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

OHIOHEALTH MANSFIELD HOSPITAL CHARGE LIST SERVICE CATEGORY DESCRIPTION CHARGE DOSE STATE OF OHIO REQUIREMENT Audiology Services ACOUSTIC IMMITTANCE TESTING $155.00 Audiology Services ACOUSTIC REFLEX TESTING THRESHOLD $89.00 Audiology Services AUDIOMETRY EVOKED POTENTIALS - COMPREHENSIVE $1,044.00 Audiology Services AUDIOMETRY EVOKED POTENTIALS - LIMITED $467.00 Audiology Services AUDITORY REHABILITATION POSTLINGUAL HEARING LOSS $186.00 Audiology Services BASE AUDIOGRAM - GN $110.00 Audiology Services BASIC VESTIBULAR EVALUATION $585.00 Audiology Services BRAINSTEM AUDITORY EVOKED POTENTIALS (BAER, BAEP) $473.00 Audiology Services BRAINSTEM AUDITORY EVOKED RESPONSE-COMPREHENSIVE-GN $343.00 Audiology Services BRAINSTEM AUDITORY EVOKED RESPONSE-LIMITED-GN $227.00 Audiology Services CALORIC VESTIBULAR TEST W/RECORDING - BILATERAL - BITHERMAL $533.00 Audiology Services CALORIC VESTIBULAR TEST W/RECORDING - BILATERAL - MONOTHERMAL $533.00 Audiology Services COMPREHENSIVE AUDIOGRAM - GN $220.00 Audiology Services COMPREHENSIVE AUDIOMETRY THRESHOLD & SPEECH RECOGNITION $494.00 Audiology Services CONDITIONING PLAY AUDIOMETRY $422.00 Audiology Services EAR PROTECTOR ATTENUATION MEASUREMENTS $155.00 Audiology Services ELECTROACOUSTIC EVALUATION FOR HEARING AID - BINAURAL $149.00 Audiology Services ELECTROACOUSTIC EVALUATION FOR HEARING AID - MONAURAL $113.00 Audiology Services ELECTROCOCHLEOGRAPHY $892.00 Audiology Services EVALUATION AUDITORY REHABILITATION STATUS - 1ST HOUR $539.00 Audiology Services EVALUATION AUDITORY REHABILITATION STATUS - EACH ADD'L 15 MINUTES $207.00 Audiology Services EVOKED OTOACOUSTIC EMISSIONS SCREENING $196.00 Audiology Services EVOKED OTOACOUSTIC EMISSION-GN $262.00 Audiology Services EVOKED OTOACOUSTIC EMISSIONS - COMPREHENSIVE OR DX EVALUATION $352.00 Audiology Services EVOKED OTOACOUSTIC EMISSIONS - LIMITED $201.00 Audiology Services HEARING AID CHECK - BINAURAL $149.00 Audiology Services HEARING AID CHECK - MONAURAL $113.00 Audiology Services HEARING AID EXAMINATION & SELECTION - BINAURAL $149.00 Audiology Services HEARING AID EXAMINATION & SELECTION - MONAURAL $113.00 Audiology Services HEARING TEST - FILTERED SPEECH $155.00 Audiology Services HEARING TEST - SHORT INCREMENT SENSITIVITY INDEX (SISI) $155.00 Audiology Services HEARING TEST - STENGER - PURE TONE $155.00 Audiology Services HEARING TEST - TONE DECAY $155.00 Audiology Services OPTOKINETIC NYSTAGMUS TEST WITH RECORDING $302.00 Audiology Services OSCILLATING TRACKING TEST WITH RECORDING $302.00 Audiology Services PRO AUDIOMETRY EVOKED POTENTIALS - COMPREHENSIVE $42.00 Audiology Services PRO BASIC VESTIBULAR EVALUATION $129.00 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 $279.00 Audiology Services PURE TONE AUDIOMETRY (THRESHOLD) - AIR ONLY $180.00 Audiology Services SCREENING TEST - PURE TONE - AIR ONLY $31.00 Audiology Services SELECT PICTURE AUDIOMETRY $155.00 Audiology Services SPEECH THRESHOLD - AUDIOMETRY $103.00 Audiology Services SPEECH THRESHOLD - AUDIOMETRY - COMPLETE $103.00 Audiology Services STENGER TEST - SPEECH $539.00 Audiology Services TYMPANOGRAM - GN $108.00 Audiology Services TYMPANOMETRY (IMPEDANCE TESTING) $103.00 Audiology Services TYMPANOMETRY AND REFLEX THRESHOLD MEASUREMENT $180.00 Audiology Services VISUAL REINFORCEMENT AUDIOMETRY (VRA) $494.00 Blood Products AUTOLOGOUS UNIT $1,041.00 Blood Products BLOOD $712.00 Blood Products BLOOD, LEUKOREDUCED IRRADIATED $862.00 Blood Products BLOOD,LEUKOREDCD,CMV NEG,IRRADIA $1,219.00 Blood Products CRYOPOOR PLASMA $171.00 Blood Products CRYOPRECIPITATE $303.00 Blood Products DIRECTED UNIT $1,080.00 Blood Products FRESH FROZEN PLASMA $231.00 Blood Products FROZEN DEGLYCED CELLS $682.00 Blood Products IRRADIATION OF BLOOD PRODUCT, EACH UNIT $51.00 Blood Products LEUKODEPLETED RBC $769.00 Blood Products PACKED RED BLOOD CELLS $712.00 Blood Products PLATELET CONCENTRATE $335.00 Blood Products PLATELET HLA MATCHED $2,407.00 Blood Products PLATELET PHERESIS $1,753.00 Blood Products PLATELET PHERESIS, LEUKORED, IRRAD $1,753.00 Blood Products PLT PHER,LEUKOREDCD,CMV NEG,IR $2,516.00 Blood Products PLT,LEUKOREDUCED, IRRADIATED $346.00 Blood Products WASHED RED BLOOD CELLS - EACH UNIT $576.00 Breast Procedures BIOPSY BREAST 1ST LESION W/MRI (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $3,536.00 Breast Procedures BIOPSY BREAST 1ST LESION W/STEREOTACTIC GUIDANCE (LOCALIZATION DEVICE & SPECIMEN IMAGING IF DONE) $5,744.00 Breast Procedures BIOPSY BREAST 1ST LESION W/ULTRASOUND GUIDANCE (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $3,379.00 Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/ULTRASOUND (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $708.00 Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/MRI (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $1,078.00 Breast Procedures BIOPSY BREAST EACH ADD'L LESION W/STEROTACTIC GUIDANCE (LOCAL DEVICE/SPECIMEN IMAGE IF DONE) $520.00 Breast Procedures INCISION OF BREAST LESION $2,490.00

Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/MAMMOGRAPHY GUIDANCE $249.00 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/STEREOTACTIC GUIDANCE $444.00 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE 1ST LESION W/ULTRASOUND GUIDANCE $473.00 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/MAMMOGRAPHY $249.00 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/STEREOTACTIC $244.00 Breast Procedures PLACEMENT BREAST LOCALIZATION DEVICE EACH ADD'L LESION W/ULTRASOUND GUIDANCE $100.00 Breast Procedures PUNCTURE ASPIRATION CYST - BREAST - EACH ADDITIONAL $185.00 Breast Procedures PUNCTURE ASPIRATION CYST OF BREAST (Mansfield US Explode Set) $1,237.00 Cardiac Procedures and Services 3-D MAPPING $16,329.00 Cardiac Procedures and Services ABLATION OF ARRHYTHMIA DISTINCT FROM PRIMARY $6,897.00 Cardiac Procedures and Services ANGIOGRAPHY - CORONARY WITHOUT LEFT HEART CATHETERIZATON $12,451.00 Cardiac Procedures and Services ANGIOGRAPHY - CORONARY/BYPASS GRAFTS/INTERNAL MAMMARY W/O LEFT HEART CATH $15,148.00 Cardiac Procedures and Services ANGIOGRAPHY - PULMONARY DURING CARDIAC CATHETERIZATION $2,147.00 Cardiac Procedures and Services ANGIOPLASTY - CORONARY - EACH ADD'L BRANCH MAJOR ARTERY $7,389.00 Cardiac Procedures and Services ANGIOPLASTY - CORONARY - SINGLE MAJOR ARTERY/BRANCH $7,720.00 Cardiac Procedures and Services AORTOGRAPHY SUPRAVALVULAR (ROOT) DURING CARDIAC CATHETERIZATION PROCEDURE $1,929.00 Cardiac Procedures and Services ATHERECTOMY - CORONARY - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $16,530.00 Cardiac Procedures and Services ATHERECTOMY - CORONARY - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $18,928.00 Cardiac Procedures and Services ATHERECTOMY W/ DRUG-ELUTING STENT PLACEMENT SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $21,309.00 Cardiac Procedures and Services ATHERECTOMY W/DRUG-ELUTING STENT PLACEMENT EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $16,530.00 Cardiac Procedures and Services ATHERECTOMY WITH STENT PLACEMENT EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $14,790.00 Cardiac Procedures and Services ATHERECTOMY WITH STENT PLACEMENT SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $18,928.00 Cardiac Procedures and Services CARDIAC REHAB PHASE II NON-MONITOR VISIT $192.00 Cardiac Procedures and Services CARDIAC REHAB VISIT $225.00 X Cardiac Procedures and Services CARDIAC REHAB-MEDICAID-PER DAY $189.00 Cardiac Procedures and Services CARDIAC STRESS TEST - TRACING ONLY WITHOUT INTERPRETATION & REPORT $1,324.00 Cardiac Procedures and Services CARDIOPULMONARY RESUSCITATION (CPR) $2,520.00 Cardiac Procedures and Services CARDIOVERSION - ELECTIVE $3,550.00 Cardiac Procedures and Services CATHETERIZATION LEFT HEART W/CORNARY ANGIO & LEFT VENTRICULAR ANGIO (IF PERFORMED) $15,351.00 Cardiac Procedures and Services CATHETERIZATION LEFT HEART W/CORONARY/CB/LIMA ANGIOGRAPHY W/ or W/O LEFT VENTRICULOGRAPHY $16,242.00 Cardiac Procedures and Services CATHETERIZATION RIGHT & LEFT HEART W/CORONARY ANGIO W/ or W/O LEFT VENTRICULOGRAPHY $16,898.00 Cardiac Procedures and Services CATHETERIZATION RIGHT & LEFT HEART W/CORONARY/CBG/LIMA ANGIOPLASTY W/ or W/O VENTRICULAR ANGIOPLASTY $18,970.00 Cardiac Procedures and Services CATHETERIZATION RIGHT HEART W/CORONARY/CBG/LIMA ANGIOPLASTY $17,054.00 Cardiac Procedures and Services CATHETERIZATION RIGHT HEART WITH CORNARY ANGIOGRAPHY $16,746.00 Cardiac Procedures and Services COLOR FLOW MAPPING $237.00 Cardiac Procedures and Services CORONARY FLOW RESERVE MEASUREMENT - INITIAL VESSEL - FRACTIONAL FLOW RESERVE (FFR) $7,397.00 Cardiac Procedures and Services CORONARY FLOW RESERVE MEASUREMENT EACH ADDITIONAL VESSEL $3,102.00 Cardiac Procedures and Services DEFIBRILLATION THRESHOLD TESTING ICD SYSTEM AT TIME OF IMPLANT (DFTs) $5,137.00 Cardiac Procedures and Services DEVICE EVALUATION & PROGRAMMING (CARDIOVERTER-DEFIBRILLATOR) - PERI-PROCEDURE $175.00 Cardiac Procedures and Services DEVICE INTERROGATION EVAL IN PERSON LEADLESS PM SYSTEM $137.00 Cardiac Procedures and Services DEVICE PROGRAMMING EVAL IN PERSON LEADLESS PM SYSTEM $137.00 Cardiac Procedures and Services DFT'S ICD LEADS AT TIME OF IMPLANT OR REPLACEMENT $5,054.00 Cardiac Procedures and Services DOPPLER ECHOCARDIOGRAPHY FOLLOW-UP OR LIMITED STUDY $318.00 Cardiac Procedures and Services DOPPLER ECHOCARDOPGRAPHY - COMPLETE $341.00 Cardiac Procedures and Services ECHOCARDIOGRAM - TRANSTHORACIC - LIMITED OR FOLLOW-UP $1,819.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSESOPHAGEAL (TEE) $3,575.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSESOPHAGEAL FOR CONGENITAL CARDIAC ANOMALIES $2,835.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC 2D (TTE) $1,665.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC FOR CONGENITAL CARDIAC ANOMOLIES - COMPLETE $2,199.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC REST & STRESS W/INTERPRETATION & REPORT $2,485.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC WITH DOPPLER & COLOR FLOW MAPPING $2,485.00 Cardiac Procedures and Services ECHOCARDIOGRAM TRANSTHORACIC WITHOUT DOPPLER OR COLOR FLOW $1,951.00 Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST - STRESS & REST STUDY W/PHYSICIAN SUPERVISION (EXPLODE SET) $3,800.00 Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST FOR CONGENITAL CARDIAC ANOMOLIES (EXPLODE SET) $3,800.00 Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST OR W/O CONTRAST FOLLOWED BY CONTRAST W/O SPECTRAL OR COLOR FLOW (EXPLODE SET) $2,907.00 Cardiac Procedures and Services ECHOCARDIOGRAM W/CONTRAST WITH SPECTRAL & COLOR FLOW DOPPLER (EXPLODE SET) $3,800.00 Cardiac Procedures and Services ECHOCARDIOGRAM WITH CONTRAST - LIMITED OR FOLLOW-UP STUDY (EXPLODE SET) $2,907.00 Cardiac Procedures and Services ECHOGARDIOGRAM TRANSTHORACIC FOR CONGENITAL CARDIAC ANOMALIES - FOLLOW-UP OR LIMITED $2,485.00 Cardiac Procedures and Services EKG (ELECTROCARDIOGRAM) - TRACING ONLY W/O INTERPRETATION & REPORT $188.00 Cardiac Procedures and Services ENDOLUMINAL IMAGING WITH INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) - EACH ADD'L VESSEL $6,161.00 Cardiac Procedures and Services ENDOLUMINAL IMAGING WITH INTRAVASCULAR ULTRASOUND (IVUS) OR OPTICAL COHERENCE TOMOGRAPHY (OCT) - INITIAL VESSEL $7,727.00 Cardiac Procedures and Services ENDOMYOCARDIAL BIOPSY $10,338.00 Cardiac Procedures and Services EP BUNDLE OF HIS RECORDING $7,384.00 Cardiac Procedures and Services EP ESOPHAGEAL RECORDING OF ATRIAL ELECTROGRAM $8,564.00 Cardiac Procedures and Services E-P EVALUATION SUBCUTANEOUS IMPLANTABLE DEFIBRILLATOR $257.00 Cardiac Procedures and Services EP FOLLOW UP STUDY $7,428.00 Cardiac Procedures and Services EP INDUCTION OF ARRHYTHMIA BY ELECTRICAL PACING $6,696.00 Cardiac Procedures and Services EP INTRA-ATRIAL PACING $6,592.00 Cardiac Procedures and Services EP INTRA-ATRIAL RECORDING $6,641.00 Cardiac Procedures and Services EP INTRAVENTRICULAR PACING $7,600.00 Cardiac Procedures and Services EP STUDY & ABLATION FOR SUPRAVENTRICULAR TACHYCARDIA $43,990.00 Cardiac Procedures and Services EP STUDY & ABLATION FOR VENTRICULAR TACHYCARDIA $53,321.00 Cardiac Procedures and Services EP STUDY COMPREHENSIVE EVALUATION RIGHT W/O ARRYTHMIA INDUCTION $17,613.00 Cardiac Procedures and Services EP VENT RECORD $7,600.00 Cardiac Procedures and Services EP-ABLATION-AV NODE FUNCTION $28,067.00 Cardiac Procedures and Services EP-COMPREHENSIVE LT ATRIAL $15,982.00 Cardiac Procedures and Services EP-COMPREHENSIVE LT VENT $16,093.00 Cardiac Procedures and Services EP-COMPREHENSIVE RT W/ARRYTH $29,630.00 Cardiac Procedures and Services EP-EVALUATION OF AICD (AUTOMATIC IMPLANTABLE CARDIOVERTER DEFIBRILLATOR) $6,021.00 Cardiac Procedures and Services EVALUATE DEVICE - IMPLANTABLE DEFIBRILLATOR SYSTEM - SINGLE/DUAL/MULTI LEAD $265.00 Cardiac Procedures and Services HOLTER MONITOR RECORDING - UP TO 48 HOURS $527.00 X

Cardiac Procedures and Services HOLTER MONITOR SCANNING - UP TO 48 HOURS $477.00 X Cardiac Procedures and Services INSERTION CATHETER (SWAN GANZ) FOR MONITORING PURPOSES $7,719.00 Cardiac Procedures and Services INSERTION SWAN-GANZ CATHETER - INPATIENT BEDSIDE PROCEDURE $5,623.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION - IMPLANTABLE SUBCUTANEOUS DEFIBRILLATOR $260.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION - PACEMAKER SYSTEM - SINGLE/DUAL/MULTI LEAD $156.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION (REMOTE) IMPLANTABLE CV MONITOR OR IMPLANTABLE LOOP RECORDER $178.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION (REMOTE) PACEMAKER SINGLE-DUAL-MULTI LEAD $123.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION IMPLANTABLE CARDIOVASCUALR MONITOR SYSTEM $119.00 Cardiac Procedures and Services INTERROGATION DEVICE EVALUATION IMPLANTABLE LOOP RECORDER $146.00 Cardiac Procedures and Services INTRACARDIAC ECHOCARDIOGRAPHY $5,631.00 Cardiac Procedures and Services LEFT HEART CATH BY TRANSEPTAL PUNCTURE $2,433.00 Cardiac Procedures and Services MULTI SITE MAPPING $14,190.00 Cardiac Procedures and Services MYOCARDIAL STRAIN IMAGING $318.00 Cardiac Procedures and Services NIPS PROCEDURE (NON-INVASIVE PACEMAKER STIMULATION) $1,215.00 Cardiac Procedures and Services NUCLEAR STRESS TEST - TRACING ONLY - NO INTERPRETATION OR REPORT $1,324.00 Cardiac Procedures and Services PERIPHERAL ARTERIAL DISEASE (PAD) REHAB, PER SESSION $214.00 Cardiac Procedures and Services PLACEMENT CORONARY STENT - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $15,067.00 Cardiac Procedures and Services PLACEMENT CORONARY STENT - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $17,330.00 Cardiac Procedures and Services PLACEMENT DRUG-ELUTING STENT - EACH ADD'L MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $7,716.00 Cardiac Procedures and Services PLACEMENT DRUG-ELUTING STENT - SINGLE MAJOR ARTERY/BRANCH (INCLUDES ANGIO IF DONE) $17,330.00 Cardiac Procedures and Services PRO PRQ CORONARY ANGIOPLASTY ADDL BRANCH $1,365.00 Cardiac Procedures and Services PRO R & L HEART CATH W/CORONARY ANGIO & LT VENTRICULAR IMAGING $966.00 Cardiac Procedures and Services PROGRAMMED STIMULATION AND PACING AFTER IV DRUG INFUSION $9,034.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - DEFIBRILLATOR MULTI LEAD $369.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - IMPLANTABLE LOOP RECORDER SYSTEM $169.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - IMPLANTED SUBCUTANEOUS DEFIBRILLATOR $257.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER DUAL LEAD SYSTEM $243.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER MULTI LEAD SYSTEM $285.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION - PACEMAKER SINGLE LEAD SYSTEM $243.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION (IN PERSON) - DUAL LEAD PACEMAKER SYSTEM $243.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUATION CARDIOVERTER-DEFIBRILLATOR - DUAL LEAD $333.00 Cardiac Procedures and Services PROGRAMMING DEVICE EVALUTATION - DEFIBRILLATOR SINGLE LEAD $257.00 Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- EACH ADD'L BRANCH - ANY METHOD $15,067.00 Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT OF OR THROUGH CABG - EACH ADD'L BRANCH - ANY METHOD $7,743.00 Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- SINGLE VESSEL $18,360.00 Cardiac Procedures and Services REVASCULARIZATION BYPASS GRAFT- SINGLE VESSEL - ANY METHOD $17,184.00 Cardiac Procedures and Services REVASCULARIZATION CHRONIC TOTAL OCCLUSION - EACH ADD'L VESSEL $14,790.00 Cardiac Procedures and Services REVASCULARIZATION DURING ACUTE MI - SINGLE VESSEL $22,084.00 Cardiac Procedures and Services REVASCULARIZATION DURING ACUTE MI - SINGLE VESSEL $20,583.00 Cardiac Procedures and Services REVASCULARIZATION OF TOTAL OCCLUSION - EACH ADD'L VESSEL $11,793.00 Cardiac Procedures and Services REVASCULARIZATION OF TOTAL OCCLUSION - SINGLE VESSEL $28,571.00 Cardiac Procedures and Services REVASCULARIZATION TOTAL OCCLUSION - SINGLE VESSEL $28,265.00 Cardiac Procedures and Services RHYTHM EKG $70.00 Cardiac Procedures and Services RIGHT HEART CATHETERIZATION $13,540.00 Cardiac Procedures and Services SIGNAL AVERAGED-EKG $173.00 Cardiac Procedures and Services TEE WITH CONTRAST (TRANSESOPHAGEAL ECHOCARDIOGRAM) (EXPLODE SET) $3,930.00 Cardiac Procedures and Services TEMPORARY TRANSCUTANEOUS PACING $1,891.00 Cardiac Procedures and Services THROMBECTOMY CORONARY PERCUTANEOUS TRANSLUMINAL $4,296.00 Cardiac Procedures and Services THROMBOLYSIS - CORONARY BY INTRACORONARY INFUSION $1,139.00 Cardiac Procedures and Services THROMBOLYSIS - CORONARY BY INTRAVENOUS INFUSION $526.00 Cardiac Procedures and Services TILT TABLE TESTING $3,212.00 Cardiac Procedures and Services TRANSCATH INSERT OR REPLACE LEADLESS PM VENTR $58,091.00 Cardiac Procedures and Services TRANSCATH REMOVAL LEADLESS PM VENTRICULAR $9,277.00 Cardiac Procedures and Services TRANSTELEPHONIC RHYTHM STRIP PACEMAKER EVALUATION - SINGLE/DUAL/MULTI LEAD $204.00 Cardiac Procedures and Services TREATMENT OF A-FIB ADD'L - AFTER PULMONARY VEIN ISOLATION $6,897.00 Cardiac Procedures and Services TREATMENT OF A-FIB BY ABLATION BY PULMONARY VEIN ISOLATION $102,561.00 Cardiac Procedures and Services UNLISTED CARDIOVASCULAR PROCEDURE $857.00 Cardiovascular procedures ANGIOJET VENOUS REPEAT SUBSEQUENT DAY $6,575.00 Cardiovascular procedures ANGIOPLASTY CENTRAL DIALYSIS SEGMENT W/IMAGING S&I $9,000.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ EACH ADD'L ARTERY INCLUDING IMAGES/S&I $6,657.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ EACH ADD'L VEIN INCLUDING IMAGES/S& $4,499.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL ARTERY INCLUDING IMAGES/S&I - BILATERAL $19,972.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL ARTERY INCLUDING IMAGES/S&I - UNILATERAL $13,315.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL VEIN INCLUDING IMAGES/S&I - BILATERAL (EXCEPT DIALYSIS CIRCUIT) $13,498.00 Cardiovascular procedures ANGIOPLASTY OPEN/PERQ INITIAL VEIN INCLUDING IMAGES/S&I - UNILATERAL (EXCEPT DIALYSIS CIRCUIT) $8,999.00 Cardiovascular procedures ARTERIAL CATHETERIZATION/CANNULATION FOR SAMPLING/MONITORING/TRANSFUSION - PERCUTANEOUS $126.00 Cardiovascular procedures ARTERIAL PUNCTURE $118.00 X Cardiovascular procedures BIOPSY 37200 TRANSCATHETER $3,999.00 Cardiovascular procedures BLOOD DRAW< 3YRS FEM/JUGULAR $32.00 Cardiovascular procedures CAPILLARY BLOOD DRAW $17.00 Cardiovascular Procedures CAROTID STENTING $11,924.00 Cardiovascular procedures CATH PLACEMENT SELECTIVE 1ST ORDER FOR RENAL ANGIOGRAPHY - BILATERAL $10,053.00 Cardiovascular procedures CATH PLACEMENT SELECTIVE 1ST ORDER FOR RENAL ANGIOGRAPHY- UNILATERAL $8,508.00 Cardiovascular procedures CATH PLACEMENT SUPERSELECTIVE FOR RENAL ANGIOGRAPHY - BILATERAL $6,872.00 Cardiovascular procedures CATH PLACEMENT SUPERSELECTIVE FOR RENAL ANGIOGRAPHY - UNILATERAL $4,968.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY 1ST ORDER THORACIC/BRACHIOCEPHALIC BRANCH $1,847.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY 2ND ORDER ABDOMEN/PELVIS/LOWER EXTREMITY $2,250.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY 2ND ORDER THORACIC/BRACHIOCEPHALIC BRANCH $1,124.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY 3RD ORDER ABDOMEN/PELVIS/LOWER EXTREMITY $2,133.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY 3RD ORDER THORACIC/BRACHIOCEPHALIC BRANCH $2,434.00 Cardiovascular procedures CATHETER PLACEMENT ARTERY ADD'L ABDOMEN/PELVIS/LOWER EXTREMITY $147.00

Cardiovascular procedures CATHETER PLACEMENT ARTERY ADD'L THORACIC/BRACHIOCEPHALIC BRANCH $798.00 Cardiovascular procedures CATHETER PLACEMENT NON-SELECTIVE UNILATERAL OR BILATERAL $13,149.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - UNILATERAL $21,507.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY - UNILATERAL $13,149.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY W/EXTRACRANIAL ANGIO - BILATERAL $20,875.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - CAROTID OR INNOMINATE ARTERY W/INTRACRANIAL ANGIO - BILATERAL $26,301.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EACH INTRACRANIAL BRANCH - BILATERAL $2,434.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EACH INTRACRANIAL BRANCH - UNILATERAL $1,532.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EXTERNAL CAROTID ARTERY - BILATERAL $900.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - EXTERNAL CAROTID ARTERY - UNILATERAL $565.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - SUBCLAVIAN OR INNOMINATE ARTERY - BILATERAL $20,875.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - SUBCLAVIAN OR INNOMINATE ARTERY - UNILATERAL $3,995.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE - VERTEBRAL ARTERY - BILATERAL $43,012.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE COMMON CAROTID OR INNOMINATE ARTERY - UNILATERAL $13,149.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE -INTERNAL CAROTID ARTERY - BILATERAL $34,137.00 Cardiovascular procedures CATHETER PLACEMENT SELECTIVE -INTERNAL CAROTID ARTERY - UNILATERAL $17,068.00 Cardiovascular procedures CATHETERIZATION UMBILICAL VEIN - NEWBORN FOR DX. OR THERAPY $201.00 Cardiovascular procedures DECLOT VASCULAR ACCESS DEVICE $615.00 Cardiovascular procedures ELECTRODE REPOSITION $14,018.00 Cardiovascular procedures EMBOLIZATION OR OCCLUSION DIALYSIS CIRCUIT W/IMAGING S&I $50,374.00 Cardiovascular procedures EMBOLIZATION/OCCLUSION ARTERIAL (OTHER THAN HEMORRHAGE OR TUMOR) $50,373.00 Cardiovascular procedures EMBOLIZATION/OCCLUSION TUMOR/ORGAN ISCHEMIA/INFARCTION $39,980.00 Cardiovascular procedures EMBOLIZATION/OCCLUSION VENOUS (OTHER THAN HEMORRHAGE) $50,373.00 Cardiovascular procedures EMBOLIZATION/OCCLUSION VENOUS OR ARTERIAL HEMORRHAGE $39,980.00 Cardiovascular procedures ENDOVASC RPR DPLMNT AORTO-BI-ILIAC ENDOGRAFT $21,439.00 Cardiovascular procedures ENDOVASC RPR DPLMNT AORTO-BI-ILIAC ENDOGRAFT RUPTURE $21,439.00 Cardiovascular procedures ENDOVASC RPR ILIO-ILIAC ENDOGRAFT $21,439.00 Cardiovascular procedures INJECT EXISTING CV DEVICE $275.00 Cardiovascular procedures INJECTION FOR TREATMENT OF EXTREMITY PSEUDOANEURYSM (EG, THROMBIN) $499.00 Cardiovascular procedures INJECTION PROCEDURE FOR EXTREMITY VENOGRAPHY $752.00 Cardiovascular procedures INSERT OR REPLACE CARDIOVERTER-DEFIBRILLATOR SYSTEM WITH LEAD(S) - SINGLE OR DUAL $25,627.00 Cardiovascular Procedures INSERT OR REPLACE TEMPORARY PACEMAKER - INPATIENT BEDSIDE PROCEDURE $8,173.00 Cardiovascular procedures INSERT PERIPHERALLY VENOUS ACCESS DEVICE W/SUBCUTANEOUS PORT AGE 5 YEARS OR > $5,762.00 Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/ TRANVENOUS ATRIAL LEAD $29,344.00 Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/ATRIAL & VENTRICULAR LEADS $23,780.00 Cardiovascular procedures INSERT/REPLACE PERMANENT PACEMAKER W/VENTRICULAR LEAD $23,780.00 Cardiovascular procedures INSERTION 36565 TUNNELED CV CATHETER W/ 2 ACCESS SITES (TESIO TYPE) $4,130.00 Cardiovascular procedures INSERTION AORTIC BALLOON PUMP $3,697.00 Cardiovascular Procedures INSERTION ARTERIAL LINE (A-LINE) - INPATIENT BEDSIDE PROCEDURE $618.00 Cardiovascular procedures INSERTION CARDIOVERTER-DEFIBRILLATOR GENERATOR WITH EXISTING DUAL LEADS $24,943.00 Cardiovascular procedures INSERTION CARDIOVERTER-DEFIBRILLATOR GENERATOR WITH EXISTING MULTIPLE LEADS $19,318.00 Cardiovascular Procedures INSERTION CENTRAL VENOUS CATHETER - INPATIENT BEDSIDE PROCEDURE $1,794.00 Cardiovascular procedures INSERTION LEFT VENTRICULAR LEAD TO PREVIOUSLY PLACED GENERATOR $36,989.00 Cardiovascular procedures INSERTION NON-TUNNEL CV CATHETER - YOUNGER THAN 5 YEARS $1,585.00 Cardiovascular procedures INSERTION NON-TUNNELED CV CATHETER > 5YRS (CENTRAL LINE) $1,794.00 Cardiovascular procedures INSERTION OF DUAL CHAMBER LEADS $19,681.00 Cardiovascular procedures INSERTION OF LV LEAD AT TIME OF INSERTION OF PACEMAKER OR DEFIBRILLATOR $25,904.00 Cardiovascular procedures INSERTION OF SINGLE TRANSVENOUS ELECTRODE (PACEMAKER OR CARDIOVERTER-DEFIBRILLATOR) $21,442.00 Cardiovascular procedures INSERTION OR REPLACEMENT SUBCUTANOEUS IMPLANTABLE DEFIBRILLAOTR W/LEAD $25,157.00 Cardiovascular procedures INSERTION OR REPLACEMENT TEMPORARY PACEMAKER-SINGLE CHAMBER $11,569.00 Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING DUAL LEADS $37,921.00 Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING MULTIPLE LEADS $13,654.00 Cardiovascular procedures INSERTION PACEMAKER GENERATOR ONLY WITH EXISTING SINGLE LEAD $18,532.00 Cardiovascular procedures INSERTION TUNNELED CV CATH W/PORT 5YRS OR OLDER $6,946.00 Cardiovascular procedures INSERTION TUNNELED CV CATHETER W/O PORT 5 YEARS OR OLDER $4,260.00 Cardiovascular procedures INSERTION VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $18,512.00 Cardiovascular procedures INSERTION VENTRICULAR ASSIST DEVICE - PERCUTANEOUS - ARTERIAL ACCESS ONLY $8,365.00 Cardiovascular procedures INTRAVASCULAR ULTRASOUND 1ST NONCORONARY VESSEL - INCLUDES S&I $1,631.00 Cardiovascular procedures INTRAVASCULAR ULTRASOUND EACH ADDITIONAL NONCORONARY VESSEL - INCLUDES S&I $251.00 Cardiovascular procedures INTRO OF NEEDLE OR INTRACATHETER UPR/LXTR ARTERY $1,513.00 Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/ANGIOPLASTY INCLUDES IMAGES/S&I $10,349.00 Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/DX ANGIOGRAPHY INCLUDES IMAGES/S&I $1,350.00 Cardiovascular procedures INTRODUCE CATH DIALYSIS CIRCUIT W/STENT PLACEMENT INCLUDES IMAGES/S&I $62,303.00 Cardiovascular procedures INTRODUCE NEEDLE AORTIC TRANSLUMBAR $699.00 Cardiovascular procedures INTRODUCTION CATHETER SUPERIOR OR INFERIOR VENA CAVA $960.00 Cardiovascular procedures INTRODUCTION CATHETER RIGHT HEART OR PULMONARY ARTERY $812.00 Cardiovascular Procedures INTRODUCTION NEEDLE CAROTID OR VERTEBRAL ARTERY $1,150.00 Cardiovascular procedures INTRODUCTION NEEDLE OR INTRACATHETER - VEIN $397.00 Cardiovascular procedures INTRODUCTION OF CATHETER - AORTA $1,301.00 Cardiovascular procedures LIGATION OF AV FISTULA $3,809.00 Cardiovascular procedures LIGATION OF INFERIOR VENA CAVA $14,689.00 Cardiovascular procedures LINE DRAW FROM VENOUS ACCESS DEVICE - COLLECTION OF BLOOD SPECIMEN $944.00 Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - ARTERY - PRIMARY INITIAL VESSEL (2016 INCLUDES GUIDANCE) $8,284.00 Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - ARTERY - SUBSEQUENT VESSEL (2016 INCLUDES GUIDANCE) $6,575.00 Cardiovascular procedures MECHANICAL (ANGIOJET) THROMBECTOMY - VENOUS $6,575.00 Cardiovascular procedures PERCUTANEOUS PORTAL VEIN CATHETERIZATION - ANY METHOD $1,328.00 Cardiovascular procedures PERICARDIOCENTESIS - INITIAL (DRAINAGE OF HEART SAC) $658.00 Cardiovascular procedures PERICARDIOCENTESIS - SUBSEQUENT (DRAINAGE OF HEART SAC) $1,634.00 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

Cardiovascular procedures PERIPHERALLY INSERTED MIDLINE CATHETER $1,394.00 Cardiovascular procedures PLACEMENT EXTN PROSTH FOR ENDOVASCULAR REPAIR $5,512.00 Cardiovascular procedures PLACEMENT INTRAVASCAULAR STENT 1ST VEIN $51,954.00 Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT 1ST ARTERY - BILATERAL $77,930.00 Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT 1ST ARTERY - UNILATERAL $18,668.00 Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT ADD'L ARTERY $19,940.00 Cardiovascular procedures PLACEMENT INTRAVASCULAR STENT ADD'L VEIN $25,125.00 Cardiovascular Procedures PLACEMENT OCCLUSIVE DEVICE $728.00 Cardiovascular procedures PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION $698.00 Cardiovascular procedures PORTACATH/GROSHONG LINE DRAW - COLLECTION OF BLOOD SPECIMEN $944.00 Cardiovascular procedures RELOCATION OF SKIN POCKET FOR CARDIOVERTER-DEFIBRILLATOR $7,376.00 Cardiovascular procedures RELOCATION OF SKIN POCKET FOR PACEMAKER $7,376.00 Cardiovascular procedures REMOVAL DEFIBRILLATOR PULSE GENERATOR ONLY $7,522.00 Cardiovascular procedures REMOVAL INTRAVASCULAR FOREIGN BODY WITH IMAGING IF PERFORMED $10,476.00 Cardiovascular procedures REMOVAL OF ELECTRODE(S) DUAL LEAD SYSTEM $8,373.00 Cardiovascular procedures REMOVAL PACEMAKER PULSE GENERATOR ONLY $8,587.00 Cardiovascular procedures REMOVAL PERCUTANEOUS VENTRICULAR ASSIST DEVICE - DIFFERENT SESSION $2,788.00 Cardiovascular procedures REMOVAL TUNNELED CENTRAL VENOUS CATHETER WITHOUT PORT OR PUMP $2,501.00 Cardiovascular procedures REMOVAL VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $12,704.00 Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - DUAL LEAD SYSTEM $23,159.00 Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - MULTIPLE LEAD SYSTEM $22,682.00 Cardiovascular procedures REMOVE & REPLACE CARDIOVERTER-DEFIBRILLATOR GENERATOR - SINGLE LEAD SYSTEM $23,491.00 Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - DUAL LEAD SYSTEM $23,809.00 Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - MULTIPLE LEAD SYSTEM $19,925.00 Cardiovascular procedures REMOVE & REPLACE PACEMAKER GENERATOR - SINGLE LEAD SYSTEM $21,520.00 Cardiovascular procedures REMOVE AORTIC BALLOON PUMP $2,450.00 Cardiovascular procedures REMOVE CARDIOVERTER-DEFIBRILLATOR LEAD(S) - SINGLE OR DUAL $33,803.00 Cardiovascular procedures REMOVE LUMEN OBSTRUCTION FROM VENOUS ACCESS DEVICE $1,048.00 Cardiovascular procedures REMOVE OBSTRUCTION FROM VENOUS ACCESS DEVICE $2,398.00 Cardiovascular procedures REMOVE TUNNELED CVA CATHETER WITH PORT $3,302.00 Cardiovascular procedures REPAIR BLOOD VESSEL LESION $3,562.00 Cardiovascular procedures REPAIR CENTRAL VENOUS ACCESS DEVICE WITH SUBCUTANEOUS PORT OR PUMP $1,503.00 Cardiovascular procedures REPAIR OF SINGLE TRANSVENOUS LEAD (PACEMAKER OR CARDIO-DEFIBRILLATOR) $28,577.00 Cardiovascular Procedures REPAIR TESIO CATHETER $562.00 Cardiovascular procedures REPLACE CV ACCESS DEVICE - COMPLETE - SAME VENOUS ACCESS WITH SQ PORT $11,850.00 Cardiovascular procedures REPLACE NON-TUNNELED CENTRAL VENOUS CATHETER THROUGH SAME VENOUS ACCESS - NO PORT OR PUMP $2,717.00 Cardiovascular procedures REPLACE TUNNELED CV CATHETER W/O PORT THRU SAME ACCESS $3,023.00 Cardiovascular procedures REPLACEMENT PICC LINE $2,213.00 Cardiovascular procedures REPLACEMENT TUNNELED CV ACCESS DEVICE W/PORT $8,014.00 Cardiovascular procedures REPOSITION CV CATH W/FLUOROSCOPY $1,321.00 Cardiovascular procedures REPOSITION LEFT VENTRICULAR LEAD (INCLUDES REMOVAL, INSERT/REPLACE GENERATOR) $21,819.00 Cardiovascular procedures REPOSITION PERCUTANEOUS VENTRICULAR ASSIST DEVICE $879.00 Cardiovascular procedures REPOSITION VENA CAVA FILTER - ENDOVASCULAR APPROACH - IMAGING INCLUDED $10,082.00 Cardiovascular procedures REVASCULARIZATION ADD'L ILIAC VESSEL WITH ANGIOPLASTY - BILATERAL $27,697.00 Cardiovascular procedures REVASCULARIZATION ADD'L ILIAC VESSEL WITH ANGIOPLASTY - UNILATERAL $18,466.00 Cardiovascular procedures REVASCULARIZATION EACH ADD'L ILIAC VESSEL W/STENT - WITH OR WITHOUT ANGIO - BILATERAL $34,900.00 Cardiovascular procedures REVASCULARIZATION EACH ADD'L ILIAC VESSEL WITH STENT - WITH OR WITHOUT ANGIO $23,266.00 Cardiovascular procedures REVASCULARIZATION EACH ADD'L TIBIAL/PERONEAL ARTERY WITH ANGIOPLASTY - UNILATERAL $23,266.00 Cardiovascular procedures REVASCULARIZATION EACH ADD'L TIBIAL/PERONEAL WITH STENT & ANGIOPLASTY - UNILATERAL $18,466.00 Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) W/STENT & ANGIOPLASTY -UNILATERAL $49,391.00 Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) W/STENT & ATHERECTOMY (INCLUDES ANGIO IF DONE) $61,522.00 Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) WITH ANGIOPLASTY - BILATERAL $34,898.00 Cardiovascular procedures REVASCULARIZATION FEMORAL-POPLITEAL ARTERY(S) WITH ANGIOPLASTY - UNILATERAL $23,266.00 Cardiovascular procedures REVASCULARIZATION ILIAC ARTERY - INITIAL VESSEL - UNILATERAL - WITH ANGIOPLASTY $23,266.00 Cardiovascular procedures REVASCULARIZATION ILIAC ARTERY W/STENT - INITIAL - UNILATERAL - W/ OR W/O ANGIOPLASTY $23,266.00 Cardiovascular procedures REVASCULARIZATION OPEN OR PERQ FEMORAL-POPLITEAL ARTERY(S) W/ATHERECTOMY - UNILATERAL $41,234.00 Cardiovascular procedures REVASCULARIZATION OPEN OR PERQ TIBIAL-PERONEAL ARTERY W/ATHERECTOMY - UNILATERAL $41,234.00 Cardiovascular procedures REVASCULARIZATION TIBIAL/PERONEAL ARTERY WITH ANGIOPLASTY - UNILATERAL $23,266.00 Cardiovascular procedures REVASCULARIZATION TIBIAL/PERONEAL ARTERY WITH STENT & ANGIOPLASTY - UNILATERAL $39,200.00 Cardiovascular procedures REVASCULARIZE ILIAC ARTERY - INITIAL VESSEL -BILATERAL - W/ANGIOPLASTY $34,900.00 Cardiovascular procedures REVASCULARIZE ILIAC ARTERY W/STENT - INITIAL VESSEL- BILATERAL W/ OR W/O ANGIOPLASTY $34,900.00 Cardiovascular procedures REVISION TIPS (TRANSVENOUS INTRAHEPATIC PORTOSYSTEMIC SHUNT) $10,963.00 Cardiovascular procedures SECONDARY ARTERIAL MECHANICAL THROMBECTOMY ADD-ON $6,575.00 Cardiovascular procedures SELECTIVE CATH PLACEMENT SEGMENTAL/SUBSEGMENTAL PULMONARY ARTERY $886.00 Cardiovascular procedures SELECTIVE CATH PLACEMENT SEGMENTAL/SUBSEGMENTAL PULMONARY ARTERY- BILATERAL $1,328.00 Cardiovascular procedures SELECTIVE CATHETER PLACEMENT ARTERY 1ST ORDER ABD/PEVIS/LEG - BILATERAL-50 $1,255.00 Cardiovascular procedures SELECTIVE CATHETER PLACEMENT EA. 1ST ORDER ARTERY ABD/PELVIS/LEG - UNILATERAL $1,356.00 Cardiovascular procedures SELECTIVE CATHETER PLACEMENT PULMONARY ARTERY $1,580.00 Cardiovascular procedures SELECTIVE CATHETER PLACEMENT VENOUS SYSTEM 1ST BRANCH $1,218.00 Cardiovascular procedures SELECTIVE CATHETER PLACEMENT VENOUS SYSTEM 2ND BRANCH $2,455.00 Cardiovascular procedures STENT PLACEMENT CENTRAL DIALYSIS SEGMENT W/IMAGING S&I $51,954.00 Cardiovascular procedures THROMBECTOMY PERCUTANEOUS A-V FISTULA GRAFT $5,436.00 Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT INCLUDES DX ANGIOGRAPHY & IMAGING S&I $6,786.00 Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT W/ANGIOPLASTY & IMAGING S&I $15,784.00 Cardiovascular procedures THROMBECTOMY/THROMBOLYSIS DIALYSIS CIRCUIT W/STENT PLACEMENT & IMAGING S&I $67,738.00 Cardiovascular procedures THROMBOLYSIS CEREBRAL BY INTRAVENOUS INFUSION (THROMBOLYTIC THERAPY - STROKE) $712.00 Cardiovascular procedures THROMBOLYSIS NON-CORONARY - CONTINUED/FOLLOW-UP $8,247.00 Cardiovascular procedures THROMBOLYSIS NON-CORONARY - SUBSEQUENT- INCLUDES REMOVAL/CLOSURE $8,247.00 Cardiovascular procedures THROMBOLYSIS NON-CORONARY ARTERIAL INFUSION - INITIAL DAY (INCLUDES S &I) $4,657.00 Cardiovascular procedures THROMBOLYSIS NON-CORONARY ARTERIAL INFUSION - INITIAL DAY (INCLUDES S &I) - BILATERAL $6,986.00 Cardiovascular procedures THROMBOLYSIS NON-CORONARY VENOUS INFUSION - INITIAL DAY $3,697.00

Cardiovascular procedures TIPS INSERTION $19,626.00 Cardiovascular procedures TRANSCATHETER PLACEMENT INTRAVASCULAR STENT CERVICAL CAROTID ARTERY W/EMBOLIC PROTECTION DEVICE $16,218.00 Cardiovascular procedures TRANSCATHETER PLACEMENT INTRAVASCULAR STENT CERVICAL CAROTID ARTERY W/O EMBOLIC PROTECTION $11,924.00 Cardiovascular procedures ULTRASOUND GUIDED ABLATION 1ST VEIN - EXTREMITY $9,133.00 Cardiovascular procedures ULTRASOUND GUIDED ABLATION ADDITIONAL VEIN - EXTREMITY $4,566.00 Cardiovascular procedures UNLISTED CARDIAC SURGERY $2,472.00 Cardiovascular procedures UNLISTED VASCULAR SURGERY PROCEDURE $3,631.00 Cardiovascular procedures UPGRADE SINGLE CHAMBER PACEMAKER SYSTEM TO DUAL CHAMBER SYSTEM $33,104.00 Cardiovascular procedures VEIN ACCESS CUTDOWN <1YR $26.00 Cardiovascular procedures VENOUS CATHETERIZATION FOR SELECTIVE ORGAN BLOOD SAMPLING $565.00 CT Scan Services 3D RENDERING W/POSTPROCESSING $1,074.00 CT Scan Services CEREBRAL PERFUSION ANALYS CT W/BLOOD FLOW&VOLUME $3,353.00 CT Scan Services CT ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST $3,159.00 CT Scan Services CT ABDOMEN AND PELVIS WITH IV CONTRAST $3,159.00 X CT Scan Services CT ABDOMEN AND PELVIS WITHOUT IV CONTRAST $3,159.00 X CT Scan Services CT ABDOMEN W&W/O IV CONTRAST - W/ ORAL CONTRAST $2,736.00 CT Scan Services CT ABDOMEN WITH IV CONTRAST-WITH OR WITHOUT ORAL CONTRAST $2,736.00 CT Scan Services CT ABDOMEN WITHOUT IV CONTRAST - WITH OR WITHOUT ORAL CONTRAST $2,736.00 CT Scan Services CT BRAIN WITH & WITHOUT CONTRAST $1,019.00 CT Scan Services CT BRAIN WITH CONTRAST $1,019.00 CT Scan Services CT BRAIN WITHOUT CONTRAST $1,019.00 X CT Scan Services CT CERVICAL SPINE WITH CONTRAST $1,929.00 CT Scan Services CT CERVICAL SPINE WITHOUT CONTRAST $1,929.00 X CT Scan Services CT CHEST - LOW DOSE FOR LUNG CANCER SCREENING (LDCT) $2,210.00 CT Scan Services CT CHEST/MEDIASTINUM WITH & WITHOUT CONTRAST $2,210.00 CT Scan Services CT CHEST/MEDIASTINUM WITH CONTRAST $2,210.00 X CT Scan Services CT CHEST/MEDIASTINUM WITHOUT CONTRAST $2,210.00 X CT Scan Services CT C-SPINE MULTI-LEVEL W&W/O CONTRAST $1,929.00 CT Scan Services CT FACIAL BONES WITH CONTRAST $1,266.00 CT Scan Services CT GUIDANCE FOR NEEDLE PLACEMENT (FINE NEEDLE ASPIRATION/BIOPSY/LOCALIZATION) $5,317.00 CT Scan Services CT GUIDANCE FOR PARENCHYMAL TISSUE ABLATION $536.00 CT Scan Services CT GUIDANCE FOR STEREOTACTIC LOCALIZATION $3,979.00 CT Scan Services CT GUIDANCE PLACEMENT RADIATION FIELDS $2,968.00 CT Scan Services CT HEART W/CONTRAST W/EVALUATION CARDIAC STRUCTURES & MORPHOLOGY (EXPLODE SET) $6,025.00 CT Scan Services CT HEART W/CONTRAST W/EVALUATION STRUCTURE & FUNCTION CONGENITAL HEART DISEASE (EXPLODE SET) $4,449.00 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 $2,338.00 CT Scan Services CT LIMITED OR FOLLOW-UP STUDY (ALSO USED FOR SINUS SCREENING) $1,767.00 CT Scan Services CT LOWER EXTREMITY W&W/O CONTRAST $1,463.00 CT Scan Services CT LOWER EXTREMITY W/CONTRAST $1,463.00 CT Scan Services CT LOWER EXTREMITY W/O CONTRAST $1,463.00 CT Scan Services CT LUMBAR SPINE W&W/O CONTRAST $1,228.00 CT Scan Services CT LUMBAR SPINE WITH CONTRAST $1,228.00 CT Scan Services CT LUMBAR SPINE WITHOUT CONTRAST $1,228.00 CT Scan Services CT MAXILLOFACIAL AREA WITHOUT CONTRAST $1,266.00 CT Scan Services CT MAXILLOFACIAL WITH & WITH0UT I.V. CONTRAST $1,266.00 CT Scan Services CT NECK (SOFT TISSUE) WITH CONTRAST $2,421.00 CT Scan Services CT NECK WITH & WITHOUT I.V. CONTRAST $2,421.00 CT Scan Services CT NECK WITHOUT CONTRAST $2,421.00 CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA OR EAR WITH & WITHOUT I.V. CONTRAST $2,109.00 CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA OR OUT/MID/INNER EAR WITH I.V. CONTRAST $2,109.00 CT Scan Services CT ORBIT,SELLA,POSTERIOR FOSSA, OR OUT/MID/INNER EAR W/O CONTRAST $2,109.00 CT Scan Services CT PELVIS W&W/O IV CONTRAST-W OR W/O ORAL CONTRAST $2,514.00 CT Scan Services CT PELVIS WITH OR WITHOUT ORAL CONTRAST $2,514.00 CT Scan Services CT PELVIS WTIH IV CONTRAST & WITH ORAL CONTRAST $2,514.00 CT Scan Services CT SINUSES WITH & WITHOUT CONTRAST - 52 $1,266.00 CT Scan Services CT SINUSES WITH CONTRAST - 52 $1,266.00 CT Scan Services CT SINUSES WITHOUT CONTRAST - 52 $1,266.00 CT Scan Services CT THORACIC SPINE W/O CONTRAST $973.00 CT Scan Services CT THORACIC SPINE WITH & WITHOUT CONTRAST $973.00 CT Scan Services CT THORACIC SPINE WITH CONTRAST $973.00 CT Scan Services CT UPPER EXTREMITY W/CONTRAST $1,611.00 CT Scan Services CT UPPER EXTREMITY W/O CONTRAST $1,611.00 CT Scan Services CT UPPER EXTREMITY WITH & WITHOUT I.V. CONTRAST $1,611.00 CT Scan Services CTA ABDOMEN & PELVIS WITH CONTRAST - INCLUDES NON-CONTRAST IF DONE $3,046.00 CT Scan Services CTA ABDOMEN WITH CONTRAST - INCLUDES NONCONTRAST IMAGES IF PERFORMED $3,085.00 CT Scan Services CTA ABDOMINAL AORTA & BILATERAL ILIOFEMORAL LOWER EXTREMITY RUNOFF WITH CONTRAST $3,046.00 CT Scan Services CTA CHEST NON-CORONARY WITH CONTRAST - INCLUDES NONCONTRAST IMAGES IF PERFORMED $1,929.00 X CT Scan Services CTA HEAD WITH & WITHOUT I.V. CONTRAST $3,051.00 CT Scan Services CTA HEART CORONARY ARTERIES (EXPLODE SET) $6,025.00 CT Scan Services CTA LOWER EXTREMITY WITH & WITHOUT I.V. CONTRAST $2,822.00 CT Scan Services CTA NECK WITH & WITHOUT IV CONTRAST $3,051.00 CT Scan Services CTA PELVIS WITH & WITHOUT IV CONTRAST $2,839.00 CT Scan Services CTA UPPER EXTREMITY WITH & WITHOUT I.V. CONTRAST $2,921.00 Dialysis Services CAPD (CONTINUOUS AMBULATORY PERITONEAL DIALYSIS) $1,664.00 Dialysis Services CCPD (CONTINUOUS CYCLING PERITONEAL DIALYSIS) $1,664.00 Dialysis Services CRRT (CONTINUOS RENAL REPLACEMENT THERAPY) $1,822.00 Dialysis Services DIALYSIS - ULTRAFILTRATION FOR MANAGEMENT OF FLUID OVERLOAD $1,822.00 Dialysis Services DIALYSIS - UNSCHEDULED/EMERGENCY OUTPATIENT $1,664.00 Dialysis Services DIALYSIS SERVICE (HEMODIALYSIS) - INPATIENT $1,664.00 Dialysis Services SCUF (SLOW CONTINUOUS ULTRA FILTRATION) $1,442.00

Digestive System Procedures ABLATION LIVER TUMOR(S) - PERCUTANEOUS - RADIOFREQUENCY $17,758.00 Digestive System Procedures ANOSCOPY WITH REMOVAL FOREIGN BODY $2,624.00 Digestive System Procedures BIOPSY ABDOMINAL OR RETROPERITONEAL MASS WITH NEEDLE $1,258.00 Digestive System Procedures BIOPSY LIVER - NEEDLE (AT TIME OF OTHER MAJOR PROCEDURE) $199.00 Digestive System Procedures BIOPSY OF SALIVARY GLAND $2,119.00 Digestive System Procedures BIOPSY PANCREAS NEEDLE PERCUTANEOUS $1,012.00 Digestive System Procedures CHOLECYSTOSTOMY - PERCUTANEOUS $3,485.00 Digestive System Procedures CONTRAST INJECTION FOR EVALUATION OF EXISTING OSTOMY TUBE, PERCUTANEOUS W/FLUORO $244.00 Digestive System Procedures CONTROL THROAT BLEEDING $186.00 Digestive System Procedures CONVERSION EXTERNAL BILIARY DRAINAGE TO INTERNAL-EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9,166.00 Digestive System Procedures CONVERT G-TUBE TO GASTRO-JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $1,172.00 Digestive System Procedures DILATION BILIARY DUCT/AMPULLA - EACH DUCT (INCLUDES IMAGE GUIDANCE AND S&I) ADD-ON $1,556.00 Digestive System Procedures DRAINAGE OF GUM LESION - 41800 $428.00 Digestive System Procedures DRAINAGE OF MOUTH LESION $399.00 Digestive System Procedures DRAINAGE OF TONSIL ABSCESS $428.00 Digestive System Procedures ENDOLUMINAL BIOPSY BILIARY TREE (INCLUDES IMAGE GUIDANCE AND S&I) ADD-ON $4,736.00 Digestive System Procedures EXCHANGE BILIARY DRAINAGE CATHETER - INCLUDES IMAGE GUIDANCE AND S&I $9,166.00 Digestive System Procedures EXCHANGE CYST OR ABSCESS DRAINAGE CATHETER $1,543.00 Digestive System Procedures EXCISION OF FRENUM - LABIAL OR BUCCAL (FRENUMECTOMY/FRENULECTOMY/FRENECTOMY) $5,329.00 Digestive System Procedures EXCISION THROMBOSED HEMORRHOID - EXTERNAL $2,320.00 Digestive System Procedures GASTRIC MOTILITY STUDIES - MANOMETRY $1,358.00 Digestive System Procedures GASTROSTOMY TUBE CHANGE WITHOUT FLUORO OR ENDOSCOPIC GUIDANCE $698.00 Digestive System Procedures IMAGE GUIDED FLUID DRAINAGE BY CATHETER - PERITONEAL/RETROPERITONEAL $5,531.00 Digestive System Procedures IMAGE GUIDED FLUID DRAINAGE BY CATHETER - VISCERAL $5,531.00 Digestive System Procedures INCISE EXTERNAL HEMORRHOID - 46083 $728.00 Digestive System Procedures INCISION OF RECTAL ABSCESS $3,482.00 Digestive System Procedures INJECTION FOR ASSESS OF ABCESS, CYST VIA PREVIOUSLY PLACED CATH OR TUBE $167.00 Digestive System Procedures INJECTION FOR CHOLANGIOGRAM - EXISTING ACCESS - INCLUDES IMAGE GUIDANCE AND S&I $1,481.00 Digestive System Procedures INJECTION FOR CHOLANGIOGRAM - NEW ACCESS - INCLUDES IMAGE GUIDANCE AND S&I $9,166.00 Digestive System Procedures INSERTION DUODENOSTOMY OR JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $1,477.00 Digestive System Procedures INSERTION GASTROSTOMY TUBE PERCUTANEOUS W/FLUORO $1,477.00 Digestive System Procedures INSERTION TUNNELED INTRAPERITONEAL CATHETER - PERCUTANEOUS $10,430.00 Digestive System Procedures LIVER BIOPSY $1,023.00 Digestive System Procedures NEEDLE BIOPSY-LIVER $1,374.00 Digestive System Procedures PARACENTESIS - INPATIENT BEDSIDE PROCEDURE $2,305.00 Digestive System Procedures PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITH IMAGING GUIDANCE $2,305.00 Digestive System Procedures PARACENTESIS (DIAGNOSTIC OR THERAPEUTIC) WITHOUT IMAGING GUIDANCE $2,305.00 Digestive System Procedures PLACEMENT ACCESS THROUGH BILIARY TREE INTO SMALL BOWEL - NEW ACCESS $9,166.00 Digestive System Procedures PLACEMENT BILIARY DRAINAGE CATHETER - EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9,166.00 Digestive System Procedures PLACEMENT BILIARY DRAINAGE CATHETER - INTERNAL-EXTERNAL - INCLUDES IMAGE GUIDANCE AND S&I $9,166.00 Digestive System Procedures PLACEMENT LONG GASTROINTESTINAL TUBE $938.00 Digestive System Procedures PLACEMENT NASAL/OROGASTRIC TUBE BY PHYSICIAN W/FLUOROSCOPY $277.00 Digestive System Procedures PLACEMENT OF SETON $2,597.00 Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - EXISTING ACCESS $17,338.00 Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - NEW ACCESS W/ PLACING SEPARATE BILIARY DRAIN $17,338.00 Digestive System Procedures PLACEMENT STENT(s) INTO BILE DUCT - NEW ACCESS W/O PLACING SEPARATE BILIARY DRAIN $17,338.00 Digestive System Procedures REMOVAL BILIARY DRAINAGE CATHETER - INCLUDES IMAGE GUIDANCE AND S&I $2,033.00 Digestive System Procedures REMOVAL CALCULI/DEBRIS FROM BILIARY DUCTS(S AND/OR GALLBLADDER ADD-ON $2,439.00 Digestive System Procedures REMOVAL TUNNELED INTRAPERITONEAL CATHETER $9,277.00 Digestive System Procedures REMOVE OBSTRUCTIVE MATERIAL FROM G, D, J, OR G-J TUBE W/FLUORO $590.00 Digestive System Procedures REPAIR INGUINAL HERNIA - REDUCEABLE $5,423.00 Digestive System Procedures REPAIR LIP, FULL THICKNESS; UP TO HALF VERTICAL HEIGHT $1,740.00 Digestive System Procedures REPAIR TONGUE LACERATION $399.00 Digestive System Procedures REPLACE DUODENOSTOMY OR JEJUNOSTOMY TUBE,PERCUTANEOUS W/FLUORO $742.00 Digestive System Procedures REPLACE GASTRO-JEJUNOSTOMY TUBE, PERCUTANEOUS W/FLUORO $742.00 Digestive System Procedures REPLACE G-TUBE OR CECOSTOMY TUBE,PERCUTANEOUS W/FLUORO $590.00 Digestive System Procedures REPOSITION G-TUBE IN DUODENUM $802.00 Digestive System Procedures SCLEROTHERAPY PERCUTANEOUS INCLUDING IMAGE GUIDANCE AND S&I $3,967.00 Digestive System Procedures UNLISTED PROCEDURE BILIARY TRACT (BILE DUCT-GALLBLADDER-LIVER) $6,073.00 Digestive System Procedures UNLISTED PROCEDURE INTESTINE $1,765.00 Ear Procedures BIOPSY EXTERNAL EAR $1,677.00 Ear Procedures DRAIN EXTERNAL EAR ABSCESS OR HEMATOMA - SIMPLE $249.00 Ear Procedures REMOVAL IMPACTED CERUMEN USING IRRIGATION/LAVAGE - UNILATERAL $170.00 Ear Procedures REMOVAL IMPACTED CERUMEN WITH IRRIGATION/LAVAGE - BILATERAL $254.00 Ear Procedures REMOVE FOREIGN BODY FROM EXTERNAL AUDITORY CANAL $227.00 Ear Procedures REMOVE IMPACTED CERUMEN W/INSTRUMENTATION - BILATERAL $237.00 Ear Procedures REMOVE IMPACTED CERUMEN W/INSTRUMENTATION - UNILATERAL $198.00 Emergency Evaluation and Management Services ER VISIT - LEVEL 3 $709.00 X Emergency Evaluation and Management Services ER VISIT - LEVEL 1 $268.00 X Emergency Evaluation and Management Services ER VISIT - LEVEL 2 $383.00 X Emergency Evaluation and Management Services ER VISIT - LEVEL 4 $1,057.00 X Emergency Evaluation and Management Services ER VISIT - LEVEL 5 $1,395.00 X Emergency Evaluation and Management Services ER VISIT LEVEL - CRITICAL CARE - EACH ADDITIONAL 30 MINUTES $421.00 X Emergency Evaluation and Management Services ER VISIT LEVEL - CRITICAL CARE - FIRST 30-74 MINUTES $2,614.00 X Emergency Services COLPOSCOPE EXAM AND PHOTOS (SANE EXAM) $288.00 Emergency Services EMERGENCY CHEST RE-OPEN - INPATIENT BEDSIDE PROCEDURE $4,674.00 Emergency Services MED SAFE SCREENING (SANE EXAM) $118.00 Emergency Services SANE EXAM (Explode Set as of 3-15-2015) $334.00 Emergency Services TRAUMA TEAM ACTIVATION-LEVEL 1 $8,364.00 X Emergency Services TRAUMA TEAM ACTIVATION-LEVEL 2 $7,160.00 X Endocrine System Procedures NEEDLE CORE BIOPSY THYROID - PERCUTANEOUS $843.00

Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 1 - ESTABLISHED - TYPICALLY 5 MINUTES $144.00 Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 2 - ESTABLISHED - TYPICALLY 10 MINUTES $185.00 Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 3 - ESTABLISHED - TYPICALLY 15 MINUTES $195.00 Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 4 - ESTABLISHED - TYPICALLY 25 MINUTES $266.00 Evaluation and Management Services ADVANCE PRACTICE PRACTITIONER VISIT - LEVEL 5 - ESTABLISHED - TYPICALLY 40 MINUTES $373.00 Evaluation and Management Services ALCOHOL AND/OR SUBSTANCE ABUSE ASSESSMENT & BRIEF INTERVENTION (15-30 MINUTES) $209.00 Evaluation and Management Services ANTICOAGULATION MANAGEMENT - LEVEL 1 $188.00 Evaluation and Management Services ANTICOAGULATION MANAGEMENT - LEVEL 2 $196.00 Evaluation and Management Services ASSESSMENT OF TINNITUS $422.00 Evaluation and Management Services ASSESSMENT-PULMONARY REHABILITATION (INITIAL OR EXIT INTERVIEW) $144.00 Evaluation and Management Services COMPLEX CONSULTATION OSTOMY/WOUND CARE 2-3 HOURS $424.00 Evaluation and Management Services CONSULTATION WITH PREOP INSTRUCTION AND STOMA SITE MARKING $379.00 Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 2 $175.00 Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 3 $206.00 Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 4 $237.00 Evaluation and Management Services ESTABLISHED OUTPATIENT - LEVEL 5 $291.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 1 VISIT - WOUND CARE $144.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 1 VISIT - WOUND CARE - IP ONLY $144.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 2 VISIT - WOUND CARE $287.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 2 VISIT - WOUND CARE - IP ONLY $311.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 3 VISIT - WOUND CARE $311.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 3 VISIT - WOUND CARE - IP ONLY $287.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 4 VISIT - WOUND CARE - IP ONLY $348.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 4 VISIT - WOUND CARE AND/OR PAIN CARE $348.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 5 VISIT - WOUND CARE $394.00 Evaluation and Management Services ESTABLISHED PATIENT LEVEL 5 VISIT - WOUND CARE - IP ONLY $394.00 Evaluation and Management Services FOLLOW-UP VISIT: COMPLEX RADIATION TX $516.00 Evaluation and Management Services FOLLOW-UP VISIT: DETAILED RADIATION TX $476.00 Evaluation and Management Services FOLLOW-UP VISIT: EXP&ED RADIATION TX $425.00 Evaluation and Management Services FOLLOW-UP VISIT: HIGH COMPLEXITY RADIATION TX $586.00 Evaluation and Management Services FOLLOW-UP VISIT: SIMPLE RADIATION TX $191.00 Evaluation and Management Services INCONTINENCE ASSESSMENT 1-2 HOURS $236.00 Evaluation and Management Services LEVEL 1 NURSING CARE (ALSO FOR ET MINIMAL CARE - UP TO 30 MINUTES) $144.00 Evaluation and Management Services LEVEL 2 NURSING CARE (ALSO FOR SIMPLE OSTOMY/WOUND MANAGEMENT UP TO 1 HOUR) $358.00 Evaluation and Management Services LEVEL 3 NURSING CARE $352.00 Evaluation and Management Services MEDICAL VISIT LEVEL 1 ESTABLISHED PATIENT - WORKABLE $144.00 Evaluation and Management Services MEDICAL VISIT LEVEL 2 ESTABLISHED PATIENT - WORKABLE $201.00 Evaluation and Management Services MEDICAL VISIT LEVEL 3 ESTABLISHED PATIENT - WORKABLE $173.00 Evaluation and Management Services MEDICAL VISIT LEVEL 3 NEW PATIENT - WORKABLE $227.00 Evaluation and Management Services MEDICAL VISIT LEVEL 4 ESTABLISHED PATIENT - WORKABLE $195.00 Evaluation and Management Services MEDICAL VISIT LEVEL 5 ESTABLISHED PATIENT - WORKABLE $285.00 Evaluation and Management Services MEDICAL/LEVEL 1/NEW PT - WORKABLE $122.00 Evaluation and Management Services MEDICAL/LEVEL 2/NEW PT - WORKABLE $173.00 Evaluation and Management Services MEDICAL/LEVEL 4/NEW PATIENT - WORKABLE $245.00 Evaluation and Management Services MEDICAL/LEVEL 5/NEW PATIENT - WORKABLE $337.00 Evaluation and Management Services OP VISIT - NEW PATIENT: SIMPLE RADIATION TX $225.00 Evaluation and Management Services OP VISIT- NEW PATIENT: EXP&ED RADIATION TX $270.00 Evaluation and Management Services OP VISIT: COMPREHENSIVE RADIATION TX $549.00 Evaluation and Management Services OP VISIT: DETAILED RADIATION TX $293.00 Evaluation and Management Services OP VISIT: HIGH COMPLEXITY RADIATION TX $303.00 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 $346.00 Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 1 $144.00 Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 2 $175.00 Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 3 $206.00 Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 4 $237.00 Evaluation and Management Services VISIT OUTPATIENT NEW - LEVEL 5 $291.00 Eye Procedures DRAINAGE OF EYELID ABSCESS $499.00 Eye Procedures FOREIGN BODY REMOVAL EYE - SUPERFICIAL $359.00 Eye Procedures REMOVE FOREIGN BODY - EYELID $205.00 Eye Procedures REMOVE FOREIGN BODY FROM EYE $236.00 Eye Procedures REMOVE FOREIGN BODY FROM EYE W/SLIT LAMP $257.00 Eye Procedures REMOVE FOREIGN BODY OF EYE - CORNEAL W/O SLIT LAMP $427.00 Eye Procedures REPAIR EYELID WOUND $2,754.00 Female Genital System Procedures EXCISION BARTHOLINS GLAND OR CYST $7,836.00 Female Genital System Procedures INCISION & DRAINAGE BARTHOLINS GLAND ABSCESS $592.00 Female Genital System Procedures INCISION & DRAINAGE OF VULVA/PERINEUM $497.00 Female Genital System Procedures INJECTION FOR UTERUS/TUBE X-RAY $463.00 Female Genital System Procedures INSERTION OF UTERINE TANDEM AND/OR OVOID $2,649.00 Female Genital System Procedures INSERTION OF VAGINAL AFTERLOADING APPARATUS $1,230.00 Gastroenterology Services ACID REFLUX TEST - PROLONGED RECORDING $818.00 Gastroenterology Services ESOPHAGEAL MOTILITY - MANOMETRY STUDY - HIGH RESOLUTION $1,617.00 Hemic and Lymphatic System Procedures BIOPSY or EXCISION LYMPH NODE by NEEDLE - SUPERFICIAL (EG, CERVICAL/INGUINAL/AXILLARY) $2,701.00 Hemic and Lymphatic System Procedures BIOPSY OR EXCISION LYMPH NODE(S) BY NEEDLE - SUPERFICIAL (CERVICAL-INGUINAL-AXILLARY) (EXPLODE SET) $3,967.00 Hemic and Lymphatic System Procedures BONE MARROW BIOPSY - INPATIENT BEDSIDE PROCEDURE $498.00 Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW ASPIRATIONS $394.00 Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW BIOPSIES & ASPIRATIONS $821.00 Hemic and Lymphatic System Procedures DIAGNOSTIC BONE MARROW BIOPSY $498.00 Hemic and Lymphatic System Procedures INJECTION FOR IDENTIFICATION OF SENTINEL NODE - RADIOACTIVE TRACER (EXPLODE SET) $968.00 Hemic and Lymphatic System Procedures UNLISTED PROCEDURE - HEMIC OR LYMPHATIC SYSTEM (SPLEEN) $1,168.00