Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee 300-399 MG/ML IODINE CONCENTRATE Q9967 Q9967 320 50.00 100.00 50.00 ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, WITH OR WITHOUT ENDOSCOPIC 51845 51845 360 100.00 0.00 CONTROL (EG, STAMEY, RAZ, MODIFIED PEREYRA) ABLATION, ONE OR MORE LIVER TUMOR(S), 47382 47382 360 100.00 0.00 PERCUTANEOUS, RADIOFREQUENCY ABLATION, OPEN, OF ONE OR MORE LIVER 47381 47381 360 100.00 0.00 TUMOR(S); CRYOSURGICAL ABLATION, OPEN, OF ONE OR MORE LIVER 47380 47380 360 100.00 0.00 TUMOR(S); RADIOFREQUENCY ABRASION; EACH ADDITIONAL FOUR LESIONS OR LESS (LIST SEPARATELY IN ADDITION TO 15787 15787 360 100.00 0.00 CODE FOR PRIMARY PROCEDURE) ABRASION; SINGLE LESION (EG, KERATOSIS, 15786 15786 360 100.00 0.00 SCAR) ACETABULOPLASTY; (EG, WHITMAN, COLONNA, 27120 27120 360 100.00 0.00 HAYGROVES, OR CUP TYPE) ACETABULOPLASTY; RESECTION, FEMORAL 27122 27122 360 100.00 0.00 HEAD (EG, GIRDLESTONE PROCEDURE) ACETONE OTHER KETONE BODIES 82009 82009 301 60.00 100.00 60.00 ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL, WITH OR WITHOUT 23130 23130 360 17,250.00 100.00 17,250.00 CORACOACROMIAL LIGAMENT RELEASE ACTH 82024 82024 301 300.00 100.00 300.00 ACUTE HEPATITIS PANEL 80074 80074 300 1,210.00 100.00 1,210.00 ADAPT/EXT, PACING OR NEUROSTIMULATOR C1883-G C1883 278 700.00 0.00 LEAD IMPLANTABLE ADAPTER/EXT, PACING OR NEUROSTIMULATOR C1883-W C1883 278 100.00 0.00 LEAD IMPLANTABLE ADENOIDECTOMY, PRIMARY; AGE 12 OR OVER 42831 42831 360 8,900.00 100.00 8,900.00

ADENOIDECTOMY, PRIMARY; UNDER AGE 12 42830 42830 360 17,100.00 100.00 17,100.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ADENOIDECTOMY, SECONDARY; AGE 12 OR 42836 42836 360 8,900.00 100.00 8,900.00 OVER ADENOIDECTOMY, SECONDARY; UNDER AGE 12 42835 42835 360 8,900.00 100.00 8,900.00 ADHESION BARRIER C1765-W C1765 278 100.00 0.00 ADHESION BARRIER C1765-G C1765 278 700.00 0.00 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; DEFECT 30.1 SQ 14301 14301 360 15,400.00 100.00 15,400.00 CM TO 60.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, ANY AREA; EACH ADDITIONAL 30.0 SQ CM, OR PART THEREOF 14302 14302 360 13,540.00 100.00 13,540.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS 14060 14060 360 10,160.00 100.00 10,160.00 AND/OR LIPS; DEFECT 10 SQ CM OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS 14061 14061 360 13,540.00 100.00 13,540.00 AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, 14040 14040 360 8,470.00 100.00 8,470.00 MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS

ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, 14041 14041 360 13,630.00 100.00 13,630.00 MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ CM, 14300 14300 360 100.00 0.00 UNUSUAL OR COMPLICATED, ANY AREA ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; 14020 14020 360 6,770.00 100.00 6,770.00 DEFECT 10 SQ CM OR LESS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; 14021 14021 360 10,900.00 100.00 10,900.00 DEFECT 10.1 SQ CM TO 30.0 SQ CM ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM 14000 14000 360 6,770.00 100.00 6,770.00 OR LESS ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM 14001 14001 360 10,160.00 100.00 10,160.00 TO 30.0 SQ CM ADJUSTMENT OR REVISION OF EXTERNAL FIXATION SYSTEM REQUIRING ANESTHESIA (EG, 20693 20693 360 7,500.00 100.00 7,500.00 NEW PIN(S) OR WIRE(S) AND/OR NEW RING(S) OR BAR(S)) ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR 60540 60540 360 100.00 0.00 WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE);

ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR 60545 60545 360 100.00 0.00 WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL (SEPARATE PROCEDURE); WIT ADVERSE REACTION WORKUP 86078 86900 305 850.00 100.00 850.00 AEROBIC CULTURE, QUANTITATIVE 87071 87071 306 180.00 100.00 180.00 AEROSOL INHALATION PENTAMIDIN 94642 94642 460 800.00 100.00 800.00 AFB STAIN-ACID FAST BACILLUS 87206 87206 306 120.00 100.00 120.00 AFP FRACT ISOFORM/TOT AFP 82107 82107 301 450.00 100.00 450.00 ALBUMIN 82040 82040 301 50.00 100.00 50.00 Albumin; urine or other source, quantitative, each 82042 82042 307 50.00 100.00 50.00 specimen ALCOHOL-ASSAY OF ETHANOL 82055 82055 301 220.00 100.00 220.00 ALK PHOS 84075 84075 301 50.00 100.00 50.00 ALLERGEN SPECIFIC IGE 86003 86003 302 80.00 100.00 80.00 ALLERGEN SPECIFIC IGG 86001 86001 302 60.00 100.00 60.00 ALLOGRAFT FOR SPINE SURGERY ONLY; 20930 20930 360 5,500.00 100.00 5,500.00 MORSELIZED Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ALLOGRAFT FOR SPINE SURGERY ONLY; 20931 20931 360 100.00 0.00 STRUCTURAL ALPHA FETOPROTEIN SERUM 82105 82105 301 340.00 100.00 340.00 ALPHA-1 ANTITRYPSIN PHENO 82104 82104 301 410.00 100.00 410.00 ALT SGPT 84460 84460 301 50.00 100.00 50.00 ALVEOLECTOMY, INCLUDING CURETTAGE OF 41830 41830 360 100.00 0.00 OSTEITIS OR SEQUESTRECTOMY ALVEOLOPLASTY, EACH QUADRANT (SPECIFY) 41874 41874 360 100.00 0.00 AMINO ACIDS, MULTIPLE QUALITATIVE, EACH 82128 82128 301 119.91 100.00 119.91 SPECIMEN AMMONIA 82140 82140 180.00 100.00 180.00 AmnioBand or Guardian, per sq cm Q4151-G Q4151 636 700.00 0.00 AmnioBand or Guardian, per sq cm - W Q4151-W Q4151 636 100.00 0.00 Amnioband, 1 mg Q4168-G Q4168 636 700.00 0.00 Amnioband, 1 mg- W Q4168-W Q4168 278 700.00 0.00 AmnioMatrix or BioDMatrix, injectable 1 cc Q4139-W Q4139 278 100.00 0.00 AmnioMatrix or BioDMatrix, injectable, 1 cc Q4139 Q4139 636 700.00 0.00 Amniotic membrane for surgical reconstruction, per V2790-G V2790 278 700.00 0.00 procedure ( Amniotic membrane ) Amniotic membrane for surgical reconstruction, per V2790-W V2790 278 100.00 0.00 procedure ( Amniotic membrane )- W AMPUTATION OF PENIS, RADICAL; IN CONTINUITY WITH BILATERAL PELVIC 54135 54135 360 100.00 0.00 LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES AMPUTATION OF PENIS, RADICAL; WITH BILATERAL INGUINOFEMORAL 54130 54130 360 100.00 0.00 LYMPHADENECTOMY AMPUTATION OF PENIS; COMPLETE 54125 54125 360 100.00 0.00 AMPUTATION OF PENIS; PARTIAL 54120 54120 360 100.00 0.00

AMPUTATION, ANKLE, THROUGH MALLEOLI OF TIBIA AND FIBULA (EG, SYME, PIROGOFF TYPE 27888 27888 360 100.00 0.00 PROCEDURES), WITH PLASTIC CLOSURE AND RESECTION OF NERVES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee AMPUTATION, ARM THROUGH HUMERUS; OPEN, 24920 24920 360 100.00 0.00 CIRCULAR (GUILLOTINE) AMPUTATION, ARM THROUGH HUMERUS; RE- 24930 24930 360 100.00 0.00 AMPUTATION AMPUTATION, ARM THROUGH HUMERUS; 24925 24925 360 100.00 0.00 SECONDARY CLOSURE OR SCAR REVISION AMPUTATION, ARM THROUGH HUMERUS; WITH 24931 24931 360 100.00 0.00 IMPLANT AMPUTATION, ARM THROUGH HUMERUS; WITH 24900 24900 360 100.00 0.00 PRIMARY CLOSURE AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, 26951 26951 360 6,380.00 100.00 6,380.00 INCLUDING NEURECTOMIES; WITH DIRECT CLOSURE AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, 26952 26952 360 7,440.00 100.00 7,440.00 INCLUDING NEURECTOMIES; WITH LOCAL ADVANCEMENT FLAPS (V-Y, HOOD) AMPUTATION, FOOT; MIDTARSAL (EG, CHOPART 28800 28800 360 100.00 0.00 TYPE PROCEDURE) AMPUTATION, FOOT; TRANSMETATARSAL 28805 28805 360 10,030.00 100.00 10,030.00 AMPUTATION, FOREARM, THROUGH RADIUS 25900 25900 360 100.00 0.00 AND ULNA; AMPUTATION, FOREARM, THROUGH RADIUS 25905 25905 360 100.00 0.00 AND ULNA; OPEN, CIRCULAR (GUILLOTINE) AMPUTATION, FOREARM, THROUGH RADIUS 25909 25909 360 100.00 0.00 AND ULNA; RE-AMPUTATION AMPUTATION, FOREARM, THROUGH RADIUS AND ULNA; SECONDARY CLOSURE OR SCAR 25907 25907 360 100.00 0.00 REVISION AMPUTATION, LEG, THROUGH TIBIA AND 27880 27880 360 21,800.00 100.00 21,800.00 FIBULA; AMPUTATION, LEG, THROUGH TIBIA AND 27882 27882 360 100.00 0.00 FIBULA; OPEN, CIRCULAR (GUILLOTINE) AMPUTATION, LEG, THROUGH TIBIA AND 27886 27886 360 21,800.00 100.00 21,800.00 FIBULA; RE-AMPUTATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR 27884 27884 360 100.00 0.00 REVISION AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; WITH IMMEDIATE FITTING TECHNIQUE 27881 27881 360 100.00 0.00 INCLUDING APPLICATION OF FIRST CAST

AMPUTATION, METACARPAL, WITH FINGER OR THUMB (RAY AMPUTATION), SINGLE, WITH OR 26910 26910 360 10,150.00 100.00 10,150.00 WITHOUT INTEROSSEOUS TRANSFER

AMPUTATION, METATARSAL, WITH TOE, SINGLE 28810 28810 360 8,000.00 100.00 8,000.00 AMPUTATION, THIGH, THROUGH FEMUR, ANY 27590 27590 360 100.00 0.00 LEVEL; AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMEDIATE FITTING TECHNIQUE 27591 27591 360 100.00 0.00 INCLUDING FIRST CAST AMPUTATION, THIGH, THROUGH FEMUR, ANY 27592 27592 360 100.00 0.00 LEVEL; OPEN, CIRCULAR (GUILLOTINE) AMPUTATION, THIGH, THROUGH FEMUR, ANY 27596 27596 360 100.00 0.00 LEVEL; RE-AMPUTATION AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECONDARY CLOSURE OR SCAR 27594 27594 360 100.00 0.00 REVISION AMPUTATION, TOE; INTERPHALANGEAL JOINT 28825 28825 360 8,000.00 100.00 8,000.00 AMPUTATION, TOE; METATARSOPHALANGEAL 28820 28820 360 8,000.00 100.00 8,000.00 JOINT AMYLASE 82150 82150 301 70.00 100.00 70.00 ANASTOMOSIS, CHOLEDOCHAL CYST, WITHOUT 47716 47716 360 100.00 0.00 EXCISION ANASTOMOSIS, OF EXTRAHEPATIC BILIARY 47760 47760 360 100.00 0.00 DUCTS AND GASTROINTESTINAL TRACT ANASTOMOSIS, OF INTRAHEPATIC DUCTS AND 47765 47765 360 100.00 0.00 GASTROINTESTINAL TRACT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC BILIARY DUCTS AND GASTROINTESTINAL 47780 47780 360 100.00 0.00 TRACT ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC BILIARY DUCTS AND GASTROINTESTINAL 47785 47785 360 100.00 0.00 TRACT ANASTOMOSIS; FACIAL-HYPOGLOSSAL 64868 64868 360 100.00 0.00 ANASTOMOSIS; FACIAL-PHRENIC 64870 64870 360 100.00 0.00 ANASTOMOSIS; FACIAL-SPINAL ACCESSORY 64866 64866 360 100.00 0.00 ANCHOR, SCREWS, PLATES, RODS, CAGES, C1713-W C1713 278 100.00 0.00 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE C1713-G C1713 278 700.00 0.00 OR SOFT TISSUE-TO-BONE(IMPLANTALBE) ANKLE ARTHOGRAM S&I 73615 73615 320 1,550.00 100.00 1,550.00 ANKLE DISARTICULATION 27889 27889 360 100.00 0.00 ANOPLASTY, PLASTIC OPERATION FOR 46700 46700 360 100.00 0.00 STRICTURE; ADULT ANORECTAL MYOMECTOMY 45108 45108 360 100.00 0.00 ANOSCOPY; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR 46600 46600 360 100.00 0.00 WASHING (SEPARATE PROCEDURE)

ANOSCOPY; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE 46615 46615 360 100.00 0.00 TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE

ANOSCOPY; WITH BIOPSY, SINGLE OR MULTIPLE 46606 46606 360 3,800.00 100.00 3,800.00 ANOSCOPY; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR 46614 46614 360 100.00 0.00 CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) ANOSCOPY; WITH DILATION (EG, BALLOON, 46604 46604 360 100.00 0.00 GUIDE WIRE, BOUGIE) ANOSCOPY; WITH REMOVAL OF FOREIGN BODY 46608 46608 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ANOSCOPY; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR OTHER LESIONS BY HOT 46612 46612 360 100.00 0.00 BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY 46610 46610 360 7,600.00 100.00 7,600.00 FORCEPS OR BIPOLAR CAUTERY ANOSCOPY; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY SNARE 46611 46611 360 100.00 0.00 TECHNIQUE ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE WITH OR WITHOUT REPAIR OF 57240 57240 360 18,200.00 100.00 18,200.00 URETHROCELE ANTERIOR INSTRUMENTATION; 2 TO 3 22845 22845 360 24,400.00 100.00 24,400.00 VERTEBRAL SEGMENTS ANTERIOR INSTRUMENTATION; 4 TO 7 22846 22846 360 100.00 0.00 VERTEBRAL SEGMENTS ANTERIOR INSTRUMENTATION; 8 OR MORE 22847 22847 360 100.00 0.00 VERTEBRAL SEGMENTS ANTERIOR TIBIAL TUBERCLEPLASTY (EG, 27418 27418 360 17,250.00 100.00 17,250.00 MAQUET TYPE PROCEDURE) ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL-MARCHETTI- 51841 51841 360 100.00 0.00 KRANTZ, BURCH); COMPLICATED (EG, SECONDARY REPAIR) ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (EG, MARSHALL-MARCHETTI- 51840 51840 360 100.00 0.00 KRANTZ, BURCH); SIMPLE ANTI PHOSPHOLIPID ANTIBODY 86148 86148 302 370.00 100.00 370.00 ANTIBODY ELUTION (RBC), EACH ELUTION 86860 86860 302 600.00 100.00 600.00 ANTIBODY IDENTIFICATION, RBC ANTIBODIES, 86870 86870 302 850.00 100.00 850.00 EACH PANEL FOR EACH SERUM TECHNIQUE ANTIBODY SCREEN, RBC, EACH SERUM 86850 86850 302 350.00 100.00 350.00 TECHNIQUE ANTIBODY, BORDATELLA ANTIBODY 86615 86615 302 360.00 100.00 360.00 ANTIBODY, VIRUS NOT ELSEWHERE 86790 86790 302 290.00 100.00 290.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ANTIBODY; HIV-1 86701 86701 302 170.00 100.00 170.00 ANTIGEN DETECTION NOT OTHERWISE 87449 87449 306 270.00 100.00 270.00 ANTIGEN TYPING, SEROLOGIC;RBC ANTIGENS, 86905 86905 302 100.00 100.00 100.00 OTHER THAN ABO OR Rh(D), EACH ANTIHUMAN GLOBULIN TEST (COOMBS TEST); 86880 86880 302 70.00 100.00 70.00 DIRECT, EACH ANTISERUM ANTIHUMAN GLOBULIN TEST (COOMBS TEST); 86885 86885 302 70.00 100.00 70.00 INDIRECT, QUALITATIVE, EACH ANTISERUM ANTINUCLEAR ANTIBODIES (ANA); 86038 86038 302 180.00 100.00 180.00 ANTITHROMBIN 111 ACTIVITY 85300 85300 305 360.00 100.00 360.00 APPENDECTOMY; 44950 44950 360 10,500.00 100.00 10,500.00 APPENDECTOMY; FOR RUPTURED APPENDIX 44960 44960 360 100.00 0.00 WITH ABSCESS OR GENERALIZED PERITONITIS APPENDECTOMY; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR PROCEDURE (NOT AS SEPARATE PROCEDURE) 44955 44955 360 100.00 0.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PR APPLICATION OF A MODALITY TO ONE OR MORE AREAS; CONTRAST BATHS, EACH 15 97034 97034 100.00 0.00 MINUTES APPLICATION OF A MODALITY TO ONE OR 97024 97024 100.00 0.00 MORE AREAS; DIATHERMY APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION 97032 97032 100.00 0.00 (MANUAL), EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR MORE AREAS; ELECTRICAL STIMULATION 97014 97014 100.00 0.00 (UNATTENDED) APPLICATION OF A MODALITY TO ONE OR 97010 97010 100.00 0.00 MORE AREAS; HOT OR COLD PACKS APPLICATION OF A MODALITY TO ONE OR MORE AREAS; HUBBARD TANK, EACH 15 97036 97036 100.00 0.00 MINUTES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee APPLICATION OF A MODALITY TO ONE OR 97026 97026 100.00 0.00 MORE AREAS; INFRARED APPLICATION OF A MODALITY TO ONE OR MORE AREAS; IONTOPHORESIS, EACH 15 97033 97033 100.00 0.00 MINUTES APPLICATION OF A MODALITY TO ONE OR 97020 97020 100.00 0.00 MORE AREAS; MICROWAVE APPLICATION OF A MODALITY TO ONE OR 97018 97018 100.00 0.00 MORE AREAS; PARAFFIN BATH APPLICATION OF A MODALITY TO ONE OR 97012 97012 100.00 0.00 MORE AREAS; TRACTION, MECHANICAL APPLICATION OF A MODALITY TO ONE OR 97035 97035 100.00 0.00 MORE AREAS; ULTRASOUND, EACH 15 MINUTES APPLICATION OF A MODALITY TO ONE OR 97028 97028 100.00 0.00 MORE AREAS; ULTRAVIOLET APPLICATION OF A MODALITY TO ONE OR 97016 97016 100.00 0.00 MORE AREAS; VASOPNEUMATIC DEVICES APPLICATION OF A MODALITY TO ONE OR 97022 97022 100.00 0.00 MORE AREAS; WHIRLPOOL APPLICATION OF A MULTIPLANE (PINS OR WIRES IN MORE THAN ONE PLANE), 20692 20692 360 100.00 0.00 UNILATERAL, EXTERNAL FIXATION SYSTEM (EG, ILIZAROV, MONTICELLI TYPE) APPLICATION OF A UNIPLANE (PINS OR WIRES IN ONE PLANE), UNILATERAL, EXTERNAL 20690 20690 360 11,900.00 100.00 11,900.00 FIXATION SYSTEM APPLICATION OF ALLOGRAFT, SKIN; 100 SQ CM 15350 15350 360 100.00 0.00 OR LESS APPLICATION OF ALLOGRAFT, SKIN; EACH ADDITIONAL 100 SQ CM (LIST SEPARATELY IN 15351 15351 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) APPLICATION OF BILAMINATE SKIN 15342 15342 360 100.00 0.00 SUBSTITUTE/NEODERMIS; 25 SQ CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

APPLICATION OF BILAMINATE SKIN SUBSTITUTE/NEODERMIS; EACH ADDITIONAL 25 15343 15343 360 100.00 0.00 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) APPLICATION OF BODY CAST, SHOULDER TO 29035 29035 360 100.00 0.00 HIPS; APPLICATION OF BODY CAST, SHOULDER TO 29046 29046 360 100.00 0.00 HIPS; INCLUDING BOTH THIGHS APPLICATION OF BODY CAST, SHOULDER TO 29040 29040 360 100.00 0.00 HIPS; INCLUDING HEAD, MINERVA TYPE APPLICATION OF BODY CAST, SHOULDER TO 29044 29044 360 100.00 0.00 HIPS; INCLUDING ONE THIGH APPLICATION OF CLUBFOOT CAST WITH MOLDING OR MANIPULATION, LONG OR SHORT 29450 29450 360 100.00 0.00 LEG APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, INCLUDING REMOVAL 20660 20660 360 100.00 0.00 (SEPARATE PROCEDURE)

APPLICATION OF FINGER SPLINT; DYNAMIC 29131 29131 360 100.00 0.00 APPLICATION OF FINGER SPLINT; STATIC 29130 29130 360 100.00 0.00 APPLICATION OF HALO TYPE APPLIANCE FOR MAXILLOFACIAL FIXATION, INCLUDES 21100 21100 360 100.00 0.00 REMOVAL (SEPARATE PROCEDURE) APPLICATION OF HALO TYPE BODY CAST (SEE 29000 29000 360 100.00 0.00 20661-20663 FOR INSERTION) APPLICATION OF HALO, INCLUDING REMOVAL, CRANIAL, 6 OR MORE PINS PLACED, FOR THIN 20664 20664 360 100.00 0.00 SKULL OSTEOLOGY (EG, PEDIATRIC PATIENTS, HYDROCEPHALUS, OSTEOGENESIS APPLICATION OF HALO, INCLUDING REMOVAL; 20661 20661 360 100.00 0.00 CRANIAL APPLICATION OF HALO, INCLUDING REMOVAL; 20663 20663 360 100.00 0.00 FEMORAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee APPLICATION OF HALO, INCLUDING REMOVAL; 20662 20662 360 100.00 0.00 PELVIC APPLICATION OF HIP SPICA CAST; ONE AND ONE- 29325 29325 360 100.00 0.00 HALF SPICA OR BOTH LEGS APPLICATION OF HIP SPICA CAST; ONE LEG 29305 29305 360 100.00 0.00 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN 21110 21110 360 100.00 0.00 FRACTURE OR DISLOCATION, INCLUDES REMOVAL APPLICATION OF INTERVERTEBRAL BIOMECHANICAL DEVICE(S) (EG, SYNTHETIC CAGE(S), THREADED BONE DOWEL(S), 22851 22851 360 22,800.00 100.00 22,800.00 METHYLMETHACRYLATE) TO VERTEBRAL DEFECT OR INTER APPLICATION OF LONG ARM SPLINT (SHOULDER 29105 29105 360 100.00 0.00 TO HAND) APPLICATION OF LONG LEG CAST (THIGH TO 29345 29345 360 100.00 0.00 TOES); APPLICATION OF LONG LEG CAST (THIGH TO 29355 29355 360 100.00 0.00 TOES); WALKER OR AMBULATORY TYPE APPLICATION OF LONG LEG CAST BRACE 29358 29358 360 100.00 0.00 APPLICATION OF LONG LEG SPLINT (THIGH TO 29505 29505 360 100.00 0.00 ANKLE OR TOES) APPLICATION OF PATELLAR TENDON BEARING 29435 29435 360 100.00 0.00 (PTB) CAST APPLICATION OF RIGID TOTAL CONTACT LEG 29445 29445 360 2,200.00 100.00 2,200.00 CAST APPLICATION OF RISSER JACKET, LOCALIZER, 29015 29015 360 100.00 0.00 BODY; INCLUDING HEAD APPLICATION OF RISSER JACKET, LOCALIZER, 29010 29010 360 100.00 0.00 BODY; ONLY APPLICATION OF SHORT ARM SPLINT (FOREARM 29126 29126 360 1,500.00 100.00 1,500.00 TO HAND); DYNAMIC APPLICATION OF SHORT ARM SPLINT (FOREARM 29125 29125 360 500.00 100.00 500.00 TO HAND); STATIC APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY 29425 29425 360 100.00 0.00 TYPE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee APPLICATION OF SHORT LEG SPLINT (CALF TO 29515 29515 360 600.00 100.00 600.00 FOOT) APPLICATION OF SURFACE (TRANSCUTANEOUS) 64550 64550 360 100.00 0.00 NEUROSTIMULATOR APPLICATION OF TURNBUCKLE JACKET, BODY; 29025 29025 360 100.00 0.00 INCLUDING HEAD APPLICATION OF TURNBUCKLE JACKET, BODY; 29020 29020 360 100.00 0.00 ONLY APPLICATION OF XENOGRAFT, SKIN; 100 SQ CM 15400 15400 360 100.00 0.00 OR LESS APPLICATION OF XENOGRAFT, SKIN; EACH ADDITIONAL 100 SQ CM (LIST SEPARATELY IN 15401 15401 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) APPLICATION, CAST; ELBOW TO FINGER (SHORT 29075 29075 360 100.00 0.00 ARM) APPLICATION, CAST; FIGURE-OF-EIGHT 29049 29049 360 100.00 0.00 APPLICATION, CAST; FINGER (EG, 29086 29086 360 100.00 0.00 CONTRACTURE) APPLICATION, CAST; HAND AND LOWER 29085 29085 360 100.00 0.00 FOREARM (GAUNTLET) APPLICATION, CAST; PLASTER VELPEAU 29058 29058 360 100.00 0.00 APPLICATION, CAST; SHOULDER SPICA 29055 29055 360 100.00 0.00 APPLICATION, CAST; SHOULDER TO HAND 29065 29065 360 100.00 0.00 (LONG ARM) AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR (EG, MOLTENO, SCHOCKET, DENVER- 66180 66180 360 100.00 0.00 KRUPIN) ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL 27740 27740 360 100.00 0.00 TIBIA AND FIBULA; ARREST, EPIPHYSEAL (EPIPHYSIODESIS), ANY METHOD, COMBINED, PROXIMAL AND DISTAL 27742 27742 360 100.00 0.00 TIBIA AND FIBULA; AND DISTAL FEMUR ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; 27732 27732 360 100.00 0.00 DISTAL FIBULA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; 27730 27730 360 100.00 0.00 DISTAL TIBIA ARREST, EPIPHYSEAL (EPIPHYSIODESIS), OPEN; 27734 27734 360 100.00 0.00 DISTAL TIBIA AND FIBULA ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); COMBINED DISTAL FEMUR, 27479 27479 360 100.00 0.00 PROXIMAL TIBIA AND FIBULA ARREST, EPIPHYSEAL, ANY METHOD (EG, 27475 27475 360 100.00 0.00 EPIPHYSIODESIS); DISTAL FEMUR ARREST, EPIPHYSEAL, ANY METHOD (EG, EPIPHYSIODESIS); TIBIA AND FIBULA, 27477 27477 360 100.00 0.00 PROXIMAL ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL TIBIA OR FIBULA (EG, GENU VARUS 27485 27485 360 100.00 0.00 OR VALGUS) ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY (CHEMOTHERAPY), 36640 36640 360 100.00 0.00 CUTDOWN ARTERIOVENOUS ANASTOMOSIS, OPEN; BY 36820 36820 360 100.00 0.00 FOREARM VEIN TRANSPOSITION ARTERIOVENOUS ANASTOMOSIS, OPEN; BY 36819 36819 360 18,790.00 100.00 18,790.00 UPPER ARM BASILIC VEIN TRANSPOSITION ARTERIOVENOUS ANASTOMOSIS, OPEN; DIRECT, ANY SITE (EG, CIMINO TYPE) (SEPARATE 36821 36821 360 15,470.00 100.00 15,470.00 PROCEDURE) Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with 20611 20611 360 1,100.00 100.00 1,100.00 ultrasound guidance, with permanent recording and reporting ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE JOINT OR BURSA (EG, TEMPOROMANDIBULAR, 20605 20605 360 1,000.00 100.00 1,000.00 ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON B ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR BURSA (EG, 20610 20610 360 1,000.00 100.00 1,000.00 SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL JOINT OR BURSA (EG, 20600 20600 360 1,000.00 100.00 1,000.00 FINGERS, TOES) ARTHRODESIS, ANKLE, OPEN 27870 27870 360 28,950.00 100.00 28,950.00 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER 22554 22554 360 100.00 0.00 THAN FOR DECOMPRESSION); CERVICAL BELOW C2 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER 22585 22585 360 100.00 0.00 THAN FOR DECOMPRESSION); EACH ADDITIONAL INTERSPA ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 22558 22558 360 100.00 0.00 DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR

ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL 22556 22556 360 100.00 0.00 DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND 22551 22551 360 43,850.00 100.00 43,850.00 DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOTS; CERVICAL BELOW C2 ARTHRODESIS, ANTERIOR INTERBODY, INCLUDING DISC SPACE PREPARATION, DISCECTOMY, OSTEOPHYTECTOMY AND DECOMPRESSION OF SPINAL CORD AND/OR 22552 22552 360 17,540.00 100.00 17,540.00 NERVE ROOTS; CERVICAL BELOW C2, EACH ADDITIONAL INTERSPACE (LIST SEPARATELY IN ADDITION TO CODE FOR SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS- 22548 22548 360 100.00 0.00 AXIS), WITH OR WITHOUT EXCISION OF ODONTOID PROCESS ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 2 TO 3 22808 22808 360 100.00 0.00 VERTEBRAL SEGMENTS ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 4 TO 7 22810 22810 360 100.00 0.00 VERTEBRAL SEGMENTS ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 8 OR 22812 22812 360 100.00 0.00 MORE VERTEBRAL SEGMENTS ARTHRODESIS, CARPOMETACARPAL JOINT, 26843 26843 360 100.00 0.00 DIGIT, OTHER THAN THUMB, EACH; ARTHRODESIS, CARPOMETACARPAL JOINT, DIGIT, OTHER THAN THUMB, EACH; WITH 26844 26844 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT) ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL 26841 26841 360 100.00 0.00 FIXATION; ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, WITH OR WITHOUT INTERNAL 26842 26842 360 100.00 0.00 FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare 22633 22633 360 100.00 0.00 interspace (other than for decompression), single interspace and segment; lumbar ARTHRODESIS, DISTAL RADIOULNAR JOINT WITH SEGMENTAL RESECTION OF ULNA, WITH 25830 25830 360 100.00 0.00 OR WITHOUT BONE GRAFT (EG, SAUVE- KAPANDJI PROCEDURE) ARTHRODESIS, ELBOW JOINT; LOCAL 24800 24800 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHRODESIS, ELBOW JOINT; WITH AUTOGENOUS GRAFT (INCLUDES OBTAINING 24802 24802 360 100.00 0.00 GRAFT) ARTHRODESIS, GLENOHUMERAL JOINT; 23800 23800 360 100.00 0.00 ARTHRODESIS, GLENOHUMERAL JOINT; WITH AUTOGENOUS GRAFT (INCLUDES OBTAINING 23802 23802 360 100.00 0.00 GRAFT) ARTHRODESIS, GREAT TOE; INTERPHALANGEAL 28755 28755 360 9,470.00 100.00 9,470.00 JOINT ARTHRODESIS, GREAT TOE; 28750 28750 360 23,900.00 100.00 23,900.00 METATARSOPHALANGEAL JOINT ARTHRODESIS, HIP JOINT (INCLUDING 27284 27284 360 100.00 0.00 OBTAINING GRAFT); ARTHRODESIS, HIP JOINT (INCLUDING OBTAINING GRAFT); WITH SUBTROCHANTERIC 27286 27286 360 100.00 0.00 OSTEOTOMY ARTHRODESIS, INTERPHALANGEAL JOINT, WITH 26860 26860 360 10,150.00 100.00 10,150.00 OR WITHOUT INTERNAL FIXATION; ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; EACH ADDITIONAL INTERPHALANGEAL JOINT (LIST 26861 26861 360 4,800.00 100.00 4,800.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; WITH 26862 26862 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT)

ARTHRODESIS, INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT), 26863 26863 360 100.00 0.00 EACH ADDITIONAL JOINT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

ARTHRODESIS, KNEE, ANY TECHNIQUE 27580 27580 360 100.00 0.00 ARTHRODESIS, METACARPOPHALANGEAL 26850 26850 360 10,150.00 100.00 10,150.00 JOINT, WITH OR WITHOUT INTERNAL FIXATION; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHRODESIS, METACARPOPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL FIXATION; 26852 26852 360 100.00 0.00 WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 28730 28730 360 23,900.00 100.00 23,900.00 TRANSVERSE; ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR 28735 28735 360 100.00 0.00 TRANSVERSE; WITH OSTEOTOMY (EG, FLATFOOT CORRECTION) ARTHRODESIS, MIDTARSAL OR 28740 28740 360 23,900.00 100.00 23,900.00 TARSOMETATARSAL, SINGLE JOINT ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO PREPARE INTERSPACE 22632 22632 360 100.00 0.00 (OTHER THAN FOR DECOMPRESSION), SINGLE IN14123 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, INCLUDING LAMINECTOMY AND/OR DISKECTOMY TO PREPARE INTERSPACE 22630 22630 360 100.00 0.00 (OTHER THAN FOR DECOMPRESSION), SINGLE INTER ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; 22600 22600 360 100.00 0.00 CERVICAL BELOW C2 SEGMENT ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; EACH ADDITIONAL VERTEBRAL SEGMENT (LIST 22614 22614 360 17,600.00 100.00 17,600.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY P ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; 22612 22612 360 100.00 0.00 LUMBAR (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; 22610 22610 360 100.00 0.00 THORACIC (WITH OR WITHOUT LATERAL TRANSVERSE TECHNIQUE) ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS- 22595 22595 360 100.00 0.00 AXIS (C1-C2) ARTHRODESIS, POSTERIOR TECHNIQUE, 22590 22590 360 100.00 0.00 CRANIOCERVICAL (OCCIPUT-C2) ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 13 OR 22804 22804 360 100.00 0.00 MORE VERTEBRAL SEGMENTS ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; 7 TO 12 22802 22802 360 100.00 0.00 VERTEBRAL SEGMENTS ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, WITH OR WITHOUT CAST; UP TO 6 22800 22800 360 100.00 0.00 VERTEBRAL SEGMENTS ARTHRODESIS, SACROILIAC JOINT (INCLUDING 27280 27280 360 100.00 0.00 OBTAINING GRAFT) ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING 27282 27282 360 100.00 0.00 OBTAINING GRAFT) ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL 27871 27871 360 28,950.00 100.00 28,950.00 OR DISTAL ARTHRODESIS, WITH EXTENSOR HALLUCIS LONGUS TRANSFER TO FIRST METATARSAL 28760 28760 360 23,900.00 100.00 23,900.00 NECK, GREAT TOE, INTERPHALANGEAL JOINT (EG, JONES TYPE PROCEDURE)

ARTHRODESIS, WITH TENDON LENGTHENING AND ADVANCEMENT, MIDTARSAL, TARSAL 28737 28737 360 23,900.00 100.00 23,900.00 NAVICULAR-CUNEIFORM (EG, MILLER TYPE PROCEDURE) ARTHRODESIS, WRIST; COMPLETE, WITHOUT BONE GRAFT (INCLUDES RADIOCARPAL AND/OR 25800 25800 360 100.00 0.00 INTERCARPAL AND/OR CARPOMETACARPAL JOINTS) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ARTHRODESIS, WRIST; LIMITED, WITHOUT BONE 25820 25820 360 100.00 0.00 GRAFT (EG, INTERCARPAL OR RADIOCARPAL) ARTHRODESIS, WRIST; WITH AUTOGRAFT 25825 25825 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) ARTHRODESIS, WRIST; WITH ILIAC OR OTHER 25810 25810 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT)

ARTHRODESIS, WRIST; WITH SLIDING GRAFT 25805 25805 360 100.00 0.00 ARTHRODESIS; PANTALAR 28705 28705 360 100.00 0.00 ARTHRODESIS; SUBTALAR 28725 28725 360 23,900.00 100.00 23,900.00 ARTHRODESIS; TRIPLE 28715 28715 360 46,750.00 100.00 46,750.00 ArthroFlex, per sq cm Q4125 Q4125 636 100.00 0.00 ARTHROPLASTY WITH PROSTHETIC 25441 25441 360 100.00 0.00 REPLACEMENT; DISTAL RADIUS ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; DISTAL RADIUS AND PARTIAL 25446 25446 360 100.00 0.00 OR ENTIRE CARPUS (TOTAL WRIST) ARTHROPLASTY WITH PROSTHETIC 25442 25442 360 100.00 0.00 REPLACEMENT; DISTAL ULNA ARTHROPLASTY WITH PROSTHETIC 25444 25444 360 46,750.00 100.00 46,750.00 REPLACEMENT; LUNATE ARTHROPLASTY WITH PROSTHETIC REPLACEMENT; SCAPHOID CARPAL 25443 25443 360 100.00 0.00 (NAVICULAR) ARTHROPLASTY WITH PROSTHETIC 25445 25445 360 100.00 0.00 REPLACEMENT; TRAPEZIUM ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL 27130 27130 360 20,250.00 100.00 20,250.00 HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT ARTHROPLASTY, ANKLE; 27700 27700 360 15,400.00 100.00 15,400.00 ARTHROPLASTY, ANKLE; REVISION, TOTAL 27703 27703 360 100.00 0.00 ANKLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROPLASTY, ANKLE; WITH IMPLANT 27702 27702 360 100.00 0.00 (TOTAL ANKLE) ARTHROPLASTY, ELBOW; WITH DISTAL 24361 24361 360 100.00 0.00 HUMERAL PROSTHETIC REPLACEMENT ARTHROPLASTY, ELBOW; WITH DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC 24363 24363 360 48,500.00 100.00 48,500.00 REPLACEMENT (EG, TOTAL ELBOW)

ARTHROPLASTY, ELBOW; WITH IMPLANT AND 24362 24362 360 100.00 0.00 FASCIA LATA LIGAMENT RECONSTRUCTION ARTHROPLASTY, ELBOW; WITH MEMBRANE (EG, 24360 24360 360 100.00 0.00 FASCIAL) ARTHROPLASTY, FEMORAL CONDYLES OR 27442 27442 360 43,850.00 100.00 43,850.00 TIBIAL PLATEAU(S), KNEE; ARTHROPLASTY, FEMORAL CONDYLES OR TIBIAL PLATEAU(S), KNEE; WITH DEBRIDEMENT 27443 27443 360 100.00 0.00 AND PARTIAL SYNOVECTOMY ARTHROPLASTY, GLENOHUMERAL JOINT; 23470 23470 360 46,750.00 100.00 46,750.00 HEMIARTHROPLASTY ARTHROPLASTY, GLENOHUMERAL JOINT; TOTAL SHOULDER (GLENOID AND PROXIMAL 23472 23472 360 27,150.00 100.00 27,150.00 HUMERAL REPLACEMENT (EG, TOTAL SHOULDER)) ARTHROPLASTY, INTERPHALANGEAL JOINT; 26535 26535 360 15,400.00 100.00 15,400.00 EACH JOINT ARTHROPLASTY, INTERPHALANGEAL JOINT; 26536 26536 360 15,400.00 100.00 15,400.00 WITH PROSTHETIC IMPLANT, EACH JOINT

ARTHROPLASTY, INTERPOSITION, INTERCARPAL 25447 25447 360 15,400.00 100.00 15,400.00 OR CARPOMETACARPAL JOINTS

ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL 27447 27447 360 21,500.00 100.00 21,500.00 COMPARTMENTS WITH OR WITHOUT PATELLA RESURFACING (TOTAL KNEE ARTHROPLASTY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ARTHROPLASTY, KNEE, CONDYLE AND 27446 27446 360 46,750.00 100.00 46,750.00 PLATEAU; MEDIAL OR LATERAL COMPARTMENT

ARTHROPLASTY, KNEE, CONDYLE AND 81.47 360 100.00 0.00 PLATEAU;MED OR LATERAL COMPARTMENT ARTHROPLASTY, KNEE, HINGE PROSTHESIS (EG, 27445 27445 360 100.00 0.00 WALLDIUS TYPE) ARTHROPLASTY, KNEE, TIBIAL PLATEAU; 27440 27440 360 100.00 0.00 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; WITH 27441 27441 360 100.00 0.00 DEBRIDEMENT AND PARTIAL SYNOVECTOMY ARTHROPLASTY, KNEE,CONDYLE AND PLATEAU;MEDIAL AND LATERAL 81.54 360 100.00 0.00 COMPARTMENTS WITH OR W/O PATELLA RESURFACING (TOT KNEE ARTHROPLASTY) ARTHROPLASTY, METACARPOPHALANGEAL 26530 26530 360 100.00 0.00 JOINT; EACH JOINT

ARTHROPLASTY, METACARPOPHALANGEAL 26531 26531 360 15,400.00 100.00 15,400.00 JOINT; WITH PROSTHETIC IMPLANT, EACH JOINT

ARTHROPLASTY, PATELLA; WITH PROSTHESIS 27438 27438 360 100.00 0.00 ARTHROPLASTY, PATELLA; WITHOUT 27437 27437 360 100.00 0.00 PROSTHESIS ARTHROPLASTY, RADIAL HEAD; 24365 24365 360 100.00 0.00 ARTHROPLASTY, RADIAL HEAD; WITH IMPLANT 24366 24366 360 24,366.00 100.00 24,366.00 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, 21242 21242 360 100.00 0.00 WITH ALLOGRAFT ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH OR WITHOUT AUTOGRAFT (INCLUDES 21240 21240 360 100.00 0.00 OBTAINING GRAFT) ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, 21243 21243 360 100.00 0.00 WITH PROSTHETIC JOINT REPLACEMENT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ARTHROPLASTY, WRIST, WITH OR WITHOUT INTERPOSITION, WITH OR WITHOUT EXTERNAL 25332 25332 360 15,400.00 100.00 15,400.00 OR INTERNAL FIXATION

ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION 29888 29888 360 28,950.00 100.00 28,950.00 OR RECONSTRUCTION

ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION 29889 29889 360 28,950.00 100.00 28,950.00 OR RECONSTRUCTION

ARTHROSCOPICALLY AIDED REPAIR OF LARGE OSTEOCHONDRITIS DISSECANS LESION, TALAR DOME FRACTURE, OR TIBIAL PLAFOND 29892 29892 360 100.00 0.00 FRACTURE, WITH OR WITHOUT INTERNAL FIXATION (INCLUDES ARTHROSCOPY) ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH 29851 29851 360 100.00 0.00 OR WITHOUT MANIPULATION; WITH INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, WITH 29850 29850 360 10,540.00 100.00 10,540.00 OR WITHOUT MANIPULATION; WITHOUT INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, WITH OR WITHOUT INTERNAL OR 29856 29856 360 100.00 0.00 EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, WITH OR WITHOUT INTERNAL 29855 29855 360 19,900.00 100.00 19,900.00 OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) ARTHROSCOPY SEP COMPARTMENT, DEBRIDE G0289 G0289 360 1,220.00 100.00 1,220.00 FB REM ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; 29898 29898 360 9,850.00 100.00 9,850.00 DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; 29897 29897 360 9,850.00 100.00 9,850.00 DEBRIDEMENT, LIMITED ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; 29895 29895 360 9,850.00 100.00 9,850.00 SYNOVECTOMY, PARTIAL ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; WITH ANKLE 29899 29899 360 100.00 0.00 ARTHRODESIS ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; WITH 29894 29894 360 9,850.00 100.00 9,850.00 REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, ANKLE, SURGICAL; EXCISION OF OSTEOCHONDRAL DEFECT OF TALUS 29891 29891 360 19,900.00 100.00 19,900.00 AND/OR TIBIA, INCLUDING DRILLING OF THE DEFECT ARTHROSCOPY, ELBOW, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29830 29830 360 100.00 0.00 PROCEDURE) ARTHROSCOPY, ELBOW, SURGICAL; 29838 29838 360 9,850.00 100.00 9,850.00 DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, ELBOW, SURGICAL; 29837 29837 360 9,850.00 100.00 9,850.00 DEBRIDEMENT, LIMITED ARTHROSCOPY, ELBOW, SURGICAL; 29836 29836 360 19,900.00 100.00 19,900.00 SYNOVECTOMY, COMPLETE ARTHROSCOPY, ELBOW, SURGICAL; 29835 29835 360 19,900.00 100.00 19,900.00 SYNOVECTOMY, PARTIAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ARTHROSCOPY, ELBOW, SURGICAL; WITH 29834 29834 360 9,850.00 100.00 9,850.00 REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, HIP, DIAGNOSTIC WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29860 29860 360 100.00 0.00 PROCEDURE) ARTHROSCOPY, HIP, SURGICAL; WITH DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY), ABRASION 29862 29862 360 100.00 0.00 ARTHROPLASTY, AND/OR RESECTION OF LABRUM ARTHROSCOPY, HIP, SURGICAL; WITH REMOVAL 29861 29861 360 100.00 0.00 OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, HIP, SURGICAL; WITH 29863 29863 360 100.00 0.00 SYNOVECTOMY ARTHROSCOPY, KNEE, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29870 29870 360 9,850.00 100.00 9,850.00 PROCEDURE) ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY 29879 29879 360 9,850.00 100.00 9,850.00 WHERE NECESSARY) OR MULTIPLE DRILLING OR MICROFRACTURE ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR 29877 29877 360 9,850.00 100.00 9,850.00 CARTILAGE (CHONDROPLASTY) ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS 29886 29886 360 100.00 0.00 LESION ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS 29887 29887 360 100.00 0.00 LESION WITH INTERNAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR OSTEOCHONDRITIS DISSECANS WITH BONE GRAFTING, WITH OR WITHOUT INTERNAL 29885 29885 360 100.00 0.00 FIXATION (INCLUDING DEBRIDEMENT OF BASE OF LESION) ARTHROSCOPY, KNEE, SURGICAL; FOR 29871 29871 360 9,850.00 100.00 9,850.00 INFECTION, LAVAGE AND DRAINAGE ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (EG, OSTEOCHONDRITIS DISSECANS 29874 29874 360 9,850.00 100.00 9,850.00 FRAGMENTATION, CHONDRAL FRAGMENTATION) ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (EG, PLICA OR SHELF 29875 29875 360 9,850.00 100.00 9,850.00 RESECTION) (SEPARATE PROCEDURE)

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE 29876 29876 360 9,850.00 100.00 9,850.00 COMPARTMENTS (EG, MEDIAL OR LATERAL)

ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE 80.76 360 100.00 0.00 COMPARTMENTS (EG, MEDIAL OR LATERAL). ARTHROSCOPY, KNEE, SURGICAL; WITH 29873 29873 360 9,850.00 100.00 9,850.00 LATERAL RELEASE ARTHROSCOPY, KNEE, SURGICAL; WITH LYSIS OF ADHESIONS, WITH OR WITHOUT 29884 29884 360 9,850.00 100.00 9,850.00 MANIPULATION (SEPARATE PROCEDURE) ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL AND LATERAL, 29880 29880 360 9,850.00 100.00 9,850.00 INCLUDING ANY MENISCAL SHAVING) ARTHROSCOPY, KNEE, SURGICAL; WITH MENISCECTOMY (MEDIAL OR LATERAL, 29881 29881 360 9,850.00 100.00 9,850.00 INCLUDING ANY MENISCAL SHAVING) ARTHROSCOPY, KNEE, SURGICAL; WITH 29883 29883 360 14,340.00 100.00 14,340.00 MENISCUS REPAIR (MEDIAL AND LATERAL) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROSCOPY, KNEE, SURGICAL; WITH 29882 29882 360 9,850.00 100.00 9,850.00 MENISCUS REPAIR (MEDIAL OR LATERAL) ARTHROSCOPY, METACARPOPHALANGEAL JOINT, DIAGNOSTIC, INCLUDES SYNOVIAL 29900 29900 360 100.00 0.00 BIOPSY ARTHROSCOPY, METACARPOPHALANGEAL 29901 29901 360 100.00 0.00 JOINT, SURGICAL; WITH DEBRIDEMENT ARTHROSCOPY, METACARPOPHALANGEAL JOINT, SURGICAL; WITH REDUCTION OF 29902 29902 360 100.00 0.00 DISPLACED ULNAR COLLATERAL LIGAMENT (EG, STENAR LESION) ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29805 29805 360 9,850.00 100.00 9,850.00 PROCEDURE) ARTHROSCOPY, SHOULDER, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29815 360 100.00 0.00 PROCEDURE)2617 ARTHROSCOPY, SHOULDER, SURGICAL; BICEPS 29828 29828 360 19,900.00 100.00 19,900.00 TENODESIS ARTHROSCOPY, SHOULDER, SURGICAL; 29806 29806 360 19,900.00 100.00 19,900.00 CAPSULORRHAPHY ARTHROSCOPY, SHOULDER, SURGICAL; 29823 29823 360 19,900.00 100.00 19,900.00 DEBRIDEMENT, EXTENSIVE ARTHROSCOPY, SHOULDER, SURGICAL; 80.81 360 100.00 0.00 DEBRIDEMENT, EXTENSIVE (MS) ARTHROSCOPY, SHOULDER, SURGICAL; 29822 29822 360 10,540.00 100.00 10,540.00 DEBRIDEMENT, LIMITED ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE 29826 29826 360 10,550.00 100.00 10,550.00 WITH PARTIAL ACROMIOPLASTY, WITH OR WITHOUT CORACOACROMIAL RELEASE ARTHROSCOPY, SHOULDER, SURGICAL; DISTAL CLAVICULECTOMY INCLUDING DISTAL 29824 29824 360 19,900.00 100.00 19,900.00 ARTICULAR SURFACE (MUMFORD PROCEDURE) ARTHROSCOPY, SHOULDER, SURGICAL; REPAIR 29807 29807 360 19,900.00 100.00 19,900.00 OF SLAP LESION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROSCOPY, SHOULDER, SURGICAL; 29821 29821 360 19,900.00 100.00 19,900.00 SYNOVECTOMY, COMPLETE ARTHROSCOPY, SHOULDER, SURGICAL; 29820 29820 360 19,900.00 100.00 19,900.00 SYNOVECTOMY, PARTIAL ARTHROSCOPY, SHOULDER, SURGICAL; WITH LYSIS AND RESECTION OF ADHESIONS, WITH OR 29825 29825 360 19,900.00 100.00 19,900.00 WITHOUT MANIPULATION

ARTHROSCOPY, SHOULDER, SURGICAL; WITH 29819 29819 360 19,900.00 100.00 19,900.00 REMOVAL OF LOOSE BODY OR FOREIGN BODY ARTHROSCOPY, SHOULDER, SURGICAL; WITH 29827 29827 360 19,900.00 100.00 19,900.00 ROTATOR CUFF REPAIR ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL 29800 29800 360 100.00 0.00 BIOPSY (SEPARATE PROCEDURE) ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, 29804 29804 360 100.00 0.00 SURGICAL ARTHROSCOPY, WRIST, DIAGNOSTIC, WITH OR WITHOUT SYNOVIAL BIOPSY (SEPARATE 29840 29840 360 9,850.00 100.00 9,850.00 PROCEDURE) ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR 29846 29846 360 9,850.00 100.00 9,850.00 FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT ARTHROSCOPY, WRIST, SURGICAL; FOR 29843 29843 360 100.00 0.00 INFECTION, LAVAGE AND DRAINAGE ARTHROSCOPY, WRIST, SURGICAL; INTERNAL 29847 29847 360 100.00 0.00 FIXATION FOR FRACTURE OR INSTABILITY ARTHROSCOPY, WRIST, SURGICAL; 29845 29845 360 100.00 0.00 SYNOVECTOMY, COMPLETE ARTHROSCOPY, WRIST, SURGICAL; 29844 29844 360 9,850.00 100.00 9,850.00 SYNOVECTOMY, PARTIAL ARTHROTOMY OF THE ELBOW, WITH CAPSULAR EXCISION FOR CAPSULAR RELEASE (SEPARATE 24006 24006 360 11,900.00 100.00 11,900.00 PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROTOMY WITH BIOPSY; 26100 26100 360 100.00 0.00 CARPOMETACARPAL JOINT, EACH ARTHROTOMY WITH BIOPSY; 28054 28054 360 100.00 0.00 INTERPHALANGEAL JOINT ARTHROTOMY WITH BIOPSY; 26110 26110 360 100.00 0.00 INTERPHALANGEAL JOINT, EACH ARTHROTOMY WITH BIOPSY; INTERTARSAL OR 28050 28050 360 100.00 0.00 TARSOMETATARSAL JOINT ARTHROTOMY WITH BIOPSY; 26105 26105 360 5,650.00 100.00 5,650.00 METACARPOPHALANGEAL JOINT, EACH ARTHROTOMY WITH BIOPSY; 28052 28052 360 100.00 0.00 METATARSOPHALANGEAL JOINT ARTHROTOMY WITH MENISCUS REPAIR, KNEE 27403 27403 360 100.00 0.00

ARTHROTOMY, ACROMIOCLAVICULAR JOINT OR STERNOCLAVICULAR JOINT, INCLUDING 23101 23101 360 100.00 0.00 BIOPSY AND/OR EXCISION OF TORN CARTILAGE ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, INCLUDING 23044 23044 360 11,900.00 100.00 11,900.00 EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY ARTHROTOMY, ANKLE, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 27610 27610 360 11,900.00 100.00 11,900.00 FOREIGN BODY ARTHROTOMY, ANKLE, WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, 27620 27620 360 14,560.00 100.00 14,560.00 WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY ARTHROTOMY, DISTAL RADIOULNAR JOINT INCLUDING REPAIR OF TRIANGULAR 25107 25107 360 100.00 0.00 CARTILAGE, COMPLEX ARTHROTOMY, ELBOW, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF 24000 24000 360 100.00 0.00 FOREIGN BODY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROTOMY, ELBOW; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, 24101 24101 360 11,900.00 100.00 11,900.00 WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY ARTHROTOMY, ELBOW; WITH SYNOVECTOMY 24102 24102 360 100.00 0.00 ARTHROTOMY, ELBOW; WITH SYNOVIAL 24100 24100 360 100.00 0.00 BIOPSY ONLY ARTHROTOMY, GLENOHUMERAL JOINT, 23100 23100 360 100.00 0.00 INCLUDING BIOPSY ARTHROTOMY, GLENOHUMERAL JOINT, INCLUDING EXPLORATION, DRAINAGE, OR 23040 23040 360 11,900.00 100.00 11,900.00 REMOVAL OF FOREIGN BODY ARTHROTOMY, GLENOHUMERAL JOINT, WITH JOINT EXPLORATION, WITH OR WITHOUT 23107 23107 360 100.00 0.00 REMOVAL OF LOOSE OR FOREIGN BODY

ARTHROTOMY, HIP, INCLUDING EXPLORATION 27033 27033 360 100.00 0.00 OR REMOVAL OF LOOSE OR FOREIGN BODY ARTHROTOMY, HIP, WITH DRAINAGE (EG, 27030 27030 360 100.00 0.00 INFECTION) ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 28024 28024 360 8,000.00 100.00 8,000.00 FOREIGN BODY; INTERPHALANGEAL JOINT ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 28020 28020 360 100.00 0.00 FOREIGN BODY; INTERTARSAL OR TARSOMETATARSAL JOINT ARTHROTOMY, INCLUDING EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 28022 28022 360 12,740.00 100.00 12,740.00 FOREIGN BODY; METATARSOPHALANGEAL JOINT ARTHROTOMY, KNEE, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 27310 27310 360 11,050.00 100.00 11,050.00 (EG, INFECTION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROTOMY, KNEE; INCLUDING JOINT EXPLORATION, BIOPSY, OR REMOVAL OF LOOSE 27331 27331 360 100.00 0.00 OR FOREIGN BODIES ARTHROTOMY, KNEE; WITH SYNOVIAL BIOPSY 27330 27330 360 100.00 0.00 ONLY ARTHROTOMY, POSTERIOR CAPSULAR RELEASE, ANKLE, WITH OR WITHOUT ACHILLES 27612 27612 360 11,900.00 100.00 11,900.00 TENDON LENGTHENING ARTHROTOMY, RADIOCARPAL OR MIDCARPAL JOINT, WITH EXPLORATION, DRAINAGE, OR 25040 25040 360 100.00 0.00 REMOVAL OF FOREIGN BODY

ARTHROTOMY, TEMPOROMANDIBULAR JOINT 21010 21010 360 100.00 0.00 ARTHROTOMY, WITH BIOPSY; HIP JOINT 27052 27052 360 100.00 0.00 ARTHROTOMY, WITH BIOPSY; SACROILIAC 27050 27050 360 100.00 0.00 JOINT ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL 27333 27333 360 100.00 0.00 AND LATERAL ARTHROTOMY, WITH EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY) KNEE; MEDIAL 27332 27332 360 100.00 0.00 OR LATERAL ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 26070 26070 360 100.00 0.00 FOREIGN BODY; CARPOMETACARPAL JOINT ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 26080 26080 360 100.00 0.00 FOREIGN BODY; INTERPHALANGEAL JOINT, EACH ARTHROTOMY, WITH EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR 26075 26075 360 9,460.00 100.00 9,460.00 FOREIGN BODY; METACARPOPHALANGEAL JOINT, EACH ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; 27625 27625 360 11,900.00 100.00 11,900.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ARTHROTOMY, WITH SYNOVECTOMY, ANKLE; 27626 27626 360 11,900.00 100.00 11,900.00 INCLUDING TENOSYNOVECTOMY ARTHROTOMY, WITH SYNOVECTOMY, KNEE; ANTERIOR AND POSTERIOR INCLUDING 27335 27335 360 100.00 0.00 POPLITEAL AREA ARTHROTOMY, WITH SYNOVECTOMY, KNEE; 27334 27334 360 100.00 0.00 ANTERIOR OR POSTERIOR ARTHROTOMY, WRIST JOINT; WITH BIOPSY 25100 25100 360 100.00 0.00 ARTHROTOMY, WRIST JOINT; WITH JOINT EXPLORATION, WITH OR WITHOUT BIOPSY, 25101 25101 360 100.00 0.00 WITH OR WITHOUT REMOVAL OF LOOSE OR FOREIGN BODY ARTHROTOMY, WRIST JOINT; WITH 25105 25105 360 100.00 0.00 SYNOVECTOMY ARTHROTOMY; GLENOHUMERAL JOINT, WITH 23105 23105 360 100.00 0.00 SYNOVECTOMY, WITH OR WITHOUT BIOPSY ARTHROTOMY; STERNOCLAVICULAR JOINT, WITH SYNOVECTOMY, WITH OR WITHOUT 23106 23106 360 100.00 0.00 BIOPSY ARYTENOIDECTOMY OR ARYTENOIDOPEXY, 31400 31400 360 100.00 0.00 EXTERNAL APPROACH ASPIRATION AND INJECTION FOR TREATMENT 20615 20615 360 100.00 0.00 OF BONE CYST ASPIRATION AND/OR INJECTION OF GANGLION 20612 20612 360 1,000.00 100.00 1,000.00 CYST(S) ANY LOCATION ASPIRATION AND/OR INJECTION OF RENAL CYST 50390 50390 360 100.00 0.00 OR PELVIS BY NEEDLE, PERCUTANEOUS

ASPIRATION AND/OR INJECTION, THYROID CYST 60001 60001 360 100.00 0.00 ASPIRATION OF BLADDER BY NEEDLE 51000 51000 360 100.00 0.00 ASPIRATION OF BLADDER; BY TROCAR OR 51005 51005 360 100.00 0.00 INTRACATHETER ASPIRATION OF BLADDER; WITH INSERTION OF 51010 51010 360 100.00 0.00 SUPRAPUBIC CATHETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ASPIRATION OR DECOMPRESSION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISK, ANY METHOD, SINGLE 62287 62287 360 20,470.00 100.00 20,470.00 OR MULTIPLE LEVELS, LUMBAR (EG, MANUAL OR AUTOMATED PERCUTANEOUS DISKECTOMY, PERCUTANEOUS LASER DISKECTOMY)

ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS 67015 67015 360 100.00 0.00 PLANA APPROACH (POSTERIOR SCLEROTOMY) AST SGOT 84450 84450 301 50.00 100.00 50.00 ATHLETIC TRAINING EVALUATION 97005 97005 100.00 0.00 ATHLETIC TRAINING RE-EVALUATION 97006 97006 100.00 0.00 Auditory osseointegrated device, includes all internal and L8690 L8690 278 700.00 0.00 external components AUGMENTATION, MANDIBULAR BODY OR 21125 21125 360 100.00 0.00 ANGLE; PROSTHETIC MATERIAL AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR 21127 21127 360 100.00 0.00 INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) AURICULAR PROSTHESES PROVIDED BY L8045-G L8045 278 700.00 0.00 NONPHYSICIAN AURICULAR PROSTHESIS L8045-W L8045 278 100.00 0.00 AUTO DIFFERENTIAL 85004 85004 305 90.00 100.00 90.00

AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL 20936 20936 360 100.00 0.00 (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); 20937 20937 360 2,500.00 100.00 2,500.00 MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL 20938 20938 360 100.00 0.00 (THROUGH SEPARATE SKIN OR FASCIAL INCISION) AUTOLOGOUS BLOOD OR COMPONENT, COLLECTION PROCESSING AND STORAGE; 86890 86890 390 600.00 100.00 600.00 PREDEPOSITED AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE, SIMPLE; EACH ADDITIONAL NAIL 11732 11732 360 100.00 0.00 PLATE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) AVULSION OF NAIL PLATE, PARTIAL OR 11730 11730 360 3,040.00 100.00 3,040.00 COMPLETE, SIMPLE; SINGLE AXILLARY LYMPHADENECTOMY; COMPLETE 38745 38745 360 19,400.00 100.00 19,400.00

AXILLARY LYMPHADENECTOMY; SUPERFICIAL 38740 38740 360 100.00 0.00 BARTONELLA SPECIES 87471 87471 302 250.00 100.00 250.00

BASIC METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CALCIUM (82310) 80048 80048 301 300.00 100.00 300.00 CARBON DIOXIDE (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947 BETA 2 GLYCOPROTEIN ANTIBODY 86146 86146 302 330.00 100.00 330.00 BETA 2 MICROGLOBULIN 82232 82232 301 400.00 100.00 400.00 BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL ABDOMINAL 58953 58953 360 100.00 0.00 HYSTERECTOMY AND RADICAL DISSECTION FOR DEBULKING; BILATERAL SALPINGO-OOPHORECTOMY WITH OMENTECTOMY, TOTAL ABDOMINAL HYSTERECTOMY AND RADICAL DISSECTION 58954 58954 360 100.00 0.00 FOR DEBULKING; WITH PELVIC LYMPHADENECTOMY AND L Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUBE TRACT, BASKET, 47630 47630 360 100.00 0.00 OR SNARE (EG, BURHENNE TECHNIQUE)

BILIARY ENDOSCOPY, INTRAOPERATIVE (CHOLEDOCHOSCOPY) (LIST SEPARATELY IN 47550 47550 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY 47552 47552 360 100.00 0.00 BRUSHING AND/OR WASHING (SEPARATE PROCEDURE) BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; WITH BIOPSY, SINGLE 47553 47553 360 100.00 0.00 OR MULTIPLE BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; WITH DILATION OF 47556 47556 360 100.00 0.00 BILIARY DUCT STRICTURE(S) WITH STENT

BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; WITH DILATION OF 47555 47555 360 100.00 0.00 BILIARY DUCT STRICTURE(S) WITHOUT STENT BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; WITH REMOVAL OF 47554 47554 360 100.00 0.00 CALCULUS/CALCULI BILIRUBIN, DIRECT 82248 82248 301 50.00 100.00 50.00 BILIRUBIN, TOTAL 82247 82247 301 50.00 100.00 50.00 BIOPSY EXTERNAL AUDITORY CANAL 69105 69105 360 100.00 0.00 BIOPSY EXTERNAL EAR 69100 69100 360 6,150.00 100.00 6,150.00 BIOPSY OF ANORECTAL WALL, ANAL 45100 45100 360 100.00 0.00 APPROACH (EG, CONGENITAL MEGACOLON) BIOPSY OF BREAST; OPEN, INCISIONAL 19101 19101 360 9,950.00 100.00 9,950.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BIOPSY OF BREAST; PERCUTANEOUS, AUTOMATED VACUUM ASSISTED OR ROTATING 19103 19103 360 100.00 0.00 BIOPSY DEVICE, USING IMAGING GUIDANCE BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE CORE, NOT USING IMAGING GUIDANCE 19100 19100 360 2,250.00 100.00 2,250.00 (SEPARATE PROCEDURE) BIOPSY OF BREAST; PERCUTANEOUS, NEEDLE 19102 19102 360 100.00 0.00 CORE, USING IMAGING GUIDANCE BIOPSY OF CONJUNCTIVA 68100 68100 360 100.00 0.00 BIOPSY OF CORNEA 65410 65410 360 100.00 0.00 BIOPSY OF EPIDIDYMIS, NEEDLE 54800 54800 360 100.00 0.00 BIOPSY OF EXTRAOCULAR MUSCLE 67350 67350 360 100.00 0.00 BIOPSY OF EYELID 67810 67810 360 100.00 0.00 BIOPSY OF FLOOR OF MOUTH 41108 41108 360 3,800.00 100.00 3,800.00 BIOPSY OF INTESTINE BY CAPSULE, TUBE, 44100 44100 360 100.00 0.00 PERORAL (ONE OR MORE SPECIMENS) BIOPSY OF LACRIMAL GLAND 68510 68510 360 7,050.00 100.00 7,050.00 BIOPSY OF LACRIMAL SAC 68525 68525 360 100.00 0.00 BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS 47000 47000 360 7,190.00 100.00 7,190.00

BIOPSY OF LIVER, NEEDLE; WHEN DONE FOR INDICATED PURPOSE AT TIME OF OTHER MAJOR 47001 47001 360 2,200.00 100.00 2,200.00 PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) BIOPSY OF LIVER, WEDGE 47100 47100 360 100.00 0.00 BIOPSY OF NAIL UNIT (EG, PLATE, BED, MATRIX, HYPONYCHIUM, PROXIMAL AND LATERAL NAIL 11755 11755 360 100.00 0.00 FOLDS) (SEPARATE PROCEDURE) BIOPSY OF NERVE 64795 64795 360 8,610.00 100.00 8,610.00 BIOPSY OF OVARY, UNILATERAL OR BILATERAL 58900 58900 360 100.00 0.00 (SEPARATE PROCEDURE) BIOPSY OF PALATE, UVULA 42100 42100 360 100.00 0.00 BIOPSY OF PANCREAS, OPEN (EG, FINE NEEDLE ASPIRATION, NEEDLE CORE BIOPSY, WEDGE 48100 48100 360 100.00 0.00 BIOPSY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE 48102 48102 360 100.00 0.00 BIOPSY OF PENIS; (SEPARATE PROCEDURE) 54100 54100 360 100.00 0.00 BIOPSY OF PENIS; DEEP STRUCTURES 54105 54105 360 100.00 0.00 BIOPSY OF SALIVARY GLAND; INCISIONAL 42405 42405 360 8,900.00 100.00 8,900.00 BIOPSY OF SALIVARY GLAND; NEEDLE 42400 42400 360 2,250.00 100.00 2,250.00

BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING 11101 11101 360 100.00 0.00 SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); EACH SEPARATE/ADD

BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING 11100 11100 360 700.00 100.00 700.00 SIMPLE CLOSURE), UNLESS OTHERWISE LISTED (SEPARATE PROCEDURE); SINGLE LESION BIOPSY OF SPINAL CORD, PERCUTANEOUS 62269 62269 360 100.00 0.00 NEEDLE BIOPSY OF STOMACH; BY CAPSULE, TUBE, 43600 43600 360 100.00 0.00 PERORAL (ONE OR MORE SPECIMENS) BIOPSY OF STOMACH; BY LAPAROTOMY 43605 43605 360 100.00 0.00 BIOPSY OF TESTIS, INCISIONAL (SEPARATE 54505 54505 360 100.00 0.00 PROCEDURE) BIOPSY OF TESTIS, NEEDLE (SEPARATE 54500 54500 360 100.00 0.00 PROCEDURE) BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS 41100 41100 360 3,000.00 100.00 3,000.00

BIOPSY OF TONGUE; POSTERIOR ONE-THIRD 41105 41105 360 100.00 0.00 BIOPSY OF URETHRA 53200 53200 360 100.00 0.00 BIOPSY OF VAGINAL MUCOSA; EXTENSIVE, 57105 57105 360 8,450.00 100.00 8,450.00 REQUIRING SUTURE (INCLUDING CYSTS) BIOPSY OF VAGINAL MUCOSA; SIMPLE 57100 57100 360 2,250.00 100.00 2,250.00 (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BIOPSY OF VULVA OR PERINEUM (SEPARATE PROCEDURE); EACH SEPARATE ADDITIONAL 56606 56606 360 100.00 0.00 LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) BIOPSY OF VULVA OR PERINEUM (SEPARATE 56605 56605 360 2,250.00 100.00 2,250.00 PROCEDURE); ONE LESION BIOPSY OR EXCISION OF LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (EG, CERVICAL, 38505 38505 360 10,750.00 100.00 10,750.00 INGUINAL, AXILLARY) BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, 38525 38525 360 10,750.00 100.00 10,750.00 DEEP AXILLARY NODE(S) BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, 38510 38510 360 10,750.00 100.00 10,750.00 DEEP CERVICAL NODE(S) BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, DEEP CERVICAL NODE(S) WITH EXCISION 38520 38520 360 10,750.00 100.00 10,750.00 SCALENE FAT PAD BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, 38530 38530 360 100.00 0.00 INTERNAL MAMMARY NODE(S) BIOPSY OR EXCISION OF LYMPH NODE(S); OPEN, 38500 38500 360 10,750.00 100.00 10,750.00 SUPERFICIAL BIOPSY THYROID, PERCUTANEOUS CORE 60100 60100 360 2,250.00 100.00 2,250.00 NEEDLE BIOPSY, ABDOMINAL OR RETROPERITONEAL 49180 49180 360 100.00 0.00 MASS, PERCUTANEOUS NEEDLE BIOPSY, BONE, EXCISIONAL; DEEP (EG, 20245 20245 360 8,350.00 100.00 8,350.00 HUMERUS, ISCHIUM, FEMUR) BIOPSY, BONE, EXCISIONAL; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS PROCESS, RIBS, 20240 20240 360 100.00 0.00 TROCHANTER OF FEMUR) BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (EG, 20225 20225 360 100.00 0.00 VERTEBRAL BODY, FEMUR) BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (EG, ILIUM, STERNUM, SPINOUS 20220 20220 360 100.00 0.00 PROCESS, RIBS) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and 19308 19308 360 41,500.00 100.00 41,500.00 imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance BIOPSY, INTRANASAL 30100 30100 360 3,000.00 100.00 3,000.00 BIOPSY, LUNG OR MEDIASTINUM, 32405 32405 360 100.00 0.00 PERCUTANEOUS NEEDLE BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE 20206 20206 360 100.00 0.00 BIOPSY, MUSCLE; DEEP 20205 20205 360 6,150.00 100.00 6,150.00 BIOPSY, MUSCLE; SUPERFICIAL 20200 20200 360 6,150.00 100.00 6,150.00 BIOPSY, PLEURA; OPEN 32402 32402 360 100.00 0.00 BIOPSY, PLEURA; PERCUTANEOUS NEEDLE 32400 32400 360 100.00 0.00 BIOPSY, PROSTATE; INCISIONAL, ANY 55705 55705 360 9,950.00 100.00 9,950.00 APPROACH BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE 55700 55700 360 6,700.00 100.00 6,700.00 OR MULTIPLE, ANY APPROACH BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, WITH OR WITHOUT 57500 57500 360 100.00 0.00 FULGURATION (SEPARATE PROCEDURE) BIOPSY, SOFT TISSUE OF BACK OR FLANK; DEEP 21925 21925 360 9,760.00 100.00 9,760.00 BIOPSY, SOFT TISSUE OF BACK OR FLANK; 21920 21920 360 3,800.00 100.00 3,800.00 SUPERFICIAL BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST; DEEP (SUBFASCIAL OR 25066 25066 360 100.00 0.00 INTRAMUSCULAR) BIOPSY, SOFT TISSUE OF FOREARM AND/OR 25065 25065 360 100.00 0.00 WRIST; SUPERFICIAL BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; 27614 27614 360 100.00 0.00 DEEP (SUBFASCIAL OR INTRAMUSCULAR) BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA; 27613 27613 360 100.00 0.00 SUPERFICIAL BIOPSY, SOFT TISSUE OF NECK OR THORAX 21550 21550 360 6,150.00 100.00 6,150.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; 27041 27041 360 100.00 0.00 DEEP, SUBFASCIAL OR INTRAMUSCULAR BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA; 27040 27040 360 100.00 0.00 SUPERFICIAL BIOPSY, SOFT TISSUE OF SHOULDER AREA; 23066 23066 360 100.00 0.00 DEEP BIOPSY, SOFT TISSUE OF SHOULDER AREA; 23065 23065 360 100.00 0.00 SUPERFICIAL BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; 27324 27324 360 10,850.00 100.00 10,850.00 DEEP (SUBFASCIAL OR INTRAMUSCULAR) BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA; 27323 27323 360 100.00 0.00 SUPERFICIAL BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW 24066 24066 360 7,230.00 100.00 7,230.00 AREA; DEEP (SUBFASCIAL OR INTRAMUSCULAR) BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW 24065 24065 360 100.00 0.00 AREA; SUPERFICIAL BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR 20251 20251 360 100.00 0.00 CERVICAL BIOPSY, VERTEBRAL BODY, OPEN; THORACIC 20250 20250 360 100.00 0.00 BIOPSY, VESTIBULE OF MOUTH 40808 40808 360 1,700.00 100.00 1,700.00 BIOPSY; HYPOPHARYNX 42802 42802 360 550.00 100.00 550.00 BIOPSY; NASOPHARYNX, SURVEY FOR 42806 42806 360 100.00 0.00 UNKNOWN PRIMARY LESION BIOPSY; NASOPHARYNX, VISIBLE LESION, 42804 42804 360 5,800.00 100.00 5,800.00 SIMPLE BIOPSY; OROPHARYNX 42800 42800 360 3,000.00 100.00 3,000.00 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT (INCLUDING 51720 51720 360 100.00 0.00 DETENTION TIME) BLADDER IRRIGATION, SIMPLE, LAVAGE 51700 51700 360 100.00 0.00 AND/OR INSTILLATION BLD OCCULT FECAL HGB IMMUN 82274 82274 301 150.00 100.00 150.00 BLEEDING TIME 85002 85002 305 140.00 100.00 140.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee BLEPHAROPLASTY, LOWER EYELID; 15820 15820 360 6,450.00 100.00 6,450.00 BLEPHAROPLASTY, LOWER EYELID; WITH 15821 15821 360 6,450.00 100.00 6,450.00 EXTENSIVE HERNIATED FAT PAD BLEPHAROPLASTY, UPPER EYELID; 15822 15822 360 6,450.00 100.00 6,450.00 BLEPHAROPLASTY, UPPER EYELID; WITH 15823 15823 360 6,450.00 100.00 6,450.00 EXCESSIVE SKIN WEIGHTING DOWN LID BLEPHAROTOMY, DRAINAGE OF ABSCESS, 67700 67700 360 100.00 0.00 EYELID BLOOD COUNT; BLOOD SMEAR, MICROSCOPIC EXAMINATION WITH MANUAL DIFFERENTIAL 85007 85007 305 100.00 100.00 100.00 WBC COUNT BLOOD COUNT; COMPLETE (CBC), AUTOMATED 85027 85027 305 120.00 100.00 120.00 (HGB, HCT, RBC, WBC AND PLATELET COUNT)

BLOOD COUNT; COMPLETE (CBC), AUTOMATED (HGB, HCT, RBC, WBC AND PLATELET COUNT) 85025 85025 305 130.00 100.00 130.00 AND AUTOMATED DIFFERENTIAL WBC COUNT BLOOD COUNT; HEMATOCRIT (HCT) 85014 85014 305 70.00 100.00 70.00 BLOOD COUNT; HEMOGLOBIN (HGB) 85018 85018 305 70.00 100.00 70.00 BLOOD COUNT; SPUN MICROHEMATOCRIT 85013 85013 305 70.00 100.00 70.00 BLOOD TYPE; ANTIGEN SCREEN COMPATIBLE 86903 86903 302 100.00 100.00 100.00 Blood typing, serologic; ABO 86900 86900 302 100.00 100.00 100.00 BLOOD TYPING; ANTIGEN SCREENING FOR COMPATIBLE UNIT USING PATIENT SERUM, PER 86904 86904 300 100.00 0.00 UNIT SCREENED BLOOD TYPING; ANTIGEN TESTING OF DONOR BLOOD USING REAGENT SERUM, EACH ANTIGEN 86902 86902 302 70.00 100.00 70.00 TEST BLOOD TYPING; RH (D) 86901 86901 302 60.00 100.00 60.00 BLOOD TYPING; RH PHENOTYPING, COMPLETE 86906 86906 302 100.00 100.00 100.00 BODY FLUID CELL COUNT 89050 89050 920 130.00 100.00 130.00 BODY FLUID CELL COUNT W/DIFF 89051 89051 301 110.00 100.00 110.00 BONE AGE STUDIES 76020 76020 329 100.00 0.00 BONE AGE STUDY 77072 77072 320 450.00 100.00 450.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee BONE GRAFT WITH MICROVASCULAR 20955 20955 360 100.00 0.00 ANASTOMOSIS; FIBULA BONE GRAFT WITH MICROVASCULAR 20956 20956 360 100.00 0.00 ANASTOMOSIS; ILIAC CREST BONE GRAFT WITH MICROVASCULAR 20957 20957 360 100.00 0.00 ANASTOMOSIS; METATARSAL BONE GRAFT WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN FIBULA, ILIAC 20962 20962 360 14,350.00 100.00 14,350.00 CREST, OR METATARSAL BONE GRAFT, ANY DONOR AREA; MAJOR OR 20902 20902 360 11,900.00 100.00 11,900.00 LARGE BONE GRAFT, ANY DONOR AREA; MINOR OR 20900 20900 360 11,900.00 100.00 11,900.00 SMALL (EG, DOWEL OR BUTTON) BONE GRAFT, FEMORAL HEAD, NECK, INTERTROCHANTERIC OR SUBTROCHANTERIC 27170 27170 360 100.00 0.00 AREA (INCLUDES OBTAINING BONE GRAFT)

Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision (List 20939 20939 360 11,900.00 100.00 11,900.00 separately in addition to code for primary procedure) BONE MARROW HARVESTING FOR 38232 38232 360 11,900.00 100.00 11,900.00 TRANSPLANTATION; AUTOLOGOUS BONE MARROW; ASPIRATION ONLY 38220 38220 360 100.00 0.00 BORRELIA BURGDOFERI ANTIBODY 86618 86618 302 360.00 100.00 360.00 BORRELIA BURGDORFERI ANTIBODY C 86617 86617 302 270.00 100.00 270.00 BREAST RECONSTRUCTION WITH FREE FLAP 19364 19364 360 100.00 0.00 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITH OR WITHOUT PROSTHETIC 19361 19361 360 100.00 0.00 IMPLANT BREAST RECONSTRUCTION WITH OTHER 19366 19366 360 13,800.00 100.00 13,800.00 TECHNIQUE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP 19369 19369 360 100.00 0.00 (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE

BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP 19367 19367 360 100.00 0.00 (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE;

BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP 19368 19368 360 100.00 0.00 (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR A BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING 19357 19357 360 34,150.00 100.00 34,150.00 SUBSEQUENT EXPANSION BRONCHODILAT RESPN PRE & POST OP 94060 94060 460 1,100.00 100.00 1,100.00 BRONCHOGRAPHY, BILATERAL, RADIOLOGICAL 71060 71060 324 100.00 0.00 SUPERVISION AND INTERPRETATION BRONCHOGRAPHY, UNILATERAL, RADIOLOGICAL SUPERVISION AND 71040 71040 324 100.00 0.00 INTERPRETATION BRONCHOPLASTY; EXCISION STENOSIS AND 31775 31775 360 100.00 0.00 ANASTOMOSIS BRONCHOPLASTY; GRAFT REPAIR 31770 31770 360 100.00 0.00 BRONCHOSCOPY (RIGID OR FLEXIBLE); DIAGNOSTIC, WITH OR WITHOUT CELL 31622 31622 360 100.00 0.00 WASHING (SEPARATE PROCEDURE) BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31625 31625 360 100.00 0.00 BIOPSY BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31624 31624 360 100.00 0.00 BRONCHIAL ALVEOLAR LAVAGE BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31623 31623 360 100.00 0.00 BRUSHING OR PROTECTED BRUSHINGS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31640 31640 360 100.00 0.00 EXCISION OF TUMOR BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31635 31635 360 100.00 0.00 REMOVAL OF FOREIGN BODY BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH TRACHEAL DILATION AND PLACEMENT OF 31631 31631 360 100.00 0.00 TRACHEAL STENT BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH TRACHEAL OR BRONCHIAL DILATION OR 31630 31630 360 10,350.00 100.00 10,350.00 CLOSED REDUCTION OF FRACTURE

BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH TRANSBRONCHIAL LUNG BIOPSY, WITH OR 31628 31628 360 100.00 0.00 WITHOUT FLUOROSCOPIC GUIDANCE

BRONCHOSCOPY (RIGID OR FLEXIBLE); WITH 31629 31629 360 100.00 0.00 TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN 31641 31641 360 100.00 0.00 EXCISION (EG, LASER THERAPY, CRYOTHERAPY) BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH INJECTION OF CONTRAST MATERIAL FOR 31656 31656 360 100.00 0.00 SEGMENTAL BRONCHOGRAPHY (FIBERSCOPE ONLY) BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH PLACEMENT OF CATHETER(S) FOR 31643 31643 360 100.00 0.00 INTRACAVITARY RADIOELEMENT APPLICATION BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION OF 31645 31645 360 100.00 0.00 TRACHEOBRONCHIAL TREE, INITIAL (EG, DRAINAGE OF LUNG ABSCESS) BRONCHOSCOPY, (RIGID OR FLEXIBLE); WITH THERAPEUTIC ASPIRATION OF 31646 31646 360 100.00 0.00 TRACHEOBRONCHIAL TREE, SUBSEQUENT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING INJECTION OF GAS, CONTRAST 61120 61120 360 100.00 0.00 MEDIA, DYE, OR RADIOACTIVE MATERIAL)

BURR HOLE(S) OR TREPHINE, INFRATENTORIAL, 61253 61253 360 100.00 0.00 UNILATERAL OR BILATERAL BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL, EXPLORATORY, NOT FOLLOWED BY OTHER 61250 61250 360 100.00 0.00 SURGERY BURR HOLE(S) OR TREPHINE; WITH BIOPSY OF 61140 61140 360 100.00 0.00 BRAIN OR INTRACRANIAL LESION BURR HOLE(S) OR TREPHINE; WITH DRAINAGE 61150 61150 360 100.00 0.00 OF BRAIN ABSCESS OR CYST BURR HOLE(S) OR TREPHINE; WITH SUBSEQUENT TAPPING (ASPIRATION) OF 61151 61151 360 100.00 0.00 INTRACRANIAL ABSCESS OR CYST BURR HOLE(S) WITH EVACUATION AND/OR DRAINAGE OF HEMATOMA, EXTRADURAL OR 61154 61154 360 100.00 0.00 SUBDURAL BURR HOLE(S); FOR IMPLANTING VENTRICULAR CATHETER, RESERVOIR, EEG ELECTRODE(S) OR 61210 61210 360 100.00 0.00 PRESSURE RECORDING DEVICE (SEPARATE PROCEDURE) BURR HOLE(S); WITH ASPIRATION OF 61156 61156 360 100.00 0.00 HEMATOMA OR CYST, INTRACEREBRAL C DIFF AMPLIFIED PROBE 87493 87493 306 250.00 100.00 250.00 C REACTIVE PROTEIN 86140 86140 302 100.00 100.00 100.00 C REACTIVE PROTEIN HIGH SENSITIVITY 86141 86141 302 140.00 100.00 140.00 CA-125 86304 86304 302 370.00 100.00 370.00 CA19-9 86301 86301 302 260.00 100.00 260.00 CALCIUM 82310 82310 301 50.00 100.00 50.00 CALCIUM URINE QUANTITATIVE 82340 82340 301 60.00 100.00 60.00 CALCIUM, IONIZED 82330 82330 301 140.00 100.00 140.00 CALCIUM; IONIZED 82230 82230 301 140.00 100.00 140.00 CANTHOPLASTY (RECONSTRUCTION OF 67950 67950 360 100.00 0.00 CANTHUS) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CANTHOTOMY (SEPARATE PROCEDURE) 67715 67715 360 100.00 0.00 CAPSULAR CONTRACTURE RELEASE (EG, SEVER 23020 23020 360 11,900.00 100.00 11,900.00 TYPE PROCEDURE) CAPSULECTOMY OR CAPSULOTOMY, HIP, WITH OR WITHOUT EXCISION OF HETEROTOPIC BONE, 27036 27036 360 100.00 0.00 WITH RELEASE OF HIP FLEXOR MUSCLES (IE, GLUTEUS MEDIUS, GLUTEUS MINIMU CAPSULECTOMY OR CAPSULOTOMY; 26525 26525 360 8,500.00 100.00 8,500.00 INTERPHALANGEAL JOINT, EACH JOINT CAPSULECTOMY OR CAPSULOTOMY; 26520 26520 360 100.00 0.00 METACARPOPHALANGEAL JOINT, EACH JOINT CAPSULODESIS, METACARPOPHALANGEAL 26516 26516 360 100.00 0.00 JOINT; SINGLE DIGIT CAPSULODESIS, METACARPOPHALANGEAL 26518 26518 360 100.00 0.00 JOINT; THREE OR FOUR DIGITS CAPSULODESIS, METACARPOPHALANGEAL 26517 26517 360 100.00 0.00 JOINT; TWO DIGITS CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, OPEN (EG, CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) 25320 25320 360 17,250.00 100.00 17,250.00 (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY CAPSULORRHAPHY, ANTERIOR, ANY TYPE; 23460 23460 360 28,950.00 100.00 28,950.00 WITH BONE BLOCK CAPSULORRHAPHY, ANTERIOR, ANY TYPE; 23462 23462 360 17,250.00 100.00 17,250.00 WITH CORACOID PROCESS TRANSFER CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT 23450 23450 360 28,950.00 100.00 28,950.00 PROCEDURE OR MAGNUSON TYPE OPERATION

CAPSULORRHAPHY, ANTERIOR; WITH LABRAL 23455 23455 360 28,950.00 100.00 28,950.00 REPAIR (EG, BANKART PROCEDURE)

CAPSULORRHAPHY, GLENOHUMERAL JOINT, 23466 23466 360 17,250.00 100.00 17,250.00 ANY TYPE MULTI-DIRECTIONAL INSTABILITY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CAPSULORRHAPHY, GLENOHUMERAL JOINT, 23465 23465 360 17,250.00 100.00 17,250.00 POSTERIOR, WITH OR WITHOUT BONE BLOCK

CAPSULOTOMY, MIDFOOT; EXTENSIVE, INCLUDING POSTERIOR TALOTIBIAL 28262 28262 360 100.00 0.00 CAPSULOTOMY AND TENDON(S) LENGTHENING (EG, RESISTANT CLUBFOOT DEFORMITY) CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE 28260 28260 360 100.00 0.00 ONLY (SEPARATE PROCEDURE) CAPSULOTOMY, MIDFOOT; WITH TENDON 28261 28261 360 100.00 0.00 LENGTHENING CAPSULOTOMY, MIDTARSAL (EG, HEYMAN 28264 28264 360 100.00 0.00 TYPE PROCEDURE) CAPSULOTOMY, POSTERIOR CAPSULAR 27435 27435 360 100.00 0.00 RELEASE, KNEE CAPSULOTOMY, WRIST (EG, CONTRACTURE) 25085 25085 360 100.00 0.00

CAPSULOTOMY; INTERPHALANGEAL JOINT, 28272 28272 360 8,000.00 100.00 8,000.00 EACH JOINT (SEPARATE PROCEDURE)

CAPSULOTOMY; METATARSOPHALANGEAL JOINT, WITH OR WITHOUT TENORRHAPHY, 28270 28270 360 8,000.00 100.00 8,000.00 EACH JOINT (SEPARATE PROCEDURE) CARBAMAZEPINE; TOTAL 80156 80156 300 100.00 0.00 CARBON DIOXIDE (BICARBONATE) 82374 82374 301 50.00 100.00 50.00 CARCINOEMBRYONIC AG 82378 82378 301 200.00 100.00 200.00 CARDIOLIPIN ANTIBODY EACH 86147 86147 302 330.00 100.00 330.00 CARINAL RECONSTRUCTION 31766 31766 360 100.00 0.00 CARPECTOMY; ALL BONES OF PROXIMAL ROW 25215 25215 360 100.00 0.00 CARPECTOMY; ONE BONE 25210 25210 360 11,900.00 100.00 11,900.00 CARTILAGE GRAFT; COSTOCHONDRAL 20910 20910 360 100.00 0.00 CARTILAGE GRAFT; NASAL SEPTUM 20912 20912 360 100.00 0.00 CATHETER ASPIRATION (SEPARATE 31720 31720 360 100.00 0.00 PROCEDURE); NASOTRACHEAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CATHETER ASPIRATION (SEPARATE PROCEDURE); TRACHEOBRONCHIAL WITH 31725 31725 360 100.00 0.00 FIBERSCOPE, BEDSIDE CATHETER BALLOON DILATATION, C1726-G C1726 278 700.00 0.00 NONVASCULAR CATHETER BALLOON DILATATION\ C1726-W C1726 278 100.00 0.00 NONVASCULAR CATHETER URETERAL C1758-W C1758 278 100.00 0.00 CATHETER, ELECTTOPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR C1733-W C1733 278 100.00 0.00 VECTOR MAPPING, OTHER THAN COOL-TIP ( CATH, EP, OTHER THAN COOL-TIP CATHETER, ELECTTOPHYSIOLOGY, DIAGNOSTIC/ABLATION, OTHER THAN 3D OR C1733-G C1733 278 100.00 0.00 VECTOR MAPPING, OTHER THAN COOL-TIP ( CATH, EP, OTHER THAN COOL-TIP ) CATHETER, INTRASPINAL C1755 C1755 278 6,965.00 700.00 48,755.00 CATHETER, URETERAL C1758-G C1758 278 700.00 0.00 CATHETERIZATION AND INTRODUCTION OF SALINE OR CONTRAST MATERIAL FOR 58340 58340 360 1,450.00 100.00 1,450.00 HYSTEROSONOGRAPHY OR HYSTEROSALPINGOGRAPHY CATHETERIZATION FOR BRONCHOGRAPHY, WITH OR WITHOUT INSTILLATION OF CONTRAST 31710 31710 360 100.00 0.00 MATERIAL CATHETERIZATION WITH BRONCHIAL BRUSH 31717 31717 360 100.00 0.00 BIOPSY CATHETERIZATION, TRANSGLOTTIC (SEPARATE 31700 31700 360 100.00 0.00 PROCEDURE) CAUTERY AND/OR ABLATION, MUCOSA OF TURBINATES, UNILATERAL OR BILATERAL, ANY 30802 30802 360 6,270.00 100.00 6,270.00 METHOD, (SEPARATE PROCEDURE); INTRAMURAL CAUTERY AND/OR ABLATION, MUCOSA OF TURBINATES, UNILATERAL OR BILATERAL, ANY 30801 30801 360 3,000.00 100.00 3,000.00 METHOD, (SEPARATE PROCEDURE); SUPERFICIAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CAUTERY OF CERVIX; CRYOCAUTERY, INITIAL 57511 57511 360 1,560.00 100.00 1,560.00 OR REPEAT CAUTERY OF CERVIX; ELECTRO OR THERMAL 57510 57510 360 100.00 0.00 CAUTERY OF CERVIX; LASER ABLATION 57513 57513 360 8,450.00 100.00 8,450.00 CCP CYCLIC CITRULLINATED PEPTI 86200 86200 302 210.00 100.00 210.00 CENTRALIZATION OF WRIST ON ULNA (EG, 25335 25335 360 100.00 0.00 RADIAL CLUB HAND) CEPHALOGRAM, ORTHODONTIC 70350 70350 320 100.00 0.00 CERCLAGE OF CERVIX, DURING PREGNANCY; 59320 59320 360 100.00 0.00 VAGINAL CERCLAGE OF UTERINE CERVIX, 57700 57700 360 100.00 0.00 NONOBSTETRICAL CERULOPLASMIN 82390 82390 301 230.00 100.00 230.00 CERVICOPLASTY 15819 15819 360 100.00 0.00 CHANGE OF CYSTOSTOMY TUBE; COMPLICATED 51710 51710 360 100.00 0.00 CHANGE OF CYSTOSTOMY TUBE; SIMPLE 51705 51705 360 100.00 0.00 CHANGE OF GASTROSTOMY TUBE 43760 43760 360 900.00 100.00 900.00 CHANGE OF NEPHROSTOMY OR PYELOSTOMY 50398 50398 360 100.00 0.00 TUBE CHANGE OF PERCUTANEOUS BILIARY 47525 47525 360 100.00 0.00 DRAINAGE CATHETER CHANGE OF URETEROSTOMY TUBE 50688 50688 360 100.00 0.00 CHEMICAL EXFOLIATION FOR ACNE (EG, ACNE 17360 17360 360 100.00 0.00 PASTE, ACID) CHEMICAL PEEL, FACIAL; DERMAL 15789 15789 360 100.00 0.00 CHEMICAL PEEL, FACIAL; EPIDERMAL 15788 15788 360 100.00 0.00 CHEMICAL PEEL, NONFACIAL; DERMAL 15793 15793 360 100.00 0.00 CHEMICAL PEEL, NONFACIAL; EPIDERMAL 15792 15792 360 100.00 0.00 CHEMICAL PLEURODESIS (EG, FOR RECURRENT 32005 32005 360 100.00 0.00 OR PERSISTENT PNEUMOTHORAX) CHEMODENERVATION OF EXTRAOCULAR 67345 67345 360 100.00 0.00 MUSCLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CHEMODENERVATION OF MUSCLE(S); CERVICAL SPINAL MUSCLE(S) (EG, FOR 64613 64613 360 100.00 0.00 SPASMODIC TORTICOLLIS) CHEMODENERVATION OF MUSCLE(S); EXTREMITY(S) AND/OR TRUNK MUSCLE(S) (EG, 64614 64614 360 100.00 0.00 FOR DYSTONIA, CEREBRAL PALSY, MULTIPLE SCLEROSIS) CHEMODENERVATION OF MUSCLE(S); MUSCLE(S) INNERVATED BY FACIAL NERVE (EG, 64612 64612 360 100.00 0.00 FOR BLEPHAROSPASM, HEMIFACIAL SPASM) CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE 17305 17305 360 100.00 0.00 SPECIMENS, MAPPING, COLOR CODING OF S13924 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE 17306 17306 360 100.00 0.00 SPECIMENS, MAPPING, COLOR CODING OF S13925 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE 17307 17307 360 100.00 0.00 SPECIMENS, MAPPING, COLOR CODING OF S13926 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE 17310 17310 360 100.00 0.00 SPECIMENS, MAPPING, COLOR CODING OF S13927 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL 17304 17304 360 100.00 0.00 GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPEC CHLORIDE, URINE 82436 82436 301 50.00 100.00 50.00 CHLORIDE; BLOOD 82435 82435 301 50.00 100.00 50.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CHOLANGIO COMPL DX PROCESS EXISTING 47531 47531 320 1,600.00 100.00 1,600.00 ACCESS CHOLANGIO COMPL DX PROCESS; NEW ACCESS 47532 47532 320 1,600.00 100.00 1,600.00 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; ADDITIONAL SET INTRAOPERATIVE, RADIOLOGICAL 74301 74301 329 100.00 0.00 SUPERVISION AND INTERPRETATION (LIST SEPARATELY IN ADDITION TO COD CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY; INTRAOPERATIVE, 74300 74300 320 500.00 100.00 500.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION CHOLANGIOGRAPHY, PERCUTANEOUS, TRANSHEPATIC, RADIOLOGICAL SUPERVISION 74320 74320 329 100.00 0.00 AND INTERPRETATION CHOLECYSTECTOMY WITH EXPLORATION OF 47610 47610 360 100.00 0.00 COMMON DUCT; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH 47612 47612 360 100.00 0.00 CHOLEDOCHOENTEROSTOMY CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT; WITH TRANSDUODENAL 47620 47620 360 100.00 0.00 SPHINCTEROTOMY OR SPHINCTEROPLASTY, WITH OR WITHOUT CHOLANGIOGRAPHY CHOLECYSTECTOMY; 47600 47600 360 100.00 0.00 CHOLECYSTECTOMY; WITH 47605 47605 360 10,500.00 100.00 10,500.00 CHOLANGIOGRAPHY CHOLECYSTOENTEROSTOMY; DIRECT 47720 47720 360 100.00 0.00 CHOLECYSTOENTEROSTOMY; ROUX-EN-Y 47740 47740 360 100.00 0.00 CHOLECYSTOENTEROSTOMY; ROUX-EN-Y WITH 47741 47741 360 100.00 0.00 GASTROENTEROSTOMY CHOLECYSTOENTEROSTOMY; WITH 47721 47721 360 100.00 0.00 GASTROENTEROSTOMY CHOLECYSTOGRAPHY, ORAL CONTRAST; 74290 74290 329 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CHOLECYSTOGRAPHY, ORAL CONTRAST; ADDITIONAL OR REPEAT EXAMINATION OR 74291 74291 329 100.00 0.00 MULTIPLE DAY EXAMINATION CHOLESTEROL, SERUM OR WHOLE BLOOD, 82465 82465 301 50.00 100.00 50.00 TOTAL CHROMATOGRAPHY QUAN COLUMN 82491 82491 301 160.00 100.00 160.00 CHROMOSOME ANALYSIS; COUNT 15-20 CELLS, 2 88262 88262 300 100.00 0.00 KARYOTYPES, WITH BANDING CHROMOTUBATION OF OVIDUCT, INCLUDING 58350 58350 360 18,200.00 100.00 18,200.00 MATERIALS CILIARY BODY DESTRUCTION; CRYOTHERAPY 66720 66720 360 100.00 0.00

CILIARY BODY DESTRUCTION; CYCLODIALYSIS 66740 66740 360 100.00 0.00 CILIARY BODY DESTRUCTION; 66710 66710 360 100.00 0.00 CYCLOPHOTOCOAGULATION CILIARY BODY DESTRUCTION; DIATHERMY 66700 66700 360 100.00 0.00 CINEPLASTY, UPPER EXTREMITY, COMPLETE 24940 24940 360 100.00 0.00 PROCEDURE CINERADIOGRAPHY/VIDEORADIOGRAPHY, 76120 76120 329 100.00 0.00 EXCEPT WHERE SPECIFICALLY INCLUDED CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE OR DORSAL SLIT; EXCEPT 54161 54161 360 8,300.00 100.00 8,300.00 NEWBORN CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE OR DORSAL SLIT; 54160 54160 360 100.00 0.00 NEWBORN CIRCUMCISION, USING CLAMP OR OTHER 54152 54152 360 100.00 0.00 DEVICE; EXCEPT NEWBORN CIRCUMCISION, USING CLAMP OR OTHER 54150 54150 360 8,300.00 100.00 8,300.00 DEVICE; NEWBORN CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITH INJECTION OF MEDICATION 61055 61055 360 100.00 0.00 OR OTHER SUBSTANCE FOR DIAGNOSIS OR TREATMENT (EG, C1-C2) CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE; WITHOUT INJECTION (SEPARATE 61050 61050 360 100.00 0.00 PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CISTERNOGRAPHY, POSITIVE CONTRAST, RADIOLOGICAL SUPERVISION AND 70015 70015 320 100.00 0.00 INTERPRETATION CLAVICULECTOMY; PARTIAL 23120 23120 360 13,240.00 100.00 13,240.00 CLAVICULECTOMY; TOTAL 23125 23125 360 100.00 0.00 CLITOROPLASTY FOR INTERSEX STATE 56805 56805 360 100.00 0.00 CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITH MANIPULATION, 27222 27222 360 100.00 0.00 WITH OR WITHOUT SKELETAL TRACTION CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S); WITHOUT 27220 27220 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF ACROMIOCLAVICULAR 23545 23545 360 100.00 0.00 DISLOCATION; WITH MANIPULATION

CLOSED TREATMENT OF ACROMIOCLAVICULAR 23540 23540 360 100.00 0.00 DISLOCATION; WITHOUT MANIPULATION

CLOSED TREATMENT OF ANKLE DISLOCATION; REQUIRING ANESTHESIA, WITH OR WITHOUT 27842 27842 360 100.00 0.00 PERCUTANEOUS SKELETAL FIXATION CLOSED TREATMENT OF ANKLE DISLOCATION; 27840 27840 360 100.00 0.00 WITHOUT ANESTHESIA CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR 26742 26742 360 2,130.00 100.00 2,130.00 INTERPHALANGEAL JOINT; WITH MANIPULATION, EACH CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR 26740 26740 360 100.00 0.00 INTERPHALANGEAL JOINT; WITHOUT MANIPULATION, EACH CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, (INCLUDING POTTS); WITH 27810 27810 360 100.00 0.00 MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, (INCLUDING POTTS); WITHOUT 27808 27808 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF CALCANEAL 28405 28405 360 100.00 0.00 FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF CALCANEAL 28400 28400 360 2,110.00 100.00 2,110.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID 25635 25635 360 6,310.00 100.00 6,310.00 (NAVICULAR)); WITH MANIPULATION, EACH BONE CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID 25630 25630 360 100.00 0.00 (NAVICULAR)); WITHOUT MANIPULATION, EACH BONE CLOSED TREATMENT OF CARPAL SCAPHOID 25624 25624 360 100.00 0.00 (NAVICULAR) FRACTURE; WITH MANIPULATION

CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH 26675 26675 360 100.00 0.00 MANIPULATION, EACH JOINT; REQUIRING ANESTHESIA

CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB, WITH 26670 26670 360 100.00 0.00 MANIPULATION, EACH JOINT; WITHOUT ANESTHESIA

CLOSED TREATMENT OF CARPOMETACARPAL 26641 26641 360 100.00 0.00 DISLOCATION, THUMB, WITH MANIPULATION

CLOSED TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT 26645 26645 360 3,190.00 100.00 3,190.00 FRACTURE), WITH MANIPULATION CLOSED TREATMENT OF CLAVICULAR 23505 23505 360 100.00 0.00 FRACTURE; WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF CLAVICULAR 23500 23500 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF COCCYGEAL 27200 27200 360 100.00 0.00 FRACTURE CLOSED TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) USING 21431 21431 360 100.00 0.00 INTERDENTAL WIRE FIXATION OF DENTURE OR SPLINT CLOSED TREATMENT OF DISTAL EXTENSOR TENDON INSERTION, WITH OR WITHOUT 26432 26432 360 6,380.00 100.00 6,380.00 PERCUTANEOUS PINNING (EG, MALLET FINGER) CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; WITH 27517 27517 360 100.00 0.00 MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION; WITHOUT 27516 27516 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITH 27788 27788 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS); WITHOUT 27786 27786 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITH 26755 26755 360 1,000.00 100.00 1,000.00 MANIPULATION, EACH CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB; WITHOUT 26750 26750 360 100.00 0.00 MANIPULATION, EACH CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, WITH OR WITHOUT 25605 25605 360 4,250.00 100.00 4,250.00 FRACTURE OF ULNAR STYLOID; WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR 25600 25600 360 100.00 0.00 EPIPHYSEAL SEPARATION, WITH OR WITHOUT FRACTURE OF ULNAR STYLOID; WITHOUT MAN

CLOSED TREATMENT OF DISTAL RADIOULNAR 25675 25675 360 100.00 0.00 DISLOCATION WITH MANIPULATION CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, 27510 27510 360 100.00 0.00 WITH MANIPULATION CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, 27508 27508 360 100.00 0.00 WITHOUT MANIPULATION

CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITH MANIPULATION, 27232 27232 360 100.00 0.00 WITH OR WITHOUT SKELETAL TRACTION CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK; WITHOUT 27230 27230 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, WITH MANIPULATION, WITH OR 27502 27502 360 100.00 0.00 WITHOUT SKIN OR SKELETAL TRACTION CLOSED TREATMENT OF FEMORAL SHAFT 27500 27500 360 100.00 0.00 FRACTURE, WITHOUT MANIPULATION CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITH 28495 28495 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES; WITHOUT 28490 28490 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF FRACTURE OF ORBIT, 21401 21401 360 100.00 0.00 EXCEPT BLOWOUT; WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF FRACTURE OF ORBIT, 21400 21400 360 100.00 0.00 EXCEPT BLOWOUT; WITHOUT MANIPULATION

CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR 27825 27825 360 7,280.00 100.00 7,280.00 WITHOUT ANESTHESIA; WITH SKELETAL TRACTION AND/OR REQUIRING MANIPULATION CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), WITH OR 27824 27824 360 100.00 0.00 WITHOUT ANESTHESIA; WITHOUT MANIPULATION CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; WITH 28515 28515 360 1,000.00 100.00 1,000.00 MANIPULATION, EACH CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE; 28510 28510 360 100.00 0.00 WITHOUT MANIPULATION, EACH

CLOSED TREATMENT OF GREATER HUMERAL 23625 23625 360 100.00 0.00 TUBEROSITY FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE; WITHOUT 23620 23620 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE, WITHOUT 27246 27246 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF HIP DISLOCATION, 27252 27252 360 100.00 0.00 TRAUMATIC; REQUIRING ANESTHESIA CLOSED TREATMENT OF HIP DISLOCATION, 27250 27250 360 100.00 0.00 TRAUMATIC; WITHOUT ANESTHESIA CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL; WITH 24577 24577 360 100.00 0.00 MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL; WITHOUT 24576 24576 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 24565 24565 360 100.00 0.00 LATERAL; WITH MANIPULATION CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR 24560 24560 360 100.00 0.00 LATERAL; WITHOUT MANIPULATION CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE; WITH MANIPULATION, WITH OR 24505 24505 360 7,040.00 100.00 7,040.00 WITHOUT SKELETAL TRACTION CLOSED TREATMENT OF HUMERAL SHAFT 24500 24500 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF HYOID FRACTURE; 21494 21494 360 100.00 0.00 WITH MANIPULATION CLOSED TREATMENT OF HYOID FRACTURE; 21493 21493 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF 27538 27538 360 100.00 0.00 KNEE, WITH OR WITHOUT MANIPULATION

CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH 26775 26775 360 100.00 0.00 MANIPULATION; REQUIRING ANESTHESIA

CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, WITH 26770 26770 450 800.00 100.00 800.00 MANIPULATION; WITHOUT ANESTHESIA

CLOSED TREATMENT OF INTERPHALANGEAL 28665 28665 360 100.00 0.00 JOINT DISLOCATION; REQUIRING ANESTHESIA

CLOSED TREATMENT OF INTERPHALANGEAL 28660 28660 360 100.00 0.00 JOINT DISLOCATION; WITHOUT ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC 27240 27240 360 100.00 0.00 FEMORAL FRACTURE; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACT

CLOSED TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC 27238 27238 360 100.00 0.00 FEMORAL FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF KNEE DISLOCATION; 27552 27552 360 100.00 0.00 REQUIRING ANESTHESIA CLOSED TREATMENT OF KNEE DISLOCATION; 27550 27550 360 100.00 0.00 WITHOUT ANESTHESIA CLOSED TREATMENT OF LUNATE DISLOCATION, 25690 25690 360 100.00 0.00 WITH MANIPULATION CLOSED TREATMENT OF MANDIBULAR 21453 21453 360 100.00 0.00 FRACTURE WITH INTERDENTAL FIXATION CLOSED TREATMENT OF MANDIBULAR 21451 21451 360 100.00 0.00 FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF MANDIBULAR 21450 21450 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE 21440 21440 360 100.00 0.00 (SEPARATE PROCEDURE) CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE; WITH MANIPULATION, WITH OR 27762 27762 360 100.00 0.00 WITHOUT SKIN OR SKELETAL TRACTION

CLOSED TREATMENT OF MEDIAL MALLEOLUS 27760 27760 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITH MANIPULATION, 26605 26605 360 2,130.00 100.00 2,130.00 EACH BONE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE; WITHOUT MANIPULATION, 26600 26600 360 1,000.00 100.00 1,000.00 EACH BONE CLOSED TREATMENT OF METACARPAL FRACTURE, WITH MANIPULATION, WITH 26607 26607 360 6,000.00 100.00 6,000.00 EXTERNAL FIXATION, EACH BONE CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, 26705 26705 360 100.00 0.00 SINGLE, WITH MANIPULATION; REQUIRING ANESTHESIA CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, 26700 26700 360 100.00 0.00 SINGLE, WITH MANIPULATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF METATARSAL 28475 28475 360 4,210.00 100.00 4,210.00 FRACTURE; WITH MANIPULATION, EACH CLOSED TREATMENT OF METATARSAL 28470 28470 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION, EACH CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION; 28635 28635 360 100.00 0.00 REQUIRING ANESTHESIA CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH 24620 24620 360 100.00 0.00 DISLOCATION OF RADIAL HEAD), WITH MANIPULATION CLOSED TREATMENT OF NASAL BONE 21310 21310 360 2,020.00 100.00 2,020.00 FRACTURE WITHOUT MANIPULATION CLOSED TREATMENT OF NASAL BONE 21320 21320 360 5,800.00 100.00 5,800.00 FRACTURE; WITH STABILIZATION CLOSED TREATMENT OF NASAL BONE 21315 21315 360 5,800.00 100.00 5,800.00 FRACTURE; WITHOUT STABILIZATION CLOSED TREATMENT OF NASAL SEPTAL 21337 21337 360 7,250.00 100.00 7,250.00 FRACTURE, WITH OR WITHOUT STABILIZATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE), WITH 21345 21345 360 100.00 0.00 INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CLOSED TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE), WITH 21421 21421 360 100.00 0.00 INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT CLOSED TREATMENT OF PATELLAR 27562 27562 360 100.00 0.00 DISLOCATION; REQUIRING ANESTHESIA CLOSED TREATMENT OF PATELLAR 27560 27560 360 3,620.00 100.00 3,620.00 DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF PATELLAR FRACTURE, 27520 27520 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR 27194 27194 360 100.00 0.00 SUBLUXATION; WITH MANIPULATION, REQUIRING MORE THAN LOCAL ANESTHESIA CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR 27193 27193 360 100.00 0.00 SUBLUXATION; WITHOUT MANIPULATION CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, 26725 26725 360 3,190.00 100.00 3,190.00 FINGER OR THUMB; WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTI CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, 26720 26720 360 100.00 0.00 FINGER OR THUMB; WITHOUT MANIPULATION, EACH CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; REQUIRING 27266 27266 360 100.00 0.00 REGIONAL OR GENERAL ANESTHESIA CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION; WITHOUT 27265 27265 360 100.00 0.00 ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF PROXIMAL FIBULA OR 27781 27781 360 100.00 0.00 SHAFT FRACTURE; WITH MANIPULATION

CLOSED TREATMENT OF PROXIMAL FIBULA OR 27780 27780 360 100.00 0.00 SHAFT FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; 23605 23605 360 100.00 0.00 WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE; 23600 23600 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION; REQUIRING 27831 27831 360 100.00 0.00 ANESTHESIA CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION; WITHOUT 27830 27830 360 100.00 0.00 ANESTHESIA CLOSED TREATMENT OF RADIAL AND ULNAR 25565 25565 360 4,250.00 100.00 4,250.00 SHAFT FRACTURES; WITH MANIPULATION

CLOSED TREATMENT OF RADIAL AND ULNAR 25560 25560 360 3,160.00 100.00 3,160.00 SHAFT FRACTURES; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL HEAD OR 24655 24655 360 100.00 0.00 NECK FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF RADIAL HEAD OR 24650 24650 360 100.00 0.00 NECK FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, NURSEMAID ELBOW, 24640 24640 360 100.00 0.00 WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF RADIAL SHAFT FRACTURE AND CLOSED TREATMENT OF 25520 25520 360 4,250.00 100.00 4,250.00 DISLOCATION OF DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION) CLOSED TREATMENT OF RADIAL SHAFT 25505 25505 360 4,250.00 100.00 4,250.00 FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF RADIAL SHAFT 25500 25500 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE OR MORE 25660 25660 360 100.00 0.00 BONES, WITH MANIPULATION CLOSED TREATMENT OF RIB FRACTURE, 21800 21800 360 100.00 0.00 UNCOMPLICATED, EACH CLOSED TREATMENT OF SCAPULAR FRACTURE; WITH MANIPULATION, WITH OR WITHOUT 23575 23575 360 100.00 0.00 SKELETAL TRACTION (WITH OR WITHOUT SHOULDER JOINT INVOLVEMENT) CLOSED TREATMENT OF SCAPULAR FRACTURE; 23570 23570 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF SESAMOID FRACTURE 28530 28530 360 100.00 0.00

CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER 23665 23665 360 100.00 0.00 HUMERAL TUBEROSITY, WITH MANIPULATION CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; 23655 23655 360 5,300.00 100.00 5,300.00 REQUIRING ANESTHESIA CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH MANIPULATION; WITHOUT 23650 23650 360 100.00 0.00 ANESTHESIA CLOSED TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR 23675 23675 360 100.00 0.00 ANATOMICAL NECK FRACTURE, WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF SKULL FRACTURE 21300 21300 360 100.00 0.00 WITHOUT OPERATION CLOSED TREATMENT OF STERNOCLAVICULAR 23525 23525 360 100.00 0.00 DISLOCATION; WITH MANIPULATION

CLOSED TREATMENT OF STERNOCLAVICULAR 23520 23520 360 100.00 0.00 DISLOCATION; WITHOUT MANIPULATION

CLOSED TREATMENT OF STERNUM FRACTURE 21820 21820 360 100.00 0.00

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE WITH OR WITHOUT INTERCONDYLAR EXTENSION, 27503 27503 360 100.00 0.00 WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE WITH 27501 27501 360 100.00 0.00 OR WITHOUT INTERCONDYLAR EXTENSION, WITHOUT MANIPULATION

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION; 24535 24535 360 100.00 0.00 WITH MANIPULATION, WITH OR WITHOUT SKIN OR SKELETAL TRACTION

CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, WITH 24530 24530 360 3,610.00 100.00 3,610.00 OR WITHOUT INTERCONDYLAR EXTENSION; WITHOUT MANIPULATION

CLOSED TREATMENT OF TALOTARSAL JOINT 28575 28575 360 100.00 0.00 DISLOCATION; REQUIRING ANESTHESIA CLOSED TREATMENT OF TALUS FRACTURE; 28435 28435 360 100.00 0.00 WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSED TREATMENT OF TALUS FRACTURE; 28430 28430 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL; 28545 28545 360 9,350.00 100.00 9,350.00 REQUIRING ANESTHESIA CLOSED TREATMENT OF TARSOMETATARSAL 28605 28605 360 100.00 0.00 JOINT DISLOCATION; REQUIRING ANESTHESIA

CLOSED TREATMENT OF TARSOMETATARSAL 28600 28600 360 100.00 0.00 JOINT DISLOCATION; WITHOUT ANESTHESIA CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (EG, RECURRENT REQUIRING 21485 21485 360 100.00 0.00 INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL 21480 21480 360 100.00 0.00 OR SUBSEQUENT CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITH OR WITHOUT 27532 27532 360 100.00 0.00 MANIPULATION, WITH SKELETAL TRACTION CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); WITHOUT 27530 27530 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR 27752 27752 360 100.00 0.00 FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR 27750 27750 360 3,640.00 100.00 3,640.00 FRACTURE); WITHOUT MANIPULATION CLOSED TREATMENT OF TRANS- SCAPHOPERILUNAR TYPE OF FRACTURE 25680 25680 360 100.00 0.00 DISLOCATION, WITH MANIPULATION CLOSED TREATMENT OF TRIMALLEOLAR 27818 27818 360 100.00 0.00 ANKLE FRACTURE; WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CLOSED TREATMENT OF TRIMALLEOLAR 27816 27816 360 100.00 0.00 ANKLE FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (OLECRANON PROCESS); WITH 24675 24675 360 100.00 0.00 MANIPULATION CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (OLECRANON PROCESS); 24670 24670 360 100.00 0.00 WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR SHAFT 25535 25535 360 4,250.00 100.00 4,250.00 FRACTURE; WITH MANIPULATION CLOSED TREATMENT OF ULNAR SHAFT 25530 25530 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION CLOSED TREATMENT OF ULNAR STYLOID 25650 25650 360 100.00 0.00 FRACTURE CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), WITHOUT MANIPULATION, 22310 22310 360 100.00 0.00 REQUIRING AND INCLUDING CASTING OR BRACING CLOSED TREATMENT OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S) REQUIRING CASTING OR BRACING, WITH AND 22315 22315 360 100.00 0.00 INCLUDING CASTING AND/OR BRACING, WITH OR WITHOUT ANESTHESIA, BY MANIPULATION OR TRACTION CLOSED TREATMENT OF VERTEBRAL PROCESS 22305 22305 360 100.00 0.00 FRACTURE(S) CLOSTRIDIUM ANTIGEN EIA 87324 87324 306 210.00 100.00 210.00 CLOSURE DEVICE, VASCULAR C1760 C1760 278 700.00 0.00 (IMPLANTABLE/INSERTABLE) CLOSURE OF ANAL FISTULA WITH RECTAL 46288 46288 360 100.00 0.00 ADVANCEMENT FLAP CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE FOR EMPYEMA (CLAGETT TYPE 32810 32810 360 100.00 0.00 PROCEDURE) CLOSURE OF CYSTOSTOMY (SEPARATE 51880 51880 360 100.00 0.00 PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSURE OF ENTEROENTERIC OR 44650 44650 360 100.00 0.00 ENTEROCOLIC FISTULA CLOSURE OF ENTEROSTOMY, LARGE OR SMALL 44620 44620 360 100.00 0.00 INTESTINE; CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND 44625 44625 360 100.00 0.00 ANASTOMOSIS OTHER THAN COLORECTAL CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; WITH RESECTION AND COLORECTAL 44626 44626 360 100.00 0.00 ANASTOMOSIS (EG, CLOSURE OF HARTMANN TYPE PROCEDURE) CLOSURE OF ENTEROVESICAL FISTULA; WITH 44661 44661 360 100.00 0.00 INTESTINE AND/OR BLADDER RESECTION

CLOSURE OF ENTEROVESICAL FISTULA; 44660 44660 360 100.00 0.00 WITHOUT INTESTINAL OR BLADDER RESECTION CLOSURE OF ESOPHAGOSTOMY OR FISTULA; 43420 43420 360 100.00 0.00 CERVICAL APPROACH CLOSURE OF ESOPHAGOSTOMY OR FISTULA; TRANSTHORACIC OR TRANSABDOMINAL 43425 43425 360 100.00 0.00 APPROACH CLOSURE OF GASTROCOLIC FISTULA 43880 43880 360 22,250.00 100.00 22,250.00 CLOSURE OF GASTROSTOMY, SURGICAL 43870 43870 360 17,500.00 100.00 17,500.00 CLOSURE OF INTESTINAL CUTANEOUS FISTULA 44640 44640 360 100.00 0.00 CLOSURE OF LACERATION, VESTIBULE OF 40830 40830 360 100.00 0.00 MOUTH; 2.5 CM OR LESS CLOSURE OF LACERATION, VESTIBULE OF 40831 40831 360 100.00 0.00 MOUTH; OVER 2.5 CM OR COMPLEX CLOSURE OF LACRIMAL FISTULA (SEPARATE 68770 68770 360 100.00 0.00 PROCEDURE) CLOSURE OF MEDIAN STERNOTOMY SEPARATION WITH OR WITHOUT DEBRIDEMENT 21750 21750 360 100.00 0.00 (SEPARATE PROCEDURE) CLOSURE OF NEPHROCUTANEOUS OR 50520 50520 360 100.00 0.00 PYELOCUTANEOUS FISTULA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSURE OF NEPHROVISCERAL FISTULA (EG, RENOCOLIC), INCLUDING VISCERAL REPAIR; 50525 50525 360 100.00 0.00 ABDOMINAL APPROACH CLOSURE OF RECTOURETHRAL FISTULA; 45820 45820 360 100.00 0.00 CLOSURE OF RECTOURETHRAL FISTULA; WITH 45825 45825 360 100.00 0.00 COLOSTOMY CLOSURE OF RECTOVAGINAL FISTULA; 57305 57305 360 100.00 0.00 ABDOMINAL APPROACH CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH, WITH CONCOMITANT 57307 57307 360 100.00 0.00 COLOSTOMY CLOSURE OF RECTOVAGINAL FISTULA; TRANSPERINEAL APPROACH, WITH PERINEAL 57308 57308 360 100.00 0.00 BODY RECONSTRUCTION, WITH OR WITHOUT LEVATOR PLICATION CLOSURE OF RECTOVAGINAL FISTULA; 57300 57300 360 100.00 0.00 VAGINAL OR TRANSANAL APPROACH CLOSURE OF RECTOVESICAL FISTULA; 45800 45800 360 100.00 0.00 CLOSURE OF RECTOVESICAL FISTULA; WITH 45805 45805 360 100.00 0.00 COLOSTOMY CLOSURE OF THE LACRIMAL PUNCTUM; BY 68761 68761 360 100.00 0.00 PLUG, EACH CLOSURE OF THE LACRIMAL PUNCTUM; BY THERMOCAUTERIZATION, LIGATION, OR LASER 68760 68760 360 100.00 0.00 SURGERY CLOSURE OF URETEROCUTANEOUS FISTULA 50920 50920 360 100.00 0.00 CLOSURE OF URETEROVISCERAL FISTULA 50930 50930 360 100.00 0.00 (INCLUDING VISCERAL REPAIR) CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE 53520 53520 360 100.00 0.00 (SEPARATE PROCEDURE) CLOSURE OF URETHROVAGINAL FISTULA; 57310 57310 360 100.00 0.00 CLOSURE OF URETHROVAGINAL FISTULA; WITH 57311 57311 360 100.00 0.00 BULBOCAVERNOSUS TRANSPLANT CLOSURE OF VESICOUTERINE FISTULA; 51920 51920 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CLOSURE OF VESICOUTERINE FISTULA; WITH 51925 51925 360 100.00 0.00 HYSTERECTOMY CLOSURE OF VESICOVAGINAL FISTULA, 51900 51900 360 100.00 0.00 ABDOMINAL APPROACH CLOSURE OF VESICOVAGINAL FISTULA; 57330 57330 360 100.00 0.00 TRANSVESICAL AND VAGINAL APPROACH CLOSURE OF VESICOVAGINAL FISTULA; 57320 57320 360 100.00 0.00 VAGINAL APPROACH CLOSURE POSTAURICULAR FISTULA, MASTOID 69700 69700 360 100.00 0.00 (SEPARATE PROCEDURE) CLOSURE SALIVARY FISTULA 42600 42600 360 100.00 0.00 CLOSURE, EXSTROPHY OF BLADDER 51940 51940 360 100.00 0.00 CLOT FACTOR 11 ACTIVITY 85210 85210 305 100.00 100.00 100.00 CLOT INHIBIT PROTEIN C ACTIVITY 85303 85303 305 420.00 100.00 420.00 CLOT INHIBITPROTEIN S FREE 85306 85306 305 440.00 100.00 440.00 COCCYGECTOMY, PRIMARY 27080 27080 360 11,900.00 100.00 11,900.00 COCHLEAR DEVICE IMPLANTATION, WITH OR 69930 69930 360 100.00 0.00 WITHOUT MASTOIDECTOMY Cochlear device, includes all internal and external L8614-W L8614 278 100.00 0.00 component Cochlear device, includes all internal and external L8614-G L8614 278 700.00 0.00 components COLD AGGLUTININ; SCREEN 86156 86156 302 100.00 100.00 100.00 COLLECTION OF CAPILLARY BLOOD SPECIMEN 36416 36416 301 30.00 100.00 30.00 (EG, FINGER, HEEL, EAR STICK) COLLECTION OF VENOUS BLOOD BY 36415 36415 301 30.00 100.00 30.00 VENIPUNCTURE COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF 44388 44388 360 3,650.00 100.00 3,650.00 SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) COLONOSCOPY THROUGH STOMA; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY 44393 44393 360 100.00 0.00 HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee COLONOSCOPY THROUGH STOMA; WITH 44389 44389 360 3,650.00 100.00 3,650.00 BIOPSY, SINGLE OR MULTIPLE COLONOSCOPY THROUGH STOMA; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, 44391 44391 360 100.00 0.00 LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) COLONOSCOPY THROUGH STOMA; WITH 44390 44390 360 100.00 0.00 REMOVAL OF FOREIGN BODY COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER 44392 44392 360 3,650.00 100.00 3,650.00 LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY COLONOSCOPY THROUGH STOMA; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER 44394 44394 360 3,650.00 100.00 3,650.00 LESION(S) BY SNARE TECHNIQUE COLONOSCOPY THROUGH STOMA; WITH TRANSENDOSCOPIC STENT PLACEMENT 44397 44397 360 100.00 0.00 (INCLUDES PREDILATION) COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY 45378 45378 360 3,650.00 100.00 3,650.00 BRUSHING OR WASHING, WITH OR WITHOUT COLON DECOMPRESSION (SEPARATE PROCEDURE) COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT 45383 45383 360 100.00 0.00 AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH BIOPSY, SINGLE OR 45380 45380 360 3,650.00 100.00 3,650.00 MULTIPLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, 45382 45382 360 3,650.00 100.00 3,650.00 UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DILATION BY 45386 45386 360 3,650.00 100.00 3,650.00 BALLOON, 1 OR MORE STRICTURES COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH DIRECTED 45381 45381 360 3,650.00 100.00 3,650.00 SUBMUCOSAL INJECTION(S), ANY SUBSTANCE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF 45379 45379 360 100.00 0.00 FOREIGN BODY COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF 45384 45384 360 3,650.00 100.00 3,650.00 TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH REMOVAL OF 45385 45385 360 3,650.00 100.00 3,650.00 TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; WITH TRANSENDOSCOPIC 45387 45387 360 100.00 0.00 STENT PLACEMENT (INCLUDES PREDILATION) COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, SINGLE OR 45355 45355 360 100.00 0.00 MULTIPLE COLORECTAL CANCER SCREENING; G0105 G0105 360 100.00 0.00 COLONOSCOPY ON INDIVIDUAL AT HIGH RISK COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING G0121 G0121 360 100.00 0.00 CRITERIA FOR HIGH RISK Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee COLOSTOMY OR SKIN LEVEL CECOSTOMY; 44320 44320 360 100.00 0.00 (SEPARATE PROCEDURE) COLOSTOMY OR SKIN LEVEL CECOSTOMY; WITH MULTIPLE BIOPSIES (EG, FOR 44322 44322 360 100.00 0.00 CONGENITAL MEGACOLON) (SEPARATE PROCEDURE) COLPOCENTESIS (SEPARATE PROCEDURE) 57020 57020 360 100.00 0.00 COLPOCLEISIS (LE FORT TYPE) 57120 57120 360 100.00 0.00 COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM 57210 57210 360 100.00 0.00 (NONOBSTETRICAL) COLPOPEXY, ABDOMINAL APPROACH 57280 57280 360 100.00 0.00 COLPORRHAPHY, SUTURE OF INJURY OF 57200 57200 360 100.00 0.00 VAGINA (NONOBSTETRICAL) COLPOSCOPY OF THE CERVIX INCLUDING 57452 57452 360 600.00 100.00 600.00 UPPER/ADJACENT VAGINA; COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF 57455 57455 360 100.00 0.00 THE CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH BIOPSY(S) OF 57454 57454 360 100.00 0.00 THE CERVIX AND ENDOCERVICAL CURETTAGE COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH 57456 57456 360 100.00 0.00 ENDOCERVICAL CURETTAGE COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP 57460 57460 360 100.00 0.00 ELECTRODE BIOPSY(S) OF THE CERVIX COLPOSCOPY OF THE CERVIX INCLUDING UPPER/ADJACENT VAGINA; WITH LOOP 57461 57461 360 100.00 0.00 ELECTRODE CONIZATION OF THE CERVIX COLPOSCOPY OF THE ENTIRE VAGINA, WITH 57420 57420 360 100.00 0.00 CERVIX IF PRESENT; COLPOSCOPY OF THE ENTIRE VAGINA, WITH 57421 57421 360 2,250.00 100.00 2,250.00 CERVIX IF PRESENT; WITH BIOPSY(S) COLPOSCOPY OF THE VULVA; 56820 56820 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

COLPOSCOPY OF THE VULVA; WITH BIOPSY(S) 56821 56821 360 100.00 0.00 COLPOTOMY; WITH DRAINAGE OF PELVIC 57010 57010 360 100.00 0.00 ABSCESS COLPOTOMY; WITH EXPLORATION 57000 57000 360 100.00 0.00 COMBINED ANTEROPOSTERIOR 57260 57260 360 18,200.00 100.00 18,200.00 COLPORRHAPHY; COMBINED ANTEROPOSTERIOR 57265 57265 360 19,200.00 100.00 19,200.00 COLPORRHAPHY; WITH ENTEROCELE REPAIR

COMMUNITY/WORK REINTEGRATION TRAINING (EG, SHOPPING, TRANSPORTATION, MONEY MANAGEMENT, AVOCATIONAL ACTIVITIES 97537 97537 100.00 0.00 AND/OR WORK ENVIRONMENT/MODIFICATION ANA COMPATABILITY TEST EACH UNIT; ELECTRONIC 86923 86923 302 600.00 100.00 600.00 CROSSMATCH COMPATIBILITY TEST EACH UNIT; 86922 86922 302 600.00 100.00 600.00 ANTIGLOBULIN TECHNIQUE COMPATIBILITY TEST EACH UNIT; IMMEDIATE 86920 86920 302 600.00 100.00 600.00 SPIN TECHNIQUE COMPLEMENT C3/C4 86160 86160 302 300.00 100.00 300.00 COMPLEMENT TOTAL (CH50) 86162 86162 302 150.00 100.00 150.00 COMPLEX CYSTOMETROGRAM (EG, 51726 51726 360 100.00 0.00 CALIBRATED ELECTRONIC EQUIPMENT) COMPLEX DYNAMIC PHARYNGEAL AND SPEECH 70371 70371 320 100.00 0.00 EVALUATION BY CINE OR VIDEO RECORDING COMPLEX STAIN OVA PARASITES 87209 87209 306 150.00 100.00 150.00 COMPLEX UROFLOWMETRY (EG, CALIBRATED 51741 51741 360 100.00 0.00 ELECTRONIC EQUIPMENT) COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: 80053 80053 301 340.00 100.00 340.00 ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM (82310) CARBON DIOXIDE (BICARBON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

COMPUTED BONE MINERAL DENSITY STUDY 77079 77079 350 1,680.00 100.00 1,680.00

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMEN, WITHOUT CONTRAST MATERIAL(S), 74175 74175 350 5,820.00 100.00 5,820.00 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS, INCLUDING IMAGE POST-P COMPUTED TOMOGRAPHIC ANGIOGRAPHY, CHEST, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND 71275 71275 350 3,700.00 100.00 3,700.00 FURTHER SECTIONS, INCLUDING IMAGE POST- PRO COMPUTED TOMOGRAPHIC ANGIOGRAPHY, HEAD, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND 70496 70496 350 4,570.00 100.00 4,570.00 FURTHER SECTIONS, INCLUDING IMAGE POST- PROC COMPUTED TOMOGRAPHIC ANGIOGRAPHY, LOWER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST 73706 73706 350 3,690.00 100.00 3,690.00 MATERIAL(S) AND FURTHER SECTIONS, INCLUDING IMAG COMPUTED TOMOGRAPHIC ANGIOGRAPHY, NECK, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND 70498 70498 350 4,560.00 100.00 4,560.00 FURTHER SECTIONS, INCLUDING IMAGE POST- PROC COMPUTED TOMOGRAPHIC ANGIOGRAPHY, PELVIS, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND 72191 72191 350 4,460.00 100.00 4,460.00 FURTHER SECTIONS, INCLUDING IMAGE POST- PR Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

COMPUTED TOMOGRAPHIC ANGIOGRAPHY, UPPER EXTREMITY, WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST 73206 73206 350 3,370.00 100.00 3,370.00 MATERIAL(S) AND FURTHER SECTIONS, INCLUDING IMAG COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), 76360 76360 350 1,980.00 100.00 1,980.00 RADIOLOGICAL SUPERVISION AND INTERPRETATIO COMPUTED TOMOGRAPHY GUIDANCE FOR 76370 76370 350 830.00 100.00 830.00 PLACEMENT OF RADIATION THERAPY FIELDS COMPUTED TOMOGRAPHY GUIDANCE FOR 76355 76355 350 1,980.00 100.00 1,980.00 STEREOTACTIC LOCALIZATION COMPUTED TOMOGRAPHY, ABDOMEN AND 74177 74177 350 1,750.00 100.00 1,750.00 PELVIS; WITH CONTRAST MATERIAL(S)

COMPUTED TOMOGRAPHY, ABDOMEN AND 74176 74176 350 1,100.00 100.00 1,100.00 PELVIS; WITHOUT CONTRAST MATERIAL

COMPUTED TOMOGRAPHY, ABDOMEN AND PELVIS; WITHOUT CONTRAST MATERIAL IN ONE OR BOTH BODY REGIONS, FOLLOWED BY 74178 74178 350 1,910.00 100.00 1,910.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS IN ONE OR BOTH BODY REGIONS COMPUTED TOMOGRAPHY, ABDOMEN; WITH 74160 74160 350 3,340.00 100.00 3,340.00 CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, ABDOMEN; 74150 74150 350 2,810.00 100.00 2,810.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, ABDOMEN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 74170 74170 350 4,110.00 100.00 4,110.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, CERVICAL SPINE; 72126 72126 350 2,780.00 100.00 2,780.00 WITH CONTRAST MATERIAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee COMPUTED TOMOGRAPHY, CERVICAL SPINE; 72125 72125 350 2,300.00 100.00 2,300.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, CERVICAL SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72127 72127 350 3,420.00 100.00 3,420.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, HEAD OR BRAIN; 70460 70460 350 2,270.00 100.00 2,270.00 WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, HEAD OR BRAIN; 70450 70450 350 1,950.00 100.00 1,950.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, HEAD OR BRAIN; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 70470 70470 350 2,890.00 100.00 2,890.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, LIMITED OR 76380 76380 329 100.00 0.00 LOCALIZED FOLLOW-UP STUDY COMPUTED TOMOGRAPHY, LOWER EXTREMITY; 73701 73701 350 1,340.00 100.00 1,340.00 WITH CONTRAST MATERIAL(S)

COMPUTED TOMOGRAPHY, LOWER EXTREMITY; 73700 73700 350 1,190.00 100.00 1,190.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, LOWER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 73702 73702 350 1,740.00 100.00 1,740.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, LUMBAR SPINE; 72132 72132 350 2,700.00 100.00 2,700.00 WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, LUMBAR SPINE; 72131 72131 350 2,280.00 100.00 2,280.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, LUMBAR SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72133 72133 350 3,270.00 100.00 3,270.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, MAXILLOFACIAL 70487 70487 350 2,290.00 100.00 2,290.00 AREA; WITH CONTRAST MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

COMPUTED TOMOGRAPHY, MAXILLOFACIAL 70486 70486 350 1,990.00 100.00 1,990.00 AREA; WITHOUT CONTRAST MATERIAL

COMPUTED TOMOGRAPHY, MAXILLOFACIAL AREA; WITHOUT CONTRAST MATERIAL, 70488 70488 350 2,830.00 100.00 2,830.00 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SECTIONS

COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR 70481 70481 350 2,310.00 100.00 2,310.00 INNER EAR; WITH CONTRAST MATERIAL(S)

COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR 70480 70480 350 2,040.00 100.00 2,040.00 INNER EAR; WITHOUT CONTRAST MATERIAL

COMPUTED TOMOGRAPHY, ORBIT, SELLA, OR POSTERIOR FOSSA OR OUTER, MIDDLE, OR 70482 70482 350 2,880.00 100.00 2,880.00 INNER EAR; WITHOUT CONTRAST MATERIAL, FOLLOWED BY CONTRAST MATERIAL(S) AND COMPUTED TOMOGRAPHY, PELVIS; WITH 72193 72193 350 2,370.00 100.00 2,370.00 CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, PELVIS; WITHOUT 72192 72192 350 2,030.00 100.00 2,030.00 CONTRAST MATERIAL COMPUTED TOMOGRAPHY, PELVIS; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72194 72194 350 2,900.00 100.00 2,900.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; 70491 70491 350 2,280.00 100.00 2,280.00 WITH CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; 70490 70490 350 2,010.00 100.00 2,010.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, SOFT TISSUE NECK; WITHOUT CONTRAST MATERIAL FOLLOWED BY 70492 70492 350 2,860.00 100.00 2,860.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee COMPUTED TOMOGRAPHY, THORACIC SPINE; 72129 72129 350 2,750.00 100.00 2,750.00 WITH CONTRAST MATERIAL COMPUTED TOMOGRAPHY, THORACIC SPINE; 72128 72128 350 2,290.00 100.00 2,290.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, THORACIC SPINE; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72130 72130 350 3,370.00 100.00 3,370.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, THORAX; WITH 71260 71260 350 2,370.00 100.00 2,370.00 CONTRAST MATERIAL(S) COMPUTED TOMOGRAPHY, THORAX; WITHOUT 71250 71250 350 2,120.00 100.00 2,120.00 CONTRAST MATERIAL COMPUTED TOMOGRAPHY, THORAX; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 71270 71270 350 3,000.00 100.00 3,000.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTED TOMOGRAPHY, UPPER EXTREMITY; 73201 73201 350 1,720.00 100.00 1,720.00 WITH CONTRAST MATERIAL(S)

COMPUTED TOMOGRAPHY, UPPER EXTREMITY; 73200 73200 350 1,490.00 100.00 1,490.00 WITHOUT CONTRAST MATERIAL COMPUTED TOMOGRAPHY, UPPER EXTREMITY; WITHOUT CONTRAST MATERIAL, FOLLOWED BY 73202 73202 350 2,060.00 100.00 2,060.00 CONTRAST MATERIAL(S) AND FURTHER SECTIONS COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS 20985 20985 360 5,000.00 100.00 5,000.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) COMPUTERIZED AXIAL TOMOGRAPHIC GUIDANCE FOR, AND MONITORING OF, TISSUE 76362 76362 329 100.00 0.00 ABLATION CONCENTRATION FOR INFECTIOUS AGENTS 87015 87015 306 140.00 100.00 140.00 CONDYLECTOMY, TEMPOROMANDIBULAR 21050 21050 360 100.00 0.00 JOINT (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION 57520 57520 360 8,450.00 100.00 8,450.00 AND CURETTAGE, WITH OR WITHOUT REPAIR; COLD KNIFE OR LASER

CONIZATION OF CERVIX, WITH OR WITHOUT FULGURATION, WITH OR WITHOUT DILATION 57522 57522 360 8,450.00 100.00 8,450.00 AND CURETTAGE, WITH OR WITHOUT REPAIR; LOOP ELECTRODE EXCISION CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL 68360 68360 360 100.00 0.00 (SEPARATE PROCEDURE) CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDERSON THIN FLAP OR PURSE STRING 68362 68362 360 100.00 0.00 FLAP) CONJUNCTIVOPLASTY, RECONSTRUCTION CUL- DE-SAC; WITH BUCCAL MUCOUS MEMBRANE 68328 68328 360 100.00 0.00 GRAFT (INCLUDES OBTAINING GRAFT) CONJUNCTIVOPLASTY, RECONSTRUCTION CUL- DE-SAC; WITH CONJUNCTIVAL GRAFT OR 68326 68326 360 100.00 0.00 EXTENSIVE REARRANGEMENT CONJUNCTIVOPLASTY; WITH BUCCAL MUCOUS MEMBRANE GRAFT (INCLUDES OBTAINING 68325 68325 360 100.00 0.00 GRAFT) CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL 68320 68320 360 100.00 0.00 GRAFT OR EXTENSIVE REARRANGEMENT

CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH 68750 68750 360 100.00 0.00 INSERTION OF TUBE OR STENT CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITHOUT 68745 68745 360 100.00 0.00 TUBE Connective tissue human (includes fascia lata) C1762-W C1762 278 100.00 0.00 Connective tissue, human (includes fascia lata) C1762-G C1762 278 700.00 0.00 Connective tissue, nonhuman (includes synthetic) C1763 C1763 278 700.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CONSTRUCTION OF ARTIFICIAL VAGINA; 57291 57291 360 100.00 0.00 WITHOUT GRAFT CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR 67880 67880 360 100.00 0.00 CANTHORRHAPHY; CONSTRUCTION OF INTERMARGINAL ADHESIONS, MEDIAN TARSORRHAPHY, OR 67882 67882 360 100.00 0.00 CANTHORRHAPHY; WITH TRANSPOSITION OF TARSAL PLATE CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBSEQUENT INSERTION OF AN 31611 31611 360 8,900.00 100.00 8,900.00 ALARYNGEAL SPEECH PROSTHESIS (EG, VOICE BUTTON, BLOM-SINGER PROSTHESIS) CONTACT LASER VAPORIZATION WITH OR WITHOUT TRANSURETHRAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE 52648 52648 360 22,400.00 100.00 22,400.00 (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) CONTINENT ILEOSTOMY (KOCK PROCEDURE) 44316 44316 360 100.00 0.00 (SEPARATE PROCEDURE) Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating 95941 95941 929 600.00 100.00 600.00 room, per hour (List separately in addition to code for primary procedure)

Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) G0453 G0453 922 100.00 0.00 each 15 minutes (list in addition to primary procedure) ( Cont intraop neuro monitor ) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CONTRAST INJECTION FOR ASSESSMENT OF ABSCESS OR CYST VIA PREVIOUSLY PLACED 49424 49424 360 100.00 0.00 DRAINAGE CATHETER OR TUBE (SEPARATE PROCEDURE) CONTROL NASAL HEMORRHAGE, ANTERIOR, COMPLEX (EXTENSIVE CAUTERY AND/OR 30903 30903 360 100.00 0.00 PACKING) ANY METHOD CONTROL NASAL HEMORRHAGE, ANTERIOR, SIMPLE (LIMITED CAUTERY AND/OR PACKING) 30901 30901 360 660.00 100.00 660.00 ANY METHOD CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR 30905 30905 360 100.00 0.00 CAUTERY, ANY METHOD; INITIAL

CONTROL NASAL HEMORRHAGE, POSTERIOR, WITH POSTERIOR NASAL PACKS AND/OR 30906 30906 360 100.00 0.00 CAUTERY, ANY METHOD; SUBSEQUENT

CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 42971 42971 360 100.00 0.00 POSTADENOIDECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POSTADENOIDECTOMY); SIMPLE, WITH 42970 42970 360 100.00 0.00 POSTERIOR NASAL PACKS, WITH OR WITHOUT ANTERIOR PACKS CONTROL OF NASOPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, 42972 42972 360 100.00 0.00 POSTADENOIDECTOMY); WITH SECONDARY SURGICAL INTERVENTION CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST- 42961 42961 360 100.00 0.00 TONSILLECTOMY); COMPLICATED, REQUIRING HOSPITALIZATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST- 42960 42960 360 750.00 100.00 750.00 TONSILLECTOMY); SIMPLE CONTROL OROPHARYNGEAL HEMORRHAGE, PRIMARY OR SECONDARY (EG, POST- 42962 42962 360 100.00 0.00 TONSILLECTOMY); WITH SECONDARY SURGICAL INTERVENTION CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP ARTHROPLASTY, WITH OR WITHOUT 27132 27132 360 100.00 0.00 AUTOGRAFT OR ALLOGRAFT COPPER 82525 82525 301 220.00 100.00 220.00 CORACOACROMIAL LIGAMENT RELEASE, WITH 23415 23415 360 17,250.00 100.00 17,250.00 OR WITHOUT ACROMIOPLASTY CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED 65772 65772 360 100.00 0.00 ASTIGMATISM CORNEAL WEDGE RESECTION FOR CORRECTION 65775 65775 360 100.00 0.00 OF SURGICALLY INDUCED ASTIGMATISM CORONAL, SAGITTAL, MULTIPLANAR, OBLIQUE, 3-DIMENSIONAL AND/OR HOLOGRAPHIC RECONSTRUCTION OF COMPUTERIZED AXIAL 76375 76375 329 100.00 0.00 TOMOGRAPHY, MAGNETIC RESONANCE IMAGING, CORONOIDECTOMY (SEPARATE PROCEDURE) 21070 21070 360 100.00 0.00 CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT (PRIAPISM OPERATION), UNILATERAL OR 54430 54430 360 100.00 0.00 BILATERAL CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (EG, BIOPSY NEEDLE, WINTER 54435 54435 360 100.00 0.00 PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (PRIAPISM OPERATION), UNILATERAL OR 54420 54420 360 100.00 0.00 BILATERAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CORPORA CAVERNOSOGRAPHY, RADIOLOGICAL 74445 74445 329 100.00 0.00 SUPERVISION AND INTERPRETATION

CORRECTION CLAW FINGER, OTHER METHODS 26499 26499 360 100.00 0.00

CORRECTION OF EVERTED PUNCTUM, CAUTERY 68705 68705 360 100.00 0.00 CORRECTION OF INVERTED NIPPLES 19355 19355 360 100.00 0.00 CORRECTION OF LID RETRACTION 67911 67911 360 100.00 0.00 CORRECTION OF TRICHIASIS; EPILATION BY OTHER THAN FORCEPS (EG, BY 67825 67825 360 100.00 0.00 ELECTROSURGERY, CRYOTHERAPY, LASER SURGERY) CORRECTION OF TRICHIASIS; EPILATION, BY 67820 67820 360 100.00 0.00 FORCEPS ONLY CORRECTION OF TRICHIASIS; INCISION OF LID 67830 67830 360 100.00 0.00 MARGIN CORRECTION OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE 67835 67835 360 100.00 0.00 GRAFT CORRECTION, COCK-UP FIFTH TOE, WITH PLASTIC SKIN CLOSURE (EG, RUIZ-MORA TYPE 28286 28286 360 3,800.00 100.00 3,800.00 PROCEDURE) CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; BY DOUBLE 28299 28299 360 12,250.00 100.00 12,250.00 OSTEOTOMY CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; BY PHALANX 28298 28298 360 12,250.00 100.00 12,250.00 OSTEOTOMY CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; KELLER, 28292 28292 360 12,250.00 100.00 12,250.00 MCBRIDE, OR MAYO TYPE PROCEDURE CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; LAPIDUS 28297 28297 360 12,250.00 100.00 12,250.00 TYPE PROCEDURE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; RESECTION 28293 28293 360 12,250.00 100.00 12,250.00 OF JOINT WITH IMPLANT CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; SIMPLE 28290 28290 360 12,250.00 100.00 12,250.00 EXOSTECTOMY (EG, SILVER TYPE PROCEDURE)

CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; WITH 28296 28296 360 12,250.00 100.00 12,250.00 METATARSAL OSTEOTOMY (EG, MITCHELL, CHEVRON, OR CONCENTRIC TYPE PROCEDURES) CORRECTION, HALLUX VALGUS (BUNION), WITH OR WITHOUT SESAMOIDECTOMY; WITH 28294 28294 360 12,250.00 100.00 12,250.00 TENDON TRANSPLANTS (EG, JOPLIN TYPE PROCEDURE) Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with proximal 28295 28295 360 12,250.00 100.00 12,250.00 metatarsal osteotomy, any method CORRECTION, HAMMERTOE (EG, INTERPHALANGEAL FUSION, PARTIAL OR 28285 28285 360 8,000.00 100.00 8,000.00 TOTAL PHALANGECTOMY) CORTICOSTERONE 82528 82528 301 200.00 100.00 200.00 CORTISOL; TOTAL 82533 82533 301 180.00 100.00 180.00 COSTOTRANSVERSECTOMY (SEPARATE 21610 21610 360 100.00 0.00 PROCEDURE) COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), (EG, HERNIATED INTERVERTEBRAL 63066 63066 360 100.00 0.00 DISK), THORACIC; EACH ADDITIONAL SEGMENT (LI COSTOVERTEBRAL APPROACH WITH DECOMPRESSION OF SPINAL CORD OR NERVE 63064 63064 360 100.00 0.00 ROOT(S), (EG, HERNIATED INTERVERTEBRAL DISK), THORACIC; SINGLE SEGMENT CPAP, BIPAP SUBSEQUENT 94660 94660 410 800.00 100.00 800.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee C-PEPTIDE 84681 84681 305 150.00 100.00 150.00

CRANIECTOMY, SUBOCCIPITAL WITH CERVICAL LAMINECTOMY FOR DECOMPRESSION OF MEDULLA AND SPINAL CORD, WITH OR 61343 61343 360 38,423.00 100.00 38,423.00 WITHOUT DURAL GRAFT (EG, ARNOLD-CHIARI MALFORMATION)

CREATINE KINASE; ISOENZYME 82552 82552 301 150.00 100.00 150.00 CREATINE KINASE; ISOFORMS 82554 82554 301 130.00 100.00 130.00 CREATINE KINASE; MB (CK-MB) 82553 82553 301 80.00 100.00 80.00 CREATINE KINASE; TOTAL (CPK) 82550 82550 301 50.00 100.00 50.00 CREATININE; BLOOD 82565 82565 301 50.00 100.00 50.00 CREATININE; CLEARANCE 82575 82575 301 110.00 100.00 110.00 CREATININE; URINE 82570 82570 301 50.00 100.00 50.00 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS 36825 36825 360 15,470.00 100.00 15,470.00 ANASTOMOSIS (SEPARATE PROCEDURE); AUTOGENOUS GRAFT CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS (SEPARATE PROCEDURE); 36830 36830 360 100.00 0.00 NONAUTOGENOUS GRAFT (EG, BIOLOGICAL COLLAGEN, THERMOPLASTIC GRAFT)

CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC 61790 61790 360 100.00 0.00 AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); GASSERIAN GANGLION

CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (EG, ALCOHOL, THERMAL, ELECTRICAL, 61791 61791 360 100.00 0.00 RADIOFREQUENCY); TRIGEMINAL MEDULLARY TRACT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, PERCUTANEOUS, ANY 63600 63600 360 100.00 0.00 MODALITY (INCLUDING STIMULATION AND/OR RECORDING) CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, OR 63740 63740 360 100.00 0.00 OTHER; INCLUDING LAMINECTOMY CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, -PLEURAL, OR 63741 63741 360 100.00 0.00 OTHER; PERCUTANEOUS, NOT REQUIRING LAMINECTOMY CRICOPHARYNGEAL MYOTOMY 43030 43030 360 17,100.00 100.00 17,100.00 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes 99292 99292 450 750.00 100.00 750.00 (List separately in addition to code for primary service)

Critical care, evaluation and management of the critically 99291 99291 450 3,050.00 100.00 3,050.00 ill or critically injured patient; first 30-74 minutes

CROSS INTRINSIC TRANSFER, EACH TENDON 26510 26510 360 100.00 0.00 CRYOPRECIPITATE P9012 P9012 302 370.00 100.00 370.00 CRYOSURGERY OF RECTAL TUMOR; BENIGN 46937 46937 360 100.00 0.00 CRYOSURGERY OF RECTAL TUMOR; 46938 46938 360 100.00 0.00 MALIGNANT CRYOSURGICAL ABLATION OF THE PROSTATE (INCLUDES ULTRASONIC GUIDANCE FOR 55873 55873 360 100.00 0.00 INTERSTITIAL CRYOSURGICAL PROBE PLACEMENT) CRYOTHERAPY (CO2 SLUSH, LIQUID N2) FOR 17340 17340 360 100.00 0.00 ACNE CRYPTECTOMY; MULTIPLE (SEPARATE 46211 46211 360 100.00 0.00 PROCEDURE) CRYPTECTOMY; SINGLE 46210 46210 360 100.00 0.00 CT BONE DENSITY STD I/MORE 76070 76070 350 980.00 100.00 980.00 CT BONE MINERAL DENSITY STUDY 77078 77078 350 1,690.00 100.00 1,690.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CT GUIDANCE & MONITORING 77013 77013 350 4,450.00 100.00 4,450.00 CT GUIDANCE NEEDLE PLACE 77012 77012 350 3,450.00 100.00 3,450.00 CT GUIDANCE RADATION 77014 77014 350 1,450.00 100.00 1,450.00 CT GUIDANCE STEREOTACTIC LOCALIZATION 77011 77011 350 3,450.00 100.00 3,450.00 CTA AA & BI ILIOFEMORAL LOWER EXTREMITY 75635 75635 350 6,030.00 100.00 6,030.00 RUNOFF CULTURE BACTERIA ANAEROBIC 87073 87073 306 190.00 100.00 190.00 CULTURE BACTERIA; AEROBE ISOLATE 87077 87077 306 190.00 100.00 190.00 CULTURE BACTERIA; ANEROBE ISOLATE 87076 87076 306 190.00 100.00 190.00 CULTURE BACTERIA; STOOL CULTURE 87046 87046 306 180.00 100.00 180.00 ADDITIONAL PATHOGENS/EACH PLATE CULTURE FUNGI DEFINITIVE ID EACH 87107 87107 306 170.00 100.00 170.00 ORGANISM; MOLD CULTURE FUNGI DEFINITIVE ID EACH 87106 87106 306 170.00 100.00 170.00 ORGANISM; YEAST CULTURE FUNGI ISOLATION W/PRESUMPTIVE ID 87103 87103 306 170.00 100.00 170.00 OF EACH ISOLATE; BLOOD

CULTURE FUNGI ISOLATION W/PRESUMPTIVE ID 87101 87101 306 160.00 100.00 160.00 OF EACH ISOLATE; SKIN, HAIR OR NAIL

CULTURE MYCOBACTERIAL INDENTIFICATION 87118 87118 306 180.00 100.00 180.00 CULTURE MYCOPLASMA ANY SOURCE 87109 87109 306 350.00 100.00 350.00 CULTURE PRESUMPTIVE PATHOGENIC 87084 87084 306 130.00 100.00 130.00 ORGANISMS, COLONY ESTIMATION CULTURE TYPE; IMMUNOLOGIC METHOD 87147 87147 306 100.00 0.00 CULTURE TYPING; GLC/HPLC 87143 87143 306 240.00 100.00 240.00 CULTURE TYPING; IMMUNOFLUORESCENCE 87140 87140 306 120.00 100.00 120.00 CULTURE TYPING; OTHER METHOD 87158 87158 306 110.00 100.00 110.00 CULTURE, BACTERIAL; ANY OTHER SOURCE EXCEPT URINE, BLOOD OR STOOL, WITH 87070 87070 306 170.00 100.00 170.00 ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CULTURE, BACTERIAL; ANY SOURCE, ANAEROBIC WITH ISOLATION AND 87075 87075 306 190.00 100.00 190.00 PRESUMPTIVE IDENTIFICATION OF ISOLATES CULTURE, BACTERIAL; BLOOD, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION 87040 87040 306 180.00 100.00 180.00 OF ISOLATES (INCLUDES ANAEROBIC CULTURE, IF APPROPRIATE) CULTURE, BACTERIAL; QUANTITATIVE COLONY 87086 87086 306 160.00 100.00 160.00 COUNT, URINE CULTURE, CHLAMYDIA, ANY SOURCE 87110 87110 300 100.00 0.00 CULTURE, FUNGI (MOLD OR YEAST) ISOLATION, WITH PRESUMPTIVE IDENTIFICATION OF 87102 87102 306 170.00 100.00 170.00 ISOLATES; OTHER SOURCE (EXCEPT BLOOD)

CULTURE, TUBERCLE OR OTHER ACID-FAST BACILLI (EG, TB, AFB, MYCOBACTERIA) ANY 87116 87116 306 190.00 100.00 190.00 SOURCE, WITH ISOLATION AND PRESUMPTIVE IDENTIFICATION OF ISOLATES

CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINCTER 46940 46940 360 100.00 0.00 (SEPARATE PROCEDURE); INITIAL

CURETTAGE OR CAUTERY OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINCTER 46942 46942 360 100.00 0.00 (SEPARATE PROCEDURE); SUBSEQUENT CURETTAGE, POSTPARTUM 59160 59160 360 100.00 0.00 CUTANEOUS VESICOSTOMY 51980 51980 360 100.00 0.00 Cymetra, injectable, 1 cc Q4112 Q4112 636 700.00 0.00

CYSTECTOMY, COMPLETE, WITH CONTINENT DIVERSION, ANY OPEN TECHNIQUE, USING ANY 51596 51596 360 100.00 0.00 SEGMENT OF SMALL AND/OR LARGE INTESTINE TO CONSTRUCT NEOBLADDER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID 51590 51590 360 100.00 0.00 BLADDER, INCLUDING INTESTINE ANASTOMOSIS; CYSTECTOMY, COMPLETE, WITH URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING INTESTINE 51595 51595 360 100.00 0.00 ANASTOMOSIS; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR 51580 51580 360 100.00 0.00 URETEROCUTANEOUS TRANSPLANTATIONS;

CYSTECTOMY, COMPLETE, WITH URETEROSIGMOIDOSTOMY OR URETEROCUTANEOUS TRANSPLANTATIONS; 51585 51585 360 100.00 0.00 WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, CYSTECTOMY, COMPLETE; (SEPARATE 51570 51570 360 100.00 0.00 PROCEDURE) CYSTECTOMY, COMPLETE; WITH BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING 51575 51575 360 100.00 0.00 EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES CYSTECTOMY, PARTIAL, WITH REIMPLANTATION OF URETER(S) INTO 51565 51565 360 100.00 0.00 BLADDER (URETERONEOCYSTOSTOMY) CYSTECTOMY, PARTIAL; COMPLICATED (EG, POSTRADIATION, PREVIOUS SURGERY, 51555 51555 360 100.00 0.00 DIFFICULT LOCATION) CYSTECTOMY, PARTIAL; SIMPLE 51550 51550 360 100.00 0.00 CYSTOGRAPHY, MINIMUM OF THREE VIEWS, RADIOLOGICAL SUPERVISION AND 74430 74430 320 1,250.00 100.00 1,250.00 INTERPRETATION CYSTOLITHOTOMY, CYSTOTOMY WITH REMOVAL OF CALCULUS, WITHOUT VESICAL 51050 51050 360 100.00 0.00 NECK RESECTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CYSTOPLASTY OR CYSTOURETHROPLASTY, PLASTIC OPERATION ON BLADDER AND/OR 51800 51800 360 100.00 0.00 VESICAL NECK (ANTERIOR Y-PLASTY, VESICAL FUNDUS RESECTION), ANY PROCEDURE, WITH

CYSTORRHAPHY, SUTURE OF BLADDER WOUND, 51865 51865 360 100.00 0.00 INJURY OR RUPTURE; COMPLICATED CYSTORRHAPHY, SUTURE OF BLADDER WOUND, 51860 51860 360 100.00 0.00 INJURY OR RUPTURE; SIMPLE CYSTOSCOPY; DIAGNOSTIC; OTHER 57.32 360 100.00 0.00 CYSTOSTOMY, CYSTOTOMY WITH DRAINAGE 51040 51040 360 100.00 0.00 CYSTOTOMY FOR EXCISION, INCISION, OR 51535 51535 360 100.00 0.00 REPAIR OF URETEROCELE CYSTOTOMY OR CYSTOSTOMY; WITH CRYOSURGICAL DESTRUCTION OF 51030 51030 360 100.00 0.00 INTRAVESICAL LESION CYSTOTOMY OR CYSTOSTOMY; WITH FULGURATION AND/OR INSERTION OF 51020 51020 360 100.00 0.00 RADIOACTIVE MATERIAL CYSTOTOMY, WITH CALCULUS BASKET EXTRACTION AND/OR ULTRASONIC OR 51065 51065 360 100.00 0.00 ELECTROHYDRAULIC FRAGMENTATION OF URETERAL CALCULUS CYSTOTOMY, WITH INSERTION OF URETERAL 51045 51045 360 100.00 0.00 CATHETER OR STENT (SEPARATE PROCEDURE) CYSTOTOMY; FOR EXCISION OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE 51525 51525 360 100.00 0.00 (SEPARATE PROCEDURE) CYSTOTOMY; FOR EXCISION OF BLADDER 51530 51530 360 100.00 0.00 TUMOR CYSTOTOMY; FOR SIMPLE EXCISION OF 51520 51520 360 100.00 0.00 VESICAL NECK (SEPARATE PROCEDURE) CYSTOURETHROPLASTY WITH UNILATERAL OR 51820 51820 360 100.00 0.00 BILATERAL URETERONEOCYSTOSTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH FRAGMENTATION OF 52325 52325 360 100.00 0.00 URETERAL CALCULUS (EG, ULTRASONIC OR ELECTRO-HYDRAULIC TECHNIQUE)

CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH MANIPULATION, 52330 52330 360 100.00 0.00 WITHOUT REMOVAL OF URETERAL CALCULUS CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH REMOVAL OF 52320 52320 360 100.00 0.00 URETERAL CALCULUS CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); WITH SUBURETERIC 52327 52327 360 100.00 0.00 INJECTION OF IMPLANT MATERIAL CYSTOURETHROSCOPY (SEPARATE 52000 52000 360 74,070.00 100.00 74,070.00 PROCEDURE) CYSTOURETHROSCOPY FOR TREATMENT OF THE FEMALE URETHRAL SYNDROME WITH ANY OR ALL OF THE FOLLOWING: URETHRAL MEATOTOMY, URETHRAL DILATION, INTERNAL 52285 52285 360 10,360.00 100.00 10,360.00 URETHROTOMY, LYSIS OF URETHROVAGINAL SEPTAL FIBROSIS, LATERAL INCISIONS OF THE BLADDER NECK, AND FULGURATION CYSTOURETHROSCOPY WITH DIRECT VISION 52276 52276 360 7,550.00 100.00 7,550.00 INTERNAL URETHROTOMY CYSTOURETHROSCOPY WITH INCISION, FULGURATION, OR RESECTION OF CONGENITAL POSTERIOR URETHRAL VALVES, OR 52400 52400 360 100.00 0.00 CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS CYSTOURETHROSCOPY WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT 52250 52250 360 100.00 0.00 BIOPSY OR FULGURATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CYSTOURETHROSCOPY WITH INSERTION OF URETERAL GUIDE WIRE THROUGH KIDNEY TO 52334 52334 360 100.00 0.00 ESTABLISH A PERCUTANEOUS NEPHROSTOMY, RETROGRADE CYSTOURETHROSCOPY WITH IRRIGATION AND EVACUATION OF MULTIPLE OBSTRUCTING 52001 52001 360 10,360.00 100.00 10,360.00 CLOTS CYSTOURETHROSCOPY WITH TRANSURETHRAL RESECTION OR INCISION OF EJACULATORY 52347 52347 360 100.00 0.00 DUCTS CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE 52346 52346 360 100.00 0.00 (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETERAL STRICTURE 52344 52344 360 100.00 0.00 (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION)

CYSTOURETHROSCOPY WITH URETEROSCOPY; WITH TREATMENT OF URETEROPELVIC 52345 52345 360 100.00 0.00 JUNCTION STRICTURE (EG, BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CYSTOURETHROSCOPY, WITH BIOPSY 52204 52204 360 10,360.00 100.00 10,360.00

CYSTOURETHROSCOPY, WITH CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, WITH OR WITHOUT MEATOTOMY, 52281 52281 360 10,360.00 100.00 10,360.00 WITH OR WITHOUT INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE CYSTOURETHROSCOPY, WITH DILATION OF BLADDER FOR INTERSTITIAL CYSTITIS; 52260 52260 360 10,360.00 100.00 10,360.00 GENERAL OR CONDUCTION (SPINAL) ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CYSTOURETHROSCOPY, WITH EJACULATORY DUCT CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR DUCT 52010 52010 360 100.00 0.00 RADIOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER 52240 52240 360 12,950.00 100.00 12,950.00 SURGERY) AND/OR RESECTION OF; LARGE BLADDER TUMOR(S) CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER 52235 52235 360 10,360.00 100.00 10,360.00 SURGERY) AND/OR RESECTION OF; MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM)

CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER 52234 52234 360 10,360.00 100.00 10,360.00 SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 TO 2.0 CM) CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, 52214 52214 360 9,550.00 100.00 9,550.00 PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS CYSTOURETHROSCOPY, WITH FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS 52224 52224 360 100.00 0.00 THAN 0.5 CM) LESION(S) WITH OR WITHOUT BIOPSY Cystourethroscopy, with injection(s) for 52287 52287 360 10,360.00 100.00 10,360.00 chemodenervation of the bladder CYSTOURETHROSCOPY, WITH INSERTION OF INDWELLING URETERAL STENT (EG, GIBBONS 52332 52332 360 14,930.00 100.00 14,930.00 OR DOUBLE-J TYPE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional 52442 52442 360 5,050.00 100.00 5,050.00 permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) Cystourethroscopy, with insertion of permanent 52441 52441 360 5,050.00 100.00 5,050.00 adjustable transprostatic implant; single implant Cystourethroscopy, with insertion of transprostatic C9739 C9739 360 17,500.00 100.00 17,500.00 implant; 1 to 3 implants Cystourethroscopy, with insertion of transprostatic C9740 C9740 360 17,500.00 100.00 17,500.00 implant; 4 or more implants CYSTOURETHROSCOPY, WITH INSERTION OF 52282 52282 360 100.00 0.00 URETHRAL STENT CYSTOURETHROSCOPY, WITH INTERNAL 52270 52270 360 100.00 0.00 URETHROTOMY; FEMALE CYSTOURETHROSCOPY, WITH INTERNAL 52275 52275 360 7,550.00 100.00 7,550.00 URETHROTOMY; MALE CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL 52315 52315 360 100.00 0.00 STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); COMPLICATED CYSTOURETHROSCOPY, WITH REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL 52310 52310 360 14,930.00 100.00 14,930.00 STENT FROM URETHRA OR BLADDER (SEPARATE PROCEDURE); SIMPLE CYSTOURETHROSCOPY, WITH RESECTION OF 52277 52277 360 100.00 0.00 EXTERNAL SPHINCTER (SPHINCTEROTOMY) CYSTOURETHROSCOPY, WITH STEROID 52283 52283 360 100.00 0.00 INJECTION INTO STRICTURE CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 52005 52005 360 14,930.00 100.00 14,930.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee CYSTOURETHROSCOPY, WITH URETERAL CATHETERIZATION, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 52007 52007 360 10,350.00 100.00 10,350.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS CYSTOURETHROSCOPY, WITH URETEROSCOPY 52351 52351 360 10,360.00 100.00 10,360.00 AND/OR PYELOSCOPY; DIAGNOSTIC CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH BIOPSY AND/OR 52354 52354 360 10,360.00 100.00 10,360.00 FULGURATION OF URETERAL OR RENAL PELVIC LESION CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH LITHOTRIPSY 52353 52353 360 14,250.00 100.00 14,250.00 (URETERAL CATHETERIZATION IS INCLUDED)

Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of indwelling ureteral 52356 52356 360 15,650.00 100.00 15,650.00 stent (eg, Gibbons or double-J type

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH REMOVAL OR 52352 52352 360 12,950.00 100.00 12,950.00 MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED)

CYSTOURETHROSCOPY, WITH URETEROSCOPY AND/OR PYELOSCOPY; WITH RESECTION OF 52355 52355 360 100.00 0.00 URETERAL OR RENAL PELVIC TUMOR CYSTOURETHROSCOPY; WITH INCISION OR RESECTION OF ORIFICE OF BLADDER 52305 52305 360 100.00 0.00 DIVERTICULUM, SINGLE OR MULTIPLE CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ECTOPIC URETEROCELE(S), 52301 52301 360 100.00 0.00 UNILATERAL OR BILATERAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

CYSTOURETHROSCOPY; WITH RESECTION OR FULGURATION OF ORTHOTOPIC 52300 52300 360 100.00 0.00 URETEROCELE(S), UNILATERAL OR BILATERAL CYSTOURETHROSCOPY; WITH TREATMENT OF INTRA-RENAL STRICTURE (EG, BALLOON 52343 52343 360 100.00 0.00 DILATION, LASER, ELECTROCAUTERY, AND INCISION) CYSTOURETHROSCOPY; WITH TREATMENT OF URETERAL STRICTURE (EG, BALLOON 52341 52341 360 100.00 0.00 DILATION, LASER, ELECTROCAUTERY, AND INCISION) CYSTOURETHROSCOPY; WITH TREATMENT OF URETEROPELVIC JUNCTION STRICTURE (EG, 52342 52342 360 100.00 0.00 BALLOON DILATION, LASER, ELECTROCAUTERY, AND INCISION) CYSTOURETHROSCOPY; WITH URETERAL 52290 52290 360 100.00 0.00 MEATOTOMY, UNILATERAL OR BILATERAL CYTO, NONGYN THIN PREP 88112 88112 311 250.00 100.00 250.00 DACRYOCYSTOGRAPHY, NASOLACRIMAL DUCT, RADIOLOGICAL SUPERVISION AND 70170 70170 320 100.00 0.00 INTERPRETATION DACRYOCYSTORHINOSTOMY (FISTULIZATION 68720 68720 360 12,200.00 100.00 12,200.00 OF LACRIMAL SAC TO NASAL CAVITY) D-DIMER 85380 85380 305 230.00 100.00 230.00

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN 11010 11010 360 3,800.00 100.00 3,800.00 FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, 11011 11011 360 2,590.00 100.00 2,590.00 SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED WITH OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, 11012 11012 360 5,000.00 100.00 5,000.00 SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE

DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN; EACH ADDITIONAL 10% OF THE 11001 11001 360 100.00 0.00 BODY SURFACE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDU

DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR 11000 11000 360 1,300.00 100.00 1,300.00 INFECTED SKIN; UP TO 10% OF BODY SURFACE DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 11720 11720 360 100.00 0.00 ONE TO FIVE DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 11721 11721 360 100.00 0.00 SIX OR MORE DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (EG, WITH ANESTHESIA OR MORE 69222 69222 360 100.00 0.00 THAN ROUTINE CLEANING) DEBRIDEMENT, MASTOIDECTOMY CAVITY, 69220 69220 360 100.00 0.00 SIMPLE (EG, ROUTINE CLEANING) DEBRIDEMENT; SKIN, AND SUBCUTANEOUS 11042 11042 360 1,560.00 100.00 1,560.00 TISSUE DEBRIDEMENT; SKIN, FULL THICKNESS 11041 11041 360 610.00 100.00 610.00 DEBRIDEMENT; SKIN, PARTIAL THICKNESS 11040 11040 360 420.00 100.00 420.00 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, 11043 11043 360 2,070.00 100.00 2,070.00 AND MUSCLE DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, 11044 11044 360 3,800.00 100.00 3,800.00 MUSCLE, AND BONE DECALCIFICATION 88311 88311 301 250.00 100.00 250.00 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; INCLUDING MEDIAL TO 69725 69725 360 100.00 0.00 GENICULATE GANGLION DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; LATERAL TO GENICULATE 69720 69720 360 100.00 0.00 GANGLION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND EXTENSOR 25025 25025 360 100.00 0.00 COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR AND EXTENSOR 25024 25024 360 100.00 0.00 COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR EXTENSOR 25023 25023 360 100.00 0.00 COMPARTMENT; WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST, FLEXOR OR EXTENSOR 25020 25020 360 100.00 0.00 COMPARTMENT; WITHOUT DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, FOREARM, 24495 24495 360 100.00 0.00 WITH BRACHIAL ARTERY EXPLORATION DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR 27600 27600 360 100.00 0.00 AND/OR LATERAL COMPARTMENTS ONLY

DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL COMPARTMENTS ONLY, WITH 27892 27892 360 10,580.92 100.00 10,580.92 DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR 27602 27602 360 100.00 0.00 COMPARTMENT(S) DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR 27894 27894 360 100.00 0.00 COMPARTMENT(S), WITH DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, LEG; 27601 27601 360 100.00 0.00 POSTERIOR COMPARTMENT(S) ONLY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) ONLY, WITH 27893 27893 360 100.00 0.00 DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, THIGH AND/OR 27498 27498 360 100.00 0.00 KNEE, MULTIPLE COMPARTMENTS; DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE COMPARTMENTS; WITH 27499 27499 360 100.00 0.00 DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE COMPARTMENT (FLEXOR OR 27496 27496 360 100.00 0.00 EXTENSOR OR ADDUCTOR); DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); WITH 27497 27497 360 100.00 0.00 DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE DECOMPRESSION FINGERS AND/OR HAND, 26035 26035 360 14,190.00 100.00 14,190.00 INJECTION INJURY (EG, GREASE GUN) DECOMPRESSION INTERNAL AUDITORY CANAL 69960 69960 360 100.00 0.00

DECOMPRESSION; PLANTAR DIGITAL NERVE 64726 64726 360 6,450.00 100.00 6,450.00 DECOMPRESSION; UNSPECIFIED NERVE(S) 64722 64722 360 6,830.00 100.00 6,830.00 (SPECIFY) DECOMPRESSIVE FASCIOTOMY, HAND 26037 26037 360 100.00 0.00 (EXCLUDES 26035) DECORTICATION AND PARIETAL PLEURECTOMY 32320 32320 360 100.00 0.00 DECORTICATION, PULMONARY (SEPARATE 32225 32225 360 100.00 0.00 PROCEDURE); PARTIAL DECORTICATION, PULMONARY (SEPARATE 32220 32220 360 100.00 0.00 PROCEDURE); TOTAL DEHYDROEPIANDROSTERONE 82626 82626 301 260.00 100.00 260.00 DEHYDROEPIANDROSTERONE - SU 82627 82627 301 230.00 100.00 230.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT EYELIDS, NOSE, 15630 15630 360 13,540.00 100.00 13,540.00 EARS, OR LIPS DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT FOREHEAD, CHEEKS, 15620 15620 360 14,540.00 100.00 14,540.00 CHIN, NECK, AXILLAE, GENITALIA, HANDS, OR FEET DELAY OF FLAP OR SECTIONING OF FLAP (DIVISION AND INSET); AT SCALP, ARMS, OR 15610 15610 360 13,540.00 100.00 13,540.00 LEGS DELAY OF FLAP OR SECTIONING OF FLAP 15600 15600 360 100.00 0.00 (DIVISION AND INSET); AT TRUNK DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN 19342 19342 360 100.00 0.00 RECONSTRUCTION DELIGATION OF URETER 50940 50940 360 100.00 0.00 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or 94664 94664 410 800.00 100.00 800.00 IPPB device DENERVATION, HIP JOINT, INTRAPELVIC OR EXTRAPELVIC INTRA-ARTICULAR BRANCHES OF 27035 27035 360 100.00 0.00 SCIATIC, FEMORAL, OR OBTURATOR NERVES DENIS-BROWNE SPLINT STRAPPING 29590 29590 360 100.00 0.00 DEOXYRIBONUCLEASE ANTIBODY 86215 86215 302 100.00 100.00 100.00 DEOXYRIBONUCLEIC ACID ANTIBODY 86225 86225 302 310.00 100.00 310.00 DERMABRASION; REGIONAL, OTHER THAN FACE 15782 15782 360 100.00 0.00 DERMABRASION; SEGMENTAL, FACE 15781 15781 360 100.00 0.00 DERMABRASION; SUPERFICIAL, ANY SITE, (EG, 15783 15783 360 100.00 0.00 TATTOO REMOVAL) DERMABRASION; TOTAL FACE (EG, FOR ACNE SCARRING, FINE WRINKLING, RHYTIDS, 15780 15780 360 100.00 0.00 GENERAL KERATOSIS) DERMACELL Q4122 Q4122 636 700.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DESTRUCTION (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY, SURGICAL CURETTEMENT), 17110 17110 360 630.00 100.00 630.00 OF FLAT WARTS, MOLLUSCUM CONTAGIOSUM, OR MILIA; UP T DESTRUCTION BY NEUROLYTIC AGENT PARAVERTEBRAL FACET JOINT NERVES(S) 64635 64635 360 3,130.00 100.00 3,130.00 (FLUORSCOPY OR CT; LUMBAR OR SACRAL, SINGLE FACET JOINT DESTRUCTION BY NEUROLYTIC AGENT, CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC 64680 64680 360 6,750.00 100.00 6,750.00 MONITORING DESTRUCTION BY NEUROLYTIC AGENT, 64620 64620 360 100.00 0.00 INTERCOSTAL NERVE Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 64634 64634 360 3,600.00 100.00 3,600.00 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure) Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); 64633 64633 360 7,200.00 100.00 7,200.00 cervical or thoracic, single facet joint DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; CERVICAL OR THORACIC, EACH ADDITIONAL 64627 64627 360 100.00 0.00 LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; 64626 64626 360 100.00 0.00 CERVICAL OR THORACIC, SINGLE LEVEL DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL 64623 64623 360 960.00 100.00 960.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DESTRUCTION BY NEUROLYTIC AGENT, PARAVERTEBRAL FACET JOINT NERVE; 64622 64622 360 1,920.00 100.00 1,920.00 LUMBAR OR SACRAL, SINGLE LEVEL DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD 64605 64605 360 6,350.00 100.00 6,350.00 DIVISION BRANCHES AT FORAMEN OVALE DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SECOND AND THIRD 64610 64610 360 100.00 0.00 DIVISION BRANCHES AT FORAMEN OVALE UNDER RADIOLOGIC MONITORING DESTRUCTION BY NEUROLYTIC AGENT, TRIGEMINAL NERVE; SUPRAORBITAL, 64600 64600 360 100.00 0.00 INFRAORBITAL, MENTAL, OR INFERIOR ALVEOLAR BRANCH DESTRUCTION BY NEUROLYTIC AGENT; OTHER 64640 64640 360 3,130.00 100.00 3,130.00 PERIPHERAL NERVE OR BRANCH DESTRUCTION BY NEUROLYTIC AGENT; 64630 64630 360 3,100.00 100.00 3,100.00 PUDENDAL NERVE DESTRUCTION OF CYST OR LESION IRIS OR 66770 66770 360 100.00 0.00 CILIARY BODY (NONEXCISIONAL PROCEDURE) DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), 67227 67227 360 100.00 0.00 ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (EG, DIABETIC RETINOPATHY), 67228 67228 360 100.00 0.00 ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON ARC) DESTRUCTION OF HEMORRHOIDS, ANY 46935 46935 360 100.00 0.00 METHOD; EXTERNAL DESTRUCTION OF HEMORRHOIDS, ANY 46934 46934 360 100.00 0.00 METHOD; INTERNAL DESTRUCTION OF HEMORRHOIDS, ANY 46936 46936 360 100.00 0.00 METHOD; INTERNAL AND EXTERNAL DESTRUCTION OF LESION (EXCEPT EXCISION), 41850 41850 360 100.00 0.00 DENTOALVEOLAR STRUCTURES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY, PHOTOCOAGULATION OR 65450 65450 360 100.00 0.00 THERMOCAUTERIZATION DESTRUCTION OF LESION OF LID MARGIN (UP 67850 67850 360 100.00 0.00 TO 1 CM) DESTRUCTION OF LESION OR SCAR OF VESTIBULE OF MOUTH BY PHYSICAL METHODS 40820 40820 360 100.00 0.00 (EG, LASER, THERMAL, CRYO, CHEMICAL) DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), 46924 46924 360 8,900.00 100.00 8,900.00 EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 46900 46900 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 46916 46916 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 46910 46910 360 5,900.00 100.00 5,900.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 46917 46917 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY DESTRUCTION OF LESION(S), ANUS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 46922 46922 360 8,900.00 100.00 8,900.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), 54065 54065 360 100.00 0.00 EXTENSIVE (EG, LASER SURGERY, ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 54050 54050 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 54056 54056 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 54055 54055 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 54057 54057 360 100.00 0.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY DESTRUCTION OF LESION(S), PENIS (EG, CONDYLOMA, PAPILLOMA, MOLLUSCUM 54060 54060 360 8,310.00 100.00 8,310.00 CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION DESTRUCTION OF LESION(S), VULVA; EXTENSIVE (EG, LASER SURGERY, 56515 56515 360 8,080.00 100.00 8,080.00 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF LESION(S), VULVA; SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, 56501 56501 360 5,900.00 100.00 5,900.00 CRYOSURGERY, CHEMOSURGERY) DESTRUCTION OF LESION, CONJUNCTIVA 68135 68135 360 100.00 0.00 DESTRUCTION OF LESION, PALATE OR UVULA 42160 42160 360 100.00 0.00 (THERMAL, CRYO OR CHEMICAL) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL 67220 67220 360 100.00 0.00 NEOVASCULARIZATION); PHOTOCOAGULATION (EG, LASER), ONE OR MORE SESSIONS

DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL 67221 67221 360 100.00 0.00 NEOVASCULARIZATION); PHOTODYNAMIC THERAPY (INCLUDES INTRAVENOUS INFUSION) DESTRUCTION OF LOCALIZED LESION OF CHOROID (EG, CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC 67225 67225 360 100.00 0.00 THERAPY, SECOND EYE, AT SINGLE SESSION (LIST SEPARATELY IN DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE 67208 67208 360 100.00 0.00 OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE 67210 67210 360 100.00 0.00 OR MORE SESSIONS; PHOTOCOAGULATION DESTRUCTION OF LOCALIZED LESION OF RETINA (EG, MACULAR EDEMA, TUMORS), ONE OR MORE SESSIONS; RADIATION BY 67218 67218 360 100.00 0.00 IMPLANTATION OF SOURCE (INCLUDES REMOVAL OF SOURCE) DESTRUCTION OF RECTAL TUMOR (EG, ELECTRODESSICATION, ELECTROSURGERY, 45190 45190 360 100.00 0.00 LASER ABLATION, LASER RESECTION, CRYOSURGERY) TRANSANAL APPROACH DESTRUCTION OF VAGINAL LESION(S); EXTENSIVE (EG, LASER SURGERY, 57065 57065 360 8,450.00 100.00 8,450.00 ELECTROSURGERY, CRYOSURGERY, CHEMOSURGERY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DESTRUCTION OF VAGINAL LESION(S); SIMPLE (EG, LASER SURGERY, ELECTROSURGERY, 57061 57061 360 8,450.00 100.00 8,450.00 CRYOSURGERY, CHEMOSURGERY) DETAILED ANATOMY SCAN 76811 76811 402 1,410.00 100.00 1,410.00 DETAILED ANATOMY SCAN (ADD GESTATION) 76812 76812 402 550.00 100.00 550.00 DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING, (INCLUDES COMPENSATORY 97532 97532 100.00 0.00 TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT B DIAPHRAGM OR CERVICAL CAP FITTING WITH 57170 57170 360 100.00 0.00 INSTRUCTIONS DIGOXIN 80162 80162 301 510.00 100.00 510.00 DILATION AND CATHETERIZATION OF 42660 42660 360 100.00 0.00 SALIVARY DUCT, WITH OR WITHOUT INJECTION DILATION AND CURETTAGE OF CERVICAL 57820 57820 360 100.00 0.00 STUMP DILATION AND CURETTAGE, DIAGNOSTIC 58120 58120 360 8,450.00 100.00 8,450.00 AND/OR THERAPEUTIC (NONOBSTETRICAL) DILATION OF ANAL SPHINCTER (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN 45905 45905 360 100.00 0.00 LOCAL DILATION OF CERVICAL CANAL, 57800 57800 360 100.00 0.00 INSTRUMENTAL (SEPARATE PROCEDURE) DILATION OF ESOPHAGUS WITH BALLOON (30 43458 43458 360 100.00 0.00 MM DIAMETER OR LARGER) FOR ACHALASIA DILATION OF ESOPHAGUS, BY BALLOON OR 43456 43456 360 2,440.00 100.00 2,440.00 DILATOR, RETROGRADE DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE 43450 43450 360 3,450.00 100.00 3,450.00 PASSES DILATION OF ESOPHAGUS, OVER GUIDE WIRE 43453 43453 360 4,900.00 100.00 4,900.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DILATION OF FEMALE URETHRA INCLUDING 53660 53660 360 100.00 0.00 SUPPOSITORY AND/OR INSTILLATION; INITIAL DILATION OF FEMALE URETHRA INCLUDING SUPPOSITORY AND/OR INSTILLATION; 53661 53661 360 100.00 0.00 SUBSEQUENT DILATION OF FEMALE URETHRA, GENERAL OR 53665 53665 360 100.00 0.00 CONDUCTION (SPINAL) ANESTHESIA DILATION OF LACRIMAL PUNCTUM, WITH OR 68801 68801 360 100.00 0.00 WITHOUT IRRIGATION DILATION OF NEPHROSTOMY, URETERS, OR URETHRA, RADIOLOGICAL SUPERVISION AND 74485 74485 329 100.00 0.00 INTERPRETATION DILATION OF RECTAL STRICTURE (SEPARATE PROCEDURE) UNDER ANESTHESIA OTHER THAN 45910 45910 360 100.00 0.00 LOCAL DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND FOLLOWER, MALE; 53620 53620 360 100.00 0.00 INITIAL DILATION OF URETHRAL STRICTURE BY PASSAGE OF FILIFORM AND FOLLOWER, MALE; 53621 53621 360 100.00 0.00 SUBSEQUENT DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, 53600 53600 360 100.00 0.00 MALE; INITIAL DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, 53601 53601 360 100.00 0.00 MALE; SUBSEQUENT DILATION OF URETHRAL STRICTURE OR VESICAL NECK BY PASSAGE OF SOUND OR 53605 53605 360 100.00 0.00 URETHRAL DILATOR, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA DILATION OF VAGINA UNDER ANESTHESIA 57400 57400 360 100.00 0.00 DILATION SALIVARY DUCT 42650 42650 360 100.00 0.00 DIPTHERIA ANTIBODY 86648 86648 302 300.00 100.00 300.00 Direct admission of patient for hospital observation care G0379 G0379 762 1,550.00 100.00 1,550.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DISARTICULATION AT KNEE 27598 27598 360 100.00 0.00 DISARTICULATION OF HIP 27295 27295 360 100.00 0.00 DISARTICULATION OF SHOULDER; 23920 23920 360 100.00 0.00 DISARTICULATION OF SHOULDER; SECONDARY 23921 23921 360 100.00 0.00 CLOSURE OR SCAR REVISION DISARTICULATION THROUGH WRIST; 25920 25920 360 100.00 0.00 DISARTICULATION THROUGH WRIST; RE- 25924 25924 360 100.00 0.00 AMPUTATION DISARTICULATION THROUGH WRIST; 25922 25922 360 100.00 0.00 SECONDARY CLOSURE OR SCAR REVISION DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER 66821 66821 360 4,680.00 100.00 4,680.00 SURGERY (EG, YAG LASER) (ONE OR MORE STAGES) DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); STAB 66820 66820 360 100.00 0.00 INCISION TECHNIQUE (ZIEGLER OR WHEELER KN DISCISSION OF VITREOUS STRANDS (WITHOUT 67030 67030 360 100.00 0.00 REMOVAL), PARS PLANA APPROACH DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING 63076 63076 360 100.00 0.00 OSTEOPHYTECTOMY; CERVICAL, EACH ADDITIONAL INTERSPACE (LIST SE DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING 63075 63075 360 18,930.00 100.00 18,930.00 OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING 63078 63078 360 100.00 0.00 OSTEOPHYTECTOMY; THORACIC, EACH ADDITIONAL INTERSPACE (LIST SE DISKECTOMY, ANTERIOR, WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S), INCLUDING 63077 63077 360 100.00 0.00 OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE DISKOGRAPHY, CERVICAL OR THORACIC, RADIOLOGICAL SUPERVISION AND 72285 72285 320 12,250.00 100.00 12,250.00 INTERPRETATION DISKOGRAPHY, LUMBAR, RADIOLOGICAL 72295 72295 320 15,250.00 100.00 15,250.00 SUPERVISION AND INTERPRETATION DISPLACEMENT THERAPY (PROETZ TYPE) 30210 30210 360 3,000.00 100.00 3,000.00 DISSECTION, DEEP JUGULAR NODE(S) 38542 38542 360 100.00 0.00 DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; 43130 43130 360 100.00 0.00 CERVICAL APPROACH DIVERTICULECTOMY OF HYPOPHARYNX OR ESOPHAGUS, WITH OR WITHOUT MYOTOMY; 43135 43135 360 100.00 0.00 THORACIC APPROACH DIVISION OF PLANTAR FASCIA AND MUSCLE (EG, STEINDLER STRIPPING) (SEPARATE 28250 28250 360 6,250.00 100.00 6,250.00 PROCEDURE) DIVISION OF SCALENUS ANTICUS; WITH 21705 21705 360 100.00 0.00 RESECTION OF CERVICAL RIB DIVISION OF SCALENUS ANTICUS; WITHOUT 21700 21700 360 100.00 0.00 RESECTION OF CERVICAL RIB DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION; WITH CAST 21725 21725 360 100.00 0.00 APPLICATION DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION; WITHOUT 21720 21720 360 100.00 0.00 CAST APPLICATION DIVISION OF STRICTURE OF RECTUM 45150 45150 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DIVISON OF JOINT CAPSULE, LIGAMENT, OR 80.46 360 100.00 0.00 CARTILAGE, KNEE DNA/RNA DIRECT PROBE 87149 87149 306 260.00 100.00 260.00 DOPPLER ECHO FETAL PULSE 76828 76828 402 450.00 100.00 450.00 DOPPLER ECHO FETAL PULSED 76827 76827 402 680.00 100.00 680.00 DRAINAGE ABSCESS OR HEMATOMA, NASAL 30020 30020 360 100.00 0.00 SEPTUM DRAINAGE ABSCESS OR HEMATOMA, NASAL, 30000 30000 360 100.00 0.00 INTERNAL APPROACH DRAINAGE EXTERNAL AUDITORY CANAL, 69020 69020 360 100.00 0.00 ABSCESS DRAINAGE EXTERNAL EAR, ABSCESS OR 69005 69005 360 5,770.00 100.00 5,770.00 HEMATOMA; COMPLICATED DRAINAGE EXTERNAL EAR, ABSCESS OR 69000 69000 360 750.00 100.00 750.00 HEMATOMA; SIMPLE DRAINAGE OF ABSCESS OF PALATE, UVULA 42000 42000 360 100.00 0.00 DRAINAGE OF ABSCESS, CYST, HEMATOMA 41800 41800 360 100.00 0.00 FROM DENTOALVEOLAR STRUCTURES DRAINAGE OF ABSCESS, CYST, HEMATOMA, 40801 40801 360 100.00 0.00 VESTIBULE OF MOUTH; COMPLICATED

DRAINAGE OF ABSCESS, CYST, HEMATOMA, 40800 40800 360 100.00 0.00 VESTIBULE OF MOUTH; SIMPLE DRAINAGE OF ABSCESS, CYST,HEMATOMA 24.0 360 100.00 0.00 FROM DENTOALVEOLAR STRUCTURES DRAINAGE OF ABSCESS; PAROTID, 42305 42305 360 100.00 0.00 COMPLICATED DRAINAGE OF ABSCESS; PAROTID, SIMPLE 42300 42300 360 100.00 0.00 DRAINAGE OF ABSCESS; SUBMAXILLARY OR 42310 42310 360 100.00 0.00 SUBLINGUAL, INTRAORAL DRAINAGE OF ABSCESS; SUBMAXILLARY, 42320 42320 360 100.00 0.00 EXTERNAL DRAINAGE OF DEEP PERIURETHRAL ABSCESS 53040 53040 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DRAINAGE OF EXTRAPERITONEAL 49062 49062 360 100.00 0.00 LYMPHOCELE TO PERITONEAL CAVITY, OPEN DRAINAGE OF FINGER ABSCESS; COMPLICATED 26011 26011 360 4,250.00 100.00 4,250.00 (EG, FELON) DRAINAGE OF FINGER ABSCESS; SIMPLE 26010 26010 360 100.00 0.00 DRAINAGE OF LYMPH NODE ABSCESS OR 38305 38305 360 100.00 0.00 LYMPHADENITIS; EXTENSIVE DRAINAGE OF LYMPH NODE ABSCESS OR 38300 38300 360 100.00 0.00 LYMPHADENITIS; SIMPLE DRAINAGE OF OVARIAN ABSCESS; ABDOMINAL 58822 58822 360 100.00 0.00 APPROACH DRAINAGE OF OVARIAN ABSCESS; VAGINAL 58820 58820 360 100.00 0.00 APPROACH, OPEN DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, (SEPARATE PROCEDURE); 58805 58805 360 100.00 0.00 ABDOMINAL APPROACH DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL, (SEPARATE PROCEDURE); 58800 58800 360 100.00 0.00 VAGINAL APPROACH DRAINAGE OF PALMAR BURSA; MULTIPLE 26030 26030 360 100.00 0.00 BURSA DRAINAGE OF PALMAR BURSA; SINGLE, BURSA 26025 26025 360 100.00 0.00

DRAINAGE OF PELVIC ABSCESS, TRANSVAGINAL OR TRANSRECTAL APPROACH, 58823 58823 360 100.00 0.00 PERCUTANEOUS (EG, OVARIAN, PERICOLIC) DRAINAGE OF PERINEAL URINARY 53085 53085 360 100.00 0.00 EXTRAVASATION; COMPLICATED DRAINAGE OF PERINEAL URINARY EXTRAVASATION; UNCOMPLICATED (SEPARATE 53080 53080 360 100.00 0.00 PROCEDURE) DRAINAGE OF PERIRENAL OR RENAL ABSCESS; 50020 50020 360 100.00 0.00 OPEN DRAINAGE OF PERIRENAL OR RENAL ABSCESS; 50021 50021 360 100.00 0.00 PERCUTANEOUS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF 49020 49020 360 100.00 0.00 APPENDICEAL ABSCESS; OPEN DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF 49021 49021 360 100.00 0.00 APPENDICEAL ABSCESS; PERCUTANEOUS DRAINAGE OF PERIVESICAL OR PREVESICAL 51080 51080 360 100.00 0.00 SPACE ABSCESS DRAINAGE OF RETROPERITONEAL ABSCESS; 49060 49060 360 100.00 0.00 OPEN DRAINAGE OF RETROPERITONEAL ABSCESS; 49061 49061 360 100.00 0.00 PERCUTANEOUS DRAINAGE OF SCROTAL WALL ABSCESS 55100 55100 360 4,000.00 100.00 4,000.00 DRAINAGE OF SKENE'S GLAND ABSCESS OR 53060 53060 360 100.00 0.00 CYST DRAINAGE OF SUBDIAPHRAGMATIC OR 49040 49040 360 100.00 0.00 SUBPHRENIC ABSCESS; OPEN DRAINAGE OF SUBDIAPHRAGMATIC OR 49041 49041 360 100.00 0.00 SUBPHRENIC ABSCESS; PERCUTANEOUS DRAINAGE OF TENDON SHEATH, DIGIT AND/OR 26020 26020 360 100.00 0.00 PALM, EACH DRESSING CHANGE (FOR OTHER THAN BURNS) 15852 15852 360 100.00 0.00 UNDER ANESTHESIA (OTHER THAN LOCAL)

DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT; UNDER ANESTHESIA, MEDIUM OR 16015 16015 360 100.00 0.00 LARGE, OR WITH MAJOR DEBRIDEMENT

DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR 16010 16010 360 100.00 0.00 SUBSEQUENT; UNDER ANESTHESIA, SMALL

DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT; WITHOUT ANESTHESIA, LARGE 16030 16030 360 100.00 0.00 (EG, MORE THAN ONE EXTREMITY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT; WITHOUT ANESTHESIA, MEDIUM 16025 16025 360 100.00 0.00 (EG, WHOLE FACE OR WHOLE EXTREMITY) DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT; WITHOUT ANESTHESIA, OFFICE 16020 16020 360 100.00 0.00 OR HOSPITAL, SMALL DRUG TEST DEFINITIVE 1-7 G0480 G0480 301 400.00 100.00 400.00 DRUGS OF ABUSE, URINE 80100 80100 301 510.00 100.00 510.00 DULPEX SCAN OF ARTERIAL INFL/VEN 93975 93975 921 1,600.00 100.00 1,600.00 OUTFLOW OF ABD, PELVIC OR RETRO ORGANS DUODENOGRAPHY, HYPOTONIC 74260 74260 320 100.00 0.00 DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), 44010 44010 360 100.00 0.00 OR FOREIGN BODY REMOVAL DUOLEX SCAN AORTA INFERIOR VENA CAVA 93978 93978 402 1,130.00 100.00 1,130.00 DUPLEX SCAN OF EXTRACRANIAL ATRERIES 93880 93880 921 1,520.00 100.00 1,520.00 COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND 93970 93970 921 1,330.00 100.00 1,330.00 OTHER MANEUVERS; COMPLETE BILATERAL STUDY DUPLEX SCAN OF EXTREMITY VEINS INCLUDING RESPONSES TO COMPRESSION AND 93971 93971 921 890.00 100.00 890.00 OTHER MANEUVERS; UNILATERAL OR LIMITED STUDY DURAL GRAFT, SPINAL 63710 63710 360 15,250.00 100.00 15,250.00 DYNAMIC CAVERNOSOMETRY, INCLUDING INTRACAVERNOSAL INJECTION OF VASOACTIVE 54231 54231 360 100.00 0.00 DRUGS (EG, PAPAVERINE, PHENTOLAMINE) E DEPT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 99285A 99285 100.00 0.00 THESE THREE KEY COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

E DEPT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 99284A 99284 1,800.00 100.00 1,800.00 THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A DETAILED E

E DEPT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 99281A 99281 100.00 0.00 THESE THREE KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PRO

E DEPT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 99283A 99283 2,000.00 100.00 2,000.00 THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED H19347

E DEPT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES 99282A 99282 100.00 0.00 THESE THREE KEY COMPONENTS: AN EXPANDED PROBLEM FOCUSED HIST EAR PIERCING 69090 69090 360 100.00 0.00 ECG ROUTINE WITH AT 12 LEADS; TRACING 93005 93005 730 400.00 100.00 400.00 ONLY ECG WITH AT LEAST 12 LEADS WITH 93000 93000 730 400.00 100.00 400.00 INTERPRETATION AND REPORT ECHOCARDIOGRAM TOTAL LIMITED STUDY OR 93303 93303 730 3,250.00 100.00 3,250.00 FOLLOW UP ECHOENCEPHALOGRAPHY, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION (GRAY SCALE) (FOR DETERMINATION OF 76506 76506 100.00 0.00 VENTRICULAR SIZE, DELINEATION OF CEREBRAL CON ECHOGRAPHY, TRANSRECTAL; 76872 76872 100.00 0.00 ECHOGRAPHY, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY 76873 76873 402 960.00 100.00 960.00 TREATMENT PLANNING (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ELECTRICAL STIMULATION TO AID BONE 20975 20975 360 100.00 0.00 HEALING; INVASIVE (OPERATIVE) ELECTRICAL STIMULATION TO AID BONE 20974 20974 360 100.00 0.00 HEALING; NONINVASIVE (NONOPERATIVE) Electroencephalogram (EEG) extended monitoring; 41- 95812 95812 740 1,050.00 100.00 1,050.00 60 minutes ELECTROLYSIS EPILATION, EACH 1/2 HOUR 17380 17380 360 100.00 0.00 ELECTROLYTE PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CARBON DIOXIDE 80051 80051 301 250.00 100.00 250.00 (82374) CHLORIDE (82435) POTASSIUM (84132) SODIUM (84295) ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, OTHER THAN 51784 51784 360 100.00 0.00 NEEDLE, ANY TECHNIQUE Electronic analysis of implanted neurostimulator pulse generator system (eg, rate, pulse amplitude, pulse duration, configuration of wave form, battery status, 95972 95972 360 600.00 100.00 600.00 electrode selectability, output modulation, cycling, impedance and patient compliance measurem ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR 95975 95975 360 100.00 0.00 SYSTEM EACH ADD 30 MINUTES AFTER 1ST HOUR ELECTRONIC ANALYSIS OF IMPLANTED NEUROSTIMULATOR PULSE GENERATOR 95974 95974 360 100.00 0.00 SYSTEM FIRST HOUR ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES 62368 62368 360 7,390.00 100.00 7,390.00 EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITH REPROGRAMMING Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ELECTRONIC ANALYSIS OF PROGRAMMABLE, IMPLANTED PUMP FOR INTRATHECAL OR EPIDURAL DRUG INFUSION (INCLUDES 62367 62367 360 100.00 0.00 EVALUATION OF RESERVOIR STATUS, ALARM STATUS, DRUG PRESCRIPTION STATUS); WITHOUT REPROGRAMMING

ELECTROPHORESIS IMMUNOFIX SER 86334 86334 302 310.00 100.00 310.00 EMBOLECTOMY OR THROMBECTOMY, WITH OR WITHOUT CATHETER; AXILLARY, BRACHIAL, 34101 34101 360 100.00 0.00 INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY 99285 99285 450 2,300.00 100.00 2,300.00 COMPONENTS WITHIN THE CONSTRAINTS IMPOSED BY EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY 99284 99284 450 1,800.00 100.00 1,800.00 COMPONENTS: A DETAILED HISTORY; A DETAILED E EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY 99281 99281 450 300.00 100.00 300.00 COMPONENTS: A PROBLEM FOCUSED HISTORY; A PRO EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY 99283 99283 450 2,000.00 100.00 2,000.00 COMPONENTS: AN EXPANDED PROBLEM FOCUSED H19347 EMERGENCY DEPARTMENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE THREE KEY 99282 99282 450 1,000.00 100.00 1,000.00 COMPONENTS: AN EXPANDED PROBLEM FOCUSED HIST EMG 922 922 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ENDOCERVICAL CURETTAGE (NOT DONE AS 57505 57505 360 2,250.00 100.00 2,250.00 PART OF A DILATION AND CURETTAGE) ENDOLYMPHATIC SAC OPERATION; WITH 69806 69806 360 100.00 0.00 SHUNT ENDOLYMPHATIC SAC OPERATION; WITHOUT 69805 69805 360 100.00 0.00 SHUNT ENDOMETRIAL ABLATION, THERMAL, WITHOUT 58353 58353 360 18,200.00 100.00 18,200.00 HYSTEROSCOPIC GUIDANCE ENDOMETRIAL SAMPLING (BIOPSY) WITH OR WITHOUT ENDOCERVICAL SAMPLING (BIOPSY), 58100 58100 360 100.00 0.00 WITHOUT CERVICAL DILATION, ANY METHOD (SEPARATE PROCEDURE) ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, RADIOLOGICAL 74328 74328 329 100.00 0.00 SUPERVISION AND INTERPRETATION ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL 74329 74329 329 100.00 0.00 SUPERVISION AND INTERPRETATION

ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; DIAGNOSTIC, WITH OR WITHOUT COLLECTION 44385 44385 360 100.00 0.00 OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; 44386 44386 360 100.00 0.00 WITH BIOPSY, SINGLE OR MULTIPLE

ENDOSCOPIC INJECTION OF IMPLANT MATERIAL INTO THE SUBMUCOSAL TISSUES OF THE 51715 51715 360 100.00 0.00 URETHRA AND/OR BLADDER NECK ENDOSCOPIC PLANTAR FASCIOTOMY 29893 29893 360 8,000.00 100.00 8,000.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, WITH OR WITHOUT COLLECTION 43260 43260 360 8,950.00 100.00 8,950.00 OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER 43272 43272 360 5,680.00 100.00 5,680.00 LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH 43261 43261 360 8,950.00 100.00 8,950.00 BIOPSY, SINGLE OR MULTIPLE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE BALLOON DILATION 43271 43271 360 4,870.00 100.00 4,870.00 OF AMPULLA, BILIARY AND/OR PANCREATIC DUCT(S) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE DESTRUCTION, 43265 43265 360 8,950.00 100.00 8,950.00 LITHOTRIPSY OF CALCULUS/CALCULI, ANY METHOD ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE INSERTION OF 43267 43267 360 100.00 0.00 NASOBILIARY OR NASOPANCREATIC DRAINAGE TUBE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH 43268 43268 360 4,870.00 100.00 4,870.00 ENDOSCOPIC RETROGRADE INSERTION OF TUBE OR STENT INTO BILE OR PANCREATIC DUCT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE REMOVAL OF 43264 43264 360 8,950.00 100.00 8,950.00 CALCULUS/CALCULI FROM BILIARY AND/OR PANCREATIC DUCTS ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH ENDOSCOPIC RETROGRADE REMOVAL OF 43269 43269 360 4,870.00 100.00 4,870.00 FOREIGN BODY AND/OR CHANGE OF TUBE OR STENT ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH PRESSURE MEASUREMENT OF SPHINCTER OF 43263 43263 360 100.00 0.00 ODDI (PANCREATIC DUCT OR COMMON BILE DUCT) ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); WITH 43262 43262 360 8,950.00 100.00 8,950.00 SPHINCTEROTOMY/PAPILLOTOMY ENDOSCOPY, WRIST, SURGICAL, WITH RELEASE 29848 29848 360 9,850.00 100.00 9,850.00 OF TRANSVERSE CARPAL LIGAMENT ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND 44120 44120 360 15,000.00 100.00 15,000.00 ANASTOMOSIS ENTEROCYSTOPLASTY, INCLUDING INTESTINAL 51960 51960 360 100.00 0.00 ANASTOMOSIS ENTEROLYSIS (FREEING OF INTESTINAL 44005 44005 360 100.00 0.00 ADHESION) (SEPARATE PROCEDURE) ENTEROSTOMY OR CECOSTOMY, TUBE (EG, FOR DECOMPRESSION OR FEEDING) (SEPARATE 44300 44300 360 100.00 0.00 PROCEDURE) ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR DECOMPRESSION (EG, BAKER 44021 44021 360 100.00 0.00 TUBE) ENTEROTOMY, SMALL INTESTINE, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR 44020 44020 360 100.00 0.00 FOREIGN BODY REMOVAL ENTEROVIRUS ANTOBODY 86658 86658 302 260.00 100.00 260.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ENUCLEATION OF EYE; WITH IMPLANT, 65105 65105 360 100.00 0.00 MUSCLES ATTACHED TO IMPLANT ENUCLEATION OF EYE; WITH IMPLANT, 65103 65103 360 100.00 0.00 MUSCLES NOT ATTACHED TO IMPLANT ENUCLEATION OF EYE; WITHOUT IMPLANT 65101 65101 360 100.00 0.00 ENUCLEATION OR EXCISION OF EXTERNAL 46320 46320 360 6,700.00 100.00 6,700.00 THROMBOTIC HEMORRHOID EPIDIDYMECTOMY; BILATERAL 54861 54861 360 100.00 0.00 EPIDIDYMECTOMY; UNILATERAL 54860 54860 360 3,500.00 100.00 3,500.00 EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF 54901 54901 360 100.00 0.00 EPIDIDYMIS TO VAS DEFERENS; BILATERAL

EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF 54900 54900 360 100.00 0.00 EPIDIDYMIS TO VAS DEFERENS; UNILATERAL EPIDUROGRAPHY, RADIOLOGICAL SUPERVISION 72275 72275 320 1,250.00 100.00 1,250.00 AND INTERPRETATION EPIGLOTTIDECTOMY 31420 31420 360 100.00 0.00 EPIKERATOPLASTY 65767 65767 360 100.00 0.00 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR 27185 27185 360 100.00 0.00 STAPLING, GREATER TROCHANTER OF FEMUR EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR 25455 25455 360 100.00 0.00 STAPLING; DISTAL RADIUS AND ULNA EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR 25450 25450 360 100.00 0.00 STAPLING; DISTAL RADIUS OR ULNA EPSTEIN-BARR ANTIBODY 86663 86663 302 230.00 100.00 230.00 EPSTEIN-BARR CAPSID VCA 86665 86665 302 260.00 100.00 260.00 EPSTEIN-BARR NUCLEAR ANTIGEN 86664 86664 302 230.00 100.00 230.00 ERROR - REBILLED PROCEDURE ERROR 360 100.00 0.00 ERYTHROCYTE SEDIMENTATION RATE 85651 85651 302 90.00 100.00 90.00 ESCHAROTOMY 16035 16035 360 100.00 0.00 ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, 43324 43324 360 100.00 0.00 BELSEY IV, HILL PROCEDURES) ESOPHAGOGASTRIC FUNDOPLASTY; WITH 43325 43325 360 100.00 0.00 FUNDIC PATCH (THAL-NISSEN PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ESOPHAGOGASTRIC FUNDOPLASTY; WITH 43326 43326 360 100.00 0.00 GASTROPLASTY (EG, COLLIS) ESOPHAGOGASTRIC TAMPONADE, WITH 43460 43460 360 100.00 0.00 BALLOON (SENGSTAAKEN TYPE) Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes 43270 43270 360 4,900.00 100.00 4,900.00 pre- and post-dilation and guide wire passage, when performed) ESOPHAGOGASTROSTOMY (CARDIOPLASTY), WITH OR WITHOUT VAGOTOMY AND 43320 43320 360 100.00 0.00 PYLOROPLASTY, TRANSABDOMINAL OR TRANSTHORACIC APPROACH

ESOPHAGOJEJUNOSTOMY (WITHOUT TOTAL 43340 43340 360 100.00 0.00 GASTRECTOMY); ABDOMINAL APPROACH ESOPHAGOMYOTOMY (HELLER TYPE); 43330 43330 360 100.00 0.00 ABDOMINAL APPROACH ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL APPROACH; 43305 43305 360 100.00 0.00 WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL APPROACH; 43300 43300 360 100.00 0.00 WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC APPROACH; 43312 43312 360 100.00 0.00 WITH REPAIR OF TRACHEOESOPHAGEAL FISTULA ESOPHAGOPLASTY (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC APPROACH; 43310 43310 360 100.00 0.00 WITHOUT REPAIR OF TRACHEOESOPHAGEAL FISTULA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR RECONSTRUCTION), 43314 43314 360 100.00 0.00 THORACIC APPROACH; WITH REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA

ESOPHAGOPLASTY FOR CONGENITAL DEFECT (PLASTIC REPAIR OR RECONSTRUCTION), 43313 43313 360 100.00 0.00 THORACIC APPROACH; WITHOUT REPAIR OF CONGENITAL TRACHEOESOPHAGEAL FISTULA

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION 43200 43200 360 3,450.00 100.00 3,450.00 OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S), NOT AMENABLE TO REMOVAL BY 43228 43228 360 100.00 0.00 HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH BALLOON DILATION (LESS THAN 30 MM 43220 43220 360 4,900.00 100.00 4,900.00 DIAMETER) ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH 43205 43205 360 100.00 0.00 BAND LIGATION OF ESOPHAGEAL VARICES ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH 43202 43202 360 100.00 0.00 BIOPSY, SINGLE OR MULTIPLE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, 43227 43227 360 100.00 0.00 LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY 43201 43201 360 100.00 0.00 SUBSTANCE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH 43231 43231 360 100.00 0.00 ENDOSCOPIC ULTRASOUND EXAMINATION ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL 43204 43204 360 100.00 0.00 VARICES ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY 43226 43226 360 100.00 0.00 DILATION OVER GUIDE WIRE

ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH 43219 43219 360 100.00 0.00 INSERTION OF PLASTIC TUBE OR STENT ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH 43215 43215 360 100.00 0.00 REMOVAL OF FOREIGN BODY ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER 43216 43216 360 100.00 0.00 LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER 43217 43217 360 100.00 0.00 LESION(S) BY SNARE TECHNIQUE ESOPHAGOSCOPY, RIGID OR FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND-GUIDED 43232 43232 360 4,900.00 100.00 4,900.00 INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) ESOPHAGOTOMY, CERVICAL APPROACH, WITH 43020 43020 360 100.00 0.00 REMOVAL OF FOREIGN BODY ESOPHAGOTOMY, THORACIC APPROACH, WITH 43045 43045 360 100.00 0.00 REMOVAL OF FOREIGN BODY ESTRADIOL 82670 82670 301 200.00 100.00 200.00 ESTRONE 82679 82679 301 230.00 100.00 230.00 ETHMOIDECTOMY; EXTRANASAL, TOTAL 31205 31205 360 100.00 0.00 ETHMOIDECTOMY; INTRANASAL, ANTERIOR 31200 31200 360 100.00 0.00 ETHMOIDECTOMY; INTRANASAL, TOTAL 31201 31201 360 12,530.00 100.00 12,530.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EUSTACHIAN TUBE CATHETERIZATION, 69405 69405 360 100.00 0.00 TRANSTYMPANIC EUSTACHIAN TUBE INFLATION, TRANSNASAL; 69400 69400 360 100.00 0.00 WITH CATHETERIZATION EUSTACHIAN TUBE INFLATION, TRANSNASAL; 69401 69401 360 100.00 0.00 WITHOUT CATHETERIZATION EVACUATION OF SUBUNGUAL HEMATOMA 11740 11740 360 100.00 0.00 EVISCERATION OF OCULAR CONTENTS; WITH 65093 65093 360 100.00 0.00 IMPLANT EVISCERATION OF OCULAR CONTENTS; 65091 65091 360 100.00 0.00 WITHOUT IMPLANT EXAM SYNOVIAL FLUID CRYSTALS 89060 89060 301 50.00 100.00 50.00 EXCHANGE OF INTRAOCULAR LENS 66986 66986 360 8,050.00 100.00 8,050.00 EXCHANGE OF PREVIOUSLY PLACED ABSCESS OR CYST DRAINAGE CATHETER UNDER 49423 49423 360 100.00 0.00 RADIOLOGICAL GUIDANCE (SEPARATE PROCEDURE) EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE 67966 67966 360 100.00 0.00 FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE-FOURTH OF LID MARGIN

EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE 67961 67961 360 10,350.00 100.00 10,350.00 FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE-FOURTH OF LID MARGIN EXCISION AURAL GLOMUS TUMOR; EXTENDED 69554 69554 360 100.00 0.00 (EXTRATEMPORAL) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION AURAL GLOMUS TUMOR; 69550 69550 360 100.00 0.00 TRANSCANAL EXCISION AURAL GLOMUS TUMOR; 69552 69552 360 100.00 0.00 TRANSMASTOID EXCISION AURAL POLYP 69540 69540 360 100.00 0.00 EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN AND SUBCUTANEOUS 42810 42810 360 8,900.00 100.00 8,900.00 TISSUES EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, EXTENDING BENEATH 42815 42815 360 17,100.00 100.00 17,100.00 SUBCUTANEOUS TISSUES AND/OR INTO PHARYNX EXCISION DERMOID CYST, NOSE; COMPLEX, 30125 30125 360 17,100.00 100.00 17,100.00 UNDER BONE OR CARTILAGE EXCISION DERMOID CYST, NOSE; SIMPLE, SKIN, 30124 30124 360 8,900.00 100.00 8,900.00 SUBCUTANEOUS EXCISION DISTAL ULNA PARTIAL OR COMPLETE 25240 25240 360 11,900.00 100.00 11,900.00 (EG, DARRACH TYPE OR MATCHED RESECTION) EXCISION EXOSTOSIS(ES), EXTERNAL 69140 69140 360 100.00 0.00 AUDITORY CANAL EXCISION EXTERNAL EAR; COMPLETE 69120 69120 360 100.00 0.00 AMPUTATION EXCISION EXTERNAL EAR; PARTIAL, SIMPLE 69110 69110 360 100.00 0.00 REPAIR EXCISION FIRST AND/OR CERVICAL RIB; 21615 21615 360 100.00 0.00 EXCISION FIRST AND/OR CERVICAL RIB; WITH 21616 21616 360 100.00 0.00 SYMPATHECTOMY EXCISION FLEXOR TENDON, WITH IMPLANTATION OF SYNTHETIC ROD FOR 26390 26390 360 100.00 0.00 DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD EXCISION OF AMPULLA OF VATER 48148 48148 360 100.00 0.00 EXCISION OF BARTHOLIN'S GLAND OR CYST 56740 56740 360 8,450.00 100.00 8,450.00 EXCISION OF BENIGN CYST OR TUMOR OF 21041 360 100.00 0.00 MANDIBLE; COMPLEX Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE, BY ENUCLEATION AND/OR 21040 21040 360 100.00 0.00 CURETTAGE EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING EXTRA-ORAL OSTEOTOMY AND PARTIAL MANDIBULECTOMY 21047 21047 360 100.00 0.00 (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) EXCISION OF BENIGN TUMOR OR CYST OF MANDIBLE; REQUIRING INTRA-ORAL 21046 21046 360 100.00 0.00 OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING EXTRA-ORAL OSTEOTOMY AND PARTIAL MAXILLECTOMY 21049 21049 360 100.00 0.00 (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) EXCISION OF BENIGN TUMOR OR CYST OF MAXILLA; REQUIRING INTRA-ORAL 21048 21048 360 100.00 0.00 OSTEOTOMY (EG, LOCALLY AGGRESSIVE OR DESTRUCTIVE LESION(S)) EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF BILE DUCT; 47711 47711 360 100.00 0.00 EXTRAHEPATIC EXCISION OF BILE DUCT TUMOR, WITH OR WITHOUT PRIMARY REPAIR OF BILE DUCT; 47712 47712 360 100.00 0.00 INTRAHEPATIC EXCISION OF BONE (EG, FOR OSTEOMYELITIS 21026 21026 360 100.00 0.00 OR BONE ABSCESS); FACIAL BONE(S)

EXCISION OF BONE (EG, FOR OSTEOMYELITIS 21025 21025 360 100.00 0.00 OR BONE ABSCESS); MANDIBLE

EXCISION OF BONE CYST OR BENIGN TUMOR; 27066 27066 360 100.00 0.00 DEEP, WITH OR WITHOUT AUTOGRAFT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL (WING OF ILIUM, SYMPHYSIS 27065 27065 360 100.00 0.00 PUBIS, OR GREATER TROCHANTER OF FEMUR) WITH OR WITHOUT AUTOGRAFT EXCISION OF BONE CYST OR BENIGN TUMOR; WITH AUTOGRAFT REQUIRING SEPARATE 27067 27067 360 100.00 0.00 INCISION

EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER, OPEN; EACH ADDITIONAL LESION 19126 19126 360 100.00 0.00 SEPARATELY IDENTIFIED BY A PREOPERATIVE RADIOLOGICAL MARKER (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL 19125 19125 360 9,950.00 100.00 9,950.00 MARKER, OPEN; SINGLE LESION EXCISION OF BULBOURETHRAL GLAND 53250 53250 360 100.00 0.00 (COWPER'S GLAND) EXCISION OF CAROTID BODY TUMOR; WITH 60605 60605 360 100.00 0.00 EXCISION OF CAROTID ARTERY EXCISION OF CAROTID BODY TUMOR; WITHOUT 60600 60600 360 100.00 0.00 EXCISION OF CAROTID ARTERY EXCISION OF CERVICAL STUMP, ABDOMINAL 57540 57540 360 100.00 0.00 APPROACH; EXCISION OF CERVICAL STUMP, ABDOMINAL 57545 57545 360 100.00 0.00 APPROACH; WITH PELVIC FLOOR REPAIR EXCISION OF CERVICAL STUMP, VAGINAL 57550 57550 360 100.00 0.00 APPROACH; EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; WITH ANTERIOR AND/OR 57555 57555 360 100.00 0.00 POSTERIOR REPAIR EXCISION OF CERVICAL STUMP, VAGINAL 57556 57556 360 100.00 0.00 APPROACH; WITH REPAIR OF ENTEROCELE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF CHALAZION; MULTIPLE, 67805 67805 360 100.00 0.00 DIFFERENT LIDS EXCISION OF CHALAZION; MULTIPLE, SAME LID 67801 67801 360 100.00 0.00 EXCISION OF CHALAZION; SINGLE 67800 67800 360 1,400.00 100.00 1,400.00 EXCISION OF CHALAZION; UNDER GENERAL ANESTHESIA AND/OR REQUIRING 67808 67808 360 100.00 0.00 HOSPITALIZATION, SINGLE OR MULTIPLE EXCISION OF CHEST WALL TUMOR INCLUDING 19260 19260 360 100.00 0.00 RIBS EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC RECONSTRUCTION; WITH 19272 19272 360 100.00 0.00 MEDIASTINAL LYMPHADENECTOMY

EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, WITH PLASTIC RECONSTRUCTION; 19271 19271 360 100.00 0.00 WITHOUT MEDIASTINAL LYMPHADENECTOMY EXCISION OF CHOLEDOCHAL CYST 47715 47715 360 100.00 0.00 EXCISION OF CONSTRICTING RING OF FINGER, 26596 26596 360 100.00 0.00 WITH MULTIPLE Z-PLASTIES EXCISION OF CYST OR ADENOMA OF THYROID, 60200 60200 360 19,400.00 100.00 19,400.00 OR TRANSECTION OF ISTHMUS EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR, ABERRANT BREAST TISSUE, DUCT LESION, NIPPLE OR 19120 19120 360 9,950.00 100.00 9,950.00 AREOLAR LESION (EXCEPT 19140), OPEN, MALE OR FEMALE, ONE OR MORE LESIONS EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITH DEEP NEUROVASCULAR 38555 38555 360 10,750.00 100.00 10,750.00 DISSECTION EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; WITHOUT DEEP NEUROVASCULAR 38550 38550 360 12,110.00 100.00 12,110.00 DISSECTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OF EPIPHYSEAL BAR, WITH OR WITHOUT AUTOGENOUS SOFT TISSUE GRAFT 20150 20150 360 100.00 0.00 OBTAINED THROUGH SAME FASCIAL INCISION EXCISION OF EXTENSOR TENDON, WITH IMPLANTATION OF SYNTHETIC ROD FOR 26415 26415 360 6,380.00 100.00 6,380.00 DELAYED TENDON GRAFT, HAND OR FINGER, EACH ROD EXCISION OF EXTERNAL HEMORRHOID TAGS 46230 46230 360 6,700.00 100.00 6,700.00 AND/OR MULTIPLE PAPILLAE EXCISION OF EXTRAPARENCHYMAL LESION OF 54512 54512 360 100.00 0.00 TESTIS EXCISION OF FIBROUS TUBEROSITIES, 41822 41822 360 100.00 0.00 DENTOALVEOLAR STRUCTURES EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, FRENULECTOMY, 40819 40819 360 5,800.00 100.00 5,800.00 FRENECTOMY) EXCISION OF GANGLION, WRIST (DORSAL OR 25111 25111 360 8,500.00 100.00 8,500.00 VOLAR); PRIMARY EXCISION OF GANGLION, WRIST (DORSAL OR 25112 25112 360 10,630.00 100.00 10,630.00 VOLAR); RECURRENT EXCISION OF HUMERUS UPPER ARM AND 24071 24071 360 2,125.40 100.00 2,125.40 ELBOW EXCISION OF HYDROCELE OF SPERMATIC CORD, 55500 55500 360 10,250.00 100.00 10,250.00 UNILATERAL (SEPARATE PROCEDURE) EXCISION OF HYDROCELE; BILATERAL 55041 55041 360 100.00 0.00 EXCISION OF HYDROCELE; UNILATERAL 55040 55040 360 12,250.00 100.00 12,250.00 EXCISION OF HYPERPLASTIC ALVEOLAR 41828 41828 360 100.00 0.00 MUCOSA, EACH QUADRANT (SPECIFY) EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR TUMOR; 68505 68505 360 9,060.00 100.00 9,060.00 PARTIAL EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR TUMOR; 68500 68500 360 100.00 0.00 TOTAL EXCISION OF LACRIMAL GLAND TUMOR; 68540 68540 360 100.00 0.00 FRONTAL APPROACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF LACRIMAL GLAND TUMOR; 68550 68550 360 100.00 0.00 INVOLVING OSTEOTOMY EXCISION OF LACRIMAL SAC 68520 68520 360 100.00 0.00 (DACRYOCYSTECTOMY) EXCISION OF LACTIFEROUS DUCT FISTULA 19112 19112 360 100.00 0.00 EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH 67840 67840 360 3,250.00 100.00 3,250.00 SIMPLE DIRECT CLOSURE EXCISION OF LESION OF MENISCUS OR CAPSULE 27347 27347 360 8,530.00 100.00 8,530.00 (EG, CYST, GANGLION), KNEE EXCISION OF LESION OF MESENTERY 44820 44820 360 100.00 0.00 (SEPARATE PROCEDURE) EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; COMPLEX, 40816 40816 360 8,900.00 100.00 8,900.00 WITH EXCISION OF UNDERLYING MUSCLE EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH 40814 40814 360 8,900.00 100.00 8,900.00 COMPLEX REPAIR EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITH 40812 40812 360 5,800.00 100.00 5,800.00 SIMPLE REPAIR EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH; WITHOUT 40810 40810 360 5,800.00 100.00 5,800.00 REPAIR EXCISION OF LESION OF PANCREAS (EG, CYST, 48120 48120 360 100.00 0.00 ADENOMA) EXCISION OF LESION OF SPERMATIC CORD 55520 55520 360 9,700.00 100.00 9,700.00 (SEPARATE PROCEDURE) EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (EG, CYST OR GANGLION), LEG 27630 27630 360 7,600.00 100.00 7,600.00 AND/OR ANKLE EXCISION OF LESION OF TENDON SHEATH OR JOINT CAPSULE (EG, CYST, MUCOUS CYST, OR 26160 26160 360 6,380.00 100.00 6,380.00 GANGLION), HAND OR FINGER EXCISION OF LESION OF TONGUE WITH 41112 41112 360 5,800.00 100.00 5,800.00 CLOSURE; ANTERIOR TWO-THIRDS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF LESION OF TONGUE WITH 41113 41113 360 5,800.00 100.00 5,800.00 CLOSURE; POSTERIOR ONE-THIRD EXCISION OF LESION OF TONGUE WITH 41114 41114 360 100.00 0.00 CLOSURE; WITH LOCAL TONGUE FLAP EXCISION OF LESION OF TONGUE WITHOUT 41110 41110 360 5,800.00 100.00 5,800.00 CLOSURE EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), DENTOALVEOLAR 41827 41827 360 100.00 0.00 STRUCTURES; WITH COMPLEX REPAIR EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), DENTOALVEOLAR 41826 41826 360 100.00 0.00 STRUCTURES; WITH SIMPLE REPAIR EXCISION OF LESION OR TUMOR (EXCEPT LISTED ABOVE), DENTOALVEOLAR 41825 41825 360 100.00 0.00 STRUCTURES; WITHOUT REPAIR EXCISION OF LESION, CONJUNCTIVA; OVER 1 68115 68115 360 7,050.00 100.00 7,050.00 CM EXCISION OF LESION, CONJUNCTIVA; UP TO 1 68110 68110 360 7,050.00 100.00 7,050.00 CM EXCISION OF LESION, CONJUNCTIVA; WITH 68130 68130 360 100.00 0.00 ADJACENT SCLERA EXCISION OF LESION, CORNEA (KERATECTOMY, 65400 65400 360 5,850.00 100.00 5,850.00 LAMELLAR, PARTIAL), EXCEPT PTERYGIUM EXCISION OF LESION, ESOPHAGUS, WITH 43100 43100 360 100.00 0.00 PRIMARY REPAIR; CERVICAL APPROACH EXCISION OF LESION, ESOPHAGUS, WITH PRIMARY REPAIR; THORACIC OR ABDOMINAL 43101 43101 360 100.00 0.00 APPROACH EXCISION OF LESION, SCLERA 66130 66130 360 100.00 0.00 EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING 28090 28090 360 8,000.00 100.00 8,000.00 SYNOVECTOMY) (EG, CYST OR GANGLION); FOOT EXCISION OF LESION, TENDON, TENDON SHEATH, OR CAPSULE (INCLUDING 28092 28092 360 8,000.00 100.00 8,000.00 SYNOVECTOMY) (EG, CYST OR GANGLION); TOE(S), EACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OF LINGUAL FRENUM (FRENECTOMY) 41115 41115 360 3,000.00 100.00 3,000.00 EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH CROSS LIP FLAP (ABBE- 40527 40527 360 17,100.00 100.00 17,100.00 ESTLANDER) EXCISION OF LIP; FULL THICKNESS, RECONSTRUCTION WITH LOCAL FLAP (EG, 40525 40525 360 8,900.00 100.00 8,900.00 ESTLANDER OR FAN) EXCISION OF LIP; TRANSVERSE WEDGE 40510 40510 360 100.00 0.00 EXCISION WITH PRIMARY CLOSURE EXCISION OF LIP; V-EXCISION WITH PRIMARY 40520 40520 360 5,800.00 100.00 5,800.00 DIRECT LINEAR CLOSURE EXCISION OF LOCAL LESION OF EPIDIDYMIS 54830 54830 360 100.00 0.00 EXCISION OF LOCAL LESION OF TESTIS 54510 360 100.00 0.00 EXCISION OF MALIGNANT TUMOR OF 21044 21044 360 17,100.00 100.00 17,100.00 MANDIBLE; EXCISION OF MALIGNANT TUMOR OF 21045 21045 360 100.00 0.00 MANDIBLE; RADICAL RESECTION EXCISION OF MALIGNANT TUMOR OF MAXILLA 21034 21034 360 100.00 0.00 OR ZYGOMA EXCISION OF MAXILLARY TORUS PALATINUS 21032 21032 360 100.00 0.00 EXCISION OF MECKEL'S DIVERTICULUM (DIVERTICULECTOMY) OR 44800 44800 360 100.00 0.00 OMPHALOMESENTERIC DUCT EXCISION OF MUCOSA OF VESTIBULE OF 40818 40818 360 100.00 0.00 MOUTH AS DONOR GRAFT EXCISION OF MULLERIAN DUCT CYST 55680 55680 360 100.00 0.00 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE, (EG, INGROWN OR DEFORMED 11750 11750 360 10,860.00 100.00 10,860.00 NAIL) FOR PERMANENT REMOVAL;

EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE, (EG, INGROWN OR DEFORMED 11752 11752 360 16,290.00 100.00 16,290.00 NAIL) FOR PERMANENT REMOVAL; WITH AMPUTATION OF TUFT OF DISTAL PHALANX Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF NEUROFIBROMA OR 64788 64788 360 100.00 0.00 NEUROLEMMOMA; CUTANEOUS NERVE EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; EXTENSIVE (INCLUDING 64792 64792 360 100.00 0.00 MALIGNANT TYPE) EXCISION OF NEUROFIBROMA OR 64790 64790 360 13,770.00 100.00 13,770.00 NEUROLEMMOMA; MAJOR PERIPHERAL NERVE EXCISION OF NEUROMA; CUTANEOUS NERVE, 64774 64774 360 10,240.00 100.00 10,240.00 SURGICALLY IDENTIFIABLE EXCISION OF NEUROMA; DIGITAL NERVE, EACH ADDITIONAL DIGIT (LIST SEPARATELY IN 64778 64778 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) EXCISION OF NEUROMA; DIGITAL NERVE, ONE 64776 64776 360 11,940.00 100.00 11,940.00 OR BOTH, SAME DIGIT EXCISION OF NEUROMA; HAND OR FOOT, EACH ADDITIONAL NERVE, EXCEPT SAME DIGIT (LIST 64783 64783 360 100.00 0.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) EXCISION OF NEUROMA; HAND OR FOOT, 64782 64782 360 11,940.00 100.00 11,940.00 EXCEPT DIGITAL NERVE EXCISION OF NEUROMA; MAJOR PERIPHERAL 64784 64784 360 100.00 0.00 NERVE, EXCEPT SCIATIC EXCISION OF NEUROMA; SCIATIC NERVE 64786 64786 360 100.00 0.00

EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE NOT REQUIRING 44111 44111 360 100.00 0.00 ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; MULTIPLE ENTEROTOMIES

EXCISION OF ONE OR MORE LESIONS OF SMALL OR LARGE INTESTINE NOT REQUIRING 44110 44110 360 100.00 0.00 ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; SINGLE ENTEROTOMY EXCISION OF OSSEOUS TUBEROSITIES, 41823 41823 360 100.00 0.00 DENTOALVEOLAR STRUCTURES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITH DISSECTION AND 42415 42415 360 17,100.00 100.00 17,100.00 PRESERVATION OF FACIAL NERVE EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, WITHOUT NERVE 42410 42410 360 17,100.00 100.00 17,100.00 DISSECTION EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, EN BLOC REMOVAL WITH 42425 42425 360 100.00 0.00 SACRIFICE OF FACIAL NERVE

EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH DISSECTION AND 42420 42420 360 17,100.00 100.00 17,100.00 PRESERVATION OF FACIAL NERVE EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, WITH UNILATERAL RADICAL 42426 42426 360 100.00 0.00 NECK DISSECTION EXCISION OF PENILE PLAQUE (PEYRONIE 54110 54110 360 15,650.00 100.00 15,650.00 DISEASE); EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); WITH GRAFT GREATER THAN 5 CM IN 54112 54112 360 100.00 0.00 LENGTH EXCISION OF PENILE PLAQUE (PEYRONIE 54111 54111 360 100.00 0.00 DISEASE); WITH GRAFT TO 5 CM IN LENGTH EXCISION OF PILONIDAL CYST OR SINUS; 11772 11772 360 27,150.00 100.00 27,150.00 COMPLICATED EXCISION OF PILONIDAL CYST OR SINUS; 11771 11771 360 21,720.00 100.00 21,720.00 EXTENSIVE EXCISION OF PILONIDAL CYST OR SINUS; 11770 11770 360 12,910.00 100.00 12,910.00 SIMPLE EXCISION OF PRESACRAL OR 49215 49215 360 100.00 0.00 SACROCOCCYGEAL TUMOR EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSSACRAL OR TRANSCOCCYGEAL 45160 45160 360 100.00 0.00 APPROACH EXCISION OF RECTAL TUMOR, TRANSANAL 45170 45170 360 100.00 0.00 APPROACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF RIB, PARTIAL 21600 21600 360 100.00 0.00 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH COMPLEX 11451 11451 360 27,150.00 100.00 27,150.00 REPAIR EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY; WITH SIMPLE 11450 11450 360 16,290.00 100.00 16,290.00 OR INTERMEDIATE REPAIR EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH COMPLEX 11463 11463 360 100.00 0.00 REPAIR EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL; WITH SIMPLE OR 11462 11462 360 100.00 0.00 INTERMEDIATE REPAIR EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR 11471 11471 360 100.00 0.00 UMBILICAL; WITH COMPLEX REPAIR EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL, OR 11470 11470 360 100.00 0.00 UMBILICAL; WITH SIMPLE OR INTERMEDIATE REPAIR EXCISION OF SPERMATOCELE, WITH OR 54840 54840 360 9,700.00 100.00 9,700.00 WITHOUT EPIDIDYMECTOMY EXCISION OF SUBLINGUAL GLAND 42450 42450 360 100.00 0.00 EXCISION OF SUBLINGUAL SALIVARY CYST 42408 42408 360 100.00 0.00 (RANULA) EXCISION OF SUBMANDIBULAR 42440 42440 360 17,100.00 100.00 17,100.00 (SUBMAXILLARY) GLAND EXCISION OF SYNOVIAL CYST OF POPLITEAL 27345 27345 360 8,530.00 100.00 8,530.00 SPACE (EG, BAKER'S CYST) EXCISION OF TENDON, FINGER, FLEXOR 26180 26180 360 100.00 0.00 (SEPARATE PROCEDURE), EACH TENDON EXCISION OF TENDON, PALM, FLEXOR, SINGLE 26170 26170 360 100.00 0.00 (SEPARATE PROCEDURE), EACH EXCISION OF THYROGLOSSAL DUCT CYST OR 60280 60280 360 19,400.00 100.00 19,400.00 SINUS; EXCISION OF THYROGLOSSAL DUCT CYST OR 60281 60281 360 100.00 0.00 SINUS; RECURRENT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OF TONSIL TAGS 42860 42860 360 100.00 0.00 EXCISION OF TORUS MANDIBULARIS 21031 21031 360 18,120.00 100.00 18,120.00 EXCISION OF TRACHEAL TUMOR OR 31785 31785 360 100.00 0.00 CARCINOMA; CERVICAL EXCISION OF TRACHEAL TUMOR OR 31786 31786 360 100.00 0.00 CARCINOMA; THORACIC EXCISION OF URACHAL CYST OR SINUS, WITH 51500 51500 360 22,400.00 100.00 22,400.00 OR WITHOUT UMBILICAL HERNIA REPAIR EXCISION OF URETHRAL DIVERTICULUM 53230 53230 360 100.00 0.00 (SEPARATE PROCEDURE); FEMALE EXCISION OF URETHRAL DIVERTICULUM 53235 53235 360 100.00 0.00 (SEPARATE PROCEDURE); MALE EXCISION OF VAGINAL CYST OR TUMOR 57135 57135 360 8,450.00 100.00 8,450.00 EXCISION OF VAGINAL SEPTUM 57130 57130 360 100.00 0.00 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; 55530 55530 360 100.00 0.00 (SEPARATE PROCEDURE) EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; 55535 55535 360 100.00 0.00 ABDOMINAL APPROACH EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; WITH 55540 55540 360 100.00 0.00 HERNIA REPAIR EXCISION OR CURETTAGE OF BONE CYST OR 25130 25130 360 11,900.00 100.00 11,900.00 BENIGN TUMOR OF CARPAL BONES; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH 25136 25136 360 100.00 0.00 ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; WITH 25135 25135 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT)

EXCISION OR CURETTAGE OF BONE CYST OR 23140 23140 360 12,310.00 100.00 12,310.00 BENIGN TUMOR OF CLAVICLE OR SCAPULA; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CLAVICLE OR SCAPULA; 23146 23146 360 100.00 0.00 WITH ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CLAVICLE OR SCAPULA; 23145 23145 360 100.00 0.00 WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR 27355 27355 360 14,460.00 100.00 14,460.00 BENIGN TUMOR OF FEMUR; EXCISION OR CURETTAGE OF BONE CYST OR 27356 27356 360 100.00 0.00 BENIGN TUMOR OF FEMUR; WITH ALLOGRAFT

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH AUTOGRAFT 27357 27357 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; WITH INTERNAL 27358 27358 360 100.00 0.00 FIXATION (LIST IN ADDITION TO CODE FOR PRIMARY PROCEDURE) EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS 24120 24120 360 4,350.00 100.00 4,350.00 OR OLECRANON PROCESS; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS 24126 24126 360 100.00 0.00 OR OLECRANON PROCESS; WITH ALLOGRAFT

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS 24125 24125 360 100.00 0.00 OR OLECRANON PROCESS; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR 26200 26200 360 100.00 0.00 BENIGN TUMOR OF METACARPAL; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; WITH 26205 26205 360 10,150.00 100.00 10,150.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OR CURETTAGE OF BONE CYST OR 23150 23150 360 100.00 0.00 BENIGN TUMOR OF PROXIMAL HUMERUS; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS; WITH 23156 23156 360 100.00 0.00 ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS; WITH 23155 23155 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR 26210 26210 360 6,380.00 100.00 6,380.00 DISTAL PHALANX OF FINGER; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE, OR 26215 26215 360 100.00 0.00 DISTAL PHALANX OF FINGER; WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA 25120 25120 360 11,900.00 100.00 11,900.00 (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA 25126 25126 360 100.00 0.00 (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); WITH ALLOGRAFT

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND 25125 25125 360 100.00 0.00 OLECRANON PROCESS); WITH AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR 24110 24110 360 100.00 0.00 BENIGN TUMOR, HUMERUS; EXCISION OR CURETTAGE OF BONE CYST OR 24116 24116 360 100.00 0.00 BENIGN TUMOR, HUMERUS; WITH ALLOGRAFT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; WITH AUTOGRAFT 24115 24115 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR 28108 28108 360 8,000.00 100.00 8,000.00 BENIGN TUMOR, PHALANGES OF FOOT EXCISION OR CURETTAGE OF BONE CYST OR 28100 28100 360 8,000.00 100.00 8,000.00 BENIGN TUMOR, TALUS OR CALCANEUS; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH 28103 28103 360 100.00 0.00 ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; WITH 28102 28102 360 100.00 0.00 ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT)

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, 28104 28104 360 8,000.00 100.00 8,000.00 EXCEPT TALUS OR CALCANEUS; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, 28107 28107 360 100.00 0.00 EXCEPT TALUS OR CALCANEUS; WITH ALLOGRAFT EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TARSAL OR METATARSAL, EXCEPT TALUS OR CALCANEUS; WITH ILIAC OR 28106 28106 360 100.00 0.00 OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR CURETTAGE OF BONE CYST OR 27635 27635 360 11,900.00 100.00 11,900.00 BENIGN TUMOR, TIBIA OR FIBULA; EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH 27638 27638 360 100.00 0.00 ALLOGRAFT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; WITH 27637 27637 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT) EXCISION OR DESTRUCTION (EG, LASER), INTRANASAL LESION; EXTERNAL APPROACH 30118 30118 360 8,900.00 100.00 8,900.00 (LATERAL RHINOTOMY) EXCISION OR DESTRUCTION (EG, LASER), 30117 30117 360 6,270.00 100.00 6,270.00 INTRANASAL LESION; INTERNAL APPROACH

EXCISION OR DESTRUCTION LINGUAL TONSIL, 42870 42870 360 8,900.00 100.00 8,900.00 ANY METHOD (SEPARATE PROCEDURE) EXCISION OR DESTRUCTION OF LESION OF 42808 42808 360 8,900.00 100.00 8,900.00 PHARYNX, ANY METHOD EXCISION OR DESTRUCTION, OPEN, INTRA- ABDOMINAL OR RETROPERITONEAL TUMORS 49200 49200 360 100.00 0.00 OR CYSTS OR ENDOMETRIOMAS; EXCISION OR DESTRUCTION, OPEN, INTRA- ABDOMINAL OR RETROPERITONEAL TUMORS 49201 49201 360 100.00 0.00 OR CYSTS OR ENDOMETRIOMAS; EXTENSIVE EXCISION OR FULGURATION OF CARCINOMA OF 53220 53220 360 100.00 0.00 URETHRA EXCISION OR FULGURATION; SKENE'S GLANDS 53270 53270 360 100.00 0.00 EXCISION OR FULGURATION; URETHRAL 53265 53265 360 12,950.00 100.00 12,950.00 CARUNCLE EXCISION OR FULGURATION; URETHRAL 53260 53260 360 100.00 0.00 POLYP(S), DISTAL URETHRA EXCISION OR FULGURATION; URETHRAL 53275 53275 360 100.00 0.00 PROLAPSE EXCISION OR SURGICAL PLANING OF SKIN OF 30120 30120 360 100.00 0.00 NOSE FOR RHINOPHYMA EXCISION OR TRANSPOSITION OF PTERYGIUM; 65426 65426 360 7,050.00 100.00 7,050.00 WITH GRAFT EXCISION OR TRANSPOSITION OF PTERYGIUM; 65420 65420 360 7,050.00 100.00 7,050.00 WITHOUT GRAFT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION PROCEDURE OF NECK (SOFT TISSUE) 21552 21552 360 23,250.00 100.00 23,250.00 AND THORAX EXCISION SKIN AND SUB-Q TISSUE 86.3 360 100.00 0.00 EXCISION SOFT TISSUE LESION, EXTERNAL 69145 69145 360 6,930.00 100.00 6,930.00 AUDITORY CANAL EXCISION TRACHEAL STENOSIS AND 31780 31780 360 100.00 0.00 ANASTOMOSIS; CERVICAL EXCISION TRACHEAL STENOSIS AND 31781 31781 360 100.00 0.00 ANASTOMOSIS; CERVICOTHORACIC EXCISION TUMOR, SOFT TISSUE OF NECK OR 21556 21556 360 8,350.00 100.00 8,350.00 THORAX; DEEP, SUBFASCIAL, INTRAMUSCULAR EXCISION TUMOR, SOFT TISSUE OF NECK OR 21555 21555 360 6,530.00 100.00 6,530.00 THORAX; SUBCUTANEOUS EXCISION TURBINATE, PARTIAL OR COMPLETE, 30130 30130 360 8,900.00 100.00 8,900.00 ANY METHOD EXCISION, ABDOMINAL WALL TUMOR, 22900 22900 360 19,450.00 100.00 19,450.00 SUBFASCIAL (EG, DESMOID) EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11420 11420 360 3,800.00 100.00 3,800.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.5 CM OR

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11421 11421 360 3,800.00 100.00 3,800.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 0.6 TO 1.0

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11422 11422 360 3,850.00 100.00 3,850.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 1.1 TO 2.0

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11423 11423 360 10,860.00 100.00 10,860.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11424 11424 360 10,860.00 100.00 10,860.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM

EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11426 11426 360 16,290.00 100.00 16,290.00 ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; EXCISED DIAMETER OVER 4.0 CM EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11400 11400 360 2,150.00 100.00 2,150.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.5 CM OR LESS EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11401 11401 360 2,720.00 100.00 2,720.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 0.6 TO 1.0 CM EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11402 11402 360 3,620.00 100.00 3,620.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 1.1 TO 2.0 CM EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11403 11403 360 4,640.00 100.00 4,640.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 2.1 TO 3.0 CM EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11404 11404 360 10,860.00 100.00 10,860.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER 3.1 TO 4.0 CM EXCISION, BENIGN LESION INCLUDING MARGINS, EXCEPT SKIN TAG (UNLESS LISTED 11406 11406 360 16,290.00 100.00 16,290.00 ELSEWHERE), TRUNK, ARMS OR LEGS; EXCISED DIAMETER OVER 4.0 CM EXCISION, COCCYGEAL PRESSURE ULCER, WITH 15922 15922 360 100.00 0.00 COCCYGECTOMY; WITH FLAP CLOSURE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, COCCYGEAL PRESSURE ULCER, WITH 15920 15920 360 100.00 0.00 COCCYGECTOMY; WITH PRIMARY SUTURE

EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15831 15831 360 100.00 0.00 LIPECTOMY); ABDOMEN (ABDOMINOPLASTY) EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15836 15836 360 100.00 0.00 LIPECTOMY); ARM EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15835 15835 360 100.00 0.00 LIPECTOMY); BUTTOCK EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15837 15837 360 100.00 0.00 LIPECTOMY); FOREARM OR HAND EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15834 15834 360 100.00 0.00 LIPECTOMY); HIP EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15833 15833 360 8,350.00 100.00 8,350.00 LIPECTOMY); LEG EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15839 15839 360 9,900.00 100.00 9,900.00 LIPECTOMY); OTHER AREA EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15838 15838 360 100.00 0.00 LIPECTOMY); SUBMENTAL FAT PAD EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDING 15832 15832 360 100.00 0.00 LIPECTOMY); THIGH EXCISION, INTERDIGITAL (MORTON) NEUROMA, 28080 28080 360 8,000.00 100.00 8,000.00 SINGLE, EACH EXCISION, ISCHIAL PRESSURE ULCER, WITH OSTECTOMY, IN PREPARATION FOR MUSCLE OR 15946 15946 360 100.00 0.00 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION, ISCHIAL PRESSURE ULCER, WITH 15940 15940 360 100.00 0.00 PRIMARY SUTURE; EXCISION, ISCHIAL PRESSURE ULCER, WITH PRIMARY SUTURE; WITH OSTECTOMY 15941 15941 360 100.00 0.00 (ISCHIECTOMY) EXCISION, ISCHIAL PRESSURE ULCER, WITH 15944 15944 360 100.00 0.00 SKIN FLAP CLOSURE; EXCISION, ISCHIAL PRESSURE ULCER, WITH 15945 15945 360 100.00 0.00 SKIN FLAP CLOSURE; WITH OSTECTOMY EXCISION, LESION OF FLOOR OF MOUTH 41116 41116 360 100.00 0.00 EXCISION, LESION OF PALATE, UVULA; WITH 42107 42107 360 100.00 0.00 LOCAL FLAP CLOSURE EXCISION, LESION OF PALATE, UVULA; WITH 42106 42106 360 5,800.00 100.00 5,800.00 SIMPLE PRIMARY CLOSURE EXCISION, LESION OF PALATE, UVULA; 42104 42104 360 5,800.00 100.00 5,800.00 WITHOUT CLOSURE EXCISION, LESION OF TENDON SHEATH, 25110 25110 360 100.00 0.00 FOREARM AND/OR WRIST EXCISION, LOCAL; MALIGNANT TUMOR OF 43611 43611 360 100.00 0.00 STOMACH EXCISION, LOCAL; ULCER OR BENIGN TUMOR 43610 43610 360 100.00 0.00 OF STOMACH EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11640 11640 360 6,460.00 100.00 6,460.00 EXCISED DIAMETER 0.5 CM OR LESS EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11641 11641 360 7,020.00 100.00 7,020.00 EXCISED DIAMETER 0.6 TO 1.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11642 11642 360 8,830.00 100.00 8,830.00 EXCISED DIAMETER 1.1 TO 2.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11643 11643 360 10,860.00 100.00 10,860.00 EXCISED DIAMETER 2.1 TO 3.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11644 11644 360 16,290.00 100.00 16,290.00 EXCISED DIAMETER 3.1 TO 4.0 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION, MALIGNANT LESION INCLUDING MARGINS, FACE, EARS, EYELIDS, NOSE, LIPS; 11646 11646 360 21,720.00 100.00 21,720.00 EXCISED DIAMETER OVER 4.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11620 11620 360 100.00 0.00 GENITALIA; EXCISED DIAMETER 0.5 CM OR LESS

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11621 11621 360 100.00 0.00 GENITALIA; EXCISED DIAMETER 0.6 TO 1.0 CM

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11622 11622 360 8,340.00 100.00 8,340.00 GENITALIA; EXCISED DIAMETER 1.1 TO 2.0 CM

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11623 11623 360 10,860.00 100.00 10,860.00 GENITALIA; EXCISED DIAMETER 2.1 TO 3.0 CM

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11624 11624 360 19,360.00 100.00 19,360.00 GENITALIA; EXCISED DIAMETER 3.1 TO 4.0 CM

EXCISION, MALIGNANT LESION INCLUDING MARGINS, SCALP, NECK, HANDS, FEET, 11626 11626 360 21,720.00 100.00 21,720.00 GENITALIA; EXCISED DIAMETER OVER 4.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11600 11600 360 100.00 0.00 DIAMETER 0.5 CM OR LESS EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11601 11601 360 4,580.00 100.00 4,580.00 DIAMETER 0.6 TO 1.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11602 11602 360 5,090.00 100.00 5,090.00 DIAMETER 1.1 TO 2.0 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11603 11603 360 12,910.00 100.00 12,910.00 DIAMETER 2.1 TO 3.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11604 11604 360 16,290.00 100.00 16,290.00 DIAMETER 3.1 TO 4.0 CM EXCISION, MALIGNANT LESION INCLUDING MARGINS, TRUNK, ARMS, OR LEGS; EXCISED 11606 11606 360 21,720.00 100.00 21,720.00 DIAMETER OVER 4.0 CM EXCISION, NASAL POLYP(S), EXTENSIVE 30115 30115 360 7,450.00 100.00 7,450.00 EXCISION, NASAL POLYP(S), SIMPLE 30110 30110 360 100.00 0.00 EXCISION, OLECRANON BURSA 24105 24105 360 8,430.00 100.00 8,430.00

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11440 11440 360 3,620.00 100.00 3,620.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.5 CM O

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11441 11441 360 3,620.00 100.00 3,620.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 0.6 TO 1

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11442 11442 360 4,870.00 100.00 4,870.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 1.1 TO 2

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11443 11443 360 10,860.00 100.00 10,860.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 2.1 TO 3

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11444 11444 360 10,860.00 100.00 10,860.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER 3.1 TO 4.0 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, OTHER BENIGN LESION INCLUDING MARGINS (UNLESS LISTED ELSEWHERE), FACE, 11446 11446 360 16,290.00 100.00 16,290.00 EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; EXCISED DIAMETER OVER 4.0 CM EXCISION, PREPATELLAR BURSA 27340 27340 360 7,600.00 100.00 7,600.00 EXCISION, RADIAL HEAD 24130 24130 360 100.00 0.00 EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 15936 15936 360 100.00 0.00 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; EXCISION, SACRAL PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 15937 15937 360 100.00 0.00 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY EXCISION, SACRAL PRESSURE ULCER, WITH 15931 15931 360 100.00 0.00 PRIMARY SUTURE; EXCISION, SACRAL PRESSURE ULCER, WITH 15933 15933 360 100.00 0.00 PRIMARY SUTURE; WITH OSTECTOMY EXCISION, SACRAL PRESSURE ULCER, WITH 15934 15934 360 100.00 0.00 SKIN FLAP CLOSURE; EXCISION, SACRAL PRESSURE ULCER, WITH 15935 15935 360 100.00 0.00 SKIN FLAP CLOSURE; WITH OSTECTOMY EXCISION, SOFT TISSUE TUMOR, SHOULDER 23076 23076 360 8,430.00 100.00 8,430.00 AREA; DEEP, SUBFASCIAL, OR INTRAMUSCULAR EXCISION, SOFT TISSUE TUMOR, SHOULDER 23075 23075 360 6,150.00 100.00 6,150.00 AREA; SUBCUTANEOUS EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 15956 15956 360 100.00 0.00 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; EXCISION, TROCHANTERIC PRESSURE ULCER, IN PREPARATION FOR MUSCLE OR 15958 15958 360 100.00 0.00 MYOCUTANEOUS FLAP OR SKIN GRAFT CLOSURE; WITH OSTECTOMY EXCISION, TROCHANTERIC PRESSURE ULCER, 15950 15950 360 100.00 0.00 WITH PRIMARY SUTURE; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, TROCHANTERIC PRESSURE ULCER, 15951 15951 360 100.00 0.00 WITH PRIMARY SUTURE; WITH OSTECTOMY EXCISION, TROCHANTERIC PRESSURE ULCER, 15952 15952 360 100.00 0.00 WITH SKIN FLAP CLOSURE; EXCISION, TROCHANTERIC PRESSURE ULCER, 15953 15953 360 100.00 0.00 WITH SKIN FLAP CLOSURE; WITH OSTECTOMY

EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR 26111 26111 360 6,150.00 100.00 6,150.00 FINGER, SUBCUTANEOUS; 1.5 CM OR GREATER EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR 26116 26116 360 6,380.00 100.00 6,380.00 FINGER; DEEP (SUBFASCIAL OR INTRAMUSCULAR) EXCISION, TUMOR OR VASCULAR MALFORMATION, SOFT TISSUE OF HAND OR 26115 26115 360 6,150.00 100.00 6,150.00 FINGER; SUBCUTANEOUS EXCISION, TUMOR, FOOT; DEEP, SUBFASCIAL, 28045 28045 360 7,370.00 100.00 7,370.00 INTRAMUSCULAR EXCISION, TUMOR, FOOT; SUBCUTANEOUS 28043 28043 360 100.00 0.00 TISSUE EXCISION, TUMOR, LEG OR ANKLE AREA; DEEP 27619 27619 360 100.00 0.00 (SUBFASCIAL OR INTRAMUSCULAR) EXCISION, TUMOR, LEG OR ANKLE AREA; 27618 27618 360 6,150.00 100.00 6,150.00 SUBCUTANEOUS TISSUE EXCISION, TUMOR, PELVIS AND HIP AREA; 27048 27048 360 11,750.00 100.00 11,750.00 DEEP, SUBFASCIAL, INTRAMUSCULAR EXCISION, TUMOR, PELVIS AND HIP AREA; 27047 27047 360 6,150.00 100.00 6,150.00 SUBCUTANEOUS TISSUE EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL 22902 22902 360 19,450.00 100.00 19,450.00 WALL, SUBCUTANEOUS, LESS THAN 3 CM

EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL 22903 22903 360 19,450.00 100.00 19,450.00 WALL, SUBCUTANEOUS; 3 CM OR GREATER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, TUMOR, SOFT TISSUE OF ABDOMINAL 22901 22901 360 19,450.00 100.00 19,450.00 WALL, SUBFASCIAL; 5CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF BACK OR 21930 21930 360 16,210.00 100.00 16,210.00 FLANK EXCISION, TUMOR, SOFT TISSUE OF BACK OR 21931 21931 360 12,600.00 100.00 12,600.00 FLANK, SUBCUTANEOUS; 3 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 5 21933 21933 360 4,650.00 100.00 4,650.00 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK, SUBFASCIAL (EG, INTRAMUSCULAR); 21932 21932 360 8,500.00 100.00 8,500.00 LESS THAN 5 CM EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, 21014 21014 360 9,900.00 100.00 9,900.00 INTRAMUSCULAR); 2 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF FACE AND SCALP, SUBFASCIAL (EG, SUBGALEAL, 21013 21013 360 7,500.00 100.00 7,500.00 INTRAMUSCULAR); LESS THAN 2 CM EXCISION, TUMOR, SOFT TISSUE OF FACE OR 21012 21012 360 7,500.00 100.00 7,500.00 SCALP, SUBCUTANEOUS; 2 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF FOOT OR TOE, SUBFASCIAL (EG, INTRAMUSCULAR); 1.5 28041 28041 360 8,420.00 100.00 8,420.00 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA, SUBCUTANEOUS; 3 CM OR 25071 25071 360 5,700.00 100.00 5,700.00 GREATER EXCISION, TUMOR, SOFT TISSUE OF FOREARM AND/OR WRIST AREA; DEEP (SUBFASCIAL OR 25076 25076 360 8,500.00 100.00 8,500.00 INTRAMUSCULAR) EXCISION, TUMOR, SOFT TISSUE OF FOREARM 25075 25075 360 6,380.00 100.00 6,380.00 AND/OR WRIST AREA; SUBCUTANEOUS EXCISION, TUMOR, SOFT TISSUE OF NECK OR ANTERIOR THORAX, SUBFASCIAL (EG, 21554 21554 360 23,250.00 100.00 23,250.00 INTRAMUSCULAR); 5 CM OR GREATER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXCISION, TUMOR, SOFT TISSUE OF PELVIS AND 27043 27043 360 23,250.00 100.00 23,250.00 HIP AREA, SUBCUTANEOUS; 3 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF SHOULDER 23071 23071 360 13,780.00 100.00 13,780.00 AREA, SUBCUTANEOUS EXCISION, TUMOR, SOFT TISSUE OF SHOULDER AREA, SUBFASCIAL (EG, INTRAMUSCULAR); 5 23073 23073 360 13,780.00 100.00 13,780.00 CM OR GREATER EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR 24076 24076 360 8,430.00 100.00 8,430.00 INTRAMUSCULAR) EXCISION, TUMOR, SOFT TISSUE OF UPPER ARM 24075 24075 360 6,150.00 100.00 6,150.00 OR ELBOW AREA; SUBCUTANEOUS EXCISION, TUMOR, THIGH OR KNEE AREA; DEEP, 27328 27328 360 7,470.00 100.00 7,470.00 SUBFASCIAL, OR INTRAMUSCULAR EXCISION, TUMOR, THIGH OR KNEE AREA; 27327 27327 360 8,350.00 100.00 8,350.00 SUBCUTANEOUS EXCISION; ISCHIAL BURSA 27060 27060 360 100.00 0.00 EXCISION; TROCHANTERIC BURSA OR 27062 27062 360 11,050.00 100.00 11,050.00 CALCIFICATION EXCLUSION OF SMALL INTESTINE FROM PELVIS BY MESH OR OTHER PROSTHESIS, OR NATIVE 44700 44700 360 100.00 0.00 TISSUE (EG, BLADDER OR OMENTUM) EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL OF ORBITAL 65110 65110 360 100.00 0.00 CONTENTS; ONLY EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL OF ORBITAL 65114 65114 360 100.00 0.00 CONTENTS; WITH MUSCLE OR MYOCUTANEOUS FLAP EXENTERATION OF ORBIT (DOES NOT INCLUDE SKIN GRAFT), REMOVAL OF ORBITAL 65112 65112 360 100.00 0.00 CONTENTS; WITH THERAPEUTIC REMOVAL OF BONE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee EXPLORATION FOR CONGENITAL ATRESIA OF BILE DUCTS, WITHOUT REPAIR, WITH OR 47700 47700 360 100.00 0.00 WITHOUT LIVER BIOPSY, WITH OR WITHOUT CHOLANGIOGRAPHY EXPLORATION FOR UNDESCENDED TESTIS 54550 54550 360 16,400.00 100.00 16,400.00 (INGUINAL OR SCROTAL AREA) EXPLORATION FOR UNDESCENDED TESTIS WITH 54560 54560 360 100.00 0.00 ABDOMINAL EXPLORATION EXPLORATION OF EPIDIDYMIS, WITH OR 54820 54820 360 100.00 0.00 WITHOUT BIOPSY EXPLORATION OF PENETRATING WOUND (SEPARATE PROCEDURE); 20102 20102 360 6,450.00 100.00 6,450.00 ABDOMEN/FLANK/BACK EXPLORATION OF PENETRATING WOUND 20101 20101 360 100.00 0.00 (SEPARATE PROCEDURE); CHEST EXPLORATION OF PENETRATING WOUND 20103 20103 360 5,350.00 100.00 5,350.00 (SEPARATE PROCEDURE); EXTREMITY EXPLORATION OF PENETRATING WOUND 20100 20100 360 100.00 0.00 (SEPARATE PROCEDURE); NECK EXPLORATION WITH REMOVAL OF DEEP 25248 25248 360 8,500.00 100.00 8,500.00 FOREIGN BODY, FOREARM OR WRIST EXPLORATION, REPAIR, AND PRESACRAL 45562 45562 360 100.00 0.00 DRAINAGE FOR RECTAL INJURY; EXPLORATION, REPAIR, AND PRESACRAL DRAINAGE FOR RECTAL INJURY; WITH 45563 45563 360 100.00 0.00 COLOSTOMY EXPLORATION, RETROPERITONEAL AREA WITH OR WITHOUT BIOPSY(S) (SEPARATE 49010 49010 360 100.00 0.00 PROCEDURE) EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY WITH OR WITHOUT BIOPSY(S) 49000 49000 360 100.00 0.00 (SEPARATE PROCEDURE)

EXPOSURE OF PROSTATE, ANY APPROACH, FOR 55860 55860 360 100.00 0.00 INSERTION OF RADIOACTIVE SUBSTANCE; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; WITH 55865 55865 360 100.00 0.00 BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTR EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; WITH 55862 55862 360 100.00 0.00 LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) EXPRESSION OF CONJUNCTIVAL FOLLICLES (EG, 68040 68040 360 100.00 0.00 FOR TRACHOMA) EXTERNAL CANNULA DECLOTTING (SEPARATE 36861 36861 360 100.00 0.00 PROCEDURE); WITH BALLOON CATHETER

EXTERNAL CANNULA DECLOTTING (SEPARATE 36860 36860 360 100.00 0.00 PROCEDURE); WITHOUT BALLOON CATHETER EXTERNAL DRAINAGE, PSEUDOCYST OF 48510 48510 360 100.00 0.00 PANCREAS; OPEN EXTERNAL DRAINAGE, PSEUDOCYST OF 48511 48511 360 100.00 0.00 PANCREAS; PERCUTANEOUS External recharging system for battery (internal) for use L8689-G L8689 278 700.00 0.00 with implantable neurostimulator, replacement only

External recharging system for battery (internal) for use L8689-W L8689 278 100.00 0.00 with implantable neurostimulator/ replacement only

EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR 66984 66984 360 8,050.00 100.00 8,050.00 MECHANICAL TECHNIQUE (EG, IRRIGATION AND ASPIRATION OR PHACOEMULSIFICATION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

EXTRACAPSULAR CATARACT REMOVAL WITH INSERTION OF INTRAOCULAR LENS PROSTHESIS (ONE STAGE PROCEDURE), MANUAL OR MECHANICAL TECHNIQUE (EG, IRRIGATION AND 66982 66982 360 8,050.00 100.00 8,050.00 ASPIRATION OR PHACOEMULSIFICATION), COMPLEX, REQUIRING DEVICES OR TECHNIQUES NOT GENERALLY USED IN ROUT EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF FLOOR OF 41018 41018 360 100.00 0.00 MOUTH; MASTICATOR SPACE EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF FLOOR OF 41015 41015 360 100.00 0.00 MOUTH; SUBLINGUAL EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF FLOOR OF 41017 41017 360 100.00 0.00 MOUTH; SUBMANDIBULAR EXTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF FLOOR OF 41016 41016 360 100.00 0.00 MOUTH; SUBMENTAL FACTOR V LEIDEN MUTATION ANALYSIS 81241 81241 305 450.00 100.00 450.00 FACTORY V111 ACTIVITY 85240 85240 305 50.00 100.00 50.00 FASCIA LATA GRAFT; BY INCISION AND AREA 20922 20922 360 100.00 0.00 EXPOSURE, COMPLEX OR SHEET FASCIA LATA GRAFT; BY STRIPPER 20920 20920 360 100.00 0.00 FASCIECTOMY, PALM ONLY, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE 26121 26121 360 10,150.00 100.00 10,150.00 REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT) FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR 26123 26123 360 10,630.00 100.00 10,630.00 WITHOUT Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FASCIECTOMY, PARTIAL PALMAR WITH RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, WITH OR WITHOUT Z-PLASTY, OTHER LOCAL TISSUE 26125 26125 360 5,350.00 100.00 5,350.00 REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION FASCIECTOMY, PLANTAR FASCIA; PARTIAL 28060 28060 360 8,420.00 100.00 8,420.00 (SEPARATE PROCEDURE) FASCIECTOMY, PLANTAR FASCIA; RADICAL 28062 28062 360 9,470.00 100.00 9,470.00 (SEPARATE PROCEDURE) FASCIOTOMY, FOOT AND/OR TOE 28008 28008 360 8,000.00 100.00 8,000.00 FASCIOTOMY, HIP OR THIGH, ANY TYPE 27025 27025 360 100.00 0.00 FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN 27305 27305 360 11,050.00 100.00 11,050.00 FASCIOTOMY, LATERAL OR MEDIAL (EG, TENNIS 24350 24350 360 100.00 0.00 ELBOW OR EPICONDYLITIS); FASCIOTOMY, LATERAL OR MEDIAL (EG, TENNIS ELBOW OR EPICONDYLITIS); WITH ANNULAR 24352 24352 360 100.00 0.00 LIGAMENT RESECTION FASCIOTOMY, LATERAL OR MEDIAL (EG, TENNIS ELBOW OR EPICONDYLITIS); WITH EXTENSOR 24351 24351 360 100.00 0.00 ORIGIN DETACHMENT FASCIOTOMY, LATERAL OR MEDIAL (EG, TENNIS ELBOW OR EPICONDYLITIS); WITH PARTIAL 24356 24356 360 100.00 0.00 OSTECTOMY FASCIOTOMY, LATERAL OR MEDIAL (EG, TENNIS 24354 24354 360 100.00 0.00 ELBOW OR EPICONDYLITIS); WITH STRIPPING FASCIOTOMY, PALMAR (EG, DUPUYTREN'S 26045 26045 360 100.00 0.00 CONTRACTURE); OPEN, PARTIAL FASCIOTOMY, PALMAR (EG, DUPUYTREN'S 26040 26040 360 100.00 0.00 CONTRACTURE); PERCUTANEOUS FECES CULTURE AEROBIC BACTERIA 87045 87045 306 180.00 100.00 180.00 FENESTRATION SEMICIRCULAR CANAL 69820 69820 360 100.00 0.00 FERRITIN 82728 82728 301 140.00 100.00 140.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FETAL BIOPHYSICAL PROFILE WITH NON 76818 76818 402 650.00 100.00 650.00 STRESS TESTING FETAL BIOPHYSICAL PROFILE WITHOUT NON 76819 76819 402 810.00 100.00 810.00 STRESS TESTING FIBRINOGEN ACTIVITY 85366 85366 301 100.00 100.00 100.00 FIBRINOGEN DEGRADATION 85379 85379 301 230.00 100.00 230.00 FIBRINOGEN; ACTIVITY 85384 85384 300 100.00 0.00 FILLETED FINGER OR TOE FLAP, INCLUDING 14350 14350 360 10,160.00 100.00 10,160.00 PREPARATION OF RECIPIENT SITE FIMBRIOPLASTY 58760 58760 360 100.00 0.00 FINE NEEDLE ASPIRATION OF ORBITAL 67415 67415 360 100.00 0.00 CONTENTS FISH, MOP ANAL MANUAL; T 88360 88360 301 1,000.00 100.00 1,000.00 FISSURECTOMY, WITH OR WITHOUT 46200 46200 360 8,900.00 100.00 8,900.00 SPHINCTEROTOMY FISTULIZATION OF SCLERA FOR GLAUCOMA; 66165 66165 360 100.00 0.00 IRIDENCLEISIS OR IRIDOTASIS FISTULIZATION OF SCLERA FOR GLAUCOMA; SCLERECTOMY WITH PUNCH OR SCISSORS, 66160 66160 360 100.00 0.00 WITH IRIDECTOMY FISTULIZATION OF SCLERA FOR GLAUCOMA; 66155 66155 360 100.00 0.00 THERMOCAUTERIZATION WITH IRIDECTOMY

FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE 66170 66170 360 100.00 0.00 OF PREVIOUS SURGERY

FISTULIZATION OF SCLERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO WITH SCARRING FROM PREVIOUS OCULAR SURGERY 66172 66172 360 100.00 0.00 OR TRAUMA (INCLUDES INJECTION OF ANTIFIBROTIC AGENTS)

FISTULIZATION OF SCLERA FOR GLAUCOMA; 66150 66150 360 100.00 0.00 TREPHINATION WITH IRIDECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FISTULIZATION OF SUBLINGUAL SALIVARY 42325 42325 360 100.00 0.00 CYST (RANULA); FISTULIZATION OF SUBLINGUAL SALIVARY 42326 42326 360 100.00 0.00 CYST (RANULA); WITH PROSTHESIS FITTING AND INSERTION OF PESSARY OR OTHER 57160 57160 360 100.00 0.00 INTRAVAGINAL SUPPORT DEVICE FIXATION OF CONTRALATERAL TESTIS 54620 54620 360 100.00 0.00 (SEPARATE PROCEDURE) FIXATION OF TONGUE, MECHANICAL, OTHER 41500 41500 360 100.00 0.00 THAN SUTURE (EG, K-WIRE) FLAP; ISLAND PEDICLE 15740 15740 360 11,850.00 100.00 11,850.00 FLAP; NEUROVASCULAR PEDICLE 15750 15750 360 11,850.00 100.00 11,850.00 FLEX HD, ALLOPATCH HD, OR MATRIX HD, PER Q4128 Q4128 278 17,080.00 700.00 119,560.00 SQUARE CENTIMETER FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PALSY, VOLKMANN CONTRACTURE), FOREARM 25315 25315 360 100.00 0.00 AND/OR WRIST; FLEXOR ORIGIN SLIDE (EG, FOR CEREBRAL PALSY, VOLKMANN CONTRACTURE), FOREARM 25316 25316 360 100.00 0.00 AND/OR WRIST; WITH TENDON(S) TRANSFER FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE 24330 24330 360 100.00 0.00 ADVANCEMENT); FLEXOR-PLASTY, ELBOW (EG, STEINDLER TYPE ADVANCEMENT); WITH EXTENSOR 24331 24331 360 100.00 0.00 ADVANCEMENT FLOUROSCOPIC GUIDANCE 77002 77002 320 650.00 100.00 650.00 FLOURSCOPIC GUIDANCE FOR CENTRAL 77001 77001 320 350.00 100.00 350.00 VENOUS ACCESS FLOW CYTOMETRY EACH ADDITIONAL 88185 88185 311 725.00 100.00 725.00 FLOW CYTOMETRY IST MA 88184 88184 311 1,000.00 100.00 1,000.00 FLUORESCENT ANTIBODY SCREEN 86255 86255 302 120.00 100.00 120.00 FLUORESCENT ANTIBODY TITER 86256 86256 302 110.00 100.00 110.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR PARASPINOUS DIAGNOSTIC OR THERAPEUTIC 77003 77003 320 650.00 100.00 650.00 INJECTION PROCEDURES (EPIDURAL, SUBARACHNOID, OR SACROILIAC JOINT), INCLUDING NEUROLYTIC AGENT DESTRUCTION

FLUOROSCOPIC GUIDANCE AND LOCALIZATION OF NEEDLE OR CATHETER TIP FOR SPINE OR 76005 76005 320 100.00 0.00 PARASPINOUS DIAGNOSTIC OR THERAPEUTIC INJECTION PROCEDURES (EPIDURAL, TR FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, 76003 76003 329 100.00 0.00 INJECTION, LOCALIZATION DEVICE) FLUOROSCOPY (SEPARATE PROCEDURE), UP TO ONE HOUR PHYSICIAN TIME, OTHER THAN 71023 76000 76000 320 750.00 100.00 750.00 OR 71034 (EG, CARDIAC FLUOROSCOPY)

FLUOROSCOPY, PHYSICIAN TIME MORE THAN ONE HOUR, ASSISTING A NON-RADIOLOGIC 76001 76001 320 300.00 100.00 300.00 PHYSICIAN (EG, NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, TRANSBRONCHIAL BIOPS

FOCAL APPLICATION OF PHASE CONTROL 69410 69410 360 100.00 0.00 SUBSTANCE, MIDDLE EAR (BAFFLE TECHNIQUE) FOLATE 82746 82746 301 160.00 100.00 160.00 FOLIC ACID; RBC 82747 82747 301 190.00 100.00 190.00 FORESKIN MANIPULATION INCLUDING LYSIS OF 54450 54450 360 100.00 0.00 PREPUTIAL ADHESIONS AND STRETCHING FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; EYELIDS, NOSE, 15576 15576 360 13,540.00 100.00 13,540.00 EARS, LIPS, OR INTRAORAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; FOREHEAD, 15574 15574 360 100.00 0.00 CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET FORMATION OF DIRECT OR TUBED PEDICLE, WITH OR WITHOUT TRANSFER; SCALP, ARMS, 15572 15572 360 100.00 0.00 OR LEGS FORMATION OF DIRECT OR TUBED PEDICLE, 15570 15570 360 100.00 0.00 WITH OR WITHOUT TRANSFER; TRUNK

FRACTURE NASAL TURBINATE(S), THERAPEUTIC 30930 30930 360 8,900.00 100.00 8,900.00 FREE FASCIAL FLAP WITH MICROVASCULAR 15758 15758 360 100.00 0.00 ANASTOMOSIS FREE JEJUNUM TRANSFER WITH 43496 43496 360 100.00 0.00 MICROVASCULAR ANASTOMOSIS FREE MUSCLE FLAP WITH OR WITHOUT SKIN 15756 15756 360 100.00 0.00 WITH MICROVASCULAR ANASTOMOSIS FREE OMENTAL FLAP WITH MICROVASCULAR 49906 49906 360 100.00 0.00 ANASTOMOSIS FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; GREAT TOE 20973 20973 360 100.00 0.00 WITH WEB SPACE FREE OSTEOCUTANEOUS FLAP WITH 20970 20970 360 100.00 0.00 MICROVASCULAR ANASTOMOSIS; ILIAC CREST

FREE OSTEOCUTANEOUS FLAP WITH 20972 20972 360 100.00 0.00 MICROVASCULAR ANASTOMOSIS; METATARSAL

FREE OSTEOCUTANEOUS FLAP WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN 20969 20969 360 100.00 0.00 ILIAC CREST, METATARSAL, OR GREAT TOE FREE SKIN FLAP WITH MICROVASCULAR 15757 15757 360 100.00 0.00 ANASTOMOSIS FRENOPLASTY (SURGICAL REVISION OF 41520 41520 360 17,100.00 100.00 17,100.00 FRENUM, EG, WITH Z-PLASTY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FRENULOTOMY OF PENIS 54164 54164 360 10,250.00 100.00 10,250.00 FRESH FROZEN PLASMA EACH UNIT P9059 P9059 306 350.00 100.00 350.00 FRESH FROZEN PLASMA THAWING, EACH UNIT 86927 86927 302 500.00 100.00 500.00 ONLY IF NOT TRANSFUSED FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 15240 15240 360 16,000.00 100.00 16,000.00 GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, 15241 15241 360 7,300.00 100.00 7,300.00 GENITALIA, HANDS, AND/OR FEET; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, 15260 15260 360 13,540.00 100.00 13,540.00 EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS

FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; EACH ADDITIONAL 20 15261 15261 360 7,300.00 100.00 7,300.00 SQ CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, 15220 15220 360 14,540.00 100.00 14,540.00 ARMS, AND/OR LEGS; 20 SQ CM OR LESS FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 20 SQ 15221 15221 360 100.00 0.00 CM (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ 15200 15200 360 14,540.00 100.00 14,540.00 CM OR LESS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; EACH ADDITIONAL 20 SQ CM (LIST SEPARATELY 15201 15201 360 100.00 0.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) FUSION IN OPPOSITION, THUMB, WITH AUTOGENOUS GRAFT (INCLUDES OBTAINING 26820 26820 360 100.00 0.00 GRAFT) GADOLINIUM CONTRAST Q9952 Q9952 320 20.00 100.00 20.00 GAMMAGLOBULIN IGE 82785 82785 301 300.00 100.00 300.00 GAMMAGLOBULIN; IMMUNOGLOBULIN 82787 82787 301 50.00 100.00 50.00 GAMMAGLOBULIN; lgA, lgD, lgG, lgM 82784 82784 301 230.00 100.00 230.00 GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING 82803 82803 300 100.00 0.00 CALCULATED O2 SATURATION); GASES, BLOOD, ANY COMBINATION OF PH, PCO2, PO2, CO2, HCO3 (INCLUDING CALCULATED O2 SATURATION); WITH O2 82805 82805 301 200.00 100.00 200.00 SATURATION, BY DIRECT MEASUREMENT, EXCEPT PULS GASES, BLOOD, PH ONLY 82800 82800 300 100.00 0.00 GASTRECTOMY, PARTIAL, DISTAL; WITH 43632 43632 360 42,000.00 100.00 42,000.00 GASTROJEJUNOSTOMY GASTRECTOMY, TOTAL; WITH 43620 43620 360 100.00 0.00 ESOPHAGOENTEROSTOMY GASTRECTOMY, TOTAL; WITH FORMATION OF 43622 43622 360 100.00 0.00 INTESTINAL POUCH, ANY TYPE GASTRECTOMY, TOTAL; WITH ROUX-EN-Y 43621 43621 360 100.00 0.00 RECONSTRUCTION GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS- PRESERVING DUODENOILEOSTOMY AND ILEOILEOSTOMY (50 TO 100 CM COMMON 43845 43845 360 17,500.00 100.00 17,500.00 CHANNEL) TO LIMIT ABSORPTION (BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee GASTRIC RESTRICTIVE PROCEDURE, OPEN; REMOVAL AND REPLACEMENT OF 43888 43888 360 39,200.00 100.00 39,200.00 SUBCUTANEOUS PORT COMPONENT ONLY GASTRIN 82941 82941 301 180.00 100.00 180.00 GASTROCNEMIUS RECESSION (EG, STRAYER 27687 27687 360 11,900.00 100.00 11,900.00 PROCEDURE) GASTROINTESTINAL ENDOSCOPIC ULTRASOUND, SUPERVISION AND 76975 76975 100.00 0.00 INTERPRETATION GASTROSTOMY JEJUNOSTOMY TUBE, B4087 B4087 278 175.07 700.00 1,225.49 STANDARD, ANY MATERIAL, ANY TYPE, EACH GASTROTOMY; WITH ESOPHAGEAL DILATION AND INSERTION OF PERMANENT 43510 43510 360 100.00 0.00 INTRALUMINAL TUBE (EG, CELESTIN OR MOUSSEAUX-BARBIN) GASTROTOMY; WITH EXPLORATION OR 43500 43500 360 100.00 0.00 FOREIGN BODY REMOVAL GASTROTOMY; WITH SUTURE REPAIR OF 43501 43501 360 100.00 0.00 BLEEDING ULCER GASTROTOMY; WITH SUTURE REPAIR OF PRE- EXISTING ESOPHAGOGASTRIC LACERATION (EG, 43502 43502 360 100.00 0.00 MALLORY-WEISS) GENIOPLASTY; AUGMENTATION (AUTOGRAFT, 21120 21120 360 100.00 0.00 ALLOGRAFT, PROSTHETIC MATERIAL) GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (EG, WEDGE EXCISION OR 21122 21122 360 100.00 0.00 BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE 21121 21121 360 100.00 0.00 PIECE GENIOPLASTY; SLIDING, AUGMENTATION WITH INTERPOSITIONAL BONE GRAFTS (INCLUDES 21123 21123 360 100.00 0.00 OBTAINING AUTOGRAFTS) GENTAMYCIN 80170 80170 301 780.00 100.00 780.00 GIARDIA ANTIGEN EIA 87329 87329 306 270.00 100.00 270.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

GIARDIA ANTIGEN IMMUNOFLOURESCENCE 87269 87269 306 330.00 100.00 330.00 GINGIVECTOMY, EXCISION GINGIVA, EACH 41820 41820 360 100.00 0.00 QUADRANT GINGIVOPLASTY, EACH QUADRANT (SPECIFY) 41872 41872 360 100.00 0.00 GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT TRACHEOSTOMY, WITH UNILATERAL 41145 41145 360 100.00 0.00 RADICAL NECK DISSECTION GLOSSECTOMY; COMPLETE OR TOTAL, WITH OR WITHOUT TRACHEOSTOMY, WITHOUT RADICAL 41140 41140 360 100.00 0.00 NECK DISSECTION GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF MOUTH AND 41150 41150 360 100.00 0.00 MANDIBULAR RESECTION, WITHOUT RADICAL NECK DISSECTION GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF MOUTH, MANDIBULAR 41155 41155 360 100.00 0.00 RESECTION, AND RADICAL NECK DISSECTION (COMMANDO TYPE) GLOSSECTOMY; COMPOSITE PROCEDURE WITH RESECTION FLOOR OF MOUTH, WITH 41153 41153 360 100.00 0.00 SUPRAHYOID NECK DISSECTION GLOSSECTOMY; HEMIGLOSSECTOMY 41130 41130 360 100.00 0.00 GLOSSECTOMY; LESS THAN ONE-HALF TONGUE 41120 41120 360 100.00 0.00 GLOSSECTOMY; PARTIAL, WITH UNILATERAL 41135 41135 360 100.00 0.00 RADICAL NECK DISSECTION GLUCOSE, BLOOD BY GLUCOSE MONITORING DEVICE(S) CLEARED BY THE FDA SPECIFICALLY 82962 82962 301 50.00 100.00 50.00 FOR HOME USE GLUCOSE; QUANTITATIVE, BLOOD (EXCEPT 82947 82947 301 50.00 100.00 50.00 REAGENT STRIP) GLUCOSE-6-PHOSPHATE DEHYDROGENASE 82960 82960 301 80.00 100.00 80.00 GLUTAMYLTRANSFERASE, GAMMA 82977 82977 301 50.00 100.00 50.00 GONADOTROPIN, CHORIONIC (HCG); 84702 84702 305 150.00 100.00 150.00 QUANTITATIVE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee GONADOTROPIN; FOLLICLE STIMULATING 83001 83001 301 150.00 100.00 150.00 HORMONE (FSH) GONIOTOMY 65820 65820 360 100.00 0.00 GRAFT (THIERSCH OPERATION) FOR RECTAL 46753 46753 360 100.00 0.00 INCONTINENCE AND/OR PROLAPSE GRAFT FOR FACIAL NERVE PARALYSIS; FREE 15840 15840 360 100.00 0.00 FASCIA GRAFT (INCLUDING OBTAINING FASCIA) GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING OBTAINING 15841 15841 360 100.00 0.00 GRAFT) GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT BY MICROSURGICAL 15842 15842 360 100.00 0.00 TECHNIQUE GRAFT FOR FACIAL NERVE PARALYSIS; 15845 15845 360 100.00 0.00 REGIONAL MUSCLE TRANSFER GRAFT, BONE; MANDIBLE (INCLUDES 21215 21215 360 100.00 0.00 OBTAINING GRAFT) GRAFT, BONE; NASAL, MAXILLARY OR MALAR 21210 21210 360 100.00 0.00 AREAS (INCLUDES OBTAINING GRAFT)

GRAFT; COMPOSITE (EG, FULL THICKNESS OF EXTERNAL EAR OR NASAL ALA), INCLUDING 15760 15760 360 10,160.00 100.00 10,160.00 PRIMARY CLOSURE, DONOR AREA GRAFT; DERMA-FAT-FASCIA 15770 15770 360 100.00 0.00 GRAFT; EAR CARTILAGE, AUTOGENOUS, TO 21235 21235 360 13,050.00 100.00 13,050.00 NOSE OR EAR (INCLUDES OBTAINING GRAFT) GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES 21230 21230 360 17,100.00 100.00 17,100.00 OBTAINING GRAFT) GTT EACH ADDITIONAL 82952 82952 301 80.00 100.00 80.00 GTT FIRST 3 82951 82951 301 260.00 100.00 260.00 GUIDEWIRE C1769-G C1769 278 700.00 0.00 GUIDEWIRES C1769-W C1769 278 100.00 0.00 HALLUX IMPLANT L8642-G L8642 278 700.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee HALLUX IMPLANTS L8642-W L8642 278 100.00 0.00 HALLUX RIGIDUS CORRECTION WITH CHEILECTOMY, DEBRIDEMENT AND CAPSULAR 28289 28289 360 12,740.00 100.00 12,740.00 RELEASE OF THE FIRST METATARSOPHALANGEAL JOINT Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal 28291 28291 360 23,950.00 100.00 23,950.00 joint; with implant HAPTOGLOBIN; QUANTITATIVE 83010 83010 301 140.00 100.00 140.00 hCG, SERUM 84703 84703 305 100.00 100.00 100.00 HELIOCOBACTOR PYLORI ANTIBODY (lgG, lgM 86677 86677 302 250.00 100.00 250.00 AND lgA) HEMIARTHROPLASTY, HIP, PARTIAL (EG, FEMORAL STEM PROSTHESIS, BIPOLAR 27125 27125 360 100.00 0.00 ARTHROPLASTY) HEMIEPIPHYSEAL ARREST (EG, CUBITUS VARUS 24470 24470 360 100.00 0.00 OR VALGUS, DISTAL HUMERUS) HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, TOE, PROXIMAL END OF 28160 28160 360 8,000.00 100.00 8,000.00 PHALANX, EACH HEMOPHILUS INFLUENZA ANTIBODY 86684 86684 302 360.00 100.00 360.00 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE 46221 46221 360 2,050.00 100.00 2,050.00 (EG, RUBBER BAND) HEMORRHOIDECTOMY, EXTERNAL, COMPLETE 46250 46250 360 8,900.00 100.00 8,900.00 HEMORRHOIDECTOMY, INTERNAL AND 46260 46260 360 8,900.00 100.00 8,900.00 EXTERNAL, COMPLEX OR EXTENSIVE; HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; WITH 46261 46261 360 8,900.00 100.00 8,900.00 FISSURECTOMY HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; WITH 46262 46262 360 8,900.00 100.00 8,900.00 FISTULECTOMY, WITH OR WITHOUT FISSURECTOMY HEMORRHOIDECTOMY, INTERNAL AND 46255 46255 360 8,900.00 100.00 8,900.00 EXTERNAL, SIMPLE; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee HEMORRHOIDECTOMY, INTERNAL AND 46257 46257 360 100.00 0.00 EXTERNAL, SIMPLE; WITH FISSURECTOMY HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; WITH FISTULECTOMY, 46258 46258 360 100.00 0.00 WITH OR WITHOUT FISSURECTOMY HEPARIN ASSAY 85520 85520 305 310.00 100.00 310.00 HEPATECTOMY, RESECTION OF LIVER; PARTIAL 47120 47120 360 100.00 0.00 LOBECTOMY HEPATECTOMY, RESECTION OF LIVER; TOTAL 47125 47125 360 100.00 0.00 LEFT LOBECTOMY HEPATECTOMY, RESECTION OF LIVER; TOTAL 47130 47130 360 100.00 0.00 RIGHT LOBECTOMY HEPATECTOMY, RESECTION OF LIVER; 47122 47122 360 100.00 0.00 TRISEGMENTECTOMY HEPATIC FUNCTION PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) 80076 80076 301 270.00 100.00 270.00 BILIRUBIN, TOTAL (82247) BILIRUBIN, DIRECT (82248) PHOSPHATASE, ALKALINE HEPATITIS A, TOTAL 86708 86708 302 190.00 100.00 190.00 HEPATITIS B CORE AB, TOTAL 86704 86704 302 180.00 100.00 180.00 HEPATITIS B CORE LGM ANTIBODY 86705 86705 302 190.00 100.00 190.00 HEPATITIS B SURFACE ANTIBODY (HBSAB) 86706 86706 302 160.00 100.00 160.00 HEPATITIS BE ANTIBODY 86707 86707 302 170.00 100.00 170.00 HEPATITIS C ANTIBODY; 86803 86803 302 250.00 100.00 250.00 HEPATITS A ANTIBODY LGM 86709 86709 302 180.00 100.00 180.00 HEPATOTOMY; FOR OPEN DRAINAGE OF 47010 47010 360 100.00 0.00 ABSCESS OR CYST, ONE OR TWO STAGES HEPATOTOMY; FOR PERCUTANEOUS DRAINAGE 47011 47011 360 100.00 0.00 OF ABSCESS OR CYST, ONE OR TWO STAGES HERPES SIMPLEX ANTIBODY 1 OR 2 lgM AND 86694 86694 302 320.00 100.00 320.00 TYPE SPECIFIC lgG HGB A1C 83036 83036 301 110.00 100.00 110.00 HIGH OSMOLAR CONTRAST MATERIAL UP TO Q9958 Q9958 320 200.00 100.00 200.00 149 MG/ML IODINE CONCENTRATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Hip-knee-ankle-foot orthotic (HKAFO) torsion control, bilateral torsion cables, ball bearing hip joint, pelvic L2060-W L2060 274 100.00 0.00 band/ belt, custom fabricated Hip-knee-ankle-foot orthotic (HKAFO), torsion control, bilateral torsion cables, ball bearing hip joint, pelvic L2060-G L2060 274 700.00 0.00 band/ belt, custom fabricated HIV-1 AND HIV-2 ANTIBODY EIA WITH REFLEX 86703 86703 302 240.00 100.00 240.00 TO HIV-1 HLA TYPING A B OR C 86812 86812 302 200.00 100.00 200.00 HOMOCYSTINE 83090 83090 301 150.00 100.00 150.00 HOSPITAL DISCHARGE DAY MANAGEMENT; 99239 99239 360 100.00 0.00 MORE THAN 30 MINUTES HOSPITAL OBSERVATION FIRT HOUR G0378 762 100.00 0.00 H-PYLORI BLOOD 83009 83009 305 500.00 100.00 500.00 HYMENOTOMY, SIMPLE INCISION 56720 56720 360 100.00 0.00 HYSTEROPLASTY, REPAIR OF UTERINE 58540 58540 360 100.00 0.00 ANOMALY (STRASSMAN TYPE) HYSTERORRHAPHY, REPAIR OF RUPTURED 58520 58520 360 100.00 0.00 UTERUS (NONOBSTETRICAL) HYSTEROSALPINGOGRAPHY 74740 74740 320 1,550.00 100.00 1,550.00 HYSTEROSCOPY, DIAGNOSTIC (SEPARATE 58555 58555 360 8,450.00 100.00 8,450.00 PROCEDURE) HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY 58560 58560 360 100.00 0.00 METHOD) HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (EG, ENDOMETRIAL 58563 58563 360 18,200.00 100.00 18,200.00 RESECTION, ELECTROSURGICAL ABLATION, THERMOABLATION) HYSTEROSCOPY, SURGICAL; WITH LYSIS OF 58559 58559 360 100.00 0.00 INTRAUTERINE ADHESIONS (ANY METHOD) HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF 58562 58562 360 11,520.00 100.00 11,520.00 IMPACTED FOREIGN BODY HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF 58561 58561 360 100.00 0.00 LEIOMYOMATA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR 58558 58558 360 8,450.00 100.00 8,450.00 POLYPECTOMY, WITH OR WITHOUT D & C HYSTEROSONOGRAPHY, WITH OR WITHOUT 76831 76831 402 1,040.00 100.00 1,040.00 COLOR FLOW DOPPLER ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF 44380 44380 360 3,900.00 100.00 3,900.00 SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) ILEOSCOPY, THROUGH STOMA; WITH BIOPSY, 44382 44382 360 3,900.00 100.00 3,900.00 SINGLE OR MULTIPLE ILEOSCOPY, THROUGH STOMA; WITH TRANSENDOSCOPIC STENT PLACEMENT 44383 44383 360 2,850.00 100.00 2,850.00 (INCLUDES PREDILATION) ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 44310 44310 360 100.00 0.00 (SEPARATE PROCEDURE) IMAGE GUIDED PLACEMENT, METALLIC LOCALIZATION CLIP, PERCUTANEOUS, DURING 19295 19295 360 100.00 0.00 BREAST BIOPSY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN 19340 19340 360 100.00 0.00 RECONSTRUCTION IMMUNFIX E PHROSIS/URINE 86335 86335 302 200.00 100.00 200.00 IMMUNIZATION ADMIN INJ 1 VACCINE 90471 90471 260 250.00 100.00 250.00 IMMUNO, EACH ADDITIONAL SLIDE 88341 88341 302 725.00 100.00 725.00 IMMUNOASSAY FOR INFECTIOUS AGENT ANTIBODY, QUNATITATIVE, NOT OTHERWISE 86317 86317 305 129.50 100.00 129.50 SPECIFIED IMMUNOASSAY NON ANTIBODY 83516 83516 301 220.00 100.00 220.00 IMMUNOPEROXIDASE 88342 88342 302 1,000.00 100.00 1,000.00 IMPLANT REMOVAL; ELBOW JOINT 24160 24160 360 100.00 0.00 IMPLANT REMOVAL; RADIAL HEAD 24164 24164 360 11,900.00 100.00 11,900.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee IMPLANTABLE ACCESS TOTAL CATHETER, A4301 A4301 278 700.00 0.00 PORT/RESERVOIR IMPLANTABLE BREAST PROSTHESIS, SILICONE L8600-G L8600 278 700.00 0.00 OR EQUAL IMPLANTABLE BREAST PROSTHESIS, SILICONE L8600-W L8600 278 100.00 0.00 OR EQUAL TYPE Implantable neurostimulator electrode, each L8680-G L8680 278 700.00 0.00 Implantable neurostimulator electrode/each L8680-W L8680 278 100.00 0.00 Implantable neurostimulator pulse generator, dual array, L8688-G L8688 278 700.00 0.00 nonrechargeable, includes extension Implantable neurostimulator pulse generator, dual array, L8688-W L8688 278 100.00 0.00 nonrechargeable/ includes extension Implantable neurostimulator, pulse generator, any type L8679-G L8679 278 700.00 0.00

Implantable neurostimulator, pulse generator/any type L8679-W L8679 278 100.00 0.00 IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM (EG, GANCICLOVIR 67027 67027 360 100.00 0.00 IMPLANT), INCLUDES CONCOMITANT REMOVAL OF VITREOUS IMPLANTATION OF MESH OR OTHER PROSTHESIS FOR INCISIONAL OR VENTRAL HERNIA REPAIR (LIST SEPARATELY IN 49568 49568 360 3,600.00 100.00 3,600.00 ADDITION TO CODE FOR THE INCISIONAL OR VENTRAL HERNIA REPAIR) IMPLANTATION OF NERVE END INTO BONE OR MUSCLE (LIST SEPARATELY IN ADDITION TO 64787 64787 360 100.00 0.00 NEUROMA EXCISION) IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG 62361 62361 360 71,250.00 100.00 71,250.00 INFUSION; NON-PROGRAMMABLE PUMP IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING 62362 62362 360 71,250.00 100.00 71,250.00 PREPARATION OF PUMP, WITH OR WITHOUT PROGRAMMING Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG 62360 62360 360 16,750.00 100.00 16,750.00 INFUSION; SUBCUTANEOUS RESERVOIR IMPLANTATION OR REPLACEMENT OF ELECTROMAGNETIC BONE CONDUCTION 69710 69710 360 11,300.00 100.00 11,300.00 HEARING DEVICE IN TEMPORAL BONE IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH 69715 69715 360 100.00 0.00 PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH 69714 69714 360 46,750.00 100.00 46,750.00 PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY

IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM MEDICATION 62350 62350 360 16,750.00 100.00 16,750.00 ADMINISTRATION VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITHOUT LAMINECTOMY

IMPLANTATION, REVISION OR REPOSITIONING OF TUNNELED INTRATHECAL OR EPIDURAL CATHETER, FOR LONG-TERM PAIN 62351 62351 360 100.00 0.00 MANAGEMENT VIA AN EXTERNAL PUMP OR IMPLANTABLE RESERVOIR/INFUSION PUMP; WITH LAMINECTOMY

IMPLANTS, NOS L8699-G L8699 278 700.00 0.00 IMPRESSION AND CUSTOM PREPARATION; 21086 21086 360 17,100.00 100.00 17,100.00 AURICULAR PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21080 21080 360 100.00 0.00 DEFINITIVE OBTURATOR PROSTHESIS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee IMPRESSION AND CUSTOM PREPARATION; 21088 21088 360 100.00 0.00 FACIAL PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21079 21079 360 100.00 0.00 INTERIM OBTURATOR PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21081 21081 360 100.00 0.00 MANDIBULAR RESECTION PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21087 21087 360 100.00 0.00 NASAL PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; ORAL 21085 21085 360 100.00 0.00 SURGICAL SPLINT IMPRESSION AND CUSTOM PREPARATION; 21077 21077 360 100.00 0.00 ORBITAL PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21082 21082 360 100.00 0.00 PALATAL AUGMENTATION PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21083 21083 360 100.00 0.00 PALATAL LIFT PROSTHESIS IMPRESSION AND CUSTOM PREPARATION; 21076 21076 360 100.00 0.00 SURGICAL OBTURATOR PROSTHESIS INCISION (EG, OSTEOMYELITIS OR BONE 27607 27607 360 7,600.00 100.00 7,600.00 ABSCESS), LEG OR ANKLE INCISION AND DRAINAGE ABSCESS; 42700 42700 360 1,700.00 100.00 1,700.00 PERITONSILLAR INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR PARAPHARYNGEAL, 42725 42725 360 100.00 0.00 EXTERNAL APPROACH INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR PARAPHARYNGEAL, 42720 42720 360 100.00 0.00 INTRAORAL APPROACH INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, 28003 28003 360 100.00 0.00 FOOT; MULTIPLE AREAS INCISION AND DRAINAGE BELOW FASCIA, WITH OR WITHOUT TENDON SHEATH INVOLVEMENT, 28002 28002 360 7,600.00 100.00 7,600.00 FOOT; SINGLE BURSAL SPACE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, 10061 10061 360 750.00 100.00 750.00 CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); COMPLICA

INCISION AND DRAINAGE OF ABSCESS (EG, CARBUNCLE, SUPPURATIVE HIDRADENITIS, 10060 10060 360 750.00 100.00 750.00 CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA); SIMPLE O INCISION AND DRAINAGE OF APPENDICEAL 44900 44900 360 100.00 0.00 ABSCESS; OPEN INCISION AND DRAINAGE OF APPENDICEAL 44901 44901 360 100.00 0.00 ABSCESS; PERCUTANEOUS INCISION AND DRAINAGE OF BARTHOLIN'S 56420 56420 360 100.00 0.00 GLAND ABSCESS INCISION AND DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, OR 45020 45020 360 100.00 0.00 RETRORECTAL ABSCESS INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (EG, ABSCESS 54700 54700 360 10,250.00 100.00 10,250.00 OR HEMATOMA) INCISION AND DRAINAGE OF HEMATOMA, 10140 10140 360 4,000.00 100.00 4,000.00 SEROMA OR FLUID COLLECTION INCISION AND DRAINAGE OF INTRAMURAL, INTRAMUSCULAR, OR SUBMUCOSAL ABSCESS, 46045 46045 360 100.00 0.00 TRANSANAL, UNDER ANESTHESIA INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS (SEPARATE 46040 46040 360 6,700.00 100.00 6,700.00 PROCEDURE) INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, WITH FISTULECTOMY 46060 46060 360 100.00 0.00 OR FISTULOTOMY, SUBMUSCULAR, WITH OR WITHOUT PLACEMENT OF SETON INCISION AND DRAINAGE OF PENIS, DEEP 54015 54015 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INCISION AND DRAINAGE OF PILONIDAL CYST; 10081 10081 360 4,000.00 100.00 4,000.00 COMPLICATED INCISION AND DRAINAGE OF PILONIDAL CYST; 10080 10080 360 750.00 100.00 750.00 SIMPLE INCISION AND DRAINAGE OF SUBMUCOSAL 45005 45005 360 100.00 0.00 ABSCESS, RECTUM INCISION AND DRAINAGE OF THYROGLOSSAL 60000 60000 360 100.00 0.00 DUCT CYST, INFECTED INCISION AND DRAINAGE OF VAGINAL HEMATOMA; NON-OBSTETRICAL (EG, POST- 57023 57023 360 100.00 0.00 TRAUMA, SPONTANEOUS BLEEDING) INCISION AND DRAINAGE OF VULVA OR 56405 56405 360 100.00 0.00 PERINEAL ABSCESS INCISION AND DRAINAGE, BURSA, FOOT 28001 28001 360 100.00 0.00 INCISION AND DRAINAGE, COMPLEX, 10180 10180 360 7,500.00 100.00 7,500.00 POSTOPERATIVE WOUND INFECTION INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR 21501 21501 360 100.00 0.00 THORAX; INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR 21502 21502 360 7,600.00 100.00 7,600.00 THORAX; WITH PARTIAL RIB OSTECTOMY INCISION AND DRAINAGE, DEEP ABSCESS, BURSA, OR HEMATOMA, THIGH OR KNEE 27301 27301 360 7,500.00 100.00 7,500.00 REGION INCISION AND DRAINAGE, FOREARM AND/OR 25031 25031 360 100.00 0.00 WRIST; BURSA INCISION AND DRAINAGE, FOREARM AND/OR 25028 25028 360 100.00 0.00 WRIST; DEEP ABSCESS OR HEMATOMA INCISION AND DRAINAGE, LEG OR ANKLE; DEEP 27603 27603 360 100.00 0.00 ABSCESS OR HEMATOMA INCISION AND DRAINAGE, LEG OR ANKLE; 27604 27604 360 100.00 0.00 INFECTED BURSA INCISION AND DRAINAGE, PELVIS OR HIP JOINT 26990 26990 360 7,600.00 100.00 7,600.00 AREA; DEEP ABSCESS OR HEMATOMA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INCISION AND DRAINAGE, PELVIS OR HIP JOINT 26991 26991 360 100.00 0.00 AREA; INFECTED BURSA INCISION AND DRAINAGE, PERIANAL ABSCESS, 46050 46050 360 2,050.00 100.00 2,050.00 SUPERFICIAL INCISION AND DRAINAGE, SHOULDER AREA; 23030 23030 360 7,500.00 100.00 7,500.00 DEEP ABSCESS OR HEMATOMA INCISION AND DRAINAGE, SHOULDER AREA; 23031 23031 360 100.00 0.00 INFECTED BURSA INCISION AND DRAINAGE, UPPER ARM OR 23931 23931 360 100.00 0.00 ELBOW AREA; BURSA INCISION AND DRAINAGE, UPPER ARM OR 23930 23930 360 100.00 0.00 ELBOW AREA; DEEP ABSCESS OR HEMATOMA

INCISION AND REMOVAL OF FOREIGN BODY, 10121 10121 360 6,150.00 100.00 6,150.00 SUBCUTANEOUS TISSUES; COMPLICATED INCISION AND REMOVAL OF FOREIGN BODY, 10120 10120 360 1,300.00 100.00 1,300.00 SUBCUTANEOUS TISSUES; SIMPLE INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR 61885 61885 360 100.00 0.00 INDUCTIVE COUPLING; WITH CONNECTION TO A SINGLE ELECTRODE ARRAY

INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR 61886 61886 360 100.00 0.00 INDUCTIVE COUPLING; WITH CONNECTION TO TWO OR MORE ELECTRODE ARRAYS

INCISION AND SUBCUTANEOUS PLACEMENT OF PERIPHERAL NEUROSTIMULATOR PULSE 64590 64590 360 78,250.00 100.00 78,250.00 GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INCISION AND SUBCUTANEOUS PLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR 63685 63685 360 119,650.00 100.00 119,650.00 OR RECEIVER, DIRECT OR INDUCTIVE COUPLING INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; AUTONOMIC 64577 64577 360 100.00 0.00 NERVE INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; CRANIAL 64573 64573 360 100.00 0.00 NERVE INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 64580 64580 360 100.00 0.00 NEUROMUSCULAR INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; PERIPHERAL 64575 64575 360 24,200.00 100.00 24,200.00 NERVE (EXCLUDES SACRAL NERVE) INCISION FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; SACRAL 64581 64581 360 24,200.00 100.00 24,200.00 NERVE (TRANSFORAMINAL PLACEMENT) INCISION OF CONJUNCTIVA, DRAINAGE OF CYST 68020 68020 360 100.00 0.00

INCISION OF LABIAL FRENUM (FRENOTOMY) 40806 40806 360 100.00 0.00

INCISION OF LINGUAL FRENUM (FRENOTOMY) 41010 41010 360 3,000.00 100.00 3,000.00 INCISION OF SOFT TISSUE ABSCESS (EG, SECONDARY TO OSTEOMYELITIS); DEEP OR 20005 20005 360 6,680.00 100.00 6,680.00 COMPLICATED INCISION OF SOFT TISSUE ABSCESS (EG, 20000 20000 360 100.00 0.00 SECONDARY TO OSTEOMYELITIS); SUPERFICIAL INCISION OF THROMBOSED HEMORRHOID, 46083 46083 360 1,000.00 100.00 1,000.00 EXTERNAL INCISION, ANAL SEPTUM (INFANT) 46070 46070 360 100.00 0.00 INCISION, BONE CORTEX (EG, OSTEOMYELITIS 28005 28005 360 8,420.00 100.00 8,420.00 OR BONE ABSCESS), FOOT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INCISION, BONE CORTEX (EG, OSTEOMYELITIS 23035 23035 360 100.00 0.00 OR BONE ABSCESS), SHOULDER AREA INCISION, BONE CORTEX, HAND OR FINGER (EG, 26034 26034 360 100.00 0.00 OSTEOMYELITIS OR BONE ABSCESS) INCISION, BONE CORTEX, PELVIS AND/OR HIP 26992 26992 360 100.00 0.00 JOINT (EG, OSTEOMYELITIS OR BONE ABSCESS) INCISION, DEEP, BONE CORTEX, FOREARM AND/OR WRIST (EG, OSTEOMYELITIS OR BONE 25035 25035 360 100.00 0.00 ABSCESS) INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR OSTEOMYELITIS OR BONE 23935 23935 360 8,430.00 100.00 8,430.00 ABSCESS), HUMERUS OR ELBOW INCISION, DEEP, WITH OPENING OF BONE CORTEX (EG, FOR OSTEOMYELITIS OR BONE 21510 21510 360 100.00 0.00 ABSCESS), THORAX INCISION, DEEP, WITH OPENING OF BONE CORTEX, FEMUR OR KNEE (EG, OSTEOMYELITIS 27303 27303 360 100.00 0.00 OR BONE ABSCESS) INCISION, DRAINAGE OF LACRIMAL GLAND 68400 68400 360 100.00 0.00 INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOTOMY OR 68420 68420 360 100.00 0.00 DACRYOCYSTOSTOMY) INCISION, EXTENSOR TENDON SHEATH, WRIST 25000 25000 360 7,600.00 100.00 7,600.00 (EG, DEQUERVAINS DISEASE) INCISION, FLEXOR TENDON SHEATH, WRIST (EG, 25001 25001 360 7,600.00 100.00 7,600.00 FLEXOR CARPI RADIALIS) INDUCED ABORTION, BY DILATION AND 59840 59840 360 100.00 0.00 CURETTAGE INDUCED ABORTION, BY DILATION AND 59841 59841 360 100.00 0.00 EVACUATION INF AGENT ACID DNA OR RNA, DIRECT PROBE 87800 87800 306 300.00 100.00 300.00 MULTIPLE ORGANISMS INF AGENT ACID DNA OR RNA, HEP C-AM 87521 87521 306 830.00 100.00 830.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INFECTIOUS AGENT ANTIGEN DETECTION BY ENZYME IMMUNOASSAY TECHNIQUE, QUALITATIVE OR SEMIQUANTITATIVE, 87340 87340 306 210.00 100.00 210.00 MULTIPLE STEP METHOD; HEPATITIS B SURFACE ANTIGEN INFLUENZA ASSAY, WAIVED 87804 87804 306 220.00 100.00 220.00 INFUSION PUMP PROGRAMMABLE C1772-W C1772 278 100.00 0.00 INFUSION PUMP, PROGRAMMABLE C1772-G C1772 278 700.00 0.00 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUETS NODE 38760 38760 360 10,750.00 100.00 10,750.00 (SEPARATE PROCEDURE) Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A 99218 99218 762 1,500.00 100.00 1,500.00 detailed or comprehensive examination; and Medical decision making that is straightforward or INITIAL TREATMENT, FIRST DEGREE BURN, WHEN NO MORE THAN LOCAL TREATMENT IS 16000 16000 360 100.00 0.00 REQUIRED INJECTION INTO TURBINATE(S), THERAPEUTIC 30200 30200 360 100.00 0.00

INJECTION OF AIR OR CONTRAST INTO 49400 49400 360 100.00 0.00 PERITONEAL CAVITY (SEPARATE PROCEDURE) INJECTION OF CONTRAST MEDIUM FOR 68850 68850 360 100.00 0.00 DACRYOCYSTOGRAPHY INJECTION OF CORPORA CAVERNOSA WITH PHARMACOLOGIC AGENT(S) (EG, PAPAVERINE, 54235 54235 360 100.00 0.00 PHENTOLAMINE) INJECTION OF MEDICATION OR OTHER 67515 67515 360 100.00 0.00 SUBSTANCE INTO TENON'S CAPSULE INJECTION OF SCLEROSING SOLUTION, 46500 46500 360 100.00 0.00 HEMORRHOIDS INJECTION OF SINUS TRACT; DIAGNOSTIC 20501 20501 360 100.00 0.00 (SINOGRAM) INJECTION OF SINUS TRACT; THERAPEUTIC 20500 20500 360 3,000.00 100.00 3,000.00 (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA OR LIMBAL APPROACH, (FLUID-GAS 67025 67025 360 100.00 0.00 EXCHANGE), WITH OR WITHOUT ASPIRATION (SEPARATE PROCEDURE) INJECTION PROCEDURE (EG, CONTRAST MEDIA) FOR EVALUATION OF PREVIOUSLY PLACED 49427 49427 360 100.00 0.00 PERITONEAL-VENOUS SHUNT INJECTION PROCEDURE AND PLACEMENT OF CHAIN FOR CONTRAST AND/OR CHAIN 51605 51605 360 100.00 0.00 URETHROCYSTOGRAPHY INJECTION PROCEDURE FOR ANKLE 27648 27648 360 950.00 100.00 950.00 ARTHROGRAPHY INJECTION PROCEDURE FOR CHEMONUCLEOLYSIS, INCLUDING 62292 62292 360 100.00 0.00 DISKOGRAPHY, INTERVERTEBRAL DISK, SINGLE OR MULTIPLE LEVELS, LUMBAR INJECTION PROCEDURE FOR CHOLANGIOGRAPHY THROUGH AN EXISTING 47505 47505 360 1,650.00 100.00 1,650.00 CATHETER (EG, PERCUTANEOUS TRANSHEPATIC OR T-TUBE) INJECTION PROCEDURE FOR CORPORA 54230 54230 360 100.00 0.00 CAVERNOSOGRAPHY INJECTION PROCEDURE FOR CYSTOGRAPHY OR 51600 51600 360 850.00 100.00 850.00 VOIDING URETHROCYSTOGRAPHY

INJECTION PROCEDURE FOR DISKOGRAPHY, 62291 62291 360 2,450.00 100.00 2,450.00 EACH LEVEL; CERVICAL OR THORACIC INJECTION PROCEDURE FOR DISKOGRAPHY, 62290 62290 360 2,600.00 100.00 2,600.00 EACH LEVEL; LUMBAR INJECTION PROCEDURE FOR ELBOW 24220 24220 360 800.00 100.00 800.00 ARTHROGRAPHY INJECTION PROCEDURE FOR HIP 27095 27095 360 100.00 0.00 ARTHROGRAPHY; WITH ANESTHESIA INJECTION PROCEDURE FOR HIP 27093 27093 360 12,050.00 100.00 12,050.00 ARTHROGRAPHY; WITHOUT ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INJECTION PROCEDURE FOR INTRAOPERATIVE PANCREATOGRAPHY (LIST SEPARATELY IN 48400 48400 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION PROCEDURE FOR KNEE 27370 27370 360 850.00 100.00 850.00 ARTHROGRAPHY INJECTION PROCEDURE FOR MYELOGRAPHY AND/OR COMPUTED TOMOGRAPHY, SPINAL 62284 62284 360 2,450.00 100.00 2,450.00 (OTHER THAN C1-C2 AND POSTERIOR FOSSA)

INJECTION PROCEDURE FOR PERCUTANEOUS 47500 47500 360 100.00 0.00 TRANSHEPATIC CHOLANGIOGRAPHY INJECTION PROCEDURE FOR PEYRONIE 54200 54200 360 100.00 0.00 DISEASE; INJECTION PROCEDURE FOR PEYRONIE DISEASE; WITH SURGICAL EXPOSURE OF 54205 54205 360 100.00 0.00 PLAQUE INJECTION PROCEDURE FOR RETROGRADE 51610 51610 360 100.00 0.00 URETHROCYSTOGRAPHY INJECTION PROCEDURE FOR SACROILIAC JOINT, 27096 27096 360 900.00 100.00 900.00 ARTHROGRAPHY AND/OR ANESTHETIC/STEROID INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR G0260 G0260 360 3,100.00 100.00 3,100.00 OTHER THERAPEUTIC AGENT AND ARTHROGRAPHY INJECTION PROCEDURE FOR SHOULDER ARTHROGRAPHY OR ENHANCED CT/MRI 23350 23350 360 750.00 100.00 750.00 SHOULDER ARTHROGRAPHY INJECTION PROCEDURE FOR SIALOGRAPHY 42550 42550 360 100.00 0.00 INJECTION PROCEDURE FOR 21116 21116 360 100.00 0.00 TEMPOROMANDIBULAR JOINT ARTHROGRAPHY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INJECTION PROCEDURE FOR URETEROGRAPHY OR URETEROPYELOGRAPHY THROUGH 50684 50684 360 100.00 0.00 URETEROSTOMY OR INDWELLING URETERAL CATHETER INJECTION PROCEDURE FOR VISUALIZATION OF ILEAL CONDUIT AND/OR 50690 50690 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE INJECTION PROCEDURE FOR WRIST 25246 25246 360 100.00 0.00 ARTHROGRAPHY INJECTION PROCEDURE, ARTERIAL, FOR OCCLUSION OF ARTERIOVENOUS 62294 62294 360 100.00 0.00 MALFORMATION, SPINAL INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE 64491 64491 360 4,500.00 100.00 4,500.00 GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCE INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES 64490 64490 360 4,500.00 100.00 4,500.00 INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; SINGLE LEVEL

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE 64492 64492 360 4,500.00 100.00 4,500.00 GUIDANCE (FLUOROSCOPY OR CT), CERVICAL OR THORACIC; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO C Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE 64494 64494 360 4,500.00 100.00 4,500.00 GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SECOND LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE

INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES 64493 64493 360 4,500.00 100.00 4,500.00 INNERVATING THAT JOINT) WITH IMAGE GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; SINGLE LEVEL INJECTION(S), DIAGNOSTIC OR THERAPEUTIC AGENT, PARAVERTEBRAL FACET (ZYGAPOPHYSEAL) JOINT (OR NERVES INNERVATING THAT JOINT) WITH IMAGE 64495 64495 360 4,500.00 100.00 4,500.00 GUIDANCE (FLUOROSCOPY OR CT), LUMBAR OR SACRAL; THIRD AND ANY ADDITIONAL LEVEL(S) (LIST SEPARATELY IN ADDITION TO CODE Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) , not including neurolytic 62324 62324 360 3,100.00 100.00 3,100.00 substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imagin Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) , not including neurolytic 62327 62327 360 4,000.00 100.00 4,000.00 substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imag Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) , not including neurolytic 62326 62326 360 3,100.00 100.00 3,100.00 substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without i Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) not including neurolytic 62325 62325 360 4,000.00 100.00 4,000.00 substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging gui Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or 62321 62321 360 4,000.00 100.00 4,000.00 catheter placement, interlaminar epidural or subarachnoid, cervical or thor Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or 62320 62320 360 3,100.00 100.00 3,100.00 catheter placement, interlaminar epidural or subarachnoid, cervical or thor Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or 62323 62323 360 4,000.00 100.00 4,000.00 catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or 62322 62322 360 3,100.00 100.00 3,100.00 catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral INJECTION(S); SINGLE OR MULTIPLE TRIGGER 20552 20552 360 1,000.00 100.00 1,000.00 POINT(S), ONE OR TWO MUSCLE(S) INJECTION(S); SINGLE OR MULTIPLE TRIGGER 20553 20553 360 1,000.00 100.00 1,000.00 POINT(S), THREE OR MORE MUSCLE(S) INJECTION(S); TENDON ORIGIN/INSERTION 20551 20551 360 100.00 0.00

INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; CERVICAL OR THORACIC, 64472 64472 360 100.00 0.00 EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR 64470 64470 360 100.00 0.00 FACET JOINT NERVE; CERVICAL OR THORACIC, SINGLE LEVEL INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR FACET JOINT NERVE; LUMBAR OR SACRAL, 64476 64476 360 100.00 0.00 EACH ADDITIONAL LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION, ANESTHETIC AGENT AND/OR STEROID, PARAVERTEBRAL FACET JOINT OR 64475 64475 360 100.00 0.00 FACET JOINT NERVE; LUMBAR OR SACRAL, SINGLE LEVEL INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; CERVICAL OR THORACIC, EACH ADDITIONAL 64480 64480 360 2,450.00 100.00 2,450.00 LEVEL (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; 64479 64479 360 3,100.00 100.00 3,100.00 CERVICAL OR THORACIC, SINGLE LEVEL INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; LUMBAR OR SACRAL, EACH ADDITIONAL LEVEL 64484 64484 360 2,450.00 100.00 2,450.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) INJECTION, ANESTHETIC AGENT AND/OR STEROID, TRANSFORAMINAL EPIDURAL; 64483 64483 360 3,100.00 100.00 3,100.00 LUMBAR OR SACRAL, SINGLE LEVEL INJECTION, ANESTHETIC AGENT; AXILLARY 64417 64417 360 2,420.00 100.00 2,420.00 NERVE INJECTION, ANESTHETIC AGENT; BRACHIAL PLEXUS, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) 64416 64416 360 3,100.00 100.00 3,100.00 INCLUDING DAILY MANAGEMENT FOR ANESTHETIC Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INJECTION, ANESTHETIC AGENT; BRACHIAL 64415 64415 360 2,420.00 100.00 2,420.00 PLEXUS, SINGLE INJECTION, ANESTHETIC AGENT; CAROTID 64508 64508 360 100.00 0.00 SINUS (SEPARATE PROCEDURE) INJECTION, ANESTHETIC AGENT; CELIAC PLEXUS, WITH OR WITHOUT RADIOLOGIC 64530 64530 360 3,100.00 100.00 3,100.00 MONITORING INJECTION, ANESTHETIC AGENT; CERVICAL 64413 64413 360 100.00 0.00 PLEXUS INJECTION, ANESTHETIC AGENT; FACIAL NERVE 64402 64402 360 100.00 0.00 INJECTION, ANESTHETIC AGENT; FEMORAL NERVE, CONTINUOUS INFUSION BY CATHETER (INCLUDING CATHETER PLACEMENT) 64448 64448 360 6,750.00 100.00 6,750.00 INCLUDING DAILY MANAGEMENT FOR ANESTHETIC A INJECTION, ANESTHETIC AGENT; FEMORAL 64447 64447 360 2,420.00 100.00 2,420.00 NERVE, SINGLE INJECTION, ANESTHETIC AGENT; GREATER 64405 64405 360 2,420.00 100.00 2,420.00 OCCIPITAL NERVE INJECTION, ANESTHETIC AGENT; ILIOINGUINAL, 64425 64425 360 2,420.00 100.00 2,420.00 ILIOHYPOGASTRIC NERVES INJECTION, ANESTHETIC AGENT; INTERCOSTAL 64420 64420 360 2,420.00 100.00 2,420.00 NERVE, SINGLE INJECTION, ANESTHETIC AGENT; INTERCOSTAL 64421 64421 360 3,100.00 100.00 3,100.00 NERVES, MULTIPLE, REGIONAL BLOCK

INJECTION, ANESTHETIC AGENT; LUMBAR OR 64520 64520 360 3,100.00 100.00 3,100.00 THORACIC (PARAVERTEBRAL SYMPATHETIC) INJECTION, ANESTHETIC AGENT; OTHER 64450 64450 360 2,420.00 100.00 2,420.00 PERIPHERAL NERVE OR BRANCH INJECTION, ANESTHETIC AGENT; 64435 64435 360 100.00 0.00 PARACERVICAL (UTERINE) NERVE INJECTION, ANESTHETIC AGENT; PHRENIC 64410 64410 360 100.00 0.00 NERVE INJECTION, ANESTHETIC AGENT; PUDENDAL 64430 64430 360 100.00 0.00 NERVE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INJECTION, ANESTHETIC AGENT; SCIATIC NERVE, CONTINUOUS INFUSION BY CATHETER, (INCLUDING CATHETER PLACEMENT) 64446 64446 360 4,870.00 100.00 4,870.00 INCLUDING DAILY MANAGEMENT FOR ANESTHETIC INJECTION, ANESTHETIC AGENT; SCIATIC 64445 64445 360 3,100.00 100.00 3,100.00 NERVE, SINGLE INJECTION, ANESTHETIC AGENT; 64505 64505 360 100.00 0.00 SPHENOPALATINE GANGLION INJECTION, ANESTHETIC AGENT; SPINAL 64412 64412 360 100.00 0.00 ACCESSORY NERVE INJECTION, ANESTHETIC AGENT; STELLATE 64510 64510 360 3,100.00 100.00 3,100.00 GANGLION (CERVICAL SYMPATHETIC) INJECTION, ANESTHETIC AGENT; 64418 64418 360 2,420.00 100.00 2,420.00 SUPRASCAPULAR NERVE INJECTION, ANESTHETIC AGENT; TRIGEMINAL 64400 64400 360 2,420.00 100.00 2,420.00 NERVE, ANY DIVISION OR BRANCH

INJECTION, ANESTHETIC AGENT; VAGUS NERVE 64408 64408 360 100.00 0.00 INJECTION, ANTERIOR CHAMBER OF EYE 66020 66020 360 100.00 0.00 (SEPARATE PROCEDURE); AIR OR LIQUID INJECTION, ANTERIOR CHAMBER OF EYE 66030 66030 360 100.00 0.00 (SEPARATE PROCEDURE); MEDICATION INJECTION, EPIDURAL, OF BLOOD OR CLOT 62273 62273 360 3,420.00 100.00 3,420.00 PATCH INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST 62318 62318 360 100.00 0.00 (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INJECTION, INCLUDING CATHETER PLACEMENT, CONTINUOUS INFUSION OR INTERMITTENT BOLUS, NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST 62319 62319 360 3,100.00 100.00 3,100.00 (FOR EITHER LOCALIZATION OR EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, INJECTION, INTRALESIONAL; MORE THAN 11901 11901 360 100.00 0.00 SEVEN LESIONS INJECTION, INTRALESIONAL; UP TO AND 11900 11900 360 630.00 100.00 630.00 INCLUDING SEVEN LESIONS INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR 62310 62310 360 3,100.00 100.00 3,100.00 EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OT INJECTION, SINGLE (NOT VIA INDWELLING CATHETER), NOT INCLUDING NEUROLYTIC SUBSTANCES, WITH OR WITHOUT CONTRAST (FOR EITHER LOCALIZATION OR 62311 62311 360 3,100.00 100.00 3,100.00 EPIDUROGRAPHY), OF DIAGNOSTIC OR THERAPEUTIC SUBSTANCE(S) (INCLUDING ANESTHETIC, ANTISPASMODIC, OPIOID, STEROID, OT INJECTION, THERAPEUTIC (EG, LOCAL ANESTHETIC, CORTICOSTEROID), CARPAL 20526 20526 360 1,000.00 100.00 1,000.00 TUNNEL INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER 62281 62281 360 100.00 0.00 THERAPEUTIC SUBSTANCE; EPIDURAL, CERVICAL OR THORACIC Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED SALINE SOLUTIONS), WITH OR WITHOUT OTHER 62282 62282 360 100.00 0.00 THERAPEUTIC SUBSTANCE; EPIDURAL, LUMBAR, SACRAL (CAUDAL) INJECTION/INFUSION OF NEUROLYTIC SUBSTANCE (EG, ALCOHOL, PHENOL, ICED 62280 62280 360 100.00 0.00 SALINE SOLUTIONS), WITH OR WITHOUT OTHER THERAPEUTIC SUBSTANCE; SUBARACHNOID INPATIENT PROCEDURES INPT 360 100.00 0.00 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); 36810 36810 360 100.00 0.00 ARTERIOVENOUS, EXTERNAL (SCRIBNER TYPE) INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); 36815 36815 360 100.00 0.00 ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE (SEPARATE PROCEDURE); VEIN 36800 36800 360 100.00 0.00 TO VEIN INSERTION OF HEYMAN CAPSULES FOR 58346 58346 360 100.00 0.00 CLINICAL BRACHYTHERAPY INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (EG, FOR CHEMOTHERAPY OF 36260 36260 360 100.00 0.00 LIVER) INSERTION OF IMPLANTABLE INTRAVENOUS 36530 36530 360 100.00 0.00 INFUSION PUMP INSERTION OF IMPLANTABLE VENOUS ACCESS DEVICE, WITH OR WITHOUT SUBCUTANEOUS 36533 36533 360 100.00 0.00 RESERVOIR INSERTION OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 53445 53445 360 100.00 0.00 INCLUDING PLACEMENT OF PUMP, RESERVOIR, AND CUFF Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

Insertion of interbody biomechanical device(s)with integral anterior instrumentation for device anchoring, 22853 22853 360 11,900.00 100.00 11,900.00 when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace.

INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT), NOT ASSOCIATED 66985 66985 360 10,530.00 100.00 10,530.00 WITH CONCURRENT CATARACT REMOVAL INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS; 49421 49421 360 10,500.00 100.00 10,500.00 PERMANENT INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS; 49420 49420 360 100.00 0.00 TEMPORARY INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER, WITH SUBCUTANEOUS RESERVOIR, 49419 49419 360 100.00 0.00 PERMANENT (IE, TOTALLY IMPLANTABLE) INSERTION OF INTRAUTERINE DEVICE (IUD) 58300 58300 360 1,000.00 100.00 1,000.00 INSERTION OF IOL 13.71 360 100.00 0.00 INSERTION OF MULTI-COMPONENT, INFLATABLE PENILE PROSTHESIS, INCLUDING 54405 54405 360 100.00 0.00 PLACEMENT OF PUMP, CYLINDERS, AND RESERVOIR INSERTION OF NON-INDWELLING BLADDER CATHETER (EG, STRAIGHT CATHETERIZATION 51701 51701 360 100.00 0.00 FOR RESIDUAL URINE) INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES ATTACHED TO 65140 65140 360 100.00 0.00 IMPLANT INSERTION OF OCULAR IMPLANT SECONDARY; AFTER ENUCLEATION, MUSCLES NOT 65135 65135 360 100.00 0.00 ATTACHED TO IMPLANT INSERTION OF OCULAR IMPLANT SECONDARY; 65130 65130 360 100.00 0.00 AFTER EVISCERATION, IN SCLERAL SHELL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INSERTION OF PENILE PROSTHESIS; 54401 54401 360 100.00 0.00 INFLATABLE (SELF-CONTAINED) INSERTION OF PENILE PROSTHESIS; NON- 54400 54400 360 100.00 0.00 INFLATABLE (SEMI-RIGID) INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC), WITHOUT 36569 36569 360 3,150.00 100.00 3,150.00 SUBCUTANEOUS PORT OR PUMP; AGE 5 YEARS OR OLDER INSERTION OF PERITONEAL-VENOUS SHUNT 49425 49425 360 100.00 0.00 INSERTION OF PIN-RETAINED PALATAL 42281 42281 360 100.00 0.00 PROSTHESIS INSERTION OF SUBCUTANEOUS RESERVOIR, PUMP OR CONTINUOUS INFUSION SYSTEM FOR 61215 61215 360 100.00 0.00 CONNECTION TO VENTRICULAR CATHETER INSERTION OF TANDEM CUFF (DUAL CUFF) 53444 53444 360 100.00 0.00 INSERTION OF TEMPORARY INDWELLING BLADDER CATHETER; COMPLICATED (EG, 51703 51703 360 100.00 0.00 ALTERED ANATOMY, FRACTURED CATHETER/BALLOON) INSERTION OF TEMPORARY INDWELLING 51702 51702 360 650.00 100.00 650.00 BLADDER CATHETER; SIMPLE (EG, FOLEY) INSERTION OF TESTICULAR PROSTHESIS 54660 54660 360 100.00 0.00 (SEPARATE PROCEDURE) INSERTION OF THOMAS SHUNT (SEPARATE 36835 36835 360 100.00 0.00 PROCEDURE) INSERTION OF TISSUE EXPANDER(S) FOR OTHER THAN BREAST, INCLUDING SUBSEQUENT 11960 11960 360 100.00 0.00 EXPANSION INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE 36563 360 100.00 0.00 WITH SUBCUTANEOUS PUMP INSERTION OF TUNNELED CENTRALLY INSERTED CENTRAL VENOUS ACCESS DEVICE, 36561 36561 360 10,250.00 100.00 10,250.00 WITH SUBCUTANEOUS PORT; AGE 5 YEARS OR OLDER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR CLINICAL 57155 57155 360 100.00 0.00 BRACHYTHERAPY INSERTION OF VASCULAR PEDICLE INTO 25430 25430 360 100.00 0.00 CARPAL BONE (EG, HORI PROCEDURE) INSERTION OF WIRE OR PIN WITH APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL 20650 20650 360 11,900.00 100.00 11,900.00 (SEPARATE PROCEDURE) INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, RADIOLOGICAL SUPERVISION 71090 71090 320 100.00 0.00 AND INTERPRETATION INSERTION, IMPLANTABLE CONTRACEPTIVE 11975 11975 360 100.00 0.00 CAPSULES INSERTION, NASAL SEPTAL PROSTHESIS 30220 30220 360 6,270.00 100.00 6,270.00 (BUTTON) INSERTION, NON-BIODEGRADABLE DRUG 11981 11981 360 450.00 100.00 450.00 DELIVERY IMPLANT INSTILLATION OF CONTRAST MATERIAL FOR LARYNGOGRAPHY OR BRONCHOGRAPHY, 31708 31708 360 100.00 0.00 WITHOUT CATHETERIZATION INSULIN, TOTAL 83525 83525 301 150.00 100.00 150.00 INTERDENTAL WIRING, FOR CONDITION OTHER 21497 21497 360 100.00 0.00 THAN FRACTURE INTERNAL ANASTOMOSIS OF PANCREATIC CYST 48520 48520 360 100.00 0.00 TO GASTROINTESTINAL TRACT; DIRECT

INTERNAL ANASTOMOSIS OF PANCREATIC CYST 48540 48540 360 100.00 0.00 TO GASTROINTESTINAL TRACT; ROUX-EN-Y INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) 64727 64727 360 3,450.00 100.00 3,450.00 (NEUROPLASTY INCLUDES EXTERNAL NEUROLYSIS) INTERNAL SPINAL FIXATION BY WIRING OF 22841 22841 360 100.00 0.00 SPINOUS PROCESSES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INTERPELVIABDOMINAL AMPUTATION 27290 27290 360 100.00 0.00 (HINDQUARTER AMPUTATION) INTERTHORACOSCAPULAR AMPUTATION 23900 23900 360 100.00 0.00 (FOREQUARTER) INTESTINAL PLICATION (SEPARATE 44680 44680 360 100.00 0.00 PROCEDURE) INTRACAPSULAR CATARACT EXTRACTION WITH INSERTION OF INTRAOCULAR LENS 66983 66983 360 100.00 0.00 PROSTHESIS (ONE STAGE PROCEDURE) INTRAOPERATIVE COLONIC LAVAGE (LIST SEPARATELY IN ADDITION TO CODE FOR 44701 44701 360 100.00 0.00 PRIMARY PROCEDURE) INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41000 41000 360 100.00 0.00 FLOOR OF MOUTH; LINGUAL INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41009 41009 360 100.00 0.00 FLOOR OF MOUTH; MASTICATOR SPACE INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41006 41006 360 100.00 0.00 FLOOR OF MOUTH; SUBLINGUAL, DEEP, SUPRAMYLOHYOID INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41005 41005 360 100.00 0.00 FLOOR OF MOUTH; SUBLINGUAL, SUPERFICIAL

INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41008 41008 360 100.00 0.00 FLOOR OF MOUTH; SUBMANDIBULAR SPACE

INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR 41007 41007 360 100.00 0.00 FLOOR OF MOUTH; SUBMENTAL SPACE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour 96367 96367 260 250.00 100.00 250.00 (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or 96365 96365 260 800.00 100.00 800.00 diagnosis (specify substance or drug); initial, up to 1 hour Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary 96361 96361 260 150.00 100.00 150.00 procedure) Intravenous infusion, hydration; initial, 31 minutes to 1 96360 96360 260 500.00 100.00 500.00 hour INTRAVENOUS INJECTION OF AGENT (EG, FLUORESCEIN) TO TEST VASCULAR FLOW IN 15860 15860 360 100.00 0.00 FLAP OR GRAFT INTRAVITREAL INJECTION OF A PHARMACOLOGIC AGENT (SEPARATE 67028 67028 360 100.00 0.00 PROCEDURE) INTRODUCTION OF ANY HEMOSTATIC AGENT OR PACK FOR SPONTANEOUS OR TRAUMATIC 57180 57180 360 100.00 0.00 NONOBSTETRICAL VAGINAL HEMORRHAGE (SEPARATE PROCEDURE) INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER WITH DILATION TO ESTABLISH 50395 50395 360 100.00 0.00 NEPHROSTOMY TRACT, PERCUTANEOUS

INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE 50392 50392 360 100.00 0.00 AND/OR INJECTION, PERCUTANEOUS INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, 74475 74475 329 100.00 0.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee INTRODUCTION OF LONG GASTROINTESTINAL TUBE (EG, MILLER-ABBOTT) (SEPARATE 44500 44500 360 100.00 0.00 PROCEDURE) INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER FOR BILIARY 47510 47510 360 100.00 0.00 DRAINAGE INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR INTERNAL AND 47511 47511 360 100.00 0.00 EXTERNAL BILIARY DRAINAGE INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER THROUGH RENAL PELVIS 50393 50393 360 100.00 0.00 FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS INTRODUCTION OF URETERAL CATHETER OR STENT INTO URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, 74480 74480 329 100.00 0.00 PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTUBATION, ENDOTRACHEAL, EMERGENCY 31500 31500 360 1,050.00 100.00 1,050.00 PROCEDURE IRIDECTOMY, WITH CORNEOSCLERAL OR 66600 66600 360 100.00 0.00 CORNEAL SECTION; FOR REMOVAL OF LESION IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; OPTICAL (SEPARATE 66635 66635 360 100.00 0.00 PROCEDURE) IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; PERIPHERAL FOR 66625 66625 360 100.00 0.00 GLAUCOMA (SEPARATE PROCEDURE) IRIDECTOMY, WITH CORNEOSCLERAL OR CORNEAL SECTION; SECTOR FOR GLAUCOMA 66630 66630 360 100.00 0.00 (SEPARATE PROCEDURE) IRIDECTOMY, WITH CORNEOSCLERAL OR 66605 66605 360 100.00 0.00 CORNEAL SECTION; WITH CYCLECTOMY IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) (EG, FOR IMPROVEMENT 66762 66762 360 100.00 0.00 OF VISION, FOR WIDENING OF ANTERIOR CHAMBER ANGLE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee IRIDOTOMY BY STAB INCISION (SEPARATE 66500 66500 360 100.00 0.00 PROCEDURE); EXCEPT TRANSFIXION IRIDOTOMY BY STAB INCISION (SEPARATE PROCEDURE); WITH TRANSFIXION AS FOR IRIS 66505 66505 360 100.00 0.00 BOMBE IRIDOTOMY/IRIDECTOMY BY LASER SURGERY 66761 66761 360 4,680.00 100.00 4,680.00 (EG, FOR GLAUCOMA) (ONE OR MORE SESSIONS) IRON 83540 83540 301 50.00 100.00 50.00 IRRADIATION OF BLOOD PRODUCT IF NOT USED 86945 86945 306 350.00 100.00 350.00 IRRIGATION OF CORPORA CAVERNOSA FOR 54220 54220 360 100.00 0.00 PRIAPISM IRRIGATION OF VAGINA AND/OR APPLICATION OF MEDICAMENT FOR TREATMENT OF 57150 57150 360 100.00 0.00 BACTERIAL, PARASITIC, OR FUNGOID DISEASE ISLET CELL ANTIBODY 86341 86341 302 180.00 100.00 180.00 I-STAT CHEM 8+ 80047 80047 301 350.00 100.00 350.00 JOINT DEVICE (IMPLANTABLE C1776-W C1776 278 100.00 0.00 JOINT DEVICE (IMPLANTABLE) C1776-G C1776 278 700.00 0.00 KERATOMILEUSIS 65760 65760 360 100.00 0.00 KERATOPHAKIA 65765 65765 360 100.00 0.00 KERATOPLASTY (CORNEAL TRANSPLANT); 65710 65710 360 100.00 0.00 LAMELLAR KERATOPLASTY (CORNEAL TRANSPLANT); 65730 65730 360 100.00 0.00 PENETRATING (EXCEPT IN APHAKIA) KERATOPLASTY (CORNEAL TRANSPLANT); 65750 65750 360 100.00 0.00 PENETRATING (IN APHAKIA) KERATOPLASTY (CORNEAL TRANSPLANT); 65755 65755 360 100.00 0.00 PENETRATING (IN PSEUDOPHAKIA) KERATOPROSTHESIS 65770 65770 360 100.00 0.00 KIDNEY STONE ANALYSIS 82360 82360 301 280.00 100.00 280.00 KRUKENBERG PROCEDURE 25915 25915 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL 22819 22819 360 100.00 0.00 SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); 3 OR MORE SEGMENTS

KYPHECTOMY, CIRCUMFERENTIAL EXPOSURE OF SPINE AND RESECTION OF VERTEBRAL 22818 22818 360 100.00 0.00 SEGMENT(S) (INCLUDING BODY AND POSTERIOR ELEMENTS); SINGLE OR 2 SEGMENTS LABS - GENERAL 300 300 100.00 0.00 LABYRINTHECTOMY; TRANSCANAL 69905 69905 360 100.00 0.00 LABYRINTHECTOMY; WITH MASTOIDECTOMY 69910 69910 360 100.00 0.00 LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER NONEXCISIONAL DESTRUCTIVE PROCEDURES 69801 69801 360 100.00 0.00 OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); TRANSCANAL

LABYRINTHOTOMY, WITH OR WITHOUT CRYOSURGERY INCLUDING OTHER NONEXCISIONAL DESTRUCTIVE PROCEDURES 69802 69802 360 100.00 0.00 OR PERFUSION OF VESTIBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); WITH MASTOIDECTOMY

LACTATE 83605 83605 301 120.00 100.00 120.00 LACTATE DEHYDROGENASE 83615 83615 301 50.00 100.00 50.00 LACTOFERRIN FECAL QUALITATIVE 83630 83630 301 220.00 100.00 220.00 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, 63182 63182 360 100.00 0.00 CERVICAL; MORE THAN TWO SEGMENTS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, WITH OR WITHOUT DURAL GRAFT, 63180 63180 360 100.00 0.00 CERVICAL; ONE OR TWO SEGMENTS LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; COMBINED 63290 63290 360 100.00 0.00 EXTRADURAL-INTRADURAL LESION, ANY LEVEL LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, 63275 63275 360 100.00 0.00 CERVICAL LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, 63277 63277 360 100.00 0.00 LUMBAR LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, 63278 63278 360 100.00 0.00 SACRAL LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, 63276 63276 360 100.00 0.00 THORACIC LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63280 63280 360 100.00 0.00 EXTRAMEDULLARY, CERVICAL LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63282 63282 360 100.00 0.00 EXTRAMEDULLARY, LUMBAR LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63281 63281 360 100.00 0.00 EXTRAMEDULLARY, THORACIC LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63285 63285 360 100.00 0.00 INTRAMEDULLARY, CERVICAL LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63286 63286 360 100.00 0.00 INTRAMEDULLARY, THORACIC LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63287 63287 360 100.00 0.00 INTRAMEDULLARY, THORACOLUMBAR Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAMINECTOMY FOR BIOPSY/EXCISION OF INTRASPINAL NEOPLASM; INTRADURAL, 63283 63283 360 100.00 0.00 SACRAL LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; 63270 63270 360 100.00 0.00 CERVICAL LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; 63273 63273 360 100.00 0.00 SACRAL LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM, INTRADURAL; 63271 63271 360 100.00 0.00 THORACIC LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN 63265 63265 360 100.00 0.00 NEOPLASM, EXTRADURAL; CERVICAL

LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN 63267 63267 360 3,800.00 100.00 3,800.00 NEOPLASM, EXTRADURAL; LUMBAR

LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN 63268 63268 360 100.00 0.00 NEOPLASM, EXTRADURAL; SACRAL

LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN 63266 63266 360 100.00 0.00 NEOPLASM, EXTRADURAL; THORACIC

LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF 63250 63250 360 100.00 0.00 SPINAL CORD; CERVICAL

LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF 63251 63251 360 100.00 0.00 SPINAL CORD; THORACIC Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF 63252 63252 360 100.00 0.00 SPINAL CORD; THORACOLUMBAR LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, 63655 63655 360 78,250.00 100.00 78,250.00 PLATE/PADDLE, EPIDURAL LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 63198 63198 360 100.00 0.00 TWO STAGES WITHIN 14 DAYS; CERVICAL

LAMINECTOMY WITH CORDOTOMY WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 63199 63199 360 100.00 0.00 TWO STAGES WITHIN 14 DAYS; THORACIC LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 63196 63196 360 100.00 0.00 ONE STAGE; CERVICAL LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF BOTH SPINOTHALAMIC TRACTS, 63197 63197 360 100.00 0.00 ONE STAGE; THORACIC LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE SPINOTHALAMIC TRACT, ONE 63194 63194 360 100.00 0.00 STAGE; CERVICAL LAMINECTOMY WITH CORDOTOMY, WITH SECTION OF ONE SPINOTHALAMIC TRACT, ONE 63195 63195 360 100.00 0.00 STAGE; THORACIC LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 63173 63173 360 100.00 0.00 PERITONEAL SPACE LAMINECTOMY WITH DRAINAGE OF INTRAMEDULLARY CYST/SYRINX; TO 63172 63172 360 100.00 0.00 SUBARACHNOID SPACE LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63003 63003 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16405 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63005 63005 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16406 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63011 63011 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16407 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63015 63015 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16409 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63016 63016 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16410 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63017 63017 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL 16411 LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT FACETECTOMY, 63001 63001 360 100.00 0.00 FORAMINOTOMY OR DISKECTOMY, (EG, SPINAL STE LAMINECTOMY WITH MYELOTOMY (EG, BISCHOF OR DREZ TYPE), CERVICAL, THORACIC, 63170 63170 360 100.00 0.00 OR THORACOLUMBAR LAMINECTOMY WITH REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS 63012 63012 360 100.00 0.00 WITH DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LU Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAMINECTOMY WITH RHIZOTOMY; MORE THAN 63190 63190 360 100.00 0.00 TWO SEGMENTS LAMINECTOMY WITH RHIZOTOMY; ONE OR 63185 63185 360 100.00 0.00 TWO SEGMENTS LAMINECTOMY WITH SECTION OF SPINAL 63191 63191 360 100.00 0.00 ACCESSORY NERVE LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, 63046 63046 360 100.00 0.00 CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINA16420 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, 63047 63047 360 22,900.00 100.00 22,900.00 CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINA16421 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, 63048 63048 360 18,930.00 100.00 18,930.00 CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINA16422 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, 63045 63045 360 100.00 0.00 CAUDA EQUINA AND/OR NERVE ROOT(S), (EG, SPINAL O LAMINECTOMY, WITH RELEASE OF TETHERED 63200 63200 360 100.00 0.00 SPINAL CORD, LUMBAR LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63030 63030 360 20,310.00 100.00 20,310.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16413 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63035 63035 360 19,450.00 100.00 19,450.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16414 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63040 63040 360 100.00 0.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16415 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63042 63042 360 22,900.00 100.00 22,900.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16416 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63043 63043 360 100.00 0.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16417 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63044 63044 360 18,850.00 100.00 18,850.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVE16418 LAMINOTOMY (HEMILAMINECTOMY), WITH DECOMPRESSION OF NERVE ROOT(S), INCLUDING PARTIAL FACETECTOMY, 63020 63020 360 100.00 0.00 FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTE LAPAROSCOPY 54.21 360 100.00 0.00 LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR 58550 58550 360 25,100.00 100.00 25,100.00 LESS; LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR 58552 58552 360 19,200.00 100.00 19,200.00 LESS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT 49320 49320 360 13,800.00 100.00 13,800.00 COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LAPAROSCOPY, SURG; COLECTOMY,PARTIAL 45.79 360 100.00 0.00 WITH ANASTOMOSIS LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE 55866 55866 360 100.00 0.00 SPARING LAPAROSCOPY, SURGICAL, ABLATION OF ONE 47371 47371 360 100.00 0.00 OR MORE LIVER TUMOR(S); CRYOSURGICAL

LAPAROSCOPY, SURGICAL, ABLATION OF ONE 47370 47370 360 100.00 0.00 OR MORE LIVER TUMOR(S); RADIOFREQUENCY

LAPAROSCOPY, SURGICAL, APPENDECTOMY 44970 44970 360 17,300.00 100.00 17,300.00 LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) 44180 44180 360 17,300.00 100.00 17,300.00 (SEPARATE PROCEDURE) LAPAROSCOPY, SURGICAL, ESOPHAGEAL LENGTHENING PROCEDURE (EG, COLLIS GASTROPLASTY OR WEDGE GASTROPLASTY) 43283 43283 360 25,100.00 100.00 25,100.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) LAPAROSCOPY, SURGICAL, ESOPHAGOGASTRIC FUNDOPLASTY (EG, NISSEN, TOUPET 43280 43280 360 25,100.00 100.00 25,100.00 PROCEDURES) LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; LONGITUDINAL 43775 43775 360 46,950.00 100.00 46,950.00 GASTRECTOMY (IE, SLEEVE GASTRECTOMY) LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE 43770 43770 360 39,160.00 100.00 39,160.00 (EG, GASTRIC BAND AND SUBCUTANEOUS PORT COMPONENTS) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF 43774 43774 360 39,200.00 100.00 39,200.00 ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; REMOVAL OF 43772 43772 360 34,200.00 100.00 34,200.00 ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH GASTRIC BYPASS AND ROUX-EN-Y 43644 43644 360 20,200.00 100.00 20,200.00 GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS) LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 1 TO 4 INTRAMURAL MYOMAS WITH 58545 58545 360 19,200.00 100.00 19,200.00 TOTAL WEIGHT OF 250 GRAMS OR LESS AND/OR REMOVAL OF SURFACE MYOMAS

LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; 5 OR MORE INTRAMURAL MYOMAS 58546 58546 360 100.00 0.00 AND/OR INTRAMURAL MYOMAS WITH TOTAL WEIGHT GREATER THAN 250 GRAMS LAPAROSCOPY, SURGICAL, REPAIR OF PARAESOPHAGEAL HERNIA, INCLUDES 43281 43281 360 25,100.00 100.00 25,100.00 FUNDOPLASTY, WHEN PERFORMED; WITHOUT IMPLANTATION OF MESH LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN 49655 49655 360 25,100.00 100.00 25,100.00 PERFORMED); INCARCERATED OR STRANGULATED LAPAROSCOPY, SURGICAL, REPAIR, INCISIONAL HERNIA (INCLUDES MESH INSERTION, WHEN 49654 49654 360 32,000.00 100.00 32,000.00 PERFORMED); REDUCIBLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH 49657 49657 360 25,100.00 100.00 25,100.00 INSERTION, WHEN PERFORMED); INCARCERATED OR STRANGULATED

LAPAROSCOPY, SURGICAL, REPAIR, RECURRENT INCISIONAL HERNIA (INCLUDES MESH 49656 49656 360 25,100.00 100.00 25,100.00 INSERTION, WHEN PERFORMED); REDUCIBLE LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA (INCLUDES MESH INSERTION, WHEN 49653 49653 360 25,100.00 100.00 25,100.00 PERFORMED); INCARCERATED OR STRANGULATED LAPAROSCOPY, SURGICAL, REPAIR, VENTRAL, UMBILICAL, SPIGELIAN OR EPIGASTRIC HERNIA 49652 49652 360 25,100.00 100.00 25,100.00 (INCLUDES MESH INSERTION, WHEN PERFORMED); REDUCIBLE

LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR 60650 60650 360 100.00 0.00 WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORS LAPAROSCOPY, SURGICAL, WITH LIGATION OF 55550 55550 360 100.00 0.00 SPERMATIC VEINS FOR VARICOCELE LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 58553 58553 360 100.00 0.00 250 GRAMS; LAPAROSCOPY, SURGICAL, WITH VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 58554 58554 360 21,120.00 100.00 21,120.00 250 GRAMS; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) LAPAROSCOPY, SURGICAL; ABLATION OF 50541 50541 360 23,300.00 100.00 23,300.00 RENAL CYSTS LAPAROSCOPY, SURGICAL; ABLATION OF 50542 50542 360 100.00 0.00 RENAL MASS LESION(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAPAROSCOPY, SURGICAL; 47562 47562 360 17,300.00 100.00 17,300.00 CHOLECYSTECTOMY LAPAROSCOPY, SURGICAL; 47563 47563 360 17,300.00 100.00 17,300.00 CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF 47564 47564 360 17,300.00 100.00 17,300.00 COMMON DUCT LAPAROSCOPY, SURGICAL; 47570 47570 360 100.00 0.00 CHOLECYSTOENTEROSTOMY LAPAROSCOPY, SURGICAL; COLECTOMY, 44204 44204 360 100.00 0.00 PARTIAL, WITH ANASTOMOSIS LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH 44207 44207 360 100.00 0.00 COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH 44208 44208 360 100.00 0.00 COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) WITH COLOSTOMY LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND 44206 44206 360 100.00 0.00 CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE) LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM 44205 44205 360 100.00 0.00 WITH ILEOCOLOSTOMY LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROCTECTOMY, 44210 44210 360 100.00 0.00 WITH ILEOSTOMY OR ILEOPROCTOSTOMY

LAPAROSCOPY, SURGICAL; EACH ADDITIONAL SMALL INTESTINE RESECTION AND 44203 44203 360 100.00 0.00 ANASTOMOSIS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE 44202 44202 360 100.00 0.00 RESECTION AND ANASTOMOSIS LAPAROSCOPY, SURGICAL; ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) 44200 44200 360 100.00 0.00 (SEPARATE PROCEDURE) LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE 43653 43653 360 17,300.00 100.00 17,300.00 (EG, STAMM PROCEDURE) (SEPARATE PROCEDURE) LAPAROSCOPY, SURGICAL; ILEOSTOMY OR 44187 44187 360 17,300.00 100.00 17,300.00 JEJUNOSTOMY, NON-TUBE LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (EG, 44201 44201 360 100.00 0.00 FOR DECOMPRESSION OR FEEDING) LAPAROSCOPY, SURGICAL; ORCHIECTOMY 54690 54690 360 100.00 0.00 LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR 54692 54692 360 100.00 0.00 INTRA-ABDOMINAL TESTIS LAPAROSCOPY, SURGICAL; PARTIAL 50543 50543 360 100.00 0.00 NEPHRECTOMY LAPAROSCOPY, SURGICAL; PYELOPLASTY 50544 50544 360 100.00 0.00 LAPAROSCOPY, SURGICAL; REPAIR INITIAL 49650 49650 360 17,300.00 100.00 17,300.00 INGUINAL HERNIA LAPAROSCOPY, SURGICAL; REPAIR RECURRENT 49651 49651 360 17,300.00 100.00 17,300.00 INGUINAL HERNIA LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (EG, FASCIA OR 51992 51992 360 33,590.00 100.00 33,590.00 SYNTHETIC) LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, SELECTIVE OR HIGHLY 43652 43652 360 100.00 0.00 SELECTIVE LAPAROSCOPY, SURGICAL; TRANSECTION OF 43651 43651 360 100.00 0.00 VAGUS NERVES, TRUNCAL LAPAROSCOPY, SURGICAL; 50945 50945 360 100.00 0.00 URETEROLITHOTOMY LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY 50947 50947 360 100.00 0.00 AND URETERAL STENT PLACEMENT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT 50948 50948 360 100.00 0.00 CYSTOSCOPY AND URETERAL STENT PLACEMENT LAPAROSCOPY, SURGICAL; URETHRAL 51990 51990 360 100.00 0.00 SUSPENSION FOR STRESS INCONTINENCE LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (EG, OVARIAN CYST) 49322 49322 360 13,800.00 100.00 13,800.00 (SINGLE OR MULTIPLE) LAPAROSCOPY, SURGICAL; WITH BILATERAL 38571 38571 360 100.00 0.00 TOTAL PELVIC LYMPHADENECTOMY

LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI- 38572 38572 360 100.00 0.00 AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE LAPAROSCOPY, SURGICAL; WITH BIOPSY 49321 49321 360 13,800.00 100.00 13,800.00 (SINGLE OR MULTIPLE) LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF 49323 49323 360 100.00 0.00 LYMPHOCELE TO PERITONEAL CAVITY LAPAROSCOPY, SURGICAL; WITH 58672 58672 360 100.00 0.00 FIMBRIOPLASTY LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT 58670 58670 360 17,300.00 100.00 17,300.00 TRANSECTION) LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, 58662 58662 360 17,300.00 100.00 17,300.00 PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY WITH 47561 47561 360 100.00 0.00 BIOPSY LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT 47560 47560 360 100.00 0.00 BIOPSY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) 58660 58660 360 17,300.00 100.00 17,300.00 (SEPARATE PROCEDURE) LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (EG, BAND, CLIP, OR 58671 58671 360 100.00 0.00 FALOPE RING) LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL 58661 58661 360 17,300.00 100.00 17,300.00 OOPHORECTOMY AND/OR SALPINGECTOMY) LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING 38570 38570 360 17,300.00 100.00 17,300.00 (BIOPSY), SINGLE OR MULTIPLE LAPAROSCOPY, SURGICAL; WITH 58673 58673 360 100.00 0.00 SALPINGOSTOMY (SALPINGONEOSTOMY) LAPAROTOMY, FOR STAGING OR RESTAGING OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY (SECOND LOOK), WITH OR 58960 58960 360 100.00 0.00 WITHOUT OMENTECTOMY, PERITONEAL WASHING LAPAROTOMY, WITH ASPIRATION AND/OR INJECTION OF HEPATIC PARASITIC (EG, 47015 47015 360 100.00 0.00 AMOEBIC OR ECHINOCOCCAL) CYST(S) OR ABSCESS(ES) LARYNGEAL REINNERVATION BY 31590 31590 360 100.00 0.00 NEUROMUSCULAR PEDICLE LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, 31368 31368 360 100.00 0.00 WITH RADICAL NECK DISSECTION

LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, 31367 31367 360 100.00 0.00 WITHOUT RADICAL NECK DISSECTION LARYNGECTOMY; TOTAL, WITH RADICAL NECK 31365 31365 360 100.00 0.00 DISSECTION LARYNGECTOMY; TOTAL, WITHOUT RADICAL 31360 31360 360 100.00 0.00 NECK DISSECTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LARYNGOGRAPHY, CONTRAST, RADIOLOGICAL 70373 70373 320 100.00 0.00 SUPERVISION AND INTERPRETATION LARYNGOPLASTY, CRICOID SPLIT 31587 31587 360 100.00 0.00 LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (EG, FOR BURNS, RECONSTRUCTION AFTER 31588 31588 360 100.00 0.00 PARTIAL LARYNGECTOMY) LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, WITH GRAFT OR CORE MOLD, INCLUDING 31582 31582 360 100.00 0.00 TRACHEOTOMY LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO 31580 31580 360 100.00 0.00 STAGE, WITH KEEL INSERTION AND REMOVAL LARYNGOPLASTY; WITH OPEN REDUCTION OF 31584 31584 360 100.00 0.00 FRACTURE LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; DIAGNOSTIC, EXCEPT 31525 31525 360 5,800.00 100.00 5,800.00 NEWBORN LARYNGOSCOPY DIRECT, WITH OR WITHOUT 31520 31520 360 100.00 0.00 TRACHEOSCOPY; DIAGNOSTIC, NEWBORN LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; DIAGNOSTIC, WITH 31526 31526 360 5,800.00 100.00 5,800.00 OPERATING MICROSCOPE LARYNGOSCOPY DIRECT, WITH OR WITHOUT 31515 31515 360 100.00 0.00 TRACHEOSCOPY; FOR ASPIRATION

LARYNGOSCOPY DIRECT, WITH OR WITHOUT 31528 31528 360 9,200.00 100.00 9,200.00 TRACHEOSCOPY; WITH DILATION, INITIAL

LARYNGOSCOPY DIRECT, WITH OR WITHOUT 31529 31529 360 100.00 0.00 TRACHEOSCOPY; WITH DILATION, SUBSEQUENT LARYNGOSCOPY DIRECT, WITH OR WITHOUT TRACHEOSCOPY; WITH INSERTION OF 31527 31527 360 100.00 0.00 OBTURATOR Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LARYNGOSCOPY, DIRECT, OPERATIVE, WITH 31560 31560 360 100.00 0.00 ARYTENOIDECTOMY; LARYNGOSCOPY, DIRECT, OPERATIVE, WITH ARYTENOIDECTOMY; WITH OPERATING 31561 31561 360 100.00 0.00 MICROSCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH 31535 31535 360 9,200.00 100.00 9,200.00 BIOPSY; LARYNGOSCOPY, DIRECT, OPERATIVE, WITH 31536 31536 360 9,200.00 100.00 9,200.00 BIOPSY; WITH OPERATING MICROSCOPE

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF 31540 31540 360 9,200.00 100.00 9,200.00 VOCAL CORDS OR EPIGLOTTIS;

LARYNGOSCOPY, DIRECT, OPERATIVE, WITH EXCISION OF TUMOR AND/OR STRIPPING OF 31541 31541 360 10,020.00 100.00 10,020.00 VOCAL CORDS OR EPIGLOTTIS; WITH OPERATING MICROSCOPE LARYNGOSCOPY, DIRECT, OPERATIVE, WITH 31530 31530 360 100.00 0.00 FOREIGN BODY REMOVAL; LARYNGOSCOPY, DIRECT, OPERATIVE, WITH FOREIGN BODY REMOVAL; WITH OPERATING 31531 31531 360 100.00 0.00 MICROSCOPE LARYNGOSCOPY, DIRECT, WITH INJECTION 31570 31570 360 5,800.00 100.00 5,800.00 INTO VOCAL CORD(S), THERAPEUTIC; LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH 31571 31571 360 9,200.00 100.00 9,200.00 OPERATING MICROSCOPE LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; 31575 31575 360 100.00 0.00 DIAGNOSTIC LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH 31576 31576 360 5,800.00 100.00 5,800.00 BIOPSY LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH 31577 31577 360 100.00 0.00 REMOVAL OF FOREIGN BODY LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; WITH 31578 31578 360 100.00 0.00 REMOVAL OF LESION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LARYNGOSCOPY, FLEXIBLE OR RIGID 31579 31579 360 100.00 0.00 FIBEROPTIC, WITH STROBOSCOPY LARYNGOSCOPY, INDIRECT; DIAGNOSTIC 31505 31505 360 100.00 0.00 (SEPARATE PROCEDURE) LARYNGOSCOPY, INDIRECT; WITH BIOPSY 31510 31510 360 100.00 0.00 LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF 31511 31511 360 100.00 0.00 FOREIGN BODY LARYNGOSCOPY, INDIRECT; WITH REMOVAL OF 31512 31512 360 100.00 0.00 LESION LARYNGOSCOPY, INDIRECT; WITH VOCAL CORD 31513 31513 360 100.00 0.00 INJECTION LARYNGOTOMY (THYROTOMY, 31320 31320 360 100.00 0.00 LARYNGOFISSURE); DIAGNOSTIC LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); WITH REMOVAL OF TUMOR 31300 31300 360 100.00 0.00 OR LARYNGOCELE, CORDECTOMY LASER ENUCLEATION OF THE PROSTATE WITH MORCELLATION, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, 52649 52649 360 16,000.00 100.00 16,000.00 CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, INTERNAL URETHROTOMY AND TRANSURETHRAL RESECTION OF PROSTATE ARE IN

LATERAL CANTHOPEXY 21282 21282 360 100.00 0.00 LATERAL RETINACULAR RELEASE OPEN 27425 27425 360 11,900.00 100.00 11,900.00 LAVAGE BY CANNULATION; MAXILLARY SINUS 31000 31000 360 1,700.00 100.00 1,700.00 (ANTRUM PUNCTURE OR NATURAL OSTIUM)

LAVAGE BY CANNULATION; SPHENOID SINUS 31002 31002 360 1,800.00 100.00 1,800.00 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12055 12055 360 100.00 0.00 MEMBRANES; 12.6 CM TO 20.0 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12051 12051 360 1,590.00 100.00 1,590.00 MEMBRANES; 2.5 CM OR LESS LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12052 12052 360 2,730.00 100.00 2,730.00 MEMBRANES; 2.6 CM TO 5.0 CM LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12056 12056 360 100.00 0.00 MEMBRANES; 20.1 CM TO 30.0 CM LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12053 12053 360 100.00 0.00 MEMBRANES; 5.1 CM TO 7.5 CM LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12054 12054 360 100.00 0.00 MEMBRANES; 7.6 CM TO 12.5 CM LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS 12057 12057 360 100.00 0.00 MEMBRANES; OVER 30.0 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 12045 12045 360 100.00 0.00 20.0 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR 12041 12041 360 1,310.00 100.00 1,310.00 LESS LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 12042 12042 360 1,420.00 100.00 1,420.00 7.5 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 12046 12046 360 100.00 0.00 30.0 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12044 12044 360 3,640.00 100.00 3,640.00 12.5 CM LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; OVER 30.0 12047 12047 360 100.00 0.00 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12035 12035 360 100.00 0.00 (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12031 12031 360 1,050.00 100.00 1,050.00 (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12032 12032 360 1,200.00 100.00 1,200.00 (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12036 12036 360 100.00 0.00 (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12034 12034 360 3,390.00 100.00 3,390.00 (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK AND/OR EXTREMITIES 12037 12037 360 100.00 0.00 (EXCLUDING HANDS AND FEET); OVER 30.0 CM LEAD 83655 83655 301 100.00 100.00 100.00 LEAD NEUROSTIMULATOR TEST KIT C1897-W C1897 278 100.00 0.00 (IMPLANTABLE) LEAD, NEUROSTIMULATOR (IMPLANTABLE C1778-W C1778 278 100.00 0.00 LEAD, NEUROSTIMULATOR (IMPLANTABLE) C1778-G C1778 278 700.00 0.00 LEAD, NEUROSTIMULATOR TEST KIT C1897-G C1897 278 700.00 0.00 (IMPLANTABLE) LENGTHENING OF HAMSTRING TENDON; 27395 27395 360 100.00 0.00 MULTIPLE TENDONS, BILATERAL LENGTHENING OF HAMSTRING TENDON; 27394 27394 360 100.00 0.00 MULTIPLE TENDONS, ONE LEG LENGTHENING OF HAMSTRING TENDON; SINGLE 27393 27393 360 100.00 0.00 TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LENGTHENING OF PALATE, AND PHARYNGEAL 42226 42226 360 100.00 0.00 FLAP LENGTHENING OF PALATE, WITH ISLAND FLAP 42227 42227 360 100.00 0.00 LENGTHENING OF TENDON, EXTENSOR, HAND 26476 26476 360 100.00 0.00 OR FINGER, EACH TENDON LENGTHENING OF TENDON, FLEXOR, HAND OR 26478 26478 360 100.00 0.00 FINGER, EACH TENDON LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, 25280 25280 360 100.00 0.00 SINGLE, EACH TENDON LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE TENDONS (THROUGH 27686 27686 360 11,900.00 100.00 11,900.00 SAME INCISION), EACH LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE TENDON (SEPARATE 27685 27685 360 6,250.00 100.00 6,250.00 PROCEDURE) LEUKOCYTE REDUCED CBC, EACH UNIT P9016 P9016 390 900.00 100.00 900.00 LH LUTENIZING HORMONE 83002 83002 301 150.00 100.00 150.00 LIGAMENTOUS RECONSTRUCTION 27427 27427 360 28,950.00 100.00 28,950.00 (AUGMENTATION), KNEE; EXTRA-ARTICULAR LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR 27428 27428 360 46,750.00 100.00 46,750.00 (OPEN) LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR 27429 27429 360 100.00 0.00 (OPEN) AND EXTRA-ARTICULAR LIGATION (PERCUTANEOUS) OF VAS DEFERENS, UNILATERAL OR BILATERAL (SEPARATE 55450 55450 360 100.00 0.00 PROCEDURE) LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG AND SHORT SAPHENOUS 37730 37730 360 100.00 0.00 VEINS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS 37720 37720 360 100.00 0.00 VEINS LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS WITH RADICAL EXCISION OF ULCER AND 37735 37735 360 100.00 0.00 SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, WITH EXCISION OF DEEP FASCIA LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR 37700 37700 360 100.00 0.00 DISTAL INTERRUPTIONS LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION 37780 37780 360 9,950.00 100.00 9,950.00 (SEPARATE PROCEDURE) LIGATION ARTERIES; ETHMOIDAL 30915 30915 360 10,020.00 100.00 10,020.00 LIGATION ARTERIES; INTERNAL MAXILLARY 30920 30920 360 10,250.00 100.00 10,250.00 ARTERY, TRANSANTRAL LIGATION OF FEMORAL VEIN 37650 37650 360 100.00 0.00 LIGATION OF INTERNAL HEMORRHOIDS; 46946 46946 360 100.00 0.00 MULTIPLE PROCEDURES LIGATION OF INTERNAL HEMORRHOIDS; SINGLE 46945 46945 360 100.00 0.00 PROCEDURE LIGATION OF PERFORATOR VEINS, SUBFASCIAL, RADICAL (LINTON TYPE), WITH OR WITHOUT 37760 37760 360 100.00 0.00 SKIN GRAFT, OPEN LIGATION OF PERITONEAL-VENOUS SHUNT 49428 49428 360 100.00 0.00 LIGATION OR BANDING OF ANGIOACCESS 37607 37607 360 9,950.00 100.00 9,950.00 ARTERIOVENOUS FISTULA LIGATION OR BIOPSY, TEMPORAL ARTERY 37609 37609 360 8,260.00 100.00 8,260.00 LIGATION OR STAPLING AT GASTROESOPHAGEAL JUNCTION FOR PRE- 43405 43405 360 100.00 0.00 EXISTING ESOPHAGEAL PERFORATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S) WHEN DONE AT THE TIME OF CESAREAN DELIVERY OR INTRA-ABDOMINAL 58611 58611 360 100.00 0.00 SURGERY (NOT A SEPARATE PROCEDURE) (LIST SE LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, 58605 58605 360 100.00 0.00 POSTPARTUM, UNILATERAL OR BILATERAL, DURING SAME HOSPITALIZATION (SEPARAT

LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, 58600 58600 360 100.00 0.00 UNILATERAL OR BILATERAL LIGATION SALIVARY DUCT, INTRAORAL 42665 42665 360 100.00 0.00 LIGATION, DIRECT, ESOPHAGEAL VARICES 43400 43400 360 100.00 0.00 LIGATION, DIVISION, AND/OR EXCISION OF RECURRENT OR SECONDARY VARICOSE VEINS 37785 37785 360 100.00 0.00 (CLUSTERS), ONE LEG LIMITED PHARYNGECTOMY 42890 42890 360 100.00 0.00 LIPASE 83690 83690 301 90.00 100.00 90.00

LIPID PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: CHOLESTEROL, SERUM, TOTAL 80061 80061 301 470.00 100.00 470.00 (82465) LIPOPROTEIN, DIRECT MEASUREMENT, HIGH DENSITY CHOLESTEROL (HDL CH LIPOPROTEIN, BLOOD, HIGH RESOLUTION 83701 83701 301 200.00 100.00 200.00 FRACTIONATION AND QUANTITATION LIPOPROTEIN, DIRECT MEASUREMENT; HIGH 83718 83718 301 100.00 100.00 100.00 DENSITY CHOLESTEROL (HDL CHOLESTEROL) LITHIUM 80178 80178 301 300.00 100.00 300.00

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND 52318 52318 360 12,950.00 100.00 12,950.00 REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND 52317 52317 360 10,360.00 100.00 10,360.00 REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)

LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE 50590 50590 360 18,660.00 100.00 18,660.00 LOW INTENSITY ULTRASOUND STIMULATION TO AID BONE HEALING, NONINVASIVE 20979 20979 360 100.00 0.00 (NONOPERATIVE) LOWER EXTREMITY ORTHOSES NOT L2999-W L2999 274 100.00 0.00 OTHERWISE SPECIFIED LOWER EXTREMITY ORTHOSES, NOS L2999-G L2999 274 700.00 0.00 LUMBAR OR SACRAL, EACH ADDITIONAL FACET 64636 64636 360 3,130.00 100.00 3,130.00 JOINT LVL 11 SURGICAL PATH GROSS MICROSCOPIC 88302 88302 311 300.00 100.00 300.00

LVL 111 SURICAL PATH GROSS MICROSCOPIC 88304 88304 311 410.00 100.00 410.00

LVL IV SURGICAL PATH GROSS MICROSCOPIC 88305 88305 311 410.00 100.00 410.00

LVL V SURGICAL PATH GROSS MICROSCOPIC 88307 88307 311 850.00 100.00 850.00

LVL VI SURGICAL PATH GROSS MICROSCOPIC 88309 88309 311 1,350.00 100.00 1,350.00 LYMPHANGIOTOMY OR OTHER OPERATIONS ON 38308 38308 360 100.00 0.00 LYMPHATIC CHANNELS LYSIS INTRANASAL SYNECHIA 30560 30560 360 100.00 0.00 LYSIS OF ADHESIONS (SALPINGOLYSIS, 58740 58740 360 100.00 0.00 OVARIOLYSIS) LYSIS OF LABIAL ADHESIONS 56441 56441 360 8,450.00 100.00 8,450.00 LYSIS OR EXCISION OF PENILE POST- 54162 54162 360 10,250.00 100.00 10,250.00 CIRCUMCISION ADHESIONS MAGNESIUM 83735 83735 301 60.00 100.00 60.00 MAGNETIC RESONANCE (EG, PROTON) IMAGING, 74182 74182 100.00 0.00 ABDOMEN; WITH CONTRAST MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MAGNETIC RESONANCE (EG, PROTON) IMAGING, 74181 74181 100.00 0.00 ABDOMEN; WITHOUT CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ABDOMEN; WITHOUT CONTRAST MATERIAL(S), 74183 74183 100.00 0.00 FOLLOWED BY WITH CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITH 73722 73722 100.00 0.00 CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT 73721 73721 100.00 0.00 CONTRAST MATERIAL

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF LOWER EXTREMITY; WITHOUT 73723 73723 100.00 0.00 CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQU

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITH 73222 73222 100.00 0.00 CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT 73221 73221 100.00 0.00 CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, ANY JOINT OF UPPER EXTREMITY; WITHOUT 73223 73223 100.00 0.00 CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQU MAGNETIC RESONANCE (EG, PROTON) IMAGING, 76400 76400 100.00 0.00 BONE MARROW BLOOD SUPPLY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITH 70552 70552 611 2,130.00 100.00 2,130.00 CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT 70551 70551 611 1,840.00 100.00 1,840.00 CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, BRAIN (INCLUDING BRAIN STEM); WITHOUT CONTRAST MATERIAL, FOLLOWED BY 70553 70553 611 2,810.00 100.00 2,810.00 CONTRAST MATERIAL(S) AND FURTHER SEQUENC MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND 71551 71551 100.00 0.00 MEDIASTINAL LYMPHADENOPATHY); WITH CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND 71550 71550 100.00 0.00 MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, CHEST (EG, FOR EVALUATION OF HILAR AND 71552 71552 100.00 0.00 MEDIASTINAL LYMPHADENOPATHY); WITHOUT CONTRAST MATERIAL(S), FOLLOWED B

MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; WITH 73719 73719 100.00 0.00 CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; 73718 73718 100.00 0.00 WITHOUT CONTRAST MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MAGNETIC RESONANCE (EG, PROTON) IMAGING, LOWER EXTREMITY OTHER THAN JOINT; 73720 73720 100.00 0.00 WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND NECK; WITH CONTRAST 70542 70542 100.00 0.00 MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND NECK; WITHOUT CONTRAST 70540 70540 100.00 0.00 MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, ORBIT, FACE, AND NECK; WITHOUT CONTRAST 70543 70543 100.00 0.00 MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES

MAGNETIC RESONANCE (EG, PROTON) IMAGING, 72196 72196 100.00 0.00 PELVIS; WITH CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, 72195 72195 100.00 0.00 PELVIS; WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, PELVIS; WITHOUT CONTRAST MATERIAL(S), 72197 72197 100.00 0.00 FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; 72142 72142 612 2,050.00 100.00 2,050.00 WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, CERVICAL; 72141 72141 612 1,830.00 100.00 1,830.00 WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; WITH 72149 72149 612 2,140.00 100.00 2,140.00 CONTRAST MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, LUMBAR; 72148 72148 612 1,900.00 100.00 1,900.00 WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; 72147 72147 612 2,170.00 100.00 2,170.00 WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, THORACIC; 72146 72146 612 1,980.00 100.00 1,980.00 WITHOUT CONTRAST MATERIAL MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72157 72157 100.00 0.00 CONTRAST MATERIAL(S) AND FURTHER SEQUENC16801 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72158 72158 100.00 0.00 CONTRAST MATERIAL(S) AND FURTHER SEQUENC16802 MAGNETIC RESONANCE (EG, PROTON) IMAGING, SPINAL CANAL AND CONTENTS, WITHOUT CONTRAST MATERIAL, FOLLOWED BY 72156 72156 612 2,660.00 100.00 2,660.00 CONTRAST MATERIAL(S) AND FURTHER SEQUENCES; MAGNETIC RESONANCE (EG, PROTON) IMAGING, 70336 70336 100.00 0.00 TEMPOROMANDIBULAR JOINT(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; WITH 73219 73219 100.00 0.00 CONTRAST MATERIAL(S)

MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; 73218 73218 100.00 0.00 WITHOUT CONTRAST MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MAGNETIC RESONANCE (EG, PROTON) IMAGING, UPPER EXTREMITY, OTHER THAN JOINT; 73220 73220 100.00 0.00 WITHOUT CONTRAST MATERIAL(S), FOLLOWED BY CONTRAST MATERIAL(S) AND FURTHER MAGNETIC RESONANCE ANGIOGRAPHY, ABDOMEN, WITH OR WITHOUT CONTRAST 74185 74185 100.00 0.00 MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, CHEST (EXCLUDING MYOCARDIUM), WITH OR 71555 71555 100.00 0.00 WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; 70545 70545 100.00 0.00 WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; 70544 70544 100.00 0.00 WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, HEAD; WITHOUT CONTRAST MATERIAL(S), FOLLOWED 70546 70546 100.00 0.00 BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES MAGNETIC RESONANCE ANGIOGRAPHY, LOWER EXTREMITY, WITH OR WITHOUT CONTRAST 73725 73725 100.00 0.00 MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK; 70548 70548 100.00 0.00 WITH CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK; 70547 70547 100.00 0.00 WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, NECK; WITHOUT CONTRAST MATERIAL(S), FOLLOWED 70549 70549 100.00 0.00 BY CONTRAST MATERIAL(S) AND FURTHER SEQUENCES MAGNETIC RESONANCE ANGIOGRAPHY, PELVIS, 72198 72198 100.00 0.00 WITH OR WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST 73225 73225 100.00 0.00 MATERIAL(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (EG, FOR BIOPSY, NEEDLE 76393 76393 100.00 0.00 ASPIRATION, INJECTION, OR PLACEMENT OF LOCALIZATION DEVICE) RADIOLOGICAL SUPE MAGNETIC RESONANCE GUIDANCE FOR, AND 76394 76394 100.00 0.00 MONITORING OF, TISSUE ABLATION MAGNETIC RESONANCE SPECTROSCOPY 76390 76390 100.00 0.00 MAJOR RECONSTRUCTION, CHEST WALL 32820 32820 360 100.00 0.00 (POSTTRAUMATIC) MALAR AUGMENTATION, PROSTHETIC 21270 21270 360 100.00 0.00 MATERIAL MAMMAPLASTY, AUGMENTATION; WITH 19325 19325 360 100.00 0.00 PROSTHETIC IMPLANT MAMMAPLASTY, AUGMENTATION; WITHOUT 19324 19324 360 100.00 0.00 PROSTHETIC IMPLANT MAMMARY DUCTOGRAM OR GALACTOGRAM, MULTIPLE DUCTS, RADIOLOGICAL SUPERVISION 76088 76088 100.00 0.00 AND INTERPRETATION

MAMMARY DUCTOGRAM OR GALACTOGRAM, SINGLE DUCT, RADIOLOGICAL SUPERVISION 76086 76086 100.00 0.00 AND INTERPRETATION MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (EG, FOR WIRE LOCALIZATION OR FOR INJECTION), EACH 76096 76096 329 100.00 0.00 LESION, RADIOLOGICAL SUPERVISION AND INTERPRETAT MAMMOGRAPHY; BILATERAL 76091 76091 100.00 0.00 MAMMOGRAPHY; UNILATERAL 76090 76090 100.00 0.00 MANAGEMENT OF LIVER HEMORRHAGE; COMPLEX SUTURE OF LIVER WOUND OR 47360 47360 360 100.00 0.00 INJURY, WITH OR WITHOUT HEPATIC ARTERY LIGATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MANAGEMENT OF LIVER HEMORRHAGE; EXPLORATION OF HEPATIC WOUND, EXTENSIVE 47361 47361 360 100.00 0.00 DEBRIDEMENT, COAGULATION AND/OR SUTURE, WITH OR WITHOUT PACKING OF LIVER MANAGEMENT OF LIVER HEMORRHAGE; RE- EXPLORATION OF HEPATIC WOUND FOR 47362 47362 360 100.00 0.00 REMOVAL OF PACKING MANAGEMENT OF LIVER HEMORRHAGE; 47350 47350 360 100.00 0.00 SIMPLE SUTURE OF LIVER WOUND OR INJURY MANIPULATION CHEST WALL FACILITY 94668 94668 460 250.00 100.00 250.00 MANIPULATION CHEST WALL FACILITY LU 94667 94667 460 800.00 100.00 800.00 MANIPULATION OF ANKLE UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF 27860 27860 360 100.00 0.00 TRACTION OR OTHER FIXATION APPARATUS) MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES 27570 27570 360 5,300.00 100.00 5,300.00 APPLICATION OF TRACTION OR OTHER FIXATION DEVICES) MANIPULATION OF SPINE REQUIRING 22505 22505 360 100.00 0.00 ANESTHESIA, ANY REGION MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF 23700 23700 360 5,300.00 100.00 5,300.00 FIXATION APPARATUS (DISLOCATION EXCLUDED) MANIPULATION, ELBOW, UNDER ANESTHESIA 24300 24300 360 5,300.00 100.00 5,300.00 MANIPULATION, FINGER JOINT, UNDER 26340 26340 360 100.00 0.00 ANESTHESIA, EACH JOINT MANIPULATION, HIP JOINT, REQUIRING 27275 27275 360 100.00 0.00 GENERAL ANESTHESIA MANIPULATION, WRIST, UNDER ANESTHESIA 25259 25259 360 100.00 0.00 MANOMETRIC STUDIES THROUGH NEPHROSTOMY OR PYELOSTOMY TUBE, OR 50396 50396 360 100.00 0.00 INDWELLING URETERAL CATHETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MANOMETRIC STUDIES THROUGH URETEROSTOMY OR INDWELLING URETERAL 50686 50686 360 100.00 0.00 CATHETER MANUAL APPLICATION OF STRESS PERFORMED BY PHYSICIAN FOR JOINT RADIOGRAPHY, 76006 76006 329 100.00 0.00 INCLUDING CONTRALATERAL JOINT IF INDICATED MANUAL RETICUTOCYTE COUNT 85045 85045 305 110.00 100.00 110.00

MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL 97140 97140 100.00 0.00 LYMPHATIC DRAINAGE, MANUAL TRACTION), ONE OR MORE REGIONS, EACH 15 MINUTES MARSUPIALIZATION OF BARTHOLIN'S GLAND 56440 56440 360 9,600.00 100.00 9,600.00 CYST MARSUPIALIZATION OF CYST OR ABSCESS OF 47300 47300 360 100.00 0.00 LIVER MARSUPIALIZATION OF PANCREATIC CYST 48500 48500 360 100.00 0.00 MARSUPIALIZATION OF SUBLINGUAL SALIVARY 42409 42409 360 8,900.00 100.00 8,900.00 CYST (RANULA) MARSUPIALIZATION OF URETHRAL 53240 53240 360 100.00 0.00 DIVERTICULUM, MALE OR FEMALE MASTECTOMY FOR GYNECOMASTIA 19140 19140 360 100.00 0.00 MASTECTOMY FOR GYNECOMASTIA14984 19300 19300 360 24,500.00 100.00 24,500.00 MASTECTOMY PROCEDURES 19305 19305 360 13,800.00 100.00 13,800.00

MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, WITH OR WITHOUT 19240 19240 360 100.00 0.00 PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE MASTECTOMY, PARTIAL (EG, LUMPECTOMY, TYLECTOMY, QUADRANTECTOMY, 19301 19301 360 13,800.00 100.00 13,800.00 SEGMENTECTOMY); MASTECTOMY, PARTIAL; 19160 19160 360 100.00 0.00 MASTECTOMY, PARTIAL; WITH AXILLARY 19162 19162 360 100.00 0.00 LYMPHADENECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY AND INTERNAL 19220 19220 360 100.00 0.00 MAMMARY LYMPH NODES (URBAN TYPE OPERATION) MASTECTOMY, RADICAL, INCLUDING 19200 19200 360 100.00 0.00 PECTORAL MUSCLES, AXILLARY LYMPH NODES MASTECTOMY, SIMPLE, COMPLETE 19180 19180 360 100.00 0.00 MASTECTOMY, SIMPLE, COMPLETE14987 19303 19303 360 20,300.00 100.00 20,300.00 MASTECTOMY, SUBCUTANEOUS 19182 19182 360 100.00 0.00 MASTECTOMY, SUBCUTANEOUS14988 19304 19304 360 13,800.00 100.00 13,800.00 MASTOID OBLITERATION (SEPARATE 69670 69670 360 100.00 0.00 PROCEDURE) MASTOIDECTOMY; COMPLETE 69502 69502 360 100.00 0.00 MASTOIDECTOMY; MODIFIED RADICAL 69505 69505 360 17,100.00 100.00 17,100.00 MASTOIDECTOMY; RADICAL 69511 69511 360 100.00 0.00 MASTOPEXY 19316 19316 360 100.00 0.00 MASTOTOMY WITH EXPLORATION OR 19020 19020 360 8,570.00 100.00 8,570.00 DRAINAGE OF ABSCESS, DEEP MAXILLARY IMPRESSION FOR PALATAL 42280 42280 360 100.00 0.00 PROSTHESIS MAXILLECTOMY; WITH ORBITAL 31230 31230 360 100.00 0.00 EXENTERATION (EN BLOC) MAXILLECTOMY; WITHOUT ORBITAL 31225 31225 360 100.00 0.00 EXENTERATION MEASUREMENT OF POST-VOIDING RESIDUAL URINE AND/OR BLADDER CAPACITY BY 51798 51798 360 100.00 0.00 ULTRASOUND, NON-IMAGING MEATOTOMY, CUTTING OF MEATUS (SEPARATE 53020 53020 360 100.00 0.00 PROCEDURE); EXCEPT INFANT MEDIAL CANTHOPEXY (SEPARATE PROCEDURE) 21280 21280 360 100.00 0.00 MemoDerm, DermaSpan, TranZgraft or InteguPly, per sq Q4126-G Q4126 278 700.00 0.00 cm MemoDerm, DermaSpan, TranZgraft or InteguPly/ per sq Q4126-W Q4126 278 100.00 0.00 cm Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE 21060 21060 360 100.00 0.00 PROCEDURE) MESH (IMPLANTABLE C1781-W C1781 278 100.00 0.00 MESH (IMPLANTABLE) C1781-G C1781 278 700.00 0.00 METATARSECTOMY 28140 28140 360 100.00 0.00 METHYLMALONIC ACID (MMA), SERUM 83921 83921 301 150.00 100.00 150.00 MICROALBUMIN URINE 82043 82043 301 140.00 100.00 140.00 MICROBE SUSCEPTIBLE MICRODILUTION 87186 87186 306 150.00 100.00 150.00 MICROSURGICAL TECHNIQUES, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY 69990 69990 360 200.00 100.00 200.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) MIDDLE CEREBRAL ARTERY DOPPLER 76821 76821 402 790.00 100.00 790.00 MIDDLE EAR EXPLORATION THROUGH 69440 69440 360 100.00 0.00 POSTAURICULAR OR EAR CANAL INCISION MOBIL WALK, MOVING FUNC LIMIT PROJECT GOAL STATUS THERAPY OUTSET REPORT G8979-G G8979 420 0.01 100.00 0.01 INTERVALS DISCHARGE END REPORTING

MOBIL, WALK, MOVING FUNC LIMIT PROJECT GOAL STATUS THERAPY OUTSET REPORT G8979-MEDICARE G8979 420 0.01 100.00 0.01 INTERVALS DISCHARGE END REPORTING MOBILITY WALK MOVING FUNCT LIMIT CURRENT STATUSTHERAPY OUTSET AND G8978-MEDICARE G8978 420 0.01 100.00 0.01 REPORT INTERVALS MOBILITY WALK MOVING FUNCT LIMIT, CURRENT STATUSTHERAPY OUTSET AND G8978-G G8978 420 0.01 100.00 0.01 REPORT INTERVALS MOBILITY WALK MOVING FUNT LIMIT DISCHARGE STATUS DISCHARGE FROM G8980-MEDICARE G8980 420 0.01 100.00 0.01 THERAPY OR END REPORT MOBILITY WALK MOVING FUNT LIMIT DISCHARGE STATUS, DISCHARGE FROM G8980-G G8980 420 0.01 100.00 0.01 THERAPY OR END REPORT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MODIFICATION OF OCULAR IMPLANT WITH PLACEMENT OR REPLACEMENT OF PEGS (EG, 65125 65125 360 100.00 0.00 DRILLING RECEPTACLE FOR PROSTHESIS APPENDAGE) (SEPARATE PROCEDURE) MOLEC DX AMP SIG NUC AC 83908 83908 301 240.00 100.00 240.00 MOLEC DX ENZYME DIGESTION 83892 83892 301 80.00 100.00 80.00 MOLEC DX ISOLATATE EXTRACT 83891 83891 301 70.00 100.00 70.00 MOLEC DX NUC ACD PRB 83896 83896 301 70.00 100.00 70.00 MOLEC DX REV TRANSCRIPT 83902 83902 301 450.00 100.00 450.00 MOLEC NUC AMPLI 2 SEQUENCE 83900 83900 301 450.00 100.00 450.00 MOLEX DX AMP NUC A 83898 83898 301 250.00 100.00 250.00 MOLEX DX INTERPRETATION AND REPORT 83912 83912 301 70.00 100.00 70.00 MONITORING OF INTERSTITIAL FLUID PRESSURE (INCLUDES INSERTION OF DEVICE, EG, WICK CATHETER TECHNIQUE, NEEDLE 20950 20950 360 100.00 0.00 MANOMETER TECHNIQUE) IN DETECTION OF MUSC MONOSPOT TEST 86308 86308 302 50.00 100.00 50.00 MRI BRAIN W/CONTRAST 70558 70558 611 16,260.00 100.00 16,260.00 MRI BRAIN W/O CONTRAST 70559 70559 611 19,270.00 100.00 19,270.00 MRI BRAIN; W/O CONTRAST 70557 70557 611 14,640.00 100.00 14,640.00 MRSA BY PCR 87641 87641 306 510.00 100.00 510.00 MRSA SCREEN 87081 87081 306 120.00 100.00 120.00 MTHFR GENE; DNA MUTATION ANALYSIS 81291 81291 311 300.00 100.00 300.00 MULTIPLE OSTEOTOMIES WITH REALIGNMENT ON INTRAMEDULLARY ROD, HUMERAL SHAFT 24410 24410 360 100.00 0.00 (SOFIELD TYPE PROCEDURE)

MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE 25375 25375 360 100.00 0.00 PROCEDURE); RADIUS AND ULNA

MULTIPLE OSTEOTOMIES, WITH REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE 25370 25370 360 100.00 0.00 PROCEDURE); RADIUS OR ULNA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

MULTIPLE PUNCTURES OF ANTERIOR CORNEA 65600 65600 360 100.00 0.00 (EG, FOR CORNEAL EROSION, TATTOO) Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of 95805 95805 920 5,160.00 100.00 5,160.00 physiological measurements of sleep during multiple trials to assess sleepiness MUMPS ANTIBODY 86735 86735 302 200.00 100.00 200.00 MUSCLE OR TENDON TRANSFER, ANY TYPE, UPPER ARM OR ELBOW, SINGLE (EXCLUDING 24301 24301 360 100.00 0.00 24320-24331) MUSCLE TRANSFER, ANY TYPE, SHOULDER OR 23397 23397 360 100.00 0.00 UPPER ARM; MULTIPLE MUSCLE TRANSFER, ANY TYPE, SHOULDER OR 23395 23395 360 23,950.00 100.00 23,950.00 UPPER ARM; SINGLE MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK (EG, 15732 15732 360 18,170.00 100.00 18,170.00 TEMPORALIS, MASSETER MUSCLE, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE)

MUSCLE, MYOCUTANEOUS, OR 15738 15738 360 16,930.00 100.00 16,930.00 FASCIOCUTANEOUS FLAP; LOWER EXTREMITY MUSCLE, MYOCUTANEOUS, OR 15734 15734 360 16,930.00 100.00 16,930.00 FASCIOCUTANEOUS FLAP; TRUNK MUSCLE, MYOCUTANEOUS, OR 15736 15736 360 16,930.00 100.00 16,930.00 FASCIOCUTANEOUS FLAP; UPPER EXTREMITY MUTATION ID OLA/SBCE/ASPE 83914 83914 301 450.00 100.00 450.00 MYCOBACTERIUM TUBERCULOSIS COMPLEX 87556 87556 302 250.00 100.00 250.00 BY PCR, NON RESPIRATORY MYELOGRAPHY, CERVICAL, RADIOLOGICAL 72240 72240 320 2,850.00 100.00 2,850.00 SUPERVISION AND INTERPRETATION MYELOGRAPHY, ENTIRE SPINAL CANAL, RADIOLOGICAL SUPERVISION AND 72270 72270 320 2,850.00 100.00 2,850.00 INTERPRETATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee MYELOGRAPHY, LUMBOSACRAL, RADIOLOGICAL SUPERVISION AND 72265 72265 320 2,850.00 100.00 2,850.00 INTERPRETATION MYELOGRAPHY, POSTERIOR FOSSA, RADIOLOGICAL SUPERVISION AND 70010 70010 320 100.00 0.00 INTERPRETATION MYELOGRAPHY, THORACIC, RADIOLOGICAL 72255 72255 320 2,850.00 100.00 2,850.00 SUPERVISION AND INTERPRETATION MYOGLOBIN SERUM 82874 82874 301 93.38 100.00 93.38 MYOGLOBIN SERUM URINE 83874 83874 301 160.00 100.00 160.00 MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 GRAMS 58140 58140 360 18,000.00 100.00 18,000.00 OR LESS AND/OR REMOVAL OF SURFACE MYOMAS MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 1 TO 4 INTRAMURAL MYOMA(S) WITH TOTAL WEIGHT OF 250 GRAMS 58145 58145 360 100.00 0.00 OR LESS AND/OR REMOVAL OF SURFACE MYOMAS; VAGINAL APPROACH MYOMECTOMY, EXCISION OF FIBROID TUMOR(S) OF UTERUS, 5 OR MORE INTRAMURAL MYOMAS AND/OR INTRAMURAL MYOMAS WITH 58146 58146 360 100.00 0.00 TOTAL WEIGHT GREATER THAN 250 GRAMS, ABD MYRINGOPLASTY (SURGERY CONFINED TO 69620 69620 360 9,230.00 100.00 9,230.00 DRUMHEAD AND DONOR AREA) MYRINGOTOMY INCLUDING ASPIRATION 69420 69420 360 1,820.00 100.00 1,820.00 AND/OR EUSTACHIAN TUBE INFLATION MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION 69421 69421 360 5,800.00 100.00 5,800.00 REQUIRING GENERAL ANESTHESIA NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL 31231 31231 360 100.00 0.00 OR BILATERAL (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Nasal endoscopy, surgical; balloon dilation of eustachian C9745 C9745 360 12,500.00 100.00 12,500.00 tube Nasal/Sinus Endoscopy , Surgical; with Dilation of 31298 31298 360 19,456.68 100.00 19,456.68 frontral and sphenoid sinus ostium (e.g. Balloon dilation)

NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH MAXILLARY SINUSOSCOPY (VIA INFERIOR 31233 31233 360 100.00 0.00 MEATUS OR CANINE FOSSA PUNCTURE) NASAL/SINUS ENDOSCOPY, DIAGNOSTIC WITH SPHENOID SINUSOSCOPY (VIA PUNCTURE OF 31235 31235 360 100.00 0.00 SPHENOIDAL FACE OR CANNULATION OF OSTIUM) NASAL/SINUS ENDOSCOPY, SURGICAL WITH FRONTAL SINUS EXPLORATION, WITH OR 31276 31276 360 14,050.00 100.00 14,050.00 WITHOUT REMOVAL OF TISSUE FROM FRONTAL SINUS NASAL/SINUS ENDOSCOPY, SURGICAL, WITH 31256 31256 360 11,280.00 100.00 11,280.00 MAXILLARY ANTROSTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH MAXILLARY ANTROSTOMY; WITH REMOVAL OF 31267 31267 360 11,280.00 100.00 11,280.00 TISSUE FROM MAXILLARY SINUS NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL FLUID LEAK; 31290 31290 360 100.00 0.00 ETHMOID REGION NASAL/SINUS ENDOSCOPY, SURGICAL, WITH REPAIR OF CEREBROSPINAL FLUID LEAK; 31291 31291 360 100.00 0.00 SPHENOID REGION NASAL/SINUS ENDOSCOPY, SURGICAL, WITH 31287 31287 360 14,050.00 100.00 14,050.00 SPHENOIDOTOMY; NASAL/SINUS ENDOSCOPY, SURGICAL, WITH SPHENOIDOTOMY; WITH REMOVAL OF TISSUE 31288 31288 360 14,050.00 100.00 14,050.00 FROM THE SPHENOID SINUS NASAL/SINUS ENDOSCOPY, SURGICAL; WITH BIOPSY, POLYPECTOMY OR DEBRIDEMENT 31237 31237 360 10,200.00 100.00 10,200.00 (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 31240 31240 360 11,280.00 100.00 11,280.00 CONCHA BULLOSA RESECTION NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 31238 31238 360 10,020.00 100.00 10,020.00 CONTROL OF NASAL HEMORRHAGE NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 31239 31239 360 11,280.00 100.00 11,280.00 DACRYOCYSTORHINOSTOMY NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF FRONTAL SINUS OSTIUM (EG, 31296 31296 360 16,510.00 100.00 16,510.00 BALLOON DILATION) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF MAXILLARY SINUS OSTIUM (EG, 31295 31295 360 16,510.00 100.00 16,510.00 BALLOON DILATION), TRANSNASAL OR VIA CANINE FOSSA NASAL/SINUS ENDOSCOPY, SURGICAL; WITH DILATION OF SPHENOID SINUS OSTIUM (EG, 31297 31297 360 16,510.00 100.00 16,510.00 BALLOON DILATION) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 31254 31254 360 11,280.00 100.00 11,280.00 ETHMOIDECTOMY, PARTIAL (ANTERIOR) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH ETHMOIDECTOMY, TOTAL (ANTERIOR AND 31255 31255 360 14,050.00 100.00 14,050.00 POSTERIOR) NASAL/SINUS ENDOSCOPY, SURGICAL; WITH MEDIAL OR INFERIOR ORBITAL WALL 31292 31292 360 100.00 0.00 DECOMPRESSION NASAL/SINUS ENDOSCOPY, SURGICAL; WITH 31294 31294 360 100.00 0.00 OPTIC NERVE DECOMPRESSION NATRIURETIC PEPTIDE (BNP) 83880 83880 301 250.00 100.00 250.00 NEEDLE ELECTROMYOGRAPHY STUDIES (EMG) OF ANAL OR URETHRAL SPHINCTER, ANY 51785 51785 360 2,220.00 100.00 2,220.00 TECHNIQUE Needle electromyography; 2 extremities with or without 95861 95861 922 750.00 100.00 750.00 related paraspinal areas NEPHROLITHOTOMY; COMPLICATED BY 50070 50070 360 100.00 0.00 CONGENITAL KIDNEY ABNORMALITY NEPHROLITHOTOMY; REMOVAL OF CALCULUS 50060 50060 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee NEPHROLITHOTOMY; REMOVAL OF LARGE STAGHORN CALCULUS FILLING RENAL PELVIS 50075 50075 360 100.00 0.00 AND CALYCES (INCLUDING ANATROPHIC PYELOLITHOTOMY) NEPHROLITHOTOMY; SECONDARY SURGICAL 50065 50065 360 100.00 0.00 OPERATION FOR CALCULUS NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND 50500 50500 360 100.00 0.00 OR INJURY NEPHROSTOMY, NEPHROTOMY WITH DRAINAGE 50040 50040 360 100.00 0.00 NEPHROTOMY, WITH EXPLORATION 50045 50045 360 100.00 0.00 NERVE GRAFT (INCLUDES OBTAINING GRAFT), 64886 64886 360 100.00 0.00 HEAD OR NECK; MORE THAN 4 CM LENGTH

NERVE GRAFT (INCLUDES OBTAINING GRAFT), 64885 64885 360 100.00 0.00 HEAD OR NECK; UP TO 4 CM IN LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), ARM OR LEG; 64898 64898 360 100.00 0.00 MORE THAN 4 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), ARM OR LEG; UP 64897 64897 360 100.00 0.00 TO 4 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), HAND OR FOOT; 64896 64896 360 100.00 0.00 MORE THAN 4 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), HAND OR FOOT; 64895 64895 360 100.00 0.00 UP TO 4 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR LEG; MORE THAN 4 64893 64893 360 100.00 0.00 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR LEG; UP TO 4 CM 64892 64892 360 100.00 0.00 LENGTH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR FOOT; MORE THAN 4 64891 64891 360 100.00 0.00 CM LENGTH NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR FOOT; UP TO 4 CM 64890 64890 360 100.00 0.00 LENGTH NERVE GRAFT, EACH ADDITIONAL NERVE; MULTIPLE STRANDS (CABLE) (LIST SEPARATELY 64902 64902 360 100.00 0.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVE GRAFT, EACH ADDITIONAL NERVE; SINGLE STRAND (LIST SEPARATELY IN 64901 64901 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) NERVE PEDICLE TRANSFER; FIRST STAGE 64905 64905 360 100.00 0.00 NERVE PEDICLE TRANSFER; SECOND STAGE 64907 64907 360 100.00 0.00 NERVE REPAIR; WITH AUTOGENOUS VEIN GRAFT (INCLUDES HARVEST OF VEIN GRAFT), 64911 64911 360 19,050.00 100.00 19,050.00 EACH NERVE NERVE REPAIR; WITH SYNTHETIC CONDUIT OR VEIN ALLOGRAFT (EG, NERVE TUBE), EACH 64910 64910 360 19,050.00 100.00 19,050.00 NERVE NEURECTOMY, HAMSTRING MUSCLE 27315 27315 360 100.00 0.00 NEURECTOMY, INTRINSIC MUSCULATURE OF 28030 28030 360 100.00 0.00 FOOT NEURECTOMY, POPLITEAL (GASTROCNEMIUS) 27320 27320 360 100.00 0.00

Neuromuscular junction testing (repetitive stimulation, 95937 95937 920 750.00 100.00 750.00 paired stimuli), each nerve, any 1 method NEUROPLASTY AND/OR TRANSPOSITION; 64716 64716 360 100.00 0.00 CRANIAL NERVE (SPECIFY) NEUROPLASTY AND/OR TRANSPOSITION; 64721 64721 360 10,240.00 100.00 10,240.00 MEDIAN NERVE AT CARPAL TUNNEL NEUROPLASTY AND/OR TRANSPOSITION; 64718 64718 360 13,650.00 100.00 13,650.00 ULNAR NERVE AT ELBOW NEUROPLASTY AND/OR TRANSPOSITION; 64719 64719 360 13,650.00 100.00 13,650.00 ULNAR NERVE AT WRIST Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee NEUROPLASTY, MAJOR PERIPHERAL NERVE, 64713 64713 360 100.00 0.00 ARM OR LEG; BRACHIAL PLEXUS NEUROPLASTY, MAJOR PERIPHERAL NERVE, 64714 64714 360 100.00 0.00 ARM OR LEG; LUMBAR PLEXUS NEUROPLASTY, MAJOR PERIPHERAL NERVE, 64708 64708 360 13,650.00 100.00 13,650.00 ARM OR LEG; OTHER THAN SPECIFIED NEUROPLASTY, MAJOR PERIPHERAL NERVE, 64712 64712 360 100.00 0.00 ARM OR LEG; SCIATIC NERVE NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME 64702 64702 360 6,830.00 100.00 6,830.00 DIGIT NEUROPLASTY; NERVE OF HAND OR FOOT 64704 64704 360 100.00 0.00 NEUROSTIMULATOR GENERATOR WITH RECHARGEABLE BATTERY AND CHARGING C1820-W C1820 278 100.00 0.00 SYSTEM NEUROSTIMULATOR HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING C1822-W C1822 278 100.00 0.00 SYSTEM NEUROSTIMULATOR, GENERATOR WITH RECHARGEABLE BATTERY AND CHARGING C1820-G C1820 278 700.00 0.00 SYSTEM NEUROSTIMULATOR, HIGH FREQUENCY WITH RECHARGEABLE BATTERY AND CHARGING C1822-G C1822 278 700.00 0.00 SYSTEM NICOTINE AND COTININE 80323 80323 301 160.00 100.00 160.00 NIPPLE EXPLORATION, WITH OR WITHOUT EXCISION OF A SOLITARY LACTIFEROUS DUCT 19110 19110 360 100.00 0.00 OR A PAPILLOMA LACTIFEROUS DUCT NIPPLE/AREOLA RECONSTRUCTION 19350 19350 360 100.00 0.00 NOCTURNAL PENILE TUMESCENCE AND/OR 54250 54250 360 100.00 0.00 RIGIDITY TEST NON INVASIVE EAR PULSE OXIMETRY 94760 94760 460 100.00 100.00 100.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee NON-CONTACT LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, 52647 52647 360 15,540.00 100.00 15,540.00 CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) Noninvasive ear or pulse oximetry for oxygen saturation; 94762 94762 460 550.00 100.00 550.00 by continuous overnight monitoring (separate procedure) NONINVASIVE EAR/PULSE OXIMETRY 94761 94761 460 150.00 100.00 150.00 NONRECHARGEABLE NEUROSTIMULATOR C1767-G C1767 278 700.00 0.00 NONRECHARGEABLE NEUROSTIMULATORS C1767-W C1767 278 100.00 0.00 NSF CHARGE NSF 100.00 0.00 NUCLEIC ACID HIGH RESOLUTION 83909 83909 301 450.00 100.00 450.00 OBS HOURS 99234 99234 762 3,750.00 100.00 3,750.00 Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from "observation status" if the discharge is 99217 99217 762 1,500.00 100.00 1,500.00 on other than the initial date of "observation status." To report services to a Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key 99235 99235 762 3,750.00 100.00 3,750.00 components: A comprehensive history; A comprehensive examination; and Medical decision m OCCLUSION OF FALLOPIAN TUBE(S) BY DEVICE (EG, BAND, CLIP, FALOPE RING) VAGINAL OR 58615 58615 360 100.00 0.00 SUPRAPUBIC APPROACH OCCULT BLOOD OTHER SOURCES THAN FECES 82271 82271 301 80.00 100.00 80.00 OCCULT BLOOD, FACES SINGLE TEST 82270 82270 301 50.00 100.00 50.00 OCCULT BLOOD, FECES (WAIVED) 1 - 3 TESTS 82272 82272 301 50.00 100.00 50.00 OCCUPATIONAL THERAPY - EVALUATION 434 434 100.00 0.00 OCCUPATIONAL THERAPY EVALUATION 97003 97003 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OCCUPATIONAL THERAPY RE-EVALUATION 97004 97004 100.00 0.00

OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99204 99204 100.00 0.00 PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A COMPREHENSIVE HISTOR

OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW 99203 99203 100.00 0.00 PATIENT, WHICH REQUIRES THESE THREE KEY COMPONENTS: A DETAILED HISTORY; A OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REQUIRES AT 99213 99213 100.00 0.00 LEAST TWO OF THESE THREE KEY COMPON19309 OMENTAL FLAP, EXTRA-ABDOMINAL (EG, FOR RECONSTRUCTION OF STERNAL AND CHEST 49904 49904 360 100.00 0.00 WALL DEFECTS) OMENTAL FLAP, INTRA-ABDOMINAL (LIST SEPARATELY IN ADDITION TO CODE FOR 49905 49905 360 100.00 0.00 PRIMARY PROCEDURE) OMENTECTOMY, EPIPLOECTOMY, RESECTION 49255 49255 360 100.00 0.00 OF OMENTUM (SEPARATE PROCEDURE) ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH EXTENSIVE DISSECTION 54328 54328 360 100.00 0.00 TO CORRECT CHORDEE AND URETHROPLASTY WITH LOCAL SKIN FLAPS, SKIN GRAFT PATCH, AND/OR ISLAND FLAP ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR 54322 54322 360 100.00 0.00 CIRCUMCISION); WITH SIMPLE MEATAL ADVANCEMENT (EG, MAGPI, V-FLAP) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY 54324 54324 360 100.00 0.00 LOCAL SKIN FLAPS (EG, FLIP-FLAP, PREPUCIAL FLAP) ONE STAGE DISTAL HYPOSPADIAS REPAIR (WITH OR WITHOUT CHORDEE OR CIRCUMCISION); WITH URETHROPLASTY BY 54326 54326 360 100.00 0.00 LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO 54336 54336 360 100.00 0.00 CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO 54332 54332 360 100.00 0.00 CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT T OOPHORECTOMY, PARTIAL OR TOTAL, 58940 58940 360 100.00 0.00 UNILATERAL OR BILATERAL; OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; FOR OVARIAN, TUBAL OR PRIMARY PERITONEAL 58943 58943 360 100.00 0.00 MALIGNANCY, WITH PARA-AORTIC AND PELVIC LYMPH NODE B OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA 32815 32815 360 100.00 0.00

OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST 19370 19370 360 100.00 0.00 OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND OR DISLOCATION(S) (INCLUDING OS 22318 22318 360 100.00 0.00 ODONTOIDEUM), ANTERIOR APPROACH, INCLUDING PLACEMENT OF IN Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT AND/OR REDUCTION OF ODONTOID FRACTURE(S) AND OR DISLOCATION(S) (INCLUDING OS 22319 22319 360 100.00 0.00 ODONTOIDEUM), ANTERIOR APPROACH, INCLUDING PLACEMENT OF14107 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE 22326 22326 360 100.00 0.00 FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; CERVICAL OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED 22328 22328 360 100.00 0.00 SEGMENT; EACH ADDITIONAL FRACTURED VERTEBRAE OR DISLOCATED SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE 22325 22325 360 100.00 0.00 FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; LUMBAR OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE 22327 22327 360 100.00 0.00 FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; THORACIC OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR AND POSTERIOR (TWO) COLUMNS, INCLUDES T- 27228 27228 360 100.00 0.00 FRACTURE AND BOTH COLUMN FRACTURE WITH COMPLETE AR OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR OR POSTERIOR (ONE) COLUMN, OR A FRACTURE 27227 27227 360 100.00 0.00 RUNNING TRANSVERSELY ACROSS THE ACETABULUM, WITH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF ACROMIOCLAVICULAR 23550 23550 360 19,350.00 100.00 19,350.00 DISLOCATION, ACUTE OR CHRONIC;

OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH 23552 23552 360 19,350.00 100.00 19,350.00 FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) OPEN TREATMENT OF ACUTE OR CHRONIC 24615 24615 360 25,500.00 100.00 25,500.00 ELBOW DISLOCATION OPEN TREATMENT OF ACUTE SHOULDER 23660 23660 360 100.00 0.00 DISLOCATION OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL 27848 27848 360 19,350.00 100.00 19,350.00 FIXATION; WITH REPAIR OR INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF ANKLE DISLOCATION, WITH OR WITHOUT PERCUTANEOUS SKELETAL 27846 27846 360 100.00 0.00 FIXATION; WITHOUT REPAIR OR INTERNAL FIXATION OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR DISLOCATION WITH 27217 27217 360 100.00 0.00 INTERNAL FIXATION (INCLUDES PUBIC SYMPHYSIS AND/OR RAMI)

OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR 26746 26746 360 9,350.00 100.00 9,350.00 INTERPHALANGEAL JOINT, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH

OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, WITH OR WITHOUT INTERNAL OR 27814 27814 360 19,350.00 100.00 19,350.00 EXTERNAL FIXATION OPEN TREATMENT OF CALCANEAL FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 28415 28415 360 25,500.00 100.00 25,500.00 FIXATION; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF CALCANEAL FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION; WITH PRIMARY ILIAC OR OTHER 28420 28420 360 100.00 0.00 AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) OPEN TREATMENT OF CARPAL BONE FRACTURE (OTHER THAN CARPAL SCAPHOID 25645 25645 360 19,350.00 100.00 19,350.00 (NAVICULAR)), EACH BONE OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, WITH OR WITHOUT 25628 25628 360 19,350.00 100.00 19,350.00 INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB; COMPLEX, 26686 26686 360 25,500.00 100.00 25,500.00 MULTIPLE OR DELAYED REDUCTION

OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB; WITH OR 26685 26685 360 100.00 0.00 WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH JOINT

OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT 26665 26665 360 19,350.00 100.00 19,350.00 FRACTURE), WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF CLAVICULAR FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 23515 23515 360 25,500.00 100.00 25,500.00 FIXATION OPEN TREATMENT OF COCCYGEAL FRACTURE 27202 27202 360 100.00 0.00 OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, 21366 21366 360 100.00 0.00 INCLUDING ZYGOMATIC ARCH AND MALAR TR14072 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, 21365 21365 360 30,200.00 100.00 30,200.00 INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; WITH INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES

OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL 21470 21470 360 100.00 0.00 FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED (EG, COMMINUTED OR INVOLVING CRANIAL 21433 21433 360 100.00 0.00 NERVE FORAMINA), MULTIPLE SURGICAL APPRO OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, 21436 21436 360 100.00 0.00 MULTIPLE SURGICAL APPROACHES, INTERNAL FIXATION, WITH BONE GRAFTING (INCLUDE

OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, 21435 21435 360 100.00 0.00 UTILIZING INTERNAL AND/OR EXTERNAL FIXATION TECHNIQUES (EG, HEAD CAP, HALO D OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); WITH WIRING 21432 21432 360 100.00 0.00 AND/OR INTERNAL FIXATION OPEN TREATMENT OF DEPRESSED FRONTAL 21343 21343 360 100.00 0.00 SINUS FRACTURE OPEN TREATMENT OF DEPRESSED MALAR FRACTURE, INCLUDING ZYGOMATIC ARCH AND 21360 21360 360 100.00 0.00 MALAR TRIPOD Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF DEPRESSED ZYGOMATIC 21356 21356 360 24,160.00 100.00 24,160.00 ARCH FRACTURE (EG, GILLIES APPROACH)

OPEN TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION, WITH OR WITHOUT 27519 27519 360 100.00 0.00 INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), WITH OR 27792 27792 360 19,350.00 100.00 19,350.00 WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, WITH OR 26765 26765 360 9,350.00 100.00 9,350.00 WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH OPEN TREATMENT OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, WITH OR WITHOUT 25620 25620 360 100.00 0.00 FRACTURE OF ULNAR STYLOID, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF DISTAL RADIAL INTRA- ARTICULAR FRACTURE OR EPIPHYSEAL 25608 25608 360 22,900.00 100.00 22,900.00 SEPARATION; WITH INTERNAL FIXATION OF 2 FRAGMENTS OPEN TREATMENT OF DISTAL RADIAL INTRA- ARTICULAR FRACTURE OR EPIPHYSEAL 25609 25609 360 25,500.00 100.00 25,500.00 SEPARATION; WITH INTERNAL FIXATION OF 3 OR MORE FRAGMENTS OPEN TREATMENT OF DISTAL RADIOULNAR 25676 25676 360 100.00 0.00 DISLOCATION, ACUTE OR CHRONIC

OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, WITH OR 27829 27829 360 19,350.00 100.00 19,350.00 WITHOUT INTERNAL OR EXTERNAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, 27514 27514 360 100.00 0.00 WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF FEMORAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR 27507 27507 360 100.00 0.00 WITHOUT CERCLAGE OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, WITH OR WITHOUT EXTERNAL FIXATION, WITH INSERTION OF 27506 27506 360 100.00 0.00 INTRAMEDULLARY IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITH INTERCONDYLAR EXTENSION, 27513 27513 360 100.00 0.00 WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE WITHOUT INTERCONDYLAR 27511 27511 360 100.00 0.00 EXTENSION, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES, WITH OR WITHOUT 28505 28505 360 9,350.00 100.00 9,350.00 INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF FRACTURE OF ORBIT, 21407 21407 360 19,300.00 100.00 19,300.00 EXCEPT BLOWOUT; WITH IMPLANT OPEN TREATMENT OF FRACTURE OF ORBIT, 21406 21406 360 19,330.00 100.00 19,330.00 EXCEPT BLOWOUT; WITHOUT IMPLANT

OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), 27828 27828 360 100.00 0.00 WITH INTERNAL OR EXTERNAL FIXATION; OF BOTH TIBIA AND FIBULA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), 27826 27826 360 100.00 0.00 WITH INTERNAL OR EXTERNAL FIXATION; OF FIBULA ONLY

OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (EG, PILON OR TIBIAL PLAFOND), 27827 27827 360 25,500.00 100.00 25,500.00 WITH INTERNAL OR EXTERNAL FIXATION; OF TIBIA ONLY OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, WITH OR 28525 28525 360 9,350.00 100.00 9,350.00 WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH OPEN TREATMENT OF GREATER HUMERAL TUBEROSITY FRACTURE, WITH OR WITHOUT 23630 23630 360 25,500.00 100.00 25,500.00 INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE, WITH OR WITHOUT INTERNAL OR 27248 27248 360 100.00 0.00 EXTERNAL FIXATION

OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, WITH ACETABULAR WALL AND 27254 27254 360 100.00 0.00 FEMORAL HEAD FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF HIP DISLOCATION, 27253 27253 360 100.00 0.00 TRAUMATIC, WITHOUT INTERNAL FIXATION

OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH OR 24579 24579 360 25,500.00 100.00 25,500.00 WITHOUT INTERNAL OR EXTERNAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, WITH OR 24575 24575 360 25,500.00 100.00 25,500.00 WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF HUMERAL SHAFT FRACTURE WITH PLATE/SCREWS, WITH OR 24515 24515 360 25,500.00 100.00 25,500.00 WITHOUT CERCLAGE OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, WITH OR WITHOUT INTERNAL OR 24546 24546 360 25,500.00 100.00 25,500.00 EXTERNAL FIXATION; WITH INTERCONDYLAR EXTENSION OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, WITH OR WITHOUT INTERNAL OR 24545 24545 360 25,500.00 100.00 25,500.00 EXTERNAL FIXATION; WITHOUT INTERCONDYLAR EXTENSION OPEN TREATMENT OF HYOID FRACTURE 21495 21495 360 100.00 0.00

OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING 27215 27215 360 100.00 0.00 FRACTURE(S) (EG, PELVIC FRACTURE(S) WHICH DO NOT DISRUPT THE PELVIC RING), WITH I

OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF 27540 27540 360 100.00 0.00 THE KNEE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, WITH OR WITHOUT 28675 28675 360 11,200.00 100.00 11,200.00 INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, WITH OR WITHOUT 26785 26785 360 9,350.00 100.00 9,350.00 INTERNAL OR EXTERNAL FIXATION, SINGLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF KNEE DISLOCATION, WITH OR WITHOUT INTERNAL OR EXTERNAL 27557 27557 360 100.00 0.00 FIXATION; WITH PRIMARY LIGAMENTOUS REPAIR OPEN TREATMENT OF KNEE DISLOCATION, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION; WITH PRIMARY LIGAMENTOUS 27558 27558 360 100.00 0.00 REPAIR, WITH AUGMENTATION/RECONSTRUCTION OPEN TREATMENT OF KNEE DISLOCATION, WITH OR WITHOUT INTERNAL OR EXTERNAL 27556 27556 360 100.00 0.00 FIXATION; WITHOUT PRIMARY LIGAMENTOUS REPAIR OR AUGMENTATION/RECONSTRUCTION

OPEN TREATMENT OF LUNATE DISLOCATION 25695 25695 360 100.00 0.00 OPEN TREATMENT OF MANDIBULAR CONDYLAR 21465 21465 360 100.00 0.00 FRACTURE OPEN TREATMENT OF MANDIBULAR FRACTURE 21454 21454 360 100.00 0.00 WITH EXTERNAL FIXATION OPEN TREATMENT OF MANDIBULAR FRACTURE; 21462 21462 360 28,990.00 100.00 28,990.00 WITH INTERDENTAL FIXATION OPEN TREATMENT OF MANDIBULAR FRACTURE; 21461 21461 360 24,160.00 100.00 24,160.00 WITHOUT INTERDENTAL FIXATION OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE 21445 21445 360 100.00 0.00 (SEPARATE PROCEDURE) OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, WITH OR WITHOUT INTERNAL OR 27766 27766 360 19,350.00 100.00 19,350.00 EXTERNAL FIXATION

OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, WITH OR WITHOUT INTERNAL OR 26615 26615 360 19,350.00 100.00 19,350.00 EXTERNAL FIXATION, EACH BONE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION, 26715 26715 360 11,050.00 100.00 11,050.00 SINGLE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF METATARSAL FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 28485 28485 360 19,350.00 100.00 19,350.00 FIXATION, EACH OPEN TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION, 28645 28645 360 100.00 0.00 WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA WITH 24635 24635 360 25,500.00 100.00 25,500.00 DISLOCATION OF RADIAL HEAD), WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF NASAL FRACTURE; COMPLICATED, WITH INTERNAL AND/OR 21330 21330 360 24,160.00 100.00 24,160.00 EXTERNAL SKELETAL FIXATION OPEN TREATMENT OF NASAL FRACTURE; 21325 21325 360 100.00 0.00 UNCOMPLICATED OPEN TREATMENT OF NASAL FRACTURE; WITH CONCOMITANT OPEN TREATMENT OF 21335 21335 360 15,660.00 100.00 15,660.00 FRACTURED SEPTUM OPEN TREATMENT OF NASAL SEPTAL 21336 21336 360 100.00 0.00 FRACTURE, WITH OR WITHOUT STABILIZATION OPEN TREATMENT OF NASOETHMOID 21339 21339 360 100.00 0.00 FRACTURE; WITH EXTERNAL FIXATION OPEN TREATMENT OF NASOETHMOID 21338 21338 360 100.00 0.00 FRACTURE; WITHOUT EXTERNAL FIXATION OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); 21347 21347 360 100.00 0.00 REQUIRING MULTIPLE OPEN APPROACHES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH 21348 21348 360 100.00 0.00 BONE GRAFTING (INCLUDES OBTAINING GRAFT) OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); WITH 21346 21346 360 100.00 0.00 WIRING AND/OR LOCAL FIXATION OPEN TREATMENT OF ORBITAL FLOOR 21387 21387 360 100.00 0.00 BLOWOUT FRACTURE; COMBINED APPROACH

OPEN TREATMENT OF ORBITAL FLOOR 21386 21386 360 100.00 0.00 BLOWOUT FRACTURE; PERIORBITAL APPROACH OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL APPROACH 21395 21395 360 100.00 0.00 WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; PERIORBITAL 21390 21390 360 19,330.00 100.00 19,330.00 APPROACH, WITH ALLOPLASTIC OR OTHER IMPLANT OPEN TREATMENT OF ORBITAL FLOOR BLOWOUT FRACTURE; TRANSANTRAL 21385 21385 360 18,120.00 100.00 18,120.00 APPROACH (CALDWELL-LUC TYPE OPERATION) OPEN TREATMENT OF PALATAL OR MAXILLARY 21422 21422 360 20,200.00 100.00 20,200.00 FRACTURE (LEFORT I TYPE); OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED 21423 21423 360 100.00 0.00 (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES OPEN TREATMENT OF PATELLAR DISLOCATION, WITH OR WITHOUT PARTIAL OR TOTAL 27566 27566 360 19,350.00 100.00 19,350.00 PATELLECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF PATELLAR FRACTURE, WITH INTERNAL FIXATION AND/OR PARTIAL OR 27524 27524 360 19,350.00 100.00 19,350.00 COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE 24586 24586 360 25,500.00 100.00 25,500.00 ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/ OR PROXIMAL RADIUS); OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND 24587 24587 360 100.00 0.00 PROXIMAL ULNA AND/ OR PROXIMAL RADIUS); WITH IMPLANT ARTHROPLASTY OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, 26735 26735 360 9,350.00 100.00 9,350.00 FINGER OR THUMB, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR WALL FRACTURE, WITH 27226 27226 360 100.00 0.00 INTERNAL FIXATION OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR DISLOCATION WITH 27218 27218 360 100.00 0.00 INTERNAL FIXATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, WITH OR WITHOUT 27784 27784 360 19,350.00 100.00 19,350.00 INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 23615 23615 360 25,500.00 100.00 25,500.00 FIXATION, WITH OR WITHOUT REPAIR OF TUBEROSITY(S); Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 23616 23616 360 27,400.00 100.00 27,400.00 FIXATION, WITH OR WITHOUT REPAIR OF TUBEROSITY(S); WITH PROXIMAL HUMERAL PROSTHETIC REPLACEMENT

OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION, WITH OR WITHOUT 27832 27832 360 100.00 0.00 INTERNAL OR EXTERNAL FIXATION, OR WITH EXCISION OF PROXIMAL FIBULA

OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL OR 25575 25575 360 25,500.00 100.00 25,500.00 EXTERNAL FIXATION; OF RADIUS AND ULNA OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, WITH INTERNAL OR 25574 25574 360 100.00 0.00 EXTERNAL FIXATION; OF RADIUS OR ULNA OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, WITH OR WITHOUT INTERNAL 24665 24665 360 19,350.00 100.00 19,350.00 FIXATION OR RADIAL HEAD EXCISION;

OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, WITH OR WITHOUT INTERNAL 24666 24666 360 25,500.00 100.00 25,500.00 FIXATION OR RADIAL HEAD EXCISION; WITH RADIAL HEAD PROSTHETIC REPLACEMENT

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL AND/ OR EXTERNAL FIXATION AND CLOSED TREATMENT OF DISLOCATION OF DISTAL RADIOULNAR 25525 25525 360 100.00 0.00 JOINT (GALEAZZI FRACTURE/DISLOCATION), WITH OR WITHOUT PERCUTANEOUS SKELETAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH INTERNAL AND/OR EXTERNAL FIXATION AND OPEN TREATMENT, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION 25526 25526 360 19,350.00 100.00 19,350.00 OF DISTAL RADIOULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION), INCLUDES REPAIR OF TRIANGULAR FIBROCARTILAGE COM

OPEN TREATMENT OF RADIAL SHAFT FRACTURE, WITH OR WITHOUT INTERNAL OR 25515 25515 360 19,350.00 100.00 19,350.00 EXTERNAL FIXATION OPEN TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE OR MORE 25670 25670 360 9,350.00 100.00 9,350.00 BONES OPEN TREATMENT OF RIB FRACTURE WITHOUT 21805 21805 360 100.00 0.00 FIXATION, EACH OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR ACROMION) WITH OR 23585 23585 360 23,950.00 100.00 23,950.00 WITHOUT INTERNAL FIXATION

OPEN TREATMENT OF SESAMOID FRACTURE, 28531 28531 360 100.00 0.00 WITH OR WITHOUT INTERNAL FIXATION

OPEN TREATMENT OF SHOULDER DISLOCATION, WITH FRACTURE OF GREATER HUMERAL 23670 23670 360 100.00 0.00 TUBEROSITY, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF SHOULDER DISLOCATION, WITH SURGICAL OR ANATOMICAL NECK 23680 23680 360 100.00 0.00 FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOPLASTY OF FEMORAL NECK 27179 27179 360 100.00 0.00 (HEYMAN TYPE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOTOMY AND INTERNAL 27181 27181 360 100.00 0.00 FIXATION OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGLE OR MULTIPLE PINNING OR 27177 27177 360 100.00 0.00 BONE GRAFT (INCLUDES OBTAINING GRAFT)

OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), 27259 27259 360 100.00 0.00 REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INC14296 OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), 27258 27258 360 100.00 0.00 REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUD OPEN TREATMENT OF STERNOCLAVICULAR 23530 23530 360 100.00 0.00 DISLOCATION, ACUTE OR CHRONIC;

OPEN TREATMENT OF STERNOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; WITH 23532 23532 360 100.00 0.00 FASCIAL GRAFT (INCLUDES OBTAINING GRAFT)

OPEN TREATMENT OF STERNUM FRACTURE 21825 21825 360 100.00 0.00 WITH OR WITHOUT SKELETAL FIXATION OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, WITH OR WITHOUT INTERNAL OR 28585 28585 360 100.00 0.00 EXTERNAL FIXATION OPEN TREATMENT OF TALUS FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 28445 28445 360 19,350.00 100.00 19,350.00 FIXATION OPEN TREATMENT OF TARSAL BONE DISLOCATION, WITH OR WITHOUT INTERNAL OR 28555 28555 360 100.00 0.00 EXTERNAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), WITH OR 28465 28465 360 19,350.00 100.00 19,350.00 WITHOUT INTERNAL OR EXTERNAL FIXATION, EACH OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, WITH OR WITHOUT 28615 28615 360 19,350.00 100.00 19,350.00 INTERNAL OR EXTERNAL FIXATION OPEN TREATMENT OF TEMPOROMANDIBULAR 21490 21490 360 100.00 0.00 DISLOCATION OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, WITH OR 27536 27536 360 100.00 0.00 WITHOUT INTERNAL FIXATION OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, WITH OR 27535 27535 360 29,200.00 100.00 29,200.00 WITHOUT INTERNAL OR EXTERNAL FIXATION

OPEN TREATMENT OF TIBIAL SHAFT FRACTURE, (WITH OR WITHOUT FIBULAR FRACTURE) WITH 27758 27758 360 100.00 0.00 PLATE/SCREWS, WITH OR WITHOUT CERCLAGE OPEN TREATMENT OF TRANS- SCAPHOPERILUNAR TYPE OF FRACTURE 25685 25685 360 9,350.00 100.00 9,350.00 DISLOCATION OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION, MEDIAL AND/OR 27823 27823 360 100.00 0.00 LATERAL MALLEOLUS; WITH FIXATION OF POSTERIOR LIP OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL FIXATION, MEDIAL AND/OR 27822 27822 360 19,350.00 100.00 19,350.00 LATERAL MALLEOLUS; WITHOUT FIXATION OF POSTERIOR LIP OPEN TREATMENT OF ULNAR FRACTURE PROXIMAL END (OLECRANON PROCESS), WITH 24685 24685 360 19,350.00 100.00 19,350.00 OR WITHOUT INTERNAL OR EXTERNAL FIXATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPEN TREATMENT OF ULNAR SHAFT FRACTURE, WITH OR WITHOUT INTERNAL OR EXTERNAL 25545 25545 360 19,350.00 100.00 19,350.00 FIXATION OPEN TREATMENT OF ULNAR STYLOID 25652 25652 360 19,350.00 100.00 19,350.00 FRACTURE OPERCULECTOMY, EXCISION PERICORONAL 41821 41821 360 100.00 0.00 TISSUES OPHTHALMIC BIOMETRY BY ULTRASOUND 76516 76516 100.00 0.00 ECHOGRAPHY, A-SCAN; OPHTHALMIC BIOMETRY BY ULTRASOUND ECHOGRAPHY, A-SCAN; WITH INTRAOCULAR 76519 76519 100.00 0.00 LENS POWER CALCULATION OPHTHALMIC ULTRASONIC FOREIGN BODY 76529 76529 100.00 0.00 LOCALIZATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; ANTERIOR SEGMENT 76513 76513 100.00 0.00 ULTRASOUND, IMMERSION (WATER BATH) B- SCAN OR HIGH RESOLUTION BIOMICROSCOPY OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; A-SCAN ONLY, WITH AMPLITUDE 76511 76511 100.00 0.00 QUANTIFICATION OPHTHALMIC ULTRASOUND, ECHOGRAPHY, DIAGNOSTIC; CONTACT B-SCAN (WITH OR 76512 76512 100.00 0.00 WITHOUT SIMULTANEOUS A-SCAN) OPHTHALMOLOGICAL EXAMINATION AND EVALUATION, UNDER GENERAL ANESTHESIA, WITH OR WITHOUT MANIPULATION OF GLOBE 92018 360 100.00 0.00 FOR PASSIVE RANGE OF MOTION OR OTHER MANI OPPONENSPLASTY; HYPOTHENAR MUSCLE 26494 26494 360 100.00 0.00 TRANSFER OPPONENSPLASTY; OTHER METHODS 26496 26496 360 100.00 0.00 OPPONENSPLASTY; SUPERFICIALIS TENDON 26490 26490 360 100.00 0.00 TRANSFER TYPE, EACH TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OPPONENSPLASTY; TENDON TRANSFER WITH GRAFT (INCLUDES OBTAINING GRAFT), EACH 26492 26492 360 100.00 0.00 TENDON OPTIC NERVE DECOMPRESSION (EG, INCISION 67570 67570 360 100.00 0.00 OR FENESTRATION OF OPTIC NERVE SHEATH) ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE 67550 67550 360 100.00 0.00 CONE); INSERTION ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE 67560 67560 360 100.00 0.00 CONE); REMOVAL OR REVISION ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, WITH BONE 21267 21267 360 100.00 0.00 GRAFTS; EXTRACRANIAL APPROACH ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); FOR 67450 67450 360 100.00 0.00 EXPLORATION, WITH OR WITHOUT BIOPSY ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH 67440 67440 360 100.00 0.00 DRAINAGE ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH 67445 67445 360 100.00 0.00 REMOVAL OF BONE FOR DECOMPRESSION

ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH 67430 67430 360 100.00 0.00 REMOVAL OF FOREIGN BODY ORBITOTOMY WITH BONE FLAP OR WINDOW, LATERAL APPROACH (EG, KROENLEIN); WITH 67420 67420 360 100.00 0.00 REMOVAL OF LESION ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR 67400 67400 360 100.00 0.00 EXPLORATION, WITH OR WITHOUT BIOPSY ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH 67405 67405 360 100.00 0.00 DRAINAGE ONLY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH 67414 67414 360 100.00 0.00 REMOVAL OF BONE FOR DECOMPRESSION

ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH 67413 67413 360 11,250.00 100.00 11,250.00 REMOVAL OF FOREIGN BODY ORBITOTOMY WITHOUT BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); WITH 67412 67412 360 100.00 0.00 REMOVAL OF LESION ORCHIECTOMY, PARTIAL 54522 54522 360 100.00 0.00 ORCHIECTOMY, RADICAL, FOR TUMOR; 54530 54530 360 16,400.00 100.00 16,400.00 INGUINAL APPROACH ORCHIECTOMY, RADICAL, FOR TUMOR; WITH 54535 54535 360 100.00 0.00 ABDOMINAL EXPLORATION ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), WITH OR WITHOUT 54520 54520 360 10,250.00 100.00 10,250.00 TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL TESTIS (EG, FOWLER- 54650 54650 360 100.00 0.00 STEPHENS) ORCHIOPEXY, INGUINAL APPROACH, WITH OR 54640 54640 360 100.00 0.00 WITHOUT HERNIA REPAIR ORTHOPANTOGRAM 70355 70355 320 100.00 0.00 Orthotic and prosthetic supply, accessory and/or service L9900-W L9900 278 100.00 0.00 component of another HCPCS L code Orthotic and prosthetic supply, accessory, and/or service L9900-G L9900 278 700.00 0.00 component of another HCPCS L code ORTHOTIC(S) FITTING AND TRAINING, UPPER EXTREMITY(IES), LOWER EXTREMITY(IES), 97504 97504 100.00 0.00 AND/OR TRUNK, EACH 15 MINUTES OSOMOLALITY; URINE 83935 83935 301 100.00 100.00 100.00 OSSICULA IMPLANTS L8613-W L8613 278 100.00 0.00 OSSICULAR IMPLANT L8613-G L8613 278 700.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OSTECTOMY OF SCAPULA, PARTIAL (EG, 23190 23190 360 100.00 0.00 SUPERIOR MEDIAL ANGLE) OSTECTOMY OF STERNUM, PARTIAL 21620 21620 360 100.00 0.00 OSTECTOMY, CALCANEUS; 28118 28118 360 8,000.00 100.00 8,000.00 OSTECTOMY, CALCANEUS; FOR SPUR, WITH OR 28119 28119 360 8,420.00 100.00 8,420.00 WITHOUT PLANTAR FASCIAL RELEASE OSTECTOMY, COMPLETE EXCISION; ALL METATARSAL HEADS, WITH PARTIAL PROXIMAL PHALANGECTOMY, EXCLUDING 28114 28114 360 100.00 0.00 FIRST METATARSAL (EG, CLAYTON TYPE PROCEDURE) OSTECTOMY, COMPLETE EXCISION; FIFTH 28113 28113 360 8,000.00 100.00 8,000.00 METATARSAL HEAD OSTECTOMY, COMPLETE EXCISION; FIRST 28111 28111 360 12,740.00 100.00 12,740.00 METATARSAL HEAD OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR 28112 28112 360 8,000.00 100.00 8,000.00 FOURTH) OSTECTOMY, EXCISION OF TARSAL COALITION 28116 28116 360 8,420.00 100.00 8,420.00 OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) (SEPARATE 28110 28110 360 8,000.00 100.00 8,000.00 PROCEDURE) OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, METATARSAL HEAD, EACH 28288 28288 360 8,000.00 100.00 8,000.00 METATARSAL HEAD OSTEOPLASTY, CARPAL BONE, SHORTENING 25394 25394 360 100.00 0.00 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC 21208 21208 360 17,100.00 100.00 17,100.00 IMPLANT) OSTEOPLASTY, FACIAL BONES; REDUCTION 21209 21209 360 100.00 0.00 OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING AND SHORTENING WITH 27468 27468 360 100.00 0.00 FEMORAL SEGMENT TRANSFER OSTEOPLASTY, FEMUR; LENGTHENING 27466 27466 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OSTEOPLASTY, FEMUR; SHORTENING 27465 27465 360 100.00 0.00 (EXCLUDING 64876) OSTEOPLASTY, HUMERUS (EG, SHORTENING OR 24420 24420 360 100.00 0.00 LENGTHENING) (EXCLUDING 64876) OSTEOPLASTY, LENGTHENING, METACARPAL 26568 26568 360 100.00 0.00 OR PHALANX OSTEOPLASTY, RADIUS AND ULNA; 25393 25393 360 100.00 0.00 LENGTHENING WITH AUTOGRAFT OSTEOPLASTY, RADIUS AND ULNA; 25392 25392 360 100.00 0.00 SHORTENING (EXCLUDING 64876) OSTEOPLASTY, RADIUS OR ULNA; 25391 25391 360 100.00 0.00 LENGTHENING WITH AUTOGRAFT OSTEOPLASTY, RADIUS OR ULNA; SHORTENING 25390 25390 360 17,250.00 100.00 17,250.00 OSTEOPLASTY, TIBIA AND FIBULA, 27715 27715 360 100.00 0.00 LENGTHENING OR SHORTENING OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER OF FEMUR (SEPARATE 27140 27140 360 100.00 0.00 PROCEDURE) OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE 22220 22220 360 100.00 0.00 VERTEBRAL SEGMENT; CERVICAL OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL 22226 22226 360 100.00 0.00 VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE 22224 22224 360 100.00 0.00 VERTEBRAL SEGMENT; LUMBAR OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE 22222 22222 360 100.00 0.00 VERTEBRAL SEGMENT; THORACIC OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL 22210 22210 360 100.00 0.00 SEGMENT; CERVICAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL 22214 22214 360 100.00 0.00 SEGMENT; LUMBAR OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL 22212 22212 360 100.00 0.00 SEGMENT; THORACIC OSTEOTOMY, CLAVICLE, WITH OR WITHOUT 23480 23480 360 11,050.00 100.00 11,050.00 INTERNAL FIXATION; OSTEOTOMY, CLAVICLE, WITH OR WITHOUT INTERNAL FIXATION; WITH BONE GRAFT FOR NONUNION OR MALUNION (INCLUDES 23485 23485 360 28,950.00 100.00 28,950.00 OBTAINING GRAFT AND/OR NECESSARY FIXATION) OSTEOTOMY, FEMORAL NECK (SEPARATE 27161 27161 360 100.00 0.00 PROCEDURE) OSTEOTOMY, FEMUR, SHAFT OR 27450 27450 360 100.00 0.00 SUPRACONDYLAR; WITH FIXATION OSTEOTOMY, FEMUR, SHAFT OR 27448 27448 360 100.00 0.00 SUPRACONDYLAR; WITHOUT FIXATION OSTEOTOMY, HUMERUS, WITH OR WITHOUT 24400 24400 360 23,950.00 100.00 23,950.00 INTERNAL FIXATION OSTEOTOMY, ILIAC, ACETABULAR OR 27146 27146 360 100.00 0.00 INNOMINATE BONE; OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 27151 27151 360 100.00 0.00 OSTEOTOMY OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH FEMORAL 27156 27156 360 100.00 0.00 OSTEOTOMY AND WITH OPEN REDUCTION OF HIP OSTEOTOMY, ILIAC, ACETABULAR OR INNOMINATE BONE; WITH OPEN REDUCTION OF 27147 27147 360 100.00 0.00 HIP OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC INCLUDING INTERNAL OR 27165 27165 360 100.00 0.00 EXTERNAL FIXATION AND/OR CAST OSTEOTOMY, MANDIBLE, SEGMENTAL; 21198 21198 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OSTEOTOMY, MANDIBLE, SEGMENTAL; WITH 21199 21199 360 100.00 0.00 GENIOGLOSSUS ADVANCEMENT OSTEOTOMY, MAXILLA, SEGMENTAL (EG, 21206 21206 360 100.00 0.00 WASSMUND OR SCHUCHARD) OSTEOTOMY, MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD, FEMORAL SHAFT 27454 27454 360 100.00 0.00 (EG, SOFIELD TYPE PROCEDURE) OSTEOTOMY, PELVIS, BILATERAL (EG, 27158 27158 360 100.00 0.00 CONGENITAL MALFORMATION) OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES 27457 27457 360 100.00 0.00 CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); AFTER EPI

OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES 27455 27455 360 100.00 0.00 CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); BEFORE EP OSTEOTOMY, RADIUS; DISTAL THIRD 25350 25350 360 100.00 0.00 OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL 25355 25355 360 100.00 0.00 THIRD OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER 28312 28312 360 8,000.00 100.00 8,000.00 PHALANGES, ANY TOE OSTEOTOMY, SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL 28310 28310 360 8,000.00 100.00 8,000.00 PHALANX, FIRST TOE (SEPARATE PROCEDURE) OSTEOTOMY, TARSAL BONES, OTHER THAN 28304 28304 360 23,900.00 100.00 23,900.00 CALCANEUS OR TALUS; OSTEOTOMY, TARSAL BONES, OTHER THAN CALCANEUS OR TALUS; WITH AUTOGRAFT 28305 28305 360 23,900.00 100.00 23,900.00 (INCLUDES OBTAINING GRAFT) (EG, FOWLER TYPE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR 28306 28306 360 8,000.00 100.00 8,000.00 CORRECTION, METATARSAL; FIRST METATARSAL OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; FIRST 28307 28307 360 8,000.00 100.00 8,000.00 METATARSAL WITH AUTOGRAFT (OTHER THAN FIRST TOE) OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR 28309 28309 360 23,900.00 100.00 23,900.00 CORRECTION, METATARSAL; MULTIPLE (EG, SWANSON TYPE CAVUS FOOT PROCEDURE) OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR 28308 28308 360 8,000.00 100.00 8,000.00 CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH OSTEOTOMY; CALCANEUS (EG, DWYER OR CHAMBERS TYPE PROCEDURE), WITH OR 28300 28300 360 23,900.00 100.00 23,900.00 WITHOUT INTERNAL FIXATION OSTEOTOMY; FIBULA 27707 27707 360 100.00 0.00 OSTEOTOMY; METACARPAL, EACH 26565 26565 360 10,630.00 100.00 10,630.00 OSTEOTOMY; MULTIPLE, WITH REALIGNMENT ON INTRAMEDULLARY ROD (EG, SOFIELD TYPE 27712 27712 360 100.00 0.00 PROCEDURE) OSTEOTOMY; PHALANX OF FINGER, EACH 26567 26567 360 10,630.00 100.00 10,630.00 OSTEOTOMY; RADIUS AND ULNA 25365 25365 360 100.00 0.00 OSTEOTOMY; TALUS 28302 28302 360 23,900.00 100.00 23,900.00 OSTEOTOMY; TIBIA 27705 27705 360 17,250.00 100.00 17,250.00 OSTEOTOMY; TIBIA AND FIBULA 27709 27709 360 100.00 0.00 OSTEOTOMY; ULNA 25360 25360 360 100.00 0.00 OTHER ARTERY AND VEIN PROCEDURES 37799 37799 360 8,260.00 100.00 8,260.00 OTHER DIAGN SERVICES - NOS 929 929 100.00 0.00 OTHER DIAGNOSTIC SERVICES 920 920 100.00 0.00 OTHER PARTIAL OSTECTOMY, TIBIA AND 77.87 360 100.00 0.00 FIBULA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Otolaryngologic examination under general anesthesia 92502 92502 360 2,050.00 100.00 2,050.00 OTOPLASTY, PROTRUDING EAR, WITH OR 69300 69300 360 8,900.00 100.00 8,900.00 WITHOUT SIZE REDUCTION OVA & PARASITES DIRECT SMEAR 87177 87177 306 230.00 100.00 230.00 OVARIAN CYSTECTOMY, UNILATERAL OR 58925 58925 360 18,200.00 100.00 18,200.00 BILATERAL PAAT SCHEDULE CODE PAAT 300 100.00 0.00 PALATOPHARYNGOPLASTY (EG, UVULOPALATOPHARYNGOPLASTY, 42145 42145 360 17,100.00 100.00 17,100.00 UVULOPHARYNGOPLASTY) PALATOPLASTY FOR CLEFT PALATE, SOFT 42200 42200 360 100.00 0.00 AND/OR HARD PALATE ONLY PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; SOFT TISSUE 42205 42205 360 100.00 0.00 ONLY PALATOPLASTY FOR CLEFT PALATE, WITH CLOSURE OF ALVEOLAR RIDGE; WITH BONE 42210 42210 360 100.00 0.00 GRAFT TO ALVEOLAR RIDGE (INCLUDES OBTAINING GRAFT) PALATOPLASTY FOR CLEFT PALATE; 42225 42225 360 100.00 0.00 ATTACHMENT PHARYNGEAL FLAP PALATOPLASTY FOR CLEFT PALATE; MAJOR 42215 42215 360 100.00 0.00 REVISION PALATOPLASTY FOR CLEFT PALATE; 42220 42220 360 100.00 0.00 SECONDARY LENGTHENING PROCEDURE PANEZ, PANEL ENZYME 86971 86971 306 600.00 100.00 600.00 PAPILLECTOMY OR EXCISION OF SINGLE TAG, 46220 46220 360 100.00 0.00 ANUS (SEPARATE PROCEDURE) PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH DIAGNOSTIC 65800 65800 360 100.00 0.00 ASPIRATION OF AQUEOUS PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF 65815 65815 360 100.00 0.00 BLOOD, WITH OR WITHOUT IRRIGATION AND/OR AIR INJECTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH REMOVAL OF VITREOUS AND/OR DISCISSION OF ANTERIOR 65810 65810 360 100.00 0.00 HYALOID MEMBRANE, WITH OR WITHOUT AIR INJECTION PARACENTESIS OF ANTERIOR CHAMBER OF EYE (SEPARATE PROCEDURE); WITH THERAPEUTIC 65805 65805 360 100.00 0.00 RELEASE OF AQUEOUS PARATHYROID AUTOTRANSPLANTATION (LIST SEPARATELY IN ADDITION TO CODE FOR 60512 60512 360 4,300.00 100.00 4,300.00 PRIMARY PROCEDURE) PARATHYROID HORMONE PTH 83970 83970 301 320.00 100.00 320.00 PARATHYROIDECTOMY OR EXPLORATION OF 60500 60500 360 17,100.00 100.00 17,100.00 PARATHYROID(S); PARATHYROIDECTOMY OR EXPLORATION OF 60502 60502 360 100.00 0.00 PARATHYROID(S); RE-EXPLORATION PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); WITH MEDIASTINAL 60505 60505 360 100.00 0.00 EXPLORATION, STERNAL SPLIT OR TRANSTHORACIC APPROACH PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, STRESS URINARY 57284 57284 360 18,200.00 100.00 18,200.00 INCONTINENCE, AND/OR INCOMPLETE VAGINAL PROLAPSE) PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11057 11057 360 100.00 0.00 CALLUS); MORE THAN FOUR LESIONS PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11055 11055 360 100.00 0.00 CALLUS); SINGLE LESION PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR 11056 11056 360 100.00 0.00 CALLUS); TWO TO FOUR LESIONS PAROTID DUCT DIVERSION, BILATERAL (WILKE 42507 42507 360 100.00 0.00 TYPE PROCEDURE); Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH EXCISION OF BOTH 42509 42509 360 100.00 0.00 SUBMANDIBULAR GLANDS PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH EXCISION OF ONE 42508 42508 360 100.00 0.00 SUBMANDIBULAR GLAND PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); WITH LIGATION OF BOTH 42510 42510 360 100.00 0.00 SUBMANDIBULAR (WHARTON'S) DUCTS PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, OSTEOMYELITIS OR BONE 27071 27071 360 100.00 0.00 ABSCESS); DEEP (SUBFASCIAL OR INTRAMUSCULAR) PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (EG, OSTEOMYELITIS OR BONE 27070 27070 360 100.00 0.00 ABSCESS); SUPERFICIAL (EG, WING OF ILIUM, SYMPHYSIS PUBIS, OR GREATER TROCH

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 27641 27641 360 12,740.00 100.00 12,740.00 (EG, OSTEOMYELITIS OR EXOSTOSIS); FIBULA

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 27640 27640 360 100.00 0.00 (EG, OSTEOMYELITIS OR EXOSTOSIS); TIBIA PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 23180 23180 360 100.00 0.00 (EG, OSTEOMYELITIS), CLAVICLE PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 24140 24140 360 12,040.00 100.00 12,040.00 (EG, OSTEOMYELITIS), HUMERUS PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 24147 24147 360 12,040.00 100.00 12,040.00 (EG, OSTEOMYELITIS), OLECRANON PROCESS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 23184 23184 360 100.00 0.00 (EG, OSTEOMYELITIS), PROXIMAL HUMERUS

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 24145 24145 360 100.00 0.00 (EG, OSTEOMYELITIS), RADIAL HEAD OR NECK PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 23182 23182 360 100.00 0.00 (EG, OSTEOMYELITIS), SCAPULA PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 26236 26236 360 9,560.00 100.00 9,560.00 (EG, OSTEOMYELITIS); DISTAL PHALANX OF FINGER PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 26230 26230 360 10,630.00 100.00 10,630.00 (EG, OSTEOMYELITIS); METACARPAL PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE 26235 26235 360 100.00 0.00 (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE, 27360 27360 360 12,420.00 100.00 12,420.00 FEMUR, PROXIMAL TIBIA AND/OR FIBULA (EG, OSTEOMYELITIS OR BONE ABSCESS) PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF 25151 25151 360 11,900.00 100.00 11,900.00 BONE (EG, FOR OSTEOMYELITIS); RADIUS PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF 25150 25150 360 100.00 0.00 BONE (EG, FOR OSTEOMYELITIS); ULNA PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR 28124 28124 360 8,000.00 100.00 8,000.00 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); PHALANX OF TOE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR 28120 28120 360 9,470.00 100.00 9,470.00 DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS OR BOSSING); TALUS OR CALCANEUS

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS 28122 28122 360 8,000.00 100.00 8,000.00 OR BOSSING); TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS

PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA 22100 22100 360 100.00 0.00 OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL

PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, 22103 22103 360 100.00 0.00 SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)

PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA 22102 22102 360 100.00 0.00 OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; LUMBAR

PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (EG, SPINOUS PROCESS, LAMINA 22101 22101 360 100.00 0.00 OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; THORACIC PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE 22116 22116 360 100.00 0.00 ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH A Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE 22114 22114 360 100.00 0.00 ROOT(S), SINGLE VERTEBRAL SEGMENT; LUMBAR PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, WITHOUT DECOMPRESSION OF SPINAL CORD OR NERVE 22112 22112 360 100.00 0.00 ROOT(S), SINGLE VERTEBRAL SEGMENT; THORAC PARTIAL HYMENECTOMY OR REVISION OF 56700 56700 360 8,450.00 100.00 8,450.00 HYMENAL RING PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO-LATERO- 31382 31382 360 100.00 0.00 VERTICAL PARTIAL LARYNGECTOMY 31380 31380 360 100.00 0.00 (HEMILARYNGECTOMY); ANTEROVERTICAL PARTIAL LARYNGECTOMY 31370 31370 360 100.00 0.00 (HEMILARYNGECTOMY); HORIZONTAL PARTIAL LARYNGECTOMY 31375 31375 360 100.00 0.00 (HEMILARYNGECTOMY); LATEROVERTICAL PARTIAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL 60212 60212 360 100.00 0.00 LOBECTOMY, INCLUDING ISTHMUSECTOMY

PARTIAL THYROID LOBECTOMY, UNILATERAL; 60210 60210 360 19,400.00 100.00 19,400.00 WITH OR WITHOUT ISTHMUSECTOMY PASS THROUGH DRUGS 636 100.00 0.00 PATELLECTOMY OR HEMIPATELLECTOMY 27350 27350 360 11,900.00 100.00 11,900.00 PATH CONSULT DURING SURGERY 88329 88329 311 190.00 100.00 190.00 PATH CONSULT EACH ADDITIONAL TISSUE 88332 88332 311 100.00 100.00 100.00 BLOCK PATH CONSULT FIRST TISSUE BLOCK 88331 88331 311 850.00 100.00 850.00 PATH REVIEW PERIPHERAL SMEAR 85060 85060 311 200.00 100.00 200.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, L8681-G L8681 278 700.00 0.00 replacement only Patient programmer (external) for use with implantable programmable neurostimulator pulse generator/ L8681-W L8681 278 100.00 0.00 replacement only PATIENT PROGRAMMER NEUROSTIMULATOR C1787-W C1787 278 100.00 0.00

PATIENT PROGRAMMER, NEUROSTIMULATOR C1787-G C1787 278 700.00 0.00 PELVIC EXAMINATION UNDER ANESTHESIA 57410 57410 360 8,450.00 100.00 8,450.00 PELVIC EXENTERATION FOR GYNECOLOGIC MALIGNANCY, WITH TOTAL ABDOMINAL HYSTERECTOMY OR CERVICECTOMY, WITH OR 58240 58240 360 100.00 0.00 WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT PELVIC EXENTERATION, COMPLETE, FOR VESICAL, PROSTATIC OR URETHRAL MALIGNANCY, WITH REMOVAL OF BLADDER 51597 51597 360 100.00 0.00 AND URETERAL TRANSPLANTATIONS, WITH OR WITHOUT H

PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY 22848 22848 360 100.00 0.00 STRUCTURES) OTHER THAN SACRUM PENILE PLETHYSMOGRAPHY 54240 54240 360 100.00 0.00 PENILE VENOUS OCCLUSIVE PROCEDURE 37790 37790 360 100.00 0.00 PERCUTANEOUS ASPIRATION, SPINAL CORD 62268 62268 360 100.00 0.00 CYST OR SYRINX PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODE ARRAY, 63650 63650 360 24,200.00 100.00 24,200.00 EPIDURAL PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; AUTONOMIC 64560 64560 360 100.00 0.00 NERVE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; CRANIAL 64553 64553 360 100.00 0.00 NERVE PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; 64565 64565 360 100.00 0.00 NEUROMUSCULAR PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; PERIPHERAL 64555 64555 360 24,200.00 100.00 24,200.00 NERVE (EXCLUDES SACRAL NERVE) PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; SACRAL 64561 64561 360 24,200.00 100.00 24,200.00 NERVE (TRANSFORAMINAL PLACEMENT) PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR 62264 62264 360 5,120.00 100.00 5,120.00 MECHANICAL MEANS (EG, CATHETER) INCLUDING RADI16392 PERCUTANEOUS LYSIS OF EPIDURAL ADHESIONS USING SOLUTION INJECTION (EG, HYPERTONIC SALINE, ENZYME) OR MECHANICAL MEANS (EG, CATHETER) 62263 62263 360 100.00 0.00 INCLUDING RADIOLOGIC LOCALIZATION (INCLUDES CONTRAST WHEN ADMINISTERED), MULTIPLE ADHESIOLYSIS SESSIONS; 2 OR MORE DAYS PERCUTANEOUS PLACEMENT OF 43750 43750 360 100.00 0.00 GASTROSTOMY TUBE PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE, RADIOLOGICAL 74350 74350 329 100.00 0.00 SUPERVISION AND INTERPRETATION PERCUTANEOUS SKELETAL FIXATION OF 28406 28406 360 9,350.00 100.00 9,350.00 CALCANEAL FRACTURE, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER 26676 26676 360 100.00 0.00 THAN THUMB, WITH MANIPULATION, EACH JOINT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), WITH 26650 26650 360 9,350.00 100.00 9,350.00 MANIPULATION, WITH OR WITHOUT EXTERNAL FIXATION PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, FINGER OR 26756 26756 360 9,350.00 100.00 9,350.00 THUMB, EACH PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE (EG, COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, 25611 25611 360 25,500.00 100.00 25,500.00 WITH OR WITHOUT FRACTURE OF ULNAR STYLOID, REQUIRING MANIPULATION, WITH OR WITHOUT EXTERNAL FIXATION PERCUTANEOUS SKELETAL FIXATION OF 25671 25671 360 5,500.00 100.00 5,500.00 DISTAL RADIOULNAR DISLOCATION PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, OR SUPRACONDYLAR OR 27509 27509 360 100.00 0.00 TRANSCONDYLAR, WITH OR WITHOUT INTERCONDYLAR EXTENSION, OR DISTAL FEMORAL EPIPHYSEAL SEPARATION

PERCUTANEOUS SKELETAL FIXATION OF 27235 27235 360 100.00 0.00 FEMORAL FRACTURE, PROXIMAL END, NECK PERCUTANEOUS SKELETAL FIXATION OF FRACTURE GREAT TOE, PHALANX OR 28496 28496 360 9,350.00 100.00 9,350.00 PHALANGES, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR 24582 24582 360 100.00 0.00 LATERAL, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL 24566 24566 360 100.00 0.00 OR LATERAL, WITH MANIPULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, 26776 26776 360 9,350.00 100.00 9,350.00 SINGLE, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, WITH 28666 28666 360 9,350.00 100.00 9,350.00 MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF 26608 26608 360 9,350.00 100.00 9,350.00 METACARPAL FRACTURE, EACH BONE PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL DISLOCATION, 26706 26706 360 100.00 0.00 SINGLE, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, WITH 28476 28476 360 9,350.00 100.00 9,350.00 MANIPULATION, EACH PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT DISLOCATION, 28636 28636 360 100.00 0.00 WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC RING FRACTURE AND/OR 27216 27216 360 100.00 0.00 DISLOCATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR TRANSCONDYLAR 24538 24538 360 9,630.00 100.00 9,630.00 HUMERAL FRACTURE, WITH OR WITHOUT INTERCONDYLAR EXTENSION PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT DISLOCATION, WITH 28576 28576 360 100.00 0.00 MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF TALUS 28436 28436 360 23,950.00 100.00 23,950.00 FRACTURE, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE DISLOCATION, OTHER THAN 28546 28546 360 100.00 0.00 TALOTARSAL, WITH MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE FRACTURE (EXCEPT TALUS AND 28456 28456 360 9,350.00 100.00 9,350.00 CALCANEUS), WITH MANIPULATION, EACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, WITH 28606 28606 360 9,350.00 100.00 9,350.00 MANIPULATION PERCUTANEOUS SKELETAL FIXATION OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR 27756 27756 360 100.00 0.00 FRACTURE) (EG, PINS OR SCREWS) PERCUTANEOUS SKELETAL FIXATION OF 25651 25651 360 100.00 0.00 ULNAR STYLOID FRACTURE PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, 26727 26727 360 9,350.00 100.00 9,350.00 PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, WITH MANIPULATION, EACH

PERCUTANEOUS TREATMENT OF FRACTURE OF MALAR AREA, INCLUDING ZYGOMATIC ARCH 21355 21355 360 100.00 0.00 AND MALAR TRIPOD, WITH MANIPULATION

PERCUTANEOUS TREATMENT OF MANDIBULAR 21452 21452 360 100.00 0.00 FRACTURE, WITH EXTERNAL FIXATION

PERCUTANEOUS TREATMENT OF NASOETHMOID COMPLEX FRACTURE, WITH SPLINT, WIRE OR HEADCAP FIXATION, 21340 21340 360 100.00 0.00 INCLUDING REPAIR OF CANTHAL LIGAMENTS AND/OR THE NASOLACRIMAL APPARATUS Percutaneous Vertebroplasty and Vertebral 22514 22514 360 13,860.00 100.00 13,860.00 Augmentation Procedures PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL 22521 22521 360 13,860.00 100.00 13,860.00 INJECTION; LUMBAR PERCUTANEOUS VERTEBROPLASTY, ONE VERTEBRAL BODY, UNILATERAL OR BILATERAL 22520 22520 360 100.00 0.00 INJECTION; THORACIC PEREYRA PROCEDURE, INCLUDING ANTERIOR 57289 57289 360 100.00 0.00 COLPORRHAPHY PERICARDIOCENTESIS; INITIAL 33010 33010 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PERICARDIOCENTESIS; SUBSEQUENT 33011 33011 360 100.00 0.00 PERINEOPLASTY, REPAIR OF PERINEUM, 56810 56810 360 9,430.00 100.00 9,430.00 NONOBSTETRICAL (SEPARATE PROCEDURE) PERIODONTAL MUCOSAL GRAFTING 41870 41870 360 100.00 0.00 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; 21260 21260 360 100.00 0.00 EXTRACRANIAL APPROACH PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, WITH BONE GRAFTS; WITH 21263 21263 360 100.00 0.00 FOREHEAD ADVANCEMENT PERIPHERAL BLOOD SMEAR REVIEW 85008 85008 305 70.00 100.00 70.00 PERIPROSTHETIC CAPSULECTOMY, BREAST 19371 19371 360 13,800.00 100.00 13,800.00 PERIRECTAL INJECTION OF SCLEROSING 45520 45520 360 100.00 0.00 SOLUTION FOR PROLAPSE PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE 49080 49080 360 2,150.00 100.00 2,150.00 (DIAGNOSTIC OR THERAPEUTIC); INITIAL PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE 49081 49081 360 1,680.00 100.00 1,680.00 (DIAGNOSTIC OR THERAPEUTIC); SUBSEQUENT PERITONEOGRAM (EG, AFTER INJECTION OF AIR OR CONTRAST), RADIOLOGICAL SUPERVISION 74190 74190 320 100.00 0.00 AND INTERPRETATION PETROUS APICECTOMY INCLUDING RADICAL 69530 69530 360 100.00 0.00 MASTOIDECTOMY PHACOEMULSIFICATION/CATARACT REMOVAL 13.41 360 100.00 0.00 PHALANGECTOMY, TOE, EACH TOE 28150 28150 360 8,000.00 100.00 8,000.00 PHARMACY/DRUGS 250 250 100.00 0.00 PHARYNGOESOPHAGEAL REPAIR 42953 42953 360 100.00 0.00 PHARYNGOLARYNGECTOMY, WITH RADICAL 31390 31390 360 100.00 0.00 NECK DISSECTION; WITHOUT RECONSTRUCTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PHARYNGOPLASTY (PLASTIC OR 42950 42950 360 100.00 0.00 RECONSTRUCTIVE OPERATION ON PHARYNX) PHARYNGOSTOMY (FISTULIZATION OF 42955 42955 360 100.00 0.00 PHARYNX, EXTERNAL FOR FEEDING) PHOSPHOLIPID NEUTRALIZATION; HEXAGONAL 85598 85598 305 100.00 100.00 100.00 PHOSPHOLIPID PHOSPHOLIPID PLATELETS NEUTRALIZATION 85597 85597 305 100.00 100.00 100.00 (drVVT CONFIRMATION) PHOSPHORUS 84100 84100 301 50.00 100.00 50.00 PHYSICAL PERFORMANCE TEST OR MEASUREMENT (EG, MUSCULOSKELETAL, 97750 97750 100.00 0.00 FUNCTIONAL CAPACITY), WITH WRITTEN REPORT, EACH 15 MINUTES PHYSICAL THERAPY 420 420 100.00 0.00 PHYSICAL THERAPY EVALUATION 97001 97001 100.00 0.00

Physical therapy evaluation moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that 97162-M 97162 420 450.00 100.00 450.00 impact the plan of care; An examination of body systems using standardized tests and measures in

Physical therapy evaluation: high complexity requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact 97163-M 97163 424 500.00 100.00 500.00 the plan of care; An examination of body systems using standardized tests and measures

Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact 97163-G 97163 424 500.00 100.00 500.00 the plan of care; An examination of body systems using standardized tests and measures Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

Physical therapy evaluation: low complexity, requiring these components A history with no personal factors and/or comorbidities that impact the plan of care; An 97161-G 97161 424 400.00 100.00 400.00 examination of body system(s) using standardized tests and measures addressing 1-2 elements f

Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An 97161-M 97161 424 400.00 100.00 400.00 examination of body system(s) using standardized tests and measures addressing 1-2 elements

Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that 97162-G 97162 424 450.00 100.00 450.00 impact the plan of care; An examination of body systems using standardized tests and measures i

PHYSICAL THERAPY RE-EVALUATION 97002 97002 100.00 0.00 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL ULCER, TIP OF DIGIT, OR OTHER 15050 15050 360 3,640.00 100.00 3,640.00 MINIMAL OPEN AREA (EXCEPT ON FACE), UP TO DEFECT SIZE 2 CM DIAMETER PLACEMENT OF ADJUSTABLE SUTURE(S) DURING STRABISMUS SURGERY, INCLUDING POSTOPERATIVE ADJUSTMENT(S) OF SUTURE(S) 67335 67335 360 5,200.00 100.00 5,200.00 (LIST SEPARATELY IN ADDITION TO CODE FOR SPECIFIC STRABISMUS SURGERY) PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (EG, FOR CENTRAL VENOUS PRESSURE, 36490 36490 360 100.00 0.00 HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); CUTDOWN, AGE 2 YEARS OR UNDER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (EG, FOR CENTRAL VENOUS PRESSURE, 36491 36491 360 100.00 0.00 HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); CUTDOWN, OVER AGE 2 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (EG, FOR CENTRAL VENOUS PRESSURE, 36488 36488 360 100.00 0.00 HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); PERCUTANEOUS, AGE 2 YEARS OR UNDER PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (EG, FOR CENTRAL VENOUS PRESSURE, 36489 36489 360 100.00 0.00 HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); PERCUTANEOUS, OVER AGE 2 PLACEMENT OF CHOLEDOCHAL STENT 47801 47801 360 100.00 0.00 PLACEMENT OF DRAINS, PERIPANCREATIC, FOR 48000 48000 360 100.00 0.00 ACUTE PANCREATITIS; PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; WITH 48001 48001 360 100.00 0.00 CHOLECYSTOSTOMY, GASTROSTOMY, AND JEJUNOSTOMY PLACEMENT OF SETON 46020 46020 360 100.00 0.00 PLASTIC OPERATION OF PENIS FOR INJURY 54440 54440 360 100.00 0.00 PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (EG, 54300 54300 360 100.00 0.00 HYPOSPADIAS), WITH OR WITHOUT MOBILIZATION OF URETHRA PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR FIRST STAGE HYPOSPADIAS REPAIR WITH OR WITHOUT 54304 54304 360 100.00 0.00 TRANSPLANTATION OF PREPUCE AND/OR SKIN FLAPS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PLASTIC OPERATION ON PENIS FOR EPISPADIAS 54380 54380 360 100.00 0.00 DISTAL TO EXTERNAL SPHINCTER;

PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINCTER; WITH 54390 54390 360 100.00 0.00 EXSTROPHY OF BLADDER PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINCTER; WITH 54385 54385 360 100.00 0.00 INCONTINENCE PLASTIC OPERATION ON PENIS TO CORRECT 54360 54360 360 100.00 0.00 ANGULATION PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (EG, KELLY URETHRAL 57220 57220 360 100.00 0.00 PLICATION) PLASTIC REPAIR OF CANALICULI 68700 68700 360 100.00 0.00 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, ONE OF 40702 40702 360 100.00 0.00 TWO STAGES PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, ONE STAGE 40701 40701 360 100.00 0.00 PROCEDURE PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR COMPLETE, 40700 40700 360 100.00 0.00 UNILATERAL PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY RECREATION OF 40720 40720 360 100.00 0.00 DEFECT AND RECLOSURE PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; WITH CROSS LIP PEDICLE FLAP 40761 40761 360 100.00 0.00 (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND INSERTING OF PEDICLE PLASTIC REPAIR OF INTROITUS 56800 56800 360 100.00 0.00 PLASTIC REPAIR OF SALIVARY DUCT, 42500 42500 360 8,900.00 100.00 8,900.00 SIALODOCHOPLASTY; PRIMARY OR SIMPLE PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; SECONDARY OR 42505 42505 360 100.00 0.00 COMPLICATED Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PLASTIC REPAIR OF URETHROCELE 57230 57230 360 100.00 0.00 PLATELET COUNT 85049 85049 305 90.00 100.00 90.00 PLATELET FUNCTION ASSAY 85576 85576 302 300.00 100.00 300.00 Platelet rich plasma, each unit P9020 P9020 390 100.00 0.00 PLATELETS PHERESIS, LEUKOCYTE REDUCED P9035 P9035 306 2,300.00 100.00 2,300.00 PLEURAL SCARIFICATION FOR REPEAT 32215 32215 360 100.00 0.00 PNEUMOTHORAX PLEURECTOMY, PARIETAL (SEPARATE 32310 32310 360 100.00 0.00 PROCEDURE) PNEUMOCENTESIS, PUNCTURE OF LUNG FOR 32420 32420 360 100.00 0.00 ASPIRATION PNEUMONOLYSIS, EXTRAPERIOSTEAL, 32940 32940 360 100.00 0.00 INCLUDING FILLING OR PACKING PROCEDURES PNEUMONOSTOMY; WITH OPEN DRAINAGE OF 32200 32200 360 100.00 0.00 ABSCESS OR CYST PNEUMOTHORAX, THERAPEUTIC, 32960 32960 360 100.00 0.00 INTRAPLEURAL INJECTION OF AIR POLLICIZATION OF A DIGIT 26550 26550 360 100.00 0.00 Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended 95810 95810 920 6,250.00 100.00 6,250.00 by a technologist Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with 95811 95811 920 4,840.00 100.00 4,840.00 initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist POROUS PURIFIED COLLAGEN MATRIX BONE C9359-W C9359 278 100.00 0.00 VOID FILLER POROUS PURIFIED COLLAGEN MATRIX BONE C9359-G C9359 278 700.00 0.00 VOID FILLERS PORT, INDWELLING (IMPLANTABLE C1788-W C1788 278 100.00 0.00 PORT, INDWELLING (IMPLANTABLE) C1788-G C1788 278 700.00 0.00 PORT-A-CATH REMOVAL 36950 36950 360 4,000.00 100.00 4,000.00 PORTOENTEROSTOMY (EG, KASAI PROCEDURE) 47701 47701 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee POSTERIOR CHAMBER INTRAOCULAR LENS V2632 V2632 276 700.00 0.00 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE WITH OR WITHOUT 57250 57250 360 18,200.00 100.00 18,200.00 PERINEORRHAPHY POSTERIOR NON-SEGMENTAL INSTRUMENTATION (EG, HARRINGTON ROD TECHNIQUE, PEDICLE FIXATION ACROSS ONE 22840 22840 360 100.00 0.00 INTERSPACE, ATLANTOAXIAL TRANSARTICULAR SCREW FIXAT POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH 22844 22844 360 100.00 0.00 MULTIPLE HOOKS AND SUBLAMINAR WIRES); 13 OR MORE VERTEBRAL SEGMENTS

POSTERIOR SEGMENTAL INSTRUMENTATION (EG, PEDICLE FIXATION, DUAL RODS WITH 22842 22842 360 100.00 0.00 MULTIPLE HOOKS AND SUBLAMINAR WIRES); 3 TO 6 VERTEBRAL SEGMENTS POSTOPERATIVE BILIARY DUCT CALCULUS REMOVAL, PERCUTANEOUS VIA T-TUBE TRACT, BASKET, OR SNARE (EG, BURHENNE 74327 74327 329 100.00 0.00 TECHNIQUE), RADIOLOGICAL SUPERVISION AND IN POTASSIUM; SERUM 84132 84132 301 50.00 100.00 50.00 POTASSIUM; URINE 84133 84133 301 60.00 100.00 60.00 POWER BONE MARROW BIOPSY NEEDLE C1830-G C1830 278 700.00 0.00 POWERED BONE MARROW BIOPSY NEEDLE C1830-W C1830 278 100.00 0.00 PREALBUMIN 84134 84134 301 130.00 100.00 130.00 PREOPERATIVE PLACEMENT OF NEEDLE 19290 19290 360 710.00 100.00 710.00 LOCALIZATION WIRE, BREAST; PREOPERATIVE PLACEMENT OF NEEDLE LOCALIZATION WIRE, BREAST; EACH 19291 19291 360 100.00 0.00 ADDITIONAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PREPARATION OF MOULAGE FOR CUSTOM 19396 19396 360 100.00 0.00 BREAST IMPLANT Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an 94640 94640 460 800.00 100.00 800.00 aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure PROBING OF LACRIMAL CANALICULI, WITH OR 68840 68840 360 100.00 0.00 WITHOUT IRRIGATION PROBING OF NASOLACRIMAL DUCT, WITH OR 68810 68810 360 1,400.00 100.00 1,400.00 WITHOUT IRRIGATION; PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; REQUIRING GENERAL 68811 68811 360 7,770.00 100.00 7,770.00 ANESTHESIA PROBING OF NASOLACRIMAL DUCT, WITH OR WITHOUT IRRIGATION; WITH INSERTION OF 68815 68815 360 7,770.00 100.00 7,770.00 TUBE OR STENT PROCTOPEXY COMBINED WITH SIGMOID 45550 45550 360 100.00 0.00 RESECTION, ABDOMINAL APPROACH PROCTOPEXY FOR PROLAPSE; ABDOMINAL 45540 45540 360 100.00 0.00 APPROACH PROCTOPEXY FOR PROLAPSE; PERINEAL 45541 45541 360 100.00 0.00 APPROACH PROCTOPLASTY; FOR PROLAPSE OF MUCOUS 45505 45505 360 100.00 0.00 MEMBRANE PROCTOPLASTY; FOR STENOSIS 45500 45500 360 100.00 0.00

PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF 45300 45300 360 2,300.00 100.00 2,300.00 SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

PROCTOSIGMOIDOSCOPY, RIGID; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY 45320 45320 360 100.00 0.00 HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE (EG, LASER) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee PROCTOSIGMOIDOSCOPY, RIGID; WITH BIOPSY, 45305 45305 360 100.00 0.00 SINGLE OR MULTIPLE PROCTOSIGMOIDOSCOPY, RIGID; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, UNIPOLAR CAUTERY, 45317 45317 360 100.00 0.00 LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) PROCTOSIGMOIDOSCOPY, RIGID; WITH 45321 45321 360 100.00 0.00 DECOMPRESSION OF VOLVULUS PROCTOSIGMOIDOSCOPY, RIGID; WITH 45303 45303 360 3,800.00 100.00 3,800.00 DILATION (EG, BALLOON, GUIDE WIRE, BOUGIE) PROCTOSIGMOIDOSCOPY, RIGID; WITH 45307 45307 360 100.00 0.00 REMOVAL OF FOREIGN BODY PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF MULTIPLE TUMORS, POLYPS, OR 45315 45315 360 100.00 0.00 OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR 45308 45308 360 100.00 0.00 OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY PROCTOSIGMOIDOSCOPY, RIGID; WITH REMOVAL OF SINGLE TUMOR, POLYP, OR 45309 45309 360 100.00 0.00 OTHER LESION BY SNARE TECHNIQUE PROCTOSIGMOIDOSCOPY, RIGID; WITH TRANSENDOSCOPIC STENT PLACEMENT 45327 45327 360 100.00 0.00 (INCLUDES PREDILATION) PROGESTERONE 84144 84144 301 200.00 100.00 200.00 PROHANCE GAD BASED MR CONT A9579 A9579 320 50.00 100.00 50.00 PROLACTIN 84146 84146 301 100.00 0.00 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 27187 27187 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 27495 27495 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE, FEMUR PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 27745 27745 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE, TIBIA PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 23490 23490 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE; CLAVICLE PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 23491 23491 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE; PROXIMAL HUMERUS PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 25490 25490 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE; RADIUS PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 25492 25492 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE; RADIUS AND ULNA PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) WITH OR 25491 25491 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE; ULNA PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING), WITH OR 24498 24498 360 100.00 0.00 WITHOUT METHYLMETHACRYLATE, HUMERAL SHAFT PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) 67141 67141 360 100.00 0.00 WITHOUT DRAINAGE, ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PROPHYLAXIS OF RETINAL DETACHMENT (EG, RETINAL BREAK, LATTICE DEGENERATION) 67145 67145 360 100.00 0.00 WITHOUT DRAINAGE, ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON A PROSTATE SPECIFIC ANTIGEN (PSA); TOTAL 84153 84153 301 200.00 100.00 200.00 PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY APPROACH; 55725 55725 360 100.00 0.00 COMPLICATED PROSTATOTOMY, EXTERNAL DRAINAGE OF 55720 55720 360 100.00 0.00 PROSTATIC ABSCESS, ANY APPROACH; SIMPLE PROSTHETIC IMPLANT OR DEVICES, NOT L8699-W L8699 278 100.00 0.00 OTHERWISE SPECIFIED PROSTHETIC TRAINING, UPPER AND/OR LOWER 97520 97520 100.00 0.00 EXTREMITIES, EACH 15 MINUTES PROTEIN E- PHORESIS/URINE/CSF 84166 84166 301 150.00 100.00 150.00 PROTEIN URINE 84156 84156 301 50.00 100.00 50.00 PROTHROMBIN FACTOR 11 MUTATION 20210G 81240 81240 305 350.00 100.00 350.00 GENE ANALYSIS PROTHROMBIN TIME; 85610 85610 305 90.00 100.00 90.00 PSA FREE 84154 84154 301 150.00 100.00 150.00 PT SERVICES - OTHER 429 429 100.00 0.00 PTERYGOMAXILLARY FOSSA SURGERY, ANY 31040 31040 360 100.00 0.00 APPROACH PULMONARY FUNCTION 460 460 100.00 0.00 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 15775 15775 360 100.00 0.00 PUNCH GRAFTS PUNCH GRAFT FOR HAIR TRANSPLANT; MORE 15776 15776 360 100.00 0.00 THAN 15 PUNCH GRAFTS PUNCTURE ASPIRATION OF ABSCESS, 10160 10160 450 750.00 100.00 750.00 HEMATOMA, BULLA, OR CYST PUNCTURE ASPIRATION OF CYST OF BREAST; 19000 19000 360 2,250.00 100.00 2,250.00 PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, WITH OR WITHOUT 55000 55000 360 2,250.00 100.00 2,250.00 INJECTION OF MEDICATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

PUNCTURE OF SHUNT TUBING OR RESERVOIR 61070 61070 360 100.00 0.00 FOR ASPIRATION OR INJECTION PROCEDURE

PYLOROMYOTOMY, CUTTING OF PYLORIC 43520 43520 360 100.00 0.00 MUSCLE (FREDET-RAMSTEDT TYPE OPERATION) QUADRICEPSPLASTY (EG, BENNETT OR 27430 27430 360 17,250.00 100.00 17,250.00 THOMPSON TYPE) QUANTITATION OF DRUG NOT ELSEWHERE 80299 80299 301 830.00 100.00 830.00 SPECIFIED RADIAL KERATOTOMY 65771 65771 360 100.00 0.00 RADIAL STYLOIDECTOMY (SEPARATE 25230 25230 360 100.00 0.00 PROCEDURE) RADICAL ABDOMINAL HYSTERECTOMY, WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC 58210 58210 360 100.00 0.00 LYMPH NODE SAMPLING (BIOPSY), WITH OR WITHOUT REMOVAL OF T RADICAL EXCISION EXTERNAL AUDITORY 69155 69155 360 100.00 0.00 CANAL LESION; WITH NECK DISSECTION RADICAL EXCISION EXTERNAL AUDITORY 69150 69150 360 100.00 0.00 CANAL LESION; WITHOUT NECK DISSECTION

RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER 25116 25116 360 9,560.00 100.00 9,560.00 GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, WITH OR WITHOUT TRANSPOSITION OF DORSAL RETINACULUM RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (EG, TENOSYNOVITIS, FUNGUS, TBC, OR OTHER 25115 25115 360 9,560.00 100.00 9,560.00 GRANULOMAS, RHEUMATOID ARTHRITIS); FLEXORS RADICAL RESECTION FOR TUMOR, RADIAL 24152 24152 360 100.00 0.00 HEAD OR NECK; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; WITH AUTOGRAFT (INCLUDES 24153 24153 360 100.00 0.00 OBTAINING GRAFT) RADICAL RESECTION FOR TUMOR, RADIUS OR 25170 25170 360 6,250.00 100.00 6,250.00 ULNA RADICAL RESECTION FOR TUMOR, SHAFT OR 24150 24150 360 100.00 0.00 DISTAL HUMERUS; RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; WITH AUTOGRAFT 24151 24151 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) RADICAL RESECTION FOR TUMOR; CLAVICLE 23200 23200 360 100.00 0.00

RADICAL RESECTION FOR TUMOR; SCAPULA 23210 23210 360 100.00 0.00 RADICAL RESECTION OF BONE TUMOR, 23220 23220 360 100.00 0.00 PROXIMAL HUMERUS; RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH AUTOGRAFT 23221 23221 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) RADICAL RESECTION OF BONE TUMOR, PROXIMAL HUMERUS; WITH PROSTHETIC 23222 23222 360 100.00 0.00 REPLACEMENT RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, WITH 24149 24149 360 12,040.00 100.00 12,040.00 CONTRACTURE RELEASE (SEPARATE PROCEDURE) RADICAL RESECTION OF STERNUM; 21630 21630 360 100.00 0.00 RADICAL RESECTION OF STERNUM; WITH 21632 21632 360 100.00 0.00 MEDIASTINAL LYMPHADENECTOMY RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; 42844 42844 360 100.00 0.00 CLOSURE WITH LOCAL FLAP (EG, TONGUE, BUCCAL) RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; 42845 42845 360 100.00 0.00 CLOSURE WITH OTHER FLAP Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; 42842 42842 360 100.00 0.00 WITHOUT CLOSURE RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF BACK 21935 21935 360 100.00 0.00 OR FLANK RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF FACE 21015 21015 360 9,140.00 100.00 9,140.00 OR SCALP RADICAL RESECTION OF TUMOR (EG, 28046 28046 360 8,420.00 100.00 8,420.00 MALIGNANT NEOPLASM), SOFT TISSUE OF FOOT RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF 25077 25077 360 100.00 0.00 FOREARM AND/OR WRIST AREA RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF HAND 26117 26117 360 100.00 0.00 OR FINGER RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF LEG 27615 27615 360 8,420.00 100.00 8,420.00 OR ANKLE AREA RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF NECK 21557 21557 360 16,910.00 100.00 16,910.00 OR THORAX RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF 23077 23077 360 100.00 0.00 SHOULDER AREA RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF 27329 27329 360 9,460.00 100.00 9,460.00 THIGH OR KNEE AREA RADICAL RESECTION OF TUMOR (EG, MALIGNANT NEOPLASM), SOFT TISSUE OF 24077 24077 360 100.00 0.00 UPPER ARM OR ELBOW AREA RADICAL RESECTION OF TUMOR OR INFECTION; ILIUM, INCLUDING ACETABULUM, BOTH PUBIC 27076 27076 360 100.00 0.00 RAMI, OR ISCHIUM AND ACETABULUM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADICAL RESECTION OF TUMOR OR INFECTION; 27077 27077 360 100.00 0.00 INNOMINATE BONE, TOTAL RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY AND GREATER 27078 27078 360 100.00 0.00 TROCHANTER OF FEMUR RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY AND GREATER 27079 27079 360 100.00 0.00 TROCHANTER OF FEMUR, WITH SKIN FLAPS RADICAL RESECTION OF TUMOR OR INFECTION; WING OF ILIUM, ONE PUBIC OR ISCHIAL RAMUS 27075 27075 360 100.00 0.00 OR SYMPHYSIS PUBIS RADICAL RESECTION OF TUMOR, BONE, FEMUR 27365 27365 360 100.00 0.00 OR KNEE RADICAL RESECTION OF TUMOR, BONE; FIBULA 27646 27646 360 100.00 0.00 RADICAL RESECTION OF TUMOR, BONE; 28173 28173 360 8,420.00 100.00 8,420.00 METATARSAL RADICAL RESECTION OF TUMOR, BONE; 28175 28175 360 3,800.00 100.00 3,800.00 PHALANX OF TOE RADICAL RESECTION OF TUMOR, BONE; TALUS 27647 27647 360 100.00 0.00 OR CALCANEUS RADICAL RESECTION OF TUMOR, BONE; TARSAL 28171 28171 360 100.00 0.00 (EXCEPT TALUS OR CALCANEUS) RADICAL RESECTION OF TUMOR, BONE; TIBIA 27645 27645 360 100.00 0.00 RADICAL RESECTION OF TUMOR, SOFT TISSUE OF PELVIS AND HIP AREA (EG, MALIGNANT 27049 27049 360 100.00 0.00 NEOPLASM) RADICAL RESECTION, DISTAL PHALANX OF 26262 26262 360 100.00 0.00 FINGER (EG, TUMOR) RADICAL RESECTION, METACARPAL (EG, 26250 26250 360 100.00 0.00 TUMOR); RADICAL RESECTION, METACARPAL (EG, TUMOR); WITH AUTOGRAFT (INCLUDES 26255 26255 360 100.00 0.00 OBTAINING GRAFT) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RADICAL RESECTION, PROXIMAL OR MIDDLE 26260 26260 360 100.00 0.00 PHALANX OF FINGER (EG, TUMOR);

RADICAL RESECTION, PROXIMAL OR MIDDLE PHALANX OF FINGER (EG, TUMOR); WITH 26261 26261 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFT) RADIOLOGIC EXAMINATION FROM NOSE TO RECTUM FOR FOREIGN BODY, SINGLE VIEW, 76010 76010 320 100.00 0.00 CHILD Radiologic examination, abdomen; 1 view 74018 74018 320 500.00 100.00 500.00 Radiologic examination, abdomen; 2 views 74019 74019 329 500.00 100.00 500.00 RADIOLOGIC EXAMINATION, ABDOMEN; ANTEROPOSTERIOR AND ADDITIONAL OBLIQUE 74010 74010 320 320.00 100.00 320.00 AND CONE VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE ACUTE ABDOMEN SERIES, 74022 74022 320 450.00 100.00 450.00 INCLUDING SUPINE, ERECT, AND/OR DECUBITUS VIEWS, SINGLE VIEW CHEST RADIOLOGIC EXAMINATION, ABDOMEN; COMPLETE, INCLUDING DECUBITUS AND/OR 74020 74020 320 450.00 100.00 450.00 ERECT VIEWS RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE 74000 74000 320 300.00 100.00 300.00 ANTEROPOSTERIOR VIEW RADIOLOGIC EXAMINATION, ANKLE; 73610 73610 320 450.00 100.00 450.00 COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ANKLE; TWO 73600 73600 320 450.00 100.00 450.00 VIEWS RADIOLOGIC EXAMINATION, CHEST, COMPLETE, 71030 71030 320 300.00 100.00 300.00 MINIMUM OF FOUR VIEWS; RADIOLOGIC EXAMINATION, CHEST, COMPLETE, MINIMUM OF FOUR VIEWS; WITH 71034 71034 320 500.00 100.00 500.00 FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, SPECIAL VIEWS (EG, LATERAL DECUBITUS, BUCKY 71035 71035 320 300.00 100.00 300.00 STUDIES) RADIOLOGIC EXAMINATION, CHEST, TWO 71020 71020 320 700.00 100.00 700.00 VIEWS, FRONTAL AND LATERAL; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH 71023 71023 320 450.00 100.00 450.00 FLUOROSCOPY RADIOLOGIC EXAMINATION, CHEST, TWO VIEWS, FRONTAL AND LATERAL; WITH OBLIQUE 71022 71022 324 300.00 100.00 300.00 PROJECTIONS RADIOLOGIC EXAMINATION, CHEST, TWO 87.44 360 100.00 0.00 VIEWS, FRONTAL AND LATERAL;. Radiologic examination, chest; 2 views 71046 71046 324 700.00 100.00 700.00 Radiologic examination, chest; single view 71045 71045 324 600.00 100.00 600.00 RADIOLOGIC EXAMINATION, CHEST; SINGLE 71010 71010 320 600.00 100.00 600.00 VIEW, FRONTAL RADIOLOGIC EXAMINATION, CHEST; STEREO, 71015 71015 324 100.00 0.00 FRONTAL RADIOLOGIC EXAMINATION, COLON; AIR CONTRAST WITH SPECIFIC HIGH DENSITY 74280 74280 320 100.00 0.00 BARIUM, WITH OR WITHOUT GLUCAGON RADIOLOGIC EXAMINATION, COLON; BARIUM 74270 74270 320 1,080.00 100.00 1,080.00 ENEMA, WITH OR WITHOUT KUB RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, 76102 76102 329 100.00 0.00 MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; BILATERAL

RADIOLOGIC EXAMINATION, COMPLEX MOTION (IE, HYPERCYCLOIDAL) BODY SECTION (EG, 76101 76101 329 100.00 0.00 MASTOID POLYTOMOGRAPHY), OTHER THAN WITH UROGRAPHY; UNILATERAL RADIOLOGIC EXAMINATION, ELBOW, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION 73085 73085 320 1,550.00 100.00 1,550.00 AND INTERPRETATION RADIOLOGIC EXAMINATION, ELBOW; 73080 73080 320 390.00 100.00 390.00 COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, ELBOW; TWO 73070 73070 320 300.00 100.00 300.00 VIEWS RADIOLOGIC EXAMINATION, EYE, FOR 70030 70030 320 350.00 100.00 350.00 DETECTION OF FOREIGN BODY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RADIOLOGIC EXAMINATION, FACIAL BONES; 70150 70150 320 450.00 100.00 450.00 COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FACIAL BONES; 70140 70140 320 360.00 100.00 360.00 LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, FEMUR, TWO 73550 73550 320 100.00 0.00 VIEWS RADIOLOGIC EXAMINATION, FINGER(S), 73140 73140 320 300.00 100.00 300.00 MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, FOOT; COMPLETE, 73630 73630 320 300.00 100.00 300.00 MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, FOOT; TWO VIEWS 73620 73620 320 300.00 100.00 300.00 RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR 74241 74241 320 100.00 0.00 WITHOUT DELAYED FILMS, WITH KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH OR 74240 74240 320 700.00 100.00 700.00 WITHOUT DELAYED FILMS, WITHOUT KUB RADIOLOGIC EXAMINATION, GASTROINTESTINAL TRACT, UPPER; WITH 74245 74245 320 1,130.00 100.00 1,130.00 SMALL INTESTINE, INCLUDES MULTIPLE SERIAL FILMS RADIOLOGIC EXAMINATION, HAND; MINIMUM 73130 73130 320 300.00 100.00 300.00 OF THREE VIEWS RADIOLOGIC EXAMINATION, HAND; TWO VIEWS 73120 73120 320 100.00 0.00 RADIOLOGIC EXAMINATION, HIP, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION 73525 73525 320 1,550.00 100.00 1,550.00 AND INTERPRETATION RADIOLOGIC EXAMINATION, HIP, DURING 73530 73530 320 100.00 0.00 OPERATIVE PROCEDURE RADIOLOGIC EXAMINATION, HIP, UNILATERAL; 73510 73510 320 100.00 0.00 COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, HIP, UNILATERAL; 73500 73500 320 100.00 0.00 ONE VIEW Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION, HIPS, BILATERAL, MINIMUM OF TWO VIEWS OF EACH HIP, 73520 73520 320 100.00 0.00 INCLUDING ANTEROPOSTERIOR VIEW OF PELVIS RADIOLOGIC EXAMINATION, INTERNAL 70134 70134 320 100.00 0.00 AUDITORY MEATI, COMPLETE RADIOLOGIC EXAMINATION, KNEE, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION 73580 73580 320 1,550.00 100.00 1,550.00 AND INTERPRETATION RADIOLOGIC EXAMINATION, KNEE; BOTH 73565 73565 320 300.00 100.00 300.00 KNEES, STANDING, ANTEROPOSTERIOR RADIOLOGIC EXAMINATION, KNEE; COMPLETE, 73564 73564 320 450.00 100.00 450.00 FOUR OR MORE VIEWS RADIOLOGIC EXAMINATION, KNEE; ONE OR 73560 73560 320 300.00 100.00 300.00 TWO VIEWS RADIOLOGIC EXAMINATION, KNEE; THREE 73562 73562 320 450.00 100.00 450.00 VIEWS RADIOLOGIC EXAMINATION, MANDIBLE; 70110 70110 320 450.00 100.00 450.00 COMPLETE, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, MANDIBLE; 70100 70100 320 450.00 100.00 450.00 PARTIAL, LESS THAN FOUR VIEWS RADIOLOGIC EXAMINATION, MASTOIDS; COMPLETE, MINIMUM OF THREE VIEWS PER 70130 70130 320 100.00 0.00 SIDE RADIOLOGIC EXAMINATION, MASTOIDS; LESS 70120 70120 320 100.00 0.00 THAN THREE VIEWS PER SIDE RADIOLOGIC EXAMINATION, NASAL BONES, 70160 70160 320 300.00 100.00 300.00 COMPLETE, MINIMUM OF THREE VIEWS

RADIOLOGIC EXAMINATION, PELVIS AND HIPS, 73540 73540 320 410.00 100.00 410.00 INFANT OR CHILD, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, PELVIS; 72190 72190 320 500.00 100.00 500.00 COMPLETE, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, PELVIS; ONE OR 72170 72170 320 450.00 100.00 450.00 TWO VIEWS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION, RENAL CYST STUDY, TRANSLUMBAR, CONTRAST 74470 74470 320 100.00 0.00 VISUALIZATION, RADIOLOGICAL SUPERVISION AND INTERPRETATION RADIOLOGIC EXAMINATION, RIBS, BILATERAL; INCLUDING POSTEROANTERIOR CHEST, 71111 71111 320 520.00 100.00 520.00 MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, RIBS, BILATERAL; 71110 71110 320 580.00 100.00 580.00 THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, UNILATERAL; INCLUDING POSTEROANTERIOR 71101 71101 320 490.00 100.00 490.00 CHEST, MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, RIBS, 71100 71100 320 430.00 100.00 430.00 UNILATERAL; TWO VIEWS RADIOLOGIC EXAMINATION, SACROILIAC 72200 72200 320 300.00 100.00 300.00 JOINTS; LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SACROILIAC 72202 72202 320 450.00 100.00 450.00 JOINTS; THREE OR MORE VIEWS RADIOLOGIC EXAMINATION, SACRUM AND 72220 72220 320 300.00 100.00 300.00 COCCYX, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, SALIVARY GLAND 70380 70380 320 100.00 0.00 FOR CALCULUS RADIOLOGIC EXAMINATION, SELLA TURCICA 70240 70240 320 100.00 0.00 RADIOLOGIC EXAMINATION, SHOULDER, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION 73040 73040 320 1,550.00 100.00 1,550.00 AND INTERPRETATION RADIOLOGIC EXAMINATION, SHOULDER; 73030 73030 320 450.00 100.00 450.00 COMPLETE, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION, SHOULDER; ONE 73020 73020 320 300.00 100.00 300.00 VIEW RADIOLOGIC EXAMINATION, SINGLE PLANE BODY SECTION (EG, TOMOGRAPHY), OTHER 76100 76100 329 100.00 0.00 THAN WITH UROGRAPHY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION, SINUSES, PARANASAL, COMPLETE, MINIMUM OF THREE 70220 70220 320 590.00 100.00 590.00 VIEWS RADIOLOGIC EXAMINATION, SINUSES, 70210 70210 320 100.00 0.00 PARANASAL, LESS THAN THREE VIEWS RADIOLOGIC EXAMINATION, SKULL; COMPLETE, MINIMUM OF FOUR VIEWS, WITH OR 70260 70260 320 560.00 100.00 560.00 WITHOUT STEREO RADIOLOGIC EXAMINATION, SKULL; LESS THAN 70250 70250 320 450.00 100.00 450.00 FOUR VIEWS, WITH OR WITHOUT STEREO

RADIOLOGIC EXAMINATION, SMALL INTESTINE, 74250 74250 320 790.00 100.00 790.00 INCLUDES MULTIPLE SERIAL FILMS; RADIOLOGIC EXAMINATION, SMALL INTESTINE, INCLUDES MULTIPLE SERIAL FILMS; VIA 74251 74251 320 100.00 0.00 ENTEROCLYSIS TUBE RADIOLOGIC EXAMINATION, SPINE, CERVICAL; COMPLETE, INCLUDING OBLIQUE AND FLEXION 72052 72052 320 640.00 100.00 640.00 AND/OR EXTENSION STUDIES RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 72050 72050 320 540.00 100.00 540.00 MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, CERVICAL; 72040 72040 320 450.00 100.00 450.00 TWO OR THREE VIEWS RADIOLOGIC EXAMINATION, SPINE, ENTIRE, SURVEY STUDY, ANTEROPOSTERIOR AND 72010 72010 100.00 0.00 LATERAL RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL, BENDING VIEWS ONLY, 72120 72120 320 560.00 100.00 560.00 MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, LUMBOSACRAL; COMPLETE, INCLUDING 72114 72114 320 720.00 100.00 720.00 BENDING VIEWS RADIOLOGIC EXAMINATION, SPINE, 72110 72110 320 580.00 100.00 580.00 LUMBOSACRAL; MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE, 72100 72100 320 450.00 100.00 450.00 LUMBOSACRAL; TWO OR THREE VIEWS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION, SPINE, SINGLE 72020 72020 320 300.00 100.00 300.00 VIEW, SPECIFY LEVEL RADIOLOGIC EXAMINATION, SPINE, 72069 72069 320 100.00 0.00 THORACOLUMBAR, STANDING (SCOLIOSIS) RADIOLOGIC EXAMINATION, SPINE; SCOLIOSIS STUDY, INCLUDING SUPINE AND ERECT 72090 72090 320 100.00 0.00 STUDIES RADIOLOGIC EXAMINATION, SPINE; THORACIC, 72074 72074 320 500.00 100.00 500.00 MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION, SPINE; THORACIC, 72072 72072 320 460.00 100.00 460.00 THREE VIEWS RADIOLOGIC EXAMINATION, SPINE; THORACIC, 72070 72070 320 450.00 100.00 450.00 TWO VIEWS RADIOLOGIC EXAMINATION, SPINE; 72080 72080 320 430.00 100.00 430.00 THORACOLUMBAR, TWO VIEWS RADIOLOGIC EXAMINATION, TEETH; PARTIAL 70310 70310 320 100.00 0.00 EXAMINATION, LESS THAN FULL MOUTH RADIOLOGIC EXAMINATION, TEETH; SINGLE 70300 70300 320 100.00 0.00 VIEW RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 70330 70330 320 100.00 0.00 CLOSED MOUTH; BILATERAL RADIOLOGIC EXAMINATION, TEMPOROMANDIBULAR JOINT, OPEN AND 70328 70328 320 100.00 0.00 CLOSED MOUTH; UNILATERAL RADIOLOGIC EXAMINATION, WRIST, ARTHROGRAPHY, RADIOLOGICAL SUPERVISION 73115 73115 320 1,550.00 100.00 1,550.00 AND INTERPRETATION RADIOLOGIC EXAMINATION, WRIST; COMPLETE, 73110 73110 320 300.00 100.00 300.00 MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION, WRIST; TWO 73100 73100 320 320.00 100.00 320.00 VIEWS RADIOLOGIC EXAMINATION; ACROMIOCLAVICULAR JOINTS, BILATERAL, 73050 73050 320 460.00 100.00 460.00 WITH OR WITHOUT WEIGHTED DISTRACTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGIC EXAMINATION; CALCANEUS, 73650 73650 320 300.00 100.00 300.00 MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; CLAVICLE, 73000 73000 320 300.00 100.00 300.00 COMPLETE RADIOLOGIC EXAMINATION; ESOPHAGUS 74220 74220 320 530.00 100.00 530.00 RADIOLOGIC EXAMINATION; FOREARM, TWO 73090 73090 320 300.00 100.00 300.00 VIEWS RADIOLOGIC EXAMINATION; HUMERUS, 73060 73060 320 330.00 100.00 330.00 MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; LOWER 73592 73592 320 100.00 0.00 EXTREMITY, INFANT, MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; NECK, SOFT 70360 70360 320 320.00 100.00 320.00 TISSUE RADIOLOGIC EXAMINATION; OPTIC FORAMINA 70190 70190 320 100.00 0.00 RADIOLOGIC EXAMINATION; ORBITS, 70200 70200 320 510.00 100.00 510.00 COMPLETE, MINIMUM OF FOUR VIEWS RADIOLOGIC EXAMINATION; PHARYNX AND/OR 74210 74210 320 100.00 0.00 CERVICAL ESOPHAGUS RADIOLOGIC EXAMINATION; PHARYNX OR LARYNX, INCLUDING FLUOROSCOPY AND/OR 70370 70370 320 100.00 0.00 MAGNIFICATION TECHNIQUE RADIOLOGIC EXAMINATION; SCAPULA, 73010 73010 320 400.00 100.00 400.00 COMPLETE RADIOLOGIC EXAMINATION; STERNOCLAVICULAR JOINT OR JOINTS, 71130 71130 320 500.00 100.00 500.00 MINIMUM OF THREE VIEWS RADIOLOGIC EXAMINATION; STERNUM, 71120 71120 320 460.00 100.00 460.00 MINIMUM OF TWO VIEWS RADIOLOGIC EXAMINATION; TIBIA AND FIBULA, 73590 73590 320 300.00 100.00 300.00 TWO VIEWS RADIOLOGIC EXAMINATION; TOE(S), MINIMUM 73660 73660 320 300.00 100.00 300.00 OF TWO VIEWS RADIOLOGIC EXAMINATION; UPPER 73092 73092 320 100.00 0.00 EXTREMITY, INFANT, MINIMUM OF TWO VIEWS Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY 74247 74247 320 970.00 100.00 970.00 BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCA16907 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY 74249 74249 320 1,510.00 100.00 1,510.00 BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCA16908 RADIOLOGICAL EXAMINATION, GASTROINTESTINAL TRACT, UPPER, AIR CONTRAST, WITH SPECIFIC HIGH DENSITY 74246 74246 320 940.00 100.00 940.00 BARIUM, EFFERVESCENT AGENT, WITH OR WITHOUT GLUCAGON RADIOLOGICAL EXAMINATION, SACROILIAC JOINT ARTHROGRAPHY, RADIOLOGICAL 73542 73542 320 100.00 0.00 SUPERVISION AND INTERPRETATION RADIOLOGICAL EXAMINATION, SURGICAL 76098 76098 329 100.00 0.00 SPECIMEN RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 76013 76013 320 100.00 0.00 VERTEBROPLASTY, PER VERTEBRAL BODY; UNDER CT GUIDANCE RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS 76012 76012 320 100.00 0.00 VERTEBROPLASTY, PER VERTEBRAL BODY; UNDER FLUOROSCOPIC GUIDANCE RADIOLOGY 329 329 100.00 0.00 RBC 85041 85041 305 90.00 100.00 90.00 RBC PRETREATMENT; DENSITY GRADIENT 86972 86972 306 600.00 100.00 600.00 RBCs IRRADIATED, EACH UNIT P9038 P9038 390 1,000.00 100.00 1,000.00 REALIGNMENT OF EXTENSOR TENDON, HAND, 26437 26437 360 100.00 0.00 EACH TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION (ADVANCEMENT), POSTERIOR TIBIAL TENDON WITH EXCISION OF 28238 28238 360 23,900.00 100.00 23,900.00 ACCESSORY TARSAL NAVICULAR BONE (EG, KIDNER TYPE PROCEDURE) RECONSTRUCTION BY CONTOURING OF BENIGN TUMOR OF CRANIAL BONES (EG, FIBROUS 21181 21181 360 100.00 0.00 DYSPLASIA), EXTRACRANIAL RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL ATRESIA, SINGLE 69320 69320 360 21,310.00 100.00 21,310.00 STAGE RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JOINT, SECONDARY BY SOFT TISSUE STABILIZATION (EG, TENDON 25337 25337 360 11,050.00 100.00 11,050.00 TRANSFER, TENDON GRAFT OR WEAVE, OR TENODESIS) WITH OR WITHOUT OPEN REDUCTION OF DISTAL RADIOULNAR JOINT RECONSTRUCTION LATERAL COLLATERAL LIGAMENT, ELBOW, WITH TENDON GRAFT 24344 24344 360 17,250.00 100.00 17,250.00 (INCLUDES HARVESTING OF GRAFT) RECONSTRUCTION MEDIAL COLLATERAL LIGAMENT, ELBOW, WITH TENDON GRAFT 24346 24346 360 100.00 0.00 (INCLUDES HARVESTING OF GRAFT) RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY 21141 21141 360 100.00 0.00 DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY 21145 21145 360 100.00 0.00 DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY 21147 21147 360 100.00 0.00 DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY 21143 21143 360 100.00 0.00 DIRECTION, WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS 21146 21146 360 100.00 0.00 (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY 21142 21142 360 100.00 0.00 DIRECTION, WITHOUT BONE GRAFT RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS 21150 21150 360 100.00 0.00 SYNDROME) RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS 21151 21151 360 100.00 0.00 (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD 21160 21160 360 100.00 0.00 ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AU14039

RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD 21159 21159 360 100.00 0.00 ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOG RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE 21155 21155 360 100.00 0.00 GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE 21154 21154 360 100.00 0.00 GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS 21188 21188 360 100.00 0.00 (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, CHRONIC 23420 23420 360 17,250.00 100.00 17,250.00 (INCLUDES ACROMIOPLASTY) RECONSTRUCTION OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, CHRONIC 83.63 360 100.00 0.00 (INCLUDES ACROMIOPLASTY) (MS) RECONSTRUCTION OF DISLOCATING PATELLA; 27420 27420 360 100.00 0.00 (EG, HAUSER TYPE PROCEDURE) RECONSTRUCTION OF DISLOCATING PATELLA; WITH EXTENSOR REALIGNMENT AND/OR 27422 27422 360 17,250.00 100.00 17,250.00 MUSCLE ADVANCEMENT OR RELEASE (EG, CAMPBELL, GOLDWAITE TYPE PROCEDURE) RECONSTRUCTION OF DISLOCATING PATELLA; 27424 27424 360 100.00 0.00 WITH PATELLECTOMY RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (EG, FOR STENOSIS DUE 69310 69310 360 17,100.00 100.00 17,100.00 TO INJURY, INFECTION) (SEPARATE PROCEDURE) RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP 67975 67975 360 100.00 0.00 FROM OPPOSING EYELID; SECOND STAGE

RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP 67973 67973 360 100.00 0.00 FROM OPPOSING EYELID; TOTAL EYELID, LOWER, ONE STAGE OR FIRST STAGE

RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP 67974 67974 360 100.00 0.00 FROM OPPOSING EYELID; TOTAL EYELID, UPPER, ONE STAGE OR FIRST STAGE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP 67971 67971 360 100.00 0.00 FROM OPPOSING EYELID; UP TO TWO-THIRDS OF EYELID, ONE STAGE OR FIRST STAGE RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); 21249 21249 360 100.00 0.00 COMPLETE RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (EG, BLADE, CYLINDER); 21248 21248 360 100.00 0.00 PARTIAL RECONSTRUCTION OF MANDIBLE OR MAXILLA, 21246 21246 360 100.00 0.00 SUBPERIOSTEAL IMPLANT; COMPLETE

RECONSTRUCTION OF MANDIBLE OR MAXILLA, 21245 21245 360 100.00 0.00 SUBPERIOSTEAL IMPLANT; PARTIAL

RECONSTRUCTION OF MANDIBLE, EXTRAORAL, WITH TRANSOSTEAL BONE PLATE (EG, 21244 21244 360 100.00 0.00 MANDIBULAR STAPLE BONE PLATE)

RECONSTRUCTION OF MANDIBULAR CONDYLE WITH BONE AND CARTILAGE AUTOGRAFTS 21247 21247 360 100.00 0.00 (INCLUDES OBTAINING GRAFTS) (EG, FOR HEMIFACIAL MICROSOMIA) RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITH 21196 21196 360 100.00 0.00 INTERNAL RIGID FIXATION RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT 21195 21195 360 100.00 0.00 INTERNAL RIGID FIXATION RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, C, OR L OSTEOTOMY; 21193 21193 360 100.00 0.00 WITHOUT BONE GRAFT RECONSTRUCTION OF NAIL BED WITH GRAFT 11762 11762 360 21,720.00 100.00 21,720.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION OF ORBIT WITH OSTEOTOMIES (EXTRACRANIAL) AND WITH 21256 21256 360 100.00 0.00 BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, MICRO-OPHTHALMIA) RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL 21182 21182 360 100.00 0.00 EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG, F RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL 21183 21183 360 100.00 0.00 EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG14046 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA- AND EXTRACRANIAL 21184 21184 360 100.00 0.00 EXCISION OF BENIGN TUMOR OF CRANIAL BONE (EG14047 RECONSTRUCTION OF POLYDACTYLOUS DIGIT, 26587 26587 360 100.00 0.00 SOFT TISSUE AND BONE RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH LOCAL TISSUES (SEPARATE 26500 26500 360 100.00 0.00 PROCEDURE) RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH TENDON OR FASCIAL GRAFT 26502 26502 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) (SEPARATE PROCEDURE) RECONSTRUCTION OF TENDON PULLEY, EACH TENDON; WITH TENDON PROSTHESIS 26504 26504 360 100.00 0.00 (SEPARATE PROCEDURE) RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA WITH BONE AND CARTILAGE 21255 21255 360 100.00 0.00 (INCLUDES OBTAINING AUTOGRAFTS) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, WITH OR 21172 21172 360 100.00 0.00 WITHOUT GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) RECONSTRUCTION, ANGULAR DEFORMITY OF TOE, SOFT TISSUE PROCEDURES ONLY (EG, 28313 28313 360 8,000.00 100.00 8,000.00 OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES) RECONSTRUCTION, BIFRONTAL, SUPERIOR- LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION 21175 21175 360 100.00 0.00 (EG, PLAGIOCEPHALY, TRIGONOCEPHALY, BRACHYCEPHA RECONSTRUCTION, CLEFT FOOT 28360 28360 360 100.00 0.00 RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL JOINT, SINGLE, INCLUDING 26545 26545 360 100.00 0.00 GRAFT, EACH JOINT RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE; WITH 26542 26542 360 3,000.00 100.00 3,000.00 LOCAL TISSUE (EG, ADDUCTOR ADVANCEMENT) RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE; WITH 26541 26541 360 11,690.00 100.00 11,690.00 TENDON OR FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH 21180 21180 360 100.00 0.00 AUTOGRAFT (INCLUDES OBTAINING GRAFTS) RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; WITH 21179 21179 360 100.00 0.00 GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC BILIARY DUCTS WITH END-TO-END 47800 47800 360 100.00 0.00 ANASTOMOSIS RECONSTRUCTION, TOE(S); POLYDACTYLY 28344 28344 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RECONSTRUCTION, TOE(S); SYNDACTYLY, WITH 28345 28345 360 100.00 0.00 OR WITHOUT SKIN GRAFT(S), EACH WEB RECONSTRUCTION, TOE, MACRODACTYLY; 28341 28341 360 100.00 0.00 REQUIRING BONE RESECTION RECONSTRUCTION, TOE, MACRODACTYLY; 28340 28340 360 100.00 0.00 SOFT TISSUE RESECTION RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY 21743 21743 360 100.00 0.00 INVASIVE APPROACH (NUSS PROCEDURE), WITH THORACOSCOPY RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM; MINIMALLY 21742 21742 360 100.00 0.00 INVASIVE APPROACH (NUSS PROCEDURE), WITHOUT THORACOSCOPY RECONSTRUCTIVE REPAIR OF PECTUS 21740 21740 360 100.00 0.00 EXCAVATUM OR CARINATUM; OPEN RED BLOOD CELLS UNIT P9021 P9021 390 710.00 100.00 710.00 RED BLOOD COUNT VOLUME DETERMINATION 1 78120 78120 320 2,900.00 100.00 2,900.00 SAMPLE REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR 21138 21138 360 100.00 0.00 BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) REDUCTION FOREHEAD; CONTOURING AND 21139 21139 360 100.00 0.00 SETBACK OF ANTERIOR FRONTAL SINUS WALL

REDUCTION FOREHEAD; CONTOURING ONLY 21137 21137 360 100.00 0.00 REDUCTION MAMMAPLASTY 19318 19318 360 19,000.00 100.00 19,000.00 REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC 21295 21295 360 100.00 0.00 HYPERTROPHY); EXTRAORAL APPROACH

REDUCTION OF MASSETER MUSCLE AND BONE (EG, FOR TREATMENT OF BENIGN MASSETERIC 21296 21296 360 100.00 0.00 HYPERTROPHY); INTRAORAL APPROACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REDUCTION OF OVERCORRECTION OF PTOSIS 67909 67909 360 100.00 0.00 REDUCTION OF PROCIDENTIA (SEPARATE 45900 45900 360 100.00 0.00 PROCEDURE) UNDER ANESTHESIA REDUCTION OF TORSION OF TESTIS, SURGICAL, WITH OR WITHOUT FIXATION OF 54600 54600 360 100.00 0.00 CONTRALATERAL TESTIS REINSERTION OF OCULAR IMPLANT; WITH OR 65150 65150 360 100.00 0.00 WITHOUT CONJUNCTIVAL GRAFT REINSERTION OF OCULAR IMPLANT; WITH USE OF FOREIGN MATERIAL FOR REINFORCEMENT 65155 65155 360 100.00 0.00 AND/OR ATTACHMENT OF MUSCLES TO IMPLANT REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, WITH OR WITHOUT TENDON 24342 24342 360 17,250.00 100.00 17,250.00 GRAFT REINSERTION OF SPINAL FIXATION DEVICE 22849 22849 360 41,550.00 100.00 41,550.00 RELEASE OF ENCIRCLING MATERIAL 67115 67115 360 100.00 0.00 (POSTERIOR SEGMENT) RELEASE OF EXTENSIVE SCAR TISSUE WITHOUT DETACHING EXTRAOCULAR MUSCLE 67343 67343 360 100.00 0.00 (SEPARATE PROCEDURE) RELEASE OF SCAR CONTRACTURE, FLEXOR OR EXTENSOR, WITH SKIN GRAFTS, 26597 360 100.00 0.00 REARRANGEMENT FLAPS, OR Z-PLASTIES, HAND AND/OR FINGER RELEASE OF THENAR MUSCLE(S) (EG, THUMB 26508 26508 360 100.00 0.00 CONTRACTURE) RELEASE OR RECESSION, HAMSTRING, 27097 27097 360 11,900.00 100.00 11,900.00 PROXIMAL RELEASE, INTRINSIC MUSCLES OF HAND, EACH 26593 26593 360 100.00 0.00 MUSCLE RELEASE, TARSAL TUNNEL (POSTERIOR TIBIAL 28035 28035 360 8,420.00 100.00 8,420.00 NERVE DECOMPRESSION) REMOVAL AND REPLACEMENT OF ALL COMPONENT(S) OF A MULTI-COMPONENT, 54410 54410 360 100.00 0.00 INFLATABLE PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL AND REPLACEMENT OF ALL COMPONENTS OF A MULTI-COMPONENT INFLATABLE PENILE PROSTHESIS THROUGH AN 54411 54411 360 100.00 0.00 INFECTED FIELD AT THE SAME OPERATIVE SESSION, I REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER 53447 53447 360 100.00 0.00 INCLUDING PUMP, RESERVOIR, AND CUFF AT THE SAME OPERATIVE SESSION REMOVAL AND REPLACEMENT OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER INCLUDING PUMP, RESERVOIR, AND CUFF 53448 53448 360 100.00 0.00 THROUGH AN INFECTED FIELD AT THE SAME OPERAT REMOVAL AND REPLACEMENT OF NON- INFLATABLE (SEMI-RIGID) OR INFLATABLE 54416 54416 360 100.00 0.00 (SELF-CONTAINED) PENILE PROSTHESIS AT THE SAME OPERATIVE SESSION REMOVAL AND REPLACEMENT OF NON- INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE PROSTHESIS 54417 54417 360 100.00 0.00 THROUGH AN INFECTED FIELD AT THE SAME OPERATIV REMOVAL BY CONTOURING OF BENIGN TUMOR 21029 21029 360 100.00 0.00 OF FACIAL BONE (EG, FIBROUS DYSPLASIA) REMOVAL FOREIGN BODY FROM DEEP PENILE 54115 54115 360 100.00 0.00 TISSUE (EG, PLASTIC IMPLANT) REMOVAL FOREIGN BODY FROM EXTERNAL 69205 69205 360 100.00 0.00 AUDITORY CANAL; WITH GENERAL ANESTHESIA REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; WITHOUT GENERAL 69200 69200 360 100.00 0.00 ANESTHESIA REMOVAL FOREIGN BODY, INTRANASAL; BY 30320 30320 360 100.00 0.00 LATERAL RHINOTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL FOREIGN BODY, INTRANASAL; 30300 30300 360 100.00 0.00 OFFICE TYPE PROCEDURE REMOVAL FOREIGN BODY, INTRANASAL; 30310 30310 360 5,800.00 100.00 5,800.00 REQUIRING GENERAL ANESTHESIA REMOVAL IMPACTED CERUMEN (SEPARATE 69210 69210 360 380.00 100.00 380.00 PROCEDURE), ONE OR BOTH EARS

REMOVAL OF ALL COMPONENTS OF A MULTI- COMPONENT, INFLATABLE PENILE PROSTHESIS 54406 54406 360 100.00 0.00 WITHOUT REPLACEMENT OF PROSTHESIS

REMOVAL OF ANAL SETON, OTHER MARKER 46030 46030 360 100.00 0.00 REMOVAL OF ANKLE IMPLANT 27704 27704 360 7,600.00 100.00 7,600.00 REMOVAL OF ANTERIOR INSTRUMENTATION 22855 22855 360 100.00 0.00 REMOVAL OF BLOOD CLOT, ANTERIOR 65930 65930 360 100.00 0.00 SEGMENT OF EYE REMOVAL OF CERCLAGE SUTURE UNDER 59871 59871 360 100.00 0.00 ANESTHESIA (OTHER THAN LOCAL) REMOVAL OF COMPLETE CSF SHUNT SYSTEM; 62256 62256 360 100.00 0.00 WITHOUT REPLACEMENT REMOVAL OF CORNEAL EPITHELIUM; WITH 65436 65436 360 100.00 0.00 APPLICATION OF CHELATING AGENT (EG, EDTA) REMOVAL OF CORNEAL EPITHELIUM; WITH OR WITHOUT CHEMOCAUTERIZATION (ABRASION, 65435 65435 360 100.00 0.00 CURETTAGE) REMOVAL OF EMBEDDED FOREIGN BODY FROM 41806 41806 360 100.00 0.00 DENTOALVEOLAR STRUCTURES; BONE

REMOVAL OF EMBEDDED FOREIGN BODY FROM 41805 41805 360 100.00 0.00 DENTOALVEOLAR STRUCTURES; SOFT TISSUES REMOVAL OF EMBEDDED FOREIGN BODY, 67938 67938 360 100.00 0.00 EYELID REMOVAL OF EMBEDDED FOREIGN BODY, 40805 40805 360 8,900.00 100.00 8,900.00 VESTIBULE OF MOUTH; COMPLICATED Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OF EMBEDDED FOREIGN BODY, 40804 40804 360 100.00 0.00 VESTIBULE OF MOUTH; SIMPLE REMOVAL OF ENTIRE LUMBOSUBARACHNOID 63746 63746 360 100.00 0.00 SHUNT SYSTEM WITHOUT REPLACEMENT REMOVAL OF EPITHELIAL DOWNGROWTH, 65900 65900 360 100.00 0.00 ANTERIOR CHAMBER OF EYE Removal of esophageal sphincter augmentation device 43285 43285 360 17,500.00 100.00 17,500.00 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY (SEPARATE PROCEDURE) UNDER 45915 45915 360 100.00 0.00 ANESTHESIA REMOVAL OF FOREIGN BODY IN MUSCLE OR 20525 20525 360 8,350.00 100.00 8,350.00 TENDON SHEATH; DEEP OR COMPLICATED REMOVAL OF FOREIGN BODY IN MUSCLE OR 20520 20520 360 3,800.00 100.00 3,800.00 TENDON SHEATH; SIMPLE REMOVAL OF FOREIGN BODY IN SCROTUM 55120 55120 360 100.00 0.00 REMOVAL OF FOREIGN BODY OR DACRYOLITH, 68530 68530 360 100.00 0.00 LACRIMAL PASSAGES REMOVAL OF FOREIGN BODY(S), ESOPHAGEAL, WITH USE OF BALLOON CATHETER, 74235 74235 320 100.00 0.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION REMOVAL OF FOREIGN BODY, DEEP, THIGH 27372 27372 360 100.00 0.00 REGION OR KNEE AREA REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL EMBEDDED (INCLUDES 65210 65210 360 100.00 0.00 CONCRETIONS), SUBCONJUNCTIVAL, OR SCLERAL NONPERFORATING REMOVAL OF FOREIGN BODY, EXTERNAL EYE; 65205 65205 360 500.00 100.00 500.00 CONJUNCTIVAL SUPERFICIAL REMOVAL OF FOREIGN BODY, EXTERNAL EYE; 65222 65222 360 100.00 0.00 CORNEAL, WITH SLIT LAMP REMOVAL OF FOREIGN BODY, EXTERNAL EYE; 65220 65220 360 500.00 100.00 500.00 CORNEAL, WITHOUT SLIT LAMP Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OF FOREIGN BODY, FOOT; 28193 28193 360 6,320.00 100.00 6,320.00 COMPLICATED REMOVAL OF FOREIGN BODY, FOOT; DEEP 28192 28192 360 6,150.00 100.00 6,150.00 REMOVAL OF FOREIGN BODY, FOOT; 28190 28190 360 3,800.00 100.00 3,800.00 SUBCUTANEOUS REMOVAL OF FOREIGN BODY, INTRAOCULAR; 65235 65235 360 100.00 0.00 FROM ANTERIOR CHAMBER OF EYE OR LENS

REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR SEGMENT, MAGNETIC 65260 65260 360 100.00 0.00 EXTRACTION, ANTERIOR OR POSTERIOR ROUTE REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR SEGMENT, NONMAGNETIC 65265 65265 360 100.00 0.00 EXTRACTION REMOVAL OF FOREIGN BODY, PELVIS OR HIP; 27087 27087 360 100.00 0.00 DEEP (SUBFASCIAL OR INTRAMUSCULAR) REMOVAL OF FOREIGN BODY, PELVIS OR HIP; 27086 27086 360 100.00 0.00 SUBCUTANEOUS TISSUE REMOVAL OF FOREIGN BODY, SHOULDER; 23332 23332 360 100.00 0.00 COMPLICATED (EG, TOTAL SHOULDER) REMOVAL OF FOREIGN BODY, SHOULDER; DEEP 23331 23331 360 100.00 0.00 (EG, NEER HEMIARTHROPLASTY REMOVAL) REMOVAL OF FOREIGN BODY, SHOULDER; 23330 23330 360 100.00 0.00 SUBCUTANEOUS REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA; DEEP (SUBFASCIAL OR 24201 24201 360 11,660.00 100.00 11,660.00 INTRAMUSCULAR) REMOVAL OF FOREIGN BODY, UPPER ARM OR 24200 24200 360 100.00 0.00 ELBOW AREA; SUBCUTANEOUS REMOVAL OF HIP PROSTHESIS; (SEPARATE 27090 27090 360 100.00 0.00 PROCEDURE) REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING TOTAL HIP PROSTHESIS, 27091 27091 360 100.00 0.00 METHYLMETHACRYLATE WITH OR WITHOUT INSERTION OF SPACER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OF IMPACTED VAGINAL FOREIGN BODY (SEPARATE PROCEDURE) UNDER 57415 57415 360 100.00 0.00 ANESTHESIA REMOVAL OF IMPLANT FROM FINGER OR HAND 26320 26320 360 6,150.00 100.00 6,150.00 REMOVAL OF IMPLANT; DEEP (EG, BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR 20680 20680 360 9,360.00 100.00 9,360.00 PLATE) REMOVAL OF IMPLANT; SUPERFICIAL, (EG, BURIED WIRE, PIN OR ROD) (SEPARATE 20670 20670 360 6,150.00 100.00 6,150.00 PROCEDURE) REMOVAL OF IMPLANTABLE INTRAVENOUS 36532 36532 360 100.00 0.00 INFUSION PUMP REMOVAL OF IMPLANTABLE VENOUS ACCESS 36535 36535 360 100.00 0.00 DEVICE, AND/OR SUBCUTANEOUS RESERVOIR REMOVAL OF IMPLANTED INTRA-ARTERIAL 36262 36262 360 100.00 0.00 INFUSION PUMP REMOVAL OF IMPLANTED MATERIAL, 65920 65920 360 100.00 0.00 ANTERIOR SEGMENT OF EYE REMOVAL OF IMPLANTED MATERIAL, 67120 67120 360 100.00 0.00 POSTERIOR SEGMENT; EXTRAOCULAR REMOVAL OF IMPLANTED MATERIAL, 67121 67121 360 100.00 0.00 POSTERIOR SEGMENT; INTRAOCULAR REMOVAL OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, 53446 53446 360 100.00 0.00 INCLUDING PUMP, RESERVOIR, AND CUFF REMOVAL OF INTACT MAMMARY IMPLANT 19328 19328 360 100.00 0.00 REMOVAL OF INTRAUTERINE DEVICE (IUD) 58301 58301 360 1,050.00 100.00 1,050.00 REMOVAL OF LENS MATERIAL; ASPIRATION 66840 66840 360 9,360.00 100.00 9,360.00 TECHNIQUE, ONE OR MORE STAGES REMOVAL OF LENS MATERIAL; EXTRACAPSULAR (OTHER THAN 66840, 66850, 66940 66940 360 100.00 0.00 66852) REMOVAL OF LENS MATERIAL; 66920 66920 360 100.00 0.00 INTRACAPSULAR Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OF LENS MATERIAL; 66930 66930 360 100.00 0.00 INTRACAPSULAR, FOR DISLOCATED LENS REMOVAL OF LENS MATERIAL; PARS PLANA 66852 66852 360 100.00 0.00 APPROACH, WITH OR WITHOUT VITRECTOMY

REMOVAL OF LENS MATERIAL; PHACOFRAGMENTATION TECHNIQUE 66850 66850 360 11,700.00 100.00 11,700.00 (MECHANICAL OR ULTRASONIC) (EG, PHACOEMULSIFICATION), WITH ASPIRATION REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WEDGE RESECTION, SINGLE 32500 32500 360 100.00 0.00 OR MULTIPLE REMOVAL OF LUNG, TOTAL PNEUMONECTOMY; 32440 32440 360 100.00 0.00

REMOVAL OF MAMMARY IMPLANT MATERIAL 19330 19330 360 100.00 0.00 REMOVAL OF NON-INFLATABLE (SEMI-RIGID) OR INFLATABLE (SELF-CONTAINED) PENILE 54415 54415 360 100.00 0.00 PROSTHESIS, WITHOUT REPLACEMENT OF PROSTHESIS REMOVAL OF OCULAR IMPLANT 65175 65175 360 100.00 0.00 REMOVAL OF PERITONEAL FOREIGN BODY 49085 49085 360 100.00 0.00 FROM PERITONEAL CAVITY REMOVAL OF PERITONEAL-VENOUS SHUNT 49429 49429 360 100.00 0.00 REMOVAL OF PERMANENT INTRAPERITONEAL 49422 49422 360 7,250.00 100.00 7,250.00 CANNULA OR CATHETER

REMOVAL OF POSTERIOR NONSEGMENTAL 22850 22850 360 100.00 0.00 INSTRUMENTATION (EG, HARRINGTON ROD) REMOVAL OF POSTERIOR SEGMENTAL 22852 22852 360 100.00 0.00 INSTRUMENTATION REMOVAL OF PREVIOUSLY IMPLANTED 62355 62355 360 6,750.00 100.00 6,750.00 INTRATHECAL OR EPIDURAL CATHETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OF PROSTHESIS, INCLUDING TOTAL KNEE PROSTHESIS, METHYLMETHACRYLATE 27488 27488 360 100.00 0.00 WITH OR WITHOUT INSERTION OF SPACER, KNEE REMOVAL OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID) WITH 66830 66830 360 100.00 0.00 CORNEO-SCLERAL SECTION, WITH OR WITHOUT IRIDECTOMY (IRIDOCAPSULOTOMY, IRIDOCAPSULECTOMY) REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; EACH ADDITIONAL TEN LESIONS (LIST SEPARATELY 11201 11201 360 100.00 0.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REMOVAL OF SKIN TAGS, MULTIPLE FIBROCUTANEOUS TAGS, ANY AREA; UP TO AND 11200 11200 360 500.00 100.00 500.00 INCLUDING 15 LESIONS REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE PERCUTANEOUS ARRAY(S), 63661 63661 360 6,350.00 100.00 6,350.00 INCLUDING FLUOROSCOPY, WHEN PERFORMED REMOVAL OF SUBCUTANEOUS RESERVOIR OR PUMP, PREVIOUSLY IMPLANTED FOR 62365 62365 360 13,500.00 100.00 13,500.00 INTRATHECAL OR EPIDURAL INFUSION REMOVAL OF SUBDELTOID CALCAREOUS 23000 23000 360 100.00 0.00 DEPOSITS, OPEN REMOVAL OF SUTURES UNDER ANESTHESIA 15851 15851 360 5,900.00 100.00 5,900.00 (OTHER THAN LOCAL), OTHER SURGEON

REMOVAL OF SUTURES UNDER ANESTHESIA 15850 15850 360 5,900.00 100.00 5,900.00 (OTHER THAN LOCAL), SAME SURGEON REMOVAL OF SYNTHETIC ROD AND INSERTION OF EXTENSOR TENDON GRAFT (INCLUDES 26416 26416 360 100.00 0.00 OBTAINING GRAFT), HAND OR FINGER, EACH ROD Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REMOVAL OF SYNTHETIC ROD AND INSERTION OF FLEXOR TENDON GRAFT, HAND OR FINGER 26392 26392 360 100.00 0.00 (INCLUDES OBTAINING GRAFT), EACH ROD REMOVAL OF THIERSCH WIRE OR SUTURE, 46754 46754 360 100.00 0.00 ANAL CANAL REMOVAL OF TISSUE EXPANDER(S) WITHOUT 11971 11971 360 100.00 0.00 INSERTION OF PROSTHESIS REMOVAL OF TONGS OR HALO APPLIED BY 20665 20665 360 100.00 0.00 ANOTHER PHYSICIAN REMOVAL OF TUMOR, TEMPORAL BONE 69970 69970 360 100.00 0.00 REMOVAL OF TUNNELED CENTRAL VENOUS ACCESS DEVICE, WITH SUBCUTANEOUS PORT 36590 36590 360 6,190.00 100.00 6,190.00 OR PUMP, CENTRAL OR PERIPHERAL INSERTION REMOVAL OF TUNNELED CENTRAL VENOUS CATHETER, WITHOUT SUBCUTANEOUS PORT OR 36589 36589 360 2,250.00 100.00 2,250.00 PUMP REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION); 67005 67005 360 12,940.00 100.00 12,940.00 PARTIAL REMOVAL REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION); 67010 67010 360 14,230.00 100.00 14,230.00 SUBTOTAL REMOVAL WITH MECHANICAL VITRECTOMY REMOVAL OF WRIST PROSTHESIS; (SEPARATE 25250 25250 360 100.00 0.00 PROCEDURE) REMOVAL OF WRIST PROSTHESIS; 25251 25251 360 100.00 0.00 COMPLICATED, INCLUDING TOTAL WRIST REMOVAL OR BIVALVING; FULL ARM OR FULL 29705 29705 360 100.00 0.00 LEG CAST REMOVAL OR BIVALVING; GAUNTLET, BOOT OR 29700 29700 360 100.00 0.00 BODY CAST REMOVAL OR BIVALVING; SHOULDER OR HIP 29710 29710 360 100.00 0.00 SPICA, MINERVA, OR RISSER JACKET, ETC. REMOVAL OR BIVALVING; TURNBUCKLE 29715 29715 360 100.00 0.00 JACKET Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REMOVAL OR REPAIR OF ELECTROMAGNETIC BONE CONDUCTION HEARING DEVICE IN 69711 69711 360 100.00 0.00 TEMPORAL BONE REMOVAL OR REVISION OF SLING FOR MALE URINARY INCONTINENCE (EG, FASCIA OR 53442 53442 360 100.00 0.00 SYNTHETIC) REMOVAL OR REVISION OF SLING FOR STRESS 57287 57287 360 12,500.00 100.00 12,500.00 INCONTINENCE (EG, FASCIA OR SYNTHETIC) REMOVAL WITH REINSERTION, IMPLANTABLE 11977 11977 360 100.00 0.00 CONTRACEPTIVE CAPSULES REMOVAL WITH REINSERTION, NON- 11983 11983 360 100.00 0.00 BIODEGRADABLE DRUG DELIVERY IMPLANT REMOVAL, IMPLANTABLE CONTRACEPTIVE 11976 11976 360 100.00 0.00 CAPSULES REMOVAL, NON-BIODEGRADABLE DRUG 11982 11982 360 100.00 0.00 DELIVERY IMPLANT REMOVAL, UNDER ANESTHESIA, OF EXTERNAL 20694 20694 360 7,600.00 100.00 7,600.00 FIXATION SYSTEM RENAL BIOPSY; BY SURGICAL EXPOSURE OF 50205 50205 360 100.00 0.00 KIDNEY RENAL BIOPSY; PERCUTANEOUS, BY TROCAR 50200 50200 360 100.00 0.00 OR NEEDLE RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50562 50562 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOL15768

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50551 50551 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50555 50555 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50557 50557 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50559 50559 360 100.00 0.00 RADIOLOGIC SERVICE; WITH INSERTION OF RADIOACTIVE SUBSTANCE WITH OR WITHOUT BIOPSY AND/OR FULGURATION

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50561 50561 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS

RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50553 50553 360 100.00 0.00 RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50570 50570 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50574 50574 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50576 50576 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY

RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50578 50578 360 100.00 0.00 RADIOLOGIC SERVICE; WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY AND/OR FULGURATION RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50580 50580 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50572 50572 360 100.00 0.00 RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RENAL EXPLORATION, NOT NECESSITATING 50010 50010 360 100.00 0.00 OTHER SPECIFIC PROCEDURES RENAL FUNCTION PANEL 80069 80069 301 310.00 100.00 310.00 REOPENING OF RECENT LAPAROTOMY 49002 49002 360 100.00 0.00 REPAIR AND RECONSTRUCTION, FINGER, VOLAR 26548 26548 360 100.00 0.00 PLATE, INTERPHALANGEAL JOINT REPAIR BIFID DIGIT 26585 360 100.00 0.00 REPAIR BLOOD VESSEL WITH VEIN GRAFT; 35236 35236 360 18,000.00 100.00 18,000.00 UPPER EXTREMITY REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER 35207 35207 360 14,750.00 100.00 14,750.00 REPAIR CHOANAL ATRESIA; INTRANASAL 30540 30540 360 100.00 0.00 REPAIR CHOANAL ATRESIA; TRANSPALATINE 30545 30545 360 100.00 0.00 REPAIR CLEFT HAND 26580 26580 360 100.00 0.00 REPAIR DEVICE, URINARY WITH A SLING GRAFT C1771-W C1771 278 100.00 0.00 REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); INCARCERATED OR 49572 49572 360 16,160.00 100.00 16,160.00 STRANGULATED REPAIR EPIGASTRIC HERNIA (EG, PREPERITONEAL FAT); REDUCIBLE (SEPARATE 49570 49570 360 14,370.00 100.00 14,370.00 PROCEDURE) REPAIR FISTULA; OROMAXILLARY (COMBINE 30580 30580 360 100.00 0.00 WITH 31030 IF ANTROTOMY IS INCLUDED) REPAIR FISTULA; ORONASAL 30600 30600 360 100.00 0.00 REPAIR INCOMPLETE CIRCUMCISION 54163 54163 360 10,250.00 100.00 10,250.00 REPAIR INGUINAL HERNIA, SLIDING, ANY AGE 49525 49525 360 12,250.00 100.00 12,250.00 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; 49553 49553 360 16,160.00 100.00 16,160.00 INCARCERATED OR STRANGULATED REPAIR INITIAL FEMORAL HERNIA, ANY AGE; 49550 49550 360 14,370.00 100.00 14,370.00 REDUCIBLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR INITIAL INCISIONAL OR VENTRAL 49561 49561 360 16,160.00 100.00 16,160.00 HERNIA; INCARCERATED OR STRANGULATED REPAIR INITIAL INCISIONAL OR VENTRAL 49560 49560 360 14,370.00 100.00 14,370.00 HERNIA; REDUCIBLE REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED OR 49507 49507 360 12,250.00 100.00 12,250.00 STRANGULATED REPAIR INITIAL INGUINAL HERNIA, AGE 5 49505 49505 360 12,250.00 100.00 12,250.00 YEARS OR OVER; REDUCIBLE REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO UNDER 5 YEARS, WITH OR 49501 49501 360 12,250.00 100.00 12,250.00 WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO UNDER 5 YEARS, WITH OR 49500 49500 360 12,250.00 100.00 12,250.00 WITHOUT HYDROCELECTOMY; REDUCIBLE REPAIR LATERAL COLLATERAL LIGAMENT, 24343 24343 360 12,040.00 100.00 12,040.00 ELBOW, WITH LOCAL TISSUE REPAIR LIP, FULL THICKNESS; OVER ONE-HALF 40654 40654 360 100.00 0.00 VERTICAL HEIGHT, OR COMPLEX REPAIR LIP, FULL THICKNESS; UP TO HALF 40652 40652 360 100.00 0.00 VERTICAL HEIGHT REPAIR LIP, FULL THICKNESS; VERMILION ONLY 40650 40650 360 100.00 0.00 REPAIR LUMBAR HERNIA 49540 49540 360 13,910.00 100.00 13,910.00 REPAIR LUNG HERNIA THROUGH CHEST WALL 32800 32800 360 100.00 0.00 REPAIR MACRODACTYLIA, EACH DIGIT 26590 26590 360 100.00 0.00 REPAIR MEDIAL COLLATERAL LIGAMENT, 24345 24345 360 12,040.00 100.00 12,040.00 ELBOW, WITH LOCAL TISSUE REPAIR NASAL SEPTAL PERFORATIONS 30630 30630 360 12,530.00 100.00 12,530.00 REPAIR NON-UNION, METACARPAL OR PHALANX, (INCLUDES OBTAINING BONE GRAFT 26546 26546 360 100.00 0.00 WITH OR WITHOUT EXTERNAL OR INTERNAL FIXATION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR OF ANAL FISTULA WITH FIBRIN GLUE 46706 46706 360 100.00 0.00 REPAIR OF ANTERIOR PALATE, INCLUDING 42235 42235 360 100.00 0.00 VOMER FLAP REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, 67904 67904 360 7,050.00 100.00 7,050.00 EXTERNAL APPROACH REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, 67903 67903 360 100.00 0.00 INTERNAL APPROACH REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO- TARSO-MULLER'S MUSCLE-LEVATOR 67908 67908 360 10,350.00 100.00 10,350.00 RESECTION (EG, FASANELLA-SERVAT TYPE) REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH FASCIAL SLING 67902 67902 360 100.00 0.00 (INCLUDES OBTAINING FASCIA) REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER 67901 67901 360 100.00 0.00 MATERIAL REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING 67906 67906 360 100.00 0.00 (INCLUDES OBTAINING FASCIA) REPAIR OF BROW PTOSIS (SUPRACILIARY, MID- 67900 67900 360 10,350.00 100.00 10,350.00 FOREHEAD OR CORONAL APPROACH) REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 46746 46746 360 100.00 0.00 URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, COMBINED ABDOMINAL AND 46748 46748 360 100.00 0.00 SACROPERINEAL APPROACH; WITH VAGINAL LENGTHENING BY INTEST REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND 46744 46744 360 100.00 0.00 URETHROPLASTY, SACROPERINEAL APPROACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR 26540 26540 360 9,560.00 100.00 9,560.00 INTERPHALANGEAL JOINT REPAIR OF COMPONENT(S) OF A MULTI- 54408 54408 360 100.00 0.00 COMPONENT, INFLATABLE PENILE PROSTHESIS REPAIR OF CONGENITAL PSEUDARTHROSIS, 27727 27727 360 100.00 0.00 TIBIA REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS 25426 25426 360 100.00 0.00 AND ULNA REPAIR OF DEFECT WITH AUTOGRAFT; RADIUS 25425 25425 360 17,250.00 100.00 17,250.00 OR ULNA REPAIR OF DURAL/CEREBROSPINAL FLUID LEAK OR PSEUDOMENINGOCELE, WITH 63709 63709 360 100.00 0.00 LAMINECTOMY REPAIR OF DURAL/CEREBROSPINAL FLUID 63707 63707 360 100.00 0.00 LEAK, NOT REQUIRING LAMINECTOMY REPAIR OF ECTROPION; BLEPHAROPLASTY, 67916 67916 360 7,050.00 100.00 7,050.00 EXCISION TARSAL WEDGE REPAIR OF ECTROPION; BLEPHAROPLASTY, EXTENSIVE (EG, KUHNT-SZYMANOWSKI OR 67917 67917 360 100.00 0.00 TARSAL STRIP OPERATIONS) REPAIR OF ECTROPION; SUTURE 67914 67914 360 7,770.00 100.00 7,770.00 REPAIR OF ECTROPION; 67915 67915 360 100.00 0.00 THERMOCAUTERIZATION REPAIR OF ENTEROCELE, ABDOMINAL 57270 57270 360 100.00 0.00 APPROACH (SEPARATE PROCEDURE) REPAIR OF ENTEROCELE, VAGINAL APPROACH 57268 57268 360 13,440.00 100.00 13,440.00 (SEPARATE PROCEDURE) REPAIR OF ENTROPION; BLEPHAROPLASTY, 67923 67923 360 9,060.00 100.00 9,060.00 EXCISION TARSAL WEDGE REPAIR OF ENTROPION; BLEPHAROPLASTY, 67924 67924 360 100.00 0.00 EXTENSIVE (EG, WHEELER OPERATION) REPAIR OF ENTROPION; SUTURE 67921 67921 360 100.00 0.00 REPAIR OF ENTROPION; 67922 67922 360 100.00 0.00 THERMOCAUTERIZATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, BOUTONNIERE DEFORMITY); 26426 26426 360 10,150.00 100.00 10,150.00 USING LOCAL TISSUE(S), INCLUDING LATERAL BAND(S), EACH FINGER

REPAIR OF EXTENSOR TENDON, CENTRAL SLIP, SECONDARY (EG, BOUTONNIERE DEFORMITY); 26428 26428 360 100.00 0.00 WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH FINGER

REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR SECONDARY; WITH 26434 26434 360 100.00 0.00 FREE GRAFT (INCLUDES OBTAINING GRAFT) REPAIR OF EXTENSOR TENDON, DISTAL INSERTION, PRIMARY OR SECONDARY; 26433 26433 360 6,380.00 100.00 6,380.00 WITHOUT GRAFT (EG, MALLET FINGER) REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR RECTOVAGINAL FISTULA; 46742 46742 360 100.00 0.00 COMBINED TRANSABDOMINAL AND SACROPERINEAL APPROACHES

REPAIR OF HIGH IMPERFORATE ANUS WITH RECTOURETHRAL OR RECTOVAGINAL FISTULA; 46740 46740 360 100.00 0.00 PERINEAL OR SACROPERINEAL APPROACH

REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; COMBINED TRANSABDOMINAL AND 46735 46735 360 100.00 0.00 SACROPERINEAL APPROACHES REPAIR OF HIGH IMPERFORATE ANUS WITHOUT FISTULA; PERINEAL OR SACROPERINEAL 46730 46730 360 100.00 0.00 APPROACH REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); BY 54340 54340 360 100.00 0.00 CLOSURE, INCISION, OR EXCISION, SIMPLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING EXTENSIVE DISSECTION AND 54348 54348 360 100.00 0.00 URETHROPLASTY WITH FLAP, PATCH OR TUBED GRAFT (INCLUDES URINARY DIVERSION)

REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); 54344 54344 360 100.00 0.00 REQUIRING MOBILIZATION OF SKIN FLAPS AND URETHROPLASTY WITH FLAP OR PATCH GRAFT

REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE DISSECTION AND EXCISION OF PREVIOUSLY CONSTRUCTED STRUCTURES INCLUDING RE-RELEASE OF CHORDEE AND 54352 54352 360 100.00 0.00 RECONSTRUCTION OF URETHRA AND PENIS BY USE OF LOCAL SKIN AS GRAFTS AND ISLAND FLAPS AND SKIN BROUGHT IN AS REPAIR OF INFLATABLE URETHRAL/BLADDER NECK SPHINCTER, INCLUDING PUMP, 53449 53449 360 100.00 0.00 RESERVOIR, AND CUFF REPAIR OF IRIS, CILIARY BODY (AS FOR 66680 66680 360 8,190.00 100.00 8,190.00 IRIDODIALYSIS) REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR ANTERIOR TWO-THIRDS OF 41250 41250 360 100.00 0.00 TONGUE REPAIR OF LACERATION 2.5 CM OR LESS; 41251 41251 360 100.00 0.00 POSTERIOR ONE-THIRD OF TONGUE REPAIR OF LACERATION OF TONGUE, FLOOR OF 41252 41252 360 100.00 0.00 MOUTH, OVER 2.6 CM OR COMPLEX REPAIR OF LACERATION; APPLICATION OF TISSUE GLUE, WOUNDS OF CORNEA AND/OR 65286 65286 360 100.00 0.00 SCLERA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, WITH 65273 65273 360 100.00 0.00 HOSPITALIZATION

REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT, 65272 65272 360 100.00 0.00 WITHOUT HOSPITALIZATION REPAIR OF LACERATION; CONJUNCTIVA, WITH OR WITHOUT NONPERFORATING LACERATION 65270 65270 360 100.00 0.00 SCLERA, DIRECT CLOSURE REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, NOT INVOLVING UVEAL 65280 65280 360 100.00 0.00 TISSUE REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, WITH REPOSITION OR 65285 65285 360 100.00 0.00 RESECTION OF UVEAL TISSUE REPAIR OF LACERATION; CORNEA, NONPERFORATING, WITH OR WITHOUT 65275 65275 360 100.00 0.00 REMOVAL FOREIGN BODY REPAIR OF LARGE OMPHALOCELE OR GASTROSCHISIS; WITH OR WITHOUT 49605 49605 360 100.00 0.00 PROSTHESIS REPAIR OF LARGE OMPHALOCELE OR GASTROSCHISIS; WITH REMOVAL OF 49606 49606 360 100.00 0.00 PROSTHESIS, FINAL REDUCTION AND CLOSURE, IN OPERATING ROOM REPAIR OF LOW IMPERFORATE ANUS; WITH ANOPERINEAL FISTULA (CUT-BACK 46715 46715 360 100.00 0.00 PROCEDURE) REPAIR OF LOW IMPERFORATE ANUS; WITH TRANSPOSITION OF ANOPERINEAL OR 46716 46716 360 100.00 0.00 ANOVESTIBULAR FISTULA REPAIR OF MENINGOCELE; LARGER THAN 5 CM 63702 63702 360 100.00 0.00 DIAMETER REPAIR OF MENINGOCELE; LESS THAN 5 CM 63700 63700 360 100.00 0.00 DIAMETER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OF MYELOMENINGOCELE; LARGER 63706 63706 360 100.00 0.00 THAN 5 CM DIAMETER REPAIR OF MYELOMENINGOCELE; LESS THAN 5 63704 63704 360 100.00 0.00 CM DIAMETER REPAIR OF NAIL BED 11760 11760 360 10,860.00 100.00 10,860.00 REPAIR OF NASAL VESTIBULAR STENOSIS (EG, SPREADER GRAFTING, LATERAL NASAL WALL 30465 30465 360 17,100.00 100.00 17,100.00 RECONSTRUCTION) REPAIR OF NASOLABIAL FISTULA 42260 42260 360 100.00 0.00

REPAIR OF NONUNION OF CARPAL BONE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)) 25431 25431 360 17,250.00 100.00 17,250.00 (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION), EACH BONE

REPAIR OF NONUNION OR MALUNION, HUMERUS; WITH ILIAC OR OTHER AUTOGRAFT 24435 24435 360 46,750.00 100.00 46,750.00 (INCLUDES OBTAINING GRAFT) REPAIR OF NONUNION OR MALUNION, HUMERUS; WITHOUT GRAFT (EG, COMPRESSION 24430 24430 360 28,950.00 100.00 28,950.00 TECHNIQUE) REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITH AUTOGRAFT (INCLUDES 25420 25420 360 100.00 0.00 OBTAINING GRAFT) REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; WITHOUT GRAFT (EG, 25415 25415 360 28,950.00 100.00 28,950.00 COMPRESSION TECHNIQUE) REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITH AUTOGRAFT (INCLUDES 25405 25405 360 28,950.00 100.00 28,950.00 OBTAINING GRAFT) REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; WITHOUT GRAFT (EG, COMPRESSION 25400 25400 360 28,950.00 100.00 28,950.00 TECHNIQUE) REPAIR OF NONUNION OR MALUNION, TIBIA; BY 27725 27725 360 100.00 0.00 SYNOSTOSIS, WITH FIBULA, ANY METHOD Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OF NONUNION OR MALUNION, TIBIA; WITH ILIAC OR OTHER AUTOGRAFT (INCLUDES 27724 27724 360 100.00 0.00 OBTAINING GRAFT) REPAIR OF NONUNION OR MALUNION, TIBIA; 27722 27722 360 100.00 0.00 WITH SLIDING GRAFT REPAIR OF NONUNION OR MALUNION, TIBIA; WITHOUT GRAFT, (EG, COMPRESSION 27720 27720 360 19,350.00 100.00 19,350.00 TECHNIQUE) REPAIR OF NONUNION, SCAPHOID CARPAL (NAVICULAR) BONE, WITH OR WITHOUT RADIAL 25440 25440 360 17,250.00 100.00 17,250.00 STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION) REPAIR OF OMPHALOCELE (GROSS TYPE 49610 49610 360 100.00 0.00 OPERATION); FIRST STAGE REPAIR OF OMPHALOCELE (GROSS TYPE 49611 49611 360 100.00 0.00 OPERATION); SECOND STAGE REPAIR OF RECTOCELE (SEPARATE 45560 45560 360 100.00 0.00 PROCEDURE) REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; PHOTOCOAGULATION, WITH 67105 67105 360 100.00 0.00 OR WITHOUT DRAINAGE OF SUBRETINAL FLUID REPAIR OF RETINAL DETACHMENT; BY INJECTION OF AIR OR OTHER GAS (EG, 67110 67110 360 100.00 0.00 PNEUMATIC RETINOPEXY) REPAIR OF RETINAL DETACHMENT; BY SCLERAL BUCKLING OR VITRECTOMY, ON PATIENT HAVING PREVIOUS IPSILATERAL 67112 67112 360 100.00 0.00 RETINAL DETACHMENT REPAIR(S) USING SCLERAL BUCKLING OR VITRECTOMY TECHNIQUES Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), WITH OR WITHOUT IMPLANT, 67107 67107 360 100.00 0.00 WITH OR WITHOUT CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID

REPAIR OF RETINAL DETACHMENT; WITH VITRECTOMY, ANY METHOD, WITH OR WITHOUT AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, 67108 67108 360 100.00 0.00 CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE

REPAIR OF RUPTURED MUSCULOTENDINOUS 23410 23410 360 17,250.00 100.00 17,250.00 CUFF (EG, ROTATOR CUFF) OPEN; ACUTE

REPAIR OF RUPTURED MUSCULOTENDINOUS 23412 23412 360 17,250.00 100.00 17,250.00 CUFF (EG, ROTATOR CUFF) OPEN; CHRONIC REPAIR OF SCLERAL STAPHYLOMA; WITH 66225 66225 360 100.00 0.00 GRAFT REPAIR OF SCLERAL STAPHYLOMA; WITHOUT 66220 66220 360 100.00 0.00 GRAFT REPAIR OF SMALL OMPHALOCELE, WITH 49600 49600 360 100.00 0.00 PRIMARY CLOSURE REPAIR OF SPICA, BODY CAST OR JACKET 29720 29720 360 100.00 0.00 REPAIR OF SYMBLEPHARON; 68330 68330 360 100.00 0.00 CONJUNCTIVOPLASTY, WITHOUT GRAFT REPAIR OF SYMBLEPHARON; DIVISION OF SYMBLEPHARON, WITH OR WITHOUT 68340 68340 360 100.00 0.00 INSERTION OF CONFORMER OR CONTACT LENS

REPAIR OF SYMBLEPHARON; WITH FREE GRAFT CONJUNCTIVA OR BUCCAL MUCOUS 68335 68335 360 100.00 0.00 MEMBRANE (INCLUDES OBTAINING GRAFT) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; COMPLEX (EG, INVOLVING BONE, 26562 26562 360 100.00 0.00 NAILS) REPAIR OF SYNDACTYLY (WEB FINGER) EACH 26560 26560 360 100.00 0.00 WEB SPACE; WITH SKIN FLAPS REPAIR OF SYNDACTYLY (WEB FINGER) EACH 26561 26561 360 100.00 0.00 WEB SPACE; WITH SKIN FLAPS AND GRAFTS REPAIR OF TUNICA VAGINALIS HYDROCELE 55060 55060 360 9,700.00 100.00 9,700.00 (BOTTLE TYPE) REPAIR OF WOUND, EXTRAOCULAR MUSCLE, 65290 65290 360 100.00 0.00 TENDON AND/OR TENON'S CAPSULE

REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; 26370 26370 360 10,150.00 100.00 10,150.00 PRIMARY, EACH TENDON

REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; 26372 26372 360 100.00 0.00 SECONDARY WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON REPAIR OR ADVANCEMENT OF PROFUNDUS TENDON, WITH INTACT SUPERFICIALIS TENDON; 26373 26373 360 100.00 0.00 SECONDARY WITHOUT FREE GRAFT, EACH TENDON REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR 26356 26356 360 10,150.00 100.00 10,150.00 SECONDARY WITHOUT FREE GRAFT, EACH TENDON REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY WITH FREE 26358 26358 360 10,150.00 100.00 10,150.00 GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR OR ADVANCEMENT, FLEXOR TENDON, IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH 26357 26357 360 100.00 0.00 (EG, NO MAN'S LAND); SECONDARY, EACH TENDON REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); PRIMARY OR 26350 26350 360 10,150.00 100.00 10,150.00 SECONDARY WITHOUT FREE GRAFT, EACH TENDON REPAIR OR ADVANCEMENT, FLEXOR TENDON, NOT IN ZONE 2 DIGITAL FLEXOR TENDON SHEATH (EG, NO MAN'S LAND); SECONDARY 26352 26352 360 100.00 0.00 WITH FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON REPAIR OVAL WINDOW FISTULA 69666 69666 360 100.00 0.00 REPAIR RECURRENT FEMORAL HERNIA; 49557 49557 360 27,820.00 100.00 27,820.00 INCARCERATED OR STRANGULATED REPAIR RECURRENT FEMORAL HERNIA; 49555 49555 360 100.00 0.00 REDUCIBLE REPAIR RECURRENT INCISIONAL OR VENTRAL 49566 49566 360 17,960.00 100.00 17,960.00 HERNIA; INCARCERATED OR STRANGULATED REPAIR RECURRENT INCISIONAL OR VENTRAL 49565 49565 360 16,160.00 100.00 16,160.00 HERNIA; REDUCIBLE REPAIR RECURRENT INGUINAL HERNIA, ANY 49521 49521 360 12,570.00 100.00 12,570.00 AGE; INCARCERATED OR STRANGULATED REPAIR RECURRENT INGUINAL HERNIA, ANY 49520 49520 360 12,250.00 100.00 12,250.00 AGE; REDUCIBLE REPAIR ROUND WINDOW FISTULA 69667 69667 360 100.00 0.00 REPAIR SPIGELIAN HERNIA 49590 49590 360 12,250.00 100.00 12,250.00 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR 49587 49587 360 12,570.00 100.00 12,570.00 OVER; INCARCERATED OR STRANGULATED REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR 49585 49585 360 12,250.00 100.00 12,250.00 OVER; REDUCIBLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR UMBILICAL HERNIA, UNDER AGE 5 49582 49582 360 19,470.00 100.00 19,470.00 YEARS; INCARCERATED OR STRANGULATED REPAIR UMBILICAL HERNIA, UNDER AGE 5 49580 49580 360 12,250.00 100.00 12,250.00 YEARS; REDUCIBLE REPAIR, ACQUIRED OR TRAUMATIC 35188 35188 360 100.00 0.00 ARTERIOVENOUS FISTULA; HEAD AND NECK REPAIR, COMPLEX, EYELIDS, NOSE, EARS 13150 13150 360 3,390.00 100.00 3,390.00 AND/OR LIPS; 1.0 CM OR LESS REPAIR, COMPLEX, EYELIDS, NOSE, EARS 13151 13151 360 5,080.00 100.00 5,080.00 AND/OR LIPS; 1.1 CM TO 2.5 CM REPAIR, COMPLEX, EYELIDS, NOSE, EARS 13152 13152 360 100.00 0.00 AND/OR LIPS; 2.6 CM TO 7.5 CM REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM OR LESS 13153 13153 360 100.00 0.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS 13131 13131 360 5,450.00 100.00 5,450.00 AND/OR FEET; 1.1 CM TO 2.5 CM REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS 13132 13132 360 6,770.00 100.00 6,770.00 AND/OR FEET; 2.6 CM TO 7.5 CM REPAIR, COMPLEX, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS 13133 13133 360 100.00 0.00 AND/OR FEET; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 13120 13120 360 3,390.00 100.00 3,390.00 1.1 CM TO 2.5 CM REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; 13121 13121 360 5,080.00 100.00 5,080.00 2.6 CM TO 7.5 CM REPAIR, COMPLEX, SCALP, ARMS, AND/OR LEGS; EACH ADDITIONAL 5 CM OR LESS (LIST 13122 13122 360 2,050.00 100.00 2,050.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR, COMPLEX, TRUNK; 1.1 CM TO 2.5 CM 13100 13100 360 2,000.00 100.00 2,000.00

REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM 13101 13101 360 5,080.00 100.00 5,080.00

REPAIR, COMPLEX, TRUNK; EACH ADDITIONAL 5 CM OR LESS (LIST SEPARATELY IN ADDITION TO 13102 13102 360 2,200.00 100.00 2,200.00 CODE FOR PRIMARY PROCEDURE) REPAIR, DISLOCATING PERONEAL TENDONS; 27676 27676 360 100.00 0.00 WITH FIBULAR OSTEOTOMY REPAIR, DISLOCATING PERONEAL TENDONS; 27675 27675 360 8,420.00 100.00 8,420.00 WITHOUT FIBULAR OSTEOTOMY REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITH FREE GRAFT (INCLUDES 26420 26420 360 10,150.00 100.00 10,150.00 OBTAINING GRAFT) EACH TENDON REPAIR, EXTENSOR TENDON, FINGER, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH 26418 26418 360 6,380.00 100.00 6,380.00 TENDON REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITH FREE GRAFT (INCLUDES 26412 26412 360 100.00 0.00 OBTAINING GRAFT), EACH TENDON REPAIR, EXTENSOR TENDON, HAND, PRIMARY OR SECONDARY; WITHOUT FREE GRAFT, EACH 26410 26410 360 6,380.00 100.00 6,380.00 TENDON REPAIR, EXTENSOR TENDON, LEG; PRIMARY, 27664 27664 360 11,900.00 100.00 11,900.00 WITHOUT GRAFT, EACH TENDON

REPAIR, EXTENSOR TENDON, LEG; SECONDARY, 27665 27665 360 14,560.00 100.00 14,560.00 WITH OR WITHOUT GRAFT, EACH TENDON REPAIR, FASCIAL DEFECT OF LEG 27656 27656 360 100.00 0.00 REPAIR, FLEXOR TENDON, LEG; PRIMARY, 27658 27658 360 7,600.00 100.00 7,600.00 WITHOUT GRAFT, EACH TENDON REPAIR, FLEXOR TENDON, LEG; SECONDARY, 27659 27659 360 100.00 0.00 WITH OR WITHOUT GRAFT, EACH TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR, INITIAL INGUINAL HERNIA, FULL TERM INFANT UNDER AGE 6 MONTHS, OR PRETERM INFANT OVER 50 WEEKS POSTCONCEPTION AGE AND UNDER AGE 6 MONTHS AT THE TIME OF 49496 49496 360 100.00 0.00 SURGERY, WITH OR WITHOUT HYDROCELECTOMY; INCARCERATED OR STRANGULATED

REPAIR, INITIAL INGUINAL HERNIA, FULL TERM INFANT UNDER AGE 6 MONTHS, OR PRETERM INFANT OVER 50 WEEKS POSTCONCEPTION AGE 49495 49495 360 100.00 0.00 AND UNDER AGE 6 MONTHS AT THE TIME OF SURGERY, WITH OR WITHOUT HYDROCELECTOMY; REDUCIBLE REPAIR, INTRINSIC MUSCLES OF HAND, EACH 26591 26591 360 100.00 0.00 MUSCLE REPAIR, LACERATION OF PALATE; OVER 2 CM 42182 42182 360 100.00 0.00 OR COMPLEX REPAIR, LACERATION OF PALATE; UP TO 2 CM 42180 42180 360 100.00 0.00 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; WITH ILIAC OR 27472 27472 360 100.00 0.00 OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; WITHOUT GRAFT 27470 27470 360 100.00 0.00 (EG, COMPRESSION TECHNIQUE) REPAIR, NONUNION OR MALUNION; METATARSAL, WITH OR WITHOUT BONE GRAFT 28322 28322 360 9,470.00 100.00 9,470.00 (INCLUDES OBTAINING GRAFT) REPAIR, NONUNION OR MALUNION; TARSAL 28320 28320 360 23,900.00 100.00 23,900.00 BONES REPAIR, PRIMARY, DISRUPTED LIGAMENT, 27696 27696 360 11,900.00 100.00 11,900.00 ANKLE; BOTH COLLATERAL LIGAMENTS REPAIR, PRIMARY, DISRUPTED LIGAMENT, 27695 27695 360 11,900.00 100.00 11,900.00 ANKLE; COLLATERAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, 27650 27650 360 17,250.00 100.00 17,250.00 RUPTURED ACHILLES TENDON;

REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; WITH GRAFT 27652 27652 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) REPAIR, PRIMARY, TORN LIGAMENT AND/OR 27405 27405 360 17,250.00 100.00 17,250.00 CAPSULE, KNEE; COLLATERAL REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL AND CRUCIATE 27409 27409 360 100.00 0.00 LIGAMENTS REPAIR, PRIMARY, TORN LIGAMENT AND/OR 27407 27407 360 100.00 0.00 CAPSULE, KNEE; CRUCIATE REPAIR, SECONDARY, ACHILLES TENDON, WITH 27654 27654 360 17,250.00 100.00 17,250.00 OR WITHOUT GRAFT REPAIR, SECONDARY, DISRUPTED LIGAMENT, ANKLE, COLLATERAL (EG, WATSON-JONES 27698 27698 360 11,900.00 100.00 11,900.00 PROCEDURE) REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, 25270 25270 360 11,900.00 100.00 11,900.00 EACH TENDON OR MUSCLE REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; SECONDARY, SINGLE, 25272 25272 360 11,900.00 100.00 11,900.00 EACH TENDON OR MUSCLE REPAIR, TENDON OR MUSCLE, EXTENSOR, FOREARM AND/OR WRIST; SECONDARY, WITH 25274 25274 360 100.00 0.00 FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, 25260 25260 360 11,900.00 100.00 11,900.00 EACH TENDON OR MUSCLE REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; SECONDARY, SINGLE, 25263 25263 360 100.00 0.00 EACH TENDON OR MUSCLE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; SECONDARY, WITH 25265 25265 360 100.00 0.00 FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY 24341 24341 360 17,250.00 100.00 17,250.00 OR SECONDARY (EXCLUDES ROTATOR CUFF)

REPAIR, TENDON SHEATH, EXTENSOR, FOREARM AND/OR WRIST, WITH FREE GRAFT 25275 25275 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) (EG, FOR EXTENSOR CARPI ULNARIS SUBLUXATION) REPAIR, TENDON, EXTENSOR, FOOT; PRIMARY 28208 28208 360 8,420.00 100.00 8,420.00 OR SECONDARY, EACH TENDON REPAIR, TENDON, EXTENSOR, FOOT; SECONDARY WITH FREE GRAFT, EACH TENDON 28210 28210 360 100.00 0.00 (INCLUDES OBTAINING GRAFT) REPAIR, TENDON, FLEXOR, FOOT; PRIMARY OR SECONDARY, WITHOUT FREE GRAFT, EACH 28200 28200 360 8,420.00 100.00 8,420.00 TENDON REPAIR, TENDON, FLEXOR, FOOT; SECONDARY WITH FREE GRAFT, EACH TENDON (INCLUDES 28202 28202 360 100.00 0.00 OBTAINING GRAFT) REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH 69718 69718 360 100.00 0.00 PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITH MASTOIDECTOMY

REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH 69717 69717 360 100.00 0.00 PERCUTANEOUS ATTACHMENT TO EXTERNAL SPEECH PROCESSOR/COCHLEAR STIMULATOR; WITHOUT MASTOIDECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPLACEMENT OF TISSUE EXPANDER WITH 11970 11970 360 100.00 0.00 PERMANENT PROSTHESIS REPLACEMENT OR IRRIGATION, 62194 62194 360 100.00 0.00 SUBARACHNOID/SUBDURAL CATHETER REPLACEMENT OR IRRIGATION, VENTRICULAR 62225 62225 360 100.00 0.00 CATHETER REPLACEMENT OR REVISION OF CEREBROSPINAL FLUID SHUNT, OBSTRUCTED 62230 62230 360 100.00 0.00 VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM REPLACEMENT, IRRIGATION OR REVISION OF 63744 63744 360 100.00 0.00 LUMBOSUBARACHNOID SHUNT REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS THROUGH ELBOW JOINT), 20802 20802 360 100.00 0.00 COMPLETE AMPUTATION REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO SUBLIMIS TENDON 20822 20822 360 100.00 0.00 INSERTION), COMPLETE AMPUTATION

REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES METACARPOPHALANGEAL JOINT TO 20816 20816 360 100.00 0.00 INSERTION OF FLEXOR SUBLIMIS TENDON), COMPLETE AMPUTATION REPLANTATION, FOOT, COMPLETE 20838 20838 360 100.00 0.00 AMPUTATION REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL CARPAL JOINT), 20805 20805 360 100.00 0.00 COMPLETE AMPUTATION REPLANTATION, HAND (INCLUDES HAND THROUGH METACARPOPHALANGEAL JOINTS), 20808 20808 360 100.00 0.00 COMPLETE AMPUTATION REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO MP JOINT), 20824 20824 360 100.00 0.00 COMPLETE AMPUTATION REPLANTATION, THUMB (INCLUDES DISTAL TIP 20827 20827 360 100.00 0.00 TO MP JOINT), COMPLETE AMPUTATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION 66825 66825 360 9,360.00 100.00 9,360.00 (SEPARATE PROCEDURE) REPOSITIONING OF THE GASTRIC FEEDING TUBE, ANY METHOD, THROUGH THE 43761 43761 360 100.00 0.00 DUODENUM FOR ENTERIC NUTRITION RESECTION OF ELBOW JOINT (ARTHRECTOMY) 24155 24155 360 100.00 0.00 RESECTION OF LATERAL PHARYNGEAL WALL OR PYRIFORM SINUS, DIRECT CLOSURE BY 42892 42892 360 100.00 0.00 ADVANCEMENT OF LATERAL AND POSTERIOR PHARYNGEAL WALLS RESECTION OF LIP, MORE THAN ONE-FOURTH, 40530 40530 360 8,900.00 100.00 8,900.00 WITHOUT RECONSTRUCTION RESECTION OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL 58950 58950 360 100.00 0.00 SALPINGO-OOPHORECTOMY AND OMENTECTOMY; RESECTION OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND 58952 58952 360 100.00 0.00 OMENTECTOMY; WITH RADICAL DISSECTION FOR DEBULKI RESECTION OF OVARIAN, TUBAL OR PRIMARY PERITONEAL MALIGNANCY WITH BILATERAL SALPINGO-OOPHORECTOMY AND 58951 58951 360 100.00 0.00 OMENTECTOMY; WITH TOTAL ABDOMINAL HYSTERECTOMY, RESECTION OF PALATE OR EXTENSIVE 42120 42120 360 100.00 0.00 RESECTION OF LESION RESECTION OF PHARYNGEAL WALL REQUIRING 42894 42894 360 100.00 0.00 CLOSURE WITH MYOCUTANEOUS FLAP RESECTION OF RIBS, EXTRAPLEURAL, ALL 32900 32900 360 100.00 0.00 STAGES RESECTION OF SCROTUM 55150 55150 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF BASE OF 61600 61600 360 100.00 0.00 ANTERIOR CRANIAL FOSSA; EXTRADURAL RESECTION OR TRANSPLANTATION OF LONG 23440 23440 360 12,040.00 100.00 12,040.00 TENDON OF BICEPS RESECTION TEMPORAL BONE, EXTERNAL 69535 69535 360 100.00 0.00 APPROACH RESECTION, CONDYLE(S), DISTAL END OF 28153 28153 360 8,000.00 100.00 8,000.00 PHALANX, EACH TOE RESECTION, HUMERAL HEAD 23195 23195 360 100.00 0.00 RESECTION, PARTIAL OR COMPLETE, 28126 28126 360 8,000.00 100.00 8,000.00 PHALANGEAL BASE, EACH TOE RETRIEVAL DEVICE (USED TO RETRIEVE C1773-W C1773 278 100.00 0.00 BROKEN MEDICAL DEVICES RETRIEVAL DEVICE (USED TO RETRIEVE C1773-G C1773 278 700.00 0.00 BROKEN MEDICAL DEVICES) RETROBULBAR INJECTION; ALCOHOL 67505 67505 360 100.00 0.00 RETROBULBAR INJECTION; MEDICATION (SEPARATE PROCEDURE, DOES NOT INCLUDE 67500 67500 360 100.00 0.00 SUPPLY OF MEDICATION) REVISION AND/OR REINSERTION OF 47530 47530 360 100.00 0.00 TRANSHEPATIC TUBE REVISION FENESTRATION OPERATION 69840 69840 360 100.00 0.00

REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR 63663 63663 360 24,200.00 100.00 24,200.00 ELECTRODE PERCUTANEOUS ARRAY(S), INCLUDING FLUOROSCOPY, WHEN PERFORMED

REVISION INCLUDING REPLACEMENT, WHEN PERFORMED, OF SPINAL NEUROSTIMULATOR ELECTRODE PLATE/PADDLE(S) PLACED VIA 63664 63664 360 24,200.00 100.00 24,200.00 LAMINOTOMY OR LAMINECTOMY, INCLUDING FLUOROSCOPY, WHEN PERFORMED Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REVISION MASTOIDECTOMY; RESULTING IN 69601 69601 360 17,100.00 100.00 17,100.00 COMPLETE MASTOIDECTOMY REVISION MASTOIDECTOMY; RESULTING IN 69602 69602 360 100.00 0.00 MODIFIED RADICAL MASTOIDECTOMY REVISION MASTOIDECTOMY; RESULTING IN 69603 69603 360 100.00 0.00 RADICAL MASTOIDECTOMY REVISION MASTOIDECTOMY; RESULTING IN 69604 69604 360 100.00 0.00 TYMPANOPLASTY REVISION MASTOIDECTOMY; WITH 69605 69605 360 100.00 0.00 APICECTOMY REVISION OF AQUEOUS SHUNT TO 66185 66185 360 100.00 0.00 EXTRAOCULAR RESERVOIR REVISION OF ARTHROPLASTY, INCLUDING 25449 25449 360 100.00 0.00 REMOVAL OF IMPLANT, WRIST JOINT REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE 44345 44345 360 100.00 0.00 PROCEDURE) REVISION OF COLOSTOMY; SIMPLE (RELEASE 44340 44340 360 100.00 0.00 OF SUPERFICIAL SCAR) (SEPARATE PROCEDURE) REVISION OF COLOSTOMY; WITH REPAIR OF PARACOLOSTOMY HERNIA (SEPARATE 44346 44346 360 100.00 0.00 PROCEDURE) REVISION OF ILEOSTOMY; COMPLICATED (RECONSTRUCTION IN-DEPTH) (SEPARATE 44314 44314 360 100.00 0.00 PROCEDURE) REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF 44312 44312 360 100.00 0.00 SUPERFICIAL SCAR) (SEPARATE PROCEDURE) REVISION OF IMPLANTABLE INTRAVENOUS 36531 36531 360 100.00 0.00 INFUSION PUMP REVISION OF IMPLANTABLE VENOUS ACCESS 36534 36534 360 100.00 0.00 DEVICE, AND/OR SUBCUTANEOUS RESERVOIR REVISION OF IMPLANTED INTRA-ARTERIAL 36261 36261 360 100.00 0.00 INFUSION PUMP REVISION OF PERITONEAL-VENOUS SHUNT 49426 49426 360 100.00 0.00 REVISION OF RECONSTRUCTED BREAST 19380 19380 360 19,000.00 100.00 19,000.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REVISION OF SKIN POCKET FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER- 33223 33223 360 100.00 0.00 DEFIBRILLATOR REVISION OF STAPEDECTOMY OR 69662 69662 360 100.00 0.00 STAPEDOTOMY Revision of total elbow arthroplasty, including allograft 24370 24370 360 43,850.00 100.00 43,850.00 when performed; humeral or ulnar component REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, WITH OR 27137 27137 360 100.00 0.00 WITHOUT AUTOGRAFT OR ALLOGRAFT REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, WITH OR WITHOUT AUTOGRAFT 27134 27134 360 100.00 0.00 OR ALLOGRAFT REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, WITH OR 27138 27138 360 100.00 0.00 WITHOUT ALLOGRAFT REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; FEMORAL AND 27487 27487 360 100.00 0.00 ENTIRE TIBIAL COMPONENT REVISION OF TOTAL KNEE ARTHROPLASTY, WITH OR WITHOUT ALLOGRAFT; ONE 27486 27486 360 52,200.00 100.00 52,200.00 COMPONENT Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid 23474 23474 360 25,000.00 100.00 25,000.00 component REVISION OF TRACHEOSTOMY SCAR 31830 31830 360 100.00 0.00 REVISION OF URINARY-CUTANEOUS 50727 50727 360 100.00 0.00 ANASTOMOSIS (ANY TYPE UROSTOMY); REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE UROSTOMY); WITH 50728 50728 360 100.00 0.00 REPAIR OF FASCIAL DEFECT AND HERNIA REVISION OR RELOCATION OF SKIN POCKET 33222 33222 360 100.00 0.00 FOR PACEMAKER REVISION OR REMOVAL OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR 61888 61888 360 100.00 0.00 RECEIVER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee REVISION OR REMOVAL OF IMPLANTED SPINAL NEUROSTIMULATOR PULSE GENERATOR OR 63688 63688 360 13,650.00 100.00 13,650.00 RECEIVER REVISION OR REMOVAL OF PERIPHERAL 64585 64585 360 9,750.00 100.00 9,750.00 NEUROSTIMULATOR ELECTRODES REVISION OR REMOVAL OF PERIPHERAL NEUROSTIMULATOR PULSE GENERATOR OR 64595 64595 360 9,750.00 100.00 9,750.00 RECEIVER REVISION OR REMOVAL OF SPINAL NEUROSTIMULATOR ELECTRODE 63660 63660 360 13,650.00 100.00 13,650.00 PERCUTANEOUS ARRAY(S) OR PLATE/PADDLE(S) REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR 66250 66250 360 100.00 0.00 LATE, MAJOR OR MINOR PROCEDURE REVISION, OPEN, ARTERIOVENOUS FISTULA; WITH THROMBECTOMY, AUTOGENOUS OR 36833 36833 360 15,470.00 100.00 15,470.00 NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) REVISION, OPEN, ARTERIOVENOUS FISTULA; WITHOUT THROMBECTOMY, AUTOGENOUS OR 36832 36832 360 15,470.00 100.00 15,470.00 NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER 43848 43848 360 17,500.00 100.00 17,500.00 THAN ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE) RHEUMATOID FACTOR QUALITATIVE 86430 86430 302 100.00 100.00 100.00 RHEUMATOID FACTOR; QUANTITATIVE 86431 86431 302 100.00 100.00 100.00 RHINECTOMY; PARTIAL 30150 30150 360 17,100.00 100.00 17,100.00 RHINECTOMY; TOTAL 30160 30160 360 100.00 0.00 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP 30460 30460 360 100.00 0.00 AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP ONLY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT LIP 30462 30462 360 100.00 0.00 AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OSTEOTOMIES

RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, 30410 30410 360 100.00 0.00 LATERAL AND ALAR CARTILAGES, AND/OR ELEVATION OF NASAL TIP RHINOPLASTY, PRIMARY; INCLUDING MAJOR 30420 30420 360 100.00 0.00 SEPTAL REPAIR RHINOPLASTY, PRIMARY; LATERAL AND ALAR 30400 30400 360 100.00 0.00 CARTILAGES AND/OR ELEVATION OF NASAL TIP

RHINOPLASTY, SECONDARY; INTERMEDIATE 30435 30435 360 100.00 0.00 REVISION (BONY WORK WITH OSTEOTOMIES)

RHINOPLASTY, SECONDARY; MAJOR REVISION 30450 30450 360 100.00 0.00 (NASAL TIP WORK AND OSTEOTOMIES)

RHINOPLASTY, SECONDARY; MINOR REVISION 30430 30430 360 100.00 0.00 (SMALL AMOUNT OF NASAL TIP WORK) RHYTIDECTOMY; CHEEK, CHIN, AND NECK 15828 15828 360 100.00 0.00 RHYTIDECTOMY; FOREHEAD 15824 15824 360 100.00 0.00 RHYTIDECTOMY; GLABELLAR FROWN LINES 15826 15826 360 100.00 0.00 RHYTIDECTOMY; NECK WITH PLATYSMAL 15825 15825 360 100.00 0.00 TIGHTENING (PLATYSMAL FLAP, P-FLAP) RHYTIDECTOMY; SUPERFICIAL 15829 15829 360 100.00 0.00 MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP RIA NON ANTIBODY 83519 83519 301 170.00 100.00 170.00 RICKETTSIA ANTIBODY 86757 86757 302 290.00 100.00 290.00 RISTOCETIN CO FACTOR ACTIVITY 85245 85245 305 100.00 100.00 100.00 ROTAVIRUS ANTIBODY 86759 86759 302 200.00 100.00 200.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee RPR SYPHILLIS TEST QUANTITATIVE 86593 86593 302 100.00 100.00 100.00 RUBELLA ANTIBODY 86762 86762 302 140.00 100.00 140.00 RUBEOLA ANTIBODY 86765 86765 302 240.00 100.00 240.00 RUSSELL VIPER VENOM TIME; DILUTED 85613 85613 305 230.00 100.00 230.00 RX SCREEN QUAL; SINGLE RX 80101 80101 301 390.00 100.00 390.00 SACROSPINOUS LIGAMENT FIXATION FOR 57282 57282 360 19,200.00 100.00 19,200.00 PROLAPSE OF VAGINA SALABRASION; 20 SQ CM OR LESS 15810 15810 360 100.00 0.00 SALABRASION; OVER 20 SQ CM 15811 15811 360 100.00 0.00 SALICYCLATE LEVEL 80196 80196 301 500.00 100.00 500.00 SALMONELLA ANTIBODY 86768 86768 302 180.00 100.00 180.00 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL (SEPARATE 58700 58700 360 100.00 0.00 PROCEDURE) SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL 58720 58720 360 100.00 0.00 (SEPARATE PROCEDURE) SALPINGOSTOMY (SALPINGONEOSTOMY) 58770 58770 360 100.00 0.00 SCAPULOPEXY (EG, SPRENGELS DEFORMITY OR 23400 23400 360 100.00 0.00 FOR PARALYSIS) SCHEDULE CODE ONLY SCHED 360 100.00 0.00 SCLERAL REINFORCEMENT (SEPARATE 67255 67255 360 100.00 0.00 PROCEDURE); WITH GRAFT SCLERAL REINFORCEMENT (SEPARATE 67250 67250 360 100.00 0.00 PROCEDURE); WITHOUT GRAFT SCRAPING OF CORNEA, DIAGNOSTIC, FOR 65430 65430 360 100.00 0.00 SMEAR AND/OR CULTURE SCREENING MAMMOGRAPHY, BILATERAL (TWO 76092 76092 100.00 0.00 VIEW FILM STUDY OF EACH BREAST) SCROTAL EXPLORATION 55110 55110 360 10,250.00 100.00 10,250.00 SCROTOPLASTY; COMPLICATED 55180 55180 360 100.00 0.00 SCROTOPLASTY; SIMPLE 55175 55175 360 100.00 0.00 SECONDARY CLOSURE OF SURGICAL WOUND 13160 13160 360 9,830.00 100.00 9,830.00 OR DEHISCENCE, EXTENSIVE OR COMPLICATED SECONDARY REVISION OF 21275 21275 360 100.00 0.00 ORBITOCRANIOFACIAL RECONSTRUCTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SECTION RECURRENT LARYNGEAL NERVE, THERAPEUTIC (SEPARATE PROCEDURE), 31595 31595 360 100.00 0.00 UNILATERAL SEDIMENTATION RATE, ERYTHROCYTE; 85652 85652 302 90.00 100.00 90.00 AUTOMATED SELENIUM 84255 84255 301 200.00 100.00 200.00 SELF-CARE/HOME MANAGEMENT TRAINING (EG, ACTIVITIES OF DAILY LIVING (ADL) AND COMPENSATORY TRAINING, MEAL 97535 97535 100.00 0.00 PREPARATION, SAFETY PROCEDURES, AND INSTRUCTI SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO 97533 97533 100.00 0.00 ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON- ONE) PATIENT CONT SEPTAL OR OTHER INTRANASAL DERMATOPLASTY (DOES NOT INCLUDE 30620 30620 360 100.00 0.00 OBTAINING GRAFT) SEPTOPLASTY OR SUBMUCOUS RESECTION, WITH OR WITHOUT CARTILAGE SCORING, 30520 30520 360 11,280.00 100.00 11,280.00 CONTOURING OR REPLACEMENT WITH GRAFT

SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS 23170 23170 360 100.00 0.00 OR BONE ABSCESS), CLAVICLE

SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS 25145 25145 360 100.00 0.00 OR BONE ABSCESS), FOREARM AND/OR WRIST SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), HUMERAL HEAD TO 23174 23174 360 100.00 0.00 SURGICAL NECK SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS 24138 24138 360 100.00 0.00 OR BONE ABSCESS), OLECRANON PROCESS

SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS 24136 24136 360 100.00 0.00 OR BONE ABSCESS), RADIAL HEAD OR NECK Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS 23172 23172 360 100.00 0.00 OR BONE ABSCESS), SCAPULA SEQUESTRECTOMY (EG, FOR OSTEOMYELITIS OR BONE ABSCESS), SHAFT OR DISTAL 24134 24134 360 100.00 0.00 HUMERUS SERUM BACTERICIDAL TITER 87197 87197 306 210.00 100.00 210.00 SERUM ELECTROPHORESIS 84165 84165 301 260.00 100.00 260.00 SESAMOIDECTOMY, FIRST TOE (SEPARATE 28315 28315 360 8,000.00 100.00 8,000.00 PROCEDURE) SESAMOIDECTOMY, THUMB OR FINGER 26185 26185 360 100.00 0.00 (SEPARATE PROCEDURE) SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) 65870 65870 360 100.00 0.00 (SEPARATE PROCEDURE); ANTERIOR SYNECHIAE, EXCEPT GONIOSYNECHIAE SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) 65880 65880 360 100.00 0.00 (SEPARATE PROCEDURE); CORNEOVITREAL ADHESIONS SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR 65865 65865 360 100.00 0.00 WITHOUT INJECTION OF AIR OR LIQUID) (SEPARATE PROCEDURE); GONIOSYNECHIAE SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (WITH OR WITHOUT INJECTION OF AIR OR LIQUID) 65875 65875 360 100.00 0.00 (SEPARATE PROCEDURE); POSTERIOR SYNECHIAE SEVERING ADHESIONS OF ANTERIOR SEGMENT, 65860 65860 360 100.00 0.00 LASER TECHNIQUE (SEPARATE PROCEDURE) SEVERING OF TARSORRHAPHY 67710 67710 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, SHEETS, MEMBRANES OR 67031 67031 360 100.00 0.00 OPACITIES, LASER SURGERY (ONE OR MORE STAGES) SEX HORMONE BINDING GLOBULIN 84270 84270 301 420.00 100.00 420.00 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, 11310 11310 360 100.00 0.00 LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, 11311 11311 360 100.00 0.00 LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, 11312 11312 360 100.00 0.00 LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE, 11313 11313 360 100.00 0.00 LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, 11305 11305 360 100.00 0.00 GENITALIA; LESION DIAMETER 0.5 CM OR LESS

SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, 11306 11306 360 700.00 100.00 700.00 GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM

SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, 11307 11307 360 100.00 0.00 GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, 11308 11308 360 100.00 0.00 GENITALIA; LESION DIAMETER 2.0 CM OR GREATER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION 11300 11300 360 700.00 100.00 700.00 DIAMETER 0.5 CM OR LESS SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION 11301 11301 360 100.00 0.00 DIAMETER 0.6 TO 1.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION 11302 11302 360 100.00 0.00 DIAMETER 1.1 TO 2.0 CM SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION 11303 11303 360 100.00 0.00 DIAMETER OVER 2.0 CM SHIGA-LIKE TOXIN ANTIGEN EIA 87427 87427 302 270.00 100.00 270.00 SHIGELLA ANTIBODY 86771 86771 302 180.00 100.00 180.00 SHORTENING OF TENDON, EXTENSOR, HAND OR 26477 26477 360 100.00 0.00 FINGER, EACH TENDON SHORTENING OF TENDON, FLEXOR, HAND OR 26479 26479 360 100.00 0.00 FINGER, EACH TENDON Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 95926 95926 922 100.00 0.00 recording from the central nervous system; in lower limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 95938 95938 920 3,370.00 100.00 3,370.00 recording from the central nervous system; in upper and lower limbs SIALOGRAPHY, RADIOLOGICAL SUPERVISION 70390 70390 320 100.00 0.00 AND INTERPRETATION SIALOLITHOTOMY; PAROTID, EXTRAORAL OR 42340 42340 360 100.00 0.00 COMPLICATED INTRAORAL SIALOLITHOTOMY; SUBMANDIBULAR 42335 42335 360 100.00 0.00 (SUBMAXILLARY), COMPLICATED, INTRAORAL SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR PAROTID, 42330 42330 360 100.00 0.00 UNCOMPLICATED, INTRAORAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY 45330 45330 360 2,300.00 100.00 2,300.00 BRUSHING OR WASHING (SEPARATE PROCEDURE) SIGMOIDOSCOPY, FLEXIBLE; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY 45339 45339 360 2,250.00 100.00 2,250.00 FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, 45331 45331 360 2,300.00 100.00 2,300.00 SINGLE OR MULTIPLE SIGMOIDOSCOPY, FLEXIBLE; WITH CONTROL OF BLEEDING (EG, INJECTION, BIPOLAR CAUTERY, 45334 45334 360 100.00 0.00 UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR)

SIGMOIDOSCOPY, FLEXIBLE; WITH 45337 45337 360 100.00 0.00 DECOMPRESSION OF VOLVULUS, ANY METHOD

SIGMOIDOSCOPY, FLEXIBLE; WITH DILATION BY 45340 45340 360 3,800.00 100.00 3,800.00 BALLOON, 1 OR MORE STRICTURES

SIGMOIDOSCOPY, FLEXIBLE; WITH DIRECTED 45335 45335 360 3,250.00 100.00 3,250.00 SUBMUCOSAL INJECTION(S), ANY SUBSTANCE SIGMOIDOSCOPY, FLEXIBLE; WITH ENDOSCOPIC 45341 45341 360 3,800.00 100.00 3,800.00 ULTRASOUND EXAMINATION SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL 45332 45332 360 3,800.00 100.00 3,800.00 OF FOREIGN BODY SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) 45333 45333 360 2,300.00 100.00 2,300.00 BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY SIGMOIDOSCOPY, FLEXIBLE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) 45338 45338 360 3,800.00 100.00 3,800.00 BY SNARE TECHNIQUE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC STENT PLACEMENT 45345 45345 360 100.00 0.00 (INCLUDES PREDILATION) SIGMOIDOSCOPY, FLEXIBLE; WITH TRANSENDOSCOPIC ULTRASOUND GUIDED 45342 45342 360 100.00 0.00 INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) SIMPLE CYSTOMETROGRAM (CMG) (EG, SPINAL 51725 51725 360 100.00 0.00 MANOMETER) SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12016 12016 360 100.00 0.00 MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12011 12011 360 820.00 100.00 820.00 MUCOUS MEMBRANES; 2.5 CM OR LESS

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12013 12013 360 1,060.00 100.00 1,060.00 MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12017 12017 360 100.00 0.00 MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12014 12014 360 100.00 0.00 MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12015 12015 360 100.00 0.00 MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR 12018 12018 360 100.00 0.00 MUCOUS MEMBRANES; OVER 30.0 CM Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12005 12005 360 100.00 0.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12001 12001 360 850.00 100.00 850.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12002 12002 360 1,030.00 100.00 1,030.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12006 12006 360 100.00 0.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12004 12004 450 500.00 100.00 500.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 C

SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, 12007 12007 360 100.00 0.00 TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM SIMPLE UROFLOWMETRY (UFR) (EG, STOP- WATCH FLOW RATE, MECHANICAL 51736 51736 360 100.00 0.00 UROFLOWMETER) SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE 31070 31070 360 100.00 0.00 (TREPHINE OPERATION) SINUSOTOMY FRONTAL; NONOBLITERATIVE, 31086 31086 360 100.00 0.00 WITH OSTEOPLASTIC FLAP, BROW INCISION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SINUSOTOMY FRONTAL; NONOBLITERATIVE, 31087 31087 360 100.00 0.00 WITH OSTEOPLASTIC FLAP, CORONAL INCISION SINUSOTOMY FRONTAL; OBLITERATIVE WITHOUT OSTEOPLASTIC FLAP, BROW INCISION 31080 31080 360 100.00 0.00 (INCLUDES ABLATION) SINUSOTOMY FRONTAL; OBLITERATIVE, WITH 31084 31084 360 100.00 0.00 OSTEOPLASTIC FLAP, BROW INCISION SINUSOTOMY FRONTAL; OBLITERATIVE, WITH 31085 31085 360 100.00 0.00 OSTEOPLASTIC FLAP, CORONAL INCISION SINUSOTOMY FRONTAL; OBLITERATIVE, WITHOUT OSTEOPLASTIC FLAP, CORONAL 31081 31081 360 100.00 0.00 INCISION (INCLUDES ABLATION) SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL (FOR MUCOCELE OR OSTEOMA, 31075 31075 360 100.00 0.00 LYNCH TYPE) SINUSOTOMY, MAXILLARY (ANTROTOMY); 31020 31020 360 100.00 0.00 INTRANASAL SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) WITH REMOVAL OF 31032 31032 360 100.00 0.00 ANTROCHOANAL POLYPS SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL-LUC) WITHOUT REMOVAL 31030 31030 360 100.00 0.00 OF ANTROCHOANAL POLYPS SINUSOTOMY, SPHENOID, WITH OR WITHOUT 31050 31050 360 17,100.00 100.00 17,100.00 BIOPSY; SINUSOTOMY, SPHENOID, WITH OR WITHOUT BIOPSY; WITH MUCOSAL STRIPPING OR 31051 31051 360 100.00 0.00 REMOVAL OF POLYP(S) SINUSOTOMY, UNILATERAL, THREE OR MORE PARANASAL SINUSES (FRONTAL, MAXILLARY, 31090 31090 360 100.00 0.00 ETHMOID, SPHENOID) Skin substitute not otherwise specified Q4100-W Q4100 636 100.00 0.00 Skin substitute, not otherwise specified Q4100-G Q4100 636 700.00 0.00 SLING OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE (EG, FASCIA OR 53440 53440 360 100.00 0.00 SYNTHETIC) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SLING OPERATION FOR STRESS INCONTINENCE 57288 57288 360 18,200.00 100.00 18,200.00 (EG, FASCIA OR SYNTHETIC)

SLITTING OF PREPUCE, DORSAL OR LATERAL 54001 54001 360 7,450.00 100.00 7,450.00 (SEPARATE PROCEDURE); EXCEPT NEWBORN

SLITTING OF PREPUCE, DORSAL OR LATERAL 54000 54000 360 100.00 0.00 (SEPARATE PROCEDURE); NEWBORN

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, 44376 44376 360 100.00 0.00 WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE) SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF 44377 44377 360 5,750.00 100.00 5,750.00 DUODENUM, INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, 44378 44378 360 100.00 0.00 BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; WITH 44379 44379 360 100.00 0.00 TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; 44360 44360 360 3,900.00 100.00 3,900.00 DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH ABLATION OF TUMOR(S), POLYP(S), OR OTHER 44369 44369 360 100.00 0.00 LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF 44361 44361 360 100.00 0.00 DUODENUM, NOT INCLUDING ILEUM; WITH BIOPSY, SINGLE OR MULTIPLE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH CONTROL OF BLEEDING (EG, INJECTION, 44366 44366 360 100.00 0.00 BIPOLAR CAUTERY, UNIPOLAR CAUTERY, LASER, HEATER PROBE, STAPLER, PLASMA COAGULATOR) SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH 44373 44373 360 100.00 0.00 CONVERSION OF PERCUTANEOUS GASTROSTOMY TUBE TO PERCUTANEOUS JEJUNOSTOMY TUBE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH 44372 44372 360 100.00 0.00 PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF 44363 44363 360 100.00 0.00 DUODENUM, NOT INCLUDING ILEUM; WITH REMOVAL OF FOREIGN BODY SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH 44365 44365 360 100.00 0.00 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH 44364 44364 360 100.00 0.00 REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; WITH 44370 44370 360 100.00 0.00 TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION) SMEAR GRAM STAIN 87205 87205 306 100.00 100.00 100.00 SMEAR SPECIAL STAIN 87207 87207 306 180.00 100.00 180.00 SMEAR WET MOUNT SALINE/INK 87210 87210 306 90.00 100.00 90.00 SNIP INCISION OF LACRIMAL PUNCTUM 68440 68440 360 100.00 0.00 SODIUM, URINE 84300 84300 301 60.00 100.00 60.00 SODIUM; SERUM 84295 84295 301 50.00 100.00 50.00 sono abdomen 2333 100.00 0.00 SPECIAL STAIN GROUP 1 88312 88312 311 310.00 100.00 310.00 SPECTROPHOTOMETRY ANALYTE 84311 84311 301 80.00 100.00 80.00 SPHINCTEROPLASTY, ANAL, FOR 46750 46750 360 100.00 0.00 INCONTINENCE OR PROLAPSE; ADULT SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; IMPLANTATION 46762 46762 360 100.00 0.00 ARTIFICIAL SPHINCTER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE 46761 46761 360 100.00 0.00 IMBRICATION (PARK POSTERIOR ANAL REPAIR)

SPHINCTEROPLASTY, ANAL, FOR 46760 46760 360 100.00 0.00 INCONTINENCE, ADULT; MUSCLE TRANSPLANT SPHINCTEROTOMY, ANAL, DIVISION OF 46080 46080 360 6,700.00 100.00 6,700.00 SPHINCTER (SEPARATE PROCEDURE) SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC 62270 62270 360 100.00 0.00 SPINAL PUNCTURE, THERAPEUTIC, FOR DRAINAGE OF CEREBROSPINAL FLUID (BY 62272 62272 360 100.00 0.00 NEEDLE OR CATHETER) Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with 94010 94010 460 750.00 100.00 750.00 or without maximal voluntary ventilation SPLINT A4570-G A4570 278 700.00 0.00 SPLINT. A4570-W A4570 278 100.00 0.00

SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT 15121 15121 360 6,800.00 100.00 6,800.00 OF BODY AREA OF INFANTS AND CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO C

SPLIT GRAFT, FACE, SCALP, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, HANDS, FEET AND/OR MULTIPLE DIGITS; FIRST 100 SQ CM OR 15120 15120 360 13,540.00 100.00 13,540.00 LESS, OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) SPLIT GRAFT, TRUNK, ARMS, LEGS; EACH ADDITIONAL 100 SQ CM, OR EACH ADDITIONAL ONE PERCENT OF BODY AREA OF INFANTS AND 15101 15101 360 6,400.00 100.00 6,400.00 CHILDREN, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SPLIT GRAFT, TRUNK, ARMS, LEGS; FIRST 100 SQ CM OR LESS, OR ONE PERCENT OF BODY AREA 15100 15100 360 11,850.00 100.00 11,850.00 OF INFANTS AND CHILDREN (EXCEPT 15050) STAGING LAPAROTOMY FOR HODGKINS DISEASE OR LYMPHOMA (INCLUDES SPLENECTOMY, NEEDLE OR OPEN BIOPSIES OF 49220 49220 360 100.00 0.00 BOTH LIVER LOBES, POSSIBLY ALSO REMOVAL OF ABDOM STAIN GROUP 2, OTHER 88313 88313 311 250.00 100.00 250.00 STANDARD U/S GREATER THAN 14 WEEKS 76802 76802 402 400.00 100.00 400.00 GESTATION STANDARD ULTRASOUND GREATER THAN 14 76810 76810 402 350.00 100.00 350.00 WEEKS( ADD GESTATION) STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR 69660 69660 360 17,760.00 100.00 17,760.00 CONTINUITY, WITH OR WITHOUT USE OF FOREIGN MATERIAL; STAPEDECTOMY OR STAPEDOTOMY WITH REESTABLISHMENT OF OSSICULAR CONTINUITY, WITH OR WITHOUT USE OF 69661 69661 360 100.00 0.00 FOREIGN MATERIAL; WITH FOOTPLATE DRILL OUT STAPES MOBILIZATION 69650 69650 360 100.00 0.00 STENT W/O DELIVERY SYSTEM C1875-G C1875 278 700.00 0.00 STENT WITHOUT A DELIVERY SYSTEM C1875-W C1875 278 100.00 0.00 STENT, NONCORONARY TEMP WITH DELIVERY C2625-G C2625 278 700.00 0.00 SYSTEM STENT, NONCORONARY TEMPORARY WITH C2625-W C2625 278 100.00 0.00 DELIVERY SYSTEM STENT, NONCORONARY TEMPORARY WITH OUT C2617-W C2617 278 100.00 0.00 DELIVERY SYSTEM STENT, NONCORONARY TEMPORARY WITHOUT C2617-G C2617 278 700.00 0.00 DELIVERY SYSTEM STEREOTACTIC BIOPSY, ASPIRATION, OR 63615 63615 360 100.00 0.00 EXCISION OF LESION, SPINAL CORD Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

STEREOTACTIC COMPUTER ASSISTED VOLUMETRIC (NAVIGATIONAL) PROCEDURE, INTRACRANIAL, EXTRACRANIAL, OR SPINAL 61795 61795 360 100.00 0.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRI

STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT (EG, 76095 76095 329 100.00 0.00 FOR WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPER

STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, SEPARATE PROCEDURE NOT 63610 63610 360 100.00 0.00 FOLLOWED BY OTHER SURGERY STERNAL DEBRIDEMENT 21627 21627 360 100.00 0.00 STIMULUS EVOKED RESPONSE (EG, MEASUREMENT OF BULBOCAVERNOSUS 51792 51792 360 100.00 0.00 REFLEX LATENCY TIME) STOOL LEUKOCYTE ASSESSMENT 89055 89055 920 120.00 100.00 120.00 STRABISMUS SURGERY BY POSTERIOR FIXATION SUTURE TECHNIQUE, WITH OR WITHOUT MUSCLE RECESSION (LIST 67334 67334 360 100.00 0.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) STRABISMUS SURGERY INVOLVING EXPLORATION AND/OR REPAIR OF DETACHED EXTRAOCULAR MUSCLE(S) (LIST SEPARATELY 67340 67340 360 100.00 0.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) STRABISMUS SURGERY ON PATIENT WITH PREVIOUS EYE SURGERY OR INJURY THAT DID NOT INVOLVE THE EXTRAOCULAR MUSCLES 67331 67331 360 100.00 0.00 (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

STRABISMUS SURGERY ON PATIENT WITH SCARRING OF EXTRAOCULAR MUSCLES (EG, PRIOR OCULAR INJURY, STRABISMUS OR RETINAL DETACHMENT SURGERY) OR 67332 67332 360 100.00 0.00 RESTRICTIVE MYOPATHY (EG, DYSTHYROID OPHTHALMOPATHY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) STRABISMUS SURGERY, ANY PROCEDURE, 67318 67318 360 100.00 0.00 SUPERIOR OBLIQUE MUSCLE STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE HORIZONTAL 67311 67311 360 9,060.00 100.00 9,060.00 MUSCLE STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; ONE VERTICAL 67314 67314 360 100.00 0.00 MUSCLE (EXCLUDING SUPERIOR OBLIQUE) STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO HORIZONTAL 67312 67312 360 10,350.00 100.00 10,350.00 MUSCLES STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE; TWO OR MORE 67316 67316 360 100.00 0.00 VERTICAL MUSCLES (EXCLUDING SUPERIOR OBLIQUE) STRAPPING; ANKLE AND/OR FOOT 29540 29540 360 750.00 100.00 750.00 STRAPPING; ELBOW OR WRIST 29260 29260 360 100.00 0.00 STRAPPING; HAND OR FINGER 29280 29280 360 100.00 0.00 STRAPPING; HIP 29520 29520 360 1,130.00 100.00 1,130.00 STRAPPING; KNEE 29530 29530 360 100.00 0.00 STRAPPING; LOW BACK 29220 29220 360 100.00 0.00 STRAPPING; SHOULDER (EG, VELPEAU) 29240 29240 360 100.00 0.00 STRAPPING; THORAX 29200 29200 360 100.00 0.00 STRAPPING; UNNA BOOT 29580 29580 360 100.00 0.00 STREP GROUP A, RAPID TEST 87880 87880 306 100.00 100.00 100.00 STREPTOCOCCUS GROUP A EIA 87430 87430 306 160.00 100.00 160.00 STREPTOCOCCUS PNEUMONIAE ANTIGEN 86403 86403 302 100.00 100.00 100.00 DETECTION STUMP ELONGATION, UPPER EXTREMITY 24935 24935 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SUBCONJUNCTIVAL INJECTION 68200 68200 360 100.00 0.00 SUBCUTANEOUS HORMONE PELLET IMPLANTATION (IMPLANTATION OF ESTRADIOL 11980 11980 360 100.00 0.00 AND/OR TESTOSTERONE PELLETS BENEATH THE SKIN) SUBCUTANEOUS INJECTION OF FILLING 11950 11950 360 100.00 0.00 MATERIAL (EG, COLLAGEN); 1 CC OR LESS SUBCUTANEOUS INJECTION OF FILLING 11952 11952 360 100.00 0.00 MATERIAL (EG, COLLAGEN); 5.1 TO 10.0 CC SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL OR BILATERAL; 61000 61000 360 100.00 0.00 INITIAL SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL OR BILATERAL; 61001 61001 360 100.00 0.00 SUBSEQUENT TAPS SUBMUCOUS RESECTION TURBINATE, PARTIAL 30140 30140 360 10,020.00 100.00 10,020.00 OR COMPLETE, ANY METHOD SUBTRACTION IN CONJUNCTION WITH 76350 76350 329 100.00 0.00 CONTRAST STUDIES SUCTION ASSISTED LIPECTOMY; HEAD AND 15876 15876 360 10,550.00 100.00 10,550.00 NECK SUCTION ASSISTED LIPECTOMY; LOWER 15879 15879 360 100.00 0.00 EXTREMITY SUCTION ASSISTED LIPECTOMY; TRUNK 15877 15877 360 100.00 0.00 SUCTION ASSISTED LIPECTOMY; UPPER 15878 15878 360 10,550.00 100.00 10,550.00 EXTREMITY SUPPLIES AND MATERIALS (EXCEPT SPECTACLES), PROVIDED BY THE PHYSICIAN 99070 99070 278 100.00 0.00 OVER AND ABOVE THOSE USUALLY INCLUDED WITH THE OFFICE VISIT OR OTHER SERVICES RE SUPPLY OF PARAMAGENTIC CONTRAST A4647 A4647 100.00 0.00 MATERIAL SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), WITH OR 58180 58180 360 100.00 0.00 WITHOUT REMOVAL OF TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SUPRAHYOID LYMPHADENECTOMY 38700 38700 360 100.00 0.00 SURG PATH GROSS EXAM ONLY 88300 88300 311 160.00 100.00 160.00 SURGICAL CLOSURE TRACHEOSTOMY OR 31825 31825 360 100.00 0.00 FISTULA; WITH PLASTIC REPAIR SURGICAL CLOSURE TRACHEOSTOMY OR 31820 31820 360 8,900.00 100.00 8,900.00 FISTULA; WITHOUT PLASTIC REPAIR SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN 15001 15001 360 100.00 0.00 WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING SUBCUTANEOUS TISSUES); EACH ADDITIONAL SURGICAL PREPARATION OR CREATION OF RECIPIENT SITE BY EXCISION OF OPEN WOUNDS, BURN ESCHAR, OR SCAR (INCLUDING 15000 15000 360 100.00 0.00 SUBCUTANEOUS TISSUES); FIRST 100 SQ CM OR ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); COMPLEX OR 46280 46280 360 8,900.00 100.00 8,900.00 MULTIPLE, WITH OR WITHOUT PLACEMENT OF SETON SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND 46285 46285 360 100.00 0.00 STAGE SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 46270 46270 360 8,900.00 100.00 8,900.00 SUBCUTANEOUS SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); 46275 46275 360 100.00 0.00 SUBMUSCULAR SUSCEPTIBILITY-AGAR DILUTION METHOD 87181 87181 306 100.00 100.00 100.00 SUSCEPTIBILITY-DISK METHOD 87184 87184 306 130.00 100.00 130.00 SUSCEPTIBILITY-ENZYME DETECTION; PER 87185 87185 306 110.00 100.00 110.00 ENZYME SUSCEPTIBILITY-MACROBROTH DILUTION, 87188 87188 306 150.00 100.00 150.00 EACH AGENT SUSCEPTIBILITY-MLC, EACH PLATE 87187 87187 306 150.00 100.00 150.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SUSCEPTIBILITY-MYCOBACTERIA, PROPORTION, 87190 87190 306 110.00 100.00 110.00 EACH AGENT SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR DECOMPRESSION; 69745 69745 360 100.00 0.00 INCLUDING MEDIAL TO GENICULATE GANGLION

SUTURE FACIAL NERVE, INTRATEMPORAL, WITH OR WITHOUT GRAFT OR DECOMPRESSION; 69740 69740 360 18,070.00 100.00 18,070.00 LATERAL TO GENICULATE GANGLION SUTURE OF DIGITAL NERVE, HAND OR FOOT; EACH ADDITIONAL DIGITAL NERVE (LIST 64832 64832 360 100.00 0.00 SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) SUTURE OF DIGITAL NERVE, HAND OR FOOT; 64831 64831 360 13,650.00 100.00 13,650.00 ONE NERVE SUTURE OF EACH ADDITIONAL MAJOR PERIPHERAL NERVE (LIST SEPARATELY IN 64859 64859 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE)

SUTURE OF EACH ADDITIONAL NERVE, HAND OR FOOT (LIST SEPARATELY IN ADDITION TO 64837 64837 360 6,000.00 100.00 6,000.00 CODE FOR PRIMARY PROCEDURE) SUTURE OF ESOPHAGEAL WOUND OR INJURY; 43410 43410 360 100.00 0.00 CERVICAL APPROACH SUTURE OF ESOPHAGEAL WOUND OR INJURY; TRANSTHORACIC OR TRANSABDOMINAL 43415 43415 360 100.00 0.00 APPROACH SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR 47900 47900 360 100.00 0.00 PRE-EXISTING INJURY (SEPARATE PROCEDURE)

SUTURE OF FACIAL NERVE; EXTRACRANIAL 64864 64864 360 100.00 0.00

SUTURE OF FACIAL NERVE; INFRATEMPORAL, 64865 64865 360 100.00 0.00 WITH OR WITHOUT GRAFTING Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SUTURE OF INFRAPATELLAR TENDON; PRIMARY 27380 27380 360 11,900.00 100.00 11,900.00 SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTRUCTION, INCLUDING 27381 27381 360 16,270.00 100.00 16,270.00 FASCIAL OR TENDON GRAFT SUTURE OF IRIS, CILIARY BODY (SEPARATE PROCEDURE) WITH RETRIEVAL OF SUTURE 66682 66682 360 100.00 0.00 THROUGH SMALL INCISION (EG, MCCANNEL SUTURE) SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, 44605 44605 360 100.00 0.00 WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITH COLOSTOMY

SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, 44604 44604 360 100.00 0.00 WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); WITHOUT COLOST SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; INCLUDING 64856 64856 360 100.00 0.00 TRANSPOSITION SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; WITHOUT 64857 64857 360 13,650.00 100.00 13,650.00 TRANSPOSITION SUTURE OF MESENTERY (SEPARATE 44850 44850 360 100.00 0.00 PROCEDURE) SUTURE OF NERVE; REQUIRING EXTENSIVE MOBILIZATION, OR TRANSPOSITION OF NERVE 64874 64874 360 100.00 0.00 (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE SUTURE) SUTURE OF NERVE; REQUIRING SECONDARY OR DELAYED SUTURE (LIST SEPARATELY IN 64872 64872 360 100.00 0.00 ADDITION TO CODE FOR PRIMARY NEURORRHAPHY) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

SUTURE OF NERVE; REQUIRING SHORTENING OF BONE OF EXTREMITY (LIST SEPARATELY IN 64876 64876 360 100.00 0.00 ADDITION TO CODE FOR NERVE SUTURE) SUTURE OF ONE NERVE, HAND OR FOOT; 64834 64834 360 13,500.00 100.00 13,500.00 COMMON SENSORY NERVE SUTURE OF ONE NERVE, HAND OR FOOT; 64835 64835 360 13,500.00 100.00 13,500.00 MEDIAN MOTOR THENAR SUTURE OF ONE NERVE, HAND OR FOOT; ULNAR 64836 64836 360 13,500.00 100.00 13,500.00 MOTOR SUTURE OF POSTERIOR TIBIAL NERVE 64840 64840 360 100.00 0.00 SUTURE OF QUADRICEPS OR HAMSTRING 27385 27385 360 100.00 0.00 MUSCLE RUPTURE; PRIMARY SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY 27386 27386 360 100.00 0.00 RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/OR 67935 67935 360 100.00 0.00 PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/OR 67930 67930 360 100.00 0.00 PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; PARTIAL THICKNESS SUTURE OF SCIATIC NERVE 64858 64858 360 100.00 0.00 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, 44603 44603 360 100.00 0.00 DIVERTICULUM, WOUND, INJURY OR RUPTURE; MULTIPLE PERFORATIONS SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, 44602 44602 360 100.00 0.00 DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION SUTURE OF TONGUE TO LIP FOR 41510 41510 360 100.00 0.00 MICROGNATHIA (DOUGLAS TYPE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SUTURE OF TRACHEAL WOUND OR INJURY; 31800 31800 360 100.00 0.00 CERVICAL SUTURE OF TRACHEAL WOUND OR INJURY; 31805 31805 360 100.00 0.00 INTRATHORACIC SUTURE OF; BRACHIAL PLEXUS 64861 64861 360 100.00 0.00 SUTURE OF; LUMBAR PLEXUS 64862 64862 360 100.00 0.00 SUTURE OR REPAIR OF TESTICULAR INJURY 54670 54670 360 100.00 0.00 SUTURE PHARYNX FOR WOUND OR INJURY 42900 42900 360 100.00 0.00 SUTURE, SECONDARY, OF ABDOMINAL WALL 49900 49900 360 100.00 0.00 FOR EVISCERATION OR DEHISCENCE SWALLOWING FUNCTION, WITH 74230 74230 320 100.00 0.00 CINERADIOGRAPHY/VIDEORADIOGRAPHY SYMPATHECTOMY, CERVICAL 64802 64802 360 100.00 0.00 SYMPATHECTOMY, CERVICOTHORACIC 64804 64804 360 100.00 0.00 SYMPATHECTOMY, LUMBAR 64818 64818 360 100.00 0.00 SYMPATHECTOMY, THORACOLUMBAR 64809 64809 360 100.00 0.00 SYMPATHECTOMY; DIGITAL ARTERIES, EACH 64820 64820 360 100.00 0.00 DIGIT SYMPATHECTOMY; RADIAL ARTERY 64821 64821 360 100.00 0.00 SYMPATHECTOMY; SUPERFICIAL PALMAR 64823 64823 360 100.00 0.00 ARCH SYMPATHECTOMY; ULNAR ARTERY 64822 64822 360 100.00 0.00 SYNDACTYLIZATION, TOES (EG, WEBBING OR 28280 28280 360 100.00 0.00 KELIKIAN TYPE PROCEDURE) SYNOVECTOMY, CARPOMETACARPAL JOINT 26130 26130 360 100.00 0.00 SYNOVECTOMY, EXTENSOR TENDON SHEATH, 25118 25118 360 11,900.00 100.00 11,900.00 WRIST, SINGLE COMPARTMENT; SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; WITH 25119 25119 360 100.00 0.00 RESECTION OF DISTAL ULNA SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING INTRINSIC RELEASE AND 26135 26135 360 9,600.00 100.00 9,600.00 EXTENSOR HOOD RECONSTRUCTION, EACH DIGIT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, INCLUDING 26140 26140 360 100.00 0.00 EXTENSOR RECONSTRUCTION, EACH INTERPHALANGEAL JOINT SYNOVECTOMY, TENDON SHEATH, FOOT; 28088 28088 360 8,000.00 100.00 8,000.00 EXTENSOR SYNOVECTOMY, TENDON SHEATH, FOOT; 28086 28086 360 8,000.00 100.00 8,000.00 FLEXOR SYNOVECTOMY, TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR TENDON, PALM 26145 26145 360 8,500.00 100.00 8,500.00 AND/OR FINGER, EACH TENDON SYNOVECTOMY; INTERTARSAL OR 28070 28070 360 100.00 0.00 TARSOMETATARSAL JOINT, EACH SYNOVECTOMY; METATARSOPHALANGEAL 28072 28072 360 3,800.00 100.00 3,800.00 JOINT, EACH SYPHILIS TEST; QUALITATIVE (EG, VDRL, RPR, 86592 86592 302 100.00 100.00 100.00 ART) T3 FREE 84481 84481 301 200.00 100.00 200.00 T3 TOTAL 84480 84480 301 150.00 100.00 150.00 TALECTOMY (ASTRAGALECTOMY) 28130 28130 360 100.00 0.00

TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT 11920 11920 360 100.00 0.00 COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS

TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING 11922 11922 360 100.00 0.00 MICROPIGMENTATION; EACH ADDITIONAL 20.0 S

TD VACC NO PRESV 7 YRS+ IM 90714 90714 250 51.36 100.00 51.36 TEMPORARY CLOSURE OF EYELIDS BY SUTURE 67875 67875 360 100.00 0.00 (EG, FROST SUTURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TEMPOROMANDIBULAR JOINT ARTHROGRAPHY, RADIOLOGICAL SUPERVISION AND 70332 70332 320 100.00 0.00 INTERPRETATION TENDON GRAFT, FROM A DISTANCE (EG, 20924 20924 360 100.00 0.00 PALMARIS, TOE EXTENSOR, PLANTARIS) TENDON LENGTHENING, UPPER ARM OR 24305 24305 360 100.00 0.00 ELBOW, EACH TENDON TENDON SHEATH INCISION (EG, FOR TRIGGER 26055 26055 360 8,500.00 100.00 8,500.00 FINGER) TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR 25310 25310 360 11,900.00 100.00 11,900.00 WRIST, SINGLE; EACH TENDON

TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR 25312 25312 360 17,250.00 100.00 17,250.00 WRIST, SINGLE; WITH TENDON GRAFT(S) (INCLUDES OBTAINING GRAFT), EACH TENDON Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector C9356-G C9356 278 100.00 0.00 Sheet), per sq cm Tendon, porous matrix of cross-linked collagen and glycosaminoglycan matrix (TenoGlide Tendon Protector C9356-W C9356 278 100.00 0.00 Sheet), per sq cm W TENODESIS AT WRIST; EXTENSORS OF FINGERS 25301 25301 360 100.00 0.00

TENODESIS AT WRIST; FLEXORS OF FINGERS 25300 25300 360 100.00 0.00 TENODESIS OF BICEPS TENDON AT ELBOW 24340 24340 360 17,250.00 100.00 17,250.00 (SEPARATE PROCEDURE) TENODESIS OF LONG TENDON OF BICEPS 23430 23430 360 17,250.00 100.00 17,250.00 TENODESIS; OF DISTAL JOINT, EACH JOINT 26474 26474 360 8,500.00 100.00 8,500.00 TENODESIS; OF PROXIMAL INTERPHALANGEAL 26471 26471 360 100.00 0.00 JOINT, EACH JOINT TENOLYSIS, COMPLEX, EXTENSOR TENDON, 26449 26449 360 100.00 0.00 FINGER, INCLUDING FOREARM, EACH TENDON Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TENOLYSIS, EXTENSOR TENDON, HAND OR 26445 26445 360 6,910.00 100.00 6,910.00 FINGER; EACH TENDON TENOLYSIS, EXTENSOR, FOOT; MULTIPLE 28226 28226 360 100.00 0.00 TENDONS TENOLYSIS, EXTENSOR, FOOT; SINGLE TENDON 28225 28225 360 100.00 0.00 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH 25295 25295 360 11,900.00 100.00 11,900.00 TENDON TENOLYSIS, FLEXOR OR EXTENSOR TENDON, LEG AND/OR ANKLE; MULTIPLE TENDONS 27681 27681 360 100.00 0.00 (THROUGH SEPARATE INCISION(S))

TENOLYSIS, FLEXOR OR EXTENSOR TENDON, 27680 27680 360 100.00 0.00 LEG AND/OR ANKLE; SINGLE, EACH TENDON TENOLYSIS, FLEXOR TENDON; PALM AND 26442 26442 360 10,150.00 100.00 10,150.00 FINGER, EACH TENDON TENOLYSIS, FLEXOR TENDON; PALM OR FINGER, 26440 26440 360 100.00 0.00 EACH TENDON TENOLYSIS, FLEXOR, FOOT; MULTIPLE 28222 28222 360 100.00 0.00 TENDONS TENOLYSIS, FLEXOR, FOOT; SINGLE TENDON 28220 28220 360 8,000.00 100.00 8,000.00 TENOLYSIS, TRICEPS 24332 24332 360 100.00 0.00 TENOPLASTY, WITH MUSCLE TRANSFER, WITH OR WITHOUT FREE GRAFT, ELBOW TO 24320 24320 360 100.00 0.00 SHOULDER, SINGLE (SEDDON-BROOKES TYPE PROCEDURE) TENOTOMY, ABDUCTORS AND/OR EXTENSOR(S) 27006 27006 360 100.00 0.00 OF HIP, OPEN (SEPARATE PROCEDURE) TENOTOMY, ADDUCTOR OF HIP, OPEN 27001 27001 360 100.00 0.00 TENOTOMY, ADDUCTOR OF HIP, 27000 27000 360 100.00 0.00 PERCUTANEOUS (SEPARATE PROCEDURE) TENOTOMY, ADDUCTOR, SUBCUTANEOUS, 27003 27003 360 100.00 0.00 OPEN, WITH OBTURATOR NEURECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S 24358 24358 360 11,200.00 100.00 11,200.00 ELBOW); DEBRIDEMENT, SOFT TISSUE AND/OR BONE, OPEN TENOTOMY, ELBOW, LATERAL OR MEDIAL (EG, EPICONDYLITIS, TENNIS ELBOW, GOLFER'S 24357 24357 360 13,600.00 100.00 13,600.00 ELBOW); PERCUTANEOUS TENOTOMY, EXTENSOR, HAND OR FINGER, 26460 26460 360 6,380.00 100.00 6,380.00 OPEN, EACH TENDON TENOTOMY, FLEXOR, FINGER, OPEN, EACH 26455 26455 360 9,460.00 100.00 9,460.00 TENDON TENOTOMY, FLEXOR, PALM, OPEN, EACH 26450 26450 360 100.00 0.00 TENDON TENOTOMY, HIP FLEXOR(S), OPEN (SEPARATE 27005 27005 360 100.00 0.00 PROCEDURE) TENOTOMY, LENGTHENING, OR RELEASE, 28240 28240 360 8,420.00 100.00 8,420.00 ABDUCTOR HALLUCIS MUSCLE TENOTOMY, OPEN, ELBOW TO SHOULDER, EACH 24310 24310 360 8,630.00 100.00 8,630.00 TENDON TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE, 28234 28234 360 8,000.00 100.00 8,000.00 EACH TENDON TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, 25290 25290 360 11,900.00 100.00 11,900.00 EACH TENDON TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; 27392 27392 360 100.00 0.00 MULTIPLE TENDONS, BILATERAL TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; 27391 27391 360 100.00 0.00 MULTIPLE TENDONS, ONE LEG TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; 27390 27390 360 100.00 0.00 SINGLE TENDON TENOTOMY, OPEN, TENDON FLEXOR; FOOT, SINGLE OR MULTIPLE TENDON(S) (SEPARATE 28230 28230 360 8,000.00 100.00 8,000.00 PROCEDURE) TENOTOMY, OPEN, TENDON FLEXOR; TOE, 28232 28232 360 8,000.00 100.00 8,000.00 SINGLE TENDON (SEPARATE PROCEDURE) TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); GENERAL 27606 27606 360 7,600.00 100.00 7,600.00 ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TENOTOMY, PERCUTANEOUS, ACHILLES TENDON (SEPARATE PROCEDURE); LOCAL 27605 27605 360 8,000.00 100.00 8,000.00 ANESTHESIA TENOTOMY, PERCUTANEOUS, ADDUCTOR OR 27307 27307 360 100.00 0.00 HAMSTRING; MULTIPLE TENDONS TENOTOMY, PERCUTANEOUS, ADDUCTOR OR HAMSTRING; SINGLE TENDON (SEPARATE 27306 27306 360 8,530.00 100.00 8,530.00 PROCEDURE) TENOTOMY, PERCUTANEOUS, SINGLE, EACH 26060 26060 360 100.00 0.00 DIGIT TENOTOMY, PERCUTANEOUS, TOE; MULTIPLE 28011 28011 360 100.00 0.00 TENDONS TENOTOMY, PERCUTANEOUS, TOE; SINGLE 28010 28010 360 5,600.00 100.00 5,600.00 TENDON TENOTOMY, SHOULDER AREA; MULTIPLE 23406 23406 360 100.00 0.00 TENDONS THROUGH SAME INCISION TENOTOMY, SHOULDER AREA; SINGLE TENDON 23405 23405 360 11,900.00 100.00 11,900.00 TESTOSTERONE, FREE 84402 84402 301 200.00 100.00 200.00 TESTOSTERONE, TOTAL 84403 84403 301 200.00 100.00 200.00 TETANUS ANTIBODY 86774 86774 302 320.00 100.00 320.00

THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON- ONE) PATIENT CONTACT BY THE PROVIDER 97530 97530 420 200.00 100.00 200.00 (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MIN THERAPEUTIC ENEMA, CONTRAST OR AIR, FOR REDUCTION OF INTUSSUSCEPTION OR OTHER 74283 74283 320 100.00 0.00 INTRALUMINAL OBSTRUCTION (EG, MECONIUM ILEUS) THERAPEUTIC PROCEDURE(S), GROUP (2 OR 97150 97150 100.00 0.00 MORE INDIVIDUALS) THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES GAIT TRAINING 97116-MEDICARE 97116 420 150.00 100.00 150.00 (INCLUDES STAIR CLIMBING) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND 97110-MEDICARE 97110 420 200.00 100.00 200.00 ENDURANCE, RANGE OF MOTION AND FLEXIBILITY THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY 97113 97113 100.00 0.00 WITH THERAPEUTIC EXERCISES THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING 97116-G 97116 420 150.00 100.00 150.00 (INCLUDES STAIR CLIMBING) THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR 97124 97124 100.00 0.00 TAPOTEMENT (STROKING, COMPRESSION, PERCUSS THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, 97112 97112 100.00 0.00 COORDINATION, KINESTHETIC SENSE, POSTURE, A THERAPEUTIC PROCEDURE, ONE OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND 97110-G 97110 420 200.00 100.00 200.00 ENDURANCE, RANGE OF MOTION AND FLEXIBILITY Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential 96375 96375 260 150.00 100.00 150.00 intravenous push of a new substance/drug (List separately in addition to code for primary procedure) Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in 96376 96376 260 100.00 100.00 100.00 a facility (List separately in addition to code for primary procedure) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial 96374 96374 260 500.00 100.00 500.00 substance/drug Therapeutic, prophylactic, or diagnostic injection (specify 96372 96372 260 250.00 100.00 250.00 substance or drug); subcutaneous or intramuscular THIAMINE (VITAMIN B1) 84425 84425 301 50.00 100.00 50.00 THORACENTESIS WITH INSERTION OF TUBE WITH OR WITHOUT WATER SEAL (EG, FOR 32002 32002 360 100.00 0.00 PNEUMOTHORAX) (SEPARATE PROCEDURE) THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, INITIAL OR 32000 32000 360 100.00 0.00 SUBSEQUENT THORACOPLASTY, SCHEDE TYPE OR 32905 32905 360 100.00 0.00 EXTRAPLEURAL (ALL STAGES); THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); WITH CLOSURE 32906 32906 360 100.00 0.00 OF BRONCHOPLEURAL FISTULA THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND PLEURAL SPACE, 32602 32602 360 100.00 0.00 WITH BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); LUNGS AND PLEURAL SPACE, 32601 32601 360 14,550.00 100.00 14,550.00 WITHOUT BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITH 32606 32606 360 100.00 0.00 BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); MEDIASTINAL SPACE, WITHOUT 32605 32605 360 100.00 0.00 BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE 32604 32604 360 100.00 0.00 PROCEDURE); PERICARDIAL SAC, WITH BIOPSY THORACOSCOPY, DIAGNOSTIC (SEPARATE PROCEDURE); PERICARDIAL SAC, WITHOUT 32603 32603 360 100.00 0.00 BIOPSY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee THORACOSCOPY, SURGICAL; WITH CONTROL OF 32654 32654 360 100.00 0.00 TRAUMATIC HEMORRHAGE THORACOSCOPY, SURGICAL; WITH CREATION OF PERICARDIAL WINDOW OR PARTIAL 32659 32659 360 100.00 0.00 RESECTION OF PERICARDIAL SAC FOR DRAINAGE THORACOSCOPY, SURGICAL; WITH 32665 32665 360 100.00 0.00 ESOPHAGOMYOTOMY (HELLER TYPE) THORACOSCOPY, SURGICAL; WITH EXCISION OF 32662 32662 360 100.00 0.00 MEDIASTINAL CYST, TUMOR, OR MASS

THORACOSCOPY, SURGICAL; WITH EXCISION OF 32661 32661 360 100.00 0.00 PERICARDIAL CYST, TUMOR, OR MASS THORACOSCOPY, SURGICAL; WITH EXCISION- PLICATION OF BULLAE, INCLUDING ANY 32655 32655 360 100.00 0.00 PLEURAL PROCEDURE THORACOSCOPY, SURGICAL; WITH 32663 32663 360 100.00 0.00 LOBECTOMY, TOTAL OR SEGMENTAL THORACOSCOPY, SURGICAL; WITH PARIETAL 32656 32656 360 100.00 0.00 PLEURECTOMY THORACOSCOPY, SURGICAL; WITH PARTIAL 32651 32651 360 100.00 0.00 PULMONARY DECORTICATION THORACOSCOPY, SURGICAL; WITH 32650 32650 360 100.00 0.00 PLEURODESIS (EG, MECHANICAL OR CHEMICAL) THORACOSCOPY, SURGICAL; WITH REMOVAL OF CLOT OR FOREIGN BODY FROM 32658 32658 360 100.00 0.00 PERICARDIAL SAC THORACOSCOPY, SURGICAL; WITH REMOVAL OF INTRAPLEURAL FOREIGN BODY OR FIBRIN 32653 32653 360 100.00 0.00 DEPOSIT THORACOSCOPY, SURGICAL; WITH THORACIC 32664 32664 360 100.00 0.00 SYMPATHECTOMY THORACOSCOPY, SURGICAL; WITH TOTAL 32660 32660 360 100.00 0.00 PERICARDIECTOMY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee THORACOSCOPY, SURGICAL; WITH TOTAL PULMONARY DECORTICATION, INCLUDING 32652 32652 360 100.00 0.00 INTRAPLEURAL PNEUMONOLYSIS THORACOSCOPY, SURGICAL; WITH WEDGE 32657 32657 360 100.00 0.00 RESECTION OF LUNG, SINGLE OR MULTIPLE THORACOSTOMY; WITH OPEN FLAP DRAINAGE 32036 32036 360 100.00 0.00 FOR EMPYEMA THORACOSTOMY; WITH RIB RESECTION FOR 32035 32035 360 100.00 0.00 EMPYEMA THORACOTOMY, LIMITED, FOR BIOPSY OF LUNG 32095 32095 360 100.00 0.00 OR PLEURA THORACOTOMY, MAJOR; FOR POSTOPERATIVE 32120 32120 360 100.00 0.00 COMPLICATIONS THORACOTOMY, MAJOR; WITH CARDIAC 32160 32160 360 100.00 0.00 MASSAGE THORACOTOMY, MAJOR; WITH CYST(S) REMOVAL, WITH OR WITHOUT A PLEURAL 32140 32140 360 100.00 0.00 PROCEDURE THORACOTOMY, MAJOR; WITH EXPLORATION 32100 32100 360 100.00 0.00 AND BIOPSY THORACOTOMY, MAJOR; WITH OPEN 32124 32124 360 100.00 0.00 INTRAPLEURAL PNEUMONOLYSIS THORACOTOMY, MAJOR; WITH REMOVAL OF INTRAPLEURAL FOREIGN BODY OR FIBRIN 32150 32150 360 100.00 0.00 DEPOSIT THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR 35875 35875 360 100.00 0.00 FISTULA); THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT (OTHER THAN HEMODIALYSIS GRAFT OR 35876 35876 360 100.00 0.00 FISTULA); WITH REVISION OF ARTERIAL OR VENOUS GRAFT THROMBECTOMY, OPEN, ARTERIOVENOUS FISTULA WITHOUT REVISION, AUTOGENOUS OR 36831 36831 360 100.00 0.00 NONAUTOGENOUS DIALYSIS GRAFT (SEPARATE PROCEDURE) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee THROMBECTOMY, PERCUTANEOUS, ARTERIOVENOUS FISTULA, AUTOGENOUS OR NONAUTOGENOUS GRAFT (INCLUDES 36870 36870 360 100.00 0.00 MECHANICAL THROMBUS EXTRACTION AND INTRA-GRAFT THROMBOLYSIS) THROMBIN TIME; PLASMA 85670 85670 305 100.00 100.00 100.00 THROMBOPLASTIN TIME, PARTIAL (PTT); 85730 85730 305 120.00 100.00 120.00 PLASMA OR WHOLE BLOOD THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC APPROACH, WITH 60522 60522 360 100.00 0.00 RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC APPROACH, 60521 60521 360 100.00 0.00 WITHOUT RADICAL MEDIASTINAL DISSECTION (SEPARATE PROCEDURE) THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH (SEPARATE 60520 60520 360 100.00 0.00 PROCEDURE) THYROGLOBULIN 84432 84432 301 180.00 100.00 180.00 THYROGLOULIN ANTIBODY 86800 86800 302 220.00 100.00 220.00 THYROID HORMONE (T3 OR T4) UPTAKE OR 84479 84479 301 70.00 100.00 70.00 THYROID HORMONE BINDING RATIO (THBR) THYROID PEROXIDASE ANTIBODIES (TPO) 86376 86376 302 210.00 100.00 210.00 THYROID STIMULATING HORMONE (TSH) 84443 84443 301 160.00 100.00 160.00 THYROIDECTOMY, INCLUDING SUBSTERNAL 60271 60271 360 100.00 0.00 THYROID; CERVICAL APPROACH THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID; STERNAL SPLIT OR TRANSTHORACIC 60270 60270 360 100.00 0.00 APPROACH THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING 60260 60260 360 17,100.00 100.00 17,100.00 PREVIOUS REMOVAL OF A PORTION OF THYROID Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee THYROIDECTOMY, TOTAL OR COMPLETE 60240 60240 360 19,400.00 100.00 19,400.00 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH LIMITED NECK 60252 60252 360 18,820.00 100.00 18,820.00 DISSECTION THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; WITH RADICAL NECK 60254 60254 360 100.00 0.00 DISSECTION THYROXINE; FREE 84439 84439 301 120.00 100.00 120.00 THYROXINE; TOTAL 84436 84436 301 70.00 100.00 70.00 TISSUE EXAM FOR FUNGI 87220 87220 306 100.00 100.00 100.00 TISSUE GRAFTS, OTHER (EG, PARATENON, FAT, 20926 20926 360 100.00 0.00 DERMIS) TONSILLECTOMY AND ADENOIDECTOMY; AGE 42821 42821 360 8,900.00 100.00 8,900.00 12 OR OVER TONSILLECTOMY AND ADENOIDECTOMY; 42820 42820 360 8,900.00 100.00 8,900.00 UNDER AGE 12 TONSILLECTOMY, PRIMARY OR SECONDARY; 42826 42826 360 8,900.00 100.00 8,900.00 AGE 12 OR OVER TONSILLECTOMY, PRIMARY OR SECONDARY; 42825 42825 360 17,100.00 100.00 17,100.00 UNDER AGE 12 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF 58150 58150 360 100.00 0.00 TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S); TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), WITH OR WITHOUT REMOVAL OF 58152 58152 360 100.00 0.00 TUBE(S), WITH OR WITHOUT REMOVAL OF OVARY(S); WITH COLPO-URETHROCYSTOPEXY TOTAL ABDOMINAL HYSTERECTOMY, INCLUDING PARTIAL VAGINECTOMY, WITH PARA-AORTIC AND PELVIC LYMPH NODE 58200 58200 360 100.00 0.00 SAMPLING, WITH OR WITHOUT REMOVAL OF TUBE(S), WITH TOTAL FACIAL NERVE DECOMPRESSION 69955 69955 360 100.00 0.00 AND/OR REPAIR (MAY INCLUDE GRAFT) TOTAL LUNG LAVAGE (UNILATERAL) 32997 32997 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE 43113 43113 360 100.00 0.00 RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, PRE TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITH THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL 43112 43112 360 100.00 0.00 ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH COLON INTERPOSITION OR SMALL INTESTINE 43108 43108 360 100.00 0.00 RECONSTRUCTION, INCLUDING INTESTINE MOBILIZATION, TOTAL OR NEAR TOTAL ESOPHAGECTOMY, WITHOUT THORACOTOMY; WITH PHARYNGOGASTROSTOMY OR CERVICAL 43107 43107 360 100.00 0.00 ESOPHAGOGASTROSTOMY, WITH OR WITHOUT PYLOROPLASTY (TRANSH TOTAL PROTEIN 84155 84155 301 50.00 100.00 50.00 TOTAL THYROID LOBECTOMY, UNILATERAL; WITH CONTRALATERAL SUBTOTAL 60225 60225 360 19,400.00 100.00 19,400.00 LOBECTOMY, INCLUDING ISTHMUSECTOMY

TOTAL THYROID LOBECTOMY, UNILATERAL; 60220 60220 360 19,400.00 100.00 19,400.00 WITH OR WITHOUT ISTHMUSECTOMY TOXIN OR ANTITOXIN ASSAY 87230 87230 306 290.00 100.00 290.00 TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE SESSIONS (DEFINED TREATMENT 65855 65855 360 100.00 0.00 SERIES) TRABECULOTOMY AB EXTERNO 65850 65850 360 100.00 0.00 TRACHEAL PUNCTURE, PERCUTANEOUS WITH TRANSTRACHEAL ASPIRATION AND/OR 31612 31612 360 100.00 0.00 INJECTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX (SEPARATE 57530 57530 360 100.00 0.00 PROCEDURE) TRACHELORRHAPHY, PLASTIC REPAIR OF 57720 57720 360 13,440.00 100.00 13,440.00 UTERINE CERVIX, VAGINAL APPROACH TRACHEOBRONCHOSCOPY THROUGH 31615 31615 360 100.00 0.00 ESTABLISHED TRACHEOSTOMY INCISION TRACHEOPLASTY; CERVICAL 31750 31750 360 100.00 0.00 TRACHEOPLASTY; INTRATHORACIC 31760 31760 360 100.00 0.00 TRACHEOPLASTY; TRACHEOPHARYNGEAL 31755 31755 360 100.00 0.00 FISTULIZATION, EACH STAGE TRACHEOSTOMA REVISION; COMPLEX, WITH 31614 31614 360 100.00 0.00 FLAP ROTATION TRACHEOSTOMA REVISION; SIMPLE, WITHOUT 31613 31613 360 100.00 0.00 FLAP ROTATION TRACHEOSTOMY, PLANNED (SEPARATE 31600 31600 360 100.00 0.00 PROCEDURE); TRACHEOSTOMY, PLANNED (SEPARATE 31601 31601 360 100.00 0.00 PROCEDURE); UNDER TWO YEARS TRACHEOTOMY TUBE CHANGE PRIOR TO 31502 31502 360 100.00 0.00 ESTABLISHMENT OF FISTULA TRACT TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR DIAGNOSIS AND/OR RE-ESTABLISHING PATENCY (ANY 58345 58345 360 100.00 0.00 METHOD), WITH OR WITHOUT HYSTEROSALPINGOGRAPHY TRANSECTION OF ESOPHAGUS WITH REPAIR, 43401 43401 360 100.00 0.00 FOR ESOPHAGEAL VARICES TRANSECTION OR AVULSION OF OBTURATOR NERVE, EXTRAPELVIC, WITH OR WITHOUT 64763 64763 360 100.00 0.00 ADDUCTOR TENOTOMY TRANSECTION OR AVULSION OF OBTURATOR NERVE, INTRAPELVIC, WITH OR WITHOUT 64766 64766 360 100.00 0.00 ADDUCTOR TENOTOMY TRANSECTION OR AVULSION OF OTHER 64771 64771 360 100.00 0.00 CRANIAL NERVE, EXTRADURAL TRANSECTION OR AVULSION OF OTHER SPINAL 64772 64772 360 11,940.00 100.00 11,940.00 NERVE, EXTRADURAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRANSECTION OR AVULSION OF; FACIAL 64742 64742 360 100.00 0.00 NERVE, DIFFERENTIAL OR COMPLETE TRANSECTION OR AVULSION OF; GREATER 64744 64744 360 100.00 0.00 OCCIPITAL NERVE TRANSECTION OR AVULSION OF; INFERIOR 64738 64738 360 100.00 0.00 ALVEOLAR NERVE BY OSTEOTOMY TRANSECTION OR AVULSION OF; 64734 64734 360 100.00 0.00 INFRAORBITAL NERVE TRANSECTION OR AVULSION OF; LINGUAL 64740 64740 360 100.00 0.00 NERVE TRANSECTION OR AVULSION OF; MENTAL 64736 64736 360 100.00 0.00 NERVE TRANSECTION OR AVULSION OF; PHRENIC 64746 64746 360 100.00 0.00 NERVE TRANSECTION OR AVULSION OF; PUDENDAL 64761 64761 360 100.00 0.00 NERVE TRANSECTION OR AVULSION OF; 64732 64732 360 100.00 0.00 SUPRAORBITAL NERVE TRANSECTION OR AVULSION OF; VAGUS NERVE 64760 64760 360 100.00 0.00 (VAGOTOMY), ABDOMINAL TRANSECTION OR AVULSION OF; VAGUS NERVE 64752 64752 360 100.00 0.00 (VAGOTOMY), TRANSTHORACIC TRANSECTION OR AVULSION OF; VAGUS NERVES LIMITED TO PROXIMAL STOMACH (SELECTIVE PROXIMAL VAGOTOMY, PROXIMAL 64755 64755 360 100.00 0.00 GASTRIC VAGOTOMY, PARIETAL CELL VAGOTOMY, TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREATER TROCHANTER INCLUDING FASCIAL 27100 27100 360 100.00 0.00 OR TENDON EXTENSION (GRAFT) TRANSFER ILIOPSOAS; TO FEMORAL NECK 27111 27111 360 100.00 0.00 TRANSFER ILIOPSOAS; TO GREATER 27110 27110 360 100.00 0.00 TROCHANTER OF FEMUR TRANSFER OF TENDON TO RESTORE INTRINSIC 26498 26498 360 100.00 0.00 FUNCTION; ALL FOUR FINGERS TRANSFER OF TENDON TO RESTORE INTRINSIC 26497 26497 360 10,630.00 100.00 10,630.00 FUNCTION; RING AND SMALL FINGER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); DEEP (EG, ANTERIOR TIBIAL OR POSTERIOR TIBIAL THROUGH INTEROSSEOUS SPACE, 27691 27691 360 17,250.00 100.00 17,250.00 FLEXOR DIGITORUM LONGUS, FLEXOR HALLUCIS LONGUS, OR PERONEAL TENDON TO MIDFOOT OR HINDFOOT)

TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); EACH ADDITIONAL TENDON (LIST SEPARATELY 27692 27692 360 900.00 100.00 900.00 IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TRANSFER OR TRANSPLANT OF SINGLE TENDON (WITH MUSCLE REDIRECTION OR REROUTING); 27690 27690 360 17,250.00 100.00 17,250.00 SUPERFICIAL (EG, ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT) TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF 26483 26483 360 10,630.00 100.00 10,630.00 HAND; WITH FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON

TRANSFER OR TRANSPLANT OF TENDON, CARPOMETACARPAL AREA OR DORSUM OF 26480 26480 360 10,150.00 100.00 10,150.00 HAND; WITHOUT FREE GRAFT, EACH TENDON

TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITH FREE TENDON GRAFT 26489 26489 360 100.00 0.00 (INCLUDES OBTAINING GRAFT), EACH TENDON TRANSFER OR TRANSPLANT OF TENDON, PALMAR; WITHOUT FREE TENDON GRAFT, EACH 26485 26485 360 10,150.00 100.00 10,150.00 TENDON TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASCIAL OR TENDON EXTENSION 27105 27105 360 100.00 0.00 GRAFT) TRANSFER, ADDUCTOR TO ISCHIUM 27098 27098 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

TRANSFER, FINGER TO ANOTHER POSITION 26555 26555 360 100.00 0.00 WITHOUT MICROVASCULAR ANASTOMOSIS TRANSFER, FREE TOE JOINT, WITH 26556 26556 360 100.00 0.00 MICROVASCULAR ANASTOMOSIS TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (EG, ABDOMEN TO WRIST, WALKING 15650 15650 360 14,540.00 100.00 14,540.00 TUBE), ANY LOCATION TRANSFER, TENDON OR MUSCLE, HAMSTRINGS 27400 27400 360 100.00 0.00 TO FEMUR (EG, EGGER'S TYPE PROCEDURE) TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; GREAT TOE 26551 26551 360 100.00 0.00 WRAP-AROUND WITH BONE GRAFT TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN 26554 26554 360 100.00 0.00 GREAT TOE, DOUBLE TRANSFER, TOE-TO-HAND WITH MICROVASCULAR ANASTOMOSIS; OTHER THAN 26553 26553 360 100.00 0.00 GREAT TOE, SINGLE TRANSFERRIN 84466 84466 301 150.00 100.00 150.00 TRANSFUSION, BLOOD OR BLOOD COMPONENTS 36430 36430 391 1,400.00 100.00 1,400.00 TRANSMASTOID ANTROTOMY (SIMPLE 69501 69501 360 100.00 0.00 MASTOIDECTOMY) TRANSMETACARPAL AMPUTATION; 25927 25927 360 100.00 0.00 TRANSMETACARPAL AMPUTATION; RE- 25931 25931 360 100.00 0.00 AMPUTATION TRANSMETACARPAL AMPUTATION; 25929 25929 360 100.00 0.00 SECONDARY CLOSURE OR SCAR REVISION TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED 63057 63057 360 100.00 0.00 INTERVERTEBRAL DISK), SINGLE SEGMENT; EACH ADDIT Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED 63056 63056 360 18,930.00 100.00 18,930.00 INTERVERTEBRAL DISK), SINGLE SEGMENT; LUMBAR (IN TRANSPEDICULAR APPROACH WITH DECOMPRESSION OF SPINAL CORD, EQUINA AND/OR NERVE ROOT(S) (EG, HERNIATED 63055 63055 360 100.00 0.00 INTERVERTEBRAL DISK), SINGLE SEGMENT; THORACIC TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO PROSTATE FOR INTERSTITIAL 55859 55859 360 100.00 0.00 RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY TRANSPLANT, HAMSTRING TENDON TO 27397 27397 360 100.00 0.00 PATELLA; MULTIPLE TENDONS TRANSPLANT, HAMSTRING TENDON TO 27396 27396 360 100.00 0.00 PATELLA; SINGLE TENDON TRANSPLANTATION OF TESTIS(ES) TO THIGH 54680 54680 360 100.00 0.00 (BECAUSE OF SCROTAL DESTRUCTION)

TRANSPOSITION PROCEDURE (EG, FOR PARETIC EXTRAOCULAR MUSCLE), ANY EXTRAOCULAR 67320 67320 360 100.00 0.00 MUSCLE (SPECIFY) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) TRANSPOSITION, OVARY(S) 58825 58825 360 100.00 0.00 TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 45000 45000 360 100.00 0.00 TRANSTRACHEAL (PERCUTANEOUS) INTRODUCTION OF NEEDLE WIRE 31730 31730 360 100.00 0.00 DILATOR/STENT OR INDWELLING TUBE FOR OXYGEN THERAPY TRANSTRACHEAL INJECTION FOR 31715 31715 360 100.00 0.00 BRONCHOGRAPHY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF URETER TO CONTRALATERAL 50770 50770 360 100.00 0.00 URETER TRANSURETHRAL BALLOON DILATION OF THE 52510 52510 360 100.00 0.00 PROSTATIC URETHRA TRANSURETHRAL DESTRUCTION OF PROSTATE 53850 53850 360 100.00 0.00 TISSUE; BY MICROWAVE THERMOTHERAPY TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY RADIOFREQUENCY 53852 53852 360 100.00 0.00 THERMOTHERAPY TRANSURETHRAL DESTRUCTION OF PROSTATE 53853 53853 360 100.00 0.00 TISSUE; BY WATER-INDUCED THERMOTHERAPY TRANSURETHRAL DRAINAGE OF PROSTATIC 52700 52700 360 100.00 0.00 ABSCESS TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, 52601 52601 360 15,540.00 100.00 15,540.00 CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) TRANSURETHRAL FULGURATION FOR POSTOPERATIVE BLEEDING OCCURRING AFTER 52606 52606 360 100.00 0.00 THE USUAL FOLLOW-UP TIME TRANSURETHRAL INCISION OF PROSTATE 52450 52450 360 3,500.00 100.00 3,500.00 TRANSURETHRAL RESECTION OF BLADDER 52500 52500 360 12,950.00 100.00 12,950.00 NECK (SEPARATE PROCEDURE) TRANSURETHRAL RESECTION OF PROSTATE; FIRST STAGE OF TWO-STAGE RESECTION 52612 52612 360 100.00 0.00 (PARTIAL RESECTION) TRANSURETHRAL RESECTION OF PROSTATE; SECOND STAGE OF TWO-STAGE RESECTION 52614 52614 360 100.00 0.00 (RESECTION COMPLETED) TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK 52640 52640 360 12,950.00 100.00 12,950.00 CONTRACTURE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRANSURETHRAL RESECTION; OF REGROWTH OF OBSTRUCTIVE TISSUE LONGER THAN ONE 52630 52630 360 100.00 0.00 YEAR POSTOPERATIVE TRANSURETHRAL RESECTION; OF RESIDUAL OBSTRUCTIVE TISSUE AFTER 90 DAYS 52620 52620 360 100.00 0.00 POSTOPERATIVE TRANSVESICAL URETEROLITHOTOMY 51060 51060 360 100.00 0.00 TREATMENT OF CLOSED ELBOW DISLOCATION; 24605 24605 360 5,300.00 100.00 5,300.00 REQUIRING ANESTHESIA TREATMENT OF CLOSED ELBOW DISLOCATION; 24600 24600 360 100.00 0.00 WITHOUT ANESTHESIA TREATMENT OF CLOSED LARYNGEAL FRACTURE; WITH CLOSED MANIPULATIVE 31586 31586 360 100.00 0.00 REDUCTION TREATMENT OF CLOSED LARYNGEAL 31585 31585 360 100.00 0.00 FRACTURE; WITHOUT MANIPULATION TREATMENT OF HUMERAL SHAFT FRACTURE, WITH INSERTION OF INTRAMEDULLARY 24516 24516 360 25,500.00 100.00 25,500.00 IMPLANT, WITH OR WITHOUT CERCLAGE AND/OR LOCKING SCREWS TREATMENT OF INCOMPLETE ABORTION, ANY 59812 59812 360 11,520.00 100.00 11,520.00 TRIMESTER, COMPLETED SURGICALLY TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; WITH INTRAMEDULLARY 27245 27245 360 100.00 0.00 IMPLANT, WITH OR WITHOUT INTERLOCKING SCREWS TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC 27244 27244 360 100.00 0.00 FEMORAL FRACTURE; WITH PLATE/SCREW TYPE IMPLANT, WITH OR WITHOUT CERCLAGE

TREATMENT OF MISSED ABORTION, 59820 59820 360 11,520.00 100.00 11,520.00 COMPLETED SURGICALLY; FIRST TRIMESTER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

TREATMENT OF MISSED ABORTION, 59821 59821 360 100.00 0.00 COMPLETED SURGICALLY; SECOND TRIMESTER TREATMENT OF RIB FRACTURE REQUIRING 21810 21810 360 100.00 0.00 EXTERNAL FIXATION (FLAIL CHEST) TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; 27176 27176 360 100.00 0.00 BY SINGLE OR MULTIPLE PINNING, IN SITU

TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; 27175 27175 360 100.00 0.00 BY TRACTION, WITHOUT REDUCTION

TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), BY 27257 27257 360 100.00 0.00 ABDUCTION, SPLINT OR TRACTION; WITH MANIPULATION, REQUIRING ANESTHESIA TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), BY 27256 27256 360 100.00 0.00 ABDUCTION, SPLINT OR TRACTION; WITHOUT ANESTHESIA, TREATMENT OF SUPERFICIAL WOUND 12020 12020 360 2,000.00 100.00 2,000.00 DEHISCENCE; SIMPLE CLOSURE TREATMENT OF SUPERFICIAL WOUND 12021 12021 360 1,520.00 100.00 1,520.00 DEHISCENCE; WITH PACKING TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITH 28455 28455 360 100.00 0.00 MANIPULATION, EACH TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITHOUT 28450 28450 360 100.00 0.00 MANIPULATION, EACH TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, WITH OR 27759 27759 360 25,500.00 100.00 25,500.00 WITHOUT INTERLOCKING SCREWS AND/OR CERCLAGE TRIGLYCERIDES 84478 84478 301 50.00 100.00 50.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TRIIODOTHYRONINE T3; REVERSE 84482 84482 301 190.00 100.00 190.00 TRIMMING OF NONDYSTROPHIC NAILS, ANY 11719 11719 360 100.00 0.00 NUMBER TROPONIN QUANTITATIVE 84484 84484 301 240.00 100.00 240.00 TUBE OR NEEDLE CATHETER JEJUNOSTOMY FOR ENTERAL ALIMENTATION, INTRAOPERATIVE, ANY METHOD (LIST 44015 44015 360 100.00 0.00 SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) TUBE THORACOSTOMY WITH OR WITHOUT WATER SEAL (EG, FOR ABSCESS, HEMOTHORAX, 32020 32020 360 100.00 0.00 EMPYEMA) (SEPARATE PROCEDURE) TUBOTUBAL ANASTOMOSIS 58750 58750 360 100.00 0.00 TUBOUTERINE IMPLANTATION 58752 58752 360 100.00 0.00 TWIST DRILL HOLE FOR SUBDURAL OR 61105 61105 360 100.00 0.00 VENTRICULAR PUNCTURE; TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; FOR EVACUATION 61108 61108 360 100.00 0.00 AND/OR DRAINAGE OF SUBDURAL HEMATOMA TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; FOR IMPLANTING 61107 61107 360 100.00 0.00 VENTRICULAR CATHETER OR PRESSURE RECORDING DEVICE TYMPANIC MEMBRANE REPAIR, WITH OR WITHOUT SITE PREPARATION OR PERFORATION 69610 69610 360 8,900.00 100.00 8,900.00 FOR CLOSURE, WITH OR WITHOUT PATCH TYMPANIC NEURECTOMY 69676 69676 360 100.00 0.00 TYMPANOLYSIS, TRANSCANAL 69450 69450 360 100.00 0.00

TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR 69636 69636 360 17,100.00 100.00 17,100.00 TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR TYMPANIC MEMBRANE REPAIR); WITH 69637 69637 360 100.00 0.00 OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP), TOTA

TYMPANOPLASTY WITH ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/OR 69635 69635 360 100.00 0.00 TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); 69646 69646 360 100.00 0.00 RADICAL OR COMPLETE, WITH OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); 69645 69645 360 100.00 0.00 RADICAL OR COMPLETE, WITHOUT OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); 69644 69644 360 100.00 0.00 WITH INTACT OR RECONSTRUCTED CANAL WALL, WITH OSSICULAR CHAIN RECONSTRUCTION TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); 69643 69643 360 100.00 0.00 WITH INTACT OR RECONSTRUCTED WALL, WITHOUT OSSICULAR CHAIN RECONSTRUCTION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR 69642 69642 360 17,100.00 100.00 17,100.00 SURGERY, TYMPANIC MEMBRANE REPAIR); WITH OSSICULAR CHAIN RECONSTRUCTION

TYMPANOPLASTY WITH MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR 69641 69641 360 17,100.00 100.00 17,100.00 SURGERY, TYMPANIC MEMBRANE REPAIR); WITHOUT OSSICULAR CHAIN RECONSTRUCTION

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR 69632 69632 360 17,760.00 100.00 17,760.00 REVISION; WITH OSSICULAR CHAIN RECONSTRUCTION (EG, POSTFENESTRATION)

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR REVISION; WITH OSSICULAR CHAIN 69633 69633 360 17,760.00 100.00 17,760.00 RECONSTRUCTION AND SYNTHETIC PROSTHESIS (EG, PARTIAL OSSICULAR REPLACEMENT PROSTHESIS (PORP), TOTAL OSSICULAR REP

TYMPANOPLASTY WITHOUT MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/OR MIDDLE EAR SURGERY), INITIAL OR 69631 69631 360 17,100.00 100.00 17,100.00 REVISION; WITHOUT OSSICULAR CHAIN RECONSTRUCTION

TYMPANOSTOMY (REQUIRING INSERTION OF 69436 69436 360 100.00 0.00 VENTILATING TUBE), GENERAL ANESTHESIA TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), LOCAL OR TOPICAL 69433 69433 360 100.00 0.00 ANESTHESIA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UIBC 83550 83550 301 100.00 100.00 100.00 ULTRASONIC GUIDANCE FOR AMNIOCENTESIS, 76946 76946 100.00 0.00 IMAGING SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR ASPIRATION OF OVA, IMAGING SUPERVISION AND 76948 76948 402 650.00 100.00 650.00 INTERPRETATION ULTRASONIC GUIDANCE FOR CHORIONIC VILLUS SAMPLING, IMAGING SUPERVISION AND 76945 76945 100.00 0.00 INTERPRETATION ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, IMAGING 76932 76932 100.00 0.00 SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR INTERSTITIAL 76965 76965 100.00 0.00 RADIOELEMENT APPLICATION

ULTRASONIC GUIDANCE FOR INTRAUTERINE FETAL TRANSFUSION OR CORDOCENTESIS, 76941 76941 100.00 0.00 IMAGING SUPERVISION AND INTERPRETATION

ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, 76942 76942 402 1,000.00 100.00 1,000.00 INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, IMAGING SUPERVISION 76930 76930 100.00 0.00 AND INTERPRETATION ULTRASONIC GUIDANCE FOR PLACEMENT OF 76950 76950 100.00 0.00 RADIATION THERAPY FIELDS ULTRASONIC GUIDANCE, INTRAOPERATIVE 76986 76986 100.00 0.00 ULTRASOUND 402 402 100.00 0.00 ULTRASOUND BONE DENSITY MEASUREMENT AND INTERPRETATION, PERIPHERAL SITE(S), 76977 76977 100.00 0.00 ANY METHOD ULTRASOUND GUIDANCE FOR, AND 76490 76490 100.00 0.00 MONITORING OF, TISSUE ABLATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE (INCLUDES 76936 76936 100.00 0.00 DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF L ULTRASOUND STUDY FOLLOW-UP (SPECIFY) 76970 76970 100.00 0.00 ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; 76700 76700 402 850.00 100.00 850.00 COMPLETE ULTRASOUND, ABDOMINAL, B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION; 76705 76705 402 650.00 100.00 650.00 LIMITED (EG, SINGLE ORGAN, QUADRANT, FOLLOW-UP) ULTRASOUND, BREAST(S) (UNILATERAL OR BILATERAL), B-SCAN AND/OR REAL TIME WITH 76645 76645 100.00 0.00 IMAGE DOCUMENTATION ULTRASOUND, CHEST, B-SCAN (INCLUDES MEDIASTINUM) AND/OR REAL TIME WITH 76604 76604 402 850.00 100.00 850.00 IMAGE DOCUMENTATION ULTRASOUND, EXTREMITY, NON-VASCULAR, B- SCAN AND/OR REAL TIME WITH IMAGE 76880 76880 100.00 0.00 DOCUMENTATION ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; 76881 76881 402 750.00 100.00 750.00 COMPLETE ULTRASOUND, EXTREMITY, NONVASCULAR, REAL-TIME WITH IMAGE DOCUMENTATION; 76882 76882 402 750.00 100.00 750.00 LIMITED, ANATOMIC SPECIFIC

ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; DYNAMIC 76885 76885 402 880.00 100.00 880.00 (REQUIRING PHYSICIAN MANIPULATION)

ULTRASOUND, INFANT HIPS, REAL TIME WITH IMAGING DOCUMENTATION; LIMITED, STATIC 76886 76886 402 790.00 100.00 790.00 (NOT REQUIRING PHYSICIAN MANIPULATION) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee ULTRASOUND, PELVIC (NONOBSTETRIC), B- SCAN AND/OR REAL TIME WITH IMAGE 76856 76856 402 720.00 100.00 720.00 DOCUMENTATION; COMPLETE ULTRASOUND, PELVIC (NONOBSTETRIC), B- SCAN AND/OR REAL TIME WITH IMAGE 76857 76857 402 800.00 100.00 800.00 DOCUMENTATION; LIMITED OR FOLLOW-UP (EG, FOR FOLLICLES) ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND 76805 76805 402 720.00 100.00 720.00 MATERNAL EVALUATION, AFTER FIRST TRIMESTER (> OR = 14 WEEKS 0 DAYS), TRANSA

ULTRASOUND, PREGNANT UTERUS, REAL TIME WITH IMAGE DOCUMENTATION, FETAL AND 76801 76801 402 860.00 100.00 860.00 MATERNAL EVALUATION, FIRST TRIMESTER (<14 WEEKS 0 DAYS), TRANSABDOMINAL APP

ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME 76770 76770 402 840.00 100.00 840.00 WITH IMAGE DOCUMENTATION; COMPLETE

ULTRASOUND, RETROPERITONEAL (EG, RENAL, AORTA, NODES), B-SCAN AND/OR REAL TIME 76775 76775 402 650.00 100.00 650.00 WITH IMAGE DOCUMENTATION; LIMITED ULTRASOUND, SCROTUM AND CONTENTS 76870 76870 402 650.00 100.00 650.00 ULTRASOUND, SOFT TISSUES OF HEAD AND NECK (EG, THYROID, PARATHYROID, PAROTID), 76536 76536 402 690.00 100.00 690.00 B-SCAN AND/OR REAL TIME WITH IMAGE DOCUMENTATION ULTRASOUND, SPINAL CANAL AND CONTENTS 76800 76800 402 710.00 100.00 710.00 ULTRASOUND, TRANSPLANTED KIDNEY, B- SCAN AND/OR REAL TIME WITH IMAGE 76778 76778 402 830.00 100.00 830.00 DOCUMENTATION, WITH OR WITHOUT DUPLEX DOPPLER STUDY ULTRASOUND, TRANSVAGINAL 76830 76830 402 820.00 100.00 820.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

UMBILECTOMY, OMPHALECTOMY, EXCISION OF 49250 49250 360 22,250.00 100.00 22,250.00 UMBILICUS (SEPARATE PROCEDURE) UMBILICAL ARTERY DOPPLER 76820 76820 402 720.00 100.00 720.00 Under Electromyography Procedures 95870 95870 922 100.00 0.00 Under Routine Electroencephalography (EEG) 95813 95813 922 100.00 0.00 Procedures UNLISTED CHEMISTRY PROCEDURE 84999 84999 301 350.00 100.00 350.00 UNLISTED DIAGNOSTIC RADIOGRAPHIC 76499 76499 320 300.00 100.00 300.00 PROCEDURE UNLISTED FLUOROSCOPIC PROCEDURE (EG, 76496 76496 320 750.00 100.00 750.00 DIAGNOSTIC, INTERVENTIONAL) Unlisted hematology and coagulation procedure 85999 85999 300 250.00 100.00 250.00 UNLISTED HYSTEROSCOPY PROCEDURE, 58579 58579 360 100.00 0.00 UTERUS UNLISTED LAPAROSCOPIC PROCEDURE, LIVER 47379 47379 360 28,620.00 100.00 28,620.00 UNLISTED LAPAROSCOPY PROCEDURE, 49329 49329 360 13,800.00 100.00 13,800.00 ABDOMEN, PERITONEUM AND OMENTUM UNLISTED LAPAROSCOPY PROCEDURE, 44979 44979 360 100.00 0.00 APPENDIX UNLISTED LAPAROSCOPY PROCEDURE, BILIARY 47579 47579 360 100.00 0.00 TRACT UNLISTED LAPAROSCOPY PROCEDURE, 60659 60659 360 100.00 0.00 ENDOCRINE SYSTEM UNLISTED LAPAROSCOPY PROCEDURE, 43289 43289 360 13,800.00 100.00 13,800.00 ESOPHAGUS UNLISTED LAPAROSCOPY PROCEDURE, HERNIOPLASTY, HERNIORRHAPHY, 49659 49659 360 13,800.00 100.00 13,800.00 HERNIOTOMY UNLISTED LAPAROSCOPY PROCEDURE, 44238 44238 360 24,440.00 100.00 24,440.00 INTESTINE (EXCEPT RECTUM) UNLISTED LAPAROSCOPY PROCEDURE, 38589 38589 360 17,950.00 100.00 17,950.00 LYMPHATIC SYSTEM UNLISTED LAPAROSCOPY PROCEDURE, 58679 58679 360 18,460.00 100.00 18,460.00 OVIDUCT, OVARY Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UNLISTED LAPAROSCOPY PROCEDURE, 55559 55559 360 100.00 0.00 SPERMATIC CORD UNLISTED LAPAROSCOPY PROCEDURE, 43659 43659 360 13,800.00 100.00 13,800.00 STOMACH UNLISTED LAPAROSCOPY PROCEDURE, TESTIS 54699 54699 360 100.00 0.00

UNLISTED LAPAROSCOPY PROCEDURE, URETER 50949 50949 360 100.00 0.00

UNLISTED LAPAROSCOPY PROCEDURE, UTERUS 58578 58578 360 100.00 0.00

UNLISTED MAGNETIC RESONANCE PROCEDURE 76498 76498 100.00 0.00 (EG, DIAGNOSTIC, INTERVENTIONAL) UNLISTED MAXILLOFACIAL PROSTHETIC 21089 21089 360 100.00 0.00 PROCEDURE UNLISTED MODALITY (SPECIFY TYPE AND TIME 97039 97039 100.00 0.00 IF CONSTANT ATTENDANCE) UNLISTED MUSCULOSKELETAL PROCEDURE, 21499 21499 360 100.00 0.00 HEAD UNLISTED PROCEDURE, ABDOMEN, 22999 22999 360 9,170.00 100.00 9,170.00 MUSCULOSKELETAL SYSTEM UNLISTED PROCEDURE, ABDOMEN, 49999 49999 360 13,640.00 100.00 13,640.00 PERITONEUM AND OMENTUM UNLISTED PROCEDURE, ACCESSORY SINUSES 31299 31299 360 19,750.00 100.00 19,750.00 UNLISTED PROCEDURE, ANUS 46999 46999 360 100.00 0.00 UNLISTED PROCEDURE, ARTHROSCOPY 29999 29999 360 13,200.00 100.00 13,200.00 UNLISTED PROCEDURE, BILIARY TRACT 47999 47999 360 100.00 0.00 UNLISTED PROCEDURE, BREAST 19499 19499 360 100.00 0.00 UNLISTED PROCEDURE, CONJUNCTIVA 68399 68399 360 100.00 0.00 UNLISTED PROCEDURE, DENTOALVEOLAR 41899 41899 360 600.00 100.00 600.00 STRUCTURES UNLISTED PROCEDURE, DENTOALVEOLAR 23.19 360 100.00 0.00 STRUCTURES. UNLISTED PROCEDURE, ENDOCRINE SYSTEM 60699 60699 360 19,400.00 100.00 19,400.00 UNLISTED PROCEDURE, ESOPHAGUS 43499 43499 360 3,450.00 100.00 3,450.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UNLISTED PROCEDURE, EXCISION PRESSURE 15999 15999 360 100.00 0.00 ULCER UNLISTED PROCEDURE, EXTERNAL EAR 69399 69399 360 18,340.00 100.00 18,340.00 UNLISTED PROCEDURE, EYELIDS 67999 67999 360 100.00 0.00 UNLISTED PROCEDURE, FEMALE GENITAL 58999 58999 360 1,000.00 100.00 1,000.00 SYSTEM (NONOBSTETRICAL) UNLISTED PROCEDURE, FEMUR OR KNEE 27599 27599 360 20,670.00 100.00 20,670.00 UNLISTED PROCEDURE, FOOT OR TOES 28899 28899 360 800.00 100.00 800.00 UNLISTED PROCEDURE, FOREARM OR WRIST 25999 25999 360 1,880.00 100.00 1,880.00 UNLISTED PROCEDURE, HANDS OR FINGERS 26989 26989 360 1,930.00 100.00 1,930.00 UNLISTED PROCEDURE, HUMERUS OR ELBOW 24999 24999 360 19,710.00 100.00 19,710.00 UNLISTED PROCEDURE, INNER EAR 69949 69949 360 100.00 0.00 UNLISTED PROCEDURE, INTESTINE 44799 44799 360 24,440.00 100.00 24,440.00 UNLISTED PROCEDURE, LACRIMAL SYSTEM 68899 68899 360 1,400.00 100.00 1,400.00 UNLISTED PROCEDURE, LARYNX 31599 31599 360 1,080.00 100.00 1,080.00 UNLISTED PROCEDURE, LEG OR ANKLE 27899 27899 360 800.00 100.00 800.00 UNLISTED PROCEDURE, LIPS 40799 40799 360 100.00 0.00 UNLISTED PROCEDURE, LIVER 47399 47399 360 100.00 0.00 UNLISTED PROCEDURE, LUNGS AND PLEURA 32999 32999 360 100.00 0.00 UNLISTED PROCEDURE, MECKELS 44899 44899 360 100.00 0.00 DIVERTICULUM AND THE MESENTERY UNLISTED PROCEDURE, MIDDLE EAR 69799 69799 360 600.00 100.00 600.00 UNLISTED PROCEDURE, MUSCULOSKELETAL 20999 20999 360 13,420.00 100.00 13,420.00 SYSTEM, GENERAL UNLISTED PROCEDURE, NECK OR THORAX 21899 21899 360 1,430.00 100.00 1,430.00 UNLISTED PROCEDURE, NERVOUS SYSTEM 64999 64999 360 131,000.00 100.00 131,000.00 UNLISTED PROCEDURE, NOSE 30999 30999 360 350.00 100.00 350.00 UNLISTED PROCEDURE, OCULAR MUSCLE 67399 67399 360 100.00 0.00 UNLISTED PROCEDURE, ORBIT 67599 67599 360 100.00 0.00 UNLISTED PROCEDURE, PALATE, UVULA 42299 42299 360 100.00 0.00 UNLISTED PROCEDURE, PELVIS OR HIP JOINT 27299 27299 360 100.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UNLISTED PROCEDURE, PHARYNX, ADENOIDS, 42999 42999 360 100.00 0.00 OR TONSILS UNLISTED PROCEDURE, POSTERIOR SEGMENT 67299 67299 360 100.00 0.00 UNLISTED PROCEDURE, RECTUM 45999 45999 360 100.00 0.00 UNLISTED PROCEDURE, SALIVARY GLANDS OR 42699 42699 360 100.00 0.00 DUCTS UNLISTED PROCEDURE, SHOULDER 23929 23929 360 11,280.00 100.00 11,280.00 UNLISTED PROCEDURE, SKIN, MUCOUS 17999 17999 360 500.00 100.00 500.00 MEMBRANE AND SUBCUTANEOUS TISSUE UNLISTED PROCEDURE, SPINE 22899 22899 360 21,750.00 100.00 21,750.00 UNLISTED PROCEDURE, STOMACH 43999 43999 360 15,000.00 100.00 15,000.00 UNLISTED PROCEDURE, TEMPORAL BONE, 69979 69979 360 100.00 0.00 MIDDLE FOSSA APPROACH UNLISTED PROCEDURE, TONGUE, FLOOR OF 41599 41599 360 100.00 0.00 MOUTH UNLISTED PROCEDURE, TRACHEA, BRONCHI 31899 31899 360 100.00 0.00 UNLISTED PROCEDURE, URINARY SYSTEM 53899 53899 360 1,410.00 100.00 1,410.00 UNLISTED PROCEDURE, VESTIBULE OF MOUTH 40899 40899 360 100.00 0.00 Unlisted pulmonary service or procedure 94799 94799 460 100.00 0.00 UNLISTED THERAPEUTIC PROCEDURE (SPECIFY) 97139 97139 100.00 0.00 UNLISTED TRANSFUSION MEDICINE 86999 86999 391 350.00 100.00 350.00 UNLISTED ULTRASOUND PROCEDURE (EG, 76999 76999 402 850.00 100.00 850.00 DIAGNOSTIC, INTERVENTIONAL) Unspecified Procedure UNSPEC 100.00 0.00 UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS ULNAR, PREFABRICATED, INCLUDES L3982-W L3982 274 100.00 0.00 FITTING AND ADJUSTMENT UPPER EXTREMITY ORTHOSIS L3982-G L3982 274 700.00 0.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43235 43235 360 12,000.00 100.00 12,000.00 APPROPRIATE; DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH ABLATION OF TUMOR(S), 43258 43258 360 1,980.00 100.00 1,980.00 POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQU

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43249 43249 360 4,900.00 100.00 4,900.00 APPROPRIATE; WITH BALLOON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43244 43244 360 100.00 0.00 APPROPRIATE; WITH BAND LIGATION OF ESOPHAGEAL AND/OR GASTRIC VARICES UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43239 43239 360 3,450.00 100.00 3,450.00 APPROPRIATE; WITH BIOPSY, SINGLE OR MULTIPLE UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43255 43255 360 4,900.00 100.00 4,900.00 APPROPRIATE; WITH CONTROL OF BLEEDING, ANY METHOD Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43245 43245 360 15,000.00 100.00 15,000.00 APPROPRIATE; WITH DILATION OF GASTRIC OUTLET FOR OBSTRUCTION (EG, BALLOON, GUIDE WIRE, BOUGIE) UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43246 43246 360 4,900.00 100.00 4,900.00 APPROPRIATE; WITH DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43236 43236 360 100.00 0.00 APPROPRIATE; WITH DIRECTED SUBMUCOSAL INJECTION(S), ANY SUBSTANCE UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43259 43259 360 4,900.00 100.00 4,900.00 APPROPRIATE; WITH ENDOSCOPIC ULTRASOUND EXAMINATION UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43243 43243 360 100.00 0.00 APPROPRIATE; WITH INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR GASTRIC VARICES UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43248 43248 360 3,450.00 100.00 3,450.00 APPROPRIATE; WITH INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OF ESOPHAGUS OVER GUIDE WIRE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43247 43247 360 3,450.00 100.00 3,450.00 APPROPRIATE; WITH REMOVAL OF FOREIGN BODY UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43250 43250 360 100.00 0.00 APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43251 43251 360 4,900.00 100.00 4,900.00 APPROPRIATE; WITH REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43241 43241 360 100.00 0.00 APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR CATHETER PLACEMENT UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43256 43256 360 100.00 0.00 APPROPRIATE; WITH TRANSENDOSCOPIC STENT PLACEMENT (INCLUDES PREDILATION)

UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC 43242 43242 360 4,900.00 100.00 4,900.00 ULTRASOUND-GUIDED INTRAMURAL OR TRANSMURAL FINE NEEDLE ASPIRATION/BIOPSY(S) Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS 43240 43240 360 100.00 0.00 APPROPRIATE; WITH TRANSMURAL DRAINAGE OF PSEUDOCYST UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION (EG, WITH 43234 43234 360 1,480.00 100.00 1,480.00 SMALL DIAMETER FLEXIBLE ENDOSCOPE) (SEPARATE PROCEDURE) UREA NITROGEN; QUANTITATIVE 84520 84520 301 50.00 100.00 50.00 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50951 50951 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50955 50955 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50957 50957 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY

URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50959 50959 360 100.00 0.00 RADIOLOGIC SERVICE; WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY AND/OR FULGURATION (NOT INCLUDING PROVI Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50961 50961 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50953 50953 360 100.00 0.00 RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50970 50970 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50974 50974 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH BIOPSY URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50976 50976 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH FULGURATION AND/OR INCISION, WITH OR WITHOUT BIOPSY

URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50978 50978 360 100.00 0.00 RADIOLOGIC SERVICE; WITH INSERTION OF RADIOACTIVE SUBSTANCE, WITH OR WITHOUT BIOPSY AND/OR FULGURATION (NOT INCLUDING PROVISION OF MATER Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR 50980 50980 360 100.00 0.00 URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; WITH REMOVAL OF FOREIGN BODY OR CALCULUS URETERAL ENDOSCOPY THROUGH URETEROTOMY, WITH OR WITHOUT IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF 50972 50972 360 100.00 0.00 RADIOLOGIC SERVICE; WITH URETERAL CATHETERIZATION, WITH OR WITHOUT DILATION OF URETER URETERECTOMY, TOTAL, ECTOPIC URETER, COMBINATION ABDOMINAL, VAGINAL AND/OR 50660 50660 360 100.00 0.00 PERINEAL APPROACH URETERECTOMY, WITH BLADDER CUFF 50650 50650 360 100.00 0.00 (SEPARATE PROCEDURE) URETEROCALYCOSTOMY, ANASTOMOSIS OF 50750 50750 360 100.00 0.00 URETER TO RENAL CALYX URETEROCOLON CONDUIT, INCLUDING 50815 50815 360 100.00 0.00 INTESTINE ANASTOMOSIS URETEROENTEROSTOMY, DIRECT 50800 50800 360 100.00 0.00 ANASTOMOSIS OF URETER TO INTESTINE URETEROILEAL CONDUIT (ILEAL BLADDER), INCLUDING INTESTINE ANASTOMOSIS (BRICKER 50820 50820 360 100.00 0.00 OPERATION) URETEROLITHOTOMY; LOWER ONE-THIRD OF 50630 50630 360 100.00 0.00 URETER URETEROLITHOTOMY; MIDDLE ONE-THIRD OF 50620 50620 360 100.00 0.00 URETER URETEROLITHOTOMY; UPPER ONE-THIRD OF 50610 50610 360 100.00 0.00 URETER URETEROLYSIS FOR OVARIAN VEIN SYNDROME 50722 50722 360 100.00 0.00 URETEROLYSIS FOR RETROCAVAL URETER, WITH REANASTOMOSIS OF UPPER URINARY 50725 50725 360 100.00 0.00 TRACT OR VENA CAVA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee URETEROLYSIS, WITH OR WITHOUT REPOSITIONING OF URETER FOR 50715 50715 360 100.00 0.00 RETROPERITONEAL FIBROSIS URETERONEOCYSTOSTOMY; ANASTOMOSIS OF 50782 50782 360 100.00 0.00 DUPLICATED URETER TO BLADDER

URETERONEOCYSTOSTOMY; ANASTOMOSIS OF 50780 50780 360 100.00 0.00 SINGLE URETER TO BLADDER URETERONEOCYSTOSTOMY; WITH EXTENSIVE 50783 50783 360 100.00 0.00 URETERAL TAILORING URETERONEOCYSTOSTOMY; WITH VESICO- 50785 50785 360 100.00 0.00 PSOAS HITCH OR BLADDER FLAP URETEROPLASTY, PLASTIC OPERATION ON 50700 50700 360 100.00 0.00 URETER (EG, STRICTURE) URETEROPYELOSTOMY, ANASTOMOSIS OF 50740 50740 360 100.00 0.00 URETER AND RENAL PELVIS URETERORRHAPHY, SUTURE OF URETER 50900 50900 360 100.00 0.00 (SEPARATE PROCEDURE) URETEROSCOPY; DIAGNOSTIC 56.31 360 100.00 0.00

URETEROSIGMOIDOSTOMY, WITH CREATION OF SIGMOID BLADDER AND ESTABLISHMENT OF 50810 50810 360 100.00 0.00 ABDOMINAL OR PERINEAL COLOSTOMY, INCLUDING INTESTINE ANASTOMOSIS URETEROTOMY FOR INSERTION OF 50605 50605 360 100.00 0.00 INDWELLING STENT, ALL TYPES URETEROTOMY WITH EXPLORATION OR 50600 50600 360 100.00 0.00 DRAINAGE (SEPARATE PROCEDURE) URETEROURETEROSTOMY 50760 50760 360 100.00 0.00 URETHRAL PRESSURE PROFILE STUDIES (UPP) (URETHRAL CLOSURE PRESSURE PROFILE), ANY 51772 51772 360 100.00 0.00 TECHNIQUE URETHRECTOMY, TOTAL, INCLUDING 53210 53210 360 100.00 0.00 CYSTOSTOMY; FEMALE URETHRECTOMY, TOTAL, INCLUDING 53215 53215 360 100.00 0.00 CYSTOSTOMY; MALE Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee URETHROCYSTOGRAPHY, RETROGRADE, RADIOLOGICAL SUPERVISION AND 74450 74450 320 1,250.00 100.00 1,250.00 INTERPRETATION URETHROCYSTOGRAPHY, VOIDING, RADIOLOGICAL SUPERVISION AND 74455 74455 329 100.00 0.00 INTERPRETATION URETHROMEATOPLASTY, WITH MUCOSAL 53450 53450 360 100.00 0.00 ADVANCEMENT URETHROMEATOPLASTY, WITH PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT 53460 53460 360 100.00 0.00 (RICHARDSON TYPE PROCEDURE) URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY 54316 54316 360 100.00 0.00 DIVERSION) WITH FREE SKIN GRAFT OBTAINED FROM SITE OTHER THAN GENITALIA

URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY 54312 54312 360 100.00 0.00 DIVERSION); GREATER THAN 3 CM URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY 54308 54308 360 100.00 0.00 DIVERSION); LESS THAN 3 CM URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE PENIS FROM 54318 54318 360 100.00 0.00 SCROTUM (EG, THIRD STAGE CECIL REPAIR) URETHROPLASTY WITH TUBULARIZATION OF POSTERIOR URETHRA AND/OR LOWER BLADDER 53431 53431 360 100.00 0.00 FOR INCONTINENCE (EG, TENAGO, LEADBETTER PROCEDURE) URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE ANTERIOR 53410 53410 360 100.00 0.00 URETHRA URETHROPLASTY, RECONSTRUCTION OF 53430 53430 360 100.00 0.00 FEMALE URETHRA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

URETHROPLASTY, TRANSPUBIC OR PERINEAL, ONE STAGE, FOR RECONSTRUCTION OR REPAIR 53415 53415 360 100.00 0.00 OF PROSTATIC OR MEMBRANOUS URETHRA

URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC 53420 53420 360 100.00 0.00 OR MEMBRANOUS URETHRA; FIRST STAGE

URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC 53425 53425 360 100.00 0.00 OR MEMBRANOUS URETHRA; SECOND STAGE URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (EG, 53400 53400 360 100.00 0.00 JOHANNSEN TYPE) URETHROPLASTY; SECOND STAGE (FORMATION 53405 53405 360 100.00 0.00 OF URETHRA), INCLUDING URINARY DIVERSION URETHRORRHAPHY, SUTURE OF URETHRAL 53502 53502 360 100.00 0.00 WOUND OR INJURY, FEMALE URETHRORRHAPHY, SUTURE OF URETHRAL 53505 53505 360 100.00 0.00 WOUND OR INJURY; PENILE URETHRORRHAPHY, SUTURE OF URETHRAL 53510 53510 360 100.00 0.00 WOUND OR INJURY; PERINEAL URETHRORRHAPHY, SUTURE OF URETHRAL 53515 53515 360 100.00 0.00 WOUND OR INJURY; PROSTATOMEMBRANOUS URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); 53000 53000 360 100.00 0.00 PENDULOUS URETHRA URETHROTOMY OR URETHROSTOMY, EXTERNAL (SEPARATE PROCEDURE); PERINEAL 53010 53010 360 100.00 0.00 URETHRA, EXTERNAL URIC ACID; BLOOD 84550 84550 301 50.00 100.00 50.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, 81002 81002 301 80.00 100.00 80.00 NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILI17443 URINALYSIS, BY DIP STICK OR TABLET REAGENT FOR BILIRUBIN, GLUCOSE, HEMOGLOBIN, KETONES, LEUKOCYTES, 81000 81000 301 100.00 100.00 100.00 NITRITE, PH, PROTEIN, SPECIFIC GRAVITY, UROBILINOG URINALYSIS; AUTOMATED WITH MICROSCOPIC 81001 81001 301 100.00 100.00 100.00 URINALYSIS; AUTOMATED, DIPSTICK ONLY 81003 81003 301 90.00 100.00 90.00 URINALYSIS; MICROSCOPIC ONLY 81015 81015 301 10.00 100.00 10.00 URINARY INCONTINENCE REP DEVICE W/SLING C1771-G C1771 278 700.00 0.00 GRAFT URINE CULTURE 87088 87088 306 160.00 100.00 160.00 URINE PREGNANCY TEST, BY VISUAL COLOR 81025 81025 300 100.00 0.00 COMPARISON METHODS URINE VMA 84585 84585 301 150.00 100.00 150.00 URINE VOLUME MEASURE 81050 81050 301 50.00 100.00 50.00 UROGRAPHY (PYELOGRAPHY), INTRAVENOUS, WITH OR WITHOUT KUB, WITH OR WITHOUT 74400 74400 320 1,250.00 100.00 1,250.00 TOMOGRAPHY UROGRAPHY, ANTEGRADE, (PYELOSTOGRAM, NEPHROSTOGRAM, LOOPOGRAM), 74425 74425 329 100.00 0.00 RADIOLOGICAL SUPERVISION AND INTERPRETATION UROGRAPHY, INFUSION, DRIP TECHNIQUE 74410 74410 329 100.00 0.00 AND/OR BOLUS TECHNIQUE; UROGRAPHY, INFUSION, DRIP TECHNIQUE AND/OR BOLUS TECHNIQUE; WITH 74415 74415 329 100.00 0.00 NEPHROTOMOGRAPHY UROGRAPHY, RETROGRADE, WITH OR WITHOUT 74420 74420 329 1,250.00 100.00 1,250.00 KUB US ART DOPPLER LOW EXT BILATERAL 93925 93925 921 1,520.00 100.00 1,520.00 US ART DOPPLER LOW EXT UNILATERAL 93926 93926 921 920.00 100.00 920.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee US ART DOPPLER UPPER EXT BILATERAL 93930 93930 921 1,330.00 100.00 1,330.00 US ART DOPPLER UPPER EXT UNILATERAL 93931 93931 921 810.00 100.00 810.00 US ARTERIAL DOPPLER 93923 93923 402 920.00 100.00 920.00 US BREAST COMPLETE 76641 76641 402 580.00 100.00 580.00 US GUIDANCE INTRA OP 76998 76998 402 250.00 100.00 250.00 US GUIDANCE VASC ACCESS 76937 76937 402 250.00 100.00 250.00 US LOW EXT ART DUPLEX BILATERAL 93922 93922 921 550.00 100.00 550.00 US PREGANANCY REALTIME W/IMAGING 76815 76815 402 650.00 100.00 650.00 US PREGNANCY UTERUS REAL TIME 76817 76817 402 650.00 100.00 650.00 US PREGNANCY UTERUS REAL TIME F/U 76816 76816 402 450.00 100.00 450.00 US TRANSPLANT KIDNEY R-T IMG + 76776 76776 402 1,050.00 100.00 1,050.00 USE OF OPHTHALMIC ENDOSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR 66990 66990 360 100.00 0.00 PRIMARY PROCEDURE) UTERINE EVACUATION AND CURETTAGE FOR 59870 59870 360 100.00 0.00 HYDATIDIFORM MOLE UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND LIGAMENTS, WITH OR 58400 58400 360 100.00 0.00 WITHOUT SHORTENING OF SACROUTERINE LIGAMENTS; (SEPARATE PROCEDURE) UTERINE SUSPENSION, WITH OR WITHOUT SHORTENING OF ROUND LIGAMENTS, WITH OR WITHOUT SHORTENING OF SACROUTERINE 58410 58410 360 100.00 0.00 LIGAMENTS; WITH PRESACRAL SYMPATHECTOMY U-TUBE HEPATICOENTEROSTOMY 47802 47802 360 100.00 0.00 UVULECTOMY, EXCISION OF UVULA 42140 42140 360 5,800.00 100.00 5,800.00 VAGINAL HYSTERECTOMY, FOR UTERUS 250 58260 58260 360 100.00 0.00 GRAMS OR LESS; VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR LESS; WITH COLPO- URETHROCYSTOPEXY (MARSHALL-MARCHETTI- 58267 58267 360 100.00 0.00 KRANTZ TYPE, PEREYRA TYPE) WITH OR WITHOUT ENDOSCO Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR LESS; WITH REMOVAL OF TUBE(S), 58262 58262 360 18,200.00 100.00 18,200.00 AND/OR OVARY(S) VAGINAL HYSTERECTOMY, FOR UTERUS 250 GRAMS OR LESS; WITH REMOVAL OF TUBE(S), 58263 58263 360 100.00 0.00 AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE VAGINAL HYSTERECTOMY, FOR UTERUS 250 58270 58270 360 100.00 0.00 GRAMS OR LESS; WITH REPAIR OF ENTEROCELE VAGINAL HYSTERECTOMY, FOR UTERUS 58290 58290 360 100.00 0.00 GREATER THAN 250 GRAMS; VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH COLPO- URETHROCYSTOPEXY (MARSHALL-MARCHETTI- 58293 58293 360 100.00 0.00 KRANTZ TYPE, PEREYRA TYPE) WITH OR WITHOUT EN VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REMOVAL OF 58291 58291 360 100.00 0.00 TUBE(S) AND/OR OVARY(S) VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REMOVAL OF 58292 58292 360 100.00 0.00 TUBE(S) AND/OR OVARY(S), WITH REPAIR OF ENTEROCELE VAGINAL HYSTERECTOMY, FOR UTERUS GREATER THAN 250 GRAMS; WITH REPAIR OF 58294 58294 360 100.00 0.00 ENTEROCELE VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA 58285 58285 360 100.00 0.00 TYPE OPERATION) VAGINAL HYSTERECTOMY, WITH TOTAL OR 58275 58275 360 100.00 0.00 PARTIAL VAGINECTOMY; VAGINAL HYSTERECTOMY, WITH TOTAL OR PARTIAL VAGINECTOMY; WITH REPAIR OF 58280 58280 360 100.00 0.00 ENTEROCELE VAGINECTOMY, COMPLETE REMOVAL OF 57110 57110 360 100.00 0.00 VAGINAL WALL; Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF 57111 57111 360 100.00 0.00 PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) VAGINECTOMY, COMPLETE REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL 57112 57112 360 100.00 0.00 VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AN VAGINECTOMY, PARTIAL REMOVAL OF 57106 57106 360 100.00 0.00 VAGINAL WALL; VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF 57107 57107 360 100.00 0.00 PARAVAGINAL TISSUE (RADICAL VAGINECTOMY) VAGINECTOMY, PARTIAL REMOVAL OF VAGINAL WALL; WITH REMOVAL OF PARAVAGINAL TISSUE (RADICAL 57109 57109 360 100.00 0.00 VAGINECTOMY) WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND VALPROIC ACID 80164 80164 301 710.00 100.00 710.00 VANCOMYCIN 80202 80202 301 460.00 100.00 460.00 VARICELLA ZOSTER - ANTIBODY 86787 86787 302 220.00 100.00 220.00 VASECTOMY, UNILATERAL OR BILATERAL (SEPARATE PROCEDURE), INCLUDING 55250 55250 360 8,300.00 100.00 8,300.00 POSTOPERATIVE SEMEN EXAMINATION(S) VASOGRAPHY, VESICULOGRAPHY, OR EPIDIDYMOGRAPHY, RADIOLOGICAL 74440 74440 329 100.00 0.00 SUPERVISION AND INTERPRETATION VASOTOMY FOR VASOGRAMS, SEMINAL VESICULOGRAMS, OR EPIDIDYMOGRAMS, 55300 55300 360 100.00 0.00 UNILATERAL OR BILATERAL VASOTOMY, CANNULIZATION WITH OR WITHOUT INCISION OF VAS, UNILATERAL OR 55200 55200 360 100.00 0.00 BILATERAL (SEPARATE PROCEDURE) VASOVASOSTOMY, VASOVASORRHAPHY 55400 55400 360 100.00 0.00 VENT ASSIST, INITIAL 94002 94002 460 1,750.00 100.00 1,750.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee VENTILATING TUBE REMOVAL WHEN ORIGINALLY INSERTED BY ANOTHER 69424 69424 360 5,800.00 100.00 5,800.00 PHYSICIAN VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, SUTURE, OR IMPLANTED VENTRICULAR 61026 61026 360 100.00 0.00 CATHETER/RESERVOIR; WITH INJECTION OF MEDICATION OR OTHER SUBSTANCE FOR DIAGNOSIS OR TREATMENT VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, SUTURE, OR 61020 61020 360 100.00 0.00 IMPLANTED VENTRICULAR CATHETER/RESERVOIR; WITHOUT INJECTION VERMILIONECTOMY (LIP SHAVE), WITH 40500 40500 360 5,800.00 100.00 5,800.00 MUCOSAL ADVANCEMENT VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR 63082 63082 360 100.00 0.00 APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CER16433

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR 63081 63081 360 100.00 0.00 APPROACH WITH DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); CERVIC VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH 63088 63088 360 100.00 0.00 DECOMPRESSION OF SPINAL CORD, CAUDA EQUI16437 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH WITH 63087 63087 360 100.00 0.00 DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63308 63308 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EACH ADDITIONAL SEGMENT (LIS

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63300 63300 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, CERVICAL

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63303 63303 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, LUMBAR OR SACRAL

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63302 63302 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY THOR

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63301 63301 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY TRAN

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63304 63304 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, CERVICAL

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63307 63307 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, LUMBAR OR SACRAL Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63306 63306 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY THOR

VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR 63305 63305 360 100.00 0.00 EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY TRAN VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL 63090 63090 360 100.00 0.00 APPROACH WITH DECOMPRESSION OF SPINAL CORD, C VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL 63091 63091 360 100.00 0.00 APPROACH WITH DECOMPRESSION OF SPINAL CORD16439 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSTHORACIC APPROACH WITH 63085 63085 360 100.00 0.00 DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S); T VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSTHORACIC APPROACH WITH 63086 63086 360 100.00 0.00 DECOMPRESSION OF SPINAL CORD AND/OR NERVE ROOT(S)16435 VESICULECTOMY, ANY APPROACH 55650 55650 360 100.00 0.00 VESICULOTOMY; 55600 55600 360 100.00 0.00 VESICULOTOMY; COMPLICATED 55605 55605 360 100.00 0.00 VESTIBULAR NERVE SECTION, TRANSCRANIAL 69950 69950 360 100.00 0.00 APPROACH VESTIBULAR NERVE SECTION, 69915 69915 360 100.00 0.00 TRANSLABYRINTHINE APPROACH Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee VESTIBULOPLASTY; ANTERIOR 40840 40840 360 100.00 0.00 VESTIBULOPLASTY; COMPLEX (INCLUDING 40845 40845 360 100.00 0.00 RIDGE EXTENSION, MUSCLE REPOSITIONING) VESTIBULOPLASTY; ENTIRE ARCH 40844 40844 360 100.00 0.00 VESTIBULOPLASTY; POSTERIOR, BILATERAL 40843 40843 360 100.00 0.00

VESTIBULOPLASTY; POSTERIOR, UNILATERAL 40842 40842 360 100.00 0.00 VIPER VENOM PROTHROMBIN TIME; 85612 85612 305 230.00 100.00 230.00 UNDILUTED VIRUS INOCULATION TISSUE 87252 87252 306 200.00 100.00 200.00

VIRUS ISOLATION; INCLUDING IDENTIFICATION BY NON-IMMUNOLOGIC METHOD, OTHER THAN 87255 87255 300 100.00 0.00 BY CYTOPATHIC EFFECT (EG, VIRUS SPECIFIC ENZYMATIC ACTIVITY) VITAMIN A 84590 84590 301 100.00 100.00 100.00 VITAMIN B12 82607 82607 301 200.00 100.00 200.00 VITAMIN B6 84207 84207 300 280.00 100.00 280.00 VITAMIN C 82180 82180 301 100.00 100.00 100.00 VITAMIN D, 25-OH 82306 82306 301 280.00 100.00 280.00 VITAMIN E (TOCOPHEROL ALPHA) 84446 84446 301 100.00 100.00 100.00 VITAMIN K 84597 84597 301 50.00 100.00 50.00 VITAMIN NOT OTHERWISE 84591 84591 301 100.00 100.00 100.00 VITRECTOMY, MECHANICAL, PARS PLANA 67036 67036 360 14,300.00 100.00 14,300.00 APPROACH; VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDOLASER PANRETINAL 67040 67040 360 100.00 0.00 PHOTOCOAGULATION VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH EPIRETINAL MEMBRANE 67038 67038 360 100.00 0.00 STRIPPING VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH FOCAL ENDOLASER 67039 67039 360 100.00 0.00 PHOTOCOAGULATION Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee VOIDING PRESSURE STUDIES (VP); BLADDER 51795 51795 360 100.00 0.00 VOIDING PRESSURE, ANY TECHNIQUE VOIDING PRESSURE STUDIES (VP); INTRA- ABDOMINAL VOIDING PRESSURE (AP) (RECTAL, 51797 51797 360 100.00 0.00 GASTRIC, INTRAPERITONEAL) VOLUME REDUCTION OF BLOOD/PRODUCT 86960 86960 306 600.00 100.00 600.00 VON WILLEBRAND FACTOR COLLAGEN BINDING 83520 83520 300 100.00 100.00 100.00 VON WILLWBRAND FACTOR ANTIGEN 85246 85246 305 100.00 100.00 100.00 VULVECTOMY SIMPLE; COMPLETE 56625 56625 360 100.00 0.00 VULVECTOMY SIMPLE; PARTIAL 56620 56620 360 8,600.00 100.00 8,600.00 VULVECTOMY, RADICAL, COMPLETE, WITH INGUINOFEMORAL, ILIAC, AND PELVIC 56640 56640 360 100.00 0.00 LYMPHADENECTOMY VULVECTOMY, RADICAL, COMPLETE; 56633 56633 360 100.00 0.00 VULVECTOMY, RADICAL, COMPLETE; WITH BILATERAL INGUINOFEMORAL 56637 56637 360 100.00 0.00 LYMPHADENECTOMY VULVECTOMY, RADICAL, COMPLETE; WITH UNILATERAL INGUINOFEMORAL 56634 56634 360 100.00 0.00 LYMPHADENECTOMY VULVECTOMY, RADICAL, PARTIAL; 56630 56630 360 100.00 0.00 VULVECTOMY, RADICAL, PARTIAL; WITH BILATERAL INGUINOFEMORAL 56632 56632 360 100.00 0.00 LYMPHADENECTOMY VULVECTOMY, RADICAL, PARTIAL; WITH UNILATERAL INGUINOFEMORAL 56631 56631 360 100.00 0.00 LYMPHADENECTOMY WBC 85048 85048 305 90.00 100.00 90.00 WEDGE EXCISION OF SKIN OF NAIL FOLD (EG, 11765 11765 360 100.00 0.00 FOR INGROWN TOENAIL) WEDGE RESECTION OR BISECTION OF OVARY, 58920 58920 360 100.00 0.00 UNILATERAL OR BILATERAL WEDGING OF CAST (EXCEPT CLUBFOOT CASTS) 29740 29740 360 100.00 0.00 WEST NILE VIRUS lgG AB 86789 86789 302 100.00 100.00 100.00 WEST NILE VIRUS lgM AB 86788 86788 302 100.00 100.00 100.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee WHEELCHAIR MANAGEMENT/PROPULSION 97542 97542 100.00 0.00 TRAINING, EACH 15 MINUTES WHITE BLOOD COUNT ANTIBODY 86021 86021 302 150.00 100.00 150.00 IDENTIFICATION WINDOWING OF CAST 29730 29730 360 100.00 0.00 WORK HARDENING/CONDITIONING; EACH ADDITIONAL HOUR (LIST SEPARATELY IN 97546 97546 100.00 0.00 ADDITION TO CODE FOR PRIMARY PROCEDURE) WORK HARDENING/CONDITIONING; INITIAL 2 97545 97545 100.00 0.00 HOURS Wound closure utilizing tissue adhesive(s) only G0168 G0168 360 100.00 0.00 X RAY ADJUSTMENT GASTRIC BAND S2083 S2083 329 420.00 100.00 420.00 X RAY BILATERAL W/PELVIS 3-4 VIEWS 73522 73522 320 500.00 100.00 500.00 X RAY CHEST 2 VIEWS FRONT LATERAL 71021 71021 320 420.00 100.00 420.00 X RAY FEMUR 1 VIEW 73551 73551 320 300.00 100.00 300.00 X RAY HIP INTRA OP PROCEDURE 73501 73501 320 300.00 100.00 300.00 X RAY HIP UNILATERAL W/RELVIS 2-3 VIEWS 73502 73502 320 300.00 100.00 300.00 X RAY HIPS BILATERAL W/PELVIS 2 VIEWS 73521 73521 320 500.00 100.00 500.00 X RAY L/T SPINE STAND/SCOLIOSIS 1 VIEW 72081 72081 320 500.00 100.00 500.00 X RAY L/T SPINE STAND/SCOLIOSIS 2-3 VIEWS 72082 72082 320 300.00 100.00 300.00 X RAY UNILATERAL W/PELVIS 4+ VIEWS 73503 73503 320 500.00 100.00 500.00 X RAYS BONE SURVEY COMPLETE 77075 77075 320 840.00 100.00 840.00 XERORADIOGRAPHY 76150 76150 329 100.00 0.00 XRAY OF ABDOMEN; OTHER 88.19 360 100.00 0.00 XRAY; OTHER AND UNSPEC 88.39 360 100.00 0.00 ZINC 84630 84630 305 150.00 100.00 150.00 Supplies

ED - SUPPLIES ED SUPP 270 200.00 100.00 Y 200.00 IP - BUTTACAVOLI IPBUTTA 270 7,500.00 100.00 Y 7,500.00 IP - DR ABBATE ABBATE IP 270 200.00 100.00 Y 200.00 IP - DR AHMED O IPAHMED 270 16,000.00 100.00 Y 16,000.00 IP - DR ALBERT ALBERT IP 270 16,000.00 100.00 Y 16,000.00 IP - DR ALVAREZ ALVAREZ IP 270 6,000.00 100.00 Y 6,000.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee IP - DR ATKINS ATKINS IP 270 200.00 100.00 Y 200.00 IP - DR BELLACOSA BELLACOSA IP 270 200.00 100.00 Y 200.00 IP - DR BONILLA BONILLA IP 270 200.00 100.00 Y 200.00 IP - DR BRUGGEMAN BRUGGEMAN IP 270 5,000.00 100.00 Y 5,000.00 IP - DR C MURPHY C MURPHY IP 270 200.00 100.00 Y 200.00 IP - DR CARCAMO CARCAMO IP 270 15,000.00 100.00 Y 15,000.00 IP - DR CAVAZOS CAVAZOS IP 270 14,000.00 100.00 Y 14,000.00 CONNAUGHTON IP - DR CONNAUGHTON 270 200.00 100.00 Y 200.00 IP IP - DR CUDA CUDA IP 270 200.00 100.00 Y 200.00 IP - DR DENNIS DENNIS IP 270 200.00 100.00 Y 200.00 IP - DR DUPERIER DUPERIER IP 270 18,500.00 100.00 Y 18,500.00 IP - DR DUTTA DUTTA IP 270 7,500.00 100.00 Y 7,500.00 IP - DR ENGLEHARDT ENGLEHARDT IP 270 19,500.00 100.00 Y 19,500.00 IP - DR FOGEL FOGEL IP 270 17,000.00 100.00 Y 17,000.00 IP - DR GLIDDEN GLIDDEN IP 270 200.00 100.00 Y 200.00 IP - DR GONZALEZ GONZALEZ IP 270 10,000.00 100.00 Y 10,000.00 IP - DR HAILPARN HAILPARN IP 270 200.00 100.00 Y 200.00 IP - DR HECKMAN HECKMAN IP 270 2,500.00 100.00 Y 2,500.00 IP - DR HLAVINKA HLAVAN 270 6,000.00 100.00 Y 6,000.00 IP - DR HOLLIMAN HOLLIMAN IP 270 6,500.00 100.00 Y 6,500.00 IP - DR JACKSON JACKSON IP 270 200.00 100.00 Y 200.00 IP - DR JUDE IP JUDE 270 16,000.00 100.00 Y 16,000.00 IP - DR KATZ KATZ IP 270 10,000.00 100.00 Y 10,000.00 IP - DR KELLA KELLA IP 270 6,000.00 100.00 Y 6,000.00 IP - DR LOWRY LOWRY IP 270 200.00 100.00 Y 200.00 IP - DR M MURPHY M MURPHY IP 270 1,500.00 100.00 Y 1,500.00 IP - DR MACKENZIE MACKENZIE IP 270 200.00 100.00 Y 200.00 IP - DR MORREY MORREY IP 270 2,500.00 100.00 Y 2,500.00 IP - DR MULLINS MULLINS IP 270 200.00 100.00 Y 200.00 IP - DR MURRAY MURRAY IP 270 200.00 100.00 Y 200.00 IP - DR NAZMY NAZMY IP 270 6,000.00 100.00 Y 6,000.00 IP - DR NEELY NEELY IP 270 14,500.00 100.00 Y 14,500.00 IP - DR P PATEL PATEL P 270 14,000.00 100.00 Y 14,000.00 IP - DR PILCHER PILCHER IP 270 18,000.00 100.00 Y 18,000.00 IP - DR REISS DREISS 272 18,500.00 100.00 Y 18,500.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee IP - DR RODRIGUEZ J IPRODRIGUEZ 270 2,500.00 100.00 Y 2,500.00 IP - DR SABELLA SABELLA IP 270 200.00 100.00 Y 200.00 IP - DR SAROSDY SAROSDY IP 270 200.00 100.00 Y 200.00 IP - DR SEGER SEGER IP 270 15,000.00 100.00 Y 15,000.00 IP - DR SHIRANI SHIRANI IP 270 200.00 100.00 Y 200.00 IP - DR STANLEY STANLEY IP 270 200.00 100.00 Y 200.00 IP - DR STEFFAN STEFFAN IP 270 5,000.00 100.00 Y 5,000.00 IP - DR TOMPKINS TOMPKINS IP 270 200.00 100.00 Y 200.00 IP - DR VICK VICK IP 270 200.00 100.00 Y 200.00 IP - DR WIRTH WIRTH IP 270 3,000.00 100.00 Y 3,000.00 IP - DR ZAVALA ZAVALA IP 270 14,500.00 100.00 Y 14,500.00 IP - MED SURGICAL SUPPLIES 01 GUTZMAN IP 270 4,500.00 100.00 Y 4,500.00 IP - MED SURGICAL SUPPLIES 02 LENDERMAN IP 270 3,500.00 100.00 Y 3,500.00 IP - MED SURGICAL SUPPLIES 03 LEONARD IP 270 16,000.00 100.00 Y 16,000.00 OP - DR ABBATE ABBATE OP 270 2,500.00 100.00 Y 2,500.00 OP - DR AHMED O OP AHMED 270 1,500.00 100.00 Y 1,500.00 OP - DR ALBERT ALBERT OP 270 1,500.00 100.00 Y 1,500.00 OP - DR ALDER ALDER OP 270 200.00 100.00 Y 200.00 OP - DR ALUYEN ALUYEN OP 270 200.00 100.00 Y 200.00 OP - DR ALVARDO ALVARADO OP 270 1,500.00 100.00 Y 1,500.00 OP - DR ALVAREZ ALVAREZ OP 270 1,500.00 100.00 Y 1,500.00 OP - DR ATKINS ATKINS OP 270 11,000.00 100.00 Y 11,000.00 OP - DR BEDDIES BEDDIES OP 270 2,000.00 100.00 Y 2,000.00 OP - DR BELLACOSA BELLACOSA OP 270 600.00 100.00 Y 600.00 OP - DR BERTINO BERTINO OP 270 1,000.00 100.00 Y 1,000.00 OP - DR BEST BEST OP 270 2,500.00 100.00 Y 2,500.00 OP - DR BINDEWALD BINDEWALD OP 270 3,150.00 100.00 Y 3,150.00 OP - DR BONILLA BONILLA OP 270 1,000.00 100.00 Y 1,000.00 OP - DR BOWSER BOWSER OP 270 1,500.00 100.00 Y 1,500.00 OP - DR BRUGGEMAN OPBRUGGEMAN 270 3,000.00 100.00 Y 3,000.00 OP - DR C MURPHY C MURPHY OP 270 200.00 100.00 Y 200.00 OP - DR CANTRILL CANTRILL OP 270 2,500.00 100.00 Y 2,500.00 OP - DR CARCAMO CARCAMO OP 270 1,500.00 100.00 Y 1,500.00 OP - DR CARROLL CARROLL OP 270 1,500.00 100.00 Y 1,500.00 OP - DR CASE CASE OP 270 2,500.00 100.00 Y 2,500.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OP - DR CAVAZOS CAVAZOS OP 270 1,500.00 100.00 Y 1,500.00 OP - DR CECCONI CECCONI OP 270 2,500.00 100.00 Y 2,500.00 OP - DR CENTENO CENTENO OP 270 2,500.00 100.00 Y 2,500.00 OP - DR CHAN CHAN OP 270 3,150.00 100.00 Y 3,150.00 OP - DR CLEMENCE CLEMENCE OP 270 3,000.00 100.00 Y 3,000.00 OP - DR COCKERILL COCKERILL OP 270 2,500.00 100.00 Y 2,500.00 OP - DR CONNAUGHTON CONNAUG OP 270 2,500.00 100.00 Y 2,500.00 OP - DR CUDA CUDA OP 270 2,000.00 100.00 Y 2,000.00 OP - DR CURTIS CURTIS OP 270 3,000.00 100.00 Y 3,000.00 OP - DR DENNIS DENNIS OP 270 3,000.00 100.00 Y 3,000.00 OP - DR DUNCAN DUNCAN OP 270 200.00 100.00 Y 200.00 OP - DR DUPERIER DUPERIER 270 2,000.00 100.00 Y 2,000.00 OP - DR DUTTA DUTTA OP 270 3,000.00 100.00 Y 3,000.00 OP - DR EARLE EARLE OP 270 1,500.00 100.00 Y 1,500.00 OP - DR ENGLEHARDT ENGLEHARDT OP 270 1,500.00 100.00 Y 1,500.00 OP - DR FELINSKI FELINSKI OP 270 2,000.00 100.00 Y 2,000.00 OP - DR FERENZ FERENZ OP 270 1,500.00 100.00 Y 1,500.00 OP - DR FOGEL FOGEL OP 270 11,000.00 100.00 Y 11,000.00 OP - DR FOX FOX OP 270 3,000.00 100.00 Y 3,000.00 OP - DR GLIDDEN GLIDDEN OP 270 2,500.00 100.00 Y 2,500.00 OP - DR GONZALEZ GONZALEZ OP 270 2,500.00 100.00 Y 2,500.00 OP - DR HAILPARN HAILPARN OP 270 200.00 100.00 Y 200.00 OP - DR HECKMAN HECKMAN OP 270 3,000.00 100.00 Y 3,000.00 OP - DR HILARIO HILARIO OP 270 600.00 100.00 Y 600.00 OP - DR HLAVINKA HLAVIKLA OP 270 2,000.00 100.00 Y 2,000.00 OP - DR HOLLIMAN HOLLIMAN OP 270 2,500.00 100.00 Y 2,500.00 OP - DR JACKSON JACKSON OP 270 1,500.00 100.00 Y 1,500.00 OP - DR JUDE JUDEOP 270 1,500.00 100.00 Y 1,500.00 OP - DR KATZ KATZ OP 270 1,500.00 100.00 Y 1,500.00 OP - DR KELLA KELLA OP 270 2,500.00 100.00 Y 2,500.00 OP - DR LOWRY LOWRY OP 270 200.00 100.00 Y 200.00 OP - DR M MURPHY M MURPHY OP 270 1,500.00 100.00 Y 1,500.00 OP - DR MACKENZIE MACKENZIE OP 270 200.00 100.00 Y 200.00 OP - DR MORREY MORREY OP 270 500.00 100.00 Y 500.00 OP - DR MULLINS MULLINS OP 270 2,500.00 100.00 Y 2,500.00 Description Q Code CPTCode Rev Code Cost Markup Flatfee Markup% Billable Billable Fee OP - DR MURRAY MURRAY OP 270 4,000.00 100.00 Y 4,000.00 OP - DR NAZMY NAZMY OP 270 2,000.00 100.00 Y 2,000.00 OP - DR NEELY NEELY OP 270 100.00 Y 0.00 OP - DR P PATEL PATEL OP 270 1,500.00 100.00 Y 1,500.00 OP - DR PILCHER PILCHER OP 270 2,500.00 100.00 Y 2,500.00 OP - DR POLLAK POLLAK OP 270 600.00 100.00 Y 600.00 OP - DR RODRIGUEZ J OPRODRIGUEZ 270 1,500.00 100.00 Y 1,500.00 OP - DR SABELLA SABELLA OP 270 1,500.00 100.00 Y 1,500.00 OP - DR SAROSDY SAROSDY OP 270 1,000.00 100.00 Y 1,000.00 OP - DR SEGER SEGER OP 270 1,500.00 100.00 Y 1,500.00 OP - DR SHAH SHAH OP 270 1,000.00 100.00 Y 1,000.00 OP - DR SHIRANI SHIRANI OP 270 1,000.00 100.00 Y 1,000.00 OP - DR STANLEY STANLEY OP 270 200.00 100.00 Y 200.00 OP - DR STEFFAN STEFFAN OP 270 1,500.00 100.00 Y 1,500.00 OP - DR TOMPKINS TOMPKINS OP 270 1,000.00 100.00 Y 1,000.00 OP - DR VICK VICK OP 270 1,000.00 100.00 Y 1,000.00 OP - DR WRIGHT WRIGHT OP 270 1,500.00 100.00 Y 1,500.00 OP - DR ZAVALA ZAVALAOP 270 4,500.00 100.00 Y 4,500.00 OP - DR. D GONZALEZ D GONZALEZ 270 2,000.00 100.00 Y 2,000.00 OP - MED SURGICAL SUPPLIES 01 GUTZMAN OP 270 2,000.00 100.00 Y 2,000.00 OP - MED SURGICAL SUPPLIES 02 LENDERMAN OP 270 1,500.00 100.00 Y 1,500.00 OP - MED SURGICAL SUPPLIES 03 LEONARD OP 270 1,500.00 100.00 Y 1,500.00 OP- DR WIRTH OPWIRTH 270 7,500.00 100.00 Y 7,500.00