Medicare One Day Surgery List

Addendum AA -- ASC Covered Surgical Procedures for CY 2008 (Including Surgical Procedures for Which Payment is Packaged)

HCPCS Code 0016T 0017T 0027T 0031T 0032T 0046T 0047T 0062T 0063T 0084T 0088T 0099T* 0100T 0101T 0102T 0123T 0124T* 0137T 0170T 0176T 0177T 0186T 10021 10022 10040 10060 10061 10080 10081 10120 10121 10140 10160 10180 11000 11001 11010 11011 11012 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11300 11301 11302 11303 11305 11306 11307 11308 11310 11311 11312 11313 11400 11401 11402 11403 11404 11406 11420 11421 11422 11423 11424 11426 11440 11441 11442 11443 11444 11446 11450 11451

Short Descriptor Thermotx choroid vasc lesion Photocoagulat macular drusen Endoscopic epidural lysis Speculoscopy Speculoscopy w/direct sample Cath lavage, mammary duct(s) Cath lavage, mammary duct(s) Rep intradisc annulus;1 lev Rep intradisc annulus;>1lev Temp prostate urethral stent Rf tongue base vol reduxn Implant corneal ring Prosth retina receive&gen Extracorp shockwv tx,hi enrg Extracorp shockwv tx,anesth Scleral fistulization Conjunctival drug placement Prostate saturation sampling Anorectal fistula plug rpr Aqu canal dilat w/o retent Aqu canal dilat w retent Suprachoroidal drug delivery Fna w/o image Fna w/image Acne surgery Drainage of skin abscess Drainage of skin abscess Drainage of pilonidal cyst Drainage of pilonidal cyst Remove foreign body Remove foreign body Drainage of hematoma/fluid Puncture drainage of lesion Complex drainage, wound Debride infected skin Debride infected skin add-on Debride skin, fx Debride skin/muscle, fx Debride skin/muscle/bone, fx Debride skin, partial Debride skin, full Debride skin/tissue Debride tissue/muscle Debride tissue/muscle/bone Trim skin lesion Trim skin lesions, 2 to 4 Trim skin lesions, over 4 Biopsy, skin lesion Biopsy, skin add-on Removal of skin tags Remove skin tags add-on Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Shave skin lesion Exc tr-ext b9+marg 0.5 < cm Exc tr-ext b9+marg 0.6-1 cm Exc tr-ext b9+marg 1.1-2 cm Exc tr-ext b9+marg 2.1-3 cm Exc tr-ext b9+marg 3.1-4 cm Exc tr-ext b9+marg > 4.0 cm Exc h-f-nk-sp b9+marg 0.5 < Exc h-f-nk-sp b9+marg 0.6-1 Exc h-f-nk-sp b9+marg 1.1-2 Exc h-f-nk-sp b9+marg 2.1-3 Exc h-f-nk-sp b9+marg 3.1-4 Exc h-f-nk-sp b9+marg > 4 cm Exc face-mm b9+marg 0.5 < cm Exc face-mm b9+marg 0.6-1 cm Exc face-mm b9+marg 1.1-2 cm Exc face-mm b9+marg 2.1-3 cm Exc face-mm b9+marg 3.1-4 cm Exc face-mm b9+marg > 4 cm Removal, sweat gland lesion Removal, sweat gland lesion

Date Printed: 10/18/2008 @ 17:45:58

Subject To Multiple Procedure Discounting Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Payment Indicator R2 R2 G2 N1 N1 R2 R2 G2 G2 G2 G2 R2 G2 G2 G2 G2 R2 G2 G2 A2 A2 G2 P2 G2 P2 P3 P2 P2 P3 P2 A2 P3 P2 A2 P3 P3 A2 A2 A2 P3 P3 A2 A2 A2 P3 P3 P3 P2 P3 P2 P3 P2 P2 P2 P2 P2 P2 P2 P2 P2 P2 P2 P2 P3 P3 P3 P3 A2 A2 P3 P3 P3 P3 A2 A2 P3 P3 P3 P3 A2 A2 A2 A2

CY 2007 ASC Payment Rate

$1,339.00 $1,339.00

$446.00

$446.00

$251.52 $251.52 $251.52

$164.42 $164.42 $423.10

$333.00 $446.00

$446.00 $446.00

$333.00 $446.00 $446.00 $446.00

CY 2008 Fully Implemented Payment Weight 4.13 4.13 18.05

CY 2008 Fully Implemented Payment $171.11 $171.11 $747.36

CY 2008 First Transition Year Payment $171.11 $171.11 $747.36

16.1 16.1 29.19 29.19 2.01 16.33 16.17 37.21 29.19 29.19 23.18 5.12 11.03 30.16 39.71 39.71 18.24 1.11 4.33 0.79 1.25 1.41 1.41 3.48 1.41 16.1 1.86 1.41 18.32 0.6 0.21 4.3 4.3 4.3 0.55 0.63 2.66 2.66 6.88 0.63 0.7 0.79 0.79 0.34 0.79 0.15 0.79 0.79 0.79 1.46 0.79 0.79 0.79 0.79 0.79 0.79 0.79 0.79 1.78 1.95 2.13 2.28 16.1 16.1 1.66 1.97 2.16 2.42 16.1 21.11 1.93 2.17 2.38 2.67 8.69 21.11 21.11 21.11

$666.56 $666.56 $1,208.50 $1,208.50 $83.12 $676.03 $669.50 $1,540.44 $1,208.50 $1,208.50 $959.50 $211.84 $456.81 $1,248.68 $1,644.04 $1,644.04 $754.95 $45.94 $179.14 $32.83 $51.80 $58.23 $58.23 $143.97 $58.23 $666.56 $76.94 $58.23 $758.45 $24.76 $8.76 $178.19 $178.19 $178.19 $22.85 $26.28 $110.14 $110.14 $284.91 $25.90 $28.95 $32.75 $32.83 $14.09 $32.83 $6.09 $32.83 $32.83 $32.83 $60.42 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $73.89 $80.74 $87.98 $94.46 $666.56 $666.56 $68.56 $81.51 $89.50 $100.17 $666.56 $873.97 $79.98 $89.89 $98.65 $110.45 $359.57 $873.97 $873.97 $873.97

$666.56 $666.56 $1,208.50 $1,208.50 $83.12 $676.03 $669.50 $1,540.44 $1,208.50 $1,208.50 $959.50 $211.84 $456.81 $1,248.68 $1,415.26 $1,415.26 $754.95 $45.94 $179.14 $32.83 $51.80 $58.23 $58.23 $143.97 $58.23 $501.14 $76.94 $58.23 $524.11 $24.76 $8.76 $233.19 $233.19 $233.19 $22.85 $26.28 $150.85 $150.85 $388.55 $25.90 $28.95 $32.75 $32.83 $14.09 $32.83 $6.09 $32.83 $32.83 $32.83 $60.42 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $32.83 $73.89 $80.74 $87.98 $94.46 $416.39 $501.14 $68.56 $81.51 $89.50 $100.17 $501.14 $552.99 $79.98 $89.89 $98.65 $110.45 $339.64 $552.99 $552.99 $552.99 Page 1 of 38

11462 11463 11470 11471 11600 11601 11602 11603 11604 11606 11620 11621 11622 11623 11624 11626 11640 11641 11642 11643 11644 11646 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 11770 11771 11772 11900 11901 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 11980 11981 11982 11983 12001 12002 12004 12005 12006 12007 12011 12013 12014 12015 12016 12017 12018 12020 12021 12031 12032 12034 12035 12036 12037 12041 12042 12044 12045 12046 12047 12051 12052 12053 12054 12055 12056 12057 13100 13101 13102 13120 13121

Removal, sweat gland lesion Removal, sweat gland lesion Removal, sweat gland lesion Removal, sweat gland lesion Exc tr-ext mlg+marg 0.5 < cm Exc tr-ext mlg+marg 0.6-1 cm Exc tr-ext mlg+marg 1.1-2 cm Exc tr-ext mlg+marg 2.1-3 cm Exc tr-ext mlg+marg 3.1-4 cm Exc tr-ext mlg+marg > 4 cm Exc h-f-nk-sp mlg+marg 0.5 < Exc h-f-nk-sp mlg+marg 0.6-1 Exc h-f-nk-sp mlg+marg 1.1-2 Exc h-f-nk-sp mlg+marg 2.1-3 Exc h-f-nk-sp mlg+marg 3.1-4 Exc h-f-nk-sp mlg+mar > 4 cm Exc face-mm malig+marg 0.5 < Exc face-mm malig+marg 0.6-1 Exc face-mm malig+marg 1.1-2 Exc face-mm malig+marg 2.1-3 Exc face-mm malig+marg 3.1-4 Exc face-mm mlg+marg > 4 cm Trim nail(s) Debride nail, 1-5 Debride nail, 6 or more Removal of nail plate Remove nail plate, add-on Drain blood from under nail Removal of nail bed Remove nail bed/finger tip Biopsy, nail unit Repair of nail bed Reconstruction of nail bed Excision of nail fold, toe Removal of pilonidal lesion Removal of pilonidal lesion Removal of pilonidal lesion Injection into skin lesions Added skin lesions injection Correct skin color defects Correct skin color defects Correct skin color defects Therapy for contour defects Therapy for contour defects Therapy for contour defects Therapy for contour defects Insert tissue expander(s) Replace tissue expander Remove tissue expander(s) Removal of contraceptive cap Implant hormone pellet(s) Insert drug implant device Remove drug implant device Remove/insert drug implant Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Repair superficial wound(s) Closure of split wound Closure of split wound Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Layer closure of wound(s) Repair of wound or lesion Repair of wound or lesion Repair wound/lesion add-on Repair of wound or lesion Repair of wound or lesion

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 P3 P3 P3 P3 A2 A2 P3 P3 P3 P3 A2 A2 P3 P3 P3 P3 A2 A2 P3 P3 P3 P2 P3 P2 P3 P3 P3 G2 P3 P2 A2 A2 A2 P3 P3 P2 P2 P3 P3 P3 P2 P2 A2 A2 A2 P3 P2 P2 P2 P2 P2 P2 P2 A2 A2 A2 P2 P2 P2 G2 A2 A2 A2 A2 A2 P2 P2 A2 A2 A2 A2 P2 P2 A2 A2 A2 A2 P2 P2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $446.00 $446.00 $446.00

$418.49 $446.00

$446.00 $446.00

$446.00 $446.00

$510.00 $510.00 $510.00

$446.00 $510.00 $333.00

$91.24 $91.24 $91.24

$91.24 $91.24 $91.24 $91.24 $91.24

$91.24 $91.24 $91.24 $323.28

$91.24 $91.24 $91.24 $323.28

$91.24 $91.24 $91.24 $323.28 $323.28 $323.28 $91.24 $91.24 $91.24

21.11 21.11 21.11 21.11 2.47 2.82 3.07 3.28 8.69 16.1 2.5 2.85 3.16 3.43 16.1 21.11 2.63 3.06 3.42 3.72 16.1 21.11 0.29 0.37 0.45 0.79 0.45 0.3 2.36 3.25 1.66 2.11 3.03 1.46 21.11 21.11 21.11 0.72 0.76 2.11 2.11 0.95 0.93 1.1 1.28 1.28 20.21 42.99 21.11 1.58 0.63 0.63 0.63 0.63 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 1.28 4.53 4.53 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 2.11 4.53 4.53 4.53 2.11 4.53

$873.97 $873.97 $873.97 $873.97 $102.45 $116.93 $127.21 $135.59 $359.57 $666.56 $103.60 $118.07 $130.64 $142.06 $666.56 $873.97 $108.93 $126.83 $141.68 $153.87 $666.56 $873.97 $11.81 $15.23 $18.66 $32.83 $18.66 $12.27 $97.50 $134.45 $68.56 $87.15 $125.31 $60.42 $873.97 $873.97 $873.97 $29.71 $31.61 $87.15 $87.15 $39.23 $38.47 $45.70 $52.96 $52.96 $836.59 $1,779.62 $873.97 $65.51 $26.12 $26.12 $26.12 $26.12 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $52.96 $187.39 $187.39 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $187.39 $187.39 $187.39 $87.15 $187.39

$552.99 $552.99 $552.99 $552.99 $102.45 $116.93 $127.21 $135.59 $403.76 $501.14 $103.60 $118.07 $130.64 $142.06 $501.14 $552.99 $108.93 $126.83 $141.68 $153.87 $501.14 $552.99 $11.81 $15.23 $18.66 $32.83 $18.66 $12.27 $97.50 $134.45 $68.56 $87.15 $125.31 $60.42 $600.99 $600.99 $600.99 $29.71 $31.61 $87.15 $87.15 $39.23 $38.47 $45.70 $52.96 $52.96 $543.65 $827.41 $468.24 $65.51 $26.12 $26.12 $26.12 $26.12 $52.96 $52.96 $52.96 $81.67 $81.67 $81.67 $52.96 $52.96 $52.96 $52.96 $81.67 $81.67 $81.67 $115.28 $115.28 $87.15 $87.15 $90.22 $90.22 $90.22 $264.25 $87.15 $87.15 $90.22 $90.22 $90.22 $264.25 $87.15 $87.15 $87.15 $90.22 $90.22 $90.22 $264.25 $289.31 $289.31 $115.28 $90.22 $115.28 Page 2 of 38

13122 13131 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15002 15003 15004 15005 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15200 15201 15220 15221 15240 15241 15260 15261 15300 15301 15320 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15431 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740 15750 15760 15770 15775 15776 15780 15781

Repair wound/lesion add-on Repair of wound or lesion Repair of wound or lesion Repair wound/lesion add-on Repair of wound or lesion Repair of wound or lesion Repair of wound or lesion Repair wound/lesion add-on Late closure of wound Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Skin tissue rearrangement Wnd prep, ch/inf, trk/arm/lg Wnd prep, ch/inf addl 100 cm Wnd prep ch/inf, f/n/hf/g Wnd prep, f/n/hf/g, addl cm Harvest cultured skin graft Skin pinch graft Skin splt grft, trnk/arm/leg Skin splt grft t/a/l, add-on Epidrm autogrft trnk/arm/leg Epidrm autogrft t/a/l add-on Epidrm a-grft face/nck/hf/g Epidrm a-grft f/n/hf/g addl Skn splt a-grft fac/nck/hf/g Skn splt a-grft f/n/hf/g add Derm autograft, trnk/arm/leg Derm autograft t/a/l add-on Derm autograft face/nck/hf/g Derm autograft, f/n/hf/g add Cult epiderm grft t/arm/leg Cult epiderm grft t/a/l addl Cult epiderm graft t/a/l +% Cult epiderm graft, f/n/hf/g Cult epidrm grft f/n/hfg add Cult epiderm grft f/n/hfg +% Skin full graft, trunk Skin full graft trunk add-on Skin full graft sclp/arm/leg Skin full graft add-on Skin full grft face/genit/hf Skin full graft add-on Skin full graft een & lips Skin full graft add-on Apply skinallogrft, t/arm/lg Apply sknallogrft t/a/l addl Apply skin allogrft f/n/hf/g Aply sknallogrft f/n/hfg add Aply acell alogrft t/arm/leg Aply acell grft t/a/l add-on Apply acell graft, f/n/hf/g Aply acell grft f/n/hf/g add Apply cult skin substitute Apply cult skin sub add-on Apply cult derm sub, t/a/l Aply cult derm sub t/a/l add Apply cult derm sub f/n/hf/g Apply cult derm f/hf/g add Apply skin xenograft, t/a/l Apply skn xenogrft t/a/l add Apply skin xgraft, f/n/hf/g Apply skn xgrft f/n/hf/g add Apply acellular xenograft Apply acellular xgraft add Form skin pedicle flap Form skin pedicle flap Form skin pedicle flap Form skin pedicle flap Skin graft Skin graft Skin graft Skin graft Transfer skin pedicle flap Forehead flap w/vasc pedicle Muscle-skin graft, head/neck Muscle-skin graft, trunk Muscle-skin graft, arm Muscle-skin graft, leg Island pedicle flap graft Neurovascular pedicle graft Composite skin graft Derma-fat-fascia graft Hair transplant punch grafts Hair transplant punch grafts Abrasion treatment of skin Abrasion treatment of skin

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P2

$91.24 $91.24 $91.24 $91.24 $323.28 $323.28 $323.28 $91.24 $446.00 $446.00 $510.00 $510.00 $510.00 $446.00 $510.00 $510.00 $510.00 $630.00 $510.00 $323.28 $323.28 $323.28 $323.28 $91.24 $323.28 $446.00 $510.00 $446.00 $333.00 $446.00 $333.00 $446.00 $510.00 $446.00 $333.00 $446.00 $333.00 $446.00 $333.00 $333.00 $446.00 $333.00 $333.00 $510.00 $323.28 $446.00 $323.28 $510.00 $323.28 $446.00 $323.28 $323.28 $323.28 $323.28 $323.28 $323.28 $323.28 $323.28 $323.28

$323.28 $323.28 $323.28 $323.28 $323.28 $323.28 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $510.00 $323.28 $323.28

2.11 4.53 4.53 4.53 4.53 4.53 4.53 2.11 20.21 15.05 15.05 15.05 15.05 15.05 15.05 15.05 15.05 20.21 20.21 4.53 4.53 4.53 4.53 2.11 4.53 20.21 20.21 4.53 4.53 4.53 4.53 20.21 20.21 15.05 15.05 15.05 15.05 4.53 4.53 4.53 4.53 4.53 4.53 15.05 15.05 15.05 4.53 15.05 4.53 15.05 15.05 4.53 4.53 4.53 4.53 4.53 4.53 4.53 4.53 2.11 2.11 2.11 2.11 2.11 2.11 4.53 4.53 4.53 4.53 4.53 4.53 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 15.05 20.21 20.21 20.21 1.28 1.28 10.47 4.3

$87.15 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $87.15 $836.59 $622.91 $622.91 $622.91 $622.91 $622.91 $622.91 $622.91 $622.91 $836.59 $836.59 $187.39 $187.39 $187.39 $187.39 $87.15 $187.39 $836.59 $836.59 $187.39 $187.39 $187.39 $187.39 $836.59 $836.59 $622.91 $622.91 $622.91 $622.91 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $622.91 $622.91 $622.91 $187.39 $622.91 $187.39 $622.91 $622.91 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $187.39 $187.39 $187.39 $187.39 $187.39 $187.39 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $622.91 $836.59 $836.59 $836.59 $52.96 $52.96 $433.43 $178.19

$90.22 $115.28 $115.28 $115.28 $289.31 $289.31 $289.31 $90.22 $543.65 $490.23 $538.23 $538.23 $538.23 $490.23 $538.23 $538.23 $538.23 $681.65 $591.65 $289.31 $289.31 $289.31 $289.31 $90.22 $289.31 $543.65 $591.65 $381.35 $296.60 $381.35 $296.60 $543.65 $591.65 $490.23 $405.48 $490.23 $405.48 $381.35 $296.60 $296.60 $381.35 $296.60 $296.60 $538.23 $398.19 $490.23 $289.31 $538.23 $289.31 $490.23 $398.19 $289.31 $289.31 $289.31 $289.31 $289.31 $289.31 $289.31 $289.31 $87.15 $87.15 $87.15 $87.15 $87.15 $87.15 $289.31 $289.31 $289.31 $289.31 $289.31 $289.31 $591.65 $591.65 $591.65 $591.65 $591.65 $591.65 $681.65 $591.65 $746.90 $591.65 $591.65 $591.65 $591.65 $591.65 $490.23 $543.65 $543.65 $591.65 $255.70 $255.70 $433.43 $178.19 Page 3 of 38

15782 15783 15786 15787 15788 15789 15792 15793 15819 15820 15821 15822 15823 15824 15825 15826 15828 15829 15830 15832 15833 15834 15835 15836 15837 15838 15839 15840 15841 15842 15845 15847 15850 15851 15852 15860 15876 15877 15878 15879 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 15946 15950 15951 15952 15953 15956 15958 16000 16020 16025 16030 16035 17000 17003 17004 17106 17107 17108 17110 17111 17250 17260 17261 17262 17263 17264 17266 17270 17271 17272 17273 17274 17276 17280 17281 17282 17283 17284 17286 17311 17312

Abrasion treatment of skin Abrasion treatment of skin Abrasion, lesion, single Abrasion, lesions, add-on Chemical peel, face, epiderm Chemical peel, face, dermal Chemical peel, nonfacial Chemical peel, nonfacial Plastic surgery, neck Revision of lower eyelid Revision of lower eyelid Revision of upper eyelid Revision of upper eyelid Removal of forehead wrinkles Removal of neck wrinkles Removal of brow wrinkles Removal of face wrinkles Removal of skin wrinkles Exc skin abd Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Excise excessive skin tissue Graft for face nerve palsy Graft for face nerve palsy Flap for face nerve palsy Skin and muscle repair, face Exc skin abd add-on Removal of sutures Removal of sutures Dressing change not for burn Test for blood flow in graft Suction assisted lipectomy Suction assisted lipectomy Suction assisted lipectomy Suction assisted lipectomy Removal of tail bone ulcer Removal of tail bone ulcer Remove sacrum pressure sore Remove sacrum pressure sore Remove sacrum pressure sore Remove sacrum pressure sore Remove sacrum pressure sore Remove sacrum pressure sore Remove hip pressure sore Remove hip pressure sore Remove hip pressure sore Remove hip pressure sore Remove hip pressure sore Remove thigh pressure sore Remove thigh pressure sore Remove thigh pressure sore Remove thigh pressure sore Remove thigh pressure sore Remove thigh pressure sore Initial treatment of burn(s) Dress/debrid p-thick burn, s Dress/debrid p-thick burn, m Dress/debrid p-thick burn, l Incision of burn scab, initi Destruct premalg lesion Destruct premalg les, 2-14 Destroy premlg lesions 15+ Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruct b9 lesion, 1-14 Destruct lesion, 15 or more Chemical cautery, tissue Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Destruction of skin lesions Mohs, 1 stage, h/n/hf/g Mohs addl stage

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P2 P2 P2 P2 P2 P2 P2 P2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 A2 A2 A2 G2 A2 A2 G2 P3 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 A2 A2 G2 P2 P3 P3 P2 P2 P2 P2 P2 P3 P3 P2 P2 P2 P2 P2 P2 P2 P2 P3 P2 P2 P2 P3 P3 P2 P2 P2 P2 P2

$510.00 $510.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $323.28 $510.00

$510.00 $630.00 $630.00 $630.00 $510.00

$510.00 $510.00 $510.00 $510.00 $251.52 $630.00 $510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $510.00 $510.00 $510.00 $630.00 $630.00 $510.00 $630.00 $510.00 $630.00 $510.00 $630.00

$67.11 $99.83

4.3 2.66 0.79 0.79 0.79 1.46 1.46 0.79 2.11 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 20.21 21.11 21.11 21.11 21.11 21.11 16.1 16.1 16.1 16.1 20.21 20.21 20.21 20.21 21.11 2.66 1.39 0.63 0.63 20.21 20.21 20.21 20.21 4.3 20.21 21.11 21.11 20.21 20.21 15.05 20.21 21.11 21.11 20.21 20.21 20.21 21.11 21.11 15.05 15.05 15.05 15.05 0.73 1.1 2.66 2.66 2.66 0.79 0.1 2.18 2.66 2.66 2.66 0.79 1.46 1.17 1.23 1.46 1.46 1.46 1.46 2.66 1.46 1.46 1.46 2.49 2.66 2.66 1.46 2.13 2.44 2.66 2.66 2.66 3.63 3.63

$178.19 $110.14 $32.83 $32.83 $32.83 $60.42 $60.42 $32.83 $87.15 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $836.59 $873.97 $873.97 $873.97 $873.97 $873.97 $666.56 $666.56 $666.56 $666.56 $836.59 $836.59 $836.59 $836.59 $873.97 $110.14 $57.51 $26.12 $26.12 $836.59 $836.59 $836.59 $836.59 $178.19 $836.59 $873.97 $873.97 $836.59 $836.59 $622.91 $836.59 $873.97 $873.97 $836.59 $836.59 $836.59 $873.97 $873.97 $622.91 $622.91 $622.91 $622.91 $30.09 $45.70 $110.14 $110.14 $110.14 $32.83 $4.19 $90.27 $110.14 $110.14 $110.14 $32.83 $60.42 $48.37 $51.04 $60.42 $60.42 $60.42 $60.42 $110.14 $60.42 $60.42 $60.42 $103.22 $110.14 $110.14 $60.42 $88.36 $100.93 $110.14 $110.14 $110.14 $150.37 $150.37

$178.19 $110.14 $32.83 $32.83 $32.83 $60.42 $60.42 $32.83 $87.15 $591.65 $591.65 $591.65 $746.90 $591.65 $591.65 $591.65 $591.65 $746.90 $600.99 $600.99 $600.99 $600.99 $460.95 $549.14 $666.56 $666.56 $549.14 $681.65 $681.65 $836.59 $681.65 $600.99 $110.14 $57.51 $26.12 $26.12 $591.65 $591.65 $591.65 $591.65 $233.19 $681.65 $600.99 $600.99 $591.65 $681.65 $628.23 $681.65 $600.99 $600.99 $591.65 $681.65 $681.65 $600.99 $690.99 $538.23 $628.23 $538.23 $628.23 $30.09 $45.70 $77.87 $102.41 $110.14 $32.83 $4.19 $90.27 $110.14 $110.14 $110.14 $32.83 $60.42 $48.37 $51.04 $60.42 $60.42 $60.42 $60.42 $110.14 $60.42 $60.42 $60.42 $103.22 $110.14 $110.14 $60.42 $88.36 $100.93 $110.14 $110.14 $110.14 $150.37 $150.37 Page 4 of 38

17313 17314 17315 17340 17360 17380 19000 19001 19020 19030 19100 19101 19102 19103 19105 19110 19112 19120 19125 19126 19290 19291 19295 19296 19297 19298 19300 19301 19302 19303 19304 19316 19318 19324 19325 19328 19330 19340 19342 19350 19355 19357 19366 19370 19371 19380 19396 20000 20005 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20500 20501 20520 20525 20526 20550 20551 20552 20553 20555 20600 20605 20610 20612 20615 20650 20662 20663 20665 20670 20680 20690 20692 20693 20694 20822 20900 20902 20910 20912 20920 20922 20924

Mohs, 1 stage, t/a/l Mohs, addl stage, t/a/l Mohs surg, addl block Cryotherapy of skin Skin peel therapy Hair removal by electrolysis Drainage of breast lesion Drain breast lesion add-on Incision of breast lesion Injection for breast x-ray Bx breast percut w/o image Biopsy of breast, open Bx breast percut w/image Bx breast percut w/device Cryosurg ablate fa, each Nipple exploration Excise breast duct fistula Removal of breast lesion Excision, breast lesion Excision, addl breast lesion Place needle wire, breast Place needle wire, breast Place breast clip, percut Place po breast cath for rad Place breast cath for rad Place breast rad tube/caths Removal of breast tissue Partical mastectomy P-mastectomy w/ln removal Mast, simple, complete Mast, subq Suspension of breast Reduction of large breast Enlarge breast Enlarge breast with implant Removal of breast implant Removal of implant material Immediate breast prosthesis Delayed breast prosthesis Breast reconstruction Correct inverted nipple(s) Breast reconstruction Breast reconstruction Surgery of breast capsule Removal of breast capsule Revise breast reconstruction Design custom breast implant Incision of abscess Incision of deep abscess Explore wound, extremity Excise epiphyseal bar Muscle biopsy Deep muscle biopsy Needle biopsy, muscle Bone biopsy, trocar/needle Bone biopsy, trocar/needle Bone biopsy, excisional Bone biopsy, excisional Open bone biopsy Open bone biopsy Injection of sinus tract Inject sinus tract for x-ray Removal of foreign body Removal of foreign body Ther injection, carp tunnel Inj tendon sheath/ligament Inj tendon origin/insertion Inj trigger point, 1/2 muscl Inject trigger points, =/> 3 Place ndl musc/tis for rt Drain/inject, joint/bursa Drain/inject, joint/bursa Drain/inject, joint/bursa Aspirate/inj ganglion cyst Treatment of bone cyst Insert and remove bone pin Application of pelvis brace Application of thigh brace Removal of fixation device Removal of support implant Removal of support implant Apply bone fixation device Apply bone fixation device Adjust bone fixation device Remove bone fixation device Replantation digit, complete Removal of bone for graft Removal of bone for graft Remove cartilage for graft Remove cartilage for graft Removal of fascia for graft Removal of fascia for graft Removal of tendon for graft

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P2 P2 P3 P3 P2 R2 P3 P3 A2 N1 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 N1 N1 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 P2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 N1 P3 A2 P3 P3 P3 P3 P3 G2 P3 P3 P3 P3 P3 A2 R2 R2 G2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2

$446.00 $240.00 $446.00 $240.00 $395.77 $446.00 $510.00 $510.00 $510.00 $510.00

$1,339.00 $1,339.00 $1,339.00 $630.00 $510.00 $995.00 $630.00 $630.00 $630.00 $630.00 $630.00 $1,339.00 $333.00 $333.00 $446.00 $510.00 $630.00 $630.00 $717.00 $717.00 $630.00 $630.00 $717.00

$446.00

$446.00 $510.00 $240.00 $251.52 $418.49 $446.00 $510.00 $510.00 $510.00

$510.00

$510.00

$333.00 $510.00 $446.00 $510.00 $510.00 $333.00 $510.00 $630.00 $510.00 $510.00 $630.00 $510.00 $630.00

3.63 3.63 1.05 0.33 0.79 0.79 1.79 0.23 18.32

$150.37 $150.37 $43.42 $13.71 $32.83 $32.83 $74.27 $9.52 $758.45

$150.37 $150.37 $43.42 $13.71 $32.83 $32.83 $74.27 $9.52 $524.11

4.33 20.64 7.11 13.58 31.71 20.64 20.64 20.64 20.64 20.64

$179.14 $854.59 $294.56 $562.08 $1,312.97 $854.59 $854.59 $854.59 $854.59 $854.59

$224.79 $548.15 $253.64 $437.35 $1,312.97 $548.15 $596.15 $596.15 $596.15 $596.15

56.58 56.58 56.58 20.64 20.64 39.82 31.71 31.71 31.71 39.82 39.82 56.58 31.71 31.71 39.82 56.58 20.64 31.71 56.58 31.71 31.71 31.71 39.82 31.71 1.41 21.27 9.63 42.99 16.1 16.1 7.11 8.69 8.69 21.11 21.11 21.27 21.27 1.66

$2,342.36 $2,342.36 $2,342.36 $854.59 $854.59 $1,648.55 $1,312.97 $1,312.97 $1,312.97 $1,648.55 $1,648.55 $2,342.36 $1,312.97 $1,312.97 $1,648.55 $2,342.36 $854.59 $1,312.97 $2,342.36 $1,312.97 $1,312.97 $1,312.97 $1,648.55 $1,312.97 $58.23 $880.55 $398.86 $1,779.62 $666.56 $666.56 $294.56 $359.57 $359.57 $873.97 $873.97 $880.55 $880.55 $68.56

$1,589.84 $1,589.84 $1,589.84 $686.15 $596.15 $1,158.39 $800.74 $800.74 $800.74 $884.64 $884.64 $1,589.84 $577.99 $577.99 $746.64 $968.09 $686.15 $800.74 $1,123.34 $865.99 $800.74 $800.74 $949.89 $1,312.97 $58.23 $554.64 $398.86 $1,779.62 $501.14 $549.14 $253.64 $278.53 $403.76 $552.99 $600.99 $602.64 $602.64 $68.56

2.54 21.11 0.82 0.62 0.61 0.6 0.67 29.19 0.61 0.69 0.93 0.64 2.86 21.27 21.27 21.27 0.63 16.1 21.11 29.19 29.19 21.27 21.27 26.31 29.19 29.19 20.21 20.21 15.05 15.05 29.19

$105.12 $873.97 $33.90 $25.52 $25.14 $24.76 $27.80 $1,208.50 $25.14 $28.57 $38.47 $26.66 $118.45 $880.55 $880.55 $880.55 $26.12 $666.56 $873.97 $1,208.50 $1,208.50 $880.55 $880.55 $1,089.28 $1,208.50 $1,208.50 $836.59 $836.59 $622.91 $622.91 $1,208.50

$105.12 $600.99 $33.90 $25.52 $25.14 $24.76 $27.80 $1,208.50 $25.14 $28.57 $38.47 $26.66 $118.45 $602.64 $880.55 $880.55 $26.12 $416.39 $600.99 $636.63 $684.63 $602.64 $469.89 $1,089.28 $684.63 $774.63 $591.65 $591.65 $628.23 $538.23 $774.63 Page 5 of 38

20926 20950 20972 20973 20975 20979 20982 20985 20986 20987 21010 21015 21025 21026 21029 21030 21031 21032 21034 21040 21044 21046 21047 21048 21050 21060 21070 21073* 21076 21077 21079 21080 21081 21082 21083 21084 21085 21086 21087 21088 21100 21110 21116 21120 21121 21122 21123 21125 21127 21137 21138 21139 21150 21181 21198 21199 21206 21208 21209 21210 21215 21230 21235 21240 21242 21243 21244 21245 21246 21248 21249 21260 21267 21270 21275 21280 21282 21295 21296 21310 21315 21320 21325 21330 21335 21336 21337 21338 21339 21340 21345 21355 21356

Removal of tissue for graft Fluid pressure, muscle Bone/skin graft, metatarsal Bone/skin graft, great toe Electrical bone stimulation Us bone stimulation Ablate, bone tumor(s) perq Cptr-asst dir ms px Cptr-asst dir ms px io img Cptr-asst dir ms px pre img Incision of jaw joint Resection of facial tumor Excision of bone, lower jaw Excision of facial bone(s) Contour of face bone lesion Excise max/zygoma b9 tumor Remove exostosis, mandible Remove exostosis, maxilla Excise max/zygoma mlg tumor Excise mandible lesion Removal of jaw bone lesion Remove mandible cyst complex Excise lwr jaw cyst w/repair Remove maxilla cyst complex Removal of jaw joint Remove jaw joint cartilage Remove coronoid process Mnpj of tmj w/anesth Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Prepare face/oral prosthesis Maxillofacial fixation Interdental fixation Injection, jaw joint x-ray Reconstruction of chin Reconstruction of chin Reconstruction of chin Reconstruction of chin Augmentation, lower jaw bone Augmentation, lower jaw bone Reduction of forehead Reduction of forehead Reduction of forehead Reconstruct midface, lefort Contour cranial bone lesion Reconstr lwr jaw segment Reconstr lwr jaw w/advance Reconstruct upper jaw bone Augmentation of facial bones Reduction of facial bones Face bone graft Lower jaw bone graft Rib cartilage graft Ear cartilage graft Reconstruction of jaw joint Reconstruction of jaw joint Reconstruction of jaw joint Reconstruction of lower jaw Reconstruction of jaw Reconstruction of jaw Reconstruction of jaw Reconstruction of jaw Revise eye sockets Revise eye sockets Augmentation, cheek bone Revision, orbitofacial bones Revision of eyelid Revision of eyelid Revision of jaw muscle/bone Revision of jaw muscle/bone Treatment of nose fracture Treatment of nose fracture Treatment of nose fracture Treatment of nose fracture Treatment of nose fracture Treatment of nose fracture Treat nasal septal fracture Treat nasal septal fracture Treat nasoethmoid fracture Treat nasoethmoid fracture Treatment of nose fracture Treat nose/jaw fracture Treat cheek bone fracture Treat cheek bone fracture

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y N N Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 G2 G2 R2 N1 P2 G2 N1 N1 N1 A2 A2 A2 A2 A2 P3 P3 P3 A2 A2 A2 A2 A2 R2 A2 A2 A2 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 R2 A2 P2 N1 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$630.00

$446.00 $510.00 $446.00 $446.00 $446.00

$510.00 $446.00 $446.00 $446.00 $446.00 $510.00 $446.00 $510.00

$446.00

$995.00 $995.00 $995.00 $995.00 $995.00 $1,339.00

$995.00

$717.00 $995.00 $717.00 $995.00 $995.00 $995.00 $995.00 $630.00 $717.00 $717.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $717.00 $995.00 $717.00 $717.00 $333.00 $333.00 $150.72 $150.72 $446.00 $630.00 $717.00 $995.00 $630.00 $446.00 $630.00 $717.00 $630.00 $995.00 $510.00 $510.00

4.53 1.41 44.27 44.27

$187.39 $58.23 $1,832.77 $1,832.77

$519.35 $58.23 $1,832.77 $1,832.77

0.63 42.99

$26.12 $1,779.62

$26.12 $1,779.62

23.98 16.33 39.88 39.88 39.88 6.22 5.1 5.24 39.88 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 5.06 9.37 22.9 16.32 18.7 17.18 15.76 15.51 18.08 7 16.87 16.72 39.88 39.88 7.45

$992.65 $676.03 $1,650.97 $1,650.97 $1,650.97 $257.47 $211.00 $217.10 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $209.48 $388.11 $947.99 $675.66 $774.31 $711.08 $652.43 $642.15 $748.41 $289.84 $698.52 $692.04 $1,650.97 $1,650.97 $308.33

$582.66 $551.51 $747.24 $747.24 $747.24 $257.47 $211.00 $217.10 $795.24 $582.66 $747.24 $747.24 $747.24 $1,650.97 $795.24 $747.24 $795.24 $209.48 $388.11 $947.99 $675.66 $774.31 $711.08 $652.43 $642.15 $748.41 $289.84 $698.52 $692.04 $1,650.97 $747.24 $308.33

23.98 23.98 23.98 23.98 23.98 39.88 23.98 39.88 39.88 39.88 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 16.33 7.45 23.98 2.5 2.5 16.33 23.98 23.98 23.98 26.16 16.33 23.98 23.98 39.88 23.98 39.88 23.98

$992.65 $992.65 $992.65 $992.65 $992.65 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $676.03 $308.33 $992.65 $103.51 $103.51 $676.03 $992.65 $992.65 $992.65 $1,083.02 $676.03 $992.65 $992.65 $1,650.97 $992.65 $1,650.97 $992.65

$994.41 $994.41 $994.41 $994.41 $994.41 $1,416.99 $992.65 $1,650.97 $1,650.97 $1,650.97 $994.41 $1,650.97 $1,650.97 $950.49 $1,158.99 $950.49 $1,158.99 $1,158.99 $1,158.99 $994.41 $885.24 $950.49 $950.49 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,650.97 $1,158.99 $950.49 $1,158.99 $950.49 $706.76 $326.83 $497.91 $138.92 $138.92 $503.51 $720.66 $785.91 $994.41 $743.26 $503.51 $720.66 $785.91 $885.24 $994.41 $795.24 $630.66 Page 6 of 38

21360 21390 21400 21401 21406 21407 21421 21440 21445 21450 21451 21452 21453 21454 21461 21462 21465 21480 21485 21490 21495 21497 21501 21502 21550 21555 21556 21557 21600 21610 21685 21700 21720 21725 21800 21805 21820 21920 21925 21930 21935 22102 22103 22305 22310 22315 22505 22520 22521 22522 22523 22524 22525 22526 22527 22900 23000 23020 23030 23031 23035 23040 23044 23065 23066 23075 23076 23077 23100 23101 23105 23106 23107 23120 23125 23130 23140 23145 23146 23150 23155 23156 23170 23172 23174 23180 23182 23184 23190 23195 23330 23331 23350

Treat cheek bone fracture Treat eye socket fracture Treat eye socket fracture Treat eye socket fracture Treat eye socket fracture Treat eye socket fracture Treat mouth roof fracture Treat dental ridge fracture Treat dental ridge fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Treat lower jaw fracture Reset dislocated jaw Reset dislocated jaw Repair dislocated jaw Treat hyoid bone fracture Interdental wiring Drain neck/chest lesion Drain chest lesion Biopsy of neck/chest Remove lesion, neck/chest Remove lesion, neck/chest Remove tumor, neck/chest Partial removal of rib Partial removal of rib Hyoid myotomy & suspension Revision of neck muscle Revision of neck muscle Revision of neck muscle Treatment of rib fracture Treatment of rib fracture Treat sternum fracture Biopsy soft tissue of back Biopsy soft tissue of back Remove lesion, back or flank Remove tumor, back Remove part, lumbar vertebra Remove extra spine segment Treat spine process fracture Treat spine fracture Treat spine fracture Manipulation of spine Percut vertebroplasty thor Percut vertebroplasty lumb Percut vertebroplasty add’l Percut kyphoplasty, thor Percut kyphoplasty, lumbar Percut kyphoplasty, add-on Idet, single level Idet, 1 or more levels Remove abdominal wall lesion Removal of calcium deposits Release shoulder joint Drain shoulder lesion Drain shoulder bursa Drain shoulder bone lesion Exploratory shoulder surgery Exploratory shoulder surgery Biopsy shoulder tissues Biopsy shoulder tissues Removal of shoulder lesion Removal of shoulder lesion Remove tumor of shoulder Biopsy of shoulder joint Shoulder joint surgery Remove shoulder joint lining Incision of collarbone joint Explore treat shoulder joint Partial removal, collar bone Removal of collar bone Remove shoulder bone, part Removal of bone lesion Removal of bone lesion Removal of bone lesion Removal of humerus lesion Removal of humerus lesion Removal of humerus lesion Remove collar bone lesion Remove shoulder blade lesion Remove humerus lesion Remove collar bone lesion Remove shoulder blade lesion Remove humerus lesion Partial removal of scapula Removal of head of humerus Remove shoulder foreign body Remove shoulder foreign body Injection for shoulder x-ray

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N

G2 G2 A2 A2 G2 G2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 G2 A2 A2 G2 A2 A2 G2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1

$446.00 $510.00

$630.00 $630.00 $150.72 $464.15 $446.00 $510.00 $717.00 $630.00 $717.00 $630.00 $150.72 $446.00 $510.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $88.46 $103.62 $446.00 $103.62 $446.00 $446.00 $510.00

$103.62 $103.62 $103.62 $446.00 $1,339.00 $1,339.00 $1,339.00

$630.00 $446.00 $446.00 $333.00 $510.00 $510.00 $510.00 $630.00 $446.00 $446.00 $446.00 $510.00 $446.00 $995.00 $630.00 $630.00 $630.00 $717.00 $717.00 $717.00 $630.00 $717.00 $717.00 $630.00 $717.00 $717.00 $446.00 $446.00 $446.00 $630.00 $630.00 $630.00 $630.00 $717.00 $333.00 $333.00

23.98 39.88 7.45 16.33 39.88 39.88 23.98 7.9 23.98 2.5 7.45 16.33 39.88 23.98 39.88 39.88 39.88 2.5 16.33 39.88 16.33 16.33 18.32 21.27 8.69 21.11 21.11 21.11 29.19 29.19 7.45 21.27 21.27 1.41 1.77 26.16 1.77 3.55 21.11 21.11 21.11 46.77 46.77 1.77 1.77 1.77 14.77 29.19 29.19 29.19 79.42 79.42 79.42 29.19 29.19 21.11 16.1 42.99 18.32 18.32 21.27 29.19 29.19 2.5 21.11 16.1 21.11 21.11 21.27 29.19 29.19 29.19 29.19 29.19 29.19 42.99 21.27 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 8.69 21.11

$992.65 $1,650.97 $308.33 $676.03 $1,650.97 $1,650.97 $992.65 $327.17 $992.65 $103.51 $308.33 $676.03 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $103.51 $676.03 $1,650.97 $676.03 $676.03 $758.45 $880.55 $359.57 $873.97 $873.97 $873.97 $1,208.50 $1,208.50 $308.33 $880.55 $880.55 $58.23 $73.21 $1,083.02 $73.21 $147.02 $873.97 $873.97 $873.97 $1,936.42 $1,936.42 $73.21 $73.21 $73.21 $611.32 $1,208.50 $1,208.50 $1,208.50 $3,288.25 $3,288.25 $3,288.25 $1,208.50 $1,208.50 $873.97 $666.56 $1,779.62 $758.45 $758.45 $880.55 $1,208.50 $1,208.50 $103.60 $873.97 $666.56 $873.97 $873.97 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,779.62 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $359.57 $873.97

$992.65 $1,650.97 $411.58 $551.51 $1,650.97 $1,650.97 $720.66 $327.17 $720.66 $138.92 $425.20 $503.51 $795.24 $785.91 $885.24 $950.49 $885.24 $138.92 $503.51 $795.24 $676.03 $503.51 $524.11 $554.64 $359.57 $552.99 $552.99 $873.97 $636.63 $636.63 $308.33 $554.64 $602.64 $80.90 $96.02 $605.26 $96.02 $147.02 $552.99 $552.99 $600.99 $1,936.42 $1,936.42 $96.02 $96.02 $96.02 $487.33 $1,306.38 $1,306.38 $1,306.38 $3,288.25 $3,288.25 $3,288.25 $1,208.50 $1,208.50 $690.99 $501.14 $779.41 $439.36 $572.11 $602.64 $684.63 $774.63 $103.60 $552.99 $501.14 $552.99 $600.99 $554.64 $1,048.38 $774.63 $774.63 $774.63 $839.88 $839.88 $982.66 $692.64 $839.88 $839.88 $774.63 $839.88 $839.88 $636.63 $636.63 $636.63 $774.63 $774.63 $774.63 $774.63 $839.88 $339.64 $468.24

Page 7 of 38

23395 23397 23400 23405 23406 23410 23412 23415 23420 23430 23440 23450 23455 23460 23462 23465 23466 23480 23485 23490 23491 23500 23505 23515 23520 23525 23530 23532 23540 23545 23550 23552 23570 23575 23585 23600 23605 23615 23616 23620 23625 23630 23650 23655 23660 23665 23670 23675 23680 23700 23800 23802 23921 23930 23931 23935 24000 24006 24065 24066 24075 24076 24077 24100 24101 24102 24105 24110 24115 24116 24120 24125 24126 24130 24134 24136 24138 24140 24145 24147 24149 24152 24153 24155 24160 24164 24200 24201 24220 24300 24301 24305 24310

Muscle transfer,shoulder/arm Muscle transfers Fixation of shoulder blade Incision of tendon & muscle Incise tendon(s) & muscle(s) Repair rotator cuff, acute Repair rotator cuff, chronic Release of shoulder ligament Repair of shoulder Repair biceps tendon Remove/transplant tendon Repair shoulder capsule Repair shoulder capsule Repair shoulder capsule Repair shoulder capsule Repair shoulder capsule Repair shoulder capsule Revision of collar bone Revision of collar bone Reinforce clavicle Reinforce shoulder bones Treat clavicle fracture Treat clavicle fracture Treat clavicle fracture Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat clavicle dislocation Treat shoulder blade fx Treat shoulder blade fx Treat scapula fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat shoulder dislocation Treat shoulder dislocation Treat shoulder dislocation Treat dislocation/fracture Treat dislocation/fracture Treat dislocation/fracture Treat dislocation/fracture Fixation of shoulder Fusion of shoulder joint Fusion of shoulder joint Amputation follow-up surgery Drainage of arm lesion Drainage of arm bursa Drain arm/elbow bone lesion Exploratory elbow surgery Release elbow joint Biopsy arm/elbow soft tissue Biopsy arm/elbow soft tissue Remove arm/elbow lesion Remove arm/elbow lesion Remove tumor of arm/elbow Biopsy elbow joint lining Explore/treat elbow joint Remove elbow joint lining Removal of elbow bursa Remove humerus lesion Remove/graft bone lesion Remove/graft bone lesion Remove elbow lesion Remove/graft bone lesion Remove/graft bone lesion Removal of head of radius Removal of arm bone lesion Remove radius bone lesion Remove elbow bone lesion Partial removal of arm bone Partial removal of radius Partial removal of elbow Radical resection of elbow Extensive radius surgery Extensive radius surgery Removal of elbow joint Remove elbow joint implant Remove radius head implant Removal of arm foreign body Removal of arm foreign body Injection for elbow x-ray Manipulate elbow w/anesth Muscle/tendon transfer Arm tendon lengthening Revision of arm tendon

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 A2 A2 A2 P3 A2 N1 G2 A2 A2 A2

$717.00 $995.00 $995.00 $446.00 $446.00 $717.00 $995.00 $717.00 $995.00 $630.00 $630.00 $717.00 $995.00 $717.00 $995.00 $717.00 $995.00 $630.00 $995.00 $510.00 $510.00 $103.62 $103.62 $510.00 $103.62 $103.62 $510.00 $630.00 $103.62 $103.62 $510.00 $630.00 $103.62 $103.62 $510.00

$446.00

42.99 79.42 29.19 29.19 29.19 42.99 42.99 42.99 42.99 42.99 42.99 79.42 79.42 79.42 42.99 79.42 42.99 42.99 79.42 42.99 79.42 1.77 1.77 59.22 1.77 1.77 41.11 26.16 1.77 1.77 41.11 41.11 1.77 1.77 59.22 1.77 1.77 59.22 59.22 1.77 1.77 59.22 1.77 14.77 41.11 1.77 59.22 1.77 41.11 14.77 79.42 42.99 15.05 18.32 18.32 21.27 29.19 29.19 3.39 16.1 16.1 21.11 21.11 21.27 29.19 29.19 21.27 21.27 29.19 29.19 21.27 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 42.99 79.42 42.99 29.19 29.19 2.83 16.1

$1,779.62 $3,288.25 $1,208.50 $1,208.50 $1,208.50 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $3,288.25 $3,288.25 $3,288.25 $1,779.62 $3,288.25 $1,779.62 $1,779.62 $3,288.25 $1,779.62 $3,288.25 $73.21 $73.21 $2,451.90 $73.21 $73.21 $1,701.96 $1,083.02 $73.21 $73.21 $1,701.96 $1,701.96 $73.21 $73.21 $2,451.90 $73.21 $73.21 $2,451.90 $2,451.90 $73.21 $73.21 $2,451.90 $73.21 $611.32 $1,701.96 $73.21 $2,451.90 $73.21 $1,701.96 $611.32 $3,288.25 $1,779.62 $622.91 $758.45 $758.45 $880.55 $1,208.50 $1,208.50 $140.16 $666.56 $666.56 $873.97 $873.97 $880.55 $1,208.50 $1,208.50 $880.55 $880.55 $1,208.50 $1,208.50 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,779.62 $3,288.25 $1,779.62 $1,208.50 $1,208.50 $117.31 $666.56

$982.66 $1,568.31 $1,048.38 $636.63 $636.63 $982.66 $1,191.16 $982.66 $1,191.16 $917.41 $917.41 $1,359.81 $1,568.31 $1,359.81 $1,191.16 $1,359.81 $1,191.16 $917.41 $1,568.31 $827.41 $1,204.56 $96.02 $96.02 $995.48 $96.02 $96.02 $807.99 $743.26 $96.02 $96.02 $807.99 $897.99 $96.02 $96.02 $995.48 $73.21 $96.02 $1,085.48 $1,085.48 $73.21 $96.02 $1,150.73 $96.02 $402.58 $807.99 $96.02 $995.48 $96.02 $807.99 $402.58 $1,294.56 $1,191.16 $398.19 $439.36 $524.11 $554.64 $774.63 $774.63 $140.16 $501.14 $501.14 $552.99 $600.99 $469.89 $774.63 $774.63 $602.64 $554.64 $684.63 $684.63 $602.64 $684.63 $684.63 $684.63 $636.63 $636.63 $636.63 $684.63 $684.63 $636.63 $1,208.50 $1,779.62 $3,288.25 $827.41 $636.63 $684.63 $117.31 $501.14

$630.00 $630.00 $510.00

14.77 29.19 29.19 21.27

$611.32 $1,208.50 $1,208.50 $880.55

$611.32 $774.63 $774.63 $602.64

$103.62 $630.00 $630.00 $103.62 $717.00 $103.62 $333.00 $510.00 $103.62 $510.00 $103.62 $510.00 $333.00 $630.00 $995.00 $323.28 $333.00 $446.00 $446.00 $630.00 $630.00 $446.00 $446.00 $446.00 $510.00 $333.00 $630.00 $630.00 $510.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $510.00 $510.00 $446.00

$510.00 $446.00 $510.00

Page 8 of 38

24320 24330 24331 24332 24340 24341 24342 24343 24344 24345 24346 24350 24351 24352 24354 24356 24357 24358 24359 24360 24361 24362 24363 24365 24366 24400 24410 24420 24430 24435 24470 24495 24498 24500 24505 24515 24516 24530 24535 24538 24545 24546 24560 24565 24566 24575 24576 24577 24579 24582 24586 24587 24600 24605 24615 24620 24635 24640 24650 24655 24665 24666 24670 24675 24685 24800 24802 24925 25000 25001 25020 25023 25024 25025 25028 25031 25035 25040 25065 25066 25075 25076 25077 25085 25100 25101 25105 25107 25109 25110 25111 25112 25115

Repair of arm tendon Revision of arm muscles Revision of arm muscles Tenolysis, triceps Repair of biceps tendon Repair arm tendon/muscle Repair of ruptured tendon Repr elbow lat ligmnt w/tiss Reconstruct elbow lat ligmnt Repr elbw med ligmnt w/tissu Reconstruct elbow med ligmnt Repair of tennis elbow Repair of tennis elbow Repair of tennis elbow Repair of tennis elbow Revision of tennis elbow Repair elbow, perc Repair elbow w/deb, open Repair elbow deb/attch open Reconstruct elbow joint Reconstruct elbow joint Reconstruct elbow joint Replace elbow joint Reconstruct head of radius Reconstruct head of radius Revision of humerus Revision of humerus Revision of humerus Repair of humerus Repair humerus with graft Revision of elbow joint Decompression of forearm Reinforce humerus Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat humerus fracture Treat elbow fracture Treat elbow fracture Treat elbow dislocation Treat elbow dislocation Treat elbow dislocation Treat elbow fracture Treat elbow fracture Treat elbow dislocation Treat radius fracture Treat radius fracture Treat radius fracture Treat radius fracture Treat ulnar fracture Treat ulnar fracture Treat ulnar fracture Fusion of elbow joint Fusion/graft of elbow joint Amputation follow-up surgery Incision of tendon sheath Incise flexor carpi radialis Decompress forearm 1 space Decompress forearm 1 space Decompress forearm 2 spaces Decompress forearm 2 spaces Drainage of forearm lesion Drainage of forearm bursa Treat forearm bone lesion Explore/treat wrist joint Biopsy forearm soft tissues Biopsy forearm soft tissues Removal forearm lesion subcu Removal forearm lesion deep Remove tumor, forearm/wrist Incision of wrist capsule Biopsy of wrist joint Explore/treat wrist joint Remove wrist joint lining Remove wrist joint cartilage Excise tendon forearm/wrist Remove wrist tendon lesion Remove wrist tendon lesion Reremove wrist tendon lesion Remove wrist/forearm lesion

Date Printed: 10/18/2008 @ 17:45:59

Y Y Y Y Y Y Y Y Y Y Y N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 G2 A2 A2 A2 G2 G2 A2 G2 D5 D5 D5 D5 D5 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2

$510.00 $510.00 $510.00 $510.00 $510.00 $510.00

$446.00

$717.00 $717.00 $717.00 $995.00 $717.00 $717.00 $630.00 $630.00 $510.00 $510.00 $630.00 $510.00 $446.00 $510.00 $103.62 $103.62 $630.00 $630.00 $103.62 $103.62 $446.00 $630.00 $717.00 $103.62 $103.62 $446.00 $510.00 $103.62 $103.62 $510.00 $446.00 $630.00 $717.00 $103.62 $446.00 $510.00 $103.62 $510.00

$103.62 $630.00 $630.00 $103.62 $103.62 $510.00 $630.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $333.00 $446.00 $446.00 $717.00 $446.00 $446.00 $510.00 $510.00 $510.00 $446.00 $510.00 $630.00 $510.00 $510.00 $510.00 $630.00 $630.00

42.99 79.42 42.99 21.27 42.99 42.99 42.99 29.19 79.42 29.19 42.99

$1,779.62 $3,288.25 $1,779.62 $880.55 $1,779.62 $1,779.62 $1,779.62 $1,208.50 $3,288.25 $1,208.50 $1,779.62

$827.41 $1,204.56 $827.41 $880.55 $827.41 $827.41 $827.41 $1,208.50 $3,288.25 $636.63 $1,779.62

29.19 29.19 29.19 35.9 122.21 50.89 122.21 35.9 122.21 29.19 29.19 42.99 79.42 79.42 42.99 29.19 79.42 1.77 1.77 59.22 59.22 1.77 1.77 26.16 59.22 59.22 1.77 1.77 26.16 59.22 1.77 1.77 59.22 26.16 59.22 59.22 1.77 14.77 59.22 1.77 59.22 1.55 1.77 1.77 41.11 59.22 1.77 1.77 41.11 42.99 42.99 21.27 21.27 21.27 21.27 29.19 29.19 29.19 21.27 21.27 21.27 29.19 3.48 21.11 16.1 21.11 21.11 21.27 21.27 29.19 29.19 29.19 21.27 21.27 16.46 16.46 21.27

$1,208.50 $1,208.50 $1,208.50 $1,486.46 $5,059.44 $2,106.80 $5,059.44 $1,486.46 $5,059.44 $1,208.50 $1,208.50 $1,779.62 $3,288.25 $3,288.25 $1,779.62 $1,208.50 $3,288.25 $73.21 $73.21 $2,451.90 $2,451.90 $73.21 $73.21 $1,083.02 $2,451.90 $2,451.90 $73.21 $73.21 $1,083.02 $2,451.90 $73.21 $73.21 $2,451.90 $1,083.02 $2,451.90 $2,451.90 $73.21 $611.32 $2,451.90 $73.21 $2,451.90 $64.37 $73.21 $73.21 $1,701.96 $2,451.90 $73.21 $73.21 $1,701.96 $1,779.62 $1,779.62 $880.55 $880.55 $880.55 $880.55 $1,208.50 $1,208.50 $1,208.50 $880.55 $880.55 $880.55 $1,208.50 $143.97 $873.97 $666.56 $873.97 $873.97 $880.55 $880.55 $1,208.50 $1,208.50 $1,208.50 $880.55 $880.55 $681.61 $681.61 $880.55

$1,208.50 $1,208.50 $1,208.50 $909.37 $1,802.61 $1,064.45 $2,011.11 $909.37 $1,802.61 $774.63 $774.63 $827.41 $1,204.56 $1,294.56 $827.41 $636.63 $1,204.56 $96.02 $96.02 $1,085.48 $1,085.48 $96.02 $96.02 $605.26 $1,085.48 $1,150.73 $96.02 $96.02 $605.26 $995.48 $96.02 $96.02 $995.48 $605.26 $1,085.48 $1,150.73 $96.02 $487.33 $995.48 $96.02 $995.48 $64.37 $73.21 $96.02 $897.99 $1,085.48 $96.02 $96.02 $807.99 $917.41 $982.66 $602.64 $602.64 $880.55 $602.64 $684.63 $684.63 $684.63 $469.89 $554.64 $554.64 $839.88 $143.97 $552.99 $501.14 $600.99 $600.99 $602.64 $554.64 $684.63 $774.63 $684.63 $880.55 $602.64 $552.90 $642.90 $692.64 Page 9 of 38

25116 25118 25119 25120 25125 25126 25130 25135 25136 25145 25150 25151 25210 25215 25230 25240 25246 25248 25250 25251 25259 25260 25263 25265 25270 25272 25274 25275 25280 25290 25295 25300 25301 25310 25312 25315 25316 25320 25332 25335 25337 25350 25355 25360 25365 25370 25375 25390 25391 25392 25393 25394 25400 25405 25415 25420 25425 25426 25430 25431 25440 25441 25442 25443 25444 25445 25446 25447 25449 25450 25455 25490 25491 25492 25500 25505 25515 25520 25525 25526 25530 25535 25545 25560 25565 25574 25575 25600 25605 25606 25607 25608 25609

Remove wrist/forearm lesion Excise wrist tendon sheath Partial removal of ulna Removal of forearm lesion Remove/graft forearm lesion Remove/graft forearm lesion Removal of wrist lesion Remove & graft wrist lesion Remove & graft wrist lesion Remove forearm bone lesion Partial removal of ulna Partial removal of radius Removal of wrist bone Removal of wrist bones Partial removal of radius Partial removal of ulna Injection for wrist x-ray Remove forearm foreign body Removal of wrist prosthesis Removal of wrist prosthesis Manipulate wrist w/anesthes Repair forearm tendon/muscle Repair forearm tendon/muscle Repair forearm tendon/muscle Repair forearm tendon/muscle Repair forearm tendon/muscle Repair forearm tendon/muscle Repair forearm tendon sheath Revise wrist/forearm tendon Incise wrist/forearm tendon Release wrist/forearm tendon Fusion of tendons at wrist Fusion of tendons at wrist Transplant forearm tendon Transplant forearm tendon Revise palsy hand tendon(s) Revise palsy hand tendon(s) Repair/revise wrist joint Revise wrist joint Realignment of hand Reconstruct ulna/radioulnar Revision of radius Revision of radius Revision of ulna Revise radius & ulna Revise radius or ulna Revise radius & ulna Shorten radius or ulna Lengthen radius or ulna Shorten radius & ulna Lengthen radius & ulna Repair carpal bone, shorten Repair radius or ulna Repair/graft radius or ulna Repair radius & ulna Repair/graft radius & ulna Repair/graft radius or ulna Repair/graft radius & ulna Vasc graft into carpal bone Repair nonunion carpal bone Repair/graft wrist bone Reconstruct wrist joint Reconstruct wrist joint Reconstruct wrist joint Reconstruct wrist joint Reconstruct wrist joint Wrist replacement Repair wrist joint(s) Remove wrist joint implant Revision of wrist joint Revision of wrist joint Reinforce radius Reinforce ulna Reinforce radius and ulna Treat fracture of radius Treat fracture of radius Treat fracture of radius Treat fracture of radius Treat fracture of radius Treat fracture of radius Treat fracture of ulna Treat fracture of ulna Treat fracture of ulna Treat fracture radius & ulna Treat fracture radius & ulna Treat fracture radius & ulna Treat fracture radius/ulna Treat fracture radius/ulna Treat fracture radius/ulna Treat fx distal radial Treat fx rad extra-articul Treat fx rad intra-articul Treat fx radial 3+ frag

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 P2 A2 A2 P2 A2 A2 A2 P2 A2 A2 A2 A2 A2

$630.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $510.00 $630.00 $630.00 $630.00

21.27 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 26.31 26.31 29.19 29.19

$880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,089.28 $1,089.28 $1,208.50 $1,208.50

$692.64 $636.63 $684.63 $684.63 $684.63 $684.63 $684.63 $684.63 $684.63 $636.63 $636.63 $636.63 $654.82 $744.82 $774.63 $774.63

$446.00 $333.00 $333.00

21.27 29.19 29.19 1.77 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 29.19 21.27 29.19 29.19 42.99 42.99 42.99 79.42 42.99 35.9 42.99 42.99 79.42 42.99 29.19 29.19 42.99 42.99 29.19 42.99 29.19 42.99 16.46 79.42 79.42 79.42 79.42 42.99 42.99 26.31 26.31 79.42 122.21 122.21 50.89 50.89 50.89 122.21 35.9 35.9 42.99 42.99 42.99 42.99 42.99 1.77 1.77 41.11 1.77 41.11 41.11 1.77 1.77 41.11 1.77 1.77 59.22 59.22 1.77 1.77 26.16 59.22 59.22 59.22

$880.55 $1,208.50 $1,208.50 $73.21 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $880.55 $1,208.50 $1,208.50 $1,779.62 $1,779.62 $1,779.62 $3,288.25 $1,779.62 $1,486.46 $1,779.62 $1,779.62 $3,288.25 $1,779.62 $1,208.50 $1,208.50 $1,779.62 $1,779.62 $1,208.50 $1,779.62 $1,208.50 $1,779.62 $681.61 $3,288.25 $3,288.25 $3,288.25 $3,288.25 $1,779.62 $1,779.62 $1,089.28 $1,089.28 $3,288.25 $5,059.44 $5,059.44 $2,106.80 $2,106.80 $2,106.80 $5,059.44 $1,486.46 $1,486.46 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $73.21 $73.21 $1,701.96 $73.21 $1,701.96 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $73.21 $2,451.90 $2,451.90 $73.21 $73.21 $1,083.02 $2,451.90 $2,451.90 $2,451.90

$554.64 $551.88 $551.88 $73.21 $774.63 $636.63 $684.63 $774.63 $684.63 $774.63 $774.63 $774.63 $684.63 $602.64 $684.63 $684.63 $827.41 $917.41 $827.41 $1,204.56 $827.41 $909.37 $827.41 $982.66 $1,204.56 $827.41 $684.63 $684.63 $827.41 $917.41 $684.63 $917.41 $684.63 $917.41 $681.61 $1,204.56 $1,294.56 $1,204.56 $1,294.56 $827.41 $917.41 $1,089.28 $1,089.28 $1,294.56 $1,802.61 $1,802.61 $1,064.45 $1,064.45 $1,064.45 $2,011.11 $909.37 $909.37 $827.41 $827.41 $827.41 $827.41 $827.41 $73.21 $96.02 $807.99 $96.02 $897.99 $963.24 $73.21 $96.02 $807.99 $73.21 $96.02 $995.48 $995.48 $73.21 $96.02 $653.26 $1,150.73 $1,150.73 $1,150.73

$630.00 $446.00 $510.00 $630.00 $510.00 $630.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $510.00 $510.00 $510.00 $717.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $510.00 $630.00 $510.00 $630.00 $510.00 $630.00 $510.00 $630.00 $510.00 $630.00

$630.00 $717.00 $717.00 $717.00 $717.00 $717.00 $995.00 $717.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $103.62 $510.00 $103.62 $630.00 $717.00 $103.62 $510.00 $103.62 $510.00 $510.00 $103.62 $510.00 $717.00 $717.00 $717.00

Page 10 of 38

25622 25624 25628 25630 25635 25645 25650 25651 25652 25660 25670 25671 25675 25676 25680 25685 25690 25695 25800 25805 25810 25820 25825 25830 25907 25922 25929 25931 26010 26011 26020 26025 26030 26034 26035 26040 26045 26055 26060 26070 26075 26080 26100 26105 26110 26115 26116 26117 26121 26123 26125 26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210 26215 26230 26235 26236 26250 26255 26260 26261 26262 26320 26340 26350 26352 26356 26357 26358 26370 26372 26373 26390 26392 26410 26412 26415 26416 26418 26420 26426 26428 26432 26433

Treat wrist bone fracture Treat wrist bone fracture Treat wrist bone fracture Treat wrist bone fracture Treat wrist bone fracture Treat wrist bone fracture Treat wrist bone fracture Pin ulnar styloid fracture Treat fracture ulnar styloid Treat wrist dislocation Treat wrist dislocation Pin radioulnar dislocation Treat wrist dislocation Treat wrist dislocation Treat wrist fracture Treat wrist fracture Treat wrist dislocation Treat wrist dislocation Fusion of wrist joint Fusion/graft of wrist joint Fusion/graft of wrist joint Fusion of hand bones Fuse hand bones with graft Fusion, radioulnar jnt/ulna Amputation follow-up surgery Amputate hand at wrist Amputation follow-up surgery Amputation follow-up surgery Drainage of finger abscess Drainage of finger abscess Drain hand tendon sheath Drainage of palm bursa Drainage of palm bursa(s) Treat hand bone lesion Decompress fingers/hand Release palm contracture Release palm contracture Incise finger tendon sheath Incision of finger tendon Explore/treat hand joint Explore/treat finger joint Explore/treat finger joint Biopsy hand joint lining Biopsy finger joint lining Biopsy finger joint lining Removal hand lesion subcut Removal hand lesion, deep Remove tumor, hand/finger Release palm contracture Release palm contracture Release palm contracture Remove wrist joint lining Revise finger joint, each Revise finger joint, each Tendon excision, palm/finger Remove tendon sheath lesion Removal of palm tendon, each Removal of finger tendon Remove finger bone Remove hand bone lesion Remove/graft bone lesion Removal of finger lesion Remove/graft finger lesion Partial removal of hand bone Partial removal, finger bone Partial removal, finger bone Extensive hand surgery Extensive hand surgery Extensive finger surgery Extensive finger surgery Partial removal of finger Removal of implant from hand Manipulate finger w/anesth Repair finger/hand tendon Repair/graft hand tendon Repair finger/hand tendon Repair finger/hand tendon Repair/graft hand tendon Repair finger/hand tendon Repair/graft hand tendon Repair finger/hand tendon Revise hand/finger tendon Repair/graft hand tendon Repair hand tendon Repair/graft hand tendon Excision, hand/finger tendon Graft hand or finger tendon Repair finger tendon Repair/graft finger tendon Repair finger/hand tendon Repair/graft finger tendon Repair finger tendon Repair finger tendon

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P2 A2 A2 P2 A2 A2 P2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 P2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$103.62 $510.00 $103.62 $510.00

$103.62 $510.00 $333.00 $103.62 $446.00 $103.62 $510.00 $103.62 $446.00 $630.00 $717.00 $717.00 $630.00 $717.00 $717.00 $510.00 $510.00 $510.00

$333.00 $446.00 $333.00 $446.00 $446.00 $630.00 $510.00 $446.00 $446.00 $446.00 $630.00 $630.00 $446.00 $333.00 $333.00 $446.00 $446.00 $510.00 $630.00 $630.00 $630.00 $510.00 $630.00 $446.00 $510.00 $510.00 $510.00 $510.00 $630.00 $446.00 $510.00 $446.00 $510.00 $992.95 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $333.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $510.00 $630.00 $510.00 $510.00 $510.00 $630.00 $510.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00

1.77 1.77 41.11 1.77 1.77 41.11 1.77 26.16 41.11 1.77 26.16 26.16 1.77 26.16 1.77 26.16 1.77 26.16 79.42 42.99 79.42 16.46 79.42 79.42 21.27 21.27 15.05 21.27 1.41 11.56 16.46 16.46 16.46 16.46 16.46 26.31 26.31 16.46 16.46 16.46 16.46 16.46 16.46 16.46 16.46 21.11 21.11 21.11 26.31 26.31 16.46 16.46 26.31 16.46 16.46 16.46 16.46 16.46 16.46 16.46 26.31 16.46 16.46 16.46 16.46 16.46 16.46 26.31 16.46 16.46 16.46 16.1 1.77 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 16.46 26.31 26.31 26.31 16.46 26.31 26.31 26.31 16.46 16.46

$73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $1,083.02 $1,701.96 $73.21 $1,083.02 $1,083.02 $73.21 $1,083.02 $73.21 $1,083.02 $73.21 $1,083.02 $3,288.25 $1,779.62 $3,288.25 $681.61 $3,288.25 $3,288.25 $880.55 $880.55 $622.91 $880.55 $58.23 $478.57 $681.61 $681.61 $681.61 $681.61 $681.61 $1,089.28 $1,089.28 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $873.97 $873.97 $873.97 $1,089.28 $1,089.28 $681.61 $681.61 $1,089.28 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $1,089.28 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $1,089.28 $681.61 $681.61 $681.61 $666.56 $73.21 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $1,089.28 $1,089.28 $1,089.28 $681.61 $1,089.28 $1,089.28 $1,089.28 $681.61 $681.61

$73.21 $96.02 $807.99 $73.21 $96.02 $807.99 $73.21 $1,083.02 $1,701.96 $96.02 $653.26 $520.51 $96.02 $605.26 $96.02 $653.26 $96.02 $605.26 $1,294.56 $982.66 $1,359.81 $642.90 $1,359.81 $1,359.81 $602.64 $602.64 $538.23 $880.55 $58.23 $369.39 $504.90 $420.15 $504.90 $504.90 $681.61 $744.82 $654.82 $504.90 $504.90 $504.90 $642.90 $642.90 $504.90 $420.15 $420.15 $552.99 $552.99 $600.99 $744.82 $744.82 $642.90 $552.90 $744.82 $504.90 $552.90 $552.90 $552.90 $552.90 $642.90 $504.90 $654.82 $504.90 $552.90 $915.12 $552.90 $552.90 $552.90 $654.82 $552.90 $552.90 $504.90 $501.14 $73.21 $522.07 $744.82 $744.82 $744.82 $744.82 $744.82 $744.82 $654.82 $744.82 $654.82 $552.90 $654.82 $744.82 $654.82 $642.90 $744.82 $654.82 $654.82 $552.90 $552.90 Page 11 of 38

26434 26437 26440 26442 26445 26449 26450 26455 26460 26471 26474 26476 26477 26478 26479 26480 26483 26485 26489 26490 26492 26494 26496 26497 26498 26499 26500 26502 26508 26510 26516 26517 26518 26520 26525 26530 26531 26535 26536 26540 26541 26542 26545 26546 26548 26550 26555 26560 26561 26562 26565 26567 26568 26580 26587 26590 26591 26593 26596 26600 26605 26607 26608 26615 26641 26645 26650 26665 26670 26675 26676 26685 26686 26700 26705 26706 26715 26720 26725 26727 26735 26740 26742 26746 26750 26755 26756 26765 26770 26775 26776 26785 26820

Repair/graft finger tendon Realignment of tendons Release palm/finger tendon Release palm & finger tendon Release hand/finger tendon Release forearm/hand tendon Incision of palm tendon Incision of finger tendon Incise hand/finger tendon Fusion of finger tendons Fusion of finger tendons Tendon lengthening Tendon shortening Lengthening of hand tendon Shortening of hand tendon Transplant hand tendon Transplant/graft hand tendon Transplant palm tendon Transplant/graft palm tendon Revise thumb tendon Tendon transfer with graft Hand tendon/muscle transfer Revise thumb tendon Finger tendon transfer Finger tendon transfer Revision of finger Hand tendon reconstruction Hand tendon reconstruction Release thumb contracture Thumb tendon transfer Fusion of knuckle joint Fusion of knuckle joints Fusion of knuckle joints Release knuckle contracture Release finger contracture Revise knuckle joint Revise knuckle with implant Revise finger joint Revise/implant finger joint Repair hand joint Repair hand joint with graft Repair hand joint with graft Reconstruct finger joint Repair nonunion hand Reconstruct finger joint Construct thumb replacement Positional change of finger Repair of web finger Repair of web finger Repair of web finger Correct metacarpal flaw Correct finger deformity Lengthen metacarpal/finger Repair hand deformity Reconstruct extra finger Repair finger deformity Repair muscles of hand Release muscles of hand Excision constricting tissue Treat metacarpal fracture Treat metacarpal fracture Treat metacarpal fracture Treat metacarpal fracture Treat metacarpal fracture Treat thumb dislocation Treat thumb fracture Treat thumb fracture Treat thumb fracture Treat hand dislocation Treat hand dislocation Pin hand dislocation Treat hand dislocation Treat hand dislocation Treat knuckle dislocation Treat knuckle dislocation Pin knuckle dislocation Treat knuckle dislocation Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Treat finger fracture, each Pin finger fracture, each Treat finger fracture, each Treat finger dislocation Treat finger dislocation Pin finger dislocation Treat finger dislocation Thumb fusion with graft

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 P2 A2 A2 A2 P2 A2 A2 A2 A2 P2 A2 A2 A2 P2 P2 A2 A2 P2 A2 A2 P2 G2 A2 A2 G2 P3 A2 A2 A2

$510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $333.00 $333.00 $333.00 $333.00 $510.00 $510.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $510.00 $630.00 $630.00 $510.00 $510.00 $333.00 $510.00 $510.00 $510.00 $510.00 $510.00 $995.00 $717.00 $717.00 $630.00 $995.00 $630.00 $630.00 $630.00 $630.00 $446.00 $510.00 $446.00 $510.00 $630.00 $717.00 $717.00 $510.00 $717.00 $717.00 $717.00 $510.00 $510.00 $446.00 $103.62 $103.62 $630.00 $630.00 $103.62 $446.00 $630.00 $103.62 $446.00 $510.00 $510.00 $103.62 $103.62 $630.00

$995.00 $630.00 $103.62 $717.00

$446.00 $630.00

$446.00 $446.00 $717.00

26.31 16.46 16.46 26.31 16.46 26.31 16.46 16.46 16.46 16.46 16.46 16.46 16.46 16.46 16.46 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 16.46 26.31 16.46 26.31 26.31 26.31 26.31 16.46 16.46 35.9 50.89 35.9 50.89 16.46 26.31 16.46 26.31 26.31 26.31 26.31 26.31 16.46 26.31 26.31 26.31 26.31 26.31 16.46 16.46 16.46 26.31 16.46 16.46 1.77 1.77 1.77 26.16 41.11 1.77 1.77 26.16 41.11 1.77 1.77 26.16 26.16 59.22 1.77 1.77 1.77 26.16 1.77 1.77 26.16 26.16 1.77 1.77 26.16 1.77 1.77 26.16 26.16 1.77 4.52 26.16 26.16 26.31

$1,089.28 $681.61 $681.61 $1,089.28 $681.61 $1,089.28 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $681.61 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $1,089.28 $681.61 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $681.61 $1,486.46 $2,106.80 $1,486.46 $2,106.80 $681.61 $1,089.28 $681.61 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $681.61 $681.61 $1,089.28 $681.61 $681.61 $73.21 $73.21 $73.21 $1,083.02 $1,701.96 $73.21 $73.21 $1,083.02 $1,701.96 $73.21 $73.21 $1,083.02 $1,083.02 $2,451.90 $73.21 $73.21 $73.21 $1,083.02 $73.21 $73.21 $1,083.02 $1,083.02 $73.21 $73.21 $1,083.02 $73.21 $73.21 $1,083.02 $1,083.02 $73.21 $187.01 $1,083.02 $1,083.02 $1,089.28

$654.82 $552.90 $552.90 $654.82 $552.90 $654.82 $552.90 $552.90 $552.90 $504.90 $504.90 $420.15 $420.15 $420.15 $420.15 $654.82 $654.82 $606.82 $654.82 $654.82 $654.82 $654.82 $654.82 $654.82 $744.82 $654.82 $642.90 $744.82 $552.90 $654.82 $522.07 $654.82 $654.82 $552.90 $552.90 $754.12 $1,272.95 $909.37 $1,064.45 $642.90 $1,018.57 $642.90 $744.82 $744.82 $744.82 $606.82 $654.82 $504.90 $654.82 $744.82 $810.07 $810.07 $654.82 $708.15 $708.15 $708.15 $654.82 $552.90 $504.90 $73.21 $96.02 $96.02 $743.26 $897.99 $73.21 $96.02 $605.26 $897.99 $73.21 $96.02 $605.26 $653.26 $995.48 $73.21 $96.02 $96.02 $743.26 $73.21 $73.21 $1,017.01 $743.26 $73.21 $96.02 $808.51 $73.21 $73.21 $605.26 $743.26 $73.21 $187.01 $605.26 $605.26 $810.07 Page 12 of 38

26841 26842 26843 26844 26850 26852 26860 26861 26862 26863 26910 26951 26952 26990 26991 27000 27001 27003 27033 27035 27040 27041 27047 27048 27049 27050 27052 27060 27062 27065 27066 27067 27080 27086 27087 27093 27095 27097 27098 27100 27105 27110 27111 27193 27194 27200 27202 27220 27230 27238 27246 27250 27252 27256 27257 27265 27266 27267 27275 27301 27305 27306 27307 27310 27323 27324 27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27340 27345 27347 27350 27355 27356 27357 27358 27360 27370 27372 27380 27381 27385 27386 27390

Fusion of thumb Thumb fusion with graft Fusion of hand joint Fusion/graft of hand joint Fusion of knuckle Fusion of knuckle with graft Fusion of finger joint Fusion of finger jnt, add-on Fusion/graft of finger joint Fuse/graft added joint Amputate metacarpal bone Amputation of finger/thumb Amputation of finger/thumb Drainage of pelvis lesion Drainage of pelvis bursa Incision of hip tendon Incision of hip tendon Incision of hip tendon Exploration of hip joint Denervation of hip joint Biopsy of soft tissues Biopsy of soft tissues Remove hip/pelvis lesion Remove hip/pelvis lesion Remove tumor, hip/pelvis Biopsy of sacroiliac joint Biopsy of hip joint Removal of ischial bursa Remove femur lesion/bursa Removal of hip bone lesion Removal of hip bone lesion Remove/graft hip bone lesion Removal of tail bone Remove hip foreign body Remove hip foreign body Injection for hip x-ray Injection for hip x-ray Revision of hip tendon Transfer tendon to pelvis Transfer of abdominal muscle Transfer of spinal muscle Transfer of iliopsoas muscle Transfer of iliopsoas muscle Treat pelvic ring fracture Treat pelvic ring fracture Treat tail bone fracture Treat tail bone fracture Treat hip socket fracture Treat thigh fracture Treat thigh fracture Treat thigh fracture Treat hip dislocation Treat hip dislocation Treat hip dislocation Treat hip dislocation Treat hip dislocation Treat hip dislocation Cltx thigh fx Manipulation of hip joint Drain thigh/knee lesion Incise thigh tendon & fascia Incision of thigh tendon Incision of thigh tendons Exploration of knee joint Biopsy, thigh soft tissues Biopsy, thigh soft tissues Neurectomy, hamstring Neurectomy, popliteal Removal of thigh lesion Removal of thigh lesion Remove tumor, thigh/knee Biopsy, knee joint lining Explore/treat knee joint Removal of knee cartilage Removal of knee cartilage Remove knee joint lining Remove knee joint lining Removal of kneecap bursa Removal of knee cyst Remove knee cyst Removal of kneecap Remove femur lesion Remove femur lesion/graft Remove femur lesion/graft Remove femur lesion/fixation Partial removal, leg bone(s) Injection for knee x-ray Removal of foreign body Repair of kneecap tendon Repair/graft kneecap tendon Repair of thigh muscle Repair/graft of thigh muscle Incision of thigh tendon

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 N1 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 G2 A2 A2 A2 A2 A2 G2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 A2 A2 A2 A2 A2

$630.00 $630.00 $510.00 $510.00 $630.00 $630.00 $510.00 $446.00 $630.00 $510.00 $510.00 $446.00 $630.00 $333.00 $333.00 $446.00 $510.00 $510.00 $510.00 $630.00 $333.00 $418.49 $446.00 $510.00 $510.00 $510.00 $510.00 $717.00 $717.00 $717.00 $717.00 $717.00 $446.00 $333.00 $510.00

26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 26.31 16.46 16.46 21.27 21.27 21.27 29.19 29.19 42.99 42.99 8.69 8.69 21.11 21.11 21.11 21.27 21.27 21.27 21.27 21.27 29.19 29.19 29.19 8.69 21.27

$1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $1,089.28 $681.61 $681.61 $880.55 $880.55 $880.55 $1,208.50 $1,208.50 $1,779.62 $1,779.62 $359.57 $359.57 $873.97 $873.97 $873.97 $880.55 $880.55 $880.55 $880.55 $880.55 $1,208.50 $1,208.50 $1,208.50 $359.57 $880.55

$744.82 $744.82 $654.82 $654.82 $744.82 $744.82 $654.82 $606.82 $744.82 $654.82 $654.82 $504.90 $642.90 $469.89 $469.89 $554.64 $684.63 $684.63 $827.41 $917.41 $339.64 $403.76 $552.99 $600.99 $600.99 $602.64 $602.64 $757.89 $757.89 $757.89 $839.88 $839.88 $636.63 $339.64 $602.64

$510.00 $510.00 $630.00 $630.00 $630.00 $630.00 $103.62 $446.00

$446.00 $510.00 $446.00 $510.00 $510.00 $630.00 $333.00 $333.00 $446.00 $446.00 $446.00 $510.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $510.00 $630.00 $630.00 $630.00 $510.00 $630.00 $717.00 $717.00 $717.00

29.19 29.19 42.99 42.99 42.99 42.99 1.77 14.77 1.77 41.11 1.77 1.77 1.77 1.77 1.77 14.77 1.77 14.77 1.77 14.77 1.77 14.77 18.32 21.27 21.27 21.27 29.19 8.69 21.11 18.05 18.05 21.11 21.11 21.11 29.19 29.19 29.19 29.19 29.19 29.19 21.27 21.27 21.27 29.19 29.19 29.19 29.19 29.19 29.19

$1,208.50 $1,208.50 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $73.21 $611.32 $73.21 $1,701.96 $73.21 $73.21 $73.21 $73.21 $73.21 $611.32 $73.21 $611.32 $73.21 $611.32 $73.21 $611.32 $758.45 $880.55 $880.55 $880.55 $1,208.50 $359.57 $873.97 $747.36 $747.36 $873.97 $873.97 $873.97 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $880.55 $880.55 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,208.50

$684.63 $684.63 $917.41 $917.41 $917.41 $917.41 $96.02 $487.33 $73.21 $759.99 $73.21 $96.02 $96.02 $96.02 $96.02 $487.33 $73.21 $535.33 $96.02 $487.33 $73.21 $487.33 $572.11 $554.64 $602.64 $602.64 $774.63 $339.64 $468.24 $521.34 $521.34 $552.99 $600.99 $690.99 $774.63 $774.63 $774.63 $774.63 $774.63 $774.63 $602.64 $692.64 $692.64 $774.63 $684.63 $774.63 $839.88 $839.88 $839.88

$995.00 $333.00 $510.00 $510.00 $510.00 $333.00

21.11 21.27 21.27 21.27 21.27 21.27

$873.97 $880.55 $880.55 $880.55 $880.55 $880.55

$964.74 $469.89 $602.64 $602.64 $602.64 $469.89

$446.00 $103.62 $103.62 $103.62 $103.62 $446.00 $510.00 $103.62 $446.00

Page 13 of 38

27391 27392 27393 27394 27395 27396 27397 27400 27403 27405 27407 27409 27416 27418 27420 27422 27424 27425 27427 27428 27429 27430 27435 27437 27438 27440 27441 27442 27443 27446 27496 27497 27498 27499 27500 27501 27502 27503 27508 27509 27510 27516 27517 27520 27530 27532 27538 27550 27552 27560 27562 27566 27570 27594 27600 27601 27602 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27635 27637 27638 27640 27641 27647 27648 27650 27652 27654 27656 27658 27659 27664 27665 27675 27676 27680 27681 27685

Incision of thigh tendons Incision of thigh tendons Lengthening of thigh tendon Lengthening of thigh tendons Lengthening of thigh tendons Transplant of thigh tendon Transplants of thigh tendons Revise thigh muscles/tendons Repair of knee cartilage Repair of knee ligament Repair of knee ligament Repair of knee ligaments Osteochondral knee autograft Repair degenerated kneecap Revision of unstable kneecap Revision of unstable kneecap Revision/removal of kneecap Lat retinacular release open Reconstruction, knee Reconstruction, knee Reconstruction, knee Revision of thigh muscles Incision of knee joint Revise kneecap Revise kneecap with implant Revision of knee joint Revision of knee joint Revision of knee joint Revision of knee joint Revision of knee joint Decompression of thigh/knee Decompression of thigh/knee Decompression of thigh/knee Decompression of thigh/knee Treatment of thigh fracture Treatment of thigh fracture Treatment of thigh fracture Treatment of thigh fracture Treatment of thigh fracture Treatment of thigh fracture Treatment of thigh fracture Treat thigh fx growth plate Treat thigh fx growth plate Treat kneecap fracture Treat knee fracture Treat knee fracture Treat knee fracture(s) Treat knee dislocation Treat knee dislocation Treat kneecap dislocation Treat kneecap dislocation Treat kneecap dislocation Fixation of knee joint Amputation follow-up surgery Decompression of lower leg Decompression of lower leg Decompression of lower leg Drain lower leg lesion Drain lower leg bursa Incision of achilles tendon Incision of achilles tendon Treat lower leg bone lesion Explore/treat ankle joint Exploration of ankle joint Biopsy lower leg soft tissue Biopsy lower leg soft tissue Remove tumor, lower leg Remove lower leg lesion Remove lower leg lesion Explore/treat ankle joint Remove ankle joint lining Remove ankle joint lining Removal of tendon lesion Remove lower leg bone lesion Remove/graft leg bone lesion Remove/graft leg bone lesion Partial removal of tibia Partial removal of fibula Extensive ankle/heel surgery Injection for ankle x-ray Repair achilles tendon Repair/graft achilles tendon Repair of achilles tendon Repair leg fascia defect Repair of leg tendon, each Repair of leg tendon, each Repair of leg tendon, each Repair of leg tendon, each Repair lower leg tendons Repair lower leg tendons Release of lower leg tendon Release of lower leg tendons Revision of lower leg tendon

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $510.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $630.00

$446.00 $510.00 $446.00 $510.00 $630.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $510.00

21.27 21.27 29.19 29.19 42.99 29.19 42.99 42.99 29.19 42.99 79.42 42.99 42.99 42.99 42.99 42.99 42.99 29.19 42.99 79.42 79.42 42.99 42.99 35.9 50.89 35.9 35.9 35.9 35.9 274.67 21.27 21.27 21.27 21.27 1.77 1.77 1.77 1.77 1.77 26.16 1.77 1.77 1.77 1.77 1.77 1.77 1.77 1.77 14.77 1.77 14.77 41.11 14.77 21.27 21.27 21.27 21.27 18.32 21.27 20.83 21.27 21.27 29.19 29.19 3.28 21.11 29.19 16.1 21.11 29.19 29.19 29.19 21.27 29.19 29.19 29.19 42.99 29.19 42.99

$880.55 $880.55 $1,208.50 $1,208.50 $1,779.62 $1,208.50 $1,779.62 $1,779.62 $1,208.50 $1,779.62 $3,288.25 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,779.62 $1,208.50 $1,779.62 $3,288.25 $3,288.25 $1,779.62 $1,779.62 $1,486.46 $2,106.80 $1,486.46 $1,486.46 $1,486.46 $1,486.46 $11,371.67 $880.55 $880.55 $880.55 $880.55 $73.21 $73.21 $73.21 $73.21 $73.21 $1,083.02 $73.21 $73.21 $73.21 $73.21 $73.21 $73.21 $73.21 $73.21 $611.32 $73.21 $611.32 $1,701.96 $611.32 $880.55 $880.55 $880.55 $880.55 $758.45 $880.55 $862.32 $880.55 $880.55 $1,208.50 $1,208.50 $135.97 $873.97 $1,208.50 $666.56 $873.97 $1,208.50 $1,208.50 $1,208.50 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,779.62 $1,208.50 $1,779.62

$554.64 $602.64 $636.63 $684.63 $827.41 $684.63 $827.41 $827.41 $774.63 $917.41 $1,294.56 $917.41 $1,779.62 $827.41 $827.41 $1,191.16 $827.41 $1,048.38 $827.41 $1,294.56 $1,294.56 $917.41 $917.41 $844.12 $1,064.45 $1,486.46 $909.37 $909.37 $909.37 $11,371.67 $757.89 $602.64 $602.64 $602.64 $96.02 $96.02 $96.02 $96.02 $96.02 $653.26 $96.02 $96.02 $96.02 $96.02 $96.02 $96.02 $96.02 $96.02 $402.58 $96.02 $402.58 $759.99 $402.58 $602.64 $602.64 $602.64 $602.64 $524.11 $554.64 $465.33 $469.89 $554.64 $636.63 $684.63 $135.97 $552.99 $684.63 $501.14 $600.99 $774.63 $774.63 $774.63 $602.64 $684.63 $684.63 $684.63 $779.41 $636.63 $827.41

$510.00 $510.00 $510.00 $446.00 $333.00 $446.00 $446.00 $446.00 $446.00 $510.00 $510.00 $446.00 $510.00

42.99 79.42 42.99 21.27 21.27 21.27 21.27 29.19 21.27 29.19 29.19 29.19 29.19

$1,779.62 $3,288.25 $1,779.62 $880.55 $880.55 $880.55 $880.55 $1,208.50 $880.55 $1,208.50 $1,208.50 $1,208.50 $1,208.50

$827.41 $1,204.56 $827.41 $554.64 $469.89 $554.64 $554.64 $636.63 $554.64 $684.63 $684.63 $636.63 $684.63

$510.00 $510.00 $995.00 $510.00 $995.00 $510.00 $630.00 $630.00 $630.00 $630.00 $630.00 $717.00 $717.00 $717.00 $717.00 $717.00 $510.00 $510.00 $510.00 $103.62 $103.62 $103.62 $103.62 $103.62 $510.00 $103.62 $103.62 $103.62 $103.62 $103.62 $103.62 $103.62 $103.62 $333.00 $103.62 $333.00 $446.00 $333.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $333.00 $333.00 $446.00 $446.00 $510.00

Page 14 of 38

27686 27687 27690 27691 27692 27695 27696 27698 27700 27704 27705 27707 27709 27726 27730 27732 27734 27740 27742 27745 27750 27752 27756 27758 27759 27760 27762 27766 27767 27768 27769 27780 27781 27784 27786 27788 27792 27808 27810 27814 27816 27818 27822 27823 27824 27825 27826 27827 27828 27829 27830 27831 27832 27840 27842 27846 27848 27860 27870 27871 27884 27889 27892 27893 27894 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28035 28043 28045 28046 28050 28052 28054 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100

Revise lower leg tendons Revision of calf tendon Revise lower leg tendon Revise lower leg tendon Revise additional leg tendon Repair of ankle ligament Repair of ankle ligaments Repair of ankle ligament Revision of ankle joint Removal of ankle implant Incision of tibia Incision of fibula Incision of tibia & fibula Repair fibula nonunion Repair of tibia epiphysis Repair of fibula epiphysis Repair lower leg epiphyses Repair of leg epiphyses Repair of leg epiphyses Reinforce tibia Treatment of tibia fracture Treatment of tibia fracture Treatment of tibia fracture Treatment of tibia fracture Treatment of tibia fracture Cltx medial ankle fx Cltx med ankle fx w/mnpj Optx medial ankle fx Cltx post ankle fx Cltx post ankle fx w/mnpj Optx post ankle fx Treatment of fibula fracture Treatment of fibula fracture Treatment of fibula fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treat lower leg fracture Treat lower leg fracture Treat lower leg fracture Treat lower leg fracture Treat lower leg fracture Treat lower leg joint Treat lower leg dislocation Treat lower leg dislocation Treat lower leg dislocation Treat ankle dislocation Treat ankle dislocation Treat ankle dislocation Treat ankle dislocation Fixation of ankle joint Fusion of ankle joint, open Fusion of tibiofibular joint Amputation follow-up surgery Amputation of foot at ankle Decompression of leg Decompression of leg Decompression of leg Drainage of bursa of foot Treatment of foot infection Treatment of foot infection Treat foot bone lesion Incision of foot fascia Incision of toe tendon Incision of toe tendons Exploration of foot joint Exploration of foot joint Exploration of toe joint Decompression of tibia nerve Excision of foot lesion Excision of foot lesion Resection of tumor, foot Biopsy of foot joint lining Biopsy of foot joint lining Biopsy of toe joint lining Neurectomy, foot Partial removal, foot fascia Removal of foot fascia Removal of foot joint lining Removal of foot joint lining Removal of foot lesion Excise foot tendon sheath Excise foot tendon sheath Removal of foot lesion Removal of toe lesions Removal of ankle/heel lesion

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$510.00 $510.00 $630.00 $630.00 $510.00 $446.00 $446.00 $446.00 $717.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $103.62 $103.62 $510.00 $630.00 $630.00 $103.62 $103.62 $510.00

$103.62 $103.62 $510.00 $103.62 $103.62 $510.00 $103.62 $103.62 $510.00 $103.62 $103.62 $510.00 $510.00 $103.62 $103.62 $510.00 $510.00 $630.00 $446.00 $103.62 $103.62 $446.00 $103.62 $333.00 $510.00 $510.00 $333.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $630.00 $446.00 $510.00 $510.00 $446.00 $446.00 $446.00 $630.00 $446.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $510.00 $510.00 $446.00

29.19 29.19 42.99 42.99 42.99 29.19 29.19 29.19 35.9 21.27 42.99 21.27 29.19 26.16 29.19 29.19 29.19 29.19 42.99 79.42 1.77 1.77 26.16 41.11 59.22 1.77 1.77 41.11 1.77 1.77 41.11 1.77 1.77 41.11 1.77 1.77 41.11 1.77 1.77 41.11 1.77 1.77 41.11 59.22 1.77 1.77 41.11 59.22 59.22 41.11 1.77 1.77 41.11 1.77 14.77 41.11 41.11 14.77 79.42 79.42 21.27 29.19 21.27 21.27 21.27 3.21 21.27 21.27 20.83 20.83 2.41 20.83 20.83 20.83 20.83 18.05 21.11 20.83 20.83 20.83 20.83 20.83 18.05 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83

$1,208.50 $1,208.50 $1,779.62 $1,779.62 $1,779.62 $1,208.50 $1,208.50 $1,208.50 $1,486.46 $880.55 $1,779.62 $880.55 $1,208.50 $1,083.02 $1,208.50 $1,208.50 $1,208.50 $1,208.50 $1,779.62 $3,288.25 $73.21 $73.21 $1,083.02 $1,701.96 $2,451.90 $73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $73.21 $1,701.96 $2,451.90 $73.21 $73.21 $1,701.96 $2,451.90 $2,451.90 $1,701.96 $73.21 $73.21 $1,701.96 $73.21 $611.32 $1,701.96 $1,701.96 $611.32 $3,288.25 $3,288.25 $880.55 $1,208.50 $880.55 $880.55 $880.55 $132.92 $880.55 $880.55 $862.32 $862.32 $99.79 $862.32 $862.32 $862.32 $862.32 $747.36 $873.97 $862.32 $862.32 $862.32 $862.32 $862.32 $747.36 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32

$684.63 $684.63 $917.41 $917.41 $827.41 $636.63 $636.63 $636.63 $909.37 $554.64 $779.41 $554.64 $636.63 $1,083.02 $636.63 $636.63 $636.63 $636.63 $779.41 $1,204.56 $96.02 $96.02 $653.26 $897.99 $1,085.48 $96.02 $96.02 $807.99 $73.21 $73.21 $1,701.96 $96.02 $96.02 $807.99 $96.02 $96.02 $807.99 $96.02 $96.02 $807.99 $96.02 $96.02 $807.99 $995.48 $96.02 $96.02 $807.99 $995.48 $1,085.48 $759.99 $96.02 $96.02 $759.99 $96.02 $402.58 $807.99 $807.99 $402.58 $1,294.56 $1,294.56 $602.64 $684.63 $602.64 $602.64 $602.64 $132.92 $602.64 $602.64 $598.08 $598.08 $99.79 $598.08 $550.08 $550.08 $550.08 $659.34 $552.99 $598.08 $598.08 $550.08 $550.08 $550.08 $659.34 $550.08 $598.08 $598.08 $598.08 $598.08 $550.08 $550.08 $598.08 $598.08 $550.08 Page 15 of 38

28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28400 28405 28406 28415 28420 28430 28435 28436 28445 28446 28450 28455 28456

Remove/graft foot lesion Remove/graft foot lesion Removal of foot lesion Remove/graft foot lesion Remove/graft foot lesion Removal of toe lesions Part removal of metatarsal Part removal of metatarsal Part removal of metatarsal Part removal of metatarsal Removal of metatarsal heads Revision of foot Removal of heel bone Removal of heel spur Part removal of ankle/heel Partial removal of foot bone Partial removal of toe Partial removal of toe Removal of ankle bone Removal of metatarsal Removal of toe Partial removal of toe Partial removal of toe Extensive foot surgery Extensive foot surgery Extensive foot surgery Removal of foot foreign body Removal of foot foreign body Removal of foot foreign body Repair of foot tendon Repair/graft of foot tendon Repair of foot tendon Repair/graft of foot tendon Release of foot tendon Release of foot tendons Release of foot tendon Release of foot tendons Incision of foot tendon(s) Incision of toe tendon Incision of foot tendon Revision of foot tendon Release of big toe Revision of foot fascia Release of midfoot joint Revision of foot tendon Revision of foot and ankle Release of midfoot joint Release of foot contracture Release of toe joint, each Fusion of toes Repair of hammertoe Repair of hammertoe Partial removal of foot bone Repair hallux rigidus Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Correction of bunion Incision of heel bone Incision of ankle bone Incision of midfoot bones Incise/graft midfoot bones Incision of metatarsal Incision of metatarsal Incision of metatarsal Incision of metatarsals Revision of big toe Revision of toe Repair deformity of toe Removal of sesamoid bone Repair of foot bones Repair of metatarsals Resect enlarged toe tissue Resect enlarged toe Repair extra toe(s) Repair webbed toe(s) Treatment of heel fracture Treatment of heel fracture Treatment of heel fracture Treat heel fracture Treat/graft heel fracture Treatment of ankle fracture Treatment of ankle fracture Treatment of ankle fracture Treat ankle fracture Osteochondral talus autogrft Treat midfoot fracture, each Treat midfoot fracture, each Treat midfoot fracture

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 P3 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 G2 P2 P2 A2

$510.00 $510.00 $446.00 $510.00 $510.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $995.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $446.00 $418.49 $510.00 $510.00 $510.00 $510.00 $333.00 $333.00 $333.00

$446.00 $510.00 $446.00 $510.00 $510.00 $510.00 $630.00 $333.00 $510.00 $446.00 $510.00 $630.00 $510.00 $510.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $717.00 $446.00 $446.00 $446.00 $510.00 $630.00 $630.00 $446.00 $630.00 $510.00 $510.00 $446.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $103.62 $103.62 $446.00 $510.00 $630.00 $103.62 $446.00 $510.00

$446.00

44.27 44.27 20.83 44.27 44.27 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 5.41 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 20.83 3.4 16.1 8.69 20.83 20.83 20.83 44.27 5.1 20.83 20.83 20.83 5.03 4.81 20.83 44.27 20.83 20.83 20.83 20.83 20.83 44.27 20.83 4.61 20.83 20.83 20.83 20.83 20.83 29.42 29.42 29.42 29.42 29.42 29.42 29.42 29.42 44.27 20.83 44.27 44.27 20.83 20.83 20.83 44.27 20.83 20.83 20.83 20.83 44.27 44.27 20.83 20.83 20.83 20.83 1.77 1.77 26.16 59.22 41.11 1.77 1.77 26.16 41.11 44.27 1.77 1.77 26.16

$1,832.77 $1,832.77 $862.32 $1,832.77 $1,832.77 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $223.95 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $862.32 $140.92 $666.56 $359.57 $862.32 $862.32 $862.32 $1,832.77 $211.00 $862.32 $862.32 $862.32 $208.34 $199.20 $862.32 $1,832.77 $862.32 $862.32 $862.32 $862.32 $862.32 $1,832.77 $862.32 $190.82 $862.32 $862.32 $862.32 $862.32 $862.32 $1,217.88 $1,217.88 $1,217.88 $1,217.88 $1,217.88 $1,217.88 $1,217.88 $1,217.88 $1,832.77 $862.32 $1,832.77 $1,832.77 $862.32 $862.32 $862.32 $1,832.77 $862.32 $862.32 $862.32 $862.32 $1,832.77 $1,832.77 $862.32 $862.32 $862.32 $862.32 $73.21 $73.21 $1,083.02 $2,451.90 $1,701.96 $73.21 $73.21 $1,083.02 $1,701.96 $1,832.77 $73.21 $73.21 $1,083.02

$840.69 $840.69 $550.08 $840.69 $840.69 $550.08 $598.08 $598.08 $598.08 $598.08 $598.08 $598.08 $688.08 $688.08 $961.83 $598.08 $223.95 $598.08 $598.08 $598.08 $598.08 $598.08 $598.08 $598.08 $598.08 $598.08 $140.92 $501.14 $403.76 $598.08 $598.08 $598.08 $840.69 $211.00 $465.33 $465.33 $465.33 $208.34 $199.20 $550.08 $840.69 $550.08 $598.08 $598.08 $598.08 $688.08 $707.94 $598.08 $190.82 $550.08 $598.08 $688.08 $598.08 $598.08 $638.97 $638.97 $686.97 $686.97 $686.97 $686.97 $686.97 $842.22 $792.69 $550.08 $792.69 $840.69 $688.08 $688.08 $550.08 $930.69 $598.08 $598.08 $550.08 $688.08 $930.69 $930.69 $688.08 $688.08 $688.08 $688.08 $96.02 $96.02 $605.26 $995.48 $897.99 $73.21 $96.02 $605.26 $807.99 $1,832.77 $73.21 $73.21 $605.26 Page 16 of 38

28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28810 28820 28825 28890* 29000 29010 29015 29020 29025 29035 29040 29044 29046 29049 29055 29058 29065 29075 29085 29086 29105 29125 29126 29130 29131 29200 29220 29240 29260 29280 29305 29325 29345 29355 29358 29365 29405 29425 29435 29440 29445 29450 29505 29515 29520 29530 29540 29550 29580

Treat midfoot fracture, each Treat metatarsal fracture Treat metatarsal fracture Treat metatarsal fracture Treat metatarsal fracture Treat big toe fracture Treat big toe fracture Treat big toe fracture Treat big toe fracture Treatment of toe fracture Treatment of toe fracture Treat toe fracture Treat sesamoid bone fracture Treat sesamoid bone fracture Treat foot dislocation Treat foot dislocation Treat foot dislocation Repair foot dislocation Treat foot dislocation Treat foot dislocation Treat foot dislocation Repair foot dislocation Treat foot dislocation Treat foot dislocation Treat foot dislocation Repair foot dislocation Treat toe dislocation Treat toe dislocation Treat toe dislocation Repair toe dislocation Treat toe dislocation Treat toe dislocation Treat toe dislocation Repair of toe dislocation Fusion of foot bones Fusion of foot bones Fusion of foot bones Fusion of foot bones Fusion of foot bones Revision of foot bones Fusion of foot bones Fusion of big toe joint Fusion of big toe joint Fusion of big toe joint Amputation toe & metatarsal Amputation of toe Partial amputation of toe High energy eswt, plantar f Application of body cast Application of body cast Application of body cast Application of body cast Application of body cast Application of body cast Application of body cast Application of body cast Application of body cast Application of figure eight Application of shoulder cast Application of shoulder cast Application of long arm cast Application of forearm cast Apply hand/wrist cast Apply finger cast Apply long arm splint Apply forearm splint Apply forearm splint Application of finger splint Application of finger splint Strapping of chest Strapping of low back Strapping of shoulder Strapping of elbow or wrist Strapping of hand or finger Application of hip cast Application of hip casts Application of long leg cast Application of long leg cast Apply long leg cast brace Application of long leg cast Apply short leg cast Apply short leg cast Apply short leg cast Addition of walker to cast Apply rigid leg cast Application of leg cast Application, long leg splint Application lower leg splint Strapping of hip Strapping of knee Strapping of ankle and/or ft Strapping of toes Application of paste boot

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N

A2 P2 P2 A2 A2 P2 P2 A2 A2 P3 P2 A2 P3 A2 P2 A2 A2 A2 P2 A2 A2 A2 P2 A2 A2 A2 P3 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 G2 P2 P2 G2 P2 P2 G2 P2 G2 P2 P2 P2 P3 P3 P2 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P2 P2 P3 P3 P3 P3 P3 P3 P3 P3 P3 P2 P3 P3 P3 P3 P3 P3 P3

$510.00

$446.00 $630.00

$446.00 $510.00

$510.00 $510.00 $333.00 $446.00 $446.00 $103.62 $510.00 $510.00 $103.62 $446.00 $510.00 $333.00 $510.00 $510.00 $333.00 $510.00 $510.00 $630.00 $630.00 $630.00 $630.00 $630.00 $717.00 $630.00 $630.00 $630.00 $630.00 $446.00 $446.00 $446.00

41.11 1.77 1.77 26.16 41.11 1.77 1.77 26.16 26.16 1.48 1.77 26.16 1.41 26.16 1.77 26.16 26.16 41.11 1.77 1.77 26.16 26.16 1.77 1.77 26.16 41.11 1.57 14.77 26.16 26.16 1.18 14.77 26.16 26.16 44.27 79.42 44.27 44.27 44.27 44.27 44.27 44.27 20.83 44.27 20.83 20.83 20.83 4.73 1.09 2.29 2.29 1.09 1.09 2.29 1.09 2.29 2.29 1.09 2.29 1.09 1.2 1.15 1.09 0.94 1.07 0.91 1.02 0.41 0.61 0.61 0.63 0.7 0.65 0.67 2.29 2.29 1.58 1.53 1.88 1.49 1.11 1.13 1.42 0.62 1.55 1.09 1.04 0.84 0.69 0.66 0.44 0.45 0.63

$1,701.96 $73.21 $73.21 $1,083.02 $1,701.96 $73.21 $73.21 $1,083.02 $1,083.02 $61.32 $73.21 $1,083.02 $58.27 $1,083.02 $73.21 $1,083.02 $1,083.02 $1,701.96 $73.21 $73.21 $1,083.02 $1,083.02 $73.21 $73.21 $1,083.02 $1,701.96 $65.13 $611.32 $1,083.02 $1,083.02 $48.75 $611.32 $1,083.02 $1,083.02 $1,832.77 $3,288.25 $1,832.77 $1,832.77 $1,832.77 $1,832.77 $1,832.77 $1,832.77 $862.32 $1,832.77 $862.32 $862.32 $862.32 $195.77 $45.26 $94.85 $94.85 $45.26 $45.26 $94.85 $45.26 $94.85 $94.85 $45.26 $94.85 $45.26 $49.51 $47.61 $45.26 $38.85 $44.18 $37.71 $42.28 $17.14 $25.14 $25.14 $26.28 $28.95 $27.04 $27.80 $94.85 $94.85 $65.51 $63.22 $77.70 $61.70 $46.09 $46.85 $58.65 $25.52 $63.99 $45.26 $43.04 $34.66 $28.57 $27.42 $18.28 $18.66 $25.90

$807.99 $73.21 $73.21 $605.26 $897.99 $73.21 $73.21 $605.26 $653.26 $61.32 $73.21 $653.26 $58.27 $653.26 $73.21 $520.51 $605.26 $759.99 $73.21 $96.02 $653.26 $653.26 $73.21 $96.02 $605.26 $807.99 $65.13 $402.58 $653.26 $653.26 $48.75 $402.58 $653.26 $653.26 $930.69 $1,294.56 $930.69 $930.69 $930.69 $995.94 $930.69 $930.69 $688.08 $930.69 $550.08 $550.08 $550.08 $195.77 $45.26 $94.85 $94.85 $45.26 $45.26 $94.85 $45.26 $94.85 $94.85 $45.26 $94.85 $45.26 $49.51 $47.61 $45.26 $38.85 $44.18 $37.71 $42.28 $17.14 $25.14 $25.14 $26.28 $28.95 $27.04 $27.80 $94.85 $94.85 $65.51 $63.22 $77.70 $61.70 $46.09 $46.85 $58.65 $25.52 $63.99 $45.26 $43.04 $34.66 $28.57 $27.42 $18.28 $18.66 $25.90 Page 17 of 38

29590 29700 29705 29710 29715 29720 29730 29740 29750 29800 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29848 29850 29851 29855 29856 29860 29861 29862 29863 29866 29870 29871 29873 29874 29875 29876 29877 29879 29880 29881 29882 29883 29884 29885 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29899 29900 29901 29902 29904 29905 29906 29907 30000 30020 30100 30110 30115 30117 30118 30120 30124 30125 30130 30140 30150 30160

Application of foot splint Removal/revision of cast Removal/revision of cast Removal/revision of cast Removal/revision of cast Repair of body cast Windowing of cast Wedging of cast Wedging of clubfoot cast Jaw arthroscopy/surgery Jaw arthroscopy/surgery Shoulder arthroscopy, dx Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Shoulder arthroscopy/surgery Arthroscop rotator cuff repr Arthroscopy biceps tenodesis Elbow arthroscopy Elbow arthroscopy/surgery Elbow arthroscopy/surgery Elbow arthroscopy/surgery Elbow arthroscopy/surgery Elbow arthroscopy/surgery Wrist arthroscopy Wrist arthroscopy/surgery Wrist arthroscopy/surgery Wrist arthroscopy/surgery Wrist arthroscopy/surgery Wrist arthroscopy/surgery Wrist endoscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Tibial arthroscopy/surgery Tibial arthroscopy/surgery Hip arthroscopy, dx Hip arthroscopy/surgery Hip arthroscopy/surgery Hip arthroscopy/surgery Autgrft implnt, knee w/scope Knee arthroscopy, dx Knee arthroscopy/drainage Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Knee arthroscopy/surgery Ankle arthroscopy/surgery Ankle arthroscopy/surgery Scope, plantar fasciotomy Ankle arthroscopy/surgery Ankle arthroscopy/surgery Ankle arthroscopy/surgery Ankle arthroscopy/surgery Ankle arthroscopy/surgery Mcp joint arthroscopy, dx Mcp joint arthroscopy, surg Mcp joint arthroscopy, surg Subtalar arthro w/fb rmvl Subtalar arthro w/exc Subtalar arthro w/deb Subtalar arthro w/fusion Drainage of nose lesion Drainage of nose lesion Intranasal biopsy Removal of nose polyp(s) Removal of nose polyp(s) Removal of intranasal lesion Removal of intranasal lesion Revision of nose Removal of nose lesion Removal of nose lesion Excise inferior turbinate Resect inferior turbinate Partial removal of nose Removal of nose

Date Printed: 10/18/2008 @ 17:46:00

N N N N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P3 P3 P3 P3 P2 P3 P3 P3 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 P2 P2 P3 P3 A2 A2 A2 A2 R2 A2 A2 A2 A2 A2

$510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $717.00 $510.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $1,339.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $1,339.00 $630.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $510.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $1,255.56 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00

$446.00 $510.00 $510.00 $333.00 $446.00 $510.00 $446.00 $510.00 $630.00

0.51 0.85 0.73 1.32 1.09 1.07 0.71 1 0.98 28.78 28.78 28.78 45.71 45.71 45.71 45.71 45.71 28.78 45.71 28.78 45.71 45.71 45.71 45.71 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 45.71 28.78 28.78 45.71 45.71 45.71 45.71 45.71 45.71 45.71 45.71 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 28.78 45.71 28.78 28.78 45.71 45.71 45.71 45.71 20.83 28.78 28.78 28.78 28.78 45.71 28.78 28.78 28.78 28.78 28.78 28.78 45.71 2.5 2.5 2.1 3.28 16.33 16.33 23.98 16.33 7.45 39.88 16.33 23.98 39.88 39.88

$20.95 $35.04 $30.09 $54.46 $45.26 $44.18 $29.33 $41.51 $40.37 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,191.53 $1,892.32 $1,191.53 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $1,191.53 $1,191.53 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $1,191.53 $1,191.53 $1,892.32 $1,892.32 $1,892.32 $1,892.32 $862.32 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $103.51 $103.51 $86.84 $135.97 $676.03 $676.03 $992.65 $676.03 $308.33 $1,650.97 $676.03 $992.65 $1,650.97 $1,650.97

$20.95 $35.04 $30.09 $54.46 $45.26 $44.18 $29.33 $41.51 $40.37 $680.38 $680.38 $680.38 $855.58 $855.58 $855.58 $855.58 $855.58 $680.38 $855.58 $835.63 $855.58 $855.58 $1,010.83 $1,892.32 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $680.38 $855.58 $1,302.13 $770.38 $945.58 $945.58 $945.58 $945.58 $945.58 $1,477.33 $945.58 $1,892.32 $680.38 $680.38 $680.38 $680.38 $770.38 $770.38 $770.38 $680.38 $770.38 $770.38 $680.38 $680.38 $680.38 $855.58 $680.38 $680.38 $855.58 $855.58 $855.58 $855.58 $1,157.25 $680.38 $680.38 $680.38 $680.38 $855.58 $680.38 $680.38 $680.38 $1,191.53 $1,191.53 $1,191.53 $1,892.32 $103.51 $103.51 $86.84 $135.97 $503.51 $551.51 $630.66 $418.76 $308.33 $747.24 $551.51 $582.66 $795.24 $885.24 Page 18 of 38

30200 30210 30220 30300 30310 30320 30400 30410 30420 30430 30435 30450 30460 30462 30465 30520 30540 30545 30560 30580 30600 30620 30630 30801 30802 30901 30903 30905 30906 30915 30920 30930 31000 31002 31020 31030 31032 31040 31050 31051 31070 31075 31080 31081 31084 31085 31086 31087 31090 31200 31201 31205 31231 31233 31235 31237 31238 31239 31240 31254 31255 31256 31267 31276 31287 31288 31300 31320 31400 31420 31500 31502 31505 31510 31511 31512 31513 31515 31520 31525 31526 31527 31528 31529 31530 31531 31535 31536 31540 31541 31545 31546 31560

Injection treatment of nose Nasal sinus therapy Insert nasal septal button Remove nasal foreign body Remove nasal foreign body Remove nasal foreign body Reconstruction of nose Reconstruction of nose Reconstruction of nose Revision of nose Revision of nose Revision of nose Revision of nose Revision of nose Repair nasal stenosis Repair of nasal septum Repair nasal defect Repair nasal defect Release of nasal adhesions Repair upper jaw fistula Repair mouth/nose fistula Intranasal reconstruction Repair nasal septum defect Ablate inf turbinate, superf Cauterization, inner nose Control of nosebleed Control of nosebleed Control of nosebleed Repeat control of nosebleed Ligation, nasal sinus artery Ligation, upper jaw artery Ther fx, nasal inf turbinate Irrigation, maxillary sinus Irrigation, sphenoid sinus Exploration, maxillary sinus Exploration, maxillary sinus Explore sinus, remove polyps Exploration behind upper jaw Exploration, sphenoid sinus Sphenoid sinus surgery Exploration of frontal sinus Exploration of frontal sinus Removal of frontal sinus Removal of frontal sinus Removal of frontal sinus Removal of frontal sinus Removal of frontal sinus Removal of frontal sinus Exploration of sinuses Removal of ethmoid sinus Removal of ethmoid sinus Removal of ethmoid sinus Nasal endoscopy, dx Nasal/sinus endoscopy, dx Nasal/sinus endoscopy, dx Nasal/sinus endoscopy, surg Nasal/sinus endoscopy, surg Nasal/sinus endoscopy, surg Nasal/sinus endoscopy, surg Revision of ethmoid sinus Removal of ethmoid sinus Exploration maxillary sinus Endoscopy, maxillary sinus Sinus endoscopy, surgical Nasal/sinus endoscopy, surg Nasal/sinus endoscopy, surg Removal of larynx lesion Diagnostic incision, larynx Revision of larynx Removal of epiglottis Insert emergency airway Change of windpipe airway Diagnostic laryngoscopy Laryngoscopy with biopsy Remove foreign body, larynx Removal of larynx lesion Injection into vocal cord Laryngoscopy for aspiration Dx laryngoscopy, newborn Dx laryngoscopy excl nb Dx laryngoscopy w/oper scope Laryngoscopy for treatment Laryngoscopy and dilation Laryngoscopy and dilation Laryngoscopy w/fb removal Laryngoscopy w/fb & op scope Laryngoscopy w/biopsy Laryngoscopy w/bx & op scope Laryngoscopy w/exc of tumor Larynscop w/tumr exc + scope Remove vc lesion w/scope Remove vc lesion scope/graft Laryngoscop w/arytenoidectom

Date Printed: 10/18/2008 @ 17:46:00

Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P3 P3 A2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 A2 P2 R2 A2 A2 A2 R2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 P2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$464.15 $333.00 $446.00 $630.00 $717.00 $717.00 $510.00 $717.00 $995.00 $995.00 $1,339.00 $1,339.00 $630.00 $717.00 $717.00 $150.72 $630.00 $630.00 $995.00 $995.00 $333.00 $333.00 $72.48 $72.48 $72.48 $446.00 $510.00 $630.00

$446.00 $510.00 $630.00 $446.00 $630.00 $446.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $717.00 $446.00 $717.00 $510.00 $86.39 $333.00 $446.00 $333.00 $630.00 $446.00 $510.00 $717.00 $510.00 $510.00 $510.00 $510.00 $510.00 $717.00 $446.00 $446.00 $446.00

$446.00 $86.39 $446.00 $86.39 $333.00 $333.00 $446.00 $333.00 $446.00 $446.00 $446.00 $510.00 $446.00 $510.00 $510.00 $630.00 $630.00 $630.00 $717.00

1.67 2.13 7.45 0.63 16.33 16.33 39.88 39.88 39.88 23.98 39.88 39.88 39.88 39.88 39.88 23.98 39.88 39.88 2.5 39.88 39.88 39.88 23.98 7.45 7.45 1.13 1.13 1.13 1.13 25.84 25.84 16.33 2.5 7.45 23.98 39.88 39.88 23.98 39.88 39.88 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 1.61 1.61 17.02 17.02 17.02 22.72 17.02 22.72 22.72 22.72 22.72 22.72 22.72 22.72 23.98 39.88 39.88 39.88 2.46 1.34 0.82 17.02 1.61 17.02 1.61 17.02 1.61 17.02 22.72 22.72 17.02 17.02 22.72 22.72 22.72 22.72 22.72 22.72 22.72 22.72 22.72

$69.32 $87.98 $308.33 $26.12 $676.03 $676.03 $1,650.97 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $103.51 $1,650.97 $1,650.97 $1,650.97 $992.65 $308.33 $308.33 $46.58 $46.58 $46.58 $46.58 $1,069.84 $1,069.84 $676.03 $103.51 $308.33 $992.65 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $66.72 $66.72 $704.48 $704.48 $704.48 $940.59 $704.48 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59 $992.65 $1,650.97 $1,650.97 $1,650.97 $101.81 $55.32 $34.05 $704.48 $66.72 $704.48 $66.72 $704.48 $66.72 $704.48 $940.59 $940.59 $704.48 $704.48 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59 $940.59

$69.32 $87.98 $425.20 $26.12 $418.76 $503.51 $885.24 $950.49 $950.49 $630.66 $950.49 $1,158.99 $1,158.99 $1,416.99 $1,416.99 $720.66 $950.49 $950.49 $138.92 $885.24 $885.24 $1,158.99 $994.41 $326.83 $326.83 $46.58 $66.01 $66.01 $66.01 $601.96 $649.96 $641.51 $103.51 $308.33 $582.66 $795.24 $885.24 $992.65 $747.24 $885.24 $582.66 $885.24 $885.24 $885.24 $885.24 $885.24 $885.24 $885.24 $950.49 $747.24 $950.49 $795.24 $66.72 $81.47 $425.87 $510.62 $425.87 $707.65 $510.62 $617.65 $772.90 $617.65 $617.65 $617.65 $617.65 $617.65 $785.91 $747.24 $747.24 $747.24 $101.81 $55.32 $34.05 $510.62 $81.47 $510.62 $81.47 $425.87 $66.72 $425.87 $569.65 $484.90 $510.62 $510.62 $569.65 $617.65 $569.65 $617.65 $617.65 $707.65 $707.65 $707.65 $772.90 Page 19 of 38

31561 31570 31571 31575 31576 31577 31578 31579 31580 31582 31588 31590 31595 31603 31605 31611 31612 31613 31614 31615 31620 31622 31623 31624 31625 31628 31629 31630 31631 31632 31633 31635 31636 31637 31638 31640 31641 31643 31645 31646 31656 31715 31717 31720 31730 31750 31755 31820 31825 31830 32000 32002 32019 32400 32405 32420 32421 32422 32550 32960 32998 33010 33011 33206 33207 33208 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33222 33223 33224 33225 33226 33233 33234 33235 33240 33241 33249 33282 33284 33508 35188 35207

Larynscop, remve cart + scop Laryngoscope w/vc inj Laryngoscop w/vc inj + scope Diagnostic laryngoscopy Laryngoscopy with biopsy Remove foreign body, larynx Removal of larynx lesion Diagnostic laryngoscopy Revision of larynx Revision of larynx Revision of larynx Reinnervate larynx Larynx nerve surgery Incision of windpipe Incision of windpipe Surgery/speech prosthesis Puncture/clear windpipe Repair windpipe opening Repair windpipe opening Visualization of windpipe Endobronchial us add-on Dx bronchoscope/wash Dx bronchoscope/brush Dx bronchoscope/lavage Bronchoscopy w/biopsy(s) Bronchoscopy/lung bx, each Bronchoscopy/needle bx, each Bronchoscopy dilate/fx repr Bronchoscopy, dilate w/stent Bronchoscopy/lung bx, add’l Bronchoscopy/needle bx add’l Bronchoscopy w/fb removal Bronchoscopy, bronch stents Bronchoscopy, stent add-on Bronchoscopy, revise stent Bronchoscopy w/tumor excise Bronchoscopy, treat blockage Diag bronchoscope/catheter Bronchoscopy, clear airways Bronchoscopy, reclear airway Bronchoscopy, inj for x-ray Injection for bronchus x-ray Bronchial brush biopsy Clearance of airways Intro, windpipe wire/tube Repair of windpipe Repair of windpipe Closure of windpipe lesion Repair of windpipe defect Revise windpipe scar Drainage of chest Treatment of collapsed lung Insert pleural catheter Needle biopsy chest lining Biopsy, lung or mediastinum Puncture/clear lung Thoracentesis for aspiration Thoracentesis w/tube insert Insert pleural cath Therapeutic pneumothorax Perq rf ablate tx, pul tumor Drainage of heart sac Repeat drainage of heart sac Insertion of heart pacemaker Insertion of heart pacemaker Insertion of heart pacemaker Insertion of heart electrode Insertion of heart electrode Insertion of pulse generator Insertion of pulse generator Upgrade of pacemaker system Reposition pacing-defib lead Insert lead pace-defib, one Insert lead pace-defib, dual Repair lead pace-defib, one Repair lead pace-defib, dual Revise pocket, pacemaker Revise pocket, pacing-defib Insert pacing lead & connect L ventric pacing lead add-on Reposition l ventric lead Removal of pacemaker system Removal of pacemaker system Removal pacemaker electrode Insert pulse generator Remove pulse generator Eltrd/insert pace-defib Implant pat-active ht record Remove pat-active ht record Endoscopic vein harvest Repair blood vessel lesion Repair blood vessel lesion

Date Printed: 10/18/2008 @ 17:46:01

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y N Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y N Y Y

A2 A2 A2 P2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 N1 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 A2 A2 A2 A2 A2 A2 A2 D5 D5 D5 A2 A2 A2 A2 G2 G2 G2 G2 A2 A2 J8 J8 J8 J8 J8 H8 H8 J8 G2 J8 J8 G2 G2 A2 A2 J8 J8 G2 A2 G2 G2 J8 G2 J8 J8 G2 N1 A2 A2

$717.00 $446.00 $446.00

22.72 17.02 22.72 1.61 22.72 3.99 22.72 3.05 39.88 39.88 39.88 39.88 39.88 7.45 7.45 23.98 23.98 23.98 39.88 9.96

$940.59 $704.48 $940.59 $66.72 $940.59 $165.36 $940.59 $126.45 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $308.33 $308.33 $992.65 $992.65 $992.65 $1,650.97 $412.25

$772.90 $510.62 $569.65 $66.72 $569.65 $218.66 $569.65 $126.45 $950.49 $950.49 $950.49 $950.49 $747.24 $326.83 $308.33 $630.66 $497.91 $582.66 $747.24 $352.81

$446.00 $446.00 $333.00 $446.00 $446.00 $446.00 $446.00 $333.00 $333.00 $333.00

9.96 9.96 9.96 9.96 9.96 9.96 24.07 24.07 9.96 9.96 9.96 24.07 9.96 24.07 24.07 24.07 9.96 9.96 9.96 9.96

$412.25 $412.25 $412.25 $412.25 $412.25 $412.25 $996.33 $996.33 $412.25 $412.25 $412.25 $996.33 $412.25 $996.33 $996.33 $996.33 $412.25 $412.25 $412.25 $412.25

$352.81 $437.56 $437.56 $437.56 $437.56 $437.56 $583.58 $583.58 $412.25 $412.25 $437.56 $583.58 $352.81 $583.58 $583.58 $583.58 $437.56 $352.81 $352.81 $352.81

$236.42 $47.32 $236.42 $717.00 $446.00 $333.00 $446.00 $446.00

3.99 0.39 3.99 39.88 39.88 16.33 23.98 23.98

$165.36 $16.05 $165.36 $1,650.97 $1,650.97 $676.03 $992.65 $992.65

$218.66 $39.50 $218.66 $950.49 $747.24 $418.76 $582.66 $582.66

$333.00 $333.00 $222.78 $222.78

9.34 9.34 5.2 5.2 5.2 30.71 5.2 43 5.2 5.2 169.46 169.46 196.3 90.58 90.58 142.1 154.67 196.3 23.98 90.58 90.58 23.98 23.98 15.05 15.05 375.17 375.17 23.98 23.98 23.98 23.98 493.98 23.98 599.4 98.42 8.69

$386.49 $386.49 $215.38 $215.38 $215.38 $1,271.41 $215.38 $1,780.16 $215.38 $215.38 $7,015.93 $7,015.93 $8,126.88 $3,750.06 $3,750.06 $5,883.26 $6,403.63 $8,126.88 $992.80 $3,750.06 $3,750.06 $992.80 $992.80 $622.91 $622.91 $15,532.24 $15,532.24 $992.80 $992.80 $992.80 $992.80 $20,451.28 $992.80 $24,815.65 $4,074.63 $359.57

$346.37 $346.37 $220.93 $220.93 $215.38 $1,271.41 $215.38 $1,780.16 $220.93 $220.93 $7,015.93 $7,015.93 $8,126.88 $3,750.06 $3,750.06 $5,514.64 $6,010.06 $8,126.88 $992.80 $3,750.06 $3,750.06 $992.80 $992.80 $490.23 $490.23 $15,532.24 $15,532.24 $992.80 $582.70 $992.80 $992.80 $20,451.28 $992.80 $24,815.65 $4,074.63 $359.57

38.77 38.77

$1,605.00 $1,605.00

$873.75 $873.75

$446.00 $236.42 $446.00 $717.00 $717.00 $717.00 $717.00 $446.00 $333.00 $510.00 $333.00 $446.00 $446.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00

$222.78 $222.78

$510.00 $510.00

$446.00 $446.00

$446.00

$630.00 $630.00

Page 20 of 38

35473 35476 35492 35572 35761 35875 35876 36000 36002 36005 36010 36011 36012 36013 36014 36015 36100 36120 36140 36145 36160 36200 36215 36216 36217 36218 36245 36246 36247 36248 36260 36261 36262 36400 36405 36406 36410 36416 36420 36425 36430 36440 36450 36468 36469 36470 36471 36475 36476 36478 36479 36481 36500 36510 36511 36512 36513 36514 36515 36516 36522 36540 36550 36555 36556 36557 36558 36560 36561 36563 36565 36566 36568 36569 36570 36571 36575 36576 36578 36580 36581 36582 36583 36584 36585 36589 36590 36591 36592 36593 36595 36596

Repair arterial blockage Repair venous blockage Atherectomy, percutaneous Harvest femoropopliteal vein Exploration of artery/vein Removal of clot in graft Removal of clot in graft Place needle in vein Pseudoaneurysm injection trt Injection ext venography Place catheter in vein Place catheter in vein Place catheter in vein Place catheter in artery Place catheter in artery Place catheter in artery Establish access to artery Establish access to artery Establish access to artery Artery to vein shunt Establish access to aorta Place catheter in aorta Place catheter in artery Place catheter in artery Place catheter in artery Place catheter in artery Place catheter in artery Place catheter in artery Place catheter in artery Place catheter in artery Insertion of infusion pump Revision of infusion pump Removal of infusion pump Bl draw < 3 yrs fem/jugular Bl draw < 3 yrs scalp vein Bl draw < 3 yrs other vein Non-routine bl draw > 3 yrs Capillary blood draw Vein access cutdown < 1 yr Vein access cutdown > 1 yr Blood transfusion service Bl push transfuse, 2 yr or < Bl exchange/transfuse, nb Injection(s), spider veins Injection(s), spider veins Injection therapy of vein Injection therapy of veins Endovenous rf, 1st vein Endovenous rf, vein add-on Endovenous laser, 1st vein Endovenous laser vein addon Insertion of catheter, vein Insertion of catheter, vein Insertion of catheter, vein Apheresis wbc Apheresis rbc Apheresis platelets Apheresis plasma Apheresis, adsorp/reinfuse Apheresis, selective Photopheresis Collect blood venous device Declot vascular device Insert non-tunnel cv cath Insert non-tunnel cv cath Insert tunneled cv cath Insert tunneled cv cath Insert tunneled cv cath Insert tunneled cv cath Insert tunneled cv cath Insert tunneled cv cath Insert tunneled cv cath Insert picc cath Insert picc cath Insert picvad cath Insert picvad cath Repair tunneled cv cath Repair tunneled cv cath Replace tunneled cv cath Replace cvad cath Replace tunneled cv cath Replace tunneled cv cath Replace tunneled cv cath Replace picc cath Replace picvad cath Removal tunneled cv cath Removal tunneled cv cath Draw blood off venous device Collect blood from picc Declot vascular device Mech remov tunneled cv cath Mech remov tunneled cv cath

Date Printed: 10/18/2008 @ 17:46:01

Y Y Y N Y Y Y N N N N N N N N N N N N N N N N N N N N N N N Y Y Y N N N N N Y Y N N N Y Y Y Y Y Y Y Y N N N N N N N N N N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y

G2 G2 G2 N1 G2 A2 A2 N1 G2 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 N1 A2 A2 A2 N1 N1 N1 N1 N1 G2 R2 P3 R2 R2 R2 R2 P2 P2 A2 A2 A2 A2 N1 N1 N1 G2 G2 G2 G2 G2 G2 G2 D5 D5 A2 A2 A2 A2 A2 A2 A2 A2 H8 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 N1 P3 G2 G2

45.38 45.38 87.51

$1,878.96 $1,878.96 $3,623.15

$1,878.96 $1,878.96 $3,623.15

29.7 38.77 38.77

$1,229.46 $1,605.00 $1,605.00

$1,229.46 $1,405.50 $1,405.50

2.38

$98.50

$98.50

$510.00 $446.00 $333.00

28.87 23.98 23.98

$1,195.42 $992.80 $992.80

$681.36 $582.70 $497.95

$1,339.00 $1,339.00 $1,339.00 $1,339.00

0.21 0.21 0.89 3.4 3.4 0.79 0.79 0.79 0.79 42.61 25.84 25.84 25.84

$8.87 $8.87 $36.94 $140.63 $140.63 $32.83 $32.83 $32.83 $32.83 $1,764.15 $1,069.84 $1,069.84 $1,069.84

$8.87 $8.87 $36.94 $140.63 $140.63 $32.83 $32.83 $32.83 $32.83 $1,445.29 $1,271.71 $1,271.71 $1,271.71

11.51 11.51 11.51 11.51 30.6 30.6 30.6

$476.35 $476.35 $476.35 $476.35 $1,267.02 $1,267.02 $1,267.02

$476.35 $476.35 $476.35 $476.35 $1,267.02 $1,267.02 $1,267.02

10.91 10.91 24.11 24.11 28.87 28.87 28.87 28.87 107.67 10.91 10.91 24.11 24.11 5.66 10.91 24.11 10.91 24.11 28.87 28.87 10.91 24.11 5.66 10.91

$451.65 $451.65 $998.05 $998.05 $1,195.42 $1,195.42 $1,195.42 $1,195.42 $4,457.50 $451.65 $451.65 $998.05 $998.05 $234.39 $451.65 $998.05 $451.65 $998.05 $1,195.42 $1,195.42 $451.65 $998.05 $234.39 $451.65

$362.66 $362.66 $584.01 $584.01 $681.36 $681.36 $681.36 $681.36 $3,796.23 $362.66 $362.66 $632.01 $632.01 $393.10 $447.41 $584.01 $362.66 $584.01 $681.36 $681.36 $362.66 $632.01 $308.35 $362.66

0.55 24.11 10.91

$22.85 $998.05 $451.65

$22.85 $998.05 $451.65

$1,339.00 $1,339.00

$333.00 $333.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $333.00 $333.00 $510.00 $510.00 $446.00 $446.00 $446.00 $333.00 $446.00 $510.00 $510.00 $333.00 $510.00 $333.00 $333.00

Page 21 of 38

36597 36598 36600 36620 36625 36640 36680 36800 36810 36815 36818 36819 36820 36821 36825 36830 36831 36832 36833 36834 36835 36860 36861 36870 37184 37185 37186 37187 37188 37200 37203 37250 37251 37500 37607 37609 37650 37700 37718 37722 37735 37760 37765 37766 37780 37785 37790 38200 38204 38205 38206 38220 38221 38230 38241 38242 38300 38305 38308 38500 38505 38510 38520 38525 38530 38542 38550 38555 38570 38571 38572 38700 38740 38745 38760 38790 38792 38794 40490 40500 40510 40520 40525 40527 40530 40650 40652 40654 40700 40701 40702 40720

Reposition venous catheter Inj w/fluor, eval cv device Withdrawal of arterial blood Insertion catheter, artery Insertion catheter, artery Insertion catheter, artery Insert needle, bone cavity Insertion of cannula Insertion of cannula Insertion of cannula Av fuse, uppr arm, cephalic Av fuse, uppr arm, basilic Av fusion/forearm vein Av fusion direct any site Artery-vein autograft Artery-vein nonautograft Open thrombect av fistula Av fistula revision, open Av fistula revision Repair a-v aneurysm Artery to vein shunt External cannula declotting Cannula declotting Percut thrombect av fistula Prim art mech thrombectomy Prim art m-thrombect add-on Sec art m-thrombect add-on Venous mech thrombectomy Venous m-thrombectomy add-on Transcatheter biopsy Transcatheter retrieval Iv us first vessel add-on Iv us each add vessel add-on Endoscopy ligate perf veins Ligation of a-v fistula Temporal artery procedure Revision of major vein Revise leg vein Ligate/strip short leg vein Ligate/strip long leg vein Removal of leg veins/lesion Ligation, leg veins, open Phleb veins extrem 10-20 Phleb veins extrem 20+ Revision of leg vein Ligate/divide/excise vein Penile venous occlusion Injection for spleen x-ray Bl donor search management Harvest allogenic stem cells Harvest auto stem cells Bone marrow aspiration Bone marrow biopsy Bone marrow collection Bone marrow/stem transplant Lymphocyte infuse transplant Drainage, lymph node lesion Drainage, lymph node lesion Incision of lymph channels Biopsy/removal, lymph nodes Needle biopsy, lymph nodes Biopsy/removal, lymph nodes Biopsy/removal, lymph nodes Biopsy/removal, lymph nodes Biopsy/removal, lymph nodes Explore deep node(s), neck Removal, neck/armpit lesion Removal, neck/armpit lesion Laparoscopy, lymph node biop Laparoscopy, lymphadenectomy Laparoscopy, lymphadenectomy Removal of lymph nodes, neck Remove armpit lymph nodes Remove armpit lymph nodes Remove groin lymph nodes Inject for lymphatic x-ray Identify sentinel node Access thoracic lymph duct Biopsy of lip Partial excision of lip Partial excision of lip Partial excision of lip Reconstruct lip with flap Reconstruct lip with flap Partial removal of lip Repair lip Repair lip Repair lip Repair cleft lip/nasal Repair cleft lip/nasal Repair cleft lip/nasal Repair cleft lip/nasal

Date Printed: 10/18/2008 @ 17:46:01

Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y

G2 P3 N1 N1 N1 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 G2 G2 G2 N1 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 R2 R2 A2 A2 A2 N1 N1 G2 G2 P3 P3 G2 G2 R2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 N1 N1 N1 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 R2 A2

$333.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $1,339.00 $630.00 $630.00 $510.00 $630.00 $127.40 $510.00 $1,339.00

$510.00 $510.00 $446.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00

$510.00 $510.00 $510.00

$333.00 $446.00 $446.00 $446.00 $240.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $630.00 $1,339.00 $1,339.00 $1,339.00 $446.00 $630.00 $446.00

$446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $464.15 $464.15 $464.15 $995.00 $995.00 $995.00

10.91 2.24

$451.65 $92.55

$451.65 $92.55

28.87 1.11 29.7 29.7 29.7 38.77 38.77 38.77 38.77 38.77 38.77 38.77 38.77 38.77 38.77 29.7 2.48 29.7 40.47 38.77 38.77 38.77 38.77 38.77 28.87 28.87

$1,195.42 $45.94 $1,229.46 $1,229.46 $1,229.46 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,229.46 $102.77 $1,229.46 $1,675.36 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,195.42 $1,195.42

$548.61 $45.94 $689.87 $689.87 $689.87 $783.75 $783.75 $783.75 $783.75 $873.75 $873.75 $1,405.50 $873.75 $873.75 $783.75 $779.87 $121.24 $689.87 $1,423.09 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,605.00 $1,195.42 $1,195.42

42.61 25.84 16.1 25.84 25.84 25.84 42.61 42.61 25.84 25.84 25.84 25.84 25.84 33.93

$1,764.15 $1,069.84 $666.56 $1,069.84 $1,069.84 $1,069.84 $1,764.15 $1,764.15 $1,069.84 $1,069.84 $1,069.84 $1,069.84 $1,069.84 $1,404.76

$823.54 $649.96 $501.14 $601.96 $601.96 $649.96 $823.54 $823.54 $649.96 $1,069.84 $1,069.84 $649.96 $649.96 $733.69

11.51 11.51 2.94 3.09 30.6 30.6 11.51 11.56 18.32 22.96 22.96 7.11 22.96 22.96 22.96 22.96 44.32 22.96 22.96 45.53 69.67 45.53 22.96 44.32 44.32 22.96

$476.35 $476.35 $121.88 $127.97 $1,267.02 $1,267.02 $476.35 $478.57 $758.45 $950.50 $950.50 $294.56 $950.50 $950.50 $950.50 $950.50 $1,835.06 $950.50 $950.50 $1,885.06 $2,884.21 $1,885.06 $950.50 $1,835.06 $1,835.06 $950.50

$476.35 $476.35 $121.88 $127.97 $1,267.02 $1,267.02 $476.35 $369.39 $524.11 $572.13 $572.13 $253.64 $572.13 $572.13 $572.13 $572.13 $793.27 $620.13 $710.13 $1,475.52 $1,725.30 $1,475.52 $950.50 $793.27 $931.27 $572.13

1.7 16.33 23.98 16.33 23.98 23.98 23.98 7.45 7.45 7.45 39.88 39.88 39.88 39.88

$70.46 $676.03 $992.65 $676.03 $992.65 $992.65 $992.65 $308.33 $308.33 $308.33 $1,650.97 $1,650.97 $1,650.97 $1,650.97

$70.46 $503.51 $582.66 $503.51 $582.66 $582.66 $582.66 $425.20 $425.20 $425.20 $1,158.99 $1,158.99 $1,650.97 $1,158.99

Page 22 of 38

40761 40800 40801 40804 40805 40806 40808 40810 40812 40814 40816 40818 40819 40820 40830 40831 40840 40842 40843 40844 40845 41000 41005 41006 41007 41008 41009 41010 41015 41016 41017 41018 41019 41100 41105 41108 41110 41112 41113 41114 41115 41116 41120 41250 41251 41252 41500 41510 41520 41800 41805 41806 41820 41821 41822 41823 41825 41826 41827 41828 41830 41850 41870 41872 41874 42000 42100 42104 42106 42107 42120 42140 42145 42160 42180 42182 42200 42205 42210 42215 42220 42226 42235 42260 42280 42281 42300 42305 42310 42320 42330 42335 42340

Repair cleft lip/nasal Drainage of mouth lesion Drainage of mouth lesion Removal, foreign body, mouth Removal, foreign body, mouth Incision of lip fold Biopsy of mouth lesion Excision of mouth lesion Excise/repair mouth lesion Excise/repair mouth lesion Excision of mouth lesion Excise oral mucosa for graft Excise lip or cheek fold Treatment of mouth lesion Repair mouth laceration Repair mouth laceration Reconstruction of mouth Reconstruction of mouth Reconstruction of mouth Reconstruction of mouth Reconstruction of mouth Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Incision of tongue fold Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Drainage of mouth lesion Place needles h&n for rt Biopsy of tongue Biopsy of tongue Biopsy of floor of mouth Excision of tongue lesion Excision of tongue lesion Excision of tongue lesion Excision of tongue lesion Excision of tongue fold Excision of mouth lesion Partial removal of tongue Repair tongue laceration Repair tongue laceration Repair tongue laceration Fixation of tongue Tongue to lip surgery Reconstruction, tongue fold Drainage of gum lesion Removal foreign body, gum Removal foreign body,jawbone Excision, gum, each quadrant Excision of gum flap Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Excision of gum lesion Removal of gum tissue Treatment of gum lesion Gum graft Repair gum Repair tooth socket Drainage mouth roof lesion Biopsy roof of mouth Excision lesion, mouth roof Excision lesion, mouth roof Excision lesion, mouth roof Remove palate/lesion Excision of uvula Repair palate, pharynx/uvula Treatment mouth roof lesion Repair palate Repair palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Reconstruct cleft palate Lengthening of palate Repair palate Repair nose to lip fistula Preparation, palate mold Insertion, palate prosthesis Drainage of salivary gland Drainage of salivary gland Drainage of salivary gland Drainage of salivary gland Removal of salivary stone Removal of salivary stone Removal of salivary stone

Date Printed: 10/18/2008 @ 17:46:01

Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 P2 A2 P2 P3 P3 P2 P3 P3 A2 A2 A2 A2 P3 G2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 P3 P3 P3 P3 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 R2 G2 P3 P3 P3 P3 A2 P3 P3 R2 G2 P3 P3 A2 P3 P3 P3 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 G2 A2 A2 A2 A2 P3 P3 A2

$510.00 $446.00

$446.00 $446.00 $150.72 $333.00

$333.00 $446.00 $510.00 $510.00 $717.00 $717.00 $150.72 $333.00 $333.00 $333.00 $150.72 $333.00 $150.72 $333.00 $333.00 $333.00

$446.00 $446.00 $446.00 $333.00 $717.00 $150.72 $150.72 $446.00 $333.00 $333.00 $446.00 $88.46

$446.00

$150.72

$446.00 $630.00 $446.00 $717.00 $150.72 $446.00 $717.00 $717.00 $717.00 $995.00 $717.00 $717.00 $717.00 $630.00

$333.00 $446.00 $150.72 $150.72

$446.00

39.88 1.41 7.45 0.63 4.43 1.96 2.5 3.03 3.8 16.33 23.98 2.5 7.45 4.25 2.5 7.45 23.98 23.98 23.98 39.88 39.88 2.24 2.5 23.98 16.33 16.33 2.5 7.45 2.5 7.45 7.45 7.45 23.98 2.35 2.29 2.12 3.05 16.33 16.33 23.98 3.44 16.33 23.98 2.5 2.5 7.45 23.98 16.33 7.45 1.41 3.37 4.33 7.45 7.45 4 5.53 3.11 3.46 23.98 3.63 5.03 16.33 23.98 5.09 4.83 2.5 2.01 2.82 3.53 23.98 39.88 7.45 23.98 3.69 2.5 39.88 39.88 39.88 39.88 39.88 39.88 39.88 16.33 23.98 1.93 16.33 16.33 16.33 2.5 2.5 3.02 4.91 16.33

$1,650.97 $58.23 $308.33 $26.12 $183.20 $81.13 $103.51 $125.31 $157.30 $676.03 $992.65 $103.51 $308.33 $175.96 $103.51 $308.33 $992.65 $992.65 $992.65 $1,650.97 $1,650.97 $92.93 $103.51 $992.65 $676.03 $676.03 $103.51 $308.33 $103.51 $308.33 $308.33 $308.33 $992.65 $97.12 $94.84 $87.60 $126.45 $676.03 $676.03 $992.65 $142.45 $676.03 $992.65 $103.51 $103.51 $308.33 $992.65 $676.03 $308.33 $58.23 $139.40 $179.39 $308.33 $308.33 $165.68 $228.90 $128.73 $143.21 $992.65 $150.44 $208.34 $676.03 $992.65 $210.62 $199.96 $103.51 $83.03 $116.55 $146.25 $992.65 $1,650.97 $308.33 $992.65 $152.73 $103.51 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $676.03 $992.65 $79.98 $676.03 $676.03 $676.03 $103.51 $103.51 $124.93 $203.38 $676.03

$795.24 $58.23 $411.58 $26.12 $183.20 $81.13 $103.51 $125.31 $157.30 $503.51 $582.66 $138.92 $326.83 $175.96 $103.51 $326.83 $582.66 $630.66 $630.66 $950.49 $950.49 $92.93 $138.92 $497.91 $418.76 $418.76 $138.92 $326.83 $138.92 $326.83 $326.83 $326.83 $992.65 $97.12 $94.84 $87.60 $126.45 $503.51 $503.51 $582.66 $142.45 $418.76 $785.91 $138.92 $138.92 $411.58 $497.91 $418.76 $411.58 $80.90 $139.40 $179.39 $308.33 $308.33 $165.68 $228.90 $128.73 $143.21 $582.66 $150.44 $208.34 $676.03 $992.65 $210.62 $199.96 $138.92 $83.03 $116.55 $146.25 $582.66 $885.24 $411.58 $785.91 $152.73 $138.92 $747.24 $950.49 $950.49 $950.49 $1,158.99 $950.49 $950.49 $706.76 $720.66 $79.98 $676.03 $418.76 $503.51 $138.92 $138.92 $124.93 $203.38 $503.51 Page 23 of 38

42400 42405 42408 42409 42410 42415 42420 42425 42440 42450 42500 42505 42507 42508 42509 42510 42550 42600 42650 42660 42665 42700 42720 42725 42800 42802 42804 42806 42808 42809 42810 42815 42820 42821 42825 42826 42830 42831 42835 42836 42860 42870 42890 42892 42900 42950 42955 42960 42962 42970 42972 43030 43200 43201 43202 43204 43205 43215 43216 43217 43219 43220 43226 43227 43228 43231 43232 43234 43235 43236 43237 43238 43239 43240 43241 43242 43243 43244 43245 43246 43247 43248 43249 43250 43251 43255 43256 43257 43258 43259 43260 43261 43262

Biopsy of salivary gland Biopsy of salivary gland Excision of salivary cyst Drainage of salivary cyst Excise parotid gland/lesion Excise parotid gland/lesion Excise parotid gland/lesion Excise parotid gland/lesion Excise submaxillary gland Excise sublingual gland Repair salivary duct Repair salivary duct Parotid duct diversion Parotid duct diversion Parotid duct diversion Parotid duct diversion Injection for salivary x-ray Closure of salivary fistula Dilation of salivary duct Dilation of salivary duct Ligation of salivary duct Drainage of tonsil abscess Drainage of throat abscess Drainage of throat abscess Biopsy of throat Biopsy of throat Biopsy of upper nose/throat Biopsy of upper nose/throat Excise pharynx lesion Remove pharynx foreign body Excision of neck cyst Excision of neck cyst Remove tonsils and adenoids Remove tonsils and adenoids Removal of tonsils Removal of tonsils Removal of adenoids Removal of adenoids Removal of adenoids Removal of adenoids Excision of tonsil tags Excision of lingual tonsil Partial removal of pharynx Revision of pharyngeal walls Repair throat wound Reconstruction of throat Surgical opening of throat Control throat bleeding Control throat bleeding Control nose/throat bleeding Control nose/throat bleeding Throat muscle surgery Esophagus endoscopy Esoph scope w/submucous inj Esophagus endoscopy, biopsy Esoph scope w/sclerosis inj Esophagus endoscopy/ligation Esophagus endoscopy Esophagus endoscopy/lesion Esophagus endoscopy Esophagus endoscopy Esoph endoscopy, dilation Esoph endoscopy, dilation Esoph endoscopy, repair Esoph endoscopy, ablation Esoph endoscopy w/us exam Esoph endoscopy w/us fn bx Upper gi endoscopy, exam Uppr gi endoscopy, diagnosis Uppr gi scope w/submuc inj Endoscopic us exam, esoph Uppr gi endoscopy w/us fn bx Upper gi endoscopy, biopsy Esoph endoscope w/drain cyst Upper gi endoscopy with tube Uppr gi endoscopy w/us fn bx Upper gi endoscopy & inject Upper gi endoscopy/ligation Uppr gi scope dilate strictr Place gastrostomy tube Operative upper gi endoscopy Uppr gi endoscopy/guide wire Esoph endoscopy, dilation Upper gi endoscopy/tumor Operative upper gi endoscopy Operative upper gi endoscopy Uppr gi endoscopy w/stent Uppr gi scope w/thrml txmnt Operative upper gi endoscopy Endoscopic ultrasound exam Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph

Date Printed: 10/18/2008 @ 17:46:01

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P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 P3 P3 A2 A2 A2 A2 P3 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 R2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $510.00 $510.00 $510.00 $995.00 $995.00 $995.00 $510.00 $446.00 $510.00 $630.00 $510.00 $630.00 $630.00 $630.00 $333.00

$995.00 $150.72 $333.00 $446.00 $333.00 $333.00 $446.00 $446.00 $510.00 $717.00 $510.00 $717.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $510.00 $510.00 $995.00 $995.00 $333.00 $446.00 $446.00 $72.48 $446.00 $510.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00

1.67 16.33 16.33 16.33 39.88 39.88 39.88 39.88 39.88 23.98 23.98 39.88 39.88 39.88 39.88 39.88

$69.32 $676.03 $676.03 $676.03 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $992.65 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97

$69.32 $503.51 $551.51 $551.51 $795.24 $1,158.99 $1,158.99 $1,158.99 $795.24 $582.66 $630.66 $885.24 $795.24 $885.24 $885.24 $885.24

16.33 1.09 1.29 23.98 2.5 16.33 39.88 2.14 16.33 16.33 23.98 16.33 0.63 23.98 39.88 22.26 22.26 22.26 22.26 22.26 22.26 22.26 22.26 22.26 22.26 39.88 39.88 7.45 23.98 23.98 1.13 39.88 1.13 16.33 16.33 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 24.98 8.5 8.5 8.5 25.32 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 8.5 24.98 25.32 8.5 8.5 20.95 20.95 20.95

$676.03 $45.32 $53.32 $992.65 $103.51 $676.03 $1,650.97 $88.74 $676.03 $676.03 $992.65 $676.03 $26.12 $992.65 $1,650.97 $921.41 $921.41 $921.41 $921.41 $921.41 $921.41 $921.41 $921.41 $921.41 $921.41 $1,650.97 $1,650.97 $308.33 $992.65 $992.65 $46.58 $1,650.97 $46.58 $676.03 $676.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $1,034.25 $352.03 $352.03 $352.03 $1,048.41 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $352.03 $1,034.25 $1,048.41 $352.03 $352.03 $867.39 $867.39 $867.39

$418.76 $45.32 $53.32 $994.41 $138.92 $418.76 $747.24 $88.74 $418.76 $418.76 $582.66 $503.51 $26.12 $630.66 $950.49 $612.85 $768.10 $702.85 $702.85 $702.85 $702.85 $702.85 $702.85 $612.85 $612.85 $1,158.99 $1,158.99 $326.83 $582.66 $582.66 $66.01 $747.24 $46.58 $551.51 $676.03 $337.76 $337.76 $337.76 $337.76 $337.76 $337.76 $337.76 $337.76 $508.31 $337.76 $337.76 $422.51 $596.60 $422.51 $422.51 $337.76 $337.76 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $422.51 $641.06 $644.60 $470.51 $470.51 $551.35 $551.35 $551.35 Page 24 of 38

43263 43264 43265 43267 43268 43269 43271 43272 43450 43453 43456 43458 43600 43653 43750 43760 43761 43870 43886 43887 43888 44100 44312 44340 44360 44361 44363 44364 44365 44366 44369 44370 44372 44373 44376 44377 44378 44379 44380 44382 44383 44385 44386 44388 44389 44390 44391 44392 44393 44394 44397 44500 44701 45000 45005 45020 45100 45108 45150 45160 45170 45190 45300 45303 45305 45307 45308 45309 45315 45317 45320 45321 45327 45330 45331 45332 45333 45334 45335 45337 45338 45339 45340 45341 45342 45345 45355 45378 45379 45380 45381 45382 45383

Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Endo cholangiopancreatograph Dilate esophagus Dilate esophagus Dilate esophagus Dilate esophagus Biopsy of stomach Laparoscopy, gastrostomy Place gastrostomy tube Change gastrostomy tube Reposition gastrostomy tube Repair stomach opening Revise gastric port, open Remove gastric port, open Change gastric port, open Biopsy of bowel Revision of ileostomy Revision of colostomy Small bowel endoscopy Small bowel endoscopy/biopsy Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy/stent Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy Small bowel endoscopy/biopsy Small bowel endoscopy S bowel endoscope w/stent Small bowel endoscopy Small bowel endoscopy Ileoscopy w/stent Endoscopy of bowel pouch Endoscopy, bowel pouch/biop Colonoscopy Colonoscopy with biopsy Colonoscopy for foreign body Colonoscopy for bleeding Colonoscopy & polypectomy Colonoscopy, lesion removal Colonoscopy w/snare Colonoscopy w/stent Intro, gastrointestinal tube Intraop colon lavage add-on Drainage of pelvic abscess Drainage of rectal abscess Drainage of rectal abscess Biopsy of rectum Removal of anorectal lesion Excision of rectal stricture Excision of rectal lesion Excision of rectal lesion Destruction, rectal tumor Proctosigmoidoscopy dx Proctosigmoidoscopy dilate Proctosigmoidoscopy w/bx Proctosigmoidoscopy fb Proctosigmoidoscopy removal Proctosigmoidoscopy removal Proctosigmoidoscopy removal Proctosigmoidoscopy bleed Proctosigmoidoscopy ablate Proctosigmoidoscopy volvul Proctosigmoidoscopy w/stent Diagnostic sigmoidoscopy Sigmoidoscopy and biopsy Sigmoidoscopy w/fb removal Sigmoidoscopy & polypectomy Sigmoidoscopy for bleeding Sigmoidoscopy w/submuc inj Sigmoidoscopy & decompress Sigmoidoscopy w/tumr remove Sigmoidoscopy w/ablate tumr Sig w/balloon dilation Sigmoidoscopy w/ultrasound Sigmoidoscopy w/us guide bx Sigmoidoscopy w/stent Surgical colonoscopy Diagnostic colonoscopy Colonoscopy w/fb removal Colonoscopy and biopsy Colonoscopy, submucous inj Colonoscopy/control bleeding Lesion removal colonoscopy

Date Printed: 10/18/2008 @ 17:46:01

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A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 D5 A2 A2 A2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $333.00 $333.00 $335.41 $335.41 $333.00 $1,339.00

20.95 20.95 20.95 20.95 24.98 24.98 20.95 20.95 5.84 5.84 5.84 8.5 8.5 45.53

$867.39 $867.39 $867.39 $867.39 $1,034.25 $1,034.25 $867.39 $867.39 $241.91 $241.91 $241.91 $352.03 $352.03 $1,885.06

$551.35 $551.35 $551.35 $551.35 $593.06 $593.06 $551.35 $551.35 $310.23 $310.23 $312.04 $339.57 $337.76 $1,475.52

$144.98 $333.00 $333.00

3.24 8.5 8.5 20.21 4.53 20.21 8.5 20.21 20.21 9.53 9.53 9.53 9.53 9.53 9.53 9.53 24.98 9.53 9.53 9.53 9.53 9.53 24.98 9.53 9.53 24.98 8.85 8.85 8.85 8.85 8.85 8.85 8.85 8.85 8.85 24.98 3.24

$134.07 $352.03 $352.03 $836.59 $187.39 $836.59 $352.03 $836.59 $836.59 $394.52 $394.52 $394.52 $394.52 $394.52 $394.52 $394.52 $1,034.25 $394.52 $394.52 $394.52 $394.52 $394.52 $1,034.25 $394.52 $394.52 $1,034.25 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34 $1,034.25 $134.07

$142.25 $337.76 $337.76 $836.59 $187.39 $836.59 $337.76 $458.90 $591.65 $433.13 $433.13 $433.13 $433.13 $433.13 $433.13 $433.13 $1,262.81 $433.13 $433.13 $433.13 $433.13 $433.13 $1,262.81 $348.38 $348.38 $1,262.81 $341.34 $341.34 $341.34 $341.34 $341.34 $341.34 $341.34 $341.34 $341.34 $508.31 $134.07

10.91 10.91 10.91 22.75 22.75 22.75 22.75 22.75 22.75 1.6 8.7 8.7 21.46 8.7 8.7 8.7 8.7 21.46 21.46 24.98 2.21 5.1 5.1 8.7 8.7 5.1 5.1 8.7 8.7 8.7 8.7 8.7 24.98 8.85 8.85 8.85 8.85 8.85 8.85 8.85

$451.82 $451.82 $451.82 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $66.27 $360.32 $360.32 $888.60 $360.32 $360.32 $360.32 $360.32 $888.60 $888.60 $1,034.25 $91.41 $211.03 $211.03 $360.32 $360.32 $211.03 $211.03 $360.32 $360.32 $360.32 $360.32 $360.32 $1,034.25 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34 $366.34

$347.01 $447.46 $447.46 $485.17 $569.92 $569.92 $569.92 $569.92 $1,239.67 $66.27 $360.32 $339.83 $471.90 $339.83 $339.83 $339.83 $339.83 $471.90 $471.90 $508.31 $91.41 $277.19 $277.19 $339.83 $339.83 $277.19 $277.19 $339.83 $339.83 $339.83 $339.83 $339.83 $508.31 $341.34 $426.09 $426.09 $426.09 $426.09 $426.09 $426.09

$333.00 $333.00 $510.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $1,339.00 $446.00 $446.00 $446.00 $446.00 $446.00 $1,339.00 $333.00 $333.00 $1,339.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00

$312.07 $446.00 $446.00 $333.00 $446.00 $446.00 $446.00 $446.00 $1,339.00

$333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $299.24 $299.24 $333.00 $333.00 $299.24 $299.24 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00

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45384 45385 45386 45387 45391 45392 45500 45505 45520 45560 45900 45905 45910 45915 45990 46020 46030 46040 46045 46050 46060 46070 46080 46083 46200 46210 46211 46220 46221 46230 46250 46255 46257 46258 46260 46261 46262 46270 46275 46280 46285 46288 46320 46500 46505 46600 46604 46606 46608 46610 46611 46612 46614 46615 46700 46706 46750 46753 46754 46760 46761 46762 46900 46910 46916 46917 46922 46924 46934 46935 46936 46937 46938 46940 46942 46945 46946 46947 47000 47001 47382 47500 47505 47510 47511 47525 47530 47552 47553 47554 47555 47556

Lesion remove colonoscopy Lesion removal colonoscopy Colonoscopy dilate stricture Colonoscopy w/stent Colonoscopy w/endoscope us Colonoscopy w/endoscopic fnb Repair of rectum Repair of rectum Treatment of rectal prolapse Repair of rectocele Reduction of rectal prolapse Dilation of anal sphincter Dilation of rectal narrowing Remove rectal obstruction Surg dx exam, anorectal Placement of seton Removal of rectal marker Incision of rectal abscess Incision of rectal abscess Incision of anal abscess Incision of rectal abscess Incision of anal septum Incision of anal sphincter Incise external hemorrhoid Removal of anal fissure Removal of anal crypt Removal of anal crypts Removal of anal tag Ligation of hemorrhoid(s) Removal of anal tags Hemorrhoidectomy Hemorrhoidectomy Remove hemorrhoids & fissure Remove hemorrhoids & fistula Hemorrhoidectomy Remove hemorrhoids & fissure Remove hemorrhoids & fistula Removal of anal fistula Removal of anal fistula Removal of anal fistula Removal of anal fistula Repair anal fistula Removal of hemorrhoid clot Injection into hemorrhoid(s) Chemodenervation anal musc Diagnostic anoscopy Anoscopy and dilation Anoscopy and biopsy Anoscopy, remove for body Anoscopy, remove lesion Anoscopy Anoscopy, remove lesions Anoscopy, control bleeding Anoscopy Repair of anal stricture Repr of anal fistula w/glue Repair of anal sphincter Reconstruction of anus Removal of suture from anus Repair of anal sphincter Repair of anal sphincter Implant artificial sphincter Destruction, anal lesion(s) Destruction, anal lesion(s) Cryosurgery, anal lesion(s) Laser surgery, anal lesions Excision of anal lesion(s) Destruction, anal lesion(s) Destruction of hemorrhoids Destruction of hemorrhoids Destruction of hemorrhoids Cryotherapy of rectal lesion Cryotherapy of rectal lesion Treatment of anal fissure Treatment of anal fissure Ligation of hemorrhoids Ligation of hemorrhoids Hemorrhoidopexy by stapling Needle biopsy of liver Needle biopsy, liver add-on Percut ablate liver rf Injection for liver x-rays Injection for liver x-rays Insert catheter, bile duct Insert bile duct drain Change bile duct catheter Revise/reinsert bile tube Biliary endoscopy thru skin Biliary endoscopy thru skin Biliary endoscopy thru skin Biliary endoscopy thru skin Biliary endoscopy thru skin

Date Printed: 10/18/2008 @ 17:46:01

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y N N Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 P2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 G2 P2 P2 P3 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 P3 P2 A2 A2 A2 P3 P3 P3 A2 A2 P3 P3 P3 A2 A2 A2 N1 G2 N1 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $446.00 $446.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $312.07 $333.00 $333.00 $312.07 $312.07 $510.00 $312.07 $510.00 $446.00 $312.07 $446.00 $510.00 $446.00 $446.00 $446.00 $333.00 $333.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $510.00 $510.00 $630.00 $333.00 $630.00

$333.00 $333.00 $333.00 $333.00 $446.00 $510.00 $333.00 $510.00 $510.00 $446.00 $446.00 $510.00 $995.00

$333.00 $333.00 $333.00

$446.00 $446.00

$333.00 $995.00 $333.00

$446.00 $1,245.85 $333.00 $333.00 $446.00 $510.00 $510.00 $510.00 $1,245.85

8.85 8.85 8.85 24.98 8.85 8.85 22.75 30.16 0.79 30.16 4.79 22.75 22.75 10.91 22.75 22.75 4.79 22.75 22.75 10.91 22.75 10.91 22.75 2.01 22.75 22.75 22.75 22.75 2.93 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 22.75 2.09 2.63 4.79 0.63 8.7 3.52 8.7 21.46 8.7 21.46 1.96 21.46 22.75 30.16 30.16 22.75 22.75 30.16 30.16 30.16 2.66 3.12 1.46 19.9 19.9 19.9 4.89 3.37 5.11 22.75 30.16 2.23 2.13 3.71 10.91 30.16 9.34

$366.34 $366.34 $366.34 $1,034.25 $366.34 $366.34 $941.67 $1,248.68 $32.83 $1,248.68 $198.46 $941.67 $941.67 $451.82 $941.67 $941.67 $198.46 $941.67 $941.67 $451.82 $941.67 $451.82 $941.67 $83.12 $941.67 $941.67 $941.67 $941.67 $121.50 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $941.67 $86.46 $108.93 $198.46 $26.12 $360.32 $145.87 $360.32 $888.60 $360.32 $888.60 $81.13 $888.60 $941.67 $1,248.68 $1,248.68 $941.67 $941.67 $1,248.68 $1,248.68 $1,248.68 $110.14 $129.11 $60.42 $824.05 $824.05 $824.05 $202.62 $139.40 $211.76 $941.67 $1,248.68 $92.17 $88.36 $153.49 $451.82 $1,248.68 $386.49

$426.09 $426.09 $426.09 $508.31 $426.09 $426.09 $569.92 $646.67 $32.83 $646.67 $283.67 $485.17 $485.17 $347.01 $469.47 $617.92 $283.67 $617.92 $569.92 $347.01 $569.92 $451.82 $617.92 $83.12 $569.92 $569.92 $569.92 $485.17 $121.50 $485.17 $617.92 $617.92 $617.92 $617.92 $617.92 $707.92 $707.92 $617.92 $617.92 $707.92 $485.17 $707.92 $86.46 $108.93 $198.46 $26.12 $360.32 $145.87 $339.83 $471.90 $339.83 $471.90 $81.13 $556.65 $617.92 $561.92 $694.67 $617.92 $569.92 $646.67 $694.67 $1,058.42 $110.14 $129.11 $60.42 $455.76 $455.76 $455.76 $202.62 $139.40 $211.76 $569.92 $646.67 $92.17 $88.36 $153.49 $362.71 $1,058.42 $346.37

43

$1,780.16

$1,780.16

28.69 28.69 15.35 15.35 28.69 28.69 28.69 28.69 28.69

$1,187.73 $1,187.73 $635.69 $635.69 $1,187.73 $1,187.73 $1,187.73 $1,187.73 $1,187.73

$631.43 $1,231.32 $408.67 $408.67 $631.43 $679.43 $679.43 $679.43 $1,231.32

Page 26 of 38

47560 47561 47562 47563 47564 47630 48102 49080 49081 49180 49250 49320 49321 49322 49400 49402 49419 49420 49421 49422 49423 49424 49426 49427 49429 49440 49441 49446 49450 49451 49452 49460 49465 49495 49496 49500 49501 49505 49507 49520 49521 49525 49540 49550 49553 49555 49557 49560 49561 49565 49566 49568 49570 49572 49580 49582 49585 49587 49590 49600 49650 49651 50200 50382 50384 50385 50386 50387 50389 50390 50391 50392 50393 50394 50395 50396 50398 50551 50553 50555 50557 50561 50562 50570 50572 50574 50575 50576 50580 50590 50592 50684

Laparoscopy w/cholangio Laparo w/cholangio/biopsy Laparoscopic cholecystectomy Laparo cholecystectomy/graph Laparo cholecystectomy/explr Remove bile duct stone Needle biopsy, pancreas Puncture, peritoneal cavity Removal of abdominal fluid Biopsy, abdominal mass Excision of umbilicus Diag laparo separate proc Laparoscopy, biopsy Laparoscopy, aspiration Air injection into abdomen Remove foreign body, adbomen Insrt abdom cath for chemotx Insert abdom drain, temp Insert abdom drain, perm Remove perm cannula/catheter Exchange drainage catheter Assess cyst, contrast inject Revise abdomen-venous shunt Injection, abdominal shunt Removal of shunt Place gastrostomy tube perc Place duod/jej tube perc Change g-tube to g-j perc Replace g/c tube perc Replace duod/jej tube perc Replace g-j tube perc Fix g/colon tube w/device Fluoro exam of g/colon tube Rpr ing hernia baby, reduc Rpr ing hernia baby, blocked Rpr ing hernia, init, reduce Rpr ing hernia, init blocked Prp i/hern init reduc >5 yr Prp i/hern init block >5 yr Rerepair ing hernia, reduce Rerepair ing hernia, blocked Repair ing hernia, sliding Repair lumbar hernia Rpr rem hernia, init, reduce Rpr fem hernia, init blocked Rerepair fem hernia, reduce Rerepair fem hernia, blocked Rpr ventral hern init, reduc Rpr ventral hern init, block Rerepair ventrl hern, reduce Rerepair ventrl hern, block Hernia repair w/mesh Rpr epigastric hern, reduce Rpr epigastric hern, blocked Rpr umbil hern, reduc < 5 yr Rpr umbil hern, block < 5 yr Rpr umbil hern, reduc > 5 yr Rpr umbil hern, block > 5 yr Repair spigelian hernia Repair umbilical lesion Laparo hernia repair initial Laparo hernia repair recur Biopsy of kidney Change ureter stent, percut Remove ureter stent, percut Change stent via transureth Remove stent via transureth Change ext/int ureter stent Remove renal tube w/fluoro Drainage of kidney lesion Instll rx agnt into rnal tub Insert kidney drain Insert ureteral tube Injection for kidney x-ray Create passage to kidney Measure kidney pressure Change kidney tube Kidney endoscopy Kidney endoscopy Kidney endoscopy & biopsy Kidney endoscopy & treatment Kidney endoscopy & treatment Renal scope w/tumor resect Kidney endoscopy Kidney endoscopy Kidney endoscopy & biopsy Kidney endoscopy Kidney endoscopy & treatment Kidney endoscopy & treatment Fragmenting of kidney stone Perc rf ablate renal tumor Injection for ureter x-ray

Date Printed: 10/18/2008 @ 17:46:01

Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N

A2 A2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 A2 A2 A2 A2 G2 N1 A2 N1 G2 G2 G2 G2 G2 G2 G2 G2 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 G2 G2 A2 P2 A2 A2 N1 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 G2 G2 G2 G2 G2 G2 N1

$510.00 $510.00

34.4 34.4 45.53 45.53 45.53 28.69 9.34 5.2 5.2 9.34 25.69 34.4 34.4 34.4

$1,424.02 $1,424.02 $1,885.06 $1,885.06 $1,885.06 $1,187.73 $386.49 $215.38 $215.38 $386.49 $1,063.79 $1,424.02 $1,424.02 $1,424.02

$738.51 $738.51 $1,885.06 $1,885.06 $1,885.06 $679.43 $346.37 $220.93 $220.93 $346.37 $738.45 $738.51 $828.51 $828.51

$446.00 $333.00 $333.00 $333.00 $333.00

25.69 29.7 30.71 30.71 23.98 15.35

$1,063.79 $1,229.46 $1,271.41 $1,271.41 $992.80 $635.69

$600.45 $557.12 $567.60 $567.60 $497.95 $635.69

$446.00

25.69

$1,063.79

$600.45

23.98 8.5 8.5 8.5 3.24 3.24 3.24 3.24

$992.80 $352.03 $352.03 $352.03 $134.07 $134.07 $134.07 $134.07

$992.80 $352.03 $352.03 $352.03 $134.07 $134.07 $134.07 $134.07

30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 30.68 45.53 45.53 9.34 24.77 17.94 17.94 5.97 15.35 5.97 9.34 1.04 17.94 24.77

$1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,270.13 $1,885.06 $1,885.06 $386.49 $1,025.71 $742.82 $742.82 $247.31 $635.69 $247.31 $386.49 $42.87 $742.82 $1,025.71

$790.03 $790.03 $790.03 $1,321.78 $790.03 $1,321.78 $1,063.78 $1,321.78 $790.03 $652.03 $855.28 $1,321.78 $855.28 $1,321.78 $790.03 $1,321.78 $790.03 $1,321.78 $1,063.78 $790.03 $1,321.78 $790.03 $1,321.78 $790.03 $1,321.78 $700.03 $790.03 $943.77 $1,217.52 $346.37 $1,025.71 $742.82 $742.82 $247.31 $635.69 $247.31 $346.37 $42.87 $435.46 $506.18

17.94 2.01 15.35 5.97 24.77 5.97 24.77 24.77 5.97 5.97 5.97 5.97 36.08 17.94 17.94 41.53 43

$742.82 $83.12 $635.69 $247.31 $1,025.71 $247.31 $1,025.71 $1,025.71 $247.31 $247.31 $247.31 $247.31 $1,493.64 $742.82 $742.82 $1,719.38 $1,780.16

$435.46 $119.41 $408.67 $311.58 $506.18 $311.58 $506.18 $506.18 $247.31 $247.31 $247.31 $247.31 $1,493.64 $742.82 $742.82 $1,719.38 $1,780.16

$510.00 $333.00 $222.78 $222.78 $333.00 $630.00 $510.00 $630.00 $630.00

$630.00 $630.00 $630.00 $1,339.00 $630.00 $1,339.00 $995.00 $1,339.00 $630.00 $446.00 $717.00 $1,339.00 $717.00 $1,339.00 $630.00 $1,339.00 $630.00 $1,339.00 $995.00 $630.00 $1,339.00 $630.00 $1,339.00 $630.00 $1,339.00 $510.00 $630.00 $630.00 $995.00 $333.00

$333.00 $333.00 $333.00 $333.00 $131.50 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00

Page 27 of 38

50686 50688 50690 50947 50948 50951 50953 50955 50957 50961 50970 50972 50974 50976 50980 51000 51005 51010 51020 51030 51040 51045 51050 51065 51080 51100 51101 51102 51500 51520 51600 51605 51610 51700 51701 51702 51703 51705 51710 51715 51720 51725 51726 51736 51741 51772 51784 51785 51792 51795 51797 51798 51880 51992 52000 52001 52005 52007 52010 52204 52214 52224 52234 52235 52240 52250 52260 52265 52270 52275 52276 52277 52281 52282 52283 52285 52290 52300 52301 52305 52310 52315 52317 52318 52320 52325 52327 52330 52332 52334 52341 52342 52343

Measure ureter pressure Change of ureter tube/stent Injection for ureter x-ray Laparo new ureter/bladder Laparo new ureter/bladder Endoscopy of ureter Endoscopy of ureter Ureter endoscopy & biopsy Ureter endoscopy & treatment Ureter endoscopy & treatment Ureter endoscopy Ureter endoscopy & catheter Ureter endoscopy & biopsy Ureter endoscopy & treatment Ureter endoscopy & treatment Drainage of bladder Drainage of bladder Drainage of bladder Incise & treat bladder Incise & treat bladder Incise & drain bladder Incise bladder/drain ureter Removal of bladder stone Remove ureter calculus Drainage of bladder abscess Drain bladder by needle Drain bladder by trocar/cath Drain bl w/cath insertion Removal of bladder cyst Removal of bladder lesion Injection for bladder x-ray Preparation for bladder xray Injection for bladder x-ray Irrigation of bladder Insert bladder catheter Insert temp bladder cath Insert bladder cath, complex Change of bladder tube Change of bladder tube Endoscopic injection/implant Treatment of bladder lesion Simple cystometrogram Complex cystometrogram Urine flow measurement Electro-uroflowmetry, first Urethra pressure profile Anal/urinary muscle study Anal/urinary muscle study Urinary reflex study Urine voiding pressure study Intraabdominal pressure test Us urine capacity measure Repair of bladder opening Laparo sling operation Cystoscopy Cystoscopy, removal of clots Cystoscopy & ureter catheter Cystoscopy and biopsy Cystoscopy & duct catheter Cystoscopy w/biopsy(s) Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and radiotracer Cystoscopy and treatment Cystoscopy and treatment Cystoscopy & revise urethra Cystoscopy & revise urethra Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy, implant stent Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Cystoscopy and treatment Remove bladder stone Remove bladder stone Cystoscopy and treatment Cystoscopy, stone removal Cystoscopy, inject material Cystoscopy and treatment Cystoscopy and treatment Create passage to kidney Cysto w/ureter stricture tx Cysto w/up stricture tx Cysto w/renal stricture tx

Date Printed: 10/18/2008 @ 17:46:01

Y Y N Y Y Y Y Y Y Y Y Y Y Y Y N N N Y Y Y Y Y Y Y Y Y Y Y Y N N N Y N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P2 A2 N1 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 D5 D5 D5 A2 A2 A2 A2 A2 A2 A2 P3 P2 A2 A2 A2 N1 N1 N1 P3 P2 P2 P2 P3 A2 A2 P3 P2 A2 P3 P3 A2 P2 A2 P2 P2 P2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$333.00

1.04 15.35

$42.87 $635.69

$42.87 $408.67

$1,339.00 $1,339.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00

45.53 45.53 5.97 5.97 24.77 24.77 24.77 5.97 5.97 17.94 17.94 24.77

$1,885.06 $1,885.06 $247.31 $247.31 $1,025.71 $1,025.71 $1,025.71 $247.31 $247.31 $742.82 $742.82 $1,025.71

$1,475.52 $1,475.52 $311.58 $311.58 $506.18 $506.18 $506.18 $311.58 $311.58 $435.46 $435.46 $506.18

$630.00 $630.00 $630.00 $399.24 $630.00 $630.00 $333.00

24.77 24.77 24.77 5.97 24.77 24.77 18.32 0.85 1.04 19.34 30.68 24.77

$1,025.71 $1,025.71 $1,025.71 $247.31 $1,025.71 $1,025.71 $758.45 $35.04 $42.87 $800.75 $1,270.13 $1,025.71

$728.93 $728.93 $728.93 $361.26 $728.93 $728.93 $439.36 $35.04 $42.87 $449.94 $790.03 $728.93

1.43 0.63 0.63 1.04 1.98 15.35 29.79 1.55 3.05 3.05 0.5 0.57 2.01 1.04 2.01 1.04 2.01 2.01 0.43 24.77 45.53 5.97 17.94 17.94 24.77 5.97 17.94 24.77 24.77 24.77 24.77 24.77 24.77 17.94 5.97 17.94 24.77 24.77 24.77 17.94 36.08 24.77 17.94 17.94 24.77 24.77 24.77 17.94 24.77 24.77 24.77 24.77 24.77 24.77 24.77 24.77 24.77 24.77 24.77 24.77

$59.03 $26.12 $26.12 $42.87 $81.89 $635.69 $1,233.19 $63.99 $126.14 $126.14 $20.57 $23.61 $83.12 $42.87 $83.12 $42.87 $83.12 $83.12 $17.90 $1,025.71 $1,885.06 $247.31 $742.82 $742.82 $1,025.71 $247.31 $742.82 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $742.82 $247.31 $742.82 $1,025.71 $1,025.71 $1,025.71 $742.82 $1,493.64 $1,025.71 $742.82 $742.82 $1,025.71 $1,025.71 $1,025.71 $742.82 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71

$59.03 $26.12 $26.12 $42.87 $81.89 $408.67 $690.80 $63.99 $126.14 $188.65 $20.57 $23.61 $119.41 $42.87 $70.97 $42.87 $83.12 $83.12 $17.90 $506.18 $1,009.02 $311.58 $485.14 $520.21 $590.93 $361.26 $520.21 $590.93 $590.93 $590.93 $638.93 $638.93 $728.93 $520.21 $247.31 $520.21 $590.93 $638.93 $590.93 $520.21 $1,377.66 $590.93 $520.21 $520.21 $590.93 $638.93 $590.93 $485.14 $590.93 $506.18 $590.93 $794.18 $728.93 $590.93 $590.93 $590.93 $638.93 $638.93 $638.93 $638.93

$333.00 $630.00 $630.00

$333.00 $510.00

$209.48

$131.50 $66.92

$333.00 $717.00 $333.00 $399.24 $446.00 $446.00 $399.24 $446.00 $446.00 $446.00 $446.00 $510.00 $510.00 $630.00 $446.00 $446.00 $446.00 $510.00 $446.00 $446.00 $1,339.00 $446.00 $446.00 $446.00 $446.00 $510.00 $446.00 $399.24 $446.00 $333.00 $446.00 $717.00 $630.00 $446.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00

Page 28 of 38

52344 52345 52346 52351 52352 52353 52354 52355 52400 52402 52450 52500 52510 52601 52606 52612 52614 52620 52630 52640 52647 52648 52700 53000 53010 53020 53025 53040 53060 53080 53085 53200 53210 53215 53220 53230 53235 53240 53250 53260 53265 53270 53275 53400 53405 53410 53420 53425 53430 53431 53440 53442 53444 53445 53446 53447 53449 53450 53460 53502 53505 53510 53515 53520 53600 53601 53605 53620 53621 53660 53661 53665 53850 53852 53853 54000 54001 54015 54050 54055 54056 54057 54060 54065 54100 54105 54110 54111 54112 54115 54120 54150 54160

Cysto/uretero, stricture tx Cysto/uretero w/up stricture Cystouretero w/renal strict Cystouretero & or pyeloscope Cystouretero w/stone remove Cystouretero w/lithotripsy Cystouretero w/biopsy Cystouretero w/excise tumor Cystouretero w/congen repr Cystourethro cut ejacul duct Incision of prostate Revision of bladder neck Dilation prostatic urethra Prostatectomy (turp) Control postop bleeding Prostatectomy, first stage Prostatectomy, second stage Remove residual prostate Remove prostate regrowth Relieve bladder contracture Laser surgery of prostate Laser surgery of prostate Drainage of prostate abscess Incision of urethra Incision of urethra Incision of urethra Incision of urethra Drainage of urethra abscess Drainage of urethra abscess Drainage of urinary leakage Drainage of urinary leakage Biopsy of urethra Removal of urethra Removal of urethra Treatment of urethra lesion Removal of urethra lesion Removal of urethra lesion Surgery for urethra pouch Removal of urethra gland Treatment of urethra lesion Treatment of urethra lesion Removal of urethra gland Repair of urethra defect Revise urethra, stage 1 Revise urethra, stage 2 Reconstruction of urethra Reconstruct urethra, stage 1 Reconstruct urethra, stage 2 Reconstruction of urethra Reconstruct urethra/bladder Male sling procedure Remove/revise male sling Insert tandem cuff Insert uro/ves nck sphincter Remove uro sphincter Remove/replace ur sphincter Repair uro sphincter Revision of urethra Revision of urethra Repair of urethra injury Repair of urethra injury Repair of urethra injury Repair of urethra injury Repair of urethra defect Dilate urethra stricture Dilate urethra stricture Dilate urethra stricture Dilate urethra stricture Dilate urethra stricture Dilation of urethra Dilation of urethra Dilation of urethra Prostatic microwave thermotx Prostatic rf thermotx Prostatic water thermother Slitting of prepuce Slitting of prepuce Drain penis lesion Destruction, penis lesion(s) Destruction, penis lesion(s) Cryosurgery, penis lesion(s) Laser surg, penis lesion(s) Excision of penis lesion(s) Destruction, penis lesion(s) Biopsy of penis Biopsy of penis Treatment of penis lesion Treat penis lesion, graft Treat penis lesion, graft Treatment of penis lesion Partial removal of penis Circumcision w/regionl block Circumcision, neonate

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y N N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 D5 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 R2 A2 P3 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 H8 A2 H8 H8 A2 H8 A2 A2 A2 A2 A2 A2 A2 A2 P3 P2 A2 P3 P3 P2 P2 A2 P2 P2 P2 A2 A2 A2 P2 P3 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $630.00 $510.00 $510.00 $510.00 $510.00 $630.00 $333.00 $446.00 $333.00 $333.00 $446.00 $446.00 $1,339.00 $1,339.00 $446.00 $333.00 $333.00 $333.00 $446.00 $510.00 $333.00 $717.00 $717.00 $446.00 $446.00 $510.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $446.00 $446.00 $510.00 $446.00 $446.00 $446.00 $446.00 $333.00 $446.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00

$446.00

$333.00

$446.00 $446.00 $630.00

$333.00 $333.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $333.00 $446.00 $333.00 $446.00

24.77 24.77 24.77 24.77 24.77 36.08 24.77 24.77 24.77 24.77 24.77 24.77

$1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,493.64 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71 $1,025.71

$638.93 $638.93 $638.93 $638.93 $728.93 $845.91 $728.93 $728.93 $638.93 $638.93 $638.93 $638.93

36.08 24.77 36.08 36.08 36.08 36.08 24.77 45.2 45.2 24.77 19.15 19.15 19.15 19.15 19.15 1.92 19.15 19.15 19.15 29.79 19.15 29.79 29.79 19.15 29.79 19.15 19.15 19.15 19.15 19.15 29.79 29.79 29.79 29.79 29.79 29.79 29.79 106.86 29.79 106.86 193.43 29.79 193.43 29.79 29.79 19.15 19.15 29.79 19.15 29.79 29.79 1.05 1.04 17.94 1.7 1.78 1.04 1.04 19.15 45.2 45.2 24.77 19.15 19.15 18.32 1.46 1.63 0.79 19.9 19.9 19.9 16.1 21.11 33.93 33.93 33.93 18.32 33.93 22.33 22.33

$1,493.64 $1,025.71 $1,493.64 $1,493.64 $1,493.64 $1,493.64 $1,025.71 $1,871.50 $1,871.50 $1,025.71 $792.85 $792.85 $792.85 $792.85 $792.85 $79.60 $792.85 $792.85 $792.85 $1,233.19 $792.85 $1,233.19 $1,233.19 $792.85 $1,233.19 $792.85 $792.85 $792.85 $792.85 $792.85 $1,233.19 $1,233.19 $1,233.19 $1,233.19 $1,233.19 $1,233.19 $1,233.19 $4,423.98 $1,233.19 $4,423.98 $8,008.10 $1,233.19 $8,008.10 $1,233.19 $1,233.19 $792.85 $792.85 $1,233.19 $792.85 $1,233.19 $1,233.19 $43.42 $42.87 $742.82 $70.46 $73.89 $42.87 $42.87 $792.85 $1,871.50 $1,871.50 $1,025.71 $792.85 $792.85 $758.45 $60.42 $67.41 $32.83 $824.05 $824.05 $824.05 $666.56 $873.97 $1,404.76 $1,404.76 $1,404.76 $758.45 $1,404.76 $924.28 $924.28

$845.91 $506.18 $707.91 $623.16 $623.16 $707.91 $590.93 $1,472.13 $1,472.13 $590.93 $447.96 $447.96 $447.96 $792.85 $532.71 $79.60 $580.71 $792.85 $447.96 $846.05 $735.96 $642.80 $642.80 $580.71 $642.80 $532.71 $532.71 $532.71 $532.71 $532.71 $690.80 $642.80 $642.80 $690.80 $642.80 $642.80 $642.80 $3,500.50 $558.05 $3,500.50 $6,625.75 $558.05 $6,625.75 $558.05 $558.05 $447.96 $532.71 $642.80 $532.71 $642.80 $642.80 $43.42 $42.87 $520.21 $70.46 $73.89 $42.87 $42.87 $447.96 $1,871.50 $1,871.50 $1,025.71 $532.71 $532.71 $662.11 $60.42 $67.41 $32.83 $455.76 $455.76 $455.76 $416.39 $468.24 $685.69 $685.69 $685.69 $439.36 $685.69 $480.82 $565.57 Page 29 of 38

54161 54162 54163 54164 54200 54205 54220 54230 54231 54235 54240 54250 54300 54304 54308 54312 54316 54318 54322 54324 54326 54328 54340 54344 54348 54352 54360 54380 54385 54400 54401 54405 54406 54408 54410 54415 54416 54420 54435 54440 54450 54500 54505 54512 54520 54522 54530 54550 54560 54600 54620 54640 54660 54670 54680 54690 54692 54700 54800 54830 54840 54860 54861 54865 54900 54901 55000 55040 55041 55060 55100 55110 55120 55150 55175 55180 55200 55250 55300 55400 55450 55500 55520 55530 55535 55540 55550 55600 55680 55700 55705 55720 55725

Circum 28 days or older Lysis penil circumic lesion Repair of circumcision Frenulotomy of penis Treatment of penis lesion Treatment of penis lesion Treatment of penis lesion Prepare penis study Dynamic cavernosometry Penile injection Penis study Penis study Revision of penis Revision of penis Reconstruction of urethra Reconstruction of urethra Reconstruction of urethra Reconstruction of urethra Reconstruction of urethra Reconstruction of urethra Reconstruction of urethra Revise penis/urethra Secondary urethral surgery Secondary urethral surgery Secondary urethral surgery Reconstruct urethra/penis Penis plastic surgery Repair penis Repair penis Insert semi-rigid prosthesis Insert self-contd prosthesis Insert multi-comp penis pros Remove muti-comp penis pros Repair multi-comp penis pros Remove/replace penis prosth Remove self-contd penis pros Remv/repl penis contain pros Revision of penis Revision of penis Repair of penis Preputial stretching Biopsy of testis Biopsy of testis Excise lesion testis Removal of testis Orchiectomy, partial Removal of testis Exploration for testis Exploration for testis Reduce testis torsion Suspension of testis Suspension of testis Revision of testis Repair testis injury Relocation of testis(es) Laparoscopy, orchiectomy Laparoscopy, orchiopexy Drainage of scrotum Biopsy of epididymis Remove epididymis lesion Remove epididymis lesion Removal of epididymis Removal of epididymis Explore epididymis Fusion of spermatic ducts Fusion of spermatic ducts Drainage of hydrocele Removal of hydrocele Removal of hydroceles Repair of hydrocele Drainage of scrotum abscess Explore scrotum Removal of scrotum lesion Removal of scrotum Revision of scrotum Revision of scrotum Incision of sperm duct Removal of sperm duct(s) Prepare, sperm duct x-ray Repair of sperm duct Ligation of sperm duct Removal of hydrocele Removal of sperm cord lesion Revise spermatic cord veins Revise spermatic cord veins Revise hernia & sperm veins Laparo ligate spermatic vein Incise sperm duct pouch Remove sperm pouch lesion Biopsy of prostate Biopsy of prostate Drainage of prostate abscess Drainage of prostate abscess

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N Y Y N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 P3 A2 A2 N1 P3 P3 P3 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 H8 H8 H8 A2 A2 H8 A2 H8 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 N1 A2 P3 A2 A2 A2 A2 A2 A2 R2 A2 A2 A2 A2 A2

$446.00 $446.00 $446.00 $446.00 $630.00 $131.50

$510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $209.48 $333.00 $333.00 $446.00 $510.00 $510.00 $630.00 $630.00 $630.00 $510.00 $630.00 $446.00 $510.00 $510.00 $1,339.00 $446.00 $127.16 $510.00 $630.00 $510.00 $630.00 $333.00 $630.00 $630.00 $510.00 $717.00 $630.00 $333.00 $446.00 $446.00 $333.00 $333.00 $446.00 $446.00 $446.00 $333.00 $510.00 $630.00 $630.00 $630.00 $717.00 $1,339.00 $333.00 $345.83 $345.83 $333.00 $446.00

22.33 22.33 22.33 22.33 1.76 33.93 2.01

$924.28 $924.28 $924.28 $924.28 $72.75 $1,404.76 $83.12

$565.57 $565.57 $565.57 $565.57 $72.75 $823.69 $119.41

1.54 1.08 0.75 0.26 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 33.93 106.86 193.43 193.43 33.93 33.93 193.43 33.93 193.43 33.93 33.93 33.93 3.05 13.58 22.33 22.33 22.33 22.33 30.68 30.68 22.33 22.33 22.33 30.68 22.33 22.33 22.33 45.53 69.67 22.33 4.33 22.33 22.33 22.33 22.33 22.33 22.33 22.33 1.8 30.68 30.68 22.33 11.56 22.33 22.33 22.33 22.33 22.33 22.33 22.33

$63.61 $44.56 $30.85 $10.66 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $1,404.76 $4,423.98 $8,008.10 $8,008.10 $1,404.76 $1,404.76 $8,008.10 $1,404.76 $8,008.10 $1,404.76 $1,404.76 $1,404.76 $126.14 $562.08 $924.28 $924.28 $924.28 $924.28 $1,270.13 $1,270.13 $924.28 $924.28 $924.28 $1,270.13 $924.28 $924.28 $924.28 $1,885.06 $2,884.21 $924.28 $179.14 $924.28 $924.28 $924.28 $924.28 $924.28 $924.28 $924.28 $74.65 $1,270.13 $1,270.13 $924.28 $478.57 $924.28 $924.28 $924.28 $924.28 $924.28 $924.28 $924.28

$63.61 $44.56 $30.85 $10.66 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $733.69 $3,548.50 $6,758.50 $6,758.50 $733.69 $733.69 $6,758.50 $733.69 $6,758.50 $823.69 $823.69 $823.69 $188.65 $390.27 $480.82 $565.57 $613.57 $613.57 $790.03 $790.03 $924.28 $703.57 $613.57 $790.03 $565.57 $613.57 $613.57 $1,475.52 $2,884.21 $565.57 $140.16 $613.57 $703.57 $613.57 $703.57 $480.82 $703.57 $703.57 $74.65 $700.03 $855.28 $703.57 $369.39 $565.57 $565.57 $480.82 $480.82 $565.57 $565.57 $565.57

22.33 5.73 22.33 22.33 22.33 30.68 30.68 45.53 22.33 22.33 11.03 11.03 24.77 24.77

$924.28 $237.28 $924.28 $924.28 $924.28 $1,270.13 $1,270.13 $1,885.06 $924.28 $924.28 $456.81 $456.81 $1,025.71 $1,025.71

$480.82 $237.28 $613.57 $703.57 $703.57 $790.03 $855.28 $1,475.52 $924.28 $480.82 $373.58 $373.58 $506.18 $590.93 Page 30 of 38

55860 55870 55873 55875 55876* 55920 56405 56420 56440 56441 56442 56501 56515 56605 56606 56620 56625 56700 56740 56800 56805 56810 56820 56821 57000 57010 57020 57022 57023 57061 57065 57100 57105 57130 57135 57150 57155 57160 57170 57180 57200 57210 57220 57230 57240 57250 57260 57265 57267 57268 57287 57288 57289 57291 57300 57320 57400 57410 57415 57420 57421 57452 57454 57455 57456 57460 57461 57500 57505 57510 57511 57513 57520 57522 57530 57550 57556 57558 57700 57720 57800 58100 58110 58120 58145 58301 58321 58322 58323 58340 58345 58346 58350

Surgical exposure, prostate Electroejaculation Cryoablate prostate Transperi needle place, pros Place rt device/marker, pros Place needles pelvic for rt I & d of vulva/perineum Drainage of gland abscess Surgery for vulva lesion Lysis of labial lesion(s) Hymenotomy Destroy, vulva lesions, sim Destroy vulva lesion/s compl Biopsy of vulva/perineum Biopsy of vulva/perineum Partial removal of vulva Complete removal of vulva Partial removal of hymen Remove vagina gland lesion Repair of vagina Repair clitoris Repair of perineum Exam of vulva w/scope Exam/biopsy of vulva w/scope Exploration of vagina Drainage of pelvic abscess Drainage of pelvic fluid I & d vaginal hematoma, pp I & d vag hematoma, non-ob Destroy vag lesions, simple Destroy vag lesions, complex Biopsy of vagina Biopsy of vagina Remove vagina lesion Remove vagina lesion Treat vagina infection Insert uteri tandems/ovoids Insert pessary/other device Fitting of diaphragm/cap Treat vaginal bleeding Repair of vagina Repair vagina/perineum Revision of urethra Repair of urethral lesion Repair bladder & vagina Repair rectum & vagina Repair of vagina Extensive repair of vagina Insert mesh/pelvic flr addon Repair of bowel bulge Revise/remove sling repair Repair bladder defect Repair bladder & vagina Construction of vagina Repair rectum-vagina fistula Repair bladder-vagina lesion Dilation of vagina Pelvic examination Remove vaginal foreign body Exam of vagina w/scope Exam/biopsy of vag w/scope Exam of cervix w/scope Bx/curett of cervix w/scope Biopsy of cervix w/scope Endocerv curettage w/scope Bx of cervix w/scope, leep Conz of cervix w/scope, leep Biopsy of cervix Endocervical curettage Cauterization of cervix Cryocautery of cervix Laser surgery of cervix Conization of cervix Conization of cervix Removal of cervix Removal of residual cervix Remove cervix, repair bowel D&c of cervical stump Revision of cervix Revision of cervix Dilation of cervical canal Biopsy of uterus lining Bx done w/colposcopy add-on Dilation and curettage Myomectomy vag method Remove intrauterine device Artificial insemination Artificial insemination Sperm washing Catheter for hysterography Reopen fallopian tube Insert heyman uteri capsule Reopen fallopian tube

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y N Y Y Y

G2 P3 H8 A2 P3 G2 P3 P2 A2 A2 A2 P3 A2 P3 P3 A2 A2 A2 A2 A2 G2 A2 P3 P2 A2 A2 A2 G2 A2 P3 A2 P3 A2 A2 A2 P3 A2 P3 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 G2 A2 A2 A2 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P3 P2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 N1 A2 A2 P3 P3 P3 P3 N1 R2 A2 A2

$1,339.00 $1,339.00

$446.00 $333.00 $333.00 $510.00

$717.00 $995.00 $333.00 $510.00 $510.00 $717.00

$333.00 $446.00 $409.33 $333.00 $333.00 $446.00 $446.00 $446.00 $409.33

$178.05 $333.00 $446.00 $510.00 $510.00 $717.00 $717.00 $717.00 $995.00 $995.00 $510.00 $717.00 $717.00 $717.00 $510.00 $446.00 $446.00 $446.00

$446.00 $446.00 $446.00 $510.00 $510.00 $717.00 $510.00 $333.00 $510.00

$446.00 $717.00

$446.00 $510.00

19.34 1.85 162.54 36.08 1.9 25.69 1.15 1.35 19.02 19.02 19.02 1.57 19.9 0.92 0.4 19.02 19.02 19.02 19.02 19.02 19.02 19.02 1.15 1.35 19.02 19.02 6.08 11.56 18.32 1.46 19.02 0.94 19.02 19.02 19.02 0.77 6.08 0.95 0.13 1.35 19.02 19.02 42.71 32.42 32.42 32.42 32.42 42.71 32.42 32.42 32.42 42.71 32.42 32.42 32.42 32.42 19.02 19.02 19.02 1.19 1.58 1.13 1.4 1.48 1.43 4.66 4.91 2.1 1.28 1.32 1.35 19.02 19.02 19.02 32.42 32.42 42.71 19.02 19.02 19.02 0.68 1.13

$800.75 $76.55 $6,729.23 $1,493.64 $78.84 $1,063.79 $47.61 $55.97 $787.46 $787.46 $787.46 $65.13 $824.05 $38.09 $16.38 $787.46 $787.46 $787.46 $787.46 $787.46 $787.46 $787.46 $47.61 $55.97 $787.46 $787.46 $251.65 $478.57 $758.45 $60.56 $787.46 $38.85 $787.46 $787.46 $787.46 $31.99 $251.65 $39.23 $5.42 $55.97 $787.46 $787.46 $1,768.23 $1,342.37 $1,342.37 $1,342.37 $1,342.37 $1,768.23 $1,342.37 $1,342.37 $1,342.37 $1,768.23 $1,342.37 $1,342.37 $1,342.37 $1,342.37 $787.46 $787.46 $787.46 $49.13 $65.51 $46.85 $57.89 $61.32 $59.03 $192.72 $203.38 $86.84 $52.94 $54.46 $55.97 $787.46 $787.46 $787.46 $1,342.37 $1,342.37 $1,768.23 $787.46 $787.46 $787.46 $28.18 $46.85

$800.75 $76.55 $6,219.63 $1,377.66 $78.84 $1,063.79 $47.61 $55.97 $531.37 $446.62 $446.62 $65.13 $588.51 $38.09 $16.38 $734.62 $943.12 $446.62 $579.37 $579.37 $787.46 $734.62 $47.61 $55.97 $446.62 $531.37 $369.91 $478.57 $439.36 $60.56 $446.62 $38.85 $531.37 $531.37 $531.37 $31.99 $369.91 $39.23 $5.42 $147.53 $446.62 $531.37 $824.56 $718.09 $873.34 $873.34 $873.34 $1,188.31 $1,081.84 $718.09 $1,342.37 $979.81 $873.34 $873.34 $718.09 $1,342.37 $531.37 $531.37 $531.37 $49.13 $65.51 $46.85 $57.89 $61.32 $59.03 $192.72 $203.38 $86.84 $52.94 $54.46 $55.97 $531.37 $531.37 $531.37 $718.09 $718.09 $979.81 $579.37 $446.62 $579.37 $28.18 $46.85

19.02 32.42 1.09 0.96 1.03 0.31

$787.46 $1,342.37 $44.94 $39.61 $42.66 $12.95

$531.37 $873.34 $44.94 $39.61 $42.66 $12.95

19.02 19.02 32.42

$787.46 $787.46 $1,342.37

$787.46 $531.37 $718.09 Page 31 of 38

58353 58356 58545 58546 58550 58552 58555 58558 58559 58560 58561 58562 58563 58565 58600 58615 58660 58661 58662 58670 58671 58672 58673 58800 58805 58820 58900 58970 58974 58976 59000 59001 59012 59015 59020 59025 59070 59072 59076 59100 59150 59151 59160 59200 59300 59320 59412 59414 59812 59820 59821 59840 59841 59866 59870 59871 60000 60001 60100 60200 60280 60281 60300 61000 61001 61020 61026 61050 61055 61070 61215 61330 61334 61790 61791 61795 61880 61885 61886 61888 62194 62225 62230 62252 62263 62264 62268 62269 62270 62272 62273 62280 62281

Endometr ablate, thermal Endometrial cryoablation Laparoscopic myomectomy Laparo-myomectomy, complex Laparo-asst vag hysterectomy Laparo-vag hyst incl t/o Hysteroscopy, dx, sep proc Hysteroscopy, biopsy Hysteroscopy, lysis Hysteroscopy, resect septum Hysteroscopy, remove myoma Hysteroscopy, remove fb Hysteroscopy, ablation Hysteroscopy, sterilization Division of fallopian tube Occlude fallopian tube(s) Laparoscopy, lysis Laparoscopy, remove adnexa Laparoscopy, excise lesions Laparoscopy, tubal cautery Laparoscopy, tubal block Laparoscopy, fimbrioplasty Laparoscopy, salpingostomy Drainage of ovarian cyst(s) Drainage of ovarian cyst(s) Drain ovary abscess, open Biopsy of ovary(s) Retrieval of oocyte Transfer of embryo Transfer of embryo Amniocentesis, diagnostic Amniocentesis, therapeutic Fetal cord puncture,prenatal Chorion biopsy Fetal contract stress test Fetal non-stress test Transabdom amnioinfus w/us Umbilical cord occlud w/us Fetal shunt placement, w/us Remove uterus lesion Treat ectopic pregnancy Treat ectopic pregnancy D & c after delivery Insert cervical dilator Episiotomy or vaginal repair Revision of cervix Antepartum manipulation Deliver placenta Treatment of miscarriage Care of miscarriage Treatment of miscarriage Abortion Abortion Abortion (mpr) Evacuate mole of uterus Remove cerclage suture Drain thyroid/tongue cyst Aspirate/inject thyriod cyst Biopsy of thyroid Remove thyroid lesion Remove thyroid duct lesion Remove thyroid duct lesion Aspir/inj thyroid cyst Remove cranial cavity fluid Remove cranial cavity fluid Remove brain cavity fluid Injection into brain canal Remove brain canal fluid Injection into brain canal Brain canal shunt procedure Insert brain-fluid device Decompress eye socket Explore orbit/remove object Treat trigeminal nerve Treat trigeminal tract Brain surgery using computer Revise/remove neuroelectrode Insrt/redo neurostim 1 array Implant neurostim arrays Revise/remove neuroreceiver Replace/irrigate catheter Replace/irrigate catheter Replace/revise brain shunt Csf shunt reprogram Epidural lysis mult sessions Epidural lysis on single day Drain spinal cord cyst Needle biopsy, spinal cord Spinal fluid tap, diagnostic Drain cerebro spinal fluid Inject epidural patch Treat spinal cord lesion Treat spinal cord lesion

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y N N Y Y Y Y N Y Y Y Y Y Y Y Y Y

A2 P2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 P3 R2 G2 P3 P3 P3 G2 G2 G2 R2 G2 G2 A2 P3 P3 A2 G2 G2 A2 A2 A2 A2 A2 G2 A2 A2 A2 D5 P3 A2 A2 A2 P3 R2 R2 A2 A2 A2 A2 A2 A2 G2 G2 A2 A2 N1 G2 H8 H8 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2

$995.00 $1,339.00 $1,339.00 $1,339.00 $333.00 $510.00 $446.00 $510.00 $510.00 $510.00 $1,339.00 $1,339.00

$717.00 $717.00 $717.00 $510.00 $510.00 $717.00 $717.00 $510.00 $510.00 $510.00 $245.92 $245.92 $245.92

$510.00

$333.00

$717.00 $717.00 $717.00 $717.00 $717.00 $717.00 $717.00 $333.00

$446.00 $630.00 $630.00

$183.83 $183.83 $183.83 $183.83 $183.83 $510.00

$510.00 $351.92

$446.00 $510.00 $333.00 $333.00 $333.00 $446.00 $333.00 $333.00 $183.83 $333.00 $139.00 $139.00 $333.00 $333.00 $333.00

32.42 42.71 34.4 45.53 69.67 45.53 21.66 21.66 21.66 34.2 34.2 21.66 34.2 42.71 32.42 19.02 45.53 45.53 45.53 45.53 45.53 45.53 45.53 19.02 32.42 32.42 19.02 2.76 2.76 2.76 1.76 6.08 2.76 1.36 0.64 0.33 2.76 2.76 2.76 32.42 45.53 45.53 19.02 0.98 2.01 19.02 19.02 19.02 19.02 19.02 19.02 19.02 19.02 2.76 19.02 19.02 7.45

$1,342.37 $1,768.23 $1,424.02 $1,885.06 $2,884.21 $1,885.06 $896.65 $896.65 $896.65 $1,416.11 $1,416.11 $896.65 $1,416.11 $1,768.23 $1,342.37 $787.46 $1,885.06 $1,885.06 $1,885.06 $1,885.06 $1,885.06 $1,885.06 $1,885.06 $787.46 $1,342.37 $1,342.37 $787.46 $114.20 $114.20 $114.20 $72.75 $251.65 $114.20 $56.37 $26.66 $13.71 $114.20 $114.20 $114.20 $1,342.37 $1,885.06 $1,885.06 $787.46 $40.37 $83.03 $787.46 $787.46 $787.46 $787.46 $787.46 $787.46 $787.46 $787.46 $114.20 $787.46 $787.46 $308.33

$1,081.84 $1,768.23 $1,360.26 $1,475.52 $1,725.30 $1,885.06 $473.91 $606.66 $558.66 $736.53 $736.53 $606.66 $1,358.28 $1,446.31 $1,342.37 $787.46 $1,009.02 $1,009.02 $1,009.02 $853.77 $853.77 $1,009.02 $1,009.02 $579.37 $1,342.37 $718.09 $579.37 $212.99 $212.99 $212.99 $72.75 $251.65 $114.20 $56.37 $26.66 $13.71 $114.20 $114.20 $114.20 $1,342.37 $1,885.06 $1,885.06 $579.37 $40.37 $83.03 $446.62 $787.46 $787.46 $734.62 $734.62 $734.62 $734.62 $734.62 $114.20 $734.62 $734.62 $326.83

1.25 44.32 44.32 44.32 1.54 8.53 8.53 8.53 8.53 8.53 8.53 3.24 36.28 39.88 39.88 18.05 14.49

$51.80 $1,835.06 $1,835.06 $1,835.06 $63.61 $353.00 $353.00 $353.00 $353.00 $353.00 $353.00 $134.07 $1,501.90 $1,650.97 $1,650.97 $747.36 $599.81

$51.80 $793.27 $931.27 $931.27 $63.61 $353.00 $353.00 $226.12 $226.12 $226.12 $226.12 $171.39 $757.98 $1,650.97 $1,650.97 $569.34 $413.89

22.47 269.54 395.28 34.42 8.53 15.35 36.28 1.2 14.49 14.49 8.53 9.34 4.1 4.1 4.1 7.05 7.05

$930.42 $11,159.35 $16,364.89 $1,424.88 $353.00 $635.69 $1,501.90 $49.51 $599.81 $599.81 $353.00 $386.49 $169.60 $169.60 $169.60 $292.07 $292.07

$930.42 $10,493.89 $15,586.16 $605.97 $338.00 $408.67 $709.98 $49.51 $399.70 $399.70 $226.12 $346.37 $146.65 $146.65 $292.15 $322.77 $322.77 Page 32 of 38

62282 62284 62287 62290 62291 62292 62294 62310 62311 62318 62319 62350 62355 62360 62361 62362 62365 62367 62368 63600 63610 63615 63650 63655 63660 63685 63688 63744 63746 64400 64402 64405 64408 64410 64412 64413 64415 64416 64417 64418 64420 64421 64425 64430 64435 64445 64446 64447 64450 64470 64472 64475 64476 64479 64480 64483 64484 64505 64508 64510 64517 64520 64530 64553 64555 64560 64561 64565 64573 64575 64577 64580 64581 64585 64590 64595 64600 64605 64610 64612 64613 64614 64620 64622 64623 64626 64627 64630 64640 64650 64653 64680 64681

Treat spinal canal lesion Injection for myelogram Percutaneous diskectomy Inject for spine disk x-ray Inject for spine disk x-ray Injection into disk lesion Injection into spinal artery Inject spine c/t Inject spine l/s (cd) Inject spine w/cath, c/t Inject spine w/cath l/s (cd) Implant spinal canal cath Remove spinal canal catheter Insert spine infusion device Implant spine infusion pump Implant spine infusion pump Remove spine infusion device Analyze spine infusion pump Analyze spine infusion pump Remove spinal cord lesion Stimulation of spinal cord Remove lesion of spinal cord Implant neuroelectrodes Implant neuroelectrodes Revise/remove neuroelectrode Insrt/redo spine n generator Revise/remove neuroreceiver Revision of spinal shunt Removal of spinal shunt N block inj, trigeminal N block inj, facial N block inj, occipital N block inj, vagus N block inj, phrenic N block inj, spinal accessor N block inj, cervical plexus N block inj, brachial plexus N block cont infuse, b plex N block inj, axillary N block inj, suprascapular N block inj, intercost, sng N block inj, intercost, mlt N block inj, ilio-ing/hypogi N block inj, pudendal N block inj, paracervical N block inj, sciatic, sng N blk inj, sciatic, cont inf N block inj fem, single N block, other peripheral Inj paravertebral c/t Inj paravertebral c/t add-on Inj paravertebral l/s Inj paravertebral l/s add-on Inj foramen epidural c/t Inj foramen epidural add-on Inj foramen epidural l/s Inj foramen epidural add-on N block, spenopalatine gangl N block, carotid sinus s/p N block, stellate ganglion N block inj, hypogas plxs N block, lumbar/thoracic N block inj, celiac pelus Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Implant neuroelectrodes Revise/remove neuroelectrode Insrt/redo pn/gastr stimul Revise/rmv pn/gastr stimul Injection treatment of nerve Injection treatment of nerve Injection treatment of nerve Destroy nerve, face muscle Destroy nerve, neck muscle Destroy nerve, extrem musc Injection treatment of nerve Destr paravertebrl nerve l/s Destr paravertebral n add-on Destr paravertebrl nerve c/t Destr paravertebral n add-on Injection treatment of nerve Injection treatment of nerve Chemodenerv eccrine glands Chemodenerv eccrine glands Injection treatment of nerve Injection treatment of nerve

Date Printed: 10/18/2008 @ 17:46:02

Y N Y N N Y Y Y Y Y Y Y Y Y Y Y Y N N Y Y Y N N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 N1 A2 N1 N1 R2 A2 A2 A2 A2 A2 A2 A2 A2 H8 H8 A2 P3 P3 A2 A2 R2 H8 J8 A2 H8 A2 A2 A2 P3 P3 P3 P3 A2 P3 P3 A2 G2 A2 P3 A2 A2 P3 A2 P3 P3 G2 R2 P3 A2 A2 A2 A2 A2 A2 A2 A2 P3 P2 A2 A2 A2 A2 H8 J8 J8 H8 J8 H8 H8 H8 H8 H8 A2 H8 A2 A2 A2 A2 P3 P3 P3 A2 A2 A2 A2 A2 A2 P3 P3 P3 A2 A2

$333.00 $1,339.00

$183.83 $333.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00

$446.00 $333.00 $446.00 $333.00 $446.00 $333.00 $510.00 $446.00

$333.00

$139.00 $139.00 $139.00 $333.00 $139.00

$333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00 $333.00

$333.00 $139.00 $333.00 $333.00 $333.00

$510.00 $333.00 $333.00 $333.00 $333.00 $510.00 $333.00 $446.00 $333.00 $333.00 $333.00 $333.00

$333.00 $333.00 $333.00 $333.00 $333.00 $351.92

$390.95 $446.00

7.05

$292.07

$322.77

33.27

$1,377.44

$1,348.61

8.53 8.53 7.05 7.05 7.05 7.05 36.28 14.49 36.28 263.83 263.83 33.27 0.48 0.58 18.05 18.05 18.05 83.11 109.9 22.47 350.83 34.42 36.28 5.66 1.53 1.39 1.21 1.39 7.05 2.2 1.45 4.1 7.05 4.1 2.08 4.1 4.1 1.35 7.05 2.08 1.98 14.49 4.1 1.16 7.05 4.1 7.05 2.32 7.05 4.1 7.05 4.1 1.09 2.32 7.05 7.05 7.05 7.05 316.54 83.11 83.11 83.11 83.11 316.54 109.9 109.9 109.9 109.9 22.47 269.54 34.42 14.49 14.49 14.49 1.87 1.98 2.23 7.05 14.49 7.05 14.49 2.32 7.05 3.04 0.73 0.76 14.49 14.49

$353.00 $353.00 $292.07 $292.07 $292.07 $292.07 $1,501.90 $599.81 $1,501.90 $10,922.89 $10,922.89 $1,377.44 $19.81 $23.99 $747.36 $747.36 $747.36 $3,440.98 $4,549.87 $930.42 $14,524.72 $1,424.88 $1,501.90 $234.39 $63.22 $57.51 $49.89 $57.51 $292.07 $91.03 $60.18 $169.60 $292.07 $169.60 $86.08 $169.60 $169.60 $55.99 $292.07 $86.08 $81.89 $599.81 $169.60 $47.99 $292.07 $169.60 $292.07 $96.10 $292.07 $169.60 $292.07 $169.60 $44.94 $96.10 $292.07 $292.07 $292.07 $292.07 $13,105.10 $3,440.98 $3,440.98 $3,440.98 $3,440.98 $13,105.10 $4,549.87 $4,549.87 $4,549.87 $4,549.87 $930.42 $11,159.35 $1,424.88 $599.81 $599.81 $599.81 $77.32 $81.89 $92.17 $292.07 $599.81 $292.07 $599.81 $96.10 $292.07 $125.69 $30.09 $31.61 $599.81 $599.81

$353.00 $226.12 $322.77 $322.77 $322.77 $322.77 $709.98 $484.45 $709.98 $10,157.07 $10,157.07 $678.86 $19.81 $23.99 $521.34 $436.59 $747.36 $2,909.36 $4,549.87 $482.36 $13,727.20 $605.97 $757.98 $393.10 $63.22 $57.51 $49.89 $57.51 $322.77 $91.03 $60.18 $146.65 $292.07 $146.65 $86.08 $146.65 $292.15 $55.99 $177.27 $86.08 $81.89 $599.81 $169.60 $47.99 $322.77 $292.15 $322.77 $273.78 $322.77 $292.15 $322.77 $292.15 $44.94 $96.10 $322.77 $177.27 $322.77 $322.77 $12,022.95 $3,440.98 $3,440.98 $2,957.36 $3,440.98 $12,022.95 $3,785.92 $3,785.92 $3,785.92 $3,918.67 $482.36 $10,493.89 $605.97 $399.70 $399.70 $399.70 $77.32 $81.89 $92.17 $322.77 $399.70 $322.77 $399.70 $273.78 $336.96 $125.69 $30.09 $31.61 $443.17 $484.45 Page 33 of 38

64702 64704 64708 64712 64713 64714 64716 64718 64719 64721 64722 64726 64727 64732 64734 64736 64738 64740 64742 64744 64746 64761 64763 64766 64771 64772 64774 64776 64778 64782 64783 64784 64786 64787 64788 64790 64792 64795 64802 64820 64821 64822 64823 64831 64832 64834 64835 64836 64837 64840 64856 64857 64858 64859 64861 64862 64864 64865 64870 64872 64874 64876 64885 64886 64890 64891 64892 64893 64895 64896 64897 64898 64901 64902 64905 64907 64910 65091 65093 65101 65103 65105 65110 65112 65114 65125 65130 65135 65140 65150 65155 65175 65205

Revise finger/toe nerve Revise hand/foot nerve Revise arm/leg nerve Revision of sciatic nerve Revision of arm nerve(s) Revise low back nerve(s) Revision of cranial nerve Revise ulnar nerve at elbow Revise ulnar nerve at wrist Carpal tunnel surgery Relieve pressure on nerve(s) Release foot/toe nerve Internal nerve revision Incision of brow nerve Incision of cheek nerve Incision of chin nerve Incision of jaw nerve Incision of tongue nerve Incision of facial nerve Incise nerve, back of head Incise diaphragm nerve Incision of pelvis nerve Incise hip/thigh nerve Incise hip/thigh nerve Sever cranial nerve Incision of spinal nerve Remove skin nerve lesion Remove digit nerve lesion Digit nerve surgery add-on Remove limb nerve lesion Limb nerve surgery add-on Remove nerve lesion Remove sciatic nerve lesion Implant nerve end Remove skin nerve lesion Removal of nerve lesion Removal of nerve lesion Biopsy of nerve Remove sympathetic nerves Remove sympathetic nerves Remove sympathetic nerves Remove sympathetic nerves Remove sympathetic nerves Repair of digit nerve Repair nerve add-on Repair of hand or foot nerve Repair of hand or foot nerve Repair of hand or foot nerve Repair nerve add-on Repair of leg nerve Repair/transpose nerve Repair arm/leg nerve Repair sciatic nerve Nerve surgery Repair of arm nerves Repair of low back nerves Repair of facial nerve Repair of facial nerve Fusion of facial/other nerve Subsequent repair of nerve Repair & revise nerve add-on Repair nerve/shorten bone Nerve graft, head or neck Nerve graft, head or neck Nerve graft, hand or foot Nerve graft, hand or foot Nerve graft, arm or leg Nerve graft, arm or leg Nerve graft, hand or foot Nerve graft, hand or foot Nerve graft, arm or leg Nerve graft, arm or leg Nerve graft add-on Nerve graft add-on Nerve pedicle transfer Nerve pedicle transfer Nerve repair w/allograft Revise eye Revise eye with implant Removal of eye Remove eye/insert implant Remove eye/attach implant Removal of eye Remove eye/revise socket Remove eye/revise socket Revise ocular implant Insert ocular implant Insert ocular implant Attach ocular implant Revise ocular implant Reinsert ocular implant Removal of ocular implant Remove foreign body from eye

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N

A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 G2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 P3

$333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $510.00 $446.00 $446.00 $446.00 $333.00 $333.00 $333.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00

$446.00 $446.00 $446.00 $510.00 $446.00 $510.00 $446.00 $510.00 $510.00 $446.00 $510.00 $510.00 $510.00 $446.00 $446.00 $630.00

$630.00 $333.00 $446.00 $510.00 $510.00 $333.00 $446.00 $446.00 $446.00 $446.00 $333.00 $510.00 $510.00 $510.00 $630.00 $630.00 $446.00 $510.00 $510.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $333.00 $510.00 $510.00 $510.00 $510.00 $630.00 $717.00 $995.00 $995.00 $510.00 $446.00 $510.00 $446.00 $510.00 $333.00

18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 33.27 18.05 18.05 18.05 18.05 18.05 18.05 18.05 18.05 33.27 18.05 18.05 18.05 33.27 18.05 18.05 18.05 26.31 26.31 26.31 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 33.27 18.05 37.72 37.72 37.72 37.72 37.72 37.72 37.72 37.72 18.73 24.31 24.31 37.72 24.31 37.72 18.73 0.55

$747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $1,377.44 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $747.36 $1,377.44 $747.36 $747.36 $747.36 $1,377.44 $747.36 $747.36 $747.36 $1,089.28 $1,089.28 $1,089.28 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $1,377.44 $747.36 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $775.47 $1,006.36 $1,006.36 $1,561.82 $1,006.36 $1,561.82 $775.47 $22.85

$436.59 $436.59 $521.34 $521.34 $521.34 $521.34 $569.34 $521.34 $521.34 $521.34 $436.59 $436.59 $436.59 $521.34 $521.34 $521.34 $521.34 $521.34 $521.34 $521.34 $521.34 $747.36 $747.36 $1,377.44 $521.34 $521.34 $521.34 $569.34 $521.34 $569.34 $521.34 $569.34 $726.86 $521.34 $569.34 $569.34 $726.86 $521.34 $521.34 $747.36 $744.82 $1,089.28 $1,089.28 $816.86 $594.11 $678.86 $726.86 $726.86 $594.11 $678.86 $678.86 $678.86 $678.86 $594.11 $726.86 $726.86 $726.86 $816.86 $816.86 $678.86 $726.86 $726.86 $678.86 $678.86 $678.86 $678.86 $678.86 $678.86 $726.86 $726.86 $726.86 $726.86 $678.86 $678.86 $678.86 $594.11 $747.36 $772.96 $772.96 $772.96 $772.96 $862.96 $928.21 $1,136.71 $1,136.71 $775.47 $634.09 $586.09 $772.96 $586.09 $772.96 $443.62 $22.85 Page 34 of 38

65210 65220 65222 65235 65260 65265 65270 65272 65275 65280 65285 65286 65290 65400 65410 65420 65426 65430 65435 65436 65450 65600 65710 65730 65750 65755 65770 65772 65775 65780 65781 65782 65800 65805 65810 65815 65820 65850 65855 65860 65865 65870 65875 65880 65900 65920 65930 66020 66030 66130 66150 66155 66160 66165 66170 66172 66180 66185 66220 66225 66250 66500 66505 66600 66605 66625 66630 66635 66680 66682 66700 66710 66711 66720 66740 66761 66762 66770 66820 66821 66825 66830 66840 66850 66852 66920 66930 66940 66982 66983 66984 66985 66986

Remove foreign body from eye Remove foreign body from eye Remove foreign body from eye Remove foreign body from eye Remove foreign body from eye Remove foreign body from eye Repair of eye wound Repair of eye wound Repair of eye wound Repair of eye wound Repair of eye wound Repair of eye wound Repair of eye socket wound Removal of eye lesion Biopsy of cornea Removal of eye lesion Removal of eye lesion Corneal smear Curette/treat cornea Curette/treat cornea Treatment of corneal lesion Revision of cornea Corneal transplant Corneal transplant Corneal transplant Corneal transplant Revise cornea with implant Correction of astigmatism Correction of astigmatism Ocular reconst, transplant Ocular reconst, transplant Ocular reconst, transplant Drainage of eye Drainage of eye Drainage of eye Drainage of eye Relieve inner eye pressure Incision of eye Laser surgery of eye Incise inner eye adhesions Incise inner eye adhesions Incise inner eye adhesions Incise inner eye adhesions Incise inner eye adhesions Remove eye lesion Remove implant of eye Remove blood clot from eye Injection treatment of eye Injection treatment of eye Remove eye lesion Glaucoma surgery Glaucoma surgery Glaucoma surgery Glaucoma surgery Glaucoma surgery Incision of eye Implant eye shunt Revise eye shunt Repair eye lesion Repair/graft eye lesion Follow-up surgery of eye Incision of iris Incision of iris Remove iris and lesion Removal of iris Removal of iris Removal of iris Removal of iris Repair iris & ciliary body Repair iris & ciliary body Destruction, ciliary body Ciliary transsleral therapy Ciliary endoscopic ablation Destruction, ciliary body Destruction, ciliary body Revision of iris Revision of iris Removal of inner eye lesion Incision, secondary cataract After cataract laser surgery Reposition intraocular lens Removal of lens lesion Removal of lens material Removal of lens material Removal of lens material Extraction of lens Extraction of lens Extraction of lens Cataract surgery, complex Cataract surg w/iol, 1 stage Cataract surg w/iol, 1 stage Insert lens prosthesis Exchange lens prosthesis

Date Printed: 10/18/2008 @ 17:46:02

N N N Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

P3 G2 P3 A2 A2 A2 A2 A2 A2 A2 A2 P2 A2 A2 A2 A2 A2 P2 P3 G2 G2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 P3 P2 G2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2

$446.00 $510.00 $630.00 $446.00 $446.00 $630.00 $630.00 $630.00 $510.00 $333.00 $446.00 $446.00 $717.00

$995.00 $995.00 $995.00 $995.00 $995.00 $630.00 $630.00 $717.00 $717.00 $717.00 $333.00 $333.00 $510.00 $446.00 $333.00 $630.00

$333.00 $630.00 $630.00 $630.00 $717.00 $995.00 $717.00 $333.00 $333.00 $995.00 $630.00 $630.00 $446.00 $630.00 $630.00 $630.00 $717.00 $446.00 $510.00 $630.00 $446.00 $333.00 $333.00 $510.00 $510.00 $372.94 $510.00 $510.00 $510.00 $446.00 $446.00 $446.00 $446.00 $446.00 $446.00

$312.50 $630.00 $372.94 $630.00 $995.00 $630.00 $630.00 $717.00 $717.00 $973.00 $973.00 $973.00 $826.00 $826.00

0.7 0.87 0.76 16.17 18.24 27.85 18.73 23.18 23.18 18.24 37.21 5.12 24.13 16.17 16.17 16.17 23.18 0.87 0.86 16.17 2.18 4.34 37.49 37.49 37.49 37.49 84.8 16.17 16.17 37.49 37.49 37.49 16.17 16.17 23.18 23.18 5.12 23.18 3.59 3.36 16.17 23.18 23.18 16.17 16.17 23.18 23.18 16.17 5.12 23.18 23.18 23.18 23.18 23.18 23.18 23.18 39.71 39.71 37.21 39.71 16.17 5.12 5.12 23.18 23.18 5.12 23.18 23.18 23.18 23.18 16.17 16.17 16.17 16.17 23.18 4.88 4.95 5.2 5.12 5.2 23.18 5.12 14.92 28.7 28.7 28.7 28.7 14.92 23.86 23.86 23.86 23.86 23.86

$28.95 $36.00 $31.61 $669.50 $754.95 $1,152.81 $775.47 $959.50 $959.50 $754.95 $1,540.44 $211.84 $998.97 $669.50 $669.50 $669.50 $959.50 $36.00 $35.42 $669.50 $90.21 $179.77 $1,552.11 $1,552.11 $1,552.11 $1,552.11 $3,510.97 $669.50 $669.50 $1,552.11 $1,552.11 $1,552.11 $669.50 $669.50 $959.50 $959.50 $211.84 $959.50 $148.54 $139.02 $669.50 $959.50 $959.50 $669.50 $669.50 $959.50 $959.50 $669.50 $211.84 $959.50 $959.50 $959.50 $959.50 $959.50 $959.50 $959.50 $1,644.04 $1,644.04 $1,540.44 $1,644.04 $669.50 $211.84 $211.84 $959.50 $959.50 $211.84 $959.50 $959.50 $959.50 $959.50 $669.50 $669.50 $669.50 $669.50 $959.50 $202.24 $204.91 $215.29 $211.84 $215.29 $959.50 $211.84 $617.58 $1,188.35 $1,188.35 $1,188.35 $1,188.35 $617.58 $988.03 $988.03 $988.03 $988.03 $988.03

$28.95 $36.00 $31.61 $501.88 $571.24 $760.70 $528.37 $574.38 $712.38 $661.24 $857.61 $211.84 $632.24 $417.13 $501.88 $501.88 $777.63 $36.00 $35.42 $669.50 $90.21 $179.77 $1,134.28 $1,134.28 $1,134.28 $1,134.28 $1,623.99 $639.88 $639.88 $925.78 $925.78 $925.78 $417.13 $417.13 $622.38 $574.38 $302.71 $712.38 $148.54 $139.02 $417.13 $712.38 $712.38 $639.88 $705.13 $986.13 $777.63 $417.13 $302.71 $986.13 $712.38 $712.38 $574.38 $712.38 $712.38 $712.38 $948.76 $745.51 $767.61 $883.51 $501.88 $302.71 $302.71 $622.38 $622.38 $332.67 $622.38 $622.38 $622.38 $574.38 $501.88 $501.88 $501.88 $501.88 $574.38 $202.24 $204.91 $215.29 $211.84 $288.20 $712.38 $332.67 $626.90 $1,043.34 $769.59 $769.59 $834.84 $692.15 $976.76 $976.76 $976.76 $866.51 $866.51 Page 35 of 38

66990 67005 67010 67015 67025 67027 67028 67030 67031 67036 67038 67039 67040 67041 67042 67043 67101 67105 67107 67108 67110 67112 67113 67115 67120 67121 67141 67145 67208 67210 67218 67220 67221 67225 67227 67228 67229* 67250 67255 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67343 67345 67346 67400 67405 67412 67413 67414 67415 67420 67430 67440 67445 67450 67500 67505 67515 67550 67560 67570 67700 67710 67715 67800 67801 67805 67808 67810 67820 67825 67830 67835 67840 67850 67875 67880 67882 67900 67901 67902 67903 67904 67906

Ophthalmic endoscope add-on Partial removal of eye fluid Partial removal of eye fluid Release of eye fluid Replace eye fluid Implant eye drug system Injection eye drug Incise inner eye strands Laser surgery, eye strands Removal of inner eye fluid Strip retinal membrane Laser treatment of retina Laser treatment of retina Vit for macular pucker Vit for macular hole Vit for membrane dissect Repair detached retina Repair detached retina Repair detached retina Repair detached retina Repair detached retina Rerepair detached retina Repair retinal detach, cplx Release encircling material Remove eye implant material Remove eye implant material Treatment of retina Treatment of retina Treatment of retinal lesion Treatment of retinal lesion Treatment of retinal lesion Treatment of choroid lesion Ocular photodynamic ther Eye photodynamic ther add-on Treatment of retinal lesion Treatment of retinal lesion Tr retinal les preterm inf Reinforce eye wall Reinforce/graft eye wall Revise eye muscle Revise two eye muscles Revise eye muscle Revise two eye muscles Revise eye muscle(s) Revise eye muscle(s) add-on Eye surgery follow-up add-on Rerevise eye muscles add-on Revise eye muscle w/suture Eye suture during surgery Revise eye muscle add-on Release eye tissue Destroy nerve of eye muscle Biopsy, eye muscle Explore/biopsy eye socket Explore/drain eye socket Explore/treat eye socket Explore/treat eye socket Explr/decompress eye socket Aspiration, orbital contents Explore/treat eye socket Explore/treat eye socket Explore/drain eye socket Explr/decompress eye socket Explore/biopsy eye socket Inject/treat eye socket Inject/treat eye socket Inject/treat eye socket Insert eye socket implant Revise eye socket implant Decompress optic nerve Drainage of eyelid abscess Incision of eyelid Incision of eyelid fold Remove eyelid lesion Remove eyelid lesions Remove eyelid lesions Remove eyelid lesion(s) Biopsy of eyelid Revise eyelashes Revise eyelashes Revise eyelashes Revise eyelashes Remove eyelid lesion Treat eyelid lesion Closure of eyelid by suture Revision of eyelid Revision of eyelid Repair brow defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect

Date Printed: 10/18/2008 @ 17:46:02

N Y Y Y Y Y N Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y

N1 A2 A2 A2 A2 A2 P2 A2 A2 A2 D5 A2 A2 G2 G2 G2 P3 P2 A2 A2 P3 A2 G2 A2 A2 A2 A2 P3 P3 P2 A2 P2 P3 P3 A2 P2 R2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 G2 A2 A2 A2 A2 A2 A2 G2 G2 P3 A2 A2 A2 P2 P3 A2 P3 P3 P3 A2 P2 P3 P3 A2 A2 P3 P3 G2 A2 A2 A2 A2 A2 A2 A2 A2

$630.00 $630.00 $333.00 $333.00 $630.00 $333.00 $312.50 $630.00 $995.00 $995.00

$717.00 $995.00 $995.00 $446.00 $446.00 $446.00 $241.77

$717.00

$333.00

$510.00 $510.00 $510.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $995.00 $333.00 $510.00 $630.00 $717.00 $717.00 $333.00 $717.00 $717.00 $717.00 $717.00 $717.00

$630.00 $446.00 $630.00

$333.00

$446.00

$446.00 $446.00

$510.00 $510.00 $630.00 $717.00 $717.00 $630.00 $630.00 $717.00

27.85 27.85 27.85 27.85 37.21 2.18 18.24 5.2 37.21

$1,152.81 $1,152.81 $1,152.81 $1,152.81 $1,540.44 $90.21 $754.95 $215.29 $1,540.44

$760.70 $760.70 $537.95 $537.95 $857.61 $90.21 $438.49 $288.20 $857.61

37.21 37.21 37.21 37.21 37.21 8.1 5.2 37.21 37.21 8.81 37.21 37.21 18.24 18.24 27.85 4.13 5.09 5.42 5.2 18.24 4.13 3.33 0.22 27.85 5.2 5.2 18.73 27.85 24.13 24.13 24.13 24.13 24.13 24.13 24.13 24.13 24.13 24.13 24.13 24.13 2.19 13.75 24.31 24.31 24.31 24.31 37.72 18.73 37.72 37.72 37.72 37.72 37.72 2.18 2.9 0.63 37.72 24.31 37.72 2.9 4.18 18.73 1.38 1.67 2.16 18.73 2.9 0.48 1.44 7.28 18.73 4.31 3.06 7.28 16.17 18.73 18.73 18.73 18.73 18.73 18.73 18.73

$1,540.44 $1,540.44 $1,540.44 $1,540.44 $1,540.44 $335.55 $215.29 $1,540.44 $1,540.44 $364.87 $1,540.44 $1,540.44 $754.95 $754.95 $1,152.81 $171.11 $210.62 $224.33 $215.29 $754.95 $171.11 $137.87 $9.14 $1,152.81 $215.29 $215.29 $775.47 $1,152.81 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $998.97 $90.65 $569.07 $1,006.36 $1,006.36 $1,006.36 $1,006.36 $1,561.82 $775.47 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $1,561.82 $90.21 $120.15 $25.90 $1,561.82 $1,006.36 $1,561.82 $120.15 $172.91 $775.47 $57.13 $69.32 $89.50 $775.47 $120.15 $19.81 $59.80 $301.59 $775.47 $178.63 $126.83 $301.59 $669.50 $775.47 $775.47 $775.47 $775.47 $775.47 $775.47 $775.47

$1,131.36 $1,131.36 $1,540.44 $1,540.44 $1,540.44 $335.55 $215.29 $922.86 $1,131.36 $364.87 $1,131.36 $1,540.44 $523.24 $523.24 $622.70 $224.11 $210.62 $224.33 $215.29 $726.49 $171.11 $137.87 $9.14 $537.95 $215.29 $215.29 $576.37 $670.70 $632.24 $722.24 $722.24 $722.24 $722.24 $722.24 $722.24 $722.24 $722.24 $722.24 $722.24 $995.99 $90.65 $392.02 $634.09 $724.09 $789.34 $789.34 $1,561.82 $443.62 $928.21 $928.21 $928.21 $928.21 $928.21 $90.21 $120.15 $25.90 $862.96 $586.09 $862.96 $120.15 $172.91 $443.62 $57.13 $69.32 $89.50 $528.37 $120.15 $19.81 $59.80 $409.90 $528.37 $178.63 $126.83 $301.59 $549.88 $576.37 $666.37 $731.62 $731.62 $666.37 $666.37 $731.62 Page 36 of 38

67908 67909 67911 67912 67914 67915 67916 67917 67921 67922 67923 67924 67930 67935 67938 67950 67961 67966 67971 67973 67974 67975 68020 68040 68100 68110 68115 68130 68135 68200 68320 68325 68326 68328 68330 68335 68340 68360 68362 68371 68400 68420 68440 68500 68505 68510 68520 68525 68530 68540 68550 68700 68705 68720 68745 68750 68760 68761 68770 68801 68810 68811 68815 68816* 68840 68850 69000 69005 69020 69100 69105 69110 69120 69140 69145 69150 69200 69205 69210 69220 69222 69300 69310 69320 69400 69401 69405 69420 69421 69424 69433 69436 69440

Repair eyelid defect Revise eyelid defect Revise eyelid defect Correction eyelid w/implant Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid defect Repair eyelid wound Repair eyelid wound Remove eyelid foreign body Revision of eyelid Revision of eyelid Revision of eyelid Reconstruction of eyelid Reconstruction of eyelid Reconstruction of eyelid Reconstruction of eyelid Incise/drain eyelid lining Treatment of eyelid lesions Biopsy of eyelid lining Remove eyelid lining lesion Remove eyelid lining lesion Remove eyelid lining lesion Remove eyelid lining lesion Treat eyelid by injection Revise/graft eyelid lining Revise/graft eyelid lining Revise/graft eyelid lining Revise/graft eyelid lining Revise eyelid lining Revise/graft eyelid lining Separate eyelid adhesions Revise eyelid lining Revise eyelid lining Harvest eye tissue, alograft Incise/drain tear gland Incise/drain tear sac Incise tear duct opening Removal of tear gland Partial removal, tear gland Biopsy of tear gland Removal of tear sac Biopsy of tear sac Clearance of tear duct Remove tear gland lesion Remove tear gland lesion Repair tear ducts Revise tear duct opening Create tear sac drain Create tear duct drain Create tear duct drain Close tear duct opening Close tear duct opening Close tear system fistula Dilate tear duct opening Probe nasolacrimal duct Probe nasolacrimal duct Probe nasolacrimal duct Probe nl duct w/balloon Explore/irrigate tear ducts Injection for tear sac x-ray Drain external ear lesion Drain external ear lesion Drain outer ear canal lesion Biopsy of external ear Biopsy of external ear canal Remove external ear, partial Removal of external ear Remove ear canal lesion(s) Remove ear canal lesion(s) Extensive ear canal surgery Clear outer ear canal Clear outer ear canal Remove impacted ear wax Clean out mastoid cavity Clean out mastoid cavity Revise external ear Rebuild outer ear canal Rebuild outer ear canal Inflate middle ear canal Inflate middle ear canal Catheterize middle ear canal Incision of eardrum Incision of eardrum Remove ventilating tube Create eardrum opening Create eardrum opening Exploration of middle ear

Date Printed: 10/18/2008 @ 17:46:02

Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y Y Y Y Y Y Y N Y Y Y Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N N Y N N Y Y Y N N Y Y Y Y Y Y Y Y Y Y N Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y

A2 A2 A2 A2 A2 P3 A2 A2 A2 P3 A2 A2 P3 A2 P2 A2 A2 A2 A2 A2 A2 A2 P3 P3 P3 P3 A2 A2 P3 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 P2 P3 P3 A2 A2 A2 A2 A2 P3 A2 A2 A2 P2 A2 A2 A2 P2 P3 A2 P2 A2 A2 A2 P3 P3 N1 P2 P3 P2 P3 P3 A2 A2 A2 A2 A2 P2 A2 P3 P2 P3 A2 A2 A2 P3 P3 P3 P2 A2 P3 P3 A2 A2

$630.00 $630.00 $510.00 $510.00 $510.00 $630.00 $630.00 $510.00 $630.00 $630.00 $446.00 $446.00 $510.00 $510.00 $510.00 $510.00 $510.00 $510.00

$446.00 $446.00

$630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $630.00 $446.00 $446.00 $446.00

$510.00 $510.00 $333.00 $510.00 $333.00 $510.00 $510.00 $446.00 $630.00 $630.00 $630.00

$630.00 $131.86 $446.00 $446.00

$333.00 $446.00 $446.00 $446.00 $464.15 $333.00

$510.00 $510.00 $995.00

$510.00

$510.00 $510.00

18.73 18.73 18.73 18.73 18.73 4.74 18.73 18.73 18.73 4.64 18.73 18.73 4.64 18.73 2.18 18.73 18.73 18.73 24.31 24.31 24.31 18.73 1.21 0.61 2.59 3.3 18.73 16.17 1.56 0.45 18.73 24.31 24.31 24.31 23.18 24.31 18.73 23.18 23.18 16.17 2.9 4.96 1.54 24.31 24.31 18.73 24.31 18.73 6.34 24.31 24.31 24.31 2.9 24.31 24.31 24.31 2.18 1.89 18.73 0.87 2.18 18.73 18.73 11.73 1.43

$775.47 $775.47 $775.47 $775.47 $775.47 $196.15 $775.47 $775.47 $775.47 $191.96 $775.47 $775.47 $191.96 $775.47 $90.21 $775.47 $775.47 $775.47 $1,006.36 $1,006.36 $1,006.36 $775.47 $50.27 $25.14 $107.02 $136.73 $775.47 $669.50 $64.75 $18.66 $775.47 $1,006.36 $1,006.36 $1,006.36 $959.50 $1,006.36 $775.47 $959.50 $959.50 $669.50 $120.15 $205.29 $63.61 $1,006.36 $1,006.36 $775.47 $1,006.36 $775.47 $262.42 $1,006.36 $1,006.36 $1,006.36 $120.15 $1,006.36 $1,006.36 $1,006.36 $90.21 $78.08 $775.47 $36.00 $90.21 $775.47 $775.47 $485.61 $59.03

$666.37 $666.37 $576.37 $576.37 $576.37 $196.15 $666.37 $666.37 $576.37 $191.96 $666.37 $666.37 $191.96 $528.37 $90.21 $528.37 $576.37 $576.37 $634.09 $634.09 $634.09 $576.37 $50.27 $25.14 $107.02 $136.73 $528.37 $501.88 $64.75 $18.66 $666.37 $724.09 $724.09 $724.09 $712.38 $724.09 $666.37 $574.38 $574.38 $501.88 $120.15 $205.29 $63.61 $634.09 $634.09 $443.62 $634.09 $443.62 $262.42 $634.09 $634.09 $586.09 $120.15 $724.09 $724.09 $724.09 $90.21 $78.08 $666.37 $36.00 $121.45 $528.37 $528.37 $485.61 $59.03

1.41 2.72 1.41 1.64 2.29 16.1 23.98 23.98 16.1 7.45 0.63 21.11 0.55 0.79 3.6 23.98 39.88 39.88 2.29 1.27 3.29 2.5 16.33 2.08 2.95 16.33 23.98

$58.23 $112.74 $58.23 $67.79 $94.84 $666.56 $992.65 $992.65 $666.56 $308.33 $26.12 $873.97 $22.85 $32.83 $148.92 $992.65 $1,650.97 $1,650.97 $94.84 $52.56 $136.35 $103.51 $676.03 $86.08 $122.26 $676.03 $992.65

$58.23 $112.74 $58.23 $67.79 $94.84 $416.39 $582.66 $582.66 $501.14 $425.20 $26.12 $468.24 $22.85 $32.83 $148.92 $630.66 $795.24 $1,158.99 $94.84 $52.56 $136.35 $103.51 $551.51 $86.08 $122.26 $551.51 $630.66 Page 37 of 38

69450 69501 69502 69505 69511 69530 69540 69550 69552 69601 69602 69603 69604 69605 69610 69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69711 69714 69715 69717 69718 69720 69740 69745 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 69990 C9716 C9724 C9725 C9726 C9727 C9728 G0104 G0105 G0121 G0127 G0186 G0247 G0259 G0260 G0268 G0269 G0289 G0364 G0392 G0393

Eardrum revision Mastoidectomy Mastoidectomy Remove mastoid structures Extensive mastoid surgery Extensive mastoid surgery Remove ear lesion Remove ear lesion Remove ear lesion Mastoid surgery revision Mastoid surgery revision Mastoid surgery revision Mastoid surgery revision Mastoid surgery revision Repair of eardrum Repair of eardrum Repair eardrum structures Rebuild eardrum structures Rebuild eardrum structures Repair eardrum structures Rebuild eardrum structures Rebuild eardrum structures Revise middle ear & mastoid Revise middle ear & mastoid Revise middle ear & mastoid Revise middle ear & mastoid Revise middle ear & mastoid Revise middle ear & mastoid Release middle ear bone Revise middle ear bone Revise middle ear bone Revise middle ear bone Repair middle ear structures Repair middle ear structures Remove mastoid air cells Remove middle ear nerve Close mastoid fistula Remove/repair hearing aid Implant temple bone w/stimul Temple bne implnt w/stimulat Temple bone implant revision Revise temple bone implant Release facial nerve Repair facial nerve Repair facial nerve Incise inner ear Incise inner ear Explore inner ear Explore inner ear Establish inner ear window Revise inner ear window Remove inner ear Remove inner ear & mastoid Incise inner ear nerve Implant cochlear device Microsurgery add-on Radiofrequency energy to anu EPS gast cardia plic Place endorectal app Rxt breast appl place/remov Insert palate implants Place device/marker, non pro CA screen;flexi sigmoidscope Colorectal scrn; hi risk ind Colon ca scrn not hi rsk ind Trim nail(s) Dstry eye lesn,fdr vssl tech Routine footcare pt w lops Inject for sacroiliac joint Inj for sacroiliac jt anesth Removal of impacted wax md Occlusive device in vein art Arthro, loose body + chondro Bone marrow aspirate &biopsy AV fistula or graft arterial AV fistula or graft venous

Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y N Y Y N N N Y N Y Y Y Y Y N Y N N N Y Y Y

A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 P3 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 A2 H8 N1 G2 G2 G2 G2 G2 R2 P3 A2 A2 P3 R2 P3 N1 A2 N1 N1 N1 P3 A2 A2

$333.00 $995.00 $995.00 $995.00 $995.00 $995.00 $717.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $446.00 $717.00 $717.00 $717.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $995.00 $717.00 $717.00 $717.00 $630.00 $630.00 $510.00 $510.00 $510.00 $333.00 $1,339.00 $1,339.00 $1,339.00 $1,339.00 $717.00 $717.00 $717.00 $717.00 $995.00 $995.00 $995.00 $717.00 $717.00 $995.00 $995.00 $995.00 $995.00

$446.00 $446.00

$333.00

$1,339.00 $1,339.00

39.88 39.88 23.98 39.88 39.88 39.88 3.51 39.88 39.88 39.88 39.88 39.88 39.88 39.88 4.82 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 23.98 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 39.88 568.84

$1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $145.49 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $199.58 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $992.65 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $1,650.97 $23,550.52

$662.49 $1,158.99 $994.41 $1,158.99 $1,158.99 $1,158.99 $145.49 $950.49 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $199.58 $582.66 $950.49 $950.49 $950.49 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $1,158.99 $994.41 $950.49 $950.49 $950.49 $885.24 $885.24 $795.24 $795.24 $795.24 $662.49 $1,416.99 $1,416.99 $1,416.99 $1,416.99 $950.49 $950.49 $950.49 $950.49 $1,158.99 $1,158.99 $1,158.99 $950.49 $950.49 $1,158.99 $1,158.99 $1,158.99 $22,213.76

30.16 25.32 8.64 10.21 13.35 3.05 2.21 7.85 7.85 0.29 4.13 0.55

$1,248.68 $1,048.41 $357.50 $422.50 $552.50 $126.14 $91.41 $325.01 $325.01 $12.19 $171.11 $22.85

$1,248.68 $1,048.41 $357.50 $422.50 $552.50 $126.14 $91.41 $415.75 $415.75 $12.19 $171.11 $22.85

7.05

$292.07

$322.77

0.14 45.38 45.38

$5.71 $1,878.96 $1,878.96

$5.71 $1,473.99 $1,473.99

NOTE: The Medicare program payment is 80 percent of the total payment amount and beneficiary coinsurance is 20 percent of the total payment amount, except for screening flexible sigmoidoscopies and screening colonoscopies for which the program payment is 75 percent and the beneficiary coinsurance is 25 percent. *Refers to codes designated as “office-based,” whose designation as office-based is temporary because we have insufficient claims data. We will reconsider this designation when new claims data become available.

Date Printed: 10/18/2008 @ 17:46:03

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