PhilHealth Procedure Case Rates (Annex B to PC2024-0037)

Annex B - List of Procedure Case Rates Case Rate Health Facility Fee Professional Fee 10060 INCISION AND DRAINAGE OF ABSCESS (E.G., CARBUNCLE, SUPPURATIVE HIDRADENITIS, CUTANEOUS OR SUBCUTANEOUS ABSCESS, CYST, FURUNCLE, OR PARONYCHIA) 7,098.00 5,460.00 1,638.00 10080 INCISION AND DRAINAGE OF PILONIDAL CYST 7,098.00 5,460.00 1,638.00 10120 INCISION AND REMOVAL OF FOREIGN BODY, SUBCUTANEOUS TISSUES 7,098.00 5,460.00 1,638.00 10140 INCISION AND DRAINAGE OF HEMATOMA, SEROMA, OR FLUID COLLECTION 7,098.00 5,460.00 1,638.00 10160 PUNCTURE ASPIRATION OF ABSCESS, HEMATOMA, BULLA, OR CYST 7,098.00 5,460.00 1,638.00 10180 INCISION AND DRAINAGE, COMPLEX, POSTOPERATIVE WOUND INFECTION 10,842.00 8,385.00 2,457.00 11000 DEBRIDEMENT OF EXTENSIVE ECZEMATOUS OR INFECTED SKIN 20,553.00 10,725.00 9,828.00 11010 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN AND SUBCUTANEOUS TISSUES 20,553.00 10,725.00 9,828.00 11011 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, AND MUSCLE 23,361.00 11,895.00 11,466.00 11012 DEBRIDEMENT INCLUDING REMOVAL OF FOREIGN MATERIAL ASSOCIATED W/ OPEN FRACTURE(S) AND/OR DISLOCATION(S); SKIN, SUBCUTANEOUS TISSUE, MUSCLE FASCIA, MUSCLE, AND BONE 23,634.00 10,530.00 13,104.00 11040 DEBRIDEMENT; SKIN, PARTIAL THICKNESS 7,098.00 5,460.00 1,638.00 11041 DEBRIDEMENT; SKIN, FULL THICKNESS 7,098.00 5,460.00 1,638.00 11042 DEBRIDEMENT; SKIN, AND SUBCUTANEOUS TISSUE 11,076.00 7,800.00 3,276.00 11043 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, AND MUSCLE 15,639.00 10,725.00 4,914.00 11044 DEBRIDEMENT; SKIN, SUBCUTANEOUS TISSUE, MUSCLE, AND BONE 15,639.00 10,725.00 4,914.00 11100 BIOPSY OF SKIN, SUBCUTANEOUS TISSUE AND/OR MUCOUS MEMBRANE (INCLUDING SIMPLE CLOSURE), UNLESS OTHERWISE LISTED; SINGLE OR MULTIPLE LESION 7,098.00 5,460.00 1,638.00 11300 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 10,842.00 8,385.00 2,457.00 11301 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM 7,215.00 4,594.20 2,620.80 11302 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM 15,639.00 10,725.00 4,914.00 11303 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 2.0 CM 16,458.00 10,725.00 5,733.00 11305 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 10,842.00 8,385.00 2,457.00 11306 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 7,215.00 4,594.20 2,620.80 11307 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM 15,639.00 10,725.00 4,914.00 11308 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 2.0 CM 16,458.00 10,725.00 5,733.00 11310 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE ,LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS 7,215.00 4,594.20 2,620.80 11311 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE ,LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 15,639.00 10,725.00 4,914.00 11312 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE ,LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM 16,458.00 10,725.00 5,733.00 11313 SHAVING OF EPIDERMAL OR DERMAL LESION, SINGLE LESION, FACE, EARS, EYELIDS, NOSE ,LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 2.0 CM 16,107.00 9,555.00 6,552.00 11400 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 7,098.00 5,460.00 1,638.00 11401 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM 7,098.00 5,460.00 1,638.00 11402 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM 7,098.00 5,460.00 1,638.00 11403 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 2.1 TO 3.0 CM 7,098.00 5,460.00 1,638.00 11404 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM 7,098.00 5,460.00 1,638.00 RVS Code Description First Case Rate Page 1 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 11406 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM 7,098.00 5,460.00 1,638.00 11420 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 7,098.00 5,460.00 1,638.00 11421 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 7,098.00 5,460.00 1,638.00 11422 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM 7,098.00 5,460.00 1,638.00 11423 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2.1 TO 3.0 CM 7,098.00 5,460.00 1,638.00 11424 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM 7,098.00 5,460.00 1,638.00 11426 EXCISION, BENIGN LESION, EXCEPT SKIN TAG (UNLESS LISTED ELSEWHERE), SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM 7,098.00 5,460.00 1,638.00 11440 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS 8,010.60 6,045.00 1,965.60 11441 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 8,010.60 6,045.00 1,965.60 11442 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM 8,010.60 6,045.00 1,965.60 11443 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM 8,010.60 6,045.00 1,965.60 11444 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM 8,010.60 6,045.00 1,965.60 11446 EXCISION, OTHER BENIGN LESION (UNLESS LISTED ELSEWHERE), FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM 8,010.60 6,045.00 1,965.60 11450 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, AXILLARY 15,639.00 10,725.00 4,914.00 11462 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, INGUINAL 15,639.00 10,725.00 4,914.00 11470 EXCISION OF SKIN AND SUBCUTANEOUS TISSUE FOR HIDRADENITIS, PERIANAL, PERINEAL OR UMBILICAL 15,639.00 10,725.00 4,914.00 11600 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 0.5 CM OR LESS 10,842.00 8,385.00 2,457.00 11601 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM 10,842.00 8,385.00 2,457.00 11602 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM 10,842.00 8,385.00 2,457.00 11603 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 2.1 TO 3.0 CM 10,842.00 8,385.00 2,457.00 11604 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM 10,842.00 8,385.00 2,457.00 11606 EXCISION, MALIGNANT LESION, TRUNK, ARMS, OR LEGS; LESION DIAMETER OVER 4.0 CM 10,842.00 8,385.00 2,457.00 11620 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 11,076.00 7,800.00 3,276.00 11621 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 11,076.00 7,800.00 3,276.00 11622 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM 11,076.00 7,800.00 3,276.00 11623 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2.1 TO 3.0 CM 11,076.00 7,800.00 3,276.00 11624 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM 11,076.00 7,800.00 3,276.00 11626 EXCISION, MALIGNANT LESION, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM 11,076.00 7,800.00 3,276.00 11640 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER 0.5 CM OR LESS 11,076.00 7,800.00 3,276.00 11641 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER 0.6 TO 1.0 CM 11,076.00 7,800.00 3,276.00 11642 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER 1.1 TO 2.0 CM 11,076.00 7,800.00 3,276.00 11643 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER 2.1 TO 3.0 CM 11,076.00 7,800.00 3,276.00 11644 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER 3.1 TO 4.0 CM 11,076.00 7,800.00 3,276.00 11646 EXCISION, MALIGNANT LESION, FACE, EARS, EYELIDS, NOSE, LIPS; LESION DIAMETER OVER 4.0 CM 11,076.00 7,800.00 3,276.00 11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); ONE TO FIVE 7,098.00 5,460.00 1,638.00 11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); SIX OR MORE 10,842.00 8,385.00 2,457.00 11730 AVULSION OF NAIL PLATE, PARTIAL OR COMPLETE 7,098.00 5,460.00 1,638.00 11740 EVACUATION OF SUBUNGUAL HEMATOMA 7,098.00 5,460.00 1,638.00 Page 2 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 11750 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., INGROWN OR DEFORMED NAIL) FOR PERMANENT REMOVAL 7,098.00 5,460.00 1,638.00 11752 EXCISION OF NAIL AND NAIL MATRIX, PARTIAL OR COMPLETE (E.G., INGROWN OR DEFORMED NAIL) FOR PERMANENT REMOVAL W/ AMPUTATION OF TUFT OF DISTAL PHALANX 18,135.00 14,040.00 4,095.00 11755 BIOPSY OF NAIL UNIT, ANY METHOD (E.G., PLATE, BED, MATRIX, HYPONYCHIUM, PROXIMAL AND LATERAL NAIL FOLDS) 7,098.00 5,460.00 1,638.00 11760 REPAIR OF NAIL BED 10,842.00 8,385.00 2,457.00 11762 RECONSTRUCTION OF NAIL BED W/ GRAFT 18,135.00 14,040.00 4,095.00 11765 WEDGE EXCISION OF SKIN OF NAIL FOLD (E.G., FOR INGROWN TOENAIL) 7,098.00 5,460.00 1,638.00 11770 EXCISION OF PILONIDAL CYST OR SINUS 11,076.00 7,800.00 3,276.00 12001 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.5 CM OR LESS 7,098.00 5,460.00 1,638.00 12002 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM 10,842.00 8,385.00 2,457.00 12004 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM 11,076.00 7,800.00 3,276.00 12005 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM 11,076.00 7,800.00 3,276.00 12006 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM 11,076.00 7,800.00 3,276.00 12007 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF SCALP, NECK, AXILLAE, EXTERNAL GENITALIA, TRUNK AND/OR EXTREMITIES (INCLUDING HANDS AND FEET); OVER 30.0 CM 11,076.00 7,800.00 3,276.00 12011 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.5 CM OR LESS 11,076.00 7,800.00 3,276.00 12013 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 2.6 CM TO 5.0 CM 18,135.00 14,040.00 4,095.00 12014 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 5.1 CM TO 7.5 CM 18,626.40 14,040.00 4,586.40 12015 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 7.6 CM TO 12.5 CM 15,639.00 10,725.00 4,914.00 12016 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 12.6 CM TO 20.0 CM 15,639.00 10,725.00 4,914.00 12017 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; 20.1 CM TO 30.0 CM 15,639.00 10,725.00 4,914.00 12018 SIMPLE REPAIR OF SUPERFICIAL WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANES; OVER 30.0 CM 15,639.00 10,725.00 4,914.00 12031 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.5 CM OR LESS 7,098.00 5,460.00 1,638.00 12032 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 2.6 CM TO 7.5 CM 10,842.00 8,385.00 2,457.00 12034 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 7.6 CM TO 12.5 CM 11,076.00 7,800.00 3,276.00 12035 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 12.6 CM TO 20.0 CM 11,076.00 7,800.00 3,276.00 12036 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); 20.1 CM TO 30.0 CM 11,076.00 7,800.00 3,276.00 12037 LAYER CLOSURE OF WOUNDS OF SCALP, AXILLAE, TRUNK, AND/OR EXTREMITIES (EXCLUDING HANDS AND FEET); OVER 30.0 CM 11,076.00 7,800.00 3,276.00 12041 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.5 CM OR LESS 11,076.00 7,800.00 3,276.00 12042 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 2.6 CM TO 7.5 CM 18,135.00 14,040.00 4,095.00 12044 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 7.6 CM TO 12.5 CM 15,639.00 10,725.00 4,914.00 12045 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 12.6 CM TO 20.0 CM 16,458.00 10,725.00 5,733.00 12046 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; 20.1 CM TO 30.0 CM 16,107.00 9,555.00 6,552.00 Page 3 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 12047 LAYER CLOSURE OF WOUNDS OF NECK, HANDS, FEET AND/OR EXTERNAL GENITALIA; OVER 30.0 CM 21,216.00 13,845.00 7,371.00 12051 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 2.5 CM OR LESS 11,076.00 7,800.00 3,276.00 12052 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 2.6 CM TO 5.0 CM 11,076.00 7,800.00 3,276.00 12053 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 5.1 CM TO 7.5 CM 15,639.00 10,725.00 4,914.00 12054 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 7.6 CM TO 12.5 CM 15,639.00 10,725.00 4,914.00 12055 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 12.6 CM TO 20.0 CM 16,107.00 9,555.00 6,552.00 12056 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; 20.1 CM TO 30.0 CM 16,107.00 9,555.00 6,552.00 12057 LAYER CLOSURE OF WOUNDS OF FACE, EARS, EYELIDS, NOSE, LIPS AND/OR MUCOUS MEMBRANCES; OVER 30.0 CM 18,915.00 10,725.00 8,190.00 14000 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10 SQ CM OR LESS 23,634.00 10,530.00 13,104.00 14001 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, TRUNK; DEFECT 10.1 SQ CM TO 30.0 SQ CM 23,634.00 10,530.00 13,104.00 14020 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10 SQ CM OR LESS 20,553.00 10,725.00 9,828.00 14021 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, SCALP, ARMS AND/OR LEGS; DEFECT 10.1 SQ CM TO 30.0 SQ CM 23,361.00 11,895.00 11,466.00 14040 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10 SQ CM OR LESS 23,634.00 10,530.00 13,104.00 14041 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS AND/OR FEET; DEFECT 10.1 SQ CM TO 30.0 SQ CM 35,100.00 18,720.00 16,380.00 14060 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10 SQ CM OR LESS 35,100.00 18,720.00 16,380.00 14061 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, EYELIDS, NOSE, EARS AND/OR LIPS; DEFECT 10.1 SQ CM TO 30.0 SQ CM 35,100.00 18,720.00 16,380.00 14300 ADJACENT TISSUE TRANSFER OR REARRANGEMENT, MORE THAN 30 SQ CM, UNUSUAL OR COMPLICATED, ANY AREA 35,100.00 18,720.00 16,380.00 14350 FILLETED FINGER OR TOE FLAP, INCLUDING PREPARATION OF RECIPIENT SITE 52,884.00 23,400.00 29,484.00 15050 PINCH GRAFT, SINGLE OR MULTIPLE, TO COVER SMALL ULCER, TIP OR DIGIT, OR OTHER MINIMAL OPEN AREA (EXCEPT ON FACE), UP TO DEFECT SIZE 2 CM DIAMETER 16,107.00 9,555.00 6,552.00 15100 SPLIT GRAFT, TRUNK, SCALP, ARMS, LEGS, HANDS, AND/OR FEET (EXCEPT MULTIPLE DIGITS); 100 SQ CM OR LESS, OR EACH ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) 16,107.00 9,555.00 6,552.00 15120 SPLIT GRAFT, FACE, EYELIDS, MOUTH, NECK, EARS, ORBITS, GENITALIA, AND/OR MULTIPLE DIGITS; 100 SQ CM OR LESS, OR EACH ONE PERCENT OF BODY AREA OF INFANTS AND CHILDREN (EXCEPT 15050) 42,783.00 24,765.00 18,018.00 15200 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, TRUNK; 20 SQ CM OR LESS 42,783.00 24,765.00 18,018.00 15220 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, SCALP, ARMS, AND/OR LEGS; 20 SQ CM OR LESS 42,783.00 24,765.00 18,018.00 15240 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS, AND/OR FEET; 20 SQ CM OR LESS 59,943.00 33,735.00 26,208.00 15260 FULL THICKNESS GRAFT, FREE, INCLUDING DIRECT CLOSURE OF DONOR SITE, NOSE, EARS, EYELIDS, AND/OR LIPS; 20 SQ CM OR LESS 59,085.00 26,325.00 32,760.00 15350 APPLICATION OF ALLOGRAFT, SKIN 59,085.00 26,325.00 32,760.00 15400 APPLICATION OF XENOGRAFT, SKIN 59,085.00 26,325.00 32,760.00 15570 FORMATION OF DIRECT OR TUBED PEDICLE, W/ OR W/O TRANSFER; TRUNK 35,100.00 18,720.00 16,380.00 15572 FORMATION OF DIRECT OR TUBED PEDICLE, W/ OR W/O TRANSFER; SCALP, ARMS, OR LEGS 59,943.00 33,735.00 26,208.00 15574 FORMATION OF DIRECT OR TUBED PEDICLE, W/ OR W/O TRANSFER; FOREHEAD, CHEEKS, CHIN, MOUTH, NECK, AXILLAE, GENITALIA, HANDS OR FEET 59,943.00 33,735.00 26,208.00 15576 FORMATION OF DIRECT OR TUBED PEDICLE, W/ OR W/O TRANSFER; EYELIDS, NOSE, EARS, LIPS OR INTRAORAL 59,085.00 26,325.00 32,760.00 15580 CROSS FINGER FLAP, INCLUDING FREE GRAFT TO DONOR SITE 42,783.00 24,765.00 18,018.00 15650 TRANSFER, INTERMEDIATE, OF ANY PEDICLE FLAP (E.G., ABDOMEN TO WRIST, "WALKING" TUBE), ANY LOCATION 42,783.00 24,765.00 18,018.00 15732 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; HEAD AND NECK (E.G., TEMPORALIS, MASSETER, STERNOCLEIDOMASTOID, LEVATOR SCAPULAE) 92,313.00 41,535.00 50,778.00 Page 4 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 15734 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; TRUNK 92,313.00 41,535.00 50,778.00 15736 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; UPPER EXTREMITY 92,313.00 41,535.00 50,778.00 15738 MUSCLE, MYOCUTANEOUS, OR FASCIOCUTANEOUS FLAP; LOWER EXTREMITY 92,313.00 41,535.00 50,778.00 15740 FLAP; ISLAND PEDICLE 75,348.00 32,760.00 42,588.00 15750 FLAP; NEUROVASCULAR PEDICLE 75,348.00 32,760.00 42,588.00 15756 FREE MUSCLE FLAP W/ OR W/O SKIN GRAFT W/ MICROVASCULAR ANASTOMOSIS 75,348.00 32,760.00 42,588.00 15757 FREE SKIN FLAP W/ MICROVASCULAR ANASTOMOSIS 75,348.00 32,760.00 42,588.00 15758 FREE FASCIAL FLAP W/ MICROVASCULAR ANASTOMOSIS 75,348.00 32,760.00 42,588.00 15760 GRAFT; COMPOSITE (E.G., FULL THICKNESS OF EXTERNAL EAR OR NASAL ALA), INCLUDING PRIMARY CLOSURE, DONOR AREA 42,783.00 24,765.00 18,018.00 15770 GRAFT; DERMA-FAT-FASCIA 42,783.00 24,765.00 18,018.00 15820 BLEPHAROPLASTY, LOWER EYELID 19,734.00 10,725.00 9,009.00 15822 BLEPHAROPLASTY, UPPER EYELID; 19,734.00 10,725.00 9,009.00 15823 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID 23,361.00 11,895.00 11,466.00 15840 GRAFT FOR FACIAL NERVE PARALYSIS; FREE FASCIA GRAFT (INCLUDING OBTAINING FASCIA) 59,085.00 26,325.00 32,760.00 15841 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT (INCLUDING OBTAINING GRAFT) 59,085.00 26,325.00 32,760.00 15842 GRAFT FOR FACIAL NERVE PARALYSIS; FREE MUSCLE GRAFT BY MICROSURGICAL TECHNIQUE 75,348.00 32,760.00 42,588.00 15845 GRAFT FOR FACIAL NERVE PARALYSIS; REGIONAL MUSCLE TRANSFER 59,085.00 26,325.00 32,760.00 15920 EXCISION, COCCYGEAL PRESSURE ULCER, W/ COCCYGECTOMY; W/ PRIMARY SUTURE 59,943.00 33,735.00 26,208.00 15922 EXCISION, COCCYGEAL PRESSURE ULCER, W/ COCCYGECTOMY; W/ FLAP CLOSURE 59,085.00 26,325.00 32,760.00 15931 EXCISION, SACRAL PRESSURE ULCER, W/ PRIMARY SUTURE; 42,783.00 24,765.00 18,018.00 15933 EXCISION, SACRAL PRESSURE ULCER, W/ PRIMARY SUTURE; W/ OSTECTOMY 59,943.00 33,735.00 26,208.00 15934 EXCISION, SACRAL PRESSURE ULCER, W/ SKIN FLAP CLOSURE; 23,634.00 10,530.00 13,104.00 15935 EXCISION, SACRAL PRESSURE ULCER, W/ SKIN FLAP CLOSURE; W/ OSTECTOMY 59,085.00 26,325.00 32,760.00 15936 EXCISION, SACRAL PRESSURE ULCER, W/ MUSCLE OR MYOCUTANEOUS FLAP CLOSURE; 74,958.00 36,465.00 38,493.00 15937 EXCISION, SACRAL PRESSURE ULCER, W/ MUSCLE OR MYOCUTANEOUS FLAP CLOSURE; W/ OSTECTOMY 73,710.00 32,760.00 40,950.00 15940 EXCISION, ISCHIAL PRESSURE ULCER, W/ PRIMARY SUTURE; 23,634.00 10,530.00 13,104.00 15941 EXCISION, ISCHIAL PRESSURE ULCER, W/ PRIMARY SUTURE; W/ OSTECTOMY (ISCHIECTOMY) 42,783.00 24,765.00 18,018.00 15944 EXCISION, ISCHIAL PRESSURE ULCER, W/ SKIN FLAP CLOSURE; 59,943.00 33,735.00 26,208.00 15945 EXCISION, ISCHIAL PRESSURE ULCER, W/ SKIN FLAP CLOSURE; W/ OSTECTOMY 59,085.00 26,325.00 32,760.00 15946 EXCISION, ISCHIAL PRESSURE ULCER, W/ OSTECTOMY, W/ MUSCLE OR MYOCUTANEOUS FLAP CLOSURE 74,958.00 36,465.00 38,493.00 15950 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ PRIMARY SUTURE; 23,361.00 11,895.00 11,466.00 15951 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ PRIMARY SUTURE; W/ OSTECTOMY 42,783.00 24,765.00 18,018.00 15952 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ SKIN FLAP CLOSURE; 42,783.00 24,765.00 18,018.00 15953 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ SKIN FLAP CLOSURE; W/ OSTECTOMY 59,943.00 33,735.00 26,208.00 15956 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ MUSCLE OR MYOCUTANEOUS FLAP CLOSURE; 60,723.00 26,325.00 34,398.00 15958 EXCISION, TROCHANTERIC PRESSURE ULCER, W/ MUSCLE OR MYOCUTANEOUS FLAP CLOSURE; W/ OSTECTOMY 74,958.00 36,465.00 38,493.00 16010 DRESSINGS AND/OR DEBRIDEMENT, INITIAL OR SUBSEQUENT 16,107.00 9,555.00 6,552.00 16035 ESCHAROTOMY 59,943.00 33,735.00 26,208.00 16040 EXCISION BURN WOUND, W/O SKIN GRAFTING, EMPLOYING ALLOPLASTIC DRESSING (E.G., SYNTHETIC MESH), ANY ANATOMIC SITE 18,915.00 10,725.00 8,190.00 17000 DESTRUCTION BY ANY METHOD, INCLUDING LASER, W/ OR W/O SURGICAL CURETTEMENT, ALL BENIGN FACIAL LESIONS OR PREMALIGNANT LESIONS IN ANY LOCATION, OR BENIGN LESIONS OTHER THAN CUTANEOUS VASCULAR PROLIFERATIVE LESIONS, INCLUDING LOCAL ANESTHESIA; ANY NUMBER OF 11,700.00 7,410.00 4,290.00 17106 DESTRUCTION OF CUTANEOUS VASCULAR PROLIFERATIVE LESIONS (E.G., LASER TECHNIQUE) 11,700.00 7,410.00 4,290.00 17250 CHEMICAL CAUTERIZATION OF GRANULATION TISSUE (PROUD FLESH, SINUS OR FISTULA) 11,076.00 7,800.00 3,276.00 17260 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.5 CM OR LESS 11,076.00 7,800.00 3,276.00 17261 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER 0.6 TO 1.0 CM 11,076.00 7,800.00 3,276.00 17262 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER 1.1 TO 2.0 CM 11,076.00 7,800.00 3,276.00 17263 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER 2.1 TO 3.0 CM 11,076.00 7,800.00 3,276.00 Page 5 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 17264 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER 3.1 TO 4.0 CM 11,076.00 7,800.00 3,276.00 17266 DESTRUCTION, MALIGNANT LESION, ANY METHOD, TRUNK, ARMS OR LEGS; LESION DIAMETER OVER 4.0 CM 11,076.00 7,800.00 3,276.00 17270 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.5 CM OR LESS 11,076.00 7,800.00 3,276.00 17271 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 0.6 TO 1.0 CM 11,076.00 7,800.00 3,276.00 17272 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 1.1 TO 2.0 CM 11,076.00 7,800.00 3,276.00 17273 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 2.1 TO 3.0 CM 11,076.00 7,800.00 3,276.00 17274 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER 3.1 TO 4.0 CM 11,076.00 7,800.00 3,276.00 17276 DESTRUCTION, MALIGNANT LESION, ANY METHOD, SCALP, NECK, HANDS, FEET, GENITALIA; LESION DIAMETER OVER 4.0 CM 11,076.00 7,800.00 3,276.00 17280 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.5 CM OR LESS 18,135.00 14,040.00 4,095.00 17281 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 0.6 TO 1.0 CM 18,135.00 14,040.00 4,095.00 17282 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 1.1 TO 2.0 CM 18,135.00 14,040.00 4,095.00 17283 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 2.1 TO 3.0 CM 18,135.00 14,040.00 4,095.00 17284 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER 3.1 TO 4.0 CM 18,135.00 14,040.00 4,095.00 17286 DESTRUCTION, MALIGNANT LESION, ANY METHOD, FACE, EARS, EYELIDS, NOSE, LIPS, MUCOUS MEMBRANE; LESION DIAMETER OVER 4.0 CM 18,135.00 14,040.00 4,095.00 17304 CHEMOSURGERY (MOHS MICROGRAPHIC TECHNIQUE), INCLUDING REMOVAL OF ALL GROSS TUMOR, SURGICAL EXCISION OF TISSUE SPECIMENS, MAPPING, COLOR CODING OF SPECIMENS, MICROSCOPIC EXAMINATION OF SPECIMENS BY THE SURGEON, AND COMPLETE HISTOPATHOLOGIC PREPARATION; FIR 15,639.00 10,725.00 4,914.00 19000 PUNCTURE ASPIRATION OF CYST OF BREAST; 7,098.00 5,460.00 1,638.00 19020 MASTOTOMY W/ EXPLORATION OR DRAINAGE OF ABSCESS, DEEP 18,915.00 10,725.00 8,190.00 19100 BIOPSY OF BREAST; NEEDLE CORE 7,098.00 5,460.00 1,638.00 19101 BIOPSY OF BREAST; INCISIONAL 10,842.00 8,385.00 2,457.00 19110 NIPPLE EXPLORATION, W/ OR W/O EXCISION OF A SOLITARY LACTIFEROUS DUCT OR A PAPILLOMA LACTIFEROUS DUCT 16,458.00 10,725.00 5,733.00 19112 EXCISION OF LACTIFEROUS DUCT FISTULA 16,107.00 9,555.00 6,552.00 19120 EXCISION OF CYST, FIBROADENOMA, OR OTHER BENIGN OR MALIGNANT TUMOR ABERRANT BREAST TISSUE, DUCT LESION OR NIPPLE LESION (EXCEPT 19140), MALE OR FEMALE, ONE OR MORE LESIONS 15,639.00 10,725.00 4,914.00 19125 EXCISION OF BREAST LESION IDENTIFIED BY PREOPERATIVE PLACEMENT OF RADIOLOGICAL MARKER; SINGLE LESION 15,639.00 10,725.00 4,914.00 19140 MASTECTOMY FOR GYNECOMASTIA 42,900.00 25,740.00 17,160.00 19160 MASTECTOMY, PARTIAL; 42,900.00 25,740.00 17,160.00 19162 MASTECTOMY, PARTIAL; WITH AXILLARY LYMPHADENECTOMY 42,900.00 25,740.00 17,160.00 19180 MASTECTOMY, SIMPLE, COMPLETE 42,900.00 25,740.00 17,160.00 19182 MASTECTOMY, SUBCUTANEOUS 42,900.00 25,740.00 17,160.00 19200 MASTECTOMY, RADICAL, ICNLUDING PECTORAL MUSCLES, AXILLARY LYMPH NODES 42,900.00 25,740.00 17,160.00 19220 MASTECTOMY, RADICAL, INCLUDING PECTORAL MUSCLES, AXILLARY AND INTERNAL MAMMARY LYMPH NODES (URBAN TYPE OPERATION) 42,900.00 25,740.00 17,160.00 19240 MASTECTOMY, MODIFIED RADICAL, INCLUDING AXILLARY LYMPH NODES, W/ OR W/O PECTORALIS MINOR MUSCLE, BUT EXCLUDING PECTORALIS MAJOR MUSCLE 42,900.00 25,740.00 17,160.00 19260 EXCISION OF CHEST WALL TUMOR INCLUDING RIBS 90,675.00 41,535.00 49,140.00 19271 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, W/ PLASTIC RECONSTRUCTION; W/O MEDIASTINAL LYMPHADENECTOMY 107,250.00 41,730.00 65,520.00 19272 EXCISION OF CHEST WALL TUMOR INVOLVING RIBS, W/ PLASTIC RECONSTRUCTION; W/ MEDIASTINAL LYMPHADENECTOMY 114,660.00 40,950.00 73,710.00 19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION 73,710.00 32,760.00 40,950.00 19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION 73,710.00 32,760.00 40,950.00 19350 NIPPLE/AREOLA RECONSTRUCTION 59,085.00 26,325.00 32,760.00 Page 6 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 19357 BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION 73,710.00 32,760.00 40,950.00 19361 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITH OR WITHOUT PROSTHETIC IMPLANT 107,250.00 41,730.00 65,520.00 19364 BREAST RECONSTRUCTION WITH FREE FLAP 107,250.00 41,730.00 65,520.00 19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE 107,250.00 41,730.00 65,520.00 19367 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; 107,250.00 41,730.00 65,520.00 19369 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE 107,250.00 41,730.00 65,520.00 19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST 59,085.00 26,325.00 32,760.00 19371 PERIPROSTHETIC CAPSULECTOMY, BREAST 73,710.00 32,760.00 40,950.00 20200 BIOPSY, MUSCLE 8,010.60 6,045.00 1,965.60 20206 BIOPSY, MUSCLE, PERCUTANEOUS NEEDLE 6,832.80 5,850.00 982.80 20220 BIOPSY, BONE, TROCAR, OR NEEDLE; SUPERFICIAL (E.G., ILIUM, STERNUM, SPINOUS PROCESS, RIBS) 21,216.00 13,845.00 7,371.00 20225 BIOPSY, BONE, TROCAR, OR NEEDLE; DEEP (VERTEBRAL BODY, FEMUR) 35,100.00 18,720.00 16,380.00 20240 BIOPSY, EXCISIONAL; SUPERFICIAL (E.G., ILIUM, STERNUM, SPINOUS PROCESS, RIBS, TROCHANTER OF FEMUR) 18,915.00 10,725.00 8,190.00 20245 BIOPSY, EXCISIONAL; DEEP (E.G., HUMERUS, ISCHIUM, FEMUR) 24,453.00 10,530.00 13,923.00 20250 BIOPSY, VERTEBRAL BODY, OPEN; THORACIC 45,435.00 20,865.00 24,570.00 20251 BIOPSY, VERTEBRAL BODY, OPEN; LUMBAR OR CERVICAL 59,943.00 33,735.00 26,208.00 20520 REMOVAL OF FOREIGN BODY IN MUSCLE OR TENDON SHEATH 15,639.00 10,725.00 4,914.00 20600 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; SMALL JOINT, BURSA OR GANGLION CYST (E.G., FINGERS, TOES) 10,842.00 8,385.00 2,457.00 20605 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; INTERMEDIATE JOINT, BURSA OR GANGLION CYST (E.G., TEMPOROMANDIBULAR, ACROMIOCLAVICULAR, WRIST, ELBOW OR ANKLE, OLECRANON BURSA) 18,135.00 14,040.00 4,095.00 20610 ARTHROCENTESIS, ASPIRATION AND/OR INJECTION; MAJOR JOINT OR BURSA (E.G., SHOULDER, HIP, KNEE JOINT, SUBACROMIAL BURSA) 18,135.00 14,040.00 4,095.00 20615 ASPIRATION AND INJECTION FOR TREATMENT OF BONE CYST 16,107.00 9,555.00 6,552.00 20650 INSERTION OF WIRE OR PIN W/ APPLICATION OF SKELETAL TRACTION, INCLUDING REMOVAL 15,639.00 10,725.00 4,914.00 20660 APPLICATION OF CRANIAL TONGS, CALIPER, OR STEREOTACTIC FRAME, INCLUDING REMOVAL 19,242.60 10,725.00 8,517.60 20661 APPLICATION OF HALO, INCLUDING REMOVAL; CRANIAL 16,785.60 10,725.00 6,060.60 20662 APPLICATION OF HALO, INCLUDING REMOVAL; PELVIC 45,435.00 20,865.00 24,570.00 20663 APPLICATION OF HALO, INCLUDING REMOVAL; FEMORAL 42,783.00 24,765.00 18,018.00 20670 REMOVAL OF IMPLANT; SUPERFICIAL (E.G., BURIED WIRE, PIN OR ROD) 20,553.00 10,725.00 9,828.00 20680 REMOVAL OF IMPLANT; DEEP (E.G., BURIED WIRE, PIN, SCREW, METAL BAND, NAIL, ROD OR PLATE) 23,361.00 11,895.00 11,466.00 20690 APPLICATION OF A UNIPLANE (PINS OR WIRES IN ONE PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM 23,634.00 10,530.00 13,104.00 20692 APPLICATION OF MULTIPLANE (PINS OR WIRES IN MORE THAN ONE PLANE), UNILATERAL, EXTERNAL FIXATION SYSTEM (E.G., LLIZAROV, MONTICELLI TYPE) 76,596.00 36,465.00 40,131.00 20802 REPLANTATION, ARM (INCLUDES SURGICAL NECK OF HUMERUS THROUGH ELBOW JOINT), COMPLETE AMPUTATION 18,135.00 14,040.00 4,095.00 20805 REPLANTATION, FOREARM (INCLUDES RADIUS AND ULNA TO RADIAL CARPAL JOINT), COMPLETE AMPUTATION 78,624.00 32,760.00 45,864.00 20808 REPLANTATION, HAND (INCLUDES HAND THROUGH METACARPOPHALANGEAL JOINT(S), COMPLETE AMPUTATION 78,624.00 32,760.00 45,864.00 20816 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES METACARPOPHALANGEAL JOINT TO INSERTION OF FLEXOR SUBLIMIS TENDON), COMPLETE AMPUTATION 45,435.00 20,865.00 24,570.00 20822 REPLANTATION, DIGIT, EXCLUDING THUMB (INCLUDES DISTAL TIP TO SUBLIMIS TENDON INSERTION), COMPLETE AMPUTATION 45,435.00 20,865.00 24,570.00 20824 REPLANTATION, THUMB (INCLUDES CARPOMETACARPAL JOINT TO MP JOINT), COMPLETE AMPUTATION 59,085.00 26,325.00 32,760.00 20827 REPLANTATION, THUMB (INCLUDES DISTAL TIP TO MP JOINT), COMPLETE AMPUTATION 45,435.00 20,865.00 24,570.00 20838 REPLANTATION, FOOT, COMPLETE AMPUTATION 73,710.00 32,760.00 40,950.00 20900 BONE GRAFT, ANY DONOR AREA; MINOR OR SMALL (E.G., DOWEL OR BUTTON) 20,553.00 10,725.00 9,828.00 20902 BONE GRAFT, ANY DONOR AREA; MAJOR OR LARGE 35,100.00 18,720.00 16,380.00 20910 CARTILAGE GRAFT; COSTOCHONDRAL 23,634.00 10,530.00 13,104.00 20912 CARTILAGE GRAFT; NASAL SEPTUM 23,634.00 10,530.00 13,104.00 20920 FASCIA LATA GRAFT; BY STRIPPER 18,915.00 10,725.00 8,190.00 20922 FASCIA LATA GRAFT; BY INCISION AND AREA EXPOSURE, COMPLEX OR SHEET 23,634.00 10,530.00 13,104.00 20924 TENDON GRAFT, FORM A DISTANCE (E.G., PALMARIS, TOE EXTENSOR, PLANTARIS) 21,372.00 10,725.00 10,647.00 20926 TISSUE GRAFTS, OTHER (E.G., PARATENON, FAT, DERMIS) 18,915.00 10,725.00 8,190.00 20930 ALLOGRAFT FOR SPINE SURGERY ONLY; MORSELIZED 23,634.00 10,530.00 13,104.00 20931 ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL 35,919.00 18,720.00 17,199.00 Page 7 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 20936 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (E.G., RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION 20,553.00 10,725.00 9,828.00 20937 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THORUGH SEPARATE SKIN OR FASCIAL INCISION) 20,553.00 10,725.00 9,828.00 20938 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTIAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) 35,100.00 18,720.00 16,380.00 20955 BONE GRAFT W/ MICROVASCULAR ANASTOMOSIS; FIBULA 73,710.00 32,760.00 40,950.00 20956 BONE GRAFT W/ MICROVASCULAR ANASTOMOSIS; ILIAC CREST 73,710.00 32,760.00 40,950.00 20957 BONE GRAFT W/ MICROVASCULAR ANASTOMOSIS; METATARSAL 40,911.00 21,255.00 19,656.00 20962 BONE GRAFT W/ MICROVASCULAR ANASTOMOSIS; OTHER THAN FIBULA, ILIAC CREST, OR METATARSAL 52,884.00 23,400.00 29,484.00 20969 FREE OSTEOCUTANEOUS FLAP W/ MICROVASCULAR ANASTOMOSIS; OTHER THAN ILIAC CREST, METATARSAL, OR GREAT TOE 73,710.00 32,760.00 40,950.00 20970 FREE OSTEOCUTANEOUS FLAP W/ MICROVASCULAR ANASTOMOSIS; ILIAC CREST 59,085.00 26,325.00 32,760.00 20972 FREE OSTEOCUTANEOUS FLAP W/ MICROVASCULAR ANASTOMOSIS; METATARSAL 45,435.00 20,865.00 24,570.00 20973 FREE OSTEOCUTANEOUS FLAP W/ MICROVASCULAR ANASTOMOSIS; GREAT TOE W/ WEB SPACE 52,884.00 23,400.00 29,484.00 20982 ABLATION, BONE TUMOR(S) (E.G., OSTEOID OSTEOMA, METASTASIS) RADIOFREQUENCY, PERCUTANEOUS, INCLUDING COMPUTED TOMOGRAPHIC GUIDANCE 18,915.00 10,725.00 8,190.00 21010 ARTHROTOMY, TEMPOROMANDIBULAR JOINT 18,915.00 10,725.00 8,190.00 21015 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF FACE OR SCALP 45,435.00 20,865.00 24,570.00 21025 EXCISION OF BONE (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS); MANDIBLE 35,100.00 18,720.00 16,380.00 21026 EXCISION OF BONE (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS); FACIAL BONE(S) 35,100.00 18,720.00 16,380.00 21029 REMOVAL BY CONTOURING OF BENIGN TUMOR OF FACIAL BONE (E.G., FIBROUS DYSPLASIA) 35,100.00 18,720.00 16,380.00 21030 EXCISION OF BENIGN TUMOR OR CYST OF FACIAL BONE OTHER THAN MANDIBLE 35,100.00 18,720.00 16,380.00 21031 EXCISION OF TORUS MANDIBULARIS 35,100.00 18,720.00 16,380.00 21032 EXCISION OF MAXILLARY TORUS PALATINUS 35,100.00 18,720.00 16,380.00 21034 EXCISION OF MALIGNANT TUMOR OF FACIAL BONE OTHER THAN MANDIBLE 45,435.00 20,865.00 24,570.00 21040 EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; SIMPLE 35,100.00 18,720.00 16,380.00 21041 EXCISION OF BENIGN CYST OR TUMOR OF MANDIBLE; COMPLEX 42,783.00 24,765.00 18,018.00 21044 EXCISION OF MALIGNANT TUMOR OF MANDIBLE; 45,435.00 20,865.00 24,570.00 21045 EXCISION OF MALIGNANT TUMOR OF MANDIBLE; RADICAL RESECTION 59,085.00 26,325.00 32,760.00 21050 CONDYLECTOMY, TEMPOROMANDIBULAR JOINT 59,085.00 26,325.00 32,760.00 21060 MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT 59,085.00 26,325.00 32,760.00 21070 CORONOIDECTOMY 59,085.00 26,325.00 32,760.00 21120 GENIOPLASTY; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, PROSTHETIC MATERIAL) 35,100.00 18,720.00 16,380.00 21121 GENIOPLASTY; SLIDING OSTEOTOMY, SINGLE PIECE 90,675.00 41,535.00 49,140.00 21122 GENIOPLASTY; SLIDING OSTEOTOMIES, TWO OR MORE OSTEOTOMIES (E.G., WEDGE EXCISION OR BONE WEDGE REVERSAL FOR ASYMMETRICAL CHIN) 59,085.00 26,325.00 32,760.00 21123 GENIOPLASTY; SLIDING, AUGMENTATION W/ INTERPOSITIONAL BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 59,085.00 26,325.00 32,760.00 21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 59,085.00 26,325.00 32,760.00 21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; W/ BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) 90,675.00 41,535.00 49,140.00 21137 REDUCTION FOREHEAD; CONTOURING ONLY 35,100.00 18,720.00 16,380.00 21138 REDUCTION FOREHEAD; CONTOURING AND APPLICATION OF PROSTHETIC MATERIAL OR BONE GRAFT (INCLUDES OBTAINING AUTOGRAFT) 90,675.00 41,535.00 49,140.00 21139 REDUCTION FOREHEAD; CONTOURING AND SETBACK OF ANTERIOR FRONTAL SINUS WALL 59,085.00 26,325.00 32,760.00 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (E.G., FOR LONG FACE SYNDROME), W/O BONE GRAFT 104,130.00 46,800.00 57,330.00 21142 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, W/O BONE GRAFT 90,675.00 41,535.00 49,140.00 21143 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, W/O BONE GRAFT 90,675.00 41,535.00 49,140.00 21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 90,675.00 41,535.00 49,140.00 Page 8 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 21146 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (E.G., UNGRAFTED UNILATERAL ALVEOLAR CLEFT) 90,675.00 41,535.00 49,140.00 21147 RECONSTRUCTION MIDFACE, LEFORT I; THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (E.G., UNGRAFTED BILATERAL ALVEOLAR CLEFT OR MULTIPLE OSTEOTOMIES) 107,250.00 41,730.00 65,520.00 21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (E.G., TREACHER-COLLINS SYNDROME) 107,250.00 41,730.00 65,520.00 21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 107,250.00 41,730.00 65,520.00 21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); W/O LEFORT I 114,660.00 40,950.00 73,710.00 21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); W/ LEFORT I 107,250.00 41,730.00 65,520.00 21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) W/ FOREHEAD ADVANCEMENT (E.G., MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); W/O LEFORT I 107,250.00 41,730.00 65,520.00 21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) W/ FOREHEAD ADVANCEMENT (E.G., MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); W/ LEFORT I 90,675.00 41,535.00 49,140.00 21172 RECONSTRUCTION SUPERIOR-LATERAL ORBITAL RIM AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION, W/ OR W/O GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 107,250.00 41,730.00 65,520.00 21175 RECONSTRUCTION, BIFRONTAL, SUPERIOR-LATERAL ORBITAL RIMS AND LOWER FOREHEAD, ADVANCEMENT OR ALTERATION (E.G., PLAGIOCEPHALY, TRIGONOCEPHALY, BRACHYCEPHALY), W/ OR W/O GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 107,250.00 41,730.00 65,520.00 21179 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; W/ GRAFTS (ALLOGRAFT OR PROSTHETIC MATERIAL) 107,250.00 41,730.00 65,520.00 21180 RECONSTRUCTION, ENTIRE OR MAJORITY OF FOREHEAD AND/OR SUPRAORBITAL RIMS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFTS) 107,250.00 41,730.00 65,520.00 21181 RECONSTRUCTION BY CONTOURING OF BENIGN TUMOR OF CRANIAL BONES (E.G., FIBROUS DYSPLASIA), EXTRACRANIAL 104,130.00 46,800.00 57,330.00 21182 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA-AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (E.G., FIBROUS DYSPLASIA), W/ MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING LESS 90,675.00 41,535.00 49,140.00 21183 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA-AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (E.G., FIBROUS DYSPLASIA), W/ MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 40 CM2 BUT LESS THAN 80 CM2 104,130.00 46,800.00 57,330.00 21184 RECONSTRUCTION OF ORBITAL WALLS, RIMS, FOREHEAD, NASOETHMOID COMPLEX FOLLOWING INTRA-AND EXTRACRANIAL EXCISION OF BENIGN TUMOR OF CRANIAL BONE (E.G., FIBROUS DYSPLASIA), W/ MULTIPLE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS); TOTAL AREA OF BONE GRAFTING GREATER THAN 80 CM2 107,250.00 41,730.00 65,520.00 21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 107,250.00 41,730.00 65,520.00 21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; W/O BONE GRAFT 90,675.00 41,535.00 49,140.00 21194 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; W/ BONE GRAFT (INCLUDES OBTAINING GRAFT) 107,250.00 41,730.00 65,520.00 21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; W/O INTERNAL RIGID FIXATION 90,675.00 41,535.00 49,140.00 21196 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; W/ INTERNAL RIGID FIXATION 107,250.00 41,730.00 65,520.00 21198 OSTEOTOMY, MANDIBLE, SEGMENTAL 59,085.00 26,325.00 32,760.00 21206 OSTEOTOMY, MAXILLA, SEGMENTAL (E.G., WASSMUND OR SCHUCHARD) 90,675.00 41,535.00 49,140.00 21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) 90,675.00 41,535.00 49,140.00 21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) 107,250.00 41,730.00 65,520.00 21230 GRAFT; RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAINING GRAFT) 90,675.00 41,535.00 49,140.00 21235 GRAFT; EAR CARTILAGE, AUTOGENOUS, TO NOSE OR EAR (INCLUDES OBTAINING GRAFT) 59,085.00 26,325.00 32,760.00 21240 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ OR W/O AUTOGRAFT (INCLUDES OBTAINING GRAFT) 90,675.00 41,535.00 49,140.00 Page 9 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 21242 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ ALLOGRAFT 90,675.00 41,535.00 49,140.00 21243 ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, W/ PROSTHETIC JOINT REPLACEMENT 107,250.00 41,730.00 65,520.00 21244 RECONSTRUCTION OF MANDIBLE, EXTRAORAL, W/ TRANSOSTEAL BONE PLATE (E.G., MANDIBULAR STAPLE BONE PLATE) 90,675.00 41,535.00 49,140.00 21245 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; PARTIAL 104,130.00 46,800.00 57,330.00 21246 RECONSTRUCTION OF MANDIBLE OR MAXILLA, SUBPERIOSTEAL IMPLANT; COMPLETE 107,250.00 41,730.00 65,520.00 21247 RECONSTRUCTION OF MANDIBULAR CONDYLE W/ BONE AND CARTILAGE AUTOGRAFTS (INCLUDES OBTAINING GRAFTS) (E.G., FOR HEMIFACIAL MICROSOMIA) 107,250.00 41,730.00 65,520.00 21248 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (E.G. BLADE, CYLINDER); PARTIAL 107,250.00 41,730.00 65,520.00 21249 RECONSTRUCTION OF MANDIBLE OR MAXILLA, ENDOSTEAL IMPLANT (E.G. BLADE, CYLINDER); COMPLETE 122,850.00 40,950.00 81,900.00 21255 RECONSTRUCTION OF ZYGOMATIC ARCH AND GLENOID FOSSA W/ BONE AND CARTILAGE (INCLUDES OBTAINING AUTOGRAFTS) 107,250.00 41,730.00 65,520.00 21256 RECONSTRUCTION OF ORBIT W/ OSTEOTOMIES (EXTRACRANIAL) AND W/ BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (E.G., MICRO-OPHTHALMIA) 107,250.00 41,730.00 65,520.00 21260 PERIORBITAL OSTEOTOMIES FOR ORBITAL HYPERTELORISM, W/ BONE GRAFTS 107,250.00 41,730.00 65,520.00 21267 ORBITAL REPOSITIONING, PERIORBITAL OSTEOTOMIES, UNILATERAL, W/ BONE GRAFTS; EXTRACRANIAL APPROACH 107,250.00 41,730.00 65,520.00 21300 CLOSED TREATMENT OF SKULL FRACTURE W/O OPERATION 20,553.00 10,725.00 9,828.00 21315 CLOSED TREATMENT OF NASAL BONE FRACTURE 20,553.00 10,725.00 9,828.00 21325 OPEN TREATMENT OF NASAL FRACTURE; UNCOMPLICATED 23,634.00 10,530.00 13,104.00 21330 OPEN TREATMENT OF NASAL FRACTURE; COMPLICATED, W/ INTERNAL AND/OR EXTERNAL SKELETAL FIXATION 23,634.00 10,530.00 13,104.00 21335 OPEN TREATMENT OF NASAL FRACTURE; W/ CONCOMITANT OPEN TREATMENT OF FRACTURED SEPTUM 23,634.00 10,530.00 13,104.00 21336 OPEN TREATMENT OF NASAL SEPTAL FRACTURE, W/ OR W/O STABILIZATION 23,634.00 10,530.00 13,104.00 21337 CLOSED TREATMENT OF NASAL SEPTAL FRACTURE 20,553.00 10,725.00 9,828.00 21338 OPEN TREATMENT OF NASOETHMOID FRACTURE; W/O EXTERNAL FIXATION 23,634.00 10,530.00 13,104.00 21339 OPEN TREATMENT OF NASOETHMOID FRACTURE; W/ EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 21340 PERCUTANEOUS TREATMENT OF NASOETHMOID COMPLEX FRACTURE, W/ SPLINT, WIRE OR HEADCAP FIXATION, INCLUDING REPAIR OF CANTHAL LIGAMENTS AND/OR THE NASOLACRIMAL APPARATUS 42,783.00 24,765.00 18,018.00 21343 OPEN TREATMENT OF DEPRESSED FRONTAL SINUS FRACTURE 42,783.00 24,765.00 18,018.00 21344 OPEN TREATMENT OF COMPLICATED (E.G., COMMINUTED OR INVOLVING POSTERIOR WALL) FRONTAL SINUS FRACTURE, VIA CORONAL OR MULTIPLE APPROACHES 45,435.00 20,865.00 24,570.00 21345 CLOSED TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE), W/ INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT 44,187.00 21,255.00 22,932.00 21346 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); W/ WIRING AND/OR LOCAL FIXATION 45,435.00 20,865.00 24,570.00 21347 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); REQUIRING MULTIPLE OPEN APPROACHES 59,085.00 26,325.00 32,760.00 21348 OPEN TREATMENT OF NASOMAXILLARY COMPLEX FRACTURE (LEFORT II TYPE); W/ BONE GRAFTING (INCLUDES OBTAINING GRAFT) 73,710.00 32,760.00 40,950.00 21355 PERCUTANEOUS TREATMENT OF FRACTURE OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD, W/ MANIPULATION 42,783.00 24,765.00 18,018.00 21356 OPEN TREATMENT OF DEPRESSED ZYGOMATIC ARCH FRACTURE (E.G., GILLES APPROACH) 45,435.00 20,865.00 24,570.00 21360 OPEN TREATMENT OF DEPRESSED MALAR FRACTURE, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD 59,085.00 26,325.00 32,760.00 21365 OPEN TREATMENT OF COMPLICATED (E.G., COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; W/ INTERNAL FIXATION AND MULTIPLE SURGICAL APPROACHES 73,710.00 32,760.00 40,950.00 21366 OPEN TREATMENT OF COMPLICATED (E.G., COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA) FRACTURE(S) OF MALAR AREA, INCLUDING ZYGOMATIC ARCH AND MALAR TRIPOD; W/ BONE GRAFTING (INCLUDES OBTAINING GRAFT) 90,675.00 41,535.00 49,140.00 21385 OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; TRANSANTRAL APPROACH (CALDWELL-LUC TYPE OPERATION) 40,911.00 21,255.00 19,656.00 21386 OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; PERIORBITAL APPROACH 35,100.00 18,720.00 16,380.00 21387 OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; COMBINED APPROACH 73,710.00 32,760.00 40,950.00 Page 10 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 21390 OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; PERIORBITAL APPROACH, W/ ALLOPLASTIC OR OTHER IMPLANT 61,581.00 33,735.00 27,846.00 21395 OPEN TREATMENT OF ORBITAL FLOOR "BLOWOUT" FRACTURE; PERIORBITAL APPROACH W/ BONE GRAFT (INCLUDES OBTAINING GRAFT) 61,581.00 33,735.00 27,846.00 21400 CLOSED TREATMENT OF FRACTURE OF ORBIT, EXCEPT "BLOWOUT" 35,100.00 18,720.00 16,380.00 21406 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT "BLOWOUT"; W/O IMPLANT 40,911.00 21,255.00 19,656.00 21407 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT "BLOWOUT"; W/ IMPLANT 61,581.00 33,735.00 27,846.00 21408 OPEN TREATMENT OF FRACTURE OF ORBIT, EXCEPT "BLOWOUT"; W/ BONE GRAFTING (INCLUDES OBTAINING GRAFT) 61,581.00 33,735.00 27,846.00 21421 CLOSED TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE), W/ INTERDENTAL WIRE FIXATION OR FIXATION OF DENTURE OR SPLINT 23,634.00 10,530.00 13,104.00 21422 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); 40,911.00 21,255.00 19,656.00 21423 OPEN TREATMENT OF PALATAL OR MAXILLARY FRACTURE (LEFORT I TYPE); COMPLICATED (COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA), MULTIPLE APPROACHES 45,435.00 20,865.00 24,570.00 21431 CLOSED TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE) USING INTERDENTAL WIRE FIXATION OF DENTURE OR SPLINT 23,634.00 10,530.00 13,104.00 21432 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); W/ WIRING AND/OR INTERNAL FIXATION 45,435.00 20,865.00 24,570.00 21433 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED (E.G., COMMINUTED OR INVOLVING CRANIAL NERVE FORAMINA); MULTIPLE SURGICAL APPROACHES 35,100.00 18,720.00 16,380.00 21435 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, UTILIZING INTERNAL AND/OR EXTERNAL FIXATION TECHNIQUES (E.G., HEAD CAP, HALO DEVICE, AND/OR INTERMAXILLARY FIXATION) 45,435.00 20,865.00 24,570.00 21436 OPEN TREATMENT OF CRANIOFACIAL SEPARATION (LEFORT III TYPE); COMPLICATED, MULTIPLE SURGICAL APPROACHES, INTERNAL FIXATION, W/ BONE GRAFTING (INCLUDES OBTAINING GRAFT) 90,675.00 41,535.00 49,140.00 21440 CLOSED TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE 23,634.00 10,530.00 13,104.00 21445 OPEN TREATMENT OF MANDIBULAR OR MAXILLARY ALVEOLAR RIDGE FRACTURE 35,100.00 18,720.00 16,380.00 21450 CLOSED TREATMENT OF MANDIBULAR FRACTURE 35,100.00 18,720.00 16,380.00 21452 PERCUTANEOUS TREATMENT OF MANDIBULAR FRACTUE, W/ EXTERNAL FIXATION 45,435.00 20,865.00 24,570.00 21453 CLOSED TREATMENT OF MANDIBULAR FRACTURE; W/ INTERDENTAL FIXATION 29,172.00 14,430.00 14,742.00 21454 OPEN TREATMENT OF MANDIBULAR FRACTURE; W/ EXTERNAL FIXATION 44,187.00 21,255.00 22,932.00 21461 OPEN TREATMENT OF MANDIBULAR FRACTURE; W/O INTERDENTAL FIXATION 44,187.00 21,255.00 22,932.00 21462 OPEN TREATMENT OF MANDIBULAR FRACTURE; W/ INTERDENTAL FIXATION 45,435.00 20,865.00 24,570.00 21465 OPEN TREATMENT OF MANDIBULAR CONDYLAR FRACTURE 59,085.00 26,325.00 32,760.00 21470 OPEN TREATMENT OF COMPLICATED MANDIBULAR FRACTURE BY MULTIPLE SURGICAL APPROACHES INCLUDING INTERNAL FIXATION, INTERDENTAL FIXATION, AND/OR WIRING OF DENTURES OR SPLINTS 73,710.00 32,760.00 40,950.00 21480 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT 18,915.00 10,725.00 8,190.00 21485 CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; COMPLICATED (E.G., RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING), INITIAL OR SUBSEQUENT 40,911.00 21,255.00 19,656.00 21490 OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION 59,085.00 26,325.00 32,760.00 21493 CLOSED TREATMENT OF HYOID FRACTURE 35,100.00 18,720.00 16,380.00 21495 OPEN TREATMENT OF HYOID FRACTURE 45,435.00 20,865.00 24,570.00 21497 INTERDENTAL WIRING, FOR CONDITION OTHER THAN FRACTURE 23,634.00 10,530.00 13,104.00 21501 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX; 11,076.00 7,800.00 3,276.00 21502 INCISION AND DRAINAGE, DEEP ABSCESS OR HEMATOMA, SOFT TISSUES OF NECK OR THORAX; W/ PARTIAL RIB OSTECTOMY 15,639.00 10,725.00 4,914.00 21510 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), THORAX 8,010.60 6,045.00 1,965.60 21550 BIOPSY, SOFT TISSUE OF NECK OR THORAX 11,076.00 7,800.00 3,276.00 21555 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; SUBCUTANEOUS 15,639.00 10,725.00 4,914.00 21556 EXCISION TUMOR, SOFT TISSUE OF NECK OR THORAX; DEEP, SUBFASCIAL, INTRAMUSCULAR 18,915.00 10,725.00 8,190.00 21557 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF NECK OR THORAX 59,085.00 26,325.00 32,760.00 21600 EXCISION OF RIB, PARTIAL 20,553.00 10,725.00 9,828.00 Page 11 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 21610 COSTOTRANSVERSECTOMY 40,911.00 21,255.00 19,656.00 21615 EXCISION FIRST AND/OR CERVICAL RIB; 72,501.00 36,465.00 36,036.00 21616 EXCISION FIRST AND/OR CERVICAL RIB; W/ SYMPATHECTOMY 73,710.00 32,760.00 40,950.00 21620 OSTECTOMY OF STERNUM, PARTIAL 52,884.00 23,400.00 29,484.00 21627 STERNAL DEBRIDEMENT 23,961.60 10,530.00 13,431.60 21630 RADICAL RESECTION OF STERNUM; 73,710.00 32,760.00 40,950.00 21700 DIVISION OF SCALENUS ANTICUS; W/O RESECTION OF CERVICAL RIB 35,100.00 18,720.00 16,380.00 21705 DIVISION OF SCALENUS ANTICUS; W/ RESECTION OF CERVICAL RIB 45,435.00 20,865.00 24,570.00 21720 DIVISION OF STERNOCLEIDOMASTOID FOR TORTICOLLIS, OPEN OPERATION 35,100.00 18,720.00 16,380.00 21740 RECONSTRUCTIVE REPAIR OF PECTUS EXCAVATUM OR CARINATUM 52,884.00 23,400.00 29,484.00 21750 CLOSURE OF STERNOTOMY SEPARATION W/ OR W/O DEBRIDEMENT 45,435.00 20,865.00 24,570.00 21800 CLOSED TREATMENT OF RIB FRACTURE 15,639.00 10,725.00 4,914.00 21805 OPEN TREATMENT OF RIB FRACTURE W/O FIXATION 21,372.00 10,725.00 10,647.00 21810 TREATMENT OF RIB FRACTURE REQUIRING EXTERNAL FIXATION ("FLAIL CHEST") 40,911.00 21,255.00 19,656.00 21820 CLOSED TREATMENT OF STERNUM FRACTURE 19,242.60 10,725.00 8,517.60 21825 OPEN TREATMENT OF STERNUM FRACTURE W/ OR W/O SKELETAL FIXATION 42,783.00 24,765.00 18,018.00 21920 BIOPSY, SOFT TISSUE OF BACK OR FLANK 6,832.80 5,850.00 982.80 21930 EXCISION, TUMOR, SOFT TISSUE OF BACK OR FLANK 11,076.00 7,800.00 3,276.00 21935 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF BACK OR FLANK 45,435.00 20,865.00 24,570.00 22100 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (E.G., SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; CERVICAL 52,884.00 23,400.00 29,484.00 22101 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (E.G., SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; THORACIC 52,884.00 23,400.00 29,484.00 22102 PARTIAL EXCISION OF POSTERIOR VERTEBRAL COMPONENT (E.G., SPINOUS PROCESS, LAMINA OR FACET) FOR INTRINSIC BONY LESION, SINGLE VERTEBRAL SEGMENT; LUMBAR 52,884.00 23,400.00 29,484.00 22110 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, W/O DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; CERVICAL 90,675.00 41,535.00 49,140.00 22112 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, W/O DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; THORACIC 59,085.00 26,325.00 32,760.00 22114 PARTIAL EXCISION OF VERTEBRAL BODY, FOR INTRINSIC BONY LESION, W/O DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; LUMBAR 59,085.00 26,325.00 32,760.00 22210 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; CERVICAL 90,675.00 41,535.00 49,140.00 22212 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; THORACIC 90,675.00 41,535.00 49,140.00 22214 OSTEOTOMY OF SPINE, POSTERIOR OR POSTEROLATERAL APPROACH, ONE VERTEBRAL SEGMENT; LUMBAR 90,675.00 41,535.00 49,140.00 22220 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; CERVICAL 104,130.00 46,800.00 57,330.00 22222 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; THORACIC 104,130.00 46,800.00 57,330.00 22224 OSTEOTOMY OF SPINE, INCLUDING DISKECTOMY, ANTERIOR APPROACH, SINGLE VERTEBRAL SEGMENT; LUMBAR 104,130.00 46,800.00 57,330.00 22305 CLOSED TREATMENT OF VERTEBRAL PROCESS FRACTURE(S) 45,435.00 20,865.00 24,570.00 22310 CLOSED TREATMENT OF VERTEBRAL BODY FRACTURE(S), REQUIRING AND INCLUDING CASTING OR BRACING 59,943.00 33,735.00 26,208.00 22325 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; LUMBAR 75,777.00 36,465.00 39,312.00 22326 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; CERVICAL 75,348.00 32,760.00 42,588.00 22327 OPEN TREATMENT AND/OR REDUCTION OF VERTEBRAL FRACTURE(S) AND/OR DISLOCATION(S), POSTERIOR APPROACH, ONE FRACTURED VERTEBRAE OR DISLOCATED SEGMENT; THORACIC 73,710.00 32,760.00 40,950.00 22548 ARTHRODESIS, ANTERIOR TRANSORAL OR EXTRAORAL TECHNIQUE, CLIVUS-C1-C2 (ATLAS-AXIS), W/ OR W/O EXCISION OF ODONTOID PROCESS 78,624.00 32,760.00 45,864.00 22554 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); CERVICAL BELOW C2 104,130.00 46,800.00 57,330.00 Page 12 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 22556 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC 90,675.00 41,535.00 49,140.00 22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR 90,675.00 41,535.00 49,140.00 22590 ARTHRODESIS; POSTERIOR TECHNIQUE, CRANIOCERVICAL (OCCIPUT-C2) 104,130.00 46,800.00 57,330.00 22595 ARTHRODESIS, POSTERIOR TECHNIQUE, ATLAS-AXIS (C1-C2) 104,130.00 46,800.00 57,330.00 22600 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT; 104,130.00 46,800.00 57,330.00 22610 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT; THORACIC (W/ OR W/O LATERAL TRANSVERSE TECHNIQUE) 59,085.00 26,325.00 32,760.00 22612 ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL; CERVICAL BELOW C2 SEGMENT; LUMBAR (W/ OR W/O LATERAL TRANSVERSE TECHNIQUE) 59,085.00 26,325.00 32,760.00 22630 ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, SINGLE INTERSPACE; LUMBAR 78,624.00 32,760.00 45,864.00 22800 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; UP TO 6 VERTEBRAL SEGMENTS 114,660.00 40,950.00 73,710.00 22802 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; 7 TO 12 VERTEBRAL SEGMENTS 122,850.00 40,950.00 81,900.00 22804 ARTHRODESIS, POSTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; 13 OR MORE VERTEBRAL SEGMENTS 131,040.00 40,950.00 90,090.00 22808 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; 2 TO 3 VERTEBRAL SEGMENTS 107,250.00 41,730.00 65,520.00 22810 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; 4 TO 7 VERTEBRAL SEGMENTS 114,660.00 40,950.00 73,710.00 22812 ARTHRODESIS, ANTERIOR, FOR SPINAL DEFORMITY, W/ OR W/O CAST; 8 OR MORE VERTEBRAL SEGMENTS 131,040.00 40,950.00 90,090.00 22840 POSTERIOR NON-SEGMENTAL INSTRUMENTATION (E.G., SINGLE HARRINGTON ROD TECHNIQUE) 107,250.00 41,730.00 65,520.00 22841 INTERNAL SPINAL FIXATION BY WIRING OF SPINOUS PROCESSES 104,130.00 46,800.00 57,330.00 22842 POSTERIOR SEGMENTAL INSTRUMENTATION (E.G., PEDICLE FIXATION, DUAL RODS W/ MULTIPLE HOOKS AND SUBLAMINAL WIRES); 3 TO 6 VERTEBRAL SEGMENTS 106,587.00 46,800.00 59,787.00 22843 POSTERIOR SEGMENTAL INSTRUMENTATION (E.G., PEDICLE FIXATION, DUAL RODS W/ MULTIPLE HOOKS AND SUBLAMINAL WIRES); 7 TO 12 VERTEBRAL SEGMENTS 114,660.00 40,950.00 73,710.00 22844 POSTERIOR SEGMENTAL INSTRUMENTATION (E.G., PEDICLE FIXATION, DUAL RODS W/ MULTIPLE HOOKS AND SUBLAMINAL WIRES); 13 OR MORE VERTEBRAL SEGMENTS 131,040.00 40,950.00 90,090.00 22845 ANTERIOR INSTRUMENTATION; 2 TO 3 VERTEBRAL SEGMENTS 107,250.00 41,730.00 65,520.00 22846 ANTERIOR INSTRUMENTATION; 4 TO 7 VERTEBRAL SEGMENTS 114,660.00 40,950.00 73,710.00 22847 ANTERIOR INSTRUMENTATION; 8 OR MORE VERTEBRAL SEGMENTS 131,040.00 40,950.00 90,090.00 22848 PELVIC FIXATION (ATTACHMENT OF CAUDAL END OF INSTRUMENTATION TO PELVIC BONY STRUCTURES) OTHER THAN SACRUM 107,250.00 41,730.00 65,520.00 22849 REINSERTION OF SPINAL FIXATION DEVICE 104,130.00 46,800.00 57,330.00 22850 REMOVAL OF POSTERIOR NONSEGMENTAL INSTRUMENTATION (E.G., HARRINGTON ROD) 42,783.00 24,765.00 18,018.00 22851 APPLICATION OF PROSTHETIC DEVICE (E.G., METAL CAGES, METHYLMETHACRYLATE) TO VERTEBRAL DEFECT OR INTERSPACE 114,660.00 40,950.00 73,710.00 22852 REMOVAL OF POSTERIOR SEGMENTAL INSTRUMENTATION 52,884.00 23,400.00 29,484.00 22855 REMOVAL OF ANTERIOR INSTRUMENTATION 59,085.00 26,325.00 32,760.00 22900 EXCISION, ABDOMINAL WALL TUMOR, SUBFASCIAL (E.G., DESMOID) 45,435.00 20,865.00 24,570.00 23000 REMOVAL OF SUBDELTOID (OR INTRATENDINOUS) CALCAREOUS DEPOSITS, OPEN METHOD 40,911.00 21,255.00 19,656.00 23020 CAPSULAR CONTRACTURE RELEASE (SEVER TYPE PROCEDURE) 52,884.00 23,400.00 29,484.00 23030 INCISION AND DRAINAGE, SHOULDER AREA; DEEP ABSCESS OR HEMATOMA 35,100.00 18,720.00 16,380.00 23031 INCISION AND DRAINAGE, SHOULDER AREA; INFECTED BURSA 29,172.00 14,430.00 14,742.00 23035 INCISION, DEEP, W/ OPENING OF CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), SHOULDER AREA 40,911.00 21,255.00 19,656.00 23040 ARTHROTOMY, GLENOHUMERAL JOINT, FOR INFECTION, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 45,435.00 20,865.00 24,570.00 23044 ARTHROTOMY, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT, FOR INFECTION, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 40,911.00 21,255.00 19,656.00 23065 BIOPSY, SOFT TISSUE OF SHOULDER AREA 6,832.80 5,850.00 982.80 23075 EXCISION, TUMOR, SHOULDER AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 Page 13 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 23076 EXCISION, TUMOR, SHOULDER AREA; DEEP, SUBFASCIAL, OR INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 23077 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF SHOULDER AREA 73,710.00 32,760.00 40,950.00 23100 ARTHROTOMY W/ BIOPSY, GLENOHUMERAL JOINT 45,435.00 20,865.00 24,570.00 23101 ARTHROTOMY W/ BIOPSY, OR W/ EXCISION OF TORN CARTILAGE, ACROMIOCLAVICULAR, STERNOCLAVICULAR JOINT 52,884.00 23,400.00 29,484.00 23105 ARTHROTOMY W/ SYNOVECTOMY; GLENOHUMERAL JOINT 52,884.00 23,400.00 29,484.00 23106 ARTHROTOMY W/ SYNOVECTOMY; STERNOCLAVICULAR JOINT 42,549.00 21,255.00 21,294.00 23107 ARTHROTOMY, GLENOHUMERAL JOINT, W/ JOINT EXPLORATION, W/ OR W/O REMOVAL OF LOOSE OR FOREIGN BODY 59,943.00 33,735.00 26,208.00 23120 CLAVICULECTOMY; PARTIAL 45,435.00 20,865.00 24,570.00 23125 CLAVICULECTOMY; TOTAL 54,522.00 23,400.00 31,122.00 23130 ACROMIOPLASTY OR ACROMIONECTOMY, PARTIAL 53,703.00 23,400.00 30,303.00 23140 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CLAVICLE OR SCAPULA; 40,911.00 21,255.00 19,656.00 23145 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CLAVICLE OR SCAPULA; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 43,368.00 21,255.00 22,113.00 23146 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CLAVICLE OR SCAPULA; W/ ALLOGRAFT 43,368.00 21,255.00 22,113.00 23150 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS; 59,943.00 33,735.00 26,208.00 23155 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 61,581.00 33,735.00 27,846.00 23156 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL HUMERUS; W/ ALLOGRAFT 61,581.00 33,735.00 27,846.00 23170 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), CLAVICLE 40,911.00 21,255.00 19,656.00 23172 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), SCAPULA 42,549.00 21,255.00 21,294.00 23174 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), HUMERAL HEAD TO SURGICAL NECK 45,435.00 20,865.00 24,570.00 23180 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION,OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), CLAVICLE 41,730.00 21,255.00 20,475.00 23182 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION,OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), SCAPULA 42,221.40 21,255.00 20,966.40 23184 PARTIAL EXCISION (CRATERIZATION, SUACERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), PROXIMAL HUMERUS 42,549.00 21,255.00 21,294.00 23190 OSTECTOMY OF SCAPULA, PARTIAL (E.G., SUPERIOR MEDIAL ANGLE) 42,549.00 21,255.00 21,294.00 23195 RESECTION HUMERAL HEAD 52,884.00 23,400.00 29,484.00 23200 RADICAL RESECTION FOR TUMOR; CLAVICLE 52,884.00 23,400.00 29,484.00 23210 RADICAL RESECTION FOR TUMOR; SCAPULA 53,703.00 23,400.00 30,303.00 23220 RADICAL RESECTION FOR TUMOR; PROXIMAL HUMERUS; 72,501.00 36,465.00 36,036.00 23221 RADICAL RESECTION FOR TUMOR; PROXIMAL HUMERUS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 78,624.00 32,760.00 45,864.00 23222 RADICAL RESECTION FOR TUMOR; PROXIMAL HUMERUS; W/ PROSTHETIC REPLACEMENT 104,130.00 46,800.00 57,330.00 23330 REMOVAL OF FOREIGN BODY, SHOULDER; SUBCUTANEOUS 10,842.00 8,385.00 2,457.00 23331 REMOVAL OF FOREIGN BODY, SHOULDER; DEEP (E.G., NEER PROSTHESIS REMOVAL) 25,155.00 12,870.00 12,285.00 23332 REMOVAL OF FOREIGN BODY, SHOULDER; COMPLICATED , INCLUDING "TOTAL SHOULDER" 29,172.00 14,430.00 14,742.00 23395 MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; SINGLE 43,368.00 21,255.00 22,113.00 23397 MUSCLE TRANSFER, ANY TYPE, SHOULDER OR UPPER ARM; MULTIPLE 45,435.00 20,865.00 24,570.00 23400 SCAPULOPEXY (E.G., SPRENGELS DEFORMITY OR FOR PARALYSIS) 52,884.00 23,400.00 29,484.00 23405 TENOMYOTOMY, SHOULDER AREA; SINGLE 42,783.00 24,765.00 18,018.00 23406 TENOMYOTOMY, SHOULDER AREA; MULTIPLE THROUGH SAME INCISION 45,006.00 21,255.00 23,751.00 23410 REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (E.G., ROTATOR CUFF); ACUTE 40,911.00 21,255.00 19,656.00 23412 REPAIR OF RUPTURED MUSCULOTENDINOUS CUFF (E.G., ROTATOR CUFF); CHRONIC 43,368.00 21,255.00 22,113.00 23415 CORACOACROMIAL LIGAMENT RELEASE, W/ OR W/O ACROMIOPLASTY 41,238.60 21,255.00 19,983.60 23420 REPAIR OF COMPLETE SHOULDER (ROTATOR) CUFF AVULSION, CHRONIC (INCLUDES ACROMIOPLASTY) 45,435.00 20,865.00 24,570.00 23430 TENODESIS OF LONG TENDON OF BICEPS 42,783.00 24,765.00 18,018.00 23440 RESECTION OR TRANSPLANTATION OF LONG TENDON OF BICEPS 40,911.00 21,255.00 19,656.00 23450 CAPSULORRHAPHY, ANTERIOR; PUTTI-PLATT PROCEDURE OR MAGNUSON TYPE OPERATION 73,710.00 32,760.00 40,950.00 23455 CAPSULORRHAPHY, ANTERIOR; BANKART TYPE OPERATION W/ OR W/O STAPLING 75,777.00 36,465.00 39,312.00 23460 CAPSULORRHAPHY, ANTERIOR, ANY TYPE; W/ BONE BLOCK 75,777.00 36,465.00 39,312.00 23462 CAPSULORRHAPHY, ANTERIOR, ANY TYPE; W/ CORACOID PROCESS TRANSFER 72,501.00 36,465.00 36,036.00 Page 14 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 23465 CAPSULORRHAPHY FOR RECURRENT DISLOCATION, POSTERIOR, W/ OR W/O BONE BLOCK 73,710.00 32,760.00 40,950.00 23466 CAPSULORRHAPHY W/ ANY TYPE MULTI-DIRECTIONAL INSTABILITY 78,624.00 32,760.00 45,864.00 23470 ARTHROPLASTY W/ PROXIMAL HUMERAL IMPLANT (E.G., NEER TYPE OPERATION) 93,951.00 41,535.00 52,416.00 23472 ARTHROPLASTY W/ GLENOID AND PROXIMAL HUMERAL REPLACEMENT (E.G. TOTAL SHOULDER) 104,130.00 46,800.00 57,330.00 23480 OSTEOTOMY, CLAVICLE, W/ OR W/O INTERNAL FIXATION; 52,884.00 23,400.00 29,484.00 23485 OSTEOTOMY, CLAVICLE, W/ OR W/O INTERNAL FIXATION; W/ BONE GRAFT FOR NONUNION OR MALUNION (INCLUDES OBTAINING GRAFT AND/OR NECESSARY FIXATION) 55,341.00 23,400.00 31,941.00 23490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE; CLAVICLE 52,884.00 23,400.00 29,484.00 23491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE; PROXIMAL HUMERUS AND HUMERAL HEAD 52,884.00 23,400.00 29,484.00 23500 CLOSED TREATMENT OF CLAVICULAR FRACTURE 15,639.00 10,725.00 4,914.00 23515 OPEN TREATMENT OF CLAVICULAR FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 24,289.20 10,530.00 13,759.20 23520 CLOSED TREATMENT OF STERNOCLAVICULAR DISLOCATION 21,216.00 13,845.00 7,371.00 23530 OPEN TREATMENT OF STERNOCLAVICULAR DISLOCTION, ACUTE OR CHRONIC; 40,911.00 21,255.00 19,656.00 23532 OPEN TREATMENT OF STERNOCLAVICULAR DISLOCTION, W/ FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) 52,884.00 23,400.00 29,484.00 23540 CLOSED TRATMENT OF ACROMIOCLAVICULAR DISLOCATION 15,639.00 10,725.00 4,914.00 23550 OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; 42,783.00 24,765.00 18,018.00 23552 OPEN TREATMENT OF ACROMIOCLAVICULAR DISLOCATION, ACUTE OR CHRONIC; W/ FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) 40,911.00 21,255.00 19,656.00 23570 CLOSED TREATMENT OF SCAPULAR FRACTURE 15,639.00 10,725.00 4,914.00 23585 OPEN TREATMENT OF SCAPULAR FRACTURE (BODY, GLENOID OR ACROMION) W/ OR W/O INTERNAL FIXATION 40,911.00 21,255.00 19,656.00 23600 CLOSED TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE 20,553.00 10,725.00 9,828.00 23615 OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, W/ OR W/O REPAIR OF TUBEROSITY(-IES); 45,435.00 20,865.00 24,570.00 23616 OPEN TREATMENT OF PROXIMAL HUMERAL (SURGICAL OR ANATOMICAL NECK) FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, W/ OR W/O REPAIR OF TUBEROSITY(-IES); W/ PROXIMAL HUMERAL PROSTHETIC REPLACEMENT 92,313.00 41,535.00 50,778.00 23620 CLOSED TREATMENT OF GREATER TUBEROSITY FRACTURE 18,915.00 10,725.00 8,190.00 23630 OPEN TREATMENT OF GREATER TUBEROSITY FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 45,435.00 20,865.00 24,570.00 23650 CLOSED TREATMENT OF SHOULDER DISLOCATION 20,553.00 10,725.00 9,828.00 23657 THORACOSCOPY, SURGICAL; W/ WEDGE RESECTION OF LUNG, SINGLE OR MUTIPLE 80,262.00 32,760.00 47,502.00 23660 OPEN TREATMENT OF ACUTE SHOULDER DISLOCATION 52,884.00 23,400.00 29,484.00 23665 CLOSED TREATMENT OF SHOULDER DISLOCATION,/ FRACTURE OF GREATER TUBEROSITY 23,361.00 11,895.00 11,466.00 23670 OPEN TREATMENT OF SHOULDER DISLOCATION, W/ FRACTURE OF GREATER TUBEROSITY, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 52,884.00 23,400.00 29,484.00 23675 CLOSED TREATMENT OF SHOULDER DISLOCATION, W/ SURGICAL OR ANATOMICAL NECK FRACTURE 23,634.00 10,530.00 13,104.00 23680 OPEN TREATMENT OF SHOULDER DISLOCATION, W/ SURGICAL OR ANATOMICAL NECK FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 52,884.00 23,400.00 29,484.00 23700 MANIPULATION UNDER ANESTHESIA, SHOULDER JOINT, INCLUDING APPLICATION OF FIXATION APPARATUS (DISLOCATION EXCLUDED) 18,915.00 10,725.00 8,190.00 23800 ARTHRODESIS, SHOULDER JOINT; W/ OR W/O LOCAL BONE GRAFT 24,289.20 10,530.00 13,759.20 23802 ARTHRODESIS, SHOULDER JOINT; W/ PRIMARY AUTOGENOUS GRAFT (INCLUDES OBTAINING GRAFT) 72,501.00 36,465.00 36,036.00 23900 INTERTHORACOSCAPULAR AMPUTATION (FOREQUARTER) 59,085.00 26,325.00 32,760.00 23920 DISARTICULATION OF SHOULDER; 52,884.00 23,400.00 29,484.00 23930 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; DEEP ABSCESS OR HEMATOMA 8,010.60 6,045.00 1,965.60 23931 INCISION AND DRAINAGE, UPPER ARM OR ELBOW AREA; INFECTED BURSA 10,842.00 8,385.00 2,457.00 23935 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OF BONE ABSCESS), HUMERUS OR ELBOW 42,783.00 24,765.00 18,018.00 24000 ARTHROTOMY, ELBOW, FOR INFECTION, W/ EXPLORATION, DRAINAGE OR REMOVAL OF FOREIGN BODY 43,602.00 24,765.00 18,837.00 24006 ARTHROTOMY OF THE ELBOW, W/ CAPSULAR EXCISION FOR CAPSULAR RELEASE 40,911.00 21,255.00 19,656.00 24065 BIOPSY, SOFT TISSUE OF UPPER ARM OR ELBOW AREA 6,832.80 5,850.00 982.80 24075 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 24076 EXCISION, TUMOR, UPPER ARM OR ELBOW AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 Page 15 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 24077 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF UPPER ARM OR ELBOW AREA 45,435.00 20,865.00 24,570.00 24100 ARTHROTOMY, ELBOW; W/ SYNOVIAL BIOPSY ONLY 40,911.00 21,255.00 19,656.00 24101 ARTHROTOMY, ELBOW; W/ JOINT EXPLORATION, W/ OR W/O BIOPSY, W/ OR W/O REMOVAL OF LOOSE OR FOREIGN BODY 42,549.00 21,255.00 21,294.00 24102 ARTHROTOMY, ELBOW; W/ SYNOVECTOMY 45,435.00 20,865.00 24,570.00 24105 EXCISION, OLECRANON BURSA 16,107.00 9,555.00 6,552.00 24110 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; 40,911.00 21,255.00 19,656.00 24115 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 45,006.00 21,255.00 23,751.00 24116 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, HUMERUS; W/ ALLOGRAFT 45,006.00 21,255.00 23,751.00 24120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; 41,238.60 21,255.00 19,983.60 24125 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 24126 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF HEAD OR NECK OF RADIUS OR OLECRANON PROCESS; W/ ALLOGRAFT 42,549.00 21,255.00 21,294.00 24130 EXCISION, RADIAL HEAD 40,911.00 21,255.00 19,656.00 24134 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), SHAFT OR DISTAL HUMERUS 40,911.00 21,255.00 19,656.00 24136 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), RADIAL HEAD OR NECK 40,911.00 21,255.00 19,656.00 24138 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), OLECRANON PROCESS 40,911.00 21,255.00 19,656.00 24140 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), HUMERUS 40,911.00 21,255.00 19,656.00 24145 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), RADIAL HEAD OR NECK 40,911.00 21,255.00 19,656.00 24147 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), OLECRANON PROCESS 40,911.00 21,255.00 19,656.00 24149 RADICAL RESECTION OF CAPSULE, SOFT TISSUE, AND HETEROTOPIC BONE, ELBOW, W/ CONTRACTURE RELEASE 41,730.00 21,255.00 20,475.00 24150 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; 45,006.00 21,255.00 23,751.00 24151 RADICAL RESECTION FOR TUMOR, SHAFT OR DISTAL HUMERUS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 59,085.00 26,325.00 32,760.00 24152 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; 45,435.00 20,865.00 24,570.00 24153 RADICAL RESECTION FOR TUMOR, RADIAL HEAD OR NECK; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 52,884.00 23,400.00 29,484.00 24155 RESECTION OF ELBOW JOINT (ARTHRECTOMY) 52,884.00 23,400.00 29,484.00 24160 IMPLANT REMOVAL; ELBOW JOINT 42,783.00 24,765.00 18,018.00 24164 IMPLANT REMOVAL; RADIAL HEAD 43,602.00 24,765.00 18,837.00 24200 REMOVAL OF FOREIGN BODY, UPPER ARM OR ELBOW AREA 16,130.40 10,725.00 5,405.40 24301 MUSCLE OR TENDON TRANSFER, ANY TYPE, UPPER ARM OR ELBOW, SINGLE 45,435.00 20,865.00 24,570.00 24305 TENDON LENGTHENING, UPPER ARM OR ELBOW, SINGLE, EACH 40,911.00 21,255.00 19,656.00 24310 TENOTOMY, OPEN, ELBOW TO SHOULDER, SINGLE, EACH 42,783.00 24,765.00 18,018.00 24320 TENOPLASTY, W/ MUSCLE TRANSFER, W/ OR W/O FREE GRAFT, ELBOW TO SHOULDER, SINGLE (SEDDON-BROOKES TYPE PROCEDURE) 52,884.00 23,400.00 29,484.00 24330 FLEXOR-PLASTY, ELBOW (E.G., STEINDLER TYPE ADVANCEMENT); 59,943.00 33,735.00 26,208.00 24331 FLEXOR-PLASTY, ELBOW (E.G., STEINDLER TYPE ADVANCEMENT); W/ EXTENSOR ADVANCEMENT 52,884.00 23,400.00 29,484.00 24340 TENODESIS OF BICEPS TENDON AT ELBOW 16,107.00 9,555.00 6,552.00 24341 REPAIR, TENDON OR MUSCLE, UPPER ARM OR ELBOW, EACH TENDON OR MUSCLE, PRIMARY OR SECONDARY (EXCLUDES ROTATOR CUFF) 40,911.00 21,255.00 19,656.00 24342 REINSERTION OF RUPTURED BICEPS OR TRICEPS TENDON, DISTAL, W/ OR W/O TENDON GRAFT 23,634.00 10,530.00 13,104.00 24350 FASCIOTOMY, LATERAL OR MEDIAL (E.G., "TENNIS ELBOW" OR EPICONDYLITIS); 20,553.00 10,725.00 9,828.00 24351 FASCIOTOMY, LATERAL OR MEDIAL (E.G., "TENNIS ELBOW" OR EPICONDYLITIS); W/ EXTENSOR ORIGIN DETACHMENT 23,634.00 10,530.00 13,104.00 24352 FASCIOTOMY, LATERAL OR MEDIAL (E.G., "TENNIS ELBOW" OR EPICONDYLITIS); W/ ANNULAR LIGAMENT RESECTION 23,634.00 10,530.00 13,104.00 24354 FASCIOTOMY, LATERAL OR MEDIAL (E.G., "TENNIS ELBOW" OR EPICONDYLITIS); W/ STRIPPING 23,634.00 10,530.00 13,104.00 24356 FASCIOTOMY, LATERAL OR MEDIAL (E.G., "TENNIS ELBOW" OR EPICONDYLITIS); W/ PARTIAL OSTECTOMY 23,634.00 10,530.00 13,104.00 24360 ARTHROPLASTY, ELBOW; W/ MEMBRANE; 52,884.00 23,400.00 29,484.00 24361 ARTHROPLASTY, ELBOW; W/ MEMBRANE; W/ DISTAL HUMERAL PROSTHETIC REPLACEMENT 72,501.00 36,465.00 36,036.00 24362 ARTHROPLASTY, ELBOW; W/ MEMBRANE; W/ IMPLANT AND FASCIA LATA LIGAMENT RECONSTRUCTION 52,884.00 23,400.00 29,484.00 24363 ARTHROPLASTY, ELBOW; W/ MEMBRANE; W/ DISTAL HUMERUS AND PROXIMAL ULNAR PROSTHETIC REPLACEMENT ("TOTAL ELBOW") 75,348.00 32,760.00 42,588.00 Page 16 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 24365 ARTHROPLASTY, RADIAL HEAD; 42,783.00 24,765.00 18,018.00 24366 ARTHROPLASTY, RADIAL HEAD; W/ IMPLANT 52,884.00 23,400.00 29,484.00 24400 OSTEOTOMY, HUMERUS, W/ OR W/O INTERNAL FIXATION 40,911.00 21,255.00 19,656.00 24410 MULTIPLE OSTEOTOMIES W/ REALIGNMENT ON INTRAMEDULLARY ROD, HUMERAL SHAFT (SOFIELD TYPE PROCEDURE) 40,911.00 21,255.00 19,656.00 24420 OSTEOPLASTY, HUMERUS (E.G., SHORTENING OR LENGTHENING) 45,435.00 20,865.00 24,570.00 24430 REPAIR OF NON-UNION OR MALUNION, HUMERUS; W/O GRAFT (E.G., COMPRESSION TECHNIQUE); 45,006.00 21,255.00 23,751.00 24435 REPAIR OF NON-UNION OR MALUNION, HUMERUS; W/O GRAFT (E.G., COMPRESSION TECHNIQUE); W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 52,884.00 23,400.00 29,484.00 24470 HEMIEPIPHYSEAL ARREST (E.G., FOR CUBITUS VARUS OR VALGUS, DISTAL HUMERUS) 43,602.00 24,765.00 18,837.00 24495 DECOMPRESSION FASCIOTOMY, FOREARM, W/ BRACHIAL ARTERY EXPLORATION 52,884.00 23,400.00 29,484.00 24498 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING), W/ OR W/O METHYLMETHACRYLATE, HUMERUS 40,911.00 21,255.00 19,656.00 24500 CLOSED TREATMENT OF HUMERAL SHAFT FRACTURE 19,734.00 10,725.00 9,009.00 24515 OPEN TREATMENT OF HUMERAL SHAFT FRACTURE W/ PLATE/SCREWS, W/ OR W/O CERCLAGE 59,943.00 33,735.00 26,208.00 24516 OPEN TREATMENT OF HUMERAL SHAFT FRACTURE, W/ INSERTION OF INTRAMEDULLARY IMPLANT, W/ OR W/O CERCLAGE AND/OR LOCKING SCREWS 59,943.00 33,735.00 26,208.00 24530 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, W/ OR W/O INTERCONDYLAR EXTENSION 19,734.00 10,725.00 9,009.00 24538 PERCUTANEOUS SKELETAL FIXATION OF SUPRACONDYLAR OR TRANSCONDYLAR HUMERAL FRACTURE, W/ OR W/O INTERCONDYLAR EXTENSION 52,884.00 23,400.00 29,484.00 24545 OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/O INTERCONDYLAR EXTENSION 24,289.20 10,530.00 13,759.20 24546 OPEN TREATMENT OF HUMERAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/ INTERCONDYLAR EXTENSION 62,400.00 33,735.00 28,665.00 24560 CLOSED TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL; 21,216.00 13,845.00 7,371.00 24566 PERCUTANEOUS SKELETAL FIXATION OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, W/ MANIPULATION 52,884.00 23,400.00 29,484.00 24575 OPEN TREATMENT OF HUMERAL EPICONDYLAR FRACTURE, MEDIAL OR LATERAL, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 24576 CLOSED TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL 21,216.00 13,845.00 7,371.00 24579 OPEN TREATMENT OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 24582 PERCUTANEOUS SKELETAL FIXATION OF HUMERAL CONDYLAR FRACTURE, MEDIAL OR LATERAL, W/ MANIPULATION 52,884.00 23,400.00 29,484.00 24586 OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); 44,187.00 21,255.00 22,932.00 24587 OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); W/ IMPLANT ARTHROPLASTY 73,710.00 32,760.00 40,950.00 24600 TREATMENT OF CLOSED ELBOW DISLOCATION 20,553.00 10,725.00 9,828.00 24615 OPEN TREATMENT OF ACUTE OR CHRONIC ELBOW DISLOCATION 45,435.00 20,865.00 24,570.00 24620 CLOSED TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA W/ DISLOCATION OF RADIAL HEAD) 21,216.00 13,845.00 7,371.00 24635 OPEN TREATMENT OF MONTEGGIA TYPE OF FRACTURE DISLOCATION AT ELBOW (FRACTURE PROXIMAL END OF ULNA W/ DISLOCATION OF RADIAL HEAD), W/ OR W/O INTERNAL OR EXTERNAL FIXATION 42,783.00 24,765.00 18,018.00 24640 CLOSED TREATMENT OF RADIAL HEAD SUBLUXATION IN CHILD, "NURSEMAID ELBOW" 11,076.00 7,800.00 3,276.00 24650 CLOSED TREATMENT OF RADIAL HEAD OR NECK FRACTURE 21,216.00 13,845.00 7,371.00 24665 OPEN TREATMENT OF RADIAL HEAD OR NECK FRACTURE, W/ OR W/O INTERNAL FIXATION OR RADIAL HEAD EXCISION; 40,911.00 21,255.00 19,656.00 24666 OPEN TREATMENT OF PERIARTICULAR FRACTURE AND/OR DISLOCATION OF THE ELBOW (FRACTURE DISTAL HUMERUS AND PROXIMAL ULNA AND/OR PROXIMAL RADIUS); W/ RADIAL HEAD PROSTHETIC REPLACEMENT 52,884.00 23,400.00 29,484.00 24670 CLOSED TREATMENT OF ULNAR FRACTURE, PROXIMAL END (OLECRANON PROCESS) 21,216.00 13,845.00 7,371.00 24685 OPEN TREATMENT OF ULNAR FRACTURE PROXIMAL END (OLECRANON PROCESS), W/ OR W/O INTERNAL OR EXTERNAL FIXATION 42,783.00 24,765.00 18,018.00 24800 ARTHRODESIS, ELBOW JOINT; W/ OR W/O LOCAL AUTOGRAFT OR ALLOGRAFT 52,884.00 23,400.00 29,484.00 Page 17 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 24802 ARTHRODESIS, ELBOW JOINT; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT OTHER THAN LOCALLY OBTAINED) 55,341.00 23,400.00 31,941.00 24900 AMPUTATION, ARM THROUGH HUMERUS; W/ PRIMARY CLOSURE 35,100.00 18,720.00 16,380.00 24920 AMPUTATION, ARM THROUGH HUMERUS; OPEN, CIRCULAR (GUILLOTINE) 23,634.00 10,530.00 13,104.00 24925 AMPUTATION, ARM THROUGH HUMERUS; SECONDARY CLOSURE OR SCAR REVISION 21,372.00 10,725.00 10,647.00 24930 AMPUTATION, ARM THROUGH HUMERUS; RE-AMPUTATION 29,172.00 14,430.00 14,742.00 24931 AMPUTATION, ARM THROUGH HUMERUS; W/ IMPLANT 29,172.00 14,430.00 14,742.00 24935 STUMP ELONGATION, UPPER EXTREMITY 23,634.00 10,530.00 13,104.00 24940 CINEPLASTY, UPPER EXTREMITY, COMPLETE PROCEDURE 52,884.00 23,400.00 29,484.00 25000 TENDON SHEATH INCISION; AT RADIAL STYLOID (E.G., FOR DEQUERVAINS DISEASE) 20,553.00 10,725.00 9,828.00 25020 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST; FLEXOR OR EXTENSOR COMPARTMENT 35,100.00 18,720.00 16,380.00 25023 DECOMPRESSION FASCIOTOMY, FOREARM AND/OR WRIST; W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 29,172.00 14,430.00 14,742.00 25028 INCISION AND DRAINAGE, FOREARM AND/OR WRIST; DEEP ABSCESS OR HEMATOMA 21,216.00 13,845.00 7,371.00 25031 INCISION AND DRAINAGE, FOREARM AND/OR WRIST; INFECTED BURSA 19,734.00 10,725.00 9,009.00 25035 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), FOREARM AND/OR WRIST 23,634.00 10,530.00 13,104.00 25040 ARTHROTOMY, RADIOCARPAL OR MIDCARPAL JOINT, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 19,734.00 10,725.00 9,009.00 25065 BIOPSY, SOFT TISSUE OF FOREARM AND/OR WRIST 6,832.80 5,850.00 982.80 25075 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 25076 EXCISION, TUMOR, FOREARM AND/OR WRIST AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 25077 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF FOREARM AND/OR WRIST AREA 45,435.00 20,865.00 24,570.00 25085 CAPSULOTOMY, WRIST (E.G., FOR CONTRACTURE) 29,991.00 14,430.00 15,561.00 25100 ARTHROTOMY, WRIST JOINT; W/ BIOPSY 21,535.80 10,725.00 10,810.80 25101 ARTHROTOMY, WRIST JOINT; W/ JOINT EXPLORATION, W/ OR W/O BIOPSY, W/ OR W/O REMOVAL OF LOOSE OR FOREIGN BODY 24,453.00 10,530.00 13,923.00 25105 ARTHROTOMY, WRIST JOINT; W/ SYNOVECTOMY 40,911.00 21,255.00 19,656.00 25107 ARTHROTOMY, DISTAL RADIOULNAR JOINT FOR REPAIR OF TRIANGLE CARTILAGE COMPLEX 40,911.00 21,255.00 19,656.00 25110 EXCISION, LESION OF TENDON SHEATH, FOREARM AND/OR WRIST 15,639.00 10,725.00 4,914.00 25111 EXCISION OF GANGLION, WRIST (DORSAL OR VOLAR) 16,107.00 9,555.00 6,552.00 25115 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (E.G., TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); FLEXORS 42,549.00 21,255.00 21,294.00 25116 RADICAL EXCISION OF BURSA, SYNOVIA OF WRIST, OR FOREARM TENDON SHEATHS (E.G., TENOSYNOVITIS, FUNGUS, TBC, OR OTHER GRANULOMAS, RHEUMATOID ARTHRITIS); EXTENSORS, W/ OR W/O TRANSPOSITION OF DORSAL RETINACULUM 35,919.00 18,720.00 17,199.00 25118 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; 19,406.40 10,725.00 8,681.40 25119 SYNOVECTOMY, EXTENSOR TENDON SHEATH, WRIST, SINGLE COMPARTMENT; W/ RESECTION OF DISTAL ULNA 42,783.00 24,765.00 18,018.00 25120 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); 40,911.00 21,255.00 19,656.00 25125 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 25126 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF RADIUS OR ULNA (EXCLUDING HEAD OR NECK OF RADIUS AND OLECRANON PROCESS); W/ ALLOGRAFT 42,549.00 21,255.00 21,294.00 25130 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; 19,406.40 10,725.00 8,681.40 25135 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 25,155.00 12,870.00 12,285.00 25136 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF CARPAL BONES; W/ ALLOGRAFT 25,155.00 12,870.00 12,285.00 25145 SEQUESTRECTOMY (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), FOREARM AND/OR WRIST 42,783.00 24,765.00 18,018.00 25150 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS); ULNA 42,783.00 24,765.00 18,018.00 25151 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS); RADIUS 42,783.00 24,765.00 18,018.00 25170 RADICAL RESECTION FOR TUMOR, RADIUS OR ULNA 52,884.00 23,400.00 29,484.00 25210 CARPECTOMY; ONE BONE 11,567.40 7,800.00 3,767.40 25215 CARPECTOMY; ALL BONES OF PROXIMAL ROW 43,602.00 24,765.00 18,837.00 Page 18 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 25230 RADIAL STYLOIDECTOMY 20,553.00 10,725.00 9,828.00 25240 EXCISION DISTAL ULNA PARTIAL OR COMPLETE (E.G., DARRACH TYPE OR MATCHED RESECTION) 20,553.00 10,725.00 9,828.00 25248 EXPLORATION W/ REMOVAL OF DEEP FOREIGN BODY, FOREARM OR WRIST 16,107.00 9,555.00 6,552.00 25250 REMOVAL OF WRIST PROSTHESIS; 42,783.00 24,765.00 18,018.00 25251 REMOVAL OF WRIST PROSTHESIS; COMPLICATED, INCLUDING "TOTAL WRIST" 59,943.00 33,735.00 26,208.00 25260 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE 20,553.00 10,725.00 9,828.00 25263 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; SECONDARY, SINGLE, EACH TENDON OR MUSCLE 16,107.00 9,555.00 6,552.00 25265 REPAIR, TENDON OR MUSCLE, FLEXOR, FOREARM AND/OR WRIST; SECONDARY, W/ FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON OR MUSCLE 19,734.00 10,725.00 9,009.00 25270 REPAIR, TENDON OR MUSLCE, EXTENSOR, FOREARM AND/OR WRIST; PRIMARY, SINGLE, EACH TENDON OR MUSCLE 20,553.00 10,725.00 9,828.00 25272 REPAIR, TENDON OR MUSLCE, EXTENSOR, FOREARM AND/OR WRIST; SECONDARY, SINGLE, EACH TENDON OR MUSCLE 16,107.00 9,555.00 6,552.00 25274 REPAIR, TENDON OR MUSCLE, EXTENSOR, SECONDARY, W/ TENDON GRAFT (INCLUDES OBTAINING GRAFT), FOREARM AND/OR WRIST, EACH TENDON OR MUSCLE 20,553.00 10,725.00 9,828.00 25280 LENGTHENING OR SHORTENING OF FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON 21,216.00 13,845.00 7,371.00 25290 TENOTOMY, OPEN, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE, EACH TENDON 21,216.00 13,845.00 7,371.00 25295 TENOLYSIS, FLEXOR OR EXTENSOR TENDON, FOREARM AND/OR WRIST, SINGLE EACH TENDON 16,107.00 9,555.00 6,552.00 25300 TENODESIS AT WRIST; FLEXORS OF FINGERS 21,372.00 10,725.00 10,647.00 25301 TENODESIS AT WRIST; EXTENSORS OF FINGERS 20,553.00 10,725.00 9,828.00 25310 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; EACH TENDON 40,911.00 21,255.00 19,656.00 25312 TENDON TRANSPLANTATION OR TRANSFER, FLEXOR OR EXTENSOR, FOREARM AND/OR WRIST, SINGLE; W/ TENDON GRAFT(S) (INCLUDES OBTAINING GRAFT), EACH TENDON 42,549.00 21,255.00 21,294.00 25315 FLEXOR ORIGIN SLIDE (E.G., FOR CEREBRAL PALSY, VOLKMANN CONTRACTURE), FOREARM AND/OR WRIST; 59,085.00 26,325.00 32,760.00 25316 FLEXOR ORIGIN SLIDE (E.G., FOR CEREBRAL PALSY, VOLKMANN CONTRACTURE), FOREARM AND/OR WRIST; W/ TENDON(S) TRANSFER 72,501.00 36,465.00 36,036.00 25320 CAPSULORRHAPHY OR RECONSTRUCTION, WRIST, ANY METHOD (E.G., CAPSULODESIS, LIGAMENT REPAIR, TENDON TRANSFER OR GRAFT) (INCLUDES SYNOVECTOMY, CAPSULOTOMY AND OPEN REDUCTION) FOR CARPAL INSTABILITY 52,884.00 23,400.00 29,484.00 25332 ARTHROPLASTY, WRIST, W/ OR W/O INTERPOSITION, W/ OR W/O EXTERNAL OR INTERNAL FIXATION 59,085.00 26,325.00 32,760.00 25335 CENTRALIZATION OF WRIST ON ULNA (E.G., RADIAL CLUB HAND) 60,723.00 26,325.00 34,398.00 25337 RECONSTRUCTION FOR STABILIZATION OF UNSTABLE DISTAL ULNA OR DISTAL RADIOULNAR JOINT, SECONDARY BY SOFT TISSUE STABILIZATION (E.G., TENDON TRANSFER, TENDON GRAFT OR WEAVE, OR TENODESIS) W/ OR W/O OPEN REDUCTION OF DISTAL RADIOULNAR JOINT 54,522.00 23,400.00 31,122.00 25350 OSTEOTOMY, RADIUS; DISTAL THIRD 35,100.00 18,720.00 16,380.00 25355 OSTEOTOMY, RADIUS; MIDDLE OR PROXIMAL THIRD 42,783.00 24,765.00 18,018.00 25360 OSTEOTOMY; ULNA 35,919.00 18,720.00 17,199.00 25365 OSTEOTOMY; RADIUS AND ULNA 45,435.00 20,865.00 24,570.00 25370 MULTIPLE OSTEOTOMIES, W/ REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE PROCEDURE); RADIUS OR ULNA 59,943.00 33,735.00 26,208.00 25375 MULTIPLE OSTEOTOMIES, W/ REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE PROCEDURE); RADIUS AND ULNA 54,522.00 23,400.00 31,122.00 25390 OSTEOPLASTY, RADIUS OR ULNA; SHORTENING 52,884.00 23,400.00 29,484.00 25391 OSTEOPLASTY, RADIUS OR ULNA; LENGTHENING W/ AUTOGRAFT 54,522.00 23,400.00 31,122.00 25392 OSTEOPLASTY, RADIUS AND ULNA; SHORTENING 52,884.00 23,400.00 29,484.00 25393 OSTEOPLASTY, RADIUS AND ULNA; LENGTHENING W/ AUTOGRAFT 54,522.00 23,400.00 31,122.00 25400 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/O GRAFT (COMPRESSION TECHNIQUE) 40,911.00 21,255.00 19,656.00 25405 REPAIR OF NONUNION OR MALUNION, RADIUS OR ULNA; W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 45,435.00 20,865.00 24,570.00 25415 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W/O GRAFT (E.G. COMPRESSION TECHNIQUE) 59,943.00 33,735.00 26,208.00 25420 REPAIR OF NONUNION OR MALUNION, RADIUS AND ULNA; W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 54,522.00 23,400.00 31,122.00 25425 REPAIR OF DEFECT W/ AUTOGRAFT; RADIUS OR ULNA 42,783.00 24,765.00 18,018.00 25426 REPAIR OF DEFECT W/ AUTOGRAFT; RADIUS AND ULNA 59,943.00 33,735.00 26,208.00 25440 REPAIR OF NONUNION, SCAPHOID (NAVICULAR) BONE, W/ OR W/O RADIAL STYLOIDECTOMY (INCLUDES OBTAINING GRAFT AND NECESSARY FIXATION) 46,254.00 20,865.00 25,389.00 Page 19 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 25441 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; DISTAL RADIUS 59,085.00 26,325.00 32,760.00 25442 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; DISTAL ULNA 52,884.00 23,400.00 29,484.00 25443 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; SCAPHOID (NAVICULAR) 52,884.00 23,400.00 29,484.00 25444 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; LUNATE 52,884.00 23,400.00 29,484.00 25445 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; TRAPEZIUM 61,581.00 33,735.00 27,846.00 25446 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; DISTAL RADIUS AND PARTIAL OR ENTIRE CARPUS ("TOTAL WRIST") 73,710.00 32,760.00 40,950.00 25447 ARTHROPLASTY W/ PROSTHETIC REPLACEMENT; INTERPOSITION ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS 54,522.00 23,400.00 31,122.00 25449 REVISION OF ARTHROPLASTY, INCLUDING REMOVAL OF IMPLANT, WRIST JOINT 78,624.00 32,760.00 45,864.00 25450 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS OR ULNA 40,911.00 21,255.00 19,656.00 25455 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL RADIUS AND ULNA 59,943.00 33,735.00 26,208.00 25490 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE; RADIUS 42,783.00 24,765.00 18,018.00 25491 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE; ULNA 42,783.00 24,765.00 18,018.00 25492 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE; RADIUS AND ULNA 72,501.00 36,465.00 36,036.00 25500 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE 18,915.00 10,725.00 8,190.00 25515 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 42,783.00 24,765.00 18,018.00 25520 CLOSED TREATMENT OF RADIAL SHAFT FRACTURE, W/ DISLOCATION OF DISTAL RADIO-ULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION) 18,915.00 10,725.00 8,190.00 25525 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, W/ INTERNAL AND/OR EXTERNAL FIXATION AND CLOSED TREATMENT OF DISLOCATION OF DISTAL RADIO-ULNAR JOINT (GALEAZZI FRACTURE/DISLOCATION), W/ OR W/O PERCUTANEOUS SKELETAL FIXATION 40,911.00 21,255.00 19,656.00 25526 OPEN TREATMENT OF RADIAL SHAFT FRACTURE, W/ INTERNAL AND/OR EXTERNAL FIXATION AND OPEN TREATMENT, W/ OR W/O INTERNAL OR EXTERNAL FIXATION OF DISTAL RADIO-ULNAR JOINT (GALLEAZI FRACTURE/DISLOCATION), INCLUDES REPAIR OF TRIANGULAR CARTILAGE 44,187.00 21,255.00 22,932.00 25530 CLOSED TREATMENT OF ULNAR SHAFT FRACTURE 16,107.00 9,555.00 6,552.00 25545 OPEN TREATMENT OF ULNAR SHAFT FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 25560 CLOSED TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES 18,915.00 10,725.00 8,190.00 25574 OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, W/ INTERNAL OR EXTERNAL FIXATION; OF RADIUS OR ULNA 54,522.00 23,400.00 31,122.00 25575 OPEN TREATMENT OF RADIAL AND ULNAR SHAFT FRACTURES, W/ INTERNAL OR EXTERNAL FIXATION; OF RADIUS AND ULNA 52,884.00 23,400.00 29,484.00 25600 CLOSED TREATMENT OF DISTAL RADIAL FRACTURE (E.G., COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, W/ OR W/O FRACTURE OF ULNAR STYLOID 16,107.00 9,555.00 6,552.00 25611 PERCUTANEOUS SKELETAL FIXATION OF DISTAL RADIAL FRACTURE (E.G., COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, W/ OR W/O FRACTURE OF ULNAR STYLOID , REQUIRING MANIPULATION, W/ OR W/O EXTERNAL FIXATION 45,435.00 20,865.00 24,570.00 25620 OPEN TREATMENT OF DISTAL RADIAL FRACTURE (E.G., COLLES OR SMITH TYPE) OR EPIPHYSEAL SEPARATION, W/ OR W/O FRACTURE OF ULNAR STYLOID, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 45,435.00 20,865.00 24,570.00 25622 CLOSED TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE 16,107.00 9,555.00 6,552.00 25628 OPEN TREATMENT OF CARPAL SCAPHOID (NAVICULAR) FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 42,549.00 21,255.00 21,294.00 25630 CLOSED TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)) 16,107.00 9,555.00 6,552.00 25645 OPEN TREATMENT OF CARPAL BONE FRACTURE (EXCLUDING CARPAL SCAPHOID (NAVICULAR)), EACH BONE 42,712.80 21,255.00 21,457.80 25650 CLOSED TREATMENT OF ULNAR STYLOID FRACTURE 16,458.00 10,725.00 5,733.00 25660 CLOSED TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE OR MORE BONES 16,107.00 9,555.00 6,552.00 25670 OPEN TREATMENT OF RADIOCARPAL OR INTERCARPAL DISLOCATION, ONE OR MORE BONES 35,100.00 18,720.00 16,380.00 25675 CLOSED TREATMENT OF DISTAL RADIOULNAR DISLOCATION 16,107.00 9,555.00 6,552.00 25676 OPEN TREATMENT OF DISTAL RADIOULNAR DISLOCATION, ACUTE OR CHRONIC 42,549.00 21,255.00 21,294.00 25680 CLOSED TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION 16,107.00 9,555.00 6,552.00 25685 OPEN TREATMENT OF TRANS-SCAPHOPERILUNAR TYPE OF FRACTURE DISLOCATION 40,911.00 21,255.00 19,656.00 25690 CLOSED TREATMENT OF LUNATE DISLOCATION 16,107.00 9,555.00 6,552.00 Page 20 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 25695 OPEN TREATMENT OF LUNATE DISLOCATION 42,783.00 24,765.00 18,018.00 25800 ARTHRODESIS, WRIST JOINT (INCLUDING RADIOCARPAL AND/OR ULNOCARPAL FUSION); W/O BONE GRAFT 35,100.00 18,720.00 16,380.00 25805 ARTHRODESIS, WRIST JOINT (INCLUDING RADIOCARPAL AND/OR ULNOCARPAL FUSION); W/ SLIDING GRAFT 42,549.00 21,255.00 21,294.00 25810 ARTHRODESIS, WRIST JOINT (INCLUDING RADIOCARPAL AND/OR ULNOCARPAL FUSION); W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 25820 INTERCARPAL FUSION; W/O BONE GRAFT 25,155.00 12,870.00 12,285.00 25825 INTERCARPAL FUSION; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 29,172.00 14,430.00 14,742.00 25830 DISTAL RADIOULNAR JOINT ARTHRODESIS AND SEGMENTAL RESECTION OF ULNA (E.G. SAUVE-KAPANDJI PROCEDURE), W/ OR W/O BONE GRAFT 42,549.00 21,255.00 21,294.00 25900 AMPUTATION, FOREARM, THROUGH, RADIUS AND ULNA; 35,100.00 18,720.00 16,380.00 25905 AMPUTATION, FOREARM, THROUGH, OPEN, CIRCULAR (GUILLOTINE) 23,634.00 10,530.00 13,104.00 25907 AMPUTATION, FOREARM, THROUGH, SECONDARY CLOSURE OR SCAR REVISION 21,372.00 10,725.00 10,647.00 25909 AMPUTATION, FOREARM, THROUGH, RE-AMPUTATION 29,172.00 14,430.00 14,742.00 25915 KRUKENBERG PROCEDURE 73,710.00 32,760.00 40,950.00 25920 DISARTICULATION THROUGH WRIST; 29,172.00 14,430.00 14,742.00 25922 DISARTICULATION THROUGH WRIST; SECONDARY CLOSURE OR SCAR REVISION 16,458.00 10,725.00 5,733.00 25924 DISARTICULATION THROUGH WRIST; RE-AMPUTATION 29,172.00 14,430.00 14,742.00 25927 TRANSMETACARPAL AMPUTATION; 29,172.00 14,430.00 14,742.00 25929 TRANSMETACARPAL AMPUTATION; SECONDARY CLOSURE OR SCAR REVISION 16,458.00 10,725.00 5,733.00 25931 TRANSMETACARPAL AMPUTATION; RE-AMPUTATION 29,172.00 14,430.00 14,742.00 26010 DRAINAGE OF FINGER ABSCESS; SIMPLE 6,832.80 5,850.00 982.80 26011 DRAINAGE OF FINGER ABSCESS; COMPLICATED (E.G., FELON) 8,010.60 6,045.00 1,965.60 26020 DRAINAGE OF TENDON SHEATH, ONE DIGIT AND/OR PALM 15,639.00 10,725.00 4,914.00 26025 DRAINAGE OF PALMAR BURSA; SINGLE, ULNAR OR RADIAL 21,216.00 13,845.00 7,371.00 26030 DRAINAGE OF PALMAR BURSA; SINGLE, MULTIPLE OR COMPLICATED 20,553.00 10,725.00 9,828.00 26034 INICISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), HAND OR FINGER 42,783.00 24,765.00 18,018.00 26035 DECOMPRESSION FINGERS AND/OR HAND, INJECTION INJURY (E.G., GREASE GUN) 29,172.00 14,430.00 14,742.00 26037 DECOMPRESSIVE FASCIOTOMY, HAND (EXCLUDES 26035) 42,783.00 24,765.00 18,018.00 26040 FASCIOTOMY, PALMAR, FOR DUPUYTRENS CONTRACTURE; PERCUTANEOUS 23,634.00 10,530.00 13,104.00 26045 FASCIOTOMY, PALMAR, FOR DUPUYTRENS CONTRACTURE; OPEN, PARTIAL 23,634.00 10,530.00 13,104.00 26055 TENDON SHEATH INCISION (E.G., FOR TRIGGER FINGER) 20,553.00 10,725.00 9,828.00 26060 TENOTOMY, PERCUTANEOUS, SINGLE, EACH DIGIT 18,915.00 10,725.00 8,190.00 26070 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY; CARPOMETACARPAL JOINT 21,216.00 13,845.00 7,371.00 26075 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY; METACARPOPHALANGEAL JOINT 21,216.00 13,845.00 7,371.00 26080 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY; INTERPHALANGEAL JOINT, EACH 16,107.00 9,555.00 6,552.00 26100 ARTHROTOMY W/ SYNOVIAL BIOPSY, CARPOMETACARPAL JOINT 23,634.00 10,530.00 13,104.00 26105 ARTHROTOMY W/ SYNOVIAL BIOPSY, METACARPOPHALANGEAL JOINT 25,155.00 12,870.00 12,285.00 26110 ARTHROTOMY W/ SYNOVIAL BIOPSY, INTERPHALANGEAL JOINT, EACH 23,361.00 11,895.00 11,466.00 26115 EXCISION, TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER; SUBCUTANEOUS 40,911.00 21,255.00 19,656.00 26116 EXCISION, TUMOR OR VASCULAR MALFORMATION, HAND OR FINGER; DEEP, SUBFASCIAL, INTRAMUSCULAR 45,435.00 20,865.00 24,570.00 26117 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF HAND OR FINGER 52,884.00 23,400.00 29,484.00 26121 FASCIECTOMY, PALM ONLY, W/ OR W/O Z-PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT) 52,884.00 23,400.00 29,484.00 26123 FASCIECTOMY, PARTIAL PALMAR W/ RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, W/ OR W/O Z- PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); 44,187.00 21,255.00 22,932.00 26125 FASCIECTOMY, PARTIAL PALMAR W/ RELEASE OF SINGLE DIGIT INCLUDING PROXIMAL INTERPHALANGEAL JOINT, W/ OR W/O Z- PLASTY, OTHER LOCAL TISSUE REARRANGEMENT, OR SKIN GRAFTING (INCLUDES OBTAINING GRAFT); EACH ADDITIONAL DIGIT (LIST SEPARATELY IN ADDITION TO CODE 16,107.00 9,555.00 6,552.00 26130 SYNOVECTOMY, CAPOMETACARPAL JOINT 44,187.00 21,255.00 22,932.00 26135 SYNOVECTOMY, METACARPOPHALANGEAL JOINT INCLUDING INTRINSIC RELEASE AND EXTENSOR HOOD RECONSTRUCTION, EACH DIGIT 25,318.80 12,870.00 12,448.80 26140 SYNOVECTOMY, PROXIMAL INTERPHALANGEAL JOINT, INCLUDING EXTENSOR RECONSTRUCTION, EACH INTERPHALANGEAL JOINT 25,318.80 12,870.00 12,448.80 Page 21 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 26145 SYNOVECTOMY TENDON SHEATH, RADICAL (TENOSYNOVECTOMY), FLEXOR, PALM OR FINGER, SINGLE, EACH DIGIT 29,991.00 14,430.00 15,561.00 26160 EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (E.G., CYST, MUCOUS CYST, OR GANGLION), HAND OR FINGER 23,361.00 11,895.00 11,466.00 26170 EXCISION OF TENDON, PALM, FLEXOR, SINGLE , EACH 16,458.00 10,725.00 5,733.00 26180 EXCISION OF TENDON, FINGER, FLEXOR 16,107.00 9,555.00 6,552.00 26185 SESAMOIDECTOMY, THUMB OR FINGER 29,991.00 14,430.00 15,561.00 26200 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; 24,616.80 10,530.00 14,086.80 26205 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF METACARPAL; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,783.00 24,765.00 18,018.00 26210 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE; OR DISTAL PHALANX OF FINGER; 23,634.00 10,530.00 13,104.00 26215 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF PROXIMAL, MIDDLE; OR DISTAL PHALANX OF FINGER; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 29,991.00 14,430.00 15,561.00 26230 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS); METACARPAL 42,783.00 24,765.00 18,018.00 26235 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER 29,991.00 14,430.00 15,561.00 26236 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS); DISTAL PHALANX OF FINGER 23,634.00 10,530.00 13,104.00 26250 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPAL; 46,090.20 20,865.00 25,225.20 26255 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, METACARPAL; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 62,400.00 33,735.00 28,665.00 26260 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL OR MIDDLE PHALANX OF FINGER; 59,943.00 33,735.00 26,208.00 26261 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, PROXIMAL OR MIDDLE PHALANX OF FINGER; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 61,581.00 33,735.00 27,846.00 26262 RADICAL RESECTION (OSTECTOMY) FOR TUMOR, DISTAL PHALANX OF FINGER 45,006.00 21,255.00 23,751.00 26350 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, NOT IN "NO MANS LAND", PRIMARY OR SECONDARY W/O FREE GRAFT, EACH TENDON 23,634.00 10,530.00 13,104.00 26352 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, NOT IN "NO MANS LAND", SECONDARY W/ FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 20,553.00 10,725.00 9,828.00 26356 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MANS LAND"; PRIMARY, EACH TENDON 21,216.00 13,845.00 7,371.00 26357 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MANS LAND"; SECONDARY, EACH TENDON 21,216.00 13,845.00 7,371.00 26358 FLEXOR TENDON REPAIR OR ADVANCEMENT, SINGLE, IN "NO MANS LAND"; SECONDARY W/ FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 21,216.00 13,845.00 7,371.00 26370 PROFUNDUS TENDON REPAIR OR ADVANCEMENT, W/ INTACT SUBLIMIS; PRIMARY 21,216.00 13,845.00 7,371.00 26372 PROFUNDUS TENDON REPAIR OR ADVANCEMENT, W/ INTACT SUBLIMIS; SECONDARY W/ FREE GRAFT (INCLUDES OBTAINING GRAFT) 20,553.00 10,725.00 9,828.00 26373 PROFUNDUS TENDON REPAIR OR ADVANCEMENT, W/ INTACT SUBLIMIS; SECONDARY W/O FREE GRAFT 21,707.40 13,845.00 7,862.40 26390 FLEXOR TENDON EXCISION, IMPLANTATION OF PLASTIC TUBE OR ROD FOR DELAYED TENDON GRAFT, HAND OR FINGER 21,216.00 13,845.00 7,371.00 26392 REMOVAL OF TUBE OR ROD AND INSERTION OF FLEXOR TENDON GRAFT (INCLUDES OBTAINING GRAFT), HAND OR FINGER 21,216.00 13,845.00 7,371.00 26410 EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PRIMARY OR SECONDARY; W/O FREE GRAFT, EACH TENDON 16,107.00 9,555.00 6,552.00 26412 EXTENSOR TENDON REPAIR, DORSUM OF HAND, SINGLE, PRIMARY OR SECONDARY; W/ FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 16,107.00 9,555.00 6,552.00 26415 EXTENSOR TENDON EXCISION, IMPLANTATION OF PLASTIC TUBE OR ROD FOR DELAYED EXTENSOR TENDON GRAFT, HAND OR FINGER 21,216.00 13,845.00 7,371.00 26416 REMOVAL OF TUBE OR ROD AND INSERTION OF EXTENSOR TENDON GRAFT (INCLUDES OBTAINING GRAFT), HAND OR FINGER 16,949.40 10,725.00 6,224.40 26418 EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE, PRIMARY OR SECONDARY; W/O FREE GRAFT, EACH TENDON 16,107.00 9,555.00 6,552.00 26420 EXTENSOR TENDON REPAIR, DORSUM OF FINGER, SINGLE, PRIMARY OR SECONDARY; W/ FREE GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 16,107.00 9,555.00 6,552.00 26426 EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECONDARY (BOUTONNIERE DEFORMITY); USING LOCAL TISSUES 16,107.00 9,555.00 6,552.00 26428 EXTENSOR TENDON REPAIR, CENTRAL SLIP REPAIR, SECONDARY (BOUTONNIERE DEFORMITY); W/ FREE GRAFT (INCLUDES OBTAINING GRAFT) 16,107.00 9,555.00 6,552.00 Page 22 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 26432 EXTENSOR TENDON REPAIR, DISTAL INSERTION ("MALLET FINGER"), CLOSED SPLINTING W/ OR W/O PERCUTANEOUS PINNING 16,107.00 9,555.00 6,552.00 26433 EXTENSOR TENDON REPAIR, DISTAL INSERTION ("MALLET FINGER"), OPEN, PRIMARY OR SECONDARY REPAIR; W/O GRAFT 16,107.00 9,555.00 6,552.00 26434 EXTENSOR TENDON REPAIR, DISTAL INSERTION ("MALLET FINGER"), OPEN, PRIMARY OR SECONDARY REPAIR; W/ FREE GRAFT (INCLUDES OBTAINING GRAFT) 21,216.00 13,845.00 7,371.00 26437 EXTENSOR TENDON REALIGNMENT, HAND 20,553.00 10,725.00 9,828.00 26440 TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM OR FINGER, SINGLE, EACH TENDON 15,639.00 10,725.00 4,914.00 26442 TENOLYSIS, SIMPLE, FLEXOR TENDON; PALM AND FINGER, EACH TENDON 16,458.00 10,725.00 5,733.00 26445 TENOLYSIS, EXTENSOR TENDON, DORSUM OF HAND OR FINGER; EACH TENDON 15,639.00 10,725.00 4,914.00 26449 TENOLYSIS, COMPLEX, EXTENSOR TENDON, DORSUM OF HAND OR FINGER, INCLUDING HAND AND FOREARM 16,458.00 10,725.00 5,733.00 26450 TENOTOMY, FLEXOR, SINGLE, PALM, OPEN, EACH 16,458.00 10,725.00 5,733.00 26455 TENOTOMY, FLEXOR, SINGLE, FINGER, OPEN, EACH 16,458.00 10,725.00 5,733.00 26460 TENOTOMY, EXTENSOR, HAND OR FINGER, SINGLE, OPEN, EACH 16,458.00 10,725.00 5,733.00 26471 TENODESIS; FOR PROXIMAL INTERPHALANGEAL JOINT STABILIZATION 16,107.00 9,555.00 6,552.00 26474 TENODESIS; FOR DISTAL JOINT STABILIZATON 21,216.00 13,845.00 7,371.00 26476 TENDON LENGTHENING, EXTENSOR, HAND OR FINGER, SINGLE, EACH 16,458.00 10,725.00 5,733.00 26477 TENDON SHORTENING, EXTENSOR, HAND OR FINGER, SINGLE, EACH 16,458.00 10,725.00 5,733.00 26478 TENDON LENGTHENING, FLEXOR, HAND OR FINGER, SINGLE, EACH 16,458.00 10,725.00 5,733.00 26479 TENDON SHORTENING, FLEXOR, HAND OR FINGER, SINGLE, EACH 16,458.00 10,725.00 5,733.00 26480 TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL AREA OR DORSUM OF HAND, SINGLE; W/O FREE GRAFT, EACH 16,458.00 10,725.00 5,733.00 26483 TENDON TRANSFER OR TRANSPLANT, CARPOMETACARPAL AREA OR DORSUM OF HAND, SINGLE; W/ FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 21,216.00 13,845.00 7,371.00 26485 TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EACH TENDON; W/O FREE TENDON GRAFT 16,107.00 9,555.00 6,552.00 26489 TENDON TRANSFER OR TRANSPLANT, PALMAR, SINGLE, EACH TENDON; W/ FREE TENDON GRAFT (INCLUDES OBTAINING GRAFT), EACH TENDON 16,107.00 9,555.00 6,552.00 26490 OPPONENSPLASTY; SUBLIMIS TENDON TRANSFER TYPE 20,553.00 10,725.00 9,828.00 26492 OPPONENSPLASTY; TENDON TRANSFER W/ GRAFT (INCLUDES OBTAINING GRAFT) 21,372.00 10,725.00 10,647.00 26494 OPPONENSPLASTY; HYPOTHENAR MUSCLE TRANSFER 20,553.00 10,725.00 9,828.00 26496 OPPONENSPLASTY; OTHER METHODS 20,553.00 10,725.00 9,828.00 26497 TENDON TRASFER TO RESTORE INTRINSIC FUNCTION; RING AND SMALL FINGER 16,434.60 9,555.00 6,879.60 26498 TENDON TRASFER TO RESTORE INTRINSIC FUNCTION; ALL FOUR FINGERS 35,100.00 18,720.00 16,380.00 26499 CORRECTION CLAW FINGER,OTHER METHODS 42,783.00 24,765.00 18,018.00 26500 TENDON PULLEY RECONSTRUCTION; W/ LOCAL TISSUES 21,216.00 13,845.00 7,371.00 26502 TENDON PULLEY RECONSTRUCTION; W/ TENDON OR FASCIAL GRAFT (INCLUDES OBTAINING GRAFT) 19,734.00 10,725.00 9,009.00 26504 TENDON PULLEY RECONSTRUCTION; W/ TENDON PROSTHESIS 25,155.00 12,870.00 12,285.00 26508 THENAR MUSCLE RELEASE FOR THUMB CONTRACTURE 16,434.60 9,555.00 6,879.60 26510 CROSS INTRINSIC TRANSFER 21,372.00 10,725.00 10,647.00 26516 CAPSULODESIS FOR M-P JOINT STABILIZATION; SINGLE DIGIT 20,553.00 10,725.00 9,828.00 26517 CAPSULODESIS FOR M-P JOINT STABILIZATION; TWO DIGITS 23,634.00 10,530.00 13,104.00 26518 CAPSULODESIS FOR M-P JOINT STABILIZATION; THREE OR FOUR DIGITS 35,100.00 18,720.00 16,380.00 26520 CAPSULECTOMY OR CAPSULOTOMY FOR CONTRACTURE; METACARPOPHALANGEAL JOINT, SINGLE, EACH 21,216.00 13,845.00 7,371.00 26525 CAPSULECTOMY OR CAPSULOTOMY FOR CONTRACTURE; INTERPHALANGEAL JOINT, SINGLE, EACH 10,974.60 3,658.20 7,316.40 26530 ARTHROPLASTY, METACARPOPHALANGEAL JOINT; SINGLE, EACH 9,336.60 3,112.20 6,224.40 26531 ARTHROPLASTY, METACARPOPHALANGEAL JOINT; W/ PROSTHETIC IMPLANT, SINGLE, EACH 15,639.00 10,725.00 4,914.00 26535 ARTHROPLASTY INTERPHALANGEAL JOINT, SINGLE, EACH 35,100.00 18,720.00 16,380.00 26536 ARTHROPLASTY INTERPHALANGEAL JOINT, W/ PROSTHETIC IMPLANT, SINGLE, EACH 40,911.00 21,255.00 19,656.00 26540 REPAIR OF COLLATERAL LIGAMENT, METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT 16,434.60 9,555.00 6,879.60 26541 RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE, W/ TENDON OR FASCIAL GRAFT (INCLUDES OBTAINIG GRAFT) 16,434.60 9,555.00 6,879.60 26542 RECONSTRUCTION, COLLATERAL LIGAMENT, METACARPOPHALANGEAL JOINT, SINGLE, W/ LOCAL TISSUE (E.G., ADDUCTOR ADVANCEMENT) 16,434.60 9,555.00 6,879.60 26545 RECONSTRUCTION, COLLATERAL LIGAMENT, INTERPHALANGEAL JOINT, SINGLE, INCLUDING GRAFT, EACH JOINT 21,216.00 13,845.00 7,371.00 Page 23 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 26546 REPAIR NON-UNION, METACARPAL OR PHALANX, (INCLUDES OBTAINING BONE GRAFT W/ OR W/O EXTERNAL OR INTERNAL FIXATION) 20,553.00 10,725.00 9,828.00 26548 REPAIR AND RECONSTRUCTION, FINGER, VOLAR PLATE, INTERPHALANGEAL JOINT 16,434.60 9,555.00 6,879.60 26550 POLLICIZATION OF A DIGIT 40,911.00 21,255.00 19,656.00 26551 TOE-TO-HAND TRANSFER W/ MICROVASCULAR ANASTMOSIS; GREAT TOE "WRAP-AROUND" W/ BONE GRAFT 59,085.00 26,325.00 32,760.00 26553 TOE-TO-HAND TRANSFER W/ MICROVASCULAR ANASTMOSIS; OTHER THAN GREAT TOE, SINGLE 59,943.00 33,735.00 26,208.00 26554 TOE-TO-HAND TRANSFER W/ MICROVASCULAR ANASTMOSIS; OTHER THAN GREAT TOE, DOUBLE 52,884.00 23,400.00 29,484.00 26555 POSITIONAL CHANGE OF OTHER FINGER 29,172.00 14,430.00 14,742.00 26556 FREE TOE JOINT TRANSFER W/ MICROVASCULAR ANASTOMOSIS 52,884.00 23,400.00 29,484.00 26560 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; W/ SKIN FLAPS 35,100.00 18,720.00 16,380.00 26561 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; W/ SKIN FLAPS AND GRAFTS 40,911.00 21,255.00 19,656.00 26562 REPAIR OF SYNDACTYLY (WEB FINGER) EACH WEB SPACE; COMPLEX (E.G., INVOLVING BONE, NAILS) 59,943.00 33,735.00 26,208.00 26565 OSTEOTOMY FOR CORRECTION OF DEFORMITY; METACARPAL 45,435.00 20,865.00 24,570.00 26567 OSTEOTOMY FOR CORRECTION OF DEFORMITY; PHALANX OF FINGER 45,435.00 20,865.00 24,570.00 26568 OSTEOPLASTY FOR LENGTHENING OF METACARPAL OR PHALANX 45,435.00 20,865.00 24,570.00 26580 REPAIR CLEFT HAND 40,911.00 21,255.00 19,656.00 26585 REPAIR BIFID DIGIT 40,911.00 21,255.00 19,656.00 26587 RECONSTRUCTION OF SUPERNUMERARY DIGIT, SOFT TISSUE AND BONE 45,435.00 20,865.00 24,570.00 26590 REPAIR MACRODACTYLIA 59,943.00 33,735.00 26,208.00 26591 REPAIR, INTRINSIC MUSCLES OF HAND (SPECIFY) 59,943.00 33,735.00 26,208.00 26593 RELEASE, INTRINSIC MUSCLES OF HAND (SPECIFY) 40,911.00 21,255.00 19,656.00 26596 EXCISION OF CONSTRICTING RING OF FINGER, W/ MULTIPLE Z- PLASTIES 42,549.00 21,255.00 21,294.00 26597 RELEASE OF SCAR CONTRACTURE, FLEXOR OR EXTENSOR, W/ SKIN GRAFTS, REARRANGEMENT FLAPS, OR Z-PLASTIES, HAND AND/OR FINGER 42,549.00 21,255.00 21,294.00 26600 CLOSED TREATMENT OF METACARPAL FRACTURE, SINGLE 19,734.00 10,725.00 9,009.00 26607 CLOSED TREATMENT OF METACARPAL FRACTURE, W/ INTERNAL OR EXTERNAL FIXATION 25,155.00 12,870.00 12,285.00 26608 PERCUTANEOUS SKELETAL FIXATION OF METACARPAL FRACTURE, EACH BONE 23,634.00 10,530.00 13,104.00 26615 OPEN TREATMENT OF METACARPAL FRACTURE, SINGLE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, EACH BONE 23,634.00 10,530.00 13,104.00 26641 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, THUMB 20,553.00 10,725.00 9,828.00 26645 CLOSED TRATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE) 23,634.00 10,530.00 13,104.00 26650 PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), W/ MANIPULATION, W/ OR W/O EXTERNAL FIXATION 29,172.00 14,430.00 14,742.00 26665 OPEN TREATMENT OF CARPOMETACARPAL FRACTURE DISLOCATION, THUMB (BENNETT FRACTURE), W/ OR W/O INTERNAL OR EXTERNAL FIXATION 29,172.00 14,430.00 14,742.00 26670 CLOSED TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB (BENNETT FRACTURE); SINGLE 20,553.00 10,725.00 9,828.00 26676 PERCUTANEOUS SKELETAL FIXATION OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB (BENNETT FRACTURE), SINGLE, W/ MANIPULATION 29,172.00 14,430.00 14,742.00 26685 OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB (BENNETT FRACTURE); SINGLE, W/ OR W/O OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB (BENNETT FRACTURE); SINGLE, INTERNAL OR EXTERNAL FIXATION 20,553.00 10,725.00 9,828.00 26686 OPEN TREATMENT OF CARPOMETACARPAL DISLOCATION, OTHER THAN THUMB (BENNETT FRACTURE); SINGLE, COMPLEX, MULTIPLE OR DELAYED REDUCTION 23,361.00 11,895.00 11,466.00 26700 CLOSED TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE 20,553.00 10,725.00 9,828.00 26706 PERCUTANEOUS SKELETAL FIXATION OF METACARPOPHALANGEAL DISLOCATION, SINGLE, W/ MANIPULATION 29,172.00 14,430.00 14,742.00 26715 OPEN TREATMENT OF METACARPOPHALANGEAL DISLOCATION, SINGLE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 24,453.00 10,530.00 13,923.00 26720 CLOSED TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB 19,734.00 10,725.00 9,009.00 26727 PERCUTANEOUS SKELETAL FIXATION OF UNSTABLE PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, W/ MANIPULATION, EACH 29,172.00 14,430.00 14,742.00 26735 OPEN TREATMENT OF PHALANGEAL SHAFT FRACTURE, PROXIMAL OR MIDDLE PHALANX, FINGER OR THUMB, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, EACH 29,172.00 14,430.00 14,742.00 Page 24 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 26740 CLOSED TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT 19,734.00 10,725.00 9,009.00 26746 OPEN TREATMENT OF ARTICULAR FRACTURE, INVOLVING METACARPOPHALANGEAL OR INTERPHALANGEAL JOINT, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, EACH 24,453.00 10,530.00 13,923.00 26750 CLOSED TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB 19,734.00 10,725.00 9,009.00 26756 PERCUTANEOUS SKELETAL FIXATION OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, EACH 29,172.00 14,430.00 14,742.00 26765 OPEN TREATMENT OF DISTAL PHALANGEAL FRACTURE, FINGER OR THUMB, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, EACH 23,634.00 10,530.00 13,104.00 26770 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE 21,216.00 13,845.00 7,371.00 26776 PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, SINGLE, W/ MANIPULATION 24,453.00 10,530.00 13,923.00 26785 OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, SINGLE 24,453.00 10,530.00 13,923.00 26820 FUSION IN OPPOSITION, THUMB, W/ AUTOGENOUS GRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 26841 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W/O INTERNAL FIXATION; 40,911.00 21,255.00 19,656.00 26842 ARTHRODESIS, CARPOMETACARPAL JOINT, THUMB, W/ OR W/O INTERNAL FIXATION; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 40,911.00 21,255.00 19,656.00 26843 ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER THAN THUMB; 42,783.00 24,765.00 18,018.00 26844 ARTHRODESIS, CARPOMETACARPAL JOINT, DIGITS, OTHER THAN THUMB; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 40,911.00 21,255.00 19,656.00 26850 ARTHRODESIS, METACARPOPHALANGEAL JOINT, W/ OR W/O INTERNAL FIXATION; 40,911.00 21,255.00 19,656.00 26852 ARTHRODESIS, METACARPOPHALANGEAL JOINT, W/ OR W/O INTERNAL FIXATION; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 26860 ARTHRODESIS, INTERPHALANGEAL JOINT, W/ OR W/O INTERNAL FIXATION; 40,911.00 21,255.00 19,656.00 26862 ARTHRODESIS, INTERPHALANGEAL JOINT, W/ OR W/O INTERNAL FIXATION; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 26910 AMPUTATION, METACARPAL, W/ FINGER OR THUMB (RAY AMPUTATION), SINGLE, W/ OR W/O INTEROSSEOUS TRANSFER 23,634.00 10,530.00 13,104.00 26951 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; W/ DIRECT CLOSURE 23,361.00 11,895.00 11,466.00 26952 AMPUTATION, FINGER OR THUMB, PRIMARY OR SECONDARY, ANY JOINT OR PHALANX, SINGLE, INCLUDING NEURECTOMIES; W/ LOCAL ADVANCEMENT FLAPS (V-Y, HOOD) 42,783.00 24,765.00 18,018.00 26990 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; DEEP ABSCESS OR HEMATOMA 23,634.00 10,530.00 13,104.00 26991 INCISION AND DRAINAGE, PELVIS OR HIP JOINT AREA; INFECTED BURSA 23,634.00 10,530.00 13,104.00 26992 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), PELVIS AND/OR HIP JOINT 45,435.00 20,865.00 24,570.00 27000 TENOTOMY, ADDUCTOR OF HIP, SUBCUTANEOUS, CLOSED 23,634.00 10,530.00 13,104.00 27001 TENOTOMY, ADDUCTOR OF HIP, SUBCUTANEOUS, OPEN 29,172.00 14,430.00 14,742.00 27003 TENOTOMY, ADDUCTOR, SUBCUTANEOUS, OPEN, W/ OBTURATOR NEURECTOMY 59,943.00 33,735.00 26,208.00 27005 TENOTOMY, ILIOPSOAS, OPEN 45,435.00 20,865.00 24,570.00 27006 TENOTOMY, ABDUCTORS OF HIP, OPEN 45,435.00 20,865.00 24,570.00 27025 FASCIOTOMY, HIP OR THIGH, ANY TYPE 42,549.00 21,255.00 21,294.00 27030 ARTHROTOMY, HIP, FOR INFECTION, W/ DRAINAGE 59,943.00 33,735.00 26,208.00 27033 ARTHROTOMY, HIP, W/ EXPLORATION OR REMOVAL OF LOOSE OR FOREIGN BODY 59,943.00 33,735.00 26,208.00 27035 HIP JOINT DENERVATION, INTRAPELVIC OR EXTRAPELVIC INTRA- ARTICULAR BRANCHES OF SCIATIC, FEMORAL, OR OBTURATOR NERVES 59,085.00 26,325.00 32,760.00 27036 CAPSULECTOMY OR CAPSULOTOMY OF HIP, W/ OR W/O EXCISION OF HETEROTOPIC BONE, W/ RELEASE OF HIP FLEXOR MUSCLES (IE, GLUTEUS MEDIUS, GLUTEUS MINIMUS, TENSOR FASCIA LATAE, RECTUS FEMORIS, SARTORIUS, ILIOPSOAS) 73,710.00 32,760.00 40,950.00 27040 BIOPSY, SOFT TISSUE OF PELVIS AND HIP AREA 6,832.80 5,850.00 982.80 27047 EXCISION, TUMOR, PELVIS AND HIP AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 27048 EXCISION, TUMOR, PELVIS AND HIP AREA; DEEP, SUBFASCIAL, INTRAMUSCULAR 16,107.00 9,555.00 6,552.00 27049 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF PELVIS AND HIP AREA 73,710.00 32,760.00 40,950.00 27050 ARTHROTOMY, W/ BIOPSY; SACROILIAC JOINT 54,522.00 23,400.00 31,122.00 27052 ARTHROTOMY, W/ BIOPSY; HIP JOINT 72,501.00 36,465.00 36,036.00 27054 ARTHROTOMY W/ SYNOVECTOMY, HIP JOINT 60,723.00 26,325.00 34,398.00 27060 EXCISION; ISCHIAL BURSA 52,884.00 23,400.00 29,484.00 27062 EXCISION; TROCHANTERIC BURSA OR CALCIFICATION 52,884.00 23,400.00 29,484.00 Page 25 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27065 EXCISION OF BONE CYST OR BENIGN TUMOR; SUPERFICIAL (WING OF ILIUM, SYMPHYSIS PUBIS, OR GREATER TROCHANTER OF FEMUR) W/ OR W/O AUTOGRAFT 54,522.00 23,400.00 31,122.00 27066 EXCISION OF BONE CYST OR BENIGN TUMOR; DEEP, W/ OR W/O AUTOGRAFT 59,085.00 26,325.00 32,760.00 27067 EXCISION OF BONE CYST OR BENIGN TUMOR; W/ AUTOGRAFT REQUIRING SEPARATE INCISION 60,723.00 26,325.00 34,398.00 27070 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (E.G., FOR OSTEOMYELITIS); SUPERFICIAL (E.G., WING OF ILIUM, SYMPHYSIS PUBIS OR GREATER TROCHANTER OF FEMUR) 90,675.00 41,535.00 49,140.00 27071 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION) (E.G., FOR OSTEOMYELITIS); DEEP 90,675.00 41,535.00 49,140.00 27075 RADICAL RESECTION OF TUMOR OR INFECTION; WING OF ILIUM, ONE PUBIC OR ISCHIAL RAMUS OR SYMPHYSIS PUBIS 75,777.00 36,465.00 39,312.00 27076 RADICAL RESECTION OF TUMOR OR INFECTION; ILIUM, INCLUDING ACETABULUM, BOTH PUBIC RAMI, OR ISCHIUM AND ACETABULUM 75,777.00 36,465.00 39,312.00 27077 RADICAL RESECTION OF TUMOR OR INFECTION; INNOMINATE BONE, TOTAL 72,501.00 36,465.00 36,036.00 27078 RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY AND GREATER TROCHANTER OF FEMUR 60,723.00 26,325.00 34,398.00 27079 RADICAL RESECTION OF TUMOR OR INFECTION; ISCHIAL TUBEROSITY AND GREATER TROCHANTER OF FEMUR, W/ SKIN FLAPS 61,542.00 26,325.00 35,217.00 27080 COCCYGECTOMY, PRIMARY 29,991.00 14,430.00 15,561.00 27086 REMOVAL OF FOREIGN BODY, PELVIS OR HIP 29,172.00 14,430.00 14,742.00 27090 REMOVAL OF HIP PROSTHESIS; 59,085.00 26,325.00 32,760.00 27091 REMOVAL OF HIP PROSTHESIS; COMPLICATED, INCLUDING "TOTAL HIP" AND METHLMETHACRYLATE, WHEN APPLICABLE 74,139.00 36,465.00 37,674.00 27097 HAMSTRING RECESSION, PROXIMAL 44,187.00 21,255.00 22,932.00 27098 ADDUCTOR TRANSFER TO ISCHIUM 45,435.00 20,865.00 24,570.00 27100 TRANSFER EXTERNAL OBLIQUE MUSCLE TO GREATER TROCHANTER INCLUDING FASCIAL OR TENDON EXTENSION (GRAFT) 59,943.00 33,735.00 26,208.00 27105 TRANSFER PARASPINAL MUSCLE TO HIP (INCLUDES FASCIAL OR TENDON EXTENSION GRAFT) 59,943.00 33,735.00 26,208.00 27110 TRANSFER ILIOPSOAS; TO GREATER TROCHANTER 59,943.00 33,735.00 26,208.00 27111 TRANSFER ILIOPSOAS; TO FEMORAL NECK 59,943.00 33,735.00 26,208.00 27120 ACETABULOPLASTY; (E.G., WHITMAN, COLONNA, HAYGROVES, OR CUP TYPE) 72,501.00 36,465.00 36,036.00 27122 ACETABULOPLASTY; RESECTION FEMORAL HEAD (GIRDLESTONE PROCEDURE) 72,501.00 36,465.00 36,036.00 27125 PARTIAL HIP REPLACEMENT, PROSTHESIS (E.G., FEMORAL STEM PROSTHESIS, BIPOLAR ARTHROPLASTY) 72,501.00 36,465.00 36,036.00 27130 ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP REPLACEMENT), W/ OR W/O AUTOGRAFT OR ALLOGRAFT 104,130.00 46,800.00 57,330.00 27132 CONVERSION OF PREVIOUS HIP SURGERY TO TOTAL HIP REPLACEMENT, W/ OR W/O AUTOGRAFT OR ALLOGRAFT 107,406.00 46,800.00 60,606.00 27134 REVISION OF TOTAL HIP ARTHROPLASTY; BOTH COMPONENTS, W/ OR W/O AUTOGRAFT OR ALLOGRAFT 107,250.00 41,730.00 65,520.00 27137 REVISION OF TOTAL HIP ARTHROPLASTY; ACETABULAR COMPONENT ONLY, W/ OR W/O AUTOGRAFT OR ALLOGRAFT 75,348.00 32,760.00 42,588.00 27138 REVISION OF TOTAL HIP ARTHROPLASTY; FEMORAL COMPONENT ONLY, W/ OR W/O ALLOGRAFT 75,348.00 32,760.00 42,588.00 27140 OSTEOTOMY AND TRANSFER OF GREATER TROCHANTER 54,522.00 23,400.00 31,122.00 27146 OSTEOTOMY , ILIAC, ACETABULAR OR INNOMINATE BONE; 59,085.00 26,325.00 32,760.00 27147 OSTEOTOMY , ILIAC, ACETABULAR OR INNOMINATE BONE; W/ OPEN REDUCTION OF HIP 60,723.00 26,325.00 34,398.00 27151 OSTEOTOMY , ILIAC, ACETABULAR OR INNOMINATE BONE; W/ FEMORAL OSTEOTOMY 72,501.00 36,465.00 36,036.00 27156 OSTEOTOMY , ILIAC, ACETABULAR OR INNOMINATE BONE; W/ FEMORAL OSTEOTOMY AND W/ OPEN REDUCTION OF HIP 74,139.00 36,465.00 37,674.00 27158 OSTEOTOMY, PELVIS, BILATERAL (E.G., FOR CONGENITAL MALFORMATION) 73,710.00 32,760.00 40,950.00 27161 OSTEOTOMY, FEMORAL NECK 60,723.00 26,325.00 34,398.00 27165 OSTEOTOMY, INTERTROCHANTERIC OR SUBTROCHANTERIC INCLUDING INTERNAL OR EXTERNAL FIXATION AND/OR CAST 72,501.00 36,465.00 36,036.00 27170 BONE GRAFT, FEMORAL HEAD, NECK, INTERTROCHANTERIC OR SUBTROCHANTERIC AREA (INCLUDES OBTAINING BONE GRAFT) 60,723.00 26,325.00 34,398.00 27175 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY TRACTION, W/O REDUCTION 45,435.00 20,865.00 24,570.00 27176 TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; BY SINGLE OR MULTIPLE PINNING, IN SITU 59,085.00 26,325.00 32,760.00 27177 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; SINGLE OF MULTIPLE PINNING OR BONE GRAFT (INCLUDES OBTAINING GRAFT) 60,723.00 26,325.00 34,398.00 27178 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; CLOSED MANIPULATION W/ SINGLE OR MULTIPLE PINNING 60,723.00 26,325.00 34,398.00 Page 26 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27179 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOPLASTY OF FEMORAL NECK (HEYMAN TYPE PROCEDURE) 60,723.00 26,325.00 34,398.00 27181 OPEN TREATMENT OF SLIPPED FEMORAL EPIPHYSIS; OSTEOTOMY AND INTERNAL FIXATION 72,501.00 36,465.00 36,036.00 27185 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, GREATER TROCHANTER 54,522.00 23,400.00 31,122.00 27187 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING, OR WIRING) W/ OR W/O METHYLMETHACRYLATE, FEMORAL NECK AND PROXIMAL FEMUR 60,723.00 26,325.00 34,398.00 27193 CLOSED TREATMENT OF PELVIC RING FRACTURE, DISLOCATION, DIASTASIS OR SUBLUXATION 54,522.00 23,400.00 31,122.00 27200 CLOSED TREATMENT OF COCCYGEAL FRACTURE 29,172.00 14,430.00 14,742.00 27202 OPEN TREATMENT OF COCCYGEAL FRACTURE 44,187.00 21,255.00 22,932.00 27215 OPEN TREATMENT OF ILIAC SPINE(S), TUBEROSITY AVULSION, OR ILIAC WING FRACTURE(S) (E.G., PELVIC FRACTURE(S) W/C DO NOT DISRUPT THE PELVIC RING), W/ INTERNAL FIXATION 73,710.00 32,760.00 40,950.00 27216 PERCUTANEOUS SKELETAL FIXATION OF POSTERIOR PELVIC RING FRACTURE AND/OR DISLOCATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) 78,624.00 32,760.00 45,864.00 27217 OPEN TREATMENT OF ANTERIOR RING FRACTURE AND/OR DISLOCATION W/ INTERNAL FIXATION (INCLUDES PUBIC SYMPHYSIS AND/OR RAMI) 90,675.00 41,535.00 49,140.00 27218 OPEN TREATMENT OF POSTERIOR RING FRACTURE AND/OR DISLOCATION W/ INTERNAL FIXATION (INCLUDES ILIUM, SACROILIAC JOINT AND/OR SACRUM) 90,675.00 41,535.00 49,140.00 27220 CLOSED TREATMENT OF ACETABULUM (HIP SOCKET) FRACTURE(S) 59,943.00 33,735.00 26,208.00 27226 OPEN TREATMENT OF POSTERIOR OR ANTERIOR ACETABULAR WALL FRACTURE, W/ INTERNAL FIXATION 75,348.00 32,760.00 42,588.00 27227 OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR OR POSTERIOR (ONE) COLUMN, OR A FRACTURE RUNNING TRANSVERSELY ACROSS THE ACETABULUM, W/ INTERNAL FIXATION 78,624.00 32,760.00 45,864.00 27228 OPEN TREATMENT OF ACETABULAR FRACTURE(S) INVOLVING ANTERIOR AND POSTERIOR (TWO) COLUMNS, INCLUDES T- FRACTURE AND BOTH COLUMN FRACTURE W/ COMPLETE ARTICULAR DETACHMENT, OR SINGLE COLUMN OR TRANSVERSE FRACTURE W/ ASSOCIATED ACETABULAR WALL FRACTURE, W/ INTE 90,675.00 41,535.00 49,140.00 27230 CLOSED TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK 45,435.00 20,865.00 24,570.00 27235 PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, PROXIMAL END, NECK, UNDISPLACED, MILDLY DISPLACED, OR IMPACTED FRACTURE 90,675.00 41,535.00 49,140.00 27236 OPEN TREATMENT OF FEMORAL FRACTURE, PROXIMAL END, NECK, INTERNAL FIXATION OR PROSTHETIC REPLACEMENT (DIRECT FRACTURE EXPOSURE) 90,675.00 41,535.00 49,140.00 27238 CLOSED TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE 45,435.00 20,865.00 24,570.00 27244 OPEN TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; W/ PLATE/SCREW TYPE IMPLANT, W/ OR W/O CERCLAGE 90,675.00 41,535.00 49,140.00 27245 OPEN TREATMENT OF INTERTROCHANTERIC, PERTROCHANTERIC, OR SUBTROCHANTERIC FEMORAL FRACTURE; W/ INTRAMEDULLARY IMPLANT, W/ OR W/O INTERLOCKING SCREWS AND/OR CERCLAGE 60,723.00 26,325.00 34,398.00 27246 CLOSED TREATMENT OF GREATER TROCHANTERIC FRACTURE 45,435.00 20,865.00 24,570.00 27248 OPEN TREATMENT OF GREATER TROCHANTERIC FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 52,884.00 23,400.00 29,484.00 27250 CLOSED TREATMENT OF HIP DISLOCATION, TRAUMATIC 45,435.00 20,865.00 24,570.00 27253 OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC, W/O INTERNAL FIXATION 72,501.00 36,465.00 36,036.00 27254 OPEN TREATMENT OF HIP DISLOCATION, TRAUMATIC W/ ACETABULAR WALL AND FEMORAL HEAD FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 78,624.00 32,760.00 45,864.00 27258 OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUDING TENOTOMY, ETC); 59,085.00 26,325.00 32,760.00 27259 OPEN TREATMENT OF SPONTANEOUS HIP DISLOCATION (DEVELOPMENTAL, INCLUDING CONGENITAL OR PATHOLOGICAL), REPLACEMENT OF FEMORAL HEAD IN ACETABULUM (INCLUDING TENOTOMY, ETC); W/ FEMORAL SHAFT SHORTENING 72,501.00 36,465.00 36,036.00 27265 CLOSED TREATMENT OF POST HIP ARTHROPLASTY DISLOCATION 35,100.00 18,720.00 16,380.00 27280 ARTHRODESIS, SACROILIAC JOINT (INCLUDING OBTAINING GRAFT) 73,710.00 32,760.00 40,950.00 27282 ARTHRODESIS, SYMPHYSIS PUBIS (INCLUDING OBTAINING GRAFT) 54,522.00 23,400.00 31,122.00 27284 ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT); 73,710.00 32,760.00 40,950.00 27286 ARTHRODESIS, HIP JOINT (INCLUDES OBTAINING GRAFT); W/ SUBTROCHANTERIC OSTEOTOMY 78,624.00 32,760.00 45,864.00 Page 27 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27290 INTERPELVIABDOMINAL AMPUTATION (HINDQUARTER AMPUTATION) 90,675.00 41,535.00 49,140.00 27295 DISARTICULATION OF HIP 59,085.00 26,325.00 32,760.00 27301 INCISION AND DRAINAGE OF DEEP ABSCESS, INFECTED BURSA, OR HEMATOMA, THIGH OR KNEE REGION 16,107.00 9,555.00 6,552.00 27303 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), FEMUR OR KNEE 45,435.00 20,865.00 24,570.00 27305 FASCIOTOMY, ILIOTIBIAL (TENOTOMY), OPEN 35,100.00 18,720.00 16,380.00 27306 TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTRING; SINGLE 35,100.00 18,720.00 16,380.00 27307 TENOTOMY, SUBCUTANEOUS, CLOSED, ADDUCTOR OR HAMSTRING; MULTIPLE 42,549.00 21,255.00 21,294.00 27310 ARTHROTOMY, KNEE, FOR INFECTION, W/ EXPLORATION, DRAINAGE OR REMOVAL OF FOREIGN BODY 52,884.00 23,400.00 29,484.00 27315 NEURECTOMY, HAMSTRING MUSCLE 45,435.00 20,865.00 24,570.00 27320 NEURECTOMY, POPLITEAL (GASTROCNEMIUS) 45,435.00 20,865.00 24,570.00 27323 BIOPSY, SOFT TISSUE OF THIGH OR KNEE AREA 6,832.80 5,850.00 982.80 27327 EXCISION, TUMOR, THIGH OR KNEE AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 27328 EXCISION, TUMOR, THIGH OR KNEE AREA; DEEP, SUBFASCIAL, OR INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 27329 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF THIGH OR KNEE AREA 52,884.00 23,400.00 29,484.00 27330 ARTHROTOMY, KNEE; W/ SYNOVIAL BIOPSY ONLY 40,911.00 21,255.00 19,656.00 27331 ARTHROTOMY, KNEE; W/ JOINT EXPLORATION, W/ OR W/O BIOPSY, W/ OR W/O REMOVAL OF LOOSE OR FOREIGN BODIES 45,435.00 20,865.00 24,570.00 27332 ARTHROTOMY, KNEE, W/ EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY); MEDIAL OR LATERAL 61,581.00 33,735.00 27,846.00 27333 ARTHROTOMY, KNEE, W/ EXCISION OF SEMILUNAR CARTILAGE (MENISCECTOMY); MEDIAL AND LATERAL 54,522.00 23,400.00 31,122.00 27334 ARTHROTOMY, KNEE, W/ SYNOVECTOMY; ANTERIOR OR POSTERIOR 25,646.40 12,870.00 12,776.40 27335 ARTHROTOMY, KNEE, W/ SYNOVECTOMY; ANTERIOR AND POSTERIOR INCLUDING POPLITEAL AREA 45,435.00 20,865.00 24,570.00 27340 EXCISION, PREPATELLAR BURSA 29,172.00 14,430.00 14,742.00 27345 EXCISION OF SYNOVIAL CYST OF POPLITEAL SPACE (BAKERS CYST) 40,911.00 21,255.00 19,656.00 27350 PATELLECTOMY OR HEMIPATELLECTOMY 59,943.00 33,735.00 26,208.00 27355 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; 43,368.00 21,255.00 22,113.00 27356 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; W/ ALLOGRAFT 46,254.00 20,865.00 25,389.00 27357 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT) 46,254.00 20,865.00 25,389.00 27358 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR OF FEMUR; W/ INTERNAL FIXATION 52,884.00 23,400.00 29,484.00 27360 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS), FEMUR, PROXIMAL TIBIA AND/OR FIBULA 46,254.00 20,865.00 25,389.00 27365 RADICAL RESECTION OF TUMOR, BONE, FEMUR OR KNEE 52,884.00 23,400.00 29,484.00 27372 REMOVAL OF FOREIGN BODY, DEEP, THIGH REGION OR KNEE AREA 35,100.00 18,720.00 16,380.00 27380 SUTURE OF INFRAPATELLAR TENDON; PRIMARY 45,435.00 20,865.00 24,570.00 27381 SUTURE OF INFRAPATELLAR TENDON; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT 52,884.00 23,400.00 29,484.00 27385 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; PRIMARY 62,400.00 33,735.00 28,665.00 27386 SUTURE OF QUADRICEPS OR HAMSTRING MUSCLE RUPTURE; SECONDARY RECONSTRUCTION, INCLUDING FASCIAL OR TENDON GRAFT 52,884.00 23,400.00 29,484.00 27390 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; SINGLE 35,100.00 18,720.00 16,380.00 27391 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE, ONE LEG 42,783.00 24,765.00 18,018.00 27392 TENOTOMY, OPEN, HAMSTRING, KNEE TO HIP; MULTIPLE, BILATERAL 40,911.00 21,255.00 19,656.00 27393 LENGTHENING OF HAMSTRING TENDON; SINGLE 45,435.00 20,865.00 24,570.00 27394 LENGTHENING OF HAMSTRING TENDON; MULTIPLE, ONE LEG 42,783.00 24,765.00 18,018.00 27395 LENGTHENING OF HAMSTRING TENDON; MULTIPLE, BILATERAL 40,911.00 21,255.00 19,656.00 27396 TRANSPLANT, HAMSTRING TENDON TO PATELLA; SINGLE 45,435.00 20,865.00 24,570.00 27397 TRANSPLANT, HAMSTRING TENDON TO PATELLA; MULTIPLE 43,602.00 24,765.00 18,837.00 27400 TENDON OR MUSCLE TRANSFER, HAMSTRINGS TO FEMUR (E.G.GERS TYPE PROCEDURE) 45,435.00 20,865.00 24,570.00 27403 ARTHROTOMY W/ OPEN MENISCUS REPAIR 54,522.00 23,400.00 31,122.00 27405 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL 52,884.00 23,400.00 29,484.00 27407 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; CRUCIATE 59,085.00 26,325.00 32,760.00 27409 REPAIR, PRIMARY, TORN LIGAMENT AND/OR CAPSULE, KNEE; COLLATERAL AND CRUCIATE LIGAMENTS 73,710.00 32,760.00 40,950.00 27418 ANTERIOR TIBIAL TUBERCLEPLASTY (E.G., FOR CHONDROMALACIA PATELLAE) 44,187.00 21,255.00 22,932.00 27420 RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA; (HAUSER TYPE PROCEDURE) 45,006.00 21,255.00 23,751.00 Page 28 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27422 RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA; W/ EXTENSOR REALIGNMENT AND/OR MUSCLE ADVANCEMENT OR RELEASE (CAMPBELL, GOLDWAITE TYPE PROCEDURE) 59,943.00 33,735.00 26,208.00 27424 RECONSTRUCTION FOR RECURRENT DISLOCATING PATELLA; W/ PATELLECTOMY 59,943.00 33,735.00 26,208.00 27425 LATERAL RETINACULAR RELEASE (ANY METHOD) 42,549.00 21,255.00 21,294.00 27427 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; EXTRA-ARTICULAR 59,085.00 26,325.00 32,760.00 27428 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR (OPEN) 60,723.00 26,325.00 34,398.00 27429 LIGAMENTOUS RECONSTRUCTION (AUGMENTATION), KNEE; INTRA-ARTICULAR (OPEN) AND EXTRA-ARTICULAR 72,501.00 36,465.00 36,036.00 27430 QUADRICEPSPLASTY (BENNETT OR THOMPSON TYPE) 52,884.00 23,400.00 29,484.00 27435 CAPSULOTOMY, KNEE, POSTERIOR CAPSULAR RELEASE 59,943.00 33,735.00 26,208.00 27437 ARTHROPLASTY, PATELLA; W/O PROSTHESIS 59,943.00 33,735.00 26,208.00 27438 ARTHROPLASTY, PATELLA; W/ PROSTHESIS 60,723.00 26,325.00 34,398.00 27440 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; 73,710.00 32,760.00 40,950.00 27441 ARTHROPLASTY, KNEE, TIBIAL PLATEAU; W/ DEBRIDEMENT AND PARTIAL SYNOVECTOMY 75,348.00 32,760.00 42,588.00 27442 ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLATEAUS; 75,348.00 32,760.00 42,588.00 27443 ARTHROPLASTY, KNEE, FEMORAL CONDYLES OR TIBIAL PLATEAUS; W/ DEBRIDEMENT AND PARTIAL SYNOVECTOMY 76,986.00 32,760.00 44,226.00 27445 ARTHROPLASTY, KNEE, CONSTRAINED PROSTHESIS (E.G., WALLDIUS TYPE) 90,675.00 41,535.00 49,140.00 27446 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL OR LATERAL COMPARTMENT 76,986.00 32,760.00 44,226.00 27447 ARTHROPLASTY, KNEE, CONDYLE AND PLATEAU; MEDIAL AND LATERAL COMPARTMENTS W/ OR W/O PATELLA RESURFACING ("TOTAL KNEE REPLACEMENT") 78,624.00 32,760.00 45,864.00 27448 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; W/O FIXATION 35,919.00 18,720.00 17,199.00 27450 OSTEOTOMY, FEMUR, SHAFT OR SUPRACONDYLAR; W/ FIXATION 45,435.00 20,865.00 24,570.00 27454 OSTEOTOMY, MULTIPLE, FEMORAL SHAFT, W/ REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE PROCEDURE) 52,884.00 23,400.00 29,484.00 27455 OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); BEFORE EPIPHYSEAL CLOSURE 52,884.00 23,400.00 29,484.00 27457 OSTEOTOMY, PROXIMAL TIBIA, INCLUDING FIBULAR EXCISION OR OSTEOTOMY (INCLUDES CORRECTION OF GENU VARUS (BOWLEG) OR GENU VALGUS (KNOCK-KNEE)); AFTER EPIPHYSEAL CLOSURE 52,884.00 23,400.00 29,484.00 27465 OSTEOPLASTY, FEMUR; SHORTENING (EXCLUDING 64876) 52,884.00 23,400.00 29,484.00 27466 OSTEOPLASTY, FEMUR; LENGTHENING 52,884.00 23,400.00 29,484.00 27468 OSTEOPLASTY, FEMUR; COMBINED, LENGTHENING AND SHORTENING W/ FEMORAL SEGMENT TRANSFER 72,501.00 36,465.00 36,036.00 27470 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; W/O GRAFT (E.G., COMPRESSION TECHNIQUE) 61,581.00 33,735.00 27,846.00 27472 REPAIR, NONUNION OR MALUNION, FEMUR, DISTAL TO HEAD AND NECK; W/ ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) 54,522.00 23,400.00 31,122.00 27475 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL FEMUR 59,943.00 33,735.00 26,208.00 27477 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; TIBIA AND FIBULA, PROXIMAL 45,435.00 20,865.00 24,570.00 27479 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; COMBINED DISTAL FEMUR, PROXIMAL TIBIA AND FIBULA 52,884.00 23,400.00 29,484.00 27485 ARREST, HEMIEPIPHYSEAL, DISTAL FEMUR OR PROXIMAL LEG (E.G., FOR GENU VARUS OR VALGUS) 59,943.00 33,735.00 26,208.00 27486 REVISION OF TOTAL KNEE ARTHROPLASTY, W/ OR W/O ALLOGRAFT; ONE COMPONENT 104,130.00 46,800.00 57,330.00 27487 REVISION OF TOTAL KNEE ARTHROPLASTY, W/ OR W/O ALLOGRAFT; ALL COMPONENTS 107,250.00 41,730.00 65,520.00 27488 REMOVAL OF KNEE PROSTHESIS, INCLUDING "TOTAL KNEE" METHYLMETHACRYLATE AND INSERTION OF SPACER, WHEN APPLICABLE 72,501.00 36,465.00 36,036.00 27495 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WRITING) W/ OR W/O METHYLMETHACRYLATE, FEMUR 59,943.00 33,735.00 26,208.00 27496 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); 40,911.00 21,255.00 19,656.00 27497 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, ONE COMPARTMENT (FLEXOR OR EXTENSOR OR ADDUCTOR); W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 42,549.00 21,255.00 21,294.00 27498 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE COMPARTMENTS; 42,549.00 21,255.00 21,294.00 27499 DECOMPRESSION FASCIOTOMY, THIGH AND/OR KNEE, MULTIPLE COMPARTMENTS; W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 45,435.00 20,865.00 24,570.00 27501 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE W/ OR W/O INTERCONDYLAR EXTENSION 29,172.00 14,430.00 14,742.00 27502 CLOSED TREATMENT OF FEMORAL SHAFT FRACTURE, W/ OR W/O SKIN OR SKELETAL TRACTION 35,919.00 18,720.00 17,199.00 Page 29 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27503 CLOSED TREATMENT OF SUPRACONDYLAR OR TRANSCONDYLAR FEMORAL FRACTURE W/ OR W/O INTERCONDYLAR EXTENSION, W/ OR W/O SKIN OR SKELETAL TRACTION 35,919.00 18,720.00 17,199.00 27506 OPEN TREATMENT OF FEMORAL SHAFT FRACTURE, W/ OR W/O EXTERNAL FIXATION, W/ INSERTION OF INTRAMEDULLARY IMPLANT, W/ OR W/O CERCLAGE AND/OR LOCKING SCREWS 59,943.00 33,735.00 26,208.00 27507 OPEN TREATMENT OF FEMORAL SHAFT FRACTURE W/ PLATE/SCREWS, W/ OR W/O CERCLAGE 59,943.00 33,735.00 26,208.00 27509 PERCUTANEOUS SKELETAL FIXATION OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, OR SUPRACONDYLAR OR TRANSCONDYLAR, W/ OR W/O INTERCONDYLAR EXTENSION, OR DISTAL FEMORAL EPIPHYSEAL SEPARATION 72,501.00 36,465.00 36,036.00 27510 CLOSED TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE 35,919.00 18,720.00 17,199.00 27511 OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE W/O INTERCONDYLAR EXTENSION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 72,501.00 36,465.00 36,036.00 27513 OPEN TREATMENT OF FEMORAL SUPRACONDYLAR OR TRANSCONDYLAR FRACTURE W/ INTERCONDYLAR EXTENSION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 73,710.00 32,760.00 40,950.00 27514 OPEN TREATMENT OF FEMORAL FRACTURE, DISTAL END, MEDIAL OR LATERAL CONDYLE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 59,943.00 33,735.00 26,208.00 27516 CLOSED TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION 45,435.00 20,865.00 24,570.00 27519 OPEN TREATMENT OF DISTAL FEMORAL EPIPHYSEAL SEPARATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 44,187.00 21,255.00 22,932.00 27520 CLOSED TREATMENT OF PATELLAR FRACTURE 40,911.00 21,255.00 19,656.00 27524 OPEN TREATMENT OF PATELLAR FRACTURE, W/ INTERNAL FIXATION AND/OR PARTIAL OR COMPLETE PATELLECTOMY AND SOFT TISSUE REPAIR 40,911.00 21,255.00 19,656.00 27530 CLOSED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU) 35,919.00 18,720.00 17,199.00 27535 OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 59,943.00 33,735.00 26,208.00 27536 OPEN TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, W/ OR W/O INTERNAL FIXATION 52,884.00 23,400.00 29,484.00 27538 CLOSED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF KNEE 20,553.00 10,725.00 9,828.00 27540 OPEN TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 42,549.00 21,255.00 21,294.00 27550 CLOSED TREATMENT OF KNEE DISLOCATION 20,553.00 10,725.00 9,828.00 27556 OPEN TREATMENT OF KNEE DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/O PRIMARY LIGAMENTOUS REPAIR OR AUGMENTATION/RECONSTRUCTION 52,884.00 23,400.00 29,484.00 27557 OPEN TREATMENT OF KNEE DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/ PRIMARY LIGAMENTOUS REPAIR 54,522.00 23,400.00 31,122.00 27558 OPEN TREATMENT OF KNEE DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/ PRIMARY LIGAMENTOUS REPAIR, W/ AUGMENTATION/RECONSTRUCTION 73,710.00 32,760.00 40,950.00 27560 CLOSED TREATMENT OF PATELLAR DISLOCATION 40,911.00 21,255.00 19,656.00 27566 OPEN TREATMENT OF PATELLAR DISLOCATION, W/ OR W/O PARTIAL OR TOTAL PATELLECTOMY 52,884.00 23,400.00 29,484.00 27580 FUSION OF KNEE, ANY TECHNIQUE 59,943.00 33,735.00 26,208.00 27590 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; 59,085.00 26,325.00 32,760.00 27591 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; IMMEDIATE FITTING TECHNIQUE INCLUDING FIRST CAST 45,435.00 20,865.00 24,570.00 27592 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; OPEN, CIRCULAR (GUILLOTINE) 45,435.00 20,865.00 24,570.00 27594 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; SECONDARY CLOSURE OR SCAR REVISION 23,361.00 11,895.00 11,466.00 27596 AMPUTATION, THIGH, THROUGH FEMUR, ANY LEVEL; RE- AMPUTAION 44,187.00 21,255.00 22,932.00 27598 DISARTICULATION AT KNEE 52,884.00 23,400.00 29,484.00 27600 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL COMPARTMENTS ONLY 15,639.00 10,725.00 4,914.00 27601 DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENTS(S) ONLY 15,639.00 10,725.00 4,914.00 27602 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S) 16,107.00 9,555.00 6,552.00 27603 INCISION AND DRAINAGE, LEG OR ANKLE; DEEP ABSCESS OR HEMATOMA 8,010.60 6,045.00 1,965.60 27604 INCISION AND DRAINAGE, LEG OR ANKLE; INFECTED BURSA 11,076.00 7,800.00 3,276.00 27605 TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS ; LOCAL ANESTHESIA; 24,453.00 10,530.00 13,923.00 27606 TENOTOMY, ACHILLES TENDON, SUBCUTANEOUS ; LOCAL ANESTHESIA; GENERAL ANESTHESIA 35,919.00 18,720.00 17,199.00 Page 30 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27607 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G., FOR OSTEOMYELITIS OR BONE ABSCESS), LEG OR ANKLE 40,911.00 21,255.00 19,656.00 27610 ARTHROTOMY, ANKLE, FOR INFECTION, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF FOREIGN BODY 42,783.00 24,765.00 18,018.00 27612 ARTHROTOMY, ANKLE, POSTERIOR CAPSULAR RELEASE, W/ OR W/O ACHILLES TENDON LENGTHENING 44,187.00 21,255.00 22,932.00 27613 BIOPSY, SOFT TISSUE OF LEG OR ANKLE AREA 6,832.80 5,850.00 982.80 27615 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF LEG OR ANKLE AREA 40,911.00 21,255.00 19,656.00 27618 EXCISION, TUMOR, LEG OR ANKLE AREA; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 27619 EXCISION, TUMOR, LEG OR ANKLE AREA; DEEP, SUBFASCIAL OR INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 27620 ARTHROTOMY, ANKLE, W/ JOINT EXPLORATION, W/ OR W/O BIOPSY, W/ OR W/O REMOVAL OF LOOSE OR FOREIGN BODY 25,155.00 12,870.00 12,285.00 27625 ARTHROTOMY, ANKLE, W/ SYNOVECTOMY; 35,919.00 18,720.00 17,199.00 27626 ARTHROTOMY, ANKLE, W/ SYNOVECTOMY; INCLUDING TENOSYNOVECTOMY 42,783.00 24,765.00 18,018.00 27630 EXCISION OF LESION OF TENDON SHEATH OR CAPSULE (E.G., CYST OR GANGLION), LEG AND/OR ANKLE 11,076.00 7,800.00 3,276.00 27635 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; 29,172.00 14,430.00 14,742.00 27637 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; W/ AUTOGRAFT(INCLUDES OBTAINING GRAFT) 42,783.00 24,765.00 18,018.00 27638 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TIBIA OR FIBULA; W/ ALLOGRAFT 42,783.00 24,765.00 18,018.00 27640 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS OR EXOSTOSIS); TIBIA 35,919.00 18,720.00 17,199.00 27641 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS OR EXOSTOSIS); FIBULA 35,100.00 18,720.00 16,380.00 27645 RADICAL RESECTION OF TUMOR, BONE; TIBIA 45,435.00 20,865.00 24,570.00 27646 RADICAL RESECTION OF TUMOR, BONE; FIBULA 44,187.00 21,255.00 22,932.00 27647 RADICAL RESECTION OF TUMOR, BONE; TALUS OR CALCANEUS 45,435.00 20,865.00 24,570.00 27650 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; 42,783.00 24,765.00 18,018.00 27652 REPAIR, PRIMARY, OPEN OR PERCUTANEOUS, RUPTURED ACHILLES TENDON; W/ GRAFT (INCLUDES OBTAINING GRAFT) 45,435.00 20,865.00 24,570.00 27654 REPAIR, SECONDARY, RUPTURED ACHILLES TENDON, W/ OR W/O GRAFT 42,549.00 21,255.00 21,294.00 27656 REPAIR, FASCIAL DEFECT OF LEG 11,076.00 7,800.00 3,276.00 27658 REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; PRIMARY, W/O GRAFT, SINGLE, EACH 29,991.00 14,430.00 15,561.00 27659 REPAIR OR SUTURE OF FLEXOR TENDON OF LEG; SECONDARY W/ OR W/O GRAFT, SINGLE TENDON, EACH 35,100.00 18,720.00 16,380.00 27664 REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; PRIMARY, W/O GRAFT, SINGLE, EACH 29,991.00 14,430.00 15,561.00 27665 REPAIR OR SUTURE OF EXTENSOR TENDON OF LEG; SECONDARY W/ OR W/O GRAFT, SINGLE TENDON, EACH 35,100.00 18,720.00 16,380.00 27675 REPAIR FOR DISLOCATING PERONEAL TENDONS; W/O FIBULAR OSTEOTOMY 35,100.00 18,720.00 16,380.00 27676 REPAIR FOR DISLOCATING PERONEAL TENDONS; W/ FIBULAR OSTEOTOMY 43,602.00 24,765.00 18,837.00 27680 TENOLYSIS, INCLUDING TIBIA, FIBULA, AND ANKLE FLEXOR; SINGLE 35,100.00 18,720.00 16,380.00 27681 TENOLYSIS, INCLUDING TIBIA, FIBULA, AND ANKLE FLEXOR; MULTIPLE (THROUGH SAME INCISION), EACH 42,783.00 24,765.00 18,018.00 27685 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; SINGLE 35,100.00 18,720.00 16,380.00 27686 LENGTHENING OR SHORTENING OF TENDON, LEG OR ANKLE; MULTIPLE (THROUGH SAME INCISION), EACH 35,100.00 18,720.00 16,380.00 27687 GASTROCNEMIUS RECESSION (E.G., STRAYER PROCEDURE) 29,172.00 14,430.00 14,742.00 27690 TRANSFER OR TRANSPLANT OF SINGLE TENDON (W/ MUSCLE REDIRECTION OR REROUTING); SUPERFICIAL (E.G., ANTERIOR TIBIAL EXTENSORS INTO MIDFOOT) 35,919.00 18,720.00 17,199.00 27692 TRANSFER OR TRANSPLANT OF SINGLE TENDON (W/ MUSCLE REDIRECTION OR REROUTING); EACH ADDITIONAL TENDON 29,991.00 14,430.00 15,561.00 27695 SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMENT, ANKLE; COLLATERAL 35,100.00 18,720.00 16,380.00 27696 SUTURE, PRIMARY, TORN, RUPTURED OR SEVERED LIGAMENT, ANKLE; BOTH COLLATERAL LIGAMENTS 45,435.00 20,865.00 24,570.00 27698 SUTURE, SECONDARY REPAIR, TORN, RUPTURED OR SEVERED LIGAMENT, ANKLE, COLLATERAL (WATSON-JONES PROCEDURE) 35,100.00 18,720.00 16,380.00 27700 ARTHROPLASTY, ANKLE; 52,884.00 23,400.00 29,484.00 27702 ARTHROPLASTY, ANKLE; W/ IMPLANT ("TOTAL ANKLE") 60,723.00 26,325.00 34,398.00 27703 ARTHROPLASTY, ANKLE; SECONDARY RECONSTRUCTION, TOTAL ANKLE 72,501.00 36,465.00 36,036.00 27704 REMOVAL OF ANKLE IMPLANT 42,549.00 21,255.00 21,294.00 27705 OSTEOTOMY; TIBIA 42,783.00 24,765.00 18,018.00 27707 OSTEOTOMY; FIBULA 35,100.00 18,720.00 16,380.00 27709 OSTEOTOMY; TIBIA AND FIBULA 44,187.00 21,255.00 22,932.00 27712 OSTEOTOMY; MULTIPLE, W/ REALIGNMENT ON INTRAMEDULLARY ROD (SOFIELD TYPE PROCEDURE) 46,254.00 20,865.00 25,389.00 Page 31 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27715 OSTEOPLASTY, TIBIA AND FIBULA, LENGTHENING 54,522.00 23,400.00 31,122.00 27720 REPAIR OF NONUNION OR MALUNION, TIBIA; W/O GRAFT, (E.G., COMPRESSION TECHNIQUE) 35,100.00 18,720.00 16,380.00 27722 REPAIR OF NONUNION OR MALUNION, TIBIA; W/ SLIDING GRAFT 40,911.00 21,255.00 19,656.00 27724 REPAIR OF NONUNION OR MALUNION, TIBIA; W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,549.00 21,255.00 21,294.00 27725 REPAIR OF NONUNION OR MALUNION, TIBIA; BY SYNOSTOSIS, W/ FIBULA, ANY METHOD 44,187.00 21,255.00 22,932.00 27727 REPAIR OF CONGENITAL PSEUDARTHROSIS, TIBIA 45,435.00 20,865.00 24,570.00 27730 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL TIBIA 42,549.00 21,255.00 21,294.00 27732 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL FIBULA 40,911.00 21,255.00 19,656.00 27734 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING; DISTAL TIBIA AND FIBULA 45,435.00 20,865.00 24,570.00 27740 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; 45,435.00 20,865.00 24,570.00 27742 EPIPHYSEAL ARREST BY EPIPHYSIODESIS OR STAPLING, COMBINED, PROXIMAL AND DISTAL TIBIA AND FIBULA; AND DISTAL FEMUR 44,187.00 21,255.00 22,932.00 27745 PROPHYLACTIC TREATMENT (NAILING, PINNING, PLATING OR WIRING) W/ OR W/O METHYLMETHACRYLATE, TIBIA 60,762.00 33,735.00 27,027.00 27750 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRACTURE) 23,634.00 10,530.00 13,104.00 27752 CLOSED TREATMENT OF TIBIAL SHAFT FRACTURE (WITH OR WITHOUT FIBULAR FRACTURE); WITH MANIPULATION, WITH OR WITHOUT SKELETAL TRACTION 23,634.00 10,530.00 13,104.00 27756 PERCUTANEOUS SKELETAL FIXATION OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRACTURE) (E.G., PINS OR SCREWS) 42,549.00 21,255.00 21,294.00 27758 OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRACTURE) W/ PLATE/SCREWS, W/ OR W/O CERCLAGE 44,187.00 21,255.00 22,932.00 27759 OPEN TREATMENT OF TIBIAL SHAFT FRACTURE (W/ OR W/O FIBULAR FRACTURE) BY INTRAMEDULLARY IMPLANT, W/ OR W/O INTERLOCKING SCREWS AND/OR CERCLAGE 52,884.00 23,400.00 29,484.00 27760 CLOSED TREATMENT OF MEDIAL MALLEOLUS FRACTURE 21,372.00 10,725.00 10,647.00 27766 OPEN TREATMENT OF MEDIAL MALLEOLUS FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 23,634.00 10,530.00 13,104.00 27780 CLOSED TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE 21,372.00 10,725.00 10,647.00 27784 OPEN TREATMENT OF PROXIMAL FIBULA OR SHAFT FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 44,187.00 21,255.00 22,932.00 27786 CLOSED TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS) 20,553.00 10,725.00 9,828.00 27792 OPEN TREATMENT OF DISTAL FIBULAR FRACTURE (LATERAL MALLEOLUS), W/ OR W/O INTERNAL OR EXTERNAL FIXATION W/O MANIPULATION 40,911.00 21,255.00 19,656.00 27808 CLOSED TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, (INCLUDING POTTS) 25,155.00 12,870.00 12,285.00 27814 OPEN TREATMENT OF BIMALLEOLAR ANKLE FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 45,435.00 20,865.00 24,570.00 27816 CLOSED TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE 45,435.00 20,865.00 24,570.00 27822 OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, MEDIAL AND/OR LATERAL MALLEOLUS; W/O FIXATION OF POSTERIOR LIP 45,435.00 20,865.00 24,570.00 27823 OPEN TREATMENT OF TRIMALLEOLAR ANKLE FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, MEDIAL AND/OR LATERAL MALLEOLUS; W/ FIXATION OF POSTERIOR LIP 45,435.00 20,865.00 24,570.00 27824 CLOSED TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR PORTION OF DISTAL TIBIA (E.G., PILON OR TIBIAL PLAFOND) 20,553.00 10,725.00 9,828.00 27826 OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (E.G., PILON OR TIBIAL PLAFOND), W/ INTERNAL OR EXTERNAL FIXATION; OF FIBULA ONLY 40,911.00 21,255.00 19,656.00 27827 OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (E.G., PILON OR TIBIAL PLAFOND), W/ INTERNAL OR EXTERNAL FIXATION; OF TIBIA ONLY 42,783.00 24,765.00 18,018.00 27828 OPEN TREATMENT OF FRACTURE OF WEIGHT BEARING ARTICULAR SURFACE/PORTION OF DISTAL TIBIA (E.G., PILON OR TIBIAL PLAFOND), W/ INTERNAL OR EXTERNAL FIXATION; OF BOTH TIBIA AND FIBULA 42,549.00 21,255.00 21,294.00 27829 OPEN TREATMENT OF DISTAL TIBIOFIBULAR JOINT (SYNDESMOSIS) DISRUPTION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 40,911.00 21,255.00 19,656.00 27830 CLOSED TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION 21,372.00 10,725.00 10,647.00 27832 OPEN TREATMENT OF PROXIMAL TIBIOFIBULAR JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION, OR W/ EXCISION OF PROXIMAL FIBULA 23,361.00 11,895.00 11,466.00 27840 CLOSED TREATMENT OF ANKLE DISLOCATION 21,372.00 10,725.00 10,647.00 27846 OPEN TREATMENT OF ANKLE DISLOCATION, W/ OR W/O PERCUTANEOUS SKELETAL FIXATION; W/O REPAIR OR INTERNAL FIXATION 44,187.00 21,255.00 22,932.00 Page 32 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 27848 OPEN TREATMENT OF ANKLE DISLOCATION, W/ OR W/O PERCUTANEOUS SKELETAL FIXATION; W/ REPAIR OR INTERNAL OR EXTERNAL FIXATION 46,254.00 20,865.00 25,389.00 27870 ARTHRODESIS, ANKLE, ANY METHOD 35,100.00 18,720.00 16,380.00 27871 ARTHRODESIS, TIBIOFIBULAR JOINT, PROXIMAL OR DISTAL 41,730.00 21,255.00 20,475.00 27880 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; 59,085.00 26,325.00 32,760.00 27881 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; W/ IMMEDIATE FITTING TECHNIQUE INCLUDING APPLICATION OF FIRST CAST 59,943.00 33,735.00 26,208.00 27882 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; OPEN, CIRCULAR (GUILLOTINE) 35,100.00 18,720.00 16,380.00 27884 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; SECONDARY CLOSURE OR SCAR REVISION 23,634.00 10,530.00 13,104.00 27886 AMPUTATION, LEG, THROUGH TIBIA AND FIBULA; RE- AMPUTATION 45,435.00 20,865.00 24,570.00 27888 AMPUTATION, ANKLE, THROUGH MALLEOLI OF TIBIA AND FIBULA (SYME, PIROGOFF TYPE PROCEDURES), W/ PLASTIC CLOSURE AND RESECTION OF NERVES 45,435.00 20,865.00 24,570.00 27889 ANKLE DISARTICULATION 42,783.00 24,765.00 18,018.00 27892 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL COMPARTMENTS ONLY, W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 35,100.00 18,720.00 16,380.00 27893 DECOMPRESSION FASCIOTOMY, LEG; POSTERIOR COMPARTMENT(S) ONLY, W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 35,100.00 18,720.00 16,380.00 27894 DECOMPRESSION FASCIOTOMY, LEG; ANTERIOR AND/OR LATERAL, AND POSTERIOR COMPARTMENT(S), W/ DEBRIDEMENT OF NONVIABLE MUSCLE AND/OR NERVE 35,919.00 18,720.00 17,199.00 28001 INCISION AND DRAINAGE, INFECTED BURSA, FOOT 11,076.00 7,800.00 3,276.00 28002 DEEP DISSECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, W/ OR W/O TENDON SHEATH INVOLVEMENT; SINGLE BURSAL SPACE, SPECIFY; 16,107.00 9,555.00 6,552.00 28003 DEEP DISSECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, W/ OR W/O TENDON SHEATH INVOLVEMENT; SINGLE BURSAL SPACE, SPECIFY; MULTIPLE AREAS 18,915.00 10,725.00 8,190.00 28005 INCISION, DEEP, W/ OPENING OF BONE CORTEX (E.G. FOR OSTEOMYELITIS OR BONE ABSCESS), FOOT 20,553.00 10,725.00 9,828.00 28008 FASCIOTOMY, FOOT AND/OR TOE 23,634.00 10,530.00 13,104.00 28010 TENOTOMY, SUBCUTANEOUS, TOE; SINGLE 16,107.00 9,555.00 6,552.00 28011 TENOTOMY, SUBCUTANEOUS, TOE; MULTIPLE 20,553.00 10,725.00 9,828.00 28020 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERTARSAL OR TARSOMETATARSAL JOINT 25,155.00 12,870.00 12,285.00 28022 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; METATARSOPHALANGEAL JOINT 16,107.00 9,555.00 6,552.00 28024 ARTHROTOMY, W/ EXPLORATION, DRAINAGE, OR REMOVAL OF LOOSE OR FOREIGN BODY; INTERPHALANGEAL JOINT 16,107.00 9,555.00 6,552.00 28030 NEURECTOMY OF INTRINSIC MUSCULATURE OF FOOT 21,707.40 13,845.00 7,862.40 28035 TARSAL TUNNEL RELEASE (POSTERIOR TIBIAL NERVE DECOMPRESSION) 35,100.00 18,720.00 16,380.00 28043 EXCISION, TUMOR, FOOT; SUBCUTANEOUS 11,076.00 7,800.00 3,276.00 28045 EXCISION, TUMOR, FOOT; DEEP, SUBFASCIAL, INTRAMUSCULAR 15,639.00 10,725.00 4,914.00 28046 RADICAL RESECTION OF TUMOR (E.G., MALIGNANT NEOPLASM), SOFT TISSUE OF FOOT 73,710.00 32,760.00 40,950.00 28050 ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERTARSAL OR TARSOMETATARSAL JOINT 19,734.00 10,725.00 9,009.00 28052 ARTHROTOMY FOR SYNOVIAL BIOPSY; METATARSOPHALANGEAL JOINT 19,734.00 10,725.00 9,009.00 28054 ARTHROTOMY FOR SYNOVIAL BIOPSY; INTERPHALANGEAL JOINT 18,915.00 10,725.00 8,190.00 28060 FASCIECTOMY, EXCISION OF PLANTAR FASCIA; PARTIAL 18,915.00 10,725.00 8,190.00 28062 FASCIECTOMY, EXCISION OF PLANTAR FASCIA; RADICAL 21,372.00 10,725.00 10,647.00 28070 SYNOVECTOMY; INTERTARSAL OR TARSOMETATARSAL JOINT, EACH 23,361.00 11,895.00 11,466.00 28072 SYNOVECTOMY; METATARSOPHALANGEAL JOINT, EACH 21,372.00 10,725.00 10,647.00 28080 EXCISION OF INTERDIGITAL (MORTON) NEUROMA, SINGLE, EACH 11,076.00 7,800.00 3,276.00 28086 SYNOVECTOMY, TENDON SHEATH, FOOT; FLEXOR 21,372.00 10,725.00 10,647.00 28088 SYNOVECTOMY, TENDON SHEATH, FOOT; EXTENSOR 21,372.00 10,725.00 10,647.00 28090 EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR CAPSULE (INCLUDING SYNOVECTOMY) (CYST OR GANGLION); FOOT 16,458.00 10,725.00 5,733.00 28092 EXCISION OF LESION OF TENDON OR FIBROUS SHEATH OR CAPSULE (INCLUDING SYNOVECTOMY) (CYST OR GANGLION); TOES 16,107.00 9,555.00 6,552.00 28100 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; 29,991.00 14,430.00 15,561.00 28102 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,783.00 24,765.00 18,018.00 28103 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR CALCANEUS; W/ ALLOGRAFT 42,783.00 24,765.00 18,018.00 28104 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR METATARSAL BONES, EXCEPT TARSAL OR CALCANEUS; 29,991.00 14,430.00 15,561.00 Page 33 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 28106 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR METATARSAL BONES, EXCEPT TARSAL OR CALCANEUS; W/ ILIAC OR OTHER AUTOGRAFT (INCLUDES OBTAINING GRAFT) 42,783.00 24,765.00 18,018.00 28107 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, TALUS OR METATARSAL BONES, EXCEPT TARSAL OR CALCANEUS; W/ ALLOGRAFT 42,783.00 24,765.00 18,018.00 28108 EXCISION OR CURETTAGE OF BONE CYST OR BENIGN TUMOR, PHALANGES OF FOOT 29,172.00 14,430.00 14,742.00 28110 OSTECTOMY, PARTIAL EXCISION, FIFTH METATARSAL HEAD (BUNIONETTE) 42,783.00 24,765.00 18,018.00 28111 OSTECTOMY, COMPLETE EXCISION; FIRST METATARSAL HEAD 35,919.00 18,720.00 17,199.00 28112 OSTECTOMY, COMPLETE EXCISION; OTHER METATARSAL HEAD (SECOND, THIRD OR FOURTH) 35,919.00 18,720.00 17,199.00 28113 OSTECTOMY, COMPLETE EXCISION; FIFTH METATARSAL HEAD 35,100.00 18,720.00 16,380.00 28114 OSTECTOMY, COMPLETE EXCISION; ALL METATARSAL HEADS, W/ PARTIAL PROXIMAL PHALANGECTOMY, EXCLUDING FIRST METATARSAL (CLAYTON TYPE PROCEDURE) 40,911.00 21,255.00 19,656.00 28116 OSTECTOMY, EXCISION OF TARSAL COALITION 29,991.00 14,430.00 15,561.00 28118 OSTECTOMY, CALCANEUS; 29,991.00 14,430.00 15,561.00 28119 OSTECTOMY, CALCANEUS; FOR SPUR, W/ OR W/O PLANTAR FASCIAL RELEASE 29,172.00 14,430.00 14,742.00 28120 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, SEQUESTRECTOMY, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS OR TALAR BOSSING); TALUS OR CALCANEUS 42,783.00 24,765.00 18,018.00 28122 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS OR TARSAL BOSSING), TARSAL OR METATARSAL BONE, EXCEPT TALUS OR CALCANEUS 35,100.00 18,720.00 16,380.00 28124 PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) OF BONE (E.G., FOR OSTEOMYELITIS OR DORSAL BOSSING), PHALANX OF TOE 35,100.00 18,720.00 16,380.00 28126 RESECTION, PARTIAL OR COMPLETE, PHALANGEAL BASE, SINGLE TOE, EACH 24,453.00 10,530.00 13,923.00 28130 TALECTOMY (ASTRAGALECTOMY) 44,187.00 21,255.00 22,932.00 28140 METATARSECTOMY 35,100.00 18,720.00 16,380.00 28150 PHALANGECTOMY OF TOE, SINGLE, EACH 23,634.00 10,530.00 13,104.00 28153 RESECTION, HEAD OF PHALANX, TOE 23,634.00 10,530.00 13,104.00 28160 HEMIPHALANGECTOMY OR INTERPHALANGEAL JOINT EXCISION, TOE, SINGLE, EACH 20,553.00 10,725.00 9,828.00 28171 RADICAL RESECTION OF TUMOR, BONE; TARSAL (EXCEPT TALUS OR CALCANEUS) 59,943.00 33,735.00 26,208.00 28173 RADICAL RESECTION OF TUMOR, BONE; METATARSAL 44,187.00 21,255.00 22,932.00 28175 RADICAL RESECTION OF TUMOR, BONE; PHALANX OF TOE 42,783.00 24,765.00 18,018.00 28200 REPAIR OR SUTURE OF TENDON, FOOT, FLEXOR, SINGLE; PRIMARY OR SECONDARY, W/O FREE GRAFT, EACH TENDON 35,100.00 18,720.00 16,380.00 28202 REPAIR OR SUTURE OF TENDON, FOOT, FLEXOR, SINGLE; SECONDARY W/ FREE GRAFT, EACH TENDON (INCLUDES OBTAINING GRAFT) 35,100.00 18,720.00 16,380.00 28208 REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE; PRIMARY OR SECONDARY, EACH TENDON 24,453.00 10,530.00 13,923.00 28210 REPAIR OR SUTURE OF TENDON, FOOT, EXTENSOR, SINGLE; SECONDARY W/ FREE GRAFT, EACH TENDON (INCLUDES OBTAINING GRAFT) 24,453.00 10,530.00 13,923.00 28220 TENOLYSIS, FLEXOR, FOOT; SINGLE 21,216.00 13,845.00 7,371.00 28222 TENOLYSIS, FLEXOR, FOOT; MULTIPLE (THROUGH SAME INCISION) 21,372.00 10,725.00 10,647.00 28225 TENOLYSIS, EXTENSOR, FOOT; SINGLE 21,216.00 13,845.00 7,371.00 28226 TENOLYSIS, EXTENSOR, FOOT; MULTIPLE (THROUGH SAME INCISION) 21,372.00 10,725.00 10,647.00 28230 TENOTOMY, OPEN, FLEXOR; FOOT, SINGLE OR MULTIPLE; 21,372.00 10,725.00 10,647.00 28232 TENOTOMY, OPEN, FLEXOR; FOOT, SINGLE OR MULTIPLE; TOE, SINGLE 21,216.00 13,845.00 7,371.00 28234 TENOTOMY, OPEN, EXTENSOR, FOOT OR TOE 21,707.40 13,845.00 7,862.40 28238 ADVANCEMENT OF POSTERIOR TIBIAL TENDON W/ EXCISION OF ACCESSORY NAVICULAR BONE (KIDNER TYPE PROCEDURE) 35,919.00 18,720.00 17,199.00 28240 TENOTOMY, LENGTHENING, OR RELEASE, ABDUCTOR HALLUCIS MUSCLE 24,453.00 10,530.00 13,923.00 28250 DIVISION OF PLANTAR FASCIA AND MUSCLE ("STEINDLER STRIPPING") 24,453.00 10,530.00 13,923.00 28260 CAPSULOTOMY, MIDFOOT; MEDIAL RELEASE ONLY 24,453.00 10,530.00 13,923.00 28261 CAPSULOTOMY, MIDFOOT; W/ TENDON LENGTHENING 35,100.00 18,720.00 16,380.00 28262 CAPSULOTOMY, MIDFOOT; EXTENSIVE, INCLUDING POSTERIOR TALOTIBIAL CAPSULOTOMY AND TENDON(S) LENGTHENING AS FOR RESISTANT CLUBFOOT DEFORMITY 40,911.00 21,255.00 19,656.00 28264 CAPSULOTOMY, MIDTARSAL (HEYMAN TYPE PROCEDURE) 23,634.00 10,530.00 13,104.00 28270 CAPSULOTOMY; METATARSOPHALANGEAL JOINT, W/ OR W/O TENORRHAPHY, SINGLE, EACH JOINT 23,634.00 10,530.00 13,104.00 28272 CAPSULOTOMY; INTERPHALANGEAL JOINT, SINGLE EACH JOINT 25,155.00 12,870.00 12,285.00 28280 WEBBING OPERATION (CREATE SYNDACTYLISM OF TOES) (KELIKIAN TYPE PROCEDURE) 40,911.00 21,255.00 19,656.00 Page 34 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 28285 HAMMERTOE OPERATION, ONE TOE (E.G., INTERPHALANGEAL FUSION, FILLETING, PHALANGECTOMY) 29,991.00 14,430.00 15,561.00 28286 COCK-UP FIFTH TOE OPERATION W/ PLASTIC SKIN CLOSURE (RUIZ- MORA TYPE PROCEDURE) 42,783.00 24,765.00 18,018.00 28288 OSTECTOMY, PARTIAL, EXOSTECTOMY OR CONDYLECTOMY, SINGLE, METATARSAL HEAD, FIRST THROUGH FIFTH, EACH METATARSAL HEAD 29,991.00 14,430.00 15,561.00 28290 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; SIMPLE EXOSTECTOMY (SILVER TYPE PROCEDURE) 40,911.00 21,255.00 19,656.00 28292 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; KELLER, MCBRIDE, OR MAYO TYPE PROCEDURE 42,549.00 21,255.00 21,294.00 28293 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; RESECTION OF JOINT W/ IMPLANT 42,549.00 21,255.00 21,294.00 28294 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; W/ TENDON TRANSPLANTS (JOPLIN TYPE PROCEDURE) 44,187.00 21,255.00 22,932.00 28296 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; W/ METATARSAL OSTEOTOMY (E.G., MITCHELL, CHEVRON, OR CONCENTRIC TYPE PROCEDURES) 44,187.00 21,255.00 22,932.00 28297 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; LAPIDUS TYPE PROCEDURE 44,187.00 21,255.00 22,932.00 28298 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; BY PHALANX OSTEOTOMY 45,006.00 21,255.00 23,751.00 28299 HALLUX VALGUS (BUNION) CORRECTION, W/ OR W/O SESAMOIDECTOMY; BY OTHER METHODS (E.G., DOUBLE OSTEOTOMY) 45,006.00 21,255.00 23,751.00 28300 OSTEOTOMY; CALCANEUS (DWYER OR CHAMBERS TYPE PROCEDURE), W/ OR W/O INTERNAL FIXATION 41,730.00 21,255.00 20,475.00 28302 OSTEOTOMY; TALUS 40,911.00 21,255.00 19,656.00 28304 OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS OR TALUS; 29,991.00 14,430.00 15,561.00 28305 OSTEOTOMY, MIDTARSAL BONES, OTHER THAN CALCANEUS OR TALUS; W/ AUTOGRAFT (INCLUDES OBTAINING GRAFT)(FOWLER TYPE) 35,919.00 18,720.00 17,199.00 28306 OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, W/ OR W/O LENGHTENING, FOR SHORTENING OR ANGULAR CORRECTION; FIRST METATARSAL 43,602.00 24,765.00 18,837.00 28307 OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, W/ OR W/O LENGHTENING, FOR SHORTENING OR ANGULAR CORRECTION; FIRST METATARSAL W/ AUTOGRAFT 43,602.00 24,765.00 18,837.00 28308 OSTEOTOMY, METATARSAL, BASE OR SHAFT, SINGLE, W/ OR W/O LENGHTENING, FOR SHORTENING OR ANGULAR CORRECTION; OTHER THAN FIRST METATARSAL 43,602.00 24,765.00 18,837.00 28309 OSTEOTOMY, METATARSALS, MULTIPLE, FOR CAVUS FOOT (SWANSON TYPE PROCEDURE) 42,783.00 24,765.00 18,018.00 28310 OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; PROXIMAL PHALANX, FIRST TOE 35,919.00 18,720.00 17,199.00 28312 OSTEOTOMY FOR SHORTENING, ANGULAR OR ROTATIONAL CORRECTION; OTHER PHALANGES, ANY TOE 29,172.00 14,430.00 14,742.00 28313 RECONSTRUCTION, ANGULAR DEFORMITY OF TOE (OVERLAPPING SECOND TOE, FIFTH TOE, CURLY TOES), SOFT TISSUE PROCEDURES ONLY 43,602.00 24,765.00 18,837.00 28315 SESAMOIDECTOMY, FIRST TOE 24,453.00 10,530.00 13,923.00 28320 REPAIR OF NONUNION OR MALUNION; TARSAL BONES (E.G., CALCANEUS, TALUS) 42,783.00 24,765.00 18,018.00 28322 REPAIR OF NONUNION OR MALUNION; METATARSAL, W/ OR W/O BONE GRAFT (INCLUDES OBTAINING GRAFT) 29,172.00 14,430.00 14,742.00 28340 RECONSTRUCTION, TOE, MACRODACTYLY; SOFT TISSUE RESECTION 23,634.00 10,530.00 13,104.00 28341 RECONSTRUCTION, TOE, MACRODACTYLY; REQUIRING BONE RESECTION 24,453.00 10,530.00 13,923.00 28344 RECONSTRUCTION, TOE(S); POLYDACTYLY 42,783.00 24,765.00 18,018.00 28345 RECONSTRUCTION, TOE(S); SYNDACTYLY, W/ OR W/O SKIN GRAFT(S) 43,602.00 24,765.00 18,837.00 28360 RECONSTRUCTION, CLEFT FOOT 29,991.00 14,430.00 15,561.00 28400 CLOSED TREATMENT OF CALCANEAL FRACTURE 21,372.00 10,725.00 10,647.00 28406 PERCUTANEOUS SKELETAL FIXATION OF CALCANEAL FRACTURE, W/ MANIPULATION 23,361.00 11,895.00 11,466.00 28415 OPEN TREATMENT OF CALCANEAL FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; 35,100.00 18,720.00 16,380.00 28420 OPEN TREATMENT OF CALCANEAL FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION; W/ PRIMARY ILIAC OR OTHER AUTOGENOUS BONE GRAFT (INCLUDES OBTAINING GRAFT) 43,602.00 24,765.00 18,837.00 28430 CLOSED TREATMENT OF TALUS FRACTURE 21,372.00 10,725.00 10,647.00 28436 PERCUTANEOUS SKELETAL FIXATION OF TALUS FRACTURE, W/ MANIPULATION 18,915.00 10,725.00 8,190.00 28445 OPEN TREATMENT OF TALUS FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 29,991.00 14,430.00 15,561.00 28450 TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS) 21,707.40 13,845.00 7,862.40 28456 PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), W/ MANIPULATION 23,361.00 11,895.00 11,466.00 Page 35 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 28465 OPEN TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS), W/ OR W/O INTERNAL OR EXTERNAL FIXATION 19,734.00 10,725.00 9,009.00 28470 CLOSED TREATMENT OF METATARSAL FRACTURE 21,216.00 13,845.00 7,371.00 28476 PERCUTANEOUS SKELETAL FIXATION OF METATARSAL FRACTURE, W/ MANIPULATION 16,107.00 9,555.00 6,552.00 28485 OPEN TREATMENT OF METATARSAL FRACTURE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 21,216.00 13,845.00 7,371.00 28490 CLOSED TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES 19,734.00 10,725.00 9,009.00 28496 PERCUTANEOUS SKELETAL FIXATION OF FRACTURE GREAT TOE, PHALANX OR PHALANGES, W/ MANIPULATION 20,553.00 10,725.00 9,828.00 28505 OPEN TREATMENT OF FRACTURE GREAT TOE, PHALANX OR PHALANGES, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 23,634.00 10,530.00 13,104.00 28510 CLOSED TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE 19,734.00 10,725.00 9,009.00 28525 OPEN TREATMENT OF FRACTURE, PHALANX OR PHALANGES, OTHER THAN GREAT TOE, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 23,634.00 10,530.00 13,104.00 28530 CLOSED TREATMENT OF SESAMOID FRACTURE 16,107.00 9,555.00 6,552.00 28531 OPEN TREATMENT OF SESAMOID FRACTURE, W/ OR W/O INTERNAL FIXATION 19,734.00 10,725.00 9,009.00 28540 CLOSED TREATMENT OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL 16,107.00 9,555.00 6,552.00 28546 PERCUTANEOUS SKELETAL FIXATION OF TARSAL BONE DISLOCATION, OTHER THAN TALOTARSAL ,W/ MANIPULATION 24,453.00 10,530.00 13,923.00 28555 OPEN TREATMENT OF TARSAL BONE DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 24,453.00 10,530.00 13,923.00 28570 CLOSED TREATMENT OF TALOTARSAL JOINT DISLOCATION 21,216.00 13,845.00 7,371.00 28576 PERCUTANEOUS SKELETAL FIXATION OF TALOTARSAL JOINT DISLOCATION, W/ MANIPULATION 24,453.00 10,530.00 13,923.00 28585 OPEN TREATMENT OF TALOTARSAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 28600 CLOSED TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION 21,372.00 10,725.00 10,647.00 28606 PERCUTANEOUS SKELETAL FIXATION OF TARSOMETATARSAL JOINT DISLOCATION, W/ MANIPULATION 24,453.00 10,530.00 13,923.00 28615 OPEN TREATMENT OF TARSOMETATARSAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 28630 CLOSED TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION 16,107.00 9,555.00 6,552.00 28636 PERCUTANEOUS SKELETAL FIXATION OF METATARSOPHALANGEAL JOINT DISLOCATION, W/ MANIPULATION 24,453.00 10,530.00 13,923.00 28645 OPEN TREATMENT OF METATARSOPHALANGEAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 28660 CLOSED TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION 21,216.00 13,845.00 7,371.00 28666 PERCUTANEOUS SKELETAL FIXATION OF INTERPHALANGEAL JOINT DISLOCATION, W/ MANIPULATION 24,453.00 10,530.00 13,923.00 28675 OPEN TREATMENT OF INTERPHALANGEAL JOINT DISLOCATION, W/ OR W/O INTERNAL OR EXTERNAL FIXATION 35,100.00 18,720.00 16,380.00 28705 PANTALAR ARTHRODESIS 52,884.00 23,400.00 29,484.00 28715 TRIPLE ARTHRODESIS 54,522.00 23,400.00 31,122.00 28725 SUBTALAR ARTHRODESIS 52,884.00 23,400.00 29,484.00 28730 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; 45,435.00 20,865.00 24,570.00 28735 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, MULTIPLE OR TRANSVERSE; W/ OSTEOTOMY AS FOR FLATFOOT CORRECTION 45,006.00 21,255.00 23,751.00 28737 ARTHRODESIS, MIDTARSAL NAVICULAR-CUNEIFORM, W/ TENDON LENGTHENING AND ADVANCEMENT (MILLER TYPE PROCEDURE) 42,783.00 24,765.00 18,018.00 28740 ARTHRODESIS, MIDTARSAL OR TARSOMETATARSAL, SINGLE JOINT 35,919.00 18,720.00 17,199.00 28750 ARTHRODESIS, GREAT TOE; METATARSOPHALANGEAL JOINT 35,919.00 18,720.00 17,199.00 28755 ARTHRODESIS, GREAT TOE; INTERPHALANGEAL JOINT 29,991.00 14,430.00 15,561.00 28760 ARTHRODESIS, GREAT TOE, INTERPHALANGEAL JOINT, W/ EXTENSOR HALLUCIS LONGUS TRANSFER TO FIRST METATARSAL NECK (JONES TYPE PROCEDURE) 43,368.00 21,255.00 22,113.00 28800 AMPUTATION, FOOT; MIDTARSAL (CHOPART TYPE PROCEDURE) 45,435.00 20,865.00 24,570.00 28802 DEEP DISECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, W/ OR W/O TENDON SHEALTH INVOLVEMENT; SINGLE BURSAL SPACE SPECIFY 16,107.00 9,555.00 6,552.00 28805 DEEP DISECTION BELOW FASCIA, FOR DEEP INFECTION OF FOOT, W/ OR W/O TENDON SHEALTH INVOLVEMENT; TRANSMETATARSAL 42,549.00 21,255.00 21,294.00 28810 AMPUTATION, METATARSAL, W/ TOE, SINGLE 23,634.00 10,530.00 13,104.00 28820 AMPUTATION, TOE; METATARSOPHALANGEAL JOINT 35,100.00 18,720.00 16,380.00 28825 AMPUTATION, TOE; INTERPHALANGEAL JOINT 23,634.00 10,530.00 13,104.00 Page 36 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 29000 APPLICATION OF HALO TYPE BODY CAST (SEE 20661-20663 FOR INSERTION) 20,553.00 10,725.00 9,828.00 29010 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; ONLY 20,553.00 10,725.00 9,828.00 29015 APPLICATION OF RISSER JACKET, LOCALIZER, BODY; INCLUDING HEAD 20,553.00 10,725.00 9,828.00 29020 APPLICATION OF TURNBUCKLE JACKET, BODY; ONLY 20,553.00 10,725.00 9,828.00 29025 APPLICATION OF TURNBUCKLE JACKET, BODY; INCLUDING HEAD 20,553.00 10,725.00 9,828.00 29035 APPLICATION OF BODY CAST, SHOULDER TO HIPS; 20,553.00 10,725.00 9,828.00 29040 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING HEAD, MINERVA TYPE 20,553.00 10,725.00 9,828.00 29044 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING ONE THIGH 23,634.00 10,530.00 13,104.00 29046 APPLICATION OF BODY CAST, SHOULDER TO HIPS; INCLUDING BOTH THIGHS 23,634.00 10,530.00 13,104.00 29055 APPLICATION OF BODY CAST, SHOULDER TO HIPS; SHOULDER SPICA 18,135.00 14,040.00 4,095.00 29058 APPLICATION OF BODY CAST, SHOULDER TO HIPS; PLASTER VELPEAU 10,842.00 8,385.00 2,457.00 29065 APPLICATION OF BODY CAST, SHOULDER TO HIPS; SHOULDER TO HAND (LONG ARM) 11,076.00 7,800.00 3,276.00 29075 APPLICATION OF BODY CAST, SHOULDER TO HIPS; ELBOW TO FINGER (SHORT ARM) 10,842.00 8,385.00 2,457.00 29085 APPLICATION OF BODY CAST, SHOULDER TO HIPS; HAND AND LOWER FOREARM (GAUNTLET) 10,842.00 8,385.00 2,457.00 29305 APPLICATION OF HIP SPICA CAST; ONE LEG 15,639.00 10,725.00 4,914.00 29325 APPLICATION OF HIP SPICA CAST; ONE AND ONE-HALF SPICA OR BOTH LEGS 16,458.00 10,725.00 5,733.00 29345 APPLICATION OF LONG LEG CAST (THIGH TO TOES); 15,639.00 10,725.00 4,914.00 29355 APPLICATION OF LONG LEG CAST (THIGH TO TOES); WALKER OR AMBULATORY TYPE 16,458.00 10,725.00 5,733.00 29358 APPLICATION OF LONG LEG CAST BRACE 16,458.00 10,725.00 5,733.00 29365 APPLICATION OF CYLINDER CAST (THIGH TO ANKLE) 15,639.00 10,725.00 4,914.00 29405 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); 15,639.00 10,725.00 4,914.00 29425 APPLICATION OF SHORT LEG CAST (BELOW KNEE TO TOES); WALKING OR AMBULATORY TYPE 15,639.00 10,725.00 4,914.00 29435 APPLICATION OF PATELLAR TENDON BEARING (PTB) CAST 15,639.00 10,725.00 4,914.00 29445 APPLICATION OF RIGID TOTAL CONTACT LEG CAST 11,076.00 7,800.00 3,276.00 29450 APPLICATION OF CLUBFOOT CAST W/ MOLDING OR MANIPULATION, LONG OR SHORT LEG 11,076.00 7,800.00 3,276.00 29800 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY 35,100.00 18,720.00 16,380.00 29804 ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL 40,911.00 21,255.00 19,656.00 29815 ARTHROSCOPY, SHOULDER, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY 35,100.00 18,720.00 16,380.00 29819 ARTHROSCOPY, SHOULDER, SURGICAL; W/ REMOVAL OF LOOSE BODY OR FOREIGN BODY 42,783.00 24,765.00 18,018.00 29820 ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, PARTIAL 40,911.00 21,255.00 19,656.00 29821 ARTHROSCOPY, SHOULDER, SURGICAL; SYNOVECTOMY, COMPLETE 42,549.00 21,255.00 21,294.00 29822 ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, LIMITED 40,911.00 21,255.00 19,656.00 29823 ARTHROSCOPY, SHOULDER, SURGICAL; DEBRIDEMENT, EXTENSIVE 45,435.00 20,865.00 24,570.00 29825 ARTHROSCOPY, SHOULDER, SURGICAL; W/ LYSIS AND RESECTION OF ADHESIONS, W/ OR W/O MANIPULATION 59,943.00 33,735.00 26,208.00 29826 ARTHROSCOPY, SHOULDER, SURGICAL; DECOMPRESSION OF SUBACROMIAL SPACE W/ PARTIAL ACROMIOPLASTY, W/ OR W/O CORACOACROMIAL RELEASE 52,884.00 23,400.00 29,484.00 29830 ARTHROSCOPY, ELBOW, DIANOSTIC, W/ OR W/O SYNOVIAL BIOPSY 35,100.00 18,720.00 16,380.00 29834 ARTHROSCOPY, ELBOW, SURGICAL; W/ REMOVAL OF LOOSE BODY OR FOREIGN BODY 42,783.00 24,765.00 18,018.00 29835 ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, PARTIAL 40,911.00 21,255.00 19,656.00 29836 ARTHROSCOPY, ELBOW, SURGICAL; SYNOVECTOMY, COMPLETE 42,549.00 21,255.00 21,294.00 29837 ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, LIMITED 40,911.00 21,255.00 19,656.00 29838 ARTHROSCOPY, ELBOW, SURGICAL; DEBRIDEMENT, EXTENSIVE 45,435.00 20,865.00 24,570.00 29840 ARTHROSCOPY, WRIST, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY 23,634.00 10,530.00 13,104.00 29843 ARTHROSCOPY, WRIST, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE 42,783.00 24,765.00 18,018.00 29844 ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, PARTIAL 40,911.00 21,255.00 19,656.00 29845 ARTHROSCOPY, WRIST, SURGICAL; SYNOVECTOMY, COMPLETE 42,549.00 21,255.00 21,294.00 29846 ARTHROSCOPY, WRIST, SURGICAL; EXCISION AND/OR REPAIR OF TRIANGULAR FIBROCARTILAGE AND/OR JOINT DEBRIDEMENT 45,435.00 20,865.00 24,570.00 29847 ARTHROSCOPY, WRIST, SURGICAL; INTERNAL FIXATION FOR FRACTURE OR INSTABILITY 45,435.00 20,865.00 24,570.00 29848 ARTHROSCOPY, WRIST, SURGICAL; W/ RELEASE OF TRANSVERSE CARPAL LIGAMENT 45,435.00 20,865.00 24,570.00 Page 37 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 29850 ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, W/ OR W/O MANIPULATION; W/O INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) 52,884.00 23,400.00 29,484.00 29851 ARTHROSCOPICALLY AIDED TREATMENT OF INTERCONDYLAR SPINE(S) AND/OR TUBEROSITY FRACTURE(S) OF THE KNEE, W/ OR W/O MANIPULATION; W/ INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) 52,884.00 23,400.00 29,484.00 29855 ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); UNICONDYLAR, W/ OR W/O INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) 52,884.00 23,400.00 29,484.00 29856 ARTHROSCOPICALLY AIDED TREATMENT OF TIBIAL FRACTURE, PROXIMAL (PLATEAU); BICONDYLAR, W/ OR W/O INTERNAL OR EXTERNAL FIXATION (INCLUDES ARTHROSCOPY) 54,522.00 23,400.00 31,122.00 29870 ARTHROSCOPY, KNEE, DIAGNOSTIC, W/ OR W/O SYNOVIAL BIOPSY 35,100.00 18,720.00 16,380.00 29871 ARTHROSCOPY, KNEE, SURGICAL; FOR INFECTION, LAVAGE AND DRAINAGE 40,911.00 21,255.00 19,656.00 29874 ARTHROSCOPY, KNEE, SURGICAL; FOR REMOVAL OF LOOSE BODY OR FOREIGN BODY (E.G., OSTEOCHONDRITIS DISSECANS FRAGMENTATION, CHONDRAL FRAGMENTATION) 42,783.00 24,765.00 18,018.00 29875 ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, LIMITED (E.G., PLICA OR SHELF RESECTION) 59,943.00 33,735.00 26,208.00 29876 ARTHROSCOPY, KNEE, SURGICAL; SYNOVECTOMY, MAJOR, TWO OR MORE COMPARTMENTS (E.G., MEDIAL OR LATERAL) 61,581.00 33,735.00 27,846.00 29877 ARTHROSCOPY, KNEE, SURGICAL; DEBRIDEMENT/SHAVING OF ARTICULAR CARTILAGE (CHONDROPLASTY) 45,435.00 20,865.00 24,570.00 29879 ARTHROSCOPY, KNEE, SURGICAL; ABRASION ARTHROPLASTY (INCLUDES CHONDROPLASTY WHERE NECESSARY) OR MULTIPLE DRILLING 45,435.00 20,865.00 24,570.00 29880 ARTHROSCOPY, KNEE, SURGICAL; W/ MENISCECTOMY (MEDIAL AND LATERAL, INCLUDING ANY MENISCAL SHAVING) 59,943.00 33,735.00 26,208.00 29881 ARTHROSCOPY, KNEE, SURGICAL; W/ MENISCECTOMY (MEDIAL OR LATERAL, INCLUDING ANY MENISCAL SHAVING) 59,943.00 33,735.00 26,208.00 29882 ARTHROSCOPY, KNEE, SURGICAL; W/ MENISCUS REPAIR (MEDIAL OR LATERAL) 52,884.00 23,400.00 29,484.00 29883 ARTHROSCOPY, KNEE, SURGICAL; W/ MENISCUS REPAIR (MEDIAL AND LATERAL) 59,085.00 26,325.00 32,760.00 29884 ARTHROSCOPY, KNEE, SURGICAL; W/ LYSIS OF ADHESIONS, W/ OR W/O MANIPULATION 45,435.00 20,865.00 24,570.00 29885 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR OSTEOCHONDRITIS DISSECANS W/ BONE GRAFTING, W/ OR W/O INTERNAL FIXATION (INCLUDING DEBRIDEMENT OF BASE OF LESION) 45,435.00 20,865.00 24,570.00 29886 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LESION 52,884.00 23,400.00 29,484.00 29887 ARTHROSCOPY, KNEE, SURGICAL; DRILLING FOR INTACT OSTEOCHONDRITIS DISSECANS LESION W/ INTERNAL FIXATION 45,435.00 20,865.00 24,570.00 29888 ARTHROSCOPICALLY AIDED ANTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION 72,501.00 36,465.00 36,036.00 29889 ARTHROSCOPICALLY AIDED POSTERIOR CRUCIATE LIGAMENT REPAIR/AUGMENTATION OR RECONSTRUCTION 75,777.00 36,465.00 39,312.00 29894 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; W/ REMOVAL OF LOOSE BODY OR FOREIGN BODY 42,783.00 24,765.00 18,018.00 29895 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; SYNOVECTOMY, PARTIAL 40,911.00 21,255.00 19,656.00 29897 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, LIMITED 40,911.00 21,255.00 19,656.00 29898 ARTHROSCOPY, ANKLE (TIBIOTALAR AND FIBULOTALAR JOINTS), SURGICAL; DEBRIDEMENT, EXTENSIVE 42,549.00 21,255.00 21,294.00 30000 DRAINAGE ABSCESS OR HEMATOMA, NASAL, INTERNAL APPROACH 10,842.00 8,385.00 2,457.00 30020 DRAINAGE ABSCESS OR HEMATOMA, NASAL SEPTUM 10,842.00 8,385.00 2,457.00 30100 BIOPSY, INTRANASAL 11,076.00 7,800.00 3,276.00 30110 EXCISION, NASAL POLYP(S), SIMPLE 15,639.00 10,725.00 4,914.00 30115 EXCISION, NASAL POLYP(S), EXTENSIVE 18,915.00 10,725.00 8,190.00 30117 EXCISION OR DESTRUCTION, ANY METHOD (INCLUDING LASER), INTRANASAL LESION; INTERNAL APPROACH 18,915.00 10,725.00 8,190.00 30118 EXCISION OR DESTRUCTION, ANY METHOD (INCLUDING LASER), INTRANASAL LESION; EXTERNAL APPROACH (LATERAL RHINOTOMY) 18,915.00 10,725.00 8,190.00 30130 EXCISION TURBINATE, PARTIAL OR COMPLETE 25,155.00 12,870.00 12,285.00 30140 SUBMUCOUS RESECTION TURBINATE, PARTIAL OR COMPLETE 25,155.00 12,870.00 12,285.00 30310 REMOVAL FOREIGN BODY, INTRANASAL; REQUIRING GENERAL ANESTHESIA 15,639.00 10,725.00 4,914.00 Page 38 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 30320 REMOVAL FOREIGN BODY, INTRANASAL; BY LATERAL RHINOTOMY 15,639.00 10,725.00 4,914.00 30460 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT TIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP ONLY 59,085.00 26,325.00 32,760.00 30462 RHINOPLASTY FOR NASAL DEFORMITY SECONDARY TO CONGENITAL CLEFT TIP AND/OR PALATE, INCLUDING COLUMELLAR LENGTHENING; TIP, SEPTUM, OSTEOTOMIES 59,085.00 26,325.00 32,760.00 30465 RHINOPLASTY FOR NASAL VESTIBULAR STENOSIS 73,710.00 32,760.00 40,950.00 30520 SEPTOPLASTY OR SUBMUCOUS RESECTION, W/ OR W/O CARTILAGE SCORING, CONTOURING OR REPLACEMENT W/ GRAFT 25,155.00 12,870.00 12,285.00 30540 REPAIR CHOANAL ATRESIA; INTRANASAL 25,155.00 12,870.00 12,285.00 30545 REPAIR CHOANAL ATRESIA; TRANSPALATINE 35,100.00 18,720.00 16,380.00 30560 LYSIS INTRANASAL SYNECHIA 16,107.00 9,555.00 6,552.00 30580 REPAIR FISTULA; OROMAXILLARY (COMBINE W/ 31030 IF ANTROTOMY IS INCLUDED) 23,634.00 10,530.00 13,104.00 30600 REPAIR FISTULA; ORONASAL 23,634.00 10,530.00 13,104.00 30630 REPAIR NASAL SEPTAL PERFORATIONS 23,634.00 10,530.00 13,104.00 30801 CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD, ; SUPERFICIAL 18,915.00 10,725.00 8,190.00 30802 CAUTERIZATION AND/OR ABLATION, MUCOSA OF TURBINATES, UNILATERAL OR BILATERAL, ANY METHOD, ; INTRAMURAL 18,915.00 10,725.00 8,190.00 30905 CONTROL NASAL HEMORRHAGE, POSTERIOR, W/ POSTERIOR NASAL PACKS AND/OR CAUTERIZATION, ANY METHOD; INITIAL 15,639.00 10,725.00 4,914.00 30915 LIGATION ARTERIES; ETHMOIDAL 23,634.00 10,530.00 13,104.00 30920 LIGATION ARTERIES; INTERNAL MAXILLARY ARTERY, TRANSANTRAL 23,634.00 10,530.00 13,104.00 30930 FRACTURE NASAL TURBINATE(S), THERAPEUTIC 18,915.00 10,725.00 8,190.00 31000 LAVAGE BY CANNULATION; MAXILLARY SINUS (ANTRUM PUNCTURE OR NATURAL OSTIUM) 18,135.00 14,040.00 4,095.00 31002 LAVAGE BY CANNULATION; SPHENOID SINUS 15,639.00 10,725.00 4,914.00 31020 SINUSOTOMY, MAXILLARY (ANTROTOMY); INTRANASAL 18,915.00 10,725.00 8,190.00 31030 SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL- LUC) W/O REMOVAL OF ANTROCHOANAL POLYPS 23,634.00 10,530.00 13,104.00 31032 SINUSOTOMY, MAXILLARY (ANTROTOMY); RADICAL (CALDWELL- LUC) W/ REMOVAL OF ANTROCHOANAL POLYPS 23,634.00 10,530.00 13,104.00 31040 PTERYGOMAXILLARY FOSSA SURGERY, ANY APPROACH 45,435.00 20,865.00 24,570.00 31050 SINUSOTOMY, SPHENOID, W/ OR W/O BIOPSY; 45,435.00 20,865.00 24,570.00 31051 SINUSOTOMY, SPHENOID, W/ OR W/O BIOPSY; W/ MUCOSAL STRIPPING OR REMOVAL OF POLYP(S) 45,435.00 20,865.00 24,570.00 31070 SINUSOTOMY FRONTAL; EXTERNAL, SIMPLE (TREPHINE OPERATION) 23,634.00 10,530.00 13,104.00 31075 SINUSOTOMY FRONTAL; TRANSORBITAL, UNILATERAL (FOR MUCOCELE OR OSTEOMA, LYNCH TYPE) 23,634.00 10,530.00 13,104.00 31080 SINUSOTOMY FRONTAL; OBLITERATIVE W/O OSTEOPLASTIC FLAP, BROW INCISION (INCLUDES ABLATION) 23,634.00 10,530.00 13,104.00 31081 SINUSOTOMY FRONTAL; OBLITERATIVE, W/O OSTEOPLASTIC FLAP, CORONAL INICISION (INCLUDES ABLATION) 23,634.00 10,530.00 13,104.00 31084 SINUSOTOMY FRONTAL; OBLITERATIVE, W/ OSTEOPLASTIC FLAP, BROW INCISION 23,634.00 10,530.00 13,104.00 31085 SINUSOTOMY FRONTAL; OBLITERATIVE, W/ OSTEOPLASTIC FLAP, CORONAL INCISION 45,435.00 20,865.00 24,570.00 31086 SINUSOTOMY FRONTAL; NONOBLITERATIVE, W/ OSTEOPLASTIC FLAP, BROW INCISION 45,435.00 20,865.00 24,570.00 31087 SINUSOTOMY FRONTAL; NONOBLITERATIVE, W/ OSTEOPLASTIC FLAP, CORONAL INCISION 45,435.00 20,865.00 24,570.00 31090 SINUSOTOMY COMBINED, THREE OR MORE SINUSES 45,435.00 20,865.00 24,570.00 31200 ETHMOIDECTOMY; INTRANASAL, ANTERIOR 23,634.00 10,530.00 13,104.00 31201 ETHMOIDECTOMY; INTRANASAL, TOTAL 23,634.00 10,530.00 13,104.00 31205 ETHMOIDECTOMY; EXTRANASAL, TOTAL 23,634.00 10,530.00 13,104.00 31225 MAXILLECTOMY; W/O ORBITAL EXENTERATION 90,675.00 41,535.00 49,140.00 31230 MAXILLECTOMY; W/ ORBITAL EXENTERATION (EN BLOC) 104,130.00 46,800.00 57,330.00 31231 NASAL ENDOSCOPY, DIAGNOSTIC, UNILATERAL OR BILATERAL 20,553.00 10,725.00 9,828.00 31233 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC W/ MAXILLARY SINUSOSCOPY (VIA INFERIOR MEATUS OR CANINE FOSSA PUNCTURE) 20,553.00 10,725.00 9,828.00 31235 NASAL/SINUS ENDOSCOPY, DIAGNOSTIC W/ SPHENOID SINUSOSCOPY (VIA PUNCTURE OF SPHENOIDAL FACE OR CANNULATION OF OSTIUM) 20,553.00 10,725.00 9,828.00 31237 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ BIOPSY, POLYPECTOMY OR DEBRIDEMENT 23,634.00 10,530.00 13,104.00 31238 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ CONTROL OF EPISTAXIS 23,634.00 10,530.00 13,104.00 31239 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ DACRYLOCYSTORHINOSTOMY 23,634.00 10,530.00 13,104.00 31240 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ CONCHA BULLOSA RESECTION 35,100.00 18,720.00 16,380.00 31254 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ ETHMOIDECTOMY, PARTIAL (ANTERIOR) 35,100.00 18,720.00 16,380.00 Page 39 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 31255 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ ETHMOIDECTOMY, TOTAL (ANTERIOR AND POSTERIOR) 35,100.00 18,720.00 16,380.00 31256 NASAL/SINUS ENDOSCOPY, SURGICAL, W/ MAXILLARY ANTROSTOMY 35,100.00 18,720.00 16,380.00 31267 NASAL/SINUS ENDOSCOPY, SURGICAL, W/ REMOVAL OF TISSUE FROM MAXILLARY SINUS 35,100.00 18,720.00 16,380.00 31276 NASAL/SINUS ENDOSCOPY, SURGICAL W/ FRONTAL SINUS EXPLORATION, W/ OR W/O REMOVAL OF TISSUE FROM FRONTAL SINUS 35,100.00 18,720.00 16,380.00 31287 NASAL/SINUS ENDOSCOPY, SURGICAL, W/ SPHENOIDOTOMY 35,100.00 18,720.00 16,380.00 31288 NASAL/SINUS ENDOSCOPY, SURGICAL, W/ REMOVAL OF TISSURE FROM THE SPHENOID SINUS 35,100.00 18,720.00 16,380.00 31290 NASAL/SINUS ENDOSCOPY, SURGICAL, W/ REPAIR OF CEREBROSPINAL FLUID LEAK; ETHMOID REGION 35,100.00 18,720.00 16,380.00 31291 NASAL/SINUS ENDOSCOPY, SURGICAL, SPHENOID REGION 35,100.00 18,720.00 16,380.00 31292 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ MEDIAL OR INFERIOR ORBITAL WALL DECOMPRESSION 35,100.00 18,720.00 16,380.00 31293 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ MEDIAL ORBITAL WALL AND INFERIOR ORBITAL WALL DECOMPRESSION 35,100.00 18,720.00 16,380.00 31294 NASAL/SINUS ENDOSCOPY, SURGICAL; W/ OPTIC NERVE DECOMPRESSION 45,435.00 20,865.00 24,570.00 31300 LARYNGOTOMY (THYROTOMY, LARYNGOFISSURE); W/ REMOVAL OF TUMOR OR LARYNGOCELE, CORDECTOMY 35,100.00 18,720.00 16,380.00 31360 LARYNGECTOMY; TOTAL, W/O RADICAL NECK DISSECTION 60,723.00 26,325.00 34,398.00 31365 LARYNGECTOMY; TOTAL, W/ RADICAL NECK DISSECTION 73,710.00 32,760.00 40,950.00 31367 LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, W/O RADICAL NECK DISSECTION 72,501.00 36,465.00 36,036.00 31368 LARYNGECTOMY; SUBTOTAL SUPRAGLOTTIC, W/ RADICAL NECK DISSECTION 75,777.00 36,465.00 39,312.00 31370 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); HORIZONTAL 60,723.00 26,325.00 34,398.00 31375 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); LATEROVERTICAL 60,723.00 26,325.00 34,398.00 31380 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTEROVERTICAL 60,723.00 26,325.00 34,398.00 31382 PARTIAL LARYNGECTOMY (HEMILARYNGECTOMY); ANTERO- LATERO-VERTICAL 60,723.00 26,325.00 34,398.00 31390 PHARYNGOLARYNGECTOMY, W/ RADICAL NECK DISSECTION; W/O RECONSTRUCTION 73,710.00 32,760.00 40,950.00 31395 PHARYNGOLARYNGECTOMY, W/ RADICAL NECK DISSECTION; W/ RECONSTRUCTION 90,675.00 41,535.00 49,140.00 31400 ARYTENOIDECTOMY OR ARYTENOIDOPEXY, EXTERNAL APPROACH 59,085.00 26,325.00 32,760.00 31420 EPIGLOTTIDECTOMY 45,435.00 20,865.00 24,570.00 31515 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; FOR ASPIRATION 15,639.00 10,725.00 4,914.00 31520 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; DIAGNOSTIC, NEWBORN 18,915.00 10,725.00 8,190.00 31525 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; DIAGNOSTIC, EXCEPT NEWBORN 15,639.00 10,725.00 4,914.00 31526 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; DIAGNOSTIC, W/ OPERATING MICROSCOPE 18,915.00 10,725.00 8,190.00 31527 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; W/ INSERTION OF OBTURATOR 15,639.00 10,725.00 4,914.00 31528 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; W/ DILATATION, INITIAL 15,639.00 10,725.00 4,914.00 31529 LARYNGOSCOPY DIRECT, W/ OR W/O TRACHEOSCOPY; W/ DILATATION, SUBSEQUENT 15,639.00 10,725.00 4,914.00 31530 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ FOREIGN BODY REMOVAL; 23,634.00 10,530.00 13,104.00 31531 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ FOREIGN BODY REMOVAL; W/ OPERATING MICROSCOPE 23,634.00 10,530.00 13,104.00 31535 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ BIOPSY; 23,634.00 10,530.00 13,104.00 31536 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ BIOPSY; W/ OPERATING MICROSCOPE 23,634.00 10,530.00 13,104.00 31540 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; 23,634.00 10,530.00 13,104.00 31541 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ EXCISION OF TUMOR AND/OR STRIPPING OF VOCAL CORDS OR EPIGLOTTIS; W/ OPERATING MICROSCOPE 23,634.00 10,530.00 13,104.00 31560 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ ARYTENOIDECTOMY; 59,085.00 26,325.00 32,760.00 31561 LARYNGOSCOPY, DIRECT, OPERATIVE, W/ ARYTENOIDECTOMY; W/ OPERATING MICROSCOPE 59,085.00 26,325.00 32,760.00 31570 LARYNGOSCOPY, DIRECT, W/ INJECTION INTO VOCAL CORD(S), THERAPEUTIC; 23,634.00 10,530.00 13,104.00 31571 LARYNGOSCOPY, DIRECT, W/ INJECTION INTO VOCAL CORD(S), THERAPEUTIC; W/ OPERATING MICROSCOPE 23,634.00 10,530.00 13,104.00 31575 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; DIAGNOSTIC 23,634.00 10,530.00 13,104.00 31576 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; W/ BIOPSY 23,634.00 10,530.00 13,104.00 31577 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; W/ REMOVAL OF FOREIGN BODY 23,634.00 10,530.00 13,104.00 31578 LARYNGOSCOPY, FLEXIBLE FIBEROPTIC; W/ REMOVAL OF LESION 23,634.00 10,530.00 13,104.00 31579 LARYNGOSCOPY, FLEXIBLE OR RIGID FIBEROPTIC, W/ STROBOSCOPY 23,634.00 10,530.00 13,104.00 Page 40 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 31580 LARYNGOPLASTY; FOR LARYNGEAL WEB, TWO STAGE, W/ KEEL INSERTION AND REMOVAL 59,085.00 26,325.00 32,760.00 31582 LARYNGOPLASTY; FOR LARYNGEAL STENOSIS, W/ GRAFT OR CORE MOLD, INCLUDING TRACHEOTOMY 59,085.00 26,325.00 32,760.00 31584 LARYNGOPLASTY; W/ OPEN REDUCTION OF FRACTURE 59,085.00 26,325.00 32,760.00 31586 LARYNGOPLASTY; W/ CLOSED MANIPULATIVE REDUCTION 59,085.00 26,325.00 32,760.00 31587 LARYNGOPLASTY, CRICOID SPLIT 59,085.00 26,325.00 32,760.00 31588 LARYNGOPLASTY, NOT OTHERWISE SPECIFIED (E.G., FOR BURNS, RECONSTRUCTION AFTER PARTIAL LARYNGECTOMY) 59,085.00 26,325.00 32,760.00 31590 LARYNGEAL REINNERVATION BY NEUROMUSCULAR PEDICLE 59,085.00 26,325.00 32,760.00 31595 SECTION RECURRENT LARYNGEAL NERVE, THERAPEUTIC , UNILATERAL 45,435.00 20,865.00 24,570.00 31600 TRACHEOSTOMY, PLANNED ; 23,634.00 10,530.00 13,104.00 31601 TRACHEOSTOMY, PLANNED ; UNDER TWO YEARS 24,453.00 10,530.00 13,923.00 31603 TRACHEOSTOMY, EMERGENCY PROCEDURE; TRANSTRACHEAL 13,923.00 4,641.00 9,282.00 31605 TRACHEOSTOMY, EMERGENCY PROCEDURE; CRICOTHYROID MEMBRANE 24,453.00 10,530.00 13,923.00 31610 TRACHEOSTOMY, FENESTRATION PROCEDURE WITH SKIN FLAPS 24,453.00 10,530.00 13,923.00 31611 CONSTRUCTION OF TRACHEOESOPHAGEAL FISTULA AND SUBSEQUENT INSERTION OF AN ALARYNGEAL SPEECH PROSTHESIS (E.G., VOICE BUTTON, BLOM-SINGER PROSTHESIS) 29,172.00 14,430.00 14,742.00 31612 TRACHEAL PUNCTURE, PERCUTANEOUS W/ TRANSTRACHEAL ASPIRATION AND/OR INJECTION 25,155.00 12,870.00 12,285.00 31613 TRACHEOSTOMA REVISION; SIMPLE, W/O FLAP ROTATION 23,634.00 10,530.00 13,104.00 31614 TRACHEOSTOMA REVISION; COMPLEX, W/ FLAP ROTATION 29,172.00 14,430.00 14,742.00 31615 TRACHEOBRONCHOSCOPY THROUGH ESTABLISHED TRACHEOSTOMY INCISION 23,634.00 10,530.00 13,104.00 31622 BRONCHOSCOPY; DIAGNOSTIC, (FLEXIBLE OR RIGID), W/ OR W/O CELL WASHING OR BRUSHING 21,372.00 10,725.00 10,647.00 31625 BRONCHOSCOPY; W/ BIOPSY 21,372.00 10,725.00 10,647.00 31628 BRONCHOSCOPY; W/ TRANSBRONCHIAL LUNG BIOPSY, W/ OR W/O FLUOROSCOPIC GUIDANCE 21,372.00 10,725.00 10,647.00 31629 BRONCHOSCOPY; W/ TRANSBRONCHIAL NEEDLE ASPIRATION BIOPSY 21,372.00 10,725.00 10,647.00 31630 BRONCHOSCOPY; W/ TRACHEAL OR BRONCHIAL DILATION OR CLOSED REDUCTION OF FRACTURE 35,100.00 18,720.00 16,380.00 31631 BRONCHOSCOPY; W/ TRACHEAL DILATION AND PLACEMENT OF TRACHEAL STENT 35,100.00 18,720.00 16,380.00 31635 BRONCHOSCOPY; W/ REMOVAL OF FOREIGN BODY 35,100.00 18,720.00 16,380.00 31636 BRONCHOSCOPY; DIAGNOSTIC, (FLEXIBLE OR RIGID),W/ PLACEMENT OF BRONCHIAL STENTS 35,100.00 18,720.00 16,380.00 31640 BRONCHOSCOPY; W/ EXCISION OF TUMOR 59,085.00 26,325.00 32,760.00 31641 BRONCHOSCOPY; W/ DESTRUCTION OF TUMOR OR RELIEF OF STENOSIS BY ANY METHOD OTHER THAN EXCISION (E.G., LASER) 59,085.00 26,325.00 32,760.00 31643 BRONCHOSCOPY; W/ PLACEMENT OF CATHETERS FOR INTRACAVITARY RADIOELEMENT APPLICATION 35,100.00 18,720.00 16,380.00 31645 BRONCHOSCOPY; W/ THERAPEUTIC ASPIRATION OF TRACHEOBRONCHIAL TREE, (E.G., DRAINAGE OF LUNG ABSCESS) 45,435.00 20,865.00 24,570.00 31710 CATHETERIZATION FOR BRONCHOGRAPHY, W/ OR W/O INSTILLATION OF CONTRAST MATERIAL 10,842.00 8,385.00 2,457.00 31717 CATHETERIZATION W/ BRONCHIAL BRUSH BIOPSY 45,435.00 20,865.00 24,570.00 31750 TRACHEOPLASTY; CERVICAL 73,710.00 32,760.00 40,950.00 31755 TRACHEOPLASTY; TRACHEOPHARYNGEAL FISTULIZATION, EACH STAGE 73,710.00 32,760.00 40,950.00 31760 TRACHEOPLASTY; INTRATHORACIC 104,130.00 46,800.00 57,330.00 31766 CARINAL RECONSTRUCTION 107,250.00 41,730.00 65,520.00 31770 BRONCHOPLASTY; GRAFT REPAIR 107,250.00 41,730.00 65,520.00 31775 BRONCHOPLASTY; EXCISION STENOSIS AND ANASTOMOSIS 107,250.00 41,730.00 65,520.00 31780 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICAL 90,675.00 41,535.00 49,140.00 31781 EXCISION TRACHEAL STENOSIS AND ANASTOMOSIS; CERVICOTHORACIC 104,130.00 46,800.00 57,330.00 31785 EXCISION OF TRACHEAL TUMOR OR CARCINOMA; CERVICAL 73,710.00 32,760.00 40,950.00 31786 EXCISION OF TRACHEAL TUMOR OR CARCINOMA; THORACIC 107,250.00 41,730.00 65,520.00 31800 SUTURE OF TRACHEAL WOUND OR INJURY; CERVICAL 45,435.00 20,865.00 24,570.00 31805 SUTURE OF TRACHEAL WOUND OR INJURY; INTRATHORACIC 73,710.00 32,760.00 40,950.00 31820 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA W/O PLASTIC REPAIR 16,458.00 10,725.00 5,733.00 31825 SURGICAL CLOSURE TRACHEOSTOMY OR FISTULA WITH PLASTIC REPAIR 18,915.00 10,725.00 8,190.00 32000 THORACENTESIS, PUNCTURE OF PLEURAL CAVITY FOR ASPIRATION, INITIAL OR SUBSEQUENT 2,457.00 819.00 1,638.00 32002 THORACENTESIS W/ INSERTION OF TUBE W/ OR W/O WATER SEAL (E.G., FOR PNEUMOTHORAX) 20,553.00 10,725.00 9,828.00 32005 CHEMICAL PLEURODESIS (E.G., FOR RECURRENT OR PERSISTENT PNEUMOTHORAX) 20,553.00 10,725.00 9,828.00 32020 TUBE THORACOSTOMY W/ OR W/O WATER SEAL (E.G., FOR ABSCESS, HEMOTHORAX, EMPYEMA) 15,561.00 5,187.00 10,374.00 32035 THORACOSTOMY; W/ RIB RESECTION FOR EMPYEMA 23,634.00 10,530.00 13,104.00 Page 41 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 32036 THORACOSTOMY; W/ OPEN FLAP DRAINAGE FOR EMPYEMA 35,919.00 18,720.00 17,199.00 32095 THORACOTOMY, LIMITED, FOR BIOPSY OF LUNG OR PLEURA 60,723.00 26,325.00 34,398.00 32100 THORACOTOMY, MAJOR; W/ EXPLORATION AND BIOPSY 73,710.00 32,760.00 40,950.00 32110 THORACOTOMY, MAJOR; W/ CONTROL OF TRAUMATIC HEMORRHAGE AND/OR REPAIR OF LUNG TEAR 73,710.00 32,760.00 40,950.00 32120 THORACOTOMY, MAJOR; FOR POSTOPERATIVE COMPLICATIONS 73,710.00 32,760.00 40,950.00 32124 THORACOTOMY, MAJOR; W/ OPEN INTRAPLEURAL PNEUMONOLYSIS 73,710.00 32,760.00 40,950.00 32140 THORACOTOMY, MAJOR; W/ CYST(S) REMOVAL, W/ OR W/O A PLEURAL PROCEDURE 73,710.00 32,760.00 40,950.00 32141 THORACOTOMY, MAJOR; W/ EXCISION-PLICATION OF BULLAE, W/ OR W/O A PLEURAL PROCEDURE 80,262.00 32,760.00 47,502.00 32150 THORACOTOMY, MAJOR; W/ REMOVAL OF INTRAPLEURAL FOREIGN BODY OR FIBRIN DEPOSIT 74,958.00 36,465.00 38,493.00 32151 THORACOTOMY, MAJOR; W/ REMOVAL OF INTRAPULMONARY FOREIGN BODY 74,958.00 36,465.00 38,493.00 32160 THORACOTOMY, MAJOR; W/ CARDIAC MASSAGE 74,958.00 36,465.00 38,493.00 32200 PNEUMONOSTOMY, W/ OPEN DRAINAGE OF ABSCESS OR CYST 19,734.00 10,725.00 9,009.00 32215 PLEURAL SCARIFICATION FOR REPEAT PNEUMOTHORAX 75,348.00 32,760.00 42,588.00 32220 DECORTICATION, PULMONARY ; TOTAL 74,958.00 36,465.00 38,493.00 32225 DECORTICATION, PULMONARY ; PARTIAL 59,085.00 26,325.00 32,760.00 32310 PLEURECTOMY, PARIETAL 73,710.00 32,760.00 40,950.00 32320 DECORTICATION AND PARIETAL PLEURECTOMY 73,710.00 32,760.00 40,950.00 32400 BIOPSY, PLEURA; PERCUTANEOUS NEEDLE 10,842.00 8,385.00 2,457.00 32402 BIOPSY, PLEURA; OPEN 72,501.00 36,465.00 36,036.00 32405 BIOPSY, LUNG OR MEDIASTINUM, PERCUTANEOUS NEEDLE 16,458.00 10,725.00 5,733.00 32420 PNEUMONOCENTESIS, PUNCTURE OF LUNG FOR ASPIRATION 10,842.00 8,385.00 2,457.00 32440 REMOVAL OF LUNG, TOTAL PNEUMONECTOMY 90,675.00 41,535.00 49,140.00 32442 REMOVAL OF LUNG, W/ RESECTION OF SEGMENT OF TRACHEA FOLLOWED BY BRONCHO-TRACHEAL ANASTOMOSIS (SLEEVE PNEUMONECTOMY) 107,406.00 46,800.00 60,606.00 32445 REMOVAL OF LUNG, EXTRAPLEURAL 107,406.00 46,800.00 60,606.00 32480 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE LOBE (LOBECTOMY) 80,262.00 32,760.00 47,502.00 32482 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY;
TWO LOBES (BILOBECTOMY) 90,675.00 41,535.00 49,140.00 32484 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; SINGLE SEGMENT (SEGMENTECTOMY) 90,675.00 41,535.00 49,140.00 32486 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; W/ CIRCUMFERENTIAL RESECTION OF SEGMENT OF BRONCHUS FOLLOWED BY BRONCHO-BRONCHIAL ANASTOMOSIS (SLEEVE LOBECTOMY) 107,406.00 46,800.00 60,606.00 32488 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; ALL REMAINING LUNG FOLLOWING PREVIOUS REMOVAL OF A PORTION OF LUNG (COMPLETION PNEUMONECTOMY) 104,130.00 46,800.00 57,330.00 32491 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; EXCISION-PLICATION OF EMPHYSEMATOUS LUNG(S) (BULLOUS OR NON-BULLOUS) FOR LUNG VOLUMEREMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; REDUCTION, STERNAL SPLIT OR TRANSTHORACIC APPROACH, W/ OR W/O ANY PLEURA 80,262.00 32,760.00 47,502.00 32500 REMOVAL OF LUNG, OTHER THAN TOTAL PNEUMONECTOMY; WEDGE RESECTION, SINGLE OR MULTIPLE 78,624.00 32,760.00 45,864.00 32520 RESECTION OF LUNG; W/ RESECTION OF CHEST WALL 104,130.00 46,800.00 57,330.00 32522 RESECTION OF LUNG; W/ RECONSTRUCTION OF CHEST WALL, W/O PROTHESIS 104,130.00 46,800.00 57,330.00 32525 RESECTION OF LUNG; W/ MAJOR RECONSTRUCTION OF CHEST WALL, W/ PROSTHESIS 104,130.00 46,800.00 57,330.00 32540 EXTRAPLEURAL ENUCLEATION OF EMPYEMA (EMPYEMECTOMY) 74,958.00 36,465.00 38,493.00 32601 THORACOSCOPY, DIAGNOSTIC ; LUNGS AND PLEURAL SPACE, W/O BIOPSY 23,361.00 11,895.00 11,466.00 32602 THORACOSCOPY, DIAGNOSTIC ; LUNGS AND PLEURAL SPACE, W/ BIOPSY 25,155.00 12,870.00 12,285.00 32603 THORACOSCOPY, DIAGNOSTIC ; PERICARDIAL SAC, W/O BIOPSY 23,634.00 10,530.00 13,104.00 32604 THORACOSCOPY, DIAGNOSTIC ; PERICARDIAL SAC, W/ BIOPSY 23,634.00 10,530.00 13,104.00 32605 THORACOSCOPY, DIAGNOSTIC ; MEDIASTINAL SPACE, W/O BIOPSY 23,634.00 10,530.00 13,104.00 32606 THORACOSCOPY, DIAGNOSTIC ; MEDIASTINAL SPACE, W/ BIOPSY 23,634.00 10,530.00 13,104.00 32650 THORACOSCOPY, SURGICAL; W/ PLEURODESIS, ANY METHOD 23,634.00 10,530.00 13,104.00 32651 THORACOSCOPY, SURGICAL; W/ PARTIAL PULMONARY DECORTICATION 23,634.00 10,530.00 13,104.00 32652 THORACOSCOPY, SURGICAL; W/ TOTAL PULMONARY DECORTICATION, INCLUDING INTRAPLEURAL PNEUMONOLYSIS 23,634.00 10,530.00 13,104.00 32653 THORACOSCOPY, SURGICAL; W/ REMOVAL OF INTRAPLEURAL FOREIGN BODY OR FIRBIN DEPOSIT 23,634.00 10,530.00 13,104.00 32654 THORACOSCOPY, SURGICAL; W/ CONTROL OF TRAUMATIC HEMORRHAGE 59,085.00 26,325.00 32,760.00 Page 42 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 32655 THORACOSCOPY, SURGICAL; W/ EXCISION-PLICATION OF BULLAE, INCLUDING ANY PLEURAL PROCEDURE 80,262.00 32,760.00 47,502.00 32656 THORACOSCOPY, SURGICAL; W/ PARIETAL PLEURECTOMY 75,348.00 32,760.00 42,588.00 32658 THORACOSCOPY, SURGICAL; W/ REMOVAL OF CLOT OR FOREIGN BODY FROM PERICARDIAL SAC 75,348.00 32,760.00 42,588.00 32659 THORACOSCOPY, SURGICAL; W/ CREATION OF PERCARDIAL WINDOW OR PARTIAL RESECTION OF PERICARDIAL SAC FOR DRAINAGE 75,348.00 32,760.00 42,588.00 32660 THORACOSCOPY, SURGICAL; W/ TOTAL PERICARDIECTOMY 80,262.00 32,760.00 47,502.00 32661 THORACOSCOPY, SURGICAL; W/ EXCISION OF PERICARDIAL CYST, TUMOR, OR MASS 80,262.00 32,760.00 47,502.00 32662 THORACOSCOPY, SURGICAL; W/ EXCISION OF MEDIASTINAL CYST, TUMOR, OR MASS 80,262.00 32,760.00 47,502.00 32663 THORACOSCOPY, SURGICAL; W/ LOBECTOMY, TOTAL OR SEGMENTAL 90,675.00 41,535.00 49,140.00 32664 THORACOSCOPY, SURGICAL; W/ THORACIC SYMPATHECTOMY 80,262.00 32,760.00 47,502.00 32665 THORACOSCOPY, SURGICAL; W/ ESOPHAGOMYOTOMY (HELLER TYPE) 80,262.00 32,760.00 47,502.00 32800 REPAIR LUNG HERNIA THROUGH CHEST WALL 45,435.00 20,865.00 24,570.00 32810 CLOSURE OF CHEST WALL FOLLOWING OPEN FLAP DRAINAGE FOR EMPYEMA (CLAGETT TYPE PROCEDURE) 45,435.00 20,865.00 24,570.00 32815 OPEN CLOSURE OF MAJOR BRONCHIAL FISTULA 90,675.00 41,535.00 49,140.00 32820 MAJOR RECONSTRUCTION, CHEST WALL (POSTTRAUMATIC) 90,675.00 41,535.00 49,140.00 32850 DONOR PNEUMONECTOMY(IES) W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT (CADAVER) 107,250.00 41,730.00 65,520.00 32851 LUNG TRANSPLANT, SINGLE; W/O CARDIOPULMONARY BYPASS 122,850.00 40,950.00 81,900.00 32852 LUNG TRANSPLANT, SINGLE; W/ CARDIOPULMONARY BYPASS 126,126.00 40,950.00 85,176.00 32853 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); W/O CARDIOPULMONARY BYPASS 127,764.00 40,950.00 86,814.00 32854 LUNG TRANSPLANT, DOUBLE (BILATERAL SEQUENTIAL OR EN BLOC); W/ CARDIOPULMONARY BYPASS 127,764.00 40,950.00 86,814.00 32900 RESECTION OF RIBS, EXTRAPLEURAL, ALL STAGES 90,675.00 41,535.00 49,140.00 32905 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); 90,675.00 41,535.00 49,140.00 32906 THORACOPLASTY, SCHEDE TYPE OR EXTRAPLEURAL (ALL STAGES); W/ CLOSURE OF BRONCHIAL FISTULA 90,675.00 41,535.00 49,140.00 32940 PNEUMONOLYSIS, EXTRAPERIOSTEAL, INCLUDING FILLING OR PACKING PROCEDURES 59,085.00 26,325.00 32,760.00 32960 PNEUMOTHORAX, THERAPEUTIC, INTRAPLEURAL INJECTION OF AIR 10,842.00 8,385.00 2,457.00 33010 PERICARDIOCENTESIS 15,639.00 10,725.00 4,914.00 33015 TUBE PERICARDIOSTOMY 18,915.00 10,725.00 8,190.00 33020 PERICARDIOTOMY FOR REMOVAL OF CLOT OR FOREIGN BODY (PRIMARY PROCEDURE) 35,100.00 18,720.00 16,380.00 33025 CREATION OF PERICARDIAL WINDOW OR PARTIAL RESECTION FOR DRAINAGE 62,400.00 33,735.00 28,665.00 33030 PERICARDIECTOMY, SUBTOTAL OR COMPLETE; W/O CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33031 PERICARDIECTOMY, SUBTOTAL OR COMPLETE; W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33050 EXCISION OF PERICARDIAL CYST OR TUMOR 73,710.00 32,760.00 40,950.00 33120 EXCISION OF INTRACARDIAC TUMOR, RESECTION W/ CARDIOPULMONARY BYPASS 118,755.00 40,950.00 77,805.00 33130 RESECTION OF EXTERNAL CARDIAC TUMOR 77,805.00 32,760.00 45,045.00 33200 INSERTION OF PERMANENT PACEMAKER W/ EPICARDIAL ELECTRODE(S); BY THORACOTOMY 41,730.00 21,255.00 20,475.00 33201 INSERTION OF PERMANENT PACEMAKER W/ EPICARDIAL ELECTRODE(S); BY XIPHOID APPROACH 41,730.00 21,255.00 20,475.00 33206 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER W/ TRANSVENOUS ELECTRODE(S); ATRIAL 35,100.00 18,720.00 16,380.00 33207 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER W/ TRANSVENOUS ELECTRODE(S); VENTRICULAR 35,100.00 18,720.00 16,380.00 33208 INSERTION OR REPLACEMENT OF PERMANENT PACEMAKER W/ TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR 41,730.00 21,255.00 20,475.00 33210 INSERTION OR PLACEMENT OF TEMPORARY TRANSVENOUS SINGLE CHAMBER CARDIAC ELECTRODES 18,915.00 10,725.00 8,190.00 33211 INSERTION OR REPLACEMENT OF TEMPORARY TRANSVENOUS DUAL CHAMBER CARDIAC ELECTRODES 18,915.00 10,725.00 8,190.00 33212 INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; SINGLE CHAMBER 18,915.00 10,725.00 8,190.00 33213 INSERTION OR REPLACEMENT OF PACEMAKER PULSE GENERATOR ONLY; DUAL CHAMBER 25,155.00 12,870.00 12,285.00 33214 UPGRADE OF IMPLANTED PACEMAKER SYSTEM, CONVERSION OF SINGLE CHAMBER SYSTEM TO DUAL CHAMBER SYSTEM (INCLUDES REMOVAL OF PREVIOUSLY PLACED PULSE GENERATOR, TESTING OF EXISTING LEAD, INSERTION OF NEW LEAD, INSERTION OF NEW PULSE GENERATOR) 62,400.00 33,735.00 28,665.00 33216 INSERTION, REPLACEMENT OR REPOSITIONING OF PERMANENT TRANSVENOUS ELECTRODE(S) ONLY (15 DAYS OR MORE AFTER INITIAL INSERTION); SINGLE CHAMBER, ATRIAL OR VENTRICULAR 25,155.00 12,870.00 12,285.00 Page 43 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 33217 INSERTION, REPLACEMENT OR REPOSITIONING OF PERMANENT TRANSVENOUS ELECTRODE(S) ONLY (15 DAYS OR MORE AFTER INITIAL INSERTION); DUAL CHAMBER 35,100.00 18,720.00 16,380.00 33218 REPAIR OF SINGLE TRANSVENOUS ELECTRODE FOR A SINGLE CHAMBER, PERMANENT PACEMAKER OR SINGLE CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR 45,435.00 20,865.00 24,570.00 33220 REPAIR OF TWO TRANSVENOUS ELECTRODE FOR A DUAL CHAMBER, PERMANENT PACEMAKER OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR 45,435.00 20,865.00 24,570.00 33222 REVISION OR RELOCATION OF SKIN POCKET FOR PACEMAKER 35,100.00 18,720.00 16,380.00 33223 REVISION OR RELOCATION OF SKIN POCKET FOR SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR 35,100.00 18,720.00 16,380.00 33233 REMOVAL OF TRANSVENOUS PACEMAKER PULSE GENERATOR 25,155.00 12,870.00 12,285.00 33234 REMOVAL OF PERMANENT OF TRANSVENOUS PACEMAKER ELECTRODE(S); SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR 45,435.00 20,865.00 24,570.00 33235 REMOVAL OF PERMANENT OF TRANSVENOUS PACEMAKER ELECTRODE(S); DUAL LEAD CHAMBER 62,400.00 33,735.00 28,665.00 33236 REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; SINGLE LEAD SYSTEM, ATRIAL OR VENTRICULAR 59,085.00 26,325.00 32,760.00 33237 REMOVAL OF PERMANENT EPICARDIAL PACEMAKER AND ELECTRODES BY THORACOTOMY; DUAL LEAD CHAMBER 73,320.00 36,465.00 36,855.00 33238 REMOVAL OF PERMANENT TRANSVENOUS ELECTRODE(S) BY THORACOTOMY 59,085.00 26,325.00 32,760.00 33240 INSERTION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER- DEFIBRILLATOR PULSE GENERATOR 35,100.00 18,720.00 16,380.00 33241 REMOVAL OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR 35,100.00 18,720.00 16,380.00 33243 REMOVAL OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR AND/OR LEAD SYSTEM; BY THORACOTOMY 59,085.00 26,325.00 32,760.00 33244 REMOVAL OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR AND/OR LEAD SYSTEM; BY TRANSVENOUS EXTRACTION 59,085.00 26,325.00 32,760.00 33245 IMPLANTATION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PADS BY THORACOTOMY, W/ OR W/O SENSING ELECTRODES; 25,155.00 12,870.00 12,285.00 33246 IMPLANTATION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PADS BY THORACOTOMY, W/ INSERTION OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PULSE GENERATOR 41,730.00 21,255.00 20,475.00 33249 IMPLANTATION OR REPLACEMENT OF IMPLANTABLE CARDIOVERTER-DEFIBRILLATOR PADS BY THORACOTOMY, W/ INSERTION OF CARDIO-DEFIBRILLATOR PULSE GENERATOR 35,100.00 18,720.00 16,380.00 33250 OPERATIVE ABLATION OF SUPRAVENTICULAR ARRHYTHMOGENIC FOCUS OR PATHWAY (E.G., WOLFF-PARKINSON-WHITE, A-V NODE REENTRY), TRACT(S) AND/OR FOCUS (FOCI); W/O CARDIOPULMONARY BYPASS 73,320.00 36,465.00 36,855.00 33251 OPERATIVE ABLATION OF SUPRAVENTICULAR ARRHYTHMOGENIC FOCUS OR PATHWAY (E.G., WOLFF-PARKINSON-WHITE, A-V NODE REENTRY), TRACT(S) AND/OR FOCUS (FOCI); W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33253 OPERATIVE INCISIONS AND RECONSTRUCTION OF ATRIA FOR TREATMENT OF ATRIAL FIBRILLATION OR ATRIAL FLUTTER (E.G., MAZE PROCEDURE) 114,660.00 40,950.00 73,710.00 33261 OPERATIVE ABLATION OF VENTRICULAR ARRHYTHMOGENIC FOCUS W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33300 REPAIR OF CARDIAC WOUND; W/O BYPASS 90,675.00 41,535.00 49,140.00 33305 REPAIR OF CARDIAC WOUND; W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33310 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY); W/O BYPASS 90,675.00 41,535.00 49,140.00 33315 CARDIOTOMY, EXPLORATORY (INCLUDES REMOVAL OF FOREIGN BODY); W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33320 SUTURE REPAIR OF AORTA OR GREAT VESSELS; W/O SHUNT OR CARDIOPULMONARY BYPASS 59,085.00 26,325.00 32,760.00 33321 SUTURE REPAIR OF AORTA OR GREAT VESSELS; W/ SHUNT BYPASS 114,660.00 40,950.00 73,710.00 33322 SUTURE REPAIR OF AORTA OR GREAT VESSELS; W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33330 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; W/O SHUNT, OR CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33332 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; W/ SHUNT BYPASS 122,850.00 40,950.00 81,900.00 33335 INSERTION OF GRAFT, AORTA OR GREAT VESSELS; W/ CARDIOPULMONARY BYPASS 122,850.00 40,950.00 81,900.00 33400 VALVULOPLASTY, AORTIC VALVE; OPEN, W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33401 VALVULOPLASTY, AORTIC VALVE; OPEN, W/ INFLOW OCCLUSION 104,130.00 46,800.00 57,330.00 33403 VALVULOPLASTY, AORTIC VALVE; USING TRANSVENTRICULAR DILATION, W/ CARDIOPULMONARY BYPASS 107,250.00 41,730.00 65,520.00 33404 CONSTRUCTION OF APICA-AORTIC CONDUIT 114,660.00 40,950.00 73,710.00 Page 44 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 33405 REPLACEMENT, AORTIC VALVE, W/ CARDIOPULMONARY BYPASS; W/ PROSTHETIC VALVE OTHER THAN HOMOGRAFT 104,130.00 46,800.00 57,330.00 33406 REPLACEMENT, AORTIC VALVE, W/ CARDIOPULMONARY BYPASS; W/ HOMOGRAFT VALVE (FREEHAND) 114,660.00 40,950.00 73,710.00 33411 REPLACEMENT, AORTIC VALVE; W/ AORTIC ANNULUS ENLARGEMENT, NONCORONARY CUSP 107,250.00 41,730.00 65,520.00 33412 REPLACEMENT, AORTIC VALVE; W/ TRANSVENTRICULAR AORTIC ANNULUS ENLARGEMENT (KONNO PROCEDURE) 114,660.00 40,950.00 73,710.00 33413 REPLACEMENT, AORTIC VALVE; W/ TRANSLOCATION OF AUTOLOGOUS PULMONARY VALVE W/ HEMOGRAFT REPACEMENT OF PULMONARY VALVE (ROSS PROCEDURE) 139,230.00 40,950.00 98,280.00 33414 REPAIR OF LEFT VENTRICULAR OUTFLOW TRACT OBTRUCTION BY PATCH ENLARGEMENT OF THE OUTFLOW TRACT 90,675.00 41,535.00 49,140.00 33415 RESECTION OR INCISION OF SUBVALVULAR TISSUE FOR DISCRETE SUBAORTIC STENOSIS (E.G., ASYMMETRIC SEPTAL HYPERTROPHY) 90,675.00 41,535.00 49,140.00 33416 VENTRICULOMYOTOMY (-MYECTOMY) FOR IDIOPATHIC HYPERTROPHIC SUBAORTIC STENOSIS (E.G., ASYMMETRIC SEPTAL HYPERTROPHY) 107,250.00 41,730.00 65,520.00 33417 AORTOPLASTY (GUSSET) FOR SUPRAVALVULAR STENOSIS 90,675.00 41,535.00 49,140.00 33420 VALVOTOMY, MITRAL VALVE; CLOSED HEART 73,710.00 32,760.00 40,950.00 33422 VALVOTOMY, MITRAL VALVE; OPEN HEART, W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33425 VALVULOPLASTY, MITRAL VALVE, W/ CARDIOPULMONARY BYPASS; 107,250.00 41,730.00 65,520.00 33426 VALVULOPLASTY, MITRAL VALVE, W/ CARDIOPULMONARY BYPASS; W/ PROSTHETIC RING 111,345.00 41,730.00 69,615.00 33427 VALVULOPLASTY, MITRAL VALVE, W/ CARDIOPULMONARY BYPASS; RADICAL RECONSTRUCTION, W/ OR W/O RING 114,660.00 40,950.00 73,710.00 33430 REPLACEMENT, MITRAL VALVE, W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33460 VALVECTOMY, TRICUSPID VALVE, W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33463 VALVULOPLASTY, TRICUSPID VALVE; W/O RING INSERTION 104,130.00 46,800.00 57,330.00 33464 VALVULOPLASTY, TRICUSPID VALVE; W/ RING INSERTION 107,250.00 41,730.00 65,520.00 33465 REPLACEMENT, TRICUSPID VALVE, W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33468 TRICUSPID VALVE REPOSITIONING AND PLICATION FOR EBSTEIN ANOMALY 114,660.00 40,950.00 73,710.00 33470 VALVOTOMY, PULMONARY VALVE, CLOSED HEART; TRANSVENTRICULAR 59,085.00 26,325.00 32,760.00 33471 VALVOTOMY, PULMONARY VALVE, CLOSED HEART; VIA PULMONARY ARTERY 45,435.00 20,865.00 24,570.00 33472 VALVOTOMY, PULMONARY VALVE, OPEN HEART; W/ INFLOW OCCLUSION 90,675.00 41,535.00 49,140.00 33474 VALVOTOMY, PULMONARY VALVE, OPEN HEART; W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33475 REPLACEMENT, PULMONARY VALVE 104,130.00 46,800.00 57,330.00 33476 RIGHT VENTRICULAR RESECTION FOR INFUNDIBULAR STENOSIS, WITH OR WITHOUT COMMISUROTOMY 90,675.00 41,535.00 49,140.00 33478 OUTFLOW TRACT AUGMENTATION (GUSSET), W/ OR W/O COMMISSUROTOMY OR INFUNDIBULAR RESECTION 104,130.00 46,800.00 57,330.00 33500 REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33501 REPAIR OF CORONARY ARTERIOVENOUS OR ARTERIOCARDIAC CHAMBER FISTULA; W/O CARDIOPULMONARY BYPASS 59,085.00 26,325.00 32,760.00 33502 REPAIR OF ANOMALOUS CORONARY ARTERY; BY LIGATION 59,085.00 26,325.00 32,760.00 33503 REPAIR OF ANOMALOUS CORONARY ARTERY; BY GRAFT, W/O CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33504 REPAIR OF ANOMALOUS CORONARY ARTERY; BY GRAFT, W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33505 REPAIR OF ANOMALOUS CORONARY ARTERY; WITH CONSTRUCTION OF INTRAPULMONARY ARTERY TUNNEL (TAKEUCHI PROCEDURE) 104,130.00 46,800.00 57,330.00 33506 REPAIR OF ANOMALOUS CORONARY ARTERY; BY TRANSLOCATION FROM PULMONARY ARTERY TO AORTA 104,130.00 46,800.00 57,330.00 33510 CORONARY ARTERY BYPASS, VEIN ONLY; SINGLE CORONARY VENOUS GRAFT 104,130.00 46,800.00 57,330.00 33511 CORONARY ARTERY BYPASS, VEIN ONLY; TWO CORONARY VENOUS GRAFTS 104,130.00 46,800.00 57,330.00 33512 CORONARY ARTERY BYPASS, VEIN ONLY; THREE CORONARY VENOUS GRAFTS 107,250.00 41,730.00 65,520.00 33513 CORONARY ARTERY BYPASS, VEIN ONLY; FOUR CORONARY VENOUS GRAFTS 114,660.00 40,950.00 73,710.00 33514 CORONARY ARTERY BYPASS, VEIN ONLY; FIVE CORONARY VENOUS GRAFTS 114,660.00 40,950.00 73,710.00 33516 CORONARY ARTERY BYPASS, VEIN ONLY; SIX OR MORE CORONARY VENOUS GRAFTS 114,660.00 40,950.00 73,710.00 33517 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); SINGLE VEIN GRAFT (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 104,130.00 46,800.00 57,330.00 33518 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); TWO VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 104,130.00 46,800.00 57,330.00 Page 45 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 33519 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); THREE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 107,250.00 41,730.00 65,520.00 33521 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); FOUR VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 114,660.00 40,950.00 73,710.00 33522 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); FIVE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 114,660.00 40,950.00 73,710.00 33523 CORONARY ARTERY BYPASS, USING VENOUS GRAFT(S) AND ARTERIAL GRAFT(S); SIX OR MORE VENOUS GRAFTS (LIST SEPARATELY IN ADDITION TO CODE FOR ARTERIAL GRAFT) 114,660.00 40,950.00 73,710.00 33530 REOPERATION, CORONARY ARTERY BYPASS PROCEDURE OR VALVE PROCEDURE, MORE THAN ONE MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 122,850.00 40,950.00 81,900.00 33533 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); SINGLE ARTERIAL GRAFT 104,130.00 46,800.00 57,330.00 33534 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); TWO CORONARY ARTERIAL GRAFTS 104,130.00 46,800.00 57,330.00 33535 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); THREE CORONARY ARTERIAL GRAFTS 107,250.00 41,730.00 65,520.00 33536 CORONARY ARTERY BYPASS, USING ARTERIAL GRAFT(S); FOUR OR MORE CORONARY ARTERIAL GRAFTS 114,660.00 40,950.00 73,710.00 33542 MYOCARDIAL RESECTION (E.G., VENTRICULAR ANEURYSMECTOMY) 122,850.00 40,950.00 81,900.00 33545 REPAIR OF POSTINFARCTION VENTRICULAR SEPTAL DEFECT, W/ OR W/O MYOCARDIAL RESECTION 122,850.00 40,950.00 81,900.00 33572 CORONARY ENDARTERECTOMY, OPEN, ANY METHOD, OF LEFT ANTERIOR DESCENDING, CIRCUMFLEX, OR RIGHT CORONARY ARTERY PERFORMED IN CONJUCTION W/ CORONARY ARTERY BYPASS GRAFT PROCEDURE, EACH VESSEL (LIST SEPARATELY IN ADDITION TO PRIMARY PROCEDURE) 18,915.00 10,725.00 8,190.00 33600 CLOSURE OF ATRIOVENTRICULAR VALVE (MITRAL OR TRICUSPID) BY SUTURE OR PATCH 90,675.00 41,535.00 49,140.00 33602 CLOSURE OF SEMILUNAR VALVE (AORTIC OR PULMONARY) BY SUTURE OR PATCH 90,675.00 41,535.00 49,140.00 33606 ANASTOMOSIS OF PULMONARY ARTERY TO AORTA (DAMUS-KAYE- STANSEL PROCEDURE) 104,130.00 46,800.00 57,330.00 33608 REPAIR OF COMPLEX CARDIAC ANOMALY OTHER THAN PULMONARY ATRESIA WITH VENTRICULAR SEPTAL DEFECT BY CONSTRUCTION OR REPLACEMNET OF CONDUIT FROM RIGHT OR LEFT VENTRICLE TO PULMONARY ARTERY 107,250.00 41,730.00 65,520.00 33610 REPAIR OF COMPLEX CARDIAC ANOMALIES (E.G., SINGLE VENTRICLE WITH SUBAORTIC OBSTRUCTION) BY SURGICAL ENLARGEMENT OF INTERVENTRICULAR SEPTAL DEFECT 107,250.00 41,730.00 65,520.00 33611 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR TUNNEL REPAIR 107,250.00 41,730.00 65,520.00 33612 REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE WITH INTRAVENTRICULAR TUNNEL REPAIR WITH REPAIR OF RIGHT VENTRICULAR OUTFLOW TRACT OBSTRUCTION 107,250.00 41,730.00 65,520.00 33615 REPAIR OF COMPLEX CARDIAC ANOMALIES (E.G., TRICUSPID ATRESIA) BY CLOSURE OF ATRIAL SEPTAL DEFECT AND ANASTOMOSIS OF ATRIA OR VENA CAVA TO PULMONARY ARTERY (SIMPLE FONTAN PROCEDURE) 107,250.00 41,730.00 65,520.00 33617 REPAIR OF COMPLEX CARDIAC ANOMALIES (E.G., SINGLE VENTRICLE) BY MODIFIED FONTAN PROCEDURE 107,250.00 41,730.00 65,520.00 33619 REPAIR OF SINGLE VENTRICLE W/ AORTIC OUTFLOW OBSTRUCTION AND AORTIC ARCH HYPOPLASIA (HYPOPLASTIC LEFT HEART SYNDROME) (E.G., NORWOOD PROCEDURE) 122,850.00 40,950.00 81,900.00 33641 REPAIR ATRIAL SEPTAL DEFECT, SECUNDUM, W/ CARDIOPULMONARY BYPASS, W/ OR W/O PATCH 90,675.00 41,535.00 49,140.00 33645 DIRECT OR PATCH CLOSURE, SINUS VENOSUS, W/ OR W/O ANOMALOUS PULMONARY VENOUS DRAINAGE 104,130.00 46,800.00 57,330.00 33647 REPAIR OF ATRIAL SEPTAL DEFECT AND VENTRICULAR SEPTAL DEFECT, W/ DIRECT OR PATCH CLOSURE 107,250.00 41,730.00 65,520.00 33660 REPAIR OF INCOMPLETE OR PARTIAL ATRIOVENTRICULAR CANAL (OSTIUM PRIMUM ATRIAL SEPTAL DEFECT), W/ OR W/O ATRIOVENTRICULAR VALVE REPAIR 107,250.00 41,730.00 65,520.00 33665 REPAIR OF INTERMEDIATE OR TRANSITIONAL ATRIOVENTRICULAR CANAL, W/ OR W/O ATRIOVENTRICULAR VALVE REPAIR 107,250.00 41,730.00 65,520.00 33670 REPAIR OF COMPLETE ATRIOVENTRICULAR CANAL, W/ OR W/O PROSTHETIC VALVE 114,660.00 40,950.00 73,710.00 33681 CLOSURE OF VENTRICULAR SEPTAL DEFECT, W/ OR W/O PATCH; 90,675.00 41,535.00 49,140.00 33684 CLOSURE OF VENTRICULAR SEPTAL DEFECT, W/ OR W/O PATCH; WITH PULMONARY VALVOTOMY OR INFUNDIBULAR RESECTION (ACYANOTIC) 107,250.00 41,730.00 65,520.00 33688 CLOSURE OF VENTRICULAR SEPTAL DEFECT, W/ OR W/O PATCH; WITH REMOVAL OF PULMONARY ARTERY BAND, W/ OR W/O GUSSET 107,250.00 41,730.00 65,520.00 33690 BANDING OF PULMONARY ARTERY 41,730.00 21,255.00 20,475.00 33692 COMPLETE REPAIR OF TETRALOGY OF FALLOT W/O PULMONARY ATRESIA; 107,250.00 41,730.00 65,520.00 Page 46 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 33694 COMPLETE REPAIR OF TETRALOGY OF FALLOT W/O PULMONARY ATRESIA; WITH TRANSANNULAR PATCH 107,250.00 41,730.00 65,520.00 33697 COMPLETE REPAIR OF TETRALOGY OF FALLOT W/ PULMONARY ATRESIA INCLUDING CONSTRUCTION OF CONDUIT RIGHT VENTRICLE TO PULMONARY ARTERY AND CLOSURE OF VENTRICULAR SEPTAL DEFECT 107,250.00 41,730.00 65,520.00 33702 REPAIR SINUS OF VALSALVA FISTULA, W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33710 REPAIR SINUS OF VALSALVA FISTULA, WITH REPAIR OF VENTRICULAR SEPTAL DEFECT 107,250.00 41,730.00 65,520.00 33720 REPAIR SINUS OF VALSALVA ANEURYSM, WITH CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33722 CLOSURE OF AORTICO-LEFT VENTRICULAR TUNNEL 104,130.00 46,800.00 57,330.00 33730 COMPLETE REPAIR OF ANOMALOUS VENOUS RETURN (SUPRACARDIAC, INTRACARDIAC, OR INFRACARDIAC TYPES) 107,250.00 41,730.00 65,520.00 33732 REPAIR OF COR TRIATUM OR SUPRAVALVULAR MITRA RING BY RESECTION OF LEFT ATRIAL MEMBRANE 107,250.00 41,730.00 65,520.00 33735 ATRIAL SEPTECTOMY OR SEPTOSTOMY; CLOSED HEART (BLALOCK- HANLON TYPE OPERATION) 41,730.00 21,255.00 20,475.00 33736 ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33737 ATRIAL SEPTECTOMY OR SEPTOSTOMY; OPEN HEART W/ INFLOW OCCLUSION 90,675.00 41,535.00 49,140.00 33750 SHUNT; SUBCLAVIAN TO PULMONARY ARTERY (BLALOCK- TAUSSIG TYPE OPERATION) 59,085.00 26,325.00 32,760.00 33764 SHUNT; CENTRAL, W/ PROSTHETIC GRAFT 45,435.00 20,865.00 24,570.00 33766 SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO ONE LUNG (CLASSICAL GLENN PROCEDURE) 59,085.00 26,325.00 32,760.00 33767 SHUNT; SUPERIOR VENA CAVA TO PULMONARY ARTERY FOR FLOW TO BOTH LUNGS (BIDIRECTIONAL GLENN PROCEDURE) 90,675.00 41,535.00 49,140.00 33770 REPAIR OF TRANSPOSITION OF GREAT ARTERIES W/ VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; W/O SURGICAL ENLARGEMENT OF VENTRICULAR SEPTAL DEFECT 114,660.00 40,950.00 73,710.00 33771 REPAIR OF TRANSPOSITION OF GREAT ARTERIES W/ VENTRICULAR SEPTAL DEFECT AND SUBPULMONARY STENOSIS; WITH SURGICAL ENLAGEMENT OF VENTRICULAR SEPTAL DEFECT 114,660.00 40,950.00 73,710.00 33774 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (E.G., MUSTARD OR SENNING TYPE) W/ CARDIOPULMONARY BYPASS 114,660.00 40,950.00 73,710.00 33775 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (E.G., MUSTARD OR SENNING TYPE) W/ REMOVAL OF PULMONARY BAND 118,755.00 40,950.00 77,805.00 33776 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (E.G., MUSTARD OR SENNING TYPE) W/ CLOSURE OF VENTRICULAR SEPTAL DEFECT 118,755.00 40,950.00 77,805.00 33777 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, ATRIAL BAFFLE PROCEDURE (E.G., MUSTARD OR SENNING TYPE) W/ REPAIR OF SUBPULMONIC OBSTRUCTION 118,755.00 40,950.00 77,805.00 33778 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC PULMONARY ARTERY RECONSTRUCTION (E.G., JATENE TYPE) 122,850.00 40,950.00 81,900.00 33779 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC PULMONARY ARTERY RECONSTRUCTION (E.G., JATENE TYPE) W/ REMOVAL OF PULMONARY BAND 126,945.00 40,950.00 85,995.00 33780 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC PULMONARY ARTERY RECONSTRUCTION (E.G., JATENE TYPE) W/ CLOSURE OF VENTRICULAR SEPTAL DEFECT 139,230.00 40,950.00 98,280.00 33781 REPAIR OF TRANSPOSITION OF THE GREAT ARTERIES, AORTIC PULMONARY ARTERY RECONSTRUCTION (E.G., JATENE TYPE) W/ REPAIR OF SUBPULMONIC OBSTRUCTION 139,230.00 40,950.00 98,280.00 33786 TOTAL REPAIR, TRUNCUS ARTERIOSUS (RASTELLI TYPE OPERATION) 114,660.00 40,950.00 73,710.00 33788 REIMPLANTATION OF AN ANOMALOUS PULMONARY ARTERY 107,250.00 41,730.00 65,520.00 33800 AORTIC SUSPENSION (AORTOPEXY) FOR TRACHEAL DECOMPRESSION (E.G., FOR TRACHEOMALACIA) 41,730.00 21,255.00 20,475.00 33802 DIVISION OF ABERRANT VESSEL (VASCULAR RING) 41,730.00 21,255.00 20,475.00 33803 DIVISION OF ABERRANT VESSEL (VASCULAR RING) W/ REANASTOMOSIS 45,435.00 20,865.00 24,570.00 33814 DIVISION OF ABERRANT VESSEL (VASCULAR RING) W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33820 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY LIGATION 62,400.00 33,735.00 28,665.00 33822 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, UNDER 18 YEARS 59,085.00 26,325.00 32,760.00 33824 REPAIR OF PATENT DUCTUS ARTERIOSUS; BY DIVISION, 18 YEARS AND OLDER 59,085.00 26,325.00 32,760.00 33840 EXCISION OF COARCTATION OF AORTA, W/ OR W/O ASSOCIATED PATENT DUCTUS ARTERIOSUS; W/ DIRECT ANASTOMOSIS 59,085.00 26,325.00 32,760.00 33845 EXCISION OF COARCTATION OF AORTA, W/ OR W/O ASSOCIATED PATENT DUCTUS ARTERIOSUS; WITH GRAFT 59,085.00 26,325.00 32,760.00 Page 47 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 33851 EXCISION OF COARCTATION OF AORTA, W/ OR W/O ASSOCIATED PATENT DUCTUS ARTERIOSUS; REPAIR USING EITHER LEFT SUBCLAVIAN ARTERY OR PROSTHETIC MATERIAL AS GUSSET FOR ENLARGEMENT 59,085.00 26,325.00 32,760.00 33852 REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING AUTOGENOUS OR PROSTHETIC MATERIAL; W/O CARDIOPULMONARY BYPASS 59,085.00 26,325.00 32,760.00 33853 REPAIR OF HYPOPLASTIC OR INTERRUPTED AORTIC ARCH USING AUTOGENOUS OR PROSTHETIC MATERIAL; W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33860 ASCENDING AORTA GRAFT, W/ CARDIOPULMONARY BYPASS, W/ OR W/O VALVE SUSPENSION; 107,250.00 41,730.00 65,520.00 33861 ASCENDING AORTA GRAFT, W/ CARDIOPULMONARY BYPASS, W/ OR W/O VALVE SUSPENSION; W/ CORONARY RECONSTRUCTION 114,660.00 40,950.00 73,710.00 33863 ASCENDING AORTA GRAFT, W/ CARDIOPULMONARY BYPASS, W/ OR W/O VALVE SUSPENSION; W/ AORTIC ROOT REPLACEMENT USING COMPOSITE PROSTHESIS AND CORONARY RECONSTRUCTION 139,230.00 40,950.00 98,280.00 33870 TRANSVERSE ARCH GRAFT, W/ CARDIOPULMONARY BYPASS 139,230.00 40,950.00 98,280.00 33875 DESCENDING THORACIC AORTA GRAFT, W/ OR W/O BYPASS 122,850.00 40,950.00 81,900.00 33877 REPAIR OF THORACOABDOMINAL AORTIC ANEURYSM W/ GRAFT, W/ OR W/O CARDIOPULMONARY BYPASS 139,230.00 40,950.00 98,280.00 33910 PULMONARY ARTERY EMBOLECTOMY; W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33915 PULMONARY ARTERY EMBOLECTOMY; W/O CARDIOPULMONARY BYPASS 59,085.00 26,325.00 32,760.00 33916 PULMONARY ENDARTERECTOMY, W/ OR W/O EMBOLECTOMY, W/ CARDIOPULMONARY BYPASS 104,130.00 46,800.00 57,330.00 33917 REPAIR OF PULMONARY ARTERY STENOSIS BY RECONSTRUCTION W/ PATCH OR GRAFT 104,130.00 46,800.00 57,330.00 33918 REPAIR OF PULMONARY ATRESIA W/ VENTRICULAR SEPTAL DEFECT, BY UNIFOCALIZATION OF PULMONARY ARTERIES; W/O CARDIOPULMONARY BYPASS 59,085.00 26,325.00 32,760.00 33919 REPAIR OF PULMONARY ATRESIA W/ VENTRICULAR SEPTAL DEFECT, BY UNIFOCALIZATION OF PULMONARY ARTERIES; W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33920 REPAIR OF PULMONARY ATRESIA W/ VENTRICULAR SEPTAL DEFECT, BY CONSTRUCTION OR REPLACEMENT OF CONDUIT FROM RIGHT OR LEFT VENTRICLE TO PULMONARY ARTERY 114,660.00 40,950.00 73,710.00 33922 TRANSECTION OF PULMONARY ARTERY W/ CARDIOPULMONARY BYPASS 90,675.00 41,535.00 49,140.00 33924 LIGATION AND TAKEDOWN OF A SYSTEMIC-TO-PULMONARY ARTERY SHUNT, PERFORMED IN CONJUCTION W/ A CONGENITAL HEART PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 35,100.00 18,720.00 16,380.00 33930 DONOR CARDIECTOMY-PNEUMONECTOMY, W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT 90,675.00 41,535.00 49,140.00 33935 HEART-LUNG TRANSPLANT W/ RECIPIENT CARDIECTOMY- PNEUMONECTOMY 147,420.00 40,950.00 106,470.00 33940 DONOR CARDIECTOMY, W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT 90,675.00 41,535.00 49,140.00 33945 HEART TRANSPLANT, W/ OR W/O RECIPIENT CARDIECTOMY 147,420.00 40,950.00 106,470.00 33970 INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE FEMORAL ARTERY, OPEN APPROACH 25,155.00 12,870.00 12,285.00 33971 REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE INCLUDING REPAIR OF FEMORAL ARTERY W/ OR W/O GRAFT 18,915.00 10,725.00 8,190.00 33973 INSERTION OF INTRA-AORTIC BALLOON ASSIST DEVICE THROUGH THE ASCENDING AORTA 41,730.00 21,255.00 20,475.00 33974 REMOVAL OF INTRA-AORTIC BALLOON ASSIST DEVICE FROM THE ASCENDING AORTA, INCLUDING REPAIR OF THE ASCENDING AORTA, W/ OR W/O GRAFT 59,085.00 26,325.00 32,760.00 33975 IMPLANTATION OF VENTRICULAR ASSIST DEVICE; SINGLE VENTRICLE SUPPORT 90,675.00 41,535.00 49,140.00 33976 IMPLANTATION OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR SUPPORT 107,250.00 41,730.00 65,520.00 33977 REMOVAL OF VENTRICULAR ASSIST DEVICE; SINGLE VENTRICLE SUPPORT 73,710.00 32,760.00 40,950.00 33978 REMOVAL OF VENTRICULAR ASSIST DEVICE; BIVENTRICULAR SUPPORT 90,675.00 41,535.00 49,140.00 34001 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; CAROTID, SUBCLAVIAN OR INNOMINATE ARTERY, BY NECK INCISION 62,400.00 33,735.00 28,665.00 34051 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION 62,400.00 33,735.00 28,665.00 34101 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; AXILLARY, BRACHIAL, INNOMINATE, SUBCLAVIAN ARTERY, BY ARM INCISION 45,435.00 20,865.00 24,570.00 34111 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; RADIAL OR ULNAR ARTERY, BY ARM INCISION 45,435.00 20,865.00 24,570.00 34151 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; RENAL, CELIAC, MESENTERY, AORTOILIAC ARTERY, BY ABDOMINAL INCISION 59,085.00 26,325.00 32,760.00 Page 48 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 34201 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; FEMOROPOPLITEAL, AORTOILIAC ARTERY, BY LEG INCISION 45,435.00 20,865.00 24,570.00 34203 EMBOLECTOMY OR THROMBECTOMY, W/ OR W/O CATHETER; POPLITEAL-TIBIO-PERONEAL ARTERY, BY LEG INCISION 45,435.00 20,865.00 24,570.00 34401 THROMBECTOMY, DIRECT OR W/ CATHETER; VENA CAVA, ILIAC VEIN, BY ABDOMINAL INCISION 59,085.00 26,325.00 32,760.00 34421 THROMBECTOMY, DIRECT OR W/ CATHETER; VENA CAVA, ILIAC, FEMOROPOPLITEAL VEIN, BY LEG INCISION 62,400.00 33,735.00 28,665.00 34451 THROMBECTOMY, DIRECT OR W/ CATHETER; VENA CAVA, ILIAC, FEMOROPOPLITEAL VEIN, BY ABDOMINAL AND LEG INCISION 73,320.00 36,465.00 36,855.00 34471 THROMBECTOMY, DIRECT OR W/ CATHETER; SUBCLAVIAN VEIN, BY NECK INCISION 62,400.00 33,735.00 28,665.00 34490 THROMBECTOMY, DIRECT OR W/ CATHETER; AXILLARY AND SUBCLAVIAN VEIN, BY ARM INCISION 45,435.00 20,865.00 24,570.00 34501 VALVULOPLASTY, FEMORAL VEIN 59,085.00 26,325.00 32,760.00 34502 RECONSTRUCTION OF VENA CAVA, ANY METHOD 59,085.00 26,325.00 32,760.00 34510 VENOUS VALVE TRANSPOSITION, ANY VEIN DONOR 59,085.00 26,325.00 32,760.00 34520 CROSS-OVER VEIN GRAFT TO VENOUS SYTEM 59,085.00 26,325.00 32,760.00 34530 SAPHENOPOPLITEAL VEIN ANASTOMOSIS 59,085.00 26,325.00 32,760.00 35001 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, CAROTID, SUBCLAVIAN ARTERY, BY NECK INCISION 45,435.00 20,865.00 24,570.00 35002 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, CAROTID, SUBCLAVIAN ARTERY, BY NECK INCISION 59,085.00 26,325.00 32,760.00 35005 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, VERTEBRAL ARTERY 59,085.00 26,325.00 32,760.00 35011 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM AND ASSOCIATED OCCLUSIVE DISEASE, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION 35,100.00 18,720.00 16,380.00 35013 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, AXILLARY-BRACHIAL ARTERY, BY ARM INCISION 45,435.00 20,865.00 24,570.00 35021 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INCISION 45,435.00 20,865.00 24,570.00 35022 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, INNOMINATE, SUBCLAVIAN ARTERY, BY THORACIC INSERTION 59,085.00 26,325.00 32,760.00 35045 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, RADIAL OR ULNAR ARTERY 35,100.00 18,720.00 16,380.00 35081 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA 90,675.00 41,535.00 49,140.00 35082 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA 104,130.00 46,800.00 57,330.00 35091 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA INVOLVING VISCERAL VESSELS (MESENTERIC, CELIAC, RENAL) 104,130.00 46,800.00 57,330.00 35092 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA INVOLVING VISCERAL VESSELS (MESENTERIC, CELIAC, RENAL) 107,250.00 41,730.00 65,520.00 35102 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ABDOMINAL AORTA INVOLVING ILIAC VESSELS (COMMON, HYPOGASTRIC, EXTERNAL) 90,675.00 41,535.00 49,140.00 Page 49 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 35103 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, ABDOMINAL AORTA INVOLVING ILIAC VESSELS (COMMON, HYPOGASTRIC, EXTERNAL) 104,130.00 46,800.00 57,330.00 35111 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, SPLENIC ARTERY 90,675.00 41,535.00 49,140.00 35112 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, SPLENIC ARTERY 104,130.00 46,800.00 57,330.00 35121 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, HEPATIC, CELIAC, RENAL, OR MESENTERIC ARTERY 90,675.00 41,535.00 49,140.00 35122 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, HEPATIC, CELIAC, RENAL, OR MESENTERIC ARTERY 104,130.00 46,800.00 57,330.00 35131 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, ILIAC ARTERY (COMMON, HYPOGASTRIC, EXTERNAL) 45,435.00 20,865.00 24,570.00 35132 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, ILIAC ARTERY (COMMON, HYPOGASTRIC, EXTERNAL) 59,085.00 26,325.00 32,760.00 35141 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, COMMON FEMORAL ARTERY (PROFUNDA FEMORIS, SUPERFICIAL FEMORAL) 45,435.00 20,865.00 24,570.00 35142 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, COMMON FEMORAL ARTERY (PROFUNDA FEMORIS, SUPERFICIAL FEMORAL) 59,085.00 26,325.00 32,760.00 35151 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, POPLITEAL ARTERY 59,085.00 26,325.00 32,760.00 35152 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, POPLITEAL ARTERY 73,710.00 32,760.00 40,950.00 35161 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR ANEURYSM, FALSE ANEURYSM, AND ASSOCIATED OCCLUSIVE DISEASE, OTHER ARTERIES 59,085.00 26,325.00 32,760.00 35162 DIRECT REPAIR OF ANEURYSM, FALSE ANEURYSM, OR EXCISION (PARTIAL OR TOTAL) AND GRAFT INSERTION, W/ OR W/O PATCH GRAFT; FOR RUPTURED ANEURYSM, OTHER ARTERIES 73,710.00 32,760.00 40,950.00 35180 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; HEAD AND NECK 45,435.00 20,865.00 24,570.00 35182 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; THORAX AND ABDOMEN 59,085.00 26,325.00 32,760.00 35184 REPAIR, CONGENITAL ARTERIOVENOUS FISTULA; EXTREMITIES 45,435.00 20,865.00 24,570.00 35188 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; HEAD AND NECK 45,435.00 20,865.00 24,570.00 35189 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; THORAX AND ABDOMEN 59,085.00 26,325.00 32,760.00 35190 REPAIR, ACQUIRED OR TRAUMATIC ARTERIOVENOUS FISTULA; EXTREMITIES 45,435.00 20,865.00 24,570.00 35201 REPAIR BLOOD VESSEL, DIRECT; NECK 35,100.00 18,720.00 16,380.00 35206 REPAIR BLOOD VESSEL, DIRECT; UPPER EXTREMITY 35,100.00 18,720.00 16,380.00 35207 REPAIR BLOOD VESSEL, DIRECT; HAND, FINGER 35,100.00 18,720.00 16,380.00 35211 REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, W/ BYPASS 90,675.00 41,535.00 49,140.00 35216 REPAIR BLOOD VESSEL, DIRECT; INTRATHORACIC, W/O BYPASS 59,085.00 26,325.00 32,760.00 35221 REPAIR BLOOD VESSEL, DIRECT; INTRA-ABDOMINAL 35,100.00 18,720.00 16,380.00 35226 REPAIR BLOOD VESSEL, DIRECT; LOWER EXTREMITY 35,100.00 18,720.00 16,380.00 35231 REPAIR BLOOD VESSEL W/ VEIN GRAFT; NECK 45,435.00 20,865.00 24,570.00 35236 REPAIR BLOOD VESSEL W/ VEIN GRAFT; UPPER EXTREMITY 35,100.00 18,720.00 16,380.00 35241 REPAIR BLOOD VESSEL W/ VEIN GRAFT; INTRATHORACIC, W/ BYPASS 90,675.00 41,535.00 49,140.00 35246 REPAIR BLOOD VESSEL W/ VEIN GRAFT; INTRATHORACIC, W/O BYPASS 59,085.00 26,325.00 32,760.00 35251 REPAIR BLOOD VESSEL W/ VEIN GRAFT; INTRA-ABDOMINAL 45,435.00 20,865.00 24,570.00 35256 REPAIR BLOOD VESSEL W/ VEIN GRAFT; LOWER EXTREMITY 35,100.00 18,720.00 16,380.00 35261 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; NECK 45,435.00 20,865.00 24,570.00 Page 50 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 35266 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; UPPER EXTREMITY 35,100.00 18,720.00 16,380.00 35271 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; INTRATHORACIC, W/ BYPASS 90,675.00 41,535.00 49,140.00 35276 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; INTRATHORACIC, W/O BYPASS 59,085.00 26,325.00 32,760.00 35281 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; INTRA- ABDOMINAL 45,435.00 20,865.00 24,570.00 35286 REPAIR BLOOD VESSEL W/ GRAFT OTHER THAN VEIN; LOWER EXTREMITY 35,100.00 18,720.00 16,380.00 35301 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; CAROTID, VERTEBRAL, SUBCLAVIAN, BY NECK INCISION 73,320.00 36,465.00 36,855.00 35311 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; SUBCLAVIAN, INNOMINATE, BY THORACIC INCISION 73,320.00 36,465.00 36,855.00 35321 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; AXILLARY-BRACHIAL 73,320.00 36,465.00 36,855.00 35331 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; ABDOMINAL AORTA 73,320.00 36,465.00 36,855.00 35341 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; MESENTERIC, CELIAC, OR RENAL 73,320.00 36,465.00 36,855.00 35351 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; ILIAC 59,085.00 26,325.00 32,760.00 35355 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; ILIOFEMORAL 59,085.00 26,325.00 32,760.00 35361 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; COMBINED AORTOILIAC 90,675.00 41,535.00 49,140.00 35363 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; COMBINED AORTOILIOFEMORAL 45,435.00 20,865.00 24,570.00 35371 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; COMMON FEMORAL 45,435.00 20,865.00 24,570.00 35372 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; DEEP (PROFUNDA) FEMORAL 45,435.00 20,865.00 24,570.00 35381 THROMBOENDARTERECTOMY, W/ OR W/O PATCH GRAFT; FEMORAL AND/OR POPLITEAL, AND/OR TIBIOPERONEAL 59,085.00 26,325.00 32,760.00 35450 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; RENAL OR OTHER VISCERAL ARTERY 41,730.00 21,255.00 20,475.00 35452 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; AORTIC 41,730.00 21,255.00 20,475.00 35454 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; ILIAC 41,730.00 21,255.00 20,475.00 35456 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; FEMORAL- POPLITEAL 41,730.00 21,255.00 20,475.00 35458 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL 41,730.00 21,255.00 20,475.00 35459 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; TIBIOPERONEAL TRUNK AND BRANCHES 41,730.00 21,255.00 20,475.00 35460 TRANSLUMINAL BALLOON ANGIOPLASTY, OPEN; VENOUS 41,730.00 21,255.00 20,475.00 35470 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; TIBIOPERONEAL TRUNK OR BRANCHES, EACH VESSEL 25,155.00 12,870.00 12,285.00 35471 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; RENAL OR VISCERAL ARTERY 25,155.00 12,870.00 12,285.00 35472 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; AORTIC 25,155.00 12,870.00 12,285.00 35473 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; ILIAC 25,155.00 12,870.00 12,285.00 35474 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; FEMORAL-POPLITEAL 25,155.00 12,870.00 12,285.00 35475 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; BRANCHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL 25,155.00 12,870.00 12,285.00 35476 TRANSLUMINAL BALLOON ANGIOPLASTY, PERCUTANEOUS; VENOUS 25,155.00 12,870.00 12,285.00 35480 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; RENAL OR OTHER VISCERAL ARTERY 45,435.00 20,865.00 24,570.00 35481 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; AORTIC 45,435.00 20,865.00 24,570.00 35482 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; ILIAC 45,435.00 20,865.00 24,570.00 35483 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; FEMORAL- POPLITEAL 45,435.00 20,865.00 24,570.00 35484 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; BRACHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL 45,435.00 20,865.00 24,570.00 35485 TRANSLUMINAL PERIPHERAL ATHERECTOMY, OPEN; TIBIOPERONEAL TRUNK AND BRANCHES 45,435.00 20,865.00 24,570.00 35490 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; RENAL OR OTHER VISCERAL ARTERY 41,730.00 21,255.00 20,475.00 35491 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; AORTIC 41,730.00 21,255.00 20,475.00 35492 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; ILIAC 41,730.00 21,255.00 20,475.00 35493 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; FEMORAL-POPLITEAL 41,730.00 21,255.00 20,475.00 35494 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; BRANCHIOCEPHALIC TRUNK OR BRANCHES, EACH VESSEL 41,730.00 21,255.00 20,475.00 35495 TRANSLUMINAL PERIPHERAL ATHERECTOMY, PERCUTANEOUS; TIBIOPERONEAL TRUNK AND BRANCHES 41,730.00 21,255.00 20,475.00 35501 BYPASS GRAFT, W/ VEIN; CAROTID 73,320.00 36,465.00 36,855.00 35506 BYPASS GRAFT, W/ VEIN; CAROTID-SUBCLAVIAN 73,320.00 36,465.00 36,855.00 35507 BYPASS GRAFT, W/ VEIN; SUBCLAVIAN-CAROTID 73,320.00 36,465.00 36,855.00 35508 BYPASS GRAFT, W/ VEIN; CAROTID-VERTEBRAL 73,320.00 36,465.00 36,855.00 35509 BYPASS GRAFT, W/ VEIN; CAROTID-CAROTID 73,320.00 36,465.00 36,855.00 35511 BYPASS GRAFT, W/ VEIN; SUBCLAVIAN-SUBCLAVIAN 73,320.00 36,465.00 36,855.00 Page 51 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 35515 BYPASS GRAFT, W/ VEIN; SUBCLAVIAN-VERTEBRAL 73,320.00 36,465.00 36,855.00 35516 BYPASS GRAFT, W/ VEIN; SUBCLAVIAN-AXILLARY 73,320.00 36,465.00 36,855.00 35518 BYPASS GRAFT, W/ VEIN; AXILLARY-AXILLARY 73,320.00 36,465.00 36,855.00 35521 BYPASS GRAFT, W/ VEIN; AXILLARY-FEMORAL 73,320.00 36,465.00 36,855.00 35526 BYPASS GRAFT, W/ VEIN; AORTOSUBCLAVIAN OR CAROTID 90,675.00 41,535.00 49,140.00 35531 BYPASS GRAFT, W/ VEIN; AORTOCELIAC OR AORTOMESENTERIC 90,675.00 41,535.00 49,140.00 35533 BYPASS GRAFT, W/ VEIN; AXILLARY-FEMORAL-FEMORAL 90,675.00 41,535.00 49,140.00 35536 BYPASS GRAFT, W/ VEIN; SPLENORENAL 90,675.00 41,535.00 49,140.00 35541 BYPASS GRAFT, W/ VEIN; AORTOILIAC OR BI-ILIAC 90,675.00 41,535.00 49,140.00 35546 BYPASS GRAFT, W/ VEIN; AORTOFEMORAL OR BIFEMORAL 90,675.00 41,535.00 49,140.00 35548 BYPASS GRAFT, W/ VEIN; AORTOILLIOFEMORAL, UNILATERAL 90,675.00 41,535.00 49,140.00 35549 BYPASS GRAFT, W/ VEIN; AORTOILLIOFEMORAL, BILATERAL 90,675.00 41,535.00 49,140.00 35551 BYPASS GRAFT, W/ VEIN; AORTOFEMORAL - POPLITEAL 90,675.00 41,535.00 49,140.00 35556 BYPASS GRAFT, W/ VEIN; FEMORAL - POPLITEAL 59,085.00 26,325.00 32,760.00 35558 BYPASS GRAFT, W/ VEIN; FEMORAL-FEMORAL 45,435.00 20,865.00 24,570.00 35560 BYPASS GRAFT, W/ VEIN; AORTORENAL 73,710.00 32,760.00 40,950.00 35563 BYPASS GRAFT, W/ VEIN; ILIOILIAC 59,085.00 26,325.00 32,760.00 35565 BYPASS GRAFT, W/ VEIN; ILIOFEMORAL 59,085.00 26,325.00 32,760.00 35566 BYPASS GRAFT, W/ VEIN; FEMORAL - ANTERIOR TIBIAL, POSTERIOR TIBIAL, PERONEAL ARTERY OR OTHER DISTAL VESSELS 59,085.00 26,325.00 32,760.00 35571 BYPASS GRAFT, W/ VEIN; POPLITEAL-TIBIAL, PERONEAL ARTERY
OR OTHER DISTAL VESSELS 45,435.00 20,865.00 24,570.00 35582 IN-SITU VEIN BYPASS; AORTOFEMORAL-POPLITEAL (ONLY FEMORAL-POPLITEAL PORTION IN-SITU) 90,675.00 41,535.00 49,140.00 35583 IN-SITU VEIN BYPASS;FEMORAL-POPLITEAL 73,710.00 32,760.00 40,950.00 35585 IN-SITU VEIN BYPASS; FEMORAL-ANTERIOR TIBIAL, POSTERIOR TIBIAL, OR PERONEAL ARTERY 73,710.00 32,760.00 40,950.00 35587 IN-SITU VEIN BYPASS; POPLITEAL -TIBIAL, PERONEAL 73,710.00 32,760.00 40,950.00 35601 BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID 73,320.00 36,465.00 36,855.00 35606 BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-SUBCLAVIAN 73,320.00 36,465.00 36,855.00 35612 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN- SUBCLAVIAN 73,320.00 36,465.00 36,855.00 35616 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN-AXILLARY 73,320.00 36,465.00 36,855.00 35621 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL 73,320.00 36,465.00 36,855.00 35623 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-POPLITEAL OR -TIBIAL 73,320.00 36,465.00 36,855.00 35626 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOSUBCLAVIAN OR CAROTID 90,675.00 41,535.00 49,140.00 35631 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOCELIAC, AORTOMESENTERIC, AORTORENAL 90,675.00 41,535.00 49,140.00 35636 BYPASS GRAFT, WITH OTHER THAN VEIN; SPLENORENAL (SPLENIC TO RENAL ARTERIAL ANASTOMOSIS) 90,675.00 41,535.00 49,140.00 35641 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOILIAC OR BI-ILIAC 90,675.00 41,535.00 49,140.00 35642 BYPASS GRAFT, WITH OTHER THAN VEIN; CAROTID-VERTEBRAL 73,320.00 36,465.00 36,855.00 35645 BYPASS GRAFT, WITH OTHER THAN VEIN; SUBCLAVIAN- VERTEBRAL 73,320.00 36,465.00 36,855.00 35646 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL OR BIFEMORAL 90,675.00 41,535.00 49,140.00 35650 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-AXILLARY 73,320.00 36,465.00 36,855.00 35651 BYPASS GRAFT, WITH OTHER THAN VEIN; AORTOFEMORAL- POPLITEAL 90,675.00 41,535.00 49,140.00 35654 BYPASS GRAFT, WITH OTHER THAN VEIN; AXILLARY-FEMORAL- FEMORAL 73,320.00 36,465.00 36,855.00 35656 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-POPLITEAL 59,085.00 26,325.00 32,760.00 35661 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-FEMORAL 45,435.00 20,865.00 24,570.00 35663 BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOILIAC 59,085.00 26,325.00 32,760.00 35665 BYPASS GRAFT, WITH OTHER THAN VEIN; ILIOFEMORAL 59,085.00 26,325.00 32,760.00 35666 BYPASS GRAFT, WITH OTHER THAN VEIN; FEMORAL-ANTERIOR TIBIAL, POSTERIOR TIBIAL, OR PERONEAL ARTERY 59,085.00 26,325.00 32,760.00 35671 BYPASS GRAFT, WITH OTHER THAN VEIN; POPLITEAL-TIBIAL OR - PERONEAL ARTERY 45,435.00 20,865.00 24,570.00 35681 BYPASS GRAFT, COMPOSITE 90,675.00 41,535.00 49,140.00 35691 TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO CAROTID ARTERY 73,320.00 36,465.00 36,855.00 35693 TRANSPOSITION AND/OR REIMPLANTATION; VERTEBRAL TO SUBCLAVIAN ARTERY 73,320.00 36,465.00 36,855.00 35694 TRANSPOSITION AND/OR REIMPLANTATION; SUBCLAVIAN TO CAROTID ARTERY 73,320.00 36,465.00 36,855.00 35695 TRANSPOSITION AND/OR REIMPLANTATION; CAROTID TO SUBCLAVIAN ARTERY 73,320.00 36,465.00 36,855.00 35700 REOPERATION, FEMORAL-POPLITEAL OR FEMORAL (POPLITEAL) - ANTERIOR TIBIAL,POSTERIOR TIBIAL, PERONEAL ARTERY OR OTHER DISTAL VESSELS, MORE THAN ONE MONTH AFTER ORIGINAL OPERATION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 35,100.00 18,720.00 16,380.00 Page 52 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 35701 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), W/ OR W/O LYSIS OF ARTERY; CAROTID ARTERY 35,100.00 18,720.00 16,380.00 35721 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), W/ OR W/O LYSIS OF ARTERY; FEMORAL ARTERY 35,100.00 18,720.00 16,380.00 35741 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), W/ OR W/O LYSIS OF ARTERY; POPLITEAL ARTERY 35,100.00 18,720.00 16,380.00 35761 EXPLORATION (NOT FOLLOWED BY SURGICAL REPAIR), W/ OR W/O LYSIS OF ARTERY; OTHER VESSELS 35,100.00 18,720.00 16,380.00 35800 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; NECK 18,915.00 10,725.00 8,190.00 35820 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; CHEST 35,100.00 18,720.00 16,380.00 35840 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; ABDOMEN 35,100.00 18,720.00 16,380.00 35860 EXPLORATION FOR POSTOPERATIVE HEMORRHAGE, THROMBOSIS OR INFECTION; EXTREMITY 18,915.00 10,725.00 8,190.00 35870 REPAIR OF GRAFT-ENTERIC FISTULA 45,435.00 20,865.00 24,570.00 35875 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; 45,435.00 20,865.00 24,570.00 35876 THROMBECTOMY OF ARTERIAL OR VENOUS GRAFT; W/ REVISION OF ARTERIAL OR VENOUS GRAFT 45,435.00 20,865.00 24,570.00 35901 EXCISION OF INFECTED GRAFT; NECK 59,085.00 26,325.00 32,760.00 35903 EXCISION OF INFECTED GRAFT; EXTREMITY 59,085.00 26,325.00 32,760.00 35905 EXCISION OF INFECTED GRAFT; THORAX 73,710.00 32,760.00 40,950.00 35907 EXCISION OF INFECTED GRAFT; ABDOMEN 59,085.00 26,325.00 32,760.00 36010 INTRODUCTION OF CATHETER, SUPERIOR OR INFERIOR VENA CAVA 7,098.00 5,460.00 1,638.00 36011 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; FIRST ORDER BRANCH (E.G., RENAL VEIN, JUGULAR VEIN) 18,135.00 14,040.00 4,095.00 36012 SELECTIVE CATHETER PLACEMENT, VENOUS SYSTEM; SECOND ORDER, OR MORE SELECTIVE, BRANCH (E.G., LEFT ADRENAL VEIN, PETROSAL SINUS) 15,639.00 10,725.00 4,914.00 36013 INTRODUCTION OF CATHETER, RIGHT HEART OR MAIN PULMONARY ARTERY 15,639.00 10,725.00 4,914.00 36014 SELECTIVE CATHETER PLACEMENT, LEFT OR RIGHT PULMONARY ARTERY 15,639.00 10,725.00 4,914.00 36015 SELECTIVE CATHETER PLACEMENT, SEGMENTAL OR SUBSEGMENTAL PULMONARY ARTERY 16,458.00 10,725.00 5,733.00 36100 INTRODUCTION OF NEEDLE OR INTRACATHETER, CAROTID OR VERTEBRAL ARTERY 16,458.00 10,725.00 5,733.00 36120 INTRODUCTION OF NEEDLE OR INTRACATHETER; RETROGRADE BRACHIAL ARTERY 18,135.00 14,040.00 4,095.00 36140 INTRODUCTION OF NEEDLE OR INTRACATHETER; EXTREMITY ARTERY 18,135.00 14,040.00 4,095.00 36145 INTRODUCTION OF NEEDLE OR INTRACATHETER; ARTERIOVENOUS SHUNT CREATED FOR DIALYSIS (CANNULA, FISTULA, OR GRAFT) 16,107.00 9,555.00 6,552.00 36200 INTRODUCTION OF CATHETER, AORTA 18,135.00 14,040.00 4,095.00 36215 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, W/IN A VASCULAR FAMILY 18,135.00 14,040.00 4,095.00 36216 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER THORACIC OR BRACHIOCEPHALIC BRANCH, W/IN A VASCULAR FAMILY 18,135.00 14,040.00 4,095.00 36217 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE THORACIC OR BRACHIOCEPHALIC BRANCH, W/IN A VASCULAR FAMILY 15,639.00 10,725.00 4,914.00 36245 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; EACH FIRST ORDER ABDOMINAL, PELVIC, OR LOWER EXTREMITY ARTERY BRANCH, W/IN A VASCULAR FAMILY 18,135.00 14,040.00 4,095.00 36246 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL SECOND ORDER ABDOMINAL, PELVIC OR LOWER EXTREMITY ARTERY BRANCH, W/IN A VASCULAR FAMILY 18,135.00 14,040.00 4,095.00 36247 SELECTIVE CATHETER PLACEMENT, ARTERIAL SYSTEM; INITIAL THIRD ORDER OR MORE SELECTIVE ABDOMINAL, PELVIC OR LOWER EXTREMITY ARTERY BRANCH, W/IN A VASCULAR FAMILY 15,639.00 10,725.00 4,914.00 36260 INSERTION OF IMPLANTABLE INTRA-ARTERIAL INFUSION PUMP (E.G., FOR CHEMOTHERAPY OF LIVER) 45,435.00 20,865.00 24,570.00 36261 REVISION OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 18,915.00 10,725.00 8,190.00 36262 REMOVAL OF IMPLANTED INTRA-ARTERIAL INFUSION PUMP 18,915.00 10,725.00 8,190.00 36430 OUTPATIENT TRANSFUSION OF BLOOD OR BLOOD PRODUCTS; ONE OR MORE UNITS 7,098.00 5,460.00 1,638.00 36450 EXCHANGE TRANSFUSION, BLOOD 11,076.00 7,800.00 3,276.00 36481 PERCUTANEOUS PORTAL VEIN CATHETERIZATION BY ANY METHOD 18,135.00 14,040.00 4,095.00 36488 PLACEMENT OF CENTRAL VENOUS CATHETER (SUBCLAVIAN, JUGULAR, OR OTHER VEIN) (E.G., FOR CENTRAL VENOUS PRESSURE, HYPERALIMENTATION, HEMODIALYSIS, OR CHEMOTHERAPY); PERCUTANEOUS OR CUTDOWN 18,915.00 10,725.00 8,190.00 36510 CATHETERIZATION OF UMBILICAL VEIN FOR DIAGNOSIS OR THERAPY, NEWBORN 7,098.00 5,460.00 1,638.00 36511 THERAPEUTIC APHERESIS 7,098.00 5,460.00 1,638.00 36568 INSERTION OF PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER (PICC) 18,915.00 10,725.00 8,190.00 36640 ARTERIAL CATHETERIZATION FOR PROLONGED INFUSION THERAPY (CHEMOTHERAPY), CUTDOWN 7,098.00 5,460.00 1,638.00 Page 53 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 36660 CATHETERIZATION, UMBILICAL ARTERY, NEWBORN, FOR DIAGNOSIS OR THERAPY 11,076.00 7,800.00 3,276.00 36781 PERCUTANEOUSPORTAL VEIN CATHETERIZATION BY ANY METHOD 18,135.00 14,040.00 4,095.00 36800 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE ; VEIN TO VEIN 18,135.00 14,040.00 4,095.00 36810 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE ; ARTERIOVENOUS, EXTERNAL (SCRIBNER TYPE) 18,915.00 10,725.00 8,190.00 36815 INSERTION OF CANNULA FOR HEMODIALYSIS, OTHER PURPOSE ; ARTERIOVENOUS, EXTERNAL REVISION, OR CLOSURE 18,915.00 10,725.00 8,190.00 36821 ARTERIOVENOUS ANASTOMOSIS, DIRECT, ANY SITE (E.G., CIMINO TYPE) 18,915.00 10,725.00 8,190.00 36822 INSERTION OF CANNULA(S) FOR PROLONGED EXTRACORPOREAL CIRCULATION FOR CARDIOPULMONARY INSUFFICIENCY (ECMO) 35,100.00 18,720.00 16,380.00 36825 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS ; AUTOGENOUS GRAFT 25,155.00 12,870.00 12,285.00 36830 CREATION OF ARTERIOVENOUS FISTULA BY OTHER THAN DIRECT ARTERIOVENOUS ANASTOMOSIS ; NONAUTOGENOUS GRAFT 25,155.00 12,870.00 12,285.00 36832 REVISION OF AN ARTERIOVENOUS FISTULA, W/ OR W/O THROMBECTOMY, AUTOGENOUS OR NONAUTOGENOUS GRAFT 18,915.00 10,725.00 8,190.00 36834 PLASTIC REPAIR OF ARTERIOVENOUS ANEURYSM 16,107.00 9,555.00 6,552.00 36835 INSERTION OF THOMAS SHUNT 18,135.00 14,040.00 4,095.00 37140 VENOUS ANASTOMOSIS; PORTOCAVAL 59,085.00 26,325.00 32,760.00 37145 VENOUS ANASTOMOSIS; RENOPORTAL 73,710.00 32,760.00 40,950.00 37160 VENOUS ANASTOMOSIS; CAVAL-MESENTERIC 59,085.00 26,325.00 32,760.00 37180 VENOUS ANASTOMOSIS; SPLENORENAL, PROXIMAL 73,320.00 36,465.00 36,855.00 37181 VENOUS ANASTOMOSIS; SPLENORENAL, DISTAL (SELECTIVE DECOMPRESSION OF ESOPHAGOGASTRIC VARICES, ANY TECHNIQUE) 73,710.00 32,760.00 40,950.00 37182 INSERTION OF TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT(S) (TIPS) INCLUDES VENOUS ACCESS, HEPATIC AND PORTAL VEIN CATHETERIZATION, PORTOGRAPHY, HEMODYNAMIC EVALUATION, INTRAHEPATIC TRACT FORMATION/DILATATION, STENT PLACEMENT AND ALL ASSOCIATED IMAGING G 104,130.00 46,800.00 57,330.00 37184 PRIMARY PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, NON-CORONARY, ARTERIAL OR ARTERIAL BYPASS GRAFT INCLUDING FLUOROSCOPIC GUIDANCE AND INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS; ONE OR MORE VESSELS 90,675.00 41,535.00 49,140.00 37187 PERCUTANEOUS TRANSLUMINAL MECHANICAL THROMBECTOMY, VEINS, INCLUDING INTRAPROCEDURAL PHARMACOLOGICAL THROMBOLYTIC INJECTIONS AND FLUOROSCOPIC GUIDANCE; ONE OR MORE VESSELS 90,675.00 41,535.00 49,140.00 37200 TRANSCATHETER BIOPSY 16,107.00 9,555.00 6,552.00 37201 TRANSCATHETER THERAPY, INFUSION FOR THROMBOLYSIS OTHER THAN CORONARY 15,639.00 10,725.00 4,914.00 37202 TRANSCHATHETER THERAPY, INFUSION OTHER THAN FOR THROMBOLYSIS, ANY TYPE (E.G., SPASMOLYTIC, VASOCONSTRICTIVE) 15,639.00 10,725.00 4,914.00 37203 TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (E.G., FRACTURED VENOUS OR ARTERIAL CATHETER) 18,915.00 10,725.00 8,190.00 37204 TRANSCATHETER OCCLUSION OR EMBOLIZATION (E.G., FOR TUMOR DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD, NON- CENTRAL NERVOUS SYSTEM, NON-HEAD OR NECK 90,675.00 41,535.00 49,140.00 37205 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), (NON-CORONARY VESSEL), PERCUTANEOUS; INITIAL VESSEL 90,675.00 41,535.00 49,140.00 37207 TRANSCATHETER PLACEMENT OF AN INTRAVASCULAR STENT(S), (NON-CORONARY VESSEL), OPEN; INITIAL VESSEL 45,435.00 20,865.00 24,570.00 37565 LIGATION, INTERNAL JUGULAR VEIN 11,076.00 7,800.00 3,276.00 37600 LIGATION; EXTERNAL CAROTID ARTERY 11,076.00 7,800.00 3,276.00 37605 LIGATION; INTERNAL OR COMMON CAROTID ARTERY 35,100.00 18,720.00 16,380.00 37606 LIGATION; INTERNAL OR COMMON CAROTID ARTERY, W/ GRADUAL OCCLUSION, AS W/ SELVERSTONE OR CRUTCHFIELD CAMP 42,783.00 24,765.00 18,018.00 37607 LIGATION OR BANDING OF ANGIOACCESS ARTERIOVENOUS FISTULA 18,135.00 14,040.00 4,095.00 37609 LIGATION OR BIOPSY, TEMPORAL ARTERY 18,135.00 14,040.00 4,095.00 37615 LIGATION, MAJOR ARTERY (E.G., POST-TRAUMATIC, RUPTURE); NECK 35,100.00 18,720.00 16,380.00 37616 LIGATION, MAJOR ARTERY (E.G., POST-TRAUMATIC, RUPTURE); CHEST 41,730.00 21,255.00 20,475.00 37617 LIGATION, MAJOR ARTERY (E.G., POST-TRAUMATIC, RUPTURE); ABDOMEN 35,100.00 18,720.00 16,380.00 37618 LIGATION, MAJOR ARTERY (E.G., POST-TRAUMATIC, RUPTURE); EXTREMITY 25,155.00 12,870.00 12,285.00 37620 INTERRUPTION, PARTIAL OR COMPLETE, OF INFERIOR VENA CAVA BY SUTURE, LIGATION, PLICATION, CLIP, EXTRAVASCULAR, INTRAVASCULAR (UMBRELLA DEVICE) 45,435.00 20,865.00 24,570.00 Page 54 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 37650 LIGATION OF FEMORAL VEIN 18,135.00 14,040.00 4,095.00 37660 LIGATION OF COMMON ILIAC VEIN 25,155.00 12,870.00 12,285.00 37700 LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS 18,135.00 14,040.00 4,095.00 37720 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS 25,155.00 12,870.00 12,285.00 37730 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG AND SHORT SAPHENOUS VEINS 35,100.00 18,720.00 16,380.00 37735 LIGATION AND DIVISION AND COMPLETE STRIPPING OF LONG OR SHORT SAPHENOUS VEINS W/ RADICAL EXCISION OF ULCER AND SKIN GRAFT AND/OR INTERRUPTION OF COMMUNICATING VEINS OF LOWER LEG, W/ EXCISION OF DEEP FASCIA 41,730.00 21,255.00 20,475.00 37760 LIGATION OF PERFORATORS, SUBFASCIAL, RADICAL (LINTON TYPE), W/ OR W/O SKIN GRAFT 41,730.00 21,255.00 20,475.00 37780 LIGATION AND DIVISION OF SHORT SAPHENOUS VEIN AT SAPHENOPOPLITEAL JUNCTION 18,915.00 10,725.00 8,190.00 37788 PENILE REVASCULARIZATION, ARTERY, W/ OR W/O VEIN GRAFT 90,675.00 41,535.00 49,140.00 37790 PENILE VENOUS OCCLUSIVE PROCEDURE 45,435.00 20,865.00 24,570.00 38100 SPLENECTOMY; TOTAL 59,943.00 33,735.00 26,208.00 38101 SPLENECTOMY; PARTIAL 45,435.00 20,865.00 24,570.00 38102 SPLENECTOMY; TOTAL, EN BLOC FOR EXTENSIVE DISEASE, IN CONJUCTION W/ OTHER PROCEDURE 62,400.00 33,735.00 28,665.00 38115 REPAIR OF RUPTURED SPLEEN (SPLENORRHAPHY) W/ OR W/O PARTIAL SPLENECTOMY 59,085.00 26,325.00 32,760.00 38120 LAPAROSCOPY, SURGICAL; SPLENECTOMY 59,943.00 33,735.00 26,208.00 38205 BLOOD-DERIVED HEMATOPOIETIC PROGENITOR CELL HARVESTING FOR TRANSPLANTATION 21,216.00 13,845.00 7,371.00 38220 BONE MARROW ASPIRATION AND/OR BIOPSY 21,216.00 13,845.00 7,371.00 38230 BONE MARROW HARVESTING FOR TRANSPLANTATION 35,100.00 18,720.00 16,380.00 38240 BONE MARROW OR PERIPHERAL BLOOD DERIVED PERIPHERAL STEM CELL TRANSPLANTATION 73,710.00 32,760.00 40,950.00 38300 DRAINAGE OF LYMPH NODE ABSCESS OR LYMPHADENITIS 16,107.00 9,555.00 6,552.00 38380 SUTURE AND/OR LIGATION OF THORACIC DUCT; CERVICAL APPROACH 59,085.00 26,325.00 32,760.00 38381 SUTURE AND/OR LIGATION OF THORACIC DUCT; THORACIC APPROACH 59,085.00 26,325.00 32,760.00 38382 SUTURE AND/OR LIGATION OF THORACIC DUCT; ABDOMINAL APPROACH 59,085.00 26,325.00 32,760.00 38500 BIOPSY OR EXCISION OR LYMPH NODE(S); SUPERFICIAL 11,076.00 7,800.00 3,276.00 38505 BIOPSY OR EXCISION OR LYMPH NODE(S); BY NEEDLE, SUPERFICIAL (E.G., CERVICAL, INGUINAL, AXILLARY) 11,076.00 7,800.00 3,276.00 38510 BIOPSY OR EXCISION OR LYMPH NODE(S); DEEP CERVICAL NODE(S) 16,107.00 9,555.00 6,552.00 38520 BIOPSY OR EXCISION OR LYMPH NODE(S); DEEP CERVICAL NODE(S) W/ EXCISION SCALENE FAT PAD 18,135.00 14,040.00 4,095.00 38525 BIOPSY OR EXCISION OR LYMPH NODE(S); DEEP AXILLARY NODE(S) 18,135.00 14,040.00 4,095.00 38530 BIOPSY OR EXCISION OR LYMPH NODE(S); INTERNAL MAMMARY NODE(S) 18,135.00 14,040.00 4,095.00 38542 DISSECTION, DEEP JUGULAR NODE(S) 42,783.00 24,765.00 18,018.00 38550 EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; W/O DEEP NEUROVASCULAR DISSECTION 73,710.00 32,760.00 40,950.00 38555 EXCISION OF CYSTIC HYGROMA, AXILLARY OR CERVICAL; W/ DEEP NEUROVASCULAR DISSECTION 90,675.00 41,535.00 49,140.00 38570 LAPAROSCOPY, SURGICAL; WITH RETROPERITONEAL LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE 52,884.00 23,400.00 29,484.00 38571 LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY 59,085.00 26,325.00 32,760.00 38572 LAPAROSCOPY, SURGICAL; WITH BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PERI-AORTIC LYMPH NODE SAMPLING (BIOPSY), SINGLE OR MULTIPLE 114,660.00 40,950.00 73,710.00 38700 SUPRAHYOID LYMPHADENECTOMY 52,884.00 23,400.00 29,484.00 38720 CERVICAL LYMPHADENECTOMY (COMPLETE) 59,085.00 26,325.00 32,760.00 38724 CERVICAL LYMPHADENECTOMY (MODIFIED RADICAL NECK DISSECTION) 59,085.00 26,325.00 32,760.00 38740 AXILLARY LYMPHADENECTOMY; SUPERFICIAL 45,435.00 20,865.00 24,570.00 38745 AXILLARY LYMPHADENECTOMY; COMPLETE 59,085.00 26,325.00 32,760.00 38746 THORACIC LYMPHADENECTOMY, REGIONAL, INCLUDING MEDIASTINAL AND PERITRACHEAL NODES 73,710.00 32,760.00 40,950.00 38747 ABDOMINAL LYMPHADENECTOMY, REGIONAL, INCLUDING CELIAC, PARA-AORTIC AND VENAL CAVAL NODES 45,435.00 20,865.00 24,570.00 38760 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, INCLUDING CLOQUETS NODE 45,435.00 20,865.00 24,570.00 38765 INGUINOFEMORAL LYMPHADENECTOMY, SUPERFICIAL, IN CONTINUITY W/ PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 45,435.00 20,865.00 24,570.00 38770 PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 73,710.00 32,760.00 40,950.00 38780 RETROPERITONEAL TRANSABDOMINAL LYMPHADENECTOMY, EXTENSIVE, INCLUDING PELVIC, AORTIC, AND RENAL NODES 73,710.00 32,760.00 40,950.00 39000 MEDIASTINOTOMY WITH EXPLORATION, DRAINAGE, REMOVAL OF FOREIGN BODY, OR BIOPSY; CERVICAL APPROACH 35,100.00 18,720.00 16,380.00 39010 TRANSTHORACIC APPROACH, INCLUDING EITHER TRANSTHORACIC OR MEDIAN STERNOTOMY 45,435.00 20,865.00 24,570.00 39200 EXCISION OF MEDIASTINAL CYST 73,710.00 32,760.00 40,950.00 Page 55 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 39220 EXCISION OF MEDIASTINAL TUMOR 80,262.00 32,760.00 47,502.00 39400 MEDIASTINOSCOPY, WITH OR WITHOUT BIOPSY 29,172.00 14,430.00 14,742.00 39501 REPAIR, LACERATION OF DIAPHRAGM, ANY APPROACH 73,710.00 32,760.00 40,950.00 39502 REPAIR, PARAESOPHAGEAL HIATUS HERNIA, TRANSABDOMINAL, WITH OR WITHOUT FUNDOPLASTY, VAGOTOMY, AND/OR PYLOROPLASTY, EXCEPT NEONATAL 78,624.00 32,760.00 45,864.00 39503 REPAIR, NEONATAL DIAPHRAGMATIC HERNIA, WITH OR WITHOUT CHEST TUBE INSERTION AND WITH OR WITHOUT CREATION OF VENTRAL HERNIA 78,624.00 32,760.00 45,864.00 39520 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); TRANSTHORACIC 78,624.00 32,760.00 45,864.00 39530 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, THORACOABDOMINAL 78,624.00 32,760.00 45,864.00 39531 REPAIR, DIAPHRAGMATIC HERNIA (ESOPHAGEAL HIATAL); COMBINED, THORACOABDOMINAL, WITH DILATION OF STRICTURE (WITH OR WITHOUT GASTROPLASTY) 78,624.00 32,760.00 45,864.00 39540 REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; ACUTE 78,624.00 32,760.00 45,864.00 39541 REPAIR, DIAPHRAGMATIC HERNIA (OTHER THAN NEONATAL), TRAUMATIC; CHRONIC 90,675.00 41,535.00 49,140.00 39545 IMBRICATION OF DIAPHRAGM FOR EVENTRATION, TRANSTHORACIC OR TRANSABDOMINAL, PARALYTIC OR NONPARALYTIC 78,624.00 32,760.00 45,864.00 40490 BIOPSY OF LIP 10,842.00 8,385.00 2,457.00 40500 VERMILIONECTOMY (LIP SHAVE), W/ MUCOSAL ADVANCEMENT 15,639.00 10,725.00 4,914.00 40510 EXCISION OF LIP; TRANSVERSE WEDGE EXCISION W/ PRIMARY CLOSURE 15,639.00 10,725.00 4,914.00 40520 V-EXCISION W/ PRIMARY DEFECT LINEAR CLOSURE; 15,639.00 10,725.00 4,914.00 40525 V-EXCISION W/ PRIMARY DEFECT LINEAR CLOSURE; FULL THICKNESS, RECONSTRUCTION W/ LOCAL FLAP (E.G., ESTLANDER OR FAN) 45,435.00 20,865.00 24,570.00 40527 V-EXCISION W/ PRIMARY DEFECT LINEAR CLOSURE; FULL THICKNESS, RECONSTRUCTION W/ CROSS LIP FLAP (ABBE- ESTLANDER) 59,943.00 33,735.00 26,208.00 40530 RESECTION OF LIP, MORE THAN ONE-FOURTH, W/O RECONSTRUCTION 16,107.00 9,555.00 6,552.00 40650 REPAIR LIP, FULL THICKNESS; VERMILION ONLY 18,915.00 10,725.00 8,190.00 40652 REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT 18,915.00 10,725.00 8,190.00 40654 REPAIR LIP, FULL THICKNESS; OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX 18,915.00 10,725.00 8,190.00 40700 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY, PARTIAL OR COMPLETE, UNILATERAL 73,710.00 32,760.00 40,950.00 40701 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, ONE STAGE PROCEDURE 73,710.00 32,760.00 40,950.00 40702 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; PRIMARY BILATERAL, ONE OF TWO STAGES 59,085.00 26,325.00 32,760.00 40720 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; SECONDARY, BY RECREATION OF DEFECT AND RECLOSURE 59,085.00 26,325.00 32,760.00 40761 PLASTIC REPAIR OF CLEFT LIP/NASAL DEFORMITY; W/ CROSS LIP PEDICLE FLAP (ABBE-ESTLANDER TYPE), INCLUDING SECTIONING AND INSERTING OF PEDICLE 73,710.00 32,760.00 40,950.00 40800 DRAINAGE OF ABSCESS, CYST, HEMATOMA, VESTIBULE OF MOUTH 11,076.00 7,800.00 3,276.00 40808 BIOPSY, VESTIBULE OF MOUTH 11,076.00 7,800.00 3,276.00 40810 EXCISION OF LESION OF MUCOSA AND SUBMUCOSA, VESTIBULE OF MOUTH 11,076.00 7,800.00 3,276.00 40818 EXCISION OF MUCOSA OF VESTIBULE OF MOUTH AS DONOR GRAFT 16,458.00 10,725.00 5,733.00 40819 EXCISION OF FRENUM, LABIAL OR BUCCAL (FRENUMECTOMY, FRENULECTOMY, FRENECTOMY) 18,135.00 14,040.00 4,095.00 40830 CLOSURE OF LACERATION, VESTIBULE OF MOUTH; 2.5 CM OR LESS 11,076.00 7,800.00 3,276.00 40831 CLOSURE OF LACERATION, VESTIBULE OF MOUTH; OVER 2.5 CM OR COMPLEX 11,076.00 7,800.00 3,276.00 40840 VESTIBULOPLASTY; ANTERIOR 23,634.00 10,530.00 13,104.00 40842 VESTIBULOPLASTY; POSTERIOR, UNILATERAL 23,634.00 10,530.00 13,104.00 40843 VESTIBULOPLASTY; POSTERIOR, BILATERAL 23,634.00 10,530.00 13,104.00 40844 VESTIBULOPLASTY; ENTIRE ARCH 35,100.00 18,720.00 16,380.00 40845 VESTIBULOPLASTY; COMPLEX (INCLUDING RIDGE EXTENSION, MUSCLE REPOSITIONING) 35,100.00 18,720.00 16,380.00 41000 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; LINGUAL 11,076.00 7,800.00 3,276.00 41005 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, SUPERFICIAL 11,076.00 7,800.00 3,276.00 41006 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; SUBLINGUAL, DEEP, SUPRAMYLOHYOID 11,076.00 7,800.00 3,276.00 41007 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; SUBMENTAL SPACE 11,076.00 7,800.00 3,276.00 41008 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; SUBMANDIBULAR SPACE 11,076.00 7,800.00 3,276.00 Page 56 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 41009 INTRAORAL INCISION AND DRAINAGE OF ABSCESS, CYST, OR HEMATOMA OF TONGUE OR FLOOR OF MOUTH; MASTICATOR SPACE 11,076.00 7,800.00 3,276.00 41015 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS,CYST,OR HEMATOMA OF FLOOR OF MOUTH; SUBLINGUAL 11,076.00 7,800.00 3,276.00 41016 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS,CYST,OR HEMATOMA OF FLOOR OF MOUTH; SUBMENTAL 11,076.00 7,800.00 3,276.00 41017 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS,CYST,OR HEMATOMA OF FLOOR OF MOUTH; SUBMANDIBULAR 11,076.00 7,800.00 3,276.00 41018 EXTRAORAL INCISION AND DRAINAGE OF ABSCESS,CYST,OR HEMATOMA OF FLOOR OF MOUTH; MASTICATOR SPACE 11,076.00 7,800.00 3,276.00 41100 BIOPSY OF TONGUE; ANTERIOR TWO-THIRDS 10,842.00 8,385.00 2,457.00 41105 BIOPSY OF TONGUE; POSTERIOR ONE-THIRD 10,842.00 8,385.00 2,457.00 41108 BIOPSY OF FLOOR OF MOUTH 10,842.00 8,385.00 2,457.00 41110 EXCISION OF LESION OF TONGUE W/O CLOSURE 18,135.00 14,040.00 4,095.00 41112 EXCISION OF LESION OF TONGUE W/ CLOSURE; ANTERIOR TWO- THIRDS 18,135.00 14,040.00 4,095.00 41113 EXCISION OF LESION OF TONGUE W/ CLOSURE; POSTERIOR ONE- THIRD 18,135.00 14,040.00 4,095.00 41114 EXCISION OF LESION OF TONGUE W/ CLOSURE; W/ LOCAL TONGUE FLAP 18,135.00 14,040.00 4,095.00 41115 EXCISION OF LINGUAL FRENUM (FRENECTOMY) 18,135.00 14,040.00 4,095.00 41116 EXCISION, LESION OF FLOOR OF MOUTH 18,135.00 14,040.00 4,095.00 41120 GLOSSECTOMY; LESS THAN ONE-HALF TONGUE 16,107.00 9,555.00 6,552.00 41130 GLOSSECTOMY; HEMIGLOSSECTOMY 21,216.00 13,845.00 7,371.00 41135 GLOSSECTOMY; PARTIAL, W/ UNILATERAL RADICAL NECK DISSECTION 73,710.00 32,760.00 40,950.00 41140 GLOSSECTOMY; COMPLETE OR TOTAL, W/ OR W/O TRACHEOSTOMY, W/O RADICAL NECK DISSECTION 73,710.00 32,760.00 40,950.00 41145 GLOSSECTOMY; COMPLETE OR TOTAL, W/ OR W/O TRACHEOSTOMY, W/ UNILATERAL RADICAL NECK DISSECTION 73,710.00 32,760.00 40,950.00 41150 GLOSSECTOMY; COMPOSITE PROCEDURE W/ RESECTION FLOOR OF MOUTH AND MANDIBULAR RESECTION, W/O RADICAL NECK DISSECTION 78,624.00 32,760.00 45,864.00 41153 GLOSSECTOMY; COMPOSITE PROCEDURE W/ RESECTION FLOOR OF MOUTH, W/ SUPRAHYOID NECK DISSECTION 90,675.00 41,535.00 49,140.00 41155 GLOSSECTOMY; COMPOSITE PROCEDURE W/ RESECTION FLOOR OF MOUTH, MANDIBULAR RESECTION, AND RADICAL NECK DISSECTION (COMMANDO TYPE) 104,130.00 46,800.00 57,330.00 41250 REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR ANTERIOR TWO-THIRDS OF TONGUE 18,915.00 10,725.00 8,190.00 41251 REPAIR OF LACERATION 2.5 CM OR LESS; POSTERIOR ONE-THIRD OF TONGUE 18,915.00 10,725.00 8,190.00 41252 REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR COMPLEX 18,915.00 10,725.00 8,190.00 41500 FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, W/ Z- PLASTY) 18,915.00 10,725.00 8,190.00 41510 SUTURE OF TONGUE TO LIP FOR MICROGNATHIA (DOUGLAS TYPE PROCEDURE) 18,915.00 10,725.00 8,190.00 41520 FRENOPLASTY (SURGICAL REVISION OF FRENUM, EG, W/ Z- PLASTY) 18,915.00 10,725.00 8,190.00 41800 DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES 11,076.00 7,800.00 3,276.00 41805 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES; SOFT TISSUES 7,098.00 5,460.00 1,638.00 41806 REMOVAL OF EMBEDDED FOREIGN BODY FROM DENTOALVEOLAR STRUCTURES; BONE 7,098.00 5,460.00 1,638.00 41820 GINGIVECTOMY, EXCISION GINGIVA 15,639.00 10,725.00 4,914.00 41821 OPERCULECTOMY, EXCISION PERICORONAL TISSUES 15,639.00 10,725.00 4,914.00 41822 EXCISION OF FIBROUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 15,639.00 10,725.00 4,914.00 41823 EXCISION OF OSSEOUS TUBEROSITIES, DENTOALVEOLAR STRUCTURES 15,639.00 10,725.00 4,914.00 41825 EXCISION OF LESION OR OR TUMOR (EXCEPT LISTED ABOVE), DENTOALVEOLAR STRUCTURES 15,639.00 10,725.00 4,914.00 41828 EXCISION OF HYPERPLASTIC ALVEOLAR MUCOSA 15,639.00 10,725.00 4,914.00 41830 ALVEOLECTOMY, INCLUDING CURETTAGE OF OSTEITIS OR SEQUESTRECTOMY 16,107.00 9,555.00 6,552.00 41850 DESTRUCTION OF LESION (EXCEPT EXCISION), DENTOALVEOLAR STRUCTURES 16,107.00 9,555.00 6,552.00 41870 PERIODONTAL MUCOSAL GRAFTING 16,107.00 9,555.00 6,552.00 41872 GINGIVOPLASTY 35,100.00 18,720.00 16,380.00 41874 ALVEOLOPLASTY 35,100.00 18,720.00 16,380.00 42000 DRAINAGE OF ABSCESS OF PALATE, UVULA 15,639.00 10,725.00 4,914.00 42100 BIOPSY OF PALATE, UVULA 10,842.00 8,385.00 2,457.00 42104 EXCISION, LESION OF PALATE , UVULA; W/O CLOSURE 11,076.00 7,800.00 3,276.00 42106 EXCISION, LESION OF PALATE , UVULA; W/ SIMPLE PRIMARY CLOSURE 18,135.00 14,040.00 4,095.00 42107 EXCISION, LESION OF PALATE , UVULA; W/ LOCAL FLAP CLOSURE 18,135.00 14,040.00 4,095.00 42120 RESECTION OF PALATE OR EXTENSIVE RESECTION OF LESION 40,911.00 21,255.00 19,656.00 42140 UVULECTOMY, EXCISION OF UVULA 23,634.00 10,530.00 13,104.00 42145 PALATOPHARYNGOPLASTY (E.G., UVULOPALATOPHARYNGOPLASTY, UVULOPHARYNGOPLASTY) 45,435.00 20,865.00 24,570.00 42160 DESTRUCTION OF LESION, PALATE OR UVULA (THERMAL, CRYO OR CHEMICAL) 20,553.00 10,725.00 9,828.00 Page 57 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 42180 REPAIR, LACERATION OF PALATE; UP TO 2 CM 23,634.00 10,530.00 13,104.00 42182 REPAIR, LACERATION OF PALATE; OVER 2 CM OR COMPLEX 35,100.00 18,720.00 16,380.00 42200 PALATOPLASTY FOR CLEFT PALATE, SOFT AND/OR HARD PALATE ONLY 40,911.00 21,255.00 19,656.00 42205 PALATOPLASTY FOR CLEFT PALATE, W/ CLOSURE OF ALVEOLAR RIDGE; SOFT TISSUE ONLY 42,549.00 21,255.00 21,294.00 42210 PALATOPLASTY FOR CLEFT PALATE, W/ CLOSURE OF ALVEOLAR RIDGE; W/ BONE GRAFT TO ALVEOLAR RIDGE (INCLUDES OBTAINING GRAFT) 44,187.00 21,255.00 22,932.00 42215 PALATOPLASTY FOR CLEFT PALATE; MAJOR REVISION 45,435.00 20,865.00 24,570.00 42220 PALATOPLASTY FOR CLEFT PALATE; SECONDARY LENGTHENING PROCEDURE 45,435.00 20,865.00 24,570.00 42225 PALATOPLASTY FOR CLEFT PALATE; ATTACHMENT PHARYNGEAL FLAP 59,943.00 33,735.00 26,208.00 42226 LENGTHENING OF PALATE, AND PHARYNGEAL FLAP 45,435.00 20,865.00 24,570.00 42227 LENGTHENING OF PALATE, W/ ISLAND FLAP 45,435.00 20,865.00 24,570.00 42235 REPAIR OF ANTERIOR PALATE, INCLUDING VOMER FLAP 45,435.00 20,865.00 24,570.00 42260 REPAIR OF NASOLABIAL FISTULA 23,634.00 10,530.00 13,104.00 42300 DRAINAGE OF ABSCESS; PAROTID 11,076.00 7,800.00 3,276.00 42310 DRAINAGE OF ABSCESS; SUBMAXILLARY OR SUBLINGUAL, INTRAORAL 11,076.00 7,800.00 3,276.00 42320 DRAINAGE OF ABSCESS; SUBMAXILLARY, EXTERNAL 11,076.00 7,800.00 3,276.00 42325 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA); 11,076.00 7,800.00 3,276.00 42326 FISTULIZATION OF SUBLINGUAL SALIVARY CYST (RANULA); W/ PROSTHESIS 18,135.00 14,040.00 4,095.00 42330 SIALOLITHOTOMY; SUBMANDIBULAR (SUBMAXILLARY), SUBLINGUAL OR PAROTID, INTRAORAL 18,135.00 14,040.00 4,095.00 42400 BIOPSY OF SALIVARY GLAND; NEEDLE 10,842.00 8,385.00 2,457.00 42405 BIOPSY OF SALIVARY GLAND; INCISIONAL 10,842.00 8,385.00 2,457.00 42408 EXCISION OF SUBLINGUAL SALIVARY CYST (RANULA) 18,135.00 14,040.00 4,095.00 42409 MARSUPIALIZATION OF SUBLINGUAL SALIVARY CYST (RANULA) 18,135.00 14,040.00 4,095.00 42410 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, W/O NERVE DISSECTION 45,435.00 20,865.00 24,570.00 42415 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; LATERAL LOBE, W/ DISSECTION AND PRESERVATION OF FACIAL NERVE 59,085.00 26,325.00 32,760.00 42420 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, W/ DISSECTION AND PRESERVATION OF FACIAL NERVE 59,085.00 26,325.00 32,760.00 42425 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, EN BLOC REMOVAL W/ SACRIFICE OF FACIAL NERVE 59,085.00 26,325.00 32,760.00 42426 EXCISION OF PAROTID TUMOR OR PAROTID GLAND; TOTAL, W/ UNILATERAL RADICAL NECK DISSECTION 73,710.00 32,760.00 40,950.00 42440 EXCISION OF SUBMANDIBULAR (SUBMAXILLARY) GLAND 35,100.00 18,720.00 16,380.00 42450 EXCISION OF SUBLINGUAL GLAND 35,100.00 18,720.00 16,380.00 42500 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; PRIMARY OR SIMPLE 35,100.00 18,720.00 16,380.00 42505 PLASTIC REPAIR OF SALIVARY DUCT, SIALODOCHOPLASTY; SECONDARY OR COMPLICATED 35,100.00 18,720.00 16,380.00 42507 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); 35,100.00 18,720.00 16,380.00 42508 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); W/ EXCISION OF ONE SUBMANDIBULAR GLAND 35,100.00 18,720.00 16,380.00 42509 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); W/ EXCISION OF BOTH SUBMANDIBULAR GLANDS 35,100.00 18,720.00 16,380.00 42510 PAROTID DUCT DIVERSION, BILATERAL (WILKE TYPE PROCEDURE); W/ LIGATION OF BOTH SUBMANDIBULAR (WHARTONS) DUCTS 35,100.00 18,720.00 16,380.00 42600 CLOSURE SALIVARY FISTULA 16,107.00 9,555.00 6,552.00 42665 LIGATION SALIVARY DUCT, INTRAORAL 16,107.00 9,555.00 6,552.00 42700 INCISION AND DRAINAGE ABSCESS; PERITONSILLAR 16,107.00 9,555.00 6,552.00 42720 INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR PARAPHARYNGEAL, INTRAORAL APPROACH 16,107.00 9,555.00 6,552.00 42725 INCISION AND DRAINAGE ABSCESS; RETROPHARYNGEAL OR PARAPHARYNGEAL, EXTERNAL APPROACH 16,107.00 9,555.00 6,552.00 42800 BIOPSY; OROPHARYNX 15,639.00 10,725.00 4,914.00 42802 BIOPSY; HYPOPHARYNX 15,639.00 10,725.00 4,914.00 42804 BIOPSY; NASOPHARYNX, VISIBLE LESION, SIMPLE 15,639.00 10,725.00 4,914.00 42806 BIOPSY; NASOPHARYNX, SURVEY FOR UNKNOWN PRIMARY LESION 15,639.00 10,725.00 4,914.00 42808 EXCISION OR DESTRUCTION OF LESION OF PHARYNX, ANY METHOD 15,639.00 10,725.00 4,914.00 42809 REMOVAL OF FOREIGN BODY FROM PHARYNX 15,639.00 10,725.00 4,914.00 42810 EXCISION BRANCHIAL CLEFT CYST OR VESTIGE, CONFINED TO SKIN AND SUBCUTANEOUS TISSUES 35,100.00 18,720.00 16,380.00 42815 EXCISION BRANCHIAL CLEFT CYST, VESTIGE, OR FISTULA, EXTENDING BENEATH SUBCUTANEOUS TISSUES AND/OR INTO PHARYNX 35,100.00 18,720.00 16,380.00 42820 TONSILLECTOMY AND ADENOIDECTOMY 35,100.00 18,720.00 16,380.00 42825 TONSILLECTOMY, PRIMARY OR SECONDARY 35,100.00 18,720.00 16,380.00 42830 ADENOIDECTOMY, PRIMARY 35,100.00 18,720.00 16,380.00 42835 ADENOIDECTOMY, SECONDARY 35,100.00 18,720.00 16,380.00 42842 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; W/O CLOSURE 20,553.00 10,725.00 9,828.00 Page 58 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 42844 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; CLOSURE W/ LOCAL FLAP (E.G., TONGUE, BUCCAL) 23,634.00 10,530.00 13,104.00 42845 RADICAL RESECTION OF TONSIL, TONSILLAR PILLARS, AND/OR RETROMOLAR TRIGONE; CLOSURE W/ OTHER FLAP 23,634.00 10,530.00 13,104.00 42860 EXCISION OF TONSIL TAGS 15,639.00 10,725.00 4,914.00 42870 EXCISION OR DESTRUCTION LINGUAL TONSIL, ANY METHOD 15,639.00 10,725.00 4,914.00 42890 LIMITED PHARYNGECTOMY 73,710.00 32,760.00 40,950.00 42892 RESECTION OF LATERAL PHARYNGEAL WALL OR PYRIFORM SINUS, DIRECT CLOSURE BY ADVANCEMENT OF LATERAL AND POSTERIOR PHARYNGEAL WALLS 90,675.00 41,535.00 49,140.00 42894 RESECTION OF PHARYNGEAL WALL REQUIRING CLOSURE W/ MYOCUTANEOUS FLAP 104,130.00 46,800.00 57,330.00 42900 SUTURE PHARYNX FOR WOUND OR INJURY 40,911.00 21,255.00 19,656.00 42950 PHARYNGOPLASTY (PLASTIC OR RECONSTRUCTIVE OPERATION ON PHARYNX) 40,911.00 21,255.00 19,656.00 42953 PHARYNGOESOPHAGEAL REPAIR 45,435.00 20,865.00 24,570.00 42955 PHARYNGOSTOMY (FISTULIZATION OF PHARYNX, EXTERNAL FOR FEEDING) 15,639.00 10,725.00 4,914.00 43020 ESOPHAGOTOMY, CERVICAL APPROACH, W/ REMOVAL OF FOREIGN BODY 23,634.00 10,530.00 13,104.00 43030 CRICOPHARYNGEAL MYOTOMY 35,100.00 18,720.00 16,380.00 43045 ESOPHAGOTOMY, THORACIC APPROACH, W/ REMOVAL OF FOREIGN BODY 73,710.00 32,760.00 40,950.00 43100 EXCISION OF LESION, ESOPHAGUS, W/ PRIMARY REPAIR; CERVICAL APPROACH 45,435.00 20,865.00 24,570.00 43101 EXCISION OF LESION, ESOPHAGUS, W/ PRIMARY REPAIR; THORACIC OR ABDOMINAL APPROACH 73,710.00 32,760.00 40,950.00 43107 TOTAL OR NEAR ESOPHAGECTOMY, W/O THORACOTOMY; W/ PHARYNGOGASTROSTOMY OR CERVICAL ESOPHAGOGASTROSTOMY, W/ OR W/O PYLOROPLASTY (TRANSHIATAL) 107,250.00 41,730.00 65,520.00 43108 TOTAL OR NEAR ESOPHAGECTOMY, W/O THORACOTOMY; W/ COLON INTERPOSITION OR SMALL BOWEL RECONSTRUCTION, INCLUDING BOWEL MOBILIZATION, PREPARATION AND ANASTOMOSIS(ES) 114,660.00 40,950.00 73,710.00 43112 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, W/ THORACOTOMY; W/ PHARYNGOGASTROSTOMY, OR CERVICAL ESOPHAGOGASTROSTOMY, W/ OR W/O PYLOROPLASTY 116,298.00 40,950.00 75,348.00 43113 TOTAL OR NEAR TOTAL ESOPHAGECTOMY, W/ THORACOTOMY; W/ COLON INTERPOSITION OR SMALL BOWEL RECONSTRUCTION, INCLUDING BOWEL MOBILIZATION, PREPARATION AND ANASTOMOSIS(ES) 122,850.00 40,950.00 81,900.00 43116 PARTIAL ESOPHAGECTOMY, CERVICAL, W/ FREE INTESTINAL GRAFT, INCLUDING MICROVASCULAR ANASTOMOSIS, OBTAINING THE GRAFT AND INTESTINAL RECONSTRUCTION 107,250.00 41,730.00 65,520.00 43117 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, W/ THORACOTOMY AND SEPARATE ABDOMINAL INCISION, W/ OR W/O PROXIMAL GASTRECTOMY; W/ THORACIC ESOPHAGOGASTROTOMY, W/ OR W/O PYLOROPLASTY (IVOR LEWIS) 107,250.00 41,730.00 65,520.00 43118 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, W/ THORACOTOMY AND SEPARATE ABDOMINAL INCISION, W/ OR W/O PROXIMAL GASTRECTOMY; W/ COLON INTERPOSITION OR SMALL BOWEL RECONSTRUCTION, INCLUDING BOWEL MOBILIZATION, PREPARATION, AND ANASTOMOSIS(SES) 114,660.00 40,950.00 73,710.00 43121 PARTIAL ESOPHAGECTOMY, DISTAL TWO-THIRDS, W/ THORACOTOMY ONLY, W/ OR W/O PROXIMAL GASTRECTOMY, W/ THORACIC ESOPHAGOGASTROSTOMY, W/ OR W/O PYLOROPLASTY 107,250.00 41,730.00 65,520.00 43122 PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, W/ OR W/O PROXIMAL GASTRECTOMY; W/ ESOPHAGOGASTROTOMY, W/ OR W/O PYLOROPLASTY 107,250.00 41,730.00 65,520.00 43123 PARTIAL ESOPHAGECTOMY, THORACOABDOMINAL OR ABDOMINAL APPROACH, W/ OR W/O PROXIMAL GASTRECTOMY; W/ COLON INTERPOSITION OR SMALL BOWEL RECONSTRUCTION, INCLUDING BOWEL MOBILIZATION, PREPARATION, AND ANASTOMOSIS(SES) 114,660.00 40,950.00 73,710.00 43124 TOTAL OR PARTIAL ESOPHAGECTOMY, W/O RECONSTRUCTION (ANY APPROACH), W/ CERVICAL ESOPHAGOSTOMY 90,675.00 41,535.00 49,140.00 43130 DIVERTICULECTOMY OF HYPOPHARYNX, OR ESOPHAGUS, W/ OR W/O MYOTOMY; CERVICAL APPROACH 45,435.00 20,865.00 24,570.00 43135 DIVERTICULECTOMY OF HYPOPHARYNX, OR ESOPHAGUS, W/ OR W/O MYOTOMY; THORACIC APPROACH 73,710.00 32,760.00 40,950.00 43200 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 20,553.00 10,725.00 9,828.00 43202 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ BIOPSY, SINGLE OR MULTIPLE 20,553.00 10,725.00 9,828.00 43204 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ INJECTION SCLEROSIS OF ESOPHAGEAL VARICES 29,172.00 14,430.00 14,742.00 Page 59 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 43205 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ BAND LIGATION OF ESOPHAGEAL VARICES 29,172.00 14,430.00 14,742.00 43215 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ REMOVAL OF FOREIGN BODY 29,172.00 14,430.00 14,742.00 43216 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 23,361.00 11,895.00 11,466.00 43217 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 23,634.00 10,530.00 13,104.00 43219 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ INSERTION OF PLASTIC TUBE OR STENT 35,100.00 18,720.00 16,380.00 43220 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ BALLOON DILATION (LESS THAN 30 MM DIAMETER) 35,100.00 18,720.00 16,380.00 43226 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OVER GUIDE WIRE 35,100.00 18,720.00 16,380.00 43227 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ CONTROL OF BLEEDING, ANY METHOD 29,172.00 14,430.00 14,742.00 43228 ESOPHAGOSCOPY, RIGID OR FLEXIBLE; W/ ABLATION OF TUMOR(S) POLYP(S), OR OTHER LESION(S), NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 35,100.00 18,720.00 16,380.00 43234 UPPER GASTROINTESTINAL ENDOSCOPY, SIMPLE PRIMARY EXAMINATION ( E.G. W/ SMALL DIAMETER FLEXIBLE ENDOSCOPE) 20,553.00 10,725.00 9,828.00 43235 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 20,553.00 10,725.00 9,828.00 43239 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ BIOPSY, SINGLE OR MULTIPLE 20,553.00 10,725.00 9,828.00 43241 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ TRANSENDOSCOPIC TUBE OR CATHETER PLACEMENT 23,634.00 10,530.00 13,104.00 43243 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ INJECTION SCLEROSIS OF ESOPHAGEAL AND/OR GASTRIC VARICES 29,172.00 14,430.00 14,742.00 43244 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ BAND LIGATION OF ESOPHAGEAL AND/OR GASTRIC VARICES 29,172.00 14,430.00 14,742.00 43245 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ DILATION OF GASTRIC OUTLET FOR OBSTRUCTION, ANY METHOD 35,100.00 18,720.00 16,380.00 43246 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ DIRECTED PLACEMENT OF PERCUTANEOUS GASTROSTOMY TUBE 35,100.00 18,720.00 16,380.00 43247 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ REMOVAL OR FOREIGN BODY 29,172.00 14,430.00 14,742.00 43248 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ INSERTION OF GUIDE WIRE FOLLOWED BY DILATION OF ESOPHAGUS OVER GUIDE WIRE 35,100.00 18,720.00 16,380.00 43249 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ BALLON DILATION OF ESOPHAGUS (LESS THAN 30 MM DIAMETER) 35,100.00 18,720.00 16,380.00 43250 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 23,361.00 11,895.00 11,466.00 43251 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 23,634.00 10,530.00 13,104.00 43255 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ CONTROL OF BLEEDING, ANY METHOD 29,172.00 14,430.00 14,742.00 43258 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 35,100.00 18,720.00 16,380.00 Page 60 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 43259 UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; W/ ENDOSCOPIC ULTRASOUND EXAMINATION 29,172.00 14,430.00 14,742.00 43260 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 40,911.00 21,255.00 19,656.00 43261 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ BIOPSY, SINGLE OR MULTIPLE 40,911.00 21,255.00 19,656.00 43262 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ SPHINCTEROTOMY/PAPILLOTOMY 42,549.00 21,255.00 21,294.00 43263 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ PRESSURE MEASUREMENT OF SPHINCTER OF ODDI (PANCREATIC DUCT OR COMMON BILE DUCT) 42,549.00 21,255.00 21,294.00 43264 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE REMOVAL OF STONE(S) FROM BILIARY AND/OR PANCREATIC DUCTS 45,435.00 20,865.00 24,570.00 43265 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE DESTRUCTION, LITHOTRIPSY OF STONE(S), ANY METHOD 59,943.00 33,735.00 26,208.00 43267 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE INSERTION OF NASOBILIARY OR NASOPANCREATIC DRAINAGE TUBE 44,187.00 21,255.00 22,932.00 43268 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE INSERTION OF TUBE OR STENT INTO BILE OR PANCREATIC DUCT 44,187.00 21,255.00 22,932.00 43269 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE REMOVAL OF FOREIGN BODY AND/OR CHANGE OF TUBE OR STENT 44,187.00 21,255.00 22,932.00 43271 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ENDOSCOPIC RETROGRADE BALLOON DILATION OF AMPULLA, BILIARY AND/OR PANCREATIC DUCT(S) 45,435.00 20,865.00 24,570.00 43272 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP); W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 45,435.00 20,865.00 24,570.00 43280 LAPAROSCOPY, SURGICAL, ESOPHAGOGASTIC FUNDOPLASTY (E.G., NISSEN, TOUPET PROCEDURES) 90,675.00 41,535.00 49,140.00 43300 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL APPROACH; W/O REPAIR OF TRACHEOESOPHAGEAL FISTULA 59,085.00 26,325.00 32,760.00 43305 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION), CERVICAL APPROACH; W/ REPAIR OF TRACHEOESOPHAGEAL FISTULA 59,085.00 26,325.00 32,760.00 43310 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC APPROACH; W/O REPAIR OF TRACHEOESOPHAGEAL FISTULA 90,675.00 41,535.00 49,140.00 43312 ESOPHAGOPLASTY, (PLASTIC REPAIR OR RECONSTRUCTION), THORACIC APPROACH; W/ REPAIR OF TRACHEOESOPHAGEAL FISTULA 104,130.00 46,800.00 57,330.00 43320 ESOPHAGOGASTROSTOMY (CARDIOPLASTY), W/ OR W/O VAGOTOMY AND PYLOROPLASTY, TRANSABDOMINAL OR TRANSTHORACIC APPROACH 90,675.00 41,535.00 49,140.00 43324 ESOPHAGOGASTRIC FUNDOPLASTY (E.G., NISSEN, BELSEY IV, HILL PROCEDURES) 90,675.00 41,535.00 49,140.00 43325 ESOPHAGOGASTRIC FUNDOPLASTY; W/ FUNDIC PATCH (THAL- NISSEN PROCEDURE) 90,675.00 41,535.00 49,140.00 43326 ESOPHAGOGASTRIC FUNDOPLASTY; W/ GASTROPLASTY (E.G., COLLIS) 94,770.00 41,535.00 53,235.00 43330 ESOPHAGOMYOTOMY (HELLER TYPE); ABDOMINAL APPROACH 73,710.00 32,760.00 40,950.00 43331 ESOPHAGOMYOTOMY (HELLER TYPE); THORACIC APPROACH 90,675.00 41,535.00 49,140.00 43340 ESOPHAGOJEJUNOSTOMY (W/O TOTAL GASTRECTOMY);
ABDOMINAL APPROACH 73,710.00 32,760.00 40,950.00 43341 ESOPHAGOJEJUNOSTOMY (W/O TOTAL GASTRECTOMY);
THORACIC APPROACH 90,675.00 41,535.00 49,140.00 43350 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; ABDOMINAL APPROACH 45,435.00 20,865.00 24,570.00 43351 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; THORACIC APPROACH 59,085.00 26,325.00 32,760.00 43352 ESOPHAGOSTOMY, FISTULIZATION OF ESOPHAGUS, EXTERNAL; CERVICAL APPROACH 23,634.00 10,530.00 13,104.00 43360 GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS ESOPHAGECTOMY, FOR OBSTRUCTING ESOPHAGEAL LESION OR FISTULA, OR FOR PREVIOUS ESOPHAGEAL EXCLUSION; W/ STOMACH, W/ OR W/O PYLOROPLASTY 114,660.00 40,950.00 73,710.00 Page 61 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 43361 GASTROINTESTINAL RECONSTRUCTION FOR PREVIOUS ESOPHAGECTOMY, FOR OBSTRUCTING ESOPHAGEAL LESION OR FISTULA, OR FOR PREVIOUS ESOPHAGEAL EXCLUSION; W/ COLON INTERPOSITION OR SMALL BOWEL RECONSTRUCTION, INCLUDING BOWEL MOBILIZATION, PREPARATION, AND ANASTOMOSI 122,850.00 40,950.00 81,900.00 43400 LIGATION, DIRECT, ESOPHAGEAL VARICES 73,710.00 32,760.00 40,950.00 43401 TRANSECTION OF ESOPHAGUS W/ REPAIR, FOR ESOPHAGEAL VARICES 73,710.00 32,760.00 40,950.00 43405 LIGATION OR STAPLING AT GASTROESOPHAGEAL JUNCTION FOR PRE-EXISTING ESOPHAGEAL PERFORATION 73,710.00 32,760.00 40,950.00 43410 SUTURE OF ESOPHAGEAL WOUND OR INJURY; CERVICAL APPROACH 23,634.00 10,530.00 13,104.00 43415 SUTURE OF ESOPHAGEAL WOUND OR INJURY; TRANSTHORACIC OR TRANSABDOMINAL APPROACH 73,710.00 32,760.00 40,950.00 43420 CLOSURE OF ESOPHAGOSTOMY OR FISTULA; CERVICAL APPROACH 23,634.00 10,530.00 13,104.00 43425 CLOSURE OF ESOPHAGOSTOMY OR FISTULA; TRANSTHORACIC OR TRANSABDOMINAL APPROACH 73,710.00 32,760.00 40,950.00 43450 DILATION OF ESOPHAGUS, BY UNGUIDED SOUND OR BOUGIE, SINGLE OR MULTIPLE PASSES 16,107.00 9,555.00 6,552.00 43453 DILATION OF ESOPHAGUS, OVER GUIDE WIRE 16,107.00 9,555.00 6,552.00 43456 DILATION OF ESOPHAGUS, BY BALLOON OR DILATOR, RETROGRADE 16,107.00 9,555.00 6,552.00 43458 DILATION OF ESOPHAGUS W/ BALLOON (30 MM DIAMETER OR LARGER) FOR ACHALASIA 16,107.00 9,555.00 6,552.00 43460 ESOPHAGOGASTRIC TAMPONADE, W/ BALLOON (SENGSTAAKEN TYPE) 18,915.00 10,725.00 8,190.00 43496 FREE JEJUNUM TRANSFER W/ MICROVASCULAR ANASTOMOSIS 114,660.00 40,950.00 73,710.00 43500 GASTROTOMY; W/ EXPLORATION OR FOREIGN BODY REMOVAL 59,085.00 26,325.00 32,760.00 43501 GASTROTOMY; W/ SUTURE REPAIR OF BLEEDING ULCER 74,139.00 36,465.00 37,674.00 43502 GASTROTOMY; W/ SUTURE REPAIR OF PRE-EXISTING ESOPHAGOGASTRIC LACERATION (E.G., MALLORY-WEISS) 74,139.00 36,465.00 37,674.00 43510 GASTROTOMY; W/ ESOPHAGEAL DILATION AND INSERTION OF PERMANENT INTRALUMINAL TUBE (E.G., CELESTIN OR MOUSSEAUX-BARBIN) 74,139.00 36,465.00 37,674.00 43520 PYLOROMYOTOMY, CUTTING OF PYLORIC MUSCLE (FREDET- RAMSTEDT TYPE OPERATION) 74,139.00 36,465.00 37,674.00 43600 BIOPSY OF STOMACH; BY CAPSULE, TUBE, PERORAL (ONE OR MORE SPECIMENS) 16,107.00 9,555.00 6,552.00 43605 BIOPSY OF STOMACH; BY LAPAROTOMY 59,085.00 26,325.00 32,760.00 43610 EXCISION, LOCAL; ULCER OR BENIGN TUMOR OF STOMACH 74,139.00 36,465.00 37,674.00 43611 EXCISION, LOCAL; MALIGNANT TUMOR OF STOMACH 74,139.00 36,465.00 37,674.00 43620 GASTRECTOMY, TOTAL; W/ ESOPHAGOENTEROSTOMY 122,850.00 40,950.00 81,900.00 43621 GASTRECTOMY, TOTAL; W/ ROUX-EN-Y RECONSTRUCTION 131,040.00 40,950.00 90,090.00 43622 GASTRECTOMY, TOTAL; W/ FORMATION OF INTESTINAL POUCH, ANY TYPE 131,040.00 40,950.00 90,090.00 43631 GASTRECTOMY, PARTIAL, DISTAL; W/ GASTRODUODENOSTOMY 107,250.00 41,730.00 65,520.00 43632 GASTRECTOMY, PARTIAL, DISTAL; W/ GASTROJEJUNOSTOMY 107,250.00 41,730.00 65,520.00 43633 GASTRECTOMY, PARTIAL, DISTAL; W/ ROUX-EN-Y RECONSTRUCTION 122,850.00 40,950.00 81,900.00 43634 GASTRECTOMY, PARTIAL, DISTAL; W/ FORMATION OF INTESTINAL POUCH 122,850.00 40,950.00 81,900.00 43638 GASTRECTOMY, PARTIAL, PROXIMAL, THORACIC OR ABDOMINAL APPROACH INCLUDING ESOPHAGOGASTROSTOMY, W/ VAGOTOMY; 122,850.00 40,950.00 81,900.00 43639 GASTRECTOMY, PARTIAL, PROXIMAL, THORACIC OR ABDOMINAL APPROACH INCLUDING ESOPHAGOGASTROSTOMY, W/ VAGOTOMY; W/ PYLOROPLASTY OR PYLOROMYOTOMY 131,040.00 40,950.00 90,090.00 43640 VAGOTOMY INCLUDING PYLOROPLASTY, W/ OR W/O GASTROSTOMY; TRUNCAL OR SELECTIVE 73,710.00 32,760.00 40,950.00 43641 VAGOTOMY INCLUDING PYLOROPLASTY, W/ OR W/O GASTROSTOMY; PARIETAL CELL (HIGHLY SELECTIVE) 90,675.00 41,535.00 49,140.00 43651 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVES, TRUNCAL 35,100.00 18,720.00 16,380.00 43652 LAPAROSCOPY, SURGICAL; TRANSECTION OF VAGUS NERVE, SELECTIVE OR HIGHLY SELECTIVE 42,783.00 24,765.00 18,018.00 43653 LAPAROSCOPY, SURGICAL; GASTROSTOMY, WITHOUT CONSTRUCTION OF GASTRIC TUBE (E.G., STAMM PROCEDURE) 35,100.00 18,720.00 16,380.00 43750 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE 15,639.00 10,725.00 4,914.00 43760 CHANGE OF GASTROSTOMY TUBE 10,842.00 8,385.00 2,457.00 43800 PYLOROPLASTY 73,710.00 32,760.00 40,950.00 43810 GASTRODUODENOSTOMY 122,850.00 40,950.00 81,900.00 43820 GASTROJEJUNOSTOMY; W/O VAGOTOMY 90,675.00 41,535.00 49,140.00 43825 GASTROJEJUNOSTOMY; W/ VAGOTOMY, ANY TYPE 104,130.00 46,800.00 57,330.00 43830 GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) ; 73,710.00 32,760.00 40,950.00 43831 GASTROSTOMY, TEMPORARY (TUBE, RUBBER OR PLASTIC) ; NEONATAL, FOR FEEDING 73,710.00 32,760.00 40,950.00 43832 GASTROSTOMY, PERMANENT, W/ CONSTRUCTION OF GASTRIC TUBE 73,710.00 32,760.00 40,950.00 43840 GASTRORRHAPHY, SUTURE OF PERFORATED DUODENAL OR GASTRIC ULCER, WOUND, OR INJURY 90,675.00 41,535.00 49,140.00 Page 62 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 43842 GASTRIC RESTRICTIVE PROCEDURE, W/O GASTRIC BYPASS, FOR MORBID OBESITY; VERTICAL-BANDED GASTROPLASTY 107,250.00 41,730.00 65,520.00 43843 GASTRIC RESTRICTIVE PROCEDURE, W/O GASTRIC BYPASS, FOR MORBID OBESITY; OTHER THAN VERTICAL-BANDED GASTROPLASTY 114,660.00 40,950.00 73,710.00 43846 GASTRIC RESTRICTIVE PROCEDURE, W/ GASTRIC BYPASS FOR MORBID OBESITY; W/ SHORT LIMB (LESS THAN 100 CM) ROUX-EN- Y GASTROENTEROSTOMY 114,660.00 40,950.00 73,710.00 43847 GASTRIC RESTRICTIVE PROCEDURE, W/ GASTRIC BYPASS FOR MORBID OBESITY; W/ SMALL BOWEL RECONSTRUCTION TO LIMIT ABSORPTION 114,660.00 40,950.00 73,710.00 43848 REVISION OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY 114,660.00 40,950.00 73,710.00 43850 REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) W/ RECONSTRUCTION; W/O VAGOTOMY 114,660.00 40,950.00 73,710.00 43855 REVISION OF GASTRODUODENAL ANASTOMOSIS (GASTRODUODENOSTOMY) W/ RECONSTRUCTION; W/ VAGOTOMY 122,850.00 40,950.00 81,900.00 43860 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) W/ RECONSTRUCTION, W/ OR W/O PARTIAL GASTRECTOMY OR BOWEL RESECTION; W/O VAGOTOMY 114,660.00 40,950.00 73,710.00 43865 REVISION OF GASTROJEJUNAL ANASTOMOSIS (GASTROJEJUNOSTOMY) W/ RECONSTRUCTION, W/ OR W/O PARTIAL GASTRECTOMY OR BOWEL RESECTION; W/ VAGOTOMY 122,850.00 40,950.00 81,900.00 43870 CLOSURE OF GASTROSTOMY, SURGICAL 90,675.00 41,535.00 49,140.00 43880 CLOSURE OF GASTROCOLIC FISTULA 114,660.00 40,950.00 73,710.00 44005 ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) 114,660.00 40,950.00 73,710.00 44010 DUODENOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL 104,130.00 46,800.00 57,330.00 44020 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL; 73,710.00 32,760.00 40,950.00 44021 ENTEROTOMY, SMALL BOWEL, OTHER THAN DUODENUM; FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL; FOR DECOMPRESSION (E.G., BAKER TUBE) 73,710.00 32,760.00 40,950.00 44025 COLOTOMY, FOR EXPLORATION, BIOPSY(S), OR FOREIGN BODY REMOVAL 73,710.00 32,760.00 40,950.00 44050 REDUCTION OF VOLVULUS, INTUSSUSCEPTION, INTERNAL HERNIA, BY LAPAROTOMY 104,130.00 46,800.00 57,330.00 44055 CORRECTION OF MALROTATION BY LYSIS OF DUODENAL BANDS AND/OR REDUCTION OF MIDGUT VOLVULUS (E.G., LADD PROCEDURE) 107,250.00 41,730.00 65,520.00 44100 BIOPSY OF INTESTINE BY CAPSULE, TUBE, PERORAL (ONE OR MORE SPECIMENS) 35,100.00 18,720.00 16,380.00 44110 EXCISION OF ONE OR MORE LESSIONS OF SMALL OR LARGE BOWEL NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; SINGLE ENTEROTOMY 73,710.00 32,760.00 40,950.00 44111 EXCISION OF ONE OR MORE LESSIONS OF SMALL OR LARGE BOWEL NOT REQUIRING ANASTOMOSIS, EXTERIORIZATION, OR FISTULIZATION; MULTIPLE ENTEROTOMIES 90,675.00 41,535.00 49,140.00 44120 ENTERECTOMY, RESECTION OF SMALL INTESTINE; SINGLE RESECTION AND ANASTOMOSIS 90,675.00 41,535.00 49,140.00 44125 ENTERECTOMY, RESECTION OF SMALL INTESTINE; W/ ENTEROSTOMY 90,675.00 41,535.00 49,140.00 44130 ENTEROENTEROSTOMY, ANASTOMOSIS OF INTESTINE, W/ OR W/O CUTANEOUS ENTEROSTOMY 104,130.00 46,800.00 57,330.00 44140 COLECTOMY, PARTIAL; W/ ANASTOMOSIS 114,660.00 40,950.00 73,710.00 44141 COLECTOMY, PARTIAL; W/ SKIN LEVEL CECOSTOMY OR COLOSTOMY 114,660.00 40,950.00 73,710.00 44143 COLECTOMY, PARTIAL; W/ END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE) 114,660.00 40,950.00 73,710.00 44144 COLECTOMY, PARTIAL; W/ RESECTION, W/ COLOSTOMY OR ILEOSTOMY AND CREATION OF MUCOFISTULA 114,660.00 40,950.00 73,710.00 44145 COLECTOMY, PARTIAL; W/ COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) 110,526.00 41,730.00 68,796.00 44146 COLECTOMY, PARTIAL; W/ COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS), W/ COLOSTOMY 114,660.00 40,950.00 73,710.00 44147 COLECTOMY, PARTIAL; ABDOMINAL AND TRANSANAL APPROACH 122,850.00 40,950.00 81,900.00 44150 COLECTOMY, TOTAL, ABDOMINAL, W/O PROCTECTOMY; W/ ILEOSTOMY OR ILEOPROCTOSTOMY 122,850.00 40,950.00 81,900.00 44151 COLECTOMY, TOTAL, ABDOMINAL, W/O PROCTECTOMY; W/ CONTINENT ILEOSTOMY 122,850.00 40,950.00 81,900.00 44152 COLECTOMY, TOTAL, ABDOMINAL, W/O PROCTECTOMY; W/ RECTAL MUCOSECTOMY, ILEOANAL ANASTOMOSIS, W/ OR W/O LOOP ILEOSTOMY 131,040.00 40,950.00 90,090.00 44153 COLECTOMY, TOTAL, ABDOMINAL, W/O PROCTECTOMY; W/ RECTAL MUCOSECTOMY, ILEOANAL ANASTOMOSIS, CREATION OF ILEAL RESERVIOR (S OR J), W/ OR W/O LOOP ILEOSTOMY 131,040.00 40,950.00 90,090.00 44155 COLECTOMY, TOTAL, ABDOMINAL, W/ PROCTECTOMY; W/ ILEOSTOMY 131,040.00 40,950.00 90,090.00 44156 COLECTOMY, TOTAL, ABDOMINAL, W/ PROCTECTOMY; W/ CONTINENT ILEOSTOMY 131,040.00 40,950.00 90,090.00 Page 63 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 44160 COLECTOMY W/ REMOVAL OF TERMINAL ILEUM AND ILEOCOLOSTOMY 131,040.00 40,950.00 90,090.00 44180 LAPAROSCOPY, SURGICAL, ENTEROLYSIS (FREEING OF INTESTINAL ADHESION) 35,100.00 18,720.00 16,380.00 44186 LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (E.G., FOR DECOMPRESSION OR FEEDING; 23,634.00 10,530.00 13,104.00 44187 LAPAROSCOPY, SURGICAL; JEJUNOSTOMY (E.G., FOR DECOMPRESSION OR FEEDING); ILEOSTOMY OR JEJUNOSTOMY, NON-TUBE 23,634.00 10,530.00 13,104.00 44188 LAPAROSCOPY, SURGICAL, COLOSTOMY OR SKIN LEVEL CECOSTOMY 35,100.00 18,720.00 16,380.00 44202 LAPAROSCOPY, SURGICAL; ENTERECTOMY, RESECTION OF SMALL INTESTINE, SINGLE RESECTION AND ANASTOMOSIS 45,435.00 20,865.00 24,570.00 44204 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS 73,710.00 32,760.00 40,950.00 44205 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH REMOVAL OF TERMINAL ILEUM WITH ILEOCOLOSTOMY 114,660.00 40,950.00 73,710.00 44206 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH END COLOSTOMY AND CLOSURE OF DISTAL SEGMENT (HARTMANN TYPE PROCEDURE) 73,710.00 32,760.00 40,950.00 44207 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) 107,250.00 41,730.00 65,520.00 44208 LAPAROSCOPY, SURGICAL; COLECTOMY, PARTIAL, WITH ANASTOMOSIS, WITH COLOPROCTOSTOMY (LOW PELVIC ANASTOMOSIS) WITH COLOSTOMY 114,660.00 40,950.00 73,710.00 44210 LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITHOUT PROTECTOMY, WITH ILEOSTOMY OR ILEOPROCTOSTOMY 107,250.00 41,730.00 65,520.00 44211 LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH PROTECTOMY, WITH ILEO-ANAL ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), WITH LOOP ILEOSTOMY, WITH OR WITHOUT RECTAL MUCOSECTOMY 114,660.00 40,950.00 73,710.00 44212 LAPAROSCOPY, SURGICAL; COLECTOMY, TOTAL, ABDOMINAL, WITH PROTECTOMY, WITH ILEOSTOMY 107,250.00 41,730.00 65,520.00 44227 LAPAROSCOPY, SURGICAL; CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE, WITH RESECTION AND ANASTOMOSIS 45,435.00 20,865.00 24,570.00 44300 ENTEROSTOMY OR CECOSTOMY, TUBE (E.G., FOR DECOMPRESSION OR FEEDING) 35,100.00 18,720.00 16,380.00 44310 ILEOSTOMY OR JEJUNOSTOMY, NON- TUBE 42,549.00 21,255.00 21,294.00 44312 REVISION OF ILEOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) 45,435.00 20,865.00 24,570.00 44314 REVISION OF ILEOSTOMY; COMPLICATED (RECONSTRUCTION IN- DEPTH) 42,549.00 21,255.00 21,294.00 44316 CONTINENT ILEOSTOMY (KOCH PROCEDURE) 59,085.00 26,325.00 32,760.00 44320 COLOSTOMY OR SKIN LEVEL CECOSTOMY; 45,435.00 20,865.00 24,570.00 44322 COLOSTOMY OR SKIN LEVEL CECOSTOMY; W/ MULTIPLE BIOPSIES (E.G., FOR HIRSCHSPRUNG DISEASE) 59,085.00 26,325.00 32,760.00 44340 REVISION OF COLOSTOMY; SIMPLE (RELEASE OF SUPERFICIAL SCAR) 45,435.00 20,865.00 24,570.00 44345 REVISION OF COLOSTOMY; COMPLICATED (RECONSTRUCTION IN - DEPTH ) 59,085.00 26,325.00 32,760.00 44346 REVISION OF COLOSTOMY; W/ REPAIR OF PARACOLOSTOMY HERNIA 59,085.00 26,325.00 32,760.00 44360 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 29,172.00 14,430.00 14,742.00 44361 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ BIOPSY, SINGLE OR MULTIPLE 29,172.00 14,430.00 14,742.00 44363 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ REMOVAL OF FOREIGN BODY 35,100.00 18,720.00 16,380.00 44364 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESIONS(S) BY SNARE TECHNIQUE 35,100.00 18,720.00 16,380.00 44365 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 35,100.00 18,720.00 16,380.00 44366 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ CONTROL OF BLEEDING, ANY METHOD 35,100.00 18,720.00 16,380.00 44369 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TENCHNIQUE 42,783.00 24,765.00 18,018.00 44372 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ PLACEMENT OF PERCUTANEOUS JEJUNOSTOMY TUBE 42,783.00 24,765.00 18,018.00 44373 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY, BEYOND SECOND PORTION OF DUODENUM, NOT INCLUDING ILEUM; W/ CONVERSION OF PERCUTANEOUS GASTROSTOMY TUBE TO PERCUTANEOUS JEJUNOSTOMY TUBE 42,783.00 24,765.00 18,018.00 Page 64 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 44376 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 35,100.00 18,720.00 16,380.00 44377 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM;W/ BIOPSY, SINGLE OR MULTIPLE 35,100.00 18,720.00 16,380.00 44378 SMALL INTESTINAL ENDOSCOPY, ENTEROSCOPY BEYOND SECOND PORTION OF DUODENUM, INCLUDING ILEUM;W/ CONTROL OF BLEEDING, ANY METHOD 42,783.00 24,765.00 18,018.00 44380 ILEOSCOPY, THROUGH STOMA; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 29,172.00 14,430.00 14,742.00 44382 ILEOSCOPY, THROUGH STOMA; W/ BIOPSY, SINGLE OR MULTIPLE 29,172.00 14,430.00 14,742.00 44385 ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 29,172.00 14,430.00 14,742.00 44386 ENDOSCOPIC EVALUATION OF SMALL INTESTINAL (ABDOMINAL OR PELVIC) POUCH; W/ BIOPSY, SINGLE OR MULTIPLE 29,172.00 14,430.00 14,742.00 44388 COLONOSCOPY THROUGH STOMA; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 29,172.00 14,430.00 14,742.00 44389 COLONOSCOPY THROUGH STOMA; W/ BIOPSY, SINGLE OR MULTIPLE 29,172.00 14,430.00 14,742.00 44390 COLONOSCOPY THROUGH STOMA; W/ REMOVAL OF FOREIGN BODY 35,100.00 18,720.00 16,380.00 44391 COLONOSCOPY THROUGH STOMA; W/ CONTROL OF BLEEDING, ANY METHOD 35,100.00 18,720.00 16,380.00 44392 COLONOSCOPY THROUGH STOMA; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 35,100.00 18,720.00 16,380.00 44393 COLONOSCOPY THROUGH STOMA; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAURTERY OR SNARE TECHNIQUE 42,783.00 24,765.00 18,018.00 44394 COLONOSCOPY THROUGH STOMA; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 42,783.00 24,765.00 18,018.00 44500 INTRODUCTION OF LONG GASTROINTESTINAL TUBE (E.G., MILLER- ABBOTT) 15,639.00 10,725.00 4,914.00 44602 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; SINGLE PERFORATION 73,710.00 32,760.00 40,950.00 44603 SUTURE OF SMALL INTESTINE (ENTERORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE; MULTIPLE PERFORATION 73,710.00 32,760.00 40,950.00 44604 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); W/O COLOSTOMY 73,710.00 32,760.00 40,950.00 44605 SUTURE OF LARGE INTESTINE (COLORRHAPHY) FOR PERFORATED ULCER, DIVERTICULUM, WOUND, INJURY OR RUPTURE (SINGLE OR MULTIPLE PERFORATIONS); W/ COLOSTOMY 73,710.00 32,760.00 40,950.00 44615 INTESTINAL STRICTUROPLASTY (ENTEROTOMY AND ENTERORRHAPHY) W/ OR W/O DILATION, FOR INTESTINAL OBSTRUCTION 73,710.00 32,760.00 40,950.00 44620 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; 59,085.00 26,325.00 32,760.00 44625 CLOSURE OF ENTEROSTOMY, LARGE OR SMALL INTESTINE; W/ RESECTION AND ANASTOMOSIS 59,085.00 26,325.00 32,760.00 44640 CLOSURE OF INTESTINAL CUTANEOUS FISTULA 59,085.00 26,325.00 32,760.00 44650 CLOSURE OF ENTEROENTERIC OR ENTEROCOLIC FISTULA 59,085.00 26,325.00 32,760.00 44660 CLOSURE OF ENTEROVESICAL FISTULA; W/O INTESTINAL OR BLADDER RESECTION 73,710.00 32,760.00 40,950.00 44661 CLOSURE OF ENTEROVESICAL FISTULA; W/ BOWEL AND/OR BLADDER RESECTION 73,710.00 32,760.00 40,950.00 44800 EXCISION OF MECKELS DIVERTICULUM (DIVERTICULECTOMY) OR OMPHALOMESENTERIC DUCT 35,100.00 18,720.00 16,380.00 44820 EXCISION OF LESION OF MESENTERY 35,100.00 18,720.00 16,380.00 44850 SUTURE OF MESENTERY 23,634.00 10,530.00 13,104.00 44900 INCISION AND DRAINAGE OF APPENDICEAL ABSCESS, TRANSABDOMINAL 20,553.00 10,725.00 9,828.00 44950 APPENDECTOMY; 46,800.00 28,080.00 18,720.00 44960 APPENDECTOMY; FOR RUPTURED APPENDIX W/ ABSCESS OR GENERALIZED PERITONITIS 46,800.00 28,080.00 18,720.00 44970 LAPAROSCOPY, SURGICAL; APPENDECTOMY 46,800.00 28,080.00 18,720.00 45000 TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 59,085.00 26,325.00 32,760.00 45005 INCISION AND DRAINAGE OF SUBMUCOSAL ABSCESS, RECTUM 35,100.00 18,720.00 16,380.00 45020 INCISION AND DRAINAGE OF DEEP SUPRALEVATOR, PELVIRECTAL, OR RETRORECTAL ABSCESS 59,085.00 26,325.00 32,760.00 45100 BIOPSY OF ANORECTAL WALL, ANAL APPROACH (E.G., CONGENITAL MEGACOLON) 45,435.00 20,865.00 24,570.00 45108 ANORECTAL MYOMECTOMY 59,085.00 26,325.00 32,760.00 45110 PROCTECTOMY; COMPLETE, COMBINED ABDOMINOPERINEAL, W/ COLOSTOMY 107,250.00 41,730.00 65,520.00 45111 PROCTECTOMY; PARTIAL RESECTION OF RECTUM, TRANSABDOMINAL APPROACH 107,250.00 41,730.00 65,520.00 Page 65 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 45112 PROCTECTOMY, COMBINED ABDOMINOPERINEAL, PULL- THROUGH PROCEDURE (E.G., COLO-ANAL ANASTOMOSIS) 107,250.00 41,730.00 65,520.00 45113 PROCTECTOMY, PARTIAL, W/ RECTAL MUCOSECTOMY, ILEOANAL ANASTOMOSIS, CREATION OF ILEAL RESERVOIR (S OR J), W/ OR W/O LOOP ILEOSTOMY 114,660.00 40,950.00 73,710.00 45114 PROCTECTOMY, PARTIAL, W/ ANASTOMOSIS; ABDOMINAL AND TRANSSACRAL APPROACH 114,660.00 40,950.00 73,710.00 45116 PROCTECTOMY, PARTIAL, W/ ANASTOMOSIS; TRANSSACRAL APPROACH ONLY (KRASKE TYPE) 107,250.00 41,730.00 65,520.00 45120 PROCTECTOMY, COMPLETE (FOR CONGENITAL MEGACOLON), ABDOMINAL AND PERINEAL APPROACH; W/ PULL-THROUGH PROCEDURE AND ANASTOMOSIS (E.G., SWENSON, DUHAMEL, OR SOAVE TYPE OPERATION) 114,660.00 40,950.00 73,710.00 45121 PROCTECTOMY, COMPLETE (FOR CONGENITAL MEGACOLON), ABDOMINAL AND PERINEAL APPROACH; W/ SUBTOTAL OR TOTAL COLECTOMY, W/ MULTIPLE BIOPSIES 114,660.00 40,950.00 73,710.00 45123 PROCTECTOMY, PARTIAL, W/O ANASTOMOSIS, PERINEAL APPROACH 107,250.00 41,730.00 65,520.00 45130 EXCISION OF RECTAL PROCIDENTIA, W/ ANATOMOSIS; PERINEAL APPROACH 104,130.00 46,800.00 57,330.00 45135 EXCISION OF RECTAL PROCIDENTIA, W/ ANATOMOSIS; ABDOMINAL AND PERINEAL APPROACH 107,250.00 41,730.00 65,520.00 45150 DIVISION OF STRICTURE OF RECTUM 23,634.00 10,530.00 13,104.00 45160 EXCISION OF RECTAL TUMOR BY PROCTOTOMY, TRANSSACRAL OR TRANSCOCCYGEAL APPROACH 107,250.00 41,730.00 65,520.00 45170 EXCISION OF RECTAL TUMOR, TRANSANAL APPROACH 35,100.00 18,720.00 16,380.00 45190 DESTRUCTION OF RECTAL TUMOR, ANY METHOD (E.G., ELECTRODESICCATION) TRANSANAL APPROACH 35,100.00 18,720.00 16,380.00 45300 PROCTOSIGMOIDOSCOPY, RIGID; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 15,639.00 10,725.00 4,914.00 45303 PROCTOSIGMOIDOSCOPY, RIGID; W/ DILATION, ANY METHOD 18,915.00 10,725.00 8,190.00 45305 PROCTOSIGMOIDOSCOPY, RIGID; W/ BIOPSY, SINGLE OR MULTIPLE 15,639.00 10,725.00 4,914.00 45307 PROCTOSIGMOIDOSCOPY, RIGID; W/ REMOVAL OF FOREIGN BODY 16,107.00 9,555.00 6,552.00 45308 PROCTOSIGMOIDOSCOPY, RIGID; W/ REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 18,915.00 10,725.00 8,190.00 45309 PROCTOSIGMOIDOSCOPY, RIGID; W/ REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY SNARE TECHNIQUE 18,915.00 10,725.00 8,190.00 45315 PROCTOSIGMOIDOSCOPY, RIGID; W/ REMOVAL OF MULTIPLE TUMORS, POLYPS OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 20,553.00 10,725.00 9,828.00 45317 PROCTOSIGMOIDOSCOPY, RIGID; W/ CONTROL OF BLEEDING, ANY METHOD 20,553.00 10,725.00 9,828.00 45320 PROCTOSIGMOIDOSCOPY, RIGID; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE (E.G., LASER) 20,553.00 10,725.00 9,828.00 45321 PROCTOSIGMOIDOSCOPY, RIGID; W/ DECOMPRESSION OF VOLVULUS 20,553.00 10,725.00 9,828.00 45330 SIGMOIDOSCOPY, FLEXIBLE; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 16,107.00 9,555.00 6,552.00 45331 SIGMOIDOSCOPY, FLEXIBLE; W/ BIOPSY, SINGLE OR MULTIPLE 16,107.00 9,555.00 6,552.00 45332 SIGMOIDOSCOPY, FLEXIBLE; W/ REMOVAL OF FOREIGN BODY 18,915.00 10,725.00 8,190.00 45333 SIGMOIDOSCOPY, FLEXIBLE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 18,915.00 10,725.00 8,190.00 45334 SIGMOIDOSCOPY, FLEXIBLE; W/ CONTROL OF BLEEDING, ANY METHOD 20,553.00 10,725.00 9,828.00 45337 SIGMOIDOSCOPY, FLEXIBLE; W/ DECOMPRESSION OF VOLVULUS, ANY METHOD 23,634.00 10,530.00 13,104.00 45338 SIGMOIDOSCOPY, FLEXIBLE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 20,553.00 10,725.00 9,828.00 45339 SIGMOIDOSCOPY, FLEXIBLE; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY
HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 23,361.00 11,895.00 11,466.00 45355 COLONOSCOPY, RIGID OR FLEXIBLE, TRANSABDOMINAL VIA COLOTOMY, SINGLE OR MULTIPLE 20,553.00 10,725.00 9,828.00 45378 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, W/ OR W/O COLON DECOMPRESSION 23,634.00 10,530.00 13,104.00 45379 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ REMOVAL OF FOREIGN BODY 23,634.00 10,530.00 13,104.00 45380 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ BIOPSY, SINGLE OR MULTIPLE 23,634.00 10,530.00 13,104.00 45382 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ CONTROL OF BLEEDING, ANY METHOD 35,100.00 18,720.00 16,380.00 45383 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 29,172.00 14,430.00 14,742.00 Page 66 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 45384 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 29,172.00 14,430.00 14,742.00 45385 COLONOSCOPY, FLEXIBLE, PROXIMAL TO SPLENIC FLEXURE; W/ REMOVAL OF TUMOR(S), POLYP(S), OR OTHER LESION(S) BY SNARE TECHNIQUE 35,100.00 18,720.00 16,380.00 45395 LAPAROSCOPY, SURGICAL; PROCTECTOMY, COMPLETE COMBINED ABDOMINOPERINEAL, WITH COLOSTOMY 107,250.00 41,730.00 65,520.00 45397 LAPAROSCOPY, SURGICAL; PROTECTOMY, COMBINED ABDOMINOPERINEAL PULL THROUGH PROCEDURE (E.G., COLO- ANAL ANASTOMOSIS), WITH CREATION OF COLONIC RESERVOIR (E.G., J-POUCH), WITH DIVERTING ENTEROSTOMY, WHEN PERFORMED 107,250.00 41,730.00 65,520.00 45400 LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE) 52,884.00 23,400.00 29,484.00 45402 LAPAROSCOPY, SURGICAL; PROCTOPEXY (FOR PROLAPSE), WITH SIGMOID RESECTION 59,085.00 26,325.00 32,760.00 45500 PROCTOPLASTY; FOR STENOSIS 35,100.00 18,720.00 16,380.00 45505 PROCTOPLASTY; FOR PROLAPSE OF MUCOUS MEMBRANE 35,100.00 18,720.00 16,380.00 45540 PROCTOPEXY FOR PROLAPSE; ABDOMINAL APPROACH 52,884.00 23,400.00 29,484.00 45541 PROCTOPEXY FOR PROLAPSE; PERINEAL APPROACH 52,884.00 23,400.00 29,484.00 45550 PROCTOPEXY COMBINED W/ SIGMOID RESECTION, ABDOMINAL APPROACH 59,085.00 26,325.00 32,760.00 45560 REPAIR OF RECTOCELE 35,100.00 18,720.00 16,380.00 45562 EXPLORATION, REPAIR AND PRESACRAL DRAINAGE FOR RECTAL INJURY; 45,435.00 20,865.00 24,570.00 45563 EXPLORATION, REPAIR AND PRESACRAL DRAINAGE FOR RECTAL INJURY; W/ COLOSTOMY 52,884.00 23,400.00 29,484.00 45800 CLOSURE OF RECTOVESICAL FISTULA; 59,085.00 26,325.00 32,760.00 45805 CLOSURE OF RECTOVESICAL FISTULA; W/ COLOSTOMY 73,710.00 32,760.00 40,950.00 45820 CLOSURE OF RECTOURETHRAL FISTULA; 59,085.00 26,325.00 32,760.00 45825 CLOSURE OF RECTOURETHRAL FISTULA; W/ COLOSTOMY 73,710.00 32,760.00 40,950.00 45905 DILATION OF ANAL SPHINCTER UNDER ANESTHESIA OTHER THAN LOCAL 16,107.00 9,555.00 6,552.00 45910 DILATION OF RECTAL STRICTURE UNDER ANESTHESIA OTHER THAN LOCAL 16,107.00 9,555.00 6,552.00 45915 REMOVAL OF FECAL IMPACTION OR FOREIGN BODY UNDER ANESTHESIA 16,107.00 9,555.00 6,552.00 46040 INCISION AND DRAINAGE OF ISCHIORECTAL AND/OR PERIRECTAL ABSCESS 16,107.00 9,555.00 6,552.00 46045 INCISION AND DRAINAGE OF INTRAMURAL, INTRAMUSCULAR, OR SUBMUCOSAL ABSCESS, TRANSANAL, UNDER ANESTHESIA 18,915.00 10,725.00 8,190.00 46050 INCISION AND DRAINAGE, PERIANAL ABSCESS, SUPERFICIAL 16,107.00 9,555.00 6,552.00 46060 INCISION AND DRAINAGE OF ISCHIORECTAL OR INTRAMURAL ABSCESS, W/ FISTULECTOMY OR FISTULOTOMY, SUBMUSCULAR, W/ OR W/O PLACEMENT OF SETON 18,915.00 10,725.00 8,190.00 46070 INCISION, ANAL SEPTUM (INFANT) 18,915.00 10,725.00 8,190.00 46080 SPHINCTEROTOMY, ANAL, DIVISION OF SPHINCTER 18,915.00 10,725.00 8,190.00 46083 INCISION OF THROMBOSED HEMORRHOID, EXTERNAL 15,639.00 10,725.00 4,914.00 46200 FISSURECTOMY, W/ OR W/O SPHINCTEROTOMY 16,107.00 9,555.00 6,552.00 46210 CRYPTECTOMY; SINGLE 16,107.00 9,555.00 6,552.00 46211 CRYPTECTOMY; MULTIPLE 18,915.00 10,725.00 8,190.00 46220 PAPILLECTOMY OR EXCISION OF SINGLE TAG, ANUS 16,107.00 9,555.00 6,552.00 46221 HEMORRHOIDECTOMY, BY SIMPLE LIGATURE (E.G., RUBBER BAND) 23,634.00 10,530.00 13,104.00 46230 EXCISION OF EXTERNAL HEMORRHOID TAGS AND/OR MULTIPLE PAPILLAE 23,634.00 10,530.00 13,104.00 46250 HEMORRHOIDECTOMY, EXTERNAL, COMPLETE 23,634.00 10,530.00 13,104.00 46255 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; 23,634.00 10,530.00 13,104.00 46257 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; W/ FISSURECTOMY 23,634.00 10,530.00 13,104.00 46258 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, SIMPLE; W/ FISTULECTOMY, W/ OR W/O FISSURECTOMY 23,634.00 10,530.00 13,104.00 46260 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; 23,634.00 10,530.00 13,104.00 46261 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; W/ FISSURECTOMY 23,634.00 10,530.00 13,104.00 46262 HEMORRHOIDECTOMY, INTERNAL AND EXTERNAL, COMPLEX OR EXTENSIVE; W/ FISTULECTOMY, W/ OR W/O FISSURECTOMY 23,634.00 10,530.00 13,104.00 46270 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBCUTANEOUS 23,634.00 10,530.00 13,104.00 46275 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SUBMUSCULAR 23,634.00 10,530.00 13,104.00 46280 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); COMPLEX OR MULTIPLE, W/ OR W/O PLACEMENT OF SETON 23,634.00 10,530.00 13,104.00 46285 SURGICAL TREATMENT OF ANAL FISTULA (FISTULECTOMY/FISTULOTOMY); SECOND STAGE 23,634.00 10,530.00 13,104.00 46288 CLOSURE OF ANAL FISTULA W/ RECTAL ADVANCEMENT FLAP 35,100.00 18,720.00 16,380.00 46320 ENUCLEATION OR EXCISION OF EXTERNAL THROMBOTIC HEMORRHOID 23,634.00 10,530.00 13,104.00 46600 ANOSCOPY; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 11,076.00 7,800.00 3,276.00 46604 ANOSCOPY; W/ DILATION, ANY METHOD 11,076.00 7,800.00 3,276.00 46606 ANOSCOPY; W/ BIOPSY, SINGLE OR MULTIPLE 11,076.00 7,800.00 3,276.00 Page 67 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 46608 ANOSCOPY; W/ REMOVAL OF FOREIGN BODY 11,076.00 7,800.00 3,276.00 46610 ANOSCOPY; W/ REMOVAL OF SINGLE TUMOR, POLYP, OR OTHER LESION BY HOT BIOPSY FORCEPS OR BIPOLAR CAUTERY 15,639.00 10,725.00 4,914.00 46611 ANOSCOPY; W/ REMOVAL OF SINGLE TUMOR, POLYP OR OTHER LESION BY SNARE TECHNIQUE 16,107.00 9,555.00 6,552.00 46612 ANOSCOPY; W/ REMOVAL OF MULTIPLE TUMOR, POLYPS, OR OTHER LESIONS BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 16,107.00 9,555.00 6,552.00 46614 ANOSCOPY; W/ CONTROL OF BLEEDING, ANY METHOD 15,639.00 10,725.00 4,914.00 46615 ANOSCOPY; W/ ABLATION OF TUMOR(S), POLYP(S), OR OTHER LESION(S) NOT AMENABLE TO REMOVAL BY HOT BIOPSY FORCEPS, BIPOLAR CAUTERY OR SNARE TECHNIQUE 18,915.00 10,725.00 8,190.00 46700 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; ADULT 25,155.00 12,870.00 12,285.00 46705 ANOPLASTY, PLASTIC OPERATION FOR STRICTURE; INFANT 45,435.00 20,865.00 24,570.00 46715 REPAIR OF LOW IMPERFORATE ANUS; W/ ANOPERINEAL FISTULA ("CUT-BACK" PROCEDURE) 45,435.00 20,865.00 24,570.00 46716 REPAIR OF LOW IMPERFORATE ANUS; W/ TRANSPORTATION OF ANOPERINEAL OR ANOVESTIBULAR FISTULA 73,710.00 32,760.00 40,950.00 46730 REPAIR OF HIGH IMPERFORATE ANUS W/O FISTULA; PERINEAL OR SACROPERINEAL APPROACH 73,710.00 32,760.00 40,950.00 46735 REPAIR OF HIGH IMPERFORATE ANUS W/O FISTULA; COMBINED TRANSABDOMINAL AND SACROPERINEAL APPROACHES 90,675.00 41,535.00 49,140.00 46740 REPAIR OF HIGH IMPERFORATE ANUS W/ RECTOURETHRAL OR RECTOVAGINAL FISTULA; PERINEAL OR SACROPERINEAL APPROACH 59,085.00 26,325.00 32,760.00 46742 REPAIR OF HIGH IMPERFORATE ANUS W/ RECTOURETHRAL OR RECTOVAGINAL FISTULA; COMBINED TRANSABDOMINAL AND SACROPERINEAL APPROACHES 104,130.00 46,800.00 57,330.00 46744 REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, SACROPERINEAL APPROACH 114,660.00 40,950.00 73,710.00 46746 REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; 122,850.00 40,950.00 81,900.00 46748 REPAIR OF CLOACAL ANOMALY BY ANORECTOVAGINOPLASTY AND URETHROPLASTY, COMBINED ABDOMINAL AND SACROPERINEAL APPROACH; W/ VAGINAL LENGTHENING BY INTESTINAL GRAFT OR PEDICLE FLAPS 122,850.00 40,950.00 81,900.00 46750 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; ADULT 29,172.00 14,430.00 14,742.00 46751 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE OR PROLAPSE; CHILD 45,435.00 20,865.00 24,570.00 46753 GRAFT (THIERSCH OPERATION) FOR RECTAL INCONTINENCE AND/OR PROLAPSE 18,915.00 10,725.00 8,190.00 46754 REMOVAL OF THIERSCH WIRE OR SUTURE, ANAL CANAL 16,107.00 9,555.00 6,552.00 46760 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; MUSCLE TRANSPLANT 78,624.00 32,760.00 45,864.00 46761 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; LEVATOR MUSCLE IMBRICATION (PARK POSTERIOR ANAL REPAIR) 40,911.00 21,255.00 19,656.00 46762 SPHINCTEROPLASTY, ANAL, FOR INCONTINENCE, ADULT; IMPLANTATION ARTIFICIAL SPHINCTER 78,624.00 32,760.00 45,864.00 46900 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CHEMICAL 16,107.00 9,555.00 6,552.00 46910 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; ELECTRODESICCATION 16,107.00 9,555.00 6,552.00 46916 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; CRYOSURGERY 16,107.00 9,555.00 6,552.00 46917 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; LASER SURGERY 16,107.00 9,555.00 6,552.00 46922 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), SIMPLE; SURGICAL EXCISION 16,107.00 9,555.00 6,552.00 46924 DESTRUCTION OF LESION(S), ANUS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), EXTENSIVE, ANY METHOD 18,915.00 10,725.00 8,190.00 46934 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL 18,915.00 10,725.00 8,190.00 46935 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; EXTERNAL 18,915.00 10,725.00 8,190.00 46936 DESTRUCTION OF HEMORRHOIDS, ANY METHOD; INTERNAL AND EXTERNAL 18,915.00 10,725.00 8,190.00 46937 CRYOSURGERY OF RECTAL TUMOR; BENIGN 18,915.00 10,725.00 8,190.00 46938 CRYOSURGERY OF RECTAL TUMOR; MALIGNANT 18,915.00 10,725.00 8,190.00 46940 CURETTAGE OR CAUTERIZATION OF ANAL FISSURE, INCLUDING DILATION OF ANAL SPHINCTER 18,915.00 10,725.00 8,190.00 46945 LIGATION OF INTERNAL HEMORRHOIDS 16,107.00 9,555.00 6,552.00 47000 BIOPSY OF LIVER, NEEDLE; PERCUTANEOUS 15,639.00 10,725.00 4,914.00 Page 68 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 47010 HEPATOTOMY FOR DRAINAGE OF ABSCESS OR CYST, ONE OR TWO STAGES 35,100.00 18,720.00 16,380.00 47015 LAPAROTOMY, W/ ASPIRATION AND/OR INJECTION OF HEPATIC PARASITIC (E.G., AMOEBIC OR ECHINOCOCCAL) CYST(S) OR ABSCESS(ES) 35,100.00 18,720.00 16,380.00 47100 BIOPSY OF LIVER, WEDGE 35,100.00 18,720.00 16,380.00 47120 HEPATECTOMY, RESECTION OF LIVER; PARTIAL LOBECTOMY 104,130.00 46,800.00 57,330.00 47122 HEPATECTOMY, RESECTION OF LIVER; TRISEGMENTECTOMY 107,250.00 41,730.00 65,520.00 47125 HEPATECTOMY, RESECTION OF LIVER; TOTAL LEFT LOBECTOMY 90,675.00 41,535.00 49,140.00 47130 HEPATECTOMY, RESECTION OF LIVER; TOTAL RIGHT LOBECTOMY 104,130.00 46,800.00 57,330.00 47134 DONOR HEPATECTOMY, W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT; PARTIAL, FROM LIVING DONOR 90,675.00 41,535.00 49,140.00 47135 LIVER ALLOTRANSPLANTATION; ORTHOTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE 107,250.00 41,730.00 65,520.00 47136 LIVER ALLOTRANSPLANTATION; HETEROTOPIC, PARTIAL OR WHOLE, FROM CADAVER OR LIVING DONOR, ANY AGE 107,250.00 41,730.00 65,520.00 47300 MARSUPIALIZATION OF CYST OR ABSCESS OF LIVER 35,100.00 18,720.00 16,380.00 47350 MANAGEMENT OF LIVER HEMORRHAGE; SIMPLE SUTURE OF LIVER WOUND OR INJURY 45,435.00 20,865.00 24,570.00 47360 MANAGEMENT OF LIVER HEMORRHAGE; COMPLEX SUTURE OF LIVER WOUND OR INJURY, W/ OR W/O HEPATIC ARTERY LIGATION 90,675.00 41,535.00 49,140.00 47361 MANAGEMENT OF LIVER HEMORRHAGE; EXPLORATION OF HEPATIC WOUND, EXTENSIVE DEBRIDEMENT, COAGULATION AND/OR SUTURE, W/ OR W/O PACKING OF LIVER 73,710.00 32,760.00 40,950.00 47362 MANAGEMENT OF LIVER HEMORRHAGE; RE-EXPLORATION OF HEPATIC WOUND FOR REMOVAL OF PACKING 73,710.00 32,760.00 40,950.00 47370 LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER TUMOR(S); RADIOFREQUENCY 35,100.00 18,720.00 16,380.00 47371 LAPAROSCOPY, SURGICAL, ABLATION OF ONE OR MORE LIVER TUMOR(S); CRYOSURGICAL 35,100.00 18,720.00 16,380.00 47380 ABLATION, OPEN, OF OR MORE LIVER TUMOR(S); RADIOFREQUENCY 18,915.00 10,725.00 8,190.00 47381 ABLATION, OPEN, OF OR MORE LIVER TUMOR(S); CRYOSURGICAL 18,915.00 10,725.00 8,190.00 47382 ABLATION, ONE OR MORE LIVER TUMOR(S), PERCUTANEOUS RADIOFREQUENCY 18,915.00 10,725.00 8,190.00 47400 HEPATICOTOMY OR HEPATICOSTOMY W/ EXPLORATION, DRAINAGE, OR REMOVAL OF CALCULUS 104,130.00 46,800.00 57,330.00 47420 CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY W/ EXPLORATION, DRAINAGE, OR REMOVAL OF CALCULUS, W/ OR W/O CHOLECYSTOTOMY; W/O TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY 73,710.00 32,760.00 40,950.00 47425 CHOLEDOCHOTOMY OR CHOLEDOCHOSTOMY W/ EXPLORATION, DRAINAGE, OR REMOVAL OF CALCULUS, W/ OR W/O CHOLECYSTOTOMY; W/ TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY 90,675.00 41,535.00 49,140.00 47460 TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, W/ OR W/O TRANSDUODENAL EXTRACTION OF CALCULUS 90,675.00 41,535.00 49,140.00 47480 CHOLECYSTOTOMY OR CHOLECYSTOSTOMY W/ EXPLORATION, DRAINAGE, OR REMOVAL OF CALCULUS 59,085.00 26,325.00 32,760.00 47490 PERCUTANEOUS CHOLECYSTOSTOMY 59,085.00 26,325.00 32,760.00 47510 INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC CATHETER FOR BILIARY DRAINAGE 59,085.00 26,325.00 32,760.00 47511 INTRODUCTION OF PERCUTANEOUS TRANSHEPATIC STENT FOR INTERNAL AND EXTERNAL BILIARY DRAINAGE 59,085.00 26,325.00 32,760.00 47525 CHANGE OF PERCUTANEOUS BILIARY DRAINAGE CATHETER 15,639.00 10,725.00 4,914.00 47530 REVISION AND/OR REINSERTION OF TRANSHEPATIC TUBE 16,107.00 9,555.00 6,552.00 47552 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; DIAGNOSTIC, W/ OR W/O COLLECTION OF SPECIMEN(S) BY BRUSHING AND/OR WASHING 45,435.00 20,865.00 24,570.00 47553 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; W/ BIOPSY, SINGLE OR MULTIPLE 45,435.00 20,865.00 24,570.00 47554 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; W/ REMOVAL OF STONE(S) 45,435.00 20,865.00 24,570.00 47555 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; W/ DILATION OF BILIARY DUCT STRICTURE(S) W/O STENT 45,435.00 20,865.00 24,570.00 47556 BILIARY ENDOSCOPY, PERCUTANEOUS VIA T- TUBE OR OTHER TRACT; W/ DILATION OF BILIARY DUCT STRICTURE(S) W/ STENT 45,435.00 20,865.00 24,570.00 47560 LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITHOUT BIOPSY 60,450.00 36,270.00 24,180.00 47561 LAPAROSCOPY, SURGICAL; WITH GUIDED TRANSHEPATIC CHOLANGIOGRAPHY, WITH BIOPSY 60,450.00 36,270.00 24,180.00 47562 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY (ANY METHOD) 60,450.00 36,270.00 24,180.00 47563 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY 60,450.00 36,270.00 24,180.00 47564 LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH EXPLORATION OF COMMON DUCT 90,675.00 41,535.00 49,140.00 Page 69 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 47570 LAPAROSCOPY, SURGICAL; CHOLECYSTOENTEROSTOMY 60,450.00 36,270.00 24,180.00 47600 CHOLECYSTECTOMY; 60,450.00 36,270.00 24,180.00 47605 CHOLECYSTECTOMY; W/ CHOLANGIOGRAPHY 60,450.00 36,270.00 24,180.00 47610 CHOLECYSTECTOMY W/ EXPLORATION OF COMMON DUCT; 90,675.00 41,535.00 49,140.00 47612 CHOLECYSTECTOMY W/ EXPLORATION OF COMMON DUCT; W/ CHOLEDOCHOENTEROSTOMY 104,130.00 46,800.00 57,330.00 47620 CHOLECYSTECTOMY W/ EXPLORATION OF COMMON DUCT; W/ TRANSDUODENAL SPHINCTEROTOMY OR SPHINCTEROPLASTY, W/ OR W/O CHOLANGIOGRAPHY 90,675.00 41,535.00 49,140.00 47630 BILIARY DUCT STONE EXTRACTION, PERCUTANEOUS VIA T-TUBE TRACT, BASKET, OR SNARE (E.G., BURHENNE TECHNIQUE) 45,435.00 20,865.00 24,570.00 47700 EXPLORATION FOR CONGENITAL ATRESIA OF BILE DUCTS, W/O REPAIR, W/ OR W/O LIVER BIOPSY, W/ OR W/O CHOLANGIOGRAPHY 104,130.00 46,800.00 57,330.00 47701 PORTOENTEROSTOMY (E.G., KASAI PROCEDURE) 107,250.00 41,730.00 65,520.00 47711 EXCISION OF BILE DUCT TUMOR, W/ OR W/O PRIMARY REPAIR OF BILE DUCT; EXTRAHEPATIC 107,250.00 41,730.00 65,520.00 47712 EXCISION OF BILE DUCT TUMOR, W/ OR W/O PRIMARY REPAIR OF BILE DUCT; INTRAHEPATIC 114,660.00 40,950.00 73,710.00 47715 EXCISION OF CHOLEDOCHAL CYST 107,250.00 41,730.00 65,520.00 47716 ANASTOMOSIS, CHOLEDOCHAL CYST, W/O EXCISION 90,675.00 41,535.00 49,140.00 47720 CHOLECYSTOENTEROSTOMY; DIRECT 73,710.00 32,760.00 40,950.00 47721 CHOLECYSTOENTEROSTOMY; W/ GASTROENTEROSTOMY 90,675.00 41,535.00 49,140.00 47740 ROUX-EN-Y 104,130.00 46,800.00 57,330.00 47741 ROUX-EN-Y W/ GASTROENTEROSTOMY 104,130.00 46,800.00 57,330.00 47760 ANASTOMOSIS, OF EXTRAHEPATIC BILIARY DUCTS AND GASTROINTESTINAL TRACT 90,675.00 41,535.00 49,140.00 47765 ANASTOMOSIS, OF INTRAHEPATIC DUCTS AND GASTROINTESTINAL TRACT 104,130.00 46,800.00 57,330.00 47780 ANASTOMOSIS, ROUX-EN-Y, OF EXTRAHEPATIC BILIARY DUCTS AND GASTROINTESTINAL TRACT 90,675.00 41,535.00 49,140.00 47785 ANASTOMOSIS, ROUX-EN-Y, OF INTRAHEPATIC BILIARY DUCTS AND GASTROINTESTINAL TRACT 104,130.00 46,800.00 57,330.00 47800 RECONSTRUCTION, PLASTIC, OF EXTRAHEPATIC BILIARY DUCTS W/ END-TO-END ANASTOMOSIS 90,675.00 41,535.00 49,140.00 47801 PLACEMENT OF CHOLEDOCHAL STENT 73,710.00 32,760.00 40,950.00 47802 U-TUBE HEPATICOENTEROSTOMY 73,710.00 32,760.00 40,950.00 47900 SUTURE OF EXTRAHEPATIC BILIARY DUCT FOR PRE-EXISTING INJURY 90,675.00 41,535.00 49,140.00 48000 PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; 45,435.00 20,865.00 24,570.00 48001 PLACEMENT OF DRAINS, PERIPANCREATIC, FOR ACUTE PANCREATITIS; W/ CHOLECYSTOSTOMY, GASTROSTOMY, AND JEJUNOSTOMY 90,675.00 41,535.00 49,140.00 48005 RESECTION OR DEBRIDEMENT OF PANCREAS AND PERIPANCREATIC TISSUE FOR ACUTE NECROTIZING PANCREATITIS 90,675.00 41,535.00 49,140.00 48020 REMOVAL OF PANCREATIC CALCULUS 73,710.00 32,760.00 40,950.00 48100 BIOPSY OF PANCREAS, OPEN, ANY METHOD (E.G., FINE NEEDLE ASPIRATION, NEEDLE CORE BIOPSY, WEDGE BIOPSY) 23,634.00 10,530.00 13,104.00 48102 BIOPSY OF PANCREAS, PERCUTANEOUS NEEDLE 18,915.00 10,725.00 8,190.00 48120 EXCISION OF LESION OF PANCREAS (E.G., CYST, ADENOMA) 59,085.00 26,325.00 32,760.00 48140 PANCREATECTOMY, DISTAL SUBTOTAL, W/ OR W/O SPLENECTOMY; W/O PANCREATICOJEJUNOSTOMY 90,675.00 41,535.00 49,140.00 48145 PANCREATECTOMY, DISTAL SUBTOTAL, W/ OR W/O SPLENECTOMY; W/ PANCREATICOJEJUNOSTOMY 104,130.00 46,800.00 57,330.00 48146 PANCREATECTOMY, DISTAL, NEAR-TOTAL W/ PRESERVATION OF DUODENUM (CHILD-TYPE PROCEDURE) 104,130.00 46,800.00 57,330.00 48148 EXCISION OF AMPULLA OF VATER 90,675.00 41,535.00 49,140.00 48150 PANCREATECTOMY, PROXIMAL SUBTOTAL W/ TOTAL DUODENECTOMY, PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); W/ PANCREATOJEJUNOSTOMY 114,660.00 40,950.00 73,710.00 48152 PANCREATECTOMY, PROXIMAL SUBTOTAL W/ TOTAL DUODENECTOMY, PARTIAL GASTRECTOMY, CHOLEDOCHOENTEROSTOMY AND GASTROJEJUNOSTOMY (WHIPPLE-TYPE PROCEDURE); W/O PANCREATOJEJUNOSTOMY 107,250.00 41,730.00 65,520.00 48153 PANCREATECTOMY, PROXIMAL SUBTOTAL W/ NEAR TOTAL DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); W/ PANCREATOJEJUNOSTOMY 122,850.00 40,950.00 81,900.00 48154 PANCREATECTOMY, PROXIMAL SUBTOTAL W/ NEAR TOTAL DUODENECTOMY, CHOLEDOCHOENTEROSTOMY AND DUODENOJEJUNOSTOMY (PYLORUS-SPARING, WHIPPLE-TYPE PROCEDURE); W/O PANCREATOJEJUNOSTOMY 114,660.00 40,950.00 73,710.00 48155 PANCREATECTOMY, TOTAL 122,850.00 40,950.00 81,900.00 48160 PANCREATECTOMY, TOTAL OR SUBTOTAL, W/ AUTOLOGOUS TRANSPLANTATION OF PANCREAS OR PANCREATIC ISLETS 122,850.00 40,950.00 81,900.00 48180 PANCREATICOJEJUNOSTOMY, SIDE-TO-SIDE ANASTOMOSIS (PUESTOW-TYPE OPERATION) 107,250.00 41,730.00 65,520.00 48500 MARSUPIALIZATION OF CYST OF PANCREAS 59,085.00 26,325.00 32,760.00 48510 EXTERNAL DRAINAGE, PSUEDOCYST OF PANCREAS 45,435.00 20,865.00 24,570.00 48520 INTERNAL ANASTOMOSIS OF PACREATIC CYST TO GASTROINTESTINAL TRACT; DIRECT 90,675.00 41,535.00 49,140.00 Page 70 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 48540 INTERNAL ANASTOMOSIS OF PACREATIC CYST TO GASTROINTESTINAL TRACT; ROUX-EN-Y 90,675.00 41,535.00 49,140.00 48545 PANCREATORRHAPHY FOR TRAUMA 104,130.00 46,800.00 57,330.00 48547 DUODENAL EXCLUSION W/ GASTROJEJUNOSTOMY FOR PANCREATIC TRAUMA 104,130.00 46,800.00 57,330.00 48550 DONOR PANCREATECTOMY, W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT FROM CADAVER DONOR, W/ OR W/O DUODENAL SEGMENT FOR TRANSPLANTATION 59,085.00 26,325.00 32,760.00 48554 TRANSPLANTATION OF PANCREATIC ALLOGRAFT 59,085.00 26,325.00 32,760.00 48556 REMOVAL OF TRANSPLANTED PANCREATIC ALLOGRAFT 45,435.00 20,865.00 24,570.00 49000 EXPLORATORY LAPAROTOMY, EXPLORATORY CELIOTOMY W/ OR W/O BIOPSY(S) 45,435.00 20,865.00 24,570.00 49010 EXPLORATION, RETROPERITONEAL AREA W/ OR W/O BIOPSY(S) 45,435.00 20,865.00 24,570.00 49020 DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF APPENDICEAL ABSCESS; OPEN 45,435.00 20,865.00 24,570.00 49021 DRAINAGE OF PERITONEAL ABSCESS OR LOCALIZED PERITONITIS, EXCLUSIVE OF APPENDICEAL ABSCESS; PERCUTANEOUS 16,107.00 9,555.00 6,552.00 49040 DRAINAGE OF SUBDIAPHARGMATIC OR SUBPHRENIC ABSCESS 45,435.00 20,865.00 24,570.00 49060 DRAINAGE OF RETROPERITONEAL ABSCESS 45,435.00 20,865.00 24,570.00 49080 PERITONEOCENTESIS, ABDOMINAL PARACENTESIS, OR PERITONEAL LAVAGE (DIAGNOSTIC OR THERAPEUTIC) 15,639.00 10,725.00 4,914.00 49085 REMOVAL OF PERITONEAL FOREIGN BODY FROM PERITONEAL CAVITY 45,435.00 20,865.00 24,570.00 49180 BIOPSY, ABDOMINAL OR RETROPERITONEAL MASS, PERCUTANEOUS NEEDLE 16,107.00 9,555.00 6,552.00 49200 EXCISION OR DESTRUCTION BY ANY METHOD OF INTRA- ABDOMINAL OR RETROPERITONEAL TUMORS OR CYSTS OR ENDOMETRIOMAS; 73,710.00 32,760.00 40,950.00 49201 EXCISION OR DESTRUCTION BY ANY METHOD OF INTRA- ABDOMINAL OR RETROPERITONEAL TUMORS OR CYSTS OR ENDOMETRIOMAS; EXTENSIVE 104,130.00 46,800.00 57,330.00 49215 EXCISION OF PRESACRAL OR SACROCOCCYGEAL TUMOR 90,675.00 41,535.00 49,140.00 49220 STAGING CELIOTOMY (LAPAROTOMY) FOR HODGKINS DISEASE OR LYMPHOMA (INCLUDES SPLENECTOMY, NEEDLE OR OPEN BIOPSIES OF BOTH LIVER LOBES, POSSIBLY ALSO REMOVAL OF ABDOMINAL NODES, ABDOMINAL NODE AND/OR BONE MARROW BIOPSIES, OVARIAN REPOSITIONING) 45,435.00 20,865.00 24,570.00 49250 UMBILECTOMY, OMPHALECTOMY, EXCISION OF UMBILICUS 18,915.00 10,725.00 8,190.00 49255 OMENTECTOMY, EPIPLOECTOMY, RESECTION OF OMENTUM 18,915.00 10,725.00 8,190.00 49320 LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING 11,076.00 7,800.00 3,276.00 49321 LAPAROSCOPY, SURGICAL; WITH BIOPSY (SINGLE OR MULTIPLE) 18,915.00 10,725.00 8,190.00 49322 LAPAROSCOPY, SURGICAL; WITH ASPIRATION OF CAVITY OR CYST (SINGLE OR MULTIPLE) 23,634.00 10,530.00 13,104.00 49323 LAPAROSCOPY, SURGICAL; WITH DRAINAGE OF LYMPHOCELE TO PERITONEAL CAVITY 16,107.00 9,555.00 6,552.00 49420 INSERTION OF INTRAPERITONEAL CANNULA OR CATHETER FOR DRAINAGE OR DIALYSIS 16,107.00 9,555.00 6,552.00 49425 INSERTION OF PERITONEAL-VENOUS SHUNT 35,100.00 18,720.00 16,380.00 49495 REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, W/ OR W/O HYDROCELECTOMY; REDUCIBLE 40,950.00 24,570.00 16,380.00 49496 REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, W/ OR W/O HYDROCELECTOMY; INCARCERATED 40,950.00 24,570.00 16,380.00 49497 REPAIR INITIAL INGUINAL HERNIA, UNDER AGE 6 MONTHS, W/ OR W/O HYDROCELECTOMY; STRANGULATED 40,950.00 24,570.00 16,380.00 49500 REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO UNDER 5 YEARS, W/ OR W/O HYDROCELECTOMY; REDUCIBLE 40,950.00 24,570.00 16,380.00 49501 REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO UNDER 5 YEARS, W/ OR W/O HYDROCELECTOMY; INCARCERATED 40,950.00 24,570.00 16,380.00 49502 REPAIR INITIAL INGUINAL HERNIA, AGE 6 MONTHS TO UNDER 5 YEARS, W/ OR W/O HYDROCELECTOMY; STRANGULATED 40,950.00 24,570.00 16,380.00 49505 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE 40,950.00 24,570.00 16,380.00 49507 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED 40,950.00 24,570.00 16,380.00 49509 REPAIR INITIAL INGUINAL HERNIA, AGE 5 YEARS OR OVER; STRANGULATED 40,950.00 24,570.00 16,380.00 49520 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; REDUCIBLE 40,950.00 24,570.00 16,380.00 49521 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; INCARCERATED 40,950.00 24,570.00 16,380.00 49522 REPAIR RECURRENT INGUINAL HERNIA, ANY AGE; STRANGULATED 40,950.00 24,570.00 16,380.00 49525 REPAIR INGUINAL HERNIA, SLIDING, ANY AGE 40,950.00 24,570.00 16,380.00 49540 REPAIR LUMBAR HERNIA 40,950.00 24,570.00 16,380.00 49550 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; REDUCIBLE 40,950.00 24,570.00 16,380.00 49553 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; INCARCERATED 40,950.00 24,570.00 16,380.00 Page 71 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 49554 REPAIR INITIAL FEMORAL HERNIA, ANY AGE; STRANGULATED 40,950.00 24,570.00 16,380.00 49555 REPAIR RECURRENT FEMORAL HERNIA; REDUCIBLE 40,950.00 24,570.00 16,380.00 49557 REPAIR RECURRENT FEMORAL HERNIA; INCARCERATED 40,950.00 24,570.00 16,380.00 49558 REPAIR RECURRENT FEMORAL HERNIA; STRANGULATED 40,950.00 24,570.00 16,380.00 49560 REPAIR INITIAL INCISIONAL HERNIA; REDUCIBLE 40,950.00 24,570.00 16,380.00 49561 REPAIR INITIAL INCISIONAL HERNIA; INCARCERATED 40,950.00 24,570.00 16,380.00 49562 REPAIR INITIAL INCISIONAL HERNIA; STRANGULATED 40,950.00 24,570.00 16,380.00 49565 REPAIR RECURRENT INCISIONAL HERNIA; REDUCIBLE 40,950.00 24,570.00 16,380.00 49566 REPAIR RECURRENT INCISIONAL HERNIA; INCARCERATED 40,950.00 24,570.00 16,380.00 49567 REPAIR RECURRENT INCISIONAL HERNIA; STRANGULATED 40,950.00 24,570.00 16,380.00 49570 REPAIR EPIGASTRIC HERNIA (E.G., PREPERITONEAL FAT); REDUCIBLE 40,950.00 24,570.00 16,380.00 49572 REPAIR EPIGASTRIC HERNIA (E.G., PREPERITONEAL FAT); INCARCERATED 40,950.00 24,570.00 16,380.00 49573 REPAIR EPIGASTRIC HERNIA (E.G., PREPERITONEAL FAT); STRANGULATED 40,950.00 24,570.00 16,380.00 49580 REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEARS; REDUCIBLE 40,950.00 24,570.00 16,380.00 49582 REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEARS; INCARCERATED 40,950.00 24,570.00 16,380.00 49583 REPAIR UMBILICAL HERNIA, UNDER AGE 5 YEARS; STRANGULATED 40,950.00 24,570.00 16,380.00 49585 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; REDUCIBLE 40,950.00 24,570.00 16,380.00 49587 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; INCARCERATED 40,950.00 24,570.00 16,380.00 49588 REPAIR UMBILICAL HERNIA, AGE 5 YEARS OR OVER; STRANGULATED 40,950.00 24,570.00 16,380.00 49590 REPAIR SPIGELIAN HERNIA 40,950.00 24,570.00 16,380.00 49600 REPAIR OF SMALL OMPHALOCELE, W/ PRIMARY CLOSURE 45,435.00 20,865.00 24,570.00 49605 REPAIR LARGE OMPHALOCELE OR GASTROSCHISIS; W/ OR W/O PROSTHESIS 73,710.00 32,760.00 40,950.00 49606 REPAIR LARGE OMPHALOCELE OR GASTROSCHISIS; W/ REMOVAL OF PROSTHESIS, FINAL REDUCTION AND CLOSURE, IN OPERATING ROOM 59,085.00 26,325.00 32,760.00 49610 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); FIRST STAGE 45,435.00 20,865.00 24,570.00 49611 REPAIR OF OMPHALOCELE (GROSS TYPE OPERATION); SECOND STAGE 59,085.00 26,325.00 32,760.00 49650 LAPAROSCOPY, SURGICAL; REPAIR OF INITIAL INGUINAL HERNIA 40,950.00 24,570.00 16,380.00 49651 LAPAROSCOPY, SURGICAL; REPAIR OF RECURRENT INGUINAL HERNIA 40,950.00 24,570.00 16,380.00 49900 SUTURE, SECONDARY, OF ABDOMINAL WALL FOR EVISCERATION OR DEHISCENCE 35,100.00 18,720.00 16,380.00 49905 OMENTAL FLAP (E.G., FOR RECONSTRUCTION OF STERNAL AND CHEST WALL DEFECTS) (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 45,435.00 20,865.00 24,570.00 49906 FREE OMENTAL FLAP W/ MICROVASCULAR ANASTOMOSIS 59,085.00 26,325.00 32,760.00 50010 RENAL EXPLORATION, NOT NECESSITATING OTHER SPECIFIC PROCEDURES 40,911.00 21,255.00 19,656.00 50020 DRAINAGE OF PERIRENAL OR RENAL ABSCESS 35,100.00 18,720.00 16,380.00 50040 NEPHROSTOMY, NEPHROTOMY W/ DRAINAGE 35,100.00 18,720.00 16,380.00 50045 NEPHROTOMY, W/ EXPLORATION 35,100.00 18,720.00 16,380.00 50060 NEPHROLITHOTOMY; REMOVAL OF CALCULUS 52,884.00 23,400.00 29,484.00 50065 NEPHROLITHOTOMY; SECONDARY SURGICAL OPERATION FOR CALCULUS 59,085.00 26,325.00 32,760.00 50070 NEPHROLITHOTOMY; COMPLICATED BY CONGENITAL KIDNEY ABNORMALITY 52,884.00 23,400.00 29,484.00 50075 NEPHROLITHOTOMY; REMOVAL OF LARGE STAGHORN CALCULUS FILLING RENAL PELVIS AND CALYCES (INCLUDING ANATROPHIC PYELOLITHOTOMY) 73,710.00 32,760.00 40,950.00 50080 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, W/ OR W/O DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; UP TO 2 CM 59,085.00 26,325.00 32,760.00 50081 PERCUTANEOUS NEPHROSTOLITHOTOMY OR PYELOSTOLITHOTOMY, W/ OR W/O DILATION, ENDOSCOPY, LITHOTRIPSY, STENTING, OR BASKET EXTRACTION; OVER 2 CM 59,085.00 26,325.00 32,760.00 50100 TRANSECTION OR REPOSITIONING OF ABERRANT RENAL VESSELS 59,085.00 26,325.00 32,760.00 50120 PYELOTOMY; W/ EXPLORATION 35,100.00 18,720.00 16,380.00 50125 PYELOTOMY; W/ DRAINAGE, PYELOSTOMY 35,100.00 18,720.00 16,380.00 50130 PYELOTOMY; W/ REMOVAL OF CALCULUS (PYELOLITHOTOMY, PELVIOLITHOTOMY, INCLUDING COAGULUM PYELOLITHOTOMY) 45,435.00 20,865.00 24,570.00 50135 PYELOTOMY; COMPLICATED (E.G., SECONDARY OPERATION, CONGENITAL KIDNEY ABNORMALITY) 61,581.00 33,735.00 27,846.00 50200 RENAL BIOPSY; PERCUTANEOUS, BY TROCAR OR NEEDLE 15,639.00 10,725.00 4,914.00 50220 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY APPROACH INCLUDING RIB RESECTION; 52,884.00 23,400.00 29,484.00 50225 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY APPROACH INCLUDING RIB RESECTION; COMPLICATED BECAUSE OF PREVIOUS SURGERY ON SAME KIDNEY 59,085.00 26,325.00 32,760.00 Page 72 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 50230 NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY, ANY APPROACH INCLUDING RIB RESECTION; RADICAL, W/ REGIONAL LYMPHADENECTOMY AND/OR VENA CAVAL THROMBECTOMY 59,085.00 26,325.00 32,760.00 50234 NEPHRECTOMY W/ TOTAL URETERECTOMY AND BLADDER CUFF; THROUGH SAME INCISION 59,085.00 26,325.00 32,760.00 50236 NEPHRECTOMY W/ TOTAL URETERECTOMY AND BLADDER CUFF; THROUGH SEPARATE INCISION 59,085.00 26,325.00 32,760.00 50240 NEPHRECTOMY, PARTIAL 52,884.00 23,400.00 29,484.00 50250 ABLATION, OPEN, ONE OR MORE RENAL MASS LESION(S), CRYOSURGICAL, INCLUDING INTRAOPERATIVE ULTRASOUND, IF PERFORMED 18,915.00 10,725.00 8,190.00 50280 EXCISION OR UNROOFING OF CYST(S) OF KIDNEY 40,911.00 21,255.00 19,656.00 50290 EXCISION OF PERINEPHRIC CYST 40,911.00 21,255.00 19,656.00 50320 DONOR NEPHRECTOMY, W/ PREPARATION AND MAINTENANCE OF ALLOGRAFT; FROM LIVING DONOR 52,884.00 23,400.00 29,484.00 50340 RECIPIENT NEPHRECTOMY 45,435.00 20,865.00 24,570.00 50360 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; EXCLUDING DONOR AND RECIPIENT NEPHRECTOMY 90,675.00 41,535.00 49,140.00 50365 RENAL ALLOTRANSPLANTATION, IMPLANTATION OF GRAFT; W/ RECIPIENT NEPHRECTOMY 119,574.00 40,950.00 78,624.00 50370 REMOVAL OF TRANSPLANTED RENAL ALLOGRAFT 59,085.00 26,325.00 32,760.00 50380 RENAL AUTOTRANSPLANTATION, REIMPLANTATION OF KIDNEY 104,130.00 46,800.00 57,330.00 50390 ASPIRATION AND/OR INJECTION OF RENAL CYST OR PELVIS BY NEEDLE, PERCUTANEOUS 11,076.00 7,800.00 3,276.00 50391 INSTILLATION OF THERAPEUTIC AGENT INTO RENAL PELVIS AND/OR URETER THROUGH ESTABLISHED NEPHROSTOMY, PYELOSTOMY OR URETEROSTOMY TUBE 18,915.00 10,725.00 8,190.00 50392 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS 18,915.00 10,725.00 8,190.00 50393 INTRODUCTION OF URETERAL CATHETER OR STENT INTO
URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS 18,915.00 10,725.00 8,190.00 50395 INTRODUCTION OF GUIDE INTO RENAL PELVIS AND/OR URETER W/ DILATION TO ESTABLISH NEPHROSTOMY TRACT, PERCUTANEOUS 16,107.00 9,555.00 6,552.00 50400 PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON RENAL PELVIS, W/ OR W/O PLASTIC OPERATION ON URETER, NEPHROPEXY, NEPHROSTOMY, PYELOSTOMY, OR URETERAL SPLINTING; SIMPLE 59,085.00 26,325.00 32,760.00 50405 PYELOPLASTY (FOLEY Y-PYELOPLASTY), PLASTIC OPERATION ON RENAL PELVIS, W/ OR W/O PLASTIC OPERATION ON URETER, NEPHROPEXY, NEPHROSTOMY, PYELOSTOMY, OR URETERAL SPLINTING; COMPLICATED (CONGENITAL KIDNEY ABNORMALITY, SECONDARY PYELOPLASTY, SOLITARY KIDNEY, CA 72,501.00 36,465.00 36,036.00 50500 NEPHRORRHAPHY, SUTURE OF KIDNEY WOUND OR INJURY 45,435.00 20,865.00 24,570.00 50520 CLOSURE OF NEPHROCUTANEOUS OR PYELOCUTANEOUS FISTULA 35,100.00 18,720.00 16,380.00 50525 CLOSURE OF NEPHROVISCERAL FISTULA (E.G., RENOCOLIC), INCLUDING VISCERAL REPAIR; ABDOMINAL APPROACH 45,435.00 20,865.00 24,570.00 50526 CLOSURE OF NEPHROVISCERAL FISTULA (E.G., RENOCOLIC), INCLUDING VISCERAL REPAIR; THORACIC APPROACH 59,085.00 26,325.00 32,760.00 50540 SYMPHYSIOTOMY FOR HORSESHOE KIDNEY W/ OR W/O PYELOPLASTY AND/OR OTHER PLASTIC PROCEDURE, UNILATERAL OR BILATERAL (ONE OPERATION) 59,085.00 26,325.00 32,760.00 50541 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL CYSTS 20,553.00 10,725.00 9,828.00 50542 LAPAROSCOPY, SURGICAL; ABLATION OF RENAL MASS LESION(S) 18,915.00 10,725.00 8,190.00 50543 LAPAROSCOPY, SURGICAL; PARTIAL NEPHRECTOMY 59,085.00 26,325.00 32,760.00 50544 LAPAROSCOPY, SURGICAL; PYELOPLASTY 52,884.00 23,400.00 29,484.00 50545 LAPAROSCOPY, SURGICAL; RADICAL NEPHRECTOMY (INCLUDES REMOVAL OF GEROTAS FASCIA AND SURROUNDING FATTY TISSUE, REMOVAL OF REGIONAL LYMPH NODES AND ADRENALECTOMY) 52,884.00 23,400.00 29,484.00 50546 LAPAROSCOPY, SURGICAL; NEPHRECTOMY, INCLUDING PARTIAL URETERECTOMY 45,435.00 20,865.00 24,570.00 50547 LAPAROSCOPY, SURGICAL; DONOR NEPHRECTOMY (INCLUDING COLD PRESERVATION), FROM LIVING DONOR 45,435.00 20,865.00 24,570.00 50548 LAPAROSCOPY, SURGICAL; NEPHRECTOMY WITH TOTAL URETERECTOMY 59,085.00 26,325.00 32,760.00 50551 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 16,949.40 10,725.00 6,224.40 50553 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ URETERAL CATHETERIZATION, W/ OR W/O DILATION OF URETER 16,107.00 9,555.00 6,552.00 50555 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ BIOPSY 21,216.00 13,845.00 7,371.00 Page 73 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 50557 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ FULGURATION AND/OR INCISION, W/ OR W/O BIOPSY 15,802.80 10,725.00 5,077.80 50559 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ INSERTION OF RADIOACTIVE SUBSTANCE W/ OR W/OUT BIOPSY AND/OR FULGURATION 16,294.20 10,725.00 5,569.20 50561 RENAL ENDOSCOPY THROUGH ESTABLISHED NEPHROSTOMY OR PYELOSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ REMOVAL OF FOREIGN BODY OR CALCULUS 18,915.00 10,725.00 8,190.00 50570 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 16,107.00 9,555.00 6,552.00 50572 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ URETERAL CATHETERIZATION, W/ OR W/O DILATION OF URETER 16,107.00 9,555.00 6,552.00 50574 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ BIOPSY 16,107.00 9,555.00 6,552.00 50575 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ ENDOPYELOTOMY (INCLUDES CYSTOSCOPY, URETEROSCOPY, DILATION OF URETER AND URETERAL PELVIC JUNCTION, INCISION OF 18,915.00 10,725.00 8,190.00 50576 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ FULGURATION AND/OR INCISION, W/ OR W/O BIOPSY 18,915.00 10,725.00 8,190.00 50578 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ INSERTION OF RADIOACTIVE SUBSTANCE, W/ OR W/O BIOPSY AND/OR FULGURATION 18,915.00 10,725.00 8,190.00 50580 RENAL ENDOSCOPY THROUGH NEPHROTOMY OR PYELOTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ REMOVAL OF FOREIGN BODY OR CALCULUS 18,915.00 10,725.00 8,190.00 50590 LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE 35,100.00 18,720.00 16,380.00 50592 ABLATION, ONE OR MORE RENAL TUMOR(S), PERCUTANEOUS, UNILATERAL FREQUENCY 18,915.00 10,725.00 8,190.00 50600 URETEROTOMY W/ EXPLORATION OR DRAINAGE 23,634.00 10,530.00 13,104.00 50605 URETEROTOMY FOR INSERTION OF INDWELLING STENT, ALL TYPES 23,634.00 10,530.00 13,104.00 50610 URETEROLITHOTOMY; UPPER ONE-THIRD OF URETER 42,549.00 21,255.00 21,294.00 50620 URETEROLITHOTOMY; MIDDLE ONE-THIRD OF URETER 40,911.00 21,255.00 19,656.00 50630 URETEROLITHOTOMY; LOWER ONE-THIRD OF URETER 42,549.00 21,255.00 21,294.00 50650 URETERECTOMY, W/ BLADDER CUFF 42,549.00 21,255.00 21,294.00 50660 URETERECTOMY, TOTAL, ECTOPIC URETER, COMBINATION ABDOMINAL, VAGINAL AND/OR PERINEAL APPROACH 40,911.00 21,255.00 19,656.00 50700 URETEROPLASTY, PLASTIC OPERATION ON URETER (E.G., STRICTURE) 42,549.00 21,255.00 21,294.00 50715 URETEROLYSIS, W/ OR W/O REPOSITIONING OF URETER FOR RETROPERITONEAL FIBROSIS 42,549.00 21,255.00 21,294.00 50722 URETEROLYSIS FOR OVARIAN VEIN SYNDROME 40,911.00 21,255.00 19,656.00 50725 URETEROLYSIS FOR RETROCAVAL URETER, W/ REANASTOMOSIS OF UPPER URINARY TRACT OR VENA CAVA 45,435.00 20,865.00 24,570.00 50727 REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE UROSTOMY); 44,187.00 21,255.00 22,932.00 50728 REVISION OF URINARY-CUTANEOUS ANASTOMOSIS (ANY TYPE UROSTOMY); W/ REPAIR OF FASCIAL DEFECT AND HERNIA 44,187.00 21,255.00 22,932.00 50740 URETEROPYELOSTOMY, ANASTOMOSIS OF URETER AND RENAL PELVIS 45,435.00 20,865.00 24,570.00 50750 URETEROCALYCOSTOMY, ANASTOMOSIS OF URETER TO RENAL CALYX 52,884.00 23,400.00 29,484.00 50760 URETEROURETEROSTOMY 42,549.00 21,255.00 21,294.00 50770 TRANSURETEROURETEROSTOMY, ANASTOMOSIS OF URETER TO CONTRALATERAL URETER 52,884.00 23,400.00 29,484.00 50780 URETERONEOCYSTOSTOMY; ANASTOMOSIS OF SINGLE URETER TO BLADDER 52,884.00 23,400.00 29,484.00 50782 URETERONEOCYSTOSTOMY; ANASTOMOSIS OF DUPLICATED URETER TO BLADDER 59,085.00 26,325.00 32,760.00 50783 URETERONEOCYSTOSTOMY; W/ EXTENSIVE URETERAL TAILORING 73,710.00 32,760.00 40,950.00 50785 URETERONEOCYSTOSTOMY; W/ VESICO-PSOAS HITCH OR BLADDER FLAP 59,085.00 26,325.00 32,760.00 Page 74 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 50800 URETEROENTEROSTOMY, DIRECT ANASTOMOSIS OF URETER TO INTESTINE 59,943.00 33,735.00 26,208.00 50810 URETEROSIGMOIDOSTOMY, W/ CREATION OF SIGMOID BLADDER AND ESTABLISHMENT OF ABDOMINAL OR PERINEAL COLOSTOMY, INCLUDING BOWEL ANASTOMOSIS 73,710.00 32,760.00 40,950.00 50815 URETEROCOLON CONDUIT, INCLUDING BOWEL ANASTOMOSIS 73,710.00 32,760.00 40,950.00 50820 URETEROILEAL CONDUIT (ILEAL BLADDER), INCLUDING BOWEL ANASTOMOSIS (BRICKER OPERATION) 78,624.00 32,760.00 45,864.00 50825 CONTINENT DIVERSION, INCLUDING BOWEL ANASTOMOSIS USING ANY SEGMENT OF SMALL AND/OR LARGE BOWEL (KOCK POUCH OR CAMEY ENTEROCYSTOPLASTY 90,675.00 41,535.00 49,140.00 50830 URINARY UNDIVERSION (E.G., TAKING DOWN OF URETEROILEAL CONDUIT, URETEROSIGMOIDOSTOMY OR URETEROENTEROSTOMY W/ URETEROURETEROSTOMY OR URETERONEOCYSTOSTOMY) 73,710.00 32,760.00 40,950.00 50840 REPLACEMENT OF ALL OR PART OF URETER BY BOWEL SEGMENT, INCLUDING BOWEL ANASTOMOSIS 73,710.00 32,760.00 40,950.00 50845 CUTANEOUS APPENDICO-VESICOSTOMY 59,085.00 26,325.00 32,760.00 50860 URETEROSTOMY, TRANSPLANTATION OF URETER TO SKIN 40,911.00 21,255.00 19,656.00 50900 URETERORRHAPHY, SUTURE OF URETER 35,100.00 18,720.00 16,380.00 50920 CLOSURE OF URETEROCUTANEOUS FISTULA 40,911.00 21,255.00 19,656.00 50930 CLOSURE OF URETEROVISCERAL FISTULA (INCLUDING VISCERAL REPAIR) 45,435.00 20,865.00 24,570.00 50940 DELIGATION OF URETER 42,549.00 21,255.00 21,294.00 50945 LAPAROSCOPY, SURGICAL; URETEROLITHOTOMY 42,783.00 24,765.00 18,018.00 50947 LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITH CYSTOSCOPY AND URETERAL STENT PLACEMENT 45,435.00 20,865.00 24,570.00 50948 LAPAROSCOPY, SURGICAL; URETERONEOCYSTOSTOMY WITHOUT CYSTOSCOPY AND URETERAL STENT PLACEMENT 45,435.00 20,865.00 24,570.00 50951 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 16,107.00 9,555.00 6,552.00 50953 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ URETERAL CATHETERIZATION, W/ OR W/O DILATION OF URETER 16,107.00 9,555.00 6,552.00 50955 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ BIOPSY 16,107.00 9,555.00 6,552.00 50957 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ FULGURATION AND/OR INCISION, W/ OR W/O BIOPSY 21,216.00 13,845.00 7,371.00 50959 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ INSERTION OF RADIOACTIVE SUBSTANCE, W/ OR W/O BIOPSY AND/OR FULGURATION (NOT INCLUDING PROVISION OF MATERIA 18,915.00 10,725.00 8,190.00 50961 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ REMOVAL OF FOREIGN BODY OR CALCULUS 23,361.00 11,895.00 11,466.00 50970 URETERAL ENDOSCOPY THROUGH URETEROTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 16,107.00 9,555.00 6,552.00 50972 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ URETERAL CATHETERIZATION, W/ OR W/O DILATION OF URETER 16,107.00 9,555.00 6,552.00 50974 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ BIOPSY 16,107.00 9,555.00 6,552.00 50976 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ FULGURATION AND/OR INCISION, W/ OR W/O BIOPSY 21,216.00 13,845.00 7,371.00 50978 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ INSERTION OF RADIOACTIVE SUBSTANCE, W/ OR W/O BIOPSY AND/OR FULGURATION (NOT INCLUDING PROVISION OF MATERIA 18,915.00 10,725.00 8,190.00 50980 URETERAL ENDOSCOPY THROUGH ESTABLISHED URETEROSTOMY, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ REMOVAL OF FOREIGN BODY OR CALCULUS 23,361.00 11,895.00 11,466.00 51010 ASPIRATION OF BLADDER; BY TROCAR OR INTRACATHETER W/ INSERTION OF SUPRAPUBIC CATHETER 11,076.00 7,800.00 3,276.00 Page 75 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 51020 CYSTOTOMY OR CYSTOSTOMY; W/ FULGURATION AND/OR INSERTION OF RADIOACTIVE MATERIAL 18,915.00 10,725.00 8,190.00 51030 CYSTOTOMY OR CYSTOSTOMY; W/ CRYOSURGICAL DESTRUCTION OF INTRAVESICAL LESION 18,915.00 10,725.00 8,190.00 51040 CYSTOSTOMY, CYSTOTOMY W/ DRAINAGE 18,915.00 10,725.00 8,190.00 51045 CYSTOTOMY, W/ INSERTION OF URETERAL CATHETER OR STENT 20,553.00 10,725.00 9,828.00 51050 CYSTOLITHOTOMY, CYSTOTOMY W/ REMOVAL OF CALCULUS, W/O VESICAL NECK RESECTION 24,453.00 10,530.00 13,923.00 51060 TRANSVESICAL URETEROLITHOTOMY 42,549.00 21,255.00 21,294.00 51065 CYSTOTOMY, W/ STONE BASKET EXTRACTION AND/OR ULTRASONIC OR ELECTROHYDRAULIC FRAGMENTATION OF URETERAL CALCULUS 42,549.00 21,255.00 21,294.00 51080 DRAINAGE OF PERIVESICAL OR PREVESICAL SPACE ABSCESS 20,553.00 10,725.00 9,828.00 51500 EXCISION OF URACHAL CYST OR SINUS, W/ OR W/O UMBILICAL HERNIA REPAIR 59,085.00 26,325.00 32,760.00 51520 CYSTOTOMY; FOR SIMPLE EXCISION OF VESICAL NECK 40,911.00 21,255.00 19,656.00 51525 CYSTOTOMY; FOR EXCISION OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE 52,884.00 23,400.00 29,484.00 51530 CYSTOTOMY; FOR EXCISION OF BLADDER TUMOR 52,884.00 23,400.00 29,484.00 51535 CYSTOTOMY FOR EXCISION, INCISION, OR REPAIR OF URETEROCELE 45,435.00 20,865.00 24,570.00 51550 CYSTECTOMY, PARTIAL 59,943.00 33,735.00 26,208.00 51555 CYSTECTOMY, COMPLICATED (E.G., POSTRADIATION, PREVIOUS SURGERY, DIFFICULT LOCATION) 73,710.00 32,760.00 40,950.00 51565 CYSTECTOMY, PARTIAL, W/ REIMPLANTATION OF URETER(S) INTO BLADDER (URETERONEOCYSTOSTOMY) 59,085.00 26,325.00 32,760.00 51570 CYSTECTOMY, COMPLETE; 73,710.00 32,760.00 40,950.00 51575 CYSTECTOMY, COMPLETE; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 90,675.00 41,535.00 49,140.00 51580 CYSTECTOMY, COMPLETE, W/ URETEROSIGMOIDOSTOMY OR URETEROCUTANEOUS TRANSPLANTATIONS; 78,624.00 32,760.00 45,864.00 51585 CYSTECTOMY, COMPLETE, W/ URETEROSIGMOIDOSTOMY OR URETEROCUTANEOUS TRANSPLANTATIONS; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 104,130.00 46,800.00 57,330.00 51590 CYSTECTOMY, COMPLETE, W/ URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING BOWEL ANASTOMOSIS; 109,044.00 46,800.00 62,244.00 51595 CYSTECTOMY, COMPLETE, W/ URETEROILEAL CONDUIT OR SIGMOID BLADDER, INCLUDING BOWEL ANASTOMOSIS; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 108,888.00 41,730.00 67,158.00 51596 CYSTECTOMY, COMPLETE, W/ CONTINENT DIVERSION, ANY TECHNIQUE, USING ANY SEGMENT OF SMALL AND/OR LARGE BOWEL TO CONSTRUCT NEOBLADDER 114,660.00 40,950.00 73,710.00 51597 PELVIC EXENTERATION, COMPLETE, FOR VESICAL, PROSTATIC OR URETHRAL MALIGNANCY, W/ REMOVAL OF BLADDER AND URETERAL TRANSPLANTATIONS, W/ OR W/O HYSTERECTOMY AND/OR ABDOMINOPERINEAL RESECTION OF RECTUM AND COLON AND COLOSTOMY, OR ANY COMBINATION THEREOF 139,230.00 40,950.00 98,280.00 51600 INJECTION PROCEDURE FOR CYSTOGRAPHY OR VOIDING URETHROCYSTOGRAPHY 15,639.00 10,725.00 4,914.00 51720 BLADDER INSTILLATION OF ANTICARCINOGENIC AGENT 15,639.00 10,725.00 4,914.00 51800 CYSTOPLASTY OR CYSTOURETHROPLASTY, PLASTIC OPERATION ON BLADDER AND/OR VESICAL NECK (ANTERIOR Y-PLASTY, VESICAL FUNDUS RESECTION), ANY PROCEDURE, W/ OR W/O WEDGE RESECTION OF POSTERIOR VESICAL NECK 40,911.00 21,255.00 19,656.00 51820 CYSTOURETHROPLASTY W/ UNILATERAL OR BILATERAL URETERONEOCYSTOSTOMY 52,884.00 23,400.00 29,484.00 51840 ANTERIOR VESICOURETHROPEXY, OR URETHROPEXY (MARSHALL- MARCHETTI-KRANTZ TYPE) 40,911.00 21,255.00 19,656.00 51841 COMPLICATED (E.G., SECONDARY REPAIR) 59,943.00 33,735.00 26,208.00 51845 ABDOMINO-VAGINAL VESICAL NECK SUSPENSION, W/ OR W/O ENDOSCOPIC CONTROL (E.G., STAMEY, RAZ, MODIFIED PEREYRA) 40,911.00 21,255.00 19,656.00 51860 CYSTORRHAPHY, SUTURE OF BLADDER WOUND, INJURY OR RUPTURE 23,634.00 10,530.00 13,104.00 51880 CLOSURE OF CYSTOSTOMY 21,216.00 13,845.00 7,371.00 51900 CLOSURE OF VESICOVAGINAL FISTULA, ABDOMINAL APPROACH 45,435.00 20,865.00 24,570.00 51920 CLOSURE OF VESICOUTERINE FISTULA; 45,435.00 20,865.00 24,570.00 51925 CLOSURE OF VESICOUTERINE FISTULA; W/ HYSTERECTOMY 59,085.00 26,325.00 32,760.00 51940 CLOSURE OF BLADDER EXSTROPHY 59,085.00 26,325.00 32,760.00 51960 ENTEROCYSTOPLASTY, INCLUDING BOWEL ANASTOMOSIS 59,943.00 33,735.00 26,208.00 51980 CUTANEOUS VESICOSTOMY 23,634.00 10,530.00 13,104.00 51990 LAPAROSCOPY, SURGICAL; URETHRAL SUSPENSION FOR STRESS INCONTINENCE 59,085.00 26,325.00 32,760.00 51992 LAPAROSCOPY, SURGICAL; SLING OPERATION FOR STRESS INCONTINENCE (E.G., FASCIA OR SYNTHETIC) 59,085.00 26,325.00 32,760.00 52000 CYSTOURETHROSCOPY 16,107.00 9,555.00 6,552.00 52005 CYSTOURETHROSCOPY, W/ URETERAL CATHETERIZATION, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; 18,915.00 10,725.00 8,190.00 Page 76 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 52007 CYSTOURETHROSCOPY, W/ URETERAL CATHETERIZATION, W/ OR W/O IRRIGATION, INSTILLATION, OR URETEROPYELOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE; W/ BRUSH BIOPSY OF URETER AND/OR RENAL PELVIS 16,107.00 9,555.00 6,552.00 52010 CYSTOURETHROSCOPY, W/ EJACULATORY DUCT CATHETERIZATION, W/ OR W/O IRRIGATION, INSTILLATION, OR DUCT RADIOGRAPHY, EXCLUSIVE OF RADIOLOGIC SERVICE 16,107.00 9,555.00 6,552.00 52204 CYSTOURETHROSCOPY, W/ BIOPSY 20,553.00 10,725.00 9,828.00 52214 CYSTOURETHROSCOPY, W/ FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OF TRIGONE, BLADDER NECK, PROSTATIC FOSSA, URETHRA, OR PERIURETHRAL GLANDS 23,361.00 11,895.00 11,466.00 52224 CYSTOURETHROSCOPY, W/ FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) OR TREATMENT OF MINOR (LESS THAN 0.5 CM) LESION(S) W/ OR W/O BIOPSY 23,361.00 11,895.00 11,466.00 52234 CYSTOURETHROSCOPY, W/ FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF; SMALL BLADDER TUMOR(S) (0.5 CM TO 2.0 CM) 40,911.00 21,255.00 19,656.00 52235 CYSTOURETHROSCOPY, W/ FULGURATION (INCLUDING CRYOSURGERY OR LASER SURGERY) AND/OR RESECTION OF MEDIUM BLADDER TUMOR(S) (2.0 TO 5.0 CM) 43,368.00 21,255.00 22,113.00 52240 LARGE BLADDER TUMOR(S) 45,435.00 20,865.00 24,570.00 52250 CYSTOURETHROSCOPY W/ INSERTIONOF RADIOACTIVE SUBSTANCE, W/ OR W/O BIOPSY OR FULGURATION 59,943.00 33,735.00 26,208.00 52260 CYSTOURETHROSCOPY, W/ DILATION OF BLADDER FOR INSTERSTITIAL CYSTITIS; GENERAL OR CONDUCTION (SPINAL) ANESTHESIA 23,361.00 11,895.00 11,466.00 52265 CYSTOURETHROSCOPY, W/ DILATION OF BLADDER FOR INSTERSTITIAL CYSTITIS; LOCAL ANESTHESIA 15,639.00 10,725.00 4,914.00 52270 CYSTOURETHROSCOPY, W/ INTERNAL URETHROTOMY; FEMALE 25,155.00 12,870.00 12,285.00 52275 CYSTOURETHROSCOPY, W/ INTERNAL URETHROTOMY; MALE 25,155.00 12,870.00 12,285.00 52276 CYSTOURETHROSCOPY W/ DIRECT VISION INTERNAL URETHROTOMY 24,453.00 10,530.00 13,923.00 52277 CYSTOURETHROSCOPY, W/ RESECTION OF EXTERNAL SPHINCTER (SPHINCTEROTOMY) 23,634.00 10,530.00 13,104.00 52281 CYSTOURETHROSCOPY, W/ CALIBRATION AND/OR DILATION OF URETHRAL STRICTURE OR STENOSIS, W/ OR W/O MEATOTOMY AND INJECTION PROCEDURE FOR CYSTOGRAPHY, MALE OR FEMALE 15,639.00 10,725.00 4,914.00 52283 CYSTOURETHROSCOPY, W/ STEROID INJECTION INTO STRICTURE 15,639.00 10,725.00 4,914.00 52285 CYSTOURETHROSCOPY, FOR TREATMENT OF THE FEMALE URETHRAL SYNDROME W/ ANY OR ALL OF THE FOLLOWING: URETHRAL MEATOTOMY, URETHRAL DILATION, INTERNAL URETHROTOMY, LYSIS OF URETHROVAGINAL SEPTAL FIBROSIS, LATERAL INCISIONS OF THE BLADDER NECK, AND FULGURATION O 20,553.00 10,725.00 9,828.00 52290 CYSTOURETHROSCOPY; W/ URETERAL MEATOTOMY, UNILATERAL OR BILATERAL 23,361.00 11,895.00 11,466.00 52300 CYSTOURETHROSCOPY; W/ RESECTION OR FULGURATION OF ORTHOTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL 42,783.00 24,765.00 18,018.00 52301 CYSTOURETHROSCOPY; W/ RESECTION OR FULGURATION OF ECTOPIC URETEROCELE(S), UNILATERAL OR BILATERAL 42,783.00 24,765.00 18,018.00 52305 CYSTOURETHROSCOPY; W/ INCISION OR RESECTION OF ORIFICE OF BLADDER DIVERTICULUM, SINGLE OR MULTIPLE 23,634.00 10,530.00 13,104.00 52310 CYSTOURETHROSCOPY, W/ REMOVAL OF FOREIGN BODY, CALCULUS, OR URETERAL STENT FROM URETHRA OR BLADDER 20,553.00 10,725.00 9,828.00 52317 LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM) 35,100.00 18,720.00 16,380.00 52318 LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM) 42,783.00 24,765.00 18,018.00 52320 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); W/ REMOVAL OF URETERAL CALCULUS 23,361.00 11,895.00 11,466.00 52325 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); W/ FRAGMENTATION OF URETERAL CALCULUS (E.G., ULTRASONIC OR ELECTRO-HYDRAULIC TECHNIQUE) 35,100.00 18,720.00 16,380.00 52327 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); W/ SUBURETERIC INJECTION OF IMPLANT MATERIAL 18,915.00 10,725.00 8,190.00 52330 CYSTOURETHROSCOPY (INCLUDING URETERAL CATHETERIZATION); W/ MANIPULATION, W/O REMOVAL OF URETERAL CALCULUS 20,553.00 10,725.00 9,828.00 52332 CYSTOURETHROSCOPY, W/ INSERTION OF INDWELLING URETERAL STENT (E.G., GIBBONS OR DOUBLE-J TYPE) 20,553.00 10,725.00 9,828.00 52334 CYSTOURETHROSCOPY W/ INSERTION OF URETERAL GUIDE WIRE THROUGH KIDNEY TO ESTABLISH A PERCUTANEOUS NEPHROSTOMY, RETROGRADE 18,915.00 10,725.00 8,190.00 Page 77 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 52335 CYSTOURETHROSCOPY, W/ URETEROSCOPY AND/OR PYELOSCOPY (INCLUDES DILATION OF THE URETER AND/OR PYELOURETERAL JUNCTION BY ANY METHOD); 23,634.00 10,530.00 13,104.00 52336 CYSTOURETHROSCOPY, W/ URETEROSCOPY AND/OR PYELOSCOPY (INCLUDES DILATION OF THE URETER AND/OR PYELOURETERAL JUNCTION BY ANY METHOD); W/ REMOVAL OR MANIPULATION OF CALCULUS (URETERAL CATHETERIZATION IS INCLUDED) 23,634.00 10,530.00 13,104.00 52337 CYSTOURETHROSCOPY, W/ URETEROSCOPY AND/OR PYELOSCOPY (INCLUDES DILATION OF THE URETER AND/OR PYELOURETERAL JUNCTION BY ANY METHOD); W/ LITHOTRIPSY (URETERAL CATHETERIZATION IS INCLUDED) 42,783.00 24,765.00 18,018.00 52338 CYSTOURETHROSCOPY, W/ URETEROSCOPY AND/OR PYELOSCOPY (INCLUDES DILATION OF THE URETER AND/OR PYELOURETERAL JUNCTION BY ANY METHOD); W/ BIOPSY AND/OR FULGURATION OF LESION 42,783.00 24,765.00 18,018.00 52339 CYSTOURETHROSCOPY, W/ URETEROSCOPY AND/OR PYELOSCOPY (INCLUDES DILATION OF THE URETER AND/OR PYELOURETERAL JUNCTION BY ANY METHOD); W/ RESECTION OF TUMOR 23,634.00 10,530.00 13,104.00 52340 CYSTOURETHROSCOPY W/ INCISION, FULGURATION, OR RESECTION OF CONGENITAL POSTERIOR URETHRAL VALVES, OR CONGENITAL OBSTRUCTIVE HYPERTROPHIC MUCOSAL FOLDS 42,783.00 24,765.00 18,018.00 52450 TRANSURETHRAL INCISION OF PROSTATE 45,435.00 20,865.00 24,570.00 52500 TRANSURETHRAL RESECTION OF BLADDER NECK 45,435.00 20,865.00 24,570.00 52510 TRANSURETHRAL BALLOON DILATION OF THE PROSTATIC URETHRA, ANY METHOD 23,634.00 10,530.00 13,104.00 52601 TRANSURETHRAL ELECTROSURGICAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) 73,710.00 32,760.00 40,950.00 52606 TRANSURETHRAL FULGURATION FOR POSTOPERATIVE BLEEDING OCCURING AFTER THE USUAL FOLLOW-UP TIME 35,100.00 18,720.00 16,380.00 52612 TRANSURETHRAL RESECTION OF PROSTATE; FIRST STAGE OF TWO- STAGE RESECTION (PARTIAL RESECTION) 42,783.00 24,765.00 18,018.00 52614 TRANSURETHRAL RESECTION OF PROSTATE; SECOND STAGE OF TWO-STAGE RESECTION (RESECTION COMPLETED) 42,783.00 24,765.00 18,018.00 52620 TRANSURETHRAL RESECTION; OF RESIDUAL OBSTRUCTIVE TISSUE AFTER 90 DAYS POSTOPERATIVE 40,911.00 21,255.00 19,656.00 52630 TRANSURETHRAL RESECTION; OF REGROWTH OF OBSTRUCTIVE TISSUE LONGER THAN ONE YEAR POSTOPERATIVE 73,710.00 32,760.00 40,950.00 52640 TRANSURETHRAL RESECTION; OF POSTOPERATIVE BLADDER NECK CONTRACTURE 40,911.00 21,255.00 19,656.00 52647 NON-CONTACT LASER COAGULATION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) 52,884.00 23,400.00 29,484.00 52648 CONTACT LASER VAPORIZATION W/ OR W/O TRANSURETHRAL RESECTION OF PROSTATE, INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, COMPLETE (VASECTOMY, MEATOTOMY, CYSTOURETHROSCOPY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY ARE INCLUDED) 52,884.00 23,400.00 29,484.00 52649 HIGH INTENSITY FOCUSED ULTRASOUND (HIFU) OF THE PROSTATE INCLUDING TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) 73,710.00 32,760.00 40,950.00 52700 TRANSURETHRAL DRAINAGE OF PROSTATIC ABSCESS 35,100.00 18,720.00 16,380.00 53000 URETHROTOMY OR URETHROSTOMY, EXTERNAL ; PENDULOUS URETHRA 11,076.00 7,800.00 3,276.00 53010 URETHROTOMY OR URETHROSTOMY, EXTERNAL ; PERINEAL URETHRA, EXTERNAL 16,107.00 9,555.00 6,552.00 53020 MEATOTOMY, CUTTING OF MEATUS ; EXCEPT INFANT 10,842.00 8,385.00 2,457.00 53025 MEATOTOMY, CUTTING OF MEATUS ; INFANT 16,107.00 9,555.00 6,552.00 53040 DRAINAGE OF DEEP PERIURETHRAL ABSCESS 18,135.00 14,040.00 4,095.00 53060 DRAINAGE OF SKENES GLAND ABSCESS OR CYST 10,842.00 8,385.00 2,457.00 53080 DRAINAGE OF PERINEAL URINARY EXTRAVASATION 15,639.00 10,725.00 4,914.00 53200 BIOPSY OF URETHRA 10,842.00 8,385.00 2,457.00 53210 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; FEMALE 42,783.00 24,765.00 18,018.00 53215 URETHRECTOMY, TOTAL, INCLUDING CYSTOSTOMY; MALE 42,549.00 21,255.00 21,294.00 53220 EXCISION OF FULGURATION OF CARCINOMA OF URETHRA 18,915.00 10,725.00 8,190.00 53230 EXCISION OF URETHRAL DIVERTICULUM ; FEMALE 35,100.00 18,720.00 16,380.00 53235 EXCISION OF URETHRAL DIVERTICULUM ; MALE 29,172.00 14,430.00 14,742.00 53240 MARSUPIALIZATION OF URETHRAL DIVERTICULUM, MALE OR FEMALE 18,135.00 14,040.00 4,095.00 53250 EXCISION OF BULBOURETHRAL GLAND (COWPERS GLAND) 23,634.00 10,530.00 13,104.00 53260 EXCISION OR FULGURATION; URETHRAL POLYP(S), DISTAL URETHRA 10,842.00 8,385.00 2,457.00 53265 EXCISION OR FULGURATION; URETHRAL CARUNCLE 10,842.00 8,385.00 2,457.00 53270 SKENES GLANDS 10,842.00 8,385.00 2,457.00 53275 SKENES GLANDS URETHRAL PROLAPSE 18,135.00 14,040.00 4,095.00 53400 URETHROPLASTY; FIRST STAGE, FOR FISTULA, DIVERTICULUM, OR STRICTURE (E.G., JOHANNSEN TYPE) 59,085.00 26,325.00 32,760.00 Page 78 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 53405 URETHROPLASTY; SECOND STAGE (FORMATION OF URETHRA), INCLUDING URINARY DIVERSION 52,884.00 23,400.00 29,484.00 53410 URETHROPLASTY, ONE-STAGE RECONSTRUCTION OF MALE ANTERIOR URETHRA 29,172.00 14,430.00 14,742.00 53415 URETHROPLASTY, TRANSPUBIC OR PERINEAL, ONE STAGE, FOR RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA 78,624.00 32,760.00 45,864.00 53420 URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; FIRST STAGE 73,710.00 32,760.00 40,950.00 53425 URETHROPLASTY, TWO-STAGE RECONSTRUCTION OR REPAIR OF PROSTATIC OR MEMBRANOUS URETHRA; SECOND STAGE 52,884.00 23,400.00 29,484.00 53430 URETHROPLASTY, RECONSTRUCTION OF FEMALE URETHRA 35,100.00 18,720.00 16,380.00 53440 OPERATION FOR CORRECTION OF MALE URINARY INCONTINENCE, W/ OR W/O INTRODUCTION OF PROSTHESIS 35,100.00 18,720.00 16,380.00 53442 REMOVAL OF PERINEAL PROSTHESIS INTRODUCED FOR CONTINENCE 35,100.00 18,720.00 16,380.00 53443 URETHROPLASTY W/ TUBULARIZATION OF POSTERIOR URETHRA AND/OR LOWER BLADDER FOR INCONTINENCE (E.G., TENAGO, LEADBETTER PROCEDURE) 60,723.00 26,325.00 34,398.00 53445 OPERATION FOR CORRECTION OF URINARY INCONTINENCE W/ PLACEMENT OF INFLATABLE URETHRAL OR BLADDER NECK SPHINCTER, INCLUDING PLACEMENT OF PUMP AND/OR RESERVOIR 72,501.00 36,465.00 36,036.00 53447 REMOVAL, REPAIR, OR REPLACEMENT OF INFLATABLE SPHINCTER INCLUDING PUMP AND/OR RESERVOIR AND/OR CUFF 78,624.00 32,760.00 45,864.00 53449 SURGICAL CORRECTION OF HYDRAULIC ABNORMALITY OF INFLATABLE SPHINCTER DEVICE 35,100.00 18,720.00 16,380.00 53450 URETHROMEATOPLASTY, W/ MUCOSAL ADVANCEMENT 16,107.00 9,555.00 6,552.00 53460 URETHROMEATOPLASTY, W/ PARTIAL EXCISION OF DISTAL URETHRAL SEGMENT (RICHARDSON TYPE PROCEDURE) 16,107.00 9,555.00 6,552.00 53502 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY, FEMALE 18,915.00 10,725.00 8,190.00 53505 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PENILE 18,915.00 10,725.00 8,190.00 53510 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PERINEAL 20,553.00 10,725.00 9,828.00 53515 URETHRORRHAPHY, SUTURE OF URETHRAL WOUND OR INJURY; PROSTATOMEMBRANOUS 20,553.00 10,725.00 9,828.00 53520 CLOSURE OF URETHROSTOMY OR URETHROCUTANEOUS FISTULA, MALE 15,639.00 10,725.00 4,914.00 53600 DILATION OF URETHRAL STRICTURE BY PASSAGE OF SOUND OR URETHRAL DILATOR, MALE 11,076.00 7,800.00 3,276.00 53605 DILATION OF URETHRAL STRICTURE OR VESICAL NECK, MALE, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA 11,076.00 7,800.00 3,276.00 53665 DILATION OF FEMALE URETHRA, GENERAL OR CONDUCTION (SPINAL) ANESTHESIA 11,076.00 7,800.00 3,276.00 53850 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY MICROWAVE THERMOTHERAPY I.E. TRANSURETHRAL MICROWAVE THERMOTHERAPY (TUMT) 73,710.00 32,760.00 40,950.00 53852 TRANSURETHRAL DESTRUCTION OF PROSTATE TISSUE; BY RADIOFREQUNCY ABLATION I.E., TRANSURETHRAL NEEDLE ABLATION (TUNA), TRANSURETHRAL LASER INCISION OF THE PROSTATE (TULIP) 73,710.00 32,760.00 40,950.00 54015 INCISION AND DRAINAGE OF PENIS 7,098.00 5,460.00 1,638.00 54050 DESTRUCTION OF LESION(S), PENIS (E.G., CONDYLOMA, PAPILLOMA, MOLLUSCUM CONTAGIOSUM, HERPETIC VESICLE), ANY METHOD 7,098.00 5,460.00 1,638.00 54100 BIOPSY OF PENIS 6,832.80 5,850.00 982.80 54110 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); 18,135.00 14,040.00 4,095.00 54111 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); W/ GRAFT TO 5 CM IN LENGTH 20,553.00 10,725.00 9,828.00 54112 EXCISION OF PENILE PLAQUE (PEYRONIE DISEASE); W/ GRAFT GREATER THAN 5 CM IN LENGTH 23,361.00 11,895.00 11,466.00 54115 REMOVAL OF FOREIGN BODY FROM DEEP PENILE TISSUE (E.G., PLASTIC IMPLANT) 16,107.00 9,555.00 6,552.00 54120 AMPUTATION OF PENIS; PARTIAL 20,553.00 10,725.00 9,828.00 54125 AMPUTATION OF PENIS; COMPLETE 41,730.00 21,255.00 20,475.00 54130 AMPUTATION OF PENIS, RADICAL; W/ BILATERAL INGUINOFEMORAL LYMPHADENECTOMY 73,710.00 32,760.00 40,950.00 54135 AMPUTATION OF PENIS, RADICAL; IN CONTINUITY W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES 90,675.00 41,535.00 49,140.00 54150 CIRCUMCISION, USING CLAMP OR OTHER DEVICE; NEWBORN 2,457.00 819.00 1,638.00 54152 CIRCUMCISION, USING CLAMP OR OTHER DEVICE; EXCEPT NEWBORN 2,457.00 819.00 1,638.00 54160 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE OR DORSAL SLIT; NEWBORN 2,457.00 819.00 1,638.00 54161 CIRCUMCISION, SURGICAL EXCISION OTHER THAN CLAMP, DEVICE OR DORSAL SLIT; EXCEPT NEWBORN 2,457.00 819.00 1,638.00 54200 INJECTION PROCEDURE FOR PEYRONIE DISEASE; 10,842.00 8,385.00 2,457.00 54205 INJECTION PROCEDURE FOR PEYRONIE DISEASE;W/ SURGICAL EXPOSURE OF PLAQUE 11,076.00 7,800.00 3,276.00 Page 79 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 54220 IRRIGATION OF CORPORA CAVERNOSA FOR PRIAPISM 15,639.00 10,725.00 4,914.00 54300 PLASTIC OPERATION OF PENIS FOR STRAIGHTENING OF CHORDEE (E.G., HYPOSPADIAS), W/ OR W/O MOBILIZATION OF URETHRA 18,915.00 10,725.00 8,190.00 54304 PLASTIC OPERATION ON PENIS FOR CORRECTION OF CHORDEE OR FOR FIRST STAGE HYPOSPADIAS REPAIR W/ OR W/O TRANSPLANTATION OF PREPUCE AND/OR SKIN FLAPS 29,172.00 14,430.00 14,742.00 54308 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); LESS THAN 3 CM 45,435.00 20,865.00 24,570.00 54312 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION); GREATER THAN 3 CM 45,435.00 20,865.00 24,570.00 54316 URETHROPLASTY FOR SECOND STAGE HYPOSPADIAS REPAIR (INCLUDING URINARY DIVERSION) W/ FREE SKIN GRAFT OBTAINED FROM SITE OTHER THAN GENITALIA 45,435.00 20,865.00 24,570.00 54318 URETHROPLASTY FOR THIRD STAGE HYPOSPADIAS REPAIR TO RELEASE PENIS FROM SCROTUM (E.G., THIRD STAGE CECIL REPAIR) 23,634.00 10,530.00 13,104.00 54322 ONE STAGE DISTAL HYPOSPADIAS REPAIR (W/ OR W/O CHORDEE OR CIRCUMCISION); W/ SIMPLE MEATAL ADVANCEMENT (E.G., MAGPI, V-FLAP) 52,884.00 23,400.00 29,484.00 54324 ONE STAGE DISTAL HYPOSPADIAS REPAIR (W/ OR W/O CHORDEE OR CIRCUMCISION); W/ URETHROPLASTY BY LOCAL SKIN FLAPS (E.G., FLIP-FLAP, PREPUCIAL FLAP) 52,884.00 23,400.00 29,484.00 54326 ONE STAGE DISTAL HYPOSPADIAS REPAIR (W/ OR W/O CHORDEE OR CIRCUMCISION); W/ URETHROPLASTY BY LOCAL SKIN FLAPS AND MOBILIZATION OF URETHRA 52,884.00 23,400.00 29,484.00 54328 ONE STAGE DISTAL HYPOSPADIAS REPAIR (W/ OR W/O CHORDEE OR CIRCUMCISION); W/ EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY W/ LOCAL SKIN FLAPS, SKIN GRAFT PATCH, AND/OR ISLAND FLAP 59,085.00 26,325.00 32,760.00 54332 ONE STAGE PROXIMAL PENILE OR PENOSCROTAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP 72,501.00 36,465.00 36,036.00 54336 ONE STAGE PERINEAL HYPOSPADIAS REPAIR REQUIRING EXTENSIVE DISSECTION TO CORRECT CHORDEE AND URETHROPLASTY BY USE OF SKIN GRAFT TUBE AND/OR ISLAND FLAP 72,501.00 36,465.00 36,036.00 54340 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); BY CLOSURE, INCISION, OR EXCISION, SIMPLE 72,501.00 36,465.00 36,036.00 54344 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING MOBILIZATION OF SKIN FLAPS AND URETHROPLASTY W/ FLAP OR PATCH GRAFT 35,100.00 18,720.00 16,380.00 54348 REPAIR OF HYPOSPADIAS COMPLICATIONS (IE, FISTULA, STRICTURE, DIVERTICULA); REQUIRING EXTENSIVE DISSECTION AND URETHROPLASTY W/ FLAP, PATCH OR TUBED GRAFT (INCLUDES URINARY DIVERSION) 40,911.00 21,255.00 19,656.00 54352 REPAIR OF HYPOSPADIAS CRIPPLE REQUIRING EXTENSIVE DISSECTION AND EXCISION OF PREVIOUSLY CONSTRUCTED STRUCTURES INCLUDING RE-RELEASE OF CHORDEE AND RECONSTRUCTION OF URETHRA AND PENIS BY USE OF LOCAL SKIN AS GRAFTS AND ISLAND FLAPS AND SKIN BROUGHT IN AS F 73,710.00 32,760.00 40,950.00 54380 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINCTER; 59,085.00 26,325.00 32,760.00 54385 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINCTER;W/ INCONTINENCE 72,501.00 36,465.00 36,036.00 54390 PLASTIC OPERATION ON PENIS FOR EPISPADIAS DISTAL TO EXTERNAL SPHINCTER;W/ EXSTROPHY OF BLADDER 73,710.00 32,760.00 40,950.00 54420 CORPORA CAVERNOSA-SAPHENOUS VEIN SHUNT (PRIAPISM OPERATION), UNILATERAL OR BILATERAL 23,634.00 10,530.00 13,104.00 54430 CORPORA CAVERNOSA-CORPUS SPONGIOSUM SHUNT (PRIAPISM OPERATION), UNILATERAL OR BILATERAL 23,634.00 10,530.00 13,104.00 54435 CORPORA CAVERNOSA-GLANS PENIS FISTULIZATION (E.G., BIOPSY NEEDLE, WINTER PROCEDURE, RONGEUR, OR PUNCH) FOR PRIAPISM 16,107.00 9,555.00 6,552.00 54440 PLASTIC OPERATION OF PENIS FOR INJURY 23,634.00 10,530.00 13,104.00 54500 BIOPSY OF TESTIS, NEEDLE 6,832.80 5,850.00 982.80 54505 BIOPSY OF TESTIS, INCISIONAL 11,076.00 7,800.00 3,276.00 54510 EXCISION OF LOCAL LESION OF TESTIS 11,076.00 7,800.00 3,276.00 54520 ORCHIECTOMY, SIMPLE (INCLUDING SUBCAPSULAR), W/ OR W/O TESTICULAR PROSTHESIS, SCROTAL OR INGUINAL APPROACH 20,553.00 10,725.00 9,828.00 54530 ORCHIECTOMY, RADICAL, FOR TUMOR; INGUINAL APPROACH 21,372.00 10,725.00 10,647.00 54535 ORCHIECTOMY, RADICAL, FOR TUMOR; W/ ABDOMINAL EXPLORATION 24,453.00 10,530.00 13,923.00 54550 EXPLORATION FOR UNDESCENDED TESTIS (INGUINAL OR SCROTAL AREA) 20,553.00 10,725.00 9,828.00 54560 EXPLORATION FOR UNDESCENDED TESTIS W/ ABDOMINAL EXPLORATION 24,453.00 10,530.00 13,923.00 54600 REDUCTION OF TORSION OF TESTIS, SURGICAL, W/ OR W/O FIXATION OF CONTRALATERAL TESTIS 21,372.00 10,725.00 10,647.00 54620 FIXATION OF CONTRALATERAL TESTIS 18,135.00 14,040.00 4,095.00 Page 80 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 54640 ORCHIOPEXY, INGUINAL APPROACH, W/ OR W/O HERNIA REPAIR 20,553.00 10,725.00 9,828.00 54650 ORCHIOPEXY, ABDOMINAL APPROACH, FOR INTRA-ABDOMINAL TESTIS (E.G., FOWLER-STEPHENS) 24,453.00 10,530.00 13,923.00 54670 SUTURE OR REPAIR OF TESTICULAR INJURY 18,915.00 10,725.00 8,190.00 54680 TRANSPLANTATION OF TESTIS(ES) TO THIGH (BECAUSE OF SCROTAL DESTRUCTION) 16,107.00 9,555.00 6,552.00 54690 LAPAROSCOPY, SURGICAL; ORCHIECTOMY 18,915.00 10,725.00 8,190.00 54692 LAPAROSCOPY, SURGICAL; ORCHIOPEXY FOR INTRA-ABDOMINAL TESTIS 23,361.00 11,895.00 11,466.00 54700 INCISION AND DRAINAGE OF EPIDIDYMIS, TESTIS AND/OR SCROTAL SPACE (E.G., ABSCESS OR HEMATOMA) 8,010.60 6,045.00 1,965.60 54800 BIOPSY OF EPIDIDYMIS, NEEDLE 6,832.80 5,850.00 982.80 54820 EXPLORATION OF EPIDIDYMIS, W/ OR W/O BIOPSY 18,135.00 14,040.00 4,095.00 54830 EXCISION OF LOCAL LESION OF EPIDYDIMIS 11,076.00 7,800.00 3,276.00 54840 EXCISION OF SPERMATOCELE, W/ OR W/O EPIDIDYMECTOMY 15,639.00 10,725.00 4,914.00 54860 EPIDIDYMECTOMY; UNILATERAL 18,135.00 14,040.00 4,095.00 54861 EPIDIDYMECTOMY; BILATERAL 16,458.00 10,725.00 5,733.00 54900 EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS DEFERENS; UNILATERAL 20,553.00 10,725.00 9,828.00 54901 EPIDIDYMOVASOSTOMY, ANASTOMOSIS OF EPIDIDYMIS TO VAS DEFERENS; BILATERAL 35,100.00 18,720.00 16,380.00 55000 PUNCTURE ASPIRATION OF HYDROCELE, TUNICA VAGINALIS, W/ OR W/O INJECTION OF MEDICATION 6,832.80 5,850.00 982.80 55040 EXCISION OF HYDROCELE; UNILATERAL 18,915.00 10,725.00 8,190.00 55041 EXCISION OF HYDROCELE; BILATERAL 35,100.00 18,720.00 16,380.00 55060 REPAIR OF TUNICA VAGINALIS HYDROCELE (BOTTLE TYPE) 18,915.00 10,725.00 8,190.00 55100 DRAINAGE OF SCROTAL WALL ABSCESS 6,832.80 5,850.00 982.80 55101 DRAINAGE AND DEBRIDEMENT OF FOURNIERS GANGRENE OF THE SCROTUM 18,135.00 14,040.00 4,095.00 55110 SCROTAL EXPLORATION 18,135.00 14,040.00 4,095.00 55120 REMOVAL OF FOREIGN BODY IN SCROTUM 8,010.60 6,045.00 1,965.60 55150 RESECTION OF SCROTUM 10,842.00 8,385.00 2,457.00 55175 SCROTOPLASTY 11,076.00 7,800.00 3,276.00 55200 VASOTOMY, CANNULIZATION W/ OR W/O INCISION OF VAS, UNILATERAL OR BILATERAL 11,076.00 7,800.00 3,276.00 55250 VASECTOMY, UNILATERAL OR BILATERAL 7,800.00 5,850.00 1,950.00 55400 VASOVASOSTOMY, VASOVASORRHAPHY 20,553.00 10,725.00 9,828.00 55500 EXCISION OF HYDROCELE OF SPERMATIC CORD, UNILATERAL 18,915.00 10,725.00 8,190.00 55520 EXCISION OF LESION OF SPERMATIC CORD 16,107.00 9,555.00 6,552.00 55530 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; 25,155.00 12,870.00 12,285.00 55535 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; ABDOMINAL APPROACH 29,172.00 14,430.00 14,742.00 55540 EXCISION OF VARICOCELE OR LIGATION OF SPERMATIC VEINS FOR VARICOCELE; W/ HERNIA REPAIR 29,172.00 14,430.00 14,742.00 55550 LAPAROSCOPY, SURGICAL; WITH LIGATION OF SPERMATIC VEINS FOR VARICOCELE 29,172.00 14,430.00 14,742.00 55600 VESICULOTOMY; 19,734.00 10,725.00 9,009.00 55650 VESICULECTOMY, ANY APPROACH 35,100.00 18,720.00 16,380.00 55680 EXCISION OF MULLERIAN DUCT CYST 35,100.00 18,720.00 16,380.00 55700 BIOPSY, PROSTATE; NEEDLE OR PUNCH, SINGLE OR MULTIPLE, ANY APPROACH 18,135.00 14,040.00 4,095.00 55720 PROSTATOTOMY, EXTERNAL DRAINAGE OF PROSTATIC ABSCESS, ANY APPROACH 11,076.00 7,800.00 3,276.00 55801 PROSTATECTOMY, PERINEAL, SUBTOTAL (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY) 75,777.00 36,465.00 39,312.00 55810 PROSTATECTOMY, PERINEAL RADICAL; 90,675.00 41,535.00 49,140.00 55812 PROSTATECTOMY, PERINEAL RADICAL; W/ LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) 93,951.00 41,535.00 52,416.00 55815 PROSTATECTOMY, PERINEAL RADICAL; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES 93,951.00 41,535.00 52,416.00 55821 PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY); SUPRAPUBIC, SUBTOTAL, ONE OR TWO STAGES 75,777.00 36,465.00 39,312.00 55831 PROSTATECTOMY (INCLUDING CONTROL OF POSTOPERATIVE BLEEDING, VASECTOMY, MEATOTOMY, URETHRAL CALIBRATION AND/OR DILATION, AND INTERNAL URETHROTOMY); RETROPUBIC, SUBTOTAL 59,085.00 26,325.00 32,760.00 55840 PROSTATECTOMY, RETROPUBIC RADICAL, W/ OR W/O NERVE SPARING; 90,675.00 41,535.00 49,140.00 55842 PROSTATECTOMY, RETROPUBIC RADICAL, W/ OR W/O NERVE SPARING; W/ LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) 93,951.00 41,535.00 52,416.00 55845 PROSTATECTOMY, RETROPUBIC RADICAL, W/ OR W/O NERVE SPARING; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC, AND OBTURATOR NODES 93,951.00 41,535.00 52,416.00 55859 TRANSPERINEAL PLACEMENT OF NEEDLES, CATHETERS OR PELLETS INTO PROSTATE FOR INTERSTITIAL RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY, ULTRASOUND OR CT SCAN GUIDANCE 35,100.00 18,720.00 16,380.00 Page 81 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 55860 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; 18,915.00 10,725.00 8,190.00 55862 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; W/ LYMPH NODE BIOPSY(S) (LIMITED PELVIC LYMPHADENECTOMY) 35,100.00 18,720.00 16,380.00 55865 EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; W/ BILATERAL PELVIC LYMPHADENECTOMY, INCLUDING EXTERNAL ILIAC, HYPOGASTRIC AND OBTURATOR NODES 45,435.00 20,865.00 24,570.00 55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING 90,675.00 41,535.00 49,140.00 55873 CRYOSURGICAL ABLATION OF THE PROSTATE (CRYOTHERAPY OF THE PROSTATE) 107,250.00 41,730.00 65,520.00 56405 INCISION AND DRAINAGE OF VULVA OR PERINEAL ABSCESS 10,842.00 8,385.00 2,457.00 56420 INCISION AND DRAINAGE OF BARTHOLINS GLAND ABSCESS 18,135.00 14,040.00 4,095.00 56440 MARSUPIALIZATION OF BARTHOLINS GLAND CYST 18,915.00 10,725.00 8,190.00 56441 LYSIS OF LABIAL ADHESIONS 18,135.00 14,040.00 4,095.00 56501 DESTRUCTION OF LESION(S), VULVA; ANY METHOD 18,135.00 14,040.00 4,095.00 56605 BIOPSY OF VULVA OR PERINEUM ; ONE LESION 18,135.00 14,040.00 4,095.00 56620 VULVECTOMY SIMPLE; PARTIAL 23,634.00 10,530.00 13,104.00 56625 VULVECTOMY SIMPLE; COMPLETE 45,435.00 20,865.00 24,570.00 56630 VULVECTOMY, RADICAL, PARTIAL; 52,884.00 23,400.00 29,484.00 56631 VULVECTOMY, RADICAL, PARTIAL; W/ UNILATERAL INGUINOFEMORAL LYMPHADENECTOMY 59,085.00 26,325.00 32,760.00 56632 VULVECTOMY, RADICAL, PARTIAL; W/ BILATERAL INGUINOFEMORAL LYMPHADENECTOMY 73,710.00 32,760.00 40,950.00 56633 VULVECTOMY, RADICAL, COMPLETE; 90,675.00 41,535.00 49,140.00 56634 VULVECTOMY, RADICAL, COMPLETE; W/ UNILATERAL INGUINOFEMORAL LYMPHADENECTOMY 104,130.00 46,800.00 57,330.00 56637 VULVECTOMY, RADICAL, COMPLETE; W/ BILATERAL INGUINOFEMORAL LYMPHADENECTOMY 107,250.00 41,730.00 65,520.00 56640 VULVECTOMY, RADICAL, COMPLETE, W/ INGUINOFEMORAL, ILIAC, AND PELVIC LYMPHADENECTOMY 114,660.00 40,950.00 73,710.00 56700 PARTIAL HYMENECTOMY OR REVISION OF HYMENAL RING 18,915.00 10,725.00 8,190.00 56720 HYMENOTOMY, SIMPLE INCISION 18,135.00 14,040.00 4,095.00 56740 EXCISION OF BARTHOLINS GLAND OR CYST 18,915.00 10,725.00 8,190.00 57000 COLPOTOMY; W/ EXPLORATION 23,634.00 10,530.00 13,104.00 57020 COLPOCENTESIS 11,076.00 7,800.00 3,276.00 57061 DESTRUCTION OF VAGINAL LESION(S) 11,076.00 7,800.00 3,276.00 57100 BIOPSY OF VAGINAL MUCOSA 11,076.00 7,800.00 3,276.00 57108 COLPECTOMY, OBLITERATION OF VAGINA; PARTIAL 45,435.00 20,865.00 24,570.00 57110 COLPECTOMY, OBLITERATION OF VAGINA; COMPLETE 59,085.00 26,325.00 32,760.00 57120 COLPOCLEISIS (LE FORT TYPE) 52,884.00 23,400.00 29,484.00 57130 EXCISION OF VAGINAL SEPTUM 18,135.00 14,040.00 4,095.00 57135 EXCISION OF VAGINAL CYST OR TUMOR 18,915.00 10,725.00 8,190.00 57155 INSERTION OF UTERINE TANDEMS AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY 18,915.00 10,725.00 8,190.00 57200 COLPORRHAPHY, SUTURE OF INJURY OF VAGINA (NONOBSTERICAL) 15,639.00 10,725.00 4,914.00 57210 COLPOPERINEORRHAPHY, SUTURE OF INJURY OF VAGINA AND/OR PERINEUM (NONOBSTETRICAL) 20,553.00 10,725.00 9,828.00 57220 PLASTIC OPERATION ON URETHRAL SPHINCTER, VAGINAL APPROACH (E.G., KELLY URETHRAL PLICATION) 23,634.00 10,530.00 13,104.00 57230 PLASTIC REPAIR OF URETHROCELE 23,634.00 10,530.00 13,104.00 57240 ANTERIOR COLPORRHAPHY, REPAIR OF CYSTOCELE W/ OR W/O REPAIR OF URETHROCELE 40,911.00 21,255.00 19,656.00 57250 POSTERIOR COLPORRHAPHY, REPAIR OF RECTOCELE W/ OR W/O PERINEORRHAPHY 40,911.00 21,255.00 19,656.00 57260 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; 45,435.00 20,865.00 24,570.00 57265 COMBINED ANTEROPOSTERIOR COLPORRHAPHY; W/ ENTEROCELE REPAIR 59,085.00 26,325.00 32,760.00 57268 REPAIR OF ENTEROCELE, VAGINAL APPROACH 45,435.00 20,865.00 24,570.00 57270 REPAIR OF ENTEROCELE, ABDOMINAL APPROACH 52,884.00 23,400.00 29,484.00 57280 COLPOPEXY, ABDOMINAL APPROACH 52,884.00 23,400.00 29,484.00 57282 SACROSPINOUS LIGAMENT FIXATION FOR PROLAPSE OF VAGINA 52,884.00 23,400.00 29,484.00 57284 PARAVAGINAL DEFECT REPAIR (INCLUDING REPAIR OF CYSTOCELE, STRESS URINARY INCONTINENCE, AND/OR INCOMPLETE VAGINAL PROLAPSE) 52,884.00 23,400.00 29,484.00 57288 SLING OPERATION FOR STRESS INCONTINENCE (E.G., FASCIA OR SYNTHETIC) 59,085.00 26,325.00 32,760.00 57289 PEREYRA PROCEDURE, INCLUDING ANTERIOR COLPORRHAPHY 59,085.00 26,325.00 32,760.00 57300 CLOSURE OF RECTOVAGINAL FISTULA; VAGINAL OR TRANSANAL APPROACH 40,911.00 21,255.00 19,656.00 57305 CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH 45,435.00 20,865.00 24,570.00 57307 CLOSURE OF RECTOVAGINAL FISTULA; ABDOMINAL APPROACH, W/ CONCOMITANT COLOSTOMY 59,085.00 26,325.00 32,760.00 57310 CLOSURE OF URETHROVAGINAL FISTULA; 40,911.00 21,255.00 19,656.00 57311 CLOSURE OF URETHROVAGINAL FISTULA; W/ BULBOCAVERNOSUS TRANSPLANT 59,085.00 26,325.00 32,760.00 57320 CLOSURE OF VESICOVAGINAL FISTULA; VAGINAL APPROACH 45,435.00 20,865.00 24,570.00 57330 CLOSURE OF VESICOVAGINAL FISTULA; TRANSVESICAL AND VAGINAL APPROACH 59,085.00 26,325.00 32,760.00 57415 REMOVAL OF IMPACTED VAGINAL FOREIGN BODY UNDER ANESTHESIA 16,107.00 9,555.00 6,552.00 Page 82 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 57425 LAPAROSCOPY, SURGICAL, COLPOPEXY (SUSPENSION OF VAGINAL APEX) 52,884.00 23,400.00 29,484.00 57452 COLPOSCOPY (VAGINOSCOPY) 15,639.00 10,725.00 4,914.00 57454 COLPOSCOPY; W/ BIOPSY(S) OF THE CERVIX AND/OR ENDOCERVICAL CURETTAGE 16,107.00 9,555.00 6,552.00 57460 COLPOSCOPY; W/ LOOP ELECTRODE EXCISION PROCEDURE OF THE CERVIX 18,915.00 10,725.00 8,190.00 57500 BIOPSY, SINGLE OR MULTIPLE, OR LOCAL EXCISION OF LESION, W/ OR W/O FULGURATION 11,076.00 7,800.00 3,276.00 57510 CAUTERIZATION OF CERVIX; ANY METHOD 11,076.00 7,800.00 3,276.00 57520 CONIZATION OF CERVIX, W/ OR W/O FULGURATION, W/ OR W/O DILATION AND CURETTAGE, W/ OR W/O REPAIR; COLD KNIFE OR LASER 18,915.00 10,725.00 8,190.00 57522 CONIZATION OF CERVIX, W/ OR W/O FULGURATION, W/ OR W/O DILATION AND CURETTAGE, W/ OR W/O REPAIR; LOOP ELECTRODE EXCISION 25,155.00 12,870.00 12,285.00 57530 TRACHELECTOMY (CERVICECTOMY), AMPUTATION OF CERVIX 35,100.00 18,720.00 16,380.00 57540 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; 59,085.00 26,325.00 32,760.00 57545 EXCISION OF CERVICAL STUMP, ABDOMINAL APPROACH; W/ PELVIC FLOOR REPAIR 73,710.00 32,760.00 40,950.00 57550 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; 45,435.00 20,865.00 24,570.00 57555 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; W/ ANTERIOR AND/OR POSTERIOR REPAIR 73,710.00 32,760.00 40,950.00 57556 EXCISION OF CERVICAL STUMP, VAGINAL APPROACH; W/ REPAIR OF ENTEROCELE 77,805.00 32,760.00 45,045.00 57700 CERCLAGE OF UTERINE CERVIX, NONOBSTETRICAL 18,915.00 10,725.00 8,190.00 57720 TRACHELORRHAPHY, PLASTIC REPAIR OF UTERINE CERVIX, VAGINAL APPROACH 35,100.00 18,720.00 16,380.00 58100 ENDOMETRIAL SAMPLING (BIOPSY) W/ OR W/O ENDOCERVICAL SAMPLING (BIOPSY), W/O CERVICAL DILATION, ANY METHOD 21,450.00 12,870.00 8,580.00 58120 DILATION AND CURETTAGE 21,450.00 12,870.00 8,580.00 58140 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, SINGLE OR MULTIPLE ; ABDOMINAL APPROACH 45,435.00 20,865.00 24,570.00 58145 MYOMECTOMY, EXCISION OF FIBROID TUMOR OF UTERUS, SINGLE OR MULTIPLE ; VAGINAL APPROACH 35,100.00 18,720.00 16,380.00 58150 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S); 58,500.00 35,100.00 23,400.00 58152 TOTAL ABDOMINAL HYSTERECTOMY (CORPUS AND CERVIX), W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S); W/ COLPO-URETHROCYSTOPEXY (MARSHALL- MARCHETTI-KRANTZ TYPE) 58,500.00 35,100.00 23,400.00 58180 SUPRACERVICAL ABDOMINAL HYSTERECTOMY (SUBTOTAL HYSTERECTOMY), W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S) 58,500.00 35,100.00 23,400.00 58200 TOTAL ABDOMINAL HYSTERECTOMY, INCLUDING PARTIAL VAGINECTOMY, W/ PARA-AORTIC AND PELVIC LYMPH NODE SAMPLING, W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S) 58,500.00 35,100.00 23,400.00 58210 RADICAL ABDOMINAL HYSTERECTOMY, W/ BILATERAL TOTAL PELVIC LYMPHADENECTOMY AND PARA-AORTIC LYMPH NODE SAMPLING (BIOPSY), W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S) 107,250.00 41,730.00 65,520.00 58240 PELVIC EXENTERATION FOR GYNECOLOGIC MALIGNANCY, W/ TOTAL ABDOMINAL HYSTERECTOMY OR CERVICECTOMY, W/ OR W/O REMOVAL OF TUBE(S), W/ OR W/O REMOVAL OF OVARY(S), W/ REMOVAL OF BLADDER AND URETERAL TRANSPLANTATIONS, AND/OR ABDOMINOPERINEAL RESECTION OF RECTUM 139,230.00 40,950.00 98,280.00 58260 VAGINAL HYSTERECTOMY; 59,085.00 26,325.00 32,760.00 58262 VAGINAL HYSTERECTOMY; W/ REMOVAL OF TUBE(S), AND/OR OVARY(S) 59,085.00 26,325.00 32,760.00 58263 VAGINAL HYSTERECTOMY; W/ REMOVAL OF TUBE(S), AND/OR OVARY(S), W/ REPAIR OF ENTEROCELE 73,710.00 32,760.00 40,950.00 58267 VAGINAL HYSTERECTOMY; W/ COLPO-URETHROCYSTOPEXY (MARSHALL-MARCHETTI-KRANTZ TYPE, PEREYRA TYPE, W/ OR W/O ENDOSCOPIC CONTROL) 90,675.00 41,535.00 49,140.00 58270 VAGINAL HYSTERECTOMY; W/ REPAIR OF ENTEROCELE 90,675.00 41,535.00 49,140.00 58275 VAGINAL HYSTERECTOMY, W/ TOTAL OR PARTIAL COLPECTOMY; 73,710.00 32,760.00 40,950.00 58280 VAGINAL HYSTERECTOMY, W/ TOTAL OR PARTIAL COLPECTOMY; W/ REPAIR OF ENTEROCELE 90,675.00 41,535.00 49,140.00 58285 VAGINAL HYSTERECTOMY, RADICAL (SCHAUTA TYPE OPERATION) 90,675.00 41,535.00 49,140.00 58345 TRANSCERVICAL INTRODUCTION OF FALLOPIAN TUBE CATHETER FOR DIAGNOSIS AND/OR RE-ESTABLISHING PATENCY (ANY METHOD), W/ OR W/O HYSTEROSALPINGOGRAPHY 35,100.00 18,720.00 16,380.00 58346 INSERTION OF HEYMAN CAPSULES FOR BRACHYTHERAPY 18,915.00 10,725.00 8,190.00 58400 UTERINE SUSPENSION, W/ OR W/O SHORTENING OF ROUND LIGAMENTS, W/ OR W/O SHORTENING OF SACROUTERINE LIGAMENTS; 45,435.00 20,865.00 24,570.00 58410 UTERINE SUSPENSION, W/ OR W/O SHORTENING OF ROUND LIGAMENTS, W/ OR W/O SHORTENING OF SACROUTERINE LIGAMENTS; W/ PRESACRAL SYMPATHECTOMY 52,884.00 23,400.00 29,484.00 58520 HYSTERORRHAPHY, REPAIR OF RUPTURED UTERUS (NONOBSTETRICAL) 45,435.00 20,865.00 24,570.00 Page 83 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 58540 HYSTEROPLASTY, REPAIR OF UTERINE ANOMALY (STRASSMAN TYPE) 73,710.00 32,760.00 40,950.00 58545 LAPAROSCOPY, SURGICAL, MYOMECTOMY, EXCISION; INTRAMURAL MYOMAS AND/OR REMOVAL OF SURFACE MYOMAS 45,435.00 20,865.00 24,570.00 58550 LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY; 59,085.00 26,325.00 32,760.00 58552 LAPAROSCOPY SURGICAL, WITH VAGINAL HYSTERECTOMY; WITH REMOVAL OF TUBE(S) AND/OR OVARY(S) 59,085.00 26,325.00 32,760.00 58555 HYSTEROSCOPY, DIAGNOSTIC 18,915.00 10,725.00 8,190.00 58558 HYSTEROSCOPY, SURGICAL; WITH SAMPLING (BIOPSY) OF ENDOMETRIUM AND/OR POLYPECTOMY, WITH OR WITHOUT D&C 25,155.00 12,870.00 12,285.00 58559 HYSTEROSCOPY, SURGICAL; WITH LYSIS OF INTRAUTERINE ADHESIONS (ANY METHOD) 35,100.00 18,720.00 16,380.00 58560 HYSTEROSCOPY, SURGICAL; WITH DIVISION OR RESECTION OF INTRAUTERINE SEPTUM (ANY METHOD) 35,100.00 18,720.00 16,380.00 58561 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF LEIOMYOMATA 45,435.00 20,865.00 24,570.00 58562 HYSTEROSCOPY, SURGICAL; WITH REMOVAL OF IMPACTED FOREIGN BODY 25,155.00 12,870.00 12,285.00 58563 HYSTEROSCOPY, SURGICAL; WITH ENDOMETRIAL ABLATION (E.G., ENDOMETRIAL RESECTION, ELECTROSURGICAL ABLATION THERMOABLATION) 23,634.00 10,530.00 13,104.00 58565 HYSTEROSCOPY, SURGICAL; WITH BILATERAL FALLOPIAN TUBE CANNULATION TO INDUCE OCCLUSION BY PLACEMENT OF PERMANENT IMPLANTS 11,076.00 7,800.00 3,276.00 58600 LIGATION OR TRANSECTION OF FALLOPIAN TUBE(S), ABDOMINAL OR VAGINAL APPROACH, UNILATERAL OR BILATERAL 7,800.00 5,850.00 1,950.00 58660 LAPAROSCOPY, SURGICAL; WITH LYSIS OF ADHESIONS (SALPHINGOLYSIS, OVARIOLYSIS) 41,730.00 21,255.00 20,475.00 58661 LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY) 104,130.00 46,800.00 57,330.00 58662 LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD 29,172.00 14,430.00 14,742.00 58670 LAPAROSCOPY, SURGICAL; WITH FULGURATION OF OVIDUCTS (WITH OR WITHOUT TRANSECTION) 29,172.00 14,430.00 14,742.00 58671 LAPAROSCOPY, SURGICAL; WITH OCCLUSION OF OVIDUCTS BY DEVICE (E.G., BAND, CLIP, OR FALOPE RING) 25,155.00 12,870.00 12,285.00 58672 LAPAROSCOPY, SURGICAL; WITH FIMBRIOPLASTY 41,730.00 21,255.00 20,475.00 58673 LAPAROSCOPY, SURGICAL; WITH SALPHINGOSTOMY (SALPINGONEOSTOMY) 45,435.00 20,865.00 24,570.00 58700 SALPINGECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL 40,911.00 21,255.00 19,656.00 58720 SALPINGO-OOPHORECTOMY, COMPLETE OR PARTIAL, UNILATERAL OR BILATERAL 45,435.00 20,865.00 24,570.00 58740 LYSIS OF ADHESIONS (SALPINGOLYSIS, OVARIOLYSIS) 45,435.00 20,865.00 24,570.00 58750 TUBOTUBAL ANASTOMOSIS 35,100.00 18,720.00 16,380.00 58760 FIMBRIOPLASTY 45,435.00 20,865.00 24,570.00 58770 SALPINGOSTOMY (SALPINGONEOSTOMY) 45,435.00 20,865.00 24,570.00 58800 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL ; VAGINAL APPROACH 40,911.00 21,255.00 19,656.00 58805 DRAINAGE OF OVARIAN CYST(S), UNILATERAL OR BILATERAL ; ABDOMINAL APPROACH 40,911.00 21,255.00 19,656.00 58820 DRAINAGE OF OVARIAN ABSCESS; VAGINAL APPROACH 40,911.00 21,255.00 19,656.00 58822 DRAINAGE OF OVARIAN ABSCESS; ABDOMINAL APPROACH 40,911.00 21,255.00 19,656.00 58825 TRANSPOSITION, OVARY(S) 40,911.00 21,255.00 19,656.00 58900 BIOPSY OF OVARY, UNILATERAL OR BILATERAL 35,100.00 18,720.00 16,380.00 58920 WEDGE RESECTION OR BISECTION OF OVARY, UNILATERAL OR BILATERAL 35,100.00 18,720.00 16,380.00 58925 OVARIAN CYSTECTOMY, UNILATERAL OR BILATERAL 45,435.00 20,865.00 24,570.00 58940 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; 35,100.00 18,720.00 16,380.00 58943 OOPHORECTOMY, PARTIAL OR TOTAL, UNILATERAL OR BILATERAL; FOR OVARIAN MALIGNANCY, W/ PARA-AORTIC AND PELVIC LYMPH NODE BIOPSIES, PERITONEAL WASHINGS, PERITONEAL BIOPSIES, DIAPHRAGMATIC ASSESSMENTS, W/ OR W/O SALPINGECTOMY(S), W/ OR W/O OMENTECTOMY 59,085.00 26,325.00 32,760.00 58950 RESECTION OF OVARIAN MALIGNANCY W/ BILATERAL SALPINGO- OOPHORECTOMY AND OMENTECTOMY; 104,130.00 46,800.00 57,330.00 58951 RESECTION OF OVARIAN MALIGNANCY W/ BILATERAL SALPINGO- OOPHORECTOMY AND OMENTECTOMY; W/ TOTAL ABDOMINAL HYSTERECTOMY, PELVIC AND LIMITED PARA-AORTIC LYMPHADENECTOMY 107,250.00 41,730.00 65,520.00 58952 RESECTION OF OVARIAN MALIGNANCY W/ BILATERAL SALPINGO- OOPHORECTOMY AND OMENTECTOMY; W/ RADICAL DISSECTION FOR DEBULKING 114,660.00 40,950.00 73,710.00 58960 LAPAROTOMY, FOR STAGING OR RESTAGING OF OVARIAN MALIGNANCY ("SECOND LOOK"), W/ OR W/O OMENTECTOMY, PERITONEAL WASHING, BIOPSY OF ABDOMINAL AND PELVIC PERITONEUM, DIAPHRAGMATIC ASSESSMENT W/ PELVIC AND LIMITED PARA-AORTIC LYMPHADENECTOMY 52,884.00 23,400.00 29,484.00 59100 HYSTEROTOMY, ABDOMINAL (E.G., FOR HYDATIDIFORM MOLE, ABORTION) 45,435.00 20,865.00 24,570.00 Page 84 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 59120 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, REQUIRING SALPINGECTOMY AND/OR OOPHORECTOMY, ABDOMINAL OR VAGINAL APPROACH 52,884.00 23,400.00 29,484.00 59121 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; TUBAL OR OVARIAN, W/O SALPINGECTOMY AND/OR OOPHORECTOMY 52,884.00 23,400.00 29,484.00 59130 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; ABDOMINAL PREGNANCY 90,675.00 41,535.00 49,140.00 59135 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE PREGNANCY REQUIRING TOTAL HYSTERECTOMY 73,710.00 32,760.00 40,950.00 59136 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; INTERSTITIAL, UTERINE PREGNANCY W/ PARTIAL RESECTION OF UTERUS 73,320.00 36,465.00 36,855.00 59140 SURGICAL TREATMENT OF ECTOPIC PREGNANCY; CERVICAL, W/ EVACUATION 59,085.00 26,325.00 32,760.00 59150 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; W/O SALPINGECTOMY AND/OR OOPHORECTOMY 52,884.00 23,400.00 29,484.00 59151 LAPAROSCOPIC TREATMENT OF ECTOPIC PREGNANCY; W/ SALPINGECTOMY AND/OR OOPHORECTOMY 52,884.00 23,400.00 29,484.00 59320 CERCLAGE OF CERVIX, DURING PREGNANCY; VAGINAL 35,100.00 18,720.00 16,380.00 59325 CERCLAGE OF CERVIX, DURING PREGNANCY; ABDOMINAL 35,100.00 18,720.00 16,380.00 59350 HYSTERORRHAPHY OF RUPTURED UTERUS 59,085.00 26,325.00 32,760.00 59403 UNDELIVERED CASES (BABY DELIVERED IN REFERRAL FACILITY) IN NON-HOSPITAL FACILITIES 1,267.50 760.50 507.00 59409 VAGINAL DELIVERY ONLY (W/ EPISIOTOMY) 18,915.00 10,725.00 8,190.00 59411 BREECH EXTRACTION 23,634.00 10,530.00 13,104.00 59513 CAESARIAN SECTION, PRIMARY 37,050.00 22,230.00 14,820.00 59514 CESARIAN DELIVERY 37,050.00 22,230.00 14,820.00 59525 SUBTOTAL OR TOTAL HYSTERECTOMY AFTER CESAREAN DELIVERY 58,500.00 35,100.00 23,400.00 59612 VAGINAL DELIVERY ONLY, AFTER PREVIOUS CESAREAN DELIVERY (W/ OR W/O EPISIOTOMY) 23,634.00 10,530.00 13,104.00 59620 CESAREAN DELIVERY ONLY, FOLLOWING ATTEMPTED VAGINAL DELIVERY AFTER PREVIOUS CESAREAN DELIVERY; 37,050.00 22,230.00 14,820.00 59812 TREATMENT OF INCOMPLETE ABORTION, ANY TRIMESTER, COMPLETED SURGICALLY 21,450.00 12,870.00 8,580.00 59814 MANUAL VACUUM ASPIRATION FOR SPONTANEOUS ABORTION 21,450.00 12,870.00 8,580.00 59870 UTERINE EVACUATION AND CURETTAGE FOR HYDATIDIFORM MOLE 23,634.00 10,530.00 13,104.00 60000 INCISION AND DRAINAGE OF THYROGLOSSAL CYST, INFECTED 6,832.80 5,850.00 982.80 60001 ASPIRATION AND/OR INJECTION, THYROID CYST 16,107.00 9,555.00 6,552.00 60100 BIOPSY THYROID, PERCUTANEOUS CORE NEEDLE 16,107.00 9,555.00 6,552.00 60200 EXCISION OF CYST OR ADENOMA OF THYROID , OR TRANSECTION OF ISTHMUS 40,911.00 21,255.00 19,656.00 60210 PARTIAL THYROID LOBECTOMY, UNILATERAL; W/ OR W/O ISTHMUSECTOMY 60,450.00 36,270.00 24,180.00 60212 PARTIAL THYROID LOBECTOMY, UNILATERAL; W/ CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY 60,450.00 36,270.00 24,180.00 60220 TOTAL THYROID LOBECTOMY, UNILATERAL; W/ OR W/O ISTHMUSECTOMY 60,450.00 36,270.00 24,180.00 60225 TOTAL THYROID LOBECTOMY, UNILATERAL; W/ CONTRALATERAL SUBTOTAL LOBECTOMY, INCLUDING ISTHMUSECTOMY 60,450.00 36,270.00 24,180.00 60240 THYROIDECTOMY, TOTAL OR COMPLETE 60,450.00 36,270.00 24,180.00 60252 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; W/ LIMITED NECK DISSECTION 60,450.00 36,270.00 24,180.00 60254 THYROIDECTOMY, TOTAL OR SUBTOTAL FOR MALIGNANCY; W/ RADICAL NECK DISSECTION 90,675.00 41,535.00 49,140.00 60260 THYROIDECTOMY, REMOVAL OF ALL REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID 60,450.00 36,270.00 24,180.00 60270 THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND; STERNAL SPLIT OR TRANSHORACIC APPROACH 90,675.00 41,535.00 49,140.00 60271 THYROIDECTOMY, INCLUDING SUBSTERNAL THYROID GLAND; CERVICAL APPROACH 90,675.00 41,535.00 49,140.00 60280 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; 40,911.00 21,255.00 19,656.00 60281 EXCISION OF THYROGLOSSAL DUCT CYST OR SINUS; RECURRENT 45,435.00 20,865.00 24,570.00 60500 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); 59,943.00 33,735.00 26,208.00 60502 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); RE- EXPLORATION 52,884.00 23,400.00 29,484.00 60505 PARATHYROIDECTOMY OR EXPLORATION OF PARATHYROID(S); W/ MEDIASTINAL EXPLORATION, STERNAL SPLIT OR TRANSTHORACIC APPROACH 77,805.00 32,760.00 45,045.00 60512 PARATHYROID AUTOTRANSPLANTATION 59,085.00 26,325.00 32,760.00 60520 THYMECTOMY, PARTIAL OR TOTAL; TRANSCERVICAL APPROACH 77,805.00 32,760.00 45,045.00 60521 THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC APPROACH, W/O RADICAL MEDIASTINAL DISSECTION 77,805.00 32,760.00 45,045.00 60522 THYMECTOMY, PARTIAL OR TOTAL; STERNAL SPLIT OR TRANSTHORACIC APPROACH, W/ RADICAL MEDIASTINAL DISSECTION 77,805.00 32,760.00 45,045.00 Page 85 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 60540 ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND W/ OR W/O BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL; 59,085.00 26,325.00 32,760.00 60545 ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND W/ OR W/O BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL; W/ EXCISION OF ADJACENT RETROPERITONEAL TUMOR 73,320.00 36,465.00 36,855.00 60600 EXCISION OF CAROTID BODY TUMOR; W/O EXCISION OF CAROTID ARTERY 59,085.00 26,325.00 32,760.00 60605 EXCISION OF CAROTID BODY TUMOR; W/ EXCISION OF CAROTID ARTERY 73,710.00 32,760.00 40,950.00 60650 LAPAROSCOPY, SURGICAL, WITH ADRENALECTOMY, PARTIAL OR COMPLETE, OR EXPLORATION OF ADRENAL GLAND WITH OR WITHOUT BIOPSY, TRANSABDOMINAL, LUMBAR OR DORSAL 59,085.00 26,325.00 32,760.00 61000 SUBDURAL TAP THROUGH FONTANELLE, OR SUTURE, INFANT, UNILATERAL OR BILATERAL 11,076.00 7,800.00 3,276.00 61020 VENTRICULAR PUNCTURE THROUGH PREVIOUS BURR HOLE, FONTANELLE, SUTURE, OR IMPLANTED VENTRICULAR CATHETER/RESERVOIR 11,076.00 7,800.00 3,276.00 61050 CISTERNAL OR LATERAL CERVICAL (C1-C2) PUNCTURE 20,553.00 10,725.00 9,828.00 61105 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; NOT FOLLOWED BY OTHER SURGERY 35,100.00 18,720.00 16,380.00 61106 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; FOLLOWED BY OTHER SURGERY 35,919.00 18,720.00 17,199.00 61107 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; FOR IMPLANTING VENTICULAR CATHETER OR PRESSURE RECORDING DEVICE 59,085.00 26,325.00 32,760.00 61108 TWIST DRILL HOLE FOR SUBDURAL OR VENTRICULAR PUNCTURE; FOR EVACUATION AND/OR DRAINAGE OF SUBDURAL HEMATOMA 73,710.00 32,760.00 40,950.00 61120 BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING INJECTION OF GAS, CONTRAST MEDIA, DYE, OR RADIOACTIVE MATERIAL); NOT FOLLOWED BY OTHER SURGERY 45,435.00 20,865.00 24,570.00 61130 BURR HOLE(S) FOR VENTRICULAR PUNCTURE (INCLUDING INJECTION OF GAS, CONTRAST MEDIA, DYE, OR RADIOACTIVE MATERIAL); FOLLOWED BY OTHER SURGERY 43,368.00 21,255.00 22,113.00 61140 BURR HOLE(S) OR TREPHINE; W/ BIOPSY OF BRAIN OR INTRACRANIAL LESION 73,710.00 32,760.00 40,950.00 61150 BURR HOLE(S) OR TREPHINE; W/ DRAINAGE OF BRAIN ABSCESS OR CYST 73,710.00 32,760.00 40,950.00 61154 BURR HOLE(S) W/ EVACUATION AND/OR DRAINAGE OF HEMATOMA, EXTRADURAL OR SUBDURAL 73,710.00 32,760.00 40,950.00 61156 BURR HOLE(S); W/ ASPIRATION OF HEMATOMA OR CYST, INTRACEREBRAL 73,710.00 32,760.00 40,950.00 61250 BURR HOLE(S) OR TREPHINE, SUPRATENTORIAL 45,435.00 20,865.00 24,570.00 61253 BURR HOLE(S) OR TREPHINE, INFRATENTORIAL, UNILATERAL OR BILATERAL 59,085.00 26,325.00 32,760.00 61304 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; SUPRATENTORIAL 73,710.00 32,760.00 40,950.00 61305 CRANIECTOMY OR CRANIOTOMY, EXPLORATORY; INFRATENTORIAL (POSTERIOR FOSSA) 90,675.00 41,535.00 49,140.00 61312 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, SUPRATENTORIAL; EXTRADURAL OR SUBDURAL 90,675.00 41,535.00 49,140.00 61313 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, SUPRATENTORIAL; INTRACEREBRAL 90,675.00 41,535.00 49,140.00 61314 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, INFRATENTORIAL; EXTRADURAL OR SUBDURAL 104,130.00 46,800.00 57,330.00 61315 CRANIECTOMY OR CRANIOTOMY FOR EVACUATION OF HEMATOMA, INFRATENTORIAL; INTRACEREBELLAR 104,130.00 46,800.00 57,330.00 61320 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; SUPRATENTORIAL 90,675.00 41,535.00 49,140.00 61321 CRANIECTOMY OR CRANIOTOMY, DRAINAGE OF INTRACRANIAL ABSCESS; INFRATENTORIAL 104,130.00 46,800.00 57,330.00 61330 DECOMPRESSION OF ORBIT ONLY, TRANSCRANIAL APPROACH 90,675.00 41,535.00 49,140.00 61332 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); W/ BIOPSY 104,130.00 46,800.00 57,330.00 61333 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); W/ REMOVAL OF LESION 104,130.00 46,800.00 57,330.00 61334 EXPLORATION OF ORBIT (TRANSCRANIAL APPROACH); W/ REMOVAL OF FOREIGN BODY 104,130.00 46,800.00 57,330.00 61340 OTHER CRANIAL DECOMPRESSION (E.G., SUBTEMPORAL), SUPRATENTORIAL 73,710.00 32,760.00 40,950.00 61343 CRANIECTOMY, SUBOCCIPITAL W/ CERVICAL LAMINECTOMY FOR DECOMPRESSION OF MEDULLA AND SPINAL CORD, W/ OR W/O DURAL GRAFT (E.G., ARNOLD-CHIARI MALFORMATION) 104,130.00 46,800.00 57,330.00 61345 OTHER CRANIAL DECOMPRESSION, POSTERIOR FOSSA 90,675.00 41,535.00 49,140.00 61440 CRANIOTOMY FOR SECTION OF TENTORIUM CEREBELLI 90,675.00 41,535.00 49,140.00 61450 CRANIECTOMY, SUBTEMPORAL, FOR SECTION, COMPRESSION, OR DECOMPRESSION OF SENSORY ROOT OF GASSERIAN GANGLION 104,130.00 46,800.00 57,330.00 61458 CRANIECTOMY, SUBOCCIPITAL; FOR EXPLORATION OR DECOMPRESSION OF CRANIAL NERVES 104,130.00 46,800.00 57,330.00 Page 86 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 61460 CRANIECTOMY, SUBOCCIPITAL; FOR SECTION OF ONE OR MORE CRANIAL NERVES 107,250.00 41,730.00 65,520.00 61470 CRANIECTOMY, SUBOCCIPITAL; FOR MEDULLARY TRACTOTOMY 107,250.00 41,730.00 65,520.00 61480 CRANIECTOMY, SUBOCCIPITAL; FOR MESENCEPHALIC TRACTOTOMY OR PEDUNCULOTOMY 107,250.00 41,730.00 65,520.00 61490 CRANIOTOMY FOR LOBOTOMY, INCLUDING CINGULOTOMY 90,675.00 41,535.00 49,140.00 61500 CRANIECTOMY; W/ EXCISION OF TUMOR OR OTHER BONE LESION OF SKULL 107,250.00 41,730.00 65,520.00 61501 CRANIECTOMY; FOR OSTEOMYELITIS 73,710.00 32,760.00 40,950.00 61510 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN TUMOR, SUPRATENTORIAL, EXCEPT MENINGIOMA 107,250.00 41,730.00 65,520.00 61512 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF MENINGIOMA, SUPRATENTORIAL 122,850.00 40,950.00 81,900.00 61514 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OF BRAIN ABSCESS, SUPRATENTORIAL 104,130.00 46,800.00 57,330.00 61516 CRANIECTOMY, TREPHINATION, BONE FLAP CRANIOTOMY; FOR EXCISION OR FENESTRATION OF CYST, SUPRATENTORIAL 104,130.00 46,800.00 57,330.00 61518 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; EXCEPT MENINGIOMA, CEREBELLOPONTINE ANGLE TUMOR, OR MIDLINE TUMOR AT BASE OF SKULL 126,945.00 40,950.00 85,995.00 61519 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MENINGIOMA 131,040.00 40,950.00 90,090.00 61520 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; CEREBELLOPONTINE ANGLE TUMOR 139,230.00 40,950.00 98,280.00 61521 CRANIECTOMY FOR EXCISION OF BRAIN TUMOR, INFRATENTORIAL OR POSTERIOR FOSSA; MIDLINE TUMOR AT BASE OF SKULL 139,230.00 40,950.00 98,280.00 61522 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OF BRAIN ABSCESS 107,250.00 41,730.00 65,520.00 61524 CRANIECTOMY, INFRATENTORIAL OR POSTERIOR FOSSA; FOR EXCISION OR FENESTRATION OF CYST, 107,250.00 41,730.00 65,520.00 61526 CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; 147,420.00 40,950.00 106,470.00 61530 CRANIECTOMY, BONE FLAP CRANIOTOMY, TRANSTEMPORAL (MASTOID) FOR EXCISION OF CEREBELLOPONTINE ANGLE TUMOR; COMBINED W/ MIDDLE/POSTERIOR FOSSA CRANIOTOMY/ CRANIECTOMY 147,420.00 40,950.00 106,470.00 61531 SUBDURAL IMPLANTATION OF STRIP ELECTRODES THROUGH ONE OR MORE BURR OR TREPHINE HOLE(S) FOR LONG TERM SEIZURE MONITORING 104,130.00 46,800.00 57,330.00 61533 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR SUBDURAL IMPLANTATION OF AN ELECTRODE ARRAY, FOR LONG TERM SEIZURE MONITORING 104,130.00 46,800.00 57,330.00 61534 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR EXCISION OF EPILEPTOGENIC FOCUS W/O ELECTROCORTICOGRAPHY DURING SURGERY 104,130.00 46,800.00 57,330.00 61535 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR REMOVAL OF EPIDURAL OR SUBDURAL ELECTRODE ARRAY, W/O EXCISION OF CEREBRAL TISSUE 104,130.00 46,800.00 57,330.00 61536 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR EXCISION OF CEREBRAL EPILEPTOGENIC FOCUS, W/ ELECTROCORTICOGRAPHY DURING SURGERY (INCLUDES REMOVAL OF ELECTRODE ARRAY) 107,250.00 41,730.00 65,520.00 61538 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR LOBECTOMY W/ ELECTROCORTICOGRAPHY DURING SURGERY, TEMPORAL LOBE 104,130.00 46,800.00 57,330.00 61539 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR LOBECTOMY W/ ELECTROCORTICOGRAPHY DURING SURGERY, OTHER THAN TEMPORAL LOBE, PARTIAL OR TOTAL 104,130.00 46,800.00 57,330.00 61541 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR TRANSECTION OF CORPUS CALLOSUM 104,130.00 46,800.00 57,330.00 61542 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR TOTAL HEMISPHERECTOMY 131,040.00 40,950.00 90,090.00 61543 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR PARTIAL OR SUBTOTAL HEMISPHERECTOMY 122,850.00 40,950.00 81,900.00 61544 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR EXCISION OF COAGULATION OF CHOROID PLEXUS 104,130.00 46,800.00 57,330.00 61545 CRANIOTOMY W/ ELEVATION OF BONE FLAP; FOR EXCISION OF CRANIOPHARYNGIOMA 122,850.00 40,950.00 81,900.00 61546 CRANIOTOMY FOR HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, INTRACRANIAL APPROACH 122,850.00 40,950.00 81,900.00 61548 HYPOPHYSECTOMY OR EXCISION OF PITUITARY TUMOR, TRANSNASAL OR TRANSSEPTAL APPROACH, NONSTEREOTACTIC 122,850.00 40,950.00 81,900.00 61550 CRANIECTOMY FOR CRANIOSYNOSTOSIS; SINGLE CRANIAL SUTURE 73,710.00 32,760.00 40,950.00 61552 CRANIECTOMY FOR CRANIOSYNOSTOSIS; MULTIPLE CRANIAL SUTURES 90,675.00 41,535.00 49,140.00 61556 CRANIOTOMY FOR CRANIOSYNOSTOSIS; FRONTAL OR PARIETAL BONE FLAP 90,675.00 41,535.00 49,140.00 61557 CRANIOTOMY FOR CRANIOSYNOSTOSIS; BIFRONTAL BONE FLAP 90,675.00 41,535.00 49,140.00 Page 87 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 61558 EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE CRANIOSYNOSTOSIS (E.G., CLOVERLEAF SKULL); NOT REQUIRING BONE GRAFTS 114,660.00 40,950.00 73,710.00 61559 EXTENSIVE CRANIECTOMY FOR MULTIPLE CRANIAL SUTURE CRANIOSYNOSTOSIS (E.G., CLOVERLEAF SKULL); RECONTOURING W/ MULTIPLE OSTEOTOMIES AND BONE AUTOGRAFTS (E.G., BARREL-STAVE PROCEDURE) (INCLUDES OBTAINING GRAFTS) 114,660.00 40,950.00 73,710.00 61563 EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (E.G., FIBROUS DYSPLASIA); W/O OPTIC NERVE DECOMPRESSION 114,660.00 40,950.00 73,710.00 61564 EXCISION, INTRA AND EXTRACRANIAL, BENIGN TUMOR OF CRANIAL BONE (E.G., FIBROUS DYSPLASIA); W/ OPTIC NERVE DECOMPRESSION 114,660.00 40,950.00 73,710.00 61570 CRANIECTOMY OR CRANIOTOMY; W/ EXCISION OF FOREIGN BODY FROM BRAIN 104,130.00 46,800.00 57,330.00 61571 CRANIECTOMY OR CRANIOTOMY; W/ TREATMENT OF PENETRATING WOUND OF BRAIN 108,225.00 46,800.00 61,425.00 61575 TRANSORAL APPROACH TO SKULL BASE, BRAIN STEM OR UPPER SPINAL CORD FOR BIOPSY, DECOMPRESSION OR EXCISION OF LESION; 147,420.00 40,950.00 106,470.00 61576 TRANSORAL APPROACH TO SKULL BASE, BRAIN STEM OR UPPER SPINAL CORD FOR BIOPSY, DECOMPRESSION OR EXCISION OF LESION; REQUIRING SPLITTING OF TONGUE AND/OR MANDIBLE (INCLUDING TRACHEOSTOMY) 147,420.00 40,950.00 106,470.00 61580 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING LATERAL RHINOTOMY, ETHMOIDECTOMY, SPHENOIDECTOMY, W/O MAXILLECTOMY OR ORBITAL EXENTERATION 122,850.00 40,950.00 81,900.00 61581 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING LATERAL RHINOTOMY, ORBITAL EXENTERATION, ETHMOIDECTOMY, SPHENOIDECTOMY AND/OR MAXILLECTOMY 122,850.00 40,950.00 81,900.00 61582 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; EXTRADURAL, INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OF FRONTAL LOBE(S), OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA 122,850.00 40,950.00 81,900.00 61583 CRANIOFACIAL APPROACH TO ANTERIOR CRANIAL FOSSA; INTRADURAL, INCLUDING UNILATERAL OR BIFRONTAL CRANIOTOMY, ELEVATION OR RESECTION OF FRONTAL LOBE, OSTEOTOMY OF BASE OF ANTERIOR CRANIAL FOSSA 122,850.00 40,950.00 81,900.00 61584 ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, EXTRADURAL, INCLUDING SUPRAORBITAL RIDGE OSTEOTOMY AND ELEVATION OF FRONTAL AND/OR TEMPORAL LOBE(S); W/O ORBITAL EXENTERATION 122,850.00 40,950.00 81,900.00 61585 ORBITOCRANIAL APPROACH TO ANTERIOR CRANIAL FOSSA, EXTRADURAL, INCLUDING SUPRAORBITAL RIDGE OSTEOTOMY AND ELEVATION OF FRONTAL AND/OR TEMPORAL LOBE(S); W/ ORBITAL EXENTERATION 122,850.00 40,950.00 81,900.00 61586 BICORONAL, TRANSZYGOMATIC AND/OR LEFORT I OSTEOTOMY APPROACH TO ANTERIOR CRANIAL FOSSA W/ OR W/O INTERNAL FIXATION, W/O BONE GRAFT 122,850.00 40,950.00 81,900.00 61590 INFRATEMPORAL PRE-AURICULAR APPROACH TO MIDDLE CRANIAL FOSSA (PARAPHARYNGEAL SPACE, INFRATEMPORAL AND MIDLINE SKULL BASE, NASOPHARYNX), W/ OR W/O DISARTICULATION OF THE MANDIBLE, INCLUDING PAROTIDECTOMY, CRANIOTOMY, DECOMPRESSION AND/OR MOBILIZATION OF TH 139,230.00 40,950.00 98,280.00 61591 INFRATEMPORAL POST-AURICULAR APPROACH TO MIDDLE CRANIAL FOSSA (INTERNAL AUDITORY MEATUS, PETROUS APEX, TENTORIUM, CAVERNOUS SINUS, PARASELLAR AREA, INFRATEMPORAL FOSSA) INLCUDING MASTOIDECTOMY, RESECTION OF SIGMOID SINUS, W/ OR W/O DECOMPRESSION AND/OR MO 139,230.00 40,950.00 98,280.00 61592 ORBITOCRANIAL ZYGOMATIC APPROACH TO MIDDLE CRANIAL FOSSA (CAVERNOUS SINUS AND CAROTID ARTERY, CLIVUS, BASILAR ARTERY OR PETROUS APEX) INCLUDING OSTEOTOMY OF ZYGOMA, CRANIOTOMY, EXTRA- OR INTRADURAL ELEVATION OF TEMPORAL LOBE 131,040.00 40,950.00 90,090.00 61595 TRANSTEMPORAL APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN OR MIDLINE SKULL BASE, INCLUDING MASTOIDECTOMY, DECOMPRESSION OF SIGMOID SINUS AND/OR FACIAL NERVE, W/ OR W/O MOBILIZATION 139,230.00 40,950.00 98,280.00 61596 TRANSCOCHLEAR APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN OR MIDLINE SKULL BASE, INCLUDING LABYRINTHECTOMY, DECOMPRESSION, W/ OR W/O MOBILIZATION OF FACIAL NERVE AND/OR PETROUS CAROTID ARTERY 139,230.00 40,950.00 98,280.00 61597 TRANSCONDYLAR (FAR LATERAL) APPROACH TO POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN OR MIDLINE SKULL BASE, INCLUDING OCCIPTAL CONDYLECTOMY, MASTOIDECTOMY, RESECTION OF C1-C3 VERTEBRAL BODY(S), DECOMPRESSION OF VERTEBRAL ARTERY, W/ OR W/O MOBILIZATION 139,230.00 40,950.00 98,280.00 61598 TRANSPETROSAL APPROACH TO POSTERIOR CRANIAL FOSSA, CLIVUS OR FRAMEN MAGNUM, INCLUDING LIGATION OF SUPERIOR PETROSAL SINUS AND/OR SIGMOID SINUS 139,230.00 40,950.00 98,280.00 Page 88 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 61600 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF BASE OF ANTERIOR CRANIAL FOSSA; EXTRADURAL 131,040.00 40,950.00 90,090.00 61601 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF BASE OF ANTERIOR CRANIAL FOSSA; INTRADURAL, INCLUDING DURAL REPAIR,W/ OR W/O GRAFT 131,040.00 40,950.00 90,090.00 61605 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF INFRATEMPORAL FOSSA, PARAPHARYNGEAL SPACE, PETROUS APEX; EXTRADURAL 139,230.00 40,950.00 98,280.00 61606 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF INFRATEMPORAL FOSSA, PARAPHARYNGEAL SPACE, PETROUS APEX; INTRADURAL, INCLUDING DURAL REPAIR, W/ OR W/O GRAFT 139,230.00 40,950.00 98,280.00 61607 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF PARASELLAR AREA, CAVERNOUS SINUS, CLIVUS OR MIDLINE SKULL BASE; EXTRADURAL 139,230.00 40,950.00 98,280.00 61608 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF PARASELLAR AREA, CAVERNOUS SINUS, CLIVUS OR MIDLINE SKULL BASE; INTRADURAL, INCLUDING DURAL REPAIR, W/ OR W/O GRAFT 139,230.00 40,950.00 98,280.00 61609 TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS SINUS; W/O REPAIR 139,230.00 40,950.00 98,280.00 61610 TRANSECTION OR LIGATION, CAROTID ARTERY IN CAVERNOUS SINUS; W/ REPAIR BY ANASTOMOSIS OR GRAFT 139,230.00 40,950.00 98,280.00 61611 TRANSECTION OR LIGATION , CAROTID ARTERY IN PETROUS CANAL; W/O REPAIR 122,850.00 40,950.00 81,900.00 61612 TRANSECTION OR LIGATION , CAROTID ARTERY IN PETROUS CANAL; W/ REPAIR BY ANASTOMOSIS OR GRAFT 139,230.00 40,950.00 98,280.00 61613 OBLITERATION OF CAROTID ANEURYSM, ARTERIOVENOUS MALFORMATION, OR CAROTID-CAVERNOUS FISTULA BY DISSECTION W/IN CAVERNOUS SINUS 139,230.00 40,950.00 98,280.00 61615 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF BASE OF POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN, FORAMEN MAGNUM, OR CI-C3 VERTEBRAL BODIES; EXTRADURAL 139,230.00 40,950.00 98,280.00 61616 RESECTION OR EXCISION OF NEOPLASTIC, VASCULAR OR INFECTIOUS LESION OF BASE OF POSTERIOR CRANIAL FOSSA, JUGULAR FORAMEN, FORAMEN MAGNUM, OR CI-C3 VERTEBRAL BODIES; INTRADURAL, INCLUDING DURAL REPAIR, W/ OR W/O GRAFT 139,230.00 40,950.00 98,280.00 61618 SECONDARY REPAIR OF DURA FOR CSF LEAK, ANTERIOR, MIDDLE OR POSTERIOR CRANIAL FOSSA FOLLOWING SURGERY OF THE SKULL BASE; BY FREE TISSUE GRAFT (E.G., PERICRANIUM, FASCIA, TENSOR FASCIA LATA, ADIPOSE TISSUE, HOMOLOGOUS OR SYNTHETIC GRAFTS) 131,040.00 40,950.00 90,090.00 61619 SECONDARY REPAIR OF DURA FOR CSF LEAK, ANTERIOR, MIDDLE OR POSTERIOR CRANIAL FOSSA FOLLOWING SURGERY OF THE SKULL BASE; BY LOCAL OR REGIONALIZED VASCULARIZED PEDICLE FLAP OR MYOCUTANEOUS FLAP (INCLUDING GALEA,TEMPORALIS, FRONTALIS OR OCCIPITALIS MUSCLE) 122,850.00 40,950.00 81,900.00 61624 TRANSCATHETER OCLUSSION OR EMBOLIZATION (E.G., FOR TUMOR DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD; CENTRAL NERVOUS SYSTEM (INTRACRANIAL, SPINAL CORD) 139,230.00 40,950.00 98,280.00 61626 TRANSCATHETER OCLUSSION OR EMBOLIZATION (E.G., FOR TUMOR DESTRUCTION, TO ACHIEVE HEMOSTASIS, TO OCCLUDE A VASCULAR MALFORMATION), PERCUTANEOUS, ANY METHOD; NON- CENTRAL NERVOUS SYSTEM, HEAD OR NECK (EXTRACRANIAL, BRACHIOCEPHALIC BRANCH) 107,250.00 41,730.00 65,520.00 61680 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; SUPRATENTORIAL, SIMPLE 122,850.00 40,950.00 81,900.00 61682 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; SUPRATENTORIAL, COMPLEX 139,230.00 40,950.00 98,280.00 61684 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; INFRATENTORIAL, SIMPLE 122,850.00 40,950.00 81,900.00 61686 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; INFRATENTORIAL, COMPLEX 139,230.00 40,950.00 98,280.00 61690 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, SIMPLE 107,250.00 41,730.00 65,520.00 61692 SURGERY OF INTRACRANIAL ARTERIOVENOUS MALFORMATION; DURAL, COMPLEX 122,850.00 40,950.00 81,900.00 61700 SURGERY OF INTRACRANIAL ANEURYSM, INTRACRANIAL APPROACH; CAROTID CIRCULATION 139,230.00 40,950.00 98,280.00 61702 SURGERY OF INTRACRANIAL ANEURYSM, INTRACRANIAL APPROACH; VERTEBRAL-BASILAR CIRCULATION 147,420.00 40,950.00 106,470.00 61703 SURGERY OF INTRACRANIAL ANEURYSM, CERVICAL APPROACH BY APPLICATION OF OCCLUDING CLAMP TO CERVICAL CAROTID ARTERY (SELVERSTONE-CRUTCHFIELD TYPE) 45,435.00 20,865.00 24,570.00 61705 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- CAVERNOUS FISTULA; BY INTRACRANIAL AND CERVICAL OCCLUSION OF CAROTID ARTERY 139,230.00 40,950.00 98,280.00 61708 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- CAVERNOUS FISTULA; BY INTRACRANIAL ELECTROTHROMBOSIS 73,710.00 32,760.00 40,950.00 Page 89 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 61710 SURGERY OF ANEURYSM, VASCULAR MALFORMATION OR CAROTID- CAVERNOUS FISTULA; BY INTRA-ARTERIAL EMBOLIZATION, INJECTION PROCEDURE OR BALLOON CATHETER 122,850.00 40,950.00 81,900.00 61711 ANASTOMOSIS, ARTERIAL, EXTRACRANIAL-INTRACRANIAL (E.G., MIDDLE CEREBRAL/CORTICAL) ARTERIES 131,040.00 40,950.00 90,090.00 61712 MICRODISSECTION, INTRACRANIAL OR SPINAL PROCEDURE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 131,040.00 40,950.00 90,090.00 61720 CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR HOLE(S) AND LOCALIZING AND RECORDING TECHNIQUES, SINGLE OR MULTIPLE STAGES; GLOBUS PALLIDUS OR THALAMUS 131,040.00 40,950.00 90,090.00 61735 CREATION OF LESION BY STEREOTACTIC METHOD, INCLUDING BURR HOLE(S) AND LOCALIZING AND RECORDING TECHNIQUES, SINGLE OR MULTIPLE STAGES; SUBCORTICAL STRUCTURE(S) OTHER THAN GLOBUS PALLIDUS OR THALAMUS 122,850.00 40,950.00 81,900.00 61750 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION,INCLUDING BURR HOLE(S), FOR INTRACRANIAL LESION; 122,850.00 40,950.00 81,900.00 61751 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION,INCLUDING BURR HOLE(S), FOR INTRACRANIAL LESION; W/ COMPUTERIZED AXIAL TOMOGRAPHY 122,850.00 40,950.00 81,900.00 61760 STEREOTACTIC IMPLANTATION OF DEPTH ELECTRODES INTO THE CEREBRUM FOR LONG TERM SEIZURE MONITORING 122,850.00 40,950.00 81,900.00 61770 STEREOTACTIC LOCALIZATION , ANY METHOD, INCLUDING BURR HOLE(S), W/ INSERTION OF CATHETER(S) FOR BRACHYTHERAPY 59,085.00 26,325.00 32,760.00 61790 CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (E.G., ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); GASSERIAN GANGLION 73,710.00 32,760.00 40,950.00 61791 CREATION OF LESION BY STEREOTACTIC METHOD, PERCUTANEOUS, BY NEUROLYTIC AGENT (E.G., ALCOHOL, THERMAL, ELECTRICAL, RADIOFREQUENCY); TRIGEMINAL MEDULLARY TRACT 73,710.00 32,760.00 40,950.00 61793 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM,GAMMA RAY OR LINEAR ACCELERATOR) 122,850.00 40,950.00 81,900.00 61795 STEREOTACTIC COMPUTER ASSISTED VOLUMETRIC INTRACRANIAL PROCEDURE 122,850.00 40,950.00 81,900.00 61850 TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; CORTICAL 104,130.00 46,800.00 57,330.00 61855 TWIST DRILL OR BURR HOLE(S) FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; SUBCORTICAL 131,040.00 40,950.00 90,090.00 61860 CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, CEREBRAL; CORTICAL 114,660.00 40,950.00 73,710.00 61865 CRANIECTOMY OR CRANIOTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, CEREBRAL; SUBCORTICAL 90,675.00 41,535.00 49,140.00 61870 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, CEREBELLAR; CORTICAL 114,660.00 40,950.00 73,710.00 61875 CRANIECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES, CEREBELLAR; SUBCORTICAL 131,040.00 40,950.00 90,090.00 61885 INCISION AND SUBCUTANEOUS PLACEMENT OF CRANIAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING 73,710.00 32,760.00 40,950.00 62000 ELEVATION OF DEPRESSED SKULL FRACTURE; SIMPLE, EXTRADURAL 59,085.00 26,325.00 32,760.00 62005 ELEVATION OF DEPRESSED SKULL FRACTURE; COMPOUND OR COMMINUTED, EXTRADURAL 73,710.00 32,760.00 40,950.00 62010 ELEVATION OF DEPRESSED SKULL FRACTURE; W/ REPAIR OF DURA AND /OR DEBRIDEMENT OF BRAIN 90,675.00 41,535.00 49,140.00 62100 CRANIOTOMY FOR REPAIR OF DURAL /CSF LEAK, INCLUDING SURGERY FOR RHINORRHEA/OTORRHEA 139,230.00 40,950.00 98,280.00 62115 REDUCTION OF CRANIOMEGALIC SKULL (E.G., TREATED HYDROCEPHALUS); NOT REQUIRING BONE GRAFTS OR CRANIOPLASTY 73,710.00 32,760.00 40,950.00 62116 REDUCTION OF CRANIOMEGALIC SKULL (E.G., TREATED HYDROCEPHALUS); W/ SIMPLE CRANIOPLASTY 90,675.00 41,535.00 49,140.00 62117 REDUCTION OF CRANIOMEGALIC SKULL (E.G., TREATED HYDROCEPHALUS); REQUIRING CRANIOTOMY AND RECONSTRUCTION W/ OR W/O BONE GRAFT (INCLUDES OBTAINING GRAFTS) 104,130.00 46,800.00 57,330.00 62120 REPAIR OF ENCEPHALOCELE, SKULL VAULT, INCLUDING CRANIOPLASTY 114,660.00 40,950.00 73,710.00 62121 CRANIOTOMY FOR REPAIR OF ENCEPHALOCELE , SKULL BASE 107,250.00 41,730.00 65,520.00 62140 CRANIOPLASTY FOR SKULL DEFECT; UP TO 5 CM DIAMETER 59,085.00 26,325.00 32,760.00 62141 CRANIOPLASTY FOR SKULL DEFECT; LARGER THAN 5 CM DIAMETER 59,085.00 26,325.00 32,760.00 62142 REMOVAL OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 59,085.00 26,325.00 32,760.00 62143 REPLACEMENT OF BONE FLAP OR PROSTHETIC PLATE OF SKULL 59,085.00 26,325.00 32,760.00 62145 CRANIOPLASTY FOR SKULL DEFECT W/ REPARATIVE BRAIN SURGERY 104,130.00 46,800.00 57,330.00 Page 90 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 62146 CRANIOPLASTY W/ AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); UP TO 5 CM DIAMETER 104,130.00 46,800.00 57,330.00 62147 CRANIOPLASTY W/ AUTOGRAFT (INCLUDES OBTAINING BONE GRAFTS); LARGER THAN 5 CM DIAMETER 107,250.00 41,730.00 65,520.00 62160 NEUROENDOSCOPY, INTRACRANIAL, FOR PLACEMENT OR REPLACEMENT OF VENTRICULAR CATHETER AND ATTACHMENT TO SHUNT SYSTEM OR EXTERNAL DRAINAGE 73,710.00 32,760.00 40,950.00 62161 NEUROENDOSCOPY, INTRACRANIAL; WITH DISSECTION OF ADHESIONS, FENESTRATION OF SEPTUM PELLUCIDUM OR INTRAVENTRICULAR CYST (INCLUDING PLACEMENT, REPLACEMENT OR REMOVAL OF VENTRICULAR CATHETER) 90,675.00 41,535.00 49,140.00 62162 NEUROENDOSCOPY, INTRACRANIAL; WITH FENESTRATION OR EXCISION OF COLLOID CYST, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE 90,675.00 41,535.00 49,140.00 62163 NEUROENDOSCOPY, INTRACRANIAL; WITH RETRIEVAL OF FOREIGN BODY 90,675.00 41,535.00 49,140.00 62165 NEUROENDOSCOPY, INTRACRANIAL; WITH EXCISION OF PITUITARY TUMOR, TRANSNASAL OR TRANSPHENOIDAL APPROACH 90,675.00 41,535.00 49,140.00 62180 VENTRICULOCISTERNOSTOMY (TORKILDSEN TYPE OPERATION) 73,710.00 32,760.00 40,950.00 62190 CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-ATRIAL, - JUGULAR, -AURICULAR 45,435.00 20,865.00 24,570.00 62192 CREATION OF SHUNT; SUBARACHNOID/SUBDURAL-PERITONIAL, - PLEURAL, OTHER TERMINUS 45,435.00 20,865.00 24,570.00 62200 VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; 73,710.00 32,760.00 40,950.00 62201 VENTRICULOCISTERNOSTOMY, THIRD VENTRICLE; STEREOTACTIC METHOD 90,675.00 41,535.00 49,140.00 62220 CREATION OF SHUNT; VENTRICULO-ATRIAL, -JUGULAR,- AURICULAR 59,085.00 26,325.00 32,760.00 62223 CREATION OF SHUNT; VENTRICULO-PERITONIAL,-PLEURAL, OTHER TERMINUS 59,085.00 26,325.00 32,760.00 62230 REPLACEMENT OR REVISION OF CSF (VP) SHUNT, OBSTRUCTED VALVE, OR DISTAL CATHETER IN SHUNT SYSTEM 45,435.00 20,865.00 24,570.00 62268 PERCUTANEOUS ASPIRATION, SPINAL CORD CYST OR SYRINX 25,155.00 12,870.00 12,285.00 62269 BIOPSY OF SPINAL CORD, PERCUTANEOUS NEEDLE 25,155.00 12,870.00 12,285.00 62270 SPINAL PUNCTURE, LUMBAR, DIAGNOSTIC 11,076.00 7,800.00 3,276.00 62272 SPINAL PUNCTURE , THERAPEUTIC, FOR DRAINAGE OF SPINAL FLUID (BY NEEDLE OR CATHETER) 10,842.00 8,385.00 2,457.00 62287 ASPIRATION PROCEDURE, PERCUTANEOUS, OF NUCLEUS PULPOSUS OF INTERVERTEBRAL DISK, ANY METHOD, SINGLE OR MULTIPLE LEVELS, LUMBAR 45,435.00 20,865.00 24,570.00 62350 IMPLANTATION, REVISION OR REPOSITIONING OF INTRATHECAL OR EPIDURAL CATHETER, FOR IMPLANTABLE RESERVOIR OR IMPLANTABLE INFUSION PUMP; W/O LAMINECTOMY 35,100.00 18,720.00 16,380.00 62351 IMPLANTATION, REVISION OR REPOSITIONING OF INTRATHECAL OR EPIDURAL CATHETER, FOR IMPLANTABLE RESERVOIR OR IMPLANTABLE INFUSION PUMP; W/ LAMINECTOMY 73,710.00 32,760.00 40,950.00 62360 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; SUBCUTANEOUS RESERVOIR 18,915.00 10,725.00 8,190.00 62361 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; NON-PROGRAMMABLE PUMP 35,100.00 18,720.00 16,380.00 62362 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; PROGRAMMABLE PUMP, INCLUDING PREPARATION OF PUMP, W/ OR W/O PROGRAMMING 45,435.00 20,865.00 24,570.00 62464 IMPLANTATION OR REPLACEMENT OF DEVICE FOR INTRATHECAL OR EPIDURAL DRUG INFUSION; WITH EXCISION OF BRAIN TUMOR, INCLUDING PLACEMENT OF EXTERNAL VENTRICULAR CATHETER FOR DRAINAGE 90,675.00 41,535.00 49,140.00 63001 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS), ONE OR TWO VERTEBRAL SEGMENTS; CERVICAL 107,250.00 41,730.00 65,520.00 63003 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS), ONE OR TWO VERTEBRAL SEGMENTS; THORACIC 104,130.00 46,800.00 57,330.00 63005 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS), ONE OR TWO VERTEBRAL SEGMENTS; LUMBAR,EXCEPT FOR SPONDYLOLISTHESIS 73,710.00 32,760.00 40,950.00 63011 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS), ONE OR TWO VERTEBRAL SEGMENTS; SACRAL 73,710.00 32,760.00 40,950.00 Page 91 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 63012 LAMINECTOMY W/ REMOVAL OF ABNORMAL FACETS AND/OR PARS INTER-ARTICULARIS W/ DECOMPRESSION OF CAUDA EQUINA AND NERVE ROOTS FOR SPONDYLOLISTHESIS, LUMBAR (GILL TYPE PROCEDURE) 104,130.00 46,800.00 57,330.00 63015 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS) , MORE THAN 2 VERTEBRAL SEGMENTS; CERVICAL 107,250.00 41,730.00 65,520.00 63016 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS) , MORE THAN 2 VERTEBRAL SEGMENTS; THORACIC 104,130.00 46,800.00 57,330.00 63017 LAMINECTOMY W/ EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, W/O FACETECTOMY, FORAMINOTOMY OR DISKECTOMY, (E.G., SPINAL STENOSIS) , MORE THAN 2 VERTEBRAL SEGMENTS; LUMBAR 90,675.00 41,535.00 49,140.00 63020 LAMINOTOMY (HEMILAMINECTOMY), W/ DECOMPRESSION OF NERVE ROOT (S), INCLUDING PARTIAL FACETECTOMY , FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISK; ONE INTERSPACE, CERVICAL 107,250.00 41,730.00 65,520.00 63030 LAMINOTOMY (HEMILAMINECTOMY), W/ DECOMPRESSION OF NERVE ROOT (S), INCLUDING PARTIAL FACETECTOMY , FORAMINOTOMY AND/OR EXCISION OF HERNIATED INTERVERTEBRAL DISK; ONE INTERSPACE,LUMBAR 90,675.00 41,535.00 49,140.00 63040 LAMINOTOMY (HEMILAMINECTOMY), W/ DECOMPRESSION OF NERVE ROOT (S), INCLUDING PARTIAL FACETECTOMY , FORAMINOTOMY AND/OR EXCISION OR HERNIATED INTERVERTEBRAL DISK; RE-EXPLORATION; CERVICAL 104,130.00 46,800.00 57,330.00 63042 LAMINOTOMY (HEMILAMINECTOMY), W/ DECOMPRESSION OF NERVE ROOT (S), INCLUDING PARTIAL FACETECTOMY , FORAMINOTOMY AND/OR EXCISION OR HERNIATED INTERVERTEBRAL DISK; RE-EXPLORATION; LUMBAR 90,675.00 41,535.00 49,140.00 63045 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL W/ DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), ( EG, SPINAL OR LATERAL RECESS STENOSIS), SINGLE VERTEBRAL SEGMENT; CERVICAL 107,250.00 41,730.00 65,520.00 63046 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL W/ DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), ( EG, SPINAL OR LATERAL RECESS STENOSIS), SINGLE VERTEBRAL SEGMENT; THORACIC 104,130.00 46,800.00 57,330.00 63047 LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL W/ DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), ( EG, SPINAL OR LATERAL RECESS STENOSIS), SINGLE VERTEBRAL SEGMENT; LUMBAR 90,675.00 41,535.00 49,140.00 63055 TRANSPEDICULAR APPROACH W/ DECOMPRESSION OF SPINAL CORD, EQUINA AND/ OR NERVE ROOT(S) (E.G., HERNIATED INTERVETEBRAL DISK), SINGLE SEGMENT; THORACIC 104,130.00 46,800.00 57,330.00 63056 TRANSPEDICULAR APPROACH W/ DECOMPRESSION OF SPINAL CORD, EQUINA AND/ OR NERVE ROOT(S) (E.G., HERNIATED INTERVETEBRAL DISK), SINGLE SEGMENT; LUMBAR 90,675.00 41,535.00 49,140.00 63064 COSTOVERTEBRAL APPROACH W/ DECOMPRESSION OF SPINAL CORD OR NERVE ROOT(S), (E.G., HERNIATED INTERVERTEBRAL DISK), THORACIC; SINGLE SEGMENT 104,130.00 46,800.00 57,330.00 63075 DISKECTOMY, ANTERIOR, W/ DECOMPRESSION OF SPINAL CORD AND/ OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; CERVICAL, SINGLE INTERSPACE 107,250.00 41,730.00 65,520.00 63077 DISKECTOMY, ANTERIOR, W/ DECOMPRESSION OF SPINAL CORD AND/ OR NERVE ROOT(S), INCLUDING OSTEOPHYTECTOMY; THORACIC, SINGLE INTERSPACE 73,710.00 32,760.00 40,950.00 63081 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, ANTERIOR APPROACH W/ DECOMPRESSION OF SPINAL CORD AND/ OR NERVE ROOT(S); CERVICAL, SINGLE SEGMENT 107,250.00 41,730.00 65,520.00 63085 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSTHORACIC APPROACH W/ DECOMPRESSION OF SPINAL CORD AND/ OR NERVE ROOT(S); THORACIC, SINGLE SEGMENT 104,130.00 46,800.00 57,330.00 63087 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, COMBINED THORACOLUMBAR APPROACH W/ DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC OR LUMBAR; SINGLE SEGMENT 90,675.00 41,535.00 49,140.00 63090 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, TRANSPERITONEAL OR RETROPERITONEAL APPROACH W/ DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA OR NERVE ROOT(S), LOWER THORACIC, LUMBAR, OR SACRAL; SINGLE SEGMENT 104,130.00 46,800.00 57,330.00 63170 LAMINECTOMY W/ MYELOTOMY (E.G., BISCHOF OR DREZ TYPE), CERVICAL THORACIC, OR THORACOLUMBAR 114,660.00 40,950.00 73,710.00 63172 LAMINECTOMY W/ DRAINAGE OF INTRAMEDULLARY CYST/ SYRINX; TO SUBARACHNOID SPACE 104,130.00 46,800.00 57,330.00 Page 92 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 63173 LAMINECTOMY W/ DRAINAGE OF INTRAMEDULLARY CYST/ SYRINX; TO PERITONEAL SPACE 107,250.00 41,730.00 65,520.00 63180 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, W/ OR W/O DURAL GRAFT, CERVICAL; ONE OF TWO SEGMENTS 107,250.00 41,730.00 65,520.00 63182 LAMINECTOMY AND SECTION OF DENTATE LIGAMENTS, W/ OR W/O DURAL GRAFT, CERVICAL; MORE THAN TWO SEGMENTS 107,250.00 41,730.00 65,520.00 63185 LAMINECTOMY W/ RHIZOTOMY; ONE OR TWO SEGMENTS 104,130.00 46,800.00 57,330.00 63190 LAMINECTOMY W/ RHIZOTOMY; MORE THAN TWO SEGMENTS 104,130.00 46,800.00 57,330.00 63191 LAMINECTOMY W/ SECTION OF SPINAL ACCESSORY NERVE 112,164.00 41,730.00 70,434.00 63194 LAMINECTOMY W/ CORDOTOMY, W/ SECTION OF ONE SPINOTHALAMIC TRACT, ONE STAGE; CERVICAL 107,250.00 41,730.00 65,520.00 63195 LAMINECTOMY W/ CORDOTOMY, W/ SECTION OF ONE SPINOTHALAMIC TRACT, ONE STAGE; THORACIC 104,130.00 46,800.00 57,330.00 63196 LAMINECTOMY W/ CORDOTOMY W/ SECTION OF BOTH SPINOTHALAMIC TRACTS, ONE STAGE; CERVICAL 107,250.00 41,730.00 65,520.00 63197 LAMINECTOMY W/ CORDOTOMY W/ SECTION OF BOTH SPINOTHALAMIC TRACTS, ONE STAGE; THORACIC 104,130.00 46,800.00 57,330.00 63198 LAMINECTOMY W/ CORDOTOMY W/ SECTION OF BOTH SPINOTHALAMIC TRACTS, TWO STAGES W/IN 14 DAYS; CERVICAL 107,250.00 41,730.00 65,520.00 63199 LAMINECTOMY W/ CORDOTOMY W/ SECTION OF BOTH SPINOTHALAMIC TRACTS, TWO STAGES W/IN 14 DAYS; THORACIC 104,130.00 46,800.00 57,330.00 63200 LAMINECTOMY, W/ RELEASE OF TETHERED SPINAL CORD, LUMBAR 95,589.00 41,535.00 54,054.00 63250 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; CERVICAL 107,250.00 41,730.00 65,520.00 63251 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACIC 104,130.00 46,800.00 57,330.00 63252 LAMINECTOMY FOR EXCISION OR OCCLUSION OF ARTERIOVENOUS MALFORMATION OF SPINAL CORD; THORACOLUMBAR 90,675.00 41,535.00 49,140.00 63265 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM; EXTRADURAL; CERVICAL 107,250.00 41,730.00 65,520.00 63266 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM; EXTRADURAL; THORACIC 104,130.00 46,800.00 57,330.00 63267 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM; EXTRADURAL; LUMBAR 90,675.00 41,535.00 49,140.00 63268 LAMINECTOMY FOR EXCISION OR EVACUATION OF INTRASPINAL LESION OTHER THAN NEOPLASM; EXTRADURAL; SACRAL 73,710.00 32,760.00 40,950.00 63270 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM; INTRADURAL; CERVICAL 107,250.00 41,730.00 65,520.00 63271 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM; INTRADURAL; THORACIC 104,130.00 46,800.00 57,330.00 63272 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM; INTRADURAL; LUMBAR 90,675.00 41,535.00 49,140.00 63273 LAMINECTOMY FOR EXCISION OF INTRASPINAL LESION OTHER THAN NEOPLASM; INTRADURAL; SACRAL 73,710.00 32,760.00 40,950.00 63275 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, CERVICAL 107,250.00 41,730.00 65,520.00 63276 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, EXTRADURAL, THORACIC 104,130.00 46,800.00 57,330.00 63277 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, EXTRADURAL, LUMBAR 90,675.00 41,535.00 49,140.00 63278 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, EXTRADURAL, SACRAL 73,710.00 32,760.00 40,950.00 63280 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, EXTRAMEDULLARY, CERVICAL 114,660.00 40,950.00 73,710.00 63281 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, EXTRAMEDULLARRY, THORACIC 107,250.00 41,730.00 65,520.00 63282 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, EXTRAMEDULLARY, LUMBAR 104,130.00 46,800.00 57,330.00 63283 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, SACRAL 90,675.00 41,535.00 49,140.00 63285 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, INTRAMEDULLARY, CERVICAL 114,660.00 40,950.00 73,710.00 63286 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, INTRAMEDULLARY, THORACIC 107,250.00 41,730.00 65,520.00 63287 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, INTRADURAL, INTRAMEDULLARY, THORACOLUMBAR 104,130.00 46,800.00 57,330.00 63290 LAMINECTOMY FOR BIOPSY/ EXCISION OF INTRASPINAL NEOPLASM; EXTRADURAL, COMBINED EXTRADURAL-INTRADURAL LESION, ANY LEVEL 90,675.00 41,535.00 49,140.00 Page 93 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 63300 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, CERVICAL 107,250.00 41,730.00 65,520.00 63301 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY TRANSTHORACIC APPROACH 104,130.00 46,800.00 57,330.00 63302 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, THORACIC BY THORACOLUMBAR APPROACH 104,130.00 46,800.00 57,330.00 63303 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; EXTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH 104,130.00 46,800.00 57,330.00 63304 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, CERVICAL 107,250.00 41,730.00 65,520.00 63305 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY TRANSTHORACIC APPROACH 104,130.00 46,800.00 57,330.00 63306 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, THORACIC BY THORACOLUMBAR APPROACH 104,130.00 46,800.00 57,330.00 63307 VERTEBRAL CORPECTOMY (VERTEBRAL BODY RESECTION), PARTIAL OR COMPLETE, FOR EXCISION OF INTRASPINAL LESION, SINGLE SEGMENT; INTRADURAL, LUMBAR OR SACRAL BY TRANSPERITONEAL OR RETROPERITONEAL APPROACH 104,130.00 46,800.00 57,330.00 63600 CREATION OF LESION OF SPINAL CORD BY STEREOTACTIC METHOD, PERCUTANEOUS, ANY MODALITY (INCLUDING STIMULATION AND/ OR RECORDING) 59,085.00 26,325.00 32,760.00 63610 STEREOTACTIC STIMULATION OF SPINAL CORD, PERCUTANEOUS, SEPARATE PROCEDURE NOT FOLLOWED BY OTHER SURGERY 59,085.00 26,325.00 32,760.00 63615 STEREOTACTIC BIOPSY, ASPIRATION, OR EXCISION OF LESION, SPINAL CORD 73,320.00 36,465.00 36,855.00 63650 PERCUTANEOUS IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; EPIDURAL 15,639.00 10,725.00 4,914.00 63655 LAMINECTOMY FOR IMPLANTATION OF NEUROSTIMULATOR ELECTRODES; EPIDURAL 90,675.00 41,535.00 49,140.00 63685 INCISION AND SUBSCUTANEOUS PLACEMENT OF SPINAL NEUROSTIMULATOR PULSE GENERATOR OR RECEIVER, DIRECT OR INDUCTIVE COUPLING 42,549.00 21,255.00 21,294.00 63700 REPAIR OF MENINGOCELE; LESS THAN 5 CM DIAMETER 59,085.00 26,325.00 32,760.00 63702 REPAIR OF MENINGOCELE; LARGER THAN 5 DIAMETER 72,501.00 36,465.00 36,036.00 63704 REPAIR OF MYELOMENINGOCELE; LESS THAN 5 CM DIAMETER 73,710.00 32,760.00 40,950.00 63706 REPAIR OF MYELOMENINGOCELE; LARGER THAN 5 DIAMETER 90,675.00 41,535.00 49,140.00 63707 REPAIR OF DURAL/ CSF LEAK, NOT REQUIRING LAMINECTOMY 59,085.00 26,325.00 32,760.00 63709 REPAIR OF DURAL/ CSF LEAK OR PSEUDOMENINGOCELE, W/ LAMINECTOMY 90,675.00 41,535.00 49,140.00 63710 DURAL GRAFT, SPINAL 90,675.00 41,535.00 49,140.00 63740 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, - PLEURAL, OR OTHER; INCLUDING LAMINECTOMY 59,085.00 26,325.00 32,760.00 63741 CREATION OF SHUNT, LUMBAR, SUBARACHNOID-PERITONEAL, - PLEURAL, OR OTHER; PERCUTANEOUS, NOT REQUIRING LAMINECTOMY 45,435.00 20,865.00 24,570.00 64702 NEUROPLASTY; DIGITAL, ONE OR BOTH, SAME DIGIT 23,634.00 10,530.00 13,104.00 64704 NEUROPLASTY; NERVE OF HAND OR FOOT 23,634.00 10,530.00 13,104.00 64708 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; OTHER THAN SPECIFIED 35,100.00 18,720.00 16,380.00 64712 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; SCIATIC NERVE 40,911.00 21,255.00 19,656.00 64713 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; BRACHIAL PLEXUS 40,911.00 21,255.00 19,656.00 64714 NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG; LUMBAR PLEXUS 40,911.00 21,255.00 19,656.00 64716 NEUROPLASTY AND/OR TRANSPOSITION; CRANIAL NERVE (SPECIFY) 73,710.00 32,760.00 40,950.00 64718 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT ELBOW 35,100.00 18,720.00 16,380.00 64719 NEUROPLASTY AND/OR TRANSPOSITION; ULNAR NERVE AT WRIST 35,100.00 18,720.00 16,380.00 64721 NEUROPLASTY AND/OR TRANSPOSITION; MEDIAN NERVE AT CARPAL TUNNEL 35,100.00 18,720.00 16,380.00 64722 DECOMPRESSION; UNSPECIFIED NERVE(S) (SPECIFY) 35,100.00 18,720.00 16,380.00 64726 DECOMPRESSION; PLANTAR DIGITAL NERVE 35,100.00 18,720.00 16,380.00 64727 INTERNAL NEUROLYSIS, REQUIRING USE OF OPERATING MICROSCOPE (LIST SEPARATELY IN ADDITION TO CODE FOR NEUROPLASTY) (NEUROPLASTY INLCUDES EXTERNAL NEUROLYSIS) 59,085.00 26,325.00 32,760.00 64732 TRANSECTION OR AVULSION OF; SUPRAORBITAL NERVE 18,915.00 10,725.00 8,190.00 Page 94 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 64734 TRANSECTION OR AVULSION OF; INFRAORBITAL NERVE 18,915.00 10,725.00 8,190.00 64736 TRANSECTION OR AVULSION OF; MENTAL NERVE 18,915.00 10,725.00 8,190.00 64738 TRANSECTION OR AVULSION OF; INFERIOR ALVEOLAR NERVE BY OSTEOTOMY 18,915.00 10,725.00 8,190.00 64740 TRANSECTION OR AVULSION OF; LINGUAL NERVE 18,915.00 10,725.00 8,190.00 64742 TRANSECTION OR AVULSION OF; FACIAL NERVE, DIFFERENTIAL OR COMPLETE 23,634.00 10,530.00 13,104.00 64744 TRANSECTION OR AVULSION OF; GREATER OCCIPITAL NERVE 18,915.00 10,725.00 8,190.00 64746 TRANSECTION OR AVULSION OF; PHRENIC NERVE 23,634.00 10,530.00 13,104.00 64752 TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), TRANSTHORACIC 42,783.00 24,765.00 18,018.00 64755 TRANSECTION OR AVULSION OF; VAGI LIMITED TO PROXIMAL STOMACH (SELECTIVE PROXIMAL VAGOTOMY, PROXIMAL GASTRIC VAGOTOMY, PARIETAL CELL VAGOTOMY, SUPRA- OR HIGHLY SELECTIVE VAGOTOMY) 42,783.00 24,765.00 18,018.00 64760 TRANSECTION OR AVULSION OF; VAGUS NERVE (VAGOTOMY), ABDOMINAL 35,100.00 18,720.00 16,380.00 64761 TRANSECTION OR AVULSION OF; PUDENDAL NERVE 18,915.00 10,725.00 8,190.00 64763 TRANSECTION OR AVULSION OF OBTURATOR NERVE, EXTRAPELVIC, W/ OR W/O ADDUCTOR TENOTOMY 35,100.00 18,720.00 16,380.00 64766 TRANSECTION OR AVULSION OF OBTURATOR NERVE, INTRAPELVIC, W/ OR W/O ADDUCTOR TENOTOMY 35,100.00 18,720.00 16,380.00 64771 TRANSECTION OR AVULSION OF OTHER CRANIAL NERVE, INTRADURAL 73,710.00 32,760.00 40,950.00 64772 TRANSECTION OR AVULSION OF OTHER SPINAL NERVE, EXTRADURAL 59,085.00 26,325.00 32,760.00 64774 EXCISION OF NEUROMA; CUTANEOUS NERVE, SURGICALLY IDENTIFIABLE 15,639.00 10,725.00 4,914.00 64776 EXCISION OF NEUROMA; DIGITAL NERVE, ONE OR BOTH, SAME DIGIT 15,639.00 10,725.00 4,914.00 64782 EXCISION OF NEUROMA; HAND OR FOOT, EXCEPT DIGITAL NERVE 15,639.00 10,725.00 4,914.00 64784 EXCISION OF NEUROMA; MAJOR PERIPHERAL NERVE, EXCEPT SCIATIC 15,639.00 10,725.00 4,914.00 64786 EXCISION OF NEUROMA; SCIATIC NERVE 18,915.00 10,725.00 8,190.00 64788 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; CUTANEOUS NERVE 15,639.00 10,725.00 4,914.00 64790 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; MAJOR PERIPHERAL NERVE 15,639.00 10,725.00 4,914.00 64792 EXCISION OF NEUROFIBROMA OR NEUROLEMMOMA; EXTENSIVE (INCLUDING MALIGNANT TYPE) 18,915.00 10,725.00 8,190.00 64795 BIOPSY OF NERVE 15,639.00 10,725.00 4,914.00 64802 SYMPATHECTOMY, CERVICAL 35,100.00 18,720.00 16,380.00 64804 SYMPATHECTOMY, CERVICOTHORACIC 35,100.00 18,720.00 16,380.00 64809 SYMPATHECTOMY, THORACOLUMBAR 35,100.00 18,720.00 16,380.00 64818 SYMPATHECTOMY, LUMBAR 35,100.00 18,720.00 16,380.00 64820 SYMPATHECTOMY, DIGITAL ARTERIES, W/ MAGNIFICATION, EACH DIGIT 23,634.00 10,530.00 13,104.00 64830 MICRODISSECTION AND/OR MICROREPAIR OF NERVE (LIST SEPARATELY IN ADDITION TO CODE FOR NERVE REPAIR) 40,911.00 21,255.00 19,656.00 64831 SUTURE OF DIGITAL NERVE, HAND OR FOOT; ONE NERVE 35,100.00 18,720.00 16,380.00 64832 SUTURE OF DIGITAL NERVE, HAND OR FOOT; EACH ADDITIONAL DIGITAL NERVE 15,639.00 10,725.00 4,914.00 64834 SUTURE OF ONE NERVE, HAND OR FOOT; COMMON SENSORY NERVE 35,100.00 18,720.00 16,380.00 64835 SUTURE OF ONE NERVE, HAND OR FOOT; MEDIAN MOTOR THENAR 35,100.00 18,720.00 16,380.00 64836 SUTURE OF ONE NERVE, HAND OR FOOT; ULNAR MOTOR 35,100.00 18,720.00 16,380.00 64837 SUTURE OF EACH ADDITIONAL NERVE, HAND OR FOOT 15,639.00 10,725.00 4,914.00 64840 SUTURE OF POSTERIOR TIBIAL NERVE 35,100.00 18,720.00 16,380.00 64856 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; INCLUDING TRANSPOSITION 40,911.00 21,255.00 19,656.00 64857 SUTURE OF MAJOR PERIPHERAL NERVE, ARM OR LEG, EXCEPT SCIATIC; W/O TRANSPOSITION 35,100.00 18,720.00 16,380.00 64858 SUTURE OF SCIATIC NERVE 35,100.00 18,720.00 16,380.00 64859 SUTURE OF EACH ADDITIONAL MAJOR PERIPHERAL NERVE 15,639.00 10,725.00 4,914.00 64861 SUTURE OF; BRACHIAL PLEXUS 40,911.00 21,255.00 19,656.00 64862 SUTURE OF; LUMBAR PLEXUS 40,911.00 21,255.00 19,656.00 64864 SUTURE OF FACIAL NERVE; EXTRACRANIAL 40,911.00 21,255.00 19,656.00 64865 SUTURE OF FACIAL NERVE; INFRATEMPORAL, W/ OR W/O GRAFTING 40,911.00 21,255.00 19,656.00 64866 ANASTOMOSIS; FACIAL-SPINAL ACCESSORY 45,435.00 20,865.00 24,570.00 64868 ANASTOMOSIS; FACIAL-HYPOGLOSSAL 45,435.00 20,865.00 24,570.00 64870 ANASTOMOSIS; FACIAL-PHRENIC 45,435.00 20,865.00 24,570.00 64885 NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; UP TO 4CM IN LENGTH 45,435.00 20,865.00 24,570.00 64886 NERVE GRAFT (INCLUDES OBTAINING GRAFT), HEAD OR NECK; MORE THAN 4 CM LENGTH 61,581.00 33,735.00 27,846.00 64890 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR FOOT; UP TO 4 CM LENGTH 59,085.00 26,325.00 32,760.00 64891 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, HAND OR FOOT; MORE THAN 4 CM LENGTH 59,085.00 26,325.00 32,760.00 64892 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR LEG; UP TO 4 CM LENGTH 45,435.00 20,865.00 24,570.00 64893 NERVE GRAFT (INCLUDES OBTAINING GRAFT), SINGLE STRAND, ARM OR LEG; MORE THAN 4 CM LENGTH 61,581.00 33,735.00 27,846.00 64895 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), HAND OR FOOT; UP TO 4 CM LENGTH 52,884.00 23,400.00 29,484.00 Page 95 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 64896 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), HAND OR FOOT; MORE THAN 4 CM LENGTH 59,085.00 26,325.00 32,760.00 64897 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), ARM OR LEG; UP TO 4 CM LENGTH 45,435.00 20,865.00 24,570.00 64898 NERVE GRAFT (INCLUDES OBTAINING GRAFT), MULTIPLE STRANDS (CABLE), ARM OR LEG; MORE THAN 4 CM LENGTH 61,581.00 33,735.00 27,846.00 64901 NERVE GRAFT, EACH ADDITIONAL NERVE; SINGLE STRAND 15,639.00 10,725.00 4,914.00 64902 NERVE GRAFT, EACH ADDITIONAL NERVE; MULTIPLE STRANDS (CABLE) 15,639.00 10,725.00 4,914.00 64905 NERVE PEDICLE TRANSFER; FIRST STAGE 40,911.00 21,255.00 19,656.00 64907 NERVE PEDICLE TRANSFER; SECOND STAGE 40,911.00 21,255.00 19,656.00 65091 EVISCERATION OF OCULAR CONTENTS; W/O IMPLANT 23,634.00 10,530.00 13,104.00 65093 EVISCERATION OF OCULAR CONTENTS; W/ IMPLANT 23,634.00 10,530.00 13,104.00 65101 ENUCLEATION OF EYE; W/O IMPLANT 23,634.00 10,530.00 13,104.00 65103 ENUCLEATION OF EYE; W/ IMPLANT, MUSCLES NOT ATTACHED TO IMPLANT 23,634.00 10,530.00 13,104.00 65105 ENUCLEATION OF EYE; W/ IMPLANT, MUSCLES ATTACHED TO IMPLANT 23,634.00 10,530.00 13,104.00 65110 EXENTERATION OF ORBIT WITHOUT SKIN GRAFT, REMOVAL OF ORBITAL CONTENTS; ONLY 73,710.00 32,760.00 40,950.00 65112 EXENTERATION OF ORBIT WITHOUT SKIN GRAFT, REMOVAL OF ORBITAL CONTENTS; W/ THERAPEUTIC REMOVAL OF BONE 75,348.00 32,760.00 42,588.00 65114 EXENTERATION OF ORBIT WITHOUT SKIN GRAFT, REMOVAL OF ORBITAL CONTENTS; W/ MUSCLE OR MYOCUTANEOUS FLAP 76,986.00 32,760.00 44,226.00 65130 INSERTION OF OCULAR IMPLANT; AFTER EVISCERATION, IN SCLERAL SHELL 21,372.00 10,725.00 10,647.00 65135 INSERTION OF OCULAR IMPLANT; AFTER ENUCLEATION, MUSCLES NOT ATTACHED TO IMPLANT 21,372.00 10,725.00 10,647.00 65140 INSERTION OF OCULAR IMPLANT; AFTER ENUCLEATION, MUSCLES ATTACHED TO IMPLANT 23,361.00 11,895.00 11,466.00 65150 REINSERTION OF OCULAR IMPLANT; WITH OR WITHOUT CONJUNCTIVAL GRAFT 23,361.00 11,895.00 11,466.00 65155 REINSERTION OF OCULAR IMPLANT; WITH USE OF FOREIGN MATERIAL FOR REINFORCEMENT AND/OR ATTACHMENT OF MUSCLES TO IMPLANT 23,361.00 11,895.00 11,466.00 65175 REMOVAL OF OCULAR IMPLANT 18,915.00 10,725.00 8,190.00 65205 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CONJUNCTIVAL, SUPERFICIAL 975.00 585.00 390.00 65210 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; SUBCONJUNCTIVAL OR SCLERAL, WITH SLIT LAMP 8,775.00 4,875.00 3,900.00 65222 REMOVAL OF FOREIGN BODY, EXTERNAL EYE; CORNEA, WITH SLIT LAMP 8,151.00 4,875.00 3,276.00 65235 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM ANTERIOR CHAMBER OR LENS 35,100.00 18,720.00 16,380.00 65260 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR SEGMENT, MAGNETIC EXTRACTION, ANTERIOR OR POSTERIOR ROUTE 104,130.00 46,800.00 57,330.00 65265 REMOVAL OF FOREIGN BODY, INTRAOCULAR; FROM POSTERIOR SEGMENT, NONMAGNETIC EXTRACTION 107,250.00 41,730.00 65,520.00 65270 REPAIR OF LACERATION; CONJUNCTIVA, W/ OR W/O NONPERFORATING LACERATION SCLERA, DIRECT CLOSURE 15,639.00 10,725.00 4,914.00 65273 REPAIR OF LACERATION; CONJUNCTIVA, BY MOBILIZATION AND REARRANGEMENT 15,639.00 10,725.00 4,914.00 65275 REPAIR OF LACERATION; CORNEA, NONPERFORATING, W/ OR W/O REMOVAL FOREIGN BODY 18,915.00 10,725.00 8,190.00 65280 REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, NOT INVOLVING UVEAL TISSUE 40,911.00 21,255.00 19,656.00 65285 REPAIR OF LACERATION; CORNEA AND/OR SCLERA, PERFORATING, W/ REPOSITION OR RESECTION OF UVEAL TISSUE 45,435.00 20,865.00 24,570.00 65286 REPAIR OF LACERATION; APPLICATION OF TISSUE GLUE, WOUNDS OF CORNEA AND/OR SCLERA 18,915.00 10,725.00 8,190.00 65290 REPAIR OF WOUND, EXTRAOCULAR MUSCLE, TENDON AND/ OR TENONS CAPSULE 18,915.00 10,725.00 8,190.00 65400 EXCISION OF LESION, CORNEA (KERATECTOMY, LAMELLAR, PARTIAL), EXCEPT PTERYGIUM 16,107.00 9,555.00 6,552.00 65410 BIOPSY OF CORNEA 15,639.00 10,725.00 4,914.00 65426 EXCISION OR TRANSPOSITION OF PTERYGIUM; WITH GRAFT 18,915.00 10,725.00 8,190.00 65450 DESTRUCTION OF LESION OF CORNEA BY CRYOTHERAPY, PHOTOCOAGULATION OR THERMOCAUTERIZATION 15,639.00 10,725.00 4,914.00 65710 KERATOPLASTY (CORNEAL TRANSPLANT); LAMELLAR 59,085.00 26,325.00 32,760.00 65730 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (EXCEPT IN APHAKIA) 59,085.00 26,325.00 32,760.00 65750 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN APHAKIA) 59,085.00 26,325.00 32,760.00 65755 KERATOPLASTY (CORNEAL TRANSPLANT); PENETRATING (IN PSEUDOPHAKIA) 59,085.00 26,325.00 32,760.00 65765 KERATOPHAKIA 20,553.00 10,725.00 9,828.00 65767 EPIKERATOPLASTY 35,100.00 18,720.00 16,380.00 65770 KERATOPROSTHESIS 59,085.00 26,325.00 32,760.00 65772 CORNEAL RELAXING INCISION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM 19,500.00 11,700.00 7,800.00 65775 CORNEAL WEDGE RESECTION FOR CORRECTION OF SURGICALLY INDUCED ASTIGMATISM 29,172.00 14,430.00 14,742.00 Page 96 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 65780 OCULAR SURFACE RECONSTRUCTION; AMNIOTIC MEMBRANE TRANSPLANTATION 59,085.00 26,325.00 32,760.00 65781 OCULAR SURFACE RECONSTRUCTION; LIMBAL STEM CELL ALLOGRAFT (EG, CADAVERIC OR LIVING DONOR) 59,085.00 26,325.00 32,760.00 65782 OCULAR SURFACE RECONSTRUCTION; LIMBAL CONJUNCTIVAL AUTOGRAFT (INCLUDES OBTAINING GRAFT) 59,085.00 26,325.00 32,760.00 65805 PARACENTESIS OF ANTERIOR CHAMBER OF EYE; W/ THERAPEUTIC RELEASE OF AQUEOUS 15,639.00 10,725.00 4,914.00 65810 PARACENTESIS OF ANTERIOR CHAMBER OF EYE; W/ REMOVAL OF VITREOUS AND/OR DISCISSION OF ANTERIOR HYALOID MEMBRANE, W/ OR W/O AIR INJECTION 18,915.00 10,725.00 8,190.00 65815 PARACENTESIS OF ANTERIOR CHAMBER OF EYE; W/ REMOVAL OF BLOOD, W/ OR W/O IRRIGATION AND/OR AIR INJECTION 18,915.00 10,725.00 8,190.00 65820 GONIOTOMY 45,435.00 20,865.00 24,570.00 65850 TRABECULOTOMY AB EXTERNO 45,435.00 20,865.00 24,570.00 65855 TRABECULOPLASTY BY LASER SURGERY, ONE OR MORE SESSIONS (DEFINED TREATMENT SERIES) 23,634.00 10,530.00 13,104.00 65860 SEVERING ADHESIONS OF ANTERIOR SEGMENT, LASER TECHNIQUE 20,553.00 10,725.00 9,828.00 65865 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (W/ OR W/O INJECTION OF AIR OR LIQUID); GONIOSYNECHIAE 20,553.00 10,725.00 9,828.00 65870 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (W/ OR W/O INJECTION OF AIR OR LIQUID); ANTERIOR SYNECHIAE, EXCEPT GONIOSYNECHIAE 20,553.00 10,725.00 9,828.00 65875 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (W/ OR W/O INJECTION OF AIR OR LIQUID); POSTERIOR SYNECHIAE 20,553.00 10,725.00 9,828.00 65880 SEVERING ADHESIONS OF ANTERIOR SEGMENT OF EYE, INCISIONAL TECHNIQUE (W/ OR W/O INJECTION OF AIR OR LIQUID); CORNEOVITREAL ADHESIONS 20,553.00 10,725.00 9,828.00 65900 REMOVAL OF EPITHELIAL MATERIAL, ANTERIOR SEGMENT EYE 20,553.00 10,725.00 9,828.00 65920 REMOVAL OF IMPLANTED MATERIAL, ANTERIOR SEGMENT EYE 23,634.00 10,530.00 13,104.00 65930 REMOVAL OF BLOOD CLOT, ANTERIOR SEGMENT EYE 15,639.00 10,725.00 4,914.00 66130 EXCISION OF LESION, SCLERA 16,107.00 9,555.00 6,552.00 66150 FISTULIZATION OF SCALERA FOR GLAUCOMA; TREPHINATION W/ IRIDECTOMY 35,100.00 18,720.00 16,380.00 66155 FISTULIZATION OF SCALERA FOR GLAUCOMA; THERMOCAUTERIZATION W/ IRIDECTOMY 35,100.00 18,720.00 16,380.00 66160 FISTULIZATION OF SCALERA FOR GLAUCOMA; SCLERECTOMY W/ PUNCH OR SCISSORS, W/ IRIDECTOMY 35,100.00 18,720.00 16,380.00 66165 FISTULIZATION OF SCALERA FOR GLAUCOMA; IRIDENCLEISIS OR IRIDOTASIS 35,100.00 18,720.00 16,380.00 66170 FISTULIZATION OF SCALERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO IN ABSENCE OF PREVIOUS SURGERY 35,100.00 18,720.00 16,380.00 66172 FISTULIZATION OF SCALERA FOR GLAUCOMA; TRABECULECTOMY AB EXTERNO W/ SCARRING FROM PREVIOUS OCULAR SURGERY OR TRAUMA (INCLUDES INJECTION OF ANTIFIBROTIC AGENTS) 52,884.00 23,400.00 29,484.00 66180 AQUENOUS SHUNT TO EXTRAOCULAR RESERVOIR (E.G., MOLTENO, SCHOCKET, DENVER-KRUPIN) 59,085.00 26,325.00 32,760.00 66185 REVISION OF AQUEOUS SHUNT TO EXTRAOCULAR RESERVOIR 59,085.00 26,325.00 32,760.00 66220 REPAIR OF SCLERAL STAPHYLOMA; W/O GRAFT 23,634.00 10,530.00 13,104.00 66225 REPAIR OF SCLERAL STAPHYLOMA; W/ GRAFT 45,435.00 20,865.00 24,570.00 66250 REVISION OR REPAIR OF OPERATIVE WOUND OF ANTERIOR SEGMENT, ANY TYPE, EARLY OR LATE, MAJOR OR MINOR PROCEDURE 29,172.00 14,430.00 14,742.00 66500 IRIDOTOMY BY STAB INCISION; EXCEPT TRANSFIXION 20,553.00 10,725.00 9,828.00 66505 IRIDOTOMY BY STAB INCISION; W/ TRANSFIXION AS FOR IRIS BOMBE 20,553.00 10,725.00 9,828.00 66600 IRIDECTOMY, W/ CORNEOSCLERAL OR CORNEAL SECTION; FOR REMOVAL OF LESION 23,634.00 10,530.00 13,104.00 66605 IRIDECTOMY, W/ CORNEOSCLERAL OR CORNEAL SECTION; W/ CYCLECTOMY 35,100.00 18,720.00 16,380.00 66625 IRIDECTOMY, W/ CORNEOSCLERAL OR CORNEAL SECTION; PERIPHERAL FOR GLAUCOMA 23,634.00 10,530.00 13,104.00 66630 IRIDECTOMY, W/ CORNEOSCLERAL OR CORNEAL SECTION; SECTOR FOR GLAUCOMA 23,634.00 10,530.00 13,104.00 66680 REPAIR OF IRIS, CILIARY BODY (AS FOR IRIDODIALYSIS) 35,100.00 18,720.00 16,380.00 66682 SUTURE OF IRIS, CILIARY BODY W/ RETRIEVAL OF SUTURE THROUGH SMALL INCISION (E.G., MCCANNEL SUTURE) 29,172.00 14,430.00 14,742.00 66700 CILIARY BODY DESTRUCTION; DIATHERMY 23,361.00 11,895.00 11,466.00 66710 CILIARY BODY DESTRUCTION; CYCLOPHOTOCOAGULATION 23,361.00 11,895.00 11,466.00 66720 CILIARY BODY DESTRUCTION; CRYOTHERAPY 23,361.00 11,895.00 11,466.00 66740 CILIARY BODY DESTRUCTION; CYCLODIALYSIS 23,361.00 11,895.00 11,466.00 66761 IRIDOTOMY/IRIDECTOMY BY LASER SURGERY (E.G., FOR GLAUCOMA) ( ONE OR MORE SESSIONS) 20,553.00 10,725.00 9,828.00 66762 IRIDOPLASTY BY PHOTOCOAGULATION (ONE OR MORE SESSIONS) (E.G., FOR IMPROVEMENT OF VISION, FOR WIDENING OF ANTERIOR CHAMBER ANGLE) 23,634.00 10,530.00 13,104.00 66770 DESTRUCTION OF CYST OR LESION IRIS OR CILIARY BODY (NONEXCISIONAL PROCEDURE) 20,553.00 10,725.00 9,828.00 Page 97 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 66820 DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); STAB INCISION TECHNIQUE (ZIEGLER OR WHEELER KNIFE) 23,634.00 10,530.00 13,104.00 66821 DISCISSION OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID); LASER SURGERY (E.G., YAG LASER) (ONE OR MORE STAGES) 16,107.00 9,555.00 6,552.00 66825 REPOSITIONING OF INTRAOCULAR LENS PROSTHESIS, REQUIRING AN INCISION 35,100.00 18,720.00 16,380.00 66830 REMOVAL OF SECONDARY MEMBRANOUS CATARACT (OPACIFIED POSTERIOR LENS CAPSULE AND/OR ANTERIOR HYALOID) W/ CORNEO-SCLERAL SECTION, W/ OR W/O IRIDECTOMY (IRIDOCAPSULOTOMY, IRIDOCAPSULECTOMY) 23,634.00 10,530.00 13,104.00 66985 INSERTION OF INTRAOCULAR LENS PROSTHESIS, NOT ASSOCIATED WITH CATARACT REMOVAL 31,200.00 18,720.00 12,480.00 66986 EXCHANGE OF INTRAOCULAR LENS 31,200.00 18,720.00 12,480.00 66991 REVISION OF FAILED FILTER; WITH OR WITHOUT EXPLANTATION/EXCHANGE OF SHUNT 73,710.00 32,760.00 40,950.00 66992 REVISION OF FAILED FILTER; WITH EXCISION OF BLEB CYST 73,710.00 32,760.00 40,950.00 66993 REVISION OF FAILED FILTER; WITH CHOROIDAL TAP 59,085.00 26,325.00 32,760.00 66994 REVISION OF FAILED FILTER; WITH POSTERIOR SCLEROTOMY 59,085.00 26,325.00 32,760.00 66995 REVISION OF FAILED FILTER; WITH ANTERIOR CHAMBER REFORMATION 59,085.00 26,325.00 32,760.00 66996 REVISION OF FILTERING BLEB, NEEDLING TECHNIQUE; WITHOUT INJECTION OF ANTI-METABOLITE 23,634.00 10,530.00 13,104.00 66997 REVISION OF FILTERING BLEB, NEEDLING TECHNIQUE; WITH INJECTION OF ANTI-METABOLITE 35,100.00 18,720.00 16,380.00 66998 RELEASE OF SCLERAL FLAP SUTURE BY LASER SUTURE LYSIS (NEW CODE) 18,915.00 10,725.00 8,190.00 66999 REVISION OF OVERFILTERING BLEB (INCLUDES AUTOLOGOUS BLOOD INJECTION, CRYOTHERAPY, MATTRESS SUTURES, ETC.) 35,100.00 18,720.00 16,380.00 67005 REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION); PARTIAL REMOVAL 73,710.00 32,760.00 40,950.00 67010 REMOVAL OF VITREOUS, ANTERIOR APPROACH (OPEN SKY TECHNIQUE OR LIMBAL INCISION); SUBTOTAL REMOVAL W/ MECHANICAL VITRECTOMY 87,750.00 46,800.00 40,950.00 67015 ASPIRATION OR RELEASE OF VITREOUS, SUBRETINAL OR CHOROIDAL FLUID, PARS PLANA APPROACH (POSTERIOR SCLEROTOMY) 18,915.00 10,725.00 8,190.00 67025 INJECTION OF VITREOUS SUBSTITUTE, PARS PLANA OR LIMBAL APPROACH, (FLUID-GAS EXCHANGE), W/ OR W/O ASPIRATION 23,634.00 10,530.00 13,104.00 67027 IMPLANTATION OF INTRAVITREAL DRUG DELIVERY SYSTEM (EG, GANCICLOVIR IMPLANT), INCLUDES CONCOMITANT REMOVAL OF VITREOUS 61,581.00 33,735.00 27,846.00 67030 DISCISSION OF VITREOUS STRANDS (W/O REMOVAL), PARS PLANA APPROACH 25,155.00 12,870.00 12,285.00 67031 SEVERING OF VITREOUS STRANDS, VITREOUS FACE ADHESIONS, SHEETS, MEMBRANES OR OPACITIES, LASER SURGERY (ONE OR MORE STAGES) 20,553.00 10,725.00 9,828.00 67036 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; 90,675.00 41,535.00 49,140.00 67038 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; W/ EPIRETINAL MEMBRANE STRIPPING 90,675.00 41,535.00 49,140.00 67039 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; W/ FOCAL ENDOLASER PHOTOCOAGULATION 90,675.00 41,535.00 49,140.00 67040 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; W/ ENDOLASER PANRETINAL PHOTOCOAGULATION 90,675.00 41,535.00 49,140.00 67041 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH INTERNAL LIMITING MEMBRANE (ILM) PEELING 90,675.00 41,535.00 49,140.00 67046 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF SUBRETINAL MEMBRANES 90,675.00 41,535.00 49,140.00 67047 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF CHOROIDAL NEOVASCULAR MEMBRANE 90,675.00 41,535.00 49,140.00 67048 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH ENDODRAINAGE OF SUBRETINAL HEMORRHAGE (WITH OR WITHOUT TPA INJECTION) 90,675.00 41,535.00 49,140.00 67049 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH REMOVAL OF DROPPED IOL 90,675.00 41,535.00 49,140.00 67050 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH PHACOFRAGMENTATION FOR DROPPED LENS MATERIAL 90,675.00 41,535.00 49,140.00 67051 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH INTERNAL TAMPONADE WITH AIR, GAS, SILICONE OIL, PERFLUOROCARBON LIQUID 90,675.00 41,535.00 49,140.00 67052 VITRECTOMY, MECHANICAL, PARS PLANA APPROACH; WITH INSERTION OF SCLERAL FIXATED INTRAOCULAR LENS, WITH OR WITHOUT ANTERIOR VITRECTOMY 73,710.00 32,760.00 40,950.00 67101 REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; CRYOTHERAPY OR DIATHERMY, W/ OR W/O DRAINAGE OF SUBRETINAL FLUID 90,675.00 41,535.00 49,140.00 67105 REPAIR OF RETINAL DETACHMENT, ONE OR MORE SESSIONS; PHOTOCOAGULATION, W/ OR W/O DRAINAGE OF SUBRETINAL FLUID 72,501.00 36,465.00 36,036.00 Page 98 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 67107 REPAIR OF RETINAL DETACHMENT; SCLERAL BUCKLING (SUCH AS LAMELLAR SCLERAL DISSECTION, IMBRICATION OR ENCIRCLING PROCEDURE), W/ OR W/O IMPLANT, W/ OR W/O CRYOTHERAPY, PHOTOCOAGULATION, AND DRAINAGE OF SUBRETINAL FLUID 90,675.00 41,535.00 49,140.00 67108 REPAIR OF RETINAL DETACHMENT; W/ VITRECTOMY, ANY METHOD, W/ OR W/O AIR OR GAS TAMPONADE, FOCAL ENDOLASER PHOTOCOAGULATION, CRYOTHERAPY, DRAINAGE OF SUBRETINAL FLUID, SCLERAL BUCKLING, AND/OR REMOVAL OF LENS BY SAME TECHNIQUE 90,675.00 41,535.00 49,140.00 67110 REPAIR OF RETINAL DETACHMENT; BY INJECTION OF AIR OR OTHER GAS (E.G., PNEUMATIC RETINOPEXY) 59,085.00 26,325.00 32,760.00 67112 REPAIR OF RETINAL DETACHMENT; BY SCLERAL BUCKLING OR VITRECTOMY, ON PATIENT HAVING PREVIOUS IPSILATERAL RETINAL DETACHMENT REPAIR(S) USING SCLERAL BUCKLING OR VITRECTOMY TECHNIQUES 90,675.00 41,535.00 49,140.00 67115 RELEASE OF ENCIRCLING MATERIAL (POSTERIOR SEGMENT) 23,634.00 10,530.00 13,104.00 67120 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; EXTRAOCULAR 23,634.00 10,530.00 13,104.00 67121 REMOVAL OF IMPLANTED MATERIAL, POSTERIOR SEGMENT; INTRAOCULAR 40,911.00 21,255.00 19,656.00 67208 DESTRUCTION OF LOCALIZED LESION OF RETINA (E.G., MACULOPATHY, CHOROIDOPATHY, SMALL TUMORS), ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY 23,634.00 10,530.00 13,104.00 67210 DESTRUCTION OF LOCALIZED LESION OF RETINA (E.G., MACULOPATHY, CHOROIDOPATHY, SMALL TUMORS), ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON ARC) 23,634.00 10,530.00 13,104.00 67218 DESTRUCTION OF LOCALIZED LESION OF RETINA (E.G., MACULOPATHY, CHOROIDOPATHY, SMALL TUMORS), ONE OR MORE SESSIONS; RADIATION BY IMPLANTATION OF SOURCE (INCLUDES REMOVAL OF SOURCE) 23,634.00 10,530.00 13,104.00 67220 DESTRUCTION OF LOCALIZED LESION OF CHOROID (E.G., CHOROIDAL NEOVASCULARIZATION); PHOTOCOAGULATION (E.G., LASER), ONE OR MORE SESSIONS 23,634.00 10,530.00 13,104.00 67221 DESTRUCTION OF LOCALIZED LESION OF CHOROID (E.G., CHOROIDAL NEOVASCULARIZATION); PHOTODYNAMIC THERAPY (INCLUDES INTRAVENOUS INFUSIONS 23,634.00 10,530.00 13,104.00 67222 DESTRUCTION OF LOCALIZED LESION OF CHOROID (E.G., CHOROIDAL NEOVASCULARIZATION); TRANSPUPILLARY THERMOTHERAPY 23,634.00 10,530.00 13,104.00 67227 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (E.G., DIABETIC RETINOPATHY), ONE OR MORE SESSIONS; CRYOTHERAPY, DIATHERMY 23,634.00 10,530.00 13,104.00 67228 DESTRUCTION OF EXTENSIVE OR PROGRESSIVE RETINOPATHY (E.G., DIABETIC RETINOPATHY), ONE OR MORE SESSIONS; PHOTOCOAGULATION (LASER OR XENON ARC) 23,634.00 10,530.00 13,104.00 67250 SCLERAL REINFORCEMENT 23,634.00 10,530.00 13,104.00 67311 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON); ONE HORIZONTAL MUSCLE 19,734.00 10,725.00 9,009.00 67312 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON); TWO HORIZONTAL MUSCLES 23,634.00 10,530.00 13,104.00 67314 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON); ONE VERTICAL MUSCLE (EXCLUDING SUPERIOR OBLIQUE) 23,634.00 10,530.00 13,104.00 67316 STRABISMUS SURGERY, RECESSION OR RESECTION PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON); TWO OR MORE VERTICAL MUSCLES (EXCLUDING SUPERIOR OBLIQUE) 35,100.00 18,720.00 16,380.00 67318 STRABISMUS SURGERY, ANY PROCEDURE (PATIENT NOT PREVIOUSLY OPERATED ON), SUPERIOR OBLIQUE MUSCLE 35,100.00 18,720.00 16,380.00 67320 TRANSPOSITION PROCEDURE (E.G., FOR PARETIC EXTRAOCULAR MUSCLE), ANY EXTRAOCULAR MUSCLE (SPECIFY) 35,100.00 18,720.00 16,380.00 67331 STRABISMUS SURGERY ON PATIENT W/ PREVIOUS EYE SURGERY OR INJURY THAT DID NOT INVOLVE THE EXTRAOCULAR MUSCLES 35,100.00 18,720.00 16,380.00 67332 STRABISMUS SURGERY ON PATIENT W/ SCARING OF EXTRAOCULAR MUSCLES (E.G., PRIOR OCULAR INJURY, STRABISMUS OR RETINAL DETACHMENT SURGERY) OR RESTRICTIVE MYOPATHY (E.G., DYSTHYROID OPHTHALMOPATHY) 42,783.00 24,765.00 18,018.00 67334 STRABISMUS SURGERY BY POSTERIOR FIXATION SUTURE TECHNIQUE, W/ OR W/O MUSCLE RECESSION 23,361.00 11,895.00 11,466.00 67340 STRABISMUS SURGERY INVOLVING EXPLORATION AND/OR REPAIR OF DETACHED EXTRAOCULAR MUSCLE(S) 44,187.00 21,255.00 22,932.00 67343 RELEASE OF EXTENSIVE SCAR TISSUE W/O DETACHING EXTRAOCULAR MUSCLE 35,100.00 18,720.00 16,380.00 67345 CHEMODENERVATION OF EXTRAOCULAR MUSCLE 18,915.00 10,725.00 8,190.00 67350 BIOPSY OF EXTRAOCULAR MUSCLE 18,915.00 10,725.00 8,190.00 67400 ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); FOR EXPLORATION, W/ OR W/O BIOPSY 90,675.00 41,535.00 49,140.00 Page 99 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 67405 ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); W/ DRAINAGE ONLY 90,675.00 41,535.00 49,140.00 67412 ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); W/ REMOVAL OF LESION 90,675.00 41,535.00 49,140.00 67413 ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); W/ REMOVAL OF FOREIGN BODY 90,675.00 41,535.00 49,140.00 67414 ORBITOTOMY W/O BONE FLAP (FRONTAL OR TRANSCONJUNCTIVAL APPROACH); W/ REMOVAL OF BONE FOR DECOMPRESSION 90,675.00 41,535.00 49,140.00 67415 FINE NEEDLE ASPIRATION OF ORBITAL CONTENTS 90,675.00 41,535.00 49,140.00 67420 ORBITOTOMY W/ BONE FLAP OR WINDOW, LATERAL APPROACH (E.G., KROENLEIN); W/ REMOVAL OF LESION 90,675.00 41,535.00 49,140.00 67430 ORBITOTOMY W/ BONE FLAP OR WINDOW, LATERAL APPROACH (E.G., KROENLEIN); W/ REMOVAL OF FOREIGN BODY 90,675.00 41,535.00 49,140.00 67440 ORBITOTOMY W/ BONE FLAP OR WINDOW, LATERAL APPROACH (E.G., KROENLEIN); W/ DRAINAGE 90,675.00 41,535.00 49,140.00 67445 ORBITOTOMY W/ BONE FLAP OR WINDOW, LATERAL APPROACH (E.G., KROENLEIN); W/ REMOVAL OF BONE FOR DECOMPRESSION 90,675.00 41,535.00 49,140.00 67550 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); INSERTION 21,372.00 10,725.00 10,647.00 67560 ORBITAL IMPLANT (IMPLANT OUTSIDE MUSCLE CONE); REMOVAL OR REVISION 21,372.00 10,725.00 10,647.00 67570 OPTIC NERVE DECOMPRESSION (E.G., INCISION OR FENESTRATION OF OPTIC NERVE SHEATH) 104,130.00 46,800.00 57,330.00 67580 REPAIR OF ANOPHTHALMIC SOCKET; WITH INSERTION OR REMOVAL OF ORBITAL IMPLANT WITHIN MUSCLE CONE 23,634.00 10,530.00 13,104.00 67581 REPAIR OF ANOPHTHALMIC SOCKET; WITH EXCHANGE OR ORBITAL IMPLANT 40,911.00 21,255.00 19,656.00 67582 REPAIR OF ANOPHTHALMIC SOCKET; WITH EXCHANGE OF ORBITAL IMPLANT AND REATTACHMENT OF MUSCLES 40,911.00 21,255.00 19,656.00 67583 REPAIR OF ANOPHTHALMIC SOCKET; WITH FORNIX RECONSTRUCTION USING SUTURES 40,911.00 21,255.00 19,656.00 67584 REPAIR OF ANOPHTHALMIC SOCKET; WITH FORNIX RECONSTRUCTION USING BUCCAL MUCOSAL GRAFT OR AMNION GRAFT, INCLUDING HARVESTING OF GRAFT 40,911.00 21,255.00 19,656.00 67585 REPAIR OF ANOPHTHALMIC SOCKET; WITH REVISION OF IMPLANT AND FORNIX RECONSTRUCTION USING SUTURES 40,911.00 21,255.00 19,656.00 67586 REPAIR OF ANOPHTHALMIC SOCKET; WITH REVISION OF IMPLANT AND FORNIX RECONSTRUCTION USING BUCCAL MUCOSAL GRAFT, OR AMNION GRAFT (INCLUDING HARVESTING OF GRAFT) 40,911.00 21,255.00 19,656.00 67700 BLEPHAROTOMY, DRAINAGE OF ABSCESS, EYELID 11,076.00 7,800.00 3,276.00 67710 SEVERING OF TARSORRHAPHY 11,076.00 7,800.00 3,276.00 67715 CANTHOTOMY 11,076.00 7,800.00 3,276.00 67800 EXCISION OF CHALAZION 11,076.00 7,800.00 3,276.00 67810 BIOPSY OF EYELID 11,076.00 7,800.00 3,276.00 67825 REPAIR OF TRICHIASIS; BY ELECTROEPILATION, ELECTROSURGERY, CRYOTHERAPY OR LASER SURGERY 11,076.00 7,800.00 3,276.00 67830 REPAIR OF TRICHIASIS; INCISION OF LID MARGIN 7,098.00 5,460.00 1,638.00 67835 REPAIR OF TRICHIASIS; INCISION OF LID MARGIN, WITH FREE MUCOUS MEMBRANE GRAFT 18,135.00 14,040.00 4,095.00 67840 EXCISION OF LESION OF EYELID (EXCEPT CHALAZION) WITHOUT CLOSURE OR WITH SIMPLE DIRECT CLOSURE 10,842.00 8,385.00 2,457.00 67875 TEMPORARY CLOSURE OF EYELIDS SUTURE (E.G., FROST SUTURE) 11,076.00 7,800.00 3,276.00 67880 CONSTRUCTION OF INTERMARGIN ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; 11,076.00 7,800.00 3,276.00 67882 CONSTRUCTION OF INTERMARGIN ADHESIONS, MEDIAN TARSORRHAPHY, OR CANTHORRHAPHY; WITH TRANSPORTATION OF TARSAL PLATE 15,639.00 10,725.00 4,914.00 67900 REPAIR OF BROW PTOSIS (SUPRACILIARY, MIDFOREHEAD OR CORONAL APPROACH) 35,100.00 18,720.00 16,380.00 67901 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH SUTURE OR OTHER MATERIAL 35,100.00 18,720.00 16,380.00 67902 REPAIR OF BLEPHAROPTOSIS; FRONTALIS MUSCLE TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA) 40,911.00 21,255.00 19,656.00 67903 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, INTERNAL APPROACH 35,100.00 18,720.00 16,380.00 67904 REPAIR OF BLEPHAROPTOSIS; (TARSO) LEVATOR RESECTION OR ADVANCEMENT, EXTERNAL APPROACH 35,100.00 18,720.00 16,380.00 67906 REPAIR OF BLEPHAROPTOSIS; SUPERIOR RECTUS TECHNIQUE WITH FASCIAL SLING (INCLUDES OBTAINING FASCIA) 35,100.00 18,720.00 16,380.00 67908 REPAIR OF BLEPHAROPTOSIS; CONJUNCTIVO-TARSO-MULLERS MUSCLE-LEVATOR RESECTION (FASANELLA-SERVAT TYPE) 35,100.00 18,720.00 16,380.00 67911 REPAIR OF LID RETRACTION (EYELID RECESSION); WITHOUT SPACER 41,730.00 21,255.00 20,475.00 67912 CORRECTION OF LAGOPHTHALMOS, WITH IMPLANTATION OF UPPER EYELID LOAD 62,400.00 33,735.00 28,665.00 67914 REPAIR OF ECTROPION; SUTURE 15,639.00 10,725.00 4,914.00 67915 REPAIR OF ECTROPION; THERMOCAUTERIZATION 15,639.00 10,725.00 4,914.00 67916 BLEPHAROPLASTY, EXCISION TARSAL WEDGE 18,915.00 10,725.00 8,190.00 Page 100 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 67917 BLEPHAROPLASTY, EXTENSIVE (E.G., KUHNT-SZYMANOWSKI OR TARSAL STRIP OPERATIONS) 25,155.00 12,870.00 12,285.00 67921 REPAIR OF ENTROPION; SUTURE 11,076.00 7,800.00 3,276.00 67922 REPAIR OF ENTROPION; THERMOCAUTERIZATION 11,076.00 7,800.00 3,276.00 67923 BLEPHAROPLASTY, EXCISION TARSAL WEDGE 18,915.00 10,725.00 8,190.00 67924 BLEPHAROPLASTY, EXTENSIVE (E.G., WHEELER OPERATION) 25,155.00 12,870.00 12,285.00 67930 SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/ OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; PARTIAL THICKNESS 18,915.00 10,725.00 8,190.00 67935 SUTURE OF RECENT WOUND, EYELID, INVOLVING LID MARGIN, TARSUS, AND/ OR PALPEBRAL CONJUNCTIVA DIRECT CLOSURE; FULL THICKNESS 23,634.00 10,530.00 13,104.00 67950 CANTHOPLASTY (RECONSTRUCTION OF CANTHUS) 23,634.00 10,530.00 13,104.00 67961 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; UP TO ONE- FOURTH OF LID MARGIN 59,943.00 33,735.00 26,208.00 67966 EXCISION AND REPAIR OF EYELID, INVOLVING LID MARGIN, TARSUS, CONJUNCTIVA, CANTHUS, OR FULL THICKNESS, MAY INCLUDE PREPARATION FOR SKIN GRAFT OR PEDICLE FLAP WITH ADJACENT TISSUE TRANSFER OR REARRANGEMENT; OVER ONE- FOURTH OF LID MARGIN 52,884.00 23,400.00 29,484.00 67971 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; UP TO TWO- THIRDS OF EYELID, ONE STAGE OR FIRST STAGE 59,085.00 26,325.00 32,760.00 67973 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, LOWER, ONE STAGE OR FIRST STAGE 73,710.00 32,760.00 40,950.00 67974 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; TOTAL EYELID, UPPER, ONE STAGE OR FIRST STAGE 73,710.00 32,760.00 40,950.00 67975 RECONSTRUCTION OF EYELID, FULL THICKNESS BY TRANSFER OF TARSOCONJUNCTIVAL FLAP FROM OPPOSING EYELID; SECOND STAGE 59,085.00 26,325.00 32,760.00 68100 BIOPSY OF CONJUNCTIVA 11,076.00 7,800.00 3,276.00 68110 EXCISION OF LESION, CONJUNCTIVA; UP TO 1 CM 15,639.00 10,725.00 4,914.00 68115 EXCISION OF LESION, CONJUNCTIVA; OVER 1 CM 15,639.00 10,725.00 4,914.00 68130 EXCISION OF LESION, CONJUNCTIVA; WITH ADJACENT SCLERA 15,639.00 10,725.00 4,914.00 68320 CONJUNCTIVOPLASTY; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT 20,553.00 10,725.00 9,828.00 68325 CONJUNCTIVOPLASTY; WITH BUCCAL MUCOUS MEMBRANE GRAFT (INCLUDES OBTAINING GRAFT) 23,634.00 10,530.00 13,104.00 68326 CONJUNCTIVOPLASTY RECONSTRUCTION CUL-DE-SAC; WITH CONJUNCTIVAL GRAFT OR EXTENSIVE REARRANGEMENT 29,172.00 14,430.00 14,742.00 68328 CONJUNCTIVOPLASTY RECONSTRUCTION CUL-DE-SAC; WITH BUCCAL MUCOUS MEMBRANE GRAFT (INCLUDES OBTAINING GRAFT) 35,100.00 18,720.00 16,380.00 68330 REPAIR OF SYMBLEPHARON; CONJUNCTIVOPLASTY, WITHOUT GRAFT 29,172.00 14,430.00 14,742.00 68335 REPAIR OF SYMBLEPHARON; WITH FREE GRAFT CONJUNCTIVA OR BUCCAL MUCOUS MEMBRANE (INCLUDES OBTAINING GRAFT) 42,783.00 24,765.00 18,018.00 68340 REPAIR OF SYMBLEPHARON; DIVISION OF SYMBLEPHARON, WITH OR WITHOUT INSERTION OF CONFORMER OR CONTACT LENS 35,100.00 18,720.00 16,380.00 68360 CONJUNCTIVAL FLAP; BRIDGE OR PARTIAL 23,361.00 11,895.00 11,466.00 68362 CONJUNCTIVAL FLAP; TOTAL (SUCH AS GUNDERSON THIN FLAP OR PURSE STRING FLAP) 23,361.00 11,895.00 11,466.00 68371 HARVESTING CONJUNCTIVAL ALLOGRAFT, LIVING DONOR 40,911.00 21,255.00 19,656.00 68400 INCISION, DRAINAGE OF LACRIMAL GLAND 11,076.00 7,800.00 3,276.00 68420 INCISION, DRAINAGE OF LACRIMAL SAC (DACRYOCYSTOSTOMY) 11,076.00 7,800.00 3,276.00 68440 SNIP INCISION OF LACRIMAL PUNCTUM 11,076.00 7,800.00 3,276.00 68500 EXCISION OF LACRIMAL GLAND (DACRYOADENECTOMY), EXCEPT FOR TUMOR 23,634.00 10,530.00 13,104.00 68510 BIOPSY OF LACRIMAL GLAND 11,076.00 7,800.00 3,276.00 68520 EXCISION OF LACRIMAL SAC (DACRYOCYSTECTOMY) 23,634.00 10,530.00 13,104.00 68525 BIOPSY OF LACRIMAL SAC 11,076.00 7,800.00 3,276.00 68540 EXCISION OF LACRIMAL GLAND TUMOR; FRONTAL APPROACH 35,100.00 18,720.00 16,380.00 68550 EXCISION OF LACRIMAL GLAND TUMOR; INVOLVING OSTEOTOMY 35,100.00 18,720.00 16,380.00 68700 PLASTIC REPAIR OF CANALICULI 18,915.00 10,725.00 8,190.00 68705 CORRECTION OF EVERTED PUNCTUM, CAUTERY 7,098.00 5,460.00 1,638.00 68720 DACRYOCYSTORHINOSTOMY (FISTULIZATION OF LACRIMAL SAC TO NASAL CAVITY) 35,100.00 18,720.00 16,380.00 68745 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITHOUT TUBE 35,100.00 18,720.00 16,380.00 68750 CONJUNCTIVORHINOSTOMY (FISTULIZATION OF CONJUNCTIVA TO NASAL CAVITY); WITH INSERTION OF TUBE OR STENT 40,911.00 21,255.00 19,656.00 Page 101 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 68760 CLOSURE OF THE LACRIMAL PUNCTUM; BY THERMOCAUTERIZATION, LIGATION, OR LASER SURGERY 15,639.00 10,725.00 4,914.00 68770 CLOSURE OF LACRIMAL FISTULA 21,216.00 13,845.00 7,371.00 68811 PROBING OF NASOLACRIMAL DUCT; REQUIRING GENERAL ANESTHESIA 15,639.00 10,725.00 4,914.00 68815 PROBING OF NASOLACRIMAL DUCT; WITH INSERTION OF TUBE OR STENT 18,915.00 10,725.00 8,190.00 69000 DRAINAGE EXTERNAL EAR, ABSCESS OR HEMATOMA 7,160.40 5,850.00 1,310.40 69020 DRAINAGE EXTERNAL AUDITORY CANAL, ABSCESS 6,770.40 6,279.00 491.40 69100 BIOPSY EXTERNAL EAR 11,076.00 7,800.00 3,276.00 69105 BIOPSY EXTERNAL AUDITORY CANAL 11,076.00 7,800.00 3,276.00 69110 EXCISION EXTERNAL EAR; PARTIAL, SIMPLE REPAIR 16,107.00 9,555.00 6,552.00 69120 EXCISION EXTERNAL EAR; COMPLETE AMPUTATION 23,634.00 10,530.00 13,104.00 69140 EXCISION EXOSTOSIS(ES), EXTERNAL AUDITORY CANAL 18,915.00 10,725.00 8,190.00 69145 EXCISION SOFT TISSUE LESION, EXTERNAL AUDITORY CANAL 18,915.00 10,725.00 8,190.00 69150 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; W/O NECK DISSECTION 45,435.00 20,865.00 24,570.00 69155 RADICAL EXCISION EXTERNAL AUDITORY CANAL LESION; W/ NECK DISSECTION 59,085.00 26,325.00 32,760.00 69200 REMOVAL FOREIGN BODY FROM EXTERNAL AUDITORY CANAL; W/ GENERAL ANESTHESIA 18,135.00 14,040.00 4,095.00 69220 DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPLE (E.G., ROUTINE CLEANING) 15,639.00 10,725.00 4,914.00 69222 DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPLEX (E.G., W/ ANESTHESIA OR MORE THAN ROUTINE CLEANING) 18,915.00 10,725.00 8,190.00 69310 RECONSTRUCTION OF EXTERNAL AUDITORY CANAL (MEATOPLASTY) (E.G., FOR STENOSIS DUE TO TRAUMA, INFECTION) 45,435.00 20,865.00 24,570.00 69320 RECONSTRUCTION EXTERNAL AUDITORY CANAL FOR CONGENITAL ATRESIA, SINGLE STAGE 45,435.00 20,865.00 24,570.00 69400 EUSTACHIAN TUBE INFLATION, TRANSNASAL; W/ CATHETERIZATION 11,333.40 8,385.00 2,948.40 69405 EUSTACHIAN TUBE CATHETERIZATION, TRANSTYMPANIC 11,076.00 7,800.00 3,276.00 69420 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION 11,076.00 7,800.00 3,276.00 69421 MYRINGOTOMY INCLUDING ASPIRATION AND/OR EUSTACHIAN TUBE INFLATION REQUIRING GENERAL ANESTHESIA 15,639.00 10,725.00 4,914.00 69433 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), LOCAL OR TOPICAL ANESTHESIA 16,107.00 9,555.00 6,552.00 69436 TYMPANOSTOMY (REQUIRING INSERTION OF VENTILATING TUBE), W/ GENERAL ANESTHESIA 16,107.00 9,555.00 6,552.00 69440 MIDDLE EAR EXPLORATION THROUGH POSTAURICULAR OR EAR CANAL INCISION 35,100.00 18,720.00 16,380.00 69450 TYMPANOLYSIS, TRANSCANAL 18,915.00 10,725.00 8,190.00 69501 TRANSMASTOID ANTROTOMY ("SIMPLE" MASTOIDECTOMY) 40,911.00 21,255.00 19,656.00 69502 MASTOIDECTOMY; COMPLETE 45,435.00 20,865.00 24,570.00 69505 MASTOIDECTOMY; MODIFIED RADICAL 45,435.00 20,865.00 24,570.00 69511 MASTOIDECTOMY; RADICAL 45,435.00 20,865.00 24,570.00 69530 PETROUS APICECTOMY INCLUDING RADICAL MASTOIDECTOMY 45,435.00 20,865.00 24,570.00 69535 RESECTION TEMPORAL BONE, EXTERNAL APPROACH 90,675.00 41,535.00 49,140.00 69540 EXCISION AURAL POLYP 15,639.00 10,725.00 4,914.00 69550 EXCISION AURAL GLOMUS TUMOR; TRANSCANAL 59,085.00 26,325.00 32,760.00 69552 EXCISION AURAL GLOMUS TUMOR; TRANSMASTOID 59,085.00 26,325.00 32,760.00 69554 EXCISION AURAL GLOMUS TUMOR; EXTENDED (EXTRATEMPORAL) 59,085.00 26,325.00 32,760.00 69601 REVISION MASTOIDECTOMY; RESULTING IN COMPLETE MASTOIDECTOMY 45,435.00 20,865.00 24,570.00 69602 REVISION MASTOIDECTOMY; RESULTING IN MODIFIED RADICAL MASTOIDECTOMY 61,581.00 33,735.00 27,846.00 69603 REVISION MASTOIDECTOMY; RESULTING IN RADICAL MASTOIDECTOMY 45,435.00 20,865.00 24,570.00 69604 REVISION MASTOIDECTOMY; RESULTING IN TYMPANOPLASTY 45,435.00 20,865.00 24,570.00 69605 REVISION MASTOIDECTOMY; W/ APICECTOMY 45,435.00 20,865.00 24,570.00 69610 TYMPANIC MEMBRANE REPAIR, W/ OR W/O SITE PREPARATION OR PERFORATION FOR CLOSURE, W/ OR W/O PATCH 23,634.00 10,530.00 13,104.00 69620 MYRINGOPLASTY (SURGERY CONFINED TO DRUMHEAD AND DONOR AREA) 40,911.00 21,255.00 19,656.00 69631 TYMPANOPLASTY W/O MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/ OR MIDDLE EAR SURGERY), INITIAL OR REVISION; W/O OSSICULAR CHAIN RECONSTRUCTION 59,943.00 33,735.00 26,208.00 69632 TYMPANOPLASTY W/O MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/ OR MIDDLE EAR SURGERY), INITIAL OR REVISION; W/ OSSICULAR CHAIN RECONSTRUCTION (E.G., POSTFENESTRATION) 59,943.00 33,735.00 26,208.00 69633 TYMPANOPLASTY W/O MASTOIDECTOMY (INCLUDING CANALPLASTY, ATTICOTOMY AND/ OR MIDDLE EAR SURGERY), INITIAL OR REVISION; W/ OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (E.G., PARTIAL OSSICULAR REPLACEMENT PROSTHESIS, (PORP), TOTAL OSSICULAR REPLAC 59,943.00 33,735.00 26,208.00 Page 102 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 69635 TYMPANOPLASTY W/ ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/ OR TYMPANIC MEMBRANE REPAIR); W/O OSSICULAR CHAIN RECONSTRUCTION 90,675.00 41,535.00 49,140.00 69636 TYMPANOPLASTY W/ ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/ OR TYMPANIC MEMBRANE REPAIR); W/ OSSICULAR CHAIN RECONSTRUCTION 92,313.00 41,535.00 50,778.00 69637 TYMPANOPLASTY W/ ANTROTOMY OR MASTOIDOTOMY (INCLUDING CANALPLASTY, ATTICOTOMY, MIDDLE EAR SURGERY, AND/ OR TYMPANIC MEMBRANE REPAIR); W/ OSSICULAR CHAIN RECONSTRUCTION AND SYNTHETIC PROSTHESIS (E.G. PARTIAL OSSICULAR REPLACEMENT PROSTHESIS, (PORP), TOTAL 92,313.00 41,535.00 50,778.00 69641 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); W/O OSSICULAR CHAIN RECONSTRUCTION 90,675.00 41,535.00 49,140.00 69642 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); W/ OSSICULAR CHAIN RECONSTRUCTION 92,313.00 41,535.00 50,778.00 69643 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); W/ INTACT OR RECONSTRUCTED WALL, W/O OSSICULAR CHAIN RECONSTRUCTION 93,951.00 41,535.00 52,416.00 69644 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); W/ INTACT OR RECONSTRUCTED CANAL WALL, W/ OSSICULAR CHAIN RECONSTRUCTION 95,589.00 41,535.00 54,054.00 69645 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, W/O OSSICULAR CHAIN RECONSTRUCTION 90,675.00 41,535.00 49,140.00 69646 TYMPANOPLASTY W/ MASTOIDECTOMY (INCLUDING CANALPLASTY, MIDDLE EAR SURGERY, TYMPANIC MEMBRANE REPAIR); RADICAL OR COMPLETE, W/ OSSICULAR CHAIN RECONSTRUCTION 90,675.00 41,535.00 49,140.00 69650 STAPES MOBILIZATION 73,710.00 32,760.00 40,950.00 69660 STAPEDECTOMY OR STAPEDOTOMY W/ REESTABLISHMENT OF OSSICULAR CONTINUITY, W/ OR W/O USE OF FOREIGN MATERIAL; 75,348.00 32,760.00 42,588.00 69661 STAPEDECTOMY OR STAPEDOTOMY W/ REESTABLISHMENT OF OSSICULAR CONTINUITY, W/ OR W/O USE OF FOREIGN MATERIAL; W/ FOOTPLATE DRILL OUT 75,348.00 32,760.00 42,588.00 69662 REVISION OF STAPEDECTOMY OR STAPEDOTOMY 75,348.00 32,760.00 42,588.00 69666 REPAIR OVAL WINDOW FISTULA 75,348.00 32,760.00 42,588.00 69667 REPAIR ROUND WINDOW FISTULA 75,348.00 32,760.00 42,588.00 69670 MASTOID OBLITERATION 61,581.00 33,735.00 27,846.00 69676 TYMPANIC NEURECTOMY 59,085.00 26,325.00 32,760.00 69700 CLOSURE POSTAURICULAR FISTULA, MASTOID 20,553.00 10,725.00 9,828.00 69720 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; LATERAL TO GENICULATE GANGLION 59,085.00 26,325.00 32,760.00 69725 DECOMPRESSION FACIAL NERVE, INTRATEMPORAL; INCLUDING MEDIAL TO GENICULATE GANGLION 59,085.00 26,325.00 32,760.00 69740 SUTURE FACIAL NERVE, INTRATEMPORAL, W/ OR W/O GRAFT OR DECOMPRESSION; LATERAL TO GENICULATE GANGLION 73,710.00 32,760.00 40,950.00 69745 SUTURE FACIAL NERVE, INTRATEMPORAL, W/ OR W/O GRAFT OR DECOMPRESSION; INCLUDING MEDIAL TO GENICULATE GANGLION 73,710.00 32,760.00 40,950.00 69801 LABYRINTHOTOMY, W/ OR W/O CRYOSURGERY INCLUDING OTHER NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); TRANSCANAL 75,348.00 32,760.00 42,588.00 69802 LABYRINTHOTOMY, W/ OR W/O CRYOSURGERY INCLUDING OTHER NONEXCISIONAL DESTRUCTIVE PROCEDURES OR PERFUSION OF VESTBULOACTIVE DRUGS (SINGLE OR MULTIPLE PERFUSIONS); W/ MASTOIDECTOMY 76,986.00 32,760.00 44,226.00 69805 ENDOLYMPHATIC SAC OPERATION; W/O SHUNT 90,675.00 41,535.00 49,140.00 69806 ENDOLYMPHATIC SAC OPERATION; W/ SHUNT 104,130.00 46,800.00 57,330.00 69820 FENESTRATION SEMICIRCULAR CANAL 90,675.00 41,535.00 49,140.00 69840 REVISION FENESTRATION OPERATION 104,130.00 46,800.00 57,330.00 69905 LABYRINTHECTOMY; TRANSCANAL 90,675.00 41,535.00 49,140.00 69910 LABYRINTHECTOMY; W/ MASTOIDECTOMY 104,130.00 46,800.00 57,330.00 69915 VESTIBULAR NERVE SECTION, TRANSLABYRINTHINE APPROACH 104,130.00 46,800.00 57,330.00 69930 COCHLEAR DEVICE IMPLANTATION, W/ OR W/O MASTOIDECTOMY 107,250.00 41,730.00 65,520.00 69950 VESTIBULAR NERVE SECTION, TRANSCRANIAL APPROACH 107,250.00 41,730.00 65,520.00 69955 TOTAL FACIAL NERVE DECOMPRESSION AND/OR REPAIR (MAY INCLUDE GRAFT) 107,250.00 41,730.00 65,520.00 69960 DECOMPRESSION INTERNAL AUDITORY CANAL 104,130.00 46,800.00 57,330.00 69970 REMOVAL OF TUMOR, TEMPORAL BONE 90,675.00 41,535.00 49,140.00 70010 MYELOGRAPHY, BRAIN, INCLUDING SPINAL PUNCTURE AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 70390 SIALOGRAPHY; INCLUDING DUCT CATHETERIZATION AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 Page 103 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 71090 INSERTION PACEMAKER, FLUOROSCOPY AND RADIOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 72240 MYELOGRAPHY, SPINE, INCLUDING SPINAL PUNCTURE AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 74300 CHOLANGIOGRAPHY AND/OR PANCREATOGRAPHY, INTRAOPERATIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 74328 ENDOSCOPIC CATHETERIZATION OF THE BILIARY DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 74329 ENDOSCOPIC CATHETERIZATION OF THE PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 74330 COMBINED ENDOSCOPIC CATHETERIZATION OF THE BILIARY AND PANCREATIC DUCTAL SYSTEM, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 74340 INTRODUCTION OF LONG GASTROINTESTINAL TUBE (E.G., MILLER- ABBOTT ), RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 74350 PERCUTANEOUS PLACEMENT OF GASTROSTOMY TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 74355 PERCUTANEOUS PLACEMENT OF ENTEROCLYSIS TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 74360 INTRALUMINAL DILATION OF STRICTURES AND/OR OBSTRUCTIONS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 74363 PERCUTANEOUS TRANSHEPATIC DILATION OF SBILIARY DUCT STRICTURE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 35,100.00 18,720.00 16,380.00 74475 INTRODUCTION OF INTRACATHETER OR CATHETER INTO RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 35,100.00 18,720.00 16,380.00 74480 INTRODUCTION OF URETERAL CATHETER OR STENT INTO
URETER THROUGH RENAL PELVIS FOR DRAINAGE AND/OR INJECTION, PERCUTANEOUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 35,100.00 18,720.00 16,380.00 74742 TRANSCERVICAL CATHETERIZATION OF FALLOPIAN TUBE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 75600 AORTOGRAPHY, THORACIC, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75625 AORTOGRAPHY, ABDOMINAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75630 AORTOGRAPHY, ABDOMINAL PLUS BILATERAL ILIOFEMORAL LOWER EXTREMITY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75635 COMPUTED TOMOGRAPHIC ANGIOGRAPHY, ABDOMINAL AORTA AND BILATERAL ILIOFEMORAL LOWER EXTREMITY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75650 ANGIOGRAPHY, CERVICOCEREBRAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75658 ANGIOGRAPHY, BRACHIAL RETROGRADE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75660 ANGIOGRAPHY, EXTERNAL CAROTID, UNILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75662 ANGIOGRAPHY, EXTERNAL CAROTID, BILATERAL, SELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75665 ANGIOGRAPHY, CEREBRAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75671 ANGIOGRAPHY, CAROTID, CEREBRAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75676 ANGIOGRAPHY, CAROTID, CERVICAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75680 ANGIOGRAPHY, CAROTID, CERVICAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75685 ANGIOGRAPHY, VERTEBRAL, CERVICAL AND/OR INTRACRANIAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75705 ANGIOGRAPHY, SPINAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75710 ANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75716 ANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75722 ANGIOGRAPHY, RENAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75724 ANGIOGRAPHY, RENAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75726 ANGIOGRAPHY, VISCERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75731 ANGIOGRAPHY, ADRENAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75733 ANGIOGRAPHY, ADRENAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75736 ANGIOGRAPHY, PELVIS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 Page 104 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 75741 ANGIOGRAPHY, PULMONARY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75743 ANGIOGRAPHY, PULMONARY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75746 ANGIOGRAPHY, PULMONARY, NONSELECTIVE, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75756 ANGIOGRAPHY, INTERNAL MAMMARY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75757 ANGIOGRAPHY, FLUORESCEIN (EYE) 6,825.00 5,850.00 975.00 75790 ANGIOGRAPHY, ARTERIOVENOUS SHUNT (E.G., DIALYSIS PATIENT), RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75801 LYMPHANGIOGRAPHY, EXTREMITY, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75803 LYMPHANGIOGRAPHY, EXTREMITY, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75805 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, UNILATERAL , RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75807 LYMPHANGIOGRAPHY, PELVIC/ABDOMINAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75810 SPLENOPORTOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75820 VENOGRAPHY, EXTREMITY, UNILATERAL OR BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75825 VENOGRAPHY, CAVAL, INFERIOR, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75827 VENOGRAPHY, CAVAL, SUPERIOR, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75831 VENOGRAPHY, RENAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75833 VENOGRAPHY, RENAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75840 VENOGRAPHY, ADRENAL, UNILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75842 VENOGRAPHY, ADRENAL, BILATERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75860 VENOGRAPHY, VENOUS SINUS(E.G., PETROSAL AND INFERIOR SAGITTAL) OR JUGULAR, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75870 VENOGRAPHY, SUPERIOR SAGITTAL SINUS, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75872 VENOGRAPHY, EPIDURAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75880 VENOGRAPHY, ORBITAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75885 PERCUTANEOUS TRANSHEPATIC PORTOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 25,155.00 12,870.00 12,285.00 75889 HEPATIC VENOGRAPHY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 25,155.00 12,870.00 12,285.00 75900 EXCHANGED OF A PREVIOUSLY PLACED INTRAVASCULAR CATHETER DURING THROMBOLYTIC THERAPY WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION 59,085.00 26,325.00 32,760.00 75901 MECHANICAL REMOVAL OF PERICATHETER OBSTRUCTIVE MATERIAL (E.G., FIBRIN SHEATH) FROM CENTRAL VENOUS DEVICE VIA SEPARATE VENOUS ACCESS, RADIOLOGIC SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75902 MECHANICAL REMOVAL OF INTRALUMINAL (INTRACATHETER) OBSTRUCTIVE MATERIAL FROM CENTRAL VENOUS DEVICE THROUGH DEVICE LUMEN, RADIOLOGIC SUPERVISION AND INTERPRETATION 18,915.00 10,725.00 8,190.00 75940 PERCUTANEOUS PLACEMENT OF IVC FILTER, RADIOLOGIC SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75945 INTRAVASCULAR ULTRASOUND (NON-CORONARY-VESSEL), RADIOLOGICAL SUPERVISION AND INTERPRETATION; INITIAL VESSEL 18,915.00 10,725.00 8,190.00 75952 ENDOVASCULAR REPAIR OF INFRARENAL ABDOMINAL AORTIC ANEURYSM OR DISSECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION 104,130.00 46,800.00 57,330.00 75953 PLACEMENT OF PROXIMAL OR DISTAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF INFRARENAL AORTIC OR ILIAC ARTERY ANEURYSM, PSEUDOANUERYSM, OR DISSECTION, RADIOLOGICAL SUPERVISION AND INTERPRETATION 107,250.00 41,730.00 65,520.00 75954 ENDOVASCULAR REPAIR OF ILIAC ARTERY ANEURYSM, PSEUDOANEURYSM, ARTERIOVENOUS MALFORMATION, OR TRAUMA, RADIOLOGICAL SUPERVISION AND INTERPRETATION 104,130.00 46,800.00 57,330.00 75956 ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (E.G., ANEURYSM, PSUEDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDING TH 107,250.00 41,730.00 65,520.00 Page 105 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 75957 ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (E.G., ANEURYSM, PSUEDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION); NOT INVOLVING COVERAGE OF LEFT SUBCLAVIAN ARTERY ORIGIN, INITIAL ENDOPROSTHESIS PLUS DESCENDIN 104,130.00 46,800.00 57,330.00 75958 PLACEMENT OF PROXIMAL EXTENSION PROSTHESIS FOR ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA (E.G., ANEURYSM, PSEUDOANEURYSM, DISSECTION, PENETRATING ULCER, INTRAMURAL HEMATOMA, OR TRAUMATIC DISRUPTION), RADIOLOGIC SUPERVISION AND INTERPRETATION 107,250.00 41,730.00 65,520.00 75959 PLACEMENT OF DISTAL EXTENSION PROSTHESIS(S) (DELAYED) AFTER ENDOVASCULAR REPAIR OF DESCENDING THORACIC AORTA, AS NEEDED, TO LEVEL OF CELIAC ORIGIN, RADIOLOGICAL SUPERVISION AND INTERPRETATION 107,250.00 41,730.00 65,520.00 75960 TRANSCATHETER INDUCTION OF INTRAVASCULAR STENT(S), (EXCEPT CORONARY, CAROTID, AND VERTEBRAL VESSEL), PERCUTANEOUS AND/ OR OPEN, RADIOLOGICAL SUPERVISION AND INTERPRETATION 90,675.00 41,535.00 49,140.00 75961 TRANSCATHETER RETRIEVAL, PERCUTANEOUS, OF INTRAVASCULAR FOREIGN BODY (E.G., FRACTURED VENOUS OR ARTERIAL CATHETER), RADIOLOGICAL SUPERVISION AND INTERPRETATION 90,675.00 41,535.00 49,140.00 75962 TRANSLUMINAL BALLOON ANGIOPLASTY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75966 TRANSLUMINAL BALLOON ANGIOPLASTY, RENAL OR OTHER VISCERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75970 TRANSCATHETER BIOPSY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75978 TRANSLUMINAL BALLOON ANGIOPLASTY, VENOUS (E.G., SUBCLAVIAN STENOSIS) RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75980 PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE WITH CONTRAST MONITORING, RADIOLOGICAL SUPERVISION AND INTERPRETATION 73,710.00 32,760.00 40,950.00 75982 PERCUTANEOUS PLACEMENT OF DRAINAGECATHETER COMBINED INTERNAL AND EXTERNAL BILLIARY DRAINAGE OR OF A DRAINAGE STENT FOR INTERNAL BILLIARY DRAINAGE IN PATIENTS WITH AN INOPERABLE MECHANICAL BILLIARY OBSTRUCTION, RADIOLOGIC SUPERVISION AND INTERPRETATION. 90,675.00 41,535.00 49,140.00 75984 CHANGE OF PERCUTANEOUS TUBE OR DRAINAGE CATHETER WITH CONTRAST MONITORING (E.G., GASTROINTESTINAL SYSTEM, GENITOURINARY SYSTEM, ABSCESS), RADIOLOGIC SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 75989 RADIOLOGICAL GUIDANCE FOR PERCUTANEOUS DRAINAGE (ABSCESS, CYST, FLUID COLLECTION), WITH PLACEMENT OF CATHETER AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 75992 TRANSLUMINAL ATHERECTOMY, PERIPHERAL ARTERY, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75994 TRANSLUMINAL ATHERECTOMY, RENAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 75995 TRANSLUMINAL ATHERECTOMY, VISCERAL, RADIOLOGICAL SUPERVISION AND INTERPRETATION 45,435.00 20,865.00 24,570.00 76003 FLUOROSCOPIC GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE) 15,639.00 10,725.00 4,914.00 76012 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION; UNDER FLUOROSCOPIC GUIDANCE 59,085.00 26,325.00 32,760.00 76013 RADIOLOGICAL SUPERVISION AND INTERPRETATION, PERCUTANEOUS VERTEBROPLASTY OR VERTEBRAL AUGMENTATION INCLUDING CAVITY CREATION; UNDER CT GUIDANCE 59,085.00 26,325.00 32,760.00 76080 RADIOLOGIC EXAMINATION, ABSCESS, FISTULA OR SINUS TRACT STUDY, INCLUDING CATHETERIZATION OF LESION AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76086 MAMMARY DUCTOGRAM OR GALACTOGRAM, 1 OR MULTIPLE DUCT, INJECTION AND RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76095 STEREOTACTIC LOCALIZATION GUIDANCE FOR BREAST BIOPSY OR NEEDLE PLACEMENT (E.G., FOR WIRE LOCALIZATION OR FOR INJECTION), ONE OR MORE LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76096 MAMMOGRAPHIC GUIDANCE FOR NEEDLE PLACEMENT, BREAST (E.G., FOR WIRE LOCALIZATION OR FOR INJECTION), EACH LESION, RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76355 COMPUTED TOMOGRAPHY GUIDANCE FOR STEREOTACTIC LOCALIZATION 15,639.00 10,725.00 4,914.00 Page 106 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 76360 COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76362 COMPUTED TOMOGRAPHY GUIDANCE FOR VISCERAL TISSUE ABLATION 15,639.00 10,725.00 4,914.00 76393 MAGNETIC RESONANCE GUIDANCE FOR NEEDLE PLACEMENT (E.G., FOR BIOPSY, NEEDLE ASPIRATION, INJECTION, OR PLACEMENT OF LOCALIZATION DEVICE) RADIOLOGICAL SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76394 MAGNETIC RESONANCE GUIDANCE FOR VISCERAL TISSUE ABLATION 15,639.00 10,725.00 4,914.00 76930 ULTRASONIC GUIDANCE FOR PERICARDIOCENTESIS, IMAGING SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76932 ULTRASONIC GUIDANCE FOR ENDOMYOCARDIAL BIOPSY, IMAGING SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76936 ULTRASOUND GUIDED COMPRESSION REPAIR OF ARTERIAL PSEUDOANEURYSM OR ARTERIOVENOUS FISTULAE (INCLUDES DIAGNOSTIC ULTRASOUND EVALUATION, COMPRESSION OF LESION AND IMAGING) 15,639.00 10,725.00 4,914.00 76940 ULTRASONIC GUIDANCE FOR VISCERAL TISSUE ABLATION 15,639.00 10,725.00 4,914.00 76942 ULTRASONIC GUIDANCE FOR NEEDLE PLACEMENT (E.G., BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), IMAGING SUPERVISION AND INTERPRETATION 15,639.00 10,725.00 4,914.00 76965 ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION 15,639.00 10,725.00 4,914.00 76986 ULTRASONIC GUIDANCE, INTRAOPERATIVE 15,639.00 10,725.00 4,914.00 77261 THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE, INTERMEDIATE OR COMPLEX, (ONLY ONE MAY BE REPORTED FOR A GIVEN COURSE OF THERAPY) 35,100.00 18,720.00 16,380.00 77401 RADIATION TREATMENT DELIVERY (LINEAR ACCELERATOR) 5,850.00 4,290.00 1,560.00 77401 RADIATION TREATMENT DELIVERY (COBALT) 3,900.00 2,340.00 1,560.00 77418 INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC PER SESSION 11,076.00 7,800.00 3,276.00 77421 STEREOSCOPIC X-RAY GUIDANCE FOR LOCALIZATION OF TARGET VOLUME FOR THE DELIVERY OF RADIATION THERAPY 59,085.00 26,325.00 32,760.00 77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CEREBRAL LESION(S) 59,085.00 26,325.00 32,760.00 77600 HYPERTHERMIA FOR TREATMENT OF MALIGNANCY, ONE OR MORE SESSIONS DURING THE COURSE OF THERAPY INCLUDING FOLLOW-UP CARE FOR 90 DAYS AFTER PROCEDURE 23,634.00 10,530.00 13,104.00 77750 INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION 11,076.00 7,800.00 3,276.00 77761 INTRACAVITARY RADIATION SOURCE APPLICATION, 1 OR MORE SOURCES/RIBBONS (BRACHYTHERAPY), ONE OR MORE SESSIONS DURING THE COURSE OF THERAPY INCLUDING FOLLOW-UP CARE FOR 90 DAYS AFTER PROCEDURE 35,100.00 18,720.00 16,380.00 77776 INTERSTITIAL RADIATION SOURCE APPLICATION, 1 OR MORE SOURCES/RIBBONS (BRACHYTHERAPY), ONE OR MORE SESSIONS DURING THE COURSE OF THERAPY INCLUDING FOLLOW-UP CARE FOR 90 DAYS AFTER PROCEDURE 35,100.00 18,720.00 16,380.00 77781 REMOTE AFTER LOADING HIGH INTENSITY BRACHYTHERAPY (RAHIB); 1 OR MORE SOURCE POSITION OR CATHETERS PER SESSION 11,076.00 7,800.00 3,276.00 77789 SURFACE APPLICATION OF RADIATION SOURCE (BRACHYTHERAPY), ONE OR MORE SESSIONS DURING THE COURSE OF THERAPY INCLUDING FOLLOW-UP CARE FOR 90 DAYS AFTER PROCEDURE 18,915.00 10,725.00 8,190.00 79000 RADIOPHARMACEUTICAL (RADIOACTIVE IODINE) THERAPY 7,098.00 5,460.00 1,638.00 79005 RADIOPHARMACEUTICAL ABLATION OF GLAND FOR THYROID CARCINOMA OR METASTASES OF THYROID CARCINOMA 15,639.00 10,725.00 4,914.00 79200 RADIOPHARMACEUTICAL THERAPY, BY INTRACAVITARY ADMINISTRATION 18,915.00 10,725.00 8,190.00 79300 RADIOPHARMACEUTICAL THERAPY, BY INTERSTITIAL RADIOACTIVE COLLOID ADMINISTRATION 18,915.00 10,725.00 8,190.00 79403 RADIOPHARMACEUTICAL THERAPY, BY RADIOLABELED MONOCLONAL ANTIBODY BY INTRAVENOUS INFUSION 15,639.00 10,725.00 4,914.00 79440 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTICULAR ADMINISTRATION 15,639.00 10,725.00 4,914.00 79445 RADIOPHARMACEUTICAL THERAPY, BY INTRA-ARTERIAL PARTICULATE ADMINISTRATION 15,639.00 10,725.00 4,914.00 87207 OUTPATIENT MALARIA PACKAGE 1,170.00 1,170.00 -
88174 EVALUATION OF ASPIRATE (CT-GUIDED BIOPSY) WITH OR WITHOUT PREPARATION OF SMEARS; IMMEDIATE CYTOLOGIC STUDY TO DETERMINE ADEQUACY OF SPECIMEN(S), INTERPRETATION AND REPORT 11,076.00 7,800.00 3,276.00 88331 PATHOLOGY CONSULTATION DURING SURGERY; WITH FROZEN SECTION(S), SINGLE BLOCK 11,076.00 7,800.00 3,276.00 88332 PATHOLOGY CONSULTATION DURING SURGERY; WITH FROZEN SECTION(S), TWO (2) OR MORE BLOCKS 18,915.00 10,725.00 8,190.00 Page 107 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 89221 DIRECTLY OBSERVED TREATMENT SHORT-COURSE; INTENSIVE PHASE 4,875.00 4,875.00 -
89222 DIRECTLY OBSERVED TREATMENT SHORT-COURSE; MAINTENANCE PHASE 2,925.00 2,925.00 -
90375 ANIMAL BITE TREATMENT (ABT) PACKAGE 5,850.00 5,850.00 -
90945 DIALYSIS PROCEDURE OTHER THAN HEMODIALYSIS (E.G. PERITONEAL, HEMOFILTRATION) 5,070.00 4,387.50 682.50 91034 ESOPHAGUS, GASTROESOPHAGEAL REFLUX TEST; WITH NASAL CATHETER PH ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION 16,107.00 9,555.00 6,552.00 91037 ESOPHAGEAL FUNCTION TEST, GASTROESOPHAGEAL REFLUX TEST WITH NASAL CATHETER INTRALUMINAL IMPEDANCE ELECTRODE(S) PLACEMENT, RECORDING, ANALYSIS AND INTERPRETATION; 16,107.00 9,555.00 6,552.00 91100 INTESTINAL BLEEDING TUBE, PASSAGE, POSITIONING AND MONITORING 16,107.00 9,555.00 6,552.00 91105 GASTRIC INTUBATION, AND ASPIRATION OR LAVAGE FOR TREATMENT (E.G., FOR INGESTED POISONS) 16,107.00 9,555.00 6,552.00 92973 PERCUTANEOUS TRANSLUMINAL CORONARY THROMBECTOMY 59,085.00 26,325.00 32,760.00 92975 THROMBOLYSIS, CORONARY; BY INTRACORONARY INFUSION, INCLUDING CORONARY ANGIOGRAPHY 45,435.00 20,865.00 24,570.00 92980 TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTIONS, ANY METHOD; SINGLE VESSEL 59,085.00 26,325.00 32,760.00 92981 TRANSCATHETER PLACEMENT OF AN INTRACORONARY STENT(S), PERCUTANEOUS, WITH OR WITHOUT OTHER THERAPEUTIC INTERVENTIONS, ANY METHOD; EACH ADDITIONAL VESSEL 59,085.00 26,325.00 32,760.00 92982 PERCUTANEOUS TRANSLUMINAL CORONARY BALLOON ANGIOPLASTY, ONE OR MORE VESSEL 59,085.00 26,325.00 32,760.00 92986 PERCUTANEOUS BALLOON VALVULOPLASTY; AORTIC 104,130.00 46,800.00 57,330.00 92987 PERCUTANEOUS BALLOON VALVULOPLASTY; MITRAL 104,130.00 46,800.00 57,330.00 92990 PERCUTANEOUS BALLOON VALVULOPLASTY; PULMONARY VALVE 104,130.00 46,800.00 57,330.00 92992 ATRIAL SEPTECTOMY OR SEPTOSTOMY; TRANSVENOUS METHOD, BALLOON (E.G., RASHKIND TYPE) (INCLUDES CARDIAC CATHETERIZATION) 41,730.00 21,255.00 20,475.00 92993 ATRIAL SEPTECTOMY OR SEPTOSTOMY; BLADE METHOD (PARK SEPTOSTOMY) (INCLUDES CARDIAC CATHETERIZATION) 41,730.00 21,255.00 20,475.00 92995 PERCUTANEOUS TRANSLUMINAL CORONARY ATHERECTOMY, BY MECHANICAL OR OTHER METHOD, WITH OR WITHOUT BALLOON ANGIOPLASTY, ONE OR MORE VESSEL 59,085.00 26,325.00 32,760.00 92997 PERCUTANEOUS TRANSLUMINAL PULMONARY BALLOON ANGIOPLASTY, ONE OR MORE VESSEL 25,155.00 12,870.00 12,285.00 93501 RIGHT HEART CATHETERIZATION 35,100.00 18,720.00 16,380.00 93503 INSERTION AND PLACEMENT OF FLOW DIRECTED CATHETER (E.G., SWAN-GANZ) FOR MONITORING PURPOSES 18,915.00 10,725.00 8,190.00 93505 ENDOMYOCARDIAL BIOPSY 45,435.00 20,865.00 24,570.00 93508 CATHETER PLACEMENT IN CORONARY ARTERY(S), ARTERIAL CORONARY CONDUITS AND/OR VENOUS CORONARY BYPASS GRAFTS FOR CORONARY ANGIOGRAPHY WITHOUT CONCOMITANT LEFT HEART CATHETERIZATION 18,915.00 10,725.00 8,190.00 93510 LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; PERCUTANEOUS 35,100.00 18,720.00 16,380.00 93511 LEFT HEART CATHETERIZATION, RETROGRADE, FROM THE BRACHIAL ARTERY, AXILLARY ARTERY OR FEMORAL ARTERY; BY CUTDOWN 35,100.00 18,720.00 16,380.00 93514 LEFT HEART CATHETERIZATION BY LEFT VENTRICULAR PUNCTURE 35,100.00 18,720.00 16,380.00 93524 COMBINED TRANSSEPTAL AND RETROGRADE LEFT HEART CATHETERIZATION 45,435.00 20,865.00 24,570.00 93526 COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT HEART CATHETERIZATION 45,435.00 20,865.00 24,570.00 93527 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH INTACT SEPTUM (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) 45,435.00 20,865.00 24,570.00 93528 COMBINED RIGHT HEART CATHETERIZATION WITH LEFT VENTRICULAR PUNCTURE (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) 45,435.00 20,865.00 24,570.00 93529 COMBINED RIGHT HEART CATHETERIZATION AND LEFT HEART CATHETERIZATION THROUGH EXISTING SEPTAL OPENING (WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION) 45,435.00 20,865.00 24,570.00 93530 RIGHT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 35,100.00 18,720.00 16,380.00 93531 COMBINED RIGHT HEART CATHETERIZATION AND RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 45,435.00 20,865.00 24,570.00 Page 108 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 93532 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH INTACT SEPTUM WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 18,915.00 10,725.00 8,190.00 93533 COMBINED RIGHT HEART CATHETERIZATION AND TRANSSEPTAL LEFT HEART CATHETERIZATION THROUGH EXISTING SEPTAL OPENING, WITH OR WITHOUT RETROGRADE LEFT HEART CATHETERIZATION, FOR CONGENITAL CARDIAC ANOMALIES 18,915.00 10,725.00 8,190.00 93539 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF ARTERIAL CONDUITS (E.G., INTERNAL MAMMARY), WHETHER NATIVE OR USED BYPASS 18,915.00 10,725.00 8,190.00 93540 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE OPACIFICATION OF AORTOCORONARY VENOUS BYPASS GRAFTS, ONE OR MORE CORONARY ARTERIES 18,915.00 10,725.00 8,190.00 93541 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR PULMONARY ANGIOGRAPHY 18,915.00 10,725.00 8,190.00 93542 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE RIGHT VENTRICULAR OR RIGHT ATRIAL ANGIOGRAPHY 18,915.00 10,725.00 8,190.00 93543 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE CORONARY ANGIOGRAPHY (INJECTION OF RADIOPAQUE MATERIAL MAY BE BY HAND) 18,915.00 10,725.00 8,190.00 93544 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR AORTOGRAPHY 45,435.00 20,865.00 24,570.00 93545 INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION; FOR SELECTIVE CORONARY ANGIOGRAPHY (INJECTION OF RADIOPAQUE MATERIAL MAY BE BY HAND) 18,915.00 10,725.00 8,190.00 93555 IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR INJECTION PROCEDURE(S) DURING CARDIAC CATHETERIZATION; VENTRICULAR AND/OR ATRIAL ANGIOGRAPHY 18,915.00 10,725.00 8,190.00 93556 IMAGING SUPERVISION, INTERPRETATION AND REPORT FOR INJECTION PROCEDURE(S) DURING CARDIAC CATHETERIZATION; PULMONARY ANGIOGRAPHY, AORTOGRAPHY, AND/OR SELECTIVE CORONARY ANGIOGRAPHY INCLUDING VENOUS BYPASS GRAFTS AND ARTERIAL CONDUITS (WHETHER NATIVE OR USE 18,915.00 10,725.00 8,190.00 93580 PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL INTERATRIAL COMMUNICATIONS (I.E., FONTAN FENESTRATION, ATRIAL SEPTAL DEFECT) WITH IMPLANT 107,250.00 41,730.00 65,520.00 93581 PERCUTANEOUS TRANSCATHETER CLOSURE OF CONGENITAL VENTRICULAR SEPTAL DEFECT WITH IMPLANT 107,250.00 41,730.00 65,520.00 93600 BUNDLE OF HIS RECORDING 18,915.00 10,725.00 8,190.00 93602 INTRA-ATRIAL RECORDING 18,915.00 10,725.00 8,190.00 93603 RIGHT VENTRICULAR RECORDING 18,915.00 10,725.00 8,190.00 93610 INTRA-ATRIAL PACING 18,915.00 10,725.00 8,190.00 93612 INTRAVENTRICULAR PACING 18,915.00 10,725.00 8,190.00 93615 ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT VENTRICULAR ELECTROGRAM(S); 18,915.00 10,725.00 8,190.00 93616 ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM WITH OR WITHOUT VENTRICULAR ELECTROGRAM(S); WITH PACING 18,915.00 10,725.00 8,190.00 93618 INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING 18,915.00 10,725.00 8,190.00 93619 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION WITH RIGHT ATRIAL PACING AND RECORDING, RIGHT VENTRICULAR PACING AND RECORDING, HIS BUNDLE RECORDING, INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS, WITHOUT INDUCTION OF ARRHYTHMIA 18,915.00 10,725.00 8,190.00 93620 COMPREHENSIVE ELECTROPHYSIOLOGIC EVALUATION INCLUDING INSERTION AND REPOSITIONING OF MULTIPLE ELECTRODE CATHETERS WITH INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA; WITH RIGHT ATRIAL PACING AND RECORDING, HIS BUNDLE RECORDING 18,915.00 10,725.00 8,190.00 93624 ELECTROPHYSIOLOGIC FOLLOW-UP STUDY WITH PACING AND RECORDING TO TEST EFFECTIVENESS OF THERAPY, INCLUDING INDUCTION OR ATTEMPTED INDUCTION OF ARRHYTHMIA 18,915.00 10,725.00 8,190.00 93631 INTRA-OPERATIVE EPICARDIAL AND ENDOCARDIAL PACING AND MAPPING TO LOCALIZE THE SITE TACHYCARDIA OR ZONE OF SLOW CONDUCTION FOR SURGICAL CORRECTION 18,915.00 10,725.00 8,190.00 93640 ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANT 18,915.00 10,725.00 8,190.00 Page 109 of 110 of Annex B

Case Rate Health Facility Fee Professional Fee RVS Code Description First Case Rate 93641 ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR LEADS INCLUDING DEFIBRILLATION THRESHOLD EVALUATION (INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION) AT TIME OF INITIAL IMPLANT 18,915.00 10,725.00 8,190.00 93642 ELECTROPHYSIOLOGIC EVALUATION OF SINGLE OR DUAL CHAMBER PACING CARDIOVERTER-DEFIBRILLATOR (INCLUDES DEFIBRILLATION THRESHOLD EVALUATION, INDUCTION OF ARRHYTHMIA, EVALUATION OF SENSING AND PACING FOR ARRHYTHMIA TERMINATION, AND PROGRAMMING OR REPROGRAMMING 18,915.00 10,725.00 8,190.00 93650 INTRACARDIAC CATHETER ABLATION OF ATRIOVENTRICULAR NODE FUNCTION, ATRIOVENTRICULAR CONDUCTION FOR CREATION OF COMPLETE HEART BLOCK, WITH OR WITHOUT TEMPORARY PACEMAKER PLACEMENT 18,915.00 10,725.00 8,190.00 93651 INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; FOR TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA BY ABLATION OF FAST OR SLOW ATRIOVENTRICULAR PATHWAYS, ACCESSORY ATRIOVENTRICULAR CONNECTIONS OR OTHER ATRIAL FOCI, SINGLY OR IN COMBINATION 18,915.00 10,725.00 8,190.00 93652 INTRACARDIAC CATHETER ABLATION OF ARRHYTHMOGENIC FOCUS; FOR TREATMENT OF VENTRICULAR TACHYCARDIA 18,915.00 10,725.00 8,190.00 93660 EVALUATION OF CARDIOVASCULAR FUNCTION WITH TILT TABLE EVALUATION, WITH CONTINUOUS ECG MONITORING AND
INTERMITTENT BLOOD PRESSURE MONITORING, WITH OR WITHOUT PHARMACOLOGICAL INTERVENTION 18,915.00 10,725.00 8,190.00 96445 CHEMOTHERAPY ADMINISTRATION INTO PERITONEAL CAVITY, REQUIRING AND INCLUDING PERITONEOCENTESIS 15,639.00 10,725.00 4,914.00 96450 CHEMOTHERAPY ADMINISTRATION INTO CNS, REQUIRING AND INCLUDING SPINAL PUNCTURE 10,842.00 8,385.00 2,457.00 96542 CHEMOTHERAPY INJECTION, SUBARACHNOID OR INTERVENTRICULAR VIA SUBCUTANEOUS RESERVOIR 7,098.00 5,460.00 1,638.00 96567 PHOTODYNAMIC THERAPY BY EXTERNAL APPLICATION OF LIGHT TO DESTROY PREMALIGNANT AND/OR MALIGNANT LESIONS OF THE SKIN AND ADJACENT MUCOSA (E.G., LIP) BY ACTIVATION OF PHOTOSENSITIVE DRUG(S), 1 OR MORE PHOTOTHERAPY EXPOSURE SESSION 15,639.00 10,725.00 4,914.00 99246 OUTPATIENT HIV / AIDS PACKAGES 14,625.00 14,625.00 -
99460 EXPANDED NEWBORN CARE PACKAGE 5,752.50 4,774.50 978.00 58300 INSERTION OF INTRAUTERINE DEVICE (IUD) 3,900.00 2,340.00 1,560.00 96408* CHEMOTHERAPY ADMINISTRATION 14,196.00 10,920.00 3,276.00 96440* CHEMOTHERAPY ADMINISTRATION INTO PLEURAL CAVITY, REQUIRING AND INCLUDING THORACENTESIS 10,842.00 8,385.00 2,457.00 96408** CHEMOTHERAPY ADMINISTRATION 10,920.00

8,400.00

2,520.00

96440** CHEMOTHERAPY ADMINISTRATION INTO PLEURAL CAVITY, REQUIRING AND INCLUDING THORACENTESIS 8,340.00

6,450.00

1,890.00

ANC01 ANTENATAL CARE PACKAGE 2,925.00 1,755.00 1,170.00 ANC02 ANTENATAL CARE SERVICES WITH INTRAPARTUM MONITORING OR LABOR WATCH (WITHOUT DELIVERY) 4,192.50 2,515.50 1,677.00 FP001 SUBDERMAL CONTRACEPTIVE IMPLANT 5,850.00 3,510.00 2,340.00 MCP01 ROUTINE OBSTETRIC CARE INCLUDING PRENATAL, DELIVERY AND NEWBORN SERVICES OF HOSPITAL FACILITIES (MATERNITY CARE PACKAGE) 12,675.00 7,605.00 5,070.00 NSD01 ROUTINE OBSTETRIC CARE INCLUDING ANTEPARTUM CARE, VAGINAL DELIVERY AND/OR POSTPARTUM CARE (NORMAL SPONTANEOUS DELIVERY PACKAGE) FOR HOSPITALS 9,750.00 5,850.00 3,900.00 P0000 RESUSCITATION PACKAGE 7,800.00 5,460.00 2,340.00 P0001 REFERRAL PACKAGE 7,800.00 5,460.00 2,340.00 Codes with * Rates appicable to all chemotherapy sessions except for Lung, Liver, Ovary, and Prostate cancer Codes with ** Rates appicable to all chemotherapy sessions for Lung, Liver, Ovary, and Prostate cancer Page 110 of 110 of Annex B

PhilHealth Procedure Case Rates (Annex B to PC2024-0037)

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PhilHealth Procedure Case Rates (Annex B to PC2024-0037)

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