH ABLA OF ATRIOVENT NODE $1,585.73 $1,585.73 $1,585.73 93651 INTRACARDIAC CATH ABLATION ARRHYTHMOGEN $1,585.73 $1,585.73 $1,585.73 93652 CARDIAC CATH ABLAT ARRHYT TRT TACHYCARDI $1,585.73 $1,585.73 $1,585.73 0017T DESTRUCT MACULAR DRUSEN,PHOTOCOAGULATION $350.00 D D 0019T EXTRACORPOREAL SHOCK WAVE THERAPY;MUSCUL $6,342.91 $6,342.91 $6,342.91 0071T FOCUS U-SND ABLAT/UTER LEIOMYOMATA<200CC $822.23 $822.23 $822.23 D7210 ORAL SURG EXTRACTION OF TOOTH ERUPTED $822.23 $822.23 $822.23 D7220 ORAL SURG IMPACT REQUIR INIC REM TOOTH $822.23 $822.23 $822.23 D7230 ORAL SURG IMPAC INCIS REM BONE AND TOOTH $822.23 $822.23 $822.23 D7240 ORAL SURG IMPAC INCIS REM/BONE-TOOTH-SEC $822.23 $822.23 $822.23 D7241 IMPACT INCIS REM/BONE SEC TOOTH-DIFFICUL $822.23 $822.23 $822.23 D7250 ORAL SURG ROOT RECOVERY (SURGI REM RES F $822.23 $822.23 $822.23

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