2019 & 2020 Facility Scoring Methodology for Cost & Quality

2019 & 2020 Facility Scoring Methodology for Cost & Quality Designations

In keeping with its goal of providing members with high-quality, lower-cost health care, Blue Cross Blue Shield of North Carolina (BCBSNC) developed the following methodology to best evaluate the quality and efficiency of partner facilities. Based on evaluation results, BCBSNC will designate PPO network facilities as Low Cost High Quality, High Quality, or Not Designated (NOTE: Critical Access facilities will maintain their Critical Access designation).

This document describes the methodology used by Blue Cross NC for the 2019 and 2020 Cost & Quality Designations and is provided for informational purposes only.

Designation Overview BCBSNC will base its designations on quality and efficiency. Any facility that does not meet the quality criteria will not be designated. Any practice that meets the quality criteria will also be assessed on efficiency criteria to determine its final designation.

Please note, the designation is made at the facility level and only includes In-network Facilities contracted with BCBSNC. The initial driver of eligibility is the ability to meet the quality standards set forth in BCBSNC’s Facility-level standards (described below). Facilities that are unable to meet the quality standard for the network are not designated.

Facilities that qualify for designation based on their quality evaluation will then be evaluated against BCBSNC’s efficiency criteria (described below) to determine if the organization meets the standards for the Low Cost High Quality designation. Facilities that meet both the quality and efficiency standards are designated as Low Cost High Quality. Facilities that meet the quality standard, but do not attain the efficiency standard, are designated as High Quality.

Tiered Network Product Quality Thresholds for Facilities The quality scoring methodology considers measures from the Hospital Compare plus a risk adjusted readmission rate measure from BCBSNC claim data. These measures assess Health Outcomes and Patient Safety (70%), Resource Use (10%), and Patient Experience (20%). The performance on each measure derives is scored based on percentile and combined into an overall score. A facility’s quality score must be above the lower quartile compared to all partner facilities to be considered a pass of the quality evaluation.

See Appendix below for underlying measures and methodology.

Efficiency Threshold for Facilities With the quality standards in place, BCBSNC then analyzed claims to stratify facilities on the basis of efficiency performance.The objective of this analysis was to distinguish between the Low Cost High Quality designation and the High Quality designation.

Facilities were assigned to cohorts based on bed size, total volume, transfers and the provision of certain types of services including burns, trauma, transplants, maternity, hip and knee arthroplasty, spine surgery, oncology, complex cardiology, and complex neurology.Bed size was obtained from the NC Division of Health Services Regulation and service volume was determined from claims from October 2016 through September 2017. Peer cohorts were established using Cohort Analysis, which identifies patterns of similarity in the selected characteristics and then classifies Facilities into groups, called “Peer Cohorts” here forward.

Cluster Variable Defined as DRGs/MDCs defining service line Hospital Beds Total hospital beds (Source: NC Division of N/A Health Services Regulation, downloaded 2/9/17 from www.ncdhhs.gov/dhsr/reports.htm) Total Volume Total volume All Transfer Dichotomous indicator if volume of cases as All a result of a transfer from another facility designated by discharge status => 10 Maternity Volume of maternity cases / total volume MDC 14 Hip & Knee Volume of hip and knee arthroplasty DRGs 469, 470, 480, 481, 461, 462, 483, Arthroplasty cases/total volume 468, 466, 467 Spine Surgery Dichotomous indicator if volume of spinal DRGs 460, 455, 456, 457, 458, 453, 454, surgery cases => 10 471, 472, 473, 459, 515, 516 Oncology Dichotomous indicator if volume of MDC 17, DRGs 054, 055, 333, 334, 374, oncology cases >= 10 375, 376, 435, 436, 437, 582, 583, 666, 667, 668, 669, 670, 711, 712, 722, 723, 736, 737, 738, 739, 740, 741, 744, 826, 827, 745, 754, 755, 756, 686, 687, 656, 657, 658, 584, 585, 597, 598, 688, 828, 829, 830, 843, 844, 845 Complex Dichotomous indicator if volume of complex DRGs 216, 217, 218, 219, 220, 221, 231, Cardiology cardiology cases >= 10 232, 233, 234, 228, 229, 230, 235, 236, 242, 243, 244, 21, 217, 218, 231, 232, 228, 229, 260, 261, 270, 271, 224, 225, 226, 227, 273, 274 Complex Dichotomous indicator if volume of DRGs 023, 024, 025, 026, 027, 031, 032, Neurology craniotomy cases >= 10 033 Burns or Trauma Dichotomous indicator if total volume of MDC 22, 24 trauma or burns => 10 Transplants Dichotomous indicator if total volume of DRGs 001, 002, 005, 006, 007, 008, 014, transplants => 5 016, 017, 652

Next, two metrics of efficiency performance were constructed based on inpatient and outpatient claims for Facilities within each peer cohort. Data preparation and analytical approaches for the evaluation are described below.

Inpatient Costs  Analyses were conducted on inpatient case data for services performed between October 2016 – September 2017.  Includes Inpatient allowed facility costs only (i.e. no professional or ancillary costs)  Lines of business: Blue Options (Group Underwritten, ASO, State Health Plan, Blue Select/Blue Select Plus, CDHP), Blue Advantage (Individual, CDHP).  Excludes denials, Medicare crossovers, COB, and State Health Plan retirees.  To reduce the effect of outliers, allowed costs were truncated at the 95th percentile by MS DRG. Analysis is limited to those MS DRGs performed at least 30 times at a minimum of two facilities statewide.  Two inpatient cost metrics were computed for each facility called “observed” and “expected” costs. o Expected costs were determined by calculating the average cost for each MS DRG within a peer cohort if there were at least 30 cases in a minimum of 2 facilities; if there was insufficient volume within a peer cohort, the expected costs reflect the average cost for Facilities statewide. o Observed costs are equivalent to the allowed costs. Observed and expected costs were summed for all cases with sufficient MS DRG volume. 2

 All DRGs were evaluated. If DRGs are missing, there was not enough volume to be evaluated. In the following table, "Cohort" refers to the DRG analysis within the cohort only. "Statewide" refers to the DRG analysis done statewide due to the low volume.

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 003 ECMO OR TRACH W MV 96+ HRS OR PDX EXC statewide statewide statewide cohort FACE, MOUTH & NECK W MAJ O.R. 004 TRACH W MV 96+ HRS OR PDX EXC FACE, statewide statewide statewide statewide statewide MOUTH & NECK W/O MAJ O.R. 014 ALLOGENEIC BONE MARROW TRANSPLANT statewide 016 AUTOLOGOUS BONE MARROW TRANSPLANT W statewide CC/MCC 023 CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX statewide statewide cohort CNS PDX W MCC OR CHEMO IMPLANT 025 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide cohort cohort PROCEDURES W MCC 026 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide statewide statewide cohort PROCEDURES W CC 027 CRANIOTOMY & ENDOVASCULAR INTRACRANIAL statewide statewide cohort cohort PROCEDURES W/O CC/MCC 029 SPINAL PROCEDURES W CC OR SPINAL statewide statewide cohort NEUROSTIMULATORS 030 SPINAL PROCEDURES W/O CC/MCC statewide statewide cohort 039 EXTRACRANIAL PROCEDURES W/O CC/MCC statewide statewide cohort cohort statewide 054 NERVOUS SYSTEM NEOPLASMS W MCC statewide statewide statewide cohort 055 NERVOUS SYSTEM NEOPLASMS W/O MCC statewide statewide statewide statewide cohort 057 DEGENERATIVE NERVOUS SYSTEM DISORDERS statewide statewide statewide statewide statewide statewide W/O MCC 060 MULTIPLE SCLEROSIS & CEREBELLAR ATAXIA statewide statewide statewide statewide W/O CC/MCC 064 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide statewide cohort cohort INFARCTION W MCC 065 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide cohort cohort cohort cohort statewide INFARCTION W CC OR TPA IN 24 HRS 066 INTRACRANIAL HEMORRHAGE OR CEREBRAL statewide cohort cohort cohort cohort statewide INFARCTION W/O CC/MCC 069 TRANSIENT ISCHEMIA statewide statewide statewide cohort statewide statewide 070 NONSPECIFIC CEREBROVASCULAR DISORDERS W statewide statewide statewide statewide MCC 074 CRANIAL & PERIPHERAL NERVE DISORDERS W/O statewide statewide cohort statewide statewide MCC 076 VIRAL MENINGITIS W/O CC/MCC statewide statewide statewide statewide statewide 087 TRAUMATIC STUPOR & COMA, COMA <1 HR statewide statewide statewide cohort W/O CC/MCC 091 OTHER DISORDERS OF NERVOUS SYSTEM W statewide statewide statewide statewide MCC 092 OTHER DISORDERS OF NERVOUS SYSTEM W CC statewide statewide statewide statewide statewide 093 OTHER DISORDERS OF NERVOUS SYSTEM W/O statewide statewide statewide statewide statewide CC/MCC 100 SEIZURES W MCC statewide statewide statewide statewide statewide 101 SEIZURES W/O MCC statewide cohort cohort cohort cohort statewide 103 HEADACHES W/O MCC statewide statewide cohort cohort cohort statewide 132 CRANIAL/FACIAL PROCEDURES W/O CC/MCC statewide statewide cohort statewide 134 OTHER EAR, NOSE, MOUTH & THROAT O.R. statewide statewide statewide statewide PROCEDURES W/O CC/MCC 149 DYSEQUILIBRIUM statewide statewide statewide statewide statewide 153 OTITIS MEDIA & URI W/O MCC statewide statewide statewide cohort cohort statewide 163 MAJOR CHEST PROCEDURES W MCC statewide statewide statewide statewide 164 MAJOR CHEST PROCEDURES W CC statewide statewide statewide cohort cohort 165 MAJOR CHEST PROCEDURES W/O CC/MCC statewide statewide cohort cohort 166 OTHER RESP SYSTEM O.R. PROCEDURES W MCC statewide statewide statewide statewide 167 OTHER RESP SYSTEM O.R. PROCEDURES W CC statewide statewide statewide statewide

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 168 OTHER RESP SYSTEM O.R. PROCEDURES W/O statewide statewide statewide statewide CC/MCC 175 PULMONARY EMBOLISM W MCC statewide statewide statewide cohort statewide 176 PULMONARY EMBOLISM W/O MCC statewide cohort cohort cohort cohort statewide 177 RESPIRATORY INFECTIONS & INFLAMMATIONS statewide statewide statewide cohort cohort W MCC 178 RESPIRATORY INFECTIONS & INFLAMMATIONS statewide statewide statewide statewide statewide W CC 180 RESPIRATORY NEOPLASMS W MCC statewide statewide statewide statewide statewide 181 RESPIRATORY NEOPLASMS W CC statewide statewide statewide statewide 189 PULMONARY EDEMA & RESPIRATORY FAILURE statewide cohort cohort cohort statewide statewide 190 CHRONIC OBSTRUCTIVE PULMONARY DISEASE statewide cohort cohort cohort cohort W MCC 191 CHRONIC OBSTRUCTIVE PULMONARY DISEASE statewide cohort cohort statewide statewide W CC 192 CHRONIC OBSTRUCTIVE PULMONARY DISEASE statewide cohort cohort statewide statewide statewide W/O CC/MCC 193 SIMPLE PNEUMONIA & PLEURISY W MCC statewide cohort cohort cohort cohort 194 SIMPLE PNEUMONIA & PLEURISY W CC statewide cohort cohort cohort cohort statewide 195 SIMPLE PNEUMONIA & PLEURISY W/O CC/MCC statewide cohort cohort cohort statewide statewide 200 PNEUMOTHORAX W CC statewide statewide statewide statewide statewide 201 PNEUMOTHORAX W/O CC/MCC statewide statewide statewide statewide statewide 202 BRONCHITIS & ASTHMA W CC/MCC statewide cohort cohort cohort cohort statewide 203 BRONCHITIS & ASTHMA W/O CC/MCC statewide cohort cohort cohort cohort statewide 204 RESPIRATORY SIGNS & SYMPTOMS statewide statewide statewide statewide statewide 206 OTHER RESPIRATORY SYSTEM DIAGNOSES W/O statewide statewide statewide statewide statewide MCC 207 RESPIRATORY SYSTEM DIAGNOSIS W statewide statewide statewide statewide statewide VENTILATOR SUPPORT 96+ HOURS 208 RESPIRATORY SYSTEM DIAGNOSIS W statewide statewide statewide cohort cohort statewide VENTILATOR SUPPORT <96 HOURS 219 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC statewide statewide cohort PROC W/O CARD CATH W MCC 220 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC statewide cohort cohort PROC W/O CARD CATH W CC 221 CARDIAC VALVE & OTH MAJ CARDIOTHORACIC statewide statewide statewide PROC W/O CARD CATH W/O CC/MCC 227 CARDIAC DEFIBRILLATOR IMPLANT W/O statewide statewide statewide CARDIAC CATH W/O MCC 229 OTHER CARDIOTHORACIC PROCEDURES W CC statewide statewide statewide 233 CORONARY BYPASS W CARDIAC CATH W MCC statewide cohort statewide 234 CORONARY BYPASS W CARDIAC CATH W/O MCC statewide cohort cohort statewide 235 CORONARY BYPASS W/O CARDIAC CATH W MCC statewide statewide cohort 236 CORONARY BYPASS W/O CARDIAC CATH W/O cohort cohort cohort MCC 237 MAJOR CARDIOVASC PROCEDURES W MCC statewide statewide statewide cohort cohort 238 MAJOR CARDIOVASC PROCEDURES W/O MCC statewide statewide statewide cohort cohort statewide 243 PERMANENT CARDIAC PACEMAKER IMPLANT W statewide statewide statewide statewide CC 244 PERMANENT CARDIAC PACEMAKER IMPLANT statewide statewide statewide statewide W/O CC/MCC 246 PERC CARDIOVASC PROC W DRUG-ELUTING statewide cohort cohort statewide STENT W MCC OR 4+ VESSELS/STENTS 247 PERC CARDIOVASC PROC W DRUG-ELUTING cohort cohort cohort cohort STENT W/O MCC 249 PERC CARDIOVASC PROC W NON-DRUG- statewide statewide statewide statewide ELUTING STENT W/O MCC 250 PERC CARDIOVASC PROC W/O CORONARY statewide statewide statewide ARTERY STENT W MCC 251 PERC CARDIOVASC PROC W/O CORONARY statewide cohort cohort cohort ARTERY STENT W/O MCC 252 OTHER VASCULAR PROCEDURES W MCC statewide statewide statewide statewide statewide statewide 253 OTHER VASCULAR PROCEDURES W CC statewide statewide cohort statewide 4

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 254 OTHER VASCULAR PROCEDURES W/O CC/MCC statewide statewide statewide statewide statewide 280 ACUTE MYOCARDIAL INFARCTION, DISCHARGED statewide statewide statewide statewide statewide statewide ALIVE W MCC 281 ACUTE MYOCARDIAL INFARCTION, DISCHARGED cohort cohort cohort statewide ALIVE W CC 282 ACUTE MYOCARDIAL INFARCTION, DISCHARGED statewide cohort cohort cohort cohort ALIVE W/O CC/MCC 286 CIRCULATORY DISORDERS EXCEPT AMI, W CARD statewide statewide statewide cohort statewide CATH W MCC 287 CIRCULATORY DISORDERS EXCEPT AMI, W CARD statewide cohort cohort cohort cohort CATH W/O MCC 291 HEART FAILURE & SHOCK W MCC statewide cohort cohort cohort cohort statewide 292 HEART FAILURE & SHOCK W CC statewide cohort cohort cohort cohort statewide 293 HEART FAILURE & SHOCK W/O CC/MCC statewide statewide statewide statewide statewide statewide 299 PERIPHERAL VASCULAR DISORDERS W MCC statewide statewide statewide statewide statewide 300 PERIPHERAL VASCULAR DISORDERS W CC statewide statewide statewide statewide statewide statewide 301 PERIPHERAL VASCULAR DISORDERS W/O statewide statewide statewide statewide statewide CC/MCC 303 ATHEROSCLEROSIS W/O MCC statewide statewide statewide statewide statewide 305 HYPERTENSION W/O MCC statewide cohort cohort statewide cohort 308 CARDIAC ARRHYTHMIA & CONDUCTION statewide statewide statewide cohort statewide statewide DISORDERS W MCC 309 CARDIAC ARRHYTHMIA & CONDUCTION statewide cohort cohort cohort cohort DISORDERS W CC 310 CARDIAC ARRHYTHMIA & CONDUCTION statewide cohort cohort cohort cohort statewide DISORDERS W/O CC/MCC 312 SYNCOPE & COLLAPSE statewide cohort statewide cohort statewide 313 CHEST PAIN statewide cohort cohort cohort statewide 314 OTHER CIRCULATORY SYSTEM DIAGNOSES W statewide statewide cohort cohort cohort MCC 315 OTHER CIRCULATORY SYSTEM DIAGNOSES W CC statewide statewide statewide statewide cohort statewide 316 OTHER CIRCULATORY SYSTEM DIAGNOSES W/O statewide statewide statewide statewide statewide statewide CC/MCC 326 STOMACH, ESOPHAGEAL & DUODENAL PROC W statewide statewide statewide statewide statewide MCC 327 STOMACH, ESOPHAGEAL & DUODENAL PROC W statewide statewide cohort cohort CC 328 STOMACH, ESOPHAGEAL & DUODENAL PROC statewide cohort cohort cohort W/O CC/MCC 329 MAJOR SMALL & LARGE BOWEL PROCEDURES W statewide cohort cohort cohort cohort MCC 330 MAJOR SMALL & LARGE BOWEL PROCEDURES W statewide cohort cohort cohort cohort statewide CC 331 MAJOR SMALL & LARGE BOWEL PROCEDURES statewide cohort cohort cohort cohort statewide W/O CC/MCC 333 RECTAL RESECTION W CC statewide statewide statewide statewide statewide 334 RECTAL RESECTION W/O CC/MCC statewide statewide statewide statewide statewide 336 PERITONEAL ADHESIOLYSIS W CC statewide statewide statewide cohort cohort 337 PERITONEAL ADHESIOLYSIS W/O CC/MCC statewide statewide statewide statewide statewide 339 APPENDECTOMY W COMPLICATED PRINCIPAL statewide statewide statewide statewide DIAG W CC 340 APPENDECTOMY W COMPLICATED PRINCIPAL statewide cohort statewide cohort statewide statewide DIAG W/O CC/MCC 342 APPENDECTOMY W/O COMPLICATED PRINCIPAL statewide statewide statewide statewide statewide DIAG W CC 343 APPENDECTOMY W/O COMPLICATED PRINCIPAL statewide cohort statewide statewide statewide DIAG W/O CC/MCC 345 MINOR SMALL & LARGE BOWEL PROCEDURES W statewide statewide statewide statewide statewide CC 346 MINOR SMALL & LARGE BOWEL PROCEDURES statewide statewide statewide statewide statewide statewide W/O CC/MCC 348 ANAL & STOMAL PROCEDURES W CC statewide statewide statewide statewide statewide 349 ANAL & STOMAL PROCEDURES W/O CC/MCC statewide statewide statewide statewide statewide 5

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 354 HERNIA PROCEDURES EXCEPT INGUINAL & statewide statewide statewide statewide statewide statewide FEMORAL W CC 355 HERNIA PROCEDURES EXCEPT INGUINAL & statewide statewide statewide statewide cohort statewide FEMORAL W/O CC/MCC 356 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W statewide statewide statewide statewide MCC 357 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES W statewide statewide statewide statewide statewide CC 358 OTHER DIGESTIVE SYSTEM O.R. PROCEDURES statewide statewide statewide statewide W/O CC/MCC 369 MAJOR ESOPHAGEAL DISORDERS W CC statewide statewide statewide statewide statewide 371 MAJOR GASTROINTESTINAL DISORDERS & statewide statewide statewide statewide statewide PERITONEAL INFECTIONS W MCC 372 MAJOR GASTROINTESTINAL DISORDERS & statewide statewide cohort cohort statewide statewide PERITONEAL INFECTIONS W CC 373 MAJOR GASTROINTESTINAL DISORDERS & statewide statewide statewide cohort statewide PERITONEAL INFECTIONS W/O CC/MCC 374 DIGESTIVE MALIGNANCY W MCC statewide statewide statewide statewide 375 DIGESTIVE MALIGNANCY W CC statewide statewide statewide statewide 377 G.I. HEMORRHAGE W MCC statewide statewide statewide statewide statewide statewide 378 G.I. HEMORRHAGE W CC statewide cohort cohort cohort cohort statewide 379 G.I. HEMORRHAGE W/O CC/MCC statewide statewide statewide statewide statewide 381 COMPLICATED PEPTIC ULCER W CC statewide statewide statewide statewide statewide 384 UNCOMPLICATED PEPTIC ULCER W/O MCC statewide statewide statewide statewide statewide 385 INFLAMMATORY BOWEL DISEASE W MCC statewide statewide statewide statewide statewide 386 INFLAMMATORY BOWEL DISEASE W CC statewide cohort cohort cohort cohort 387 INFLAMMATORY BOWEL DISEASE W/O CC/MCC statewide statewide statewide cohort cohort statewide 388 G.I. OBSTRUCTION W MCC statewide statewide statewide statewide statewide 389 G.I. OBSTRUCTION W CC statewide cohort cohort cohort cohort statewide 390 G.I. OBSTRUCTION W/O CC/MCC statewide cohort cohort cohort cohort statewide 391 ESOPHAGITIS, GASTROENT & MISC DIGEST statewide cohort cohort cohort cohort statewide DISORDERS W MCC 392 ESOPHAGITIS, GASTROENT & MISC DIGEST cohort cohort cohort cohort cohort statewide DISORDERS W/O MCC 393 OTHER DIGESTIVE SYSTEM DIAGNOSES W MCC statewide statewide statewide statewide cohort statewide 394 OTHER DIGESTIVE SYSTEM DIAGNOSES W CC statewide cohort cohort cohort cohort statewide 395 OTHER DIGESTIVE SYSTEM DIAGNOSES W/O statewide statewide statewide cohort statewide statewide CC/MCC 406 PANCREAS, LIVER & SHUNT PROCEDURES W CC statewide statewide cohort statewide 407 PANCREAS, LIVER & SHUNT PROCEDURES W/O statewide statewide statewide statewide statewide CC/MCC 416 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE statewide statewide statewide statewide statewide W/O C.D.E. W/O CC/MCC 417 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. statewide statewide statewide statewide statewide statewide W MCC 418 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. statewide cohort cohort cohort cohort statewide W CC 419 LAPAROSCOPIC CHOLECYSTECTOMY W/O C.D.E. statewide cohort cohort cohort cohort W/O CC/MCC 432 CIRRHOSIS & ALCOHOLIC HEPATITIS W MCC statewide statewide statewide statewide statewide statewide 433 CIRRHOSIS & ALCOHOLIC HEPATITIS W CC statewide statewide statewide statewide statewide 435 MALIGNANCY OF HEPATOBILIARY SYSTEM OR statewide statewide statewide statewide statewide statewide PANCREAS W MCC 436 MALIGNANCY OF HEPATOBILIARY SYSTEM OR statewide statewide statewide statewide PANCREAS W CC 438 DISORDERS OF PANCREAS EXCEPT MALIGNANCY statewide statewide statewide statewide statewide statewide W MCC 439 DISORDERS OF PANCREAS EXCEPT MALIGNANCY statewide cohort cohort cohort cohort W CC 440 DISORDERS OF PANCREAS EXCEPT MALIGNANCY statewide cohort cohort cohort cohort statewide W/O CC/MCC 441 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC statewide statewide statewide statewide cohort statewide HEPA W MCC 6

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 442 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC statewide statewide statewide cohort cohort statewide HEPA W CC 443 DISORDERS OF LIVER EXCEPT MALIG,CIRR,ALC statewide statewide statewide statewide statewide HEPA W/O CC/MCC 444 DISORDERS OF THE BILIARY TRACT W MCC statewide statewide statewide statewide 445 DISORDERS OF THE BILIARY TRACT W CC statewide statewide statewide statewide statewide 446 DISORDERS OF THE BILIARY TRACT W/O CC/MCC statewide statewide statewide statewide statewide 455 COMBINED ANTERIOR/POSTERIOR SPINAL statewide cohort statewide statewide statewide FUSION W/O CC/MCC 457 SPINAL FUS EXC CERV W SPINAL statewide statewide statewide statewide CURV/MALIG/INFEC OR 9+ FUS W CC 458 SPINAL FUS EXC CERV W SPINAL statewide statewide cohort CURV/MALIG/INFEC OR 9+ FUS W/O CC/MCC 460 SPINAL FUSION EXCEPT CERVICAL W/O MCC statewide statewide cohort cohort cohort statewide 462 BILATERAL OR MULTIPLE MAJOR JOINT PROCS statewide statewide cohort cohort statewide statewide OF LOWER EXTREMITY W/O MCC 464 WND DEBRID & SKN GRFT EXC HAND, FOR statewide statewide statewide statewide statewide MUSCULO-CONN TISS DIS W CC 465 WND DEBRID & SKN GRFT EXC HAND, FOR statewide statewide statewide statewide statewide statewide MUSCULO-CONN TISS DIS W/O CC/MCC 467 REVISION OF HIP OR KNEE REPLACEMENT W CC statewide statewide statewide cohort statewide statewide 468 REVISION OF HIP OR KNEE REPLACEMENT W/O statewide statewide cohort cohort statewide statewide CC/MCC 470 MAJOR JOINT REPLACEMENT OR cohort cohort cohort cohort cohort cohort REATTACHMENT OF LOWER EXTREMITY W/O MCC 472 CERVICAL SPINAL FUSION W CC statewide statewide statewide cohort cohort statewide 473 CERVICAL SPINAL FUSION W/O CC/MCC statewide statewide cohort cohort cohort statewide 481 HIP & FEMUR PROCEDURES EXCEPT MAJOR statewide statewide statewide cohort cohort JOINT W CC 482 HIP & FEMUR PROCEDURES EXCEPT MAJOR statewide statewide cohort cohort cohort statewide JOINT W/O CC/MCC 483 MAJOR JOINT & LIMB REATTACHMENT PROC OF statewide statewide statewide cohort statewide statewide UPPER EXTREMITY W CC/MCC 489 KNEE PROCEDURES W/O PDX OF INFECTION statewide statewide statewide statewide statewide statewide W/O CC/MCC 491 BACK & NECK PROC EXC SPINAL FUSION W/O statewide statewide statewide statewide CC/MCC 493 LOWER EXTREM & HUMER PROC EXCEPT statewide statewide statewide cohort cohort statewide HIP,FOOT,FEMUR W CC 494 LOWER EXTREM & HUMER PROC EXCEPT statewide cohort cohort cohort cohort statewide HIP,FOOT,FEMUR W/O CC/MCC 496 LOCAL EXCISION & REMOVAL INT FIX DEVICES statewide statewide statewide statewide statewide EXC HIP & FEMUR W CC 501 SOFT TISSUE PROCEDURES W CC statewide statewide statewide statewide statewide 502 SOFT TISSUE PROCEDURES W/O CC/MCC statewide statewide statewide statewide statewide 512 SHOULDER,ELBOW OR FOREARM PROC,EXC statewide statewide statewide statewide MAJOR JOINT PROC W/O CC/MCC 516 OTHER MUSCULOSKELET SYS & CONN TISS O.R. statewide statewide statewide PROC W CC 517 OTHER MUSCULOSKELET SYS & CONN TISS O.R. statewide statewide statewide statewide PROC W/O CC/MCC 520 BACK & NECK PROC EXC SPINAL FUSION W/O statewide statewide statewide statewide statewide statewide CC/MCC 543 PATHOLOGICAL FRACTURES & MUSCULOSKELET statewide statewide statewide statewide & CONN TISS MALIG W CC 546 CONNECTIVE TISSUE DISORDERS W CC statewide statewide statewide statewide statewide 552 MEDICAL BACK PROBLEMS W/O MCC statewide statewide statewide cohort cohort statewide 556 SIGNS & SYMPTOMS OF MUSCULOSKELETAL statewide statewide statewide statewide statewide SYSTEM & CONN TISSUE W/O MCC 558 TENDONITIS, MYOSITIS & BURSITIS W/O MCC statewide statewide statewide statewide statewide 563 FX, SPRN, STRN & DISL EXCEPT FEMUR, HIP, statewide statewide statewide statewide statewide PELVIS & THIGH W/O MCC

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 572 SKIN DEBRIDEMENT W/O CC/MCC statewide statewide statewide statewide statewide statewide 580 OTHER SKIN, SUBCUT TISS & BREAST PROC W CC statewide statewide statewide statewide statewide statewide 581 OTHER SKIN, SUBCUT TISS & BREAST PROC W/O statewide statewide statewide cohort statewide statewide CC/MCC 583 MASTECTOMY FOR MALIGNANCY W/O CC/MCC statewide statewide statewide statewide statewide 585 BREAST BIOPSY, LOCAL EXCISION & OTHER statewide statewide statewide statewide statewide BREAST PROCEDURES W/O CC/MCC 596 MAJOR SKIN DISORDERS W/O MCC statewide statewide statewide statewide statewide statewide 602 CELLULITIS W MCC statewide statewide statewide statewide statewide 603 CELLULITIS W/O MCC cohort cohort cohort cohort cohort statewide 607 MINOR SKIN DISORDERS W/O MCC statewide statewide statewide statewide statewide statewide 617 AMPUTAT OF LOWER LIMB FOR statewide statewide statewide statewide statewide statewide ENDOCRINE,NUTRIT,& METABOL DIS W CC 620 O.R. PROCEDURES FOR OBESITY W CC statewide cohort cohort cohort statewide 621 O.R. PROCEDURES FOR OBESITY W/O CC/MCC cohort cohort cohort cohort cohort 637 DIABETES W MCC statewide statewide statewide statewide statewide 638 DIABETES W CC statewide cohort cohort cohort cohort statewide 639 DIABETES W/O CC/MCC statewide cohort cohort cohort cohort statewide 640 MISC DISORDERS OF statewide statewide statewide cohort cohort NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W MCC 641 MISC DISORDERS OF statewide cohort cohort cohort cohort statewide NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC 644 ENDOCRINE DISORDERS W CC statewide statewide statewide statewide statewide statewide 652 KIDNEY TRANSPLANT statewide 657 KIDNEY & URETER PROCEDURES FOR NEOPLASM statewide statewide statewide statewide cohort statewide W CC 658 KIDNEY & URETER PROCEDURES FOR NEOPLASM statewide statewide cohort statewide cohort W/O CC/MCC 660 KIDNEY & URETER PROCEDURES FOR NON- statewide statewide statewide cohort NEOPLASM W CC 661 KIDNEY & URETER PROCEDURES FOR NON- statewide statewide statewide statewide statewide NEOPLASM W/O CC/MCC 669 TRANSURETHRAL PROCEDURES W CC statewide statewide statewide statewide statewide 682 RENAL FAILURE W MCC statewide cohort cohort cohort statewide statewide 683 RENAL FAILURE W CC statewide cohort cohort cohort cohort statewide 684 RENAL FAILURE W/O CC/MCC statewide statewide statewide cohort statewide 689 KIDNEY & URINARY TRACT INFECTIONS W MCC statewide statewide statewide statewide statewide 690 KIDNEY & URINARY TRACT INFECTIONS W/O statewide cohort cohort cohort cohort statewide MCC 694 URINARY STONES W/O ESW LITHOTRIPSY W/O statewide cohort cohort statewide statewide statewide MCC 698 OTHER KIDNEY & URINARY TRACT DIAGNOSES W statewide statewide statewide statewide cohort statewide MCC 699 OTHER KIDNEY & URINARY TRACT DIAGNOSES W statewide statewide statewide statewide cohort CC 700 OTHER KIDNEY & URINARY TRACT DIAGNOSES statewide statewide statewide statewide statewide statewide W/O CC/MCC 707 MAJOR MALE PELVIC PROCEDURES W CC/MCC statewide statewide statewide statewide 708 MAJOR MALE PELVIC PROCEDURES W/O statewide statewide cohort cohort cohort statewide CC/MCC 728 INFLAMMATION OF THE MALE REPRODUCTIVE statewide statewide statewide statewide statewide SYSTEM W/O MCC 737 UTERINE & ADNEXA PROC FOR OVARIAN OR statewide statewide statewide cohort ADNEXAL MALIGNANCY W CC 740 UTERINE,ADNEXA PROC FOR NON- statewide statewide statewide statewide OVARIAN/ADNEXAL MALIG W CC 742 UTERINE & ADNEXA PROC FOR NON- statewide cohort cohort cohort cohort statewide MALIGNANCY W CC/MCC 743 UTERINE & ADNEXA PROC FOR NON- cohort cohort cohort cohort cohort statewide MALIGNANCY W/O CC/MCC

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 759 INFECTIONS, FEMALE REPRODUCTIVE SYSTEM statewide statewide statewide statewide statewide W/O CC/MCC 765 CESAREAN SECTION W CC/MCC statewide cohort cohort cohort cohort 766 CESAREAN SECTION W/O CC/MCC cohort cohort cohort cohort cohort 767 VAGINAL DELIVERY W STERILIZATION &/OR D&C statewide cohort cohort cohort cohort 770 ABORTION W D&C, ASPIRATION CURETTAGE OR statewide statewide statewide statewide HYSTEROTOMY 774 VAGINAL DELIVERY W COMPLICATING statewide cohort cohort cohort cohort DIAGNOSES 775 VAGINAL DELIVERY W/O COMPLICATING cohort cohort cohort cohort cohort DIAGNOSES 776 POSTPARTUM & POST ABORTION DIAGNOSES cohort cohort cohort cohort W/O O.R. PROCEDURE 778 THREATENED ABORTION statewide statewide statewide cohort statewide 779 ABORTION W/O D&C statewide statewide statewide statewide statewide 781 OTHER ANTEPARTUM DIAGNOSES W MEDICAL statewide cohort cohort cohort cohort COMPLICATIONS 782 OTHER ANTEPARTUM DIAGNOSES W/O statewide statewide cohort statewide MEDICAL COMPLICATIONS 789 NEONATES, DIED OR TRANSFERRED TO statewide cohort cohort cohort cohort ANOTHER ACUTE CARE FACILITY 790 EXTREME IMMATURITY OR RESPIRATORY statewide statewide cohort cohort cohort DISTRESS SYNDROME, NEONATE 791 PREMATURITY W MAJOR PROBLEMS statewide statewide cohort cohort cohort 792 PREMATURITY W/O MAJOR PROBLEMS statewide cohort cohort cohort cohort 793 FULL TERM NEONATE W MAJOR PROBLEMS statewide cohort cohort cohort cohort 794 NEONATE W OTHER SIGNIFICANT PROBLEMS cohort cohort cohort cohort cohort 795 NORMAL NEWBORN cohort cohort cohort cohort cohort 808 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE statewide statewide statewide statewide CELL CRISIS & COAGUL W MCC 809 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE statewide statewide statewide cohort cohort CELL CRISIS & COAGUL W CC 810 MAJOR HEMATOL/IMMUN DIAG EXC SICKLE statewide statewide statewide statewide CELL CRISIS & COAGUL W/O CC/MCC 811 RED BLOOD CELL DISORDERS W MCC statewide statewide statewide statewide statewide statewide 812 RED BLOOD CELL DISORDERS W/O MCC statewide cohort cohort cohort cohort statewide 813 COAGULATION DISORDERS statewide statewide statewide statewide statewide 834 ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE statewide statewide cohort W MCC 837 CHEMO W ACUTE LEUKEMIA AS SDX OR W HIGH statewide statewide cohort DOSE CHEMO AGENT W MCC 838 CHEMO W ACUTE LEUKEMIA AS SDX W CC OR statewide cohort HIGH DOSE CHEMO AGENT 839 CHEMO W ACUTE LEUKEMIA AS SDX W/O statewide statewide cohort CC/MCC 840 LYMPHOMA & NON-ACUTE LEUKEMIA W MCC statewide statewide statewide statewide 841 LYMPHOMA & NON-ACUTE LEUKEMIA W CC statewide statewide statewide statewide statewide 842 LYMPHOMA & NON-ACUTE LEUKEMIA W/O statewide statewide statewide statewide CC/MCC 846 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS statewide statewide statewide cohort SECONDARY DIAGNOSIS W MCC 847 CHEMOTHERAPY W/O ACUTE LEUKEMIA AS statewide statewide statewide cohort cohort SECONDARY DIAGNOSIS W CC 853 INFECTIOUS & PARASITIC DISEASES W O.R. statewide cohort cohort cohort cohort statewide PROCEDURE W MCC 854 INFECTIOUS & PARASITIC DISEASES W O.R. statewide statewide statewide statewide statewide statewide PROCEDURE W CC 856 POSTOPERATIVE OR POST-TRAUMATIC statewide statewide statewide statewide statewide INFECTIONS W O.R. PROC W MCC 857 POSTOPERATIVE OR POST-TRAUMATIC statewide statewide statewide statewide statewide statewide INFECTIONS W O.R. PROC W CC 862 POSTOPERATIVE & POST-TRAUMATIC statewide statewide statewide statewide cohort statewide INFECTIONS W MCC

MS Description Peer Peer Peer Peer Peer Peer DRG Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 863 POSTOPERATIVE & POST-TRAUMATIC statewide cohort cohort cohort cohort INFECTIONS W/O MCC 864 FEVER statewide statewide cohort cohort statewide 866 VIRAL ILLNESS W/O MCC statewide statewide statewide statewide cohort 870 SEPTICEMIA OR SEVERE SEPSIS W MV 96+ statewide statewide statewide statewide statewide HOURS 871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ cohort cohort cohort cohort cohort statewide HOURS W MCC 872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ cohort cohort cohort cohort cohort statewide HOURS W/O MCC 880 ACUTE ADJUSTMENT REACTION & statewide statewide statewide cohort cohort statewide PSYCHOSOCIAL DYSFUNCTION 881 DEPRESSIVE NEUROSES statewide cohort cohort cohort cohort 882 NEUROSES EXCEPT DEPRESSIVE statewide statewide statewide statewide statewide statewide 883 DISORDERS OF PERSONALITY & IMPULSE statewide statewide statewide statewide cohort CONTROL 885 PSYCHOSES cohort cohort cohort cohort cohort statewide 895 ALCOHOL/DRUG ABUSE OR DEPENDENCE W statewide statewide REHABILITATION THERAPY 896 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O statewide statewide statewide statewide statewide statewide REHABILITATION THERAPY W MCC 897 ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O cohort cohort cohort cohort cohort cohort REHABILITATION THERAPY W/O MCC 907 OTHER O.R. PROCEDURES FOR INJURIES W MCC statewide statewide statewide statewide statewide 908 OTHER O.R. PROCEDURES FOR INJURIES W CC statewide statewide statewide statewide cohort 909 OTHER O.R. PROCEDURES FOR INJURIES W/O statewide statewide statewide statewide statewide statewide CC/MCC 916 ALLERGIC REACTIONS W/O MCC statewide statewide statewide statewide statewide statewide 917 POISONING & TOXIC EFFECTS OF DRUGS W MCC statewide cohort cohort cohort statewide statewide 918 POISONING & TOXIC EFFECTS OF DRUGS W/O statewide cohort cohort cohort cohort MCC 919 COMPLICATIONS OF TREATMENT W MCC statewide statewide statewide statewide cohort statewide 920 COMPLICATIONS OF TREATMENT W CC statewide statewide statewide cohort cohort 921 COMPLICATIONS OF TREATMENT W/O CC/MCC statewide statewide statewide statewide statewide statewide 935 NON-EXTENSIVE BURNS statewide cohort 945 REHABILITATION W CC/MCC statewide statewide cohort cohort statewide 946 REHABILITATION W/O CC/MCC statewide statewide statewide statewide statewide 947 SIGNS & SYMPTOMS W MCC statewide statewide statewide statewide statewide 948 SIGNS & SYMPTOMS W/O MCC statewide statewide cohort statewide cohort 956 LIMB REATTACHMENT, HIP & FEMUR PROC FOR statewide statewide statewide MULTIPLE SIGNIFICANT TRAUMA 957 OTHER O.R. PROCEDURES FOR MULTIPLE statewide statewide cohort SIGNIFICANT TRAUMA W MCC 958 OTHER O.R. PROCEDURES FOR MULTIPLE statewide statewide cohort SIGNIFICANT TRAUMA W CC 964 OTHER MULTIPLE SIGNIFICANT TRAUMA W CC statewide statewide statewide 981 EXTENSIVE O.R. PROCEDURE UNRELATED TO statewide statewide statewide cohort PRINCIPAL DIAGNOSIS W MCC 982 EXTENSIVE O.R. PROCEDURE UNRELATED TO statewide statewide statewide statewide statewide PRINCIPAL DIAGNOSIS W CC 983 EXTENSIVE O.R. PROCEDURE UNRELATED TO statewide statewide statewide statewide statewide PRINCIPAL DIAGNOSIS W/O CC/MCC 988 NON-EXTENSIVE O.R. PROC UNRELATED TO statewide statewide statewide statewide statewide PRINCIPAL DIAGNOSIS W CC 999 UNGROUPABLE statewide cohort cohort cohort cohort statewide

Outpatient Costs  Includes Outpatient allowed facility costs (POS=22, POS=23) only (i.e. no professional or ancillary costs)  Dates of Service: October 2016 - September 2017  Lines of business: Blue Options (Group Underwritten, ASO, State Health Plan, Blue Select/Blue Select Plus, CDHP), Blue Advantage (Individual, CDHP).  Excludes denials, Medicare crossovers, COB, and State Health Plan retirees.  To reduce the effect of outliers, claims with allowed costs below the 5th percentile by CPT were dropped and allowed costs were truncated at the 95th percentile by CPT.  CPTs were limited to those CPTs performed at least 30 times in at least 2 facilities statewide.  CPTs were further limited to those CPTs where CPT code is required according to BCBSNC policy titled “Provider Update: Effective April 10, 2012 – BCBSNC Requires CPT and HCPCS Codes to be Included on UB-04 Claim Submissions”.  Analysis excludes CPTs associated with the following revenue code groupings: o Pharmacy o IV Therapy o Laboratory o Pathology o Blood and Blood Components o Administration, Processing, and Storage for Blood and Blood Components o Physical Therapy o Occupational Therapy o Speech Therapy - Language Pathology o Free-Standing Clinic o Hemodialysis - Outpatient or Home o Peritoneal Dialysis - Outpatient or Home o Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home o Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home o Miscellaneous Dialysis o Other Therapeutic Services.  Observed and expected costs were also calculated for each facility’s outpatient costs. o Expected costs were determined by calculating the average cost for each CPT within a peer cohort if there were at least 30 cases in a minimum of 2 facilities; if there was insufficient volume within a peer cohort, the expected costs reflect the average cost for Facilities statewide. o Observed costs are equivalent to the allowed costs. Observed and expected costs were summed for all cases with sufficient CPT volume.  Both Inpatient and Outpatient costs were forward-adjusted to reflect each facility’s contractual changes through 2019 once the final summary amounts were tabulated.

For example, if a facility had a $100,000 inpatient observed costs based on the October 2016 – September 2017 data, and had a 4% contractual increase through 2019, then the Inpatient observed amount for that facility would be increased to $104,000 for comparison purposes.

Note: Increases are prorated to reflect when the increase went into effect during the calendar year. To forward- adjust the expected cost metrics, the peer cohort weighted average increase was blended with the statewide weighted average increase by facility based on how much each group contributed to the development of that facility’s expected costs.

Once the observed and expected cost metrics were forward-adjusted, the observed cost metric was divided by the expected cost metric for both inpatient and outpatient to create efficiency ratios. The efficiency ratios were 11

normalized to ensure that the weighted average for both inpatient and outpatient in any given peer cohort was 1.0. Finally, each facility’s inpatient and outpatient normalized efficiency factors were blended using the aggregate allowed Inpatient and Outpatient charges for their peer cohort.

For example, if peer cohort six had 60% of allowed charges associated with inpatient and 40% associated with outpatient the inpatient normalized efficiency factor blend would be 60% inpatient/ 40% outpatient.

Note: If the normalized efficiency factor for a facility is 1.10 that would imply the facility is 10% less efficient than the peer cohort average.

Next, all facilities were categorized into seven macro regions made up of various combinations of the 16 regions as defined by the DOI per the Affordable Care Act. Facilities were categorized based where the majority of its claims dollars originated from based on patient address. A crosswalk of these regional definitions by county is provided below. Facilities that fell at or below the lowest 40th percentile of normalized efficiency factor within their given macro region were designated Low Cost High Quality and all other facilities were designated as High Quality. CMS defined Critical Access facilities were excluded from this process and were default designated as Low Cost High Quality.

ACA Macro ACA Macro County Region Region County Region Region ALAMANCE Region 11 Triangle CUMBERLAND Region 9 Fayetteville ALEXANDER Region 2 Asheville CURRITUCK Region 12 Eastern ALLEGHANY Region 3 Asheville DARE Region 16 Eastern ANSON Region 4 Charlotte DAVIDSON Region 6 Triad ASHE Region 3 Asheville DAVIE Region 6 Triad AVERY Region 1 Asheville DUPLIN Region 15 Wilmington BEAUFORT Region 16 Eastern DURHAM Region 11 Triangle BERTIE Region 12 Eastern EDGECOMBE Region 14 Eastern BLADEN Region 9 Fayetteville FORSYTH Region 6 Triad BRUNSWICK Region 15 Wilmington FRANKLIN Region 13 Triangle BUNCOMBE Region 1 Asheville GASTON Region 5 Charlotte BURKE Region 2 Asheville GATES Region 12 Eastern CABARRUS Region 4 Charlotte GRAHAM Region 1 Asheville CALDWELL Region 2 Asheville GRANVILLE Region 10 Triangle CAMDEN Region 12 Eastern GREENE Region 14 Eastern CARTERET Region 16 Eastern GUILFORD Region 7 Triad CASWELL Region 11 Triangle HALIFAX Region 12 Eastern CATAWBA Region 2 Asheville HARNETT Region 9 Fayetteville CHATHAM Region 11 Triangle HAYWOOD Region 1 Asheville CHEROKEE Region 1 Asheville HENDERSON Region 1 Asheville CHOWAN Region 12 Eastern HERTFORD Region 12 Eastern CLAY Region 1 Asheville HOKE Region 9 Fayetteville CLEVELAND Region 5 Charlotte HYDE Region 16 Eastern COLUMBUS Region 15 Wilmington IREDELL Region 2 Asheville CRAVEN Region 16 Eastern JACKSON Region 1 Asheville

ACA Macro ACA Macro County Region Region County Region Region JOHNSTON Region 13 Triangle RANDOLPH Region 7 Triad JONES Region 16 Eastern RICHMOND Region 9 Fayetteville LEE Region 11 Triangle ROBESON Region 9 Fayetteville LENOIR Region 16 Eastern ROCKINGHAM Region 7 Triad LINCOLN Region 5 Charlotte ROWAN Region 4 Charlotte MACON Region 1 Asheville RUTHERFORD Region 1 Asheville MADISON Region 1 Asheville SAMPSON Region 9 Fayetteville MARTIN Region 12 Eastern SCOTLAND Region 9 Fayetteville MCDOWELL Region 1 Asheville STANLY Region 4 Charlotte MECKLENBURG Region 4 Charlotte STOKES Region 6 Triad MITCHELL Region 1 Asheville SURRY Region 6 Triad MONTGOMERY Region 8 Fayetteville SWAIN Region 1 Asheville MOORE Region 8 Fayetteville TRANSYLVANIA Region 1 Asheville NASH Region 14 Eastern TYRRELL Region 16 Eastern NEW HANOVER Region 15 Wilmington UNION Region 4 Charlotte NORTHAMPTON Region 12 Eastern VANCE Region 10 Triangle ONSLOW Region 15 Wilmington WAKE Region 13 Triangle ORANGE Region 11 Triangle WARREN Region 10 Triangle PAMLICO Region 16 Eastern WASHINGTON Region 16 Eastern PASQUOTANK Region 12 Eastern WATAUGA Region 3 Asheville PENDER Region 15 Wilmington WAYNE Region 14 Eastern PERQUIMANS Region 12 Eastern WILKES Region 3 Asheville PERSON Region 11 Triangle WILSON Region 14 Eastern PITT Region 14 Eastern YADKIN Region 6 Triad POLK Region 1 Asheville YANCEY Region 1 Asheville

 All CPTs were evaluated. In the following table, "Cohort" refers to the CPT analysis within the cohort only. "Statewide" refers to the CPT analysis done statewide due to the low volume. Outpatient CPT information was not used to determine peer cohorts.

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 00103 BLEPHAROPLASTY statewide statewide statewide statewide 00104 ANESTHESIA FOR ELECTROCONVULSIVE statewide cohort statewide statewide THERAPY 00120 ANESTHESIA FOR PROCEDURES ON EXTERNAL, statewide cohort statewide statewide statewide MIDDLE, ANDINNER EARINCLUDING BIOPSY; NOT OTHERWISE SPECIFIE D 00126 TYMPANOTOMY statewide cohort statewide statewide statewide 00140 ANESTHESIA FOR PROCEDURES ON EYE; NOT statewide statewide statewide cohort statewide statewide OTHERWISE SPECIFIED 00142 LENS SURGERY cohort cohort cohort cohort statewide 00145 VITRECTOMY statewide statewide statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 00160 ANESTHESIA FOR PROCEDURES ON NOSE AND statewide cohort statewide cohort cohort statewide ACCESSORY SINUSES; NOT OTHERWISE SPECIFIED 00170 ANESTHESIA FOR INTRAORAL PROCEDURES, statewide cohort cohort cohort cohort INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED 00190 ANESTHESIA FOR PROCEDURES ON FACIAL statewide statewide statewide statewide statewide BONES; NOT OTHERWISE SPECIFIED 00300 ANESTHESIA FOR ALL PROCEDURES ON statewide cohort cohort cohort cohort statewide INTEGUMENTARY SYSTEM OF NECK, INCLUDING SUBCUTANEOUS TISSUE 00320 ANESTHESIA FOR ALL PROCEDURES ON statewide cohort cohort statewide cohort ESOPHAGUS, THYROID, LARYNX, TRACHEA AND LYMPHATIC SYSTEM OF NECK; NOT OTHERWISE SPECIFIED 00400 ANESTHESIA FOR PROCEDURES ON ANTERIOR cohort cohort cohort cohort cohort statewide INTEGUMENTARY SYSTEM OF CHEST, INCLUDING SUBCUTANEOUS TISSUE; NOT OTHERWISE SPECIFIED 00402 RECONSTRUCTIVE PROCEDURES ON BREAST (EG. statewide cohort statewide cohort statewide REDUCTIONOR AUGMENTATION MAMOPLASTY, MUSCLE FLAPS) 00404 RADICAL OR MODIFIED RADICAL PROCEDURES statewide statewide statewide statewide statewide ON BREAST 00406 RADICAL OR MODIFIED RADICAL PROCEDURES statewide statewide statewide statewide ON BREAST WITH INTERNAL MAMMARY NODE DISSECTION 00410 ELECTRICAL CONVERSION OF ARRHYTHMIAS statewide statewide statewide 00450 ANESTHESIA FOR PROCEDURES ON CLAVICLE statewide statewide statewide statewide statewide statewide AND SCAPULA; NOT OTHERWISE SPECIFIED 00520 ANESTHESIA FOR CLOSED CHEST PROCEDURES statewide statewide statewide statewide cohort (INCLUDING ESOPHAGOSCOPY, BRONCHOSCOPY, DIAGNOSTIC THORACOSCOPY); NOT OTHERWISE SPECIFIED 00532 ANESTHESIA FOR ACCESS TO CENTRAL VENOUS statewide cohort cohort statewide cohort statewide CIRCULATION 00534 ANESTHESIA FOR TRANSVENOUS INSERTION OR statewide statewide REPLACEMENT OF CARDIOVERTER/DEFIBRILLATOR (FOR TRANSTHORACIC APPROACH, USE 00560) 00537 ANESTHESIA FOR CARDIAC statewide statewide cohort ELECTROPHYSIOLOGIC PROCEDURES INCLUDING RADIOFREQUENCY ABLATION 00600 ANESTHESIA FOR PROCEDURES ON CERVICAL statewide statewide statewide statewide statewide SPINE AND CORD; NOT OTHERWISE SPECIFIED 00630 ANESTHESIA FOR PROCEDURES IN LUMBAR cohort cohort cohort cohort statewide REGION; NOT OTHERWISE SPECIFIED 00635 ANESTHESIA FOR PROCEDURES IN LUMBAR statewide statewide cohort REGION; DIAGNOSTIC OR THERAPEUTIC LUMBAR PUNCTURE. 00670 ANESTHESIA FOR EXTENSIVE SPINE AND SPINAL statewide statewide statewide statewide statewide CORD PROCEDURES (EG, HARRINGTON ROD TECHNIQUE) 00740 ANESTHESIA FOR UPPER GASTROINTESTINAL cohort cohort cohort cohort cohort statewide ENDOSCOPIC PROCEDURES 00750 ANESTHESIA FOR HERNIA REPAIRS IN UPPDER statewide statewide statewide cohort statewide ABDOMEN; NOT OTHERWISE SPECIFIED 00752 LUMBAR AND VENTRAL (INCISIONAL)HERNIAS statewide statewide statewide statewide AND/OR WOUND DEHISCENCE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 00790 ANESTHESIA FOR INTRAPERITONEAL cohort cohort cohort cohort cohort statewide PROCEDURES IN UPPERABDOMEN INCLUDING LAPAROSCOPY, NOT OTHERWISE SPECIFIED 00810 ANESTHESIA FOR INTESTINAL ENDOSCOPIC cohort cohort cohort statewide cohort statewide PROCEDURES 00830 ANESTHESIA FOR HERNIA REPAIRS IN LOWER cohort cohort cohort cohort cohort statewide ABDOMEN; NOT OTHERWISE SPECIFIED 00832 VENTRAL AND INCISIONAL HERNIAS statewide cohort statewide statewide statewide 00840 ANESTHESIA FOR INTRAPERITONEAL cohort cohort cohort cohort cohort statewide PROCEDURES IN LOWERABDOMEN INCLUDING LAPAROSCOPY; NOT OTHERWISE SPECIFIED 00846 RADICAL HYSTERECTOMY cohort statewide statewide statewide 00851 ANESTHESIA, INTRAPERITONEAL PROC, LOWER statewide statewide statewide statewide statewide ABDOMEN W/LAPAROSCOPY; TUBAL LIGATION/TRANSECTION 00860 ANESTHESIA FOR EXTRAPERITONEAL statewide statewide cohort statewide cohort statewide PROCEDURES IN LOWERABDOMEN, INCLUDING URINARY TRACT; NOT OTHERWISE SPECIFIED 00862 RENAL PROCEDURES, INCLUDING UPPER 1/3 OF statewide statewide statewide statewide URETER, OR DONOR NEPHRECTOMY 00873 WITHOUT WATER BATH cohort cohort statewide 00902 ANORECTAL PROCEDURE (INCLUDING statewide cohort cohort cohort statewide statewide ENDOSCOPY AND/OR BIOPSY 00910 ANESTHESIA FOR TRANSURETHRAL statewide cohort cohort cohort cohort statewide PROCEDURES (INCLUDINGURETHROCYSTOSCOPY); NOT OTHERWISE SPECIFIED 00912 TRANSURETHRAL RESECTION OF BLADDER statewide statewide statewide statewide statewide statewide TUMOR(S) 00914 TRANSURETHRAL RESECTION OF PROSTATE statewide statewide statewide statewide statewide statewide 00918 WITH FRAGMENTATION AND/OR REMOVAL OF statewide cohort cohort statewide cohort statewide URETERAL CALCULUS 00920 ANESTHESIA FOR PROCEDURES ON MALE statewide cohort cohort cohort cohort statewide EXTERNAL GENITALIA; NOT OTHERWISE SPECIFIED 00930 ORCHIOPEXY, UNILATERAL OR BILATERAL statewide statewide statewide statewide 00940 ANESTHESIA FOR VAGINAL PROCEDURES statewide cohort cohort cohort cohort statewide (INCLUDING BIOPSY OF LABIA, VAGINA, CERVIX OR ENDOMETRIUM); NOT OTHERWISE SPECIFIED 00942 COLPOTOMY, COLPECTOMY, COLPORRHAPHY statewide statewide statewide statewide statewide 00944 VAGINAL HYSTERECTOMY statewide cohort statewide cohort statewide statewide 00952 HYSTEROSCOPY statewide cohort cohort cohort cohort 01320 ANESTHESIA FOR ALL PROCEDURES ON NERVES, statewide statewide statewide statewide statewide statewide MUSCLES, TENDONS, FASCIA, AND BURSAE OF KNEE AND/OR POPLITEAL AREA 01382 ANESTHESIA FOR ARTHROSCOPIC PROCEDURES statewide cohort statewide statewide statewide statewide OF KNEE JOINT 01392 ANESTHESIA FOR ALL OPEN PROCEDURES ON statewide statewide statewide statewide statewide statewide UPPER ENDS OF TIBIA, FIBULA, AND/OR PATELLA 01400 ANESTHESIA FOR OPEN PROCEDURES ON KNEE cohort cohort cohort cohort cohort statewide JOINT; NOT OTHERWISE SPECIFIED 01470 ANESTHESIA FOR PROCEDURES ON NERVES, statewide statewide statewide statewide statewide statewide MUSCLES, TENDONS, AND FASCIA OF LOWER LEG, ANKLE, AND FOOT;NOT OTHERWISE SPECIFIED

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 01472 REPAIR OF RUPTURED ACHILLES TENDON, WITH statewide statewide statewide statewide statewide statewide OR WITHOUT GRAFT 01480 ANESTHESIA FOR OPEN PROCEDURES ON BONES cohort cohort cohort cohort statewide statewide OF LOWE LEG, ANKLE, AND FOOT; NOT OTHERWISE SPECIFIED 01610 ANESTHESIA FOR ALL PROCEDURES ON NERVES, statewide statewide statewide statewide statewide statewide MUSCLES, TENDONS, FASCIA, AND BURSAE OF SHOULDER AND AXILLA 01622 ANESTHESIA FOR ARTROSCOPIC PROCEDURES statewide statewide statewide statewide statewide OF SHOULDER JOINT 01630 ANESTHESIA FOR OPEN PROCEDURES ON cohort cohort cohort statewide cohort statewide HUMERAL HEAD ANDNECK, STERNOCLAVICULAR JOINT, ACROMIOCLAVICULAR JOINT, AND SHOULDER JOINT; NOT OTHERWISE SPECIFIED 01710 ANESTHESIA FOR PROCEDURES ON NERVES, statewide statewide statewide statewide statewide statewide MUSCLES, TENDONS, FASCIA, AND BURSAE OF UPPER ARM AND ELBOW; NOT OTHERWISE SPECIFIED 01740 ANESTHESIA FOR OPEN PROCEDURES ON statewide statewide statewide statewide statewide statewide HUMERUS AND ELBOW; NOT OTHERWISE SPECIFIED 01810 ANESTHESIA FOR ALL PROCEDURES ON NERVES, cohort cohort cohort cohort cohort statewide MUSCLES, TENDONS, FASCIA, AND BURSAE OF FOREARM, WRIST, ANDHAND 01820 ANESTHESIA FOR ALL CLOSED PROCEDURES ON statewide statewide statewide statewide statewide RADIUS, ULNA, WRIST, OR HAND BONES HAND 01830 ANESTHESIA FOR OPEN PROCEDURES ON statewide cohort cohort cohort cohort statewide RADIUS, ULNA, WRIST, OR HAND BONES; NOT OTHERWISE SPECIFIED HAND 01844 ANESTHESIA FOR VASCULAR SHUNT, OR SHUNT statewide statewide statewide statewide statewide statewide REVISION, ANY TYPE (EG. DIALYSIS) 0191T INSERTION OF ANTERIOR SEGMENT AQUEOUS statewide statewide statewide statewide DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, INTERNAL APPROACH, INTO THE TRABECULAR MESHWORK; INITIAL INSERTION 01922 ANESTHESIA FOR NON-INVASIVE IMAGING OR statewide statewide cohort statewide cohort statewide RADIATION THERAPY 01930 ANES, THERAPEUTIC INTERVEN RADIOL, statewide statewide statewide statewide VENOUS/LYMPHATISYSTEM W/O CENTRAL CIRC ACCESS; NOS 01965 ANESTHESIA FOR INCOMPLETE OR MISSED statewide cohort cohort cohort statewide ABORTION PROCEDURES 0296T External electrocardiographic recording for statewide statewide statewide cohort more than 48 hours up to 21 days by continuous rhythm recording and storage; recording (includes connection and initial recording) 0297T External electrocardiographic recording for statewide cohort more than 48 hours up to 21 days by continuous rhythm recording and storage; scanning analysis with report 10021 FINE NEEDLE ASPIRATION; W/OUT IMAGING statewide statewide statewide statewide cohort GUIDANCE 10022 FINE NEEDLE ASPIRATION; W/IMAGING statewide cohort cohort cohort cohort statewide GUIDANCE 10060 *INCISION AND DRAINAGE OF ABSCESS (EG, cohort cohort cohort cohort cohort statewide CARBUNCLE,SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUSABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE OR SINGLE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 10061 INCISION AND DRAINAGE OF ABSCESS (EG, cohort cohort cohort cohort cohort CARBUNCLE, SUPPURATIVEHIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICATED OR MULTIPLE 10080 *INCISION AND DRAINAGE OF PILONIDAL CYST; statewide statewide statewide statewide statewide statewide SIMPLE 10120 *INCISION AND REMOVAL OF FOREIGN BODY, statewide cohort cohort cohort statewide SUBCUTANEOUS TISSUES;SIMPLE *INCISION AND REMOVAL OF FOREIGNBODY, SUBCUTANEOUS TISSUES; 10140 *INCISION AND DRAINAGE OF HEMATOMA, statewide statewide statewide cohort cohort statewide SEROMA OR FLUIDCOLLECTION 10160 *PUNCTURE ASPIRATION OF ABSCESS, statewide statewide statewide statewide statewide statewide HEMATOMA, BULLA, OR CYST*PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST 11012 Debridement including removal of foreign statewide statewide statewide statewide statewide statewide material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone 11042 Debridement, subcutaneous tissue (includes cohort cohort cohort cohort cohort cohort epidermis and dermis, if performed); first 20 sq cm or less 11043 Debridement, muscle and/or fascia (includes statewide cohort cohort cohort statewide statewide epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less 11044 Debridement, bone (includes epidermis, dermis, statewide cohort cohort statewide statewide statewide subcutaneous tissue, muscle and/or fascia, if performed); first 20 sq cm or less 11045 Debridement, subcutaneous tissue (includes statewide cohort cohort statewide cohort statewide epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in additionto code for primary procedure) 11046 Debridement, muscle and/or fascia (includes statewide statewide cohort statewide statewide statewide epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (Listseparately in addition to code for primary proced 11055 PARING OR CUTTING OF BENIGN statewide cohort statewide statewide statewide statewide HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN 11056 PARING OR CUTTING OF BENIGN statewide statewide statewide statewide HYPERKERATOTIC LESION (EG, CORN OR CALLUS); TWO TO FOUR LESIONS PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE statewide statewide statewide statewide cohort statewide AND/OR MUCOUS MEMBRANE(INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SINGLE LESION 11101 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE statewide statewide statewide statewide statewide AND/OR MUCOUS MEMBRANE(INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); EACH SEPARATE/ADDITIONAL LESION (LIST 11200 *REMOVAL OF SKIN TAGS, MULTIPLE statewide statewide statewide statewide statewide statewide FIBROCUTANEOUS TAGS, ANYAREA; UP TO AND 17

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 INCLUDING 15 LESIONS *REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY 11400 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 11401 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM 11402 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide cohort cohort statewide statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM 11403 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide cohort statewide statewide statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 2.1 TO 3.0 CM 11404 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide cohort statewide statewide statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM 11406 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide cohort cohort cohort cohort statewide (UNLESS LISTEDELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM 11420 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide cohort statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 11421 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 11422 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide cohort cohort statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM 11423 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2.1 TO 3.0 CM 11424 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM 11426 EXCISION, BENIGN LESION, EXCEPT SKIN TAG statewide statewide statewide statewide statewide statewide (UNLESS LISTEDELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM 11440 EXCISION, OTHER BENIGN LESION (UNLESS statewide statewide statewide statewide statewide statewide LISTED ELSEWHERE),FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS 11441 EXCISION, OTHER BENIGN LESION (UNLESS statewide statewide statewide statewide LISTED ELSEWHERE),FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 11442 EXCISION, OTHER BENIGN LESION (UNLESS statewide statewide statewide statewide statewide LISTED ELSEWHERE),FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM 11443 EXCISION, OTHER BENIGN LESION (UNLESS statewide statewide statewide statewide statewide LISTED ELSEWHERE),FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE statewide statewide statewide statewide statewide FOR HIDRADENITIS,AXILLARY; WITH SIMPLE OR INTERMEDIATE REPAIR 11603 EXCISION, MALIGNANT LESION, TRUNK, ARMS, statewide statewide statewide statewide OR LEGS; LESIONDIAMETER 2.1 TO 3.0 CM 11604 EXCISION, MALIGNANT LESION, TRUNK, ARMS, statewide statewide statewide statewide OR LEGS; LESIONDIAMETER 3.1 TO 4.0 CM 11606 EXCISION, MALIGNANT LESION, TRUNK, ARMS, statewide statewide statewide cohort cohort OR LEGS; LESIONDIAMETER OVER 4.0 CM 11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); statewide cohort statewide statewide statewide SIX OR MOREDEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE 11730 *AVULSION OF NAIL PLATE, PARTIAL OR statewide cohort statewide statewide statewide statewide COMPLETE, SIMPLE; SINGLE 11740 EVACUATION OF SUBUNGUAL statewide statewide statewide statewide statewide HEMATOMAEVACUATION OF SUBUNGUAL HEMATOMA 11750 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL statewide statewide statewide statewide statewide OR COMPLETE, (EG, INGROWN OR DEFORMED NAIL) FOR PERMANENT REMOVAL; EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE, (EG, 11760 REPAIR OF NAIL BEDREPAIR OF NAIL BED statewide statewide statewide statewide statewide 11770 EXCISION OF PILONIDAL CYST OR SINUS; SIMPLE statewide cohort cohort cohort statewide statewide 11771 EXCISION OF PILONIDAL CYST OR SINUS; statewide statewide cohort statewide statewide statewide EXTENSIVE 11772 EXCISION OF PILONIDAL CYST OR SINUS; statewide statewide statewide statewide statewide COMPLICATED 11970 REPLACEMENT OF TISSUE EXPANDER WITH statewide statewide cohort cohort cohort statewide PERMANENT PROSTHESIS 11981 INSERTION, NON-BIODEGRADABLE DRUG statewide statewide statewide cohort DELIVERY IMPLANT 11982 REMOVAL, NON-BIODEGRADABLE DRUG statewide statewide statewide statewide DELIVERY IMPLANT 12001 *SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF cohort cohort cohort cohort cohort statewide SCALP, NECK,AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS 12002 *SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF cohort cohort cohort cohort cohort statewide SCALP, NECK,AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM 12004 *SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF statewide cohort cohort cohort statewide statewide SCALP, NECK,AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM 12005 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF statewide statewide statewide statewide statewide SCALP, NECK, AXILLAE,EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM 12011 *SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF cohort cohort cohort cohort cohort statewide FACE, EARS, EYELIDS,NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS 12013 *SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF cohort cohort cohort cohort cohort statewide FACE, EARS, EYELIDS,NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM 12014 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF statewide statewide statewide statewide statewide FACE, EARS,EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM 19

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 12015 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF statewide statewide statewide statewide statewide FACE, EARS,EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM 12031 Repair, intermediate, wounds of scalp, axillae, statewide cohort cohort statewide statewide statewide trunk and/or extremities (excluding hands and feet);2.5 cm or less 12032 Repair, intermediate, wounds of scalp, axillae, statewide cohort cohort cohort cohort statewide trunk and/or extremities (excluding hands and feet);2.6 cm to 7.5 cm 12034 Repair, intermediate, wounds of scalp, axillae, statewide cohort statewide cohort statewide statewide trunk and/or extremities (excluding hands and feet);7.6 cm to 12.5 cm 12035 Repair, intermediate, wounds of scalp, axillae, statewide statewide statewide statewide statewide trunk and/or extremities (excluding hands and feet);12.6 cm to 20.0 cm 12041 Repair, intermediate, wounds of neck, hands, statewide statewide statewide statewide statewide statewide feet and/or external genitalia; 2.5 cm or less 12042 Repair, intermediate, wounds of neck, hands, statewide cohort cohort cohort statewide feet and/or external genitalia; 2.6 cm to 7.5 cm 12051 Repair, intermediate, wounds of face, ears, statewide statewide statewide cohort cohort eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 12052 Repair, intermediate, wounds of face, ears, statewide statewide statewide statewide statewide eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 13101 REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM statewide statewide statewide statewide statewide statewide 13102 REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 statewide statewide statewide statewide statewide CM OR LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 13121 REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; statewide statewide statewide statewide statewide 2.6 CM TO 7.5 CM 13132 REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, statewide statewide statewide statewide statewide MOUTH, NECK,AXILLAE, GENITALIA, HANDS AND/OR FEET; 2.6 CM TO 7.5 CM REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN,MOUTH, NECK, 13152 Repair, complex, eyelids, nose, ears and/or lips; statewide statewide statewide statewide statewide 2.6 cm to 7.5 cm 14000 ADJACENT TISSUE TRANSFER OR statewide statewide statewide statewide REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 14001 ADJACENT TISSUE TRANSFER OR statewide statewide statewide statewide REARRANGEMENT, TRUNK; DEFECT10.1 SQ CM TO 30.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 14020 ADJACENT TISSUE TRANSFER OR statewide statewide cohort statewide REARRANGEMENT, SCALP, ARMSAND/OR LEGS; DEFECT 10 SQ CM OR LESS ADJACENTTISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS 14040 ADJACENT TISSUE TRANSFER OR statewide statewide statewide cohort cohort REARRANGEMENT, FOREHEAD, CHEEKS,CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS 14060 ADJACENT TISSUE TRANSFER OR statewide statewide statewide statewide cohort REARRANGEMENT, EYELIDS, NOSE,EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE,

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 14301 ADJACENT TISSUE TRANSFER OR statewide statewide statewide cohort REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ CM TO 60.0 SQ CM 14302 ADJACENT TISSUE TRANSFER OR statewide statewide statewide statewide REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 15002 SURGICAL PREPARATION OR CREATION OF statewide statewide statewide statewide statewide RECIPIENT SITEBY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES), OR INCISIONAL RELEASE OF SCAR CONTRACTURE, TRUNK, ARMS, LEGS; FIRS 15100 SPLIT GRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ statewide statewide statewide statewide statewide CM ORLESS, OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) 15260 FULL THICKNESS GRAFT, FREE, INCLUDING statewide statewide statewide statewide DIRECT CLOSURE OFDONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS;20 SQ CM OR LESS 15271 APPLICATION OF SKIN SUBSTITUTE GRAFT TO cohort statewide statewide statewide statewide TRUNK, ARMS, LEGS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM;FIRST 25 SQ CM OR LESS WOUND SURFACE AREA 15275 APPLICATION OF SKIN SUBSTITUTE GRAFT TO statewide statewide statewide statewide statewide statewide FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET, AND/OR MULTIPLE DIGITS, TOTAL WOUND SURFACE AREA UP TO 100 SQ CM; FIRST 25 SQ CM OR LES 15777 IMPLANTATION OF BIOLOGIC IMPLANT (EG, statewide statewide cohort cohort statewide ACELLULAR DERMAL MATRIX) FOR SOFT TISSUE REINFORCEMENT (IE, BREAST, TRUNK) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 15823 BLEPHAROPLASTY, UPPER EYELID; WITH statewide statewide cohort statewide statewide statewide EXCESSIVE SKIN WEIGHTING DOWN LID 16020 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR statewide cohort cohort cohort cohort SUBSEQUENT;WITHOUT ANESTHESIA, OFFICE OR HOSPITAL, SMALL 17000 Destruction (eg, laser surgery, electrosurgery, statewide statewide statewide statewide cryosurgery chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratosis) first lesion 17003 DESTRUCTION BY ANY METHOD, INCLUDING statewide statewide statewide LASER, WITH OR WITHOUT SURGICAL CURETTEMENT, ALL BENIGN OR PREMALIGNANT LESIONS (EG, ACTINIC KERATOSES) OTHER THAN SKIN TAGS OR CUTANEOUS 17106 DESTRUCTION OF CUTANEOUS VASCULAR statewide cohort PROLIFERATIVE LESIONS (EG,LASER TECHNIQUE); LESS THAN 10 SQ CM DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, 17107 DESTRUCTION OF CUTANEOUS VASCULAR statewide cohort PROLIFERATIVE LESIONS (EG,LASER TECHNIQUE); 10.0 - 50.0 SQ CM DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (EG, 17108 DESTRUCTION OF CUTANEOUS VASCULAR cohort PROLIFERATIVE LESIONS (EG,LASER TECHNIQUE); OVER 50.0 SQ CM DESTRUCTION

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS(EG, 17110 Destruction (e.g., laser surgery, electrosurgery, statewide statewide statewide cohort cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions 17111 DESTRUCTION BY ANY METHOD OF FLAT statewide statewide cohort WARTS, MOLLUSCUMCONTAGIOSUM, OR MILIA; 15 OR MORE LESIONS 17250 *CHEMICAL CAUTERIZATION OF GRANULATION statewide cohort cohort cohort statewide cohort TISSUE (PROUD FLESH, SINUS OR FISTULA) 19000 *PUNCTURE ASPIRATION OF CYST OF BREAST; statewide cohort cohort cohort cohort statewide 19030 INJECTION PROCEDURE ONLY FOR MAMMARY statewide statewide statewide DUCTOGRAM ORGALACTOGRAM 19081 BIOPSY, BREAST, WITH PLACEMENT OF BREAST statewide cohort cohort cohort cohort LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING S 19082 BIOPSY, BREAST, WITH PLACEMENT OF BREAST statewide statewide statewide statewide statewide LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, I 19083 BIOPSY, BREAST, WITH PLACEMENT OF BREAST cohort cohort cohort cohort cohort statewide LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING U 19084 BIOPSY, BREAST, WITH PLACEMENT OF BREAST statewide statewide cohort cohort cohort LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; EACH ADDITIONAL LESION, I 19085 BIOPSY, BREAST, WITH PLACEMENT OF BREAST statewide statewide statewide cohort LOCALIZATION DEVICE(S) (EG, CLIP, METALLIC PELLET), WHEN PERFORMED, AND IMAGING OF THE BIOPSY SPECIMEN, WHEN PERFORMED, PERCUTANEOUS; FIRST LESION, INCLUDING M 19101 BIOPSY OF BREAST; INCISIONAL statewide statewide cohort statewide statewide 19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER cohort cohort cohort cohort cohort statewide BENIGN ORMALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LES ION, NIPPLE OR AREOLAR LESION (EXCEPT 19300), OPEN, MALE OR FEMALE, 1 OR MORE LESIONS 19125 EXCISION OF BREAST LESION IDENTIFIED BY PRE- statewide cohort cohort cohort cohort statewide OPERATIVEPLACEMENT OF RADIOLOGICAL MARKER; SINGLE LESION 19281 PLACEMENT OF BREAST LOCALIZATION statewide cohort cohort cohort cohort DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING MAMMOGRAPHIC GUIDANCE 19282 PLACEMENT OF BREAST LOCALIZATION statewide statewide statewide statewide DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; EACH ADDITIONAL LESION, INCLUDING MAMMOGRAPHIC GUIDANCE (LIST SEPARATELY IN ADDITI

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 19283 PLACEMENT OF BREAST LOCALIZATION statewide cohort statewide DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING STEREOTACTIC GUIDANCE 19285 PLACEMENT OF BREAST LOCALIZATION statewide cohort cohort cohort cohort DEVICE(S) (EG, CLIP, METALLIC PELLET, WIRE/NEEDLE, RADIOACTIVE SEEDS), PERCUTANEOUS; FIRST LESION, INCLUDING ULTRASOUND GUIDANCE 19301 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, statewide cohort cohort cohort cohort statewide TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); 19302 MASTECTOMY, PARTIAL (EG, LUMPECTOMY, statewide statewide statewide statewide statewide TYLECTOMY, QUADRANTECTOMY, SEGMENTECTOMY); WITH AXILLARY LYMPHADENECTOMY 19303 MASTECTOMY, SIMPLE, COMPLETE statewide cohort cohort cohort cohort 19304 MASTECTOMY, SUBCUTANEOUS statewide statewide statewide statewide statewide 19307 MASTECTOMY, MODIFIED RADICAL, INCLUDING statewide statewide cohort cohort cohort AXILLARY LYMPH NODES, WITH OR WITHOUT PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE 19316 MASTOPEXY statewide statewide cohort statewide 19318 REDUCTION MAMMAPLASTY statewide statewide cohort cohort cohort statewide 19328 REMOVAL OF INTACT MAMMARY IMPLANT statewide statewide statewide statewide statewide statewide 19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS statewide statewide cohort cohort statewide statewide FOLLOWINGMASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING 19342 DELAYED INSERTION OF BREAST PROSTHESIS statewide statewide statewide statewide FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION DELAYEDINSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEX Y, 19350 NIPPLE/AREOLA RECONSTRUCTION statewide statewide cohort statewide 19357 BREAST RECONSTRUCTION, IMMEDIATE OR statewide statewide cohort cohort cohort DELAYED, WITH TISSUEEXPANDER, INCLUDING SUBSEQUENT EXPANSION 19366 BREAST RECONSTRUCTION WITH OTHER statewide statewide statewide cohort statewide TECHNIQUE 19371 PERIPROSTHETIC CAPSULECTOMY, BREAST statewide cohort statewide statewide 19380 REVISION OF RECONSTRUCTED BREAST statewide statewide cohort cohort cohort statewide 20103 EXPLORATION OF PENETRATING WOUND statewide statewide statewide statewide statewide (SEPARATE PROCEDURE);EXTREMITY 20205 BIOPSY, MUSCLE; DEEP statewide statewide statewide statewide statewide statewide 20206 *BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE statewide statewide statewide statewide cohort 20220 BIOPSY, BONE, TROCAR OR NEEDLE; statewide statewide statewide statewide SUPERFICIAL (EG, ILIUM,STERNUM, SPINOUS PROCESS, RIBS) BIOPSY, BONE, TROCAR OR NEEDLE; SUPERFICIAL (EG, ILIUM, 20225 BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP statewide statewide statewide cohort statewide (VERTEBRAL BODY,FEMUR) BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (VERTEBRAL BODY, 20550 *INJECTION, TENDON SHEATH, LIGAMENT, statewide statewide statewide statewide statewide statewide TRIGGER POINTS ORGANGLION CYST 20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER cohort cohort cohort cohort cohort statewide POINT(S);1 OR 2 MUSCLE(S)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER statewide cohort cohort cohort cohort statewide POINT(S);3 OR MORE MUSCLES 20600 ARTHROCENTESIS, ASPIRATION AND/OR statewide cohort statewide cohort statewide statewide INJECTION, SMALLJOINT OR BURSA (EG, FINGERS, TOES); WITHOUT ULTRA SOUND GUIDANCE 20605 ARTHROCENTESIS, ASPIRATION AND/OR statewide cohort cohort cohort cohort statewide INJECTION, INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA); WITHOUT ULTRASOUND GUIDANCE 20610 ARTHROCENTESIS, ASPIRATION AND/OR cohort cohort cohort cohort cohort cohort INJECTION, MAJORJOINT OR BURSA (EG, SHOULDER, HIP, KNEE, SUBACROM IAL BURSA); WITHOUT ULTRASOUND GUIDANCE 20670 *REMOVAL OF IMPLANT; SUPERFICIAL, (EG, statewide statewide statewide statewide statewide BURIED WIRE, PIN ORROD) (SEPARATE PROCEDURE) *REMOVAL OF IMPLANT; SUPERFICIAL, (EG, BURIED WIRE, PIN OR 20680 REMOVAL OF IMPLANT; DEEP (EG, BURIED cohort cohort cohort cohort cohort statewide WIRE, PIN, SCREW, METALBAND, NAIL, ROD OR PLATE) REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL 20694 REMOVAL, UNDER ANESTHESIA, OF EXTERNAL statewide statewide statewide statewide statewide statewide FIXATION SYSTEM 20900 Bone graft, any donor area; minor or small (e.g., statewide statewide statewide statewide statewide statewide dowel or button) 20926 Tissue grafts, other (e.g., paratenon, far, dermis) statewide statewide statewide statewide cohort statewide 20930 Allograft, morselized, or placement of statewide statewide cohort cohort statewide statewide osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 20931 Allograft, structural, for spine surgery only (List statewide cohort cohort statewide statewide separately in addition to code for primary procedure) 20936 Autograft for spine surgery only (includes statewide statewide statewide cohort statewide statewide harvesting the graft); local (e.g. ribs, spinous process,or laminar fragments) obtained from the same inci sion 20937 Autograft for spine surgery only (includes statewide statewide statewide statewide statewide harvesting the graft); morselized (through separate skin or fascial incision) 20938 Autograft for spine surgery only (includes statewide statewide harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) 21235 GRAFT; EAR CARTILAGE, AUTOGENOUS, TO statewide statewide statewide statewide statewide NOSE OR EAR (INCLUDESOBTAINING GRAFT) 21320 CLOSED TREATMENT OF NASAL BONE statewide statewide statewide statewide statewide FRACTURE; WITH STABILIZATION CLOSED TREATMENT OF NASAL BONE FRACTURE;WITH STABILIZATION 21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX statewide statewide statewide statewide statewide 21552 EXCISION, TUMOR, SOFT TISSUE OF NECK OR statewide statewide statewide statewide ANTERIOR THORAX, SUBCUTANEOUS; 3 CM OR GREATER 21554 EXCISION, TUMOR, SOFT TISSUE OF NECK OR statewide statewide statewide statewide statewide ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER 24

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 21556 EXCISION, TUMOR, SOFT TISSUE OF NECK OR statewide statewide statewide statewide statewide statewide ANTERIOR THORAX, SUBFASCIAL (EG, INTRAMUSCULAR); LESS THAN 5CM 21931 EXCISION, TUMOR, SOFT TISSUE OF BACK OR statewide statewide statewide statewide statewide statewide FLANK, SUBCUTANEOUS; 3 CM OR GREATER 21933 EXCISION, TUMOR, SOFT TISSUE OF BACK OR statewide statewide statewide statewide statewide statewide FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 CM OR GREATER 22551 Arthrodesis, anterior interbody, including disc statewide cohort cohort cohort cohort statewide space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2 22552 Arthrodesis, anterior interbody, including disc statewide statewide cohort cohort statewide statewide space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List 22554 ARTHRODESIS, ANTERIOR INTERBODY statewide statewide statewide statewide TECHNIQUE, INCLUDING MINIMALDISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2 22845 Anterior instrumentation; 2 to 3 vertebral statewide cohort cohort cohort statewide statewide segments 22846 Anterior instrumentation; 4 to 7 vertebral statewide statewide statewide statewide segments 22851 Application of intervertebral biomechanical statewide cohort cohort cohort statewide statewide device(s) (eg, synthetic cage(s), methylmethacrylate) tovertebral defect or interspace (List separately i n addition to code for primary procedure) 22903 EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL statewide statewide statewide statewide statewide statewide WALL, SUBCUTANEOUS; 3 CM OR GREATER 23071 EXCISION, TUMOR, SOFT TISSUE OF SHOULDER statewide statewide statewide statewide statewide statewide AREA, SUBCUTANEOUS; 3 CM OR GREATER 23120 CLAVICULECTOMY; PARTIAL statewide cohort statewide statewide statewide statewide 23350 INJECTION PROCEDURE FOR SHOULDER cohort cohort cohort cohort cohort statewide ARTHROGRAPHY 23410 REPAIR OF RUPTURED MUSCULOTENDINOUS statewide statewide statewide statewide statewide CUFF (EG, ROTATOR CUFF);ACUTE 23412 REPAIR OF RUPTURED MUSCULOTENDINOUS statewide cohort cohort statewide statewide CUFF (EG, ROTATOR CUFF);CHRONIC 23420 RECONSTRUCTION OF COMPLETE SHOULDER statewide statewide statewide statewide statewide statewide (ROTATOR) CUFFAVULSION,CHRONIC (INCLUDES ACROMIOPLASTY) 23430 TENODESIS OF LONG TENDON OF BICEPS statewide cohort cohort cohort cohort statewide 23515 Open treatment of clavicular fracture, includes statewide statewide statewide cohort statewide statewide internal fixation when performed 23615 Open treatment of proximal humeral (surgical or statewide statewide statewide statewide statewide statewide anatomical neck) fracture, includes internal fixation when performed, includes repair of tuberosity(s)when performed; 23650 CLOSED TREATMENT OF SHOULDER statewide cohort cohort cohort statewide DISLOCATION, WITH MANIPULATION;WITHOUT ANESTHESIA CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 23655 CLOSED TREATMENT OF SHOULDER statewide statewide statewide statewide statewide DISLOCATION, WITH MANIPULATION;REQUIRING ANESTHESIA

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 23700 *MANIPULATION UNDER ANESTHESIA, statewide statewide statewide statewide statewide statewide SHOULDER JOINT, INCLUDINGAPPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED) 24105 EXCISION, OLECRANON BURSA statewide statewide statewide statewide statewide statewide 24220 INJECTION PROCEDURE FOR ELBOW statewide statewide statewide statewide ARTHROGRAPHY 24341 REPAIR, TENDON OR MUSCLE, UPPER ARM OR statewide statewide statewide statewide statewide statewide ELBOW, EACHTENDON ORMUSCLE, PRIMARY OR SECONDARY (EXCLUDES R OTATOR CUFF) 24342 REINSERTION OF RUPTURED BICEPS OR TRICEPS statewide statewide statewide statewide statewide statewide TENDON, DISTAL,WITH OR WITHOUT TENDON GRAFT 24358 Tenotomy, elbow, lateral or medial (e.g., statewide statewide statewide statewide statewide epicondylitis, tennis elbow, golfer's elbow); debridement,soft tissue and/or bone, open 24359 Tenotomy, elbow, lateral or medial (e.g., statewide statewide statewide statewide statewide statewide epicondylitis, tennis elbow, golfer's elbow); debridement,soft tissue and/or bone, open with tendon repair or reattachment 24538 PERCUTANEOUS SKELETAL FIXATION OF statewide statewide statewide statewide cohort statewide SUPRACONDYLAR ORTRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION 24600 TREATMENT OF CLOSED ELBOW DISLOCATION; statewide statewide statewide statewide statewide WITHOUT ANESTHESIATREATMENT OF CLOSED ELBOW DISLOCATION; WITHOUT ANESTHESIA 24640 *CLOSED TREATMENT OF RADIAL HEAD statewide statewide statewide cohort statewide SUBLUXATION IN CHILD,"NURSEMAID ELBOW", WITH MANIPULATION *CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, 24685 Open treatment of ulnar fracture, proximal end statewide statewide statewide statewide statewide statewide (e.g., olecranon or coronoid process[es]), includes internal fixation when performed 25000 INCISION, EXTENSOR TENDON SHEATH, WRIST statewide statewide statewide cohort statewide statewide (EG, DEQUERVAIN'SDISEASE) 25111 EXCISION OF GANGLION, WRIST (DORSAL OR statewide cohort cohort cohort statewide statewide VOLAR); PRIMARY 25246 INJECTION PROCEDURE FOR WRIST statewide statewide statewide cohort statewide ARTHROGRAPHY 25310 TENDON TRANSPLANTATION OR TRANSFER, statewide statewide statewide statewide statewide statewide FLEXOR OR EXTENSOR,FOREARM AND/OR WRIST, SINGLE; EACH TENDON 25447 ARTHROPLASTY, INTERPOSITION, INTERCARPAL statewide statewide cohort cohort statewide statewide OR CARPOMETACARPAL JOINTS 25565 CLOSED TREATMENT OF RADIAL AND ULNAR statewide cohort statewide statewide statewide statewide SHAFT FRACTURES; WITHMANIPULATION CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES; WITH 25575 Open treatment of radial AND ulnar shaft statewide statewide statewide statewide fractures, with internal fixation when performed; of radiusAND ulna 25600 Closed treatment of distal radial fracture (eg, statewide statewide statewide statewide statewide Colles or Smith type) or epiphyseal separation includes closed treatment of fracture of ulnar styloid when performed; without manipulation

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 25605 CLOSED TREATMENT OF DISTAL RADIAL statewide cohort cohort cohort cohort statewide FRACTURE (EG, COLLES ORSMITH TYPE) OR EPIPHYSEAL SEPARATION, WITH OR WITHOUT FRACTURE OF ULNAR STYLOID; WITH MANIPULATION 25606 PERCUTANEOUS SKELETAL FIXATION OF DISTAL statewide cohort statewide statewide statewide statewide RADIAL FRACTURE OR EPIPHYSEAL SEPARATION 25607 OPEN TREATMENT OF DISTAL RADIAL EXTRA- statewide cohort statewide cohort statewide statewide ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION, WITH INTERNAL FIXATION 25608 OPEN TREATMENT OF DISTAL RADIAL INTRA- statewide statewide statewide statewide statewide statewide ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS 25609 OPEN TREATMENT OF DISTAL RADIAL INTRA- statewide cohort statewide cohort statewide statewide ARTICULAR FRACTURE OR EPIPHYSEAL SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS 26010 *DRAINAGE OF FINGER ABSCESS; SIMPLE statewide statewide statewide statewide statewide statewide 26055 TENDON SHEATH INCISION (EG, FOR TRIGGER cohort cohort cohort cohort cohort statewide FINGER) 26115 EXCISION, TUMOR OR VASCULAR statewide statewide statewide statewide statewide statewide MALFORMATION, SOFT TISSUE OF HAND OR FINGER, SUBCUTANEOUS; LESS THAN 1.5CM 26123 FASCIECTOMY, PARTIAL PALMAR WITH RELEASE statewide statewide statewide statewide statewide OF SINGLEDIGITINCLUDING PROXIMAL INTERPHALANGEAL JOINT, WI TH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING 26145 SYNOVECTOMY, TENDON SHEATH, RADICAL statewide statewide statewide statewide statewide (TENOSYNOVECTOMY),FLEXOR TENDON, PALM AND/OR FINGER, EACH TENDONSYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVEC TOMY), 26160 EXCISION OF LESION OF TENDON SHEATH OR statewide statewide statewide cohort statewide statewide CAPSULE (EG, CYST,MUCOUS CYST, OR GANGLION), HAND OR FINGER 26350 REPAIR OR ADVANCEMENT, FLEXOR TENDON, statewide statewide statewide statewide NOT IN DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR SECONDARY WITHOUT FREE GRAFT, EACH TENDON 26356 REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN statewide statewide statewide statewide statewide DIGITAL FLEXORTENDON SHEATH (EG, NO MAN'S LAND); PRIMARY, EACH TENDON 26418 REPAIR, EXTENSOR TENDON, FINGER, PRIMARY statewide statewide statewide statewide statewide OR SECONDARY;WITHOUT FREE GRAFT, EACH TENDON 26480 TRANSFER OR TRANSPLANT OF TENDON, statewide statewide statewide statewide statewide statewide CARPOMETACARPAL AREA ORDORSUM OF HAND; WITHOUT FREE GRAFT, EACH TENDON 26540 REPAIR OF COLLATERAL LIGAMENT, statewide statewide statewide statewide statewide statewide METACARPOPHALANGEALORINTERPHALANGEAL JOINT 26608 PERCUTANEOUS SKELETAL FIXATION OF statewide statewide statewide statewide statewide METACARPAL FRACTURE, EACH BONE PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH 26615 Open treatment of metacarpal fracture, single, statewide statewide statewide statewide statewide statewide includes internal fixation when performed, each bone

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 26725 CLOSED TREATMENT OF PHALANGEAL SHAFT statewide statewide statewide statewide statewide FRACTURE, PROXIMAL ORMIDDLE PHALANX, FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION, EACH 26727 PERCUTANEOUS SKELETAL FIXATION OF statewide statewide statewide statewide statewide UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH 26735 Open treatment of phalangeal shaft fracture, statewide statewide statewide cohort statewide statewide proximal or middle phalanx, finger or thumb, includes internal fixation when performed, each 26765 Open treatment of distal phalangeal fracture, statewide statewide statewide statewide statewide statewide finger or thumb, includes internal fixation when performed, each 26770 CLOSED TREATMENT OF INTERPHALANGEAL statewide statewide statewide statewide statewide JOINT DISLOCATION,SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCA TION, 26951 AMPUTATION, FINGER OR THUMB, PRIMARY OR statewide statewide statewide statewide statewide statewide SECONDARY,ANY JOINTOR PHALANX, SINGLE, INCLUDING NEURECTOMI ES; WITH DIRECT CLOSURE 27093 INJECTION PROCEDURE FOR HIP statewide cohort cohort statewide cohort statewide ARTHROGRAPHY; WITHOUT ANESTHESIA 27095 INJECTION PROCEDURE FOR HIP statewide statewide statewide statewide statewide ARTHROGRAPHY; WITH ANESTHESIA 27096 INJECTION PROCEDURE FOR SACROILIAC JOINT, cohort cohort cohort cohort cohort statewide ANESTHETIC/STEROID, WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT) INCLUDING ARTHROGRAPHY WHEN PERFORMED 27337 EXCISION, TUMOR, SOFT TISSUE OF THIGH OR statewide statewide statewide statewide statewide KNEE AREA, SUBCUTANEOUS; 3 CM OR GREATER 27370 INJECTION OF CONTRAST FOR KNEE statewide statewide statewide ARTHROGRAPHY 27380 SUTURE OF INFRAPATELLAR TENDON; PRIMARY statewide statewide statewide statewide statewide 27385 SUTURE OF QUADRICEPS OR HAMSTRING statewide statewide statewide statewide statewide MUSCLE RUPTURE; PRIMARY 27427 LIGAMENTOUS RECONSTRUCTION statewide statewide statewide statewide statewide statewide (AUGMENTATION), KNEE;EXTRA-ARTICULAR 27446 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; statewide statewide statewide statewide cohort statewide MEDIAL ORLATERALCOMPARTMENT 27524 OPEN TREATMENT OF PATELLAR FRACTURE, statewide statewide statewide statewide statewide statewide WITH INTERNALFIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR 27560 CLOSED TREATMENT OF PATELLAR statewide statewide statewide statewide statewide DISLOCATION; WITHOUT ANESTHESIACLOSED TREATMENT OF PATELLAR DISLOCATION; WITHOUT ANESTHESIA 27570 *MANIPULATION OF KNEE JOINT UNDER statewide statewide cohort statewide statewide statewide GENERAL ANESTHESIA(INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES) 27635 EXCISION OR CURETTAGE OF BONE CYST OR statewide statewide statewide statewide statewide BENIGN TUMOR, TIBIA ORFIBULA; 27650 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, statewide cohort cohort cohort statewide statewide RUPTURED ACHILLESTENDON;

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 27654 REPAIR, SECONDARY, ACHILLES TENDON, WITH statewide statewide statewide statewide statewide statewide OR WITHOUT GRAFT 27685 LENGTHENING OR SHORTENING OF TENDON, statewide statewide statewide statewide statewide LEG OR ANKLE;SINGLETENDON (SEPARATE PROCEDURE) 27687 GASTROCNEMIUS RECESSION (EG, STRAYER statewide statewide statewide statewide statewide statewide PROCEDURE) 27691 TRANSFER OR TRANSPLANT OF SINGLE TENDON statewide statewide statewide statewide statewide statewide (WITH MUSCLEREDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, FLEXOR 27695 REPAIR, PRIMARY, DISRUPTED LIGAMENT, statewide statewide statewide statewide statewide statewide ANKLE; COLLATERAL 27698 REPAIR, SECONDARY DISRUPTED LIGAMENT, statewide statewide statewide statewide statewide statewide ANKLE, COLLATERAL (EG,WATSON-JONES PROCEDURE) 27792 Open treatment of distal fibular fracture statewide cohort cohort cohort statewide statewide (lateralmalleolus), includes internal fixation when perfo rmed 27814 Open treatment of bimalleolar ankle fracture statewide statewide cohort cohort statewide statewide (e.g., lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli),includes internal fixation when performed 27818 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE statewide statewide statewide statewide statewide FRACTURE; WITHMANIPULATION CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE; WITH 27822 Open treatment of trimalleolar ankle fracture, statewide statewide statewide statewide statewide statewide includes internal fixation when performed, medial and/or lateral malleolus; without fixation of posterior lip 27829 Open treatment of distal tibiofibular joint statewide statewide statewide statewide statewide statewide (syndesmosis) disruption, includes internal fixation when performed 28008 FASCIOTOMY, FOOT AND/OR TOE statewide statewide statewide statewide statewide statewide 28080 EXCISION, INTERDIGITAL (MORTON) NEUROMA, statewide statewide statewide statewide statewide statewide SINGLE, EACH 28090 EXCISION OF LESION, TENDON, TENDON statewide statewide statewide statewide statewide statewide SHEATH, OR CAPSULE(INCLUDING SYNOVECTOMY) (EG, CYST OR GANGLION);FOOT EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE 28104 EXCISION OR CURETTAGE OF BONE CYST OR statewide statewide statewide statewide statewide statewide BENIGN TUMOR, TARSALOR METATARSAL BONES, EXCEPT TALUS OR CALCANEUS; 28108 EXCISION OR CURETTAGE OF BONE CYST OR statewide statewide statewide statewide statewide BENIGN TUMOR,PHALANGES OF FOOT 28110 OSTECTOMY, PARTIAL EXCISION, FIFTH statewide statewide statewide statewide statewide statewide METATARSAL HEAD(BUNIONETTE) (SEPARATE PROCEDURE) 28119 OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR statewide statewide statewide statewide statewide statewide WITHOUT PLANTARFASCIAL RELEASE 28120 PARTIAL EXCISION (CRATERIZATION, statewide statewide statewide statewide statewide statewide SAUCERIZATION,SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS 28122 PARTIAL EXCISION (CRATERIZATION, statewide statewide statewide statewide statewide statewide SAUCERIZATION,SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS 29

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR 28232 TENOTOMY, OPEN, TENDON FLEXOR; TOE, statewide statewide statewide statewide statewide SINGLE TENDON (SEPARATE PROCEDURE) 28270 CAPSULOTOMY; METATARSOPHALANGEAL statewide statewide cohort statewide statewide JOINT, WITH OR WITHOUTTENORRHAPHY, EACH JOINT (SEPARATE PROCEDURE) 28285 CORRECTION, HAMMERTOE (EG, cohort cohort cohort cohort statewide statewide INTERPHALANGEAL FUSION,PARTIALOR TOTAL PHALANGECTOMY) 28288 OSTECTOMY, PARTIAL, EXOSTECTOMY OR statewide statewide statewide statewide statewide CONDYLECTOMY, METATARSAL HEAD, EACH METATARSAL HEAD 28289 HALLUX RIGIDUS CORRECTION WITH statewide statewide statewide cohort statewide statewide CHEILECTOMY, DEBRIDEMENT AND CAPSULAR RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT 28290 CORRECTION, HALLUX VALGUS (BUNION), WITH statewide statewide statewide statewide statewide statewide OR WITHOUTSESAMOIDECTOMY; SIMPLE EXOSTECTOMY (EG, SILVER TYPE PROCEDURE) 28292 CORRECTION, HALLUX VALGUS (BUNION), WITH statewide statewide statewide statewide statewide statewide OR WITHOUTSESAMOIDECTOMY; KELLER, MCBRIDE, OR MAYO TYPE PROCEDURE 28296 CORRECTION, HALLUX VALGUS (BUNION), WITH statewide cohort cohort cohort statewide statewide OR WITHOUTSESAMOIDECTOMY; WITH METATARSAL OSTEOTOMY (EG, MITCHELL, CHEVRON, OR CONCENTRIC TYPE PROCEDURES) 28299 CORRECTION, HALLUX VALGUS (BUNION), WITH statewide statewide cohort statewide statewide statewide OR WITHOUTSESAMOIDECTOMY; BY OTHER METHODS (EG, DOUBLE OSTEOTOMY) 28300 OSTEOTOMY; CALCANEUS (EG, DWYER OR statewide statewide statewide statewide statewide statewide CHAMBERS TYPE PROCEDURE),WITH OR WITHOUT INTERNAL FIXATION 28306 OSTEOTOMY, WITH OR WITHOUT statewide statewide statewide statewide statewide statewide LENGTHENING, SHORTENINGORANGULAR CORRECTION, METATARSAL; FIRST METATARSA L 28308 OSTEOTOMY, WITH OR WITHOUT statewide statewide cohort cohort statewide statewide LENGTHENING, SHORTENINGORANGULAR CORRECTION, METATARSAL; OTHER THAN FIRS T METATARSAL, EACH 28313 RECONSTRUCTION, ANGULAR DEFORMITY OF statewide statewide statewide statewide statewide statewide TOE, SOFT TISSUEPROCEDURES ONLY (EG, OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES) 28485 Open treatment of metatarsal fracture, includes statewide statewide statewide statewide statewide statewide internal fixation when performed, each 28725 ARTHRODESIS; SUBTALARARTHRODESIS; statewide statewide statewide statewide statewide statewide SUBTALAR 28740 ARTHRODESIS, MIDTARSAL OR statewide statewide statewide statewide statewide TARSOMETATARSAL, SINGLE JOINT 28750 ARTHRODESIS, GREAT TOE; statewide statewide statewide statewide statewide statewide METATARSOPHALANGEAL JOINT 28810 AMPUTATION, METATARSAL, WITH TOE, SINGLE statewide statewide statewide statewide statewide 28820 AMPUTATION, TOE; METATARSOPHALANGEAL statewide statewide statewide statewide statewide statewide JOINT 28825 AMPUTATION, TOE; INTERPHALANGEAL JOINT statewide statewide statewide statewide statewide 28899 UNLISTED PROCEDURE, FOOT OR TOES statewide statewide statewide statewide statewide statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 29075 APPLICATION; ELBOW TO FINGER (SHORT statewide statewide ARM)APPLICATION; ELBOW TO FINGER (SHORT ARM) 29105 APPLICATION OF LONG ARM SPLINT (SHOULDER cohort cohort cohort cohort cohort TO HAND)APPLICATION OF LONG ARM SPLINT (SHOULDER TO HAND) 29125 APPLICATION OF SHORT ARM SPLINT (FOREARM cohort cohort cohort cohort cohort statewide TO HAND);STATICAPPLICATION OF SHORT ARM SPLINT (FOREARM TO HAND); STATIC 29126 APPLICATION OF SHORT ARM SPLINT (FOREARM statewide statewide cohort statewide TO HAND);DYNAMICAPPLICATION OF SHORT ARM SPLINT (FOREARM T O HAND); DYNAMIC 29130 APPLICATION OF FINGER SPLINT; cohort cohort cohort cohort cohort STATICAPPLICATION OFFINGER SPLINT; STATIC 29240 STRAPPING; SHOULDER (EG, VELPEAU) statewide cohort statewide cohort statewide 29260 STRAPPING; ELBOW OR WRIST statewide statewide cohort 29405 APPLICATION OF SHORT LEG CAST (BELOW KNEE statewide statewide statewide statewide statewide TO TOES);APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); 29445 APPLICATION OF RIGID TOTAL CONTACT LEG cohort cohort cohort cohort statewide statewide CASTAPPLICATION OF RIGID TOTAL CONTACT LEG CAST 29450 APPLICATION OF CLUBFOOT CAST WITH cohort MOLDING OR MANIPULATION,LONG OR SHORT LEG APPLICATION OF CLUBFOOTCAST WITH MOLDING OR MANIPULATION, 29505 APPLICATION OF LONG LEG SPLINT (THIGH TO cohort cohort cohort cohort cohort statewide ANKLE OR TOES)APPLICATION OF LONG LEG SPLINT (THIGH TO ANKLE OR TOES) 29515 APPLICATION OF SHORT LEG SPLINT (CALF TO cohort cohort cohort cohort cohort statewide FOOT)APPLICATION OF SHORT LEG SPLINT (CALF TO FOOT) 29530 STRAPPING; KNEE statewide cohort statewide cohort statewide statewide 29540 STRAPPING; ANKLE statewide statewide cohort 29580 STRAPPING; UNNA BOOT cohort cohort cohort cohort statewide 29581 APPLICATION OF MULTI-LAYER COMPRESSION statewide cohort cohort cohort statewide cohort SYSTEM; LEG(BELOW KNEE), INCLUDING ANKLE AND FOOT 29806 ARTHROSCOPY, SHOULDER, SURGICAL; statewide cohort cohort cohort cohort statewide CAPSULORRHAPY 29807 REPAIR, SLAP LESION statewide cohort cohort cohort statewide statewide 29822 ARTHROSCOPY, SHOULDER, SURGICAL; cohort cohort cohort cohort cohort statewide DEBRIDEMENT, LIMITED 29823 ARTHROSCOPY, SHOULDER, SURGICAL; statewide cohort cohort cohort cohort cohort DEBRIDEMENT, EXTENSIVE 29824 ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL cohort cohort cohort cohort statewide cohort CLAVICULECTOMY W/ARTICULAR SURFACE 29825 ARTHROSCOPY, SHOULDER, SURGICAL; WITH statewide statewide cohort statewide statewide statewide LYSIS AND RESECTION OFADHESIONS, WITH OR WITHOUT MANIPULATION 29826 ARTHROSCOPY, SHOULDER, SURGICAL; cohort cohort cohort cohort cohort cohort DECOMPRESSION OF SUBACROMIAL SPACE WITH PARTIAL ACROMIOPLASTY, WITHCORACOACROMIAL LIGAMENT (IE, ARCH) RELEASE, WHEN PERFORMED (LIST SEPARATELY IN ADDITION TO CODE FOR 29827 ARTHROSCOPY, SHOULDER, SURGICAL; cohort cohort cohort cohort cohort cohort W/ROTATOR CUFF REPAIR 31

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 29828 Arthroscopy, shoulder, surgical; biceps statewide cohort cohort cohort statewide cohort tenodesis 29846 ARTHROSCOPY, WRIST, SURGICAL; EXCISION statewide statewide statewide statewide statewide statewide AND/OR REPAIR OFTRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT 29848 ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE statewide statewide statewide statewide cohort statewide OF TRANSVERSECARPAL LIGAMENT 29862 ARTHROSCOPY, HIP, SURGICAL; WITH statewide statewide statewide statewide statewide DEBRIDEMENT/SHAVING OFARTICULAR CARTILAGE (CHONDROPLASTY), ABRASIONARTHROPLASTY, AND/OR RESECTION OF LABRUM 29873 ARTHROSCOPY, KNEE, SURGICAL; W/LATERAL cohort statewide statewide cohort statewide statewide RELEASE 29874 ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL statewide statewide statewide statewide statewide statewide OF LOOSE BODY ORFOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANSFRAGMENTATION, CHONDRAL FRAGMENTATION) 29875 ARTHROSCOPY, KNEE, SURGICAL; statewide cohort cohort cohort cohort statewide SYNOVECTOMY, LIMITED (EG, PLICAOR SHELF RESECTION) (SEPARATE PROCEDURE) 29876 ARTHROSCOPY, KNEE, SURGICAL; cohort cohort cohort cohort cohort statewide SYNOVECTOMY, MAJOR, 2OR MORE COMPARTMENTS (EG, MEDIAL OR LATERAL) 29877 ARTHROSCOPY, KNEE, SURGICAL; statewide cohort cohort cohort statewide statewide DEBRIDEMENT/SHAVING OFARTICULAR CARTILAGE (CHONDROPLASTY) 29879 ARTHROSCOPY, KNEE, SURGICAL; ABRASION statewide cohort cohort cohort statewide statewide ARTHROPLASTY(INCLUDESCHONDROPLASTY WHERE NECESSARY) OR MULTIP LE DRILLING 29880 ARTHROSCOPY, KNEE, SURGICAL; WITH cohort cohort cohort cohort cohort statewide MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S 29881 ARTHROSCOPY, KNEE, SURGICAL; WITH cohort cohort cohort cohort cohort cohort MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) INCLUDING DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), SAME OR SEPARATE COMPARTMENT(S) 29882 ARTHROSCOPY, KNEE, SURGICAL; WITH statewide statewide statewide cohort cohort statewide MENISCUS REPAIR (MEDIAL ORLATERAL) 29884 ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF statewide statewide statewide statewide statewide statewide ADHESIONS, WITHOR WITHOUT MANIPULATION (SEPARATE PROCEDURE) 29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE cohort cohort cohort cohort cohort statewide LIGAMENTREPAIR/AUGMENTATION OR RECONSTRUCTION 29893 ENDOSCOPIC PLANTAR FASCIOTOMY statewide statewide statewide statewide 29897 ARTHROSCOPY, ANKLE (TIBIOTALAR AND statewide statewide statewide statewide statewide statewide FIBULOTALAR JOINTS),SURGICAL; DEBRIDEMENT, LIMITED ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), 29898 ARTHROSCOPY, ANKLE (TIBIOTALAR AND statewide statewide statewide statewide statewide statewide FIBULOTALAR JOINTS),SURGICAL; DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS),

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 29914 Arthroscopy, hip, surgical; with femoroplasty statewide statewide statewide cohort (ie,treatment of cam lesion) 29915 Arthroscopy, subtalar joint, surgical; with statewide statewide statewide statewide acetabuloplasty (ie, treatment of pincer lesion) 29916 Arthroscopy, subtalar joint, surgical; with statewide statewide statewide cohort labralrepair 29999 UNLISTED PROC, ARTHROSCOPY statewide statewide cohort statewide cohort statewide 30130 EXCISION TURBINATE, PARTIAL OR COMPLETE, statewide statewide statewide statewide statewide statewide ANY METHOD 30140 SUBMUCOUS RESECTION TURBINATE, PARTIAL cohort cohort cohort cohort cohort statewide OR COMPLETE, ANYMETHOD 30300 *REMOVAL FOREIGN BODY, INTRANASAL; statewide statewide statewide statewide statewide OFFICE TYPE PROCEDURE*REMOVAL FOREIGN BODY, INTRANASAL; OFFICE TYPE PROCEDURE 30465 REPAIR OF NASAL VESTIBULAR STENOSIS (EG, statewide statewide statewide statewide statewide SPREADER GRAFTING, LATERAL NASAL WALL RECONSTRUCTION) 30520 SEPTOPLASTY OR SUBMUCOUS RESECTION, cohort cohort cohort cohort cohort statewide WITH OR WITHOUTCARTILAGE SCORING, CONTOURING OR REPLACEMENT WITHGRAFT 30801 ABLATION, SOFT TISSUE OF INFERIOR statewide statewide statewide statewide statewide TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); SUPERFICIAL 30802 ABLATION, SOFT TISSUE OF INFERIOR statewide statewide statewide statewide statewide statewide TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD (EG, ELECTROCAUTERY, RADIOFREQUENCY ABLATION, OR TISSUE VOLUME REDUCTION); INTRAMURAL (IE, SUBMUCOSAL) 30901 *CONTROL NASAL HEMORRHAGE, ANTERIOR, statewide cohort statewide cohort statewide SIMPLE (LIMITED CAUTERYAND/OR PACKING) ANY METHOD 30930 FRACTURE NASAL TURBINATE(S), THERAPEUTIC cohort statewide statewide statewide statewide 31231 NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL statewide statewide statewide statewide cohort OR BILATERAL(SEPARATE PROCEDURE) 31237 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH statewide statewide statewide statewide cohort statewide BIOPSY, POLYPECTOMY ORDEBRIDEMENT (SEPARATE PROCEDURE) 31238 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH statewide statewide statewide statewide statewide CONTROL OF EPISTAXIS 31240 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH statewide statewide statewide statewide statewide statewide CONCHA BULLOSARESECTION 31254 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH statewide cohort statewide statewide statewide statewide ETHMOIDECTOMY, PARTIAL(ANTERIOR) 31255 NASAL/SINUS ENDOSCOPY, SURGICAL; WITH statewide cohort cohort cohort cohort ETHMOIDECTOMY, TOTAL(ANTERIOR AND POSTERIOR) 31256 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH statewide cohort statewide statewide statewide statewide MAXILLARY ANTROSTOMY; 31267 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH statewide cohort cohort cohort cohort MAXILLARY ANTROSTOMY; WITH REMOVAL OF TISSUE FROM MAXILLARY SINUS 31276 NASAL/SINUS ENDOSCOPY, SURGICAL WITH statewide cohort statewide cohort cohort FRONTAL SINUSEXPLORATION, WITH OR SINUS 31287 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH statewide cohort statewide statewide statewide statewide SPHENOIDOTOMY;

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 31288 NASAL/SINUS ENDOSCOPY, SURGICAL, WITH statewide statewide statewide statewide cohort SPHENOIDOTOMY; WITHREMOVAL OF TISSUE FROM THE SPHENOID SINUS 31500 INTUBATION, ENDOTRACHEAL, EMERGENCY cohort cohort cohort statewide statewide PROCEDURE 31525 LARYNGOSCOPY DIRECT, WITH OR WITHOUT statewide statewide statewide statewide statewide TRACHEOSCOPY;DIAGNOSTIC, EXCEPT NEWBORN 31526 LARYNGOSCOPY DIRECT, WITH OR WITHOUT statewide statewide statewide statewide TRACHEOSCOPY;DIAGNOSTIC, WITH OPERATING MICROSCOPE 31535 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH statewide statewide statewide statewide BIOPSY; 31536 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH statewide statewide statewide statewide statewide statewide BIOPSY; WITHOPERATINGMICROSCOPE 31541 LARYNGOSCOPY, DIRECT, OPERATIVE, WITH statewide statewide statewide statewide cohort statewide EXCISION OF TUMORAND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE 31571 LARYNGOSCOPY, DIRECT, WITH INJECTION INTO statewide statewide statewide statewide cohort VOCAL CORD(S),THERAPEUTIC; WITH OPERATING MICROSCOPE 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; statewide statewide cohort statewide cohort DIAGNOSTIC 31579 LARYNGOSCOPY, FLEXIBLE OR RIGID statewide cohort FIBEROPTIC, WITH STROBOSCOPY 31620 ENDOBRONCHIAL ULTRASOUND (EBUS) DURING statewide statewide cohort cohort BRONCHOSCOPIC DIAGNOSTIC OR THERAPEUTIC INTERVENTION(S) (LISTSEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCED URE(S)) 31622 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide statewide cohort cohort cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; DIAGNOSTIC, WITH CELL WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 31623 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide statewide cohort cohort statewide INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRUSHING OR PROTECTED BRUSHINGS 31624 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide cohort cohort cohort cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL ALVEOLAR LAVAGE 31625 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide statewide cohort statewide cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH BRONCHIAL OR ENDOBRONCHIAL BIOPSY(S), SINGLE OR MULTIPLE SITES 31628 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide statewide cohort cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL LUNG BIOPSY(S), SINGLE LOBE 31629 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide cohort cohort cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), TRACHEA, MAIN STEM AND/OR LOBAR BRONCHUS(I) 31633 BRONCHOSCOPY, RIGID OR FLEXIBLE, statewide statewide cohort INCLUDING FLUOROSCOPIC GUIDANCE, WHEN

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 PERFORMED; WITH TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY(S), EACH ADDITIONAL LOBE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 31720 CATHETER ASPIRATION (SEPARATE statewide statewide statewide cohort statewide PROCEDURE); NASOTRACHEAL 32405 BIOPSY, LUNG OR MEDIASTINUM, statewide statewide cohort cohort cohort statewide PERCUTANEOUS NEEDLE 32551 TUBE THORACOSTOMY, INCLUDES CONNECTION statewide statewide statewide statewide statewide TO DRAINAGESYSTEM (EG, WATER SEAL), WHEN PERFORMED, OPEN (SE PARATE PROCEDURE) 32554 THORACENTESIS, NEEDLE OR CATHETER, statewide statewide statewide statewide ASPIRATION OF THE PLEURAL SPACE; WITHOUT IMAGING GUIDANCE 32555 THORACENTESIS, NEEDLE OR CATHETER, statewide statewide cohort cohort cohort statewide ASPIRATION OF THE PLEURAL SPACE; WITH IMAGING GUIDANCE 33208 INSERTION OF NEW OR REPLACEMENT OF statewide statewide statewide statewide PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR 33225 INSERTION OF PACING ELECTRODE, CARDIAC statewide statewide cohort statewide VENOUS SYSTEM, FOR LEFT VENTRICULAR PACING, AT TIME OF INSERTION OF IMPLANTABLE DEFIBRILLATOR OR PACEMAKER PULSE GENERATOR (EG, FOR UPGRADE TO DUAL CHAMBER SYSTE 33228 REMOVAL OF PERMANENT PACEMAKER PULSE statewide statewide statewide statewide GENERATOR WITH REPLACEMENT OF PACEMAKER PULSE GENERATOR; DUAL LEAD SYSTEM 33249 INSERTION OR REPLACEMENT OF PERMANENT statewide cohort cohort cohort IMPLANTABLE DEFIBRILLATOR SYSTEM, WITH TRANSVENOUS LEAD(S), SINGLE OR DUAL CHAMBER 33263 REMOVAL OF IMPLANTABLE DEFIBRILLATOR statewide statewide statewide statewide PULSE GENERATOR WITH REPLACEMENT OF IMPLANTABLE DEFIBRILLATOR PULSE GENERATOR; DUAL LEAD SYSTEM 33282 IMPLANTATION OF PATIENT-ACTIVATED statewide cohort cohort cohort CARDIAC EVENT RECORDER 33284 REMOVAL OF AN IMPLANTABLE, PATIENT- statewide statewide statewide statewide ACTIVATED CARDIAC EVENT RECORDER 35476 TRANSLUMINAL BALLOON ANGIOPLASTY, statewide statewide cohort statewide statewide PERCUTANEOUS; VENOUS 36000 *INTRODUCTION OF NEEDLE OR cohort statewide statewide cohort INTRACATHETER, VEIN 36005 INJECTION PROCEDURE FOR CONTRAST statewide statewide statewide statewide statewide VENOGRAPHY (INCLUDINGINTRODUCTION OF NEEDLE OR INTRACATHETER) 36010 INTRODUCTION OF CATHETER, SUPERIOR OR statewide statewide statewide statewide statewide statewide INFERIOR VENA CAVA 36011 Selective Catheter placement statewide statewide statewide 36012 SELECTIVE CATHETER PLACEMENT, VENOUS statewide statewide statewide statewide SYSTEM; SECOND ORDER,OR MORE SELECTIVE, BRANCH (EG, LEFT ADRENAL VEIN, PETROSAL SINUS) 36147 INTRODUCTION OF NEEDLE AND/OR CATHETER, statewide statewide cohort cohort statewide statewide ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (GRAFT/FISTULA); INITIAL ACCESS WITH COMPLETE RADIOLOGICAL EVALUATIONOF 35

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 DIALYSIS ACCESS, INCLUDING FLUOROSCOPY, IMAGE 36200 INTRODUCTION OF CATHETER, AORTA statewide statewide cohort statewide 36223 SELECTIVE CATHETER PLACEMENT, COMMON statewide statewide cohort statewide CAROTID OR INNOMINATE ARTERY, UNILATERAL, ANY APPROACH, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERV 36224 SELECTIVE CATHETER PLACEMENT, INTERNAL statewide cohort cohort CAROTID ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL INTRACRANIAL CAROTID CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, 36226 SELECTIVE CATHETER PLACEMENT, VERTEBRAL statewide cohort cohort ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL VERTEBRAL CIRCULATION AND ALL ASSOCIATED RADIOLOGICAL SUPERVISION AND INTERPRETATION, INCLUDES ANGIOGRAP 36227 SELECTIVE CATHETER PLACEMENT, EXTERNAL statewide statewide statewide CAROTID ARTERY, UNILATERAL, WITH ANGIOGRAPHY OF THE IPSILATERAL EXTERNAL CAROTID CIRCULATION AND ALL ASSOCIATEDRADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST 36245 SELECTIVE CATHETER PLACEMENT, ARTERIAL statewide statewide cohort SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY 36246 SELECTIVE CATHETER PLACEMENT, ARTERIAL statewide statewide statewide statewide statewide SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY 36247 SELECTIVE CATHETER PLACEMENT, ARTERIAL statewide statewide statewide cohort SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY 36248 SELECTIVE CATHETER PLACEMENT, ARTERIAL statewide statewide cohort SYSTEM; ADDITIONAL SECOND ORDER, THIRD ORDER, AND BEYOND, ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, WITHIN A VASCULAR FAMILY (LIST IN ADDITION TO CODE 36252 SELECTIVE CATHETER PLACEMENT (FIRST- statewide cohort statewide statewide ORDER), MAIN RENAL ARTERY AND ANY ACCESSORY RENAL ARTERY(S) FOR RENAL ANGIOGRAPHY, INCLUDING ARTERIAL PUNCTURE ANDCATHETER PLACEMENT(S), FLUOROSCOPY, CONTRAST INJE 36430 TRANSFUSION, BLOOD OR BLOOD statewide statewide statewide statewide statewide COMPONENTSTRANSFUSION,BLOOD OR BLOOD COMPONENTS 36475 ENDOVENOUS ABLATION THERAPY OF statewide statewide INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 36478 ENDOVENOUS ABLATION THERAPY OF statewide cohort INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 ALL IMAGING GUIDANCE & MONITORING, PERCUTANEOUS, LASER; FIRST VEIN TREATED 36514 THERAPEUTIC APHERESIS; PLASMA PHERESIS cohort cohort 36522 PHOTOPHERESIS, EXTRACORPOREAL cohort 36556 INSERTION OF NON-TUNNELED CENTRALLY statewide cohort statewide statewide statewide INSERTED CENTRAL VENOUS CATHETER; AGE 5 YEARS OR OLDER 36558 INSERTION OF TUNNELED CENTRALLY INSERTED statewide statewide statewide statewide cohort statewide CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR PUMP;AGE 5 YEARS OR OLDER 36561 INSERTION OF TUNNELED CENTRALLY INSERTED statewide cohort cohort cohort cohort statewide CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER 36569 INSERTION OF PERIPHERALLY INSERTED statewide cohort cohort cohort cohort statewide CENTRAL VENOUS CATHETER (PICC), WITHOUT SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER 36571 INSERTION OF PERIPHERALLY INSERTED statewide statewide statewide statewide statewide CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT; AGE 5 YEARSOR OLDER 36589 REMOVAL OF TUNNELED CENTRAL VENOUS statewide statewide statewide cohort statewide CATHETER WITHOUT SUBCUTANEOUS PORT OR PUMP 36590 REMOVAL OF TUNNELED CENTRAL VENOUS statewide cohort cohort cohort cohort statewide ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP CENTRAL OR PERIPHERAL INSERTION 36591 Collection of blood specimen from a completely statewide statewide cohort statewide cohort statewide implantable venous access device 36592 Collection of blood specimen using established statewide statewide statewide cohort central or peripheral catheter, venous, not otherwisespecified 36593 Declotting by thrombolytic agent of implanted statewide statewide cohort cohort cohort statewide vascular access device or catheter 36598 CONTRAST INJECTION(S) FOR RADIOLOGIC statewide statewide statewide cohort statewide statewide EVALUATION OFEXISTING CENTRAL VENOUS ACCESS DEVICE, INCLUDING FLUOROSCOPY, IMAGE DOCUMENTATION AND REPORT 36600 *ARTERIAL PUNCTURE, WITHDRAWAL OF cohort cohort cohort cohort cohort statewide BLOOD FOR DIAGNOSIS 36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY statewide statewide statewide cohort cohort statewide SITE (EG, CIMINOTYPE) (SEPARATE ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (EG, CIMINO 36832 REVISION, ARTERIOVENOUS FISTULA; WITHOUT statewide statewide statewide statewide statewide THROMBECTOMY,AUTOGENOUS OR NONAUTOGENOUS, DIALYSIS GRAFT (SEPARATE PROCEDURE) 37191 INSERTION OF INTRAVASCULAR VENA CAVA statewide statewide statewide statewide FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSELSELECTION, AND RADIOLOGICAL SUPERVISION AND INTER PRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGIN 37193 RETRIEVAL (REMOVAL) OF INTRAVASCULAR statewide statewide cohort statewide VENA CAVA FILTER, ENDOVASCULAR APPROACH INCLUDING VASCULAR ACCESS, VESSEL SELECTION, AND RADIOLOGICAL SUPERVISIONAND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, 37

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 37221 Revascularization, endovascular, open or statewide statewide cohort statewide statewide percutaneous, iliac artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed 37224 Revascularization, endovascular, open or statewide statewide statewide statewide statewide percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty 37226 Revascularization, endovascular, open or statewide statewide statewide statewide statewide statewide percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed 37236 TRANSCATHETER PLACEMENT OF AN statewide statewide statewide statewide statewide INTRAVASCULAR STENT(S) (EXCEPT LOWER EXTREMITY ARTERY(S) FOR OCCLUSIVEDISEASE, CERVICAL CAROTID, EXTRACRANIAL VERTEBRAL OR INTRATHORACIC CAROTID, INTRACRANIAL, OR CORONA 37238 TRANSCATHETER PLACEMENT OF AN statewide statewide statewide statewide statewide statewide INTRAVASCULAR STENT(S), OPEN OR PERCUTANEOUS, INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION AND INCLUDING ANGIOPLASTY WITHIN THE SAME VESSEL, WHEN PERFORMED; INIT 37241 VASCULAR EMBOLIZATION OR OCCLUSION, statewide statewide cohort INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; VENOUS, OTHE 37242 VASCULAR EMBOLIZATION OR OCCLUSION, statewide statewide cohort INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; ARTERIAL, OT 37243 VASCULAR EMBOLIZATION OR OCCLUSION, statewide statewide cohort cohort INCLUSIVE OF ALL RADIOLOGICAL SUPERVISION AND INTERPRETATION, INTRAPROCEDURAL ROADMAPPING, AND IMAGING GUIDANCE NECESSARY TO COMPLETE THE INTERVENTION; FOR TUMORS, 37250 INTRAVASCULAR ULTRASOUND (NON- statewide statewide statewide statewide statewide statewide CORONARY VESSEL) DURNG THERAPEUTIC INTERVENTION; INITIAL VESSEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 37766 STAB PHLEBECTOMY OF VARICOSE VEINS, 1 statewide statewide cohort statewide EXTREMITY; MORE THAN 20 INCISIONS 38206 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR cohort CELL HARVESTING, TRANSPLANTATION/COLLECTION; AUTOLOGOUS 38207 TRANSPLANT PREPARATION, HEMATOPIETIC cohort PROGENITOR CELLS, CRYOPRESERVATION AND STORAGE 38220 BONE MARROW ASPIRATION statewide statewide statewide cohort cohort statewide 38221 BONE MARROW BX. NEEDLE/TROCAR statewide statewide cohort cohort cohort statewide 38500 BIOPSY OR EXCISION OF LYMPH NODE(S); statewide cohort cohort cohort cohort statewide SUPERFICIAL (SEPARATEPROCEDURE)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 38505 BIOPSY OR EXCISION OF LYMPH NODE(S); BY statewide statewide cohort statewide cohort statewide NEEDLE, SUPERFICIAL (EG, CERVICAL, INGUINAL, AXILLARY) 38510 BIOPSY OR EXCISION OF LYMPH NODE(S); DEEP statewide statewide cohort cohort cohort statewide CERVICALNODE(S) 38525 BIOPSY OR EXCISION OF LYMPH NODE(S); DEEP statewide cohort cohort cohort cohort statewide AXILLARYNODE(S) 38570 LAPAROSCOPY, SURGICAL;WITH statewide statewide statewide statewide RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE 38571 LAPAROSCOPY, SURGICAL;WITH BILATERAL statewide statewide statewide statewide TOTAL PELVIC LYMPHADENECTOMY 38572 LAPAROSCOPY, SURGICAL;WITH BILATERAL statewide statewide statewide TOTAL PELVIC LYMPHADENECTOMY AND PERI- AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE 38724 CERVICAL LYMPHADENECTOMY (MODIFIED statewide statewide statewide statewide RADICAL NECK DISSECTION) CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION) 38792 INJECTION PROCEDURE; RADIOACTIVE TRACER statewide cohort cohort cohort cohort FOR IDENTIFICATION OF SENTINEL NODE 38900 Intraoperative identification (eg, mapping) of statewide statewide cohort cohort cohort statewide sentinel lymph node(s) includes injection of non- radioactive dye, when performed (List separately in addition to code for primary procedure) 39400 MEDIASTINOSCOPY, INCLUDES BIOPSY(IES), statewide statewide statewide statewide WHEN PERFORMED 41800 *DRAINAGE OF ABSCESS, CYST, HEMATOMA statewide statewide statewide statewide statewide FROM DENTOALVEOLARSTRUCTURES 41899 UNLISTED PROCEDURE, DENTOALVEOLAR statewide cohort cohort cohort cohort statewide STRUCTURES 42140 UVULECTOMY, EXCISION OF UVULA statewide statewide statewide statewide statewide statewide 42415 EXCISION OF PAROTID TUMOR OR PAROTID statewide statewide statewide statewide GLAND; LATERAL LOBE,WITH DISSECTION AND PRESERVATION OF FACIAL NERVE 42700 *INCISION AND DRAINAGE ABSCESS; statewide statewide statewide statewide PERITONSILLAR 42820 TONSILLECTOMY AND ADENOIDECTOMY; statewide cohort cohort cohort cohort statewide UNDER AGE 12 42821 TONSILLECTOMY AND ADENOIDECTOMY; AGE statewide cohort cohort cohort statewide statewide 12 OR OVER 42825 TONSILLECTOMY, PRIMARY OR SECONDARY; statewide statewide statewide statewide statewide UNDER AGE 12 42826 TONSILLECTOMY, PRIMARY OR SECONDARY; statewide cohort cohort cohort cohort statewide AGE 12 OR OVER 42830 ADENOIDECTOMY, PRIMARY; UNDER AGE 12 statewide cohort cohort cohort cohort statewide 42831 ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER statewide statewide statewide statewide statewide 42960 CONTROL OROPHARYNGEAL HEMORRHAGE, statewide statewide statewide statewide statewide PRIMARY OR SECONDARY (EG, POSTTONSILLECTOMY); SIMPLE CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 43191 ESOPHAGOSCOPY, RIGID, TRANSORAL; statewide statewide statewide statewide statewide DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING WHEN PERFORMED (SEPARATE PROCEDURE)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 43200 ESOPHAGOSCOPY, FLEXIBLE, TRANSORAL; statewide statewide statewide statewide statewide DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 43235 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, cohort cohort cohort cohort cohort statewide TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 43236 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide statewide TRANSORAL; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE 43237 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide cohort cohort TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED TO THE ESOPHAGUS, STOMACH OR DUODENUM, AND ADJACENT STRUCTURES 43238 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide cohort TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S), (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION LIMITED T 43239 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, cohort cohort cohort cohort cohort cohort TRANSORAL; WITH BIOPSY, SINGLE OR MULTIPLE 43242 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide cohort cohort TRANSORAL; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) (INCLUDES ENDOSCOPIC ULTRASOUND EXAMINATION OF THE ESO 43244 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide statewide cohort TRANSORAL; WITH BAND LIGATION OF ESOPHAGEAL/GASTRIC VARICES 43245 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide statewide statewide TRANSORAL; WITH DILATION OF GASTRIC/DUODENAL STRICTURE(S) (EG,BALLOON, BOUGIE) 43246 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide statewide statewide TRANSORAL; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMYTUBE 43247 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide cohort cohort cohort cohort statewide TRANSORAL; WITH REMOVAL OF FOREIGN BODY(S) 43248 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide cohort cohort cohort cohort TRANSORAL; WITH INSERTION OF GUIDE WIRE FOLLOWED BY PASSAGE OFDILATOR(S) THROUGH ESOPHAGUS OVER GUIDE WIRE 43249 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide cohort cohort cohort cohort statewide TRANSORAL; WITH TRANSENDOSCOPIC BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER) 43251 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide cohort statewide statewide cohort TRANSORAL; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 43259 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, cohort cohort cohort TRANSORAL; WITH ENDOSCOPIC ULTRASOUND EXAMINATION, INCLUDING THE ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM OR A

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 SURGICALLY ALTERED STOMACH WHERE THE JEJUNUM IS 43260 ENDOSCOPIC RETROGRADE statewide statewide statewide statewide CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 43261 ENDOSCOPIC RETROGRADE statewide statewide statewide statewide CHOLANGIOPANCREATOGRAPHY (ERCP); WITH BIOPSY, SINGLE OR MULTIPLE 43262 ENDOSCOPIC RETROGRADE statewide statewide statewide cohort cohort CHOLANGIOPANCREATOGRAPHY (ERCP); WITH SPHINCTEROTOMY/PAPILLOTOMY 43264 ENDOSCOPIC RETROGRADE statewide statewide statewide statewide cohort CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF CALCULI/DEBRIS FROM BILIARY/PANCREATIC DUCT(S) 43270 ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, statewide statewide statewide statewide cohort TRANSORAL; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) 43274 ENDOSCOPIC RETROGRADE statewide statewide statewide statewide cohort CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PLACEMENT OF ENDOSCOPIC STENT INTO BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCL 43275 ENDOSCOPIC RETROGRADE statewide statewide statewide statewide cohort CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL OF FOREIGN BODY(S) OR STENT(S) FROM BILIARY/PANCREATIC DUCT(S) 43276 ENDOSCOPIC RETROGRADE statewide statewide cohort CHOLANGIOPANCREATOGRAPHY (ERCP); WITH REMOVAL AND EXCHANGE OF STENT(S), BILIARY OR PANCREATIC DUCT, INCLUDING PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED, INCLU 43277 ENDOSCOPIC RETROGRADE statewide statewide statewide CHOLANGIOPANCREATOGRAPHY (ERCP); WITH TRANS-ENDOSCOPIC BALLOON DILATION OF BILIARY/PANCREATIC DUCT(S) OR OF AMPULLA (SPHINCTEROPLASTY), INCLUDING SPHINCTEROTOMY, WHEN PERFORMED, 43280 LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC statewide statewide statewide statewide FUNDOPLASTY(EG, NISSEN, TOUPET PROCEDURES) 43281 LAPAROSCOPY, SURGICAL, REPAIR OF statewide statewide cohort cohort PARAESOPHAGEAL HERNIA, INCLUDES FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH 43450 *DILATION OF ESOPHAGUS, BY UNGUIDED statewide cohort cohort cohort statewide SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES *DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE 43753 Gastric intubation and aspiration(s) therapeutic, statewide statewide statewide statewide statewide necessitating physician's skill (eg, for gastrointestinal hemorrhage), including lavage if performed 43760 Change of gastrostomy tube, percutaneous, statewide statewide statewide statewide statewide without imaging or endoscopic guidance

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 43770 Laparoscopy, surgical, gastric restrictive statewide statewide statewide procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) 43774 Laparoscopy, surgical, gastric restrictive statewide statewide statewide statewide procedure; removal of adjustable gastric restrictive device and subcutaneous port components 43775 LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE cohort statewide cohort statewide statewide PROCEDURE; LONGITUDINAL GASTRECTOMY (IE, SLEEVE GASTRECTOMY) 44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS statewide statewide statewide statewide statewide (FREEING OF INTESTINAL ADHESION) (SEPARATE PROCEDURE) 44386 ENDOSCOPIC EVALUATION OF SMALL statewide cohort INTESTINAL POUCH (EG, KOCK POUCH, ILEAL RESERVOIR [S OR J]); WITH BIOPSY, SINGLE OR MULTIPLE 44950 APPENDECTOMY; statewide statewide statewide statewide statewide statewide 44970 LAPAROSCOPY, SURGICAL; APPENDECTOMY cohort cohort cohort cohort cohort statewide 45171 EXCISION OF RECTAL TUMOR, TRANSANAL statewide statewide statewide statewide statewide APPROACH; NOT INCLUDING MUSCULARIS PROPRIA (IE, PARTIAL THICKNESS) 45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, statewide statewide statewide cohort WITH OR WITHOUTCOLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) 45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, statewide statewide cohort cohort cohort INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 45331 SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, statewide statewide statewide cohort cohort statewide SINGLE OR MULTIPLESIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLEOR MULTIPLE 45338 SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF statewide statewide statewide statewide TUMOR(S),POLYP(S),OR OTHER LESION(S) BY SNARE TECHNIQUE S IGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), 45341 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH statewide cohort cohort OR W/OUTCOLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) WITH ENDOSCOPIC ULTRASOUND EXAMINATION. 45378 COLONOSCOPY, FLEXIBLE; DIAGNOSTIC, cohort cohort cohort cohort cohort cohort INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 45380 COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE cohort cohort cohort cohort cohort statewide OR MULTIPLE 45381 COLONOSCOPY, FLEXIBLE; WITH DIRECTED statewide cohort statewide statewide statewide SUBMUCOSAL INJECTION(S), ANY SUBSTANCE 45382 COLONOSCOPY, FLEXIBLE; WITH CONTROL OF statewide statewide statewide statewide statewide BLEEDING, ANY METHOD 45383 LESION REMOVAL COLONOSCOPY statewide statewide statewide statewide statewide 45384 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF cohort cohort statewide cohort statewide statewide TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 45385 COLONOSCOPY, FLEXIBLE; WITH REMOVAL OF cohort cohort cohort cohort cohort statewide TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 45388 COLONOSCOPY, FLEXIBLE; WITH ABLATION OF statewide statewide statewide statewide statewide TUMOR(S), POLYP(S), OR OTHER LESION(S) (INCLUDES PRE- AND POST-DILATION AND GUIDE WIRE PASSAGE, WHEN PERFORMED) 45990 ANORECTAL EXAM, SURGICAL, REQUIRING statewide statewide statewide statewide statewide ANESTHESIA (GENERAL, SPINAL, OR EPIDURAL), DIAGNOSTIC 46020 PLACEMENT, SETON statewide statewide statewide cohort cohort statewide 46040 INCISION AND DRAINAGE OF ISCHIORECTAL statewide statewide statewide cohort statewide AND/OR PERIRECTALABSCESS (SEPARATE PROCEDURE) 46050 *INCISION AND DRAINAGE, PERIANAL ABSCESS, statewide statewide statewide statewide statewide SUPERFICIAL 46080 *SPHINCTEROTOMY, ANAL, DIVISION OF statewide statewide statewide statewide statewide SPHINCTER (SEPARATEPROCEDURE) 46083 INCISION OF THROMBOSED HEMORRHOID, statewide statewide statewide statewide statewide EXTERNAL 46200 FISSURECTOMY, INCLUDING SPHINCTEROTOMY, statewide statewide statewide statewide WHEN PERFORMED 46221 HEMORRHOIDECTOMY, INTERNAL, BY RUBBER statewide statewide statewide statewide statewide statewide BAND LIGATION(S) 46250 HEMORRHOIDECTOMY, EXTERNAL, 2 OR MORE statewide statewide statewide COLUMNS/GROUPS 46255 HEMORRHOIDECTOMY, INTERNAL AND statewide statewide statewide statewide statewide statewide EXTERNAL, SINGLE COLUMN/GROUP; 46260 HEMORRHOIDECTOMY, INTERNAL AND statewide cohort cohort cohort statewide EXTERNAL, 2 OR MORECOLUMNS/GROUPS; 46270 SURGICAL TREATMENT OF ANAL statewide statewide cohort statewide statewide statewide FISTULA(FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS 46275 SURGICAL TREATMENT OF ANAL FISTULA statewide statewide cohort statewide statewide (FISTULECTOMY/FISTULOTOMY); INTERSPHINCTERIC 46280 SURGICAL TREATMENT OF ANAL FISTULA statewide statewide statewide statewide (FISTULECTOMY/FISTULOTOMY); TRANSSPHINCTERIC, SUPRASPHINCTERIC, EXTRASPHINCTERIC OR MULTIPLE, INCLUDING PLACEMENT OF SETON, WHEN PERFORMED 46320 EXCISION OF THROMBOSED HEMORRHOID, statewide statewide statewide statewide statewide EXTERNAL 46600 ANOSCOPY; DIAGNOSTIC, INCLUDING statewide cohort statewide cohort COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 46922 DESTRUCTION OF LESION(S), ANUS (EG, statewide statewide statewide cohort statewide statewide CONDYLOMA, PAPILLOMA,MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION 46946 HEMORRHOIDECTOMY, INTERNAL, BY LIGATION statewide statewide statewide statewide statewide OTHER THANRUBBER BAND; 2 OR MORE HEMORRHOID COLUMNS/GROUPS 46947 HEMORRHOIDOPEXY (EG,FOR PROLAPSING statewide statewide statewide statewide statewide statewide INTERNAL HEMORRHOIDS) BY STAPLING 47000 *BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS statewide cohort cohort cohort cohort statewide 47379 UNLISTED LAPAROSCOPIC PROCEDURE, LIVER statewide statewide statewide statewide statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 47505 INJECTION PROCEDURE FOR statewide statewide statewide statewide statewide CHOLANGIOGRAPHY THROUGH ANEXISTING CATHETER (EG, PERCUTANEOUS TRANSHEPATIC OR T-TUBE) INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN EXISTING 47525 CHANGE OF PERCUTANEOUS BILIARY DRAINAGE statewide statewide statewide statewide CATHETER 47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY cohort cohort cohort cohort cohort statewide 47563 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY cohort cohort cohort cohort cohort statewide WITH CHOLANGIOGRAPHY 49083 ABDOMINAL PARACENTESIS (DIAGNOSTIC OR statewide cohort cohort cohort cohort THERAPEUTIC); WITH IMAGING GUIDANCE 49180 *BIOPSY, ABDOMINAL OR RETROPERITONEAL statewide statewide statewide cohort cohort statewide MASS, PERCUTANEOUSNEEDLE 49320 LAPAROSCOPY, SURGICAL, ABDOMEN, statewide cohort cohort cohort cohort statewide PERITONEUM, AND OMENTUM; DIAGNOSTIC , WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) 49321 LAPAROSCOPY, SURGICAL, ABDOMEN, statewide statewide cohort cohort statewide PERITONEUM, AND OMENTUM; WITH BIOPSY (SINGLE OR MULTIPLE) 49322 LAPAROSCOPY, SURGICAL, ABDOMEN, statewide statewide statewide cohort statewide statewide PERITONEUM, AND OMENTUM; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) (SINGLE OR MULTIPLE) 49324 Laparoscopy, surgical; with insertion of tunneled statewide statewide statewide statewide statewide statewide intraperitoneal catheter 49329 LAPAROSCOPY, SURGICAL, ABDOMEN, statewide cohort cohort cohort statewide statewide PERITONEUM, AND OMENTUM; UNLISTED LAPAROSCOPY PROCEDURE, ABDOMEN, PERITONEUM AND OMENTUM 49406 IMAGE-GUIDED FLUID COLLECTION DRAINAGE statewide statewide statewide statewide statewide BY CATHETER(EG, ABSCESS, HEMATOMA, SEROMA, LYMPHOCELE, CYST) ; PERITONEAL OR RETROPERITONEAL, PERCUTANEOUS 49422 Removal of tunneled intraperitoneal catheter statewide statewide statewide statewide statewide 49423 EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR statewide statewide statewide statewide CYST DRAINAGECATHETER UNDER RADIOLOGICAL GUIDANCE (SEPARATEPROCEDURE) 49424 CONTRAST INJECTION FOR ASSESSMENT OF statewide statewide statewide cohort ABSCESS OR CYST VIAPREVIOUSLY PLACED CATHETER (SEPARATE PROCEDURE) 49440 Insertion of gastrostomy tube, percutaneous, statewide statewide statewide statewide underfluoroscopic guidance including contrast injectio n(s), image documentation and report 49450 Replacement of gastrostomy or cecostomy (or statewide statewide statewide statewide statewide other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49452 Replacement of gastro-jejunostomy tube, statewide statewide cohort statewide percutaneous, under fluoroscopic guidance including contrastinjection(s), image documentation and report 49465 Contrast injection(s) for radiological evaluation statewide statewide statewide statewide statewide of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including i 44

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 49500 REPAIR INITIAL INGUINAL HERNIA, AGE 6 statewide statewide cohort MONTHS TO UNDER 5YEARS, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE 49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS cohort cohort cohort cohort cohort statewide OR OVER;REDUCIBLE 49507 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS statewide statewide statewide statewide statewide statewide OR OVER;INCARCERATED OR STRANGULATED 49520 REPAIR RECURRENT INGUINAL HERNIA, ANY statewide statewide statewide statewide statewide statewide AGE; REDUCIBLE 49560 REPAIR INITIAL INCISIONAL OR VENTRAL statewide cohort cohort cohort statewide statewide HERNIA; REDUCIBLE 49561 REPAIR INITIAL INCISIONAL OR VENTRAL statewide statewide cohort cohort statewide statewide HERNIA; INCARCERATED ORSTRANGULATED 49565 REPAIR RECURRENT INCISIONAL OR VENTRAL statewide statewide statewide statewide statewide HERNIA; REDUCIBLE 49568 Implantation of mesh or other prosthesis for statewide cohort cohort cohort statewide statewide open incisional or ventral hernia repari or mesh for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for 49570 REPAIR EPIGASTRIC HERNIA (EG, statewide statewide statewide statewide statewide PREPERITONEAL FAT); REDUCIBLE (SEPARATE PROCEDURE) 49572 REPAIR EPIGASTRIC HERNIA (EG, statewide statewide statewide statewide statewide statewide PREPERITONEAL FAT);INCARCERATED OR STRANGULATED 49580 REPAIR UMBILICAL HERNIA, UNDER AGE 5 statewide statewide statewide statewide YEARS; REDUCIBLE 49585 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR statewide cohort cohort cohort cohort statewide OVER; REDUCIBLE 49587 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR statewide cohort cohort cohort cohort statewide OVER; INCARCERATEDOR STRANGULATED 49650 LAPAROSCOPY, SURGICAL; REPAIR INTIAL statewide cohort cohort cohort cohort INQUINAL HERNIA 49651 LAPAROSCOPY, SURGICAL; REPAIR RECURRENT statewide statewide statewide statewide statewide statewide INQUINAL HERNIA 49652 Laparoscopy, surgical repair, ventral, umbilical, statewide cohort cohort cohort cohort statewide spigelian or epigastric hernia (includes mesh insertion, when performed); reducible 49653 Laparoscopy, surgical repair, ventral, umbilical, statewide cohort cohort cohort statewide statewide spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated 49654 Laparoscopy, surgical, repair, incisional hernia statewide cohort cohort cohort statewide statewide (includes mesh insertion, when performed); reducible 49655 Laparoscopy, surgical, repair, incisional hernia statewide statewide statewide statewide statewide statewide (includes mesh insertion, when performed); incarcerated or strangulated 50080 PERCUTANEOUS NEPHROSTOLITHOTOMY OR statewide statewide statewide statewide PYELOSTOLITHOTOMY, WITHOR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING OR BASKET EXTRACTION; UP TO 2 CM 50081 PERCUTANEOUS NEPHROSTOLITHOTOMY OR statewide statewide statewide statewide statewide statewide PYELOSTOLITHOTOMY, WITHOR WITHOUT DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING OR BASKET EXTRACTION; OVER 2 CM 50200 *RENAL BIOPSY; PERCUTANEOUS, BY TROCAR statewide statewide cohort cohort cohort statewide OR NEEDLE 45

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 50392 INTRODUCTION OF INTRACATHETER OR statewide statewide statewide statewide statewide CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS 50393 INTRODUCTION OF URETERAL CATHETER OR statewide statewide statewide statewide statewide STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS 50394 INJECTION PROCEDURE FOR PYELOGRAPHY (AS statewide statewide statewide cohort cohort statewide NEPHROSTOGRAM,PYELOSTOGRAM, ANTEGRADE PYELOURETEROGRAMS) THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, OR INDWELLING URETERAL 50395 INTRODUCTION OF GUIDE INTO RENAL PELVIS statewide statewide cohort statewide AND/OR URETER WITHDILATION TO ESTABLISH NEPHROSTOMY TRACT, PERCUTANEOUS INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER WITH 50398 *CHANGE OF NEPHROSTOMY OR PYELOSTOMY statewide statewide cohort statewide statewide TUBE 50590 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE cohort cohort cohort cohort statewide statewide 51600 *INJECTION PROCEDURE FOR CYSTOGRAPHY OR statewide statewide cohort cohort cohort statewide VOIDINGURETHROCYSTOGRAPHY 51610 INJECTION PROCEDURE FOR RETROGRADE statewide statewide statewide cohort URETHROCYSTOGRAPHY 51700 *BLADDER IRRIGATION, SIMPLE, LAVAGE statewide statewide statewide statewide statewide AND/OR INSTILLATION 51701 INSERTION, NON-INDWELLING BLADDER statewide cohort cohort statewide cohort CATHETER 51702 INSERTION, TEMPORARY INDWELLING BLADDER cohort cohort cohort cohort cohort statewide CATHETER; SIMPLE 51720 Bladder instillation of anticarcinogenic agent statewide statewide statewide statewide cohort (including retention time) 51726 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED statewide cohort ELECTRONIC EQUIPMENT); 51728 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED statewide cohort ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE), ANY TECHNIQUE 51729 COMPLEX CYSTOMETROGRAM (IE, CALIBRATED statewide statewide ELECTRONIC EQUIPMENT); WITH VOIDING PRESSURE STUDIES (IE, BLADDER VOIDING PRESSURE) AND URETHRAL PRESSURE PROFILE STUDIES (IE, URETHRAL CLOSURE PRESSURE PROFILE) 51736 SIMPLE UROFLOWMETRY (UFR) (EG, STOP- statewide statewide WATCH FLOW RATE,MECHANICAL UROFLOWMETER) 51741 COMPLEX UROFLOWMETRY (EG, CALIBRATED statewide statewide cohort ELECTRONIC EQUIPMENT) 51784 ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL statewide statewide cohort OR URETHRALSPHINCTER, OTHER THAN NEEDLE, ANY TECHNIQUE 51785 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) statewide statewide statewide OF ANAL OR URETHRALSPHINCTER, ANY TECHNIQUE 51797 VOIDING PRESSURE STUDIES, INTRA- statewide cohort ABDOMINAL (IE, RECTAL, GASTRIC, INTRAPERITONEAL) (LIST SEPARATELY

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 INADDITION TO CODE FOR PRIMARY PROCEDURE) 51798 MEASUREMENT, POST-VOIDING RESIDUAL statewide cohort cohort cohort cohort statewide URINE &/OR BLADDER CAPACITY, US, NON- IMAGING 52000 CYSTOURETHROSCOPY (SEPARATE cohort cohort cohort cohort cohort statewide PROCEDURE)CYSTOURETHROSCOPY (SEPARATE PROCEDURE) 52005 CYSTOURETHROSCOPY, WITH URETERAL statewide cohort cohort statewide statewide statewide CATHETERIZATION, WITH ORWITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 52204 Cystourethroscopy, with biopsy(s) statewide statewide cohort cohort statewide statewide 52214 CYSTOURETHROSCOPY, WITH FULGURATION statewide statewide statewide statewide statewide (INCLUDING CRYOSURGERYOR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS 52224 CYSTOURETHROSCOPY, WITH FULGURATION statewide statewide statewide statewide statewide (INCLUDING CRYOSURGERYOR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY 52234 CYSTOURETHROSCOPY, WITH FULGURATION statewide statewide cohort statewide statewide statewide (INCLUDING CRYOSURGERYOR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 TO 2.0 CM) 52235 CYSTOURETHROSCOPY, WITH FULGURATION statewide statewide cohort statewide statewide (INCLUDING CRYOSURGERYOR LASER SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM) 52240 CYSTOURETHROSCOPY, WITH FULGURATION statewide statewide statewide statewide statewide statewide (INCLUDING CRYOSURGERYOR LASER SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S) 52260 CYSTOURETHROSCOPY, WITH DILATION OF statewide statewide statewide statewide cohort statewide BLADDER FOR INTERSTITIALCYSTITIS; GENERAL OR CONDUCTION (SPINAL)ANESTHESIA CYSTOURETHROSCOPY, WITH DILATION OF B LADDER FOR INTERSTITIAL 52276 CYSTOURETHROSCOPY WITH DIRECT VISION statewide statewide statewide statewide statewide INTERNAL URETHROTOMYCYSTOURETHROSCOPY WITH DIRECT VISION INTERNAL URETHROTOMY 52281 CYSTOURETHROSCOPY, WITH CALIBRATION statewide statewide statewide statewide statewide statewide AND/OR DILATION OFURETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR 52310 CYSTOURETHROSCOPY, WITH REMOVAL OF statewide cohort statewide statewide cohort statewide FOREIGN BODY, CALCULUS,OR URETERAL STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE 52317 LITHOLAPAXY: CRUSHING OR FRAGMENTATION statewide statewide statewide statewide statewide statewide OF CALCULUSBY ANYMEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM) 52320 CYSTOURETHROSCOPY (INCLUDING URETERAL statewide statewide statewide statewide statewide CATHETERIZATION); WITHREMOVAL OF URETERAL CALCULUS CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 47

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 52330 CYSTOURETHROSCOPY (INCLUDING URETERAL statewide statewide statewide statewide statewide CATHETERIZATION); WITHMANIPULATION, WITHOUT REMOVAL OF URETERAL CALCULUS CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH 52332 CYSTOURETHROSCOPY, WITH INSERTION OF cohort cohort cohort cohort cohort statewide INDWELLING URETERALSTENT (EG, GIBBONS OR DOUBLE-J TYPE) CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL 52344 CYSTOURETHROSCOPY WITH URETEROSCOPY; statewide statewide statewide statewide statewide statewide WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON DILATION, LASER ELECTROCAUTERY, AND INCISION) 52351 CYSTOURETHROSCOPY WITH URETEROSCOPY statewide cohort cohort cohort statewide statewide AND/OR PYELOSCOPY; DIAGNOSTIC 52352 CYSTOURETHROSCOPY WITH URETEROSCOPY statewide cohort cohort cohort cohort statewide AND/OR PYELOSCOPY; WITH REMOVAL OR MANIPULATION OR CALCULUS (URETERAL CATHETERIZATION IS INCLUDED) 52353 CYSTOURETHROSCOPY WITH URETEROSCOPY statewide cohort cohort cohort statewide statewide AND/OR PYELOSCOPY; WITH LITHROTIPSY (URETERAL CATHETERIZATION ISINCLUDED) 52354 CYSTOURETHROSCOPY WITH URETEROSCOPY statewide statewide statewide statewide statewide AND/OR PYELOSCOPY; WITH BIOPSY AND/OR FULGURATION OF LESION 52356 CYSTOURETHROSCOPY, WITH URETEROSCOPY cohort cohort cohort cohort cohort statewide AND/OR PYELOSCOPY; WITH LITHOTRIPSY INCLUDING INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS OR DOUBLE-J TYPE) 52601 TRANSURETHRAL ELECTROSURGICAL RESECTION statewide statewide cohort cohort statewide statewide OF PROSTATE,INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL 52648 CONTACT LASER VAPORIZATION WITH OR statewide statewide statewide statewide statewide statewide WITHOUT TRANSURETHRALRESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, 53450 URETHROMEATOPLASTY, WITH MUCOSAL statewide statewide statewide cohort ADVANCEMENT 54150 Circumcision, using clamp or other device with statewide statewide statewide statewide regional dorsal penile or ring block 54161 CIRCUMCISION, SURGICAL EXCISION OTHER statewide cohort cohort statewide cohort statewide THAN CLAMP, DEVICE OR DORSAL SLIT; OLDER THAN 28 DAYS OF AGE 54405 INSERTION OF INFLATABLE (MULTI- statewide statewide statewide statewide statewide statewide COMPONENT) PENILE PROSTHESIS,INCLUDING PLACEMENT OF PUMP, CYLINDERS, AND/OR RESERVOIR 54520 ORCHIECTOMY, SIMPLE (INCLUDING statewide statewide statewide statewide statewide SUBCAPSULAR), WITH OR WITHOUTTESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH 54530 ORCHIECTOMY, RADICAL, FOR TUMOR; statewide statewide statewide statewide statewide INGUINAL APPROACH 54640 ORCHIOPEXY, INGUINAL APPROACH, WITH OR statewide statewide statewide cohort cohort WITHOUT HERNIA REPAIR 54830 EXCISION OF LOCAL LESION OF EPIDIDYMIS statewide statewide statewide statewide statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 54840 EXCISION OF SPERMATOCELE, WITH OR statewide statewide statewide statewide statewide statewide WITHOUT EPIDIDYMECTOMY 55040 EXCISION OF HYDROCELE; UNILATERAL statewide statewide cohort cohort statewide statewide 55250 VASECTOMY, UNILATERAL OR BILATERAL statewide statewide statewide statewide cohort statewide (SEPARATE PROCEDURE),INCLUDING POSTOPERATIVE SEMEN EXAMINATION(S) 55520 EXCISION OF LESION OF SPERMATIC CORD statewide statewide statewide statewide statewide statewide (SEPARATE PROCEDURE) 55530 EXCISION OF VARICOCELE OR LIGATION OF statewide statewide statewide statewide statewide SPERMATIC VEINS FORVARICOCELE; (SEPARATE PROCEDURE) 55700 BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE statewide statewide statewide cohort statewide OR MULTIPLE, ANYAPPROACH 55866 Laparoscopy, surgical prostatectomy, retropubic statewide statewide statewide statewide radical, including nerve sparing, includes robotic assistance, when performed 55875 TRANSPERINEAL PLACEMENT OF NEEDLES OR statewide statewide statewide statewide CATHETERS INTO PROSTATE FOR INTERSTITIAL RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY 56405 *INCISION AND DRAINAGE OF VULVA OR statewide statewide statewide statewide statewide statewide PERINEAL ABSCESS 56420 *INCISION AND DRAINAGE OF BARTHOLIN'S statewide statewide statewide statewide statewide GLAND ABSCESS 56605 BIOPSY OF VULVA OR PERINEUM (SEPARATE statewide statewide statewide statewide PROCEDURE); 1 LESION 56620 VULVECTOMY SIMPLE; PARTIAL statewide statewide statewide statewide statewide 57100 *BIOPSY OF VAGINAL MUCOSA; SIMPLE statewide statewide statewide (SEPARATE PROCEDURE) 57135 EXCISION OF VAGINAL CYST OR TUMOR statewide statewide statewide statewide statewide statewide 57155 Insertion of uterine tandem and/or vaginal statewide cohort statewide ovoids for clinical brachytherapy 57156 Insertion of a vaginal radiation afterloading statewide cohort cohort apparatus for clinical brachytherapy 57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA statewide statewide statewide statewide statewide (NONOBSTETRICAL)COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTETRICAL) 57240 ANTERIOR COLPORRHAPHY, REPAIR OF statewide cohort cohort cohort statewide statewide CYSTOCELE WITH ORWITHOUTREPAIR OF URETHROCELE ANTERIOR COLPORRHAP HY, REPAIR OF CYSTOCELE WITH OR WITHOUT 57250 POSTERIOR COLPORRHAPHY, REPAIR OF statewide statewide cohort cohort statewide statewide RECTOCELE WITH OR WITHOUT PERINEORRHAPHY POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT 57260 COMBINED ANTEROPOSTERIOR cohort statewide cohort statewide COLPORRHAPHY;COMBINED ANTEROPOSTERIOR COLPORRHAPHY; 57265 COMBINED ANTEROPOSTERIOR statewide statewide statewide statewide COLPORRHAPHY; WITH ENTEROCELEREPAIR COMBINED ANTEROPOSTERIOR COLPORRHAPHY;WITH ENTEROCELE 57267 INSERT MESH/PELVIC FLR ADDON statewide statewide statewide statewide statewide 57268 REPAIR OF ENTEROCELE, VAGINAL APPROACH statewide statewide statewide statewide statewide (SEPARATE PROCEDURE) 57282 SACROSPINOUS LIGAMENT FIXATION FOR statewide statewide statewide statewide statewide statewide PROLAPSE OF VAGINA 57283 COLPOPEXY, INTRAPERITONEAL statewide statewide statewide statewide statewide statewide 49

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 57287 REMOVAL OR REVISION OF SLING FOR STRESS statewide statewide statewide statewide statewide INCONTINENCE (EG, FASCIA OR SYNTHETIC) 57288 SLING OPERATION FOR STRESS INCONTINENCE statewide cohort cohort cohort cohort statewide (EG, FASCIA ORSYNTHETIC) SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR 57295 REVISION (INCLUDING REMOVAL) OF statewide statewide statewide statewide statewide PROSTHETIC VAGINALGRAFT, VAGINAL APPROACH 57420 COLPOSCOPY ENTIRE VAGINA, W/CERVIX IF statewide statewide statewide PRESENT 57425 LAPAROSCOPY SURGICAL COLPOPEXY statewide statewide statewide cohort statewide statewide (SUSPENSION OF VAGINAL APEX) 57452 *COLPOSCOPY (VAGINOSCOPY); (SEPARATE statewide statewide statewide statewide PROCEDURE) 57454 *COLPOSCOPY (VAGINOSCOPY); WITH BIOPSY(S) statewide statewide statewide cohort OF THE CERVIXAND/OR ENDOCERVICAL CURETTAGE 57460 COLPOSCOPY (VAGINOSCOPY); WITH LOOP statewide statewide statewide statewide statewide ELECTRODE EXCISIONPROCEDURE OF THE CERVIX 57461 COLPOSCOPY CERVIX W/UPPER ADJACENT statewide statewide statewide statewide VAGINA; W/LOOP ELECTRODE CONIZATION CERVIX 57500 Biopsy of cervix, single or multiple, or local statewide statewide statewide statewide statewide excision of lesion, with or without fulguration (separate procedure) 57520 CONIZATION OF CERVIX, WITH OR WITHOUT statewide cohort cohort cohort cohort FULGURATION,WITH ORWITHOUT DILATION AND CURETTAGE, WITH OR WI THOUT REPAIR; COLD KNIFE OR LASER 57522 CONIZATION OF CERVIX, WITH OR WITHOUT statewide statewide cohort cohort statewide FULGURATION,WITH ORWITHOUT DILATION AND CURETTAGE, WITH OR WI THOUT REPAIR; LOOP ELECTRODE EXCISION 58100 *ENDOMETRIAL SAMPLING (BIOPSY) WITH OR statewide statewide statewide cohort cohort WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE) 58120 DILATION AND CURETTAGE, DIAGNOSTIC statewide cohort statewide cohort statewide AND/OR THERAPEUTIC(NONOBSTETRICAL) 58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR statewide statewide statewide statewide statewide OF UTERUS, SINGLE ORMULTIPLE (SEPARATE PROCEDURE); ABDOMINAL APPROACH 58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS statewide statewide statewide statewide statewide AND CERVIX), WITH ORWITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUTREMOVAL OF OVARY(S); 58260 VAGINAL HYSTERECTOMY; statewide cohort cohort cohort statewide statewide 58262 VAGINAL HYSTERECTOMY; WITH REMOVAL OF statewide cohort cohort cohort cohort statewide TUBE(S), AND/OROVARY(S) 58263 VAGINAL HYSTERECTOMY; WITH REMOVAL OF statewide statewide statewide TUBE(S), AND/OROVARY(S), WITH REPAIR OF ENTEROCELE 58300 *INSERTION OF INTRAUTERINE DEVICE statewide statewide statewide cohort cohort statewide (IUD)*INSERTION OF INTRAUTERINE DEVICE (IUD) 58301 REMOVAL OF INTRAUTERINE DEVICE statewide cohort statewide cohort cohort statewide (IUD)REMOVAL OF INTRAUTERINE DEVICE (IUD)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 58340 *CATHETERIZATION AND INTRODUCTION OF statewide cohort cohort cohort cohort statewide SALINE OR CONTRASTMATERIAL FOR HYSTEROSONOGRAPHY OR HYSTEROSALPINGOGRAPHY 58350 *CHROMOTUBATION OF OVIDUCT, INCLUDING cohort statewide cohort statewide MATERIALS 58353 ENDOMETRIAL ABLATION, THERMAL, WITHOUT statewide cohort statewide statewide statewide HYSTEROSCOPIC GUIDANCE. 58541 LAPAROSCOPY, SURGICAL, SUPRACERVICAL statewide statewide statewide statewide statewide HYSTERECTOMY,FOR UTERUS 250 G OR LESS; 58542 LAPAROSCOPY, SURGICAL, SUPRACERVICAL statewide statewide cohort statewide statewide statewide HYSTERECTOMY,FOR UTERUS 250 G OR LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 58545 LAPAROSCOPY, SURG, MYOMECTOMY; 1-4 statewide statewide statewide statewide statewide INTRAMURAL MYOMAS, TOTAL WT 250 GMS, &/OR REMOVE SURFACE MYOMAS 58550 LAPAROSCOPY, SURGICAL; WITH VAGINAL statewide statewide cohort statewide statewide statewide HYSTERECTOMY WITH OR WITHOUT REMOVAL OF TUBE(S),WITH OR WITHOUTREMOVAL OF OVARY(S) (LAPAROSCOPIC ASSISTED VAGINALHYSTERECTOMY) 58552 LAPAROSCOPY, SURG, W/VAGINAL statewide cohort cohort cohort statewide statewide HYSTERECTOMY, UTERUS 250 GMS/<; W/REMOVAL TUBE(S) &/OR OVARY(S) 58554 LAPAROSCOPY SURG W/VAGINAL statewide statewide statewide statewide statewide HYSTERECTOMY, UTERUS >250 GMS; W/REMOVE TUBE(S) &/OR OVARY(S) 58555 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE statewide statewide statewide statewide statewide PROCEDURE) 58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING cohort cohort cohort cohort cohort statewide (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D & C 58561 HYSTEROSCOPY, SURGICAL;WITH REMOVAL OF statewide cohort cohort cohort cohort LEIOMYOMATA 58562 HYSTEROSCOPY, SURGICAL;WITH REMOVAL OF statewide statewide statewide statewide statewide IMPACTED FOREIGN BODY 58563 HYSTEROSCOPY, SURGICAL; WITH cohort cohort cohort cohort cohort ENDOMETRIAL ABLATION (ANY METHOD) 58570 Laparoscopy, surgical, with total hysterectomy, statewide statewide statewide cohort statewide for uterus 250 g or less; 58571 Laparoscopy, surgical, with total hysterectomy, statewide cohort cohort cohort cohort statewide for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58573 Laparoscopy, surgical, with total hysterectomy, statewide cohort cohort cohort cohort statewide for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) 58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF statewide statewide statewide statewide statewide ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) (SEPARATE PROCEDURE) 58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF statewide cohort cohort cohort cohort statewide ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY) 58662 LAPAROSCOPY, SURGICAL;WITH FULGURATION statewide cohort cohort cohort cohort statewide OR EXCISIONOF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD 58670 LAPAROSCOPY, SURGICAL;WITH FULGURATION statewide cohort cohort cohort statewide OF OVIDUCTS(WITH OR WITHOUT TRANSECTION) 51

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF statewide cohort cohort cohort statewide OVIDUCTS BY DEVICE (EG. BAND, CLIP, OR FALOPE RING) 59000 *AMNIOCENTESIS, ANY METHOD statewide statewide statewide statewide 59025 FETAL NON-STRESS TESTFETAL NON-STRESS cohort cohort cohort cohort cohort TEST 59151 LAPAROSCOPIC TREATMENT OF ECTOPIC statewide cohort cohort cohort statewide PREGNANCY; WITHSALPINGECTOMY AND/OR OOPHORECTOMY 59160 CURETTAGE, POSTPARTUM statewide statewide statewide statewide 59320 CERCLAGE OF CERVIX, DURING PREGNANCY; statewide statewide statewide cohort cohort VAGINAL 59412 EXTERNAL CEPHALIC VERSION, WITH OR statewide statewide statewide statewide WITHOUT TOCOLYSIS (LISTIN ADDITION TO CODE(S) FOR DELIVERY) 59812 TREATMENT OF INCOMPLETE ABORTION, ANY statewide cohort cohort cohort statewide TRIMESTER, COMPLETEDSURGICALLY 59820 TREATMENT OF MISSED ABORTION, statewide cohort cohort cohort cohort COMPLETED SURGICALLY; FIRSTTRIMESTER TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; FIRST 59821 TREATMENT OF MISSED ABORTION, statewide statewide statewide statewide COMPLETED SURGICALLY; SECONDTRIMESTER TREATMENT OF MISSED ABORTION, COMPLETED SURGICALLY; SECOND 59841 INDUCED ABORTION, BY DILATION AND statewide statewide statewide EVACUATION 60100 *BIOPSY THYROID, PERCUTANEOUS CORE statewide statewide statewide statewide statewide statewide NEEDLE 60220 TOTAL THYROID LOBECTOMY, UNILATERAL; statewide cohort cohort cohort cohort WITH OR WITHOUTISTHMUSECTOMY 60240 THYROIDECTOMY, TOTAL OR COMPLETE statewide cohort cohort cohort cohort 60252 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR statewide statewide statewide statewide MALIGNANCY; WITHLIMITED NECK DISSECTION 60500 PARATHYROIDECTOMY OR EXPLORATION OF statewide statewide statewide cohort cohort statewide PARATHYROID(S); 60512 PARATHYROID AUTOTRANSPLANTATION (LIST statewide statewide cohort statewide SEPARATELY IN ADDITIONTO CODE FOR PRIMARY PROCEDURE) 61782 Stereotactic computer-assisted (navigational) statewide cohort statewide cohort cohort statewide procedure; cranial, extradural (List separately in addition to code for primary procedure) 62270 *SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC cohort cohort cohort cohort cohort statewide 62272 *SPINAL PUNCTURE, THERAPEUTIC, FOR statewide statewide statewide statewide DRAINAGE OF SPINAL FLUID (BY NEEDLE OR CATHETER) 62273 *INJECTION, LUMBAR EPIDURAL, OF BLOOD OR statewide statewide cohort cohort cohort statewide CLOT PATCH*INJECTION, LUMBAR EPIDURAL, OF BLOOD OR CLOT PATCH 62284 INJECTION PROCEDURE FOR MYELOGRAPHY statewide statewide cohort cohort cohort statewide AND/OR COMPUTED TOMOGRAPHY, LUMBAR 62302 MYELOGRAPHY VIA LUMBAR INJECTION, statewide statewide cohort statewide statewide INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; CERVICAL 62304 MYELOGRAPHY VIA LUMBAR INJECTION, statewide statewide cohort cohort statewide statewide INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; LUMBOSACRAL

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 62305 MYELOGRAPHY VIA LUMBAR INJECTION, statewide statewide statewide statewide statewide INCLUDING RADIOLOGICAL SUPERVISION AND INTERPRETATION; 2 OR MORE REGIONS (EG, LUMBAR/THORACIC, CERVICAL/THORACIC, LUMBAR/CERVICAL, LUMBAR/THORACIC/CERVICAL) 62310 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort cohort cohort statewide SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEM 62311 INJECTION(S), OF DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort cohort cohort cohort SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OTHER SOLUTION), NOT INCLUDING NEUROLYTIC SUBSTANCES, INCLUDING NEEDLE OR CATHETER PLACEM 62368 ELECTRONIC ANALYSIS OF PROGRAMMABLE, statewide statewide statewide statewide statewide IMPLANTED PUMP FORINTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION 62369 ELECTRONIC ANALYSIS OF PROGRAMMABLE, statewide statewide statewide statewide statewide IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND 62370 ELECTRONIC ANALYSIS OF PROGRAMMABLE, statewide statewide statewide cohort IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING AND 63030 LAMINOTOMY (HEMILAMINECTOMY), WITH statewide cohort cohort cohort cohort cohort DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; 1 INTERSPACE, LUMBAR 63035 LAMINOTOMY (HEMILAMINECTOMY), WITH statewide statewide cohort cohort statewide statewide DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISC; EACH ADDITIONAL INTERSPACE, CERVICAL OR 63042 LAMINOTOMY (HEMILAMINECTOMY), WITH statewide statewide statewide cohort statewide statewide DECOMPRESSION OF NERVEROOT(S), INCLUDING PARTIAL FACETECTOMY, FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISK, RE- EXPLORATION; 63045 LAMINECTOMY, FACETECTOMY AND statewide statewide statewide statewide statewide FORAMINOTOMY (UNILATERAL ORBILATERAL WITH DECOMPRESSION OF SPINAL CORD,CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL O R LATERAL RECESS 63047 LAMINECTOMY, FACETECTOMY AND statewide cohort cohort cohort statewide statewide FORAMINOTOMY (UNILATERAL ORBILATERAL WITH DECOMPRESSION OF SPINAL CORD,CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL O R LATERAL RECESS 53

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 63048 LAMINECTOMY, FACETECTOMY AND statewide statewide cohort cohort statewide statewide FORAMINOTOMY (UNILATERAL ORBILATERAL WITH DECOMPRESSION OF SPINAL CORD,CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL O R LATERAL RECESS 63056 TRANSPEDICULAR APPROACH WITH statewide statewide statewide statewide statewide DECOMPRESSION OF SPINAL CORD,EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATEDINTERVERTEBRAL DISK), SINGLE SEGMENT; LUMBAR 63267 LAMINECTOMY FOR EXCISION OR EVACUATION statewide statewide statewide statewide statewide OF INTRASPINAL LESIONOTHER THAN NEOPLASM, EXTRADURAL; LUMBAR 63650 PERCUTANEOUS IMPLANTATION OF statewide cohort statewide statewide statewide statewide NEUROSTIMULATOR ELECTRODEARRAY, EPIDURAL PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE 63685 INCISION AND SUBCUTANEOUS PLACEMENT OF statewide cohort statewide statewide statewide SPINALNEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING 64400 *INJECTION, ANESTHETIC AGENT; TRIGEMINAL statewide cohort statewide statewide statewide NERVE, ANY DIVISIONOR BRANCH 64402 *INJECTION, ANESTHETIC AGENT; FACIAL NERVE statewide statewide statewide statewide cohort 64405 *INJECTION, ANESTHETIC AGENT; GREATER statewide cohort statewide statewide OCCIPITAL NERVE 64415 *INJECTION, ANESTHETIC AGENT; BRACHIAL cohort cohort cohort cohort statewide PLEXUS 64416 Injection, anesthetic agent; brachialplexus, statewide statewide statewide continuous infusion by catheter (including catheter placement) 64417 *INJECTION, ANESTHETIC AGENT; AXILLARY statewide cohort statewide statewide NERVE 64421 *INJECTION, ANESTHETIC AGENT; INTERCOSTAL statewide statewide statewide statewide statewide statewide NERVES, MULTIPLE, REGIONAL BLOCK *INJECTION, ANESTHETIC AGENT; INTERCOSTAL NERVES, MULTIPLE, 64425 *INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, statewide statewide statewide statewide statewide statewide ILIOHYPOGASTRIC NERVES 64445 *INJECTION, ANESTHETIC AGENT; SCIATIC statewide statewide statewide cohort statewide NERVE 64447 INJECTION ANESTHETIC AGENT; FEMORAL statewide cohort statewide cohort statewide statewide NERVE SINGLE 64450 *INJECTION, ANESTHETIC AGENT; OTHER cohort cohort cohort cohort cohort statewide PERIPHERAL NERVE ORBRANCH 64479 Injection(s), anesthetic agent and/or steroid, statewide statewide statewide statewide statewide statewide transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level 64483 Injection(s), anesthetic agent and/or steroid, cohort cohort cohort cohort cohort cohort transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, single level 64484 Injection(s), anesthetic agent and/or steroid, statewide cohort cohort cohort cohort statewide transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for prim 64490 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort cohort cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE 54

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL 64491 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC statewide statewide cohort cohort cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL 64492 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC statewide statewide statewide statewide cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY 64493 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort cohort cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL 64494 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort cohort cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIS 64495 INJECTION(S), DIAGNOSTIC OR THERAPEUTIC cohort cohort cohort statewide cohort statewide AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADD 64505 *INJECTION, ANESTHETIC AGENT; statewide statewide statewide SPHENOPALATINE GANGLION 64510 *INJECTION, ANESTHETIC AGENT; STELLATE statewide statewide statewide statewide statewide GANGLION (CERVICALSYMPATHETIC) 64520 *INJECTION, ANESTHETIC AGENT; LUMBAR OR statewide statewide statewide statewide statewide statewide THORACIC(PARAVERTEBRAL SYMPATHETIC) 64530 *INJECTION, ANESTHETIC AGENT; CELIAC statewide statewide statewide statewide PLEXUS, WITH OR WITHOUTRADIOLOGIC MONITORING 64590 Insertion or replacement of peripheral or gastric statewide statewide statewide statewide statewide neurostimulator pulse generator or receiver, direct or inductive coupling 64612 CHEMODENERVATION OF MUSCLE(S); statewide statewide statewide MUSCLE(S) INNERVATED BY FACIAL NERVE, UNILATERAL (EG, FOR BLEPHAROSPASM, HEMIFACIAL SPASM) 64615 CHEMODENERVATION OF MUSCLE(S); statewide statewide MUSCLE(S) INNERVATED BY FACIAL, TRIGEMINAL, CERVICAL SPINAL AND ACCESSORY NERVES, BILATERAL (EG, FOR CHRONIC MIGRAINE) 64616 CHEMODENERVATION OF MUSCLE(S); NECK statewide statewide cohort MUSCLE(S), EXCLUDING MUSCLES OF THE LARYNX, UNILATERAL (EG, FOR CERVICAL DYSTONIA, SPASMODIC TORTICOLLIS) 64617 CHEMODENERVATION OF MUSCLE(S); LARYNX, statewide cohort UNILATERAL,PERCUTANEOUS (EG, FOR SPASMODIC DYSPHONIA), INCLU DES GUIDANCE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 BY NEEDLE ELECTROMYOGRAPHY, WHEN PERFORMED 64633 DESTRUCTION BY NEUROLYTIC AGENT, statewide statewide statewide statewide statewide PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, SINGLE FACET JOINT 64634 DESTRUCTION BY NEUROLYTIC AGENT, statewide statewide statewide statewide statewide PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); CERVICAL OR THORACIC, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE F 64635 DESTRUCTION BY NEUROLYTIC AGENT, statewide statewide statewide statewide statewide statewide PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, SINGLE FACET JOINT 64636 DESTRUCTION BY NEUROLYTIC AGENT, statewide statewide statewide statewide statewide statewide PARAVERTEBRAL FACET JOINT NERVE(S), WITH IMAGING GUIDANCE (FLUOROSCOPY OR CT); LUMBAR OR SACRAL, EACH ADDITIONAL FACET JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR P 64640 DESTRUCTION BY NEUROLYTIC AGENT; OTHER statewide statewide cohort statewide cohort statewide PERIPHERAL NERVE OR BRANCH 64642 CHEMODENERVATION OF ONE EXTREMITY; 1-4 statewide statewide cohort MUSCLE(S) 64643 CHEMODENERVATION OF ONE EXTREMITY; statewide statewide cohort EACH ADDITIONALEXTREMITY, 1-4 MUSCLE(S) (LIST SEPARATELY IN ADDI TION TO CODE FOR PRIMARY PROCEDURE) 64644 CHEMODENERVATION OF ONE EXTREMITY; 5 OR statewide statewide cohort MORE MUSCLES 64708 Neuroplasty, major peripheral nerve, arm or leg, statewide statewide statewide statewide statewide open; other than specified 64718 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR statewide statewide cohort cohort statewide statewide NERVE AT ELBOWNEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW 64719 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR statewide statewide statewide statewide statewide NERVE AT WRISTNEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST 64721 NEUROPLASTY AND/OR TRANSPOSITION; cohort cohort cohort cohort cohort cohort MEDIAN NERVE AT CARPALTUNNEL 64831 SUTURE OF DIGITAL NERVE, HAND OR FOOT; statewide statewide statewide statewide statewide ONE NERVE 65205 *REMOVAL OF FOREIGN BODY, EXTERNAL EYE; statewide statewide statewide statewide statewide CONJUNCTIVALSUPERFICIAL *REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL 65220 *REMOVAL OF FOREIGN BODY, EXTERNAL EYE; statewide statewide statewide statewide statewide CORNEAL, WITHOUTSLIT LAMP *REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEAL, WITHOUT 65426 EXCISION OR TRANSPOSITION OF PTERYGIUM; statewide statewide statewide statewide statewide statewide WITH GRAFT 65756 Keratoplasty (corneal transplant); endothelial statewide statewide statewide statewide statewide 65855 TRABECULOPLASTY BY LASER SURGERY statewide statewide statewide statewide 66180 AQUEOUS SHUNT TO EXTRAOCULAR statewide statewide cohort statewide EQUATORIAL PLATE RESERVOIR, EXTERNAL APPROACH; WITH GRAFT

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 66183 INSERTION OF ANTERIOR SEGMENT AQUEOUS statewide statewide statewide statewide DRAINAGE DEVICE, WITHOUT EXTRAOCULAR RESERVOIR, EXTERNAL APPROACH 66761 Iridotomy/iridectomy by laser surgery (eg, for statewide statewide statewide statewide statewide statewide glaucoma) (per session) 66821 DISCISSION OF SECONDARY MEMBRANOUS statewide statewide statewide CATARACT (OPACIFIEDPOSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (EG, YAG LASER) (ONE OR MORE STAGES) 66982 EXTRACAPSULAR CATARACT REMOVAL WITH statewide cohort cohort cohort cohort statewide INSERTION OF INTRAOCULAR LENS PROSTHESIS (1-STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIR 66984 EXTRACAPSULAR CATARACT REMOVAL WITH cohort cohort cohort cohort cohort cohort INSERTION OF INTRAOCULARLENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR 66986 EXCHANGE OF INTRAOCULAR LENS statewide statewide statewide statewide statewide 67028 INTRAVITREAL INJECTION OF A statewide statewide statewide PHARMACOLOGIC AGENT (SEPARATEPROCEDURE) 67036 VITRECTOMY, MECHANICAL, PARS PLANA statewide statewide statewide cohort statewide statewide APPROACH; 67039 VITRECTOMY, MECHANICAL, PARS PLANA statewide statewide statewide statewide APPROACH; WITH FOCALENDOLASER PHOTOCOAGULATION 67040 VITRECTOMY, MECHANICAL, PARS PLANA statewide statewide cohort statewide APPROACH; WITH ENDOLASER PANRETINAL PHOTOCOAGULATION 67041 Vitrectomy, mechanical, pars plana approach; statewide statewide statewide cohort statewide statewide with removal of preretinal cellular membrane (e.g., macular pucker) 67042 Vitrectomy, mechanical, pars plana approach; statewide statewide statewide cohort statewide with removal of internal limiting membrane of retina (e.g., for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tampon 67107 REPAIR OF RETINAL DETACHMENT; SCLERAL statewide statewide statewide BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), INCLUDING, WHEN PERFORMED, IMPLANT, CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINA 67108 REPAIR OF RETINAL DETACHMENT; WITH statewide statewide statewide cohort cohort statewide VITRECTOMY, ANYMETHOD, INCLUDING, WHEN PERFORMED, AIR OR GAS TAM PONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLIN 67113 REPAIR OF COMPLEX RETINAL DETACHMENT statewide statewide statewide cohort cohort statewide (EG, PROLIFERATIVE VITREORETINOPATHY, STAGE C-1 OR GREATER, DIABETIC TRACTION RETINAL DETACHMENT, RETINOPATHY OF PREMATURITY, RETINAL TEAR OF GREATER THAN 90 DEGRE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 67228 TREATMENT OF EXTENSIVE OR PROGRESSIVE statewide statewide RETINOPATHY (EG, DIABETIC RETINOPATHY), PHOTOCOAGULATION 67311 STRABISMUS SURGERY, RECESSION OR statewide statewide statewide cohort cohort statewide RESECTION PROCEDURE; ONEHORIZONTAL MUSCLE 67312 STRABISMUS SURGERY, RECESSION OR statewide statewide statewide cohort RESECTION PROCEDURE; TWOHORIZONTAL MUSCLES 67314 STRABISMUS SURGERY, RECESSION OR statewide statewide statewide cohort statewide RESECTION PROCEDURE; ONEVERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE) 67904 REPAIR OF BLEPHAROPTOSIS; (TARSO)LEVATOR statewide statewide statewide statewide statewide statewide RESECTIONORADVANCEMENT, EXTERNAL APPROACH 68815 PROBING OF NASOLACRIMAL DUCT, WITH OR statewide statewide statewide statewide statewide WITHOUT IRRIGATION;WITH INSERTION OF TUBE OR STENT 69200 REMOVAL FOREIGN BODY FROM EXTERNAL statewide cohort statewide statewide statewide AUDITORY CANAL;WITHOUTGENERAL ANESTHESIA 69210 REMOVAL IMPACTED CERUMEN REQUIRING statewide statewide statewide statewide cohort statewide INSTRUMENTATION, UNILATERAL 69424 VENTILATING TUBE REMOVAL WHEN statewide statewide statewide statewide statewide statewide ORIGINALLY INSERTED BY ANOTHERPHYSICIAN 69436 TYMPANOSTOMY (REQUIRING INSERTION OF cohort cohort cohort cohort cohort statewide VENTILATING TUBE),GENERAL ANESTHESIA 69610 TYMPANIC MEMBRANE REPAIR, WITH OR statewide statewide statewide statewide statewide statewide WITHOUT SITE PREPARATIONOR PERFORATION FOR CLOSURE, WITH OR WITHOUT PATCH 69631 TYMPANOPLASTY WITHOUT MASTOIDECTOMY statewide statewide statewide statewide statewide (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION 69660 STAPEDECTOMY OR STAPEDOTOMY WITH statewide statewide statewide statewide statewide REESTABLISHMENT OFOSSICULAR CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; 69714 IMPLANTATION OSSEOINTEGRATED IMPLANT statewide statewide statewide statewide TEMPORAL BONEW/ PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR, WITHOUT MASTIODECTOMY 69930 COCHLEAR DEVICE IMPLANTATION, WITH OR statewide statewide statewide WITHOUT MASTOIDECTOMY 70030 RADIOLOGIC EXAMINATION, EYE, FOR statewide cohort cohort cohort statewide statewide DETECTION OF FOREIGN BODY 70110 RADIOLOGIC EXAMINATION, MANDIBLE; statewide statewide statewide statewide statewide COMPLETE, MINIMUM OF FOUR VIEWS 70150 RADIOLOGIC EXAMINATION, FACIAL BONES; statewide cohort cohort cohort statewide statewide COMPLETE, MINIMUM OFTHREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; COMPLETE, MINIMUM OF 70160 RADIOLOGIC EXAMINATION, NASAL BONES, statewide cohort cohort cohort statewide COMPLETE, MINIMUM OF 3 VIEWS 70200 RADIOLOGIC EXAMINATION; ORBITS, cohort statewide statewide statewide COMPLETE, MINIMUM OF FOURVIEWS 70210 RADIOLOGIC EXAMINATION, SINUSES, statewide statewide statewide statewide statewide PARANASAL, LESS THAN THREE VIEWS 58

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 70220 RADIOLOGIC EXAMINATION, SINUSES, cohort cohort cohort cohort statewide statewide PARANASAL, COMPLETE,MINIMUM OF THREE VIEWS 70250 RADIOLOGIC EXAMINATION, SKULL; LESS THAN statewide cohort cohort cohort cohort statewide FOUR VIEWS, WITH ORWITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; LESS THAN FOUR VIEWS, WITH OR 70260 RADIOLOGIC EXAMINATION, SKULL; COMPLETE, statewide statewide statewide statewide statewide MINIMUM OF FOURVIEWS, WITH OR WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR 70336 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide statewide statewide IMAGING, TEMPOROMANDIBULARJOINT 70355 ORTHOPANTOGRAM (EG, PANORAMIC X-RAY) statewide cohort cohort 70360 RADIOLOGIC EXAMINATION; NECK, SOFT TISSUE cohort cohort cohort cohort cohort statewide 70450 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR cohort cohort cohort cohort cohort cohort BRAIN; WITHOUTCONTRAST MATERIAL 70460 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR statewide cohort cohort statewide cohort statewide BRAIN; WITHCONTRAST MATERIAL(S) 70470 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR cohort cohort cohort cohort cohort BRAIN; WITHOUTCONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 70480 COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, statewide cohort cohort cohort cohort statewide SELLA, OR POSTERIORFOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL 70481 COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, statewide statewide statewide statewide statewide statewide SELLA, OR POSTERIORFOSSA OR OUTER, MIDDLE, OR INNER EAR; WITH CONTRAST MATERIAL(S) 70482 COMPUTERIZED AXIAL TOMOGRAPHY, ORBIT, statewide statewide statewide statewide statewide SELLA, OR POSTERIORFOSSA OR OUTER, MIDDLE, OR INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER 70486 COMPUTERIZED AXIAL TOMOGRAPHY, cohort cohort cohort cohort cohort statewide MAXILLOFACIAL AREA;WITHOUTCONTRAST MATERIAL 70487 COMPUTERIZED AXIAL TOMOGRAPHY, statewide cohort cohort cohort cohort MAXILLOFACIAL AREA;WITHCONTRAST MATERIAL(S) 70490 COMPUTERIZED AXIAL TOMOGRAPHY, SOFT statewide cohort cohort cohort cohort statewide TISSUE NECK; WITHOUTCONTRAST MATERIAL 70491 COMPUTERIZED AXIAL TOMOGRAPHY, SOFT cohort cohort cohort cohort cohort statewide TISSUE NECK; WITHCONTRAST MATERIAL(S) 70492 COMPUTERIZED AXIAL TOMOGRAPHY, SOFT statewide cohort statewide statewide statewide TISSUE NECK; WITHOUTCONTRAST MATERIAL FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 70496 Computed tomographic angiography, head, with cohort cohort cohort cohort cohort statewide contrast material(s), including noncontrast images, if performed and image postprocessing 70498 Computed tomographic angiography, neck, with cohort cohort cohort cohort cohort statewide contrast material(s), including noncontrast image, if performed, and image postprocessing 70543 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort statewide IMAGING; ORBIT, FACE, AND NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 70544 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; cohort cohort cohort cohort cohort statewide WITHOUT CON-TRAST MATERIAL(S) 70546 MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; statewide statewide statewide statewide cohort statewide WITHOUT CON-TRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 70547 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; statewide cohort cohort statewide cohort statewide WITHOUT CON-TRAST MATERIAL(S) 70548 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; statewide cohort statewide cohort WITH CON- TRAST MATERIAL(S) 70549 MAGNETIC RESONANCE ANGIOGRAPHY, NECK; statewide cohort cohort cohort cohort statewide WITHOUT CON-TRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 70551 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, BRAIN (INCLUDINGBRAIN STEM); WITHOUT CONTRAST MATERIAL 70552 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide cohort IMAGING, BRAIN (INCLUDINGBRAIN STEM); WITH CONTRAST MATERIAL(S) 70553 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort cohort IMAGING, BRAIN (INCLUDINGBRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE cohort cohort cohort cohort cohort cohort VIEW, FRONTAL 71020 RADIOLOGIC EXAMINATION, CHEST, TWO cohort cohort cohort cohort cohort cohort VIEWS, FRONTAL ANDLATERAL; 71035 RADIOLOGIC EXAMINATION, CHEST, SPECIAL statewide statewide statewide cohort statewide VIEWS (EG, LATERALDECUBITUS, BUCKY STUDIES) 71100 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; cohort cohort cohort cohort cohort statewide TWO VIEWS 71101 RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; cohort cohort cohort cohort cohort statewide INCLUDINGPOSTEROANTERIOR CHEST, MINIMUM OF THREE VIEWS 71110 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; statewide statewide statewide statewide statewide THREE VIEWS 71111 RADIOLOGIC EXAMINATION, RIBS, BILATERAL; statewide cohort statewide statewide statewide statewide INCLUDINGPOSTEROANTERIOR CHEST, MINIMUM OF FOUR VIEWS 71120 RADIOLOGIC EXAMINATION; STERNUM, statewide cohort statewide cohort statewide statewide MINIMUM OF TWO VIEWS 71250 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; cohort cohort cohort cohort cohort statewide WITHOUT CONTRASTMATERIAL 71260 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; cohort cohort cohort cohort cohort statewide WITH CONTRASTMATERIAL(S) 71270 COMPUTERIZED AXIAL TOMOGRAPHY, THORAX; statewide cohort cohort cohort statewide statewide WITHOUT CONTRASTMATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 71275 Computed tomographic angiography, chest cohort cohort cohort cohort cohort cohort (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 71550 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide IMAGING, CHEST (EG, FOREVALUATION OF HILAR AND MEDIASTINAL LYMPHADENOPATHY) 71552 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide cohort IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND MEDIASTINAL LYMPHA- DENOPATHY); WITHOUT CONTRAST MATERIAL(S) FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 71555 MAGNETIC RESONANCE ANGIOGRAPHY, CHEST statewide statewide statewide cohort (EXCLUDINGMYOCARDIUM), WITH OR WITHOUT CONTRAST MATERIAL(S) 72020 RADIOLOGIC EXAMINATION, SPINE, SINGLE statewide cohort cohort cohort cohort cohort VIEW, SPECIFY LEVEL 72040 Radiologic examination, spine, cervical; 2 or 3 cohort cohort cohort cohort cohort statewide views 72050 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 4 cohort cohort cohort cohort cohort statewide OR 5 VIEWS 72052 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 6 cohort cohort cohort cohort statewide OR MOREVIEWS 72069 RADIOLOGIC EXAMINATION, SPINE, statewide cohort cohort cohort cohort statewide THORACOLUMBAR, STANDING (SCOLIOSIS) 72070 RADIOLOGIC EXAMINATION, SPINE; THORACIC, cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERAL 72072 RADIOLOGIC EXAMINATION, SPINE; THORACIC, cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERAL, INCLUDING SWIMMER'S VIEW OF THECERVICOTHORACIC JUNCTION 72074 RADIOLOGIC EXAMINATION, SPINE; THORACIC, statewide cohort statewide cohort COMPLETE,INCLUDINGOBLIQUES, MINIMUM OF FOUR VIEWS 72080 RADIOLOGIC EXAMINATION, SPINE; statewide statewide statewide cohort cohort statewide THORACOLUMBAR JUNCTION, MINIMUM OF 2 VIEWS 72090 RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS statewide cohort cohort cohort cohort STUDY, INCLUDING SUPINE AND ERECT STUDIES 72100 RADIOLOGIC EXAMINATION, SPINE, cohort cohort cohort cohort cohort statewide LUMBOSACRAL; ANTEROPOSTERIOR AND LATERAL 72110 RADIOLOGIC EXAMINATION, SPINE, cohort cohort cohort cohort cohort statewide LUMBOSACRAL; COMPLETE, WITHOBLIQUE VIEWS 72114 RADIOLOGIC EXAMINATION, SPINE, statewide cohort cohort statewide statewide LUMBOSACRAL; COMPLETE, INCLUDING BENDING VIEWS, MINIMUM OF 6 VIEWS 72120 RADIOLOGIC EXAMINATION, SPINE, statewide cohort cohort cohort cohort LUMBOSACRAL; BENDING VIEWS ONLY, 2 OR 3 VIEWS 72125 COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL cohort cohort cohort cohort cohort statewide SPINE; WITHOUTCONTRAST MATERIAL 72126 COMPUTERIZED AXIAL TOMOGRAPHY, CERVICAL statewide cohort cohort cohort statewide SPINE; WITH CONTRASTMATERIAL 72128 COMPUTERIZED AXIAL TOMOGRAPHY, cohort cohort cohort cohort cohort statewide THORACIC SPINE; WITHOUTCONTRAST MATERIAL 72129 COMPUTERIZED AXIAL TOMOGRAPHY, statewide statewide cohort cohort statewide THORACIC SPINE; WITH CONTRASTMATERIAL 72131 COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR cohort cohort cohort cohort cohort statewide SPINE; WITHOUTCONTRAST MATERIAL 61

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 72132 COMPUTERIZED AXIAL TOMOGRAPHY, LUMBAR statewide cohort cohort cohort cohort statewide SPINE; WITH CONTRASTMATERIAL 72141 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, SPINAL CANAL ANDCONTENTS, CERVICAL; WITHOUT CONTRAST MATERIAL 72142 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide statewide IMAGING, SPINAL CANAL ANDCONTENTS, CERVICAL; WITH CONTRAST MATERIAL(S) 72146 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, SPINAL CANAL ANDCONTENTS, THORACIC; WITHOUT CONTRAST MATERIAL 72148 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort cohort IMAGING, SPINAL CANAL ANDCONTENTS, LUMBAR; WITHOUT CONTRAST MATERIAL 72149 MAGNETIC RESONANCE (EG, PROTON) statewide statewide statewide statewide statewide IMAGING, SPINAL CANAL ANDCONTENTS, LUMBAR; WITH CONTRAST MATERIAL(S) 72156 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, SPINAL CANAL ANDCONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; CERVICAL 72157 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort statewide IMAGING, SPINAL CANAL ANDCONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; THORACIC 72158 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, SPINAL CANAL ANDCONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; LUMBAR 72170 RADIOLOGIC EXAMINATION, PELVIS; cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ONLY 72190 RADIOLOGIC EXAMINATION, PELVIS; COMPLETE, cohort statewide statewide cohort cohort MINIMUM OF THREEVIEWS 72192 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; statewide cohort cohort cohort cohort statewide WITHOUT CONTRASTMATERIAL 72193 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; statewide cohort cohort cohort cohort statewide WITH CONTRASTMATERIAL(S) 72194 COMPUTERIZED AXIAL TOMOGRAPHY, PELVIS; statewide statewide statewide statewide statewide statewide WITHOUT CONTRASTMATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 72195 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort statewide IMAGING; PELVIS; WITHOUT CONTRAST MATERIAL(S) 72197 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort statewide IMAGING; PELVIS; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRASTMATERIAL(S) AND FURTHER SEQUENCES 72198 MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, statewide statewide statewide statewide WITH OR WITHOUTCONTRAST MATERIAL(S) 72202 RADIOLOGIC EXAMINATION, SACROILIAC statewide cohort cohort statewide cohort statewide JOINTS; THREE OR MOREVIEWS 72220 RADIOLOGIC EXAMINATION, SACRUM AND cohort cohort cohort cohort cohort statewide COCCYX, MINIMUMOF TWOVIEWS

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 72240 MYELOGRAPHY, CERVICAL, RADIOLOGICAL statewide statewide statewide statewide statewide SUPERVISION ANDINTERPRETATION 72265 MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL statewide statewide statewide cohort statewide statewide SUPERVISIONANDINTERPRETATION 73000 RADIOLOGIC EXAMINATION; CLAVICLE, cohort cohort cohort cohort cohort statewide COMPLETE 73010 RADIOLOGIC EXAMINATION; SCAPULA, statewide cohort statewide statewide cohort statewide COMPLETE 73020 RADIOLOGIC EXAMINATION, SHOULDER; ONE statewide cohort statewide cohort cohort statewide VIEW 73030 RADIOLOGIC EXAMINATION, SHOULDER; cohort cohort cohort cohort cohort cohort COMPLETE, MINIMUM OF TWOVIEWS 73040 RADIOLOGIC EXAMINATION, SHOULDER, statewide cohort cohort cohort statewide ARTHROGRAPHY, RADIOLOGICALSUPERVISION AND INTERPRETATION 73050 RADIOLOGIC EXAMINATION; statewide statewide statewide statewide statewide ACROMIOCLAVICULAR JOINTS, BILATERAL,WITH OR WITHOUT WEIGHTED DISTRACTION 73060 RADIOLOGIC EXAMINATION; HUMERUS, cohort cohort cohort cohort cohort statewide MINIMUM OF TWO VIEWS 73070 RADIOLOGIC EXAMINATION, ELBOW; cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERALVIEWS 73080 RADIOLOGIC EXAMINATION, ELBOW; cohort cohort cohort cohort cohort statewide COMPLETE, MINIMUM OF THREEVIEWS 73090 RADIOLOGIC EXAMINATION; FOREARM, cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR AND LATERALVIEWS RADIOLOGIC EXAMINATION; FOREARM, ANTEROPOSTERIOR AND LATERAL 73100 RADIOLOGIC EXAMINATION, WRIST; cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERALVIEWS 73110 RADIOLOGIC EXAMINATION, WRIST; COMPLETE, cohort cohort cohort cohort cohort statewide MINIMUM OF THREEVIEWS 73115 RADIOLOGIC EXAMINATION, WRIST, statewide statewide statewide statewide ARTHROGRAPHY, RADIOLOGICALSUPERVISION AND INTERPRETATION 73120 RADIOLOGIC EXAMINATION, HAND; TWO VIEWS cohort cohort cohort cohort cohort statewide 73130 RADIOLOGIC EXAMINATION, HAND; MINIMUM cohort cohort cohort cohort cohort statewide OF THREE VIEWS 73140 RADIOLOGIC EXAMINATION, FINGER(S), cohort cohort cohort cohort cohort statewide MINIMUM OF TWO VIEWS 73200 COMPUTERIZED AXIAL TOMOGRAPHY, UPPER cohort cohort cohort cohort cohort statewide EXTREMITY; WITHOUTCONTRAST MATERIAL 73201 COMPUTERIZED AXIAL TOMOGRAPHY, UPPER statewide statewide statewide statewide statewide EXTREMITY; WITHCONTRAST MATERIAL(S) 73218 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort statewide cohort statewide IMAGING; UPPER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) 73220 MAGNETIC RESONANCE (EG, PROTON) statewide statewide cohort statewide cohort statewide IMAGING, UPPER EXTREMITY,OTHER THAN JOINT 73221 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, ANY JOINTOF UPPER EXTREMITY 73222 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, ANY JOINTOF UPPER EXTREMITY; WITH CONTRAST MATERIAL(S) 73223 MAGNETIC RESONANCE (EG, PROTON) statewide cohort statewide statewide cohort IMAGING, ANY JOINTOF UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED 63

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 73500 RADIOLOGIC EXAMINATION, HIP; UNILATERAL, cohort cohort statewide statewide cohort ONE VIEW 73510 RADIOLOGIC EXAMINATION, HIP, UNILATERAL; cohort cohort cohort cohort cohort statewide COMPLETE,MINIMUM OF TWO VIEWS 73520 RADIOLOGIC EXAMINATION, HIPS, BILATERAL, cohort cohort cohort cohort cohort MINIMUM OF TWO VIEWS OF EACH HIP, INCLUDING ANTEROPOSTERIORVIEW OF PELVIS 73525 RADIOLOGIC EXAMINATION, HIP, statewide cohort statewide statewide statewide ARTHROGRAPHY, RADIOLOGICALSUPERVISION AND INTERPRETATION 73530 RADIOLOGIC EXAMINATION, HIP, DURING statewide statewide statewide statewide statewide OPERATIVE PROCEDURE 73540 RADIOLOGIC EXAMINATION, PELVIS AND HIPS, statewide statewide statewide cohort cohort INFANT ORCHILD,MINIMUM OF TWO VIEWS 73550 RADIOLOGIC EXAMINATION, FEMUR, cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERAL VIEWS 73560 RADIOLOGIC EXAMINATION, KNEE; ONE OR cohort cohort cohort cohort cohort statewide TWO VIEWS 73562 RADIOLOGIC EXAMINATION, KNEE; THREE cohort cohort cohort cohort cohort statewide VIEWS 73564 RADIOLOGIC EXAMINATION, KNEE; COMPLETE, cohort cohort cohort cohort cohort statewide FOUR OR MORE VIEWS 73565 RADIOLOGIC EXAMINATION, KNEE; BOTH statewide statewide statewide statewide statewide KNEES, STANDING,ANTEROPOSTERIOR 73580 RADIOLOGIC EXAMINATION, KNEE, statewide statewide statewide statewide ARTHROGRAPHY, RADIOLOGICALSUPERVISION AND INTERPRETATION 73590 RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, cohort cohort cohort cohort cohort statewide ANTEROPOSTERIORAND LATERAL VIEWS 73592 RADIOLOGIC EXAMINATION; LOWER statewide statewide statewide statewide statewide EXTREMITY, INFANT, MINIMUM OF TWO VIEWS 73600 RADIOLOGIC EXAMINATION, ANKLE; cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR ANDLATERALVIEWS 73610 RADIOLOGIC EXAMINATION, ANKLE; COMPLETE, cohort cohort cohort cohort cohort statewide MINIMUM OF THREEVIEWS 73620 RADIOLOGIC EXAMINATION, FOOT; cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR AND LATERAL VIEWS 73630 RADIOLOGIC EXAMINATION, FOOT; COMPLETE, cohort cohort cohort cohort cohort cohort MINIMUM OFTHREEVIEWS 73650 RADIOLOGIC EXAMINATION; CALCANEUS, cohort cohort cohort cohort cohort statewide MINIMUM OF TWO VIEWS 73660 RADIOLOGIC EXAMINATION; TOE(S), MINIMUM cohort cohort cohort cohort cohort statewide OF TWO VIEWS 73700 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER cohort cohort cohort cohort cohort statewide EXTREMITY; WITHOUTCONTRAST MATERIAL 73701 COMPUTERIZED AXIAL TOMOGRAPHY, LOWER statewide cohort statewide statewide statewide statewide EXTREMITY; WITHCONTRAST MATERIAL(S) 73718 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING; LOWER EXTREMITY, OTHER THAN JOINT; WITHOUT CONTRAST MATERIAL(S) 73720 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort IMAGING, LOWER EXTREMITY,OTHER THAN JOINT

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 73721 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort statewide IMAGING, ANY JOINTOF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL 73722 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort statewide IMAGING, ANY JOINTOF LOWER EXTREMITY; WITH CONTRAST MATERIAL(S) 73723 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort IMAGING, ANY JOINTOF LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 73725 MAGNETIC RESONANCE ANGIOGRAPHY, LOWER statewide statewide statewide statewide EXTREMITY, WITH ORWITHOUT CONTRAST MATERIAL(S) 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE cohort cohort cohort cohort cohort statewide ANTEROPOSTERIOR VIEW 74010 RADIOLOGIC EXAMINATION, ABDOMEN; statewide cohort cohort cohort statewide ANTEROPOSTERIOR ANDADDITIONAL OBLIQUE AND CONE VIEWS 74020 RADIOLOGIC EXAMINATION, ABDOMEN; cohort cohort cohort cohort cohort statewide COMPLETE, INCLUDINGDECUBITUS AND/OR ERECT VIEWS 74022 RADIOLOGIC EXAMINATION, ABDOMEN; cohort cohort cohort cohort cohort statewide COMPLETE ACUTE ABDOMENSERIES, INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, UPRIGHT PA CHEST 74150 COMPUTERIZED AXIAL TOMOGRAPHY, statewide cohort cohort cohort cohort statewide ABDOMEN; WITHOUT CONTRASTMATERIAL 74160 COMPUTERIZED AXIAL TOMOGRAPHY, cohort cohort cohort cohort cohort statewide ABDOMEN; WITH CONTRASTMATERIAL(S) 74170 COMPUTERIZED AXIAL TOMOGRAPHY, cohort cohort cohort cohort cohort statewide ABDOMEN; WITHOUT CONTRASTMATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS 74174 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, statewide cohort cohort cohort cohort statewide ABDOMEN AND PELVIS, WITH CONTRAST MATERIAL(S), INCLUDING NONCONTRAST IMAGES, IF PERFORMED, AND IMAGE POSTPROCESSING 74175 Computed tomographic angiography, abdomen, statewide cohort cohort cohort cohort statewide with contrast material(s), including noncontrast images, if performed, and image postprocessing 74176 Computed tomography, abdomen and pelvis; cohort cohort cohort cohort cohort cohort without contrast material 74177 Computed tomography, abdomen and pelvis; cohort cohort cohort cohort cohort cohort with contrast material(s) 74178 Computed tomography, abdomen and pelvis; cohort cohort cohort cohort cohort statewide without contrast material in one or both body regions, followed by contrast material(s) and further sections in one or both body regions 74181 MAGNETIC RESONANCE (EG, PROTON) statewide cohort cohort cohort cohort IMAGING, ABDOMEN WITHOUT CONTRAST MATERIAL(S) 74183 MAGNETIC RESONANCE (EG, PROTON) cohort cohort cohort cohort cohort IMAGING, ABDOMEN WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES 74185 MAGNETIC RESONANCE ANGIOGRAPHY, statewide statewide statewide statewide cohort ABDOMEN, WITH OR WITHOUTCONTRAST MATERIAL(S) 65

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 74220 RADIOLOGIC EXAMINATION; ESOPHAGUS cohort cohort cohort cohort cohort statewide 74230 SWALLOWING FUNCTION, PHARYNX AND/OR statewide cohort cohort cohort cohort statewide ESOPHAGUS, WITHCINERADIOGRAPHY AND/OR VIDEO 74240 RADIOLOGIC EXAMINATION, statewide cohort cohort cohort cohort statewide GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED IMAGES, WITHOUT KUB 74241 RADIOLOGIC EXAMINATION, statewide statewide cohort cohort cohort GASTROINTESTINAL TRACT, UPPER; WITH OR WITHOUT DELAYED IMAGES, WITH KUB 74245 RADIOLOGIC EXAMINATION, statewide cohort cohort cohort cohort GASTROINTESTINAL TRACT, UPPER; WITH SMALL INTESTINE, INCLUDES MULTIPLE SERIAL IMAGES 74246 RADIOLOGICAL EXAMINATION, cohort cohort cohort cohort cohort statewide GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT DELAYED IMAGES, WITHOUT KUB 74247 RADIOLOGICAL EXAMINATION, statewide cohort cohort cohort cohort GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH OR WITHOUT DELAYED IMAGES, WITH KUB 74249 RADIOLOGICAL EXAMINATION, statewide cohort cohort statewide statewide GASTROINTESTINAL TRACT, UPPER, AIRCONTRAST, WITH SPECIFIC HIGH DENSITY BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON; WITH SMALL BOWEL 74250 RADIOLOGIC EXAMINATION, SMALL INTESTINE, statewide cohort cohort cohort cohort statewide INCLUDES MULTIPLE SERIAL IMAGES; 74261 COMPUTED TOMOGRAPHIC (CT) statewide statewide statewide statewide statewide statewide COLONOGRAPHY, DIAGNOSTIC, INCLUDING IMAGE POSTPROCESSING; WITHOUT CONTRASTMATERIAL 74270 Radiologic examination, colon; contrast (e.g., statewide cohort cohort cohort cohort statewide barium) enema, with or without KUB 74280 RADIOLOGIC EXAMINATION, COLON; AIR statewide statewide statewide statewide statewide statewide CONTRAST WITH SPECIFICHIGH DENSITY BARIUM, WITH OR WITHOUT GLUCAGON 74300 CHOLANGIOGRAPHY AND/OR cohort cohort cohort cohort cohort PANCREATOGRAPHY; INTRAOPERATIVE,RADIOLOGICAL SUPERVISION AND INTERPRETATION 74305 CHOLANGIOGRAPHY AND/OR statewide statewide statewide statewide statewide PANCREATOGRAPHY; POSTOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 74328 ENDOSCOPIC CATHETERIZATION OF THE BILIARY statewide statewide statewide statewide cohort DUCTAL SYSTEM,RADIOLOGICAL SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, 74330 COMBINED ENDOSCOPIC CATHETERIZATION OF statewide cohort statewide cohort statewide THE BILIARYANDPANCREATIC DUCTAL SYSTEMS, RADIOLOGICAL SUPERV ISION AND INTERPRETATION 74360 INTRALUMINAL DILATION OF STRICTURES statewide statewide statewide statewide statewide AND/OR OBSTRUCTIONS (EG,ESOPHAGUS),

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 RADIOLOGICAL SUPERVISION ANDINTERPRETATION 74400 UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, cohort cohort cohort statewide statewide statewide WITH OR WITHOUT KUB,WITH OR WITHOUT TOMOGRAPHY; UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, 74410 UROGRAPHY, INFUSION, DRIP TECHNIQUE statewide statewide statewide AND/OR BOLUS TECHNIQUE; UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 74415 UROGRAPHY, INFUSION, DRIP TECHNIQUE statewide statewide statewide statewide statewide AND/OR BOLUS TECHNIQUE; WITH NEPHROTOMOGRAPHY UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; 74420 UROGRAPHY, RETROGRADE, WITH OR WITHOUT cohort cohort cohort cohort cohort statewide KUB 74425 UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, statewide statewide statewide cohort cohort statewide NEPHROSTOGRAM,LOOPOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION 74430 CYSTOGRAPHY, MINIMUM OF THREE VIEWS, statewide statewide statewide cohort statewide RADIOLOGICALSUPERVISION AND INTERPRETATION 74450 URETHROCYSTOGRAPHY, RETROGRADE, statewide statewide statewide cohort RADIOLOGICAL SUPERVISION ANDINTERPRETATION 74455 URETHROCYSTOGRAPHY, VOIDING, statewide statewide cohort cohort cohort statewide RADIOLOGICAL SUPERVISION ANDINTERPRETATION 74475 INTRODUCTION OF INTRACATHETER OR statewide statewide cohort cohort statewide CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 74480 INTRODUCTION OF URETERAL CATHETER OR statewide statewide statewide statewide statewide STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION ANDINTERPRETATION 74740 HYSTEROSALPINGOGRAPHY, RADIOLOGICAL statewide cohort cohort cohort statewide statewide SUPERVISION ANDINTERPRETATION 75557 Cardiac magnetic resonance imaging for statewide statewide statewide morphology and function without contrast material; 75561 Cardiac magnetic resonance imaging for statewide cohort cohort morphology and function without contrast material(s), followed by contrast material(s) and further sequences; 75563 Cardiac magnetic resonance imaging for statewide cohort morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging 75565 CARDIAC MAGNETIC RESONANCE IMAGING FOR statewide cohort VELOCITY FLOW MAPPING (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 75571 COMPUTED TOMOGRAPHY, HEART, WITHOUT statewide statewide statewide statewide CONTRAST MATERIAL, WITH QUANTITATIVE EVALUATION OF CORONARY CALCIUM 75572 COMPUTED TOMOGRAPHY, HEART, WITH statewide cohort cohort CONTRAST MATERIAL, FOR EVALUATION OF

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 CARDIAC STRUCTURE AND MORPHOLOGY (INCLUDING 3D IMAGE POSTPROCESSING, ASSESSMENT OF CARDIAC FUNCTION, AND EVALUATION OF VENOUS STRU 75574 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, statewide cohort cohort cohort HEART, CORONARY ARTERIES AND BYPASS GRAFTS (WHEN PRESENT), WITH CONTRAST MATERIAL, INCLUDING 3D IMAGE POSTPROCESSING(INCLUDING EVALUATION OF CARDIAC STRUCTURE AND MO 75625 AORTOGRAPHY, ABDOMINAL, BY statewide statewide cohort cohort cohort SERIALOGRAPHY, RADIOLOGICALSUPERVISION AND INTERPRETATION 75630 AORTOGRAPHY, ABDOMINAL PLUS BILATERAL statewide statewide statewide statewide statewide ILIOFEMORAL LOWEREXTREMITY, CATHETER, BY SERIALOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 75635 Computed tomographic angiography, abdominal statewide cohort cohort statewide cohort aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing. 75710 ANGIOGRAPHY, EXTREMITY, UNILATERAL, statewide cohort cohort cohort statewide RADIOLOGICAL SUPERVISIONAND INTERPRETATION 75716 ANGIOGRAPHY, EXTREMITY, BILATERAL, statewide statewide cohort cohort statewide RADIOLOGICAL SUPERVISION AND INTERPRETATION 75726 ANGIOGRAPHY, VISCERAL, SELECTIVE OR statewide statewide cohort SUPRASELECTIVE, (WITH ORWITHOUT FLUSH AORTOGRAM), RADIOLOGICAL SUPERVISION AND INTERPRETATION 75774 ANGIOGRAPHY, SELECTIVE, EACH ADDITIONAL statewide statewide statewide cohort statewide VESSEL STUDIED AFTERBASIC EXAMINATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO CODE FOR 75820 VENOGRAPHY, EXTREMITY, UNILATERAL, statewide statewide statewide cohort statewide RADIOLOGICAL SUPERVISION AND INTERPRETATION 75825 VENOGRAPHY, CAVAL, INFERIOR, WITH statewide statewide statewide statewide statewide SERIALOGRAPHY,RADIOLOGICAL SUPERVISION AND INTERPRETATION 75860 VENOGRAPHY, SINUS OR JUGULAR, CATHETER, cohort RADIOLOGICALSUPERVISION AND INTERPRETATION 75945 INTRAVASCULAR ULTRASOUND (NON- statewide statewide statewide statewide statewide CORONARY VESSEL), RADIOLOGICALSUPERVISION AND INTERPRETATION; INITIAL VESSEL 75978 TRANSLUMINAL BALLOON ANGIOPLASTY, statewide statewide cohort statewide statewide VENOUS (EG, SUBCLAVIANSTENOSIS), RADIOLOGICAL SUPERVISION AND INTERPRETATION 75984 Change of percutaneous tube or drainage statewide statewide cohort cohort statewide catheter with contrast monitoring (e.g., genitourinary system, abscess), radiological supervision and interpretation 75989 RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS statewide statewide statewide statewide statewide DRAINAGE OFABSCESS, OR SPECIMEN COLLECTION (IE, FLUOROSCOPY, ULTRASOUND, 68

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 OR COMPUTED TOMOGRAPHY), WITH PLACEM ENT OF INDWELLING CATHETER, 76000 FLUOROSCOPY (SEPARATE PROCEDURE), UP TO cohort cohort cohort cohort cohort cohort 1 HOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONALTIME, OTHER THAN 71023 OR 71034 (EG, CARDIAC FLUO ROSCOPY) 76001 FLUOROSCOPY, PHYSICIAN OR OTHER statewide cohort cohort cohort cohort cohort QUALIFIED HEALTH CARE PROFESSIONAL TIME MORE THAN 1 HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL (EG, NEPHROSTOLITHOTOMY, ERCP, 76010 RADIOLOGIC EXAMINATION FROM NOSE TO statewide cohort cohort statewide RECTUM FOR FOREIGN BODY,SINGLE FILM, CHILD 76080 RADIOLOGIC EXAMINATION, ABSCESS, FISTULA statewide statewide statewide cohort statewide OR SINUS TRACTSTUDY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 76098 RADIOLOGICAL EXAMINATION, SURGICAL statewide cohort cohort cohort cohort SPECIMEN 76100 RADIOLOGIC EXAMINATION, SINGLE PLANE statewide statewide BODY SECTION (EG,TOMOGRAPHY), OTHER THAN WITH UROGRAPHY 76376 3D RENDERING WITH INTERPRETATION AND statewide cohort cohort cohort REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; NOT 76377 3D RENDERING WITH INTERPRETATION AND statewide cohort cohort cohort cohort statewide REPORTING OF COMPUTED TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, ULTRASOUND, OR OTHER TOMOGRAPHIC MODALITY WITH IMAGE POSTPROCESSING UNDER CONCURRENT SUPERVISION; REQ 76380 COMPUTERIZED TOMOGRAPHY, LIMITED OR statewide cohort cohort cohort statewide statewide LOCALIZED FOLLOW-UPSTUDY 76498 UNLISTED MAGNETIC RESONANCE PROCEDURE statewide statewide statewide cohort 76499 UNLISTED DIAGNOSTIC RADIOLOGIC cohort cohort cohort cohort PROCEDUREUNLISTED DIAGNOSTIC RADIOLOGIC PROCEDURE 76506 Echoencephalography, real time with image statewide statewide statewide cohort statewide documentation (gray sale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnorm 76536 Ultrasound, soft tissues of head and neck (eg, cohort cohort cohort cohort cohort statewide thyroid, parathyroid, parotid) real time with image documentation 76604 Ultrasound, chest (includes mediastinum), real statewide cohort cohort cohort cohort statewide time with image documentation 76641 ULTRASOUND, BREAST, UNILATERAL, REAL TIME cohort cohort cohort cohort cohort statewide WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED;COMPLETE 76642 ULTRASOUND, BREAST, UNILATERAL, REAL TIME cohort cohort cohort cohort cohort statewide WITH IMAGE DOCUMENTATION, INCLUDING AXILLA WHEN PERFORMED;LIMITED 76645 US EXAM BREAST(S) cohort cohort cohort cohort cohort statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 76700 Ultrasound, abdominal, real time with image cohort cohort cohort cohort cohort cohort documentation; complete 76705 ECHOGRAPHY, ABDOMINAL, B-SCAN AND/OR cohort cohort cohort cohort cohort cohort REAL TIME WITH IMAGEDOCUMENTATION; LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP) 76770 Ultrasound, retroperitoneal (eg, renal, aorta, cohort cohort cohort cohort cohort statewide nodes), real time with image documentation; complete 76775 ECHOGRAPHY, RETROPERITONEAL (EG, RENAL, cohort cohort cohort cohort cohort AORTA, NODES),B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; LIMITED 76776 ULTRASOUND, TRANSPLANTED KIDNEY, REAL statewide statewide statewide cohort TIME AND DUPLEX DOPPLER WITH IMAGE DOCUMENTATION 76800 ECHOGRAPHY, SPINAL CANAL AND CONTENTS statewide statewide statewide statewide statewide 76801 US,PREG UTER, REAL TIME W/IMAGE cohort cohort cohort cohort cohort statewide DOCUMENT, FETAL & MATERNAL, 1ST TRIMEST, TRANSABDOM SINGL/1ST GEST 76802 US,PREG UTER, REAL TIME W/IMAGE statewide statewide statewide cohort DOCUMENT, FETAL & MATERNAL, 1ST TRIMEST, TRANSABDOM;EA ADD'L GEST 76805 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN cohort cohort cohort cohort cohort AND/OR REAL TIME WITHIMAGE DOCUMENTATION; COMPLETE (COMPLETE FETAL AND MATERNAL EVALUATION) 76811 US,PREG UTER, REAL TIME W/IMAGE DOC FETL statewide cohort cohort cohort & MATRNL + DETL FETL EXM, TRANSABD; SINGL/1ST ADD'L GEST 76812 US,PREG UTER, REAL TIME W/IMAGE DOC FETAL statewide statewide cohort & MATERNAL,+ DETAIL FETAL EXAM TRANSABD; EA ADD'L GEST 76813 ULTRASOUND, PREGNANT UTERUS, REAL TIME statewide cohort cohort cohort WITH IMAGE DOCUMENTATION, FIRST TRIMESTER FETAL NUCHAL TRANSLUCENCY MEASUREMENT, TRANSABDOMINAL OR TRANSVAGINALAPPROACH; SINGLE OR FIRST GESTATION 76815 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN statewide cohort cohort cohort cohort AND/OR REAL TIME WITHIMAGE DOCUMENTATION; LIMITED (FETAL SIZE, HEART BEAT, PLACENTAL LOCATION, FETAL POSITION, OREMERGENCY IN THE 76816 ECHOGRAPHY, PREGNANT UTERUS, B-SCAN statewide cohort cohort cohort cohort AND/OR REAL TIME WITHIMAGE DOCUMENTATION; FOLLOW-UP OR REPEAT 76817 US,PREGNANT UTERUS,REAL TIME W/IMAGE cohort cohort cohort cohort cohort statewide DOCUMENT TRANSVAGINAL 76818 FETAL BIOPHYSICAL PROFILE statewide statewide statewide cohort statewide 76819 FETAL BIOPHYSICAL PROFILE : WITH NON- statewide cohort cohort cohort cohort STRESS TESTING 76820 UMBILICAL ARTERY ECHO statewide cohort cohort cohort 76821 MIDDLE CEREBRAL ARTERY ECHO statewide statewide cohort 76825 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR statewide statewide cohort SYSTEM, REAL TIMEWITH IMAGE DOCUMENTATION (2D) WITH OR WITHOUT M- MODE RECORDING; 76826 ECHOCARDIOGRAPHY, FETAL, CARDIOVASCULAR statewide cohort SYSTEM, REAL TIMEWITH IMAGE 70

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 DOCUMENTATION (2D) WITH OR WITHOUT M- MODE RECORDING; FOLLOW-UP OR REPEAT STUDY 76827 DOPPLER ECHOCARDIOGRAPHY, FETAL, statewide statewide statewide cohort CARDIOVASCULAR SYSTEM,PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; COMPLETE 76828 DOPPLER ECHOCARDIOGRAPHY, FETAL, cohort CARDIOVASCULAR SYSTEM,PULSED WAVE AND/OR CONTINUOUS WAVE WITH SPECTRAL DISPLAY; FOLLOW-UP OR REPEAT STUDY 76830 ECHOGRAPHY, TRANSVAGINAL cohort cohort cohort cohort cohort cohort 76831 HYSTEROSONOGRAPHY, WITH OR WITHOUT statewide cohort COLOR FLOW DOPPLER 76856 Ultrasound, pelvic (nonobstetric), real time with cohort cohort cohort cohort cohort statewide image documentation; complete 76857 ECHOGRAPHY, PELVIC (NONOBSTETRIC), B-SCAN statewide cohort cohort cohort cohort AND/OR REAL TIMEWITH IMAGE DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES) 76870 ECHOGRAPHY, SCROTUM AND CONTENTS cohort cohort cohort cohort cohort statewide 76872 ECHOGRAPHY, TRANSRECTAL statewide statewide statewide statewide cohort 76881 Ultrasound, extremity, nonvascular, real-time cohort cohort cohort cohort cohort statewide withimage documentation; complete 76882 Ultrasound, extremity, nonvascular, real-time cohort cohort cohort cohort cohort statewide withimage documentation; limited, anatomic specific 76885 ULTRASOUND, INFANT HIPS, REAL TIME WITH statewide statewide cohort cohort cohort IMAGING DOCUMENTATION; DYNAMIC (REQUIRING PHYSICIAN OR OTHERQUALIFIED HEALTH CARE PROFESSIONAL MANIPULATION) 76937 ULTRASOUND GUIDANCE FOR VASCULAR statewide cohort cohort cohort cohort statewide ACCESS REQUIRING ULTRASOUND EVALUATION OF POTENTIAL ACCESS SITES, DOCUMENTATION OF SELECTED VESSEL PATENCY, CONCURRENT REALTIME ULTRASOUND VISUALIZATION OF VASCULAR NE 76942 ULTRASONIC GUIDANCE FOR NEEDLE cohort cohort cohort cohort cohort cohort PLACEMENT(EG,BIOPSYASPIRATION, INJECTION,LOCALIZATION DEVICE) IMAGINGSUPERVISION AND INTERPRETATION 76946 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, statewide statewide statewide cohort RADIOLOGICALSUPERVISION AND INTERPRETATION 76965 ULTRASONIC GUIDANCE FOR INTERSTITIAL statewide statewide statewide statewide RADIOELEMENTAPPLICATION ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT 76998 ULTRASONIC GUIDANCE, INTRAOPERATIVE statewide statewide statewide cohort statewide statewide 76999 UNLISTED ULTRASOUND PROCEDURE statewide cohort statewide statewide statewide 77001 FLUOROSCOPIC GUIDANCE FOR CENTRAL statewide cohort cohort cohort cohort statewide VENOUS ACCESS DEVICE PLACEMENT, REPLACEMENT (CATHETER ONLY OR COMPLETE), OR REMOVAL (INCLUDES FLUOROSCOPIC GUIDANCE FOR VASCULAR ACCESS AND CATHETER MANIPULATION, ANY 77002 FLUOROSCOPIC GUIDANCE FOR NEEDLE cohort cohort cohort cohort cohort statewide PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 77003 FLUOROSCOPIC GUIDANCE AND LOCALIZATION cohort cohort cohort cohort cohort cohort OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTICOR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL OR SUBARACHNOID) 77012 COMPUTED TOMOGRAPHY GUIDANCE FOR statewide cohort cohort cohort cohort statewide NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION 77014 COMPUTED TOMOGRAPHY GUIDANCE FOR cohort cohort cohort cohort cohort statewide PLACEMENT OF RADIATION THERAPY FIELDS 77051 COMPUTER-AIDED DETECTION (COMPUTER cohort cohort cohort cohort statewide statewide ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; DIAG 77052 COMPUTER-AIDED DETECTION (COMPUTER cohort cohort cohort cohort statewide statewide ALGORITHM ANALYSIS OF DIGITAL IMAGE DATA FOR LESION DETECTION) WITH FURTHER REVIEW FOR INTERPRETATION, WITH OR WITHOUT DIGITIZATION OF FILM RADIOGRAPHIC IMAGES; SCRE 77055 MAMMOGRAPHY; UNILATERAL cohort cohort cohort statewide statewide 77056 MAMMOGRAPHY; BILATERAL statewide cohort cohort statewide 77057 SCREENING MAMMOGRAPHY, BILATERAL (2- cohort cohort cohort statewide statewide VIEW STUDY OF EACH BREAST) 77059 MAGNETIC RESONANCE IMAGING, BREAST, statewide cohort cohort cohort cohort WITHOUT AND/ORWITH CONTRAST MATERIAL(S); BILATERAL 77063 SCREENING DIGITAL BREAST TOMOSYNTHESIS, statewide cohort statewide BILATERAL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77072 BONE AGE STUDIES statewide cohort cohort cohort cohort 77073 BONE LENGTH STUDIES statewide statewide statewide cohort cohort (ORTHOROENTGENOGRAM, SCANOGRAM) 77075 RADIOLOGIC EXAMINATION, OSSEOUS SURVEY; statewide statewide statewide cohort cohort COMPLETE (AXIAL AND APPENDICULAR SKELETON) 77077 JOINT SURVEY, SINGLE VIEW, 2 OR MORE JOINTS statewide statewide (SPECIFY) 77080 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), cohort cohort cohort cohort cohort statewide BONE DENSITY STUDY, 1 OR MORE SITES; AXIAL SKELETON (EG, HIPS, PELVIS, SPINE) 77081 DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA), statewide statewide statewide BONE DENSITY STUDY, 1 OR MORE SITES; APPENDICULAR SKELETON (PERIPHERAL) (EG, RADIUS, WRIST, HEEL) 77280 THERAPEUTIC RADIOLOGY SIMULATION-AIDED cohort cohort cohort cohort cohort FIELD SETTING; SIMPLE 77290 THERAPEUTIC RADIOLOGY SIMULATION-AIDED cohort cohort cohort cohort cohort statewide FIELD SETTING;COMPLEX 77293 RESPIRATORY MOTION MANAGEMENT statewide cohort statewide cohort SIMULATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 77295 3-DIMENSIONAL RADIOTHERAPY PLAN, statewide cohort cohort cohort cohort INCLUDING DOSE-VOLUME HISTOGRAMS

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 77300 BASIC RADIATION DOSIMETRY CALCULATION, cohort cohort cohort cohort cohort CENTRAL AXIS DEPTHDOSE, TDF, NSD, GAP CALCULATION, OFF AXIS FACTOR, TISSUE INHOMOGENEITY FACTORS, AS REQUIREDDURING COURSE OF 77301 INTENSITY MODULATED RADIOTHERAPY PLAN statewide cohort cohort cohort cohort W/DOSE VOLUME HISTOGRAMS 77307 TELETHERAPY ISODOSE PLAN; COMPLEX statewide cohort cohort cohort cohort (MULTIPLE TREATMENT AREAS, TANGENTIAL PORTS, THE USE OF WEDGES, BLOCKING, ROTATIONAL BEAM, OR SPECIAL BEAM CONSIDERATIONS), INCLUDES BASIC DOSIMETRY CALCULATION(S) 77315 TELETX ISODOSE PLAN COMPLEX statewide statewide cohort cohort statewide 77316 BRACHYTHERAPY ISODOSE PLAN; SIMPLE statewide statewide statewide (CALCULATION[S]MADE FROM 1 TO 4 SOURCES, OR REMOTE AFTERLOADING BRACHYTHERAPY, 1 CHANNEL), INCLUDES BASIC DOSIMETRY CALCULATION(S) 77321 SPECIAL TELETHERAPY PORT PLAN, PARTICLES, statewide cohort cohort cohort cohort HEMI-BODY, TOTALBODY 77331 SPECIAL DOSIMETRY (EG, TLD, statewide cohort cohort statewide cohort MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY 77332 TREATMENT DEVICES, DESIGN AND statewide cohort cohort cohort cohort CONSTRUCTION; SIMPLE(SIMPLEBLOCK, SIMPLE BOLUS) 77333 TREATMENT DEVICES, DESIGN AND statewide statewide cohort cohort cohort CONSTRUCTION; INTERMEDIATE(MULTIPLE BLOCKS, STENTS, BITE BLOCKS, SPECIAL BOLUS) 77334 TREATMENT DEVICES, DESIGN AND cohort cohort cohort cohort cohort statewide CONSTRUCTION; COMPLEX(IRREGULAR BLOCKS, SPECIAL SHIELDS, COMPENSATORS,WEDGES, MOLDS OR CASTS) 77336 CONTINUING MEDICAL PHYSICS cohort cohort cohort cohort cohort CONSULTATION, INCLUDINGASSESSMENT OF TREATMENT PARAMETERS, QUALITY ASSURANCE OF DOSE DELIVERY, AND REVIEW OF PATIENT TREATMENT DOCUMENTATION 77338 MULTI-LEAF COLLIMATOR(MLC) DEVICE(S) FOR statewide cohort cohort cohort cohort INTENSITYMODULATED RADIATION THERAPY (IMRT),DESIGN AND CONSTRUCTION PER IMRT PLAN 77370 SPECIAL MEDICAL RADIATION PHYSICS statewide statewide cohort cohort cohort CONSULTATION 77371 Radiation treatment delivery, stereotactic cohort radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-sourceCobalt 60 based 77372 Radiation treatment delivery, stereotactic statewide statewide cohort radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based 77373 STEREOTACTIC BODY RADIATION THERAPY, cohort cohort cohort TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS 77385 INTENSITY MODULATED RADIATION statewide cohort cohort cohort cohort TREATMENT DELIVERY (IMRT), INCLUDES 73

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 GUIDANCE AND TRACKING, WHEN PERFORMED; SIMPLE 77386 INTENSITY MODULATED RADIATION cohort cohort cohort cohort cohort TREATMENT DELIVERY (IMRT), INCLUDES GUIDANCE AND TRACKING, WHEN PERFORMED; COMPLEX 77387 GUIDANCE FOR LOCALIZATION OF TARGET cohort cohort cohort cohort VOLUME FOR DELIVERY OF RADIATION TREATMENT DELIVERY, INCLUDES INTRAFRACTION TRACKING, WHEN PERFORMED 77399 UNLISTED PROCEDURE, MEDICAL RADIATION statewide statewide statewide PHYSICS, DOSIMETRY ANDTREATMENT DEVICES, AND SPECIAL SERVICES 77402 RADIATION TREATMENT DELIVERY, >1 MEV; statewide cohort cohort SIMPLE 77407 RADIATION TREATMENT DELIVERY, >1 MEV; statewide statewide statewide statewide INTERMEDIATE 77408 RADIATION TREATMENT DELIVERY cohort 77409 RADIATION TREATMENT DELIVERY statewide statewide statewide statewide 77412 RADIATION TREATMENT DELIVERY, >1 MEV; cohort cohort cohort cohort cohort COMPLEX 77413 RADIATION TREATMENT DELIVERY cohort cohort cohort cohort cohort 77414 RADIATION TREATMENT DELIVERY cohort cohort cohort cohort cohort 77416 RADIATION TREATMENT DELIVERY statewide statewide statewide 77417 THERAPEUTIC RADIOLOGY PORT IMAGE(S) cohort cohort cohort cohort cohort 77418 RADIATION TX DELIVERY IMRT statewide cohort cohort cohort cohort 77421 STEREOSCOPIC X-RAY GUIDANCE cohort cohort cohort cohort 77470 SPECIAL TREATMENT PROCEDURE (EG, TOTAL statewide cohort cohort cohort cohort BODY IRRADIATION, HEMIBODY RADIATION, PER ORAL OR ENDOCAVITARY IRRADIATION) 77778 INTERSTITIAL RADIATION SOURCE APPLICATION, statewide statewide statewide statewide COMPLEX, INCLUDES SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE, WHEN PERFORMED 77785 Remote afterloading high dose rate radionuclide statewide statewide cohort cohort brachytherapy; 1 channel 77786 Remote afterloading high dose rate radionuclide statewide cohort cohort brachytherapy; 2-12 channels 77790 SUPERVISION, HANDLING, LOADING OF statewide cohort statewide statewide RADIOELEMENT 78012 THYROID UPTAKE, SINGLE OR MULTIPLE statewide statewide statewide statewide statewide QUANTITATIVE MEASUREMENT(S) (INCLUDING STIMULATION, SUPPRESSION, OR DISCHARGE, WHEN PERFORMED) 78013 THYROID IMAGING (INCLUDING VASCULAR statewide statewide statewide statewide FLOW, WHEN PERFORMED); 78014 THYROID IMAGING (INCLUDING VASCULAR statewide cohort cohort cohort cohort FLOW, WHEN PERFORMED); WITH SINGLE OR MULTIPLE UPTAKE(S) QUANTITATIVE MEASUREMENT(S) (INCLUDING STIMULATION, SUPPRESSION, OR DISCHARGE, WHEN PERFORMED) 78018 THYROID CARCINOMA METASTASES IMAGING; statewide statewide cohort cohort cohort WHOLE BODY 78020 THYROID CARCINOMA METASTASES UPTAKE statewide cohort (LIST SEPARATELY INADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 78070 PARATHYROID PLANAR IMAGING (INCLUDING statewide statewide statewide cohort statewide SUBTRACTION,WHEN PERFORMED); 78071 PARATHYROID PLANAR IMAGING (INCLUDING statewide statewide statewide statewide SUBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC (SPECT) 78072 PARATHYROID PLANAR IMAGING (INCLUDING statewide statewide statewide SUBTRACTION,WHEN PERFORMED); WITH TOMOGRAPHIC (SPECT), AND CO NCURRENTLY ACQUIRED COMPUTED TOMOGRAPHY (CT) FOR ANATOMICAL LOCALIZATION 78195 LYMPHATICS AND LYMPH GLANDS IMAGING statewide cohort cohort cohort cohort 78205 LIVER IMAGING (SPECT) statewide statewide statewide statewide cohort 78226 HEPATOBILIARY SYSTEM IMAGING, INCLUDING statewide cohort cohort cohort statewide statewide GALLBLADDER WHEN PRESENT; 78227 HEPATOBILIARY SYSTEM IMAGING, INCLUDING cohort cohort cohort cohort cohort statewide GALLBLADDER WHEN PRESENT; WITH PHARMACOLOGIC INTERVENTION, INCLUDING QUANTITATIVE MEASUREMENT(S) WHEN PERFORMED 78264 GASTRIC EMPTYING IMAGING STUDY (EG, cohort cohort cohort cohort cohort statewide SOLID, LIQUID,OR BOTH); 78300 BONE AND/OR JOINT IMAGING; LIMITED AREA statewide statewide cohort statewide statewide 78306 BONE AND/OR JOINT IMAGING; WHOLE BODY cohort cohort cohort cohort cohort statewide 78315 BONE AND/OR JOINT IMAGING; THREE PHASE statewide cohort cohort cohort cohort statewide STUDY 78320 BONE AND/OR JOINT IMAGING; TOMOGRAPHIC statewide statewide statewide statewide cohort statewide (SPECT) 78451 MYOCARDIAL PERFUSION IMAGING, statewide statewide cohort cohort statewide statewide TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICAT 78452 MYOCARDIAL PERFUSION IMAGING, cohort cohort cohort cohort cohort statewide TOMOGRAPHIC (SPECT) (INCLUDING ATTENUATION CORRECTION, QUALITATIVE OR QUANTITATIVE WALL MOTION, EJECTION FRACTION BY FIRST PASS OR GATED TECHNIQUE, ADDITIONAL QUANTIFICAT 78472 CARDIAC BLOOD POOL IMAGING, GATED statewide cohort cohort cohort cohort statewide EQUILIBRIUM; PLANAR,SINGLE STUDY AT REST OR STRESS (EXERCISE AND/OR PHARMACOLOGIC), WALL MOTION STUDY PLUS EJECTIONFRACTION, 78582 PULMONARY VENTILATION (EG, AEROSOL OR statewide cohort cohort cohort cohort statewide GAS) AND PERFUSION IMAGING 78598 QUANTITATIVE DIFFERENTIAL PULMONARY statewide statewide statewide PERFUSION AND VENTILATION (EG, AEROSOL OR GAS), INCLUDING IMAGING WHEN PERFORMED 78608 BRAIN IMAGING, POSITRON EMISSION statewide statewide cohort TOMOGRAPHY (PET);METABOLICEVALUATION BRAIN IMAGING, POSITRON EMIS SION TOMOGRAPHY (PET); METABOLIC 78707 with vascular flow and function, single study statewide statewide statewide statewide statewide statewide without pharmocological intervention 78708 with vascular flow and function, single study, statewide cohort cohort cohort cohort with pharmacological intervention (eg, angiotension converting enzyme inhibitor and/or diuretic)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 78725 KIDNEY FUNCTION STUDY, NON-IMAGING cohort RADIOISOTOPIC STUDY 78802 RADIOPHARMACEUTICAL LOCALIZATION OF statewide statewide cohort TUMOR; WHOLE BODY 78803 RADIOPHARMACEUTICAL LOCALIZATION OF statewide statewide cohort cohort TUMOR; TOMOGRAPHIC(SPECT) 78804 RADIOPHARMACEUTICAL LOCALIZATION OF statewide statewide statewide statewide TUMOR OR DISTRIBUTION OF RADIOPHARMACEUTICAL AGENT(S); WHOLE BODY, REQUIRING TWO OR MORE DAYS IMAGING 78812 Positron emission tomography (PET) imaging; cohort skull base to mid-thigh 78813 Positron emission tomography (PET) imaging; statewide statewide whole body 78815 Positron emission tomography (PET) with statewide cohort cohort cohort cohort concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging;skull base to mid-thigh 78816 Positron emission tomography (PET) with statewide statewide statewide cohort cohort concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging;whole body 79005 NUCLEAR RX, ORAL ADMIN statewide cohort cohort cohort 79101 NUCLEAR RX, IV ADMIN statewide statewide statewide 80048 Basic metabolic panel (Calcium, total) This panel statewide statewide statewide must include the following: Calcium, total (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), 80053 Comprehensive metabolic panel This panel must statewide statewide cohort include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide(bicarbonate) (82374), Chloride (82435), Creatini 80061 Lipid panel This panel must include the statewide cohort following:Cholesterol, serum, total (82465), Lipoprotein, d irect measurement, high density cholesterol (HDL cholesterol) (83718), Triglycerides (84478) 81000 URINALYSIS, BY DIP STICK OR TABLET REAGENT statewide statewide statewide statewide statewide FOR BILIRUBIN,GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE 81001 URINALYSIS, BY DIP STICK OR TABLET REAGENT cohort cohort cohort cohort cohort cohort FOR BILIRUBIN,GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE 81002 URINALYSIS, BY DIP STICK OR TABLET REAGENT cohort cohort cohort cohort cohort statewide FOR BILIRUBIN,GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE 81003 URINALYSIS, BY DIP STICK OR TABLET REAGENT cohort cohort cohort cohort cohort cohort FOR BILIRUBIN,GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOGEN, ANY NUMBER OF THESE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 81015 URINALYSIS; MICROSCOPIC ONLYURINALYSIS; cohort cohort cohort cohort cohort statewide MICROSCOPIC ONLY 81025 URINE PREGNANCY TEST, BY VISUAL COLOR cohort cohort cohort cohort cohort cohort COMPARISON METHODSURINE PREGNANCY TEST, BY VISUAL COLOR COMPARISON METHODS 81050 VOLUME MEASUREMENT FOR TIMED statewide cohort cohort cohort cohort COLLECTION, EACHVOLUME MEASUREMENT FOR TIMED COLLECTION, EACH 82040 Albumin serum, plasma or whole blood statewide statewide statewide 82043 ALBUMIN; URINE, MICROALBUMIN, statewide statewide cohort QUANTITATIVE 82270 BLOOD, OCCULT; FECES, 1-3 SIMULTANEOUS statewide statewide DETERMINATIONS 82272 Blood, occult, by peroxidase activity (e.g., guiac), statewide cohort statewide cohort qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasmscreening 82465 CHOLESTEROL, SERUM, TOTALCHOLESTEROL, cohort SERUM, TOTAL 82728 FERRITIN cohort 82962 GLUCOSE, BLOOD BY GLUCOSE MONITORING statewide cohort DEVICE(S) CLEARED BYTHE FDA SPECIFICALLY FOR HOME USE GLUCOSE,BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY 83036 HEMOGLOBIN; GLYCATEDHEMOGLOBIN; cohort GLYCATED 83540 IRON cohort 83735 MAGNESIUM cohort 84100 PHOSPHORUS INORGANIC (PHOSPHATE); cohort 84443 THYROID STIMULATING HORMONE (TSH) statewide statewide 85025 BLOOD COUNT; HEMOGRAM AND PLATELET statewide statewide statewide cohort COUNT, AUTOMATED, ANDAUTOMATED COMPLETE DIFFERENTIAL WBC COUNT (CBC) 85027 BLOOD COUNT; HEMOGRAM AND PLATELET statewide statewide cohort COUNT, AUTOMATED 85610 PROTHROMBIN TIME; statewide statewide statewide statewide 86140 C-REACTIVE PROTEIN statewide statewide 86592 SYPHILIS TEST, NON-TREPONEMAL ANTIBODY; statewide statewide QUALITATIVE (EG, VDRL, RPR, ART) 86703 ANTIBODY; HIV-1 AND HIV-2, SINGLE RESULT statewide statewide statewide 86706 HEPATITIS B SURFACE ANTIBODY statewide cohort (HBSAB)HEPATITIS B SURFACE ANTIBODY (HBSAB) 86900 BLOOD TYPING, SEROLOGIC; ABO statewide statewide cohort 86901 BLOOD TYPING, SEROLOGIC; RH (D) statewide cohort 87015 CONCENTRATION (ANY TYPE), FOR PARASITES, statewide cohort cohort cohort cohort statewide OVA, OR TUBERCLEBACILLUS (TB, AFB) 87040 CULTURE, BACTERIAL, DEFINITIVE; BLOOD cohort cohort cohort cohort cohort statewide (INCLUDES ANAEROBICSCREEN) 87045 CULTURE, BACTERIAL, DEFINITIVE; STOOL cohort cohort cohort cohort cohort statewide 87046 CULTURE, BACTERIAL; STOOL, ADDITIONAL cohort cohort cohort cohort cohort statewide PATHOGENS, ISOLATION AND PRELIMINARY EXAMINATION (EG, CAMPYLOBACTER, YERSINIA, VIBRO, E. COLI O157),EACH PLATE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 87070 CULTURE, BACTERIAL, DEFINITIVE; ANY OTHER cohort cohort cohort cohort cohort cohort SOURCE 87071 CULTURE, BACTERIAL; QUANTITATIVE, AEROBIC statewide cohort cohort cohort cohort WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES, ANY SOURCE EXCEPT URINE, BLOOD OR STOOL 87075 CULTURE, BACTERIAL, ANY SOURCE; ANAEROBIC cohort cohort cohort cohort cohort statewide (ISOLATION) 87076 CULTURE, BACTERIAL, ANY SOURCE; DEFINITIVE statewide cohort statewide cohort statewide IDENTIFICATION,EACH ANAEROBIC ORGANISM, INCLUDING GAS CHROMATOGRAPHY 87077 CULTURE, BACTERIAL, ANY SOURCE; AEROBIC cohort cohort cohort cohort cohort statewide ISOLATE, ADDITIONAL METHODS REQUIRED FOR DEFINITIVE IDENTI FICATION, EACH ISOLATE 87081 CULTURE, BACTERIAL, SCREENING ONLY, FOR cohort cohort cohort cohort cohort statewide SINGLE ORGANISMS 87086 CULTURE, BACTERIAL, URINE; QUANTITATIVE, cohort cohort cohort cohort cohort cohort COLONY COUNT 87088 CULTURE, BACTERIAL, URINE; IDENTIFICATION, cohort cohort cohort cohort cohort statewide IN ADDITION TOQUANTITATIVE OR COMMERCIAL KIT CULTURE, BACTERIAL, URINE; IDENTIFICATION, IN ADDITION TO 87101 CULTURE, FUNGI, ISOLATION (WITH OR statewide cohort statewide statewide statewide WITHOUT PRESUMPTIVEIDENTIFICATION); SKIN 87102 CULTURE, FUNGI, ISOLATION (WITH OR statewide cohort cohort cohort cohort statewide WITHOUT PRESUMPTIVEIDENTIFICATION); OTHER SOURCE (EXCEPT BLOOD) 87106 CULTURE, FUNGI, DEFINITIVE statewide statewide statewide statewide IDENTIFICATION,EACH ORGANISM; YEAST (USE 87106 IN ADDITIONAL TO CODES 87101, 87102, OR 87103 WHEN APPROPRIATE) 87107 CULTURE, FUNGI, DEFINITIVE statewide statewide cohort IDENTIFICATION,EACH ORGANISM; MOLD (USE 87106 IN ADDITIONAL TO CODES 87101, 87102, OR 87103 WHEN APPROPRIATE) 87116 CULTURE, TUBERCLE OR OTHER ACID-FAST statewide cohort cohort cohort cohort statewide BACILLI (EG, TB, AFB,MYCOBACTERIA); ANY SOURCE, ISOLATION ONLY 87118 CULTURE, MYCOBACTERIA, DEFINITIVE statewide statewide cohort IDENTIFICATION OF EACHORGANISM 87147 CULTURE, TYPING; SEROLOGIC METHOD, cohort cohort cohort cohort cohort statewide AGGLUTINATION GROUPING,PER ANTISERUM 87149 CULTURE, TYPING; IDENTIFICATION BY NUCLEIC statewide statewide statewide statewide statewide statewide ACID (DNA OR RNA) PROBE, DIRECT PROBE TECHNIQUE, PER CULTURE OR ISOLATE, EACH ORGANISM PROBED 87176 ENDOTOXIN, BACTERIAL (PYROGENS); statewide statewide cohort cohort cohort statewide HOMOGENIZATION, TISSUE, FORCULTURE 87177 OVA AND PARASITES, DIRECT SMEARS, cohort cohort cohort cohort cohort statewide CONCENTRATION ANDIDENTIFICATION 87181 SENSITIVITY STUDIES, ANTIBIOTIC; AGAR statewide statewide statewide cohort cohort statewide DIFFUSION METHOD, PER ANTIBIOTIC 87184 SENSITIVITY STUDIES, ANTIBIOTIC; DISK statewide statewide statewide cohort cohort statewide METHOD, PER PLATE (12 OR FEWER DISKS) 87185 SUSCEPTIBILITY STUDIES, ANTIMICROBIAL statewide cohort cohort cohort statewide statewide AGENT; ENZYME DETECTION (EG, BETA LACTAMASE), PER ENZYME

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 87186 SENSITIVITY STUDIES, ANTIBIOTIC; MICROTITER, cohort cohort cohort cohort cohort cohort MINIMUMINHIBITORY CONCENTRATION (MIC), ANY NUMBER OF ANTIBIOTICS 87205 SMEAR, PRIMARY SOURCE, WITH cohort cohort cohort cohort cohort cohort INTERPRETATION; ROUTINE STAINFOR BACTERIA, FUNGI, OR CELL TYPES 87206 SMEAR, PRIMARY SOURCE, WITH statewide cohort cohort cohort cohort statewide INTERPRETATION; FLUORESCENTAND/OR ACID FAST STAIN FOR BACTERIA, FUNGI, OR CELL TYPES 87207 SMEAR, PRIMARY SOURCE, WITH statewide statewide statewide statewide statewide INTERPRETATION; SPECIAL STAINFOR INCLUSION BODIES OR INTRACELLULAR PARASITES (EG, MALARIA, KALA AZAR, HERPES) 87209 SMEAR, PRIMARY SOURCE WITH cohort cohort cohort cohort statewide statewide INTERPRETATION; COMPLEXSPECIAL STAIN (EG, TRICHROME, IRON HEMOTOXYLIN) F OR OVA AND PARASITES 87210 SMEAR, PRIMARY SOURCE, WITH cohort cohort cohort cohort cohort statewide INTERPRETATION; WET MOUNT WITHSIMPLE STAIN, FOR BACTERIA, FUNGI, OVA, AND/OR PARASITES SMEAR, PRIMARY SOURCE, WITH INTERPRETATION; WET MOUNT WITH 87220 TISSUE EXAMINATION FOR FUNGI (EG, KOH cohort statewide statewide statewide SLIDE)TISSUEEXAMINATION FOR FUNGI (EG, KOH SLIDE) 87230 TOXIN OR ANTITOXIN ASSAY, TISSUE CULTURE statewide cohort statewide (EG, CLOSTRIDIUMDIFFICILE TOXIN) 87252 VIRUS IDENTIFICATION; TISSUE CULTURE statewide cohort statewide cohort statewide INOCULATION ANDOBSERVATION 87254 VIRUS ISOLATION; SHELL VIAL, INCLUDES statewide statewide statewide statewide statewide IDENTIFICATION WITH IMMUNOFLUORESCENCE STAIN, EACH VIRUS 87255 VIRUS ISOLATION; ID, NON-IMMUNOLOGIC statewide cohort statewide statewide METHOD, OTHER THAN CYTOPATHIC EFFECT 87260 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide DIRECT FLUORESCENTANTIBODY TECHNIQUE; ADENOVIRUS INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT 87275 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide statewide IMMUNOFLUORESCENT TECHNIQUE; INFLUENZA B VIRUS 87276 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide statewide DIRECT FLUORESCENTANTIBODY TECHNIQUE; INFLUENZA A VIRUS INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT 87279 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide IMMUNOFLUORESCENT TECHNIQUE; PARAINFLUENZA VIRUS, EACH TYPE 87280 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide cohort statewide statewide DIRECT FLUORESCENTANTIBODY TECHNIQUE; RESPIRATORY SYNCYTIAL VIRUS INFECTIOUS AGENT ANTIGEN DETECTION BY DIRECT FLUORESCENT 87281 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide cohort IMMUNOFLUORESCENT TECHNIQUE; PNEUMOCYSTIS CARINII 87305 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87324 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87328 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87329 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87336 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87338 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort statewide statewide cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87340 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87341 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87350 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide statewide statewide cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87389 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87400 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort statewide statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 80

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 87420 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide cohort statewide cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87425 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide cohort statewide statewide statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87427 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort statewide cohort IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87430 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]) QUALITATIVE OR SEMIQUANTITA 87449 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort cohort cohort cohort cohort statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTIT 87450 INFECTIOUS AGENT ANTIGEN DETECTION BY statewide statewide IMMUNOASSAY TECHNIQUE, (EG, ENZYME IMMUNOASSAY [EIA], ENZYME-LINKED IMMUNOSORBENT ASSAY [ELISA], IMMUNOCHEMILUMINOMETRIC ASSAY [IMCA]), QUALITATIVE OR SEMIQUANTIT 87476 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide statewide ACID (DNA ORRNA);BORRELIA BURGDORFERI, AMPLIFIED PROBE TECHNI QUE 87486 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort ACID (DNA ORRNA);CHLAMYDIA PNEUMONIAE, AMPLIFIED PROBE TECHNI QUE 87490 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort statewide ACID (DNA ORRNA);CHLAMYDIA TRACHOMATIS, DIRECT PROBE TECHNIQU E INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNAOR RNA); 87491 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort cohort cohort cohort statewide ACID (DNA ORRNA);CHLAMYDIA TRACHOMATIS, AMPLIFIED PROBE TECHN IQUE 87493 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort cohort cohort cohort ACID (DNA ORRNA); CLOSTRIDIUM DIFFICILE, TOXIN GENE(S), AMPLI FIED PROBE TECHNIQUE 87496 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide statewide cohort statewide ACID (DNA ORRNA);CYTOMEGALOVIRUS, AMPLIFIED PROBE TECHNIQUE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA ORRNA); 87497 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort statewide statewide cohort statewide ACID (DNA ORRNA);CYTOMEGALOVIRUS, QUANTIFICATION INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA);

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 87498 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide statewide ACID (DNA ORRNA); ENTEROVIRUS, AMPLIFIED PROBE TECHNIQUE, INC LUDES REVERSE TRANSCRIPTION WHEN PERFORMED 87502 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide cohort cohort statewide ACID (DNA ORRNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB- TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHN 87503 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide cohort cohort ACID (DNA ORRNA); INFLUENZA VIRUS, FOR MULTIPLE TYPES OR SUB- TYPES, INCLUDES MULTIPLEX REVERSE TRANSCRIPTION, WHEN PERFORMED, AND MULTIPLEX AMPLIFIED PROBE TECHN 87506 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide ACID (DNA ORRNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPT 87507 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA); GASTROINTESTINAL PATHOGEN (EG, CLOSTRIDIUM DIFFICILE, E. COLI, SALMONELLA, SHIGELLA, NOROVIRUS, GIARDIA), INCLUDES MULTIPLEX REVERSE TRANSCRIPT 87516 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA);HEPATITIS B VIRUS, AMPLIFIED PROBE TECHNIQUE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87517 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide statewide cohort ACID (DNA ORRNA);HEPATITIS B VIRUS, QUANTIFICATION INFECTIOU S AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87522 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort statewide cohort cohort ACID (DNA ORRNA); HEPATITIS C, QUANTIFICATION, INCLUDES REVER SE TRANSCRIPTION WHEN PERFORMED 87529 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide cohort cohort cohort statewide ACID (DNA ORRNA);HERPES SIMPLEX VIRUS, AMPLIFIED PROBE TECHNI QUE 87532 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA);HERPES VIRUS-6, AMPLIFIED PROBE TECHNIQUE 87533 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide cohort ACID (DNA ORRNA);HERPES VIRUS-6, QUANTIFICATION INFECTIOUS A GENT DETECTION BY NUCLEIC ACID (DNA OR RNA); 87536 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide cohort cohort ACID (DNA ORRNA); HIV-1, QUANTIFICATION, INCLUDES REVERSE TRA NSCRIPTION WHEN PERFORMED 87581 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort ACID (DNA ORRNA);MYCOPLASMA PNEUMONIAE, AMPLIFIED PROBE TECHN IQUE 87591 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort cohort cohort cohort statewide ACID (DNA ORRNA);NEISSERIA GONORRHOEAE, AMPLIFIED PROBE TECHN IQUE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 87621 HPV DNA AMP PROBE statewide cohort cohort cohort cohort 87624 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort statewide statewide cohort ACID (DNA ORRNA); HUMAN PAPILLOMAVIRUS (HPV), HIGH-RISK TYPES (EG, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) 87631 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort ACID (DNA ORRNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZ A VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS) 87632 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort ACID (DNA ORRNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZ A VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS) 87633 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA); RESPIRATORY VIRUS (EG, ADENOVIRUS, INFLUENZ A VIRUS, CORONAVIRUS, METAPNEUMOVIRUS, PARAINFLUENZA VIRUS, RESPIRATORY SYNCYTIAL VIRUS, RHINOVIRUS) 87640 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA); STAPHYLOCOCCUS AUREUS, AMPLIFIED PROBE TECH NIQUE 87641 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide cohort cohort cohort cohort statewide ACID (DNA ORRNA); STAPHYLOCOCCUS AUREUS, METHICILLIN RESISTAN T, AMPLIFIED PROBE TECHNIQUE 87653 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide cohort statewide ACID (DNA ORRNA); STREPTOCOCCUS, GROUP B, AMPLIFIED PROBE TEC HNIQUE 87661 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide ACID (DNA ORRNA); TRICHOMONAS VAGINALIS, AMPLIFIED PROBE TECH NIQUE 87798 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort statewide cohort cohort ACID (DNA ORRNA); NOTOTHERWISE SPECIFIED, AMPLIFIED PROBE TEC HNIQUE INFECTIOUS AGENT DETECTION BY NUCLEIC ACID(DNA OR RNA); NOT 87799 INFECTIOUS AGENT DETECTION BY NUCLEIC statewide statewide statewide statewide cohort statewide ACID (DNA ORRNA); NOTOTHERWISE SPECIFIED, QUANTIFICATION INF ECTIOUS AGENT DETECTION BY NUCLEIC ACID (DNA OR RNA); NOT 87801 INFECTIOUS AGENT DETECTION BY NUCLEIC cohort cohort statewide statewide ACID (DNA ORRNA),MULTIPLE ORGANISMS; AMPLIFIED PROBE(S) TECHNIQUE 87804 INFECTIOUS AGENT, IMMUNOASSAY, DIRECT cohort cohort cohort cohort statewide statewide OBSERVATION;INFLUENZA 87806 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; HIV-1 ANTIGEN(S),WITH HIV-1 AND HIV-2 ANTIBODIES 87807 RSV ASSAY W/OPTIC statewide cohort cohort statewide 87808 INFECTIOUS AGENT ANTIGEN DETECTION BY cohort IMMUNOASSAY WITH DIRECT OPTICAL OBSERVATION; TRICHOMONAS VAGINALIS 87880 INFECTIOUS AGENT DETECTION BY cohort cohort cohort cohort cohort statewide IMMUNOASSAY WITH DIRECTOPTICAL 83

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 OBSERVATION; STREPTOCOCCUS, GROUP A INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87899 INFECTIOUS AGENT DETECTION BY cohort cohort cohort cohort statewide IMMUNOASSAY WITH DIRECTOPTICAL OBSERVATION; NOT OTHERWISE SPECIFIED INFECTIOUS AGENT DETECTION BY IMMUNOASSAY WITH DIRECT 87902 INFECTIOUS AGENT, GENOTYPE ANALYSIS, statewide statewide statewide statewide cohort NUCLEIC ACID (DNA/RNA); HEPATITIS C VIRUS 88142 CYTOPATHOLOGY, CERVICAL OR VAGINAL (ANY statewide cohort REPORTING SYSTEM),COLLECTED IN PRESERVATIVE FLUID, AUTOMATEDTHIN LAYER PREPARATION; MANUAL SCREENING UNDER P HYSICIAN SUPERVISION 88175 CYTOPATHOLOGY, CERVICAL/VAGINAL,AUTO cohort statewide THIN LAYER PREP; AUTO SCREEN & MANUAL RESCREEN, WITH PHYSICIAN INTERPRETATION 88305 LEVEL IV - SURGICAL PATHOLOGY, GROSS AND statewide statewide statewide cohort MICROSCOPIC EXAMINATION 90375 Rabies immune globulin (RIg), human, for statewide statewide statewide statewide statewide intramuscular and/or subcutaneous use 90460 IMMUNIZATION ADMINISTRATION THROUGH 18 statewide statewide cohort YEARS OF AGE VIA ANY ROUTE OF ADMINISTRATION, WITH COUNSELINGBY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFE SSIONAL; FIRST OR ONLY COMPONENT OF EACH VACCINE O 90471 IMMUNIZATION ADMINISTRATION (INCLUDES cohort cohort cohort cohort cohort statewide PERCUTANEOUS, INTRADERMAL, SUBCUTANEOUS, OR INTRAMUSCULAR INJECTIONS); 1 VACCINE (SINGLE OR COMBINATION VACCINE/TOXOID) 90472 IMMUNIZATION ADMINISTRATION (INCLUDES statewide statewide cohort cohort cohort statewide PERCUTANEOUS,INTRADERMAL, SUBCUTANEOUS, INTRAMUSCULAR AND JET INJECTIONS AND/OR INTRANASAL OR ORAL ADMINISTRATION); TWO OR MORE 90645 Hemophilus influenza b vaccine (Hib), HbOC statewide cohort conjugate (4 dose schedule), for intramuscular use 90649 HUMAN PAPILLOMAVIRUS VACCINE, TYPES 6, statewide statewide 11, 16, 18,QUADRIVALENT (4VHPV), 3 DOSE SCHEDULE, FOR INTRAM USCULAR USE 90656 Influenza virus vaccine, trivalent (IIV3), split statewide cohort statewide cohort virus, preservative free, when administered to individuals 3 years and older, for intramuscular use 90661 Influenza virus vaccine (ccIIV3), derived from cell statewide statewide statewide cultures, subunit, preservative and antibiotic free, for intramuscular use 90670 Pneumococcal conjugate vaccine, 13 valent statewide statewide statewide cohort (PCV13),for intramuscular use 90675 Rabies vaccine, for intramuscular use statewide statewide cohort cohort statewide 90686 Influenza virus vaccine, quadrivalent (IIV4), split statewide cohort virus, preservative free, when administered to individuals 3 years of age and older, for intramuscular use 90714 Tetanus and diphtheria toxoids adsorbed (Td), statewide statewide statewide statewide preservative free, when administered to

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 individuals 7 years or older, for intramuscular use 90715 Tetanus diphtheria toxoids and acellular cohort cohort cohort cohort cohort pertussisvaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use 90732 Pneumococcal polysaccharide vaccine, 23-valent statewide statewide statewide statewide cohort (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use 90746 HEPATITIS B VACCINE (HEPB), ADULT DOSAGE, 3 statewide statewide statewide DOSE SCHEDULE, FOR INTRAMUSCULAR USE 90791 PSYCHIATRIC DIAGNOSTIC EVALUATION statewide statewide 90837 PSYCHOTHERAPY, 60 MINUTES WITH PATIENT statewide statewide AND/OR FAMILY MEMBER 90853 GROUP PSYCHOTHERAPY (OTHER THAN OF A cohort cohort cohort statewide MULTIPLE-FAMILY GROUP) GROUP PSYCHOTHERAPY (OTHER THAN OF A MULTIPLE- FAMILY GROUP) 90870 ELECTROCONVULSIVE THERAPY (INCLUDES cohort cohort cohort cohort statewide NECESSARY MONITORING);SINGLE SEIZURE ELECTROCONVULSIVE THERAPY (INCLUDES NECESSARY MONITORING); 91010 ESOPHAGEAL MOTILITY (MANOMETRIC STUDY cohort cohort cohort cohort OF THE ESOPHAGUS AND/OR GASTROESOPHAGEAL JUNCTION) STUDY WITH INTERPRETATION AND REPORT; 91034 GASTROESOPHAGEAL REFLUX TEST statewide statewide statewide cohort 91035 ESOPHAGUS, GASTROESOPHAGEAL REFLUX statewide statewide statewide statewide TEST, WITH ELECTRODE 91037 ESOPHAGEAL FUNCTION TEST, statewide cohort statewide GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER INTRALUMINAL IMPEDANCE ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION 91038 ESOPHAGEAL FUNCTION TEST, statewide statewide cohort GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER INTRALUMINAL, > 1 HR 91065 BREATH HYDROGEN OR METHANE TEST (EG, statewide statewide cohort FOR DETECTIONOF LACTASE DEFICIENCY, FRUCTOSE INTOLERANCE, BACT ERIAL OVERGROWTH, OR ORO-CECAL GASTROINTESTINAL TRANSIT) 91110 GASTROINTESTINAL TRACT IMAGING, statewide statewide statewide statewide INTRALUMINAL (EG, CAPSULE ENDOSCOPY), ESOPHAGUS THROUGH ILEUM, WITH INTERPRETATION AND REPORT 91120 RECTAL SENSATION TEST cohort 91122 ANORECTAL MANOMETRY statewide statewide cohort 91200 LIVER ELASTOGRAPHY, MECHANICALLY statewide statewide cohort INDUCED SHEAR WAVE (EG, VIBRATION), WITHOUT IMAGING, WITH INTERPRETATION AND REPORT 91299 UNLISTED DIAGNOSTIC GASTROENTEROLOGY cohort PROCEDURE 92250 FUNDUS PHOTOGRAPHY WITH INTERPRETATION cohort AND REPORTFUNDUS PHOTOGRAPHY WITH INTERPRETATION AND REPORT

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 92285 EXTERNAL OCULAR PHOTOGRAPHY WITH statewide statewide INTERPRETATION AND REPORTFOR DOCUMENTATION OF MEDICAL PROGRESS (EG,CLOSE-UP PHOTOGRAPHY, SLIT LAMP PHOTOGRAPHY, GON IOPHOTOGRAPHY, 92511 NASOPHARYNGOSCOPY WITH ENDOSCOPE statewide statewide statewide (SEPARATE PROCEDURE) 92540 BASIC VESTIBULAR EVALUATION, INCLUDES statewide statewide statewide cohort SPONTANEOUS NYSTAGMUS TEST WITH ECCENTRIC GAZE FIXATION NYSTAGMUS, WITH RECORDING, POSITIONAL NYSTAGMUS TEST, MINIMUM OF 4 POSITIONS, WITH RECORDING, OPTOKINETIC 92543 CALORIC VESTIBULAR TEST, EACH IRRIGATION statewide cohort (BINAURAL, BITHERMAL STIMULATION CONSTITUTES 4 TESTS), WIT H RECORDING 92546 SINUSOIDAL VERTICAL AXIS ROTATIONAL cohort TESTINGSINUSOIDAL VERTICAL AXIS ROTATIONAL TESTING 92550 TYMPANOMETRY AND REFLEX THRESHOLD statewide cohort cohort MEASUREMENTS 92551 SCREENING TEST, PURE TONE, AIR ONLY statewide statewide statewide statewide statewide 92552 PURE TONE AUDIOMETRY (THRESHOLD); AIR statewide statewide statewide cohort ONLY 92553 PURE TONE AUDIOMETRY (THRESHOLD); AIR statewide cohort AND BONE 92555 SPEECH AUDIOMETRY THRESHOLD; statewide statewide statewide cohort 92556 SPEECH AUDIOMETRY THRESHOLD; WITH statewide statewide statewide statewide cohort SPEECH RECOGNITION 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD statewide statewide statewide cohort cohort EVALUATION AND SPEECHRECOGNITION (92553 AND 92556 COMBINED) 92567 TYMPANOMETRY (IMPEDANCE TESTING) statewide statewide cohort cohort 92579 VISUAL REINFORCEMENT AUDIOMETRY (VRA) statewide statewide cohort cohort 92582 CONDITIONING PLAY AUDIOMETRY statewide statewide cohort 92585 AUDITORY EVOKED POTENTIALS FOR EVOKED statewide statewide statewide cohort RESPONSE AUDIOMETRYAND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM 92586 AUDITORY EVOKED POTENTIALS FOR EVOKED statewide statewide cohort statewide RESPONSE AUDIOMETRY AND/OR TESTING OF THE CENTRAL NERVOUS SYSTEM; LIMITED 92587 DISTORTION PRODUCT EVOKED OTOACOUSTIC statewide statewide statewide cohort cohort EMISSIONS; LIMITED EVALUATION (TO CONFIRM THE PRESENCE OR ABSENCE OF HEARING DISORDER, 3-6 FREQUENCIES) OR TRANSIENT EVOKED OTOACOUSTIC EMISSIONS, WITH INTERPRETA 92588 DISTORTION PRODUCT EVOKED OTOACOUSTIC statewide cohort EMISSIONS; COMPREHENSIVE DIAGNOSTIC EVALUATION (QUANTITATIVE ANALYSIS OF OUTER HAIR CELL FUNCTION BY COCHLEAR MAPPING, MINIMUM OF 12 FREQUENCIES), WITH INTERPRETA 92603 DX ANALYSIS COCHLEAR IMPLANT, PATIENT >7 cohort YRS. W/PROGRAMMING 92604 DX ANALYSIS COCHLEAR IMPLANT, PATIENT >7 cohort YRS. REPROGRAMMING 92620 AUDITORY FUNCTION, 60 MIN statewide cohort statewide

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 92625 TINNITUS ASSESSMENT statewide statewide 92626 EVALUATION OF AUDITORY REHABILITATION statewide cohort STATUS; FIRST HOUR 92920 PERCUTANEOUS TRANSLUMINAL CORONARY statewide statewide statewide statewide ANGIOPLASTY; SINGLE MAJOR CORONARY ARTERY OR BRANCH 92921 PERCUTANEOUS TRANSLUMINAL CORONARY statewide statewide statewide ANGIOPLASTY; EACH ADDITIONAL BRANCH OF A MAJOR CORONARY ARTERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 92928 PERCUTANEOUS TRANSCATHETER PLACEMENT statewide cohort cohort cohort OF INTRACORONARY STENT(S), WITH CORONARY ANGIOPLASTY WHEN PERFORMED; SINGLE MAJOR CORONARY ARTERY OR BRANCH 92943 PERCUTANEOUS TRANSLUMINAL statewide statewide statewide statewide REVASCULARIZATION OF CHRONIC TOTAL OCCLUSION, CORONARY ARTERY, CORONARY ARTERY BRANCH, OR CORONARY ARTERY BYPASS GRAFT, ANY COMBINATION OF INTRACORONARY STENT, ATHERECTOMY AN 92950 CARDIOPULMONARY RESUSCITATION (EG, IN statewide cohort cohort cohort statewide CARDIAC ARREST) 92960 CARDIOVERSION, ELECTIVE, ELECTRICAL statewide cohort cohort cohort cohort CONVERSION OFARRHYTHMIA, EXTERNAL 92971 Cardioassist-method of circulatory assist; statewide statewide external 92978 INTRAVASCULAR ULTRASOUND (CORONARY statewide cohort cohort statewide VESSEL OR GRAFT) DURINGTHERAPEUTIC INTERVENTION INCLUDING IMAGINGSUPERVISION, INTERPRETATION AND REPORT; INITIAL VESSEL (LIST SEPARATELY 93005 ELECTROCARDIOGRAM, ROUTINE ECG WITH AT cohort cohort cohort cohort cohort cohort LEAST 12 LEADS;TRACING ONLY, WITHOUT INTERPRETATION AND REPORT ELECTROCARDIOGRAM, ROUTINE ECG WITH AT LEAST 12LEADS; 93017 CARDIOVASCULAR STRESS TEST USING cohort cohort cohort cohort cohort statewide MAXIMAL OR SUBMAXIMALTREADMILL OR BICYCLE EXERCISE, CONTINOUS ELECTROCARDIOGRAPHIC MONITORING, AND/OR PHARMACOLOGICAL 93041 RHYTHM ECG, ONE TO THREE LEADS; TRACING cohort cohort cohort cohort cohort ONLY WITHOUTINTERPRETATION AND REPORT 93225 External electrocardiographic recording up to 48 cohort cohort cohort cohort cohort statewide hours by continuous rhythm recording and storage; recording (includes connection, recording, and disconnection) 93226 External electrocardiographic recording up to 48 cohort cohort cohort statewide cohort hours by continuous rhythm recording and storage; scanning analysis with report 93270 External patient and, when performed, auto statewide cohort cohort statewide cohort activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attende 93271 External patient and, when performed, auto statewide statewide cohort activated electrocardiographic rhythm derived event recording with symptom-related memory loop with remote download capability up to 30 days, 24-hour attende

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 93280 PROGRAMMING DEVICE EVALUATION (IN statewide statewide statewide cohort PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AN 93282 PROGRAMMING DEVICE EVALUATION (IN statewide cohort PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AN 93283 PROGRAMMING DEVICE EVALUATION (IN statewide statewide cohort PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AN 93284 PROGRAMMING DEVICE EVALUATION (IN statewide statewide cohort PERSON) WITH ITERATIVE ADJUSTMENT OF THE IMPLANTABLE DEVICE TO TEST THE FUNCTION OF THE DEVICE AND SELECT OPTIMAL PERMANENT PROGRAMMED VALUES WITH ANALYSIS, REVIEW AN 93288 INTERROGATION DEVICE EVALUATION (IN cohort PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHERQUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONN ECTION, RECORDING AND DISCONNECTION PER PATIENT EN 93289 INTERROGATION DEVICE EVALUATION (IN statewide cohort PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHERQUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONN ECTION, RECORDING AND DISCONNECTION PER PATIENT EN 93291 INTERROGATION DEVICE EVALUATION (IN statewide cohort PERSON) WITH ANALYSIS, REVIEW AND REPORT BY A PHYSICIAN OR OTHERQUALIFIED HEALTH CARE PROFESSIONAL, INCLUDES CONN ECTION, RECORDING AND DISCONNECTION PER PATIENT EN 93293 TRANSTELEPHONIC RHYTHM STRIP PACEMAKER cohort EVALUATION(S) SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM, INCLUDES RECORDING WITH AND WITHOUT MAGNET APPLICATION WITH ANALYSIS, REVIEW AND REPORT(S) BY A PH 93296 INTERROGATION DEVICE EVALUATION(S) statewide cohort statewide cohort (REMOTE), UP TO90 DAYS; SINGLE, DUAL, OR MULTIPLE LEAD PACEMAKER SYSTEM OR IMPLANTABLE DEFIBRILLATOR SYSTEM, REMOT E DATA ACQUISITION(S), RECEIPT OF TRANSMISSIONS AN 93299 Interrogation device evaluation(s), (remote) up statewide cohort to30 days; implantable cardiovascular monitor syste m or implantable loop recorded system, remote dataacquisition(s), receipt of transmissions and tech 93303 TRANSTHORACIC ECHOCARDIOGRAPHY FOR statewide statewide cohort cohort CONGENITAL CARDIACANOMALIES; COMPLETE

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 93306 Echocardiography, transthoracic, real-time with cohort cohort cohort cohort cohort statewide image documentation (2D), includes M-mode recording,when performed, complete with spectral Doppler ec hocardiography, and with color flow Doppler echoca 93307 Echocardiography, transthoracic, real-time with statewide statewide statewide image documentation (2D), includes M-mode recording,when performed, complete, without spectral or col or Doppler echocardiography 93308 Echocardiography, transthoracic, real-time with statewide cohort cohort cohort cohort statewide image documentation (2D), includes M-mode recording,when performed, follow-up or limited study 93312 ECHOCARDIOGRAPHY, TRANSESOPHAGEAL, statewide cohort cohort cohort cohort REAL TIME WITH IMAGEDOCUMENTATION (2D) (WITH OR WITHOUT M-MODE RECORDING); INCLUDING PROBE PLACEMENT, IMAGE ACQUISITION, INTERPRETATION 93320 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE cohort cohort cohort cohort cohort AND/OR CONTINUOUS WAVEWITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); COMPLETE 93321 DOPPLER ECHOCARDIOGRAPHY, PULSED WAVE statewide statewide statewide cohort cohort statewide AND/OR CONTINUOUS WAVEWITH SPECTRAL DISPLAY (LIST SEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHIC IMAGING); FOLLOW-UP OR LIMITED STUDY 93325 DOPPLER ECHOCARDIOGRAPHY COLOR FLOW cohort cohort cohort cohort cohort statewide VELOCITY MAPPING (LISTSEPARATELY IN ADDITION TO CODES FOR ECHOCARDIOGRAPHY) 93350 Echocardiography, transthoracic, real-time with cohort cohort cohort cohort cohort statewide image documentation (2D), includes M-mode recording,when performed, during rest and cardiovascular st ress test using treadmill, bicycle exercise and/or 93351 ECHOCARDIOGRAPHY, TRANSTHORACIC, REAL- cohort cohort cohort cohort statewide TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING,WHEN PERFORMED, DURING REST AND CARDIOVASCULAR ST RESS TEST USING TREADMILL, BICYCLE EXERCISE AND/OR 93451 Right heart catheterization including statewide statewide statewide cohort measurement(s) of oxygen saturation and cardiac output, when performed 93454 Catheter placement in coronary artery(s) for statewide cohort cohort cohort coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; 93455 Catheter placement in coronary artery(s) for statewide statewide statewide coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) i 93456 Catheter placement in coronary artery(s) for statewide statewide statewide cohort coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheteriza 93458 Catheter placement in coronary artery(s) for cohort cohort cohort cohort cohort coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging 89

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 supervision and interpretation; with left heart catheterizat 93459 Catheter placement in coronary artery(s) for statewide statewide cohort cohort cohort coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterizat 93460 Catheter placement in coronary artery(s) for statewide cohort cohort cohort cohort coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart ca 93462 Left heart catheterization by transseptal statewide statewide statewide puncturethrough intact septum or by transapical puncture (List separately in addition to code for primary procedure) 93505 Endomyocardial biopsy cohort 93531 Combined right heart catheterization and cohort retrograde left heart catheterization, for congenital cardiac anomalies 93567 Injection procedure during cardiac statewide cohort cohort cohort catheterizationincluding imaging supervision, interpretation, an d report; for supravalvular aortography (List separately in addition to code for primary procedure) 93568 Injection procedure during cardiac cohort catheterizationincluding imaging supervision, interpretation, an d report; for pulmonary angiography (List separately in addition to code for primary procedure) 93571 INTRAVASCULAR DOPPLER VELOCITY AND/OR statewide cohort cohort cohort PRESSURE DERIVEDCORONARY FLOW RESERVE MEASUREMENT (CORONARY VESSEL OR GRAFT) DURING CORONARY ANGIOGRAPHY INCLUDING PHARMACOLOGICALLY 93572 INTRAVASCULAR DOPPLER VELOCITY AND/OR statewide statewide statewide PRESSURE DERIVEDCORONARY FLOW RESERVE MEASUREMENT (CORONARY VESSEL OR GRAFT) DURING CORONARY ANGIOGRAPHY INCLUDING PHARMACOLOGICALLY 93609 INTRAVENTRICULAR AND/OR INTRA-ATRIAL statewide cohort statewide MAPPING OF TACHYCARDIA SITE(S) WITH CATHETER MANIPULATION TO RECORD FROM MULTIPLE SITES TO IDENTIFY ORIGIN OF TACHYCARDIA 93613 INTRACARDIAC ELECTROPHYSIOLOGIC 3- cohort cohort cohort DIMENSIONAL MAPPING 93620 Comprehensive electrophysiologic evaluation statewide statewide cohort including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and reco 93621 COMPREHENSIVE ELECTROPHYSIOLOGIC cohort cohort cohort EVALUATION WITH RIGHTATRIAL PACING AND RECORDING, RIGHT VENTRICULARPACING AND RECORDING, HIS BUNDLE RECORDING, INCL UDING INSERTION AND 93623 PROGRAMMED STIMULATION AND PACING cohort cohort cohort AFTER INTRAVENOUS DRUGINFUSION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 93641 Electrophysiologic evaluation of single or dual cohort cohort statewide chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing 93653 COMPREHENSIVE ELECTROPHYSIOLOGIC cohort cohort cohort EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RE 93654 COMPREHENSIVE ELECTROPHYSIOLOGIC statewide statewide statewide EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA WITH RIGHT ATRIAL PACING AND RE 93655 INTRACARDIAC CATHETER ABLATION OF A statewide cohort cohort DISCRETE MECHANISM OF ARRHYTHMIA WHICH IS DISTINCT FROM THE PRIMARY ABLATED MECHANISM, INCLUDING REPEAT DIAGNOSTICMANEUVERS, TO TREAT A SPONTANEOUS OR INDUCED ARRH 93656 COMPREHENSIVE ELECTROPHYSIOLOGIC statewide cohort cohort EVALUATION INCLUDING TRANSSEPTAL CATHETERIZATIONS, INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF AN ARRHYTHMIA I 93657 ADDITIONAL LINEAR OR FOCAL INTRACARDIAC statewide cohort statewide CATHETER ABLATION OF THE LEFT OR RIGHT ATRIUM FOR TREATMENT OF ATRIAL FIBRILLATION REMAINING AFTER COMPLETION OF PULMONARY VEIN ISOLATION (LIST SEPARATELY IN AD 93660 Evaluation of cardiovascular function with tilt statewide statewide cohort cohort cohort table evaluation, with continuous ECG monitoring andintermittent blood pressure monitoring, with or w ithout pharmacological intervention 93662 INTRACARDIAC ECHOCARDIOGRAPHY DURING statewide cohort cohort THERAPEUTIC/ DIAGNOSTIC INTERVENTION, INCLUDING IMAGING SUPERVISION AND INTERPRETATION (LIST SEPARATELY INADDITION TO CODE FOR PRIMARY PROCEDURE) 93750 INTERROGATION OF VENTRICULAR ASSIST cohort DEVICE (VAD), IN PERSON, WITH PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL ANALYSIS OF DEVICE PARAMETERS (EG, DRIVELINES, ALARMS, POWER SURGES), REVIEW OF 93799 UNLISTED CARDIOVASCULAR SERVICE OR cohort statewide PROCEDURE 93880 DUPLEX SCAN OF EXTRACRANIAL ARTERIES; cohort cohort cohort cohort cohort statewide COMPLETE BILATERALSTUDY 93886 TRANSCRANIAL DOPPLER STUDY OF THE statewide statewide cohort INTRACRANIAL ARTERIES;COMPLETE STUDY 93922 Limited bilateral noninvasive physiologic studies statewide cohort cohort cohort cohort statewide of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis a 91

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 93923 Complete bilateral noninvasive physiologic cohort cohort cohort cohort statewide statewide studiesof upper or lower extremity arteries, 3 or more l evels (eg, for lower extremity: ankle/brachial indices at distal posterior tibial and anterior tibia 93924 Noninvasive physiologic studies of lower statewide statewide statewide statewide statewide extremityarteries, at rest and following treadmill stress testing, (ie, bidirectional Doppler waveform or volume plethysmography recording and analysis at res 93925 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES statewide cohort cohort cohort statewide statewide OR ARTERIAL BYPASSGRAFTS; COMPLETE BILATERAL STUDY 93926 DUPLEX SCAN OF LOWER EXTREMITY ARTERIES statewide cohort cohort cohort cohort OR ARTERIAL BYPASSGRAFTS; UNILATERAL OR LIMITED STUDY 93931 DUPLEX SCAN OF UPPER EXTREMITY ARTERIES statewide statewide statewide cohort statewide statewide OR ARTERIAL BYPASSGRAFTS; UNILATERAL OR LIMITED STUDY 93965 NON-INVASIVE PHYSIOLOGIC STUDIES OF statewide cohort cohort statewide EXTREMITY VEINS,COMPLETE BILATERAL STUDY(EG, DOPPLER WAVEFORM ANALYSIS WITH RESPONSES TO COMPRESSION AND OTHER MANEUVERS, 93970 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING cohort cohort cohort cohort cohort statewide RESPONSESTOCOMPRESSION AND OTHER MANEUVERS; COMPLETE BILAT ERAL STUDY 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING cohort cohort cohort cohort cohort cohort RESPONSESTOCOMPRESSION AND OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY 93975 DUPLEX SCAN OF ARTERIAL INFLOW AND cohort cohort cohort cohort cohort statewide VENOUS OUTFLOW OFABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY 93976 DUPLEX SCAN OF ARTERIAL INFLOW AND statewide cohort cohort cohort cohort statewide VENOUS OUTFLOW OFABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY 93978 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, statewide statewide statewide cohort cohort statewide ILIAC VASCULATURE,OR BYPASS GRAFTS; COMPLETE STUDY 93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, statewide cohort statewide ILIAC VASCULATURE,OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY 93990 DUPLEX SCAN OF HEMODIALYSIS ACCESS statewide statewide statewide statewide statewide (INCLUDING ARTERIALINFLOW, BODY OF ACCESS AND VENOUS OUTFLOW) 94002 VENTILATION ASSIST AND MANAGEMENT, statewide cohort cohort cohort statewide INITIATION OF PRESSURE OR VOLUME PRESET VENTILATORS FOR ASSISTED OR CONTROLLED BREATHING; HOSPITAL INPATIENT/OBSERVATION, INITIAL DAY 94010 SPIROMETRY, INCLUDING GRAPHIC RECORD, cohort cohort cohort cohort cohort statewide TOTAL AND TIMED VITAL CAPACITY, EXPIRATORY FLOW RATE MEASUREMENT(S), WITH OR WITHOUT MAXIMAL VOLUNTARY VENTILATION 94060 BRONCHOSPASM EVALUATION: SPIROMETRY AS cohort cohort cohort cohort cohort statewide IN 94010, BEFORE AND AFTER BRONCHODILATOR (AEROSOL OR PARENTERAL)

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 94070 PROLONGED POSTEXPOSURE EVALUATION OF statewide cohort cohort cohort cohort BRONCHOSPASM WITHMULTIPLE SPIROMETRIC DETERMINATIONS AFTER ANTIGEN, COLD AIR, METHACHOLINE OR OTHER CHEMICAL AGENT, WITH SUBSEQUENT 94150 VITAL CAPACITY, TOTAL (SEPARATE statewide cohort statewide cohort PROCEDURE) 94200 MAXIMUM BREATHING CAPACITY, MAXIMAL statewide statewide statewide statewide VOLUNTARY VENTILATION 94375 RESPIRATORY FLOW VOLUME LOOP statewide cohort cohort statewide cohort 94620 Pulmonary stress testing; simple (eg, 6-minute statewide statewide statewide cohort cohort walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry 94621 PULMONARY STRESS TESTING; COMPLEX statewide statewide cohort cohort (INCLUDING MEASUREMENTS OFCO2 PRODUCTION, O2 UPTAKE, AND ELECTROCARDIOGRAPHIC RECORDINGS) 94640 PRESSURIZED OR NONPRESSURIZED cohort cohort cohort cohort cohort statewide INHALATION TREATMENTFOR ACUTE AIRWAY OBSTRUCTION FOR THERAPEUTIC PURP OSES AND/OR FOR DIAGNOSTIC PURPOSES SUCH AS SPUTUMINDUCTION WITH AN AEROSOL GENERATOR, NEBULIZER, M 94642 AEROSOL INHALATION OF PENTAMIDINE FOR statewide cohort PNEUMOCYSTISCARINIIPNEUMONIA TREATMENT OR PROPHYLAXIS 94644 CONTINUOUS INHALATION TREATMENT WITH statewide cohort cohort cohort statewide AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; FIRST HOUR 94645 CONTINUOUS INHALATION TREATMENT WITH statewide statewide statewide statewide AEROSOL MEDICATION FOR ACUTE AIRWAY OBSTRUCTION; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 94660 CONTINUOUS POSITIVE AIRWAY PRESSURE cohort cohort cohort cohort cohort statewide VENTILATION (CPAP),INITIATION AND MANAGEMENT 94664 AEROSOL OR VAPOR INHALATIONS FOR cohort cohort cohort cohort cohort statewide SPUTUM MOBILIZATION,BRONCHODILATION, OR SPUTUM INDUCTION FOR DIAGNOSTIC PURPOSES; INITIAL DEMONSTRATION AND/OR EVALUATION 94667 MANIPULATION CHEST WALL, SUCH AS statewide statewide statewide statewide statewide CUPPING, PERCUSSING, ANDVIBRATION TO FACILITATE LUNG FUNCTION; INITIAL DEMONSTRATION AND/OR EVALUATION 94726 PLETHYSMOGRAPHY FOR DETERMINATION OF cohort cohort cohort cohort cohort statewide LUNG VOLUMES AND, WHEN PERFORMED, AIRWAY RESISTANCE 94727 GAS DILUTION OR WASHOUT FOR statewide cohort cohort cohort cohort DETERMINATION OF LUNG VOLUMES AND, WHEN PERFORMED, DISTRIBUTION OF VENTILATION AND CLOSING VOLUMES 94729 DIFFUSING CAPACITY (EG, CARBON MONOXIDE, cohort cohort cohort cohort cohort statewide MEMBRANE)(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 94750 PULMONARY COMPLIANCE STUDY, ANY statewide statewide statewide METHOD

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 94760 NONINVASIVE EAR OR PULSE OXIMETRY FOR cohort cohort cohort cohort cohort cohort OXYGEN SATURATION;SINGLE DETERMINATION 94761 NONINVASIVE EAR OR PULSE OXIMETRY FOR cohort cohort cohort cohort cohort statewide OXYGEN SATURATION;MULTIPLE DETERMINATIONS (EG, DURING EXERCISE) 94762 NONINVASIVE EAR OR PULSE OXIMETRY FOR cohort cohort cohort cohort statewide OXYGEN SATURATION; BY CONTINUOUS OVERNIGHT MONITORING (SEPARATE PROCEDURE) 94770 CARBON DIOXIDE, EXPIRED GAS statewide statewide cohort cohort cohort DETERMINATION BY INFRAREDANALYZER 94799 UNLISTED PULMONARY SERVICE OR cohort cohort cohort statewide cohort statewide PROCEDURE 95004 PERCUTANEOUS TESTS (SCRATCH, PUNCTURE, cohort PRICK) WITHALLERGENIC EXTRACTS, IMMEDIATE TYPE REACTION, INC LUDING TEST INTERPRETATION AND REPORT, SPECIFY NUMBER OF TESTS 95070 INHALATION BRONCHIAL CHALLENGE TESTING cohort statewide cohort (NOT INCLUDINGNECESSARY PULMONARY FUNCTION TESTS); WITH HISTAMINE, METHACHOLINE, OR SIMILAR COMPOUNDS 95115 PROFESSIONAL SERVICES FOR ALLERGEN statewide statewide cohort IMMUNOTHERAPY NOTINCLUDING PROVISION OF ALLERGENIC EXTRACTS; SINGLE INJECTION 95117 PROFESSIONAL SERVICES FOR ALLERGEN statewide statewide cohort IMMUNOTHERAPY NOTINCLUDING PROVISION OF ALLERGENIC EXTRACTS; TWO OR MORE INJECTIONS 95782 POLYSOMNOGRAPHY; YOUNGER THAN 6 YEARS, statewide statewide statewide cohort SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST 95805 MULTIPLE SLEEP LATENCY OR MAINTENANCE OF statewide cohort statewide statewide cohort statewide WAKEFULNESSTESTING, RECORDING, ANALYSIS AND INTERPRETATION OF PHYSIOLOGICAL MEASUREMENTS OF SLEEP DURING MULTIPLE TRIALS 95806 SLEEP STUDY, UNATTENDED, SIMULTANEOUS statewide statewide statewide statewide RECORDING OF, HEART RATE, OXYGEN SATURATION, RESPIRATORY AIRFLOW, AND RESPIRATORY EFFORT (EG, THORACOABDOMINAL MOVEMENT) 95810 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, cohort cohort cohort cohort cohort statewide SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, ATTENDED BY A TECHNOLOGIST 95811 POLYSOMNOGRAPHY; AGE 6 YEARS OR OLDER, cohort cohort cohort cohort cohort statewide SLEEP STAGING WITH 4 OR MORE ADDITIONAL PARAMETERS OF SLEEP, WITH INITIATION OF CONTINUOUS POSITIVE AIRWAY PRESSURE THERAPY OR BILEVEL VENTILATION, ATTENDED BY A 95812 ELECTROENCEPHALOGRAM (EEG) EXTENDED statewide statewide cohort cohort statewide MONITORING; UPTO ONEHOUR 95813 ELECTROENCEPHALOGRAM (EEG) EXTENDED cohort statewide cohort statewide MONITORING; GREATER THANONE HOUR 95816 ELECTROENCEPHALOGRAM (EEG) INCLUDING cohort cohort cohort cohort cohort statewide RECORDING AWAKE ANDDROWSY, WITH

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 HYPERVENTILATION AND/OR PHOTIC STIMULATION 95819 ELECTROENCEPHALOGRAM (EEG) INCLUDING statewide cohort cohort cohort cohort statewide RECORDING AWAKE ANDASLEEP, WITH HYPERVENTILATION AND/OR PHOTIC STIMULATION 95860 NEEDLE ELECTROMYOGRAPHY; 1 EXTREMITY statewide statewide statewide statewide statewide statewide WITH OR WITHOUT RELATED PARASPINAL AREAS 95861 NEEDLE ELECTROMYOGRAPHY, TWO statewide statewide cohort statewide cohort EXTREMITIES WITH OR WITHOUTRELATED PARASPINAL AREAS 95870 NEEDLE ELECTROMYOGRAPHY; LIMITED STUDY statewide cohort statewide statewide OF MUSCLES IN 1 EXTREMITY OR NON-LIMB (AXIAL) MUSCLES (UNILATERAL OR BILATERAL), OTHER THAN THORACIC PARASPINAL, CRANIAL NERVE SUPPLIED MUSCLES, OR SPHINCTERS 95872 NEEDLE ELECTROMYOGRAPHY USING SINGLE cohort FIBER ELECTRODE, WITHQUANTITATIVE MEASUREMENT OF JITTER, BLOCKING AND/OR FIBER DENSITY, ANY/ALL SITES OF EACH MUSCLE STUDIED 95873 ELECTRICAL STIMULATION FOR GUIDANCE IN statewide statewide CONJUNCTIONWITH CHEMODENERVATION (LIST SEPARATELY IN ADDITIO N TO CODE FOR PRIMARY PROCEDURE) 95874 NEEDLE ELECTROMYOGRAPHY FOR GUIDANCE statewide cohort IN CONJUNCTION WITH CHEMODENERVATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 95885 NEEDLE ELECTROMYOGRAPHY, EACH statewide statewide statewide statewide cohort EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; LIMITED (LIST SEPARATELY IN ADDITION TO CODE F 95886 NEEDLE ELECTROMYOGRAPHY, EACH cohort cohort statewide statewide cohort EXTREMITY, WITH RELATED PARASPINAL AREAS, WHEN PERFORMED, DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY; COMPLETE, FIVE OR MORE MUSCLES STUDIED, INNERV 95887 NEEDLE ELECTROMYOGRAPHY, NON-EXTREMITY cohort (CRANIAL NERVE SUPPLIED OR AXIAL) MUSCLE(S) DONE WITH NERVE CONDUCTION, AMPLITUDE AND LATENCY/VELOCITY STUDY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PRO 95907 NERVE CONDUCTION STUDIES; 1-2 STUDIES statewide statewide statewide statewide 95908 NERVE CONDUCTION STUDIES; 3-4 STUDIES statewide statewide statewide statewide cohort 95909 NERVE CONDUCTION STUDIES; 5-6 STUDIES cohort cohort statewide statewide cohort 95910 NERVE CONDUCTION STUDIES; 7-8 STUDIES statewide cohort statewide statewide cohort 95911 NERVE CONDUCTION STUDIES; 9-10 STUDIES statewide cohort statewide statewide cohort 95912 NERVE CONDUCTION STUDIES; 11-12 STUDIES statewide statewide statewide cohort 95913 NERVE CONDUCTION STUDIES; 13 OR MORE statewide statewide statewide statewide cohort STUDIES 95923 TESTING OF AUTONOMIC NERVOUS SYSTEM cohort FUNCTION; SUDOMOTOR, INCLUDING 1 OR MORE OF THE FOLLOWING: QUANTITATIVE SUDOMOTOR AXON REFLEX TEST (QSART), 95

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 SILASTIC SWEAT IMPRINT, THERMOREGULATORY SWEAT TEST, AND 95926 SHORT-LATENCY SOMATOSENSORY EVOKED statewide cohort POTENTIAL STUDY,STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM;IN LOWER LIMBS 95930 VISUAL EVOKED POTENTIAL (VEP) TESTING statewide statewide statewide statewide CENTRAL NERVOUSSYSTEM, CHECKERBOARD OR FLASH 95937 NEUROMUSCULAR JUNCTION TESTING statewide cohort statewide statewide (REPETITIVE STIMULATION, PAIRED STIMULI), EACH NERVE, ANY 1 METHOD 95938 SHORT-LATENCY SOMATOSENSORY EVOKED statewide statewide cohort cohort cohort POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKINSITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS 95939 SHORT-LATENCY SOMATOSENSORY EVOKED statewide cohort statewide statewide POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKINSITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWER LIMBS 95940 CONTINUOUS INTRAOPERATIVE statewide statewide cohort cohort NEUROPHYSIOLOGY MONITORING IN THE OPERATING ROOM, ONE ON ONE MONITORING REQUIRING PERSONAL ATTENDANCE, EACH 15 MINUTES (LISTSEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCED 95941 CONTINUOUS INTRAOPERATIVE statewide cohort statewide statewide NEUROPHYSIOLOGY MONITORING, FROM OUTSIDE THE OPERATING ROOM (REMOTE OR NEARBY) OR FOR MONITORING OF MORE THAN ONE CASE WHILEIN THE OPERATING ROOM, PER HOUR (LIST SEPARATELY 95951 MONITORING FOR LOCALIZATION OF CEREBRAL statewide statewide statewide cohort cohort SEIZURE FOCUS BYCABLE OR RADIO, 16 OR MORE CHANNEL TELEMETRY, COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND 95953 Monitoring for localization of cerebral seizure statewide statewide cohort cohort statewide focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended 95957 DIGITAL ANALYSIS OF statewide statewide statewide statewide ELECTROENCEPHALOGRAM (EEG) (EG, FOREPILEPTIC SPIKE ANALYSIS) 95971 ELECTRONIC ANALYSIS OF IMPLANTED statewide statewide statewide statewide statewide NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE, PULSE DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATI 95972 ELECTRONIC ANALYSIS OF IMPLANTED statewide statewide statewide cohort NEUROSTIMULATOR PULSE GENERATOR SYSTEM (EG, RATE, PULSE AMPLITUDE, PULSE DURATION, CONFIGURATION OF WAVE FORM, BATTERY STATUS, ELECTRODE SELECTABILITY, OUTPUT MODULATI 95978 ANALYZE NEUROSTIM BRAIN / 1 HOUR cohort

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 96101 Psychological testing (includes psychodiagnostic statewide cohort assessment of emotionality, intellectual abilities,personality and psychopathology, e.g., MMPI, Rors chach, WAIS), per hour of the psychologist's or ph 96118 Neuropsychological testing (e.g., Halstead- cohort Reitan Neuropsychological Battery, Wechsler Memory Scalesand Wisconsin Card Sorting Test), per hour of the psychologist's or physician's time, both face-to- 96360 Intravenous infusion, hydration; initial, 31 cohort cohort cohort cohort cohort minutes to 1 hour 96361 Intravenous infusion, hydration; each additional cohort cohort cohort cohort cohort hour (List separately in addition to code for primary procedure) 96365 Intravenous infusion, for therapy, prophylaxis, cohort cohort cohort cohort cohort ordiagnosis (specify substance or drug); initial, u p to 1 hour 96366 Intravenous infusion, for therapy, prophylaxis, cohort cohort cohort cohort cohort ordiagnosis (specify substance or drug); each addit ional hour (List separately in addition to code for primary procedure) 96367 INTRAVENOUS INFUSION, FOR THERAPY, cohort cohort cohort statewide cohort PROPHYLAXIS, ORDIAGNOSIS (SPECIFY SUBSTANCE OR DRUG); ADDITIONAL SEQUENTIAL INFUSION OF A NEW DRUG/SUBSTANCE, UP T O 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR 96368 Intravenous infusion, for therapy, prophylaxis, statewide cohort statewide statewide ordiagnosis (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) 96372 Therapeutic, prophylactic, or diagnostic cohort cohort cohort cohort cohort injection(specify substance or drug); subcutaneous or intr amuscular 96374 Therapeutic, prophylactic, or diagnostic cohort cohort cohort cohort cohort injection(specify substance or drug); intravenous push, si ngle or initial substance/drug 96375 Therapeutic, prophylactic, or diagnostic cohort cohort cohort cohort cohort injection(specify substance or drug); each additional sequ ential intravenous push of a new substance/drug (List separately in addition to code for primary pro 96376 Therapeutic, prophylactic, or diagnostic cohort cohort cohort cohort cohort injection(specify substance or drug); each additional sequ ential intraveous push of the same substance/drug provided in a facility (List separately in additio 96401 CHEMOTHERAPY ADMINISTRATION, cohort cohort cohort cohort cohort SUBCUTANEOUS OR INTRAMUSCULAR; NON- HORMONAL ANTI-NEOPLASTIC 96402 CHEMOTHERAPY ADMINISTRATION, statewide cohort cohort cohort cohort SUBCUTANEOUS OR INTRAMUSCULAR; HORMONAL ANTI-NEOPLASTIC 96409 CHEMOTHERAPY ADMINISTRATION; cohort cohort cohort cohort cohort INTRAVENOUS, PUSH TECHNIQUE, SINGLE OR INITIAL SUBSTANCE/DRUG 96411 CHEMOTHERAPY ADMINISTRATION; cohort cohort cohort cohort cohort INTRAVENOUS, PUSH TECHNIQUE, EACH ADDITIONAL SUBSTANCE/DRUG (LIST

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96413 CHEMOTHERAPY ADMINISTRATION, cohort cohort cohort cohort cohort INTRAVENOUS INFUSION TECHNIQUE; UP TO 1 HOUR, SINGLE OR INITIAL SUBSTANCE/DRUG 96415 CHEMOTHERAPY ADMINISTRATION, cohort cohort cohort cohort cohort INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96416 CHEMOTHERAPY ADMINISTRATION, cohort cohort cohort cohort cohort INTRAVENOUS INFUSION TECHNIQUE; INITIATION OF PROLONGED CHEMOTHERAPY INFUSION (MORE THAN 8 HOURS), REQUIRING USE OF A PORTABLE OR IMPLANTABLE PUMP 96417 CHEMOTHERAPY ADMINISTRATION, cohort cohort cohort cohort cohort INTRAVENOUS INFUSION TECHNIQUE; EACH ADDITIONAL SEQUENTIAL INFUSION (DIFFERENT SUBSTANCE/DRUG), UP TO 1 HOUR (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 96446 Chemotherapy administration into the cohort statewide peritoneal cavity via indwelling port or catheter 96450 CHEMOTHERAPY ADMINISTRATION, INTO CNS statewide cohort cohort (EG, INTRATHECAL),REQUIRING AND INCLUDING LUMBAR PUNCTURE CHEMOTHERAPY ADMINISTRATION, INTO CNS (EG, INTRATHECAL), 96521 REFILLING AND MAINTENANCE OF PORTABLE statewide statewide statewide PUMP 96522 REFILLING AND MAINTENANCE OF statewide statewide IMPLANTABLE PUMP OR RESERVOIR FOR DRUG DELIVERY, SYSTEMIC (EG, INTRAVENOUS, INTRA- ARTERIAL) 96523 IRRIGATION OF IMPLANTED VENOUS ACCESS statewide cohort cohort cohort cohort DEVICE FOR DRUG DELIVERY SYSTEMS 97150 THERAPEUTIC PROCEDURE(S), GROUP (2 OR cohort statewide MORE INDIVIDUALS)THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS) 97597 Debridement (eg, high pressure waterjet cohort cohort cohort cohort cohort cohort with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, de 97598 Debridement (eg, high pressure waterjet statewide cohort cohort cohort statewide statewide with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, de 97602 REMOVAL OF DEVITALIZED TISSUE FROM statewide cohort cohort statewide WOUND;NONSELECTIVE DEBRIDEMENT, WITHOUT ANESTHESIA, WOUND ASSESS-MENT, AND INSTUCTION FOR ONGING CARE, PER SESSION 97605 NEGATIVE PRESSURE WOUND THERAPY (EG, cohort cohort cohort statewide VACUUM ASSISTED DRAINAGE COLLECTION), UTILIZING DURABLE MEDICALEQUIPMENT (DME), INCLUDING TOPICAL APPLICATION(S) , WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 99140 ANESTHESIA COMPLICATED BY EMERGENCY statewide statewide CONDITIONS (SPECIFY)(LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY ANESTHESIA PROCEDURE) 99143 MODERATE SEDATION SERVICES (OTHER THAN statewide statewide statewide cohort cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999) PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTI 99144 MODERATE SEDATION SERVICES (OTHER THAN cohort cohort cohort cohort cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999) PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTI 99145 MODERATE SEDATION SERVICES (OTHER THAN statewide statewide cohort cohort cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999) PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTI 99148 MODERATE SEDATION SERVICES (OTHER THAN statewide statewide cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999), PROVIDED BY APHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSI ONAL OTHER THAN THE HEALTH CARE PROFESSIONAL PERFO 99149 MODERATE SEDATION SERVICES (OTHER THAN statewide statewide statewide cohort cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999), PROVIDED BY APHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSI ONAL OTHER THAN THE HEALTH CARE PROFESSIONAL PERFO 99150 MODERATE SEDATION SERVICES (OTHER THAN statewide statewide cohort THOSE SERVICES DESCRIBED BY CODES 00100- 01999), PROVIDED BY APHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSI ONAL OTHER THAN THE HEALTH CARE PROFESSIONAL PERFO 99173 SCREENING TEST OF VISUAL ACUITY, statewide statewide QUANTITATIVE, BILATERAL 99183 PHYSICIAN OR OTHER QUALIFIED HEALTH CARE statewide cohort cohort cohort statewide statewide PROFESSIONAL ATTENDANCE AND SUPERVISION OF HYPERBARIC OXYGEN THERAPY, PER SESSION 99195 PHLEBOTOMY, THERAPEUTIC (SEPARATE statewide cohort cohort cohort cohort PROCEDURE) 99201 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort statewide statewide cohort statewide EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY;A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD ME 99202 OFFICE OR OTHER OUTPATIENT VISIT FOR THE statewide cohort cohort statewide cohort statewide EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROBLEM FOCUSED EXAMINATION 99203 OFFICE OR OTHER OUTPATIENT VISIT FOR THE statewide cohort cohort cohort cohort statewide EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL DECISION MAKING OF LOW C 99204 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort cohort statewide cohort statewide EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY 99

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKIN 99205 OFFICE OR OTHER OUTPATIENT VISIT FOR THE statewide cohort cohort statewide statewide EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; ACOMPREHENSIVE EXAMINATION; MEDICAL DECISION MAKIN 99211 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort cohort cohort cohort statewide EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN. USUALLY, THE PRESENTING PROBLEM(S) ARE MINIMAL. TYPICALL 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINAT 99213 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY; AN EXPANDED PROB 99214 OFFICE OR OTHER OUTPATIENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; MEDICAL D 99215 OFFICE OR OTHER OUTPATIENT VISIT FOR THE statewide cohort cohort cohort cohort statewide EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT LEAST 2 OF THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; 99217 OBSERVATION CARE DISCHARGE DAY statewide cohort statewide MANAGEMENT (THIS CODE IS TO BE UTILIZED TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM "OBSERVATION STATUS" IF THE DISCHARGE IS ON OTHER THAN THE INITIAL 99218 INITIAL OBSERVATION CARE, PER DAY, FOR THE cohort cohort cohort cohort statewide EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; A 99224 SUBSEQUENT OBSERVATION CARE, PER DAY, cohort statewide FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRESAT LEAST 2 OF THESE 3 KEY COMPONENTS: PROBLEM FOC USED INTERVAL HISTORY; PROBLEM FOCUSED EXAMINATION 99234 OBSERVATION OR INPATIENT HOSPITAL CARE, cohort statewide FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHE 100

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 99244 OFFICE CONSULTATION FOR A NEW OR statewide statewide statewide ESTABLISHED PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; ANDMEDICAL DECISION MAKING OF MODERATE COMPLEXITY. C 99281 EMERGENCY DEPARTMENT VISIT FOR THE cohort cohort cohort cohort cohort statewide EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEMFOCUSED EXAMINATION; AND STRAIGHTFORWARD MEDICAL 99282 EMERGENCY DEPARTMENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY;AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDI 99283 EMERGENCY DEPARTMENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HISTORY;AN EXPANDED PROBLEM FOCUSED EXAMINATION; AND MEDI 99284 EMERGENCY DEPARTMENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED HISTORY; A DETAILED EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE CO 99285 EMERGENCY DEPARTMENT VISIT FOR THE cohort cohort cohort cohort cohort cohort EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY THEURGENCY OF THE PATIENT'S CLINICAL CONDITION AND/O 99291 CRITICAL CARE, EVALUATION AND cohort cohort cohort cohort cohort statewide MANAGEMENT OF THE UNSTABLECRITICALLY ILL OR UNSTABLE CRITICALLY INJURED PATIENT, REQUIRING THE CONSTANT ATTENDANCE OF THE PHYSICIAN; FIRST 99292 CRITICAL CARE, EVALUATION AND statewide cohort cohort statewide statewide MANAGEMENT OF THE CRITICALLYILL OR CRITICALLY INJURED PATIENT, REQUIRING THE CONSTANT ATTENDANCE OF THE PHYSICIAN; EACHADDITIONAL 30 MINUTES 99401 PREVENTIVE MEDICINE COUNSELING AND/OR cohort RISK FACTOR REDUCTION INTERVENTION(S) PROVIDED TO AN INDIVIDUAL (SEPARATE PROCEDURE); APPROXIMATELY 15 MINUTES A0425 GROUND MILEAGE , PER STATUTE MILE cohort cohort cohort cohort A0426 AMBULANCE SERVICE, ADVANCED LIFE statewide cohort cohort cohort SUPPORT, NON- EMERGENCY TRANSPORT, LEVEL 1 (ALS 1) A0427 AMBULANCE SERVICE, ADVANCED LIFE cohort cohort cohort cohort SUPPORT, EMERGENCY TRANSPORT LEVEL 1 A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, statewide cohort cohort cohort NON- EMERGENCY TRANSPORT (BLS) A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, cohort cohort cohort statewide EMERGENCY TRANSPORT (BLS- EMERGENCY

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CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 A0431 AMBULANCE SERVICE, CONVENTIONAL AIR cohort SERVICES, TRANSPORT, ONE WAY (ROTARY WING) A0433 ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2) statewide cohort cohort statewide A0434 SPECIALTY CARE TRANSPORT (SCT) statewide statewide cohort cohort A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE cohort A4212 NON-CORING NEEDLE OR STYLET WITH OR statewide statewide WITHOUT CATHETER A4216 STERILE WATER, SALINE AND/OR DEXTROSE, cohort cohort cohort statewide cohort statewide DILUENT/FLUSH, 10 ML A4217 STERILE WATER/SALINE, 500 ML statewide cohort cohort statewide statewide statewide A4264 PERMANENT IMPLANTABLE CONTRACEPTIVE statewide statewide statewide statewide statewide INTRATUBAL OCCLUSION DEVICE(S) AND DELIVERY SYSTEM A4300 IMPLANTABLE ACCESS CATHETER (VENOUS, statewide statewide ARTERIAL, EPIDURAL ORPERITONEAL), EXTERNAL ACCESS A4306 DISPOSABLE DRUG DELIVERY SYSTEM, FLOW statewide statewide RATE OF LESSTHAN 50 ML PER HOUR A4314 INSERTION TRAY WITH DRAINAGE BAG WITH statewide statewide statewide statewide statewide INDWELLING CATHETER,FOLEY TYPE, TWO-WAY LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER OR HYDROPHILIC, ETC.) A4338 INDWELLING CATHETER; FOLEY TYPE, TWO-WAY statewide statewide statewide LATEX WITH COATING (TEFLON, SILICONE, SILICONE ELASTOMER, OR HYDROPHILIC, ETC.), EACH A4344 INDWELLING CATHETER, FOLEY TYPE, TWO- statewide statewide cohort WAY, ALL SILICONE, EACH A4550 SURGICAL TRAYS statewide statewide statewide statewide A4565 SLINGS cohort statewide cohort A4615 CANNULA, NASAL statewide cohort A4648 Tissue marker, implantable, any type, each cohort cohort cohort cohort cohort statewide A4649 SURGICAL SUPPLY; MISCELLANEOUS statewide statewide statewide statewide A6021 Collagen dressing, sterile, size 16 sq. In. Or less, statewide statewide each A6022 Collagen dressing, sterile, size more than 16 sq. statewide statewide statewide In. But less than or equal to 48 sq. In. , each A6196 ALGINATE OR OTHER FIBER GELLING DRESSING, statewide cohort statewide statewide WOUND COVER, STERILE, PAD SIZE 16 SQ.IN. OR LESS, EACH DRESSING A6197 ALGINATE OR OTHER FIBER GELLING DRESSING, statewide cohort statewide statewide WOUND COVER, STERILE, PAD SIZE MORE THAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6209 FOAM DRESSING, WOUND COVER, STERILE, PAD statewide statewide statewide statewide SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6210 FOAM DRESSING, WOUND COVER, STERILE, PAD statewide statewide statewide statewide SIZE MORETHAN 16 SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., WITHOUT ADHESIVE BORDER, EACH DRESSING A6212 FOAM DRESSING, WOUND COVER, STERILE, PAD statewide cohort statewide SIZE 16 SQ. IN. OR LESS, WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6213 FOAM DRESSING, WOUND COVER, STERILE, PAD statewide statewide SIZE MORETHAN 16 SQ. IN. BUT LESS THAN OR

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CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 EQUAL TO 48 SQ. IN., WITH ANY SIZE ADHESIVE BORDER, EACH DRESSING A6222 GAUZE, IMPREGNATED WITH OTHER THAN statewide statewide WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH A6223 GAUZE, IMPREGNATED WITH OTHER THAN statewide statewide statewide WATER, NORMAL SALINE, OR HYDROGEL, STERILE, PAD SIZE MORE THAN 16SQ INCHES, WITHOUT ADHESIVE BORDER, EACH DRESSING A6234 HYDROCOLLOID DRESSING, WOUND COVER, statewide statewide STERILE, PAD SIZE 16 SQ. IN. OR LESS, WITHOUT ADHESIVE BORDER, EACH DRESSING A6240 HYDROCOLLOID DRESSING, WOUND FILLER, cohort statewide statewide PASTE, STERILE, PER OUNCE A6248 HYDROGEL DRESSING, WOUND FILLER, GEL, PER statewide statewide FLUID OUNCE A6257 TRANSPARENT FILM, STERILE, 16 SQ. IN. OR statewide statewide LESS, EACH DRESSING A6258 TRANSPARENT FILM, STERILE, MORE THAN 16 statewide statewide SQ. IN. BUT LESS THAN OR EQUAL TO 48 SQ. IN., EACH DRESSING A6448 LIGHT COMPRESSION BANDAGE, ELASTIC, statewide statewide KNITTED/WOVEN,WIDTH LESS THAN THREE A6449 LIGHT COMPRESSION BANDAGE, ELASTIC, statewide statewide statewide KNITTED/WOVEN,WIDTH GREATER THAN OR EQUAL A6453 SELF-ADHERENT BANDAGE, ELASTIC, NON- statewide statewide KNITTED/NON-WOVEN, WIDTH LESS THAN THREE A6456 ZINC PASTE IMPREGNATED BANDAGE, NON- statewide statewide statewide ELASTIC, KNITTED/WOVEN, WIDTH GREATER THAN OR EQUAL TO THREE INCHES AND LESS THAN FIVE INCHES, PER YARD A9150 NON-PRESCRIPTION DRUGS cohort cohort cohort statewide statewide A9270 NON-COVERED ITEM OR SERVICE cohort cohort cohort cohort cohort statewide A9500 TECHNETIUM TC-99M SESTAMIBI, DIAGNOSTIC, cohort cohort cohort cohort cohort PER STUDYDOSE A9502 TECHNETIUM TC-99M TETROFOSMIN, statewide cohort cohort cohort statewide DIAGNOSTIC, PER STUDY DOSE A9503 TECHNETIUM TC-99M MEDRONATE, cohort cohort cohort cohort cohort statewide DIAGNOSTIC, PER STUDYDOSE, UP TO 30 MILLICURIES A9509 Iodine I-123 Sodium Iodide, diagnostic, per statewide statewide statewide millicurie A9512 TECHNETIUM TC-99M PERTECHNETATE, statewide cohort cohort cohort cohort DIAGNOSTIC, PER MILLICURIE A9516 Iodine I-123 Sodium Iodide, diagnostic, per 100 statewide cohort cohort statewide statewide microcuries, up to 999 microcuries A9517 IODINE I-131 SODIUM IODIDE CAPSULE(S), statewide cohort cohort cohort THERAPEUTIC, PER MILLICURIE A9520 Technetium tc-99m, tilmanocept, diagnostic, up statewide statewide cohort to 0.5 millicuries A9528 IODINE I-131 SODIUM IODIDE CAPSULE(S), statewide statewide cohort cohort statewide DIAGNOSTIC,PER MILLICURIE A9531 IODINE I-131 SODIUM IODIDE, DIAGNOSTIC, PER statewide statewide cohort cohort cohort MICROCURIE (UP TO 100 MICROCURIES)

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CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 A9537 TECHNETIUM TC-99M MEBROFENIN, cohort cohort cohort cohort cohort statewide DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES A9539 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, statewide cohort cohort statewide PER STUDYDOSE, UP TO 25 MILLICURIES A9540 TECHNETIUM TC-99M MACROAGGREGATED statewide cohort cohort cohort cohort statewide ALBUMIN, DIAGNOSTIC, PER STUDY DOSE, UP TO 10 MILLICURIES A9541 TECHNETIUM TC-99M SULFUR COLLOID, cohort cohort cohort cohort cohort statewide DIAGNOSTIC, PER STUDY DOSE, UP TO 20 MILLICURIES A9552 FLUORODEOXYGLUCOSE F-18 FDG, DIAGNOSTIC, statewide cohort cohort cohort cohort PER STUDYDOSE, UP TO 45 MILLICURIES A9558 XENON XE-133 GAS, DIAGNOSTIC, PER 10 statewide cohort cohort cohort cohort MILLICURIES A9560 TECHNETIUM TC-99M LABELED RED BLOOD statewide cohort cohort cohort cohort statewide CELLS, DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES A9561 TECHNETIUM TC-99M OXIDRONATE, statewide cohort cohort statewide statewide DIAGNOSTIC, PER STUDY DOSE, UP TO 30 MILLICURIES A9562 TECHNETIUM TC-99M MERTIATIDE, statewide cohort cohort cohort cohort statewide DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES A9567 TECHNETIUM TC-99M PENTETATE, DIAGNOSTIC, statewide statewide statewide statewide cohort statewide AEROSOL, PER STUDY DOSE, UP TO 75 MILLICURIES A9572 Indium IN-111 Pentetreotide, diagnostic, per statewide statewide statewide statewide studydose up to 6 millicuries A9577 Injection, Gadobenate Dimeglumine statewide cohort statewide (Multihance), per ml A9579 Injection, Gadolinium-based magnetic statewide statewide statewide resonance contrast agent, not other wise specified (NOS), per ml A9581 INJECTION, GADOXETATE DISODIUM, 1 ML statewide statewide A9585 INJECTION, GADOBUTROL, 0.1 ML cohort statewide C1300 Hyperbaric oxygen under pressure, full body statewide cohort cohort cohort statewide statewide chamber, per 30 minute interval C1713 C CODE VALID FOR UB CLAIMS ONLY. cohort cohort cohort cohort cohort cohort ANCHOR/SCREW FOR OPPOSING BONE-TO- BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) C1717 C code valid for UB claims only cohort cohort cohort C1721 C code valid for UB claims only statewide cohort cohort C1722 C code valid for UB claims only statewide statewide cohort cohort C1724 C code valid for UB claims only statewide statewide statewide statewide statewide C1725 CATHETER, TRANSLUMINAL ANGIOPLASTY, statewide cohort cohort cohort cohort statewide NON-LASER (MAYINCLUDE GUIDANCE, INFUSION/PERFUSION CAPABILITY) (FOR FACILITY USE ONLY) C1726 C code valid for UB claims only statewide cohort cohort cohort cohort statewide C1727 C code valid for UB claims only statewide cohort cohort statewide C1729 C CODE VALID FOR UB CLAIMS ONLY. CATHETER, statewide cohort cohort cohort cohort statewide DRAINAGE. C1730 C CODE VALID FOR UB CLAIMS ONLY. CATHETER, cohort cohort cohort cohort ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (19 OR FEWER ELECTRODES)

104

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 C1731 C CODE VALID FOR UB CLAIMS ONLY. CATHETER, cohort cohort cohort ELECTROPHYSIOLOGY, DIAGNOSTIC, OTHER THAN 3D MAPPING (20 OR MORE ELECTRODES) C1732 C CODE VALID FOR UB CLAIMS ONLY CATHETER, cohort cohort cohort ELECTROPHYSIOLOGY, DIAGNOSTIC/ABLATION, 3D OR VECTOR MAPPING C1733 C code valid for UB claims only cohort cohort cohort C1750 C code valid for UB claims only statewide statewide statewide statewide cohort statewide C1751 C CODE VALID FOR UB CLAIMS ONLY statewide cohort cohort cohort cohort statewide C1752 C code valid for UB claims only statewide statewide cohort C1753 C code valid for UB claims only statewide statewide cohort cohort cohort statewide C1755 C code valid for UB claims only statewide statewide cohort statewide statewide C1757 CATHETER, THROMBECTOMY/EMBOLECTOMY. C statewide statewide statewide statewide CODE VALID FOR UB CLAIMS ONLY C1758 C code valid for UB claims only cohort cohort cohort cohort cohort statewide C1759 C code valid for UB claims only cohort cohort cohort C1760 C code valid for UB claims only statewide cohort cohort cohort cohort statewide C1762 C code valid for UB claims only statewide cohort cohort cohort cohort statewide C1763 C code valid for UB claims only cohort statewide cohort cohort statewide C1764 C code valid for UB claims only statewide cohort cohort cohort C1765 C code valid for UB claims only statewide cohort cohort statewide statewide statewide C1766 C code valid for UB claims only statewide cohort cohort cohort C1767 C CODE VALID FOR UB CLAIMS ONLY statewide statewide statewide statewide cohort C1768 C code valid for UB claims only statewide statewide statewide statewide statewide statewide C1769 C CODE VALID FOR UB CLAIMS ONLY. GUIDE cohort cohort cohort cohort cohort statewide WIRE C1771 C code valid for UB claims only statewide cohort cohort cohort cohort statewide C1773 C code valid for UB claims only statewide cohort cohort cohort statewide C1776 C CODE VALID FOR UB CLAIMS ONLY. JOINT cohort cohort cohort cohort statewide DEVICE (IMPLANTABLE) C1777 C code valid for UB claims only statewide statewide cohort cohort C1778 C CODE VALID FOR UB CLAIMS ONLY statewide cohort cohort statewide cohort statewide C1780 LENS, INTRAOCULAR (NEW TECHNOLOGY) [C statewide cohort cohort cohort statewide CODES FOR FACILITY CLAIMS ONLY] C1781 C CODE VALID FOR UB CLAIMS ONLY. MESH cohort cohort cohort cohort cohort statewide (IMPLANATABLE) C1782 C code valid for UB claims only cohort cohort statewide cohort C1783 C code valid for UB claims only statewide statewide statewide statewide C1784 C code valid for UB claims only statewide statewide statewide C1785 C code valid for UB claims only statewide statewide cohort cohort C1787 C code valid for UB claims only statewide statewide statewide statewide statewide C1788 C code valid for UB claims only cohort cohort cohort cohort cohort statewide C1789 C code valid for UB claims only statewide cohort cohort cohort statewide C1813 C code valid for UB claims only statewide statewide statewide statewide statewide statewide C1814 C CODES VALID FOR UB ONLY statewide statewide statewide statewide C1819 C code valid for UB claims only cohort statewide C1820 Generator, neurostimulator (implantable), non statewide cohort statewide statewide statewide high-frequency with rechargeable battery and charging system C1874 C code valid for UB claims only statewide cohort cohort cohort cohort statewide C1876 C CODE VALID FOR UB CLAIMS ONLY statewide cohort cohort cohort cohort statewide C1880 C code valid for UB claims only statewide statewide statewide statewide

105

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 C1882 C CODE VALID FOR UB CLAIMS ONLY. statewide statewide cohort statewide CARDIOVERTER-DEFIBRILLATOR, OTHER THAN SINGLE OR DUAL CHAMBER (IMPLANTABLE) C1884 C code valid for UB claims only statewide statewide statewide statewide C1886 CATHETER, EXTRAVASCULAR TISSUE ABLATION, statewide statewide statewide ANY MODALITY (INSERTABLE) [C codes used by facilities only] C1887 CATHETER, GUIDING(MAY INCLUDE statewide cohort cohort cohort cohort statewide INFUSION/PERFUSION CAPABILITY). C CODE VALID FOR UB CLAIMS ONLY. C1892 C code valid for UB claims only statewide cohort cohort cohort statewide C1893 C code valid for UB claims only statewide cohort cohort cohort C1894 C CODE VALID FOR UB CLAIMS ONLY. cohort cohort cohort cohort cohort statewide INTRODUCER/SHEATH, OTHER THAN GUIDING, OTHER THAN INTRACARDIAC ELECTROPHYSIOLOGICAL, NONLASER C1895 C code valid for UB claims only statewide cohort statewide C1898 C code valid for UB claims only statewide cohort cohort cohort statewide C1900 C CODE VALID FOR UB CLAIMS ONLY. LEAD, LEFT statewide statewide cohort statewide VENTRICULAR CORONARY VENOUS SYSTEM C2615 C code valid for UB claims only statewide cohort cohort statewide statewide statewide C2617 C code valid for UB claims only cohort cohort cohort cohort cohort statewide C2618 Probe/needle, cryoablation statewide statewide statewide cohort C2625 C code valid for UB claims only statewide cohort statewide cohort statewide C2628 C code valid for UB claims only statewide statewide cohort statewide C2630 C code valid for UB claims only statewide cohort cohort C8908 C code valid for UB claims only statewide cohort cohort C8923 C code valid for UB claims only statewide statewide statewide C8928 C code valid for UB claims only statewide statewide cohort cohort statewide C8929 C CODE VALID FOR UB CLAIMS ONLY. statewide cohort cohort statewide cohort statewide TRANSTHORACIC ECHOCARDIOGRAPHY WITH CONTRAST, OR WITHOUT CONTRAST FOLLOWED BY WITH CONTRAST, REAL-TIME WITH IMAGE DOCUMENTATION (2D), INCLUDES M-MODE RECORDING, WHEN C8930 C Code valid for UB claims only statewide statewide statewide C9113 C CODE VALID FOR UB CLAIMS ONLY statewide cohort cohort C9290 Injection, bupivacaine liposome, 1 mg [C codes cohort statewide valid with facility claims only] C9600 Percutaneous transcatheter placement of drug statewide cohort cohort cohort cohort eluting intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery orbranch [C code for facility claims only] D392 ESOPHAGITIS, GASTROENT & MISC DIGEST statewide statewide statewide statewide statewide DISORDERS W/OMCC D951 Other factors influencing health status statewide statewide E0110 CRUTCHES, FOREARM, INCLUDES CRUTCHES OF statewide statewide VARIOUS MATERIALS,ADJUSTABLE OR FIXED, PAIR, COMPLETE WITH TIPS AND HANDGRIPS E0112 CRUTCHES, UNDERARM, WOOD, ADJUSTABLE statewide statewide statewide OR FIXED, PAIR, WITHPADS, TIPS AND HANDGRIPS E0114 CRUTCHES UNDERARM, OTHER THAN WOOD, statewide cohort statewide ADJUSTABLE OR FIXED,PAIR, WITH PADS, TIPS AND HANDGRIPS

106

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 E0218 WATER CIRCULATING COLD PAD WITH PUMP statewide cohort statewide G0008 ADMINISTRATION OF INFLUENZA VIRUS cohort cohort cohort cohort cohort statewide VACCINE G0009 ADMINISTRATION OF PNEUMOCOCCAL VACCINE statewide cohort cohort cohort statewide statewide G0010 ADMINISTRATION OF HEPATITIS B VACCINE statewide statewide G0105 COLORECTAL CANCER SCREENING; cohort cohort cohort statewide statewide COLONOSCOPY ON INDIVIDUAL ATHIGH RISK G0108 DIABETES OUTPATIENT SELF-MANAGEMENT cohort statewide TRAINING SERVICES,INDIVIDUAL, PER SESSION G0121 COLORECTAL CANCER SCREENING; cohort cohort cohort statewide statewide statewide COLONOSCOPY ON INDIVIDUAL NOTMEETING CRITERIA FOR HIGH RISK G0168 WOUND CLOSURE UTILIZING TISSUE statewide statewide cohort ADHESIVE(S) ONLY G0202 SCREENING MAMOGRAPHY PRODUCING DIRECT cohort cohort cohort cohort cohort statewide DIGITAL IMAGE, BILATERAL ALL VIEWS. G0204 Diagnostic mammography, producing direct 2-d cohort cohort cohort cohort cohort statewide digital image, bilateral, all views G0206 Diagnostic mammography, producing direct 2-d cohort cohort cohort cohort cohort statewide digital image, unilateral, all views G0237 THERAPEUTIC PROCEDURES TO INCREASE statewide cohort cohort cohort cohort STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, FACE TO FACE ONE ON ONE EACH 15 MINUTES (INCLUDES MONITORING) G0238 THERAPEUTIC PROCEDURES TO IMPROVE statewide cohort cohort cohort cohort RESPIRATORY FUNCTION, OTHER THAN DESCRIBED BY G0237 ONE ON ONEFACE TO FACE PER 15 MINUTES (INCLUDES MONITORING) G0239 THERAPEUTIC PROCEDURES TO IMPROVE cohort cohort cohort cohort statewide RESPIRATORY FUNCTION, OTHER THAN SERVICES DESCRIBED BY G0237 TWO OR MORE (INCLUDING MONITORING) G0260 INJECTION PROCEDURE FOR SACROILIAC JOINT; statewide cohort cohort cohort statewide PROVISION OF ANESTHETIC, STEROID G0269 PLACEMENT OF OCCLUSIVE DEVICE INTO EITHER statewide statewide statewide cohort statewide A VENOUS OR ARTIERIAL ACCESS SITE G0277 Hyperbaric oxygen under pressure, full body cohort cohort cohort cohort cohort cohort chamber, per 30 minute interval G0364 BONE MARROR ASPIRATE & BIOPSY statewide statewide statewide statewide statewide G0378 HOSPITAL OBSERVATION SERVICE, PER HOUR cohort cohort cohort cohort cohort statewide G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL cohort cohort cohort cohort cohort statewide OBSERVATION CARE G0380 Level I hospital emergency department visit statewide statewide statewide statewide provided in a type B emergency department; (The ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is loc G0381 Level 2 hospital emergency department visit statewide statewide statewide provided in a type B emergency department; (The ED must meet at least one of the following requirements: G0382 Level 3 hospital emergency department visit statewide statewide cohort provided in a type B emergency department; (The ED must meet at least one of the following requirements: G0383 Level 4 hospital emergency department visit cohort statewide cohort provided in a type B emergency department; 107

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 (The ED must meet at least one of the following requirements: G0384 Level 5 hospital emergency department visit statewide statewide statewide provided in a type B emergency department; (The ED must meet at least one of the following requirements: G0389 ULTRASOUND B-SCAN AND/OR REAL TIME WITH statewide statewide statewide statewide statewide IMAGE DOCUMENTATION; FOR ABDOMINAL AORTIC ANEURYSM (AAA) SCREENING G0390 TRAUMA RESPONSE TEAM ASSOCIATED WITH statewide statewide cohort cohort HOSPITAL CRITICAL CARE SERVICE G0424 PULMONARY REHABILITATION, INCLUDING cohort cohort cohort cohort cohort EXERCISE (INCLUDES MONITORING), ONE HOUR, PER SESSION, G0463 Hospital outpatient clinic visit for assessment cohort cohort cohort cohort cohort cohort and management of a patient G6001 Ultrasonic guidance for placement of radiation statewide statewide statewide therapy fields G6002 Stereoscopic X-ray guidance for localization of statewide statewide statewide target volume for the delivery of radiation therapy G6011 Radiation treatment delivery,3 or more separate cohort cohort statewide statewide treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5MeV G6012 Radiation treatment delivery,3 or more separate cohort treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10MeV G6015 Intensity modulated treatment delivery, single statewide cohort cohort statewide cohort or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session G6016 Compensator-based beam modulation cohort treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session J0131 INJECTION, ACETAMINOPHEN, 10 MG statewide statewide cohort statewide statewide J0153 Injection, adenosine, 1 mg (not to be used to statewide statewide statewide statewide statewide report any adenosine phosphate compounds) J0171 INJECTION, ADRENALIN, EPINEPHRINE, 0.1 MG statewide cohort cohort statewide statewide J0280 INJECTION, AMINOPHYLLIN, UP TO 250 MG statewide statewide statewide J0290 INJECTION, AMPICILLIN SODIUM, statewide statewide statewide statewide J0295 INJECTION, AMPICILLIN SODIUM/SULBACTAM statewide statewide cohort statewide statewide SODIUM, PER1.5 GM J0330 INJECTION, SUCCINYLCHOLINE CHLORIDE, UP TO cohort cohort cohort statewide cohort statewide 20 MG J0360 INJECTION, HYDRALAZINE HCL, UP TO 20 MG statewide cohort cohort statewide cohort statewide J0456 AZITHROMYCIN- INJECTION, AZITHROMYCIN, statewide statewide statewide statewide statewide statewide 500 MG J0461 INJECTION, ATROPINE SULFATE, 0.01 MG statewide cohort cohort statewide cohort statewide J0500 INJECTION, DICYCLOMINE HCL, UP TO 20 MG statewide cohort cohort statewide statewide J0561 INJECTION, PENICILLIN G BENZATHINE, 100,000 statewide cohort statewide cohort statewide statewide UNITS J0583 INJECTION BIVALIRUDIN 1MG statewide statewide statewide statewide statewide J0585 INJECTION, ONABOTULINUMTOXINA, 1 UNIT statewide cohort

108

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 J0595 INJECTION BUTORPHANOL TARTRATE 1 MG statewide statewide statewide statewide J0610 INJECTION, CALCIUM GLUCONATE, PER 10 ML statewide cohort statewide statewide cohort J0640 INJECTION, LEUCOVORIN CALCIUM, PER 50 MG statewide cohort statewide statewide cohort J0670 INJECTION, MEPIVACAINE HYDROCHLORIDE, statewide statewide statewide statewide statewide PER 10 ML J0690 INJECTION, CEFAZOLIN SODIUM, cohort cohort cohort statewide cohort cohort J0692 INJECTION, CEFEPIME HYDROCHLORIDE, statewide statewide statewide statewide statewide statewide 500MG. J0694 INJECTION, CEFOXITIN SODIUM, 1 GM statewide cohort cohort statewide J0696 INJECTION, CEFTRIAXONE SODIUM, PER 250 MG cohort cohort cohort cohort cohort statewide J0697 INJECTION, STERILE CEFUROXIME SODIUM, PER statewide statewide statewide 750 MG J0702 Injection, Betamethasone Acetate 3 mg and statewide statewide statewide statewide cohort Betamethasone Sodium Phosphate 3 mg J0744 INJECTION CIPROFLOXACIN FOR INTRAVENOUS cohort cohort cohort statewide cohort statewide INFUSION 200MG J0780 INJECTION, PROCHLORPERAZINE, UP TO 10 MG cohort cohort cohort cohort J0833 INJECTION, COSYNTROPIN, NOT OTHERWISE cohort SPECIFIED, 0.25 MG J0878 DAPTOMYCIN INJECTION 1MG statewide statewide statewide J0881 INJECTION, DARBEPOETIN ALFA, 1 MICROGRAM statewide statewide statewide cohort (NON-ESRDUSE) J0885 INJECTION, EPOETIN ALFA, (FOR NON-ESRD statewide statewide USE), 1000 UNITS J0897 INJECTION, DENOSUMAB, 1 MG [Prolia] [XGEVA] statewide statewide statewide statewide J1030 INJECTION, METHYLPREDNISOLONE ACETATE, statewide cohort statewide cohort 40 MG J1040 INJECTION, METHYLPREDNISOLONE ACETATE, statewide cohort statewide statewide statewide 80 MG J1050 Injection, medroxyprogesterone acetate, 1 mg statewide statewide statewide statewide J1071 INJECTION, TESTOSTERONE CYPIONATE, 1MG statewide statewide J1100 INJECTION, DEXAMETHOSONE SODIUM cohort cohort cohort cohort cohort cohort PHOSPHATE, UP TO 4MG/ML J1110 INJECTION, DIHYDROERGOTAMINE MESYLATE, statewide statewide statewide PER 1 MG J1170 INJECTION, HYDROMORPHONE, UP TO 4 MG cohort cohort cohort cohort cohort statewide J1200 INJECTION, DIPHENHYDRAMINE HCL, cohort cohort cohort statewide cohort J1250 INJECTION, DOBUTAMINE HYDROCHLORIDE, statewide statewide statewide statewide statewide PER 250 MG J1300 Injection, Eculizumab, 10 mg statewide statewide statewide J1335 INJECTION ERTAPENEM SODIUM 500MG statewide cohort statewide statewide statewide J1442 Injection, filgrastim (g-csf), excludes biosimilars, statewide statewide statewide 1 microgram J1446 Injection, tbo-filgrastim, 5 micrograms statewide statewide J1453 INJECTION, FOSAPREPITANT, 1 MG statewide statewide statewide statewide statewide J1561 Injection, immune globulin, (gamunex- statewide statewide statewide c/gammaked), non-lyophilized (e. g. Liquid), 500 mg J1580 INJECTION, GARAMYCIN, GENTAMICIN, UP TO cohort cohort cohort statewide cohort statewide 80 MG J1610 INJECTION, GLUCAGON HYDROCHLORIDE, PER 1 statewide statewide statewide statewide statewide MG J1630 INJECTION, HALOPERIDOL, UP TO 5 MG statewide cohort statewide cohort statewide statewide

109

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 J1642 INJECTION, HEPARIN SODIUM, (HEPARIN LOCK statewide cohort cohort cohort cohort statewide FLUSH), PER 10UNITS J1644 INJECTION, HEPARIN SODIUM, PER 1000 UNITS cohort cohort cohort statewide cohort cohort J1650 INJECTION, ENOXAPARIN SODIUM, 10 MG cohort cohort cohort cohort statewide J1720 INJECTION, HYDROCORTISONE cohort statewide statewide cohort J1725 INJECTION, HYDROXYPROGESTERONE statewide statewide CAPROATE, 1 MG [Makena] J1745 INJECTION INFLIXIMAB, 10MG statewide statewide cohort statewide cohort J1750 INJECTION, IRON DEXTRAN, 50MG statewide statewide statewide J1756 INJECTION IRON SUCROSE 1 MG. statewide statewide statewide statewide statewide J1815 INJECTION INSULIN PER 5 UNITS statewide cohort cohort cohort cohort statewide J1885 INJECTION, KETOROLAC TROMETHAMINE, PER cohort cohort cohort statewide cohort 15 MG J1940 INJECTION, FUROSEMIDE, UP TO 20 MG statewide cohort cohort statewide cohort J1950 INJECTION, LEUPROLIDE ACETATE (FOR DEPOT statewide statewide statewide SUSPENSION), PER3.75 MG J1953 INJECTION, LEVETIRACETAM, 10 MG statewide statewide statewide statewide J1956 INJECTION, LEVOFLOXACIN, 250 MG statewide cohort cohort statewide statewide J2001 INJECTION LIDOCAINE HCL FOR INTRAVENOUS cohort cohort cohort statewide statewide statewide INFUSION 10 MG J2060 INJECTION, LORAZEPAM, 2 MG cohort cohort cohort cohort cohort statewide J2150 INJECTION, MANNITOL, 25% IN 50 ML statewide statewide statewide cohort statewide J2175 INJECTION, MEPERIDINE HYDROCHLORIDE, PER cohort cohort cohort statewide statewide statewide 100 MG J2210 INJECTION, METHYLERGONOVINE MALEATE, UP statewide statewide statewide statewide TO 0.2 MG J2250 INJECTION, MIDAZOLAM HYDROCHLORIDE, PER cohort cohort cohort statewide cohort statewide 1 MG J2270 INJECTION, MORPHINE SULFATE, UP TO 10 MG cohort cohort cohort statewide cohort cohort J2274 Injection, morphine sulfate, preservative-free statewide statewide statewide statewide statewide forepidural or intrathecal use, 10mg J2310 INJECTION, NALOXONE HYDROCHLORIDE, PER 1 statewide cohort statewide statewide statewide statewide MG J2323 Injection, Natalizumab, 1 mg statewide statewide statewide J2353 INJECTION OCTREOTIDE DEPOT FORM FOR statewide statewide statewide INTRAMUSCULAR INJECTION 1 MG J2360 INJECTION, ORPHENADRINE CITRATE, UP TO 60 statewide cohort statewide MG J2370 INJECTION, PHENYLEPHRINE HCL, UP TO 1 ML statewide cohort cohort cohort cohort statewide J2405 INJECTION, ONDANSETRON HYDROCHLORIDE, cohort cohort cohort cohort cohort PER 1 MG J2430 INJECTION, PAMIDRONATE DISODIUM, PER 30 statewide statewide MG J2469 PALONOSETRON HCL INJECTION, 25MCG statewide cohort statewide statewide statewide J2505 INJECTION PEGFILGRASTIM 6 MG cohort statewide statewide statewide J2543 INJECTION, PIPERACILLIN statewide statewide cohort statewide cohort SODIUM/TAZOBACTAM SODIUM, 1 GRAM0.125 GRAMS (1.125 GRAMS) J2550 INJECTION, PROMETHAZINE HCL, UP TO 50 MG statewide cohort cohort statewide cohort J2590 INJECTION, OXYTOCIN, UP TO 10 UNITS statewide statewide statewide statewide statewide J2704 Injection, propofol, 10 mg cohort cohort cohort cohort cohort cohort J2710 INJECTION, NEOSTIGMINE METHYLSULFATE, UP cohort cohort cohort statewide cohort statewide TO 0.5 MG

110

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 J2720 INJECTION, PROTAMINE SULFATE, PER 10 MG statewide statewide statewide cohort statewide J2765 INJECTION, METOCLOPRAMIDE HCL, UP TO 10 cohort cohort cohort statewide cohort cohort MG J2780 INJECTION, RANITIDINE HYDROCHLORIDE, 25 statewide statewide statewide statewide MG J2785 INJECTION, REGADENOSON, 0.1 MG statewide cohort cohort statewide statewide J2795 INJECTION, ROPIVACAINE HYDROCHLORIDE, 1 cohort cohort statewide cohort MG J2800 INJECTION, METHOCARBAMOL, UP TO 10 ML statewide statewide statewide statewide J2805 INJECTION, SINCALIDE, 5 MICROGRAMS cohort cohort statewide statewide J2916 INJECTION SODIUM FERRIC GLUCONATE statewide statewide statewide statewide statewide COMPLEX IN SUCROSE INJECTION 12.5 MG J2920 INJECTION, METHYLPREDNISOLONE SODIUM statewide cohort statewide statewide cohort statewide SUCCINATE, UPTO 40 MG J2930 INJECTION, METHYLPREDNISOLONE SODIUM statewide cohort cohort statewide cohort SUCCINATE, UPTO 125 MG J2997 INJECTION, ALTEPLASE RECOMBINANT, 1 MG statewide statewide statewide statewide statewide J3010 INJECTION, FENTANYL CITRATE, UP TO 2 ML cohort cohort cohort cohort cohort cohort J3030 INJECTION, SUMATRIPTAN SUCCINATE, 6 MG, statewide statewide statewide statewide statewide ADMINISTERED UNDERDIRECT PHYSICIAN SUPERVISION, EXCLUDES SELF ADMINISTRATION J3105 INJECTION, TERBUTALINE SULFATE, UP TO 1 MG. statewide cohort statewide statewide statewide J3240 INJECTION, THYROTROPIN, UP TO 10 I.U. statewide cohort statewide J3260 INJECTION, TOBRAMYCIN SULFATE, UP TO 80 statewide statewide statewide MG J3300 INJECTION, TRIAMCINOLONE ACETONIDE, statewide statewide PRESERVATIVE FREE, 1MG J3301 INJECTION, TRIAMCINOLONE ACETONIDE, NOT statewide cohort cohort cohort cohort statewide OTHERWISESPECIFIED, 10 MG J3315 INJECTION TRIPTORELIN PAMOATE 3.75 MG. statewide statewide J3360 INJECTION, DIAZEPAM, UP TO 5 MG statewide cohort cohort statewide statewide statewide J3370 INJECTION, VANCOMYCIN HCL, UP TO 500 MG statewide cohort cohort cohort cohort statewide J3411 INJECTION THIAMINE HCL 100MG statewide statewide cohort statewide statewide statewide J3420 INJECTION, VITAMIN B-12 CYANOCOBALAMIN, cohort cohort statewide cohort UP TO 1000MCG J3473 INJECTION, HYALURONIDASE, RECOMBINANT, 1 statewide statewide USP UNIT J3475 INJECTION, MAGNESIUM SULFATE, PER 500 MG statewide cohort cohort statewide statewide J3480 INJECTION, POTASSIUM CHLORIDE, PER 2 MEQ cohort cohort cohort cohort cohort statewide J3489 Injection, zoledronic acid, 1 mg statewide statewide statewide J3490 UNCLASSIFIED DRUGS cohort cohort cohort cohort cohort cohort J3590 UNCLASSIFIED BIOLOGICS statewide statewide statewide statewide J7030 INFUSION, NORMAL SALINE SOLUTION, 1000 CC cohort cohort cohort cohort cohort statewide J7040 INFUSION, NORMAL SALINE SOLUTION, STERILE cohort cohort cohort cohort cohort statewide (500 ML=1 UNIT) J7042 5% DEXTROSE/NORMAL SALINE (500 ML = 1 statewide cohort cohort cohort cohort statewide UNIT) J7050 INFUSION, NORMAL SALINE SOLUTION, 250 CC cohort cohort cohort cohort cohort statewide J7060 5% DEXTROSE/WATER (500 ML = 1 UNIT) cohort cohort cohort statewide cohort statewide J7070 INFUSION, D5W, 1000 CC statewide cohort cohort cohort J7120 RINGERS LACTATE INFUSION, UP TO 1000 CC cohort cohort cohort cohort cohort statewide J7302 Levonorgestrel-releasing intrauterine statewide statewide statewide cohort contraceptive system, 52 mg

111

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 J7307 Etonogestrel (contraceptive) Implant System, statewide cohort including implant and supplies J7506 Prednisone, oral, per 5 mg cohort cohort cohort cohort statewide J7510 PREDNISOLONE ORAL, PER 5 MG statewide cohort cohort cohort cohort J7611 Albuterol, inhalation solution, FDA-approved statewide statewide statewide statewide statewide finalproduct, non-compounded, administered through DME , concentrated form, 1 mg J7612 Levalbuterol, inhalation solution, FDA-approved statewide statewide cohort statewide final product, non-compounded, administered through DME, unit dose, 1 mg J7613 Albuterol, inhalation solution, FDA-approved cohort cohort statewide cohort finalproduct, non-compounded, administered through DME , unit dose, 1 mg J7620 ALBUTEROL, UP TO 2.5 MG AND IPRATROPIUM statewide cohort statewide cohort BROMIDE, UP TO 0.5 MG, FDA-APPROVED J7642 GLYCOPYRROLATE, INHALATION SOLUTION, cohort COMPOUNDED PRODUCT, ADMINISTERED THROUGH J7644 IPRATROPIUM BROMIDE, INHALATION statewide cohort cohort statewide statewide SOLUTION, FDA-APPROVED FINAL PRODUCT, J8499 PRESCRIPTION DRUG, ORAL, NON statewide statewide statewide CHEMOTHERAPEUTIC, NOS J8501 APREPITANT, ORAL, 5MG statewide statewide statewide statewide J8540 DEXAMETHASONE, ORAL, 0.25 MG statewide cohort cohort cohort cohort statewide J8597 ANTIEMETIC DRUG, ORAL, NOT OTHERWISE statewide statewide SPECIFIED J9000 INJECTION, DOXORUBICIN HYDROCHLORIDE, 10 statewide statewide statewide statewide MG J9031 BCG (INTRAVESICAL) PER INSTILLATION statewide statewide J9033 INJECTION, BENDAMUSTINE HCL, 1 MG statewide statewide statewide statewide J9035 BEVACIZUMAB INJECTION, 10MG statewide statewide statewide statewide J9040 INJECTION, BLEOMYCIN SULFATE, 15 UNITS statewide statewide statewide J9041 BORTEZOMIB INJECTION, 0.1 MG statewide statewide statewide J9045 INJECTION, CARBOPLATIN, 50 MG statewide statewide statewide statewide statewide J9060 INJECTION, CISPLATIN, POWDER OR S0LUTION, statewide statewide statewide statewide 10 MG J9070 CYCLOPHOSPHAMIDE, 100 MG statewide statewide statewide cohort J9130 DACARBAZINE, 100 MG statewide statewide statewide J9155 INJECTION, DEGARELIX, 1 MG statewide statewide J9171 INJECTION, DOCETAXEL, 1 MG statewide statewide statewide cohort J9179 INJECTION, ERIBULIN MESYLATE, 0.1 MG statewide statewide J9181 INJECTION, ETOPOSIDE, 10 MG statewide statewide statewide statewide J9190 INJECTION, FLUOROURACIL, 500 MG statewide statewide statewide statewide J9201 INJECTION, GEMCITABINE HYDROCHLORIDE, 200 statewide statewide statewide cohort MG J9202 GOSERELIN ACETATE IMPLANT, PER 3.6 MG statewide statewide J9206 INJECTION, IRINOTECAN, 20 MG statewide statewide statewide statewide J9217 LEUPROLIDE ACETATE (FOR DEPOT statewide cohort statewide statewide SUSPENSION), 7.5 MG J9250 METHOTREXATE SODIUM, 5 MG statewide cohort J9263 INJECTION OXALIPLATIN 0.5 MG statewide statewide statewide statewide J9264 INJECTION, PACLITAXEL PROTEIN-BOUND statewide statewide statewide PARTICLES, 1 MG J9265 Injection, paclitaxel, 30 mg statewide statewide statewide statewide 112

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 J9267 Injection, paclitaxel, 1 mg statewide statewide statewide statewide statewide J9303 Injection, Panitumumab, 10 mg statewide statewide J9305 PEMETREXED INJECTION, 10MG statewide statewide statewide statewide cohort J9306 Injection, pertuzumab, 1 mg statewide statewide statewide J9310 INJECTION, RITUXIMAB, 100 MG statewide statewide statewide statewide cohort J9330 INJECTION, TEMSIROLIMUS, 1 MG statewide statewide J9351 INJECTION, TOPOTECAN, 0.1 MG statewide statewide statewide statewide J9355 INJECTION, TRASTUZUMAB, 10 MG statewide statewide statewide statewide J9360 INJECTION, VINBLASTINE SULFATE, 1 MG statewide statewide statewide J9370 VINCRISTINE SULFATE, 1 MG statewide statewide cohort J9395 INJECTION, FULVESTRANT, 25 MG statewide statewide statewide L0120 Cervical, flexible, non-adjustable, statewide statewide statewide statewide statewide prefabricated,off-the-shelf (foam collar) L0172 Cervical, collar, semi-rigid thermoplastic foam, statewide statewide cohort statewide statewide two-piece, prefabricated, off-the-shelf L0174 Cervical, collar, semi-rigid, thermoplastic foam, statewide statewide statewide two piece with thoracic extension, prefabricated, off-the-shelf L0625 Lumbar orthosis, flexible, provides lumbar statewide cohort support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closu L1830 Knee orthosis, immobilizer, canvas longitudinal, statewide cohort cohort cohort statewide statewide prefabricated, off-the-shelf L1902 Ankle orthosis, ankle gauntlet or similiar, with or statewide statewide statewide cohort without joints, prefabricated, off-the-shelf L1930 AFO, PLASTIC statewide statewide statewide L2999 LOWER EXTREMITY ORTHOSES, NOT statewide statewide OTHERWISE SPECIFIED L3260 AMBULATORY SURGICAL BOOT, EACH statewide statewide statewide statewide L3660 Shoulder orthosis, figure of eight design statewide statewide statewide statewide abduction restrainer, canvas and webbing, prefabricated, off-the-shelf L3670 Shoulder orthosis, acromio/clavicular (canvas statewide statewide statewide statewide statewide and webbing type), prefabricated, off-the-shelf L3808 WRIST HAND FINGER ORTHOSIS, RIGID statewide statewide statewide statewide statewide WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE MATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT L3908 Wrist hand orthosis, wrist extension control statewide cohort statewide cohort statewide cock-up, non molded, prefabricated, off-the- shelf L4350 Ankle control orthosis, stirrup style, rigid, statewide statewide statewide statewide statewide includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf L4386 Walking boot, non-pneumatic, with or without statewide statewide statewide statewide statewide joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific pa L8000 Breast prosthesis, mastectomy bra, without statewide statewide integrated breast prosthesis form, any size, any type L8600 IMPLANTABLE BREAST PROSTHESIS, SILICONE statewide statewide statewide statewide statewide statewide OR EQUAL 113

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 L8612 AQUEOUS SHUNT statewide statewide L8614 COCHLEAR DEVICE, INCLUDES ALL INTERNAL statewide statewide cohort AND EXTERNAL COMPONENTS L8699 PROSTHETIC IMPLANT, NOT OTHERWISE statewide cohort statewide SPECIFIED P9045 INFUSION ALBUMIN (HUMAN), 5%, 250 ML. statewide statewide statewide P9047 INFUSION ALBUMIN (HUMAN) 25%, 50ML. statewide statewide statewide statewide statewide P9612 CATHETERIZATION FOR COLLECTION OF cohort cohort statewide cohort SPECIMEN, SINGLEPATIENT, ALL PLACES OF SERVICE Q0114 FERN TEST statewide statewide statewide Q0138 INJECTION, FERUMOXYTOL, FOR TREATMENT OF statewide statewide IRON DEFICIENCY ANEMIA, 1 MG (FOR NON- ESRD ON DIALYSIS) Q0144 AZITHROMYCIN DIHYDRATE, ORAL, cohort cohort cohort statewide statewide statewide CAPSULES/POWDER, 1 GRAM Q0162 ONDANSETRON 1 MG, ORAL, FDA APPROVED cohort cohort cohort cohort cohort cohort PRESCRIPTION ANTI-EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY TREATMENT NOT TO EXCEED A 48 HOUR DOSAGE R Q0163 DIPHENHYDRAMINE HYDROCHLORIDE, 50 MG, statewide cohort statewide statewide statewide ORAL, FDA APPROVEDPRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETICAT TIME OF CHEMOTHERAPY Q0169 PROMETHAZINE HYDROCHLORIDE, 12.5 MG, statewide statewide statewide statewide ORAL, FDA APPROVEDPRESCRIPTION ANTI- EMETIC, FOR USE AS A COMPLETE THERAPEUTIC SUBSTITUTE FOR AN IV ANTI-EMETIC AT THE TIME OF CHEMOTHERAPY Q3014 TELEHEALTH ORIGINATING SITE FACILITY FEE cohort cohort cohort statewide statewide Q9957 INJECTION, PERFLUTREN LIPID MICROSPHERES, statewide statewide statewide PER ML Q9958 HIGH OSMOLAR CONTRAST MATERIAL, UP TO cohort statewide cohort 149 MG/ML IODINE CONCENTRATION PER ML Q9963 HIGH OSMOLAR CONTRAST MATERIAL, 350-399 statewide cohort statewide MG/ML IODINE CONCENTRATION PER ML Q9966 Low osmolar contrast material, 200-299 mg/ml cohort statewide statewide iodine concentration, per ml Q9967 Low osmolar contrast material, 300-399 mg/ml cohort cohort cohort statewide statewide iodine concentration, per ml Q9968 INJECTION, NON-RADIOACTIVE, NON- cohort cohort statewide statewide CONTRAST, VISUALIZATION ADJUNCT (E.G., METHYLENE BLUE, ISOSULFAN BLUE), 1 MG Q9974 Injection, morphine sulfate, preservative-free statewide statewide statewide forepidural or intrathecal use, 10 mg S0020 INJECTION, BUPIVICAINE HYDROCHLORIDE, 30 cohort cohort cohort statewide statewide cohort ML S0028 INJECTION FAMOTIDINE 20 MG. cohort cohort cohort statewide cohort statewide S0030 INJECTION METRONIDAZOLE, 500MG statewide cohort statewide statewide statewide S0077 INJECTON CLINDAMYCIN PHOSPHATE 300MG. cohort cohort cohort cohort statewide S0164 INJECTION, PANTOPRAZOLE SODIUM, 40 MG statewide statewide statewide S2083 ADJUSTMENT OF GASTRIC BAND DIAMETER VIA statewide cohort statewide statewide SUBCUT- ANEOUS PORT BY INJECTION OR ASPIRATION OF SALINE

114

CPT Description Peer Peer Peer Peer Peer Peer Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5 Cohort 6 S2900 SURGICAL TECHNIQUES REQUIRING USE OF statewide cohort cohort cohort statewide ROBOTICS SURGICAL SYSTEM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) S8032 Low-dose Computed Tomography For Lung statewide statewide statewide statewide Cancer Screening S9443 LACTATION CLASSES, NON-PHYSICIAN PROVIDER cohort statewide cohort PER SESSION S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, statewide statewide PER DIEM V2632 POSTERIOR CHAMBER INTRAOCULAR LENS cohort cohort cohort cohort cohort statewide V2785 PROCESSING, PRESERVING AND TRANSPORTING statewide statewide statewide statewide cohort CORNEAL TISSUE V2787 Astigmatism correcting function of intraocular statewide cohort statewide cohort statewide lens V2788 PRESBYOPIA CORRECTING FUNCTION OF statewide statewide statewide cohort statewide INTRAOCULAR LENS V5264 EAR MOLD/INSERT NOT DISPOSABLE ANY TYPE statewide cohort V5267 Hearing aid supplies / accessories statewide statewide V5299 HEARING SERVICE, MISCELLANEOUS statewide cohort

Appendix

2019 and 2020 Quality Thresholds for Facilities

Methodology: 1. Pull in 13 measures from Hospital Compare and risk adjusted readmission rates from BCBSNC claims data for each individual hospital 2. Allocate points for each measure by individual hospital based on scoring key 3. Determine total maximum (weighted) points achievable by hospital (i.e. if hospital has valid value for 14 of 14 measures, the maximum (weighted) points they can earn would be 75) 4. Sum earned points for each hospital 5. Determine hospital score by dividing total points earned by maximum achievable points. Score is in the form of a percentage.

Scoring Key: 1 point: less than 25th percentile 2 points: greater than or equal to 25th percentile, less than 50th percentile 3 points: greater than or equal to 50th percentile, less than 75th percentile 4 points: greater than or equal to 75th percentile, less than 90th percentile 5 points: greater than or equal to 90th percentile * Unless otherwise specified

Note: data is limited to general acute care facilities

Measures: MEASURE_ID MEASURE_DESC HAI1 CLABSI HAI2 CAUTI

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HA15 MRSA Blood Lab Identified Events HAI6 C Diff. Lab Identified Events PSI90 PSI 90 Surgical Complications Composite Score. Deaths among patients with serious treatable complications PSI4 after surgery (PSI04)

Patients who reported that staff "Always" explained about medicines before giving it to them (HCAHPS) H_COMP_5_A_P

Patients who reported that YES, they were given information about what to do during their recovery at home (HCAHPS) H_COMP_6_Y_P Patients who "Strongly Agree" they understood their care when H_COMP_7_SA they left the hospital (HCAHPS)

Percent of Patients Rating Hospital 9 or 10 (HCAHPS) HSP_9_10

All Cause 30-Day Unplanned Readmission Rate (risk-adjusted) READMISSIONS

Surgical Site Infections from Abdominal Hysterectomy Rate HAI4 HAI3 Surgical Site Infections from Colon Surgery Rate *Uses 10th, 25th, 50th, and 75th percentiles since 75th and 90th percentiles are 0 ELECT_DELIV39** Elective Delivery Prior to 39 Weeks Rate **Uses 0.5th, 10th, 25th, 50th, percentiles since 50th, 75th and 90th percentiles are 0

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