OHIOHEALTH MANSFIELD HOSPITAL CHARGE LIST SERVICE CATEGORY DESCRIPTION CHARGE DOSE STATE OF OHIO REQUIREMENT Audiology Services ACOUSTIC IMMITTANCE

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1 OHIOHEALTH MANSFIELD HOSPITAL CHARGE LIST SERVICE CATEGORY DESCRIPTION CHARGE DOSE STATE OF OHIO REQUIREMENT Audiology Services ACOUSTIC IMMITTANCE TESTING $ Audiology Services ACOUSTIC REFLEX TESTING THRESHOLD $89.00 Audiology Services AUDIOMETRY EVOKED POTENTIALS - COMPREHENSIVE $1, Audiology Services AUDIOMETRY EVOKED POTENTIALS - LIMITED $ Audiology Services AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS $ Audiology Services BASE AUDIOGRAM - GN $ Audiology Services BASIC VESTIBULAR EVALUATION $ Audiology Services BRAINSTEM AUDITORY EVOKED POTENTIALS (BAER, BAEP) $ Audiology Services BRAINSTEM AUDITORY EVOKED RESPONSE-COMPREHENSIVE-GN $ Audiology Services BRAINSTEM AUDITORY EVOKED RESPONSE-LIMITED-GN $ Audiology Services CALORIC VESTIBULAR TEST W/RECORDING - BILATERAL - BITHERMAL $ Audiology Services CALORIC VESTIBULAR TEST W/RECORDING - BILATERAL - MONOTHERMAL $ Audiology Services COMPREHENSIVE AUDIOGRAM - GN $ Audiology Services COMPREHENSIVE AUDIOMETRY THRESHOLD & SPEECH RECOGNITION $ Audiology Services CONDITIONING PLAY AUDIOMETRY $ Audiology Services EAR PROTECTOR ATTENUATION MEASUREMENTS $ Audiology Services ELECTROACOUSTIC EVALUATION FOR HEARING AID - BINAURAL $ Audiology Services ELECTROACOUSTIC EVALUATION FOR HEARING AID - MONAURAL $ Audiology Services ELECTROCOCHLEOGRAPHY $ Audiology Services EVALUATION AUDITORY REHABILITATION STATUS - 1ST HOUR $ Audiology Services EVALUATION AUDITORY REHABILITATION STATUS - EACH ADD'L 15 MINUTES $ Audiology Services EVOKED OTOACOUSTIC EMISSIONS SCREENING $ Audiology Services EVOKED OTOACOUSTIC EMISSION-GN $ Audiology Services EVOKED OTOACOUSTIC EMISSIONS - COMPREHENSIVE OR DX EVALUATION $ Audiology Services EVOKED OTOACOUSTIC EMISSIONS - LIMITED $ Audiology Services HEARING AID CHECK - BINAURAL $ Audiology Services HEARING AID CHECK - MONAURAL $ Audiology Services HEARING AID EXAMINATION & SELECTION - BINAURAL $ Audiology Services HEARING AID EXAMINATION & SELECTION - MONAURAL $ Audiology Services HEARING TEST - FILTERED SPEECH $ Audiology Services HEARING TEST - SHORT INCREMENT SENSITIVITY INDEX (SISI) $ Audiology Services HEARING TEST - STENGER - PURE TONE $ Audiology Services HEARING TEST - TONE DECAY $ Audiology Services OPTOKINETIC NYSTAGMUS TEST WITH RECORDING $ Audiology Services OSCILLATING TRACKING TEST WITH RECORDING $ Audiology Services PRO AUDIOMETRY EVOKED POTENTIALS - COMPREHENSIVE $42.00 Audiology Services PRO BASIC VESTIBULAR EVALUATION $ Audiology Services PRO EVOKED OTOACOUSTIC EMISSIONS - COMPREHENSIVE $30.00 Audiology Services PRO EVOKED OTOACOUSTIC EMISSIONS - LIMITED $11.00 Audiology Services PRO OPTOKINETIC NYSTAGMUS TEST WITH RECORDING $22.00 Audiology Services PRO OSCILLATING TRACKING TEST WITH RECORDING $20.00 Audiology Services PURE TONE AUDIOMETRY (THRESHOLD) - AIR & BONE $ Audiology Services PURE TONE AUDIOMETRY (THRESHOLD) - AIR ONLY $ Audiology Services SCREENING TEST - PURE TONE - AIR ONLY $31.00 Audiology Services SELECT PICTURE AUDIOMETRY $ Audiology Services SPEECH THRESHOLD - AUDIOMETRY $ Audiology Services SPEECH THRESHOLD - AUDIOMETRY - COMPLETE $ Audiology Services STENGER TEST - SPEECH $ Audiology Services TYMPANOGRAM - GN $ Audiology Services TYMPANOMETRY (IMPEDANCE TESTING) $ Audiology Services TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENT $ Audiology Services VISUAL REINFORCEMENT AUDIOMETRY (VRA) $ Blood Products AUTOLOGOUS UNIT $1, Blood Products BLOOD $ Blood Products BLOOD, LEUKOREDUCED IRRADIATED $ Blood Products BLOOD,LEUKOREDCD,CMV NEG,IRRADIA $1, Blood Products CRYOPOOR PLASMA $ Blood Products CRYOPRECIPITATE $ Blood Products DIRECTED UNIT $1, Blood Products FRESH FROZEN PLASMA $ Blood Products FROZEN DEGLYCED CELLS $ Blood Products IRRADIATION OF BLOOD PRODUCT, EACH UNIT $51.00 Blood Products LEUKODEPLETED RBC $ Blood Products PACKED RED BLOOD CELLS $ Blood Products PLATELET CONCENTRATE $ Blood Products PLATELET HLA MATCHED $2, Blood Products PLATELET PHERESIS $1, Blood Products PLATELET PHERESIS, LEUKORED, IRRAD $1, Blood Products PLT PHER,LEUKOREDCD,CMV NEG,IR $2, Blood Products PLT,LEUKOREDUCED, IRRADIATED $ Blood Products WASHED RED BLOOD CELLS - EACH UNIT $ Breast Procedures BIOPSY BREAST 1ST LESION W/MRI (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $3, Breast Procedures BIOPSY BREAST 1ST LESION W/STEREOTACTIC GUIDANCE (LOCALIZATION DEVICE & SPECIMEN IMAGING IF DONE) $5, Breast Procedures BIOPSY BREAST 1ST LESION W/ULTRASOUND GUIDANCE (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $3, Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/ULTRASOUND (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $ Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/MRI (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $1, Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/STEROTACTIC GUIDANCE (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $ Breast Procedures INCISION OF BREAST LESION $2,490.00

2 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/MAMMOGRAPHY GUIDANCE $ Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/STEREOTACTIC GUIDANCE $ Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/ULTRASOUND GUIDANCE $ Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/MAMMOGRAPHY $ Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/STEREOTACTIC $ Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/ULTRASOUND GUIDANCE $ Breast Procedures PUNCTURE ASPIRATION CYST - BREAST - EACH ADDITIONAL $ Breast Procedures PUNCTURE ASPIRATION CYST OF BREAST (Mansfield US Explode Set) $1, Cardiac Procedures and Services 3-D MAPPING $16, Cardiac Procedures and Services ABLATION OF ARRHYTHMIA DISTINCT FROM PRIMARY $6, Cardiac Procedures and Services ANGIOGRAPHY - CORONARY WITHOUT LEFT HEART CATHETERIZATON $12, Cardiac Procedures and Services ANGIOGRAPHY - CORONARY/BYPASS GRAFTS/INTERNAL MAMMARY W/O LEFT HEART CATH $15, Cardiac Procedures and Services ANGIOGRAPHY - PULMONARY DURING CARDIAC CATHETERIZATION $2, Cardiac Procedures and Services ANGIOPLASTY - CORONARY - EACH ADD'L BRANCH MAJOR ARTERY $7, Cardiac Procedures and Services ANGIOPLASTY - CORONARY - SINGLE MAJOR ARTERY/BRANCH $7, Cardiac Procedures and Services AORTOGRAPHY SUPRAVALVULAR (ROOT) DURING CARDIAC CATHETERIZATION PROCEDURE $1, Cardiac Procedures and Services ATHERECTOMY - CORONARY - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $16, Cardiac Procedures and Services ATHERECTOMY - CORONARY - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $18, Cardiac Procedures and Services ATHERECTOMY W/ DRUG-ELUTING STENT PLACEMENT SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $21, Cardiac Procedures and Services ATHERECTOMY W/DRUG-ELUTING STENT PLACEMENT EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $16, Cardiac Procedures and Services ATHERECTOMY WITH STENT PLACEMENT EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $14, Cardiac Procedures and Services ATHERECTOMY WITH STENT PLACEMENT SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $18, Cardiac Procedures and Services CARDIAC REHAB PHASE II NON-MONITOR VISIT $ Cardiac Procedures and Services CARDIAC REHAB VISIT $ X Cardiac Procedures and Services CARDIAC REHAB-MEDICAID-PER DAY $ Cardiac Procedures and Services CARDIAC STRESS TEST - TRACING ONLY WITHOUT INTERPRETATION & REPORT $1, Cardiac Procedures and Services CARDIOPULMONARY RESUSCITATION (CPR) $2, Cardiac Procedures and Services CARDIOVERSION - ELECTIVE $3, Cardiac Procedures and Services CATHETERIZATION LEFT HEART W/CORNARY ANGIO & LEFT VENTRICULAR ANGIO (IF PERFORMED) $15, Cardiac Procedures and Services CATHETERIZATION LEFT HEART W/CORONARY/CB/LIMA ANGIOGRAPHY W/ or W/O LEFT VENTRICULOGRAPHY $16, Cardiac Procedures and Services CATHETERIZATION RIGHT & LEFT HEART W/CORONARY ANGIO W/ or W/O LEFT VENTRICULOGRAPHY $16, Cardiac Procedures and Services CATHETERIZATION RIGHT & LEFT HEART W/CORONARY/CBG/LIMA ANGIOPLASTY W/ or W/O VENTRICULAR ANGIOPLASTY $18, Cardiac Procedures and Services CATHETERIZATION RIGHT HEART W/CORONARY/CBG/LIMA ANGIOPLASTY $17, Cardiac Procedures and Services CATHETERIZATION RIGHT HEART WITH CORNARY ANGIOGRAPHY $16, Cardiac Procedures and Services COLOR FLOW MAPPING $ Cardiac Procedures and Services CORONARY FLOW RESERVE MEASUREMENT - INITIAL VESSEL - FRACTIONAL FLOW RESERVE (FFR) $7, Cardiac Procedures and Services CORONARY FLOW RESERVE MEASUREMENT EACH ADDITIONAL VESSEL $3, Cardiac Procedures and Services DEFIBRILLATION THRESHOLD TESTING ICD SYSTEM AT TIME OF IMPLANT (DFTs) $5, Cardiac Procedures and Services DEVICE EVALUATION & PROGRAMMING (CARDIOVERTER-DEFIBRILLATOR) - PERI-PROCEDURE $ Cardiac Procedures and Services DEVICE INTERROGATION EVAL IN PERSON LEADLESS PM SYSTEM $ Cardiac Procedures and Services DEVICE PROGRAMMING EVAL IN PERSON LEADLESS PM SYSTEM $ Cardiac Procedures and Services DFT'S ICD LEADS AT TIME OF IMPLANT OR REPLACEMENT $5, Cardiac Procedures and Services DOPPLER ECHOCARDIOGRAPHY FOLLOW-UP OR LIMITED STUDY $ Cardiac Procedures and Services DOPPLER ECHOCARDOPGRAPHY - COMPLETE $ Cardiac Procedures and Services ECHOCARDIOGRAM - TRANSTHORACIC - LIMITED OR FOLLOW-UP $1, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSESOPHAGEAL (TEE) $3, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSESOPHAGEAL FOR CONGENITAL CARDIAC ANOMALIES $2, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC 2D (TTE) $1, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC FOR CONGENITAL CARDIAC ANOMOLIES - COMPLETE $2, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC REST & STRESS W/INTERPRETATION & REPORT $2, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC WITH DOPPLER & COLOR FLOW MAPPING $2, Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC WITHOUT DOPPLER OR COLOR FLOW $1, Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST - STRESS & REST STUDY W/PHYSICIAN SUPERVISION (EXPLODE SET) $3, Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST FOR CONGENITAL CARDIAC ANOMOLIES (EXPLODE SET) $3, Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST OR W/O CONTRAST FOLLOWED BY CONTRAST W/O SPECTRAL OR COLOR FLOW (EXPLODE SET) $2, Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST WITH SPECTRAL & COLOR FLOW DOPPLER (EXPLODE SET) $3, Cardiac Procedures and Services ECHOCARDIOGRAM WITH CONTRAST - LIMITED OR FOLLOW-UP STUDY (EXPLODE SET) $2, Cardiac Procedures and Services ECHOGARDIOGRAM TRANSTHORACIC FOR CONGENITAL CARDIAC ANOMALIES - FOLLOW-UP OR LIMITED $2, Cardiac Procedures and Services EKG (ELECTROCARDIOGRAM) - TRACING ONLY W/O INTERPRETATION & REPORT $ Cardiac Procedures and Services ENDOLUMINAL IMAGING WITH INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) - EACH ADD'L VESSEL $6, Cardiac Procedures and Services ENDOLUMINAL IMAGING WITH INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) - INITIAL VESSEL $7, Cardiac Procedures and Services ENDOMYOCARDIAL BIOPSY $10, Cardiac Procedures and Services EP BUNDLE OF HIS RECORDING $7, Cardiac Procedures and Services EP ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM $8, Cardiac Procedures and Services E-P EVALUATION SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR $ Cardiac Procedures and Services EP FOLLOW UP STUDY $7, Cardiac Procedures and Services EP INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING $6, Cardiac Procedures and Services EP INTRA-ATRIAL PACING $6, Cardiac Procedures and Services EP INTRA-ATRIAL RECORDING $6, Cardiac Procedures and Services EP INTRAVENTRICULAR PACING $7, Cardiac Procedures and Services EP STUDY & ABLATION FOR SUPRAVENTRICULAR TACHYCARDIA $43, Cardiac Procedures and Services EP STUDY & ABLATION FOR VENTRICULAR TACHYCARDIA $53, Cardiac Procedures and Services EP STUDY COMPREHENSIVE EVALUATION RIGHT W/O ARRYTHMIA INDUCTION $17, Cardiac Procedures and Services EP VENT RECORD $7, Cardiac Procedures and Services EP-ABLATION-AV NODE FUNCTION $28, Cardiac Procedures and Services EP-COMPREHENSIVE LT ATRIAL $15, Cardiac Procedures and Services EP-COMPREHENSIVE LT VENT $16, Cardiac Procedures and Services EP-COMPREHENSIVE RT W/ARRYTH $29, Cardiac Procedures and Services EP-EVALUATION OF AICD (AUTOMATIC IMPLANTABLE CARDIOVERTER DEFIBRILLATOR) $6, Cardiac Procedures and Services EVALUATE DEVICE - IMPLANTABLE DEFIBRILLATOR SYSTEM - SINGLE/DUAL/MULTI LEAD $ Cardiac Procedures and Services HOLTER MONITOR RECORDING - UP TO 48 HOURS $ X

3 Cardiac Procedures and Services HOLTER MONITOR SCANNING - UP TO 48 HOURS $ X Cardiac Procedures and Services INSERTION CATHETER (SWAN GANZ) FOR MONITORING PURPOSES $7, Cardiac Procedures and Services INSERTION SWAN-GANZ CATHETER - INPATIENT BEDSIDE PROCEDURE $5, Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION - IMPLANTABLE SUBCUTANEOUS DEFIBRILLATOR $ Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION - PACEMAKER SYSTEM - SINGLE/DUAL/MULTI LEAD $ Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION (REMOTE) IMPLANTABLE CV MONITOR OR IMPLANTABLE LOOP RECORDER $ Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION (REMOTE) PACEMAKER SINGLE-DUAL-MULTI LEAD $ Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION IMPLANTABLE CARDIOVASCUALR MONITOR SYSTEM $ Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION IMPLANTABLE LOOP RECORDER $ Cardiac Procedures and Services INTRACARDIAC ECHOCARDIOGRAPHY $5, Cardiac Procedures and Services LEFT HEART CATH BY TRANSEPTAL PUNCTURE $2, Cardiac Procedures and Services MULTI SITE MAPPING $14, Cardiac Procedures and Services MYOCARDIAL STRAIN IMAGING $ Cardiac Procedures and Services NIPS PROCEDURE (NON-INVASIVE PACEMAKER STIMULATION) $1, Cardiac Procedures and Services NUCLEAR STRESS TEST - TRACING ONLY - NO INTERPRETATION OR REPORT $1, Cardiac Procedures and Services PERIPHERAL ARTERIAL DISEASE (PAD) REHAB, PER SESSION $ Cardiac Procedures and Services PLACEMENT CORONARY STENT - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $15, Cardiac Procedures and Services PLACEMENT CORONARY STENT - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $17, Cardiac Procedures and Services PLACEMENT DRUG-ELUTING STENT - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $7, Cardiac Procedures and Services PLACEMENT DRUG-ELUTING STENT - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $17, Cardiac Procedures and Services PRO PRQ CORONARY ANGIOPLASTY ADDL BRANCH $1, Cardiac Procedures and Services PRO R & L HEART CATH W/CORONARY ANGIO & LT VENTRICULAR IMAGING $ Cardiac Procedures and Services PROGRAMMED STIMULATION AND PACING AFTER IV DRUG INFUSION $9, Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - DEFIBRILLATOR MULTI LEAD $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - IMPLANTABLE LOOP RECORDER SYSTEM $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - IMPLANTED SUBCUTANEOUS DEFIBRILLATOR $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER DUAL LEAD SYSTEM $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER MULTI LEAD SYSTEM $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER SINGLE LEAD SYSTEM $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION (IN PERSON) - DUAL LEAD PACEMAKER SYSTEM $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION CARDIOVERTER-DEFIBRILLATOR - DUAL LEAD $ Cardiac Procedures and Services PROGRAMMING DEVICE EVALUTATION - DEFIBRILLATOR SINGLE LEAD $ Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- EACH ADD'L BRANCH - ANY METHOD $15, Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT OF OR THROUGH CABG - EACH ADD'L BRANCH - ANY METHOD $7, Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- SINGLE VESSEL $18, Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- SINGLE VESSEL - ANY METHOD $17, Cardiac Procedures and Services REVASCULARIZATION CHRONIC TOTAL OCCLUSION - EACH ADD'L VESSEL $14, Cardiac Procedures and Services REVASCULARIZATION DURING ACUTE MI - SINGLE VESSEL $22, Cardiac Procedures and Services REVASCULARIZATION DURING ACUTE MI - SINGLE VESSEL $20, Cardiac Procedures and Services REVASCULARIZATION OF TOTAL OCCLUSION - EACH ADD'L VESSEL $11, Cardiac Procedures and Services REVASCULARIZATION OF TOTAL OCCLUSION - SINGLE VESSEL $28, Cardiac Procedures and Services REVASCULARIZATION TOTAL OCCLUSION - SINGLE VESSEL $28, Cardiac Procedures and Services RHYTHM EKG $70.00 Cardiac Procedures and Services RIGHT HEART CATHETERIZATION $13, Cardiac Procedures and Services SIGNAL AVERAGED-EKG $ Cardiac Procedures and Services TEE WITH CONTRAST (TRANSESOPHAGEAL ECHOCARDIOGRAM) (EXPLODE SET) $3, Cardiac Procedures and Services TEMPORARY TRANSCUTANEOUS PACING $1, Cardiac Procedures and Services THROMBECTOMY CORONARY PERCUTANEOUS TRANSLUMINAL $4, Cardiac Procedures and Services THROMBOLYSIS - CORONARY BY INTRACORONARY INFUSION $1, Cardiac Procedures and Services THROMBOLYSIS - CORONARY BY INTRAVENOUS INFUSION $ Cardiac Procedures and Services TILT TABLE TESTING $3, Cardiac Procedures and Services TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR $58, Cardiac Procedures and Services TRANSCATH REMOVAL LEADLESS PM VENTRICULAR $9, Cardiac Procedures and Services TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVALUATION - SINGLE/DUAL/MULTI LEAD $ Cardiac Procedures and Services TREATMENT OF A-FIB ADD'L - AFTER PULMONARY VEIN ISOLATION $6, Cardiac Procedures and Services TREATMENT OF A-FIB BY ABLATION BY PULMONARY VEIN ISOLATION $102, Cardiac Procedures and Services UNLISTED CARDIOVASCULAR PROCEDURE $ Cardiovascular procedures ANGIOJET VENOUS REPEAT SUBSEQUENT DAY $6, Cardiovascular procedures ANGIOPLASTY CENTRAL DIALYSIS SEGMENT W/IMAGING S&I $9, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ EACH ADD'L ARTERY INCLUDING IMAGES/S&I $6, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ EACH ADD'L VEIN INCLUDING IMAGES/S& $4, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL ARTERY INCLUDING IMAGES/S&I - BILATERAL $19, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL ARTERY INCLUDING IMAGES/S&I - UNILATERAL $13, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL VEIN INCLUDING IMAGES/S&I - BILATERAL (EXCEPT DIALYSIS CIRCUIT) $13, Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL VEIN INCLUDING IMAGES/S&I - UNILATERAL (EXCEPT DIALYSIS CIRCUIT) $8, Cardiovascular procedures ARTERIAL CATHETERIZATION/CANNULATION FOR SAMPLING/MONITORING/TRANSFUSION - PERCUTANEOUS $ Cardiovascular procedures ARTERIAL PUNCTURE $ X Cardiovascular procedures BIOPSY TRANSCATHETER $3, Cardiovascular procedures BLOOD DRAW< 3YRS FEM/JUGULAR $32.00 Cardiovascular procedures CAPILLARY BLOOD DRAW $17.00 Cardiovascular Procedures CAROTID STENTING $11, Cardiovascular procedures CATH PLACEMENT SELECTIVE 1ST ORDER FOR RENAL ANGIOGRAPHY - BILATERAL $10, Cardiovascular procedures CATH PLACEMENT SELECTIVE 1ST ORDER FOR RENAL ANGIOGRAPHY- UNILATERAL $8, Cardiovascular procedures CATH PLACEMENT SUPERSELECTIVE FOR RENAL ANGIOGRAPHY - BILATERAL $6, Cardiovascular procedures CATH PLACEMENT SUPERSELECTIVE FOR RENAL ANGIOGRAPHY - UNILATERAL $4, Cardiovascular procedures CATHETER PLACEMENT ARTERY 1ST ORDER THORACIC/BRACHIOCEPHALIC BRANCH $1, Cardiovascular procedures CATHETER PLACEMENT ARTERY 2ND ORDER ABDOMEN/PELVIS/LOWER EXTREMITY $2, Cardiovascular procedures CATHETER PLACEMENT ARTERY 2ND ORDER THORACIC/BRACHIOCEPHALIC BRANCH $1, Cardiovascular procedures CATHETER PLACEMENT ARTERY 3RD ORDER ABDOMEN/PELVIS/LOWER EXTREMITY $2, Cardiovascular procedures CATHETER PLACEMENT ARTERY 3RD ORDER THORACIC/BRACHIOCEPHALIC BRANCH $2, Cardiovascular procedures CATHETER PLACEMENT ARTERY ADD'L ABDOMEN/PELVIS/LOWER EXTREMITY $147.00

4 Cardiovascular procedures CATHETER PLACEMENT ARTERY ADD'L THORACIC/BRACHIOCEPHALIC BRANCH $ Cardiovascular procedures CATHETER PLACEMENT NON-SELECTIVE UNILATERAL OR BILATERAL $13, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - UNILATERAL $21, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY - UNILATERAL $13, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY W/EXTRACRANIAL ANGIO - BILATERAL $20, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY W/INTRACRANIAL ANGIO - BILATERAL $26, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EACH INTRACRANIAL BRANCH - BILATERAL $2, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EACH INTRACRANIAL BRANCH - UNILATERAL $1, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EXTERNAL CAROTID ARTERY - BILATERAL $ Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EXTERNAL CAROTID ARTERY - UNILATERAL $ Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - SUBCLAVIAN OR INNOMINATE ARTERY - BILATERAL $20, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - SUBCLAVIAN OR INNOMINATE ARTERY - UNILATERAL $3, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - VERTEBRAL ARTERY - BILATERAL $43, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE COMMON CAROTID OR INNOMINATE ARTERY - UNILATERAL $13, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE -INTERNAL CAROTID ARTERY - BILATERAL $34, Cardiovascular procedures CATHETER PLACEMENT SELECTIVE -INTERNAL CAROTID ARTERY - UNILATERAL $17, Cardiovascular procedures CATHETERIZATION UMBILICAL VEIN - NEWBORN FOR DX. OR THERAPY $ Cardiovascular procedures DECLOT VASCULAR ACCESS DEVICE $ Cardiovascular procedures ELECTRODE REPOSITION $14, Cardiovascular procedures EMBOLIZATION OR OCCLUSION DIALYSIS CIRCUIT W/IMAGING S&I $50, Cardiovascular procedures EMBOLIZATION/OCCLUSION ARTERIAL (OTHER THAN HEMORRHAGE OR TUMOR) $50, Cardiovascular procedures EMBOLIZATION/OCCLUSION TUMOR/ORGAN ISCHEMIA/INFARCTION $39, Cardiovascular procedures EMBOLIZATION/OCCLUSION VENOUS (OTHER THAN HEMORRHAGE) $50, Cardiovascular procedures EMBOLIZATION/OCCLUSION VENOUS OR ARTERIAL HEMORRHAGE $39, Cardiovascular procedures ENDOVASC RPR DPLMNT AORTO-BI-ILIAC ENDOGRAFT $21, Cardiovascular procedures ENDOVASC RPR DPLMNT AORTO-BI-ILIAC ENDOGRAFT RUPTURE $21, Cardiovascular procedures ENDOVASC RPR ILIO-ILIAC ENDOGRAFT $21, Cardiovascular procedures INJECT EXISTING CV DEVICE $ Cardiovascular procedures INJECTION FOR TREATMENT OF EXTREMITY PSEUDOANEURYSM (EG, THROMBIN) $ Cardiovascular procedures INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY $ Cardiovascular procedures INSERT OR REPLACE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH LEAD(S) - SINGLE OR DUAL $25, Cardiovascular Procedures INSERT OR REPLACE TEMPORARY PACEMAKER - INPATIENT BEDSIDE PROCEDURE $8, Cardiovascular procedures INSERT PERIPHERALLY VENOUS ACCESS DEVICE W/SUBCUTANEOUS PORT AGE 5 YEARS OR > $5, Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/ TRANVENOUS ATRIAL LEAD $29, Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/ATRIAL & VENTRICULAR LEADS $23, Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/VENTRICULAR LEAD $23, Cardiovascular procedures INSERTION TUNNELED CV CATHETER W/ 2 ACCESS SITES (TESIO TYPE) $4, Cardiovascular procedures INSERTION AORTIC BALLOON PUMP $3, Cardiovascular Procedures INSERTION ARTERIAL LINE (A-LINE) - INPATIENT BEDSIDE PROCEDURE $ Cardiovascular procedures INSERTION CARDIOVERTER-DEFIBRILLATOR GENERATOR WITH EXISTING DUAL LEADS $24, Cardiovascular procedures INSERTION CARDIOVERTER-DEFIBRILLATOR GENERATOR WITH EXISTING MULTIPLE LEADS $19, Cardiovascular Procedures INSERTION CENTRAL VENOUS CATHETER - INPATIENT BEDSIDE PROCEDURE $1, Cardiovascular procedures INSERTION LEFT VENTRICULAR LEAD TO PREVIOUSLY PLACED GENERATOR $36, Cardiovascular procedures INSERTION NON-TUNNEL CV CATHETER - YOUNGER THAN 5 YEARS $1, Cardiovascular procedures INSERTION NON-TUNNELED CV CATHETER > 5YRS (CENTRAL LINE) $1, Cardiovascular procedures INSERTION OF DUAL CHAMBER LEADS $19, Cardiovascular procedures INSERTION OF LV LEAD AT TIME OF INSERTION OF PACEMAKER OR DEFIBRILLATOR $25, Cardiovascular procedures INSERTION OF SINGLE TRANSVENOUS ELECTRODE (PACEMAKER OR CARDIOVERTER-DEFIBRILLATOR) $21, Cardiovascular procedures INSERTION OR REPLACEMENT SUBCUTANOEUS IMPLANTABLE DEFIBRILLAOTR W/LEAD $25, Cardiovascular procedures INSERTION OR REPLACEMENT TEMPORARY PACEMAKER-SINGLE CHAMBER $11, Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING DUAL LEADS $37, Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING MULTIPLE LEADS $13, Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING SINGLE LEAD $18, Cardiovascular procedures INSERTION TUNNELED CV CATH W/PORT 5YRS OR OLDER $6, Cardiovascular procedures INSERTION TUNNELED CV CATHETER W/O PORT 5 YEARS OR OLDER $4, Cardiovascular procedures INSERTION VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $18, Cardiovascular procedures INSERTION VENTRICULAR ASSIST DEVICE - PERCUTANEOUS - ARTERIAL ACCESS ONLY $8, Cardiovascular procedures INTRAVASCULAR ULTRASOUND 1ST NONCORONARY VESSEL - INCLUDES S&I $1, Cardiovascular procedures INTRAVASCULAR ULTRASOUND EACH ADDITIONAL NONCORONARY VESSEL - INCLUDES S&I $ Cardiovascular procedures INTRO OF NEEDLE OR INTRACATHETER UPR/LXTR ARTERY $1, Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/ANGIOPLASTY INCLUDES IMAGES/S&I $10, Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/DX ANGIOGRAPHY INCLUDES IMAGES/S&I $1, Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/STENT PLACEMENT INCLUDES IMAGES/S&I $62, Cardiovascular procedures INTRODUCE NEEDLE AORTIC TRANSLUMBAR $ Cardiovascular procedures INTRODUCTION CATHETER SUPERIOR OR INFERIOR VENA CAVA $ Cardiovascular procedures INTRODUCTION CATHETER RIGHT HEART OR PULMONARY ARTERY $ Cardiovascular Procedures INTRODUCTION NEEDLE CAROTID OR VERTEBRAL ARTERY $1, Cardiovascular procedures INTRODUCTION NEEDLE OR INTRACATHETER - VEIN $ Cardiovascular procedures INTRODUCTION OF CATHETER - AORTA $1, Cardiovascular procedures LIGATION OF AV FISTULA $3, Cardiovascular procedures LIGATION OF INFERIOR VENA CAVA $14, Cardiovascular procedures LINE DRAW FROM VENOUS ACCESS DEVICE - COLLECTION OF BLOOD SPECIMEN $ Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - ARTERY - PRIMARY INITIAL VESSEL (2016 INCLUDES GUIDANCE) $8, Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - ARTERY - SUBSEQUENT VESSEL (2016 INCLUDES GUIDANCE) $6, Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - VENOUS $6, Cardiovascular procedures PERCUTANEOUS PORTAL VEIN CATHETERIZATION - ANY METHOD $1, Cardiovascular procedures PERICARDIOCENTESIS - INITIAL (DRAINAGE OF HEART SAC) $ Cardiovascular procedures PERICARDIOCENTESIS - SUBSEQUENT (DRAINAGE OF HEART SAC) $1, Cardiovascular procedures PERIPHERAL BLOOD DRAW - VENIPUNCTURE $17.00 Cardiovascular procedures PERIPHERAL BLOOD DRAW - VENIPUNCTURE - OUTREACH $17.00 Cardiovascular procedures PERIPHERALLY INSERTED CENTRAL CATHETER - 5 YRS. OR OLDER (PICC LINE) $2,788.00

5 Cardiovascular procedures PERIPHERALLY INSERTED MIDLINE CATHETER $1, Cardiovascular procedures PLACEMENT EXTN PROSTH FOR ENDOVASCULAR REPAIR $5, Cardiovascular procedures PLACEMENT INTRAVASCAULAR STENT 1ST VEIN $51, Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT 1ST ARTERY - BILATERAL $77, Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT 1ST ARTERY - UNILATERAL $18, Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT ADD'L ARTERY $19, Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT ADD'L VEIN $25, Cardiovascular Procedures PLACEMENT OCCLUSIVE DEVICE $ Cardiovascular procedures PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION $ Cardiovascular procedures PORTACATH/GROSHONG LINE DRAW - COLLECTION OF BLOOD SPECIMEN $ Cardiovascular procedures RELOCATION OF SKIN POCKET FOR CARDIOVERTER-DEFIBRILLATOR $7, Cardiovascular procedures RELOCATION OF SKIN POCKET FOR PACEMAKER $7, Cardiovascular procedures REMOVAL DEFIBRILLATOR PULSE GENERATOR ONLY $7, Cardiovascular procedures REMOVAL INTRAVASCULAR FOREIGN BODY WITH IMAGING IF PERFORMED $10, Cardiovascular procedures REMOVAL OF ELECTRODE(S) DUAL LEAD SYSTEM $8, Cardiovascular procedures REMOVAL PACEMAKER PULSE GENERATOR ONLY $8, Cardiovascular procedures REMOVAL PERCUTANEOUS VENTRICULAR ASSIST DEVICE - DIFFERENT SESSION $2, Cardiovascular procedures REMOVAL TUNNELED CENTRAL VENOUS CATHETER WITHOUT PORT OR PUMP $2, Cardiovascular procedures REMOVAL VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $12, Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - DUAL LEAD SYSTEM $23, Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - MULTIPLE LEAD SYSTEM $22, Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - SINGLE LEAD SYSTEM $23, Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - DUAL LEAD SYSTEM $23, Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - MULTIPLE LEAD SYSTEM $19, Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - SINGLE LEAD SYSTEM $21, Cardiovascular procedures REMOVE AORTIC BALLOON PUMP $2, Cardiovascular procedures REMOVE CARDIOVERTER-DEFIBRILLATOR LEAD(S) - SINGLE OR DUAL $33, Cardiovascular procedures REMOVE LUMEN OBSTRUCTION FROM VENOUS ACCESS DEVICE $1, Cardiovascular procedures REMOVE OBSTRUCTION FROM VENOUS ACCESS DEVICE $2, Cardiovascular procedures REMOVE TUNNELED CVA CATHETER WITH PORT $3, Cardiovascular procedures REPAIR BLOOD VESSEL LESION $3, Cardiovascular procedures REPAIR CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP $1, Cardiovascular procedures REPAIR OF SINGLE TRANSVENOUS LEAD (PACEMAKER OR CARDIO-DEFIBRILLATOR) $28, Cardiovascular Procedures REPAIR TESIO CATHETER $ Cardiovascular procedures REPLACE CV ACCESS DEVICE - COMPLETE - SAME VENOUS ACCESS WITH SQ PORT $11, Cardiovascular procedures REPLACE NON-TUNNELED CENTRAL VENOUS CATHETER THROUGH SAME VENOUS ACCESS - NO PORT OR PUMP $2, Cardiovascular procedures REPLACE TUNNELED CV CATHETER W/O PORT THRU SAME ACCESS $3, Cardiovascular procedures REPLACEMENT PICC LINE $2, Cardiovascular procedures REPLACEMENT TUNNELED CV ACCESS DEVICE W/PORT $8, Cardiovascular procedures REPOSITION CV CATH W/FLUOROSCOPY $1, Cardiovascular procedures REPOSITION LEFT VENTRICULAR LEAD (INCLUDES REMOVAL, INSERT/REPLACE GENERATOR) $21, Cardiovascular procedures REPOSITION PERCUTANEOUS VENTRICULAR ASSIST DEVICE $ Cardiovascular procedures REPOSITION VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $10, Cardiovascular procedures REVASCULARIZATION ADD'L ILIAC VESSEL WITH ANGIOPLASTY - BILATERAL $27, Cardiovascular procedures REVASCULARIZATION ADD'L ILIAC VESSEL WITH ANGIOPLASTY - UNILATERAL $18, Cardiovascular procedures REVASCULARIZATION EACH ADD'L ILIAC VESSEL W/STENT - WITH OR WITHOUT ANGIO - BILATERAL $34, Cardiovascular procedures REVASCULARIZATION EACH ADD'L ILIAC VESSEL WITH STENT - WITH OR WITHOUT ANGIO $23, Cardiovascular procedures REVASCULARIZATION EACH ADD'L TIBIAL/PERONEAL ARTERY WITH ANGIOPLASTY - UNILATERAL $23, Cardiovascular procedures REVASCULARIZATION EACH ADD'L TIBIAL/PERONEAL WITH STENT & ANGIOPLASTY - UNILATERAL $18, Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) W/STENT & ANGIOPLASTY -UNILATERAL $49, Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) W/STENT & ATHERECTOMY (INCLUDES ANGIO IF DONE) $61, Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) WITH ANGIOPLASTY - BILATERAL $34, Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) WITH ANGIOPLASTY - UNILATERAL $23, Cardiovascular procedures REVASCULARIZATION ILIAC ARTERY - INITIAL VESSEL - UNILATERAL - WITH ANGIOPLASTY $23, Cardiovascular procedures REVASCULARIZATION ILIAC ARTERY W/STENT - INITIAL - UNILATERAL - W/ OR W/O ANGIOPLASTY $23, Cardiovascular procedures REVASCULARIZATION OPEN OR PERQ FEMORAL-POPLITEAL ARTERY(S) W/ATHERECTOMY - UNILATERAL $41, Cardiovascular procedures REVASCULARIZATION OPEN OR PERQ TIBIAL-PERONEAL ARTERY W/ATHERECTOMY - UNILATERAL $41, Cardiovascular procedures REVASCULARIZATION TIBIAL/PERONEAL ARTERY WITH ANGIOPLASTY - UNILATERAL $23, Cardiovascular procedures REVASCULARIZATION TIBIAL/PERONEAL ARTERY WITH STENT & ANGIOPLASTY - UNILATERAL $39, Cardiovascular procedures REVASCULARIZE ILIAC ARTERY - INITIAL VESSEL -BILATERAL - W/ANGIOPLASTY $34, Cardiovascular procedures REVASCULARIZE ILIAC ARTERY W/STENT - INITIAL VESSEL- BILATERAL W/ OR W/O ANGIOPLASTY $34, Cardiovascular procedures REVISION TIPS (TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT) $10, Cardiovascular procedures SECONDARY ARTERIAL MECHANICAL THROMBECTOMY ADD-ON $6, Cardiovascular procedures SELECTIVE CATH PLACEMENT SEGMENTAL/SUBSEGMENTAL PULMONARY ARTERY $ Cardiovascular procedures SELECTIVE CATH PLACEMENT SEGMENTAL/SUBSEGMENTAL PULMONARY ARTERY- BILATERAL $1, Cardiovascular procedures SELECTIVE CATHETER PLACEMENT ARTERY 1ST ORDER ABD/PEVIS/LEG - BILATERAL-50 $1, Cardiovascular procedures SELECTIVE CATHETER PLACEMENT EA. 1ST ORDER ARTERY ABD/PELVIS/LEG - UNILATERAL $1, Cardiovascular procedures SELECTIVE CATHETER PLACEMENT PULMONARY ARTERY $1, Cardiovascular procedures SELECTIVE CATHETER PLACEMENT VENOUS SYSTEM 1ST BRANCH $1, Cardiovascular procedures SELECTIVE CATHETER PLACEMENT VENOUS SYSTEM 2ND BRANCH $2, Cardiovascular procedures STENT PLACEMENT CENTRAL DIALYSIS SEGMENT W/IMAGING S&I $51, Cardiovascular procedures THROMBECTOMY PERCUTANEOUS A-V FISTULA GRAFT $5, Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT INCLUDES DX ANGIOGRAPHY & IMAGING S&I $6, Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT W/ANGIOPLASTY & IMAGING S&I $15, Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT W/STENT PLACEMENT & IMAGING S&I $67, Cardiovascular procedures THROMBOLYSIS CEREBRAL BY INTRAVENOUS INFUSION (THROMBOLYTIC THERAPY - STROKE) $ Cardiovascular procedures THROMBOLYSIS NON-CORONARY - CONTINUED/FOLLOW-UP $8, Cardiovascular procedures THROMBOLYSIS NON-CORONARY - SUBSEQUENT- INCLUDES REMOVAL/CLOSURE $8, Cardiovascular procedures THROMBOLYSIS NON-CORONARY ARTERIAL INFUSION - INITIAL DAY (INCLUDES S &I) $4, Cardiovascular procedures THROMBOLYSIS NON-CORONARY ARTERIAL INFUSION - INITIAL DAY (INCLUDES S &I) - BILATERAL $6, Cardiovascular procedures THROMBOLYSIS NON-CORONARY VENOUS INFUSION - INITIAL DAY $3,697.00

6 Cardiovascular procedures TIPS INSERTION $19, Cardiovascular procedures TRANSCATHETER PLACEMENT INTRAVASCULAR STENT CERVICAL CAROTID ARTERY W/EMBOLIC PROTECTION DEVICE $16, Cardiovascular procedures TRANSCATHETER PLACEMENT INTRAVASCULAR STENT CERVICAL CAROTID ARTERY W/O EMBOLIC PROTECTION $11, Cardiovascular procedures ULTRASOUND GUIDED ABLATION 1ST VEIN - EXTREMITY $9, Cardiovascular procedures ULTRASOUND GUIDED ABLATION ADDITIONAL VEIN - EXTREMITY $4, Cardiovascular procedures UNLISTED CARDIAC SURGERY $2, Cardiovascular procedures UNLISTED VASCULAR SURGERY PROCEDURE $3, Cardiovascular procedures UPGRADE SINGLE CHAMBER PACEMAKER SYSTEM TO DUAL CHAMBER SYSTEM $33, Cardiovascular procedures VEIN ACCESS CUTDOWN <1YR $26.00 Cardiovascular procedures VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING $ CT Scan Services 3D RENDERING W/POSTPROCESSING $1, CT Scan Services CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME $3, CT Scan Services CT ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST $3, CT Scan Services CT ABDOMEN AND PELVIS WITH IV CONTRAST $3, X CT Scan Services CT ABDOMEN AND PELVIS WITHOUT IV CONTRAST $3, X CT Scan Services CT ABDOMEN W&W/O IV CONTRAST - W/ ORAL CONTRAST $2, CT Scan Services CT ABDOMEN WITH IV CONTRAST-WITH OR WITHOUT ORAL CONTRAST $2, CT Scan Services CT ABDOMEN WITHOUT IV CONTRAST - WITH OR WITHOUT ORAL CONTRAST $2, CT Scan Services CT BRAIN WITH & WITHOUT CONTRAST $1, CT Scan Services CT BRAIN WITH CONTRAST $1, CT Scan Services CT BRAIN WITHOUT CONTRAST $1, X CT Scan Services CT CERVICAL SPINE WITH CONTRAST $1, CT Scan Services CT CERVICAL SPINE WITHOUT CONTRAST $1, X CT Scan Services CT CHEST - LOW DOSE FOR LUNG CANCER SCREENING (LDCT) $2, CT Scan Services CT CHEST/MEDIASTINUM WITH & WITHOUT CONTRAST $2, CT Scan Services CT CHEST/MEDIASTINUM WITH CONTRAST $2, X CT Scan Services CT CHEST/MEDIASTINUM WITHOUT CONTRAST $2, X CT Scan Services CT C-SPINE MULTI-LEVEL W&W/O CONTRAST $1, CT Scan Services CT FACIAL BONES WITH CONTRAST $1, CT Scan Services CT GUIDANCE FOR NEEDLE PLACEMENT (FINE NEEDLE ASPIRATION/BIOPSY/LOCALIZATION) $5, CT Scan Services CT GUIDANCE FOR PARENCHYMAL TISSUE ABLATION $ CT Scan Services CT GUIDANCE FOR STEREOTACTIC LOCALIZATION $3, CT Scan Services CT GUIDANCE PLACEMENT RADIATION FIELDS $2, CT Scan Services CT HEART W/CONTRAST W/EVALUATION CARDIAC STRUCTURES & MORPHOLOGY (EXPLODE SET) $6, CT Scan Services CT HEART W/CONTRAST W/EVALUATION STRUCTURE & FUNCTION CONGENITAL HEART DISEASE (EXPLODE SET) $4, CT Scan Services CT HEART W/O CONTRAST W/EVAL OF CORONARY CALCIUM (EXPLODE SET) - SCREENING ONLY $95.00 CT Scan Services CT HEART W/O CONTRAST W/EVAL OF CORONARY CALCIUM (EXPLODE SET) -DIAGNOSTIC ONLY $2, CT Scan Services CT LIMITED OR FOLLOW-UP STUDY (ALSO USED FOR SINUS SCREENING) $1, CT Scan Services CT LOWER EXTREMITY W&W/O CONTRAST $1, CT Scan Services CT LOWER EXTREMITY W/CONTRAST $1, CT Scan Services CT LOWER EXTREMITY W/O CONTRAST $1, CT Scan Services CT LUMBAR SPINE W&W/O CONTRAST $1, CT Scan Services CT LUMBAR SPINE WITH CONTRAST $1, CT Scan Services CT LUMBAR SPINE WITHOUT CONTRAST $1, CT Scan Services CT MAXILLOFACIAL AREA WITHOUT CONTRAST $1, CT Scan Services CT MAXILLOFACIAL WITH & WITH0UT I.V. CONTRAST $1, CT Scan Services CT NECK (SOFT TISSUE) WITH CONTRAST $2, CT Scan Services CT NECK WITH & WITHOUT I.V. CONTRAST $2, CT Scan Services CT NECK WITHOUT CONTRAST $2, CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA OR EAR WITH & WITHOUT I.V. CONTRAST $2, CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA OR OUT/MID/INNER EAR WITH I.V. CONTRAST $2, CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA, OR OUT/MID/INNER EAR W/O CONTRAST $2, CT Scan Services CT PELVIS W&W/O IV CONTRAST-W OR W/O ORAL CONTRAST $2, CT Scan Services CT PELVIS WITH OR WITHOUT ORAL CONTRAST $2, CT Scan Services CT PELVIS WTIH IV CONTRAST & WITH ORAL CONTRAST $2, CT Scan Services CT SINUSES WITH & WITHOUT CONTRAST - 52 $1, CT Scan Services CT SINUSES WITH CONTRAST - 52 $1, CT Scan Services CT SINUSES WITHOUT CONTRAST - 52 $1, CT Scan Services CT THORACIC SPINE W/O CONTRAST $ CT Scan Services CT THORACIC SPINE WITH & WITHOUT CONTRAST $ CT Scan Services CT THORACIC SPINE WITH CONTRAST $ CT Scan Services CT UPPER EXTREMITY W/CONTRAST $1, CT Scan Services CT UPPER EXTREMITY W/O CONTRAST $1, CT Scan Services CT UPPER EXTREMITY WITH & WITHOUT I.V. CONTRAST $1, CT Scan Services CTA ABDOMEN & PELVIS WITH CONTRAST - INCLUDES NON-CONTRAST IF DONE $3, CT Scan Services CTA ABDOMEN WITH CONTRAST - INCLUDES NONCONTRAST IMAGES IF PERFORMED $3, CT Scan Services CTA ABDOMINAL AORTA & BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF WITH CONTRAST $3, CT Scan Services CTA CHEST NON-CORONARY WITH CONTRAST - INCLUDES NONCONTRAST IMAGES IF PERFORMED $1, X CT Scan Services CTA HEAD WITH & WITHOUT I.V. CONTRAST $3, CT Scan Services CTA HEART CORONARY ARTERIES (EXPLODE SET) $6, CT Scan Services CTA LOWER EXTREMITY WITH & WITHOUT I.V. CONTRAST $2, CT Scan Services CTA NECK WITH & WITHOUT IV CONTRAST $3, CT Scan Services CTA PELVIS WITH & WITHOUT IV CONTRAST $2, CT Scan Services CTA UPPER EXTREMITY WITH & WITHOUT I.V. CONTRAST $2, Dialysis Services CAPD (CONTINUOUS AMBULATORY PERITONEAL DIALYSIS) $1, Dialysis Services CCPD (CONTINUOUS CYCLING PERITONEAL DIALYSIS) $1, Dialysis Services CRRT (CONTINUOS RENAL REPLACEMENT THERAPY) $1, Dialysis Services DIALYSIS - ULTRAFILTRATION FOR MANAGEMENT OF FLUID OVERLOAD $1, Dialysis Services DIALYSIS - UNSCHEDULED/EMERGENCY OUTPATIENT $1, Dialysis Services DIALYSIS SERVICE (HEMODIALYSIS) - INPATIENT $1, Dialysis Services SCUF (SLOW CONTINUOUS ULTRA FILTRATION) $1,442.00

7 Digestive System Procedures ABLATION LIVER TUMOR(S) - PERCUTANEOUS - RADIOFREQUENCY $17, Digestive System Procedures ANOSCOPY WITH REMOVAL FOREIGN BODY $2, Digestive System Procedures BIOPSY ABDOMINAL OR RETROPERITONEAL MASS WITH NEEDLE $1, Digestive System Procedures BIOPSY LIVER - NEEDLE (AT TIME OF OTHER MAJOR PROCEDURE) $ Digestive System Procedures BIOPSY OF SALIVARY GLAND $2, Digestive System Procedures BIOPSY PANCREAS NEEDLE PERCUTANEOUS $1, Digestive System Procedures CHOLECYSTOSTOMY - PERCUTANEOUS $3, Digestive System Procedures CONTRAST INJECTION FOR EVALUATION OF EXISTING OSTOMY TUBE, PERCUTANEOUS W/FLUORO $ Digestive System Procedures CONTROL THROAT BLEEDING $ Digestive System Procedures CONVERSION EXTERNAL BILIARY DRAINAGE TO INTERNAL-EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9, Digestive System Procedures CONVERT G-TUBE TO GASTRO-JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $1, Digestive System Procedures DILATION BILIARY DUCT/AMPULLA - EACH DUCT (INCLUDES IMAGE GUIDANCE AND S&I) ADD-ON $1, Digestive System Procedures DRAINAGE OF GUM LESION $ Digestive System Procedures DRAINAGE OF MOUTH LESION $ Digestive System Procedures DRAINAGE OF TONSIL ABSCESS $ Digestive System Procedures ENDOLUMINAL BIOPSY BILIARY TREE (INCLUDES IMAGE GUIDANCE AND S&I) ADD-ON $4, Digestive System Procedures EXCHANGE BILIARY DRAINAGE CATHETER - INCLUDES IMAGE GUIDANCE AND S&I $9, Digestive System Procedures EXCHANGE CYST OR ABSCESS DRAINAGE CATHETER $1, Digestive System Procedures EXCISION OF FRENUM - LABIAL OR BUCCAL (FRENUMECTOMY/FRENULECTOMY/FRENECTOMY) $5, Digestive System Procedures EXCISION THROMBOSED HEMORRHOID - EXTERNAL $2, Digestive System Procedures GASTRIC MOTILITY STUDIES - MANOMETRY $1, Digestive System Procedures GASTROSTOMY TUBE CHANGE WITHOUT FLUORO OR ENDOSCOPIC GUIDANCE $ Digestive System Procedures IMAGE GUIDED FLUID DRAINAGE BY CATHETER - PERITONEAL/RETROPERITONEAL $5, Digestive System Procedures IMAGE GUIDED FLUID DRAINAGE BY CATHETER - VISCERAL $5, Digestive System Procedures INCISE EXTERNAL HEMORRHOID $ Digestive System Procedures INCISION OF RECTAL ABSCESS $3, Digestive System Procedures INJECTION FOR ASSESS OF ABCESS, CYST VIA PREVIOUSLY PLACED CATH OR TUBE $ Digestive System Procedures INJECTION FOR CHOLANGIOGRAM - EXISTING ACCESS - INCLUDES IMAGE GUIDANCE AND S&I $1, Digestive System Procedures INJECTION FOR CHOLANGIOGRAM - NEW ACCESS - INCLUDES IMAGE GUIDANCE AND S&I $9, Digestive System Procedures INSERTION DUODENOSTOMY OR JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $1, Digestive System Procedures INSERTION GASTROSTOMY TUBE PERCUTANEOUS W/FLUORO $1, Digestive System Procedures INSERTION TUNNELED INTRAPERITONEAL CATHETER - PERCUTANEOUS $10, Digestive System Procedures LIVER BIOPSY $1, Digestive System Procedures NEEDLE BIOPSY-LIVER $1, Digestive System Procedures PARACENTESIS - INPATIENT BEDSIDE PROCEDURE $2, Digestive System Procedures PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMAGING GUIDANCE $2, Digestive System Procedures PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING GUIDANCE $2, Digestive System Procedures PLACEMENT ACCESS THROUGH BILIARY TREE INTO SMALL BOWEL - NEW ACCESS $9, Digestive System Procedures PLACEMENT BILIARY DRAINAGE CATHETER - EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9, Digestive System Procedures PLACEMENT BILIARY DRAINAGE CATHETER - INTERNAL-EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9, Digestive System Procedures PLACEMENT LONG GASTROINTESTINAL TUBE $ Digestive System Procedures PLACEMENT NASAL/OROGASTRIC TUBE BY PHYSICIAN W/FLUOROSCOPY $ Digestive System Procedures PLACEMENT OF SETON $2, Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - EXISTING ACCESS $17, Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - NEW ACCESS W/ PLACING SEPARATE BILIARY DRAIN $17, Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - NEW ACCESS W/O PLACING SEPARATE BILIARY DRAIN $17, Digestive System Procedures REMOVAL BILIARY DRAINAGE CATHETER - INCLUDES IMAGE GUIDANCE AND S&I $2, Digestive System Procedures REMOVAL CALCULI/DEBRIS FROM BILIARY DUCTS(S AND/OR GALLBLADDER ADD-ON $2, Digestive System Procedures REMOVAL TUNNELED INTRAPERITONEAL CATHETER $9, Digestive System Procedures REMOVE OBSTRUCTIVE MATERIAL FROM G, D, J, OR G-J TUBE W/FLUORO $ Digestive System Procedures REPAIR INGUINAL HERNIA - REDUCEABLE $5, Digestive System Procedures REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT $1, Digestive System Procedures REPAIR TONGUE LACERATION $ Digestive System Procedures REPLACE DUODENOSTOMY OR JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $ Digestive System Procedures REPLACE GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS W/FLUORO $ Digestive System Procedures REPLACE G-TUBE OR CECOSTOMY TUBE,PERCUTANEOUS W/FLUORO $ Digestive System Procedures REPOSITION G-TUBE IN DUODENUM $ Digestive System Procedures SCLEROTHERAPY PERCUTANEOUS INCLUDING IMAGE GUIDANCE AND S&I $3, Digestive System Procedures UNLISTED PROCEDURE BILIARY TRACT (BILE DUCT-GALLBLADDER-LIVER) $6, Digestive System Procedures UNLISTED PROCEDURE INTESTINE $1, Ear Procedures BIOPSY EXTERNAL EAR $1, Ear Procedures DRAIN EXTERNAL EAR ABSCESS OR HEMATOMA - SIMPLE $ Ear Procedures REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE - UNILATERAL $ Ear Procedures REMOVAL IMPACTED CERUMEN WITH IRRIGATION/LAVAGE - BILATERAL $ Ear Procedures REMOVE FOREIGN BODY FROM EXTERNAL AUDITORY CANAL $ Ear Procedures REMOVE IMPACTED CERUMEN W/INSTRUMENTATION - BILATERAL $ Ear Procedures REMOVE IMPACTED CERUMEN W/INSTRUMENTATION - UNILATERAL $ Emergency Evaluation and Management Services ER VISIT - LEVEL 3 $ X Emergency Evaluation and Management Services ER VISIT - LEVEL 1 $ X Emergency Evaluation and Management Services ER VISIT - LEVEL 2 $ X Emergency Evaluation and Management Services ER VISIT - LEVEL 4 $1, X Emergency Evaluation and Management Services ER VISIT - LEVEL 5 $1, X Emergency Evaluation and Management Services ER VISIT LEVEL - CRITICAL CARE - EACH ADDITIONAL 30 MINUTES $ X Emergency Evaluation and Management Services ER VISIT LEVEL - CRITICAL CARE - FIRST MINUTES $2, X Emergency Services COLPOSCOPE EXAM AND PHOTOS (SANE EXAM) $ Emergency Services EMERGENCY CHEST RE-OPEN - INPATIENT BEDSIDE PROCEDURE $4, Emergency Services MED SAFE SCREENING (SANE EXAM) $ Emergency Services SANE EXAM (Explode Set as of ) $ Emergency Services TRAUMA TEAM ACTIVATION-LEVEL 1 $8, X Emergency Services TRAUMA TEAM ACTIVATION-LEVEL 2 $7, X Endocrine System Procedures NEEDLE CORE BIOPSY THYROID - PERCUTANEOUS $843.00

8 Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 1 - ESTABLISHED - TYPICALLY 5 MINUTES $ Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 2 - ESTABLISHED - TYPICALLY 10 MINUTES $ Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 3 - ESTABLISHED - TYPICALLY 15 MINUTES $ Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 4 - ESTABLISHED - TYPICALLY 25 MINUTES $ Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 5 - ESTABLISHED - TYPICALLY 40 MINUTES $ Evaluation and Management Services ALCOHOL AND/OR SUBSTANCE ABUSE ASSESSMENT & BRIEF INTERVENTION (15-30 MINUTES) $ Evaluation and Management Services ANTICOAGULATION MANAGEMENT - LEVEL 1 $ Evaluation and Management Services ANTICOAGULATION MANAGEMENT - LEVEL 2 $ Evaluation and Management Services ASSESSMENT OF TINNITUS $ Evaluation and Management Services ASSESSMENT-PULMONARY REHABILITATION (INITIAL OR EXIT INTERVIEW) $ Evaluation and Management Services COMPLEX CONSULTATION OSTOMY/WOUND CARE 2-3 HOURS $ Evaluation and Management Services CONSULTATION WITH PREOP INSTRUCTION AND STOMA SITE MARKING $ Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 2 $ Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 3 $ Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 4 $ Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 5 $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 1 VISIT - WOUND CARE $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 1 VISIT - WOUND CARE - IP ONLY $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 2 VISIT - WOUND CARE $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 2 VISIT - WOUND CARE - IP ONLY $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 3 VISIT - WOUND CARE $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 3 VISIT - WOUND CARE - IP ONLY $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 4 VISIT - WOUND CARE - IP ONLY $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 4 VISIT - WOUND CARE AND/OR PAIN CARE $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 5 VISIT - WOUND CARE $ Evaluation and Management Services ESTABLISHED PATIENT LEVEL 5 VISIT - WOUND CARE - IP ONLY $ Evaluation and Management Services FOLLOW-UP VISIT: COMPLEX RADIATION TX $ Evaluation and Management Services FOLLOW-UP VISIT: DETAILED RADIATION TX $ Evaluation and Management Services FOLLOW-UP VISIT: EXP&ED RADIATION TX $ Evaluation and Management Services FOLLOW-UP VISIT: HIGH COMPLEXITY RADIATION TX $ Evaluation and Management Services FOLLOW-UP VISIT: SIMPLE RADIATION TX $ Evaluation and Management Services INCONTINENCE ASSESSMENT 1-2 HOURS $ Evaluation and Management Services LEVEL 1 NURSING CARE (ALSO FOR ET MINIMAL CARE - UP TO 30 MINUTES) $ Evaluation and Management Services LEVEL 2 NURSING CARE (ALSO FOR SIMPLE OSTOMY/WOUND MANAGEMENT UP TO 1 HOUR) $ Evaluation and Management Services LEVEL 3 NURSING CARE $ Evaluation and Management Services MEDICAL VISIT LEVEL 1 ESTABLISHED PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL VISIT LEVEL 2 ESTABLISHED PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL VISIT LEVEL 3 ESTABLISHED PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL VISIT LEVEL 3 NEW PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL VISIT LEVEL 4 ESTABLISHED PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL VISIT LEVEL 5 ESTABLISHED PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL/LEVEL 1/NEW PT - WORKABLE $ Evaluation and Management Services MEDICAL/LEVEL 2/NEW PT - WORKABLE $ Evaluation and Management Services MEDICAL/LEVEL 4/NEW PATIENT - WORKABLE $ Evaluation and Management Services MEDICAL/LEVEL 5/NEW PATIENT - WORKABLE $ Evaluation and Management Services OP VISIT - NEW PATIENT: SIMPLE RADIATION TX $ Evaluation and Management Services OP VISIT- NEW PATIENT: EXP&ED RADIATION TX $ Evaluation and Management Services OP VISIT: COMPREHENSIVE RADIATION TX $ Evaluation and Management Services OP VISIT: DETAILED RADIATION TX $ Evaluation and Management Services OP VISIT: HIGH COMPLEXITY RADIATION TX $ Evaluation and Management Services PHYSICAL-CHILD 5-11 $92.00 Evaluation and Management Services REHAB FAMILY CONFERENCE - 30 MINUTES OR MORE - PHYSICAL THERAPY $90.00 Evaluation and Management Services ROUTINE OSTOMY MANAGEMENT/WOUND CARE 1-2 HOURS $ Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 1 $ Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 2 $ Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 3 $ Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 4 $ Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 5 $ Eye Procedures DRAINAGE OF EYELID ABSCESS $ Eye Procedures FOREIGN BODY REMOVAL EYE - SUPERFICIAL $ Eye Procedures REMOVE FOREIGN BODY - EYELID $ Eye Procedures REMOVE FOREIGN BODY FROM EYE $ Eye Procedures REMOVE FOREIGN BODY FROM EYE W/SLIT LAMP $ Eye Procedures REMOVE FOREIGN BODY OF EYE - CORNEAL W/O SLIT LAMP $ Eye Procedures REPAIR EYELID WOUND $2, Female Genital System Procedures EXCISION BARTHOLINS GLAND OR CYST $7, Female Genital System Procedures INCISION & DRAINAGE BARTHOLINS GLAND ABSCESS $ Female Genital System Procedures INCISION & DRAINAGE OF VULVA/PERINEUM $ Female Genital System Procedures INJECTION FOR UTERUS/TUBE X-RAY $ Female Genital System Procedures INSERTION OF UTERINE TANDEM AND/OR OVOID $2, Female Genital System Procedures INSERTION OF VAGINAL AFTERLOADING APPARATUS $1, Gastroenterology Services ACID REFLUX TEST - PROLONGED RECORDING $ Gastroenterology Services ESOPHAGEAL MOTILITY - MANOMETRY STUDY - HIGH RESOLUTION $1, Hemic and Lymphatic System Procedures BIOPSY or EXCISION LYMPH NODE by NEEDLE - SUPERFICIAL (EG, CERVICAL/INGUINAL/AXILLARY) $2, Hemic and Lymphatic System Procedures BIOPSY OR EXCISION LYMPH NODE(S) BY NEEDLE - SUPERFICIAL (CERVICAL-INGUINAL-AXILLARY) (EXPLODE SET) $3, Hemic and Lymphatic System Procedures BONE MARROW BIOPSY - INPATIENT BEDSIDE PROCEDURE $ Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW ASPIRATIONS $ Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS $ Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW BIOPSY $ Hemic and Lymphatic System Procedures INJECTION FOR IDENTIFICATION OF SENTINEL NODE - RADIOACTIVE TRACER (EXPLODE SET) $ Hemic and Lymphatic System Procedures UNLISTED PROCEDURE - HEMIC OR LYMPHATIC SYSTEM (SPLEEN) $1,168.00