Code NFAC FAC Global PC TC Description

Home , Astragalectomy, Cervical canal, Cholecystostomy, Coccygectomy, Cubitus varus, Escharotomy

Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Fine needle aspiration biopsy, without imaging guidance; each additional lesion (List separately 10004 $40.44 $33.77 - - - in addition to code for primary procedure) 10005 $102.20 $55.83 - - - Fine needle aspiration biopsy, including ultrasound guidance; first lesion Fine needle aspiration biopsy, including ultrasound guidance; each additional lesion (List 10006 $46.41 $38.30 - - - separately in addition to code for primary procedure) 10007 $239.08 $72.71 - - - Fine needle aspiration biopsy, including fluoroscopic guidance; first lesion Fine needle aspiration biopsy, including fluoroscopic guidance; each additional lesion (List 10008 $135.39 $47.57 - - - separately in addition to code for primary procedure) 10009 $379.52 $88.53 - - - Fine needle aspiration biopsy, including CT guidance; first lesion Fine needle aspiration biopsy, including CT guidance; each additional lesion (List separately in 10010 $227.72 $64.25 - - - addition to code for primary procedure) 10011 - - I.C. - - Fine needle aspiration biopsy, including MR guidance; first lesion Fine needle aspiration biopsy, including MR guidance; each additional lesion (List separately in 10012 - - I.C. - - addition to code for primary procedure) 10021 $78.04 $43.26 - - - Fine needle aspiration biopsy, without imaging guidance; first lesion

10030 $500.16 $107.43 - - - Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, lymphocele, cyst), soft tissue (eg, extremity, abdominal wall, neck), percutaneous

10035 $367.39 $66.54 - - - Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous, including imaging guidance; first lesion Placement of soft tissue localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 10036 $314.01 $33.74 - - - seeds), percutaneous, including imaging guidance; each additional lesion (List separately in addition to code for primary procedure) Acne surgery (eg, marsupialization, opening or removal of multiple milia, comedones, cysts, 10040 $87.50 $41.70 - - - pustules) Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or 10060 $96.12 $79.60 - - - subcutaneous abscess, cyst, furuncle, or paronychia); simple or single

10061 $165.57 $143.55 - - - Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple 10080 $169.76 $81.65 - - - Incision and drainage of pilonidal cyst; simple 10081 $243.39 $134.99 - - - Incision and drainage of pilonidal cyst; complicated 10120 $121.34 $81.63 - - - Incision and removal of foreign body, subcutaneous tissues; simple 10121 $216.34 $145.91 - - - Incision and removal of foreign body, subcutaneous tissues; complicated 10140 $135.70 $93.96 - - - Incision and drainage of hematoma, seroma or fluid collection 10160 $103.78 $74.80 - - - Puncture aspiration of abscess, hematoma, bulla, or cyst 10180 $203.72 $140.25 - - - Incision and drainage, complex, postoperative wound infection 11000 $44.92 $22.02 - - - Debridement of extensive eczematous or infected skin; up to 10% of body surface

11001 $18.55 $11.01 - - - Debridement of extensive eczematous or infected skin; each additional 10% of the body surface, or part thereof (List separately in addition to code for primary procedure) Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue 11004 - - $448.00 - - infection; external genitalia and perineum Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue 11005 - - $608.93 - - infection; abdominal wall, with or without fascial closure

11006 - - $549.89 - - Debridement of skin, subcutaneous tissue, muscle and fascia for necrotizing soft tissue infection; external genitalia, perineum and abdominal wall, with or without fascial closure Removal of prosthetic material or mesh, abdominal wall for infection (eg, for chronic or 11008 - - $214.07 - - recurrent mesh infection or necrotizing soft tissue infection) (List separately in addition to code for primary procedure)

11010 $379.48 $217.17 - - - Debridement including removal of foreign material at the site of an open fracture and/or an open dislocation (eg, excisional debridement); skin and subcutaneous tissues Debridement including removal of foreign material at the site of an open fracture and/or an 11011 $421.24 $235.45 - - - open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, and muscle Debridement including removal of foreign material at the site of an open fracture and/or an 11012 $537.99 $327.86 - - - open dislocation (eg, excisional debridement); skin, subcutaneous tissue, muscle fascia, muscle, and bone Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm 11042 $100.45 $47.70 - - - or less

Page 1 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if 11043 $183.93 $121.03 - - - performed); first 20 sq cm or less Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if 11044 $246.74 $177.18 - - - performed); first 20 sq cm or less

11045 $32.86 $20.68 - - - Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if 11046 $58.06 $43.57 - - - performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Debridement, bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if 11047 $96.31 $76.90 - - - performed); each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) 11055 $50.60 $12.34 - - - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion 11056 $59.41 $17.97 - - - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions 11057 $65.13 $22.81 - - - Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions 11102 $80.33 $30.48 - - - Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); each separate/additional lesion 11103 $42.61 $17.68 - - - (List separately in addition to code for primary procedure) 11104 $101.03 $38.13 - - - Punch biopsy of skin (including simple closure, when performed); single lesion Punch biopsy of skin (including simple closure, when performed); each separate/additional 11105 $48.52 $20.70 - - - lesion (List separately in addition to code for primary procedure)

11106 $122.32 $46.10 - - - Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); single lesion Incisional biopsy of skin (eg, wedge) (including simple closure, when performed); each 11107 $57.58 $24.82 - - - separate/additional lesion (List separately in addition to code for primary procedure) 11200 $70.62 $58.45 - - - Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions Removal of skin tags, multiple fibrocutaneous tags, any area; each additional 10 lesions, or part 11201 $14.51 $12.77 - - - thereof (List separately in addition to code for primary procedure) Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm 11300 $80.57 $26.95 - - - or less Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 11301 $97.38 $40.86 - - - 1.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 11302 $112.57 $47.94 - - - 2.0 cm Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 11303 $123.63 $56.39 - - - 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion 11305 $84.34 $30.43 - - - diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion 11306 $98.68 $39.26 - - - diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion 11307 $115.10 $50.76 - - - diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion 11308 $122.53 $57.03 - - - diameter over 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous 11310 $92.99 $36.47 - - - membrane; lesion diameter 0.5 cm or less Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous 11311 $109.84 $49.84 - - - membrane; lesion diameter 0.6 to 1.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous 11312 $126.94 $59.12 - - - membrane; lesion diameter 1.1 to 2.0 cm Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous 11313 $147.81 $76.80 - - - membrane; lesion diameter over 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11400 $100.77 $64.83 - - - or legs; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11401 $122.26 $81.97 - - - or legs; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11402 $135.57 $90.36 - - - or legs; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11403 $155.95 $116.82 - - - or legs; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11404 $177.00 $128.30 - - - or legs; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms 11406 $251.35 $193.96 - - - or legs; excised diameter over 4.0 cm

Page 2 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11420 $101.32 $64.80 - - - hands, feet, genitalia; excised diameter 0.5 cm or less Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11421 $127.16 $86.30 - - - hands, feet, genitalia; excised diameter 0.6 to 1.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11422 $142.94 $107.29 - - - hands, feet, genitalia; excised diameter 1.1 to 2.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11423 $162.07 $122.66 - - - hands, feet, genitalia; excised diameter 2.1 to 3.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11424 $186.72 $140.35 - - - hands, feet, genitalia; excised diameter 3.1 to 4.0 cm Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, 11426 $266.00 $215.57 - - - hands, feet, genitalia; excised diameter over 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11440 $111.99 $82.14 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11441 $136.83 $103.50 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11442 $151.95 $114.56 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11443 $179.76 $140.05 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11444 $224.57 $178.20 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, 11446 $308.03 $253.54 - - - ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate 11450 $327.18 $202.26 - - - repair 11451 $406.44 $257.75 - - - Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate 11462 $319.05 $192.97 - - - repair 11463 $413.64 $260.03 - - - Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with 11470 $346.34 $222.58 - - - simple or intermediate repair Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with 11471 $420.96 $274.31 - - - complex repair Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or 11600 $157.65 $95.33 - - - less

11601 $182.76 $116.68 - - - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm

11602 $196.76 $127.49 - - - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm

11603 $223.50 $152.20 - - - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm

11604 $249.19 $167.75 - - - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm

11606 $355.39 $249.31 - - - Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11620 $158.45 $96.42 - - - diameter 0.5 cm or less Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11621 $183.56 $117.48 - - - diameter 0.6 to 1.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11622 $203.00 $133.44 - - - diameter 1.1 to 2.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11623 $237.55 $165.38 - - - diameter 2.1 to 3.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11624 $268.59 $187.44 - - - diameter 3.1 to 4.0 cm Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised 11626 $323.29 $229.97 - - - diameter over 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 11640 $162.19 $99.00 - - - cm or less Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 11641 $189.96 $122.43 - - - to 1.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 11642 $215.01 $143.42 - - - to 2.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 11643 $252.21 $179.46 - - - to 3.0 cm

Page 3 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 11644 $310.67 $222.56 - - - to 4.0 cm Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 11646 $402.82 $307.46 - - - over 4.0 cm 11719 $11.13 $5.91 - - - Trimming of nondystrophic nails, any number 11720 $26.03 $11.25 - - - Debridement of nail(s) by any method(s); 1 to 5 11721 $35.84 $19.32 - - - Debridement of nail(s) by any method(s); 6 or more 11730 $88.02 $42.52 - - - Avulsion of nail plate, partial or complete, simple; single Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in 11732 $26.47 $13.42 - - - addition to code for primary procedure) 11740 $43.01 $25.04 - - - Evacuation of subungual hematoma Excision of nail and nail matrix, partial or complete (eg, ingrown or deformed nail), for 11750 $124.56 $79.92 - - - permanent removal; Biopsy of nail unit (eg, plate, bed, matrix, hyponychium, proximal and lateral nail folds) 11755 $97.10 $48.12 - - - (separate procedure) 11760 $155.91 $90.41 - - - Repair of nail bed 11762 $235.96 $150.17 - - - Reconstruction of nail bed with graft 11765 $135.72 $73.12 - - - Wedge excision of skin of nail fold (eg, for ingrown toenail) 11770 $249.48 $145.72 - - - Excision of pilonidal cyst or sinus; simple 11771 $480.04 $348.16 - - - Excision of pilonidal cyst or sinus; extensive 11772 $581.90 $458.14 - - - Excision of pilonidal cyst or sinus; complicated 11900 $43.71 $23.71 - - - Injection, intralesional; up to and including 7 lesions 11901 $54.73 $37.05 - - - Injection, intralesional; more than 7 lesions Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of 11920 $149.27 $88.40 - - - skin, including micropigmentation; 6.0 sq cm or less Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of 11921 $169.95 $104.16 - - - skin, including micropigmentation; 6.1 to 20.0 sq cm Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of 11922 $47.95 $23.32 - - - skin, including micropigmentation; each additional 20.0 sq cm, or part thereof (List separately in addition to code for primary procedure) 11950 $62.85 $41.12 - - - Subcutaneous injection of filling material (eg, collagen); 1 cc or less 11951 $85.07 $58.40 - - - Subcutaneous injection of filling material (eg, collagen); 1.1 to 5.0 cc 11952 $114.20 $82.32 - - - Subcutaneous injection of filling material (eg, collagen); 5.1 to 10.0 cc 11954 $125.60 $89.37 - - - Subcutaneous injection of filling material (eg, collagen); over 10.0 cc 11960 - - $777.41 - - Insertion of tissue expander(s) for other than breast, including subsequent expansion 11970 - - $484.62 - - Replacement of tissue expander with permanent prosthesis 11971 $388.03 $258.76 - - - Removal of tissue expander(s) without insertion of prosthesis 11976 $114.65 $73.49 - - - Removal, implantable contraceptive capsules Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone 11980 $74.68 $43.38 - - - pellets beneath the skin) 11981 $82.00 $50.12 - - - Insertion, non-biodegradable drug delivery implant 11982 $92.97 $59.06 - - - Removal, non-biodegradable drug delivery implant 11983 $114.19 $81.15 - - - Removal with reinsertion, non-biodegradable drug delivery implant Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12001 $72.04 $34.94 - - - extremities (including hands and feet); 2.5 cm or less Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12002 $87.80 $46.35 - - - extremities (including hands and feet); 2.6 cm to 7.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12004 $102.20 $57.56 - - - extremities (including hands and feet); 7.6 cm to 12.5 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12005 $134.89 $74.60 - - - extremities (including hands and feet); 12.6 cm to 20.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12006 $159.00 $91.47 - - - extremities (including hands and feet); 20.1 cm to 30.0 cm Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or 12007 $181.16 $113.04 - - - extremities (including hands and feet); over 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12011 $87.72 $43.67 - - - 2.5 cm or less Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12013 $91.28 $45.77 - - - 2.6 cm to 5.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12014 $110.73 $58.56 - - - 5.1 cm to 7.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12015 $133.71 $74.00 - - - 7.6 cm to 12.5 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12016 $169.61 $100.34 - - - 12.6 cm to 20.0 cm

Page 4 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12017 - - $119.20 - - 20.1 cm to 30.0 cm Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12018 - - $135.08 - - over 30.0 cm 12020 $235.26 $148.89 - - - Treatment of superficial wound dehiscence; simple closure 12021 $135.94 $110.14 - - - Treatment of superficial wound dehiscence; with packing Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12031 $201.73 $120.29 - - - feet); 2.5 cm or less Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12032 $241.56 $150.85 - - - feet); 2.6 cm to 7.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12034 $258.67 $162.15 - - - feet); 7.6 cm to 12.5 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12035 $308.30 $189.76 - - - feet); 12.6 cm to 20.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12036 $343.48 $222.04 - - - feet); 20.1 cm to 30.0 cm Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and 12037 $389.18 $259.34 - - - feet); over 30.0 cm 12041 $202.02 $115.94 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 12042 $239.27 $155.22 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm

12044 $297.32 $168.63 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm

12045 $324.99 $212.82 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm

12046 $391.97 $247.92 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm 12047 $429.61 $275.99 - - - Repair, intermediate, wounds of neck, hands, feet and/or external genitalia; over 30.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 12051 $217.06 $133.59 - - - cm or less Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 12052 $242.80 $157.88 - - - cm to 5.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 12053 $284.84 $170.07 - - - cm to 7.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 12054 $299.68 $173.02 - - - cm to 12.5 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 12055 $388.84 $236.39 - - - cm to 20.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 12056 $456.43 $304.56 - - - cm to 30.0 cm Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 12057 $483.98 $336.45 - - - 30.0 cm 13100 $272.78 $159.45 - - - Repair, complex, trunk; 1.1 cm to 2.5 cm 13101 $320.35 $196.59 - - - Repair, complex, trunk; 2.6 cm to 7.5 cm Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for 13102 $95.56 $57.01 - - - primary procedure) 13120 $284.25 $183.97 - - - Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm 13121 $343.00 $205.62 - - - Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in 13122 $104.01 $65.75 - - - addition to code for primary procedure) Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 13131 $310.91 $192.95 - - - cm to 2.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 13132 $379.85 $241.31 - - - cm to 7.5 cm Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each 13133 $137.74 $100.35 - - - additional 5 cm or less (List separately in addition to code for primary procedure) 13151 $338.62 $221.52 - - - Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 13152 $400.48 $266.57 - - - Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in 13153 $150.58 $109.14 - - - addition to code for primary procedure) 13160 - - $627.48 - - Secondary closure of surgical wound or dehiscence, extensive or complicated 14000 $498.23 $394.18 - - - Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less 14001 $633.73 $510.26 - - - Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm 14020 $551.95 $443.27 - - - Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq 14021 $684.41 $558.62 - - - cm

Page 5 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, 14040 $599.22 $491.11 - - - genitalia, hands and/or feet; defect 10 sq cm or less Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, 14041 $732.21 $601.49 - - - genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or 14060 $607.39 $523.34 - - - less Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 14061 $788.06 $644.59 - - - 30.0 sq cm 14350 - - $539.44 - - Filleted finger or toe flap, including preparation of recipient site Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or 15002 $279.15 $175.10 - - - scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; 15003 $57.60 $35.57 - - - each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, 15004 $317.53 $207.68 - - - eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, 15005 $96.07 $71.72 - - - eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15040 $209.79 $97.63 - - - Harvest of skin for tissue cultured skin autograft, 100 sq cm or less Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area 15050 $468.09 $361.43 - - - (except on face), up to defect size 2 cm diameter Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants 15100 $687.17 $563.99 - - - and children (except 15050) Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of 15101 $150.71 $88.11 - - - body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and 15110 $634.66 $542.49 - - - children Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body 15111 $90.03 $81.05 - - - area of infants and children, or part thereof (List separately in addition to code for primary procedure) Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 15115 $627.48 $536.18 - - - multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 15116 $131.29 $119.12 - - - multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 15120 $673.86 $546.04 - - - and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050)

Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, 15121 $168.68 $106.37 - - - and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and 15130 $573.49 $472.34 - - - children Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body 15131 $77.99 $71.91 - - - area of infants and children, or part thereof (List separately in addition to code for primary procedure) Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 15135 $690.63 $595.85 - - - multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or 15136 $77.12 $71.91 - - - multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15150 $555.03 $501.12 - - - Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately 15151 $93.45 $85.92 - - - in addition to code for primary procedure)

Page 6 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 15152 $121.07 $113.83 - - - 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, 15155 $635.35 $580.86 - - - feet, and/or multiple digits; first 25 sq cm or less Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, 15156 $124.80 $117.55 - - - feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure)

Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, 15157 $139.77 $129.04 - - - feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15200 $664.44 $529.95 - - - Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm, 15201 $117.36 $61.13 - - - or part thereof (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq 15220 $612.19 $481.76 - - - cm or less

15221 $108.10 $55.06 - - - Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, 15240 $737.33 $627.48 - - - neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, 15241 $144.31 $85.47 - - - neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 15260 $791.82 $666.61 - - - 20 sq cm or less Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 15261 $166.78 $107.95 - - - each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure) Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq 15271 $119.62 $66.29 - - - cm; first 25 sq cm or less wound surface area Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq 15272 $20.66 $13.70 - - - cm; each additional 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure) Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than 15273 $247.39 $157.25 - - - or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children Application of skin substitute graft to trunk, arms, legs, total wound surface area greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area, or part thereof, or each 15274 $62.82 $35.57 - - - additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 15275 $124.50 $74.36 - - - hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; each additional 15276 $26.82 $20.15 - - - 25 sq cm wound surface area, or part thereof (List separately in addition to code for primary procedure)

Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, 15277 $270.77 $178.31 - - - hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area greater than or equal to 100 sq 15278 $73.98 $45.00 - - - cm; each additional 100 sq cm wound surface area, or part thereof, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15570 $726.49 $580.13 - - - Formation of direct or tubed pedicle, with or without transfer; trunk 15572 $700.82 $584.01 - - - Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, 15574 $712.89 $593.18 - - - neck, axillae, genitalia, hands or feet Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or 15576 $631.19 $520.47 - - - intraoral 15600 $267.96 $166.23 - - - Delay of flap or sectioning of flap (division and inset); at trunk 15610 $290.07 $191.53 - - - Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs

Page 7 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, 15620 $353.46 $256.66 - - - genitalia, hands, or feet 15630 $366.12 $270.76 - - - Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips 15650 $405.55 $301.50 - - - Transfer, intermediate, of any pedicle flap (eg, abdomen to wrist, Walking tube), any location 15730 $1,203.76 $723.50 - - - Midface flap (ie, zygomaticofacial flap) with preservation of vascular pedicle(s) Forehead flap with preservation of vascular pedicle (eg, axial pattern flap, paramedian forehead 15731 $885.40 $786.27 - - - flap)

15733 - - $819.03 - - Muscle, myocutaneous, or fasciocutaneous flap; head and neck with named vascular pedicle (ie, buccinators, genioglossus, temporalis, masseter, sternocleidomastoid, levator scapulae) 15734 - - $1,186.26 - - Muscle, myocutaneous, or fasciocutaneous flap; trunk 15736 - - $966.94 - - Muscle, myocutaneous, or fasciocutaneous flap; upper extremity 15738 - - $1,022.23 - - Muscle, myocutaneous, or fasciocutaneous flap; lower extremity 15740 $793.14 $658.66 - - - Flap; island pedicle requiring identification and dissection of an anatomically named axial vessel 15750 - - $723.58 - - Flap; neurovascular pedicle 15756 - - $1,796.91 - - Free muscle or myocutaneous flap with microvascular anastomosis 15757 - - $1,785.48 - - Free skin flap with microvascular anastomosis 15758 - - $1,798.00 - - Free fascial flap with microvascular anastomosis Graft; composite (eg, full thickness of external ear or nasal ala), including primary closure, 15760 $669.59 $551.92 - - - donor area

15769 - - $380.17 - - Grafting of autologous soft tissue, other, harvested by direct excision (eg, fat, dermis, fascia) 15770 - - $524.32 - - Graft; derma-fat-fascia Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, 15771 $457.97 $377.10 - - - and/or legs; 50 cc or less injectate Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, 15772 $143.22 $109.89 - - - and/or legs; each additional 50 cc injectate, or part thereof (List separately in addition to code for primary procedure) Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, 15773 $462.07 $381.21 - - - ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, 15774 $138.94 $105.60 - - - ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof (List separately in addition to code for primary procedure) 15775 $294.51 $202.92 - - - Punch graft for hair transplant; 1 to 15 punch grafts 15776 $403.51 $278.31 - - - Punch graft for hair transplant; more than 15 punch grafts Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, 15777 - - $169.30 - - breast, trunk) (List separately in addition to code for primary procedure) 15780 $705.39 $535.55 - - - Dermabrasion; total face (eg, for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 $438.28 $340.90 - - - Dermabrasion; segmental, face 15782 $432.10 $313.27 - - - Dermabrasion; regional, other than face 15783 $369.86 $284.65 - - - Dermabrasion; superficial, any site (eg, tattoo removal) 15786 $193.06 $105.53 - - - Abrasion; single lesion (eg, keratosis, scar) Abrasion; each additional 4 lesions or less (List separately in addition to code for primary 15787 $32.43 $13.59 - - - procedure) 15788 $348.99 $183.49 - - - Chemical peel, facial; epidermal 15789 $430.74 $322.63 - - - Chemical peel, facial; dermal 15792 $312.84 $185.89 - - - Chemical peel, nonfacial; epidermal 15793 $382.91 $279.15 - - - Chemical peel, nonfacial; dermal 15819 - - $630.84 - - Cervicoplasty 15820 $452.89 $403.04 - - - Blepharoplasty, lower eyelid; 15821 $485.30 $430.53 - - - Blepharoplasty, lower eyelid; with extensive herniated fat pad 15822 $360.54 $311.55 - - - Blepharoplasty, upper eyelid; 15823 $486.18 $431.11 - - - Blepharoplasty, upper eyelid; with excessive skin weighting down lid 15824 - - I.C. - - Rhytidectomy; forehead 15825 - - I.C. - - Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 - - I.C. - - Rhytidectomy; glabellar frown lines 15828 - - I.C. - - Rhytidectomy; cheek, chin, and neck 15829 - - I.C. - - Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical 15830 - - $928.20 - - panniculectomy 15832 - - $727.86 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 - - $692.66 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 - - $706.17 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 - - $739.76 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock

Page 8 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 15836 - - $592.73 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15837 $690.67 $569.81 - - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand 15838 - - $510.32 - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 $702.99 $581.26 - - - Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area 15840 - - $791.91 - - Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 15841 - - $1,410.31 - - Graft for facial nerve paralysis; free muscle graft (including obtaining graft) 15842 - - $2,143.36 - - Graft for facial nerve paralysis; free muscle flap by microsurgical technique 15845 - - $797.24 - - Graft for facial nerve paralysis; regional muscle transfer Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, 15847 - - I.C. - - abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) 15850 $72.30 $30.86 - - - Removal of sutures under anesthesia (other than local), same surgeon 15851 $82.40 $35.45 - - - Removal of sutures under anesthesia (other than local), other surgeon 15852 - - $36.14 - - Dressing change (for other than burns) under anesthesia (other than local) 15860 - - $84.35 - - Intravenous injection of agent (eg, fluorescein) to test vascular flow in flap or graft 15876 - - I.C. - - Suction assisted lipectomy; head and neck 15877 - - I.C. - - Suction assisted lipectomy; trunk 15878 - - I.C. - - Suction assisted lipectomy; upper extremity 15879 - - I.C. - - Suction assisted lipectomy; lower extremity 15920 - - $494.68 - - Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture 15922 - - $627.13 - - Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure 15931 - - $549.93 - - Excision, sacral pressure ulcer, with primary suture; 15933 - - $683.08 - - Excision, sacral pressure ulcer, with primary suture; with ostectomy 15934 - - $745.46 - - Excision, sacral pressure ulcer, with skin flap closure; 15935 - - $911.55 - - Excision, sacral pressure ulcer, with skin flap closure; with ostectomy Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft 15936 - - $709.91 - - closure; Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft 15937 - - $822.89 - - closure; with ostectomy 15940 - - $553.29 - - Excision, ischial pressure ulcer, with primary suture; 15941 - - $724.70 - - Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy) 15944 - - $720.26 - - Excision, ischial pressure ulcer, with skin flap closure; 15945 - - $804.55 - - Excision, ischial pressure ulcer, with skin flap closure; with ostectomy Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap 15946 - - $1,284.96 - - or skin graft closure 15950 - - $483.06 - - Excision, trochanteric pressure ulcer, with primary suture; 15951 - - $707.34 - - Excision, trochanteric pressure ulcer, with primary suture; with ostectomy 15952 - - $722.55 - - Excision, trochanteric pressure ulcer, with skin flap closure; 15953 - - $795.36 - - Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin 15956 - - $921.91 - - graft closure; Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin 15958 - - $932.65 - - graft closure; with ostectomy 15999 - - I.C. - - Unlisted procedure, excision pressure ulcer 16000 $57.85 $35.82 - - - Initial treatment, first degree burn, when no more than local treatment is required Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 16020 $65.87 $42.98 - - - 5% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (eg, 16025 $121.70 $86.63 - - - whole face or whole extremity, or 5% to 10% total body surface area) Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (eg, more 16030 $153.79 $104.52 - - - than 1 extremity, or greater than 10% total body surface area) 16035 - - $153.79 - - Escharotomy; initial incision Escharotomy; each additional incision (List separately in addition to code for primary 16036 - - $63.75 - - procedure) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17000 $51.85 $42.58 - - - curettement), premalignant lesions (eg, actinic keratoses); first lesion Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17003 $4.83 $1.64 - - - curettement), premalignant lesions (eg, actinic keratoses); second through 14 lesions, each (List separately in addition to code for first lesion) Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17004 $125.94 $76.96 - - - curettement), premalignant lesions (eg, actinic keratoses), 15 or more lesions

17106 $270.86 $216.37 - - - Destruction of cutaneous vascular proliferative lesions (eg, laser technique); less than 10 sq cm

17107 $354.49 $280.30 - - - Destruction of cutaneous vascular proliferative lesions (eg, laser technique); 10.0 to 50.0 sq cm

Page 9 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

17108 $503.49 $412.78 - - - Destruction of cutaneous vascular proliferative lesions (eg, laser technique); over 50.0 sq cm Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17110 $89.80 $53.28 - - - curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical 17111 $105.03 $65.03 - - - curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions; 15 or more lesions 17250 $68.51 $29.38 - - - Chemical cauterization of granulation tissue (ie, proud flesh) Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17260 $76.65 $55.20 - - - surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17261 $116.21 $68.68 - - - surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17262 $140.53 $87.78 - - - surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17263 $152.63 $97.56 - - - surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17264 $163.52 $104.11 - - - surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17266 $186.08 $122.61 - - - surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17270 $118.36 $75.47 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17271 $130.41 $83.16 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17272 $148.91 $96.74 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17273 $165.48 $109.54 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17274 $194.36 $133.79 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17276 $224.52 $160.47 - - - surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17280 $110.70 $68.39 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17281 $141.59 $93.77 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17282 $162.61 $108.99 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17283 $193.32 $136.23 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17284 $219.72 $158.85 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm Destruction, malignant lesion (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, 17286 $281.93 $214.69 - - - surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm

Page 10 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue 17313 $495.85 $254.71 - - - specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks

Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the 17314 $304.25 $140.20 - - - surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the 17315 $61.80 $40.06 - - - surgeon, and histopathologic preparation including routine stain(s) (eg, hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) 17340 $41.18 $38.57 - - - Cryotherapy (CO2 slush, liquid N2) for acne 17360 $97.85 $73.22 - - - Chemical exfoliation for acne (eg, acne paste, acid) 17380 - - I.C. - - Electrolysis epilation, each 30 minutes 17999 - - I.C. - - Unlisted procedure, skin, mucous membrane and subcutaneous tissue 19000 $87.58 $33.96 - - - Puncture aspiration of cyst of breast; Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for 19001 $21.35 $17.00 - - - primary procedure) 19020 $379.16 $245.54 - - - Mastotomy with exploration or drainage of abscess, deep 19030 $134.53 $60.05 - - - Injection procedure only for mammary ductogram or galactogram Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when 19081 $493.05 $130.18 - - - performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including stereotactic guidance Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each 19082 $400.42 $65.37 - - - additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when 19083 $488.30 $123.11 - - - performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including ultrasound guidance Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each 19084 $389.78 $60.82 - - - additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when 19085 $748.50 $142.74 - - - performed, and imaging of the biopsy specimen, when performed, percutaneous; first lesion, including magnetic resonance guidance Biopsy, breast, with placement of breast localization device(s) (eg, clip, metallic pellet), when performed, and imaging of the biopsy specimen, when performed, percutaneous; each 19086 $598.09 $71.17 - - - additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure)

19100 $123.06 $54.66 - - - Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 19101 $267.55 $175.68 - - - Biopsy of breast; open, incisional 19105 $2,237.21 $164.89 - - - Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma 19110 $390.42 $274.49 - - - lactiferous duct 19112 $369.12 $250.87 - - - Excision of lactiferous duct fistula Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, 19120 $400.04 $327.00 - - - duct lesion, nipple or areolar lesion (except 19300), open, male or female, 1 or more lesions Excision of breast lesion identified by preoperative placement of radiological marker, open; 19125 $441.50 $362.66 - - - single lesion Excision of breast lesion identified by preoperative placement of radiological marker, open; 19126 - - $125.38 - - each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure) Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19281 $196.38 $78.42 - - - seeds), percutaneous; first lesion, including mammographic guidance Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19282 $139.74 $39.46 - - - seeds), percutaneous; each additional lesion, including mammographic guidance (List separately in addition to code for primary procedure)

Page 11 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19283 $218.57 $79.15 - - - seeds), percutaneous; first lesion, including stereotactic guidance Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19284 $168.01 $40.19 - - - seeds), percutaneous; each additional lesion, including stereotactic guidance (List separately in addition to code for primary procedure) Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19285 $371.31 $67.27 - - - seeds), percutaneous; first lesion, including ultrasound guidance Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive 19286 $318.65 $34.03 - - - seeds), percutaneous; each additional lesion, including ultrasound guidance (List separately in addition to code for primary procedure) Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive 19287 $633.28 $100.57 - - - seeds), percutaneous; first lesion, including magnetic resonance guidance Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive 19288 $505.89 $50.56 - - - seeds), percutaneous; each additional lesion, including magnetic resonance guidance (List separately in addition to code for primary procedure) Preparation of tumor cavity, with placement of a radiation therapy applicator for intraoperative 19294 - - $128.80 - - radiation therapy (IORT) concurrent with partial mastectomy (List separately in addition to code for primary procedure) Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the 19296 $3,298.09 $164.39 - - - breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging 19297 - - $74.17 - - guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure) Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button 19298 $807.48 $249.55 - - - type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance 19300 $440.45 $333.79 - - - Mastectomy for gynecomastia 19301 - - $516.64 - - Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); Mastectomy, partial (eg, lumpectomy, tylectomy, quadrantectomy, segmentectomy); with 19302 - - $709.87 - - axillary lymphadenectomy 19303 - - $753.93 - - Mastectomy, simple, complete 19305 - - $896.19 - - Mastectomy, radical, including pectoral muscles, axillary lymph nodes Mastectomy, radical, including pectoral muscles, axillary and internal mammary lymph nodes 19306 - - $952.67 - - (Urban type operation) Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor 19307 - - $949.38 - - muscle, but excluding pectoralis major muscle 19316 - - $611.80 - - Mastopexy 19318 - - $867.06 - - Reduction mammaplasty 19325 - - $513.63 - - Mammaplasty, augmentation; with prosthetic implant 19328 - - $397.00 - - Removal of intact mammary implant 19330 - - $502.73 - - Removal of mammary implant material 19340 - - $782.32 - - Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction

19342 - - $735.16 - - Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19350 $660.76 $533.52 - - - Nipple/areola reconstruction 19355 $603.00 $490.83 - - - Correction of inverted nipples Breast reconstruction, immediate or delayed, with tissue expander, including subsequent 19357 - - $1,196.89 - - expansion 19361 - - $1,241.48 - - Breast reconstruction with latissimus dorsi flap, without prosthetic implant 19364 - - $2,171.93 - - Breast reconstruction with free flap Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single 19367 - - $1,405.25 - - pedicle, including closure of donor site; Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), single 19368 - - $1,731.55 - - pedicle, including closure of donor site; with microvascular anastomosis (supercharging) Breast reconstruction with transverse rectus abdominis myocutaneous flap (TRAM), double 19369 - - $1,608.55 - - pedicle, including closure of donor site 19370 - - $547.20 - - Open periprosthetic capsulotomy, breast 19371 - - $625.07 - - Periprosthetic capsulectomy, breast 19380 - - $617.36 - - Revision of reconstructed breast 19396 $230.58 $114.06 - - - Preparation of moulage for custom breast implant 19499 - - I.C. - - Unlisted procedure, breast 20100 - - $471.57 - - Exploration of penetrating wound (separate procedure); neck 20101 $385.87 $165.31 - - - Exploration of penetrating wound (separate procedure); chest

Page 12 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 20102 $413.39 $201.52 - - - Exploration of penetrating wound (separate procedure); abdomen/flank/back 20103 $462.82 $272.69 - - - Exploration of penetrating wound (separate procedure); extremity Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same 20150 - - $792.83 - - fascial incision 20200 $170.77 $73.96 - - - Biopsy, muscle; superficial 20205 $237.01 $120.21 - - - Biopsy, muscle; deep 20206 $193.09 $45.57 - - - Biopsy, muscle, percutaneous needle 20220 $199.41 $69.27 - - - Biopsy, bone, trocar, or needle; superficial (eg, ilium, sternum, spinous process, ribs) 20225 $338.43 $103.09 - - - Biopsy, bone, trocar, or needle; deep (eg, vertebral body, femur) Biopsy, bone, open; superficial (eg, sternum, spinous process, rib, patella, olecranon process, 20240 - - $114.17 - - calcaneus, tarsal, metatarsal, carpal, metacarpal, phalanx) 20245 - - $272.76 - - Biopsy, bone, open; deep (eg, humeral shaft, ischium, femoral shaft) 20250 - - $310.69 - - Biopsy, vertebral body, open; thoracic 20251 - - $337.07 - - Biopsy, vertebral body, open; lumbar or cervical 20500 $90.47 $68.44 - - - Injection of sinus tract; therapeutic (separate procedure) 20501 $111.10 $29.66 - - - Injection of sinus tract; diagnostic (sinogram) 20520 $168.84 $116.38 - - - Removal of foreign body in muscle or tendon sheath; simple 20525 $382.69 $194.59 - - - Removal of foreign body in muscle or tendon sheath; deep or complicated 20526 $62.18 $44.79 - - - Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel 20527 $67.16 $51.80 - - - Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture) 20550 $42.97 $30.50 - - - Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia") 20551 $44.13 $31.08 - - - Injection(s); single tendon origin/insertion 20552 $44.06 $30.15 - - - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 20553 $50.50 $33.98 - - - Injection(s); single or multiple trigger point(s), 3 or more muscles Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial 20555 - - $257.01 - - radioelement application (at the time of or subsequent to the procedure) 20560 $20.53 $12.70 - - - Needle insertion(s) without injection(s); 1 or 2 muscle(s) 20561 $30.48 $19.17 - - - Needle insertion(s) without injection(s); 3 or more muscles Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without 20600 $39.71 $28.12 - - - ultrasound guidance Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with 20604 $60.30 $35.67 - - - ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, 20605 $41.11 $29.23 - - - temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, 20606 $66.61 $41.10 - - - temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 20610 $48.82 $35.78 - - - subacromial bursa); without ultrasound guidance Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, 20611 $74.39 $46.85 - - - subacromial bursa); with ultrasound guidance, with permanent recording and reporting 20612 $48.89 $32.37 - - - Aspiration and/or injection of ganglion cyst(s) any location 20615 $198.80 $126.34 - - - Aspiration and injection for treatment of bone cyst Insertion of wire or pin with application of skeletal traction, including removal (separate 20650 $169.18 $124.54 - - - procedure) Application of cranial tongs, caliper, or stereotactic frame, including removal (separate 20660 - - $187.88 - - procedure) 20661 - - $397.88 - - Application of halo, including removal; cranial 20662 - - $407.61 - - Application of halo, including removal; pelvic 20663 - - $375.23 - - Application of halo, including removal; femoral Application of halo, including removal, cranial, 6 or more pins placed, for thin skull osteology 20664 - - $683.98 - - (eg, pediatric patients, hydrocephalus, osteogenesis imperfecta) 20665 $88.71 $73.93 - - - Removal of tongs or halo applied by another individual 20670 $299.54 $115.49 - - - Removal of implant; superficial (eg, buried wire, pin or rod) (separate procedure) 20680 $490.68 $332.43 - - - Removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate) 20690 - - $470.10 - - Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation 20692 - - $883.02 - - system (eg, Ilizarov, Monticelli type) Adjustment or revision of external fixation system requiring anesthesia (eg, new pin[s] or 20693 - - $350.58 - - wire[s] and/or new ring[s] or bar[s]) 20694 $341.07 $267.74 - - - Removal, under anesthesia, of external fixation system Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with 20696 - - $937.69 - - stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment schedule(s)

Page 13 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with 20697 - - $1,675.40 - - stereotactic computer-assisted adjustment (eg, spatial frame), including imaging; exchange (ie, removal and replacement) of strut, each Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List 20700 - - $65.82 - - separately in addition to code for primary procedure) Removal of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for 20701 - - $49.12 - - primary procedure) Manual preparation and insertion of drug-delivery device(s), intramedullary (List separately in 20702 - - $109.46 - - addition to code for primary procedure) Removal of drug-delivery device(s), intramedullary (List separately in addition to code for 20703 - - $78.52 - - primary procedure) Manual preparation and insertion of drug-delivery device(s), intra-articular (List separately in 20704 - - $114.05 - - addition to code for primary procedure) Removal of drug-delivery device(s), intra-articular (List separately in addition to code for 20705 - - $93.87 - - primary procedure) Replantation, arm (includes surgical neck of humerus through elbow joint), complete 20802 - - $2,162.60 - - amputation

20805 - - $2,572.51 - - Replantation, forearm (includes radius and ulna to radial carpal joint), complete amputation

20808 - - $3,107.52 - - Replantation, hand (includes hand through metacarpophalangeal joints), complete amputation Replantation, digit, excluding thumb (includes metacarpophalangeal joint to insertion of flexor 20816 - - $1,619.80 - - sublimis tendon), complete amputation Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete 20822 - - $1,395.80 - - amputation 20824 - - $1,622.70 - - Replantation, thumb (includes carpometacarpal joint to MP joint), complete amputation 20827 - - $1,433.65 - - Replantation, thumb (includes distal tip to MP joint), complete amputation 20838 - - $2,193.57 - - Replantation, foot, complete amputation 20900 $327.70 $144.82 - - - Bone graft, any donor area; minor or small (eg, dowel or button) 20902 - - $221.38 - - Bone graft, any donor area; major or large 20910 - - $372.78 - - Cartilage graft; costochondral 20920 - - $308.24 - - Fascia lata graft; by stripper 20922 $471.22 $381.95 - - - Fascia lata graft; by incision and area exposure, complex or sheet 20924 - - $401.26 - - Tendon graft, from a distance (eg, palmaris, toe extensor, plantaris) Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List 20930 - - I.C. - - separately in addition to code for primary procedure) Allograft, structural, for spine surgery only (List separately in addition to code for primary 20931 - - $86.45 - - procedure) Allograft, includes templating, cutting, placement and internal fixation, when performed; 20932 - - $556.83 - - osteoarticular, including articular surface and contiguous bone (List separately in addition to code for primary procedure) Allograft, includes templating, cutting, placement and internal fixation, when performed; 20933 - - $511.73 - - hemicortical intercalary, partial (ie, hemicylindrical) (List separately in addition to code for primary procedure)

20934 - - $556.57 - - Allograft, includes templating, cutting, placement and internal fixation, when performed; intercalary, complete (ie, cylindrical) (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, 20936 - - I.C. - - or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); morselized (through separate 20937 - - $130.56 - - skin or fascial incision) (List separately in addition to code for primary procedure) Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or 20938 - - $143.39 - - tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial 20939 - - $54.59 - - incision (List separately in addition to code for primary procedure) Monitoring of interstitial fluid pressure (includes insertion of device, eg, wick catheter 20950 $211.22 $70.07 - - - technique, needle manometer technique) in detection of muscle compartment syndrome 20955 - - $1,931.64 - - Bone graft with microvascular anastomosis; fibula 20956 - - $2,079.91 - - Bone graft with microvascular anastomosis; iliac crest 20957 - - $2,164.94 - - Bone graft with microvascular anastomosis; metatarsal 20962 - - $2,097.43 - - Bone graft with microvascular anastomosis; other than fibula, iliac crest, or metatarsal Free osteocutaneous flap with microvascular anastomosis; other than iliac crest, metatarsal, or 20969 - - $2,137.59 - - great toe 20970 - - $2,246.61 - - Free osteocutaneous flap with microvascular anastomosis; iliac crest

Page 14 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 20972 - - $2,240.54 - - Free osteocutaneous flap with microvascular anastomosis; metatarsal 20973 - - $2,365.86 - - Free osteocutaneous flap with microvascular anastomosis; great toe with web space 20974 $63.30 $39.83 - - - Electrical stimulation to aid bone healing; noninvasive (nonoperative) 20975 - - $139.13 - - Electrical stimulation to aid bone healing; invasive (operative) 20979 $42.42 $25.03 - - - Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) 20982 $3,141.75 $285.13 - - - including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; radiofrequency Ablation therapy for reduction or eradication of 1 or more bone tumors (eg, metastasis) 20983 $4,692.99 $270.39 - - - including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablation Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less 20985 - - $114.54 - - (List separately in addition to code for primary procedure) 20999 - - I.C. - - Unlisted procedure, musculoskeletal system, general 21010 - - $591.15 - - Arthrotomy, temporomandibular joint 21011 $290.34 $204.26 - - - Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm 21012 - - $266.87 - - Excision, tumor, soft tissue of face or scalp, subcutaneous; 2 cm or greater Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); less than 21013 $422.60 $317.10 - - - 2 cm Excision, tumor, soft tissue of face and scalp, subfascial (eg, subgaleal, intramuscular); 2 cm or 21014 - - $411.43 - - greater 21015 - - $555.93 - - Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; less than 2 cm 21016 - - $793.40 - - Radical resection of tumor (eg, sarcoma), soft tissue of face or scalp; 2 cm or greater 21025 $656.55 $548.44 - - - Excision of bone (eg, for osteomyelitis or bone abscess); mandible 21026 $449.63 $359.78 - - - Excision of bone (eg, for osteomyelitis or bone abscess); facial bone(s) 21029 $608.00 $493.52 - - - Removal by contouring of benign tumor of facial bone (eg, fibrous dysplasia) 21030 $393.67 $308.17 - - - Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage 21031 $312.84 $223.28 - - - Excision of torus mandibularis 21032 $313.23 $218.75 - - - Excision of maxillary torus palatinus 21034 $1,025.79 $892.18 - - - Excision of malignant tumor of maxilla or zygoma 21040 $396.86 $309.04 - - - Excision of benign tumor or cyst of mandible, by enucleation and/or curettage 21044 - - $679.45 - - Excision of malignant tumor of mandible; 21045 - - $949.33 - - Excision of malignant tumor of mandible; radical resection Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (eg, locally 21046 - - $830.79 - - aggressive or destructive lesion[s]) Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial 21047 - - $1,005.86 - - mandibulectomy (eg, locally aggressive or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (eg, locally aggressive 21048 - - $841.71 - - or destructive lesion[s]) Excision of benign tumor or cyst of maxilla; requiring extra-oral osteotomy and partial 21049 - - $946.10 - - maxillectomy (eg, locally aggressive or destructive lesion[s]) 21050 - - $696.93 - - Condylectomy, temporomandibular joint (separate procedure) 21060 - - $632.48 - - Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21070 - - $496.57 - - Coronoidectomy (separate procedure) Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service 21073 $306.50 $198.39 - - - (ie, general or monitored anesthesia care) 21076 $712.16 $586.09 - - - Impression and custom preparation; surgical obturator prosthesis 21077 $1,760.09 $1,453.16 - - - Impression and custom preparation; orbital prosthesis 21079 $1,200.01 $976.83 - - - Impression and custom preparation; interim obturator prosthesis 21080 $1,373.23 $1,101.94 - - - Impression and custom preparation; definitive obturator prosthesis 21081 $1,262.13 $1,007.65 - - - Impression and custom preparation; mandibular resection prosthesis 21082 $1,170.00 $927.41 - - - Impression and custom preparation; palatal augmentation prosthesis 21083 $1,116.81 $861.18 - - - Impression and custom preparation; palatal lift prosthesis 21084 $1,277.27 $996.13 - - - Impression and custom preparation; speech aid prosthesis 21085 $555.80 $400.73 - - - Impression and custom preparation; oral surgical splint 21086 $1,310.38 $1,071.84 - - - Impression and custom preparation; auricular prosthesis 21087 $1,310.38 $1,071.84 - - - Impression and custom preparation; nasal prosthesis 21088 - - I.C. - - Impression and custom preparation; facial prosthesis 21089 - - I.C. - - Unlisted maxillofacial prosthetic procedure Application of halo type appliance for maxillofacial fixation, includes removal (separate 21100 $535.49 $294.92 - - - procedure) Application of interdental fixation device for conditions other than fracture or dislocation, 21110 $666.63 $553.01 - - - includes removal 21116 $160.49 $36.44 - - - Injection procedure for temporomandibular joint arthrography 21121 $541.38 $453.85 - - - Genioplasty; sliding osteotomy, single piece

Page 15 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Genioplasty; sliding osteotomies, 2 or more osteotomies (eg, wedge excision or bone wedge 21122 - - $613.46 - - reversal for asymmetrical chin) 21125 $2,313.86 $545.57 - - - Augmentation, mandibular body or angle; prosthetic material Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes 21127 $3,302.18 $627.87 - - - obtaining autograft) Reduction forehead; contouring and application of prosthetic material or bone graft (includes 21138 - - $728.26 - - obtaining autograft) Reconstruction midface, LeFort I; single piece, segment movement in any direction (eg, for Long 21141 - - $1,058.54 - - Face Syndrome), without bone graft Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, without bone 21142 - - $1,087.45 - - graft Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, 21143 - - $1,129.59 - - without bone graft Reconstruction midface, LeFort I; single piece, segment movement in any direction, requiring 21145 - - $1,233.54 - - bone grafts (includes obtaining autografts) Reconstruction midface, LeFort I; 2 pieces, segment movement in any direction, requiring bone 21146 - - $1,287.61 - - grafts (includes obtaining autografts) (eg, ungrafted unilateral alveolar cleft) Reconstruction midface, LeFort I; 3 or more pieces, segment movement in any direction, 21147 - - $1,356.33 - - requiring bone grafts (includes obtaining autografts) (eg, ungrafted bilateral alveolar cleft or multiple osteotomies) 21150 - - $1,291.22 - - Reconstruction midface, LeFort II; anterior intrusion (eg, Treacher-Collins Syndrome) Reconstruction midface, LeFort II; any direction, requiring bone grafts (includes obtaining 21151 - - $1,420.36 - - autografts) Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes 21154 - - $1,528.11 - - obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extracranial), any type, requiring bone grafts (includes 21155 - - $1,694.57 - - obtaining autografts); with LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, 21159 - - $2,029.36 - - mono bloc), requiring bone grafts (includes obtaining autografts); without LeFort I Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (eg, 21160 - - $2,200.45 - - mono bloc), requiring bone grafts (includes obtaining autografts); with LeFort I Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, 21172 - - $1,630.31 - - with or without grafts (includes obtaining autografts) Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or 21175 - - $1,757.20 - - alteration (eg, plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) Reconstruction, entire or majority of forehead and/or supraorbital rims; with grafts (allograft or 21179 - - $1,207.51 - - prosthetic material) Reconstruction, entire or majority of forehead and/or supraorbital rims; with autograft 21180 - - $1,349.85 - - (includes obtaining grafts) Reconstruction by contouring of benign tumor of cranial bones (eg, fibrous dysplasia), 21181 - - $588.34 - - extracranial Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and 21182 - - $1,682.16 - - extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting less than 40 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple 21183 - - $1,831.34 - - autografts (includes obtaining grafts); total area of bone grafting greater than 40 sq cm but less than 80 sq cm Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra- and 21184 - - $1,970.60 - - extracranial excision of benign tumor of cranial bone (eg, fibrous dysplasia), with multiple autografts (includes obtaining grafts); total area of bone grafting greater than 80 sq cm Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes 21188 - - $1,283.23 - - obtaining autografts)

21193 - - $982.78 - - Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graft Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; with bone graft 21194 - - $1,132.69 - - (includes obtaining graft) 21195 - - $1,090.99 - - Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixation 21196 - - $1,124.58 - - Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixation 21198 - - $876.01 - - Osteotomy, mandible, segmental; 21199 - - $817.96 - - Osteotomy, mandible, segmental; with genioglossus advancement 21206 - - $909.41 - - Osteotomy, maxilla, segmental (eg, Wassmund or Schuchard) 21215 $3,365.01 $638.53 - - - Graft, bone; mandible (includes obtaining graft) 21230 - - $584.67 - - Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 $577.22 $444.47 - - - Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft)

Page 16 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 21240 - - $847.92 - - Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 - - $804.50 - - Arthroplasty, temporomandibular joint, with allograft 21243 - - $1,293.14 - - Arthroplasty, temporomandibular joint, with prosthetic joint replacement Reconstruction of mandible, extraoral, with transosteal bone plate (eg, mandibular staple bone 21244 - - $808.78 - - plate) 21245 $964.54 $739.34 - - - Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 - - $678.23 - - Reconstruction of mandible or maxilla, subperiosteal implant; complete Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining 21247 - - $1,261.24 - - grafts) (eg, for hemifacial microsomia) 21248 $814.29 $649.38 - - - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); partial 21249 $1,110.57 $915.51 - - - Reconstruction of mandible or maxilla, endosteal implant (eg, blade, cylinder); complete Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining 21255 - - $1,085.82 - - autografts) Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining 21256 - - $985.49 - - autografts) (eg, micro-ophthalmia) 21260 - - $1,104.18 - - Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach Periorbital osteotomies for orbital hypertelorism, with bone grafts; combined intra- and 21261 - - $1,950.74 - - extracranial approach

21263 - - $1,805.49 - - Periorbital osteotomies for orbital hypertelorism, with bone grafts; with forehead advancement Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial 21267 - - $1,291.82 - - approach Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; combined intra- and 21268 - - $1,617.17 - - extracranial approach 21270 $810.87 $596.10 - - - Malar augmentation, prosthetic material 21275 - - $669.04 - - Secondary revision of orbitocraniofacial reconstruction 21280 - - $455.96 - - Medial canthopexy (separate procedure) 21282 - - $308.64 - - Lateral canthopexy Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); 21295 - - $150.34 - - extraoral approach 21299 - - I.C. - - Unlisted craniofacial and maxillofacial procedure 21310 $102.13 $21.27 - - - Closed treatment of nasal bone fracture without manipulation 21315 $220.32 $119.16 - - - Closed treatment of nasal bone fracture; without stabilization 21320 $203.72 $104.88 - - - Closed treatment of nasal bone fracture; with stabilization 21325 - - $348.06 - - Open treatment of nasal fracture; uncomplicated

21330 - - $445.89 - - Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation 21335 - - $562.03 - - Open treatment of nasal fracture; with concomitant open treatment of fractured septum 21336 - - $506.55 - - Open treatment of nasal septal fracture, with or without stabilization 21337 $328.57 $233.22 - - - Closed treatment of nasal septal fracture, with or without stabilization 21338 - - $522.09 - - Open treatment of nasoethmoid fracture; without external fixation 21339 - - $591.25 - - Open treatment of nasoethmoid fracture; with external fixation Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap 21340 - - $582.93 - - fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus 21343 - - $845.80 - - Open treatment of depressed frontal sinus fracture Open treatment of complicated (eg, comminuted or involving posterior wall) frontal sinus 21344 - - $1,083.52 - - fracture, via coronal or multiple approaches Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire 21345 $620.48 $492.66 - - - fixation or fixation of denture or splint Open treatment of nasomaxillary complex fracture (LeFort II type); with wiring and/or local 21346 - - $758.96 - - fixation Open treatment of nasomaxillary complex fracture (LeFort II type); requiring multiple open 21347 - - $800.99 - - approaches Open treatment of nasomaxillary complex fracture (LeFort II type); with bone grafting (includes 21348 - - $846.77 - - obtaining graft) Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, 21355 $341.71 $252.44 - - - with manipulation 21356 $397.89 $297.03 - - - Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) 21360 - - $402.29 - - Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) 21365 - - $865.27 - - fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) 21366 - - $1,012.89 - - fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft)

Page 17 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type 21385 - - $594.39 - - operation) 21386 - - $513.50 - - Open treatment of orbital floor blowout fracture; periorbital approach 21387 - - $620.15 - - Open treatment of orbital floor blowout fracture; combined approach Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other 21390 - - $631.82 - - implant Open treatment of orbital floor blowout fracture; periorbital approach with bone graft 21395 - - $802.32 - - (includes obtaining graft) 21400 $162.33 $128.13 - - - Closed treatment of fracture of orbit, except blowout; without manipulation 21401 $416.50 $257.67 - - - Closed treatment of fracture of orbit, except blowout; with manipulation 21406 - - $461.10 - - Open treatment of fracture of orbit, except blowout; without implant 21407 - - $508.24 - - Open treatment of fracture of orbit, except blowout; with implant Open treatment of fracture of orbit, except blowout; with bone grafting (includes obtaining 21408 - - $716.97 - - graft) Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or 21421 $538.54 $451.58 - - - fixation of denture or splint 21422 - - $508.22 - - Open treatment of palatal or maxillary fracture (LeFort I type); Open treatment of palatal or maxillary fracture (LeFort I type); complicated (comminuted or 21423 - - $605.26 - - involving cranial nerve foramina), multiple approaches Closed treatment of craniofacial separation (LeFort III type) using interdental wire fixation of 21431 - - $555.03 - - denture or splint

21432 - - $573.01 - - Open treatment of craniofacial separation (LeFort III type); with wiring and/or internal fixation Open treatment of craniofacial separation (LeFort III type); complicated (eg, comminuted or 21433 - - $1,378.53 - - involving cranial nerve foramina), multiple surgical approaches

21435 - - $1,115.86 - - Open treatment of craniofacial separation (LeFort III type); complicated, utilizing internal and/or external fixation techniques (eg, head cap, halo device, and/or intermaxillary fixation) Open treatment of craniofacial separation (LeFort III type); complicated, multiple surgical 21436 - - $1,617.98 - - approaches, internal fixation, with bone grafting (includes obtaining graft) 21440 $509.65 $408.79 - - - Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 21445 $625.36 $501.89 - - - Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 21450 $465.94 $377.83 - - - Closed treatment of mandibular fracture; without manipulation 21451 $608.56 $506.83 - - - Closed treatment of mandibular fracture; with manipulation 21452 $576.22 $342.61 - - - Percutaneous treatment of mandibular fracture, with external fixation 21453 $812.16 $690.72 - - - Closed treatment of mandibular fracture with interdental fixation 21454 - - $403.74 - - Open treatment of mandibular fracture with external fixation 21461 $1,637.33 $807.82 - - - Open treatment of mandibular fracture; without interdental fixation 21462 $1,748.35 $891.59 - - - Open treatment of mandibular fracture; with interdental fixation 21465 - - $661.24 - - Open treatment of mandibular condylar fracture Open treatment of complicated mandibular fracture by multiple surgical approaches including 21470 - - $928.24 - - internal fixation, interdental fixation, and/or wiring of dentures or splints 21480 $94.81 $24.67 - - - Closed treatment of temporomandibular dislocation; initial or subsequent Closed treatment of temporomandibular dislocation; complicated (eg, recurrent requiring 21485 $716.98 $583.66 - - - intermaxillary fixation or splinting), initial or subsequent 21490 - - $652.14 - - Open treatment of temporomandibular dislocation 21497 $554.88 $462.13 - - - Interdental wiring, for condition other than fracture 21499 - - I.C. - - Unlisted musculoskeletal procedure, head 21501 $375.96 $258.29 - - - Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib 21502 - - $397.25 - - ostectomy 21510 - - $352.84 - - Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), thorax 21550 $210.93 $123.11 - - - Biopsy, soft tissue of neck or thorax 21552 - - $351.21 - - Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; 3 cm or greater Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); 5 cm or 21554 - - $574.63 - - greater 21555 $342.34 $241.48 - - - Excision, tumor, soft tissue of neck or anterior thorax, subcutaneous; less than 3 cm Excision, tumor, soft tissue of neck or anterior thorax, subfascial (eg, intramuscular); less than 5 21556 - - $415.92 - - cm

21557 - - $749.83 - - Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; less than 5 cm

21558 - - $1,053.56 - - Radical resection of tumor (eg, sarcoma), soft tissue of neck or anterior thorax; 5 cm or greater 21600 - - $437.09 - - Excision of rib, partial 21601 - - $928.00 - - Excision of chest wall tumor including rib(s)

Page 18 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Excision of chest wall tumor involving rib(s), with plastic reconstruction; without mediastinal 21602 - - $1,251.10 - - lymphadenectomy Excision of chest wall tumor involving rib(s), with plastic reconstruction; with mediastinal 21603 - - $1,381.91 - - lymphadenectomy 21610 - - $934.48 - - Costotransversectomy (separate procedure) 21615 - - $481.18 - - Excision first and/or cervical rib; 21616 - - $555.29 - - Excision first and/or cervical rib; with sympathectomy 21620 - - $398.31 - - Ostectomy of sternum, partial 21627 - - $425.89 - - Sternal debridement 21630 - - $953.20 - - Radical resection of sternum; 21632 - - $944.41 - - Radical resection of sternum; with mediastinal lymphadenectomy 21685 - - $769.89 - - Hyoid myotomy and suspension 21700 - - $277.97 - - Division of scalenus anticus; without resection of cervical rib 21705 - - $415.36 - - Division of scalenus anticus; with resection of cervical rib 21720 - - $410.91 - - Division of sternocleidomastoid for torticollis, open operation; without cast application 21725 - - $428.09 - - Division of sternocleidomastoid for torticollis, open operation; with cast application 21740 - - $801.66 - - Reconstructive repair of pectus excavatum or carinatum; open Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss 21742 - - I.C. - - procedure), without thoracoscopy Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss 21743 - - I.C. - - procedure), with thoracoscopy

21750 - - $530.28 - - Closure of median sternotomy separation with or without debridement (separate procedure) Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization 21811 - - $462.50 - - when performed, unilateral; 1-3 ribs Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization 21812 - - $564.62 - - when performed, unilateral; 4-6 ribs Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization 21813 - - $770.74 - - when performed, unilateral; 7 or more ribs 21820 $116.59 $115.72 - - - Closed treatment of sternum fracture 21825 - - $426.45 - - Open treatment of sternum fracture with or without skeletal fixation 21899 - - I.C. - - Unlisted procedure, neck or thorax 21920 $205.72 $123.98 - - - Biopsy, soft tissue of back or flank; superficial 21925 $373.26 $286.31 - - - Biopsy, soft tissue of back or flank; deep 21930 $392.27 $287.06 - - - Excision, tumor, soft tissue of back or flank, subcutaneous; less than 3 cm 21931 - - $370.78 - - Excision, tumor, soft tissue of back or flank, subcutaneous; 3 cm or greater 21932 - - $522.01 - - Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); less than 5 cm 21933 - - $581.11 - - Excision, tumor, soft tissue of back or flank, subfascial (eg, intramuscular); 5 cm or greater 21935 - - $807.80 - - Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; less than 5 cm 21936 - - $1,110.32 - - Radical resection of tumor (eg, sarcoma), soft tissue of back or flank; 5 cm or greater Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or 22010 - - $755.97 - - cervicothoracic Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or 22015 - - $744.71 - - lumbosacral Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for 22100 - - $674.73 - - intrinsic bony lesion, single vertebral segment; cervical Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for 22101 - - $686.83 - - intrinsic bony lesion, single vertebral segment; thoracic Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for 22102 - - $646.71 - - intrinsic bony lesion, single vertebral segment; lumbar Partial excision of posterior vertebral component (eg, spinous process, lamina or facet) for 22103 - - $109.91 - - intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal 22110 - - $819.49 - - cord or nerve root(s), single vertebral segment; cervical Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal 22112 - - $878.12 - - cord or nerve root(s), single vertebral segment; thoracic Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal 22114 - - $878.12 - - cord or nerve root(s), single vertebral segment; lumbar Partial excision of vertebral body, for intrinsic bony lesion, without decompression of spinal 22116 - - $109.58 - - cord or nerve root(s), single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, 22206 - - $1,919.19 - - pedicle/vertebral body subtraction); thoracic Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, 22207 - - $1,879.39 - - pedicle/vertebral body subtraction); lumbar

Page 19 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Osteotomy of spine, posterior or posterolateral approach, 3 columns, 1 vertebral segment (eg, 22208 - - $459.92 - - pedicle/vertebral body subtraction); each additional vertebral segment (List separately in addition to code for primary procedure) 22210 - - $1,404.16 - - Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical 22212 - - $1,177.02 - - Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; thoracic 22214 - - $1,181.37 - - Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; lumbar Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; each additional 22216 - - $284.00 - - vertebral segment (List separately in addition to primary procedure)

22220 - - $1,285.06 - - Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; cervical Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; 22222 - - $1,361.59 - - thoracic

22224 - - $1,254.06 - - Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; lumbar

22226 - - $283.91 - - Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; each additional vertebral segment (List separately in addition to code for primary procedure) Closed treatment of vertebral body fracture(s), without manipulation, requiring and including 22310 $240.39 $231.12 - - - casting or bracing Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with 22315 $698.44 $608.30 - - - and including casting and/or bracing by manipulation or traction Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os 22318 - - $1,279.79 - - odontoideum), anterior approach, including placement of internal fixation; without grafting Open treatment and/or reduction of odontoid fracture(s) and or dislocation(s) (including os 22319 - - $1,421.62 - - odontoideum), anterior approach, including placement of internal fixation; with grafting Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior 22325 - - $1,141.58 - - approach, 1 fractured vertebra or dislocated segment; lumbar Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior 22326 - - $1,173.96 - - approach, 1 fractured vertebra or dislocated segment; cervical Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior 22327 - - $1,188.04 - - approach, 1 fractured vertebra or dislocated segment; thoracic Open treatment and/or reduction of vertebral fracture(s) and/or dislocation(s), posterior 22328 - - $219.32 - - approach, 1 fractured vertebra or dislocated segment; each additional fractured vertebra or dislocated segment (List separately in addition to code for primary procedure) 22505 - - $102.72 - - Manipulation of spine requiring anesthesia, any region Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, 22510 $1,480.79 $338.84 - - - unilateral or bilateral injection, inclusive of all imaging guidance; cervicothoracic Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, 22511 $1,467.93 $317.86 - - - unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral Percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; each additional 22512 $696.39 $160.49 - - - cervicothoracic or lumbosacral vertebral body (List separately in addition to code for primary procedure)

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone 22513 $5,454.33 $401.91 - - - biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; thoracic Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone 22514 $5,432.92 $375.00 - - - biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; lumbar

Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone 22515 $3,046.68 $172.09 - - - biopsy included when performed) using mechanical device (eg, kyphoplasty), 1 vertebral body, unilateral or bilateral cannulation, inclusive of all imaging guidance; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including 22526 $1,822.23 $257.12 - - - fluoroscopic guidance; single level Percutaneous intradiscal electrothermal annuloplasty, unilateral or bilateral including 22527 $1,531.62 $120.12 - - - fluoroscopic guidance; 1 or more additional levels (List separately in addition to code for primary procedure) Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare 22532 - - $1,411.02 - - interspace (other than for decompression); thoracic Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare 22533 - - $1,304.85 - - interspace (other than for decompression); lumbar

Page 20 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Arthrodesis, lateral extracavitary technique, including minimal discectomy to prepare 22534 - - $281.78 - - interspace (other than for decompression); thoracic or lumbar, each additional vertebral segment (List separately in addition to code for primary procedure) Arthrodesis, anterior transoral or extraoral technique, clivus-C1-C2 (atlas-axis), with or without 22548 - - $1,525.74 - - excision of odontoid process Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy 22551 - - $1,335.28 - - and decompression of spinal cord and/or nerve roots; cervical below C2 Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy 22552 - - $309.96 - - and decompression of spinal cord and/or nerve roots; cervical below C2, each additional interspace (List separately in addition to code for separate procedure) Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 22554 - - $985.86 - - (other than for decompression); cervical below C2 Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 22556 - - $1,304.98 - - (other than for decompression); thoracic Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 22558 - - $1,201.97 - - (other than for decompression); lumbar Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace 22585 - - $255.45 - - (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with 22586 - - $1,579.34 - - posterior instrumentation, with image guidance, includes bone graft when performed, L5-S1 interspace 22590 - - $1,236.44 - - Arthrodesis, posterior technique, craniocervical (occiput-C2) 22595 - - $1,179.53 - - Arthrodesis, posterior technique, atlas-axis (C1-C2) 22600 - - $1,013.45 - - Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse 22610 - - $996.97 - - technique, when performed) Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse 22612 - - $1,247.19 - - technique, when performed) Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral 22614 - - $305.66 - - segment (List separately in addition to code for primary procedure) Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to 22630 - - $1,235.01 - - prepare interspace (other than for decompression), single interspace; lumbar Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to 22632 - - $250.94 - - prepare interspace (other than for decompression), single interspace; each additional interspace (List separately in addition to code for primary procedure) Arthrodesis, combined posterior or posterolateral technique with posterior interbody 22633 - - $1,451.78 - - technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other 22634 - - $387.02 - - than for decompression), single interspace and segment; each additional interspace and segment (List separately in addition to code for primary procedure)

22800 - - $1,070.43 - - Arthrodesis, posterior, for spinal deformity, with or without cast; up to 6 vertebral segments

22802 - - $1,654.53 - - Arthrodesis, posterior, for spinal deformity, with or without cast; 7 to 12 vertebral segments Arthrodesis, posterior, for spinal deformity, with or without cast; 13 or more vertebral 22804 - - $1,904.49 - - segments 22808 - - $1,439.51 - - Arthrodesis, anterior, for spinal deformity, with or without cast; 2 to 3 vertebral segments 22810 - - $1,608.48 - - Arthrodesis, anterior, for spinal deformity, with or without cast; 4 to 7 vertebral segments

22812 - - $1,737.58 - - Arthrodesis, anterior, for spinal deformity, with or without cast; 8 or more vertebral segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including 22818 - - $1,701.11 - - body and posterior elements); single or 2 segments Kyphectomy, circumferential exposure of spine and resection of vertebral segment(s) (including 22819 - - $1,957.23 - - body and posterior elements); 3 or more segments 22830 - - $644.07 - - Exploration of spinal fusion Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 22840 - - $593.21 - - 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure) Internal spinal fixation by wiring of spinous processes (List separately in addition to code for 22841 - - I.C. - - primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and 22842 - - $595.78 - - sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)

Page 21 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and 22843 - - $636.77 - - sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure) Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and 22844 - - $770.70 - - sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure) Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for 22845 - - $568.21 - - primary procedure) Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for 22846 - - $590.75 - - primary procedure) Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for 22847 - - $632.89 - - primary procedure) Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other 22848 - - $281.71 - - than sacrum (List separately in addition to code for primary procedure) 22849 - - $1,023.38 - - Reinsertion of spinal fixation device 22850 - - $574.88 - - Removal of posterior nonsegmental instrumentation (eg, Harrington rod) 22852 - - $552.37 - - Removal of posterior segmental instrumentation Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral 22853 - - $201.93 - - disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to 22854 - - $261.53 - - vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) 22855 - - $871.17 - - Removal of anterior instrumentation Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate 22856 - - $1,281.99 - - preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare 22857 - - $1,395.94 - - interspace (other than for decompression), single interspace, lumbar Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and 22858 - - $399.11 - - microdissection); second level, cervical (List separately in addition to code for primary procedure)

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, 22859 - - $261.53 - - methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, 22861 - - $1,803.91 - - single interspace; cervical Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, 22862 - - $1,801.36 - - single interspace; lumbar

22864 - - $1,610.13 - - Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical

22865 - - $1,758.06 - - Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; lumbar

22867 - - $769.01 - - Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, 22868 - - $190.06 - - including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure)

22869 - - $351.62 - - Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level Insertion of interlaminar/interspinous process stabilization/distraction device, without open 22870 - - $97.09 - - decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) 22899 - - I.C. - - Unlisted procedure, spine 22900 - - $443.62 - - Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); less than 5 cm 22901 - - $525.50 - - Excision, tumor, soft tissue of abdominal wall, subfascial (eg, intramuscular); 5 cm or greater 22902 $366.60 $261.97 - - - Excision, tumor, soft tissue of abdominal wall, subcutaneous; less than 3 cm 22903 - - $346.35 - - Excision, tumor, soft tissue of abdominal wall, subcutaneous; 3 cm or greater

Page 22 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 22904 - - $827.38 - - Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; less than 5 cm 22905 - - $1,043.82 - - Radical resection of tumor (eg, sarcoma), soft tissue of abdominal wall; 5 cm or greater 22999 - - I.C. - - Unlisted procedure, abdomen, musculoskeletal system 23000 $463.11 $290.36 - - - Removal of subdeltoid calcareous deposits, open 23020 - - $546.16 - - Capsular contracture release (eg, Sever type procedure) 23030 $349.19 $196.74 - - - Incision and drainage, shoulder area; deep abscess or hematoma 23031 $325.79 $165.22 - - - Incision and drainage, shoulder area; infected bursa 23035 - - $538.63 - - Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area 23040 - - $567.79 - - Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or 23044 - - $447.81 - - removal of foreign body 23065 $177.87 $129.47 - - - Biopsy, soft tissue of shoulder area; superficial 23066 $456.55 $286.99 - - - Biopsy, soft tissue of shoulder area; deep 23071 - - $331.69 - - Excision, tumor, soft tissue of shoulder area, subcutaneous; 3 cm or greater 23073 - - $548.49 - - Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); 5 cm or greater 23075 $402.77 $259.30 - - - Excision, tumor, soft tissue of shoulder area, subcutaneous; less than 3 cm 23076 - - $427.78 - - Excision, tumor, soft tissue of shoulder area, subfascial (eg, intramuscular); less than 5 cm 23077 - - $887.95 - - Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; less than 5 cm 23078 - - $1,128.99 - - Radical resection of tumor (eg, sarcoma), soft tissue of shoulder area; 5 cm or greater 23100 - - $399.45 - - Arthrotomy, glenohumeral joint, including biopsy Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of 23101 - - $362.24 - - torn cartilage 23105 - - $503.63 - - Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy 23106 - - $396.23 - - Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or 23107 - - $522.11 - - foreign body 23120 - - $464.07 - - Claviculectomy; partial 23125 - - $561.30 - - Claviculectomy; total

23130 - - $486.50 - - Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release 23140 - - $438.69 - - Excision or curettage of bone cyst or benign tumor of clavicle or scapula; Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft 23145 - - $550.23 - - (includes obtaining graft) 23146 - - $492.87 - - Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft 23150 - - $527.78 - - Excision or curettage of bone cyst or benign tumor of proximal humerus; Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft 23155 - - $629.35 - - (includes obtaining graft) 23156 - - $536.72 - - Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft 23170 - - $445.43 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle 23172 - - $450.02 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula 23174 - - $602.00 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical neck Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), 23180 - - $525.78 - - clavicle Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), 23182 - - $522.26 - - scapula Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), 23184 - - $584.00 - - proximal humerus 23190 - - $454.42 - - Ostectomy of scapula, partial (eg, superior medial angle) 23195 - - $591.10 - - Resection, humeral head 23200 - - $1,189.08 - - Radical resection of tumor; clavicle 23210 - - $1,395.45 - - Radical resection of tumor; scapula 23220 - - $1,533.29 - - Radical resection of tumor, proximal humerus 23330 $233.89 $132.16 - - - Removal of foreign body, shoulder; subcutaneous 23333 - - $367.32 - - Removal of foreign body, shoulder; deep (subfascial or intramuscular) Removal of prosthesis, includes debridement and synovectomy when performed; humeral or 23334 - - $841.96 - - glenoid component Removal of prosthesis, includes debridement and synovectomy when performed; humeral and 23335 - - $1,002.13 - - glenoid components (eg, total shoulder) 23350 $123.22 $39.74 - - - Injection procedure for shoulder arthrography or enhanced CT/MRI shoulder arthrography 23395 - - $1,013.00 - - Muscle transfer, any type, shoulder or upper arm; single 23397 - - $900.23 - - Muscle transfer, any type, shoulder or upper arm; multiple 23400 - - $767.45 - - Scapulopexy (eg, Sprengels deformity or for paralysis) 23405 - - $490.27 - - Tenotomy, shoulder area; single tendon 23406 - - $607.52 - - Tenotomy, shoulder area; multiple tendons through same incision 23410 - - $648.40 - - Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute 23412 - - $673.73 - - Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic

Page 23 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 23415 - - $552.03 - - Coracoacromial ligament release, with or without acromioplasty 23420 - - $768.28 - - Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) 23430 - - $589.14 - - Tenodesis of long tendon of biceps 23440 - - $597.30 - - Resection or transplantation of long tendon of biceps 23450 - - $747.91 - - Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation 23455 - - $783.90 - - Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) 23460 - - $859.53 - - Capsulorrhaphy, anterior, any type; with bone block 23462 - - $843.01 - - Capsulorrhaphy, anterior, any type; with coracoid process transfer 23465 - - $882.41 - - Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block 23466 - - $876.31 - - Capsulorrhaphy, glenohumeral joint, any type multi-directional instability 23470 - - $946.92 - - Arthroplasty, glenohumeral joint; hemiarthroplasty Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement 23472 - - $1,143.32 - - (eg, total shoulder)) Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid 23473 - - $1,274.32 - - component Revision of total shoulder arthroplasty, including allograft when performed; humeral and 23474 - - $1,376.26 - - glenoid component 23480 - - $648.25 - - Osteotomy, clavicle, with or without internal fixation; Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion 23485 - - $754.78 - - (includes obtaining graft and/or necessary fixation) Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; 23490 - - $680.39 - - clavicle Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; 23491 - - $801.64 - - proximal humerus 23500 $175.81 $179.58 - - - Closed treatment of clavicular fracture; without manipulation 23505 $284.54 $265.70 - - - Closed treatment of clavicular fracture; with manipulation 23515 - - $569.72 - - Open treatment of clavicular fracture, includes internal fixation, when performed 23520 $189.39 $188.52 - - - Closed treatment of sternoclavicular dislocation; without manipulation 23525 $312.17 $286.38 - - - Closed treatment of sternoclavicular dislocation; with manipulation 23530 - - $454.68 - - Open treatment of sternoclavicular dislocation, acute or chronic; Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes 23532 - - $495.09 - - obtaining graft) 23540 $185.45 $184.58 - - - Closed treatment of acromioclavicular dislocation; without manipulation 23545 $274.29 $247.05 - - - Closed treatment of acromioclavicular dislocation; with manipulation 23550 - - $453.77 - - Open treatment of acromioclavicular dislocation, acute or chronic; Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes 23552 - - $516.86 - - obtaining graft) 23570 $186.03 $191.83 - - - Closed treatment of scapular fracture; without manipulation Closed treatment of scapular fracture; with manipulation, with or without skeletal traction 23575 $323.77 $300.01 - - - (with or without shoulder joint involvement) Open treatment of scapular fracture (body, glenoid or acromion) includes internal fixation, 23585 - - $772.69 - - when performed Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without 23600 $263.96 $248.60 - - - manipulation Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with 23605 $372.90 $338.41 - - - manipulation, with or without skeletal traction Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal 23615 - - $698.15 - - fixation, when performed, includes repair of tuberosity(s), when performed; Open treatment of proximal humeral (surgical or anatomical neck) fracture, includes internal 23616 - - $975.29 - - fixation, when performed, includes repair of tuberosity(s), when performed; with proximal humeral prosthetic replacement 23620 $214.99 $206.01 - - - Closed treatment of greater humeral tuberosity fracture; without manipulation 23625 $303.45 $279.39 - - - Closed treatment of greater humeral tuberosity fracture; with manipulation Open treatment of greater humeral tuberosity fracture, includes internal fixation, when 23630 - - $616.78 - - performed 23650 $254.38 $230.61 - - - Closed treatment of shoulder dislocation, with manipulation; without anesthesia 23655 - - $321.58 - - Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia 23660 - - $462.89 - - Open treatment of acute shoulder dislocation Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with 23665 $341.87 $315.20 - - - manipulation Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, includes 23670 - - $690.22 - - internal fixation, when performed Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with 23675 $439.85 $398.12 - - - manipulation

Page 24 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, includes 23680 - - $734.38 - - internal fixation, when performed Manipulation under anesthesia, shoulder joint, including application of fixation apparatus 23700 - - $154.66 - - (dislocation excluded) 23800 - - $810.27 - - Arthrodesis, glenohumeral joint; 23802 - - $1,011.57 - - Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) 23900 - - $1,092.54 - - Interthoracoscapular amputation (forequarter) 23920 - - $886.73 - - Disarticulation of shoulder; 23921 - - $372.38 - - Disarticulation of shoulder; secondary closure or scar revision 23929 - - I.C. - - Unlisted procedure, shoulder 23930 $286.59 $167.47 - - - Incision and drainage, upper arm or elbow area; deep abscess or hematoma 23931 $234.31 $123.60 - - - Incision and drainage, upper arm or elbow area; bursa Incision, deep, with opening of bone cortex (eg, for osteomyelitis or bone abscess), humerus or 23935 - - $405.96 - - elbow 24000 - - $379.23 - - Arthrotomy, elbow, including exploration, drainage, or removal of foreign body 24006 - - $563.00 - - Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) 24065 $208.28 $130.02 - - - Biopsy, soft tissue of upper arm or elbow area; superficial 24066 $499.46 $328.75 - - - Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 24071 - - $320.34 - - Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; 3 cm or greater Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); 5 cm or 24073 - - $548.54 - - greater 24075 $416.94 $260.14 - - - Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; less than 3 cm Excision, tumor, soft tissue of upper arm or elbow area, subfascial (eg, intramuscular); less than 24076 - - $429.79 - - 5 cm

24077 - - $818.66 - - Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; less than 5 cm Radical resection of tumor (eg, sarcoma), soft tissue of upper arm or elbow area; 5 cm or 24079 - - $1,041.65 - - greater 24100 - - $332.25 - - Arthrotomy, elbow; with synovial biopsy only Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of 24101 - - $397.98 - - loose or foreign body 24102 - - $488.15 - - Arthrotomy, elbow; with synovectomy 24105 - - $282.48 - - Excision, olecranon bursa 24110 - - $465.45 - - Excision or curettage of bone cyst or benign tumor, humerus; Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining 24115 - - $582.95 - - graft) 24116 - - $679.88 - - Excision or curettage of bone cyst or benign tumor, humerus; with allograft Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon 24120 - - $422.00 - - process; Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon 24125 - - $492.14 - - process; with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon 24126 - - $513.79 - - process; with allograft 24130 - - $404.55 - - Excision, radial head 24134 - - $590.97 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), shaft or distal humerus 24136 - - $500.21 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), radial head or neck 24138 - - $540.21 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), olecranon process Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), 24140 - - $556.13 - - humerus Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), radial 24145 - - $470.03 - - head or neck Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis), 24147 - - $495.49 - - olecranon process Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release 24149 - - $928.61 - - (separate procedure) 24150 - - $1,220.23 - - Radical resection of tumor, shaft or distal humerus 24152 - - $1,061.10 - - Radical resection of tumor, radial head or neck 24155 - - $672.87 - - Resection of elbow joint (arthrectomy) Removal of prosthesis, includes debridement and synovectomy when performed; humeral and 24160 - - $991.78 - - ulnar components

24164 - - $570.54 - - Removal of prosthesis, includes debridement and synovectomy when performed; radial head 24200 $173.86 $111.54 - - - Removal of foreign body, upper arm or elbow area; subcutaneous 24201 $440.44 $286.83 - - - Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) 24220 $144.35 $52.76 - - - Injection procedure for elbow arthrography 24300 - - $341.84 - - Manipulation, elbow, under anesthesia

Page 25 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 24301 - - $592.45 - - Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) 24305 - - $459.09 - - Tendon lengthening, upper arm or elbow, each tendon 24310 - - $373.81 - - Tenotomy, open, elbow to shoulder, each tendon Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon- 24320 - - $617.17 - - Brookes type procedure) 24330 - - $567.75 - - Flexor-plasty, elbow (eg, Steindler type advancement); 24331 - - $621.26 - - Flexor-plasty, elbow (eg, Steindler type advancement); with extensor advancement 24332 - - $486.22 - - Tenolysis, triceps 24340 - - $486.71 - - Tenodesis of biceps tendon at elbow (separate procedure) Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary 24341 - - $590.86 - - (excludes rotator cuff) 24342 - - $613.12 - - Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft 24343 - - $561.73 - - Repair lateral collateral ligament, elbow, with local tissue Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of 24344 - - $864.90 - - graft) 24345 - - $556.52 - - Repair medial collateral ligament, elbow, with local tissue Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of 24346 - - $869.84 - - graft) Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); 24357 - - $330.62 - - percutaneous Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); 24358 - - $417.69 - - debridement, soft tissue and/or bone, open Tenotomy, elbow, lateral or medial (eg, epicondylitis, tennis elbow, golfer's elbow); 24359 - - $523.67 - - debridement, soft tissue and/or bone, open with tendon repair or reattachment 24360 - - $711.97 - - Arthroplasty, elbow; with membrane (eg, fascial) 24361 - - $795.14 - - Arthroplasty, elbow; with distal humeral prosthetic replacement 24362 - - $836.73 - - Arthroplasty, elbow; with implant and fascia lata ligament reconstruction Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (eg, total 24363 - - $1,144.38 - - elbow) 24365 - - $506.25 - - Arthroplasty, radial head; 24366 - - $540.17 - - Arthroplasty, radial head; with implant Revision of total elbow arthroplasty, including allograft when performed; humeral or ulnar 24370 - - $1,216.07 - - component Revision of total elbow arthroplasty, including allograft when performed; humeral and ulnar 24371 - - $1,401.77 - - component 24400 - - $650.91 - - Osteotomy, humerus, with or without internal fixation Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type 24410 - - $834.53 - - procedure) 24420 - - $812.14 - - Osteoplasty, humerus (eg, shortening or lengthening) (excluding 64876) 24430 - - $833.21 - - Repair of nonunion or malunion, humerus; without graft (eg, compression technique) Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining 24435 - - $849.72 - - graft) 24470 - - $531.50 - - Hemiepiphyseal arrest (eg, cubitus varus or valgus, distal humerus) 24495 - - $650.61 - - Decompression fasciotomy, forearm, with brachial artery exploration Prophylactic treatment (nailing, pinning, plating or wiring), with or without 24498 - - $684.15 - - methylmethacrylate, humeral shaft 24500 $286.69 $262.93 - - - Closed treatment of humeral shaft fracture; without manipulation Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal 24505 $397.66 $357.08 - - - traction 24515 - - $694.96 - - Open treatment of humeral shaft fracture with plate/screws, with or without cerclage Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without 24516 - - $678.17 - - cerclage and/or locking screws Closed treatment of supracondylar or transcondylar humeral fracture, with or without 24530 $303.70 $276.46 - - - intercondylar extension; without manipulation Closed treatment of supracondylar or transcondylar humeral fracture, with or without 24535 $490.49 $449.91 - - - intercondylar extension; with manipulation, with or without skin or skeletal traction Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or 24538 - - $605.19 - - without intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, 24545 - - $734.09 - - when performed; without intercondylar extension Open treatment of humeral supracondylar or transcondylar fracture, includes internal fixation, 24546 - - $819.33 - - when performed; with intercondylar extension 24560 $263.43 $233.86 - - - Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation 24565 $428.42 $390.74 - - - Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with 24566 - - $569.89 - - manipulation

Page 26 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open treatment of humeral epicondylar fracture, medial or lateral, includes internal fixation, 24575 - - $580.19 - - when performed 24576 $277.39 $247.25 - - - Closed treatment of humeral condylar fracture, medial or lateral; without manipulation 24577 $440.43 $401.30 - - - Closed treatment of humeral condylar fracture, medial or lateral; with manipulation Open treatment of humeral condylar fracture, medial or lateral, includes internal fixation, when 24579 - - $657.73 - - performed Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with 24582 - - $643.19 - - manipulation Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal 24586 - - $857.92 - - humerus and proximal ulna and/or proximal radius); Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal 24587 - - $858.16 - - humerus and proximal ulna and/or proximal radius); with implant arthroplasty 24600 $294.40 $266.87 - - - Treatment of closed elbow dislocation; without anesthesia 24605 - - $376.57 - - Treatment of closed elbow dislocation; requiring anesthesia 24615 - - $564.45 - - Open treatment of acute or chronic elbow dislocation Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of 24620 - - $439.45 - - ulna with dislocation of radial head), with manipulation Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of 24635 - - $533.92 - - ulna with dislocation of radial head), includes internal fixation, when performed 24640 $80.29 $62.03 - - - Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation 24650 $210.01 $194.07 - - - Closed treatment of radial head or neck fracture; without manipulation 24655 $352.15 $317.37 - - - Closed treatment of radial head or neck fracture; with manipulation Open treatment of radial head or neck fracture, includes internal fixation or radial head 24665 - - $519.27 - - excision, when performed; Open treatment of radial head or neck fracture, includes internal fixation or radial head 24666 - - $580.32 - - excision, when performed; with radial head prosthetic replacement Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); 24670 $233.35 $211.90 - - - without manipulation Closed treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]); with 24675 $365.91 $331.13 - - - manipulation Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process[es]), 24685 - - $518.24 - - includes internal fixation, when performed 24800 - - $657.15 - - Arthrodesis, elbow joint; local 24802 - - $791.11 - - Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) 24900 - - $583.43 - - Amputation, arm through humerus; with primary closure 24920 - - $579.16 - - Amputation, arm through humerus; open, circular (guillotine) 24925 - - $449.46 - - Amputation, arm through humerus; secondary closure or scar revision 24930 - - $611.79 - - Amputation, arm through humerus; re-amputation 24931 - - $735.49 - - Amputation, arm through humerus; with implant 24935 - - $938.76 - - Stump elongation, upper extremity 24940 - - I.C. - - Cineplasty, upper extremity, complete procedure 24999 - - I.C. - - Unlisted procedure, humerus or elbow 25000 - - $270.74 - - Incision, extensor tendon sheath, wrist (eg, deQuervains disease) 25001 - - $274.08 - - Incision, flexor tendon sheath, wrist (eg, flexor carpi radialis) Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without 25020 - - $512.34 - - debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with 25023 - - $953.78 - - debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without 25024 - - $618.42 - - debridement of nonviable muscle and/or nerve Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with 25025 - - $948.24 - - debridement of nonviable muscle and/or nerve 25028 - - $476.83 - - Incision and drainage, forearm and/or wrist; deep abscess or hematoma 25031 - - $278.56 - - Incision and drainage, forearm and/or wrist; bursa 25035 - - $462.23 - - Incision, deep, bone cortex, forearm and/or wrist (eg, osteomyelitis or bone abscess) Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign 25040 - - $444.36 - - body 25065 $207.38 $126.81 - - - Biopsy, soft tissue of forearm and/or wrist; superficial 25066 - - $284.48 - - Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) 25071 - - $334.90 - - Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; 3 cm or greater Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); 3 cm or 25073 - - $423.35 - - greater 25075 $407.56 $250.17 - - - Excision, tumor, soft tissue of forearm and/or wrist area, subcutaneous; less than 3 cm Excision, tumor, soft tissue of forearm and/or wrist area, subfascial (eg, intramuscular); less 25076 - - $409.96 - - than 3 cm

Page 27 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; less than 3 25077 - - $699.91 - - cm Radical resection of tumor (eg, sarcoma), soft tissue of forearm and/or wrist area; 3 cm or 25078 - - $914.84 - - greater 25085 - - $356.26 - - Capsulotomy, wrist (eg, contracture) 25100 - - $276.40 - - Arthrotomy, wrist joint; with biopsy Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal 25101 - - $321.16 - - of loose or foreign body 25105 - - $385.25 - - Arthrotomy, wrist joint; with synovectomy 25107 - - $488.41 - - Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex 25109 - - $426.03 - - Excision of tendon, forearm and/or wrist, flexor or extensor, each 25110 - - $271.85 - - Excision, lesion of tendon sheath, forearm and/or wrist 25111 - - $256.25 - - Excision of ganglion, wrist (dorsal or volar); primary 25112 - - $307.78 - - Excision of ganglion, wrist (dorsal or volar); recurrent Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, 25115 - - $599.24 - - Tbc, or other granulomas, rheumatoid arthritis); flexors Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (eg, tenosynovitis, fungus, 25116 - - $476.81 - - Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum 25118 - - $303.02 - - Synovectomy, extensor tendon sheath, wrist, single compartment; 25119 - - $394.01 - - Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of 25120 - - $397.36 - - radius and olecranon process); Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of 25125 - - $470.27 - - radius and olecranon process); with autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of 25126 - - $473.77 - - radius and olecranon process); with allograft 25130 - - $356.56 - - Excision or curettage of bone cyst or benign tumor of carpal bones; Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes 25135 - - $443.47 - - obtaining graft) 25136 - - $393.80 - - Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft 25145 - - $411.72 - - Sequestrectomy (eg, for osteomyelitis or bone abscess), forearm and/or wrist Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); 25150 - - $447.69 - - ulna Partial excision (craterization, saucerization, or diaphysectomy) of bone (eg, for osteomyelitis); 25151 - - $462.09 - - radius 25170 - - $1,160.04 - - Radical resection of tumor, radius or ulna 25210 - - $389.35 - - Carpectomy; 1 bone 25215 - - $489.67 - - Carpectomy; all bones of proximal row 25230 - - $343.04 - - Radial styloidectomy (separate procedure) 25240 - - $340.63 - - Excision distal ulna partial or complete (eg, Darrach type or matched resection) 25246 $148.06 $57.92 - - - Injection procedure for wrist arthrography 25248 - - $329.16 - - Exploration with removal of deep foreign body, forearm or wrist 25250 - - $421.70 - - Removal of wrist prosthesis; (separate procedure) 25251 - - $569.08 - - Removal of wrist prosthesis; complicated, including total wrist 25259 - - $339.54 - - Manipulation, wrist, under anesthesia

25260 - - $500.69 - - Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or 25263 - - $500.21 - - muscle Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes 25265 - - $592.79 - - obtaining graft), each tendon or muscle Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or 25270 - - $391.03 - - muscle Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or 25272 - - $442.24 - - muscle Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes 25274 - - $526.98 - - obtaining graft), each tendon or muscle Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) 25275 - - $532.15 - - (eg, for extensor carpi ulnaris subluxation) Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each 25280 - - $448.38 - - tendon 25290 - - $345.84 - - Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon 25295 - - $417.14 - - Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon 25300 - - $541.86 - - Tenodesis at wrist; flexors of fingers

Page 28 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 25301 - - $509.23 - - Tenodesis at wrist; extensors of fingers Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each 25310 - - $491.07 - - tendon Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with 25312 - - $568.20 - - tendon graft(s) (includes obtaining graft), each tendon 25315 - - $608.81 - - Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; Flexor origin slide (eg, for cerebral palsy, Volkmann contracture), forearm and/or wrist; with 25316 - - $722.82 - - tendon(s) transfer

25320 - - $779.72 - - Capsulorrhaphy or reconstruction, wrist, open (eg, capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability

25332 - - $666.07 - - Arthroplasty, wrist, with or without interposition, with or without external or internal fixation 25335 - - $745.26 - - Centralization of wrist on ulna (eg, radial club hand) Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by 25337 - - $701.48 - - soft tissue stabilization (eg, tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint 25350 - - $534.55 - - Osteotomy, radius; distal third 25355 - - $604.77 - - Osteotomy, radius; middle or proximal third 25360 - - $517.91 - - Osteotomy; ulna 25365 - - $723.37 - - Osteotomy; radius AND ulna Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius 25370 - - $797.58 - - OR ulna Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius 25375 - - $753.59 - - AND ulna 25390 - - $608.02 - - Osteoplasty, radius OR ulna; shortening 25391 - - $786.57 - - Osteoplasty, radius OR ulna; lengthening with autograft 25392 - - $800.59 - - Osteoplasty, radius AND ulna; shortening (excluding 64876) 25393 - - $890.86 - - Osteoplasty, radius AND ulna; lengthening with autograft 25394 - - $620.10 - - Osteoplasty, carpal bone, shortening 25400 - - $634.47 - - Repair of nonunion or malunion, radius OR ulna; without graft (eg, compression technique) 25405 - - $818.67 - - Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft)

25415 - - $764.43 - - Repair of nonunion or malunion, radius AND ulna; without graft (eg, compression technique) 25420 - - $920.00 - - Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft) 25425 - - $760.90 - - Repair of defect with autograft; radius OR ulna 25426 - - $886.01 - - Repair of defect with autograft; radius AND ulna 25430 - - $578.18 - - Insertion of vascular pedicle into carpal bone (eg, Hori procedure) Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining 25431 - - $623.43 - - graft and necessary fixation), each bone Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy 25440 - - $606.66 - - (includes obtaining graft and necessary fixation) 25441 - - $740.14 - - Arthroplasty with prosthetic replacement; distal radius 25442 - - $638.55 - - Arthroplasty with prosthetic replacement; distal ulna 25443 - - $619.58 - - Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) 25444 - - $654.43 - - Arthroplasty with prosthetic replacement; lunate 25445 - - $570.97 - - Arthroplasty with prosthetic replacement; trapezium

25446 - - $924.79 - - Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 25447 - - $655.85 - - Arthroplasty, interposition, intercarpal or carpometacarpal joints 25449 - - $816.75 - - Revision of arthroplasty, including removal of implant, wrist joint 25450 - - $488.57 - - Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna 25455 - - $576.16 - - Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; 25490 - - $568.53 - - radius Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; 25491 - - $584.03 - - ulna Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; 25492 - - $715.47 - - radius AND ulna 25500 $222.74 $201.58 - - - Closed treatment of radial shaft fracture; without manipulation 25505 $401.86 $364.76 - - - Closed treatment of radial shaft fracture; with manipulation 25515 - - $530.20 - - Open treatment of radial shaft fracture, includes internal fixation, when performed Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar 25520 $455.92 $429.54 - - - joint (Galeazzi fracture/dislocation)

Page 29 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open treatment of radial shaft fracture, includes internal fixation, when performed, and closed 25525 - - $624.07 - - treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes percutaneous skeletal fixation, when performed

Open treatment of radial shaft fracture, includes internal fixation, when performed, and open 25526 - - $754.77 - - treatment of distal radioulnar joint dislocation (Galeazzi fracture/ dislocation), includes internal fixation, when performed, includes repair of triangular fibrocartilage complex 25530 $210.52 $191.97 - - - Closed treatment of ulnar shaft fracture; without manipulation 25535 $390.66 $360.23 - - - Closed treatment of ulnar shaft fracture; with manipulation 25545 - - $493.71 - - Open treatment of ulnar shaft fracture, includes internal fixation, when performed 25560 $227.69 $203.35 - - - Closed treatment of radial and ulnar shaft fractures; without manipulation 25565 $410.95 $368.34 - - - Closed treatment of radial and ulnar shaft fractures; with manipulation Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of 25574 - - $533.63 - - radius OR ulna Open treatment of radial AND ulnar shaft fractures, with internal fixation, when performed; of 25575 - - $712.80 - - radius AND ulna

25600 $266.46 $253.42 - - - Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation

25605 $430.63 $405.99 - - - Closed treatment of distal radial fracture (eg, Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation 25606 - - $526.21 - - Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal 25607 - - $582.86 - - fixation Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal 25608 - - $652.67 - - fixation of 2 fragments Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal 25609 - - $829.60 - - fixation of 3 or more fragments 25622 $244.70 $224.70 - - - Closed treatment of carpal scaphoid (navicular) fracture; without manipulation 25624 $386.68 $350.16 - - - Closed treatment of carpal scaphoid (navicular) fracture; with manipulation Open treatment of carpal scaphoid (navicular) fracture, includes internal fixation, when 25628 - - $569.29 - - performed Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); without 25630 $244.22 $225.67 - - - manipulation, each bone Closed treatment of carpal bone fracture (excluding carpal scaphoid [navicular]); with 25635 $367.79 $333.29 - - - manipulation, each bone 25645 - - $451.69 - - Open treatment of carpal bone fracture (other than carpal scaphoid [navicular]), each bone 25650 $260.36 $241.52 - - - Closed treatment of ulnar styloid fracture 25651 - - $388.01 - - Percutaneous skeletal fixation of ulnar styloid fracture 25652 - - $493.08 - - Open treatment of ulnar styloid fracture

25660 - - $329.55 - - Closed treatment of radiocarpal or intercarpal dislocation, 1 or more bones, with manipulation 25670 - - $481.18 - - Open treatment of radiocarpal or intercarpal dislocation, 1 or more bones 25671 - - $422.00 - - Percutaneous skeletal fixation of distal radioulnar dislocation 25675 $352.67 $318.18 - - - Closed treatment of distal radioulnar dislocation with manipulation 25676 - - $500.31 - - Open treatment of distal radioulnar dislocation, acute or chronic 25680 - - $417.01 - - Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation 25685 - - $581.33 - - Open treatment of trans-scaphoperilunar type of fracture dislocation 25690 - - $386.58 - - Closed treatment of lunate dislocation, with manipulation 25695 - - $501.88 - - Open treatment of lunate dislocation Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal 25800 - - $578.67 - - and/or carpometacarpal joints) 25805 - - $669.29 - - Arthrodesis, wrist; with sliding graft 25810 - - $685.26 - - Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) 25820 - - $502.27 - - Arthrodesis, wrist; limited, without bone graft (eg, intercarpal or radiocarpal) 25825 - - $615.46 - - Arthrodesis, wrist; with autograft (includes obtaining graft) Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft 25830 - - $779.96 - - (eg, Sauve-Kapandji procedure) 25900 - - $562.76 - - Amputation, forearm, through radius and ulna; 25905 - - $554.80 - - Amputation, forearm, through radius and ulna; open, circular (guillotine) 25907 - - $486.18 - - Amputation, forearm, through radius and ulna; secondary closure or scar revision 25909 - - $542.09 - - Amputation, forearm, through radius and ulna; re-amputation 25915 - - $920.73 - - Krukenberg procedure 25920 - - $566.48 - - Disarticulation through wrist; 25922 - - $499.59 - - Disarticulation through wrist; secondary closure or scar revision

Page 30 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 25924 - - $552.80 - - Disarticulation through wrist; re-amputation 25927 - - $665.17 - - Transmetacarpal amputation; 25929 - - $473.20 - - Transmetacarpal amputation; secondary closure or scar revision 25931 - - $614.12 - - Transmetacarpal amputation; re-amputation 25999 - - I.C. - - Unlisted procedure, forearm or wrist 26010 $244.72 $109.94 - - - Drainage of finger abscess; simple 26011 $354.08 $146.84 - - - Drainage of finger abscess; complicated (eg, felon) 26020 - - $440.15 - - Drainage of tendon sheath, digit and/or palm, each 26025 - - $334.52 - - Drainage of palmar bursa; single, bursa 26030 - - $389.50 - - Drainage of palmar bursa; multiple bursa 26034 - - $433.84 - - Incision, bone cortex, hand or finger (eg, osteomyelitis or bone abscess) 26035 - - $679.28 - - Decompression fingers and/or hand, injection injury (eg, grease gun) 26037 - - $448.16 - - Decompressive fasciotomy, hand (excludes 26035) 26040 - - $249.65 - - Fasciotomy, palmar (eg, Dupuytren's contracture); percutaneous 26045 - - $373.05 - - Fasciotomy, palmar (eg, Dupuytren's contracture); open, partial 26055 $442.56 $230.69 - - - Tendon sheath incision (eg, for trigger finger) 26060 - - $205.55 - - Tenotomy, percutaneous, single, each digit Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal 26070 - - $255.28 - - joint Arthrotomy, with exploration, drainage, or removal of loose or foreign body; 26075 - - $266.73 - - metacarpophalangeal joint, each Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal 26080 - - $313.27 - - joint, each 26100 - - $268.70 - - Arthrotomy with biopsy; carpometacarpal joint, each 26105 - - $270.58 - - Arthrotomy with biopsy; metacarpophalangeal joint, each 26110 - - $257.12 - - Arthrotomy with biopsy; interphalangeal joint, each Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; 1.5 cm or 26111 - - $329.70 - - greater Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, 26113 - - $433.55 - - intramuscular); 1.5 cm or greater Excision, tumor or vascular malformation, soft tissue of hand or finger, subcutaneous; less than 26115 $428.83 $262.75 - - - 1.5 cm Excision, tumor, soft tissue, or vascular malformation, of hand or finger, subfascial (eg, 26116 - - $416.52 - - intramuscular); less than 1.5 cm 26117 - - $588.21 - - Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; less than 3 cm 26118 - - $831.82 - - Radical resection of tumor (eg, sarcoma), soft tissue of hand or finger; 3 cm or greater Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin 26121 - - $474.14 - - grafting (includes obtaining graft) Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, 26123 - - $661.26 - - with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft);

Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, 26125 - - $213.11 - - with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure) 26130 - - $369.94 - - Synovectomy, carpometacarpal joint Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood 26135 - - $438.19 - - reconstruction, each digit Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each 26140 - - $401.63 - - interphalangeal joint Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, 26145 - - $408.04 - - each tendon Excision of lesion of tendon sheath or joint capsule (eg, cyst, mucous cyst, or ganglion), hand or 26160 $461.98 $250.41 - - - finger 26170 - - $323.46 - - Excision of tendon, palm, flexor or extensor, single, each tendon 26180 - - $355.15 - - Excision of tendon, finger, flexor or extensor, each tendon 26185 - - $438.48 - - Sesamoidectomy, thumb or finger (separate procedure) 26200 - - $358.51 - - Excision or curettage of bone cyst or benign tumor of metacarpal; Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes 26205 - - $478.59 - - obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of 26210 - - $353.15 - - finger; Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of 26215 - - $447.84 - - finger; with autograft (includes obtaining graft) Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); 26230 - - $396.29 - - metacarpal

Page 31 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); 26235 - - $390.88 - - proximal or middle phalanx of finger Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, osteomyelitis); distal 26236 - - $350.22 - - phalanx of finger 26250 - - $841.73 - - Radical resection of tumor, metacarpal 26260 - - $631.33 - - Radical resection of tumor, proximal or middle phalanx of finger 26262 - - $499.46 - - Radical resection of tumor, distal phalanx of finger 26320 - - $276.77 - - Removal of implant from finger or hand 26340 - - $274.71 - - Manipulation, finger joint, under anesthesia, each joint Manipulation, palmar fascial cord (ie, Dupuytren's cord), post enzyme injection (eg, 26341 $85.44 $60.52 - - - collagenase), single cord Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's 26350 - - $582.76 - - land); primary or secondary without free graft, each tendon Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (eg, no man's 26352 - - $650.22 - - land); secondary with free graft (includes obtaining graft), each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's 26356 - - $631.43 - - land); primary, without free graft, each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's 26357 - - $705.76 - - land); secondary, without free graft, each tendon Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (eg, no man's 26358 - - $779.76 - - land); secondary, with free graft (includes obtaining graft), each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each 26370 - - $613.28 - - tendon Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with 26372 - - $715.80 - - free graft (includes obtaining graft), each tendon Repair or advancement of profundus tendon, with intact superficialis tendon; secondary 26373 - - $688.00 - - without free graft, each tendon Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or 26390 - - $677.89 - - finger, each rod Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining 26392 - - $783.67 - - graft), each rod 26410 - - $464.38 - - Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), 26412 - - $551.28 - - each tendon Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand 26415 - - $660.71 - - or finger, each rod Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand 26416 - - $715.49 - - or finger, each rod 26418 - - $478.96 - - Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) 26420 - - $576.41 - - each tendon Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); using local 26426 - - $398.40 - - tissue(s), including lateral band(s), each finger Repair of extensor tendon, central slip, secondary (eg, boutonniere deformity); with free graft 26428 - - $616.65 - - (includes obtaining graft), each finger Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (eg, 26432 - - $412.51 - - mallet finger) Repair of extensor tendon, distal insertion, primary or secondary; without graft (eg, mallet 26433 - - $437.35 - - finger) Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes 26434 - - $532.58 - - obtaining graft) 26437 - - $510.87 - - Realignment of extensor tendon, hand, each tendon 26440 - - $506.14 - - Tenolysis, flexor tendon; palm OR finger, each tendon 26442 - - $773.27 - - Tenolysis, flexor tendon; palm AND finger, each tendon 26445 - - $472.73 - - Tenolysis, extensor tendon, hand OR finger, each tendon 26449 - - $550.72 - - Tenolysis, complex, extensor tendon, finger, including forearm, each tendon 26450 - - $341.99 - - Tenotomy, flexor, palm, open, each tendon 26455 - - $339.45 - - Tenotomy, flexor, finger, open, each tendon 26460 - - $331.87 - - Tenotomy, extensor, hand or finger, open, each tendon 26471 - - $505.14 - - Tenodesis; of proximal interphalangeal joint, each joint 26474 - - $496.69 - - Tenodesis; of distal joint, each joint 26476 - - $490.21 - - Lengthening of tendon, extensor, hand or finger, each tendon 26477 - - $477.83 - - Shortening of tendon, extensor, hand or finger, each tendon 26478 - - $509.56 - - Lengthening of tendon, flexor, hand or finger, each tendon 26479 - - $516.12 - - Shortening of tendon, flexor, hand or finger, each tendon

Page 32 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, 26480 - - $612.50 - - each tendon Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon 26483 - - $681.06 - - graft (includes obtaining graft), each tendon 26485 - - $653.64 - - Transfer or transplant of tendon, palmar; without free tendon graft, each tendon Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each 26489 - - $754.48 - - tendon 26490 - - $646.29 - - Opponensplasty; superficialis tendon transfer type, each tendon 26492 - - $715.98 - - Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon 26494 - - $649.00 - - Opponensplasty; hypothenar muscle transfer 26496 - - $691.17 - - Opponensplasty; other methods 26497 - - $700.04 - - Transfer of tendon to restore intrinsic function; ring and small finger 26498 - - $916.68 - - Transfer of tendon to restore intrinsic function; all 4 fingers 26499 - - $672.75 - - Correction claw finger, other methods 26500 - - $509.32 - - Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining 26502 - - $580.15 - - graft) (separate procedure) 26508 - - $519.11 - - Release of thenar muscle(s) (eg, thumb contracture) 26510 - - $493.26 - - Cross intrinsic transfer, each tendon 26516 - - $572.94 - - Capsulodesis, metacarpophalangeal joint; single digit 26517 - - $668.96 - - Capsulodesis, metacarpophalangeal joint; 2 digits 26518 - - $677.59 - - Capsulodesis, metacarpophalangeal joint; 3 or 4 digits 26520 - - $531.19 - - Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint 26525 - - $532.52 - - Capsulectomy or capsulotomy; interphalangeal joint, each joint 26530 - - $427.30 - - Arthroplasty, metacarpophalangeal joint; each joint 26531 - - $497.28 - - Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint 26535 - - $344.33 - - Arthroplasty, interphalangeal joint; each joint 26536 - - $582.34 - - Arthroplasty, interphalangeal joint; with prosthetic implant, each joint 26540 - - $538.39 - - Repair of collateral ligament, metacarpophalangeal or interphalangeal joint Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial 26541 - - $648.16 - - graft (includes obtaining graft) Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (eg, 26542 - - $554.94 - - adductor advancement) 26545 - - $578.42 - - Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint Repair non-union, metacarpal or phalanx (includes obtaining bone graft with or without 26546 - - $803.40 - - external or internal fixation) 26548 - - $617.25 - - Repair and reconstruction, finger, volar plate, interphalangeal joint 26550 - - $1,302.11 - - Pollicization of a digit 26551 - - $2,596.19 - - Transfer, toe-to-hand with microvascular anastomosis; great toe wrap-around with bone graft 26553 - - $2,579.21 - - Transfer, toe-to-hand with microvascular anastomosis; other than great toe, single 26554 - - $3,005.10 - - Transfer, toe-to-hand with microvascular anastomosis; other than great toe, double 26555 - - $1,090.86 - - Transfer, finger to another position without microvascular anastomosis 26556 - - $2,680.35 - - Transfer, free toe joint, with microvascular anastomosis 26560 - - $486.14 - - Repair of syndactyly (web finger) each web space; with skin flaps 26561 - - $761.32 - - Repair of syndactyly (web finger) each web space; with skin flaps and grafts 26562 - - $1,070.80 - - Repair of syndactyly (web finger) each web space; complex (eg, involving bone, nails) 26565 - - $552.72 - - Osteotomy; metacarpal, each 26567 - - $556.00 - - Osteotomy; phalanx of finger, each 26568 - - $727.73 - - Osteoplasty, lengthening, metacarpal or phalanx 26580 - - $1,202.78 - - Repair cleft hand 26587 - - $822.37 - - Reconstruction of polydactylous digit, soft tissue and bone 26590 - - $1,119.38 - - Repair macrodactylia, each digit 26591 - - $366.94 - - Repair, intrinsic muscles of hand, each muscle 26593 - - $493.73 - - Release, intrinsic muscles of hand, each muscle 26596 - - $621.53 - - Excision of constricting ring of finger, with multiple Z-plasties 26600 $237.81 $225.06 - - - Closed treatment of metacarpal fracture, single; without manipulation, each bone 26605 $260.45 $234.95 - - - Closed treatment of metacarpal fracture, single; with manipulation, each bone

26607 - - $386.57 - - Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone 26608 - - $381.75 - - Percutaneous skeletal fixation of metacarpal fracture, each bone Open treatment of metacarpal fracture, single, includes internal fixation, when performed, 26615 - - $456.50 - - each bone 26641 $305.12 $275.26 - - - Closed treatment of carpometacarpal dislocation, thumb, with manipulation Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with 26645 $343.51 $312.79 - - - manipulation

Page 33 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett 26650 - - $381.50 - - fracture), with manipulation Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), includes 26665 - - $496.01 - - internal fixation, when performed Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each 26670 $273.22 $244.52 - - - joint; without anesthesia Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each 26675 $366.10 $333.93 - - - joint; requiring anesthesia Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with 26676 - - $402.64 - - manipulation, each joint Open treatment of carpometacarpal dislocation, other than thumb; includes internal fixation, 26685 - - $456.55 - - when performed, each joint Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple, or 26686 - - $494.29 - - delayed reduction Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without 26700 $264.10 $244.10 - - - anesthesia Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring 26705 $336.38 $305.08 - - - anesthesia

26706 - - $351.01 - - Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation Open treatment of metacarpophalangeal dislocation, single, includes internal fixation, when 26715 - - $454.42 - - performed Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; 26720 $158.28 $148.43 - - - without manipulation, each Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; 26725 $271.16 $241.60 - - - with manipulation, with or without skin or skeletal traction, each Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle 26727 - - $375.34 - - phalanx, finger or thumb, with manipulation, each Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, 26735 - - $471.65 - - includes internal fixation, when performed, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; 26740 $184.50 $174.35 - - - without manipulation, each Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; 26742 $296.75 $266.31 - - - with manipulation, each Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, 26746 - - $587.67 - - includes internal fixation, when performed, each

26750 $148.24 $149.11 - - - Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each 26755 $253.69 $217.46 - - - Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each 26756 - - $336.34 - - Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each Open treatment of distal phalangeal fracture, finger or thumb, includes internal fixation, when 26765 - - $398.82 - - performed, each Closed treatment of interphalangeal joint dislocation, single, with manipulation; without 26770 $223.75 $204.33 - - - anesthesia Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring 26775 $307.38 $276.08 - - - anesthesia

26776 - - $355.84 - - Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation Open treatment of interphalangeal joint dislocation, includes internal fixation, when 26785 - - $433.67 - - performed, single 26820 - - $640.04 - - Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) 26841 - - $592.15 - - Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft 26842 - - $634.82 - - (includes obtaining graft) 26843 - - $601.49 - - Arthrodesis, carpometacarpal joint, digit, other than thumb, each; Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes 26844 - - $664.37 - - obtaining graft) 26850 - - $564.53 - - Arthrodesis, metacarpophalangeal joint, with or without internal fixation; Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft 26852 - - $644.33 - - (includes obtaining graft) 26860 - - $466.38 - - Arthrodesis, interphalangeal joint, with or without internal fixation; Arthrodesis, interphalangeal joint, with or without internal fixation; each additional 26861 - - $80.70 - - interphalangeal joint (List separately in addition to code for primary procedure) Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes 26862 - - $589.65 - - obtaining graft)

Page 34 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

26863 - - $178.80 - - Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure) Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without 26910 - - $587.05 - - interosseous transfer Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including 26951 - - $535.06 - - neurectomies; with direct closure Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including 26952 - - $526.89 - - neurectomies; with local advancement flaps (V-Y, hood) 26989 - - I.C. - - Unlisted procedure, hands or fingers 26990 - - $520.14 - - Incision and drainage, pelvis or hip joint area; deep abscess or hematoma 26991 $569.02 $415.70 - - - Incision and drainage, pelvis or hip joint area; infected bursa 26992 - - $782.21 - - Incision, bone cortex, pelvis and/or hip joint (eg, osteomyelitis or bone abscess) 27000 - - $320.54 - - Tenotomy, adductor of hip, percutaneous (separate procedure) 27001 - - $428.79 - - Tenotomy, adductor of hip, open 27003 - - $473.22 - - Tenotomy, adductor, subcutaneous, open, with obturator neurectomy 27005 - - $571.59 - - Tenotomy, hip flexor(s), open (separate procedure) 27006 - - $567.79 - - Tenotomy, abductors and/or extensor(s) of hip, open (separate procedure) 27025 - - $725.32 - - Fasciotomy, hip or thigh, any type Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, 27027 - - $705.43 - - gluteus maximus, iliopsoas, and/or tensor fascia lata muscle), unilateral 27030 - - $740.30 - - Arthrotomy, hip, with drainage (eg, infection) 27033 - - $767.84 - - Arthrotomy, hip, including exploration or removal of loose or foreign body Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or 27035 - - $910.56 - - obturator nerves Capsulectomy or capsulotomy, hip, with or without excision of heterotopic bone, with release 27036 - - $798.88 - - of hip flexor muscles (ie, gluteus medius, gluteus minimus, tensor fascia latae, rectus femoris, sartorius, iliopsoas) 27040 $277.49 $156.63 - - - Biopsy, soft tissue of pelvis and hip area; superficial 27041 - - $550.84 - - Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular 27043 - - $369.33 - - Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; 3 cm or greater 27045 - - $581.68 - - Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); 5 cm or greater 27047 $386.05 $284.61 - - - Excision, tumor, soft tissue of pelvis and hip area, subcutaneous; less than 3 cm 27048 - - $480.44 - - Excision, tumor, soft tissue of pelvis and hip area, subfascial (eg, intramuscular); less than 5 cm 27049 - - $1,047.16 - - Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; less than 5 cm 27050 - - $319.80 - - Arthrotomy, with biopsy; sacroiliac joint 27052 - - $457.77 - - Arthrotomy, with biopsy; hip joint 27054 - - $543.39 - - Arthrotomy with synovectomy, hip joint Decompression fasciotomy(ies), pelvic (buttock) compartment(s) (eg, gluteus medius-minimus, 27057 - - $798.68 - - gluteus maximus, iliopsoas, and/or tensor fascia lata muscle) with debridement of nonviable muscle, unilateral 27059 - - $1,422.42 - - Radical resection of tumor (eg, sarcoma), soft tissue of pelvis and hip area; 5 cm or greater 27060 - - $368.74 - - Excision; ischial bursa 27062 - - $360.23 - - Excision; trochanteric bursa or calcification Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of 27065 - - $412.90 - - femur; superficial, includes autograft, when performed Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of 27066 - - $640.64 - - femur; deep (subfascial), includes autograft, when performed Excision of bone cyst or benign tumor, wing of ilium, symphysis pubis, or greater trochanter of 27067 - - $816.96 - - femur; with autograft requiring separate incision Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, 27070 - - $695.24 - - saucerization) (eg, osteomyelitis or bone abscess); superficial

27071 - - $749.20 - - Partial excision, wing of ilium, symphysis pubis, or greater trochanter of femur, (craterization, saucerization) (eg, osteomyelitis or bone abscess); deep (subfascial or intramuscular) 27075 - - $1,645.37 - - Radical resection of tumor; wing of ilium, 1 pubic or ischial ramus or symphysis pubis Radical resection of tumor; ilium, including acetabulum, both pubic rami, or ischium and 27076 - - $1,989.74 - - acetabulum 27077 - - $2,219.36 - - Radical resection of tumor; innominate bone, total 27078 - - $1,621.88 - - Radical resection of tumor; ischial tuberosity and greater trochanter of femur 27080 - - $404.67 - - Coccygectomy, primary 27086 $248.00 $133.23 - - - Removal of foreign body, pelvis or hip; subcutaneous tissue 27087 - - $485.77 - - Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) 27090 - - $656.73 - - Removal of hip prosthesis; (separate procedure)

Page 35 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Removal of hip prosthesis; complicated, including total hip prosthesis, methylmethacrylate with 27091 - - $1,256.65 - - or without insertion of spacer 27093 $176.50 $54.19 - - - Injection procedure for hip arthrography; without anesthesia 27095 $237.58 $65.71 - - - Injection procedure for hip arthrography; with anesthesia Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or 27096 $129.39 $65.05 - - - CT) including arthrography when performed 27097 - - $539.92 - - Release or recession, hamstring, proximal 27098 - - $549.60 - - Transfer, adductor to ischium Transfer external oblique muscle to greater trochanter including fascial or tendon extension 27100 - - $654.69 - - (graft) 27105 - - $686.08 - - Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) 27110 - - $766.24 - - Transfer iliopsoas; to greater trochanter of femur 27111 - - $712.23 - - Transfer iliopsoas; to femoral neck 27120 - - $1,024.13 - - Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type) 27122 - - $868.50 - - Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure) 27125 - - $892.78 - - Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), 27130 - - $1,067.04 - - with or without autograft or allograft Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or 27132 - - $1,318.31 - - allograft 27134 - - $1,504.18 - - Revision of total hip arthroplasty; both components, with or without autograft or allograft Revision of total hip arthroplasty; acetabular component only, with or without autograft or 27137 - - $1,157.85 - - allograft 27138 - - $1,203.27 - - Revision of total hip arthroplasty; femoral component only, with or without allograft 27140 - - $706.48 - - Osteotomy and transfer of greater trochanter of femur (separate procedure) 27146 - - $1,007.20 - - Osteotomy, iliac, acetabular or innominate bone; 27147 - - $1,154.96 - - Osteotomy, iliac, acetabular or innominate bone; with open reduction of hip 27151 - - $1,248.94 - - Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy Osteotomy, iliac, acetabular or innominate bone; with femoral osteotomy and with open 27156 - - $1,345.92 - - reduction of hip 27158 - - $1,103.66 - - Osteotomy, pelvis, bilateral (eg, congenital malformation) 27161 - - $962.07 - - Osteotomy, femoral neck (separate procedure) Osteotomy, intertrochanteric or subtrochanteric including internal or external fixation and/or 27165 - - $1,082.39 - - cast Bone graft, femoral head, neck, intertrochanteric or subtrochanteric area (includes obtaining 27170 - - $925.60 - - bone graft) 27175 - - $526.23 - - Treatment of slipped femoral epiphysis; by traction, without reduction 27176 - - $726.83 - - Treatment of slipped femoral epiphysis; by single or multiple pinning, in situ Open treatment of slipped femoral epiphysis; single or multiple pinning or bone graft (includes 27177 - - $879.13 - - obtaining graft) Open treatment of slipped femoral epiphysis; closed manipulation with single or multiple 27178 - - $726.83 - - pinning Open treatment of slipped femoral epiphysis; osteoplasty of femoral neck (Heyman type 27179 - - $771.99 - - procedure) 27181 - - $884.04 - - Open treatment of slipped femoral epiphysis; osteotomy and internal fixation 27185 - - $567.75 - - Epiphyseal arrest by epiphysiodesis or stapling, greater trochanter of femur Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, 27187 - - $785.91 - - femoral neck and proximal femur Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or 27197 - - $101.55 - - dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; without manipulation Closed treatment of posterior pelvic ring fracture(s), dislocation(s), diastasis or subluxation of the ilium, sacroiliac joint, and/or sacrum, with or without anterior pelvic ring fracture(s) and/or 27198 - - $240.99 - - dislocation(s) of the pubic symphysis and/or superior/inferior rami, unilateral or bilateral; with manipulation, requiring more than local anesthesia (ie, general anesthesia, moderate sedation, spinal/epidural) 27200 $147.81 $150.13 - - - Closed treatment of coccygeal fracture 27202 - - $418.72 - - Open treatment of coccygeal fracture Open treatment of iliac spine(s), tuberosity avulsion, or iliac wing fracture(s), unilateral, for 27215 - - $476.12 - - pelvic bone fracture patterns that do not disrupt the pelvic ring, includes internal fixation, when performed Percutaneous skeletal fixation of posterior pelvic bone fracture and/or dislocation, for fracture 27216 - - $705.26 - - patterns that disrupt the pelvic ring, unilateral (includes ipsilateral ilium, sacroiliac joint and/or sacrum)

Page 36 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open treatment of anterior pelvic bone fracture and/or dislocation for fracture patterns that 27217 - - $662.23 - - disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes pubic symphysis and/or ipsilateral superior/inferior rami) Open treatment of posterior pelvic bone fracture and/or dislocation, for fracture patterns that 27218 - - $911.16 - - disrupt the pelvic ring, unilateral, includes internal fixation, when performed (includes ipsilateral ilium, sacroiliac joint and/or sacrum) 27220 $341.07 $336.14 - - - Closed treatment of acetabulum (hip socket) fracture(s); without manipulation Closed treatment of acetabulum (hip socket) fracture(s); with manipulation, with or without 27222 - - $768.31 - - skeletal traction 27226 - - $832.75 - - Open treatment of posterior or anterior acetabular wall fracture, with internal fixation Open treatment of acetabular fracture(s) involving anterior or posterior (one) column, or a 27227 - - $1,301.93 - - fracture running transversely across the acetabulum, with internal fixation

Open treatment of acetabular fracture(s) involving anterior and posterior (two) columns, 27228 - - $1,477.65 - - includes T-fracture and both column fracture with complete articular detachment, or single column or transverse fracture with associated acetabular wall fracture, with internal fixation 27230 $383.22 $377.13 - - - Closed treatment of femoral fracture, proximal end, neck; without manipulation Closed treatment of femoral fracture, proximal end, neck; with manipulation, with or without 27232 - - $587.34 - - skeletal traction 27235 - - $716.78 - - Percutaneous skeletal fixation of femoral fracture, proximal end, neck Open treatment of femoral fracture, proximal end, neck, internal fixation or prosthetic 27236 - - $942.01 - - replacement Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; 27238 - - $368.59 - - without manipulation Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; 27240 - - $752.08 - - with manipulation, with or without skin or skeletal traction Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with 27244 - - $969.29 - - plate/screw type implant, with or without cerclage Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with 27245 - - $968.27 - - intramedullary implant, with or without interlocking screws and/or cerclage 27246 $308.27 $306.24 - - - Closed treatment of greater trochanteric fracture, without manipulation 27248 - - $589.10 - - Open treatment of greater trochanteric fracture, includes internal fixation, when performed 27250 - - $141.63 - - Closed treatment of hip dislocation, traumatic; without anesthesia 27252 - - $595.55 - - Closed treatment of hip dislocation, traumatic; requiring anesthesia 27253 - - $743.37 - - Open treatment of hip dislocation, traumatic, without internal fixation Open treatment of hip dislocation, traumatic, with acetabular wall and femoral head fracture, 27254 - - $1,003.43 - - with or without internal or external fixation Treatment of spontaneous hip dislocation (developmental, including congenital or 27256 $239.75 $185.55 - - - pathological), by abduction, splint or traction; without anesthesia, without manipulation Treatment of spontaneous hip dislocation (developmental, including congenital or 27257 - - $284.64 - - pathological), by abduction, splint or traction; with manipulation, requiring anesthesia Open treatment of spontaneous hip dislocation (developmental, including congenital or 27258 - - $876.21 - - pathological), replacement of femoral head in acetabulum (including tenotomy, etc); Open treatment of spontaneous hip dislocation (developmental, including congenital or 27259 - - $1,218.78 - - pathological), replacement of femoral head in acetabulum (including tenotomy, etc); with femoral shaft shortening 27265 - - $320.39 - - Closed treatment of post hip arthroplasty dislocation; without anesthesia

27266 - - $461.01 - - Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia 27267 - - $346.71 - - Closed treatment of femoral fracture, proximal end, head; without manipulation 27268 - - $428.84 - - Closed treatment of femoral fracture, proximal end, head; with manipulation Open treatment of femoral fracture, proximal end, head, includes internal fixation, when 27269 - - $979.92 - - performed 27275 - - $144.86 - - Manipulation, hip joint, requiring general anesthesia Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with 27279 - - $690.00 - - image guidance, includes obtaining bone graft when performed, and placement of transfixing device Arthrodesis, open, sacroiliac joint, including obtaining bone graft, including instrumentation, 27280 - - $1,063.86 - - when performed 27282 - - $677.65 - - Arthrodesis, symphysis pubis (including obtaining graft) 27284 - - $1,267.32 - - Arthrodesis, hip joint (including obtaining graft); 27286 - - $1,297.30 - - Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy 27290 - - $1,279.79 - - Interpelviabdominal amputation (hindquarter amputation) 27295 - - $989.56 - - Disarticulation of hip 27299 - - I.C. - - Unlisted procedure, pelvis or hip joint

Page 37 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 27301 $540.28 $398.84 - - - Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region 27303 - - $507.63 - - Incision, deep, with opening of bone cortex, femur or knee (eg, osteomyelitis or bone abscess) 27305 - - $381.37 - - Fasciotomy, iliotibial (tenotomy), open 27306 - - $272.13 - - Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) 27307 - - $380.80 - - Tenotomy, percutaneous, adductor or hamstring; multiple tendons 27310 - - $578.45 - - Arthrotomy, knee, with exploration, drainage, or removal of foreign body (eg, infection) 27323 $221.96 $139.94 - - - Biopsy, soft tissue of thigh or knee area; superficial 27324 - - $320.28 - - Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) 27325 - - $444.87 - - Neurectomy, hamstring muscle 27326 - - $411.11 - - Neurectomy, popliteal (gastrocnemius) 27327 $390.52 $247.63 - - - Excision, tumor, soft tissue of thigh or knee area, subcutaneous; less than 3 cm 27328 - - $492.21 - - Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); less than 5 cm 27329 - - $819.52 - - Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 5 cm 27330 - - $326.87 - - Arthrotomy, knee; with synovial biopsy only 27331 - - $376.44 - - Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies 27332 - - $510.17 - - Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral 27333 - - $465.10 - - Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral 27334 - - $542.03 - - Arthrotomy, with synovectomy, knee; anterior OR posterior 27335 - - $605.01 - - Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area 27337 - - $330.53 - - Excision, tumor, soft tissue of thigh or knee area, subcutaneous; 3 cm or greater 27339 - - $594.85 - - Excision, tumor, soft tissue of thigh or knee area, subfascial (eg, intramuscular); 5 cm or greater 27340 - - $295.68 - - Excision, prepatellar bursa 27345 - - $383.71 - - Excision of synovial cyst of popliteal space (eg, Baker's cyst) 27347 - - $417.87 - - Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee 27350 - - $516.88 - - Patellectomy or hemipatellectomy 27355 - - $479.04 - - Excision or curettage of bone cyst or benign tumor of femur; 27356 - - $584.52 - - Excision or curettage of bone cyst or benign tumor of femur; with allograft Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining 27357 - - $645.24 - - graft) Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in 27358 - - $216.93 - - addition to code for primary procedure) Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia 27360 - - $695.87 - - and/or fibula (eg, osteomyelitis or bone abscess) 27364 - - $1,227.51 - - Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or greater 27365 - - $1,621.26 - - Radical resection of tumor, femur or knee Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee 27369 $127.55 $31.90 - - - arthrography 27372 $482.53 $318.48 - - - Removal of foreign body, deep, thigh region or knee area 27380 - - $483.30 - - Suture of infrapatellar tendon; primary 27381 - - $641.01 - - Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft 27385 - - $469.17 - - Suture of quadriceps or hamstring muscle rupture; primary Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial 27386 - - $669.84 - - or tendon graft 27390 - - $355.97 - - Tenotomy, open, hamstring, knee to hip; single tendon 27391 - - $447.19 - - Tenotomy, open, hamstring, knee to hip; multiple tendons, 1 leg 27392 - - $563.64 - - Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral 27393 - - $403.73 - - Lengthening of hamstring tendon; single tendon 27394 - - $517.83 - - Lengthening of hamstring tendon; multiple tendons, 1 leg 27395 - - $695.51 - - Lengthening of hamstring tendon; multiple tendons, bilateral Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); 27396 - - $488.35 - - single tendon Transplant or transfer (with muscle redirection or rerouting), thigh (eg, extensor to flexor); 27397 - - $723.01 - - multiple tendons 27400 - - $549.87 - - Transfer, tendon or muscle, hamstrings to femur (eg, Egger's type procedure) 27403 - - $509.15 - - Arthrotomy with meniscus repair, knee 27405 - - $534.95 - - Repair, primary, torn ligament and/or capsule, knee; collateral 27407 - - $628.79 - - Repair, primary, torn ligament and/or capsule, knee; cruciate 27409 - - $763.54 - - Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments 27412 - - $1,299.76 - - Autologous chondrocyte implantation, knee 27415 - - $1,082.77 - - Osteochondral allograft, knee, open 27416 - - $773.62 - - Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) 27418 - - $654.93 - - Anterior tibial tubercleplasty (eg, Maquet type procedure)

Page 38 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 27420 - - $588.16 - - Reconstruction of dislocating patella; (eg, Hauser type procedure) Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or 27422 - - $588.52 - - release (eg, Campbell, Goldwaite type procedure) 27424 - - $591.50 - - Reconstruction of dislocating patella; with patellectomy 27425 - - $357.66 - - Lateral retinacular release, open 27427 - - $562.61 - - Ligamentous reconstruction (augmentation), knee; extra-articular 27428 - - $881.08 - - Ligamentous reconstruction (augmentation), knee; intra-articular (open) 27429 - - $991.03 - - Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular 27430 - - $586.66 - - Quadricepsplasty (eg, Bennett or Thompson type) 27435 - - $640.56 - - Capsulotomy, posterior capsular release, knee 27437 - - $521.49 - - Arthroplasty, patella; without prosthesis 27438 - - $664.84 - - Arthroplasty, patella; with prosthesis 27440 - - $630.63 - - Arthroplasty, knee, tibial plateau; 27441 - - $651.15 - - Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy 27442 - - $689.01 - - Arthroplasty, femoral condyles or tibial plateau(s), knee; Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial 27443 - - $642.17 - - synovectomy 27445 - - $989.31 - - Arthroplasty, knee, hinge prosthesis (eg, Walldius type) 27446 - - $912.23 - - Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without 27447 - - $1,065.68 - - patella resurfacing (total knee arthroplasty) 27448 - - $648.73 - - Osteotomy, femur, shaft or supracondylar; without fixation 27450 - - $801.36 - - Osteotomy, femur, shaft or supracondylar; with fixation Osteotomy, multiple, with realignment on intramedullary rod, femoral shaft (eg, Sofield type 27454 - - $1,021.52 - - procedure) Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu 27455 - - $752.29 - - varus [bowleg] or genu valgus [knock-knee]); before epiphyseal closure Osteotomy, proximal tibia, including fibular excision or osteotomy (includes correction of genu 27457 - - $758.76 - - varus [bowleg] or genu valgus [knock-knee]); after epiphyseal closure 27465 - - $985.98 - - Osteoplasty, femur; shortening (excluding 64876) 27466 - - $934.21 - - Osteoplasty, femur; lengthening 27468 - - $1,057.67 - - Osteoplasty, femur; combined, lengthening and shortening with femoral segment transfer Repair, nonunion or malunion, femur, distal to head and neck; without graft (eg, compression 27470 - - $929.27 - - technique) Repair, nonunion or malunion, femur, distal to head and neck; with iliac or other autogenous 27472 - - $996.01 - - bone graft (includes obtaining graft) 27475 - - $524.26 - - Arrest, epiphyseal, any method (eg, epiphysiodesis); distal femur 27477 - - $579.42 - - Arrest, epiphyseal, any method (eg, epiphysiodesis); tibia and fibula, proximal Arrest, epiphyseal, any method (eg, epiphysiodesis); combined distal femur, proximal tibia and 27479 - - $725.48 - - fibula 27485 - - $530.88 - - Arrest, hemiepiphyseal, distal femur or proximal tibia or fibula (eg, genu varus or valgus) 27486 - - $1,108.44 - - Revision of total knee arthroplasty, with or without allograft; 1 component Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial 27487 - - $1,383.99 - - component Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without 27488 - - $946.91 - - insertion of spacer, knee Prophylactic treatment (nailing, pinning, plating, or wiring) with or without 27495 - - $889.55 - - methylmethacrylate, femur

27496 - - $432.69 - - Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); Decompression fasciotomy, thigh and/or knee, 1 compartment (flexor or extensor or adductor); 27497 - - $460.23 - - with debridement of nonviable muscle and/or nerve 27498 - - $518.57 - - Decompression fasciotomy, thigh and/or knee, multiple compartments; Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of 27499 - - $554.71 - - nonviable muscle and/or nerve 27500 $413.69 $380.36 - - - Closed treatment of femoral shaft fracture, without manipulation Closed treatment of supracondylar or transcondylar femoral fracture with or without 27501 $400.82 $394.15 - - - intercondylar extension, without manipulation Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal 27502 - - $597.95 - - traction Closed treatment of supracondylar or transcondylar femoral fracture with or without 27503 - - $632.46 - - intercondylar extension, with manipulation, with or without skin or skeletal traction Open treatment of femoral shaft fracture, with or without external fixation, with insertion of 27506 - - $1,054.32 - - intramedullary implant, with or without cerclage and/or locking screws 27507 - - $765.16 - - Open treatment of femoral shaft fracture with plate/screws, with or without cerclage

Page 39 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Closed treatment of femoral fracture, distal end, medial or lateral condyle, without 27508 $416.77 $393.88 - - - manipulation Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or 27509 - - $525.47 - - supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation

27510 - - $536.56 - - Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation Open treatment of femoral supracondylar or transcondylar fracture without intercondylar 27511 - - $786.80 - - extension, includes internal fixation, when performed Open treatment of femoral supracondylar or transcondylar fracture with intercondylar 27513 - - $976.40 - - extension, includes internal fixation, when performed Open treatment of femoral fracture, distal end, medial or lateral condyle, includes internal 27514 - - $762.51 - - fixation, when performed 27516 $408.49 $382.11 - - - Closed treatment of distal femoral epiphyseal separation; without manipulation Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without 27517 - - $543.94 - - skin or skeletal traction Open treatment of distal femoral epiphyseal separation, includes internal fixation, when 27519 - - $703.14 - - performed 27520 $258.06 $237.49 - - - Closed treatment of patellar fracture, without manipulation Open treatment of patellar fracture, with internal fixation and/or partial or complete 27524 - - $595.24 - - patellectomy and soft tissue repair 27530 $243.35 $227.41 - - - Closed treatment of tibial fracture, proximal (plateau); without manipulation Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with 27532 $489.58 $456.83 - - - skeletal traction Open treatment of tibial fracture, proximal (plateau); unicondylar, includes internal fixation, 27535 - - $707.67 - - when performed Open treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal 27536 - - $937.13 - - fixation Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or 27538 $380.78 $353.83 - - - without manipulation Open treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, includes 27540 - - $640.26 - - internal fixation, when performed 27550 $416.20 $384.61 - - - Closed treatment of knee dislocation; without anesthesia 27552 - - $498.42 - - Closed treatment of knee dislocation; requiring anesthesia Open treatment of knee dislocation, includes internal fixation, when performed; without 27556 - - $692.05 - - primary ligamentous repair or augmentation/reconstruction Open treatment of knee dislocation, includes internal fixation, when performed; with primary 27557 - - $824.76 - - ligamentous repair Open treatment of knee dislocation, includes internal fixation, when performed; with primary 27558 - - $939.23 - - ligamentous repair, with augmentation/reconstruction 27560 $297.92 $273.00 - - - Closed treatment of patellar dislocation; without anesthesia 27562 - - $386.06 - - Closed treatment of patellar dislocation; requiring anesthesia 27566 - - $705.69 - - Open treatment of patellar dislocation, with or without partial or total patellectomy Manipulation of knee joint under general anesthesia (includes application of traction or other 27570 - - $119.82 - - fixation devices) 27580 - - $1,152.10 - - Arthrodesis, knee, any technique 27590 - - $620.15 - - Amputation, thigh, through femur, any level; 27591 - - $761.92 - - Amputation, thigh, through femur, any level; immediate fitting technique including first cast 27592 - - $529.31 - - Amputation, thigh, through femur, any level; open, circular (guillotine) 27594 - - $403.51 - - Amputation, thigh, through femur, any level; secondary closure or scar revision 27596 - - $560.45 - - Amputation, thigh, through femur, any level; re-amputation 27598 - - $558.15 - - Disarticulation at knee 27599 - - I.C. - - Unlisted procedure, femur or knee 27600 - - $319.00 - - Decompression fasciotomy, leg; anterior and/or lateral compartments only 27601 - - $353.18 - - Decompression fasciotomy, leg; posterior compartment(s) only 27602 - - $379.41 - - Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) 27603 $427.10 $308.27 - - - Incision and drainage, leg or ankle; deep abscess or hematoma 27604 $381.58 $264.20 - - - Incision and drainage, leg or ankle; infected bursa 27605 $276.39 $146.25 - - - Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia 27606 - - $218.43 - - Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia 27607 - - $478.30 - - Incision (eg, osteomyelitis or bone abscess), leg or ankle 27610 - - $512.74 - - Arthrotomy, ankle, including exploration, drainage, or removal of foreign body 27612 - - $440.90 - - Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening 27613 $202.55 $126.61 - - - Biopsy, soft tissue of leg or ankle area; superficial 27614 $463.94 $320.76 - - - Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) 27615 - - $806.51 - - Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; less than 5 cm

Page 40 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 27616 - - $1,000.73 - - Radical resection of tumor (eg, sarcoma), soft tissue of leg or ankle area; 5 cm or greater 27618 $379.58 $241.33 - - - Excision, tumor, soft tissue of leg or ankle area, subcutaneous; less than 3 cm 27619 - - $364.07 - - Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); less than 5 cm Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of 27620 - - $354.64 - - loose or foreign body 27625 - - $455.76 - - Arthrotomy, with synovectomy, ankle; 27626 - - $477.22 - - Arthrotomy, with synovectomy, ankle; including tenosynovectomy 27630 $442.94 $284.98 - - - Excision of lesion of tendon sheath or capsule (eg, cyst or ganglion), leg and/or ankle 27632 - - $326.05 - - Excision, tumor, soft tissue of leg or ankle area, subcutaneous; 3 cm or greater 27634 - - $538.00 - - Excision, tumor, soft tissue of leg or ankle area, subfascial (eg, intramuscular); 5 cm or greater 27635 - - $460.12 - - Excision or curettage of bone cyst or benign tumor, tibia or fibula; Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes 27637 - - $591.87 - - obtaining graft) 27638 - - $604.62 - - Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograft 27640 - - $655.52 - - Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); tibia

27641 - - $521.97 - - Partial excision (craterization, saucerization, or diaphysectomy), bone (eg, osteomyelitis); fibula 27645 - - $1,395.45 - - Radical resection of tumor; tibia 27646 - - $1,212.28 - - Radical resection of tumor; fibula 27647 - - $793.31 - - Radical resection of tumor; talus or calcaneus 27648 $163.13 $41.11 - - - Injection procedure for ankle arthrography 27650 - - $520.27 - - Repair, primary, open or percutaneous, ruptured Achilles tendon; Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining 27652 - - $523.04 - - graft) 27654 - - $562.70 - - Repair, secondary, Achilles tendon, with or without graft 27656 $513.24 $315.28 - - - Repair, fascial defect of leg 27658 - - $292.37 - - Repair, flexor tendon, leg; primary, without graft, each tendon 27659 - - $370.95 - - Repair, flexor tendon, leg; secondary, with or without graft, each tendon 27664 - - $285.99 - - Repair, extensor tendon, leg; primary, without graft, each tendon 27665 - - $328.60 - - Repair, extensor tendon, leg; secondary, with or without graft, each tendon 27675 - - $387.41 - - Repair, dislocating peroneal tendons; without fibular osteotomy 27676 - - $472.49 - - Repair, dislocating peroneal tendons; with fibular osteotomy 27680 - - $335.68 - - Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate 27681 - - $409.51 - - incision[s]) 27685 $530.83 $366.78 - - - Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure) Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), 27686 - - $427.81 - - each 27687 - - $359.51 - - Gastrocnemius recession (eg, Strayer procedure) Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (eg, 27690 - - $505.26 - - anterior tibial extensors into midfoot) Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (eg, 27691 - - $588.57 - - anterior tibial or posterior tibial through interosseous space, 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 27692 - - $81.21 - - tendon (List separately in addition to code for primary procedure) 27695 - - $375.18 - - Repair, primary, disrupted ligament, ankle; collateral 27696 - - $440.23 - - Repair, primary, disrupted ligament, ankle; both collateral ligaments 27698 - - $503.01 - - Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure) 27700 - - $483.27 - - Arthroplasty, ankle; 27702 - - $760.24 - - Arthroplasty, ankle; with implant (total ankle) 27703 - - $879.26 - - Arthroplasty, ankle; revision, total ankle 27704 - - $453.79 - - Removal of ankle implant 27705 - - $598.32 - - Osteotomy; tibia 27707 - - $317.45 - - Osteotomy; fibula 27709 - - $919.15 - - Osteotomy; tibia and fibula 27712 - - $869.51 - - Osteotomy; multiple, with realignment on intramedullary rod (eg, Sofield type procedure) 27715 - - $845.67 - - Osteoplasty, tibia and fibula, lengthening or shortening 27720 - - $691.71 - - Repair of nonunion or malunion, tibia; without graft, (eg, compression technique) 27722 - - $705.49 - - Repair of nonunion or malunion, tibia; with sliding graft 27724 - - $991.50 - - Repair of nonunion or malunion, tibia; with iliac or other autograft (includes obtaining graft) 27725 - - $959.60 - - Repair of nonunion or malunion, tibia; by synostosis, with fibula, any method

Page 41 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 27726 - - $754.53 - - Repair of fibula nonunion and/or malunion with internal fixation 27727 - - $818.94 - - Repair of congenital pseudarthrosis, tibia 27730 - - $464.93 - - Arrest, epiphyseal (epiphysiodesis), open; distal tibia 27732 - - $357.64 - - Arrest, epiphyseal (epiphysiodesis), open; distal fibula 27734 - - $519.71 - - Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula 27740 - - $559.97 - - Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; 27742 - - $614.82 - - and distal femur Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, 27745 - - $601.48 - - tibia

27750 $276.11 $254.95 - - - Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, 27752 $425.94 $390.29 - - - with or without skeletal traction Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (eg, pins 27756 - - $455.56 - - or screws) Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, 27758 - - $706.76 - - with or without cerclage Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, 27759 - - $787.89 - - with or without interlocking screws and/or cerclage 27760 $266.68 $244.94 - - - Closed treatment of medial malleolus fracture; without manipulation Closed treatment of medial malleolus fracture; with manipulation, with or without skin or 27762 $380.69 $343.88 - - - skeletal traction 27766 - - $478.74 - - Open treatment of medial malleolus fracture, includes internal fixation, when performed 27767 $230.18 $229.02 - - - Closed treatment of posterior malleolus fracture; without manipulation 27768 - - $352.61 - - Closed treatment of posterior malleolus fracture; with manipulation 27769 - - $576.46 - - Open treatment of posterior malleolus fracture, includes internal fixation, when performed 27780 $245.72 $224.85 - - - Closed treatment of proximal fibula or shaft fracture; without manipulation 27781 $344.98 $317.16 - - - Closed treatment of proximal fibula or shaft fracture; with manipulation

27784 - - $562.59 - - Open treatment of proximal fibula or shaft fracture, includes internal fixation, when performed 27786 $251.29 $229.26 - - - Closed treatment of distal fibular fracture (lateral malleolus); without manipulation 27788 $338.57 $306.40 - - - Closed treatment of distal fibular fracture (lateral malleolus); with manipulation Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when 27792 - - $512.18 - - performed Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and 27808 $267.41 $242.19 - - - posterior malleoli or medial and posterior malleoli); without manipulation Closed treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and 27810 $372.99 $335.89 - - - posterior malleoli or medial and posterior malleoli); with manipulation

27814 - - $606.40 - - Open treatment of bimalleolar ankle fracture (eg, lateral and medial malleoli, or lateral and posterior malleoli, or medial and posterior malleoli), includes internal fixation, when performed 27816 $261.22 $232.24 - - - Closed treatment of trimalleolar ankle fracture; without manipulation 27818 $386.59 $344.57 - - - Closed treatment of trimalleolar ankle fracture; with manipulation Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, 27822 - - $687.11 - - medial and/or lateral malleolus; without fixation of posterior lip Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, 27823 - - $775.63 - - medial and/or lateral malleolus; with fixation of posterior lip Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial 27824 $253.21 $242.77 - - - plafond), with or without anesthesia; without manipulation

27825 $433.47 $390.86 - - - Closed treatment of fracture of weight bearing articular portion of distal tibia (eg, pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon 27826 - - $675.27 - - or tibial plafond), with internal fixation, when performed; of fibula only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon 27827 - - $879.80 - - or tibial plafond), with internal fixation, when performed; of tibia only Open treatment of fracture of weight bearing articular surface/portion of distal tibia (eg, pilon 27828 - - $1,043.19 - - or tibial plafond), with internal fixation, when performed; of both tibia and fibula Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, 27829 - - $556.60 - - when performed 27830 $308.72 $284.67 - - - Closed treatment of proximal tibiofibular joint dislocation; without anesthesia 27831 - - $321.27 - - Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia Open treatment of proximal tibiofibular joint dislocation, includes internal fixation, when 27832 - - $598.43 - - performed, or with excision of proximal fibula

Page 42 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 27840 - - $298.37 - - Closed treatment of ankle dislocation; without anesthesia Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous 27842 - - $390.25 - - skeletal fixation Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without 27846 - - $563.99 - - repair or internal fixation Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair 27848 - - $630.68 - - or internal or external fixation Manipulation of ankle under general anesthesia (includes application of traction or other 27860 - - $134.73 - - fixation apparatus) 27870 - - $805.43 - - Arthrodesis, ankle, open 27871 - - $544.79 - - Arthrodesis, tibiofibular joint, proximal or distal 27880 - - $710.24 - - Amputation, leg, through tibia and fibula; Amputation, leg, through tibia and fibula; with immediate fitting technique including 27881 - - $673.67 - - application of first cast 27882 - - $467.39 - - Amputation, leg, through tibia and fibula; open, circular (guillotine) 27884 - - $449.96 - - Amputation, leg, through tibia and fibula; secondary closure or scar revision 27886 - - $514.91 - - Amputation, leg, through tibia and fibula; re-amputation Amputation, ankle, through malleoli of tibia and fibula (eg, Syme, Pirogoff type procedures), 27888 - - $514.85 - - with plastic closure and resection of nerves 27889 - - $501.85 - - Ankle disarticulation Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement 27892 - - $433.97 - - of nonviable muscle and/or nerve Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable 27893 - - $484.21 - - muscle and/or nerve Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with 27894 - - $662.14 - - debridement of nonviable muscle and/or nerve 27899 - - I.C. - - Unlisted procedure, leg or ankle 28001 $225.56 $135.14 - - - Incision and drainage, bursa, foot Incision and drainage below fascia, with or without tendon sheath involvement, foot; single 28002 $354.19 $251.30 - - - bursal space Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple 28003 $558.45 $441.36 - - - areas 28005 - - $455.05 - - Incision, bone cortex (eg, osteomyelitis or bone abscess), foot 28008 $349.13 $232.91 - - - Fasciotomy, foot and/or toe 28010 $185.39 $165.10 - - - Tenotomy, percutaneous, toe; single tendon 28011 $251.15 $222.46 - - - Tenotomy, percutaneous, toe; multiple tendons Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or 28020 $433.71 $284.74 - - - tarsometatarsal joint Arthrotomy, including exploration, drainage, or removal of loose or foreign body; 28022 $393.35 $257.13 - - - metatarsophalangeal joint Arthrotomy, including exploration, drainage, or removal of loose or foreign body; 28024 $368.92 $239.37 - - - interphalangeal joint 28035 $424.42 $280.38 - - - Release, tarsal tunnel (posterior tibial nerve decompression) 28039 $398.27 $271.90 - - - Excision, tumor, soft tissue of foot or toe, subcutaneous; 1.5 cm or greater 28041 - - $357.66 - - Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); 1.5 cm or greater 28043 $316.95 $206.52 - - - Excision, tumor, soft tissue of foot or toe, subcutaneous; less than 1.5 cm 28045 $391.54 $273.29 - - - Excision, tumor, soft tissue of foot or toe, subfascial (eg, intramuscular); less than 1.5 cm 28046 - - $562.74 - - Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; less than 3 cm 28047 - - $817.33 - - Radical resection of tumor (eg, sarcoma), soft tissue of foot or toe; 3 cm or greater 28050 $340.71 $220.43 - - - Arthrotomy with biopsy; intertarsal or tarsometatarsal joint 28052 $360.35 $225.00 - - - Arthrotomy with biopsy; metatarsophalangeal joint 28054 $301.84 $185.61 - - - Arthrotomy with biopsy; interphalangeal joint 28055 - - $304.73 - - Neurectomy, intrinsic musculature of foot 28060 $420.95 $284.44 - - - Fasciectomy, plantar fascia; partial (separate procedure) 28062 $467.50 $319.98 - - - Fasciectomy, plantar fascia; radical (separate procedure) 28070 $426.72 $279.77 - - - Synovectomy; intertarsal or tarsometatarsal joint, each 28072 $393.62 $253.63 - - - Synovectomy; metatarsophalangeal joint, each 28080 $425.83 $293.66 - - - Excision, interdigital (Morton) neuroma, single, each 28086 $433.65 $280.91 - - - Synovectomy, tendon sheath, foot; flexor 28088 $350.54 $217.79 - - - Synovectomy, tendon sheath, foot; extensor Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or 28090 $377.41 $242.63 - - - ganglion); foot Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (eg, cyst or 28092 $342.90 $213.63 - - - ganglion); toe(s), each 28100 $492.81 $329.35 - - - Excision or curettage of bone cyst or benign tumor, talus or calcaneus;

Page 43 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other 28102 - - $481.85 - - autograft (includes obtaining graft) 28103 - - $307.10 - - Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or 28104 $426.67 $280.01 - - - calcaneus; Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or 28106 - - $337.09 - - calcaneus; with iliac or other autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or 28107 $411.75 $274.07 - - - calcaneus; with allograft 28108 $354.57 $227.91 - - - Excision or curettage of bone cyst or benign tumor, phalanges of foot 28110 $374.92 $229.71 - - - Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) 28111 $393.21 $255.25 - - - Ostectomy, complete excision; first metatarsal head 28112 $394.13 $247.18 - - - Ostectomy, complete excision; other metatarsal head (second, third or fourth) 28113 $473.27 $335.31 - - - Ostectomy, complete excision; fifth metatarsal head Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, 28114 $847.21 $654.18 - - - excluding first metatarsal (eg, Clayton type procedure) 28116 $610.80 $454.58 - - - Ostectomy, excision of tarsal coalition 28118 $483.38 $330.35 - - - Ostectomy, calcaneus; 28119 $421.86 $285.05 - - - Ostectomy, calcaneus; for spur, with or without plantar fascial release Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, 28120 $543.82 $393.10 - - - osteomyelitis or bossing); talus or calcaneus Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, 28122 $477.89 $346.02 - - - osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (eg, 28124 $385.71 $262.53 - - - osteomyelitis or bossing); phalanx of toe 28126 $317.62 $195.60 - - - Resection, partial or complete, phalangeal base, each toe 28130 - - $498.78 - - Talectomy (astragalectomy) 28140 $470.51 $342.40 - - - Metatarsectomy 28150 $339.83 $219.83 - - - Phalangectomy, toe, each toe 28153 $334.49 $210.44 - - - Resection, condyle(s), distal end of phalanx, each toe 28160 $336.03 $211.69 - - - Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each 28171 - - $875.67 - - Radical resection of tumor; tarsal (except talus or calcaneus) 28173 - - $576.27 - - Radical resection of tumor; metatarsal 28175 - - $372.19 - - Radical resection of tumor; phalanx of toe 28190 $204.83 $105.70 - - - Removal of foreign body, foot; subcutaneous 28192 $377.38 $247.24 - - - Removal of foreign body, foot; deep 28193 $425.95 $291.17 - - - Removal of foreign body, foot; complicated 28200 $398.74 $256.43 - - - Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon 28202 $485.09 $340.18 - - - Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) 28208 $389.45 $250.62 - - - Repair, tendon, extensor, foot; primary or secondary, each tendon 28210 $473.27 $330.67 - - - Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) 28220 $363.63 $239.29 - - - Tenolysis, flexor, foot; single tendon 28222 $417.31 $281.66 - - - Tenolysis, flexor, foot; multiple tendons 28225 $338.17 $208.90 - - - Tenolysis, extensor, foot; single tendon 28226 $497.15 $313.39 - - - Tenolysis, extensor, foot; multiple tendons 28230 $351.48 $223.95 - - - Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) 28232 $311.66 $191.38 - - - Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) 28234 $332.03 $210.59 - - - Tenotomy, open, extensor, foot or toe, each tendon Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal 28238 $533.15 $381.57 - - - navicular bone (eg, Kidner type procedure) 28240 $361.77 $232.22 - - - Tenotomy, lengthening, or release, abductor hallucis muscle 28250 $467.12 $319.60 - - - Division of plantar fascia and muscle (eg, Steindler stripping) (separate procedure) 28260 $560.76 $409.18 - - - Capsulotomy, midfoot; medial release only (separate procedure) 28261 $960.12 $740.72 - - - Capsulotomy, midfoot; with tendon lengthening Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) 28262 $1,115.26 $890.06 - - - lengthening (eg, resistant clubfoot deformity) 28264 $809.74 $608.31 - - - Capsulotomy, midtarsal (eg, Heyman type procedure) Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate 28270 $397.45 $265.00 - - - procedure) 28272 $315.04 $199.11 - - - Capsulotomy; interphalangeal joint, each joint (separate procedure) 28280 $414.21 $275.09 - - - Syndactylization, toes (eg, webbing or Kelikian type procedure) 28285 $432.34 $300.76 - - - Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy) 28286 $360.30 $234.80 - - - Correction, cock-up fifth toe, with plastic skin closure (eg, Ruiz-Mora type procedure) 28288 $491.58 $343.47 - - - Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head

Page 44 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Hallux rigidus correction with cheilectomy, debridement and capsular release of the first 28289 $576.31 $362.70 - - - metatarsophalangeal joint; without implant Hallux rigidus correction with cheilectomy, debridement and capsular release of the first 28291 $587.30 $385.87 - - - metatarsophalangeal joint; with implant Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with 28292 $583.95 $382.23 - - - resection of proximal phalanx base, when performed, any method Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with 28295 $801.53 $443.00 - - - proximal metatarsal osteotomy, any method Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with distal 28296 $735.11 $405.56 - - - metatarsal osteotomy, any method Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with first 28297 $849.90 $476.59 - - - metatarsal and medial cuneiform joint arthrodesis, any method Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with 28298 $681.73 $392.76 - - - proximal phalanx osteotomy, any method Correction, hallux valgus (bunionectomy), with sesamoidectomy, when performed; with double 28299 $816.28 $459.79 - - - osteotomy, any method Osteotomy; calcaneus (eg, Dwyer or Chambers type procedure), with or without internal 28300 - - $513.66 - - fixation 28302 - - $566.18 - - Osteotomy; talus 28304 $655.56 $475.57 - - - Osteotomy, tarsal bones, other than calcaneus or talus; Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) 28305 - - $526.99 - - (eg, Fowler type) Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first 28306 $488.76 $316.60 - - - metatarsal Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first 28307 $499.83 $327.95 - - - metatarsal with autograft (other than first toe) Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other 28308 $459.95 $301.70 - - - than first metatarsal, each Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple 28309 - - $694.81 - - (eg, Swanson type cavus foot procedure) Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate 28310 $441.07 $283.69 - - - procedure) 28312 $406.25 $250.61 - - - Osteotomy, shortening, angular or rotational correction; other phalanges, any toe Reconstruction, angular deformity of toe, soft tissue procedures only (eg, overlapping second 28313 $423.08 $281.06 - - - toe, fifth toe, curly toes) 28315 $388.30 $257.29 - - - Sesamoidectomy, first toe (separate procedure) 28320 - - $482.94 - - Repair, nonunion or malunion; tarsal bones

28322 $627.62 $453.43 - - - Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) 28340 $460.27 $323.76 - - - Reconstruction, toe, macrodactyly; soft tissue resection 28341 $532.14 $385.20 - - - Reconstruction, toe, macrodactyly; requiring bone resection 28344 $343.00 $220.69 - - - Reconstruction, toe(s); polydactyly 28345 $417.35 $287.21 - - - Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web 28360 - - $863.87 - - Reconstruction, cleft foot 28400 $198.15 $182.50 - - - Closed treatment of calcaneal fracture; without manipulation 28405 $307.77 $277.63 - - - Closed treatment of calcaneal fracture; with manipulation 28406 - - $430.23 - - Percutaneous skeletal fixation of calcaneal fracture, with manipulation 28415 - - $884.02 - - Open treatment of calcaneal fracture, includes internal fixation, when performed; Open treatment of calcaneal fracture, includes internal fixation, when performed; with primary 28420 - - $1,016.67 - - iliac or other autogenous bone graft (includes obtaining graft) 28430 $191.51 $167.74 - - - Closed treatment of talus fracture; without manipulation 28435 $291.41 $258.08 - - - Closed treatment of talus fracture; with manipulation 28436 - - $373.47 - - Percutaneous skeletal fixation of talus fracture, with manipulation 28445 - - $816.70 - - Open treatment of talus fracture, includes internal fixation, when performed 28446 - - $965.06 - - Open osteochondral autograft, talus (includes obtaining graft[s]) 28450 $169.68 $152.29 - - - Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each 28455 $230.03 $204.81 - - - Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with 28456 - - $272.75 - - manipulation, each Open treatment of tarsal bone fracture (except talus and calcaneus), includes internal fixation, 28465 - - $499.72 - - when performed, each 28470 $175.10 $163.22 - - - Closed treatment of metatarsal fracture; without manipulation, each 28475 $204.55 $179.91 - - - Closed treatment of metatarsal fracture; with manipulation, each 28476 - - $294.66 - - Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each 28485 - - $438.13 - - Open treatment of metatarsal fracture, includes internal fixation, when performed, each 28490 $114.37 $99.30 - - - Closed treatment of fracture great toe, phalanx or phalanges; without manipulation

Page 45 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 28495 $142.83 $118.20 - - - Closed treatment of fracture great toe, phalanx or phalanges; with manipulation 28496 $368.36 $193.01 - - - Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation Open treatment of fracture, great toe, phalanx or phalanges, includes internal fixation, when 28505 $531.84 $392.72 - - - performed Closed treatment of fracture, phalanx or phalanges, other than great toe; without 28510 $97.11 $95.38 - - - manipulation, each Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, 28515 $130.71 $113.61 - - - each Open treatment of fracture, phalanx or phalanges, other than great toe, includes internal 28525 $461.45 $319.72 - - - fixation, when performed, each 28530 $92.42 $80.25 - - - Closed treatment of sesamoid fracture 28531 $274.75 $144.04 - - - Open treatment of sesamoid fracture, with or without internal fixation 28540 $155.25 $139.02 - - - Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia 28545 $242.56 $212.13 - - - Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with 28546 $473.91 $274.21 - - - manipulation 28555 $682.90 $513.35 - - - Open treatment of tarsal bone dislocation, includes internal fixation, when performed 28570 $184.52 $154.09 - - - Closed treatment of talotarsal joint dislocation; without anesthesia 28575 $296.79 $265.78 - - - Closed treatment of talotarsal joint dislocation; requiring anesthesia 28576 - - $307.52 - - Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation 28585 $690.07 $535.88 - - - Open treatment of talotarsal joint dislocation, includes internal fixation, when performed 28600 $173.23 $147.44 - - - Closed treatment of tarsometatarsal joint dislocation; without anesthesia 28605 $268.00 $238.72 - - - Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia 28606 - - $308.04 - - Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation

28615 - - $645.06 - - Open treatment of tarsometatarsal joint dislocation, includes internal fixation, when performed 28630 $124.62 $87.23 - - - Closed treatment of metatarsophalangeal joint dislocation; without anesthesia 28635 $140.23 $104.58 - - - Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia 28636 $251.62 $157.72 - - - Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation Open treatment of metatarsophalangeal joint dislocation, includes internal fixation, when 28645 $526.60 $383.72 - - - performed 28660 $94.94 $71.76 - - - Closed treatment of interphalangeal joint dislocation; without anesthesia 28665 $122.03 $102.04 - - - Closed treatment of interphalangeal joint dislocation; requiring anesthesia 28666 - - $131.35 - - Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation

28675 $459.18 $320.06 - - - Open treatment of interphalangeal joint dislocation, includes internal fixation, when performed 28705 - - $964.83 - - Arthrodesis; pantalar 28715 - - $742.94 - - Arthrodesis; triple 28725 - - $615.60 - - Arthrodesis; subtalar 28730 - - $581.12 - - Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (eg, flatfoot 28735 - - $611.05 - - correction) Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform 28737 - - $543.36 - - (eg, Miller type procedure) 28740 $672.96 $490.36 - - - Arthrodesis, midtarsal or tarsometatarsal, single joint 28750 $640.11 $460.99 - - - Arthrodesis, great toe; metatarsophalangeal joint 28755 $411.64 $263.25 - - - Arthrodesis, great toe; interphalangeal joint Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, 28760 $626.58 $454.13 - - - interphalangeal joint (eg, Jones type procedure) 28800 - - $420.29 - - Amputation, foot; midtarsal (eg, Chopart type procedure) 28805 - - $565.59 - - Amputation, foot; transmetatarsal 28810 - - $337.35 - - Amputation, metatarsal, with toe, single 28820 $449.30 $310.18 - - - Amputation, toe; metatarsophalangeal joint 28825 $430.28 $291.16 - - - Amputation, toe; interphalangeal joint Extracorporeal shock wave, high energy, performed by a physician or other qualified health 28890 $256.25 $175.09 - - - care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia 28899 - - I.C. - - Unlisted procedure, foot or toes 29000 $271.63 $152.22 - - - Application of halo type body cast (see 20661-20663 for insertion) 29010 $214.24 $125.84 - - - Application of Risser jacket, localizer, body; only 29015 $230.16 $142.05 - - - Application of Risser jacket, localizer, body; including head 29035 $200.73 $112.33 - - - Application of body cast, shoulder to hips; 29040 $229.36 $136.03 - - - Application of body cast, shoulder to hips; including head, Minerva type 29044 $225.01 $131.40 - - - Application of body cast, shoulder to hips; including 1 thigh 29046 $246.39 $147.56 - - - Application of body cast, shoulder to hips; including both thighs

Page 46 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 29049 $77.87 $54.97 - - - Application, cast; figure-of-eight 29055 $174.33 $107.96 - - - Application, cast; shoulder spica 29058 $97.30 $74.11 - - - Application, cast; plaster Velpeau 29065 $75.40 $53.66 - - - Application, cast; shoulder to hand (long arm) 29075 $67.95 $48.53 - - - Application, cast; elbow to finger (short arm) 29085 $74.86 $52.84 - - - Application, cast; hand and lower forearm (gauntlet) 29086 $62.42 $40.68 - - - Application, cast; finger (eg, contracture) 29105 $64.40 $32.52 - - - Application of long arm splint (shoulder to hand) 29125 $51.12 $31.12 - - - Application of short arm splint (forearm to hand); static 29126 $61.11 $38.50 - - - Application of short arm splint (forearm to hand); dynamic 29130 $32.57 $23.00 - - - Application of finger splint; static 29131 $41.14 $26.65 - - - Application of finger splint; dynamic 29200 $25.91 $14.60 - - - Strapping; thorax 29240 $24.46 $14.60 - - - Strapping; shoulder (eg, Velpeau) 29260 $23.83 $15.14 - - - Strapping; elbow or wrist 29280 $24.32 $16.21 - - - Strapping; hand or finger 29305 $194.02 $124.46 - - - Application of hip spica cast; 1 leg 29325 $214.78 $139.71 - - - Application of hip spica cast; 1 and one-half spica or both legs 29345 $106.93 $78.53 - - - Application of long leg cast (thigh to toes); 29355 $111.78 $83.96 - - - Application of long leg cast (thigh to toes); walker or ambulatory type 29358 $125.94 $81.02 - - - Application of long leg cast brace 29365 $96.64 $68.52 - - - Application of cylinder cast (thigh to ankle) 29405 $63.00 $46.48 - - - Application of short leg cast (below knee to toes); 29425 $60.43 $43.62 - - - Application of short leg cast (below knee to toes); walking or ambulatory type 29435 $90.35 $64.27 - - - Application of patellar tendon bearing (PTB) cast 29440 $34.02 $22.43 - - - Adding walker to previously applied cast 29445 $102.46 $79.85 - - - Application of rigid total contact leg cast 29450 $113.02 $88.39 - - - Application of clubfoot cast with molding or manipulation, long or short leg 29505 $67.66 $39.84 - - - Application of long leg splint (thigh to ankle or toes) 29515 $55.97 $38.87 - - - Application of short leg splint (calf to foot) 29520 $27.94 $14.89 - - - Strapping; hip 29530 $24.17 $14.60 - - - Strapping; knee 29540 $22.38 $13.69 - - - Strapping; ankle and/or foot 29550 $14.95 $8.86 - - - Strapping; toes 29580 $50.46 $21.19 - - - Strapping; Unna boot 29581 $72.06 $21.62 - - - Application of multi-layer compression system; leg (below knee), including ankle and foot 29584 $67.79 $12.72 - - - Application of multi-layer compression system; upper arm, forearm, hand, and fingers 29700 $49.79 $26.02 - - - Removal or bivalving; gauntlet, boot or body cast 29705 $50.39 $35.61 - - - Removal or bivalving; full arm or full leg cast 29710 $96.36 $65.34 - - - Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. 29720 $66.73 $34.26 - - - Repair of spica, body cast or jacket 29730 $48.67 $33.89 - - - Windowing of cast 29740 $77.95 $54.76 - - - Wedging of cast (except clubfoot casts) 29750 $84.42 $61.24 - - - Wedging of clubfoot cast 29799 - - I.C. - - Unlisted procedure, casting or strapping Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate 29800 - - $418.58 - - procedure) 29804 - - $489.32 - - Arthroscopy, temporomandibular joint, surgical 29805 - - $372.69 - - Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) 29806 - - $834.86 - - Arthroscopy, shoulder, surgical; capsulorrhaphy 29807 - - $816.91 - - Arthroscopy, shoulder, surgical; repair of SLAP lesion 29819 - - $464.22 - - Arthroscopy, shoulder, surgical; with removal of loose body or foreign body 29820 - - $424.78 - - Arthroscopy, shoulder, surgical; synovectomy, partial 29821 - - $469.44 - - Arthroscopy, shoulder, surgical; synovectomy, complete 29822 - - $456.75 - - Arthroscopy, shoulder, surgical; debridement, limited 29823 - - $496.82 - - Arthroscopy, shoulder, surgical; debridement, extensive Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface 29824 - - $534.31 - - (Mumford procedure) Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without 29825 - - $464.22 - - manipulation Arthroscopy, shoulder, surgical; decompression of subacromial space with partial 29826 - - $136.43 - - acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure) 29827 - - $844.17 - - Arthroscopy, shoulder, surgical; with rotator cuff repair 29828 - - $724.97 - - Arthroscopy, shoulder, surgical; biceps tenodesis 29830 - - $361.76 - - Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure)

Page 47 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 29834 - - $390.01 - - Arthroscopy, elbow, surgical; with removal of loose body or foreign body 29835 - - $403.03 - - Arthroscopy, elbow, surgical; synovectomy, partial 29836 - - $462.54 - - Arthroscopy, elbow, surgical; synovectomy, complete 29837 - - $417.43 - - Arthroscopy, elbow, surgical; debridement, limited 29838 - - $468.82 - - Arthroscopy, elbow, surgical; debridement, extensive 29840 - - $357.95 - - Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) 29843 - - $385.08 - - Arthroscopy, wrist, surgical; for infection, lavage and drainage 29844 - - $396.15 - - Arthroscopy, wrist, surgical; synovectomy, partial 29845 - - $462.06 - - Arthroscopy, wrist, surgical; synovectomy, complete Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint 29846 - - $413.98 - - debridement 29847 - - $430.33 - - Arthroscopy, wrist, surgical; internal fixation for fracture or instability 29848 - - $404.85 - - Endoscopy, wrist, surgical, with release of transverse carpal ligament

29850 - - $493.42 - - Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy)

29851 - - $734.42 - - Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, includes 29855 - - $618.41 - - internal fixation, when performed (includes arthroscopy) Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, includes 29856 - - $781.24 - - internal fixation, when performed (includes arthroscopy) 29860 - - $527.43 - - Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) 29861 - - $569.94 - - Arthroscopy, hip, surgical; with removal of loose body or foreign body Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), 29862 - - $642.63 - - abrasion arthroplasty, and/or resection of labrum 29863 - - $644.53 - - Arthroscopy, hip, surgical; with synovectomy Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting 29866 - - $829.88 - - of the autograft[s]) 29867 - - $1,008.51 - - Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal 29868 - - $1,316.98 - - insertion), medial or lateral 29870 $458.79 $325.18 - - - Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) 29871 - - $406.96 - - Arthroscopy, knee, surgical; for infection, lavage and drainage 29873 - - $420.89 - - Arthroscopy, knee, surgical; with lateral release Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis 29874 - - $425.61 - - dissecans fragmentation, chondral fragmentation) Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate 29875 - - $393.28 - - procedure) Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or 29876 - - $516.90 - - lateral) 29877 - - $491.46 - - Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or 29879 - - $523.38 - - multiple drilling or microfracture Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal 29880 - - $444.70 - - shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal 29881 - - $428.75 - - shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed 29882 - - $547.22 - - Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 29883 - - $664.50 - - Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate 29884 - - $489.77 - - procedure) Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or 29885 - - $596.79 - - without internal fixation (including debridement of base of lesion) 29886 - - $503.43 - - Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal 29887 - - $594.11 - - fixation 29888 - - $773.44 - - Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction 29889 - - $965.39 - - Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including 29891 - - $529.46 - - drilling of the defect Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or 29892 - - $513.46 - - tibial plafond fracture, with or without internal fixation (includes arthroscopy)

Page 48 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 29893 $512.83 $340.96 - - - Endoscopic plantar fasciotomy Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or 29894 - - $393.98 - - foreign body 29895 - - $366.68 - - Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial 29897 - - $394.59 - - Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited 29898 - - $444.26 - - Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive 29899 - - $812.60 - - Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis 29900 - - $396.25 - - Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy 29901 - - $425.75 - - Arthroscopy, metacarpophalangeal joint, surgical; with debridement Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral 29902 - - $451.64 - - ligament (eg, Stenar lesion) 29904 - - $503.86 - - Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body 29905 - - $406.74 - - Arthroscopy, subtalar joint, surgical; with synovectomy 29906 - - $524.29 - - Arthroscopy, subtalar joint, surgical; with debridement 29907 - - $692.51 - - Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis 29914 - - $784.03 - - Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) 29915 - - $807.23 - - Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) 29916 - - $807.61 - - Arthroscopy, hip, surgical; with labral repair 29999 - - I.C. - - Unlisted procedure, arthroscopy 30000 $203.48 $93.34 - - - Drainage abscess or hematoma, nasal, internal approach 30020 $205.50 $93.92 - - - Drainage abscess or hematoma, nasal septum 30100 $113.95 $52.51 - - - Biopsy, intranasal 30110 $192.46 $102.03 - - - Excision, nasal polyp(s), simple 30115 - - $354.48 - - Excision, nasal polyp(s), extensive 30117 $757.21 $264.49 - - - Excision or destruction (eg, laser), intranasal lesion; internal approach 30118 - - $609.85 - - Excision or destruction (eg, laser), intranasal lesion; external approach (lateral rhinotomy) 30120 $406.79 $336.94 - - - Excision or surgical planing of skin of nose for rhinophyma 30124 - - $231.59 - - Excision dermoid cyst, nose; simple, skin, subcutaneous 30125 - - $498.11 - - Excision dermoid cyst, nose; complex, under bone or cartilage 30130 - - $316.30 - - Excision inferior turbinate, partial or complete, any method 30140 $224.93 $138.85 - - - Submucous resection inferior turbinate, partial or complete, any method 30150 - - $621.45 - - Rhinectomy; partial 30160 - - $624.66 - - Rhinectomy; total 30200 $89.76 $45.70 - - - Injection into turbinate(s), therapeutic 30210 $119.44 $78.28 - - - Displacement therapy (Proetz type) 30220 $247.22 $98.53 - - - Insertion, nasal septal prosthesis (button) 30300 $153.25 $90.35 - - - Removal foreign body, intranasal; office type procedure 30310 - - $161.91 - - Removal foreign body, intranasal; requiring general anesthesia 30320 - - $370.42 - - Removal foreign body, intranasal; by lateral rhinotomy 30400 - - $960.02 - - Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30430 - - $834.96 - - Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 - - $1,049.34 - - Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 - - $1,379.84 - - Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including 30460 - - $658.63 - - columellar lengthening; tip only Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including 30462 - - $1,265.37 - - columellar lengthening; tip, septum, osteotomies 30468 $2,431.79 $132.08 - - - Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) Septoplasty or submucous resection, with or without cartilage scoring, contouring or 30520 - - $512.92 - - replacement with graft 30540 - - $562.31 - - Repair choanal atresia; intranasal 30545 - - $765.70 - - Repair choanal atresia; transpalatine 30560 $237.69 $112.49 - - - Lysis intranasal synechia 30580 $496.42 $375.27 - - - Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) 30600 $470.54 $339.24 - - - Repair fistula; oronasal 30620 - - $509.99 - - Septal or other intranasal dermatoplasty (does not include obtaining graft) 30630 - - $512.29 - - Repair nasal septal perforations Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, 30801 $175.64 $115.36 - - - electrocautery, radiofrequency ablation, or tissue volume reduction); superficial Ablation, soft tissue of inferior turbinates, unilateral or bilateral, any method (eg, 30802 $221.44 $155.36 - - - electrocautery, radiofrequency ablation, or tissue volume reduction); intramural (ie, submucosal) 30901 $115.03 $44.02 - - - Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method 30903 $183.10 $61.08 - - - Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method

Page 49 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; 30905 $273.03 $82.61 - - - initial Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; 30906 $283.31 $105.93 - - - subsequent 30915 - - $463.19 - - Ligation arteries; ethmoidal 30920 - - $670.67 - - Ligation arteries; internal maxillary artery, transantral 30930 - - $93.65 - - Fracture nasal inferior turbinate(s), therapeutic 30999 - - I.C. - - Unlisted procedure, nose 31000 $146.18 $83.86 - - - Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) 31002 - - $150.55 - - Lavage by cannulation; sphenoid sinus 31020 $382.47 $297.84 - - - Sinusotomy, maxillary (antrotomy); intranasal Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal 31030 $517.39 $408.42 - - - polyps

31032 - - $458.89 - - Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps 31040 - - $620.76 - - Pterygomaxillary fossa surgery, any approach 31050 - - $394.51 - - Sinusotomy, sphenoid, with or without biopsy; 31051 - - $528.42 - - Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) 31070 - - $360.96 - - Sinusotomy frontal; external, simple (trephine operation) 31075 - - $632.82 - - Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) 31080 - - $833.03 - - Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) 31081 - - $894.61 - - Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) 31084 - - $926.00 - - Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision 31085 - - $955.70 - - Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision 31086 - - $901.93 - - Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow incision 31087 - - $861.33 - - Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision 31090 - - $845.26 - - Sinusotomy, unilateral, 3 or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) 31200 - - $479.43 - - Ethmoidectomy; intranasal, anterior 31201 - - $610.64 - - Ethmoidectomy; intranasal, total 31205 - - $733.30 - - Ethmoidectomy; extranasal, total 31225 - - $1,429.90 - - Maxillectomy; without orbital exenteration 31230 - - $1,583.25 - - Maxillectomy; with orbital exenteration (en bloc) 31231 $155.54 $49.46 - - - Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) Nasal/sinus endoscopy, diagnostic; with maxillary sinusoscopy (via inferior meatus or canine 31233 $209.22 $104.59 - - - fossa puncture) Nasal/sinus endoscopy, diagnostic; with sphenoid sinusoscopy (via puncture of sphenoidal face 31235 $238.15 $123.66 - - - or cannulation of ostium) Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate 31237 $201.01 $123.62 - - - procedure) 31238 $197.63 $129.81 - - - Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage 31239 - - $478.31 - - Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy 31240 - - $123.02 - - Nasal/sinus endoscopy, surgical; with concha bullosa resection 31241 - - $345.56 - - Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery

31253 - - $389.67 - - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including frontal sinus exploration, with removal of tissue from frontal sinus, when performed 31254 $334.41 $189.21 - - - Nasal/sinus endoscopy, surgical with ethmoidectomy; partial (anterior) 31255 - - $252.16 - - Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior) 31256 - - $140.27 - - Nasal/sinus endoscopy, surgical, with maxillary antrostomy; Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including 31257 - - $347.01 - - sphenoidotomy Nasal/sinus endoscopy, surgical with ethmoidectomy; total (anterior and posterior), including 31259 - - $367.26 - - sphenoidotomy, with removal of tissue from the sphenoid sinus Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from 31267 - - $206.23 - - maxillary sinus Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from 31276 - - $294.09 - - frontal sinus, when performed 31287 - - $156.77 - - Nasal/sinus endoscopy, surgical, with sphenoidotomy; Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid 31288 - - $181.89 - - sinus 31290 - - $890.46 - - Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; ethmoid region 31291 - - $950.43 - - Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region 31292 - - $774.93 - - Nasal/sinus endoscopy, surgical, with orbital decompression; medial or inferior wall 31293 - - $836.51 - - Nasal/sinus endoscopy, surgical, with orbital decompression; medial and inferior wall

Page 50 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 31294 - - $956.95 - - Nasal/sinus endoscopy, surgical, with optic nerve decompression Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, 31295 $1,543.48 $122.71 - - - transnasal or via canine fossa 31296 $1,563.39 $139.72 - - - Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium 31297 $1,532.08 $111.89 - - - Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); sphenoid sinus ostium Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus 31298 $2,945.67 $198.90 - - - ostia 31299 - - I.C. - - Unlisted procedure, accessory sinuses 31300 - - $998.33 - - Laryngotomy (thyrotomy, laryngofissure), with removal of tumor or laryngocele, cordectomy 31360 - - $1,624.50 - - Laryngectomy; total, without radical neck dissection 31365 - - $2,004.61 - - Laryngectomy; total, with radical neck dissection 31367 - - $1,721.09 - - Laryngectomy; subtotal supraglottic, without radical neck dissection 31368 - - $1,908.24 - - Laryngectomy; subtotal supraglottic, with radical neck dissection 31370 - - $1,620.41 - - Partial laryngectomy (hemilaryngectomy); horizontal 31375 - - $1,538.38 - - Partial laryngectomy (hemilaryngectomy); laterovertical 31380 - - $1,517.32 - - Partial laryngectomy (hemilaryngectomy); anterovertical 31382 - - $1,662.59 - - Partial laryngectomy (hemilaryngectomy); antero-latero-vertical 31390 - - $2,219.51 - - Pharyngolaryngectomy, with radical neck dissection; without reconstruction 31395 - - $2,342.19 - - Pharyngolaryngectomy, with radical neck dissection; with reconstruction 31400 - - $776.47 - - Arytenoidectomy or arytenoidopexy, external approach 31420 - - $645.73 - - Epiglottidectomy 31500 - - $110.69 - - Intubation, endotracheal, emergency procedure 31502 - - $27.27 - - Tracheotomy tube change prior to establishment of fistula tract 31505 $69.98 $38.38 - - - Laryngoscopy, indirect; diagnostic (separate procedure) 31510 $169.71 $94.06 - - - Laryngoscopy, indirect; with biopsy 31511 $168.31 $103.10 - - - Laryngoscopy, indirect; with removal of foreign body 31512 $167.27 $100.02 - - - Laryngoscopy, indirect; with removal of lesion 31513 - - $101.40 - - Laryngoscopy, indirect; with vocal cord injection 31515 $165.50 $85.51 - - - Laryngoscopy direct, with or without tracheoscopy; for aspiration 31520 - - $120.82 - - Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn 31525 $199.11 $124.04 - - - Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or 31526 - - $121.38 - - telescope 31527 - - $150.85 - - Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator 31528 - - $111.28 - - Laryngoscopy direct, with or without tracheoscopy; with dilation, initial 31529 - - $124.79 - - Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent 31530 - - $154.74 - - Laryngoscopy, direct, operative, with foreign body removal; Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or 31531 - - $164.06 - - telescope 31535 - - $146.48 - - Laryngoscopy, direct, operative, with biopsy; 31536 - - $162.98 - - Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or 31540 - - $187.06 - - epiglottis; Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or 31541 - - $204.06 - - epiglottis; with operating microscope or telescope Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal 31545 - - $280.10 - - removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal 31546 - - $425.20 - - removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, younger 31551 - - $1,197.35 - - than 12 years of age Laryngoplasty; for laryngeal stenosis, with graft, without indwelling stent placement, age 12 31552 - - $1,155.76 - - years or older Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, younger than 31553 - - $1,319.57 - - 12 years of age Laryngoplasty; for laryngeal stenosis, with graft, with indwelling stent placement, age 12 years 31554 - - $1,319.85 - - or older 31560 - - $242.11 - - Laryngoscopy, direct, operative, with arytenoidectomy;

31561 - - $264.03 - - Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope 31570 $268.56 $177.26 - - - Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope 31571 - - $192.71 - - or telescope 31572 $418.51 $139.98 - - - Laryngoscopy, flexible; with ablation or destruction of lesion(s) with laser, unilateral

Page 51 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Laryngoscopy, flexible; with therapeutic injection(s) (eg, chemodenervation agent or 31573 $219.24 $114.90 - - - corticosteroid, injected percutaneous, transoral, or via endoscope channel), unilateral Laryngoscopy, flexible; with injection(s) for augmentation (eg, percutaneous, transoral), 31574 $819.49 $114.90 - - - unilateral 31575 $98.30 $52.22 - - - Laryngoscopy, flexible; diagnostic 31576 $215.33 $92.15 - - - Laryngoscopy, flexible; with biopsy(ies) 31577 $223.02 $103.90 - - - Laryngoscopy, flexible; with removal of foreign body(s) 31578 $241.85 $114.61 - - - Laryngoscopy, flexible; with removal of lesion(s), non-laser 31579 $152.46 $93.05 - - - Laryngoscopy, flexible or rigid telescopic, with stroboscopy 31580 - - $1,006.46 - - Laryngoplasty; for laryngeal web, with indwelling keel or stent insertion Laryngoplasty; with open reduction and fixation of (eg, plating) fracture, includes tracheostomy, 31584 - - $1,109.99 - - if performed 31587 - - $933.98 - - Laryngoplasty, cricoid split, without graft placement 31590 - - $699.04 - - Laryngeal reinnervation by neuromuscular pedicle 31591 - - $849.85 - - Laryngoplasty, medialization, unilateral 31592 - - $1,345.76 - - Cricotracheal resection 31599 - - I.C. - - Unlisted procedure, larynx 31600 - - $239.46 - - Tracheostomy, planned (separate procedure); 31601 - - $349.91 - - Tracheostomy, planned (separate procedure); younger than 2 years 31603 - - $250.26 - - Tracheostomy, emergency procedure; transtracheal 31605 - - $259.71 - - Tracheostomy, emergency procedure; cricothyroid membrane 31610 - - $753.27 - - Tracheostomy, fenestration procedure with skin flaps Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech 31611 - - $419.71 - - prosthesis (eg, voice button, Blom-Singer prosthesis) 31612 $68.52 $36.93 - - - Tracheal puncture, percutaneous with transtracheal aspiration and/or injection 31613 - - $345.99 - - Tracheostoma revision; simple, without flap rotation 31614 - - $574.29 - - Tracheostoma revision; complex, with flap rotation 31615 $135.79 $89.42 - - - Tracheobronchoscopy through established tracheostomy incision Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, 31622 $192.27 $102.42 - - - with cell washing, when performed (separate procedure) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with brushing 31623 $214.57 $103.27 - - - or protected brushings Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31624 $200.03 $104.67 - - - bronchial alveolar lavage Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31625 $275.19 $121.57 - - - bronchial or endobronchial biopsy(s), single or multiple sites Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31626 $678.89 $153.71 - - - placement of fiducial markers, single or multiple Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31627 $1,046.67 $74.85 - - - computer-assisted, image-guided navigation (List separately in addition to code for primary procedure[s]) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31628 $291.50 $136.72 - - - transbronchial lung biopsy(s), single lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31629 $362.12 $145.04 - - - transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31630 - - $154.49 - - tracheal/bronchial dilation or closed reduction of fracture Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31631 - - $177.04 - - placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31632 $49.82 $38.51 - - - transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31633 $61.86 $49.10 - - - transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon 31634 $1,407.82 $149.07 - - - occlusion, with assessment of air leak, with administration of occlusive substance (eg, fibrin glue), if performed Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal 31635 $224.55 $136.73 - - - of foreign body Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31636 - - $170.79 - - placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus

31637 - - $59.88 - - Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; each additional major bronchus stented (List separately in addition to code for primary procedure)

Page 52 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with revision 31638 - - $193.49 - - of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with excision 31640 - - $194.66 - - of tumor Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31641 - - $198.98 - - destruction of tumor or relief of stenosis by any method other than excision (eg, laser therapy, cryotherapy) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31643 - - $136.25 - - placement of catheter(s) for intracavitary radioelement application Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31645 $209.71 $114.36 - - - therapeutic aspiration of tracheobronchial tree, initial Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31646 - - $110.35 - - therapeutic aspiration of tracheobronchial tree, subsequent, same hospital stay Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon 31647 - - $163.76 - - occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), initial lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal 31648 - - $155.55 - - of bronchial valve(s), initial lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with removal 31649 - - $52.49 - - of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure)

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with balloon 31651 - - $57.36 - - occlusion, when performed, assessment of air leak, airway sizing, and insertion of bronchial valve(s), each additional lobe (List separately in addition to code for primary procedure[s])

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31652 $893.32 $172.21 - - - endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), one or two mediastinal and/or hilar lymph node stations or structures

Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31653 $930.99 $191.04 - - - endobronchial ultrasound (EBUS) guided transtracheal and/or transbronchial sampling (eg, aspiration[s]/biopsy[ies]), 3 or more mediastinal and/or hilar lymph node stations or structures Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with transendoscopic endobronchial ultrasound (EBUS) during bronchoscopic diagnostic or 31654 $96.93 $52.29 - - - therapeutic intervention(s) for peripheral lesion(s) (List separately in addition to code for primary procedure[s]) Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31660 - - $151.42 - - bronchial thermoplasty, 1 lobe Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with 31661 - - $160.58 - - bronchial thermoplasty, 2 or more lobes 31717 $219.03 $82.52 - - - Catheterization with bronchial brush biopsy 31720 - - $42.99 - - Catheter aspiration (separate procedure); nasotracheal 31725 - - $60.87 - - Catheter aspiration (separate procedure); tracheobronchial with fiberscope, bedside Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for 31730 $971.42 $116.11 - - - oxygen therapy 31755 - - $1,371.90 - - Tracheoplasty; tracheopharyngeal fistulization, each stage 31760 - - $1,067.13 - - Tracheoplasty; intrathoracic 31766 - - $1,378.52 - - Carinal reconstruction 31770 - - $1,032.11 - - Bronchoplasty; graft repair 31775 - - $1,084.82 - - Bronchoplasty; excision stenosis and anastomosis 31780 - - $931.09 - - Excision tracheal stenosis and anastomosis; cervical 31781 - - $1,074.30 - - Excision tracheal stenosis and anastomosis; cervicothoracic 31785 - - $837.15 - - Excision of tracheal tumor or carcinoma; cervical 31786 - - $1,118.68 - - Excision of tracheal tumor or carcinoma; thoracic 31800 - - $564.97 - - Suture of tracheal wound or injury; cervical 31805 - - $636.06 - - Suture of tracheal wound or injury; intrathoracic 31820 $345.61 $256.34 - - - Surgical closure tracheostomy or fistula; without plastic repair 31825 $475.25 $374.67 - - - Surgical closure tracheostomy or fistula; with plastic repair 31830 $369.55 $277.67 - - - Revision of tracheostomy scar 31899 - - I.C. - - Unlisted procedure, trachea, bronchi 32035 - - $569.30 - - Thoracostomy; with rib resection for empyema 32036 - - $609.30 - - Thoracostomy; with open flap drainage for empyema 32096 - - $623.23 - - Thoracotomy, with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral

Page 53 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Thoracotomy, with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), 32097 - - $623.81 - - unilateral 32098 - - $591.52 - - Thoracotomy, with biopsy(ies) of pleura 32100 - - $630.18 - - Thoracotomy; with exploration 32110 - - $1,141.35 - - Thoracotomy; with control of traumatic hemorrhage and/or repair of lung tear 32120 - - $680.35 - - Thoracotomy; for postoperative complications 32124 - - $721.55 - - Thoracotomy; with open intrapleural pneumonolysis 32140 - - $770.60 - - Thoracotomy; with cyst(s) removal, includes pleural procedure when performed Thoracotomy; with resection-plication of bullae, includes any pleural procedure when 32141 - - $1,181.88 - - performed 32150 - - $781.82 - - Thoracotomy; with removal of intrapleural foreign body or fibrin deposit 32151 - - $781.81 - - Thoracotomy; with removal of intrapulmonary foreign body 32160 - - $620.37 - - Thoracotomy; with cardiac massage 32200 - - $885.34 - - Pneumonostomy, with open drainage of abscess or cyst 32215 - - $621.95 - - Pleural scarification for repeat pneumothorax 32220 - - $1,237.54 - - Decortication, pulmonary (separate procedure); total 32225 - - $774.14 - - Decortication, pulmonary (separate procedure); partial 32310 - - $710.35 - - Pleurectomy, parietal (separate procedure) 32320 - - $1,242.68 - - Decortication and parietal pleurectomy 32400 $127.17 $66.88 - - - Biopsy, pleura, percutaneous needle Core needle biopsy, lung or mediastinum, percutaneous, including imaging guidance, when 32408 $796.68 $119.54 - - - performed 32440 - - $1,216.61 - - Removal of lung, pneumonectomy; Removal of lung, pneumonectomy; with resection of segment of trachea followed by broncho- 32442 - - $2,371.38 - - tracheal anastomosis (sleeve pneumonectomy) 32445 - - $2,741.26 - - Removal of lung, pneumonectomy; extrapleural 32480 - - $1,148.89 - - Removal of lung, other than pneumonectomy; single lobe (lobectomy) 32482 - - $1,232.13 - - Removal of lung, other than pneumonectomy; 2 lobes (bilobectomy) 32484 - - $1,112.36 - - Removal of lung, other than pneumonectomy; single segment (segmentectomy) Removal of lung, other than pneumonectomy; with circumferential resection of segment of 32486 - - $1,824.24 - - bronchus followed by broncho-bronchial anastomosis (sleeve lobectomy) Removal of lung, other than pneumonectomy; with all remaining lung following previous 32488 - - $1,855.49 - - removal of a portion of lung (completion pneumonectomy) Removal of lung, other than pneumonectomy; with resection-plication of emphysematous 32491 - - $1,143.36 - - lung(s) (bullous or non-bullous) for lung volume reduction, sternal split or transthoracic approach, includes any pleural procedure, when performed Resection and repair of portion of bronchus (bronchoplasty) when performed at time of 32501 - - $187.82 - - lobectomy or segmentectomy (List separately in addition to code for primary procedure)

32503 - - $1,393.95 - - Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) resection(s), neurovascular dissection, when performed; without chest wall reconstruction(s) Resection of apical lung tumor (eg, Pancoast tumor), including chest wall resection, rib(s) 32504 - - $1,587.34 - - resection(s), neurovascular dissection, when performed; with chest wall reconstruction 32505 - - $724.84 - - Thoracotomy; with therapeutic wedge resection (eg, mass, nodule), initial Thoracotomy; with therapeutic wedge resection (eg, mass or nodule), each additional 32506 - - $120.66 - - resection, ipsilateral (List separately in addition to code for primary procedure) Thoracotomy; with diagnostic wedge resection followed by anatomic lung resection (List 32507 - - $120.66 - - separately in addition to code for primary procedure) 32540 - - $1,346.49 - - Extrapleural enucleation of empyema (empyemectomy) 32550 $638.67 $161.02 - - - Insertion of indwelling tunneled pleural catheter with cuff Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, 32551 - - $122.31 - - open (separate procedure) 32552 $145.24 $124.09 - - - Removal of indwelling tunneled pleural catheter with cuff Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, 32553 $427.49 $139.69 - - - dosimeter), percutaneous, intra-thoracic, single or multiple

32554 $178.14 $69.74 - - - Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance 32555 $250.07 $86.90 - - - Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance

32556 $544.74 $95.78 - - - Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance

32557 $499.78 $118.65 - - - Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance Instillation, via chest tube/catheter, agent for pleurodesis (eg, talc for recurrent or persistent 32560 $209.04 $60.35 - - - pneumothorax) Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up 32561 $73.10 $52.52 - - - of multiloculated effusion); initial day

Page 54 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Instillation(s), via chest tube/catheter, agent for fibrinolysis (eg, fibrinolytic agent for break up 32562 $65.93 $47.09 - - - of multiloculated effusion); subsequent day Thoracoscopy, diagnostic (separate procedure); lungs, pericardial sac, mediastinal or pleural 32601 - - $239.68 - - space, without biopsy 32604 - - $371.54 - - Thoracoscopy, diagnostic (separate procedure); pericardial sac, with biopsy 32606 - - $358.59 - - Thoracoscopy, diagnostic (separate procedure); mediastinal space, with biopsy 32607 - - $239.39 - - Thoracoscopy; with diagnostic biopsy(ies) of lung infiltrate(s) (eg, wedge, incisional), unilateral Thoracoscopy; with diagnostic biopsy(ies) of lung nodule(s) or mass(es) (eg, wedge, incisional), 32608 - - $293.83 - - unilateral 32609 - - $199.82 - - Thoracoscopy; with biopsy(ies) of pleura 32650 - - $519.27 - - Thoracoscopy, surgical; with pleurodesis (eg, mechanical or chemical) 32651 - - $851.34 - - Thoracoscopy, surgical; with partial pulmonary decortication Thoracoscopy, surgical; with total pulmonary decortication, including intrapleural 32652 - - $1,289.74 - - pneumonolysis 32653 - - $825.78 - - Thoracoscopy, surgical; with removal of intrapleural foreign body or fibrin deposit 32654 - - $903.73 - - Thoracoscopy, surgical; with control of traumatic hemorrhage Thoracoscopy, surgical; with resection-plication of bullae, includes any pleural procedure when 32655 - - $743.27 - - performed 32656 - - $624.84 - - Thoracoscopy, surgical; with parietal pleurectomy 32658 - - $556.18 - - Thoracoscopy, surgical; with removal of clot or foreign body from pericardial sac Thoracoscopy, surgical; with creation of pericardial window or partial resection of pericardial 32659 - - $570.21 - - sac for drainage 32661 - - $621.05 - - Thoracoscopy, surgical; with excision of pericardial cyst, tumor, or mass 32662 - - $694.14 - - Thoracoscopy, surgical; with excision of mediastinal cyst, tumor, or mass 32663 - - $1,086.14 - - Thoracoscopy, surgical; with lobectomy (single lobe) 32664 - - $659.17 - - Thoracoscopy, surgical; with thoracic sympathectomy 32665 - - $956.52 - - Thoracoscopy, surgical; with esophagomyotomy (Heller type)

32666 - - $676.47 - - Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass, nodule), initial unilateral Thoracoscopy, surgical; with therapeutic wedge resection (eg, mass or nodule), each additional 32667 - - $120.95 - - resection, ipsilateral (List separately in addition to code for primary procedure) Thoracoscopy, surgical; with diagnostic wedge resection followed by anatomic lung resection 32668 - - $120.95 - - (List separately in addition to code for primary procedure) 32669 - - $1,043.35 - - Thoracoscopy, surgical; with removal of a single lung segment (segmentectomy) 32670 - - $1,244.90 - - Thoracoscopy, surgical; with removal of two lobes (bilobectomy) 32671 - - $1,376.81 - - Thoracoscopy, surgical; with removal of lung (pneumonectomy) Thoracoscopy, surgical; with resection-plication for emphysematous lung (bullous or non- 32672 - - $1,181.96 - - bullous) for lung volume reduction (LVRS), unilateral includes any pleural procedure, when performed 32673 - - $945.78 - - Thoracoscopy, surgical; with resection of thymus, unilateral or bilateral Thoracoscopy, surgical; with mediastinal and regional lymphadenectomy (List separately in 32674 - - $166.26 - - addition to code for primary procedure) Thoracic target(s) delineation for stereotactic body radiation therapy (SRS/SBRT), (photon or 32701 - - $165.67 - - particle beam), entire course of treatment 32800 - - $736.18 - - Repair lung hernia through chest wall 32810 - - $700.91 - - Closure of chest wall following open flap drainage for empyema (Clagett type procedure) 32815 - - $2,170.76 - - Open closure of major bronchial fistula 32820 - - $1,034.27 - - Major reconstruction, chest wall (posttraumatic) 32850 - - I.C. - - Donor pneumonectomy(s) (including cold preservation), from cadaver donor 32851 - - $2,540.92 - - Lung transplant, single; without cardiopulmonary bypass 32852 - - $2,758.27 - - Lung transplant, single; with cardiopulmonary bypass 32853 - - $3,556.51 - - Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass 32854 - - $3,776.25 - - Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass Backbench standard preparation of cadaver donor lung allograft prior to transplantation, 32855 - - I.C. - - including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral Backbench standard preparation of cadaver donor lung allograft prior to transplantation, 32856 - - I.C. - - including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral 32900 - - $1,106.45 - - Resection of ribs, extrapleural, all stages 32905 - - $1,036.52 - - Thoracoplasty, Schede type or extrapleural (all stages); 32906 - - $1,279.25 - - Thoracoplasty, Schede type or extrapleural (all stages); with closure of bronchopleural fistula 32940 - - $957.84 - - Pneumonolysis, extraperiosteal, including filling or packing procedures 32960 $99.53 $70.83 - - - Pneumothorax, therapeutic, intrapleural injection of air

Page 55 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura 32994 $4,489.04 $345.26 - - - or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; cryoablation 32997 - - $264.86 - - Total lung lavage (unilateral) Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura 32998 $2,860.16 $344.39 - - - or chest wall when involved by tumor extension, percutaneous, including imaging guidance when performed, unilateral; radiofrequency 32999 - - I.C. - - Unlisted procedure, lungs and pleura 33016 - - $183.59 - - Pericardiocentesis, including imaging guidance, when performed Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy 33017 - - $190.38 - - and/or ultrasound guidance, when performed; 6 years and older without congenital cardiac anomaly Pericardial drainage with insertion of indwelling catheter, percutaneous, including fluoroscopy 33018 - - $217.07 - - and/or ultrasound guidance, when performed; birth through 5 years of age or any age with congenital cardiac anomaly

33019 - - $176.24 - - Pericardial drainage with insertion of indwelling catheter, percutaneous, including CT guidance 33020 - - $642.58 - - Pericardiotomy for removal of clot or foreign body (primary procedure) 33025 - - $599.23 - - Creation of pericardial window or partial resection for drainage 33030 - - $1,552.04 - - Pericardiectomy, subtotal or complete; without cardiopulmonary bypass 33031 - - $1,921.41 - - Pericardiectomy, subtotal or complete; with cardiopulmonary bypass 33050 - - $781.74 - - Resection of pericardial cyst or tumor 33120 - - $1,625.08 - - Excision of intracardiac tumor, resection with cardiopulmonary bypass 33130 - - $1,062.13 - - Resection of external cardiac tumor 33140 - - $1,210.01 - - Transmyocardial laser revascularization, by thoracotomy; (separate procedure) Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open 33141 - - $101.91 - - cardiac procedure(s) (List separately in addition to code for primary procedure) Insertion of epicardial electrode(s); open incision (eg, thoracotomy, median sternotomy, 33202 - - $599.81 - - subxiphoid approach)

33203 - - $627.35 - - Insertion of epicardial electrode(s); endoscopic approach (eg, thoracoscopy, pericardioscopy)

33206 - - $357.35 - - Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); 33207 - - $376.54 - - ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial 33208 - - $409.08 - - and ventricular Insertion or replacement of temporary transvenous single chamber cardiac electrode or 33210 - - $127.10 - - pacemaker catheter (separate procedure) Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate 33211 - - $131.42 - - procedure) 33212 - - $252.82 - - Insertion of pacemaker pulse generator only; with existing single lead 33213 - - $263.77 - - Insertion of pacemaker pulse generator only; with existing dual leads Upgrade of implanted pacemaker system, conversion of single chamber system to dual 33214 - - $376.37 - - chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) Repositioning of previously implanted transvenous pacemaker or implantable defibrillator 33215 - - $244.15 - - (right atrial or right ventricular) electrode

33216 - - $293.30 - - Insertion of a single transvenous electrode, permanent pacemaker or implantable defibrillator 33217 - - $288.78 - - Insertion of 2 transvenous electrodes, permanent pacemaker or implantable defibrillator 33218 - - $304.60 - - Repair of single transvenous electrode, permanent pacemaker or implantable defibrillator 33220 - - $295.77 - - Repair of 2 transvenous electrodes for permanent pacemaker or implantable defibrillator 33221 - - $284.82 - - Insertion of pacemaker pulse generator only; with existing multiple leads 33222 - - $268.46 - - Relocation of skin pocket for pacemaker 33223 - - $322.59 - - Relocation of skin pocket for implantable defibrillator Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with 33224 - - $403.05 - - attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of 33225 - - $366.83 - - insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure) Repositioning of previously implanted cardiac venous system (left ventricular) electrode 33226 - - $387.35 - - (including removal, insertion and/or replacement of existing generator) Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse 33227 - - $266.45 - - generator; single lead system

Page 56 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse 33228 - - $278.81 - - generator; dual lead system Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse 33229 - - $295.06 - - generator; multiple lead system 33230 - - $300.57 - - Insertion of implantable defibrillator pulse generator only; with existing dual leads 33231 - - $316.02 - - Insertion of implantable defibrillator pulse generator only; with existing multiple leads 33233 - - $182.83 - - Removal of permanent pacemaker pulse generator only 33234 - - $381.95 - - Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular 33235 - - $502.01 - - Removal of transvenous pacemaker electrode(s); dual lead system Removal of permanent epicardial pacemaker and electrodes by thoracotomy; single lead 33236 - - $609.38 - - system, atrial or ventricular

33237 - - $653.15 - - Removal of permanent epicardial pacemaker and electrodes by thoracotomy; dual lead system 33238 - - $733.82 - - Removal of permanent transvenous electrode(s) by thoracotomy 33240 - - $286.88 - - Insertion of implantable defibrillator pulse generator only; with existing single lead 33241 - - $169.30 - - Removal of implantable defibrillator pulse generator only 33243 - - $1,066.85 - - Removal of single or dual chamber implantable defibrillator electrode(s); by thoracotomy Removal of single or dual chamber implantable defibrillator electrode(s); by transvenous 33244 - - $680.15 - - extraction Insertion or replacement of permanent implantable defibrillator system, with transvenous 33249 - - $720.07 - - lead(s), single or dual chamber Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson- 33250 - - $1,130.95 - - White, atrioventricular node re-entry), tract(s) and/or focus (foci); without cardiopulmonary bypass

33251 - - $1,263.53 - - Operative ablation of supraventricular arrhythmogenic focus or pathway (eg, Wolff-Parkinson- White, atrioventricular node re-entry), tract(s) and/or focus (foci); with cardiopulmonary bypass

33254 - - $1,050.71 - - Operative tissue ablation and reconstruction of atria, limited (eg, modified maze procedure) Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); without 33255 - - $1,263.84 - - cardiopulmonary bypass Operative tissue ablation and reconstruction of atria, extensive (eg, maze procedure); with 33256 - - $1,504.53 - - cardiopulmonary bypass Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac 33257 - - $453.49 - - procedure(s), limited (eg, modified maze procedure) (List separately in addition to code for primary procedure) Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac 33258 - - $506.16 - - procedure(s), extensive (eg, maze procedure), without cardiopulmonary bypass (List separately in addition to code for primary procedure) Operative tissue ablation and reconstruction of atria, performed at the time of other cardiac 33259 - - $657.65 - - procedure(s), extensive (eg, maze procedure), with cardiopulmonary bypass (List separately in addition to code for primary procedure) 33261 - - $1,251.76 - - Operative ablation of ventricular arrhythmogenic focus with cardiopulmonary bypass Removal of implantable defibrillator pulse generator with replacement of implantable 33262 - - $293.85 - - defibrillator pulse generator; single lead system Removal of implantable defibrillator pulse generator with replacement of implantable 33263 - - $305.43 - - defibrillator pulse generator; dual lead system Removal of implantable defibrillator pulse generator with replacement of implantable 33264 - - $319.14 - - defibrillator pulse generator; multiple lead system Endoscopy, surgical; operative tissue ablation and reconstruction of atria, limited (eg, modified 33265 - - $1,056.53 - - maze procedure), without cardiopulmonary bypass Endoscopy, surgical; operative tissue ablation and reconstruction of atria, extensive (eg, maze 33266 - - $1,433.69 - - procedure), without cardiopulmonary bypass Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, 33270 - - $444.88 - - evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed 33271 - - $355.68 - - Insertion of subcutaneous implantable defibrillator electrode 33272 - - $273.19 - - Removal of subcutaneous implantable defibrillator electrode 33273 - - $313.42 - - Repositioning of previously implanted subcutaneous implantable defibrillator electrode Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, 33274 - - $382.34 - - including imaging guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging 33275 - - $418.00 - - guidance (eg, fluoroscopy, venous ultrasound, ventriculography, femoral venography), when performed

Page 57 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 33285 $4,138.20 $69.20 - - - Insertion, subcutaneous cardiac rhythm monitor, including programming 33286 $105.21 $68.11 - - - Removal, subcutaneous cardiac rhythm monitor Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart 33289 - - $256.42 - - catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed 33300 - - $1,902.84 - - Repair of cardiac wound; without bypass 33305 - - $3,178.90 - - Repair of cardiac wound; with cardiopulmonary bypass Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); 33310 - - $908.85 - - without bypass Cardiotomy, exploratory (includes removal of foreign body, atrial or ventricular thrombus); with 33315 - - $1,484.42 - - cardiopulmonary bypass 33320 - - $818.27 - - Suture repair of aorta or great vessels; without shunt or cardiopulmonary bypass 33321 - - $923.14 - - Suture repair of aorta or great vessels; with shunt bypass 33322 - - $1,080.71 - - Suture repair of aorta or great vessels; with cardiopulmonary bypass 33330 - - $1,106.70 - - Insertion of graft, aorta or great vessels; without shunt, or cardiopulmonary bypass 33335 - - $1,451.46 - - Insertion of graft, aorta or great vessels; with cardiopulmonary bypass Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left 33340 - - $616.33 - - atrial appendage angiography, when performed, and radiological supervision and interpretation Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; percutaneous 33361 - - $941.30 - - femoral artery approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open femoral artery 33362 - - $1,025.21 - - approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open axillary artery 33363 - - $1,062.98 - - approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; open iliac artery 33364 - - $1,061.42 - - approach Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transaortic approach 33365 - - $1,124.66 - - (eg, median sternotomy, mediastinotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; transapical exposure 33366 - - $1,223.21 - - (eg, left thoracotomy) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary 33367 - - $488.67 - - bypass support with percutaneous peripheral arterial and venous cannulation (eg, femoral vessels) (List separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary 33368 - - $575.19 - - bypass support with open peripheral arterial and venous cannulation (eg, femoral, iliac, axillary vessels) (List separately in addition to code for primary procedure) Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary 33369 - - $759.21 - - bypass support with central arterial and venous cannulation (eg, aorta, right atrium, pulmonary artery) (List separately in addition to code for primary procedure) Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; simple (ie, valvotomy, 33390 - - $1,498.73 - - debridement, debulking, and/or simple commissural resuspension) Valvuloplasty, aortic valve, open, with cardiopulmonary bypass; complex (eg, leaflet extension, 33391 - - $1,781.06 - - leaflet resection, leaflet reconstruction, or annuloplasty) 33404 - - $1,358.29 - - Construction of apical-aortic conduit Replacement, aortic valve, open, with cardiopulmonary bypass; with prosthetic valve other 33405 - - $1,762.29 - - than homograft or stentless valve

33406 - - $2,235.19 - - Replacement, aortic valve, open, with cardiopulmonary bypass; with allograft valve (freehand) 33410 - - $1,974.27 - - Replacement, aortic valve, open, with cardiopulmonary bypass; with stentless tissue valve 33411 - - $2,606.60 - - Replacement, aortic valve; with aortic annulus enlargement, noncoronary sinus 33412 - - $2,445.97 - - Replacement, aortic valve; with transventricular aortic annulus enlargement (Konno procedure) Replacement, aortic valve; by translocation of autologous pulmonary valve with allograft 33413 - - $2,505.15 - - replacement of pulmonary valve (Ross procedure)

33414 - - $1,666.77 - - Repair of left ventricular outflow tract obstruction by patch enlargement of the outflow tract 33415 - - $1,576.75 - - Resection or incision of subvalvular tissue for discrete subvalvular aortic stenosis Ventriculomyotomy (-myectomy) for idiopathic hypertrophic subaortic stenosis (eg, asymmetric 33416 - - $1,569.77 - - septal hypertrophy) 33417 - - $1,295.69 - - Aortoplasty (gusset) for supravalvular stenosis Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when 33418 - - $1,400.90 - - performed; initial prosthesis

Page 58 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when 33419 - - $329.99 - - performed; additional prosthesis(es) during same session (List separately in addition to code for primary procedure) 33420 - - $1,127.01 - - Valvotomy, mitral valve; closed heart 33422 - - $1,292.97 - - Valvotomy, mitral valve; open heart, with cardiopulmonary bypass 33425 - - $2,120.35 - - Valvuloplasty, mitral valve, with cardiopulmonary bypass; 33426 - - $1,849.49 - - Valvuloplasty, mitral valve, with cardiopulmonary bypass; with prosthetic ring Valvuloplasty, mitral valve, with cardiopulmonary bypass; radical reconstruction, with or 33427 - - $1,895.82 - - without ring 33430 - - $2,174.74 - - Replacement, mitral valve, with cardiopulmonary bypass Replacement, aortic valve; by translocation of autologous pulmonary valve and transventricular 33440 - - $2,658.83 - - aortic annulus enlargement of the left ventricular outflow tract with valved conduit replacement of pulmonary valve (Ross-Konno procedure) 33460 - - $1,864.61 - - Valvectomy, tricuspid valve, with cardiopulmonary bypass 33463 - - $2,396.46 - - Valvuloplasty, tricuspid valve; without ring insertion 33464 - - $1,895.15 - - Valvuloplasty, tricuspid valve; with ring insertion 33465 - - $2,139.69 - - Replacement, tricuspid valve, with cardiopulmonary bypass 33468 - - $1,901.64 - - Tricuspid valve repositioning and plication for Ebstein anomaly 33470 - - $962.87 - - Valvotomy, pulmonary valve, closed heart; transventricular 33471 - - $1,029.73 - - Valvotomy, pulmonary valve, closed heart; via pulmonary artery 33474 - - $1,690.71 - - Valvotomy, pulmonary valve, open heart, with cardiopulmonary bypass 33475 - - $1,811.18 - - Replacement, pulmonary valve 33476 - - $1,183.33 - - Right ventricular resection for infundibular stenosis, with or without commissurotomy Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of 33477 - - $1,055.94 - - the valve delivery site, when performed Outflow tract augmentation (gusset), with or without commissurotomy or infundibular 33478 - - $1,222.57 - - resection Repair of non-structural prosthetic valve dysfunction with cardiopulmonary bypass (separate 33496 - - $1,293.24 - - procedure) Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary 33500 - - $1,213.04 - - bypass Repair of coronary arteriovenous or arteriocardiac chamber fistula; without cardiopulmonary 33501 - - $867.89 - - bypass 33502 - - $993.39 - - Repair of anomalous coronary artery from pulmonary artery origin; by ligation Repair of anomalous coronary artery from pulmonary artery origin; by graft, without 33503 - - $1,032.54 - - cardiopulmonary bypass Repair of anomalous coronary artery from pulmonary artery origin; by graft, with 33504 - - $1,139.70 - - cardiopulmonary bypass Repair of anomalous coronary artery from pulmonary artery origin; with construction of 33505 - - $1,599.34 - - intrapulmonary artery tunnel (Takeuchi procedure) Repair of anomalous coronary artery from pulmonary artery origin; by translocation from 33506 - - $1,592.87 - - pulmonary artery to aorta Repair of anomalous (eg, intramural) aortic origin of coronary artery by unroofing or 33507 - - $1,336.60 - - translocation Endoscopy, surgical, including video-assisted harvest of vein(s) for coronary artery bypass 33508 - - $12.79 - - procedure (List separately in addition to code for primary procedure) 33510 - - $1,502.59 - - Coronary artery bypass, vein only; single coronary venous graft 33511 - - $1,649.05 - - Coronary artery bypass, vein only; 2 coronary venous grafts 33512 - - $1,877.69 - - Coronary artery bypass, vein only; 3 coronary venous grafts 33513 - - $1,926.63 - - Coronary artery bypass, vein only; 4 coronary venous grafts 33514 - - $2,025.66 - - Coronary artery bypass, vein only; 5 coronary venous grafts 33516 - - $2,099.69 - - Coronary artery bypass, vein only; 6 or more coronary venous grafts Coronary artery bypass, using venous graft(s) and arterial graft(s); single vein graft (List 33517 - - $145.15 - - separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); 2 venous grafts (List 33518 - - $318.77 - - separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); 3 venous grafts (List 33519 - - $421.54 - - separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); 4 venous grafts (List 33521 - - $506.01 - - separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); 5 venous grafts (List 33522 - - $567.09 - - separately in addition to code for primary procedure) Coronary artery bypass, using venous graft(s) and arterial graft(s); 6 or more venous grafts (List 33523 - - $644.35 - - separately in addition to code for primary procedure) Reoperation, coronary artery bypass procedure or valve procedure, more than 1 month after 33530 - - $407.09 - - original operation (List separately in addition to code for primary procedure)

Page 59 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 33533 - - $1,453.21 - - Coronary artery bypass, using arterial graft(s); single arterial graft 33534 - - $1,706.94 - - Coronary artery bypass, using arterial graft(s); 2 coronary arterial grafts 33535 - - $1,902.72 - - Coronary artery bypass, using arterial graft(s); 3 coronary arterial grafts 33536 - - $2,049.77 - - Coronary artery bypass, using arterial graft(s); 4 or more coronary arterial grafts 33542 - - $2,039.21 - - Myocardial resection (eg, ventricular aneurysmectomy) 33545 - - $2,383.69 - - Repair of postinfarction ventricular septal defect, with or without myocardial resection Surgical ventricular restoration procedure, includes prosthetic patch, when performed (eg, 33548 - - $2,298.07 - - ventricular remodeling, SVR, SAVER, Dor procedures) Coronary endarterectomy, open, any method, of left anterior descending, circumflex, or right 33572 - - $178.15 - - coronary artery performed in conjunction with coronary artery bypass graft procedure, each vessel (List separately in addition to primary procedure) 33600 - - $1,334.95 - - Closure of atrioventricular valve (mitral or tricuspid) by suture or patch 33602 - - $1,296.25 - - Closure of semilunar valve (aortic or pulmonary) by suture or patch 33606 - - $1,381.32 - - Anastomosis of pulmonary artery to aorta (Damus-Kaye-Stansel procedure)

33608 - - $1,398.94 - - Repair of complex cardiac anomaly other than pulmonary atresia with ventricular septal defect by construction or replacement of conduit from right or left ventricle to pulmonary artery Repair of complex cardiac anomalies (eg, single ventricle with subaortic obstruction) by surgical 33610 - - $1,379.21 - - enlargement of ventricular septal defect 33611 - - $1,513.91 - - Repair of double outlet right ventricle with intraventricular tunnel repair; Repair of double outlet right ventricle with intraventricular tunnel repair; with repair of right 33612 - - $1,553.93 - - ventricular outflow tract obstruction Repair of complex cardiac anomalies (eg, tricuspid atresia) by closure of atrial septal defect and 33615 - - $1,550.53 - - anastomosis of atria or vena cava to pulmonary artery (simple Fontan procedure) 33617 - - $1,679.57 - - Repair of complex cardiac anomalies (eg, single ventricle) by modified Fontan procedure Repair of single ventricle with aortic outflow obstruction and aortic arch hypoplasia 33619 - - $2,127.72 - - (hypoplastic left heart syndrome) (eg, Norwood procedure) 33620 - - $1,280.04 - - Application of right and left pulmonary artery bands (eg, hybrid approach stage 1) Transthoracic insertion of catheter for stent placement with catheter removal and closure (eg, 33621 - - $723.53 - - hybrid approach stage 1)

Reconstruction of complex cardiac anomaly (eg, single ventricle or hypoplastic left heart) with 33622 - - $2,663.88 - - palliation of single ventricle with aortic outflow obstruction and aortic arch hypoplasia, creation of cavopulmonary anastomosis, and removal of right and left pulmonary bands (eg, hybrid approach stage 2, Norwood, bidirectional Glenn, pulmonary artery debanding) 33641 - - $1,272.49 - - Repair atrial septal defect, secundum, with cardiopulmonary bypass, with or without patch 33645 - - $1,343.89 - - Direct or patch closure, sinus venosus, with or without anomalous pulmonary venous drainage 33647 - - $1,410.13 - - Repair of atrial septal defect and ventricular septal defect, with direct or patch closure Repair of incomplete or partial atrioventricular canal (ostium primum atrial septal defect), with 33660 - - $1,363.46 - - or without atrioventricular valve repair Repair of intermediate or transitional atrioventricular canal, with or without atrioventricular 33665 - - $1,484.80 - - valve repair 33670 - - $1,529.69 - - Repair of complete atrioventricular canal, with or without prosthetic valve 33675 - - $1,529.71 - - Closure of multiple ventricular septal defects; Closure of multiple ventricular septal defects; with pulmonary valvotomy or infundibular 33676 - - $1,569.74 - - resection (acyanotic) Closure of multiple ventricular septal defects; with removal of pulmonary artery band, with or 33677 - - $1,631.05 - - without gusset 33681 - - $1,431.31 - - Closure of single ventricular septal defect, with or without patch; Closure of single ventricular septal defect, with or without patch; with pulmonary valvotomy or 33684 - - $1,465.61 - - infundibular resection (acyanotic) Closure of single ventricular septal defect, with or without patch; with removal of pulmonary 33688 - - $1,461.42 - - artery band, with or without gusset 33690 - - $934.52 - - Banding of pulmonary artery 33692 - - $1,517.20 - - Complete repair tetralogy of Fallot without pulmonary atresia; 33694 - - $1,513.91 - - Complete repair tetralogy of Fallot without pulmonary atresia; with transannular patch Complete repair tetralogy of Fallot with pulmonary atresia including construction of conduit 33697 - - $1,594.45 - - from right ventricle to pulmonary artery and closure of ventricular septal defect 33702 - - $1,201.88 - - Repair sinus of Valsalva fistula, with cardiopulmonary bypass; Repair sinus of Valsalva fistula, with cardiopulmonary bypass; with repair of ventricular septal 33710 - - $1,591.04 - - defect 33720 - - $1,202.66 - - Repair sinus of Valsalva aneurysm, with cardiopulmonary bypass 33722 - - $1,263.66 - - Closure of aortico-left ventricular tunnel 33724 - - $1,194.63 - - Repair of isolated partial anomalous pulmonary venous return (eg, Scimitar Syndrome) 33726 - - $1,576.68 - - Repair of pulmonary venous stenosis

Page 60 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Complete repair of anomalous pulmonary venous return (supracardiac, intracardiac, or 33730 - - $1,556.94 - - infracardiac types) 33732 - - $1,281.27 - - Repair of cor triatriatum or supravalvular mitral ring by resection of left atrial membrane 33735 - - $1,008.40 - - Atrial septectomy or septostomy; closed heart (Blalock-Hanlon type operation) 33736 - - $1,094.02 - - Atrial septectomy or septostomy; open heart with cardiopulmonary bypass 33737 - - $1,009.49 - - Atrial septectomy or septostomy; open heart, with inflow occlusion Transcatheter atrial septostomy (TAS) for congenital cardiac anomalies to create effective atrial 33741 - - $585.82 - - flow, including all imaging guidance by the proceduralist, when performed, any method (eg, Rashkind, Sang-Park, balloon, cutting balloon, blade) Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac catherization for 33745 - - $829.79 - - congenital cardiac anomalies, and target zone angioplasty, when performed (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); initial intracardiac shunt

Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the 33746 - - $328.55 - - proceduralist, when performed, left and right heart diagnostic cardiac catherization for congenital cardiac anomalies, and target zone angioplasty, when performed (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); each additional intracardiac shunt location (List separately in addition to code for primary procedure) 33750 - - $981.97 - - Shunt; subclavian to pulmonary artery (Blalock-Taussig type operation) 33755 - - $1,024.69 - - Shunt; ascending aorta to pulmonary artery (Waterston type operation) 33762 - - $997.15 - - Shunt; descending aorta to pulmonary artery (Potts-Smith type operation) 33764 - - $1,024.69 - - Shunt; central, with prosthetic graft

33766 - - $1,036.88 - - Shunt; superior vena cava to pulmonary artery for flow to 1 lung (classical Glenn procedure) Shunt; superior vena cava to pulmonary artery for flow to both lungs (bidirectional Glenn 33767 - - $1,105.25 - - procedure) Anastomosis, cavopulmonary, second superior vena cava (List separately in addition to primary 33768 - - $322.27 - - procedure) Repair of transposition of the great arteries with ventricular septal defect and subpulmonary 33770 - - $1,642.23 - - stenosis; without surgical enlargement of ventricular septal defect Repair of transposition of the great arteries with ventricular septal defect and subpulmonary 33771 - - $1,688.99 - - stenosis; with surgical enlargement of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning 33774 - - $1,398.33 - - type) with cardiopulmonary bypass; Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning 33775 - - $1,439.76 - - type) with cardiopulmonary bypass; with removal of pulmonary band Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning 33776 - - $1,522.57 - - type) with cardiopulmonary bypass; with closure of ventricular septal defect Repair of transposition of the great arteries, atrial baffle procedure (eg, Mustard or Senning 33777 - - $1,469.27 - - type) with cardiopulmonary bypass; with repair of subpulmonic obstruction Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene 33778 - - $1,823.64 - - type); Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene 33779 - - $1,803.13 - - type); with removal of pulmonary band Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene 33780 - - $1,836.17 - - type); with closure of ventricular septal defect Repair of transposition of the great arteries, aortic pulmonary artery reconstruction (eg, Jatene 33781 - - $1,793.03 - - type); with repair of subpulmonic obstruction Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, 33782 - - $2,504.76 - - Nikaidoh procedure); without coronary ostium reimplantation Aortic root translocation with ventricular septal defect and pulmonary stenosis repair (ie, 33783 - - $2,707.88 - - Nikaidoh procedure); with reimplantation of 1 or both coronary ostia 33786 - - $1,766.95 - - Total repair, truncus arteriosus (Rastelli type operation) 33788 - - $1,191.11 - - Reimplantation of an anomalous pulmonary artery Aortic suspension (aortopexy) for tracheal decompression (eg, for tracheomalacia) (separate 33800 - - $767.28 - - procedure) 33802 - - $844.39 - - Division of aberrant vessel (vascular ring); 33803 - - $895.27 - - Division of aberrant vessel (vascular ring); with reanastomosis 33813 - - $964.99 - - Obliteration of aortopulmonary septal defect; without cardiopulmonary bypass 33814 - - $1,184.49 - - Obliteration of aortopulmonary septal defect; with cardiopulmonary bypass 33820 - - $753.13 - - Repair of patent ductus arteriosus; by ligation 33822 - - $793.65 - - Repair of patent ductus arteriosus; by division, younger than 18 years

Page 61 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 33824 - - $918.99 - - Repair of patent ductus arteriosus; by division, 18 years and older Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with direct 33840 - - $963.92 - - anastomosis

33845 - - $1,037.76 - - Excision of coarctation of aorta, with or without associated patent ductus arteriosus; with graft Excision of coarctation of aorta, with or without associated patent ductus arteriosus; repair 33851 - - $990.03 - - using either left subclavian artery or prosthetic material as gusset for enlargement Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; 33852 - - $1,087.91 - - without cardiopulmonary bypass Repair of hypoplastic or interrupted aortic arch using autogenous or prosthetic material; with 33853 - - $1,424.05 - - cardiopulmonary bypass Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when 33858 - - $2,635.07 - - performed; for aortic dissection Ascending aorta graft, with cardiopulmonary bypass, includes valve suspension, when 33859 - - $1,893.22 - - performed; for aortic disease other than dissection (eg, aneurysm) Ascending aorta graft, with cardiopulmonary bypass, with aortic root replacement using valved 33863 - - $2,444.52 - - conduit and coronary reconstruction (eg, Bentall) Ascending aorta graft, with cardiopulmonary bypass with valve suspension, with coronary 33864 - - $2,497.39 - - reconstruction and valve-sparing aortic root remodeling (eg, David Procedure, Yacoub Procedure)

Aortic hemiarch graft including isolation and control of the arch vessels, beveled open distal 33866 - - $715.12 - - aortic anastomosis extending under one or more of the arch vessels, and total circulatory arrest or isolated cerebral perfusion (List separately in addition to code for primary procedure) Transverse aortic arch graft, with cardiopulmonary bypass, with profound hypothermia, total 33871 - - $2,533.06 - - circulatory arrest and isolated cerebral perfusion with reimplantation of arch vessel(s) (eg, island pedicle or individual arch vessel reimplantation) 33875 - - $2,127.23 - - Descending thoracic aorta graft, with or without bypass Repair of thoracoabdominal aortic aneurysm with graft, with or without cardiopulmonary 33877 - - $2,804.26 - - bypass Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); involving coverage of left 33880 - - $1,388.49 - - subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin Endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); not involving coverage of left 33881 - - $1,192.12 - - subclavian artery origin, initial endoprosthesis plus descending thoracic aortic extension(s), if required, to level of celiac artery origin Placement of proximal extension prosthesis for endovascular repair of descending thoracic 33883 - - $864.46 - - aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption); initial extension Placement of proximal extension prosthesis for endovascular repair of descending thoracic aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or 33884 - - $304.29 - - traumatic disruption); each additional proximal extension (List separately in addition to code for primary procedure) Placement of distal extension prosthesis(s) delayed after endovascular repair of descending 33886 - - $741.30 - - thoracic aorta Open subclavian to carotid artery transposition performed in conjunction with endovascular 33889 - - $609.31 - - repair of descending thoracic aorta, by neck incision, unilateral

33891 - - $742.77 - - Bypass graft, with other than vein, transcervical retropharyngeal carotid-carotid, performed in conjunction with endovascular repair of descending thoracic aorta, by neck incision 33910 - - $2,067.89 - - Pulmonary artery embolectomy; with cardiopulmonary bypass 33915 - - $1,069.44 - - Pulmonary artery embolectomy; without cardiopulmonary bypass 33916 - - $3,274.79 - - Pulmonary endarterectomy, with or without embolectomy, with cardiopulmonary bypass 33917 - - $1,132.78 - - Repair of pulmonary artery stenosis by reconstruction with patch or graft Repair of pulmonary atresia with ventricular septal defect, by construction or replacement of 33920 - - $1,406.07 - - conduit from right or left ventricle to pulmonary artery 33922 - - $1,080.44 - - Transection of pulmonary artery with cardiopulmonary bypass

33924 - - $221.16 - - Ligation and takedown of a systemic-to-pulmonary artery shunt, performed in conjunction with a congenital heart procedure (List separately in addition to code for primary procedure) Repair of pulmonary artery arborization anomalies by unifocalization; without cardiopulmonary 33925 - - $1,332.59 - - bypass Repair of pulmonary artery arborization anomalies by unifocalization; with cardiopulmonary 33926 - - $1,874.05 - - bypass

Page 62 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

33927 - - $1,975.57 - - Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy 33928 - - I.C. - - Removal and replacement of total replacement heart system (artificial heart) Removal of a total replacement heart system (artificial heart) for heart transplantation (List 33929 - - I.C. - - separately in addition to code for primary procedure) 33930 - - I.C. - - Donor cardiectomy-pneumonectomy (including cold preservation) Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation, 33933 - - I.C. - - including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, and trachea for implantation 33935 - - $3,842.66 - - Heart-lung transplant with recipient cardiectomy-pneumonectomy 33940 - - I.C. - - Donor cardiectomy (including cold preservation) Backbench standard preparation of cadaver donor heart allograft prior to transplantation, 33944 - - I.C. - - including dissection of allograft from surrounding soft tissues to prepare aorta, superior vena cava, inferior vena cava, pulmonary artery, and left atrium for implantation 33945 - - $3,776.38 - - Heart transplant, with or without recipient cardiectomy Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33946 - - $239.30 - - physician; initiation, veno-venous Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33947 - - $265.88 - - physician; initiation, veno-arterial Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33948 - - $185.91 - - physician; daily management, each day, veno-venous Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33949 - - $180.34 - - physician; daily management, each day, veno-arterial

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33951 - - $328.48 - - physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33952 - - $331.98 - - physician; insertion of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33953 - - $366.13 - - physician; insertion of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age

33954 - - $369.03 - - Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of peripheral (arterial and/or venous) cannula(e), open, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33955 - - $642.07 - - physician; insertion of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

33956 - - $646.62 - - Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; insertion of central cannula(e) by sternotomy or thoracotomy, 6 years and older

Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33957 - - $143.17 - - physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33958 - - $143.17 - - physician; reposition peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33959 - - $181.27 - - physician; reposition peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33962 - - $181.27 - - physician; reposition peripheral (arterial and/or venous) cannula(e), open, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33963 - - $362.10 - - physician; reposition of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33964 - - $382.11 - - physician; reposition central cannula(e) by sternotomy or thoracotomy, 6 years and older (includes fluoroscopic guidance, when performed) Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33965 - - $143.17 - - physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, birth through 5 years of age

Page 63 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33966 - - $183.74 - - physician; removal of peripheral (arterial and/or venous) cannula(e), percutaneous, 6 years and older 33967 - - $201.05 - - Insertion of intra-aortic balloon assist device, percutaneous 33968 - - $26.25 - - Removal of intra-aortic balloon assist device, percutaneous Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33969 - - $211.17 - - physician; removal of peripheral (arterial and/or venous) cannula(e), open, birth through 5 years of age 33970 - - $274.35 - - Insertion of intra-aortic balloon assist device through the femoral artery, open approach Removal of intra-aortic balloon assist device including repair of femoral artery, with or without 33971 - - $548.82 - - graft 33973 - - $397.49 - - Insertion of intra-aortic balloon assist device through the ascending aorta Removal of intra-aortic balloon assist device from the ascending aorta, including repair of the 33974 - - $692.73 - - ascending aorta, with or without graft 33975 - - $1,011.40 - - Insertion of ventricular assist device; extracorporeal, single ventricle 33976 - - $1,228.32 - - Insertion of ventricular assist device; extracorporeal, biventricular 33977 - - $872.89 - - Removal of ventricular assist device; extracorporeal, single ventricle 33978 - - $1,031.01 - - Removal of ventricular assist device; extracorporeal, biventricular 33979 - - $1,507.16 - - Insertion of ventricular assist device, implantable intracorporeal, single ventricle 33980 - - $1,378.05 - - Removal of ventricular assist device, implantable intracorporeal, single ventricle Replacement of extracorporeal ventricular assist device, single or biventricular, pump(s), single 33981 - - $643.74 - - or each pump Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, 33982 - - $1,512.57 - - without cardiopulmonary bypass Replacement of ventricular assist device pump(s); implantable intracorporeal, single ventricle, 33983 - - $1,788.39 - - with cardiopulmonary bypass

33984 - - $220.07 - - Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of peripheral (arterial and/or venous) cannula(e), open, 6 years and older Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by 33985 - - $397.61 - - physician; removal of central cannula(e) by sternotomy or thoracotomy, birth through 5 years of age

33986 - - $405.47 - - Extracorporeal membrane oxygenation (ECMO)/extracorporeal life support (ECLS) provided by physician; removal of central cannula(e) by sternotomy or thoracotomy, 6 years and older Arterial exposure with creation of graft conduit (eg, chimney graft) to facilitate arterial 33987 - - $161.08 - - perfusion for ECMO/ECLS (List separately in addition to code for primary procedure)

33988 - - $601.84 - - Insertion of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS

33989 - - $382.11 - - Removal of left heart vent by thoracic incision (eg, sternotomy, thoracotomy) for ECMO/ECLS Insertion of ventricular assist device, percutaneous including radiological supervision and 33990 - - $329.88 - - interpretation; arterial access only Insertion of ventricular assist device, percutaneous including radiological supervision and 33991 - - $483.97 - - interpretation; both arterial and venous access, with transseptal puncture Removal of percutaneous ventricular assist device at separate and distinct session from 33992 - - $154.62 - - insertion Repositioning of percutaneous ventricular assist device with imaging guidance at separate and 33993 - - $135.10 - - distinct session from insertion Insertion of ventricular assist device, percutaneous, including radiological supervision and 33995 - - $281.76 - - interpretation; right heart, venous access only Removal of percutaneous right heart ventricular assist device, venous cannula, at separate and 33997 - - $125.36 - - distinct session from insertion 33999 - - I.C. - - Unlisted procedure, cardiac surgery Embolectomy or thrombectomy, with or without catheter; carotid, subclavian or innominate 34001 - - $706.56 - - artery, by neck incision Embolectomy or thrombectomy, with or without catheter; innominate, subclavian artery, by 34051 - - $771.73 - - thoracic incision Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innominate, 34101 - - $465.17 - - subclavian artery, by arm incision Embolectomy or thrombectomy, with or without catheter; radial or ulnar artery, by arm 34111 - - $467.96 - - incision Embolectomy or thrombectomy, with or without catheter; renal, celiac, mesentery, aortoiliac 34151 - - $1,078.44 - - artery, by abdominal incision Embolectomy or thrombectomy, with or without catheter; femoropopliteal, aortoiliac artery, by 34201 - - $795.58 - - leg incision

Page 64 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Embolectomy or thrombectomy, with or without catheter; popliteal-tibio-peroneal artery, by 34203 - - $737.51 - - leg incision 34401 - - $1,132.33 - - Thrombectomy, direct or with catheter; vena cava, iliac vein, by abdominal incision 34421 - - $578.08 - - Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by leg incision Thrombectomy, direct or with catheter; vena cava, iliac, femoropopliteal vein, by abdominal 34451 - - $1,107.99 - - and leg incision 34471 - - $832.82 - - Thrombectomy, direct or with catheter; subclavian vein, by neck incision 34490 - - $498.15 - - Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision 34501 - - $689.92 - - Valvuloplasty, femoral vein 34502 - - $1,201.05 - - Reconstruction of vena cava, any method 34510 - - $788.63 - - Venous valve transposition, any vein donor 34520 - - $764.23 - - Cross-over vein graft to venous system 34530 - - $726.39 - - Saphenopopliteal vein anastomosis

Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all 34701 - - $965.25 - - associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

Endovascular repair of infrarenal aorta by deployment of an aorto-aortic tube endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the 34702 - - $1,438.28 - - aorta from the level of the renal arteries to the aortic bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the aortic bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni- iliac endograft including pre-procedure sizing and device selection, all nonselective 34703 - - $1,063.24 - - catheterization(s), all associated radiological supervision and interpretation, all endograft extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-uni- iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft 34704 - - $1,768.19 - - extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption)

Endovascular repair of infrarenal aorta and/or iliac artery(ies) by deployment of an aorto-bi-iliac endograft including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, all endograft 34706 - - $1,788.75 - - extension(s) placed in the aorta from the level of the renal arteries to the iliac bifurcation, and all angioplasty/stenting performed from the level of the renal arteries to the iliac bifurcation; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, penetrating ulcer, traumatic disruption) Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the 34707 - - $900.67 - - aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation)

Page 65 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Endovascular repair of iliac artery by deployment of an ilio-iliac tube endograft including pre- procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally to the 34708 - - $1,434.93 - - aortic bifurcation and distally to the iliac bifurcation, and treatment zone angioplasty/stenting, when performed, unilateral; for rupture including temporary aortic and/or iliac balloon occlusion, when performed (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, traumatic disruption) Placement of extension prosthesis(es) distal to the common iliac artery(ies) or proximal to the renal artery(ies) for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, penetrating ulcer, including pre-procedure sizing and device selection, all 34709 - - $250.30 - - nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed, per vessel treated (List separately in addition to code for primary procedure) Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or 34710 - - $623.44 - - endograft migration, including pre-procedure sizing and device selection, all nonselective catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; initial vessel treated Delayed placement of distal or proximal extension prosthesis for endovascular repair of infrarenal abdominal aortic or iliac aneurysm, false aneurysm, dissection, endoleak, or endograft migration, including pre-procedure sizing and device selection, all nonselective 34711 - - $230.62 - - catheterization(s), all associated radiological supervision and interpretation, and treatment zone angioplasty/stenting, when performed; each additional vessel treated (List separately in addition to code for primary procedure) Transcatheter delivery of enhanced fixation device(s) to the endograft (eg, anchor, screw, tack) 34712 - - $514.80 - - and all associated radiological supervision and interpretation Percutaneous access and closure of femoral artery for delivery of endograft through a large 34713 - - $96.55 - - sheath (12 French or larger), including ultrasound guidance, when performed, unilateral (List separately in addition to code for primary procedure) Open femoral artery exposure with creation of conduit for delivery of endovascular prosthesis 34714 - - $209.75 - - or for establishment of cardiopulmonary bypass, by groin incision, unilateral (List separately in addition to code for primary procedure) Open axillary/subclavian artery exposure for delivery of endovascular prosthesis by 34715 - - $231.65 - - infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)

Open axillary/subclavian artery exposure with creation of conduit for delivery of endovascular 34716 - - $288.02 - - prosthesis or for establishment of cardiopulmonary bypass, by infraclavicular or supraclavicular incision, unilateral (List separately in addition to code for primary procedure)

Endovascular repair of iliac artery at the time of aorto-iliac artery endograft placement by deployment of an iliac branched endograft including pre-procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and 34717 - - $343.57 - - interpretation, and all endograft extension(s) proximally to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for rupture or other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer, traumatic disruption), unilateral (List separately in addition to code for primary procedure) Endovascular repair of iliac artery, not associated with placement of an aorto-iliac artery endograft at the same session, by deployment of an iliac branched endograft, including pre- procedure sizing and device selection, all ipsilateral selective iliac artery catheterization(s), all associated radiological supervision and interpretation, and all endograft extension(s) proximally 34718 - - $961.68 - - to the aortic bifurcation and distally in the internal iliac, external iliac, and common femoral artery(ies), and treatment zone angioplasty/stenting, when performed, for other than rupture (eg, for aneurysm, pseudoaneurysm, dissection, arteriovenous malformation, penetrating ulcer), unilateral Endovascular placement of iliac artery occlusion device (List separately in addition to code for 34808 - - $153.81 - - primary procedure) Open femoral artery exposure for delivery of endovascular prosthesis, by groin incision, 34812 - - $159.72 - - unilateral (List separately in addition to code for primary procedure) Placement of femoral-femoral prosthetic graft during endovascular aortic aneurysm repair (List 34813 - - $183.08 - - separately in addition to code for primary procedure) Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during 34820 - - $270.42 - - endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)

Page 66 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial 34830 - - $1,359.59 - - trauma, following unsuccessful endovascular repair; tube prosthesis Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial 34831 - - $1,490.08 - - trauma, following unsuccessful endovascular repair; aorto-bi-iliac prosthesis Open repair of infrarenal aortic aneurysm or dissection, plus repair of associated arterial 34832 - - $1,461.94 - - trauma, following unsuccessful endovascular repair; aorto-bifemoral prosthesis Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis or 34833 - - $311.57 - - for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure) Open brachial artery exposure for delivery of endovascular prosthesis, unilateral (List separately 34834 - - $99.97 - - in addition to code for primary procedure) Physician planning of a patient-specific fenestrated visceral aortic endograft requiring a 34839 - - I.C. - - minimum of 90 minutes of physician time Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral 34841 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral 34842 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral 34843 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) by deployment of a fenestrated visceral 34844 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal 34845 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including one visceral artery endoprosthesis (superior mesenteric, celiac or renal artery) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal 34846 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including two visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal 34847 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including three visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Endovascular repair of visceral aorta and infrarenal abdominal aorta (eg, aneurysm, pseudoaneurysm, dissection, penetrating ulcer, intramural hematoma, or traumatic disruption) with a fenestrated visceral aortic endograft and concomitant unibody or modular infrarenal 34848 - - I.C. - - aortic endograft and all associated radiological supervision and interpretation, including target zone angioplasty, when performed; including four or more visceral artery endoprostheses (superior mesenteric, celiac and/or renal artery[s]) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35001 - - $871.45 - - with or without patch graft; for aneurysm and associated occlusive disease, carotid, subclavian artery, by neck incision

35002 - - $877.84 - - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, carotid, subclavian artery, by neck incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35005 - - $768.80 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, vertebral artery

Page 67 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35011 - - $779.03 - - with or without patch graft; for aneurysm and associated occlusive disease, axillary-brachial artery, by arm incision

35013 - - $980.52 - - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, axillary-brachial artery, by arm incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35021 - - $979.18 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35022 - - $1,119.49 - - with or without patch graft; for ruptured aneurysm, innominate, subclavian artery, by thoracic incision Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35045 - - $761.27 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, radial or ulnar artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35081 - - $1,340.56 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35082 - - $1,691.90 - - with or without patch graft; for ruptured aneurysm, abdominal aorta Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35091 - - $1,382.96 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35092 - - $2,015.76 - - with or without patch graft; for ruptured aneurysm, abdominal aorta involving visceral vessels (mesenteric, celiac, renal) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35102 - - $1,454.73 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35103 - - $1,730.86 - - with or without patch graft; for ruptured aneurysm, abdominal aorta involving iliac vessels (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35111 - - $1,025.40 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, splenic artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35112 - - $1,261.15 - - with or without patch graft; for ruptured aneurysm, splenic artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35121 - - $1,219.93 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, hepatic, celiac, renal, or mesenteric artery

35122 - - $1,458.53 - - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, hepatic, celiac, renal, or mesenteric artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35131 - - $1,066.98 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, iliac artery (common, hypogastric, external)

35132 - - $1,261.15 - - Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, with or without patch graft; for ruptured aneurysm, iliac artery (common, hypogastric, external) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35141 - - $855.01 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35142 - - $1,031.56 - - with or without patch graft; for ruptured aneurysm, common femoral artery (profunda femoris, superficial femoral) Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35151 - - $958.86 - - with or without patch graft; for aneurysm, pseudoaneurysm, and associated occlusive disease, popliteal artery Direct repair of aneurysm, pseudoaneurysm, or excision (partial or total) and graft insertion, 35152 - - $1,078.54 - - with or without patch graft; for ruptured aneurysm, popliteal artery 35180 - - $684.46 - - Repair, congenital arteriovenous fistula; head and neck 35182 - - $1,390.55 - - Repair, congenital arteriovenous fistula; thorax and abdomen 35184 - - $744.70 - - Repair, congenital arteriovenous fistula; extremities 35188 - - $997.67 - - Repair, acquired or traumatic arteriovenous fistula; head and neck 35189 - - $1,164.80 - - Repair, acquired or traumatic arteriovenous fistula; thorax and abdomen 35190 - - $594.49 - - Repair, acquired or traumatic arteriovenous fistula; extremities

Page 68 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 35201 - - $733.48 - - Repair blood vessel, direct; neck 35206 - - $609.30 - - Repair blood vessel, direct; upper extremity 35207 - - $594.98 - - Repair blood vessel, direct; hand, finger 35211 - - $1,080.92 - - Repair blood vessel, direct; intrathoracic, with bypass 35216 - - $1,614.62 - - Repair blood vessel, direct; intrathoracic, without bypass 35221 - - $1,142.45 - - Repair blood vessel, direct; intra-abdominal 35226 - - $646.91 - - Repair blood vessel, direct; lower extremity 35231 - - $984.81 - - Repair blood vessel with vein graft; neck 35236 - - $783.23 - - Repair blood vessel with vein graft; upper extremity 35241 - - $1,114.70 - - Repair blood vessel with vein graft; intrathoracic, with bypass 35246 - - $1,214.72 - - Repair blood vessel with vein graft; intrathoracic, without bypass 35251 - - $1,358.08 - - Repair blood vessel with vein graft; intra-abdominal 35256 - - $796.22 - - Repair blood vessel with vein graft; lower extremity 35261 - - $756.93 - - Repair blood vessel with graft other than vein; neck 35266 - - $672.74 - - Repair blood vessel with graft other than vein; upper extremity 35271 - - $1,072.94 - - Repair blood vessel with graft other than vein; intrathoracic, with bypass 35276 - - $1,132.08 - - Repair blood vessel with graft other than vein; intrathoracic, without bypass 35281 - - $1,265.48 - - Repair blood vessel with graft other than vein; intra-abdominal 35286 - - $726.77 - - Repair blood vessel with graft other than vein; lower extremity Thromboendarterectomy, including patch graft, if performed; carotid, vertebral, subclavian, by 35301 - - $878.74 - - neck incision 35302 - - $869.58 - - Thromboendarterectomy, including patch graft, if performed; superficial femoral artery 35303 - - $960.30 - - Thromboendarterectomy, including patch graft, if performed; popliteal artery 35304 - - $987.64 - - Thromboendarterectomy, including patch graft, if performed; tibioperoneal trunk artery Thromboendarterectomy, including patch graft, if performed; tibial or peroneal artery, initial 35305 - - $948.99 - - vessel Thromboendarterectomy, including patch graft, if performed; each additional tibial or peroneal 35306 - - $342.95 - - artery (List separately in addition to code for primary procedure) Thromboendarterectomy, including patch graft, if performed; subclavian, innominate, by 35311 - - $1,208.81 - - thoracic incision 35321 - - $693.33 - - Thromboendarterectomy, including patch graft, if performed; axillary-brachial 35331 - - $1,126.19 - - Thromboendarterectomy, including patch graft, if performed; abdominal aorta 35341 - - $1,066.18 - - Thromboendarterectomy, including patch graft, if performed; mesenteric, celiac, or renal 35351 - - $994.66 - - Thromboendarterectomy, including patch graft, if performed; iliac 35355 - - $799.08 - - Thromboendarterectomy, including patch graft, if performed; iliofemoral 35361 - - $1,174.86 - - Thromboendarterectomy, including patch graft, if performed; combined aortoiliac 35363 - - $1,253.17 - - Thromboendarterectomy, including patch graft, if performed; combined aortoiliofemoral 35371 - - $634.35 - - Thromboendarterectomy, including patch graft, if performed; common femoral 35372 - - $759.03 - - Thromboendarterectomy, including patch graft, if performed; deep (profunda) femoral Reoperation, carotid, thromboendarterectomy, more than 1 month after original operation 35390 - - $123.51 - - (List separately in addition to code for primary procedure) Angioscopy (noncoronary vessels or grafts) during therapeutic intervention (List separately in 35400 - - $114.69 - - addition to code for primary procedure) Harvest of upper extremity vein, 1 segment, for lower extremity or coronary artery bypass 35500 - - $246.59 - - procedure (List separately in addition to code for primary procedure) 35501 - - $1,126.82 - - Bypass graft, with vein; common carotid-ipsilateral internal carotid 35506 - - $983.07 - - Bypass graft, with vein; carotid-subclavian or subclavian-carotid 35508 - - $1,024.45 - - Bypass graft, with vein; carotid-vertebral 35509 - - $1,090.65 - - Bypass graft, with vein; carotid-contralateral carotid 35510 - - $948.49 - - Bypass graft, with vein; carotid-brachial 35511 - - $864.87 - - Bypass graft, with vein; subclavian-subclavian 35512 - - $930.51 - - Bypass graft, with vein; subclavian-brachial 35515 - - $1,024.45 - - Bypass graft, with vein; subclavian-vertebral 35516 - - $941.29 - - Bypass graft, with vein; subclavian-axillary 35518 - - $881.53 - - Bypass graft, with vein; axillary-axillary 35521 - - $947.08 - - Bypass graft, with vein; axillary-femoral 35522 - - $943.61 - - Bypass graft, with vein; axillary-brachial 35523 - - $994.64 - - Bypass graft, with vein; brachial-ulnar or -radial 35525 - - $880.31 - - Bypass graft, with vein; brachial-brachial 35526 - - $1,344.04 - - Bypass graft, with vein; aortosubclavian, aortoinnominate, or aortocarotid 35531 - - $1,503.30 - - Bypass graft, with vein; aortoceliac or aortomesenteric 35533 - - $1,162.68 - - Bypass graft, with vein; axillary-femoral-femoral 35535 - - $1,468.59 - - Bypass graft, with vein; hepatorenal 35536 - - $1,304.28 - - Bypass graft, with vein; splenorenal 35537 - - $1,608.65 - - Bypass graft, with vein; aortoiliac 35538 - - $1,802.48 - - Bypass graft, with vein; aortobi-iliac

Page 69 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 35539 - - $1,691.70 - - Bypass graft, with vein; aortofemoral 35540 - - $1,885.65 - - Bypass graft, with vein; aortobifemoral 35556 - - $1,086.18 - - Bypass graft, with vein; femoral-popliteal 35558 - - $954.79 - - Bypass graft, with vein; femoral-femoral 35560 - - $1,315.16 - - Bypass graft, with vein; aortorenal 35563 - - $1,021.14 - - Bypass graft, with vein; ilioiliac 35565 - - $1,014.33 - - Bypass graft, with vein; iliofemoral Bypass graft, with vein; femoral-anterior tibial, posterior tibial, peroneal artery or other distal 35566 - - $1,294.40 - - vessels 35570 - - $1,137.31 - - Bypass graft, with vein; tibial-tibial, peroneal-tibial, or tibial/peroneal trunk-tibial 35571 - - $1,027.24 - - Bypass graft, with vein; popliteal-tibial, -peroneal artery or other distal vessels Harvest of femoropopliteal vein, 1 segment, for vascular reconstruction procedure (eg, aortic, 35572 - - $267.15 - - vena caval, coronary, peripheral artery) (List separately in addition to code for primary procedure) 35583 - - $1,119.23 - - In-situ vein bypass; femoral-popliteal 35585 - - $1,296.74 - - In-situ vein bypass; femoral-anterior tibial, posterior tibial, or peroneal artery 35587 - - $1,056.43 - - In-situ vein bypass; popliteal-tibial, peroneal Harvest of upper extremity artery, 1 segment, for coronary artery bypass procedure (List 35600 - - $198.46 - - separately in addition to code for primary procedure) 35601 - - $1,082.73 - - Bypass graft, with other than vein; common carotid-ipsilateral internal carotid 35606 - - $909.00 - - Bypass graft, with other than vein; carotid-subclavian 35612 - - $806.32 - - Bypass graft, with other than vein; subclavian-subclavian 35616 - - $850.80 - - Bypass graft, with other than vein; subclavian-axillary 35621 - - $850.10 - - Bypass graft, with other than vein; axillary-femoral 35623 - - $1,013.74 - - Bypass graft, with other than vein; axillary-popliteal or -tibial 35626 - - $1,234.96 - - Bypass graft, with other than vein; aortosubclavian, aortoinnominate, or aortocarotid 35631 - - $1,433.18 - - Bypass graft, with other than vein; aortoceliac, aortomesenteric, aortorenal 35632 - - $1,394.27 - - Bypass graft, with other than vein; ilio-celiac 35633 - - $1,532.91 - - Bypass graft, with other than vein; ilio-mesenteric 35634 - - $1,364.68 - - Bypass graft, with other than vein; iliorenal 35636 - - $1,230.44 - - Bypass graft, with other than vein; splenorenal (splenic to renal arterial anastomosis) 35637 - - $1,280.59 - - Bypass graft, with other than vein; aortoiliac 35638 - - $1,351.21 - - Bypass graft, with other than vein; aortobi-iliac 35642 - - $762.24 - - Bypass graft, with other than vein; carotid-vertebral 35645 - - $731.28 - - Bypass graft, with other than vein; subclavian-vertebral 35646 - - $1,330.08 - - Bypass graft, with other than vein; aortobifemoral 35647 - - $1,199.18 - - Bypass graft, with other than vein; aortofemoral 35650 - - $788.66 - - Bypass graft, with other than vein; axillary-axillary 35654 - - $1,061.75 - - Bypass graft, with other than vein; axillary-femoral-femoral 35656 - - $838.29 - - Bypass graft, with other than vein; femoral-popliteal 35661 - - $841.57 - - Bypass graft, with other than vein; femoral-femoral 35663 - - $939.68 - - Bypass graft, with other than vein; ilioiliac 35665 - - $910.43 - - Bypass graft, with other than vein; iliofemoral 35666 - - $989.58 - - Bypass graft, with other than vein; femoral-anterior tibial, posterior tibial, or peroneal artery 35671 - - $873.04 - - Bypass graft, with other than vein; popliteal-tibial or -peroneal artery Bypass graft; composite, prosthetic and vein (List separately in addition to code for primary 35681 - - $62.76 - - procedure) Bypass graft; autogenous composite, 2 segments of veins from 2 locations (List separately in 35682 - - $272.92 - - addition to code for primary procedure) Bypass graft; autogenous composite, 3 or more segments of vein from 2 or more locations (List 35683 - - $314.66 - - separately in addition to code for primary procedure) Placement of vein patch or cuff at distal anastomosis of bypass graft, synthetic conduit (List 35685 - - $153.28 - - separately in addition to code for primary procedure) Creation of distal arteriovenous fistula during lower extremity bypass surgery (non- 35686 - - $123.88 - - hemodialysis) (List separately in addition to code for primary procedure) 35691 - - $730.46 - - Transposition and/or reimplantation; vertebral to carotid artery 35693 - - $645.44 - - Transposition and/or reimplantation; vertebral to subclavian artery 35694 - - $763.03 - - Transposition and/or reimplantation; subclavian to carotid artery 35695 - - $791.85 - - Transposition and/or reimplantation; carotid to subclavian artery Reimplantation, visceral artery to infrarenal aortic prosthesis, each artery (List separately in 35697 - - $113.82 - - addition to code for primary procedure) Reoperation, femoral-popliteal or femoral (popliteal)-anterior tibial, posterior tibial, peroneal 35700 - - $117.83 - - artery, or other distal vessels, more than 1 month after original operation (List separately in addition to code for primary procedure) 35701 - - $342.88 - - Exploration not followed by surgical repair, artery; neck (eg, carotid, subclavian)

Page 70 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Exploration not followed by surgical repair, artery; upper extremity (eg, axillary, brachial, radial, 35702 - - $320.43 - - ulnar) Exploration not followed by surgical repair, artery; lower extremity (eg, common femoral, deep 35703 - - $324.04 - - femoral, superficial femoral, popliteal, tibial, peroneal) 35800 - - $563.29 - - Exploration for postoperative hemorrhage, thrombosis or infection; neck 35820 - - $1,561.02 - - Exploration for postoperative hemorrhage, thrombosis or infection; chest 35840 - - $938.09 - - Exploration for postoperative hemorrhage, thrombosis or infection; abdomen 35860 - - $650.96 - - Exploration for postoperative hemorrhage, thrombosis or infection; extremity 35870 - - $961.71 - - Repair of graft-enteric fistula 35875 - - $463.55 - - Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with 35876 - - $734.98 - - revision of arterial or venous graft Revision, lower extremity arterial bypass, without thrombectomy, open; with vein patch 35879 - - $718.15 - - angioplasty Revision, lower extremity arterial bypass, without thrombectomy, open; with segmental vein 35881 - - $791.84 - - interposition Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with 35883 - - $931.09 - - nonautogenous patch graft (eg, Dacron, ePTFE, bovine pericardium) Revision, femoral anastomosis of synthetic arterial bypass graft in groin, open; with autogenous 35884 - - $956.77 - - vein patch graft 35901 - - $366.37 - - Excision of infected graft; neck 35903 - - $441.98 - - Excision of infected graft; extremity 35905 - - $1,373.93 - - Excision of infected graft; thorax 35907 - - $1,472.17 - - Excision of infected graft; abdomen 36000 $22.41 $7.05 - - - Introduction of needle or intracatheter, vein

36002 $122.32 $82.04 - - - Injection procedures (eg, thrombin) for percutaneous treatment of extremity pseudoaneurysm Injection procedure for extremity venography (including introduction of needle or 36005 $241.70 $37.08 - - - intracatheter) 36010 $428.85 $85.39 - - - Introduction of catheter, superior or inferior vena cava 36011 $705.15 $122.58 - - - Selective catheter placement, venous system; first order branch (eg, renal vein, jugular vein) Selective catheter placement, venous system; second order, or more selective, branch (eg, left 36012 $715.27 $135.02 - - - adrenal vein, petrosal sinus) 36013 $652.80 $94.86 - - - Introduction of catheter, right heart or main pulmonary artery 36014 $678.67 $118.42 - - - Selective catheter placement, left or right pulmonary artery 36015 $735.04 $134.50 - - - Selective catheter placement, segmental or subsegmental pulmonary artery 36100 $420.26 $117.96 - - - Introduction of needle or intracatheter, carotid or vertebral artery 36140 $390.02 $69.46 - - - Introduction of needle or intracatheter, upper or lower extremity artery 36160 $443.93 $97.00 - - - Introduction of needle or intracatheter, aortic, translumbar 36200 $478.87 $108.17 - - - Introduction of catheter, aorta Selective catheter placement, arterial system; each first order thoracic or brachiocephalic 36215 $877.70 $165.00 - - - branch, within a vascular family Selective catheter placement, arterial system; initial second order thoracic or brachiocephalic 36216 $926.77 $211.75 - - - branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective thoracic or 36217 $1,542.47 $255.02 - - - brachiocephalic branch, within a vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, 36218 $186.26 $40.18 - - - thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) Non-selective catheter placement, thoracic aorta, with angiography of the extracranial carotid, vertebral, and/or intracranial vessels, unilateral or bilateral, and all associated radiological 36221 $857.34 $155.65 - - - supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral extracranial carotid circulation and all associated radiological 36222 $1,012.17 $219.18 - - - supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, common carotid or innominate artery, unilateral, any approach, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological 36223 $1,302.54 $246.09 - - - supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed Selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and 36224 $1,685.57 $279.87 - - - interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed

Page 71 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Selective catheter placement, subclavian or innominate artery, unilateral, with angiography of 36225 $1,247.91 $245.08 - - - the ipsilateral vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, vertebral artery, unilateral, with angiography of the ipsilateral 36226 $1,592.56 $275.84 - - - vertebral circulation and all associated radiological supervision and interpretation, includes angiography of the cervicocerebral arch, when performed Selective catheter placement, external carotid artery, unilateral, with angiography of the 36227 $198.64 $91.40 - - - ipsilateral external carotid circulation and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) Selective catheter placement, each intracranial branch of the internal carotid or vertebral arteries, unilateral, with angiography of the selected vessel circulation and all associated 36228 $1,076.55 $187.04 - - - radiological supervision and interpretation (eg, middle cerebral artery, posterior inferior cerebellar artery) (List separately in addition to code for primary procedure) Selective catheter placement, arterial system; each first order abdominal, pelvic, or lower 36245 $1,091.95 $184.76 - - - extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial second order abdominal, pelvic, or lower 36246 $694.89 $196.37 - - - extremity artery branch, within a vascular family Selective catheter placement, arterial system; initial third order or more selective abdominal, 36247 $1,233.53 $234.18 - - - pelvic, or lower extremity artery branch, within a vascular family Selective catheter placement, arterial system; additional second order, third order, and beyond, 36248 $110.64 $37.89 - - - abdominal, pelvic, or lower extremity artery branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate) Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, 36251 $1,135.94 $201.22 - - - contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; unilateral Selective catheter placement (first-order), main renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture and catheter placement(s), fluoroscopy, 36252 $1,217.83 $279.35 - - - contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral

Superselective catheter placement (one or more second order or higher renal artery branches) renal artery and any accessory renal artery(s) for renal angiography, including arterial puncture, 36254 $1,759.73 $321.86 - - - catheterization, fluoroscopy, contrast injection(s), image postprocessing, permanent recording of images, and radiological supervision and interpretation, including pressure gradient measurements when performed, and flush aortogram when performed; bilateral 36260 - - $513.50 - - Insertion of implantable intra-arterial infusion pump (eg, for chemotherapy of liver) 36261 - - $320.60 - - Revision of implanted intra-arterial infusion pump 36262 - - $245.09 - - Removal of implanted intra-arterial infusion pump 36299 - - I.C. - - Unlisted procedure, vascular injection

36400 $20.96 $14.58 - - - Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; femoral or jugular vein Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified 36405 $18.28 $11.90 - - - health care professional, not to be used for routine venipuncture; scalp vein Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified 36406 $13.14 $6.76 - - - health care professional, not to be used for routine venipuncture; other vein Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified 36410 $13.67 $7.29 - - - health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture) 36415 - - I.C. - - Collection of venous blood by venipuncture 36416 - - I.C. - - Collection of capillary blood specimen (eg, finger, heel, ear stick) 36420 - - $36.86 - - Venipuncture, cutdown; younger than age 1 year 36425 - - $31.06 - - Venipuncture, cutdown; age 1 or over 36430 - - $28.60 - - Transfusion, blood or blood components 36440 - - $39.72 - - Push transfusion, blood, 2 years or younger 36450 - - $133.26 - - Exchange transfusion, blood; newborn 36455 - - $98.17 - - Exchange transfusion, blood; other than newborn

Page 72 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Partial exchange transfusion, blood, plasma or crystalloid necessitating the skill of a physician or 36456 - - $79.29 - - other qualified health care professional, newborn 36460 - - $271.89 - - Transfusion, intrauterine, fetal Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to 36465 $1,237.00 $93.02 - - - guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (eg, great saphenous vein, accessory saphenous vein) Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to 36466 $1,371.31 $119.51 - - - guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent truncal veins (eg, great saphenous vein, accessory saphenous vein), same leg 36468 - - I.C. - - Injection(s) of sclerosant for spider veins (telangiectasia), limb or trunk 36470 $87.42 $29.45 - - - Injection of sclerosant; single incompetent vein (other than telangiectasia) 36471 $157.07 $59.40 - - - Injection of sclerosant; multiple incompetent veins (other than telangiectasia), same leg Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 36473 $1,159.66 $138.57 - - - and monitoring, percutaneous, mechanochemical; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single 36474 $232.66 $69.48 - - - extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 36475 $1,110.49 $216.64 - - - and monitoring, percutaneous, radiofrequency; first vein treated Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single 36476 $246.40 $104.67 - - - extremity, each through separate access sites (List separately in addition to code for primary procedure) Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 36478 $859.47 $216.04 - - - and monitoring, percutaneous, laser; first vein treated

Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance 36479 $260.12 $105.92 - - - and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36481 $1,564.41 $257.54 - - - Percutaneous portal vein catheterization by any method Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a 36482 $1,554.37 $139.10 - - - chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated

Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a 36483 $123.01 $69.68 - - - chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36500 - - $142.00 - - Venous catheterization for selective organ blood sampling 36510 $65.36 $41.89 - - - Catheterization of umbilical vein for diagnosis or therapy, newborn 36511 - - $85.80 - - Therapeutic apheresis; for white blood cells 36512 - - $84.93 - - Therapeutic apheresis; for red blood cells 36513 - - $85.31 - - Therapeutic apheresis; for platelets 36514 $550.49 $74.58 - - - Therapeutic apheresis; for plasma pheresis Therapeutic apheresis; with extracorporeal immunoadsorption, selective adsorption or 36516 $1,601.89 $65.76 - - - selective filtration and plasma reinfusion 36522 $1,577.71 $76.94 - - - Photopheresis, extracorporeal Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of 36555 $149.65 $65.31 - - - age 36556 $170.93 $66.01 - - - Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or 36557 $891.55 $250.72 - - - pump; younger than 5 years of age Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or 36558 $657.57 $204.85 - - - pump; age 5 years or older Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; 36560 $1,063.44 $299.72 - - - younger than 5 years of age Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; 36561 $868.78 $263.89 - - - age 5 years or older

36563 $962.24 $286.34 - - - Insertion of tunneled centrally inserted central venous access device with subcutaneous pump

36565 $705.36 $261.62 - - - Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 separate venous access sites; without subcutaneous port or pump (eg, Tesio type catheter) Insertion of tunneled centrally inserted central venous access device, requiring 2 catheters via 2 36566 $3,811.59 $281.98 - - - separate venous access sites; with subcutaneous port(s)

Page 73 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or 36568 - - $71.55 - - pump, without imaging guidance; younger than 5 years of age Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or 36569 - - $73.65 - - pump, without imaging guidance; age 5 years or older Insertion of peripherally inserted central venous access device, with subcutaneous port; 36570 $1,208.40 $260.35 - - - younger than 5 years of age Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 36571 $1,056.97 $244.85 - - - years or older

Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or 36572 $352.51 $70.79 - - - pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; younger than 5 years of age

Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or 36573 $324.80 $65.98 - - - pump, including all imaging guidance, image documentation, and all associated radiological supervision and interpretation required to perform the insertion; age 5 years or older Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port 36575 $130.40 $27.22 - - - or pump, central or peripheral insertion site Repair of central venous access device, with subcutaneous port or pump, central or peripheral 36576 $271.85 $145.20 - - - insertion site Replacement, catheter only, of central venous access device, with subcutaneous port or pump, 36578 $378.36 $160.11 - - - central or peripheral insertion site Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without 36580 $176.39 $51.47 - - - subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous catheter, without 36581 $654.32 $143.92 - - - subcutaneous port or pump, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with 36582 $802.84 $227.51 - - - subcutaneous port, through same venous access Replacement, complete, of a tunneled centrally inserted central venous access device, with 36583 $1,027.18 $257.67 - - - subcutaneous pump, through same venous access Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access, including all imaging guidance, 36584 $284.07 $46.70 - - - image documentation, and all associated radiological supervision and interpretation required to perform the replacement Replacement, complete, of a peripherally inserted central venous access device, with 36585 $895.83 $212.98 - - - subcutaneous port, through same venous access 36589 $130.92 $108.02 - - - Removal of tunneled central venous catheter, without subcutaneous port or pump Removal of tunneled central venous access device, with subcutaneous port or pump, central or 36590 $175.45 $149.65 - - - peripheral insertion 36591 - - $20.24 - - Collection of blood specimen from a completely implantable venous access device Collection of blood specimen using established central or peripheral catheter, venous, not 36592 - - $22.85 - - otherwise specified 36593 - - $25.71 - - Declotting by thrombolytic agent of implanted vascular access device or catheter Mechanical removal of pericatheter obstructive material (eg, fibrin sheath) from central venous 36595 $508.03 $142.26 - - - device via separate venous access Mechanical removal of intraluminal (intracatheter) obstructive material from central venous 36596 $98.33 $34.27 - - - device through device lumen 36597 $106.34 $47.21 - - - Repositioning of previously placed central venous catheter under fluoroscopic guidance Contrast injection(s) for radiologic evaluation of existing central venous access device, including 36598 $97.53 $28.83 - - - fluoroscopy, image documentation and report 36600 $24.00 $12.12 - - - Arterial puncture, withdrawal of blood for diagnosis Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate 36620 - - $34.24 - - procedure); percutaneous Arterial catheterization or cannulation for sampling, monitoring or transfusion (separate 36625 - - $82.07 - - procedure); cutdown 36640 - - $90.10 - - Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown 36660 - - $53.25 - - Catheterization, umbilical artery, newborn, for diagnosis or therapy 36680 - - $46.45 - - Placement of needle for intraosseous infusion 36800 - - $95.53 - - Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, 36810 - - $165.07 - - external (Scribner type) Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, 36815 - - $104.39 - - external revision, or closure 36818 - - $539.18 - - Arteriovenous anastomosis, open; by upper arm cephalic vein transposition 36819 - - $569.64 - - Arteriovenous anastomosis, open; by upper arm basilic vein transposition 36820 - - $568.43 - - Arteriovenous anastomosis, open; by forearm vein transposition

Page 74 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 36821 - - $517.69 - - Arteriovenous anastomosis, open; direct, any site (eg, Cimino type) (separate procedure) Insertion of arterial and venous cannula(s) for isolated extracorporeal circulation including 36823 - - $1,098.38 - - regional chemotherapy perfusion to an extremity, with or without hyperthermia, with removal of cannula(s) and repair of arteriotomy and venotomy sites Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate 36825 - - $619.82 - - procedure); autogenous graft Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate 36830 - - $520.09 - - procedure); nonautogenous graft (eg, biological collagen, thermoplastic graft) Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous 36831 - - $479.98 - - dialysis graft (separate procedure) Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous 36832 - - $589.24 - - dialysis graft (separate procedure) Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous 36833 - - $631.69 - - dialysis graft (separate procedure) 36835 - - $375.65 - - Insertion of Thomas shunt (separate procedure) Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal 36838 - - $888.63 - - syndrome) 36860 $197.19 $86.47 - - - External cannula declotting (separate procedure); without balloon catheter 36861 - - $108.40 - - External cannula declotting (separate procedure); with balloon catheter Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of 36901 $561.43 $131.61 - - - contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire 36902 $1,057.07 $186.40 - - - venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological supervision and interpretation and image documentation and report; with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty Introduction of needle(s) and/or catheter(s), dialysis circuit, with diagnostic angiography of the dialysis circuit, including all direct puncture(s) and catheter placement(s), injection(s) of contrast, all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava, fluoroscopic guidance, radiological 36903 $4,221.28 $246.77 - - - supervision and interpretation and image documentation and report; with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis segment Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, 36904 $1,563.88 $288.31 - - - diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s); Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural 36905 $1,965.34 $346.03 - - - pharmacological thrombolytic injection(s); with transluminal balloon angioplasty, peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural 36906 $5,233.35 $399.18 - - - pharmacological thrombolytic injection(s); with transcatheter placement of intravascular stent(s), peripheral dialysis segment, including all imaging and radiological supervision and interpretation necessary to perform the stenting, and all angioplasty within the peripheral dialysis circuit Transluminal balloon angioplasty, central dialysis segment, performed through dialysis circuit, 36907 $560.60 $113.97 - - - including all imaging and radiological supervision and interpretation required to perform the angioplasty (List separately in addition to code for primary procedure) Transcatheter placement of intravascular stent(s), central dialysis segment, performed through dialysis circuit, including all imaging and radiological supervision and interpretation required to 36908 $1,715.01 $161.21 - - - perform the stenting, and all angioplasty in the central dialysis segment (List separately in addition to code for primary procedure)

Page 75 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Dialysis circuit permanent vascular embolization or occlusion (including main circuit or any accessory veins), endovascular, including all imaging and radiological supervision and 36909 $1,634.02 $156.15 - - - interpretation necessary to complete the intervention (List separately in addition to code for primary procedure) 37140 - - $1,820.05 - - Venous anastomosis, open; portocaval 37145 - - $1,687.91 - - Venous anastomosis, open; renoportal 37160 - - $1,733.89 - - Venous anastomosis, open; caval-mesenteric 37180 - - $1,666.98 - - Venous anastomosis, open; splenorenal, proximal Venous anastomosis, open; splenorenal, distal (selective decompression of esophagogastric 37181 - - $1,820.05 - - varices, any technique) Insertion of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, 37182 - - $639.82 - - intrahepatic tract formation/dilatation, stent placement and all associated imaging guidance and documentation) Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, 37183 $5,081.78 $291.38 - - - intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation) Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, 37184 $1,595.32 $338.31 - - - arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel Primary percutaneous transluminal mechanical thrombectomy, noncoronary, non-intracranial, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural 37185 $479.46 $127.31 - - - pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure)

Secondary percutaneous transluminal thrombectomy (eg, nonprimary mechanical, snare basket, suction technique), noncoronary, non-intracranial, arterial or arterial bypass graft, 37186 $1,073.51 $189.22 - - - including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure) Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural 37187 $1,571.30 $306.46 - - - pharmacological thrombolytic injections and fluoroscopic guidance Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural 37188 $1,325.23 $217.48 - - - pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy Insertion of intravascular vena cava filter, endovascular approach including vascular access, 37191 $1,958.67 $174.16 - - - vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed Repositioning of intravascular vena cava filter, endovascular approach including vascular access, 37192 $1,084.73 $265.36 - - - vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed

Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular 37193 $1,285.15 $271.89 - - - access, vessel selection, and radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance (ultrasound and fluoroscopy), when performed 37195 - - I.C. - - Thrombolysis, cerebral, by intravenous infusion Transcatheter retrieval, percutaneous, of intravascular foreign body (eg, fractured venous or 37197 $1,304.50 $234.43 - - - arterial catheter), includes radiological supervision and interpretation, and imaging guidance (ultrasound or fluoroscopy), when performed 37200 - - $169.58 - - Transcatheter biopsy

37211 - - $300.17 - - Transcatheter therapy, arterial infusion for thrombolysis other than coronary or intracranial, any method, including radiological supervision and interpretation, initial treatment day Transcatheter therapy, venous infusion for thrombolysis, any method, including radiological 37212 - - $262.78 - - supervision and interpretation, initial treatment day Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on 37213 - - $181.02 - - subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; Transcatheter therapy, arterial or venous infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on 37214 - - $95.55 - - subsequent day during course of thrombolytic therapy, including follow-up catheter contrast injection, position change, or exchange, when performed; cessation of thrombolysis including removal of catheter and vessel closure by any method

Page 76 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transcatheter placement of intravascular stent(s), cervical carotid artery, open or 37215 - - $779.34 - - percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; with distal embolic protection Transcatheter placement of intravascular stent(s), cervical carotid artery, open or 37216 - - $768.82 - - percutaneous, including angioplasty, when performed, and radiological supervision and interpretation; without distal embolic protection

Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or 37217 - - $838.02 - - innominate artery by retrograde treatment, open ipsilateral cervical carotid artery exposure, including angioplasty, when performed, and radiological supervision and interpretation Transcatheter placement of intravascular stent(s), intrathoracic common carotid artery or 37218 - - $637.91 - - innominate artery, open or percutaneous antegrade approach, including angioplasty, when performed, and radiological supervision and interpretation Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; 37220 $2,352.49 $310.88 - - - with transluminal angioplasty Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; 37221 $3,188.78 $383.75 - - - with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral 37222 $603.09 $144.28 - - - iliac vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, iliac artery, each additional ipsilateral 37223 $1,563.91 $164.87 - - - iliac vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 37224 $2,800.37 $345.47 - - - with transluminal angioplasty Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 37225 $9,261.28 $468.25 - - - with atherectomy, includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 37226 $8,225.25 $403.75 - - - with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; 37227 $11,910.50 $562.86 - - - with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 37228 $4,037.01 $421.02 - - - vessel; with transluminal angioplasty

37229 $9,290.36 $546.02 - - - Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 37230 $8,351.68 $542.93 - - - vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial 37231 $11,575.67 $588.87 - - - vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each 37232 $829.17 $155.59 - - - additional vessel; with transluminal angioplasty (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each 37233 $1,012.85 $252.90 - - - additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each 37234 $3,181.83 $221.74 - - - additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (List separately in addition to code for primary procedure) Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty 37235 $3,345.82 $312.70 - - - within the same vessel, when performed (List separately in addition to code for primary procedure)

Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for 37236 $2,749.34 $345.16 - - - occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; initial artery

Page 77 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transcatheter placement of an intravascular stent(s) (except lower extremity artery(s) for occlusive disease, cervical carotid, extracranial vertebral or intrathoracic carotid, intracranial, or 37237 $1,527.43 $164.62 - - - coronary), open or percutaneous, including radiological supervision and interpretation and including all angioplasty within the same vessel, when performed; each additional artery (List separately in addition to code for primary procedure) Transcatheter placement of an intravascular stent(s), open or percutaneous, including 37238 $2,598.38 $237.67 - - - radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, 37239 $1,202.96 $118.40 - - - when performed; each additional vein (List separately in addition to code for primary procedure) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; 37241 $4,035.68 $340.57 - - - venous, other than hemorrhage (eg, congenital or acquired venous malformations, venous and capillary hemangiomas, varices, varicoceles)

Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, 37242 $6,252.86 $371.23 - - - intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor (eg, congenital or acquired arterial malformations, arteriovenous malformations, arteriovenous fistulas, aneurysms, pseudoaneurysms) Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, 37243 $7,895.81 $438.92 - - - intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, 37244 $5,779.63 $519.99 - - - intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for arterial or venous hemorrhage or lymphatic extravasation Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all 37246 $1,668.82 $270.94 - - - imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; initial artery Transluminal balloon angioplasty (except lower extremity artery(ies) for occlusive disease, intracranial, coronary, pulmonary, or dialysis circuit), open or percutaneous, including all 37247 $583.87 $132.88 - - - imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same artery; each additional artery (List separately in addition to code for primary procedure) Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all 37248 $1,225.84 $231.99 - - - imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty 37249 $444.90 $113.61 - - - within the same vein; each additional vein (List separately in addition to code for primary procedure) Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 37252 $958.77 $70.14 - - - intervention, including radiological supervision and interpretation; initial noncoronary vessel (List separately in addition to code for primary procedure) Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic 37253 $151.04 $56.27 - - - intervention, including radiological supervision and interpretation; each additional noncoronary vessel (List separately in addition to code for primary procedure) 37500 - - $491.06 - - Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) 37501 - - I.C. - - Unlisted vascular endoscopy procedure 37565 - - $566.35 - - Ligation, internal jugular vein 37600 - - $575.25 - - Ligation; external carotid artery 37605 - - $570.59 - - Ligation; internal or common carotid artery Ligation; internal or common carotid artery, with gradual occlusion, as with Selverstone or 37606 - - $563.62 - - Crutchfield clamp 37607 - - $292.88 - - Ligation or banding of angioaccess arteriovenous fistula 37609 $248.83 $161.88 - - - Ligation or biopsy, temporal artery 37615 - - $416.35 - - Ligation, major artery (eg, post-traumatic, rupture); neck 37616 - - $862.17 - - Ligation, major artery (eg, post-traumatic, rupture); chest 37617 - - $1,037.66 - - Ligation, major artery (eg, post-traumatic, rupture); abdomen 37618 - - $304.55 - - Ligation, major artery (eg, post-traumatic, rupture); extremity 37619 - - $1,353.66 - - Ligation of inferior vena cava 37650 - - $355.24 - - Ligation of femoral vein 37660 - - $1,031.88 - - Ligation of common iliac vein

Page 78 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

37700 - - $191.77 - - Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 37718 - - $328.52 - - Ligation, division, and stripping, short saphenous vein Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction 37722 - - $368.00 - - to knee or below Ligation and division and complete stripping of long or short saphenous veins with radical 37735 - - $449.84 - - excision of ulcer and skin graft and/or interruption of communicating veins of lower leg, with excision of deep fascia Ligation of perforator veins, subfascial, radical (Linton type), including skin graft, when 37760 - - $486.63 - - performed, open,1 leg Ligation of perforator vein(s), subfascial, open, including ultrasound guidance, when performed, 37761 - - $423.35 - - 1 leg 37765 $351.17 $212.05 - - - Stab phlebectomy of varicose veins, 1 extremity; 10-20 stab incisions 37766 $409.17 $259.32 - - - Stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions 37780 - - $182.38 - - Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 37785 $281.97 $202.55 - - - Ligation, division, and/or excision of varicose vein cluster(s), 1 leg 37788 - - $989.07 - - Penile revascularization, artery, with or without vein graft 37790 - - $381.61 - - Penile venous occlusive procedure 37799 - - I.C. - - Unlisted procedure, vascular surgery 38100 - - $905.08 - - Splenectomy; total (separate procedure) 38101 - - $914.90 - - Splenectomy; partial (separate procedure) Splenectomy; total, en bloc for extensive disease, in conjunction with other procedure (List in 38102 - - $204.69 - - addition to code for primary procedure) 38115 - - $1,001.74 - - Repair of ruptured spleen (splenorrhaphy) with or without partial splenectomy 38120 - - $828.79 - - Laparoscopy, surgical, splenectomy 38129 - - I.C. - - Unlisted laparoscopy procedure, spleen 38200 - - $104.11 - - Injection procedure for splenoportography 38204 - - $79.29 - - Management of recipient hematopoietic progenitor cell donor search and cell acquisition Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; 38205 - - $66.63 - - allogeneic Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; 38206 - - $66.34 - - autologous 38207 - - $35.42 - - Transplant preparation of hematopoietic progenitor cells; cryopreservation and storage Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, 38208 - - $22.46 - - without washing, per donor Transplant preparation of hematopoietic progenitor cells; thawing of previously frozen harvest, 38209 - - $9.46 - - with washing, per donor Transplant preparation of hematopoietic progenitor cells; specific cell depletion within harvest, 38210 - - $61.98 - - T-cell depletion 38211 - - $56.30 - - Transplant preparation of hematopoietic progenitor cells; tumor cell depletion 38212 - - $37.57 - - Transplant preparation of hematopoietic progenitor cells; red blood cell removal 38213 - - $9.46 - - Transplant preparation of hematopoietic progenitor cells; platelet depletion 38214 - - $32.43 - - Transplant preparation of hematopoietic progenitor cells; plasma (volume) depletion Transplant preparation of hematopoietic progenitor cells; cell concentration in plasma, 38215 - - $37.57 - - mononuclear, or buffy coat layer 38220 $134.49 $54.50 - - - Diagnostic bone marrow; aspiration(s) 38221 $126.01 $54.42 - - - Diagnostic bone marrow; biopsy(ies) 38222 $139.15 $60.89 - - - Diagnostic bone marrow; biopsy(ies) and aspiration(s) 38230 - - $159.97 - - Bone marrow harvesting for transplantation; allogeneic 38232 - - $155.83 - - Bone marrow harvesting for transplantation; autologous 38240 - - $185.47 - - Hematopoietic progenitor cell (HPC); allogeneic transplantation per donor 38241 - - $137.19 - - Hematopoietic progenitor cell (HPC); autologous transplantation 38242 - - $99.44 - - Allogeneic lymphocyte infusions 38243 - - $95.34 - - Hematopoietic progenitor cell (HPC); HPC boost 38300 $264.08 $162.93 - - - Drainage of lymph node abscess or lymphadenitis; simple 38305 - - $385.79 - - Drainage of lymph node abscess or lymphadenitis; extensive 38308 - - $358.23 - - Lymphangiotomy or other operations on lymphatic channels 38380 - - $447.22 - - Suture and/or ligation of thoracic duct; cervical approach 38381 - - $626.64 - - Suture and/or ligation of thoracic duct; thoracic approach 38382 - - $531.84 - - Suture and/or ligation of thoracic duct; abdominal approach 38500 $267.38 $200.71 - - - Biopsy or excision of lymph node(s); open, superficial 38505 $99.60 $55.25 - - - Biopsy or excision of lymph node(s); by needle, superficial (eg, cervical, inguinal, axillary) 38510 $415.47 $328.23 - - - Biopsy or excision of lymph node(s); open, deep cervical node(s) 38520 - - $365.83 - - Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad

Page 79 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 38525 - - $345.45 - - Biopsy or excision of lymph node(s); open, deep axillary node(s) 38530 - - $445.27 - - Biopsy or excision of lymph node(s); open, internal mammary node(s) 38531 - - $341.32 - - Biopsy or excision of lymph node(s); open, inguinofemoral node(s) 38542 - - $405.69 - - Dissection, deep jugular node(s) 38550 - - $406.93 - - Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection 38555 - - $801.05 - - Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection 38562 - - $555.56 - - Limited lymphadenectomy for staging (separate procedure); pelvic and para-aortic Limited lymphadenectomy for staging (separate procedure); retroperitoneal (aortic and/or 38564 - - $553.60 - - splenic) 38570 - - $401.42 - - Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple 38571 - - $519.57 - - Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node 38572 - - $713.90 - - sampling (biopsy), single or multiple

Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node 38573 - - $908.58 - - sampling, peritoneal washings, peritoneal biopsy(ies), omentectomy, and diaphragmatic washings, including diaphragmatic and other serosal biopsy(ies), when performed 38589 - - I.C. - - Unlisted laparoscopy procedure, lymphatic system 38700 - - $629.10 - - Suprahyoid lymphadenectomy 38720 - - $1,046.97 - - Cervical lymphadenectomy (complete) 38724 - - $1,129.91 - - Cervical lymphadenectomy (modified radical neck dissection) 38740 - - $550.26 - - Axillary lymphadenectomy; superficial 38745 - - $691.68 - - Axillary lymphadenectomy; complete Thoracic lymphadenectomy by thoracotomy, mediastinal and regional lymphadenectomy (List 38746 - - $165.97 - - separately in addition to code for primary procedure) Abdominal lymphadenectomy, regional, including celiac, gastric, portal, peripancreatic, with or 38747 - - $208.46 - - without para-aortic and vena caval nodes (List separately in addition to code for primary procedure)

38760 - - $657.85 - - Inguinofemoral lymphadenectomy, superficial, including Cloquet's node (separate procedure) Inguinofemoral lymphadenectomy, superficial, in continuity with pelvic lymphadenectomy, 38765 - - $1,019.49 - - including external iliac, hypogastric, and obturator nodes (separate procedure) Pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes (separate 38770 - - $629.68 - - procedure) Retroperitoneal transabdominal lymphadenectomy, extensive, including pelvic, aortic, and 38780 - - $810.70 - - renal nodes (separate procedure) 38790 - - $64.38 - - Injection procedure; lymphangiography 38792 $66.69 $26.11 - - - Injection procedure; radioactive tracer for identification of sentinel node 38794 - - $233.93 - - Cannulation, thoracic duct

38900 - - $107.96 - - Intraoperative identification (eg, mapping) of sentinel lymph node(s) includes injection of non- radioactive dye, when performed (List separately in addition to code for primary procedure) 38999 - - I.C. - - Unlisted procedure, hemic or lymphatic system Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; cervical 39000 - - $389.69 - - approach Mediastinotomy with exploration, drainage, removal of foreign body, or biopsy; transthoracic 39010 - - $613.55 - - approach, including either transthoracic or median sternotomy 39200 - - $678.11 - - Resection of mediastinal cyst 39220 - - $883.40 - - Resection of mediastinal tumor 39401 - - $239.83 - - Mediastinoscopy; includes biopsy(ies) of mediastinal mass (eg, lymphoma), when performed 39402 - - $313.29 - - Mediastinoscopy; with lymph node biopsy(ies) (eg, lung cancer staging) 39499 - - I.C. - - Unlisted procedure, mediastinum 39501 - - $669.68 - - Repair, laceration of diaphragm, any approach Repair, neonatal diaphragmatic hernia, with or without chest tube insertion and with or 39503 - - $4,620.99 - - without creation of ventral hernia 39540 - - $682.74 - - Repair, diaphragmatic hernia (other than neonatal), traumatic; acute 39541 - - $736.94 - - Repair, diaphragmatic hernia (other than neonatal), traumatic; chronic Imbrication of diaphragm for eventration, transthoracic or transabdominal, paralytic or 39545 - - $698.23 - - nonparalytic 39560 - - $626.10 - - Resection, diaphragm; with simple repair (eg, primary suture) 39561 - - $970.26 - - Resection, diaphragm; with complex repair (eg, prosthetic material, local muscle flap) 39599 - - I.C. - - Unlisted procedure, diaphragm 40490 $99.40 $55.35 - - - Biopsy of lip 40500 $412.80 $287.88 - - - Vermilionectomy (lip shave), with mucosal advancement 40510 $390.23 $276.61 - - - Excision of lip; transverse wedge excision with primary closure

Page 80 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 40520 $397.36 $280.85 - - - Excision of lip; V-excision with primary direct linear closure 40525 - - $436.03 - - Excision of lip; full thickness, reconstruction with local flap (eg, Estlander or fan) 40527 - - $485.31 - - Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) 40530 $435.27 $315.86 - - - Resection of lip, more than one-fourth, without reconstruction 40650 $372.26 $242.42 - - - Repair lip, full thickness; vermilion only 40652 $407.25 $282.04 - - - Repair lip, full thickness; up to half vertical height 40654 $462.08 $335.42 - - - Repair lip, full thickness; over one-half vertical height, or complex 40700 - - $801.17 - - Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral 40701 - - $947.40 - - Plastic repair of cleft lip/nasal deformity; primary bilateral, 1-stage procedure 40702 - - $795.57 - - Plastic repair of cleft lip/nasal deformity; primary bilateral, 1 of 2 stages 40720 - - $816.76 - - Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), 40761 - - $860.30 - - including sectioning and inserting of pedicle 40799 - - I.C. - - Unlisted procedure, lips 40800 $169.18 $99.62 - - - Drainage of abscess, cyst, hematoma, vestibule of mouth; simple 40801 $241.34 $165.11 - - - Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated 40804 $159.17 $94.25 - - - Removal of embedded foreign body, vestibule of mouth; simple 40805 $238.09 $165.92 - - - Removal of embedded foreign body, vestibule of mouth; complicated 40806 $81.33 $24.23 - - - Incision of labial frenum (frenotomy) 40808 $128.51 $68.52 - - - Biopsy, vestibule of mouth 40810 $170.13 $98.54 - - - Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair 40812 $230.38 $150.97 - - - Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair 40814 $304.99 $233.40 - - - Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of 40816 $320.62 $244.11 - - - underlying muscle 40818 $295.45 $217.19 - - - Excision of mucosa of vestibule of mouth as donor graft 40819 $226.45 $168.78 - - - Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Destruction of lesion or scar of vestibule of mouth by physical methods (eg, laser, thermal, cryo, 40820 $211.18 $134.67 - - - chemical) 40830 $225.38 $134.37 - - - Closure of laceration, vestibule of mouth; 2.5 cm or less 40831 $286.80 $184.20 - - - Closure of laceration, vestibule of mouth; over 2.5 cm or complex 40840 $665.47 $494.18 - - - Vestibuloplasty; anterior 40842 $729.64 $537.77 - - - Vestibuloplasty; posterior, unilateral 40843 $948.82 $694.63 - - - Vestibuloplasty; posterior, bilateral 40844 $1,189.96 $936.64 - - - Vestibuloplasty; entire arch 40845 $1,160.91 $950.48 - - - Vestibuloplasty; complex (including ridge extension, muscle repositioning) 40899 - - I.C. - - Unlisted procedure, vestibule of mouth Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41000 $127.59 $86.73 - - - lingual Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41005 $175.99 $91.93 - - - sublingual, superficial Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41006 $274.87 $189.07 - - - sublingual, deep, supramylohyoid Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41007 $270.04 $183.38 - - - submental space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41008 $308.46 $205.85 - - - submandibular space Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; 41009 $331.47 $226.55 - - - masticator space 41010 $169.63 $86.16 - - - Incision of lingual frenum (frenotomy) 41015 $324.61 $246.94 - - - Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual

41016 $364.71 $275.16 - - - Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental

41017 $363.45 $273.60 - - - Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator 41018 $407.42 $316.99 - - - space Placement of needles, catheters, or other device(s) into the head and/or neck region 41019 - - $378.37 - - (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application 41100 $140.62 $83.23 - - - Biopsy of tongue; anterior two-thirds 41105 $141.95 $85.72 - - - Biopsy of tongue; posterior one-third 41108 $125.11 $69.75 - - - Biopsy of floor of mouth 41110 $177.53 $103.33 - - - Excision of lesion of tongue without closure 41112 $268.98 $195.36 - - - Excision of lesion of tongue with closure; anterior two-thirds 41113 $291.68 $215.17 - - - Excision of lesion of tongue with closure; posterior one-third 41114 - - $487.51 - - Excision of lesion of tongue with closure; with local tongue flap

Page 81 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 41115 $204.61 $115.05 - - - Excision of lingual frenum (frenectomy) 41116 $267.76 $171.53 - - - Excision, lesion of floor of mouth 41120 - - $846.60 - - Glossectomy; less than one-half tongue 41130 - - $1,040.77 - - Glossectomy; hemiglossectomy 41135 - - $1,706.30 - - Glossectomy; partial, with unilateral radical neck dissection 41140 - - $1,718.52 - - Glossectomy; complete or total, with or without tracheostomy, without radical neck dissection Glossectomy; complete or total, with or without tracheostomy, with unilateral radical neck 41145 - - $2,171.39 - - dissection Glossectomy; composite procedure with resection floor of mouth and mandibular resection, 41150 - - $1,728.72 - - without radical neck dissection Glossectomy; composite procedure with resection floor of mouth, with suprahyoid neck 41153 - - $1,879.66 - - dissection Glossectomy; composite procedure with resection floor of mouth, mandibular resection, and 41155 - - $2,362.34 - - radical neck dissection (Commando type) 41250 $224.90 $122.01 - - - Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue 41251 $248.06 $144.88 - - - Repair of laceration 2.5 cm or less; posterior one-third of tongue 41252 $256.49 $164.61 - - - Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex 41510 - - $359.34 - - Suture of tongue to lip for micrognathia (Douglas type procedure) 41512 - - $524.43 - - Tongue base suspension, permanent suture technique 41520 $285.77 $196.50 - - - Frenoplasty (surgical revision of frenum, eg, with Z-plasty) 41530 $775.28 $298.50 - - - Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session 41599 - - I.C. - - Unlisted procedure, tongue, floor of mouth 41800 $238.77 $122.55 - - - Drainage of abscess, cyst, hematoma from dentoalveolar structures 41805 $241.08 $153.26 - - - Removal of embedded foreign body from dentoalveolar structures; soft tissues 41806 $323.79 $219.74 - - - Removal of embedded foreign body from dentoalveolar structures; bone 41820 - - I.C. - - Gingivectomy, excision gingiva, each quadrant 41821 - - I.C. - - Operculectomy, excision pericoronal tissues 41822 $278.50 $157.64 - - - Excision of fibrous tuberosities, dentoalveolar structures 41823 $409.28 $285.52 - - - Excision of osseous tuberosities, dentoalveolar structures 41825 $175.36 $95.37 - - - Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair 41826 $252.65 $163.38 - - - Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair

41827 $358.58 $237.72 - - - Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair 41828 $278.24 $176.22 - - - Excision of hyperplastic alveolar mucosa, each quadrant (specify) 41830 $367.64 $247.07 - - - Alveolectomy, including curettage of osteitis or sequestrectomy 41850 - - I.C. - - Destruction of lesion (except excision), dentoalveolar structures 41870 - - I.C. - - Periodontal mucosal grafting 41872 $361.79 $237.74 - - - Gingivoplasty, each quadrant (specify) 41874 $315.34 $199.70 - - - Alveoloplasty, each quadrant (specify) 41899 - - I.C. - - Unlisted procedure, dentoalveolar structures 42000 $126.18 $82.42 - - - Drainage of abscess of palate, uvula 42100 $118.25 $85.21 - - - Biopsy of palate, uvula 42104 $174.56 $107.89 - - - Excision, lesion of palate, uvula; without closure 42106 $214.54 $134.54 - - - Excision, lesion of palate, uvula; with simple primary closure 42107 $370.98 $268.38 - - - Excision, lesion of palate, uvula; with local flap closure 42120 - - $796.61 - - Resection of palate or extensive resection of lesion 42140 $227.77 $124.01 - - - Uvulectomy, excision of uvula 42145 - - $543.91 - - Palatopharyngoplasty (eg, uvulopalatopharyngoplasty, uvulopharyngoplasty) 42160 $188.86 $114.66 - - - Destruction of lesion, palate or uvula (thermal, cryo or chemical) 42180 $199.97 $145.19 - - - Repair, laceration of palate; up to 2 cm 42182 $258.81 $200.85 - - - Repair, laceration of palate; over 2 cm or complex 42200 - - $749.41 - - Palatoplasty for cleft palate, soft and/or hard palate only 42205 - - $779.35 - - Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge 42210 - - $869.97 - - (includes obtaining graft) 42215 - - $569.56 - - Palatoplasty for cleft palate; major revision 42220 - - $469.21 - - Palatoplasty for cleft palate; secondary lengthening procedure 42225 - - $786.84 - - Palatoplasty for cleft palate; attachment pharyngeal flap 42226 - - $701.18 - - Lengthening of palate, and pharyngeal flap 42227 - - $655.11 - - Lengthening of palate, with island flap 42235 - - $575.38 - - Repair of anterior palate, including vomer flap 42260 $658.45 $518.75 - - - Repair of nasolabial fistula 42280 $142.75 $85.94 - - - Maxillary impression for palatal prosthesis 42281 $183.01 $128.81 - - - Insertion of pin-retained palatal prosthesis

Page 82 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 42299 - - I.C. - - Unlisted procedure, palate, uvula 42300 $170.68 $121.11 - - - Drainage of abscess; parotid, simple 42305 - - $335.72 - - Drainage of abscess; parotid, complicated 42310 $140.09 $105.89 - - - Drainage of abscess; submaxillary or sublingual, intraoral 42320 $204.53 $138.45 - - - Drainage of abscess; submaxillary, external 42330 $185.26 $129.03 - - - Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral 42335 $324.31 $203.16 - - - Sialolithotomy; submandibular (submaxillary), complicated, intraoral 42340 $396.85 $265.26 - - - Sialolithotomy; parotid, extraoral or complicated intraoral 42400 $83.18 $42.31 - - - Biopsy of salivary gland; needle 42405 $239.27 $177.54 - - - Biopsy of salivary gland; incisional 42408 $422.20 $276.99 - - - Excision of sublingual salivary cyst (ranula) 42409 $292.48 $177.13 - - - Marsupialization of sublingual salivary cyst (ranula) 42410 - - $489.15 - - Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of 42415 - - $823.80 - - facial nerve Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial 42420 - - $924.85 - - nerve

42425 - - $653.26 - - Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve 42426 - - $1,053.36 - - Excision of parotid tumor or parotid gland; total, with unilateral radical neck dissection 42440 - - $323.10 - - Excision of submandibular (submaxillary) gland 42450 $367.81 $284.05 - - - Excision of sublingual gland 42500 $348.29 $268.01 - - - Plastic repair of salivary duct, sialodochoplasty; primary or simple 42505 $444.68 $355.12 - - - Plastic repair of salivary duct, sialodochoplasty; secondary or complicated 42507 - - $394.13 - - Parotid duct diversion, bilateral (Wilke type procedure); Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular 42509 - - $650.20 - - glands Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular 42510 - - $482.97 - - (Wharton's) ducts 42550 $123.67 $49.47 - - - Injection procedure for sialography 42600 $407.23 $274.49 - - - Closure salivary fistula 42650 $62.83 $45.44 - - - Dilation salivary duct 42660 $97.89 $68.91 - - - Dilation and catheterization of salivary duct, with or without injection 42665 $276.58 $165.00 - - - Ligation salivary duct, intraoral 42699 - - I.C. - - Unlisted procedure, salivary glands or ducts 42700 $153.02 $106.65 - - - Incision and drainage abscess; peritonsillar 42720 $356.01 $303.84 - - - Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach 42725 - - $630.32 - - Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach 42800 $125.74 $88.93 - - - Biopsy; oropharynx 42804 $159.78 $90.80 - - - Biopsy; nasopharynx, visible lesion, simple 42806 $178.43 $105.39 - - - Biopsy; nasopharynx, survey for unknown primary lesion 42808 $182.05 $127.85 - - - Excision or destruction of lesion of pharynx, any method 42809 $161.12 $97.35 - - - Removal of foreign body from pharynx 42810 $308.40 $224.35 - - - Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or 42815 - - $430.09 - - into pharynx 42820 - - $226.47 - - Tonsillectomy and adenoidectomy; younger than age 12 42821 - - $236.43 - - Tonsillectomy and adenoidectomy; age 12 or over 42825 - - $207.17 - - Tonsillectomy, primary or secondary; younger than age 12 42826 - - $198.05 - - Tonsillectomy, primary or secondary; age 12 or over 42830 - - $164.28 - - Adenoidectomy, primary; younger than age 12 42831 - - $178.00 - - Adenoidectomy, primary; age 12 or over 42835 - - $152.41 - - Adenoidectomy, secondary; younger than age 12 42836 - - $189.71 - - Adenoidectomy, secondary; age 12 or over 42842 - - $796.50 - - Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; without closure Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with local flap 42844 - - $1,095.03 - - (eg, tongue, buccal)

42845 - - $1,752.27 - - Radical resection of tonsil, tonsillar pillars, and/or retromolar trigone; closure with other flap 42860 - - $149.42 - - Excision of tonsil tags 42870 - - $469.32 - - Excision or destruction lingual tonsil, any method (separate procedure) 42890 - - $1,122.94 - - Limited pharyngectomy Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral 42892 - - $1,473.65 - - and posterior pharyngeal walls

Page 83 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Resection of pharyngeal wall requiring closure with myocutaneous or fasciocutaneous flap or 42894 - - $1,859.14 - - free muscle, skin, or fascial flap with microvascular anastomosis 42900 - - $260.85 - - Suture pharynx for wound or injury 42950 - - $637.07 - - Pharyngoplasty (plastic or reconstructive operation on pharynx) 42953 - - $763.84 - - Pharyngoesophageal repair 42955 - - $604.36 - - Pharyngostomy (fistulization of pharynx, external for feeding) 42960 - - $129.81 - - Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); simple Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); 42961 - - $327.76 - - complicated, requiring hospitalization Control oropharyngeal hemorrhage, primary or secondary (eg, post-tonsillectomy); with 42962 - - $403.43 - - secondary surgical intervention Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); simple, 42970 - - $322.13 - - with posterior nasal packs, with or without anterior packs and/or cautery Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); 42971 - - $355.07 - - complicated, requiring hospitalization Control of nasopharyngeal hemorrhage, primary or secondary (eg, postadenoidectomy); with 42972 - - $397.23 - - secondary surgical intervention 42999 - - I.C. - - Unlisted procedure, pharynx, adenoids, or tonsils 43020 - - $442.43 - - Esophagotomy, cervical approach, with removal of foreign body 43030 - - $406.67 - - Cricopharyngeal myotomy 43045 - - $1,014.67 - - Esophagotomy, thoracic approach, with removal of foreign body 43100 - - $492.37 - - Excision of lesion, esophagus, with primary repair; cervical approach 43101 - - $783.97 - - Excision of lesion, esophagus, with primary repair; thoracic or abdominal approach Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical 43107 - - $2,326.65 - - esophagogastrostomy, with or without pyloroplasty (transhiatal) Total or near total esophagectomy, without thoracotomy; with colon interposition or small 43108 - - $3,464.39 - - intestine reconstruction, including intestine mobilization, preparation and anastomosis(es) Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical 43112 - - $2,717.63 - - esophagogastrostomy, with or without pyloroplasty (ie, McKeown esophagectomy or tri- incisional esophagectomy) Total or near total esophagectomy, with thoracotomy; with colon interposition or small 43113 - - $3,384.56 - - intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, 43116 - - $3,877.18 - - obtaining the graft and intestinal reconstruction Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, 43117 - - $2,533.19 - - with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis) Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, 43118 - - $2,820.82 - - with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal 43121 - - $2,220.64 - - gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal 43122 - - $2,000.58 - - gastrectomy; with esophagogastrostomy, with or without pyloroplasty Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal 43123 - - $3,509.79 - - gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) Total or partial esophagectomy, without reconstruction (any approach), with cervical 43124 - - $2,961.96 - - esophagostomy

43130 - - $616.22 - - Diverticulectomy of hypopharynx or esophagus, with or without myotomy; cervical approach

43135 - - $1,143.90 - - Diverticulectomy of hypopharynx or esophagus, with or without myotomy; thoracic approach Esophagoscopy, rigid, transoral with diverticulectomy of hypopharynx or cervical esophagus 43180 - - $426.61 - - (eg, Zenker's diverticulum), with cricopharyngeal myotomy, includes use of telescope or operating microscope and repair, when performed Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or 43191 - - $120.71 - - washing when performed (separate procedure) 43192 - - $132.25 - - Esophagoscopy, rigid, transoral; with directed submucosal injection(s), any substance 43193 - - $131.96 - - Esophagoscopy, rigid, transoral; with biopsy, single or multiple 43194 - - $149.81 - - Esophagoscopy, rigid, transoral; with removal of foreign body(s) 43195 - - $143.56 - - Esophagoscopy, rigid, transoral; with balloon dilation (less than 30 mm diameter) Esophagoscopy, rigid, transoral; with insertion of guide wire followed by dilation over guide 43196 - - $153.07 - - wire Esophagoscopy, flexible, transnasal; diagnostic, including collection of specimen(s) by brushing 43197 $155.13 $64.70 - - - or washing, when performed (separate procedure)

Page 84 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 43198 $170.58 $77.25 - - - Esophagoscopy, flexible, transnasal; with biopsy, single or multiple Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or 43200 $195.26 $68.61 - - - washing, when performed (separate procedure) 43201 $194.39 $81.07 - - - Esophagoscopy, flexible, transoral; with directed submucosal injection(s), any substance 43202 $274.14 $80.82 - - - Esophagoscopy, flexible, transoral; with biopsy, single or multiple 43204 - - $106.14 - - Esophagoscopy, flexible, transoral; with injection sclerosis of esophageal varices 43205 - - $110.75 - - Esophagoscopy, flexible, transoral; with band ligation of esophageal varices 43206 $229.18 $104.26 - - - Esophagoscopy, flexible, transoral; with optical endomicroscopy Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or 43210 - - $337.87 - - complete, includes duodenoscopy when performed 43211 - - $183.92 - - Esophagoscopy, flexible, transoral; with endoscopic mucosal resection Esophagoscopy, flexible, transoral; with placement of endoscopic stent (includes pre- and post- 43212 - - $147.96 - - dilation and guide wire passage, when performed) Esophagoscopy, flexible, transoral; with dilation of esophagus, by balloon or dilator, retrograde 43213 $999.88 $202.54 - - - (includes fluoroscopic guidance, when performed) Esophagoscopy, flexible, transoral; with dilation of esophagus with balloon (30 mm diameter or 43214 - - $150.95 - - larger) (includes fluoroscopic guidance, when performed) 43215 $309.80 $110.68 - - - Esophagoscopy, flexible, transoral; with removal of foreign body(s) Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot 43216 $317.46 $105.01 - - - biopsy forceps Esophagoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by 43217 $323.05 $125.68 - - - snare technique Esophagoscopy, flexible, transoral; with transendoscopic balloon dilation (less than 30 mm 43220 $828.35 $92.46 - - - diameter) Esophagoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) 43226 $288.40 $101.75 - - - over guide wire 43227 $504.18 $129.13 - - - Esophagoscopy, flexible, transoral; with control of bleeding, any method Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) 43229 $563.99 $154.74 - - - (includes pre- and post-dilation and guide wire passage, when performed) 43231 - - $124.90 - - Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination Esophagoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or 43232 - - $156.26 - - transmural fine needle aspiration/biopsy(s) Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon (30 43233 - - $179.31 - - mm diameter or larger) (includes fluoroscopic guidance, when performed) Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of 43235 $224.98 $96.30 - - - specimen(s) by brushing or washing, when performed (separate procedure) Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any 43236 $301.59 $108.56 - - - substance Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination 43237 - - $153.28 - - limited to the esophagus, stomach or duodenum, and adjacent structures Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided 43238 - - $181.99 - - intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) 43239 $300.96 $108.51 - - - Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple Esophagogastroduodenoscopy, flexible, transoral; with transmural drainage of pseudocyst 43240 - - $307.31 - - (includes placement of transmural drainage catheter[s]/stent[s], when performed, and endoscopic ultrasound, when performed) Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or 43241 - - $111.17 - - catheter Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound 43242 - - $205.87 - - examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) Esophagogastroduodenoscopy, flexible, transoral; with injection sclerosis of esophageal/gastric 43243 - - $185.89 - - varices Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric 43244 - - $192.28 - - varices Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) 43245 $477.22 $137.83 - - - (eg, balloon, bougie) Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous 43246 - - $157.06 - - gastrostomy tube 43247 $297.01 $138.76 - - - Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by 43248 $312.26 $129.95 - - - passage of dilator(s) through esophagus over guide wire Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of 43249 $891.99 $120.15 - - - esophagus (less than 30 mm diameter)

Page 85 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other 43250 $348.67 $133.90 - - - lesion(s) by hot biopsy forceps Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other 43251 $383.27 $153.72 - - - lesion(s) by snare technique 43252 $259.16 $132.50 - - - Esophagogastroduodenoscopy, flexible, transoral; with optical endomicroscopy Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided transmural injection of diagnostic or therapeutic substance(s) (eg, anesthetic, neurolytic agent) 43253 - - $206.36 - - or fiducial marker(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) 43254 - - $211.77 - - Esophagogastroduodenoscopy, flexible, transoral; with endoscopic mucosal resection 43255 $531.20 $157.32 - - - Esophagogastroduodenoscopy, flexible, transoral; with control of bleeding, any method Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the 43257 - - $182.77 - - muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, 43259 - - $177.40 - - including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, including collection of 43260 - - $252.68 - - specimen(s) by brushing or washing, when performed (separate procedure) 43261 - - $264.89 - - Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple 43262 - - $279.55 - - Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of 43263 - - $279.55 - - sphincter of Oddi Endoscopic retrograde cholangiopancreatography (ERCP); with removal of calculi/debris from 43264 - - $284.69 - - biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with destruction of calculi, any 43265 - - $339.33 - - method (eg, mechanical, electrohydraulic, lithotripsy) Esophagogastroduodenoscopy, flexible, transoral; with placement of endoscopic stent (includes 43266 - - $170.52 - - pre- and post-dilation and guide wire passage, when performed) Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other 43270 $577.99 $175.98 - - - lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) Endoscopic cannulation of papilla with direct visualization of pancreatic/common bile duct(s) 43273 - - $93.95 - - (List separately in addition to code(s) for primary procedure) Endoscopic retrograde cholangiopancreatography (ERCP); with placement of endoscopic stent 43274 - - $362.34 - - into biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent Endoscopic retrograde cholangiopancreatography (ERCP); with removal of foreign body(s) or 43275 - - $294.63 - - stent(s) from biliary/pancreatic duct(s) Endoscopic retrograde cholangiopancreatography (ERCP); with removal and exchange of 43276 - - $377.02 - - stent(s), biliary or pancreatic duct, including pre- and post-dilation and guide wire passage, when performed, including sphincterotomy, when performed, each stent exchanged Endoscopic retrograde cholangiopancreatography (ERCP); with trans-endoscopic balloon 43277 - - $296.27 - - dilation of biliary/pancreatic duct(s) or of ampulla (sphincteroplasty), including sphincterotomy, when performed, each duct

43278 - - $339.31 - - Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s), including pre- and post-dilation and guide wire passage, when performed 43279 - - $1,010.62 - - Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed 43280 - - $848.61 - - Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures) Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; 43281 - - $1,210.94 - - without implantation of mesh Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; 43282 - - $1,360.86 - - with implantation of mesh Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge 43283 - - $123.06 - - gastroplasty) (List separately in addition to code for primary procedure) Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter 43284 - - $512.98 - - augmentation device (ie, magnetic band), including cruroplasty when performed 43285 - - $528.22 - - Removal of esophageal sphincter augmentation device Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure 43286 - - $2,484.97 - - if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, laparoscopic transhiatal esophagectomy)

Page 86 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Esophagectomy, distal two-thirds, with laparoscopic mobilization of the abdominal and lower mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure 43287 - - $2,805.38 - - if performed, with separate thoracoscopic mobilization of the middle and upper mediastinal esophagus and thoracic esophagogastrostomy (ie, laparoscopic thoracoscopic esophagectomy, Ivor Lewis esophagectomy) Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, and lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with 43288 - - $2,952.05 - - laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (ie, thoracoscopic, laparoscopic and cervical incision esophagectomy, McKeown esophagectomy, tri-incisional esophagectomy) 43289 - - I.C. - - Unlisted laparoscopy procedure, esophagus Esophagoplasty (plastic repair or reconstruction), cervical approach; without repair of 43300 - - $484.09 - - tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), cervical approach; with repair of 43305 - - $851.03 - - tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), thoracic approach; without repair of 43310 - - $1,152.57 - - tracheoesophageal fistula Esophagoplasty (plastic repair or reconstruction), thoracic approach; with repair of 43312 - - $1,236.18 - - tracheoesophageal fistula Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; 43313 - - $2,124.83 - - without repair of congenital tracheoesophageal fistula Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; with 43314 - - $2,285.58 - - repair of congenital tracheoesophageal fistula Esophagogastrostomy (cardioplasty), with or without vagotomy and pyloroplasty, 43320 - - $1,098.37 - - transabdominal or transthoracic approach 43325 - - $1,068.08 - - Esophagogastric fundoplasty, with fundic patch (Thal-Nissen procedure) 43327 - - $645.59 - - Esophagogastric fundoplasty partial or complete; laparotomy 43328 - - $875.55 - - Esophagogastric fundoplasty partial or complete; thoracotomy 43330 - - $1,050.41 - - Esophagomyotomy (Heller type); abdominal approach 43331 - - $1,043.06 - - Esophagomyotomy (Heller type); thoracic approach Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except 43332 - - $907.94 - - neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except 43333 - - $991.62 - - neonatal; with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except 43334 - - $972.70 - - neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia (including fundoplication), via thoracotomy, except 43335 - - $1,039.59 - - neonatal; with implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, 43336 - - $1,128.34 - - except neonatal; without implantation of mesh or other prosthesis Repair, paraesophageal hiatal hernia, (including fundoplication), via thoracoabdominal incision, 43337 - - $1,203.48 - - except neonatal; with implantation of mesh or other prosthesis Esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty) (List 43338 - - $89.95 - - separately in addition to code for primary procedure) 43340 - - $1,084.44 - - Esophagojejunostomy (without total gastrectomy); abdominal approach 43341 - - $1,090.27 - - Esophagojejunostomy (without total gastrectomy); thoracic approach 43351 - - $1,026.58 - - Esophagostomy, fistulization of esophagus, external; thoracic approach 43352 - - $831.28 - - Esophagostomy, fistulization of esophagus, external; cervical approach

43360 - - $1,750.18 - - Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion or fistula, or for previous esophageal exclusion; with stomach, with or without pyloroplasty Gastrointestinal reconstruction for previous esophagectomy, for obstructing esophageal lesion 43361 - - $2,116.24 - - or fistula, or for previous esophageal exclusion; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es) 43400 - - $1,196.30 - - Ligation, direct, esophageal varices 43405 - - $1,134.39 - - Ligation or stapling at gastroesophageal junction for pre-existing esophageal perforation 43410 - - $800.90 - - Suture of esophageal wound or injury; cervical approach 43415 - - $2,003.79 - - Suture of esophageal wound or injury; transthoracic or transabdominal approach 43420 - - $791.90 - - Closure of esophagostomy or fistula; cervical approach 43425 - - $1,122.59 - - Closure of esophagostomy or fistula; transthoracic or transabdominal approach 43450 $137.42 $62.06 - - - Dilation of esophagus, by unguided sound or bougie, single or multiple passes 43453 $722.43 $67.41 - - - Dilation of esophagus, over guide wire 43460 - - $166.52 - - Esophagogastric tamponade, with balloon (Sengstaken type) 43496 - - I.C. - - Free jejunum transfer with microvascular anastomosis 43499 - - I.C. - - Unlisted procedure, esophagus 43500 - - $617.08 - - Gastrotomy; with exploration or foreign body removal

Page 87 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 43501 - - $1,058.99 - - Gastrotomy; with suture repair of bleeding ulcer 43502 - - $1,198.88 - - Gastrotomy; with suture repair of pre-existing esophagogastric laceration (eg, Mallory-Weiss) Gastrotomy; with esophageal dilation and insertion of permanent intraluminal tube (eg, 43510 - - $747.25 - - Celestin or Mousseaux-Barbin) 43520 - - $538.78 - - Pyloromyotomy, cutting of pyloric muscle (Fredet-Ramstedt type operation) 43605 - - $660.35 - - Biopsy of stomach, by laparotomy 43610 - - $771.09 - - Excision, local; ulcer or benign tumor of stomach 43611 - - $961.27 - - Excision, local; malignant tumor of stomach 43620 - - $1,557.07 - - Gastrectomy, total; with esophagoenterostomy 43621 - - $1,779.98 - - Gastrectomy, total; with Roux-en-Y reconstruction 43622 - - $1,815.05 - - Gastrectomy, total; with formation of intestinal pouch, any type 43631 - - $1,139.85 - - Gastrectomy, partial, distal; with gastroduodenostomy 43632 - - $1,596.33 - - Gastrectomy, partial, distal; with gastrojejunostomy 43633 - - $1,509.99 - - Gastrectomy, partial, distal; with Roux-en-Y reconstruction 43634 - - $1,669.40 - - Gastrectomy, partial, distal; with formation of intestinal pouch Vagotomy when performed with partial distal gastrectomy (List separately in addition to 43635 - - $88.09 - - code[s] for primary procedure) 43640 - - $926.90 - - Vagotomy including pyloroplasty, with or without gastrostomy; truncal or selective 43641 - - $947.24 - - Vagotomy including pyloroplasty, with or without gastrostomy; parietal cell (highly selective) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y 43644 - - $1,364.44 - - gastroenterostomy (roux limb 150 cm or less) Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine 43645 - - $1,452.20 - - reconstruction to limit absorption Laparoscopy, surgical; implantation or replacement of gastric neurostimulator electrodes, 43647 - - I.C. - - antrum 43648 - - I.C. - - Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum 43651 - - $517.04 - - Laparoscopy, surgical; transection of vagus nerves, truncal 43652 - - $602.96 - - Laparoscopy, surgical; transection of vagus nerves, selective or highly selective Laparoscopy, surgical; gastrostomy, without construction of gastric tube (eg, Stamm procedure) 43653 - - $454.76 - - (separate procedure) 43659 - - I.C. - - Unlisted laparoscopy procedure, stomach Naso- or oro-gastric tube placement, requiring physician's skill and fluoroscopic guidance 43752 - - $31.81 - - (includes fluoroscopy, image documentation and report) Gastric intubation and aspiration(s) therapeutic, necessitating physician's skill (eg, for 43753 - - $17.33 - - gastrointestinal hemorrhage), including lavage if performed 43754 $148.62 $28.34 - - - Gastric intubation and aspiration, diagnostic; single specimen (eg, acid analysis) Gastric intubation and aspiration, diagnostic; collection of multiple fractional specimens with 43755 $139.02 $46.56 - - - gastric stimulation, single or double lumen tube (gastric secretory study) (eg, histamine, insulin, pentagastrin, calcium, secretin), includes drug administration Duodenal intubation and aspiration, diagnostic, includes image guidance; single specimen (eg, 43756 $203.78 $40.02 - - - bile study for crystals or afferent loop culture) Duodenal intubation and aspiration, diagnostic, includes image guidance; collection of multiple 43757 $279.20 $60.08 - - - fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube, includes drug administration Repositioning of a naso- or oro-gastric feeding tube, through the duodenum for enteric 43761 $95.29 $81.09 - - - nutrition Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without 43762 $184.56 $29.50 - - - imaging or endoscopic guidance; not requiring revision of gastrostomy tract Replacement of gastrostomy tube, percutaneous, includes removal, when performed, without 43763 $274.81 $66.13 - - - imaging or endoscopic guidance; requiring revision of gastrostomy tract Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive 43770 - - $887.00 - - device (eg, gastric band and subcutaneous port components) Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive 43771 - - $1,006.73 - - device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive 43772 - - $748.61 - - device component only Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable 43773 - - $1,006.73 - - gastric restrictive device component only Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive 43774 - - $756.09 - - device and subcutaneous port components Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (ie, sleeve 43775 - - $871.99 - - gastrectomy) 43800 - - $733.78 - - Pyloroplasty 43810 - - $800.83 - - Gastroduodenostomy

Page 88 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 43820 - - $1,056.22 - - Gastrojejunostomy; without vagotomy 43825 - - $1,030.76 - - Gastrojejunostomy; with vagotomy, any type Gastrostomy, open; without construction of gastric tube (eg, Stamm procedure) (separate 43830 - - $554.33 - - procedure) 43831 - - $477.66 - - Gastrostomy, open; neonatal, for feeding 43832 - - $818.23 - - Gastrostomy, open; with construction of gastric tube (eg, Janeway procedure) 43840 - - $1,069.42 - - Gastrorrhaphy, suture of perforated duodenal or gastric ulcer, wound, or injury Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded 43842 - - $909.13 - - gastroplasty Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical- 43843 - - $1,009.26 - - banded gastroplasty Gastric restrictive procedure with partial gastrectomy, pylorus-preserving duodenoileostomy 43845 - - $1,529.46 - - and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or 43846 - - $1,277.14 - - less) Roux-en-Y gastroenterostomy Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine 43847 - - $1,419.94 - - reconstruction to limit absorption Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric 43848 - - $1,521.74 - - restrictive device (separate procedure) Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without 43850 - - $1,280.52 - - vagotomy Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with 43855 - - $1,328.17 - - vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without 43860 - - $1,285.57 - - partial gastrectomy or intestine resection; without vagotomy Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without 43865 - - $1,343.69 - - partial gastrectomy or intestine resection; with vagotomy 43870 - - $559.66 - - Closure of gastrostomy, surgical 43880 - - $1,250.30 - - Closure of gastrocolic fistula 43881 - - I.C. - - Implantation or replacement of gastric neurostimulator electrodes, antrum, open 43882 - - I.C. - - Revision or removal of gastric neurostimulator electrodes, antrum, open 43886 - - $290.16 - - Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 - - $260.63 - - Gastric restrictive procedure, open; removal of subcutaneous port component only Gastric restrictive procedure, open; removal and replacement of subcutaneous port component 43888 - - $367.23 - - only 43999 - - I.C. - - Unlisted procedure, stomach 44005 - - $858.63 - - Enterolysis (freeing of intestinal adhesion) (separate procedure) 44010 - - $674.03 - - Duodenotomy, for exploration, biopsy(s), or foreign body removal Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (List 44015 - - $111.05 - - separately in addition to primary procedure) Enterotomy, small intestine, other than duodenum; for exploration, biopsy(s), or foreign body 44020 - - $765.59 - - removal 44021 - - $765.82 - - Enterotomy, small intestine, other than duodenum; for decompression (eg, Baker tube) 44025 - - $772.18 - - Colotomy, for exploration, biopsy(s), or foreign body removal 44050 - - $735.42 - - Reduction of volvulus, intussusception, internal hernia, by laparotomy Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, 44055 - - $1,169.08 - - Ladd procedure) 44100 - - $84.21 - - Biopsy of intestine by capsule, tube, peroral (1 or more specimens) Excision of 1 or more lesions of small or large intestine not requiring anastomosis, 44110 - - $663.98 - - exteriorization, or fistulization; single enterotomy Excision of 1 or more lesions of small or large intestine not requiring anastomosis, 44111 - - $769.18 - - exteriorization, or fistulization; multiple enterotomies 44120 - - $960.01 - - Enterectomy, resection of small intestine; single resection and anastomosis Enterectomy, resection of small intestine; each additional resection and anastomosis (List 44121 - - $188.63 - - separately in addition to code for primary procedure) 44125 - - $925.94 - - Enterectomy, resection of small intestine; with enterostomy Enterectomy, resection of small intestine for congenital atresia, single resection and 44126 - - $1,939.00 - - anastomosis of proximal segment of intestine; without tapering Enterectomy, resection of small intestine for congenital atresia, single resection and 44127 - - $2,240.39 - - anastomosis of proximal segment of intestine; with tapering Enterectomy, resection of small intestine for congenital atresia, single resection and 44128 - - $190.35 - - anastomosis of proximal segment of intestine; each additional resection and anastomosis (List separately in addition to code for primary procedure) Enteroenterostomy, anastomosis of intestine, with or without cutaneous enterostomy 44130 - - $1,032.65 - - (separate procedure)

Page 89 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 44132 - - I.C. - - Donor enterectomy (including cold preservation), open; from cadaver donor 44133 - - I.C. - - Donor enterectomy (including cold preservation), open; partial, from living donor 44135 - - I.C. - - Intestinal allotransplantation; from cadaver donor 44136 - - I.C. - - Intestinal allotransplantation; from living donor 44137 - - I.C. - - Removal of transplanted intestinal allograft, complete Mobilization (take-down) of splenic flexure performed in conjunction with partial colectomy 44139 - - $94.38 - - (List separately in addition to primary procedure) 44140 - - $1,053.92 - - Colectomy, partial; with anastomosis 44141 - - $1,433.41 - - Colectomy, partial; with skin level cecostomy or colostomy Colectomy, partial; with end colostomy and closure of distal segment (Hartmann type 44143 - - $1,306.63 - - procedure)

44144 - - $1,387.20 - - Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula 44145 - - $1,296.08 - - Colectomy, partial; with coloproctostomy (low pelvic anastomosis) 44146 - - $1,656.50 - - Colectomy, partial; with coloproctostomy (low pelvic anastomosis), with colostomy 44147 - - $1,518.99 - - Colectomy, partial; abdominal and transanal approach 44150 - - $1,466.38 - - Colectomy, total, abdominal, without proctectomy; with ileostomy or ileoproctostomy 44151 - - $1,700.44 - - Colectomy, total, abdominal, without proctectomy; with continent ileostomy 44155 - - $1,626.36 - - Colectomy, total, abdominal, with proctectomy; with ileostomy 44156 - - $1,820.53 - - Colectomy, total, abdominal, with proctectomy; with continent ileostomy Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, includes loop 44157 - - $1,725.78 - - ileostomy, and rectal mucosectomy, when performed Colectomy, total, abdominal, with proctectomy; with ileoanal anastomosis, creation of ileal 44158 - - $1,768.62 - - reservoir (S or J), includes loop ileostomy, and rectal mucosectomy, when performed 44160 - - $975.29 - - Colectomy, partial, with removal of terminal ileum with ileocolostomy 44180 - - $723.10 - - Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure) 44186 - - $513.53 - - Laparoscopy, surgical; jejunostomy (eg, for decompression or feeding) 44187 - - $864.59 - - Laparoscopy, surgical; ileostomy or jejunostomy, non-tube 44188 - - $961.49 - - Laparoscopy, surgical, colostomy or skin level cecostomy Laparoscopy, surgical; enterectomy, resection of small intestine, single resection and 44202 - - $1,087.96 - - anastomosis Laparoscopy, surgical; each additional small intestine resection and anastomosis (List separately 44203 - - $187.65 - - in addition to code for primary procedure) 44204 - - $1,205.76 - - Laparoscopy, surgical; colectomy, partial, with anastomosis 44205 - - $1,047.73 - - Laparoscopy, surgical; colectomy, partial, with removal of terminal ileum with ileocolostomy Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment 44206 - - $1,370.84 - - (Hartmann type procedure) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic 44207 - - $1,420.99 - - anastomosis) Laparoscopy, surgical; colectomy, partial, with anastomosis, with coloproctostomy (low pelvic 44208 - - $1,550.62 - - anastomosis) with colostomy Laparoscopy, surgical; colectomy, total, abdominal, without proctectomy, with ileostomy or 44210 - - $1,390.28 - - ileoproctostomy Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileoanal 44211 - - $1,662.23 - - anastomosis, creation of ileal reservoir (S or J), with loop ileostomy, includes rectal mucosectomy, when performed 44212 - - $1,599.60 - - Laparoscopy, surgical; colectomy, total, abdominal, with proctectomy, with ileostomy Laparoscopy, surgical, mobilization (take-down) of splenic flexure performed in conjunction 44213 - - $145.77 - - with partial colectomy (List separately in addition to primary procedure) Laparoscopy, surgical, closure of enterostomy, large or small intestine, with resection and 44227 - - $1,304.84 - - anastomosis 44238 - - I.C. - - Unlisted laparoscopy procedure, intestine (except rectum) Placement, enterostomy or cecostomy, tube open (eg, for feeding or decompression) (separate 44300 - - $662.88 - - procedure) 44310 - - $817.44 - - Ileostomy or jejunostomy, non-tube 44312 - - $467.65 - - Revision of ileostomy; simple (release of superficial scar) (separate procedure) 44314 - - $789.94 - - Revision of ileostomy; complicated (reconstruction in-depth) (separate procedure) 44316 - - $1,112.14 - - Continent ileostomy (Kock procedure) (separate procedure) 44320 - - $943.40 - - Colostomy or skin level cecostomy; Colostomy or skin level cecostomy; with multiple biopsies (eg, for congenital megacolon) 44322 - - $800.12 - - (separate procedure) 44340 - - $491.82 - - Revision of colostomy; simple (release of superficial scar) (separate procedure) 44345 - - $825.13 - - Revision of colostomy; complicated (reconstruction in-depth) (separate procedure) 44346 - - $928.96 - - Revision of colostomy; with repair of paracolostomy hernia (separate procedure)

Page 90 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44360 - - $112.66 - - ileum; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44361 - - $124.30 - - ileum; with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44363 - - $150.49 - - ileum; with removal of foreign body(s) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44364 - - $160.33 - - ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44365 - - $142.46 - - ileum; with 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 44366 - - $188.22 - - ileum; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44369 - - $192.84 - - ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44370 - - $209.07 - - ileum; with transendoscopic stent placement (includes predilation) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including 44372 - - $187.91 - - ileum; with placement of percutaneous jejunostomy tube

44373 - - $150.60 - - Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; 44376 - - $222.59 - - diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; 44377 - - $234.21 - - with biopsy, single or multiple Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; 44378 - - $301.19 - - with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; 44379 - - $320.37 - - with transendoscopic stent placement (includes predilation) Ileoscopy, through stoma; diagnostic, including collection of specimen(s) by brushing or 44380 $148.17 $44.12 - - - washing, when performed (separate procedure) 44381 $803.95 $65.45 - - - Ileoscopy, through stoma; with transendoscopic balloon dilation 44382 $232.47 $57.41 - - - Ileoscopy, through stoma; with biopsy, single or multiple Ileoscopy, through stoma; with placement of endoscopic stent (includes pre- and post-dilation 44384 - - $120.16 - - and guide wire passage, when performed) Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); 44385 $161.87 $56.66 - - - diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Endoscopic evaluation of small intestinal pouch (eg, Kock pouch, ileal reservoir [S or J]); with 44386 $243.03 $69.99 - - - biopsy, single or multiple Colonoscopy through stoma; diagnostic, including collection of specimen(s) by brushing or 44388 $243.39 $122.52 - - - washing, when performed (separate procedure) 44389 $322.40 $134.87 - - - Colonoscopy through stoma; with biopsy, single or multiple 44390 $314.21 $164.94 - - - Colonoscopy through stoma; with removal of foreign body(s) 44391 $546.32 $180.55 - - - Colonoscopy through stoma; with control of bleeding, any method Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy 44392 $295.59 $156.47 - - - forceps Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare 44394 $338.80 $176.78 - - - technique Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- 44401 $2,312.58 $190.11 - - - and post-dilation and guide wire passage, when performed) Colonoscopy through stoma; with endoscopic stent placement (including pre- and post-dilation 44402 - - $205.28 - - and guide wire passage, when performed) 44403 - - $238.07 - - Colonoscopy through stoma; with endoscopic mucosal resection 44404 $320.70 $134.92 - - - Colonoscopy through stoma; with directed submucosal injection(s), any substance 44405 $451.62 $143.52 - - - Colonoscopy through stoma; with transendoscopic balloon dilation Colonoscopy through stoma; with endoscopic ultrasound examination, limited to the sigmoid, 44406 - - $179.82 - - descending, transverse, or ascending colon and cecum and adjacent structures

Page 91 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

Colonoscopy through stoma; with transendoscopic ultrasound guided intramural or transmural 44407 - - $215.85 - - fine needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the sigmoid, descending, transverse, or ascending colon and cecum and adjacent structures Colonoscopy through stoma; with decompression (for pathologic distention) (eg, volvulus, 44408 - - $181.46 - - megacolon), including placement of decompression tube, when performed 44500 - - $15.14 - - Introduction of long gastrointestinal tube (eg, Miller-Abbott) (separate procedure) Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or 44602 - - $1,105.03 - - rupture; single perforation Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or 44603 - - $1,269.47 - - rupture; multiple perforations Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or 44604 - - $829.40 - - rupture (single or multiple perforations); without colostomy Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or 44605 - - $1,023.22 - - rupture (single or multiple perforations); with colostomy Intestinal stricturoplasty (enterotomy and enterorrhaphy) with or without dilation, for 44615 - - $845.80 - - intestinal obstruction 44620 - - $680.22 - - Closure of enterostomy, large or small intestine; Closure of enterostomy, large or small intestine; with resection and anastomosis other than 44625 - - $794.09 - - colorectal Closure of enterostomy, large or small intestine; with resection and colorectal anastomosis (eg, 44626 - - $1,252.86 - - closure of Hartmann type procedure) 44640 - - $1,096.38 - - Closure of intestinal cutaneous fistula 44650 - - $1,133.47 - - Closure of enteroenteric or enterocolic fistula 44660 - - $1,044.96 - - Closure of enterovesical fistula; without intestinal or bladder resection 44661 - - $1,214.15 - - Closure of enterovesical fistula; with intestine and/or bladder resection 44680 - - $832.59 - - Intestinal plication (separate procedure) Exclusion of small intestine from pelvis by mesh or other prosthesis, or native tissue (eg, 44700 - - $786.22 - - bladder or omentum) 44701 - - $133.01 - - Intraoperative colonic lavage (List separately in addition to code for primary procedure) 44705 $87.61 $56.30 - - - Preparation of fecal microbiota for instillation, including assessment of donor specimen Backbench standard preparation of cadaver or living donor intestine allograft prior to 44715 - - I.C. - - transplantation, including mobilization and fashioning of the superior mesenteric artery and vein Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; 44720 - - $214.67 - - venous anastomosis, each Backbench reconstruction of cadaver or living donor intestine allograft prior to transplantation; 44721 - - $300.10 - - arterial anastomosis, each 44799 - - I.C. - - Unlisted procedure, small intestine 44800 - - $606.46 - - Excision of Meckel's diverticulum (diverticulectomy) or omphalomesenteric duct 44820 - - $656.88 - - Excision of lesion of mesentery (separate procedure) 44850 - - $586.27 - - Suture of mesentery (separate procedure) 44899 - - I.C. - - Unlisted procedure, Meckel's diverticulum and the mesentery 44900 - - $616.99 - - Incision and drainage of appendiceal abscess, open 44950 - - $505.65 - - Appendectomy; Appendectomy; when done for indicated purpose at time of other major procedure (not as 44955 - - $65.23 - - separate procedure) (List separately in addition to code for primary procedure) 44960 - - $689.70 - - Appendectomy; for ruptured appendix with abscess or generalized peritonitis 44970 - - $473.71 - - Laparoscopy, surgical, appendectomy 44979 - - I.C. - - Unlisted laparoscopy procedure, appendix 45000 - - $337.38 - - Transrectal drainage of pelvic abscess 45005 $235.94 $128.99 - - - Incision and drainage of submucosal abscess, rectum 45020 - - $451.68 - - Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess 45100 - - $237.50 - - Biopsy of anorectal wall, anal approach (eg, congenital megacolon) 45108 - - $293.94 - - Anorectal myomectomy 45110 - - $1,439.21 - - Proctectomy; complete, combined abdominoperineal, with colostomy 45111 - - $852.93 - - Proctectomy; partial resection of rectum, transabdominal approach

45112 - - $1,457.12 - - Proctectomy, combined abdominoperineal, pull-through procedure (eg, colo-anal anastomosis) Proctectomy, partial, with rectal mucosectomy, ileoanal anastomosis, creation of ileal reservoir 45113 - - $1,470.70 - - (S or J), with or without loop ileostomy 45114 - - $1,427.62 - - Proctectomy, partial, with anastomosis; abdominal and transsacral approach 45116 - - $1,211.48 - - Proctectomy, partial, with anastomosis; transsacral approach only (Kraske type)

45119 - - $1,509.42 - - Proctectomy, combined abdominoperineal pull-through procedure (eg, colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy when performed

Page 92 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with pull- 45120 - - $1,255.46 - - through procedure and anastomosis (eg, Swenson, Duhamel, or Soave type operation) Proctectomy, complete (for congenital megacolon), abdominal and perineal approach; with 45121 - - $1,370.77 - - subtotal or total colectomy, with multiple biopsies 45123 - - $874.14 - - Proctectomy, partial, without anastomosis, perineal approach Pelvic exenteration for colorectal malignancy, with proctectomy (with or without colostomy), with removal of bladder and ureteral transplantations, and/or hysterectomy, or cervicectomy, 45126 - - $2,167.14 - - with or without removal of tube(s), with or without removal of ovary(s), or any combination thereof 45130 - - $850.60 - - Excision of rectal procidentia, with anastomosis; perineal approach 45135 - - $1,015.99 - - Excision of rectal procidentia, with anastomosis; abdominal and perineal approach 45136 - - $1,408.67 - - Excision of ileoanal reservoir with ileostomy 45150 - - $331.38 - - Division of stricture of rectum 45160 - - $806.87 - - Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach Excision of rectal tumor, transanal approach; not including muscularis propria (ie, partial 45171 - - $480.44 - - thickness) 45172 - - $642.51 - - Excision of rectal tumor, transanal approach; including muscularis propria (ie, full thickness) Destruction of rectal tumor (eg, electrodesiccation, electrosurgery, laser ablation, laser 45190 - - $553.34 - - resection, cryosurgery) transanal approach Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or 45300 $99.56 $37.54 - - - washing (separate procedure) 45303 $785.42 $66.63 - - - Proctosigmoidoscopy, rigid; with dilation (eg, balloon, guide wire, bougie) 45305 $130.51 $57.19 - - - Proctosigmoidoscopy, rigid; with biopsy, single or multiple 45307 $149.38 $76.34 - - - Proctosigmoidoscopy, rigid; with removal of foreign body Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy 45308 $147.53 $66.08 - - - forceps or bipolar cautery Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare 45309 $152.41 $70.39 - - - technique Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot 45315 $165.80 $83.20 - - - biopsy forceps, bipolar cautery or snare technique Proctosigmoidoscopy, rigid; with control of bleeding (eg, injection, bipolar cautery, unipolar 45317 $161.60 $87.11 - - - cautery, laser, heater probe, stapler, plasma coagulator) Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable 45320 $161.55 $82.43 - - - to removal by hot biopsy forceps, bipolar cautery or snare technique (eg, laser) 45321 - - $81.34 - - Proctosigmoidoscopy, rigid; with decompression of volvulus 45327 - - $92.05 - - Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, 45330 $141.78 $44.11 - - - when performed (separate procedure) 45331 $223.56 $56.32 - - - Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 $213.13 $82.71 - - - Sigmoidoscopy, flexible; with removal of foreign body(s) Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy 45333 $253.74 $73.75 - - - forceps 45334 $429.68 $92.02 - - - Sigmoidoscopy, flexible; with control of bleeding, any method 45335 $216.56 $52.22 - - - Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance Sigmoidoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, 45337 - - $90.43 - - megacolon), including placement of decompression tube, when performed Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare 45338 $227.69 $94.37 - - - technique 45340 $370.68 $61.13 - - - Sigmoidoscopy, flexible; with transendoscopic balloon dilation 45341 - - $97.18 - - Sigmoidoscopy, flexible; with endoscopic ultrasound examination Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine 45342 - - $132.97 - - needle aspiration/biopsy(s) Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and 45346 $2,259.91 $125.56 - - - post-dilation and guide wire passage, when performed) Sigmoidoscopy, flexible; with placement of endoscopic stent (includes pre- and post-dilation 45347 - - $120.66 - - and guide wire passage, when performed) 45349 - - $155.67 - - Sigmoidoscopy, flexible; with endoscopic mucosal resection 45350 $511.08 $79.52 - - - Sigmoidoscopy, flexible; with band ligation(s) (eg, hemorrhoids) Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, 45378 $263.17 $145.21 - - - when performed (separate procedure) 45379 $339.34 $187.47 - - - Colonoscopy, flexible; with removal of foreign body(s) 45380 $340.98 $157.23 - - - Colonoscopy, flexible; with biopsy, single or multiple 45381 $338.37 $157.23 - - - Colonoscopy, flexible; with directed submucosal injection(s), any substance 45382 $566.51 $203.06 - - - Colonoscopy, flexible; with control of bleeding, any method Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy 45384 $379.63 $178.77 - - - forceps

Page 93 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

45385 $353.66 $199.46 - - - Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 $493.36 $165.85 - - - Colonoscopy, flexible; with transendoscopic balloon dilation Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and 45388 $2,388.05 $212.25 - - - post-dilation and guide wire passage, when performed) Colonoscopy, flexible; with endoscopic stent placement (includes pre- and post-dilation and 45389 - - $227.02 - - guide wire passage, when performed) 45390 - - $260.28 - - Colonoscopy, flexible; with endoscopic mucosal resection Colonoscopy, flexible; with endoscopic ultrasound examination limited to the rectum, sigmoid, 45391 - - $201.75 - - descending, transverse, or ascending colon and cecum, and adjacent structures

Colonoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine 45392 - - $238.27 - - needle aspiration/biopsy(s), includes endoscopic ultrasound examination limited to the rectum, sigmoid, descending, transverse, or ascending colon and cecum, and adjacent structures Colonoscopy, flexible; with decompression (for pathologic distention) (eg, volvulus, megacolon), 45393 - - $197.76 - - including placement of decompression tube, when performed

45395 - - $1,542.08 - - Laparoscopy, surgical; proctectomy, complete, combined abdominoperineal, with colostomy Laparoscopy, surgical; proctectomy, combined abdominoperineal pull-through procedure (eg, 45397 - - $1,677.02 - - colo-anal anastomosis), with creation of colonic reservoir (eg, J-pouch), with diverting enterostomy, when performed 45398 $635.25 $184.85 - - - Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids) 45399 - - I.C. - - Unlisted procedure, colon 45400 - - $890.57 - - Laparoscopy, surgical; proctopexy (for prolapse) 45402 - - $1,186.28 - - Laparoscopy, surgical; proctopexy (for prolapse), with sigmoid resection 45499 - - I.C. - - Unlisted laparoscopy procedure, rectum 45500 - - $447.00 - - Proctoplasty; for stenosis 45505 - - $472.70 - - Proctoplasty; for prolapse of mucous membrane 45520 $127.27 $31.62 - - - Perirectal injection of sclerosing solution for prolapse 45540 - - $830.35 - - Proctopexy (eg, for prolapse); abdominal approach 45541 - - $743.52 - - Proctopexy (eg, for prolapse); perineal approach 45550 - - $1,147.68 - - Proctopexy (eg, for prolapse); with sigmoid resection, abdominal approach 45560 - - $544.35 - - Repair of rectocele (separate procedure) 45562 - - $887.60 - - Exploration, repair, and presacral drainage for rectal injury; 45563 - - $1,306.23 - - Exploration, repair, and presacral drainage for rectal injury; with colostomy 45800 - - $998.89 - - Closure of rectovesical fistula; 45805 - - $1,158.05 - - Closure of rectovesical fistula; with colostomy 45820 - - $1,001.55 - - Closure of rectourethral fistula; 45825 - - $1,210.95 - - Closure of rectourethral fistula; with colostomy 45900 - - $167.33 - - Reduction of procidentia (separate procedure) under anesthesia 45905 - - $133.24 - - Dilation of anal sphincter (separate procedure) under anesthesia other than local 45910 - - $151.50 - - Dilation of rectal stricture (separate procedure) under anesthesia other than local 45915 $276.67 $182.47 - - - Removal of fecal impaction or foreign body (separate procedure) under anesthesia 45990 - - $83.16 - - Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic 45999 - - I.C. - - Unlisted procedure, rectum 46020 $225.01 $187.91 - - - Placement of seton 46030 $115.62 $70.98 - - - Removal of anal seton, other marker 46040 $437.63 $334.16 - - - Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under 46045 - - $347.24 - - anesthesia 46050 $177.55 $78.43 - - - Incision and drainage, perianal abscess, superficial Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, 46060 - - $382.34 - - submuscular, with or without placement of seton 46070 - - $211.90 - - Incision, anal septum (infant) 46080 $215.85 $124.84 - - - Sphincterotomy, anal, division of sphincter (separate procedure) 46083 $155.21 $85.94 - - - Incision of thrombosed hemorrhoid, external 46200 $372.42 $264.89 - - - Fissurectomy, including sphincterotomy, when performed 46220 $184.34 $94.20 - - - Excision of single external papilla or tag, anus 46221 $219.99 $152.75 - - - Hemorrhoidectomy, internal, by rubber band ligation(s) 46230 $235.82 $136.41 - - - Excision of multiple external papillae or tags, anus 46250 $380.76 $252.36 - - - Hemorrhoidectomy, external, 2 or more columns/groups 46255 $414.90 $282.16 - - - Hemorrhoidectomy, internal and external, single column/group; 46257 - - $338.98 - - Hemorrhoidectomy, internal and external, single column/group; with fissurectomy Hemorrhoidectomy, internal and external, single column/group; with fistulectomy, including 46258 - - $374.88 - - fissurectomy, when performed 46260 - - $379.71 - - Hemorrhoidectomy, internal and external, 2 or more columns/groups;

Page 94 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 46261 - - $414.39 - - Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fissurectomy Hemorrhoidectomy, internal and external, 2 or more columns/groups; with fistulectomy, 46262 - - $440.86 - - including fissurectomy, when performed 46270 $420.13 $314.92 - - - Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous 46275 $442.51 $331.22 - - - Surgical treatment of anal fistula (fistulectomy/fistulotomy); intersphincteric

46280 - - $376.85 - - Surgical treatment of anal fistula (fistulectomy/fistulotomy); transsphincteric, suprasphincteric, extrasphincteric or multiple, including placement of seton, when performed 46285 $440.04 $331.06 - - - Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage 46288 - - $437.14 - - Closure of anal fistula with rectal advancement flap 46320 $158.47 $88.04 - - - Excision of thrombosed hemorrhoid, external 46500 $242.03 $145.22 - - - Injection of sclerosing solution, hemorrhoids 46505 $237.61 $192.69 - - - Chemodenervation of internal anal sphincter Anoscopy; diagnostic, including collection of specimen(s) by brushing or washing, when 46600 $83.46 $32.15 - - - performed (separate procedure) Anoscopy; diagnostic, with high-resolution magnification (HRA) (eg, colposcope, operating 46601 $114.05 $73.76 - - - microscope) and chemical agent enhancement, including collection of specimen(s) by brushing or washing, when performed 46604 $547.19 $51.57 - - - Anoscopy; with dilation (eg, balloon, guide wire, bougie) 46606 $208.07 $59.09 - - - Anoscopy; with biopsy, single or multiple Anoscopy; with high-resolution magnification (HRA) (eg, colposcope, operating microscope) and 46607 $159.99 $99.13 - - - chemical agent enhancement, with biopsy, single or multiple 46608 $217.96 $66.08 - - - Anoscopy; with removal of foreign body Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar 46610 $207.31 $63.55 - - - cautery 46611 $163.48 $62.90 - - - Anoscopy; with removal of single tumor, polyp, or other lesion by snare technique Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, 46612 $252.60 $74.64 - - - bipolar cautery or snare technique Anoscopy; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, 46614 $118.89 $50.49 - - - heater probe, stapler, plasma coagulator) Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by 46615 $128.69 $71.89 - - - hot biopsy forceps, bipolar cautery or snare technique 46700 - - $518.70 - - Anoplasty, plastic operation for stricture; adult 46705 - - $447.23 - - Anoplasty, plastic operation for stricture; infant 46706 - - $140.28 - - Repair of anal fistula with fibrin glue 46707 - - $394.93 - - Repair of anorectal fistula with plug (eg, porcine small intestine submucosa [SIS]) Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; 46710 - - $876.19 - - transperineal approach Repair of ileoanal pouch fistula/sinus (eg, perineal or vaginal), pouch advancement; combined 46712 - - $1,754.68 - - transperineal and transabdominal approach 46715 - - $436.35 - - Repair of low imperforate anus; with anoperineal fistula (cut-back procedure) 46716 - - $964.94 - - Repair of low imperforate anus; with transposition of anoperineal or anovestibular fistula 46730 - - $1,557.03 - - Repair of high imperforate anus without fistula; perineal or sacroperineal approach Repair of high imperforate anus without fistula; combined transabdominal and sacroperineal 46735 - - $1,792.61 - - approaches Repair of high imperforate anus with rectourethral or rectovaginal fistula; perineal or 46740 - - $1,698.66 - - sacroperineal approach Repair of high imperforate anus with rectourethral or rectovaginal fistula; combined 46742 - - $1,964.49 - - transabdominal and sacroperineal approaches

46744 - - $2,777.03 - - Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, sacroperineal approach Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and 46746 - - $3,062.07 - - sacroperineal approach;

46748 - - $3,321.74 - - Repair of cloacal anomaly by anorectovaginoplasty and urethroplasty, combined abdominal and sacroperineal approach; with vaginal lengthening by intestinal graft or pedicle flaps 46750 - - $592.22 - - Sphincteroplasty, anal, for incontinence or prolapse; adult 46751 - - $524.37 - - Sphincteroplasty, anal, for incontinence or prolapse; child 46753 - - $488.35 - - Graft (Thiersch operation) for rectal incontinence and/or prolapse 46754 $260.40 $186.78 - - - Removal of Thiersch wire or suture, anal canal 46760 - - $863.12 - - Sphincteroplasty, anal, for incontinence, adult; muscle transplant Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal 46761 - - $724.43 - - repair) Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46900 $190.31 $107.71 - - - vesicle), simple; chemical

Page 95 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46910 $208.15 $105.25 - - - vesicle), simple; electrodesiccation Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46916 $197.38 $112.17 - - - vesicle), simple; cryosurgery Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46917 $341.18 $100.62 - - - vesicle), simple; laser surgery Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46922 $236.90 $107.64 - - - vesicle), simple; surgical excision Destruction of lesion(s), anus (eg, condyloma, papilloma, molluscum contagiosum, herpetic 46924 $436.97 $141.92 - - - vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) Destruction of internal hemorrhoid(s) by thermal energy (eg, infrared coagulation, cautery, 46930 $172.43 $120.55 - - - radiofrequency) Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); 46940 $197.12 $113.36 - - - initial Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); 46942 $188.42 $102.05 - - - subsequent Hemorrhoidectomy, internal, by ligation other than rubber band; single hemorrhoid 46945 - - $267.21 - - column/group, without imaging guidance Hemorrhoidectomy, internal, by ligation other than rubber band; 2 or more hemorrhoid 46946 - - $300.38 - - columns/groups, without imaging guidance 46947 - - $304.26 - - Hemorrhoidopexy (eg, for prolapsing internal hemorrhoids) by stapling

46948 - - $349.79 - - Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed 46999 - - I.C. - - Unlisted procedure, anus 47000 $251.87 $69.56 - - - Biopsy of liver, needle; percutaneous Biopsy of liver, needle; when done for indicated purpose at time of other major procedure (List 47001 - - $81.37 - - separately in addition to code for primary procedure) 47010 - - $953.50 - - Hepatotomy, for open drainage of abscess or cyst, 1 or 2 stages Laparotomy, with aspiration and/or injection of hepatic parasitic (eg, amoebic or echinococcal) 47015 - - $918.85 - - cyst(s) or abscess(es) 47100 - - $668.84 - - Biopsy of liver, wedge 47120 - - $1,833.99 - - Hepatectomy, resection of liver; partial lobectomy 47122 - - $2,691.71 - - Hepatectomy, resection of liver; trisegmentectomy 47125 - - $2,415.49 - - Hepatectomy, resection of liver; total left lobectomy 47130 - - $2,593.58 - - Hepatectomy, resection of liver; total right lobectomy 47133 - - I.C. - - Donor hepatectomy (including cold preservation), from cadaver donor

47135 - - $4,231.45 - - Liver allotransplantation, orthotopic, partial or whole, from cadaver or living donor, any age Donor hepatectomy (including cold preservation), from living donor; left lateral segment only 47140 - - $2,802.11 - - (segments II and III) Donor hepatectomy (including cold preservation), from living donor; total left lobectomy 47141 - - $3,354.25 - - (segments II, III and IV) Donor hepatectomy (including cold preservation), from living donor; total right lobectomy 47142 - - $3,698.39 - - (segments V, VI, VII and VIII) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues 47143 - - I.C. - - to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; without trisegment or lobe split

Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues 47144 - - I.C. - - to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with trisegment split of whole liver graft into 2 partial liver grafts (ie, left lateral segment [segments II and III] and right trisegment [segments I and IV through VIII]) Backbench standard preparation of cadaver donor whole liver graft prior to allotransplantation, including cholecystectomy, if necessary, and dissection and removal of surrounding soft tissues 47145 - - I.C. - - to prepare the vena cava, portal vein, hepatic artery, and common bile duct for implantation; with lobe split of whole liver graft into 2 partial liver grafts (ie, left lobe [segments II, III, and IV] and right lobe [segments I and V through VIII]) Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; 47146 - - $256.28 - - venous anastomosis, each Backbench reconstruction of cadaver or living donor liver graft prior to allotransplantation; 47147 - - $298.87 - - arterial anastomosis, each 47300 - - $890.34 - - Marsupialization of cyst or abscess of liver 47350 - - $1,077.28 - - Management of liver hemorrhage; simple suture of liver wound or injury

Page 96 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Management of liver hemorrhage; complex suture of liver wound or injury, with or without 47360 - - $1,477.10 - - hepatic artery ligation Management of liver hemorrhage; exploration of hepatic wound, extensive debridement, 47361 - - $2,376.35 - - coagulation and/or suture, with or without packing of liver 47362 - - $1,143.32 - - Management of liver hemorrhage; re-exploration of hepatic wound for removal of packing 47370 - - $982.03 - - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); radiofrequency 47371 - - $988.98 - - Laparoscopy, surgical, ablation of 1 or more liver tumor(s); cryosurgical 47379 - - I.C. - - Unlisted laparoscopic procedure, liver 47380 - - $1,135.17 - - Ablation, open, of 1 or more liver tumor(s); radiofrequency 47381 - - $1,164.05 - - Ablation, open, of 1 or more liver tumor(s); cryosurgical 47382 $3,589.02 $579.95 - - - Ablation, 1 or more liver tumor(s), percutaneous, radiofrequency 47383 $5,629.06 $356.37 - - - Ablation, 1 or more liver tumor(s), percutaneous, cryoablation 47399 - - I.C. - - Unlisted procedure, liver 47400 - - $1,694.17 - - Hepaticotomy or hepaticostomy with exploration, drainage, or removal of calculus

47420 - - $1,055.81 - - Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with or without cholecystotomy; without transduodenal sphincterotomy or sphincteroplasty Choledochotomy or choledochostomy with exploration, drainage, or removal of calculus, with 47425 - - $1,077.56 - - or without cholecystotomy; with transduodenal sphincterotomy or sphincteroplasty Transduodenal sphincterotomy or sphincteroplasty, with or without transduodenal extraction 47460 - - $1,001.49 - - of calculus (separate procedure) Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus 47480 - - $696.05 - - (separate procedure)

47490 - - $264.42 - - Cholecystostomy, percutaneous, complete procedure, including imaging guidance, catheter placement, cholecystogram when performed, and radiological supervision and interpretation Injection procedure for cholangiography, percutaneous, complete diagnostic procedure 47531 $314.84 $55.44 - - - including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; existing access

Injection procedure for cholangiography, percutaneous, complete diagnostic procedure 47532 $687.42 $166.30 - - - including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation; new access (eg, percutaneous transhepatic cholangiogram) Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography 47533 $1,022.24 $208.38 - - - when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; external Placement of biliary drainage catheter, percutaneous, including diagnostic cholangiography 47534 $1,157.80 $290.61 - - - when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; internal-external Conversion of external biliary drainage catheter to internal-external biliary drainage catheter, 47535 $805.82 $153.40 - - - percutaneous, including diagnostic cholangiography when performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation Exchange of biliary drainage catheter (eg, external, internal-external, or conversion of internal- external to external only), percutaneous, including diagnostic cholangiography when 47536 $567.83 $103.81 - - - performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation Removal of biliary drainage catheter, percutaneous, requiring fluoroscopic guidance (eg, with concurrent indwelling biliary stents), including diagnostic cholangiography when performed, 47537 $366.04 $75.63 - - - imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) 47538 $3,518.67 $185.56 - - - and catheter removal(s) when performed, and all associated radiological supervision and interpretation; existing access

Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, 47539 $3,869.48 $332.03 - - - imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, without placement of separate biliary drainage catheter Placement of stent(s) into a bile duct, percutaneous, including diagnostic cholangiography, imaging guidance (eg, fluoroscopy and/or ultrasound), balloon dilation, catheter exchange(s) 47540 $3,947.62 $345.26 - - - and catheter removal(s) when performed, and all associated radiological supervision and interpretation; new access, with placement of separate biliary drainage catheter (eg, external or internal-external)

Page 97 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Placement of access through the biliary tree and into small bowel to assist with an endoscopic biliary procedure (eg, rendezvous procedure), percutaneous, including diagnostic 47541 $984.13 $260.12 - - - cholangiography when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation, new access Balloon dilation of biliary duct(s) or of ampulla (sphincteroplasty), percutaneous, including 47542 $420.21 $106.61 - - - imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation, each duct (List separately in addition to code for primary procedure) Endoluminal biopsy(ies) of biliary tree, percutaneous, any method(s) (eg, brush, forceps, and/or needle), including imaging guidance (eg, fluoroscopy), and all associated radiological 47543 $373.71 $113.44 - - - supervision and interpretation, single or multiple (List separately in addition to code for primary procedure) Removal of calculi/debris from biliary duct(s) and/or gallbladder, percutaneous, including destruction of calculi by any method (eg, mechanical, electrohydraulic, lithotripsy) when 47544 $810.92 $122.56 - - - performed, imaging guidance (eg, fluoroscopy), and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) Biliary endoscopy, intraoperative (choledochoscopy) (List separately in addition to code for 47550 - - $128.84 - - primary procedure) Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with collection of 47552 - - $213.29 - - specimen(s) by brushing and/or washing, when performed (separate procedure) 47553 - - $214.67 - - Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple 47554 - - $403.48 - - Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct 47555 - - $255.21 - - stricture(s) without stent Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct 47556 - - $289.11 - - stricture(s) with stent 47562 - - $519.21 - - Laparoscopy, surgical; cholecystectomy 47563 - - $564.95 - - Laparoscopy, surgical; cholecystectomy with cholangiography 47564 - - $877.84 - - Laparoscopy, surgical; cholecystectomy with exploration of common duct 47570 - - $610.97 - - Laparoscopy, surgical; cholecystoenterostomy 47579 - - I.C. - - Unlisted laparoscopy procedure, biliary tract 47600 - - $841.87 - - Cholecystectomy; 47605 - - $885.49 - - Cholecystectomy; with cholangiography 47610 - - $987.46 - - Cholecystectomy with exploration of common duct; 47612 - - $1,004.04 - - Cholecystectomy with exploration of common duct; with choledochoenterostomy Cholecystectomy with exploration of common duct; with transduodenal sphincterotomy or 47620 - - $1,083.33 - - sphincteroplasty, with or without cholangiography Exploration for congenital atresia of bile ducts, without repair, with or without liver biopsy, with 47700 - - $834.43 - - or without cholangiography 47701 - - $1,368.07 - - Portoenterostomy (eg, Kasai procedure) 47711 - - $1,226.14 - - Excision of bile duct tumor, with or without primary repair of bile duct; extrahepatic 47712 - - $1,571.46 - - Excision of bile duct tumor, with or without primary repair of bile duct; intrahepatic 47715 - - $1,049.71 - - Excision of choledochal cyst 47720 - - $911.89 - - Cholecystoenterostomy; direct 47721 - - $1,068.22 - - Cholecystoenterostomy; with gastroenterostomy 47740 - - $1,036.12 - - Cholecystoenterostomy; Roux-en-Y 47741 - - $1,163.28 - - Cholecystoenterostomy; Roux-en-Y with gastroenterostomy 47760 - - $1,769.12 - - Anastomosis, of extrahepatic biliary ducts and gastrointestinal tract 47765 - - $2,387.43 - - Anastomosis, of intrahepatic ducts and gastrointestinal tract 47780 - - $1,942.25 - - Anastomosis, Roux-en-Y, of extrahepatic biliary ducts and gastrointestinal tract 47785 - - $2,550.31 - - Anastomosis, Roux-en-Y, of intrahepatic biliary ducts and gastrointestinal tract 47800 - - $1,241.10 - - Reconstruction, plastic, of extrahepatic biliary ducts with end-to-end anastomosis 47801 - - $880.03 - - Placement of choledochal stent 47802 - - $1,203.30 - - U-tube hepaticoenterostomy 47900 - - $1,073.92 - - Suture of extrahepatic biliary duct for pre-existing injury (separate procedure) 47999 - - I.C. - - Unlisted procedure, biliary tract 48000 - - $1,481.39 - - Placement of drains, peripancreatic, for acute pancreatitis; Placement of drains, peripancreatic, for acute pancreatitis; with cholecystostomy, gastrostomy, 48001 - - $1,813.10 - - and jejunostomy 48020 - - $928.70 - - Removal of pancreatic calculus 48100 - - $696.57 - - Biopsy of pancreas, open (eg, fine needle aspiration, needle core biopsy, wedge biopsy) 48102 $432.96 $187.18 - - - Biopsy of pancreas, percutaneous needle Resection or debridement of pancreas and peripancreatic tissue for acute necrotizing 48105 - - $2,229.15 - - pancreatitis 48120 - - $869.60 - - Excision of lesion of pancreas (eg, cyst, adenoma) 48140 - - $1,228.62 - - Pancreatectomy, distal subtotal, with or without splenectomy; without pancreaticojejunostomy

Page 98 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

48145 - - $1,284.98 - - Pancreatectomy, distal subtotal, with or without splenectomy; with pancreaticojejunostomy 48146 - - $1,484.63 - - Pancreatectomy, distal, near-total with preservation of duodenum (Child-type procedure) 48148 - - $984.40 - - Excision of ampulla of Vater Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, 48150 - - $2,447.71 - - choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, 48152 - - $2,274.63 - - choledochoenterostomy and gastrojejunostomy (Whipple-type procedure); without pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy 48153 - - $2,437.67 - - and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); with pancreatojejunostomy Pancreatectomy, proximal subtotal with near-total duodenectomy, choledochoenterostomy 48154 - - $2,284.28 - - and duodenojejunostomy (pylorus-sparing, Whipple-type procedure); without pancreatojejunostomy 48155 - - $1,427.20 - - Pancreatectomy, total Pancreatectomy, total or subtotal, with autologous transplantation of pancreas or pancreatic 48160 - - I.C. - - islet cells Injection procedure for intraoperative pancreatography (List separately in addition to code for 48400 - - $84.06 - - primary procedure) 48500 - - $908.79 - - Marsupialization of pancreatic cyst 48510 - - $866.75 - - External drainage, pseudocyst of pancreas, open 48520 - - $859.98 - - Internal anastomosis of pancreatic cyst to gastrointestinal tract; direct 48540 - - $1,030.42 - - Internal anastomosis of pancreatic cyst to gastrointestinal tract; Roux-en-Y 48545 - - $1,059.58 - - Pancreatorrhaphy for injury 48547 - - $1,409.66 - - Duodenal exclusion with gastrojejunostomy for pancreatic injury 48548 - - $1,308.77 - - Pancreaticojejunostomy, side-to-side anastomosis (Puestow-type operation) Donor pancreatectomy (including cold preservation), with or without duodenal segment for 48550 - - I.C. - - transplantation Backbench standard preparation of cadaver donor pancreas allograft prior to transplantation, including dissection of allograft from surrounding soft tissues, splenectomy, duodenotomy, 48551 - - I.C. - - ligation of bile duct, ligation of mesenteric vessels, and Y-graft arterial anastomoses from iliac artery to superior mesenteric artery and to splenic artery Backbench reconstruction of cadaver donor pancreas allograft prior to transplantation, venous 48552 - - $184.45 - - anastomosis, each 48554 - - $2,024.74 - - Transplantation of pancreatic allograft 48556 - - $1,007.02 - - Removal of transplanted pancreatic allograft 48999 - - I.C. - - Unlisted procedure, pancreas 49000 - - $605.10 - - Exploratory laparotomy, exploratory celiotomy with or without biopsy(s) (separate procedure) 49002 - - $820.93 - - Reopening of recent laparotomy 49010 - - $724.33 - - Exploration, retroperitoneal area with or without biopsy(s) (separate procedure) Preperitoneal pelvic packing for hemorrhage associated with pelvic trauma, including local 49013 - - $341.43 - - exploration Re-exploration of pelvic wound with removal of preperitoneal pelvic packing, including 49014 - - $282.86 - - repacking, when performed

49020 - - $1,251.36 - - Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess, open 49040 - - $787.78 - - Drainage of subdiaphragmatic or subphrenic abscess, open 49060 - - $864.38 - - Drainage of retroperitoneal abscess, open 49062 - - $605.21 - - Drainage of extraperitoneal lymphocele to peritoneal cavity, open 49082 $164.83 $58.17 - - - Abdominal paracentesis (diagnostic or therapeutic); without imaging guidance 49083 $242.38 $84.42 - - - Abdominal paracentesis (diagnostic or therapeutic); with imaging guidance 49084 - - $84.74 - - Peritoneal lavage, including imaging guidance, when performed 49180 $136.03 $65.60 - - - Biopsy, abdominal or retroperitoneal mass, percutaneous needle

Sclerotherapy of a fluid collection (eg, lymphocele, cyst, or seroma), percutaneous, including 49185 $961.87 $93.81 - - - contrast injection(s), sclerosant injection(s), diagnostic study, imaging guidance (eg, ultrasound, fluoroscopy) and radiological supervision and interpretation when performed Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more 49203 - - $936.92 - - peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5 cm diameter or less Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more 49204 - - $1,193.17 - - peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor 5.1-10.0 cm diameter

Page 99 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Excision or destruction, open, intra-abdominal tumors, cysts or endometriomas, 1 or more 49205 - - $1,366.15 - - peritoneal, mesenteric, or retroperitoneal primary or secondary tumors; largest tumor greater than 10.0 cm diameter 49215 - - $1,739.99 - - Excision of presacral or sacrococcygeal tumor 49250 - - $464.23 - - Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) 49255 - - $620.09 - - Omentectomy, epiploectomy, resection of omentum (separate procedure) Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of 49320 - - $258.74 - - specimen(s) by brushing or washing (separate procedure) 49321 - - $271.74 - - Laparoscopy, surgical; with biopsy (single or multiple) 49322 - - $293.90 - - Laparoscopy, surgical; with aspiration of cavity or cyst (eg, ovarian cyst) (single or multiple) 49323 - - $504.85 - - Laparoscopy, surgical; with drainage of lymphocele to peritoneal cavity 49324 - - $306.39 - - Laparoscopy, surgical; with insertion of tunneled intraperitoneal catheter Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, 49325 - - $326.60 - - with removal of intraluminal obstructive material if performed Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in 49326 - - $147.61 - - addition to code for primary procedure) Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, 49327 - - $102.01 - - including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure) 49329 - - I.C. - - Unlisted laparoscopy procedure, abdomen, peritoneum and omentum 49400 $114.72 $72.11 - - - Injection of air or contrast into peritoneal cavity (separate procedure) 49402 - - $673.44 - - Removal of peritoneal foreign body from peritoneal cavity Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, 49405 $717.25 $154.10 - - - lymphocele, cyst); visceral (eg, kidney, liver, spleen, lung/mediastinum), percutaneous Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, 49406 $717.00 $153.85 - - - lymphocele, cyst); peritoneal or retroperitoneal, percutaneous Image-guided fluid collection drainage by catheter (eg, abscess, hematoma, seroma, 49407 $586.23 $163.07 - - - lymphocele, cyst); peritoneal or retroperitoneal, transvaginal or transrectal Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, 49411 $393.33 $144.36 - - - dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image 49412 - - $64.50 - - guidance, if performed, single or multiple (List separately in addition to code for primary procedure) Insertion of tunneled intraperitoneal catheter (eg, dialysis, intraperitoneal chemotherapy instillation, management of ascites), complete procedure, including imaging guidance, catheter 49418 $977.15 $158.94 - - - placement, contrast injection when performed, and radiological supervision and interpretation, percutaneous

49419 - - $339.85 - - Insertion of tunneled intraperitoneal catheter, with subcutaneous port (ie, totally implantable) 49421 - - $178.12 - - Insertion of tunneled intraperitoneal catheter for dialysis, open 49422 - - $173.40 - - Removal of tunneled intraperitoneal catheter Exchange of previously placed abscess or cyst drainage catheter under radiological guidance 49423 $488.02 $55.29 - - - (separate procedure) Contrast injection for assessment of abscess or cyst via previously placed drainage catheter or 49424 $136.60 $29.95 - - - tube (separate procedure) 49425 - - $561.42 - - Insertion of peritoneal-venous shunt 49426 - - $526.67 - - Revision of peritoneal-venous shunt Injection procedure (eg, contrast media) for evaluation of previously placed peritoneal-venous 49427 - - $30.16 - - shunt 49428 - - $340.17 - - Ligation of peritoneal-venous shunt 49429 - - $360.84 - - Removal of peritoneal-venous shunt Insertion of subcutaneous extension to intraperitoneal cannula or catheter with remote chest 49435 - - $93.48 - - exit site (List separately in addition to code for primary procedure) Delayed creation of exit site from embedded subcutaneous segment of intraperitoneal cannula 49436 - - $147.53 - - or catheter Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast 49440 $761.09 $160.56 - - - injection(s), image documentation and report Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance 49441 $861.39 $188.97 - - - including contrast injection(s), image documentation and report Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance 49442 $720.70 $163.34 - - - including contrast injection(s), image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic 49446 $733.54 $115.90 - - - guidance including contrast injection(s), image documentation and report

Page 100 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under 49450 $539.85 $51.48 - - - fluoroscopic guidance including contrast injection(s), image documentation and report Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic 49451 $583.91 $70.32 - - - guidance including contrast injection(s), image documentation and report Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including 49452 $713.21 $108.32 - - - contrast injection(s), image documentation and report

Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, 49460 $600.00 $38.01 - - - gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, 49465 $124.04 $24.05 - - - jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), 49491 - - $627.85 - - performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; reducible Repair, initial inguinal hernia, preterm infant (younger than 37 weeks gestation at birth), 49492 - - $754.71 - - performed from birth up to 50 weeks postconception age, with or without hydrocelectomy; incarcerated or strangulated Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant 49495 - - $322.63 - - older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant 49496 - - $484.77 - - older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without 49500 - - $326.77 - - hydrocelectomy; reducible Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without 49501 - - $477.72 - - hydrocelectomy; incarcerated or strangulated 49505 - - $411.61 - - Repair initial inguinal hernia, age 5 years or older; reducible 49507 - - $462.64 - - Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated 49520 - - $498.08 - - Repair recurrent inguinal hernia, any age; reducible 49521 - - $564.92 - - Repair recurrent inguinal hernia, any age; incarcerated or strangulated 49525 - - $452.78 - - Repair inguinal hernia, sliding, any age 49540 - - $531.50 - - Repair lumbar hernia 49550 - - $454.66 - - Repair initial femoral hernia, any age; reducible 49553 - - $497.76 - - Repair initial femoral hernia, any age; incarcerated or strangulated 49555 - - $475.17 - - Repair recurrent femoral hernia; reducible 49557 - - $570.04 - - Repair recurrent femoral hernia; incarcerated or strangulated 49560 - - $581.25 - - Repair initial incisional or ventral hernia; reducible 49561 - - $730.99 - - Repair initial incisional or ventral hernia; incarcerated or strangulated 49565 - - $605.25 - - Repair recurrent incisional or ventral hernia; reducible 49566 - - $737.77 - - Repair recurrent incisional or ventral hernia; incarcerated or strangulated Implantation of mesh or other prosthesis for open incisional or ventral hernia repair or mesh 49568 - - $208.90 - - for closure of debridement for necrotizing soft tissue infection (List separately in addition to code for the incisional or ventral hernia repair) 49570 - - $329.98 - - Repair epigastric hernia (eg, preperitoneal fat); reducible (separate procedure) 49572 - - $408.65 - - Repair epigastric hernia (eg, preperitoneal fat); incarcerated or strangulated 49580 - - $265.00 - - Repair umbilical hernia, younger than age 5 years; reducible 49582 - - $381.96 - - Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated 49585 - - $352.46 - - Repair umbilical hernia, age 5 years or older; reducible 49587 - - $376.75 - - Repair umbilical hernia, age 5 years or older; incarcerated or strangulated 49590 - - $451.99 - - Repair spigelian hernia 49600 - - $578.30 - - Repair of small omphalocele, with primary closure 49605 - - $3,879.03 - - Repair of large omphalocele or gastroschisis; with or without prosthesis Repair of large omphalocele or gastroschisis; with removal of prosthesis, final reduction and 49606 - - $891.87 - - closure, in operating room 49610 - - $544.70 - - Repair of omphalocele (Gross type operation); first stage 49611 - - $480.42 - - Repair of omphalocele (Gross type operation); second stage 49650 - - $339.87 - - Laparoscopy, surgical; repair initial inguinal hernia 49651 - - $442.35 - - Laparoscopy, surgical; repair recurrent inguinal hernia Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh 49652 - - $586.58 - - insertion, when performed); reducible Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh 49653 - - $732.14 - - insertion, when performed); incarcerated or strangulated

Page 101 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); 49654 - - $665.38 - - reducible Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); 49655 - - $813.55 - - incarcerated or strangulated Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when 49656 - - $721.22 - - performed); reducible Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when 49657 - - $1,038.35 - - performed); incarcerated or strangulated 49659 - - I.C. - - Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy 49900 - - $645.17 - - Suture, secondary, of abdominal wall for evisceration or dehiscence 49904 - - $1,100.58 - - Omental flap, extra-abdominal (eg, for reconstruction of sternal and chest wall defects) 49905 - - $276.11 - - Omental flap, intra-abdominal (List separately in addition to code for primary procedure) 49906 - - I.C. - - Free omental flap with microvascular anastomosis 49999 - - I.C. - - Unlisted procedure, abdomen, peritoneum and omentum 50010 - - $576.53 - - Renal exploration, not necessitating other specific procedures 50020 - - $793.80 - - Drainage of perirenal or renal abscess, open 50040 - - $722.22 - - Nephrostomy, nephrotomy with drainage 50045 - - $729.99 - - Nephrotomy, with exploration 50060 - - $891.88 - - Nephrolithotomy; removal of calculus 50065 - - $945.47 - - Nephrolithotomy; secondary surgical operation for calculus 50070 - - $926.90 - - Nephrolithotomy; complicated by congenital kidney abnormality Nephrolithotomy; removal of large staghorn calculus filling renal pelvis and calyces (including 50075 - - $1,139.72 - - anatrophic pyelolithotomy) Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, 50080 - - $680.44 - - lithotripsy, stenting, or basket extraction; up to 2 cm Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, 50081 - - $999.58 - - lithotripsy, stenting, or basket extraction; over 2 cm 50100 - - $850.15 - - Transection or repositioning of aberrant renal vessels (separate procedure) 50120 - - $743.30 - - Pyelotomy; with exploration 50125 - - $768.82 - - Pyelotomy; with drainage, pyelostomy Pyelotomy; with removal of calculus (pyelolithotomy, pelviolithotomy, including coagulum 50130 - - $808.63 - - pyelolithotomy) 50135 - - $877.63 - - Pyelotomy; complicated (eg, secondary operation, congenital kidney abnormality) 50200 $441.54 $100.40 - - - Renal biopsy; percutaneous, by trocar or needle 50205 - - $593.32 - - Renal biopsy; by surgical exposure of kidney 50220 - - $820.72 - - Nephrectomy, including partial ureterectomy, any open approach including rib resection; Nephrectomy, including partial ureterectomy, any open approach including rib resection; 50225 - - $939.94 - - complicated because of previous surgery on same kidney Nephrectomy, including partial ureterectomy, any open approach including rib resection; 50230 - - $1,001.79 - - radical, with regional lymphadenectomy and/or vena caval thrombectomy 50234 - - $1,018.10 - - Nephrectomy with total ureterectomy and bladder cuff; through same incision 50236 - - $1,145.88 - - Nephrectomy with total ureterectomy and bladder cuff; through separate incision 50240 - - $1,037.15 - - Nephrectomy, partial Ablation, open, 1 or more renal mass lesion(s), cryosurgical, including intraoperative ultrasound 50250 - - $952.38 - - guidance and monitoring, if performed 50280 - - $750.54 - - Excision or unroofing of cyst(s) of kidney 50290 - - $703.84 - - Excision of perinephric cyst

50300 - - I.C. - - Donor nephrectomy (including cold preservation); from cadaver donor, unilateral or bilateral 50320 - - $1,187.51 - - Donor nephrectomy (including cold preservation); open, from living donor Backbench standard preparation of cadaver donor renal allograft prior to transplantation, including dissection and removal of perinephric fat, diaphragmatic and retroperitoneal 50323 - - I.C. - - attachments, excision of adrenal gland, and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary Backbench standard preparation of living donor renal allograft (open or laparoscopic) prior to 50325 - - I.C. - - transplantation, including dissection and removal of perinephric fat and preparation of ureter(s), renal vein(s), and renal artery(s), ligating branches, as necessary Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; 50327 - - $169.01 - - venous anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; 50328 - - $148.12 - - arterial anastomosis, each Backbench reconstruction of cadaver or living donor renal allograft prior to transplantation; 50329 - - $140.96 - - ureteral anastomosis, each 50340 - - $749.52 - - Recipient nephrectomy (separate procedure) 50360 - - $1,899.34 - - Renal allotransplantation, implantation of graft; without recipient nephrectomy 50365 - - $2,260.53 - - Renal allotransplantation, implantation of graft; with recipient nephrectomy

Page 102 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 50370 - - $950.51 - - Removal of transplanted renal allograft 50380 - - $1,587.73 - - Renal autotransplantation, reimplantation of kidney Removal (via snare/capture) and replacement of internally dwelling ureteral stent via 50382 $893.00 $200.29 - - - percutaneous approach, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, 50384 $728.04 $179.09 - - - including radiological supervision and interpretation Removal (via snare/capture) and replacement of internally dwelling ureteral stent via 50385 $880.47 $170.95 - - - transurethral approach, without use of cystoscopy, including radiological supervision and interpretation Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, 50386 $602.82 $126.62 - - - without use of cystoscopy, including radiological supervision and interpretation Removal and replacement of externally accessible nephroureteral catheter (eg, 50387 $447.75 $65.46 - - - external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation Removal of nephrostomy tube, requiring fluoroscopic guidance (eg, with concurrent indwelling 50389 $306.73 $41.82 - - - ureteral stent) 50390 - - $74.75 - - Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established 50391 $97.04 $76.75 - - - nephrostomy, pyelostomy or ureterostomy tube (eg, anticarcinogenic or antifungal agent)

50396 - - $91.53 - - Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic 50400 - - $910.15 - - operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; simple

Pyeloplasty (Foley Y-pyeloplasty), plastic operation on renal pelvis, with or without plastic 50405 - - $1,091.49 - - operation on ureter, nephropexy, nephrostomy, pyelostomy, or ureteral splinting; complicated (congenital kidney abnormality, secondary pyeloplasty, solitary kidney, calycoplasty) Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic 50430 $460.33 $120.93 - - - procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; new access Injection procedure for antegrade nephrostogram and/or ureterogram, complete diagnostic 50431 $210.21 $51.38 - - - procedure including imaging guidance (eg, ultrasound and fluoroscopy) and all associated radiological supervision and interpretation; existing access Placement of nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or 50432 $721.89 $161.34 - - - ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation Placement of nephroureteral catheter, percutaneous, including diagnostic nephrostogram 50433 $934.25 $200.10 - - - and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, new access Convert nephrostomy catheter to nephroureteral catheter, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or 50434 $744.66 $150.50 - - - fluoroscopy) and all associated radiological supervision and interpretation, via pre-existing nephrostomy tract Exchange nephrostomy catheter, percutaneous, including diagnostic nephrostogram and/or 50435 $459.46 $78.33 - - - ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation Dilation of existing tract, percutaneous, for an endourologic procedure including imaging 50436 - - $118.04 - - guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation, with postprocedure tube placement, when performed Dilation of existing tract, percutaneous, for an endourologic procedure including imaging guidance (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and 50437 - - $197.26 - - interpretation, with postprocedure tube placement, when performed; including new access into the renal collecting system 50500 - - $969.98 - - Nephrorrhaphy, suture of kidney wound or injury 50520 - - $911.18 - - Closure of nephrocutaneous or pyelocutaneous fistula

50525 - - $1,155.07 - - Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; abdominal approach 50526 - - $1,237.80 - - Closure of nephrovisceral fistula (eg, renocolic), including visceral repair; thoracic approach Symphysiotomy for horseshoe kidney with or without pyeloplasty and/or other plastic 50540 - - $897.55 - - procedure, unilateral or bilateral (1 operation) 50541 - - $717.83 - - Laparoscopy, surgical; ablation of renal cysts Laparoscopy, surgical; ablation of renal mass lesion(s), including intraoperative ultrasound 50542 - - $912.10 - - guidance and monitoring, when performed 50543 - - $1,164.75 - - Laparoscopy, surgical; partial nephrectomy 50544 - - $972.65 - - Laparoscopy, surgical; pyeloplasty

Page 103 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Laparoscopy, surgical; radical nephrectomy (includes removal of Gerota's fascia and 50545 - - $1,045.77 - - surrounding fatty tissue, removal of regional lymph nodes, and adrenalectomy) 50546 - - $942.00 - - Laparoscopy, surgical; nephrectomy, including partial ureterectomy 50547 - - $1,261.71 - - Laparoscopy, surgical; donor nephrectomy (including cold preservation), from living donor 50548 - - $1,051.31 - - Laparoscopy, surgical; nephrectomy with total ureterectomy 50549 - - I.C. - - Unlisted laparoscopy procedure, renal Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, 50551 $283.70 $229.22 - - - instillation, or ureteropyelography, exclusive of radiologic service; Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, 50553 $303.19 $244.35 - - - instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, 50555 $324.89 $266.34 - - - instillation, or ureteropyelography, exclusive of radiologic service; with biopsy Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, 50557 $330.42 $269.84 - - - instillation, or 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, 50561 $373.43 $306.77 - - - instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus

50562 - - $452.50 - - Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 50570 - - $382.67 - - ureteropyelography, exclusive of radiologic service; Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 50572 - - $413.92 - - ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 50574 - - $440.08 - - ureteropyelography, exclusive of radiologic service; with biopsy Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, 50575 - - $556.69 - - ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent) Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or 50576 - - $438.99 - - ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy

50580 - - $472.97 - - Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 50590 $584.50 $446.83 - - - Lithotripsy, extracorporeal shock wave 50592 $2,624.40 $268.91 - - - Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency 50593 $3,548.60 $360.41 - - - Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy 50600 - - $734.42 - - Ureterotomy with exploration or drainage (separate procedure) 50605 - - $780.15 - - Ureterotomy for insertion of indwelling stent, all types Endoluminal biopsy of ureter and/or renal pelvis, non-endoscopic, including imaging guidance 50606 $506.89 $118.80 - - - (eg, ultrasound and/or fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) 50610 - - $739.68 - - Ureterolithotomy; upper one-third of ureter 50620 - - $707.61 - - Ureterolithotomy; middle one-third of ureter 50630 - - $698.72 - - Ureterolithotomy; lower one-third of ureter 50650 - - $813.02 - - Ureterectomy, with bladder cuff (separate procedure)

50660 - - $894.61 - - Ureterectomy, total, ectopic ureter, combination abdominal, vaginal and/or perineal approach Injection procedure for ureterography or ureteropyelography through ureterostomy or 50684 $94.53 $39.75 - - - indwelling ureteral catheter 50686 $112.28 $69.10 - - - Manometric studies through ureterostomy or indwelling ureteral catheter 50688 - - $61.48 - - Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit Injection procedure for visualization of ileal conduit and/or ureteropyelography, exclusive of 50690 $86.22 $55.20 - - - radiologic service Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or 50693 $848.69 $160.33 - - - ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all associated radiological supervision and interpretation; pre-existing nephrostomy tract Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all 50694 $940.04 $210.53 - - - associated radiological supervision and interpretation; new access, without separate nephrostomy catheter

Page 104 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Placement of ureteral stent, percutaneous, including diagnostic nephrostogram and/or ureterogram when performed, imaging guidance (eg, ultrasound and/or fluoroscopy), and all 50695 $1,137.71 $269.66 - - - associated radiological supervision and interpretation; new access, with separate nephrostomy catheter 50700 - - $724.85 - - Ureteroplasty, plastic operation on ureter (eg, stricture) Ureteral embolization or occlusion, including imaging guidance (eg, ultrasound and/or 50705 $1,554.86 $136.41 - - - fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) Balloon dilation, ureteral stricture, including imaging guidance (eg, ultrasound and/or 50706 $770.53 $142.75 - - - fluoroscopy) and all associated radiological supervision and interpretation (List separately in addition to code for primary procedure) 50715 - - $941.73 - - Ureterolysis, with or without repositioning of ureter for retroperitoneal fibrosis 50722 - - $807.46 - - Ureterolysis for ovarian vein syndrome 50725 - - $863.03 - - Ureterolysis for retrocaval ureter, with reanastomosis of upper urinary tract or vena cava 50727 - - $400.75 - - Revision of urinary-cutaneous anastomosis (any type urostomy); Revision of urinary-cutaneous anastomosis (any type urostomy); with repair of fascial defect 50728 - - $577.78 - - and hernia 50740 - - $962.07 - - Ureteropyelostomy, anastomosis of ureter and renal pelvis 50750 - - $902.39 - - Ureterocalycostomy, anastomosis of ureter to renal calyx 50760 - - $884.33 - - Ureteroureterostomy 50770 - - $902.39 - - Transureteroureterostomy, anastomosis of ureter to contralateral ureter 50780 - - $866.59 - - Ureteroneocystostomy; anastomosis of single ureter to bladder 50782 - - $841.23 - - Ureteroneocystostomy; anastomosis of duplicated ureter to bladder 50783 - - $881.95 - - Ureteroneocystostomy; with extensive ureteral tailoring 50785 - - $949.07 - - Ureteroneocystostomy; with vesico-psoas hitch or bladder flap 50800 - - $726.00 - - Ureteroenterostomy, direct anastomosis of ureter to intestine Ureterosigmoidostomy, with creation of sigmoid bladder and establishment of abdominal or 50810 - - $1,102.26 - - perineal colostomy, including intestine anastomosis 50815 - - $958.08 - - Ureterocolon conduit, including intestine anastomosis 50820 - - $1,027.66 - - Ureteroileal conduit (ileal bladder), including intestine anastomosis (Bricker operation) Continent diversion, including intestine anastomosis using any segment of small and/or large 50825 - - $1,295.10 - - intestine (Kock pouch or Camey enterocystoplasty) Urinary undiversion (eg, taking down of ureteroileal conduit, ureterosigmoidostomy or 50830 - - $1,408.28 - - ureteroenterostomy with ureteroureterostomy or ureteroneocystostomy) 50840 - - $962.69 - - Replacement of all or part of ureter by intestine segment, including intestine anastomosis 50845 - - $980.40 - - Cutaneous appendico-vesicostomy 50860 - - $740.48 - - Ureterostomy, transplantation of ureter to skin 50900 - - $660.00 - - Ureterorrhaphy, suture of ureter (separate procedure) 50920 - - $690.12 - - Closure of ureterocutaneous fistula 50930 - - $862.47 - - Closure of ureterovisceral fistula (including visceral repair) 50940 - - $694.95 - - Deligation of ureter 50945 - - $760.20 - - Laparoscopy, surgical; ureterolithotomy

50947 - - $1,083.97 - - Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement

50948 - - $995.47 - - Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement 50949 - - I.C. - - Unlisted laparoscopy procedure, ureter Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 50951 $296.94 $238.68 - - - ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 50953 $314.57 $254.28 - - - ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 50955 $335.85 $274.99 - - - ureteropyelography, exclusive of radiologic service; with biopsy Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or 50957 $339.19 $276.58 - - - ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy

50961 $305.56 $247.01 - - - Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or 50970 - - $288.68 - - ureteropyelography, exclusive of radiologic service; Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or 50972 - - $279.24 - - ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter

Page 105 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or 50974 - - $368.16 - - ureteropyelography, exclusive of radiologic service; with biopsy Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or 50976 - - $363.26 - - ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy

50980 - - $277.89 - - Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 51020 - - $368.72 - - Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material 51030 - - $371.28 - - Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion 51040 - - $228.35 - - Cystostomy, cystotomy with drainage 51045 - - $393.24 - - Cystotomy, with insertion of ureteral catheter or stent (separate procedure) 51050 - - $370.51 - - Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection 51060 - - $457.31 - - Transvesical ureterolithotomy Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation 51065 - - $455.04 - - of ureteral calculus 51080 - - $321.72 - - Drainage of perivesical or prevesical space abscess 51100 $54.20 $30.14 - - - Aspiration of bladder; by needle 51101 $114.63 $40.14 - - - Aspiration of bladder; by trocar or intracatheter 51102 $188.53 $113.75 - - - Aspiration of bladder; with insertion of suprapubic catheter 51500 - - $499.62 - - Excision of urachal cyst or sinus, with or without umbilical hernia repair 51520 - - $467.30 - - Cystotomy; for simple excision of vesical neck (separate procedure) 51525 - - $673.06 - - Cystotomy; for excision of bladder diverticulum, single or multiple (separate procedure) 51530 - - $603.85 - - Cystotomy; for excision of bladder tumor 51535 - - $611.90 - - Cystotomy for excision, incision, or repair of ureterocele 51550 - - $753.96 - - Cystectomy, partial; simple 51555 - - $990.32 - - Cystectomy, partial; complicated (eg, postradiation, previous surgery, difficult location) 51565 - - $1,018.01 - - Cystectomy, partial, with reimplantation of ureter(s) into bladder (ureteroneocystostomy) 51570 - - $1,152.87 - - Cystectomy, complete; (separate procedure) Cystectomy, complete; with bilateral pelvic lymphadenectomy, including external iliac, 51575 - - $1,424.45 - - hypogastric, and obturator nodes 51580 - - $1,482.08 - - Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations;

51585 - - $1,649.09 - - Cystectomy, complete, with ureterosigmoidostomy or ureterocutaneous transplantations; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine 51590 - - $1,511.17 - - anastomosis; Cystectomy, complete, with ureteroileal conduit or sigmoid bladder, including intestine 51595 - - $1,708.96 - - anastomosis; with bilateral pelvic lymphadenectomy, including external iliac, hypogastric, and obturator nodes Cystectomy, complete, with continent diversion, any open technique, using any segment of 51596 - - $1,838.46 - - small and/or large intestine to construct neobladder

Pelvic exenteration, complete, for vesical, prostatic or urethral malignancy, with removal of 51597 - - $1,792.53 - - bladder and ureteral transplantations, with or without hysterectomy and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof 51600 $167.86 $34.53 - - - Injection procedure for cystography or voiding urethrocystography 51605 - - $30.48 - - Injection procedure and placement of chain for contrast and/or chain urethrocystography 51610 $96.34 $50.55 - - - Injection procedure for retrograde urethrocystography 51700 $60.15 $24.21 - - - Bladder irrigation, simple, lavage and/or instillation 51701 $35.51 $20.44 - - - Insertion of non-indwelling bladder catheter (eg, straight catheterization for residual urine) 51702 $48.93 $19.95 - - - Insertion of temporary indwelling bladder catheter; simple (eg, Foley) Insertion of temporary indwelling bladder catheter; complicated (eg, altered anatomy, 51703 $110.93 $60.21 - - - fractured catheter/balloon) 51705 $75.84 $40.77 - - - Change of cystostomy tube; simple 51710 $105.28 $62.09 - - - Change of cystostomy tube; complicated Endoscopic injection of implant material into the submucosal tissues of the urethra and/or 51715 $272.14 $156.49 - - - bladder neck 51720 $66.44 $33.98 - - - Bladder instillation of anticarcinogenic agent (including retention time) 51725 - - $170.68 $58.89 $111.79 Simple cystometrogram (CMG) (eg, spinal manometer) 51726 - - $233.66 $65.65 $168.01 Complex cystometrogram (ie, calibrated electronic equipment); Complex cystometrogram (ie, calibrated electronic equipment); with urethral pressure profile 51727 - - $280.14 $83.14 $197.00 studies (ie, urethral closure pressure profile), any technique Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies 51728 - - $283.75 $81.54 $202.21 (ie, bladder voiding pressure), any technique

Page 106 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Complex cystometrogram (ie, calibrated electronic equipment); with voiding pressure studies 51729 - - $301.87 $98.79 $203.08 (ie, bladder voiding pressure) and urethral pressure profile studies (ie, urethral closure pressure profile), any technique 51736 - - $10.80 $6.49 $4.30 Simple uroflowmetry (UFR) (eg, stop-watch flow rate, mechanical uroflowmeter) 51741 - - $11.33 $6.74 $4.59 Complex uroflowmetry (eg, calibrated electronic equipment) Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any 51784 - - $53.40 $29.68 $23.72 technique 51785 - - $302.55 $71.36 $231.20 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 51792 - - $200.85 $42.69 $158.16 Stimulus evoked response (eg, measurement of bulbocavernosus reflex latency time) Voiding pressure studies, intra-abdominal (ie, rectal, gastric, intraperitoneal) (List separately in 51797 - - $131.29 $31.30 $99.99 addition to code for primary procedure) Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non- 51798 - - $8.36 - - imaging Cystoplasty or cystourethroplasty, plastic operation on bladder and/or vesical neck (anterior Y- 51800 - - $816.46 - - plasty, vesical fundus resection), any procedure, with or without wedge resection of posterior vesical neck 51820 - - $849.03 - - Cystourethroplasty with unilateral or bilateral ureteroneocystostomy 51840 - - $536.46 - - Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); simple Anterior vesicourethropexy, or urethropexy (eg, Marshall-Marchetti-Krantz, Burch); 51841 - - $620.45 - - complicated (eg, secondary repair) Abdomino-vaginal vesical neck suspension, with or without endoscopic control (eg, Stamey, 51845 - - $456.77 - - Raz, modified Pereyra) 51860 - - $585.27 - - Cystorrhaphy, suture of bladder wound, injury or rupture; simple 51865 - - $704.35 - - Cystorrhaphy, suture of bladder wound, injury or rupture; complicated 51880 - - $366.00 - - Closure of cystostomy (separate procedure) 51900 - - $646.31 - - Closure of vesicovaginal fistula, abdominal approach 51920 - - $598.68 - - Closure of vesicouterine fistula; 51925 - - $835.22 - - Closure of vesicouterine fistula; with hysterectomy 51940 - - $1,282.81 - - Closure, exstrophy of bladder 51960 - - $1,083.81 - - Enterocystoplasty, including intestinal anastomosis 51980 - - $559.46 - - Cutaneous vesicostomy 51990 - - $585.69 - - Laparoscopy, surgical; urethral suspension for stress incontinence 51992 - - $658.23 - - Laparoscopy, surgical; sling operation for stress incontinence (eg, fascia or synthetic) 51999 - - I.C. - - Unlisted laparoscopy procedure, bladder 52000 $169.04 $62.96 - - - Cystourethroscopy (separate procedure) 52001 $328.46 $223.54 - - - Cystourethroscopy with irrigation and evacuation of multiple obstructing clots Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or 52005 $235.56 $103.39 - - - ureteropyelography, exclusive of radiologic service; Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or 52007 $382.57 $128.97 - - - ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, 52010 $319.39 $128.97 - - - or duct radiography, exclusive of radiologic service 52204 $310.24 $110.25 - - - Cystourethroscopy, with biopsy(s) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder 52214 $592.71 $137.08 - - - neck, prostatic fossa, urethra, or periurethral glands Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of 52224 $618.04 $158.65 - - - MINOR (less than 0.5 cm) lesion(s) with or without biopsy Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; 52234 - - $191.47 - - SMALL bladder tumor(s) (0.5 up to 2.0 cm) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; 52235 - - $224.70 - - MEDIUM bladder tumor(s) (2.0 to 5.0 cm) Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; 52240 - - $305.51 - - LARGE bladder tumor(s) Cystourethroscopy with insertion of radioactive substance, with or without biopsy or 52250 - - $186.62 - - fulguration Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction 52260 - - $164.46 - - (spinal) anesthesia 52265 $305.78 $127.25 - - - Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia 52270 $322.43 $141.58 - - - Cystourethroscopy, with internal urethrotomy; female 52275 $422.25 $193.57 - - - Cystourethroscopy, with internal urethrotomy; male 52276 - - $206.03 - - Cystourethroscopy with direct vision internal urethrotomy 52277 - - $251.36 - - Cystourethroscopy, with resection of external sphincter (sphincterotomy) Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or 52281 $257.29 $118.46 - - - without meatotomy, with or without injection procedure for cystography, male or female 52282 - - $263.05 - - Cystourethroscopy, with insertion of permanent urethral stent

Page 107 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 52283 $258.69 $157.25 - - - Cystourethroscopy, with steroid injection into stricture Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal 52285 $257.85 $152.64 - - - septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone 52287 $288.05 $132.11 - - - Cystourethroscopy, with injection(s) for chemodenervation of the bladder 52290 - - $190.12 - - Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or 52300 - - $217.89 - - bilateral

52301 - - $225.71 - - Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or 52305 - - $217.22 - - multiple Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or 52310 $231.06 $117.74 - - - bladder (separate procedure); simple Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or 52315 $369.43 $213.79 - - - bladder (separate procedure); complicated Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of 52317 $703.73 $271.00 - - - fragments; simple or small (less than 2.5 cm) Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of 52318 - - $368.64 - - fragments; complicated or large (over 2.5 cm) 52320 - - $192.12 - - Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus 52325 - - $249.06 - - (eg, ultrasonic or electro-hydraulic technique) Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant 52327 - - $204.47 - - material Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of 52330 $465.63 $205.36 - - - ureteral calculus

52332 $366.97 $120.90 - - - Cystourethroscopy, with insertion of indwelling ureteral stent (eg, Gibbons or double-J type) Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a 52334 - - $142.71 - - percutaneous nephrostomy, retrograde Cystourethroscopy; with treatment of ureteral stricture (eg, balloon dilation, laser, 52341 - - $221.44 - - electrocautery, and incision) Cystourethroscopy; with treatment of ureteropelvic junction stricture (eg, balloon dilation, 52342 - - $240.37 - - laser, electrocautery, and incision) Cystourethroscopy; with treatment of intra-renal stricture (eg, balloon dilation, laser, 52343 - - $268.30 - - electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (eg, balloon dilation, 52344 - - $287.22 - - laser, electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (eg, 52345 - - $307.13 - - balloon dilation, laser, electrocautery, and incision) Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (eg, balloon 52346 - - $347.33 - - dilation, laser, electrocautery, and incision) 52351 - - $235.44 - - Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of 52352 - - $276.37 - - calculus (ureteral catheterization is included) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral 52353 - - $305.51 - - catheterization is included) Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of 52354 - - $324.93 - - ureteral or renal pelvic lesion Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal 52355 - - $363.96 - - pelvic tumor Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy including insertion of 52356 - - $323.52 - - indwelling ureteral stent (eg, Gibbons or double-J type) Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral 52400 - - $373.55 - - valves, or congenital obstructive hypertrophic mucosal folds 52402 - - $207.53 - - Cystourethroscopy with transurethral resection or incision of ejaculatory ducts Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single 52441 $1,109.72 $163.99 - - - implant Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each 52442 $813.78 $39.34 - - - additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure) 52450 - - $370.77 - - Transurethral incision of prostate 52500 - - $384.53 - - Transurethral resection of bladder neck (separate procedure)

Page 108 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, 52601 - - $571.03 - - complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) Transurethral resection; residual or regrowth of obstructive prostate tissue including control of 52630 - - $316.70 - - postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) 52640 - - $250.13 - - Transurethral resection; of postoperative bladder neck contracture Laser coagulation of prostate, including control of postoperative bleeding, complete 52647 $1,309.87 $508.19 - - - (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) Laser vaporization of prostate, including control of postoperative bleeding, complete 52648 $1,349.90 $541.83 - - - (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) Laser enucleation of the prostate with morcellation, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or 52649 - - $647.36 - - dilation, internal urethrotomy and transurethral resection of prostate are included if performed) 52700 - - $346.74 - - Transurethral drainage of prostatic abscess 53000 - - $116.82 - - Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra 53010 - - $232.85 - - Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external 53020 - - $75.86 - - Meatotomy, cutting of meatus (separate procedure); except infant 53025 - - $53.20 - - Meatotomy, cutting of meatus (separate procedure); infant 53040 - - $308.59 - - Drainage of deep periurethral abscess 53060 $147.41 $130.60 - - - Drainage of Skene's gland abscess or cyst 53080 - - $330.44 - - Drainage of perineal urinary extravasation; uncomplicated (separate procedure) 53085 - - $509.69 - - Drainage of perineal urinary extravasation; complicated 53200 $123.78 $110.74 - - - Biopsy of urethra 53210 - - $612.27 - - Urethrectomy, total, including cystostomy; female 53215 - - $727.13 - - Urethrectomy, total, including cystostomy; male 53220 - - $355.00 - - Excision or fulguration of carcinoma of urethra 53230 - - $478.13 - - Excision of urethral diverticulum (separate procedure); female 53235 - - $496.91 - - Excision of urethral diverticulum (separate procedure); male 53240 - - $333.23 - - Marsupialization of urethral diverticulum, male or female 53250 - - $311.56 - - Excision of bulbourethral gland (Cowper's gland) 53260 $160.94 $142.10 - - - Excision or fulguration; urethral polyp(s), distal urethra 53265 $177.31 $147.46 - - - Excision or fulguration; urethral caruncle 53270 $164.03 $144.33 - - - Excision or fulguration; Skene's glands 53275 - - $206.04 - - Excision or fulguration; urethral prolapse 53400 - - $629.17 - - Urethroplasty; first stage, for fistula, diverticulum, or stricture (eg, Johannsen type) 53405 - - $684.40 - - Urethroplasty; second stage (formation of urethra), including urinary diversion 53410 - - $766.56 - - Urethroplasty, 1-stage reconstruction of male anterior urethra Urethroplasty, transpubic or perineal, 1-stage, for reconstruction or repair of prostatic or 53415 - - $884.51 - - membranous urethra

53420 - - $659.25 - - Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; first stage Urethroplasty, 2-stage reconstruction or repair of prostatic or membranous urethra; second 53425 - - $733.30 - - stage 53430 - - $760.72 - - Urethroplasty, reconstruction of female urethra Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence 53431 - - $902.82 - - (eg, Tenago, Leadbetter procedure) 53440 - - $590.40 - - Sling operation for correction of male urinary incontinence (eg, fascia or synthetic) 53442 - - $615.50 - - Removal or revision of sling for male urinary incontinence (eg, fascia or synthetic) 53444 - - $622.11 - - Insertion of tandem cuff (dual cuff) Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, 53445 - - $592.38 - - and cuff 53446 - - $504.33 - - Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff Removal and replacement of inflatable urethral/bladder neck sphincter including pump, 53447 - - $633.73 - - reservoir, and cuff at the same operative session Removal and replacement of inflatable urethral/bladder neck sphincter including pump, 53448 - - $1,000.93 - - reservoir, and cuff through an infected field at the same operative session including irrigation and debridement of infected tissue 53449 - - $480.71 - - Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff 53450 - - $321.82 - - Urethromeatoplasty, with mucosal advancement Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type 53460 - - $359.59 - - procedure)

Page 109 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Urethrolysis, transvaginal, secondary, open, including cystourethroscopy (eg, postsurgical 53500 - - $587.96 - - obstruction, scarring) 53502 - - $381.59 - - Urethrorrhaphy, suture of urethral wound or injury, female 53505 - - $381.30 - - Urethrorrhaphy, suture of urethral wound or injury; penile 53510 - - $495.82 - - Urethrorrhaphy, suture of urethral wound or injury; perineal 53515 - - $623.78 - - Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous 53520 - - $437.91 - - Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) 53600 $66.87 $49.48 - - - Dilation of urethral stricture by passage of sound or urethral dilator, male; initial 53601 $64.05 $41.73 - - - Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, 53605 - - $50.38 - - general or conduction (spinal) anesthesia 53620 $117.52 $67.96 - - - Dilation of urethral stricture by passage of filiform and follower, male; initial 53621 $111.36 $56.01 - - - Dilation of urethral stricture by passage of filiform and follower, male; subsequent 53660 $56.40 $32.63 - - - Dilation of female urethra including suppository and/or instillation; initial 53661 $55.50 $31.74 - - - Dilation of female urethra including suppository and/or instillation; subsequent 53665 - - $29.90 - - Dilation of female urethra, general or conduction (spinal) anesthesia 53850 $1,269.03 $276.63 - - - Transurethral destruction of prostate tissue; by microwave thermotherapy 53852 $1,228.76 $296.07 - - - Transurethral destruction of prostate tissue; by radiofrequency thermotherapy Transurethral destruction of prostate tissue; by radiofrequency generated water vapor 53854 $1,465.89 $295.82 - - - thermotherapy 53855 $606.38 $64.39 - - - Insertion of a temporary prostatic urethral stent, including urethral measurement Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal 53860 $1,720.53 $175.12 - - - urethra for stress urinary incontinence 53899 - - I.C. - - Unlisted procedure, urinary system 54000 $125.42 $85.71 - - - Slitting of prepuce, dorsal or lateral (separate procedure); newborn 54001 $154.14 $109.80 - - - Slitting of prepuce, dorsal or lateral (separate procedure); except newborn 54015 - - $239.97 - - Incision and drainage of penis, deep Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54050 $107.25 $82.91 - - - vesicle), simple; chemical Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54055 $100.40 $73.73 - - - vesicle), simple; electrodesiccation Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54056 $111.94 $86.72 - - - vesicle), simple; cryosurgery Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54057 $110.44 $75.08 - - - vesicle), simple; laser surgery Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54060 $149.70 $102.45 - - - vesicle), simple; surgical excision Destruction of lesion(s), penis (eg, condyloma, papilloma, molluscum contagiosum, herpetic 54065 $174.49 $134.78 - - - vesicle), extensive (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery) 54100 $158.82 $95.92 - - - Biopsy of penis; (separate procedure) 54105 $213.79 $167.13 - - - Biopsy of penis; deep structures 54110 - - $489.84 - - Excision of penile plaque (Peyronie disease); 54111 - - $626.97 - - Excision of penile plaque (Peyronie disease); with graft to 5 cm in length 54112 - - $734.15 - - Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length 54115 $358.48 $334.13 - - - Removal foreign body from deep penile tissue (eg, plastic implant) 54120 - - $495.61 - - Amputation of penis; partial 54125 - - $638.43 - - Amputation of penis; complete 54130 - - $933.88 - - Amputation of penis, radical; with bilateral inguinofemoral lymphadenectomy Amputation of penis, radical; in continuity with bilateral pelvic lymphadenectomy, including 54135 - - $1,182.23 - - external iliac, hypogastric and obturator nodes 54150 $121.74 $76.52 - - - Circumcision, using clamp or other device with regional dorsal penile or ring block Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age 54160 $174.83 $113.39 - - - or less)

54161 - - $154.72 - - Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age 54162 $204.28 $156.75 - - - Lysis or excision of penile post-circumcision adhesions 54163 - - $171.82 - - Repair incomplete circumcision 54164 - - $152.20 - - Frenulotomy of penis 54200 $88.61 $66.58 - - - Injection procedure for Peyronie disease; 54205 - - $418.52 - - Injection procedure for Peyronie disease; with surgical exposure of plaque 54220 $168.41 $104.36 - - - Irrigation of corpora cavernosa for priapism 54230 $79.22 $62.12 - - - Injection procedure for corpora cavernosography Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (eg, 54231 $111.87 $90.71 - - - papaverine, phentolamine) 54235 $69.82 $57.36 - - - Injection of corpora cavernosa with pharmacologic agent(s) (eg, papaverine, phentolamine) 54240 - - $81.36 $50.69 $30.68 Penile plethysmography

Page 110 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 54250 - - $95.43 $85.33 $10.10 Nocturnal penile tumescence and/or rigidity test Plastic operation of penis for straightening of chordee (eg, hypospadias), with or without 54300 - - $506.36 - - mobilization of urethra Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or 54304 - - $587.50 - - without transplantation of prepuce and/or skin flaps

54308 - - $561.37 - - Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 54312 - - $642.02 - - cm Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin 54316 - - $780.25 - - graft obtained from site other than genitalia Urethroplasty for third stage hypospadias repair to release penis from scrotum (eg, third stage 54318 - - $558.40 - - Cecil repair) 1-stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal 54322 - - $612.87 - - advancement (eg, Magpi, V-flap) 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty 54324 - - $758.32 - - by local skin flaps (eg, flip-flap, prepucial flap) 1-stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty 54326 - - $739.80 - - by local skin flaps and mobilization of urethra 1-stage distal hypospadias repair (with or without chordee or circumcision); with extensive 54328 - - $734.99 - - dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap 1-stage proximal penile or penoscrotal hypospadias repair requiring extensive dissection to 54332 - - $792.91 - - correct chordee and urethroplasty by use of skin graft tube and/or island flap 1-stage perineal hypospadias repair requiring extensive dissection to correct chordee and 54336 - - $931.32 - - urethroplasty by use of skin graft tube and/or island flap Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or 54340 - - $447.60 - - excision, simple Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of 54344 - - $741.44 - - skin flaps and urethroplasty with flap or patch graft Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive 54348 - - $792.54 - - dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion) Repair of hypospadias cripple requiring extensive dissection and excision of previously 54352 - - $1,108.04 - - constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts 54360 - - $565.48 - - Plastic operation on penis to correct angulation 54380 - - $627.07 - - Plastic operation on penis for epispadias distal to external sphincter; 54385 - - $728.74 - - Plastic operation on penis for epispadias distal to external sphincter; with incontinence 54390 - - $971.72 - - Plastic operation on penis for epispadias distal to external sphincter; with exstrophy of bladder 54400 - - $417.40 - - Insertion of penile prosthesis; non-inflatable (semi-rigid) 54401 - - $519.11 - - Insertion of penile prosthesis; inflatable (self-contained) Insertion of multi-component, inflatable penile prosthesis, including placement of pump, 54405 - - $634.17 - - cylinders, and reservoir Removal of all components of a multi-component, inflatable penile prosthesis without 54406 - - $573.52 - - replacement of prosthesis 54408 - - $620.28 - - Repair of component(s) of a multi-component, inflatable penile prosthesis Removal and replacement of all component(s) of a multi-component, inflatable penile 54410 - - $675.17 - - prosthesis at the same operative session Removal and replacement of all components of a multi-component inflatable penile prosthesis 54411 - - $806.78 - - through an infected field at the same operative session, including irrigation and debridement of infected tissue Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without 54415 - - $416.18 - - replacement of prosthesis Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile 54416 - - $559.44 - - prosthesis at the same operative session Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile 54417 - - $704.54 - - prosthesis through an infected field at the same operative session, including irrigation and debridement of infected tissue 54420 - - $552.41 - - Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral 54430 - - $501.91 - - Corpora cavernosa-corpus spongiosum shunt (priapism operation), unilateral or bilateral Corpora cavernosa-glans penis fistulization (eg, biopsy needle, Winter procedure, rongeur, or 54435 - - $326.94 - - punch) for priapism 54437 - - $530.17 - - Repair of traumatic corporeal tear(s) 54438 - - $1,047.06 - - Replantation, penis, complete amputation including urethral repair 54440 - - I.C. - - Plastic operation of penis for injury

Page 111 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 54450 $54.05 $44.78 - - - Foreskin manipulation including lysis of preputial adhesions and stretching 54500 - - $58.13 - - Biopsy of testis, needle (separate procedure) 54505 - - $165.20 - - Biopsy of testis, incisional (separate procedure) 54512 - - $423.07 - - Excision of extraparenchymal lesion of testis Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or 54520 - - $256.50 - - inguinal approach 54522 - - $462.57 - - Orchiectomy, partial 54530 - - $398.75 - - Orchiectomy, radical, for tumor; inguinal approach 54535 - - $583.71 - - Orchiectomy, radical, for tumor; with abdominal exploration 54550 - - $386.59 - - Exploration for undescended testis (inguinal or scrotal area) 54560 - - $539.10 - - Exploration for undescended testis with abdominal exploration 54600 - - $356.13 - - Reduction of torsion of testis, surgical, with or without fixation of contralateral testis 54620 - - $234.92 - - Fixation of contralateral testis (separate procedure) 54640 - - $340.44 - - Orchiopexy, inguinal or scrotal approach 54650 - - $558.79 - - Orchiopexy, abdominal approach, for intra-abdominal testis (eg, Fowler-Stephens) 54660 - - $281.26 - - Insertion of testicular prosthesis (separate procedure) 54670 - - $320.76 - - Suture or repair of testicular injury 54680 - - $617.65 - - Transplantation of testis(es) to thigh (because of scrotal destruction) 54690 - - $514.27 - - Laparoscopy, surgical; orchiectomy 54692 - - $593.88 - - Laparoscopy, surgical; orchiopexy for intra-abdominal testis 54699 - - I.C. - - Unlisted laparoscopy procedure, testis 54700 - - $168.48 - - Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma) 54800 - - $98.27 - - Biopsy of epididymis, needle 54830 - - $292.88 - - Excision of local lesion of epididymis 54840 - - $253.03 - - Excision of spermatocele, with or without epididymectomy 54860 - - $329.21 - - Epididymectomy; unilateral 54861 - - $445.89 - - Epididymectomy; bilateral 54865 - - $282.35 - - Exploration of epididymis, with or without biopsy 54900 - - $628.18 - - Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral 54901 - - $828.68 - - Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral 55000 $93.93 $66.40 - - - Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication 55040 - - $265.45 - - Excision of hydrocele; unilateral 55041 - - $401.94 - - Excision of hydrocele; bilateral 55060 - - $299.51 - - Repair of tunica vaginalis hydrocele (Bottle type) 55100 $178.77 $131.53 - - - Drainage of scrotal wall abscess 55110 - - $305.27 - - Scrotal exploration 55120 - - $278.41 - - Removal of foreign body in scrotum 55150 - - $387.12 - - Resection of scrotum 55175 - - $285.73 - - Scrotoplasty; simple 55180 - - $544.26 - - Scrotoplasty; complicated Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate 55200 $328.20 $218.35 - - - procedure) Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen 55250 $422.22 $244.77 - - - examination(s) 55300 - - $145.78 - - Vasotomy for vasograms, seminal vesiculograms, or epididymograms, unilateral or bilateral 55400 - - $392.34 - - Vasovasostomy, vasovasorrhaphy 55500 - - $309.63 - - Excision of hydrocele of spermatic cord, unilateral (separate procedure) 55520 - - $359.42 - - Excision of lesion of spermatic cord (separate procedure) 55530 - - $276.56 - - Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure) 55535 - - $338.34 - - Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach 55540 - - $436.08 - - Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair 55550 - - $337.15 - - Laparoscopy, surgical, with ligation of spermatic veins for varicocele 55559 - - I.C. - - Unlisted laparoscopy procedure, spermatic cord 55600 - - $331.38 - - Vesiculotomy; 55605 - - $410.77 - - Vesiculotomy; complicated 55650 - - $562.99 - - Vesiculectomy, any approach 55680 - - $272.74 - - Excision of Mullerian duct cyst 55700 $198.09 $101.87 - - - Biopsy, prostate; needle or punch, single or multiple, any approach 55705 - - $208.60 - - Biopsy, prostate; incisional, any approach Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, 55706 - - $293.13 - - including imaging guidance 55720 - - $355.29 - - Prostatotomy, external drainage of prostatic abscess, any approach; simple 55725 - - $466.92 - - Prostatotomy, external drainage of prostatic abscess, any approach; complicated Prostatectomy, perineal, subtotal (including control of postoperative bleeding, vasectomy, 55801 - - $857.61 - - meatotomy, urethral calibration and/or dilation, and internal urethrotomy) 55810 - - $1,024.97 - - Prostatectomy, perineal radical;

Page 112 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

55812 - - $1,258.30 - - Prostatectomy, perineal radical; with lymph node biopsy(s) (limited pelvic lymphadenectomy) Prostatectomy, perineal radical; with bilateral pelvic lymphadenectomy, including external iliac, 55815 - - $1,377.90 - - hypogastric and obturator nodes

55821 - - $684.64 - - Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral calibration and/or dilation, and internal urethrotomy); suprapubic, subtotal, 1 or 2 stages Prostatectomy (including control of postoperative bleeding, vasectomy, meatotomy, urethral 55831 - - $740.70 - - calibration and/or dilation, and internal urethrotomy); retropubic, subtotal 55840 - - $916.35 - - Prostatectomy, retropubic radical, with or without nerve sparing; Prostatectomy, retropubic radical, with or without nerve sparing; with lymph node biopsy(s) 55842 - - $916.84 - - (limited pelvic lymphadenectomy) Prostatectomy, retropubic radical, with or without nerve sparing; with bilateral pelvic 55845 - - $1,066.38 - - lymphadenectomy, including external iliac, hypogastric, and obturator nodes 55860 - - $685.65 - - Exposure of prostate, any approach, for insertion of radioactive substance; Exposure of prostate, any approach, for insertion of radioactive substance; with lymph node 55862 - - $858.34 - - biopsy(s) (limited pelvic lymphadenectomy) Exposure of prostate, any approach, for insertion of radioactive substance; with bilateral pelvic 55865 - - $1,044.86 - - lymphadenectomy, including external iliac, hypogastric and obturator nodes Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes 55866 - - $1,128.59 - - robotic assistance, when performed 55870 $138.10 $110.86 - - - Electroejaculation 55873 $5,047.06 $598.95 - - - Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) Transperineal placement of biodegradable material, peri-prostatic, single or multiple 55874 $2,515.52 $129.60 - - - injection(s), including image guidance, when performed Transperineal placement of needles or catheters into prostate for interstitial radioelement 55875 - - $604.12 - - application, with or without cystoscopy Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, 55876 $115.51 $79.28 - - - dosimeter), prostate (via needle, any approach), single or multiple Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound 55880 - - $772.71 - - (HIFU), including ultrasound guidance 55899 - - I.C. - - Unlisted procedure, male genital system Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for 55920 - - $356.11 - - subsequent interstitial radioelement application 55970 - - I.C. - - Intersex surgery; male to female 55980 - - I.C. - - Intersex surgery; female to male 56405 $102.12 $94.58 - - - Incision and drainage of vulva or perineal abscess 56420 $124.89 $81.42 - - - Incision and drainage of Bartholin's gland abscess 56440 - - $142.95 - - Marsupialization of Bartholin's gland cyst 56441 $130.58 $116.67 - - - Lysis of labial adhesions 56442 - - $37.25 - - Hymenotomy, simple incision Destruction of lesion(s), vulva; simple (eg, laser surgery, electrosurgery, cryosurgery, 56501 $130.97 $99.38 - - - chemosurgery) Destruction of lesion(s), vulva; extensive (eg, laser surgery, electrosurgery, cryosurgery, 56515 $200.40 $163.31 - - - chemosurgery) 56605 $71.84 $47.21 - - - Biopsy of vulva or perineum (separate procedure); 1 lesion Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List 56606 $30.42 $23.17 - - - separately in addition to code for primary procedure) 56620 - - $437.61 - - Vulvectomy simple; partial 56625 - - $508.76 - - Vulvectomy simple; complete 56630 - - $737.94 - - Vulvectomy, radical, partial; 56631 - - $920.36 - - Vulvectomy, radical, partial; with unilateral inguinofemoral lymphadenectomy 56632 - - $1,098.23 - - Vulvectomy, radical, partial; with bilateral inguinofemoral lymphadenectomy 56633 - - $951.11 - - Vulvectomy, radical, complete; 56634 - - $1,003.49 - - Vulvectomy, radical, complete; with unilateral inguinofemoral lymphadenectomy 56637 - - $1,163.35 - - Vulvectomy, radical, complete; with bilateral inguinofemoral lymphadenectomy 56640 - - $1,178.59 - - Vulvectomy, radical, complete, with inguinofemoral, iliac, and pelvic lymphadenectomy 56700 - - $155.58 - - Partial hymenectomy or revision of hymenal ring 56740 - - $242.99 - - Excision of Bartholin's gland or cyst 56800 - - $195.46 - - Plastic repair of introitus 56805 - - $911.88 - - Clitoroplasty for intersex state 56810 - - $210.33 - - Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 56820 $94.65 $66.82 - - - Colposcopy of the vulva; 56821 $125.98 $89.17 - - - Colposcopy of the vulva; with biopsy(s) 57000 - - $155.34 - - Colpotomy; with exploration 57010 - - $353.72 - - Colpotomy; with drainage of pelvic abscess

Page 113 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 57020 $87.07 $63.30 - - - Colpocentesis (separate procedure) 57022 - - $139.13 - - Incision and drainage of vaginal hematoma; obstetrical/postpartum Incision and drainage of vaginal hematoma; non-obstetrical (eg, post-trauma, spontaneous 57023 - - $249.12 - - bleeding) Destruction of vaginal lesion(s); simple (eg, laser surgery, electrosurgery, cryosurgery, 57061 $113.24 $85.42 - - - chemosurgery) Destruction of vaginal lesion(s); extensive (eg, laser surgery, electrosurgery, cryosurgery, 57065 $176.20 $142.29 - - - chemosurgery) 57100 $76.24 $51.31 - - - Biopsy of vaginal mucosa; simple (separate procedure) 57105 $126.68 $108.42 - - - Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) 57106 - - $407.97 - - Vaginectomy, partial removal of vaginal wall; Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical 57107 - - $1,126.97 - - vaginectomy) Vaginectomy, partial removal of vaginal wall; with removal of paravaginal tissue (radical 57109 - - $1,340.21 - - vaginectomy) with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling (biopsy) 57110 - - $708.94 - - Vaginectomy, complete removal of vaginal wall; Vaginectomy, complete removal of vaginal wall; with removal of paravaginal tissue (radical 57111 - - $1,340.21 - - vaginectomy) 57120 - - $411.98 - - Colpocleisis (Le Fort type) 57130 $164.07 $132.19 - - - Excision of vaginal septum 57135 $176.39 $143.35 - - - Excision of vaginal cyst or tumor Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or 57150 $43.00 $20.97 - - - fungoid disease 57155 $301.38 $221.10 - - - Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy 57156 $170.21 $117.17 - - - Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy 57160 $54.04 $36.36 - - - Fitting and insertion of pessary or other intravaginal support device 57170 $73.73 $49.19 - - - Diaphragm or cervical cap fitting with instructions Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical 57180 $138.87 $91.05 - - - vaginal hemorrhage (separate procedure) 57200 - - $251.86 - - Colporrhaphy, suture of injury of vagina (nonobstetrical) 57210 - - $302.82 - - Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) 57220 - - $265.03 - - Plastic operation on urethral sphincter, vaginal approach (eg, Kelly urethral plication) 57230 - - $323.52 - - Plastic repair of urethrocele Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele, including 57240 - - $475.64 - - cystourethroscopy, when performed 57250 - - $478.51 - - Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy 57260 - - $608.55 - - Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; Combined anteroposterior colporrhaphy, including cystourethroscopy, when performed; with 57265 - - $682.52 - - enterocele repair Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, 57267 - - $197.69 - - posterior compartment), vaginal approach (List separately in addition to code for primary procedure) 57268 - - $392.43 - - Repair of enterocele, vaginal approach (separate procedure) 57270 - - $636.34 - - Repair of enterocele, abdominal approach (separate procedure) 57280 - - $755.72 - - Colpopexy, abdominal approach 57282 - - $415.08 - - Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) 57283 - - $550.26 - - Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) Paravaginal defect repair (including repair of cystocele, if performed); open abdominal 57284 - - $647.97 - - approach 57285 - - $540.09 - - Paravaginal defect repair (including repair of cystocele, if performed); vaginal approach 57287 - - $565.20 - - Removal or revision of sling for stress incontinence (eg, fascia or synthetic) 57288 - - $576.76 - - Sling operation for stress incontinence (eg, fascia or synthetic) 57289 - - $616.03 - - Pereyra procedure, including anterior colporrhaphy 57291 - - $427.21 - - Construction of artificial vagina; without graft 57292 - - $649.26 - - Construction of artificial vagina; with graft 57295 - - $388.14 - - Revision (including removal) of prosthetic vaginal graft; vaginal approach 57296 - - $742.76 - - Revision (including removal) of prosthetic vaginal graft; open abdominal approach 57300 - - $466.20 - - Closure of rectovaginal fistula; vaginal or transanal approach 57305 - - $759.79 - - Closure of rectovaginal fistula; abdominal approach 57307 - - $828.87 - - Closure of rectovaginal fistula; abdominal approach, with concomitant colostomy Closure of rectovaginal fistula; transperineal approach, with perineal body reconstruction, with 57308 - - $518.69 - - or without levator plication 57310 - - $378.72 - - Closure of urethrovaginal fistula; 57311 - - $427.99 - - Closure of urethrovaginal fistula; with bulbocavernosus transplant 57320 - - $432.36 - - Closure of vesicovaginal fistula; vaginal approach

Page 114 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 57330 - - $594.67 - - Closure of vesicovaginal fistula; transvesical and vaginal approach 57335 - - $921.01 - - Vaginoplasty for intersex state 57400 - - $103.28 - - Dilation of vagina under anesthesia (other than local) 57410 - - $83.47 - - Pelvic examination under anesthesia (other than local) Removal of impacted vaginal foreign body (separate procedure) under anesthesia (other than 57415 - - $133.95 - - local) 57420 $99.53 $70.84 - - - Colposcopy of the entire vagina, with cervix if present; 57421 $133.88 $95.91 - - - Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix 57423 - - $727.24 - - Paravaginal defect repair (including repair of cystocele, if performed), laparoscopic approach 57425 - - $767.53 - - Laparoscopy, surgical, colpopexy (suspension of vaginal apex) 57426 - - $676.24 - - Revision (including removal) of prosthetic vaginal graft, laparoscopic approach 57452 $95.23 $71.75 - - - Colposcopy of the cervix including upper/adjacent vagina; Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and 57454 $129.12 $105.36 - - - endocervical curettage 57455 $122.40 $86.17 - - - Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix 57456 $115.06 $79.70 - - - Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the 57460 $245.54 $126.13 - - - cervix Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the 57461 $274.63 $145.36 - - - cervix Computer-aided mapping of cervix uteri during colposcopy, including optical dynamic spectral 57465 $60.03 $45.01 - - - imaging and algorithmic quantification of the acetowhitening effect (List separately in addition to code for primary procedure) Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration 57500 $115.32 $59.09 - - - (separate procedure) 57505 $103.22 $80.32 - - - Endocervical curettage (not done as part of a dilation and curettage) 57510 $119.48 $89.34 - - - Cautery of cervix; electro or thermal 57511 $138.73 $111.49 - - - Cautery of cervix; cryocautery, initial or repeat 57513 $141.05 $111.20 - - - Cautery of cervix; laser ablation Conization of cervix, with or without fulguration, with or without dilation and curettage, with or 57520 $265.02 $225.60 - - - without repair; cold knife or laser Conization of cervix, with or without fulguration, with or without dilation and curettage, with or 57522 $227.53 $197.39 - - - without repair; loop electrode excision 57530 - - $285.37 - - Trachelectomy (cervicectomy), amputation of cervix (separate procedure)

57531 - - $1,423.31 - - Radical trachelectomy, with bilateral total pelvic lymphadenectomy and para-aortic lymph node sampling biopsy, with or without removal of tube(s), with or without removal of ovary(s) 57540 - - $619.97 - - Excision of cervical stump, abdominal approach; 57545 - - $653.34 - - Excision of cervical stump, abdominal approach; with pelvic floor repair 57550 - - $333.23 - - Excision of cervical stump, vaginal approach; 57555 - - $482.97 - - Excision of cervical stump, vaginal approach; with anterior and/or posterior repair 57556 - - $457.65 - - Excision of cervical stump, vaginal approach; with repair of enterocele 57558 $114.55 $96.87 - - - Dilation and curettage of cervical stump 57700 - - $266.90 - - Cerclage of uterine cervix, nonobstetrical 57720 - - $255.85 - - Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach 57800 $55.83 $37.86 - - - Dilation of cervical canal, instrumental (separate procedure) Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical 58100 $77.33 $50.08 - - - dilation, any method (separate procedure) Endometrial sampling (biopsy) performed in conjunction with colposcopy (List separately in 58110 $39.88 $32.06 - - - addition to code for primary procedure) 58120 $222.85 $178.79 - - - Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total 58140 - - $729.74 - - weight of 250 g or less and/or removal of surface myomas; abdominal approach Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total 58145 - - $442.55 - - weight of 250 g 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 58146 - - $908.94 - - intramural myomas with total weight greater than 250 g, abdominal approach Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or 58150 - - $792.91 - - without removal of ovary(s); Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or 58152 - - $983.76 - - without removal of ovary(s); with colpo-urethrocystopexy (eg, Marshall-Marchetti-Krantz, Burch) Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of 58180 - - $754.38 - - tube(s), with or without removal of ovary(s)

Page 115 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

58200 - - $1,058.19 - - Total abdominal hysterectomy, including partial vaginectomy, with para-aortic and pelvic lymph node sampling, with or without removal of tube(s), with or without removal of ovary(s) Radical abdominal hysterectomy, with bilateral total pelvic lymphadenectomy and para-aortic 58210 - - $1,419.79 - - lymph node sampling (biopsy), with or without removal of tube(s), with or without removal of ovary(s) Pelvic exenteration for gynecologic malignancy, with total abdominal hysterectomy or cervicectomy, with or without removal of tube(s), with or without removal of ovary(s), with 58240 - - $2,273.05 - - removal of bladder and ureteral transplantations, and/or abdominoperineal resection of rectum and colon and colostomy, or any combination thereof 58260 - - $656.74 - - Vaginal hysterectomy, for uterus 250 g or less; 58262 - - $728.47 - - Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with 58263 - - $782.23 - - repair of enterocele Vaginal hysterectomy, for uterus 250 g or less; with colpo-urethrocystopexy (Marshall- 58267 - - $837.91 - - Marchetti-Krantz type, Pereyra type) with or without endoscopic control 58270 - - $700.26 - - Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele 58275 - - $777.04 - - Vaginal hysterectomy, with total or partial vaginectomy; 58280 - - $832.34 - - Vaginal hysterectomy, with total or partial vaginectomy; with repair of enterocele 58285 - - $1,098.88 - - Vaginal hysterectomy, radical (Schauta type operation) 58290 - - $905.68 - - Vaginal hysterectomy, for uterus greater than 250 g; 58291 - - $981.20 - - Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), 58292 - - $1,033.54 - - with repair of enterocele 58294 - - $958.98 - - Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele 58300 $95.89 $56.15 - - - Insertion of intrauterine device (IUD) 58301 $106.33 $70.41 - - - Removal of intrauterine device (IUD) 58321 $62.66 $37.73 - - - Artificial insemination; intra-cervical 58322 $70.69 $45.76 - - - Artificial insemination; intra-uterine 58323 $12.25 $9.93 - - - Sperm washing for artificial insemination Catheterization and introduction of saline or contrast material for saline infusion 58340 $157.58 $45.12 - - - sonohysterography (SIS) or hysterosalpingography Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing 58345 - - $224.82 - - patency (any method), with or without hysterosalpingography 58346 - - $374.63 - - Insertion of Heyman capsules for clinical brachytherapy 58350 $101.60 $69.42 - - - Chromotubation of oviduct, including materials 58353 $814.96 $178.19 - - - Endometrial ablation, thermal, without hysteroscopic guidance Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when 58356 $1,488.01 $276.79 - - - performed Uterine suspension, with or without shortening of round ligaments, with or without shortening 58400 - - $358.62 - - of sacrouterine ligaments; (separate procedure) Uterine suspension, with or without shortening of round ligaments, with or without shortening 58410 - - $639.76 - - of sacrouterine ligaments; with presacral sympathectomy 58520 - - $626.53 - - Hysterorrhaphy, repair of ruptured uterus (nonobstetrical) 58540 - - $720.09 - - Hysteroplasty, repair of uterine anomaly (Strassman type) 58541 - - $571.83 - - Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of 58542 - - $650.18 - - tube(s) and/or ovary(s) 58543 - - $660.47 - - Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal 58544 - - $710.98 - - of tube(s) and/or ovary(s) Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 58545 - - $706.24 - - 250 g or less and/or removal of surface myomas Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural 58546 - - $879.27 - - myomas with total weight greater than 250 g Laparoscopy, surgical, with radical hysterectomy, with bilateral total pelvic lymphadenectomy 58548 - - $1,464.80 - - and para-aortic lymph node sampling (biopsy), with removal of tube(s) and ovary(s), if performed 58550 - - $693.93 - - Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of 58552 - - $773.05 - - tube(s) and/or ovary(s) 58553 - - $884.40 - - Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g; with removal of 58554 - - $1,031.99 - - tube(s) and/or ovary(s) 58555 $259.99 $119.71 - - - Hysteroscopy, diagnostic (separate procedure)

Page 116 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or 58558 $1,134.91 $182.22 - - - without D & C 58559 - - $225.01 - - Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) 58560 - - $247.31 - - Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) 58561 - - $282.85 - - Hysteroscopy, surgical; with removal of leiomyomata 58562 $315.19 $174.91 - - - Hysteroscopy, surgical; with removal of impacted foreign body Hysteroscopy, surgical; with endometrial ablation (eg, endometrial resection, electrosurgical 58563 $1,597.73 $194.06 - - - ablation, thermoablation) Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by 58565 $2,085.42 $467.49 - - - placement of permanent implants 58570 - - $624.15 - - Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) 58571 - - $704.12 - - and/or ovary(s) 58572 - - $809.72 - - Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of 58573 - - $949.55 - - tube(s) and/or ovary(s)

58575 - - $1,488.45 - - Laparoscopy, surgical, total hysterectomy for resection of malignancy (tumor debulking), with omentectomy including salpingo-oophorectomy, unilateral or bilateral, when performed 58578 - - I.C. - - Unlisted laparoscopy procedure, uterus 58579 - - I.C. - - Unlisted hysteroscopy procedure, uterus Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or 58600 - - $384.10 - - bilateral Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, 58605 - - $348.01 - - unilateral or bilateral, during same hospitalization (separate procedure) Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra- 58611 - - $80.33 - - abdominal surgery (not a separate procedure) (List separately in addition to code for primary procedure) Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or suprapubic 58615 - - $261.14 - - approach

58660 - - $532.14 - - Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or 58661 - - $510.65 - - salpingectomy) Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or 58662 - - $559.26 - - peritoneal surface by any method 58670 - - $291.13 - - Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 - - $290.60 - - Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) 58672 - - $576.83 - - Laparoscopy, surgical; with fimbrioplasty 58673 - - $626.58 - - Laparoscopy, surgical; with salpingostomy (salpingoneostomy) Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound 58674 - - $641.79 - - guidance and monitoring, radiofrequency 58679 - - I.C. - - Unlisted laparoscopy procedure, oviduct, ovary 58700 - - $621.78 - - Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 58720 - - $586.30 - - Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58740 - - $704.20 - - Lysis of adhesions (salpingolysis, ovariolysis) 58750 - - $714.51 - - Tubotubal anastomosis 58752 - - $712.48 - - Tubouterine implantation 58760 - - $643.99 - - Fimbrioplasty 58770 - - $676.90 - - Salpingostomy (salpingoneostomy) 58800 $274.04 $243.90 - - - Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); vaginal approach

58805 - - $330.67 - - Drainage of ovarian cyst(s), unilateral or bilateral (separate procedure); abdominal approach 58820 - - $259.60 - - Drainage of ovarian abscess; vaginal approach, open 58822 - - $559.10 - - Drainage of ovarian abscess; abdominal approach 58825 - - $555.11 - - Transposition, ovary(s) 58900 - - $337.95 - - Biopsy of ovary, unilateral or bilateral (separate procedure) 58920 - - $559.49 - - Wedge resection or bisection of ovary, unilateral or bilateral 58925 - - $596.75 - - Ovarian cystectomy, unilateral or bilateral 58940 - - $426.78 - - Oophorectomy, partial or total, unilateral or bilateral; Oophorectomy, partial or total, unilateral or bilateral; for ovarian, tubal or primary peritoneal malignancy, with para-aortic and pelvic lymph node biopsies, peritoneal washings, peritoneal 58943 - - $914.26 - - biopsies, diaphragmatic assessments, with or without salpingectomy(s), with or without omentectomy Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo- 58950 - - $888.87 - - oophorectomy and omentectomy;

Page 117 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo- 58951 - - $1,121.92 - - oophorectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para- aortic lymphadenectomy Resection (initial) of ovarian, tubal or primary peritoneal malignancy with bilateral salpingo- 58952 - - $1,274.83 - - oophorectomy and omentectomy; with radical dissection for debulking (ie, radical excision or destruction, intra-abdominal or retroperitoneal tumors) Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical 58953 - - $1,561.64 - - dissection for debulking; Bilateral salpingo-oophorectomy with omentectomy, total abdominal hysterectomy and radical 58954 - - $1,691.81 - - dissection for debulking; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Bilateral salpingo-oophorectomy with total omentectomy, total abdominal hysterectomy for 58956 - - $1,062.36 - - malignancy Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy 58957 - - $1,234.05 - - (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; Resection (tumor debulking) of recurrent ovarian, tubal, primary peritoneal, uterine malignancy 58958 - - $1,365.26 - - (intra-abdominal, retroperitoneal tumors), with omentectomy, if performed; with pelvic lymphadenectomy and limited para-aortic lymphadenectomy Laparotomy, for staging or restaging of ovarian, tubal, or primary peritoneal malignancy (second look), with or without omentectomy, peritoneal washing, biopsy of abdominal and 58960 - - $760.67 - - pelvic peritoneum, diaphragmatic assessment with pelvic and limited para-aortic lymphadenectomy 58970 $184.47 $155.20 - - - Follicle puncture for oocyte retrieval, any method 58974 - - I.C. - - Embryo transfer, intrauterine 58976 $200.36 $167.61 - - - Gamete, zygote, or embryo intrafallopian transfer, any method 58999 - - I.C. - - Unlisted procedure, female genital system (nonobstetrical) 59000 $134.97 $84.03 - - - Amniocentesis; diagnostic 59001 - - $185.91 - - Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) 59012 - - $209.45 - - Cordocentesis (intrauterine), any method 59015 $163.20 $136.53 - - - Chorionic villus sampling, any method 59020 - - $76.83 $38.21 $38.62 Fetal contraction stress test 59025 - - $51.56 $30.72 $20.84 Fetal non-stress test 59030 - - $116.09 - - Fetal scalp blood sampling Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written 59050 - - $52.69 - - report; supervision and interpretation Fetal monitoring during labor by consulting physician (ie, non-attending physician) with written 59051 - - $43.51 - - report; interpretation only 59070 $317.43 $241.20 - - - Transabdominal amnioinfusion, including ultrasound guidance 59072 - - $407.29 - - Fetal umbilical cord occlusion, including ultrasound guidance Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis), including ultrasound 59074 $304.39 $241.20 - - - guidance 59076 - - $407.29 - - Fetal shunt placement, including ultrasound guidance 59100 - - $665.22 - - Hysterotomy, abdominal (eg, for hydatidiform mole, abortion) Surgical treatment of ectopic pregnancy; tubal or ovarian, requiring salpingectomy and/or 59120 - - $838.80 - - oophorectomy, abdominal or vaginal approach Surgical treatment of ectopic pregnancy; tubal or ovarian, without salpingectomy and/or 59121 - - $839.60 - - oophorectomy 59130 - - $737.78 - - Surgical treatment of ectopic pregnancy; abdominal pregnancy Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy requiring total 59135 - - $729.33 - - hysterectomy Surgical treatment of ectopic pregnancy; interstitial, uterine pregnancy with partial resection of 59136 - - $925.70 - - uterus 59140 - - $323.79 - - Surgical treatment of ectopic pregnancy; cervical, with evacuation

59150 - - $813.78 - - Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy 59151 - - $793.96 - - Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy 59160 $251.98 $189.48 - - - Curettage, postpartum 59200 $94.35 $46.03 - - - Insertion of cervical dilator (eg, laminaria, prostaglandin) (separate procedure) 59300 $224.19 $154.10 - - - Episiotomy or vaginal repair, by other than attending 59320 - - $158.12 - - Cerclage of cervix, during pregnancy; vaginal 59325 - - $250.86 - - Cerclage of cervix, during pregnancy; abdominal 59350 - - $218.24 - - Hysterorrhaphy of ruptured uterus Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, 59400 - - $2,173.45 - - and/or forceps) and postpartum care 59409 - - $839.04 - - Vaginal delivery only (with or without episiotomy and/or forceps);

Page 118 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

59410 - - $1,076.12 - - Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59412 - - $80.59 - - External cephalic version, with or without tocolysis 59414 - - $94.25 - - Delivery of placenta (separate procedure) 59425 $488.47 $366.51 - - - Antepartum care only; 4-6 visits 59426 $870.03 $647.36 - - - Antepartum care only; 7 or more visits 59430 $216.83 $143.58 - - - Postpartum care only (separate procedure) 59510 - - $2,405.36 - - Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59514 - - $943.39 - - Cesarean delivery only; 59515 - - $1,310.04 - - Cesarean delivery only; including postpartum care Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for 59525 - - $377.13 - - primary procedure) Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, 59610 - - $2,281.10 - - and/or forceps) and postpartum care, after previous cesarean delivery Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or 59612 - - $942.04 - - forceps); Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or 59614 - - $1,173.73 - - forceps); including postpartum care Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, 59618 - - $2,435.34 - - following attempted vaginal delivery after previous cesarean delivery

59620 - - $974.84 - - Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery; 59622 - - $1,354.11 - - including postpartum care 59812 $357.55 $315.37 - - - Treatment of incomplete abortion, any trimester, completed surgically 59820 $431.20 $389.02 - - - Treatment of missed abortion, completed surgically; first trimester 59821 $428.32 $383.83 - - - Treatment of missed abortion, completed surgically; second trimester 59830 - - $355.92 - - Treatment of septic abortion, completed surgically 59840 $187.07 $170.55 - - - Induced abortion, by dilation and curettage 59841 $320.23 $288.64 - - - Induced abortion, by dilation and evacuation Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including 59850 - - $303.65 - - hospital admission and visits, delivery of fetus and secundines; Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including 59851 - - $327.08 - - hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation Induced abortion, by 1 or more intra-amniotic injections (amniocentesis-injections), including 59852 - - $450.06 - - hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed intra- amniotic injection) Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without 59855 - - $330.65 - - cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without 59856 - - $387.34 - - cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with dilation and curettage and/or evacuation Induced abortion, by 1 or more vaginal suppositories (eg, prostaglandin) with or without 59857 - - $452.67 - - cervical dilation (eg, laminaria), including hospital admission and visits, delivery of fetus and secundines; with hysterotomy (failed medical evacuation) 59866 - - $186.34 - - Multifetal pregnancy reduction(s) (MPR) 59870 - - $402.05 - - Uterine evacuation and curettage for hydatidiform mole 59871 - - $103.74 - - Removal of cerclage suture under anesthesia (other than local) 59897 - - I.C. - - Unlisted fetal invasive procedure, including ultrasound guidance, when performed 59898 - - I.C. - - Unlisted laparoscopy procedure, maternity care and delivery 59899 - - I.C. - - Unlisted procedure, maternity care and delivery 60000 $139.01 $121.04 - - - Incision and drainage of thyroglossal duct cyst, infected 60100 $87.75 $60.80 - - - Biopsy thyroid, percutaneous core needle 60200 - - $521.58 - - Excision of cyst or adenoma of thyroid, or transection of isthmus 60210 - - $553.91 - - Partial thyroid lobectomy, unilateral; with or without isthmusectomy Partial thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including 60212 - - $806.87 - - isthmusectomy 60220 - - $552.94 - - Total thyroid lobectomy, unilateral; with or without isthmusectomy Total thyroid lobectomy, unilateral; with contralateral subtotal lobectomy, including 60225 - - $730.34 - - isthmusectomy 60240 - - $718.88 - - Thyroidectomy, total or complete 60252 - - $1,032.34 - - Thyroidectomy, total or subtotal for malignancy; with limited neck dissection 60254 - - $1,304.23 - - Thyroidectomy, total or subtotal for malignancy; with radical neck dissection

Page 119 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Thyroidectomy, removal of all remaining thyroid tissue following previous removal of a portion 60260 - - $851.86 - - of thyroid 60270 - - $1,067.20 - - Thyroidectomy, including substernal thyroid; sternal split or transthoracic approach 60271 - - $825.46 - - Thyroidectomy, including substernal thyroid; cervical approach 60280 - - $350.36 - - Excision of thyroglossal duct cyst or sinus; 60281 - - $461.55 - - Excision of thyroglossal duct cyst or sinus; recurrent 60300 $91.12 $38.37 - - - Aspiration and/or injection, thyroid cyst 60500 - - $757.98 - - Parathyroidectomy or exploration of parathyroid(s); 60502 - - $1,014.75 - - Parathyroidectomy or exploration of parathyroid(s); re-exploration Parathyroidectomy or exploration of parathyroid(s); with mediastinal exploration, sternal split 60505 - - $1,086.63 - - or transthoracic approach 60512 - - $188.84 - - Parathyroid autotransplantation (List separately in addition to code for primary procedure) 60520 - - $821.29 - - Thymectomy, partial or total; transcervical approach (separate procedure) Thymectomy, partial or total; sternal split or transthoracic approach, without radical 60521 - - $873.32 - - mediastinal dissection (separate procedure) Thymectomy, partial or total; sternal split or transthoracic approach, with radical mediastinal 60522 - - $1,062.14 - - dissection (separate procedure) Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, 60540 - - $839.00 - - transabdominal, lumbar or dorsal (separate procedure); Adrenalectomy, partial or complete, or exploration of adrenal gland with or without biopsy, 60545 - - $966.12 - - transabdominal, lumbar or dorsal (separate procedure); with excision of adjacent retroperitoneal tumor 60600 - - $1,064.51 - - Excision of carotid body tumor; without excision of carotid artery 60605 - - $1,284.43 - - Excision of carotid body tumor; with excision of carotid artery Laparoscopy, surgical, with adrenalectomy, partial or complete, or exploration of adrenal gland 60650 - - $933.80 - - with or without biopsy, transabdominal, lumbar or dorsal 60659 - - I.C. - - Unlisted laparoscopy procedure, endocrine system 60699 - - I.C. - - Unlisted procedure, endocrine system 61000 - - $87.70 - - Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial 61001 - - $83.47 - - Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular 61020 - - $81.90 - - catheter/reservoir; without injection

61026 - - $83.54 - - Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment 61050 - - $66.34 - - Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance 61055 - - $96.22 - - for diagnosis or treatment 61070 - - $44.38 - - Puncture of shunt tubing or reservoir for aspiration or injection procedure 61105 - - $361.68 - - Twist drill hole for subdural or ventricular puncture Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular 61107 - - $242.80 - - catheter, pressure recording device, or other intracerebral monitoring device Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or 61108 - - $701.80 - - drainage of subdural hematoma Burr hole(s) for ventricular puncture (including injection of gas, contrast media, dye, or 61120 - - $584.23 - - radioactive material) 61140 - - $988.20 - - Burr hole(s) or trephine; with biopsy of brain or intracranial lesion 61150 - - $1,052.81 - - Burr hole(s) or trephine; with drainage of brain abscess or cyst 61151 - - $774.31 - - Burr hole(s) or trephine; with subsequent tapping (aspiration) of intracranial abscess or cyst 61154 - - $993.06 - - Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural 61156 - - $967.01 - - Burr hole(s); with aspiration of hematoma or cyst, intracerebral Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording 61210 - - $284.75 - - device, or other cerebral monitoring device (separate procedure) Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to 61215 - - $398.61 - - ventricular catheter 61250 - - $676.96 - - Burr hole(s) or trephine, supratentorial, exploratory, not followed by other surgery 61253 - - $774.31 - - Burr hole(s) or trephine, infratentorial, unilateral or bilateral 61304 - - $1,278.72 - - Craniectomy or craniotomy, exploratory; supratentorial 61305 - - $1,561.56 - - Craniectomy or craniotomy, exploratory; infratentorial (posterior fossa) 61312 - - $1,614.05 - - Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural 61313 - - $1,543.84 - - Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral 61314 - - $1,422.87 - - Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural 61315 - - $1,607.78 - - Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar

Page 120 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Incision and subcutaneous placement of cranial bone graft (List separately in addition to code 61316 - - $67.91 - - for primary procedure) 61320 - - $1,477.32 - - Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial 61321 - - $1,654.78 - - Craniectomy or craniotomy, drainage of intracranial abscess; infratentorial Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of 61322 - - $1,850.66 - - intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of 61323 - - $1,862.21 - - intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy 61330 - - $1,395.99 - - Decompression of orbit only, transcranial approach 61333 - - $1,571.93 - - Exploration of orbit (transcranial approach); with removal of lesion 61340 - - $1,122.63 - - Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal 61343 - - $1,707.97 - - cord, with or without dural graft (eg, Arnold-Chiari malformation) 61345 - - $1,588.05 - - Other cranial decompression, posterior fossa Craniectomy, subtemporal, for section, compression, or decompression of sensory root of 61450 - - $1,493.83 - - gasserian ganglion 61458 - - $1,564.83 - - Craniectomy, suboccipital; for exploration or decompression of cranial nerves 61460 - - $1,638.26 - - Craniectomy, suboccipital; for section of 1 or more cranial nerves 61500 - - $1,026.33 - - Craniectomy; with excision of tumor or other bone lesion of skull 61501 - - $893.01 - - Craniectomy; for osteomyelitis Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, 61510 - - $1,709.37 - - except meningioma

61512 - - $1,986.45 - - Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial

61514 - - $1,486.37 - - Craniectomy, trephination, bone flap craniotomy; for excision of brain abscess, supratentorial Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, 61516 - - $1,456.90 - - supratentorial Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for 61517 - - $67.64 - - primary procedure) Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, 61518 - - $2,152.67 - - cerebellopontine angle tumor, or midline tumor at base of skull 61519 - - $2,297.08 - - Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma Craniectomy for excision of brain tumor, infratentorial or posterior fossa; cerebellopontine 61520 - - $2,916.87 - - angle tumor Craniectomy for excision of brain tumor, infratentorial or posterior fossa; midline tumor at base 61521 - - $2,478.43 - - of skull 61522 - - $1,701.88 - - Craniectomy, infratentorial or posterior fossa; for excision of brain abscess 61524 - - $1,620.67 - - Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine 61526 - - $2,612.57 - - angle tumor;

61530 - - $2,394.91 - - Craniectomy, bone flap craniotomy, transtemporal (mastoid) for excision of cerebellopontine angle tumor; combined with middle/posterior fossa craniotomy/craniectomy Subdural implantation of strip electrodes through 1 or more burr or trephine hole(s) for long- 61531 - - $953.27 - - term seizure monitoring Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for 61533 - - $1,188.60 - - long-term seizure monitoring Craniotomy with elevation of bone flap; for excision of epileptogenic focus without 61534 - - $1,282.89 - - electrocorticography during surgery Craniotomy with elevation of bone flap; for removal of epidural or subdural electrode array, 61535 - - $781.52 - - without excision of cerebral tissue (separate procedure) Craniotomy with elevation of bone flap; for excision of cerebral epileptogenic focus, with 61536 - - $2,006.19 - - electrocorticography during surgery (includes removal of electrode array) Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, without 61537 - - $1,916.74 - - electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, temporal lobe, with 61538 - - $2,072.25 - - electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or 61539 - - $1,836.54 - - total, with electrocorticography during surgery Craniotomy with elevation of bone flap; for lobectomy, other than temporal lobe, partial or 61540 - - $1,695.47 - - total, without electrocorticography during surgery 61541 - - $1,672.22 - - Craniotomy with elevation of bone flap; for transection of corpus callosum

Page 121 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

61543 - - $1,690.64 - - Craniotomy with elevation of bone flap; for partial or subtotal (functional) hemispherectomy 61544 - - $1,477.80 - - Craniotomy with elevation of bone flap; for excision or coagulation of choroid plexus 61545 - - $2,482.59 - - Craniotomy with elevation of bone flap; for excision of craniopharyngioma 61546 - - $1,794.88 - - Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, 61548 - - $1,219.71 - - nonstereotactic 61550 - - $928.56 - - Craniectomy for craniosynostosis; single cranial suture 61552 - - $1,155.33 - - Craniectomy for craniosynostosis; multiple cranial sutures 61556 - - $1,328.68 - - Craniotomy for craniosynostosis; frontal or parietal bone flap 61557 - - $1,311.08 - - Craniotomy for craniosynostosis; bifrontal bone flap Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); not 61558 - - $1,462.89 - - requiring bone grafts Extensive craniectomy for multiple cranial suture craniosynostosis (eg, cloverleaf skull); 61559 - - $1,864.59 - - recontouring with multiple osteotomies and bone autografts (eg, barrel-stave procedure) (includes obtaining grafts) Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); without 61563 - - $1,541.99 - - optic nerve decompression Excision, intra and extracranial, benign tumor of cranial bone (eg, fibrous dysplasia); with optic 61564 - - $1,872.03 - - nerve decompression 61566 - - $1,745.94 - - Craniotomy with elevation of bone flap; for selective amygdalohippocampectomy Craniotomy with elevation of bone flap; for multiple subpial transections, with 61567 - - $1,990.04 - - electrocorticography during surgery 61570 - - $1,454.71 - - Craniectomy or craniotomy; with excision of foreign body from brain 61571 - - $1,548.70 - - Craniectomy or craniotomy; with treatment of penetrating wound of brain Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or 61575 - - $1,948.75 - - excision of lesion;

61576 - - $3,287.12 - - Transoral approach to skull base, brain stem or upper spinal cord for biopsy, decompression or excision of lesion; requiring splitting of tongue and/or mandible (including tracheostomy) Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, 61580 - - $1,930.05 - - ethmoidectomy, sphenoidectomy, without maxillectomy or orbital exenteration Craniofacial approach to anterior cranial fossa; extradural, including lateral rhinotomy, orbital 61581 - - $2,100.28 - - exenteration, ethmoidectomy, sphenoidectomy and/or maxillectomy Craniofacial approach to anterior cranial fossa; extradural, including unilateral or bifrontal 61582 - - $2,426.57 - - craniotomy, elevation of frontal lobe(s), osteotomy of base of anterior cranial fossa

61583 - - $2,261.24 - - Craniofacial approach to anterior cranial fossa; intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge 61584 - - $2,250.06 - - osteotomy and elevation of frontal and/or temporal lobe(s); without orbital exenteration Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge 61585 - - $2,549.68 - - osteotomy and elevation of frontal and/or temporal lobe(s); with orbital exenteration Bicoronal, transzygomatic and/or LeFort I osteotomy approach to anterior cranial fossa with or 61586 - - $1,951.20 - - without internal fixation, without bone graft Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the 61590 - - $2,386.46 - - mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery Infratemporal post-auricular approach to middle cranial fossa (internal auditory meatus, petrous apex, tentorium, cavernous sinus, parasellar area, infratemporal fossa) including 61591 - - $2,410.43 - - mastoidectomy, resection of sigmoid sinus, with or without decompression and/or mobilization of contents of auditory canal or petrous carotid artery Orbitocranial zygomatic approach to middle cranial fossa (cavernous sinus and carotid artery, 61592 - - $2,486.78 - - clivus, basilar artery or petrous apex) including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe Transtemporal approach to posterior cranial fossa, jugular foramen or midline skull base, 61595 - - $1,861.21 - - including mastoidectomy, decompression of sigmoid sinus and/or facial nerve, with or without mobilization Transcochlear approach to posterior cranial fossa, jugular foramen or midline skull base, 61596 - - $1,910.34 - - including labyrinthectomy, decompression, with or without mobilization of facial nerve and/or petrous carotid artery Transcondylar (far lateral) approach to posterior cranial fossa, jugular foramen or midline skull 61597 - - $2,298.99 - - base, including occipital condylectomy, mastoidectomy, resection of C1-C3 vertebral body(s), decompression of vertebral artery, with or without mobilization

Page 122 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Transpetrosal approach to posterior cranial fossa, clivus or foramen magnum, including ligation 61598 - - $2,238.42 - - of superior petrosal sinus and/or sigmoid sinus Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; 61600 - - $1,677.15 - - extradural Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; 61601 - - $1,893.37 - - intradural, including dural repair, with or without graft Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, 61605 - - $1,701.60 - - parapharyngeal space, petrous apex; extradural Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, 61606 - - $2,295.30 - - parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous 61607 - - $2,096.52 - - sinus, clivus or midline skull base; extradural

61608 - - $2,546.05 - - Resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft Transection or ligation, carotid artery in petrous canal; without repair (List separately in 61611 - - $362.46 - - addition to code for primary procedure) Obliteration of carotid aneurysm, arteriovenous malformation, or carotid-cavernous fistula by 61613 - - $2,577.28 - - dissection within cavernous sinus Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial 61615 - - $2,208.55 - - fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; extradural Resection or excision of neoplastic, vascular or infectious lesion of base of posterior cranial 61616 - - $2,601.37 - - fossa, jugular foramen, foramen magnum, or C1-C3 vertebral bodies; intradural, including dural repair, with or without graft Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa 61618 - - $997.68 - - following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts) Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa 61619 - - $1,100.48 - - following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle) Endovascular temporary balloon arterial occlusion, head or neck (extracranial/intracranial) including selective catheterization of vessel to be occluded, positioning and inflation of 61623 - - $443.86 - - occlusion balloon, concomitant neurological monitoring, and radiologic supervision and interpretation of all angiography required for balloon occlusion and to exclude vascular injury post occlusion Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve 61624 - - $893.64 - - hemostasis, to occlude a vascular malformation), percutaneous, any method; central nervous system (intracranial, spinal cord) Transcatheter permanent occlusion or embolization (eg, for tumor destruction, to achieve 61626 - - $688.07 - - hemostasis, to occlude a vascular malformation), percutaneous, any method; non-central nervous system, head or neck (extracranial, brachiocephalic branch) 61630 - - $1,064.50 - - Balloon angioplasty, intracranial (eg, atherosclerotic stenosis), percutaneous Transcatheter placement of intravascular stent(s), intracranial (eg, atherosclerotic stenosis), 61635 - - $1,131.96 - - including balloon angioplasty, if performed 61640 - - $368.19 - - Balloon dilatation of intracranial vasospasm, percutaneous; initial vessel Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in same 61641 - - $129.31 - - vascular territory (List separately in addition to code for primary procedure) Balloon dilatation of intracranial vasospasm, percutaneous; each additional vessel in different 61642 - - $258.62 - - vascular territory (List separately in addition to code for primary procedure)

Percutaneous arterial transluminal mechanical thrombectomy and/or infusion for thrombolysis, 61645 - - $649.08 - - intracranial, any method, including diagnostic angiography, fluoroscopic guidance, catheter placement, and intraprocedural pharmacological thrombolytic injection(s) Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for 61650 - - $442.28 - - thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging guidance; initial vascular territory Endovascular intracranial prolonged administration of pharmacologic agent(s) other than for thrombolysis, arterial, including catheter placement, diagnostic angiography, and imaging 61651 - - $189.47 - - guidance; each additional vascular territory (List separately in addition to code for primary procedure) 61680 - - $1,754.20 - - Surgery of intracranial arteriovenous malformation; supratentorial, simple 61682 - - $3,311.73 - - Surgery of intracranial arteriovenous malformation; supratentorial, complex 61684 - - $2,213.33 - - Surgery of intracranial arteriovenous malformation; infratentorial, simple 61686 - - $3,591.10 - - Surgery of intracranial arteriovenous malformation; infratentorial, complex 61690 - - $1,697.76 - - Surgery of intracranial arteriovenous malformation; dural, simple 61692 - - $2,847.95 - - Surgery of intracranial arteriovenous malformation; dural, complex

Page 123 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 61697 - - $3,290.77 - - Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation 61698 - - $3,694.57 - - Surgery of complex intracranial aneurysm, intracranial approach; vertebrobasilar circulation 61700 - - $2,653.58 - - Surgery of simple intracranial aneurysm, intracranial approach; carotid circulation 61702 - - $3,142.46 - - Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation Surgery of intracranial aneurysm, cervical approach by application of occluding clamp to 61703 - - $1,058.40 - - cervical carotid artery (Selverstone-Crutchfield type) Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and 61705 - - $2,024.62 - - cervical occlusion of carotid artery Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial 61708 - - $1,980.30 - - electrothrombosis Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intra-arterial 61710 - - $1,670.49 - - embolization, injection procedure, or balloon catheter 61711 - - $2,015.96 - - Anastomosis, arterial, extracranial-intracranial (eg, middle cerebral/cortical) arteries Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording 61720 - - $989.71 - - techniques, single or multiple stages; globus pallidus or thalamus Creation of lesion by stereotactic method, including burr hole(s) and localizing and recording 61735 - - $1,239.80 - - techniques, single or multiple stages; subcortical structure(s) other than globus pallidus or thalamus 61750 - - $1,096.37 - - Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion; with 61751 - - $1,075.55 - - computed tomography and/or magnetic resonance guidance Stereotactic implantation of depth electrodes into the cerebrum for long-term seizure 61760 - - $1,229.94 - - monitoring Stereotactic localization, including burr hole(s), with insertion of catheter(s) or probe(s) for 61770 - - $1,262.13 - - placement of radiation source Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in 61781 - - $182.13 - - addition to code for primary procedure) Stereotactic computer-assisted (navigational) procedure; cranial, extradural (List separately in 61782 - - $135.33 - - addition to code for primary procedure) Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to 61783 - - $181.08 - - code for primary procedure) Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, 61790 - - $686.19 - - thermal, electrical, radiofrequency); gasserian ganglion Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (eg, alcohol, 61791 - - $877.15 - - thermal, electrical, radiofrequency); trigeminal medullary tract Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial 61796 - - $790.36 - - lesion Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional 61797 - - $169.77 - - cranial lesion, simple (List separately in addition to code for primary procedure) Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial 61798 - - $1,072.74 - - lesion Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional 61799 - - $234.73 - - cranial lesion, complex (List separately in addition to code for primary procedure) Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition 61800 - - $118.35 - - to code for primary procedure) 61850 - - $767.32 - - Twist drill or burr hole(s) for implantation of neurostimulator electrodes, cortical

61860 - - $1,216.92 - - Craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebral, cortical Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic 61863 - - $1,171.17 - - nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; first array

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of 61864 - - $219.20 - - neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), without use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic 61867 - - $1,774.14 - - nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; first array

Page 124 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of 61868 - - $386.27 - - neurostimulator electrode array in subcortical site (eg, thalamus, globus pallidus, subthalamic nucleus, periventricular, periaqueductal gray), with use of intraoperative microelectrode recording; each additional array (List separately in addition to primary procedure) 61880 - - $453.14 - - Revision or removal of intracranial neurostimulator electrodes Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or 61885 - - $408.31 - - inductive coupling; with connection to a single electrode array Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or 61886 - - $674.80 - - inductive coupling; with connection to 2 or more electrode arrays 61888 - - $309.07 - - Revision or removal of cranial neurostimulator pulse generator or receiver 62000 - - $804.92 - - Elevation of depressed skull fracture; simple, extradural 62005 - - $989.98 - - Elevation of depressed skull fracture; compound or comminuted, extradural 62010 - - $1,195.14 - - Elevation of depressed skull fracture; with repair of dura and/or debridement of brain Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for 62100 - - $1,231.82 - - rhinorrhea/otorrhea Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or 62115 - - $1,308.44 - - cranioplasty Reduction of craniomegalic skull (eg, treated hydrocephalus); requiring craniotomy and 62117 - - $1,528.43 - - reconstruction with or without bone graft (includes obtaining grafts) 62120 - - $1,655.94 - - Repair of encephalocele, skull vault, including cranioplasty 62121 - - $1,225.42 - - Craniotomy for repair of encephalocele, skull base 62140 - - $800.73 - - Cranioplasty for skull defect; up to 5 cm diameter 62141 - - $890.93 - - Cranioplasty for skull defect; larger than 5 cm diameter 62142 - - $692.41 - - Removal of bone flap or prosthetic plate of skull 62143 - - $812.81 - - Replacement of bone flap or prosthetic plate of skull 62145 - - $1,108.35 - - Cranioplasty for skull defect with reparative brain surgery 62146 - - $883.67 - - Cranioplasty with autograft (includes obtaining bone grafts); up to 5 cm diameter 62147 - - $1,108.27 - - Cranioplasty with autograft (includes obtaining bone grafts); larger than 5 cm diameter Incision and retrieval of subcutaneous cranial bone graft for cranioplasty (List separately in 62148 - - $98.12 - - addition to code for primary procedure) Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and 62160 - - $146.26 - - attachment to shunt system or external drainage (List separately in addition to code for primary procedure)

62161 - - $1,178.32 - - Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter) Neuroendoscopy, intracranial; with fenestration or excision of colloid cyst, including placement 62162 - - $1,470.02 - - of external ventricular catheter for drainage Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external 62164 - - $1,628.60 - - ventricular catheter for drainage Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal 62165 - - $1,187.24 - - approach 62180 - - $1,244.87 - - Ventriculocisternostomy (Torkildsen type operation) 62190 - - $723.15 - - Creation of shunt; subarachnoid/subdural-atrial, -jugular, -auricular 62192 - - $766.66 - - Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus 62194 - - $383.71 - - Replacement or irrigation, subarachnoid/subdural catheter 62200 - - $1,071.75 - - Ventriculocisternostomy, third ventricle; 62201 - - $942.77 - - Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method 62220 - - $769.68 - - Creation of shunt; ventriculo-atrial, -jugular, -auricular 62223 - - $813.94 - - Creation of shunt; ventriculo-peritoneal, -pleural, other terminus 62225 - - $414.33 - - Replacement or irrigation, ventricular catheter Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in 62230 - - $657.33 - - shunt system 62252 - - $63.96 $35.60 $28.36 Reprogramming of programmable cerebrospinal shunt 62256 - - $473.15 - - Removal of complete cerebrospinal fluid shunt system; without replacement Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other 62258 - - $865.92 - - shunt at same operation Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) 62263 $492.82 $243.56 - - - or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days Percutaneous lysis of epidural adhesions using solution injection (eg, hypertonic saline, enzyme) 62264 $350.33 $190.34 - - - or mechanical means (eg, catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day Percutaneous aspiration within the nucleus pulposus, intervertebral disc, or paravertebral 62267 $211.69 $123.00 - - - tissue for diagnostic purposes

Page 125 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 62268 - - $201.73 - - Percutaneous aspiration, spinal cord cyst or syrinx 62269 - - $207.58 - - Biopsy of spinal cord, percutaneous needle 62270 $111.35 $48.16 - - - Spinal puncture, lumbar, diagnostic; 62272 $145.97 $68.30 - - - Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); 62273 $135.88 $88.35 - - - Injection, epidural, of blood or clot patch Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or 62280 $284.51 $133.22 - - - without other therapeutic substance; subarachnoid Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or 62281 $190.25 $125.04 - - - without other therapeutic substance; epidural, cervical or thoracic Injection/infusion of neurolytic substance (eg, alcohol, phenol, iced saline solutions), with or 62282 $247.18 $112.99 - - - without other therapeutic substance; epidural, lumbar, sacral (caudal) 62284 $159.45 $67.87 - - - Injection procedure for myelography and/or computed tomography, lumbar Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or 62287 - - $458.41 - - other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar 62290 $283.53 $130.20 - - - Injection procedure for discography, each level; lumbar 62291 $268.43 $124.09 - - - Injection procedure for discography, each level; cervical or thoracic Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or 62292 - - $456.68 - - multiple levels, lumbar 62294 - - $740.30 - - Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal 62302 $207.13 $94.96 - - - Myelography via lumbar injection, including radiological supervision and interpretation; cervical Myelography via lumbar injection, including radiological supervision and interpretation; 62303 $211.19 $94.96 - - - thoracic Myelography via lumbar injection, including radiological supervision and interpretation; 62304 $204.33 $93.61 - - - lumbosacral

62305 $222.63 $97.42 - - - Myelography via lumbar injection, including radiological supervision and interpretation; 2 or more regions (eg, lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 62320 $130.12 $77.66 - - - placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 62321 $208.01 $83.96 - - - placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 62322 $119.28 $65.95 - - - placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter 62323 $206.06 $77.66 - - - placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other 62324 $112.36 $69.46 - - - solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other 62325 $194.89 $84.46 - - - solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT) Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other 62326 $116.10 $67.99 - - - solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other 62327 $199.44 $78.29 - - - solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT) 62328 $209.15 $69.74 - - - Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with 62329 $259.44 $87.56 - - - fluoroscopic or CT guidance

Page 126 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long- 62350 - - $311.96 - - term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long- 62351 - - $684.15 - - term medication administration via an external pump or implantable reservoir/infusion pump; with laminectomy 62355 - - $213.55 - - Removal of previously implanted intrathecal or epidural catheter Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous 62360 - - $247.28 - - reservoir Implantation or replacement of device for intrathecal or epidural drug infusion; 62361 - - $336.46 - - nonprogrammable pump Implantation or replacement of device for intrathecal or epidural drug infusion; programmable 62362 - - $300.66 - - pump, including preparation of pump, with or without programming Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural 62365 - - $232.07 - - infusion Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion 62367 $25.22 $19.71 - - - (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming or refill Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion 62368 $35.34 $27.80 - - - (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion 62369 $77.07 $27.80 - - - (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming and refill Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with 62370 $79.41 $36.22 - - - reprogramming and refill (requiring skill of a physician or other qualified health care professional) Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial 62380 - - I.C. - - facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63001 - - $965.71 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63003 - - $966.90 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63005 - - $933.90 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63011 - - $853.92 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral

63012 - - $936.00 - - Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure) Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63015 - - $1,156.64 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63016 - - $1,189.36 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; thoracic Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, 63017 - - $985.82 - - without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 63020 - - $908.63 - - facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 63030 - - $764.69 - - facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar

Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 63035 - - $149.07 - - facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)

Page 127 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 63040 - - $1,090.95 - - facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial 63042 - - $1,018.48 - - facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, 63043 - - I.C. - - single interspace; each additional cervical interspace (List separately in addition to code for primary procedure) Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, 63044 - - I.C. - - single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure) Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 63045 - - $1,007.53 - - spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 63046 - - $962.55 - - spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of 63047 - - $866.50 - - spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single 63048 - - $164.64 - - vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

63050 - - $1,178.28 - - Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments;

Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; 63051 - - $1,336.08 - - with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed) Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, 63055 - - $1,270.09 - - herniated intervertebral disc), single segment; thoracic Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, 63056 - - $1,165.58 - - herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc) Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, 63057 - - $249.22 - - herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure) Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated 63064 - - $1,391.08 - - intervertebral disc), thoracic; single segment Costovertebral approach with decompression of spinal cord or nerve root(s) (eg, herniated 63066 - - $159.57 - - intervertebral disc), thoracic; each additional segment (List separately in addition to code for primary procedure) Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including 63075 - - $1,059.29 - - osteophytectomy; cervical, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including 63076 - - $191.75 - - osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure) Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including 63077 - - $1,179.99 - - osteophytectomy; thoracic, single interspace Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including 63078 - - $160.64 - - osteophytectomy; thoracic, each additional interspace (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with 63081 - - $1,377.49 - - decompression of spinal cord and/or nerve root(s); cervical, single segment Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with 63082 - - $207.27 - - decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach 63085 - - $1,504.74 - - with decompression of spinal cord and/or nerve root(s); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, transthoracic approach 63086 - - $148.48 - - with decompression of spinal cord and/or nerve root(s); thoracic, each additional segment (List separately in addition to code for primary procedure)

Page 128 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar 63087 - - $1,882.38 - - approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; single segment

Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar 63088 - - $199.51 - - approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or 63090 - - $1,538.28 - - retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic, lumbar, or sacral; single segment Vertebral corpectomy (vertebral body resection), partial or complete, transperitoneal or retroperitoneal approach with decompression of spinal cord, cauda equina or nerve root(s), 63091 - - $139.36 - - lower thoracic, lumbar, or sacral; each additional segment (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary 63101 - - $1,816.48 - - approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); thoracic, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary 63102 - - $1,772.22 - - approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed 63103 - - $228.99 - - bone fragments); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure)

63170 - - $1,240.32 - - Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar 63172 - - $1,081.17 - - Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space 63173 - - $1,342.94 - - Laminectomy with drainage of intramedullary cyst/syrinx; to peritoneal or pleural space 63185 - - $900.11 - - Laminectomy with rhizotomy; 1 or 2 segments 63190 - - $980.99 - - Laminectomy with rhizotomy; more than 2 segments 63191 - - $1,074.78 - - Laminectomy with section of spinal accessory nerve 63194 - - $1,243.96 - - Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; cervical 63195 - - $1,193.60 - - Laminectomy with cordotomy, with section of 1 spinothalamic tract, 1 stage; thoracic 63196 - - $1,385.38 - - Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; cervical 63197 - - $1,331.70 - - Laminectomy with cordotomy, with section of both spinothalamic tracts, 1 stage; thoracic Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 63198 - - $1,626.10 - - days; cervical Laminectomy with cordotomy with section of both spinothalamic tracts, 2 stages within 14 63199 - - $1,703.35 - - days; thoracic 63200 - - $1,193.86 - - Laminectomy, with release of tethered spinal cord, lumbar

63250 - - $2,310.27 - - Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; cervical

63251 - - $2,362.08 - - Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; 63252 - - $2,361.52 - - thoracolumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; 63265 - - $1,303.86 - - cervical Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; 63266 - - $1,343.27 - - thoracic Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; 63267 - - $1,074.53 - - lumbar Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; 63268 - - $1,107.46 - - sacral 63270 - - $1,616.34 - - Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical 63271 - - $1,612.38 - - Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; thoracic 63272 - - $1,473.47 - - Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar 63273 - - $1,452.58 - - Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; sacral 63275 - - $1,406.98 - - Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical 63276 - - $1,396.06 - - Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, thoracic 63277 - - $1,219.38 - - Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, lumbar 63278 - - $1,239.56 - - Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral 63280 - - $1,650.23 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, cervical

63281 - - $1,631.20 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, thoracic

Page 129 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

63282 - - $1,539.39 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, extramedullary, lumbar 63283 - - $1,480.06 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, sacral 63285 - - $2,035.22 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical

63286 - - $2,011.41 - - Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, thoracic Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, 63287 - - $2,135.65 - - thoracolumbar Laminectomy for biopsy/excision of intraspinal neoplasm; combined extradural-intradural 63290 - - $2,172.28 - - lesion, any level Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure 63295 - - $255.51 - - (List separately in addition to code for primary procedure) Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63300 - - $1,434.67 - - lesion, single segment; extradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63301 - - $1,716.26 - - lesion, single segment; extradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63302 - - $1,695.69 - - lesion, single segment; extradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63303 - - $1,800.71 - - lesion, single segment; extradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63304 - - $1,827.98 - - lesion, single segment; intradural, cervical Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63305 - - $1,945.82 - - lesion, single segment; intradural, thoracic by transthoracic approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63306 - - $1,912.37 - - lesion, single segment; intradural, thoracic by thoracolumbar approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63307 - - $1,872.25 - - lesion, single segment; intradural, lumbar or sacral by transperitoneal or retroperitoneal approach Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal 63308 - - $251.09 - - lesion, single segment; each additional segment (List separately in addition to codes for single segment) Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including 63600 - - $850.16 - - stimulation and/or recording) Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by 63610 - - $449.63 - - other surgery 63620 - - $871.96 - - Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional 63621 - - $195.17 - - spinal lesion (List separately in addition to code for primary procedure) 63650 $1,549.30 $324.75 - - - Percutaneous implantation of neurostimulator electrode array, epidural 63655 - - $653.52 - - Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, 63661 $514.67 $254.11 - - - when performed Removal of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or 63662 - - $661.46 - - laminectomy, including fluoroscopy, when performed Revision including replacement, when performed, of spinal neurostimulator electrode 63663 $682.90 $353.07 - - - percutaneous array(s), including fluoroscopy, when performed

63664 - - $687.89 - - Revision including replacement, when performed, of spinal neurostimulator electrode plate/paddle(s) placed via laminotomy or laminectomy, including fluoroscopy, when performed Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or 63685 - - $283.17 - - inductive coupling 63688 - - $292.06 - - Revision or removal of implanted spinal neurostimulator pulse generator or receiver 63700 - - $1,018.42 - - Repair of meningocele; less than 5 cm diameter 63702 - - $1,113.06 - - Repair of meningocele; larger than 5 cm diameter 63704 - - $1,292.26 - - Repair of myelomeningocele; less than 5 cm diameter 63706 - - $1,436.31 - - Repair of myelomeningocele; larger than 5 cm diameter 63707 - - $729.14 - - Repair of dural/cerebrospinal fluid leak, not requiring laminectomy 63709 - - $869.64 - - Repair of dural/cerebrospinal fluid leak or pseudomeningocele, with laminectomy 63710 - - $852.74 - - Dural graft, spinal 63740 - - $764.24 - - Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; including laminectomy Creation of shunt, lumbar, subarachnoid-peritoneal, -pleural, or other; percutaneous, not 63741 - - $529.64 - - requiring laminectomy

Page 130 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 63744 - - $533.44 - - Replacement, irrigation or revision of lumbosubarachnoid shunt 63746 - - $474.05 - - Removal of entire lumbosubarachnoid shunt system without replacement Injection(s), anesthetic agent(s) and/or steroid; trigeminal nerve, each branch (ie, ophthalmic, 64400 $85.75 $39.08 - - - maxillary, mandibular) 64405 $56.74 $41.67 - - - Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve 64408 $54.85 $33.98 - - - Injection(s), anesthetic agent(s) and/or steroid; vagus nerve 64415 $89.52 $49.23 - - - Injection(s), anesthetic agent(s) and/or steroid; brachial plexus Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter 64416 - - $49.49 - - (including catheter placement) 64417 $109.13 $47.11 - - - Injection(s), anesthetic agent(s) and/or steroid; axillary nerve 64418 $66.90 $44.29 - - - Injection(s), anesthetic agent(s) and/or steroid; suprascapular nerve 64420 $79.46 $46.70 - - - Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, single level Injection(s), anesthetic agent(s) and/or steroid; intercostal nerve, each additional level (List 64421 $26.66 $19.70 - - - separately in addition to code for primary procedure) 64425 $89.51 $43.42 - - - Injection(s), anesthetic agent(s) and/or steroid; ilioinguinal, iliohypogastric nerves 64430 $71.54 $43.13 - - - Injection(s), anesthetic agent(s) and/or steroid; pudendal nerve 64435 $58.24 $34.18 - - - Injection(s), anesthetic agent(s) and/or steroid; paracervical (uterine) nerve 64445 $100.61 $42.06 - - - Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter 64446 - - $45.73 - - (including catheter placement) 64447 $70.22 $41.24 - - - Injection(s), anesthetic agent(s) and/or steroid; femoral nerve Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter 64448 - - $47.34 - - (including catheter placement) Injection(s), anesthetic agent(s) and/or steroid; lumbar plexus, posterior approach, continuous 64449 - - $48.22 - - infusion by catheter (including catheter placement) 64450 $60.94 $33.40 - - - Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with 64451 $169.20 $61.96 - - - image guidance (ie, fluoroscopy or computed tomography) Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging 64454 $170.94 $63.99 - - - guidance, when performed Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (eg, Morton's 64455 $37.89 $26.87 - - - neuroma) Paravertebral block (PVB) (paraspinous block), thoracic; single injection site (includes imaging 64461 $103.81 $59.46 - - - guidance, when performed) Paravertebral block (PVB) (paraspinous block), thoracic; second and any additional injection 64462 $58.05 $38.05 - - - site(s) (includes imaging guidance, when performed) (List separately in addition to code for primary procedure) Paravertebral block (PVB) (paraspinous block), thoracic; continuous infusion by catheter 64463 $159.87 $63.93 - - - (includes imaging guidance, when performed) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance 64479 $203.81 $102.65 - - - (fluoroscopy or CT); cervical or thoracic, single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance 64480 $101.14 $48.68 - - - (fluoroscopy or CT); cervical or thoracic, each additional level (List separately in addition to code for primary procedure) Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance 64483 $189.58 $87.56 - - - (fluoroscopy or CT); lumbar or sacral, single level Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance 64484 $82.93 $40.61 - - - (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) 64486 $88.26 $43.34 - - - unilateral; by injection(s) (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) 64487 $145.43 $49.49 - - - unilateral; by continuous infusion(s) (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; 64488 $108.28 $53.50 - - - by injections (includes imaging guidance, when performed) Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) bilateral; 64489 $226.57 $60.21 - - - by continuous infusions (includes imaging guidance, when performed) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 64490 $151.81 $82.83 - - - nerves 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 64491 $75.49 $46.80 - - - nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure) Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 64492 $76.07 $47.38 - - - nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Page 131 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or 64493 $138.57 $70.46 - - - nerves 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 64494 $70.47 $40.32 - - - nerves innervating that joint) with image 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 64495 $70.47 $40.90 - - - nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) 64505 $100.32 $76.26 - - - Injection, anesthetic agent; sphenopalatine ganglion 64510 $110.99 $59.11 - - - Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64517 $152.28 $98.08 - - - Injection, anesthetic agent; superior hypogastric plexus 64520 $172.61 $65.08 - - - Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64530 $172.91 $72.63 - - - Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 64553 $1,647.45 $279.13 - - - Percutaneous implantation of neurostimulator electrode array; cranial nerve Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes 64555 $1,525.67 $268.36 - - - sacral nerve) Percutaneous implantation of neurostimulator electrode array; sacral nerve (transforaminal 64561 $602.76 $237.85 - - - placement) including image guidance, if performed Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes 64566 $102.17 $24.21 - - - programming Incision for implantation of cranial nerve (eg, vagus nerve) neurostimulator electrode array and 64568 - - $490.84 - - pulse generator Revision or replacement of cranial nerve (eg, vagus nerve) neurostimulator electrode array, 64569 - - $593.07 - - including connection to existing pulse generator

64570 - - $573.48 - - Removal of cranial nerve (eg, vagus nerve) neurostimulator electrode array and pulse generator Incision for implantation of neurostimulator electrode array; peripheral nerve (excludes sacral 64575 - - $268.36 - - nerve) 64580 - - $245.09 - - Incision for implantation of neurostimulator electrode array; neuromuscular Incision for implantation of neurostimulator electrode array; sacral nerve (transforaminal 64581 - - $518.58 - - placement) 64585 $197.89 $113.55 - - - Revision or removal of peripheral neurostimulator electrode array Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, 64590 $212.15 $126.65 - - - direct or inductive coupling 64595 $191.59 $100.00 - - - Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior 64600 $357.62 $179.37 - - - alveolar branch Destruction by neurolytic agent, trigeminal nerve; second and third division branches at 64605 $497.79 $276.64 - - - foramen ovale Destruction by neurolytic agent, trigeminal nerve; second and third division branches at 64610 $618.87 $378.01 - - - foramen ovale under radiologic monitoring 64611 $96.47 $83.42 - - - Chemodenervation of parotid and submandibular salivary glands, bilateral Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for 64612 $106.04 $92.42 - - - blepharospasm, hemifacial spasm) Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and 64615 $118.05 $95.73 - - - accessory nerves, bilateral (eg, for chronic migraine) Chemodenervation of muscle(s); neck muscle(s), excluding muscles of the larynx, unilateral (eg, 64616 $104.80 $85.09 - - - for cervical dystonia, spasmodic torticollis) Chemodenervation of muscle(s); larynx, unilateral, percutaneous (eg, for spasmodic dysphonia), 64617 $128.31 $84.84 - - - includes guidance by needle electromyography, when performed 64620 $164.38 $137.43 - - - Destruction by neurolytic agent, intercostal nerve Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when 64624 $328.12 $115.38 - - - performed Radiofrequency ablation, nerves innervating the sacroiliac joint, with image guidance (ie, 64625 $400.06 $152.25 - - - fluoroscopy or computed tomography) 64630 $191.81 $148.33 - - - Destruction by neurolytic agent; pudendal nerve 64632 $69.03 $52.80 - - - Destruction by neurolytic agent; plantar common digital nerve Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 64633 $334.97 $176.14 - - - (fluoroscopy or CT); cervical or thoracic, single facet joint Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 64634 $150.99 $53.03 - - - (fluoroscopy or CT); 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 64635 $331.44 $173.77 - - - (fluoroscopy or CT); lumbar or sacral, single facet joint

Page 132 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance 64636 $137.81 $46.51 - - - (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure) 64640 $198.66 $92.29 - - - Destruction by neurolytic agent; other peripheral nerve or branch 64642 $115.81 $83.93 - - - Chemodenervation of one extremity; 1-4 muscle(s) Chemodenervation of one extremity; each additional extremity, 1-4 muscle(s) (List separately in 64643 $72.82 $55.72 - - - addition to code for primary procedure) 64644 $135.59 $91.54 - - - Chemodenervation of one extremity; 5 or more muscles Chemodenervation of one extremity; each additional extremity, 5 or more muscles (List 64645 $92.42 $64.02 - - - separately in addition to code for primary procedure) 64646 $121.55 $89.96 - - - Chemodenervation of trunk muscle(s); 1-5 muscle(s) 64647 $139.82 $105.04 - - - Chemodenervation of trunk muscle(s); 6 or more muscles 64650 $64.45 $32.28 - - - Chemodenervation of eccrine glands; both axillae 64653 $77.85 $41.33 - - - Chemodenervation of eccrine glands; other area(s) (eg, scalp, face, neck), per day 64680 $269.07 $127.34 - - - Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric 64681 $454.01 $204.17 - - - plexus 64702 - - $399.87 - - Neuroplasty; digital, 1 or both, same digit 64704 - - $254.48 - - Neuroplasty; nerve of hand or foot 64708 - - $399.57 - - Neuroplasty, major peripheral nerve, arm or leg, open; other than specified 64712 - - $464.33 - - Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve 64713 - - $615.48 - - Neuroplasty, major peripheral nerve, arm or leg, open; brachial plexus 64714 - - $577.36 - - Neuroplasty, major peripheral nerve, arm or leg, open; lumbar plexus 64718 - - $472.55 - - Neuroplasty and/or transposition; ulnar nerve at elbow 64719 - - $319.66 - - Neuroplasty and/or transposition; ulnar nerve at wrist 64721 $346.92 $341.99 - - - Neuroplasty and/or transposition; median nerve at carpal tunnel 64722 - - $284.31 - - Decompression; unspecified nerve(s) (specify) 64726 - - $211.85 - - Decompression; plantar digital nerve Internal neurolysis, requiring use of operating microscope (List separately in addition to code 64727 - - $142.34 - - for neuroplasty) (Neuroplasty includes external neurolysis) 64732 - - $349.71 - - Transection or avulsion of; supraorbital nerve 64734 - - $394.87 - - Transection or avulsion of; infraorbital nerve 64736 - - $275.30 - - Transection or avulsion of; mental nerve 64738 - - $358.56 - - Transection or avulsion of; inferior alveolar nerve by osteotomy 64740 - - $373.44 - - Transection or avulsion of; lingual nerve 64742 - - $388.10 - - Transection or avulsion of; facial nerve, differential or complete 64744 - - $390.37 - - Transection or avulsion of; greater occipital nerve 64746 - - $337.97 - - Transection or avulsion of; phrenic nerve Transection or avulsion of; vagus nerves limited to proximal stomach (selective proximal 64755 - - $723.93 - - vagotomy, proximal gastric vagotomy, parietal cell vagotomy, supra- or highly selective vagotomy) 64760 - - $408.35 - - Transection or avulsion of; vagus nerve (vagotomy), abdominal 64763 - - $404.13 - - Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy 64766 - - $498.22 - - Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy 64772 - - $445.55 - - Transection or avulsion of other spinal nerve, extradural 64774 - - $323.73 - - Excision of neuroma; cutaneous nerve, surgically identifiable 64776 - - $308.04 - - Excision of neuroma; digital nerve, 1 or both, same digit Excision of neuroma; digital nerve, each additional digit (List separately in addition to code for 64778 - - $142.89 - - primary procedure) 64782 - - $359.56 - - Excision of neuroma; hand or foot, except digital nerve Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in 64783 - - $170.44 - - addition to code for primary procedure) 64784 - - $575.91 - - Excision of neuroma; major peripheral nerve, except sciatic 64786 - - $789.23 - - Excision of neuroma; sciatic nerve 64787 - - $188.17 - - Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) 64788 - - $318.61 - - Excision of neurofibroma or neurolemmoma; cutaneous nerve 64790 - - $657.04 - - Excision of neurofibroma or neurolemmoma; major peripheral nerve 64792 - - $830.05 - - Excision of neurofibroma or neurolemmoma; extensive (including malignant type) 64795 - - $150.58 - - Biopsy of nerve 64802 - - $654.07 - - Sympathectomy, cervical 64804 - - $924.63 - - Sympathectomy, cervicothoracic 64809 - - $847.25 - - Sympathectomy, thoracolumbar 64818 - - $615.30 - - Sympathectomy, lumbar 64820 - - $575.60 - - Sympathectomy; digital arteries, each digit 64821 - - $549.87 - - Sympathectomy; radial artery

Page 133 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 64822 - - $549.87 - - Sympathectomy; ulnar artery 64823 - - $623.89 - - Sympathectomy; superficial palmar arch 64831 - - $545.77 - - Suture of digital nerve, hand or foot; 1 nerve Suture of digital nerve, hand or foot; each additional digital nerve (List separately in addition to 64832 - - $263.58 - - code for primary procedure) 64834 - - $584.47 - - Suture of 1 nerve; hand or foot, common sensory nerve 64835 - - $644.37 - - Suture of 1 nerve; median motor thenar 64836 - - $644.37 - - Suture of 1 nerve; ulnar motor Suture of each additional nerve, hand or foot (List separately in addition to code for primary 64837 - - $287.40 - - procedure) 64840 - - $758.78 - - Suture of posterior tibial nerve 64856 - - $797.56 - - Suture of major peripheral nerve, arm or leg, except sciatic; including transposition 64857 - - $830.61 - - Suture of major peripheral nerve, arm or leg, except sciatic; without transposition 64858 - - $926.64 - - Suture of sciatic nerve Suture of each additional major peripheral nerve (List separately in addition to code for primary 64859 - - $195.28 - - procedure) 64861 - - $1,181.47 - - Suture of; brachial plexus 64862 - - $1,082.96 - - Suture of; lumbar plexus 64864 - - $677.63 - - Suture of facial nerve; extracranial 64865 - - $857.47 - - Suture of facial nerve; infratemporal, with or without grafting 64866 - - $1,009.90 - - Anastomosis; facial-spinal accessory 64868 - - $784.98 - - Anastomosis; facial-hypoglossal Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for 64872 - - $91.56 - - primary neurorrhaphy) Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in 64874 - - $136.43 - - addition to code for nerve suture) Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code 64876 - - $154.29 - - for nerve suture) 64885 - - $868.28 - - Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length 64886 - - $1,000.54 - - Nerve graft (includes obtaining graft), head or neck; more than 4 cm length 64890 - - $851.05 - - Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length 64891 - - $905.01 - - Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length 64892 - - $827.60 - - Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length 64893 - - $882.87 - - Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length 64895 - - $1,044.69 - - Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm 64896 - - $1,126.63 - - length 64897 - - $998.22 - - Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm 64898 - - $1,080.98 - - length Nerve graft, each additional nerve; single strand (List separately in addition to code for primary 64901 - - $467.93 - - procedure) Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code 64902 - - $542.40 - - for primary procedure) 64905 - - $805.22 - - Nerve pedicle transfer; first stage 64907 - - $1,025.02 - - Nerve pedicle transfer; second stage 64910 - - $624.94 - - Nerve repair; with synthetic conduit or vein allograft (eg, nerve tube), each nerve 64911 - - $810.42 - - Nerve repair; with autogenous vein graft (includes harvest of vein graft), each nerve 64912 - - $721.90 - - Nerve repair; with nerve allograft, each nerve, first strand (cable) Nerve repair; with nerve allograft, each additional strand (List separately in addition to code for 64913 - - $140.02 - - primary procedure) 64999 - - I.C. - - Unlisted procedure, nervous system 65091 - - $545.50 - - Evisceration of ocular contents; without implant 65093 - - $540.53 - - Evisceration of ocular contents; with implant 65101 - - $628.38 - - Enucleation of eye; without implant 65103 - - $651.02 - - Enucleation of eye; with implant, muscles not attached to implant 65105 - - $713.01 - - Enucleation of eye; with implant, muscles attached to implant 65110 - - $1,000.50 - - Exenteration of orbit (does not include skin graft), removal of orbital contents; only Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic 65112 - - $1,152.36 - - removal of bone Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or 65114 - - $1,204.84 - - myocutaneous flap Modification of ocular implant with placement or replacement of pegs (eg, drilling receptacle 65125 $366.47 $230.25 - - - for prosthesis appendage) (separate procedure) 65130 - - $624.89 - - Insertion of ocular implant secondary; after evisceration, in scleral shell

Page 134 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 65135 - - $632.86 - - Insertion of ocular implant secondary; after enucleation, muscles not attached to implant 65140 - - $683.52 - - Insertion of ocular implant secondary; after enucleation, muscles attached to implant 65150 - - $505.20 - - Reinsertion of ocular implant; with or without conjunctival graft Reinsertion of ocular implant; with use of foreign material for reinforcement and/or 65155 - - $713.76 - - attachment of muscles to implant 65175 - - $566.80 - - Removal of ocular implant 65205 $29.43 $22.76 - - - Removal of foreign body, external eye; conjunctival superficial Removal of foreign body, external eye; conjunctival embedded (includes concretions), 65210 $36.05 $28.51 - - - subconjunctival, or scleral nonperforating 65220 $47.12 $32.34 - - - Removal of foreign body, external eye; corneal, without slit lamp 65222 $53.65 $40.03 - - - Removal of foreign body, external eye; corneal, with slit lamp 65235 - - $564.43 - - Removal of foreign body, intraocular; from anterior chamber of eye or lens Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or 65260 - - $762.69 - - posterior route 65265 - - $855.99 - - Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct 65270 $224.76 $110.27 - - - closure

65272 $413.14 $276.91 - - - Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization 65273 - - $298.60 - - Repair of laceration; conjunctiva, by mobilization and rearrangement, with hospitalization 65275 $462.36 $362.37 - - - Repair of laceration; cornea, nonperforating, with or without removal foreign body 65280 - - $525.42 - - Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal 65285 - - $867.81 - - tissue 65286 $559.45 $388.73 - - - Repair of laceration; application of tissue glue, wounds of cornea and/or sclera 65290 - - $384.68 - - Repair of wound, extraocular muscle, tendon and/or Tenon's capsule 65400 $541.63 $472.65 - - - Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium 65410 $114.15 $80.53 - - - Biopsy of cornea 65420 $422.90 $296.82 - - - Excision or transposition of pterygium; without graft 65426 $528.83 $375.22 - - - Excision or transposition of pterygium; with graft 65430 $90.96 $79.95 - - - Scraping of cornea, diagnostic, for smear and/or culture 65435 $64.91 $54.77 - - - Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) 65436 $304.25 $289.76 - - - Removal of corneal epithelium; with application of chelating agent (eg, EDTA) 65450 $258.07 $253.14 - - - Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization 65600 $327.73 $266.87 - - - Multiple punctures of anterior cornea (eg, for corneal erosion, tattoo) 65710 - - $882.92 - - Keratoplasty (corneal transplant); anterior lamellar 65730 - - $975.45 - - Keratoplasty (corneal transplant); penetrating (except in aphakia or pseudophakia) 65750 - - $979.47 - - Keratoplasty (corneal transplant); penetrating (in aphakia) 65755 - - $975.10 - - Keratoplasty (corneal transplant); penetrating (in pseudophakia) 65756 - - $922.23 - - Keratoplasty (corneal transplant); endothelial Backbench preparation of corneal endothelial allograft prior to transplantation (List separately 65757 - - I.C. - - in addition to code for primary procedure) 65760 - - I.C. - - Keratomileusis 65765 - - I.C. - - Keratophakia 65767 - - I.C. - - Epikeratoplasty 65770 - - $1,091.77 - - Keratoprosthesis 65771 - - I.C. - - Radial keratotomy 65772 $357.07 $317.65 - - - Corneal relaxing incision for correction of surgically induced astigmatism 65775 - - $442.44 - - Corneal wedge resection for correction of surgically induced astigmatism 65778 $1,150.86 $42.24 - - - Placement of amniotic membrane on the ocular surface; without sutures 65779 $990.95 $116.81 - - - Placement of amniotic membrane on the ocular surface; single layer, sutured 65780 - - $524.31 - - Ocular surface reconstruction; amniotic membrane transplantation, multiple layers 65781 - - $1,041.28 - - Ocular surface reconstruction; limbal stem cell allograft (eg, cadaveric or living donor) 65782 - - $899.48 - - Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) 65785 $1,939.86 $347.50 - - - Implantation of intrastromal corneal ring segments 65800 $94.00 $70.53 - - - Paracentesis of anterior chamber of eye (separate procedure); with removal of aqueous Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or 65810 - - $364.57 - - discission of anterior hyaloid membrane, with or without air injection Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or 65815 $511.37 $373.98 - - - without irrigation and/or air injection 65820 - - $618.96 - - Goniotomy 65850 - - $659.75 - - Trabeculotomy ab externo 65855 $194.19 $161.73 - - - Trabeculoplasty by laser surgery 65860 $244.15 $196.04 - - - Severing adhesions of anterior segment, laser technique (separate procedure) Severing adhesions of anterior segment of eye, incisional technique (with or without injection 65865 - - $373.72 - - of air or liquid) (separate procedure); goniosynechiae

Page 135 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Severing adhesions of anterior segment of eye, incisional technique (with or without injection 65870 - - $465.48 - - of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae Severing adhesions of anterior segment of eye, incisional technique (with or without injection 65875 - - $496.19 - - of air or liquid) (separate procedure); posterior synechiae Severing adhesions of anterior segment of eye, incisional technique (with or without injection 65880 - - $521.86 - - of air or liquid) (separate procedure); corneovitreal adhesions 65900 - - $769.48 - - Removal of epithelial downgrowth, anterior chamber of eye 65920 - - $620.50 - - Removal of implanted material, anterior segment of eye 65930 - - $501.50 - - Removal of blood clot, anterior segment of eye 66020 $154.55 $102.67 - - - Injection, anterior chamber of eye (separate procedure); air or liquid 66030 $138.71 $86.83 - - - Injection, anterior chamber of eye (separate procedure); medication 66130 $555.85 $442.52 - - - Excision of lesion, sclera 66150 - - $689.96 - - Fistulization of sclera for glaucoma; trephination with iridectomy 66155 - - $689.40 - - Fistulization of sclera for glaucoma; thermocauterization with iridectomy 66160 - - $774.99 - - Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy 66170 - - $857.88 - - Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous 66172 - - $935.40 - - ocular surgery or trauma (includes injection of antifibrotic agents) 66174 - - $740.06 - - Transluminal dilation of aqueous outflow canal; without retention of device or stent 66175 - - $774.76 - - Transluminal dilation of aqueous outflow canal; with retention of device or stent 66179 - - $845.81 - - Aqueous shunt to extraocular equatorial plate reservoir, external approach; without graft 66180 - - $892.26 - - Aqueous shunt to extraocular equatorial plate reservoir, external approach; with graft Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external 66183 - - $807.22 - - approach 66184 - - $618.21 - - Revision of aqueous shunt to extraocular equatorial plate reservoir; without graft 66185 - - $664.91 - - Revision of aqueous shunt to extraocular equatorial plate reservoir; with graft 66225 - - $730.01 - - Repair of scleral staphyloma; with graft Revision or repair of operative wound of anterior segment, any type, early or late, major or 66250 $599.27 $436.38 - - - minor procedure 66500 - - $295.40 - - Iridotomy by stab incision (separate procedure); except transfixion 66505 - - $322.38 - - Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe 66600 - - $685.01 - - Iridectomy, with corneoscleral or corneal section; for removal of lesion 66605 - - $845.51 - - Iridectomy, with corneoscleral or corneal section; with cyclectomy 66625 - - $336.75 - - Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure)

66630 - - $445.17 - - Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) 66635 - - $449.00 - - Iridectomy, with corneoscleral or corneal section; optical (separate procedure) 66680 - - $407.92 - - Repair of iris, ciliary body (as for iridodialysis) Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision 66682 - - $532.58 - - (eg, McCannel suture) 66700 $356.90 $307.05 - - - Ciliary body destruction; diathermy 66710 $349.66 $307.05 - - - Ciliary body destruction; cyclophotocoagulation, transscleral Ciliary body destruction; cyclophotocoagulation, endoscopic, without concomitant removal of 66711 - - $396.74 - - crystalline lens 66720 $366.15 $320.94 - - - Ciliary body destruction; cryotherapy 66740 $346.47 $307.05 - - - Ciliary body destruction; cyclodialysis 66761 $237.67 $185.21 - - - Iridotomy/iridectomy by laser surgery (eg, for glaucoma) (per session) Iridoplasty by photocoagulation (1 or more sessions) (eg, for improvement of vision, for 66762 $376.56 $333.08 - - - widening of anterior chamber angle) 66770 $417.92 $377.92 - - - Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior 66820 - - $341.82 - - hyaloid); stab incision technique (Ziegler or Wheeler knife) Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior 66821 $262.88 $245.78 - - - hyaloid); laser surgery (eg, YAG laser) (1 or more stages) 66825 - - $626.83 - - Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior 66830 - - $555.72 - - hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) 66840 - - $543.72 - - Removal of lens material; aspiration technique, 1 or more stages Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (eg, 66850 - - $619.19 - - phacoemulsification), with aspiration 66852 - - $659.12 - - Removal of lens material; pars plana approach, with or without vitrectomy 66920 - - $588.47 - - Removal of lens material; intracapsular 66930 - - $670.47 - - Removal of lens material; intracapsular, for dislocated lens

Page 136 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 66940 - - $613.30 - - Removal of lens material; extracapsular (other than 66840, 66850, 66852) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris 66982 - - $585.86 - - expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation Intracapsular cataract extraction with insertion of intraocular lens prosthesis (1 stage 66983 - - I.C. - - procedure) Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), 66984 - - $427.36 - - manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent 66985 - - $601.77 - - cataract removal 66986 - - $708.98 - - Exchange of intraocular lens Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris 66987 - - I.C. - - expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), 66988 - - I.C. - - manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation 66990 - - $69.70 - - Use of ophthalmic endoscope (List separately in addition to code for primary procedure) 66999 - - I.C. - - Unlisted procedure, anterior segment of eye

67005 - - $370.78 - - Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal 67010 - - $424.35 - - removal with mechanical vitrectomy Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior 67015 - - $465.56 - - sclerotomy) Injection of vitreous substitute, pars plana or limbal approach (fluid-gas exchange), with or 67025 $583.14 $495.03 - - - without aspiration (separate procedure) Implantation of intravitreal drug delivery system (eg, ganciclovir implant), includes concomitant 67027 - - $665.23 - - removal of vitreous 67028 $78.86 $76.83 - - - Intravitreal injection of a pharmacologic agent (separate procedure) 67030 - - $428.69 - - Discission of vitreous strands (without removal), pars plana approach Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser 67031 $308.14 $279.16 - - - surgery (1 or more stages) 67036 - - $703.50 - - Vitrectomy, mechanical, pars plana approach; 67039 - - $752.73 - - Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation 67040 - - $812.85 - - Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane 67041 - - $897.53 - - (eg, macular pucker) Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of 67042 - - $897.24 - - retina (eg, for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (eg, 67043 - - $946.52 - - choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation Repair of retinal detachment, including drainage of subretinal fluid when performed; 67101 $262.35 $223.51 - - - cryotherapy Repair of retinal detachment, including drainage of subretinal fluid when performed; 67105 $233.97 $215.71 - - - photocoagulation Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or 67107 - - $882.00 - - encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid Repair of retinal detachment; with vitrectomy, any method, including, when performed, air or 67108 - - $933.94 - - gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique 67110 $699.14 $637.70 - - - Repair of retinal detachment; by injection of air or other gas (eg, pneumatic retinopexy)

Page 137 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Repair of complex retinal detachment (eg, proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 67113 - - $1,043.98 - - degrees), with vitrectomy and membrane peeling, including, when performed, air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens 67115 - - $391.59 - - Release of encircling material (posterior segment) 67120 $527.68 $435.51 - - - Removal of implanted material, posterior segment; extraocular 67121 - - $708.72 - - Removal of implanted material, posterior segment; intraocular Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 67141 $413.23 $381.35 - - - or more sessions; cryotherapy, diathermy Prophylaxis of retinal detachment (eg, retinal break, lattice degeneration) without drainage, 1 67145 $415.62 $389.54 - - - or more sessions; photocoagulation (laser or xenon arc) Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; 67208 $471.41 $451.42 - - - cryotherapy, diathermy Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; 67210 $406.83 $391.47 - - - photocoagulation Destruction of localized lesion of retina (eg, macular edema, tumors), 1 or more sessions; 67218 - - $1,085.49 - - radiation by implantation of source (includes removal of source) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photocoagulation 67220 $419.58 $391.47 - - - (eg, laser), 1 or more sessions Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic 67221 $221.02 $164.79 - - - therapy (includes intravenous infusion) Destruction of localized lesion of choroid (eg, choroidal neovascularization); photodynamic 67225 $23.26 $22.10 - - - therapy, second eye, at single session (List separately in addition to code for primary eye treatment) Destruction of extensive or progressive retinopathy (eg, diabetic retinopathy), cryotherapy, 67227 $231.62 $200.03 - - - diathermy

67228 $268.05 $238.20 - - - Treatment of extensive or progressive retinopathy (eg, diabetic retinopathy), photocoagulation Treatment of extensive or progressive retinopathy, 1 or more sessions, preterm infant (less 67229 - - $909.49 - - than 37 weeks gestation at birth), performed from birth up to 1 year of age (eg, retinopathy of prematurity), photocoagulation or cryotherapy 67250 - - $663.93 - - Scleral reinforcement (separate procedure); without graft 67255 - - $537.46 - - Scleral reinforcement (separate procedure); with graft 67299 - - I.C. - - Unlisted procedure, posterior segment 67311 - - $467.89 - - Strabismus surgery, recession or resection procedure; 1 horizontal muscle 67312 - - $561.40 - - Strabismus surgery, recession or resection procedure; 2 horizontal muscles Strabismus surgery, recession or resection procedure; 1 vertical muscle (excluding superior 67314 - - $531.44 - - oblique) Strabismus surgery, recession or resection procedure; 2 or more vertical muscles (excluding 67316 - - $629.27 - - superior oblique) 67318 - - $554.93 - - Strabismus surgery, any procedure, superior oblique muscle Transposition procedure (eg, for paretic extraocular muscle), any extraocular muscle (specify) 67320 - - $248.64 - - (List separately in addition to code for primary procedure) Strabismus surgery on patient with previous eye surgery or injury that did not involve the 67331 - - $236.35 - - extraocular muscles (List separately in addition to code for primary procedure) Strabismus surgery on patient with scarring of extraocular muscles (eg, prior ocular injury, 67332 - - $256.03 - - strabismus or retinal detachment surgery) or restrictive myopathy (eg, dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure) Strabismus surgery by posterior fixation suture technique, with or without muscle recession 67334 - - $232.83 - - (List separately in addition to code for primary procedure)

67335 - - $113.94 - - Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery) Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List 67340 - - $276.60 - - separately in addition to code for primary procedure)

67343 - - $515.41 - - Release of extensive scar tissue without detaching extraocular muscle (separate procedure) 67345 $191.33 $169.88 - - - Chemodenervation of extraocular muscle 67346 - - $149.92 - - Biopsy of extraocular muscle 67399 - - I.C. - - Unlisted procedure, extraocular muscle Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or 67400 - - $776.44 - - without biopsy 67405 - - $668.30 - - Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only 67412 - - $727.82 - - Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion

Page 138 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign 67413 - - $718.80 - - body Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for 67414 - - $1,096.32 - - decompression 67415 - - $80.88 - - Fine needle aspiration of orbital contents 67420 - - $1,316.85 - - Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of lesion Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of foreign 67430 - - $1,038.99 - - body 67440 - - $1,006.41 - - Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with drainage Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); with removal of bone 67445 - - $1,154.10 - - for decompression Orbitotomy with bone flap or window, lateral approach (eg, Kroenlein); for exploration, with or 67450 - - $1,044.44 - - without biopsy

67500 $56.69 $47.13 - - - Retrobulbar injection; medication (separate procedure, does not include supply of medication) 67505 $64.81 $54.08 - - - Retrobulbar injection; alcohol 67515 $50.35 $46.29 - - - Injection of medication or other substance into Tenon's capsule 67550 - - $807.92 - - Orbital implant (implant outside muscle cone); insertion 67560 - - $827.27 - - Orbital implant (implant outside muscle cone); removal or revision 67570 - - $988.77 - - Optic nerve decompression (eg, incision or fenestration of optic nerve sheath) 67599 - - I.C. - - Unlisted procedure, orbit 67700 $225.62 $91.13 - - - Blepharotomy, drainage of abscess, eyelid 67710 $190.58 $76.67 - - - Severing of tarsorrhaphy 67715 $204.69 $84.12 - - - Canthotomy (separate procedure) 67800 $101.54 $80.38 - - - Excision of chalazion; single 67801 $128.34 $103.12 - - - Excision of chalazion; multiple, same lid 67805 $159.49 $127.90 - - - Excision of chalazion; multiple, different lids Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or 67808 - - $289.00 - - multiple 67810 $145.29 $54.57 - - - Incisional biopsy of eyelid skin including lid margin 67820 $20.86 $22.31 - - - Correction of trichiasis; epilation, by forceps only Correction of trichiasis; epilation by other than forceps (eg, by electrosurgery, cryotherapy, 67825 $105.26 $95.41 - - - laser surgery) 67830 $215.97 $107.57 - - - Correction of trichiasis; incision of lid margin 67835 - - $344.33 - - Correction of trichiasis; incision of lid margin, with free mucous membrane graft 67840 $223.41 $123.41 - - - Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure 67850 $172.52 $103.83 - - - Destruction of lesion of lid margin (up to 1 cm) 67875 $141.40 $75.02 - - - Temporary closure of eyelids by suture (eg, Frost suture) 67880 $366.81 $288.27 - - - Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with 67882 $449.74 $369.74 - - - transposition of tarsal plate 67900 $510.95 $397.33 - - - Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked 67901 $619.98 $457.96 - - - fascia) Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes 67902 - - $566.49 - - obtaining fascia) 67903 $474.39 $377.59 - - - Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904 $583.93 $466.83 - - - Repair of blepharoptosis; (tarso) levator resection or advancement, external approach 67906 - - $396.02 - - Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella- 67908 $408.88 $336.13 - - - Servat type) 67909 $431.38 $343.85 - - - Reduction of overcorrection of ptosis 67911 - - $438.65 - - Correction of lid retraction 67912 $726.18 $380.98 - - - Correction of lagophthalmos, with implantation of upper eyelid lid load (eg, gold weight) 67914 $385.07 $257.25 - - - Repair of ectropion; suture 67915 $245.34 $155.49 - - - Repair of ectropion; thermocauterization 67916 $481.92 $336.71 - - - Repair of ectropion; excision tarsal wedge 67917 $490.49 $358.03 - - - Repair of ectropion; extensive (eg, tarsal strip operations) 67921 $378.06 $244.16 - - - Repair of entropion; suture 67922 $238.47 $154.42 - - - Repair of entropion; thermocauterization 67923 $481.96 $337.34 - - - Repair of entropion; excision tarsal wedge 67924 $512.85 $358.08 - - - Repair of entropion; extensive (eg, tarsal strip or capsulopalpebral fascia repairs operation) Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct 67930 $292.65 $186.28 - - - closure; partial thickness

Page 139 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct 67935 $472.35 $344.82 - - - closure; full thickness 67938 $209.53 $91.27 - - - Removal of embedded foreign body, eyelid 67950 $459.19 $362.68 - - - Canthoplasty (reconstruction of canthus) Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, 67961 $461.43 $356.22 - - - may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, 67966 $611.21 $512.96 - - - may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing 67971 - - $564.58 - - eyelid; up to two-thirds of eyelid, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing 67973 - - $725.68 - - eyelid; total eyelid, lower, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing 67974 - - $724.15 - - eyelid; total eyelid, upper, 1 stage or first stage Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing 67975 - - $535.27 - - eyelid; second stage 67999 - - I.C. - - Unlisted procedure, eyelids 68020 $94.94 $86.25 - - - Incision of conjunctiva, drainage of cyst 68040 $49.28 $38.26 - - - Expression of conjunctival follicles (eg, for trachoma) 68100 $142.85 $75.02 - - - Biopsy of conjunctiva 68110 $187.11 $116.10 - - - Excision of lesion, conjunctiva; up to 1 cm 68115 $259.63 $143.41 - - - Excision of lesion, conjunctiva; over 1 cm 68130 $435.30 $323.13 - - - Excision of lesion, conjunctiva; with adjacent sclera 68135 $124.04 $117.66 - - - Destruction of lesion, conjunctiva 68200 $33.06 $27.27 - - - Subconjunctival injection 68320 $586.53 $423.06 - - - Conjunctivoplasty; with conjunctival graft or extensive rearrangement 68325 - - $513.91 - - Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive 68326 - - $504.57 - - rearrangement Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes 68328 - - $554.07 - - obtaining graft) 68330 $489.88 $360.90 - - - Repair of symblepharon; conjunctivoplasty, without graft Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes 68335 - - $506.21 - - obtaining graft) Repair of symblepharon; division of symblepharon, with or without insertion of conformer or 68340 $462.62 $312.19 - - - contact lens 68360 $427.84 $321.47 - - - Conjunctival flap; bridge or partial (separate procedure) 68362 - - $512.80 - - Conjunctival flap; total (such as Gunderson thin flap or purse string flap) 68371 - - $324.03 - - Harvesting conjunctival allograft, living donor 68399 - - I.C. - - Unlisted procedure, conjunctiva 68400 $235.71 $102.67 - - - Incision, drainage of lacrimal gland 68420 $264.37 $131.05 - - - Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) 68440 $81.80 $78.32 - - - Snip incision of lacrimal punctum 68500 - - $795.70 - - Excision of lacrimal gland (dacryoadenectomy), except for tumor; total 68505 - - $792.13 - - Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial 68510 $361.08 $226.31 - - - Biopsy of lacrimal gland 68520 - - $557.37 - - Excision of lacrimal sac (dacryocystectomy) 68525 - - $203.94 - - Biopsy of lacrimal sac 68530 $345.57 $199.20 - - - Removal of foreign body or dacryolith, lacrimal passages 68540 - - $748.88 - - Excision of lacrimal gland tumor; frontal approach 68550 - - $924.29 - - Excision of lacrimal gland tumor; involving osteotomy 68700 - - $472.72 - - Plastic repair of canaliculi 68705 $202.49 $129.74 - - - Correction of everted punctum, cautery 68720 - - $613.39 - - Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) 68745 - - $616.13 - - Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or 68750 - - $643.19 - - stent 68760 $170.97 $114.17 - - - Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery 68761 $117.86 $92.36 - - - Closure of the lacrimal punctum; by plug, each 68770 - - $491.60 - - Closure of lacrimal fistula (separate procedure) 68801 $73.12 $60.95 - - - Dilation of lacrimal punctum, with or without irrigation 68810 $126.44 $100.06 - - - Probing of nasolacrimal duct, with or without irrigation; 68811 - - $105.86 - - Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia 68815 $312.36 $174.11 - - - Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent

Page 140 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter 68816 $639.30 $123.10 - - - dilation 68840 $103.64 $91.18 - - - Probing of lacrimal canaliculi, with or without irrigation 68850 $49.85 $43.76 - - - Injection of contrast medium for dacryocystography 68899 - - I.C. - - Unlisted procedure, lacrimal system 69000 $150.05 $95.85 - - - Drainage external ear, abscess or hematoma; simple 69005 $172.42 $123.72 - - - Drainage external ear, abscess or hematoma; complicated 69020 $185.09 $111.48 - - - Drainage external auditory canal, abscess 69090 - - I.C. - - Ear piercing 69100 $78.47 $37.31 - - - Biopsy external ear 69105 $113.35 $49.01 - - - Biopsy external auditory canal 69110 $370.46 $258.00 - - - Excision external ear; partial, simple repair 69120 - - $310.72 - - Excision external ear; complete amputation 69140 - - $695.79 - - Excision exostosis(es), external auditory canal 69145 $320.33 $198.60 - - - Excision soft tissue lesion, external auditory canal 69150 - - $805.38 - - Radical excision external auditory canal lesion; without neck dissection 69155 - - $1,280.41 - - Radical excision external auditory canal lesion; with neck dissection 69200 $64.57 $36.74 - - - Removal foreign body from external auditory canal; without general anesthesia 69205 - - $76.59 - - Removal foreign body from external auditory canal; with general anesthesia 69209 - - $11.55 - - Removal impacted cerumen using irrigation/lavage, unilateral 69210 $37.51 $25.92 - - - Removal impacted cerumen requiring instrumentation, unilateral 69220 $62.68 $39.78 - - - Debridement, mastoidectomy cavity, simple (eg, routine cleaning) Debridement, mastoidectomy cavity, complex (eg, with anesthesia or more than routine 69222 $169.97 $105.92 - - - cleaning) 69300 $491.78 $360.77 - - - Otoplasty, protruding ear, with or without size reduction Reconstruction of external auditory canal (meatoplasty) (eg, for stenosis due to injury, 69310 - - $864.37 - - infection) (separate procedure) 69320 - - $1,207.14 - - Reconstruction external auditory canal for congenital atresia, single stage 69399 - - I.C. - - Unlisted procedure, external ear 69420 $149.66 $94.01 - - - Myringotomy including aspiration and/or eustachian tube inflation

69421 - - $116.52 - - Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia 69424 $102.34 $47.56 - - - Ventilating tube removal requiring general anesthesia 69433 $158.04 $102.97 - - - Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia 69436 - - $123.65 - - Tympanostomy (requiring insertion of ventilating tube), general anesthesia 69440 - - $541.80 - - Middle ear exploration through postauricular or ear canal incision 69450 - - $429.68 - - Tympanolysis, transcanal 69501 - - $562.73 - - Transmastoid antrotomy (simple mastoidectomy) 69502 - - $747.15 - - Mastoidectomy; complete 69505 - - $951.37 - - Mastoidectomy; modified radical 69511 - - $974.05 - - Mastoidectomy; radical 69530 - - $1,300.14 - - Petrous apicectomy including radical mastoidectomy 69535 - - $2,072.34 - - Resection temporal bone, external approach 69540 $165.09 $99.88 - - - Excision aural polyp 69550 - - $822.86 - - Excision aural glomus tumor; transcanal 69552 - - $1,232.88 - - Excision aural glomus tumor; transmastoid 69554 - - $1,964.48 - - Excision aural glomus tumor; extended (extratemporal) 69601 - - $805.29 - - Revision mastoidectomy; resulting in complete mastoidectomy 69602 - - $853.00 - - Revision mastoidectomy; resulting in modified radical mastoidectomy 69603 - - $994.87 - - Revision mastoidectomy; resulting in radical mastoidectomy 69604 - - $871.40 - - Revision mastoidectomy; resulting in tympanoplasty Tympanic membrane repair, with or without site preparation of perforation for closure, with or 69610 $297.80 $225.05 - - - without patch 69620 $562.62 $384.37 - - - Myringoplasty (surgery confined to drumhead and donor area) Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear 69631 - - $696.34 - - surgery), initial or revision; without ossicular chain reconstruction Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear 69632 - - $846.23 - - surgery), initial or revision; with ossicular chain reconstruction (eg, postfenestration)

Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear 69633 - - $820.65 - - surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP]) Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear 69635 - - $975.07 - - surgery, and/or tympanic membrane repair); without ossicular chain reconstruction Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear 69636 - - $1,090.25 - - surgery, and/or tympanic membrane repair); with ossicular chain reconstruction

Page 141 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic 69637 - - $1,085.39 - - prosthesis (eg, partial ossicular replacement prosthesis [PORP], total ossicular replacement prosthesis [TORP]) Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic 69641 - - $816.88 - - membrane repair); without ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic 69642 - - $1,048.02 - - membrane repair); with ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic 69643 - - $957.56 - - membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction

69644 - - $1,165.28 - - Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic 69645 - - $1,147.23 - - membrane repair); radical or complete, without ossicular chain reconstruction Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic 69646 - - $1,214.17 - - membrane repair); radical or complete, with ossicular chain reconstruction 69650 - - $629.65 - - Stapes mobilization Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without 69660 - - $724.42 - - use of foreign material; Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without 69661 - - $944.97 - - use of foreign material; with footplate drill out 69662 - - $900.48 - - Revision of stapedectomy or stapedotomy 69666 - - $634.94 - - Repair oval window fistula 69667 - - $634.24 - - Repair round window fistula 69670 - - $741.68 - - Mastoid obliteration (separate procedure) 69676 - - $653.11 - - Tympanic neurectomy 69700 - - $527.85 - - Closure postauricular fistula, mastoid (separate procedure) 69705 $2,585.15 $136.75 - - - Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); unilateral

69706 $2,659.15 $190.09 - - - Nasopharyngoscopy, surgical, with dilation of eustachian tube (ie, balloon dilation); bilateral Implantation or replacement of electromagnetic bone conduction hearing device in temporal 69710 - - I.C. - - bone 69711 - - $663.62 - - Removal or repair of electromagnetic bone conduction hearing device in temporal bone Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to 69714 - - $828.58 - - external speech processor/cochlear stimulator; without mastoidectomy Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to 69715 - - $1,022.28 - - external speech processor/cochlear stimulator; with mastoidectomy Replacement (including removal of existing device), osseointegrated implant, temporal bone, 69717 - - $868.82 - - with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy Replacement (including removal of existing device), osseointegrated implant, temporal bone, 69718 - - $1,032.83 - - with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69720 - - $932.00 - - Decompression facial nerve, intratemporal; lateral to geniculate ganglion 69725 - - $1,462.23 - - Decompression facial nerve, intratemporal; including medial to geniculate ganglion Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate 69740 - - $909.15 - - ganglion Suture facial nerve, intratemporal, with or without graft or decompression; including medial to 69745 - - $969.62 - - geniculate ganglion 69799 - - I.C. - - Unlisted procedure, middle ear 69801 $169.03 $96.57 - - - Labyrinthotomy, with perfusion of vestibuloactive drug(s), transcanal 69805 - - $810.79 - - Endolymphatic sac operation; without shunt 69806 - - $728.14 - - Endolymphatic sac operation; with shunt 69905 - - $719.61 - - Labyrinthectomy; transcanal 69910 - - $782.44 - - Labyrinthectomy; with mastoidectomy 69915 - - $1,183.36 - - Vestibular nerve section, translabyrinthine approach 69930 - - $952.74 - - Cochlear device implantation, with or without mastoidectomy 69949 - - I.C. - - Unlisted procedure, inner ear 69950 - - $1,371.25 - - Vestibular nerve section, transcranial approach 69955 - - $1,537.98 - - Total facial nerve decompression and/or repair (may include graft) 69960 - - $1,480.59 - - Decompression internal auditory canal 69970 - - $1,664.10 - - Removal of tumor, temporal bone 69979 - - I.C. - - Unlisted procedure, temporal bone, middle fossa approach

Page 142 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Microsurgical techniques, requiring use of operating microscope (List separately in addition to 69990 - - $168.46 - - code for primary procedure)

80500 $17.55 $15.23 - - - Clinical pathology consultation; limited, without review of patient's history and medical records Clinical pathology consultation; comprehensive, for a complex diagnostic problem, with review 80502 $57.53 $54.92 - - - of patient's history and medical records 83020 - - - $14.36 - Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 84165 - - - $14.36 - Protein; electrophoretic fractionation and quantitation, serum Protein; electrophoretic fractionation and quantitation, other fluids with concentration (eg, 84166 - - - $14.36 - urine, CSF) 84181 - - - $14.36 - Protein; Western Blot, with interpretation and report, blood or other body fluid Protein; Western Blot, with interpretation and report, blood or other body fluid, immunological 84182 - - - $14.36 - probe for band identification, each 85060 - - $19.05 - - Blood smear, peripheral, interpretation by physician with written report 85097 $54.85 $38.62 - - - Bone marrow, smear interpretation 85390 - - - $29.04 - Fibrinolysins or coagulopathy screen, interpretation and report

85396 - - $15.81 - - Coagulation/fibrinolysis assay, whole blood (eg, viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day 85576 - - - $14.36 - Platelet, aggregation (in vitro), each agent Blood bank physician services; difficult cross match and/or evaluation of irregular antibody(s), 86077 $42.68 $39.78 - - - interpretation and written report Blood bank physician services; investigation of transfusion reaction including suspicion of 86078 $42.68 $39.78 - - - transmissible disease, interpretation and written report Blood bank physician services; authorization for deviation from standard blood banking 86079 $42.68 $39.49 - - - procedures (eg, use of outdated blood, transfusion of Rh incompatible units), with written report Cell enumeration using immunologic selection and identification in fluid specimen (eg, 86153 - - $26.86 $26.86 - circulating tumor cells in blood); physician interpretation and report, when required 86255 - - - $14.36 - Fluorescent noninfectious agent antibody; screen, each antibody 86256 - - - $14.36 - Fluorescent noninfectious agent antibody; titer, each antibody 86320 - - - $14.36 - Immunoelectrophoresis; serum 86325 - - - $14.36 - Immunoelectrophoresis; other fluids (eg, urine, cerebrospinal fluid) with concentration 86327 - - - $17.47 - Immunoelectrophoresis; crossed (2-dimensional assay) 86334 - - - $14.36 - Immunofixation electrophoresis; serum 86335 - - - $14.36 - Immunofixation electrophoresis; other fluids with concentration (eg, urine, CSF) 86486 - - $4.30 - - Skin test; unlisted antigen, each 86490 - - $71.83 - - Skin test; coccidioidomycosis 86510 - - $5.46 - - Skin test; histoplasmosis 86580 - - $7.49 - - Skin test; tuberculosis, intradermal

87164 - - - $15.57 - Dark field examination, any source (eg, penile, vaginal, oral, skin); includes specimen collection Smear, primary source with interpretation; special stain for inclusion bodies or parasites (eg, 87207 - - - $14.36 - malaria, coccidia, microsporidia, trypanosomes, herpes viruses) Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with 88104 - - $54.47 $22.06 $32.42 interpretation Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method 88106 - - $52.04 $15.28 $36.76 with interpretation Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno 88108 - - $49.55 $17.71 $31.84 technique) Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based 88112 - - $53.60 $21.77 $31.84 slide preparation method), except cervical or vaginal Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric 88120 - - $470.18 $45.37 $424.81 analysis, 3-5 molecular probes, each specimen; manual Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric 88121 - - $359.12 $38.32 $320.80 analysis, 3-5 molecular probes, each specimen; using computer-assisted technology 88125 - - $21.01 $10.91 $10.10 Cytopathology, forensic (eg, sperm)

88141 - - $20.47 - - Cytopathology, cervical or vaginal (any reporting system), requiring interpretation by physician 88160 - - $56.94 $20.47 $36.47 Cytopathology, smears, any other source; screening and interpretation 88161 - - $54.62 $19.89 $34.74 Cytopathology, smears, any other source; preparation, screening and interpretation Cytopathology, smears, any other source; extended study involving over 5 slides and/or 88162 - - $79.15 $30.26 $48.89 multiple stains Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine 88172 - - $44.01 $28.40 $15.61 adequacy for diagnosis, first evaluation episode, each site 88173 - - $122.73 $55.87 $66.86 Cytopathology, evaluation of fine needle aspirate; interpretation and report

Page 143 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine 88177 - - $23.27 $17.47 $5.80 adequacy for diagnosis, each separate additional evaluation episode, same site (List separately in addition to code for primary procedure) 88182 - - $110.68 $30.53 $80.15 Flow cytometry, cell cycle or DNA analysis Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first 88184 - - $54.69 - - marker Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each 88185 - - $17.97 - - additional marker (List separately in addition to code for first marker) 88187 - - $29.55 - - Flow cytometry, interpretation; 2 to 8 markers 88188 - - $49.82 - - Flow cytometry, interpretation; 9 to 15 markers 88189 - - $66.72 - - Flow cytometry, interpretation; 16 or more markers 88199 - - I.C. - - Unlisted cytopathology procedure 88291 - - $26.41 - - Cytogenetics and molecular cytogenetics, interpretation and report 88299 - - I.C. - - Unlisted cytogenetic study 88300 - - $12.47 $3.53 $8.94 Level I - Surgical pathology, gross examination only Level II - Surgical pathology, gross and microscopic examination Appendix, incidental Fallopian tube, sterilization Fingers/toes, amputation, traumatic Foreskin, newborn Hernia sac, any 88302 - - $24.81 $5.43 $19.37 location Hydrocele sac Nerve Skin, plastic repair Sympathetic ganglion Testis, castration Vaginal mucosa, incidental Vas deferens, sterilization Level III - Surgical pathology, gross and microscopic examination Abortion, induced Abscess Aneurysm - arterial/ventricular Anus, tag Appendix, other than incidental Artery, atheromatous plaque Bartholin's gland cyst Bone fragment(s), other than pathologic fracture Bursa/synovial cyst Carpal tunnel tissue Cartilage, shavings Cholesteatoma Colon, colostomy stoma Conjunctiva - biopsy/pterygium Cornea Diverticulum - esophagus/small intestine Dupuytren's contracture tissue Femoral head, other than fracture Fissure/fistula Foreskin, other than newborn 88304 - - $32.99 $8.98 $24.01 Gallbladder Ganglion cyst Hematoma Hemorrhoids Hydatid of Morgagni Intervertebral disc Joint, loose body Meniscus Mucocele, salivary Neuroma - Morton's/traumatic Pilonidal cyst/sinus Polyps, inflammatory - nasal/sinusoidal Skin - cyst/tag/debridement Soft tissue, debridement Soft tissue, lipoma Spermatocele Tendon/tendon sheath Testicular appendage Thrombus or embolus Tonsil and/or adenoids Varicocele Vas deferens, other than sterilization Vein, varicosity

Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph 88305 - - $55.46 $29.71 $25.75 node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy Level V - Surgical pathology, gross and microscopic examination Adrenal, resection Bone - biopsy/curettings Bone fragment(s), pathologic fracture Brain, biopsy Brain/meninges, tumor resection Breast, excision of lesion, requiring microscopic evaluation of surgical margins Breast, mastectomy - partial/simple Cervix, conization Colon, segmental resection, other than for tumor Extremity, amputation, non-traumatic Eye, enucleation Kidney, partial/total nephrectomy Larynx, partial/total resection Liver, biopsy - needle/wedge Liver, partial resection 88307 - - $221.90 $65.52 $156.38 Lung, wedge biopsy Lymph nodes, regional resection Mediastinum, mass Myocardium, biopsy Odontogenic tumor Ovary with or without tube, neoplastic Pancreas, biopsy Placenta, third trimester Prostate, except radical resection Salivary gland Sentinel lymph node Small intestine, resection, other than for tumor Soft tissue mass (except lipoma) - biopsy/simple excision Stomach - subtotal/total resection, other than for tumor Testis, biopsy Thymus, tumor Thyroid, total/lobe Ureter, resection Urinary bladder, TUR Uterus, with or without tubes and ovaries, other than neoplastic/prolapse

Page 144 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description

Level VI - Surgical pathology, gross and microscopic examination Bone resection Breast, mastectomy - with regional lymph nodes Colon, segmental resection for tumor Colon, total resection Esophagus, partial/total resection Extremity, disarticulation Fetus, with dissection 88309 - - $336.22 $115.50 $220.72 Larynx, partial/total resection - with regional lymph nodes Lung - total/lobe/segment resection Pancreas, total/subtotal resection Prostate, radical resection Small intestine, resection for tumor Soft tissue tumor, extensive resection Stomach - subtotal/total resection for tumor Testis, tumor Tongue/tonsil -resection for tumor Urinary bladder, partial/total resection Uterus, with or without tubes and ovaries, neoplastic Vulva, total/subtotal resection Decalcification procedure (List separately in addition to code for surgical pathology 88311 - - $17.00 $9.80 $7.20 examination) Special stain including interpretation and report; Group I for microorganisms (eg, acid fast, 88312 - - $84.67 $20.95 $63.72 methenamine silver) Special stain including interpretation and report; Group II, all other (eg, iron, trichrome), except 88313 - - $61.35 $9.51 $51.84 stain for microorganisms, stains for enzyme constituents, or immunocytochemistry and immunohistochemistry Special stain including interpretation and report; histochemical stain on frozen tissue block (List 88314 - - $77.93 $17.40 $60.53 separately in addition to code for primary procedure) 88319 - - $89.91 $21.26 $68.65 Special stain including interpretation and report; Group III, for enzyme constituents 88321 $77.91 $66.31 - - - Consultation and report on referred slides prepared elsewhere 88323 - - $89.86 $68.46 $21.40 Consultation and report on referred material requiring preparation of slides Consultation, comprehensive, with review of records and specimens, with report on referred 88325 $136.22 $113.61 - - - material 88329 $41.89 $28.56 - - - Pathology consultation during surgery; 88331 - - $77.52 $49.45 $28.07 Pathology consultation during surgery; first tissue block, with frozen section(s), single specimen Pathology consultation during surgery; each additional tissue block with frozen section(s) (List 88332 - - $43.10 $24.59 $18.50 separately in addition to code for primary procedure) Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), 88333 - - $70.83 $49.42 $21.40 initial site Pathology consultation during surgery; cytologic examination (eg, touch prep, squash prep), 88334 - - $44.54 $30.04 $14.49 each additional site (List separately in addition to code for primary procedure) Immunohistochemistry or immunocytochemistry, per specimen; each additional single antibody 88341 - - $74.23 $22.35 $51.88 stain procedure (List separately in addition to code for primary procedure) Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain 88344 - - $138.88 $30.24 $108.64 procedure 88346 - - $101.27 $28.28 $72.99 Immunofluorescence, per specimen; initial single antibody stain procedure 88348 - - $312.43 $60.26 $252.18 Electron microscopy, diagnostic Immunofluorescence, per specimen; each additional single antibody stain procedure (List 88350 - - $74.11 $22.85 $51.26 separately in addition to code for primary procedure) 88355 - - $107.82 $64.39 $43.43 Morphometric analysis; skeletal muscle 88356 - - $185.71 $100.43 $85.28 Morphometric analysis; nerve 88358 - - $106.80 $39.60 $67.20 Morphometric analysis; tumor (eg, DNA ploidy) Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen 88360 - - $100.14 $33.23 $66.91 receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; manual Morphometric analysis, tumor immunohistochemistry (eg, Her-2/neu, estrogen 88361 - - $101.34 $35.01 $66.33 receptor/progesterone receptor), quantitative or semiquantitative, per specimen, each single antibody stain procedure; using computer-assisted technology 88362 - - $180.97 $89.18 $91.79 Nerve teasing preparations Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular 88363 $18.42 $15.52 - - - analysis (eg, KRAS mutational analysis) 88365 - - $145.48 $34.56 $110.92 In situ hybridization (eg, FISH), per specimen; initial single probe stain procedure 88366 - - $222.85 $49.04 $173.81 In situ hybridization (eg, FISH), per specimen; each multiplex probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer- 88367 - - $90.58 $26.86 $63.72 assisted technology, per specimen; initial single probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 88368 - - $105.23 $32.57 $72.66 specimen; initial single probe stain procedure Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 88369 - - $91.81 $25.48 $66.33 specimen; each additional single probe stain procedure (List separately in addition to code for primary procedure) 88371 - - - $15.57 - Protein analysis of tissue by Western Blot, with interpretation and report; Protein analysis of tissue by Western Blot, with interpretation and report; immunological probe 88372 - - - $14.36 - for band identification, each Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), using computer- 88374 - - $277.32 $34.77 $242.55 assisted technology, per specimen; each multiplex probe stain procedure

Page 145 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description Optical endomicroscopic image(s), interpretation and report, real-time or referred, each 88375 - - $38.70 - - endoscopic session Morphometric analysis, in situ hybridization (quantitative or semi-quantitative), manual, per 88377 - - $327.08 $50.67 $276.41 specimen; each multiplex probe stain procedure 88380 - - $107.74 $43.48 $64.25 Microdissection (ie, sample preparation of microscopically identified target); laser capture 88381 - - $145.47 $19.52 $125.94 Microdissection (ie, sample preparation of microscopically identified target); manual Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical 88387 - - $27.37 $21.62 $5.75 studies (eg, nucleic acid-based molecular studies); each tissue preparation (eg, a single lymph node) Macroscopic examination, dissection, and preparation of tissue for non-microscopic analytical studies (eg, nucleic acid-based molecular studies); in conjunction with a touch imprint, 88388 - - $28.95 $18.85 $10.10 intraoperative consultation, or frozen section, each tissue preparation (eg, a single lymph node) (List separately in addition to code for primary procedure) 88399 - - I.C. - - Unlisted surgical pathology procedure Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including 89049 $202.72 $46.79 - - - interpretation and report Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any 89060 - - - $14.36 - body fluid (except urine) 89220 - - $13.29 - - Sputum, obtaining specimen, aerosol induced technique (separate procedure) 89230 - - $1.98 - - Sweat collection by iontophoresis 89240 - - I.C. - - Unlisted miscellaneous pathology test 14301* $854.99 $685.43 - - - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof 14302* - - $170.93 - - (List separately in addition to code for primary procedure) 20912* - - $374.66 - - Cartilage graft; nasal septum 21120* $540.53 $418.51 - - - Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining 21123* - - $696.70 - - autografts) 21137* - - $597.13 - - Reduction forehead; contouring only 21139* - - $881.01 - - Reduction forehead; contouring and setback of anterior frontal sinus wall 21208* $1,379.58 $597.31 - - - Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209* $643.08 $482.80 - - - Osteoplasty, facial bones; reduction 21210* $1,604.90 $614.82 - - - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); 21296* - - $321.88 - - intraoral approach Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar 30410* - - $1,109.82 - - cartilages, and/or elevation of nasal tip 30420* - - $1,116.68 - - Rhinoplasty, primary; including major septal repair 30465* - - $789.18 - - Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction) 31750* - - $1,085.74 - - Tracheoplasty; cervical 64716* - - $406.94 - - Neuroplasty and/or transposition; cranial nerve (specify) 64771* - - $481.38 - - Transection or avulsion of other cranial nerve, extradural G0105 $414.57 $204.78 - - - Colorectal cancer screening; colonoscopy on individual at high risk G0121 $414.80 $205.01 - - - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk S2260 - - I.C. - - Induced abortion, 17 to 24 weeks *See 101 CMR 316.05(1) Facial Feminization Services Code NFAC FAC Global PC TC Description 14301 $1,200.35 $962.30 - - - Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof 14302 - - $239.98 - - (List separately in addition to code for primary procedure) 20912 - - $526.00 - - Cartilage graft; nasal septum 21120 $758.87 $587.56 - - - Genioplasty; augmentation (autograft, allograft, prosthetic material) Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining 21123 - - $978.12 - - autografts) 21137 - - $838.34 - - Reduction forehead; contouring only 21139 - - $1,236.88 - - Reduction forehead; contouring and setback of anterior frontal sinus wall 21208 $1,936.84 $838.59 - - - Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 $902.84 $677.82 - - - Osteoplasty, facial bones; reduction 21210 $2,253.17 $863.16 - - - Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) Reduction of masseter muscle and bone (eg, for treatment of benign masseteric hypertrophy); 21296 - - $451.89 - - intraoral approach Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar 30410 - - $1,558.11 - - cartilages, and/or elevation of nasal tip 30420 - - $1,567.75 - - Rhinoplasty, primary; including major septal repair 30465 - - $1,107.96 - - Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)

Page 146 of 147 Surgery Service Codes Spreadsheet as of August 1, 2021 Note: Procedure codes and their corresponding descriptions are obtained from the AMA 2020 CPT and HCPCS. Code NFAC FAC Global PC TC Description 31750 - - $1,524.31 - - Tracheoplasty; cervical 64716 - - $571.32 - - Neuroplasty and/or transposition; cranial nerve (specify) 64771 - - $675.82 - - Transection or avulsion of other cranial nerve, extradural

Page 147 of 147