Chapter 10.8. TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SUBCHAPTER 140-10.8 SCHEDULE OF MEDICAL AND OTHER RELATED FEES Part 001 General Provisions Part 200 BEH Fees [Reserved] § 140-10.8-201 BEH Fees Part 100 New Chargemaster § 140-10.8-101 CHCC Chargemaster Subchapter Authority: 3 CMC § 2824 (c), (l). Subchapter History: Amdts Adopted 46 Com. Reg. 51459 (Nov. 15, 2024); Amdts Proposed 45 Com. Reg. 51321 (Sept. 15, 2024); Amdts Adopted 46 Com. Reg. 50760 (Mar. 15, 2024); Amdts Proposed 45 Com. Reg. 50547 (Oct. 28, 2023); Amdts Adopted 45 Com. Reg. 50325 (Sept. 28, 2023); Amdts Proposed 45 Com. Reg. 50039 (July 28, 2023); Amdts Adopted 45 Com. Reg. 50322 (Sept. 28, 2023); Amdts Proposed 45 Com. Reg. 50032 (July 28, 2023); Amdts Adopted 44 Com. Reg. 49229 (Nov. 28, 2022); Amdts Proposed 44 Com. Reg. 49019 (Sept. 28, 2022); Amdts Adopted 44 Com. Reg. 48669 (July 28, 2022); Amdts Proposed 44 Com. Reg. 48397 (Apr. 28, 2022); Amdts Adopted 43 Com. Reg. 47890 (Nov. 28, 2021); Amdts Proposed 43 Com. Reg. 47718 (Oct. 28, 2021); Amdts Adopted 43 Com. Reg. 46395 (June 28, 2021); Amdts Proposed 43 Com. Reg. 45582 (Mar. 28, 2021); Amdts Adopted 43 Com. Reg. 45069 (Feb. 28, 2021); Amdts Proposed 42 Com. Reg. 44676 (Dec. 28, 2020); Amdts Adopted 42 Com. Reg. 43639 (June 28, 2020); Amdts Proposed 42 Com. Reg. 43515 (Apr. 28, 2020); Amdts Adopted 42 Com. Reg. 43064 (Jan. 28, 2020); Amdts Proposed 41 Com. Reg. 42881 (Nov. 28, 2019); Amdts Adopted 41 Com. Reg. 42761 (Aug. 28, 2019); Amdts Proposed 41 Com. Reg. 42071 (June 28, 2019); Amdts Adopted 41 Com. Reg. 42021 (June 28, 2019); Amdts Proposed 41 Com. Reg. 41637 (Apr. 28, 2019); Adopted 41 Com. Reg. 041326 (Jan. 28, 2019) (repealing and replacing subchapter 140-10.8); Proposed 40 Com. Reg. 041013 (Nov. 28, 2018) (repealing and replacing subchapter 140-10.8); Amdts Adopted 39 Com. Reg. 40413 (Dec. 28, 2017); Amdts Proposed 39 Com. Reg. 40290 (Oct. 28, 2017); Amdts Adopted 39 Com. Reg. 40222 (Oct. 28, 2017); Amdts Proposed 39 Com. Reg. 39410 (Mar. 28, 2017); Amdts Adopted 39 Com. Reg. 39218 (Feb. 28, 2017); Amdts Proposed 36 Com. Reg. 35137 (July 28, 2014); Amdts Adopted 33 Com. Reg. 32154 (Dec. 29, 2011); Amdts Proposed 33 Com. Reg. 31985 (Oct. 26, 2011); Amdts Adopted 27 Com. Reg. 25393 (Dec. 30, 2005); Amdts Proposed 27 Com. Reg. 25239 (Nov. 25, 2005); Amdts Adopted 26 Com. Reg. 21895 (Feb. 23, 2004); Amdts Proposed 26 Com. Reg. 21659 (Jan. 22, 2004); Amdts Adopted 25 Com. Reg. 20080 (Mar. 31, 2003); Amdts Proposed 24 Com. Reg. 19495 (Aug. 21, 2002); Amdts Proposed 23 Com. Reg. 18240 (Aug. 16, 2001);* Amdts Proposed 22 Com. Reg. 17094 (Apr. 20, 2000);* Amdts Proposed 21 Com. Reg. 16899 (Aug. 23, 1999);* Amdts Proposed 21 Com. Reg. 16594 (Mar. 18, 1999);* Amdts Adopted 21 Com. Reg. 16627 (Mar. 18, 1999); Amdts Proposed 21 Com. Reg. 16421 (Jan. 18, 1999); Amdts Adopted 21 Com. Reg. 16444 (Jan. 18, 1999); Amdts Proposed 20 Com. Reg. 16302 (Nov. 15, 1998); Amdts Adopted 20 Com. Reg. 16300 (Nov. 15, 1998); Amdts Proposed 20 Com. Reg. 16097 (Aug. 15, 1998); Amdts Adopted 20 Com. Reg. 16101 (Aug. 15, 1998); Amdts Proposed 20 Com. Reg. 15922 (June 15, 1998); Amdts Adopted 20 Com. Reg. 15961 (June 15, 1998); Amdts Emergency and Proposed 20 Com. Reg. 15878 (Mar. 16, 1998) (effective for 120 days from Mar. 16, 1998); Amdts Adopted 20 Com. Reg. 15953 (June 15, 1998); Amdts Proposed 20 Com. Reg. 15861 (Feb. 15, 1998); Amdts Adopted 19 Com. Reg. 15733 (Oct. 15, 1997); Amdts Proposed 19 Com. Reg. 15391 (June 15, 1997); Amdts Adopted 19 Com. Reg. 15420 (July 15, 1997); Amdts Proposed 19 Com. Reg. 15360 (May 15, 1997); Amdts Adopted 19 Com. Reg. 15418 (July 15, 1997); Amdts Proposed 19 Com. Reg. 15367 (May 15, 1997); Amdts Adopted 19 Com. Reg. 14888 (Jan. 15, 1997); Amdts Proposed 18 Com. Reg. 14383 (Oct. 15, 1996); Amdts Adopted 18 Com. Reg. 14203 and 14209 (July 15, 1996); Amdts Proposed 18 Com. Reg. 14156 (June 15, 1996); Amdts Adopted 18 Com. Reg. 13931 (Jan. 15, 1996); Amdts Proposed 17 Com. Reg. 13915 (Dec. 15, 1995); Amdts Adopted 17 Com. Reg. 13922 (Dec. 15, 1995); Amdts Proposed 17 Com. Reg. 13816 (Nov. 15, 1995); Amdts Adopted 17 Com. Reg. 13717 (Sept. 15, 1995); Amdts Proposed 17 Com. Reg. 13657 (Aug. 16, 1995); Amdts Adopted 17 Com. Reg. 13293 (Apr. 15, 1995); Amdts Proposed 17 Com. Reg. 12752 (Feb. 15, 1995). *Notices of adoption for the March 1999, August 1999, April 2000 and August 2001 proposed amendments have not been published. © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 1 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION Commission Comment: [Historical comments removed] Public Law 16-51 (effective Jan. 15, 2010), the “Commonwealth Healthcare Corporation Act of 2008,” codified at 3 CMC § 2801 et seq., established the Commonwealth Healthcare Corporation, which assumed the duties of the Department of Public Health as of January 15, 2011. In January, 2019, 41 Com. Reg. 041326 (Jan. 28, 2019), the Commonwealth Healthcare Corporation adopted its proposed regulations that had been published at 40 Com. Reg. 041013 (Nov. 28, 2018) and specifically provided that the “current NMIAC Subchapter 140-10.8, Schedule of Medical and Other Related Fees will be repealed and replaced in its entirety. Part 100 will be the new Chargemaster. Part 200 will be the new Bureau of Environmental Health Fees.” In codifying the adoption of the repeal and replacement, the Commission reserved Part 100 for consistency, provided section numbers within the parts, and maintained the source history for the subchapter and § 140-10.8-101 for reference. The Commission removed the source history for § 140-10.8-201, as it is unrelated to the new section and new Part 200. The Commission also removed historical comments that are not directly relevant after the repeal and replacement. Part 001 - General Provisions [Reserved.] Commission Comment: The Commission named, numbered, and reserved this Part. Part 100 - New Chargemaster § 140-10.8-101 CHCC Chargemaster [first part] [Rows 1-1000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE Room & Board Private, per day (ISOLATION $2, 800.00110 ROOM) PST A Y / P V T$ 3,300.00 114 Room & Board Telemetry, per day $2, 800.00120 ROOM - BO A R D / SEM I$ 3,000.00 120 OB/2BED $2, 550.00122 PE D S /2 BE D$ 2,550.00 123 PSTAY/2BED $2, 550.00124 OT H ER /2 BE D$ 2,550.00 129 PSTAY/DLX $2, 800.00144 N U RSER Y$ 710.00 170 NURSERY/PREMIE $2, 550.00172 N U RSER Y / I C U$ 2,550.00 174 INTENSIVE CARE OR (ICU) $4, 000.00200 I C U / S U RG I C A L$ 4,000.00 201 ICU/MEDICAL $4, 000.00202 I C U / OT H ER$ 4,000.00 209 Operating Room, Major Srg, 1st Hr $10, 500.00360 Op er a t in g R oo m (15 M I N)$ 2,500.00 360 Operating Room, Minor Srg, each addl 15 min $1, 575.00360 Op er a t in g R oo m, M in or S r g, 1 s t Hr$ 6,300.00 360 Operating Room, Major Srg, each addl 15 min $2, 625.00360 D E L I V ER Y ROOM$ 1,347.00 722 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 2 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION DELIVROOM/LABOR $1, 347.00720 L R - O U TPTOBSER V A T I ONNO D E L I V ER Y$ 216.30 762 Recovery Room/OB $210.00710 R eco v ery R oo m 15 min$ 210.00 710 Recovery Room 1st 1/2 hour $250.00710 R eco v ery R oo m 1 s t h o u r$ 315.00 710 Recovery Room each addl 15 min $210.00710 O b ser v a t i o n B e d, L ab or R oo m, NO De l i v ery, p er d a y$ 525.00 762 L&D Mid-level Professional Services, per hour $105.00 960 Observation Services at L&D, NO Delivery, per day$ 525.00 960 Non CHCC Provider, per day $210.00960 PTESCORT / D A Y - H I, SF, U S$ 400.00 270 PT ESCORT/DAY-ALL OTHERS $350.00270 PTESCORT / D A Y - G U A M$ 300.00 270 OFF-ISLAND TRANSPORT-INTERMEDIATE $2, 245.95540 C A REOFF - I S L A N D TR A NSPORT - CR I T I C A L C A RE$ 3,608.85 540 AMBULANCE BILLING FEE, CHARGED TO $52.50540 A MB UL A NCECOMP A N Y OFF - I S L A N D TR A NSPORT - M I N I M A L C A RE$ 1,373.40 540 DIET CONSULTATION $39.90940 SPEC I A L C H A RGES$ - 220 LEAVE OF ABSENCE OR LOA $- 180 L A TE D I SC H A RGE$ - 996 Burial Plot Child (Below 15 years) $75.00999 B u r ia lPl o t A d u lt$ 150.00 999 ISSUANCE OF A BURIAL TRANSIT PERMIT $10.00999 I SS U A NCEOF A REMO V A L OF H U M A N$ 10.00 999 REMAIN PERMIT MEALS, BREAKFAST, LUNCH, OR DINNER, $10.00999 PRO V I D E D TONON - P A T I ENTS I SS U A NCEOF A Q U A R A NT I NEPERM I T$ 10.00 999 CERTIFIED COPY OF DEATH CERTIFICATE $20.00999 EXPE D I TE D CERT I FC A TESER V I CEST H A T$ 350.00 999 REQUIRE SPECIAL ATTENTION CERTIFCATION LETTER OF AUTHENTICITY $10.00999 OF V I T A L RECOR D REP L A CEMENTOF A B I RT H CERT I F I C A TE$ 15.00 999 SUBSEQUENT TO ADOPTION, LEGITIMATION… MAILING AN OFF-ISLAND REQUEST VIA US $5.00999 POST A L SER V I CECERT I F I E D COP Y OFB I RT H CERT I F I C A TE$ 25.00 999 APPLICATION TO AMEND A VITAL $15.00999 A DD I T I ON A L C H A RGESFOREXPE D I TE D$ 10.00 999 CORRECTION AND AMENDMENT SERVICES CERTIFICATION LETTER WHEN NO VITAL $10.00999 RECOR D I SFO U N DH OSPPR I V I L EGES - RE A PP L I C A T I ONFEE$ 200.00 999 HOSP PRIVILEGES APPL FEE $250.00999 I NC I NER A TOR U SE$ 100.00 999 RESTOCKING FEE $10.00999 COMPO U N D I NGFEE$ 35.00 999 MEDICAL RECORDS, FOR EACH COPY >5 & $0.25999 T H ERE A FTERME D I C A L RECOR D S, U PTO 5 COP I ES$ 10.00 999 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 3 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION Immunization Summary $5.00999 X - R A Y COP Y - C D$ 8.00 999 X-RAY COPY-FILM&IMAGING, INIT $35.00999 T r an s i t i o na l L i v in g C e n t er F ee - D ai l y O cc u p an cy$ 100.00 999 Rate MORGUE, PER DAY $50.00999 C ha p e l, P erD a y$ 50.00 999 No Show Fee $50.00999 P i ll o w$ 21.00 999 Lamp Light Bulb $5.00999 Wa ll m o u n t e d BP A pp$ 800.00 999 Television $1, 000.00999 O x y g e n Fl o w m e t er$ 400.00 999 Pillow Case $7.00999 B e d s i d e St an d$ 1,124.00 999 Step Stool $74.80999 T r a s h C an$ 68.00 999 Alaris IV System $4, 000.00999 He a lt h C er t i f i c a t e$ 5.00 999 Wall Clock $360.00999 B L A N K ETB A B Y$ 9.00 999 Fitted Bed Sheet $16.00999 B a t h T o w e l$ 20.00 999 Telephone $125.00999 Bl ank e t / Fl a t s h ee t s$ 15.00 999 Patient Gown $10.00999 A i r M a tt ress$ 500.00 999 Vacuum Regulator $500.00999 B e d$ 1,653.00 999 Over-Bed Table $1, 080.00999 C a ll L i g h tP i ll o w$ 1,008.00 999 Bedside Chair $986.00999 S h o w er C u r t ain$ 50.00 999 Anesthesia, Major Srg, 1st hr $525.00370 A n es t h es ia R e g i o na l (p er min u t e)$ 15.75 370 Anesthesia, Major Srg, each addl 15 min $210.00370 A n es t h es ia M A C (p er min u t e)$ 15.75 370 Anesthesia per 15 min $210.00370 A n es t h es ia, M in or S r g, 1 s t h r$ 262.50 370 Anesthesia, Minor Srg, each addl 15 min $157.50370 A 9270 N o n - co v ere d i t e m orser v i ce$ 50.00 999 0003A ADM SARSCOV2 30MCG/0.3ML 3RD $85.170004 AA D MS A RSCO V 230 MCG /0.3 M L BST$ 85.17 0013A ADM SARSCOV2 100MCG/0.5ML 3RD $85.170021 A I MM A D MNS A RSCO V 25 X 10"10 V P /. SM L 1$ 50.82 0022A IMM ADMN SARSCOV2 5X10”10VP/.SML 2 $85.170031 A I MM A D MNS A RSCO V 2 V A C A D 26.5 M L$ 85.17 0034A ADM SARSCOV2 VAC AD26 .5ML B $85.170041 AA D MS A RSCO V 25 MCG /0.5 M L 1 ST$ 85.17 0042A ADM SARSCOV2 5MCG/0.5ML 2ND $85.170051 AA D MS A RSC V 230 MCGTRS - S U CR 1$ 85.17 0052A ADM SARSCV2 30MCG TRS-SUCR 2 $85.170053 AA D MS A RSC V 230 MCGTRS - S U CR 3$ 85.17 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 4 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 0054A ADM SARSCV2 30MCG TRS-SUCR B $85.170064 AA D MS A RSCO V 250 MCG /0.25 M L BST$ 85.17 0071A ADM SARSCV2 10MCG TRS-SUCR 1 $85.170072 AA D MS A RSC V 210 MCGTRS - S U CR 2$ 85.17 0081A ADM SARSCV2 3MCG TRS-SUCR l $85.170082 AA D MS A RSC V 23 MCGTRS - S U CR 2$ 85.17 0083A ADM SARSCV2 3MCG TRS-SUCR 3 $85.170091 AA D MS A RSCO V 250 MCG /.5 M L 1 ST$ 85.17 0092A ADM SARSCOV2 50 MCG/.5 ML 2ND $85.170093 AA D MS A RSCO V 250 MCG /.5 M L 3 R D$ 85.17 0111A ADM SARSCOV2 25MCG/0.25 ML 1ST DOSE $85.177710112 AA D MS A RSCO V 225 MCG /0.25 M L 2 N DD OSE$ 85.17 0113A ADM SARSCOV2 25MCG/0.25 ML 3RD $85.170124 AA D MS A RSC V 2 B V L 30 MCG /.3 M L B$ 85.17 0134A IMM ADMN SARSCOV2 BIVALENT 50 MCG/0.5 $85.17771 M L BST 0144 AA D MSRSC V 2 B V L 25 MCG /.25 M L A$ 85.17 771 0154A ADM SARSCV2 BVL 10MCG/.2ML A $85.1777100100 A NEST H S A L I V A R Y G L A N D$ 221.90 963 00102 ANESTH REPAIR OF CLEFT LIP $266.3096300103 A NEST H B L EP H A ROP L A ST Y$ 221.90 963 00120 ANESTH EAR SURGERY $1, 144.5096300120 A NEST H E A RS U RGER Y$ 222.80 370 00124 ANESTH EAR EXAM $177.5096300126 A NEST H T Y MP A NOTOM Y$ 177.50 963 00140 ANESTH PROCEDURES ON EYE $221.9096300142 A NEST H L ENSS U RGER Y (A NEST)$ 177.50 963 00145 ANESTH VITREORETINAL SURG (ANEST) $266.3096300147 A NEST H I R I D ECTOM Y$ 177.50 963 00148 ANESTH EYE EXAM $177.5096300160 A NEST H NOSE / S I N U SS U RGER Y$ 52.50 963 00160 ANESTH NOSE/SINUS SURGERY NOS $52.5096300160 A NEST H NOSE / S I N U SS U RGER Y$ 222.80 370 00162 ANESTH NOSE/SINUS SURGERY RADICAL $310.6596300164 A NEST H B I OPS Y OFNOSE$ 177.50 963 00170 ANESTH PROCEDURE ON MOUTH (ANEST) $221.9096300172 A NEST H C L EFTP A L A TEREP A I R$ 266.30 963 00174 ANESTH PHARYNGEAL SURG EXCISION $266.3096300174 AA D MS A RSC V 2 N V L 3 MC H /.2 M L A$ 85.17 00176 ANESTH PHARYNGEAL SURG RADICAL $310.6596300190 A NEST H F A CE / S K ULL BONES U RG$ 221.90 963 00211 ANESTH CRAN SURG HEMOTOMA $445.6037000214 A NEST H ES I A S K ULL D R A I N A GE$ 362.16 00214 26 ANESTHESIA FOR INTRACRANIAL $588.06 PROCE D U RESB U RR H O L ES 00300 A NEST HH E A D / NEC K / PTR U N K (A NEST)$ 221.90 963 00320 ANESTH NECK ORGAN 1YR/> (ANEST) $266.3096300322 A NEST H B I OPS Y OFT H Y RO I D$ 133.15 963 00350 ANESTHESIA MAJOR VESSELS NECK NOS $423.6037000352 A NEST H NEC K V ESSE L S U RGER Y (A NEST)$ 221.90 963 00400 ANESTH SKIN EXT/PER/ATRUNK (ANEST) $133.1596300402 A NEST H S U RGER Y OFBRE A ST (A NEST)$ 221.90 963 00404 ANESTH SURGERY OF BREAST RADICAL $221.90 963 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 5 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 00406 ANESTH SURGERY OF BREAST (ANEST) $576.9596300450 A NEST H S U RGER Y OFS H O UL D ERNOS$ 221.90 963 00454 ANESTH COLLAR BONE BIOPSY $133.1596300472 A NEST H C H EST W A LL REP A I R$ 443.80 963 00520 ANESTH CHEST PROCEDURE (ANEST) $266.3096300524 A NEST H C H EST D R A I N A GE$ 177.50 963 00529 26 ANES MEDIASTINOSCOPY& $496.54 T H OR A COSCOP YW /1 LU NG V NT 00532 A NEST H V A SC UL A R A CCESS (A NEST)$ 177.50 963 00541 ANES THORACOTOMY & THORACOSCOPY $635.40 W /1 LU NG V NT J 00548 A NEST H TR A C H E A BRONC H I S U RG$ 754.45 963 00550 ANESTH STERNAL DEBRIDEMENT $443.8096300632 A NEST H LU MB A RREMO V A L OFNER V ES$ 310.65 963 00635 ANESTH LUMBAR PUNCTURE $177.5096300700 A NEST H A B D OM I N A L W A LL S U RG (A NEST)$ 177.50 963 00702 ANESTH FOR LIVER BIOPSY $177.5096300730 A NEST H A B D OM I N A L W A LL S U RG (A NEST)$ 221.90 963 00731 ANESTH UPPER GI VISUALIZE (ANEST) $221.9096300732 A NES U PRG I N D SCPXERCP$ 266.30 963 00750 ANESTH REPAIR OF HERNIA (ANEST) $177.5096300752 A NEST H REP A I ROF H ERN I A$ 266.30 963 00754 ANESTH REPAIR OF HERNIA AMPHALOCELE $310.6596300756 A NEST H REP A I ROF H ERN I A TR A NS A B D O$ 310.65 963 00770 ANESTH BLOOD VESSEL REPAIR $665.7096300790 A NEST H S U RG U PPER A B D OMEN (A NEST)$ 310.65 963 00794 ANESTH PANCREAS REMOVAL $355.0596300800 A NEST H A B D OM I N A L W A LL S U RG (A NEST)$ 177.50 963 00811 ANESTH LOW INTESTINE SCOPE (ANEST) $177.5096300812 A NES L W R I NTSTSCRCO L SC$ 133.15 963 00813 ANES UPR LWR GI NDSC PX $221.9096300820 A NEST H A B D OM I N A L W A LL S U RG L O W ER$ 221.90 963 POST 00830 ANESTH REPAIR OF HERNIA (ANEST) $177.50 963 00832 ANESTH REPAIR OF HERNIA V&A$ 266.30 963 00840 ANESTH SURG LOWER ABDOMEN (ANEST) $266.3096300842 A NEST H A MN I OCENTES I S$ 177.50 963 00844 ANESTH PELVIS SURGERY $310.6596300846 A NEST HH Y STERECTOM Y$ 355.05 963 00848 ANESTH PELVIC ORGAN SURG $355.0596300851 A NEST H T U B A LL I G A T I ON (A NEST)$ 266.30 963 00860 ANESTH SURGERY OF ABDOMEN $266.3096300862 A NEST HK I D NE Y / U RETERS U RG$ 310.65 963 00865 ANESTH REMOVAL OF PROSTATE RADICAL $310.6596300870 A NEST H B L A DD ERSTONES U RG$ 221.90 963 00880 ANESTHESIA MAJOR LOWER ABDOMINAL $635.40370 V ESSE L SNOS 00882 A NEST H M A J OR V E I N L I G A T I ON$ 443.80 963 00902 ANESTH ANORECTAL SURGERY (ANEST) $221.9096300904 A NEST H PER I NE A L S U RGER Y$ 310.65 963 00906 ANESTH REMOVAL OF VULVA $177.5096300908 A NEST H REMO V A L OFPROST A TEPER I NE A L$ 266.30 963 00910 ANESTH BLADDER SURGERY (ANEST) $133.1596300912 A NEST H B L A DD ERT U MORS U RG$ 221.90 963 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 6 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 00914 ANESTH REMOVAL OF PROSTATE $221.90963 RESECT I ON 00916 A NEST H B L EE D I NGCONTRO L$ 221.90 963 00918 ANESTH STONE REMOVAL $221.9096300920 A NEST H GEN I T A L I A S U RGER Y (A NEST)$ 133.15 963 00921 ANESTH VASECTOMY $133.1596300922 A NEST H SPERM D U CTS U RGER Y$ 266.30 963 00924 ANESTH TESTIS EXPLORATION (ANEST) $177.5096300926 A NEST H REMO V A L OFTEST I S I NG U I N A L$ 177.50 963 00928 ANESTH REMOVAL OF TESTIS ABDOMINAL $266.3096300930 A NEST H TEST I SS U SPENS I ON$ 177.50 963 0094A IMM ADMN SARSCOV2 SO MCG/0.S ML $85.17 BOOSTER D OSE 00940 A NEST H V A G I N A L PROCE D U RES (A NEST)$ 133.15 963 00942 ANESTH SURG ON VAG/URETHRAL $177.5096300944 A NEST H V A G I N A L H Y STERECTOM Y (A NEST)$ 266.30 963 00948 ANESTH REPAIR OF CERVIX $177.5096300950 A NEST H V A G I N A L EN D OSCOP Y$ 221.90 963 00952 ANESTH HYSTEROSCOPE/GRAPH $177.5096301112 A NEST H BONE A SP I R A TE / BX$ 221.90 963 01130 ANESTHESIA BODY CAST APPLICATION OR $124.14370 RE V I S I ON 01150 A NEST H PE L V I CT U MORS U RGER Y$ 443.80 963 01160 ANESTH PELVIS PROCEDURE $177.5096301170 A NEST H PE L V I SS U RGER Y (A NEST)$ 355.05 963 01200 ANESTH HIP JOINT PROCEDURE $177.5096301202 A NEST H A RT H ROSCOP Y OF H I P$ 177.50 963 01210 ANESTH HIP JOINT SURGERY $266.3096301214 A NEST HH I P A RT H ROP L A ST Y$ 355.05 963 01220 ANESTH PROCEDURE ON FEMUR $177.5096301230 A NEST H S U RGER Y OFFEM U R$ 266.30 963 01232 ANESTH AMPUTATION OF FEMUR (ANEST) $221.9096301250 A NEST H U PPER L EGS U RGER Y (A NEST)$ 177.50 963 01260 ANESTH UPPER LEG VEINS SURG $133.1596301270 A NEST H T H I G H A RTER I ESS U RG (A NEST)$ 355.05 963 01272 ANESTH FEMORAL ARTERY SURG $177.5096301274 A NEST H FEMOR A L EMBO L ECTOM Y$ 266.30 963 01320 ANESTH KNEE AREA SURGERY $177.5096301340 A NEST HK NEE A RE A PROCE D U RE L O W ER$ 177.50 963 01360 ANESTH KNEE AREA SURGERY LOWER $221.9096301380 A NEST HK NEE J O I NTPROCE D U RE$ 133.15 963 01382 ANESTH DX KNEE ARTHROSCOPY $133.1596301390 A NEST HK NEE A RE A PROCE D U RE U PPER$ 133.15 963 01392 ANESTH KNEE AREA SURGERY UPPER $177.5096301400 A NEST HK NEE J O I NTS U RGER Y (A NEST)$ 177.50 963 01402 ANESTH KNEE ARTHROPLASTY $310.6596301404 A NEST H A MP U T A T I ON A T K NEE$ 221.90 963 01420 ANESTH KNEE JOINT CASTING $133.15 963 01440 ANES ARTERIES OF KNEE & POPLITEAL$ 534.72 AREA NOS 01462 ANESTH LOWER LEG PROCEDURE (ANEST) $133.1596301464 A NEST H A N K L E / FT A RT H ROSCOP Y$ 133.15 963 01470 ANESTH LOWER LEG SURGERY (ANEST) $133.1596301472 A NEST H A C H I LL ESTEN D ONS U RG$ 221.90 963 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 7 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 01474 ANESTH LOWER LEG SURGERY $221.9096301480 A NEST H L O W ER L EGBONES U RG (A NEST)$ 133.15 963 01482 ANESTH RADICAL LEG SURGERY (ANEST) $177.5096301484 A NEST H L O W ER L EGRE V I S I ON$ 177.50 963 01520 ANESTH LOWER LEG VEIN SURG NOS $133.1596301522 A NEST H L O W ER L EG V E I NS U RG$ 221.90 963 01610 ANESTH SURGERY OF SHOULDER $221.9096301620 A NEST H S H O UL D ERPROCE D U RE$ 177.50 963 01622 ANES DX SHOULDER ARTHROSCOPY $177.5096301630 A NEST H S U RGER Y OFS H O UL D ERNOS$ 221.90 963 01710 ANESTH ELBOW AREA SURGERY $133.1596301712 A NEST H U PPR A RMTEN D ONS U RGOPEN$ 221.90 963 01714 ANESTH UPPR ARM TENDON SURG $221.9096301716 A NEST H B I CEPSTEN D ONREP A I R$ 221.90 963 01730 ANESTH UPPR ARM PROCEDURE $133.1596301732 A NEST HD XE L BO W A RT H ROSCOP Y$ 133.15 963 01740 ANESTH UPPER ARM SURGERY (ANEST) $177.5096301742 A NEST HH U MER U SS U RGER Y$ 221.90 963 01744 ANESTH HUMERUS REPAIR $221.9096301758 A NEST HH U MER A LL ES I ONS U RG$ 221.90 963 01770 ANESTH UPPR ARM ARTERY SURG (ANEST) $266.3096301810 A NEST H L O W ER A RMS U RGER Y (A NEST)$ 133.15 963 01820 ANESTH LOWER ARM PROCEDURE (ANEST) $133.1596301829 A NEST HD X W R I ST A RT H ROSCOP Y$ 133.15 963 01830 ANESTH LOWER ARM SURGERY (ANEST) $133.1596301840 A NEST H L W R A RM A RTER Y S U RG (A NEST)$ 266.30 963 01844 ANESTH VASCULAR SHUNT SURG (ANEST) $266.3096301850 A NEST H L O W ER A RM V E I NS U RG$ 133.15 963 01852 ANESTH LWR ARM VEIN REPAIR $177.5096301916 A NEST HD X A RTER I OGR A P H Y$ 221.90 963 01958 ANESTH ANTEPARTUM MANIPUL $221.9096301960 A NEST H V A G I N A L D E L I V ER Y$ 221.90 963 01961 ANESTH CS DELIVERY (ANEST) $310.6596301962 A NEST H EMER H Y STERECTOM Y$ 355.05 963 01963 ANESTH CS HYSTERECTOMY $355.0596301965 A NEST H I NC / M I SSE D A BPROC (A NEST)$ 177.50 963 01966 ANESTH INDUCED AB PROCEDURE $177.5096301967 A NEST H / A N A L G V A G D E L I V ER Y$ 221.90 963 01968 ANES/ANALG CS DELIVER ADD-ON $88.7596301969 A NEST H / A N A L GCS H Y ST A DD - ON$ 221.90 963 01991 ANESTH NERVE BLOCK/INJ $133.1596301992 A NEST H NB L OC K / I N J PRONE$ 221.90 963 01922 ANES NON-INVASIVE IMAGING/RADIATION $269.52636 T H ER A P Y 01996 H OSPM A N A GECONT D R U G A D M I N$ 133.15 963 01999 UNLISTED ANESTH PROCEDURE $- 9630202 U NFCTOSBCT / V I RRESP I R D N A / RN A 22 TRGT$ 1,250.34 SARSCOV2 0240U INFCT DS RNA 3 TARGETS UPPER RESP $427.89 SPEC I MENXPERT 0241 U I NFCT D SRN A 4 T A RGETS U PPERRESP$ 427.89 SPECIMEN XPERT 0254T EVASC RPR ILIAC ART BIFUR $- 36010004 FN A BX W / O I MGG D NE AA DD L$ 136.01 320 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 8 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 10005 FNA BX W/US GDN 1ST LES $228.6836010006 FN A BX W / U SG D NE AA DD L$ 155.75 360 10007 FNA BX W/FLUOR GDN 1ST LES $295.2332010008 FN A BX W / F LU ORG D NE AA DD L$ 192.67 320 10009 FNA BX W/CT GDN 1ST LES $357.0835010010 FN A BX W / CTG D NE AA DD L$ 267.06 350 10021 26 Midlevel Fna w/o image $217.779691002126 F na w / o ima g e$ 256.20 969 10021 Fna w/o image $256.203601002226 F na w / ima g e$ 235.20 969 10022 26 Midlevel Fna w/image $199.9096910022 FN A W / I M A GE$ 235.20 360 10030 26 GUIDE CATHET FLUID DRAINAGE $434.409751004026 M i d l e v e l A c n es u r g ery$ 274.90 969 10040 26 Acne surgery $323.4096910040 A CNES U RGER Y M I L I A C Y STS$ 323.40 360 10060 26 Drainage of skin abscess $342.309831006026 M i d l e v e l Dr aina g eo f s kinab scess$ 290.95 969 10060 Drainage of skin abscess $342.305101006126 M i d l e v e l Dr aina g eo f s kinab scess$ 535.50 969 10061 26 Drainage of skin abscess $630.0096910061 Dr aina g eo f s kinab scess$ 630.00 360 10080 26 Drainage of pilonidal cyst $367.509691008026 M i d l e v e l Dr aina g eo f p i l o ni d a l cys t$ 312.40 969 10080 I&D PILONID CYS; SMPL $367.503601008126 M i d l e v e l Dr aina g eo f p i l o ni d a l cys t$ 528.35 969 10081 26 Drainage of pilonidal cyst $621.60 969 10081 I&D PILONID CYST; CPLX$ 621.60 360 10120 26 Midlevel Remove foreign body $286.509691012026 R e m o v e f ore i g nb o d y$ 337.05 969 10120 INC & REM FB SQ; SMPL $337.053601012126 R e m o v e f ore i g nb o d y$ 673.05 969 10121 26 Midlevel Remove foreign body $572.10 969 10121 INC & REM FB SQ; COMPL$ 673.05 360 10140 26 Drainage of hematoma/fluid $817.959691014026 M i d l e v e l Dr aina g eo f h e ma t o ma / f l u i d$ 695.25 969 10140 I&D HEMATOMA/FLUID $817.953601016026 P u n c t u re d r aina g eo f l es i o n$ 346.50 969 10160 26 Midlevel Puncture drainage of lesion $294.5596910160 P U NCT A SP - A BSC H EM A TC Y ST$ 346.50 360 10180 26 Complex drainage, wound $649.959691018026 M i d l e v e lC o m pl e x d r aina g e, w o u n d$ 552.45 969 10180 I&D CPLX POSTOP WND INF $649.953601100026 De b r i d e in f ec t e d s kin$ 128.10 969 11000 26 Midlevel Debride infected skin $108.9096911000 D EBREXZ / I NFS K I N <= 10$ 128.10 360 11001 26 Midlevel Debride infected skin add-on $43.759691100126 De b r i d e in f ec t e d s kina dd - o n$ 51.45 969 11001 DEBRIDE INFECTED SKIN EA ADDL =<10% BS $51.45 360 11004 26 Debride genitalia & perineum$ 2,114.70 969 11004 26 Midlevel Debride genitalia & perineum $1,797.50 969 11004 Debride genitalia & perineum$ 2,114.70 360 11005 26 Debride abdom wall $2, 848.659691100526 M i d l e v e l De b r i d e ab d o m w a ll$ 2,421.35 969 11005 Debride abdom wall $2, 848.653601100626 M i d l e v e l De b r i d e g e ni t / p er / ab d o m w a ll$ 2,189.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 9 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 11006 26 Debride genit/per/abdom wall $2, 575.6596911006 De b r i d e g e ni t / p er / ab d o m w a ll$ 2,575.65 360 11008 26 Remove mesh from abd wall $999.609691100826 M i d l e v e lR e m o v e m es h f ro mab d w a ll$ 849.65 969 11008 Remove mesh from abd wall $999.603601101026 De b r i d es kin, f x$ 1,025.85 969 11010 26 Midlevel Debride skin, fx $871.9596911010 D EBR I D ES K I N A TFXS I TE$ 1,025.85 360 11011 26 Debride skin/muscle, fx $1, 096.209691101126 M i d l e v e l De b r i d es kin / m u sc l e, f x$ 931.75 969 11011 DEBRIDE SKIN MUSC AT FX SITE $1, 096.203601101226 M i d l e v e l De b r i d es kin / m u sc l e / b o n e, f x$ 1,321.80 969 11012 26 Debride skin/muscle/bone, fx $1, 555.0596911012 D EBS K I NBONE A TFXS I TE$ 1,555.05 360 11042 26 Midlevel Debride skin/tissue $196.359691104226 De b r i d es kin / t i ss u e$ 231.00 969 11042 Deb subq tissue 20 sq cm/< $231.003601104326 M i d l e v e l De b r i d e t i ss u e / m u sc l e$ 489.10 969 11043 26 Debride tissue/muscle $575.4096911043 De bm u sc / f a sc ia 20 s q c m / <$ 575.40 360 11044 26 Debride tissue/muscle/bone $859.959691104426 M i d l e v e l De b r i d e t i ss u e / m u sc l e / b o n e$ 730.95 969 11044 Deb bone 20 sq cm/< $859.9536011045 D EBS U BQT I SS U E A DD - ON =< 20 SQCM$ 97.65 360 11045 26 DEBRIDEMENT SUBCUTANEOUS TISSUE EA $73.92960 A DD L 20 SQCM 11046 D EBM U SC / F A SC I AA DD - ON =< 20 SQCM$ 200.55 360 11047 DEB BONE ADD-ON =<20 SQ CM $354.903601105526 T r im s kin l es i o n$ 73.50 969 11055 26 Midlevel Trim skin lesion $62.5096911055 P A REBEN I GN L ES; SG L$ 73.50 360 11056 26 Trim skin lesions, 2 to 4 $84.009691105626 M i d l e v e lT r im s kin l es i o n s, 2 t o 4$ 71.40 969 11056 TRIM SKIN LESIONS 2 TO 4 $84.003601105726 M i d l e v e lT r im s kin l es i o n s, o v er 4$ 112.45 969 11057 26 Trim skin lesions, over 4 $132.3096911057 TR I MS K I N L ES I ONSO V ER 4$ 132.30 360 11100 26 Midlevel Biopsy, skin lesion $152.609691110026 B i o p sy, s kin l es i o n$ 179.55 969 11100 BX-SKIN SQ/MM; SGL $179.553601110126 B i o p sy, s kina dd - o n$ 90.30 969 11101 26 Midlevel Biopsy, skin add-on $76.7596911101 BX - S K I NSQ / MM; E AA DD L$ 90.30 360 11104 26 PUNCH BX SKIN SINGLE LESION $157.849601110526 P U NC H BXS K I NE A SEP / A DD L$ 86.14 960 11106 26 INCISIONAL BIOPSY SKIN SINGLE LESION $191.709601110726 I NC I S I ON A L B I OPS Y S K I NE A$ 102.74 960 SEP/ADDITIONAL LESION 11200 26 Midlevel Removal of skin tags $223.159691120026 R e m o v a l o f s kin t a g s$ 262.50 969 11200 REM SKIN TAGS; ⇐15 LESIONS $262.503601120126 R e m o v es kin t a g s a dd - o n$ 60.90 969 11201 26 Midlevel Remove skin tags add-on $51.7596911201 REMO V ES K I NT A GS A DD - ON =< 10 L ES I ONS$ 60.90 360 1123F Acp discuss/dscn mkr docd $- 000 1123F 26 ADV CARE PLN TLKD & ALT DCSN MARKER$ 0.00 OOCD © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 10 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 1124F Acp discuss-no dscnmkr docd $- 0001124 F 26 A D V C A REP L N / NO A L T D CSNM K R D OC D OR$ 50.00 REFUSAL 11300 26 Shave skin lesion $109.209691130026 M i d l e v e lS ha v es kin l es i o n$ 92.80 969 11300 SHAVE LES T/A/L; 0.5CM/< $109.203601130126 M i d l e v e lS ha v es kin l es i o n$ 157.10 969 11301 26 Shave skin lesion $184.8096911301 S H A V E L EST / A / L; 0.6 - 1.0 CM$ 184.80 360 11302 26 Midlevel Shave skin lesion $194.559691130226 S ha v es kin l es i o n$ 228.90 969 11302 SHAVE LES T/A/L; 1.1-2.0CM $228.903601130326 M i d l e v e lS ha v es kin l es i o n$ 230.25 969 11303 26 Shave skin lesion $270.9096911303 S H A V E L EST / A / L; > 2.0 CM$ 270.90 360 11305 26 Midlevel Shave skin lesion $101.759691130526 S ha v es kin l es i o n$ 119.70 969 11305 SHAVE LES S/N/H/F/G; 0.5CM/< $119.703601130626 S ha v es kin l es i o n$ 194.25 969 11306 26 Midlevel Shave skin lesion $165.1096911306 S H A V E L ESS / N / H / F / G; 0.6 - 1.0 CM$ 194.25 360 11307 26 Midlevel Shave skin lesion $198.159691130726 S ha v es kin l es i o n$ 233.10 969 11307 SHAVE LES S/N/H/F/G; 1.1-2.0CM $233.103601130826 M i d l e v e lS ha v es kin l es i o n$ 227.60 969 11308 26 Shave skin lesion $267.7596911308 S H A V E L ESS / N / H / F / G; > 2.0 CM$ 267.75 360 11310 26 Shave skin lesion $157.509691131026 M i d l e v e lS ha v es kin l es i o n$ 133.90 969 11310 SHAVE LES F/E/N/L; 0.5CM/< $157.503601131126 S ha v es kin l es i o n$ 229.95 969 11311 26 Midlevel Shave skin lesion $195.4596911311 S H A V E L ESF / E / N / L; 0.6 - 1.0 CM$ 229.95 360 11312 26 Shave skin lesion $265.659691131226 M i d l e v e lS ha v es kin l es i o n$ 225.80 969 11312 SHAVE LES F/E/N/L; 1.1-2.0CM $265.653601131326 M i d l e v e lS ha v es kin l es i o n$ 301.65 969 11313 26 Shave skin lesion $354.9096911313 S H A V E L ESF / E / N / L; > 2.0 CM$ 354.90 360 11400 26 Midlevel Exc tr-ext b9+marg 0.5 < cm $243.659691140026 E x c t r - e x t b 9 + ma r g 0.5 < c m$ 286.65 969 11400 EXC TR-EXT B9+MARG 0.5CM/< $286.653601140126 M i d l e v e lE x c t r - e x t b 9 + ma r g 0.6 - 1 c m$ 319.50 969 11401 26 Exc tr-ext b9+marg 0.6-1 cm $375.9096911401 EXCTR - EXTB 9 + M A RG 0.6 - 1 CM$ 375.90 360 11402 26 Midlevel Exc tr-ext b9+marg 1.1-2 cm $351.659691140226 E x c t r - e x t b 9 + ma r g 1.1 - 2 c m$ 413.70 969 11402 EXC TR-EXT B9+MARG 1.1-2 CM $413.703601140326 M i d l e v e lE x c t r - e x t b 9 + ma r g 2.1 - 3 c m$ 451.60 969 11403 26 Exc tr-ext b9+marg 2.1-3 cm $531.3096911403 EXCTR - EXTB 9 + M A RG 2.1 - 3 CM$ 531.30 360 11404 26 Midlevel Exc tr-ext b9+marg 3.1-4 cm $496.259691140426 E x c t r - e x t b 9 + ma r g 3.1 - 4 c m$ 583.80 969 11404 EXC TR-EXT B9+MARG 3.1-4 CM $583.803601140626 E x c t r - e x t b 9 + ma r g > 4.0 c m$ 882.00 969 11406 26 Midlevel Exc tr-ext b9+marg > 4.0 cm $749.7096911406 EXCTR - EXTB 9 + M A RG > 4.0 CM$ 882.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 11 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 11420 26 Exc h-f-nk-sp b9+marg 0.5 < $296.109691142026 M i d l e v e lE x c h - f - nk - s p b 9 + ma r g 0.5 <$ 251.70 969 11420 EXC BLES S/N/EX G; 0.5CM/< $296.103601142126 E x c h - f - nk - s p b 9 + ma r g 0.6 - 1$ 402.15 969 11421 26 Midlevel Exc h-f-nk-sp b9+marg 0.6-1 $341.8596911421 EXCB L ESS / N / EXG; 0.6 - 1.0 CM$ 402.15 360 11422 26 Midlevel Exc h-f-nk-sp b9+marg 1.1-2 $416.809691142226 E x c h - f - nk - s p b 9 + ma r g 1.1 - 2$ 490.35 969 11422 EXC BLES S/N/EX G; 1.1-2.0CM $490.353601142326 M i d l e v e lE x c h - f - nk - s p b 9 + ma r g 2.1 - 3$ 484.65 969 11423 26 Exc h-f-nk-sp b9+marg 2.1-3 $570.1596911423 EXCB L ESS / N / EXG; 2.1 - 3.0 CM$ 570.15 360 11424 26 Midlevel Exc h-f-nk-sp b9+marg 3.1-4 $552.459691142426 E x c h - f - nk - s p b 9 + ma r g 3.1 - 4$ 649.95 969 11424 EXC BLES S/N/EX G; 3.1-4.0CM $649.953601142626 M i d l e v e lE x c h - f - nk - s p b 9 + ma r g > 4 c m$ 841.65 969 11426 26 Exc h-f-nk-sp b9+marg > 4 cm $990.1596911426 EXCB L ESS / N / EXG; > 4.0 CM$ 990.15 360 11440 26 Exc face-mm b9+marg 0.5 < cm $372.759691144026 M i d l e v e lE x c f a ce - mmb 9 + ma r g 0.5 < c m$ 316.85 969 11440 EXC FACE-MM B9+MARG 0.5CM/< $372.753601144126 M i d l e v e lE x c f a ce - mmb 9 + ma r g 0.6 - 1 c m$ 406.10 969 11441 26 Exc face-mm b9+marg 0.6-1 cm $477.7596911441 EXCF A CE - MMB 9 + M A RG 0.6 - 1 CM$ 477.75 360 11442 26 Exc face-mm b9+marg 1.1-2 cm $531.309691144226 M i d l e v e lE x c f a ce - mmb 9 + ma r g 1.1 - 2 c m$ 451.60 969 11442 EXC FACE-MM B9+MARG 1.1-2 CM $531.303601144326 E x c f a ce - mmb 9 + ma r g 2.1 - 3 c m$ 649.95 969 11443 26 Midlevel Exc face-mm b9+marg 2.1-3 cm $552.4596911443 EXCF A CE - MMB 9 + M A RG 2.1 - 3 CM$ 649.95 360 11444 26 Midlevel Exc face-mm b9+marg 3.1-4 cm $702.409691144426 E x c f a ce - mmb 9 + ma r g 3.1 - 4 c m$ 826.35 969 11444 EXC FACE-MM B9+MARG 3.1-4 CM $826.353601144626 E x c f a ce - mmb 9 + ma r g > 4 c m$ 1,174.95 969 11446 26 Midlevel Exc face-mm b9+marg > 4 cm $998.7096911446 EXCF A CE - MMB 9 + M A RG > 4 CM$ 1,174.95 360 11450 26 Removal, sweat gland lesion $899.859691145026 M i d l e v e lR e m o v a l, s w e a t g l an d l es i o n$ 764.85 969 11450 EXC HIDRAD AXIL; S/I REP $899.853601145126 M i d l e v e lR e m o v a l, s w e a t g l an d l es i o n$ 988.90 969 11451 26 Removal, sweat gland lesion $1, 163.4096911451 EXC H I D R A D A X I L; CP L XREP$ 1,163.40 360 11462 26 Midlevel Removal, sweat gland lesion $739.009691146226 R e m o v a l, s w e a t g l an d l es i o n$ 869.40 969 11462 EXC HIDRAD ING; S/I REP $869.403601146326 R e m o v a l, s w e a t g l an d l es i o n$ 1,172.85 969 11463 26 Midlevel Removal, sweat gland lesion $996.9096911463 EXC H I D R A D I NG; CP L XREP$ 1,172.85 360 11470 26 Midlevel Removal, sweat gland lesion $858.609691147026 R e m o v a l, s w e a t g l an d l es i o n$ 1,010.10 969 11470 EXC HIDRAD UMBIL; S/I REP $1, 010.103601147126 M i d l e v e lR e m o v a l, s w e a t g l an d l es i o n$ 1,067.45 969 11471 26 Removal, sweat gland lesion $1, 255.8096911471 EXC H I D R A D U MB I L; CP L XREP$ 1,255.80 360 11600 26 Exc tr-ext mlg+marg 0.5 < cm $430.509691160026 M i d l e v e lE x c t r - e x t m l g + ma r g 0.5 < c m$ 365.95 969 11600 EXC TR-EXT MAL+MARG ⇐ 0.5 CM $430.50 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 12 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 11601 26 Midlevel Exc tr-ext mlg+marg 0.6-1 cm $460.559691160126 E x c t r - e x t m l g + ma r g 0.6 - 1 c m$ 541.80 969 11601 EXC TR-EXT MAL+MARG 0.6-1 CM $541.803601160226 E x c t r - e x t m l g + ma r g 1.1 - 2 c m$ 596.40 969 11602 26 Midlevel Exc tr-ext mlg+marg 1.1-2 cm $506.9596911602 EXCTR - EXTM A L + M A RG 1.1 - 2 CM$ 596.40 360 11603 26 Midlevel Exc tr-ext mlg+marg 2.1-3 cm $602.459691160326 E x c t r - e x t m l g + ma r g 2.1 - 3 c m$ 708.75 969 11603 EXC TR-EXT MAL+MARG 2.1-3 CM $708.753601160426 E x c t r - e x t m l g + ma r g 3.1 - 4 c m$ 781.20 969 11604 26 Midlevel Exc tr-ext mlg+marg 3.1-4 cm $664.0096911604 EXCTR - EXTM A L + M A RG 3.1 - 4 CM$ 781.20 360 11606 26 Midlevel Exc tr-ext mlg+marg > 4 cm $980.859691160626 E x c t r - e x t m l g + ma r g > 4 c m$ 1,153.95 969 11606 EXC TR-EXT MAL+MARG > 4 CM $1, 153.953601162026 M i d l e v e lE x c h - f - nk - s p m l g + ma r g 0.5 <$ 371.30 969 11620 26 Exc h-f-nk-sp mlg+marg 0.5 < $436.8096911620 EXC H - F - N K - SPM A L + M A RG <= 0.5 CM$ 436.80 360 11621 26 Midlevel Exc h-f-nk-sp mlg+marg 0.6-1 $465.009691162126 E x c h - f - nk - s p m l g + ma r g 0.6 - 1$ 547.05 969 11621 EXC S/N/H/F/G MAL+MRG 0.6-1 CM $547.053601162226 E x c h - f - nk - s p m l g + ma r g 1.1 - 2$ 626.85 969 11622 26 Midlevel Exc h-f-nk-sp mlg+marg 1.1-2 $532.8096911622 EXCS / N / H / F / GM A L + MRG 1.1 - 2 CM$ 626.85 360 11623 26 Exc h-f-nk-sp mlg+marg 2.1-3 $772.809691162326 M i d l e v e lE x c h - f - nk - s p m l g + ma r g 2.1 - 3$ 656.90 969 11623 EXC S/N/H/F/G MAL+MRG 2.1-3 CM $772.803601162426 M i d l e v e lE x c h - f - nk - s p m l g + ma r g 3.1 - 4$ 744.35 969 11624 26 Exc h-f-nk-sp mlg+marg 3.1-4 $875.7096911624 EXCS / N / H / F / GM A L + MRG 3.1 - 4 CM$ 875.70 360 11626 26 Exc h-f-nk-sp mlg+mar > 4 cm $1, 076.259691162626 M i d l e v e lE x c h - f - nk - s p m l g + ma r > 4 c m$ 914.80 969 11626 EXC S/N/H/F/G MAL+MRG > 4 CM $1, 076.253601164026 E x c f a ce - mmma l i g + ma r g 0.5 <$ 455.70 969 11640 26 Midlevel Exc face-mm malig+marg 0.5 < $387.3596911640 EXCF / E / E / N / L M A L + MRG <= 0.5 CM$ 455.70 360 11641 26 Midlevel Exc face-mm malig+marg 0.6-1 $488.209691164126 E x c f a ce - mmma l i g + ma r g 0.6 - 1$ 574.35 969 11641 EXC F/E/E/N/L MAL+MRG 0.6-1 CM $574.353601164226 M i d l e v e lE x c f a ce - mmma l i g + ma r g 1.1 - 2$ 573.00 969 11642 26 Exc face-mm malig+marg 1.1-2 $674.1096911642 EXCF / E / E / N / L M A L + MRG 1.1 - 2 CM$ 674.10 360 11643 26 Exc face-mm malig+marg 2.1-3 $845.259691164326 M i d l e v e lE x c f a ce - mmma l i g + ma r g 2.1 - 3$ 718.45 969 11643 EXC F/E/E/N/L MAL+MRG 2.1-3 CM $845.253601164426 M i d l e v e lE x c f a ce - mmma l i g + ma r g 3.1 - 4$ 890.70 969 11644 26 Exc face-mm malig+marg 3.1-4 $1, 047.9096911644 EXCF / E / E / N / L M A L + MRG 3.1 - 4 CM$ 1,047.90 360 11646 26 Midlevel Exc face-mm mlg+marg > 4 cm $1, 236.109691164626 E x c f a ce - mmm l g + ma r g > 4 c m$ 1,454.25 969 11646 EXC F/E/E/N/L MAL+MRG > 4 CM $1, 454.253601171926 T r imnai l (s)$ 63.00 969 11719 26 Midlevel Trim nail(s) $53.5596911719 TR I MN D N A I L S$ 63.00 360 11720 26 Midlevel Debride nail, 1-5 $66.959691172026 De b r i d e nai l, 1 - 5$ 78.75 969 11720 DEBRIDE NAIL 1-5 $78.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 13 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 11721 26 Debride nail, 6 or more $94.509691172126 M i d l e v e l De b r i d e nai l, 6 or m ore$ 80.35 969 11721 DEBRIDE NAIL 6 OR MORE $94.503601173026 R e m o v a l o f nai lpl a t e$ 185.85 983 11730 26 Midlevel Removal of nail plate $157.9596911730 R e m o v a l o f nai lpl a t e$ 185.85 510 11732 26 Remove nail plate, add-on $89.259831173226 M i d l e v e lR e m o v e nai lpl a t e, a dd - o n$ 75.85 969 11732 Remove nail plate add-on $89.255101174026 Dr ainb l oo df ro m u n d er nai l$ 116.55 969 11740 26 Midlevel Drain blood from under nail $99.0596911740 E V A CS U H EM A TOM A$ 116.55 360 11750 26 Removal of nail bed $625.809831175026 M i d l e v e lR e m o v a l o f nai l b e d$ 531.95 969 11750 Removal of nail bed $625.805101175526 M i d l e v e lB i o p sy, nai l u ni t$ 312.40 969 11755 26 Biopsy, nail unit $367.5096911755 BXN A I LU N I T$ 367.50 360 11760 26 Midlevel Repair of nail bed $414.109691176026 R e p ai ro f nai l b e d$ 487.20 969 11760 Repair of nail bed $487.203601176226 R eco n s t r u c t i o n o f nai l b e d$ 678.30 969 11762 26 Midlevel Reconstruction of nail bed $576.5596911762 RECONSTN A I L BE D W GRFT$ 678.30 360 11765 26 Midlevel Excision of nail fold, toe $278.459691176526 E x c i s i o n o f nai l f o l d, t oe$ 327.60 969 11765 Excision of nail fold toe $327.603601177026 R e m o v a l o f p i l o ni d a ll es i o n$ 660.45 969 11770 26 Midlevel Removal of pilonidal lesion $561.4096911770 EXCP I L ON I D C Y ST; SMP L$ 660.45 360 11771 26 Midlevel Removal of pilonidal lesion $1, 322.709691177126 R e m o v a l o f p i l o ni d a ll es i o n$ 1,556.10 969 11771 EXC PILONID CYST; EXTENS $1, 556.103601177226 M i d l e v e lR e m o v a l o f p i l o ni d a ll es i o n$ 1,752.85 969 11772 26 Removal of pilonidal lesion $2, 062.2096911772 EXCP I L ON I D C Y T; COMP L$ 2,062.20 360 11900 26 Injection into skin lesions $115.509691190026 M i d l e v e l I nj ec t i o nin t os kin l es i o n s$ 98.15 969 11900 INJECTION INTO SKIN LESIONS =<7 $115.503601190126 M i d l e v e l A dd e d s kin l es i o n s inj ec t i o n$ 151.70 969 11901 26 Added skin lesions injection $178.5096911901 A DD E D S K I N L ES I ONS I N J ECT I ON > 7$ 178.50 360 11920 26 Correct skin color defects $427.359691192026 M i d l e v e lC orrec t s kin co l or d e f ec t s$ 363.25 969 11920 TATTOO ⇐ 6.0 SQ CM $427.353601192126 C orrec t s kin co l or d e f ec t s$ 499.80 969 11921 26 Midlevel Correct skin color defects $424.8596911921 CORRECTS K NCO L OR 6.1 - 20.0 CM$ 499.80 360 11922 26 Midlevel Correct skin color defects $92.809691192226 C orrec t s kin co l or d e f ec t s$ 109.20 969 11922 CORRECT SKIN COLOR DEFECTS ADDL =<20 $109.20360 SQCM 1195026 M i d l e v e lT h er a p y f orco n t o u r d e f ec t s$ 150.85 969 11950 26 Therapy for contour defects $177.4596911950 SQCO LL A GEN; <= 1 CC$ 177.45 360 11951 26 Therapy for contour defects $276.159691195126 M i d l e v e lT h er a p y f orco n t o u r d e f ec t s$ 234.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 14 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 11951 SQ COLLAGEN; 1.1-5.0CC $276.153601195226 M i d l e v e lT h er a p y f orco n t o u r d e f ec t s$ 322.20 969 11952 26 Therapy for contour defects $379.0596911952 SQCO LL A GEN; 5.1 - 10.0 CC$ 379.05 360 11954 26 Therapy for contour defects $427.359691195426 M i d l e v e lT h er a p y f orco n t o u r d e f ec t s$ 363.25 969 11954 SQ COLLAGEN; 10+ CC $427.353601196026 M i d l e v e l I n ser tt i ss u ee x p an d er (s)$ 2,799.75 969 11960 26 Insert tissue expander(s) $3, 293.8596911960 I NST I SSEXPNOTBRE A ST$ 3,293.85 360 11970 26 Replace tissue expander $2, 252.259691197026 M i d l e v e lR e pl a ce t i ss u ee x p an d er$ 1,914.40 969 11970 REPL TE W PERM PROSTH $2, 252.253601197126 M i d l e v e lR e m o v e t i ss u ee x p an d er (s)$ 990.70 969 11971 26 Remove tissue expander(s) $1, 165.5096911971 REMTE W O I NSPERMPROST H$ 1,165.50 360 11976 26 Midlevel Removal of contraceptive cap $299.009691197626 R e m o v a l o f co n t r a ce pt i v ec a p$ 351.75 969 11976 REM IMPL CONTRACEP CAPS $351.753601198026 M i d l e v e l I m pl an t h or m o n e p e ll e t (s)$ 249.90 969 11980 26 Implant hormone pellet(s) $294.0096911980 SQ H ORMONEPE LL ET I MP L$ 294.00 360 11981 26 Midlevel Insert drug implant device $253.459691198126 I n ser t d r ug im pl an t d e v i ce$ 298.20 969 11981 INSERT DRUG IMPLANT $298.203601198226 M i d l e v e lR e m o v e d r ug im pl an t d e v i ce$ 301.65 969 11982 26 Remove drug implant device $354.9096911982 REMO V E D R U G I MP L A NT$ 354.90 360 11983 26 Remove/insert drug implant $623.709691198326 M i d l e v e lR e m o v e / in ser t d r ug im pl an t$ 530.15 969 11983 REMOVE W INS DRUG IMPLANT $623.703601200126 R e p ai rs u p er f i c ia lw o u n d (s)$ 210.00 969 12001 26 Midlevel Repair superficial wound(s) $178.5096912001 SREPS / N / A / G / TR / E; 2.5 CM / <$ 210.00 360 12002 26 Midlevel Repair superficial wound(s) $199.909691200226 R e p ai rs u p er f i c ia lw o u n d (s)$ 235.20 969 12002 SREPS/N/A/G/TR/E; 2.6-7.5CM $235.203601200426 R e p ai rs u p er f i c ia lw o u n d (s)$ 289.80 969 12004 26 Midlevel Repair superficial wound(s) $246.3596912004 SREPS / N / A / G / TR / E; 7.6 - 12.5 CM$ 289.80 360 12005 26 Repair superficial wound(s) $386.409691200526 M i d l e v e lR e p ai rs u p er f i c ia lw o u n d (s)$ 328.45 969 12005 SREP S/N/A/G/TR/E; 12.6-20.0CM $386.403601200626 M i d l e v e lR e p ai rs u p er f i c ia lw o u n d (s)$ 400.75 969 12006 26 Repair superficial wound(s) $471.4596912006 SREPS / N / A / G / TR / E; 20.1 - 30.0 CM$ 471.45 360 12007 26 Midlevel Repair superficial wound(s) $489.109691200726 R e p ai rs u p er f i c ia lw o u n d (s)$ 575.40 969 12007 SREP S/N/A/G/TR/E; > 30CM $575.403601201126 R e p ai rs u p er f i c ia lw o u n d (s)$ 221.55 969 12011 26 Midlevel Repair superficial wound(s) $188.3096912011 SREPF / E / N / L / MM; 2.5 CM / <$ 221.55 360 12013 26 Midlevel Repair superficial wound(s) $211.509691201326 R e p ai rs u p er f i c ia lw o u n d (s)$ 248.85 969 12013 SREP F/E/N/L/MM; 2.6-5.0CM $248.853601201426 M i d l e v e lR e p ai rs u p er f i c ia lw o u n d (s)$ 265.05 969 12014 26 Repair superficial wound(s) $311.85 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 15 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 12014 SREP F/E/N/L/MM; 5.1-7.5CM $311.853601201526 R e p ai rs u p er f i c ia lw o u n d (s)$ 384.30 969 12015 26 Midlevel Repair superficial wound(s) $326.6596912015 SREPF / E / N / L / MM; 7.6 - 12.5 CM$ 384.30 360 12016 26 Midlevel Repair superficial wound(s) $440.009691201626 R e p ai rs u p er f i c ia lw o u n d (s)$ 517.65 969 12016 SREP F/E/N/L/MM; 12.6-20.0CM $517.653601201726 R e p ai rs u p er f i c ia lw o u n d (s)$ 592.20 969 12017 26 Midlevel Repair superficial wound(s) $503.3596912017 SREPF / E / N / L / MM; 20.1 - 30.0 CM$ 592.20 360 12018 26 Midlevel Repair superficial wound(s) $584.609691201826 R e p ai rs u p er f i c ia lw o u n d (s)$ 687.75 969 12018 SREP F/E/N/L/MM; > 30.0CM $687.753601202026 Cl os u reo f s pl i tw o u n d$ 679.35 969 12020 26 Midlevel Closure of split wound $577.4596912020 TXS W N DD E H I SC; SMP L$ 679.35 360 12021 26 Midlevel Closure of split wound $434.659691202126 Cl os u reo f s pl i tw o u n d$ 511.35 969 12021 TX S WND DEHIS; W PACK $511.353601203126 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 473.05 969 12031 26 Layer closure of wound(s) $556.5096912031 NTM D W N D REP A I RS / A / T / EXT <= 2.5 CM$ 556.50 360 12032 26 Midlevel Layer closure of wound(s) $606.909691203226 L a yerc l os u reo f w o u n d (s)$ 714.00 969 12032 Intmd wnd repair s/a/t/ext 2.6-7.5 cm $714.003601203426 L a yerc l os u reo f w o u n d (s)$ 749.70 969 12034 26 Midlevel Layer closure of wound(s) $637.2596912034 I NTM D W N D REP A I RS / TR / EXT 7.6 - 12.5 CM$ 749.70 360 12035 26 Midlevel Layer closure of wound(s) $741.659691203526 L a yerc l os u reo f w o u n d (s)$ 872.55 969 12035 Intmd wnd repair s/a/t/ext 12.6-20 cm $872.553601203626 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 868.40 969 12036 26 Layer closure of wound(s) $1, 021.6596912036 I NTM D W N D REP A I RS / A / T / EXT 20.1 - 30 CM$ 1,021.65 360 12037 26 Layer closure of wound(s) $1, 192.809691203726 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 1,013.90 969 12037 INTMD WND REPAIR S/TR/EXT 30.0+ CM $1, 192.803601204126 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 484.65 969 12041 26 Layer closure of wound(s) $570.1596912041 I NTM D W N D REP A I RN - H F / GEN I T =< 2.5 CM$ 570.15 360 12042 26 Midlevel Layer closure of wound(s) $620.309691204226 L a yerc l os u reo f w o u n d (s)$ 729.75 969 12042 Intmd wnd repair n-hf/genit 2.6-7.5 cm $729.753601204426 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 662.25 969 12044 26 Layer closure of wound(s) $779.1096912044 I n t m d w n d re p ai r n - h f / g e ni t 7.6 - 12.5 CM$ 779.10 360 12045 26 Layer closure of wound(s) $961.809691204526 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 817.55 969 12045 INTMD WND REPAIR N-HF/GENIT 12.6-20 CM $961.803601204626 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 933.55 969 12046 26 Layer closure of wound(s) $1, 098.3096912046 I NTM D W N D REP A I RN - H F / GEN I T 20.1 - 30 CM$ 1,098.30 360 12047 26 Layer closure of wound(s) $1, 234.809691204726 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 1,049.60 969 12047 INTMD WND REPAIR N-HF/GENIT >30 CM $1, 234.803601205126 L a yerc l os u reo f w o u n d (s)$ 630.00 969 12051 26 Midlevel Layer closure of wound(s) $535.50 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 16 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 12051 INTMD WND REPAIR FACE/MM =< 2.5 CM $630.003601205226 L a yerc l os u reo f w o u n d (s)$ 754.95 969 12052 26 Midlevel Layer closure of wound(s) $641.7096912052 I NTM D W N D REP A I RF A CE / MM 2.6 - 5.0 CM$ 754.95 360 12053 26 Midlevel Layer closure of wound(s) $673.859691205326 L a yerc l os u reo f w o u n d (s)$ 792.75 969 12053 INTMD WND REPAIR FACE/MM 5.1-7.5 CM $792.753601205426 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 708.65 969 12054 26 Layer closure of wound(s) $833.7096912054 I NTM D W N D REP A I RF A CE / MM 7.6 - 12.5 CM$ 833.70 360 12055 26 Layer closure of wound(s) $1, 079.409691205526 M i d l e v e l L a yerc l os u reo f w o u n d (s)$ 917.50 969 12055 INTMD WND REPAIR FACE/MM 12.6-20.0 CM $1, 079.403601205626 L a yerc l os u reo f w o u n d (s)$ 1,347.15 969 12056 26 Midlevel Layer closure of wound(s) $1, 145.1096912056 I NTM D W N D REP A I RF A CE / MM 20.1 - 30.0 CM$ 1,347.15 360 12057 26 Midlevel Layer closure of wound(s) $1, 243.259691205726 L a yerc l os u reo f w o u n d (s)$ 1,462.65 969 12057 INTMD WND REPAIR FACE/MM 30.0+ CM $1, 462.653601310026 M i d l e v e lR e p ai ro f w o u n d or l es i o n$ 726.50 969 13100 26 Repair of wound or lesion $854.7096913100 CREPTR U N K; 1.1 - 2.5 CM$ 854.70 360 13101 26 Midlevel Repair of wound or lesion $882.709691310126 R e p ai ro f w o u n d or l es i o n$ 1,038.45 969 13101 CREP TRUNK; 2.6-7.5CM $1, 038.453601310226 M i d l e v e lR e p ai r w o u n d / l es i o na dd - o n$ 233.85 969 13102 26 Repair wound/lesion add-on $275.1096913102 CREPTR U N K; E AA DD T L 5 CM / <$ 275.10 360 13120 26 Midlevel Repair of wound or lesion $761.309691312026 R e p ai ro f w o u n d or l es i o n$ 895.65 969 13120 C REP S/A/L; 1.1-2.5CM $895.653601312126 M i d l e v e lR e p ai ro f w o u n d or l es i o n$ 1,016.55 969 13121 26 Repair of wound or lesion $1, 195.9596913121 CREPS / A / L; 2.6 - 7.5 CM$ 1,195.95 360 13122 26 Midlevel Repair wound/lesion add-on $266.859691312226 R e p ai r w o u n d / l es i o na dd - o n$ 313.95 969 13122 C REP S/A/L; EA ADD 5 CM/< $313.953601313126 R e p ai ro f w o u n d or l es i o n$ 1,005.90 969 13131 26 Midlevel Repair of wound or lesion $855.0096913131 CREPF / G / H / F; 1.1 - 2.5 CM$ 1,005.90 360 13132 26 Repair of wound or lesion $1, 715.709691313226 M i d l e v e lR e p ai ro f w o u n d or l es i o n$ 1,458.35 969 13132 CREP F/G/H/F; 2.6-7.5CM $1, 715.703601313326 M i d l e v e lR e p ai r w o u n d / l es i o na dd - o n$ 411.45 969 13133 26 Repair wound/lesion add-on $484.0596913133 CREP H / A / G / EXTR; E AA DD 5 CM / <$ 484.05 360 13151 26 Midlevel Repair of wound or lesion $984.459691315126 R e p ai ro f w o u n d or l es i o n$ 1,158.15 969 13151 CREP E/N/E/L; 1.1-2.5CM $1, 158.153601315226 R e p ai ro f w o u n d or l es i o n$ 1,547.70 969 13152 26 Midlevel Repair of wound or lesion $1, 315.5596913152 CREPE / N / E / L; 2.6 - 7.5 CM$ 1,547.70 360 13153 26 Midlevel Repair wound/lesion add-on $444.459691315326 R e p ai r w o u n d / l es i o na dd - o n$ 522.90 969 13153 CREP E/N/E/L; EA ADDTL 5 CM/< $522.903601316026 M i d l e v e l L a t ec l os u reo f w o u n d$ 2,505.25 969 13160 26 Late closure of wound $2,947.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 17 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 13160 LCL SURG WND/DEH EXTENS $2, 947.353601400026 S kin t i ss u ere a rr an g e m e n t$ 1,854.30 969 14000 26 Midlevel Skin tissue rearrangement $1, 576.1596914000 A TTTR U N K; D 10 SQCM / <$ 1,854.30 360 14001 26 Skin tissue rearrangement $2, 419.209691400126 M i d l e v e lS kin t i ss u ere a rr an g e m e n t$ 2,056.30 969 14001 ATT TRUNK; D 10.1-30 SQ $2, 419.203601402026 S kin t i ss u ere a rr an g e m e n t$ 2,106.30 969 14020 26 Midlevel Skin tissue rearrangement $1, 790.3596914020 A TTS / A / L; D 10 SQCM / <$ 2,106.30 360 14021 26 Skin tissue rearrangement $2, 669.109691402126 M i d l e v e lS kin t i ss u ere a rr an g e m e n t$ 2,268.75 969 14021 ATT S/A/L; D 10.1-30 SQ CM $2, 669.103601404026 M i d l e v e lS kin t i ss u ere a rr an g e m e n t$ 2,000.10 969 14040 26 Skin tissue rearrangement $2, 353.0596914040 A TTF / C / M / N / A / G / H / F; <= 10 SQCM$ 2,353.05 360 14041 26 Midlevel Skin tissue rearrangement $2, 454.409691404126 S kin t i ss u ere a rr an g e m e n t$ 2,887.50 969 14041 ATT F/C/M/N/A/G/H/F; 10.1-30SQCM $2, 887.503601406026 S kin t i ss u ere a rr an g e m e n t$ 2,492.70 969 14060 26 Midlevel Skin tissue rearrangement $2, 118.8096914060 A TTE / N / E / L; D 10 SQCM$ 2,492.70 360 14061 26 Skin tissue rearrangement $3, 083.859691406126 M i d l e v e lS kin t i ss u ere a rr an g e m e n t$ 2,621.25 969 14061 ATT E/N/E/L; D 10.1-30 $3, 083.8536014301 S K I NT I SS U ERE A RR A NGEMENT 30.1 - 60.0 SQ$ 3,294.90 360 CM 14302 TIS TRNFR EA ADDL UP TO 30 SQ CM $823.203601435026 S kin t i ss u ere a rr an g e m e n t$ 2,628.15 969 14350 26 Midlevel Skin tissue rearrangement $2, 233.9596914350 F I LL ETE D FGR / TOEF L A P$ 2,628.15 360 15002 26 Wnd prep, ch/inf, trk/arm/lg $829.509691500226 M i d l e v e l Wn d p re p, c h / in f, t r k / a r m / l g$ 705.10 969 15002 WOUND PREP TRK/ARM/LEG 100 SQ CM/1% $829.50360 B A 1500326 Wn d p re p, c h / in f a dd l 100 c m$ 166.95 969 15003 26 Midlevel Wnd prep, ch/inf addl 100 cm $141.9096915003 W O U N D PREPE A DD LU PTO 100 CM$ 166.95 360 15004 26 Midlevel Wnd prep ch/inf, f/n/hf/g $840.759691500426 Wn d p re p c h / in f, f / n / h f / g$ 989.10 969 15004 WOUND PREP F/N/HF/G 100 SQ CM/1% BA $989.103601500526 M i d l e v e l Wn d p re p, f / n / h f / g, a dd l c m$ 283.80 969 15005 26 Wnd prep, f/n/hf/g, addl cm $333.9096915005 W N D PREPF / N / H F / GE AA DD LU PTO 100 SQ$ 333.90 360 CM/1% BA 15040 26 Harvest cultured skin graft $464.109691504026 M i d l e v e l H a r v es t c u lt u re d s kin g r a f t$ 394.50 969 15040 HARVEST CULTURED SKIN GRAFT =< 100 SQ $464.10360 CM 1505026 M i d l e v e lS kin p in c h g r a f t$ 10,318.20 969 15050 26 Skin pinch graft $12, 139.0596915050 P I NC H GRFTSM; D EFECTTO 2 CM$ 12,139.05 360 15100 26 Midlevel Skin splt grft, trnk/arm/leg $2, 241.959691510026 S kin s plt g r f t, t r nk / a r m / l e g$ 2,637.60 969 15100 SKIN SPLT GRFT TRNK/ARM/LEG 100 SQ $2, 637.60360 CM /11510126 M i d l e v e lS kin s plt g r f tt / a / l, a dd - o n$ 345.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 18 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15101 26 Skin splt grft t/a/l, add-on $406.3596915101 S K I NSP L TGRFTT / A / L A DD L 100 SQCM /1$ 406.35 360 BA 15110 26 Midlevel Epidrm autogrft trnk/arm/leg $2, 331.209691511026 Ep i d r ma u t o g r f tt r nk / a r m / l e g$ 2,742.60 969 15110 EPIDRM AUTOGRFT TRNK/ARM/LEG 100 SQ $2, 742.60360 CM /11511126 M i d l e v e lEp i d r ma u t o g r f tt / a / l a dd - o n$ 316.85 969 15111 26 Epidrm autogrft t/a/l add-on $372.7596915111 EP I D RM A U TOGRFTT / A / L A DD L 100 SQ$ 372.75 360 CM/1% BA 15115 26 Midlevel Epidrm a-grft face/nck/hf/g $2, 362.459691511526 Ep i d r ma - g r f t f a ce / n c k / h f / g$ 2,779.35 969 15115 EPIDRM A-GRFT FACE/NCK/HF/G ⇐100 SQ $2, 779.35360 CM /11511626 M i d l e v e lEp i d r ma - g r f t f / n / h f / g a dd l$ 481.05 969 15116 26 Epidrm a-grft f/n/hf/g addl $565.9596915116 EP I D RM A - GRFTF / N / H F / G A DD L 100 SQ$ 565.95 360 CM/1% BA 15120 26 Midlevel Skn splt a-grft fac/nck/hf/g $2, 216.959691512026 S kn s plt a - g r f t f a c / n c k / h f / g$ 2,608.20 969 15120 SKN SPLT A-GRFT FAC/NCK/HF/G ⇐100 SQ $2, 608.20360 CM /11512126 S kn s plt a - g r f t f / n / h f / g a dd$ 494.55 969 15121 26 Midlevel Skn splt a-grft f/n/hf/g add $420.3596915121 S K NSP L T A - GRFTF / N / H F / G A DD L 100 SQ$ 494.55 360 CM/1% BA 15130 26 Derm autograft, trnk/arm/leg $2, 075.859691513026 M i d l e v e l Der ma u t o g r a f t, t r nk / a r m / l e g$ 1,764.45 969 15130 DERM AUTOGRAFT TRNK/ARM/LEG 100 SQ $2, 075.85360 CM /11513126 M i d l e v e l Der ma u t o g r a f tt / a / l a dd - o n$ 288.30 969 15131 26 Derm autograft t/a/l add-on $339.1596915131 D ERM A U TOGR A FTT / A / L A DD L 100 SQ$ 339.15 360 CM/1% BA 15135 26 Midlevel Derm autograft face/nck/hf/g $2, 386.559691513526 Der ma u t o g r a f t f a ce / n c k / h f / g$ 2,807.70 969 15135 DERM AUTOGRAFT FACE/NCK/HF/G 100 SQ $2, 807.70360 CM /11513626 M i d l e v e l Der ma u t o g r a f t, f / n / h f / g a dd$ 248.10 969 15136 26 Derm autograft, f/n/hf/g add $291.9096915136 D ERM A U TOGR A FTF / N / H F / G A DD L 100 SQ$ 291.90 360 CM/1% BA 15150 26 Cult epiderm grft t/arm/leg $2, 302.659691515026 M i d l e v e lC u lt e p i d er m g r f tt / a r m / l e g$ 1,957.25 969 15150 CULT SKIN GRFT T/ARM/LEG ⇐25 SQ CM $2, 302.653601515126 C u lt e p i d er m g r f tt / a / l a dd l$ 403.20 969 15151 26 Midlevel Cult epiderm grft t/a/l addl $342.7096915151 C UL TS K I NGRFTT / A / L A DD L 1 - 75 SQCM$ 403.20 360 15152 26 Cult epiderm graft t/a/l +% $569.109691515226 M i d l e v e lC u lt e p i d er m g r a f tt / a / l +$ 483.75 969 15152 CULT SKIN GRAFT T/A/L +% EA ADDL UP TO $569.10360100 CM 1515526 C u lt e p i d er m g r a f t, f / n / h f / g$ 2,287.95 969 15155 26 Midlevel Cult epiderm graft, f/n/hf/g $1, 944.7596915155 C UL TS K I NGR A FTF / N / H F / G <= 25 SQCM$ 2,287.95 360 15156 26 Cult epidrm grft f/n/hfg add $618.459691515626 M i d l e v e lC u lt e p i d r m g r f t f / n / h f g a dd$ 525.70 969 15156 CULT SKIN GRFT F/N/HFG ADDL 1-75 SQ CM $618.45 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 19 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15157 26 Midlevel Cult epiderm grft f/n/hfg +% $519.459691515726 C u lt e p i d er m g r f t f / n / h f g +$ 611.10 969 15157 CULT EPIDERM GRFT F/N/HFG +% EA ADDL $611.10360 U PTO 100 CM 1520026 S kin f u ll g r a f t, t r u nk$ 2,454.90 969 15200 26 Midlevel Skin full graft, trunk $2, 086.6596915200 S K I NF ULL GR A FTTR U N K =< 20 SQCM$ 2,454.90 360 15201 26 Skin full graft trunk add-on $294.009691520126 M i d l e v e lS kin f u ll g r a f tt r u nka dd - o n$ 249.90 969 15201 SKIN FULL GRAFT TRUNK ADDL =<20 SQ CM $294.003601522026 S kin f u ll g r a f t sc lp / a r m / l e g$ 2,274.30 969 15220 26 Midlevel Skin full graft sclp/arm/leg $1, 933.1596915220 S K I NF ULL GR A FTSC L P / A RM / L EG =< 20 SQ$ 2,274.30 360 CM 15221 26 Midlevel Skin full graft add-on $225.809691522126 S kin f u ll g r a f t a dd - o n$ 265.65 969 15221 SKIN FULL GRAFT S/A/L ADDL =<20 SQ CM $265.653601524026 S kin f u ll g r f t f a ce / g e ni t / h f$ 2,952.60 969 15240 26 Midlevel Skin full grft face/genit/hf $2, 509.7096915240 S K I NF ULL GRFTF A CE / GEN I T / H F =< 20 SQCM$ 2,952.60 360 15241 26 Skin full graft add-on $413.709691524126 M i d l e v e lS kin f u ll g r a f t a dd - o n$ 351.65 969 15241 SKIN FULL GRAFT F/C/C/M/N/AX/G/H/F ADDL $413.70 360 =<20 SQ CM 15260 26 Midlevel Skin full graft een & lips$ 2,695.35 969 15260 26 Skin full graft een & lips $3,171.00 969 15260 SKIN FULL GRAFT EEN & LIPS =< 20 SQ CM$ 3,171.00 360 15261 26 Skin full graft add-on $522.909691526126 M i d l e v e lS kin f u ll g r a f t a dd - o n$ 444.45 969 15261 SKIN FULL GRAFT N/E/E/L ADDL =<20 SQ CM $522.9036015271 S K I NS U BGR A FTTRN K / A RM / L EG <= 25 SQCM$ 319.20 360 15272 SKIN SUB GRAFT T/A/L EA ADDL UP TO 25 CM $63.0036015273 S K I NS U BGRFTT / A RM / L GC H I L D <= 100 SQ$ 761.25 360 CM 15274 SKN SUB GRFT T/A/L CHILD EA ADDL UP TO $160.65360100 CM 15275 S K I NS U BGR A FTF A CE / N K / H F / G, = 25 SQCM$ 369.60 360 15276 SKIN SUB GRAFT F/N/HF/G EA ADDL UP TO 25 $90.30360 CM 15277 S K NS U BGRFTF / N / H F / GC H I L D <= 100 CM$ 785.40 360 15278 SKN SUB GRFT F/N/HF/G CH EA ADDL UP TO $199.50360100 CM 1557026 M i d l e v e lF or m s kin p e d i c l e f l a p$ 2,287.50 969 15570 26 Form skin pedicle flap $2, 691.1596915570 PE D I C L EF L A P; TR U N K$ 2,691.15 360 15572 26 Form skin pedicle flap $2, 721.609691557226 M i d l e v e lF or m s kin p e d i c l e f l a p$ 2,313.35 969 15572 PEDICLE FLAP; SCALP/ARM/LEG $2, 721.603601557426 F or m s kin p e d i c l e f l a p$ 2,816.10 969 15574 26 Midlevel Form skin pedicle flap $2, 393.7096915574 PE D I C L EF L A P; FC / C K / MT H$ 2,816.10 360 15576 26 Midlevel Form skin pedicle flap $2, 105.409691557626 F or m s kin p e d i c l e f l a p$ 2,476.95 969 15576 PEDICLE FAP; EL/NS/ER/LIP $2, 476.953601560026 M i d l e v e lS kin g r a f t$ 652.40 969 15600 26 Skin graft $767.5596915600 D E L A Y F L A P; TR U N K$ 767.55 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 20 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15610 26 Midlevel Skin graft $756.859691561026 S kin g r a f t$ 890.40 969 15610 DELAY FLAP; SCALP/ARM/LEG $890.403601562026 M i d l e v e lS kin g r a f t$ 1,015.65 969 15620 26 Skin graft $1, 194.9096915620 D E L A Y F L A P; F H / C K / C H / N / A / HD$ 1,194.90 360 15630 26 Midlevel Skin graft $1, 089.759691563026 S kin g r a f t$ 1,282.05 969 15630 DELAY FLAP; EL/NS/ER/LIP $1, 282.053601565026 T r an s f ers kin p e d i c l e f l a p$ 1,422.75 969 15650 26 Midlevel Transfer skin pedicle flap $1, 209.3596915650 I NTTR A NSFPE D I C L EF L A P$ 1,422.75 360 15731 26 Midlevel Forehead flap w/vasc pedicle $3, 196.959691573126 F ore h e a df l a pw / v a sc p e d i c l e$ 3,761.10 969 15731 FOREHEAD FLAP W/VASC PEDICLE $3,761.10 360 15733 MUSC MYOQ/FSCQ FLP H&N PEDCL$ 5,420.95 360 15734 26 Midlevel Muscle-skin graft, trunk $4, 179.609691573426 M u sc l e - s kin g r a f t, t r u nk$ 4,917.15 969 15734 MUSCLE FLAP; TRUNK $4, 917.153601573626 M i d l e v e lM u sc l e - s kin g r a f t, a r m$ 3,619.10 969 15736 26 Muscle-skin graft, arm $4, 257.7596915736 M U SC L EF L A P; U PPEREXTREM I T Y$ 4,257.75 360 15738 26 Muscle-skin graft, leg $4, 606.359691573826 M i d l e v e lM u sc l e - s kin g r a f t, l e g$ 3,915.40 969 15738 MUSCLE FLAP; LOWER EXTREMITY $4, 606.353601574026 M i d l e v e l I s l an d p e d i c l e f l a p g r a f t$ 2,686.45 969 15740 26 Island pedicle flap graft $3, 160.5096915740 I S L A N D PE D I C L EF L A PGR A FT$ 3,160.50 360 15750 26 Neurovascular pedicle graft $3, 362.109691575026 M i d l e v e lN e u ro v a sc u l a r p e d i c l e g r a f t$ 2,857.80 969 15750 FLAP; NV PEDICLE $3, 362.103601575626 F ree m yo / s kin f l a p mi cro v a sc$ 8,692.95 969 15756 26 Midlevel Free myo/skin flap microvasc $7, 389.0096915756 F ree m yo / s kin f l a p mi cro v a sc$ 8,692.95 360 15757 26 Free skin flap, microvasc $8, 537.559691575726 M i d l e v e lF rees kin f l a p, mi cro v a sc$ 7,256.90 969 15757 Free skin flap, microvasc $8, 537.553601575826 F ree f a sc ia l f l a p, mi cro v a sc$ 8,554.35 969 15758 26 Midlevel Free fascial flap, microvasc $7, 271.2096915758 F ree f a sc ia l f l a p, mi cro v a sc$ 8,554.35 360 15760 26 Midlevel Composite skin graft $2, 226.809691576026 C o m p os i t es kin g r a f t$ 2,619.75 969 15760 GRAFT; COMPOSITE $2, 619.753601577026 Der ma - f a t - f a sc ia g r a f t$ 2,469.60 969 15770 26 Midlevel Derma-fat-fascia graft $2, 099.1596915770 GR A FT; D FF$ 2,469.60 360 15775 26 Hair transplant punch grafts $774.909691577526 M i d l e v e l H ai r t r an s pl an tp u n c h g r a f t s$ 658.65 969 15775 PUNCH GRAFT HAIR; 1-15 PUNCH $774.903601577626 H ai r t r an s pl an tp u n c h g r a f t s$ 1,071.00 969 15776 26 Midlevel Hair transplant punch grafts $910.3596915776 P U NC H GR A FT H A I R; > 15 P U NC H$ 1,071.00 360 15777 ACELLULAR DERM MATRIX IMPLT $778.053601578026 A b r a s i o n t re a t m e n t o f s kin$ 2,308.95 969 15780 26 Midlevel Abrasion treatment of skin $1, 962.6096915780 D ERM A BR A S I ON; TOT A L F A CE$ 2,308.95 360 15781 26 Abrasion treatment of skin $1,582.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 21 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15781 26 Midlevel Abrasion treatment of skin $1, 345.0096915781 D ERM A BR A S I ON; SEGMF A CE$ 1,582.35 360 15782 26 Midlevel Abrasion treatment of skin $1, 332.509691578226 A b r a s i o n t re a t m e n t o f s kin$ 1,567.65 969 15782 DERMABRASION; REGIONAL FACE $1, 567.653601578326 A b r a s i o n t re a t m e n t o f s kin$ 1,372.35 969 15783 26 Midlevel Abrasion treatment of skin $1, 166.5096915783 A BR A S I ONTRE A TMENTOFS K I N$ 1,372.35 360 15786 26 Midlevel Abrasion, lesion, single $429.309691578626 A b r a s i o n, l es i o n, s in g l e$ 505.05 969 15786 ABRASION; SGL LERS $505.053601578726 A b r a s i o n, l es i o n s, a dd - o n$ 64.05 969 15787 26 Midlevel Abrasion, lesions, add-on $54.4596915787 A BR A S I ON L ES I ONS A DD L =< 4$ 64.05 360 [Rows 1001-2000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 15788 26 Chemical peel, face, epiderm $913.509691578826 M i d l e v e lC h e mi c a lp ee l, f a ce, e p i d er m$ 776.50 969 15788 CHEM FACE PEEL; EPIDERM $913.503601578926 C h e mi c a lp ee l, f a ce, d er ma l$ 1,547.70 969 15789 26 Midlevel Chemical peel, face, dermal $1, 315.5596915789 C H EMF A CEPEE L; D ERM$ 1,547.70 360 15792 26 Midlevel Chemical peel, nonfacial $822.009691579226 C h e mi c a lp ee l, n o n f a c ia l$ 967.05 969 15792 CHEM PEEL; EPIDERM $967.053601579326 M i d l e v e lC h e mi c a lp ee l, n o n f a c ia l$ 1,134.35 969 15793 26 Chemical peel, nonfacial $1, 334.5596915793 C H EMPEE L; D ERM A L$ 1,334.55 360 15819 26 Plastic surgery, neck $2, 768.859691581926 M i d l e v e lPl a s t i cs u r g ery, n ec k$ 2,353.50 969 15819 Plastic surgery, neck $2, 768.853601582026 R e v i s i o n o f l o w ereye l i d$ 1,879.50 969 15820 26 Midlevel Revision of lower eyelid $1, 597.6096915820 B L EP H A ROP L A ST Y L E Y E L I D;$ 1,879.50 360 15821 26 Midlevel Revision of lower eyelid $1, 698.459691582126 R e v i s i o n o f l o w ereye l i d$ 1,998.15 969 15821 BLEPHAROPL LL; W EXT FAT PAD $1, 998.153601582226 M i d l e v e lR e v i s i o n o f u pp ereye l i d$ 1,211.10 969 15822 26 Revision of upper eyelid $1, 424.8596915822 B L EP H A ROP L A ST Y U E Y E L I D;$ 1,424.85 360 15823 26 Revision of upper eyelid $2, 026.509691582326 M i d l e v e lR e v i s i o n o f u pp ereye l i d$ 1,722.55 969 15823 BLEPHAROPL UL; W EXC SKIN $2, 026.5036015824 R H Y T I D ECTOM Y; F H$ 1,785.00 360 15825 RHYTIDECTOMY; NECK W TIGHTEN $3, 255.0036015826 R H Y T I D ECTOM Y; FO W N L I NES$ 1,995.00 360 15828 RHYTIDECT; CK/CH/NK $5, 775.0036015829 R H Y T I D ECTOM Y; SM A SF L A P$ 5,775.00 360 15830 26 Exc skin abd $4, 286.109691583026 M i d l e v e lE x cs kinab d$ 3,643.20 969 15830 EXC SKIN ABD $4, 286.103601583226 M i d l e v e lE x c i see x cess i v es kin t i ss u e$ 2,820.30 969 15832 26 Excise excessive skin tissue $3,318.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 22 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15832 EXCISE EXCESS SKIN TISSUE; THIGH $3, 318.003601583326 E x c i see x cess i v es kin t i ss u e$ 3,214.05 969 15833 26 Midlevel Excise excessive skin tissue $2, 731.9596915833 EXC I SEEXCESSS K I NT I SS U E; L EG$ 3,214.05 360 15834 26 Midlevel Excise excessive skin tissue $2, 769.459691583426 E x c i see x cess i v es kin t i ss u e$ 3,258.15 969 15834 EXCISE EXCESS SKIN TISSUE; HIP $3, 258.153601583526 E x c i see x cess i v es kin t i ss u e$ 3,115.35 969 15835 26 Midlevel Excise excessive skin tissue $2, 648.0596915835 EXC I SEEXCESSS K I NT I SS U E; B U TTOC K$ 3,115.35 360 15836 26 Midlevel Excise excessive skin tissue $2, 340.159691583626 E x c i see x cess i v es kin t i ss u e$ 2,753.10 969 15836 EXCISE EXCESS SKIN TISSUE; ARM $2, 753.103601583726 E x c i see x cess i v es kin t i ss u e$ 2,593.50 969 15837 26 Midlevel Excise excessive skin tissue $2, 204.4596915837 EXC I SEEXCESSS K I NT I SS U E : F A / H A N D$ 2,593.50 360 15838 26 Midlevel Excise excessive skin tissue $1, 793.059691583826 E x c i see x cess i v es kin t i ss u e$ 2,109.45 969 15838 EXCISE EXCESS SKIN TISSUE: FAT PAD $2, 109.453601583926 M i d l e v e lE x c i see x cess i v es kin t i ss u e$ 2,282.10 969 15839 26 Excise excessive skin tissue $2, 684.8596915839 EXC I SEEXCESSS K I NT I SS U E; OT H ER$ 2,684.85 360 15840 26 Midlevel Graft for face nerve palsy $3, 188.909691584026 G r a f t f or f a ce n er v e p a l sy$ 3,751.65 969 15840 FFG - FACE NRV PARALYSIS $3, 751.653601584126 G r a f t f or f a ce n er v e p a l sy$ 5,949.30 969 15841 26 Midlevel Graft for face nerve palsy $5, 056.9096915841 FMG - F A CENR V P A R A L Y S I S$ 5,949.30 360 15842 26 Flap for face nerve palsy $9, 120.309691584226 M i d l e v e lFl a p f or f a ce n er v e p a l sy$ 7,752.25 969 15842 M MG - FACE NRV PARALYSIS $9, 120.303601584526 S kinan d m u sc l ere p ai r, f a ce$ 3,605.70 969 15845 26 Midlevel Skin and muscle repair, face $3, 064.8596915845 REG I ONMT - F A CENR V P A R A L Y S I S$ 3,605.70 360 15847 EXC SKIN ABD ADD-ON $1, 659.0036015850 REMS U T U RE W A N; SS$ 142.80 360 15851 26 Removal of sutures $168.009691585126 M i d l e v e lR e m o v a l o f s u t u res$ 142.80 969 15851 REM SUTURE W AN; OS $168.003601585226 M i d l e v e l Dress in g c han g e n o t f or b u r n$ 145.50 969 15852 26 Dressing change not for burn $171.1596915852 D RESSNGC H GNOTFORB U RN$ 171.15 360 15860 26 Test for blood flow in graft $404.259691586026 M i d l e v e lT es t f or b l oo df l o w in g r a f t$ 343.60 969 15860 GRAFT BLD FLOW TEST $404.25 360 15876 SUCTION LIPECTOMY; HD & NECK$ 1,785.00 360 15877 SUCTION LIPECTOMY; TRUNK $2, 520.0036015878 S U CT I ON L I PECTOM Y; U EXTR$ 1,995.00 360 15879 SUCTION LIPECTOMY; L EXTR $2, 100.003601592026 M i d l e v e lR e m o v a l o f t ai l b o n e u l cer$ 1,893.00 969 15920 26 Removal of tail bone ulcer $2, 227.0596915920 EXCCP UL CER; W 1^{'} S U T U RE$ 2,227.05 360 15922 26 Removal of tail bone ulcer $2, 866.509691592226 M i d l e v e lR e m o v a l o f t ai l b o n e u l cer$ 2,436.55 969 15922 EXC C P ULCER; W FLAP $2, 866.503601593126 M i d l e v e lR e m o v es a cr u m p ress u resore$ 2,099.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 23 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 15931 26 Remove sacrum pressure sore $2, 469.6096915931 REMO V ES A CR U MPRESS U RESORE$ 2,469.60 360 15933 26 Midlevel Remove sacrum pressure sore $2, 604.309691593326 R e m o v es a cr u m p ress u resore$ 3,063.90 969 15933 EXC S P ULCER W OSTECTOMY $3, 063.903601593426 R e m o v es a cr u m p ress u resore$ 3,368.40 969 15934 26 Midlevel Remove sacrum pressure sore $2, 863.1596915934 EXCSP UL CER W S K I NF L A P$ 3,368.40 360 15935 26 Remove sacrum pressure sore $4, 050.909691593526 M i d l e v e lR e m o v es a cr u m p ress u resore$ 3,443.25 969 15935 EXC S P ULCER W SF OSTECTOMY $4, 050.903601593626 M i d l e v e lR e m o v es a cr u m p ress u resore$ 2,784.60 969 15936 26 Remove sacrum pressure sore $3, 276.0096915936 EXCSP UL CERPREPFORF L A P$ 3,276.00 360 15937 26 Remove sacrum pressure sore $3, 815.709691593726 M i d l e v e lR e m o v es a cr u m p ress u resore$ 3,243.35 969 15937 EXC S P ULCER-PREP FOR FLAP/GRAFT $3, 815.703601594026 M i d l e v e lR e m o v e hi pp ress u resore$ 2,151.80 969 15940 26 Remove hip pressure sore $2, 531.5596915940 EXC I P UL CER W 1^{'} S U T U RE$ 2,531.55 360 15941 26 Midlevel Remove hip pressure sore $2, 794.409691594126 R e m o v e hi pp ress u resore$ 3,287.55 969 15941 EXC I P ULCER W 1’ SUTURE W OSTECTOMY $3, 287.553601594426 M i d l e v e lR e m o v e hi pp ress u resore$ 2,796.20 969 15944 26 Remove hip pressure sore $3, 289.6596915944 EXC I P UL CER W S K I NF L A P$ 3,289.65 360 15945 26 Remove hip pressure sore $3, 641.409691594526 M i d l e v e lR e m o v e hi pp ress u resore$ 3,095.20 969 15945 EXC I P ULCER W SKIN FLAP W OSTECTOMY $3, 641.403601594626 R e m o v e hi pp ress u resore$ 6,030.15 969 15946 26 Midlevel Remove hip pressure sore $5,125.65 969 15946 ESC I P ULCER W OSTECT & FLAP$ 6,030.15 360 15950 26 Midlevel Remove thigh pressure sore $1, 803.759691595026 R e m o v e t hi g h p ress u resore$ 2,122.05 969 15950 EXC T P ULCER 1’ SUTURE $2, 122.053601595126 R e m o v e t hi g h p ress u resore$ 3,203.55 969 15951 26 Midlevel Remove thigh pressure sore $2, 723.0096915951 EXCTP UL CER W OSTECTOM Y$ 3,203.55 360 15952 26 Remove thigh pressure sore $3, 336.909691595226 M i d l e v e lR e m o v e t hi g h p ress u resore$ 2,836.35 969 15952 EXC T P ULCER W FLAP $3, 336.903601595326 M i d l e v e lR e m o v e t hi g h p ress u resore$ 3,105.00 969 15953 26 Remove thigh pressure sore $3,652.95 969 15953 EXC T P ULCER W SF & OSTECT$ 3,652.95 360 15956 26 Midlevel Remove thigh pressure sore $3, 603.009691595626 R e m o v e t hi g h p ress u resore$ 4,238.85 969 15956 EXC T P ULCER; W FLAP $4, 238.853601595826 M i d l e v e lR e m o v e t hi g h p ress u resore$ 3,678.00 969 15958 26 Remove thigh pressure sore $4, 327.0596915958 EXCTP UL CER; W OSTECTOM Y$ 4,327.05 360 15999 Removal of pressure sore $1, 145.703601600026 M i d l e v e l I ni t ia lt re a t m e n t o f b u r n (s)$ 141.90 969 16000 26 Initial treatment of burn(s) $166.9596916000 I N I TTX 1 ST D EGRB U RN$ 166.95 360 16020 26 Dress/debrid p-thick burn, s $195.309831602026 M i d l e v e l Dress / d e b r i d p - t hi c kb u r n, s$ 166.00 969 16020 DRESS/DEBRID P-THICK BURN S $195.30 510 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 24 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 16025 26 Dress/debrid p-thick burn, m $407.409691602526 M i d l e v e l Dress / d e b r i d p - t hi c kb u r n, m$ 346.30 969 16025 DRESS/DEBRID P-THICK BURN M $407.403601603026 Dress / d e b r i d p - t hi c kb u r n, l$ 483.00 969 16030 26 Midlevel Dress/debrid p-thick burn, l $410.5596916030 D RESS / D EBR I D P - T H I C K B U RN L$ 483.00 360 16035 26 Midlevel Incision of burn scab, initi $620.309691603526 I n c i s i o n o f b u r n sc ab, ini t i$ 729.75 969 16035 ESCHAROTOMY; INIT INC $729.753601603626 E sc ha ro t o m y; a d d^{'} l in c i s i o n$ 304.50 969 16036 26 Midlevel Escharotomy; add’l incision $258.8096916036 E sc ha ro t o m y; a d d^{'} l in c i s i o n$ 304.50 360 17000 26 Destruct premalg lesion $203.709691700026 M i d l e v e l Des t r u c tp re ma l g l es i o n$ 173.15 969 17000 Destruct premalg lesion $203.703601700326 Des t r u c tp re ma l g l es, 2 - 14$ 15.75 969 17003 26 Midlevel Destruct premalg les, 2-14 $13.4096917003 Des t r u c tp re ma l g l es 2 - 14$ 15.75 360 17004 26 Destroy premlg lesions 15+ $483.009691700426 M i d l e v e l Des t roy p re m l g l es i o n s 15 +$ 410.55 969 17004 DESTROY PREMAL LESIONS >=15 $483.003601710626 Des t r u c t i o n o f s kin l es i o n s$ 1,004.85 969 17106 26 Midlevel Destruction of skin lesions $854.1096917106 D ESTRC U T V A SC L ES; <= 10 SQCM$ 1,004.85 360 17107 26 Destruction of skin lesions $1, 288.359691710726 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 1,095.10 969 17107 DESTR CV LES; 10 - 50 SQCM $1, 288.353601710826 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 1,634.15 969 17108 26 Destruction of skin lesions $1, 922.5596917108 D ESTRC V L ES; > 50 SQCM$ 1,922.55 360 17110 26 Destruct b9 lesion, 1-14 $254.109831711026 M i d l e v e l Des t r u c t b 9 l es i o n, 1 - 14$ 216.00 969 17110 DESTRUCT B9 LESION 1-14 $254.105101711126 Des t r u c tl es i o n, 15 or m ore$ 311.85 983 17111 26 Midlevel Destruct lesion, 15 or more $265.0596917111 D ESTR U CT L ES I ON 15 ORMORE$ 311.85 510 17250 26 Chemical cautery, tissue $132.309831725026 M i d l e v e lC h e mi c a l c a u t ery, t i ss u e$ 112.45 969 17250 Chemical cautery tissue $132.305101726026 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 214.20 969 17260 26 Destruction of skin lesions $252.0096917260 D ESTRM L EST / A / L; 0.5 CM / <$ 252.00 360 17261 26 Midlevel Destruction of skin lesions $286.509691726126 Des t r u c t i o n o f s kin l es i o n s$ 337.05 969 17261 DESTR MLES T/A/L; 0.6-1.0 CM $337.053601726226 Des t r u c t i o n o f s kin l es i o n s$ 427.35 969 17262 26 Midlevel Destruction of skin lesions $363.2596917262 D ESTRM L EST / A / L; 1.1 - 2.0 CM$ 427.35 360 17263 26 Destruction of skin lesions $473.559691726326 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 402.50 969 17263 DESTR MLES T/A/L; 2.1-3.0 CM $473.553601726426 Des t r u c t i o n o f s kin l es i o n s$ 506.10 969 17264 26 Midlevel Destruction of skin lesions $430.2096917264 D ESTRM L EST / A / L; 3.1 - 4.0 CM$ 506.10 360 17266 26 Destruction of skin lesions $589.059691726626 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 500.70 969 17266 DESTR MLES T/A/L; > 4.0 CM $589.05 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 25 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 17270 26 Midlevel Destruction of skin lesions $311.509691727026 Des t r u c t i o n o f s kin l es i o n s$ 366.45 969 17270 DESTR M LES S/N/H/F/G; 0.5 CM/< $366.453601727126 Des t r u c t i o n o f s kin l es i o n s$ 408.45 969 17271 26 Midlevel Destruction of skin lesions $347.2096917271 D ESTRM L ESS / N / H / F / G; 0.6 - 1 CM$ 408.45 360 17272 26 Midlevel Destruction of skin lesions $399.859691727226 Des t r u c t i o n o f s kin l es i o n s$ 470.40 969 17272 DESTR MLES S/N/H/F/G; 1.1-2.0 CM $470.403601727326 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 451.60 969 17273 26 Destruction of skin lesions $531.3096917273 D ESTRM L ESS / N / H / F / G; 2.1 - 3.0 CM$ 531.30 360 17274 26 Destruction of skin lesions $647.859691727426 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 550.65 969 17274 DESTR MLES S/N/H/F/G; 3.1-4.0 CM $647.853601727626 Des t r u c t i o n o f s kin l es i o n s$ 779.10 969 17276 26 Midlevel Destruction of skin lesions $662.2596917276 D ESTRM L ES L S / N / H / F / G; > 4.0 CM$ 779.10 360 17280 26 Midlevel Destruction of skin lesions $282.909691728026 Des t r u c t i o n o f s kin l es i o n s$ 332.85 969 17280 DESTR MLES F/E/E/N/L/MM; 0.5/< $332.853601728126 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 390.00 969 17281 26 Destruction of skin lesions $458.8596917281 D ESTRM L ESF / E / E / N / L / MM; 0.6 - 1 CM$ 458.85 360 17282 26 Midlevel Destruction of skin lesions $449.809691728226 Des t r u c t i o n o f s kin l es i o n s$ 529.20 969 17282 DESTR MLES F/E/E/N/L/MM; 1.1-2CM $529.203601728326 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 561.40 969 17283 26 Destruction of skin lesions $660.4596917283 D ESTRM L ESF / E / E / N / L / MM; 2.1 - 3 CM$ 660.45 360 17284 26 Midlevel Destruction of skin lesions $653.309691728426 Des t r u c t i o n o f s kin l es i o n s$ 768.60 969 17284 DESTR MLES F/E/E/N/L/MM; 3.1-4CM $768.603601728626 M i d l e v e l Des t r u c t i o n o f s kin l es i o n s$ 894.30 969 17286 26 Destruction of skin lesions $1, 052.1096917286 D ESTRM L ESF / E / E / N / L / MM; > 4 CM$ 1,052.10 360 17311 26 Midlevel Mohs, 1 stage, h/n/hf/g $1, 182.559691731126 M o h s, 1 s t a g e, h / n / h f / g$ 1,391.25 969 17311 MOHS 1 STAGE H/N/HF/G $1, 391.253601731226 M o h s a dd l s t a g e$ 738.15 969 17312 26 Midlevel Mohs addl stage $627.4596917312 MO H S A DD L ST A GE$ 738.15 360 17313 26 Midlevel Mohs, 1 stage, t/a/l $1, 060.309691731326 M o h s, 1 s t a g e, t / a / l$ 1,247.40 969 17313 MOHS 1 STAGE T/A/L $1, 247.403601731426 M i d l e v e lM o h s, a dd l s t a g e, t / a / l$ 582.80 969 17314 26 Mohs, addl stage, t/a/l $685.6596917314 MO H S A DD L ST A GET / A / L$ 685.65 360 17315 26 Mohs surg, addl block $194.259691731526 M i d l e v e lM o h ss u r g, a dd l b l oc k$ 165.10 969 17315 MOHS SURG ADDL BLOCK $194.253601734026 C ryo t h er a p yo f s kin$ 174.30 969 17340 26 Midlevel Cryotherapy of skin $148.1596917340 A CNECR Y OT H ER A P Y$ 174.30 360 17360 26 Midlevel Skin peel therapy $307.009691736026 S kin p ee lt h er a p y$ 361.20 969 17360 CHEMICAL EXFOLIATION - ACNE $361.20 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 26 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 17380 HAIR REMOVAL BY ELECTROLYSIS 30 MINS $105.0036017999 S kin t i ss u e p roce d u re$ 210.00 360 19000 26 Midlevel Drainage of breast lesion $134.759691900026 Dr aina g eo f b re a s tl es i o n$ 158.55 969 19000 PUNCT ASP BRST CYST - INITIAL $158.553601900126 M i d l e v e l Dr ainb re a s tl es i o na dd - o n$ 66.05 969 19001 26 Drain breast lesion add-on $77.7096919001 P U NCT A SPBRSTC Y ST - E AA DD T L$ 77.70 360 19020 26 Midlevel Incision of breast lesion $930.909691902026 I n c i s i o n o f b re a s tl es i o n$ 1,095.15 969 19020 Incision of breast lesion $1, 095.153601903026 I nj ec t i o n f or b re a s t x - r a y$ 278.25 969 19030 26 Midlevel Injection for breast x-ray $236.5096919030 M A MM A R Y D U CT I N J$ 278.25 329 19081 BX BREAST 1ST LESION STRTCTC $- 36019081 BXBRE A ST W / D E V I CE 1 ST L ES I ON$ 495.48 960 STEREOTACTIC GUID 19082 BX BREAST ADD LESION STRTCTC $177.6532919083 BXBRE A ST 1 ST L ES I ON U S I M A G$ 2,251.15 360 19083 BX BREAST W/ DEVICE 1ST LESION $466.05960 UL TR A SO U N D G U I D 19084 BXBRE A ST A DD L ES I ON U S I M A G$ 1,840.50 360 19100 26 Bx breast percut w/o image $250.959691910026 M i d l e v e lB x b re a s tp erc u tw / o ima g e$ 213.30 969 19100 Bx breast percut w/o image $250.953601910126 B i o p syo f b re a s t, o p e n$ 796.95 969 19101 26 Midlevel Biopsy of breast, open $677.4096919101 B i o p syo f b re a s t o p e n$ 796.95 360 19105 26 Cryosurg ablate fa, each $717.159691910526 M i d l e v e lC ryos u r g ab l a t e f a, e a c h$ 609.60 969 19105 CRYOSURG ABLATE FA EACH $717.153601911026 M i d l e v e lN i ppl ee x pl or a t i o n$ 1,039.75 969 19110 26 Nipple exploration $1, 223.2596919110 N I PP L EEXP L W / W OEXC D U CT$ 1,223.25 360 19112 26 Excise breast duct fistula $1, 117.209691911226 M i d l e v e lE x c i se b re a s t d u c t f i s t u l a$ 949.60 969 19112 EXC LACTIFEROUS DUCT FISTULA $1, 117.203601912026 R e m o v a l o f b re a s tl es i o n$ 1,477.35 969 19120 26 Midlevel Removal of breast lesion $1, 255.7596919120 REMO V A L OFBRE A ST L ES I ON 1 +$ 1,477.35 360 19125 26 Excision, breast lesion $1, 641.159691912526 M i d l e v e lE x c i s i o n, b re a s tl es i o n$ 1,395.00 969 19125 EXC BREAST LES BY N LOC; SGL $1, 641.153601912626 M i d l e v e lE x c i s i o n, a dd l b re a s tl es i o n$ 494.45 969 19126 26 Excision, addl breast lesion $581.7096919126 EXCBRE A ST L ESN L OC; E AA DD T L$ 581.70 360 19260 26 Midlevel Removal of chest wall lesion $3, 730.659691926026 R e m o v a l o f c h es tw a lll es i o n$ 4,389.00 969 19260 Removal of chest wall lesion $4, 389.003601927126 R e v i s i o n o f c h es tw a ll$ 5,985.00 969 19271 26 Midlevel Revision of chest wall $5, 087.2596919271 R e v i s i o n o f c h es tw a ll$ 5,985.00 360 19272 26 Extensive chest wall surgery $6, 597.159691927226 M i d l e v e lE x t e n s i v ec h es tw a ll s u r g ery$ 5,607.60 969 19272 Extensive chest wall surgery $6, 597.1536019281 PERQ D E V I CEBRE A ST 1 ST I M A G$ 97.65 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 27 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 19282 PERQ DEVICE BREAST EA ADDL IMAG $106.6036019283 PERQ D E V BRE A ST 1 STSTRTCTC$ 244.65 360 19284 PERQ DEV BREAST ADD STRTCTC $107.5036019285 PERQ D E V BRE A ST 1 ST U S I M A G$ 1,145.70 360 19286 PERQ DEV BREAST EA ADDL US IMAG $90.803601929626 Pl a ce p o b re a s t c a t h f orr a d$ 757.05 969 19296 26 Midlevel Place po breast cath for rad $643.509691929726 M i d l e v e lPl a ce b re a s t c a t h f orr a d$ 289.15 969 19297 26 Place breast cath for rad $340.209691929826 M i d l e v e lPl a ce b re a s t r a d t u b e / c a t h s$ 986.20 969 19298 26 Place breast rad tube/caths $1, 160.2596919298 P L A CEBRE A STR A D T U BE / C A T H S$ 1,160.25 360 19300 26 Midlevel Removal of breast tissue $1, 248.609691930026 R e m o v a l o f b re a s tt i ss u e$ 1,468.95 969 19300 REMOVAL OF BREAST TISSUE $1, 468.953601930126 M i d l e v e lP a r t i c a l ma s t ec t o m y$ 1,978.65 969 19301 26 Partical mastectomy $2, 327.8596919301 P A RT I A L M A STECTOM Y$ 2,327.85 360 19302 26 Midlevel P-mastectomy w/ln removal $2, 735.509691930226 P - ma s t ec t o m y w / l n re m o v a l$ 3,218.25 969 19302 P-MASTECTOMY W/LN REMOVAL $3, 218.253601930326 M a s t, s im pl e, co m pl e t e$ 3,605.70 969 19303 26 Midlevel Mast, simple, complete $3, 064.8596919303 M A STS I MP L ECOMP L ETE$ 3,605.70 360 19304 26 Mast, subq $2, 059.059691930426 M i d l e v e lM a s t, s u b q$ 1,750.20 969 19304 MAST SUBQ $2, 059.053601930526 M a s t, r a d i c a l$ 4,062.45 969 19305 26 Midlevel Mast, radical $3, 453.1096919305 M a s t, r a d i c a l$ 4,062.45 360 19306 26 Midlevel Mast, rad, urban type $3, 653.909691930626 M a s t, r a d, u r ban t y p e$ 4,298.70 969 19306 Mast, rad, urban type $4, 298.703601930726 M a s t, m o d r a d$ 4,285.05 969 19307 26 Midlevel Mast, mod rad $3, 642.3096919307 M a s t m o d r a d$ 4,285.05 360 19316 26 Suspension of breast $2, 844.459691931626 M i d l e v e lS u s p e n s i o n o f b re a s t$ 2,417.80 969 19316 MASTOPEXY $2, 844.453601931826 M i d l e v e lR e d u c t i o n o f l a r g e b re a s t$ 3,495.05 969 19318 26 Reduction of large breast $4, 111.8096919318 RE D U CT I ONM A MM A P L A ST Y$ 4,111.80 360 19324 26 Midlevel Enlarge breast $1, 504.759691932426 E n l a r g e b re a s t$ 1,770.30 969 19324 MAMMAPL; WO PROSTHETIC $1, 770.303601932526 M i d l e v e lE n l a r g e b re a s tw i t him pl an t$ 2,030.45 969 19325 26 Enlarge breast with implant $2, 388.7596919325 M A MM A P L; W PROST H ET I C$ 2,388.75 360 19328 26 Midlevel Removal of breast implant $1, 554.759691932826 R e m o v a l o f b re a s t im pl an t$ 1,829.10 969 19328 REM MAMMARY IMPLANT $1, 829.103601933026 M i d l e v e lR e m o v a l o f im pl an t ma t er ia l$ 1,984.90 969 19330 26 Removal of implant material $2, 335.2096919330 REMM A MM A R Y I MP L M A TER I A L$ 2,335.20 360 19340 26 Midlevel Immediate breast prosthesis $2, 955.059691934026 I mm e d ia t e b re a s tp ros t h es i s$ 3,476.55 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 28 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 19340 IM INS BREAST PROSTH S/P M $3, 476.553601934226 M i d l e v e l De l a ye d b re a s tp ros t h es i s$ 2,906.00 969 19342 26 Delayed breast prosthesis $3, 418.8096919342 D L Y I NSBRE A STPROST H S / PM$ 3,418.80 360 19350 26 Midlevel Breast reconstruction $2, 121.459691935026 B re a s t reco n s t r u c t i o n$ 2,495.85 969 19350 NIPPLE/AREOLA RECONSTRUCTION $2, 495.853601935526 C orrec t in v er t e d ni ppl e (s)$ 2,065.35 969 19355 26 Midlevel Correct inverted nipple(s) $1, 755.5596919355 CORRECT I N V ERTE D N I PP L ES$ 2,065.35 360 19357 26 Breast reconstruction $5, 541.909691935726 M i d l e v e lB re a s t reco n s t r u c t i o n$ 4,710.60 969 19357 BREAST RECONST W TISS EXP $5, 541.903601936126 M i d l e v e lB re a s t reco n s t r w / l a t f l a p$ 5,041.75 969 19361 26 Breast reconstr w/lat flap $5, 931.4596919361 B re a s t reco n s t r w / l a t f l a p$ 5,931.45 360 19364 26 Breast reconstruction $10, 259.559691936426 M i d l e v e lB re a s t reco n s t r u c t i o n$ 8,720.60 969 19364 Breast reconstruction $10, 259.553601936626 M i d l e v e lB re a s t reco n s t r u c t i o n$ 4,296.50 969 19366 26 Breast reconstruction $5, 054.7096919366 BRE A STRECONSTR U CT W OT H R$ 5,054.70 360 19367 26 Breast reconstruction $6, 663.309691936726 M i d l e v e lB re a s t reco n s t r u c t i o n$ 5,663.80 969 19367 Breast reconstruction $6, 663.303601936826 M i d l e v e lB re a s t reco n s t r u c t i o n$ 6,984.70 969 19368 26 Breast reconstruction $8, 217.3096919368 B re a s t reco n s t r u c t i o n$ 8,217.30 360 19369 26 Breast reconstruction $7, 607.259691936926 M i d l e v e lB re a s t reco n s t r u c t i o n$ 6,466.15 969 19369 Breast reconstruction $7, 607.253601937026 S u r g eryo f b re a s t c a p s u l e$ 2,537.85 969 19370 26 Midlevel Surgery of breast capsule $2, 157.1596919370 OPBRE A STC A PS UL OTOM Y$ 2,537.85 360 19371 26 Removal of breast capsule $2, 904.309691937126 M i d l e v e lR e m o v a l o f b re a s t c a p s u l e$ 2,468.65 969 19371 PERIPROSTH CAPSULECT BREAST $2, 904.303601938026 M i d l e v e lR e v i se b re a s t reco n s t r u c t i o n$ 2,432.95 969 19380 26 Revise breast reconstruction $2, 862.3096919380 RE V I SERECONSTRBRE A ST$ 2,862.30 360 19396 26 Design custom breast implant $534.459691939626 M i d l e v e l Des i g n c u s t o mb re a s t im pl an t$ 454.30 969 19396 PREP MOULAGE CUST BREAST IMPL $534.4536019499 B re a s t s u r g ery p roce d u re$ 5,455.70 360 20005 26 Incision of deep abscess $840.009692000526 M i d l e v e l I n c i s i o n o fd ee p ab scess$ 714.00 969 20005 INC ST ABSC; DEEP $840.003602010026 E x pl ore w o u n d, n ec k$ 2,182.95 969 20100 26 Midlevel Explore wound, neck $1, 855.5096920100 E x pl ore w o u n d, n ec k$ 2,182.95 360 20101 26 Midlevel Explore wound, chest $639.059692010126 E x pl ore w o u n d, c h es t$ 751.80 969 20101 Explore wound, chest $751.803602010226 E x pl ore w o u n d, ab d o m e n$ 914.55 969 20102 26 Midlevel Explore wound, abdomen $777.3596920102 E x pl ore w o u n d, ab d o m e n$ 914.55 360 20103 26 Explore wound, extremity $1,282.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 29 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 20103 26 Midlevel Explore wound, extremity $1, 089.7596920103 EXP L P W N D; EXTREM$ 1,282.05 360 20150 26 Excise epiphyseal bar $3, 625.659692015026 M i d l e v e lE x c i see p i p h yse a l ba r$ 3,081.80 969 20150 EXC EPIPHYSEAL AR $3, 625.653602020026 M i d l e v e lM u sc l e bi o p sy$ 293.65 969 20200 26 Muscle biopsy $345.4596920200 M U SC L EBX; S U PERF$ 345.45 360 20205 26 Midlevel Deep muscle biopsy $472.159692020526 Dee p m u sc l e bi o p sy$ 555.45 969 20205 MUSCLE BX; DEEP $555.453602020626 N ee d l e bi o p sy, m u sc l e$ 215.25 969 20206 26 Midlevel Needle biopsy, muscle $182.9596920206 M U SC L EBX; PERCN D L$ 215.25 360 20220 26 Midlevel Bone biopsy, trocar/needle $224.909692022026 B o n e bi o p sy, t roc a r / n ee d l e$ 264.60 969 20220 BONE BX TR/NDL; SUPERF $264.603602022526 B o n e bi o p sy, t roc a r / n ee d l e$ 404.25 969 20225 26 Midlevel Bone biopsy, trocar/needle $343.6096920225 D EEPBONEBXTRCR / N D L$ 404.25 360 20240 26 Bone biopsy, excisional $806.409692024026 M i d l e v e lB o n e bi o p sy, e x c i s i o na l$ 685.45 969 20240 BONE BIOPSY OPEN SUPERFICIAL $806.403602024526 B o n e bi o p sy, e x c i s i o na l$ 2,284.80 969 20245 26 Midlevel Bone biopsy, excisional $1, 942.1096920245 BONEB I OPS Y OPEN D EEP$ 2,284.80 360 20250 26 Open bone biopsy $1, 392.309692025026 M i d l e v e lOp e nb o n e bi o p sy$ 1,183.45 969 20250 O VB BX; THORACIC $1, 392.303602025126 M i d l e v e lOp e nb o n e bi o p sy$ 1,283.40 969 20251 26 Open bone biopsy $1, 509.9096920251 OB V BX; LU MB / CER V$ 1,509.90 360 20500 26 Midlevel Injection of sinus tract $270.459692050026 I nj ec t i o n o f s in u s t r a c t$ 318.15 969 20500 SINUS TRACT INJ; THERAPEUTIC $318.153292050126 I nj ec t s in u s t r a c t f or x - r a y$ 138.60 969 20501 26 Midlevel Inject sinus tract for x-ray $117.8096920501 S I N U STR A CT I N J; D X$ 138.60 329 20520 26 Midlevel Removal of foreign body $451.609692052026 R e m o v a l o ff ore i g nb o d y$ 531.30 969 20520 REM FB MUSCLE; SMPL $531.303602052526 M i d l e v e lR e m o v a l o ff ore i g nb o d y$ 772.90 969 20525 26 Removal of foreign body $909.3096920525 REMFBM U SC L E; D EEP$ 909.30 360 20526 26 Midlevel Ther injection, carp tunnel $177.609692052626 T h er inj ec t i o n, c a r pt u nn e l$ 208.95 969 20526 CARPAL TUNNEL TX INJ $208.9536020527 I N J D U P U Y TRENCOR D W / ENZ Y ME$ 216.30 360 20550 26 Midlevel Inj tendon sheath/ligament $160.659692055026 I nj t e n d o n s h e a t h / l i g am e n t$ 189.00 969 20550 INJ SGL TENDON SHTH OR LIGAMENT $189.003602055126 I nj t e n d o n or i g in / in ser t i o n$ 189.00 969 20551 26 Midlevel Inj tendon origin/insertion $160.6596920551 I N J TEN D ONOR I G I N / I NSERT$ 189.00 360 20552 26 Midlevel Inj trigger point, 1/2 muscl $160.659692055226 I nj t r i gg er p o in t, 1/2 m u sc l$ 189.00 969 20552 INJ TRIGGER POINT 1/2 MUSC $189.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 30 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 20553 26 Inject trigger points, =/> 3 $189.009692055326 M i d l e v e l I nj ec tt r i gg er p o in t s, = / > 3$ 160.65 969 20553 INJECT TRIGGER POINTS >=3 MUSC $189.0036020555 P L A CEN D L M U SC / T I SFORRT$ 1,199.10 360 20600 26 Drain/inject, joint/bursa $219.459692060026 M i d l e v e l Dr ain / inj ec t, j o in t / b u rs a$ 186.55 969 20600 DRAIN/INJ SMALL JOINT/BURSA W/O US $219.4536020604 D R A I N / I N J SM A LL J O I NT / B U RS A W / U S$ 489.40 360 20605 26 Midlevel Drain/inject, joint/bursa $205.309692060526 Dr ain / inj ec t, j o in t / b u rs a$ 241.50 969 20605 DRAIN/INJ INTER JOINT/BURSA W/O US $241.503602060626 D R A I N / I N J I NTER J O I NT / B U RS A W / U S$ 166.99 960 20606 DRAIN/INJ INTER JOINT/BURSA W/US $1, 086.753602061026 Dr ain / inj ec t, j o in t / b u rs a$ 180.60 983 20610 26 Midlevel Drain/inject, joint/bursa $153.5096920610 D R A I N / I N J M A J OR J O I NT / B U RS A W / O U S$ 180.60 510 20611 DRAIN/INJ MAJOR JOINT/BURSA W/US $202.30 360 20611 26 ARTHROCENTESIS ASPIR&/INJ MAJOR$ 173.88 960 JT/BURSA W/US 20612 26 Aspirate/inj ganglion cyst $151.209692061226 M i d l e v e l A s p i r a t e / inj g an g l i o n cys t$ 128.50 969 20612 ASPIRATE/INJ GANGLION CYST $151.203602061526 M i d l e v e lT re a t m e n t o f b o n ecys t$ 491.75 969 20615 26 Treatment of bone cyst $578.55 969 20615 ASP & INJ TX OF BONE CYST$ 578.55 360 20650 26 Midlevel Insert and remove bone pin $470.359692065026 I n ser t an d re m o v e b o n e p in$ 553.35 969 20650 INS WIRE/PIN W SK TRACT $553.353602066026 A ppl y, re m f i x a t i o n d e v i ce$ 886.20 969 20660 26 Midlevel Apply, rem fixation device $753.2596920660 A ppl y, re m f i x a t i o n d e v i ce$ 886.20 360 20661 26 Midlevel Application of head brace $1, 554.759692066126 A ppl i c a t i o n o f h e a d b r a ce$ 1,829.10 969 20661 Application of head brace $1, 829.103602066226 M i d l e v e l A ppl i c a t i o n o f p e l v i s b r a ce$ 1,344.10 969 20662 26 Application of pelvis brace $1, 581.3096920662 A PP Y H A L O; PE L V I C$ 1,581.30 360 20663 26 Midlevel Application of thigh brace $1, 260.209692066326 A ppl i c a t i o n o f t hi g hb r a ce$ 1,482.60 969 20663 APPLY HALO; FEMORAL $1, 482.603602066426 M i d l e v e l H a l o b r a ce a ppl i c a t i o n$ 2,668.60 969 20664 26 Halo brace application $3, 139.5096920664 H a l o b r a ce a ppl i c a t i o n$ 3,139.50 360 20665 26 Midlevel Removal of fixation device $275.809692066526 R e m o v a l o ff i x a t i o n d e v i ce$ 324.45 969 20665 REMOVAL OF FIXATION DEVICE $324.453602067026 R e m o v a l o f s u pp or t im pl an t$ 539.70 969 20670 26 Midlevel Removal of support implant $458.7596920670 REMO V A L OFS U PPORT I MP L A NT$ 539.70 360 20680 26 Midlevel Removal of support implant $1, 313.759692068026 R e m o v a l o f s u pp or t im pl an t$ 1,545.60 969 20680 REM IMPL; DEEP $1, 545.603602069026 A ppl y b o n e f i x a t i o n d e v i ce$ 2,110.50 969 20690 26 Midlevel Apply bone fixation device $1, 793.9596920690 A PP L Y BONEF I X A T I ON D E V I CE 1 P L A NE$ 2,110.50 360 20692 26 Apply bone fixation device $3, 994.209692069226 M i d l e v e l A ppl y b o n e f i x a t i o n d e v i ce$ 3,395.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 31 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 20692 APPLY BONE FIXATION DEVICE >1 PLANE $3, 994.203602069326 A d j u s t b o n e f i x a t i o n d e v i ce$ 1,651.65 969 20693 26 Midlevel Adjust bone fixation device $1, 403.9096920693 A D J U STBONEF I X A T I ON D E V I CE$ 1,651.65 360 20694 26 Remove bone fixation device $1, 225.359692069426 M i d l e v e lR e m o v e b o n e f i x a t i o n d e v i ce$ 1,041.55 969 20694 REM EXT FIX SYS W ANESTH $1, 225.3536020696 COMPM UL T I P L A NEEXTF I X A T I ON > 1 P L A NE$ 4,003.65 360 20697 COMP EXT FIXATE STRUT CHANGE >1 PLANE $7, 079.103602080226 M i d l e v e lR e pl an t a t i o n, a r m, co m pl e t e$ 7,093.60 969 20802 26 Replantation, arm, complete $8, 345.4096920802 R e pl an t a t i o n, a r m, co m pl e t e$ 8,345.40 360 20805 26 Replant forearm, complete $10, 487.409692080526 M i d l e v e lR e pl an t f ore a r m, co m pl e t e$ 8,914.30 969 20805 Replant forearm, complete $10, 487.403602080826 M i d l e v e lR e pl an t a t i o nhan d, co m pl e t e$ 12,401.30 969 20808 26 Replantation hand, complete $14, 589.7596920808 R e pl an t a t i o nhan d, co m pl e t e$ 14,589.75 360 20816 26 Midlevel Replantation digit, complete $6, 567.909692081626 R e pl an t a t i o n d i g i t, co m pl e t e$ 7,726.95 969 20816 Replantation digit, complete $7, 726.953602082226 M i d l e v e lR e pl an t a t i o n d i g i t, co m pl e t e$ 5,600.45 969 20822 26 Replantation digit, complete $6, 588.7596920822 REP L D T I PTOST$ 6,588.75 360 20824 26 Replantation thumb, complete $8, 010.459692082426 M i d l e v e lR e pl an t a t i o n t h u mb, co m pl e t e$ 6,808.90 969 20824 Replantation thumb, complete $8, 010.453602082726 R e pl an t a t i o n t h u mb, co m pl e t e$ 6,805.05 969 20827 26 Midlevel Replantation thumb, complete $5, 784.3096920827 R e pl an t a t i o n t h u mb, co m pl e t e$ 6,805.05 360 20838 26 Midlevel Replantation foot, complete $7, 919.159692083826 R e pl an t a t i o n f oo t, co m pl e t e$ 9,316.65 969 20838 Replantation foot, complete $9, 316.653602090026 M i d l e v e lR e m o v a l o f b o n e f or g r a f t$ 683.65 969 20900 26 Removal of bone for graft $804.3096920900 BONEGRFT; M I NOR / SM$ 804.30 360 20902 26 Removal of bone for graft $1, 151.859692090226 M i d l e v e lR e m o v a l o f b o n e f or g r a f t$ 979.05 969 20902 BONE GRFT; MAJ/LG $1, 151.853602091026 R e m o v ec a r t i l a g e f or g r a f t$ 1,643.25 969 20910 26 Midlevel Remove cartilage for graft $1, 396.7596920910 C A RT I L A GEGR A FT; COSTOC H ON D R A L$ 1,643.25 360 20912 26 Remove cartilage for graft $1, 780.809692091226 M i d l e v e lR e m o v ec a r t i l a g e f or g r a f t$ 1,513.70 969 20912 CARTILAGE FRAFT; N SEPTUM $1, 780.803602092026 M i d l e v e lR e m o v a l o ff a sc ia f or g r a f t$ 1,245.05 969 20920 26 Removal of fascia for graft $1, 464.7596920920 F L GR A FT; STR I PPER$ 1,464.75 360 20922 26 Midlevel Removal of fascia for graft $1, 534.209692092226 R e m o v a l o ff a sc ia f or g r a f t$ 1,804.95 969 20922 FL GRAFT; INC COMPLEX $1, 804.953602092426 M i d l e v e lR e m o v a l o f t e n d o n f or g r a f t$ 1,566.35 969 20924 26 Removal of tendon for graft $1, 842.7596920924 D I ST A NCETEN D ONGR A FT$ 1,842.75 360 20926 26 Midlevel Removal of tissue for graft $1, 355.709692092626 R e m o v a l o f t i ss u e f or g r a f t$ 1,594.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 32 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 20926 TISSUE GRAFTS OTHER $1, 594.9536020930 SPBONE A L GRFTMORSE L A DD - ON$ 598.50 360 20931 26 Spinal bone allograft $411.609692093126 M i d l e v e lSp ina l b o n e a ll o g r a f t$ 349.85 969 20931 SP BONE ALGRFT STRUCT ADD-ON $411.6036020936 SPBONE A GRFT L OC A L A DD - ON$ 892.50 360 20937 26 Spinal bone autograft $616.359692093726 M i d l e v e lSp ina l b o n e a u t o g r a f t$ 523.90 969 20937 SP BONE AGRFT MORSEL ADD-ON $616.353602093826 M i d l e v e lSp ina l b o n e a u t o g r a f t$ 575.65 969 20938 26 Spinal bone autograft $677.2596920938 SPBONE A GRFTSTR U CT A DD - ON$ 677.25 360 20950 26 Midlevel Fluid pressure, muscle $281.159692095026 Fl u i d p ress u re, m u sc l e$ 330.75 969 20950 MONITOR INTERST FLD PRESSURE $330.753602095526 F ib u l ab o n e g r a f t, mi cro v a sc$ 9,286.20 969 20955 26 Midlevel Fibula bone graft, microvasc $7, 893.2596920955 F ib u l ab o n e g r a f t, mi cro v a sc$ 9,286.20 360 20956 26 Midlevel Iliac bone graft, microvasc $8, 186.909692095626 I l ia c b o n e g r a f t, mi cro v a sc$ 9,631.65 969 20956 Iliac bone graft, microvasc $9, 631.653602095726 Mt b o n e g r a f t, mi cro v a sc$ 9,803.85 969 20957 26 Midlevel Mt bone graft, microvasc $8, 333.2596920957 Mt b o n e g r a f t, mi cro v a sc$ 9,803.85 360 20962 26 Other bone graft, microvasc $8, 268.759692096226 M i d l e v e lOt h er b o n e g r a f t, mi cro v a sc$ 7,028.45 969 20962 Other bone graft, microvasc $8, 268.753602096926 B o n e / s kin g r a f t, mi cro v a sc$ 10,285.80 969 20969 26 Midlevel Bone/skin graft, microvasc $8, 742.9596920969 B o n e / s kin g r a f t, mi cro v a sc$ 10,285.80 360 20970 26 Midlevel Bone/skin graft, iliac crest $8, 670.659692097026 B o n e / s kin g r a f t, i l ia ccres t$ 10,200.75 969 20970 Bone/skin graft, iliac crest $10, 200.753602097226 B o n e / s kin g r a f t, m e t a t a rs a l$ 8,123.85 969 20972 26 Midlevel Bone/skin graft, metatarsal $6, 905.2596920972 FREEOF A P; MET A T A RS A L$ 8,123.85 360 20973 26 Bone/skin graft, great toe $10, 003.359692097326 M i d l e v e lB o n e / s kin g r a f t, g re a tt oe$ 8,502.85 969 20973 FREE O FLAP; GREAT TOE $10, 003.353602097426 El ec t r i c a l b o n es t im u l a t i o n$ 179.55 969 20974 26 Midlevel Electrical bone stimulation $152.6096920974 El ec t r i c a l b o n es t im u l a t i o n$ 179.55 360 20975 26 Midlevel Electrical bone stimulation $548.009692097526 El ec t r i c a l b o n es t im u l a t i o n$ 644.70 969 20975 ELECTR BONE STIM; IV $644.703602097926 U s b o n es t im u l a t i o n$ 120.75 969 20979 26 Midlevel Us bone stimulation $102.6596920979 U SST I MFORBONE H E A L I NG$ 120.75 360 20982 26 Ablate, bone tumor(s) perq $1, 386.009692098226 M i d l e v e l A b l a t e, b o n e t u m or (s) p er q$ 1,178.10 969 20982 ABLATE BONE TUMOR(S) PERQ $1, 386.0036020985 CPTR - A SST D I RMSPX$ 538.65 360 20999 Musculoskeletal surgery $429.803602101026 I n c i s i o n o f ja w j o in t$ 2,683.80 969 21010 26 Midlevel Incision of jaw joint $2, 281.2596921010 TM J A RT H ROTOM Y$ 2,683.80 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 33 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21011 Exc face les sc < 2 cm $955.5036021012 EXCF A CE L ESSBQ 2 CM / >$ 1,239.00 360 21013 EXC FACE TUM DEEP < 2 CM $1, 488.9036021014 EXCF A CET U M D EEP 2 CM / >$ 1,919.40 360 21015 26 Midlevel Resection of facial tumor $2, 136.659692101526 R esec t i o n o ff a c ia lt u m or$ 2,513.70 969 21015 RESECT FACE/SCALP TUM < 2 CM $2, 513.7036021016 RESECTF A CE / SC A L PT U M 2 CM / >$ 3,826.20 360 21025 26 Midlevel Excision of bone, lower jaw $2, 316.959692102526 E x c i s i o n o f b o n e, l o w er ja w$ 2,725.80 969 21025 EXC BONE; MANDIBLE $2, 725.803602102626 E x c i s i o n o ff a c ia l b o n e (s)$ 1,812.30 969 21026 26 Midlevel Excision of facial bone(s) $1, 540.4596921026 EXCBONE; F A C I A L BONE (S)$ 1,812.30 360 21029 26 Midlevel Contour of face bone lesion $2, 016.159692102926 C o n t o u ro ff a ce b o n e l es i o n$ 2,371.95 969 21029 CONTOUR B TUMOR FACE $2, 371.953602103026 E x c i se ma x / zy g o mab 9 t u m or$ 1,510.95 969 21030 26 Midlevel Excise max/zygoma b9 tumor $1, 284.3096921030 EXCM A X / Z Y GOM A T U MOR$ 1,510.95 360 21031 26 Midlevel Remove exostosis, mandible $896.959692103126 R e m o v ee x os t os i s, man d ib l e$ 1,055.25 969 21031 EXC TORUS MANDIBULARIS $1, 055.253602103226 R e m o v ee x os t os i s, ma x i ll a$ 1,044.75 969 21032 26 Midlevel Remove exostosis, maxilla $888.0596921032 EXCM A X I LL A R Y TOR U SP A L A T I N U S$ 1,044.75 360 21034 26 Midlevel Excise max/zygoma mlg tumor $3, 645.859692103426 E x c i se ma x / zy g o mam l g t u m or$ 4,289.25 969 21034 EXCISE MAX/ZYGOMA MAL TUMOR $4, 289.253602104026 M i d l e v e lE x c i se man d ib l e l es i o n$ 1,284.30 969 21040 26 Excise mandible lesion $1, 510.9596921040 EXCM A N D I B L ET U MOR / C Y ST$ 1,510.95 360 21044 26 Removal of jaw bone lesion $3, 240.309692104426 M i d l e v e lR e m o v a l o f ja w b o n e l es i o n$ 2,754.25 969 21044 EXC M TUMOR MANDIBLE $3, 240.303602104526 E x t e n s i v e ja w s u r g ery$ 4,521.30 969 21045 26 Midlevel Extensive jaw surgery $3, 843.1096921045 E x t e n s i v e ja w s u r g ery$ 4,521.30 360 21046 26 Midlevel Remove mandible cyst complex $3, 402.209692104626 R e m o v e man d ib l ecys t co m pl e x$ 4,002.60 969 21046 EXC MANDIBL TUMOR W OSTEOT $4, 002.603602104726 M i d l e v e lE x c i se lw r ja w cys tw / re p ai r$ 4,036.80 969 21047 26 Excise lwr jaw cyst w/repair $4, 749.1596921047 EXCM A N D I BT U MOR W EOO$ 4,749.15 360 21048 26 Midlevel Remove maxilla cyst complex $3, 483.459692104826 R e m o v e ma x i ll a cys t co m pl e x$ 4,098.15 969 21048 EXC MAXILLA TUMOR CMPLX $4, 098.153602104926 M i d l e v e lE x c i s u pp r ja w cys tw / re p ai r$ 3,845.80 969 21049 26 Excis uppr jaw cyst w/repair $4, 524.4596921049 E x c i s u pp r ja w cys tw / re p ai r$ 4,524.45 360 21050 26 Removal of jaw joint $3, 210.909692105026 M i d l e v e lR e m o v a l o f ja w j o in t$ 2,729.25 969 21050 CONDYLECTOMY TMJ $3, 210.903602106026 M i d l e v e lR e m o v e ja w j o in t c a r t i l a g e$ 2,575.75 969 21060 26 Remove jaw joint cartilage $3, 030.3096921060 MEN I SCECTOM Y TM J$ 3,030.30 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 34 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21070 26 Remove coronoid process $2, 281.659692107026 M i d l e v e lR e m o v ecoro n o i d p rocess$ 1,939.40 969 21070 CORONOIDECTOMY $2, 281.6536021073 MNP J OFTM J W / A NEST H$ 929.25 360 21076 26 Prepare face/oral prosthesis $2, 995.659692107626 M i d l e v e lP re p a re f a ce / or a lp ros t h es i s$ 2,546.30 969 21076 PREP; SURG OBTURATOR PROSTH $2, 995.653602107726 P re p a re f a ce / or a lp ros t h es i s$ 7,563.15 969 21077 26 Midlevel Prepare face/oral prosthesis $6, 428.7096921077 PREP; ORB I T A L PROST H$ 7,563.15 360 21079 26 Midlevel Prepare face/oral prosthesis $4, 275.059692107926 P re p a re f a ce / or a lp ros t h es i s$ 5,029.50 969 21079 PREP; INTERIM OBTURATOR PROSTH $5, 029.503602108026 P re p a re f a ce / or a lp ros t h es i s$ 5,601.75 969 21080 26 Midlevel Prepare face/oral prosthesis $4, 761.5096921080 PREP; D EF I N I T I V EOBT U R A TORPROST H$ 5,601.75 360 21081 26 Midlevel Prepare face/oral prosthesis $4, 358.109692108126 P re p a re f a ce / or a lp ros t h es i s$ 5,127.15 969 21081 PREP; MANDIBULAR RESECTION PROSTH $5, 127.153602108226 P re p a re f a ce / or a lp ros t h es i s$ 4,802.70 969 21082 26 Midlevel Prepare face/oral prosthesis $4, 082.3096921082 PREP; P A L A T A L A U GMENT A T I ONPROST H$ 4,802.70 360 21083 26 Prepare face/oral prosthesis $4, 321.809692108326 M i d l e v e lP re p a re f a ce / or a lp ros t h es i s$ 3,673.55 969 21083 PREP; PALATAL LIFT PROSTHESIS $4, 321.803602108426 P re p a re f a ce / or a lp ros t h es i s$ 5,174.40 969 21084 26 Midlevel Prepare face/oral prosthesis $4, 398.2596921084 PREP; SPEEC H A I D PROST H ES I S$ 5,174.40 360 21085 26 Prepare face/oral prosthesis $2, 310.009692108526 M i d l e v e lP re p a re f a ce / or a lp ros t h es i s$ 1,963.50 969 21085 PREP; ORAL SURGICAL SPLINT $2, 310.003602108626 M i d l e v e lP re p a re f a ce / or a lp ros t h es i s$ 4,726.70 969 21086 26 Prepare face/oral prosthesis $5, 560.8096921086 PREP; A U R I C UL A RPROST H ES I S$ 5,560.80 360 21087 26 Midlevel Prepare face/oral prosthesis $4, 688.309692108726 P re p a re f a ce / or a lp ros t h es i s$ 5,515.65 969 21087 PREP; NASAL PROSTHESIS $5, 515.6536021088 PREP; F A C I A L PROST H ES I S$ 2,310.00 360 21089 Prepare face/oral prosthesis $357.003602110026 M i d l e v e lM a x i ll o f a c ia l f i x a t i o n$ 1,203.10 969 21100 26 Maxillofacial fixation $1, 415.4096921100 A PP L Y H A L OM A X I LL OF A C I A L$ 1,415.40 360 21110 26 Interdental fixation $2, 408.709692111026 M i d l e v e l I n t er d e n t a l f i x a t i o n$ 2,047.40 969 21110 APPLY INTERDENTAL FIXATION DEVICE $2, 408.703602111626 M i d l e v e l I nj ec t i o n, ja w j o in t x - r a y$ 129.40 969 21116 26 Injection, jaw joint x-ray $152.2596921116 TM J A RT H ROGR A P H Y I N J$ 152.25 360 21120 26 Midlevel Reconstruction of chin $1, 693.059692112026 R eco n s t r u c t i o n o f c hin$ 1,991.85 969 21120 GENIOPLASTY; AUGMENTATION $1, 991.853602112126 R eco n s t r u c t i o n o f c hin$ 2,302.65 969 21121 26 Midlevel Reconstruction of chin $1, 957.2596921121 GEN I OP L A ST Y; SOSG L$ 2,302.65 360 21122 26 Reconstruction of chin $2, 354.109692112226 M i d l e v e lR eco n s t r u c t i o n o f c hin$ 2,001.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 35 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21122 RECONSTRUCTION OF CHIN 2+ $2, 354.10360 OSTEOTOM I ES 2112326 R eco n s t r u c t i o n o f c hin$ 3,070.20 969 21123 26 Midlevel Reconstruction of chin $2, 609.6596921123 GEN I OP L A ST Y; S L W BNGRFT$ 3,070.20 360 21125 26 Midlevel Augmentation, lower jaw bone $2, 456.159692112526 A ug m e n t a t i o n, l o w er ja w b o n e$ 2,889.60 969 21125 AUGMENT MAND; PROSTHETIC $2, 889.603602112726 A ug m e n t a t i o n, l o w er ja w b o n e$ 3,118.50 969 21127 26 Midlevel Augmentation, lower jaw bone $2, 650.7096921127 A U GMENTM A N D; BONEGRFT$ 3,118.50 360 21137 26 Midlevel Reduction of forehead $2, 362.459692113726 R e d u c t i o n o ff ore h e a d$ 2,779.35 969 21137 REDUCE FH; CONTOUR $2, 779.353602113826 M i d l e v e lR e d u c t i o n o ff ore h e a d$ 2,768.55 969 21138 26 Reduction of forehead $3, 257.1096921138 RE D U CEF H; PROST H$ 3,257.10 360 21139 26 Midlevel Reduction of forehead $3, 301.359692113926 R e d u c t i o n o ff ore h e a d$ 3,883.95 969 21139 REDUCE FH; SETBACK ASWL $3, 883.953602114126 R eco n s t r u c t mi df a ce, l e f or t$ 5,083.05 969 21141 26 Midlevel Reconstruct midface, lefort $4, 320.6096921141 R eco n s t r u c t mi df a ce, l e f or t$ 5,083.05 360 21142 26 Midlevel Reconstruct midface, lefort $4, 403.609692114226 R eco n s t r u c t mi df a ce, l e f or t$ 5,180.70 969 21142 Reconstruct midface, lefort $5, 180.703602114326 R eco n s t r u c t mi df a ce, l e f or t$ 5,373.90 969 21143 26 Midlevel Reconstruct midface, lefort $4, 567.8096921143 R eco n s t r u c t mi df a ce, l e f or t$ 5,373.90 360 21145 26 Reconstruct midface, lefort $5, 589.159692114526 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 4,750.80 969 21145 Reconstruct midface, lefort $5, 589.153602114626 R eco n s t r u c t mi df a ce, l e f or t$ 6,390.30 969 21146 26 Midlevel Reconstruct midface, lefort $5, 431.7596921146 R eco n s t r u c t mi df a ce, l e f or t$ 6,390.30 360 21147 26 Reconstruct midface, lefort $6, 011.259692114726 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 5,109.55 969 21147 Reconstruct midface, lefort $6, 011.253602115026 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 5,121.15 969 21150 26 Reconstruct midface, lefort $6, 024.9096921150 L EFORT II; A NT I NTR U S I ON$ 6,024.90 360 21151 26 Reconstruct midface, lefort $7, 014.009692115126 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 5,961.90 969 21151 Reconstruct midface, lefort $7, 014.003602115426 R eco n s t r u c t mi df a ce, l e f or t$ 7,922.25 969 21154 26 Midlevel Reconstruct midface, lefort $6, 733.9096921154 R eco n s t r u c t mi df a ce, l e f or t$ 7,922.25 360 21155 26 Midlevel Reconstruct midface, lefort $6, 729.459692115526 R eco n s t r u c t mi df a ce, l e f or t$ 7,917.00 969 21155 Reconstruct midface, lefort $7, 917.003602115926 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 7,777.25 969 21159 26 Reconstruct midface, lefort $9, 149.7096921159 R eco n s t r u c t mi df a ce, l e f or t$ 9,149.70 360 21160 26 Reconstruct midface, lefort $9, 559.209692116026 M i d l e v e lR eco n s t r u c t mi df a ce, l e f or t$ 8,125.30 969 21160 Reconstruct midface, lefort $9, 559.203602117226 R eco n s t r u c t or bi t / f ore h e a d$ 6,616.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 36 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21172 26 Midlevel Reconstruct orbit/forehead $5, 623.6596921172 R eco n s t r u c t or bi t / f ore h e a d$ 6,616.05 360 21175 26 Midlevel Reconstruct orbit/forehead $7, 116.809692117526 R eco n s t r u c t or bi t / f ore h e a d$ 8,372.70 969 21175 Reconstruct orbit/forehead $8, 372.703602117926 R eco n s t r u c t e n t i re f ore h e a d$ 5,297.25 969 21179 26 Midlevel Reconstruct entire forehead $4, 502.6596921179 R eco n s t r u c t e n t i re f ore h e a d$ 5,297.25 360 21180 26 Midlevel Reconstruct entire forehead $4, 876.609692118026 R eco n s t r u c t e n t i re f ore h e a d$ 5,737.20 969 21180 Reconstruct entire forehead $5, 737.203602118126 M i d l e v e lC o n t o u rcr ania l b o n e l es i o n$ 2,203.60 969 21181 26 Contour cranial bone lesion $2, 592.4596921181 CONTO U RBCR A N I A L BONEST U MOR$ 2,592.45 360 21182 26 Reconstruct cranial bone $7, 153.659692118226 M i d l e v e lR eco n s t r u c t cr ania l b o n e$ 6,080.60 969 21182 RECONSTR CRANIAL BONE < 40 CM $7, 153.653602118326 R eco n s t r u c t cr ania l b o n e$ 8,526.00 969 21183 26 Midlevel Reconstruct cranial bone $7, 247.1096921183 RECONSTRCR A NBN 40 - 80 SQCM$ 8,526.00 360 21184 26 Midlevel Reconstruct cranial bone $7, 399.709692118426 R eco n s t r u c t cr ania l b o n e$ 8,705.55 969 21184 RECONSTR CRANIAL BN > 80CM $8, 705.553602118826 R eco n s t r u c t i o n o f mi df a ce$ 5,862.15 969 21188 26 Midlevel Reconstruction of midface $4, 982.8596921188 R eco n s t r u c t i o n o f mi df a ce$ 5,862.15 360 21193 26 Midlevel Reconst lwr jaw w/o graft $4, 085.859692119326 R eco n s tlw r ja ww / o g r a f t$ 4,806.90 969 21193 Reconst lwr jaw w/o graft $4, 806.903602119426 R eco n s tlw r ja ww / g r a f t$ 5,074.65 969 21194 26 Midlevel Reconst lwr jaw w/graft $4, 313.4596921194 R eco n s tlw r ja ww / g r a f t$ 5,074.65 360 21195 26 Reconst lwr jaw w/o fixation $4, 938.159692119526 M i d l e v e lR eco n s tlw r ja ww / o f i x a t i o n$ 4,197.45 969 21195 Reconst lwr jaw w/o fixation $4, 938.153602119626 R eco n s tlw r ja ww / f i x a t i o n$ 5,405.40 969 21196 26 Midlevel Reconst lwr jaw w/fixation $4, 594.6096921196 R eco n s tlw r ja ww / f i x a t i o n$ 5,405.40 360 21198 26 Reconstr lwr jaw segment $4, 253.559692119826 M i d l e v e lR eco n s t r lw r ja w se g m e n t$ 3,615.50 969 21198 OSTEOTOMY MANDIBLE SEGM $4, 253.553602119926 M i d l e v e lR eco n s t r lw r ja ww / a d v an ce$ 3,166.60 969 21199 26 Reconstr lwr jaw w/advance $3, 725.4096921199 RECONST L J A WW A D V$ 3,725.40 360 21206 26 Midlevel Reconstruct upper jaw bone $3, 724.409692120626 R eco n s t r u c t u pp er ja w b o n e$ 4,381.65 969 21206 OSTEOTOMY MAXILLA SEGMENT $4, 381.653602120826 A ug m e n t a t i o n o ff a c ia l b o n es$ 3,110.10 969 21208 26 Midlevel Augmentation of facial bones $2, 643.6096921208 OSTEOP L FB; AA GMENT$ 3,110.10 360 21209 26 Reduction of facial bones $2, 409.759692120926 M i d l e v e lR e d u c t i o n o ff a c ia l b o n es$ 2,048.30 969 21209 OSTEOPLAST FB; REDUCTION $2, 409.753602121026 F a ce b o n e g r a f t$ 3,087.00 969 21210 26 Midlevel Face bone graft $2, 623.9596921210 GR A FTBONE; NOSE / M A X I L / M A L A R$ 3,087.00 360 21215 26 Midlevel Lower jaw bone graft $2,811.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 37 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21215 26 Lower jaw bone graft $3, 307.5096921215 GR A FTBONE; M A N D I B L E$ 3,307.50 360 21230 26 Rib cartilage graft $2, 848.659692123026 M i d l e v e lR ib c a r t i l a g e g r a f t$ 2,421.35 969 21230 GRAFT; RIB CARTILAGE $2, 848.653602123526 E a rc a r t i l a g e g r a f t$ 2,103.15 969 21235 26 Midlevel Ear cartilage graft $1, 787.7096921235 GR A FT; E A RC A RT I L A GE$ 2,103.15 360 21240 26 Midlevel Reconstruction of jaw joint $3, 395.959692124026 R eco n s t r u c t i o n o f ja w j o in t$ 3,995.25 969 21240 TMJ ARTHROPLASTY $3, 995.253602124226 M i d l e v e lR eco n s t r u c t i o n o f ja w j o in t$ 3,117.50 969 21242 26 Reconstruction of jaw joint $3, 667.6596921242 A RT H ROP L TM J W A LL OGR A FT$ 3,667.65 360 21243 26 Midlevel Reconstruction of jaw joint $5, 172.959692124326 R eco n s t r u c t i o n o f ja w j o in t$ 6,085.80 969 21243 ARTHROPL TMJ W PROSTH JNT $6, 085.803602124426 M i d l e v e lR eco n s t r u c t i o n o f l o w er ja w$ 3,318.30 969 21244 26 Reconstruction of lower jaw $3, 903.9096921244 RECONSTRM A N D I B L W TTBONEP L$ 3,903.90 360 21245 26 Midlevel Reconstruction of jaw $2, 807.809692124526 R eco n s t r u c t i o n o f ja w$ 3,303.30 969 21245 RECONST MAND/MAXILLA; PARTIAL $3, 303.303602124626 M i d l e v e lR eco n s t r u c t i o n o f ja w$ 2,590.05 969 21246 26 Reconstruction of jaw $3, 047.1096921246 RECONSTRM A N D / M A X I LL A L; COMP L$ 3,047.10 360 21247 26 Midlevel Reconstruct lower jaw bone $5, 223.809692124726 R eco n s t r u c tl o w er ja w b o n e$ 6,145.65 969 21247 Reconstruct lower jaw bone $6, 145.653602124826 R eco n s t r u c t i o n o f ja w$ 3,235.05 969 21248 26 Midlevel Reconstruction of jaw $2, 749.8096921248 RECONSTRM A N D / M A X I LL A; P A RT I A L$ 3,235.05 360 21249 26 Reconstruction of jaw $4, 474.059692124926 M i d l e v e lR eco n s t r u c t i o n o f ja w$ 3,802.95 969 21249 RECONST MAND/MAXILLA; COMPL $4, 474.053602125526 M i d l e v e lR eco n s t r u c tl o w er ja w b o n e$ 4,341.10 969 21255 26 Reconstruct lower jaw bone $5, 107.2096921255 R eco n s t r u c tl o w er ja w b o n e$ 5,107.20 360 21256 26 Midlevel Reconstruction of orbit $3, 713.709692125626 R eco n s t r u c t i o n o f or bi t$ 4,369.05 969 21256 Reconstruction of orbit $4, 369.053602126026 R e v i seeyesoc k e t s$ 4,494.00 969 21260 26 Midlevel Revise eye sockets $3, 819.9096921260 PER I ORB I TOSTEOT W BG; EXCR A N$ 4,494.00 360 21261 26 Revise eye sockets $7, 964.259692126126 M i d l e v e lR e v i seeyesoc k e t s$ 6,769.60 969 21261 Revise eye sockets $7, 964.253602126326 M i d l e v e lR e v i seeyesoc k e t s$ 5,808.40 969 21263 26 Revise eye sockets $6, 833.4096921263 R e v i seeyesoc k e t s$ 6,833.40 360 21267 26 Revise eye sockets $5, 703.609692126726 M i d l e v e lR e v i seeyesoc k e t s$ 4,848.05 969 21267 ORBITAL REPOSITION; EXTRACRANIAL $5, 703.603602126826 M i d l e v e lR e v i seeyesoc k e t s$ 5,608.45 969 21268 26 Revise eye sockets $6, 598.2096921268 R e v i seeyesoc k e t s$ 6,598.20 360 21270 26 Midlevel Augmentation, cheek bone $2,281.25 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 38 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21270 26 Augmentation, cheek bone $2, 683.8096921270 M A L A R A U GMENT W PROST H M A T$ 2,683.80 360 21275 26 Revision, orbitofacial bones $3, 101.709692127526 M i d l e v e lR e v i s i o n, or bi t o f a c ia l b o n es$ 2,636.45 969 21275 2’ REVISION ORBITOCRAN RECONSTR $3, 101.703602128026 R e v i s i o n o f eye l i d$ 2,102.10 969 21280 26 Midlevel Revision of eyelid $1, 786.8096921280 ME D I A L C A NT H OPEX Y$ 2,102.10 360 21282 26 Midlevel Revision of eyelid $1, 179.009692128226 R e v i s i o n o f eye l i d$ 1,387.05 969 21282 LATERAL CANTHOPEXY $1, 387.053602129526 M i d l e v e lR e v i s i o n o f ja w m u sc l e / b o n e$ 573.00 969 21295 26 Revision of jaw muscle/bone $674.10 969 21295 RED MASSETER M & B; EXTRAORAL$ 674.10 360 21296 26 Midlevel Revision of jaw muscle/bone $1, 334.309692129626 R e v i s i o n o f ja w m u sc l e / b o n e$ 1,569.75 969 21296 REDUCE MASSETER M & B; INTRAORAL $1, 569.7536021299 C r ani o / ma x i ll o f a c ia l s u r g ery$ 357.00 360 21310 26 Midlevel Treatment of nose fracture $312.409692131026 T re a t m e n t o f n ose f r a c t u re$ 367.50 969 21310 CL TXT OF NASAL BONE FX WO MANIP $367.503602131526 T re a t m e n t o f n ose f r a c t u re$ 563.85 969 21315 26 Midlevel Treatment of nose fracture $479.2596921315 C L TXOFN A S A L BONEFX; W OST A B I L I Z$ 563.85 360 21320 26 Treatment of nose fracture $501.909692132026 M i d l e v e lT re a t m e n t o f n ose f r a c t u re$ 426.60 969 21320 CL TX OF NASAL BONE FX; W STABILIZ $501.903602132526 T re a t m e n t o f n ose f r a c t u re$ 1,746.15 969 21325 26 Midlevel Treatment of nose fracture $1, 484.2596921325 OPTXOFN A S A L FX; U NCOMP L I C A TE D$ 1,746.15 360 21330 26 Treatment of nose fracture $2, 110.509692133026 M i d l e v e lT re a t m e n t o f n ose f r a c t u re$ 1,793.95 969 21330 OP TX OF NASAL FX; COMPLIC W FIX $2, 110.503602133526 M i d l e v e lT re a t m e n t o f n ose f r a c t u re$ 2,295.50 969 21335 26 Treatment of nose fracture $2, 700.6096921335 OPTXOFN A S A L FX; W OPTXSEPT A L FX$ 2,700.60 360 21336 26 Midlevel Treat nasal septal fracture $2, 040.259692133626 T re a t na s a l se pt a l f r a c t u re$ 2,400.30 969 21336 OP TX NASAL SEPTAL FX $2, 400.303602133726 T re a t na s a l se pt a l f r a c t u re$ 1,089.90 969 21337 26 Midlevel Treat nasal septal fracture $926.4096921337 C L TXN A S A L SEPT A L FX$ 1,089.90 360 21338 26 Midlevel Treat nasoethmoid fracture $2, 376.759692133826 T re a t na soe t hm o i df r a c t u re$ 2,796.15 969 21338 OP TX NASOETHM FX; WO EXT FIX $2, 796.153602133926 M i d l e v e lT re a t na soe t hm o i df r a c t u re$ 2,491.85 969 21339 26 Treat nasoethmoid fracture $2, 931.6096921339 OPTXN A SOET H MFX; W EXTF I X$ 2,931.60 360 21340 26 Treatment of nose fracture $3, 003.009692134026 M i d l e v e lT re a t m e n t o f n ose f r a c t u re$ 2,552.55 969 21340 PERC TX NASOETHMD CPLX FX W FIX $3, 003.003602134326 M i d l e v e lT re a t m e n t o f s in u s f r a c t u re$ 3,822.60 969 21343 26 Treatment of sinus fracture $4, 497.1596921343 T re a t m e n t o f s in u s f r a c t u re$ 4,497.15 360 21344 26 Treatment of sinus fracture $5, 822.259692134426 M i d l e v e lT re a t m e n t o f s in u s f r a c t u re$ 4,948.90 969 21344 Treatment of sinus fracture $5,822.25 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 39 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21345 26 Treat nose/jaw fracture $2, 346.759692134526 M i d l e v e lT re a t n ose / ja w f r a c t u re$ 1,994.75 969 21345 CL TX LEFORT II FX; W FIXATION $2, 346.753602134626 T re a t n ose / ja w f r a c t u re$ 3,403.05 969 21346 26 Midlevel Treat nose/jaw fracture $2, 892.6096921346 T re a t n ose / ja w f r a c t u re$ 3,403.05 360 21347 26 Treat nose/jaw fracture $4, 103.409692134726 M i d l e v e lT re a t n ose / ja w f r a c t u re$ 3,487.90 969 [Rows 2001-3000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 21347 Treat nose/jaw fracture $4, 103.403602134826 M i d l e v e lT re a t n ose / ja w f r a c t u re$ 3,436.15 969 21348 26 Treat nose/jaw fracture $4, 042.5096921348 T re a t n ose / ja w f r a c t u re$ 4,042.50 360 21355 26 Treat cheek bone fracture $1, 192.809692135526 M i d l e v e lT re a t c h ee kb o n e f r a c t u re$ 1,013.90 969 21355 PERC TX MALAR FX NOT ZYG ARCH $1, 192.803602135626 T re a t c h ee kb o n e f r a c t u re$ 1,388.10 969 21356 26 Midlevel Treat cheek bone fracture $1, 179.9096921356 OPTX D EPRZ Y GOM A T I C A RC H FX$ 1,388.10 360 21360 26 Midlevel Treat cheek bone fracture $1, 659.159692136026 T re a t c h ee kb o n e f r a c t u re$ 1,951.95 969 21360 OP TX DEPR MALAR FX INCL ZYGOM ARCH $1, 951.953602136526 M i d l e v e lT re a t c h ee kb o n e f r a c t u re$ 3,483.45 969 21365 26 Treat cheek bone fracture $4, 098.1596921365 T re a t c h ee kb o n e f r a c t u re$ 4,098.15 360 21366 26 Treat cheek bone fracture $4, 422.609692136626 M i d l e v e lT re a t c h ee kb o n e f r a c t u re$ 3,759.20 969 21366 Treat cheek bone fracture $4, 422.603602138526 T re a t eyesoc k e t f r a c t u re$ 2,547.30 969 21385 26 Midlevel Treat eye socket fracture $2, 165.2096921385 T re a t eyesoc k e t f r a c t u re$ 2,547.30 360 21386 26 Midlevel Treat eye socket fracture $2, 052.759692138626 T re a t eyesoc k e t f r a c t u re$ 2,415.00 969 21386 Treat eye socket fracture $2, 415.003602138726 T re a t eyesoc k e t f r a c t u re$ 2,738.40 969 21387 26 Midlevel Treat eye socket fracture $2, 327.6596921387 T re a t eyesoc k e t f r a c t u re$ 2,738.40 360 21390 26 Treat eye socket fracture $2, 929.509692139026 M i d l e v e lT re a t eyesoc k e t f r a c t u re$ 2,490.10 969 21390 OP TX ORBIT FLR FX; PERIORBIT W IMPL $2, 929.503602139526 T re a t eyesoc k e t f r a c t u re$ 3,608.85 969 21395 26 Midlevel Treat eye socket fracture $3, 067.5096921395 T re a t eyesoc k e t f r a c t u re$ 3,608.85 360 21400 26 Midlevel Treat eye socket fracture $481.959692140026 T re a t eyesoc k e t f r a c t u re$ 567.00 969 21400 CL TX ORBIT FX NOT “BOT”; WO MANIP $567.003602140126 M i d l e v e lT re a t eyesoc k e t f r a c t u re$ 951.40 969 21401 26 Treat eye socket fracture $1, 119.3096921401 C L TXORB I TFXNOT " BO "; W M A N I P$ 1,119.30 360 21406 26 Midlevel Treat eye socket fracture $1, 743.959692140626 T re a t eyesoc k e t f r a c t u re$ 2,051.70 969 21406 OP TX ORBIT FX NOT “BO”; WO IMPL $2,051.70 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 40 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21407 26 Treat eye socket fracture $2, 388.759692140726 M i d l e v e lT re a t eyesoc k e t f r a c t u re$ 2,030.45 969 21407 OP TX ORBIT FX NOT “BO”; W IMPL $2, 388.753602140826 M i d l e v e lT re a t eyesoc k e t f r a c t u re$ 2,840.85 969 21408 26 Treat eye socket fracture $3, 342.1596921408 T re a t eyesoc k e t f r a c t u re$ 3,342.15 360 21421 26 Midlevel Treat mouth roof fracture $2, 051.859692142126 T re a t m o u t h roo ff r a c t u re$ 2,413.95 969 21421 CL TX LEFORT I FX; W ID W FIX $2, 413.953602142226 M i d l e v e lT re a t m o u t h roo ff r a c t u re$ 2,079.55 969 21422 26 Treat mouth roof fracture $2, 446.509692142326 M i d l e v e lT re a t m o u t h roo ff r a c t u re$ 2,500.80 969 21423 26 Treat mouth roof fracture $2, 942.109692143126 M i d l e v e lT re a t cr ani o f a c ia l f r a c t u re$ 2,120.60 969 21431 26 Treat craniofacial fracture $2, 494.809692143226 T re a t cr ani o f a c ia l f r a c t u re$ 2,630.25 969 21432 26 Midlevel Treat craniofacial fracture $2, 235.709692143326 T re a t cr ani o f a c ia l f r a c t u re$ 6,088.95 969 21433 26 Midlevel Treat craniofacial fracture $5, 175.609692143526 T re a t cr ani o f a c ia l f r a c t u re$ 5,035.80 969 21435 26 Midlevel Treat craniofacial fracture $4, 280.459692143626 M i d l e v e lT re a t cr ani o f a c ia l f r a c t u re$ 6,450.10 969 21436 26 Treat craniofacial fracture $7, 588.359692144026 M i d l e v e lT re a t d e n t a l r i d g e f r a c t u re$ 1,449.40 969 21440 26 Treat dental ridge fracture $1, 705.2096921440 C L TXM A N D / M A X I LL A L V EO L A RR I D GEFX$ 1,705.20 360 21445 26 Midlevel Treat dental ridge fracture $1, 921.559692144526 T re a t d e n t a l r i d g e f r a c t u re$ 2,260.65 969 21445 OP TX MANDIB/MAXILL ALV RIDGE FX $2, 260.653602145026 M i d l e v e lT re a tl o w er ja w f r a c t u re$ 1,517.25 969 21450 26 Treat lower jaw fracture $1, 785.0096921450 C L TXM A N D I B UL A RFX; W OM A N I P$ 1,785.00 360 21451 26 Midlevel Treat lower jaw fracture $1, 958.159692145126 T re a tl o w er ja w f r a c t u re$ 2,303.70 969 21451 CL TX MANDIBULAR FX; W MANIP $2, 303.703602145226 M i d l e v e lT re a tl o w er ja w f r a c t u re$ 1,102.25 969 21452 26 Treat lower jaw fracture $1, 296.7596921452 PERCTXOFM A N D FX W EXTF I X$ 1,296.75 360 21453 26 Midlevel Treat lower jaw fracture $2, 422.259692145326 T re a tl o w er ja w f r a c t u re$ 2,849.70 969 21453 CL TX OF MAND FX W ID FIX $2, 849.703602145426 M i d l e v e lT re a tl o w er ja w f r a c t u re$ 1,824.25 969 21454 26 Treat lower jaw fracture $2, 146.2096921454 OPTXOFM A N D FX W EXTF I X$ 2,146.20 360 21461 26 Treat lower jaw fracture $3, 462.909692146126 M i d l e v e lT re a tl o w er ja w f r a c t u re$ 2,943.45 969 21461 OP TX MANDIBULAR FX; WO ID FIX $3, 462.903602146226 M i d l e v e lT re a tl o w er ja w f r a c t u re$ 3,211.20 969 21462 26 Treat lower jaw fracture $3, 777.9096921462 OPTXM A N D I B UL A RFX; W I D F I X$ 3,777.90 360 21465 26 Midlevel Treat lower jaw fracture $2, 960.409692146526 T re a tl o w er ja w f r a c t u re$ 3,482.85 969 21465 OP TX MANDIB CONDYLAR FX $3, 482.853602147026 T re a tl o w er ja w f r a c t u re$ 4,420.50 969 21470 26 Midlevel Treat lower jaw fracture $3, 757.4596921470 T re a tl o w er ja w f r a c t u re$ 4,420.50 360 21480 26 Midlevel Reset dislocated jaw $99.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 41 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21480 26 Reset dislocated jaw $117.6096921480 R ese t d i s l oc a t e d ja w$ 117.60 360 21485 26 Midlevel Reset dislocated jaw $1, 788.559692148526 R ese t d i s l oc a t e d ja w$ 2,104.20 969 21485 CL TX TMJ DISLOCATION; COMPLIC $2, 104.203602149026 R e p ai r d i s l oc a t e d ja w$ 3,396.75 969 21490 26 Midlevel Repair dislocated jaw $2, 887.2596921490 OPTXTM J D I S L OC A T I ON$ 3,396.75 360 21497 26 Interdental wiring $2, 226.009692149726 M i d l e v e l I n t er d e n t a lw i r in g$ 1,892.10 969 21497 IDL WIRING FOR OTHER THAN FX $2, 226.0036021499 He a d s u r g ery p roce d u re$ 357.00 360 21501 26 Drain neck/chest lesion $1, 174.959692150126 M i d l e v e l Dr ainn ec k / c h es tl es i o n$ 998.70 969 21501 I&D DEEP ABSC SFT TISS NK/THOR $1, 174.953602150226 M i d l e v e l Dr ain c h es tl es i o n$ 1,650.25 969 21502 26 Drain chest lesion $1,941.45 969 21502 I&D DEEP ABSC ST NK/TH W RIB O$ 1,941.45 360 21510 26 Midlevel Drainage of bone lesion $1, 604.709692151026 Dr aina g eo f b o n e l es i o n$ 1,887.90 969 21550 26 Biopsy of neck/chest $576.459692155026 M i d l e v e lB i o p syo f n ec k / c h es t$ 490.00 969 21550 SFT TISS BX - NECK/THORAX $576.4536021552 EXCNEC K L ESSC 3 CM / >$ 1,631.70 360 21554 EXC NECK TUM DEEP 5 CM/> $2, 670.153602155526 R e m o v e l es i o n, n ec k / c h es t$ 1,127.70 969 21555 26 Midlevel Remove lesion, neck/chest $958.5596921555 E x c n ec k l essc < 3 c m$ 1,127.70 360 21556 26 Midlevel Remove lesion, neck/chest $1, 634.159692155626 R e m o v e l es i o n, n ec k / c h es t$ 1,922.55 969 21556 EXC NECK TUM DEEP < 5 CM $1, 922.553602155726 R e m o v e t u m or, n ec k / c h es t$ 3,390.45 969 21557 26 Midlevel Remove tumor, neck/chest $2, 881.9096921557 RESECTNEC K T H OR A XT U MOR < 5 CM$ 3,390.45 360 21558 RESECT NECK TUMOR 5 CM/> $4, 939.203602160026 M i d l e v e lP a r t ia l re m o v a l o f r ib$ 1,775.20 969 21600 26 Partial removal of rib $2, 088.4596921600 P A RT I A L EXCR I B$ 2,088.45 360 21610 26 Midlevel Partial removal of rib $3, 679.809692161026 P a r t ia l re m o v a l o f r ib$ 4,329.15 969 21610 COSTOTRANSVERSECTOMY $4, 329.153602161526 M i d l e v e lR e m o v a l o f r ib$ 2,030.45 969 21615 26 Removal of rib $2, 388.759692161626 M i d l e v e lR e m o v a l o f r iban d n er v es$ 2,634.65 969 21616 26 Removal of rib and nerves $3, 099.609692162026 M i d l e v e lP a r t ia l re m o v a l o f s t er n u m$ 1,615.45 969 21620 26 Partial removal of sternum $1, 900.509692162726 M i d l e v e lSt er na l d e b r i d e m e n t$ 1,719.85 969 21627 26 Sternal debridement $2, 023.359692163026 E x t e n s i v es t er n u m s u r g ery$ 4,599.00 969 21630 26 Midlevel Extensive sternum surgery $3, 909.159692163226 E x t e n s i v es t er n u m s u r g ery$ 4,529.70 969 21632 26 Midlevel Extensive sternum surgery $3,850.25 969 21685 26 Hyoid myotomy & suspension$ 3,678.15 969 21685 26 Midlevel Hyoid myotomy & suspension $3,126.45 969 21685 HYOID MYOTOMY & SUSPENSION$ 3,678.15 360 21700 26 Revision of neck muscle $1,431.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 42 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 21700 26 Midlevel Revision of neck muscle $1, 216.5096921700 D I V S A NT I C U S; W OCER V R I BRESECT$ 1,431.15 360 21705 26 Midlevel Revision of neck muscle/rib $1, 945.659692170526 R e v i s i o n o f n ec km u sc l e / r ib$ 2,289.00 969 21705 Revision of neck muscle/rib $2, 289.003602172026 M i d l e v e lR e v i s i o n o f n ec km u sc l e$ 1,568.10 969 21720 26 Revision of neck muscle $1, 844.8596921720 D I V I D ESCM; W OC A ST$ 1,844.85 360 21725 26 Revision of neck muscle $1, 745.109692172526 M i d l e v e lR e v i s i o n o f n ec km u sc l e$ 1,483.35 969 21725 DIVIDE SCM; W CAST $1, 745.103602174026 R eco n s t r u c t i o n o f s t er n u m$ 4,378.50 969 21740 26 Midlevel Reconstruction of sternum $3, 721.7596921740 R eco n s t r u c t i o n o f s t er n u m$ 4,378.50 360 21742 Repair stern/nuss w/o scope $3, 780.0036021743 R e p ai rs t er n u m / n u ss w / sco p e$ 4,200.00 360 21750 26 Repair of sternum separation $2, 572.509692175026 M i d l e v e lR e p ai ro f s t er n u m se p a r a t i o n$ 2,186.65 969 21750 Repair of sternum separation $2, 572.503602182026 M i d l e v e lT re a t s t er n u m f r a c t u re$ 440.00 969 21820 26 Treat sternum fracture $517.6596921820 C L TXSTERN U MFX$ 517.65 360 21825 26 Treat sternum fracture $2, 037.009692182526 M i d l e v e lT re a t s t er n u m f r a c t u re$ 1,731.45 969 21825 Treat sternum fracture $2, 037.0036021899 N ec k / c h es t s u r g ery p roce d u re$ 357.00 360 21920 26 Biopsy soft tissue of back $592.209692192026 M i d l e v e lB i o p syso f tt i ss u eo f ba c k$ 503.35 969 21920 ST BX BACK/FLANK; SUPERF $592.203602192526 B i o p syso f tt i ss u eo f ba c k$ 1,274.70 969 21925 26 Midlevel Biopsy soft tissue of back $1, 083.5096921925 STBXB A C K / F L A N K; D EEP$ 1,274.70 360 21930 26 Remove lesion, back or flank $1, 331.409692193026 M i d l e v e lR e m o v e l es i o n, ba c k or f l ank$ 1,131.70 969 21930 EXC BACK LES SC < 3 CM $1, 331.4036021931 EXCB A C K L ESSC 3 CM / >$ 1,718.85 360 21931 EXCISION TUMOR SOFT TIS BACK/FLANK $1, 457.97960 S U BQ 3 CM / > 21932 E x c ba c k t u m d ee p < 5 c m$ 2,415.00 360 21933 Exc back tum deep 5 cm/> $2, 703.753602193526 R e m o v e t u m or, ba c k$ 3,756.90 969 21935 26 Midlevel Remove tumor, back $3, 193.3596921935 RESECTB A C K T U M < 5 CM$ 3,756.90 360 21936 RESECT BACK TUM 5 CM/> $5,138.70 360 22010 26 Midlevel I&d, p-spine, c/t/cerv-thor$ 2,918.45 969 22010 26 I&d, p-spine, c/t/cerv-thor $3,433.50 969 22010 I&d, p-spine, c/t/cerv-thor$ 3,433.50 360 22015 26 I&d, p-spine, l/s/ls $3,372.60 969 22015 26 Midlevel I&d, p-spine, l/s/ls$ 2,866.70 969 22015 I&d, p-spine, l/s/ls $3, 372.603602210026 R e m o v e p a r t o f n ec k v er t e b r a$ 3,336.90 969 22100 26 Midlevel Remove part of neck vertebra $2, 836.3596922100 R e m o v e p a r t o f n ec k v er t e b r a$ 3,336.90 360 22101 26 Remove part, thorax vertebra $3, 351.609692210126 M i d l e v e lR e m o v e p a r t, t h or a xv er t e b r a$ 2,848.85 969 22101 Remove part, thorax vertebra $3,351.60 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 43 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 22102 26 Midlevel Remove part, lumbar vertebra $2, 530.259692210226 R e m o v e p a r t, l u mba r v er t e b r a$ 2,976.75 969 22102 PEXC PVC B LES 1 SEGM; LUMB $2, 976.753602210326 R e m o v ee x t r a s p in ese g m e n t$ 521.85 969 22103 26 Midlevel Remove extra spine segment $443.5596922103 PEXCP V CB L ES; E AA DD L SEGM$ 521.85 360 22110 26 Midlevel Remove part of neck vertebra $3, 350.459692211026 R e m o v e p a r t o f n ec k v er t e b r a$ 3,941.70 969 22110 Remove part of neck vertebra $3, 941.703602211226 R e m o v e p a r t, t h or a xv er t e b r a$ 3,870.30 969 22112 26 Midlevel Remove part, thorax vertebra $3, 289.7596922112 R e m o v e p a r t, t h or a xv er t e b r a$ 3,870.30 360 22114 26 Remove part, lumbar vertebra $3, 623.559692211426 M i d l e v e lR e m o v e p a r t, l u mba r v er t e b r a$ 3,080.00 969 22114 Remove part, lumbar vertebra $3, 623.553602211626 R e m o v ee x t r a s p in ese g m e n t$ 514.50 969 22116 26 Midlevel Remove extra spine segment $437.3596922116 R e m o v ee x t r a s p in ese g m e n t$ 514.50 360 22206 Cut spine 3 col thor $8, 578.5036022207 C u t s p in e 3 co ll u mb$ 8,713.95 360 22208 Cut spine 3 col addl seg $2, 154.603602221026 R e v i s i o n o f n ec k s p in e$ 6,453.30 969 22210 26 Midlevel Revision of neck spine $5, 485.3096922210 R e v i s i o n o f n ec k s p in e$ 6,453.30 360 22212 26 Midlevel Revision of thorax spine $4, 549.959692221226 R e v i s i o n o f t h or a x s p in e$ 5,352.90 969 22212 Revision of thorax spine $5, 352.903602221426 M i d l e v e lR e v i s i o n o f l u mba rs p in e$ 4,584.75 969 22214 26 Revision of lumbar spine $5, 393.8596922214 R e v i s i o n o f l u mba rs p in e$ 5,393.85 360 22216 26 Midlevel Revise, extra spine segment $1, 137.059692221626 R e v i se, e x t r a s p in ese g m e n t$ 1,337.70 969 22216 Revise, extra spine segment $1, 337.703602222026 R e v i s i o n o f n ec k s p in e$ 5,901.00 969 22220 26 Midlevel Revision of neck spine $5, 015.8596922220 R e v i s i o n o f n ec k s p in e$ 5,901.00 360 22222 26 Revision of thorax spine $5, 551.359692222226 M i d l e v e lR e v i s i o n o f t h or a x s p in e$ 4,718.65 969 22222 Revision of thorax spine $5, 551.353602222426 M i d l e v e lR e v i s i o n o f l u mba rs p in e$ 4,892.70 969 22224 26 Revision of lumbar spine $5, 756.1096922224 R e v i s i o n o f l u mba rs p in e$ 5,756.10 360 22226 26 Revise, extra spine segment $1, 340.859692222626 M i d l e v e lR e v i se, e x t r a s p in ese g m e n t$ 1,139.70 969 22226 Revise, extra spine segment $1, 340.853602231026 M i d l e v e lT re a t s p in e f r a c t u re$ 863.05 969 22310 26 Treat spine fracture $1, 015.3596922310 C L TX V ERTEBR A L BO D Y FX W OM A N I P$ 1,015.35 360 22315 26 Treat spine fracture $2, 807.709692231526 M i d l e v e lT re a t s p in e f r a c t u re$ 2,386.55 969 22315 CL TX VERTEBR FX/DISLOC W CAST/BRACE $2, 807.7036022318 T re a t o d o n t o i df x w / o g r a f t$ 5,966.10 360 22319 Treat odontoid fx w/graft $6, 661.2036022325 T re a t s p in e f r a c t u re$ 5,241.60 360 22326 Treat neck spine fracture $5, 423.2536022327 T re a tt h or a x s p in e f r a c t u re$ 5,397.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 44 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 22328 Treat each add spine fx $1, 041.603602250526 M ani p u l a t i o n o f s p in e$ 432.60 969 22505 26 Midlevel Manipulation of spine $367.7096922505 M A N I P UL A TESP I NEREQ A NEST H$ 432.60 360 22526 26 Midlevel Idet, single level $1, 024.609602252626 I d e t, s in g l e l e v e l$ 1,205.40 960 22526 Idet, single level $1, 205.403602252726 I d e t, 1 or m ore l e v e l s$ 540.75 960 22527 26 Midlevel Idet, 1 or more levels $459.6596022527 I d e t, 1 or m ore l e v e l s$ 540.75 360 22532 26 Midlevel Lat thorax spine fusion $5, 534.409692253226 L a tt h or a x s p in e f u s i o n$ 6,511.05 969 22533 26 Lat lumbar spine fusion $6, 132.009692253326 M i d l e v e l L a tl u mba rs p in e f u s i o n$ 5,212.20 969 22534 26 Lat thor/lumb, addÆl seg $1, 333.509692253426 M i d l e v e l L a tt h or / l u mb, a dd Æ l se g$ 1,133.50 969 22548 26 Neck spine fusion $7, 151.559692254826 M i d l e v e lN ec k s p in e f u s i o n$ 6,078.80 969 22551 NECK SPINE FUSE&REMOV BEL C2 $6,313.65 360 22552 SPINE FUSE&REMV CERV BELW C2, EA ADDL$ 1,446.90 360 22554 26 Neck spine fusion $4, 669.359692255426 M i d l e v e lN ec k s p in e f u s i o n$ 3,968.95 969 22554 SPINE FUSION WO DECOMPRS CERV BELW $4, 669.35360 C 22255626 M i d l e v e lT h or a x s p in e f u s i o n$ 5,169.35 969 22556 26 Thorax spine fusion $6, 081.609692255826 M i d l e v e l Lu mba rs p in e f u s i o n$ 4,782.90 969 22558 26 Lumbar spine fusion $5, 626.959692258526 M i d l e v e l A dd i t i o na l s p ina l f u s i o n$ 1,053.15 969 22585 26 Additional spinal fusion $1, 239.0096922585 A DD I T I ON A L SP I N A L F U S I ON$ 1,239.00 360 22590 26 Midlevel Spine & skull spinal fusion $4,901.60 969 22590 26 Spine & skull spinal fusion$ 5,766.60 969 22595 26 Midlevel Neck spinal fusion $4, 668.659692259526 N ec k s p ina l f u s i o n$ 5,492.55 969 22600 26 Neck spine fusion $4, 701.909692260026 M i d l e v e lN ec k s p in e f u s i o n$ 3,996.60 969 22610 26 Thorax spine fusion $4, 592.709692261026 M i d l e v e lT h or a x s p in e f u s i o n$ 3,903.80 969 22612 26 Lumbar spine fusion $5, 832.759692261226 M i d l e v e l Lu mba rs p in e f u s i o n$ 4,957.85 969 22612 LUMBAR SPINE FUSION $5, 832.753602261426 M i d l e v e lSp in e f u s i o n, e x t r a se g m e n t$ 1,225.40 969 22614 26 Spine fusion, extra segment $1, 441.6596922614 A RT H RO D ES I SPOSTER I OR; E AA DD LL E V E L$ 1,441.65 360 22630 26 Lumbar spine fusion $5, 644.809692263026 M i d l e v e l Lu mba rs p in e f u s i o n$ 4,798.10 969 22632 26 Midlevel Spine fusion, extra segment $1, 000.509692263226 Sp in e f u s i o n, e x t r a se g m e n t$ 1,177.05 969 22633 Lumbar spine fusion combined $6, 778.8036022634 Sp in e f u s i o n e x t r a se g m e n t$ 1,829.10 360 22800 26 Fusion of spine $4, 944.459692280026 M i d l e v e lF u s i o n o f s p in e$ 4,202.80 969 22802 26 Fusion of spine $7, 679.709692280226 M i d l e v e lF u s i o n o f s p in e$ 6,527.75 969 22804 26 Midlevel Fusion of spine $7, 506.809692280426 F u s i o n o f s p in e$ 8,831.55 969 22808 26 Fusion of spine $6,661.20 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 45 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 22808 26 Midlevel Fusion of spine $5, 662.009692281026 M i d l e v e lF u s i o n o f s p in e$ 6,313.55 969 22810 26 Fusion of spine $7, 427.709692281226 F u s i o n o f s p in e$ 8,045.10 969 22812 26 Midlevel Fusion of spine $6, 838.359692281826 M i d l e v e l Ky p h ec t o m y, 1 - 2 se g m e n t s$ 6,728.55 969 22818 26 Kyphectomy, 1-2 segments $7, 915.959692281926 Ky p h ec t o m y, 3 or m ore$ 10,021.20 969 22819 26 Midlevel Kyphectomy, 3 or more $8, 518.009692283026 E x pl or a t i o n o f s p ina l f u s i o n$ 2,959.95 969 22830 26 Midlevel Exploration of spinal fusion $2, 515.959692284026 I n ser t s p in e f i x a t i o n d e v i ce$ 2,808.75 969 22840 26 Midlevel Insert spine fixation device $2, 387.4596922840 I NSERTSP I NEF I X A T I ON D E V I CEPOSTER I OR$ 2,808.75 360 22841 Insert spine fixation device $2, 415.003602284226 M i d l e v e l I n ser t s p in e f i x a t i o n d e v i ce$ 2,390.10 969 22842 26 Insert spine fixation device $2, 811.9096922842 I NSERTSP I NEF I X A T I ON D E V I CE 3 - 6$ 2,811.90 360 SEGMENTS 22843 26 Insert spine fixation device $2, 988.309692284326 M i d l e v e l I n ser t s p in e f i x a t i o n d e v i ce$ 2,540.05 969 22844 26 Midlevel Insert spine fixation device $3, 059.509692284426 I n ser t s p in e f i x a t i o n d e v i ce$ 3,599.40 969 22845 26 Midlevel Insert spine fixation device $2, 306.209692284526 I n ser t s p in e f i x a t i o n d e v i ce$ 2,713.20 969 22845 INSERT SPINE FIXATION DEVICE 2-3 $2, 713.20360 SEGMENTS 2284626 I n ser t s p in e f i x a t i o n d e v i ce$ 2,815.05 969 22846 26 Midlevel Insert spine fixation device $2, 392.809692284726 I n ser t s p in e f i x a t i o n d e v i ce$ 3,246.60 969 22847 26 Midlevel Insert spine fixation device $2, 759.609692284826 I n ser tp e l v f i x a t i o n d e v i ce$ 1,317.75 969 22848 26 Midlevel Insert pelv fixation device $1, 120.109692284926 R e in ser t s p ina l f i x a t i o n$ 4,759.65 969 22849 26 Midlevel Reinsert spinal fixation $4, 045.709692285026 R e m o v es p in e f i x a t i o n d e v i ce$ 2,635.50 969 22850 26 Midlevel Remove spine fixation device $2, 240.209692285226 M i d l e v e lR e m o v es p in e f i x a t i o n d e v i ce$ 2,141.10 969 22852 26 Remove spine fixation device $2, 518.959692285526 R e m o v es p in e f i x a t i o n d e v i ce$ 4,095.00 969 22855 26 Midlevel Remove spine fixation device $3, 480.7596922856 CER V A RT I F I C D I S K ECTOM Y$ 6,087.90 360 22857 26 Lumbar artif diskectomy $6, 050.109692285726 M i d l e v e l Lu mba r a r t i fd i s k ec t o m y$ 5,142.60 969 22861 Revise cerv artific disc $7, 303.803602286226 R e v i se l u mba r a r t i fd i sc$ 7,657.65 969 22862 26 Midlevel Revise lumbar artif disc $6, 509.0096922864 R e m o v ecer v a r t i fd i sc$ 7,018.20 360 22865 26 Remove lumb artif disc $7, 505.409692286526 M i d l e v e lR e m o v e l u mba r t i fd i sc$ 6,379.60 969 22900 26 Remove abdominal wall lesion $1, 991.859692290026 M i d l e v e lR e m o v e ab d o mina lw a lll es i o n$ 1,693.05 969 22900 EXC ABDL TUM DEEP < 5 CM $1, 991.8536022901 EXC A B D L T U M D EEP 5 CM / >$ 2,432.85 360 22902 EXC ABD LES SC < 3 CM $1, 187.5536022903 EXC A B D L ESSC 3 CM / >$ 1,589.70 360 22904 RADICAL RESECT ABD TUMOR<5CM $3, 845.1036022905 R A D RESECT A B D T U MOR 5 CM / >$ 4,878.30 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 46 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 22999 Abdomen surgery procedure $429.803602300026 R e m o v a l o f c a l c i u m d e p os i t s$ 1,329.30 969 23000 26 Midlevel Removal of calcium deposits $1, 129.9096923000 OPENREMS D C A L C I U M D EP$ 1,329.30 360 23020 26 Release shoulder joint $2, 504.259692302026 M i d l e v e lR e l e a ses h o u l d er j o in t$ 2,128.60 969 23020 CAPSULAR CONTRACTURE RELEASE $2, 504.253602303026 M i d l e v e l Dr ain s h o u l d er l es i o n$ 786.30 969 23030 26 Drain shoulder lesion $925.05 969 23030 I & D SHLDR; DEEP ABSC$ 925.05 360 23031 26 Midlevel Drain shoulder bursa $667.609692303126 Dr ain s h o u l d er b u rs a$ 785.40 969 23031 I & D SHLDR; INF BURSA $785.403602303526 M i d l e v e l Dr ain s h o u l d er b o n e l es i o n$ 2,103.60 969 23035 26 Drain shoulder bone lesion $2, 474.8596923035 I NC I SEBONECORTEXS H O UL D ER$ 2,474.85 360 23040 26 Exploratory shoulder surgery $2, 610.309692304026 M i d l e v e lE x pl or a t orys h o u l d ers u r g ery$ 2,218.75 969 23040 ARTHROTOMY GHJ FOR INFECTION $2, 610.303602304426 E x pl or a t orys h o u l d ers u r g ery$ 2,082.15 969 23044 26 Midlevel Exploratory shoulder surgery $1, 769.8596923044 A RT H ROT A C L SC L I NF J NT$ 2,082.15 360 23065 26 Biopsy shoulder tissues $619.509692306526 M i d l e v e lB i o p sys h o u l d er t i ss u es$ 526.60 969 23065 ST BX SHOULDER; SUPERFICIAL $619.503602306626 B i o p sys h o u l d er t i ss u es$ 1,265.25 969 23066 26 Midlevel Biopsy shoulder tissues $1, 075.4596923066 STBXS H O UL D ER; D EEP$ 1,265.25 360 23071 EXC SHOULDER LES SC 3 CM/> $1, 527.7536023073 EXCS H O UL D ERT U M D EEP 5 CM / >$ 2,530.50 360 23075 26 Removal of shoulder lesion $1, 127.709692307526 M i d l e v e lR e m o v a l o f s h o u l d er l es i o n$ 958.55 969 23075 EXC SHOULDER LES SC < 3 CM $1, 127.703602307626 M i d l e v e lR e m o v a l o f s h o u l d er l es i o n$ 1,673.45 969 23076 26 Removal of shoulder lesion $1, 968.7596923076 EXCS H O UL D ERT U M D EEP < 5 CM$ 1,968.75 360 23077 26 Remove tumor of shoulder $4, 196.859692307726 M i d l e v e lR e m o v e t u m oro f s h o u l d er$ 3,567.30 969 23077 RESECT SHOULDER TUMOR < 5 CM $4, 196.8536023078 RESECTS H O UL D ERT U MOR 5 CM / >$ 5,193.30 360 23100 26 Midlevel Biopsy of shoulder joint $1, 531.559692310026 B i o p syo f s h o u l d er j o in t$ 1,801.80 969 23100 ARTHROTOMY W BX GHJ $1, 801.803602310126 S h o u l d er j o in t s u r g ery$ 1,644.30 969 23101 26 Midlevel Shoulder joint surgery $1, 397.6596923101 A RT H ROTOM YW BX / EXC; A C J / SC J$ 1,644.30 360 23105 26 Remove shoulder joint lining $2, 312.109692310526 M i d l e v e lR e m o v es h o u l d er j o in tl inin g$ 1,965.30 969 23105 ARTHROT W SYNOV; GHJ $2, 312.103602310626 I n c i s i o n o f co ll a r b o n e j o in t$ 1,780.80 969 23106 26 Midlevel Incision of collarbone joint $1, 513.7096923106 A RT H ROT W S Y NO V; SC J$ 1,780.80 360 23107 26 Explore treat shoulder joint $2, 394.009692310726 M i d l e v e lE x pl ore t re a t s h o u l d er j o in t$ 2,034.90 969 23107 ARTHROTOMY; GHJ W JNT EXPL $2, 394.003602312026 P a r t ia l re m o v a l, co ll a r b o n e$ 2,119.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 47 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 23120 26 Midlevel Partial removal, collar bone $1, 801.9596923120 C L A V I C UL ECTOM Y; P A RT I A L$ 2,119.95 360 23125 26 Midlevel Removal of collar bone $2, 175.909692312526 R e m o v a l o f co ll a r b o n e$ 2,559.90 969 23125 CLAVICULECTOMY; TOTAL $2, 559.903602313026 R e m o v es h o u l d er b o n e, p a r t$ 2,203.95 969 23130 26 Midlevel Remove shoulder bone, part $1, 873.3596923130 A CROM I OP L / A CROM I ONECTP A RT I A L$ 2,203.95 360 23140 26 Removal of bone lesion $1, 917.309692314026 M i d l e v e lR e m o v a l o f b o n e l es i o n$ 1,629.70 969 23140 EXC BC/B TUMOR CLAV/SCAPULA $1, 917.303602314526 R e m o v a l o f b o n e l es i o n$ 2,513.70 969 23145 26 Midlevel Removal of bone lesion $2, 136.6596923145 EXCBC / BTC L A V / SC A P W A U TOGRFT$ 2,513.70 360 23146 26 Removal of bone lesion $2, 231.259692314626 M i d l e v e lR e m o v a l o f b o n e l es i o n$ 1,896.55 969 23146 EXC BC/BT CLAV/SCAP W ALLOGRF $2, 231.253602315026 R e m o v a l o f h u m er u s l es i o n$ 2,387.70 969 23150 26 Midlevel Removal of humerus lesion $2, 029.5596923150 EXCBC / BTPROX H U MER U S;$ 2,387.70 360 23155 26 Removal of humerus lesion $2, 870.709692315526 M i d l e v e lR e m o v a l o f h u m er u s l es i o n$ 2,440.10 969 23155 EXC BC/BT PROX HUM W AUTOGRFT $2, 870.703602315626 R e m o v a l o f h u m er u s l es i o n$ 2,450.70 969 23156 26 Midlevel Removal of humerus lesion $2, 083.1096923156 EXCBC / BTPROX H U M W A LL OGRFT$ 2,450.70 360 23170 26 Midlevel Remove collar bone lesion $1, 702.909692317026 R e m o v eco ll a r b o n e l es i o n$ 2,003.40 969 23170 SEQUESTRECTOMY; CLAVICLE $2, 003.403602317226 R e m o v es h o u l d er b l a d e l es i o n$ 2,037.00 969 23172 26 Midlevel Remove shoulder blade lesion $1, 731.4596923172 SEQ U ESTRECTOM Y; SC A P UL A$ 2,037.00 360 23174 26 Midlevel Remove humerus lesion $2, 330.309692317426 R e m o v e h u m er u s l es i o n$ 2,741.55 969 23174 SEQUESTRECT; HUM HD TO SURG NCK $2, 741.553602318026 M i d l e v e lR e m o v eco ll a r b o n e l es i o n$ 2,081.30 969 23180 26 Remove collar bone lesion $2, 448.6096923180 P A RT I A L EXCBONE; C L A V I C L E$ 2,448.60 360 23182 26 Midlevel Remove shoulder blade lesion $2, 029.559692318226 R e m o v es h o u l d er b l a d e l es i o n$ 2,387.70 969 23182 PARTIAL EXC BONE; SCAPULA $2, 387.703602318426 M i d l e v e lR e m o v e h u m er u s l es i o n$ 2,272.30 969 23184 26 Remove humerus lesion $2, 673.3096923184 P A RT I A L EXCBONE; PROX H U MER U S$ 2,673.30 360 23190 26 Partial removal of scapula $2, 052.759692319026 M i d l e v e lP a r t ia l re m o v a l o f sc a p u l a$ 1,744.85 969 23190 OSTECTOMY OF SCAPULA PARTIAL $2, 052.753602319526 M i d l e v e lR e m o v a l o f h e a d o f h u m er u s$ 2,322.30 969 23195 26 Removal of head of humerus $2, 732.1096923195 RESECT H U MER A L H E A D$ 2,732.10 360 23200 26 Midlevel Removal of collar bone $4, 520.509692320026 R e m o v a l o f co ll a r b o n e$ 5,318.25 969 23200 Removal of collar bone $5, 318.253602321026 R e m o v a l o f s h o u l d er b l a d e$ 6,233.85 969 23210 26 Midlevel Removal of shoulder blade $5, 298.7596923210 R e m o v a l o f s h o u l d er b l a d e$ 6,233.85 360 23220 26 Midlevel Partial removal of humerus $5,809.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 48 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 23220 26 Partial removal of humerus $6, 834.4596923220 P a r t ia l re m o v a l o f h u m er u s$ 6,834.45 360 23330 26 Remove shoulder foreign body $552.309692333026 M i d l e v e lR e m o v es h o u l d er f ore i g nb o d y$ 469.45 969 23330 REM FB SHOULDER; SQ $552.303602335026 I nj ec t i o n f ors h o u l d er x - r a y$ 184.80 969 23350 26 Midlevel Injection for shoulder x-ray $157.1096923350 S H O UL D ER A RT H ROGR A M I N J$ 184.80 360 23395 26 Midlevel Muscle transfer,shoulder/arm $3, 978.759692339526 M u sc l e t r an s f er, s h o u l d er / a r m$ 4,680.90 969 23395 MUSCLE TRANSF UARM/SHLDR; SGL $4, 680.903602339726 M u sc l e t r an s f ers$ 4,146.45 969 23397 26 Midlevel Muscle transfers $3, 524.5096923397 M U SC L ETR A NSF U A RM / S H L D R; M UL T I$ 4,146.45 360 23400 26 Fixation of shoulder blade $3, 524.859692340026 M i d l e v e lF i x a t i o n o f s h o u l d er b l a d e$ 2,996.10 969 23400 SCAPULOPEXY $3,524.85 360 23405 26 Midlevel Incision of tendon & muscle$ 1,940.30 969 23405 26 Incision of tendon & muscle $2, 282.7096923405 TENOM Y OTOM Y S H O UL D ER; S I NG L E$ 2,282.70 360 23406 26 Midlevel Incise tendon(s) & muscle(s) $2,401.70 969 23406 26 Incise tendon(s) & muscle(s)$ 2,825.55 969 23406 TENOMYOT SHOULDER; MULTI $2, 825.553602341026 M i d l e v e lR e p ai rro t a t orc u ff, a c u t e$ 2,541.85 969 23410 26 Repair rotator cuff, acute $2, 990.4096923410 OPENREP A I RROT A TORC U FF$ 2,990.40 360 23412 26 Midlevel Repair rotator cuff, chronic $2, 640.909692341226 R e p ai rro t a t orc u ff, c h ro ni c$ 3,106.95 969 23412 REPAIR ROTATOR CUFF; CHRONIC $3, 106.953602341526 R e l e a seo f s h o u l d er l i g am e n t$ 2,523.15 969 23415 26 Midlevel Release of shoulder ligament $2, 144.7096923415 COR A CO A CROM I A LL I G A MENTRE L E A SE$ 2,523.15 360 23420 26 Midlevel Repair of shoulder $2, 997.009692342026 R e p ai ro f s h o u l d er$ 3,525.90 969 23420 RECONSTR RC AVULSION CHRONIC $3, 525.903602343026 R e p ai r bi ce p s t e n d o n$ 2,712.15 969 23430 26 Midlevel Repair biceps tendon $2, 305.3596923430 TENO D ES I S L GTEN D ONOFB I CEPS$ 2,712.15 360 23440 26 Remove/transplant tendon $2, 748.909692344026 M i d l e v e lR e m o v e / t r an s pl an tt e n d o n$ 2,336.55 969 23440 RESECT/TRANSPL BICEPS LG TENDON $2, 748.903602345026 R e p ai rs h o u l d erc a p s u l e$ 3,442.95 969 23450 26 Midlevel Repair shoulder capsule $2, 926.5096923450 C A PS UL ORR H A P H Y; P U TT I - P L A TT / M A GN U S$ 3,442.95 360 23455 26 Midlevel Repair shoulder capsule $3, 102.359692345526 R e p ai rs h o u l d erc a p s u l e$ 3,649.80 969 23455 CAPSULORRHAPHY; BANKART $3, 649.803602346026 R e p ai rs h o u l d erc a p s u l e$ 3,961.65 969 23460 26 Midlevel Repair shoulder capsule $3, 367.4096923460 C A PS UL ORR H A P H Y A NTER I OR W BB$ 3,961.65 360 23462 26 Repair shoulder capsule $3, 897.609692346226 M i d l e v e lR e p ai rs h o u l d erc a p s u l e$ 3,312.95 969 23462 CAPSULORRHAPHY ANT; W CPT $3, 897.603602346526 R e p ai rs h o u l d erc a p s u l e$ 4,071.90 969 23465 26 Midlevel Repair shoulder capsule $3, 461.1096923465 C A PS UL ORR H A P H Y G H J POSTER I OR$ 4,071.90 360 23466 26 Midlevel Repair shoulder capsule $3,469.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 49 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 23466 26 Repair shoulder capsule $4, 081.3596923466 C A PS UL ORR H A P H Y G H J M UL T I D I R$ 4,081.35 360 UNSTABLE 23470 26 Reconstruct shoulder joint $4, 399.509692347026 M i d l e v e lR eco n s t r u c t s h o u l d er j o in t$ 3,739.60 969 23470 Reconstruct shoulder joint $4, 399.503602347226 M i d l e v e lR eco n s t r u c t s h o u l d er j o in t$ 4,632.05 969 23472 26 Reconstruct shoulder joint $5, 449.5096923472 R eco n s t r u c t s h o u l d er j o in t$ 5,449.50 360 23473 REVIS RECONST SHOULDER JOINT $5, 322.1036023474 RE V I SRECONSTS H O UL D ER J O I NT$ 5,742.35 360 23480 26 Midlevel Revision of collar bone $2, 528.459692348026 R e v i s i o n o f co ll a r b o n e$ 2,974.65 969 23480 OSTEOTOMY CLAVICLE W OR WO INT FIX $2, 974.653602348526 R e v i s i o n o f co ll a r b o n e$ 3,490.20 969 23485 26 Midlevel Revision of collar bone $2, 966.6596923485 OSTEOTOM Y C L A V I C L E; W BONEGR A FT$ 3,490.20 360 23490 26 Reinforce clavicle $3, 223.509692349026 M i d l e v e lR e in f orcec l a v i c l e$ 2,739.95 969 23490 NAIL/PIN/PLATE/WIRE; CLAVICLE $3, 223.503602349126 R e in f orces h o u l d er b o n es$ 3,682.35 969 23491 26 Midlevel Reinforce shoulder bones $3, 130.0096923491 N A I L / P I N / P L A TE / W I RE; PROX H U MER U S$ 3,682.35 360 23500 26 Treat clavicle fracture $794.859692350026 M i d l e v e lT re a t c l a v i c l e f r a c t u re$ 675.60 969 23500 CL TX CLAVICULAR FX; WO MANIP $794.853602350526 M i d l e v e lT re a t c l a v i c l e f r a c t u re$ 1,006.75 969 23505 26 Treat clavicle fracture $1, 184.4096923505 C L TXC L A V I C UL A RFX; W M A N I P$ 1,184.40 360 23515 26 Midlevel Treat clavicle fracture $286.809692351526 T re a t c l a v i c l e f r a c t u re$ 337.05 969 23515 TREAT CLAVICLE FRACTURE $2, 610.303602352026 T re a t c l a v i c l e d i s l oc a t i o n$ 832.65 969 23520 26 Midlevel Treat clavicle dislocation $707.7596923520 C L TXSC L A V D I S L OC W OM A N I P$ 832.65 360 23525 26 Treat clavicle dislocation $1, 249.509692352526 M i d l e v e lT re a t c l a v i c l e d i s l oc a t i o n$ 1,062.10 969 23525 CL TX SCCLAV DISLOC W MANIP $1, 249.503602353026 T re a t c l a v i c l e d i s l oc a t i o n$ 2,044.35 969 23530 26 Midlevel Treat clavicle dislocation $1, 737.7096923530 OPTXSC L A V D I S L A C U TE / C H R$ 2,044.35 360 23532 26 Midlevel Treat clavicle dislocation $1, 917.109692353226 T re a t c l a v i c l e d i s l oc a t i o n$ 2,255.40 969 23532 OP TX SCLAV DISLOC W FASC GRFT $2, 255.403602354026 T re a t c l a v i c l e d i s l oc a t i o n$ 811.65 969 23540 26 Midlevel Treat clavicle dislocation $689.9096923540 C L TX A C L A V D I S L OC; W OM A N I P$ 811.65 360 23545 26 Treat clavicle dislocation $1, 100.409692354526 M i d l e v e lT re a t c l a v i c l e d i s l oc a t i o n$ 935.35 969 23545 CL TX ACLAV DISLOC; W MANIP $1, 100.403602355026 M i d l e v e lT re a t c l a v i c l e d i s l oc a t i o n$ 1,756.45 969 23550 26 Treat clavicle dislocation $2, 066.4096923550 OPTX A C L A V D I S L OC A C U TE / C H RON I C$ 2,066.40 360 23552 26 Midlevel Treat clavicle dislocation $2, 028.659692355226 T re a t c l a v i c l e d i s l oc a t i o n$ 2,386.65 969 23552 OP TX ACLAV DISLOC W GRAFT $2, 386.653602357026 M i d l e v e lT re a t s h o u l d er b l a d e f x$ 725.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 50 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 23570 26 Treat shoulder blade fx $853.6596923570 C L TXSC A P UL A RFX; W OM A N I P$ 853.65 360 23575 26 Treat shoulder blade fx $1, 340.859692357526 M i d l e v e lT re a t s h o u l d er b l a d e f x$ 1,139.70 969 23575 Treat shoulder blade fx $1, 340.853602358526 M i d l e v e lT re a t sc a p u l a f r a c t u re$ 3,028.25 969 23585 26 Treat scapula fracture $3, 562.6596923585 TRE A TSC A P UL A FR A CT U RE$ 3,562.65 360 23600 26 Treat humerus fracture $1, 088.859692360026 M i d l e v e lT re a t h u m er u s f r a c t u re$ 925.50 969 23600 CL TX PROX HUMERAL FX; WO MANIP $1, 088.853602360526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,308.40 969 23605 26 Treat humerus fracture $1, 539.3096923605 C L TXPROX H U MER A L FX; W M A N I P$ 1,539.30 360 23615 26 Midlevel Treat humerus fracture $2, 731.059692361526 T re a t h u m er u s f r a c t u re$ 3,213.00 969 23615 OPEN TX PROXIMAL HUMERAL FRACTURE $3, 213.003602361626 T re a t h u m er u s f r a c t u re$ 4,543.35 969 23616 26 Midlevel Treat humerus fracture $3, 861.8596923616 OPENPROX H U MER A L FR A CTPROST H$ 4,543.35 360 RPLCMT 23620 26 Treat humerus fracture $919.809692362026 M i d l e v e lT re a t h u m er u s f r a c t u re$ 781.85 969 23620 CL TX GR TUBEROSITY FX; WO MANIP $919.803602362526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,077.25 969 23625 26 Treat humerus fracture $1, 267.3596923625 C L TXGRT U BEROS I T Y FX; W M A N I P$ 1,267.35 360 23630 26 Midlevel Treat humerus fracture $2, 403.509692363026 T re a t h u m er u s f r a c t u re$ 2,827.65 969 23630 OPEN TX GRTER HUMERAL TUBEROSITY $2, 827.65360 FR A CT 2365026 M i d l e v e lT re a t s h o u l d er d i s l oc a t i o n$ 863.05 969 23650 26 Treat shoulder dislocation $1, 015.3596923650 T re a t s h o u l d er d i s l oc a t i o n$ 1,015.35 360 23655 26 Midlevel Treat shoulder dislocation $1, 211.109692365526 T re a t s h o u l d er d i s l oc a t i o n$ 1,424.85 969 23655 Treat shoulder dislocation $1, 424.853602366026 T re a t s h o u l d er d i s l oc a t i o n$ 2,114.70 969 23660 26 Midlevel Treat shoulder dislocation $1, 797.5096923660 OPENTX A C U TES H O UL D ER D I S L OC A T$ 2,114.70 360 23665 26 Treat dislocation/fracture $1, 421.709692366526 M i d l e v e lT re a t d i s l oc a t i o n / f r a c t u re$ 1,208.45 969 23665 CL TX SHLDR DISLOC & FX GT; W MAN $1, 421.703602367026 M i d l e v e lT re a t d i s l oc a t i o n / f r a c t u re$ 2,683.75 969 23670 26 Treat dislocation/fracture $3, 157.3596923670 OPENTXS H L D ER D I S L C W H U MER A L$ 3,157.35 360 TUBEROSITY FX 23675 26 Treat dislocation/fracture $1, 802.859692367526 M i d l e v e lT re a t d i s l oc a t i o n / f r a c t u re$ 1,532.40 969 23675 CL TX SHDR DISLOC W NK FX W MANIP $1, 802.853602368026 T re a t d i s l oc a t i o n / f r a c t u re$ 3,364.20 969 23680 26 Midlevel Treat dislocation/fracture $2, 859.5596923680 OPENTXS H L D ER D I S L C W NEC K FR A CT U RE$ 3,364.20 360 23700 26 Fixation of shoulder $706.659692370026 M i d l e v e lF i x a t i o n o f s h o u l d er$ 600.65 969 23700 MANIP SHLDR JOINT UNDER ANESTH $706.653602380026 M i d l e v e lF u s i o n o f s h o u l d er j o in t$ 3,165.70 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 51 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 23800 26 Fusion of shoulder joint $3, 724.3596923800 A RT H RO D ES I SS H O UL D ER J O I NT;$ 3,724.35 360 23802 26 Midlevel Fusion of shoulder joint $3, 938.609692380226 F u s i o n o f s h o u l d er j o in t$ 4,633.65 969 23802 ARTHRODESIS SHLDR JNT; W AG $4,633.65 360 23900 26 Amputation of arm & girdle$ 4,984.35 969 23900 26 Midlevel Amputation of arm & girdle $4,236.70 969 23900 Amputation of arm & girdle$ 4,984.35 360 23920 26 Midlevel Amputation at shoulder joint $3, 442.359692392026 A m p u t a t i o na t s h o u l d er j o in t$ 4,049.85 969 23920 Amputation at shoulder joint $4, 049.853602392126 A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,545.60 969 23921 26 Midlevel Amputation follow-up surgery $1, 313.7596923921 A MP U T A T I ON 2 FO LL O W - U P$ 1,545.60 360 23929 Shoulder surgery procedure $429.803602393026 Dr aina g eo f a r m l es i o n$ 784.35 969 23930 26 Midlevel Drainage of arm lesion $666.7096923930 Dr aina g eo f a r m l es i o n$ 784.35 360 23931 26 Midlevel Drainage of arm bursa $491.759692393126 Dr aina g eo f a r mb u rs a$ 578.55 969 23931 INF BURSA I&D - UA/ELBOW $578.553602393526 M i d l e v e l Dr aina r m / e l b o w b o n e l es i o n$ 1,554.75 969 23935 26 Drain arm/elbow bone lesion $1, 829.1096923935 D EEP I NC W OBC - E L BO W$ 1,829.10 360 24000 26 Midlevel Exploratory elbow surgery $1, 468.159692400026 E x pl or a t orye l b o w s u r g ery$ 1,727.25 969 24000 EXPL INF/REM FB - ELBOW $1, 727.253602400626 M i d l e v e lR e l e a see l b o w j o in t$ 2,198.25 969 24006 26 Release elbow joint $2, 586.1596924006 C A PS UL A RRE L E A SE - E L BO W$ 2,586.15 360 24065 26 Biopsy arm/elbow soft tissue $615.309692406526 M i d l e v e lB i o p sy a r m / e l b o w so f tt i ss u e$ 523.00 969 24065 ST BX U ARM/ELB; SUPERF $615.303602406626 M i d l e v e lB i o p sy a r m / e l b o w so f tt i ss u e$ 1,262.00 969 24066 26 Biopsy arm/elbow soft tissue $1, 484.7096924066 D EEPSTBX - U A ORE L BO W$ 1,484.70 360 24071 EXC ARM/ELBOW LES SC 3 CM/> $1, 485.7536024073 EX A RM / E L BO W T U M D EEP 5 CM / >$ 2,532.60 360 24075 26 Midlevel Remove arm/elbow lesion $1, 014.759692407526 R e m o v e a r m / e l b o wl es i o n$ 1,193.85 969 24075 EXC ARM/ELBOW LES SC < 3 CM $1, 193.853602407626 R e m o v e a r m / e l b o wl es i o n$ 1,957.20 969 24076 26 Midlevel Remove arm/elbow lesion $1, 663.6096924076 EX A RM / E L BO W T U M D EEP < 5 CM$ 1,957.20 360 24077 26 Midlevel Remove tumor of arm/elbow $3, 177.309692407726 R e m o v e t u m oro f a r m / e l b o w$ 3,738.00 969 24077 RESECT ARM/ELBOW TUM < 5 CM $3, 738.0036024079 RESECT A RM / E L BO W T U M 5 CM / >$ 4,863.60 360 24100 26 Biopsy elbow joint lining $1, 500.459692410026 M i d l e v e lB i o p sye l b o w j o in tl inin g$ 1,275.40 969 24100 SYNOVIAL BX OF ELBOW $1, 500.453602410126 M i d l e v e lE x pl ore / t re a t e l b o w j o in t$ 1,536.90 969 24101 26 Explore/treat elbow joint $1, 808.1096924101 E L BO W J O I NTEXP L OR A T I ON$ 1,808.10 360 24102 26 Midlevel Remove elbow joint lining $1, 896.559692410226 R e m o v ee l b o w j o in tl inin g$ 2,231.25 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 52 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24102 SYNOVECTOMY OF ELBOW $2, 231.253602410526 M i d l e v e lR e m o v a l o f e l b o w b u rs a$ 1,069.20 969 24105 26 Removal of elbow bursa $1, 257.9096924105 EXC I SEO L ECR A NONB U RS A$ 1,257.90 360 24110 26 Midlevel Remove humerus lesion $1, 803.759692411026 R e m o v e h u m er u s l es i o n$ 2,122.05 969 24110 EXCISE CYST/TUMOR - HUMERUS $2, 122.053602411526 M i d l e v e lR e m o v e / g r a f t b o n e l es i o n$ 2,264.25 969 24115 26 Remove/graft bone lesion $2, 663.8596924115 EXC H U MER U SC Y ST / T U MOR W A U TOGRFT$ 2,663.85 360 24116 26 Midlevel Remove/graft bone lesion $2, 655.209692411626 R e m o v e / g r a f t b o n e l es i o n$ 3,123.75 969 24116 EXC HUMERUS CYST/TUMOR W ALLOGRFT $3, 123.753602412026 R e m o v ee l b o wl es i o n$ 1,912.05 969 24120 26 Midlevel Remove elbow lesion $1, 625.2596924120 EXCC Y ST / T U MOR - R A D I U S$ 1,912.05 360 24125 26 Midlevel Remove/graft bone lesion $1, 899.259692412526 R e m o v e / g r a f t b o n e l es i o n$ 2,234.40 969 24125 EXC CYST/TUMOR RADIUS HD W AUTOGRFT $2, 234.403602412626 R e m o v e / g r a f t b o n e l es i o n$ 2,344.65 969 24126 26 Midlevel Remove/graft bone lesion $1, 992.9596924126 EXCC Y ST / T U MORR A D I U S HD W A LL OGRFT$ 2,344.65 360 24130 26 Removal of head of radius $1, 839.609692413026 M i d l e v e lR e m o v a l o f h e a d o f r a d i u s$ 1,563.65 969 24130 EXCISION RADIAL HEAD $1, 839.603602413426 R e m o v a l o f a r mb o n e l es i o n$ 2,711.10 969 24134 26 Midlevel Removal of arm bone lesion $2, 304.4596924134 SEQ U ESTRECTS H A FT / D I ST A L H U MER U S$ 2,711.10 360 24136 26 Remove radius bone lesion $2, 250.159692413626 M i d l e v e lR e m o v er a d i u s b o n e l es i o n$ 1,912.65 969 24136 SEQUESTRECT RADIAL HEAD OR NECK $2, 250.153602413826 R e m o v ee l b o w b o n e l es i o n$ 2,433.90 969 24138 26 Midlevel Remove elbow bone lesion $2, 068.8096924138 SEQ U ESTRECTO L ECR A NONPROCESS$ 2,433.90 360 24140 26 Partial removal of arm bone $2, 564.109692414026 M i d l e v e lP a r t ia l re m o v a l o f a r mb o n e$ 2,179.50 969 24140 PARTIAL EXCISION - HUMERUS BONE $2, 564.103602414526 P a r t ia l re m o v a l o f r a d i u s$ 2,154.60 969 24145 26 Midlevel Partial removal of radius $1, 831.4096924145 P A RT I A L EXCBONE - R A D I A L HD / N K$ 2,154.60 360 24147 26 Midlevel Partial removal of elbow $1, 924.259692414726 P a r t ia l re m o v a l o f e l b o w$ 2,263.80 969 24147 PART EXC OLECRANON PROCESS BONE $2, 263.803602414926 R a d i c a l resec t i o n o f e l b o w$ 4,254.60 969 24149 26 Midlevel Radical resection of elbow $3, 616.4096924149 R A D RESECTE L BO W C A PS / SRBONE W RE L S$ 4,254.60 360 24150 26 Midlevel Extensive humerus surgery $4, 670.459692415026 E x t e n s i v e h u m er u ss u r g ery$ 5,494.65 969 24150 Extensive humerus surgery $5, 494.653602415226 E x t e n s i v er a d i u ss u r g ery$ 4,725.00 969 24152 26 Midlevel Extensive radius surgery $4, 016.2596924152 RESECTR A D I U ST U MOR$ 4,725.00 360 24155 26 Removal of elbow joint $3, 089.109692415526 M i d l e v e lR e m o v a l o f e l b o w j o in t$ 2,625.75 969 24155 REMOVE ELBOW JOINT $3, 089.103602416026 M i d l e v e lR e m o v ee l b o w j o in t im pl an t$ 1,864.45 969 24160 26 Remove elbow joint implant $2,193.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 53 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24160 REMOVE ELBOW JOINT IMPLANT $2, 193.453602416426 M i d l e v e lR e m o v er a d i u s h e a d im pl an t$ 1,528.85 969 24164 26 Remove radius head implant $1, 798.6596924164 REMO V ER A D I U S H E A D I MP L A NT$ 1,798.65 360 24200 26 Removal of arm foreign body $504.009692420026 M i d l e v e lR e m o v a l o f a r m f ore i g nb o d y$ 428.40 969 24200 REM FB UP ARM OR ELBOW; SQ $504.003602420126 R e m o v a l o f a r m f ore i g nb o d y$ 1,324.05 969 24201 26 Midlevel Removal of arm foreign body $1, 125.4596924201 D EEPREMFBFROM U A / E L BO W$ 1,324.05 360 24220 26 Injection for elbow x-ray $244.659692422026 M i d l e v e l I nj ec t i o n f ore l b o w x - r a y$ 207.95 969 24220 ELBOW ARTHROGRAM INJ $244.653602430026 M ani p u l a t ee l b o ww / an es t h$ 1,478.40 969 24300 26 Midlevel Manipulate elbow w/anesth $1, 256.6596924300 M A N I PE L BO WW A NEST H$ 1,478.40 360 24301 26 Muscle/tendon transfer $2, 733.159692430126 M i d l e v e lM u sc l e / t e n d o n t r an s f er$ 2,323.20 969 24301 SGL MSCL TRANSF - UA/ELBOW $2, 733.153602430526 A r m t e n d o n l e n g t h e nin g$ 2,101.05 969 24305 26 Midlevel Arm tendon lengthening $1, 785.9096924305 L ENGT H ENE A TEN D ON - U A / E L BO W$ 2,101.05 360 24310 26 Revision of arm tendon $1, 728.309692431026 M i d l e v e lR e v i s i o n o f a r m t e n d o n$ 1,469.05 969 24310 OP REVISN TENDON - ELB TO SHLDR $1, 728.303602432026 M i d l e v e lR e p ai ro f a r m t e n d o n$ 2,400.85 969 24320 26 Repair of arm tendon $2, 824.5096924320 RPRTEN D ON W MSC L TR A NSF - E L BTO$ 2,824.50 360 SHLDR 24330 26 Midlevel Revision of arm muscles $2, 207.159692433026 R e v i s i o n o f a r mm u sc l es$ 2,596.65 969 24330 ELBOW FLEXOR-PLSTY $2, 596.653602433126 M i d l e v e lR e v i s i o n o f a r mm u sc l es$ 2,272.30 969 24331 26 Revision of arm muscles $2, 673.3096924331 E L BO W F L EXOR - P L ST YW EXT A D V A NCMNT$ 2,673.30 360 24332 26 Midlevel Tenolysis, triceps $1, 879.609692433226 T e n o l ys i s, t r i ce p s$ 2,211.30 969 24332 TENOLYSIS TRICEPS $2, 211.303602434026 M i d l e v e lR e p ai ro f bi ce p s t e n d o n$ 1,893.90 969 24340 26 Repair of biceps tendon $2, 228.1096924340 TENO D ES I SOFB I CEPSTEN D ON A TE L BO W$ 2,228.10 360 24341 26 Midlevel Repair arm tendon/muscle $2, 299.959692434126 R e p ai r a r m t e n d o n / m u sc l e$ 2,705.85 969 24341 REPAIR UA/ELBOW TENDON/MUSCLE $2, 705.853602434226 M i d l e v e lR e p ai ro f r u pt u re d t e n d o n$ 2,403.50 969 24342 26 Repair of ruptured tendon $2, 827.6596924342 RE I NSERTR U PTR D B I C / TR I CTEN D ON$ 2,827.65 360 24343 26 Midlevel Repr elbow lat ligmnt w/tiss $2, 173.259692434326 R e p re l b o wl a tl i g mn tw / t i ss$ 2,556.75 969 24343 REPR ELBOW LAT LIGMNT W/TISS $2, 556.753602434426 M i d l e v e lR eco n s t r u c t e l b o wl a tl i g mn t$ 3,399.55 969 24344 26 Reconstruct elbow lat ligmnt $3, 999.4596924344 RECONSTRE L BO WW TEN D GRFT$ 3,999.45 360 24345 26 Repr elbw med ligmnt w/tissu $2, 541.009692434526 M i d l e v e lR e p re l b w m e d l i g mn tw / t i ss u$ 2,159.85 969 24345 REPR ELBW MED LIGMNT W LCL TISS $2, 541.003602434626 M i d l e v e lR eco n s t r u c t e l b o w m e d l i g mn t$ 3,384.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 54 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24346 26 Reconstruct elbow med ligmnt $3, 981.6096924346 RECONSTRE L BO W M L W GRFT$ 3,981.60 360 24357 REPAIR ELBOW PERC $1, 607.5536024358 REP A I RE L BO WW / D EBOPEN$ 1,896.30 360 24359 REPAIR ELBOW DEB/ATTCH OPEN $2, 387.703602436026 R eco n s t r u c t e l b o w j o in t$ 3,260.25 969 24360 26 Midlevel Reconstruct elbow joint $2, 771.2096924360 E L BO W A RT H ROP L ST YW MEMBR A NE$ 3,260.25 360 24361 26 Midlevel Reconstruct elbow joint $3, 105.909692436126 R eco n s t r u c t e l b o w j o in t$ 3,654.00 969 24361 ELBOW ARTHROPLSTY W D HUM PROSTH $3, 654.00360 REP L 2436226 R eco n s t r u c t e l b o w j o in t$ 3,848.25 969 24362 26 Midlevel Reconstruct elbow joint $3, 271.0096924362 E L BO W A RT H ROP L ST YW I MP L A N D$ 3,848.25 360 RECONSTR 24363 26 Midlevel Replace elbow joint $4, 629.409692436326 R e pl a cee l b o w j o in t$ 5,446.35 969 24363 ELBOW ARTHROPLSTY W PROSTH $5, 446.35360 REP L A CEMNT 2436526 R eco n s t r u c t h e a d o f r a d i u s$ 2,314.20 969 24365 26 Midlevel Reconstruct head of radius $1, 967.0596924365 R A D I A L H E A D A RT H ROP L A ST Y$ 2,314.20 360 24366 26 Reconstruct head of radius $2, 473.809692436626 M i d l e v e lR eco n s t r u c t h e a d o f r a d i u s$ 2,102.75 969 24366 RADIAL HD ARTHROPLSTY W IMPLANT $2, 473.8036024370 RE V I SERECONSTE L BO W J O I NT$ 5,042.50 360 24371 REVISE RECONST ELBOW JOINT $5, 800.453602440026 M i d l e v e lR e v i s i o n o f h u m er u s$ 2,535.60 969 24400 26 Revision of humerus $2, 983.0596924400 H U MER U SOSTEOTOM Y$ 2,983.05 360 24410 26 Revision of humerus $3, 467.109692441026 M i d l e v e lR e v i s i o n o f h u m er u s$ 2,947.05 969 24410 MULTI HUM SHFT OSTEOTMY W REALIGNM $3, 467.103602442026 M i d l e v e lR e v i s i o n o f h u m er u s$ 3,054.15 969 24420 26 Revision of humerus $3, 593.1096924420 S H ORTENOR L ENGT H EN H U MER U S$ 3,593.10 360 24430 26 Midlevel Repair of humerus $3, 268.359692443026 R e p ai ro f h u m er u s$ 3,845.10 969 24430 REPAIR HUMERUS MALUNION WO GRAFT $3, 845.103602443526 M i d l e v e lR e p ai r h u m er u s w i t h g r a f t$ 3,327.25 969 24435 26 Repair humerus with graft $3, 914.4096924435 REP A I R H U MER U SM A LU N I ON W$ 3,914.40 360 AUTOGRAFT 24470 26 Midlevel Revision of elbow joint $2, 034.909692447026 R e v i s i o n o f e l b o w j o in t$ 2,394.00 969 24470 HEMIPIPHYSEAL ARREST DISTAL HUMERUS $2, 394.003602449526 M i d l e v e l Deco m p ress i o n o ff ore a r m$ 2,032.20 969 24495 26 Decompression of forearm $2, 390.8596924495 FORE A RM D ECOMPRESSNF A XSC I OTOM Y$ 2,390.85 360 24498 26 Midlevel Reinforce humerus $2, 676.609692449826 R e in f orce h u m er u s$ 3,148.95 969 24498 NAIL PIN OR WIRE HUMERUS $3, 148.953602450026 M i d l e v e lT re a t h u m er u s f r a c t u re$ 988.90 969 24500 26 Treat humerus fracture $1, 163.4096924500 C L TX H U MER U SFX W OM A N I P$ 1,163.40 360 24505 26 Midlevel Treat humerus fracture $1,390.50 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 55 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24505 26 Treat humerus fracture $1, 635.9096924505 C L TX H U MER U SFX W M A N I P$ 1,635.90 360 24515 26 Treat humerus fracture $3, 182.559692451526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 2,705.15 969 24515 OP TX HUMERUS SHFT FX W PLATE/SCREWS $3, 182.553602451626 M i d l e v e lT re a t h u m er u s f r a c t u re$ 2,657.85 969 24516 26 Treat humerus fracture $3, 126.9096924516 TX H U MER U SS H FX W I M L A NT$ 3,126.90 360 24530 26 Treat humerus fracture $1, 234.809692453026 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,049.60 969 24530 CL TX SC/TC HUMERUS FX WO MANIPL $1, 234.803602453526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,745.75 969 24535 26 Treat humerus fracture $2, 053.8096924535 C L TXSC / TX H U MER U SS H FTFX W M A N I P$ 2,053.80 360 24538 26 Treat humerus fracture $2, 695.359692453826 M i d l e v e lT re a t h u m er u s f r a c t u re$ 2,291.05 969 24538 PERC FIX SC/TC HUMERUS FX $2, 695.353602454526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 2,864.95 969 24545 26 Treat humerus fracture $3, 370.5096924545 TRE A T H U MER U SFR A CT U RE W OEXTN$ 3,370.50 360 24546 26 Treat humerus fracture $3, 788.409692454626 M i d l e v e lT re a t h u m er u s f r a c t u re$ 3,220.15 969 24546 TREAT HUMERUS FRACTURE W EXTN $3, 788.403602456026 T re a t h u m er u s f r a c t u re$ 1,027.95 969 24560 26 Midlevel Treat humerus fracture $873.7596924560 C L TXEC H U MER U SFX W OM A N I P$ 1,027.95 360 24565 26 Treat humerus fracture $1, 746.159692456526 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,484.25 969 24565 CL TX EC HUMERUS FX W MANIP $1, 746.153602456626 M i d l e v e lT re a t h u m er u s f r a c t u re$ 2,202.70 969 24566 26 Treat humerus fracture $2, 591.4096924566 PERCF I XEP H U MER U SFX W M A N I P$ 2,591.40 360 24575 26 Midlevel Treat humerus fracture $2, 263.409692457526 T re a t h u m er u s f r a c t u re$ 2,662.80 969 24575 TREAT HUMERUS EPICONDYLAR FRACTURE $2, 662.803602457626 T re a t h u m er u s f r a c t u re$ 1,090.95 969 24576 26 Midlevel Treat humerus fracture $927.3096924576 C L TXC H U MER U SFX W OM A N I P$ 1,090.95 360 24577 26 Treat humerus fracture $1, 797.609692457726 M i d l e v e lT re a t h u m er u s f r a c t u re$ 1,527.95 969 24577 CL TX C HUMERUS FX W MANIP $1, 797.603602457926 T re a t h u m er u s f r a c t u re$ 3,031.35 969 24579 26 Midlevel Treat humerus fracture $2, 576.6596924579 TRE A T H U MER U SCON D Y L A RFR A CT U RE$ 3,031.35 360 24582 26 Midlevel Treat humerus fracture $2, 474.909692458226 T re a t h u m er u s f r a c t u re$ 2,911.65 969 24582 PERC SK FIX HUMERAL C FX; W MANIP $2, 911.653602458626 M i d l e v e lT re a t e l b o w f r a c t u re$ 3,360.25 969 24586 26 Treat elbow fracture $3, 953.2596924586 OPTXE L BO W P A FX / D I S L OC$ 3,953.25 360 24587 26 Midlevel Treat elbow fracture $3, 344.209692458726 T re a t e l b o w f r a c t u re$ 3,934.35 969 24587 OP TX PA ELBOW FX/DISLOC W IMPL $3, 934.353602460026 M i d l e v e lT re a t e l b o w d i s l oc a t i o n$ 1,016.55 969 24600 26 Treat elbow dislocation $1, 195.9596924600 RXC L E L BO W D I S L OC W O A NEST H$ 1,195.95 360 24605 26 Midlevel Treat elbow dislocation $1,436.90 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 56 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24605 26 Treat elbow dislocation $1, 690.5096924605 T re a t e l b o w d i s l oc a t i o n$ 1,690.50 360 24615 26 Treat elbow dislocation $2, 578.809692461526 M i d l e v e lT re a t e l b o w d i s l oc a t i o n$ 2,192.00 969 24615 OP TX ACUTE/CHRONIC ELBOW DISLOC $2, 578.803602462026 T re a t e l b o w f r a c t u re$ 1,995.00 969 24620 26 Midlevel Treat elbow fracture $1, 695.7596924620 C L TXMONTEGG I A E L BFX W M A N I P$ 1,995.00 360 24635 26 Treat elbow fracture $2, 497.959692463526 M i d l e v e lT re a t e l b o w f r a c t u re$ 2,123.25 969 24635 TREAT ELBOW FRACTURE $2, 497.953602464026 M i d l e v e lT re a t e l b o w d i s l oc a t i o n$ 283.80 969 24640 26 Treat elbow dislocation $333.9096924640 T re a t e l b o w d i s l oc a t i o n$ 333.90 360 24650 26 Midlevel Treat radius fracture $729.159692465026 T re a t r a d i u s f r a c t u re$ 857.85 969 24650 CL TX RADIAL HD/NECK FX; WO MANIP $857.853602465526 M i d l e v e lT re a t r a d i u s f r a c t u re$ 1,228.10 969 24655 26 Treat radius fracture $1, 444.8096924655 C L TXR A D I A L HD / NEC K FX; W M A N I P$ 1,444.80 360 24665 26 Midlevel Treat radius fracture $2, 005.459692466526 T re a t r a d i u s f r a c t u re$ 2,359.35 969 24665 OPEN TX RADIAL HEAD/NECK FRACTURE $2, 359.353602466626 T re a t r a d i u s f r a c t u re$ 2,657.55 969 24666 26 Midlevel Treat radius fracture $2, 258.9096924666 OPENTXR A D I A L H E A D / NEC K FR A CT U RE$ 2,657.55 360 PROSTH 24670 26 Treat ulnar fracture $940.809692467026 M i d l e v e lT re a t u l na r f r a c t u re$ 799.70 969 24670 CLOSED TX ULNAR FRACTURE PROXIMAL $940.80360 EN D W OMNP 2467526 T re a t u l na r f r a c t u re$ 1,506.75 969 24675 26 Midlevel Treat ulnar fracture $1, 280.7596924675 C L OSE D TX UL N A RFR A CT U REPROX I M A L$ 1,506.75 360 END W MNP 24685 26 Treat ulnar fracture $2, 369.859692468526 M i d l e v e lT re a t u l na r f r a c t u re$ 2,014.35 969 24685 OPEN TX ULNAR FRACTURE PROXIMAL END $2, 369.853602480026 M i d l e v e lF u s i o n o f e l b o w j o in t$ 2,532.90 969 24800 26 Fusion of elbow joint $2, 979.9096924800 E L BO W J O I NT A RT H RO D ES I S$ 2,979.90 360 24802 26 Fusion/graft of elbow joint $3, 629.859692480226 M i d l e v e lF u s i o n / g r a f t o f e l b o w j o in t$ 3,085.35 969 24802 ELBOW JNT ARTHRODESIS W AUTOGFT $3, 629.853602490026 M i d l e v e l A m p u t a t i o n o f u pp er a r m$ 2,241.05 969 24900 26 Amputation of upper arm $2, 636.5596924900 A m p u t a t i o n o f u pp er a r m$ 2,636.55 360 24920 26 Midlevel Amputation of upper arm $2, 087.559692492026 A m p u t a t i o n o f u pp er a r m$ 2,455.95 969 24920 Amputation of upper arm $2, 455.953602492526 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,735.00 969 24925 26 Amputation follow-up surgery $2, 041.2096924925 A MP U T A T I ON 2^{'} C L OS U RE / SC A RRE V I SE$ 2,041.20 360 24930 26 Midlevel Amputation follow-up surgery $2, 370.509692493026 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,788.80 969 24930 Amputation follow-up surgery $2,788.80 360 24931 26 Amputate upper arm & implant$ 2,781.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 57 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 24931 26 Midlevel Amputate upper arm & implant $2,364.25 969 24931 Amputate upper arm & implant$ 2,781.45 360 24935 26 Midlevel Revision of amputation $3, 124.659692493526 R e v i s i o n o f am p u t a t i o n$ 3,676.05 969 24935 Revision of amputation $3, 676.0536024940 R e v i s i o n o f u pp er a r m$ 2,740.50 360 24999 Upper arm/elbow surgery $429.80360 [R o w s 3001 - 4000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 2500026 I n c i s i o n o f t e n d o n s h e a t h$ 1,234.80 969 25000 26 Midlevel Incision of tendon sheath $1, 049.6096925000 I NC I S I ONOFTEN D ONS H E A T H$ 1,234.80 360 25001 26 Midlevel Incise flexor carpi radialis $1, 051.359692500126 I n c i se f l e x orc a r p i r a d ia l i s$ 1,236.90 969 25001 INC FTS WRIST $1, 236.903602502026 M i d l e v e l Deco m p ress f ore a r m 1 s p a ce$ 1,788.55 969 25020 26 Decompress forearm 1 space $2, 104.2096925020 D ECOMPRESSFR A RM / W R I ST; 1 COMP A RTM$ 2,104.20 360 25023 26 Midlevel Decompress forearm 1 space $3, 421.859692502326 Deco m p ress f ore a r m 1 s p a ce$ 4,025.70 969 25023 DECOMPR FARM/WRIST W DEBRIDEM $4, 025.703602502426 M i d l e v e l Deco m p ress f ore a r m 2 s p a ces$ 2,416.90 969 25024 26 Decompress forearm 2 spaces $2,843.40 969 25024 DECOMPR FARM/WRIST FLEX & EXT$ 2,843.40 360 25025 26 Midlevel Decompress forearm 2 spaces $3, 759.209692502526 Deco m p ress f ore a r m 2 s p a ces$ 4,422.60 969 25025 DECOMPR FA/WRIST FLEX & EXT W DEBR $4, 422.603602502826 M i d l e v e l Dr aina g eo ff ore a r m l es i o n$ 1,610.95 969 25028 26 Drainage of forearm lesion $1,895.25 969 25028 DEEP I&D ABSC - FARM/WRIST$ 1,895.25 360 25031 26 Drainage of forearm bursa $1, 332.459692503126 M i d l e v e l Dr aina g eo ff ore a r mb u rs a$ 1,132.60 969 25031 INF BURSA I&D - FARM/WRIST $1, 332.453602503526 M i d l e v e lT re a t f ore a r mb o n e l es i o n$ 1,851.05 969 25035 26 Treat forearm bone lesion $2, 177.7096925035 D EEP I NCTOBONEOFFORE A RM / W R I ST$ 2,177.70 360 25040 26 Midlevel Explore/treat wrist joint $1, 744.859692504026 E x pl ore / t re a tw r i s t j o in t$ 2,052.75 969 25040 EXPL/TX RADIOCARPAL/MIDCARPAL JNT $2, 052.753602506526 B i o p sy f ore a r m so f tt i ss u es$ 602.70 969 25065 26 Midlevel Biopsy forearm soft tissues $512.3096925065 STBXF A / W R I ST; S U PERF I C I A L$ 602.70 360 25066 26 Biopsy forearm soft tissues $1, 319.859692506626 M i d l e v e lB i o p sy f ore a r m so f tt i ss u es$ 1,121.85 969 25066 DEEP STISS BX FOREARM/WRIST $1, 319.8536025071 EXCFORE A RM L ESSC 3 CM / >$ 1,559.25 360 25073 EXC FOREARM TUM DEEP 3 CM/> $1, 948.803602507526 M i d l e v e lR e m o v a l f ore a r m l es i o n s u b c u$ 995.15 969 25075 26 Removal forearm lesion subcu $1, 170.7596925075 EXCFORE A RM L ESSC < 3 CM$ 1,170.75 360 25076 26 Removal forearm lesion deep $1, 882.659692507626 M i d l e v e lR e m o v a l f ore a r m l es i o n d ee p$ 1,600.25 969 25076 EXC FOREARM TUM DEEP < 3 CM $1,882.65 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 58 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25077 26 Remove tumor, forearm/wrist $3, 209.859692507726 M i d l e v e lR e m o v e t u m or, f ore a r m / w r i s t$ 2,728.35 969 25077 RESECT FOREARM/WRIST TUM<3CM $3, 209.8536025078 RESECTFOR A RM / W R I STT U M >= 3 CM$ 4,293.45 360 25085 26 Midlevel Incision of wrist capsule $1, 401.259692508526 I n c i s i o n o f w r i s t c a p s u l e$ 1,648.50 969 25085 CAPSULOTOMY WRIST $1, 648.503602510026 B i o p syo f w r i s t j o in t$ 1,252.65 969 25100 26 Midlevel Biopsy of wrist joint $1, 064.7596925100 B I OPS Y OF W R I ST J O I NT$ 1,252.65 360 25101 26 Explore/treat wrist joint $1, 464.759692510126 M i d l e v e lE x pl ore / t re a tw r i s t j o in t$ 1,245.05 969 25101 WRIST JOINT EXPLORATION $1, 464.753602510526 R e m o v e w r i s t j o in tl inin g$ 1,757.70 969 25105 26 Midlevel Remove wrist joint lining $1, 494.0596925105 S Y NO V ECTOM YW R I ST J O I NT$ 1,757.70 360 25107 26 Remove wrist joint cartilage $2, 240.709692510726 M i d l e v e lR e m o v e w r i s t j o in t c a r t i l a g e$ 1,904.60 969 25107 REPAIR WRIST JOINT CARTILAGE $2, 240.703602510926 M i d l e v e lE x c i se t e n d o n f ore a r m / w r i s t$ 1,648.45 969 25109 26 Excise tendon forearm/wrist $1, 939.3596925109 EXC I SETEN D ONFORE A RM / W R I ST$ 1,939.35 360 25110 26 Remove wrist tendon lesion $1, 254.759692511026 M i d l e v e lR e m o v e w r i s tt e n d o n l es i o n$ 1,066.55 969 25110 EXC TENDON SHTH LESION - FARM/WRIST $1, 254.753602511126 R e m o v e w r i s tt e n d o n l es i o n$ 1,159.20 969 25111 26 Midlevel Remove wrist tendon lesion $985.3096925111 EXC 1^{'} W R I STG A NG L I ON$ 1,159.20 360 25112 26 Reremove wrist tendon lesion $1, 403.859692511226 M i d l e v e lR ere m o v e w r i s tt e n d o n l es i o n$ 1,193.25 969 25112 EXC RECURRENT WRIST GANGLION $1, 403.853602511526 M i d l e v e lR e m o v e w r i s t / f ore a r m l es i o n$ 2,388.35 969 25115 26 Remove wrist/forearm lesion $2, 809.8096925115 R A D EXC W R I STB U RS A / F A RMTEN D S H T H$ 2,809.80 360 25116 26 Midlevel Remove wrist/forearm lesion $1, 897.459692511626 R e m o v e w r i s t / f ore a r m l es i o n$ 2,232.30 969 25116 RAD EXC WRIST/FARM EXTENSORS $2, 232.303602511826 M i d l e v e lE x c i se w r i s tt e n d o n s h e a t h$ 1,179.90 969 25118 26 Excise wrist tendon sheath $1, 388.1096925118 W R I STS Y NO V ECTOM Y - 1 COMP A RTM$ 1,388.10 360 25119 26 Partial removal of ulna $1, 825.959692511926 M i d l e v e lP a r t ia l re m o v a l o f u l na$ 1,552.05 969 25119 RESECTION OF DISTAL ULNA $1, 825.953602512026 M i d l e v e lR e m o v a l o ff ore a r m l es i o n$ 1,581.50 969 25120 26 Removal of forearm lesion $1, 860.6096925120 EXCBNC Y ST / T U MOR - R A D I U S / UL N A$ 1,860.60 360 25125 26 Remove/graft forearm lesion $2, 247.009692512526 M i d l e v e lR e m o v e / g r a f t f ore a r m l es i o n$ 1,909.95 969 25125 EXC CYT/TMR RADS/ULNA W AUTOGRFT $2, 247.003602512626 M i d l e v e lR e m o v e / g r a f t f ore a r m l es i o n$ 1,880.50 969 25126 26 Remove/graft forearm lesion $2, 212.3596925126 EXCC Y ST / TMR - R A D S / UL N A W A LL OGRFT$ 2,212.35 360 25130 26 Midlevel Removal of wrist lesion $1, 384.259692513026 R e m o v a l o f w r i s tl es i o n$ 1,628.55 969 25130 EXC BN CYST/TUMOR - CARPAL BONES $1,628.55 360 25135 26 Midlevel Remove & graft wrist lesion$ 1,756.45 969 25135 26 Remove & graft wrist lesion $2,066.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 59 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25135 EXC CYST/TMR CARPAL BONES W $2,066.40 360 AUTOGRFT 25136 26 Remove & graft wrist lesion$ 1,787.10 969 25136 26 Midlevel Remove & graft wrist lesion $1, 519.0596925136 EXCC Y ST / TMRC A RP A L BONES W$ 1,787.10 360 ALLOGRFT 25145 26 Remove forearm bone lesion $1, 921.509692514526 M i d l e v e lR e m o v e f ore a r mb o n e l es i o n$ 1,633.30 969 25145 REM BN ABSC/OSTEOMY - FOREARM.WRIST $1, 921.503602515026 P a r t ia l re m o v a l o f u l na$ 2,065.35 969 25150 26 Midlevel Partial removal of ulna $1, 755.5596925150 P A RT I A L EXC I S I ONOF UL N A BONE$ 2,065.35 360 25151 26 Midlevel Partial removal of radius $1, 852.859692515126 P a r t ia l re m o v a l o f r a d i u s$ 2,179.80 969 25151 PARTIAL EXC OF RADIUS BONE $2, 179.803602517026 E x t e n s i v e f ore a r m s u r g ery$ 5,250.00 969 25170 26 Midlevel Extensive forearm surgery $4, 462.5096925170 E x t e n s i v e f ore a r m s u r g ery$ 5,250.00 360 25210 26 Removal of wrist bone $1, 780.809692521026 M i d l e v e lR e m o v a l o f w r i s t b o n e$ 1,513.70 969 25210 REMOVAL OF WRIST BONE; 1 BONE $1, 780.803602521526 R e m o v a l o f w r i s t b o n es$ 2,252.25 969 25215 26 Midlevel Removal of wrist bones $1, 914.4096925215 C A RPECTOM Y; A LL BONESPROXRO W$ 2,252.25 360 25230 26 Partial removal of radius $1, 567.659692523026 M i d l e v e lP a r t ia l re m o v a l o f r a d i u s$ 1,332.50 969 25230 RADIAL STYLOIDECTOMY $1, 567.653602524026 P a r t ia l re m o v a l o f u l na$ 1,566.60 969 25240 26 Midlevel Partial removal of ulna $1, 331.6096925240 EXC I S I ONOF D I ST A LUL N A$ 1,566.60 360 25246 26 Midlevel Injection for wrist x-ray $229.359692524626 I nj ec t i o n f or w r i s t x - r a y$ 269.85 969 25246 WRIST ARTHROGRAPHY INJ $269.853602524826 M i d l e v e lR e m o v e f ore a r m f ore i g nb o d y$ 1,309.30 969 25248 26 Remove forearm foreign body $1, 540.3596925248 D EEPFBREM - FORE A RM / W R I ST$ 1,540.35 360 25250 26 Midlevel Removal of wrist prosthesis $1, 626.159692525026 R e m o v a l o f w r i s tp ros t h es i s$ 1,913.10 969 25250 REMOVE WRIST PROSTHESIS $1, 913.103602525126 M i d l e v e lR e m o v a l o f w r i s tp ros t h es i s$ 2,212.50 969 25251 26 Removal of wrist prosthesis $2, 602.9596925251 COMP L I C A TE D REM W R I STPROST H$ 2,602.95 360 25259 26 Manipulate wrist w/anesthes $1, 488.909692525926 M i d l e v e lM ani p u l a t e w r i s tw / an es t h es$ 1,265.55 969 25259 MANIPULATE WRIST W ANESTH $1, 488.903602526026 M i d l e v e lR e p ai r f ore a r m t e n d o n / m u sc l e$ 1,992.95 969 25260 26 Repair forearm tendon/muscle $2, 344.6596925260 REPTEN D N / MSC L - F A RM . W R I ST$ 2,344.65 360 25263 26 Midlevel Repair forearm tendon/muscle $1, 974.209692526326 R e p ai r f ore a r m t e n d o n / m u sc l e$ 2,322.60 969 25263 REP T/M FLEXOR FA/WRIST; 2’ EA $2, 322.603602526526 R e p ai r f ore a r m t e n d o n / m u sc l e$ 2,764.65 969 25265 26 Midlevel Repair forearm tendon/muscle $2, 349.9596925265 REPT / MF L EXORF A / W; 2^{'} W GR A FT$ 2,764.65 360 25270 26 Repair forearm tendon/muscle $1, 846.959692527026 M i d l e v e lR e p ai r f ore a r m t e n d o n / m u sc l e$ 1,569.90 969 25270 REP T/M EXTENSOR FA/W ; 1’ EA $1,846.95 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 60 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25272 26 Midlevel Repair forearm tendon/muscle $1, 762.709692527226 R e p ai r f ore a r m t e n d o n / m u sc l e$ 2,073.75 969 25272 REP T/M EXTENSOR FA/W; 2’ EA $2, 073.753602527426 R e p ai r f ore a r m t e n d o n / m u sc l e$ 2,497.95 969 25274 26 Midlevel Repair forearm tendon/muscle $2, 123.2596925274 REPTEN D / MSC L F / WW FG$ 2,497.95 360 25275 26 Repair forearm tendon sheath $2, 463.309692527526 M i d l e v e lR e p ai r f ore a r m t e n d o n s h e a t h$ 2,093.80 969 25275 REP TS FA/WR W FGRAFT $2, 463.303602528026 M i d l e v e lR e v i se w r i s t / f ore a r m t e n d o n$ 1,786.80 969 25280 26 Revise wrist/forearm tendon $2, 102.1096925280 L ENGT H / S H F L EX / EXTTEN D ONF / W; E A$ 2,102.10 360 25290 26 Midlevel Incise wrist/forearm tendon $1, 420.859692529026 I n c i se w r i s t / f ore a r m t e n d o n$ 1,671.60 969 25290 OP TENOT FLEX/EXT TENDON FA/W EA $1, 671.603602529526 R e l e a se w r i s t / f ore a r m t e n d o n$ 1,951.95 969 25295 26 Midlevel Release wrist/forearm tendon $1, 659.1596925295 TENO L Y S I SF L / EXTEN D F A / W E A TEN D$ 1,951.95 360 25300 26 Midlevel Fusion of tendons at wrist $2, 158.059692530026 F u s i o n o f t e n d o n s a tw r i s t$ 2,538.90 969 25300 TENODESIS WRIST; FLEXORS OF FINGERS $2, 538.903602530126 M i d l e v e lF u s i o n o f t e n d o n s a tw r i s t$ 1,992.05 969 25301 26 Fusion of tendons at wrist $2, 343.6096925301 W R I STTENO D ES I S - F I NGEREXTENSORS$ 2,343.60 360 25310 26 Midlevel Transplant forearm tendon $1, 955.459692531026 T r an s pl an t f ore a r m t e n d o n$ 2,300.55 969 25310 TRANSPLANT FOREARM TENDON $2, 300.553602531226 M i d l e v e lT r an s pl an t f ore a r m t e n d o n$ 2,268.75 969 25312 26 Transplant forearm tendon $2, 669.1096925312 TEN D TR A NSFF L EX / EXTF / WW GR A FTS$ 2,669.10 360 25315 26 Revise palsy hand tendon(s) $2, 850.759692531526 M i d l e v e lR e v i se p a l sy han d t e n d o n (s)$ 2,423.15 969 25315 FLEXOR ORIGIN SLIDE FA AND/OR WRIST $2, 850.753602531626 R e v i se p a l sy han d t e n d o n (s)$ 3,246.60 969 25316 26 Midlevel Revise palsy hand tendon(s) $2, 759.6096925316 F L EXOROR I GS L I D EF A / W; W TT$ 3,246.60 360 25320 26 Repair/revise wrist joint $3, 587.859692532026 M i d l e v e lR e p ai r / re v i se w r i s t j o in t$ 3,049.65 969 25320 OPEN REPAIR WRIST JOINT $3, 587.853602533226 M i d l e v e lR e v i se w r i s t j o in t$ 2,614.15 969 25332 26 Revise wrist joint $3, 075.4596925332 W R I ST A RT H ROP L A ST Y$ 3,075.45 360 25335 26 Realignment of hand $3, 225.609692533526 M i d l e v e lR e a l i g nm e n t o f han d$ 2,741.75 969 25335 CENTRALIZATION OF WRIST ON ULNA $3, 225.603602533726 R eco n s t r u c t u l na / r a d i o u l na r$ 3,232.95 969 25337 26 Midlevel Reconstruct ulna/radioulnar $2, 748.0096925337 RECONSTR UL N A / R A D I O UL N A R J NT$ 3,232.95 360 25350 26 Revision of radius $2, 504.259692535026 M i d l e v e lR e v i s i o n o f r a d i u s$ 2,128.60 969 25350 OSTEOTOMY RADIUS; DISTAL THIRD $2, 504.253602535526 R e v i s i o n o f r a d i u s$ 2,832.90 969 25355 26 Midlevel Revision of radius $2, 407.9596925355 OSTEOTOM Y R A D I U S; M I D ORPROX 3 R D$ 2,832.90 360 25360 26 Revision of ulna $2, 433.909692536026 M i d l e v e lR e v i s i o n o f u l na$ 2,068.80 969 25360 OSTEOTOMY; ULNA $2,433.90 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 61 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25365 26 Revise radius & ulna $3,366.30 969 25365 26 Midlevel Revise radius & ulna$ 2,861.35 969 25365 OSTEOTOMY; RADIUS AND ULNA $3, 366.303602537026 R e v i ser a d i u sor u l na$ 3,354.75 969 25370 26 Midlevel Revise radius or ulna $2, 851.5596925370 M UL T I OSTEOT W RE A L I G; R A D I U S / UL N A$ 3,354.75 360 25375 26 Midlevel Revise radius & ulna $2,453.50 969 25375 26 Revise radius & ulna$ 2,886.45 969 25375 MULTI OSTEOT W REALIGN; RADIUS & ULNA $2, 886.453602539026 M i d l e v e lS h or t e n r a d i u sor u l na$ 2,423.15 969 25390 26 Shorten radius or ulna $2, 850.7596925390 S H ORTEN I NGOFR A D I U SOR UL N A$ 2,850.75 360 25391 26 Lengthen radius or ulna $3, 668.709692539126 M i d l e v e l L e n g t h e n r a d i u sor u l na$ 3,118.40 969 25391 LENGTHEN RADIUS OR ULNA W AUTOGRFT $3,668.70 360 25392 26 Shorten radius & ulna$ 3,736.95 969 25392 26 Midlevel Shorten radius & ulna $3, 176.4096925392 S H ORTENR A D I U S A N D UL N A$ 3,736.95 360 25393 26 Lengthen radius & ulna $4,163.25 969 25393 26 Midlevel Lengthen radius & ulna$ 3,538.75 969 25393 LENGTHEN RADIUS AND ULNA W $4, 163.25360 A U TOGRFT 2539426 M i d l e v e lR e p ai rc a r p a l b o n e, s h or t e n$ 2,410.65 969 25394 26 Repair carpal bone, shorten $2, 836.0596925394 S H ORTENC A RP A L BONE$ 2,836.05 360 25400 26 Midlevel Repair radius or ulna $2, 535.609692540026 R e p ai rr a d i u sor u l na$ 2,983.05 969 25400 REPAIR NONUNION OF RADIUS OR ULNA $2, 983.053602540526 M i d l e v e lR e p ai r / g r a f t r a d i u sor u l na$ 2,357.10 969 25405 26 Repair/graft radius or ulna $2, 773.0596925405 REP A I RNON U N I ONR A D I U S / UL N A W$ 2,773.05 360 AUTOGRFT 25415 26 Repair radius & ulna $3,576.30 969 25415 26 Midlevel Repair radius & ulna$ 3,039.85 969 25415 REPAIR NONUNION RADIUS AND ULNA $3,576.30 360 25420 26 Midlevel Repair/graft radius & ulna$ 3,659.25 969 25420 26 Repair/graft radius & ulna $4, 305.0096925420 REP A I RNON U N I ONR A D I U S A N D UL N A W$ 4,305.00 360 AUTOGRFT 25425 26 Midlevel Repair/graft radius or ulna $3, 055.059692542526 R e p ai r / g r a f t r a d i u sor u l na$ 3,594.15 969 25425 REPAIR RADIUS OR ULNA W AUTOGRAFT $3,594.15 360 25426 26 Midlevel Repair/graft radius & ulna$ 3,461.10 969 25426 26 Repair/graft radius & ulna $4, 071.9096925426 REP A I RR A D I U S A N D UL N A W A U TOGRFT$ 4,071.90 360 25430 26 Vasc graft into carpal bone $2, 550.459692543026 M i d l e v e l Va sc g r a f t in t oc a r p a l b o n e$ 2,167.90 969 25430 VASC GRAFT INTO CARPAL BONE $2, 550.453602543126 M i d l e v e lR e p ai r n o n u ni o n c a r p a l b o n e$ 2,423.15 969 25431 26 Repair nonunion carpal bone $2, 850.7596925431 REPN U C A RP A L BONEE A C H$ 2,850.75 360 25440 26 Midlevel Repair/graft wrist bone $2, 382.109692544026 R e p ai r / g r a f tw r i s t b o n e$ 2,802.45 969 25440 REPAIR NONUNION CARPAL NAVICULAR $2, 802.45360 BONE 2544126 R eco n s t r u c tw r i s t j o in t$ 3,280.20 969 25441 26 Midlevel Reconstruct wrist joint $2,788.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 62 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25441 PROSTH REPL DISTAL RADIUS $3, 280.203602544226 M i d l e v e lR eco n s t r u c tw r i s t j o in t$ 2,430.30 969 25442 26 Reconstruct wrist joint $2, 859.1596925442 PROST H REP L D I ST A LUL N A$ 2,859.15 360 25443 26 Midlevel Reconstruct wrist joint $2, 406.209692544326 R eco n s t r u c tw r i s t j o in t$ 2,830.80 969 25443 PROSTH REPL SCAPHOID $2, 830.803602544426 M i d l e v e lR eco n s t r u c tw r i s t j o in t$ 2,456.15 969 25444 26 Reconstruct wrist joint $2, 889.6096925444 PROST H REP LLU N A TEBONE$ 2,889.60 360 25445 26 Reconstruct wrist joint $2, 615.559692544526 M i d l e v e lR eco n s t r u c tw r i s t j o in t$ 2,223.20 969 25445 PROSTH REPL TRAPEZIUM BONE $2, 615.553602544626 W r i s t re pl a ce m e n t$ 4,256.70 969 25446 26 Midlevel Wrist replacement $3, 618.2096925446 PROST H REP L - TOT A L W R I ST$ 4,256.70 360 25447 26 Repair wrist joint(s) $2, 997.759692544726 M i d l e v e lR e p ai r w r i s t j o in t (s)$ 2,548.10 969 25447 REPAIR WRIST JOINTS $2, 997.753602544926 R e m o v e w r i s t j o in t im pl an t$ 3,788.40 969 25449 26 Midlevel Remove wrist joint implant $3, 220.1596925449 RE V I SE W R I ST J NT A RT H ROP L I NC L I MP L$ 3,788.40 360 REMOV 25450 26 Midlevel Revision of wrist joint $1, 886.759692545026 R e v i s i o n o f w r i s t j o in t$ 2,219.70 969 25450 EPIPHYSEAL ARREST; D RADIUS/ ULNA $2, 219.703602545526 R e v i s i o n o f w r i s t j o in t$ 2,458.05 969 25455 26 Midlevel Revision of wrist joint $2, 089.3596925455 EP I P H Y SE A L A RREST; D R A D I U S W UL N A$ 2,458.05 360 25490 26 Reinforce radius $2, 463.309692549026 M i d l e v e lR e in f orcer a d i u s$ 2,093.80 969 25490 PROPHYLACTIC TX; RADIUS $2, 463.303602549126 M i d l e v e lR e in f orce u l na$ 2,326.75 969 25491 26 Reinforce ulna $2, 737.3596925491 PROP H Y L A CT I CTX; UL N A$ 2,737.35 360 25492 26 Midlevel Reinforce radius and ulna $2, 828.359692549226 R e in f orcer a d i u s an d u l na$ 3,327.45 969 25492 PROPHYLACTIC TX; RADIUS AND ULNA $3, 327.453602550026 T re a t f r a c t u reo f r a d i u s$ 888.30 969 25500 26 Midlevel Treat fracture of radius $755.0596925500 C L TXOFR A D I A L S H A FTFX; W OM A N I P$ 888.30 360 25505 26 Midlevel Treat fracture of radius $1, 413.709692550526 T re a t f r a c t u reo f r a d i u s$ 1,663.20 969 25505 Treat fracture of radius $1, 663.203602551526 T re a t f r a c t u reo f r a d i u s$ 2,422.35 969 25515 26 Midlevel Treat fracture of radius $2, 059.0096925515 OPENTXR A D I A L S H A FTFR A CT U RE$ 2,422.35 360 25520 26 Midlevel Treat fracture of radius $1, 634.159692552026 T re a t f r a c t u reo f r a d i u s$ 1,922.55 969 25520 GALEAZZI FX/DISLOC $1, 922.553602552526 T re a t f r a c t u reo f r a d i u s$ 2,856.00 969 25525 26 Midlevel Treat fracture of radius $2, 427.6096925525 OPENR D L S H A FTFXC L OSE D R A D / UL N J T$ 2,856.00 360 DISLC 25526 26 Midlevel Treat fracture of radius $2, 966.659692552626 T re a t f r a c t u reo f r a d i u s$ 3,490.20 969 25526 OPEN RDL SHAFT FX OPEN RAD/ULN JT $3,490.20 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 63 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION DISLC 25530 26 Treat fracture of ulna $845.259692553026 M i d l e v e lT re a t f r a c t u reo f u l na$ 718.45 969 25530 CL TX ULNAR SHAFT FX; WO MANIP $845.253602553526 T re a t f r a c t u reo f u l na$ 1,636.95 969 25535 26 Midlevel Treat fracture of ulna $1, 391.4096925535 C L TX UL N A RS H FTFX W M A N I P$ 1,636.95 360 25545 26 Midlevel Treat fracture of ulna $1, 921.559692554526 T re a t f r a c t u reo f u l na$ 2,260.65 969 25545 TREAT FRACTURE OF ULNA $2,260.65 360 25560 26 Midlevel Treat fracture radius & ulna$ 754.15 969 25560 26 Treat fracture radius & ulna $887.25 969 25560 CL TX RADIAL & ULNAR SHFT FX; WO MANIP$ 887.25 360 25565 26 Treat fracture radius & ulna $1,708.35 969 25565 26 Midlevel Treat fracture radius & ulna$ 1,452.10 969 25565 Treat fracture radius & ulna $1,708.35 360 25574 26 Treat fracture radius & ulna$ 2,429.70 969 25574 26 Midlevel Treat fracture radius & ulna $2,065.25 969 25574 TREAT FRACTURE RADIUS & ULNA$ 2,429.70 360 25575 26 Midlevel Treat fracture radius/ulna $2, 770.309692557526 T re a t f r a c t u rer a d i u s / u l na$ 3,259.20 969 25575 OPEN TX RADIAL & ULNAR SHAFT FX FIXJ $3, 259.20360 R A D I U S / UL N A 2560026 T re a t f r a c t u rer a d i u s / u l na$ 1,076.25 969 25600 26 Midlevel Treat fracture radius/ulna $914.8096925600 T re a t f r a c t u rer a d i u s / u l na$ 1,076.25 360 25605 26 Midlevel Treat fracture radius/ulna $1, 607.409692560526 T re a t f r a c t u rer a d i u s / u l na$ 1,891.05 969 25605 CLTX DSTL RDL FX/EPIPHYSL SEP W MNP $1, 891.053602560626 M i d l e v e lT re a t f x d i s t a l r a d ia l$ 2,043.85 969 25606 26 Treat fx distal radial $2, 404.5096925606 TRE A TFX D I ST A L R A D I A L$ 2,404.50 360 25607 26 Treat fx rad extra-articul $2, 654.409692560726 M i d l e v e lT re a t f x r a d e x t r a - a r t i c u l$ 2,256.25 969 25607 TREAT FX RAD EXTRA-ARTICUL $2, 654.403602560826 T re a t f x r a d in t r a - a r t i c u l$ 2,976.75 969 25608 26 Midlevel Treat fx rad intra-articul $2, 530.2596925608 TRE A TFXR A D I NTR A - A RT I C UL; 2 FR A GS$ 2,976.75 360 25609 26 Treat fx radial 3+ frag $3, 788.409692560926 M i d l e v e lT re a t f x r a d ia l 3 + f r a g$ 3,220.15 969 25609 TREAT FX RADIAL 3+ FRAG $3, 788.403602562226 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 842.50 969 25622 26 Treat wrist bone fracture $991.2096925622 C L TXC A RP A L SC A P H O I D FX; W OM A N I P$ 991.20 360 25624 26 Treat wrist bone fracture $1, 547.709692562426 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 1,315.55 969 25624 CL TX CARPL SCAPHOID FX W MANIP $1, 547.703602562826 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 2,218.75 969 25628 26 Treat wrist bone fracture $2, 610.3096925628 OPENTXC A RP A L SC A P H O I D N A V I C UL A R$ 2,610.30 360 FRACT 25630 26 Treat wrist bone fracture $1, 005.909692563026 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 855.00 969 25630 CLTX CARPL BONE FX WO MNP EA BONE $1, 005.903602563526 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 1,250.40 969 25635 26 Treat wrist bone fracture $1, 471.0596925635 C L TXC A RP L BONEFX W MNPE A BONE$ 1,471.05 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 64 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25645 26 Midlevel Treat wrist bone fracture $1, 746.609692564526 T re a tw r i s t b o n e f r a c t u re$ 2,054.85 969 25645 OPEN TX CARPAL BONE FRACT OTH/THN $2, 054.85360 SC A P H O I D E A 2565026 M i d l e v e lT re a tw r i s t b o n e f r a c t u re$ 914.80 969 25650 26 Treat wrist bone fracture $1, 076.2596925650 C L OSE D TXOF UL N A RST Y L O I D FX$ 1,076.25 360 25651 26 Pin ulnar styloid fracture $1, 754.559692565126 M i d l e v e lP in u l na rs t y l o i df r a c t u re$ 1,491.35 969 25651 PIN ULNAR STYLOID FX $1, 754.553602565226 T re a t f r a c t u re u l na rs t y l o i d$ 2,253.30 969 25652 26 Midlevel Treat fracture ulnar styloid $1, 915.3096925652 OPTX UL N A RST Y L FX$ 2,253.30 360 25660 26 Midlevel Treat wrist dislocation $1, 250.409692566026 T re a tw r i s t d i s l oc a t i o n$ 1,471.05 969 25660 CLTX RDCRPL/INTERCARPL DISLC 1+ BONES $1, 471.05360 W MNP 2567026 T re a tw r i s t d i s l oc a t i o n$ 2,190.30 969 25670 26 Midlevel Treat wrist dislocation $1, 861.7596925670 OPENTXR A D I OC A RP A L / I NTERC A RP A L$ 2,190.30 360 DISLC 1+ BONES 25671 26 Midlevel Pin radioulnar dislocation $1, 625.259692567126 P in r a d i o u l na r d i s l oc a t i o n$ 1,912.05 969 25671 PIN RADIOULNAR DISLOC $1, 912.053602567526 T re a tw r i s t d i s l oc a t i o n$ 1,442.70 969 25675 26 Midlevel Treat wrist dislocation $1, 226.3096925675 C L TX D ST L R A D I O UL N A R D I S L OC W M A N I P$ 1,442.70 360 25676 26 Midlevel Treat wrist dislocation $1, 938.509692567626 T re a tw r i s t d i s l oc a t i o n$ 2,280.60 969 25676 OP TX DSTL RADIOULNAR DISLOCATION $2, 280.603602568026 M i d l e v e lT re a tw r i s t f r a c t u re$ 1,451.20 969 25680 26 Treat wrist fracture $1, 707.3096925680 C L TXTR A NS - SP L FX D I S L; W M A N I P$ 1,707.30 360 25685 26 Treat wrist fracture $2, 657.559692568526 M i d l e v e lT re a tw r i s t f r a c t u re$ 2,258.90 969 25685 OP TX TRANS-SCAPHOPERIL FX DISLOCAT; $2, 657.553602569026 M i d l e v e lT re a tw r i s t d i s l oc a t i o n$ 1,464.60 969 25690 26 Treat wrist dislocation $1, 723.0596925690 C L TX LU N A TE D I S L OC W M A N I P$ 1,723.05 360 25695 26 Midlevel Treat wrist dislocation $1, 945.659692569526 T re a tw r i s t d i s l oc a t i o n$ 2,289.00 969 25695 OPEN TX OF LUNATE DISLOCATION $2, 289.003602580026 F u s i o n o f w r i s t j o in t$ 2,663.85 969 25800 26 Midlevel Fusion of wrist joint $2, 264.2596925800 F U S I ONOF W R I ST J O I NT W OGR A FT$ 2,663.85 360 25805 26 Midlevel Fusion/graft of wrist joint $2, 611.459692580526 F u s i o n / g r a f t o f w r i s t j o in t$ 3,072.30 969 25805 FUSION WRIST JNT W SLIDING GRAFT $3, 072.303602581026 M i d l e v e lF u s i o n / g r a f t o f w r i s t j o in t$ 2,683.75 969 25810 26 Fusion/graft of wrist joint $3, 157.3596925810 F U S I ON W R I ST J O I NT W A U TOGR A FT$ 3,157.35 360 25820 26 Fusion of hand bones $2, 234.409692582026 M i d l e v e lF u s i o n o f han d b o n es$ 1,899.25 969 25820 INTERCARPAL FUSION; WO BONE GRAFT $2, 234.403602582526 F u se han d b o n es w i t h g r a f t$ 2,751.00 969 25825 26 Midlevel Fuse hand bones with graft $2, 338.3596925825 I NTERC A RP A L F U S I ON; W A U TOGR A FT$ 2,751.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 65 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 25830 26 Midlevel Fusion, radioulnar jnt/ulna $2, 941.709692583026 F u s i o n, r a d i o u l na r jn t / u l na$ 3,460.80 969 25830 RADIOULNAR JNT FUSION W ULNA $3, 460.80360 RESECT I ON 2590026 A m p u t a t i o n o ff ore a r m$ 2,622.90 969 25900 26 Midlevel Amputation of forearm $2, 229.4596925900 A m p u t a t i o n o ff ore a r m$ 2,622.90 360 25905 26 Amputation of forearm $2, 578.809692590526 M i d l e v e l A m p u t a t i o n o ff ore a r m$ 2,192.00 969 25905 Amputation of forearm $2, 578.803602590726 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,103.15 969 25907 26 Midlevel Amputation follow-up surgery $1, 787.7096925907 FORE A RM A MP U T 2^{'} C L OS U RE$ 2,103.15 360 25909 26 Amputation follow-up surgery $2, 522.109692590926 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,143.80 969 25909 Amputation follow-up surgery $2, 522.103602591526 A m p u t a t i o n o ff ore a r m$ 3,850.35 969 25915 26 Midlevel Amputation of forearm $3, 272.8096925915 A m p u t a t i o n o ff ore a r m$ 3,850.35 360 25920 26 Midlevel Amputate hand at wrist $2, 138.459692592026 A m p u t a t e han d a tw r i s t$ 2,515.80 969 25920 Amputate hand at wrist $2, 515.803602592226 M i d l e v e l A m p u t a t e han d a tw r i s t$ 1,757.35 969 25922 26 Amputate hand at wrist $2, 067.4596925922 W R I ST A MP U T A T I ON W 2^{'} C L OS U RE$ 2,067.45 360 25924 26 Amputation follow-up surgery $2, 281.659692592426 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,939.40 969 25924 Amputation follow-up surgery $2, 281.653602592726 A m p u t a t i o n o f han d$ 2,920.05 969 25927 26 Midlevel Amputation of hand $2, 482.0596925927 A m p u t a t i o n o f han d$ 2,920.05 360 25929 26 Amputation follow-up surgery $2, 176.659692592926 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,850.15 969 25929 TRANSMETACARPL AMPUTATE 2’ CLOSURE $2, 176.653602593126 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,496.90 969 25931 26 Midlevel Amputation follow-up surgery $2, 122.3596925931 TR A NSMC; RE - A MP U T A T I ON$ 2,496.90 360 25999 Forearm or wrist surgery $429.803602601026 Dr aina g eo ff in g er ab scess$ 496.65 969 26010 26 Midlevel Drainage of finger abscess $422.1596926010 D R A I NF I NGER A BSC; S I MP L E$ 496.65 360 26011 26 Drainage of finger abscess $670.959692601126 M i d l e v e l Dr aina g eo ff in g er ab scess$ 570.30 969 26011 DRAIN FINGER ABSC; COMPLICATED $670.953602602026 Dr ainhan d t e n d o n s h e a t h$ 1,569.75 969 26020 26 Midlevel Drain hand tendon sheath $1, 334.3096926020 D RTEN D ONS H E A T H 1 D I G A N D / P A L M$ 1,569.75 360 26025 26 Drainage of palm bursa $1, 525.659692602526 M i d l e v e l Dr aina g eo f p a l mb u rs a$ 1,296.80 969 26025 DRAIN PALMAR BURSA SGL $1, 525.653602603026 Dr aina g eo f p a l mb u rs a (s)$ 1,791.30 969 26030 26 Midlevel Drainage of palm bursa(s) $1, 522.6096926030 D R A I N A GEOFP A L MB U RS A S$ 1,791.30 360 26034 26 Midlevel Treat hand bone lesion $1, 655.609692603426 T re a t han d b o n e l es i o n$ 1,947.75 969 26034 DEEP INCISION OF HAND/FINGER $1, 947.753602603526 M i d l e v e l Deco m p ress f in g ers / han d$ 2,618.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 66 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26035 26 Decompress fingers/hand $3, 080.7096926035 D ECOMPRF I NGERS / H A N D I N J I N J U R Y$ 3,080.70 360 26037 26 Decompress fingers/hand $2, 073.759692603726 M i d l e v e l Deco m p ress f in g ers / han d$ 1,762.70 969 26037 DECOMPR FASCIOTOMY HAND $2, 073.753602604026 R e l e a se p a l m co n t r a c t u re$ 1,123.50 969 26040 26 Midlevel Release palm contracture $955.0096926040 PERCRE L E A SE - D U P U Y TRE N^{'} SCONTR A CTR$ 1,123.50 360 26045 26 Midlevel Release palm contracture $1, 436.909692604526 R e l e a se p a l m co n t r a c t u re$ 1,690.50 969 26045 P OP RELEASE DUPUYTREN’S CONTRACTR $1, 690.503602605526 I n c i se f in g er t e n d o n s h e a t h$ 1,116.15 969 26055 26 Midlevel Incise finger tendon sheath $948.7596926055 TEN D ONS H E A T H I NC I S I ON$ 1,116.15 360 26060 26 Incision of finger tendon $964.959692606026 M i d l e v e l I n c i s i o n o ff in g er t e n d o n$ 820.20 969 26060 PERC INC FINGER TENDON EA DIGIT $964.953602607026 M i d l e v e lE x pl ore / t re a t han d j o in t$ 956.75 969 26070 26 Explore/treat hand joint $1, 125.6096926070 EXP L / REMFBCMC J O I NT$ 1,125.60 360 26075 26 Explore/treat finger joint $1, 174.959692607526 M i d l e v e lE x pl ore / t re a t f in g er j o in t$ 998.70 969 26075 EXPL/REM FB MCP JOINT $1, 174.953602608026 M i d l e v e lE x pl ore / t re a t f in g er j o in t$ 1,195.05 969 26080 26 Explore/treat finger joint $1, 405.9596926080 EXP L / REMFB I P H J O I NTE A$ 1,405.95 360 26100 26 Midlevel Biopsy hand joint lining $1, 018.359692610026 B i o p sy han d j o in tl inin g$ 1,198.05 969 26100 SYNOVIAL BX CMC JOINT $1, 198.053602610526 M i d l e v e lB i o p sy f in g er j o in tl inin g$ 1,031.75 969 26105 26 Biopsy finger joint lining $1, 213.8096926105 S Y NO V I A L BXMCP J O I NT$ 1,213.80 360 26110 26 Biopsy finger joint lining $1, 160.259692611026 M i d l e v e lB i o p sy f in g er j o in tl inin g$ 986.20 969 26110 SYNOVIAL BX IP JOINT $1, 160.2536026111 EXC H A N D L ESSC 1.5 CM / >$ 1,534.05 360 26111 26 EX TUM/VASC MALF SFT TISS HAND/FNGR $1, 316.07960 S U BQl .5 CM / > 26113 EXC H A N D T U M D EEP 1.5 CM / >$ 2,011.80 360 26115 26 Removal hand lesion subcut $1, 227.459692611526 M i d l e v e lR e m o v a l han d l es i o n s u b c u t$ 1,043.35 969 26115 EXC HAND LES SC < 1.5 CM $1, 227.453602611626 M i d l e v e lR e m o v a l han d l es i o n, d ee p$ 1,621.65 969 26116 26 Removal hand lesion, deep $1, 907.8596926116 EXC H A N D T U M D EEP < 1.5 CM$ 1,907.85 360 26117 26 Midlevel Remove tumor, hand/finger $2, 286.609692611726 R e m o v e t u m or, han d / f in g er$ 2,690.10 969 26117 RAD RESECT HAND TUMOR < 3 CM $2, 690.1036026118 R A D RESECT H A N D T U MOR 3 CM / >$ 3,898.65 360 26121 26 Midlevel Release palm contracture $1, 841.259692612126 R e l e a se p a l m co n t r a c t u re$ 2,166.15 969 26121 FASCIECTOMY PALM ONLY $2, 166.153602612326 M i d l e v e lR e l e a se p a l m co n t r a c t u re$ 2,564.15 969 26123 26 Release palm contracture $3, 016.6596926123 P A L M W SG L D I G I TRE L E A SE$ 3,016.65 360 26125 26 Release palm contracture $1, 005.909692612526 M i d l e v e lR e l e a se p a l m co n t r a c t u re$ 855.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 67 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26125 PALM RELEASE W EA ADDTL DIGIT $1, 005.903602613026 R e m o v e w r i s t j o in tl inin g$ 1,667.40 969 26130 26 Midlevel Remove wrist joint lining $1, 417.3096926130 S Y NO V ECTOM Y CMC J O I NT$ 1,667.40 360 26135 26 Revise finger joint, each $1, 997.109692613526 M i d l e v e lR e v i se f in g er j o in t, e a c h$ 1,697.55 969 26135 SYNOVECTOMY MCP JNT ; EA DIGIT $1, 997.103602614026 R e v i se f in g er j o in t, e a c h$ 1,830.15 969 26140 26 Midlevel Revise finger joint, each $1, 555.6596926140 S Y NO V ECTOM Y P I P J NT; E A I P J O I NT$ 1,830.15 360 26145 26 Tendon excision, palm/finger $1, 857.459692614526 M i d l e v e lT e n d o n e x c i s i o n, p a l m / f in g er$ 1,578.85 969 26145 SYNOVECTOMY TENDON SHTH RADICAL $1, 857.453602616026 M i d l e v e lR e m o v e t e n d o n s h e a t h l es i o n$ 1,023.70 969 26160 26 Remove tendon sheath lesion $1, 204.3596926160 EXCTN D NS H T H L ES H N D / F I NG$ 1,204.35 360 26170 26 Midlevel Removal of palm tendon, each $1, 250.409692617026 R e m o v a l o f p a l m t e n d o n, e a c h$ 1,471.05 969 26170 REMOVAL OF PALM TENDON EACH $1, 471.053602618026 M i d l e v e lR e m o v a l o ff in g er t e n d o n$ 1,365.55 969 26180 26 Removal of finger tendon $1, 606.5096926180 REMO V A L OFF I NGERTEN D ON$ 1,606.50 360 26185 26 Midlevel Remove finger bone $1, 709.159692618526 R e m o v e f in g er b o n e$ 2,010.75 969 26185 SESAMOIDECTOMY THUMB OR FINGER $2, 010.753602620026 R e m o v e han d b o n e l es i o n$ 1,634.85 969 26200 26 Midlevel Remove hand bone lesion $1, 389.6096926200 EXCC Y ST / T U MORMCP$ 1,634.85 360 26205 26 Midlevel Remove/graft bone lesion $1, 851.059692620526 R e m o v e / g r a f t b o n e l es i o n$ 2,177.70 969 26205 EXC MCP CYST/TUMOR W AUTOGRFT $2, 177.703602621026 M i d l e v e lR e m o v a l o ff in g er l es i o n$ 1,360.15 969 26210 26 Removal of finger lesion $1, 600.2096926210 EXCC Y ST / T U MORF I NGERP H A L A NX$ 1,600.20 360 26215 26 Midlevel Remove/graft finger lesion $1, 726.109692621526 R e m o v e / g r a f t f in g er l es i o n$ 2,030.70 969 26215 EXC CYST/TUMOR FING PHALANX W $2, 030.70360 A U TOGRFT 2623026 M i d l e v e lP a r t ia l re m o v a l o f han d b o n e$ 1,537.80 969 26230 26 Partial removal of hand bone $1, 809.1596926230 P A RT I A L EXCMCPBONE$ 1,809.15 360 26235 26 Partial removal, finger bone $1, 788.159692623526 M i d l e v e lP a r t ia l re m o v a l, f in g er b o n e$ 1,519.95 969 26235 PARTL EXC MDL PHALANX BONE $1, 788.153602623626 M i d l e v e lP a r t ia l re m o v a l, f in g er b o n e$ 1,357.50 969 26236 26 Partial removal, finger bone $1, 597.0596926236 P A RTEXCBONE; D I ST A L P H A L A NX$ 1,597.05 360 26250 26 Midlevel Extensive hand surgery $3, 175.509692625026 E x t e n s i v e han d s u r g ery$ 3,735.90 969 26250 EXTENSIVE HAND SURGERY $3, 735.903602626026 M i d l e v e lE x t e n s i v e f in g ers u r g ery$ 2,407.95 969 26260 26 Extensive finger surgery $2, 832.9096926260 RESECTPROXF I NGERT U MOR$ 2,832.90 360 26262 26 Partial removal of finger $2, 281.659692626226 M i d l e v e lP a r t ia l re m o v a l o ff in g er$ 1,939.40 969 26262 RESECT DISTAL FINGER TUMOR $2, 281.653602632026 M i d l e v e lR e m o v a l o f im pl an t f ro mhan d$ 1,066.55 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 68 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26320 26 Removal of implant from hand $1, 254.7596926320 REM I MP L A NTFROMF I NGEROR H A N D$ 1,254.75 360 26340 26 Midlevel Manipulate finger w/anesth $1, 019.259692634026 M ani p u l a t e f in g er w / an es t h$ 1,199.10 969 26340 MANIP FING JNT W AN EA $1, 199.1036026341 M A N I P UL A TP A L MCOR D POST I N J$ 270.90 360 26350 26 Midlevel Repair finger/hand tendon $2, 189.309692635026 R e p ai r f in g er / han d t e n d o n$ 2,575.65 969 26350 REP FLXR TENDON NOT ZONE 2 WO GRFT EA $2, 575.653602635226 R e p ai r / g r a f t han d t e n d o n$ 2,934.75 969 26352 26 Midlevel Repair/graft hand tendon $2, 494.5596926352 REPF L XRTEN D ONNOTZONE 2 W GRFTE A$ 2,934.75 360 26356 26 Midlevel Repair finger/hand tendon $3, 359.359692635626 R e p ai r f in g er / han d t e n d o n$ 3,952.20 969 26356 FLEX TENDON REP ZONE 2 EACH $3, 952.203602635726 R e p ai r f in g er / han d t e n d o n$ 3,127.95 969 26357 26 Midlevel Repair finger/hand tendon $2, 658.75969263572 N D R Y TEN D ONREPNOM A N^{'} SE A C H$ 3,127.95 360 26358 26 Midlevel Repair/graft hand tendon $2, 808.709692635826 R e p ai r / g r a f t han d t e n d o n$ 3,304.35 969 26358 REP FLXR TENDN ZONE 2 SECNDRY W GRF $3, 304.35360 E A 2637026 R e p ai r f in g er / han d t e n d o n$ 2,756.25 969 26370 26 Midlevel Repair finger/hand tendon $2, 342.8096926370 1^{'} PROF U N D U STEN D ONREP A I R$ 2,756.25 360 26372 26 Repair/graft hand tendon $3, 189.909692637226 M i d l e v e lR e p ai r / g r a f t han d t e n d o n$ 2,711.40 969 26372 PROFUNDUS TEND REP/ADV; 2’ W FG $3, 189.903602637326 M i d l e v e lR e p ai r f in g er / han d t e n d o n$ 2,596.30 969 26373 26 Repair finger/hand tendon $3, 054.4596926373 PROF U N D U STEN D REP / A D V^{'}; 2^{'} W OFGE A T D$ 3,054.45 360 26390 26 Revise hand/finger tendon $3, 001.959692639026 M i d l e v e lR e v i se han d / f in g er t e n d o n$ 2,551.65 969 26390 EXC TEND H/F W ROD EA $3, 001.953602639226 M i d l e v e lR e p ai r / g r a f t han d t e n d o n$ 3,013.10 969 26392 26 Repair/graft hand tendon $3, 544.8096926392 REMRO D W I NSG H N D / F I NG$ 3,544.80 360 26410 26 Repair hand tendon $2, 044.359692641026 M i d l e v e lR e p ai r han d t e n d o n$ 1,737.70 969 26410 Repair hand tendon $2, 044.353602641226 M i d l e v e lR e p ai r / g r a f t han d t e n d o n$ 2,100.05 969 26412 26 Repair/graft hand tendon $2, 470.6596926412 REPET H A N D; W FGE A TEN D ON$ 2,470.65 360 26415 26 Excision, hand/finger tendon $2, 466.459692641526 M i d l e v e lE x c i s i o n, han d / f in g er t e n d o n$ 2,096.50 969 26415 EXC ET W ROD H/F EA $2, 466.453602641626 M i d l e v e lG r a f t han d or f in g er t e n d o n$ 2,632.00 969 26416 26 Graft hand or finger tendon $3, 096.4596926416 REMRO D W TG H / FE A$ 3,096.45 360 26418 26 Midlevel Repair finger tendon $1, 775.209692641826 R e p ai r f in g er t e n d o n$ 2,088.45 969 26418 EXTENSOR TENDON REPAIR EACH $2, 088.453602642026 M i d l e v e lR e p ai r / g r a f t f in g er t e n d o n$ 2,197.35 969 26420 26 Repair/graft finger tendon $2, 585.1096926420 EXTENSORTEN D ONREP A I R W FGE A C H$ 2,585.10 360 TENDON 26426 26 Repair finger/hand tendon $1,882.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 69 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26426 26 Midlevel Repair finger/hand tendon $1, 600.25969264262" REP A I REXTENSORTEN D ON$ 1,882.65 360 26428 26 Repair/graft finger tendon $2, 719.509692642826 M i d l e v e lR e p ai r / g r a f t f in g er t e n d o n$ 2,311.60 969 26428 EXTENSOR TENDON REPAIR W FG EACH $2, 719.50360 F I NGER 2643226 R e p ai r f in g er t e n d o n$ 1,798.65 969 26432 26 Midlevel Repair finger tendon $1, 528.8596926432 C L TX " M A LL ETF I NGER "$ 1,798.65 360 26433 26 Midlevel Repair finger tendon $1, 634.159692643326 R e p ai r f in g er t e n d o n$ 1,922.55 969 26433 REPAIR “MALLET FINGER”; WO GRAFT $1, 922.553602643426 R e p ai r / g r a f t f in g er t e n d o n$ 2,321.55 969 26434 26 Midlevel Repair/graft finger tendon $1, 973.3096926434 REP A I R " M A LL ETF I NGER " W FREEGR A FT$ 2,321.55 360 26437 26 Realignment of tendons $2, 241.759692643726 M i d l e v e lR e a l i g nm e n t o f t e n d o n s$ 1,905.50 969 26437 EXTENSOR TENDON REALIGNMENT $2, 241.753602644026 M i d l e v e lR e l e a se p a l m / f in g er t e n d o n$ 1,911.75 969 26440 26 Release palm/finger tendon $2, 249.1096926440 RE L E A SEF L EXORTEN D ONP A L M / F I NGER$ 2,249.10 360 26442 26 Release palm & finger tendon $3,483.90 969 26442 26 Midlevel Release palm & finger tendon$ 2,961.30 969 26442 RELEASE FLEXOR TENDON PALM & FINGER $3, 483.903602644526 M i d l e v e lR e l e a se han d / f in g er t e n d o n$ 1,778.75 969 26445 26 Release hand/finger tendon $2, 092.6596926445 RE L E A SEEXTENSORTEN D ON H A N D / F I NGER$ 2,092.65 360 26449 26 Midlevel Release forearm/hand tendon $2, 204.459692644926 R e l e a se f ore a r m / han d t e n d o n$ 2,593.50 969 26449 COMPLEX RELEASE OF EXTENSOR TENDON $2, 593.503602645026 M i d l e v e l I n c i s i o n o f p a l m t e n d o n$ 1,238.80 969 26450 26 Incision of palm tendon $1, 457.4096926450 OP I NCP A L MF L EXOR$ 1,457.40 360 26455 26 Midlevel Incision of finger tendon $1, 237.909692645526 I n c i s i o n o ff in g er t e n d o n$ 1,456.35 969 26455 OP INC FINGER FLEXOR $1, 456.353602646026 M i d l e v e l I n c i se han d / f in g er t e n d o n$ 1,204.00 969 26460 26 Incise hand/finger tendon $1, 416.4596926460 OP I NC H A N D / F I NGEREXTENSOR$ 1,416.45 360 26471 26 Midlevel Fusion of finger tendons $1, 884.959692647126 F u s i o n o ff in g er t e n d o n s$ 2,217.60 969 26471 FUSION FOR PROX IP JNT STABLIZ $2, 217.603602647426 M i d l e v e lF u s i o n o ff in g er t e n d o n s$ 1,467.25 969 26474 26 Fusion of finger tendons $1, 726.2096926474 F U S I ONFOR D I ST L J NTST A B I L I Z$ 1,726.20 360 26476 26 Tendon lengthening $2, 116.809692647626 M i d l e v e lT e n d o n l e n g t h e nin g$ 1,799.30 969 26476 LENGTHEN EXTENSOR TENDON $2, 116.803602647726 T e n d o n s h or t e nin g$ 2,110.50 969 26477 26 Midlevel Tendon shortening $1, 793.9596926477 S H ORTENEXTENSORTEN D ON$ 2,110.50 360 26478 26 Midlevel Lengthening of hand tendon $1, 914.409692647826 L e n g t h e nin g o f han d t e n d o n$ 2,252.25 969 26478 LENGTHEN FLEXOR TENDON $2, 252.253602647926 S h or t e nin g o f han d t e n d o n$ 2,247.00 969 26479 26 Midlevel Shortening of hand tendon $1, 909.9596926479 S H ORTENF L EXORTEN D ON$ 2,247.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 70 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26480 26 Transplant hand tendon $2, 724.759692648026 M i d l e v e lT r an s pl an t han d t e n d o n$ 2,316.05 969 26480 CMC TENDON TRANSFER/TRANSPL $2, 724.753602648326 T r an s pl an t / g r a f t han d t e n d o n$ 3,063.90 969 26483 26 Midlevel Transplant/graft hand tendon $2, 604.3096926483 CMPTEN D ONTR A NF / TR A NSP L W GR A FT$ 3,063.90 360 26485 26 Midlevel Transplant palm tendon $2, 486.509692648526 T r an s pl an tp a l m t e n d o n$ 2,925.30 969 26485 PALM TENDON TRANSFER/TRANSPL $2, 925.303602648926 M i d l e v e lT r an s pl an t / g r a f tp a l m t e n d o n$ 2,820.30 969 26489 26 Transplant/graft palm tendon $3, 318.0096926489 P A L MTEN D ONTR A NSFER / TR A NSP L W$ 3,318.00 360 GRAFT 26490 26 Revise thumb tendon $2, 854.959692649026 M i d l e v e lR e v i se t h u mb t e n d o n$ 2,426.70 969 26490 SUBLIMIS TENDON TRANSFER $2, 854.953602649226 T e n d o n t r an s f er w i t h g r a f t$ 3,165.75 969 26492 26 Midlevel Tendon transfer with graft $2, 690.9096926492 OPPONENSP L; TEN D ONTR A NSFER W GRFT$ 3,165.75 360 26494 26 Midlevel Hand tendon/muscle transfer $2, 439.209692649426 H an d t e n d o n / m u sc l e t r an s f er$ 2,869.65 969 26494 HYPOTHENAR MUSCLE TRANSFER $2, 869.653602649626 R e v i se t h u mb t e n d o n$ 3,093.30 969 26496 26 Midlevel Revise thumb tendon $2, 629.3096926496 OPPONENSP L A ST Y; OT H ERMET H O D S$ 3,093.30 360 26497 26 Midlevel Finger tendon transfer $2, 641.809692649726 F in g er t e n d o n t r an s f er$ 3,108.00 969 26497 RING & SM FINGER TENDON TRANSFER $3, 108.003602649826 F in g er t e n d o n t r an s f er$ 4,112.85 969 26498 26 Midlevel Finger tendon transfer $3, 495.9096926498 F I NGERTEN D ONTR A NSFER; 4 F I NGERS$ 4,112.85 360 26499 26 Revision of finger $2, 980.959692649926 M i d l e v e lR e v i s i o n o ff in g er$ 2,533.80 969 26499 CORRECT CLAW FINGER OTHR METHODS $2, 980.953602650026 H an d t e n d o n reco n s t r u c t i o n$ 2,269.05 969 26500 26 Midlevel Hand tendon reconstruction $1, 928.7096926500 TEN D ONP ULL E Y RECONSTR U CT I ON$ 2,269.05 360 26502 26 Midlevel Hand tendon reconstruction $2, 167.909692650226 H an d t e n d o n reco n s t r u c t i o n$ 2,550.45 969 26502 TENDON PULLEY RECONSTR; W GRAFT $2, 550.453602650826 R e l e a se t h u mb co n t r a c t u re$ 2,244.90 969 26508 26 Midlevel Release thumb contracture $1, 908.1596926508 RE L E A SET H EN A RM U SC L ET H U MB$ 2,244.90 360 CONTRACTR 26510 26 Midlevel Thumb tendon transfer $1, 831.409692651026 T h u mb t e n d o n t r an s f er$ 2,154.60 969 26510 CROSS INTR TRANSFER EA TENDON $2, 154.603602651626 F u s i o n o f kn u c k l e j o in t$ 2,535.75 969 26516 26 Midlevel Fusion of knuckle joint $2, 155.4096926516 C A PS UL O D ES I SMCP J NT; 1 D I G I T$ 2,535.75 360 26517 26 Fusion of knuckle joints $3, 006.159692651726 M i d l e v e lF u s i o n o f kn u c k l e j o in t s$ 2,555.25 969 26517 FUSION OF KNUCKLE JOINTS 2 DIGITS $3, 006.153602651826 M i d l e v e lF u s i o n o f kn u c k l e j o in t s$ 2,553.45 969 26518 26 Fusion of knuckle joints $3, 004.0596926518 F U S I ONOF K N U C K L E J O I NTS 3 - 4 D I G I TS$ 3,004.05 360 26520 26 Midlevel Release knuckle contracture $2,003.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 71 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26520 26 Release knuckle contracture $2, 357.2596926520 RE L E A SEMCP J NTCONTR A CT U REE A$ 2,357.25 360 26525 26 Midlevel Release finger contracture $2, 006.359692652526 R e l e a se f in g erco n t r a c t u re$ 2,360.40 969 26525 RELEASE IP JNT CONTRACTURE - EA $2, 360.403602653026 R e v i se kn u c k l e j o in t$ 1,943.55 969 26530 26 Midlevel Revise knuckle joint $1, 652.0096926530 A RT H ROP L A ST Y MCP J O I NT; E A J O I NT$ 1,943.55 360 26531 26 Revise knuckle with implant $2, 258.559692653126 M i d l e v e lR e v i se kn u c k l e w i t him pl an t$ 1,919.75 969 26531 MCP ARTHROPL W IMPL EACH $2, 258.553602653526 M i d l e v e lR e v i se f in g er j o in t$ 1,265.55 969 26535 26 Revise finger joint $1, 488.9096926535 I P J NT A RT H ROP L A ST Y - E A$ 1,488.90 360 26536 26 Midlevel Revise/implant finger joint $2, 153.609692653626 R e v i se / im pl an t f in g er j o in t$ 2,533.65 969 26536 IP JNT ARTHROPL W IMPL - EACH $2, 533.653602654026 M i d l e v e lR e p ai r han d j o in t$ 2,020.60 969 26540 26 Repair hand joint $2, 377.2096926540 REPMCP / I P J NTCO LL A T L I G A MENT$ 2,377.20 360 26541 26 Repair hand joint with graft $2, 887.509692654126 M i d l e v e lR e p ai r han d j o in tw i t h g r a f t$ 2,454.40 969 26541 RECONSTR MCP JNT COL LIGAM W GRAFT $2, 887.503602654226 M i d l e v e lR e p ai r han d j o in tw i t h g r a f t$ 2,086.65 969 26542 26 Repair hand joint with graft $2, 454.9096926542 RECONSTRMCP J NTCO LLL I G A M W L T I SS$ 2,454.90 360 GRAFT 26545 26 Reconstruct finger joint $2, 508.459692654526 M i d l e v e lR eco n s t r u c t f in g er j o in t$ 2,132.20 969 26545 RECONSTR IP JNT COLL LIGAM - EA $2, 508.453602654626 R e p ai r n o n u ni o nhan d$ 3,577.35 969 26546 26 Midlevel Repair nonunion hand $3, 040.7596926546 REP A I RNON U N I ON H A N D$ 3,577.35 360 26548 26 Reconstruct finger joint $2, 756.259692654826 M i d l e v e lR eco n s t r u c t f in g er j o in t$ 2,342.80 969 26548 REP & RECONSTR FINGER VP IP JNT $2, 756.253602655026 C o n s t r u c tt h u mb re pl a ce m e n t$ 5,796.00 969 26550 26 Midlevel Construct thumb replacement $4, 926.6096926550 CONSTR U CTT H U MBREP L A CEMENT$ 5,796.00 360 26551 26 Midlevel Great toe-hand transfer $9, 157.959692655126 G re a tt oe - han d t r an s f er$ 10,774.05 969 26551 Great toe-hand transfer $10, 774.053602655326 M i d l e v e lS in g l e t r an s f er, t oe - han d$ 8,273.50 969 26553 26 Single transfer, toe-hand $9, 733.5096926553 S in g l e t r an s f er, t oe - han d$ 9,733.50 360 26554 26 Midlevel Double transfer, toe-hand $9, 846.959692655426 Do u b l e t r an s f er, t oe - han d$ 11,584.65 969 26554 Double transfer, toe-hand $11, 584.653602655526 M i d l e v e lP os i t i o na l c han g eo ff in g er$ 4,198.30 969 26555 26 Positional change of finger $4, 939.2096926555 POS I T I ON A L C H A NGEOFOT H ERF I NGER$ 4,939.20 360 26556 26 Toe joint transfer $10, 420.209692655626 M i d l e v e lT oe j o in tt r an s f er$ 8,857.15 969 26556 Toe joint transfer $10, 420.203602656026 M i d l e v e lR e p ai ro f w e b f in g er$ 1,790.35 969 26560 26 Repair of web finger $2, 106.3096926560 REP W EBF I NGER W S K I NF L A PS$ 2,106.30 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 72 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26561 26 Repair of web finger $3, 427.209692656126 M i d l e v e lR e p ai ro f w e b f in g er$ 2,913.10 969 26561 REP WEB FINGER W FLAPS & GRAFTS $3, 427.203602656226 M i d l e v e lR e p ai ro f w e b f in g er$ 3,955.55 969 26562 26 Repair of web finger $4, 653.6096926562 COMP L EXREP A I ROF W EBF I NGER$ 4,653.60 360 26565 26 Correct metacarpal flaw $2, 462.259692656526 M i d l e v e lC orrec t m e t a c a r p a l f l a w$ 2,092.90 969 26565 OSTEOTOMY CORRECT DEFORMITY; MCP $2, 462.253602656726 C orrec t f in g er d e f or mi t y$ 2,453.85 969 26567 26 Midlevel Correct finger deformity $2, 085.7596926567 OSTEOTOM Y CORRECT D EFORM I T Y;$ 2,453.85 360 PHALANX 26568 26 Lengthen metacarpal/finger $3, 234.009692656826 M i d l e v e l L e n g t h e nm e t a c a r p a l / f in g er$ 2,748.90 969 26568 LENGTHEN METACARPAL OR PHALANX $3, 234.003602658026 R e p ai r han dd e f or mi t y$ 5,478.90 969 26580 26 Midlevel Repair hand deformity $4, 657.0596926580 REP A I RC L EFT H A N D$ 5,478.90 360 26587 26 Reconstruct extra finger $3, 362.109692658726 M i d l e v e lR eco n s t r u c t e x t r a f in g er$ 2,857.80 969 26587 RECONS EXTRA FINGER $3, 362.103602659026 M i d l e v e lR e p ai r f in g er d e f or mi t y$ 3,907.35 969 26590 26 Repair finger deformity $4, 596.9096926590 REP A I RM A CRO D A CT Y L I A$ 4,596.90 360 26591 26 Repair muscles of hand $1, 586.559692659126 M i d l e v e lR e p ai r m u sc l eso f han d$ 1,348.55 969 26591 REPAIR INTRINSIC MUSCLES OF HAND $1, 586.553602659326 M i d l e v e lR e l e a se m u sc l eso f han d$ 1,838.55 969 26593 26 Release muscles of hand $2, 163.0096926593 RE L E A SE I NTR I NS I CM U SC L ESOF H A N D$ 2,163.00 360 26596 26 Excision constricting tissue $2, 716.359692659626 M i d l e v e lE x c i s i o n co n s t r i c t in g t i ss u e$ 2,308.90 969 26596 EXC CONSTRICT RING- FINGER W Z-PLASTY $2, 716.353602660026 M i d l e v e lT re a t m e t a c a r p a l f r a c t u re$ 835.40 969 26600 26 Treat metacarpal fracture $982.8096926600 C L TXMCFXSG L; W OM A N I PE A BONE$ 982.80 360 26605 26 Midlevel Treat metacarpal fracture $896.059692660526 T re a t m e t a c a r p a l f r a c t u re$ 1,054.20 969 26605 Treat metacarpal fracture $1, 054.203602660726 T re a t m e t a c a r p a l f r a c t u re$ 1,645.35 969 26607 26 Midlevel Treat metacarpal fracture $1, 398.5596926607 C L TXMCFX W M + FE A$ 1,645.35 360 26608 26 Treat metacarpal fracture $1, 728.309692660826 M i d l e v e lT re a t m e t a c a r p a l f r a c t u re$ 1,469.05 969 26608 PERC SK FIXATION MC FX; EA BONE $1, 728.303602661526 M i d l e v e lT re a t m e t a c a r p a l f r a c t u re$ 1,759.10 969 26615 26 Treat metacarpal fracture $2, 069.5596926615 TRE A TMET A C A RP A L FR A CT U RE$ 2,069.55 360 26641 26 Treat thumb dislocation $1, 193.859692664126 M i d l e v e lT re a tt h u mb d i s l oc a t i o n$ 1,014.75 969 26641 CL TX CMC DISLOC THUMB W MANIP $1, 193.853602664526 T re a tt h u mb f r a c t u re$ 1,396.50 969 26645 26 Midlevel Treat thumb fracture $1, 187.0596926645 C L TXCMCFX D I S L OCT H U MB W M A N I P$ 1,396.50 360 26650 26 Midlevel Treat thumb fracture $1, 471.759692665026 T re a tt h u mb f r a c t u re$ 1,731.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 73 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26650 PRQ SKEL FIXATION CARP/MTCRPL FX DISLC $1, 731.45360 T H U MB 2666526 M i d l e v e lT re a tt h u mb f r a c t u re$ 1,926.00 969 26665 26 Treat thumb fracture $2, 265.9096926665 OPENTXC A RPOMET A C A RP A L FR A CT U RE$ 2,265.90 360 DISLC THUMB 26670 26 Midlevel Treat hand dislocation $919.309692667026 T re a t han dd i s l oc a t i o n$ 1,081.50 969 26670 CL TX CMC DISL W M EA $1, 081.503602667526 T re a t han dd i s l oc a t i o n$ 1,489.95 969 26675 26 Midlevel Treat hand dislocation $1,266.45 969 26675 CL TX CMC DISLOC W MANIP & ANESTH$ 1,489.95 360 26676 26 Midlevel Pin hand dislocation $1, 543.159692667626 P inhan dd i s l oc a t i o n$ 1,815.45 969 26676 PIN CMC DISL EA JNT $1, 815.453602668526 M i d l e v e lT re a t han dd i s l oc a t i o n$ 1,770.70 969 26685 26 Treat hand dislocation $2, 083.2096926685 OPENTXC A RPOMET A C A RP A L D I S L CNOT$ 2,083.20 360 THUMB 26686 26 Treat hand dislocation $2, 252.259692668626 M i d l e v e lT re a t han dd i s l oc a t i o n$ 1,914.40 969 26686 OPTX CARP/MTCRPL DISLC THMB CPLX $2, 252.25360 M L T / D L Y D R D CT 2670026 M i d l e v e lT re a t kn u c k l e d i s l oc a t i o n$ 913.90 969 26700 26 Treat knuckle dislocation $1, 075.2096926700 C L TXMCP D I S L OCSG L W M A N I P$ 1,075.20 360 26705 26 Treat knuckle dislocation $1, 353.459692670526 M i d l e v e lT re a t kn u c k l e d i s l oc a t i o n$ 1,150.45 969 26705 CL TX MCP DISLOC W MANIP & ANESTH $1, 353.453602670626 P inkn u c k l e d i s l oc a t i o n$ 1,592.85 969 26706 26 Midlevel Pin knuckle dislocation $1, 353.9096926706 PERCS K F I XMCP D I S L W M A N I P$ 1,592.85 360 26715 26 Treat knuckle dislocation $2, 069.559692671526 M i d l e v e lT re a t kn u c k l e d i s l oc a t i o n$ 1,759.10 969 26715 TREAT KNUCKLE DISLOCATION $2, 069.553602672026 T re a t f in g er f r a c t u re, e a c h$ 658.35 969 26720 26 Midlevel Treat finger fracture, each $559.6096926720 T re a t f in g er f r a c t u ree a c h$ 658.35 360 26725 26 Treat finger fracture, each $1, 098.309692672526 M i d l e v e lT re a t f in g er f r a c t u re, e a c h$ 933.55 969 26725 CL TX PHALANG SHFT FX; W MANIP $1, 098.303602672726 M i d l e v e lT re a t f in g er f r a c t u re, e a c h$ 1,444.95 969 26727 26 Treat finger fracture, each $1, 699.9596926727 PERCS K F I X U NSTP H A L S H FTFXPR / M I D P H$ 1,699.95 360 26735 26 Midlevel Treat finger fracture, each $1, 828.759692673526 T re a t f in g er f r a c t u re, e a c h$ 2,151.45 969 26735 OPEN TX PHALANG SHAFT FRACT $2, 151.45360 PROX / M I DD L EE A 2674026 T re a t f in g er f r a c t u re, e a c h$ 768.60 969 26740 26 Midlevel Treat finger fracture, each $653.3096926740 C L TX A RTFXMCP / I P J NT; W OM A N$ 768.60 360 26742 26 Treat finger fracture, each $1, 207.509692674226 M i d l e v e lT re a t f in g er f r a c t u re, e a c h$ 1,026.40 969 26742 CL TX ARTFX MCP/IP JNT; W MANIP $1, 207.503602674626 T re a t f in g er f r a c t u re, e a c h$ 2,671.20 969 26746 26 Midlevel Treat finger fracture, each $2, 270.5096926746 OPENTX A RT I C UL A RFR A CTMCP / I P J O I NT$ 2,671.20 360 EA © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 74 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26750 26 Midlevel Treat finger fracture, each $558.709692675026 T re a t f in g er f r a c t u re, e a c h$ 657.30 969 26750 CL TX D PHAL FX FGR/THMB; WO MANIP $657.303602675526 T re a t f in g er f r a c t u re, e a c h$ 985.95 969 26755 26 Midlevel Treat finger fracture, each $838.0596926755 C L TX D P H A L FXFGRR / T H MB; W M A N I P$ 985.95 360 26756 26 Midlevel Pin finger fracture, each $1, 287.009692675626 P in f in g er f r a c t u re, e a c h$ 1,514.10 969 26756 PERC SKTL FIX D PHALANG FX $1, 514.10360 F I NGER / T H U MB 2676526 T re a t f in g er f r a c t u re, e a c h$ 1,797.60 969 26765 26 Midlevel Treat finger fracture, each $1, 527.9596926765 OPENTX D I ST A L P H A L A NGFR A CTE A$ 1,797.60 360 26770 26 Treat finger dislocation $906.159692677026 M i d l e v e lT re a t f in g er d i s l oc a t i o n$ 770.25 969 26770 CL TX IP JNT D W MANIP ; WO ANESTH $906.153602677526 M i d l e v e lT re a t f in g er d i s l oc a t i o n$ 1,059.40 969 26775 26 Treat finger dislocation $1, 246.3596926775 C L TX I P J T D W M A N I P; W A NEST H$ 1,246.35 360 26776 26 Midlevel Pin finger dislocation $1, 361.059692677626 P in f in g er d i s l oc a t i o n$ 1,601.25 969 26776 PERC SK FIX IP JNT DISL SGL; W MANIP $1, 601.253602678526 M i d l e v e lT re a t f in g er d i s l oc a t i o n$ 1,661.85 969 26785 26 Treat finger dislocation $1, 955.1096926785 TRE A TF I NGER D I S L OC A T I ON$ 1,955.10 360 26820 26 Thumb fusion with graft $2, 829.759692682026 M i d l e v e lT h u mb f u s i o n w i t h g r a f t$ 2,405.30 969 26820 FUSE IN OPPOSITION THUMB W AUTOG $2, 829.75360 GR A FT 2684126 M i d l e v e lF u s i o n o f t h u mb$ 2,230.35 969 26841 26 Fusion of thumb $2, 623.9596926841 A RT H RO D CMC J NTT H U MB W / W OF I X$ 2,623.95 360 26842 26 Thumb fusion with graft $2, 845.509692684226 M i d l e v e lT h u mb f u s i o n w i t h g r a f t$ 2,418.70 969 26842 ARTHROD CMC JOINT THUMB W GRAFT $2, 845.503602684326 F u s i o n o f han d j o in t$ 2,650.20 969 26843 26 Midlevel Fusion of hand joint $2, 252.6596926843 CMC J NTF U S I ONE A$ 2,650.20 360 26844 26 Midlevel Fusion/graft of hand joint $2, 536.509692684426 F u s i o n / g r a f t o f han d j o in t$ 2,984.10 969 26844 ARTHROD CMC JNT NOT THUMB W GRAFT $2, 984.103602685026 M i d l e v e lF u s i o n o f kn u c k l e$ 2,122.35 969 26850 26 Fusion of knuckle $2, 496.9096926850 A RT H RO D MCP J O I NT W / W OF I X A T I ON$ 2,496.90 360 26852 26 Fusion of knuckle with graft $2, 863.359692685226 M i d l e v e lF u s i o n o f kn u c k l e w i t h g r a f t$ 2,433.85 969 26852 ARTHROD MCP JOINT W AUTOGRAFT $2, 863.353602686026 M i d l e v e lF u s i o n o ff in g er j o in t$ 1,727.00 969 26860 26 Fusion of finger joint $2, 031.7596926860 A RT H RO D I P J O I NT W / W OF I X A T I ON$ 2,031.75 360 26861 26 Midlevel Fusion of finger jnt, add-on $322.209692686126 F u s i o n o ff in g er jn t, a dd - o n$ 379.05 969 26861 ARTHROD IP JOINT; EA ADDTL IP JNT $379.053602686226 M i d l e v e lF u s i o n / g r a f t o ff in g er j o in t$ 2,228.55 969 26862 26 Fusion/graft of finger joint $2, 621.8596926862 A RT H RO D I P J O I NT W A U TOGR A FT$ 2,621.85 360 26863 26 Fuse/graft added joint $840.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 75 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 26863 26 Midlevel Fuse/graft added joint $714.0096926863 A RT H RO D I P J NT W A - GR A FT; E AA DD T L$ 840.00 360 26910 26 Amputate metacarpal bone $2, 595.609692691026 M i d l e v e l A m p u t a t e m e t a c a r p a l b o n e$ 2,206.25 969 26910 AMPUTATION MC W FING/THUMB $2, 595.603602695126 M i d l e v e l A m p u t a t i o n o ff in g er / t h u mb$ 1,986.70 969 26951 26 Amputation of finger/thumb $2, 337.3096926951 A m p u t a t i o n o ff in g er / t h u mb$ 2,337.30 360 26952 26 Amputation of finger/thumb $2, 338.359692695226 M i d l e v e l A m p u t a t i o n o ff in g er / t h u mb$ 1,987.60 969 26952 AMPUTATE FING/TH SGL; W LOC ADV FLAP $2, 338.3536026989 H an d / f in g ers u r g ery$ 429.80 360 26990 26 Drainage of pelvis lesion $2, 260.659692699026 M i d l e v e l Dr aina g eo f p e l v i s l es i o n$ 1,921.55 969 26990 I&D PELV/HIP JNT ABSC; DEEP $2, 260.653602699126 M i d l e v e l Dr aina g eo f p e l v i s b u rs a$ 1,619.90 969 26991 26 Drainage of pelvis bursa $1,905.75 969 26991 I&D PELV/HIP JNT; INF BURSA$ 1,905.75 360 26992 26 Drainage of bone lesion $3, 476.55969 [R o w s 4001 - 5000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 2699226 M i d l e v e l Dr aina g eo f b o n e l es i o n$ 2,955.05 969 26992 Drainage of bone lesion $3, 476.553602700026 M i d l e v e l I n c i s i o n o f hi pt e n d o n$ 1,345.90 969 27000 26 Incision of hip tendon $1, 583.4096927000 PERC I NC H I P A DD U CTOR$ 1,583.40 360 27001 26 Midlevel Incision of hip tendon $1, 669.009692700126 I n c i s i o n o f hi pt e n d o n$ 1,963.50 969 27001 OPEN INC HIP ADDUCTOR $1, 963.503602700326 I n c i s i o n o f hi pt e n d o n$ 2,148.30 969 27003 26 Midlevel Incision of hip tendon $1, 826.0596927003 TENOT A DD U CTSQOP W NE U RECT$ 2,148.30 360 27005 26 Midlevel Incision of hip tendon $2, 242.859692700526 I n c i s i o n o f hi pt e n d o n$ 2,638.65 969 27005 Incision of hip tendon $2, 638.653602700626 I n c i s i o n o f hi pt e n d o n s$ 2,675.40 969 27006 26 Midlevel Incision of hip tendons $2, 274.1096927006 I n c i s i o n o f hi pt e n d o n s$ 2,675.40 360 27025 26 Midlevel Incision of hip/thigh fascia $2, 837.259692702526 I n c i s i o n o f hi p / t hi g h f a sc ia$ 3,337.95 969 27025 Incision of hip/thigh fascia $3, 337.9536027027 B u tt oc k f a sc i o t o m y$ 3,045.00 360 27030 26 Midlevel Drainage of hip joint $2, 887.259692703026 Dr aina g eo f hi p j o in t$ 3,396.75 969 27030 Drainage of hip joint $3, 396.753602703326 E x pl or a t i o n o f hi p j o in t$ 3,541.65 969 27033 26 Midlevel Exploration of hip joint $3, 010.4096927033 EXP L / REMFBFROM H I P$ 3,541.65 360 27035 26 Denervation of hip joint $3, 740.109692703526 M i d l e v e l De n er v a t i o n o f hi p j o in t$ 3,179.10 969 27035 DEVERV HIP JNT - SCIATIC FEM OBTURA $3, 740.103602703626 E x c i s i o n o f hi p j o in t / m u sc l e$ 3,663.45 969 27036 26 Midlevel Excision of hip joint/muscle $3,113.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 76 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27036 Excision of hip joint/muscle $3, 663.453602704026 M i d l e v e lB i o p syo f so f tt i ss u es$ 618.50 969 27040 26 Biopsy of soft tissues $727.6596927040 STBX; H I P / PE L V I S; S U PERF I C I A L$ 727.65 360 27041 26 Biopsy of soft tissues $2, 463.309692704126 M i d l e v e lB i o p syo f so f tt i ss u es$ 2,093.80 969 27041 ST BX; HIP/PELVIS; DEEP $2, 463.3036027043 EXC H I PPE L V I S L ESSC 3 CM / >$ 1,719.90 360 27045 EXC HIP/PELV TUM DEEP 5 CM/> $2, 739.453602704726 M i d l e v e lR e m o v e hi p / p e l v i s l es i o n$ 1,155.80 969 27047 26 Remove hip/pelvis lesion $1, 359.7596927047 EXC H I P / PE L V I S L ESSC < 3 CM$ 1,359.75 360 27048 26 Midlevel Remove hip/pelvis lesion $1, 860.859692704826 R e m o v e hi p / p e l v i s l es i o n$ 2,189.25 969 27048 EXC HIP/PELV TUM DEEP < 5 CM $2, 189.253602704926 M i d l e v e lR e m o v e t u m or, hi p / p e l v i s$ 4,150.15 969 27049 26 Remove tumor, hip/pelvis $4, 882.5096927049 RESECT H I P / PE L V T U M < 5 CM$ 4,882.50 360 27050 26 Midlevel Biopsy of sacroiliac joint $1, 201.309692705026 B i o p syo f s a cro i l ia c j o in t$ 1,413.30 969 27050 ARTHROTOMY W BIOPSY; SIJ $1, 413.303602705226 B i o p syo f hi p j o in t$ 2,083.20 969 27052 26 Midlevel Biopsy of hip joint $1, 770.7096927052 A RT H ROTOM YW B I OPS Y; H I P J O I NT$ 2,083.20 360 27054 26 Removal of hip joint lining $2, 481.159692705426 M i d l e v e lR e m o v a l o f hi p j o in tl inin g$ 2,109.00 969 27054 Removal of hip joint lining $2, 481.1536027057 B u tt oc k f a sc i o t o m y w / d b r d m t$ 3,418.80 360 27059 RESECT HIP/PELV TUM 5 CM/> $6, 573.003602706026 M i d l e v e lR e m o v a l o f i sc hia l b u rs a$ 1,409.25 969 27060 26 Removal of ischial bursa $1, 657.9596927060 EXC I S I ON; I SC H I A L B U RS A$ 1,657.95 360 27062 26 Midlevel Remove femur lesion/bursa $1, 402.109692706226 R e m o v e f e m u r l es i o n / b u rs a$ 1,649.55 969 27062 EXC TROCHANTERIC BURSA/CALCIFICAT $1, 649.553602706526 M i d l e v e lR e m o v a l o f hi p b o n e l es i o n$ 1,569.00 969 27065 26 Removal of hip bone lesion $1, 845.9096927065 EXCBC / BTR; S U PERF$ 1,845.90 360 27066 26 Removal of hip bone lesion $2, 945.259692706626 M i d l e v e lR e m o v a l o f hi p b o n e l es i o n$ 2,503.45 969 27066 EXC BC/BT; DEEP $2, 945.253602706726 R e m o v e / g r a f t hi p b o n e l es i o n$ 3,752.70 969 27067 26 Midlevel Remove/graft hip bone lesion $3, 189.8096927067 EXCBC / BT; W A U TOGFT$ 3,752.70 360 27070 26 Partial removal of hip bone $3, 095.409692707026 M i d l e v e lP a r t ia l re m o v a l o f hi p b o n e$ 2,631.10 969 27070 Partial removal of hip bone $3, 095.403602707126 P a r t ia l re m o v a l o f hi p b o n e$ 3,324.30 969 27071 26 Midlevel Partial removal of hip bone $2, 825.6596927071 P a r t ia l re m o v a l o f hi p b o n e$ 3,324.30 360 27075 26 Extensive hip surgery $7, 661.859692707526 M i d l e v e lE x t e n s i v e hi p s u r g ery$ 6,512.55 969 27075 Extensive hip surgery $7, 661.853602707626 M i d l e v e lE x t e n s i v e hi p s u r g ery$ 7,651.40 969 27076 26 Extensive hip surgery $9, 001.6596927076 E x t e n s i v e hi p s u r g ery$ 9,001.65 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 77 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27077 26 Midlevel Extensive hip surgery $8, 726.859692707726 E x t e n s i v e hi p s u r g ery$ 10,266.90 969 27077 Extensive hip surgery $10, 266.903602707826 E x t e n s i v e hi p s u r g ery$ 7,250.25 969 27078 26 Midlevel Extensive hip surgery $6, 162.7096927078 E x t e n s i v e hi p s u r g ery$ 7,250.25 360 27080 26 Removal of tail bone $1, 836.459692708026 M i d l e v e lR e m o v a l o f t ai l b o n e$ 1,561.00 969 27080 REMOVAL OF TAIL BONE $1, 836.453602708626 R e m o v e hi p f ore i g nb o d y$ 540.75 969 27086 26 Midlevel Remove hip foreign body $459.6596927086 REMFBPE L V I SOR H I P; SQ$ 540.75 360 27087 26 Remove hip foreign body $2, 294.259692708726 M i d l e v e lR e m o v e hi p f ore i g nb o d y$ 1,950.10 969 27087 REM FB PELVIS OR HIP; DEEP $2, 294.253602709026 R e m o v a l o f hi pp ros t h es i s$ 3,015.60 969 27090 26 Midlevel Removal of hip prosthesis $2, 563.2596927090 R e m o v a l o f hi pp ros t h es i s$ 3,015.60 360 27091 26 Removal of hip prosthesis $5, 821.209692709126 M i d l e v e lR e m o v a l o f hi pp ros t h es i s$ 4,948.00 969 27091 Removal of hip prosthesis $5, 821.203602709326 I nj ec t i o n f or hi p x - r a y$ 255.15 969 27093 26 Midlevel Injection for hip x-ray $216.9096927093 H I P A RT H ROGR A P H Y I N J W O A NEST H$ 255.15 360 27095 26 Injection for hip x-ray $297.159692709526 M i d l e v e l I nj ec t i o n f or hi p x - r a y$ 252.60 969 27095 HIP ARTHROGRAPHY INJ W ANESTH $297.153602709626 M i d l e v e l I nj ec t s a cro i l ia c j o in t$ 253.45 969 27096 26 Inject sacroiliac joint $298.2096927096 I nj ec t s a cro i l ia c j o in t$ 298.20 360 27097 26 Revision of hip tendon $2, 454.909692709726 M i d l e v e lR e v i s i o n o f hi pt e n d o n$ 2,086.65 969 27097 REVISION OF PROXIMAL HIP TENDON $2, 454.903602709826 M i d l e v e lT r an s f er t e n d o n t o p e l v i s$ 2,093.80 969 27098 26 Transfer tendon to pelvis $2, 463.3096927098 A DD U CTORTR A NSFERTO I SC H I U M$ 2,463.30 360 27100 26 Midlevel Transfer of abdominal muscle $2, 540.059692710026 T r an s f ero f ab d o mina l m u sc l e$ 2,988.30 969 27100 TRANSF EXT OBLIZ TO GRTR TROCHANTER $2, 988.303602710526 M i d l e v e lT r an s f ero f s p ina l m u sc l e$ 2,666.80 969 27105 26 Transfer of spinal muscle $3, 137.4096927105 TR A NSFERP A R A SP I N A L M U SC L ETO H I P$ 3,137.40 360 27110 26 Midlevel Transfer of iliopsoas muscle $2, 978.259692711026 T r an s f ero f i l i o p so a s m u sc l e$ 3,503.85 969 27110 TRANF ILIOPS MSCL TO FEMUR $3, 503.853602711126 T r an s f ero f i l i o p so a s m u sc l e$ 3,000.90 969 27111 26 Midlevel Transfer of iliopsoas muscle $2, 550.7596927111 TR A NSF I L I OPSO A S; TOFEMOR A L NEC K$ 3,000.90 360 27120 26 Midlevel Reconstruction of hip socket $3, 992.159692712026 R eco n s t r u c t i o n o f hi p soc k e t$ 4,696.65 969 27120 Reconstruction of hip socket $4, 696.653602712226 M i d l e v e lR eco n s t r u c t i o n o f hi p soc k e t$ 3,407.55 969 27122 26 Reconstruction of hip socket $4, 008.9096927122 R eco n s t r u c t i o n o f hi p soc k e t$ 4,008.90 360 27125 26 Midlevel Partial hip replacement $3, 501.309692712526 P a r t ia l hi p re pl a ce m e n t$ 4,119.15 969 27125 Partial hip replacement $4,119.15 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 78 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27130 26 Midlevel Total hip arthroplasty $4, 466.959692713026 T o t a l hi p a r t h ro pl a s t y$ 5,255.25 969 27130 Total hip arthroplasty $5, 255.253602713226 T o t a l hi p a r t h ro pl a s t y$ 6,120.45 969 27132 26 Midlevel Total hip arthroplasty $5, 202.4096927132 T o t a l hi p a r t h ro pl a s t y$ 6,120.45 360 27134 26 Midlevel Revise hip joint replacement $5, 964.609692713426 R e v i se hi p j o in t re pl a ce m e n t$ 7,017.15 969 27134 Revise hip joint replacement $7, 017.153602713726 M i d l e v e lR e v i se hi p j o in t re pl a ce m e n t$ 4,575.85 969 27137 26 Revise hip joint replacement $5, 383.3596927137 R e v i se hi p j o in t re pl a ce m e n t$ 5,383.35 360 27138 26 Revise hip joint replacement $5, 601.759692713826 M i d l e v e lR e v i se hi p j o in t re pl a ce m e n t$ 4,761.50 969 27138 Revise hip joint replacement $5, 601.753602714026 M i d l e v e lT r an s pl an t f e m u rr i d g e$ 2,765.85 969 27140 26 Transplant femur ridge $3, 253.9596927140 T r an s pl an t f e m u rr i d g e$ 3,253.95 360 27146 26 Midlevel Incision of hip bone $3, 955.559692714626 I n c i s i o n o f hi p b o n e$ 4,653.60 969 27146 Incision of hip bone $4, 653.603602714726 R e v i s i o n o f hi p b o n e$ 5,343.45 969 27147 26 Midlevel Revision of hip bone $4, 541.9596927147 R e v i s i o n o f hi p b o n e$ 5,343.45 360 27151 26 Incision of hip bones $5, 727.759692715126 M i d l e v e l I n c i s i o n o f hi p b o n es$ 4,868.60 969 27151 Incision of hip bones $5, 727.753602715626 R e v i s i o n o f hi p b o n es$ 6,232.80 969 27156 26 Midlevel Revision of hip bones $5, 297.9096927156 R e v i s i o n o f hi p b o n es$ 6,232.80 360 27158 26 Revision of pelvis $5, 076.759692715826 M i d l e v e lR e v i s i o n o f p e l v i s$ 4,315.25 969 27158 Revision of pelvis $5, 076.753602716126 I n c i s i o n o f n ec k o ff e m u r$ 4,423.65 969 27161 26 Midlevel Incision of neck of femur $3, 760.1096927161 I n c i s i o n o f n ec k o ff e m u r$ 4,423.65 360 27165 26 Midlevel Incision/fixation of femur $4, 247.409692716526 I n c i s i o n / f i x a t i o n o ff e m u r$ 4,996.95 969 27165 Incision/fixation of femur $4, 996.953602717026 R e p ai r / g r a f t f e m u r h e a d / n ec k$ 4,285.05 969 27170 26 Midlevel Repair/graft femur head/neck $3, 642.3096927170 R e p ai r / g r a f t f e m u r h e a d / n ec k$ 4,285.05 360 27175 26 Midlevel Treat slipped epiphysis $2, 052.759692717526 T re a t s l i pp e d e p i p h ys i s$ 2,415.00 969 27175 Treat slipped epiphysis $2, 415.003602717626 M i d l e v e lT re a t s l i pp e d e p i p h ys i s$ 2,828.35 969 27176 26 Treat slipped epiphysis $3, 327.4596927176 T re a t s l i pp e d e p i p h ys i s$ 3,327.45 360 27177 26 Midlevel Treat slipped epiphysis $3, 436.159692717726 T re a t s l i pp e d e p i p h ys i s$ 4,042.50 969 27177 Treat slipped epiphysis $4, 042.503602717826 M i d l e v e lT re a t s l i pp e d e p i p h ys i s$ 2,823.00 969 27178 26 Treat slipped epiphysis $3, 321.1596927178 T re a t s l i pp e d e p i p h ys i s$ 3,321.15 360 27179 26 Midlevel Revise head/neck of femur $3, 007.709692717926 R e v i se h e a d / n ec k o ff e m u r$ 3,538.50 969 27179 Revise head/neck of femur $3,538.50 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 79 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27181 26 Midlevel Treat slipped epiphysis $3, 460.209692718126 T re a t s l i pp e d e p i p h ys i s$ 4,070.85 969 27181 Treat slipped epiphysis $4, 070.853602718526 R e v i s i o n o ff e m u re p i p h ys i s$ 2,404.50 969 27185 26 Midlevel Revision of femur epiphysis $2, 043.8596927185 R e v i s i o n o ff e m u re p i p h ys i s$ 2,404.50 360 27187 26 Midlevel Reinforce hip bones $3, 065.759692718726 R e in f orce hi p b o n es$ 3,606.75 969 27187 Reinforce hip bones $3, 606.753602720026 M i d l e v e lT re a tt ai l b o n e f r a c t u re$ 567.65 969 27200 26 Treat tail bone fracture $667.8096927200 C L TXCOCC Y GE A L FR A CT U RE$ 667.80 360 27202 26 Treat tail bone fracture $2, 031.759692720226 M i d l e v e lT re a tt ai l b o n e f r a c t u re$ 1,727.00 969 27202 OP TX TAIL BONE FRACTURE $2, 031.753602721526 T re a tp e l v i c f r a c t u re (s)$ 2,228.10 960 27215 26 Midlevel Treat pelvic fracture(s) $1, 893.9096027215 T re a tp e l v i c f r a c t u re (s)$ 2,228.10 360 27216 26 Treat pelvic ring fracture $3, 299.109602721626 M i d l e v e lT re a tp e l v i cr in g f r a c t u re$ 2,804.25 960 27216 Treat pelvic ring fracture $3, 299.103602721726 T re a tp e l v i cr in g f r a c t u re$ 3,105.90 960 27217 26 Midlevel Treat pelvic ring fracture $2, 640.0096027217 T re a tp e l v i cr in g f r a c t u re$ 3,105.90 360 27218 26 Treat pelvic ring fracture $4, 265.109602721826 M i d l e v e lT re a tp e l v i cr in g f r a c t u re$ 3,625.35 960 27218 Treat pelvic ring fracture $4, 265.103602722026 M i d l e v e lT re a t hi p soc k e t f r a c t u re$ 1,614.55 969 27220 26 Treat hip socket fracture $1, 899.4596927220 C L TXOF A CET A B ULU MX (S); W OM A N$ 1,899.45 360 27222 26 Treat hip socket fracture $3, 553.209692722226 M i d l e v e lT re a t hi p soc k e t f r a c t u re$ 3,020.20 969 27222 Treat hip socket fracture $3, 553.203602722626 T re a t hi pw a ll f r a c t u re$ 3,833.55 969 27226 26 Midlevel Treat hip wall fracture $3, 258.5096927226 T re a t hi pw a ll f r a c t u re$ 3,833.55 360 27227 26 Treat hip fracture(s) $6, 053.259692722726 M i d l e v e lT re a t hi p f r a c t u re (s)$ 5,145.25 969 27227 Treat hip fracture(s) $6, 053.253602722826 M i d l e v e lT re a t hi p f r a c t u re (s)$ 5,874.45 969 27228 26 Treat hip fracture(s) $6, 911.1096927228 T re a t hi p f r a c t u re (s)$ 6,911.10 360 27230 26 Treat thigh fracture $1, 701.009692723026 M i d l e v e lT re a tt hi g h f r a c t u re$ 1,445.85 969 27230 CL TX PROX FEM FX WO MANIP $1, 701.003602723226 T re a tt hi g h f r a c t u re$ 2,779.35 969 27232 26 Midlevel Treat thigh fracture $2, 362.4596927232 T re a tt hi g h f r a c t u re$ 2,779.35 360 27235 26 Treat thigh fracture $3, 306.459692723526 M i d l e v e lT re a tt hi g h f r a c t u re$ 2,810.50 969 27235 Treat thigh fracture $3, 306.453602723626 T re a tt hi g h f r a c t u re$ 4,353.30 969 27236 26 Midlevel Treat thigh fracture $3, 700.3096927236 T re a tt hi g h f r a c t u re$ 4,353.30 360 27238 26 Midlevel Treat thigh fracture $1, 411.059692723826 T re a tt hi g h f r a c t u re$ 1,660.05 969 27238 CLTX INTER/PERI/SUBTROCHANTERIC FEM $1,660.05 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 80 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION FX WO MNP 27240 26 Treat thigh fracture $3, 483.909692724026 M i d l e v e lT re a tt hi g h f r a c t u re$ 2,961.30 969 27240 Treat thigh fracture $3, 483.903602724426 M i d l e v e lT re a tt hi g h f r a c t u re$ 3,804.75 969 27244 26 Treat thigh fracture $4, 476.1596927244 T re a tt hi g h f r a c t u re$ 4,476.15 360 27245 26 Treat thigh fracture $4, 501.359692724526 M i d l e v e lT re a tt hi g h f r a c t u re$ 3,826.15 969 27245 Treat thigh fracture $4, 501.353602724626 T re a tt hi g h f r a c t u re$ 1,396.50 969 27246 26 Midlevel Treat thigh fracture $1, 187.0596927246 C L TXGTRTROC H NTRCFX W OM A N I P$ 1,396.50 360 27248 26 Midlevel Treat thigh fracture $2, 304.459692724826 T re a tt hi g h f r a c t u re$ 2,711.10 969 27248 Treat thigh fracture $2, 711.103602725026 M i d l e v e lT re a t hi p d i s l oc a t i o n$ 597.10 969 27250 26 Treat hip dislocation $702.4596927250 C L TXTR A U M A H I P D I C L OC W O A NEST H$ 702.45 360 27252 26 Midlevel Treat hip dislocation $2, 341.909692725226 T re a t hi p d i s l oc a t i o n$ 2,755.20 969 27252 Treat hip dislocation $2, 755.203602725326 T re a t hi p d i s l oc a t i o n$ 3,425.10 969 27253 26 Midlevel Treat hip dislocation $2, 911.3596927253 T re a t hi p d i s l oc a t i o n$ 3,425.10 360 27254 26 Treat hip dislocation $4, 624.209692725426 M i d l e v e lT re a t hi p d i s l oc a t i o n$ 3,930.55 969 27254 Treat hip dislocation $4, 624.203602725626 T re a t hi p d i s l oc a t i o n$ 858.90 969 27256 26 Midlevel Treat hip dislocation $730.0596927256 TXSP H I P D I S L A B D SP L NT / TR A C; W O$ 858.90 360 27257 26 Treat hip dislocation $1, 213.809692725726 M i d l e v e lT re a t hi p d i s l oc a t i o n$ 1,031.75 969 27257 TX SPONTAN HIP DISLOC W ANESTH $1, 213.803602725826 T re a t hi p d i s l oc a t i o n$ 4,029.90 969 27258 26 Midlevel Treat hip dislocation $3, 425.4096927258 T re a t hi p d i s l oc a t i o n$ 4,029.90 360 27259 26 Treat hip dislocation $5, 640.609692725926 M i d l e v e lT re a t hi p d i s l oc a t i o n$ 4,794.50 969 27259 Treat hip dislocation $5, 640.603602726526 T re a t hi p d i s l oc a t i o n$ 1,444.80 969 27265 26 Midlevel Treat hip dislocation $1, 228.1096927265 C L TXPOST H I P D I S L OC W O A NEST H$ 1,444.80 360 27266 26 Midlevel Treat hip dislocation $1, 788.559692726626 T re a t hi p d i s l oc a t i o n$ 2,104.20 969 27266 CL TX POSTOP HIP DISLOC W ANESTH $2, 104.2036027267 C L TXT H I G H FX$ 1,566.60 360 27268 Cltx thigh fx w/mnpj $1, 926.7536027269 Opt x t hi g h f x$ 4,492.95 360 27275 26 Midlevel Manipulation of hip joint $553.359692727526 M ani p u l a t i o n o f hi p j o in t$ 651.00 969 27275 MANIPULATE HIP JNT W ANESTH $651.003602728026 M i d l e v e lF u s i o n o f s a cro i l ia c j o in t$ 3,193.35 969 27280 26 Fusion of sacroiliac joint $3, 756.9096927280 F u s i o n o f s a cro i l ia c j o in t$ 3,756.90 360 27282 26 Midlevel Fusion of pubic bones $2, 598.959692728226 F u s i o n o f p u bi c b o n es$ 3,057.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 81 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27282 Fusion of pubic bones $3, 057.603602728426 F u s i o n o f hi p j o in t$ 5,825.40 969 27284 26 Midlevel Fusion of hip joint $4, 951.6096927284 F u s i o n o f hi p j o in t$ 5,825.40 360 27286 26 Fusion of hip joint $6, 022.809692728626 M i d l e v e lF u s i o n o f hi p j o in t$ 5,119.40 969 27286 Fusion of hip joint $6, 022.803602729026 M i d l e v e l A m p u t a t i o n o f l e g a t hi p$ 4,986.40 969 27290 26 Amputation of leg at hip $5, 866.3596927290 A m p u t a t i o n o f l e g a t hi p$ 5,866.35 360 27295 26 Midlevel Amputation of leg at hip $3, 899.359692729526 A m p u t a t i o n o f l e g a t hi p$ 4,587.45 969 27295 Amputation of leg at hip $4, 587.4536027299 P e l v i s / hi p j o in t s u r g ery$ 429.80 360 27301 26 Midlevel Drain thigh/knee lesion $1, 544.909692730126 Dr ain t hi g h / kn ee l es i o n$ 1,817.55 969 27301 DEEP I&D THIGH/KNEE $1, 817.553602730326 M i d l e v e l Dr aina g eo f b o n e l es i o n$ 1,969.75 969 27303 26 Drainage of bone lesion $2, 317.3596927303 Dr aina g eo f b o n e l es i o n$ 2,317.35 360 27305 26 Incise thigh tendon & fascia $1,731.45 969 27305 26 Midlevel Incise thigh tendon & fascia$ 1,471.75 969 27305 FASCIOTOMY ILIOTIBIAL OPEN $1, 731.453602730626 I n c i s i o n o f t hi g h t e n d o n$ 1,292.55 969 27306 26 Midlevel Incision of thigh tendon $1, 098.6596927306 PERC I NC A DD U CTOR / H A MSTR I NGTEN D ON$ 1,292.55 360 27307 26 Midlevel Incision of thigh tendons $1, 466.409692730726 I n c i s i o n o f t hi g h t e n d o n s$ 1,725.15 969 27307 PERC INC ADDUCTOR/HAMSTRING TENDON $1, 725.15360 M UL T I P L E 2731026 M i d l e v e lE x pl or a t i o n o f kn ee j o in t$ 2,253.55 969 27310 26 Exploration of knee joint $2, 651.2596927310 EXP L K NEE W D R A I N / REMFB$ 2,651.25 360 27323 26 Midlevel Biopsy, thigh soft tissues $553.359692732326 B i o p sy, t hi g h so f tt i ss u es$ 651.00 969 27323 SUPERF SFT TISS BX THIGH/KNEE $651.003602732426 M i d l e v e lB i o p sy, t hi g h so f tt i ss u es$ 1,204.90 969 27324 26 Biopsy, thigh soft tissues $1, 417.5096927324 D EEPSFTT I SSBXT H I G H / K NEE$ 1,417.50 360 27325 26 Neurectomy, hamstring $1, 853.259692732526 M i d l e v e lN e u rec t o m y, ham s t r in g$ 1,575.25 969 27325 NEURECTOMY HAMSTRING $1, 853.253602732626 N e u rec t o m y, p o pl i t e a l$ 1,836.45 969 27326 26 Midlevel Neurectomy, popliteal $1, 561.0096927326 NE U RECTOM Y POP L I TE A L$ 1,836.45 360 27327 26 Midlevel Removal of thigh lesion $974.609692732726 R e m o v a l o f t hi g h l es i o n$ 1,146.60 969 27327 EXC THIGH/KNEE LES SC < 3 CM $1, 146.603602732826 R e m o v a l o f t hi g h l es i o n$ 2,208.15 969 27328 26 Midlevel Removal of thigh lesion $1, 876.9596927328 EXCT H I G H / K NEET U M D EEP < 5 CM$ 2,208.15 360 27329 26 Midlevel Remove tumor, thigh/knee $3, 215.709692732926 R e m o v e t u m or, t hi g h / kn ee$ 3,783.15 969 27329 RESECT THIGH/KNEE TUM < 5 CM $3, 783.153602733026 B i o p sy, kn ee j o in tl inin g$ 1,482.60 969 27330 26 Midlevel Biopsy, knee joint lining $1, 260.2096927330 A RT H ROTOM Y K NEE; W S Y NO V I A L BX$ 1,482.60 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 82 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27331 26 Explore/treat knee joint $1, 722.009692733126 M i d l e v e lE x pl ore / t re a t kn ee j o in t$ 1,463.70 969 27331 ARTHROT KNEE; W EXPL/BX/REM FB $1, 722.003602733226 M i d l e v e lR e m o v a l o f kn eec a r t i l a g e$ 1,971.55 969 27332 26 Removal of knee cartilage $2, 319.4596927332 A RT H ROT K NEE W MEN I SC; ME D OR L A T$ 2,319.45 360 27333 26 Midlevel Removal of knee cartilage $1, 799.309692733326 R e m o v a l o f kn eec a r t i l a g e$ 2,116.80 969 27333 ARTHROT KNEE W MENISC; MED & LAT $2, 116.803602733426 R e m o v e kn ee j o in tl inin g$ 2,478.00 969 27334 26 Midlevel Remove knee joint lining $2, 106.3096927334 A RT H ROT K NEE W S Y NO V; A NT / POST$ 2,478.00 360 27335 26 Midlevel Remove knee joint lining $2, 358.909692733526 R e m o v e kn ee j o in tl inin g$ 2,775.15 969 27335 ARTHROT KNEE W SYNOV; ANT & POS $2, 775.1536027337 EXCT H I G H / K NEE L ESSC 3 CM / >$ 1,537.20 360 27339 EXC THIGH/KNEE TUM DEP 5CM/> $2, 740.503602734026 R e m o v a l o f kn eec a p b u rs a$ 1,339.80 969 27340 26 Midlevel Removal of kneecap bursa $1, 138.8596927340 EXC I S I ONPREP A TE LL A RB U RS A$ 1,339.80 360 27345 26 Removal of knee cyst $1, 747.209692734526 M i d l e v e lR e m o v a l o f kn eecys t$ 1,485.10 969 27345 EXC SYNOVIAL CYST POPLITEAL SPACE $1, 747.203602734726 R e m o v e kn eecys t$ 1,912.05 969 27347 26 Midlevel Remove knee cyst $1, 625.2596927347 EXC L ES I ONMEN I SC U S / C A PS UL E$ 1,912.05 360 27350 26 Removal of kneecap $2, 363.559692735026 M i d l e v e lR e m o v a l o f kn eec a p$ 2,009.00 969 27350 REMOVAL OF KNEECAP $2, 363.553602735526 M i d l e v e lR e m o v e f e m u r l es i o n$ 1,858.20 969 27355 26 Remove femur lesion $2, 186.1096927355 EXCFEM U RBONEC Y ST / T U MOR$ 2,186.10 360 27356 26 Remove femur lesion/graft $2, 673.309692735626 M i d l e v e lR e m o v e f e m u r l es i o n / g r a f t$ 2,272.30 969 27356 EXC FEMUR BN CYST/TUMOR W ALLOGRFT $2, 673.303602735726 M i d l e v e lR e m o v e f e m u r l es i o n / g r a f t$ 2,507.95 969 27357 26 Remove femur lesion/graft $2, 950.5096927357 EXCFEM U RBNC Y ST / T U MOR W A U TOGRFT$ 2,950.50 360 27358 26 Midlevel Remove femur lesion/fixation $867.509692735826 R e m o v e f e m u r l es i o n / f i x a t i o n$ 1,020.60 969 27358 EXC FEMUR BN CYST/TUMOR W INT FIX $1, 020.603602736026 P a r t ia l re m o v a l, l e g b o n e (s)$ 3,098.55 969 27360 26 Midlevel Partial removal, leg bone(s) $2, 633.7596927360 P A RTEXCBONEFEM U RPROXT I B I A$ 3,098.55 360 27364 RESECT THIGH/KNEE TUM 5 CM/> $5, 701.503602736526 E x t e n s i v e l e g s u r g ery$ 7,309.05 969 27365 26 Midlevel Extensive leg surgery $6, 212.7096927365 E x t e n s i v e l e g s u r g ery$ 7,309.05 360 27370 26 Midlevel Injection for knee x-ray $161.559692737026 I nj ec t i o n f or kn ee x - r a y$ 190.05 969 27370 INJECTION FOR KNEE X-RAY $190.053602737226 R e m o v a l o ff ore i g nb o d y$ 1,465.80 969 27372 26 Midlevel Removal of foreign body $1, 245.9596927372 REM D EEPFBT H I G H OR K NEE$ 1,465.80 360 27380 26 Midlevel Repair of kneecap tendon $1, 832.309692738026 R e p ai ro f kn eec a pt e n d o n$ 2,155.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 83 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27380 REPAIR KNEECAP TENDON $2, 155.653602738126 M i d l e v e lR e p ai r / g r a f t kn eec a pt e n d o n$ 2,466.85 969 27381 26 Repair/graft kneecap tendon $2, 902.2096927381 RECONSTR U CT I NFR A P A TEE L A RTEN D ON$ 2,902.20 360 27385 26 Midlevel Repair of thigh muscle $1, 782.309692738526 R e p ai ro f t hi g hm u sc l e$ 2,096.85 969 27385 SUTURE QUAD/HAMSTRING MSCL RUPT $2, 096.853602738626 R e p ai r / g r a f t o f t hi g hm u sc l e$ 3,017.70 969 27386 26 Midlevel Repair/graft of thigh muscle $2, 565.0596927386 RECONSTRQ U A D / H A MSTR I NGMSC L R U PT$ 3,017.70 360 27390 26 Incision of thigh tendon $1, 615.959692739026 M i d l e v e l I n c i s i o n o f t hi g h t e n d o n$ 1,373.55 969 27390 OP INC HAMSTRING KNEE TO HIP SGL $1, 615.953602739126 I n c i s i o n o f t hi g h t e n d o n s$ 2,083.20 969 27391 26 Midlevel Incision of thigh tendons $1, 770.7096927391 I NC I S I ONOFT H I G H TEN D ONS 1 L EG$ 2,083.20 360 27392 26 Incision of thigh tendons $2, 569.359692739226 M i d l e v e l I n c i s i o n o f t hi g h t e n d o n s$ 2,183.95 969 27392 OP INC HAMSTRING MULTI BILAT $2, 569.353602739326 L e n g t h e nin g o f t hi g h t e n d o n$ 1,843.80 969 27393 26 Midlevel Lengthening of thigh tendon $1, 567.2596927393 L ENGT H EN H A MSTR I NGTEN D ON; S I NG L E$ 1,843.80 360 27394 26 Midlevel Lengthening of thigh tendons $2, 006.359692739426 L e n g t h e nin g o f t hi g h t e n d o n s$ 2,360.40 969 27394 LENGTHENING OF THIGH TENDONS 1 LEG $2, 360.403602739526 M i d l e v e l L e n g t h e nin g o f t hi g h t e n d o n s$ 2,706.05 969 27395 26 Lengthening of thigh tendons $3, 183.6096927395 L ENGT H EN H STEN D ON; M UL T I B I L A T$ 3,183.60 360 27396 26 Midlevel Transplant of thigh tendon $1, 893.909692739626 T r an s pl an t o f t hi g h t e n d o n$ 2,228.10 969 27396 TRANSPLANT OF THIGH TENDON $2, 228.103602739726 M i d l e v e lT r an s pl an t so f t hi g h t e n d o n s$ 2,816.75 969 27397 26 Transplants of thigh tendons $3, 313.8096927397 TR A NSP L A NTSOFT H I G H TEN D ONS$ 3,313.80 360 27400 26 Midlevel Revise thigh muscles/tendons $2, 133.959692740026 R e v i se t hi g hm u sc l es / t e n d o n s$ 2,510.55 969 27400 TEND/MUSCLE TRANSF HS TO FEMUR $2, 510.553602740326 R e p ai ro f kn eec a r t i l a g e$ 2,324.70 969 27403 26 Midlevel Repair of knee cartilage $1, 976.0096927403 A RT H ROTOM YW OPMEN I SC U SREP A I R$ 2,324.70 360 27405 26 Repair of knee ligament $2, 457.009692740526 M i d l e v e lR e p ai ro f kn ee l i g am e n t$ 2,088.45 969 27405 REPR TORN COLLATERAL KNEE LIGAM $2, 457.003602740726 R e p ai ro f kn ee l i g am e n t$ 2,851.80 969 27407 26 Midlevel Repair of knee ligament $2, 424.0596927407 REPRTORNCR U C I A TE K NEE L I G A M$ 2,851.80 360 27409 26 Repair of knee ligaments $3, 500.709692740926 M i d l e v e lR e p ai ro f kn ee l i g am e n t s$ 2,975.60 969 27409 REPAIR TORN COLLAT & CRUCIATE KNEE $3, 500.70360 L I G A M 2741226 A u t oc h o n d rocy t e im pl an t kn ee$ 6,009.15 969 27412 26 Midlevel Autochondrocyte implant knee $5, 107.8096927412 A u t oc h o n d rocy t e im pl an t kn ee$ 6,009.15 360 27415 26 Osteochondral knee allograft $4, 984.359692741526 M i d l e v e lO s t eoc h o n d r a l kn ee a ll o g r a f t$ 4,236.70 969 27415 OPEN OSTEOCHONDRAL KNEE ALLOGRAFT $4, 984.3536027416 OSTEOC H ON D R A L K NEE A U TOGR A FT$ 3,543.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 84 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27418 26 Repair degenerated kneecap $3, 026.109692741826 M i d l e v e lR e p ai r d e g e n er a t e d kn eec a p$ 2,572.20 969 27418 ANTERIOR TIBIAL TUBERCLEPLASTY $3, 026.103602742026 M i d l e v e lR e v i s i o n o f u n s t ab l e kn eec a p$ 2,292.85 969 27420 26 Revision of unstable kneecap $2, 697.4596927420 RECONSTR D I L OC A T I NGP A TE LL A$ 2,697.45 360 27422 26 Midlevel Revision of unstable kneecap $2, 294.609692742226 R e v i s i o n o f u n s t ab l e kn eec a p$ 2,699.55 969 27422 RECONSTR DISLOC PATELLA W MSCL ADV $2, 699.553602742426 R e v i s i o n / re m o v a l o f kn eec a p$ 2,707.95 969 27424 26 Midlevel Revision/removal of kneecap $2, 301.7596927424 RECONSTREC D I S L P A TE LL A; W$ 2,707.95 360 PATELLECTOMY 27425 26 Lat retinacular release open $1, 615.959692742526 M i d l e v e l L a t re t ina c u l a rre l e a seo p e n$ 1,373.55 969 27425 OPEN LAT RETINA RELEASE $1, 615.953602742726 M i d l e v e lR eco n s t r u c t i o n, kn ee$ 2,217.85 969 27427 26 Reconstruction, knee $2, 609.2596927427 L I G A MENT A U GM K NEE; EXTR A - A RT I C$ 2,609.25 360 27428 26 Reconstruction, knee $4, 045.659692742826 M i d l e v e lR eco n s t r u c t i o n, kn ee$ 3,438.80 969 27428 LIGAMENT AUGM KNEE; INTRA-ARTICULAR $4, 045.653602742926 R eco n s t r u c t i o n, kn ee$ 4,539.15 969 27429 26 Midlevel Reconstruction, knee $3,858.30 969 27429 LIGAMENT AUGM KNEE; IA & EA$ 4,539.15 360 27430 26 Revision of thigh muscles $2, 686.959692743026 M i d l e v e lR e v i s i o n o f t hi g hm u sc l es$ 2,283.90 969 27430 QUADRICEPSPLASTY $2, 686.953602743526 I n c i s i o n o f kn ee j o in t$ 2,931.60 969 27435 26 Midlevel Incision of knee joint $2, 491.8596927435 POSTC A PS UL A RRE L E A SE K NEE$ 2,931.60 360 27437 26 Revise kneecap $2, 395.059692743726 M i d l e v e lR e v i se kn eec a p$ 2,035.80 969 27437 ARTHROPLASTY PATELLA; WO PROSTH $2, 395.053602743826 R e v i se kn eec a pw i t him pl an t$ 3,056.55 969 27438 26 Midlevel Revise kneecap with implant $2, 598.0596927438 A RT H ROP L A ST Y P A TE LL A; W PROST H$ 3,056.55 360 27440 26 Revision of knee joint $2, 865.459692744026 M i d l e v e lR e v i s i o n o f kn ee j o in t$ 2,435.65 969 27440 ARTHROPLASTY KNEE TIBIAL PLATEAU; $2, 865.453602744126 M i d l e v e lR e v i s i o n o f kn ee j o in t$ 2,515.95 969 27441 26 Revision of knee joint $2, 959.9596927441 A RT H ROP L A ST Y K NEETP; W D EBR I D$ 2,959.95 360 27442 26 Revision of knee joint $3, 157.359692744226 M i d l e v e lR e v i s i o n o f kn ee j o in t$ 2,683.75 969 27442 ARTHROPLASTY KNEE FC/TP $3, 157.353602744326 R e v i s i o n o f kn ee j o in t$ 2,961.00 969 27443 26 Midlevel Revision of knee joint $2, 516.8596927443 A RT H ROP L A ST Y K NEEFC / TP; W D EBR I D$ 2,961.00 360 27445 26 Midlevel Revision of knee joint $3, 877.009692744526 R e v i s i o n o f kn ee j o in t$ 4,561.20 969 27445 Revision of knee joint $4, 561.203602744626 M i d l e v e lR e v i s i o n o f kn ee j o in t$ 3,427.20 969 27446 26 Revision of knee joint $4,032.00 969 27446 ARTHROPL KNEE C&P; MEDIAL LAT$ 4,032.00 360 27447 26 Midlevel Total knee arthroplasty $4, 771.309692744726 T o t a l kn ee a r t h ro pl a s t y$ 5,613.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 85 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27447 Total knee arthroplasty $5, 613.303602744826 I n c i s i o n o f t hi g h$ 2,976.75 969 27448 26 Midlevel Incision of thigh $2, 530.2596927448 I n c i s i o n o f t hi g h$ 2,976.75 360 27450 26 Midlevel Incision of thigh $3, 143.409692745026 I n c i s i o n o f t hi g h$ 3,698.10 969 27450 Incision of thigh $3, 698.103602745426 R e a l i g nm e n t o f t hi g hb o n e$ 4,708.20 969 27454 26 Midlevel Realignment of thigh bone $4, 001.9596927454 R e a l i g nm e n t o f t hi g hb o n e$ 4,708.20 360 27455 26 Midlevel Realignment of knee $2, 906.009692745526 R e a l i g nm e n t o f kn ee$ 3,418.80 969 27455 Realignment of knee $3, 418.803602745726 M i d l e v e lR e a l i g nm e n t o f kn ee$ 2,972.90 969 27457 26 Realignment of knee $3, 497.5596927457 R e a l i g nm e n t o f kn ee$ 3,497.55 360 27465 26 Shortening of thigh bone $4, 527.609692746526 M i d l e v e lS h or t e nin g o f t hi g hb o n e$ 3,848.45 969 27465 Shortening of thigh bone $4, 527.603602746626 M i d l e v e l L e n g t h e nin g o f t hi g hb o n e$ 3,653.00 969 27466 26 Lengthening of thigh bone $4, 297.6596927466 L e n g t h e nin g o f t hi g hb o n e$ 4,297.65 360 27468 26 Shorten/lengthen thighs $4, 872.009692746826 M i d l e v e lS h or t e n / l e n g t h e n t hi g h s$ 4,141.20 969 27468 Shorten/lengthen thighs $4, 872.003602747026 R e p ai ro f t hi g h$ 4,292.40 969 27470 26 Midlevel Repair of thigh $3, 648.5596927470 R e p ai ro f t hi g h$ 4,292.40 360 27472 26 Repair/graft of thigh $4, 614.759692747226 M i d l e v e lR e p ai r / g r a f t o f t hi g h$ 3,922.55 969 27472 Repair/graft of thigh $4, 614.753602747526 M i d l e v e lS u r g ery t os t o pl e gg ro wt h$ 2,035.80 969 27475 26 Surgery to stop leg growth $2, 395.0596927475 EP I P H Y SE A L A RREST; D I ST A L FEM U R$ 2,395.05 360 27477 26 Surgery to stop leg growth $2, 654.409692747726 M i d l e v e lS u r g ery t os t o pl e gg ro wt h$ 2,256.25 969 27477 Surgery to stop leg growth $2, 654.403602747926 S u r g ery t os t o pl e gg ro wt h$ 3,135.30 969 27479 26 Midlevel Surgery to stop leg growth $2,665.00 969 27479 EPIPHYS ARRES; COMB D FEM & TIB-FIB$ 3,135.30 360 27485 26 Midlevel Surgery to stop leg growth $2, 065.259692748526 S u r g ery t os t o pl e gg ro wt h$ 2,429.70 969 27485 Surgery to stop leg growth $2, 429.703602748626 R e v i se / re pl a ce kn ee j o in t$ 5,133.45 969 27486 26 Midlevel Revise/replace knee joint $4, 363.4596927486 R e v i se / re pl a ce kn ee j o in t$ 5,133.45 360 27487 26 Revise/replace knee joint $6, 428.109692748726 M i d l e v e lR e v i se / re pl a ce kn ee j o in t$ 5,463.90 969 27487 Revise/replace knee joint $6, 428.103602748826 R e m o v a l o f kn ee p ros t h es i s$ 4,376.40 969 27488 26 Midlevel Removal of knee prosthesis $3, 719.9596927488 R e m o v a l o f kn ee p ros t h es i s$ 4,376.40 360 27495 26 Reinforce thigh $4, 108.659692749526 M i d l e v e lR e in f orce t hi g h$ 3,492.35 969 27495 Reinforce thigh $4, 108.653602749626 Deco m p ress i o n o f t hi g h / kn ee$ 1,936.20 969 27496 26 Midlevel Decompression of thigh/knee $1,645.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 86 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27496 DECOMP OF THIGH/KNEE 1 COMPART $1, 936.203602749726 Deco m p ress i o n o f t hi g h / kn ee$ 2,077.95 969 27497 26 Midlevel Decompression of thigh/knee $1, 766.2596927497 D ECOMPOFT H I G H / K NEE W D EBR I D E 1$ 2,077.95 360 COMPART 27498 26 Midlevel Decompression of thigh/knee $1, 970.659692749826 Deco m p ress i o n o f t hi g h / kn ee$ 2,318.40 969 27498 DECOMPRESS THIGH/KNEE MULTI $2, 318.40360 COMPRTM 2749926 Deco m p ress i o n o f t hi g h / kn ee$ 2,327.85 969 27499 26 Midlevel Decompression of thigh/knee $1, 978.6596927499 D ECOMPRESST H I G H / K NEEM UL T I CMPRTM$ 2,327.85 360 W DEBR 27500 26 Midlevel Treatment of thigh fracture $1, 469.059692750026 T re a t m e n t o f t hi g h f r a c t u re$ 1,728.30 969 27500 CL TX FEMORAL SHAFT FX WO MANIP $1, 728.303602750126 T re a t m e n t o f t hi g h f r a c t u re$ 1,804.95 969 27501 26 Midlevel Treatment of thigh fracture $1, 534.2096927501 C L TXSC / TCFEM U RFX W OM A N I P$ 1,804.95 360 27502 26 Treatment of thigh fracture $2, 827.659692750226 M i d l e v e lT re a t m e n t o f t hi g h f r a c t u re$ 2,403.50 969 27502 CL TX FEMORAL SHAFT FX W MANIP $2, 827.653602750326 T re a t m e n t o f t hi g h f r a c t u re$ 2,907.45 969 27503 26 Midlevel Treatment of thigh fracture $2, 471.3596927503 C L TXSC / TCFEM U RFX W M A N I P$ 2,907.45 360 27506 26 Treatment of thigh fracture $4, 872.009692750626 M i d l e v e lT re a t m e n t o f t hi g h f r a c t u re$ 4,141.20 969 27506 Treatment of thigh fracture $4, 872.003602750726 T re a t m e n t o f t hi g h f r a c t u re$ 3,551.10 969 27507 26 Midlevel Treatment of thigh fracture $3, 018.4596927507 T re a t m e n t o f t hi g h f r a c t u re$ 3,551.10 360 27508 26 Midlevel Treatment of thigh fracture $1, 516.359692750826 T re a t m e n t o f t hi g h f r a c t u re$ 1,783.95 969 27508 CL TX D FEM FX WO MANIP $1, 783.953602750926 M i d l e v e lT re a t m e n t o f t hi g h f r a c t u re$ 1,986.70 969 27509 26 Treatment of thigh fracture $2, 337.3096927509 PERCS K F I XFEMOR A L FX D I ST A L EN D$ 2,337.30 360 27510 26 Midlevel Treatment of thigh fracture $2, 142.009692751026 T re a t m e n t o f t hi g h f r a c t u re$ 2,520.00 969 27510 CL TX FEMUR FX OR EPIPHYS SEP $2, 520.003602751126 M i d l e v e lT re a t m e n t o f t hi g h f r a c t u re$ 3,105.90 969 27511 26 Treatment of thigh fracture $3, 654.0096927511 T re a t m e n t o f t hi g h f r a c t u re$ 3,654.00 360 27513 26 Midlevel Treatment of thigh fracture $3, 871.659692751326 T re a t m e n t o f t hi g h f r a c t u re$ 4,554.90 969 27513 Treatment of thigh fracture $4, 554.903602751426 M i d l e v e lT re a t m e n t o f t hi g h f r a c t u re$ 3,029.15 969 27514 26 Treatment of thigh fracture $3, 563.7096927514 T re a t m e n t o f t hi g h f r a c t u re$ 3,563.70 360 27516 26 Treat thigh fx growth plate $1, 711.509692751626 M i d l e v e lT re a tt hi g h f xg ro wt h pl a t e$ 1,454.80 969 27516 CL TX DIST FEM EPIPHYS SEP; WO MAN $1, 711.503602751726 M i d l e v e lT re a tt hi g h f xg ro wt h pl a t e$ 2,109.00 969 27517 26 Treat thigh fx growth plate $2, 481.1596927517 C L TX D I STFEMEP I P H Y SSEP; W M A N$ 2,481.15 360 27519 26 Midlevel Treat thigh fx growth plate $2, 777.459692751926 T re a tt hi g h f xg ro wt h pl a t e$ 3,267.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 87 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27519 Treat thigh fx growth plate $3, 267.603602752026 M i d l e v e lT re a t kn eec a p f r a c t u re$ 900.55 969 27520 26 Treat kneecap fracture $1, 059.4596927520 C L OSE D TXP A TE LL A RFX W OM A N I P$ 1,059.45 360 27524 26 Midlevel Treat kneecap fracture $2, 324.959692752426 T re a t kn eec a p f r a c t u re$ 2,735.25 969 27524 OP TX PATEL FX W IF &/REP $2, 735.253602753026 M i d l e v e lT re a t kn ee f r a c t u re$ 878.20 969 27530 26 Treat knee fracture $1, 033.2096927530 C L TXPROXT I B I A L FX W OM A N I P$ 1,033.20 360 27532 26 Midlevel Treat knee fracture $1, 778.759692753226 T re a t kn ee f r a c t u re$ 2,092.65 969 27532 CL TX PROX TIBIAL FX W SK TRACTION $2, 092.653602753526 T re a t kn ee f r a c t u re$ 3,282.30 969 27535 26 Midlevel Treat knee fracture $2, 789.9596927535 T re a t kn ee f r a c t u re$ 3,282.30 360 27536 26 Treat knee fracture $4, 334.409692753626 M i d l e v e lT re a t kn ee f r a c t u re$ 3,684.25 969 27536 Treat knee fracture $4, 334.403602753826 M i d l e v e lT re a t kn ee f r a c t u re (s)$ 1,358.40 969 27538 26 Treat knee fracture(s) $1, 598.1096927538 C L OSE D TX I CSPORT U BEROS I T Y$ 1,598.10 360 27540 26 Midlevel Treat knee fracture $2, 521.309692754026 T re a t kn ee f r a c t u re$ 2,966.25 969 27540 Treat knee fracture $2, 966.253602755026 T re a t kn ee d i s l oc a t i o n$ 1,660.05 969 27550 26 Midlevel Treat knee dislocation $1, 411.0596927550 C L TX K NEE D I S L; W O A NEST H$ 1,660.05 360 27552 26 Midlevel Treat knee dislocation $1, 927.809692755226 T re a t kn ee d i s l oc a t i o n$ 2,268.00 969 27552 CL TX KNEE DISL; W ANESTHESIA $2, 268.003602755626 M i d l e v e lT re a t kn ee d i s l oc a t i o n$ 2,731.95 969 27556 26 Treat knee dislocation $3, 214.0596927556 T re a t kn ee d i s l oc a t i o n$ 3,214.05 360 27557 26 Treat knee dislocation $3, 843.009692755726 M i d l e v e lT re a t kn ee d i s l oc a t i o n$ 3,266.55 969 27557 Treat knee dislocation $3, 843.003602755826 T re a t kn ee d i s l oc a t i o n$ 4,369.05 969 27558 26 Midlevel Treat knee dislocation $3, 713.7096927558 T re a t kn ee d i s l oc a t i o n$ 4,369.05 360 27560 26 Treat kneecap dislocation $1, 260.009692756026 M i d l e v e lT re a t kn eec a p d i s l oc a t i o n$ 1,071.00 969 27560 C TX PATELLAR DISLOCATION; WO ANESTH $1, 260.003602756226 M i d l e v e lT re a t kn eec a p d i s l oc a t i o n$ 1,471.75 969 27562 26 Treat kneecap dislocation $1, 731.4596927562 C L TXP A TE LL A R D I S L OC A T I ON; W A NEST H$ 1,731.45 360 27566 26 Midlevel Treat kneecap dislocation $2, 754.259692756626 T re a t kn eec a p d i s l oc a t i o n$ 3,240.30 969 27566 OPEN TX PATELLAR DISOCATION $3, 240.303602757026 M i d l e v e lF i x a t i o n o f kn ee j o in t$ 461.40 969 27570 26 Fixation of knee joint $542.8596927570 M A N I P UL A TE K NEE J NT U N D ER A NEST H$ 542.85 360 27580 26 Fusion of knee $5, 242.659692758026 M i d l e v e lF u s i o n o f kn ee$ 4,456.25 969 27580 Fusion of knee $5, 242.653602759026 M i d l e v e l A m p u t a t e l e g a tt hi g h$ 2,565.95 969 27590 26 Amputate leg at thigh $3,018.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 88 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27590 Amputate leg at thigh $3, 018.753602759126 A m p u t a t e l e g a tt hi g h$ 3,210.90 969 27591 26 Midlevel Amputate leg at thigh $2, 729.2596927591 A m p u t a t e l e g a tt hi g h$ 3,210.90 360 27592 26 Amputate leg at thigh $2, 558.859692759226 M i d l e v e l A m p u t a t e l e g a tt hi g h$ 2,175.00 969 27592 Amputate leg at thigh $2, 558.853602759426 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,611.85 969 27594 26 Amputation follow-up surgery $1, 896.3096927594 A MP U T A TET H I G H - FEM U R; 2^{'} C L OS U RE$ 1,896.30 360 27596 26 Midlevel Amputation follow-up surgery $2, 282.109692759626 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,684.85 969 27596 Amputation follow-up surgery $2, 684.853602759826 M i d l e v e l A m p u t a t e l o w er l e g a t kn ee$ 2,320.50 969 27598 26 Amputate lower leg at knee $2, 730.0096927598 A m p u t a t e l o w er l e g a t kn ee$ 2,730.00 360 27599 Leg surgery procedure $429.803602760026 Deco m p ress i o n o f l o w er l e g$ 1,538.25 969 27600 26 Midlevel Decompression of lower leg $1, 307.5096927600 L EG D ECMPRSN A NT / L A TCOMP$ 1,538.25 360 27601 26 Midlevel Decompression of lower leg $1, 363.759692760126 Deco m p ress i o n o f l o w er l e g$ 1,604.40 969 27601 LEG DECOMPRESSION LWR COMPARTM $1, 604.403602760226 Deco m p ress i o n o f l o w er l e g$ 1,863.75 969 27602 26 Midlevel Decompression of lower leg $1,584.20 969 27602 DF LEG; ANT/LAT & P COMPARTM$ 1,863.75 360 27603 26 Drain lower leg lesion $1, 431.159692760326 M i d l e v e l Dr ain l o w er l e g l es i o n$ 1,216.50 969 27603 I&D LEG/ANKLE DEEP ABSC/HEMATOMA $1, 431.153602760426 M i d l e v e l Dr ain l o w er l e g b u rs a$ 1,042.45 969 27604 26 Drain lower leg bursa $1,226.40 969 27604 I&D LEG OR ANKLE; INFECTED BURSA$ 1,226.40 360 27605 26 Incision of achilles tendon $681.459692760526 M i d l e v e l I n c i s i o n o f a c hi ll es t e n d o n$ 579.25 969 27605 SQ INC ACHILLES TENDON W LCL ANESTH $681.453602760626 M i d l e v e l I n c i s i o n o f a c hi ll es t e n d o n$ 889.80 969 27606 26 Incision of achilles tendon $1, 046.8596927606 I NC A C H I LL ESTEN D ON W GEN A NEST H$ 1,046.85 360 27607 26 Midlevel Treat lower leg bone lesion $1, 899.259692760726 T re a tl o w er l e g b o n e l es i o n$ 2,234.40 969 27607 DEEP INC LEG/ANKLE $2, 234.403602761026 M i d l e v e lE x pl ore / t re a t ank l e j o in t$ 2,017.95 969 27610 26 Explore/treat ankle joint $2, 374.0596927610 I NC A N K L E W EXP L - I NFECT I ON / REMFB$ 2,374.05 360 27612 26 Midlevel Exploration of ankle joint $1, 727.009692761226 E x pl or a t i o n o f ank l e j o in t$ 2,031.75 969 27612 INC ANKLE - POST CAPSL RELEASE $2, 031.753602761326 B i o p sy l o w er l e g so f tt i ss u e$ 602.70 969 27613 26 Midlevel Biopsy lower leg soft tissue $512.3096927613 S U PERFSFTT I SSBX L EG / A N K L E$ 602.70 360 27614 26 Midlevel Biopsy lower leg soft tissue $1, 266.459692761426 B i o p sy l o w er l e g so f tt i ss u e$ 1,489.95 969 27614 DEEP SFT TISS BX LEG/ANKLE $1, 489.953602761526 R e m o v e t u m or, l o w er l e g$ 3,729.60 969 27615 26 Midlevel Remove tumor, lower leg $3, 170.1596927615 RESECT L EG / A N K L ET U M < 5 CM$ 3,729.60 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 89 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27616 RESECT LEG/ANKLE TUM 5 CM/> $4, 651.503602761826 R e m o v e l o w er l e g l es i o n$ 1,130.85 969 27618 26 Midlevel Remove lower leg lesion $961.2096927618 EXC L EG / A N K L ET U M < 3 CM$ 1,130.85 360 27619 26 Midlevel Remove lower leg lesion $1, 508.359692761926 R e m o v e l o w er l e g l es i o n$ 1,774.50 969 27619 EXC LEG/ANKLE TUM DEEP <5 CM $1, 774.503602762026 E x pl ore / t re a t ank l e j o in t$ 1,660.05 969 27620 26 Midlevel Explore/treat ankle joint $1, 411.0596927620 EXP L OR / TRE A T A N K L E J O I NT$ 1,660.05 360 27625 26 Midlevel Remove ankle joint lining $1, 775.209692762526 R e m o v e ank l e j o in tl inin g$ 2,088.45 969 27625 ARTHROTOMY ANKLE W SYNOVECTOMY $2, 088.453602762626 M i d l e v e lR e m o v e ank l e j o in tl inin g$ 1,962.60 969 27626 26 Remove ankle joint lining $2, 308.9596927626 A RT H ROT A N K L E W S Y NO V ECT; W TENOS Y$ 2,308.95 360 27630 26 Midlevel Removal of tendon lesion $1, 142.409692763026 R e m o v a l o f t e n d o n l es i o n$ 1,344.00 969 27630 EXC TENDON SHTH LESION LEG/ANKLE $1, 344.0036027632 EXC L EG / A N K L E L ESSC 3 CM / >$ 1,528.80 360 27632 26 EXCISION TUMOR SOFT TISSUE LEG/ANKLE $1, 261.47960 S U BQ 3 CM / > 27634 EXC L EG / A N K L ET U M D EP 5 CM / >$ 2,517.90 360 27635 26 Remove lower leg bone lesion $2, 154.609692763526 M i d l e v e lR e m o v e l o w er l e g b o n e l es i o n$ 1,831.40 969 27635 EXC TIB/FIB BONE CYST/TUMOR $2, 154.603602763726 M i d l e v e lR e m o v e / g r a f tl e g b o n e l es i o n$ 2,347.30 969 27637 26 Remove/graft leg bone lesion $2, 761.5096927637 EXCT I B / F I GC Y ST / T U MOR W A U TOGRFT$ 2,761.50 360 27638 26 Remove/graft leg bone lesion $2, 816.109692763826 M i d l e v e lR e m o v e / g r a f tl e g b o n e l es i o n$ 2,393.70 969 27638 EXC TIB/FIB CYST/TUMOR W ALLOGRFT $2, 816.103602764026 P a r t ia l re m o v a l o f t ibia$ 3,063.90 969 27640 26 Midlevel Partial removal of tibia $2, 604.3096927640 P A RT I A L REMO V A L OFT I B I A$ 3,063.90 360 27641 26 Partial removal of fibula $2, 449.659692764126 M i d l e v e lP a r t ia l re m o v a l o ff ib u l a$ 2,082.20 969 27641 PARTIAL REMOVAL OF FIBULA $2, 449.653602764526 E x t e n s i v e l o w er l e g s u r g ery$ 6,285.30 969 27645 26 Midlevel Extensive lower leg surgery $5, 342.5096927645 E x t e n s i v e l o w er l e g s u r g ery$ 6,285.30 360 27646 26 Extensive lower leg surgery $5, 442.159692764626 M i d l e v e lE x t e n s i v e l o w er l e g s u r g ery$ 4,625.85 969 27646 Extensive lower leg surgery $5, 442.153602764726 E x t e n s i v e ank l e / h ee l s u r g ery$ 3,778.95 969 27647 26 Midlevel Extensive ankle/heel surgery $3, 212.1096927647 RESECTT A LU S / C A L C A NE U ST U M$ 3,778.95 360 27648 26 Injection for ankle x-ray $187.959692764826 M i d l e v e l I nj ec t i o n f or ank l e x - r a y$ 159.75 969 27648 ANKLE ARTHROGRAPHY INJ $187.953602765026 R e p ai r a c hi ll es t e n d o n$ 2,428.65 969 27650 26 Midlevel Repair achilles tendon $2, 064.3596927650 PR I M A R Y REP A I RR U PT A C H I LL ESTEN D ON$ 2,428.65 360 27652 26 Repair/graft achilles tendon $2, 541.009692765226 M i d l e v e lR e p ai r / g r a f t a c hi ll es t e n d o n$ 2,159.85 969 27652 PRIMARY REPR RUPT ACHILLES TNDN W $2,541.00 360 GRFT © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 90 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27654 26 Repair of achilles tendon $2, 580.909692765426 M i d l e v e lR e p ai ro f a c hi ll es t e n d o n$ 2,193.75 969 27654 SECONDRY REPR RUPT ACHILLES TENDON $2, 580.903602765626 R e p ai r l e g f a sc ia d e f ec t$ 1,401.75 969 27656 26 Midlevel Repair leg fascia defect $1, 191.5096927656 REP A I R L EGF A SC I A D EFECT$ 1,401.75 360 27658 26 Repair of leg tendon, each $1, 363.959692765826 M i d l e v e lR e p ai ro f l e g t e n d o n, e a c h$ 1,159.35 969 27658 1’ REPR/SUTR LEG FLEXOR TENDON $1, 363.953602765926 R e p ai ro f l e g t e n d o n, e a c h$ 1,785.00 969 27659 26 Midlevel Repair of leg tendon, each $1, 517.2596927659 2^{'} REPR / S U TR L EGF L EXORTEN D ON$ 1,785.00 360 27664 26 Midlevel Repair of leg tendon, each $1, 124.559692766426 R e p ai ro f l e g t e n d o n, e a c h$ 1,323.00 969 27664 1’ REPR/SUTR LEG EXTENSOR TENDON $1, 323.003602766526 M i d l e v e lR e p ai ro f l e g t e n d o n, e a c h$ 1,286.10 969 27665 26 Repair of leg tendon, each $1, 513.0596927665 2^{'} REPR / S U TR L EGEXTENSORTEN D ON$ 1,513.05 360 27675 26 Midlevel Repair lower leg tendons $1, 517.259692767526 R e p ai r l o w er l e g t e n d o n s$ 1,785.00 969 27675 REPAIR DISLOCATED PERONEAL TENDONS $1, 785.003602767626 R e p ai r l o w er l e g t e n d o n s$ 2,253.30 969 27676 26 Midlevel Repair lower leg tendons $1, 915.3096927676 REPR D I S L PERONE A L TEN D ON W F I B I NC$ 2,253.30 360 27680 26 Midlevel Release of lower leg tendon $1, 336.959692768026 R e l e a seo f l o w er l e g t e n d o n$ 1,572.90 969 27680 RELEASE SGL TIB FIB ANKLE FLEXOR $1, 572.903602768126 M i d l e v e lR e l e a seo f l o w er l e g t e n d o n s$ 1,666.30 969 27681 26 Release of lower leg tendons $1, 960.3596927681 RE L E A SEM UL T I PT I BF I B A N K L EF L EXOR$ 1,960.35 360 27685 26 Revision of lower leg tendon $1, 691.559692768526 M i d l e v e lR e v i s i o n o f l o w er l e g t e n d o n$ 1,437.80 969 27685 LENGTH/SHORT TENDON LEG/ANKLE; SGL $1, 691.553602768626 R e v i se l o w er l e g t e n d o n s$ 2,029.65 969 27686 26 Midlevel Revise lower leg tendons $1, 725.2096927686 L NGT H N . S H ORTNM UL T I L EG / A N K L E$ 2,029.65 360 TENDONS EA 27687 26 Revision of calf tendon $1, 664.259692768726 M i d l e v e lR e v i s i o n o f c a l f t e n d o n$ 1,414.60 969 27687 GASTROCNEMIUS RECESSION $1, 664.253602769026 R e v i se l o w er l e g t e n d o n$ 2,301.60 969 27690 26 Midlevel Revise lower leg tendon $1, 956.3596927690 S U PERFTR A NF / TR A SP L SG L TEN D ON$ 2,301.60 360 27691 26 Revise lower leg tendon $2, 735.259692769126 M i d l e v e lR e v i se l o w er l e g t e n d o n$ 2,324.95 969 27691 DEEP TRANSF/TRANSPL SGL LLEG TENDON $2, 735.253602769226 M i d l e v e lR e v i se a dd i t i o na ll e g t e n d o n$ 333.80 969 27692 26 Revise additional leg tendon $392.7096927692 TR A NSF / TR A NSP L SG L ETEN D ONE AA DD T L$ 392.70 360 27695 26 Midlevel Repair of ankle ligament $1, 497.609692769526 R e p ai ro f ank l e l i g am e n t$ 1,761.90 969 27695 SUTURE LIGAMENT ANKLE; COLLATERAL $1, 761.903602769626 M i d l e v e lR e p ai ro f ank l e l i g am e n t s$ 1,743.95 969 27696 26 Repair of ankle ligaments $2, 051.7096927696 1^{'} S U TRBOT H R U PTR A N K L ECO LL A TR L$ 2,051.70 360 LIGAM 27698 26 Repair of ankle ligament $2,345.70 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 91 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27698 26 Midlevel Repair of ankle ligament $1, 993.8596927698 2^{'} REPRTORNCO LL A T A N K L E L I G A M$ 2,345.70 360 27700 26 Midlevel Revision of ankle joint $1, 837.659692770026 R e v i s i o n o f ank l e j o in t$ 2,161.95 969 27700 ARTHROPLASTY ANKLE; $2, 161.953602770226 R eco n s t r u c t ank l e j o in t$ 3,552.15 969 27702 26 Midlevel Reconstruct ankle joint $3, 019.3596927702 R eco n s t r u c t ank l e j o in t$ 3,552.15 360 27703 26 Midlevel Reconstruction, ankle joint $3, 524.509692770326 R eco n s t r u c t i o n, ank l e j o in t$ 4,146.45 969 27703 Reconstruction, ankle joint $4, 146.453602770426 R e m o v a l o f ank l e im pl an t$ 2,096.85 969 27704 26 Midlevel Removal of ankle implant $1, 782.3096927704 REMO V E A N K L E I MP L A NT$ 2,096.85 360 27705 26 Incision of tibia $2, 777.259692770526 M i d l e v e l I n c i s i o n o f t ibia$ 2,360.65 969 27705 INCISION OF TIBIA $2, 777.253602770726 I n c i s i o n o ff ib u l a$ 1,463.70 969 27707 26 Midlevel Incision of fibula $1, 244.1596927707 I NC I S I ONOFF I B UL A$ 1,463.70 360 27709 26 Midlevel Incision of tibia & fibula $3,623.55 969 27709 26 Incision of tibia & fibula$ 4,263.00 969 27709 INCISION OF TIBIA & FIBULA $4, 263.003602771226 M i d l e v e lR e a l i g nm e n t o f l o w er l e g$ 3,410.25 969 27712 26 Realignment of lower leg $4, 012.0596927712 R e a l i g nm e n t o f l o w er l e g$ 4,012.05 360 27715 26 Midlevel Revision of lower leg $3, 287.959692771526 R e v i s i o n o f l o w er l e g$ 3,868.20 969 27715 Revision of lower leg $3, 868.203602772026 M i d l e v e lR e p ai ro f t ibia$ 2,714.10 969 27720 26 Repair of tibia $3, 193.0596927720 REPN U / M U T I B I A; W OGR A FT$ 3,193.05 360 27722 26 Midlevel Repair/graft of tibia $2, 737.309692772226 R e p ai r / g r a f t o f t ibia$ 3,220.35 969 27722 Repair/graft of tibia $3, 220.353602772426 M i d l e v e lR e p ai r / g r a f t o f t ibia$ 3,938.60 969 27724 26 Repair/graft of tibia $4, 633.6596927724 R e p ai r / g r a f t o f t ibia$ 4,633.65 360 27725 26 Repair of lower leg $4, 424.709692772526 M i d l e v e lR e p ai ro f l o w er l e g$ 3,761.00 969 27725 Repair of lower leg $4, 424.7036027726 REP A I RF I B UL A NON U N I ON$ 3,501.75 360 27727 26 Midlevel Repair of lower leg $3, 153.209692772726 R e p ai ro f l o w er l e g$ 3,709.65 969 27727 Repair of lower leg $3, 709.653602773026 M i d l e v e lR e p ai ro f t ibia e p i p h ys i s$ 1,800.15 969 27730 26 Repair of tibia epiphysis $2, 117.8596927730 OPENEP I P H Y S A R D I STT I B$ 2,117.85 360 27732 26 Repair of fibula epiphysis $1, 394.409692773226 M i d l e v e lR e p ai ro ff ib u l a e p i p h ys i s$ 1,185.25 969 27732 OPEN EPIPHYS AR DIST FIB $1, 394.403602773426 R e p ai r l o w er l e g e p i p h yses$ 2,192.40 969 27734 26 Midlevel Repair lower leg epiphyses $1,863.55 969 27734 OP EPIPHYSEAL ARREST- DISTL TIB & FIB$ 2,192.40 360 27740 26 Midlevel Repair of leg epiphyses $1, 926.909692774026 R e p ai ro f l e g e p i p h yses$ 2,266.95 969 27740 TIB-FIB EPIPHYS ARRST BY STAPLING $2,266.95 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 92 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27742 26 Repair of leg epiphyses $2, 751.009692774226 M i d l e v e lR e p ai ro f l e g e p i p h yses$ 2,338.35 969 27742 TIB-FIB&FEM EPHIPHYS ARREST BY $2, 751.00360 ST A P L I NG 2774526 R e in f orce t ibia$ 2,752.05 969 27745 26 Midlevel Reinforce tibia $2, 339.2596927745 P I NP L A TE / W I RET I B I A$ 2,752.05 360 27750 26 Midlevel Treatment of tibia fracture $971.059692775026 T re a t m e n t o f t ibia f r a c t u re$ 1,142.40 969 27750 Treatment of tibia fracture $1, 142.403602775226 T re a t m e n t o f t ibia f r a c t u re$ 1,802.85 969 27752 26 Midlevel Treatment of tibia fracture $1, 532.4096927752 C L TXT I BS H FTFX W M A N I P$ 1,802.85 360 27756 26 Midlevel Treatment of tibia fracture $1, 778.759692775626 T re a t m e n t o f t ibia f r a c t u re$ 2,092.65 969 27756 PERC SKELETAL FIXATION TIBIAL SHAFT FX $2, 092.653602775826 T re a t m e n t o f t ibia f r a c t u re$ 3,239.25 969 27758 26 Midlevel Treatment of tibia fracture $2, 753.3596927758 TRE A TMENTOFT I B I A FR A CT U RE$ 3,239.25 360 27759 26 Treatment of tibia fracture $3, 640.359692775926 M i d l e v e lT re a t m e n t o f t ibia f r a c t u re$ 3,094.30 969 27759 OP/PERC TX TIB SHAFT FX BY IM IMPL $3, 640.353602776026 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 932.65 969 27760 26 Treatment of ankle fracture $1, 097.2596927760 C L TXME D I A L A N K L EFX$ 1,097.25 360 27762 26 Midlevel Treatment of ankle fracture $1, 355.709692776226 T re a t m e n t o f ank l e f r a c t u re$ 1,594.95 969 27762 CLTX MED ANKLE FX W/MNPJ $1, 594.953602776626 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 1,883.20 969 27766 26 Treatment of ankle fracture $2, 215.5096927766 OPTXME D I A L A N K L EFX$ 2,215.50 360 27767 CLTX POST ANKLE FX $1, 014.3036027768 C L TXPOST A N K L EFX W / MNP J$ 1,566.60 360 27769 OPTX POST ANKLE FX $2, 638.653602778026 T re a t m e n t o ff ib u l a f r a c t u re$ 998.55 969 27780 26 Midlevel Treatment of fibula fracture $848.7596927780 C L TXPROXF I B / S H A FTFX W OM A N I P$ 998.55 360 27781 26 Treatment of fibula fracture $1, 428.009692778126 M i d l e v e lT re a t m e n t o ff ib u l a f r a c t u re$ 1,213.80 969 27781 CL TX PROX FIB/SHAFT FX W MANIP $1, 428.003602778426 M i d l e v e lT re a t m e n t o ff ib u l a f r a c t u re$ 2,208.95 969 27784 26 Treatment of fibula fracture $2, 598.7596927784 TRE A TMENTOFF I B UL A FR A CT U RE$ 2,598.75 360 27786 26 Midlevel Treatment of ankle fracture $874.659692778626 T re a t m e n t o f ank l e f r a c t u re$ 1,029.00 969 27786 CL TX DSTL FIB FX WO MANIP $1, 029.003602778826 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 1,191.50 969 27788 26 Treatment of ankle fracture $1, 401.7596927788 C L TX D I ST L F I BFX W M A N I P$ 1,401.75 360 27792 26 Treatment of ankle fracture $2, 386.659692779226 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 2,028.65 969 27792 OPEN TX DISTAL FIBULAR FRACT LAT $2, 386.65360 M A LL EO LU S 2780826 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 918.40 969 27808 26 Treatment of ankle fracture $1, 080.4596927808 C L TXB I M A LL EO L A R A N K L EFR A CT W OMNP$ 1,080.45 360 27810 26 Midlevel Treatment of ankle fracture $1,324.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 93 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27810 26 Treatment of ankle fracture $1, 558.2096927810 T re a t m e n t o f ank l e f r a c t u re$ 1,558.20 360 27814 26 Treatment of ankle fracture $2, 815.059692781426 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 2,392.80 969 27814 OPEN TX BIMALLEOLAR ANKLE FRACTURE $2, 815.053602781626 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 872.85 969 27816 26 Treatment of ankle fracture $1, 026.9096927816 C L TXTR I M A LL A N K L EFX; W OM A N I P$ 1,026.90 360 27818 26 Midlevel Treatment of ankle fracture $1, 345.909692781826 T re a t m e n t o f ank l e f r a c t u re$ 1,583.40 969 27818 Treatment of ankle fracture $1, 583.403602782226 T re a t m e n t o f ank l e f r a c t u re$ 3,075.45 969 27822 26 Midlevel Treatment of ankle fracture $2, 614.1596927822 OPENTXTR I M A LL EO L A R A N K L EFX W OF I X$ 3,075.45 360 PST LIP 27823 26 Midlevel Treatment of ankle fracture $2, 964.909692782326 T re a t m e n t o f ank l e f r a c t u re$ 3,488.10 969 [Rows 5001-6000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 27823 OPEN TX TRIMALLEOLAR ANKLE FX W FIX $3, 488.10360 PST L I P 2782426 M i d l e v e lT re a tl o w er l e g f r a c t u re$ 929.10 969 27824 26 Treat lower leg fracture $1, 093.0596927824 C L TX W B D ST L T I B W OM A N I P$ 1,093.05 360 27825 26 Midlevel Treat lower leg fracture $1, 530.659692782526 T re a tl o w er l e g f r a c t u re$ 1,800.75 969 27825 CL TX WB DSTL TIB FX W MANIP $1, 800.753602782626 M i d l e v e lT re a tl o w er l e g f r a c t u re$ 2,574.85 969 27826 26 Treat lower leg fracture $3, 029.2596927826 OPENTXFR A CT U RE D I ST A L T I B I A F I B UL A$ 3,029.25 360 27827 26 Treat lower leg fracture $3, 953.259692782726 M i d l e v e lT re a tl o w er l e g f r a c t u re$ 3,360.25 969 27827 OPEN TX FRACTURE DISTAL TIBIA ONLY $3, 953.253602782826 T re a tl o w er l e g f r a c t u re$ 4,729.20 969 27828 26 Midlevel Treat lower leg fracture $4, 019.8096927828 T re a tl o w er l e g f r a c t u re$ 4,729.20 360 27829 26 Midlevel Treat lower leg joint $2, 112.559692782926 T re a tl o w er l e g j o in t$ 2,485.35 969 27829 TREAT LOWER LEG JOINT $2, 485.353602783026 T re a tl o w er l e g d i s l oc a t i o n$ 1,261.05 969 27830 26 Midlevel Treat lower leg dislocation $1, 071.9096927830 C L TXPROXT I B - F I B J NT D I S L; W O A NEST H$ 1,261.05 360 27831 26 Midlevel Treat lower leg dislocation $1, 214.709692783126 T re a tl o w er l e g d i s l oc a t i o n$ 1,429.05 969 27831 CL TX PROX TIB-FIB JNT DISL; W ANESTH $1, 429.053602783226 M i d l e v e lT re a tl o w er l e g d i s l oc a t i o n$ 2,305.35 969 27832 26 Treat lower leg dislocation $2, 712.1596927832 TRE A T L O W ER L EG D I S L OC A T I ON$ 2,712.15 360 27840 26 Treat ankle dislocation $1, 323.009692784026 M i d l e v e lT re a t ank l e d i s l oc a t i o n$ 1,124.55 969 27840 CL TX ANKLE DISLOCATION; WO ANESTH $1, 323.003602784226 T re a t ank l e d i s l oc a t i o n$ 1,789.20 969 27842 26 Midlevel Treat ankle dislocation $1, 520.8096927842 C L TX A N K L E D I S L OC W A NEST H$ 1,789.20 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 94 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 27846 26 Midlevel Treat ankle dislocation $2, 275.009692784626 T re a t ank l e d i s l oc a t i o n$ 2,676.45 969 27846 OP TX ANKLE DISLOCATION; WO REPAIR $2, 676.453602784826 T re a t ank l e d i s l oc a t i o n$ 2,980.95 969 27848 26 Midlevel Treat ankle dislocation $2, 533.8096927848 OPTX A N K L E D I S L OC W REPR / EXTF I X$ 2,980.95 360 27860 26 Fixation of ankle joint $643.659692786026 M i d l e v e lF i x a t i o n o f ank l e j o in t$ 547.10 969 27860 MANIPULATE ANKLE UNDER GEN ANESTH $643.653602787026 F u s i o n o f ank l e j o in t, o p e n$ 3,789.45 969 27870 26 Midlevel Fusion of ankle joint, open $3, 221.0596927870 OPEN A N K L E J NTF U S I ON$ 3,789.45 360 27871 26 Fusion of tibiofibular joint $2, 525.259692787126 M i d l e v e lF u s i o n o f t ibi o f ib u l a r j o in t$ 2,146.45 969 27871 ARTHROD TIB-FIB JNT PROX OR DISTAL $2, 525.253602788026 A m p u t a t i o n o f l o w er l e g$ 3,412.50 969 27880 26 Midlevel Amputation of lower leg $2, 900.6596927880 A m p u t a t i o n o f l o w er l e g$ 3,412.50 360 27881 26 Midlevel Amputation of lower leg $2, 753.359692788126 A m p u t a t i o n o f l o w er l e g$ 3,239.25 969 27881 Amputation of lower leg $3, 239.253602788226 A m p u t a t i o n o f l o w er l e g$ 2,270.10 969 27882 26 Midlevel Amputation of lower leg $1, 929.6096927882 A m p u t a t i o n o f l o w er l e g$ 2,270.10 360 27884 26 Amputation follow-up surgery $2, 146.209692788426 M i d l e v e l A m p u t a t i o n f o ll o w - u p s u r g ery$ 1,824.25 969 27884 Amputation follow-up surgery $2, 146.203602788626 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,466.45 969 27886 26 Midlevel Amputation follow-up surgery $2, 096.5096927886 A m p u t a t i o n f o ll o w - u p s u r g ery$ 2,466.45 360 27888 26 Amputation of foot at ankle $2, 513.709692788826 M i d l e v e l A m p u t a t i o n o ff oo t a t ank l e$ 2,136.65 969 27888 Amputation of foot at ankle $2, 513.703602788926 M i d l e v e l A m p u t a t i o n o ff oo t a t ank l e$ 2,100.95 969 27889 26 Amputation of foot at ankle $2, 471.7096927889 A MP U T A TEFOOT A T A N K L E$ 2,471.70 360 27892 26 Midlevel Decompression of leg $1, 735.009692789226 Deco m p ress i o n o f l e g$ 2,041.20 969 27892 DECOMPRESS ANT/LAT CMPRT LEG W DEBR $2, 041.203602789326 M i d l e v e l Deco m p ress i o n o f l e g$ 1,855.50 969 27893 26 Decompression of leg $2, 182.9596927893 D ECOMPRESSPOSTCMPRTM L EG W$ 2,182.95 360 DEBRIDE 27894 26 Decompression of leg $3, 163.659692789426 M i d l e v e l Deco m p ress i o n o f l e g$ 2,689.10 969 27894 DECOMPRESS ANT/LAT CMPRTM LEG W $3, 163.65360 D EBR I D EM 27899 L e g / ank l es u r g ery p roce d u re$ 429.80 360 28001 26 Drainage of bursa of foot $616.359692800126 M i d l e v e l Dr aina g eo f b u rs a o ff oo t$ 523.90 969 28001 I & D INFECTED BURSA; FOOT $616.353602800226 M i d l e v e lT re a t m e n t o ff oo t in f ec t i o n$ 1,020.15 969 28002 26 Treatment of foot infection $1, 200.1596928002 D EEP D I SSECTFOOT I NF; SG L B U RS A SP$ 1,200.15 360 28003 26 Midlevel Treatment of foot infection $1, 746.609692800326 T re a t m e n t o ff oo t in f ec t i o n$ 2,054.85 969 28003 DEEP DISSECT FOOT INF; MULTI AREAS $2,054.85 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 95 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28005 26 Midlevel Treat foot bone lesion $1, 816.259692800526 T re a t f oo t b o n e l es i o n$ 2,136.75 969 28005 DEEP INC FOOT W OP BONE CORTEX $2, 136.753602800826 M i d l e v e l I n c i s i o n o ff oo t f a sc ia$ 910.35 969 28008 26 Incision of foot fascia $1, 071.0096928008 I NC I SEFOOT / TOEF A SC I A$ 1,071.00 360 28010 26 Incision of toe tendon $764.409692801026 M i d l e v e l I n c i s i o n o f t oe t e n d o n$ 649.75 969 28010 TENOTOMY SQ TOE; SINGLE $764.403602801126 I n c i s i o n o f t oe t e n d o n s$ 1,075.20 969 28011 26 Midlevel Incision of toe tendons $913.9096928011 I NCM UL T I SQTOETEN D ONS$ 1,075.20 360 28020 26 Midlevel Exploration of foot joint $1, 101.359692802026 E x pl or a t i o n o ff oo t j o in t$ 1,295.70 969 28020 EXPL W DRAIN/REM FB - IT/MT FOOT JNT $1, 295.703602802226 M i d l e v e lE x pl or a t i o n o ff oo t j o in t$ 996.90 969 28022 26 Exploration of foot joint $1, 172.8596928022 EXP L W D R / REMFB - MTPFOOT J O I NT$ 1,172.85 360 28024 26 Exploration of toe joint $1, 100.409692802426 M i d l e v e lE x pl or a t i o n o f t oe j o in t$ 935.35 969 28024 EXPL W DR/REM FB - IP FOOT JNT $1, 100.403602803526 Deco m p ress i o n o f t ibian er v e$ 1,298.85 969 28035 26 Midlevel Decompression of tibia nerve $1, 104.0096928035 T A RS A L T U NNE L RE L E A SET I B I A L NER V E$ 1,298.85 360 28039 EXC FOOT/TOE TUM SC >=1.5 CM $1, 308.303602803926 EXC I S I ONT U MORSOFTT I SFOOT / TOES U BQ$ 1,040.10 960 1.5 CM/> 28041 EXC FOOT/TOE TUM DEP >=1.5 CM $1, 720.953602804326 M i d l e v e lE x c i s i o n o ff oo tl es i o n$ 819.30 969 28043 26 Excision of foot lesion $963.9096928043 EXCFOOT / TOET U MSC < 1.5 CM$ 963.90 360 28045 26 Midlevel Excision of foot lesion $1, 089.759692804526 E x c i s i o n o ff oo tl es i o n$ 1,282.05 969 28045 EXC FOOT/TOE TUM DEEP <1.5 CM $1, 282.053602804626 R esec t i o n o f t u m or, f oo t$ 2,702.70 969 28046 26 Midlevel Resection of tumor, foot $2, 297.3096928046 RESECTFOOT / TOET U MOR < 3 CM$ 2,702.70 360 28047 RESECT FOOT/TOE TUMOR >=3 CM $3, 762.153602805026 B i o p syo ff oo t j o in tl inin g$ 1,105.65 969 28050 26 Midlevel Biopsy of foot joint lining $939.8096928050 S Y NO V I A L BXT A RS A L J O I NT$ 1,105.65 360 28052 26 Midlevel Biopsy of foot joint lining $866.609692805226 B i o p syo ff oo t j o in tl inin g$ 1,019.55 969 28052 SYNOVIAL MTP JOINT BX $1, 019.553602805426 B i o p syo f t oe j o in tl inin g$ 869.40 969 28054 26 Midlevel Biopsy of toe joint lining $739.0096928054 S Y NO V I A L I P J NTBX$ 869.40 360 28055 26 Neurectomy, foot $1, 372.359692805526 M i d l e v e lN e u rec t o m y, f oo t$ 1,166.50 969 28055 NEURECTOMY FOOT $1, 372.353602806026 P a r t ia l re m o v a l, f oo t f a sc ia$ 1,288.35 969 28060 26 Midlevel Partial removal, foot fascia $1, 095.1096928060 P A RT I A L REMFOOTP L A NT A RF A SC I A$ 1,288.35 360 28062 26 Removal of foot fascia $1, 482.609692806226 M i d l e v e lR e m o v a l o ff oo t f a sc ia$ 1,260.20 969 28062 RADICAL REMOV FOOT PLANTAR FASCIA $1, 482.603602807026 R e m o v a l o ff oo t j o in tl inin g$ 1,287.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 96 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28070 26 Midlevel Removal of foot joint lining $1, 094.2096928070 REM I T / MTFOOT J NT L I N I NGE A$ 1,287.30 360 28072 26 Midlevel Removal of foot joint lining $1, 054.059692807226 R e m o v a l o ff oo t j o in tl inin g$ 1,240.05 969 28072 REMOVE MTP FOOT JNT LINING EA $1, 240.053602808026 R e m o v a l o ff oo tl es i o n$ 1,318.80 969 28080 26 Midlevel Removal of foot lesion $1, 121.0096928080 EXC I NTER D I GMORTONNE U ROM A E A SG L$ 1,318.80 360 28086 26 Midlevel Excise foot tendon sheath $1, 112.059692808626 E x c i se f oo tt e n d o n s h e a t h$ 1,308.30 969 28086 EXC FOOT FLEXOR TENDON SHTH $1, 308.303602808826 M i d l e v e lE x c i se f oo tt e n d o n s h e a t h$ 921.95 969 28088 26 Excise foot tendon sheath $1, 084.6596928088 EXCFOOTEXTNSRTEN D ONS H T H$ 1,084.65 360 28090 26 Midlevel Removal of foot lesion $953.209692809026 R e m o v a l o ff oo tl es i o n$ 1,121.40 969 28090 EXC FOOT CYST/GANGLION $1, 121.403602809226 M i d l e v e lR e m o v a l o f t oe l es i o n s$ 837.15 969 28092 26 Removal of toe lesions $984.9096928092 R e m o v a l o f t oe l es i o n s$ 984.90 360 28100 26 Removal of ankle/heel lesion $1, 477.359692810026 M i d l e v e lR e m o v a l o f ank l e / h ee ll es i o n$ 1,255.75 969 28100 EXC HEEL TALUS/CALCAN CYST/TUMOR $1, 477.353602810226 M i d l e v e lR e m o v e / g r a f t f oo tl es i o n$ 1,463.70 969 28102 26 Remove/graft foot lesion $1, 722.0096928102 EXCT A LU S / C A L C A NSC Y ST / T U MR W$ 1,722.00 360 AUTOGRFT 28103 26 Midlevel Remove/graft foot lesion $1, 237.009692810326 R e m o v e / g r a f t f oo tl es i o n$ 1,455.30 969 28103 EXC TALUS/CALCAN CYST/TUMR W $1, 455.30360 A LL OGR A FT 2810426 R e m o v a l o ff oo tl es i o n$ 1,261.05 969 28104 26 Midlevel Removal of foot lesion $1, 071.9096928104 EXCT A RS A L / MET A TR A SC Y ST / T U MOR$ 1,261.05 360 28106 26 Midlevel Remove/graft foot lesion $1, 342.309692810626 R e m o v e / g r a f t f oo tl es i o n$ 1,579.20 969 28106 EXC TRSL/MTRSL CYST/TUMOR W $1, 579.20360 A U TOGR A FT 2810726 R e m o v e / g r a f t f oo tl es i o n$ 1,288.35 969 28107 26 Midlevel Remove/graft foot lesion $1, 095.1096928107 EXCTRS L / MTRS L C Y ST / T U MOR W$ 1,288.35 360 ALLOGRFT 28108 26 Removal of toe lesions $1, 039.509692810826 M i d l e v e lR e m o v a l o f t oe l es i o n s$ 883.60 969 28108 EXC BC/BT FOOT PHALANGE $1, 039.503602811026 M i d l e v e lP a r t re m o v a l o f m e t a t a rs a l$ 894.30 969 28110 26 Part removal of metatarsal $1, 052.1096928110 PRT L EXC 5 T H MET A TRS L H E A D$ 1,052.10 360 28111 26 Midlevel Part removal of metatarsal $1, 031.759692811126 P a r t re m o v a l o f m e t a t a rs a l$ 1,213.80 969 28111 COMPL EXC 1ST METATRSL HEAD $1, 213.803602811226 P a r t re m o v a l o f m e t a t a rs a l$ 1,146.60 969 28112 26 Midlevel Part removal of metatarsal $974.6096928112 COMP L EXCOT H RMET A TRS L H E A D$ 1,146.60 360 28113 26 Part removal of metatarsal $1, 552.959692811326 M i d l e v e lP a r t re m o v a l o f m e t a t a rs a l$ 1,320.00 969 28113 COMPL EXC 5TH METATRSL HEAD $1,552.95 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 97 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28114 26 Midlevel Removal of metatarsal heads $2, 591.809692811426 R e m o v a l o f m e t a t a rs a l h e a d s$ 3,049.20 969 28114 COMPL EXC ALL METATRSL HDS $3, 049.203602811626 R e v i s i o n o ff oo t$ 2,083.20 969 28116 26 Midlevel Revision of foot $1, 770.7096928116 EXCOFT A RS A L CO A L I T I ON$ 2,083.20 360 28118 26 Midlevel Removal of heel bone $1, 274.509692811826 R e m o v a l o f h ee l b o n e$ 1,499.40 969 28118 CALCANEUS REMOVAL $1, 499.403602811926 R e m o v a l o f h ee l s p u r$ 1,313.55 969 28119 26 Midlevel Removal of heel spur $1, 116.5096928119 REMO V E H EE L SP U R$ 1,313.55 360 28120 26 Part removal of ankle/heel $1, 782.909692812026 M i d l e v e lP a r t re m o v a l o f ank l e / h ee l$ 1,515.45 969 28120 PARTL EXC ANKLE OR HEEL BONE $1, 782.903602812226 M i d l e v e lP a r t ia l re m o v a l o ff oo t b o n e$ 1,385.15 969 28122 26 Partial removal of foot bone $1, 629.6096928122 P a r t ia l re m o v a l o ff oo t b o n e$ 1,629.60 360 28124 26 Partial removal of toe $1, 200.159692812426 M i d l e v e lP a r t ia l re m o v a l o f t oe$ 1,020.15 969 28124 PARTIAL EXC PHALANX TOE BONE $1, 200.153602812626 M i d l e v e lP a r t ia l re m o v a l o f t oe$ 772.00 969 28126 26 Partial removal of toe $908.2596928126 RESECTP H A L A NG L BSSG L TOEE A$ 908.25 360 28130 26 Midlevel Removal of ankle bone $2, 046.509692813026 R e m o v a l o f ank l e b o n e$ 2,407.65 969 28130 REMOVE ANKLE BONE $2, 407.653602814026 M i d l e v e lR e m o v a l o f m e t a t a rs a l$ 1,384.25 969 28140 26 Removal of metatarsal $1, 628.5596928140 REMO V EMET A T A RS A L$ 1,628.55 360 28150 26 Midlevel Removal of toe $879.109692815026 R e m o v a l o f t oe$ 1,034.25 969 28150 REMOVE SGLE TOE PHALNGE EA $1, 034.253602815326 P a r t ia l re m o v a l o f t oe$ 964.95 969 28153 26 Midlevel Partial removal of toe $820.2096928153 RESECT HD OFTOEP H A L A NX$ 964.95 360 28160 26 Midlevel Partial removal of toe $841.659692816026 P a r t ia l re m o v a l o f t oe$ 990.15 969 28160 INTERPHALANG TOE JNT EXC EA SGL $990.153602817126 E x t e n s i v e f oo t s u r g ery$ 3,058.65 969 28171 26 Midlevel Extensive foot surgery $2, 599.8596928171 RESECTT A RS A L T U MOR$ 3,058.65 360 28173 26 Extensive foot surgery $2, 780.409692817326 M i d l e v e lE x t e n s i v e f oo t s u r g ery$ 2,363.35 969 28173 RESECT METATARSAL TUMOR $2, 780.403602817526 E x t e n s i v e f oo t s u r g ery$ 1,756.65 969 28175 26 Midlevel Extensive foot surgery $1, 493.1596928175 RESECTP H A L A NXOFTOET U MOR$ 1,756.65 360 28190 26 Midlevel Removal of foot foreign body $414.109692819026 R e m o v a l o ff oo t f ore i g nb o d y$ 487.20 969 28190 REM FB FOOT; SQ $487.203602819226 R e m o v a l o ff oo t f ore i g nb o d y$ 1,151.85 969 28192 26 Midlevel Removal of foot foreign body $979.0596928192 REM D EEPFBOFFOOT$ 1,151.85 360 28193 26 Removal of foot foreign body $1, 358.709692819326 M i d l e v e lR e m o v a l o ff oo t f ore i g nb o d y$ 1,154.90 969 28193 COMPLIC REM FB FROM FOOT $1,358.70 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 98 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28200 26 Midlevel Repair of foot tendon $978.209692820026 R e p ai ro ff oo tt e n d o n$ 1,150.80 969 28200 REPR FOOT FLEXOR TENDON EA $1, 150.803602820226 R e p ai r / g r a f t o ff oo tt e n d o n$ 1,541.40 969 28202 26 Midlevel Repair/graft of foot tendon $1, 310.2096928202 2^{'} REPRFOOTF L EXORTEN D W FREEGRFT$ 1,541.40 360 28208 26 Midlevel Repair of foot tendon $950.509692820826 R e p ai ro ff oo tt e n d o n$ 1,118.25 969 28208 REPR FOOT EXTENSOR TENDON EA $1, 118.253602821026 R e p ai r / g r a f t o ff oo tt e n d o n$ 1,481.55 969 28210 26 Midlevel Repair/graft of foot tendon $1, 259.3096928210 2^{'} REPRFOOTEXTNSRTEN D ON W FREEGRFT$ 1,481.55 360 EA 28220 26 Release of foot tendon $1, 100.409692822026 M i d l e v e lR e l e a seo ff oo tt e n d o n$ 935.35 969 28220 TENOLYSIS FOOT FLEXOR; SINGLE $1, 100.403602822226 R e l e a seo ff oo tt e n d o n s$ 1,282.05 969 28222 26 Midlevel Release of foot tendons $1, 089.7596928222 RE L E A SEFOOTF L EXORSM UL T I$ 1,282.05 360 28225 26 Release of foot tendon $940.809692822526 M i d l e v e lR e l e a seo ff oo tt e n d o n$ 799.70 969 28225 RELEASE FOOT EXTNSOR TENDON SGL $940.803602822626 R e l e a seo ff oo tt e n d o n s$ 1,130.85 969 28226 26 Midlevel Release of foot tendons $961.2096928226 RE L E A SEFOOTEXTNSORTEN D ONM UL T I$ 1,130.85 360 28230 26 Midlevel Incision of foot tendon(s) $877.359692823026 I n c i s i o n o ff oo tt e n d o n (s)$ 1,032.15 969 28230 TENOTOMY OP FLEXOR; FT SGL/MULTI $1, 032.153602823226 I n c i s i o n o f t oe t e n d o n$ 901.95 969 28232 26 Midlevel Incision of toe tendon $766.6596928232 TENOTOM Y OPF L EXOR; TOES I NG L E$ 901.95 360 28234 26 Midlevel Incision of foot tendon $824.659692823426 I n c i s i o n o ff oo tt e n d o n$ 970.20 969 28234 OP INC FOOT/TOE EXTENSOR TENDON $970.203602823826 R e v i s i o n o ff oo tt e n d o n$ 1,797.60 969 28238 26 Midlevel Revision of foot tendon $1, 527.9596928238 A D V POSTT I B I A L TEN D ON W EXCN A V I C L R$ 1,797.60 360 BONE 28240 26 Release of big toe $1, 061.559692824026 M i d l e v e lR e l e a seo f bi g t oe$ 902.30 969 28240 LENGTH/RELS ABD HALLUCIS MSCL $1, 061.553602825026 M i d l e v e lR e v i s i o n o ff oo t f a sc ia$ 1,237.00 969 28250 26 Revision of foot fascia $1,455.30 969 28250 DIVIDE PLANTAR FASCIA & MSCL$ 1,455.30 360 28260 26 Release of midfoot joint $1, 893.159692826026 M i d l e v e lR e l e a seo f mi df oo t j o in t$ 1,609.20 969 28260 CAPSULOTOMY MIDFOOT; MED RELEASE $1, 893.153602826126 M i d l e v e lR e v i s i o n o ff oo tt e n d o n$ 2,385.65 969 28261 26 Revision of foot tendon $2, 806.6596928261 C A PS UL OTOM Y M I D FOOT; TEN D L ENGT H EN$ 2,806.65 360 28262 26 Revision of foot and ankle $4, 225.209692826226 M i d l e v e lR e v i s i o n o ff oo t an d ank l e$ 3,591.40 969 28262 EXTENSIVE MIDFOOT CAPSULOTOMY $4, 225.203602826426 M i d l e v e lR e l e a seo f mi df oo t j o in t$ 2,207.15 969 28264 26 Release of midfoot joint $2, 596.6596928264 C A PS UL OTOM Y M I D T A RS A L$ 2,596.65 360 28270 26 Release of foot contracture $1,219.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 99 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28270 26 Midlevel Release of foot contracture $1, 036.2096928270 MTP J NTC A PS UL OTOM Y E A SG L J NT$ 1,219.05 360 28272 26 Midlevel Release of toe joint, each $786.309692827226 R e l e a seo f t oe j o in t, e a c h$ 925.05 969 28272 CAPSULOTOMY; IP JNT SGL EA JOINT $925.053602828026 F u s i o n o f t oes$ 1,305.15 969 28280 26 Midlevel Fusion of toes $1, 109.4096928280 TOE W EBB I NGOP$ 1,305.15 360 28285 26 Midlevel Repair of hammertoe $1, 144.209692828526 R e p ai ro f hamm er t oe$ 1,346.10 969 28285 HAMMERTOE OP ONE TOE $1, 346.103602828626 R e p ai ro f hamm er t oe$ 1,097.25 969 28286 26 Midlevel Repair of hammertoe $932.6596928286 COC K - U P 5 T H TOE W P L STCC L OSE$ 1,097.25 360 28288 26 Partial removal of foot bone $1, 573.959692828826 M i d l e v e lP a r t ia l re m o v a l o ff oo t b o n e$ 1,337.85 969 28288 PRTL REM FOOT BONE MTRSL HD 1-5 EA $1, 573.953602828926 R e p ai r ha ll ux r i g i d u s$ 2,003.40 969 28289 26 Midlevel Repair hallux rigidus $1, 702.9096928289 CORR J H A LU XR I G D U S W / O I MP L T$ 2,003.40 360 28292 26 Midlevel Correction of bunion $1, 856.409692829226 C orrec t i o n o f b u ni o n$ 2,184.00 969 28292 CORRECTION HALLUX VALGUS $2, 184.003602829626 M i d l e v e lC orrec t i o n o f b u ni o n$ 1,616.30 969 28296 26 Correction of bunion $1, 901.5596928296 CORRECT I ON H A LLU X V A L G U S$ 1,901.55 360 28297 26 Midlevel Correction of bunion $1, 827.859692829726 C orrec t i o n o f b u ni o n$ 2,150.40 969 28297 CORRECTION HALLUX VALGUS $2, 150.403602829826 C orrec t i o n o f b u ni o n$ 1,835.40 969 28298 26 Midlevel Correction of bunion $1, 560.1096928298 CORRECT I ON H A LLU X V A L G U S$ 1,835.40 360 28299 26 Correction of bunion $2, 461.209692829926 M i d l e v e lC orrec t i o n o f b u ni o n$ 2,092.00 969 28299 CORRECTION HALLUX VALGUS $2, 461.203602830026 I n c i s i o n o f h ee l b o n e$ 2,402.40 969 28300 26 Midlevel Incision of heel bone $2, 042.0596928300 OSTEOTOM Y; C A L C A NE U S$ 2,402.40 360 28302 26 Incision of ankle bone $2, 564.109692830226 M i d l e v e l I n c i s i o n o f ank l e b o n e$ 2,179.50 969 28302 OSTEOTOMY; TALUS $2, 564.103602830426 M i d l e v e l I n c i s i o n o f mi df oo t b o n es$ 1,843.00 969 28304 26 Incision of midfoot bones $2, 168.2596928304 OSTEOTOM Y M I D TBONE$ 2,168.25 360 28305 26 Incise/graft midfoot bones $2, 346.759692830526 M i d l e v e l I n c i se / g r a f t mi df oo t b o n es$ 1,994.75 969 28305 OSTEOTOMY MIDT BONES; W AUTOGRAFT $2, 346.753602830626 I n c i s i o n o f m e t a t a rs a l$ 1,481.55 969 28306 26 Midlevel Incision of metatarsal $1, 259.3096928306 MTTOS H ORTEN; 1 STMT$ 1,481.55 360 28307 26 Midlevel Incision of metatarsal $1, 436.909692830726 I n c i s i o n o f m e t a t a rs a l$ 1,690.50 969 28307 MT SHORTEN; 1ST MT W ALLOGR $1, 690.503602830826 M i d l e v e l I n c i s i o n o f m e t a t a rs a l$ 1,156.70 969 28308 26 Incision of metatarsal $1, 360.8096928308 MTS H ORTENNOT 1 STMT$ 1,360.80 360 28309 26 Midlevel Incision of metatarsals $2,742.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 100 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28309 26 Incision of metatarsals $3, 226.6596928309 MTM UL T I P L FORC A V U SFOOT$ 3,226.65 360 28310 26 Revision of big toe $1, 285.209692831026 M i d l e v e lR e v i s i o n o f bi g t oe$ 1,092.40 969 28310 SHORTEN; PROX PHALYNX 1ST TOE $1, 285.203602831226 R e v i s i o n o f t oe$ 1,163.40 969 28312 26 Midlevel Revision of toe $988.9096928312 S H ORTENP H A L A NGE A N Y TOE$ 1,163.40 360 28313 26 Midlevel Repair deformity of toe $1, 110.259692831326 R e p ai r d e f or mi t yo f t oe$ 1,306.20 969 28313 RECONSTR ANGLE TOE DEFORMITY ST $1, 306.203602831526 R e m o v a l o f ses am o i d b o n e$ 1,180.20 969 28315 26 Midlevel Removal of sesamoid bone $1, 003.1596928315 SES A MO I D ECTOM Y F I RSTTOE$ 1,180.20 360 28320 26 Midlevel Repair of foot bones $1, 910.859692832026 R e p ai ro ff oo t b o n es$ 2,248.05 969 28320 REP NU/MU; TARSAL BONES $2, 248.053602832226 R e p ai ro f m e t a t a rs a l s$ 2,106.30 969 28322 26 Midlevel Repair of metatarsals $1, 790.3596928322 REPN U / M U; MET A T A RS A L$ 2,106.30 360 28340 26 Midlevel Resect enlarged toe tissue $1, 289.659692834026 R esec t e n l a r g e d t oe t i ss u e$ 1,517.25 969 28340 RECONST TOE MACRODACTYLY; ST $1, 517.253602834126 R esec t e n l a r g e d t oe$ 1,801.80 969 28341 26 Midlevel Resect enlarged toe $1, 531.5596928341 RECONSTRTOEM A CRO D A CT Y L Y; W BR$ 1,801.80 360 28344 26 Midlevel Repair extra toe(s) $971.959692834426 R e p ai re x t r a t oe (s)$ 1,143.45 969 28344 RECONSTR TOE(S); POLYDACTYLY $1, 143.453602834526 R e p ai r w e bb e d t oe (s)$ 1,353.45 969 28345 26 Midlevel Repair webbed toe(s) $1, 150.4596928345 RECONSTR U CTTOE (S); S Y N D A CT Y L Y$ 1,353.45 360 28360 26 Reconstruct cleft foot $3, 889.209692836026 M i d l e v e lR eco n s t r u c t c l e f t f oo t$ 3,305.80 969 28360 Reconstruct cleft foot $3, 889.203602840026 T re a t m e n t o f h ee l f r a c t u re$ 821.10 969 28400 26 Midlevel Treatment of heel fracture $697.9596928400 C L TXC A L C A NE A L FX; W OM A N I P$ 821.10 360 28405 26 Midlevel Treatment of heel fracture $1, 079.059692840526 T re a t m e n t o f h ee l f r a c t u re$ 1,269.45 969 28405 CL TX CALCANEAL FX; W MANIP $1, 269.453602840626 M i d l e v e lT re a t m e n t o f h ee l f r a c t u re$ 1,638.65 969 28406 26 Treatment of heel fracture $1, 927.8096928406 PERCS K E L ET A L F I X A T I ONC A L C A NE A L FX$ 1,927.80 360 28415 26 Midlevel Treat heel fracture $3, 456.659692841526 T re a t h ee l f r a c t u re$ 4,066.65 969 28415 TREAT HEEL FRACTURE $4, 066.653602842026 T re a t / g r a f t h ee l f r a c t u re$ 4,521.30 969 28420 26 Midlevel Treat/graft heel fracture $3, 843.1096928420 TRE A T / GR A FT H EE L FR A CT U RE$ 4,521.30 360 28430 26 Treatment of ankle fracture $753.909692843026 M i d l e v e lT re a t m e n t o f ank l e f r a c t u re$ 640.80 969 28430 CL TX TALUS FX; WO MANIP $753.903602843526 T re a t m e n t o f ank l e f r a c t u re$ 946.05 969 28435 26 Midlevel Treatment of ankle fracture $804.1596928435 C L TXT A LU SFX; W M A N I P$ 946.05 360 28436 26 Treatment of ankle fracture $1,615.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 101 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28436 26 Midlevel Treatment of ankle fracture $1, 373.5596928436 PERCS K E L ET A L F I X A T I ONOFT A LU SFX$ 1,615.95 360 28445 26 Midlevel Treat ankle fracture $3, 315.659692844526 T re a t ank l e f r a c t u re$ 3,900.75 969 28445 TREAT ANKLE FRACTURE $3, 900.7536028446 OSTEOC H ON D R A L T A LU S A U TOGRFT$ 4,425.75 360 28450 26 Treat midfoot fracture, each $696.159692845026 M i d l e v e lT re a t mi df oo t f r a c t u re, e a c h$ 591.75 969 28450 TX TARSAL BONE FX ; WO MANIPU $696.153602845526 T re a t mi df oo t f r a c t u re, e a c h$ 948.15 969 28455 26 Midlevel Treat midfoot fracture, each $805.9596928455 TXT A RS A L BONEFX; W M A N I P$ 948.15 360 28456 26 Treat midfoot fracture $1, 125.609692845626 M i d l e v e lT re a t mi df oo t f r a c t u re$ 956.75 969 28456 PERC SK FIX TARSAL BONE FX; W MANIP $1, 125.603602846526 M i d l e v e lT re a t mi df oo t f r a c t u re, e a c h$ 1,912.65 969 28465 26 Treat midfoot fracture, each $2, 250.1596928465 TRE A TM I D FOOTFR A CT U REE A C H$ 2,250.15 360 28470 26 Midlevel Treat metatarsal fracture $588.159692847026 T re a t m e t a t a rs a l f r a c t u re$ 691.95 969 28470 CL TX METATARSAL FX; WO MANIP $691.953602847526 M i d l e v e lT re a t m e t a t a rs a l f r a c t u re$ 712.20 969 28475 26 Treat metatarsal fracture $837.9096928475 T re a t m e t a t a rs a l f r a c t u re$ 837.90 360 28476 26 Midlevel Treat metatarsal fracture $1, 073.709692847626 T re a t m e t a t a rs a l f r a c t u re$ 1,263.15 969 28476 PERC SK FIX METATARSAL FX W MANIP $1, 263.153602848526 M i d l e v e lT re a t m e t a t a rs a l f r a c t u re$ 1,632.40 969 28485 26 Treat metatarsal fracture $1, 920.4596928485 TRE A TMET A T A RS A L FR A CT U RE$ 1,920.45 360 28490 26 Treat big toe fracture $449.409692849026 M i d l e v e lT re a t bi g t oe f r a c t u re$ 382.00 969 28490 CL TX FX GT PHALANX(S); WO MANIP $449.403602849526 M i d l e v e lT re a t bi g t oe f r a c t u re$ 465.00 969 28495 26 Treat big toe fracture $547.0596928495 C L TXFXGTP H A L A NX (S); W M A N I P$ 547.05 360 28496 26 Midlevel Treat big toe fracture $707.759692849626 T re a t bi g t oe f r a c t u re$ 832.65 969 28496 PERC SKEL FIX FX GT; W MANIP $832.653602850526 M i d l e v e lT re a t bi g t oe f r a c t u re$ 1,537.80 969 28505 26 Treat big toe fracture $1, 809.1596928505 TRE A TB I GTOEFR A CT U RE$ 1,809.15 360 28510 26 Treatment of toe fracture $429.459692851026 M i d l e v e lT re a t m e n t o f t oe f r a c t u re$ 365.05 969 28510 CL TX FX PHALNX/PHALANG WO MANIP $429.453602851526 M i d l e v e lT re a t m e n t o f t oe f r a c t u re$ 435.55 969 28515 26 Treatment of toe fracture $512.4096928515 C L TXFXP H A L A NX / P H A L A NG; W M A N I P$ 512.40 360 28525 26 Treat toe fracture $1, 456.359692852526 M i d l e v e lT re a tt oe f r a c t u re$ 1,237.90 969 28525 TREAT TOE FRACTURE $1, 456.353602853026 M i d l e v e lT re a t ses am o i d b o n e f r a c t u re$ 312.40 969 28530 26 Treat sesamoid bone fracture $367.5096928530 C L TXSES A MO I D FR A CT U RE$ 367.50 360 28531 26 Midlevel Treat sesamoid bone fracture $596.209692853126 T re a t ses am o i d b o n e f r a c t u re$ 701.40 969 28531 OP TX SESAMOID FRACTURE $701.40 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 102 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28540 26 Midlevel Treat foot dislocation $565.859692854026 T re a t f oo t d i s l oc a t i o n$ 665.70 969 28540 CL TX TARSAL BONE DISLO; WO ANESTH $665.703602854526 M i d l e v e lT re a t f oo t d i s l oc a t i o n$ 782.70 969 28545 26 Treat foot dislocation $920.8596928545 C L TXT A RS A L BONE D I S L OC; W A NEST H$ 920.85 360 28546 26 Treat foot dislocation $1, 205.409692854626 M i d l e v e lT re a t f oo t d i s l oc a t i o n$ 1,024.60 969 28546 PERC SK FIX TARS BONE DISL; W MANIP $1, 205.403602855526 M i d l e v e lR e p ai r f oo t d i s l oc a t i o n$ 2,083.10 969 28555 26 Repair foot dislocation $2, 450.7096928555 REP A I RT A RS A L BONE D I S L OC A T I ON$ 2,450.70 360 28570 26 Midlevel Treat foot dislocation $432.859692857026 T re a t f oo t d i s l oc a t i o n$ 509.25 969 28570 CL TX TALOTARSAL JOINT DIS; WO ANEST $509.253602857526 M i d l e v e lT re a t f oo t d i s l oc a t i o n$ 1,001.40 969 28575 26 Treat foot dislocation $1, 178.1096928575 C L TXT A L OT A RS A L J O I NT D I S L; W A NEST H$ 1,178.10 360 28576 26 Treat foot dislocation $1, 403.859692857626 M i d l e v e lT re a t f oo t d i s l oc a t i o n$ 1,193.25 969 28576 PERC SK FIX TT JNT DISL W REDUC $1, 403.853602858526 R e p ai r f oo t d i s l oc a t i o n$ 2,553.60 969 28585 26 Midlevel Repair foot dislocation $2, 170.5596928585 REP A I RT A L OT A RS A L J O I NT D I S L OC A T I ON$ 2,553.60 360 28600 26 Midlevel Treat foot dislocation $576.559692860026 T re a t f oo t d i s l oc a t i o n$ 678.30 969 28600 CL TX TMT JNT DISL; WO ANESTHESIA $678.303602860526 T re a t f oo t d i s l oc a t i o n$ 1,033.20 969 28605 26 Midlevel Treat foot dislocation $878.2096928605 C L TXTMT J NT D I S L; W A NEST H ES I A$ 1,033.20 360 28606 26 Midlevel Treat foot dislocation $1, 215.609692860626 T re a t f oo t d i s l oc a t i o n$ 1,430.10 969 28606 PERC SK FIX TMT JNT DISL; W MANIP $1, 430.103602861526 R e p ai r f oo t d i s l oc a t i o n$ 2,887.50 969 28615 26 Midlevel Repair foot dislocation $2, 454.4096928615 REP A I RT A RSOMET A T A RS A L J O I NT$ 2,887.50 360 DISLOCATION 28630 26 Midlevel Treat toe dislocation $337.359692863026 T re a tt oe d i s l oc a t i o n$ 396.90 969 28630 CL TX MTP JNT DISLOC; WO ANESTH $396.903602863526 T re a tt oe d i s l oc a t i o n$ 493.50 969 28635 26 Midlevel Treat toe dislocation $419.5096928635 C L TXMTP J NT D I S L OC; W A NEST H$ 493.50 360 28636 26 Midlevel Treat toe dislocation $608.709692863626 T re a tt oe d i s l oc a t i o n$ 716.10 969 28636 PERC SK FIX MTP JNT DISL; W MANIP $716.103602864526 M i d l e v e lR e p ai r t oe d i s l oc a t i o n$ 1,485.10 969 28645 26 Repair toe dislocation $1, 747.2096928645 REP A I RTOE D I S L OC A T I ON$ 1,747.20 360 28660 26 Midlevel Treat toe dislocation $272.209692866026 T re a tt oe d i s l oc a t i o n$ 320.25 969 28660 CL TX IP JOINT DISL; WO ANESTH $320.253602866526 M i d l e v e lT re a tt oe d i s l oc a t i o n$ 408.75 969 28665 26 Treat toe dislocation $480.9096928665 T re a tt oe d i s l oc a t i o n$ 480.90 360 28666 26 Treat toe dislocation $694.059692866626 M i d l e v e lT re a tt oe d i s l oc a t i o n$ 589.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 103 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 28666 PERC SK FIX IP JNT DISL; W MANIP $694.053602867526 R e p ai ro f t oe d i s l oc a t i o n$ 1,494.15 969 28675 26 Midlevel Repair of toe dislocation $1, 270.0596928675 REP A I ROFTOE D I S L OC A T I ON$ 1,494.15 360 28705 26 Midlevel Fusion of foot bones $3, 985.909692870526 F u s i o n o ff oo t b o n es$ 4,689.30 969 28705 PANTALAR ARTHRODESIS $4, 689.303602871526 M i d l e v e lF u s i o n o ff oo t b o n es$ 2,904.20 969 28715 26 Fusion of foot bones $3, 416.7096928715 TR I P L E A RT H RO D ES I S$ 3,416.70 360 28725 26 Fusion of foot bones $2, 802.459692872526 M i d l e v e lF u s i o n o ff oo t b o n es$ 2,382.10 969 28725 SUBTALAR ARTHRODESIS $2, 802.453602873026 M i d l e v e lF u s i o n o ff oo t b o n es$ 2,299.95 969 28730 26 Fusion of foot bones $2, 705.8596928730 A RT H RO D MTORTMTM UL T I / TR A NS V$ 2,705.85 360 28735 26 Midlevel Fusion of foot bones $2, 452.609692873526 F u s i o n o ff oo t b o n es$ 2,885.40 969 28735 ARTHROD MT/TMT; W OSTEOT FOR FF $2, 885.403602873726 R e v i s i o n o ff oo t b o n es$ 2,485.35 969 28737 26 Midlevel Revision of foot bones $2, 112.5596928737 M I LL ERT Y PFOOTRE V I S$ 2,485.35 360 28740 26 Fusion of foot bones $2, 290.059692874026 M i d l e v e lF u s i o n o ff oo t b o n es$ 1,946.55 969 28740 ARTHRODESIS MT OR TME; SGL JOINT $2, 290.053602875026 F u s i o n o f bi g t oe j o in t$ 2,186.10 969 28750 26 Midlevel Fusion of big toe joint $1, 858.2096928750 A RT H RO D ES I SGRE A TTOE; MTP J O I NT$ 2,186.10 360 28755 26 Midlevel Fusion of big toe joint $1, 020.159692875526 F u s i o n o f bi g t oe j o in t$ 1,200.15 969 28755 ARTHRODESIS GREAT TOE; IP JOINT $1, 200.153602876026 F u s i o n o f bi g t oe j o in t$ 2,100.00 969 28760 26 Midlevel Fusion of big toe joint $1, 785.0096928760 A RT H RO D GT I P J NT W E H L TR A NSFER$ 2,100.00 360 28800 26 Amputation of midfoot $2, 024.409692880026 M i d l e v e l A m p u t a t i o n o f mi df oo t$ 1,720.75 969 28800 Amputation of midfoot $2, 024.403602880526 M i d l e v e l A m p u t a t i o n t h r u m e t a t a rs a l$ 2,340.15 969 28805 26 Amputation thru metatarsal $2, 753.1096928805 A m p u t a t i o n t h r u m e t a t a rs a l$ 2,753.10 360 28810 26 Midlevel Amputation toe & metatarsal $1,375.35 969 28810 26 Amputation toe & metatarsal$ 1,618.05 969 28810 Amputation toe & metatarsal $1, 618.053602882026 M i d l e v e l A m p u t a t i o n o f t oe$ 1,231.65 969 28820 26 Amputation of toe $1, 449.0096928820 A m p u t a t i o n o f t oe$ 1,449.00 360 28825 26 Partial amputation of toe $1, 375.509692882526 M i d l e v e lP a r t ia l am p u t a t i o n o f t oe$ 1,169.15 969 28825 Partial amputation of toe $1, 375.503602889026 M i d l e v e l H i g h e n er g yes wt, pl an t a r f$ 697.05 969 28890 26 High energy eswt, plantar f $820.0596928890 H I ENRG Y ES W TP L A NT A RF A SC I A$ 820.05 360 28899 Foot/toes surgery procedure $429.803602900026 M i d l e v e l A ppl i c a t i o n o f b o d yc a s t$ 539.95 969 29000 26 Application of body cast $635.2596929000 A PP L Y H A L OT Y PEBO D Y C A ST$ 635.25 360 29010 26 Midlevel Application of body cast $436.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 104 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29010 26 Application of body cast $513.4596929010 A PP L Y R I SSER J A C K ETBO D Y; ON L Y$ 513.45 360 29015 26 Midlevel Application of body cast $541.759692901526 A ppl i c a t i o n o f b o d yc a s t$ 637.35 969 29015 APPLY RISSER JACKET BODY; W HEAD $637.353602903526 A ppl i c a t i o n o f b o d yc a s t$ 520.80 969 29035 26 Midlevel Application of body cast $442.7096929035 A PP L Y BO D Y C A STS H O UL D ERTO H I PS$ 520.80 360 29040 26 Application of body cast $543.909692904026 M i d l e v e l A ppl i c a t i o n o f b o d yc a s t$ 462.30 969 29040 APPLY BODY CAST SHLDR- HIPS; W HD $543.903602904426 M i d l e v e l A ppl i c a t i o n o f b o d yc a s t$ 514.95 969 29044 26 Application of body cast $605.8596929044 A PP L I C A T I ONOFBO D Y C A ST 1 T H I G H$ 605.85 360 29046 26 Application of body cast $656.259692904626 M i d l e v e l A ppl i c a t i o n o f b o d yc a s t$ 557.80 969 29046 APPLY B CAST SHLDR-HIPS; 2 THIGHS $656.253602904926 A ppl i c a t i o n o ff i gu ree i g h t$ 247.80 969 29049 26 Midlevel Application of figure eight $210.6596929049 A PP L Y F I G U RE 8 C A ST$ 247.80 360 29055 26 Application of shoulder cast $499.809692905526 M i d l e v e l A ppl i c a t i o n o f s h o u l d erc a s t$ 424.85 969 29055 APPLY SHOULDER SPICA $499.803602905826 M i d l e v e l A ppl i c a t i o n o f s h o u l d erc a s t$ 243.65 969 29058 26 Application of shoulder cast $286.6596929058 A PP L Y P L A STER V E L PE A U$ 286.65 360 29065 26 Application of long arm cast $248.859832906526 M i d l e v e l A ppl i c a t i o n o f l o n g a r m c a s t$ 211.50 969 29065 Application of long arm cast $248.855102907526 A ppl i c a t i o n o ff ore a r m c a s t$ 226.80 983 29075 26 Midlevel Application of forearm cast $192.8096929075 A ppl i c a t i o n o ff ore a r m c a s t$ 226.80 510 29085 26 Apply hand/wrist cast $242.559832908526 M i d l e v e l A ppl y han d / w r i s t c a s t$ 206.15 969 29085 Apply hand/wrist cast $242.555102908626 A ppl y f in g erc a s t$ 184.80 983 29086 26 Midlevel Apply finger cast $157.1096929086 A PP L Y F I NGERC A ST$ 184.80 510 29105 26 Apply long arm splint $215.259832910526 M i d l e v e l A ppl y l o n g a r m s pl in t$ 182.95 969 29105 Apply long arm splint $215.255102912526 A ppl y f ore a r m s pl in t$ 142.80 983 29125 26 Midlevel Apply forearm splint $121.4096929125 A ppl y f ore a r m s pl in t$ 142.80 510 29126 26 Apply forearm splint $177.459692912626 M i d l e v e l A ppl y f ore a r m s pl in t$ 150.85 969 29126 APPLY SHORT ARM SPLINT; DYNAMIC $177.453602913026 A ppl i c a t i o n o ff in g ers pl in t$ 113.40 969 29130 26 Midlevel Application of finger splint $96.4096929130 A PP L Y F I NGERSP L I NT; ST A T I C$ 113.40 450 29131 26 Application of finger splint $122.859832913126 M i d l e v e l A ppl i c a t i o n o ff in g ers pl in t$ 104.40 969 29131 APPLY FINGER SPLINT; DYNAMIC $122.855102920026 St r a pp in g o f c h es t$ 142.80 969 29200 26 Midlevel Strapping of chest $121.4096929200 STR A PP I NG; T H OR A X$ 142.80 360 29240 26 Strapping of shoulder $155.40 983 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 105 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29240 26 Midlevel Strapping of shoulder $132.1096929240 STR A PP I NG; S H O UL D ER$ 155.40 510 29260 26 Strapping of elbow or wrist $134.409832926026 M i d l e v e lSt r a pp in g o f e l b o w or w r i s t$ 114.25 969 29260 Strapping of elbow or wrist $134.405102928026 St r a pp in g o f han d or f in g er$ 130.20 983 29280 26 Midlevel Strapping of hand or finger $110.6596929280 STR A PP I NG; H A N D ORF I NGER$ 130.20 510 29305 26 Application of hip cast $576.459692930526 M i d l e v e l A ppl i c a t i o n o f hi p c a s t$ 490.00 969 29305 APPLICATION OF HIP CAST 1 LEG $576.453602932526 A ppl i c a t i o n o f hi p c a s t s$ 647.85 969 29325 26 Midlevel Application of hip casts $550.6596929325 A PP L I C A T I ONOF H I PC A STS 1.5 SP I C A /2 L EGS$ 647.85 360 29345 26 Application of long leg cast $368.559832934526 M i d l e v e l A ppl i c a t i o n o f l o n g l e g c a s t$ 313.25 969 29345 APPLY LONG LEG CAST $368.555102935526 A ppl i c a t i o n o f l o n g l e g c a s t$ 392.70 983 29355 26 Midlevel Application of long leg cast $333.8096929355 A PP L YW L K R L G L EGC A ST$ 392.70 510 29358 26 Apply long leg cast brace $376.959832935826 M i d l e v e l A ppl y l o n g l e g c a s t b r a ce$ 320.40 969 29358 APPLY LONG LEG CAST BRACE $376.955102936526 A ppl i c a t i o n o f l o n g l e g c a s t$ 320.25 969 29365 26 Midlevel Application of long leg cast $272.2096929365 A PP L Y C Y L I N D ERC A ST$ 320.25 510 29405 26 Apply short leg cast $217.359832940526 M i d l e v e l A ppl ys h or tl e g c a s t$ 184.75 969 29405 Apply short leg cast $217.355102942526 A ppl ys h or tl e g c a s t$ 262.50 983 29425 26 Midlevel Apply short leg cast $223.1596929425 A ppl ys h or tl e g c a s t$ 262.50 510 29435 26 Midlevel Apply short leg cast $265.059692943526 A ppl ys h or tl e g c a s t$ 311.85 969 29435 APPY PATELLAR TENDON BEARING CAST $311.853602944026 A dd i t i o n o f w a l k er t oc a s t$ 130.20 969 29440 26 Midlevel Addition of walker to cast $110.6596929440 A DD W A L K ERTOO L D C A ST$ 130.20 360 29445 26 Midlevel Apply rigid leg cast $329.359692944526 A ppl yr i g i d l e g c a s t$ 387.45 969 29445 APPLY RIGID TOTAL CONTACT LEG CAST $387.455102945026 M i d l e v e l A ppl i c a t i o n o f l e g c a s t$ 354.30 969 29450 26 Application of leg cast $416.8596929450 A ppl i c a t i o n o f l e g c a s t$ 416.85 450 29505 26 Application, long leg splint $177.459832950526 M i d l e v e l A ppl i c a t i o n, l o n g l e g s pl in t$ 150.85 969 29505 Application long leg splint $177.455102951526 M i d l e v e l A ppl i c a t i o n l o w er l e g s pl in t$ 152.60 969 29515 26 Application lower leg splint $179.5596929515 A ppl i c a t i o n l o w er l e g s pl in t$ 179.55 450 29520 26 Midlevel Strapping of hip $110.659692952026 St r a pp in g o f hi p$ 130.20 969 29520 HIP STRAPPING $130.203602953026 St r a pp in g o f kn ee$ 136.50 969 29530 26 Midlevel Strapping of knee $116.0596929530 K NEESTR A PP I NG$ 136.50 360 29540 26 Midlevel Strapping of ankle and/or ft $106.20 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 106 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29540 26 Strapping of ankle and/or ft $124.9596929540 STR A P A N K L EORFOOT$ 124.95 360 29550 26 Midlevel Strapping of toes $97.309692955026 St r a pp in g o f t oes$ 114.45 969 29550 STRAPPING OF TOES $114.453602958026 A ppl i c a t i o n o f p a s t e b oo t$ 130.20 983 29580 26 Midlevel Application of paste boot $110.6596929580 U NN A BOOTSTR A PP I NG$ 130.20 420 29581 APPLY MULTLAY COMPRS LWR LEG $46.2036029584 A PP L M UL T L A Y COMPRS A RM / H A N D$ 55.65 360 29700 26 Midlevel Removal/revision of cast $106.209692970026 R e m o v a l / re v i s i o n o f c a s t$ 124.95 969 29700 REM GAUNTLET BOOT OR BODY CAST $124.953602970526 M i d l e v e lR e m o v a l / re v i s i o n o f c a s t$ 145.50 969 29705 26 Removal/revision of cast $171.1596929705 REMO V EF ULL A RMOR L EGC A ST$ 171.15 360 29710 26 Removal/revision of cast $286.659692971026 M i d l e v e lR e m o v a l / re v i s i o n o f c a s t$ 243.65 969 29710 REM SHOULDER OR HIP SPICA $286.653602972026 R e p ai ro f b o d yc a s t$ 158.55 969 29720 26 Midlevel Repair of body cast $134.7596929720 REPSP I C A BO D Y C A STOR J A C K ET$ 158.55 360 29730 26 Midlevel Windowing of cast $139.259692973026 Win d o w in g o f c a s t$ 163.80 969 29730 WINDOWING OF CAST $163.803602974026 M i d l e v e l W e d g in g o f c a s t$ 200.80 969 29740 26 Wedging of cast $236.2596929740 W E D G I NGOFC A STNOTC LU BFOOTC A ST$ 236.25 360 29750 26 Wedging of clubfoot cast $280.359692975026 M i d l e v e l W e d g in g o f c l u b f oo t c a s t$ 238.30 969 29750 WEDGING OF CLUBFOOT CAST $280.3536029799 C a s t in g / s t r a pp in g p roce d u re$ 270.85 360 29800 26 Midlevel Jaw arthroscopy/surgery $1, 594.009692980026 J a w a r t h rosco p y / s u r g ery$ 1,875.30 969 29800 TMJ DX ARTHROSCOPY $1, 875.303602980426 M i d l e v e l J a w a r t h rosco p y / s u r g ery$ 2,006.35 969 29804 26 Jaw arthroscopy/surgery $2, 360.4096929804 A RT H ROSCOP Y TM J S U RG I C A L$ 2,360.40 360 29805 26 Shoulder arthroscopy, dx $1, 712.559692980526 M i d l e v e lS h o u l d er a r t h rosco p y, d x$ 1,455.65 969 29805 SHOULDER ARTHROSCOPY DX $1, 712.553602980626 S h o u l d er a r t h rosco p y / s u r g ery$ 3,866.10 969 29806 26 Midlevel Shoulder arthroscopy/surgery $3, 286.2096929806 S H L D RC A PS UL OR A RT H ROSC$ 3,866.10 360 29807 26 Shoulder arthroscopy/surgery $3, 766.359692980726 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 3,201.40 969 29807 REP SHLDR SLAP LES $3, 766.353602981926 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 1,811.80 969 29819 26 Shoulder arthroscopy/surgery $2, 131.5096929819 A RT H ROSCOP Y S H L D R; W REMFB / L B$ 2,131.50 360 29820 26 Midlevel Shoulder arthroscopy/surgery $1, 669.009692982026 S h o u l d er a r t h rosco p y / s u r g ery$ 1,963.50 969 29820 ARTHROSCOPY SHLDRR; SYNOVEC PARTIAL $1, 963.503602982126 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 1,829.65 969 29821 26 Shoulder arthroscopy/surgery $2, 152.5096929821 A RT H ROSCOP Y S H L D R; S Y NO V ECCOMP L$ 2,152.50 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 107 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29822 26 Shoulder arthroscopy/surgery $2, 093.709692982226 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 1,779.65 969 29822 ARTHROSCOPY SHLDR; DEBRID LIMITED $2, 093.703602982326 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 1,943.85 969 29823 26 Shoulder arthroscopy/surgery $2, 286.9096929823 A RT H ROSCOP Y S H L D R; D EBR I D EXTENS$ 2,286.90 360 29824 26 Midlevel Shoulder arthroscopy/surgery $2, 093.809692982426 S h o u l d er a r t h rosco p y / s u r g ery$ 2,463.30 969 29824 SHOULDER MUMFORD PROC $2, 463.303602982526 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 1,810.90 969 29825 26 Shoulder arthroscopy/surgery $2, 130.4596929825 A RT H ROSCOP Y S H L D R; W L Y S I SOF A DH$ 2,130.45 360 29826 26 Shoulder arthroscopy/surgery $3, 255.009692982626 M i d l e v e lS h o u l d er a r t h rosco p y / s u r g ery$ 2,766.75 969 29826 SHOULDER ARTHROSCOPY/SURGERY $3, 255.003602982726 A r t h rosco p ro t a t orc u ff re p r$ 3,925.95 969 29827 26 Midlevel Arthroscop rotator cuff repr $3, 337.0596929827 ROT A TORC U FFREP A RT H ROSCOP Y$ 3,925.95 360 29828 ARTHROSCOPY BICEPS TENODESIS $3, 356.853602983026 El b o w a r t h rosco p y$ 1,650.60 969 29830 26 Midlevel Elbow arthroscopy $1, 403.0096929830 A RT H ROSCOP Y E L BO W D I A GNOST I C$ 1,650.60 360 29834 26 Midlevel Elbow arthroscopy/surgery $1, 522.609692983426 El b o w a r t h rosco p y / s u r g ery$ 1,791.30 969 29834 ARTHROSCOPY ELBOW; REM LOOSE BODIES $1, 791.303602983526 El b o w a r t h rosco p y / s u r g ery$ 1,838.55 969 29835 26 Midlevel Elbow arthroscopy/surgery $1, 562.7596929835 A RT H ROSCOP Y E L B; PS Y NO V ECTOM Y$ 1,838.55 360 29836 26 Midlevel Elbow arthroscopy/surgery $1, 802.859692983626 El b o w a r t h rosco p y / s u r g ery$ 2,121.00 969 29836 ARTHROSCOPY ELB; C SYNOVECTOMY $2, 121.003602983726 El b o w a r t h rosco p y / s u r g ery$ 1,926.75 969 29837 26 Midlevel Elbow arthroscopy/surgery $1, 637.7596929837 A RT H ROSCOP Y E L BO W; L I M D EBR I D$ 1,926.75 360 29838 26 Elbow arthroscopy/surgery $2, 150.409692983826 M i d l e v e lEl b o w a r t h rosco p y / s u r g ery$ 1,827.85 969 29838 ARTHROSCOPY ELBOW; EXT DEBRID $2, 150.403602984026 M i d l e v e l W r i s t a r t h rosco p y$ 1,404.80 969 29840 26 Wrist arthroscopy $1, 652.7096929840 A RT H ROSCOP YW R I ST D I A GNOST I C$ 1,652.70 360 29843 26 Wrist arthroscopy/surgery $1, 753.509692984326 M i d l e v e l W r i s t a r t h rosco p y / s u r g ery$ 1,490.50 969 29843 ARTHROSCOPY WRIST; FOR INF/LAVAGE/DR $1, 753.503602984426 W r i s t a r t h rosco p y / s u r g ery$ 1,816.50 969 29844 26 Midlevel Wrist arthroscopy/surgery $1, 544.0596929844 A RT H ROSCOP YW R I ST; PS Y NO V ECTOM Y$ 1,816.50 360 29845 26 Wrist arthroscopy/surgery $2, 093.709692984526 M i d l e v e l W r i s t a r t h rosco p y / s u r g ery$ 1,779.65 969 29845 ARTHROSCOPY WRIST; C SYNOVECTOMY $2, 093.703602984626 M i d l e v e l W r i s t a r t h rosco p y / s u r g ery$ 1,613.65 969 29846 26 Wrist arthroscopy/surgery $1, 898.4096929846 A RT H ROSCOP YW R I ST; EXC / REPC A RT I L$ 1,898.40 360 29847 26 Wrist arthroscopy/surgery $1, 970.859692984726 M i d l e v e l W r i s t a r t h rosco p y / s u r g ery$ 1,675.20 969 29847 ARTHROSCOPY WRIST; INT FIX - FX/INSTAB $1, 970.853602984826 W r i s t e n d osco p y / s u r g ery$ 1,852.20 969 29848 26 Midlevel Wrist endoscopy/surgery $1,574.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 108 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29848 ARTHROSCOPY WRIST; W RLS TRNSV CARP $1, 852.20360 L I G 2985026 K n ee a r t h rosco p y / s u r g ery$ 2,027.55 969 29850 26 Midlevel Knee arthroscopy/surgery $1, 723.4096929850 A RT H ROSCOPETX I C K NEEFX$ 2,027.55 360 29851 26 Knee arthroscopy/surgery $3, 387.309692985126 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 2,879.20 969 29851 ARTHROSCOPE TX IC KNEE FX ; W FIX $3, 387.303602985526 T ibia l a r t h rosco p y / s u r g ery$ 2,859.15 969 29855 26 Midlevel Tibial arthroscopy/surgery $2, 430.3096929855 A RT H RS A I D T I B I A L FXPROX$ 2,859.15 360 UNICONDYLAR 29856 26 Tibial arthroscopy/surgery $3, 626.709692985626 M i d l e v e lT ibia l a r t h rosco p y / s u r g ery$ 3,082.70 969 29856 ARTHRS AID TIBIAL FX PROX $3, 626.70360 U N I CON D Y L A RB I CON D Y L A R 2986026 M i d l e v e l H i p a r t h rosco p y, d x$ 2,050.05 969 29860 26 Hip arthroscopy, dx $2, 411.8596929860 A RT H ROSCOP Y H I P D X W / W OS Y NBX$ 2,411.85 360 29861 26 Hip arthroscopy/surgery $2, 638.659692986126 M i d l e v e l H i p a r t h rosco p y / s u r g ery$ 2,242.85 969 29861 ARTHROSCOPY HIP; REM LOOSE OR FB $2, 638.653602986226 M i d l e v e l H i p a r t h rosco p y / s u r g ery$ 2,527.55 969 29862 26 Hip arthroscopy/surgery $2, 973.6096929862 A RT H ROSC H I P; W REMFB W C H ON D ROP L$ 2,973.60 360 29863 26 Hip arthroscopy/surgery $2, 973.609692986326 M i d l e v e l H i p a r t h rosco p y / s u r g ery$ 2,527.55 969 29863 ARTHROSC HIP; W REM FB W SYNOVECT $2, 973.603602986626 A u t g r f t im pl n t, kn ee w / sco p e$ 3,812.55 969 29866 26 Midlevel Autgrft implnt, knee w/scope $3, 240.6596929866 A U TGRFT I MP L NT K NEE W / SCOPE$ 3,812.55 360 29867 26 Allgrft implnt, knee w/scope $4, 638.909692986726 M i d l e v e l A ll g r f t im pl n t, kn ee w / sco p e$ 3,943.05 969 29867 Allgrft implnt, knee w/scope $4, 638.903602986826 M i d l e v e lM e ni sc a lt r n s pl, kn ee w / sc p e$ 5,175.60 969 29868 26 Meniscal trnspl, knee w/scpe $6, 088.9596929868 M e ni sc a lt r n s pl, kn ee w / sc p e$ 6,088.95 360 29870 26 Knee arthroscopy, dx $1, 496.259692987026 M i d l e v e l K n ee a r t h rosco p y, d x$ 1,271.80 969 29870 DX KNEE ARTHROSCOPY $1, 496.253602987126 K n ee a r t h rosco p y / d r aina g e$ 1,865.85 969 29871 26 Midlevel Knee arthroscopy/drainage $1, 585.9596929871 A RT H ROSC K NEE; FOR I NF / L A V A GE / D R$ 1,865.85 360 29873 26 Knee arthroscopy/surgery $1, 898.409692987326 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 1,613.65 969 29873 KNEE ARTHROSCOPY W LAT RLS $1, 898.403602987426 K n ee a r t h rosco p y / s u r g ery$ 1,956.15 969 29874 26 Midlevel Knee arthroscopy/surgery $1, 662.7596929874 A RT H ROSCOP Y K NEE; REM L OOSEORFB$ 1,956.15 360 29875 26 Knee arthroscopy/surgery $1, 801.809692987526 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 1,531.55 969 29875 ARTHROSCOPY KNEE; LIM SYNOVECTOMY $1, 801.803602987626 K n ee a r t h rosco p y / s u r g ery$ 2,384.55 969 29876 26 Midlevel Knee arthroscopy/surgery $2, 026.8596929876 K NEE A RT H ROSCOP Y / S U RGER Y 2 +$ 2,384.55 360 COMPART 29877 26 Knee arthroscopy/surgery $2,262.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 109 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29877 26 Midlevel Knee arthroscopy/surgery $1, 923.3596929877 A RT H ROSCOP Y K NEE; D EBR I D / S H V A C$ 2,262.75 360 29879 26 Knee arthroscopy/surgery $2, 409.759692987926 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 2,048.30 969 29879 ARTHROSCOPY KNEE; ABRAS ARTHROPL $2, 409.753602988026 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 1,772.50 969 29880 26 Knee arthroscopy/surgery $2, 085.3096929880 K NEE A RT H ROSCOP Y / S U RGER Y$ 2,085.30 360 29881 26 Knee arthroscopy/surgery $1, 999.209692988126 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 1,699.30 969 29881 KNEE ARTHROSCOPY/SURGERY $1, 999.203602988226 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 2,158.95 969 29882 26 Knee arthroscopy/surgery $2,539.95 969 29882 ARTHROSC KNEE; W MEN REP-MED&LAT$ 2,539.95 360 29883 26 Knee arthroscopy/surgery $3, 061.809692988326 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 2,602.55 969 29883 ARTHROSC KNEE; W MEN REPAIR-MED/LAT $3, 061.803602988426 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 1,919.75 969 29884 26 Knee arthroscopy/surgery $2, 258.5596929884 A RT H ROSC K NEE; W L Y S I SOF A DH ES$ 2,258.55 360 29885 26 Midlevel Knee arthroscopy/surgery $2, 318.709692988526 K n ee a r t h rosco p y / s u r g ery$ 2,727.90 969 29885 ARTHROSC KNEE; DRILL FOR $2, 727.90360 OSTEOC H ON D R I T I S 2988626 K n ee a r t h rosco p y / s u r g ery$ 2,304.75 969 29886 26 Midlevel Knee arthroscopy/surgery $1, 959.0596929886 A RT H ROSC K NEE; D R I LL FORO . D . L ES I ON$ 2,304.75 360 29887 26 Midlevel Knee arthroscopy/surgery $2, 308.909692988726 K n ee a r t h rosco p y / s u r g ery$ 2,716.35 969 29887 ARTHROSC KNEE; DRILL FOR OD LES W $2, 716.35360 F I X A T 2988826 K n ee a r t h rosco p y / s u r g ery$ 3,604.65 969 29888 26 Midlevel Knee arthroscopy/surgery $3, 063.9596929888 A RT H ROSC; A NTCR U C I A TE L I GREP / A U GM$ 3,604.65 360 29889 26 Knee arthroscopy/surgery $4, 408.959692988926 M i d l e v e l K n ee a r t h rosco p y / s u r g ery$ 3,747.60 969 29889 ARTHROSC; P CRUCIATE LIG REP/AUG $4, 408.953602989126 M i d l e v e l A nk l e a r t h rosco p y / s u r g ery$ 2,127.70 969 29891 26 Ankle arthroscopy/surgery $2, 503.2096929891 A RT H ROSC A N K L E; EXCOSC H ON D EFECT$ 2,503.20 360 29892 26 Midlevel Ankle arthroscopy/surgery $1, 976.909692989226 A nk l e a r t h rosco p y / s u r g ery$ 2,325.75 969 29892 ARTHROSC REPAIR O.D. LESION OR FX $2, 325.753602989326 S co p e, pl an t a r f a sc i o t o m y$ 1,547.70 969 29893 26 Midlevel Scope, plantar fasciotomy $1, 315.5596929893 EN D OSCOP I CP L A NT A RF A SC I OTOM Y$ 1,547.70 360 29894 26 Ankle arthroscopy/surgery $1, 870.059692989426 M i d l e v e l A nk l e a r t h rosco p y / s u r g ery$ 1,589.55 969 29894 ARTHROSCOPY ANKLE; W REM FB $1, 870.053602989526 M i d l e v e l A nk l e a r t h rosco p y / s u r g ery$ 1,510.10 969 29895 26 Ankle arthroscopy/surgery $1, 776.6096929895 A RT H ROSCOP Y A N K L E; PS Y NO V ECTOM Y$ 1,776.60 360 29897 26 Ankle arthroscopy/surgery $1, 881.609692989726 M i d l e v e l A nk l e a r t h rosco p y / s u r g ery$ 1,599.35 969 29897 ARTHROSCOPY ANKLE; SMPL DEBRID $1, 881.603602989826 A nk l e a r t h rosco p y / s u r g ery$ 2,080.05 969 29898 26 Midlevel Ankle arthroscopy/surgery $1,768.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 110 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 29898 ARTHROSCOPY ANKLE; EXT DEBRIDEM $2, 080.053602989926 M i d l e v e l A nk l e a r t h rosco p y / s u r g ery$ 3,226.40 969 29899 26 Ankle arthroscopy/surgery $3, 795.7596929899 A N K L E A RT H ROSCOP YW F U S I ON$ 3,795.75 360 29900 26 Mcp joint arthroscopy, dx $1, 705.209692990026 M i d l e v e lM c p j o in t a r t h rosco p y, d x$ 1,449.40 969 29900 MCP JNT DX ARTHROSC $1, 705.203602990126 M c p j o in t a r t h rosco p y, s u r g$ 1,944.60 969 29901 26 Midlevel Mcp joint arthroscopy, surg $1, 652.9096929901 MCP J NT A RT H R W D EBR I D$ 1,944.60 360 29902 26 Mcp joint arthroscopy, surg $2, 175.609692990226 M i d l e v e lM c p j o in t a r t h rosco p y, s u r g$ 1,849.25 969 29902 MCP JOINT ARTHROSCOPY SURG $2, 175.6036029999 A r t h rosco p yo f j o in t$ 429.80 360 30000 26 Drainage of nose lesion $573.309693000026 M i d l e v e l Dr aina g eo f n ose l es i o n$ 486.95 969 30000 DR ABSC/HEMATOMA NASAL INT $441.003603002026 M i d l e v e l Dr aina g eo f n ose l es i o n$ 103.10 969 30020 26 Drainage of nose lesion $121.8096930020 D R A BSC / H EM A TOM A N A S A L SEPT U M$ 441.00 360 30100 26 Intranasal biopsy $124.959693010026 M i d l e v e l I n t r ana s a l bi o p sy$ 105.90 969 30100 BIOPSY INTRANASAL $255.153603011026 R e m o v a l o f n ose p o l y p (s)$ 74.55 969 30110 26 Midlevel Removal of nose polyp(s) $63.5096930110 EXC I S I ONN A S A L PO L Y P (S) S I MP L E$ 483.00 360 30115 26 Removal of nose polyp(s) $136.509693011526 M i d l e v e lR e m o v a l o f n ose p o l y p (s)$ 116.40 969 30115 EXC NASAL POLYP(S) EXTENSIVE $1, 594.953603011726 M i d l e v e lR e m o v a l o f in t r ana s a ll es i o n$ 377.40 969 30117 26 Removal of intranasal lesion $444.1596930117 REM I - N A S A LL ES I NT A PPR$ 1,249.50 360 30118 26 Midlevel Removal of intranasal lesion $292.309693011826 R e m o v a l o f in t r ana s a ll es i o n$ 344.40 969 30118 EXC/DESTRUCT INTRANASAL LESION; EXT $2, 830.803603012026 R e v i s i o n o f n ose$ 808.50 969 30120 26 Midlevel Revision of nose $686.8596930120 EXC / P L A NENOSEFORR H I NOP H Y M A$ 1,623.30 360 30124 26 Removal of nose lesion $485.109693012426 M i d l e v e lR e m o v a l o f n ose l es i o n$ 412.05 969 30124 EXC DERMOID CYST NOSE; SIMPLE $1, 045.803603012526 M i d l e v e lR e m o v a l o f n ose l es i o n$ 250.75 969 30125 26 Removal of nose lesion $295.0596930125 EXC D ERMO I D C Y STNOSE; COMP L EX$ 2,253.30 360 30130 26 Midlevel Excise inferior turbinate $565.109693013026 E x c i se in f er i or t u r bina t e$ 664.65 969 30130 EXCISE INFERIOR TURBINATE $1, 407.003603014026 M i d l e v e lR esec t in f er i or t u r bina t e$ 336.45 969 30140 26 Resect inferior turbinate $395.8596930140 RESECT I NFER I ORT U RB I N A TE$ 1,630.65 360 30150 26 Midlevel Partial removal of nose $370.159693015026 P a r t ia l re m o v a l o f n ose$ 435.75 969 30150 RHINECTOMY; PARTIAL $2, 856.003603016026 R e m o v a l o f n ose$ 871.50 969 30160 26 Midlevel Removal of nose $740.9096930160 R H I NECTOM Y; TOT A L$ 2,869.65 360 30200 26 Injection treatment of nose $853.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 111 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 30200 26 Midlevel Injection treatment of nose $725.7096930200 I N J T U RB I N A TE (S) T H ER A PE U T I C$ 221.55 360 30210 26 Nasal sinus therapy $64.059693021026 M i d l e v e lN a s a l s in u s t h er a p y$ 54.75 969 30210 DISPL THERAPY (PROETZ TYPE) $368.553603022026 I n ser t na s a l se pt a l b u tt o n$ 103.95 969 30220 26 Midlevel Insert nasal septal button $88.4596930220 I NSN A S A L SEPT A L PROST H (B U TTON)$ 465.15 360 30300 26 Remove nasal foreign body $131.259833030026 M i d l e v e lR e m o v e na s a l f ore i g nb o d y$ 111.85 969 30300 Remove nasal foreign body $466.205103031026 M i d l e v e lR e m o v e na s a l f ore i g nb o d y$ 110.45 969 30310 26 Remove nasal foreign body $130.2096930310 REMFBNTR A N A S A L; W A NEST H$ 1,242.15 360 30320 26 Remove nasal foreign body $220.50969 [R o w s 6001 - 7000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 3032026 M i d l e v e lR e m o v e na s a l f ore i g nb o d y$ 187.00 969 30320 REM FB IN; BY LAT RHINECTOMY $1, 675.803603040026 R eco n s t r u c t i o n o f n ose$ 499.80 969 30400 26 Midlevel Reconstruction of nose $425.25 969 30400 RHINOPLASTY 1'; CARTIL & ELVATE NOSE$ 3,762.15 360 TIP 30410 26 Reconstruction of nose $1, 135.059693041026 M i d l e v e lR eco n s t r u c t i o n o f n ose$ 964.55 969 30410 RHINOPL 1’; COMPLETE EXT PARTS $4, 743.903603042026 M i d l e v e lR eco n s t r u c t i o n o f n ose$ 1,167.50 969 30420 26 Reconstruction of nose $1, 373.4096930420 R H I NOP L A ST Y 1^{'}; W M A J ORSEPT A L REP A I R$ 5,064.15 360 30430 26 Revision of nose $1, 474.209693043026 M i d l e v e lR e v i s i o n o f n ose$ 1,252.70 969 30430 RHINOPLASTY 2’; MINOR REVISION $3, 454.503603043526 R e v i s i o n o f n ose$ 1,034.25 969 30435 26 Midlevel Revision of nose $879.1096930435 R H I NOP L A ST Y 2^{'}; I NTERMRE V I S I ON$ 4,189.50 360 30450 26 Midlevel Revision of nose $1, 154.459693045026 R e v i s i o n o f n ose$ 1,358.70 969 30450 RHINOPLASTY 2’; MAJOR REVISION $5, 588.103603046026 R e v i s i o n o f n ose$ 1,750.35 969 30460 26 Midlevel Revision of nose $1, 487.9096930460 R H I NOP L 2^{'} TOCC L ORCCP; T I PON L Y$ 2,793.00 360 30462 26 Revision of nose $851.559693046226 M i d l e v e lR e v i s i o n o f n ose$ 723.95 969 30462 RHINOPL 2’ TO CCL OR CCP; TIP & SEPTUM $5, 785.503603046526 M i d l e v e lR e p ai r na s a l s t e n os i s$ 1,460.95 969 30465 26 Repair nasal stenosis $1, 718.8596930465 REP A I RN A S A L STENOS I S$ 3,626.70 360 30520 26 Repair of nasal septum $1, 034.259693052026 M i d l e v e lR e p ai ro f na s a l se pt u m$ 878.90 969 30520 SEPTOPLASTY OR SUBMUCOUS RESECT $2, 296.353603054026 R e p ai r na s a l d e f ec t$ 592.20 969 30540 26 Midlevel Repair nasal defect $503.5096930540 REP A I RC H O A N A L A TRES I A; I NTR A N A S A L$ 2,529.45 360 30545 26 Repair nasal defect $722.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 112 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 30545 26 Midlevel Repair nasal defect $613.9596930545 REPC H O A N A L A TRES I A; TR A NSP A L A T I NE$ 3,398.85 360 30560 26 Midlevel Release of nasal adhesions $869.859693056026 R e l e a seo f na s a l a d h es i o n s$ 1,023.75 969 30560 LYSIS INTRANASAL SYNECHIA $514.503603058026 M i d l e v e lR e p ai r u pp er ja w f i s t u l a$ 125.65 969 30580 26 Repair upper jaw fistula $148.0596930580 REP A I RF I ST UL A; OROM A X I LL A R Y$ 1,823.85 360 30600 26 Repair mouth/nose fistula $541.809693060026 M i d l e v e lR e p ai r m o u t h / n ose f i s t u l a$ 460.50 969 30600 REPAIR FISTULA; ORONASAL $1, 586.553603062026 M i d l e v e l I n t r ana s a l reco n s t r u c t i o n$ 403.80 969 30620 26 Intranasal reconstruction $474.6096930620 SEPT A L OROT H ER I N D ERM A TOP L A ST Y$ 2,304.75 360 30630 26 Midlevel Repair nasal septum defect $552.059693063026 R e p ai r na s a l se pt u m d e f ec t$ 649.95 969 30630 REPAIR NASAL SEPTAL PERFORATIONS $2, 310.003603080126 M i d l e v e l A b l a t e in f t u r bina t e, s u p er f$ 553.95 969 30801 26 Ablate inf turbinate, superf $652.0596930801 A B L A TE I NFT U RB I N A TES U PERF$ 506.10 360 30802 26 Midlevel Cauterization, inner nose $114.509693080226 C a u t er i z a t i o n, inn er n ose$ 134.40 969 30802 ABLATE INF TURBINATE SUBMUC $703.503603090126 M i d l e v e lC o n t ro l o f n ose b l ee d$ 163.05 969 30901 26 Control of nosebleed $192.1596930901 CONT L N A S A L H EMORR H A NTSMP L E$ 207.90 360 30903 26 Control of nosebleed $64.059693090326 M i d l e v e lC o n t ro l o f n ose b l ee d$ 54.25 969 30903 CONTROL NASAL HEMORRH ANT COMPLEX $294.003603090526 M i d l e v e lC o n t ro l o f n ose b l ee d$ 71.80 969 30905 26 Control of nosebleed $84.0096930905 C o n t ro l o f n ose b l ee d$ 372.75 360 30906 26 Repeat control of nosebleed $112.359693090626 M i d l e v e lR e p e a t co n t ro l o f n ose b l ee d$ 95.20 969 30906 Repeat control of nosebleed $486.153603091526 M i d l e v e l L i g a t i o n, na s a l s in u s a r t ery$ 126.40 969 30915 26 Ligation, nasal sinus artery $149.1096930915 L I G A T I ON A RTER I ES; ET H MO I D A L$ 2,130.45 360 30920 26 Ligation, upper jaw artery $598.509693092026 M i d l e v e l L i g a t i o n, u pp er ja w a r t ery$ 509.05 969 30920 LIGATE ARTERIES; INT MAXILL T-ANTRAL $3, 075.453603093026 T h er f x, na s a l in f t u r bina t e$ 851.55 969 30930 26 Midlevel Ther fx, nasal inf turbinate $723.8596930930 T H ERFXN A S A L I NFT U RB I N A TE$ 457.80 360 30999 Nasal surgery procedure $357.003603100026 M i d l e v e l I rr i g a t i o n, ma x i ll a rys in u s$ 107.65 969 31000 26 Irrigation, maxillary sinus $127.0596931000 L A V A GEB Y C A NN UL A; M A X I LL S I N U S$ 384.30 360 31002 26 Midlevel Irrigation, sphenoid sinus $93.759693100226 I rr i g a t i o n, s p h e n o i d s in u s$ 110.25 969 31002 CANNULA LAVAGE; SPHENOID SINUS $741.303603102026 M i d l e v e lE x pl or a t i o n, ma x i ll a rys in u s$ 187.25 969 31020 26 Exploration, maxillary sinus $220.5096931020 S I N U SOTOM Y M A X I LL A R Y; I NTR A N A S A L$ 1,324.05 360 31030 26 Exploration, maxillary sinus $363.309693103026 M i d l e v e lE x pl or a t i o n, ma x i ll a rys in u s$ 308.90 969 31030 CALDWELL-LUC WO REM ANTROCH POLYPS $1,919.40 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 113 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31032 26 Midlevel Explore sinus, remove polyps $465.059693103226 E x pl ores in u s, re m o v e p o l y p s$ 547.05 969 31032 CALDWELL-LUC W REM ANTROCH POLYPS $2, 108.403603104026 M i d l e v e lE x pl or a t i o nb e hin d u pp er ja w$ 507.95 969 31040 26 Exploration behind upper jaw $597.4596931040 PTER Y GOM A X I LL A R Y FOSS A S U RGER Y$ 2,798.25 360 31050 26 Midlevel Exploration, sphenoid sinus $697.759693105026 E x pl or a t i o n, s p h e n o i d s in u s$ 821.10 969 31050 SINUSOTOMY SPHENOID; W/WO BX $1, 796.553603105126 Sp h e n o i d s in u ss u r g ery$ 510.30 969 31051 26 Midlevel Sphenoid sinus surgery $433.7096931051 S I N U SOTSP H ENO I D; W PO L Y PREM$ 2,383.50 360 31070 26 Midlevel Exploration of frontal sinus $568.159693107026 E x pl or a t i o n o ff ro n t a l s in u s$ 668.85 969 31070 SINUSOTOMY FRONTAL; EXT SIMPLE $1, 624.353603107526 E x pl or a t i o n o ff ro n t a l s in u s$ 449.40 969 31075 26 Midlevel Exploration of frontal sinus $381.9096931075 S I N U SOTOM Y FRONT A L; L Y NC H T Y PE$ 2,887.50 360 31080 26 Removal of frontal sinus $819.009693108026 M i d l e v e lR e m o v a l o ff ro n t a l s in u s$ 696.10 969 31080 SINUSOTOMY FRONT; OBLIT WO BROW INC $3, 783.153603108126 M i d l e v e lR e m o v a l o ff ro n t a l s in u s$ 941.75 969 31081 26 Removal of frontal sinus $1, 107.7596931081 S I N U SOTOM Y FRONT; OB L I T W OCOR I NC$ 5,335.05 360 31084 26 Removal of frontal sinus $1, 269.459693108426 M i d l e v e lR e m o v a l o ff ro n t a l s in u s$ 1,079.35 969 31084 SINUSOT FR ; OBLIT W FLAP; BROW INC $4, 278.753603108526 M i d l e v e lR e m o v a l o ff ro n t a l s in u s$ 1,025.50 969 31085 26 Removal of frontal sinus $1, 206.4596931085 S I N U SOTFRONT; OB L I T W F L A P; CORON A L$ 4,880.40 360 IN 31086 26 Midlevel Removal of frontal sinus $1, 086.859693108626 R e m o v a l o ff ro n t a l s in u s$ 1,278.90 969 31086 SINUSOT FR ; NONOBLIT W FLAP; BROW INC $4, 133.853603108726 M i d l e v e lR e m o v a l o ff ro n t a l s in u s$ 995.35 969 31087 26 Removal of frontal sinus $1, 170.7596931087 S I N U SOTFR; NONOB L I W F L A P; CORON A L$ 3,996.30 360 IN 31090 26 Exploration of sinuses $1, 153.959693109026 M i d l e v e lE x pl or a t i o n o f s in u ses$ 980.80 969 31090 EXPLORATION OF 3+ SINUSES $3, 764.253603120026 M i d l e v e lR e m o v a l o f e t hm o i d s in u s$ 870.20 969 31200 26 Removal of ethmoid sinus $1, 023.7596931200 ET H MO I D ECTOM Y; I NTR A N A S A L A NT$ 2,046.45 360 31201 26 Removal of ethmoid sinus $606.909693120126 M i d l e v e lR e m o v a l o f e t hm o i d s in u s$ 516.10 969 31201 ETHMOIDECTOMY; INTRANASAL TOTAL $2, 724.753603120526 R e m o v a l o f e t hm o i d s in u s$ 764.40 969 31205 26 Midlevel Removal of ethmoid sinus $649.7596931205 ET H MO I D ECTOM Y; EXTR A N A S A L TOT A L$ 3,265.50 360 31225 26 Midlevel Removal of upper jaw $802.009693122526 R e m o v a l o f u pp er ja w$ 943.95 969 31225 Removal of upper jaw $6, 851.253603123026 M i d l e v e lR e m o v a l o f u pp er ja w$ 1,584.95 969 31230 26 Removal of upper jaw $1, 864.8096931230 R e m o v a l o f u pp er ja w$ 7,629.30 360 31231 26 Nasal endoscopy, dx $204.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 114 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31231 26 Midlevel Nasal endoscopy, dx $185.4596931231 D XN A S A L EN D OSCOP Y$ 283.50 360 31233 26 Midlevel Nasal/sinus endoscopy, dx $71.059693123326 N a s a l / s in u se n d osco p y, d x$ 84.00 969 31233 NASAL ENDO DX W MAXIL SINUSOT $508.203603123526 M i d l e v e lN a s a l / s in u se n d osco p y, d x$ 129.70 969 31235 26 Nasal/sinus endoscopy, dx $152.2596931235 N A S A L EN D O D X W SP H ENS I N U TSOT$ 597.45 360 31237 26 Midlevel Nasal/sinus endoscopy, surg $154.309693123726 N a s a l / s in u se n d osco p y, s u r g$ 181.65 969 31237 NASAL ENDO; W BX POLYPECT/DEBRIDE $670.953603123826 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 171.45 969 31238 26 Nasal/sinus endoscopy, surg $201.6096931238 N A S A L EN D O W B L D CNTR L$ 727.65 360 31239 26 Nasal/sinus endoscopy, surg $220.509693123926 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 187.25 969 31239 NASAL ENDO; W DACRYOCYSTORHINOST $2, 499.003603124026 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 613.60 969 31240 26 Nasal/sinus endoscopy, surg $722.4096931240 N A S A L EN D O; W CONC H A B ULL A RESECT$ 596.40 360 31254 26 Midlevel Revision of ethmoid sinus $153.459693125426 R e v i s i o n o f e t hm o i d s in u s$ 180.60 969 31254 NSL/SINS NDSC W/PRTL ETHMDCT $1, 012.203603125526 R e m o v a l o f e t hm o i d s in u s$ 309.75 969 31255 26 Midlevel Removal of ethmoid sinus $263.0096931255 NS L / S I NSN D SC W / TOTET H M D CT$ 1,482.60 360 31256 26 Midlevel Exploration maxillary sinus $389.359693125626 E x pl or a t i o nma x i ll a rys in u s$ 457.80 969 31256 NASAL ENDO W MAXILL ANTROSTOMY $732.903603126726 M i d l e v e lE n d osco p y, ma x i ll a rys in u s$ 190.75 969 31267 26 Endoscopy, maxillary sinus $224.7096931267 N A S A L EN D O W M A; W REMT I SSMS$ 1,174.95 360 31276 26 Sinus endoscopy, surgical $361.209693127626 M i d l e v e lS in u se n d osco p y, s u r g i c a l$ 307.25 969 31276 NSL/SINS NDSC FRNT TISS RMVL $1, 871.103603128726 N a s a l / s in u se n d osco p y, s u r g$ 577.50 969 31287 26 Midlevel Nasal/sinus endoscopy, surg $490.5096931287 N A S A L / S I N U SEN D O W SPENO I D OTOM Y;$ 861.00 360 31288 26 Nasal/sinus endoscopy, surg $263.559693128826 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 224.30 969 31288 NASAL ENDO; W REM T SPHEN SINUS $998.553603129026 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 259.95 969 31290 26 Nasal/sinus endoscopy, surg $305.5596931290 N a s a l / s in u se n d osco p y, s u r g$ 4,280.85 360 31291 26 Midlevel Nasal/sinus endoscopy, surg $1, 071.409693129126 N a s a l / s in u se n d osco p y, s u r g$ 1,260.00 969 31291 Nasal/sinus endoscopy, surg $4, 549.653603129226 N a s a l / s in u se n d osco p y, s u r g$ 1,327.20 969 31292 26 Midlevel Nasal/sinus endoscopy, surg $1, 128.0596931292 N a s a l / s in u se n d osco p y, s u r g$ 3,701.25 360 31293 26 Nasal/sinus endoscopy, surg $1, 092.009693129326 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 928.00 969 31293 Nasal/sinus endoscopy, surg $4, 015.203603129426 M i d l e v e lN a s a l / s in u se n d osco p y, s u r g$ 1,009.55 969 31294 26 Nasal/sinus endoscopy, surg $1, 187.5596931294 N a s a l / s in u se n d osco p y, s u r g$ 4,597.95 360 31299 Sinus surgery procedure $357.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 115 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31300 26 Removal of larynx lesion $1, 366.059693130026 M i d l e v e lR e m o v a l o f l a ry n x l es i o n$ 1,160.90 969 31300 REMOVAL OF LARYNX LESION $4, 666.203603136026 M i d l e v e lR e m o v a l o f l a ry n x$ 1,115.35 969 31360 26 Removal of larynx $1, 312.5096931360 R e m o v a l o f l a ry n x$ 7,636.65 360 31365 26 Midlevel Removal of larynx $1, 664.709693136526 R e m o v a l o f l a ry n x$ 1,958.25 969 31365 Removal of larynx $9, 438.453603136726 P a r t ia l re m o v a l o f l a ry n x$ 2,471.70 969 31367 26 Midlevel Partial removal of larynx $2, 100.6096931367 P a r t ia l re m o v a l o f l a ry n x$ 8,119.65 360 31368 26 Midlevel Partial removal of larynx $1, 871.959693136826 P a r t ia l re m o v a l o f l a ry n x$ 2,201.85 969 31368 Partial removal of larynx $9, 003.753603137026 P a r t ia l re m o v a l o f l a ry n x$ 2,501.10 969 31370 26 Midlevel Partial removal of larynx $2, 125.7596931370 P a r t ia l re m o v a l o f l a ry n x$ 7,636.65 360 31375 26 Midlevel Partial removal of larynx $1, 784.359693137526 P a r t ia l re m o v a l o f l a ry n x$ 2,098.95 969 31375 Partial removal of larynx $7, 246.053603138026 P a r t ia l re m o v a l o f l a ry n x$ 1,962.45 969 31380 26 Midlevel Partial removal of larynx $1, 668.3596931380 P a r t ia l re m o v a l o f l a ry n x$ 7,140.00 360 31382 26 Partial removal of larynx $1, 949.859693138226 M i d l e v e lP a r t ia l re m o v a l o f l a ry n x$ 1,657.70 969 31382 Partial removal of larynx $7,831.95 360 31390 26 Removal of larynx & pharynx$ 2,115.75 969 31390 26 Midlevel Removal of larynx & pharynx $1,798.30 969 31390 Removal of larynx & pharynx$ 10,525.20 360 31395 26 Midlevel Reconstruct larynx & pharynx $2,373.00 969 31395 26 Reconstruct larynx & pharynx$ 2,791.95 969 31395 Reconstruct larynx & pharynx $11, 057.553603140026 M i d l e v e lR e v i s i o n o f l a ry n x$ 2,560.50 969 31400 26 Revision of larynx $3, 012.4596931400 A R Y TENO I D ECT / A R Y PEX Y EXTERN A L$ 3,706.50 360 31420 26 Removal of epiglottis $1, 075.209693142026 M i d l e v e lR e m o v a l o f e p i g l o tt i s$ 914.05 969 31420 EPIGLOTTIDECTOMY $3, 088.053603150026 I n ser t e m er g e n cy ai r w a y$ 879.90 969 31500 26 Midlevel Insert emergency airway $747.8596931500 I n ser t e m er g e n cy ai r w a y$ 401.10 360 31502 26 Change of windpipe airway $117.609693150226 M i d l e v e lC han g eo f w in d p i p e ai r w a y$ 100.25 969 31502 Change of windpipe airway $127.053603150526 M i d l e v e l D ia g n os t i c l a ry n g osco p y$ 32.40 969 31505 26 Diagnostic laryngoscopy $37.8096931505 L A R Y NGOSCOP Y I N D; D I A GNOST I C$ 181.65 360 31510 26 Laryngoscopy with biopsy $52.509693151026 M i d l e v e l L a ry n g osco p y w i t hbi o p sy$ 44.75 969 31510 LARYNGOSCOPY IND; W BX $1, 167.603603151126 R e m o v e f ore i g nb o d y, l a ry n x$ 132.30 969 31511 26 Midlevel Remove foreign body, larynx $112.4596931511 L A R Y NGOSCOP Y I N D; W REMOFFB$ 478.80 360 31512 26 Removal of larynx lesion $135.459693151226 M i d l e v e lR e m o v a l o f l a ry n x l es i o n$ 115.25 969 31512 LARYNGOSCOPY IND; W REM OF LESION $1,167.60 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 116 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31513 26 Midlevel Injection into vocal cord $121.259693151326 I nj ec t i o nin t o v oc a l cor d$ 142.80 969 31513 LARYNGOSCOPY IND; W VC INJ $491.403603151526 L a ry n g osco p y f or a s p i r a t i o n$ 147.00 969 31515 26 Midlevel Laryngoscopy for aspiration $125.2096931515 L A R Y NGOSCOP Y D I RECT; FOR A SP$ 408.45 360 31520 26 Midlevel Dx laryngoscopy, newborn $101.659693152026 D x l a ry n g osco p y, n e w b or n$ 119.70 969 31520 DX LARYNGOSCOPY NEWBORN $581.703603152526 M i d l e v e l D x l a ry n g osco p ye x c l nb$ 145.00 969 31525 26 Dx laryngoscopy excl nb $170.1096931525 D X L A R Y NGOSCOP Y EXC L NB$ 592.20 360 31526 26 Midlevel Dx laryngoscopy w/oper scope $150.959693152626 D x l a ry n g osco p y w / o p ersco p e$ 177.45 969 31526 DX LARYNGOSCOPY W/OPER SCOPE $586.953603152726 M i d l e v e l L a ry n g osco p y f or t re a t m e n t$ 150.40 969 31527 26 Laryngoscopy for treatment $177.4596931527 L A R Y NGOSCOP Y D I R; W I NSOBT U R A TOR$ 725.55 360 31528 26 Midlevel Laryngoscopy and dilation $180.609693152826 L a ry n g osco p y an dd i l a t i o n$ 212.10 969 31528 INIT DIR LARYNG W DIL $539.703603152926 M i d l e v e l L a ry n g osco p y an dd i l a t i o n$ 134.30 969 31529 26 Laryngoscopy and dilation $157.5096931529 D I R L A R Y NG W D I L SQ$ 602.70 360 31530 26 Midlevel Laryngoscopy w/fb removal $153.859693153026 L a ry n g osco p y w / f b re m o v a l$ 180.60 969 31530 LARYNGOSCOPY W/FB REMOVAL $1,890.00 360 31531 26 Midlevel Laryngoscopy w/fb & op scope$ 187.35 969 31531 26 Laryngoscopy w/fb & op scope $220.50 969 31531 LARYNGOSCOPY W/FB & OP SCOPE$ 791.70 360 31535 26 Midlevel Laryngoscopy w/biopsy $204.459693153526 L a ry n g osco p y w / bi o p sy$ 240.45 969 31535 LARYNGOSCOPY W/BIOPSY $706.65 360 31536 26 Midlevel Laryngoscopy w/bx & op scope$ 180.55 969 31536 26 Laryngoscopy w/bx & op scope $212.10 969 31536 Laryngoscopy w/bx & op scope$ 786.45 360 31540 26 Laryngoscopy w/exc of tumor $238.359693154026 M i d l e v e l L a ry n g osco p y w / e x co f t u m or$ 202.60 969 31540 LARYNGOSCOPY W/EXC OF TUMOR $903.003603154126 M i d l e v e l L a ry n sco pw / t u m re x c + sco p e$ 232.55 969 31541 26 Larynscop w/tumr exc + scope $274.0596931541 L A R Y NSCOP W / T U MREXC + SCOPE$ 987.00 360 31545 26 Remove vc lesion w/scope $299.259693154526 M i d l e v e lR e m o v e v c l es i o n w / sco p e$ 254.80 969 31545 SCOPE REM VC LESION W FLAPS $1, 351.353603154626 R e m o v e v c l es i o n sco p e / g r a f t$ 397.95 969 31546 26 Midlevel Remove vc lesion scope/graft $338.0596931546 SCOPEREM V C L ES I ON W GR A FT (S)$ 2,048.55 360 31560 26 Midlevel Laryngoscop w/arytenoidectom $518.709693156026 L a ry n g osco pw / a ry t e n o i d ec t o m$ 610.05 969 31560 LARYNGOSCOP W/ARYTENOIDECTOM $1, 169.703603156126 L a ry n sco p, re m v ec a r t + sco p$ 351.75 969 31561 26 Midlevel Larynscop, remve cart + scop $299.1596931561 L A R Y NSCOPREM V EC A RT + SCOP$ 1,276.80 360 31570 26 Laryngoscope w/vc inj $384.309693157026 M i d l e v e l L a ry n g osco p e w / v c inj$ 326.65 969 31570 LARYNGOSCOPE W/VC INJ $851.55 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 117 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31571 26 Laryngoscop w/vc inj + scope $256.209693157126 M i d l e v e l L a ry n g osco pw / v c inj + sco p e$ 217.90 969 31571 LARYNGOSCOP W/VC INJ + SCOPE $930.303603157526 M i d l e v e l D ia g n os t i c l a ry n g osco p y$ 239.75 969 31575 26 Diagnostic laryngoscopy $282.4596931575 D I A GNOST I C L A R Y NGOSCOP Y$ 282.45 360 31576 26 Midlevel Laryngoscopy with biopsy $71.059693157626 L a ry n g osco p y w i t hbi o p sy$ 84.00 969 31576 LARYNGOSCOPY WITH BIOPSY $457.803603157726 M i d l e v e lR e m o v e f ore i g nb o d y, l a ry n x$ 114.90 969 31577 26 Remove foreign body, larynx $135.4596931577 L A RGSC W / RM V L FORE I GNB D Y (S)$ 550.20 360 31578 26 Removal of larynx lesion $166.959693157826 M i d l e v e lR e m o v a l o f l a ry n x l es i o n$ 141.65 969 31578 LARGSC W/REMOVAL LESION $636.303603157926 D ia g n os t i c l a ry n g osco p y$ 181.65 969 31579 26 Midlevel Diagnostic laryngoscopy $154.3596931579 L A R Y NGOSCOP Y TE L ESCOP I C$ 525.00 360 31580 26 Revision of larynx $155.409693158026 M i d l e v e lR e v i s i o n o f l a ry n x$ 131.65 969 31580 LARYNGOPLASTY LARYNGEAL WEB $4, 517.103603158426 T re a tl a ry n x f r a c t u re$ 1,291.50 969 31584 26 Midlevel Treat larynx fracture $1, 097.5096931584 T re a tl a ry n x f r a c t u re$ 5,583.90 360 31587 26 Revision of larynx $1, 624.359693158726 M i d l e v e lR e v i s i o n o f l a ry n x$ 1,380.75 969 31587 Revision of larynx $3, 689.703603159026 M i d l e v e lR e inn er v a t e l a ry n x$ 866.70 969 31590 26 Reinnervate larynx $1, 019.5596931590 L A R Y NGE A L RE I NNER V A TENE U ROM U SC$ 3,327.45 360 PEDICLE 31595 26 Larynx nerve surgery $997.509693159526 M i d l e v e l L a ry n x n er v es u r g ery$ 848.20 969 31595 SECTION RECUR LARYNG NERVE THERAP $2, 839.20360 U N I L 31599 L a ry n x s u r g ery p roce d u re$ 357.00 360 31600 26 Midlevel Incision of windpipe $701.109693160026 I n c i s i o n o f w in d p i p e$ 825.30 969 31600 Incision of windpipe $1, 461.603603160126 I n c i s i o n o f w in d p i p e$ 434.70 969 31601 26 Midlevel Incision of windpipe $369.2096931601 I NC I S I ONOF W I N D P I PE < 2 Y RS$ 962.85 360 31603 26 Midlevel Incision of windpipe $240.959693160326 I n c i s i o n o f w in d p i p e$ 283.50 969 31603 Incision of windpipe $820.053603160526 M i d l e v e l I n c i s i o n o f w in d p i p e$ 207.15 969 31605 26 Incision of windpipe $243.6096931605 TR A C H EOSTOM Y EMERG; CR I COT H Y RO I D$ 667.80 360 31610 26 Incision of windpipe $199.509693161026 M i d l e v e l I n c i s i o n o f w in d p i p e$ 169.25 969 31610 Incision of windpipe $2, 637.603603161126 S u r g ery / s p eec h p ros t h es i s$ 748.65 969 31611 26 Midlevel Surgery/speech prosthesis $636.3096931611 TEF I ST UL A W I NSSPEEC H PROST H$ 2,005.50 360 31612 26 Puncture/clear windpipe $560.709693161226 M i d l e v e lP u n c t u re / c l e a r w in d p i p e$ 476.25 969 31612 TRACH PUNCT PERC W TT ASP OR INJECTION $174.30 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 118 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31613 26 Midlevel Repair windpipe opening $44.559693161326 R e p ai r w in d p i p eo p e nin g$ 52.50 969 31613 TRACHEOSTOMA REV; SIMPLE WO FL $1, 677.90360 ROT A TE 3161426 M i d l e v e lR e p ai r w in d p i p eo p e nin g$ 395.00 969 31614 26 Repair windpipe opening $465.1596931614 TR A C H EOSTOM A RE V; COMP L EX W F L$ 2,790.90 360 ROTATE 31615 26 Midlevel Visualization of windpipe $634.459693161526 Vi s u a l i z a t i o n o f w in d p i p e$ 746.55 969 31615 TRACHEOBRONCH THRU OLD INCISION $473.553603162226 D x b ro n c h osco p e / w a s h$ 137.55 969 31622 26 Midlevel Dx bronchoscope/wash $116.6596931622 D XBRONC H OSCOPE / W A S H$ 536.55 360 31623 26 Dx bronchoscope/brush $158.559693162326 M i d l e v e l D x b ro n c h osco p e / b r u s h$ 134.60 969 31623 DX BRONCHOSCOPE/BRUSH $535.503603162426 D x b ro n c h osco p e / l a v a g e$ 160.65 969 31624 26 Midlevel Dx bronchoscope/lavage $136.4096931624 D XBRONC H OSCOPE / L A V A GE$ 538.65 360 31625 26 Midlevel Bronchoscopy w/biopsy(s) $136.409693162526 B ro n c h osco p y w / bi o p sy (s)$ 160.65 969 31625 BRONCHOSCOPY W/BIOPSY(S) $623.7036031626 BRONC H OSCOP YW / M A R K ERS$ 751.80 360 31627 NAVIGATIONAL BRONCHOSCOPY $346.503603162826 B ro n c h osco p y / l u n g b x, e a c h$ 186.90 969 31628 26 Midlevel Bronchoscopy/lung bx, each $159.1096931628 BRONC H OSCOP Y / LU NGBXE A C H$ 691.95 360 31629 26 Bronchoscopy/needle bx, each $207.909693162926 M i d l e v e lB ro n c h osco p y / n ee d l e b x, e a c h$ 176.90 969 31629 BRONCHOSCOPY/NEEDLE BX EACH $744.453603163026 B ro n c h osco p y d i l a t e / f x re p r$ 222.60 969 31630 26 Midlevel Bronchoscopy dilate/fx repr $189.2096931630 BRONC H OSCOP Y D I L A TE / FXREPR$ 744.45 360 31631 26 Midlevel Bronchoscopy, dilate w/stent $195.009693163126 B ro n c h osco p y, d i l a t e w / s t e n t$ 228.90 969 31631 BRONCHOSCOPY DILATE W/STENT $845.253603163226 M i d l e v e lB ro n c h osco p y / l u n g b x, a d d^{'} l$ 215.40 969 31632 26 Bronchoscopy/lung bx, add’l $253.0596931632 BRONC H OSCOP Y / LU NGBX A DD L$ 179.55 360 31633 26 Midlevel Bronchoscopy/needle bx add’l $50.059693163326 B ro n c h osco p y / n ee d l e b x a d d^{'} l$ 58.80 969 31633 BRONCHOSCOPY/NEEDLE BX ADDL $229.9536031634 BRONC H W / B A LL OONOCC LU S I ON$ 783.30 360 31635 26 Bronchoscopy w/fb removal $72.459693163526 M i d l e v e lB ro n c h osco p y w / f b re m o v a l$ 61.95 969 31635 BRONCHOSCOPY W/FB REMOVAL $691.953603163626 B ro n c h osco p y, b ro n c h s t e n t s$ 210.00 969 31636 26 Midlevel Bronchoscopy, bronch stents $178.2596931636 BRONC H OSCOP Y BRONC H STENTS$ 823.20 360 31637 26 Midlevel Bronchoscopy, stent add-on $212.809693163726 B ro n c h osco p y, s t e n t a dd - o n$ 249.90 969 31637 BRONCHOSCOPY STENT ADD-ON $278.253603163826 B ro n c h osco p y, re v i ses t e n t$ 88.20 969 31638 26 Midlevel Bronchoscopy, revise stent $75.2596931638 BRONC H OSCOP Y RE V I SESTENT$ 946.05 360 31640 26 Bronchoscopy w/tumor excise $278.25 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 119 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31640 26 Midlevel Bronchoscopy w/tumor excise $236.7596931640 BRONC H OSCOP YW / T U MOREXC I SE$ 949.20 360 31641 26 Bronchoscopy, treat blockage $290.859693164126 M i d l e v e lB ro n c h osco p y, t re a t b l oc ka g e$ 247.65 969 31641 BRONCHOSCOPY TREAT BLOCKAGE $948.153603164326 M i d l e v e l D ia g b ro n c h osco p e / c a t h e t er$ 241.50 969 31643 26 Diag bronchoscope/catheter $284.5596931643 D I A GBRONC H OSCOPE / C A T H ETER$ 644.70 360 31645 26 Bronchoscopy, clear airways $194.259693164526 M i d l e v e lB ro n c h osco p y, c l e a r ai r w a ys$ 164.70 969 31645 BRNCHSC W/THER ASPIR 1ST $588.003603164626 B ro n c h osco p y, rec l e a r ai r w a y$ 175.35 969 31646 26 Midlevel Bronchoscopy, reclear airway $148.9596931646 BRNC H SC W / T H ER A SP I RSBSQ$ 511.35 360 31647 BRONCHIAL VALVE INIT INSERT $721.1536031648 BRONC H I A L V A L V EREMO V I N I T$ 762.10 360 31649 BRONCHIAL VALVE REMOV ADDL $241.1036031651 BRONC H I A L V A L V E A DD L I NSERT$ 254.35 360 31660 BRONCH THERMOPLSTY 1 LOBE $727.1036031661 BRONC H T H ERMOP L ST Y 2/ > L OBES$ 766.30 360 31717 26 Bronchial brush biopsy $152.259693171726 M i d l e v e lB ro n c hia l b r u s hbi o p sy$ 129.70 969 31717 CATHE W BRONCHIAL BRUSH BX $400.053603172026 M i d l e v e lCl e a r an ceo f ai r w a ys$ 103.30 969 31720 26 Clearance of airways $121.8096931720 C A T H ETER A SP I R A T I ON$ 186.90 360 31725 26 Clearance of airways $56.709693172526 M i d l e v e lCl e a r an ceo f ai r w a ys$ 48.10 969 31725 Clearance of airways $344.403603173026 M i d l e v e l I n t ro, w in d p i p e w i re / t u b e$ 88.45 969 31730 26 Intro, windpipe wire/tube $103.9596931730 TTN D L W I RE / D I L A TOR / STENTFORO 2 TX$ 538.65 360 31750 26 Repair of windpipe $158.559693175026 M i d l e v e lR e p ai ro f w in d p i p e$ 134.40 969 31750 TRACHEOPLASTY; CERVICAL $5, 050.503603175526 M i d l e v e lR e p ai ro f w in d p i p e$ 1,197.60 969 31755 26 Repair of windpipe $1, 409.1096931755 TR A C H EOP L A ST Y; TPF I ST UL I Z$ 6,418.65 360 31760 26 Midlevel Repair of windpipe $1, 535.359693176026 R e p ai ro f w in d p i p e$ 1,806.00 969 31760 Repair of windpipe $5, 118.753603176626 M i d l e v e lR eco n s t r u c t i o n o f w in d p i p e$ 1,246.20 969 31766 26 Reconstruction of windpipe $1, 465.8096931766 R eco n s t r u c t i o n o f w in d p i p e$ 6,884.85 360 31770 26 Midlevel Repair/graft of bronchus $1, 658.109693177026 R e p ai r / g r a f t o f b ro n c h u s$ 1,950.90 969 31770 Repair/graft of bronchus $4, 962.303603177526 R eco n s t r u c t b ro n c h u s$ 1,439.55 969 31775 26 Midlevel Reconstruct bronchus $1, 223.7596931775 R eco n s t r u c t b ro n c h u s$ 5,183.85 360 31780 26 Reconstruct windpipe $1, 539.309693178026 M i d l e v e lR eco n s t r u c tw in d p i p e$ 1,308.65 969 31780 Reconstruct windpipe $4, 397.403603178126 M i d l e v e lR eco n s t r u c tw in d p i p e$ 1,086.50 969 31781 26 Reconstruct windpipe $1, 277.8596931781 R eco n s t r u c tw in d p i p e$ 5,202.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 120 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 31785 26 Midlevel Remove windpipe lesion $1, 309.159693178526 R e m o v e w in d p i p e l es i o n$ 1,540.35 969 31785 Remove windpipe lesion $3, 972.153603178626 M i d l e v e lR e m o v e w in d p i p e l es i o n$ 988.90 969 31786 26 Remove windpipe lesion $1, 163.4096931786 R e m o v e w in d p i p e l es i o n$ 5,411.70 360 31800 26 Repair of windpipe injury $1, 635.909693180026 M i d l e v e lR e p ai ro f w in d p i p e inj u ry$ 1,390.65 969 31800 Repair of windpipe injury $2, 637.603603180526 M i d l e v e lR e p ai ro f w in d p i p e inj u ry$ 638.40 969 31805 26 Repair of windpipe injury $750.7596931805 R e p ai ro f w in d p i p e inj u ry$ 3,043.95 360 31820 26 Midlevel Closure of windpipe lesion $755.759693182026 Cl os u reo f w in d p i p e l es i o n$ 889.35 969 31820 SURG CLOSE TRACHEOSTOMY/FISTULA; WO $1, 220.10360 PREP 3182526 R e p ai ro f w in d p i p e d e f ec t$ 347.55 969 31825 26 Midlevel Repair of windpipe defect $295.6596931825 S U RGC L OSETR A C H EOSTOM Y / F I ST UL A; W P$ 1,785.00 360 REP 31830 26 Revise windpipe scar $515.559693183026 M i d l e v e lR e v i se w in d p i p esc a r$ 438.55 969 31830 REVISION OF TRACHEOSTOMY SCAR $1, 267.3536031899 A i r w a yss u r g i c a lp roce d u re$ 314.15 360 32035 26 Midlevel Exploration of chest $309.309693203526 E x pl or a t i o n o f c h es t$ 364.35 969 32035 Exploration of chest $2, 673.303603203626 M i d l e v e lE x pl or a t i o n o f c h es t$ 628.25 969 32036 26 Exploration of chest $739.2096932036 E x pl or a t i o n o f c h es t$ 2,894.85 360 32096 Open wedge/bx lung infiltr $3, 000.9036032097 Op e n w e d g e / b x l u n g n o d u l e$ 3,000.90 360 32098 Open biopsy of lung pleura $2, 820.303603210026 E x pl or a t i o n / bi o p syo f c h es t$ 806.40 969 32100 26 Midlevel Exploration/biopsy of chest $685.6596932100 E x pl or a t i o n / bi o p syo f c h es t$ 3,088.05 360 32110 26 Midlevel Explore/repair chest $880.309693211026 E x pl ore / re p ai rc h es t$ 1,035.30 969 32110 Explore/repair chest $5, 439.003603212026 R e - e x pl or a t i o n o f c h es t$ 1,546.65 969 32120 26 Midlevel Re-exploration of chest $1, 314.4096932120 R e - e x pl or a t i o n o f c h es t$ 3,259.20 360 32124 26 Explore chest free adhesions $918.759693212426 M i d l e v e lE x pl orec h es t f ree a d h es i o n s$ 780.95 969 32124 Explore chest free adhesions $3, 467.103603214026 M i d l e v e lR e m o v a l o f l u n g l es i o n (s)$ 828.70 969 32140 26 Removal of lung lesion(s) $975.4596932140 R e m o v a l o f l u n g l es i o n (s)$ 3,701.25 360 32141 26 Remove/treat lung lesions $1, 043.709693214126 M i d l e v e lR e m o v e / t re a tl u n g l es i o n s$ 887.35 969 32141 Remove/treat lung lesions $5, 686.803603215026 M i d l e v e lR e m o v a l o f l u n g l es i o n (s)$ 1,252.10 969 32150 26 Removal of lung lesion(s) $1, 473.1596932150 R e m o v a l o f l u n g l es i o n (s)$ 3,738.00 360 32151 26 Midlevel Remove lung foreign body $891.909693215126 R e m o v e l u n g f ore i g nb o d y$ 1,048.95 969 32151 Remove lung foreign body $3,762.15 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 121 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 32160 26 Open chest heart massage $1, 083.609693216026 M i d l e v e lOp e n c h es t h e a r t ma ss a g e$ 920.80 969 32160 Open chest heart massage $2, 902.203603220026 M i d l e v e l Dr ain, o p e n, l u n g l es i o n$ 668.40 969 32200 26 Drain, open, lung lesion $786.4596932200 Dr ain, o p e n, l u n g l es i o n$ 4,232.55 360 32215 26 Treat chest lining $1, 170.759693221526 M i d l e v e lT re a t c h es tl inin g$ 994.95 969 32215 Treat chest lining $2, 975.703603222026 M i d l e v e lR e l e a seo f l u n g$ 729.95 969 32220 26 Release of lung $858.9096932220 R e l e a seo f l u n g$ 5,930.40 360 32225 26 Midlevel Partial release of lung $1, 450.659693222526 P a r t ia l re l e a seo f l u n g$ 1,706.25 969 32225 Partial release of lung $3, 715.953603231026 R e m o v a l o f c h es tl inin g$ 1,051.05 969 32310 26 Midlevel Removal of chest lining $893.0096932310 R e m o v a l o f c h es tl inin g$ 3,434.55 360 32320 26 Midlevel Free/remove chest lining $830.159693232026 F ree / re m o v ec h es tl inin g$ 976.50 969 32320 Free/remove chest lining $5, 955.603603240026 N ee d l e bi o p syc h es tl inin g$ 1,695.75 969 32400 26 Midlevel Needle biopsy chest lining $1, 441.1596932400 NEE D L EB I OPS Y C H EST L I N I NG$ 319.20 360 32405 26 Midlevel Biopsy, lung or mediastinum $80.159693240526 B i o p sy, l u n g or m e d ia s t in u m$ 94.50 969 32405 PERCUT BX LUNG/MEDIASTINUM $371.7036032551 I n ser t i o n o f c h es tt u b e$ 1,965.95 360 32554 ASPIRATE PLEURA W/O IMAGING $446.2536032555 A SP I R A TEP L E U R A W / I M A G I NG$ 359.65 360 32556 INSERT CATH PLEURA W/O IMAGE $394.4536032557 I NSERTC A T H P L E U R A W / I M A GE$ 518.70 360 32560 26 INSTLI VIA CHEST TUBE/CATH AGENT FOR $691.51 P L E U RO D ES I S 3256126 I NST L I V I A C H T U BE / C A T H A GENT$ 294.83 FBRNLYSIS 1ST DAY 32562 26 INSTLI CH TUBE/CATH AGENT FBRNLYSIS $252.84 SBSQ D A Y 3260826 T H OR A SCOP YW / D I A GNOST I CBXOF LU NG$ 1,143.54 NODULE(S) OR MASS(ES) 32650 26 Midlevel Therapeutic pneumothorax $89.309693265026 T h or a cosco p y, S u r g i c a l$ 105.00 969 32650 Thoracoscopy, Surgical $2, 490.603603296026 M i d l e v e lT h er a p e u t i c p n e u m o t h or a x$ 612.00 969 32960 26 Therapeutic pneumothorax $720.3096932960 T h er a p e u t i c p n e u m o t h or a x$ 381.15 360 32997 26 Total lung lavage $101.859693299726 M i d l e v e lT o t a ll u n g l a v a g e$ 86.30 969 32997 Total lung lavage $1, 297.803603299826 M i d l e v e lP er q r f ab l a t e t x, p u lt u m or$ 325.00 969 32998 26 Perq rf ablate tx, pul tumor $382.2096932998 A B L A TEP UL MT U MORPERQRF$ 1,059.45 360 32999 Chest surgery procedure $1, 225.153603301026 Dr aina g eo f h e a r t s a c$ 308.70 969 33010 26 Midlevel Drainage of heart sac $262.4096933010 PER I C A R D I OCENTES I S; I N I T I A L$ 444.15 360 33011 26 Repeat drainage of heart sac $128.10 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 122 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 33011 26 Midlevel Repeat drainage of heart sac $109.2596933011 PER I C A R D I OCENTES I S; S U BSEQ U ENT$ 448.35 360 33207 INSERT HEART PM VENTRICULAR $1, 550.2536033210 I n ser t e l ec t r d / p m c a t h s n g l$ 534.35 360 33215 REPOSITION PACING-DEFIB LEAD $977.303603321626 I NSERT 1 E L ECTRO D EPM - D EF I B$ 1,167.79 975 33285 26 INSERTION SUBQ CARDIAC RHYTHM $268.50 MON I TOR I NC LU D I NGPROGR A MN I NG 33285 TC I NSERT I ONS U BQC A R D I A CR H Y T H M$ 24,997.11 MONITOR INCLUDING PROGRAMNING 33286 26 REMOVAL SUBQ CARDIAC RYTHYM $265.35 MON I TOR 33286 TCREMO V A L S U BQC A R D I A CR Y T H Y M$ 1,906.62 MONITOR 33990 INSERT VAD ARTERY ACCESS $1,376.65 360 33991 INSERT VAD ART&VEIN ACCESS$ 2,005.90 360 33992 REMOVE VAD DIFFERENT SESSION $651.5536033993 REPOS I T I ON V A DD I FFSESS I ON$ 572.20 360 34701 EVASC RPR A-AO NDGFT $2, 511.7036034702 E V A SCRPR A - A ON D GFTRPT$ 3,749.25 360 34703 EVASC RPR A-UNILAC NDGFT $2, 816.3036034704 E V A SCRPR A - U N I L A CN D GFTRPT$ 4,682.00 360 34705 EVAC RPR A-BIILIAC NDGFT $3, 112.2536034706 E V A SCRPR A - B II L I A CRPT$ 4,676.95 360 34707 EVASC RPR ILIO-ILIAC NDGFT $2, 339.2536034708 E V A SCRPR I L I O - I L I A CRPT$ 3,758.15 360 34709 PLMT XTN PROSTH EVASC RPR $652.8536034710 D L Y D P L MTXTNPROST H 1 ST V S L$ 1,640.35 360 34711 DLYD PLMT XTN PROSTH EA ADDL $602.5036035011 D I RRPR A NE U R Y SM A X I L - BR A C H I A L A RM$ 5,139.76 INCISION 35184 RPR CONGENITAL AV FISTULA EXTREMITIES $3, 763.5736035190 REP A CQ / TR A U M A V F I ST UL A; EXTREM I T I ES$ 2,870.55 360 35206 Repair blood vessel lesion $2, 539.0536035207 REPB L OO D V ESSE L D I RECT; H A N D F I NGER$ 2,539.35 360 35221 26 RPR BLOOD VESSEL DIRECT INTRA- $5, 144.37 A B D OM I N A L 35236 REPB L D V ESSE L WV E I NGR A FT; U PR$ 3,198.65 360 EXTREM 35371 RECHANNELING OF ARTERY $2, 697.603603570226 EXP L OR A T I ONN / F L W D S U RG U PPER$ 1,222.65 EXTREMITY ARTERY 35703 26 EXPLORATION N/FLWD SURG LOWER $1, 223.58 EXTREM I T Y A RTER Y 3580026 EXP L PO H EMRRGT H ROMBOS I S / I NFCT J NC K$ 2,588.70 35840 26 EXPL POSTOP HEMOR/THROMB/INF; $3, 696.35975 A B D OMEN 35860 E x pl ore l imb v esse l s$ 2,712.71 360 35901 EXCIS INFECT GRAFT; NECK $1, 670.4036035903 EXC I S I NFECTGR A FT; EXTREM I T Y$ 1,903.25 360 35905 26 Midlevel Excision, graft, thorax $111.109693590526 E x c i s i o n, g r a f t, t h or a x$ 130.20 969 35907 26 Midlevel Excision, graft, abdomen $1, 692.809693590726 E x c i s i o n, g r a f t, ab d o m e n$ 1,991.85 969 36000 26 Midlevel Place needle in vein $1, 860.909603600026 Pl a ce n ee d l e in v e in$ 2,189.25 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 123 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36000 NONSELECTIVE CATH PLACEMENT IN VEIN $35.703603600226 M i d l e v e lP se u d o an e u rys minj ec t i o n t r t$ 7.95 969 36002 26 Pseudoaneurysm injection trt $9.4596936002 I N J PERCEXTR A NE U R Y SM$ 397.95 360 36005 26 Midlevel Injection ext venography $103.959693600526 I nj ec t i o n e x t v e n o g r a p h y$ 121.80 969 36005 EXTREM VENOGRAM INJ $179.553603601026 M i d l e v e lPl a cec a t h e t er in v e in$ 44.40 969 36010 26 Place catheter in vein $52.5096936010 NONSE L ECT I V EC A T H S U P / I NF V EN A C A V A$ 451.50 360 36011 26 Midlevel Place catheter in vein $114.209693601126 Pl a cec a t h e t er in v e in$ 134.40 969 36011 SELECTIVE CATH VEIN; 1ST ORDER FAMILY $584.853603601226 M i d l e v e lPl a cec a t h e t er in v e in$ 148.90 969 36012 26 Place catheter in vein $175.3596936012 SE L ECT I V EC A T H V E I N; 2 N D OR D ERF A M I L Y$ 659.40 360 36013 26 Place catheter in artery $194.259693601326 M i d l e v e lPl a cec a t h e t er ina r t ery$ 165.45 969 36013 NONSELECT CATH RT HEART/MAIN PULMON $484.05360 A RT 3601426 Pl a cec a t h e t er ina r t ery$ 138.60 969 36014 26 Midlevel Place catheter in artery $118.0596936014 SE L ECT I V EC A T H - L T / RTP UL MON A R Y$ 555.45 360 ARTERY 36015 26 Place catheter in artery $166.959693601526 M i d l e v e lPl a cec a t h e t er ina r t ery$ 142.30 969 36015 SELECTIVE CATH - SEGMENTAL ARTERY $642.603603610026 M i d l e v e lE s t ab l i s ha ccess t o a r t ery$ 162.95 969 36100 26 Establish access to artery $192.1596936100 NONSE L ECTC A T H - C A ROT I D / V ERTEBR A L$ 602.70 360 ART 36140 26 Establish access to artery $175.359693614026 M i d l e v e lE s t ab l i s ha ccess t o a r t ery$ 149.40 969 36140 INTRO NDL ICATH UPR/LXTR ART $386.403603616026 E s t ab l i s ha ccess t o a or t a$ 111.30 969 36160 26 Midlevel Establish access to aorta $94.7596936160 NONSE L ECTC A T H - TR A NS LU MB A R A ORT A$ 478.80 360 36200 26 Midlevel Place catheter in aorta $120.709693620026 Pl a cec a t h e t er ina or t a$ 141.75 969 36200 NONSELECTIVE CATH - AORTA $577.503603621526 Pl a cec a t h e t er ina r t ery$ 169.05 969 36215 26 Midlevel Place catheter in artery $143.3096936215 SE L ECTC A T H A RT - BR A C H - CEP H; 1 ST$ 907.20 360 ORDER 36216 26 Midlevel Place catheter in artery $222.659693621626 Pl a cec a t h e t er ina r t ery$ 261.45 969 36216 SELECT CATH ART - BRACH-CEPH; 2ND $1, 029.00360 OR D ER 3621726 Pl a cec a t h e t er ina r t ery$ 294.00 969 36217 26 Midlevel Place catheter in artery $249.8096936217 SE L ECTC A T H A RT - BR A C H - CEP H; 3 R D$ 1,225.35 360 ORDER 36218 26 Midlevel Place catheter in artery $300.109693621826 Pl a cec a t h e t er ina r t ery$ 352.80 969 36218 SELECT CATH ART - BRACH-CEPH; EA ADDTL $195.3036036221 P L A CEC A T H T H OR A C I C A ORT A$ 681.40 360 36222 PLACE CATH CAROTID/INOM ART $930.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 124 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36223 PLACE CATH CAROTID/INOM ART $1, 005.0036036224 P L A CEC A T H C A ROT D A RT$ 1,097.45 360 36225 PLACE CATH SUBCLAVIAN ART $1, 000.5036036226 P L A CEC A T H V ERTEBR A L A RT$ 1,099.95 360 36227 PLACE CATH XTRNL CAROTID $347.853603624526 M i d l e v e lPl a cec a t h e t er ina r t ery$ 47.85 969 36245 26 Place catheter in artery $56.7096936245 I NSC A T H A B D / L - EXT A RT 1 ST$ 916.65 360 36246 26 Midlevel Place catheter in artery $228.959693624626 Pl a cec a t h e t er ina r t ery$ 269.85 969 36246 INS CATH ABD/L-EXT ART 2ND $1, 014.303603624726 M i d l e v e lPl a cec a t h e t er ina r t ery$ 252.55 969 36247 26 Place catheter in artery $297.1596936247 I NSC A T H A B D / L - EXT A RT 3 R D$ 1,208.55 360 36248 26 Midlevel Place catheter in artery $300.959693624826 Pl a cec a t h e t er ina r t ery$ 353.85 969 36248 INS CATH ABD/L-EXT ART ADDL $190.053603626026 I n ser t i o n o f in f u s i o n p u m p$ 56.70 969 36260 26 Midlevel Insertion of infusion pump $48.3096936260 I NS I MP L I NTR A - A RT I NF U S I ONP U MP$ 2,332.05 360 36261 26 Midlevel Revision of infusion pump $543.709693626126 R e v i s i o n o f in f u s i o n p u m p$ 639.45 969 36261 REVISE IMPL INTRA-ARTERIAL INFUSION $1, 459.50360 P U MP 3626226 R e m o v a l o f in f u s i o n p u m p$ 396.90 969 36262 26 Midlevel Removal of infusion pump $337.6096936262 REM I MP L I NTR A - A RT I NF U S I ONP U MP$ 1,110.90 360 36400 26 Midlevel Bl draw < 3 yrs fem/jugular $252.909693640026 Bl d r a w < 3 yrs f e m / j ugu l a r$ 297.15 969 36400 BL DRAW < 3 YRS FEM/JUGULAR $70.353603640526 Bl d r a w < 3 yrssc a lp v e in$ 19.95 969 36405 26 Midlevel Bl draw < 3 yrs scalp vein $16.9596936405 B L D R A W < 3 Y RSSC A L P V E I N$ 60.90 360 36406 26 Midlevel Bl draw < 3 yrs other vein $14.009693640626 Bl d r a w < 3 yrso t h er v e in$ 16.80 969 36406 Bl draw < 3 yrs other vein $32.553603641026 N o n - ro u t in e b l d r a w > 3 yrs$ 9.45 969 36410 26 Midlevel Non-routine bl draw > 3 yrs $8.3596936410 NON - RO U T I NEB L D R A W >= 3 Y RS$ 34.65 360 36415 Routine venipuncture $15.7530036416 C a p i ll a ry b l oo dd r a w$ 9.45 300 36420 26 Vein access cutdown < 1 yr $9.459693642026 M i d l e v e l V e ina ccessc u t d o w n < 1 yr$ 7.95 969 36420 VEIN ACCESS CUTDOWN < 1 YR $187.953603642526 V e ina ccessc u t d o w n > 1 yr$ 52.50 969 36425 26 Midlevel Vein access cutdown > 1 yr $44.7096936425 V EN I P U NCT U REC U T D O W N; A GE 1 ORO V ER$ 145.95 360 36430 Blood transfusion service $630.003913644026 M i d l e v e lBlp u s h t r an s f u se, 2 yror <$ 34.65 969 36440 26 Bl push transfuse, 2 yr or < $40.9596936440 B L P U S H TR A NSF U SE 2 Y ROR <$ 577.50 391 36450 26 Midlevel Bl exchange/transfuse, nb $49.059693645026 Bl e x c han g e / t r an s f u se, nb$ 57.75 969 36450 EXCHANGE TRANSFUSION BLOOD; $577.50391 NE W BORN 3645526 M i d l e v e lBl e x c han g e / t r an s f u se n o n - nb$ 106.45 969 36455 26 Bl exchange/transfuse non-nb $124.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 125 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36455 EXCHANGE TRANSFUSION BLOOD; NOT $577.50391 NE W BORN 36456 PRT L EXC H A NGETR A NSF U SENB$ 342.28 391 36460 26 Transfusion service, fetal $140.709693646026 M i d l e v e lT r an s f u s i o n ser v i ce, f e t a l$ 119.90 969 36460 Transfusion service, fetal $1, 308.3036036468 N J XSC L RSNTSP I D ER V E I NS$ 283.50 360 36470 26 Injection therapy of vein $372.759693647026 M i d l e v e l I nj ec t i o n t h er a p yo f v e in$ 316.40 969 36470 NJX SCLRSNT 1 INCMPTNT VEIN $303.453603647126 I nj ec t i o n t h er a p yo f v e in s$ 77.70 969 36471 26 Midlevel Injection therapy of veins $66.4096936471 N J XSC L RSNTM L T I NCMPTNT V N$ 374.85 360 36475 26 Midlevel Endovenous rf, 1st vein $93.109693647526 E n d o v e n o u sr f, 1 s t v e in$ 109.20 969 36475 ENDOVENOUS RF 1ST VEIN $1, 323.003603647626 E n d o v e n o u sr f, v e ina dd - o n$ 376.95 969 36476 26 Midlevel Endovenous rf, vein add-on $320.4096936476 EN D O V ENO U SRF V E I N A DD - ON$ 649.95 360 36478 26 Midlevel Endovenous laser, 1st vein $156.259693647826 E n d o v e n o u s l a ser, 1 s t v e in$ 183.75 969 36478 LASER ABLTN EXT VEIN 1ST VEIN $1, 317.753603647926 E n d o v e n o u s l a ser v e ina dd o n$ 378.00 969 36479 26 Midlevel Endovenous laser vein addon $321.2096936479 EN D O V ENO U S L A SER V E I N A DD ON$ 649.95 360 36481 26 Midlevel Insertion of catheter, vein $157.009693648126 I n ser t i o n o f c a t h e t er, v e in$ 184.80 969 36481 PERC PORTAL VEIN CATHETERIZATION $1, 318.803603650026 I n ser t i o n o f c a t h e t er, v e in$ 395.85 969 36500 26 Midlevel Insertion of catheter, vein $336.7596936500 V ENO U SSE L ECT I V EORG A NB L OO D$ 666.75 360 SAMPLING 36510 26 Midlevel Insertion of catheter, vein $170.559693651026 I n ser t i o n o f c a t h e t er, v e in$ 200.55 969 36510 Insertion of catheter vein $223.653603651126 A p h eres i s w b c$ 69.30 969 36511 26 Midlevel Apheresis wbc $59.1096936511 A P H ERES I S W BC$ 347.55 360 36512 26 Apheresis rbc $99.759693651226 M i d l e v e l A p h eres i sr b c$ 85.20 969 36512 APHERESIS RBC $334.953603651326 M i d l e v e l A p h eres i s pl a t e l e t s$ 86.00 969 36513 26 Apheresis platelets $100.8096936513 A P H ERES I SP L A TE L ETS$ 366.45 360 36514 26 Midlevel Apheresis plasma $87.309693651426 A p h eres i s pl a s ma$ 102.90 969 36514 APHERESIS PLASMA $340.203603651626 M i d l e v e l A p h eres i s, se l ec t i v e$ 84.40 969 36516 26 Apheresis, selective $99.7596936516 A P H ERES I S I MM U NO A D SS L CT V$ 257.25 360 36522 26 Midlevel Photopheresis $59.659693652226 P h o t o p h eres i s$ 70.35 969 36522 PHOTOPHERESIS EXTRACORPOREAL $371.703603655526 M i d l e v e l I n ser t n o n - t u nn e l c v c a t h$ 94.35 969 36555 26 Insert non-tunnel cv cath $111.3096936555 I NSERTNON - T U NNE L C V C A T H < 5 Y RS$ 731.85 360 36556 26 Midlevel Insert non-tunnel cv cath $119.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 126 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36556 26 Insert non-tunnel cv cath $140.7096936556 I NSNON - T U NNE L C V C A T H >= 5 Y RS$ 721.35 360 36557 26 Insert tunneled cv cath $133.359693655726 M i d l e v e l I n ser tt u nn e l e d c v c a t h$ 113.30 969 36557 INS TUNNELED CV CATH WO SQ PORT <5 YRS $1, 198.053603655826 I n ser tt u nn e l e d c v c a t h$ 330.75 969 36558 26 Midlevel Insert tunneled cv cath $280.9096936558 I NST U NNE L E D C V C A T H A GE >= 5 Y RS$ 1,033.20 360 36560 26 Insert tunneled cv cath $315.009693656026 M i d l e v e l I n ser tt u nn e l e d c v c a t h$ 267.70 969 36560 INS TUNNELED CV CATH W SQ PORT <5 YRS $1, 332.453603656126 I n ser tt u nn e l e d c v c a t h$ 389.55 969 36561 26 Midlevel Insert tunneled cv cath $331.5096936561 I NST U NNE L E D C V A D W PORT >= 5 Y RS$ 1,312.50 360 36461 26 INSJ TUNNELED CTR VAD W/SUBQ PORT AGE $983.109605 Y R / > 3656326 I n ser tt u nn e l e d c v c a t h$ 378.00 969 36563 26 Midlevel Insert tunneled cv cath $321.7096936563 I NST U NNE L C V A D W SQP U MP$ 1,395.45 360 36565 26 Insert tunneled cv cath $396.909693656526 M i d l e v e l I n ser tt u nn e l e d c v c a t h$ 337.25 969 36565 INSERT TUNNELED CV 2X CATH WO SQ PORT $1, 309.353603656626 I n ser tt u nn e l e d c v c a t h$ 378.00 969 36566 26 Midlevel Insert tunneled cv cath $320.9096936566 I NSERTT U NNE L E D C V 2 XC A T H W SQPORT$ 1,409.10 360 36568 26 Insert picc cath $404.259693656826 M i d l e v e l I n ser tp i ccc a t h$ 343.30 969 36568 INSERT PICC CATH <5 YRS $657.303603656926 I n ser tp i ccc a t h$ 102.90 969 36569 26 Midlevel Insert picc cath $87.3596936569 I NSP I CC A GE >= 5 Y RS$ 651.00 360 36570 26 Insert picvad cath $101.859693657026 M i d l e v e l I n ser tp i c v a d c a t h$ 86.35 969 36570 INSERT PICVAD CATH <5 YRS $1, 135.053603657126 I n ser tp i c v a d c a t h$ 341.25 969 36571 26 Midlevel Insert picvad cath $290.0596936571 I NSP I CC D E V I CE W PORT 5 Y RS / >$ 1,187.55 360 36575 26 Midlevel Repair tunneled cv cath $290.109693657526 R e p ai r t u nn e l e d c v c a t h$ 341.25 969 36575 REPAIR CVA CATHETER $131.253603657626 R e p ai r t u nn e l e d c v c a t h$ 43.05 969 36576 26 Midlevel Repair tunneled cv cath $36.9096936576 REP A I RC V A D E V I CE W PORT / P U MP$ 720.30 360 36578 26 Replace tunneled cv cath $208.959693657826 M i d l e v e lR e pl a ce t u nn e l e d c v c a t h$ 178.05 969 36578 REPLACE CATH ONLY OF VAD $802.203603658026 M i d l e v e lR e pl a cec v a d c a t h$ 204.25 969 36580 26 Replace cvad cath $240.4596936580 REP L A CENON - T U NNE L E D C V C A T H$ 244.65 360 36581 26 RPLCMT COMPL TUN CVC W/O SUBQ $535.71960 PORT / PMP 3658126 M i d l e v e lR e pl a ce t u nn e l e d c v c a t h$ 63.65 969 36581 Replace tunneled cv cath $730.803603658226 M i d l e v e lR e pl a ce t u nn e l e d c v c a t h$ 188.30 969 36582 26 Replace tunneled cv cath $221.5596936582 R e pl a ce t u nn e l e d c v c a t h$ 1,137.15 360 36583 26 Midlevel Replace tunneled cv cath $279.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 127 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36583 26 Replace tunneled cv cath $328.6596936583 REP L TN L C V A D W P U MP$ 1,192.80 360 36584 26 Midlevel Replace picc cath $282.059693658426 R e pl a ce p i ccc a t h$ 331.80 969 36584 REPLACE PICC CATH $242.553603658526 R e pl a ce p i c v a d c a t h$ 76.65 969 36585 26 Midlevel Replace picvad cath $65.2096936585 REP L PER I P H V A D W PORT$ 1,036.35 360 36589 26 Removal tunneled cv cath $308.709693658926 M i d l e v e lR e m o v a lt u nn e l e d c v c a t h$ 262.25 969 36589 Removal tunneled cv cath $517.653603659026 R e m o v a lt u nn e l e d c v c a t h$ 155.40 969 36590 26 Midlevel Removal tunneled cv cath $132.5096936590 R e m o v a lt u nn e l e d c v c a t h$ 757.05 360 36591 DRAW BLOOD OFF VENOUS DEVICE $84.0030036592 C o ll ec t b l oo df ro m p i cc$ 95.55 300 36593 DECLOT VASCULAR DEVICE $109.203603659526 M ec h re m o v t u nn e l e d c v c a t h$ 218.40 969 36595 26 Midlevel Mech remov tunneled cv cath $185.4596936595 S A MEC H REMOBSTRC V A D$ 684.60 360 36596 26 Midlevel Mech remov tunneled cv cath $176.109693659626 M ec h re m o v t u nn e l e d c v c a t h$ 206.85 969 36596 LMN MECH REM OBSTR CVAD $166.953603659726 R e p os i t i o n v e n o u sc a t h e t er$ 51.45 969 36597 26 Midlevel Reposition venous catheter $43.9096936597 REPOS I TC V C W F LU ORO$ 223.65 360 36598 26 Inj w/fluor, eval cv device $68.259723659826 M i d l e v e l I nj w / f l u or, e v a l c v d e v i ce$ 57.85 972 36598 INJ W/FLUOR EVAL CV DEVICE $155.403603660026 Wi t h d r a w a l o f a r t er ia l b l oo d$ 124.95 969 36600 26 Midlevel Withdrawal of arterial blood $105.9596936600 A RTER I A L P U NCT U REB L OO D FOR D X$ 55.65 410 36620 26 Midlevel Insertion catheter, artery $14.459693662026 I n ser t i o n c a t h e t er, a r t ery$ 16.80 969 36620 Insertion catheter artery $186.903603662526 M i d l e v e l I n ser t i o n c a t h e t er, a r t ery$ 47.40 969 36625 26 Insertion catheter, artery $55.6596936625 I n ser t i o n c a t h e t er a r t ery$ 395.85 360 36640 26 Insertion catheter, artery $112.359693664026 M i d l e v e l I n ser t i o n c a t h e t er, a r t ery$ 95.65 969 36640 ARTERIAL CATHE - PROLONGED INFUSION $476.70360 (C H EMO) 3666026 I n ser t i o n c a t h e t er, a r t ery$ 133.35 969 36660 26 Midlevel Insertion catheter, artery $113.2596936660 I n ser t i o n c a t h e t er a r t ery$ 279.30 360 36680 26 Insert needle, bone cavity $75.609693668026 M i d l e v e l I n ser t n ee d l e, b o n ec a v i t y$ 63.90 969 36680 PLACE NEEDLE INTRAOSSEOUS INFUSION $219.453603680026 M i d l e v e l I n ser t i o n o f c ann u l a$ 59.40 969 36800 26 Insertion of cannula $70.3596936800 I NSC A NN UL A FOR H EMO D I A L Y S I S; V TO V$ 602.70 360 36810 26 Midlevel Insertion of cannula $153.959693681026 I n ser t i o n o f c ann u l a$ 180.60 969 36810 Insertion of cannula $792.753603681526 I n ser t i o n o f c ann u l a$ 238.35 969 36815 26 Midlevel Insertion of cannula $202.9096936815 I n ser t i o n o f c ann u l a$ 562.80 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 128 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36818 26 Av fuse, uppr arm, cephalic $163.809693681826 M i d l e v e l A v f u se, u pp r a r m, ce p ha l i c$ 139.10 969 36818 Av fuse uppr arm cephalic $2, 545.203603681926 A v f u se, u pp r a r m, ba s i l i c$ 774.90 969 36819 26 Midlevel Av fuse, uppr arm, basilic $658.6596936819 A V F U SE U PPR A RMB A S I L I C$ 2,814.00 360 36820 26 Midlevel Av fusion/forearm vein $757.009693682026 A v f u s i o n / f ore a r m v e in$ 890.40 969 36820 Av fusion/forearm vein $3, 054.453603682126 M i d l e v e l A v f u s i o n d i rec t an ys i t e$ 757.90 969 36821 26 Av fusion direct any site $891.4596936821 A v f u s i o n d i rec t an ys i t e$ 2,621.85 360 36823 26 Insertion of cannula(s) $594.309693682326 M i d l e v e l I n ser t i o n o f c ann u l a (s)$ 505.60 969 36823 Insertion of cannula(s) $4, 925.553603682526 M i d l e v e l A r t ery - v e ina u t o g r a f t$ 1,178.00 969 36825 26 Artery-vein autograft $1, 386.0096936825 A r t ery - v e ina u t o g r a f t$ 2,971.50 360 36830 26 Artery-vein nonautograft $1, 893.249603683026 M i d l e v e l A r t ery - v e inn o na u t o g r a f t$ 551.10 969 36830 CREATE AV FISTULA; NOT AUTOGENOUS $2, 497.95360 GR A FT 3683126 M i d l e v e lOp e n t h ro mb ec t a v f i s t u l a$ 628.35 969 36831 26 Open thrombect av fistula $739.2096936831 Op e n t h ro mb ec t a v f i s t u l a$ 1,736.70 360 36832 26 Av fistula revision, open $513.459693683226 M i d l e v e l A v f i s t u l a re v i s i o n, o p e n$ 436.45 969 36832 Av fistula revision open $2, 203.953603683326 M i d l e v e l A v f i s t u l a re v i s i o n$ 555.05 969 36833 26 REVJ OPN ARVEN FSTL W/THRMBC DIAL GRF $2, 293.3896036833 A v f i s t u l a re v i s i o n$ 2,490.60 360 36835 26 Artery to vein shunt $736.059693683526 M i d l e v e l A r t ery t o v e in s h u n t$ 625.85 969 36835 INSERT THOMAS SHUNT $1, 857.453603683826 M i d l e v e l D i s t re v a s l i g a t i o n, h e m o$ 432.25 969 36838 26 Dist revas ligation, hemo $508.2096936838 D i s t re v a s l i g a t i o n, h e m o$ 4,396.35 360 36860 26 External cannula declotting $1, 324.059693686026 M i d l e v e lE x t er na l c ann u l a d ec l o tt in g$ 1,125.80 969 36860 CANNULA DECLOTTING ; WO BALLOON $401.10360 C A T H 3686126 C ann u l a d ec l o tt in g$ 110.25 969 36861 26 Midlevel Cannula declotting $94.1596936861 C A NN UL A D EC L OTT I NG; W I T H B A LL OON$ 574.35 360 CATH 36901 26 INTRO CATH DIALYSIS CIRCUIT $524.9496036901 I NTROC A T HD I A L Y S I SC I RC U I T$ - 360 36901 INTRO CATH DIALYSIS CIRCUIT $1, 423.9432936901 TC I NTROC A T HD I A L Y S I SC I RC U I T$ 899.00 320 36901 26 INTRO CATH DIALYSIS CIRCUIT $2, 523.6936902 I NTROC A T HD I A L Y S I SC I RC U I TB A LL OON$ - 360 36902 26 INTRO CATH DIALYSIS CIRCUIT W/TRLUML $4, 561.92 B A L O A NG I OP 36903 I NTROC A T HD I A L Y S I SC I RC U I TSTENT$ - 360 36903 26 INTRO CATH DIALYSIS CIRCUIT W/TCAT $17, 530.11 P L MT I V STENT 36904 T H RMBC / NFS D I A L Y S I SC I RC U I T$ - 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 129 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 36904 26 PERQ TH RM BC/NFS DIALYSIS CIRCUIT IMG $6, 695.01 D X A NGRP H 36905 T H RMBC / NFS D I A L Y S I SC I RC U I T W$ - 360 BALLOON 36905 26 PERQ TH RM BC/NFS DIAL CI RCUIT TRLUML $8, 573.73 B A L O A NG I OP 36906 T H RMBC / NFS D I A L Y S I SC I RC U I T W STENT$ - 360 36906 26 PF PERQ TH RM BC/NFS DIAL CIRCUIT TCAT $21, 922.02 P L MT I V STENT 36907 B A L O A NG I OPCTR D I A L Y S I SSEG$ 305.35 329 36907 26 PF PTA DIAL CENTRAL SEG THRU CIRCUIT $2, 302.62 A LL I NC L 3690826 PFSTENTP L MTCTR D I A L Y S I SSEG$ 6,417.15 36909 26 PF DIALYSIS CI RCUIT EMBOU $7, 302.453714026 R e v i s i o n o f c i rc u l a t i o n$ 170.10 969 37140 26 Midlevel Revision of circulation $144.7096937140 R e v i s i o n o f c i rc u l a t i o n$ 8,212.05 360 37145 26 Midlevel Revision of circulation $1, 260.809693714526 R e v i s i o n o f c i rc u l a t i o n$ 1,483.65 969 37145 Revision of circulation $7, 698.603603716026 M i d l e v e lR e v i s i o n o f c i rc u l a t i o n$ 1,341.40 969 37160 26 Revision of circulation $1, 578.1596937160 R e v i s i o n o f c i rc u l a t i o n$ 7,812.00 360 37180 26 Midlevel Revision of circulation $1, 175.809693718026 R e v i s i o n o f c i rc u l a t i o n$ 1,382.85 969 37180 Revision of circulation $7, 549.503603719126 I NSEN D O V A S V EN A C A V A F I L TR$ 699.70 975 37197 REMOVE INTRVAS FOREIGN BODY $984.4536037211 T H ROMBO L Y T I C A RTT H ER A P Y$ 1,278.80 360 37212 THROMBOLYTIC VENOUS THERAPY $1, 128.9036037213 T H ROMB L Y T I C A RT / V ENT H ER A P Y$ 787.00 360 37214 CESSJ THERAPY CATH REMOVAL $467.153603721526 T r an sc a t h s t e n t, cc a w / e p s$ 1,560.30 969 37215 26 Midlevel Transcath stent, cca w/eps $1, 326.1096937215 T r an sc a t h s t e n t, cc a w / e p s$ 4,106.55 360 37216 Transcath stent, cca w/o eps $3, 708.603603722426 RE V SCOPN / PRGFEM / POP W / A NG I OP L A ST Y$ 10,061.29 UNI 37224 TC REVSC OPN/PRG FEM/POP W/ANGIOPLASTY $9, 118.37 U N I 37236 OPEN / PERQP L A CESTENT 1 ST$ 21,020.90 360 37237 OPEN/PERQ PLACE STENT EA ADD $435.1536037238 OPEN / PERQP L A CESTENTS A ME$ 21,020.90 360 37239 OPEN/PERQ PLACE STENT EA ADD $311.5536037246 TR LU M L B A L O A NG I OP 1 ST A RT$ 10,170.00 360 37247 TRLUML BALO ANGIOP ADDL ART $344.4036037248 TR LU M L B A L O A NG I OP 1 ST V E I N$ 10,170.00 360 37249 TRLUML BALO ANGIOP ADDL VEIN $301.5036037252 I NTR V A SC U SNONCORON A R Y 1 ST$ 103.95 360 37253 INTRVASC US NONCORONARY ADDL $177.453603750026 M i d l e v e lE n d osco p y l i g a t e p er f v e in s$ 1,028.20 969 37500 26 Endoscopy ligate perf veins $1, 209.6096937500 EN D OSCOP Y L I G A TEPERF V E I NS$ 2,623.95 360 37501 Vascular endoscopy procedure $1, 225.1536037607 L i g a t i o n o f a - v f i s t u l a$ 1,259.20 360 37607 LIG/BANDING ANGIOACCESS $1,114.02 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 130 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION ARTERIOVENOUS FISTULA 37609 Temporal artery procedure $688.8836037660 L I G A T I ONOFCOMMON I L I A C V E I N,$ 3,937.71 960 37718 26 Ligate/strip short leg vein $788.559693771826 M i d l e v e l L i g a t e / s t r i p s h or tl e gv e in$ 670.05 969 37718 LIGATE/STRIP SHORT LEG VEIN $1, 657.953603772226 L i g a t e / s t r i pl o n g l e gv e in$ 453.60 969 37722 26 Midlevel Ligate/strip long leg vein $385.1596937722 L I G A TE / STR I P L ONG L EG V E I N$ 1,837.50 360 37735 26 Midlevel Removal of leg veins/lesion $451.509693773526 R e m o v a l o f l e gv e in s / l es i o n$ 531.30 969 37735 LIG & STRIP SAPH V W RAD EXC ULCR/GRFT $2, 385.603603776026 L i g a t i o n, l e gv e in s, o p e n$ 702.45 969 37760 26 Midlevel Ligation, leg veins, open $597.4096937760 L I G A TE L EG V E I NSR A D I C A L 1 L EG$ 2,373.00 360 37761 LIGATE LEG VEINS OPEN 1 LEG $2, 088.453603776526 M i d l e v e lP h l e b v e in s - e x t re m - t o 20$ 586.45 969 [Rows 7001-8000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 37765 26 Phleb veins - extrem - to 20 $689.8596937765 ST A BP H L EB V E I NSXTR 10 - 20$ 1,717.80 360 37766 26 Midlevel Phleb veins - extrem 20+ $430.609693776626 P h l e b v e in s - e x t re m 20 +$ 506.10 969 37766 PHLEB VEINS - EXTREM 20+ $2, 096.853603778026 R e v i s i o n o f l e gv e in$ 611.10 969 37780 26 Midlevel Revision of leg vein $519.10 969 37780 LIG & DIV SH SAPHEN VEIN AT SAPH-POP JCN$ 978.60 360 38120 26 Laparoscopy, splenectomy $291.909693812026 M i d l e v e l L a p a rosco p y, s pl e n ec t o m y$ 248.15 969 38120 Laparoscopy, splenectomy $3, 805.2036038129 L a p a rosco p e p roc, s pl ee n$ 8,977.35 360 38200 26 Injection for spleen x-ray $1, 053.159693820026 M i d l e v e l I nj ec t i o n f ors pl ee n x - r a y$ 894.90 969 38200 Injection for spleen x-ray $531.303603822026 M i d l e v e lB o n e ma rro w a s p i r a t i o n$ 448.00 969 38220 26 Bone marrow aspiration $528.0096938220 D XBONEM A RRO W A SP I R A T I ONS$ 1,308.00 360 38221 26 Midlevel Bone marrow biopsy $403.759693822126 B o n e ma rro w bi o p sy$ 475.20 969 38221 DX BONE MARROW BIOPSIES $1,208.80 360 38222 26 Bone marrow bx & asp$ 1,003.20 969 38222 26 Midlevel Bone marrow bx & asp $852.72 969 38222 DX BONE MARROW BX & ASPIR$ 2,512.80 360 38243 TRANSPLJ HEMATOPOIETIC BOOST $382.154903850026 M i d l e v e lB i o p sy / re m o v a l, l y m p hn o d es$ 70.75 969 38500 26 Biopsy/removal, lymph nodes $82.9596938500 OPENBXOREXC L N; S U PERF I C I A L$ 917.70 360 38505 26 Midlevel Needle biopsy, lymph nodes $216.159693850526 N ee d l e bi o p sy, l y m p hn o d es$ 254.10 969 38505 Needle biopsy lymph nodes $261.453603851026 M i d l e v e lB i o p sy / re m o v a l, l y m p hn o d es$ 68.95 969 38510 26 Biopsy/removal, lymph nodes $80.8596938510 B i o p sy / re m o v a ll y m p hn o d es$ 1,537.20 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 131 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 38520 26 Midlevel Biopsy/removal, lymph nodes $367.809693852026 B i o p sy / re m o v a l, l y m p hn o d es$ 432.60 969 38520 OPEN BX/EXC LN; CERV W SFP EXC $1, 696.803603852526 B i o p sy / re m o v a l, l y m p hn o d es$ 474.60 969 38525 26 Midlevel Biopsy/removal, lymph nodes $403.1096938525 OPENBX / EXC L N; A X I LL A R Y NO D E (S)$ 1,568.70 360 38530 26 Biopsy/removal, lymph nodes $421.059693853026 M i d l e v e lB i o p sy / re m o v a l, l y m p hn o d es$ 357.80 969 38530 OPEN BX/EXC LN; INT MAMM NODE(S) $1, 996.053603854226 M i d l e v e lE x pl ore d ee p n o d e (s), n ec k$ 467.25 969 38542 26 Explore deep node(s), neck $550.2096938542 EXC I SESENT I NE L NO D E$ 1,901.55 360 38550 26 Midlevel Removal, neck/armpit lesion $381.959693855026 R e m o v a l, n ec k / a r m p i tl es i o n$ 449.40 969 38550 EXC CYST HYGROMA; WO D NEUROVASC $1, 825.95360 D I SECT 3855526 R e m o v a l, n ec k / a r m p i tl es i o n$ 478.80 969 38555 26 Midlevel Removal, neck/armpit lesion $406.8096938555 EXCC Y S H Y GROM A; W D NE U RO V A SC$ 3,635.10 360 DISECT 38562 26 Midlevel Removal, pelvic lymph nodes $869.159693856226 R e m o v a l, p e l v i c l y m p hn o d es$ 1,022.70 969 38562 Removal, pelvic lymph nodes $2, 543.103603856426 M i d l e v e lR e m o v a l, ab d o m e n l y m p hn o d es$ 612.10 969 38564 26 Removal, abdomen lymph nodes $720.3096938564 R e m o v a l, ab d o m e n l y m p hn o d es$ 2,546.25 360 38570 26 Laparoscopy, lymph node biop $712.959693857026 M i d l e v e l L a p a rosco p y, l y m p hn o d e bi o p$ 606.30 969 38570 LAP; W RETROP LN BX SINGLE/MULTIPLE $1, 942.503603857126 L a p a rosco p y, l y m p ha d e n ec t o m y$ 573.30 969 38571 26 Midlevel Laparoscopy, lymphadenectomy $486.9596938571 L A P; W B I L TOTPE L V I C$ 2,893.80 360 LYMPHADECECTOMY 38572 26 Laparoscopy, lymphadenectomy $870.459693857226 M i d l e v e l L a p a rosco p y, l y m p ha d e n ec t o m y$ 740.00 969 38572 LAP; W BTPL & LN BX SGLE/MULTI $3, 449.2536038589 L a p a rosco p e p roc, l y m p ha t i c$ 8,977.35 360 38700 26 Removal of lymph nodes, neck $1, 018.509693870026 M i d l e v e lR e m o v a l o f l y m p hn o d es, n ec k$ 865.65 969 38700 SUPRAHYOID LYMPHADENECTOMY $2, 963.103603872026 R e m o v a l o f l y m p hn o d es, n ec k$ 789.60 969 38720 26 Midlevel Removal of lymph nodes, neck $671.3096938720 R e m o v a l o f l y m p hn o d es, n ec k$ 4,949.70 360 38724 26 Removal of lymph nodes, neck $1, 294.659693872426 M i d l e v e lR e m o v a l o f l y m p hn o d es, n ec k$ 1,100.60 969 38724 Removal of lymph nodes, neck $5, 347.653603874026 R e m o v e a r m p i tl y m p hn o d es$ 1,396.50 969 38740 26 Midlevel Remove armpit lymph nodes $1, 187.2596938740 A X I LL A R Y L Y MP H A D ENECTOM Y;$ 2,488.50 360 SUPERFICIAL 38745 26 Midlevel Remove armpit lymph nodes $572.409693874526 R e m o v e a r m p i tl y m p hn o d es$ 673.05 969 38745 AXILLARY LYMPHADENECTOMY; $3, 153.15360 COMP L ETE 3874626 M i d l e v e lR e m o v e t h or a c i c l y m p hn o d es$ 728.65 969 38746 26 Remove thoracic lymph nodes $856.8096938746 R e m o v e t h or a c i c l y m p hn o d es$ 817.95 360 38747 26 Remove abdominal lymph nodes $281.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 132 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 38747 26 Midlevel Remove abdominal lymph nodes $238.9096938747 R e m o v e ab d o mina ll y m p hn o d es$ 963.90 360 38760 26 Midlevel Remove groin lymph nodes $236.659693876026 R e m o v e g ro in l y m p hn o d es$ 278.25 969 38760 REMOVE GROIN LYMPH NODES $3, 050.253603876526 M i d l e v e lR e m o v e g ro in l y m p hn o d es$ 721.75 969 38765 26 Remove groin lymph nodes $849.4596938765 R e m o v e g ro in l y m p hn o d es$ 4,659.90 360 38770 26 Midlevel Remove pelvis lymph nodes $1, 115.209693877026 R e m o v e p e l v i s l y m p hn o d es$ 1,312.50 969 38770 Remove pelvis lymph nodes $2, 919.003603878026 R e m o v e ab d o m e n l y m p hn o d es$ 855.75 969 38780 26 Midlevel Remove abdomen lymph nodes $726.9596938780 R e m o v e ab d o m e n l y m p hn o d es$ 3,745.35 360 38790 26 Inject for lymphatic x-ray $1, 104.609693879026 M i d l e v e l I nj ec t f or l y m p ha t i c x - r a y$ 938.95 969 38790 INJECTION FOR LYMPHANGIOGRAPHY $305.553603879226 I d e n t i f yse n t in e l n o d e$ 88.20 969 38792 26 Midlevel Identify sentinel node $74.7096938792 R A TR A CER I D OFSENT I N L NO D E$ 148.05 360 38794 26 Midlevel Access thoracic lymph duct $36.259693879426 A ccess t h or a c i c l y m p h d u c t$ 43.05 969 38794 CANNULATION THORACIC DUCT $1, 071.0036038900 I OM A POFSENT L Y MP H NO D E$ 491.40 360 38900 26 INTRAOP SENTINEL LYMPH NODE ID W/DYE $397.44960 I N J ECT I ON 38999 Bl oo d / l y m p h sys t e m p roce d u re$ 750.15 360 39000 26 Midlevel Exploration of chest $284.309693900026 E x pl or a t i o n o f c h es t$ 334.95 969 39000 Exploration of chest $1, 854.303603901026 E x pl or a t i o n o f c h es t$ 525.00 969 39010 26 Midlevel Exploration of chest $446.1096939010 E x pl or a t i o n o f c h es t$ 2,966.25 360 39200 26 Removal chest lesion $887.259693920026 M i d l e v e lR e m o v a l c h es tl es i o n$ 754.20 969 39200 Removal chest lesion $3, 286.503603922026 R e m o v a l c h es tl es i o n$ 970.20 969 39220 26 Midlevel Removal chest lesion $824.6596939220 R e m o v a l c h es tl es i o n$ 4,239.90 360 39499 Chest procedure $- 3603950126 R e p ai r d ia p h r a g m l a cer a t i o n$ 1,236.90 969 39501 26 Midlevel Repair diaphragm laceration $1, 051.0596939501 R e p ai r d ia p h r a g m l a cer a t i o n$ 3,101.70 360 39503 26 Midlevel Repair of diaphragm hernia $745.359693950326 R e p ai ro fd ia p h r a g mh er nia$ 876.75 969 39503 Repair of diaphragm hernia $22, 143.453603954026 M i d l e v e lR e p ai ro fd ia p h r a g mh er nia$ 5,089.20 969 39540 26 Repair of diaphragm hernia $5, 987.1096939540 R e p ai ro fd ia p h r a g mh er nia$ 3,165.75 360 39541 26 Repair of diaphragm hernia $889.359693954126 M i d l e v e lR e p ai ro fd ia p h r a g mh er nia$ 756.05 969 39541 Repair of diaphragm hernia $3, 440.853603954526 R e v i s i o n o fd ia p h r a g m$ 956.55 969 39545 26 Midlevel Revision of diaphragm $813.0096939545 R e v i s i o n o fd ia p h r a g m$ 3,335.85 360 39560 26 Midlevel Resect diaphragm, simple $814.259693956026 R esec t d ia p h r a g m, s im pl e$ 957.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 133 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 39560 Resect diaphragm, simple $2, 887.503603956126 M i d l e v e lR esec t d ia p h r a g m, co m pl e x$ 702.10 969 39561 26 Resect diaphragm, complex $826.3596939561 R esec t d ia p h r a g m, co m pl e x$ 4,558.05 360 39599 Diaphragm surgery procedure $- 3604049026 B i o p syo f l i p$ 1,261.05 969 40490 26 Midlevel Biopsy of lip $1, 071.5596940490 B i o p syo f l i p$ 271.95 360 40500 26 Partial excision of lip $76.659694050026 M i d l e v e lP a r t ia l e x c i s i o n o f l i p$ 64.75 969 40500 Partial excision of lip $1, 351.353604051026 P a r t ia l e x c i s i o n o f l i p$ 378.00 969 40510 26 Midlevel Partial excision of lip $320.9596940510 P a r t ia l e x c i s i o n o f l i p$ 1,317.75 360 40520 26 Partial excision of lip $375.909694052026 M i d l e v e lP a r t ia l e x c i s i o n o f l i p$ 319.50 969 40520 Partial excision of lip $1, 333.503604052526 M i d l e v e lR eco n s t r u c tl i pw i t h f l a p$ 325.15 969 40525 26 Reconstruct lip with flap $382.2096940525 R eco n s t r u c tl i pw i t h f l a p$ 2,068.50 360 40527 26 Midlevel Reconstruct lip with flap $507.459694052726 R eco n s t r u c tl i pw i t h f l a p$ 597.45 969 40527 Reconstruct lip with flap $2, 325.753604053026 P a r t ia l re m o v a l o f l i p$ 705.60 969 40530 26 Midlevel Partial removal of lip $599.3596940530 P a r t ia l re m o v a l o f l i p$ 1,504.65 360 40650 26 Repair lip $431.559694065026 M i d l e v e lR e p ai r l i p$ 366.95 969 40650 Repair lip $1, 090.953604065226 M i d l e v e lR e p ai r l i p$ 257.95 969 40652 26 Repair lip $303.4596940652 R e p ai r l i p$ 1,317.75 360 40654 26 Repair lip $375.909694065426 M i d l e v e lR e p ai r l i p$ 319.80 969 40654 Repair lip $1, 581.303604070026 M i d l e v e lR e p ai rc l e f tl i p / na s a l$ 382.05 969 40700 26 Repair cleft lip/nasal $449.4096940700 R e p ai rc l e f tl i p / na s a l$ 3,512.25 360 40701 26 Repair cleft lip/nasal $982.809694070126 M i d l e v e lR e p ai rc l e f tl i p / na s a l$ 835.75 969 40701 Repair cleft lip/nasal 1 stage $4, 309.203604070226 M i d l e v e lR e p ai rc l e f tl i p / na s a l$ 1,041.95 969 40702 26 Repair cleft lip/nasal $1, 225.3596940702 R e p ai rc l e f tl i p / na s a l 2 s t a g es$ 2,998.80 360 40720 26 Midlevel Repair cleft lip/nasal $803.609694072026 R e p ai rc l e f tl i p / na s a l$ 945.00 969 40720 Repair cleft lip/nasal $3, 828.303604076126 M i d l e v e lR e p ai rc l e f tl i p / na s a l$ 901.35 969 40761 26 Repair cleft lip/nasal $1, 060.5096940761 R e p ai rc l e f tl i p / na s a l$ 3,814.65 360 40799 Lip surgery procedure $357.003604080026 Dr aina g eo f m o u t h l es i o n$ 1,120.35 969 40800 26 Midlevel Drainage of mouth lesion $951.9596940800 Dr aina g eo f m o u t h l es i o n$ 484.05 360 40801 26 Drainage of mouth lesion $133.359694080126 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 112.95 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 134 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 40801 Drainage of mouth lesion $813.753604080426 R e m o v a l, f ore i g nb o d y, m o u t h$ 233.10 969 40804 26 Midlevel Removal, foreign body, mouth $197.8596940804 R e m o v a l, f ore i g nb o d y, m o u t h$ 494.55 360 40805 26 Midlevel Removal, foreign body, mouth $115.759694080526 R e m o v a l, f ore i g nb o d y, m o u t h$ 136.50 969 40805 Removal, foreign body, mouth $830.553604080626 M i d l e v e l I n c i s i o n o f l i p f o l d$ 205.85 969 40806 26 Incision of lip fold $242.5596940806 I n c i s i o n o f l i p f o l d$ 139.65 360 40808 26 Midlevel Biopsy of mouth lesion $30.909694080826 B i o p syo f m o u t h l es i o n$ 36.75 969 40808 Biopsy of mouth lesion $401.103604081026 M i d l e v e lE x c i s i o n o f m o u t h l es i o n$ 93.90 969 40810 26 Excision of mouth lesion $110.2596940810 E x c i s i o n o f m o u t h l es i o n$ 474.60 360 40812 26 Excise/repair mouth lesion $132.309694081226 M i d l e v e lE x c i se / re p ai r m o u t h l es i o n$ 112.10 969 40812 Excise/repair mouth lesion $723.453604081426 M i d l e v e lE x c i se / re p ai r m o u t h l es i o n$ 176.45 969 40814 26 Excise/repair mouth lesion $207.9096940814 E x c i se / re p ai r m o u t h l es i o n$ 1,123.50 360 40816 26 Excision of mouth lesion $321.309694081626 M i d l e v e lE x c i s i o n o f m o u t h l es i o n$ 273.50 969 40816 Excision of mouth lesion $1, 174.953604081826 M i d l e v e lE x c i seor a l m u cos a f or g r a f t$ 285.40 969 40818 26 Excise oral mucosa for graft $336.0096940818 E x c i seor a l m u cos a f or g r a f t$ 1,000.65 360 40819 26 Excise lip or cheek fold $291.909694081926 M i d l e v e lE x c i se l i p orc h ee k f o l d$ 247.85 969 40819 Excise lip or cheek fold $867.303604082026 T re a t m e n t o f m o u t h l es i o n$ 245.70 969 40820 26 Midlevel Treatment of mouth lesion $208.7596940820 T re a t m e n t o f m o u t h l es i o n$ 644.70 360 40830 26 Midlevel Repair mouth laceration $145.259694083026 R e p ai r m o u t h l a cer a t i o n$ 171.15 969 40830 CL LACERATION MOUTH VESTIB; 2.5CM/ < $612.153604083126 R e p ai r m o u t h l a cer a t i o n$ 170.10 969 40831 26 Midlevel Repair mouth laceration $144.2596940831 C LL A CER A T I ONMO U T H V EST I B; > 2.5 CM$ 832.65 360 40840 26 Reconstruction of mouth $242.559694084026 M i d l e v e lR eco n s t r u c t i o n o f m o u t h$ 206.50 969 40842 26 Midlevel Reconstruction of mouth $582.509694084226 R eco n s t r u c t i o n o f m o u t h$ 685.65 969 40843 26 Midlevel Reconstruction of mouth $574.559694084326 R eco n s t r u c t i o n o f m o u t h$ 676.20 969 40844 26 Reconstruction of mouth $866.259694084426 M i d l e v e lR eco n s t r u c t i o n o f m o u t h$ 736.05 969 40845 26 Midlevel Reconstruction of mouth $1, 018.159694084526 R eco n s t r u c t i o n o f m o u t h$ 1,198.05 969 41000 26 Midlevel Drainage of mouth lesion $1, 158.609694100026 Dr aina g eo f m o u t h l es i o n$ 1,362.90 969 41005 26 Midlevel Drainage of mouth lesion $100.759694100526 Dr aina g eo f m o u t h l es i o n$ 118.65 969 41005 Drainage of mouth lesion $471.453604100626 Dr aina g eo f m o u t h l es i o n$ 132.30 969 41006 26 Midlevel Drainage of mouth lesion $112.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 135 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 41007 26 Midlevel Drainage of mouth lesion $236.409694100726 Dr aina g eo f m o u t h l es i o n$ 278.25 969 41008 26 Drainage of mouth lesion $265.659694100826 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 225.90 969 41009 26 Drainage of mouth lesion $286.659694100926 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 243.90 969 41009 Drainage of mouth lesion $1, 073.103604101026 M i d l e v e l I n c i s i o n o f t o n gu e f o l d$ 266.65 969 41010 26 Incision of tongue fold $313.9596941010 I n c i s i o n o f t o n gu e f o l d$ 411.60 360 41015 26 Midlevel Drainage of mouth lesion $97.459694101526 Dr aina g eo f m o u t h l es i o n$ 114.45 969 41015 Drainage of mouth lesion $1, 250.553604101626 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 303.00 969 41016 26 Drainage of mouth lesion $355.9596941016 Dr aina g eo f m o u t h l es i o n$ 1,285.20 360 41017 26 Drainage of mouth lesion $367.509694101726 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 312.10 969 41017 Drainage of mouth lesion $1, 289.403604101826 M i d l e v e l Dr aina g eo f m o u t h l es i o n$ 314.85 969 41018 26 Drainage of mouth lesion $370.6596941018 Dr aina g eo f m o u t h l es i o n$ 1,509.90 360 41019 Place needles h&n for rt $1, 665.303604110026 B i o p syo f t o n gu e$ 426.30 969 41100 26 Midlevel Biopsy of tongue $362.6096941100 B i o p syo f t o n gu e$ 403.20 360 41105 26 Midlevel Biopsy of tongue $102.209694110526 B i o p syo f t o n gu e$ 120.75 969 41105 Biopsy of tongue $414.753604110826 M i d l e v e lB i o p syo ff l ooro f m o u t h$ 100.65 969 41108 26 Biopsy of floor of mouth $118.6596941108 B i o p syo ff l ooro f m o u t h$ 337.05 360 41110 26 Excision of tongue lesion $95.559694111026 M i d l e v e lE x c i s i o n o f t o n gu e l es i o n$ 80.95 969 41110 Excision of tongue lesion $494.553604111226 M i d l e v e lE x c i s i o n o f t o n gu e l es i o n$ 116.95 969 41112 26 Excision of tongue lesion $137.5596941112 E x c i s i o n o f t o n gu e l es i o n$ 937.65 360 41113 26 Excision of tongue lesion $263.559694111326 M i d l e v e lE x c i s i o n o f t o n gu e l es i o n$ 223.60 969 41113 Excision of tongue lesion $1, 034.253604111426 M i d l e v e lE x c i s i o n o f t o n gu e l es i o n$ 249.35 969 41114 26 Excision of tongue lesion $292.9596941114 E x c i s i o n o f t o n gu e l es i o n$ 2,350.95 360 41115 26 Excision of tongue fold $677.259694111526 M i d l e v e lE x c i s i o n o f t o n gu e f o l d$ 575.40 969 41115 Excision of tongue fold $549.1536041116 E x c i s i o n o f m o u t h l es i o n$ 820.05 360 41120 GLOSSECTOMY; < 1/2 OF TONGUE $3, 569.339694125026 M i d l e v e lR e p ai r t o n gu e l a cer a t i o n$ 133.75 969 41250 26 Repair tongue laceration $157.5096941250 REP L A CER A T 2.5 CM / <; F L R - MO U T H / A NT 2/3$ 557.55 360 41251 26 Midlevel Repair tongue laceration $117.759694125126 R e p ai r t o n gu e l a cer a t i o n$ 138.60 969 41251 REP LACERAT 2.5 CM/<; POST 1/3 TONGUE $647.853604125226 R e p ai r t o n gu e l a cer a t i o n$ 166.95 969 41252 26 Midlevel Repair tongue laceration $142.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 136 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 41252 REP LACERAT-TONGUE FLR-MOUTH > $786.453602.6/ CP L X 4150026 F i x a t i o n o f t o n gu e$ 223.65 969 41500 26 Midlevel Fixation of tongue $190.3096941500 F i x a t i o n o f t o n gu e$ 1,720.95 360 41510 26 Tongue to lip surgery $487.209694151026 M i d l e v e lT o n gu e t o l i p s u r g ery$ 413.70 969 41510 Tongue to lip surgery $1, 547.703604180026 M i d l e v e l Dr aina g eo f gu m l es i o n$ 421.00 969 41800 26 Drainage of gum lesion $495.6096941800 Dr aina g eo f gu m l es i o n$ 532.35 360 41805 26 Removal foreign body, gum $118.659694180526 M i d l e v e lR e m o v a l f ore i g nb o d y, gu m$ 101.15 969 41805 Removal foreign body, gum $624.753604180626 R e m o v a l f ore i g nb o d y, ja w b o n e$ 161.70 969 41806 26 Midlevel Removal foreign body,jawbone $137.5596941806 R e m o v a l f ore i g nb o d y, ja w b o n e$ 972.30 360 41820 Excision, gum, each quadrant $631.0536041821 E x c i s i o n o f gu m f l a p$ 152.25 360 41822 26 Excision of gum lesion $261.459694182226 M i d l e v e lE x c i s i o n o f gu m l es i o n$ 221.85 969 41822 Excision of gum lesion $661.503604182326 M i d l e v e lE x c i s i o n o f gu m l es i o n$ 157.10 969 41823 26 Excision of gum lesion $184.8096941823 E x c i s i o n o f gu m l es i o n$ 1,181.25 360 41825 26 Midlevel Excision of gum lesion $285.659694182526 E x c i s i o n o f gu m l es i o n$ 336.00 969 41825 Excision of gum lesion $456.753604182626 M i d l e v e lE x c i s i o n o f gu m l es i o n$ 128.00 969 41826 26 Excision of gum lesion $150.1596941826 E x c i s i o n o f gu m l es i o n$ 771.75 360 41827 26 Excision of gum lesion $202.659694182726 M i d l e v e lE x c i s i o n o f gu m l es i o n$ 171.85 969 41827 Excision of gum lesion $1, 130.853604182826 M i d l e v e lE x c i s i o n o f gu m l es i o n$ 271.25 969 41828 26 Excision of gum lesion $319.2096941828 E x c i s i o n o f gu m l es i o n$ 777.00 360 41830 26 Removal of gum tissue $255.159694183026 M i d l e v e lR e m o v a l o f gu m t i ss u e$ 216.60 969 41830 Removal of gum tissue $1, 033.2036041850 T re a t m e n t o f gu m l es i o n$ 307.65 360 41870 Gum graft $693.003604187226 R e p ai r gu m$ 305.55 969 41872 26 Midlevel Repair gum $259.5596941872 R e p ai r gu m$ 1,076.25 360 41874 26 Repair tooth socket $278.259694187426 M i d l e v e lR e p ai r t oo t h soc k e t$ 236.70 969 41874 Repair tooth socket $929.2536041899 De n t a l s u r g ery p roce d u re$ 357.00 360 42000 26 Midlevel Drainage mouth roof lesion $235.009694200026 Dr aina g e m o u t h roo f l es i o n$ 276.15 969 42000 Drainage mouth roof lesion $387.453604210026 M i d l e v e lB i o p syroo f o f m o u t h$ 91.95 969 42100 26 Biopsy roof of mouth $108.1596942100 B i o p syroo f o f m o u t h$ 407.40 360 42104 26 Excision lesion, mouth roof $116.559694210426 M i d l e v e lE x c i s i o n l es i o n, m o u t h roo f$ 99.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 137 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 42104 Excision lesion, mouth roof $518.703604210626 E x c i s i o n l es i o n, m o u t h roo f$ 140.70 969 42106 26 Midlevel Excision lesion, mouth roof $119.3096942106 E x c i s i o n l es i o n, m o u t h roo f$ 659.40 360 42107 26 Excision lesion, mouth roof $197.409694210726 M i d l e v e lE x c i s i o n l es i o n, m o u t h roo f$ 168.05 969 42107 Excision lesion, mouth roof $1, 284.153604212026 R e m o v e p a l a t e / l es i o n$ 363.30 969 42120 26 Midlevel Remove palate/lesion $308.7096942120 R e m o v e p a l a t e / l es i o n$ 3,710.70 360 42140 26 Excision of uvula $1, 003.809694214026 M i d l e v e lE x c i s i o n o f uvu l a$ 852.90 969 42140 Excision of uvula $586.953604214526 R e p ai r p a l a t e, p ha ry n x / uvu l a$ 162.75 969 42145 26 Midlevel Repair palate, pharynx/uvula $137.9096942145 R e p ai r p a l a t e, p ha ry n x / uvu l a$ 2,631.30 360 42160 26 Midlevel Treatment mouth roof lesion $617.009694216026 T re a t m e n t m o u t h roo f l es i o n$ 725.55 969 42160 Treatment mouth roof lesion $554.403604218026 R e p ai r p a l a t e$ 173.25 969 42180 26 Midlevel Repair palate $147.1096942180 REP A I RP A L A TE L A CER A T I ON; U PTO 2 CM$ 687.75 360 42182 26 Midlevel Repair palate $166.759694218226 R e p ai r p a l a t e$ 196.35 969 42182 REPAIR PALATE LACERATION; OVER 2 CM $962.853604220026 M i d l e v e lR eco n s t r u c t c l e f tp a l a t e$ 248.15 969 42200 26 Reconstruct cleft palate $291.9096942200 R eco n s t r u c t c l e f tp a l a t e$ 3,197.25 360 42205 26 Midlevel Reconstruct cleft palate $818.059694220526 R eco n s t r u c t c l e f tp a l a t e$ 962.85 969 42205 Reconstruct cleft palate $3, 232.953604221026 M i d l e v e lR eco n s t r u c t c l e f tp a l a t e$ 853.15 969 42210 26 Reconstruct cleft palate $1, 003.8096942210 R eco n s t r u c t c l e f tp a l a t e$ 4,112.85 360 42215 26 Reconstruct cleft palate $1, 148.709694221526 M i d l e v e lR eco n s t r u c t c l e f tp a l a t e$ 976.45 969 42215 Reconstruct cleft palate $2, 524.203604222026 M i d l e v e lR eco n s t r u c t c l e f tp a l a t e$ 663.30 969 42220 26 Reconstruct cleft palate $780.1596942220 R eco n s t r u c t c l e f tp a l a t e$ 1,944.60 360 42225 26 Midlevel Reconstruct cleft palate $515.809694222526 R eco n s t r u c t c l e f tp a l a t e$ 606.90 969 42225 Reconstruct cleft palate $3, 357.903604222626 L e n g t h e nin g o f p a l a t e$ 1,129.80 969 42226 26 Midlevel Lengthening of palate $959.9596942226 L e n g t h e nin g o f p a l a t e$ 3,387.30 360 42227 26 Midlevel Lengthening of palate $906.009694222726 L e n g t h e nin g o f p a l a t e$ 1,065.75 969 42227 Lengthening of palate $3, 204.603604223526 R e p ai r p a l a t e$ 1,058.40 969 42235 26 Midlevel Repair palate $899.5596942235 R e p ai r p a l a t e$ 2,768.85 360 42260 26 Midlevel Repair nose to lip fistula $728.059694226026 R e p ai r n ose t o l i p f i s t u l a$ 856.80 969 42260 Repair nose to lip fistula $2, 466.453604228026 M i d l e v e lP re p a r a t i o n, p a l a t e m o l d$ 627.30 969 42280 26 Preparation, palate mold $738.15 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 138 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 42280 Preparation, palate mold $409.503604228126 I n ser t i o n, p a l a t e p ros t h es i s$ 114.45 969 42281 26 Midlevel Insertion, palate prosthesis $97.6096942281 I n ser t i o n, p a l a t e p ros t h es i s$ 569.10 360 42299 Palate/uvula surgery $357.003604230026 M i d l e v e l Dr aina g eo f s a l i v a ry g l an d$ 138.35 969 42300 26 Drainage of salivary gland $162.7596942300 Dr aina g eo f s a l i v a ry g l an d$ 573.30 360 42305 26 Drainage of salivary gland $160.659694230526 M i d l e v e l Dr aina g eo f s a l i v a ry g l an d$ 136.50 969 42305 Drainage of salivary gland $1, 597.053604231026 M i d l e v e l Dr aina g eo f s a l i v a ry g l an d$ 390.80 969 42310 26 Drainage of salivary gland $459.9096942310 Dr aina g eo f s a l i v a ry g l an d$ 469.35 360 42320 26 Midlevel Drainage of salivary gland $113.209694232026 Dr aina g eo f s a l i v a ry g l an d$ 133.35 969 42320 Drainage of salivary gland $659.403604233026 M i d l e v e lR e m o v a l o f s a l i v a rys t o n e$ 161.35 969 42330 26 Removal of salivary stone $190.0596942330 R e m o v a l o f s a l i v a rys t o n e$ 616.35 360 42335 26 Midlevel Removal of salivary stone $147.809694233526 R e m o v a l o f s a l i v a rys t o n e$ 174.30 969 42335 Removal of salivary stone $962.853604234026 M i d l e v e lR e m o v a l o f s a l i v a rys t o n e$ 235.30 969 42340 26 Removal of salivary stone $277.2096942340 R e m o v a l o f s a l i v a rys t o n e$ 1,261.05 360 42400 26 Biopsy of salivary gland $363.309694240026 M i d l e v e lB i o p syo f s a l i v a ry g l an d$ 309.20 969 42400 Biopsy of salivary gland $206.853604240526 M i d l e v e lB i o p syo f s a l i v a ry g l an d$ 53.95 969 42405 26 Biopsy of salivary gland $63.0096942405 B i o p syo f s a l i v a ry g l an d$ 838.95 360 42408 26 Midlevel Excision of salivary cyst $206.709694240826 E x c i s i o n o f s a l i v a rycys t$ 243.60 969 42408 Excision of salivary cyst $1, 221.153604240926 Dr aina g eo f s a l i v a rycys t$ 349.65 969 42409 26 Midlevel Drainage of salivary cyst $297.2096942409 Dr aina g eo f s a l i v a rycys t$ 834.75 360 42410 26 Excise parotid gland/lesion $240.459694241026 M i d l e v e lE x c i se p a ro t i d g l an d / l es i o n$ 204.45 969 42410 Excise parotid gland/lesion $2, 312.103604241526 E x c i se p a ro t i d g l an d / l es i o n$ 662.55 969 42415 26 Midlevel Excise parotid gland/lesion $562.8096942415 E x c i se p a ro t i d g l an d / l es i o n$ 3,944.85 360 42420 26 Excise parotid gland/lesion $1, 197.009694242026 M i d l e v e lE x c i se p a ro t i d g l an d / l es i o n$ 1,017.10 969 42420 Excise parotid gland/lesion $4, 438.353604242526 E x c i se p a ro t i d g l an d / l es i o n$ 1,375.50 969 42425 26 Midlevel Excise parotid gland/lesion $1, 169.0596942425 E x c i se p a ro t i d g l an d / l es i o n$ 3,115.35 360 42426 26 Midlevel Excise parotid gland/lesion $772.809694242626 E x c i se p a ro t i d g l an d / l es i o n$ 909.30 969 42426 Excise parotid gland/lesion $5, 027.403604244026 M i d l e v e lE x c i ses u bma x i ll a ry g l an d$ 1,248.40 969 42440 26 Excise submaxillary gland $1, 468.9596942440 E x c i ses u bma x i ll a ry g l an d$ 1,548.75 360 42450 26 Excise sublingual gland $493.50 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 139 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 42450 26 Midlevel Excise sublingual gland $419.8596942450 E x c i ses u b l in gu a l g l an d$ 1,340.85 360 42500 26 Repair salivary duct $381.159694250026 M i d l e v e lR e p ai rs a l i v a ry d u c t$ 323.75 969 42500 Repair salivary duct $1, 277.853604250526 R e p ai rs a l i v a ry d u c t$ 365.40 969 42505 26 Midlevel Repair salivary duct $310.7596942505 R e p ai rs a l i v a ry d u c t$ 1,687.35 360 42507 26 Midlevel Parotid duct diversion $417.659694250726 P a ro t i dd u c t d i v ers i o n$ 491.40 969 42507 Parotid duct diversion $1, 929.903604250926 M i d l e v e lP a ro t i dd u c t d i v ers i o n$ 464.00 969 42509 26 Parotid duct diversion $546.0096942509 P a ro t i dd u c t d i v ers i o n$ 3,250.80 360 42510 26 Parotid duct diversion $928.209694251026 M i d l e v e lP a ro t i dd u c t d i v ers i o n$ 788.60 969 42510 Parotid duct diversion $2, 358.303604255026 M i d l e v e l I nj ec t i o n f ors a l i v a ry x - r a y$ 578.15 969 42550 26 Injection for salivary x-ray $680.4096942550 I nj ec t i o n f ors a l i v a ry x - r a y$ 227.85 360 42600 26 Closure of salivary fistula $68.259694260026 M i d l e v e lCl os u reo f s a l i v a ry f i s t u l a$ 57.75 969 42600 Closure of salivary fistula $1, 309.353604265026 D i l a t i o n o f s a l i v a ry d u c t$ 381.15 969 42650 26 Midlevel Dilation of salivary duct $323.7596942650 D i l a t i o n o f s a l i v a ry d u c t$ 219.45 360 42660 26 Dilation of salivary duct $63.009694266026 M i d l e v e l D i l a t i o n o f s a l i v a ry d u c t$ 53.85 969 42660 Dilation of salivary duct $286.653604266526 M i d l e v e l L i g a t i o n o f s a l i v a ry d u c t$ 71.35 969 42665 26 Ligation of salivary duct $84.0096942665 L i g a t i o n o f s a l i v a ry d u c t$ 778.05 360 42699 Salivary surgery procedure $357.003604270026 Dr aina g eo f t o n s i l ab scess$ 220.50 969 42700 26 Midlevel Drainage of tonsil abscess $187.7096942700 Dr aina g eo f t o n s i l ab scess$ 512.40 360 42720 26 Midlevel Drainage of throat abscess $122.059694272026 Dr aina g eo f t h ro a t ab scess$ 143.85 969 42720 Drainage of throat abscess $1, 461.603604272526 M i d l e v e l Dr aina g eo f t h ro a t ab scess$ 356.15 969 42725 26 Drainage of throat abscess $418.9596942725 Dr aina g eo f t h ro a t ab scess$ 3,010.35 360 42800 26 Midlevel Biopsy of throat $729.409694280026 B i o p syo f t h ro a t$ 857.85 969 42800 Biopsy of throat $422.103604280426 M i d l e v e lB i o p syo f u pp er n ose / t h ro a t$ 101.75 969 42804 26 Biopsy of upper nose/throat $119.7096942804 B i o p syo f u pp er n ose / t h ro a t$ 429.45 360 42806 26 Biopsy of upper nose/throat $127.059694280626 M i d l e v e lB i o p syo f u pp er n ose / t h ro a t$ 107.95 969 42806 Biopsy of upper nose/throat $500.853604280826 E x c i se p ha ry n x l es i o n$ 149.10 969 42808 26 Midlevel Excise pharynx lesion $126.9596942808 E x c i se p ha ry n x l es i o n$ 607.95 360 42809 26 Midlevel Remove pharynx foreign body $151.859694280926 R e m o v e p ha ry n x f ore i g nb o d y$ 178.50 969 42809 Remove pharynx foreign body $490.35 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 140 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 42810 26 Excision of neck cyst $135.459694281026 M i d l e v e lE x c i s i o n o f n ec k cys t$ 115.15 969 42810 Excision of neck cyst $1, 086.753604281526 E x c i s i o n o f n ec k cys t$ 297.15 969 42815 26 Midlevel Excision of neck cyst $252.8596942815 E x c i s i o n o f n ec k cys t$ 2,088.45 360 42820 26 Remove tonsils and adenoids $583.809694282026 M i d l e v e lR e m o v e t o n s i l s an d a d e n o i d s$ 496.10 969 42820 REMOVE TONSILS AND ADENOIDS <12 YRS $1, 084.653604282126 M i d l e v e lR e m o v e t o n s i l s an d a d e n o i d s$ 265.45 969 42821 26 Remove tonsils and adenoids $311.85 969 42821 T & A; AGE 12 OR MORE$ 1,127.70 360 42825 26 Midlevel Removal of tonsils $279.109694282526 R e m o v a l o f t o n s i l s$ 328.65 969 42825 REMOVAL OF TONSILS <12 YRS $907.203604282626 M i d l e v e lR e m o v a l o f t o n s i l s$ 235.80 969 42826 26 Removal of tonsils $277.2096942826 TONS I LL ECTOM Y; A GE 12 ORMORE$ 942.90 360 42830 26 Midlevel Removal of adenoids $231.009694283026 R e m o v a l o f a d e n o i d s$ 271.95 969 42830 REMOVAL OF ADENOIDS <12 YRS $779.103604283126 R e m o v a l o f a d e n o i d s$ 220.50 969 42831 26 Midlevel Removal of adenoids $187.1596942831 A D ENO I D ECTOM Y; A GE 12 ORMORE$ 838.95 360 42835 26 Midlevel Removal of adenoids $202.609694283526 R e m o v a l o f a d e n o i d s$ 238.35 969 42835 REMOVAL OF ADENOIDS SECONDARY <12 $717.15360 Y RS 4283626 M i d l e v e lR e m o v a l o f a d e n o i d s$ 171.35 969 42836 26 Removal of adenoids $201.6096942836 A D ENO I D ECTOM Y 2 N D A R Y; A GE 12 OR$ 903.00 360 MORE 42842 26 Extensive surgery of throat $261.459694284226 M i d l e v e lE x t e n s i v es u r g eryo f t h ro a t$ 222.30 969 42842 Extensive surgery of throat $3, 708.603604284426 M i d l e v e lE x t e n s i v es u r g eryo f t h ro a t$ 840.90 969 42844 26 Extensive surgery of throat $989.1096942844 E x t e n s i v es u r g eryo f t h ro a t$ 5,109.30 360 42845 26 Midlevel Extensive surgery of throat $1, 217.759694284526 E x t e n s i v es u r g eryo f t h ro a t$ 1,432.20 969 42845 Extensive surgery of throat $8, 260.353604286026 M i d l e v e lE x c i s i o n o f t o n s i lt a g s$ 1,972.20 969 42860 26 Excision of tonsil tags $2, 320.5096942860 E x c i s i o n o f t o n s i lt a g s$ 708.75 360 42870 26 Excision of lingual tonsil $199.509694287026 M i d l e v e lE x c i s i o n o f l in gu a lt o n s i l$ 169.25 969 42870 Excision of lingual tonsil $2, 180.853604289026 P a r t ia l re m o v a l o f p ha ry n x$ 612.15 969 42890 26 Midlevel Partial removal of pharynx $520.0596942890 P a r t ia l re m o v a l o f p ha ry n x$ 5,262.60 360 42892 26 Revision of pharyngeal walls $1, 404.909694289226 M i d l e v e lR e v i s i o n o f p ha ry n g e a lw a ll s$ 1,194.55 969 42892 Revision of pharyngeal walls $6, 980.403604289426 M i d l e v e lR e v i s i o n o f p ha ry n g e a lw a ll s$ 1,546.15 969 42894 26 Revision of pharyngeal walls $1, 818.6096942894 R e v i s i o n o f p ha ry n g e a lw a ll s$ 8,793.75 360 42900 26 Midlevel Repair throat wound $1,995.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 141 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 42900 26 Repair throat wound $2, 347.8096942900 R e p ai r t h ro a tw o u n d$ 1,267.35 360 42950 26 Midlevel Reconstruction of throat $318.409694295026 R eco n s t r u c t i o n o f t h ro a t$ 374.85 969 42950 Reconstruction of throat $2, 983.053604295326 R e p ai r t h ro a t, eso p ha gu s$ 866.25 969 42953 26 Midlevel Repair throat, esophagus $735.9096942953 R e p ai r t h ro a t, eso p ha gu s$ 3,615.15 360 42955 26 Surgical opening of throat $1, 136.109694295526 M i d l e v e lS u r g i c a l o p e nin g o f t h ro a t$ 966.00 969 42955 Surgical opening of throat $2, 823.453604296026 C o n t ro lt h ro a t b l ee d in g$ 806.40 969 42960 26 Midlevel Control throat bleeding $685.2096942960 C o n t ro lt h ro a t b l ee d in g$ 631.05 360 42961 26 Midlevel Control throat bleeding $154.559694296126 C o n t ro lt h ro a t b l ee d in g$ 181.65 969 42961 Control throat bleeding $1, 572.903604296226 C o n t ro lt h ro a t b l ee d in g$ 451.50 969 42962 26 Midlevel Control throat bleeding $383.4596942962 C o n t ro lt h ro a t b l ee d in g$ 1,939.35 360 42970 26 Control nose/throat bleeding $556.509694297026 M i d l e v e lC o n t ro l n ose / t h ro a t b l ee d in g$ 473.25 969 42970 Control nose/throat bleeding $1, 497.303604297126 C o n t ro l n ose / t h ro a t b l ee d in g$ 416.85 969 42971 26 Midlevel Control nose/throat bleeding $354.7096942971 C o n t ro l n ose / t h ro a t b l ee d in g$ 1,710.45 360 42972 26 Control nose/throat bleeding $490.359694297226 M i d l e v e lC o n t ro l n ose / t h ro a t b l ee d in g$ 417.00 969 42972 Control nose/throat bleeding $1, 913.1036042999 T h ro a t s u r g ery p roce d u re$ 357.00 360 43020 26 Incision of esophagus $555.459694302026 M i d l e v e l I n c i s i o n o f eso p ha gu s$ 472.40 969 43020 Incision of esophagus $1, 996.053604303026 T h ro a t m u sc l es u r g ery$ 575.40 969 43030 26 Midlevel Throat muscle surgery $489.1596943030 T h ro a t m u sc l es u r g ery$ 1,930.95 360 43045 26 Incision of esophagus $561.759694304526 M i d l e v e l I n c i s i o n o f eso p ha gu s$ 477.70 969 43045 Incision of esophagus $4, 851.003604310026 E x c i s i o n o f eso p ha gu s l es i o n$ 1,395.45 969 43100 26 Midlevel Excision of esophagus lesion $1, 185.7096943100 E x c i s i o n o f eso p ha gu s l es i o n$ 2,329.95 360 43101 26 Excision of esophagus lesion $667.809694310126 M i d l e v e lE x c i s i o n o f eso p ha gu s l es i o n$ 567.40 969 43101 Excision of esophagus lesion $3, 751.653604310726 R e m o v a l o f eso p ha gu s$ 1,077.30 969 43107 26 Midlevel Removal of esophagus $915.4096943107 R e m o v a l o f eso p ha gu s$ 9,363.90 360 43108 26 Removal of esophagus $2, 662.809694310826 M i d l e v e lR e m o v a l o f eso p ha gu s$ 2,263.25 969 43108 Removal of esophagus $16, 244.553604311226 M i d l e v e lR e m o v a l o f eso p ha gu s$ 3,442.95 969 43112 26 Removal of esophagus $4, 050.9096943112 R e m o v a l o f eso p ha gu s$ 9,959.25 360 43113 26 Removal of esophagus $2, 849.709694311326 M i d l e v e lR e m o v a l o f eso p ha gu s$ 2,422.40 969 43113 Removal of esophagus $16,598.40 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 142 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43116 26 Midlevel Partial removal of esophagus $3, 410.209694311626 P a r t ia l re m o v a l o f eso p ha gu s$ 4,012.05 969 43116 Partial removal of esophagus $19, 095.303604311726 M i d l e v e lP a r t ia l re m o v a l o f eso p ha gu s$ 3,844.70 969 43117 26 Partial removal of esophagus $4, 523.4096943117 P a r t ia l re m o v a l o f eso p ha gu s$ 9,101.40 360 43118 26 Midlevel Partial removal of esophagus $2, 205.359694311826 P a r t ia l re m o v a l o f eso p ha gu s$ 2,594.55 969 43118 Partial removal of esophagus $13, 790.703604312126 P a r t ia l re m o v a l o f eso p ha gu s$ 3,389.40 969 43121 26 Midlevel Partial removal of esophagus $2, 880.8596943121 P a r t ia l re m o v a l o f eso p ha gu s$ 10,603.95 360 43122 26 Midlevel Partial removal of esophagus $2, 339.459694312226 P a r t ia l re m o v a l o f eso p ha gu s$ 2,752.05 969 43122 Partial removal of esophagus $9, 350.253604312326 M i d l e v e lP a r t ia l re m o v a l o f eso p ha gu s$ 2,234.30 969 43123 26 Partial removal of esophagus $2, 628.1596943123 P a r t ia l re m o v a l o f eso p ha gu s$ 17,088.75 360 43124 26 Midlevel Removal of esophagus $3, 451.809694312426 R e m o v a l o f eso p ha gu s$ 4,061.40 969 43124 Removal of esophagus $14, 115.153604313026 R e m o v a l o f eso p ha gu s p o u c h$ 3,457.65 969 43130 26 Midlevel Removal of esophagus pouch $2, 938.8096943130 R e m o v a l o f eso p ha gu s p o u c h$ 2,925.30 360 43135 26 Removal of esophagus pouch $840.009694313526 M i d l e v e lR e m o v a l o f eso p ha gu s p o u c h$ 714.15 969 43135 Removal of esophagus pouch $5, 487.303604320026 E so p ha gu se n d osco p y$ 1,460.55 969 43200 26 Midlevel Esophagus endoscopy $1, 241.8596943200 E so p ha gu se n d osco p y$ 388.50 360 43201 26 Midlevel Esoph scope w/submucous inj $95.809694320126 E so p h sco p e w / s u bm u co u s inj$ 112.35 969 43201 Esoph scope w/submucous inj $474.603604320226 E so p ha gu se n d osco p y, bi o p sy$ 135.45 969 43202 26 Midlevel Esophagus endoscopy, biopsy $115.5596943202 E so p ha gu se n d osco p y, bi o p sy$ 428.40 360 43204 26 Midlevel Esoph scope w/sclerosis inj $102.409694320426 E so p h sco p e w / sc l eros i s inj$ 120.75 969 43204 Esoph scope w/sclerosis inj $812.703604320526 E so p ha gu se n d osco p y / l i g a t i o n$ 227.85 969 43205 26 Midlevel Esophagus endoscopy/ligation $193.4596943205 E so p ha gu se n d osco p y / l i g a t i o n$ 830.55 360 43215 26 Midlevel Esophagus endoscopy $194.809694321526 E so p ha gu se n d osco p y$ 228.90 969 43215 Esophagus endoscopy $573.303604321626 M i d l e v e lE so p ha gu se n d osco p y / l es i o n$ 137.90 969 43216 26 Esophagus endoscopy/lesion $162.7596943216 E so p ha gu se n d osco p y / l es i o n$ 534.45 360 43217 26 Esophagus endoscopy $148.059694321726 M i d l e v e lE so p ha gu se n d osco p y$ 126.15 969 43217 Esophagus endoscopy $632.103604322026 M i d l e v e lE so p h e n d osco p y, d i l a t i o n$ 149.85 969 43220 26 Esoph endoscopy, dilation $176.4096943220 ESOP H A GOSCOP Y B A LL OON < 30 MM$ 470.40 360 43226 26 Esoph endoscopy, dilation $132.309694322626 M i d l e v e lE so p h e n d osco p y, d i l a t i o n$ 112.15 969 43226 Esoph endoscopy, dilation $522.90 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 143 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43227 26 Midlevel Esoph endoscopy, repair $123.759694322726 E so p h e n d osco p y, re p ai r$ 145.95 969 43227 Esoph endoscopy, repair $781.203604323126 E so p h e n d osco p y w / u se x am$ 217.35 969 43231 26 Midlevel Esoph endoscopy w/us exam $184.4096943231 E so p h e n d osco p y w / u se x am$ 705.60 360 43232 26 Midlevel Esoph endoscopy w/us fn bx $165.009694323226 E so p h e n d osco p y w / u s f nb x$ 194.25 969 43232 Esoph endoscopy w/us fn bx $963.903604323526 M i d l e v e l U pp r g i e n d osco p y, d ia g n os i s$ 230.45 969 43235 26 Uppr gi endoscopy, diagnosis $270.9096943235 U pp r g i e n d osco p y d ia g n os i s$ 538.65 360 43236 26 Midlevel Uppr gi scope w/submuc inj $125.959694323626 U pp r g i sco p e w / s u bm u c inj$ 148.05 969 43236 Uppr gi scope w/submuc inj $647.853604323726 M i d l e v e lE n d osco p i c u se x am, eso p h$ 152.30 969 43237 26 Endoscopic us exam, esoph $179.5596943237 E n d osco p i c u se x am, eso p h$ 866.25 360 43238 26 Uppr gi endoscopy w/us fn bx $245.709694323826 M i d l e v e l U pp r g i e n d osco p y w / u s f nb x$ 208.60 969 43238 Uppr gi endoscopy w/us fn bx $1, 081.503604323926 M i d l e v e l U pp er G I e n d osco p y, bi o p sy$ 256.40 969 43239 26 Upper GI endoscopy, biopsy $301.3596943239 U pp er g i e n d osco p y bi o p sy$ 635.25 360 43240 26 Esoph endoscope w/drain cyst $175.359694324026 M i d l e v e lE so p h e n d osco p e w / d r ain cys t$ 149.25 969 43240 Esoph endoscope w/drain cyst $1, 464.753604324126 M i d l e v e l U pp er G I e n d osco p y w i t h t u b e$ 347.00 969 43241 26 Upper GI endoscopy with tube $408.4596943241 U pp er G I e n d osco p y w i t h t u b e$ 576.45 360 43242 26 Midlevel Uppr gi endoscopy w/us fn bx $135.709694324226 U pp r g i e n d osco p y w / u s f nb x$ 159.60 969 43242 Uppr gi endoscopy w/us fn bx $1,562.40 360 43243 26 Midlevel Upper gi endoscopy & inject$ 367.10 969 43243 26 Upper gi endoscopy & inject $431.55 969 43243 Upper gi endoscopy & inject$ 987.00 360 43244 26 Midlevel Upper GI endoscopy/ligation $232.259694324426 U pp er G I e n d osco p y / l i g a t i o n$ 273.00 969 43244 Upper GI endoscopy/ligation $1, 089.903604324526 M i d l e v e l U pp r g i sco p e d i l a t es t r i c t r$ 256.60 969 43245 26 Uppr gi scope dilate strictr $302.4096943245 U pp r g i sco p e d i l a t es t r i c t r$ 695.10 360 43246 26 Place gastrostomy tube $193.209694324626 M i d l e v e lPl a ce g a s t ros t o m y t u b e$ 164.30 969 43246 Place gastrostomy tube $930.303604324726 M i d l e v e lOp er a t i v e u pp er G I e n d osco p y$ 219.50 969 43247 26 Operative upper GI endoscopy $258.3096943247 Op er a t i v e u pp er G I e n d osco p y$ 741.30 360 43248 26 Midlevel Uppr gi endoscopy/guide wire $174.559694324826 U pp r g i e n d osco p y / gu i d e w i re$ 205.80 969 43248 Uppr gi endoscopy/guide wire $696.153604324926 M i d l e v e lE so p h e n d osco p y, d i l a t i o n$ 163.95 969 43249 26 Esoph endoscopy, dilation $193.2096943249 ESOP H EG DD I L A T I ON < 30 MM$ 642.60 360 43250 26 Upper GI endoscopy/tumor $178.509694325026 M i d l e v e l U pp er G I e n d osco p y / t u m or$ 151.50 969 43250 Upper GI endoscopy/tumor $699.30 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 144 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43251 26 Midlevel Operative upper GI endoscopy $165.409694325126 Op er a t i v e u pp er G I e n d osco p y$ 194.25 969 43251 Operative upper GI endoscopy $806.4036043252 EG D OPT I C A L EN D OM I CROSCOP Y$ 717.30 360 43255 26 Midlevel Operative upper GI endoscopy $189.859694325526 Op er a t i v e u pp er G I e n d osco p y$ 223.65 969 43255 Operative upper GI endoscopy $1, 042.653604325726 U pp r g i sco p e w / t h r m lt x mn t$ 288.75 969 43257 26 Midlevel Uppr gi scope w/thrml txmnt $245.3596943257 U pp r g i sco p e w / t h r m lt x mn t$ 1,185.45 360 43259 26 Midlevel Endoscopic ultrasound exam $272.159694325926 E n d osco p i c u lt r a so u n d e x am$ 320.25 969 43259 Endoscopic ultrasound exam $1, 121.403604326026 E n d oc h o l an g i o p an cre a t o g r a p h$ 308.70 969 43260 26 Midlevel Endo cholangiopancreatograph $262.2596943260 E n d oc h o l an g i o p an cre a t o g r a p h$ 1,278.90 360 43261 26 Endo cholangiopancreatograph $354.909694326126 M i d l e v e lE n d oc h o l an g i o p an cre a t o g r a p h$ 301.40 969 43261 Endo cholangiopancreatograph $1, 344.003604326226 E n d oc h o l an g i o p an cre a t o g r a p h$ 372.75 969 43262 26 Midlevel Endo cholangiopancreatograph $316.9596943262 E n d oc h o l an g i o p an cre a t o g r a p h$ 1,579.20 360 43263 26 Endo cholangiopancreatograph $437.859694326326 M i d l e v e lE n d oc h o l an g i o p an cre a t o g r a p h$ 371.85 969 43263 Endo cholangiopancreatograph $1, 559.253604326426 E n d oc h o l an g i o p an cre a t o g r a p h$ 433.65 969 43264 26 Midlevel Endo cholangiopancreatograph $368.2596943264 E n d oc h o l an g i o p an cre a t o g r a p h$ 1,894.20 360 43265 26 Endo cholangiopancreatograph $525.009694326526 M i d l e v e lE n d oc h o l an g i o p an cre a t o g r a p h$ 446.40 969 43265 Endo cholangiopancreatograph $2, 124.1536043270 E g d l es i o nab l a t i o n$ 760.99 750 43273 Endoscopic pancreatoscopy $469.3536043279 L a p m yo t o m y h e ll er$ 4,690.35 360 43280 26 Laparoscopy, fundoplasty $589.059694328026 M i d l e v e l L a p a rosco p y, f u n d o pl a s t y$ 500.60 969 43280 Laparoscopy, fundoplasty $3, 919.6536043281 L a pp a r a eso p ha g h er n re p ai r$ 5,652.15 360 43282 Lap paraesoph her rpr w/mesh $6, 354.6036043283 L a p eso p h l e n g t h e nin g$ 586.95 360 43289 Laparoscope proc, esoph $8, 977.353604330026 M i d l e v e lR e p ai ro f eso p ha gu s$ 923.40 969 43300 26 Repair of esophagus $1, 086.7596943300 R e p ai ro f eso p ha gu s$ 2,291.10 360 43305 26 Midlevel Repair esophagus and fistula $567.159694330526 R e p ai reso p ha gu s an df i s t u l a$ 666.75 969 43305 Repair esophagus and fistula $4, 063.503604331026 M i d l e v e lR e p ai ro f eso p ha gu s$ 1,012.70 969 43310 26 Repair of esophagus $1, 191.7596943310 R e p ai ro f eso p ha gu s$ 5,541.90 360 43312 26 Midlevel Repair esophagus and fistula $1, 369.159694331226 R e p ai reso p ha gu s an df i s t u l a$ 1,610.70 969 43312 Repair esophagus and fistula $5, 999.703604331326 M i d l e v e lE so p ha g o pl a s t yco n g e ni t a l$ 1,501.45 969 43313 26 Esophagoplasty congenital $1, 766.1096943313 E so p ha g o pl a s t yco n g e ni t a l$ 10,522.05 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 145 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43314 26 Midlevel Tracheo-esophagoplasty cong $2, 427.559694331426 T r a c h eo - eso p ha g o pl a s t yco n g$ 2,856.00 969 43314 Tracheo-esophagoplasty cong $10,654.35 360 43320 26 Fuse esophagus & stomach$ 3,108.00 969 43320 26 Midlevel Fuse esophagus & stomach $2,642.20 969 43320 Fuse esophagus & stomach$ 5,040.00 360 43325 26 Midlevel Revise esophagus & stomach $1,180.85 969 43325 26 Revise esophagus & stomach$ 1,389.15 969 43325 Revise esophagus & stomach $4, 902.453604333026 R e p ai ro f eso p ha gu s$ 1,337.70 969 43330 26 Midlevel Repair of esophagus $1, 137.1096943330 R e p ai ro f eso p ha gu s$ 4,753.35 360 43331 26 Midlevel Repair of esophagus $1, 116.059694333126 R e p ai ro f eso p ha gu s$ 1,312.50 969 43331 Repair of esophagus $5,006.40 360 43340 26 Fuse esophagus & intestine$ 1,414.35 969 43340 26 Midlevel Fuse esophagus & intestine $1,202.35 969 43340 Fuse esophagus & intestine$ 4,986.45 360 43341 26 Fuse esophagus & intestine $1,361.85 969 43341 26 Midlevel Fuse esophagus & intestine$ 1,157.95 969 43341 Fuse esophagus & intestine $5, 250.003604335126 M i d l e v e lS u r g i c a l o p e nin g, eso p ha gu s$ 1,251.90 969 43351 26 Surgical opening, esophagus $1, 473.1596943351 S u r g i c a l o p e nin g, eso p ha gu s$ 4,898.25 360 43352 26 Midlevel Surgical opening, esophagus $1, 156.109694335226 S u r g i c a l o p e nin g, eso p ha gu s$ 1,359.75 969 43352 Surgical opening, esophagus $3, 977.403604336026 G a s t ro in t es t ina l re p ai r$ 1,122.45 969 43360 26 Midlevel Gastrointestinal repair $954.3596943360 G a s t ro in t es t ina l re p ai r$ 8,740.20 360 43361 26 Midlevel Gastrointestinal repair $2, 023.109694336126 G a s t ro in t es t ina l re p ai r$ 2,380.35 969 43361 Gastrointestinal repair $9, 751.353604340026 L i g a t eeso p ha gu s v e in s$ 2,651.25 969 43400 26 Midlevel Ligate esophagus veins $2, 253.5596943400 L i g a t eeso p ha gu s v e in s$ 5,444.25 360 43401 26 Midlevel Esophagus surgery for veins $1, 287.959694340126 E so p ha gu ss u r g ery f or v e in s$ 1,515.15 969 43401 Esophagus surgery for veins $5, 595.453604340526 M i d l e v e l L i g a t e / s t a pl eeso p ha gu s$ 1,305.85 969 43405 26 Ligate/staple esophagus $1, 536.1596943405 L i g a t e / s t a pl eeso p ha gu s$ 5,348.70 360 43410 26 Midlevel Repair esophagus wound $1, 254.059694341026 R e p ai reso p ha gu s w o u n d$ 1,475.25 969 43410 Repair esophagus wound $4, 006.803604341526 R e p ai reso p ha gu s w o u n d$ 1,024.80 969 43415 26 Midlevel Repair esophagus wound $871.4096943415 R e p ai reso p ha gu s w o u n d$ 9,308.25 360 43420 26 Midlevel Repair esophagus opening $1, 485.909694342026 R e p ai reso p ha gu so p e nin g$ 1,748.25 969 43420 Repair esophagus opening $3, 761.103604342526 M i d l e v e lR e p ai reso p ha gu so p e nin g$ 862.80 969 43425 26 Repair esophagus opening $1, 015.3596943425 R e p ai reso p ha gu so p e nin g$ 5,340.30 360 43450 26 Midlevel Dilate esophagus $1, 282.259694345026 D i l a t eeso p ha gu s$ 1,508.85 969 43450 Dilate esophagus $330.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 146 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43453 26 Dilate esophagus $90.309694345326 M i d l e v e l D i l a t eeso p ha gu s$ 77.00 969 43453 Dilate esophagus $355.953604346026 P ress u re t re a t m e n t eso p ha gu s$ 97.65 969 43460 26 Midlevel Pressure treatment esophagus $83.2596943460 P ress u re t re a t m e n t eso p ha gu s$ 823.20 360 43496 Free jejunum flap, microvasc $- 36043499 E so p ha gu ss u r g ery p roce d u re$ 1,487.00 360 43500 26 Surgical opening of stomach $225.759694350026 M i d l e v e lS u r g i c a l o p e nin g o f s t o ma c h$ 191.65 969 43500 Surgical opening of stomach $2, 838.153604350126 S u r g i c a l re p ai ro f s t o ma c h$ 762.30 969 43501 26 Midlevel Surgical repair of stomach $647.7096943501 S u r g i c a l re p ai ro f s t o ma c h$ 4,866.75 360 43502 26 Midlevel Surgical repair of stomach $1, 121.909694350226 S u r g i c a l re p ai ro f s t o ma c h$ 1,319.85 969 43502 Surgical repair of stomach $5, 498.853604351026 S u r g i c a l o p e nin g o f s t o ma c h$ 1,501.50 969 43510 26 Midlevel Surgical opening of stomach $1, 276.4096943510 S u r g i c a l o p e nin g o f s t o ma c h$ 3,477.60 360 43520 26 Midlevel Incision of pyloric muscle $786.059694352026 I n c i s i o n o f p y l or i c m u sc l e$ 925.05 969 43520 Incision of pyloric muscle $2, 512.653604360526 M i d l e v e lB i o p syo f s t o ma c h$ 601.35 969 43605 26 Biopsy of stomach $707.7096943605 B i o p syo f s t o ma c h$ 3,018.75 360 43610 EXCISION OF STOMACH LESION $3, 147.4536043632 G A STRECTOM Y P D I ST; W$ 6,456.40 360 GASTROJEJUNOSTOMY 43659 UNLISTED LAPAROSCOPY STOMACH $4, 488.683604375226 N a s a l / oro g a s t r i c w / s t e n t$ 814.80 969 43752 26 Midlevel Nasal/orogastric w/stent $692.4096943752 N a s a l / oro g a s t r i c w / s t e n t$ 147.00 360 43753 Tx gastro intub w/asp $74.5536043754 D xg a s t r in t u b w / a s p s p ec$ 116.55 360 43755 Dx gastr intub w/asp specs $210.0036043756 D x d u o d in t u b w / a s p s p ec$ 189.00 360 43757 Dx duod intub w/asp specs $286.653604376026 M i d l e v e lC han g e g a s t ros t o m y t u b e$ 36.50 969 43760 26 Change gastrostomy tube $43.0596943760 C han g e g a s t ros t o m y t u b e$ 179.55 360 43761 26 Midlevel Reposition gastrostomy tube $55.259694376126 R e p os i t i o n g a s t ros t o m y t u b e$ 65.10 969 43761 Reposition gastrostomy tube $376.953604383026 Pl a ce g a s t ros t o m y t u b e$ 110.25 969 43830 26 Midlevel Place gastrostomy tube $93.5596943830 Pl a ce g a s t ros t o m y t u b e$ 2,523.15 360 43831 26 Place gastrostomy tube $676.209694383126 M i d l e v e lPl a ce g a s t ros t o m y t u b e$ 574.95 969 43831 Place gastrostomy tube $2, 146.203604383226 Pl a ce g a s t ros t o m y t u b e$ 568.05 969 43832 26 Midlevel Place gastrostomy tube $482.5096943832 Pl a ce g a s t ros t o m y t u b e$ 3,807.30 360 43840 26 Midlevel Repair of stomach lesion $882.809694384026 R e p ai ro f s t o ma c h l es i o n$ 1,038.45 969 43840 Repair of stomach lesion $4,889.85 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 147 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 43842 V-band gastroplasty $4, 156.953604384326 M i d l e v e lG a s t ro pl a s t y w / o v - ban d$ 1,068.25 969 43843 26 Gastroplasty w/o v-band $1, 256.8596943843 G a s t ro pl a s t y w / o v - ban d$ 4,611.60 360 43845 26 Midlevel Gastroplasty duodenal switch $1, 052.609694384526 G a s t ro pl a s t y d u o d e na l s w i t c h$ 1,237.95 969 43845 Gastroplasty duodenal switch $7, 057.053604384626 M i d l e v e lG a s t r i c b y p a ss f oro b es i t y$ 1,619.10 969 43846 26 Gastric bypass for obesity $1, 904.7096943846 G A STR I CBPFOROBES I T Y 150 CM / <$ 5,876.85 360 43847 26 Gastric bypass incl small i $1, 600.209694384726 M i d l e v e lG a s t r i c b y p a ss in c l s ma ll i$ 1,359.75 969 43847 GASTRIC BP FOR OBESITY > 150 CM $6, 487.9536043848 R e v i s i o n g a s t ro pl a s t y$ 6,963.60 360 43850 Revise stomach-bowel fusion $5, 867.4036043855 R e v i ses t o ma c h - b o w e l f u s i o n$ 6,095.25 360 43860 Revise stomach-bowel fusion $5, 893.6536043865 R e v i ses t o ma c h - b o w e l f u s i o n$ 6,165.60 360 43870 26 Midlevel Repair stomach opening $1, 494.159694387026 R e p ai rs t o ma c h o p e nin g$ 1,757.70 969 43870 Repair stomach opening $2, 569.3536043880 R e p ai rs t o ma c h - b o w e l f i s t u l a$ 5,759.25 360 43886 26 Midlevel Revise gastric port, open $583.659694388626 R e v i se g a s t r i c p or t, o p e n$ 686.70 969 43886 Revise gastric port, open $1, 302.003604388726 M i d l e v e lR e m o v e g a s t r i c p or t, o p e n$ 278.70 969 43887 26 Remove gastric port, open $327.6096943887 R e m o v e g a s t r i c p or t, o p e n$ 1,179.15 360 43888 26 Midlevel Change gastric port, open $261.309694388826 C han g e g a s t r i c p or t, o p e n$ 307.65 969 43888 Change gastric port, open $1, 653.7536043999 St o ma c h s u r g ery p roce d u re$ 1,487.00 360 44005 26 Freeing of bowel adhesion $438.909694400526 M i d l e v e lF ree in g o f b o w e l a d h es i o n$ 372.80 969 44005 Freeing of bowel adhesion $3, 951.153604401026 I n c i s i o n o f s ma ll b o w e l$ 1,076.25 969 44010 26 Midlevel Incision of small bowel $914.5596944010 I n c i s i o n o f s ma ll b o w e l$ 3,127.95 360 44015 Insert needle cath bowel $517.653604402026 E x pl ores ma ll in t es t in e$ 844.20 969 44020 26 Midlevel Explore small intestine $717.1596944020 E x pl ores ma ll in t es t in e$ 3,515.40 360 44021 26 Decompress small bowel $948.159694402126 M i d l e v e l Deco m p resss ma ll b o w e l$ 805.80 969 44021 Decompress small bowel $3, 544.803604402526 I n c i s i o n o f l a r g e b o w e l$ 955.50 969 44025 26 Midlevel Incision of large bowel $812.5096944025 I n c i s i o n o f l a r g e b o w e l$ 3,571.05 360 44050 26 Reduce bowel obstruction $964.959694405026 M i d l e v e lR e d u ce b o w e l o b s t r u c t i o n$ 820.20 969 44050 Reduce bowel obstruction $3, 376.803604405526 C orrec t ma l ro t a t i o n o f b o w e l$ 919.80 969 44055 26 Midlevel Correct malrotation of bowel $782.1596944055 C orrec t ma l ro t a t i o n o f b o w e l$ 5,405.40 360 44100 26 Midlevel Biopsy of bowel $1, 243.959694410026 B i o p syo f b o w e l$ 1,463.70 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 148 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 44100 Biopsy of bowel $417.903604411026 M i d l e v e lE x c i se in t es t in e l es i o n (s)$ 99.40 969 44110 26 Excise intestine lesion(s) $116.5596944110 E x c i se in t es t in e l es i o n (s)$ 3,067.05 360 44111 26 Excision of bowel lesion(s) $825.309694411126 M i d l e v e lE x c i s i o n o f b o w e ll es i o n (s)$ 701.50 969 44111 Excision of bowel lesion(s) $3, 552.153604412026 M i d l e v e lR e m o v a l o f s ma ll in t es t in e$ 822.05 969 44120 26 Removal of small intestine $967.0596944120 R e m o v a l o f s ma ll in t es t in e$ 4,413.15 360 44121 26 Removal of small intestine $1, 187.55969 [R o w s 8001 - 9000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 4412126 M i d l e v e lR e m o v a l o f s ma ll in t es t in e$ 1,009.60 969 44121 Removal of small intestine $876.7536044125 R e m o v a l o f s ma ll in t es t in e$ 4,266.15 360 44126 26 Enterectomy w/o taper, cong $253.059694412626 M i d l e v e lE n t erec t o m y w / o t a p er, co n g$ 215.15 969 44126 Enterectomy w/o taper, cong $8, 886.153604414026 P a r t ia l re m o v a l o f co l o n$ 2,280.60 969 44140 26 Midlevel Partial removal of colon $1, 938.7096944140 P a r t ia l re m o v a l o f co l o n$ 4,847.85 360 44141 26 Partial removal of colon $1, 333.509694414126 M i d l e v e lP a r t ia l re m o v a l o f co l o n$ 1,133.50 969 44141 Partial removal of colon $6, 580.353604414326 M i d l e v e lP a r t ia l re m o v a l o f co l o n$ 1,441.30 969 44143 26 Partial removal of colon $1, 695.7596944143 P a r t ia l re m o v a l o f co l o n$ 6,019.65 360 44144 26 Midlevel Partial removal of colon $1, 391.209694414426 P a r t ia l re m o v a l o f co l o n$ 1,636.95 969 44144 Partial removal of colon $6, 389.253604414526 P a r t ia l re m o v a l o f co l o n$ 1,676.85 969 44145 26 Midlevel Partial removal of colon $1, 425.6096944145 P a r t ia l re m o v a l o f co l o n$ 6,006.00 360 44146 26 Partial removal of colon $1, 670.559694414626 M i d l e v e lP a r t ia l re m o v a l o f co l o n$ 1,420.35 969 44146 Partial removal of colon $7, 653.453604414726 P a r t ia l re m o v a l o f co l o n$ 2,043.30 969 44147 26 Midlevel Partial removal of colon $1, 736.6596944147 P a r t ia l re m o v a l o f co l o n$ 6,984.60 360 44150 26 Removal of colon $1, 782.909694415026 M i d l e v e lR e m o v a l o f co l o n$ 1,515.15 969 44150 Removal of colon $6, 763.053604415126 R e m o v a l o f co l o n / i l eos t o m y$ 1,799.70 969 44151 26 Midlevel Removal of colon/ileostomy $1, 529.4596944151 R e m o v a l o f co l o n / i l eos t o m y$ 7,731.15 360 44155 26 Midlevel Removal of colon/ileostomy $1, 748.959694415526 R e m o v a l o f co l o n / i l eos t o m y$ 2,058.00 969 44155 Removal of colon/ileostomy $7, 534.803604415626 R e m o v a l o f co l o n / i l eos t o m y$ 2,022.30 969 44156 26 Midlevel Removal of colon/ileostomy $1, 719.1096944156 R e m o v a l o f co l o n / i l eos t o m y$ 8,342.25 360 44157 26 Midlevel Colectomy w/ileoanal anast $1,897.10 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 149 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 44157 26 Colectomy w/ileoanal anast $2, 232.3096944157 C o l ec t o m y w / i l eo ana l ana s t$ 7,866.60 360 44158 26 Colectomy w/neo-rectum pouch $2, 198.709694415826 M i d l e v e lC o l ec t o m y w / n eo - rec t u m p o u c h$ 1,868.55 969 44158 Colectomy w/neo-rectum pouch $8, 067.153604416026 R e m o v a l o f co l o n$ 2,254.35 969 44160 26 Midlevel Removal of colon $1, 916.1596944160 R e m o v a l o f co l o n$ 4,487.70 360 44180 26 Midlevel Lap, enterolysis $1, 037.709694418026 L a p, e n t ero l ys i s$ 1,221.15 969 44180 Lap, enterolysis $3, 327.453604418626 M i d l e v e l L a p, j e j u n os t o m y$ 780.25 969 44186 26 Lap, jejunostomy $917.7096944186 L a p, j e j u n os t o m y$ 2,362.50 360 44187 26 Lap, ileo/jejuno-stomy $648.909694418726 M i d l e v e l L a p, i l eo / j e j u n o - s t o m y$ 551.80 969 44187 Lap, ileo/jejuno-stomy $4, 007.853604418826 M i d l e v e l L a p, co l os t o m y$ 935.20 969 44188 26 Lap, colostomy $1, 100.4096944188 L a p, co l os t o m y$ 4,437.30 360 44202 26 Midlevel Lap, enterectomy $1, 027.659694420226 L a p, e n t erec t o m y$ 1,208.55 969 44202 Lap enterectomy $5, 015.853604420326 L a p resec t s / in t es t in e, a dd l$ 1,380.75 969 44203 26 Midlevel Lap resect s/intestine, addl $1, 173.4096944203 L a p resec t s / in t es t in e, a dd l$ 878.85 360 44204 26 Laparo partial colectomy $252.009694420426 M i d l e v e l L a p a ro p a r t ia l co l ec t o m y$ 214.05 969 44204 Laparo partial colectomy $5, 575.503604420526 L a p co l ec t o m y p a r tw / i l e u m$ 1,546.65 969 44205 26 Midlevel Lap colectomy part w/ileum $1, 314.8596944205 L a p co l ec t o m y p a r tw / i l e u m$ 4,849.95 360 44206 26 Lap part colectomy w/stoma $1, 353.459694420626 M i d l e v e l L a pp a r t co l ec t o m y w / s t o ma$ 1,150.65 969 44206 Lap part colectomy w/stoma $6, 360.903604420726 L co l ec t o m y / co l o p roc t os t o m y$ 1,748.25 969 44207 26 Midlevel L colectomy/coloproctostomy $1, 485.9096944207 L co l ec t o m y / co l o p roc t os t o m y$ 6,623.40 360 44208 26 Midlevel L colectomy/coloproctostomy $1, 564.559694420826 L co l ec t o m y / co l o p roc t os t o m y$ 1,840.65 969 44208 L colectomy/coloproctostomy $7, 207.203604421026 M i d l e v e l L a p a ro t o t a lp roc t oco l ec t o m y$ 1,704.80 969 44210 26 Laparo total proctocolectomy $2, 005.5096944210 L a p a ro t o t a lp roc t oco l ec t o m y$ 6,506.85 360 44211 26 Lap colectomy w/proctectomy $1, 786.059694421126 M i d l e v e l L a p co l ec t o m y w / p roc t ec t o m y$ 1,517.90 969 44211 Lap colectomy w/proctectomy $8, 135.403604421226 M i d l e v e l L a p a ro t o t a lp roc t oco l ec t o m y$ 1,872.10 969 44212 26 Laparo total proctocolectomy $2, 202.9096944212 L a p a ro t o t a lp roc t oco l ec t o m y$ 7,482.30 360 44213 26 Midlevel Lap, mobil splenic fl add-on $1, 745.709694421326 L a p, m o bi l s pl e ni c f l a dd - o n$ 2,053.80 969 44213 Lap, mobil splenic fl add-on $685.653604422726 M i d l e v e l L a p, c l osee n t eros t o m y$ 169.80 969 44227 26 Lap, close enterostomy $199.5096944227 L a p, c l osee n t eros t o m y$ 6,046.95 360 44238 Laparoscope proc, intestine $8,977.35 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 150 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 44300 26 Open bowel to skin $1, 668.459694430026 M i d l e v e lOp e nb o w e lt os kin$ 1,418.40 969 44300 Open bowel to skin $3, 046.053604431026 M i d l e v e l I l eos t o m y / j e j u n os t o m y$ 700.80 969 44310 26 Ileostomy/jejunostomy $824.2596944310 I l eos t o m y / j e j u n os t o m y$ 3,775.80 360 44312 26 Revision of ileostomy $1, 034.259694431226 M i d l e v e lR e v i s i o n o f i l eos t o m y$ 879.15 969 44312 Revision of ileostomy $2, 144.103604431426 R e v i s i o n o f i l eos t o m y$ 576.45 969 44314 26 Midlevel Revision of ileostomy $489.6096944314 R e v i s i o n o f i l eos t o m y$ 3,649.80 360 44316 26 Devise bowel pouch $993.309694431626 M i d l e v e l De v i se b o w e lp o u c h$ 844.20 969 44316 Devise bowel pouch $5, 097.753604432026 M i d l e v e lC o l os t o m y$ 1,165.10 969 44320 26 Colostomy $1, 370.2596944320 C o l os t o m y$ 4,347.00 360 44322 26 Midlevel Colostomy with biopsies $999.459694432226 C o l os t o m y w i t hbi o p s i es$ 1,176.00 969 44322 Colostomy with biopsies $3, 610.953604434026 M i d l e v e lR e v i s i o n o f co l os t o m y$ 812.35 969 44340 26 Revision of colostomy $955.5096944340 R e v i s i o n o f co l os t o m y$ 2,248.05 360 44345 26 Revision of colostomy $583.809694434526 M i d l e v e lR e v i s i o n o f co l os t o m y$ 495.85 969 44345 Revision of colostomy $3, 807.303604434626 R e v i s i o n o f co l os t o m y$ 1,030.05 969 44346 26 Midlevel Revision of colostomy $875.3096944346 R e v i s i o n o f co l os t o m y$ 4,274.55 360 44360 26 Midlevel Small bowel endoscopy $978.209694436026 S ma ll b o w e l e n d osco p y$ 1,150.80 969 44360 Small bowel endoscopy $581.703604436126 M i d l e v e lS ma ll b o w e l e n d osco p y / bi o p sy$ 136.30 969 44361 26 Small bowel endoscopy/biopsy $160.6596944361 S ma ll b o w e l e n d osco p y / bi o p sy$ 639.45 360 44363 26 Small bowel endoscopy $176.409694436326 M i d l e v e lS ma ll b o w e l e n d osco p y$ 150.15 969 44363 Small bowel endoscopy $764.403604436426 S ma ll b o w e l e n d osco p y$ 212.10 969 44364 26 Midlevel Small bowel endoscopy $180.1096944364 S ma ll b o w e l e n d osco p y$ 816.90 360 44365 26 Small bowel endoscopy $225.759694436526 M i d l e v e lS ma ll b o w e l e n d osco p y$ 191.55 969 44365 Small bowel endoscopy $730.803604436626 S ma ll b o w e l e n d osco p y$ 201.60 969 44366 26 Midlevel Small bowel endoscopy $171.1596944366 S ma ll b o w e l e n d osco p y$ 958.65 360 44369 26 Small bowel endoscopy $265.659694436926 M i d l e v e lS ma ll b o w e l e n d osco p y$ 225.40 969 44369 Small bowel endoscopy $980.703604437026 M i d l e v e lS ma ll b o w e l e n d osco p y / s t e n t$ 229.65 969 44370 26 Small bowel endoscopy/stent $269.8596944370 S ma ll b o w e l e n d osco p y / s t e n t$ 1,058.40 360 44372 26 Small bowel endoscopy $291.909694437226 M i d l e v e lS ma ll b o w e l e n d osco p y$ 247.95 969 44372 Small bowel endoscopy $945.00 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 151 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 44373 26 Small bowel endoscopy $263.559694437326 M i d l e v e lS ma ll b o w e l e n d osco p y$ 223.85 969 44373 Small bowel endoscopy $761.253604437626 M i d l e v e lS ma ll b o w e l e n d osco p y$ 178.90 969 44376 26 Small bowel endoscopy $210.0096944376 S ma ll b o w e l e n d osco p y$ 1,122.45 360 44377 26 Small bowel endoscopy/biopsy $311.859694437726 M i d l e v e lS ma ll b o w e l e n d osco p y / bi o p sy$ 264.80 969 44377 Small bowel endoscopy/biopsy $1, 186.503604437826 S ma ll b o w e l e n d osco p y$ 328.65 969 44378 26 Midlevel Small bowel endoscopy $279.5096944378 S ma ll b o w e l e n d osco p y$ 1,521.45 360 44379 26 S bowel endoscope w/stent $422.109694437926 M i d l e v e lS b o w e l e n d osco p e w / s t e n t$ 358.40 969 44379 S bowel endoscope w/stent $1, 618.053604438026 S ma ll b o w e l e n d osco p y$ 443.10 969 44380 26 Midlevel Small bowel endoscopy $376.2096944380 S ma ll b o w e l e n d osco p y$ 252.00 360 44382 26 Midlevel Small bowel endoscopy $59.509694438226 S ma ll b o w e l e n d osco p y$ 70.35 969 44382 Small bowel endoscopy $304.503604438526 M i d l e v e lE n d osco p yo f b o w e lp o u c h$ 70.55 969 44385 26 Endoscopy of bowel pouch $82.9596944385 E n d osco p yo f b o w e lp o u c h$ 390.60 360 44386 26 Endoscopy, bowel pouch/biop $110.259694438626 M i d l e v e lE n d osco p y, b o w e lp o u c h / bi o p$ 93.95 969 44386 Endoscopy, bowel pouch/biop $467.253604438826 M i d l e v e lC o l o n osco p y$ 110.50 969 44388 26 Colonoscopy $130.2096944388 C o l o n osco p y$ 613.20 360 44389 26 Colonoscopy with biopsy $171.159694438926 M i d l e v e lC o l o n osco p y w i t hbi o p sy$ 145.75 969 44389 Colonoscopy with biopsy $684.603604439026 M i d l e v e lC o l o n osco p y f or f ore i g nb o d y$ 161.55 969 44390 26 Colonoscopy for foreign body $190.0596944390 C o l o n osco p y f or f ore i g nb o d y$ 805.35 360 44391 26 Colonoscopy for bleeding $227.859694439126 M i d l e v e lC o l o n osco p y f or b l ee d in g$ 193.80 969 44391 Colonoscopy for bleeding $927.15 360 44392 26 Midlevel Colonoscopy & polypectomy$ 220.35 969 44392 26 Colonoscopy & polypectomy $259.35 969 44392 Colonoscopy & polypectomy$ 810.60 360 44394 26 Midlevel Colonoscopy w/snare $193.209694439426 C o l o n osco p y w / s na re$ 226.80 969 44394 Colonoscopy w/snare $945.003604450026 M i d l e v e l I n t ro, g a s t ro in t es t ina lt u b e$ 224.25 969 44500 26 Intro, gastrointestinal tube $263.5596944500 I n t ro, g a s t ro in t es t ina lt u b e$ 89.25 360 44602 26 Suture, small intestine $27.309694460226 M i d l e v e lS u t u re, s ma ll in t es t in e$ 22.85 969 44602 Suture, small intestine $5, 074.653604460326 M i d l e v e lS u t u re, s ma ll in t es t in e$ 1,115.80 969 44603 26 Suture, small intestine $1, 312.5096944603 S u t u re, s ma ll in t es t in e$ 5,828.55 360 44604 26 Midlevel Suture, large intestine $1, 272.609694460426 S u t u re, l a r g e in t es t in e$ 1,497.30 969 44604 Suture, large intestine $3,819.90 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 152 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 44605 26 Repair of bowel lesion $1, 047.909694460526 M i d l e v e lR e p ai ro f b o w e ll es i o n$ 890.70 969 44605 Repair of bowel lesion $4, 737.603604461526 M i d l e v e l I n t es t ina l s t r i c t u ro pl a s t y$ 1,104.10 969 44615 26 Intestinal stricturoplasty $1, 298.8596944615 I n t es t ina l s t r i c t u ro pl a s t y$ 3,891.30 360 44620 26 Repair bowel opening $1, 060.509694462026 M i d l e v e lR e p ai r b o w e l o p e nin g$ 901.45 969 44620 Repair bowel opening $3, 135.303604462526 R e p ai r b o w e l o p e nin g$ 842.10 969 44625 26 Midlevel Repair bowel opening $715.6596944625 R e p ai r b o w e l o p e nin g$ 3,691.80 360 44626 26 Midlevel Repair bowel opening $852.409694462626 R e p ai r b o w e l o p e nin g$ 1,002.75 969 44626 Repair bowel opening $5, 809.653604464026 M i d l e v e lR e p ai r b o w e l - s kin f i s t u l a$ 1,364.30 969 44640 26 Repair bowel-skin fistula $1, 605.4596944640 R e p ai r b o w e l - s kin f i s t u l a$ 5,076.75 360 44650 26 Midlevel Repair bowel fistula $1, 186.259694465026 R e p ai r b o w e l f i s t u l a$ 1,395.45 969 44650 Repair bowel fistula $5, 251.053604466026 M i d l e v e lR e p ai r b o w e l - b l a dd er f i s t u l a$ 1,231.95 969 44660 26 Repair bowel-bladder fistula $1, 449.0096944660 R e p ai r b o w e l - b l a dd er f i s t u l a$ 4,855.20 360 44661 26 Repair bowel-bladder fistula $1, 374.459694466126 M i d l e v e lR e p ai r b o w e l - b l a dd er f i s t u l a$ 1,168.60 969 44661 Repair bowel-bladder fistula $5, 628.0036044850 S U T U REOFMESENTER Y$ 2,440.25 360 44950 26 Appendectomy $1, 565.559694495026 M i d l e v e l A pp e n d ec t o m y$ 1,330.75 969 44950 Appendectomy $2, 319.453604495526 M i d l e v e l A pp e n d ec t o m y a dd - o n$ 542.25 969 44955 26 Appendectomy add-on $638.4096944955 A pp e n d ec t o m y a dd - o n$ 304.50 360 44960 26 Appendectomy $88.209694496026 M i d l e v e l A pp e n d ec t o m y$ 75.00 969 44960 Appendectomy $3, 155.253604497026 M i d l e v e l L a p a rosco p y, a pp e n d ec t o m y$ 719.30 969 44970 26 Laparoscopy, appendectomy $846.3096944970 L a p a rosco p y a pp e n d ec t o m y$ 2,163.00 360 44979 Laparoscope proc, app $8, 977.353604500026 M i d l e v e l Dr aina g eo f p e l v i c ab scess$ 494.50 969 45000 26 Drainage of pelvic abscess $581.7096945000 Dr aina g eo f p e l v i c ab scess$ 1,526.70 360 45005 26 Midlevel Drainage of rectal abscess $336.259694500526 Dr aina g eo f rec t a l ab scess$ 395.85 969 45005 Drainage of rectal abscess $574.353604502026 M i d l e v e l Dr aina g eo f rec t a l ab scess$ 133.70 969 45020 26 Drainage of rectal abscess $157.5096945020 Dr aina g eo f rec t a l ab scess$ 2,051.70 360 45100 26 Midlevel Biopsy of rectum $427.459694510026 B i o p syo f rec t u m$ 502.95 969 45100 Biopsy of rectum $1, 079.403604510826 M i d l e v e lR e m o v a l o f an orec t a ll es i o n$ 237.40 969 45108 26 Removal of anorectal lesion $279.3096945108 R e m o v a l o f an orec t a ll es i o n$ 1,326.15 360 45110 26 Midlevel Removal of rectum $290.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 153 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 45110 26 Removal of rectum $341.2596945110 R e m o v a l o f rec t u m$ 6,706.35 360 45123 26 Midlevel Partial proctectomy $1, 560.909694512326 P a r t ia lp roc t ec t o m y$ 1,836.45 969 45123 Partial proctectomy $4, 036.203604512626 M i d l e v e lP e l v i ce x e n t er a t i o n$ 925.85 969 45126 26 Pelvic exenteration $1, 088.8596945126 P e l v i ce x e n t er a t i o n$ 10,399.20 360 45130 26 Midlevel Excision of rectal prolapse $2, 431.559694513026 E x c i s i o n o f rec t a lp ro l a p se$ 2,860.20 969 45130 Excision of rectal prolapse $3, 945.903604513526 M i d l e v e lE x c i s i o n o f rec t a lp ro l a p se$ 907.55 969 45135 26 Excision of rectal prolapse $1, 067.8596945135 E x c i s i o n o f rec t a lp ro l a p se$ 4,922.40 360 45136 26 Midlevel Excise ileoanal reservior $1, 118.859694513626 E x c i se i l eo ana l reser v i or$ 1,316.70 969 45136 Excise ileoanal reservior $6, 574.053604515026 E x c i s i o n o f rec t a l s t r i c t u re$ 1,824.90 969 45150 26 Midlevel Excision of rectal stricture $1, 551.1096945150 E x c i s i o n o f rec t a l s t r i c t u re$ 1,422.75 360 45160 26 Excision of rectal lesion $381.159694516026 M i d l e v e lE x c i s i o n o f rec t a ll es i o n$ 324.05 969 45160 Excision of rectal lesion $3, 662.4036045172 EXCRECTT U MTR A NS A N A L F ULL$ 2,705.25 360 45190 26 Destruction, rectal tumor $974.409694519026 M i d l e v e l Des t r u c t i o n, rec t a lt u m or$ 828.00 969 45190 Destruction, rectal tumor $2, 490.603604530026 M i d l e v e lP roc t os i g m o i d osco p y d x$ 554.25 969 45300 26 Proctosigmoidoscopy dx $652.0596945300 P roc t os i g m o i d osco p y d x$ 194.25 360 45303 26 Proctosigmoidoscopy dilate $29.409694530326 M i d l e v e lP roc t os i g m o i d osco p y d i l a t e$ 25.10 969 45303 Proctosigmoidoscopy dilate $331.803604530526 M i d l e v e lP roc t os i g m o i d osco p y w / b x$ 29.10 969 45305 26 Proctosigmoidoscopy w/bx $34.6596945305 P roc t os i g m o i d osco p y w / b x$ 288.75 360 45307 26 Midlevel Proctosigmoidoscopy fb $55.709694530726 P roc t os i g m o i d osco p y f b$ 65.10 969 45307 Proctosigmoidoscopy fb $375.903604530826 P roc t os i g m o i d osco p yre m o v a l$ 61.95 969 45308 26 Midlevel Proctosigmoidoscopy removal $52.8096945308 P roc t os i g m o i d osco p yre m o v a l$ 317.10 360 45309 26 Midlevel Proctosigmoidoscopy removal $47.059694530926 P roc t os i g m o i d osco p yre m o v a l$ 55.65 969 45309 Proctosigmoidoscopy removal $339.153604531526 M i d l e v e lP roc t os i g m o i d osco p yre m o v a l$ 103.95 969 45315 26 Proctosigmoidoscopy removal $121.8096945315 P roc t os i g m o i d osco p yre m o v a l$ 401.10 360 45317 26 Proctosigmoidoscopy bleed $87.159694531726 M i d l e v e lP roc t os i g m o i d osco p y b l ee d$ 74.45 969 45317 Proctosigmoidoscopy bleed $429.453604532026 M i d l e v e lP roc t os i g m o i d osco p y ab l a t e$ 78.45 969 45320 26 Proctosigmoidoscopy ablate $92.4096945320 P roc t os i g m o i d osco p y ab l a t e$ 393.75 360 45321 26 Midlevel Proctosigmoidoscopy volvul $83.609694532126 P roc t os i g m o i d osco p y v o l vu l$ 98.70 969 45321 Proctosigmoidoscopy volvul $393.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 154 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 45327 26 Proctosigmoidoscopy w/stent $75.609694532726 M i d l e v e lP roc t os i g m o i d osco p y w / s t e n t$ 64.05 969 45327 Proctosigmoidoscopy w/stent $447.303604533026 D ia g n os t i cs i g m o i d osco p y$ 100.80 969 45330 26 Midlevel Diagnostic sigmoidoscopy $85.7596945330 D ia g n os t i cs i g m o i d osco p y$ 234.15 360 45331 26 SIGMOIDOSCOPY FLX W/BIOPSY $220.92960 S I NG L E / M UL T I P L E 4533126 M i d l e v e lS i g m o i d osco p y an d bi o p sy$ 53.90 969 45331 Sigmoidoscopy and biopsy $280.353604533226 M i d l e v e lS i g m o i d osco p y w / f b re m o v a l$ 64.60 969 45332 26 Sigmoidoscopy w/fb removal $75.6096945332 S i g m o i d osco p y w / f b re m o v a l$ 410.55 360 45333 26 Sigmoidoscopy & polypectomy $113.40 969 45333 26 Midlevel Sigmoidoscopy & polypectomy$ 95.95 969 45333 Sigmoidoscopy & polypectomy $407.403604533426 S i g m o i d osco p y f or b l ee d in g$ 112.35 969 45334 26 Midlevel Sigmoidoscopy for bleeding $95.2596945334 S i g m o i d osco p y f or b l ee d in g$ 604.80 360 45335 26 Sigmoidoscopy w/submuc inj $168.009694533526 M i d l e v e lS i g m o i d osco p y w / s u bm u c inj$ 142.40 969 45335 Sigmoidoscopy w/submuc inj $341.25 360 45337 26 Midlevel Sigmoidoscopy & decompress$ 79.45 969 45337 26 Sigmoidoscopy & decompress $93.45 969 45337 Sigmoidoscopy & decompress$ 525.00 360 45338 26 Midlevel Sigmoidoscopy w/tumr remove $123.459694533826 S i g m o i d osco p y w / t u m rre m o v e$ 144.90 969 45338 Sigmoidoscopy w/tumr remove $521.853604534026 M i d l e v e lS i g w / ba ll oo n d i l a t i o n$ 122.55 969 45340 26 Sig w/balloon dilation $143.8596945340 S i g w / ba ll oo n d i l a t i o n$ 429.45 360 45341 26 Midlevel Sigmoidoscopy w/ultrasound $100.059694534126 S i g m o i d osco p y w / u lt r a so u n d$ 117.60 969 45341 Sigmoidoscopy w/ultrasound $578.553604534226 S i g m o i d osco p y w / u s gu i d e b x$ 158.55 969 45342 26 Midlevel Sigmoidoscopy w/us guide bx $135.1096945342 S i g m o i d osco p y w / u s gu i d e b x$ 885.15 360 45378 53 Diagnostic colonoscopy $234.159694537826 D ia g n os t i cco l o n osco p y$ 242.55 969 45378 26 Midlevel Diagnostic colonoscopy $205.9096945378 D ia g n os t i cco l o n osco p y$ 802.20 360 45379 26 Midlevel Colonoscopy w/fb removal $415.009694537926 C o l o n osco p y w / f b re m o v a l$ 488.25 969 45379 Colonoscopy w/fb removal $1, 001.703604538026 C o l o n osco p y an d bi o p sy$ 279.30 969 45380 26 Midlevel Colonoscopy and biopsy $237.0596945380 C o l o n osco p y an d bi o p sy$ 958.65 360 45381 26 Midlevel Colonoscopy, submucous inj $225.759694538126 C o l o n osco p y, s u bm u co u s inj$ 265.65 969 45381 Colonoscopy, submucous inj $909.303604538226 M i d l e v e lC o l o n osco p y / co n t ro l b l ee d in g$ 213.70 969 45382 26 Colonoscopy/control bleeding $250.9596945382 C o l o n osco p y / co n t ro l b l ee d in g$ 1,221.15 360 45384 26 Lesion remove colonoscopy $338.109694538426 M i d l e v e l L es i o n re m o v eco l o n osco p y$ 287.55 969 45384 Lesion remove colonoscopy $999.603604538526 M i d l e v e l L es i o n re m o v a l co l o n osco p y$ 237.55 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 155 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 45385 26 Lesion removal colonoscopy $279.3096945385 L es i o n re m o v a l co l o n osco p y$ 1,137.15 360 45386 26 Colonoscopy dilate stricture $315.009694538626 M i d l e v e lC o l o n osco p y d i l a t es t r i c t u re$ 268.15 969 45386 Colonoscopy dilate stricture $982.803604539126 M i d l e v e lC o l o n osco p y w / e n d osco p e u s$ 232.30 969 45391 26 Colonoscopy w/endoscope us $273.0096945391 C o l o n osco p y w / e n d osco p e u s$ 1,089.90 360 45392 26 Colonoscopy w/endoscopic fnb $305.559694539226 M i d l e v e lC o l o n osco p y w / e n d osco p i c f nb$ 259.40 969 45392 Colonoscopy w/endoscopic fnb $1, 402.803604539526 M i d l e v e l L a p, re m o v a l o f rec t u m$ 326.35 969 45395 26 Lap, removal of rectum $384.3096945395 L a p, re m o v a l o f rec t u m$ 7,207.20 360 45397 26 Midlevel Lap, remove rectum w/pouch $1, 688.059694539726 L a p, re m o v erec t u m w / p o u c h$ 1,985.55 969 45397 Lap, remove rectum w/pouch $7, 777.353604540026 M i d l e v e l L a p a rosco p i c p roc$ 1,825.30 969 45400 26 Laparoscopic proc $2, 147.2596945400 L a p a rosco p i c p roc$ 4,177.95 360 45402 26 Lap proctopexy w/sig resect $1, 152.909694540226 M i d l e v e l L a pp roc t o p e x y w / s i g resec t$ 980.30 969 45402 Lap proctopexy w/sig resect $5, 541.9036045499 L a p a rosco p e p roc, rec t u m$ 8,977.35 360 45500 26 Midlevel Repair of rectum $1, 309.609694550026 R e p ai ro f rec t u m$ 1,540.35 969 45500 Repair of rectum $1, 893.153604550526 R e p ai ro f rec t u m$ 487.20 969 45505 26 Midlevel Repair of rectum $414.4096945505 R e p ai ro f rec t u m$ 2,123.10 360 45520 26 Midlevel Treatment of rectal prolapse $452.309694552026 T re a t m e n t o f rec t a lp ro l a p se$ 532.35 969 45520 Treatment of rectal prolapse $144.903604554026 M i d l e v e lC orrec t rec t a lp ro l a p se$ 33.90 969 45540 26 Correct rectal prolapse $39.9096945540 C orrec t rec t a lp ro l a p se$ 3,831.45 360 45541 26 Midlevel Correct rectal prolapse $889.209694554126 C orrec t rec t a lp ro l a p se$ 1,045.80 969 45541 Correct rectal prolapse $3, 350.553604555026 M i d l e v e lR e p ai rrec t u m / re m o v es i g m o i d$ 757.40 969 45550 26 Repair rectum/remove sigmoid $891.4596945550 R e p ai rrec t u m / re m o v es i g m o i d$ 5,299.35 360 45560 26 Repair of rectocele $1, 444.809694556026 M i d l e v e lR e p ai ro f rec t oce l e$ 1,227.70 969 45560 Repair of rectocele $2, 544.153604556226 E x pl or a t i o n / re p ai ro f rec t u m$ 709.80 969 45562 26 Midlevel Exploration/repair of rectum $602.9096945562 E x pl or a t i o n / re p ai ro f rec t u m$ 4,015.20 360 45563 26 Midlevel Exploration/repair of rectum $911.359694556326 E x pl or a t i o n / re p ai ro f rec t u m$ 1,072.05 969 45563 Exploration/repair of rectum $5, 928.303604580026 R e p ai rrec t / b l a dd er f i s t u l a$ 1,586.55 969 45800 26 Midlevel Repair rect/bladder fistula $1, 348.3596945800 R e p ai rrec t / b l a dd er f i s t u l a$ 4,347.00 360 45805 26 Midlevel Repair fistula w/colostomy $1, 011.709694580526 R e p ai r f i s t u l a w / co l os t o m y$ 1,190.70 969 45805 Repair fistula w/colostomy $5,260.50 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 156 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 45820 26 Repair rectourethral fistula $1, 381.809694582026 M i d l e v e lR e p ai rrec t o u re t h r a l f i s t u l a$ 1,174.40 969 45820 Repair rectourethral fistula $4, 243.053604582526 M i d l e v e lR e p ai r f i s t u l a w / co l os t o m y$ 1,012.35 969 45825 26 Repair fistula w/colostomy $1, 190.7096945825 R e p ai r f i s t u l a w / co l os t o m y$ 5,298.30 360 45900 26 Reduction of rectal prolapse $1, 453.209694590026 M i d l e v e lR e d u c t i o n o f rec t a lp ro l a p se$ 1,235.45 969 45900 Reduction of rectal prolapse $729.753604590526 M i d l e v e l D i l a t i o n o f ana l s p hin c t er$ 164.60 969 45905 26 Dilation of anal sphincter $193.2096945905 D I L A TE A N A L SP H I NCTER U N D ER A NEST H$ 611.10 360 45910 26 Midlevel Dilation of rectal narrowing $141.059694591026 D i l a t i o n o f rec t a l na rro w in g$ 165.90 969 45910 Dilation of rectal narrowing $709.803604591526 M i d l e v e lR e m o v erec t a l o b s t r u c t i o n$ 166.25 969 45915 26 Remove rectal obstruction $195.3096945915 R e m o v erec t a l o b s t r u c t i o n$ 813.75 360 45990 26 Midlevel Surg dx exam, anorectal $191.959694599026 S u r g d x e x am, an orec t a l$ 225.75 969 45990 Surg dx exam anorectal $388.5036045999 R ec t u m s u r g ery p roce d u re$ 1,419.95 360 46020 26 Midlevel Placement of seton $93.809694602026 Pl a ce m e n t o f se t o n$ 110.25 969 46020 Placement of seton $841.053604603026 M i d l e v e lR e m o v a l o f rec t a l ma r k er$ 181.15 969 46030 26 Removal of rectal marker $213.1596946030 R e m o v a l o f rec t a l ma r k er$ 326.55 360 46040 26 Midlevel Incision of rectal abscess $73.159694604026 I n c i s i o n o f rec t a l ab scess$ 86.10 969 46040 26 I&D ISCHIORECTAL&/PERIRECTAL ABSCESS $1, 331.58960 SPX 46040 I n c i s i o n o f rec t a l ab scess$ 1,485.75 360 46045 26 Midlevel Incision of rectal abscess $331.609694604526 I n c i s i o n o f rec t a l ab scess$ 390.60 969 46045 Incision of rectal abscess $1, 547.703604605026 M i d l e v e l I n c i s i o n o f ana l ab scess$ 325.55 969 46050 26 Incision of anal abscess $383.2596946050 I n c i s i o n o f ana l ab scess$ 352.80 360 46060 26 Incision of rectal abscess $91.359694606026 M i d l e v e l I n c i s i o n o f rec t a l ab scess$ 77.60 969 46060 Incision of rectal abscess $1, 705.203604607026 M i d l e v e l I n c i s i o n o f ana l se pt u m$ 358.90 969 46070 26 Incision of anal septum $422.1096946070 I n c i s i o n o f ana l se pt u m$ 859.95 360 46080 26 Midlevel Incision of anal sphincter $175.359694608026 I n c i s i o n o f ana l s p hin c t er$ 205.80 969 46080 Incision of anal sphincter $576.453604608326 I n c i see x t er na l h e m orr h o i d$ 156.45 969 46083 26 Midlevel Incise external hemorrhoid $133.3596946083 I n c i see x t er na l h e m orr h o i d$ 387.45 360 46200 26 Midlevel Removal of anal fissure $86.659694620026 R e m o v a l o f ana l f i ss u re$ 101.85 969 46200 Removal of anal fissure $1, 162.353604622026 R e m o v a l o f ana lt a g$ 287.70 969 46220 26 Midlevel Removal of anal tag $244.3596946220 R e m o v a l o f ana lt a g$ 429.45 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 157 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 46221 26 Ligation of hemorrhoid(s) $111.309694622126 M i d l e v e l L i g a t i o n o f h e m orr h o i d (s)$ 94.55 969 46221 Ligation of hemorrhoid(s) $688.803604623026 M i d l e v e lR e m o v a l o f ana lt a g s$ 152.20 969 46230 26 Removal of anal tags $179.5596946230 R e m o v a l o f ana lt a g s$ 624.75 360 46250 26 Hemorrhoidectomy $168.009694625026 M i d l e v e l He m orr h o i d ec t o m y$ 142.95 969 46250 Hemorrhoidectomy $1, 128.753604625526 He m orr h o i d ec t o m y$ 297.15 969 46255 26 Midlevel Hemorrhoidectomy $252.8096946255 R e m o v e in t / e x t h e m 1 g ro u p$ 1,271.55 360 46257 26 Midlevel Remove hemorrhoids & fissure $287.55 969 46257 26 Remove hemorrhoids & fissure$ 338.10 969 46257 Remove hemorrhoids & fissure $1,512.00 360 46258 26 Midlevel Remove hemorrhoids & fistula$ 323.20 969 46258 26 Remove hemorrhoids & fistula $380.10 969 46258 Remove hemorrhoids & fistula$ 1,671.60 360 46260 26 Midlevel Hemorrhoidectomy $357.459694626026 He m orr h o i d ec t o m y$ 421.05 969 46260 Hemorrhoidectomy $1,702.05 360 46261 26 Remove hemorrhoids & fissure$ 434.70 969 46261 26 Midlevel Remove hemorrhoids & fissure $369.05 969 46261 Remove hemorrhoids & fissure$ 1,886.85 360 46262 26 Midlevel Remove hemorrhoids & fistula $416.75 969 46262 26 Remove hemorrhoids & fistula$ 490.35 969 46262 Remove hemorrhoids & fistula $1, 988.703604627026 M i d l e v e lR e m o v a l o f ana l f i s t u l a$ 430.70 969 46270 26 Removal of anal fistula $507.1596946270 R e m o v e ana l f i s t s u b q$ 1,400.70 360 46275 26 Midlevel Removal of anal fistula $289.559694627526 R e m o v a l o f ana l f i s t u l a$ 340.20 969 46275 Removal of anal fistula $1, 482.603604628026 M i d l e v e lR e m o v a l o f ana l f i s t u l a$ 312.40 969 46280 26 Removal of anal fistula $367.5096946280 R e m o v e ana l f i s t co m pl e x$ 1,681.05 360 46285 26 Midlevel Removal of anal fistula $358.859694628526 R e m o v a l o f ana l f i s t u l a$ 422.10 969 46285 Removal of anal fistula $1, 473.153604628826 M i d l e v e lR e p ai r ana l f i s t u l a$ 303.45 969 46288 26 Repair anal fistula $357.0096946288 R e p ai r ana l f i s t u l a$ 1,963.50 360 46320 26 Midlevel Removal of hemorrhoid clot $424.059694632026 R e m o v a l o f h e m orr h o i d c l o t$ 498.75 969 46320 Removal of hemorrhoid clot $401.103604650026 I nj ec t i o nin t o h e m orr h o i d (s)$ 107.10 969 46500 26 Midlevel Injection into hemorrhoid(s) $91.1596946500 I nj ec t i o nin t o h e m orr h o i d (s)$ 466.20 360 46505 Chemodenervation anal musc $866.253604660026 D ia g n os t i c an osco p y$ 121.80 983 46600 26 Midlevel Diagnostic anoscopy $103.9596946600 D ia g n os t i c an osco p y$ 145.95 510 46604 26 Midlevel Anoscopy and dilation $31.309694660426 A n osco p y an dd i l a t i o n$ 36.75 969 46604 Anoscopy and dilation $240.453604660626 A n osco p y an d bi o p sy$ 81.90 969 46606 26 Midlevel Anoscopy and biopsy $69.60 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 158 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 46606 Anoscopy and biopsy $278.253604660826 M i d l e v e l A n osco p y, re m o v e f or b o d y$ 45.95 969 46608 26 Anoscopy, remove for body $53.5596946608 A n osco p y, re m o v e f or b o d y$ 291.90 360 46610 26 Anoscopy, remove lesion $92.409694661026 M i d l e v e l A n osco p y, re m o v e l es i o n$ 78.30 969 46610 Anoscopy, remove lesion $294.003604661126 A n osco p y$ 84.00 969 46611 26 Midlevel Anoscopy $71.5596946611 A n osco p y$ 299.25 360 46612 26 Midlevel Anoscopy, remove lesions $93.909694661226 A n osco p y, re m o v e l es i o n s$ 110.25 969 46612 Anoscopy, remove lesions $344.403604661426 M i d l e v e l A n osco p y, co n t ro l b l ee d in g$ 121.50 969 46614 26 Anoscopy, control bleeding $142.8096946614 A n osco p y, co n t ro l b l ee d in g$ 236.25 360 46615 26 Midlevel Anoscopy $103.409694661526 A n osco p y$ 121.80 969 46615 Anoscopy $342.303604670026 R e p ai ro f ana l s t r i c t u re$ 160.65 969 46700 26 Midlevel Repair of anal stricture $136.7596946700 R e p ai ro f ana l s t r i c t u re$ 2,346.75 360 46705 26 Repair of anal stricture $603.759694670526 M i d l e v e lR e p ai ro f ana l s t r i c t u re$ 513.05 969 46705 Repair of anal stricture $1, 839.603604670626 M i d l e v e lR e p ro f ana l f i s t u l a w / g l u e$ 409.30 969 46706 26 Repr of anal fistula w/glue $481.9596946706 R e p ro f ana l f i s t u l a w / g l u e$ 601.65 360 46754 26 Removal of suture from anus $160.659694675426 M i d l e v e lR e m o v a l o f s u t u re f ro man u s$ 136.65 969 46754 Removal of suture from anus $832.653604690026 M i d l e v e l Des t r u c t i o n, ana ll es i o n (s)$ 169.70 969 46900 26 Destruction, anal lesion(s) $199.5096946900 Des t r u c t i o n, ana ll es i o n (s)$ 500.85 360 46910 26 Destruction, anal lesion(s) $137.559694691026 M i d l e v e l Des t r u c t i o n, ana ll es i o n (s)$ 116.75 969 46910 Destruction anal lesion(s) $488.253604691626 C ryos u r g ery, ana ll es i o n (s)$ 128.10 969 46916 26 Midlevel Cryosurgery, anal lesion(s) $109.1096946916 C ryos u r g ery, ana ll es i o n (s)$ 528.15 360 46917 26 Laser surgery, anal lesions $141.759694691726 M i d l e v e l L a sers u r g ery, ana ll es i o n s$ 120.70 969 46917 Laser surgery, anal lesions $485.103604692226 E x c i s i o n o f ana ll es i o n (s)$ 131.25 969 46922 26 Midlevel Excision of anal lesion(s) $111.2596946922 E x c i s i o n o f ana ll es i o n (s)$ 488.25 360 46924 26 Midlevel Destruction, anal lesion(s) $109.959694692426 Des t r u c t i o n, ana ll es i o n (s)$ 129.15 969 46924 Destruction, anal lesion(s) $669.9036046930 Des t roy in t er na l h e m orr h o i d s$ 543.90 360 46940 26 Midlevel Treatment of anal fissure $151.859694694026 T re a t m e n t o f ana l f i ss u re$ 178.50 969 46940 Treatment of anal fissure $531.303604694226 T re a t m e n t o f ana l f i ss u re$ 145.95 969 46942 26 Midlevel Treatment of anal fissure $124.1096946942 T re a t m e n t o f ana l f i ss u re$ 474.60 360 46945 26 Midlevel Ligation of hemorrhoids $110.90 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 159 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 46945 26 Ligation of hemorrhoids $130.2096946945 L i g a t i o n o f h e m orr h o i d s$ 812.70 360 46945 26 INT HRHC BY LIGATION SINGLE HROID W/O $1, 088.22960 I MGG D N 4694626 M i d l e v e l L i g a t i o n o f h e m orr h o i d s$ 176.60 969 46946 26 Ligation of hemorrhoids $207.9096946946 L i g a t i o n o f h e m orr h o i d s$ 813.75 360 46947 26 Hemorrhoidopexy by stapling $221.559694694726 M i d l e v e l He m orr h o i d o p e x y b ys t a pl in g$ 188.30 969 46947 Hemorrhoidopexy by stapling $1, 377.6036046999 A n u ss u r g ery p roce d u re$ 1,419.95 360 47000 26 Midlevel Needle biopsy of liver $308.359694700026 N ee d l e bi o p syo f l i v er$ 362.25 969 47000 Needle biopsy of liver $372.753604700126 M i d l e v e lN ee d l e bi o p sy, l i v er a dd - o n$ 88.90 969 47001 26 Needle biopsy, liver add-on $105.0096947001 N ee d l e bi o p sy, l i v er a dd - o n$ 373.80 360 47010 26 Midlevel Open drainage, liver lesion $92.159694701026 Op e n d r aina g e, l i v er l es i o n$ 108.15 969 47010 Open drainage, liver lesion $4, 322.853604701526 M i d l e v e l I nj ec t / a s p i r a t e l i v ercys t$ 998.40 969 47015 26 Inject/aspirate liver cyst $1, 174.9596947015 I nj ec t / a s p i r a t e l i v ercys t$ 4,185.30 360 47100 26 Midlevel Wedge biopsy of liver $939.909694710026 W e d g e bi o p syo f l i v er$ 1,105.65 969 47100 Wedge biopsy of liver $3, 039.753604712026 M i d l e v e lP a r t ia l re m o v a l o f l i v er$ 694.40 969 47120 26 Partial removal of liver $816.9096947120 P a r t ia l re m o v a l o f l i v er$ 8,372.70 360 47490 26 Incision of gallbladder $2, 311.059694749026 M i d l e v e l I n c i s i o n o f g a ll b l a dd er$ 1,964.45 969 47490 Incision of gallbladder $1, 257.9036047531 I N J ECT I ONFORC H O L A NG I OGR A MEX I ST I NG$ 81.90 360 ACC 47532 INJECTION FOR CHOLANGIOGRAM NEW $289.80360 A CCESS 47533 P L MTB I L I A R Y D R A I N A GEC A T H$ 5,822.30 360 47534 PLMT BILIARY DRAINAGE CATH $5, 822.303604753426 PRQP L MTB I L I A R Y D RGC A T H W / I MGG I D$ 1,068.30 960 RS&I INT-EXT 47535 CONVERSION EXT BIL DRG CATH $5, 822.3036047536 EXC H A NGEB I L I A R Y D RGC A T H$ 5,822.30 360 47536 26 EXCHANGE BILIARY DRG CATH $384.7896047537 REMO V A L B I L I A R Y D RGC A T H$ 1,487.00 360 47538 PERQ PLMT BILE DUCT STENT $8, 977.3536047539 PERQP L MTB I L E D U CTSTENT$ 8,977.35 360 47540 PERQ PLMT BILE DUCT STENT $8, 977.353604754226 B A LL OON D I L A TB I L I A R Y D U CT / A MP ULL A$ 559.58 PRO EACH DUCT 47544 REMOVAL DUCT GLBLDR CALCULI $381.15 360 47544 26 REMOVAL BI LIARY DUCT &/GLBLDR$ 642.99 CALCULI PERO RS&I 47550 26 Midlevel Bile duct endoscopy add-on $480.709694755026 B i l e d u c t e n d osco p y a dd - o n$ 565.95 969 47550 Bile duct endoscopy add-on $598.503604755226 B i l ia rye n d osco p y t h r u s kin$ 172.20 969 47552 26 Midlevel Biliary endoscopy thru skin $146.20 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 160 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 47552 Biliary endoscopy thru skin $1, 153.953604755326 B i l ia rye n d osco p y t h r u s kin$ 348.60 969 47553 26 Midlevel Biliary endoscopy thru skin $296.1096947553 B i l ia rye n d osco p y t h r u s kin$ 1,153.95 360 47554 26 Biliary endoscopy thru skin $345.459694755426 M i d l e v e lB i l ia rye n d osco p y t h r u s kin$ 293.25 969 47554 Biliary endoscopy thru skin $1, 789.203604755526 B i l ia rye n d osco p y t h r u s kin$ 523.95 969 47555 26 Midlevel Biliary endoscopy thru skin $445.4596947555 B i l ia rye n d osco p y t h r u s kin$ 1,367.10 360 47556 26 Midlevel Biliary endoscopy thru skin $349.809694755626 B i l ia rye n d osco p y t h r u s kin$ 411.60 969 47556 Biliary endoscopy thru skin $1, 548.753604756226 L a p a rosco p i cc h o l ecys t ec t o m y$ 465.15 969 47562 26 Midlevel Laparoscopic cholecystectomy $395.1596947562 L a p a rosco p i cc h o l ecys t ec t o m y$ 2,703.75 360 47563 26 Midlevel Laparo cholecystectomy/graph $614.159694756326 L a p a roc h o l ecys t ec t o m y / g r a p h$ 722.40 969 47563 Laparo cholecystectomy/graph $2, 589.303604756426 M i d l e v e l L a p a roc h o l ecys t ec t o m y / e x pl r$ 637.50 969 47564 26 Laparo cholecystectomy/explr $749.7096947564 L a p a roc h o l ecys t ec t o m y / e x pl r$ 3,946.95 360 47570 26 Midlevel Laparo cholecystoenterostomy $739.009694757026 L a p a roc h o l ecys t oe n t eros t o m y$ 869.40 969 47570 Laparo cholecystoenterostomy $2, 796.1536047579 L a p a rosco p e p roc, bi l ia ry$ 8,977.35 360 47600 26 Removal of gallbladder $773.859694760026 M i d l e v e lR e m o v a l o f g a ll b l a dd er$ 658.15 969 47600 Removal of gallbladder $3, 902.853604760526 R e m o v a l o f g a ll b l a dd er$ 1,012.20 969 47605 26 Midlevel Removal of gallbladder $860.1096947605 R e m o v a l o f g a ll b l a dd er$ 3,543.75 360 47610 26 Midlevel Removal of gallbladder $820.659694761026 R e m o v a l o f g a ll b l a dd er$ 964.95 969 47610 Removal of gallbladder $4, 526.553604761226 M i d l e v e lR e m o v a l o f g a ll b l a dd er$ 1,049.55 969 47612 26 Removal of gallbladder $1, 234.8096947612 R e m o v a l o f g a ll b l a dd er$ 4,572.75 360 47620 26 Removal of gallbladder $1, 244.259694762026 M i d l e v e lR e m o v a l o f g a ll b l a dd er$ 1,057.35 969 47620 Removal of gallbladder $4, 944.453604770026 M i d l e v e lE x pl or a t i o n o f bi l e d u c t s$ 1,148.30 969 47700 26 Exploration of bile ducts $1, 351.3596947700 E x pl or a t i o n o f bi l e d u c t s$ 3,798.90 360 47701 26 Bile duct revision $1, 030.059694770126 M i d l e v e lB i l e d u c t re v i s i o n$ 875.30 969 47701 Bile duct revision $6, 309.453604771126 M i d l e v e lE x c i s i o n o f bi l e d u c tt u m or$ 1,461.55 969 47711 26 Excision of bile duct tumor $1, 719.9096947711 E x c i s i o n o f bi l e d u c tt u m or$ 5,613.30 360 47712 26 Midlevel Excision of bile duct tumor $1, 301.159694771226 E x c i s i o n o f bi l e d u c tt u m or$ 1,530.90 969 47712 Excision of bile duct tumor $7, 211.403604771526 M i d l e v e lE x c i s i o n o f bi l e d u c t cys t$ 1,670.35 969 47715 26 Excision of bile duct cyst $1, 965.6096947715 E x c i s i o n o f bi l e d u c t cys t$ 4,791.15 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 161 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 47760 ANAST XTRHEPATC BILIARY DUCTS & GI $6, 762.66960 TR A CT 4810226 M i d l e v e lN ee d l e bi o p sy, p an cre a s$ 754.15 969 48102 26 Needle biopsy, pancreas $887.2596948102 N ee d l e bi o p sy, p an cre a s$ 887.25 360 48120 26 Removal of pancreas lesion $3, 975.309694812026 M i d l e v e lR e m o v a l o f p an cre a s l es i o n$ 3,379.00 969 48120 Removal of pancreas lesion $3, 975.303604851026 M i d l e v e l Dr ain p an cre a t i c p se u d ocys t$ 3,314.75 969 48510 26 Drain pancreatic pseudocyst $3, 899.7096948510 Dr ain p an cre a t i c p se u d ocys t$ 3,899.70 360 49000 26 Midlevel Exploration of abdomen $2, 367.809694900026 E x pl or a t i o n o f ab d o m e n$ 2,785.65 969 49000 Exploration of abdomen $2, 785.653604900226 M i d l e v e lR eo p e nin g o f ab d o m e n$ 3,200.50 969 49002 26 Reopening of abdomen $3, 765.3096949002 R eo p e nin g o f ab d o m e n$ 3,765.30 360 49010 26 Exploration behind abdomen $3, 413.559694901026 M i d l e v e lE x pl or a t i o nb e hin d ab d o m e n$ 2,901.50 969 49010 Exploration behind abdomen $3, 413.553604902026 M i d l e v e l Dr ainab d o mina l ab scess$ 4,879.30 969 49020 26 Drain abdominal abscess $5, 740.3596949020 Dr ainab d o mina l ab scess$ 5,740.35 360 49040 26 Midlevel Drain, open, abdom abscess $3, 078.259694904026 Dr ain, o p e n, ab d o mab scess$ 3,621.45 969 49040 Drain, open, abdom abscess $3, 621.453604906026 M i d l e v e l Dr ain, o p e n, re t ro p ab scess$ 3,389.70 969 49060 26 Drain, open, retrop abscess $3, 987.9096949060 Dr ain, o p e n, re t ro p ab scess$ 3,987.90 360 49062 26 Midlevel Drain to peritoneal cavity $2, 289.259694906226 Dr ain t o p er i t o n e a l c a v i t y$ 2,693.25 969 49062 Drain to peritoneal cavity $2, 693.2536049082 A b d p a r a ce n t es i s$ 263.55 360 49083 Abd paracentesis w/imaging $365.653604908326 A B D OMP A R A CENTES I S D X / T H ER$ 316.50 960 W/IMAGING GUIDANCE 49180 26 Biopsy, abdominal mass $313.959694918026 M i d l e v e lB i o p sy, ab d o mina l ma ss$ 266.85 969 49180 Biopsy, abdominal mass $313.9536049203 EXC A B D T U M 5 CMOR L ESS$ 4,354.05 360 49205 26 EXC/DESTRUCTION OPEN ABDOMINAL $5, 417.13 T U MORS > 10.0 CM 4925026 M i d l e v e lE x c i s i o n o f u mbi l i c u s$ 80.20 969 49250 26 Excision of umbilicus $94.5096949250 E x c i s i o n o f u mbi l i c u s$ 5,822.30 360 49255 26 Midlevel Removal of omentum $2, 430.309694925526 R e m o v a l o f o m e n t u m$ 2,859.15 969 49255 Removal of omentum $2, 859.153604932026 D ia g l a p a rose p a r a t e p roc$ 1,186.50 969 49320 26 Midlevel Diag laparo separate proc $1, 008.5596949320 D ia g l a p a rose p a r a t e p roc$ 1,186.50 360 49321 26 Laparoscopy, biopsy $1, 255.809694932126 M i d l e v e l L a p a rosco p y, bi o p sy$ 1,067.45 969 49321 Laparoscopy, biopsy $1, 255.803604932226 L a p a rosco p y, a s p i r a t i o n$ 1,347.15 969 49322 26 Midlevel Laparoscopy, aspiration $1, 145.1096949322 L a p a rosco p y, a s p i r a t i o n$ 1,347.15 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 162 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 49323 Laparo drain lymphocele $2, 339.4036049324 L a p in ser tt u nn e l i p c a t h$ 1,429.05 360 49325 Lap revision perm ip cath $1, 525.6536049326 L a pw / o m e n t o p e x y a dd - o n$ 684.60 360 49327 Lap ins device for rt $473.5536049329 U N L I STE D L A P A ROSCOP Y A B D PER I T$ 8,977.35 360 OMENT 49400 Air injection into abdomen $348.6036049402 R e m o v e f ore i g nb o d y a d b o m e n$ 3,084.90 360 49405 IMAGE CATH FLUID COLXN VISC $2, 696.0536049406 I M A GEC A T H F LU I D PER I / RETRO$ 625.88 360 49407 26 IMAGE FLUID COLLXN ORAINAG CATH $5, 632.19 TR A NSRECN A G I N A L 49407 TC I M A GEF LU I D CO LL XN D R A I N A GC A T H$ 4,310.97 TRANSRECNAGINAL 49411 Ins mark abd/pel for rt perq $705.6036049412 I n s d e v i ce f orr t gu i d eo p e n$ 294.00 360 49418 Insert tun ip cath perc $837.9036049419 I n ser tt u ni p c a t h w / p or t$ 1,603.35 360 49421 Ins tun ip cath for dial opn $908.2536049422 R e m o v e t u nn e l e d i p c a t h$ 1,389.15 360 49422 REMOVAL TUNNELED INTRAPERITONEAL $656.10960 C A T H ETER 49423 E x c han g e d r aina g ec a t h e t er$ 267.75 360 49424 Assess cyst contrast inject $142.8036049425 I n ser t ab d o m e n - v e n o u s d r ain$ 2,737.35 360 49426 Revise abdomen-venous shunt $2, 300.5536049427 I nj ec t i o nab d o mina l s h u n t$ 164.85 360 49428 Ligation of shunt $1, 746.1536049429 R e m o v a l o f s h u n t$ 1,617.00 360 49435 Insert subq exten to ip cath $436.8036049436 E mb e dd e d i p c a t h e x i t - s i t e$ 673.05 360 49440 Place gastrostomy tube perc $825.3036049441 Pl a ce d u o d / j e j t u b e p erc$ 938.70 360 49442 Place cecostomy tube perc $788.5536049446 C han g e g - t u b e t o g - j p erc$ 601.65 360 49450 Replace g/c tube perc $244.6536049451 R e pl a ce d u o d / j e j t u b e p erc$ 338.10 360 49452 Replace g-j tube perc $519.7536049460 F i xg / co l o n t u b e w / d e v i ce$ 177.45 360 49465 Fluoro exam of g/colon tube $111.3036049491 Rp r h er n p ree mi ere d u c$ 2,779.35 360 49492 Rpr ing hern premie blocked $3, 446.1036049495 Rp r in g h er niabab yre d u c$ 1,470.00 360 49496 Rpr ing hernia baby blocked $2, 164.053604950026 Rp r in g h er nia, ini t, re d u ce$ 1,476.30 969 49500 26 Midlevel Rpr ing hernia, init, reduce $1, 254.8596949500 RPR I NG H ERN I A I N I TRE D U CE 0.5 - 5 Y RS$ 1,476.30 360 49501 26 Rpr ing hernia, init blocked $2, 178.759694950126 M i d l e v e lRp r in g h er nia, ini t b l oc k e d$ 1,851.95 969 49501 RPR ING HERNIA INIT BLOCKED 0.5-5 YRS $2, 178.753604950526 P r p i / h er nini t re d u c > 5 yr$ 1,874.25 969 49505 26 Midlevel Prp i/hern init reduc >5 yr $1, 593.1096949505 P r p i / h er nini t re d u c >= 5 yr$ 1,874.25 360 49507 26 Midlevel Prp i/hern init block >5 yr $1,802.85 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 163 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 49507 26 Prp i/hern init block >5 yr $2, 121.0096949507 P r p i / h er nini t b l oc k >= 5 yr$ 2,121.00 360 49520 26 Rerepair ing hernia, reduce $2, 277.459694952026 M i d l e v e lR ere p ai r in g h er nia, re d u ce$ 1,935.85 969 49520 Rerepair ing hernia, reduce $2, 277.453604952126 M i d l e v e lR ere p ai r in g h er nia, b l oc k e d$ 2,200.00 969 49521 26 Rerepair ing hernia, blocked $2, 588.2596949521 R ere p ai r in g h er nia, b l oc k e d$ 2,588.25 360 49525 26 Repair ing hernia, sliding $2, 066.409694952526 M i d l e v e lR e p ai r in g h er nia, s l i d in g$ 1,756.45 969 49525 Repair ing hernia, sliding $2, 066.403604954026 R e p ai r l u mba r h er nia$ 2,423.40 969 49540 26 Midlevel Repair lumbar hernia $2, 059.9096949540 R e p ai r l u mba r h er nia$ 2,423.40 360 49550 26 Midlevel Rpr rem hernia, init, reduce $1, 764.459694955026 Rp rre mh er nia, ini t, re d u ce$ 2,075.85 969 49550 Rpr rem hernia, init, reduce $2, 075.853604955326 Rp r f e mh er nia, ini t b l oc k e d$ 2,276.40 969 49553 26 Midlevel Rpr fem hernia, init blocked $1, 934.9596949553 Rp r f e mh er nia, ini t b l oc k e d$ 2,276.40 360 49555 26 Midlevel Rerepair fem hernia, reduce $1, 835.859694955526 R ere p ai r f e mh er nia, re d u ce$ 2,159.85 969 49555 Rerepair fem hernia, reduce $2, 159.853604955726 M i d l e v e lR ere p ai r f e mh er nia, b l oc k e d$ 2,216.95 969 49557 26 Rerepair fem hernia, blocked $2, 608.2096949557 R ere p ai r f e mh er nia, b l oc k e d$ 2,608.20 360 49560 26 Midlevel Rpr ventral hern init, reduc $2, 259.809694956026 Rp r v e n t r a l h er nini t, re d u c$ 2,658.60 969 49560 Rpr ventral hern init, reduc $2, 658.603604956126 M i d l e v e lRp r v e n t r a l h er nini t, b l oc k$ 2,851.55 969 49561 26 Rpr ventral hern init, block $3, 354.7596949561 Rp r v e n t r a l h er nini t b l oc k$ 3,354.75 360 49565 26 Midlevel Rerepair ventrl hern, reduce $2, 356.209694956526 R ere p ai r v e n t r l h er n, re d u ce$ 2,772.00 969 49565 Rerepair ventrl hern, reduce $2, 772.003604956626 M i d l e v e lR ere p ai r v e n t r l h er n, b l oc k$ 2,883.65 969 49566 26 Rerepair ventrl hern, block $3, 392.5596949566 R ere p ai r v e n t r l h er n, b l oc k$ 3,392.55 360 49568 26 Hernia repair w/mesh $969.159694956826 M i d l e v e l Her nia re p ai r w / m es h$ 823.80 969 49568 Hernia repair w/mesh $969.153604957026 M i d l e v e lRp re p i g a s t r i c h er n, re d u ce$ 1,275.40 969 49570 26 Rpr epigastric hern, reduce $1, 500.4596949570 Rp re p i g a s t r i c h er n, re d u ce$ 1,500.45 360 49572 26 Midlevel Rpr epigastric hern, blocked $1, 576.159694957226 Rp re p i g a s t r i c h er n, b l oc k e d$ 1,854.30 969 49572 Rpr epigastric hern, blocked $1, 854.303604958026 Rp r u mbi l h er n, re d u c < 5 yr$ 1,194.90 969 49580 26 Midlevel Rpr umbil hern, reduc < 5 yr $1, 015.6596949580 Rp r u mbi l h er n, re d u c < 5 yr$ 1,194.90 360 49582 26 Midlevel Rpr umbil hern, block < 5 yr $1, 475.309694958226 Rp r u mbi l h er n, b l oc k < 5 yr$ 1,735.65 969 49582 Rpr umbil hern, block < 5 yr $1, 735.653604958526 M i d l e v e lRp r u mbi l h er n, re d u c > 5 yr$ 1,361.05 969 49585 26 Rpr umbil hern, reduc > 5 yr $1, 601.2596949585 Rp r u mbi l h er n re d u c >= 5 yr$ 1,601.25 360 49587 26 Midlevel Rpr umbil hern, block > 5 yr $1,461.90 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 164 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 49587 26 Rpr umbil hern, block > 5 yr $1, 719.9096949587 Rp r u mbi l h er nb l oc k >= 5 yrs$ 1,719.90 360 49590 26 Midlevel Repair spigelian hernia $1, 752.009694959026 R e p ai rs p i g e l ianh er nia$ 2,061.15 969 49590 Repair spigelian hernia $2, 061.153604959126 RPR AA H ERN I A 1 ST < 3 CMRE D U C I B L E$ 999.93 960 49593 26 RPR AA HERNIA 1ST 3-10 CM REDUCIBLE $1, 637.679604960026 M i d l e v e lR e p ai r u mbi l i c a ll es i o n$ 2,244.65 969 49600 26 Repair umbilical lesion $2, 640.7596949600 R e p ai r u mbi l i c a ll es i o n$ 2,640.75 360 49605 26 Midlevel Repair umbilical lesion $15, 204.659694960526 R e p ai r u mbi l i c a ll es i o n$ 17,887.80 969 49605 Repair umbilical lesion $17, 887.803604960626 R e p ai r u mbi l i c a ll es i o n$ 4,087.65 969 49606 26 Midlevel Repair umbilical lesion $3, 474.5096949606 R e p ai r u mbi l i c a ll es i o n$ 4,087.65 360 49610 26 Midlevel Repair umbilical lesion $2, 109.009694961026 R e p ai r u mbi l i c a ll es i o n$ 2,481.15 969 49610 Repair umbilical lesion $2, 481.153604961126 M i d l e v e lR e p ai r u mbi l i c a ll es i o n$ 1,676.10 969 49611 26 Repair umbilical lesion $1, 971.9096949611 R e p ai r u mbi l i c a ll es i o n$ 1,971.90 360 49650 26 Laparo hernia repair initial $1, 541.409694965026 M i d l e v e l L a p a ro h er nia re p ai r ini t ia l$ 1,310.20 969 49650 Laparo hernia repair initial $1, 541.403604965126 M i d l e v e l L a p a ro h er nia re p ai rrec u r$ 1,705.55 969 49651 26 Laparo hernia repair recur $2, 006.5596949651 L a p a ro h er nia re p ai rrec u r$ 2,006.55 360 49652 Lap vent/abd hernia repair $2, 485.3536049653 L a p v e n t / ab d h er n p rocco m p$ 3,104.85 360 49654 Lap inc hernia repair $2, 823.4536049655 L a p in c h er n re p ai rco m p$ 3,447.15 360 49656 Lap inc hernia repair recur $3, 052.3536049657 L a p in c h er n rec u rco m p$ 4,383.75 360 49659 Laparo proc, hernia repair $8, 977.353604990026 R e p ai ro f ab d o mina lw a ll$ 2,943.15 969 49900 26 Midlevel Repair of abdominal wall $2, 501.7096949900 R e p ai ro f ab d o mina lw a ll$ 2,943.15 360 49904 26 Omental flap, extra-abdom $5, 318.259694990426 M i d l e v e lO m e n t a l f l a p, e x t r a - ab d o m$ 4,520.50 969 49904 Omental flap, extra-abdom $5, 318.253604990526 M i d l e v e lO m e n t a l f l a p, I n t r a - ab d o m$ 1,086.15 969 49905 26 Omental flap, Intra-abdom $1, 277.8596949905 O m e n t a l f l a p, I n t r a - ab d o m$ 1,277.85 360 50020 26 RENAL ABSCESS OPEN DRAIN $3, 231.869755007526 M i d l e v e lR e m o v a l o f ki d n eys t o n e$ 4,541.05 969 50075 26 Removal of kidney stone $5, 342.4096950075 R e m o v a l o f ki d n eys t o n e$ 5,342.40 360 50080 26 Removal of kidney stone $3, 189.909695008026 M i d l e v e lR e m o v a l o f ki d n eys t o n e$ 2,711.40 969 50080 Removal of kidney stone ⇐2 cm $3, 189.903605008126 M i d l e v e lR e m o v a l o f ki d n eys t o n e$ 3,979.65 969 50081 26 Removal of kidney stone $4, 681.9596950081 R e m o v a l o f ki d n eys t o n e > 2 c m$ 4,681.95 360 50200 RENAL BIOPSY PERQ $463.653605038226 C han g e u re t ers t e n t, p erc u t$ 1,003.80 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 165 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 50382 26 Midlevel Change ureter stent, percut $853.2596950382 C han g e u re t ers t e n t, p erc u t$ 1,003.80 360 50384 26 Midlevel Remove ureter stent, percut $776.509695038426 R e m o v e u re t ers t e n t, p erc u t$ 913.50 969 50384 Remove ureter stent, percut $913.5036050385 C han g es t e n t v ia t r an s u re t h$ 855.75 360 50386 Remove stent via transureth $646.803605038726 M i d l e v e lC han g ee x t / in t u re t ers t e n t$ 308.80 969 50387 26 Change ext/int ureter stent $363.3096950387 C han g ee x t / in t u re t ers t e n t$ 363.30 360 50389 26 Midlevel Remove renal tube w/fluoro $169.609695038926 R e m o v ere na lt u b e w / f l u oro$ 199.50 969 50389 Remove renal tube w/fluoro $199.5036050390 Dr aina g eo f ki d n ey l es i o n$ 354.90 360 50391 Instll rx agnt into rnal tub $362.253605039526 C re a t e p a ss a g e t o ki d n ey$ 660.45 969 50395 26 Midlevel Create passage to kidney $561.4096950395 C re a t e p a ss a g e t o ki d n ey$ 660.45 360 50396 26 Midlevel Measure kidney pressure $363.259695039626 M e a s u re ki d n ey p ress u re$ 427.35 969 50396 Measure kidney pressure $427.3536050432 P L MTNEP H ROSTOM Y C A T H ETER$ 692.15 360 50432 26 PLMT NEPHROSTOMY CATH PRQ NEW $600.84 ACCESS RS&I 50433 PLMT NEPHROURETERAL CATHETER$ 3,391.35 360 50434 CONVERT NEPHROSTOMY CATHETER $3, 391.3536050435 EXC H A NGENEP H ROSTOM Y C A T H$ 3,391.35 360 50541 26 Midlevel Laparo ablate renal cyst $2, 864.959695054126 L a p a ro ab l a t ere na l cys t$ 3,370.50 969 50541 Laparo ablate renal cyst $3, 370.503605054226 M i d l e v e l L a p a ro ab l a t ere na l ma ss$ 3,633.35 969 50542 26 Laparo ablate renal mass $4, 274.5596950542 L a p a ro ab l a t ere na l ma ss$ 4,274.55 360 50590 26 LITHOTRIPSY XTRCORP SHOCK WAVE $1, 751.4096050590 TC L I T H OTR I PS Y XTRCORPS H OC K W A V E$ 6,643.16 360 50606 ENDOLUMINAL BX URTR RNL PLVS $323.903605061026 M i d l e v e lR e m o v a l o f u re t ers t o n e$ 2,941.70 969 50610 26 Removal of ureter stone $3, 460.8096950610 R e m o v a l o f u re t ers t o n e$ 3,460.80 360 50620 26 Midlevel Removal of ureter stone $2, 814.059695062026 R e m o v a l o f u re t ers t o n e$ 3,310.65 969 50620 Removal of ureter stone $3, 310.653605063026 R e m o v a l o f u re t ers t o n e$ 3,258.15 969 50630 26 Midlevel Removal of ureter stone $2, 769.4596950630 R e m o v a l o f u re t ers t o n e$ 3,258.15 360 50650 26 Removal of ureter $3, 793.659695065026 M i d l e v e lR e m o v a l o f u re t er$ 3,224.60 969 50650 Removal of ureter $3, 793.653605066026 M i d l e v e lR e m o v a l o f u re t er$ 3,553.95 969 50660 26 Removal of ureter $4, 181.1096950660 R e m o v a l o f u re t er$ 4,181.10 360 50684 26 Midlevel Injection for ureter x-ray $155.309695068426 I nj ec t i o n f or u re t er x - r a y$ 182.70 969 50684 Injection for ureter x-ray $182.7036050686 M e a s u re u re t er p ress u re$ 334.95 360 50688 26 Change of ureter tube/stent $291.90 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 166 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 50688 26 Midlevel Change of ureter tube/stent $248.1096950688 C han g eo f u re t er t u b e / s t e n t$ 291.90 360 50693 PLMT URETERAL STENT PRQ $5, 393.5036050694 P L MT U RETER A L STENTPRQ$ 5,393.50 360 50695 PLMT URETERAL STENT PRQ $5, 393.503605094726 M i d l e v e l L a p a ro n e w u re t er / b l a dd er$ 4,297.40 969 50947 26 Laparo new ureter/bladder $5, 055.7596950947 L a p a ro n e w u re t er / b l a dd er$ 5,055.75 360 50948 26 Midlevel Laparo new ureter/bladder $3, 974.309695094826 L a p a ro n e w u re t er / b l a dd er$ 4,675.65 969 50948 Laparo new ureter/bladder $4, 675.6536050949 L a p a rosco p e p roc, u re t er$ 8,977.35 360 50951 26 Midlevel Endoscopy of ureter $958.559695095126 E n d osco p yo f u re t er$ 1,127.70 969 50951 Endoscopy of ureter $1, 127.703605095326 E n d osco p yo f u re t er$ 1,247.40 969 50953 26 Midlevel Endoscopy of ureter $1, 060.3096950953 E n d osco p yo f u re t er$ 1,247.40 360 50955 26 Ureter endoscopy & biopsy $1,342.95 969 50955 26 Midlevel Ureter endoscopy & biopsy$ 1,141.50 969 50955 Ureter endoscopy & biopsy $1,342.95 360 50957 26 Midlevel Ureter endoscopy & treatment$ 1,104.90 969 50957 26 Ureter endoscopy & treatment $1,299.90 969 50957 Ureter endoscopy & treatment$ 1,299.90 360 50961 26 Midlevel Ureter endoscopy & treatment $991.55 969 50961 26 Ureter endoscopy & treatment$ 1,166.55 969 50961 Ureter endoscopy & treatment $1, 166.553605097026 M i d l e v e l U re t ere n d osco p y$ 1,156.70 969 50970 26 Ureter endoscopy $1, 360.80969 [R o w s 9001 - 10000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 50970 U re t ere n d osco p y$ 1,360.80 360 50972 26 Ureter endoscopy & catheter $1,315.65 969 50972 26 Midlevel Ureter endoscopy & catheter$ 1,118.30 969 50972 Ureter endoscopy & catheter $1,315.65 360 50974 26 Ureter endoscopy & biopsy$ 1,736.70 969 50974 26 Midlevel Ureter endoscopy & biopsy $1,476.20 969 50974 Ureter endoscopy & biopsy$ 1,736.70 360 50976 26 Ureter endoscopy & treatment $1,711.50 969 50976 26 Midlevel Ureter endoscopy & treatment$ 1,454.80 969 50976 Ureter endoscopy & treatment $1,711.50 360 50980 26 Midlevel Ureter endoscopy & treatment$ 1,112.05 969 50980 26 Ureter endoscopy & treatment $1,308.30 969 50980 Ureter endoscopy & treatment$ 1,308.30 360 51020 26 Incise & treat bladder $1,722.00 969 51020 26 Midlevel Incise & treat bladder$ 1,463.70 969 51020 Incise & treat bladder $1,722.00 360 51030 26 Midlevel Incise & treat bladder$ 1,445.85 969 51030 26 Incise & treat bladder $1,701.00 969 51030 Incise & treat bladder$ 1,701.00 360 51040 26 Incise & drain bladder $1,063.65 969 51040 26 Midlevel Incise & drain bladder$ 904.10 969 51040 Incise & drain bladder $1,063.65 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 167 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 51045 26 Incise bladder/drain ureter $1, 794.459695104526 M i d l e v e l I n c i se b l a dd er / d r ain u re t er$ 1,525.30 969 51045 Incise bladder/drain ureter $1, 794.453605105026 M i d l e v e lR e m o v a l o f b l a dd ers t o n e$ 1,472.65 969 51050 26 Removal of bladder stone $1, 732.5096951050 R e m o v a l o f b l a dd ers t o n e$ 1,732.50 360 51060 26 Removal of ureter stone $2, 131.509695106026 M i d l e v e lR e m o v a l o f u re t ers t o n e$ 1,811.80 969 51060 Removal of ureter stone $2, 131.503605106526 M i d l e v e lR e m o v e u re t erc a l c u l u s$ 1,801.95 969 51065 26 Remove ureter calculus $2, 119.9596951065 R e m o v e u re t erc a l c u l u s$ 2,119.95 360 51080 26 Drainage of bladder abscess $1, 494.159695108026 M i d l e v e l Dr aina g eo f b l a dd er ab scess$ 1,270.05 969 51080 Drainage of bladder abscess $1, 494.1536051100 Dr ainb l a dd er b y n ee d l e$ 142.80 360 51101 Drain bladder by trocar/cath $193.2036051102 Dr ainb lw / c a t hin ser t i o n$ 536.55 360 51500 26 Removal of bladder cyst $2, 454.909695150026 M i d l e v e lR e m o v a l o f b l a dd ercys t$ 2,086.65 969 51500 Removal of bladder cyst $2, 454.903605152026 R e m o v a l o f b l a dd er l es i o n$ 2,166.15 969 51520 26 Midlevel Removal of bladder lesion $1, 841.2596951520 R e m o v a l o f b l a dd er l es i o n$ 2,166.15 360 51600 INJ FOR CYSTOGRAM $93.803605170026 I rr i g a t i o n o f b l a dd er$ 161.70 969 51700 26 Midlevel Irrigation of bladder $137.4596951700 I rr i g a t i o n o f b l a dd er$ 161.70 360 51701 26 Insert bladder catheter $99.759835170126 M i d l e v e l I n ser t b l a dd erc a t h e t er$ 84.80 969 51701 Insert bladder catheter $99.755105170226 I n ser tt e m p b l a dd erc a t h$ 110.25 983 51702 26 Midlevel Insert temp bladder cath $93.7096951702 I n ser tt e m p b l a dd erc a t h$ 110.25 510 51703 26 Insert bladder cath, complex $298.209695170326 M i d l e v e l I n ser t b l a dd erc a t h, co m pl e x$ 253.45 969 51703 Insert bladder cath, complex $298.203605170526 M i d l e v e lC han g eo f b l a dd er t u b e$ 158.85 969 51705 26 Change of bladder tube $186.9096951705 C han g eo f b l a dd er t u b e$ 186.90 360 51710 26 Midlevel Change of bladder tube $242.759695171026 C han g eo f b l a dd er t u b e$ 285.60 969 51710 Change of bladder tube $285.603605171526 E n d osco p i c inj ec t i o n / im pl an t$ 733.95 969 51715 26 Midlevel Endoscopic injection/implant $623.8596951715 E n d osco p i c inj ec t i o n / im pl an t$ 733.95 360 51720 Treatment of bladder lesion $254.2536051860 R e p ai ro f b l a dd er w o u n d$ 2,484.45 360 52000 26 Cystoscopy $463.059695200026 M i d l e v e lC ys t osco p y$ 393.60 969 52000 Cystoscopy $463.053605200126 M i d l e v e lC ys t osco p y, re m o v a l o f c l o t s$ 896.05 969 52001 26 Cystoscopy, removal of clots $1, 054.2096952001 C ys t osco p y, re m o v a l o f c l o t s$ 1,054.20 360 52005 26 Cystoscopy & ureter catheter $488.25 969 52005 26 Midlevel Cystoscopy & ureter catheter$ 415.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 168 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 52005 Cystoscopy & ureter catheter $488.253605200726 C ys t osco p y an d bi o p sy$ 609.00 969 52007 26 Midlevel Cystoscopy and biopsy $517.6596952007 C ys t osco p y an d bi o p sy$ 609.00 360 52010 26 Cystoscopy & duct catheter $603.75 969 52010 26 Midlevel Cystoscopy & duct catheter$ 513.20 969 52010 Cystoscopy & duct catheter $603.753605220426 M i d l e v e lC ys t osco p y w / bi o p sy (s)$ 441.80 969 52204 26 Cystoscopy w/biopsy(s) $519.7596952204 C ys t osco p y w / bi o p sy (s)$ 519.75 360 52214 26 Midlevel Cystoscopy and treatment $631.909695221426 C ys t osco p y an d t re a t m e n t$ 743.40 969 52214 Cystoscopy and treatment $743.403605222426 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 528.35 969 52224 26 Cystoscopy and treatment $621.6096952224 C ys t osco p y an d t re a t m e n t < 0.5 c m$ 621.60 360 52234 26 Cystoscopy and treatment $903.009695223426 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 767.55 969 52234 Cystoscopy and treatment 0.5-2 cm $903.003605223526 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 900.55 969 52235 26 Cystoscopy and treatment $1, 059.4596952235 C Y STO W F UL GB L A DD RT U MOR (S); 2.0 -$ 1,059.45 360 5.0CM 52240 26 Cystoscopy and treatment $1, 850.109695224026 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 1,572.60 969 52240 Cystoscopy and treatment $1, 850.103605225026 M i d l e v e lC ys t osco p y an d r a d i o t r a cer$ 756.85 969 52250 26 Cystoscopy and radiotracer $890.4096952250 C ys t osco p y an d r a d i o t r a cer$ 890.40 360 52260 26 Cystoscopy and treatment $771.759695226026 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 656.00 969 52260 Cystoscopy and treatment $771.753605226526 C ys t osco p y an d t re a t m e n t$ 601.65 969 52265 26 Midlevel Cystoscopy and treatment $511.4096952265 C ys t osco p y an d t re a t m e n t$ 601.65 360 52270 26 Cystoscopy & revise urethra $667.80 969 52270 26 Midlevel Cystoscopy & revise urethra$ 567.65 969 52270 Cystoscopy & revise urethra $667.80 360 52275 26 Midlevel Cystoscopy & revise urethra$ 774.70 969 52275 26 Cystoscopy & revise urethra $911.40 969 52275 Cystoscopy & revise urethra$ 911.40 360 52276 26 Midlevel Cystoscopy and treatment $830.059695227626 C ys t osco p y an d t re a t m e n t$ 976.50 969 52276 Cystoscopy and treatment $976.503605227726 C ys t osco p y an d t re a t m e n t$ 1,195.95 969 52277 26 Midlevel Cystoscopy and treatment $1, 016.5596952277 C ys t osco p y an d t re a t m e n t$ 1,195.95 360 52281 26 Cystoscopy and treatment $561.759695228126 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 477.50 969 52281 Cystoscopy and treatment $561.753605228226 C ys t osco p y, im pl an t s t e n t$ 1,241.10 969 52282 26 Midlevel Cystoscopy, implant stent $1, 054.9596952282 C ys t osco p y, im pl an t s t e n t$ 1,241.10 360 52283 26 Midlevel Cystoscopy and treatment $627.459695228326 C ys t osco p y an d t re a t m e n t$ 738.15 969 52283 Cystoscopy and treatment $738.153605228526 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 612.25 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 169 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 52285 26 Cystoscopy and treatment $720.3096952285 C ys t osco p y an d t re a t m e n t$ 720.30 360 52287 CYSTOSCOPY CHEMODENERVATION $534.903605229026 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 762.20 969 52290 26 Cystoscopy and treatment $896.7096952290 C ys t osco p y an d t re a t m e n t$ 896.70 360 52300 26 Cystoscopy and treatment $1, 045.809695230026 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 888.95 969 52300 Cystoscopy and treatment $1, 045.803605230126 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 913.90 969 52301 26 Cystoscopy and treatment $1, 075.2096952301 C ys t osco p y an d t re a t m e n t$ 1,075.20 360 52305 26 Midlevel Cystoscopy and treatment $871.109695230526 C ys t osco p y an d t re a t m e n t$ 1,024.80 969 52305 Cystoscopy and treatment $1, 024.803605231026 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 473.90 969 52310 26 Cystoscopy and treatment $557.5596952310 C ys t osco p y an d t re a t m e n t$ 557.55 360 52315 26 Midlevel Cystoscopy and treatment $855.909695231526 C ys t osco p y an d t re a t m e n t$ 1,006.95 969 52315 Cystoscopy and treatment $1, 006.953605231726 M i d l e v e lR e m o v e b l a dd ers t o n e$ 1,084.40 969 52317 26 Remove bladder stone $1, 275.7596952317 R e m o v e b l a dd ers t o n e < 2.5 c m$ 1,275.75 360 52318 26 Midlevel Remove bladder stone $1, 478.009695231826 R e m o v e b l a dd ers t o n e$ 1,738.80 969 52318 Remove bladder stone >2.5 cm $1, 738.803605232026 C ys t osco p y an d t re a t m e n t$ 904.05 969 52320 26 Midlevel Cystoscopy and treatment $768.4596952320 C ys t osco p y an d t re a t m e n t$ 904.05 360 52325 26 Cystoscopy, stone removal $1, 179.159695232526 M i d l e v e lC ys t osco p y, s t o n ere m o v a l$ 1,002.30 969 52325 Cystoscopy, stone removal $1, 179.153605232726 M i d l e v e lC ys t osco p y, inj ec t ma t er ia l$ 820.20 969 52327 26 Cystoscopy, inject material $964.9596952327 C ys t osco p y, inj ec t ma t er ia l$ 964.95 360 52330 26 Midlevel Cystoscopy and treatment $823.809695233026 C ys t osco p y an d t re a t m e n t$ 969.15 969 52330 Cystoscopy and treatment $969.153605233226 M i d l e v e lC ys t osco p y an d t re a t m e n t$ 485.50 969 52332 26 Cystoscopy and treatment $571.2096952332 C ys t osco p y an d t re a t m e n t$ 571.20 360 52334 26 Midlevel Create passage to kidney $801.459695233426 C re a t e p a ss a g e t o ki d n ey$ 942.90 969 52334 Create passage to kidney $942.903605234126 C ys t o w / u re t ers t r i c t u re t x$ 1,062.60 969 52341 26 Midlevel Cysto w/ureter stricture tx $903.2096952341 C ys t o w / u re t ers t r i c t u re t x$ 1,062.60 360 52342 26 Midlevel Cysto w/up stricture tx $980.859695234226 C ys t o w / u p s t r i c t u re t x$ 1,153.95 969 52342 Cysto w/up stricture tx $1, 153.953605234326 M i d l e v e lC ys t o w / re na l s t r i c t u re t x$ 1,092.40 969 52343 26 Cysto w/renal stricture tx $1, 285.2096952343 C ys t o w / re na l s t r i c t u re t x$ 1,285.20 360 52344 26 Cysto/uretero, stricture tx $1, 396.509695234426 M i d l e v e lC ys t o / u re t ero, s t r i c t u re t x$ 1,187.05 969 52344 Cysto/uretero, stricture tx $1,396.50 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 170 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 52345 26 Cysto/uretero w/up stricture $1, 488.909695234526 M i d l e v e lC ys t o / u re t ero w / u p s t r i c t u re$ 1,265.55 969 52345 Cysto/uretero w/up stricture $1, 488.903605234626 M i d l e v e lC ys t o u re t ero w / re na l s t r i c t$ 1,430.70 969 52346 26 Cystouretero w/renal strict $1, 683.1596952346 C ys t o u re t ero w / re na l s t r i c t$ 1,683.15 360 52351 26 Midlevel Cystouretero & or pyeloscope $979.95 969 52351 26 Cystouretero & or pyeloscope$ 1,152.90 969 52351 Cystouretero & or pyeloscope $1, 152.903605235226 C ys t o u re t ero w / s t o n ere m o v e$ 1,354.50 969 52352 26 Midlevel Cystouretero w/stone remove $1, 151.3596952352 C ys t o u re t ero w / s t o n ere m o v e$ 1,354.50 360 52353 26 Midlevel Cystouretero w/lithotripsy $1, 320.909695235326 C ys t o u re t ero w / l i t h o t r i p sy$ 1,554.00 969 52353 Cystouretero w/lithotripsy $1, 554.003605235426 M i d l e v e lC ys t o u re t ero w / bi o p sy$ 1,222.75 969 52354 26 Cystouretero w/biopsy $1, 438.5096952354 C ys t o u re t ero w / bi o p sy$ 1,438.50 360 52355 26 Midlevel Cystouretero w/excise tumor $1, 456.559695235526 C ys t o u re t ero w / e x c i se t u m or$ 1,713.60 969 52355 Cystouretero w/excise tumor $1, 713.603605240026 C ys t o u re t ero w / co n g e n re p r$ 1,756.65 969 52400 26 Midlevel Cystouretero w/congen repr $1, 493.1596952400 C ys t o u re t ero w / co n g e n re p r$ 1,756.65 360 52402 26 Cystourethro cut ejacul duct $978.609695240226 M i d l e v e lC ys t o u re t h roc u t e ja c u l d u c t$ 831.80 969 52402 Cystourethro cut ejacul duct $978.603605245026 M i d l e v e l I n c i s i o n o f p ros t a t e$ 1,463.70 969 52450 26 Incision of prostate $1, 722.0096952450 I n c i s i o n o f p ros t a t e$ 1,722.00 360 52500 26 Midlevel Revision of bladder neck $1, 521.709695250026 R e v i s i o n o f b l a dd er n ec k$ 1,790.25 969 52500 Revision of bladder neck $1, 790.253605260126 M i d l e v e lP ros t a t ec t o m y (T U RP)$ 2,618.60 969 52601 26 Prostatectomy (TURP) $3, 080.7096952601 P ros t a t ec t o m y (T U RP)$ 3,080.70 360 52630 26 Midlevel Remove prostate regrowth $1, 248.609695263026 R e m o v e p ros t a t ere g ro wt h$ 1,468.95 969 52630 Remove prostate regrowth $1, 468.953605264026 R e l i e v e b l a dd erco n t r a c t u re$ 1,140.30 969 52640 26 Midlevel Relieve bladder contracture $969.2596952640 R e l i e v e b l a dd erco n t r a c t u re$ 1,140.30 360 52647 26 Midlevel Laser surgery of prostate $2, 015.259695264726 L a sers u r g eryo f p ros t a t e$ 2,370.90 969 52647 Laser surgery of prostate $2, 370.903605264826 M i d l e v e l L a sers u r g eryo f p ros t a t e$ 2,150.95 969 52648 26 Laser surgery of prostate $2, 530.5096952648 L a sers u r g eryo f p ros t a t e$ 2,530.50 360 52649 Prostate laser enucleation $3, 056.553605270026 M i d l e v e l Dr aina g eo f p ros t a t e ab scess$ 1,379.80 969 52700 26 Drainage of prostate abscess $1, 623.3096952700 Dr aina g eo f p ros t a t e ab scess$ 1,623.30 360 53000 26 Midlevel Incision of urethra $464.109695300026 I n c i s i o n o f u re t h r a$ 546.00 969 53000 Incision of urethra $546.003605301026 M i d l e v e l I n c i s i o n o f u re t h r a$ 918.40 969 53010 26 Incision of urethra $1,080.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 171 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 53010 Incision of urethra $1, 080.453605302026 M i d l e v e l I n c i s i o n o f u re t h r a$ 302.55 969 53020 26 Incision of urethra $355.9596953020 I n c i s i o n o f u re t h r a$ 355.95 360 53025 26 Incision of urethra $248.859695302526 M i d l e v e l I n c i s i o n o f u re t h r a$ 211.50 969 53025 Incision of urethra $248.853605304026 Dr aina g eo f u re t h r aab scess$ 1,437.45 969 53040 26 Midlevel Drainage of urethra abscess $1, 221.8596953040 Dr aina g eo f u re t h r aab scess$ 1,437.45 360 53060 26 Drainage of urethra abscess $617.409695306026 M i d l e v e l Dr aina g eo f u re t h r aab scess$ 524.80 969 53060 Drainage of urethra abscess $617.403605308026 Dr aina g eo f u r ina ry l e aka g e$ 1,555.05 969 53080 26 Midlevel Drainage of urinary leakage $1, 321.8096953080 Dr aina g eo f u r ina ry l e aka g e$ 1,555.05 360 53085 26 Midlevel Drainage of urinary leakage $2, 026.859695308526 Dr aina g eo f u r ina ry l e aka g e$ 2,384.55 969 53085 Drainage of urinary leakage $2, 384.553605320026 B i o p syo f u re t h r a$ 519.75 969 53200 26 Midlevel Biopsy of urethra $441.8096953200 B i o p syo f u re t h r a$ 519.75 360 53210 26 Removal of urethra $2, 836.059695321026 M i d l e v e lR e m o v a l o f u re t h r a$ 2,410.65 969 53210 Removal of urethra $2, 836.053605321526 R e m o v a l o f u re t h r a$ 3,400.95 969 53215 26 Midlevel Removal of urethra $2, 890.8096953215 R e m o v a l o f u re t h r a$ 3,400.95 360 53220 26 Midlevel Treatment of urethra lesion $1, 419.109695322026 T re a t m e n t o f u re t h r a l es i o n$ 1,669.50 969 53220 Treatment of urethra lesion $1, 669.503605323026 R e m o v a l o f u re t h r a l es i o n$ 2,237.55 969 53230 26 Midlevel Removal of urethra lesion $1, 901.9096953230 R e m o v a l o f u re t h r a l es i o n$ 2,237.55 360 53235 26 Removal of urethra lesion $2, 322.609695323526 M i d l e v e lR e m o v a l o f u re t h r a l es i o n$ 1,974.20 969 53235 Removal of urethra lesion $2, 322.603605324026 S u r g ery f or u re t h r a p o u c h$ 1,560.30 969 53240 26 Midlevel Surgery for urethra pouch $1, 326.2596953240 S u r g ery f or u re t h r a p o u c h$ 1,560.30 360 53250 26 Midlevel Removal of urethra gland $1, 318.209695325026 R e m o v a l o f u re t h r a g l an d$ 1,550.85 969 53250 Removal of urethra gland $1, 550.853605326026 M i d l e v e lT re a t m e n t o f u re t h r a l es i o n$ 564.05 969 53260 26 Treatment of urethra lesion $663.6096953260 T re a t m e n t o f u re t h r a l es i o n$ 663.60 360 53265 26 Midlevel Treatment of urethra lesion $580.159695326526 T re a t m e n t o f u re t h r a l es i o n$ 682.50 969 53265 Treatment of urethra lesion $682.503605327026 R e m o v a l o f u re t h r a g l an d$ 694.05 969 53270 26 Midlevel Removal of urethra gland $589.9596953270 R e m o v a l o f u re t h r a g l an d$ 694.05 360 53275 26 Midlevel Repair of urethra defect $820.209695327526 R e p ai ro f u re t h r a d e f ec t$ 964.95 969 53275 Repair of urethra defect $964.953605340026 R e v i se u re t h r a, s t a g e 1$ 2,946.30 969 53400 26 Midlevel Revise urethra, stage 1 $2,504.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 172 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 53400 Revise urethra, stage 1 $2, 946.303605340526 R e v i se u re t h r a, s t a g e 2$ 3,204.60 969 53405 26 Midlevel Revise urethra, stage 2 $2, 723.9096953405 R e v i se u re t h r a, s t a g e 2$ 3,204.60 360 53410 26 Midlevel Reconstruction of urethra $3, 046.109695341026 R eco n s t r u c t i o n o f u re t h r a$ 3,583.65 969 53410 Reconstruction of urethra $3, 583.653605341526 M i d l e v e lR eco n s t r u c t i o n o f u re t h r a$ 3,523.60 969 53415 26 Reconstruction of urethra $4, 145.4096953415 R eco n s t r u c t i o n o f u re t h r a$ 4,145.40 360 53420 26 Midlevel Reconstruct urethra, stage 1 $2, 586.459695342026 R eco n s t r u c t u re t h r a, s t a g e 1$ 3,042.90 969 53420 Reconstruct urethra, stage 1 $3, 042.903605342526 R eco n s t r u c t u re t h r a, s t a g e 2$ 3,437.70 969 53425 26 Midlevel Reconstruct urethra, stage 2 $2, 922.0596953425 R eco n s t r u c t u re t h r a, s t a g e 2$ 3,437.70 360 53430 26 Midlevel Reconstruction of urethra $3, 012.209695343026 R eco n s t r u c t i o n o f u re t h r a$ 3,543.75 969 53430 Reconstruction of urethra $3, 543.753605343126 R eco n s t r u c t u re t h r a / b l a dd er$ 4,224.15 969 53431 26 Midlevel Reconstruct urethra/bladder $3, 590.5596953431 R eco n s t r u c t u re t h r a / b l a dd er$ 4,224.15 360 53440 26 Midlevel Male sling procedure $2, 387.459695344026 M a l es l in g p roce d u re$ 2,808.75 969 53440 Male sling procedure $2, 808.753605344226 M i d l e v e lR e m o v e / re v i se ma l es l in g$ 2,432.95 969 53442 26 Remove/revise male sling $2, 862.3096953442 R e m o v e / re v i se ma l es l in g$ 2,862.30 360 53444 26 Insert tandem cuff $2, 907.459695344426 M i d l e v e l I n ser tt an d e m c u ff$ 2,471.35 969 53444 Insert tandem cuff $2, 907.453605344526 M i d l e v e l I n ser t u ro / v es n c k s p hin c t er$ 2,383.85 969 53445 26 Insert uro/ves nck sphincter $2, 804.5596953445 I n ser t u ro / v es n c k s p hin c t er$ 2,804.55 360 53446 26 Remove uro sphincter $2, 358.309695344626 M i d l e v e lR e m o v e u ros p hin c t er$ 2,004.55 969 53446 Remove uro sphincter $2, 358.303605344726 R e m o v e / re pl a ce u rs p hin c t er$ 2,968.35 969 53447 26 Midlevel Remove/replace ur sphincter $2, 523.1096953447 R e m o v e / re pl a ce u rs p hin c t er$ 2,968.35 360 53448 26 Midlevel Remov/replc ur sphinctr comp $3, 986.809695344826 R e m o v / re pl c u rs p hin c t rco m p$ 4,690.35 969 53448 Remov/replc ur sphinctr comp $4, 690.353605344926 R e p ai r u ros p hin c t er$ 2,245.95 969 53449 26 Midlevel Repair uro sphincter $1, 909.0596953449 R e p ai r u ros p hin c t er$ 2,245.95 360 53450 26 Midlevel Revision of urethra $1, 274.509695345026 R e v i s i o n o f u re t h r a$ 1,499.40 969 53450 Revision of urethra $1, 499.403605346026 R e v i s i o n o f u re t h r a$ 1,676.85 969 53460 26 Midlevel Revision of urethra $1, 425.3096953460 R e v i s i o n o f u re t h r a$ 1,676.85 360 53500 26 Urethrlys, transvag w/ scope $2, 759.409695350026 M i d l e v e l U re t h r l ys, t r an s v a g w / sco p e$ 2,345.50 969 53500 Urethrlys, transvag w/ scope $2, 759.403605350226 M i d l e v e lR e p ai ro f u re t h r ainj u ry$ 1,512.80 969 53502 26 Repair of urethra injury $1,779.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 173 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 53502 Repair of urethra injury $1, 779.753605350526 M i d l e v e lR e p ai ro f u re t h r ainj u ry$ 1,515.45 969 53505 26 Repair of urethra injury $1, 782.9096953505 R e p ai ro f u re t h r ainj u ry$ 1,782.90 360 53510 26 Midlevel Repair of urethra injury $1, 967.059695351026 R e p ai ro f u re t h r ainj u ry$ 2,314.20 969 53510 Repair of urethra injury $2, 314.203605351526 M i d l e v e lR e p ai ro f u re t h r ainj u ry$ 2,474.00 969 53515 26 Repair of urethra injury $2, 910.6096953515 R e p ai ro f u re t h r ainj u ry$ 2,910.60 360 53520 26 Repair of urethra defect $2, 039.109695352026 M i d l e v e lR e p ai ro f u re t h r a d e f ec t$ 1,733.25 969 53520 Repair of urethra defect $2, 039.103605360026 M i d l e v e l D i l a t e u re t h r a s t r i c t u re$ 199.05 969 53600 26 Dilate urethra stricture $234.1596953600 D i l a t e u re t h r a s t r i c t u re$ 234.15 360 53601 26 Dilate urethra stricture $194.259695360126 M i d l e v e l D i l a t e u re t h r a s t r i c t u re$ 165.10 969 53601 Dilate urethra stricture $194.253605360526 D i l a t e u re t h r a s t r i c t u re$ 235.20 969 53605 26 Midlevel Dilate urethra stricture $199.9096953605 D i l a t e u re t h r a s t r i c t u re$ 235.20 360 53620 26 Dilate urethra stricture $320.259695362026 M i d l e v e l D i l a t e u re t h r a s t r i c t u re$ 272.20 969 53620 Dilate urethra stricture $320.253605362126 M i d l e v e l D i l a t e u re t h r a s t r i c t u re$ 224.00 969 53621 26 Dilate urethra stricture $263.5596953621 D i l a t e u re t h r a s t r i c t u re$ 263.55 360 53660 26 Midlevel Dilation of urethra $129.409695366026 D i l a t i o n o f u re t h r a$ 152.25 969 53660 Dilation of urethra $152.253605366126 M i d l e v e l D i l a t i o n o f u re t h r a$ 125.85 969 53661 26 Dilation of urethra $148.0596953661 D i l a t i o n o f u re t h r a$ 148.05 360 53665 26 Midlevel Dilation of urethra $119.609695366526 D i l a t i o n o f u re t h r a$ 140.70 969 53665 Dilation of urethra $140.703605385026 P ros t a t i c mi cro w a v e t h er m o t x$ 2,083.20 969 53850 26 Midlevel Prostatic microwave thermotx $1, 770.7096953850 P ros t a t i c mi cro w a v e t h er m o t x$ 2,083.20 360 53852 26 Prostatic rf thermotx $2, 280.609695385226 M i d l e v e lP ros t a t i cr f t h er m o t x$ 1,938.50 969 53852 Prostatic rf thermotx $2, 280.6036053855 I n ser tp ros t u re t h r a l s t e n t$ 296.10 360 53860 Transurethral rf treatment $851.5536053899 U ro l o g ys u r g ery p roce d u re$ 459.05 360 54000 26 Slitting of prepuce $394.809695400026 M i d l e v e lSl i tt in g o f p re p u ce$ 335.60 969 54000 Slitting of prepuce $394.803605400126 Sl i tt in g o f p re p u ce$ 509.25 969 54001 26 Midlevel Slitting of prepuce $432.8596954001 Sl i tt in g o f p re p u ce$ 509.25 360 54015 26 Midlevel Drain penis lesion $959.459695401526 Dr ain p e ni s l es i o n$ 1,128.75 969 54015 Drain penis lesion $1, 128.753605405026 M i d l e v e l Des t r u c t i o n, p e ni s l es i o n (s)$ 324.00 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 174 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 54050 26 Destruction, penis lesion(s) $381.1596954050 Des t r u c t i o n, p e ni s l es i o n (s)$ 381.15 360 54055 26 Midlevel Destruction, penis lesion(s) $286.509695405526 Des t r u c t i o n, p e ni s l es i o n (s)$ 337.05 969 54055 Destruction, penis lesion(s) $337.053605405626 M i d l e v e lC ryos u r g ery, p e ni s l es i o n (s)$ 345.40 969 54056 26 Cryosurgery, penis lesion(s) $406.3596954056 C ryos u r g ery, p e ni s l es i o n (s)$ 406.35 360 54057 26 Midlevel Laser surg, penis lesion(s) $292.759695405726 L a sers u r g, p e ni s l es i o n (s)$ 344.40 969 54057 Laser surg, penis lesion(s) $344.403605406026 E x c i s i o n o f p e ni s l es i o n (s)$ 478.80 969 54060 26 Midlevel Excision of penis lesion(s) $407.0096954060 E x c i s i o n o f p e ni s l es i o n (s)$ 478.80 360 54065 26 Midlevel Destruction, penis lesion(s) $535.509695406526 Des t r u c t i o n, p e ni s l es i o n (s)$ 630.00 969 54065 Destruction, penis lesion(s) $630.003605410026 M i d l e v e lB i o p syo f p e ni s$ 393.60 969 54100 26 Biopsy of penis $463.0596954100 B i o p syo f p e ni s$ 463.05 360 54105 26 Midlevel Biopsy of penis $664.009695410526 B i o p syo f p e ni s$ 781.20 969 54105 Biopsy of penis $781.203605411026 M i d l e v e lT re a t m e n t o f p e ni s l es i o n$ 1,943.85 969 54110 26 Treatment of penis lesion $2, 286.9096954110 T re a t m e n t o f p e ni s l es i o n$ 2,286.90 360 54150 26 Circumcision w/regionl block $361.209695415026 M i d l e v e lC i rc u m c i s i o n w / re g i o n l b l oc k$ 307.00 969 54150 Circumcision w/regionl block $361.207235416026 M i d l e v e lC i rc u m c i s i o n, n eo na t e$ 448.05 969 54160 26 Circumcision, neonate $527.1096954160 C i rc u m c i s i o n, n eo na t e <= 28 d a ys$ 527.10 360 54161 26 Midlevel Circum 28 days or older $614.959695416126 C i rc u m 28 d a ysoro l d er$ 723.45 969 54161 Circum older than 28 days $723.453605416226 L ys i s p e ni l c i rc u mi c l es i o n$ 728.70 969 54162 26 Midlevel Lysis penil circumic lesion $619.4096954162 L ys i s p e ni l c i rc u mi c l es i o n$ 728.70 360 54163 26 Repair of circumcision $804.309695416326 M i d l e v e lR e p ai ro f c i rc u m c i s i o n$ 683.65 969 54163 Repair of circumcision $804.3036054300 RE V I S I ONOFPEN I S$ - 360 54308 26 Reconstruction of urethra $2, 700.609695430826 M i d l e v e lR eco n s t r u c t i o n o f u re t h r a$ 2,295.50 969 54308 Reconstruction of urethra <3 cm $2, 700.603605431226 M i d l e v e lR eco n s t r u c t i o n o f u re t h r a$ 2,557.90 969 54312 26 Reconstruction of urethra $3, 009.3096954312 R eco n s t r u c t i o n o f u re t h r a > 3 c m$ 3,009.30 360 54316 26 Midlevel Reconstruction of urethra $3, 199.609695431626 R eco n s t r u c t i o n o f u re t h r a$ 3,764.25 969 54316 Reconstruction of urethra $3, 764.253605431826 R eco n s t r u c t i o n o f u re t h r a$ 2,571.45 969 54318 26 Midlevel Reconstruction of urethra $2, 185.7596954318 R eco n s t r u c t i o n o f u re t h r a$ 2,571.45 360 54322 26 Reconstruction of urethra $2, 871.759695432226 M i d l e v e lR eco n s t r u c t i o n o f u re t h r a$ 2,441.00 969 54322 Reconstruction of urethra $2,871.75 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 175 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 54324 26 Midlevel Reconstruction of urethra $3, 026.459695432426 R eco n s t r u c t i o n o f u re t h r a$ 3,560.55 969 54324 Reconstruction of urethra $3, 560.553605432626 M i d l e v e lR eco n s t r u c t i o n o f u re t h r a$ 2,924.70 969 54326 26 Reconstruction of urethra $3, 440.8596954326 R eco n s t r u c t i o n o f u re t h r a$ 3,440.85 360 54450 26 Preputial stretching $210.009695445026 M i d l e v e lP re p u t ia l s t re t c hin g$ 178.50 969 54450 Preputial stretching $210.003605450026 B i o p syo f t es t i s$ 273.00 969 54500 26 Midlevel Biopsy of testis $232.0596954500 B i o p syo f t es t i s$ 273.00 360 54505 26 Biopsy of testis $771.759695450526 M i d l e v e lB i o p syo f t es t i s$ 656.00 969 54505 Biopsy of testis $771.753605451226 E x c i se l es i o n t es t i s$ 1,978.20 969 54512 26 Midlevel Excise lesion testis $1, 681.4596954512 E x c i se l es i o n t es t i s$ 1,978.20 360 54520 26 Removal of testis $1, 201.209695452026 M i d l e v e lR e m o v a l o f t es t i s$ 1,021.00 969 54520 Removal of testis $1, 201.203605452226 O rc hi ec t o m y, p a r t ia l$ 2,149.35 969 54522 26 Midlevel Orchiectomy, partial $1, 826.9596954522 O rc hi ec t o m y, p a r t ia l$ 2,149.35 360 54530 26 Midlevel Removal of testis $1, 578.859695453026 R e m o v a l o f t es t i s$ 1,857.45 969 54530 Removal of testis $1, 857.453605453526 M i d l e v e lE x t e n s i v e t es t i ss u r g ery$ 2,307.10 969 54535 26 Extensive testis surgery $2, 714.2596954535 E x t e n s i v e t es t i ss u r g ery$ 2,714.25 360 54550 26 Midlevel Exploration for testis $1, 530.659695455026 E x pl or a t i o n f or t es t i s$ 1,800.75 969 54550 Exploration for testis $1, 800.753605456026 E x pl or a t i o n f or t es t i s$ 2,638.65 969 54560 26 Midlevel Exploration for testis $2, 242.8596954560 E x pl or a t i o n f or t es t i s$ 2,638.65 360 54600 26 Reduce testis torsion $1, 659.009695460026 M i d l e v e lR e d u ce t es t i s t ors i o n$ 1,410.15 969 54600 Reduce testis torsion $1, 659.003605462026 S u s p e n s i o n o f t es t i s$ 1,101.45 969 54620 26 Midlevel Suspension of testis $936.2596954620 S u s p e n s i o n o f t es t i s$ 1,101.45 360 54640 26 Midlevel Suspension of testis $1, 490.509695464026 S u s p e n s i o n o f t es t i s$ 1,753.50 969 54640 Suspension of testis $1, 753.503605465026 M i d l e v e lO rc hi o p e x y (F o wl er - St e p h e n s)$ 2,209.85 969 54650 26 Orchiopexy (Fowler-Stephens) $2, 599.8096954650 O rc hi o p e x y (F o wl er - St e p h e n s)$ 2,599.80 360 54660 26 Revision of testis $1, 306.209695466026 M i d l e v e lR e v i s i o n o f t es t i s$ 1,110.25 969 54660 Revision of testis $1, 306.203605467026 R e p ai r t es t i s inj u ry$ 1,484.70 969 54670 26 Midlevel Repair testis injury $1, 262.0096954670 R e p ai r t es t i s inj u ry$ 1,484.70 360 54680 26 Midlevel Relocation of testis(es) $2, 441.909695468026 R e l oc a t i o n o f t es t i s (es)$ 2,872.80 969 54680 Relocation of testis(es) $2,872.80 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 176 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 54690 26 Laparoscopy, orchiectomy $2, 676.459695469026 M i d l e v e l L a p a rosco p y, orc hi ec t o m y$ 2,275.00 969 54690 Laparoscopy, orchiectomy $2, 676.453605469226 M i d l e v e l L a p a rosco p y, orc hi o p e x y$ 2,365.15 969 54692 26 Laparoscopy, orchiopexy $2, 782.5096954692 L a p a rosco p y, orc hi o p e x y$ 2,782.50 360 54699 Laparoscope proc, testis $8, 977.353605470026 M i d l e v e l Dr aina g eo f scro t u m$ 666.70 969 54700 26 Drainage of scrotum $784.3596954700 Dr aina g eo f scro t u m$ 784.35 360 54800 26 Biopsy of epididymis $478.809695480026 M i d l e v e lB i o p syo f e p i d i d y mi s$ 407.00 969 54800 Biopsy of epididymis $478.803605483026 R e m o v ee p i d i d y mi s l es i o n$ 1,368.15 969 54830 26 Midlevel Remove epididymis lesion $1, 162.9596954830 R e m o v ee p i d i d y mi s l es i o n$ 1,368.15 360 54840 26 Remove epididymis lesion $1, 180.209695484026 M i d l e v e lR e m o v ee p i d i d y mi s l es i o n$ 1,003.15 969 54840 Remove epididymis lesion $1, 180.203605486026 R e m o v a l o f e p i d i d y mi s$ 1,535.10 969 54860 26 Midlevel Removal of epididymis $1, 304.8596954860 R e m o v a l o f e p i d i d y mi s$ 1,535.10 360 54861 26 Midlevel Removal of epididymis $1, 761.809695486126 R e m o v a l o f e p i d i d y mi s$ 2,072.70 969 54861 Removal of epididymis $2, 072.703605486526 M i d l e v e lE x pl oree p i d i d y mi s$ 1,116.50 969 54865 26 Explore epididymis $1, 313.5596954865 E x pl oree p i d i d y mi s$ 1,313.55 360 54900 26 Fusion of spermatic ducts $2, 839.209695490026 M i d l e v e lF u s i o n o f s p er ma t i c d u c t s$ 2,413.30 969 54900 Fusion of spermatic ducts $2, 839.203605490126 F u s i o n o f s p er ma t i c d u c t s$ 3,812.55 969 54901 26 Midlevel Fusion of spermatic ducts $3, 240.6596954901 F u s i o n o f s p er ma t i c d u c t s$ 3,812.55 360 55000 26 Drainage of hydrocele $310.809695500026 M i d l e v e l Dr aina g eo f h y d roce l e$ 264.20 969 55000 Drainage of hydrocele $310.803605504026 R e m o v a l o f h y d roce l e$ 1,244.25 969 55040 26 Midlevel Removal of hydrocele $1, 057.6096955040 R e m o v a l o f h y d roce l e$ 1,244.25 360 55041 26 Midlevel Removal of hydroceles $1, 591.359695504126 R e m o v a l o f h y d roce l es$ 1,872.15 969 55041 Removal of hydroceles $1, 872.153605506026 M i d l e v e lR e p ai ro f h y d roce l e$ 1,187.05 969 55060 26 Repair of hydrocele $1, 396.5096955060 R e p ai ro f h y d roce l e$ 1,396.50 360 55100 26 Drainage of scrotum abscess $611.109695510026 M i d l e v e l Dr aina g eo f scro t u mab scess$ 519.45 969 55100 Drainage of scrotum abscess $611.103605511026 M i d l e v e lE x pl orescro t u m$ 1,211.10 969 55110 26 Explore scrotum $1, 424.8596955110 E x pl orescro t u m$ 1,424.85 360 55120 26 Removal of scrotum lesion $1, 318.809695512026 M i d l e v e lR e m o v a l o f scro t u m l es i o n$ 1,121.00 969 55120 Removal of scrotum lesion $1, 318.803605515026 R e m o v a l o f scro t u m$ 1,802.85 969 55150 26 Midlevel Removal of scrotum $1,532.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 177 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 55150 Removal of scrotum $1, 802.853605517526 R e v i s i o n o f scro t u m$ 1,333.50 969 55175 26 Midlevel Revision of scrotum $1, 133.5096955175 R e v i s i o n o f scro t u m$ 1,333.50 360 55180 26 Revision of scrotum $2, 546.259695518026 M i d l e v e lR e v i s i o n o f scro t u m$ 2,164.30 969 55180 Revision of scrotum $2, 546.253605520026 M i d l e v e l I n c i s i o n o f s p er m d u c t$ 864.85 969 55200 26 Incision of sperm duct $1, 017.4596955200 I n c i s i o n o f s p er m d u c t$ 1,017.45 360 55250 26 Midlevel Removal of sperm duct(s) $708.659695525026 R e m o v a l o f s p er m d u c t (s)$ 833.70 969 55250 Removal of sperm duct(s) $833.703605530026 P re p a re, s p er m d u c t x - r a y$ 678.30 969 55300 26 Midlevel Prepare, sperm duct x-ray $576.5596955300 P re p a re, s p er m d u c t x - r a y$ 678.30 360 55400 26 Repair of sperm duct $1, 830.159695540026 M i d l e v e lR e p ai ro f s p er m d u c t$ 1,555.65 969 55400 Repair of sperm duct $1, 830.153605550026 M i d l e v e lR e m o v a l o f h y d roce l e$ 1,233.45 969 55500 26 Removal of hydrocele $1, 451.1096955500 R e m o v a l o f h y d roce l e$ 1,451.10 360 55520 26 Removal of sperm cord lesion $1, 634.859695552026 M i d l e v e lR e m o v a l o f s p er m cor d l es i o n$ 1,389.60 969 55520 Removal of sperm cord lesion $1, 634.853605553026 M i d l e v e lR e v i ses p er ma t i ccor d v e in s$ 1,104.90 969 55530 26 Revise spermatic cord veins $1, 299.9096955530 R e v i ses p er ma t i ccor d v e in s$ 1,299.90 360 55535 26 Midlevel Revise spermatic cord veins $1, 337.859695553526 R e v i ses p er ma t i ccor d v e in s$ 1,573.95 969 55535 Revise spermatic cord veins $1,573.95 360 55540 26 Midlevel Revise hernia & sperm veins$ 1,655.60 969 55540 26 Revise hernia & sperm veins $1,947.75 969 55540 Revise hernia & sperm veins$ 1,947.75 360 55550 26 Laparo ligate spermatic vein $1, 561.359695555026 M i d l e v e l L a p a ro l i g a t es p er ma t i c v e in$ 1,327.15 969 55550 Laparo ligate spermatic vein $1, 561.3536055559 L a p a ro p roc, s p er ma t i ccor d$ 8,977.35 360 55700 26 Midlevel Biopsy of prostate $432.859695570026 B i o p syo f p ros t a t e$ 509.25 969 55700 Biopsy of prostate $509.253605570526 B i o p syo f p ros t a t e$ 978.60 969 55705 26 Midlevel Biopsy of prostate $831.8096955705 B i o p syo f p ros t a t e$ 978.60 360 55720 26 Midlevel Drainage of prostate abscess $1, 405.709695572026 Dr aina g eo f p ros t a t e ab scess$ 1,653.75 969 55720 Drainage of prostate abscess $1, 653.753605572526 M i d l e v e l Dr aina g eo f p ros t a t e ab scess$ 1,844.80 969 55725 26 Drainage of prostate abscess $2, 170.3596955725 Dr aina g eo f p ros t a t e ab scess$ 2,170.35 360 55801 26 Midlevel Removal of prostate $3, 397.759695580126 R e m o v a l o f p ros t a t e$ 3,997.35 969 55801 Removal of prostate $3, 997.353605581026 E x t e n s i v e p ros t a t es u r g ery$ 4,825.80 969 55810 26 Midlevel Extensive prostate surgery $4, 101.9596955810 E x t e n s i v e p ros t a t es u r g ery$ 4,825.80 360 55812 26 Extensive prostate surgery $5,894.70 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 178 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 55812 26 Midlevel Extensive prostate surgery $5, 010.5096955812 E x t e n s i v e p ros t a t es u r g ery$ 5,894.70 360 55815 26 Extensive prostate surgery $6, 461.709695581526 M i d l e v e lE x t e n s i v e p ros t a t es u r g ery$ 5,492.45 969 55815 Extensive prostate surgery $6, 461.703605582126 R e m o v a l o f p ros t a t e$ 3,204.60 969 55821 26 Midlevel Removal of prostate $2, 723.9096955821 R e m o v a l o f p ros t a t e 1 - 2 s t a g es$ 3,204.60 360 55831 26 Midlevel Removal of prostate $2, 944.359695583126 R e m o v a l o f p ros t a t e$ 3,463.95 969 55831 Removal of prostate $3, 463.953605584026 E x t e n s i v e p ros t a t es u r g ery$ 4,902.45 969 55840 26 Midlevel Extensive prostate surgery $4, 167.1096955840 E x t e n s i v e p ros t a t es u r g ery$ 4,902.45 360 55842 26 Extensive prostate surgery $5, 252.109695584226 M i d l e v e lE x t e n s i v e p ros t a t es u r g ery$ 4,464.30 969 55842 Extensive prostate surgery $5, 252.103605584526 M i d l e v e lE x t e n s i v e p ros t a t es u r g ery$ 5,095.30 969 55845 26 Extensive prostate surgery $5, 994.4596955845 E x t e n s i v e p ros t a t es u r g ery$ 5,994.45 360 55860 26 Surgical exposure, prostate $3, 203.559695586026 M i d l e v e lS u r g i c a l e x p os u re, p ros t a t e$ 2,723.00 969 55860 Surgical exposure, prostate $3, 203.553605586226 M i d l e v e lE x t e n s i v e p ros t a t es u r g ery$ 3,419.15 969 55862 26 Extensive prostate surgery $4, 022.5596955862 E x t e n s i v e p ros t a t es u r g ery$ 4,022.55 360 55865 26 Midlevel Extensive prostate surgery $4, 158.159695586526 E x t e n s i v e p ros t a t es u r g ery$ 4,891.95 969 55865 Extensive prostate surgery $4, 891.953605586626 L a p a ror a d i c a lp ros t a t ec t o m y$ 6,355.65 969 55866 26 Midlevel Laparo radical prostatectomy $5, 402.3096955866 L a p a ror a d i c a lp ros t a t ec t o m y$ 6,355.65 360 55870 26 Midlevel Electroejaculation $446.259695587026 El ec t roe ja c u l a t i o n$ 525.00 969 55870 Electroejaculation $525.003605587326 C ryo ab l a t e p ros t a t e$ 2,941.05 969 55873 26 Midlevel Cryoablate prostate $2, 499.9096955873 C ryo ab l a t e p ros t a t e$ 2,941.05 360 55875 26 Midlevel Transperi needle place, pros $2, 372.259695587526 T r an s p er in ee d l e pl a ce, p ros$ 2,790.90 969 55875 Transperi needle place, pros $2, 790.903605587626 M i d l e v e lPl a cer t d e v i ce / ma r k er, p ros$ 704.30 969 55876 26 Place rt device/marker, pros $828.4596955876 Pl a cer t d e v i ce / ma r k er, p ros$ 2,373.35 360 55920 Place needles pelvic for rt $1,585.50 360 56405 26 I & D of vulva/perineum$ 400.05 969 56405 26 Midlevel I & D of vulva/perineum $340.05 969 56405 I & D of vulva/perineum$ 400.05 360 56420 26 Drainage of gland abscess $338.109695642026 M i d l e v e l Dr aina g eo f g l an d ab scess$ 287.40 969 56420 Drainage of gland abscess $338.103605644026 M i d l e v e lS u r g ery f or vu l v a l es i o n$ 573.90 969 56440 26 Surgery for vulva lesion $675.1596956440 S u r g ery f or vu l v a l es i o n$ 675.15 360 56441 26 Midlevel Lysis of labial lesion(s) $432.859695644126 L ys i so f l abia ll es i o n (s)$ 509.25 969 56441 Lysis of labial lesion(s) $509.25 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 179 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 56442 26 Midlevel Hymenotomy $151.709695644226 Hy m e n o t o m y$ 178.50 969 56442 Hymenotomy $178.503605650126 M i d l e v e l Des t roy, vu l v a l es i o n s, s im$ 359.70 969 56501 26 Destroy, vulva lesions, sim $423.1596956501 Des t roy, vu l v a l es i o n s, s im$ 423.15 360 56515 26 Midlevel Destroy vulva lesion/s compl $623.859695651526 Des t roy vu l v a l es i o n / sco m pl$ 733.95 969 56515 Destroy vulva lesion/s compl $733.953605660526 B i o p syo f vu l v a / p er in e u m$ 222.60 969 56605 26 Midlevel Biopsy of vulva/perineum $189.2096956605 B I OPS Y OF V UL V A / PER I NE U M 1 L ES I ON$ 222.60 360 56606 26 Biopsy of vulva/perineum $108.159695660626 M i d l e v e lB i o p syo f vu l v a / p er in e u m$ 91.95 969 56606 Biopsy of vulva/perineum $108.153605662026 M i d l e v e lP a r t ia l re m o v a l o f vu l v a$ 1,581.50 969 56620 26 Partial removal of vulva $1, 860.6096956620 P a r t ia l re m o v a l o f vu l v a$ 1,860.60 360 56625 26 Complete removal of vulva $2, 226.009695662526 M i d l e v e lC o m pl e t ere m o v a l o f vu l v a$ 1,892.10 969 56625 Complete removal of vulva $2, 226.0036056630 E x t e n s i v e vu l v a s u r g ery$ 3,278.10 360 56631 Extensive vulva surgery $4, 155.9036056632 E x t e n s i v e vu l v a s u r g ery$ 4,830.00 360 56633 Extensive vulva surgery $4, 258.8036056634 E x t e n s i v e vu l v a s u r g ery$ 4,517.10 360 56637 Extensive vulva surgery $5, 293.0536056640 E x t e n s i v e vu l v a s u r g ery$ 5,278.35 360 56700 Partial removal of hymen $693.003605674026 M i d l e v e lR e m o v e v a g ina g l an d l es i o n$ 933.55 969 56740 26 Remove vagina gland lesion $1, 098.3096956740 R e m o v e v a g ina g l an d l es i o n$ 1,098.30 360 56800 26 Midlevel Repair of vagina $755.059695680026 R e p ai ro f v a g ina$ 888.30 969 56800 Repair of vagina $888.303605680526 R e p ai rc l i t or i s$ 4,240.95 969 56805 26 Midlevel Repair clitoris $3, 604.8096956805 R e p ai rc l i t or i s$ 4,240.95 360 56810 26 Repair of perineum $957.609695681026 M i d l e v e lR e p ai ro f p er in e u m$ 813.95 969 56810 Repair of perineum $957.603605682026 M i d l e v e lE x am o f vu l v a w / sco p e$ 267.75 969 56820 26 Exam of vulva w/scope $315.0096956820 E x am o f vu l v a w / sco p e$ 315.00 360 56821 26 Exam/biopsy of vulva w/scope $423.159695682126 M i d l e v e lE x am / bi o p syo f vu l v a w / sco p e$ 359.70 969 56821 Exam/biopsy of vulva w/scope $423.153605700026 E x pl or a t i o n o f v a g ina$ 681.45 969 57000 26 Midlevel Exploration of vagina $579.2596957000 E x pl or a t i o n o f v a g ina$ 681.45 360 57010 26 Midlevel Drainage of pelvic abscess $1, 363.759695701026 Dr aina g eo f p e l v i c ab scess$ 1,604.40 969 57010 Drainage of pelvic abscess $1, 604.403605702026 M i d l e v e l Dr aina g eo f p e l v i c f l u i d$ 257.05 969 57020 26 Drainage of pelvic fluid $302.4096957020 Dr aina g eo f p e l v i c f l u i d$ 302.40 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 180 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 57022 26 Midlevel I & d vaginal hematoma, pp $526.60 969 57022 26 I & d vaginal hematoma, pp$ 619.50 969 57022 I & D VAGINAL HEMATOMA PP $619.50 360 57023 26 Midlevel I & d vag hematoma, non-ob$ 977.30 969 57023 26 I & d vag hematoma, non-ob $1,149.75 969 57023 I & d vag hematoma, non-ob$ 1,149.75 360 57061 26 Midlevel Destroy vag lesions, simple $307.909695706126 Des t roy v a g l es i o n s, s im pl e$ 362.25 969 57061 Destroy vag lesions, simple $362.253605706526 M i d l e v e l Des t roy v a g l es i o n s, co m pl e x$ 537.30 969 57065 26 Destroy vag lesions, complex $632.1096957065 Des t roy v a g l es i o n s, co m pl e x$ 632.10 360 57100 26 Biopsy of vagina $242.559695710026 M i d l e v e lB i o p syo f v a g ina$ 206.15 969 57100 Biopsy of vagina $242.553605710526 B i o p syo f v a g ina$ 462.00 969 57105 26 Midlevel Biopsy of vagina $392.7096957105 B i o p syo f v a g ina$ 462.00 360 57106 26 Midlevel Remove vagina wall, partial $1, 511.009695710626 R e m o v e v a g ina w a ll, p a r t ia l$ 1,777.65 969 57106 Remove vagina wall, partial $1, 777.653605710726 R e m o v e v a g ina t i ss u e, p a r t$ 5,180.70 969 57107 26 Midlevel Remove vagina tissue, part $4, 403.6096957107 R e m o v e v a g ina t i ss u e, p a r t$ 5,180.70 360 57109 26 Vaginectomy partial w/nodes $5, 924.109695710926 M i d l e v e l Va g in ec t o m y p a r t ia lw / n o d es$ 5,035.50 969 57109 Vaginectomy partial w/nodes $5, 924.103605713026 R e m o v e v a g ina l es i o n$ 590.10 969 57130 26 Midlevel Remove vagina lesion $501.6096957130 R e m o v e v a g ina l es i o n$ 590.10 360 57135 26 Midlevel Remove vagina lesion $540.859695713526 R e m o v e v a g ina l es i o n$ 636.30 969 57135 Remove vagina lesion $636.303605715026 T re a t v a g inain f ec t i o n$ 108.15 969 57150 26 Midlevel Treat vagina infection $91.9596957150 T re a t v a g inain f ec t i o n$ 108.15 360 57155 26 Midlevel Insert uteri tandems/ovoids $862.159695715526 I n ser t u t er i t an d e m s / o v o i d s$ 1,014.30 969 57155 Insert uteri tandems/ovoids $1, 014.3036057156 I n s v a g b r a c h y t x d e v i ce$ 514.50 360 57160 26 Midlevel Insert pessary/other device $148.159695716026 I n ser tp ess a ry / o t h er d e v i ce$ 174.30 969 57160 Insert pessary/other device $174.303605717026 F i tt in g o fd ia p h r a g m / c a p$ 178.50 969 57170 26 Midlevel Fitting of diaphragm/cap $151.7096957170 D ia p h r a g m, c a p f i tt in g$ 178.50 510 57170 Fitting of diaphragm/cap $178.503605718026 T re a t v a g ina l b l ee d in g$ 390.60 969 57180 26 Midlevel Treat vaginal bleeding $332.0096957180 T re a t v a g ina l b l ee d in g$ 390.60 360 57200 26 Midlevel Repair of vagina $933.559695720026 R e p ai ro f v a g ina$ 1,098.30 969 57200 Repair of vagina $1, 098.303605721026 R e p ai r v a g ina / p er in e u m$ 1,350.30 969 57210 26 Midlevel Repair vagina/perineum $1, 147.7596957210 R e p ai r v a g ina / p er in e u m$ 1,350.30 360 57220 26 Midlevel Revision of urethra $1,002.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 181 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 57220 26 Revision of urethra $1, 179.1596957220 R e v i s i o n o f u re t h r a$ 1,179.15 360 57230 26 Midlevel Repair of urethral lesion $1, 249.509695723026 R e p ai ro f u re t h r a ll es i o n$ 1,470.00 969 57230 Repair of urethral lesion $1,470.00 360 57240 26 Midlevel Repair bladder & vagina$ 2,082.20 969 57240 26 Repair bladder & vagina $2,449.65 969 57240 Repair bladder & vagina$ 2,449.65 360 57250 26 Repair rectum & vagina $2,481.15 969 57250 26 Midlevel Repair rectum & vagina$ 2,109.00 969 57250 Repair rectum & vagina $2, 481.153605726026 R e p ai ro f v a g ina$ 3,058.65 969 57260 26 Midlevel Repair of vagina $2, 599.8596957260 R e p ai ro f v a g ina$ 3,058.65 360 57265 26 Midlevel Extensive repair of vagina $2, 855.109695726526 E x t e n s i v ere p ai ro f v a g ina$ 3,358.95 969 57265 Extensive repair of vagina $3, 358.953605726726 I n ser t m es h / p e l v i c f l r a dd o n$ 949.20 969 57267 26 Midlevel Insert mesh/pelvic flr addon $806.8096957267 I n ser t m es h / p e l v i c f l r a dd o n$ 949.20 360 57268 26 Repair of bowel bulge $1, 779.759695726826 M i d l e v e lR e p ai ro f b o w e l b u l g e$ 1,512.80 969 57268 Repair of bowel bulge $1, 779.753605727026 M i d l e v e lR e p ai ro f b o w e lp o u c h$ 2,503.45 969 57270 26 Repair of bowel pouch $2, 945.2596957270 R e p ai ro f b o w e lp o u c h$ 2,945.25 360 57280 26 Suspension of vagina $3, 517.509695728026 M i d l e v e lS u s p e n s i o n o f v a g ina$ 2,989.90 969 57280 Suspension of vagina $3, 517.503605728226 C o lp o p e x y, e x t r a p er i t o n e a l$ 1,846.95 969 57282 26 Midlevel Colpopexy, extraperitoneal $1, 569.9096957282 C o lp o p e x y, e x t r a p er i t o n e a l$ 1,846.95 360 57283 26 Midlevel Colpopexy, intraperitoneal $2, 165.209695728326 C o lp o p e x y, in t r a p er i t o n e a l$ 2,547.30 969 57283 Colpopexy, intraperitoneal $2, 547.303605728426 R e p ai r p a r a v a g ina l d e f ec t$ 3,012.45 969 57284 26 Midlevel Repair paravaginal defect $2, 560.6096957284 R e p ai r p a r a v a g ina l d e f ec t$ 3,012.45 360 57285 Repair paravag defect vag $2, 484.303605728726 M i d l e v e lR e v i se / re m o v es l in g re p ai r$ 2,127.70 969 57287 26 Revise/remove sling repair $2, 503.2096957287 R e v i se / re m o v es l in g re p ai r$ 2,503.20 360 57288 26 Repair bladder defect $2, 617.659695728826 M i d l e v e lR e p ai r b l a dd er d e f ec t$ 2,225.00 969 57288 Repair bladder defect $2,617.65 360 57289 26 Repair bladder & vagina$ 2,642.85 969 57289 26 Midlevel Repair bladder & vagina $2,246.40 969 57289 Repair bladder & vagina$ 2,642.85 360 57291 26 Construction of vagina $2, 263.809695729126 M i d l e v e lC o n s t r u c t i o n o f v a g ina$ 1,924.25 969 57291 Construction of vagina $2, 263.803605729226 M i d l e v e lC o n s t r u c t v a g ina w i t h g r a f t$ 2,575.75 969 57292 26 Construct vagina with graft $3, 030.3096957292 C o n s t r u c t v a g ina w i t h g r a f t$ 3,030.30 360 57307 Fistula repair & colostomy $3, 854.5536057308 F i s t u l a re p ai r t r an s p er in e$ 2,363.55 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 182 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 57310 26 Repair urethrovaginal lesion $1, 678.959695731026 M i d l e v e lR e p ai r u re t h ro v a g ina ll es i o n$ 1,427.10 969 57310 Repair urethrovaginal lesion $1, 678.953605731126 R e p ai r u re t h ro v a g ina ll es i o n$ 1,909.95 969 57311 26 Midlevel Repair urethrovaginal lesion $1, 623.4596957311 R e p ai r u re t h ro v a g ina ll es i o n$ 1,909.95 360 57320 26 Midlevel Repair bladder-vagina lesion $1, 659.159695732026 R e p ai r b l a dd er - v a g ina l es i o n$ 1,951.95 969 57320 Repair bladder-vagina lesion $1, 951.953605733026 R e p ai r b l a dd er - v a g ina l es i o n$ 2,690.10 969 57330 26 Midlevel Repair bladder-vagina lesion $2, 286.6096957330 R e p ai r b l a dd er - v a g ina l es i o n$ 2,690.10 360 57335 26 Repair vagina $4, 153.809695733526 M i d l e v e lR e p ai r v a g ina$ 3,530.75 969 57335 Repair vagina $4, 153.803605740026 D i l a t i o n o f v a g ina$ 492.45 969 57400 26 Midlevel Dilation of vagina $418.6096957400 D i l a t i o n o f v a g ina$ 492.45 360 57410 26 Pelvic examination $394.809695741026 M i d l e v e lP e l v i ce x amina t i o n$ 335.60 969 57410 Pelvic examination $394.803605741526 M i d l e v e lR e m o v e v a g ina l f ore i g nb o d y$ 499.80 969 57415 26 Remove vaginal foreign body $588.0096957415 R e m o v e v a g ina l f ore i g nb o d y$ 588.00 360 57420 26 Exam of vagina w/scope $331.809695742026 M i d l e v e lE x am o f v a g ina w / sco p e$ 282.05 969 57420 Exam of vagina w/scope $331.803605742126 E x am / bi o p syo f v a g w / sco p e$ 452.55 969 57421 26 Midlevel Exam/biopsy of vag w/scope $384.6596957421 E x am / bi o p syo f v a g w / sco p e$ 452.55 360 57423 Repair paravag defect lap $3, 397.803605742526 L a p a rosco p y, s u r g, co lp o p e x y$ 3,577.35 969 57425 26 Midlevel Laparoscopy, surg, colpopexy $3, 040.7596957425 L a p a rosco p y, s u r g, co lp o p e x y$ 3,577.35 360 57426 Revise prosth vag graft lap $3, 147.903605745226 E x am o f cer v i x w / sco p e$ 338.10 969 57452 26 Midlevel Exam of cervix w/scope $287.4096957452 E x am o f cer v i x w / sco p e$ 338.10 360 57454 26 Midlevel Bx/curett of cervix w/scope $426.609695745426 B x / c u re tt o f cer v i x w / sco p e$ 501.90 969 57454 Bx/curett of cervix w/scope $501.903605745526 M i d l e v e lB i o p syo f cer v i x w / sco p e$ 348.05 969 57455 26 Biopsy of cervix w/scope $409.5096957455 B i o p syo f cer v i x w / sco p e$ 409.50 360 57456 26 Endocerv curettage w/scope $382.209695745626 M i d l e v e lE n d ocer v c u re tt a g e w / sco p e$ 324.85 969 57456 Endocerv curettage w/scope $382.203605746026 B x o f cer v i x w / sco p e, l ee p$ 603.75 969 57460 26 Midlevel Bx of cervix w/scope, leep $513.2096957460 B x o f cer v i x w / sco p e, l ee p$ 603.75 360 57461 26 Conz of cervix w/scope, leep $696.159695746126 M i d l e v e lC o n zo f cer v i x w / sco p e, l ee p$ 591.75 969 57461 Conz of cervix w/scope, leep $696.153605750026 M i d l e v e lB i o p syo f cer v i x$ 237.40 969 57500 26 Biopsy of cervix $279.3096957500 B i o p syo f cer v i x$ 279.30 360 57505 26 Midlevel Endocervical curettage $288.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 183 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 57505 26 Endocervical curettage $339.1596957505 E n d ocer v i c a l c u re tt a g e$ 339.15 360 57510 26 Cauterization of cervix $425.259695751026 M i d l e v e lC a u t er i z a t i o n o f cer v i x$ 361.45 969 57510 Cauterization of cervix $425.253605751126 C ryoc a u t eryo f cer v i x$ 488.25 969 57511 26 Midlevel Cryocautery of cervix $415.0096957511 C ryoc a u t eryo f cer v i x$ 488.25 360 57513 26 Midlevel Laser surgery of cervix $417.709695751326 L a sers u r g eryo f cer v i x$ 491.40 969 57513 Laser surgery of cervix $491.403605752026 M i d l e v e lC o ni z a t i o n o f cer v i x$ 855.00 969 57520 26 Conization of cervix $1, 005.9096957520 C o ni z a t i o n o f cer v i x$ 1,005.90 360 57522 26 Midlevel Conization of cervix $764.859695752226 C o ni z a t i o n o f cer v i x$ 899.85 969 57522 Conization of cervix $899.853605753026 R e m o v a l o f cer v i x$ 1,271.55 969 57530 26 Midlevel Removal of cervix $1, 080.8096957530 R e m o v a l o f cer v i x$ 1,271.55 360 57531 26 Removal of cervix, radical $6, 380.859695753126 M i d l e v e lR e m o v a l o f cer v i x, r a d i c a l$ 5,423.70 969 57531 Removal of cervix, radical $6, 380.853605754026 R e m o v a l o f res i d u a l cer v i x$ 2,878.05 969 57540 26 Midlevel Removal of residual cervix $2, 446.3596957540 R e m o v a l o f res i d u a l cer v i x$ 2,878.05 360 57545 26 Midlevel Remove cervix/repair pelvis $2, 581.109695754526 R e m o v ecer v i x / re p ai r p e l v i s$ 3,036.60 969 57545 Remove cervix/repair pelvis $3, 036.603605755026 R e m o v a l o f res i d u a l cer v i x$ 1,509.90 969 57550 26 Midlevel Removal of residual cervix $1, 283.4096957550 R e m o v a l o f res i d u a l cer v i x$ 1,509.90 360 57555 26 Midlevel Remove cervix/repair vagina $1, 886.759695755526 R e m o v ecer v i x / re p ai r v a g ina$ 2,219.70 969 57555 Remove cervix/repair vagina $2, 219.703605755626 M i d l e v e lR e m o v ecer v i x, re p ai r b o w e l$ 1,773.40 969 57556 26 Remove cervix, repair bowel $2, 086.3596957556 R e m o v ecer v i x, re p ai r b o w e l$ 2,086.35 360 57558 26 D&c of cervical stump $421.05 969 57558 26 Midlevel D&c of cervical stump$ 357.90 969 57558 D&c of cervical stump $421.053605770026 M i d l e v e lR e v i s i o n o f cer v i x$ 977.30 969 57700 26 Revision of cervix $1, 149.7596957700 R e v i s i o n o f cer v i x$ 1,149.75 360 57720 26 Midlevel Revision of cervix $965.709695772026 R e v i s i o n o f cer v i x$ 1,136.10 969 57720 Revision of cervix $1, 136.103605780026 D i l a t i o n o f cer v i c a l c ana l$ 178.50 969 57800 26 Midlevel Dilation of cervical canal $151.7096957800 D i l a t i o n o f cer v i c a l c ana l$ 178.50 360 58100 26 Biopsy of uterus lining $324.459695810026 M i d l e v e lB i o p syo f u t er u s l inin g$ 275.80 969 58100 Biopsy of uterus lining $324.453605811026 M i d l e v e lB x d o n e w / co lp osco p y a dd - o n$ 128.50 969 58110 26 Bx done w/colposcopy add-on $151.2096958110 B x d o n e w / co lp osco p y a dd - o n$ 151.20 360 58120 26 Dilation and curettage $804.30 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 184 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 58120 26 Midlevel Dilation and curettage $683.6596958120 D i l a t i o nan d c u re tt a g e$ 804.30 360 58140 26 Midlevel Myomectomy abdom method $2, 883.659695814026 M yo m ec t o m y ab d o mm e t h o d$ 3,392.55 969 58140 MYOMECTOMY ABDOM METHOD 1-4 $3, 392.55360 M Y OM A S 5814526 M yo m ec t o m y v a g m e t h o d$ 2,009.70 969 58145 26 Midlevel Myomectomy vag method $1, 708.2596958145 M Y OMECTOM YV A GMET H O D 1 - 4 M Y OM A S$ 2,009.70 360 58146 26 Myomectomy abdom complex $4, 268.259695814626 M i d l e v e lM yo m ec t o m y ab d o m co m pl e x$ 3,628.00 969 58146 MYOMECTOMY ABDOM COMPLEX 5+ $4, 268.25360 M Y OM A S 5815026 T o t a l h ys t erec t o m y$ 3,678.15 969 58150 26 Midlevel Total hysterectomy $3, 126.4596958150 T o t a l h ys t erec t o m y$ 3,678.15 360 [Rows 10001-11000:] [See second part.] © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 185 of 185

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SUBCHAPTER 140-10.8 SCHEDULE OF MEDICAL AND OTHER RELATED FEES [continued] § 140-10.8-101 CHCC Chargemaster [second part] [Rows 10001-11000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 58152 26 Midlevel Total hysterectomy $3, 915.409695815226 T o t a l h ys t erec t o m y$ 4,606.35 969 58152 Total hysterectomy $4, 606.353605818026 P a r t ia l h ys t erec t o m y$ 3,532.20 969 58180 26 Midlevel Partial hysterectomy $3, 002.3596958180 P a r t ia l h ys t erec t o m y$ 3,532.20 360 58200 26 Midlevel Extensive hysterectomy $4, 126.059695820026 E x t e n s i v e h ys t erec t o m y$ 4,854.15 969 58200 Extensive hysterectomy $4, 854.153605821026 E x t e n s i v e h ys t erec t o m y$ 6,501.60 969 58210 26 Midlevel Extensive hysterectomy $5, 526.3596958210 E x t e n s i v e h ys t erec t o m y$ 6,501.60 360 58240 26 Removal of pelvis contents $10, 315.209695824026 M i d l e v e lR e m o v a l o f p e l v i sco n t e n t s$ 8,767.90 969 58240 Removal of pelvis contents $10, 315.203605826026 M i d l e v e l Va g ina l h ys t erec t o m y$ 2,596.30 969 58260 26 Vaginal hysterectomy $3, 054.4596958260 V A G I N A L H Y STERECTOM Y =< 250 GM$ 3,054.45 360 58262 26 Midlevel Vag hyst including t/o $2, 896.159695826226 Va g h ys t in c l u d in g t / o$ 3,407.25 969 58262 Vag hyst including t/o ⇐250 grams $3,407.25 360 58263 26 Midlevel Vag hyst w/t/o & vag repair$ 3,113.95 969 58263 26 Vag hyst w/t/o & vag repair $3,663.45 969 58263 Vag hyst w/t/o & vag repair <=250 grams$ 3,663.45 360 58267 26 Vag hyst w/urinary repair $3, 903.909695826726 M i d l e v e l Va g h ys tw / u r ina ryre p ai r$ 3,318.30 969 58267 Vag hyst w/urinary repair ⇐250 grams $3, 903.903605827026 M i d l e v e l Va g h ys tw / e n t eroce l ere p ai r$ 2,768.55 969 58270 26 Vag hyst w/enterocele repair $3, 257.1096958270 Va g h ys tw / e n t eroce l ere p ai r <= 250 g r am s$ 3,257.10 360 58275 26 Hysterectomy/revise vagina $3, 637.209695827526 M i d l e v e l Hys t erec t o m y / re v i se v a g ina$ 3,091.60 969 58275 Hysterectomy/revise vagina $3, 637.203605828026 M i d l e v e l Hys t erec t o m y / re v i se v a g ina$ 3,307.60 969 58280 26 Hysterectomy/revise vagina $3, 891.3096958280 Hys t erec t o m y / re v i se v a g ina$ 3,891.30 360 58285 26 Extensive hysterectomy $4, 846.809695828526 M i d l e v e lE x t e n s i v e h ys t erec t o m y$ 4,119.80 969 58285 Extensive hysterectomy $4, 846.803605829026 M i d l e v e l Va g h ys t co m pl e x$ 3,613.75 969 58290 26 Vag hyst complex $4, 251.4596958290 Va g h ys t co m pl e x > 250 g r am s$ 4,251.45 360 58291 26 Midlevel Vag hyst incl t/o, complex $3, 915.409695829126 Va g h ys t in c lt / o, co m pl e x$ 4,606.35 969 58291 Vag hyst incl t/o, complex >250 grams $4,606.35 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 1 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 58292 26 Midlevel Vag hyst t/o & repair, compl $4,132.30 969 58292 26 Vag hyst t/o & repair, compl$ 4,861.50 969 58292 Vag hyst t/o & repair, compl >205 grams $4, 861.503605829326 M i d l e v e l Va g h ys tw / u rore p ai r, co m pl$ 4,296.50 969 58293 26 Vag hyst w/uro repair, compl $5, 054.7096958293 Va g h ys tw / u rore p ai r, co m pl > 250 g r am s$ 5,054.70 360 58294 26 Midlevel Vag hyst w/enterocele, compl $3, 830.609695829426 Va g h ys tw / e n t eroce l e, co m pl$ 4,506.60 969 58294 Vag hyst w/enterocele, compl >250 grams $4, 506.603605830026 M i d l e v e l I n ser t in t r a u t er in e d e v i ce$ 157.95 960 58300 26 Insert intrauterine device $185.8596058300 I n ser t in t r a u t er in e d e v i ce$ 185.85 510 58301 26 Midlevel Remove intrauterine device $213.309695830126 R e m o v e in t r a u t er in e d e v i ce$ 250.95 969 58301 Remove intrauterine device $250.955105834026 M i d l e v e lC a t h e t er f or h ys t ero g r a p h y$ 181.20 969 58340 26 Catheter for hysterography $213.1596958340 C a t h e t er f or h ys t ero g r a p h y$ 213.15 360 58345 26 Reopen fallopian tube $1, 033.209695834526 M i d l e v e lR eo p e n f a ll o p ian t u b e$ 878.20 969 58345 Reopen fallopian tube $1, 033.203605834626 I n ser t h ey man u t er i c a p s u l e$ 1,634.85 969 58346 26 Midlevel Insert heyman uteri capsule $1, 389.6096958346 I n ser t h ey man u t er i c a p s u l e$ 1,634.85 360 58350 26 Midlevel Reopen fallopian tube $248.109695835026 R eo p e n f a ll o p ian t u b e$ 291.90 969 58350 Reopen fallopian tube $291.903605835326 E n d o m e t r ab l a t e, t h er ma l$ 811.65 969 58353 26 Midlevel Endometr ablate, thermal $689.9096958353 E n d o m e t r ab l a t e, t h er ma l$ 811.65 360 58356 26 Endometrial cryoablation $1, 282.059695835626 M i d l e v e lE n d o m e t r ia l cryo ab l a t i o n$ 1,089.75 969 58356 Endometrial cryoablation $1, 282.053605840026 M i d l e v e lS u s p e n s i o n o f u t er u s$ 1,377.15 969 58400 26 Suspension of uterus $1, 620.1596958400 S u s p e n s i o n o f u t er u s$ 1,620.15 360 58410 26 Suspension of uterus $2, 969.409695841026 M i d l e v e lS u s p e n s i o n o f u t er u s$ 2,524.00 969 58410 Suspension of uterus $2, 969.403605852026 M i d l e v e lR e p ai ro f r u pt u re d u t er u s$ 2,535.60 969 58520 26 Repair of ruptured uterus $2, 983.0596958520 R e p ai ro f r u pt u re d u t er u s$ 2,983.05 360 58540 26 Midlevel Revision of uterus $2, 853.309695854026 R e v i s i o n o f u t er u s$ 3,356.85 969 58540 Revision of uterus $3, 356.853605854126 M i d l e v e l L s h, u t er u s 250 g or l ess$ 2,706.95 969 58541 26 Lsh, uterus 250 g or less $3, 184.6596958541 L s h, u t er u s 250 g or l ess$ 3,184.65 360 58542 26 Lsh w/t/o ut 250 g or less $3, 557.409695854226 M i d l e v e l L s h w / t / o u t 250 g or l ess$ 3,023.80 969 58542 Lsh w/t/o ut 250 g or less $3, 557.403605854326 L s h u t er u s ab o v e 250 g$ 3,616.20 969 58543 26 Midlevel Lsh uterus above 250 g $3, 073.7596958543 L s h u t er u s ab o v e 250 g$ 3,616.20 360 58544 26 Lsh w/t/o uterus above 250 g $3, 914.409695854426 M i d l e v e l L s h w / t / o u t er u s ab o v e 250 g$ 3,327.25 969 58544 Lsh w/t/o uterus above 250 g $3,914.40 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 2 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 58545 26 Midlevel Laparoscopic myomectomy $2, 808.709695854526 L a p a rosco p i c m yo m ec t o m y$ 3,304.35 969 58545 Laparoscopic myomectomy ⇐250 grams $3, 304.353605854626 L a p a ro - m yo m ec t o m y, co m pl e x$ 4,166.40 969 58546 26 Midlevel Laparo-myomectomy, complex $3, 541.4596958546 L a p a ro - m yo m ec t o m y, co m pl e x > 250 g r am s$ 4,166.40 360 58548 26 Midlevel Lap radical hyst $5, 658.459695854826 L a p r a d i c a l h ys t$ 6,657.00 969 58548 Lap radical hyst $6, 657.003605855026 M i d l e v e l L a p a ro - a ss t v a g h ys t erec t o m y$ 2,772.10 969 58550 26 Laparo-asst vag hysterectomy $3, 261.3096958550 L a p a ro - a ss t v a g h ys t erec t o m y <= 250 g r am s$ 3,261.30 360 58552 26 Laparo-vag hyst incl t/o $3, 622.509695855226 M i d l e v e l L a p a ro - v a g h ys t in c lt / o$ 3,079.15 969 58552 Laparo-vag hyst incl t/o ⇐ 250 grams $3, 622.503605855326 M i d l e v e l L a p a ro - v a g h ys t, co m pl e x$ 3,565.55 969 58553 26 Laparo-vag hyst, complex $4, 194.7596958553 L a p a ro - v a g h ys t, co m pl e x > 250 g r am s$ 4,194.75 360 58554 26 Midlevel Laparo-vag hyst w/t/o, compl $4, 123.359695855426 L a p a ro - v a g h ys tw / t / o, co m pl$ 4,851.00 969 58554 Laparo-vag hyst w/t/o, compl > 250 grams $4, 851.003605855526 Hys t erosco p y, d x, se pp roc$ 701.40 969 58555 26 Midlevel Hysteroscopy, dx, sep proc $596.2096958555 Hys t erosco p y, d x, se pp roc$ 701.40 360 58558 26 Hysteroscopy, biopsy $985.959695855826 M i d l e v e l Hys t erosco p y, bi o p sy$ 838.05 969 58558 Hysteroscopy, biopsy $985.953605855926 M i d l e v e l Hys t erosco p y, l ys i s$ 1,079.05 969 58559 26 Hysteroscopy, lysis $1, 269.4596958559 Hys t erosco p y, l ys i s$ 1,269.45 360 58560 26 Midlevel Hysteroscopy, resect septum $1, 216.509695856026 Hys t erosco p y, resec t se pt u m$ 1,431.15 969 58560 Hysteroscopy, resect septum $1, 431.153605856126 Hys t erosco p y, re m o v e m yo ma$ 2,024.40 969 58561 26 Midlevel Hysteroscopy, remove myoma $1, 720.7596958561 Hys t erosco p y, re m o v e m yo ma$ 2,024.40 360 58562 26 Hysteroscopy, remove fb $1, 071.009695856226 M i d l e v e l Hys t erosco p y, re m o v e f b$ 910.35 969 58562 Hysteroscopy, remove fb $1, 071.003605856326 Hys t erosco p y, ab l a t i o n$ 1,268.40 969 58563 26 Midlevel Hysteroscopy, ablation $1, 078.1596958563 Hys t erosco p y, ab l a t i o n$ 1,268.40 360 58565 26 Hysteroscopy, sterilization $1, 603.359695856526 M i d l e v e l Hys t erosco p y, s t er i l i z a t i o n$ 1,362.85 969 58565 Hysteroscopy, sterilization $1, 603.353605857126 T L H W / T / O 250 GOR L ESS$ 2,817.42 975 58571 TC TLH W/T/O 250 G OR LESS $15, 483.263605857226 T L H U TER U SO V ER 250 G$ 3,213.64 975 58573 26 TLH W/T/O UTERUS OVER 250 G $3, 805.8997558578 L a p a ro p roc, u t er u s$ 8,977.35 360 58579 Hysteroscope procedure $321.403605860026 D i v i s i o n o ff a ll o p ian t u b e$ 1,347.15 969 58600 26 Midlevel Division of fallopian tube $1, 145.1096958600 D i v i s i o n o ff a ll o p ian t u b e$ 1,347.15 360 58605 26 Midlevel Division of fallopian tube $1, 033.509695860526 D i v i s i o n o ff a ll o p ian t u b e$ 1,215.90 969 58605 Division of fallopian tube $1,215.90 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 3 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 58611 26 Midlevel Ligate oviduct(s) add-on $242.759695861126 L i g a t eo v i d u c t (s) a dd - o n$ 285.60 969 58611 Ligate oviduct(s) add-on $285.603605861526 M i d l e v e lO cc l u d e f a ll o p ian t u b e (s)$ 771.10 969 58615 26 Occlude fallopian tube(s) $907.2096958615 O cc l u d e f a ll o p ian t u b e (s)$ 907.20 360 58660 26 Laparoscopy, lysis $2, 482.209695866026 M i d l e v e l L a p a rosco p y, l ys i s$ 2,109.85 969 58660 Laparoscopy, lysis $2, 482.203605866126 L a p a rosco p y, re m o v e a d n e x a$ 2,375.10 969 58661 26 Midlevel Laparoscopy, remove adnexa $2, 018.8596958661 L a p a rosco p y, re m o v e a d n e x a$ 2,375.10 360 58662 26 Midlevel Laparoscopy, excise lesions $2, 212.509695866226 L a p a rosco p y, e x c i se l es i o n s$ 2,602.95 969 58662 Laparoscopy excise lesions $2, 602.953605867026 M i d l e v e l L a p a rosco p y, t u ba l c a u t ery$ 1,148.65 969 58670 26 Laparoscopy, tubal cautery $1, 351.3596958670 L a p a rosco p y, t u ba l c a u t ery$ 1,351.35 360 58671 26 Midlevel Laparoscopy, tubal block $1, 147.759695867126 L a p a rosco p y, t u ba l b l oc k$ 1,350.30 969 58671 Laparoscopy tubal block $1, 350.303605867226 M i d l e v e l L a p a rosco p y, f imb r i o pl a s t y$ 2,311.60 969 58672 26 Laparoscopy, fimbrioplasty $2, 719.5096958672 L a p a rosco p y, f imb r i o pl a s t y$ 2,719.50 360 58673 26 Laparoscopy, salpingostomy $2, 955.759695867326 M i d l e v e l L a p a rosco p y, s a lp in g os t o m y$ 2,512.40 969 58673 Laparoscopy, salpingostomy $2, 955.7536058679 L a p a ro p roc, o v i d u c t - o v a ry$ 8,977.35 360 58700 26 Midlevel Removal of fallopian tube $2, 429.409695870026 R e m o v a l o ff a ll o p ian t u b e$ 2,858.10 969 58700 Removal of fallopian tube $2, 858.103605872026 M i d l e v e lR e m o v a l o f o v a ry / t u b e (s)$ 2,264.25 969 58720 26 Removal of ovary/tube(s) $2, 663.8596958720 R e m o v a l o f o v a ry / t u b e (s)$ 2,663.85 360 58740 26 Revise fallopian tube(s) $3, 234.009695874026 M i d l e v e lR e v i se f a ll o p ian t u b e (s)$ 2,748.90 969 58740 Adhesiolysis tube ovary $3, 234.003605875026 R e p ai ro v i d u c t$ 3,333.75 969 58750 26 Midlevel Repair oviduct $2, 833.7096958750 R e p ai ro v i d u c t$ 3,333.75 360 58752 26 Revise ovarian tube(s) $3, 143.709695875226 M i d l e v e lR e v i seo v a r ian t u b e (s)$ 2,672.15 969 58752 Revise ovarian tube(s) $3, 143.703605876026 M i d l e v e lR e m o v e t u ba l o b s t r u c t i o n$ 2,547.20 969 58760 26 Remove tubal obstruction $2, 996.7096958760 R e m o v e t u ba l o b s t r u c t i o n$ 2,996.70 360 58770 26 Create new tubal opening $3, 136.359695877026 M i d l e v e lC re a t e n e wt u ba l o p e nin g$ 2,665.90 969 58770 Create new tubal opening $3, 136.353605880026 Dr aina g eo f o v a r ian cys t (s)$ 1,103.55 969 58800 26 Midlevel Drainage of ovarian cyst(s) $938.0096958800 Dr aina g eo f o v a r ian cys t (s)$ 1,103.55 360 58805 26 Drainage of ovarian cyst(s) $1, 486.809695880526 M i d l e v e l Dr aina g eo f o v a r ian cys t (s)$ 1,263.80 969 58805 Drainage of ovarian cyst(s) $1, 486.803605882026 M i d l e v e l Dr ain o v a ry ab scess, o p e n$ 982.65 969 58820 26 Drain ovary abscess, open $1,156.05 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 4 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 58820 Drain ovary abscess, open $1, 156.053605882226 Dr ain o v a ry ab scess, p erc u t$ 2,721.60 969 58822 26 Midlevel Drain ovary abscess, percut $2, 313.3596958822 Dr ain o v a ry ab scess p erc u t$ 2,721.60 360 58825 26 Transposition, ovary(s) $2, 614.509695882526 M i d l e v e lT r an s p os i t i o n, o v a ry (s)$ 2,222.35 969 58825 Transposition, ovary(s) $2, 614.503605890026 M i d l e v e lB i o p syo f o v a ry (s)$ 1,387.85 969 58900 26 Biopsy of ovary(s) $1, 632.7596958900 B i o p syo f o v a ry (s)$ 1,632.75 360 58920 26 Midlevel Partial removal of ovary(s) $2, 195.559695892026 P a r t ia l re m o v a l o f o v a ry (s)$ 2,583.00 969 58920 Partial removal of ovary(s) $2, 583.003605892526 R e m o v a l o f o v a r ian cys t (s)$ 2,727.90 969 58925 26 Midlevel Removal of ovarian cyst(s) $2, 318.7096958925 R e m o v a l o f o v a r ian cys t (s)$ 2,727.90 360 58940 26 Removal of ovary(s) $1, 907.859695894026 M i d l e v e lR e m o v a l o f o v a ry (s)$ 1,621.65 969 58940 Removal of ovary(s) $1, 907.853605894326 M i d l e v e lR e m o v a l o f o v a ry (s)$ 3,549.45 969 58943 26 Removal of ovary(s) $4, 175.8596958943 R e m o v a l o f o v a ry (s)$ 4,175.85 360 58950 26 Resect ovarian malignancy $3, 994.209695895026 M i d l e v e lR esec t o v a r ianma l i g nan cy$ 3,395.05 969 58950 Resect ovarian malignancy $3, 994.203605895126 M i d l e v e lR esec t o v a r ianma l i g nan cy$ 4,358.95 969 58951 26 Resect ovarian malignancy $5, 128.2096958951 R esec t o v a r ianma l i g nan cy$ 5,128.20 360 58952 26 Midlevel Resect ovarian malignancy $4, 926.609695895226 R esec t o v a r ianma l i g nan cy$ 5,796.00 969 58952 Resect ovarian malignancy $5, 796.003605895326 M i d l e v e lT ah, r a dd i ssec t f or d e b u l k$ 6,092.20 969 58953 26 Tah, rad dissect for debulk $7, 167.3096958953 T ah, r a dd i ssec t f or d e b u l k$ 7,167.30 360 58954 26 Midlevel Tah rad debulk/lymph remove $6, 602.709695895426 T ah r a dd e b u l k / l y m p h re m o v e$ 7,767.90 969 58954 Tah rad debulk/lymph remove $7, 767.903605895626 B so, o m e n t ec t o m y w / t ah$ 4,897.20 969 58956 26 Midlevel Bso, omentectomy w/tah $4, 162.6096958956 B so, o m e n t ec t o m y w / t ah$ 4,897.20 360 58957 26 Midlevel Resect recurrent gyn mal $4, 756.159695895726 R esec t rec u rre n t g y nma l$ 5,595.45 969 58957 Resect recurrent gyn mal $5, 595.453605895826 M i d l e v e lR esec t rec u r g y nma lw / l y m$ 5,225.60 969 58958 26 Resect recur gyn mal w/lym $6, 147.7596958958 R esec t rec u r g y nma lw / l y m$ 6,147.75 360 58960 26 Midlevel Exploration of abdomen $2, 911.359695896026 E x pl or a t i o n o f ab d o m e n$ 3,425.10 969 58960 Exploration of abdomen $3, 425.103605899926 U N L I STE D PXFEM A L EGEN I T A L S Y STEM$ 4,167.20 960 NONOBSTETRICAL 59000 26 Midlevel Amniocentesis, diagnostic $257.059695900026 A mni oce n t es i s, d ia g n os t i c$ 302.40 969 59000 Amniocentesis diagnostic $302.403605900126 M i d l e v e l A mni oce n t es i s, t h er a p e u t i c$ 573.90 969 59001 26 Amniocentesis, therapeutic $675.1596959001 A mni oce n t es i s, t h er a p e u t i c$ 675.15 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 5 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 59012 26 Midlevel Fetal cord puncture,prenatal $636.359695901226 F e t a l cor d p u n c t u re, p re na t a l$ 748.65 969 59012 Fetal cord puncture,prenatal $748.653605901526 C h or i o nbi o p sy$ 493.50 969 59015 26 Midlevel Chorion biopsy $419.5096959015 C h or i o nbi o p sy$ 493.50 360 59020 26 Fetal contract stress test $259.359605902026 M i d l e v e lF e t a l co n t r a c t s t ress t es t$ 220.45 960 59020 Fetal contract stress test $259.353605902526 F e t a l n o n - s t ress t es t$ 175.35 960 59025 26 Midlevel Fetal non-stress test $149.0596059025 F e t a l n o n - s t ress t es t$ 175.35 720 59030 26 Fetal scalp blood sample $360.159695903026 M i d l e v e lF e t a l sc a lp b l oo d s am pl e$ 306.15 969 59030 Fetal scalp blood sample $360.153605905026 M i d l e v e lF e t a l m o ni t or w / re p or t$ 160.65 969 59050 26 Fetal monitor w/report $189.0096959050 F e t a l m o ni t or w / re p or t$ 189.00 360 59051 26 Fetal monitor/interpret only $157.509695905126 M i d l e v e lF e t a l m o ni t or / in t er p re t o n l y$ 133.90 969 59051 Fetal monitor/interpret only $157.503605907026 T r an s ab d o mamni o in f u s w / u s$ 1,165.50 969 59070 26 Midlevel Transabdom amnioinfus w/us $990.7096959070 T r an s ab d o mamni o in f u s w / u s$ 1,165.50 360 59072 Umbilical cord occlud w/us $1, 937.253605907426 M i d l e v e lF e t a l f l u i dd r aina g e w / u s$ 1,007.65 969 59074 26 Fetal fluid drainage w/us $1, 185.4596959074 F e t a l f l u i dd r aina g e w / u s$ 1,185.45 360 59076 Fetal shunt placement w/us $1, 927.803605910026 M i d l e v e lR e m o v e u t er u s l es i o n$ 2,635.55 969 59100 26 Remove uterus lesion $3, 100.6596959100 R e m o v e u t er u s l es i o n$ 3,100.65 360 59120 26 Treat ectopic pregnancy $2, 959.959695912026 M i d l e v e lT re a t ec t o p i c p re g nan cy$ 2,515.95 969 59120 Treat ectopic pregnancy $2, 959.953605912126 M i d l e v e lT re a t ec t o p i c p re g nan cy$ 2,517.75 969 59121 26 Treat ectopic pregnancy $2, 962.0596959121 T re a t ec t o p i c p re g nan cy$ 2,962.05 360 59130 26 Treat ectopic pregnancy $3, 026.109695913026 M i d l e v e lT re a t ec t o p i c p re g nan cy$ 2,572.20 969 59130 Treat ectopic pregnancy $3, 026.103605913526 T re a t ec t o p i c p re g nan cy$ 3,077.55 969 59135 26 Midlevel Treat ectopic pregnancy $2, 615.9096959135 T re a t ec t o p i c p re g nan cy$ 3,077.55 360 59136 26 Midlevel Treat ectopic pregnancy $2, 761.409695913626 T re a t ec t o p i c p re g nan cy$ 3,248.70 969 59136 Treat ectopic pregnancy $3, 248.703605914026 T re a t ec t o p i c p re g nan cy$ 1,326.15 969 59140 26 Midlevel Treat ectopic pregnancy $1, 127.2596959140 T re a t ec t o p i c p re g nan cy$ 1,326.15 360 59150 26 Midlevel Treat ectopic pregnancy $2, 434.759695915026 T re a t ec t o p i c p re g nan cy$ 2,864.40 969 59150 Treat ectopic pregnancy $2, 864.403605915126 T re a t ec t o p i c p re g nan cy$ 2,787.75 969 59151 26 Midlevel Treat ectopic pregnancy $2, 369.6096959151 T re a t ec t o p i c p re g nan cy$ 2,787.75 360 59160 26 Midlevel D & c after delivery $553.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 6 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 59160 26 D & c after delivery $651.00 969 59160 D & c after delivery$ 651.00 360 59200 26 Midlevel Insert cervical dilator $142.809695920026 I n ser t cer v i c a l d i l a t or$ 168.00 969 59200 Insert cervical dilator $168.003605930026 M i d l e v e lEp i s i o t o m yor v a g ina l re p ai r$ 467.65 969 59300 26 Episiotomy or vaginal repair $550.2096959300 EP I S I OTOM Y OR V A G I N A L REP A I R$ 550.20 360 59320 26 Midlevel Revision of cervix $482.859695932026 R e v i s i o n o f cer v i x$ 568.05 969 59320 Revision of cervix $568.053605932526 R e v i s i o n o f cer v i x$ 798.00 969 59325 26 Midlevel Revision of cervix $678.3096959325 R e v i s i o n o f cer v i x$ 798.00 360 59350 26 Midlevel Repair of uterus $888.959695935026 R e p ai ro f u t er u s$ 1,045.80 969 59350 Repair of uterus $1, 045.803605940026 O b s t e t r i c a l c a re$ 7,708.05 969 59400 26 Midlevel Obstetrical care $6, 551.8596959400 O b s t e t r i c a l c a re$ 7,708.05 360 59409 26 Midlevel Obstetrical care $2, 576.659695940926 O b s t e t r i c a l c a re$ 3,031.35 969 59409 Obstetrical care, Vag. Delivery only $3, 031.357225941026 M i d l e v e lO b s t e t r i c a l c a re$ 3,274.60 969 59410 26 Obstetrical care $3, 852.4596959410 V A G I N A L D E L I V ER Y ON L Y; I NC L PP$ 3,852.45 722 59412 26 Antepartum manipulation $386.409695941226 M i d l e v e l A n t e p a r t u mmani p u l a t i o n$ 328.45 969 59412 Antepartum manipulation $386.403605941426 M i d l e v e l De l i v er pl a ce n t a$ 290.05 969 59414 26 Deliver placenta $341.2596959414 De l i v er pl a ce n t a$ 341.25 360 59425 26 Midlevel Antepartum care only $1, 126.359695942526 A n t e p a r t u m c a reo n l y$ 1,325.10 969 59425 Antepartum care only $1, 325.103605942626 M i d l e v e l A n t e p a r t u m c a reo n l y$ 1,986.70 969 59426 26 Antepartum care only $2, 337.3096959426 A n t e p a r t u m c a reo n l y$ 2,337.30 360 59430 26 Midlevel Care after delivery $442.709695943026 C a re a f t er d e l i v ery$ 520.80 969 59430 Care after delivery $520.803605951026 M i d l e v e lC es a re an d e l i v ery$ 7,264.95 969 59510 26 Cesarean delivery $8, 547.0096959510 C es a re an d e l i v ery$ 8,547.00 360 59514 26 Cesarean delivery only $3, 424.059695951426 M i d l e v e lC es a re an d e l i v eryo n l y$ 2,910.45 969 59514 Cesarean delivery only $3, 424.057225951526 M i d l e v e lC es a re an d e l i v ery$ 3,967.15 969 59515 26 Cesarean delivery $4, 667.2596959515 CES A RE A N D E L I V ER Y ON L Y; I NC L PP$ 4,667.25 722 59525 26 Remove uterus after cesarean $1, 811.259695952526 M i d l e v e lR e m o v e u t er u s a f t erces a re an$ 1,539.55 969 59525 Remove uterus after cesarean $1, 811.253605961026 Vba c d e l i v ery$ 8,099.70 969 59610 26 Midlevel Vbac delivery $6, 884.7596959610 Vba c d e l i v ery$ 8,099.70 360 59612 26 Vbac delivery only $3,411.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 7 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 59612 26 Midlevel Vbac delivery only $2, 899.7596959612 Vba c d e l i v eryo n l y$ 3,411.45 722 59614 26 Vbac care after delivery $4, 219.959695961426 M i d l e v e l Vba cc a re a f t er d e l i v ery$ 3,586.95 969 59614 Vbac care after delivery $4, 219.957225961826 M i d l e v e l A tt e m pt e d v ba c d e l i v ery$ 7,381.85 969 59618 26 Attempted vbac delivery $8, 684.5596959618 A tt e m pt e d v ba c d e l i v ery$ 8,684.55 360 59620 26 Midlevel Attempted vbac delivery only $3, 020.209695962026 A tt e m pt e d v ba c d e l i v eryo n l y$ 3,553.20 969 59620 Attempted vbac delivery only $3, 553.203605962226 M i d l e v e l A tt e m pt e d v ba c a f t erc a re$ 4,091.20 969 59622 26 Attempted vbac after care $4, 813.2096959622 A tt e m pt e d v ba c a f t erc a re$ 4,813.20 360 59812 26 Midlevel Treatment of miscarriage $931.759695981226 T re a t m e n t o f mi sc a rr ia g e$ 1,096.20 969 59812 Treatment of miscarriage $1, 096.203605982026 C a reo f mi sc a rr ia g e$ 1,324.05 969 59820 26 Midlevel Care of miscarriage $1, 125.4596959820 C a reo f mi sc a rr ia g e$ 1,324.05 360 59821 26 Treatment of miscarriage $1, 329.309695982126 M i d l e v e lT re a t m e n t o f mi sc a rr ia g e$ 1,129.90 969 59821 Treatment of miscarriage $1, 329.303605983026 M i d l e v e lT re a t u t er u s in f ec t i o n$ 1,380.70 969 59830 26 Treat uterus infection $1, 624.3596959830 T re a t u t er u s in f ec t i o n$ 1,624.35 360 59840 26 Midlevel Abortion $653.309695984026 A b or t i o n$ 768.60 969 59840 Abortion $768.603605984126 M i d l e v e l A b or t i o n$ 1,139.70 969 59841 26 Abortion $1, 340.8596959841 A b or t i o n$ 1,340.85 360 59850 26 Abortion $1, 261.059695985026 M i d l e v e l A b or t i o n$ 1,071.90 969 59850 Abortion $1, 261.053605985126 A b or t i o n$ 1,485.75 969 59851 26 Midlevel Abortion $1, 262.9096959851 A b or t i o n$ 1,485.75 360 59852 26 Abortion $1, 825.959695985226 M i d l e v e l A b or t i o n$ 1,552.05 969 59852 Abortion $1, 825.953605985526 A b or t i o n$ 1,545.60 969 59855 26 Midlevel Abortion $1, 313.7596959855 A b or t i o n$ 1,545.60 360 59856 26 Abortion $1, 816.509695985626 M i d l e v e l A b or t i o n$ 1,544.05 969 59856 Abortion $1, 816.503605985726 M i d l e v e l A b or t i o n$ 1,594.00 969 59857 26 Abortion $1, 875.3096959857 A b or t i o n$ 1,875.30 360 59866 26 Midlevel Abortion (mpr) $664.909695986626 A b or t i o n (m p r)$ 782.25 969 59866 Abortion (mpr) $782.253605987026 M i d l e v e lE v a c u a t e m o l eo f u t er u s$ 1,495.85 969 59870 26 Evacuate mole of uterus $1, 759.8096959870 E v a c u a t e m o l eo f u t er u s$ 1,759.80 360 59871 26 Remove cerclage suture $499.80 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 8 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 59871 26 Midlevel Remove cerclage suture $424.8596959871 R e m o v ecerc l a g es u t u re$ 499.80 360 59899 Maternity care procedure $996.0036060100 B i o p syo f t h yro i d$ 286.65 360 60200 Remove thyroid lesion $2, 418.1536060210 P a r t ia lt h yro i d e x c i s i o n$ 2,587.20 360 60212 Partial thyroid excision $3, 697.0536060220 P a r t ia l re m o v a l o f t h yro i d$ 2,600.85 360 60225 Partial removal of thyroid $3, 396.7536060240 R e m o v a l o f t h yro i d$ 3,363.15 360 60252 Removal of thyroid $4, 809.0036060254 E x t e n s i v e t h yro i d s u r g ery$ 6,116.25 360 60260 Repeat thyroid surgery $4, 007.8536060270 R e m o v a l o f t h yro i d$ 5,006.40 360 60271 Removal of thyroid $3, 865.0536060280 R e m o v e t h yro i dd u c tl es i o n$ 1,636.95 360 60281 Remove thyroid duct lesion $2, 176.6536060300 A s p i r / inj t h yro i d cys t$ 179.55 360 60500 Explore parathyroid glands $3, 514.3536060502 R e - e x pl ore p a r a t h yro i d s$ 4,656.75 360 60505 Explore parathyroid glands $5, 113.5036060512 A u t o t r an s pl an tp a r a t h yro i d$ 885.15 360 61055 INJECTION INTO BRAIN CANAL $489.4036061070 P U NCT U RES H U NTORRS V RFOR A SPOR I N J$ 191.55 360 61154 BURR HOLE W DR HEMATOM $4, 115.55360 EXTR A D / S U B D U R 61156 B U RR H O L ES; W A SP H EM A T / C Y ST;$ 3,983.95 360 INTRACEREB 61210 26 BURR HOLE IMPLANT VENTRICULAR $1, 020.99960 C A T H / OT H ER D E V I CE 61312 CR A N I ECTOM Y; E V A C H EM A TOMSTE D S D$ 7,635.40 360 61510 REMOVAL OF BRAIN LESION $6, 997.4536061650 E V A SCPR L NG A D MNRX A GNT 1 ST$ 395.85 360 61651 EVASC PRLNG ADMN RX AGNT ADD $395.8536062263 Ep i d u r a ll ys i s m u lt sess i o n s$ 1,239.00 360 62264 Epidural lysis on single day $868.3536062267 I n t er d i sc a lp er q a s p i r d x$ 574.35 360 62268 Drain spinal cord cyst $945.0036062269 N ee d l e bi o p sys p ina l cor d$ 962.85 360 62270 26 Midlevel Lumbar puncture $357.009696227026 Lu mba r p u n c t u re$ 420.00 969 62270 Spinal fluid tap diagnostic $420.0036062272 Dr ain cere b ros p ina l f l u i d$ 309.75 360 62273 Inject epidural patch $411.6036062273 I N J ECT I ONEP I D U R A L B L OO D / C L OTP A TC H$ 346.05 960 62282 INJ NEUROLYTIC; EPIDURAL LUMB/CAUDAL $480.7036062284 I N J ECT I ONFORM Y E L OGR A M$ 185.00 360 63321 26 NJX DX/THER SBST INTRLMNR CRV/THRC $321.66960 W / I MGG D N 62322 N j x in t er l amina r l mb r / s a c$ 289.65 360 62323 NJX INTERLAMINAR LMBR/SAC $333.953606232326 N J X D X / T H ERSBST I NTR L MNR L MBR / S A C$ 297.36 960 W/IMG GDN 62324 26 NJX DX/THER SBST INTRLMNR CRV/THRC $597.24 W/O IMG GDN © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 9 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 62324 NJX DX/THER SBST INTRLMNR CRV/THRC $372.19 W / O I MGG D N 6232526 N J X D X / T H ERSBST I NTR L MNRCR V / T H RC W /$ 764.18 IMG GDN 62326 26 NJX DX/THER SBST INTRLMNR LMBR/SAC $585.99 W / O I MGG D N 6232726 N J X D X / T H ERSBST I NTR L MNR L MBR / S A C$ 777.74 W/IMG GDN 62328 26 DIAGNOSTIC LUMBAR SPINAL PUNCTURE $253.44960 W / F LU ORORCT 6440026 M i d l e v e lN b l oc kinj, t r i g e mina l$ 210.65 969 64400 26 N block inj, trigeminal $247.8096964400 N b l oc kinj, t r i g e mina l$ 247.80 360 64402 26 Midlevel N block inj, facial $231.159696440226 N b l oc kinj, f a c ia l$ 271.95 969 64402 N block inj, facial $271.953606440526 N b l oc kinj, occ i p i t a l$ 224.70 969 64405 26 Midlevel N block inj, occipital $191.0096964405 N b l oc kinj, occ i p i t a l$ 224.70 360 64408 26 N block inj, vagus $285.609696440826 M i d l e v e lN b l oc kinj, v a gu s$ 242.75 969 64408 N block inj, vagus $285.603606441026 N b l oc kinj, p h re ni c$ 318.15 969 64410 26 Midlevel N block inj, phrenic $270.4596964410 N b l oc kinj, p h re ni c$ 318.15 360 64413 26 Midlevel N block inj, cervical plexus $248.109696441326 N b l oc kinj, cer v i c a lpl e xu s$ 291.90 969 64413 N block inj, cervical plexus $291.903606441526 M i d l e v e lN b l oc kinj, b r a c hia lpl e xu s$ 206.15 969 64415 26 N block inj, brachial plexus $242.5596964415 N b l oc kinj, b r a c hia lpl e xu s$ 242.55 360 64416 26 Midlevel N block cont infuse, b plex $249.909696441626 N b l oc k co n t in f u se, b pl e x$ 294.00 969 64416 N block cont infuse, b plex $294.003606441726 M i d l e v e lN b l oc kinj, a x i ll a ry$ 219.55 969 64417 26 N block inj, axillary $258.3096964417 N b l oc kinj, a x i ll a ry$ 258.30 360 64418 26 Midlevel N block inj, suprascapular $229.359696441826 N b l oc kinj, s u p r a sc a p u l a r$ 269.85 969 64418 N block inj, suprascapular $269.853606442026 M i d l e v e lN b l oc kinj, in t ercos t, s n g$ 210.65 969 64420 26 N block inj, intercost, sng $247.8096964420 N b l oc kinj, in t ercos t, s n g$ 247.80 360 64421 26 Midlevel N block inj, intercost, mlt $290.959696442126 N b l oc kinj, in t ercos t, m lt$ 342.30 969 64421 N block inj, intercost, mlt $342.303606442526 N b l oc kinj, i l i o - in g / h y p o g i$ 346.50 969 64425 26 Midlevel N block inj, ilio-ing/hypogi $294.5596964425 N b l oc kinj, i l i o - in g / h y p o g i$ 346.50 360 64430 26 Midlevel N block inj, pudendal $255.259696443026 N b l oc kinj, p u d e n d a l$ 300.30 969 64430 N block inj, pudendal $300.303606443526 M i d l e v e lN b l oc kinj, p a r a cer v i c a l$ 259.70 969 64435 26 N block inj, paracervical $305.5596964435 N b l oc kinj, p a r a cer v i c a l$ 305.55 360 64445 26 N block inj, sciatic, sng $269.859696444526 M i d l e v e lN b l oc kinj, sc ia t i c, s n g$ 229.35 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 10 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 64445 N block inj, sciatic, sng $269.853606444626 M i d l e v e lN b l kinj, sc ia t i c, co n t in f$ 252.60 969 64446 26 N blk inj, sciatic, cont inf $297.1596964446 N b l kinj, sc ia t i c, co n t in f$ 297.15 360 64447 26 Midlevel N block inj fem, single $205.309696444726 N b l oc kinj f e m, s in g l e$ 241.50 969 64447 N block inj fem, single $241.503606444826 M i d l e v e lN b l oc kinj f e m, co n t in f$ 224.90 969 64448 26 N block inj fem, cont inf $264.6096964448 N b l oc kinj f e m, co n t in f$ 264.60 360 64449 26 N block inj, lumbar plexus $306.609696444926 M i d l e v e lN b l oc kinj, l u mba r pl e xu s$ 260.60 969 64449 N block inj, lumbar plexus $306.603606445026 N b l oc k, o t h er p er i p h er a l$ 250.95 969 64450 26 Midlevel N block, other peripheral $213.3096964450 N b l oc k o t h er p er i p h er a l$ 250.95 360 64450 TC INJECTION AA&/STRD OTHER PERIPHERAL $1,317.80 361 NERVE/BRANCH 64450 26 INJECTION AA&/STRD OTHER PERIPHERAL$ 250.95 960 NERVE/BRANCH 64455 N block inj plantar digit $131.25 360 64455 26 NJX AA&/STRD PLANTAR COMMON DIGITAL$ 97.29 960 NERVES 64479 26 Inj foramen epidural c/t $487.209696447926 M i d l e v e l I nj f or am e n e p i d u r a l c / t$ 414.10 969 64479 Inj foramen epidural c/t $487.203606448026 I nj f or am e n e p i d u r a l a dd - o n$ 242.55 969 64480 26 Midlevel Inj foramen epidural add-on $206.1596964480 I nj f or am e n e p i d u r a l a dd - o n$ 242.55 360 64483 26 Inj foramen epidural l/s $407.409696448326 M i d l e v e l I nj f or am e n e p i d u r a ll / s$ 346.30 969 64483 Inj foramen epidural l/s $407.403606448426 M i d l e v e l I nj f or am e n e p i d u r a l a dd - o n$ 163.35 969 64484 26 Inj foramen epidural add-on $192.1596964484 I nj f or am e n e p i d u r a l a dd - o n$ 192.15 360 64490 Inj paravert f jnt c/t 1 lev $403.203606449026 N J X D X / T H ER A GTP V RTF A CET J T$ 317.37 960 CRV/THRC 1 LEVEL 64491 Inj paravert f jnt c/t 2 lev $224.703606449126 N J X D X / T H ER A GTP V RTF A CET J TCR V / T H RC$ 174.75 960 2ND LEVEL 64492 Inj paravert f jnt c/t >=3 lev $227.853606449226 N J X D X / T H ER A GTP V RTF A CET J TCR V / T H RC$ 178.14 960 3+ LEVEL 64493 Inj paravert f jnt l/s 1 lev $339.1536064494 I nj p a r a v er t f jn tl / s 2 l e v$ 190.05 360 64495 Inj paravert f jnt l/s 3 lev $194.253606450526 M i d l e v e lN b l oc k, s p e n o p a l a t in e g an g l$ 258.80 969 64505 26 N block, spenopalatine gangl $304.5096964505 N b l oc k, s p e n o p a l a t in e g an g l$ 304.50 360 64508 26 N block, carotid sinus s/p $279.309696450826 M i d l e v e lN b l oc k, c a ro t i d s in u ss / p$ 237.40 969 64508 N block, carotid sinus s/p $279.303606451026 N b l oc k, s t e ll a t e g an g l i o n$ 263.55 969 64510 26 Midlevel N block, stellate ganglion $224.0096964510 N b l oc k, s t e ll a t e g an g l i o n$ 263.55 360 64517 26 N block inj, hypogas plxs $456.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 11 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 64517 26 Midlevel N block inj, hypogas plxs $388.2596964517 N b l oc kinj, h y p o g a s pl x s$ 456.75 360 64520 26 N block, lumbar/thoracic $291.909696452026 M i d l e v e lN b l oc k, l u mba r / t h or a c i c$ 248.10 969 64520 N block, lumbar/thoracic $291.903606453026 N b l oc kinj, ce l ia c p e l u s$ 338.10 969 64530 26 Midlevel N block inj, celiac pelus $287.4096964530 N b l oc kinj, ce l ia c p e l u s$ 338.10 360 64550 26 Apply neurostimulator $32.559696455026 M i d l e v e l A ppl y n e u ros t im u l a t or$ 27.65 969 64550 Apply neurostimulator $32.5536064615 C H EMO D ENER V M U SCM I GR A I NE$ 411.65 360 64636 26 DSTR NROLYTC AGNT PARVERTEB FCT $173.07960 A DD LL MBR / S A CR A L 64624 TC D ESTR U CT I ONNE U RO L Y T I C A GT$ 3,679.26 361 GENICULAR NERVE W/IMG 64624 26 DESTRUCTION NEUROLYTIC AGT $442.23960 GEN I C UL A RNER V E W / I MG 6464626 C H EMO D ENER V A T I ONOFTR U N K M U SC L E$ 344.91 960 1-5 MUSCLES 64646 TC CHEMODENERVATION OF TRUNK MUSCLE $1, 317.803691 - 5 M U SC L ES 64721 C A RP A L T U NNE L S U RGER Y$ 1,371.50 975 64831 SUTURE DIGITAL NERVE HAND/FOOT 1 $2, 208.63969 NER V E 6520526 M i d l e v e lR e m o v e f ore i g nb o d y f ro m eye$ 133.90 969 65205 26 Remove foreign body from eye $157.5096965205 R e m o v e f ore i g nb o d y f ro m eye$ 157.50 360 65210 26 Midlevel Remove foreign body from eye $165.109696521026 R e m o v e f ore i g nb o d y f ro m eye$ 194.25 969 65210 Remove foreign body from eye $194.253606522026 M i d l e v e lR e m o v e f ore i g nb o d y f ro m eye$ 130.30 969 65220 26 Remove foreign body from eye $153.3096965220 R e m o v e f ore i g nb o d y f ro m eye$ 153.30 360 65222 26 Remove foreign body from eye $212.109696522226 M i d l e v e lR e m o v e f ore i g nb o d y f ro m eye$ 180.30 969 65222 Remove foreign body from eye $212.103606523526 R e m o v e f ore i g nb o d y f ro m eye$ 2,541.00 969 65235 26 Midlevel Remove foreign body from eye $2, 159.8596965235 R e m o v e f ore i g nb o d y f ro m eye$ 2,541.00 360 65260 26 Midlevel Remove foreign body from eye $2, 834.609696526026 R e m o v e f ore i g nb o d y f ro m eye$ 3,334.80 969 65260 Remove foreign body from eye $3, 334.803606526526 M i d l e v e lR e m o v e f ore i g nb o d y f ro m eye$ 3,410.25 969 65265 26 Remove foreign body from eye $4, 012.0596965265 R e m o v e f ore i g nb o d y f ro m eye$ 4,012.05 360 65426 TC EXCISION/TRANSPOSITION PTERYGIUM $4, 452.96369 W / GR A FG 66625 I R I D ECTOM Y PER I P H ER A L FORG L A U COM A$ 1,494.60 360 66820 26 Midlevel Incision, secondary cataract $882.709696682026 I n c i s i o n, seco n d a ryc a t a r a c t$ 1,038.45 969 66820 Incision, secondary cataract $3, 842.203606682126 A f t erc a t a r a c tl a sers u r g ery$ 412.65 969 66821 26 Midlevel After cataract laser surgery $350.7096966821 A f t erc a t a r a c tl a sers u r g ery$ 975.95 360 66825 26 Reposition intraocular lens $296.109696682526 M i d l e v e lR e p os i t i o nin t r a oc u l a r l e n s$ 252.10 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 12 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 66825 Reposition intraocular lens $3, 842.203606698226 C a t a r a c t s u r g ery, co m pl e x$ 3,833.55 969 66982 26 Midlevel Cataract surgery, complex $3, 258.5096966982 C a t a r a c t s u r g ery, co m pl e x$ 3,833.55 360 66983 26 Midlevel Cataract surg w/iol, 1 stage $2, 215.209696698326 C a t a r a c t s u r g w / i o l, 1 s t a g e$ 2,606.10 969 66983 Cataract surg w/iol, 1 stage $2, 606.103606698426 M i d l e v e lC a t a r a c t s u r g w / i o l, 1 s t a g e$ 2,350.85 969 66984 26 Cataract surg w/iol, 1 stage $2, 765.7096966984 C A TRCTS U RG W / I O L 1 STGEXTR A C A P$ 2,765.70 360 66985 26 Insert lens prosthesis $2, 755.209696698526 M i d l e v e l I n ser tl e n s p ros t h es i s$ 2,341.90 969 66985 Insert lens prosthesis $2, 755.203606698626 M i d l e v e lE x c han g e l e n s p ros t h es i s$ 2,770.30 969 66986 26 Exchange lens prosthesis $3, 259.2096966986 E x c han g e l e n s p ros t h es i s$ 3,259.20 360 66990 26 Ophthalmic endoscope add-on $315.009696699026 M i d l e v e lOp h t ha l mi ce n d osco p e a dd - o n$ 267.75 969 66990 Ophthalmic endoscope add-on $315.0036066999 E yes u r g ery p roce d u re$ 3,842.20 360 67005 26 Partial removal of eye fluid $1, 747.209696700526 M i d l e v e lP a r t ia l re m o v a l o f eye f l u i d$ 1,485.10 969 67005 Partial removal of eye fluid $1, 747.203606701026 M i d l e v e lP a r t ia l re m o v a l o f eye f l u i d$ 1,656.50 969 67010 26 Partial removal of eye fluid $1, 948.8096967010 P a r t ia l re m o v a l o f eye f l u i d$ 1,948.80 360 67015 26 Midlevel Release of eye fluid $1, 769.859696701526 R e l e a seo f eye f l u i d$ 2,082.15 969 67015 Release of eye fluid $2, 082.153606702526 R e pl a ceeye f l u i d$ 2,307.90 969 67025 26 Midlevel Replace eye fluid $1, 961.7096967025 R e pl a ceeye f l u i d$ 2,307.90 360 67027 26 Implant eye drug system $3, 115.359696702726 M i d l e v e l I m pl an t eye d r ug sys t e m$ 2,648.05 969 67027 Implant eye drug system $3, 115.353606702826 M i d l e v e l I nj ec t i o n eye d r ug$ 322.20 969 67028 26 Injection eye drug $379.0596967028 I nj ec t i o n eye d r ug$ 379.05 360 67030 26 Incise inner eye strands $1, 849.059696703026 M i d l e v e l I n c i se inn ereyes t r an d s$ 1,571.70 969 67030 Incise inner eye strands $1, 849.053606703126 L a sers u r g ery, eyes t r an d s$ 1,275.75 969 67031 26 Midlevel Laser surgery, eye strands $1, 084.4096967031 L a sers u r g ery, eyes t r an d s$ 1,275.75 360 67036 26 Removal of inner eye fluid $3, 449.259696703626 M i d l e v e lR e m o v a l o f inn ereye f l u i d$ 2,931.85 969 67036 Removal of inner eye fluid $3, 449.253606703926 M i d l e v e l L a ser t re a t m e n t o f re t ina$ 3,843.10 969 67039 26 Laser treatment of retina $4, 521.3096967039 L a ser t re a t m e n t o f re t ina$ 4,521.30 360 67040 26 Laser treatment of retina $5, 109.309696704026 M i d l e v e l L a ser t re a t m e n t o f re t ina$ 4,342.90 969 67040 Laser treatment of retina $5, 109.303606710126 R e p ai r d e t a c h e d re t ina$ 2,461.20 969 67101 26 Midlevel Repair detached retina $2, 092.0096967101 R e p ai r d e t a c h e d re t ina$ 2,461.20 360 67105 26 Repair detached retina $2,312.10 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 13 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 67105 26 Midlevel Repair detached retina $1, 965.3096967105 R e p ai r d e t a c h e d re t ina$ 2,312.10 360 67107 26 Repair detached retina $4, 450.959696710726 M i d l e v e lR e p ai r d e t a c h e d re t ina$ 3,783.30 969 67107 Repair detached retina $4, 450.953606710826 R e p ai r d e t a c h e d re t ina$ 5,778.15 969 67108 26 Midlevel Repair detached retina $4, 911.4596967108 R e p ai r d e t a c h e d re t ina$ 5,778.15 360 67110 26 Repair detached retina $2, 768.859696711026 M i d l e v e lR e p ai r d e t a c h e d re t ina$ 2,353.50 969 67110 Repair detached retina $2, 768.8536067113 R e p ai rre t ina l d e t a c h c pl x$ 6,276.90 360 67115 26 Release encircling material $1, 780.809696711526 M i d l e v e lR e l e a see n c i rc l in g ma t er ia l$ 1,513.70 969 67115 Release encircling material $1, 780.803606712026 M i d l e v e lR e m o v eeye im pl an t ma t er ia l$ 1,745.75 969 67120 26 Remove eye implant material $2, 053.8096967120 R e m o v eeye im pl an t ma t er ia l$ 2,053.80 360 67121 26 Remove eye implant material $3, 322.209696712126 M i d l e v e lR e m o v eeye im pl an t ma t er ia l$ 2,823.85 969 67121 Remove eye implant material $3, 322.203606714126 M i d l e v e lT re a t m e n t o f re t ina$ 1,511.00 969 67141 26 Treatment of retina $1, 777.6596967141 T re a t m e n t o f re t ina$ 1,777.65 360 67145 26 Midlevel Treatment of retina $1, 515.459696714526 T re a t m e n t o f re t ina$ 1,782.90 969 67145 Treatment of retina $1, 782.903606720826 T re a t m e n t o f re t ina ll es i o n$ 2,010.75 969 67208 26 Midlevel Treatment of retinal lesion $1, 709.1596967208 T re a t m e n t o f re t ina ll es i o n$ 2,010.75 360 67210 26 Treatment of retinal lesion $1, 832.259696721026 M i d l e v e lT re a t m e n t o f re t ina ll es i o n$ 1,557.40 969 67210 Treatment of retinal lesion $1, 832.253606721826 M i d l e v e lT re a t m e n t o f re t ina ll es i o n$ 4,093.90 969 67218 26 Treatment of retinal lesion $4, 816.3596967218 T re a t m e n t o f re t ina ll es i o n$ 4,816.35 360 67220 26 Treatment of choroid lesion $1, 965.609696722026 M i d l e v e lT re a t m e n t o f c h oro i d l es i o n$ 1,670.75 969 67220 Treatment of choroid lesion $1, 965.603606722126 M i d l e v e lO c u l a r p h o t o d y nami c t h er$ 659.55 969 67221 26 Ocular photodynamic ther $775.9596967221 O c u l a r p h o t o d y nami c t h er$ 775.95 360 67225 26 Midlevel Eye photodynamic ther add-on $83.009696722526 E ye p h o t o d y nami c t h er a dd - o n$ 97.65 969 67225 Eye photodynamic ther add-on $97.653606722726 M i d l e v e lT re a t m e n t o f re t ina ll es i o n$ 1,687.70 969 67227 26 Treatment of retinal lesion $1, 985.5596967227 T re a t m e n t o f re t ina ll es i o n$ 1,985.55 360 67228 26 Midlevel Treatment of retinal lesion $2, 989.909696722826 T re a t m e n t o f re t ina ll es i o n$ 3,517.50 969 67228 Treatment of retinal lesion $3, 517.5036067229 T rre t ina ll es p re t er min f$ 3,900.75 360 67250 26 Midlevel Reinforce eye wall $2, 413.309696725026 R e in f orceeye w a ll$ 2,839.20 969 67250 Reinforce eye wall $2, 839.203606725526 M i d l e v e lR e in f orce / g r a f t eye w a ll$ 667.50 969 67255 26 Reinforce/graft eye wall $785.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 14 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 67255 Reinforce/graft eye wall $3, 842.2036067299 E yes u r g ery p roce d u re$ 3,842.20 360 67311 26 Revise eye muscle $2, 176.659696731126 M i d l e v e lR e v i seeye m u sc l e$ 1,850.15 969 67311 REVISE EYE MUSCLE 1 HORIZONTAL $2, 176.65360 M U SC L E 6731226 M i d l e v e lR e v i se tw oeye m u sc l es$ 2,236.60 969 67312 26 Revise two eye muscles $2, 631.3096967312 R e v i se tw oeye m u sc l es$ 2,631.30 360 67314 26 Revise eye muscle $2, 449.659696731426 M i d l e v e lR e v i seeye m u sc l e$ 2,082.20 969 67314 REVISE EYE MUSCLE 1 VERTICAL MUSCLE $2, 449.653606731626 M i d l e v e lR e v i se tw oeye m u sc l es$ 2,516.85 969 67316 26 Revise two eye muscles $2, 961.0096967316 R e v i se tw oeye m u sc l es$ 2,961.00 360 67318 26 Midlevel Revise eye muscle(s) $2, 083.109696731826 R e v i seeye m u sc l e (s)$ 2,450.70 969 67318 Revise eye muscle(s) $2, 450.703606732026 R e v i seeye m u sc l e (s) a dd - o n$ 1,124.55 969 67320 26 Midlevel Revise eye muscle(s) add-on $955.8596967320 R e v i seeye m u sc l e (s) a dd - o n$ 1,124.55 360 67331 26 Midlevel Eye surgery follow-up add-on $956.759696733126 E yes u r g ery f o ll o w - u p a dd - o n$ 1,125.60 969 67331 Eye surgery follow-up add-on $1, 125.603606733226 M i d l e v e lR ere v i seeye m u sc l es a dd - o n$ 1,039.75 969 67332 26 Rerevise eye muscles add-on $1, 223.2596967332 R ere v i seeye m u sc l es a dd - o n$ 1,223.25 360 67334 26 Midlevel Revise eye muscle w/suture $892.509696733426 R e v i seeye m u sc l e w / s u t u re$ 1,050.00 969 67334 Revise eye muscle w/suture $1, 050.003606733526 E yes u t u re d u r in g s u r g ery$ 549.15 969 67335 26 Midlevel Eye suture during surgery $466.8096967335 E yes u t u re d u r in g s u r g ery$ 549.15 360 67340 26 Revise eye muscle add-on $1, 249.509696734026 M i d l e v e lR e v i seeye m u sc l e a dd - o n$ 1,062.10 969 67340 Revise eye muscle add-on $1, 249.503606734326 M i d l e v e lR e l e a seeye t i ss u e$ 2,042.05 969 67343 26 Release eye tissue $2, 402.4096967343 R e l e a seeye t i ss u e$ 2,402.40 360 67345 26 Destroy nerve of eye muscle $807.459696734526 M i d l e v e l Des t roy n er v eo f eye m u sc l e$ 686.35 969 67345 Destroy nerve of eye muscle $807.453606734626 M i d l e v e lB i o p sy, eye m u sc l e$ 637.25 969 67346 26 Biopsy, eye muscle $749.7096967346 B i o p sy, eye m u sc l e$ 749.70 360 67700 BLEPHAROTOMY DRAIN ABSC EYELID $441.7036067840 EXC L ES I ONE Y E L I D W /0 C L SR / W / S I MP L E D I R$ 1,745.28 360 CLOSURE 67840 EXC LESION EYELID W/0 CLSR/W/SIMPLE DIR $500.52960 C L OS U RE 67875 TCTEMPOR A R Y C L OS U REE Y E L I D SS U T U RE$ 1,745.28 68811 26 Probe nasolacrimal duct $760.209696881126 M i d l e v e lP ro b e na so l a cr ima l d u c t$ 646.15 969 68811 Probe nasolacrimal duct $760.203606881526 P ro b e na so l a cr ima l d u c t$ 942.90 969 68815 26 Midlevel Probe nasolacrimal duct $801.4596968815 P ro b e na so l a cr ima l d u c t$ 942.90 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 15 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 68840 26 Midlevel Explore/irrigate tear ducts $359.709696884026 E x pl ore / i rr i g a t e t e a r d u c t s$ 423.15 969 68840 Explore/irrigate tear ducts $423.153606885026 I nj ec t i o n f or t e a rs a c x - r a y$ 195.30 969 68850 26 Midlevel Injection for tear sac x-ray $166.0096968850 I nj ec t i o n f or t e a rs a c x - r a y$ 195.30 360 68899 Tear duct system surgery $535.303606900026 M i d l e v e l Dr aina g ee x t er na l e a r, s im pl e$ 375.75 969 69000 26 Drainage external ear,simple $442.0596969000 Dr aina g ee x t er na l e a r, s im pl e$ 442.05 360 69005 26 Midlevel Drainage external ear,complex $496.259696900526 Dr aina g ee x t er na l e a r, co m pl e x$ 583.80 969 69005 Drainage external ear,complex $583.803606902026 M i d l e v e l Dr aina g e, e x t . a u d i t oryc ana l$ 454.30 969 69020 26 Drainage,ext.auditory canal $534.4596969020 Dr aina g e, e x t . a u d i t oryc ana l$ 534.45 360 69100 26 Biopsy of external ear $180.609696910026 M i d l e v e lB i o p syo f e x t er na l e a r$ 153.50 969 69100 Biopsy of external ear $180.603606910526 B i o p syo f e x t er na l e a rc ana l$ 236.25 969 69105 26 Midlevel Biopsy of external ear canal $200.8096969105 B i o p syo f e x t er na l e a rc ana l$ 236.25 360 69110 26 Remove external ear, partial $1, 209.609696911026 M i d l e v e lR e m o v ee x t er na l e a r, p a r t ia l$ 1,028.15 969 69110 Remove external ear, partial $1, 209.603606912026 R e m o v a l o f e x t er na l e a r$ 1,498.35 969 69120 26 Midlevel Removal of external ear $1, 273.6096969120 R e m o v a l o f e x t er na l e a r$ 1,498.35 360 69140 26 Remove ear canal lesion(s) $3, 283.359696914026 M i d l e v e lR e m o v ee a rc ana ll es i o n (s)$ 2,790.85 969 69140 Remove ear canal lesion(s) $3, 283.353606914526 M i d l e v e lR e m o v ee a rc ana ll es i o n (s)$ 791.65 969 69145 26 Remove ear canal lesion(s) $931.3596969145 R e m o v ee a rc ana ll es i o n (s)$ 931.35 360 69150 26 Midlevel Extensive ear canal surgery $3, 311.209696915026 E x t e n s i v ee a rc ana l s u r g ery$ 3,895.50 969 69150 Extensive ear canal surgery $3, 895.503606915526 E x t e n s i v ee a r / n ec k s u r g ery$ 6,212.85 969 69155 26 Midlevel Extensive ear/neck surgery $5, 280.9096969155 E x t e n s i v ee a r / n ec k s u r g ery$ 6,212.85 360 69200 26 Clear outer ear canal $213.159696920026 M i d l e v e lCl e a ro u t ere a rc ana l$ 181.20 969 69200 Clear outer ear canal $213.153606920526 Cl e a ro u t ere a rc ana l$ 375.90 969 69205 26 Midlevel Clear outer ear canal $319.5096969205 Cl e a ro u t ere a rc ana l$ 375.90 360 69209 REMOVE IMPACTED EAR WAX UNI $44.053606921026 R e m o v e im p a c t e d e a r w a x$ 118.65 983 69210 26 Midlevel Remove impacted ear wax $100.8596969210 REMO V E I MP A CTE D E A R W A X$ 118.65 510 W/INSTRUMENT 69220 26 Debridement,mast,simple $229.959696922026 M i d l e v e l De b r i d e m e n t, ma s t, s im pl e$ 195.45 969 69220 Debridement,mast,simple $229.953606922226 De b r i d e m e n t, ma s t, co m pl e x$ 513.45 969 69222 26 Midlevel Debridement,mast,complex $436.4596969222 De b r i d e m e n t, ma s t, co m pl e x$ 513.45 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 16 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 69320 26 Reconstruction,external aud $5, 718.309696932026 M i d l e v e lR eco n s t r u c t i o n, e x t er na l a u d$ 4,860.55 969 69320 Reconstruction,external aud $5, 718.303606942026 M yr in g o t o m y w / o an es t h es ia$ 450.45 969 69420 26 Midlevel Myringotomy w/o anesthesia $382.9096969420 M yr in g o t o m y w / o an es t h es ia$ 450.45 360 69421 26 Myringotomy w/ anesthesia $559.659696942126 M i d l e v e lM yr in g o t o m y w / an es t h es ia$ 475.70 969 69421 Myringotomy w/ anesthesia $559.653606942426 V e n t i l a t in g t u b ere m o v a l$ 231.00 969 69424 26 Midlevel Ventilating tube removal $196.3596969424 V e n t i l a t in g t u b ere m o v a l$ 231.00 360 69433 26 Midlevel Tympanostomy,local anesth $414.109696943326 T y m p an os t o m y, l oc a l an es t h$ 487.20 969 69433 Tympanostomy,local anesth $487.203606943626 T y m p an os t o m y, g e n er a l an es t h$ 602.70 969 69436 26 Midlevel Tympanostomy,general anesth $512.3096969436 T y m p an os t o m y, g e n er a l an es t h$ 602.70 360 69440 26 Midlevel Middle ear exploration $2, 187.509696944026 M i dd l ee a re x pl or a t i o n$ 2,573.55 969 69440 Middle ear exploration $2, 573.553606950126 M i d l e v e lT r an s ma s t o i d an t ro t o m y$ 2,318.70 969 69501 26 Transmastoid antrotomy $2, 727.9096969501 T r an s ma s t o i d an t ro t o m y$ 2,727.90 360 69502 26 Midlevel Mastoidectomy, complete $3, 076.459696950226 M a s t o i d ec t o m y, co m pl e t e$ 3,619.35 969 69502 Mastoidectomy, complete $3, 619.353606950526 M a s t o i d ec t o m y, m o d . r a d i c a l$ 4,501.35 969 69505 26 Midlevel Mastoidectomy,mod. radical $3, 826.1596969505 M a s t o i d ec t o m y, m o d . r a d i c a l$ 4,501.35 360 69511 26 Midlevel Mastoidectomy, radical $3, 920.759696951126 M a s t o i d ec t o m y, r a d i c a l$ 4,612.65 969 69511 Mastoidectomy, radical $4, 612.653606954026 E x c i s i o na u r a lp o l y p$ 478.80 969 69540 26 Midlevel Excision aural polyp $407.0096969540 E x c i s i o na u r a lp o l y p$ 478.80 360 69610 26 Tympanic memb repair $1, 086.759696961026 M i d l e v e lT y m p ani c m e mb re p ai r$ 923.75 969 69610 Tympanic memb repair $1, 086.753606962026 M i d l e v e lM yr in g o pl a s t y$ 1,546.70 969 69620 26 Myringoplasty $1, 819.6596969620 M yr in g o pl a s t y$ 1,819.65 360 69631 26 Tympanoplasty w/o ossicular $3, 302.259696963126 M i d l e v e lT y m p an o pl a s t y w / ooss i c u l a r$ 2,806.90 969 69631 Tympanoplasty w/o ossicular $3, 302.253606963226 T y m p an o pl a s t y w / oss i c u l a r$ 4,024.65 969 69632 26 Midlevel Tympanoplasty w/ ossicular $3, 420.9596969632 T y m p an o pl a s t y w / oss i c u l a r$ 4,024.65 360 69641 26 Midlevel Tympanoplasty, middle ear $3, 304.059696964126 T y m p an o pl a s t y, mi dd l ee a r$ 3,887.10 969 69641 Tympanoplasty, middle ear $3, 887.103606966026 M i d l e v e lSt a p e d ec t o m y$ 2,939.90 969 69660 26 Stapedectomy $3, 458.7096969660 St a p e d ec t o m y$ 3,458.70 360 69720 26 Decompression facial nerve $4, 422.609696972026 M i d l e v e l Deco m p ress i o n f a c ia l n er v e$ 3,759.20 969 69720 Decompression facial nerve $4,422.60 360 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 17 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 69801 TC LABYRINTHOTOMY TRANSCANAL $2, 776.286980126 L A B Y R I NT H OTOM Y TR A NSC A N A L$ 386.73925 69960 26 Midlevel Decompression, internal canal $6, 085.059696996026 Deco m p ress i o n, in t er na l c ana l$ 7,158.90 969 69960 Decompression, internal canal $7, 158.903607001026 M i d l e v e lC o n t r a s t x - r a yo f b r ain$ 411.20 969 70010 26 Contrast x-ray of brain $483.7596970010 M Y E L OGR A P H Y POSTER I ORFOSS A$ 344.40 320 70015 26 Contrast x-ray of brain $215.259727001526 M i d l e v e lC o n t r a s t x - r a yo f b r ain$ 182.95 972 70015 CISTERNOGRAPHY $569.1032970015 TCC I STERNOGR A P H Y$ 353.85 320 70030 26 Midlevel X-ray eye for foreign body $24.999727003026 X - r a yeye f or f ore i g nb o d y$ 29.40 972 70030 X-RAY EYE FOR FOREIGN BODY $106.0532970030 TCX - R A Y E Y EFORFORE I GNBO D Y$ 76.65 320 70100 26 Midlevel X-ray exam of jaw $27.659727010026 X - r a ye x am o f ja w$ 32.55 972 70100 X-RAY EXAM OF JAW <4VIEWS $127.0532970100 TCX - R A Y EX A MOF J A W < 4 V I E W S$ 94.50 320 70110 26 Midlevel X-ray exam of jaw $37.459727011026 X - r a ye x am o f ja w$ 44.10 972 70110 TC X-RAY EXAM OF JAW 4+ VIEWS $102.9032070110 X - R A Y EX A MOF J A W 4 + V I E W S$ 147.00 320 70120 26 X-ray exam of mastoids $33.609727012026 M i d l e v e lX - r a ye x am o f ma s t o i d s$ 28.56 972 70120 X-RAY EXAM OF MASTOIDS <3 VIEWS $134.4032970120 TCX - R A Y EX A MOFM A STO I D S < 3 V I E W S$ 100.80 320 70130 26 Midlevel X-ray exam of mastoids $51.809727013026 X - r a ye x am o f ma s t o i d s$ 60.90 972 70130 X-RAY EXAM OF MASTOIDS 3+ VIEWS $212.1032970130 TCX - R A Y EX A MOFM A STO I D S$ 151.20 320 70134 26 X-ray exam of middle ear $64.059727013426 M i d l e v e lX - r a ye x am o f mi dd l ee a r$ 54.45 972 70134 X-RAY EXAM OF MIDDLE EAR $207.9032970134 TCX - R A Y EX A MOFM I DD L EE A R$ 143.85 320 70140 26 Midlevel X-ray exam of facial bones $30.359727014026 X - r a ye x am o ff a c ia l b o n es$ 35.70 972 70140 X-RAY EXAM OF FACIAL BONES <3 VIEWS $112.3532970140 TCX - R A Y EX A MOFF A C I A L BONES < 3 V I E W S$ 76.65 320 70150 26 X-ray exam of facial bones $46.209727015026 M i d l e v e lX - r a ye x am o ff a c ia l b o n es$ 39.30 972 70150 X-RAY EXAM OF FACIAL BONES 3+ VIEWS $158.5532970150 TCX - R A Y EX A MOFF A C I A L BONES 3 + V I E W S$ 112.35 320 70160 26 X-ray exam of nasal bones $31.509727016026 M i d l e v e lX - r a ye x am o f na s a l b o n es$ 28.65 972 70160 X-RAY EXAM OF NASAL BONES 3+ VIEWS $123.9032070160 TCX - R A Y EX A MOFN A S A L BONES 3 + V I E W S$ 92.40 320 70170 26 X-ray exam of tear duct $54.609727017026 M i d l e v e lX - r a ye x am o f t e a r d u c t$ 46.41 972 70170 X-ray exam of tear duct $149.6032070170 TCX - R A Y EX A MOFTE A R D U CT$ 95.00 320 70190 26 Midlevel X-ray exam of eye sockets $33.009727019026 X - r a ye x am o f eyesoc k e t s$ 38.85 972 70190 X-RAY EXAM OF EYE SOCKETS $133.3532970190 TCX - R A Y EX A MOFE Y ESOC K ETS$ 94.50 320 70200 26 Midlevel X-ray exam of eye sockets $41.94 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 18 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 70200 26 X-ray exam of eye sockets $49.3597270200 X - R A Y EX A MOFE Y ESOC K ETS 4 + V I E W S$ 161.70 329 70200 TC X-RAY EXAM OF EYE SOCKETS $112.353207021026 M i d l e v e lX - r a ye x am o f s in u ses$ 25.90 972 70210 26 X-ray exam of sinuses $30.4597270210 X - R A Y EX A MOFS I N U SES < 3 V I E W S$ 116.55 329 70210 TC X-RAY EXAM OF SINUSES $86.103207022026 X - r a ye x am o f s in u ses$ 44.10 972 70220 26 Midlevel X-ray exam of sinuses $37.5097270220 X - R A Y EX A MOFS I N U SES 3 + V I E W S$ 145.95 329 70220 TC X-RAY EXAM OF SINUSES $101.853207024026 M i d l e v e lX - r a ye x am, p i t u i t a rys a dd l e$ 29.45 972 70240 26 X-ray exam, pituitary saddle $34.6597270240 X - R A Y EX A MP I T U I T A R Y S A DD L E$ 111.30 329 70240 TC X-RAY EXAM PITUITARY SADDLE $76.653207025026 X - r a ye x am o f s k u ll$ 43.05 972 70250 26 Midlevel X-ray exam of skull $36.6097270250 X - R A Y EX A MOFS K ULL < 4 V I E W S$ 137.55 320 70250 TC X-RAY EXAM OF SKULL <4 VIEWS $94.503207026026 M i d l e v e lX - r a ye x am o f s k u ll$ 51.75 972 70260 26 X-ray exam of skull $60.9097270260 TCX - R A Y EX A MOFS K ULL 4 + V I E W S$ 115.50 320 70260 X-RAY EXAM OF SKULL 4+ VIEWS $176.403207030026 X - r a ye x am o f t ee t h$ 21.00 972 70300 26 Midlevel X-ray exam of teeth $17.8597270300 X - R A Y EX A MOFTEET H$ 54.60 329 70300 TC X-RAY EXAM OF TEETH $33.603207031026 M i d l e v e lX - r a ye x am o f t ee t h$ 25.00 972 70310 26 X-ray exam of teeth $29.4097270310 TEET H; P A RT I A L EX A M < F ULL MO U T H$ 139.65 329 70310 TC X-RAY EXAM OF TEETH $110.253207032026 M i d l e v e lF u ll m o u t h x - r a yo f t ee t h$ 35.70 972 70320 26 Full mouth x-ray of teeth $42.0097270320 F ULL MO U T H X - R A Y OFTEET H$ 190.05 329 70320 TC FULL MOUTH X-RAY OF TEETH $148.053207032826 X - r a ye x am o f ja w j o in t$ 32.55 972 70328 26 Midlevel X-ray exam of jaw joint $27.6597270328 TM JJ O I NT - U N I L A TER A L$ 115.50 329 70328 TC TMJ JOINT - UNILATERAL $82.953207033026 M i d l e v e lX - r a ye x am o f ja w j o in t s$ 37.50 972 70330 26 X-ray exam of jaw joints $44.1097270330 TM JJ O I NT - B I L A TER A L$ 180.60 329 70330 TC TMJ JOINT - BILATERAL $136.503207033226 M i d l e v e lX - r a ye x am o f ja w j o in t$ 81.20 972 70332 26 X-ray exam of jaw joint $95.55972 [R o w s 11001 - 12000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 70332 TM JJ O I NT A RT H ROGR A P H Y$ 278.25 329 70332 TC TMJ JOINT ARTHROGRAPHY $182.703207035026 X - r a y h e a df oror t h o d o n t ia$ 34.65 972 70350 26 Midlevel X-ray head for orthodontia $29.4597270350 X - R A Y H E A D FORORT H O D ONT I A$ 78.75 329 70350 TC X-RAY HEAD FOR ORTHODONTIA $44.103207035526 M i d l e v e lP an or ami c x - r a yo f ja w s$ 33.00 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 19 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 70355 26 Panoramic x-ray of jaws $38.8597270355 P A NOR A M I CX - R A Y OF J A W S$ 77.70 329 70355 TC PANORAMIC X-RAY OF JAWS $38.853207036026 M i d l e v e lX - r a ye x am o f n ec k$ 33.30 972 70360 26 X-ray exam of neck $39.2097270360 TCXRNEC K SOFTT I SS U E$ 73.70 320 70360 XR NECK SOFT TISSUE $112.90 320 70370 26 Throat x-ray & fluoroscopy$ 56.70 972 70370 26 Midlevel Throat x-ray & fluoroscopy $48.20 972 70370 THROAT X-RAY & FLUOROSCOPY$ 319.20 329 70370 TC THROAT X-RAY & FLUOROSCOPY $262.503207037126 M i d l e v e lSp eec h e v a l u a t i o n, co m pl e x$ 125.85 972 70371 26 Speech evaluation, complex $148.0597270371 C I NEOR V I D EOSPEEC H E V A L$ 346.50 329 70371 TC CINE OR VIDEO SPEECH EVAL $198.453207038026 X - r a ye x am o f s a l i v a ry g l an d$ 33.60 972 70380 26 Midlevel X-ray exam of salivary gland $28.6097270380 X - R A Y EX A MOFS A L I V A R Y G L A N D$ 150.15 329 70380 TC X-RAY EXAM OF SALIVARY GLAND $116.553207039026 X - r a ye x am o f s a l i v a ry d u c t$ 68.25 972 70390 26 Midlevel X-ray exam of salivary duct $58.0097270390 X - R A Y EX A MOFS A L I V A R Y D U CT$ 380.10 329 70390 TC X-RAY EXAM OF SALIVARY DUCT $311.853207045026 M i d l e v e lCt h e a d / b r ain w / o d ye$ 127.65 972 70450 26 Ct head/brain w/o dye $150.1597270450 Ct h e a d / b r ain w / o d ye$ 403.56 351 70450 TC Ct head/brain w/o dye $253.413517046026 Ct h e a d / b r ain w / d ye$ 199.50 972 70460 26 Midlevel Ct head/brain w/dye $169.6097270460 Ct h e a d / b r ain w / d ye$ 569.40 351 70460 TC Ct head/brain w/dye $369.90 351 70470 26 Ct head/brain w/o & w/dye$ 224.70 972 70470 26 Midlevel Ct head/brain w/o & w/dye $199.99 972 70470 Ct head/brain w/o & w/dye$ 667.71 351 70470 TC Ct head/brain w/o & w/dye $443.013517048026 CT - ORB I TSE LL A M I D / I NNERE A R W OCONT$ 227.85 972 70480 26 Midlevel Ct orbit/ear/fossa w/o dye $193.7097270480 Ct or bi t / e a r / f oss a w / o d ye$ 615.09 351 70480 TC Ct orbit/ear/fossa w/o dye $387.243517048126 M i d l e v e lCt or bi t / e a r / f oss a w / d ye$ 207.95 972 70481 26 Ct orbit/ear/fossa w/dye $244.6597270481 TCCt or bi t / e a r / f oss a w / d ye$ 693.27 351 70481 Ct orbit/ear/fossa w/dye $937.92 351 70482 26 Ct orbit/ear/fossa w/o&w/dye$ 256.20 972 70482 26 Midlevel Ct orbit/ear/fossa w/o&w/dye $217.75 972 70482 TC Ct orbit/ear/fossa w/o&w/dye$ 692.70 351 70482 Ct orbit/ear/fossa w/o&w/dye $948.903517048626 Ct ma x i ll o f a c ia lw / o d ye$ 201.60 972 70486 26 Midlevel Ct maxillofacial w/o dye $171.3597270486 Ct ma x i ll o f a c ia lw / o d ye$ 911.40 351 70486 TC Ct maxillofacial w/o dye $709.803517048726 Ct ma x i ll o f a c ia lw / d ye$ 229.95 972 70487 26 Midlevel Ct maxillofacial w/dye $195.4597270487 CTM A X I LL OF A C I A L W / D Y E$ 1,097.25 351 70487 TC CT MAXILLOFACIAL W/DYE $867.30 350 70488 26 Midlevel Ct maxillofacial w/o & w/dye$ 210.65 972 70488 26 Ct maxillofacial w/o & w/dye $247.80 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 20 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 70488 TC Ct maxillofacial w/o & w/dye $1,076.25 351 70488 Ct maxillofacial w/o & w/dye$ 1,324.05 351 70490 26 Midlevel Ct soft tissue neck w/o dye $193.659727049026 Ct so f tt i ss u e n ec k w / o d ye$ 227.85 972 70490 TC Ct soft tissue neck w/o dye $661.5035170490 Ct so f tt i ss u e n ec k w / o d ye$ 889.35 351 70491 26 CT - ST NECK W CONTR $244.659727049126 M i d l e v e lCt so f tt i ss u e n ec k w / d ye$ 207.95 972 70491 TC Ct soft tissue neck w/dye $827.4035170491 Ct so f tt i ss u e n ec k w / d ye$ 1,072.05 351 70492 26 Ct sft tsue nck w/o & w/dye $256.20 972 70492 26 Midlevel Ct sft tsue nck w/o & w/dye$ 217.75 972 70492 TC Ct sft tsue nck w/o & w/dye $1,033.20 351 70492 Ct sft tsue nck w/o & w/dye$ 1,289.40 351 70496 26 Midlevel Ct angiography, head $264.209727049626 Ct an g i o g r a p h y h e a d$ 310.80 972 70496 Ct angiography head $2, 043.3035170496 TCCt an g i o g r a p h y h e a d$ 1,732.50 351 70498 26 Ct angiography neck $310.809727049826 M i d l e v e lCt an g i o g r a p h y, n ec k$ 264.20 972 70498 TC Ct angiography neck $1, 787.1035170498 Ct an g i o g r a p h y n ec k$ 2,096.85 351 71045 26 X-RAY EXAM CHEST 1 VIEW $32.5597271045 X - R A Y EX A MC H EST 1 V I E W$ 86.10 324 71045 X-RAY EXAM CHEST 1 VIEW STEREO $87.15324 FRONT A L 71045 TCX - R A Y EX A MC H EST 1 V I E W TEC H COMP$ 54.60 324 71046 26 X-RAY EXAM CHEST 2 VIEWS $34.3597271046 X - R A Y EX A MC H EST 2 V I E W S$ 108.90 324 71046 TC X-RAY EXAM CHEST 2 VIEWS TECH COMP $74.553247104726 X - R A Y EX A MC H EST 3 V I E W SFRT L A T L OR D$ 44.70 972 71047 X-RAY EXAM CHEST 3 VIEWS FRT LAT LORD $130.7732471047 TCX - R A Y EX A MC H EST 3 V I E W SFRT L A T L OR D$ 86.06 324 71048 26 X-RAY EXAM CHEST 4+ VIEWS $54.6097271048 X - R A Y EX A MC H EST 4 + V I E W SFRT L A T$ 116.55 324 OBLQUE 71048 X-RAY EXAM CHEST 4+ VIEWS $171.1532471048 TCX - R A Y EX A MC H EST 4 + V I E W STEC H COMP$ 116.55 324 71100 26 X-ray exam of ribs $39.909727110026 M i d l e v e lX - r a ye x am o f r ib s$ 33.90 972 71100 TC X-RAY EXAM OF RIBS 2 VIEWS UNILAT $81.9032071100 X - R A Y EX A MOFR I BS 2 V I E W S U N I L A T$ 121.80 320 71101 26 Midlevel X-ray exam of ribs/chest $40.159727110126 X - r a ye x am o f r ib s / c h es t$ 47.25 972 71101 X-RAY EXAM OF RIBS/CHEST 3+ VIEWS $145.95324 U N I L A T 71101 TCX - R A Y EX A MOFR I BS / C H EST 3 + V I E W S$ 97.70 324 UNILAT 71110 26 X-ray exam of ribs $48.309727111026 M i d l e v e lX - r a ye x am o f r ib s$ 41.05 972 71110 X-RAY EXAM RIBS BIL 3 VIEWS $151.2032471110 TCX - R A Y EX A MR I BSB I L 3 V I E W S$ 102.90 324 71111 26 X-ray exam of ribs/chest $56.709727111126 M i d l e v e lX - r a ye x am o f r ib s / c h es t$ 48.20 972 71111 TC X-RAY EXAM OF RIBS/CHEST 4+ VIEWS $139.65320 B I L A T 71111 X - R A Y EX A MOFR I BS / C H EST 4 + V I E W S$ 196.35 320 BILAT © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 21 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 71120 26 X-ray exam of breastbone $35.709727112026 M i d l e v e lX - r a ye x am o f b re a s t b o n e$ 30.35 972 71120 X-RAY EXAM OF BREASTBONE 2+ VIEWS $117.6032071120 TCX - R A Y EX A MOFBRE A STBONE 2 + V I E W S$ 81.90 320 71130 26 Midlevel X-ray exam of breastbone $33.909727113026 X - r a ye x am o f b re a s t b o n e$ 39.90 972 71130 X-RAY EXAM OF BREASTBONE 3+ VIEWS $138.6032471130 TCX - R A Y EX A MOFBRE A STBONE 3 + V I E W S$ 98.70 324 71250 26 Midlevel Ct thorax w/o dye $154.409727125026 Ctt h or a x w / o d ye$ 181.65 972 71250 Ct thorax w/o dye $856.8035271250 TCCtt h or a x w / o d ye$ 675.15 352 71260 26 Ct thorax w/dye $220.509727126026 M i d l e v e lCtt h or a x w / d ye$ 187.45 972 71260 Ct thorax w/dye $1, 064.7035271260 TCCtt h or a x w / d ye$ 844.20 352 71270 26 Midlevel Ct thorax w/o & w/dye $207.05 972 71270 26 Ct thorax w/o & w/dye$ 243.60 972 71270 TC Ct thorax w/o & w/dye $1,058.40 352 71270 Ct thorax w/o & w/dye$ 1,302.00 352 71275 26 Ct angiography chest $340.209727127526 M i d l e v e lCt an g i o g r a p h y, c h es t$ 289.20 972 71275 Ct angiography chest $1, 623.3035271275 TCCt an g i o g r a p h yc h es t$ 1,283.10 352 72020 26 X-ray exam of spine $27.309727202026 M i d l e v e lX - r a ye x am o f s p in e$ 23.20 972 72020 X-RAY EXAM OF SPINE 1 VIEW $88.2032972020 TCX - R A Y EX A MOFSP I NE 1 V I E W$ 60.90 320 72040 26 X-ray exam of neck spine $42.009727204026 M i d l e v e lX - r a ye x am o f n ec k s p in e$ 35.70 972 72040 TC X-RAY EXAM NECK SPINE 2-3 VW $110.0032072040 X - R A Y EX A MNEC K SP I NE 2 - 3 VW$ 152.00 320 72050 26 Midlevel X-ray exam of neck spine $48.209727205026 X - r a ye x am o f n ec k s p in e$ 56.70 972 72050 TC X-RAY EXAM NECK SPINE 4/5VWS $140.7032072050 X - R A Y EX A MNEC K SP I NE 4/5 VW S$ 198.45 320 72052 26 X-ray exam of neck spine $70.409727205226 M i d l e v e lX - r a ye x am o f n ec k s p in e$ 59.85 972 72052 X-RAY EXAM NECK SPINE 6/>VWS $266.2032972052 TCX - R A Y EX A MNEC K SP I NE 6/ > VW S$ 195.80 320 72070 26 X-ray exam of thoracic spine $39.909727207026 M i d l e v e lX - r a ye x am o f t h or a c i cs p in e$ 33.90 972 72070 TC X-RAY EXAM OF THORACIC SPINE 2 VIEWS $89.1032072070 X - R A Y EX A MOFT H OR A C I CSP I NE 2 V I E W S$ 129.00 320 72072 26 X-ray exam of thoracic spine $38.859727207226 M i d l e v e lX - r a ye x am o f t h or a c i cs p in e$ 33.05 972 72072 X-RAY EXAM OF THORACIC SPINE 3 VIEWS $138.6032972072 TCX - R A Y EX A MOFT H OR A C I CSP I NE 3 V I E W S$ 99.75 320 72074 26 Midlevel X-ray exam of thoracic spine $33.059727207426 X - r a ye x am o f t h or a c i cs p in e$ 38.85 972 72074 TC X-RAY EXAM OF THORACIC SPINE 4+ VIEWS $126.0032072074 X - R A Y EX A MOFT H OR A C I CSP I NE 4 + V I E W S$ 164.85 320 72080 26 Midlevel X-ray exam of trunk spine $35.709727208026 X - r a ye x am o f t r u nk s p in e$ 42.00 972 72080 TC X-RAY EXAM THORACOLMB 2/> VW $94.5032072080 X - R A Y EX A MT H OR A CO L MB 2/ > VW$ 136.50 320 72081 26 X-RAY EXAM ENTIRE SPI 1 VW $43.11 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 22 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 72081 X-RAY EXAM ENTIRE SPI 1 VW $135.4532972081 TCX - R A Y EX A MENT I RESP I 1 VW$ 92.34 320 72082 26 X-RAY EXAM ENTIRE SPI 2/3 VW AP &LAT $50.97 972 72082 X-RAY EXAM ENTIRE SPI 2/3 VW AP &LAT$ 220.17 329 72082 TC X-RAY EXAM ENTIRE SPI 2/3 VW AP &LAT $169.173207208326 X - R A Y EX A MENT I RESP I 4/5 VW SCO L I ERCT$ 57.78 972 72083 X-RAY EXAM ENTIRE SPI 4/5 VW SCOLI ERCT $260.4332972083 TCX - R A Y EX A MENT I RESP I 4/5 VW SCO L I ERCT$ 202.62 320 72084 26 X-RAY EXAM ENTIRE SPI 6/> VW $66.1897272084 X - R A Y EX A MENT I RESP I 6/ > VW$ 303.51 320 72084 TC X-RAY EXAM ENTIRE SPI 6/> VW TECH COMP $133.353207210026 M i d l e v e lX - r a ye x am o f l o w ers p in e$ 35.70 972 72100 26 X-ray exam of lower spine $42.0097272100 TCX - R A Y EX A MOF L O W ERSP I NE 2 - 3 V I E W S$ 100.10 320 72100 X-RAY EXAM OF LOWER SPINE 2-3 VIEWS $142.103207211026 X - r a ye x am o f l o w ers p in e$ 56.70 972 72110 26 Midlevel X-ray exam of lower spine $48.2097272110 TCX - R A Y EX A MOF L O W ERSP I NE 4 + V I E W S$ 136.40 320 72110 X-RAY EXAM OF LOWER SPINE 4+ VIEWS $193.103207211426 X - r a ye x am o f l o w ers p in e$ 61.95 972 72114 26 Midlevel X-ray exam of lower spine $52.6597272114 X - R A Y EX A MOF L - SSP I NEBEN D I NG >= 6$ 244.65 329 VWS 72114 TC X-RAY EXAM OF L-S SPINE BENDING >=6 $182.70320 VW S 7212026 M i d l e v e lX - r a ye x am o f l o w ers p in e$ 36.59 972 72120 26 X-ray exam of lower spine $43.0597272120 XR A Y EX A MOF L O W ERSP I NE 2 - 3 VW S$ 163.80 329 72120 TC XRAY EXAM OF LOWER SPINE 2-3 VWS $120.753207212526 Ct n ec k s p in e w / o d ye$ 189.00 972 72125 26 Midlevel Ct neck spine w/o dye $160.6597272125 Ct n ec k s p in e w / o d ye$ 870.45 352 72125 TC Ct neck spine w/o dye $681.453527212626 Ct n ec k s p in e w / d ye$ 216.30 972 72126 26 Midlevel Ct neck spine w/dye $183.8597272126 CTNEC K SP I NE W / D Y E$ 1,065.75 352 72126 TC CT NECK SPINE W/DYE $849.45 350 72127 26 Ct neck spine w/o & w/dye$ 223.65 972 72127 26 Midlevel Ct neck spine w/o & w/dye $190.10 972 72127 Ct neck spine w/o & w/dye$ 1,277.85 352 72127 TC Ct neck spine w/o & w/dye $1, 054.203527212826 M i d l e v e lCt c h es t s p in e w / o d ye$ 151.70 972 72128 26 Ct chest spine w/o dye $178.5097272128 TCCt c h es t s p in e w / o d ye$ 679.35 352 72128 Ct chest spine w/o dye $857.853527212926 Ct c h es t s p in e w / d ye$ 216.30 972 72129 26 Midlevel Ct chest spine w/dye $183.8597272129 Ct c h es t s p in e w / d ye$ 1,064.70 352 72129 TC Ct chest spine w/dye $848.40 352 72130 26 Ct chest spine w/o & w/dye$ 224.70 972 72130 26 Midlevel Ct chest spine w/o & w/dye $190.99 972 72130 Ct chest spine w/o & w/dye$ 1,287.30 352 72130 TC Ct chest spine w/o & w/dye $1, 062.603527213126 Ctl u mba rs p in e w / o d ye$ 178.50 972 72131 26 Midlevel Ct lumbar spine w/o dye $151.7097272131 TCCtl u mba rs p in e w / o d ye$ 709.50 352 72131 Ct lumbar spine w/o dye $895.40 352 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 23 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 72132 26 Ct lumbar spine w/dye $216.309727213226 M i d l e v e lCtl u mba rs p in e w / d ye$ 183.85 972 72132 Ct lumbar spine w/dye $1, 113.2035272132 TCCtl u mba rs p in e w / d ye$ 886.60 352 72133 26 Ct lumbar spine w/o & w/dye $224.70 972 72133 26 Midlevel Ct lumbar spine w/o & w/dye$ 190.99 972 72133 TC Ct lumbar spine w/o & w/dye $1,060.50 352 72133 Ct lumbar spine w/o & w/dye$ 1,285.20 352 72170 26 X-ray exam of pelvis $33.609727217026 M i d l e v e lX - r a ye x am o f p e l v i s$ 28.55 972 72170 TC X-RAY EXAM OF PELVIS 1-2 VIEWS $68.2032072170 X - R A Y EX A MOFPE L V I S 1 - 2 V I E W S$ 101.80 320 72190 26 X-ray exam of pelvis $40.959727219026 M i d l e v e lX - r a ye x am o f p e l v i s$ 34.80 972 72190 X-RAY EXAM OF PELVIS 3+ VIEWS $159.6032972190 TCX - R A Y EX A MOFPE L V I S 3 + V I E W S$ 115.65 320 72191 26 Midlevel Ct angiograph pelv w/o&w/dye $274.89 972 72191 26 Ct angiograph pelv w/o&w/dye$ 323.40 972 72191 CT ANGIOGRAPH PELV W/O&W/DYE $1,671.60 352 72191 TC CT ANGIOGRAPH PELV W/O&W/DYE$ 1,348.20 350 72192 26 Ct pelvis w/o dye $201.309727219226 M i d l e v e lCtp e l v i s w / o d ye$ 171.10 972 72192 TC Ct pelvis w/o dye $566.6135272192 Ctp e l v i s w / o d ye$ 767.91 352 72193 26 Midlevel Ct pelvis w/dye $175.809727219326 Ctp e l v i s w / d ye$ 206.85 972 72193 Ct pelvis w/dye $1, 045.0535272193 TCCtp e l v i s w / d ye$ 838.20 352 72194 26 Ct pelvis w/o & w/dye $216.30 972 72194 26 Midlevel Ct pelvis w/o & w/dye$ 183.85 972 72194 TC Ct pelvis w/o & w/dye $1,075.20 352 72194 Ct pelvis w/o & w/dye$ 1,291.50 352 72200 26 X-ray exam sacroiliac joints $30.459727220026 M i d l e v e lX - r a ye x am s a cro i l ia c j o in t s$ 25.90 972 72200 X-RAY EXAM SACROILIAC JOINTS <3 VIEWS $111.3032972200 TCX - R A Y EX A MS A CRO I L I A C J O I NTS < 3 V I E W S$ 80.85 320 72202 26 Midlevel X-ray exam sacroiliac joints $28.569727220226 X - r a ye x am s a cro i l ia c j o in t s$ 33.60 972 72202 X-RAY EXAM SACROILIAC JOINTS 3+ VIEWS $129.1532072202 TCX - R A Y EX A MS A CRO I L I A C J O I NTS 3 + V I E W S$ 95.55 320 72220 26 Midlevel X-ray exam of tailbone $30.459727222026 X - r a ye x am o f t ai l b o n e$ 76.65 972 72220 TC X-RAY EXAM OF TAILBONE 2+ VIEWS $25.8832072220 X - R A Y EX A MOFT A I L BONE 2 + V I E W S$ 102.53 320 72240 26 Midlevel Contrast x-ray of neck spine $137.459727224026 C o n t r a s t x - r a yo f n ec k s p in e$ 161.70 972 72240 MYELOGRAM CERVICAL $508.2032972240 TCM Y E L OGR A MCER V I C A L$ 346.50 320 72255 26 Contrast x-ray, thorax spine $160.659727225526 M i d l e v e lC o n t r a s t x - r a y, t h or a x s p in e$ 136.55 972 72255 MYELOGRAM THORACIC $483.0032972255 TCM Y E L OGR A MT H OR A C I C$ 322.35 320 72265 26 Contrast x-ray lower spine $147.009727226526 M i d l e v e lC o n t r a s t x - r a y, l o w ers p in e$ 124.95 972 72265 MYELOGRAM LUMBOSACRAL $488.2532072265 TCM Y E L OGR A M LU MBOS A CR A L$ 341.25 320 72270 26 Midlevel Contrast x-ray, spine $200.81 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 24 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 72270 26 Contrast x-ray, spine $236.2597272270 CONTR A STX - R A Y SP I NE 2 + REG I ONS$ 764.40 329 72270 TC CONTRAST X-RAY SPINE 2+ REGIONS $528.153207227526 Ep i d u ro g r a p h y$ 139.65 972 72275 26 Midlevel Epidurography $118.7097272275 EP I D U ROGR A P H Y$ 437.85 320 72275 TC EPIDUROGRAPHY $298.203207228526 M i d l e v e lX - r a yc / t s p in e d i s k$ 181.20 972 72285 26 X-ray c/t spine disk $213.1597272285 D I SCOGR A P H Y CER V / T H ORSP I NE$ 491.40 329 72285 TC DISCOGRAPHY CERV/THOR SPINE $278.253207229526 X - r a yo f l o w ers p in e d i s k$ 154.35 972 72295 26 Midlevel X-ray of lower spine disk $131.2097272295 X - R A Y OF L O W ERSP I NE D I S K$ 434.70 329 72295 TC X-RAY OF LOWER SPINE DISK $280.353207300026 X - r a ye x am o f co ll a r b o n e$ 29.40 972 73000 26 Midlevel X-ray exam of collar bone $24.9997273000 TCC L A V I C L ECOMP L ETE$ 81.40 320 73000 CLAVICLE COMPLETE $110.803207301026 M i d l e v e lX - r a ye x am o f s h o u l d er b l a d e$ 29.45 972 73010 26 X-ray exam of shoulder blade $34.6597273010 SC A P UL A COMP L ETE$ 105.15 320 73010 TC SCAPULA COMPLETE $70.503207302026 X - r a ye x am o f s h o u l d er$ 27.30 972 73020 26 Midlevel X-ray exam of shoulder $23.2097273020 TCX - r a ye x am o f s h o u l d er$ 64.90 320 73020 X-ray exam of shoulder $92.203207303026 X - r a ye x am o f s h o u l d er$ 35.70 972 73030 26 Midlevel X-ray exam of shoulder $30.3597273030 TCX - R A Y EX A MOFS H O UL D ER 2 + V I E W S$ 82.50 320 73030 X-RAY EXAM OF SHOULDER 2+ VIEWS $118.203207304026 C o n t r a s t x - r a yo f s h o u l d er$ 98.70 972 73040 26 Midlevel Contrast x-ray of shoulder $83.9097273040 S H O UL D ER A RT H ROGR A M$ 402.15 329 73040 TC SHOULDER ARTHROGRAM $303.453207305026 M i d l e v e lX - r a ye x am o f s h o u l d ers$ 34.80 972 73050 26 X-ray exam of shoulders $40.9597273050 A C J B I L A TER A L W / W O W E I G H TS$ 150.15 329 73050 TC ACJ BILATERAL W/WO WEIGHTS $109.203207306026 M i d l e v e lX - r a ye x am o f h u m er u s$ 25.90 972 73060 26 X-ray exam of humerus $30.4597273060 X - R A Y EX A MOF H U MER U S 2 + V I E W S$ 111.85 320 73060 TC X-RAY EXAM OF HUMERUS 2+ VIEWS $81.403207307026 X - r a ye x am o f e l b o w$ 29.70 972 73070 26 Midlevel X-ray exam of elbow $25.2597273070 X - R A Y EX A MOFE L BO W 2 V I E W S$ 140.80 329 73070 X-RAY EXAM OF ELBOW 2 VIEWS $111.1032073070 TCX - R A Y EX A MOFE L BO W 2 V I E W S$ 111.10 320 73080 26 Midlevel X-ray exam of elbow $25.909727308026 X - r a ye x am o f e l b o w$ 30.45 972 73080 X-RAY EXAM OF ELBOW 3+ VIEWS $126.0032073080 TCX - R A Y EX A MOFE L BO W 3 + V I E W S$ 95.55 320 73085 26 Midlevel Contrast x-ray of elbow $84.809727308526 C o n t r a s t x - r a yo f e l b o w$ 99.75 972 73085 ELBOW ARTHROGRAM $374.8532973085 TCE L BO W A RT H ROGR A M$ 275.10 320 73090 26 Midlevel X-ray exam of forearm $24.10 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 25 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 73090 26 X-ray exam of forearm $28.3597273090 TCX - R A Y EX A MOFFORE A RM 2 V I E W S$ 78.10 320 73090 X-RAY EXAM OF FOREARM 2 VIEWS $106.453207309226 X - r a ye x am o f a r m, in f an t$ 28.35 972 73092 26 Midlevel X-ray exam of arm, infant $24.1097273092 X - R A Y EX A MOF A RM I NF A NT 2 + V I E W S$ 103.95 329 73092 TC X-RAY EXAM OF ARM INFANT 2+ VIEWS $75.603207310026 X - r a ye x am o f w r i s t$ 33.60 972 73100 26 Midlevel X-ray exam of wrist $28.5597273100 TCX - R A Y EX A MOF W R I ST 2 V I E W S$ 89.10 320 73100 X-RAY EXAM OF WRIST 2 VIEWS $122.703207311026 M i d l e v e lX - r a ye x am o f w r i s t$ 25.90 972 73110 26 X-ray exam of wrist $30.4597273110 X - R A Y EX A MOF W R I ST 3 + V I E W S$ 143.75 320 73110 TC X-RAY EXAM OF WRIST 3+ VIEWS $113.303207311526 M i d l e v e lC o n t r a s t x - r a yo f w r i s t$ 86.55 972 73115 26 Contrast x-ray of wrist $101.8597273115 W R I ST A RT H ROGR A M$ 421.05 329 73115 TC WRIST ARTHROGRAM $319.203207312026 X - r a ye x am o f han d$ 30.80 972 73120 26 Midlevel X-ray exam of hand $26.2097273120 TCX - R A Y EX A MOF H A N D 2 V I E W S$ 74.55 320 73120 X-RAY EXAM OF HAND 2 VIEWS $105.353207313026 X - r a ye x am o f han d$ 31.90 972 73130 26 Midlevel X-ray exam of hand $27.1097273130 X - R A Y EX A MOF H A N D 3 + V I E W S$ 121.15 320 73130 TC X-RAY EXAM OF HAND 3+ VIEWS $89.253207314026 X - r a ye x am o ff in g er (s)$ 25.20 972 73140 26 Midlevel X-ray exam of finger(s) $21.4597273140 X - R A Y EX A MOFF I NGER (S) 2 + V I E W S$ 127.50 320 73140 TC X-RAY EXAM OF FINGER(S) 2+ VIEWS $102.303207320026 M i d l e v e lCt u pp ere x t re mi t y w / o d ye$ 153.50 972 73200 26 Ct upper extremity w/o dye $180.6097273200 Ct u pp ere x t re mi t y w / o d ye$ 844.20 352 73200 TC Ct upper extremity w/o dye $663.603527320126 M i d l e v e lCt u pp ere x t re mi t y w / d ye$ 175.10 972 73201 26 Ct upper extremity w/dye $206.8597273201 CT U PPEREXTREM I T YW / D Y E$ 1,034.25 352 73201 TC CT UPPER EXTREMITY W/DYE $827.40 350 73202 26 Midlevel Ct uppr extremity w/o&w/dye$ 183.55 972 73202 26 Ct uppr extremity w/o&w/dye $216.30 972 73202 TC Ct uppr extremity w/o&w/dye$ 1,110.90 352 73202 Ct uppr extremity w/o&w/dye $1,327.20 352 73206 26 Ct angio upr extrm w/o&w/dye$ 319.20 972 73206 26 Midlevel Ct angio upr extrm w/o&w/dye $271.32 972 73206 CT ANGIO UPR EXTRM W/O&W/DYE$ 1,478.40 350 73206 TC CT ANGIO UPR EXTRM W/O&W/DYE $1, 159.203507350126 X - R A Y EX A M H I P U N I 1 V I E W$ 30.06 972 73501 X-RAY EXAM HIP UNI 1 VIEW $103.8332073501 TCX - R A Y EX A M H I P U N I 1 V I E W$ 73.77 320 73502 26 X-RAY EXAM HIP UNI 2-3 VIEWS $35.6197273502 X - R A Y EX A M H I P U N I 2 - 3 V I E W S$ 145.32 320 73502 TC X-RAY EXAM HIP UNI 2-3 VIEWS $109.713207350326 X - R A Y EX A M H I P U N I 4/ > V I E W S$ 44.19 972 73503 X-RAY EXAM HIP UNI 4/> VIEWS $181.1432973503 TCX - R A Y EX A M H I P U N I 4/ > V I E W S$ 136.95 320 73521 26 X-RAY EXAM HIPS BI 2 VIEWS $35.61 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 26 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 73521 X-RAY EXAM HIPS BI 2 VIEWS $129.2132073521 TCX - R A Y EX A M H I PSB I 2 V I E W S$ 93.60 320 73522 26 X-RAY EXAM HIPS BI 3-4 VIEWS $49.3597273522 TCX - R A Y EX A M H I PSB I 3 - 4 V I E W STEC H COMP$ 103.95 320 73522 X-RAY EXAM HIPS BI 3-4 VIEWS $153.303207352326 X - R A Y EX A M H I PSB I 5/ > V I E W S$ 50.97 972 73523 X-RAY EXAM HIPS BI 5/> VIEWS $197.8532973523 TCX - R A Y EX A M H I PSB I 5/ > V I E W S$ 146.88 320 73525 26 Contrast x-ray of hip $102.909727352526 M i d l e v e lC o n t r a s t x - r a yo f hi p$ 87.46 972 73525 HIP ARTHROGRAM $387.4532973525 TC H I P A RT H ROGR A M$ 284.55 320 73551 26 X-RAY EXAM OF THIGH $26.6497273551 X - R A Y EX A MOFT H I G H$ 95.46 320 73551 TC X-RAY EXAM OF THIGH $68.823207355226 X - R A Y EX A MOFFEM U R 2/ >$ 35.20 972 73552 TC X-RAY EXAM OF FEMUR 2/> TECH COMP $77.0032073552 X - R A Y EX A MOFFEM U R 2/ >$ 112.20 320 73560 26 X-ray exam of knee 1 or 2 $34.659727356026 M i d l e v e lX - r a ye x am o f kn ee, 1 or 2$ 29.45 972 73560 TC X-ray exam of knee 1 or 2 $116.5532073560 X - r a ye x am o f kn ee 1 or 2$ 151.20 320 73562 26 X-ray exam of knee, 3 $35.709727356226 M i d l e v e lX - r a ye x am o f kn ee, 3$ 30.34 972 73562 X-RAY EXAM OF KNEE 3 $138.6032973562 TCX - R A Y EX A MOF K NEE 3$ 102.90 320 73564 26 X-ray exam knee 4 or more $43.059727356426 M i d l e v e lX - r a ye x am, kn ee, 4 or m ore$ 36.60 972 73564 X-ray exam knee 4 or more $161.7032073564 TCX - r a ye x amkn ee 4 or m ore$ 118.65 320 73565 26 Midlevel X-ray exam of knees $31.809727356526 X - r a ye x am o f kn ees$ 37.40 972 73565 KNEE; BOTH KNEES STANDING AP $138.6032973565 TC K NEE; BOT HK NEESST A N D I NG A P$ 101.20 320 73580 26 Contrast x-ray of knee joint $105.009727358026 M i d l e v e lC o n t r a s t x - r a yo f kn ee j o in t$ 89.25 972 73580 KNEE ARTHROGRAM $504.0032973580 TC K NEE A RT H ROGR A M$ 399.00 320 73590 26 Midlevel X-ray exam of lower leg $23.109727359026 X - r a ye x am o f l o w er l e g$ 25.41 972 73590 X-RAY EXAM OF LOWER LEG 2 VIEWS $99.1832073590 TCX - R A Y EX A MOF L O W ER L EG 2 V I E W S$ 73.77 320 73592 26 X-ray exam of leg, infant $29.409727359226 M i d l e v e lX - r a ye x am o f l e g, in f an t$ 24.99 972 73592 X-RAY EXAM OF LEG INFANT 2 VIEWS $119.7032973592 TCX - R A Y EX A MOF L EG I NF A NT 2 V I E W S$ 90.30 320 73600 26 X-ray exam of ankle $30.809727360026 M i d l e v e lX - r a ye x am o f ank l e$ 26.20 972 73600 X-RAY EXAM OF ANKLE 2 VIEWS $108.5032073600 TCX - R A Y EX A MOF A N K L E 2 V I E W S$ 77.70 320 73610 26 Midlevel X-ray exam of ankle $27.109727361026 X - r a ye x am o f ank l e$ 31.90 972 73610 TC X-RAY EXAM OF ANKLE 3+ VIEWS $96.8032073610 X - R A Y EX A MOF A N K L E 3 + V I E W S$ 128.70 320 73615 26 Contrast x-ray of ankle $91.509727361526 M i d l e v e lC o n t r a s t x - r a yo f ank l e$ 83.20 972 73615 ANKLE ARTHROGRAM $401.91 329 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 27 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 73615 TC ANKLE ARTHROGRAM $310.413207362026 M i d l e v e lX - r a ye x am o ff oo t$ 24.30 972 73620 26 X-ray exam of foot $28.6097273620 X - R A Y EX A MOFFOOT; 2 V I E W S$ 106.70 320 73620 TC X-RAY EXAM OF FOOT; 2 VIEWS $78.103207363026 M i d l e v e lX - r a ye x am o ff oo t$ 26.20 972 73630 26 X-ray exam of foot $30.8097273630 TCX - R A Y EX A MOFFOOT; 3 + V I E W S$ 92.40 320 73630 X-RAY EXAM OF FOOT; 3+ VIEWS $123.203207365026 X - r a ye x am o f h ee l$ 28.35 972 73650 26 Midlevel X-ray exam of heel $24.1097273650 TCX - R A Y EX A MOF H EE L 2 + V I E W S$ 76.65 320 73650 X-RAY EXAM OF HEEL 2+ VIEWS $105.003207366026 M i d l e v e lX - r a ye x am o f t oe (s)$ 20.60 972 73660 26 X-ray exam of toe(s) $24.2097273660 X - R A Y EX A MOFTOE (S) 2 + V I E W S$ 116.60 320 73660 TC X-RAY EXAM OF TOE(S) 2+ VIEWS $92.403207370026 Ctl o w ere x t re mi t y w / o d ye$ 188.10 972 73700 26 Midlevel Ct lower extremity w/o dye $159.9097273700 Ctl o w ere x t re mi t y w / o d ye$ 885.50 352 73700 TC Ct lower extremity w/o dye $697.403527370126 Ctl o w ere x t re mi t y w / d ye$ 206.85 972 73701 26 Midlevel Ct lower extremity w/dye $175.8097273701 Ctl o w ere x t re mi t y w / d ye$ 1,045.80 352 73701 TC Ct lower extremity w/dye $838.95 352 73702 26 Midlevel Ct lwr extremity w/o&w/dye$ 183.85 972 73702 26 Ct lwr extremity w/o&w/dye $216.30 972 73702 TC Ct lwr extremity w/o&w/dye$ 1,110.90 352 73702 Ct lwr extremity w/o&w/dye $1,327.20 352 73706 26 Midlevel Ct angio lwr extr w/o&w/dye$ 287.40 972 73706 26 Ct angio lwr extr w/o&w/dye $338.10 972 73706 TC Ct angio lwr extr w/o&w/dye$ 1,299.90 352 73706 Ct angio lwr extr w/o&w/dye $1, 638.003527401826 X - R A Y EX A M A B D OMEN 1 V I E W$ 59.85 972 74018 X-RAY EXAM ABDOMEN 1 VIEW $92.4032074018 TCX - R A Y EX A M A B D OMEN 1 V I E W TEC H COMP$ 32.55 320 74019 26 X-RAY EXAM ABDOMEN 2 VIEWS $36.7297274019 X - R A Y EX A M A B D OMEN 2 V I E W S$ 116.67 329 74019 TC X-RAY EXAM ABDOMEN 2 VIEWS $79.953207402126 X - R A Y EX A M A B D OMEN 3 + V I E W S$ 101.85 972 74021 X-RAY EXAM ABDOMEN 3+ VIEWS $149.1032074021 TCX - R A Y EX A M A B D OMEN 3 + V I E W STEC H$ 47.25 320 COMP 74022 26 Midlevel X-ray exam series, abdomen $49.559727402226 X - r a ye x am ser i es ab d o m e n$ 58.30 972 74022 X-ray exam series abdomen $187.0032074022 TCX - r a ye x am ser i es ab d o m e n$ 128.70 320 74150 26 Ct abdomen w/o dye $222.209727415026 M i d l e v e lCt ab d o m e n w / o d ye$ 188.90 972 74150 TC Ct abdomen w/o dye $663.3035274150 Ct ab d o m e n w / o d ye$ 885.50 352 74160 26 Ct abdomen w/dye $235.409727416026 M i d l e v e lCt ab d o m e n w / d ye$ 200.10 972 74160 TC Ct abdomen w/dye $969.1035274160 Ct ab d o m e n w / d ye$ 1,204.50 352 74170 26 Ct abdomen w/o & w/dye $248.85 972 74170 26 Midlevel Ct abdomen w/o & w/dye$ 211.55 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 28 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 74170 TC Ct abdomen w/o & w/dye $1,275.75 352 74170 Ct abdomen w/o & w/dye$ 1,524.60 352 74174 26 Ct angio abd&pelv w/o&w/dye $401.50 972 74174 TC Ct angio abd&pelv w/o&w/dye$ 1,739.10 352 74174 Ct angio abd&pelv w/o&w/dye $2,140.60 352 74175 26 Midlevel Ct angio abdom w/o & w/dye$ 287.40 972 74175 26 Ct angio abdom w/o & w/dye $338.10 972 74175 Ct angio abdom w/o & w/dye$ 1,776.60 352 74175 TC Ct angio abdom w/o & w/dye $1,438.50 352 74176 26 Ct abd & pelvis$ 303.45 972 74176 Ct abd & pelvis $823.20 352 74176 TC Ct abd & pelvis$ 519.75 352 74177 26 Ct abd & pelv w/contrast $317.10 972 74177 Ct abd & pelv w/contrast$ 1,300.95 352 74177 TC Ct abd & pelv w/contrast $983.85 352 74178 26 Ct abd & pelv 1/> regns$ 351.75 972 74178 Ct abd & pelv 1-2 regns $1,651.65 352 74178 TC Ct abd & pelv 1-2 regns$ 1,299.90 352 74190 26 Midlevel X-ray exam of peritoneum $84.809727419026 X - r a ye x am o f p er i t o n e u m$ 99.75 972 74190 PERITONEOGRAM AFTER INJECTION $99.753207421026 M i d l e v e lC o n t rs t x - r a ye x am o f t h ro a t$ 53.55 972 74210 26 Contrst x-ray exam of throat $63.0097274210 CONTRSTX - R A Y EX A MOFT H RO A T$ 292.95 329 74210 TC CONTRST X-RAY EXAM OF THROAT $229.953207422026 C o n t r a s t x - r a yeso p ha gu s$ 85.80 972 74220 26 Midlevel Contrast x-ray, esophagus $72.9097274220 TCC o n t r a s t x - r a yeso p ha gu s$ 267.30 320 74220 Contrast x-ray esophagus $353.103207423026 M i d l e v e lC in e / v i d x - r a y, t h ro a t / eso p h$ 80.30 972 74230 26 Cine/vid x-ray, throat/esoph $94.5097274230 C I NE / V I D X - R A Y T H RO A T / ESOP H$ 444.57 329 74230 TC CINE/VID X-RAY THROAT/ESOPH $350.073207423526 R e m o v eeso p ha gu so b s t r u c t i o n$ 236.25 972 74235 26 Midlevel Remove esophagus obstruction $200.8097274235 REMO V EESOP H A G U SOBSTR U CT I ON$ 236.25 329 74240 26 X-ray exam, upper gi tract $123.909727424026 M i d l e v e lX - r a ye x am, u pp er g i t r a c t$ 105.30 972 74240 X-RAY UPPER GI DELAY W/O KUB $424.2032974240 TCX - R A Y U PPERG I D E L A YW / O K U B$ 300.30 320 74241 26 Midlevel X-ray exam, upper gi tract $102.659727424126 X - r a ye x am, u pp er g i t r a c t$ 120.75 972 74241 X-RAYUPPER GI DELAY W/KUB $444.1532974241 TCX - R A Y U PPERG I D E L A YW / K U B$ 323.40 320 74245 26 Midlevel X-ray exam, upper gi tract $136.559727424526 X - r a ye x am, u pp er g i t r a c t$ 160.65 972 74245 X-RAY UPPER GI&SMALL INTEST $661.50 329 74245 TC X-RAY UPPER GI&SMALL INTEST$ 500.85 320 74246 26 Contrst x-ray uppr gi tract $122.859727424626 M i d l e v e lC o n t rs t x - r a y u pp r g i t r a c t$ 104.45 972 74246 CONTRST X-RAY UPPR GI TRACT $476.7032974246 TCCONTRSTX - R A Y U PPRG I TR A CT$ 353.85 320 74247 26 Contrst x-ray uppr gi tract $122.859727424726 M i d l e v e lC o n t rs t x - r a y u pp r g i t r a c t$ 104.45 972 74247 Contrst x-ray uppr gi tract $530.2532074247 TCC o n t rs t x - r a y u pp r g i t r a c t$ 407.40 320 74249 26 Contrst x-ray uppr gi tract $160.65 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 29 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 74249 26 Midlevel Contrst x-ray uppr gi tract $136.55 972 74249 UGI W AIR & BARIUM W SB$ 715.05 329 74249 TC UGI W AIR & BARIUM W SB $554.403207425026 M i d l e v e lX - r a ye x am o f s ma ll b o w e l$ 71.40 972 74250 26 X-ray exam of small bowel $84.0097274250 X - r a ye x am o f s ma ll b o w e l$ 402.15 320 74250 TC X-ray exam of small bowel $318.153207425126 M i d l e v e lX - r a ye x am o f s ma ll b o w e l$ 103.70 972 74251 26 X-ray exam of small bowel $122.8597274251 X - R A Y EX A MOFSM A LL BO W E L$ 1,434.30 320 74251 TC X-RAY EXAM OF SMALL BOWEL $1, 311.453207426026 M i d l e v e lX - r a ye x am o f s ma ll b o w e l$ 75.85 972 74260 26 X-ray exam of small bowel $89.2597274260 X - R A Y EX A MOFSM A LL BO W E L$ 1,192.80 329 74260 TC X-RAY EXAM OF SMALL BOWEL $1, 103.553207426126 CTCO L ONOGR A P H Y D X$ 378.06 972 74261 CT COLONOGRAPHY DX $765.3035074261 TCCTCO L ONOGR A P H Y D X$ 387.24 350 74262 CT COLONOGRAPHY DX W/DYE $1, 087.1435074263 CTCO L ONOGR A P H Y SCREEN I NG$ 2,941.05 350 74270 26 Midlevel Contrast x-ray exam of colon $104.459727427026 C o n t r a s t x - r a ye x am o f co l o n$ 122.85 972 74270 CONTRAST X-RAY EXAM OF COLON $578.5532974270 TCCONTR A STX - R A Y EX A MOFCO L ON$ 455.70 320 74280 26 Midlevel Contrast x-ray exam of colon $148.159727428026 C o n t r a s t x - r a ye x am o f co l o n$ 174.30 972 74280 BE COLON W AIR & BARIUM $802.20 329 74280 TC BE COLON W AIR & BARIUM$ 627.90 320 74283 26 Midlevel Contrast x-ray exam of colon $298.009727428326 C o n t r a s t x - r a ye x am o f co l o n$ 351.75 972 74283 THER NMA RDCTJ INTUS/OBSTRCJ $805.8932974283 TCT H ERNM A R D CT J I NT U S / OBSTRC J$ 454.14 320 74290 26 Midlevel Contrast x-ray, gallbladder $47.309727429026 C o n t r a s t x - r a y, g a ll b l a dd er$ 55.65 972 74290 CONTRAST X-RAY GALLBLADDER $258.3032974290 TCCONTR A STX - R A Y G A LL B L A DD ER$ 202.65 320 74300 26 X-ray bile ducts/pancreas $65.109727430026 M i d l e v e lX - r a y bi l e d u c t s / p an cre a s$ 55.33 972 74300 CHOLANGIOGRAM INTRAOP $78.753297430126 X - r a ys a t s u r g ery a dd - o n$ 39.90 972 74301 26 Midlevel X-rays at surgery add-on $33.9097274301 C H O L A NG I OGR A M A DD T L I NTR A OP$ 81.90 329 74328 26 X-ray bile duct endoscopy $129.159727432826 M i d l e v e lX - r a y bi l e d u c t e n d osco p y$ 109.75 972 74328 X-RAY BILE DUCT ENDOSCOPY $129.153297432926 X - r a y f or p an cre a se n d osco p y$ 129.15 972 74329 26 Midlevel X-ray for pancreas endoscopy $109.7597274329 X - R A Y FORP A NCRE A SEN D OSCOP Y$ 129.15 329 74330 26 X-ray bile/panc endoscopy $164.859727433026 M i d l e v e lX - r a y bi l e / p an ce n d osco p y$ 140.15 972 74330 X-RAY BILE/PANC ENDOSCOPY $164.853297434026 M i d l e v e lX - r a y gu i d e f or G I t u b e$ 96.60 972 74340 26 X-ray guide for GI tube $96.6097274340 X - R A Y G U I D EFORG I T U BE$ 91.35 329 74355 26 Midlevel X-ray guide, intestinal tube $121.389727435526 X - r a y gu i d e, in t es t ina lt u b e$ 142.80 972 74355 X-RAY GUIDE INTESTINAL TUBE $142.80 329 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 30 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 74360 26 Midlevel X-ray guide, GI dilation $89.259727436026 X - r a y gu i d e, G I d i l a t i o n$ 105.00 972 74360 X-RAY GUIDE GI DILATION $105.003297436326 M i d l e v e lX - r a y, bi l e d u c t d i l a t i o n$ 135.65 972 74363 26 X-ray, bile duct dilation $159.6097274363 X - R A Y B I L E D U CT D I L A T I ON$ 159.60 329 74400 26 Contrst x-ray, urinary tract $86.109727440026 M i d l e v e lC o n t rs t x - r a y, u r ina ry t r a c t$ 73.20 972 74400 IVP W/WO TOMO/KUB $416.8532974400 TCCONTRSTX - R A Y, U R I N A R Y TR A CT$ 330.75 320 74410 26 Contrst x-ray, urinary tract $88.209727441026 M i d l e v e lC o n t rs t x - r a y, u r ina ry t r a c t$ 75.00 972 74410 INFUSION IVP $422.1032974410 TC I NF U S I ON I V P$ 333.90 320 74415 26 Midlevel Contrst x-ray, urinary tract $73.209727441526 C o n t rs t x - r a y, u r ina ry t r a c t$ 86.10 972 74415 IVP W TOMOGRAPHY $509.2532974415 TC I V P W TOMOGR A P H Y$ 423.15 320 74420 26 Midlevel Contrst x-ray, urinary tract $73.789727442026 C o n t rs t x - r a y, u r ina ry t r a c t$ 81.15 972 74420 RETROGRADE PYELOGRAM $240.4232974420 TCRETROGR A D EP Y E L OGR A M$ 159.27 320 74425 26 Midlevel Contrst x-ray, urinary tract $54.459727442526 C o n t rs t x - r a y, u r ina ry t r a c t$ 64.05 972 74425 CONTRST X-RAY URINARY TRACT $64.053297443026 C o n t r a s t x - r a y, b l a dd er$ 55.65 972 74430 26 Midlevel Contrast x-ray, bladder $47.3097274430 CONTR A STX - R A Y B L A DD ER 3 + V I E W S$ 186.90 329 74430 TC CONTRAST X-RAY BLADDER 3+ VIEWS $131.253207444026 M i d l e v e lX - r a y, ma l e g e ni t a lt r a c t$ 58.00 972 74440 26 X-ray, male genital tract $68.2597274440 X - R A Y M A L EGEN I T A L TR A CT$ 307.65 329 74440 TC X-RAY MALE GENITAL TRACT $239.403207444526 M i d l e v e lX - r a ye x am o f p e ni s$ 177.60 972 74445 26 X-ray exam of penis $208.9597274445 X - R A Y EX A MOFPEN I S$ 208.95 329 74450 26 X-ray, urethra/bladder Retrograde $60.909727445026 M i d l e v e lX - r a y, u re t h r a / b l a dd er R e t ro g r a d e$ 93.45 972 74450 X-RAY URETHRA/BLADDER RETRODGRADE $93.453297445526 X - r a y, u re t h r a / b l a dd er v o i d in g$ 57.75 972 74455 26 Midlevel X-ray, urethra/bladder voiding $49.1097274455 X - R A Y U RET H R A / B L A DD ER V O I D I NG$ 327.60 329 74455 TC X-RAY, URETHRA/BLADDER VOIDING $269.853207447026 M i d l e v e lX - r a ye x am o f ki d n ey l es i o n$ 82.10 972 74470 26 X-ray exam of kidney lesion $96.6097274470 X - R A Y EX A MOF K I D NE Y L ES I ON$ 96.60 329 74485 26 X-ray guide, GU dilation $95.559727448526 M i d l e v e lX - r a y gu i d e, G U d i l a t i o n$ 81.20 972 74485 X-RAY GUIDE GU DILATION $389.5532974485 TCX - R A Y G U I D EG U D I L A T I ON$ 294.00 320 74710 26 Midlevel X-ray measurement of pelvis $50.909727471026 X - r a y m e a s u re m e n t o f p e l v i s$ 59.85 972 74710 PELVIMETRY W/WO PLACENTAL $139.65329 L OC A L I Z A T I ON 74710 TCPE L V I METR YW / W OP L A CENT A L$ 79.80 320 LOCALIZATION 74740 26 X-ray, female genital tract $67.20 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 31 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 74740 26 Midlevel X-ray, female genital tract $57.1597274740 X - R A Y FEM A L EGEN I T A L TR A CT$ 294.00 329 74740 TC X-RAY FEMALE GENITAL TRACT $226.803207474226 X - r a y, f a ll o p ian t u b e$ 111.30 972 74742 26 Midlevel X-ray, fallopian tube $94.6097274742 X - R A Y F A LL OP I A NT U BE$ 111.30 320 74775 26 X-ray exam of perineum $111.309727477526 M i d l e v e lX - r a ye x am o f p er in e u m$ 94.60 972 74775 X-RAY EXAM OF PERINEUM $111.303297560026 M i d l e v e lC o n t r a s t x - r a ye x am o f a or t a$ 75.85 972 75600 26 Contrast x-ray exam of aorta $89.2597275600 T H OR A C I C A ORTOGR A M W O$ 892.50 323 SERIALOGRAPHY 75600 TC THORACIC AORTOGRAM WO $803.25320 SER I A L OGR A P H Y 7560526 M i d l e v e lC o n t r a s t x - r a ye x am o f a or t a$ 173.15 972 75605 26 Contrast x-ray exam of aorta $203.7097275605 T H OR A C I C A ORTOGR A M W$ 475.71 323 SERIALOGRAPHY 75605 TC MIDLEVEL CONTRAST X-RAY EXAM OF $272.01320 A ORT A 7562526 C o n t r a s t x - r a ye x am o f a or t a$ 203.70 972 75625 26 Midlevel Contrast x-ray exam of aorta $173.1597275625 A B D OM I N A L A ORTOGR A M$ 684.60 323 75625 TC ABDOMINAL AORTOGRAM $480.903207563026 X - r a y a or t a, l e g a r t er i es$ 317.10 972 75630 26 Midlevel X-ray aorta, leg arteries $269.5597275630 A B D A ORTOGR A M W B I L A TER A L R U NOFF$ 803.25 323 75630 TC ABD AORTOGRAM W BILATERAL RUNOFF $486.153207563526 Ct an g i o ab d o mina l a r t er i es$ 425.25 972 75635 26 Midlevel Ct angio abdominal arteries $361.4597275635 CT A NG I O A B D OM I N A L A RTER I ES$ 1,827.00 350 75635 TC CT ANGIO ABDOMINAL ARTERIES $1, 401.753507570526 A r t ery x - r a ys, s p in e$ 387.45 972 75705 26 Midlevel Artery x-rays, spine $329.3597275705 A RTER Y X - R A Y SSP I NE$ 984.90 323 75705 TC ARTERY X-RAYS SPINE $597.453207571026 M i d l e v e l A r t ery x - r a ys, a r m / l e g$ 169.55 972 75710 26 Artery x-rays, arm/leg $199.5097275710 EXTREM I T Y A NG I O - U N I L$ 758.10 323 75710 TC EXTREMITY ANGIO - UNIL $558.603207571626 A r t ery x - r a ys, a r m s / l e g s$ 234.15 972 75716 26 Midlevel Artery x-rays, arms/legs $199.0097275716 EXTREM I T Y A NG I O - B I L A T$ 893.55 323 75716 TC EXTREMITY ANGIO - BILAT $659.403207572626 M i d l e v e l A r t ery x - r a ys, ab d o m e n$ 172.25 972 75726 26 Artery x-rays, abdomen $202.6597275726 A RTER Y X - R A Y S A B D OMEN$ 756.00 323 75726 TC ARTERY X-RAYS ABDOMEN $553.353207573126 A r t ery x - r a ys, a d re na l g l an d$ 203.70 972 75731 26 Midlevel Artery x-rays, adrenal gland $173.1597275731 A D REN A L A NG I OGR - U N I L$ 729.75 323 75731 TC ADRENAL ANGIOGR - UNIL $526.053207573326 A r t ery x - r a ys, a d re na l s$ 235.20 972 75733 26 Midlevel Artery x-rays, adrenals $199.9097275733 A D REN A L A NG I OGR - B I L A T$ 875.70 323 75733 TC ADRENAL ANGIOGR - BILAT $640.503207573626 M i d l e v e l A r t ery x - r a ys, p e l v i s$ 169.55 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 32 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 75736 26 Artery x-rays, pelvis $199.5097275736 PE L V I C A NG I OGR A M$ 744.45 323 75736 TC PELVIC ANGIOGRAM $544.953207574126 A r t ery x - r a ys, l u n g$ 231.00 972 75741 26 Midlevel Artery x-rays, lung $196.3597275741 P UL MON A R Y U N I L A TSE L ECT I V E A NG I O$ 700.35 323 75741 TC PULMONARY UNILATSELECTIVE ANGIO $469.353207574326 A r t ery x - r a ys, l u n g s$ 294.00 972 75743 26 Midlevel Artery x-rays, lungs $249.9097275743 P UL MON A R Y B I L A TSE L ECT I V E A NG I OGR$ 798.00 323 75743 TC PULMONARY BILAT SELECTIVE ANGIOGR $504.003207574626 M i d l e v e l A r t ery x - r a ys, l u n g$ 172.25 972 75746 26 Artery x-rays, lung $202.6597275746 P UL MON A R Y NONSE L ECT I V E A NG I O$ 728.70 323 75746 TC PULMONARY NONSELECTIVE ANGIO $409.623207575626 A r t ery x - r a ys, c h es t$ 223.65 972 75756 26 Midlevel Artery x-rays, chest $190.1097275756 I NTERN A L M A MM A R Y A NG I O$ 840.00 323 75756 TC INTERNAL MAMMARY ANGIO $616.353207577426 M i d l e v e l A r t ery x - r a y, e a c h v esse l$ 54.45 972 75774 26 Artery x-ray, each vessel $64.0597275774 A RTER Y X - R A Y E A C H V ESSE L$ 480.90 323 75774 TC ARTERY X-RAY EACH VESSEL $416.853207580126 L y m p h v esse l x - r a y, a r m / l e g$ 161.70 972 75801 26 Midlevel Lymph vessel x-ray, arm/leg $147.0097275801 L Y MP H A NG I OEXTREMON L Y; U N I L A T$ 161.70 329 75803 26 Lymph vessel x-ray,arms/legs $213.159727580326 M i d l e v e l L y m p h v esse l x - r a y, a r m s / l e g s$ 181.15 972 75803 LYMPHANGIOGRAM EXTREMITY; BILAT $213.153297580526 M i d l e v e l L y m p h v esse l x - r a y, t r u nk$ 124.95 972 75805 26 Lymph vessel x-ray, trunk $147.0097275805 L Y MP H A NG I OGR A MPE L V I C / A B D; U N I L A T$ 147.00 329 75807 26 Lymph vessel x-ray, trunk $213.159727580726 M i d l e v e l L y m p h v esse l x - r a y, t r u nk$ 181.15 972 75807 LYMPHANGIOGRAM PELVIC/ABD; BILAT $213.153297580926 M i d l e v e lN o n v a sc u l a rs h u n t, x - r a y$ 72.30 972 75809 26 Nonvascular shunt, x-ray $85.0597275809 NON V A SC UL A RS H U NTX - R A Y$ 382.20 320 75809 TC NONVASCULAR SHUNT X-RAY $297.153207581026 M i d l e v e l V e in x - r a y, s pl ee n / l i v er$ 176.70 972 75810 26 Vein x-ray, spleen/liver $207.9097275810 SP L ENOPORTOGR A M$ 207.90 329 75820 26 Midlevel Vein x-ray, arm/leg $106.209727582026 V e in x - r a y, a r m / l e g$ 124.95 972 75820 VENOGRAM EXTREMITY; UNILATERAL $467.2532975820 TC V ENOGR A MEXTREM I T Y; U N I L A TER A L$ 342.29 320 75822 26 Vein x-ray, arms/legs $187.959727582226 M i d l e v e l V e in x - r a y, a r m s / l e g s$ 159.75 972 75822 VENOGRAPHY EXTREMITY; BILATERAL $575.4032975822 TC V ENOGR A P H Y EXTREM I T Y; B I L A TER A L$ 387.45 320 75825 26 Vein x-ray, trunk $201.609727582526 M i d l e v e l V e in x - r a y, t r u nk$ 171.35 972 75825 VENOGRAM IVC W SERIALOGRAPHY $657.3032975825 TC V ENOGR A M I V C W SER I A L OGR A P H Y$ 455.70 320 75827 26 Vein x-ray, chest $199.509727582726 M i d l e v e l V e in x - r a y, c h es t$ 169.55 972 75827 VENOGRAM SVC W SERIALOGRAPHY $669.90 329 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 33 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 75827 TC VENOGRAM SVC W SERIALOGRAPHY $470.403207583126 V e in x - r a y, ki d n ey$ 221.55 972 75831 26 Midlevel Vein x-ray, kidney $188.3097275831 U N I L SE L CT V REN A L V ENOGR A M$ 691.95 329 75831 TC UNIL SELCTV RENAL VENOGRAM $470.403207583326 V e in x - r a y, ki d n eys$ 257.25 972 75833 26 Midlevel Vein x-ray, kidneys $218.6597275833 B I L A TSE L CT V REN A L V ENOGR A M$ 786.45 329 75833 TC BILAT SELCTV RENAL VENOGRAM $529.203207584026 M i d l e v e l V e in x - r a y, a d re na l g l an d$ 189.20 972 75840 26 Vein x-ray, adrenal gland $222.6097275840 U N I L SE L CT V A D REN A L V ENOGR A M$ 686.70 329 75840 TC UNIL SELCTV ADRENAL VENOGRAM $464.103207584226 M i d l e v e l V e in x - r a y, a d re na l g l an d s$ 224.90 972 75842 26 Vein x-ray, adrenal glands $264.6097275842 B I L A TSE L CT V A D REN A L V ENOGR A M$ 798.00 329 75842 TC BILAT SELCTV ADRENAL VENOGRAM $533.403207586026 V e in x - r a y, n ec k$ 205.80 972 75860 26 Midlevel Vein x-ray, neck $174.9597275860 S I N U SOR J U G L C A T H V ENOGR A M$ 678.30 329 75860 TC SINUS OR JUGL CATH VENOGRAM $472.503207587026 M i d l e v e l V e in x - r a y, s k u ll$ 172.25 972 75870 26 Vein x-ray, skull $202.6597275870 S U PER I ORS A G I TT A L S I N U S V ENOGR A M$ 670.95 329 75870 TC SUPERIOR SAGITTAL SINUS VENOGRAM $468.303207587226 M i d l e v e l V e in x - r a y, s k u ll$ 187.40 972 75872 26 Vein x-ray, skull $220.5097275872 EP I D U R A L V ENOGR A M$ 523.50 329 75872 TC EPIDURAL VENOGRAM $303.003207588026 V e in x - r a y, eyesoc k e t$ 123.90 972 75880 26 Midlevel Vein x-ray, eye socket $105.3097275880 ORB I T A L V ENOGR A M$ 487.20 329 75880 TC ORBITAL VENOGRAM $363.303207588526 V e in x - r a y, l i v er$ 255.15 972 75885 26 Midlevel Vein x-ray, liver $216.8597275885 PERCTR A NS H EPPORTOGR A M W HD M$ 722.40 329 75885 TC PERC TRANSHEP PORTOGRAM W HDM $467.253207588726 M i d l e v e l V e in x - r a y, l i v er$ 212.40 972 75887 26 Vein x-ray, liver $249.9097275887 PERCTR A NS H EPPORTOGR A M W O HD M$ 722.40 329 75887 TC PERC TRANSHEP PORTOGRAM WO HDM $428.103207588926 V e in x - r a y, l i v er$ 201.60 972 75889 26 Midlevel Vein x-ray, liver $171.3597275889 H EP A T I C V ENOGR A M W HD M$ 672.00 329 75889 TC HEPATIC VENOGRAM W HDM $470.403207589126 V e in x - r a y, l i v er$ 201.60 972 75891 26 Midlevel Vein x-ray, liver $171.3597275891 H EP A T I C V ENOGR A M W O HD M$ 673.05 329 75891 TC HEPATIC VENOGRAM WO HDM $471.453207589326 V e n o u ss am pl in g b yc a t h e t er$ 92.40 972 75893 26 Midlevel Venous sampling by catheter $78.5597275893 V ENO U SS A MP L I NGB Y C A T H ETER$ 560.70 329 75893 TC VENOUS SAMPLING BY CATHETER $468.303207589426 X - r a ys, t r an sc a t h t h er a p y$ 241.50 960 75894 26 Midlevel X-rays, transcath therapy $205.2596075894 X - R A Y STR A NSC A T H T H ER A P Y$ 241.50 329 75898 26 Midlevel Follow-up angiography $260.60 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 34 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 75898 26 Follow-up angiography $306.6096075898 F o ll o w - u p an g i o g r a p h y$ 306.60 320 75901 26 Midlevel Remove cva device obstruct $73.209607590126 R e m o v ec v a d e v i ceo b s t r u c t$ 86.10 960 75901 REMOVE CVA DEVICE OBSTRUCT $640.5032975901 TCREMO V EC V A D E V I CEOBSTR U CT$ 554.40 320 75902 26 Remove cva lumen obstruct $70.359607590226 M i d l e v e lR e m o v ec v a l u m e n o b s t r u c t$ 59.80 960 75902 REMOVE CVA LUMEN OBSTRUCT $285.6032975902 TCREMO V EC V A LU MENOBSTR U CT$ 215.25 320 75956 26 Midlevel Xray, endovasc thor ao repr $1, 125.459607595626 X r a y, e n d o v a sc t h or a ore p r$ 1,324.05 960 75956 XRAY ENDOVASC THOR AO REPR $1, 324.053297595726 M i d l e v e lX r a y, e n d o v a sc t h or a ore p r$ 963.00 960 75957 26 Xray, endovasc thor ao repr $1, 132.9596075957 XR A Y EN D O V A SCT H OR A OREPR$ 1,132.95 329 75958 26 Midlevel Xray, place prox ext thor ao $641.709607595826 X r a y, pl a ce p ro x e x tt h or a o$ 754.95 960 75958 XRAY PLACE PROX EXT THOR AO $754.953297595926 M i d l e v e lX r a y, pl a ce d i s t e x tt h or a o$ 561.35 960 75959 26 Xray, place dist ext thor ao $660.4596075959 XR A Y P L A CE D I STEXTT H OR A O$ 660.45 329 75970 26 Vascular biopsy $150.159607597026 M i d l e v e l Va sc u l a r bi o p sy$ 127.65 960 75970 VASCULAR BIOPSY $150.153297598426 X r a yco n t ro l c a t h e t erc han g e$ 127.05 972 75984 26 Midlevel Xray control catheter change $108.0097275984 XR A Y CONTRO L C A T H ETERC H A NGE$ 421.05 329 75984 TC XRAY CONTROL CATHETER CHANGE $186.213207598926 A b scess d r aina g e u n d er x - r a y$ 207.90 972 75989 26 Midlevel Abscess drainage under x-ray $176.7097275989 A BSCESS D R A I N A GE U N D ERX - R A Y$ 480.90 329 75989 TC ABSCESS DRAINAGE UNDER X-RAY $273.003207600026 F LU OROSCOP Y <= 1 H RP H Y S / Q H P$ 207.90 972 76000 26 Midlevel Fluoroscope examination $176.7097276000 TCF LU OROSCOP Y <= 1 H RP H Y S / Q H P$ 383.80 320 76000 FLUOROSCOPY ⇐1 HR PHYS/QHP $591.703207600126 M i d l e v e lFl u orosco p ee x am, e x t e n s i v e$ 108.00 972 76001 26 Fluoroscope exam, extensive $127.0597276001 F LU OROSCOPEEX A MEXTENS I V E > 1 H R$ 451.50 329 76010 26 Midlevel X-ray, nose to rectum $55.459727601026 X - r a y n ose t orec t u m$ 68.25 972 76010 NOSE TO RECTUM FOR FB CHILD $159.6932076010 TCNOSETORECT U MFORFBC H I L D$ 191.00 320 76080 26 Midlevel X-ray exam of fistula $81.209727608026 X - r a ye x am o ff i s t u l a$ 95.55 972 76080 X-RAY EXAM OF FISTULA $224.7032976080 TCX - R A Y EX A MOFF I ST UL A$ 129.15 320 76098 26 Midlevel X-ray exam, breast specimen $24.109727609826 X - r a ye x am, b re a s t s p ec im e n$ 28.35 972 76098 X-RAY EXAM BREAST SPECIMEN $68.2532976098 TCX - R A Y EX A MBRE A STSPEC I MEN$ 39.90 320 76100 26 X-ray exam of body section $112.359727610026 M i d l e v e lX - r a ye x am o f b o d ysec t i o n$ 95.50 972 76100 X-RAY EXAM OF BODY SECTION $414.7532976100 TCX - R A Y EX A MOFBO D Y SECT I ON$ 302.40 320 76101 26 Midlevel Complex body section x-ray $106.20 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 35 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76101 26 Complex body section x-ray $124.9597276101 COMP L EXMOT I ON; U N I L A TER A L$ 609.00 329 76101 TC COMPLEX MOTION; UNILATERAL $484.053207610226 M i d l e v e lC o m pl e x b o d ysec t i o n x - r a ys$ 107.10 972 76102 26 Complex body section x-rays $126.0097276102 COMP L EXMOT I ON; B I L A TER A L$ 821.10 329 76102 TC COMPLEX MOTION; BILATERAL $695.103207612026 C in e / v i d eo x - r a ys$ 68.25 972 76120 26 Midlevel Cine/video x-rays $58.0097276120 C I NE / V I D EOX - R A Y S$ 358.86 329 76120 TC CINE/VIDEO X-RAYS $290.613207612526 M i d l e v e lC in e / v i d eo x - r a ys a dd - o n$ 54.60 972 76125 26 Cine/video x-rays add-on $54.6097276125 C in e / v i d eo x - r a ys a dd - o n$ 49.60 320 76376 26 Midlevel 3d render w/o postprocess $30.3597276376263 d re n d er w / o p os tp rocess$ 35.70 972 76376 3D RENDER W/INTRP POSTPROCES $242.5535076376 TC 3 D REN D ER W / I NTRPPOSTPROCES$ 206.85 350 76377 26 3d rendering w/postprocess $139.659727637726 M i d l e v e l 3 d re n d er in g w / p os tp rocess$ 118.70 972 76377 3D RENDER W/INTRP POSTPROCES $318.1535076377 TC 3 D REN D ER W / I NTRPPOSTPROCES$ 178.50 350 76380 26 CAT scan follow-up study $173.259727638026 M i d l e v e lC A T sc an f o ll o w - u p s t u d y$ 147.25 972 76380 CAT SCAN FOLLOW-UP STUDY $658.3535076380 TCC A TSC A NFO LL O W - U PST U D Y$ 485.10 350 76496 UNLISTED FLUORO $124.2532076497 U N L I STE D CT$ 124.25 350 76499 AIR CONTRAST X-RAY OF BRAIN $257.2532976499 CONTR A STX - R A Y OF L A R Y NX$ 394.80 329 76499 CONTRAST XRAY BRONCHI BILAT $220.5032076499 CONTR A STXR A Y BRONC H I U N I L A T$ 112.35 320 76506 26 Midlevel Echo exam of head $90.109727650626 E c h oe x am o f h e a d$ 99.99 972 76506 Echo exam of head $632.7940276506 TCE c h oe x am o f h e a d$ 532.80 402 76510 26 Ophth us, b & quant a $340.20 972 76510 26 Midlevel Ophth us, b & quant a$ 289.20 972 76510 OPHTH US B & QUANT A $626.85 402 76510 TC OPHTH US B & QUANT A$ 286.65 402 76511 26 Midlevel Ophth us, quant a only $158.859727651126 Op h t h u s, q u an t a o n l y$ 186.90 972 76511 OPHTH US QUANT A ONLY $367.5040276511 TCOP H T H U SQ U A NT A ON L Y$ 180.60 402 76512 26 Midlevel Ophth us, b w/non-quant a $241.259727651226 Op h t h u s, b w / n o n - q u an t a$ 283.80 972 76512 OPHTH US B W/NON-QUANT A $338.1040276512 TCOP H T H U SB W / NON - Q U A NT A$ 54.30 402 76513 26 Echo exam of eye, water bath $45.509727651326 M i d l e v e lE c h oe x am o f eye, w a t er ba t h$ 38.65 972 76513 ECHO EXAM OF EYE WATER BATH $333.9040276513 TCEC H OEX A MOFE Y E W A TERB A T H$ 288.40 402 76514 26 Echo exam of eye, thickness $34.659727651426 M i d l e v e lE c h oe x am o f eye, t hi c kn ess$ 29.45 972 76514 TC ECHO EXAM OF EYE THICKNESS $15.5440276514 EC H OEX A MOFE Y ET H I C K NESS$ 50.19 402 76516 26 Echo exam of eye $73.68 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 36 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76516 26 Midlevel Echo exam of eye $67.0097276516 E Y EB I OMETR Y B Y U S A - SC A N;$ 182.13 402 76516 TC EYE BIOMETRY BY US A-SCAN; $108.454027651926 E c h oe x am o f eye$ 101.22 972 76519 26 Midlevel Echo exam of eye $92.0097276519 A - SC A NE Y E U S W I O L ME A SR$ 222.09 402 76519 TC A-SCAN EYE US W IOL MEASR $120.844027652926 M i d l e v e lE c h oe x am o f eye$ 98.80 972 76529 26 Echo exam of eye $108.6997276529 U STO L OC A L I ZEFB I NE Y E$ 280.35 402 76529 TC US TO LOCALIZE FB IN EYE $171.664027653626 M i d l e v e l U se x am o f h e a d an d n ec k$ 87.99 972 76536 26 Us exam of head and neck $103.4097276536 U se x am o f h e a d an d n ec k$ 393.25 402 76536 TC Us exam of head and neck $289.854027660426 M i d l e v e l U se x am, c h es t$ 82.10 972 76604 26 Us exam chest $96.6097276604 TC U se x am c h es t$ 443.55 402 76604 Us exam chest $540.154027664126 UL TR A SO U N D BRE A STCOMP L ETE$ 96.60 972 76641 TC ULTRASOUND BREAST COMPLETE $264.6040276641 UL TR A SO U N D BRE A STCOMP L ETE$ 361.20 402 76642 26 ULTRASOUND BREAST LIMITED $107.2297276642 UL TR A SO U N D BRE A ST L I M I TE D$ 371.82 402 76642 TC ULTRASOUND BREAST LIMITED $264.604027670026 M i d l e v e l U se x am, ab d o m, co m pl e t e$ 122.25 972 76700 26 Us exam abdom complete $143.8597276700 U se x amab d o m co m pl e t e$ 483.90 402 76700 TC Us exam abdom complete $340.054027670526 M i d l e v e lE c h oe x am o f ab d o m e n$ 88.35 972 76705 26 Echo exam of abdomen $103.9597276705 E c h oe x am o f ab d o m e n$ 524.30 402 76705 TC Echo exam of abdomen $420.354027670626 U S A B D L A ORT A SCREEN AAA$ 91.20 972 76706 US ABDL AORTA SCREEN AAA $428.7040276706 TC U S A B D L A ORT A SCREEN AAA$ 337.50 402 76770 26 Midlevel Us exam abdo back wall, comp $111.55972 [R o w s 12001 - 13000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 7677026 U se x amab d o ba c k w a ll co m p$ 131.25 972 76770 Us exam abdo back wall comp $478.4540276770 TC U se x amab d o ba c k w a ll co m p$ 347.20 402 76775 26 Us exam abdo back wall lim $102.909727677526 M i d l e v e l U se x amab d o ba c k w a ll, l im$ 87.45 972 76775 TC Us exam abdo back wall lim $482.8540276775 U se x amab d o ba c k w a lll im$ 585.75 402 76776 26 Us exam k transpl w/doppler $133.359727677626 M i d l e v e l U se x amk t r an s plw / d o ppl er$ 113.35 972 76776 Us exam k transpl w/doppler $547.4540276776 TC U se x amk t r an s plw / d o ppl er$ 414.10 402 76800 26 Midlevel Us exam, spinal canal $166.909727680026 U se x am s p ina l c ana l$ 196.35 972 76800 TC Us exam spinal canal $407.0040276800 U se x am s p ina l c ana l$ 603.35 402 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 37 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76801 26 Ob us < 14 wks single fetus $175.359727680126 M i d l e v e lO b u s < 14 w k s, s in g l e f e t u s$ 149.05 972 76801 TC Ob us < 14 wks single fetus $303.4540276801 O b u s < 14 w k ss in g l e f e t u s$ 478.80 402 76802 26 Ob us < 14 wks, add’l fetus $176.439727680226 M i d l e v e lO b u s < 14 w k s, a d d^{'} l f e t u s$ 160.40 972 76802 OB US < 14 WKS ADDL FETUS $252.0040276802 TCOB U S < 14 W K S A DD L FET U S$ 75.57 402 76805 26 Ob us >/= 14 wks sngl fetus $175.359727680526 M i d l e v e lO b u s > / = 14 w k s, s n g l f e t u s$ 149.05 972 76805 Ob us >/= 14 wks sngl fetus $483.2540276805 TCO b u s > / = 14 w k ss n g l f e t u s$ 307.90 402 76810 26 Midlevel Ob us >/= 14 wks, addl fetus $148.159727681026 O b u s > / = 14 w k s a dd l f e t u s$ 174.30 972 76810 Ob us >/= 14 wks addl fetus $362.2540276810 TCO b u s > / = 14 w k s a dd l f e t u s$ 187.95 402 76811 26 Midlevel Ob us, detailed, sngl fetus $290.059727681126 O b u s d e t ai l e d s n g l f e t u s$ 341.25 972 76811 Ob us detailed sngl fetus $658.6540276811 TCO b u s d e t ai l e d s n g l f e t u s$ 317.40 402 76812 26 Ob us, detailed, addl fetus $287.529727681226 M i d l e v e lO b u s, d e t ai l e d, a dd l f e t u s$ 261.40 972 76812 OB US DETAILED ADDL FETUS $671.0440276812 TCOB U S D ET A I L E D A DD L FET U S$ 383.52 402 76813 26 Midlevel Ob us nuchal meas, 1 gest $216.209727681326 O b u s n u c ha l m e a s, 1 g es t$ 254.35 972 76813 OB US NUCHAL MEAS 1 GEST $465.1540276813 TCOB U SN U C H A L ME A S 1 GEST$ 210.80 402 76814 26 Midlevel Ob us nuchal meas, add-on $245.059727681426 O b u s n u c ha l m e a s, a dd - o n$ 288.30 972 76814 OB US NUCHAL MEAS ADD-ON $388.0840276814 TCOB U SN U C H A L ME A S A DD - ON$ 99.78 402 76815 26 Ob us limited fetus(s) $113.409727681526 M i d l e v e lO b u s, l imi t e d, f e t u s (s)$ 96.40 972 76815 Ob us limited fetus(s) $490.0540276815 TCO b u s l imi t e df e t u s (s)$ 376.65 402 76816 26 Midlevel Ob us, follow-up, per fetus $179.209727681626 O b u s, f o ll o w - u p, p er f e t u s$ 197.10 972 76816 OB US FOLLOW-UP PER FETUS $443.1040276816 TCOB U SFO LL O W - U PPERFET U S$ 246.00 402 76817 26 Transvaginal us obstetric $133.359727681726 M i d l e v e lT r an s v a g ina l u s, o b s t e t r i c$ 113.35 972 76817 TC Transvaginal us obstetric $388.2540276817 T r an s v a g ina l u so b s t e t r i c$ 382.20 402 76818 26 Fetal biophys profile w/nst $189.009727681826 M i d l e v e lF e t a l bi o p h ys p ro f i l e w / n s t$ 160.65 972 76818 TC Fetal biophys profile w/nst $287.4040276818 F e t a l bi o p h ys p ro f i l e w / n s t$ 476.40 402 76819 26 Fetal biophys profil w/o nst $136.559727681926 M i d l e v e lF e t a l bi o p h ys p ro f i lw / o n s t$ 116.05 972 76819 FETAL BIOPHYS PROFIL W/O NST $338.1040276819 TCFET A L B I OP H Y SPROF I L W / ONST$ 201.55 402 76820 26 Midlevel Umbilical artery echo $75.859727682026 U mbi l i c a l a r t eryec h o$ 89.25 972 76820 Umbilical artery echo $160.6540276820 TC U mbi l i c a l a r t eryec h o$ 71.40 402 76821 26 Midlevel Middle cerebral artery echo $118.70 972 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 38 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76821 26 Middle cerebral artery echo $100.9197276821 M I DD L ECEREBR A L A RTER Y EC H O$ 314.25 402 76821 TC MIDDLE CEREBRAL ARTERY ECHO $195.554027682526 E c h oe x am o ff e t a l h e a r t$ 297.15 972 76825 26 Midlevel Echo exam of fetal heart $252.6097276825 TCFET A L C A R D I O V A SC 2 - D U S$ 669.15 402 76825 FETAL CARDIOVASC 2-D US $966.304027682626 M i d l e v e lE c h oe x am o ff e t a l h e a r t$ 170.65 972 76826 26 Echo exam of fetal heart $200.8097276826 FET A L C A R D I O V A SC 2 - D FO LL O W U P U S$ 627.70 402 76826 TC FETAL CARDIOVASC 2-D FOLLOWUP US $426.904027682726 M i d l e v e lE c h oe x am o ff e t a l h e a r t$ 124.40 972 76827 26 Echo exam of fetal heart $146.3597276827 COMP L FET A L D OPP L EREC H OC A RG I OGR A M$ 305.62 402 76827 TC COMPL FETAL DOPPLER ECHOCARGIOGRAM $159.274027682826 E c h oe x am o ff e t a l h e a r t$ 98.70 972 76828 26 Midlevel Echo exam of fetal heart $83.9097276828 L I M I TFET A L D OPP L EREC H OC A R D I OGR A M$ 172.20 402 76828 TC LIMIT FETAL DOPPLER ECHOCARDIOGRAM $73.504027683026 T r an s v a g ina l u s n o n - o b$ 122.85 972 76830 26 Midlevel Transvaginal us, non-ob $104.4097276830 T r an s v a g ina l u s n o n - o b$ 525.35 402 76830 TC Transvaginal us non-ob $402.504027683126 M i d l e v e lE c h oe x am, u t er u s$ 110.67 972 76831 26 Echo exam, uterus $130.2097276831 EC H OEX A M U TER U S$ 473.55 402 76831 TC ECHO EXAM UTERUS $343.354027685626 M i d l e v e l U se x am, p e l v i c, co m pl e t e$ 102.65 972 76856 26 Us exam pelvic complete $120.7597276856 U se x am p e l v i cco m pl e t e$ 463.05 402 76856 TC Us exam pelvic complete $342.304027685726 M i d l e v e l U se x am, p e l v i c, l imi t e d$ 71.30 972 76857 26 Us exam pelvic limited $78.4297276857 U se x am p e l v i c l imi t e d$ 160.86 402 76857 TC Us exam pelvic limited $82.444027687026 U se x am scro t u m$ 113.40 972 76870 26 Midlevel Us exam, scrotum $96.4097276870 TC U se x am scro t u m$ 347.55 402 76870 Us exam scrotum $460.954027687226 M i d l e v e l U s, t r an srec t a l$ 105.30 972 76872 26 Us, transrectal $123.9097276872 U STR A NSRECT A L$ 454.14 402 76872 TC US TRANSRECTAL $330.244027687326 E c h o g r a pt r an sr, p ross t u d y$ 277.20 972 76873 26 Midlevel Echograp trans r, pros study $235.9697276873 EC H OGR A PTR A NSRPROSST U D Y$ 609.93 402 76873 TC ECHOGRAP TRANS R PROS STUDY $332.734027688126 U s x t r n o n - v a scco m pl e t e$ 110.25 972 76881 TC Us xtr non-vasc complete $38.0040276881 U s x t r n o n - v a scco m pl e t e$ 448.35 402 76882 26 Us xtr non-vasc lmtd $86.2597276882 U s x t r n o n - v a sc l m t d$ 199.68 402 76882 TC Us xtr non-vasc lmtd $113.434027688526 U se x amin f an t hi p s, d y nami c$ 132.30 972 76885 26 Midlevel Us exam infant hips, dynamic $122.4597276885 U SEX A M I NF A NT H I PS D Y N A M I C$ 418.95 402 76885 TC US EXAM INFANT HIPS DYNAMIC $286.39 402 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 39 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76886 26 Us exam infant hips, static $106.059727688626 M i d l e v e l U se x amin f an t hi p s, s t a t i c$ 90.15 972 76886 US EXAM INFANT HIPS STATIC $319.8340276886 TC U SEX A M I NF A NT H I PSST A T I C$ 213.78 402 76930 26 Echo guide, cardiocentesis $118.659727693026 M i d l e v e lE c h o gu i d e, c a r d i oce n t es i s$ 100.85 972 76930 ECHO GUIDE CARDIOCENTESIS $118.654027693226 E c h o gu i d e f or h e a r t bi o p sy$ 122.85 972 76932 26 Midlevel Echo guide for heart biopsy $104.4097276932 EC H OG U I D EFOR H E A RTB I OPS Y$ 122.85 402 76936 26 Midlevel Echo guide for artery repair $307.009607693626 E c h o gu i d e f or a r t eryre p ai r$ 361.20 960 76936 ECHO GUIDE FOR ARTERY REPAIR $1, 103.5540276936 TCEC H OG U I D EFOR A RTER Y REP A I R$ 742.35 402 76937 26 Midlevel Us guide, vascular access $46.409727693726 U s gu i d e v a sc u l a r a ccess$ 54.60 972 76937 Us guide vascular access $129.1540276937 TC U s gu i d e v a sc u l a r a ccess$ 74.55 402 76940 26 Midlevel Us guide, tissue ablation $320.409607694026 U s gu i d e, t i ss u e ab l a t i o n$ 376.95 960 76940 US GUIDE TISSUE ABLATION $376.954027694126 E c h o gu i d e f or t r an s f u s i o n$ 241.50 972 76941 26 Midlevel Echo guide for transfusion $205.2597276941 EC H OG U I D EFORTR A NSF U S I ON$ 241.50 402 76942 26 Echo guide for biopsy $119.709727694226 M i d l e v e lE c h o gu i d e f or bi o p sy$ 101.75 972 76942 TC US GUIDED NEEDLE PLACEMENT $631.0540276942 U SG U I D E D NEE D L EP L A CEMENT$ 750.75 402 76945 26 Echo guide, villus sampling $123.909727694526 M i d l e v e lE c h o gu i d e, v i ll u ss am pl in g$ 105.30 972 76945 ECHO GUIDE VILLUS SAMPLING $123.904027694626 M i d l e v e lE c h o gu i d e f or amni oce n t es i s$ 58.00 972 76946 26 Echo guide for amniocentesis $68.2597276946 EC H OG U I D EFOR A MN I OCENTES I S$ 129.15 402 76946 TC ECHO GUIDE FOR AMNIOCENTESIS $60.904027694826 M i d l e v e lE c h o gu i d e, o v aa s p i r a t i o n$ 59.80 972 76948 26 Echo guide, ova aspiration $70.3597276948 EC H OG U I D EO V AA SP I R A T I ON$ 209.79 402 76948 TC ECHO GUIDE OVA ASPIRATION $139.444027696526 E c h o gu i d an cer a d i o t h er a p y$ 241.50 960 76965 26 Midlevel Echo guidance radiotherapy $205.2596076965 EC H OG U I D A NCER A D I OT H ER A P Y$ 327.66 402 76965 TC ECHO GUIDANCE RADIOTHERAPY $86.164027697026 U lt r a so u n d e x am f o ll o w - u p$ 73.50 972 76970 26 Midlevel Ultrasound exam follow-up $62.4597276970 UL TR A SO U N D EX A MFO LL O W - U P$ 374.85 402 76970 TC ULTRASOUND EXAM FOLLOW-UP $301.354027697526 M i d l e v e lG I e n d osco p i c u lt r a so u n d$ 133.85 972 76975 26 GI endoscopic ultrasound $157.5097276975 G I EN D OSCOP I C UL TR A SO U N D$ 157.50 402 76977 26 Midlevel Us bone density measure $8.059727697726 U s b o n e d e n s i t y m e a s u re$ 9.45 972 76977 US BONE DENSITY - PERIPHERAL $31.5040276977 TC U SBONE D ENS I T Y - PER I P H ER A L$ 22.05 402 76998 26 Us guide, intraop $236.259727699826 M i d l e v e l U s gu i d e, in t r a o p$ 200.80 972 76998 US GUIDE INTRAOP $236.25 402 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 40 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 76999 UNLISTED ULTRASOUND $124.254027700126 Fl u oro gu i d e f or v e in d e v i ce$ 71.50 972 77001 26 Midlevel Fluoroguide for vein device $60.7597277001 TCFl u oro gu i d e f or v e in d e v i ce$ 366.45 320 77001 Fluoroguide for vein device $437.953207700226 N ee d l e l oc a l i z a t i o nb y x r a y$ 98.70 972 77002 26 Midlevel Needle localization by xray $83.9097277002 TCNEE D L E L OC A L I Z A T I ONB Y XR A Y$ 255.90 320 77002 NEEDLE LOCALIZATION BY XRAY $354.603207700326 M i d l e v e lFl u oro gu i d e f ors p in e inj ec t$ 92.80 972 77003 26 Fluoroguide for spine inject $109.2097277003 TCF LU OROG U I D EFORSP I NE I N J ECT$ 236.07 320 77003 FLUOROGUIDE FOR SPINE INJECT $345.273207701126 M i d l e v e lCt sc an f or l oc a l i z a t i o n$ 184.75 972 77011 26 Ct scan for localization $217.3597277011 CTSC A NFOR L OC A L I Z A T I ON$ 796.65 350 77011 TC CT SCAN FOR LOCALIZATION $579.303507701226 M i d l e v e lCt sc an f or n ee d l e bi o p sy$ 231.51 972 77012 26 Ct scan for needle biopsy $210.5097277012 CTSC A NFORNEE D L EB I OPS Y$ 499.80 350 77012 TC CT SCAN FOR NEEDLE BIOPSY $268.293507701326 Ct gu i d e f or t i ss u e ab l a t i o n$ 722.40 972 77013 26 Midlevel Ct guide for tissue ablation $614.0597277013 CTG U I D EFORT I SS U E A B L A T I ON$ 722.40 350 77014 26 Ct scan for therapy guide $152.259607701426 M i d l e v e lCt sc an f or t h er a p y gu i d e$ 129.40 960 77014 CT SCAN FOR THERAPY GUIDE $416.8235077014 TCCTSC A NFORT H ER A P Y G U I D E$ 264.57 350 77053 26 Midlevel X-ray of mammary duct $52.659727705326 X - r a yo f mamma ry d u c t$ 61.95 972 77053 X-RAY OF MAMMARY DUCT $198.9032077053 TCX - R A Y OFM A MM A R Y D U CT$ 136.95 320 77054 26 Midlevel X-ray of mammary ducts $68.709727705426 X - r a yo f mamma ry d u c t s$ 80.85 972 77054 X-RAY OF MAMMARY DUCTS $262.4132077054 TCX - R A Y OFM A MM A R Y D U CTS$ 181.56 320 77062 DIGITAL BREASTTOMOSYNTHESIS $87.33 B I L A TER A L 77063 SCREEN I NG D I G I T A L BRE A ST$ 87.33 TOMOSYNTHESIS BI 77063 26 SCREENING DIGITAL BREAST $106.47 TOMOS Y NT H ES I SB I 7706526 D XM A MMO I NC L C A D U N I$ 124.95 972 77065 TC DX MAMMO INCL CAD UNI TECH COMP $319.2040177065 D XM A MMO I NC L C A D U N I$ 444.15 401 77066 26 DX MAMMO INCL CAD BI $158.0497277066 D XM A MMO I NC L C A D B I$ 571.32 401 77066 TC DX MAMMO INCL CAD BI TECH COMP $413.254017706726 SCRM A MMOB II NC L C A D$ 119.61 972 77067 26 Comp screen mammogram add-on $11.5597277067 TCSCRM A MMOB II NC L C A D TEC H COMP$ 341.40 403 77067 TC Comp screen mammogram add-on $296.104037706752 M A MMOGR A MSCREEN I NG, U N I L A T$ 124.95 403 77067 MAMMOGRAM SCREENING $461.014037707126 X - r a ys t ress v i e w$ 72.30 960 77071 26 Midlevel X-ray stress view $65.7096077071 X - r a ys t ress v i e w$ 72.30 320 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 41 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 77072 26 Midlevel X-rays for bone age $28.559727707226 X - r a ys f or b o n e a g e$ 33.60 972 77072 X-RAYS FOR BONE AGE $83.8232077072 TCX - R A Y SFORBONE A GE$ 50.22 320 77073 26 X-rays, bone length studies $53.559727707326 M i d l e v e lX - r a ys, b o n e l e n g t h s t u d i es$ 45.50 972 77073 X-RAYS BONE LENGTH STUDIES $133.5032077073 TCX - R A Y SBONE L ENGT H ST U D I ES$ 79.95 320 77074 26 X-rays, bone survey, limited $80.859727707426 M i d l e v e lX - r a ys, b o n es u r v ey, l imi t e d$ 68.70 972 77074 X-RAYS BONE SURVEY LIMITED $177.4532077074 TCX - R A Y SBONES U R V E Y L I M I TE D$ 155.55 320 77075 26 X-rays, bone survey complete $96.609727707526 M i d l e v e lX - r a ys, b o n es u r v eyco m pl e t e$ 82.10 972 77075 X-RAYS BONE SURVEY COMPLETE $385.3532077075 TCX - R A Y SBONES U R V E Y COMP L ETE$ 226.17 320 77076 26 X-rays, bone survey, infant $124.959727707626 M i d l e v e lX - r a ys, b o n es u r v ey, in f an t$ 106.20 972 77076 X-RAYS BONE SURVEY INFANT $353.5832077076 TCX - R A Y SBONES U R V E Y I NF A NT$ 228.63 320 77077 26 Midlevel Joint survey, single view $51.759727707726 J o in t s u r v ey, s in g l e v i e w$ 60.90 972 77077 JOINT SURVEY SINGLE VIEW $138.3932077077 TC J O I NTS U R V E Y S I NG L E V I E W 2 + J O I NTS$ 77.49 320 77078 26 Ct bone density, axial $43.059727707826 M i d l e v e lCt b o n e d e n s i t y, a x ia l$ 36.60 972 77078 CT BONE DENSITY AXIAL $256.8335277078 TCM I D L E V E L CTBONE D ENS I T Y, A X I A L$ 213.78 350 77080 26 Midlevel Dxa bone density, axial $33.909727708026 D x ab o n e d e n s i t y, a x ia l$ 39.90 972 77080 DXA BONE DENSITY AXIAL $144.6332077080 TC D X A BONE D ENS I T Y, A X I A L$ 104.73 320 77081 26 Dxa bone density/peripheral $39.909727708126 M i d l e v e l D x ab o n e d e n s i t y / p er i p h er a l$ 33.90 972 77081 DXA BONE DENSITY/PERIPHERAL $119.8532077081 TC D X A BONE D ENS I T Y / PER I P H ER A L$ 79.95 320 77086 26 FRACTURE ASSESSMENT VIA DXA $26.4997277086 FR A CT U RE A SSESSMENT V I A D X A$ 118.86 320 77086 TC FRACTURE ASSESSMENT VIA DXA $92.3432080047 M e t ab o l i c p an e l i o ni ze d c a$ 27.30 300 80048 Metabolic panel total ca $30.8030180050 GENER A L H E A L T H P A NE L$ 18.90 300 80051 Electrolyte panel $27.5030180053 C o m p re h e nm e t ab o l i c p an e l$ 38.50 301 80055 OBSTETRIC PANEL $159.3630080061 L i p i d p an e l$ 49.50 301 80069 Renal function panel $30.8030180074 A c u t e h e p a t i t i s p an e l$ 162.75 301 80076 Hepatic function panel $29.7030180143 TC D R U G A SS A Y A CET A M I NOP H EN$ 55.92 300 80150 ASSAY OF AMIKACIN $50.4030080156 A ss a yc a r bama ze p in e t o t a l$ 63.00 301 80157 ASSAY CARBAMAZEPINE FREE $63.0030080158 A ss a yo f cyc l os p or in e$ 63.00 301 80159 TC DRUG ASSAY CLOZAPINE $60.4530080162 A ss a yo fd i g o x in$ 66.00 301 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 42 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 80164 Assay dipropylacetic acid $66.0030180168 A SS A Y OFET H OS U X I M I D E$ 71.40 300 80170 Assay of gentamicin $71.4030180173 A SS A Y OF H A L OPER I D O L$ 50.40 300 80175 DRUG SCREEN QUAN LAMOTRIGINE $44.1930180176 A SS A Y OF L I D OC A I NE$ 60.90 300 80177 DRUG SCRN QUAN LEVETIRACETAM $44.1930180178 A SS A Y OF L I T H I U M$ 34.65 300 80179 TC DRUG ASSAY SALICYLATE $55.9280184 A ss a yo f p h e n o ba r bi t a l$ 49.60 301 80185 Assay of phenytoin total $60.1530180186 A SS A Y OFP H EN Y TO I NFREE$ 59.60 300 80188 ASSAY OF PRIMIDONE $71.8530080190 A SS A Y OFPROC A I N A M I D E$ 72.55 300 80192 PROCAINAMIDE W METABOLITES $72.5530080194 A SS A Y OFQ U I N I D I NE$ 63.20 300 80195 ASSAY OF SIROLIMUS $59.4530080197 A SS A Y OFT A CRO L I M U S$ 59.45 300 80198 Assay of theophylline $61.2530180200 A SS A Y OFTOBR A M Y C I N$ 69.80 300 80201 ASSAY OF TOPIRAMATE $51.6530080202 A ss a yo f v an co m yc in$ 58.70 301 80299 QUANTITATIVE ASSAY DRUG NOS $59.3030080305 D R U GTESTPRSM V D I ROPTOBS$ 29.90 301 80306 DRUG TEST PRSMV INSTRMNT $39.9030180307 D R U GTESTPRSM V C H EM A N L Y ZR$ 159.60 301 80320 DRUG SCREEN QUANTALCOHOLS $52.0030180321 A L CO H O L SB I OM A R K ERS 1 OR 2$ 46.80 301 80322 ALCOHOLS BIOMARKERS 3/MORE $46.8030080323 A L K A L O I D SNOS$ 129.95 300 80324 DRUG SCREEN AMPHETAMINES 1/2 $67.3030080325 A MP H ET A M I NES 3 OR 4$ - 301 80326 AMPHETAMINES 5 OR MORE $- 30180327 A N A BO L I CSTERO I D 1 OR 2$ 49.95 300 80328 ANABOLIC STEROID 3 OR MORE $126.7530080329 A N A L GES I CSNON - OP I O I D 1 OR 2$ - 301 80330 ANALGESICS NON-OPIOID 3-5 $30.7030080331 A N A L GES I CSNON - OP I O I D 6/ MORE$ 30.70 301 80335 ANTIDEPRESSANT TRICYCLIC 1/2 $63.0030080336 A NT I D EPRESS A NTTR I C Y C L I C 3 - 5$ 63.00 300 80337 TRICYCLIC & CYCLICALS 6/MORE $63.0030080339 A NT I EP I L EPT I CSNOS 1 - 3$ 64.15 300 80340 ANTIEPILEPTICS NOS 4-6 $89.4530080341 A NT I EP I L EPT I CSNOS 7/ MORE$ - 301 80342 ANTIPSYCHOTICS NOS 1-3 $67.4530080343 A NT I PS Y C H OT I CSNOS 4 - 6$ - 301 80344 ANTIPSYCHOTICS NOS 7/MORE $- 30180345 D R U GSCREEN I NGB A RB I T U R A TES$ 49.60 300 80346 BENZODIAZEPINES1-12 $63.0030080347 BENZO D I A ZEP I NES 13 ORMORE$ 57.65 300 80353 DRUG SCREENING COCAINE $65.6030080358 D R U GSCREEN I NGMET H A D ONE$ 70.70 300 80361 OPIATES 1 OR MORE $84.25 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 43 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 80362 OPIOIDS & OPIATE ANALOGS 1/2 $- 301 80363 OPIOIDS & OPIATE ANALOGS 3/4$ - 301 80364 OPIOID &OPIATE ANALOG 5/MORE $- 30180369 S K E L ET A L M U SC L ERE L A X A NT 1/2$ 76.30 300 80370 SKEL MUSC RELAXANT 3 OR MORE $- 30180375 D R U G / S U BST A NCENOS 1 - 3$ 71.40 300 80400 Acth stimulation panel $141.2030180402 A CT H ST I M UL A T I ONP A NE L$ 376.50 300 80406 ACTH STIMULATION PANEL $338.8030080408 A L D OSTERONES U PPRESS I ONE V A L$ 543.45 300 80410 CALCITONIN STIMUL PANEL $347.9530080412 CR H ST I M UL A T I ONP A NE L$ 1,427.15 300 80414 TESTOSTERONE RESPONSE $223.6030080415 ESTR A D I O L RESPONSEP A NE L$ 242.00 300 80416 RENIN STIMULATION PANEL $571.5530080417 REN I NST I M UL A T I ONP A NE L$ 190.50 300 80418 PITUITARY EVALUATION PANEL $2, 509.6530080420 D EX A MET H A SONEP A NE L 48 H R$ 311.85 300 80422 GT PANEL; FOR INSULINOMA $199.4030080424 GTP A NE L; FORP H EOC H ROMOC Y TOM A$ 218.65 300 80426 GONADOTROPIN HORMONE PANEL $642.6030080428 G H ST I MP A NE L$ 288.90 300 80430 GH SUPPRESSION PANEL $339.8530080432 I NS UL I NS U PPRESS I ONP A NE L$ 585.00 300 80434 INSULIN TOLERANCE PANEL $437.8530080435 I NS UL I NTO L ER A NCEP A NE L$ 446.05 300 80436 METYRAPONE PANEL $394.7030080438 TR H ST I M UL A T I ONP A NE L 1 H O U R$ 218.30 300 80439 TRH STIMULATION PANEL 2 HOURS $291.053008050026 M i d l e v e l L ab p a t h o l o g yco n s u lt a t i o n$ 535.50 969 80500 26 Lab pathology consultation $630.0096980500 P A T H CONS UL T; L I M I TE D$ 64.05 310 80502 26 Lab pathology consultation $21.009698050226 M i d l e v e l L ab p a t h o l o g yco n s u lt a t i o n$ 18.00 969 80502 PATH CONSULT; COMPREH $222.6031081000 U r ina l ys i s n o na u t o w / sco p e$ 13.70 307 81001 Urinalysis auto w/scope $13.7030781002 U r ina l ys i s n o na u t o w / osco p e$ 11.10 307 81003 Urinalysis auto w/o scope $9.7530781005 U R I N A L Y S I S$ 9.40 300 81007 URINE SCREEN FOR BACTERIA $11.1030081015 M i crosco p i ce x am o f u r in e$ 13.15 307 81020 URINALYSIS GLASS TEST $14.5030081025 U r in e p re g nan cy t es t$ 28.70 307 81050 Urinalysis volume measure $13.0030781099 U R I N A L Y S I STESTPROCE D U RE U N L I STE D$ 157.50 300 81206 BCR/ABL1 GENE MAJOR BP $674.7330181207 BCR / A B L 1 GENEM I NORBP$ 596.04 301 81208 BCR/ABL1 GENE OTHER BP $661.8930181220 CFTRGENE A N A L Y S I SCOMMON V A R I A NTS$ 1,669.80 310 81229 CYTOG ALYS CHRML ABNR SNPCGH $3, 480.0081234 D MP K GENE A N A L Y S I SE V A L D ETECT$ 411.00 ABNORMAL ALLELES 81235 EGFR GENE ANALYSIS COMMON VARIANTS $973.74 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 44 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 81243 FMRl ANALYSIS EVAL TO DETECT $171.12 A BNORM A L A U E L ES 81256 H FE H EMOC H ROM A TOS I SGENE A N A L$ 196.08 COMMON VARIANTS 81257 HBA1/HBA2 GENE $306.7831081270 J A K 2 GENE$ 366.64 300 82009 TEST FOR ACETONE/KETONES $19.5530082010 A ce t o n e a ss a y$ 35.35 301 82013 ACETYLCHOLINESTERASE ASSAY $48.4030082016 A C Y L C A RN I T I NESQ U A L$ 60.05 300 82017 Acylcarnitines quant $73.0030182024 A ss a yo f a c t h$ 175.25 301 82030 ASSAY OF ADP & AMP $111.7030082040 A ss a yo f ser u ma l b u min$ 22.45 301 82042 ASSAY OF URINE ALBUMIN $22.4030082043 M i cro a l b u min q u an t i t a t i v e$ 26.25 301 82044 Microalbumin semiquant $19.8030182045 A L B U M I N I SC H EM I A MO D I F I E D$ 147.00 300 82075 ASSAY OF BREATH ETHANOL $52.2030082085 A SS A Y OF A L D O L A SE$ 42.00 300 82088 Assay of aldosterone $176.4530182103 A lp ha - 1 - an t i t ry p s in t o t a l$ 60.95 301 82104 Alpha-1-antitrypsin pheno $62.6030182105 A lp ha - f e t o p ro t e in ser u m$ 76.10 301 82106 Alpha-fetoprotein amniotic $72.6530182107 A L P H A - FETOPROTE I N L 3$ 278.90 300 82108 ASSAY OF ALUMINUM $68.0530082120 A M I NES V A G I N A L F LU I D Q U A L$ 16.30 300 82127 AMINO ACID SINGLE QUAL $60.0530082128 A min o a c i d s m u ltq u a l$ 60.05 301 82131 Amino acids single quant $73.0030182135 A SS A Y A M I NO L E V UL I N I C A C I D$ 71.25 300 82136 AMINO ACIDS QUANT 2-5 $73.0030082139 A min o a c i d s q u an 6 or m ore$ 73.00 301 82140 ASSAY OF AMMONIA $66.1030082143 A MN I OT I CF LU I D SC A N$ 29.75 300 82150 Assay of amylase $29.4030182154 A N D ROST A NE D I O L G LU C U RON I D E$ 124.85 300 82157 ASSAY OF ANDROSTENEDIONE $126.7530082160 A SS A Y OF A N D ROSTERONE$ 108.25 300 82163 ASSAY OF ANGIOTENSIN II $88.8530082164 A NG I OTENS I N I ENZ Y METEST$ 63.20 300 82166 TC ASSAY OF ANTI-MULLERIAN HORMONE $115.8630082172 A SS A Y OF A PO L I POPROTE I N$ 67.10 300 82175 ASSAY OF ARSENIC $82.1530082180 A SS A Y OF A SCORB I C A C I D$ 42.80 300 82190 ATOMIC ABSORPTION $64.5530082232 A SS A Y OFBET A - 2 PROTE I N$ 70.05 300 82239 Bile acids total $74.2030182240 B I L E A C I D SC H O L Y L G L Y C I NE$ 115.05 300 82247 Bilirubin total $22.7530182248 B i l i r u bin d i rec t$ 22.75 301 82252 FECAL BILIRUBIN TEST $19.70 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 45 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 82261 ASSAY OF BIOTINIDASE $73.0030082270 O cc u lt b l oo df eces$ 14.80 301 82271 OCCULT BLOOD OTHER SOURCES $14.1030082272 OCC UL TB L D FECES 1 - 3 TESTS$ 14.10 300 82274 OCCULT BLD FHG QUAL 1-3 $68.8530082286 A SS A Y OFBR A D Y K I N I N$ 29.85 300 82300 ASSAY OF CADMIUM $100.2030082306 Vi t amin d 25 h y d ro x y$ 134.30 301 82308 ASSAY OF CALCITONIN $116.0030082310 C A L C I U M; TOT A L$ 23.40 301 82330 CALCIUM; IONIZED $59.2030182331 C A L C I U M I NF U S I ONTEST$ 22.40 300 82340 ASSAY OF CALCIUM IN URINE $26.1030082355 C A L C ULU S A N A L Y S I SQ U A L$ 50.10 300 82360 Calculus assay quant $55.7030182365 C a l c u l u ss p ec t rosco p y$ 35.85 301 82370 X-RAY ASSAY CALCULUS $54.2530082373 A SS A Y C - D TR A NSFERME A S U RE$ 78.20 300 82374 Assay blood carbon dioxide $21.1530182375 A SS A Y C A RBOX Y H BQ U A NT$ 53.35 300 82376 ASSAY CARBOXYHB QUAL $25.9530082378 C a rc in oe mb ryo ni c an t i g e n$ 86.05 301 82379 Assay of carnitine $73.0030182380 A SS A Y OFC A ROTENE$ 39.95 300 82382 ASSAY URINE CATECHOLAMINES $74.4530082383 A SS A Y B L OO D C A TEC H O L A M I NES$ 108.50 300 82384 ASSAY THREE CATECHOLAMINES $109.3530082387 A SS A Y OFC A T H EPS I N - D$ 90.10 300 82390 Assay of ceruloplasmin $46.5030182397 C H EM I LU M I NESCENT A SS A Y$ 61.15 300 82415 ASSAY OF CHLORAMPHENICOL $54.8530082435 A ss a yo f b l oo d c h l or i d e$ 19.90 301 82436 Assay of urine chloride $22.8030182438 A SS A Y OT H ERF LU I D C H L OR I D ES$ 21.15 300 82441 TEST FOR CHLOROHYDROCARBONS $26.0030082465 A ss a y b l d / ser u m c h o l es t ero l$ 19.75 301 82480 ASSAY SERUM CHOLINESTERASE $34.1030082482 A SS A Y RBCC H O L I NESTER A SE$ 33.25 300 82485 ASSAY CHONDROITIN SULFATE $89.4530082495 A SS A Y OFC H ROM I U M$ 87.80 300 82507 ASSAY OF CITRATE $120.4030082523 CO LL A GENCROSS L I N K S$ 80.90 300 82525 ASSAY OF COPPER $80.9030082528 A SS A Y OFCORT I COSTERONE$ 53.75 300 82530 Cortisol free $97.5030182533 T o t a l cor t i so l$ 75.80 301 82540 ASSAY OF CREATINE $70.6030082542 CO LU MNC H ROMOTOGR A P H Y Q U A NT$ 78.20 300 82550 Assay of ck (cpk) $29.5530182552 A SS A Y OFCP K I NB L OO D$ 28.20 301 82553 Creatine mb fraction $50.0030182554 CRE A T I NE I SOFORMS$ 58.00 300 82565 Assay of creatinine $23.25 301 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 46 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 82570 Assay of urine creatinine $23.4530182575 C re a t inin ec l e a r an ce t es t$ 40.90 301 82585 ASSAY OF CRYOFIBRINOGEN $22.2030082595 A ss a yo f cryo g l o b u l in$ 22.40 301 82600 ASSAY OF CYANIDE $22.4030082607 Vi t amin B - 12$ 42.85 301 82608 B-12 BINDING CAPACITY $37.1530082610 C Y ST A T I NC$ 28.00 300 82615 TEST FOR URINE CYSTINES $84.0030082626 D E H Y D ROEP I A N D ROSTERONE$ 65.25 300 82627 Dehydroepiandrosterone $62.0030182633 D ESOX Y CORT I COSTERONE$ 58.85 300 82634 DEOXYCORTISOL $35.3530082638 A SS A Y OF D I B U C A I NEN U MBER$ 109.45 300 82652 Vit d 1 25-dihydroxy $53.0530182656 P A NCRE A T I CE L A ST A SEFEC A L$ 111.30 300 82657 ENZYME CELL ACTIVITY $111.7530082658 ENZ Y MECE LL A CT I V I T Y R A$ 166.70 300 82664 ELECTROPHORETIC TEST $59.9530082668 A SS A Y OFER Y T H ROPO I ET I N$ 78.20 300 82670 Assay of estradiol $78.2030182671 ESTROGENS; FR A CT I ON A TE D$ 148.75 301 82672 ESTROGENS; TOTAL $93.0030082677 A ss a yo f es t r i o l$ 104.75 301 82679 ASSAY OF ESTRONE $121.0030082693 A SS A Y OFET H Y L ENEG L Y CO L$ 93.95 300 82696 ASSAY OF ETIOCHOLANOLONE $104.7530082705 F A TS / L I P I D SFECESQ U A L$ 108.10 300 82710 FATS/LIPIDS FECES QUANT $108.1030082715 A SS A Y OFFEC A L F A T$ 74.80 300 82725 ASSAY OF BLOOD FATTY ACIDS $64.5030082726 L ONGC H A I NF A TT Y A C I D S$ 102.10 300 82728 Assay of ferritin $51.8530182731 A SS A Y OFFET A L F I BRONECT I N$ 72.75 300 82735 ASSAY OF FLUORIDE $74.5530082746 Bl oo df o l i c a c i d ser u m$ 78.20 301 82747 Assay of folic acid rbc $49.5030182757 A SS A Y OFSEMENFR U CTOSE$ 278.90 300 82759 ASSAY OF RBC GALACTOKINASE $80.3030082760 A SS A Y OFG A L A CTOSE$ 85.70 300 82775 ASSAY GALACTOSE TRANSFERASE $63.6530082776 G a l a c t ose t r an s f er a se t es t$ 75.00 301 82777 GALECTIN-3 $56.0530082784 A ss a y i g a / i g d / i gg / i g m e a c h$ 33.10 301 82785 ASSAY OF IGE $71.3030082787 I GG 123 OR 4 E A C H$ 34.75 300 82800 Blood pH $36.6530182803 Bl oo d g a ses an yco mbina t i o n$ 83.80 301 82805 BLOOD GASES W/O2 SATURATION $122.9030082810 B L OO D G A SESO 2 S A TON L Y$ 37.80 300 82820 HEMOGLOBIN-OXYGEN AFFINITY $40.3030082930 G A STR I C A N A L YW / P H E A SPEC$ 23.65 300 82938 GASTRIN TEST $76.60 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 47 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 82941 ASSAY OF GASTRIN $76.3530082943 A SS A Y OFG LU C A GON$ 61.85 300 82945 Glucose other fluid $17.8030182946 G LU C A GONTO L ER A NCETEST$ 65.25 300 82947 Assay glucose blood quant $65.2530182948 R e a g e n t s t r i p / b l oo d g l u cose$ 13.70 301 82950 GLUCOSE; POST GLUCOSE DOSE $20.5530182951 G LU COSETO L ER A NCETEST (GTT) 3 SPECM$ 55.70 301 82952 GTT-added samples $17.0030182955 A SS A Y OFG 6 P D ENZ Y ME$ 42.00 300 82960 TEST FOR G6PD ENZYME $26.2030082962 G LU COSE; B L D B Y MON I TOR D E V I CE$ 8.20 301 82963 ASSAY OF GLUCOSIDASE $93.0030082965 A SS A Y OFG DH ENZ Y ME$ 33.50 300 82977 Assay of GGT $31.2030182978 A SS A Y OFG LU T A T H I ONE$ 61.75 300 82979 ASSAY RBC GLUTATHIONE $29.8530082985 A SS A Y OFG L Y C A TE D PROTE I N$ 65.25 300 83001 Gonadotropin (FSH) $80.4530183002 G o na d o t ro p in (L H)$ 80.20 301 83003 ASSAY GROWTH HORMONE (HGH) $72.2530083009 H P Y L OR I (C - 13) B L OO D$ 291.65 300 83010 ASSAY OF HAPTOGLOBIN QUANT $57.0530083012 A SS A Y OF H A PTOG L OB I NS$ 74.45 300 83013 H PYLORI (C-13) BREATH $291.6530083014 H P Y L OR I D R U G A D M I N$ 34.05 300 83015 HEAVY METAL SCREEN $62.0030083018 Q U A NT I T A T I V ESCREENMET A L S$ 95.10 300 83020 26 Midlevel Hemoglobin electrophoresis $22.309718302026 He m o g l o bin e l ec t ro p h ores i s$ 26.25 971 83020 TC HGB FRACT & QUAN; EP $70.3530183021 H EMOG L OB I NC H ROMOTOGR A P H Y$ 78.20 300 83026 HEMOGLOBIN COPPER SULFATE $10.2530083030 FET A L H EMOG L OB I NC H EM I C A L$ 35.80 300 83033 FETAL HEMOGLOBIN ASSAY QUAL $25.8030083036 Gl ycosy l a t e d h e m o g l o bin t es t$ 44.00 301 83037 Glycosylated hb home device $42.0030183045 B L OO D MET H EMOG L OB I NTEST$ 21.45 300 83050 BLOOD METHEMOGLOBIN ASSAY $31.7030083051 A SS A Y OFP L A SM A H EMOG L OB I N$ 31.65 300 83060 BLOOD SULFHEMOGLOBIN ASSAY $35.8030083065 A SS A Y OF H EMOG L OB I N H E A T$ 29.85 300 83068 HEMOGLOBIN STABILITY SCREEN $36.6530083069 A SS A Y OF U R I NE H EMOG L OB I N$ 17.10 300 83070 ASSAY OF HEMOSIDERIN QUAL $20.5530083080 A SS A Y OFB H EXOS A M I N I D A SE$ 73.00 300 83088 ASSAY OF HISTAMINE $127.9030083090 A SS A Y OF H OMOC Y ST I NE$ 73.05 300 83150 ASSAY OF HOMOVANILLIC ACID $62.0030083491 A SS A Y OFCORT I COSTERO I D S 17$ 75.85 300 83497 ASSAY OF 5-HIAA $55.8030083498 A SS A Y OFPROGESTERONE 17 - D$ 117.65 300 83500 ASSAY FREE HYDROXYPROLINE $98.05 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 48 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 83505 ASSAY TOTAL HYDROXYPROLINE $105.2530083516 I MM U NO A SS A Y NON A NT I BO D Y$ 49.95 300 83518 IMMUNOASSAY DIPSTICK $36.7030083519 R I A NON A NT I BO D Y$ 58.50 300 83520 Immunoassay quant nos nonab $56.0530183521 I MM U NOG L OB UL I N L I G H TC H A I NSFREE$ 51.81 300 EACH 83525 INSULIN; TOTAL $49.5030183527 FREE I NS UL I N$ 56.05 300 83528 ASSAY OF INTRINSIC FACTOR $68.8530083540 A ss a yo f i ro n$ 29.35 301 83550 Iron binding test $37.8530183570 A SS A Y OF I DH ENZ Y ME$ 38.30 300 83582 ASSAY OF KETOGENIC STEROIDS $61.3530083586 A SS A Y 17 - K ETOSTERO I D S$ 55.45 300 83593 FRACTIONATION KETOSTEROIDS $113.8530083605 A SS A Y OF L A CT I C A C I D$ 48.45 300 83615 Lactate (LD) (LDH) enzyme $27.4030183625 A SS A Y OF L DH ENZ Y MES$ 55.45 300 83630 LACTOFERRIN FECAL (QUAL) $85.0030083631 L A CTOFERR I NFEC A L (Q U A NT)$ 85.00 300 83632 PLACENTAL LACTOGEN $87.5530083633 TEST U R I NEFOR L A CTOSE$ 23.80 300 83655 Assay of lead $52.4030183661 L / SR A T I OFET A LLU NG$ 95.20 300 83662 FOAM STABILITY FETAL LUNG $81.9030083663 F LU OROPO L A R I ZEFET A LLU NG$ 81.90 300 83664 LAMELLAR BDY FETAL LUNG $81.9030083670 A SS A Y OF L A PENZ Y ME$ 39.65 300 83690 Assay of lipase $31.2530183695 A SS A Y OF L I POPROTE I N (A)$ 56.05 300 83698 ASSAY LIPOPROTEIN PLA2 $147.0030083700 L I POPROB L D E L ECTROP H ORET I C$ 48.75 300 83701 LIPOPROTEIN BLD HR FRACTION $107.5030083704 L I POPROTE I NB L D B Y NMR$ 136.60 300 83718 LIPOPROTEIN; HDL $37.1530183719 A SS A Y OFB L OO D L I POPROTE I N V L D L$ 50.35 300 83721 ASSAY OF BLOOD LIPOPROTEIN LDL $41.3030083727 A SS A Y OF L R HH ORMONE$ 74.45 300 83735 Assay of magnesium $30.4030183775 A SS A Y M A L A TE D E H Y D ROGEN A SE$ 31.90 300 83785 ASSAY OF MANGANESE $106.4530083789 M a sss p ec t ro m e t ry q u an t$ 109.48 301 83825 ASSAY OF MERCURY $70.4030083835 A SS A Y OFMET A NEP H R I NES$ 73.35 300 83857 ASSAY OF METHEMALBUMIN $46.5030083861 M I CROF LU I D A N A L Y TE A RS$ 71.55 300 83864 MUCOPOLYSACCHARIDES $86.2030083872 A SS A Y S Y NO V I A L F LU I D M U C I N$ 25.40 300 83873 ASSAY OF CSF PROTEIN $74.5030083874 A SS A Y OFM Y OG L OB I N$ 55.90 300 83876 ASSAY MYELOPEROXIDASE $147.0030083880 N a t r i u re t i c p e pt i d e$ 147.00 301 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 49 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 83883 ASSAY NEPHELOMETRY NOT SPEC $58.8530083885 A SS A Y OFN I C K E L$ 106.10 300 83915 ASSAY OF NUCLEOTIDASE $48.3030083916 O L I GOC L ON A L B A N D S$ 87.05 300 83918 Organic acids total quant $71.2530183919 ORG A N I C A C I D SQ U A L E A C H$ 71.25 300 83921 ORGANIC ACID SINGLE QUANT $71.2530083930 A SS A Y OFB L OO D OSMO L A L I T Y$ 28.65 300 83935 Assay of urine osmolality $29.5030183937 A SS A Y OFOSTEOC A L C I N$ 129.25 300 83945 Assay of oxalate $55.7030183950 ONCOPROTE I N H ER - 2/ NE U$ 278.90 300 83951 ONCOPROTEIN DCP $278.9030083970 A ss a yo f p a r a t h or m o n e$ 178.75 301 83986 Assay ph body fluid nos $15.5030183987 EX H A L E D BRE A T H CON D ENS A TE$ 68.75 300 83992 ASSAY FOR PHENCYCLIDINE $63.6530083993 A SS A Y FORC A L PROTECT I NFEC A L$ 85.00 300 84030 Assay of blood pku $23.8030184035 A SS A Y OFP H EN Y L K ETONES$ 15.85 300 84060 ASSAY ACID PHOSPHATASE $31.9530084066 A SS A Y PROST A TEP H OSP H A T A SE$ 41.85 300 84075 Assay alkaline phosphatase $23.4530184078 A SS A Y A L K A L I NEP H OSP H A T A SE$ 31.60 300 84080 ASSAY ALKALINE PHOSPHATASES $64.0530084081 A SS A Y P H OSP H A T I D Y L G L Y CERO L$ 71.55 300 84085 ASSAY OF RBC PG6D ENZYME $29.1530084087 A SS A Y P H OSP H O H EXOSEENZ Y MES$ 44.70 300 84100 Assay of phosphorus $21.5030184105 A SS A Y OF U R I NEP H OSP H OR U S$ 22.40 300 84106 TEST FOR PORPHOBILINOGEN $18.5030084110 A SS A Y OFPORP H OB I L I NOGEN$ 36.55 300 84112 EVAL AMNIOTIC FLUID PROTEIN $278.9030084119 TEST U R I NEFORPORP H Y R I NS$ 37.30 300 84120 ASSAY OF URINE PORPHYRINS $63.7030084126 A SS A Y OFFECESPORP H Y R I NS$ 110.30 300 84132 Assay of serum potassium $20.8530184133 A ss a yo f u r in e p o t a ss i u m$ 19.50 301 84134 Assay of prealbumin $63.1530184135 A SS A Y OFPREGN A NE D I O L$ 82.85 300 84138 ASSAY OF PREGNANETRIOL $82.0030084140 A SS A Y OFPREGNENO L ONE$ 89.50 300 84143 ASSAY OF 17-HYDROXYPREGNENO $98.8030084144 A ss a yo f p ro g es t ero n e$ 90.35 301 84145 PROCALCITONIN (PCT) $116.0030084146 PRO L A CT I N A SS A Y$ 251.75 300 84146 ASSAY OF PROLACTIN $83.9030084150 A SS A Y OFPROST A G L A N D I N$ 108.10 300 84152 ASSAY OF PSA COMPLEXED $79.6530084153 A ss a yo f p s a t o t a l$ 83.45 301 84154 ASSAY OF PSA FREE $79.6530084155 A ss a yo f p ro t e in ser u m$ 16.65 301 84156 Assay of protein urine $16.65 301 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 50 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 84157 ASSAY OF PROTEIN OTHER $16.6530084160 A SS A Y OFPROTE I N A N Y SO U RCE$ 14.50 300 84163 PAPPA SERUM $65.203008416526 P ro t e in e - p h ores i sser u m$ 26.25 971 84165 26 Midlevel Protein e-phoresis, serum $22.30 971 84165 TC PROTEIN; EP FRACT & QUAN$ 69.30 301 84166 26 Protein e-phoresis/urine/csf $26.259718416626 M i d l e v e lP ro t e in e - p h ores i s / u r in e / cs f$ 22.30 971 84166 PROTEIN E-PHORESIS/URINE/CSF $26.253008418126 M i d l e v e l W es t er nb l o tt es t$ 22.30 971 84181 26 Western blot test $26.2597184181 W ESTERNB L OTTEST$ 26.25 300 84182 26 Protein, western blot test $26.259718418226 M i d l e v e lP ro t e in, w es t er nb l o tt es t$ 22.30 971 84182 PROTEIN WESTERN BLOT TEST $26.2530084202 A SS A Y RBCPROTOPORP H Y R I N$ 62.10 300 84203 TEST RBC PROTOPORPHYRIN $37.2530084206 A SS A Y OFPRO I NS UL I N$ 77.15 300 84207 ASSAY OF VITAMIN B-6 $82.5530084210 A SS A Y OFP Y R U V A TE$ 47.00 300 84220 ASSAY OF PYRUVATE KINASE $40.8530084228 A SS A Y OFQ U I N I NE$ 50.35 300 84233 ASSAY OF ESTROGEN $278.9030084234 A SS A Y OFPROGESTERONE$ 280.90 300 84235 ASSAY OF ENDOCRINE HORMONE $226.6030084238 A SS A Y NONEN D OCR I NERECEPTOR$ 158.35 300 84244 Assay of renin $95.2530184252 A SS A Y OF V I T A M I NB - 2$ 82.55 300 84255 ASSAY OF SELENIUM $110.5530084260 A SS A Y OFSEROTON I N$ 134.15 300 84270 ASSAY OF SEX HORMONE GLOBUL $41.1030084275 A SS A Y OFS I A L I C A C I D$ 58.20 300 84285 ASSAY OF SILICA $101.9530084295 A ss a yo f ser u m so d i u m$ 20.85 301 84300 Assay of urine sodium $22.1030184302 A SS A Y OFS W E A TSO D I U M$ 21.05 300 84305 ASSAY OF SOMATOMEDIN $92.0530084307 A SS A Y OFSOM A TOST A T I N$ 79.15 300 84311 SPECTROPHOTOMETRY $30.2530084315 BO D Y F LU I D SPEC I F I CGR A V I T Y$ 10.85 300 84375 CHROMATOGRAM ASSAY SUGARS $84.9030084376 S U G A RSS I NG L EQ U A L$ 23.80 300 84377 SUGARS MULTIPLE QUAL $23.8030084378 S U G A RSS I NG L EQ U A NT$ 49.90 300 84379 SUGARS MULTIPLE QUANT $49.9030084392 A SS A Y OF U R I NES UL F A TE$ 20.55 300 84402 ASSAY OF FREE TESTOSTERONE $110.2530084403 A ss a yo f t o t a lt es t os t ero n e$ 111.80 301 84425 ASSAY OF VITAMIN B-1 $86.5030084430 A SS A Y OFT H I OC Y A N A TE$ 50.35 300 84431 THROMBOXANE URINE $72.7530084432 A SS A Y OFT H Y ROG L OB UL I N$ 69.55 300 84436 Assay of total thyroxine $31.1530184437 A ss a yo f n eo na t a lt h yro x in e$ 28.00 301 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 51 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 84439 Assay of free thyroxine $39.0530184442 A SS A Y OFT H Y RO I D A CT I V I T Y$ 64.05 300 84443 Assay thyroid stim hormone $76.2530184445 A SS A Y OFTS I G L OB UL I N$ 103.15 300 84446 ASSAY OF VITAMIN E $61.4030084449 A SS A Y OFTR A NSCORT I N$ 77.95 300 84450 Transferase (AST) (SGOT) $23.4530184460 A l anin e amin o (A L T) (SGPT)$ 24.00 301 84466 Assay of transferrin $55.3030184478 A ss a yo f t r i g l ycer i d es$ 26.05 301 84479 Assay of thyroid (t3 or t4) $28.0030184480 A ss a y t r ii o d o t h yro nin e (t 3)$ 61.40 301 84481 Free assay (FT-3) $73.3530184482 T 3 RE V ERSE$ 68.25 300 84484 Assay of troponin quant $44.6530184485 A SS A Y D U O D EN A L F LU I D TR Y PS I N$ 32.50 300 84488 TEST FECES FOR TRYPSIN $31.6030084490 TR Y PS I N; FECESQ U A N 24 - H R$ 32.95 300 84510 ASSAY OF TYROSINE $45.0530084512 A SS A Y OFTROPON I NQ U A L$ 33.35 300 84520 Assay of urea nitrogen $17.9030184525 U RE A N I TROGENSEM I - Q U A NT$ 16.30 300 84540 ASSAY OF URINE/UREA-N $20.5530084545 U RE A - NC L E A R A NCETEST$ 28.60 300 84550 Assay of blood/uric acid $20.5030184560 A ss a yo f u r in e / u r i c a c i d$ 21.55 301 84577 ASSAY OF FECES/UROBILINOGEN $54.0030084578 TEST U R I NE U ROB I L I NOGEN$ 14.10 300 84580 ASSAY OF URINE UROBILINOGEN $30.7030084583 A SS A Y OF U R I NE U ROB I L I NOGEN$ 21.75 300 84585 ASSAY OF URINE VMA $67.1030084586 A SS A Y OF V I P$ 144.90 300 84588 ASSAY OF VASOPRESSIN $147.0030084590 A SS A Y OF V I T A M I N A$ 50.25 300 84591 ASSAY OF NOS VITAMIN $50.2530084597 A SS A Y OF V I T A M I N K$ 59.40 300 84600 ASSAY OF VOLATILES $69.6030084620 X Y L OSETO L ER A NCETEST$ 51.30 300 84630 ASSAY OF ZINC $49.3030084681 A SS A Y OFC - PEPT I D E$ 90.10 300 84702 HCG; QUAN $68.3030184703 H CG; Q U A L$ 34.10 301 84704 HCG FREE BETACHAIN TEST $65.2030084830 O V UL A T I ONTESTS$ 43.45 300 84999 CLINICAL CHEMISTRY TEST UNLISTED $157.5030085002 B L EE D I NGT I METEST$ 19.50 300 85004 AUTOMATED DIFF WBC COUNT $28.0030085007 B L SME A R W / D I FF W BCCO U NT$ 14.90 300 85008 BL SMEAR W/O DIFF WBC COUNT $14.9030085009 M A N U A L D I FF W BCCO U NTB - CO A T$ 16.10 300 85013 Spun microhematocrit $10.2530585014 He ma t ocr i t$ 10.25 305 85018 Hemoglobin $10.75 305 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 52 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 85025 Complete cbc w/auto diff wbc $33.6530585027 C o m pl e t ec b c a u t o ma t e d$ 28.00 305 85032 MANUAL CELL COUNT EACH $18.6030085041 A u t o ma t e d r b cco u n t$ 13.05 305 85044 Manual reticulocyte count $19.5030585045 A U TOM A TE D RET I C UL OC Y TECO U NT$ 17.30 300 85046 RETICYTE/HGB CONCENTRATE $24.1530085048 A u t o ma t e d l e u k ocy t eco u n t$ 11.00 305 85049 Automated platelet count $19.3530585055 RET I C UL A TE D P L A TE L ET A SS A Y$ 78.35 300 85060 26 Blood smear interpretation $84.009718506026 M i d l e v e lBl oo d s m e a r in t er p re t a t i o n$ 71.40 971 85060 Blood smear interpretation $84.003058509726 B o n e ma rro w in t er p re t a t i o n$ 168.00 969 85097 26 Midlevel Bone marrow interpretation $142.8096985097 BONEM A RRO W I NTERPRET A T I ON$ 168.00 300 85130 CHROMOGENIC SUBSTRATE ASSAY $51.5030085170 B L OO D C L OTRETR A CT I ON$ 15.65 300 85175 BLOOD CLOT LYSIS TIME $19.7030085210 C L OTF A CTOR II PROT H ROMSPEC$ 56.25 300 85220 BLOOC CLOT FACTOR V TEST $76.4030085230 C L OTF A CTOR V II PROCON V ERT I N$ 77.50 300 85240 Blood clot factor VIII test $77.5030585244 C L OTF A CTOR V III RE L T D A NTGN$ 88.40 300 85245 CLOTTING; FACTOR VIII RISTOCETIN $99.35305 COF A CT 85246 C L OTT I NG : F A CTOR V III VW F A CTOR A G$ 99.35 305 85247 FACTOR 8 VWF MULTIMRIC $99.3530585250 C L OTF A CTOR I XPTC / C H RSTM A S$ 82.45 300 85260 CLOT FACTOR X STUART-POWER $77.5030085270 Bl oo d c l o t f a c t or X I t es t$ 77.50 305 85280 CLOT FACTOR XII HAGEMAN $83.8030085290 C L OTF A CTORX III F I BR I NST A B$ 70.80 300 85291 CLOT FACTOR XIII FIBRIN SCRN $38.5030085292 C L OTF A CTORF L ETC H ERF A CT$ 82.00 300 85293 CLOT FACTOR WGHT KININOGEN $82.0030085300 A n t i t h ro mbin III t es t$ 51.30 305 85301 ANTITHROMBIN III ANTIGEN $46.8030085302 C L OT I N H I B I TPROTC A NT I GEN$ 52.05 300 85303 CLOT INHIBIT PROT C ACTIVITY $59.9030085305 C L OT I N H I B I TPROTSTOT A L$ 50.25 300 85306 CLOT INHIBIT PROT S FREE $66.3530085307 A SS A Y A CT I V A TE D PROTE I NC$ 66.35 300 85335 FACTOR INHIBITOR TEST $55.7030085337 T H ROMBOMO D UL I N$ 45.15 300 85345 COAGULATION TIME LEE & WHITE $18.6030085347 CO A G UL A T I ONT I ME A CT I V A TE D$ 18.45 300 85348 COAGULATION TIME OTR METHOD $16.1530085360 E U G L OB UL I N L Y S I S$ 36.40 300 85362 FIBRIN DEGRADATION PRODUCTS $29.8530085366 F I BR I NOGENTESTP A R A CO A G UL A T I ON$ 37.30 300 85370 FIBRINOGEN TEST QUANTITATIVE $49.1530085378 F I BR I N D EGR A D ESEM I Q U A NT$ 30.90 300 85379 FIBRIN DEGRADATION QUANT $46.15 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 53 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 85380 FIBRIN DEGRADJ D-DIMER $44.0530085384 F ib r in o g e n$ 36.80 305 85385 FIBRINOGEN ANTIGEN $36.803008539026 M i d l e v e lF ib r in o l ys in sscree n$ 33.90 971 85390 26 Fibrinolysins screen $39.90 971 85390 FIBRINOLYSINS SCREEN I&R$ 39.90 300 85396 26 Clotting assay, whole blood $69.309698539626 M i d l e v e lCl o tt in g a ss a y, w h o l e b l oo d$ 58.90 969 85396 CLOTTING ASSAY WHOLE BLOOD $69.3030085397 C L OTT I NGF U NCT A CT I V I T Y$ 99.35 300 85400 FIBRINOLYTIC PLASMIN $38.3030085410 F I BR I NO L Y T I C A NT I P L A SM I N$ 33.40 300 85415 PLASMINOGEN ACTIVATOR $74.4530085420 F U NCT I ON A L P L A SM I NOGEN$ 28.30 300 85421 PLASMINOGEN ANTIGEN LEVEL $44.1030085441 H E I NZBO D I ES D I RECT$ 18.20 300 85445 HEINZ BODIES INDUCED $29.5030085460 K - BST A I NFORFET A L H GB$ 33.50 300 85461 FETAL HGB SCREENING TEST $28.7530085475 H EMO L Y S I N A C I D$ 38.45 300 85520 HEPARIN ASSAY $49.5030085525 H EP A R I NNE U TR A L I Z A T I ON$ 50.55 300 85530 HEPARIN-PROTAMINE TOLERANCE $61.4030085536 I RONST A I NPER I P H ER A L B L OO D$ 28.00 300 85540 WBC ALKALINE PHOSPHATASE $37.2530085547 RBCMEC H A N I C A L FR A G I L I T Y$ 37.25 300 85549 MURAMIDASE $81.2030085555 OSMOT I CFR A G I L I T Y RBC; U N I NC U B A TE D$ 28.90 300 85557 OSMOTIC FRAGILITY RBC; INCUBATED $57.853008557626 Bl oo d pl a t e l e t a gg re g a t i o n$ 40.95 971 85576 26 Midlevel Blood platelet aggregation $34.8097185576 B L OO D P L A TE L ET A GGREG A T I ON$ 40.95 300 85597 PHOSPHOLIPID PLTLT NEUTRALIZ $77.8530085598 H EX A GN A L P H OSP H P L T L TNE U TR L$ 77.85 300 85610 Prothrombin time $17.8030585611 PROT H ROMB I NTEST$ 17.05 300 85612 VIPER VENOM PROTHROMBIN TIME $41.4530085613 R U SSE LL V I PER V ENOM D I LU TE D$ 41.45 300 85635 REPTILASE TEST $42.6030085651 R b cse d r a t e n o na u t o ma t e d$ 15.40 305 85652 RBC SED RATE AUTOMATED $11.7030085660 RBCS I C K L ECE LL TEST$ 23.90 300 85670 THROMBIN TIME PLASMA $25.0030085675 T H ROMB I NT I MET I TER$ 29.65 300 85705 THROMBOPLASTIN INHIBITION $41.6530085730 PTT; P L A SM A OR W H O L EB L OO D$ 27.25 305 85732 PTT; SUBSTITUTION PLASMA FRACTIONS EA $28.0030085810 B L OO D V I SCOS I T Y EX A M I N A T I ON$ 50.55 300 85999 HEMATOLOGY PROCEDURE UNLISTED $157.5030086000 A GG LU T I N I NSFEBR I L E A NT I GEN$ 29.00 300 86001 ALLERG SP IGG QUAN OR SEMIQUAN $22.6030086003 A LL GSPEC I GECR U D EXTRCE A$ 22.60 300 86005 ALLG SPEC IGE MULTIALLG SCR $5.4530086021 W BC A NT I BO D Y I D ENT I F I C A T I ON$ 65.20 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 54 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 86022 PLATELET ANTIBODIES $79.5530086023 I MM U NOG L OB UL I N A SS A Y$ 53.95 300 86037 ANTINEUTROPHIL CYTOPLASMIC ANTB $36.15 T I TERE AA NTB 86038 A n t in u c l e a r an t ib o d i es$ 52.35 302 86039 Antinuclear antibodies (ANA) $50.6530286060 A n t i s t re pt o l ys in o t i t er$ 31.60 302 86063 ANTISTREPTOLYSIN O SCREEN $82.953008607726 P h ys i c ianb l oo d bank ser v i ce$ 21.00 969 86077 26 Midlevel Physician blood bank service $18.0096986077 D I FF I C UL TCROSSM A TC H$ 173.25 300 86078 26 Midlevel Physician blood bank service $45.809698607826 P h ys i c ianb l oo d bank ser v i ce$ 53.55 969 86078 INVESTIG TRANSFUS REACTION $174.303028607926 M i d l e v e lP h ys i c ianb l oo d bank ser v i ce$ 46.20 969 86079 26 Physician blood bank service $54.6096986079 P H Y SB L OO D B A N K SER V A U T H R J$ 174.30 300 86140 C-reactive protein $23.4530286141 C - RE A CT I V EPROTE I N H S$ 56.05 300 86146 BETA-2 GLYCOPROTEIN ANTIBODY $110.1530086147 C A R D I O L I P I N A NT I BO D Y E A I G$ 110.15 300 86148 ANTI-PHOSPHOLIPID ANTIBODY $69.5530086155 C H EMOT A X I S A SS A Y$ 69.20 300 86156 COLD AGGLUTININ SCREEN $29.0030086157 CO L D A GG LU T I N I NT I TER$ 34.95 300 86160 Complement antigen $52.0030286161 COMP L EMENT / F U NCT I ON A CT I V I T Y$ 52.00 300 86162 COMPLEMENT TOTAL (CH50) $88.0030086171 COMP L EMENTF I X A T I ONE A C H$ 43.35 300 86200 CCP ANTIBODY $56.0530086215 D EOX Y R I BON U C L E A SE A NT I BO D Y$ 57.35 300 86225 DNA antibody $59.4530286226 D naan t ib o d ys in g l es t r an d$ 52.45 302 86235 Nuclear antigen antibody $77.653028625526 Fl u oresce n t an t ib o d yscree n$ 29.40 971 86255 26 Midlevel Fluorescent antibody, screen $25.0097186255 TCF LU ORESCENT A B; SCRNE AA B$ 70.35 302 86256 26 Fluorescent antibody, titer $29.409718625626 M i d l e v e lFl u oresce n t an t ib o d y, t i t er$ 25.00 971 86256 FLUORESCENT AB; TITER EA AB $29.4030086258 G L I A D I N A NT I BO D Y E A C H$ 36.15 300 IMMUNOGLOBULIN CLASS 86270 AK2 GENE ANALYSIS P.VAL617PHE $274.98 V A R I A NT 86277 GRO W T HH ORMONE A NT I BO D Y$ 68.15 300 86280 HEMAGGLUTINATION INHIBITION $35.4530086294 I MM U NO A SS A Y T U MORQ U A L$ 84.95 300 86300 TC Immunoassay tumor ca 15-3 $94.4030286301 I MM U NO A SS A Y T U MORC A 19 - 9$ 90.10 300 86304 TC Immunoassay tumor ca 125 $90.1030286305 H U M A NEP I D I D Y M I SPROTE I N 4$ 90.10 300 86308 TC QUAL HETEROPHILE AB $22.4030286309 Q U A N H ETEROP H I L E A B$ 28.00 300 86310 HETEROPHILE ANTIBODY ABSRBJ $31.9030086316 I MM U NO A SS A Y T U MOROT H ER$ 90.10 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 55 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 86317 TC IA INFECTIOUS AGENT AB QUAN $64.9030286318 I A I NFECT I O U S A GENTSG L STEP$ 56.05 300 86320 26 Serum immunoelectrophoresis $34.659718632026 M i d l e v e lS er u mimm u n oe l ec t ro p h ores i s$ 29.40 971 86320 SERUM IMMUNOELECTROPHORESIS $29.403008632526 Ot h er imm u n oe l ec t ro p h ores i s$ 34.65 971 86325 26 Midlevel Other immunoelectrophoresis $29.4097186325 OT H ER I MM U NOE L ECTROP H ORES I S$ 29.40 300 86327 26 Immunoelectrophoresis assay $47.259718632726 M i d l e v e l I mm u n oe l ec t ro p h ores i s a ss a y$ 39.90 971 86327 IMMUNOELECTROPHORESIS ASSAY $39.9030086329 I MM U NO D I FF U S I ONNES$ 60.80 300 86331 IMMUNODIFFUSION OUCHTERLONY $51.9030086332 I MM U NECOMP L EX A SS A Y$ 105.55 300 86334 26 Immunofix e-phoresis, serum $39.909718633426 M i d l e v e l I mm u n o f i x e - p h ores i s, ser u m$ 33.90 971 86334 IMMUNOFIX E-PHORESIS SERUM $41.803008633526 I mm u n f i x e - p h ors i s / u r in e / cs f$ 42.00 971 86335 26 Midlevel Immunfix e-phorsis/urine/csf $35.5597186335 I MM U NF I XE - P H ORS I S / U R I NE / CSF$ 39.90 300 86336 Inhibin A $56.0530286337 I NS UL I N A NT I BO D I ES$ 92.70 300 86340 Intrinsic factor antibody $65.2530286341 I S L ETCE LL A NT I BO D Y$ 78.80 300 86343 LEUKOCYTE HISTAMINE RELEASE $53.9530086344 L E U K OC Y TEP H A GOC Y TOS I S$ 34.60 300 86352 CELL FUNCTION ASSAY W/STIM $588.2530086353 L Y MP H OC Y TETR A NSFORM A T I ON$ 212.30 300 86355 B CELLS TOTAL COUNT $163.3530086356 MONON U C L E A RCE LL A NT I GEN$ 78.35 300 86357 NK CELLS TOTAL COUNT $163.3530086359 T ce ll s t o t a l co u n t$ 163.35 302 86360 T cell absolute count/ratio $203.4530286361 TCE LL A BSO LU TECO U NT$ 78.35 300 86364 TISSUE TRANSGLUTAMINASE EA $34.59 I MM U NOG L OB UL I NC L A SS 86367 STEMCE LL STOT A L CO U NT$ 163.35 300 [Rows 13001-14000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE 86376 Microsomal antibody $62.9530286382 NE U TR A L I Z A T I ONTEST V I R A L$ 73.25 300 86384 NITROBLUE TETRAZOLIUM DYE $49.3030086386 N U C L E A RM A TR I XPROTE I N 22$ 69.15 300 86403 Particle agglutination test $44.1530286406 P A RT I C L E A GG LU T A NTB D Y T I TR$ 46.05 300 86430 Rheumatoid factor test $25.7530286431 R h e u ma t o i df a c t or q u an t$ 24.55 302 86480 TB TEST CELL IMMUN MEASURE $268.4030086481 TB A GRESPONSET - CE LL S U SP$ 324.40 300 86485 SKIN TEST CANDIDA $20.3030086486 S K I NTESTNOS A NT I GEN$ 26.10 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 56 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 86490 COCCIDIOIDOMYCOSIS SKIN TEST $23.1030086510 H I STOP L A SMOS I SS K I NTEST$ 23.10 300 86580 TB intradermal test $28.3530286590 STREPTO K I N A SE A NT I BO D Y$ 47.80 300 86592 Syphilis test non-trep qual $47.8030286593 S Y P H I L I STESTNON - TREPQ U A NT$ 19.05 300 86602 ANTINOMYCES ANTIBODY $44.0530086603 A D ENO V I R U S A NT I BO D Y$ 55.70 300 86606 ASPERGILLUS ANTIBODY $65.2030086609 B A CTER I U M A NT I BO D Y$ 55.80 300 86611 BARTONELLA ANTIBODY $44.0530086612 B L A STOM Y CES A NT I BO D Y$ 55.90 300 86615 BORDETELLA ANTIBODY $57.1030086617 L Y ME D I SE A SE A NT I BO D Y$ 67.10 300 86618 LYME DISEASE ANTIBODY $73.7530086619 BORRE L I AA NT I BO D Y$ 57.95 300 86622 BRUCELLA ANTIBODY $38.7030086625 C A MP Y L OB A CTER A NT I BO D Y$ 56.80 300 86628 CANDIDA ANTIBODY $52.0030086631 C H L A M Y D I AA NT I BO D Y$ 51.20 300 86632 CHLAMYDIA IGM ANTIBODY $54.9530086635 COCC I D I O I D ES A NT I BO D Y$ 49.70 300 86638 Q FEVER ANTIBODY $52.5030086641 CR Y PTOCOCC U S A NT I BO D Y$ 62.40 300 86644 CMV antibody $62.3530286645 CM V A NT I BO D Y I GM$ 72.90 300 86648 DIPHTHERIA ANTIBODY $65.8530086651 ENCEP H A L I T I SC A L I FORN A NTB D Y$ 57.10 300 86652 ENCEPHALTIS EAST EQNE ANBDY $57.1030086653 ENCEP H A L T I SST L O U I S A NTBO D Y$ 57.10 300 86654 ENCEPHALTIS WEST EQNE ANTBDY $57.1030086658 ENTERO V I R U S A NT I BO D Y$ 56.40 300 86663 EPSTEIN-BARR ANTIBODY $56.8030086664 EPSTE I N - B A RRN U C L E A R A NT I GEN$ 66.25 300 86665 EPSTEIN-BARR CAPSID VCA $78.5530086666 E H R L I C H I AA NT I BO D Y$ 44.05 300 86668 FRANCISELLA TULARENSIS $45.0530086671 F U NG U SNES A NT I BO D Y$ 53.10 300 86674 GIARDIA LAMBLIA ANTIBODY $63.7530086677 He l i co ba c t er p y l or i$ 65.85 302 86682 HELMINTH ANTIBODY $41.7030086684 H EMOP H I LU S I NF LU ENZ AA NT I B D Y$ 68.60 300 86687 HTLV-I ANTIBODY $36.3530086688 H T L V - II A NT I BO D Y$ 60.65 300 86689 HTLV/HIV CONFIRMJ ANTIBODY $83.8030086692 H EP A T I T I S D E L T AA GENT A NTB D Y$ 74.30 300 86694 HERPES SIMPLEX NES ANTBDY $62.3530086695 Her p ess im pl e x t es t$ 57.10 302 86696 Herpes simplex type 2 $83.8030286698 H I STOP L A SM AA NT I BO D Y$ 54.10 300 86701 HIV-1 $38.4530286702 H I V - 2 A NT I BO D Y$ 58.55 300 86703 Hiv-1/hiv-2 single result $59.40 302 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 57 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 86704 Hep b core antibody total $52.2030286705 He p b core an t ib o d y i g m$ 50.95 302 86706 Hep b surface antibody $48.7030286707 He p b e an t ib o d y$ 50.10 302 86708 Hep a antibody total $39.6530286709 He p aan t ib o d y i g m$ 48.75 302 86710 INFLUENZA VIRUS ANTIBODY $58.7030086711 J O H NC U NN I NG H A M A NT I BO D Y$ 62.35 300 86713 LEGIONELLA ANTIBODY $66.3030086717 L E I S H M A N I AA NT I BO D Y$ 53.05 300 86720 LEPTOSPIRA ANTIBODY $57.1030086723 L I STER I A MONOC Y TOGENES$ 57.10 300 86727 LYMPH CHORIOMENINGITIS AB $55.7030086732 M U CORM Y COS I S A NT I BO D Y$ 57.10 300 86735 Mumps antibody $56.5030286738 M Y COP L A SM AA NT I BO D Y$ 57.35 300 86741 NEISSERIA MENINGITIDIS $57.1030086744 NOC A R D I AA NT I BO D Y$ 57.10 300 86747 PARVOVIRUS ANTIBODY $65.1030086750 M A L A R I AA NT I BO D Y$ 5,710.95 300 86753 PROTOZOA ANTIBODY NOS $53.6530086756 RESP I R A TOR YV I R U S A NT I BO D Y$ 55.80 300 86757 RICKETTSIA ANTIBODY $83.8030086759 ROT A V I R U S A NT I BO D Y$ 57.10 300 86762 Rubella antibody $62.3530286765 R u b eo l aan t ib o d y$ 55.80 302 86768 SALMONELLA ANTIBODY $57.1030086771 S H I GE LL AA NT I BO D Y$ 57.10 300 86774 TETANUS ANTIBODY $64.0530086777 TOXOP L A SM AA NT I BO D Y$ 62.35 300 86778 TOXOPLASMA ANTIBODY IGM $62.3530086780 T re p o n e ma p a ll i d u m$ 57.35 302 86784 TRICHINELLA ANTIBODY $54.4030086787 Va r i ce ll a - zos t er an t ib o d y$ 55.80 302 86788 WEST NILE VIRUS AB IGM $72.9030086789 W ESTN I L E V I R U S A NT I BO D Y$ 62.35 300 86790 VIRUS ANTIBODY NOS $55.8030086793 Y ERS I N I AA NT I BO D Y$ 57.10 300 86800 Thyroglobulin antibody $68.8530286803 He p a t i t i sc ab t es t$ 64.75 302 86804 HEP C AB TEST CONFIRM $67.1030086805 L Y MP H OC Y TOTOX V C; W T I TR A TE$ 145.80 300 86806 LYMPHOCYTOTOX VC; WO TITRATE $131.2530086807 PR A SCREEN$ 145.80 300 86808 PRA SCREEN; QUICK METHOD $128.5030086812 H L A T Y PE; A BCSG L A G$ 111.75 300 86813 HLA TYPE; A B C MULTI AG $251.1030086816 H L A T Y PE; D R / D QSG L A G$ 76.40 300 86817 HLA TYPE; DR/DQ MULTI AG $176.6530086821 L y m p h ocy t ec u lt u re, mi x e d$ 154.90 300 86825 HLA X-MATH NON-CYTOTOXIC $235.1030086826 H L A X - M A TC H NONC Y TOTOXC A DD L$ 78.35 300 86828 HLA CLASS I&II ANTIBODY QUAL $145.80 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 58 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 86829 HLA CLASS I/II ANTIBODY QUAL $128.5030086830 H L A C L A SS I P H ENOT Y PEQ U A L$ 349.60 300 86831 HLA CLASS II PHENOTYPE QUAL $299.6530086832 H L A C L A SS I H I G HD EF I NQ U A L$ 549.35 300 86833 HLA CLASS II HIGH DEFIN QUAL $499.4530086834 H L A C L A SS I SEM I Q U A NTP A NE L$ 1,548.20 300 86835 HLA CLASS II SEMIQUANT PANEL $1, 398.4030086849 U N L I STE D I MM U NO L OG Y PROCE D U RE$ 37.65 300 86850 RBC ANTIBODY SCREEN $21.1530086860 RBC A NT I BO D Y E LU T I ON$ 81.15 300 86870 RBC antibody identification $23.3030286880 C oo mb s t es t d i rec t$ 24.40 302 86885 COOMBS TEST INDIRECT QUAL $24.8030086886 COOMBSTEST I N D I RECTT I TER$ 22.40 300 86890 AUTOLOG BLOOD PREDEPOSITED $365.1530086891 A U TO L OGO U SB L OO D OPS A L V A GE$ 12.90 300 86900 Blood typing abo $13.5530086901 Bl oo d t y p in g r h (d)$ 13.55 300 86902 Blood type antigen donor ea $16.5530086904 B L OO D T Y P I NGP A T I ENTSER U M$ 20.75 300 86905 BLOOD TYPING RBC ANTIGENS $16.5530086906 B L D T Y P I NGSERO L OG I CR H P H NT$ 33.60 300 86910 BLD TYPE PATERNITY; ABO RH MN $72.4530086911 B L D T Y PEP A TERN I T Y; E AA DD T L A G$ 69.55 300 86920 Compatibility test spin $10.5030086921 COMP A T I B I L I T Y TEST I NC U B A TE$ 37.65 300 86922 COMPATIBILITY TEST ANTIGLOB $113.0030086923 COMP A T I B I L I T Y TESTE L ECTR I C$ 72.45 300 86927 PLASMA FRESH FROZEN $52.5030086930 FROZENB L OO D PREP$ 266.60 300 86931 FROZEN BLOOD THAW $52.5030086932 FROZENB L OO D FREEZE / T H A W$ 35.50 300 86940 HEMOLYSINS/AGGLUTININS AUTO $35.5030086941 H EMO L Y S I NS / A GG LU T I N I NS$ 52.45 300 86945 BLOOD PRODUCT/IRRADIATION $188.3530086950 L E U K A C Y TETR A NSF U S I ON$ - 300 86960 VOL REDUCTION OF BLOOD/PROD $46.3530086965 POO L I NGB L OO D P L A TE L ETS$ 49.25 300 86972 RBC PRETX INCUBATJ W/DENSITY $29.0030086977 RBCSER U MPRETX I NC U B J / I N H I B$ 81.15 300 86978 RBC PRETREATMENT SERUM $52.1530086985 SP L I TB L OO D ORPRO D U CTS$ 52.50 300 86999 TRANSFUSION PROCEDURE UNLISTED $157.5030087003 SM A LL A N I M A L I NOC UL A T I ON$ 44.70 300 87015 SPECIMEN INFECT AGNT CONCNTJ $28.9030087040 A EROBB A CTER I A L B L OO D C UL T U RE$ 46.85 300 87045 FECES CULTURE AEROBIC BACT $37.3030087046 A EROB I CSTOO L C UL TR A DD T L P A T H OGE A$ 40.85 300 PLATE 87070 BACTERIAL CULTURE - OTHR SOURCE $39.0530087071 C UL T U RE A EROB I CQ U A NTOT H ER$ 41.00 300 87073 CULTURE BACTERIA ANAEROBIC $40.8530087075 A N A EROBB A CTC UL T U RE W I D$ 41.00 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 59 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87076 CULTURE ANAEROBE IDENT EACH $28.7530087077 C u lt u re a ero bi c i d e n t i f y$ 36.65 300 87081 Culture screen only $28.7530087084 C UL T U REOFSPEC I MENB Y K I T$ 37.30 300 87086 Urine culture/colony count $36.6530087088 U R I NEB A CTER I A C UL T U RE$ 34.65 300 87101 SKIN FUNGI CULTURE $33.4030087102 F U NG U S I SO L A T I ONC UL T U RE$ 36.40 300 87103 BLOOD FUNGUS CULTURE $39.0530087106 F U NG II D ENT I F I C A T I ON Y E A ST$ 44.70 300 87107 FUNGI IDENTIFICATION MOLD $44.7030087109 M Y COP L A SM A$ 49.25 300 87110 CHLAMYDIA CULTURE $84.8530087116 M yco ba c t er ia c u lt u re$ 44.75 300 87118 MYCOBACTERIC IDENTIFICATION $47.4030087140 C UL T U RET Y PE I MM U NOF LU ORESC$ 24.15 300 87143 CULTURE TYPING GLC/HPLC $54.2530087147 C u lt u re t y p e imm u n o l o g i c$ 23.45 300 87149 DNA/RNA DIRECT PROBE $86.8530087150 D N A / RN AA MP L I F I E D PROBE$ 151.95 300 87152 CULTURE TYPE PULSE FIELD GEL $22.6530087153 D N A / RN A SEQ U ENC I NG$ 499.50 300 87154 CULTURE TYPING ID BLD PTHGN&RESIST $654.18 T Y P I NG 6 + TRGT 87158 C UL T U RET Y P I NG A DD E D MET H O D$ 22.65 300 87164 26 Dark field examination $40.959718716426 M i d l e v e l D a r k f i e l d e x amina t i o n$ 34.80 971 87164 DARK FIELD; W SPEC COLLECT $40.9530087166 D A R K F I E L D; W OSPECCO LL ECT$ 48.90 300 87168 MACROSCOPIC EXAM ARTHROPOD $18.5030087169 M A CROSCOP I CEX A MP A R A S I TE$ 18.50 300 87172 PINWORM EXAM $38.5030087176 T I SS U E H OMOGEN I Z A T I ONC UL TR$ 25.50 300 87177 TC OVA & PARASITES DIR SMR W ID $38.5030087181 M I CROBES U SCEPT I B L E D I FF U SE$ 8.05 300 87184 MICROBE SUSCEPTIBLE DISK $29.903008718526 M i cro b es u sce pt ib l ee n zy m e$ 8.05 971 87185 MICROBE SUSCEPTIBLE ENZYME $8.0530087186 TCM i cro b es u sce pt ib l e mi c$ 39.20 300 87187 MICROBE SUSCEPTIBLE MLC $44.9030087188 M I CROBES U SCEPTM A CROBROT H$ 28.75 300 87190 MICROBE SUSCEPT MYCOBACTERI $18.5030087197 B A CTER I C I D A LL E V E L SER U M$ 23.30 300 87205 26 Smear gram stain $18.5097187205 SME A RGR A MST A I N$ 18.50 300 87206 TC SMEAR; FLUORESCENT OR AFB STAIN $23.303008720726 M i d l e v e lS m e a r, s p ec ia l s t ain$ 39.25 971 87207 26 Smear, special stain $46.2097187207 SME A RSPEC I A L ST A I N$ 46.20 300 87209 SMEAR COMPLEX STAIN $57.5030087210 S m e a r w e t m o u n t s a l in e / ink$ 19.35 300 87220 KOH FOR FUNGI/PARASITES/MITES $18.5030087230 A SS A Y TOX I NOR A NT I TOX I N$ 85.50 300 87250 VIRUS INOCULATE EGGS/ANIMAL $84.65 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 60 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87252 VIRUS INOCULATION TISSUE $112.8530087253 V I R U S I NOC UL A TET I SS U E A DD L$ 38.85 300 87254 VIRUS INOCULATION SHELL VIA $84.6530087255 GENET V I R U S I SO L A TE H S V$ 133.00 300 87260 ADENOVIRUS AG IF $51.9530087265 PERT U SS I S A G I F$ 51.95 300 87267 ENTEROVIRUS ANTIBODY DFA $51.9530087269 G I A R D I AA G I F$ 51.95 300 87270 CHLAMYDIA TRACHOMATIS AG IF $51.9530087271 C Y TOMEG A L O V I R U S D F A$ 51.95 300 87272 CRYPTOSPORIDIUM AG IF $51.9530087273 H ERPESS I MP L EX 2 A G I F$ 51.95 300 87274 HERPES SIMPLEX 1 AG IF $51.9530087275 I NF LU ENZ A B A G I F$ 51.95 300 87276 INFLUENZA A AG IF $51.9530087278 L EG I ONPNE U MOP H I L I AA G I F$ 51.95 300 87279 PARAINFLUENZA AG IF $51.9530087280 RESP I R A TOR Y S Y NC Y T I A L A G I F$ 51.95 300 87281 PNEUMOCYSTIS CARINII AG IF $51.9530087283 R U BEO L AA G I F$ 51.95 300 87285 TREPONEMA PALLIDUM AG IF $51.9530087290 V A R I CE LL A ZOSTER A G I F$ 51.95 300 87299 ANTIBODY DETECTION NOS IF $51.9530087300 A G D ETECT I ONPO L YV A L I F$ 51.95 300 87301 ADENOVIRUS AG EIA $51.9530087305 A SPERG I LLU S A GE I A$ 51.95 300 87320 CHYLMD TRACH AG EIA $51.9530087324 Cl os t r i d i u ma g e ia$ 51.95 306 87327 CRYPTOCOCCUS NEOFORM AG EIA $51.9530087328 CR Y PTOSPOR I D I U M A GE I A$ 51.95 300 87329 GIARDIA AG EIA $51.9530087332 C Y TOMEG A L O V I R U S A GE I A$ 51.95 300 87335 E COLI 0157 AG EIA $51.9530087336 ENT A MOEB H I ST D I SPR A GE I A$ 51.95 300 87337 ENTAMOEB HIST GROUP AG EIA $51.9530087338 H p y l or i s t oo l e ia$ 51.95 306 87339 H PYLORI AG EIA $51.9530087340 He p a t i t i s b s u r f a ce a g e ia$ 46.85 306 87341 HEPATITIS B SURFACE AG EIA $44.7530087350 He p a t i t i s b e a g e ia$ 49.90 306 87380 HEPATITIS DELTA AG EIA $71.0530087385 H I STOP L A SM A C A PS UL A GE I A$ 51.95 300 87389 HIV-1 AG W/HIV-1 & HIV-2 AB $104.3030087390 H I V - 1 A GE I A$ 65.55 300 87391 HIV-2 AG EIA $65.5530087400 I NF LU ENZ AA / B A GE I A$ 51.95 300 87420 RESP SYNCYTIAL AG EIA $51.9530087425 ROT A V I R U S A GE I A$ 51.95 300 87427 SHIGA-LIKE TOXIN AG EIA $51.9530087430 St re p aa g e ia$ 51.95 306 87449 AG DETECT NOS EIA MULT $51.9530087450 A G D ETECTNOSE I A S I NG L E$ 41.50 300 87451 AG DETECT POLYVAL EIA MULT $41.50 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 61 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87471 BARTONELLA DNA AMP PROBE $151.9530087472 B A RTONE LL A D N A Q U A NT$ 185.45 300 87475 LYME DIS DNA DIR PROBE $86.8530087476 L Y ME D I S D N AA MPPROBE$ 151.95 300 87480 CANDIDA DNA DIR PROBE $86.8530087481 C A N D I D A D N AA MPPROBE$ 151.95 300 87482 CANDIDA DNA QUANT $180.8030087483 CNS D N A / RN AA MPPROBEM UL T I P L E$ 1250.34 SUBTYPES 12-25 TARGETS 87485 Chylmd pneum dna dir probe $86.8530687486 C H Y L M D PNE U M D N AA MPPROBE$ 112.30 300 87487 CHYLMD PNEUM DNA QUANT $185.4530087490 C h y l m d t r a c h d na d i r p ro b e$ 86.85 306 87491 Chylmd trach dna amp probe $159.2030687492 C H Y L M D TR A C HD N A Q U A NT$ 151.40 300 87493 C DIFF AMPLIFIED PROBE $151.9530087495 C Y TOMEG D N A D I RPROBE$ 86.85 300 87496 CYTOMEG DNA AMP PROBE $151.9530087497 C Y TOMEG D N A Q U A NT$ 185.45 300 87498 ENTEROVIRUS PROBE&REVRS TRNS $151.9530087500 V A NOM Y C I N D N AA MPPROBE$ 151.95 300 87501 INFLUENZA DNA AMP PROB 1+ $222.2030087502 I NF LU ENZ A D N AA MPPROBE$ 368.40 300 87503 INFLUENZA DNA AMP PROB ADDL $89.9530087505 NFCT A GENT D N A / RN A G A STRO I NTEST I N A L$ 384.87 PATHOGEN 87506 IADNA-DNA/RNA GI PTHGN MULTIPLEX $788.97 PROBETQ 6 - 1187507 I A D N A - D N A / RN A G I PT H GNM UL T I P L EX$ 1,250.34 PROBE TO 12-25 87510 GARDNER VAG DNA DIR PROBE $86.8530087511 G A R D NER V A G D N AA MPPROBE$ 151.95 300 87512 GARDNER VAG DNA QUANT $180.8030087516 H EP A T I T I SB D N AA MPPROBE$ 151.95 300 87517 Hepatitis b dna quant $185.4530687520 H EP A T I T I SCRN A D I RPROBE$ 86.85 300 87521 HEPATITIS C PROBE&RVRS TRNSC $151.9530087522 H EP A T I T I SCRE V RSTRNSCRP J$ 185.45 300 87525 HEPATITIS G DNA DIR PROBE $86.8530087526 H EP A T I T I SG D N AA MPPROBE$ 151.95 300 87527 HEPATITIS G DNA QUANT $180.8030087528 H S V D N A D I RPROBE$ 86.85 300 87529 Hsv dna amp probe $151.9530687530 H S V D N A Q U A NT$ 185.45 300 87531 HHV-6 DNA DIR PROBE $86.8530087532 HH V - 6 D N AA MPPROBE$ 151.95 300 87533 HHV-6 DNA QUANT $180.8030087534 H I V - 1 D N A D I RPROBE$ 86.85 300 87535 HIV-1 PROBE&REVERSE TRNSCRPJ $151.9530087536 H i v - 1 d na q u an t$ 368.40 306 87537 HIV-2 DNA DIR PROBE $86.85 300 87538 HIV-2 PROBE&REVRSE TRNSCRIPJ$ 151.95 300 87539 HIV-2 QUANT&REVRSE TRNSCRIPJ $185.4530087540 L EG I ONPNE U MO D N A D I RPROB$ 86.85 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 62 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87541 LEGION PNEUMO DNA AMP PROB $151.9530087542 L EG I ONPNE U MO D N A Q U A NT$ 180.80 300 87550 MYCOBACTERIA DNA DIR PROBE $86.8530087551 M Y COB A CTER I A D N AA MPPROBE$ 151.95 300 87552 MYCOBACTERIA DNA QUANT $185.4530087555 M . T U BERC UL O D N A D I RPROBE$ 185.45 300 87556 M.tuberculo dna amp probe $86.8530687557 M . T U BERC UL O D N A Q U A NT$ 185.45 300 87560 M.AVIUM-INTRA DNA DIR PROB $86.8530087561 M . A V I U M - I NTR A D N AA MPPROB$ 151.95 300 87562 M.AVIUM-INTRA DNA QUANT $185.4530087580 M . PNE U MON D N A D I RPROBE$ 86.85 300 87581 M.PNEUMON DNA AMP PROBE $112.3030087582 M . PNE U MON D N A Q U A NT$ 180.80 300 87590 N.gonorrhoeae dna dir prob $86.8530687591 N . g o n orr h oe a e d naam pp ro b$ 159.20 306 87592 N.GONORRHOEAE DNA QUANT $185.4530087623 H P V L O W - R I S K T Y PES$ 151.95 306 87624 HPV HIGH-RISK TYPES $151.95 306 87625 HPV TYPES 16 & 18 ONLY$ 180.80 300 87631 RESP VIRUS 3-5 TARGETS $555.4530087632 RESP V I R U S 6 - 11 T A RGETS$ 924.10 300 87633 RESP VIRUS 12-25 TARGETS $1,804.65 300 87636 IADAN SARSCOV2 & INF A&B MUT$ 427.89 AOMPLIFIED PROBE TQ 87637 ADNA SARSCOV2 & INF A&B & RSV MULT $427.89300 A MPPROBETQ 87640 ST A P H A D N AA MPPROBE$ 151.95 300 87641 MR-STAPH DNA AMP PROBE $151.9530087650 STREP A D N A D I RPROBE$ 86.85 300 87651 Strep a, dna, amp probe $96.3030087652 St re p a, d na, q u an t$ 114.55 300 87653 Strep b, dna, amp probe $96.3030087660 T r i c h o m o na s v a g in, d i r p ro b e$ 55.00 300 87797 Detect agent nos, dna, dir $55.0030087798 D ETECT A GENTNOS D N AA MP$ 112.30 306 87799 DETECT AGENT NOS DNA QUANT $185.4530087800 D ETECT A GNTM UL T D N A D I REC$ 173.70 300 87801 Detect agnt mult, dna, ampli $192.6030087802 STREPB A SS A YW / OPT I C$ 51.95 300 87803 CLOSTRIDIUM TOXIN A W/OPTIC $51.9530087804 I n f l u e n z aa ss a y w / o pt i c$ 54.40 306 87807 RSV ASSAY W/OPTIC $51.9530087808 TR I C H OMON A S A SS A YW / OPT I C$ 51.95 300 87809 ADENOVIRUS ASSAY W/OPTIC $51.9530087810 C H Y L M D TR A C H A SS A YW / OPT I C$ 51.95 300 87850 N. GONORRHOEAE ASSAY W/OPTIC $51.9530087880 St re p aa ss a y w / o pt i c$ 54.40 306 87899 AGENT NOS ASSAY W/OPTIC $51.9530087900 P H ENOT Y PE I NFECT A GENT D R U G$ 564.40 300 87901 GENOTYPE DNA HIV REVERSE T $1, 114.7030087902 GENOT Y PE D N A / RN A H EPC$ 1,114.70 300 87903 Phenotype, dna hiv w/culture $1,340.60 300 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 63 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87904 Phenotype, dna hiv w/clt add $71.5030087910 GENOT Y PEC Y TOMEG A L O V I R U S$ 1,114.70 300 87912 GENOTYPE DNA HEPATITIS B $1, 114.7030087999 M i cro bi o l o g y p roce d u re u n l i s t e d$ - 300 88000 Necropsy (autopsy), gross examination only; without $995.00310 CNS 88005 N ecro p sy (a u t o p sy), g rosse x amina t i o n o n l y; w i t h$ 1,114.00 310 brain 88007 Necropsy (autopsy), gross examination only; with $1, 226.00310 b r ainan d s p ina l cor d 88012 N ecro p sy (a u t o p sy), g rosse x amina t i o n o n l y; in f an t$ 1,020.00 310 with brain 88014 Necropsy (autopsy), gross examination only; $1, 009.00310 s t i ll b or n or n e w b or n w i t hb r ain 88016 N ecro p sy (a u t o p sy), g rosse x amina t i o n o n l y;$ 969.00 310 macerated stillborn 88020 Necropsy (autopsy), gross and microscopic; without $1, 282.00310 CNS 88025 N ecro p sy (a u t o p sy), g ross an d mi crosco p i c; w i t h$ 1,393.00 310 brain 88027 Necropsy (autopsy), gross and microscopic; with $1, 455.00310 b r ainan d s p ina l cor d 88028 N ecro p sy (a u t o p sy), g ross an d mi crosco p i c; in f an t$ 1,198.00 310 with brain 88029 AUTOPSY GROSS&MICRO SB/NB W BR $1, 245.3031088036 A U TOPS Y L I M I TE D REG I ON A L$ 1,032.00 310 88037 AUTOPSY LIMITED SGL ORGAN $813.0031088040 FORENS I C A U TOPS Y (NECROPS Y)$ 3,060.00 310 88045 CORONERS AUTOPSY (NECROPSY) $650.7531088099 NECROPS Y (A U TOPS Y) PROCE D U RE$ 539.70 310 UNLISTED 88104 26 Cytopath fl nongyn smears $116.559718810426 M i d l e v e lC y t o p a t h f l n o n g y n, s m e a rs$ 98.70 960 88104 Cytopath fl nongyn smears $245.7031188104 TCC y t o p a t h f l n o n g y n s m e a rs$ 147.00 311 88106 26 Cytopath fl nongyn, filter $79.809608810626 M i d l e v e lC y t o p a t h f l n o n g y n, f i lt er$ 68.25 960 88106 CYTOPATH FL NONGYN FILTER $264.603108810826 M i d l e v e lC y t o p a t h, co n ce n t r a t e t ec h$ 77.70 960 88108 26 Cytopath, concentrate tech $91.3596088108 C Y TOP A T H CONCENTR A TETEC H$ 257.25 310 88112 26 Cytopath cell enhance tech $239.409718811226 M i d l e v e lC y t o p a t h, ce ll e nhan ce t ec h$ 203.70 960 88112 Cytopath cell enhance tech $372.7531188112 TCC y t o p a t h ce ll e nhan ce t ec h$ 168.00 311 88120 CYTP URNE 3-5 PROBES EA SPEC $2, 051.2031088121 C Y TP U R I NE 3 - 5 PROBESCMPTR$ 1,849.30 310 88125 26 Forensic cytopathology $55.659608812526 M i d l e v e lF ore n s i ccy t o p a t h o l o g y$ 47.25 960 88125 FORENSIC CYTOPATHOLOGY $80.8531088130 SEXC I D; B A RRBO D I ES$ 65.15 310 88140 SEX C ID; PERIPH BLD SMR $34.603108814126 M i d l e v e lC y t o p a t h, c / v, in t er p re t$ 12.45 960 88141 26 Cytopath, c/v, interpret $14.7096088141 C Y TOP A T H C / V I NTERPRET$ 106.05 310 88142 Cytopath c/v thin layer $87.7531188143 C Y TOP A T H C / V T H I N L A Y ERRE D O$ 65.80 310 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 64 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 88147 CYTOPATH C/V AUTOMATED $36.4031088148 C y t o p a t h c / v a u t orescree n$ 65.80 311 88150 CYTOPATH C/V MANUAL $45.7531088152 C Y TOP A T H C / V A U TORE D O$ 45.75 310 88153 CYTOPATH C/V REDO $45.7531088155 C Y TOP A T H C / V I N D EX A DD - ON$ 23.80 310 88160 26 Midlevel Cytopath smear, other source $88.209608816026 C y t o p a t h s m e a r, o t h erso u rce$ 103.95 960 88160 CP SMR OTHR; SCRN & INT $202.653108816126 M i d l e v e lC y t o p a t h s m e a r, o t h erso u rce$ 86.10 960 88161 26 Cytopath smear, other source $100.8096088161 CPSMROT H R; PREPSCRN I NT$ 207.90 310 88162 26 Cytopath smear, other source $161.709608816226 M i d l e v e lC y t o p a t h s m e a r, o t h erso u rce$ 137.55 960 88162 CP SMR OTHR; > 5 SLIDES $311.8531088164 C Y TOP A T H TBSC / V M A N U A L$ 61.95 310 88165 CYTOPATH TBS C/V REDO $61.9531088166 C Y TOP A T H TBSC / V A U TORE D O$ 61.95 310 88167 CYTOPATH TBS C/V SELECT $61.953108817226 C y t o p a t h o l o g ye v a l o ff na$ 144.90 960 88172 26 Midlevel Cytopathology eval of fna $122.8596088172 C Y TP D XE V A L FN A 1 STE A S I TE$ 192.15 310 88173 26 Cytopath eval fna report $288.759718817326 M i d l e v e lC y t o p a t h e v a l, f na, re p or t$ 245.70 960 88173 TC Cytopath eval fna report $258.3031188173 C y t o p a t h e v a l f na re p or t$ 505.05 311 88174 CYTOPATH C/V AUTO IN FLUID $114.4531088175 C y t o p a t h c / v a u t o f l u i d re d o$ 114.45 311 88177 CYTP FNA EVAL EA ADDL $99.753108818226 C e ll ma r k ers t u d y$ 145.95 960 88182 26 Midlevel Cell marker study $123.9096088182 CE LL M A R K ERST U D Y$ 371.70 310 88184 FLOWCYTOMETRY/ TC 1 MARKER $300.3031088185 F L O W C Y TOMETR Y / TC A DD - ON$ 181.65 310 88187 26 Flowcytometry/read, 2-8 $43.059608818726 M i d l e v e lFl o w cy t o m e t ry / re a d, 2 - 8$ 36.55 960 88187 FLOWCYTOMETRY/READ 2-8 $223.653108818826 Fl o w cy t o m e t ry / re a d, 9 - 15$ 72.45 960 88188 26 Midlevel Flowcytometry/read, 9-15 $61.2096088188 F L O W C Y TOMETR Y / RE A D 9 - 15$ 304.50 310 88189 26 Flowcytometry/read, 16 & > $89.25 960 88189 26 Midlevel Flowcytometry/read, 16 & >$ 75.90 960 88189 FLOWCYTOMETRY/READ 16 & > $372.7531088230 T I SS U EC UL T U RE L Y MP H OC Y TE$ 626.85 310 88233 TISSUE CULTURE SKIN/BIOPSY $941.8531088235 T I SS U EC UL T U RE; A MN I OT I CF LU I D$ 630.00 310 88237 TISSUE CULTURE BONE MARROW $598.5031088239 T I SS U EC UL T U RET U MOR$ 577.50 310 88240 CELL CRYOPRESERVE/STORAGE $136.5031088241 T H A W FROZENCE LL S / A L I Q U OT$ 162.75 310 88245 CHROMOSOME ANALYSIS 20-25 $577.5031088248 C H ROMOSOME A N A L Y S I S 50 - 100$ 787.50 310 88249 CHROMOSOME ANALYSIS 100 $997.5031088261 C H ROMOSOME A N A L Y S I S 5$ 577.50 310 88262 Chromosome analysis 15-20 $603.75 311 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 65 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 88263 CHROMOSOME ANALYSIS 45 $682.5031088264 C H ROMOSOME A N A L Y S I S 20 - 25$ 609.00 310 88267 CHROM ANALY; AF/CV 15 CELLS $785.4031088269 C H ROMOSOME A N A L Y S A MN I OT I C$ 742.35 310 88271 CYTOGENETICS DNA PROBE $134.4031088272 C Y TOGENET I CS 3 - 5$ 155.40 310 88273 CYTOGENETICS 10-30 $162.7531088274 C Y TOGENET I CS 25 - 99$ 134.40 310 88275 CYTOGENETICS 100-300 $163.8031088280 C H ROMOSOME K A R Y OT Y PEST U D Y$ 112.35 310 88283 CHROMOSOME BANDING STUDY $334.9531088285 C H ROMOSOMECO U NT A DD I T I ON A L$ 115.50 310 88289 CHROMOSOME STUDY ADDITIONAL $115.503108829126 C y t o / m o l ec u l a rre p or t$ 116.55 960 88291 26 Midlevel Cyto/molecular report $98.9096088299 C Y TOGENET I CST U D Y U N L I STE D$ 21.75 310 88300 26 Surgical path, gross $18.909608830026 M i d l e v e lS u r g i c a lp a t h, g ross$ 15.75 960 88300 SURG PATH LEVEL-I GROSS ONLY $102.903108830226 T i ss u ee x amb y p a t h o l o g i s t$ 27.30 971 88302 26 Midlevel Tissue exam by pathologist $23.1096088302 TCS U RGP A T H L V L 2$ 188.10 310 88302 SURG PATH LVL 2 $212.303108830426 T i ss u ee x amb y p a t h o l o g i s t$ 49.35 971 88304 26 Midlevel Tissue exam by pathologist $41.8096088304 TCT I SS U EEX A MB Y P A T H O L OG I ST L V L 3$ 185.85 310 88304 TISSUE EXAM BY PATHOLOGIST LVL 3 $224.703108830526 T i ss u ee x amb y p a t h o l o g i s t$ 154.35 971 88305 26 Midlevel Tissue exam by pathologist $131.2596088305 T I SS U EEX A MB Y P A T H O L OG I ST L V L 4$ 384.30 310 88305 TC TISSUE EXAM BY PATHOLOGIST LVL 4 $254.103108830726 T i ss u ee x amb y p a t h o l o g i s t$ 337.05 960 88307 26 Midlevel Tissue exam by pathologist $286.6596088307 T I SS U EEX A MB Y P A T H O L OG I ST L V L 5$ 852.60 310 88309 26 Tissue exam by pathologist $594.309608830926 M i d l e v e lT i ss u ee x amb y p a t h o l o g i s t$ 505.05 960 88309 TISSUE EXAM BY PATHOLOGIST LVL 6 $1, 291.503108831126 Dec a l c i f y t i ss u e$ 50.40 960 88311 26 Midlevel Decalcify tissue $43.0596088311 D EC A L C I F Y T I SS U E$ 69.30 310 88312 26 Midlevel Special stains $94.509608831226 Sp ec ia l s t ain s$ 111.30 960 88312 SPECIAL STAINS GROUP 1 $340.203108831326 Sp ec ia l s t ain s g ro u p 2$ 49.35 971 88313 26 Midlevel Special stains $42.0096088313 Sp ec ia l s t ain s g ro u p 2$ 238.35 310 88313 TC Special stains group 2 $196.353108831426 M i d l e v e l H i s t oc h e mi c a l s t ain$ 78.75 960 88314 26 Histochemical stain $92.4096088314 H I STOC H EM I C A L ST A I NS A DD - ON$ 290.85 310 88319 26 Enzyme histochemistry $112.359608831926 M i d l e v e lE n zy m e hi s t oc h e mi s t ry$ 95.55 960 88319 ENZYME HISTOCHEMISTRY $355.953108832126 M i cros l i d eco n s u lt a t i o n$ 30.45 969 88321 26 Midlevel Microslide consultation $25.609698832326 M i d l e v e lM i cros l i d eco n s u lt a t i o n$ 296.10 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 66 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 88323 26 Microslide consultation $348.6096088323 M I CROS L I D ECONS UL T A T I ON$ 498.75 310 88325 26 Comprehensive review of data $95.559698832526 M i d l e v e lC o m p re h e n s i v ere v i e w o fd a t a$ 81.65 969 88329 26 Path consult introp $137.559698832926 M i d l e v e lP a t h co n s u lt in t ro p$ 116.65 969 88331 26 Path consult intraop, 1 bloc $252.009608833126 M i d l e v e lP a t h co n s u lt in t r a o p, 1 b l oc$ 214.20 960 88331 PATH CONSULT INTRAOP 1 BLOC $337.053108833226 M i d l e v e lP a t h co n s u lt in t r a o p, a dd Æ l$ 106.05 960 88332 26 Path consult intraop, addÆl $124.9596088332 P A T H CONS UL T I NTR A OP A DD L$ 148.05 310 88333 26 Intraop cyto path consult, 1 $256.209608833326 M i d l e v e l I n t r a o p cy t o p a t h co n s u lt, 1$ 217.35 960 88333 INTRAOP CYTO PATH CONSULT 1 $352.803108833426 I n t r a o p cy t o p a t h co n s u lt, 2$ 156.45 960 88334 26 Midlevel Intraop cyto path consult, 2 $133.3596088334 I NTR A OPC Y TOP A T H CONS UL T 2$ 219.45 310 88342 26 Immunohistochemistry $174.309608834226 M i d l e v e l I mm u n o hi s t oc h e mi s t ry$ 148.05 960 88342 IMMUNOHISTO ANTIBODY STAIN $383.253108834626 I mm u n o f l u oresce n t s t u d y$ 176.40 960 88346 26 Midlevel Immunofluorescent study $150.1596088346 I MM U NOF LU ORESCENTST U D Y$ 375.90 310 88348 26 Electron microscopy $308.709608834826 M i d l e v e lEl ec t ro nmi crosco p y$ 262.50 960 88348 ELECTRON MICROSCOPY $2, 556.7531088350 I MM U NOF LU OR A NTB A DD L ST A I N$ 133.35 310 88355 26 Analysis, skeletal muscle $350.709608835526 M i d l e v e l A na l ys i s, s k e l e t a l m u sc l e$ 298.20 960 88355 MORPHOMETRICS; SKEL MSCL $705.603108835626 A na l ys i s, n er v e$ 543.90 960 88356 26 Midlevel Analysis, nerve $462.0096088356 MORP H OMETR I CS; NER V E$ 991.20 310 88358 26 Midlevel Analysis, tumor $152.259608835826 A na l ys i s, t u m or$ 179.55 960 88358 MORPHOMETRICS; TUMOR $275.103108836026 T u m or imm u n o hi s t oc h e m / man u a l$ 218.40 960 88360 26 Midlevel Tumor immunohistochem/manual $185.8596088360 T U MOR I MM U NO H I STOC H EM / M A N U A L$ 437.85 310 88361 26 Midlevel Tumor immunohistochem/comput $172.259608836126 T u m or imm u n o hi s t oc h e m / co m p u t$ 202.65 960 88361 TUMOR IMMUNOHISTOCHEM/COMPUT $550.203108836226 M i d l e v e lN er v e t e a s in g p re p a r a t i o n s$ 389.55 960 88362 26 Nerve teasing preparations $457.8096088362 NER V ETE A S I NGPREP A R A T I ONS$ 1,098.30 310 88363 Xm archive tissue molec anal $56.703108836526 I n s i t u h y b r i d i z a t i o n (f i s h)$ 242.55 960 88365 26 Midlevel Insitu hybridization (fish) $205.8096088365 I NS I T U H Y BR I D I Z A T I ON (F I S H)$ 602.70 310 88367 26 Insitu hybridization, auto $258.309608836726 M i d l e v e l I n s i t u h y b r i d i z a t i o n, a u t o$ 219.45 960 88367 INSITU HYBRIDIZATION AUTO $959.703108836826 I n s i t u h y b r i d i z a t i o n, man u a l$ 261.45 960 88368 26 Midlevel Insitu hybridization, manual $222.6096088368 I NS I T U H Y BR I D I Z A T I ONM A N U A L$ 804.30 310 88371 26 Protein, western blot tissue $68.25 971 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 67 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 88371 26 Midlevel Protein, western blot tissue $58.0097188371 PROTE I N W ESTERNB L OTT I SS U E$ 68.25 310 88372 26 Protein analysis w/probe $68.259718837226 M i d l e v e lP ro t e inana l ys i s w / p ro b e$ 58.00 971 88372 PROTEIN ANALYSIS W/PROBE $68.2531088380 M I CRO D I SSECT I ON L A SER$ 23.85 310 88381 MICRODISSECTION MANUAL $18.7031088399 S U RG I C A L P A T H O L OG Y PROCE D U RE$ 157.50 310 UNLISTED 88720 BILIRUBIN TOTAL TRANSCUT $21.7530088738 H GBQ U A NTTR A NSC U T A NEO U S$ 21.75 300 88740 TRANSCUTANEOUS CARBOXYHB PER DAY $21.7530088741 TR A NSC U T A NEO U SMET H BPER D A Y$ 21.75 300 88749 IN VIVO LAB SERVICE $20.503008904926 M i d l e v e lC h c t f or ma l h y p er t h er mia$ 18.00 969 89049 26 Chct for mal hyperthermia $21.0096989050 CE LL CO U NTNOTB L OO D$ 26.25 300 89051 DIFF CELL COUNT NOT BLOOD $26.2530089055 L E U K OC Y TE A SSESSMENTFEC A L$ 26.25 300 89060 26 Midlevel Exam,synovial fluid crystals $37.509718906026 E x am sy n o v ia l f l u i d crys t a l s$ 44.10 971 89060 TC Exam synovial fluid crystals $69.3030089125 SPEC I MENF A TST A I N$ 18.90 300 89160 EXAM FECES FOR MEAT FIBERS $18.9030089190 N A S A L SME A RFOREOS I NOP H I L S$ 18.90 300 89220 SPUTUM SPECIMEN COLLECTION $59.8530089300 SEMEN A N A L Y S I S W / H U H NER$ 38.60 300 89310 SEMEN ANALYSIS W/COUNT $37.2530089320 S e m e nana l v o l / co u n t / m o t$ 52.20 300 89321 SEMEN ANAL SPERM DETECTION $52.2030089322 SEMEN A N A L STR I CTCR I TER I A$ 67.10 300 89325 SPERM ANTIBODY TEST $46.2030089329 SPERME V A LU A T I ONTEST$ 90.80 300 89330 EVALUATION CERVICAL MUCUS $42.8530089331 RETROGR A D EE J A C UL A T I ON A N A L$ 84.85 300 90460 Vaccine administration ⇐19 yrs (related to $56.00771 co n t r a ce pt i v e d e v i ce) 90461 I ma d min e a c ha dd l co m p o n e n t <= 19 yrs$ 36.00 771 90471 IMMUNIZATION ADMIN 1 VACCINE $52.0077190472 I mm u ni z a t i o na d min e a c ha dd$ 35.00 771 90473 Immune admin oral/nasal $52.0077190474 I mm u n e a d min or a l / na s a l a dd l$ 31.00 771 90677 PCV20 VACCINE FOR INTRAMUSCULAR USE $304.619078526 I n t a c g ro u pp sy t x$ 28.35 961 90785 PSYTX COMPLEX INTERACTIVE $109.209009079126 PS Y C HD I A GNOST I CE V A LU A T I ON$ 258.20 961 90791 PSYCH DIAGNOSTIC EVALUATION $258.209009079226 PS Y C HD I A GE V A L W / ME D SR V CS$ 291.20 961 90792 PSYCH DIAG EVAL W/MED SRVCS $291.20 900 90832 26 PSYTX PT&/FAMILY 30 MINUTES$ 128.45 961 90832 PSYTX W PT 30 MINUTES $128.4591490833 PS Y TX W PT W E / M 30 M I N$ 134.30 961 90833 PSYTX W PT W E/M 30 MIN $134.30 914 90834 26 PSYTX PT&/FAMILY 45 MINUTES$ 171.15 961 90834 PSYTX W PT 45 MINUTES $171.15 914 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 68 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90836 26 PSYTX W PT W E/M 45 MIN $169.3596190836 PS Y TX W PT W E / M 45 M I N$ 169.35 914 90837 26 PSYTX PT&/FAMILY 60 MINUTES $257.4096190837 PS Y TX W PT 60 M I N U TES$ 257.40 914 90838 26 PSYTX W PT W E/M 60 MIN $223.8096190838 PS Y TX W PT W E / M 60 M I N$ 118.05 914 90845 26 Psychoanalysis $184.6096190845 P syc h o ana l ys i s$ 275.10 900 90846 26 Family psytx w/o patient $207.5096190846 F A M I L Y PS Y TX W / OPT 50 M I N$ 285.60 900 90847 26 Family psytx w/patient $216.3596190847 F A M I L Y PS Y TX W / PT 50 M I N$ 340.20 900 90849 26 Multiple family group psytx $66.1096190849 M u lt i pl e f ami l y g ro u pp sy t x$ 101.85 900 90853 26 Group psychotherapy $50.8596190853 GRO U PT H ER A P Y NOTM UL T I - F A M I L Y$ 103.95 900 90863 26 Medication management $- 96190863 P H A RM A CO L OG I CMGMT W / PS Y TX$ 160.65 900 90865 26 Narcosynthesis $264.8096190865 N a rcosy n t h es i s$ 451.50 900 90867 26 Tcranial magn stim tx plan $- 96190867 T cr ania l ma g n s t im t x pl an$ 631.05 900 90868 26 Tcranial magn stim tx deli $- 96190868 T cr ania l ma g n s t im t x d e l i$ 86.10 900 90869 26 Tcran magn stim redetemine $- 96190869 T cr anma g n s t im re d e t e min e$ 421.05 900 90870 26 Electroconvulsive therapy $228.3096190870 El ec t roco n vu l s i v e t h er a p y$ 387.45 900 90875 26 Psychophysiological therapy $- 96190875 P syc h o p h ys i o l o g i c a lt h er a p y 20 - 30 min$ 220.50 900 90876 26 Psychophysiological therapy $- 96190876 P syc h o p h ys i o l o g i c a lt h er a p y 45 - 50 min$ 346.50 900 90880 26 Hypnotherapy $188.6096190880 Hy p n o t h er a p y$ 327.60 900 90882 26 ENVIRONMENTAL MANAGEMENT $- 96190882 EN V I RONMENT A L M A N A GEMENT$ - 900 90885 26 Psy evaluation of records $- 96190885 P sye v a l u a t i o n o f recor d s$ 178.50 900 90887 26 Consultation with family $- 96190887 C o n s u lt a t i o n w i t h f ami l y$ 270.90 900 90889 26 PREPARATION OF REPORT $- 9619088926 PREP A R A T I ONOFREPORT$ - 961 90889 22 PREPARATION OF REPORT $- 90090889 PREP A R A T I ONOFREPORT$ - 900 90901 26 Biofeedback train any meth $41.1596190901 B i o f ee d ba c k t r ainan y m e t h$ 74.55 917 90911 26 Biofeedback peri/uro/rectal $93.2096190911 B i o f ee d ba c k p er i / u ro / rec t a l$ 161.70 917 90935 Hemodialysis one evaluation $429.4598390935 He m o d ia l ys i so n ee v a l u a t i o n$ 429.45 820 90937 Hemodialysis repeated eval $534.4598390945 PER I TONE A L D I A L Y S I S$ 429.45 983 90945 PERITONEAL DIALYSIS $429.4583090947 C A P D SER V I CES$ 660.45 983 90951 Esrd serv 4 visits p mo <2 $3,384.15 983 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 69 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90951 Esrd serv 4 visits p mo <2 yrs $3, 384.1582190954 E sr d ser v 4 v s t s p m o 2 - 11$ 2,886.45 983 90954 Esrd serv 4 vsts p mo 2-11 yrs $2, 886.4582190955 E sr d sr v 2 - 3 v s t s p m o 2 - 11$ 1,631.70 983 90955 Esrd srv 2-3 vsts p mo 2-11 ys $1, 631.7082190956 E sr d sr v 1 v i s i tp m o 2 - 11$ 1,128.75 983 90956 Esrd srv 1 visit p mo 2-11 yrs $1, 128.7582190957 E sr d sr v 4 v s t s p m o 12 - 19$ 2,307.90 983 90957 Esrd srv 4 vsts p mo 12-19 yrs $2, 307.9082190958 E sr d sr v 2 - 3 v s t s p m o 12 - 19$ 1,563.45 983 90958 Esrd srv 2-3 vsts p mo 12-19 yrs $1, 563.4582190959 E sr d ser v 1 v s tp m o 12 - 19$ 1,050.00 983 90959 Esrd serv 1 vst p mo 12-19 yrs $1, 050.0082190960 E sr d sr v 4 v i s i t s p m o 20 +$ 1,025.85 983 90960 Esrd srv 4 visits p mo 20+ yrs $1, 025.8582190961 E sr d sr v 2 - 3 v s t s p m o 20 +$ 853.65 983 90961 Esrd srv 2-3 vsts p mo 20+ yrs $853.6582190962 E sr d ser v 1 v i s i tp m o 20 +$ 649.95 983 90962 Esrd serv 1 visit p mo 20+ yrs $649.9582190963 E sr d h o m e pt ser v p m o < 2 yrs$ 1,957.20 821 90964 Esrd home pt serv p mo 2-11 yrs $1, 684.2082190965 E sr d h o m e pt ser v p m o 12 - 19 yrs$ 1,604.40 821 90966 Esrd home pt serv p mo 20+ ys $850.5082190967 ESR D S V CPR D A Y PT < 2 Y RS$ 86.10 821 90968 ESRD SVC PR DAY PT 2-11 YRS $75.6082190969 ESR D S V CPR D A Y PT 12 - 19 Y RS$ 74.55 821 90970 ESRD SVC PR DAY PT 20+ YRS $59.8582190989 D I A L Y S I STR A I N I NGCOMP L ETE$ 900.00 821 90993 DIALYSIS TRAINING INCOMPLETE $160.0082190997 He m o p er f u s i o n$ 320.25 800 90999 UNLISTED DIALYSIS PROCEDURE $997.758219101026 E so p ha gu s m o t i l i t ys t u d y$ 680.40 960 91010 26 Midlevel Esophagus motility study $578.359609101326 E so p h g l m o t i lw / s t im / p er f u s$ 34.65 960 91013 Esophgl motil w/stim/perfus $88.2092091013 TCE so p h g l m o t i lw / s t im / p er f u s$ 53.55 920 91020 26 Midlevel Gastric motility studies $758.659609102026 G a s t r i c m o t i l i t ys t u d i es$ 892.50 960 91022 26 Duodenal motility study $663.609609102226 M i d l e v e l D u o d e na l m o t i l i t ys t u d y$ 564.05 960 91030 26 Midlevel Acid perfusion of esophagus $444.459609103026 A c i d p er f u s i o n o f eso p ha gu s$ 522.90 960 91034 26 Midlevel Gastroesophageal reflux test $617.609609103426 G a s t roeso p ha g e a l re f l ux t es t$ 726.60 960 91302 SARSCOV2 VAC 5X10”10VP/.SMLIM $- 91303 S A RSCO V 2 V A C A D 26.5 M L I M$ - 92002 26 Eye exam, new patient $55.659699200226 M i d l e v e lE yee x am, n e wp a t i e n t$ 46.95 969 92002 INTERM EYE EXAM NEW PT $227.405109200426 E yee x am, n e wp a t i e n t$ 49.35 969 92004 26 Midlevel Eye exam, new patient $41.8096992004 E Y EEX A MNE W P A T I ENT 1 + V I S I TS$ 227.40 510 92012 26 Eye exam established pat $94.509699201226 M i d l e v e lE yee x am es t ab l i s h e d p a t$ 80.35 969 92012 Eye exam established pat $227.40 510 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 70 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 92014 26 Midlevel Eye exam & treatment $33.05 969 92014 26 Eye exam & treatment$ 38.85 969 92014 Eye exam & treatment $227.4051092015 R e f r a c t i o n$ 120.00 510 92018 26 New eye exam & treatment $63.00 969 92018 26 Midlevel New eye exam & treatment$ 53.95 969 92018 EYE EXAM W ANESTH; COMPLETE $3,622.70 510 92019 26 Midlevel Eye exam & treatment$ 123.40 969 92019 26 Eye exam & treatment $144.9096992019 E Y EEX A M W A NEST H; L I M I TE D$ 3,622.70 510 92020 26 Midlevel Special eye evaluation $64.259699202026 Sp ec ia l eyee v a l u a t i o n$ 75.60 969 92020 GONIOSCOPY $75.605109202526 C or n e a lt o p o g r a p h y$ 21.00 960 92025 26 Midlevel Corneal topography $18.0096092025 C or n e a lt o p o g r a p h y$ 111.90 510 92060 26 Special eye evaluation $18.909609206026 M i d l e v e lSp ec ia l eyee v a l u a t i o n$ 16.10 960 92060 BINOCULAR VISION EXAM $111.905109206526 O r t h o pt i c / pl eo pt i c t r ainin g$ 39.90 960 92065 26 Midlevel Orthoptic/pleoptic training $33.7596092065 O r t h o pt i c / pl eo pt i c t r ainin g$ 111.90 510 92081 26 Visual field examination(s) $178.509609208126 M i d l e v e l Vi s u a l f i e l d e x amina t i o n (s)$ 151.70 960 92081 LIMITED VISUAL FIELD EXAM $178.505109208226 Vi s u a l f i e l d e x amina t i o n (s)$ 254.10 960 92082 26 Midlevel Visual field examination(s) $216.0096092082 I NTERM V I S U A L F I E L D EX A M$ 254.10 510 92083 26 Midlevel Visual field examination(s) $276.709609208326 Vi s u a l f i e l d e x amina t i o n (s)$ 325.50 960 92083 Visual field examination(s) $325.505109210026 M i d l e v e lS er ia lt o n o m e t rye x am (s)$ 152.60 969 92100 26 Serial tonometry exam(s) $179.5596992100 S er ia lt o n o m e t rye x am (s)$ 179.55 510 92132 26 Cmptr ophth dx img ant segmt $74.5596092132 C m pt ro p h t h d x im g an t se g m t$ 134.40 920 92132 TC Cmptr ophth dx img ant segmt $60.909209213326 C m pt ro p h t him g o pt i c n er v e$ 103.95 960 92133 TC Cmptr ophth img optic nerve $59.8592092133 C m pt ro p h t him g o pt i c n er v e$ 163.80 920 92134 26 Cptr ophth dx img post segmt $103.9596092134 TCCpt ro p h t h d x im g p os t se g m t$ 59.85 920 92134 Cptr ophth dx img post segmt $163.809209213626 M i d l e v e lOp h t ha l mi c bi o m e t ry$ 269.55 960 92136 26 Ophthalmic biometry $317.1096092136 Op h t ha l mi c bi o m e t ry$ 317.10 510 92225 26 Special eye exam, initial $76.659699222526 M i d l e v e lSp ec ia l eyee x am, ini t ia l$ 65.15 969 92225 OPTHALMOSCOPY; INITIAL $76.655109222626 M i d l e v e lSp ec ia l eyee x am, s u b se q u e n t$ 57.10 969 92226 26 Special eye exam, subsequent $67.2096992226 OP H T H A L MOSCOP Y; FO LL O W - U P$ 67.20 510 92227 Remote dx retinal imaging $44.109209222826 R e m o t ere t ina l ima g in g m g m t$ 75.60 960 92228 Remote retinal imaging mgmt $124.9592092228 TCR e m o t ere t ina l ima g in g m g m t$ 49.35 920 92230 26 Eye exam with photos $198.45 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 71 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 92230 26 Midlevel Eye exam with photos $168.70 969 92230 FLUORESCEIN ANGIOSCOPY W INT & REP$ 198.45 510 92235 26 Midlevel Eye exam with photos $423.959609223526 E yee x am w i t h p h o t os$ 498.75 960 92235 FLUORESCEIN ANGRPH UNI/BI $498.755109224026 M i d l e v e l I c g an g i o g r a p h y$ 767.55 960 92240 26 Icg angiography $903.0096092240 I c g an g i o g r a p h y$ 903.00 510 92250 26 Eye exam with photos $278.259609225026 M i d l e v e lE yee x am w i t h p h o t os$ 236.50 960 92250 FUNDUS PHOTOGRAPHY $278.255109226026 M i d l e v e lOp h t ha l m osco p y / d y nam o m e t ry$ 79.45 969 92260 26 Ophthalmoscopy/dynamometry $93.4596992260 Op h t ha l m osco p y / d y nam o m e t ry$ 93.45 510 92265 26 Eye muscle evaluation $298.209609226526 M i d l e v e lE ye m u sc l ee v a l u a t i o n$ 253.45 960 92265 Eye muscle evaluation $298.205109227026 El ec t ro - oc u l o g r a p h y$ 333.90 960 92270 26 Midlevel Electro-oculography $283.8096092270 El ec t ro - oc u l o g r a p h y$ 333.90 510 92275 26 Midlevel Electroretinography $467.659609227526 El ec t rore t in o g r a p h y$ 550.20 960 92275 Electroretinography $550.205109228326 C o l or v i s i o n e x amina t i o n$ 190.05 960 92283 26 Midlevel Color vision examination $161.5596092283 C o l or v i s i o n e x amina t i o n$ 190.05 510 92284 26 Midlevel Dark adaptation eye exam $188.309609228426 D a r ka d a pt a t i o n eyee x am$ 221.55 960 92284 Dark adaptation eye exam $221.555109228526 E ye p h o t o g r a p h y$ 89.25 960 92285 26 Midlevel Eye photography $75.8596092285 S L I T L A MPP H OTOGR A P H Y (EXT)$ 89.25 510 92286 26 Internal eye photography $445.209609228626 M i d l e v e l I n t er na l eye p h o t o g r a p h y$ 378.40 960 92286 Internal eye photography $445.205109228726 I n t er na l eye p h o t o g r a p h y$ 165.90 960 92287 26 Midlevel Internal eye photography $141.0096092287 I n t er na l eye p h o t o g r a p h y$ 165.90 510 92502 26 Ear and throat examination $353.859699250226 M i d l e v e lE a r an d t h ro a t e x amina t i o n$ 300.75 969 92502 OTOLARYNGOLOGIC EXAM W ANESTH $353.855109250426 E a r mi crosco p ye x amina t i o n$ 34.65 969 92504 26 Midlevel Ear microscopy examination $29.4596992504 E a r mi crosco p ye x amina t i o n$ 34.65 510 92507 SPEECH/HEARING THERAPY INDIV $271.9544092508 SPEEC H / H E A R I NGT H ER A P Y GRO U P$ 166.95 440 92511 TC NASOPHARYNGOSCOPY W/ENDOSCOPE SPX $536.259251126 N A SOP H A R Y NGOSCOP YW / EN D OSCOPESPX$ 119.46 92520 TC LARYNGEAL FUNCTION STUDIES $232.2292521 TCE V A LU A T I ONOFSPEEC H F LU ENC Y$ 425.58 (STUTTER CLUTTER) 92522 TC EVALUATION OF SPEECH SOUND $353.97 PRO D U CT I ON A RT I C UL A TE 92523 TCE V A L SPEEC H SO U N D PRO D U CT L A NG U A GE$ 729.87 COMPREHENSION 92524 TC BEHAVIORAL & QUALIT ANALYSIS VOICE $349.26 AND RESONANCE © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 72 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 92526 TC TX SWALLOWING DYSFUNCTION&/ORAL $273.12 FUNCJ FEEDING 92550 TYMPANOMETRY & REFLEX THRESH$ 71.05 471 92551 SCREENING PURE TONE AIR ONLY $219.4547092552 P u re t o n e a u d i o m e t ry ai r$ 261.45 471 92553 Audiometry, air & bone $997.5047092555 Sp eec h t h res h o l d a u d i o m e t ry$ 466.20 471 92556 Speech audiometry, complete $470.4047092557 C o m p re h e n s i v e h e a r in g t es t$ 324.45 471 92558 Evoked otoacoustic emissions, screening $144.0047092561 B e k esy a u d i o m e t ry, d ia g n os i s$ 429.45 470 92562 Loudness balance test $454.6547092563 T o n e d ec a y h e a r in g t es t$ 454.65 470 92564 Sisi hearing test $454.6547092565 St e n g er t es t, p u re t o n e$ 454.65 470 92567 Tympanometry $124.9547192568 A co u s t i cre f lt h res h o l d t s t$ 513.45 470 92570 Acoustic immitance testing $108.1547192571 F i lt ere d s p eec hh e a r in g t es t$ 488.25 470 92572 Staggered spondaic word test $1, 579.2047092575 S e n sor in e u r a l a c u i t y t es t$ 409.50 470 92576 Synthetic sentence test $439.9547092577 St e n g er t es t, s p eec h$ 1,594.95 470 92579 Visual audiometry (vra) $995.4047092582 C o n d i t i o nin g pl a y a u d i o m e t ry$ 1,059.45 470 92583 Select picture audiometry $932.4047092584 El ec t rococ h l eo g r a p h y$ 1,479.45 470 92585 26 Midlevel Auditor evoke potent, compre $1, 961.709609258526 A u d i t ore v o k e p o t e n t, co m p re$ 2,307.90 960 92585 AUDITORY EP - COMPREHENSIVE $2, 307.9047092586 A U D I TOR Y EP - L I M I TE D$ 291.90 471 92587 26 Evoked auditory test limited $262.509609258726 M i d l e v e lE v o k e d a u d i t ory t es t$ 223.15 960 92587 Evoked auditory test limited $262.5047192587 TCE v o k e d a u d i t ory t es tl imi t e d$ 197.40 471 92588 26 Evoked auditory test $1, 142.409609258826 M i d l e v e lE v o k e d a u d i t ory t es t$ 971.05 960 92588 EVOKED AUDITORY TST COMPLETE $1,142.40 470 92591 26 HEARING AID EXAMINATION & SELECTION$ 150.00 960 BINAURAL 92592 26 HEARING AID CHECK MONAURAL $65.009609259326 H E A R I NG A I D C H EC K B I N A U R A L$ 85.00 960 92596 Ear protector evaluation $428.40 470 92610 TC EVAL ORAL&PHARYNGEAL SWLNG FUNCJ$ 273.72 92611 MOTION FLUORO SWALLOW FCN $281.3632092612 TCF L EX I B L EEN D OSCOP I CE V A L S W A LL O W C / V$ 663.36 REC 92613 26 FLEXIBLE ENDOSCOPIC EVAL SWLLOW C/V $114.51 REC I&R 92614 TC FLEXIBLE ENDOSCOPIC EVAL LARYN$ 489.24 SENSORY C/V REC 92615 26 FLEXIBLE ENDOSCOPIC EVAL LARYN SENS $101.70 C/V REC I&R 92616 TC FLEXIBLE NDSC EVAL SWLNG&LARYN SENS$ 747.87 C/V REC 92617 26 FLEXIBLE NDSC EVAL SWLNG&LARYN SENS $126.18 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 73 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION C/V I&R 92620 26 Auditory function, 60 min $1, 047.909609262026 M i d l e v e l A u d i t ory f u n c t i o n, 60 min$ 890.70 960 92620 Auditory function, 60 min $1, 047.904719262126 A u d i t ory f u n c t i o n, + 15 min$ 65.10 960 92621 26 Midlevel Auditory function, + 15 min $55.3596092621 A U D I TOR Y F U NCT I ON + 15 M I N$ 65.10 471 92625 26 Midlevel Tinnitus assessment $890.709609262526 T inni t u s a ssess m e n t$ 1,047.90 960 92625 Tinnitus assessment $1, 047.904719262626 M i d l e v e lE v a l a u d re hab s t a t u s$ 900.55 960 92626 26 Eval aud rehab status $1, 059.4596092626 E v a l a u d re hab s t a t u s 1 h r$ 1,059.45 470 92627 26 Eval aud status rehab add-on $65.109609262726 M i d l e v e lE v a l a u d s t a t u sre haba dd - o n$ 55.35 960 92627 EVAL AUD STATUS REHAB EA ADDL 15 MIN $65.1044092630 TC A U D I TOR Y RE H A B I L I T A T I ONPRE U NG U A L$ 205.20 HEARING LOSS 92633 TC AUDITORY REHABILITATION POSTLINGUAL $118.80 H E A R I NG L OSS 9264026 A u d b r ain s t e mim pltp ro g r am g$ 1,059.45 960 92640 26 Midlevel Aud brainstem implt programg $900.5596092640 A u d b r ain s t e mim pltp ro g r am g 1 h r$ 1,059.45 471 92700 UNLISTED ENT PROCED/SERVICE $34.954709295026 C a r d i o p u l m o na ry R es u sc i t a t i o n$ 666.75 969 92950 26 Midlevel Cardiopulmonary Resuscitation $566.7596992950 He a r t / l u n g res u sc i t a t i o n c p r$ 666.75 410 92953 26 Midlevel Temporary external pacing $33.909699295326 T e m p or a rye x t er na lp a c in g$ 39.90 969 92953 Temporary external pacing $39.9048092960 C a r d i o v ers i o n e l ec t r i ce x t$ 366.70 480 92975 26 Midlevel Coronary Thrombolysis,intracoronary $1, 253.959699297526 C oro na ry T h ro mb o l ys i s, in t r a coro na ry$ 1,475.25 969 92975 Coronary Thrombolysis,intracoronary $1, 475.2548092977 C oro na ry T h ro mb o l ys i s, in t r a v e n o u s$ 701.40 480 93000 Electrocardiogram complete $84.0073093005 El ec t roc a r d i o g r am t r a c in g$ 49.35 730 93010 Electrocardiogram report $45.159859301026 El ec t roc a r d i o g r am re p or t$ 45.15 985 93010 26 Midlevel Electrocardiogram report $38.4098593015 C a r d i o v a sc u l a rs t ress t es t$ 321.30 482 93016 26 Midlevel Cardiovascular stress test $68.709859301626 C a r d i o v a sc u l a rs t ress t es t$ 80.85 985 93016 Cardiovascular stress test $80.8598593017 C V S L RSTRESSTEST; TR A C I NG$ 159.60 482 93018 Cardiovascular stress test $54.609859301826 M i d l e v e lC a r d i o v a sc u l a rs t ress t es t$ 46.40 985 93018 26 Cardiovascular stress test $54.609859302426 C a r d ia c d r ug s t ress t es t$ 3,675.00 960 93024 26 Midlevel Cardiac drug stress test $3, 123.7596093024 C a r d ia c d r ug s t ress t es t$ 3,675.00 481 93025 26 Midlevel Microvolt t-wave assess $558.709609302526 M i cro v o ltt - w a v e a ssess$ 657.30 960 93040 Rhythm ECG with report $53.5598593040 M i d l e v e lR h y t hm ECGw i t h re p or t$ 22.30 985 93041 Rhythm ECG, tracing 1-3 leads $27.30 730 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 74 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 93042 26 Rhythm ECG, report $63.009859304226 M i d l e v e lR h y t hm ECG, re p or t$ 53.55 985 93224 Ecg monit/reprt up to 48 hrs $360.1573193225 ECG U PTO 48 H RSRECOR D$ 174.30 731 93226 ECG UP TO 48 HRS SCANNING ANALYSIS $157.50731 REPORT 9322726 ECG m o ni t or / re v i e w, 24 h rs$ 96.60 960 93227 26 Midlevel ECG monitor/review, 24 hrs $82.1096093227 E c g m o ni t / re p r t u pt o 48 h rs$ 96.60 960 93228 Remote ⇐30 days ecg rev/report $92.4073293229 R e m o t e <= 30 d a ysec g t ec h s u pp$ 2,523.15 732 93268 ECG record/review ⇐30 days $866.2573193270 REMOTEPT <= 30 D A Y ECGRE V / REPORT$ 355.95 730 93271 Ecg/monitoring and analysis ⇐30 days $730.807319327226 E c g / re v i e w, in t er p re t o n l y$ 90.30 960 93272 26 Midlevel Ecg/review, interpret only $76.759609327826 ECG / s i g na l - a v er a g e d$ 119.70 960 93278 26 Midlevel ECG/signal-averaged $101.759609327926 PM D E V I CEPROGRE V A L SNG L$ 75.50 960 93279 PM DEVICE PROGR EVAL SNGL $117.4048093279 TCPM D E V I CEPROGRE V A L SNG L$ 75.50 480 93285 26 PRGRMG DEV EVAL SCRMS IN PERSON $80.8593285 TCPRGRMG D E V E V A L SCRMS I NPERSON$ 114.09 93288 26 Pm device eval in person $75.5096093288 TCP m d e v i cee v a l in p erso n$ 75.50 480 93288 Pm device eval in person $161.404809329126 I NTERROG D E V E V A L SCRMS I NPERSON$ 75.69 93291 TC INTERROG DEV EVAL SCRMS IN PERSON $82.2693294 PM D E V I CE I NTERROG A TEREMOTE$ 106.10 960 93296 26 REM INTERROG EVL PM/IDS $88.639609329826 REMOTE I NTEROG D E V E V A L SCRMS$ 82.26 93303 26 Echo transthoracic $756.009729330326 M i d l e v e lE c h o t r an s t h or a c i c$ 642.60 972 93303 TTE CONG ABN; COMPLETE $756.004809330426 M i d l e v e lE c h o t r an s t h or a c i c$ 416.80 972 93304 26 Echo transthoracic $490.3597293304 TTECONG A BN; L I M I TE D / F - U P$ 490.35 480 93306 26 Tte w/doppler complete $235.2096093306 Tt e w / d o ppl erco m pl e t e$ 774.90 483 93306 TC Tte w/doppler complete $539.704839330726 M i d l e v e lE c h oe x am o f h e a r t$ 408.75 972 93307 26 Tte w/o doppler complete $480.9096093307 TCTt e w / o d o ppl erco m pl e t e$ 313.95 483 93307 Tte w/o doppler complete $480.904839330826 E c h oe x am o f h e a r t$ 369.60 972 93308 26 Midlevel Echo exam of heart $314.1597293308 TTEF - U POR L MT D$ 369.60 480 93312 26 Echo transesophageal $1, 146.609609331226 M i d l e v e lE c h o t r an seso p ha g e a l$ 974.60 960 93313 26 Midlevel Echo transesophageal $129.409699331326 E c h o t r an seso p ha g e a l$ 152.25 969 93313 ECHO TRANSESOPHAGEAL PROBE PLACE $152.25480 ON L Y 9331426 E c h o t r an seso p ha g e a l$ 1,041.60 960 93314 26 Midlevel Echo transesophageal $885.359609331526 M i d l e v e lE c h o t r an seso p ha g e a l$ 979.95 960 93315 26 Echo transesophageal $1,152.90 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 75 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 93316 26 Midlevel Echo transesophageal $552.459699331626 E c h o t r an seso p ha g e a l$ 649.95 969 93316 TEE CONGENITAL; PROBE PLCMT $649.954809331726 M i d l e v e lE c h o t r an seso p ha g e a l$ 714.00 960 93317 26 Echo transesophageal $840.009609331826 M i d l e v e lE c h o t r an seso p ha g e a l in t r a o p$ 721.15 960 93318 26 Echo transesophageal intraop $848.409609332026 M i d l e v e l Do ppl erec h oe x am, h e a r t$ 166.90 972 93320 26 Doppler echo exam, heart $196.3597293320 D OPP L EREC H O; COMP L ETE$ 196.35 480 93321 26 Doppler echo exam, heart $145.95972 [R o w s 14001 - 15000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D E 9332126 M i d l e v e l Do ppl erec h oe x am, h e a r t$ 124.05 972 93321 DOPPLER ECHO; LIMITED/ F-UP $145.954809332526 M i d l e v e l Do ppl erco l or f l o w a dd - o n$ 118.70 972 93325 26 DOPPLER COLOR FLOW $139.6596093325 TC D OPP L ERCO L ORF L O W$ 126.00 483 93325 DOPPLER COLOR FLOW $139.654839335026 M i d l e v e lE c h o t r an s t h or a c i c$ 641.70 972 93350 26 Echo transthoracic $754.9597293350 STRESSTTEON L Y$ 754.95 480 93351 26 Stress tte complete $318.1596093351 TCSt ress tt eco m pl e t e$ 563.85 483 93351 Stress tte complete $882.0048093355 EC H OTR A NSESOP H A GE A L (TEE)$ 475.00 483 93662 INTRACARDIAC ECG AT OP $303.6048093792 PT / C A REG I V ERTR A I N J H OME I NR$ 115.50 920 93793 Anticoag mgmt init $300.309609388026 M i d l e v e lE x t r a cr ania l s t u d y$ 779.15 972 93880 26 Extracranial study $916.6596093880 C A ROT I DD U P L EXSC A N; B I L A T$ 916.65 921 93880 TC CAROTID DUPLEX SCAN; BILAT $809.559219388226 E x t r a cr ania l s t u d y$ 649.95 972 93882 26 Midlevel Extracranial study $552.4597293882 C A ROT I DD U P L EXSC A N; U N I L / L I M I T$ 649.95 920 93886 26 Midlevel Intracranial study $1, 101.359729388626 I n t r a cr ania l s t u d y$ 1,295.70 972 93886 INTRACRANIAL ARTERY DOPPLER; COMPL $1, 295.709209388826 M i d l e v e l I n t r a cr ania l s t u d y$ 672.95 972 93888 26 Intracranial study $791.7097293888 I NTR A CR A N I A L A RTER Y D OPP L ER; L I M I TE D$ 791.70 920 93890 26 Tcd, vasoreactivity study $1, 035.309729389026 M i d l e v e lT c d, v a sore a c t i v i t ys t u d y$ 880.00 972 93890 Tcd, vasoreactivity study $1, 035.309209389226 M i d l e v e lT c d, e mb o l i d e t ec tw / o inj$ 1,010.30 972 93892 26 Tcd, emboli detect w/o inj $1, 188.6097293892 T c d, e mb o l i d e t ec tw / o inj$ 1,188.60 920 93893 26 Tcd, emboli detect w/inj $1, 200.159729389326 M i d l e v e lT c d, e mb o l i d e t ec tw / inj$ 1,020.15 972 93893 Tcd, emboli detect w/inj $1, 200.159209392226 M i d l e v e lE x t re mi t ys t u d y$ 322.20 972 93922 26 Upr/l xtremity art 2 levels $379.05 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 76 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 93922 Upr/l xtremity art 1-2 levels $379.0592193922 TC U p r / l x t re mi t y a r t 1 - 2 l e v e l s$ 334.95 921 93923 26 Extremity study $586.959729392326 M i d l e v e lE x t re mi t ys t u d y$ 498.90 972 93923 UPR/LXTR ART STDY 3+ LVLS $586.959209392426 M i d l e v e lE x t re mi t ys t u d y$ 627.45 972 93924 26 Extremity study $738.1597293924 L W RXTR V A SCST D Y B I L A T$ 738.15 920 93925 26 Midlevel Lower extremity study $980.859729392526 L o w ere x t re mi t ys t u d y$ 1,153.95 960 93925 TC DUPLEX LE ART/BPG; BILAT $1, 052.1092193925 D U P L EX L E A RT / BPG; B I L A T$ 1,153.95 921 93926 26 Midlevel Lower extremity study $640.809729392626 L o w ere x t re mi t ys t u d y$ 753.90 960 93926 DUPLEX LE ART/BPG; UNIL/LIMIT $753.9092193926 TC D U P L EX L E A RT / BPG; U N I L / L I M I T$ 682.50 921 93930 26 Midlevel Upper extremity study $783.609729393026 U pp ere x t re mi t ys t u d y$ 921.90 960 93930 TC DUPLEX UE ART/BPG; BILAT $838.9592193930 D U P L EX U E A RT / BPG; B I L A T$ 921.90 921 93931 26 Midlevel Upper extremity study $520.359729393126 U pp ere x t re mi t ys t u d y$ 612.15 960 93931 DUPLEX UE ART/BPG; UNIL/LIMIT $612.1592193931 TC D U P L EX U E A RT / BPG; U N I L / L I M I T$ 556.50 921 93970 26 Midlevel Extremity study $806.809729397026 E x t re mi t ys t u d y$ 949.20 960 93970 DUPLEX EXT VEINS; BILAT $949.2092193970 TC D U P L EXEXT V E I NS; B I L A T$ 826.35 921 93971 26 Midlevel Extremity study $479.259729397126 E x t re mi t ys t u d y$ 563.85 960 93971 DUPLEX EXT VEINS; UNIL/LIMIT $563.8592193971 TC D U P L EXEXT V E I NS; U N I L / L I M I T$ 484.05 921 93975 26 Midlevel Vascular study $1, 178.109729397526 Va sc u l a rs t u d y$ 1,386.00 960 93975 TC DUPLEX ARTERIAL FLOW; COMPL $1, 062.6092193975 D U P L EX A RTER I A L F L O W; COMP L$ 1,386.00 921 93976 26 Midlevel Vascular study $673.859729397626 Va sc u l a rs t u d y$ 792.75 960 93976 TC DUPLEX ARTERIAL FLOW; LIMITED $577.5092193976 D U P L EX A RTER I A L F L O W; L I M I TE D$ 792.75 921 93978 26 Midlevel Vascular study $754.159729397826 Va sc u l a rs t u d y$ 887.25 960 93978 DUPLEX A IVC IL/BPG; COMPL $887.2592193978 TC D U P L EX A I V C I L / BPG; COMP L$ 769.65 921 93979 26 Midlevel Vascular study $525.709729397926 Va sc u l a rs t u d y$ 618.45 972 93979 DUPLEX A IVC IL/BPG; UNIL/LIM $618.459209399026 M i d l e v e l Do ppl er f l o wt es t in g$ 668.50 972 93990 26 Doppler flow testing $786.4596093990 D U P L EX H EMO D I A L Y S I S A CCESS$ 786.45 921 93990 TC DUPLEX HEMODIALYSIS ACCESS $741.3092194002 V e n t m g m t in p a t ini t d a y$ 332.85 410 94003 Vent mgmt inpat subq day $238.3541094004 V e n t m g m t n f p er d a y$ 174.30 410 94005 Home vent mgmt supervision $331.809609401026 B re a t hin g c a p a c i t y t es t$ 152.25 960 94010 26 Midlevel Breathing capacity test $129.40 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 77 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 94010 SPIROMETRY, P/P BRONCHODIL $152.2546094011 Sp i ro m e t ry t h r u 2 yrso l d$ 365.40 460 94012 Spirometry w/brnchdil inf thru 2 yrs $577.5046094013 M e a s l u n gv o lt h r u 2 yrs$ 119.70 460 94014 Patient recorded spirometry per 30 days $1, 248.4546094015 P a t i e n t recor d e d s p i ro m e t ry p er 30 d a ys$ 1,030.05 460 94016 26 Midlevel Review patient spirometry $185.659609401626 R e v i e wp a t i e n t s p i ro m e t ry$ 218.40 960 94016 Review patient spirometry per 30 days $218.404609406026 E V A LU A T I ONOF W H EEZ I NG$ 244.65 960 94060 26 Midlevel Evaluation of wheezing $207.95 960 94060 TC BRONCHOSPASM - PRE & POST BD$ 198.45 460 94060 BRONCHOSPASM - PRE & POST BD $244.654609407026 E v a l u a t i o n o f w h eez in g$ 406.35 960 94070 26 Midlevel Evaluation of wheezing $345.4096094070 E V A LU A T I ONOF W H EEZ I NG$ 406.35 460 94150 TOTAL VITAL CAPACITY $118.654609420026 M i d l e v e l Lu n g f u n c t i o n t es t (MBC / M VV)$ 882.70 960 94200 26 Lung function test (MBC/MVV) $1, 038.4596094200 M VV$ 1,038.45 460 94250 26 Midlevel Expired gas collection $882.709609425026 E x p i re d g a sco ll ec t i o n$ 1,038.45 960 94250 Expired gas collection $1, 038.454609437526 R es p i r a t ory f l o w v o l u m e l oo p$ 142.80 960 94375 26 Midlevel Respiratory flow volume loop $121.4096094375 R es p i r a t ory f l o w v o l u m e l oo p$ 142.80 460 94400 26 Midlevel CO2 breathing response curve $882.709609440026 CO 2 b re a t hin g res p o n sec u r v e$ 1,038.45 960 94400 CO2 breathing response curve $1, 038.454609445026 M i d l e v e l Hy p o x ia res p o n sec u r v e$ 1,489.60 960 94450 26 Hypoxia response curve $1, 752.4596094450 Hy p o x ia res p o n sec u r v e$ 1,752.45 460 94452 26 Hast w/report $1, 575.009609445226 M i d l e v e l H a s tw / re p or t$ 1,338.75 960 94452 Hast w/report $1, 575.004609445326 H a s tw / o x y g e n t i t r a t e$ 288.75 960 94453 26 Midlevel Hast w/oxygen titrate $245.4596094453 H a s tw / o x y g e n t i t r a t e$ 288.75 460 94610 26 Surfactant admin thru tube $216.309699461026 M i d l e v e lS u r f a c t an t a d min t h r u t u b e$ 183.85 969 94610 Surfactant admin thru tube $216.304609462126 P u l m s t ress t es t / co m pl e x$ 595.35 960 94621 26 Midlevel Pulm stress test/complex $506.0596094621 P u l m s t ress t es t / co m pl e x$ 595.35 460 94640 Airway inhalation treatment $92.4046094642 A EROSO L PENT A M I D ENFORP . C A R I N II$ 71.40 410 94644 Cbt 1st hour $158.5541094645 C b t e a c ha dd l h o u r$ 51.45 410 94660 26 Midlevel Pos airway pressure, CPAP $167.809699466026 P os ai r w a y p ress u re, CP A P$ 197.40 969 94660 Pos airway pressure cpap $197.404109466226 N e g p ress v e n t i l a t i o n, c n p$ 194.25 969 94662 26 Midlevel Neg press ventilation, cnp $165.1096994662 N e g p ress v e n t i l a t i o n, c n p$ 194.25 410 94664 Evaluate pt use of inhaler $61.9541094667 C H ESTPT; I N I TORE V A L$ 88.20 410 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 78 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 94668 CHEST PT; SUBSEQUENT $86.1041094669 MEC H A N I C A L C H EST W A LL OSC I LL E A$ 372.75 410 SESSION 94680 26 Exhaled air analysis, o2 $216.309609468026 M i d l e v e lE x ha l e d ai r ana l ys i s, o 2$ 183.85 960 94680 Exhaled air analysis, o2 $216.304609468126 E x ha l e d ai r ana l ys i s, o 2/ co 2$ 196.35 960 94681 26 Midlevel Exhaled air analysis, o2/co2 $166.9096094681 E x ha l e d ai r ana l ys i s, o 2/ co 2$ 196.35 460 94690 26 Midlevel Exhaled air analysis $160.659609469026 E x ha l e d ai r ana l ys i s$ 189.00 960 94690 Exhaled air analysis $189.0046094729 C 0 D I FF U SEC A P A C I T Y$ 106.05 460 94750 26 Pulmonary compliance study $4.209609475026 M i d l e v e lP u l m o na ryco m pl ian ces t u d y$ 3.20 960 94750 Pulmonary compliance study $272.6546094760 P UL SEOXSG L$ 24.15 460 94761 O2 SATURATION, MULTIPLE $22.0546094762 O 2 S A T U R A T I ON, CONT I N U O U S$ 89.25 460 94770 26 Exhaled carbon dioxide test $56.709699477026 M i d l e v e lE x ha l e d c a r b o n d i o x i d e t es t$ 48.20 969 94770 CO EXPIRED GAS BY IR $56.7046094780 C A RSE A T / BE D TEST 60 M I N$ 63.60 410 94781 CAR SEAT/BED TEST + 30 MIN $17.6541094799 U N L I STE D P UL MON A R Y SER V I CE$ 272.65 460 95800 TC SLP STOY UNATND W/HRT RATE/02 $418.65 S A T / RESP / S L PT I ME 9580026 S L PSTO Y U N A TN D W / H RTR A TE /02$ 224.25 SAT/RESP/SLP TIME 95801 TC SLP STOY UNATND W/MIN HRT RATE/02 $335.85 S A T / RESP A N A L 9580126 S L PST D Y U N A TN D W / M I N H RTR A TE /02$ 224.25 SAT/RESP ANAL 95806 26 SLEEP STD AIRFLOW HRT RATE&02 SAT $493.65 EFFORT U N A T I 9580826 PO L Y SOM A N Y A GE 1 - 3 > P A R A M$ 348.63 95810 26 POLYSOM 6/> YRS 4/> PARAM $508.7495810 TCPO L Y SOM 6/ > Y RS 4/ > P A R A M$ 2,759.46 95811 TC POLYSOM 6/>YRS CPAP 4/> PARM $2, 759.469581126 PO L Y SOM 6/ > Y RSCP A P 4/ > P A RM$ 525.03 95812 26 Eeg, 41-60 minutes $1, 333.509609581226 M i d l e v e lE e g, 41 - 60 min u t es$ 1,133.50 960 95812 Eeg, 41-60 minutes $1, 333.507409581326 M i d l e v e lE e g, o v er 1 h o u r$ 1,313.75 960 95813 26 Eeg, over 1 hour $1, 545.6096095813 E e g, o v er 1 h o u r$ 1,545.60 740 95816 26 Eeg, awake and drowsy $1, 225.359609581626 M i d l e v e lE e g, a w ak e an dd ro w sy$ 1,041.55 960 95816 Eeg, awake and drowsy $1, 225.357409581926 M i d l e v e lE e g, a w ak e an d a s l ee p$ 1,182.55 960 95819 26 Eeg, awake and asleep $1, 391.2596095819 E e g, a w ak e an d a s l ee p$ 1,391.25 740 95827 26 Eeg, all night recording $2, 440.209609582726 M i d l e v e lE e g, a ll ni g h t recor d in g$ 2,074.15 960 95827 Eeg, all night recording $2, 440.2074095830 I n ser t e l ec t ro d es f or EEG$ 313.95 983 95831 26 Limb muscle testing, manual $78.75 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 79 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 95831 26 Midlevel Limb muscle testing, manual $66.9596995831 M U SC L ETEST; EXTREMORTR U N K$ 78.75 920 95832 26 Hand muscle testing, manual $81.909699583226 M i d l e v e l H an d m u sc l e t es t in g, man u a l$ 69.60 969 95832 Hand muscle testing, manual $81.909209583326 M i d l e v e lB o d y m u sc l e t es t in g, man u a l$ 70.50 969 95833 26 Body muscle testing, manual $82.9596995833 M U SC L ETEST; TOTBO D YW O H A N D S$ 82.95 920 95834 26 Body muscle testing, manual $114.459699583426 M i d l e v e lB o d y m u sc l e t es t in g, man u a l$ 97.30 969 95834 MUSCLE TEST; TOT BODY W HANDS $114.459209585126 R an g eo f m o t i o nm e a s u re m e n t s$ 30.45 969 95851 26 Midlevel Range of motion measurements $25.9096995851 ROM; E A EXTREMTTR U N K (NOT H A N D)$ 30.45 920 95852 26 Range of motion measurements $29.409699585226 M i d l e v e lR an g eo f m o t i o nm e a s u re m e n t s$ 25.00 969 95852 ROM MEASURE & REP; HAND $29.409209585726 T e n s i l o n t es t$ 113.40 969 95857 26 Midlevel Tensilon test $96.4096995857 T e n s i l o n t es t$ 113.40 920 95860 26 Muscle test, one limb $348.609609586026 M i d l e v e lM u sc l e t es t, o n e l imb$ 296.30 960 95860 Muscle test, one limb $348.609209586126 M i d l e v e lM u sc l e t es t, 2 l imb s$ 431.10 960 95861 26 Muscle test, 2 limbs $507.1596095861 M u sc l e t es t, 2 l imb s$ 507.15 920 95863 26 Muscle test, 3 limbs $613.209609586326 M i d l e v e lM u sc l e t es t, 3 l imb s$ 521.20 960 95863 Muscle test, 3 limbs $613.209209586426 M i d l e v e lM u sc l e t es t, 4 l imb s$ 564.95 960 95864 26 Muscle test, 4 limbs $664.6596095864 M u sc l e t es t, 4 l imb s$ 664.65 920 95865 26 Midlevel Muscle test, larynx $383.809609586526 M u sc l e t es t, l a ry n x$ 451.50 960 95865 Muscle test, larynx $451.509209586626 M i d l e v e lM u sc l e t es t, h e mi d ia p h r a g m$ 343.60 960 95866 26 Muscle test, hemidiaphragm $404.2596095866 M u sc l e t es t, h e mi d ia p h r a g m$ 404.25 920 95867 26 Midlevel Muscle test cran nerv unilat $282.909609586726 M u sc l e t es t cr ann er vu ni l a t$ 332.85 960 95867 Muscle test cran nerv unilat $332.859209586826 M i d l e v e lM u sc l e t es t cr ann er v e bi l a t$ 378.40 960 95868 26 Muscle test cran nerve bilat $445.2096095868 M u sc l e t es t cr ann er v e bi l a t$ 445.20 920 95869 26 Midlevel Muscle test, thor paraspinal $210.659609586926 M u sc l e t es t, t h or p a r a s p ina l$ 247.80 960 95869 Muscle test, thor paraspinal $247.809209587026 M i d l e v e lM u sc l e t es t, n o n p a r a s p ina l$ 201.70 960 95870 26 Muscle test, nonparaspinal $237.3096095870 M u sc l e t es t, n o n p a r a s p ina l$ 237.30 920 95872 26 Midlevel Muscle test, one fiber $572.109609587226 M u sc l e t es t, o n e f ib er$ 673.05 960 95872 Muscle test, one fiber $673.059209587326 G u i d e n er v d es t r, e l ecs t im$ 242.55 960 95873 26 Midlevel Guide nerv destr, elec stim $206.1596095873 G u i d e n er v d es t r, e l ecs t im$ 242.55 920 95874 26 Guide nerv destr, needle emg $229.95 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 80 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 95874 26 Midlevel Guide nerv destr, needle emg $195.4596095874 G u i d e n er v d es t r, n ee d l ee m g$ 229.95 920 95875 26 Limb exercise test $406.359609587526 M i d l e v e l L imb e x erc i se t es t$ 345.40 960 95875 Limb exercise test $406.359209588526 M u sc t s t d o n e w / n er v t s tl im$ 64.05 960 95885 TC Musc tst done w/nerv tst lim $138.6092095885 M u sc t s t d o n e w / n er v t s tl im$ 202.65 920 95886 26 Musc test done w/n test comp $172.2096095886 M u sc t es t d o n e w / n t es t co m p$ 318.15 920 95886 TC Musc test done w/n test comp $145.959209588726 M u sc t s t d o n e w / n t s t n o n e x t$ 134.40 960 95887 Musc tst done w/n tst nonext $283.5092095887 TCM u sc t s t d o n e w / n t s t n o n e x t$ 148.05 920 95905 26 Motor/sens nrve conduct test $9.4596095905 M o t or / se n s n r v eco n d u c tt es t$ 244.65 920 95905 TC Motor/sens nrve conduct test $235.209209590726 N V RCN D J TST 1 - 2 ST U D I ES$ 102.75 983 95907 NVR CNDJ TST 1-2 STUDIES $102.759229590826 NR V CN D J TST 3 - 4 ST U D I ES$ 137.40 983 95908 NRV CNDJ TST 3-4 STUDIES $137.409229590926 NR V CN D J TST 5 - 6 ST U D I ES$ 163.80 983 95909 NRV CNDJ TST 5-6 STUDIES $163.809229591026 NR V CN D J TEST 7 - 8 ST U D I ES$ 212.50 983 95910 NRV CNDJ TEST 7-8 STUDIES $212.509229591126 NR V CN D J TEST 9 - 10 ST U D I ES$ 239.70 983 95911 NRV CNDJ TEST 9-10 STUDIES $239.709229591226 NR V CN D J TEST 11 - 12 ST U D I ES$ 241.40 983 95912 NRV CNDJ TEST 11-12 STUDIES $241.409229591326 NR V CN D J TEST 13/ > ST U D I ES$ 266.95 983 95913 NRV CNDJ TEST 13/> STUDIES $266.959229592126 A u t o n o mi c n er v f u n c t i o n t es t$ 305.55 960 95921 26 Midlevel Autonomic nerv function test $259.7096095921 A U TONOM I CNER V F U NCT I ONTEST$ 305.55 920 CARDIOVAGAL 95922 26 Midlevel Autonomic nerv function test $325.759609592226 A u t o n o mi c n er v f u n c t i o n t es t$ 383.25 960 95922 AUTONOMIC NERV FUNCTION TEST $383.25920 V A SOMOTOR 9592326 A u t o n o mi c n er v f u n c t i o n t es t$ 574.35 960 95923 26 Midlevel Autonomic nerv function test $488.2096095923 A U TONOM I CNER V F U NCT I ONTEST$ 574.35 920 SUDOMOTOR 95925 26 Somatosensory testing $604.809609592526 M i d l e v e lS o ma t ose n sory t es t in g$ 514.10 960 95925 SLS-EPS; PERIPH NRV; UP LIMBS $604.809209592626 S o ma t ose n sory t es t in g$ 586.95 960 95926 26 Midlevel Somatosensory testing $498.9096095926 S L S - EPSPER I P H NR V; L W R L I MBS$ 586.95 920 95927 26 Midlevel Somatosensory testing $505.159609592726 S o ma t ose n sory t es t in g$ 594.30 960 95927 SLS-EPS PERIPH NRV; TRUNK/HD $594.309209592826 M i d l e v e lC m o t ore v o k e d, u pp r l imb s$ 788.10 960 95928 26 C motor evoked, uppr limbs $927.1596095928 C m o t ore v o k e d, u pp r l imb s$ 927.15 920 95929 26 Midlevel C motor evoked, lwr limbs $800.559609592926 C m o t ore v o k e d, lw r l imb s$ 941.85 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 81 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 95929 C motor evoked, lwr limbs $941.859209593026 Vi s u a l e v o k e d p o t e n t ia lt es t$ 654.15 960 95930 26 Midlevel Visual evoked potential test $556.0596095930 Vi s u a l e v o k e d p o t e n t ia lt es t$ 654.15 920 95933 26 Midlevel Blink reflex test $249.909609593326 Bl ink re f l e x t es t$ 294.00 960 95933 Blink reflex test $294.009209593726 N e u ro m u sc u l a r j u n c t i o n t es t$ 252.00 960 95937 26 Midlevel Neuromuscular junction test $214.2096095937 NE U ROM U SC UL A R J U NCT I ONTESTE A$ 252.00 920 NERVE 95938 26 Somatosensory testing $158.5596095938 S o ma t ose n sory t es t in g$ 1,075.20 920 95938 TC Somatosensory testing $916.65 920 95939 26 C motor evoked upr&lwr limbs$ 416.85 960 95939 TC C motor evoked upr&lwr limbs $1,265.25 920 95939 C motor evoked upr&lwr limbs$ 1,683.15 920 95950 Ambulatory eeg monitoring $1, 083.609839595026 M i d l e v e l A mb u l a t oryee g m o ni t or in g$ 921.05 960 95950 26 Ambulatory eeg monitoring $1, 083.6096095951 EEG m o ni t or in g / v i d eorecor d$ 2,646.00 983 95951 26 EEG monitoring/videorecord $2, 646.009609595126 M i d l e v e lEEG m o ni t or in g / v i d eorecor d$ 2,249.10 960 95953 EEG monitoring/computer $1, 561.359839595326 M i d l e v e lEEG m o ni t or in g / co m p u t er$ 1,327.15 960 95953 26 EEG monitoring/computer $1, 561.3596095954 EEG m o ni t or in g / g i v in g d r ug s$ 1,475.25 983 95954 26 Midlevel EEG monitoring/giving drugs $1, 253.959609595426 EEG m o ni t or in g / g i v in g d r ug s$ 1,475.25 960 95955 EEG during surgery $705.609839595526 M i d l e v e lEEG d u r in g s u r g ery$ 599.75 960 95955 26 EEG during surgery $705.6096095956 E e g m o ni t or in g, c ab l e / r a d i o$ 4,286.10 983 95956 26 Midlevel Eeg monitoring, cable/radio $3, 643.209609595626 E e g m o ni t or in g, c ab l e / r a d i o$ 4,286.10 960 95957 EEG digital analysis $1, 405.959839595726 M i d l e v e lEEG d i g i t a l ana l ys i s$ 1,195.05 960 95957 26 EEG digital analysis $1, 405.9596095958 EEG m o ni t or in g / f u n c t i o n t es t$ 1,800.75 983 95958 26 Midlevel EEG monitoring/function test $1, 530.659609595826 EEG m o ni t or in g / f u n c t i o n t es t$ 1,800.75 960 96040 Genetic counseling 30 min $168.005109610126 P syc h o t es t in g b y p syc h / p h ys$ 162.70 961 96101 Psycho testing by psych/phys 1 hr $277.209189610226 P syc h o t es t in g b y t ec hni c ian$ 48.90 961 96102 Psycho testing by technician 1 hr $81.909189610326 P syc h o t es t in g a d minb yco m p$ 55.00 961 96103 Psycho testing admin by comp $88.2091896105 A P H A S I AA SSESMENTPER H R$ 369.60 920 96110 Developmental screen $35.7042096111 De v e l o p m e n t a lt es t e x t e n d$ 431.55 420 96116 26 Neurobehavioral status exam $176.8096196116 N e u ro b e ha v i or a l s t a t u se x am 1 h r$ 303.45 918 96118 26 Neuropsych tst by psych/phys $161.1096196118 N e u ro p syc h t s t b y p syc h / p h ys 1 h r$ 275.10 918 96119 26 Neuropsych testing by tec $48.80 961 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 82 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 96119 Neuropsych testing by tech 1 hr $81.909189612026 N e u ro p syc h t s t a d min w / co m p$ 53.75 961 96120 Neuropsych tst admin w/comp $88.2091896125 C o g ni t i v e t es t b y h c p ro 1 h r$ 360.15 440 96150 26 Assess hlth/behave init $43.5096196150 A SSESS H L T H / BE H A V EE A 15 M I NS I N I T$ 73.50 900 96151 26 Assess hlth/behave subseq $42.1096196151 A SSESS H L T H / BE H A V EE A 15 M I NSS U BSEQ$ 70.35 900 96152 26 Intervene hlth/behave indiv $39.8096196152 I NTER V ENE H L T H / BE H A V EE A 15 M I NS$ 67.20 900 INDIV 96153 26 Intervene hlth/behave group $8.5096196153 I NTER V ENE H L T H / BE H A V EE A 15 M I NS$ 15.75 900 GROUP 96154 26 Interv hlth/behav fam w/pt $38.2596196154 I NTER V H L T H / BE H A V E A 15 M I NSF A M W / PT$ 65.10 900 96155 26 Interv hlth/behav fam no pt $- 96196155 I NTER V H L T H / BE H A V E A 15 M I NSF A MNOPT$ 80.85 900 96160 Health risk assessment test $38.8545096360 H Y D R A T I ON I V I NF U S I ON I N I T 31 - 60 M I NS$ 207.90 260 96361 Hydrate iv infusion add-on 1 hr $55.6526096365 T H ER / PROP H / D I A G I V I NF I N I T =< 1 H R$ 263.55 260 96366 THER/PROPH/DIAG IV INF ADDON 1 HR $77.7026096367 T x / p ro p h / d g a dd l se q i v in f <= 1 h r$ 117.60 260 96368 Ther/diag concurrent inf $69.3026096369 S c t h er in f u s i o n u pt o 1 h r$ 680.40 260 96370 SC THER INFUSION ADDL HR $56.7026096371 S c t h er in f u s i o n rese tp u m p$ 312.90 260 96372 Ther/proph/diag inj sc/im $88.2026096373 T h er / p ro p h / d ia g injia$ 71.40 260 96374 Ther/proph/diag inj iv push $202.6526096375 T x / p ro / d x injn e w d r ug a dd o n$ 81.90 260 96376 TX/PRO/DX INJ SAME DRUG ADDON $61.9526096401 C h e m o an t i - n eo pl s q / im$ 630.00 331 96402 Chemo hormon antineopl sq/im $630.0033196405 C h e m o in t r a l es i o na l, u pt o 7$ 630.00 331 96406 Chemo intralesional over 7 $630.0033196409 C H EMO I V P U S H SNG L D R U G$ 1,470.00 331 96411 Chemo iv push addl drug $1, 470.0033196413 C h e m o i v in f u s i o n <= 1 h r$ 2,305.00 335 96415 Chemo iv infusion addl hr $735.0033596416 C H EMOPRO L ONG 8 + H RS I NF U SE W / P U MP$ 2,200.00 335 96417 CHEMO IV INFUS EACH ADDL SEQ =<1 HR $735.0033596420 C h e m o, ia, p u s h t ec ni q u e$ 1,584.45 331 96422 Chemo ia infusion up to 1 hr $624.7533596423 C h e m o iain f u see a c ha dd l h r$ 286.65 335 96425 CHEMO IA; INFUSION; > 8 HRS $2, 109.4533596440 C H EMO - P L E U R A L C A VW T H OR A C$ 2,109.45 335 96446 Chemotx admn prtl cavity $76.6533196450 C h e m o t h er a p y, in t o CNS$ 2,109.45 331 96521 Refill/maint portable pump $506.3526096522 R e f i ll / main tp u m p / res v rsys t$ 409.85 260 96523 Irrig drug delivery device $90.4033596542 C H EMO I N J V I A SQRESER V O I R$ 630.00 331 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 83 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 96567 Photodynamic tx skin $496.6536096570 P h o t o d y nm c t x 30 mina dd - o n$ 210.00 360 96571 Photodynamic tx addl 15 min $96.6036096900 U lt r a v i o l e tl i g h tt h er a p y$ 77.70 940 96902 MICRO EXAM OF HAIRS $75.6094096904 Wh o l e b o d y p h o t o g r a p h y$ 258.30 920 96910 Photochemotherapy with UV-B $262.5094096912 P h o t oc h e m o t h er a p y w i t h U V - A$ 337.05 940 96913 Photochemotherapy uv-a or b >=4 hrs $469.3594096920 L a ser t x s kin < 250 s q c m$ 242.55 940 96921 Laser tx skin 250-500 sq cm $243.6094096922 L a ser t x s kin > 500 s q c m$ 437.85 940 97010 Hot or cold packs therapy $21.0042097012 MEC H A N I C A L TR A CT I ONT H ER A P Y 1 +$ 56.70 420 AREAS 97014 ELECTRIC STIMULATION THERAPY 1+ $55.65420 A RE A S 97016 Va so p n e u ma t i c d e v i ce t h er a p y$ 67.20 420 97018 Paraffin bath therapy $36.7542097022 W H I R L POO L T H ER A P Y 1 + A RE A S$ 80.85 420 97024 Diathermy eg, microwave $23.1042097026 I NFR A RE D T H ER A P Y 1 + A RE A S$ 21.00 420 97028 ULTRAVIOLET THERAPY 1+ AREAS $78.7542097032 El ec t r i c a l s t im u l a t i o n p er 15 min$ 67.20 420 97033 Electric current therapy per 15 min $111.3042097034 CONTR A STB A T H T H ER A P Y E A 15 M I NS$ 61.95 420 97035 Ultrasound therapy per 15 min $44.1042097036 Hy d ro t h er a p y p er 15 min$ 112.35 420 97039 Physical therapy treatment, unlisted $40.9542097110 T h er a p e u t i ce x erc i ses p er 15 min$ 111.30 420 97112 Neuromuscular reeducation per 15 min $116.5542097113 A q u a t i c t h er a p y / e x erc i ses p er 15 min$ 148.05 420 97116 Gait training therapy per 15 min $98.7042097124 M a ss a g e t h er a p y p er 15 min$ 91.35 420 97139 Physical medicine procedure, unlisted $- 42097140 M an u a lt h er a p y p er 15 min$ 103.95 420 97150 Group therapeutic procedures $71.4042097161 PTE V A LL O W COMP L EX 20 M I N$ 181.95 424 97162 PT EVAL MODERATE COMPLEX 30 MIN $181.9542497163 PTE V A L H I G H COMP L EX 45 M I N$ 181.95 424 97164 PT RE-EVAL EST PLAN CARE $148.0542497165 OCC U P A T I ON A L T H ER A P Y E V A LL O W$ 328.95 COMPLEX 30 MIN 97166 OCCUPATIONAL THERAPY EVAL HIGH $328.95 COMP L EX 45 M I NS 97167 OCC U P A T I ON A L T H ER A P Y E V A L H I G H$ 328.95 COMPLEX 60 MINS 97168 OCCUPATIONAL THER RE-EVAL EST PLAN $228.06 C A RE 30 M I N 97530 T h er a p e u t i c a c t i v i t i es p er 15 min$ 122.85 420 97533 Sensory integration per 15 min $102.9042097535 S e l f c a re mn g m e n tt r ainin g p er 15 min$ 120.75 420 97537 COMMUNITY/WORK REINTEGRATION PER 15 $105.00420 M I N 97542 W H EE L C H A I RMNGMENTTR A I N I NGE A 15$ 108.15 420 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 84 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION MINS 97597 Rmvl devital tis 20 cm/< $236.2598397597 R m v l d e v i t a lt i s 20 c m / <$ 236.25 420 97598 Rmvl devital tis addl 20 cm< $257.2598397598 R m v l d e v i t a lt i s a dd l 20 c m <$ 257.25 420 97602 Wound(s) care non-selective per session $315.0042097605 N e g p ress w o u n d t x, <= 50 s q c m$ 97.65 420 97606 Neg press wound tx, > 50 cm $108.1542097750 P h ys i c a lp er f or man ce t es tp er 15 min$ 117.60 420 97755 Assistive technology assess per 15 min $127.0542097760 O r t h o t i c m g m t an d t r ainin g p er 15 min$ 133.35 420 97761 Prosthetic training per 15 min $116.5542097763 ORT H C / PROSTCMGMTSBSQENC$ 160.65 420 97799 Physical medicine procedure, unlisted $- 42097802 I N I TN U TR I T I ONT H ER A P Y; E A C H 15 M$ 115.50 942 97803 RE-ASSESS NUTRITION THER; EA 15M $98.7094297804 GRPN U TR I T I ONT H ER A P Y; E A 30 M$ 53.55 942 97810 Acupunct w/o stimul 15 min $110.2537497811 A c u p u n c tw / os t im u l a dd l 15 m$ 90.30 374 97813 Acupunct w/stimul 15 min $118.6537497814 A c u p u n c tw / s t im u l a dd l 15 m$ 101.85 374 98925 OSTEOPATHIC MANIPULATION 1-2 BODY $84.00530 REG I ONS 98926 OSTEOP A T H I CM A N I P UL A T I ON 3 - 4 BO D Y$ 126.00 530 REGIONS 98927 OSTEOPATHIC MANIPULATION 5-6 BODY $166.95530 REG I ONS 98928 OSTEOP A T H I CM A N I P UL A T I ON 7 - 8 BO D Y$ 212.10 530 REGIONS 98929 OSTEOPATHIC MANIPULATION 9-10 BODY $254.10530 REG I ONS 98940 C H I ROPR A CT I CM A N I P UL A T I ON 1 - 2$ 75.60 940 REGIONS 98941 CHIROPRACTIC MANIPULATION 3-4 $111.30940 REG I ONS 98942 C H I ROPR A CT I CM A N I P UL A T I ON 5 REG I ONS$ 147.00 940 98943 CHIRO MANIPULATION EXTRASPINAL 1+ $74.55 940 REGIONS 98960 Self-mgmt educ & train, 1 pt 30 min$ 535.50 942 98961 Self-mgmt educ/train, 2-4 pt 30 min $220.5094298962 S e l f - m g m t e d u c / t r ain, 5 - 8 pt 30 min$ 219.45 942 98966 Hc pro phone call 5-10 min $44.1096098967 Hc p ro p h o n ec a ll 11 - 20 min$ 90.30 960 98968 Hc pro phone call 21-30 min $137.5596099000 SPEC I MEN H A N D L I NGOFF I CE - L A B$ 52.50 300 99001 SPECIMEN HANDLING PT-LAB $63.0030099024 P os t o p f o ll o w - u p v i s i t$ 63.00 960 99026 In-hospital on call service 1 hr $31.5094099027 O u t - o f - h os p o n c a ll ser v i ce 1 h r$ 42.00 940 99050 Medical services after hrs $73.5096099051 M e d ser v e v e / w k e n d / h o l i d a y$ 42.00 969 99056 Med service out of office $42.0096099058 O ff i cee m er g e n cyc a re$ 63.00 960 99075 Medical testimony $630.0096099078 G ro u p h e a lt h e d u c a t i o n$ 52.50 942 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 85 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99080 Special reports or forms $73.5096099082 U n u s u a lp h ys i c ian t r a v e l$ 42.00 983 99090 Computer data analysis $84.0096099091 C o ll ec t / re v i e w d a t a f ro m pt >= 30 min$ 200.55 456 99100 Special anesthesia service $105.0096399116 A n es t h es ia w i t hh y p o t h er mia$ 472.50 963 99135 Special anesthesia procedure $315.0096399140 E m er g e n cy an es t h es ia$ 183.75 963 99151 MOD SED SAME PHYS/QHP <5 YRS $183.7537099152 MO D SE D S A MEP H Y S / Q H P 5/ > Y RS$ 194.25 370 99153 MOD SED SAME PHYS/QHP EA 15 MIN ADD $89.25370 ON 99155 M o d cs d i ff p h ys < 5 yrs$ 316.40 370 99156 MOD SED OTH PHYS/QHP 5/>YRS $178.5037099157 M o d cs d i ff p h ys 5 yrs + 15 min$ 178.50 370 99170 ANOGENITAL EXAM CHILD W IMAG $323.4092099172 O c u l a r f u n c t i o n scree n$ 40.95 920 99173 Visual acuity screen $42.0092099174 O c u l a r p h o t oscree nin g$ 105.00 920 99175 IPECAC ADMINISTRATION $429.4545099183 Hy p er ba r i co x y g e n t h er a p y$ 434.70 960 99190 PUMP W OXYGENAT/HEATEXCHAN; EA HR $945.0048099191 SPEC I A L P U MPSER V I CES 45 M I NS$ 735.00 480 99192 SPECIAL PUMP SERVICES 30 MINS $420.0048099195 P H L EBOTOM Y T H ER A PE U T I C$ 339.15 940 99199 UNLISTED SPECIAL SERVICE OR REPORT $5.259409920126 PROFEEOFF I CEO U TPTNE W L V L 1$ 94.50 983 99201 26 Midlevel Office/outpatient visit, new $80.3596999201 L ab or C h ec k / O u tp a t i e n tN e w L e v e l 1$ 57.75 769 99201 Office/outpatient visit new $57.755109920226 O ff i ce / o u tp a t i e n t v i s i t n e w$ 178.50 983 99202 26 Midlevel Office/outpatient visit, new $151.7096999202 L ab or C h ec k / O u tp a t i e n tN e w L e v e l 2$ 68.25 769 99202 Office/outpatient visit new $68.255109920326 O ff i ce / o u tp a t i e n t v i s i t n e w$ 271.95 983 99203 26 Midlevel Office/outpatient visit, new $231.1596999203 L ab or C h ec k / O u tp a t i e n tN e w L e v e l 3$ 89.25 769 99203 Office/outpatient visit new $89.255109920426 O ff i ce / o u tp a t i e n t v i s i t n e w$ 462.00 983 99204 26 Midlevel Office/outpatient visit, new $392.7096999204 L ab or C h ec k / O u tp a t i e n tN e w L e v e l 4$ 120.75 769 99204 Office/outpatient visit new $120.755109920526 O ff i ce / o u tp a t i e n t v i s i t n e w$ 591.15 983 99205 26 Midlevel Office/outpatient visit, new $502.5096999205 L ab or C h ec k / O u tp a t i e n tN e w L e v e l 5$ 183.75 769 99205 Office/outpatient visit new $183.755109921126 O ff i ce / o u tp a t i e n t v i s i t es t$ 68.25 983 99211 FP Family planning supply visit $19.209699921126 M i d l e v e lO ff i ce / o u tp a t i e n t v i s i t, es t$ 58.00 969 99211 Labor Check/Outpatient Established Level 1 $57.7576999211 O ff i ce / o u tp a t i e n t v i s i t es t$ 57.75 510 99211 MEDICINE REFILL, NO FACE-TO-FACE $68.25 510 99211 BP CHECK, NO E&M DONE$ 68.25 510 99212 26 Office/outpatient visit est $91.359839921226 M i d l e v e lO ff i ce / o u tp a t i e n t v i s i t, es t$ 77.65 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 86 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99212 Labor Check/Outpatient Established Level 2 $68.2576999212 O ff i ce / o u tp a t i e n t v i s i t es t$ 68.25 510 99213 26 Office/outpatient visit est $180.609839921326 M i d l e v e lO ff i ce / o u tp a t i e n t v i s i t, es t$ 153.50 969 99213 Labor Check/Outpatient Established Level 3 $89.2576999213 O ff i ce / o u tp a t i e n t v i s i t es t$ 89.25 510 99214 26 Office/outpatient visit est $277.209839921426 M i d l e v e lO ff i ce / o u tp a t i e n t v i s i t, es t$ 235.60 969 99214 Labor Check/Outpatient Established Level 4 $120.7576999214 O ff i ce / o u tp a t i e n t v i s i t es t$ 120.75 510 99215 26 Office/outpatient visit est $389.559839921526 M i d l e v e lO ff i ce / o u tp a t i e n t v i s i t, es t$ 331.10 969 99215 Labor Check/Outpatient Established Level 5 $183.7576999215 O ff i ce / o u tp a t i e n t v i s i t es t$ 183.75 510 99217 26 Midlevel Observation care discharge $216.909699921726 O b ser v a t i o n c a re d i sc ha r g e$ 255.15 960 99218 26 Midlevel Observation care $290.959699921826 O b ser v a t i o n c a re$ 342.30 969 99218 Initial observation care per day low level $342.307629921926 M i d l e v e lO b ser v a t i o n c a re$ 400.75 969 99219 26 Observation care $471.4596999219 I ni t ia l o b ser v a t i o n c a re p er d a y m o d er a t e l e v e l$ 471.45 762 99220 26 Observation care $646.809699922026 M i d l e v e lO b ser v a t i o n c a re$ 549.80 969 99220 Initial observation care per day high level $646.807629922126 I ni t ia l h os p i t a l c a re$ 358.05 987 99221 26 Midlevel Initial hospital care $304.359699922226 I ni t ia l h os p i t a l c a re$ 484.05 987 99222 26 Midlevel Initial hospital care $411.459699922326 I ni t ia l h os p i t a l c a re$ 709.80 987 99223 26 Midlevel Initial hospital care $603.359699922426 S u b se q u e n t o b ser v a t i o n c a re$ 140.70 987 99225 26 Subsequent observation care $255.159879922626 S u b se q u e n t o b ser v a t i o n c a re$ 366.45 987 99231 26 Subsequent hospital care $138.609879923126 M i d l e v e lS u b se q u e n t h os p i t a l c a re$ 117.80 969 99232 26 Subsequent hospital care $254.109879923226 M i d l e v e lS u b se q u e n t h os p i t a l c a re$ 216.00 969 99233 26 Subsequent hospital care $363.309879923326 M i d l e v e lS u b se q u e n t h os p i t a l c a re$ 308.80 969 99234 26 Midlevel Observ/hosp same date $406.109699923426 O b ser v / h os p s am e d a t e$ 477.75 960 99235 26 Midlevel Observ/hosp same date $508.759699923526 O b ser v / h os p s am e d a t e$ 598.50 960 99236 26 Midlevel Observ/hosp same date $655.109699923626 O b ser v / h os p s am e d a t e$ 770.70 960 99238 26 Hospital discharge day $254.109879923826 M i d l e v e l Hos p i t a l d i sc ha r g e d a y$ 216.00 969 99239 26 Hospital discharge day $374.859879923926 M i d l e v e l Hos p i t a l d i sc ha r g e d a y$ 318.60 969 99241 26 Office consultation $117.609889924126 M i d l e v e lO ff i ceco n s u lt a t i o n$ 99.95 960 99241 Office consultation $117.605109924226 O ff i ceco n s u lt a t i o n$ 245.70 988 99242 26 Midlevel Office consultation $208.8596099242 O ff i ceco n s u lt a t i o n$ 245.70 510 99243 26 Office consultation $342.30 988 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 87 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99243 26 Midlevel Office consultation $290.9596099243 O ff i ceco n s u lt a t i o n$ 342.30 510 99244 26 Office consultation $541.809889924426 M i d l e v e lO ff i ceco n s u lt a t i o n$ 460.55 960 99244 Office consultation $541.805109924526 O ff i ceco n s u lt a t i o n$ 673.05 988 99245 26 Midlevel Office consultation $572.1096099245 O ff i ceco n s u lt a t i o n$ 673.05 510 99251 26 Inpatient consultation $172.209889925126 M i d l e v e l I n p a t i e n t co n s u lt a t i o n$ 146.35 960 99252 26 Inpatient consultation $264.609609925226 M i d l e v e l I n p a t i e n t co n s u lt a t i o n$ 224.90 960 99253 26 Inpatient consultation $403.209889925326 M i d l e v e l I n p a t i e n t co n s u lt a t i o n$ 342.70 960 99254 26 Inpatient consultation $581.709609925426 M i d l e v e l I n p a t i e n t co n s u lt a t i o n$ 494.45 960 99255 26 Inpatient consultation $702.459609925526 M i d l e v e l I n p a t i e n t co n s u lt a t i o n$ 597.10 960 99281 26 Midlevel Emergency dept visit $106.059819928126 E m er g e n cy d e pt v i s i t$ 124.95 981 99281 Emergency dept visit $111.104509928226 E m er g e n cy d e pt v i s i t$ 154.35 981 99282 26 Midlevel Emergency dept visit $130.9098199282 E m er g e n cy d e pt v i s i t$ 130.90 450 99283 26 Emergency dept visit $270.909819928326 M i d l e v e lE m er g e n cy d e pt v i s i t$ 229.90 981 99283 Emergency dept visit $229.904509928426 M i d l e v e lE m er g e n cy d e pt v i s i t$ 436.70 981 99284 26 Emergency dept visit $513.4598199284 E m er g e n cy d e pt v i s i t$ 436.70 450 99285 26 Midlevel Emergency dept visit $640.209819928526 E m er g e n cy d e pt v i s i t$ 752.85 981 99285 Emergency dept visit $640.204509929126 M i d l e v e lC r i t i c a l c a re, f i rs t h o u r$ 827.20 981 99291 26 Critical care first hour $973.3598199291 CR I T I C A L C A RE 1 ST 30 - 74 M I N$ 789.60 450 99292 26 Midlevel Critical care, add’l 30 min $640.509819929226 C r i t i c a l c a re a dd l 30 min$ 753.90 981 99292 Critical care addl 30 min $640.504509934126 M i d l e v e l Ho m e Vi s i t, St r ai g h t f or w a r d, N e w$ 166.90 969 99341 26 Home Visit, Straight forward, New $196.359699934226 Ho m e Vi s i t, L o w co m pl e x i t y, N e w$ 285.60 969 99342 26 Midlevel Home Visit, Low complexity, New $242.759699934326 M i d l e v e l Ho m e Vi s i t, M o d er a t e, N e w$ 397.15 969 99343 26 Home Visit,Moderate, New $467.259699934426 Ho m e Vi s i t, C o m p re h e n s i v e, N e w$ 640.50 969 99344 26 Midlevel Home Visit,Comprehensive, New $544.459699934526 M i d l e v e l Ho m e Vi s i t, C o m p . H i g h co m pl e x i t y, N e w$ 650.65 969 99345 26 Home Visit,Comp. High complexity, New $765.459699934726 Ho m e Vi s i t, EST, p ro b l e m f oc u se d$ 198.45 969 99347 26 Midlevel Home Visit, EST, problem focused $168.709699934826 M i d l e v e l Ho m e Vi s i t, EST, e x p an d e d$ 253.45 969 99348 26 Home Visit, EST, expanded $298.209699934926 Ho m e Vi s i t, EST, d e t ai l e d$ 448.35 969 99349 26 Midlevel Home Visit, EST, detailed $381.109699935026 M i d l e v e l Ho m e Vi s i t, EST, co m p re h e n s i v e$ 529.25 969 99350 26 Home Visit, EST, comprehensive $622.65 969 99354 PROLONG E&M/PSYCTX SERV O/P 1 HR$ 325.50 510 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 88 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99355 PROLONG E&M/PSYCTX SERV O/P 30 MIN $319.2051099356 P ro l o n g e d ser v i ce in p a t i e n t$ 321.30 983 99357 Prolonged service inpatient $320.2598399358 P ro l o n g ser v i ce w / oco n t a c t 1 h r$ 388.50 450 99359 Prolong serv w/o contact add 30 min $187.9545099360 P h ys i c ian s t an d b yser v i ces$ 219.45 960 99366 TEAM CONF W/PAT BY HC PRO 30+ MINS $148.0551099367 TE A MCONF W / OP A TB Y P H Y S 30 + M I NS$ 200.55 510 99368 TEAM CONF W/O PAT BY HC PRO 30+ MINS $130.205109937426 M i d l e v e l Ho m e h e a lt h c a res u p er v i s i o n$ 170.45 960 99374 26 Home health care supervision $200.559609937526 M i d l e v e l Ho m e h e a lt h c a res u p er v i s i o n$ 52.65 960 99375 26 Home health care supervision $61.9596099377 Hos p i cec a res u p er v i s i o n 15 - 29 min$ 200.55 657 99378 Hospice care supervision $327.6096099379 N u rs in g f a cc a res u p er v i s i o n$ 200.55 960 99380 Nursing fac care supervision $315.009609938126 I ni tp m e / m, n e wp a t, in f$ 269.85 960 99381 26 Midlevel Init pm e/m, new pat, inf $229.3596099381 I N I TPME / MNE W P A T I NF < 1 Y R$ 269.85 510 99382 26 Init pm e/m, new pat 1-4 yrs $286.659609938226 M i d l e v e l I ni tp m e / m, n e wp a t 1 - 4 yrs$ 243.65 960 99382 Init pm e/m new pat 1-4 yrs $286.655109938326 P re vv i s i t, n e w, a g e 5 - 11$ 304.50 960 99383 26 Midlevel Prev visit, new, age 5-11 $258.8096099383 P re vv i s i t n e w a g e 5 - 11$ 304.50 510 99384 26 Midlevel Prev visit, new, age 12-17 $305.259609938426 P re vv i s i t, n e w, a g e 12 - 17$ 359.10 960 99384 FP FAMILY PLANNING VISIT NEW AGE 12-17 $294.5551099384 P re vv i s i t n e w a g e 12 - 17$ 359.10 510 99385 26 Midlevel Prev visit, new, age 18-39 $294.559609938526 P re vv i s i t, n e w, a g e 18 - 39$ 346.50 960 99385 FP FAMILY PLANNING VISIT NEW AGE 18-39 $356.1051099385 P re vv i s i t n e w a g e 18 - 39$ 346.50 510 99386 26 Midlevel Prev visit, new, age 40-64 $356.109609938626 P re vv i s i t, n e w, a g e 40 - 64$ 418.95 960 99386 Prev visit new age 40-64 $418.9551099386 FPF A M I L Y P L A NN I NG V I S I TNE W A GE 40 - 64$ 384.65 510 99387 26 Midlevel Init pm e/m, new pat 65+ yrs $384.659609938726 I ni tp m e / m, n e wp a t 65 + yrs$ 452.55 960 99387 Init pm e/m new pat 65+ yrs $452.555109939126 P er p m ree v a l, es tp a t, in f$ 245.70 960 99391 26 Midlevel Per pm reeval, est pat, inf $208.8596099391 P er p m ree v a l es tp a t in f < 1 yr$ 245.70 510 99392 26 Prev visit, est, age 1-4 $269.859609939226 M i d l e v e lP re vv i s i t, es t, a g e 1 - 4$ 229.35 960 99392 Prev visit est age 1-4 $269.855109939326 P re vv i s i t, es t, a g e 5 - 11$ 269.85 960 99393 26 Midlevel Prev visit, est, age 5-11 $229.3596099393 P re vv i s i t es t a g e 5 - 11$ 269.85 510 99394 26 Midlevel Prev visit, est, age 12-17 $258.809609939426 P re vv i s i t, es t, a g e 12 - 17$ 304.50 960 99394 FP FAMILY PLANNING VISIT EST AGE 12-17 $265.9551099394 P re vv i s i t es t a g e 12 - 17$ 304.50 510 99395 26 Prev visit, est, age 18-39 $312.909609939526 M i d l e v e lP re vv i s i t, es t, a g e 18 - 39$ 265.95 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 89 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99395 Prev visit est age 18-39 $312.9051099395 FPF A M I L Y P L A NN I NG V I S I TEST A GE 18 - 39$ 290.05 510 99396 26 Prev visit, est, age 40-64 $341.259609939626 M i d l e v e lP re vv i s i t, es t, a g e 40 - 64$ 290.05 960 99396 FP FAMILY PLANNING VISIT EST AGE 40-64 $307.9051099396 PRE VV I S I TEST A GE 40 - 64$ 341.25 510 99397 26 Midlevel Per pm reeval est pat 65+ yr $307.909609939726 P er p m ree v a l es tp a t 65 + yr$ 362.25 960 99397 Per pm reeval est pat 65+ yr $362.255109940126 P re v e n t i v eco u n se l in g, in d i v$ 88.20 960 99401 26 Midlevel Preventive counseling, indiv $74.9596099401 PRE V ENT I V ECO U NSE L I NG I N D I V; 15 M I N$ 88.20 510 99401 FP HIV counseling (pre-test) 15 min $152.605109940226 M i d l e v e lP re v e n t i v eco u n se l in g, in d i v$ 152.60 960 99402 26 Preventive counseling, indiv $179.5596099402 H I V co u n se l in g (p os t - t es t) 30 min$ 179.55 510 99402 FP HIV counseling (post-test) 30 min $227.605109940326 P re v e n t i v eco u n se l in g, in d i v$ 267.75 960 99403 26 Midlevel Preventive counseling, indiv $227.6096099403 FPF A M I L Y P L A NN I NGCO U NSE L I NG I N D I V; 45$ 301.65 510 MIN 99403 FAMILY PLANNING COUNSELING INDIV; 45 $267.75510 M I N 9940426 M i d l e v e lP re v e n t i v eco u n se l in g, in d i v$ 301.65 960 99404 26 Preventive counseling, indiv $354.9096099404 PRE V ENT I V ECO U NSE L I NG I N D I V; 60 M I N$ 354.90 510 99406 Behav chng smoking 3-10 min $42.0098399406 B e ha v c hn g s m o kin g 3 - 10 min$ 42.00 942 99407 Behav chng smoking > 10 min $90.3098399407 B e ha v c hn g s m o kin g > 10 min$ 90.30 942 99408 Audit/dast 15-30 min $118.6545099409 A u d i t / d a s t o v er 30 min$ 236.25 450 99411 26 Preventive counseling, group $51.459609941126 M i d l e v e lP re v e n t i v eco u n se l in g, g ro u p$ 43.75 960 99412 26 Preventive counseling, group $78.759609941226 M i d l e v e lP re v e n t i v eco u n se l in g, g ro u p$ 66.95 960 99417 26 PROLONGED OFFICE/OUTPATIENT E/M SVC $114.45 E A 15 M I N 99441 P h o n ee / mb y p h ys 5 - 10 min$ 44.10 960 99442 Phone e/m by phys 11-20 min $90.3096099443 P h o n ee / mb y p h ys 21 - 30 min$ 137.55 960 99444 Online e/m by phys $92.4096099450 B a s i c l i f e d i s abi l i t ye x am$ 57.75 960 99455 Work related disability exam $162.7596099456 D i s abi l i t ye x amina t i o n$ 162.75 960 99460 Init nb em per day hosp $339.1572499461 I ni t nb e m p er d a y n o n - f a c$ 228.90 960 99462 Sbsq nb em per day hosp $152.2598799463 S am e d a y nb d i sc ha r g e$ 401.10 960 99464 Attendance at delivery $261.4572299465 N b res u sc i t a t i o n$ 526.05 722 99466 Ped crit care transport 30-74 min $967.0554099467 P e d cr i t c a re t r an s p or t a dd l 30 min$ 431.55 540 99468 Neonate crit care initial $3, 269.7098799469 N eo na t ecr i t c a res u b s q$ 1,472.10 960 99471 Ped critical care initial $2,796.15 960 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 90 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 99472 Ped critical care subsq $1, 421.7096099475 P e d cr i t c a re a g e 2 - 5 ini t$ 1,988.70 960 99476 Ped crit care age 2-5 subsq $1, 206.4596099477 I ni t d a y h os p n eo na t ec a re$ 1,228.50 987 99478 Ic lbw inf < 1500 gm subsq $490.3598799479 I c l b w in f 1500 - 2500 g s u b s q$ 450.45 987 99480 Ic inf pbw 2501-5000 g subsq $424.209879949726 A D V A NCEC A REP L A NN I NGF I RST 30 M I NS$ 228.84 960 99498 26 ADVANCE CARE PLANNING EA ADDL 30 $215.40 M I NS A 0420 A L S / B L S W A I T I NGT I MEPER 1/2 H R$ - 540 A0425 GROUND MILEAGE PER STATUTE MILE $- 540 A 0426 A L S 1$ - 540 A0427 ALS1-EMERGENCY $- 540 A 0428 B L S - NON - EMERGENT$ - 540 A0429 BLS-emergency $- 540 A 0433 A L S 2$ - 540 C8921 TTE W OR W/O FOL W/CONT COM $1, 363.75483 C 8922 TTE W OR W / OFO L W / CONTF / U$ 1,363.75 483 C8923 2D TTE W OR W/O FOL W/CON CO $1, 363.75483 C 89242 D TTE W OR W / OFO L W / CONF U$ 912.75 483 C8925 2D TEE W OR W/O FOL W/CON IN $1, 363.75483 C 8926 TEE W OR W / OFO L W / CONTCONG$ 1,363.75 483 C8927 TEE W OR W/O FOL W/CONT MON $1, 363.75483 C 8928 TTE W OR W / OFO L W / CONSTRES$ 1,363.75 483 C8929 TTE W OR WO FOL WCON DOPPLER $1, 363.75483 C 8930 TTE W OR W / OCONTRCONTECG$ 1,363.75 483 C8957 PROLONGED IV INF REQ PUMP >8 HOURS $595.15260 D 0120 PER I O D I COR A L E V A LU A T I ON -$ 20.00 512 ESTABLISHED P D0140 LIMITED ORAL EVALUATION - PROBLEM $30.00512 FOC U SE D 0150 COMPRE H ENS I V EOR A L E V A LU A T I ON - NE W$ 50.00 512 OR E D0170 RE-EVAL,EST PT,PROBLEM FOCUS $10.00512 D 0210 I NTR A OR A L - COMP L ETESER I ESOF$ 90.00 512 RADIOGRAP D0220 INTRAORAL - PERIAPICAL FIRST $20.00512 R A D I OGR A P H I D 0230 I NTR A OR A L - PER I A P I C A L E A C H$ 15.00 512 ADDITIONAL R D0240 Intraoral occlusal film $- 512 D 0250 E x t r a or a l f i rs t f i l m$ - 512 D0270 Dental bitewing single film $- 512 D 0272 B I TE W I NGS - T W OR A D I OGR A P H I C I M A GES$ 30.00 512 D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES $45.00512 D 0277 V er t bi t e w in g s - se v t oe i g h t$ - 512 D0330 PANORAMIC IMAGE $80.00512 D 0460 P u lp v i t a l i t y t es t$ - 512 D1110 DENTAL PROPHYLAXIS ADULT STAINS $80.00512 D 1110 PROP H Y L A X I S - A D UL T$ 60.00 512 D1120 PROPHYLAXIS - CHILD $45.00512 D 1206 TOP I C A L A PP L I C A T I ONOFF LU OR I D E$ 35.00 512 VARNISH D1208 TOPICAL APPLICATION OF FLUORIDE - $35.00 512 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 91 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION EXCLUD D1330 ORAL HYGIENE INSTRUCTION $20.00512 D 1351 SE A L A NT - PERTOOT H$ 40.00 512 D1353 SEALANT REPAIR PER TOOTH $20.00512 D 1354 I NTC A R I ESME D A PPPERTOOT H$ 35.00 512 D1510 Space maintainer fxd unilat $325.00512 D 1515 F i x e d bi l a t s p a ce main t ain er$ 425.00 512 D1520 Remove unilat space maintain $- 512 D 1525 R e m o v e bi l a t s p a ce main t ain$ - 512 D1550 Recement space maintainer $- 512 D 2140 A ma l g am, 1 S u r f a ce P er man e n t$ 80.00 512 D2140 Amalgam, 1 Surface Deciduous $70.00512 D 2150 A ma l g am, 2 S u r f a ceDec i d u o u s$ 85.00 512 D2150 Amalgam, 2 Surface Permanent $100.00512 D 2160 A ma l g am, 3 S u r f a ce P er man e n t$ 120.00 512 D2160 Amalgam, 3 Surface Deciduous $105.00512 D 2161 A ma l g am, 4 or m ore S u r f a ce P er man e n t$ 145.00 512 D2161 Amalgam, 4 or more Surface Deciduous $125.00512 D 2330 RES I N - B A SE D COMPOS I TE - ONES U RF A CE,$ 100.00 512 ANT D2331 RESIN-BASED COMPOSITE - TWO SURFACES, $120.00512 A N D 2332 RES I N - B A SE D COMPOS I TE - T H REE$ 150.00 512 SURFACES, D2335 RESIN-BASED COMPOSITE - FOUR OR MORE $190.00512 S U R D 2391 RES I N - B A SE D COMPOS I TE - ONES U RF A CE,$ 100.00 512 POS D2392 RESIN-BASED COMPOSITE - TWO SURFACES, $120.00512 PO D 2393 RES I N - B A SE D COMPOS I TE - T H REE$ 150.00 512 SURFACES, D2394 RESIN-BASED COMPOSITE - FOUR OR MORE $190.00512 S U R D 2920 RECEMENTCRO W N$ 50.00 512 D2930 CROWN-STAINLESS STEEL, PRIMARY TOOTH $265.00512 D 2931 PREF A BSTN L SSSTEE L CRO W NPE$ 280.00 512 D2932 PREFABRICATED RESIN CROWN $250.00512 D 2940 PROTECT I V ERESTOR A T I ON$ 50.00 512 D2999 Dental unspec restorative pr $- 512 D 3110 P UL PC A P D I RECT$ 70.00 512 D3220 THERAPEUTIC PULPOTOMY (EXCLUDING $125.00512 F I N A L R D 3310 EN D T H XP Y, A NTER I ORTOOT H$ 450.00 512 D3320 END THXPY, PREMOLAR TOOTH $600.00512 D 3330 EN D T H XP Y, MO L A RTOOT H$ 700.00 512 D3460 Endodontic endosseous implan $- 512 D 3999 E n d o d o n t i c p roce d u re$ - 512 D4210 GINGIVECTOMY/PLASTY 4 OR MOR $75.00512 D 4211 G I NG I V ECTOM Y / P L A ST Y 1 TO 3$ 20.00 512 D4260 Osseous surgery per quadrant $- 512 D 4263 B o n ere pl ce g r a f t f i rs t s i t e$ - 512 D4264 Bone replce graft each add $- 512 D 4268 S u r g i c a l re v i s i o n p roce d u re$ - 512 D4270 Pedicle soft tissue graft pr $- 512 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 92 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION D4273 Subepithelial tissue graft $- 512 D4341 PERIODONTAL SCALING & ROOT$ 75.00 512 D4342 PERIODONTAL SCALING 1-3TEETH $45.00512 D 4355 F u ll m o u t h d e b r i d e m e n t$ - 512 D4381 Localized delivery antimicro $- 512 D 4910 PER I O D ONT A L M A I NTEN A NCE$ 60.00 512 D5110 DENTURES COMPLETE MAXILLARY $800.00512 D 5120 D ENT U RESCOMP L ETEM A N D I B L E$ 800.00 512 D5130 DENTURES IMMEDIAT MAXILLARY $800.00512 D 5140 D ENT U RES I MME D I A TM A N D I B L E$ 800.00 512 D5211 DENTURES MAXILL PART RESIN $200.00512 D 5211 D ENT U RESM A X I LL P A RTRES I N (A DD T L PER$ 50.00 512 TOOTH) D5212 DENTURES MAND PART RESIN (ADDTL PER $50.00512 TOOT H) D 5410 D ENT U RES A D J U STCMP L TM A X I L$ 50.00 512 D5411 DENTURES ADJUST CMPLT MAND $550.00512 D 5421 D ENT U RES A D J U STP A RTM A X I LL$ 50.00 512 D5422 DENTURES ADJUST PART MANDBL $50.00512 D 5611 REPRES I NP A RT D ENTB A SEM A N$ 150.00 512 D5612 REP RESIN PART DENT BASE MAX $150.00512 D 5621 REPC A STP A RTFR A MEM A N$ 200.00 512 D5622 REP CAST PART FRAME MAX $200.00512 D 5660 A DD C L A SPTOP A RT I A L D ENT U RE$ 20.00 512 D5730 DENTURE RELN CMPLT MAXIL CH $200.00512 D 5731 D ENT U RERE L NCMP L TM A N D C H R$ 200.00 512 D5740 DENTURE RELN PART MAXIL CHR $250.00512 D 5741 D ENT U RERE L NP A RTM A N D C H R$ 250.00 512 D5911 Facial moulage sectional $- 512 D 5912 F a c ia l m o u l a g eco m pl e t e$ - 512 D5983 Radiation applicator $- 512 D 5984 R a d ia t i o n s hi e l d$ - 512 D5985 Radiation cone locator $- 512 D 5987 C o mmi ss u res pl in t$ - 512 D6920 Dental connector bar $- 512 D 6930 R ece m e n tB r i d g e$ 50.00 512 D7111 Extraction coronal remnants $- 512 D 7140 EXTR A CT I ON, ER U PTE DD EC I D U O U S$ 75.00 512 D7140 EXTRACTION, SIMPLE PERMANENT $85.00512 D 7210 S U RG I C A L REMO V A L OFER U PTE D TOOT H$ 150.00 512 REQUIR D7220 Impact tooth remov soft tiss $175.00512 D 7230 I m p a c tt oo t h re m o v p a r t b o n y$ 265.00 512 D7240 Impact tooth remov comp bony $275.00512 D 7241 I m p a c tt oo t h re mb o n y w / co m p$ - 512 D7250 REMOVE RESIDUAL ROOTS, UNEXPOSED $120.00512 D 7250 REMO V ERES I D U A L ROOTSEXPOSE D$ 85.00 512 D7260 Oral antral fistula closure $- 512 D 7261 P r ima ryc l os u res in u s p er f$ - 512 D7285 BIOPSY OF ORAL TISSUE HARD $300.00512 D 7286 B I OPS Y OFOR A L T I SS U ESOFT$ 300.00 512 D7291 Transseptal fiberotomy $- 512 D 7471 REMEXOSTOS I S A N Y S I TE$ 100.00 512 D7510 I&D ABSC INTRAORAL SOFT TISS $50.00 512 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 93 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION D7940 Reshaping bone orthognathic $- 512 D 7999 OR A L S U RGER Y PROCE D U RE$ 50.00 512 D9110 EMERGENCY TX DENTAL PAIN (PALLIATIVE) $25.00512 D 9230 A N A L GES I A$ 150.00 512 D9630 Other drugs/medicaments $- 512 D 9910 D ENT A PP L D ESENS I T I Z I NGME D$ 25.00 512 D9930 Treatment of complications $- 512 D 9940 De n t a l occ l u s a l gu a r d$ - 512 D9950 Occlusion analysis $- 512 D 9951 L imi t e d occ l u s a l a d j u s t m e n t$ - 512 D9952 Complete occlusal adjustment $- 512 D 9991 C A SEMGMT, A PPTB A RR I ERS - REF U SE D TX$ - 512 D9999 ADJUNCTIVE PROCEDURE $25.00512 G 0008 A d minin f l u e n z a v i r u s v a c$ 74.05 771 G0009 Admin pneumococcal vaccine $74.05771 G 0010 A d minh e p a t i t i s b v a cc in e$ 74.05 771 G0027 Semen analysis $28.15300 G 010126 M i d l e v e lC A scree n; p e l v i c / b re a s t e x am$ 35.00 969 G0101 26 CA screen;pelvic/breast exam $40.95969 G 0101 C A scree n; p e l v i c / b re a s t e x am$ 90.10 510 G0102 26 Prostate ca screening; dre $9.45969 G 010226 M i d l e v e lP ros t a t ec a scree nin g; d re$ 8.00 969 G0103 Psa screening $79.65300 G 010426 C A scree n; f l e x i s i g m o i d sco p e$ 63.00 969 G0104 26 Midlevel CA screen;flexi sigmoidscope $53.90969 G 0104 C A scree n; f l e x i s i g m o i d sco p e$ 1,419.95 750 G0105 26 Colorectal scrn; hi risk ind $222.60969 G 010526 M i d l e v e lC o l orec t a l scr n; hi r i s kin d$ 188.95 969 G0105 Colorectal scrn; hi risk ind $623.70750 G 010626 C o l o n C A scree n; ba r i u m e n e ma$ 53.55 972 G0106 26 Midlevel Colon CA screen;barium enema $45.15972 G 0106 C o l o n C A scree n; ba r i u m e n e ma$ 505.50 320 G0108 26 Midlevel Diab manage trn per indiv $30.70969 G 010826 D iabmana g e t r n p er in d i v$ 35.70 969 G0108 DM OP SMT INDIV PER 30 MIN $113.65942 G 010926 M i d l e v e l D iabmana g e t r nin d / g ro u p$ 17.65 969 G0109 26 Diab manage trn ind/group $21.00969 G 0109 D MOPSMTGRPPER 30 M I N$ 30.85 942 G0117 26 Midlevel Glaucoma scrn hgh risk direc $43.80969 G 011726 Gl a u co ma scr nh g h r i s k d i rec$ 51.45 969 G0117 GLAUCOMA SCRN FOR HI RISK PT $63.60770 G 011826 Gl a u co ma scr nh g h r i s k d i rec$ 34.65 969 G0118 26 Midlevel Glaucoma scrn hgh risk direc $29.35969 G 0118 G L A U COM A SCRN W D I RS U PER V$ 63.60 770 G0120 26 Midlevel Colon ca scrn; barium enema $45.15972 G 012026 C o l o n c a scr n; ba r i u m e n e ma$ 53.55 972 G0120 Colon ca scrn; barium enema $505.50320 G 012126 M i d l e v e lC o l o n c a scr nn o t hi rs kin d$ 188.95 969 G0121 26 Colon ca scrn not hi rsk ind $222.60969 G 0121 C o l o n c a scr nn o t hi rs kin d$ 625.10 750 G0122 Colon ca scrn; barium enema $- 320 G 0123 S cree n cer v / v a g t hin l a yer$ 87.75 923 G0124 26 Midlevel Screen c/v thin layer by MD $22.45969 G 012426 S cree n c / v t hin l a yer b y M D$ 26.25 969 G0127 26 Trim nail(s) $9.45969 G 012726 M i d l e v e lT r imnai l (s)$ 8.40 969 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 94 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION G0127 Trim nail(s) $111.90360 G 013026 S in g l ee n er g y x - r a ys t u d y$ 11.55 972 G0130 26 Midlevel Single energy x-ray study $10.20972 G 014126 M i d l e v e lS crc / v cy t o, a u t osys an d m d$ 22.45 969 G0141 26 Scr c/v cyto,autosys and md $26.25 969 G0143 SCRN PAP TL; SCRN & RESCRN BY TECH$ 87.75 923 G0144 TL PAP W AUTOM SCRN $92.50 923 G0145 TL PAP W AUTO SCRN & MANUAL RSCR$ 114.70 923 G0147 Scr c/v cyto, automated sys $49.30923 G 0148 S crc / v cy t o, a u t osys, rescr$ 65.80 923 G0166 26 Midlevel Extrnl counterpulse, per tx $153.00969 G 016626 E x t r n l co u n t er p u l se, p er t x$ 179.55 969 G0168 26 Midlevel Wound closure by adhesive $23.80969 G 016826 W o u n d c l os u re b y a d h es i v e$ 28.35 969 G0179 26 Midlevel MD recertification HHA PT $50.00969 G 0179 M Drecer t i f i c a t i o n HH A PT$ 142.05 960 G0180 26 Midlevel MD certification HHA patient $65.35969 G 0180 M Dcer t i f i c a t i o n HH A p a t i e n t$ 180.00 960 G0181 26 Midlevel Home health care supervision $109.80969 G 0181 Ho m e h e a lt h c a res u p er v i s i o n$ 351.35 960 G0182 26 Midlevel Hospice care supervision $115.35969 G 018226 Hos p i cec a res u p er v i s i o n$ 135.45 969 G0237 Therapeutic procd strg endur per 15 min $63.60410 G 0238 Ot h res pp roc, in d i v p er 15 min$ 63.60 410 [Rows 15001-16000:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE G0239 Oth resp proc, group $63.60410 G 024526 I ni t ia l f oo t e x am ptl o p s$ 49.35 969 G0245 26 Midlevel Initial foot exam pt lops $41.55969 G 0245 I ni t ia l f oo t e x am ptl o p s$ 227.40 510 G0246 26 Midlevel Followup eval of foot pt lop $21.15969 G 024626 F o ll o w u p e v a l o ff oo tptl o p$ 25.20 969 G0246 Followup eval of foot pt lop $227.40510 G 024726 R o u t in e f oo t c a re ptwl o p s$ 29.40 969 G0247 26 Midlevel Routine footcare pt w lops $24.55969 G 0247 R o u t in e f oo t c a re ptwl o p s$ 337.90 510 G0249 26 Midlevel Provide test material,equipm $141.40960 G 024926 I NRTESTM A TER I A L S / EQ, 1 TEST / W K$ 165.90 960 G0249 INR TEST MATERIALS/EQ, 1 TEST/WK $206.70920 G 025026 M Dre v i e w in t er p re t o f t es t$ 10.50 960 G0250 26 Midlevel MD review interpret of test $8.75960 G 0260 I nj f ors a cro i l ia c j t an es t h$ 1,086.75 360 G0268 26 Removal of impacted wax md $34.65969 G 026826 M i d l e v e lR e m o v a l o f im p a c t e d w a x m d$ 29.30 969 G0281 WND CARE ELEC STIM UA, STAGE 3- 4 $32.40420 UL CERSG 0282 NC W N D CRE L ECTRST I M U A$ - 420 G0283 Elec stim other than wound $32.40420 G 028926 A r t h ro, l oose b o d y + c h o n d ro$ 99.75 969 G0289 26 Midlevel Arthro, loose body + chondro $84.40969 G 0289 A r t h ro, l oose b o d y + c h o n d ro$ 180.55 360 G0297 26 LDCT FOR LUNG CA SCREEN $161.46960 G 0297 L D CTFOR LU NGC A SCREEN$ 911.50 770 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 95 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION G0297 TC LDCT FOR LUNG CA SCREEN $647.43350 G 0306 C b c / d i ff w b c w / o pl a t e l e t$ 33.65 300 G0307 Cbc without platelet $28.00300 G 0328 F ec a l b l oo d scr nimm u n o a ss a y$ 68.85 300 G0329 Electromagntic tx for ulcers stage III & IV $24.55420 G 034126 M i d l e v e lP erc u t an eo u s i s l e t ce llt r an s$ 334.80 969 G0341 26 Percutaneous islet celltrans $393.75969 G 034226 L a p a rosco p y i s l e t ce llt r an s$ 741.30 969 G0342 26 Midlevel Laparoscopy islet cell trans $630.55969 G 034326 L a p a ro t o m y i s l e t ce llt r an s p$ 1,223.25 969 G0343 26 Midlevel Laparotomy islet cell transp $1, 039.65969 G 036526 V esse l ma pp in g h e m o a ccess$ 13.65 972 G0365 26 Midlevel Vessel mapping hemo access $11.55972 G 037226 M Dser v i cere q u i re df or PM D$ 9.45 969 G0372 26 Midlevel MD service required for PMD $8.00969 G 0378 H OSP I T A L OBSER V A T I ONPER H R$ 105.00 762 G0379 Direct refer hospital observ $1, 041.70762 G 0396 A L CO H O L / S U BS I NTER V 15 - 30 MN$ 60.85 510 G0397 ALCOHOL/SUBS INTERV >30 MIN $143.90510 G 0400 H OMES L EEPTEST / T Y PE 4 PORT A$ 793.35 G0406 INPT/TELE FOLLOW UP 15 $120.71988 G 0407 I NPT / TE L EFO LL O W U P 25$ 226.12 988 G0408 INPT/TELE FOLLOW UP 35 $324.42988 G 0425 I NPT / E D TE L ECONS UL T 30$ 207.30 988 G0426 INPT/ED TELECONSULT50 $281.80988 G 0427 I NPT / E D TE L ECONS UL T 70$ 420.45 988 G0432 Eia hiv-1/hiv-2 screen $59.40300 G 0433 El i s ahi v - 1/ hi v - 2 scree n$ 59.40 300 G0435 Oral hiv-1/hiv-2 screen $51.95300 G 0438 PPPS I N I T I A L V I S I T$ 370.35 770 G0439 PPPS SUBSEQ VISIT $253.60770 G 0442 A NN U A L A L CO H O L M I S U SESCREEN I NG, 15$ 60.85 770 MINUTES G0443 BRIEF FACE-TO-FACE BEHAVIORAL $143.90770 CO U NSE L I NGFOR A L CO H O L M I S U SE, 15 M I N U TESG 0444 A NN U A L D EPRESS I ONSCREEN I NG, 15$ 60.85 770 MINUTES G0459 TELEHEALTH INPT PHARM MGMT $84.25960 G 0463 Hos p i t a l o u tpt c l ini c v i s i t$ 227.40 510 G0480 DRUG TEST DEF 1-7 CLASSES $235.30301 G 0481 D R U GTEST D EF 8 - 14 C L A SSES$ 322.00 301 G0482 DRUG TEST DEF 15-21 CLASSES $408.70301 G 0483 D R U GTEST D EF 22 + C L A SSES$ 507.75 301 G0498 CHEMO EXTEND IV INFUS W/PUMP $595.15335 G 050026 MO D SE D A TEN D OSER V I CE > 5 Y RS$ 17.09 963 G0508 CRIT CARE TELEHEA CONSULT 60 $416.10960 G 0509 CR I TC A RETE L E H E A CONS UL T 50$ 401.90 960 G0515 COGNITIVE SKILLS DEVELOPMENT 15 MIN $92.40420 G 0659 D R U GTEST D EFS I MP L E A LL C L$ 159.60 301 G8978 Mobility current status $- 420 G 8979 M o bi l i t y g o a l s t a t u s$ - 420 G8980 Mobility D/C status $- 420 G 8984 C a rryc u rre n t s t a t u s$ - 420 G8985 Carry goal status $- 420 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 96 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION G8986 Carry D/C status $- 420 G 8990 Ot h er PT / OT c u rre n t s t a t u s$ - 420 G8991 Other PT/OT goal status $- 420 G 8992 Ot h er PT / OT D / C s t a t u s$ - 420 G8993 Sub PT/OT current status $- 420 G 9143 Wa r f a r in res p o n g e n e t i c t es t$ 522.70 300 H1011 Family assessment by licensed behavioral health $- 944 p ro f ess i o na l f ors t a t e d e f in e d p u r p osesH 2000 C o m p re h e n s i v e m u lt i d i sc i pl ina rye v a l u a t i o n$ 808.00 944 H2001 Rehabilitation program, per 1/2 day $- 944 H 2011 C r i s i s in t er v e n t i o n ser v i ce, p er 15 min u t es$ 69.00 944 H2012 Behavioral health day treatment, per hour $27.00944 H 2015 C o m p re h e n s i v eco mm u ni t ys u pp or t ser v i ces, p er 15$ 6.00 944 minutes H2017 Psychosocial rehabilitation services, per 15 minutes $28.00944 H 2019 T h er a p e u t i c b e ha v i or a l ser v i ces, p er 15 min u t es$ 9.00 944 H2021 Community-based wrap-around services, per 15 $20.00944 min u t esH 2023 S u pp or t e d e m pl oy m e n t, p er 15 min u t es$ 16.88 944 H2025 Ongoing support to maintain employment, per 15 $20.00944 min u t esH 2027 P syc h oe d u c a t i o na l ser v i ce, p er 15 min u t es$ 29.00 944 H2030 Mental health clubhouse services, per 15 minutes $8.00944 H 2032 A c t i v i t y t h er a p y, p er 15 min u t es$ 8.44 944 H2033 Multisystemic therapy for juveniles, per 15 minutes $34.00944 H 2034 A l co h o l an d / or d r ug ab u se ha l f w a y h o u seser v i ces,$ - 944 per diem H2037 Developmental delay prevention activities, $18.75944 d e p e n d e n t c hi l d o f c l i e n t, p er 15 min u t es P 2038 Bl oo d m u co p ro t e in$ 21.75 300 P3000 Screen pap by tech w md supv $45.75960 P 300126 S cree nin g p a p s m e a r b y p h ys$ 70.75 969 P9011 BLOOD SPLIT UNIT $205.35390 P 9012 CR Y OPREC I P I T A TEE A U N I T$ 88.00 390 P9017 FRESH FROZEN PLASMA $840.00390 P 9019 Pl a t e l e t s, e a c h u ni t$ 229.90 390 P9021 PACKED RED BLOOD CELLS $630.00390 P 9034 P L A TE L ET, P H ERES I S$ 1,370.25 390 P9044 CRYOPR REDUCED PLASMA EA UNIT $211.10390 P 9059 Pl a s ma, f rz b e tw ee n 8 - 24 h o u r$ 148.50 390 P9612 CATH FOR SPECIMEN COLLECT SGL PT $9.45300 P 9615 C A T H FORSPEC I MENCO LL ECTM UL T I PT$ 9.45 300 Q0035 26 Midlevel Cardiokymography $8.00960 Q 003526 C a r d i o k y m o g r a p h y$ 9.45 960 Q0091 26 Midlevel Obtaining screen pap smear $17.45969 Q 009126 O b t ainin g scree n p a p s m e a r$ 21.00 969 Q0091 Obtaining screen pap smear $61.70923 Q 0091 O b t ainin g scree n p a p s m e a r$ 61.70 311 Q0111 Wet mounts/ w preparations $18.50300 Q 0112 P o t a ss i u mh y d ro x i d e p re p s$ 18.50 300 Q0113 Pinworm examinations $23.45300 Q 0114 F er n t es t$ 30.95 309 Q0115 Post-coital mucous exam $42.85300 Q 3014 TE L E H E A L T H F A C I L I T Y FEE$ 65.00 780 Q4081 Epoetin alfa, 100 units ESRD $- 634 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 97 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION MORPHINE 60MG EXTENDED-RELEASE $- 250 TOT A L P A RENTER A L N U TR I T I ON 200$ - 250 GLUCAGON DIAGNOSTIC KIT $- 250 MORP H I NES UL F A TE 10 MG / M L T U BEX$ - 250 FERROGELS FORTE,100 $- 250 P A C L i t a x e l 6 MG / M L, 50 M L V I A L I$ - 250 SODIUM ACETATE 2MEQ/ML INJ $- 250 L E U CO V OR I NC A L C I U MPF, 350 MG / V$ - 250 DERMAGINATE ROPE 12 IN $- 250 SO D I U MC H L OR I D E 0.9$ - 250 INJECTION, MALOGEN LA IN OIL $351.00250 MORP H I NE 15 MG / M L, 20 M L M D V I N J$ - 250 PHENYTOIN SOD 100MG/2ML VIAL $- 250 C A SPOF U NG I N A CET A TE 70 MG V I A L,$ - 250 TOTAL PARENTERAL NUTRITION 300 $- 250 H EP A R I N 10, 000 U N I TS / M L 4 M L$ - 250 POTASSIUM CHLORIDE 20MEQ/PACKE $- 250 SO D I U MC H L OR I D E 23.4$ - 250 MULTIVITAMINS/FLUORIDE 0.5MG/M $- 250 D OP A M I NE 800 MG /500 M L D 5 W I N J$ - 250 HYDROCORTISONE 100MG/2ML VIAL $- 250 B A C I TR A C I NTOP . U NG 1/32 OZ$ - 250 DEXTROSE 5% 100ML INJ $- 250 ESMO L O L 100 MG /10 M L I N J ECT I ON$ - 250 EPOETIN ALFA 1 UNIT $- 250 I M I PENEM / C I L A ST A T I N 500 MG A DD -$ - 250 PRALIDOXIME 1GM/20ML INJ $- 250 I NTR A L I P I D F A TEM UL S I ON 20$ - 250 LEUPROLIDE ACETATE 22.5MG DEPO $- 250 V A R I CE LL A V I R U S V A CC I NE I N J .$ - 250 LEVONORGESTREL/ETHINYL ESTRADI $- 250 C I SP L A T I N 200 MG V I A L, 200 M L$ - 250 CYTARABINE 100MG INJ $- 250 PROP A R A C A I NE 0.5$ - 250 BACITRACIN/POLYMIX OPHTH UNG 3 $- 250 MEPER I D I NE 100 MG / M L S Y R I NGE I N$ - 250 CARBACHOL 3% OPHTHALMIC SOLN $- 250 FENT A N Y L 25 MCG / H O U RTR A NS D ERM A$ - 250 BUTALBITAL/ACETAMINOPHEN/CAFFE $- 250 A M I NOC A PRO I C A C I D 25$ - 250 SELENIUM SULFIDE 1% SHAMPOO $- 250 ENGER I X - B H EP A T I T I SBS D V PF 2$ - 250 MAGNESIUM SULFATE 40MG/ML 100M $- 250 CEF A ZO L I N 1 GM /50 M L D EXTROSEPR$ - 250 VERAPAMIL 2.5MG/ML, 2ML/VL INJ $- 250 C A SPOF U NG I N A CET A TE 50 MG V I A L,$ - 250 LIDOCAINE MPF 2% INJ. (20MG/ML $- 250 C A RBOP L A T I N 450 MG / V I A L I N J .$ - 250 NYSTATIN/TRIAMCINOLONE 100,000 $- 250 Q U I N I NES UL F A TEQ U A L A Q U I N 324 M$ - 250 WATER FOR INJ PRESERVATIVE FRE $- 250 TR I MET H OPR I M / PO L Y M Y X I NOP H T H A L$ - 250 ALBUTEROL/IPRATROPIUM 90-18MCG $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 98 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION DARBEPOETIN ALFA 100 MCG/0.5ML $- 250 P A C L I T A XE L 6 MG / M L 16.7 M L$ - 250 DALTEPARIN 2500IU/O.2ML $- 250 SE V OF LU R A NEP . E . N . BOTT L E, 250$ - 250 TEMSIROLIMUS 25MG/ML KIT INJ $- 250 PNE U MOCOCC A L V A CC I NEPO L YV A L EN$ - 250 LIDOCAINE 2%, 20ML VIAL $- 250 H Y D ROX Y Z I NE 50 MG / M L, 1 M L I N J$ - 250 OXALIPLATIN 50MG INJ. $- 250 P L A SM A PROTE I NFR A CT I ON 5$ - 250 AMINO ACID 10% 500ML INJ $- 250 A SP I R I N / D I P Y R I D A MO L 25/200 MGE$ - 250 AMYL NITRATE INH 0.3ML AMP, 12 $- 250 P A C L I T A XE L 6 MG / M L, 16.7 M L V I A$ - 250 PROPRANOLOL 1MG/ML INJ $- 250 M I L R I NONE 20 MG /100 M L PREM I X I N$ - 250 HYDROMORPHONE CPJ 2MG/ML, 1ML $- 250 BOOSTR I XPFS 0.5 M L$ - 250 MANNITOL 25% 50ML INJ $- 250 PEMETREXE D 100 MG V I A L$ - 250 IMMUNE GLOBULIN I.V. 5GM (10%) $- 250 S UL F A CET A M I D E 10$ - 250 CYCLOPENTOLATE 0.5% OPHTHALMIC $- 250 STREPTOM Y C I N 1 GM I N J$ - 250 MORPHINE 30MG IMMEDIATE-RELEAS $- 250 B U D ESON I D E / FORMOTERO L 160 MCG / S$ - 250 PEGINTERFERON REDIPEN 120MCG/0 $- 250 GEMC I T A B I NE H C L 1 GM / M L, 50 M L$ - 250 ERYTHROMYCIN 0.5% OPHTHALMIC O $- 250 F LU CON A ZO L E L I Q 40 MG / M L NF, 3$ - 250 METHYLPREDNISOLONE 80MG 1ML VI $- 250 OX A L I P L A T I N 5 MG / M L, 20 M L V I A L$ - 250 CARBIDOPA/LEVODOPA 25MG-100MG $- 250 F LU T I C A SONE 44 MCG I N H A L ER$ - 250 TROPICAMIDE 1% OPHTHALMIC SOLN $- 250 M I TOM Y C I N 40 MG / V I A L I N J$ - 250 PROCHLORPERAZINE 5MG/ML, 2ML V $- 250 FENT A N Y L 50 MCG / H O U RTR A NS D ERM A$ - 250 SODIUM CHLORIDE 5% OPHTHALMIC $- 250 I M I PENEM / C I L A ST A T I N 250 MG A DD -$ - 250 MULTIVITAMIN PEDIATRIC SDV INJ $- 250 EP I R U B I C I N 2 MG / M L, 25 M L V I A L I$ - 250 FILGRASTIM 300MCG/ML, 1ML $- 250 MET H Y L ERGONO V I NE 0.2 MG / M L V I A L$ - 250 PROMETHAZINE/CODEINE 6.25MG-10 $- 250 MEPER I D I NE 50 MG / M L I N J, V I / A MP$ - 250 MORPHINE 30MG EXTENDED-RELEASE $- 250 A ZTREON A M 1 GM V I A L$ - 250 CYCLOPENTOLATE 1% OPTH DROPS, $- 250 D I P H ENOX Y L A TE / A TROP I NE 2.5 MG - 0$ - 250 DEGARELIX 80MG/VIAL INJ $- 250 C A RB I D OP A / L E V O D OP A 25 MG - 250 MG$ - 250 MORPHINE SULFATE 60MG SR, BULK $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 99 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION LEVOLEUCOVORIN 50MG/VIAL INJ $- 250 D I MERC A PRO L 100 MG / M L I N J$ - 250 EPHEDRINE SULFATE 50 MG/ML INJ $- 250 FENT A N Y L 50 MCG / M L, 5 M L V I A L$ - 250 MEGLUMINE IODIPAMIDE 20% INJ. $- 250 C A RB I D OP A / L E V O D OP A 25/250$ - 250 THEOPHYLLINE 80MG/15ML ELIXER $- 250 R A N I T I D I NE 25 MG / M L 6 M L / V I A L I N$ - 250 CISPLATIN 1MG/ML, 100ML MDV $- 250 PRO V ENT I L H F A 6.7 GM 200 D OSE$ - 250 TESTOSTERONE CYPIONATE 200MG/M $- 250 H EP A R I N L OC K 100 U / M L, 1 M L$ - 250 DEXAMETHASONE 10MG 1ML VIAL NF $- 250 TR A ST U Z U M A B 440 MG V I A L I N J$ - 250 TOTAL PARENTERAL NUTRITION 100 $- 250 S U M A TR I PT A NS U CC I N A TE 6 MG /0.5 M$ - 250 PANCRELIPASE (10,000 UNITS LIP $- 250 TETR A C A I NEPONTOC A I NE 1$ - 250 DORZOLAMIDE 2% OPHTH SOL., 5ML $- 250 A M I NO A C I D 8.5$ - 250 ALBUTEROL 0.083% NEBULIZER SOL $- 250 OX A L I P L A T I N 50 MG / V I L (5 MG / M L)$ - 250 ATROPINE SULFATE 1% OPHTHALMIC $- 250 D ERM A G I N A TE 4 X 4 D ER, 10/ BX$ - 250 PILOCARPINE 1% OPHTHALMIC SOLN $- 250 ER Y T H ROM Y C I N 200 MG /5 M L S U SP$ - 250 DEFEROXAMINE 500MG/VIAL INJ $- 250 W A TERFOR I RR I G A T I ON 1 L I TER$ - 250 KETOROLAC 0.5% OPHTHALMIC SOLN $- 250 FERRO U SS UL F A TE 25 MG / M LL I Q$ - 250 CYANOCOBALAMINE 1,000MCG/ML IN $- 250 D 5 W / N A C L 0.45$ - 250 TRIPTORELIN PAMOATE 11.25MG KI $- 250 P A C L I T A XE L 30 MG /5 M L I N J$ - 250 POTASSIUM ACETATE 19.6% (2MEQ/ $- 250 M UL T I V I T A M I NS / F LU OR I D E 0.25 MG /$ - 250 LIDOCAINE 5%/DEXTROSE 7.5% SPI $- 250 L OP I N A V I R / R I TON A V I R 200 MG /50 MG$ - 250 EMTRICITABINE/TENOFOVIR 200MG- $- 250 D OP A M I NE 400 MG /10 M L I N J ECT I ON$ - 250 PHENYLEPHRINE 2.5% OPHTHALMIC $- 250 FERR I CS U BS UL F A TESO L N$ - 250 FORMOTEROL FUM (FORADIL) 12MCG $- 250 R I SPER I D ONE L A 25 MG I N J .$ - 250 AMMONIA INHALANT AMPS $- 250 MET H Y L CE LLUL OSEOP H T H SO L$ - 250 SODIUM NITROPRUSSIDE 50MG INJ $- 250 GENT A M I C I N 0.3$ - 250 BELLADONNA/PHENOBARBITAL 0.129 $- 250 G L Y COP Y RRO L A TES D V 0.2 MG / M L, 1$ - 250 SULFACETAMIDE/PREDNISOLONE 10% $- 250 F LU ORO U R A C I L 50 MG / M L, 50 M L V I A$ - 250 ISOMETHEPTENE/DICHLORALPHENAZO $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 100 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION CISPLATIN 1MG/ML 50ML VIAL INJ $- 250 N A L OXONE 0.02 MG / M L I N J$ - 250 MORPHINE 15MG IMMEDIATE-RELEAS $- 250 P Y R I D OX I NE 100 MG / M L I N J$ - 250 OXACILLIN 2GM VIAL INJ $- 250 MORP H I NE 15 MGEXTEN D E D - RE L E A SE$ - 250 LIDOCAINE JEL 2% 5ML URO-JET $- 250 P I L OC A RP I NE 2$ - 250 METHOTREXATE 25MG/ML 10ML/VIAL $- 250 I M I PENEM / C I L A ST A T I N 500 MG / V I A L$ - 250 DOCETAXEL 20MG/VIAL INJ $- 250 L E V OT H Y ROX I NE 500 MCG I N J .$ - 250 COAGULATION FACTOR IX (HUMAN) $- 250 TR I A MTERENE / H Y D ROC H L OROT H I A Z I D$ - 250 INTRASITE GEL 0.52oz. $- 250 PROT A M I NESO 410 MG / M L, 5 M L V I A$ - 250 SODIUM CHLORIDE 0.9% NEBULIZER $- 250 C A RBOP L A T I N 150 MG / V I A L I N J .$ - 250 CYTARABINE 500MG INJ $- 250 L O V ENOXENOX A P A R I NN A 80 m g /0.8$ - 250 ondansetron $- 250 H OM A TROP I NE 5$ - 250 CARBOPLATIN MDV 10MG/ML,5ML $- 250 P H EN I R A M I NE 0.3$ - 250 DORZOLAMIDE 2% OPHTHALMIC SOLN $- 250 H Y D ROCO D ONE / A CET A M I NOP H EN 5 MG -$ - 250 POLYVINYL ALCOHOL 1.4% OPHTHAL $- 250 C A L C I TON I NS A L MON 200 I U / M L I N J$ - 250 GLYCERIN, USP $- 250 A CET I C A C I D 2$ - 250 LIDOCAINE 2%, 100MG/5ML SYRING $- 250 M I TOM Y C I N 20 MG / V I A L I N J$ - 250 LIDOCAINE 2% W/EPI 20ML INJ. $- 250 C A RB I D OP A / L E V O D OP A 10 MG - 100 MG$ - 250 GEMCITABINE HCL 200MG/ML, 10ML $- 250 ER Y T H ROM Y C I N 0.5$ - 250 MULTIVITAMIN PEDIATRIC SDV IN $- 250 I MM U NEG L OB UL I N I . V .10 GM (10$ - 250 DOCUSATE SOD 50MG/5ML,16OZ $- 250 M I NER A L O I L RECT A L ENEM A$ - 250 AMINOSALICYLIC ACID 4 GRAM $- 250 Z I D O V U D I NE 10 MG / M L, 20 M L S D V I$ - 250 PROCAINAMIDE 100MG/ML 10ML/VIA $- 250 D A L TEP A R I N 5000 I U / O .2 M L$ - 250 CYCLOPENTOLATE 1% OPHTHALMIC S $- 250 TOPOTEC A N H C L 4 MGPFS D V$ - 250 TUBERCULIN PURIFIED PROTEIN, 1 $- 250 O L A NZ A P I NE 5 MGR A P I D - D I S I NTEGR$ - 250 BEVACIZUMAB 25MG/ML, 16ML VIAL $- 250 L E V ET I R A CET A M 100 MG / M L, 500 M L$ - 250 TRACE ELEMENTS (MTE-4) 5ML/VIA $- 250 C H L ORPROM A Z I NE A MP 25 MG 1 M L$ - 250 MONONINE 915 UNITS VIAL $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 101 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION LIDOCAINE 2% VISCOUS SOLN $- 250 I NF L I X I M A B 100 MG I N J$ - 250 CEFTRIAXONE 1GM/50ML DEXTROSE $- 250 BENZO I NT I NCT U RE, COMPO U N D$ - 250 TIMOLOL 0.5% OPHTHALMIC SOLN $- 250 V I NORE L B I NE 10 MG / M L, 1 M L V I A L$ - 250 POTASSIUM CHLORIDE ER 10MEQ TA $- 250 MESN A 100 MG / M L 10 M L / V I A L I N J$ - 250 hydroxyzine $- 250 F LU ORO U R A C I L 50 MG / M L, 10 M L / V I A$ - 250 PODOPHYLLIN 25% SOL $- 250 D UL OXET I NE H C L C Y MB A L T A 30 MGT$ - 250 VITAMIN E SFTGEL 400IU, 300 $- 250 GR I SEOF UL V I N 125 MG /5 M L$ - 250 IOPAMIDOL 61% INJECTION $- 250 D A RBEPOET I N A L F A 40 MCG /0.4 M L$ - 250 ANTIPYRINE/BENZOCAINE 5.4%-1.4 $- 250 F I L GR A ST I M 480 MCG /1.6 M L, 1.6 M L$ - 250 MORPHINE SULFATE 10MG/ML 1ML V $- 250 H EP A T I T I SB V A CC I NE 10 MCG /0.5 M$ - 250 PREDNISOLONE 1% OPHTHALMIC SOL $- 250 FR A GM I N D A L TEP A R I N 25000 I U / M L,$ - 250 OPTI-CHAMBER ADVANTAGE $- 250 GEMC I T A B I NE 1 GM V I A L I N J$ - 250 BENDAMUSTINE HCL TREANDA 100MG $- 250 SO D I U MC H L OR I D E 0.9$ - 250 VINCRISTINE 2MG/2ML,VIAL $- 250 I X A BEP I L ONE 45 MG K I T I N J$ - 250 SODIUM METABISULFITE 1LB $- 250 SO D I U MC H L OR I D E 0.9$ - 250 PILOCARPINE 4% OPHTHALMIC SOLN $- 250 V ENTO L I N H F A 60 D OSE W / CO U NTE$ - 250 LIDOCAINE 2% JELLY, 30ML $- 250 A CET Y L C Y STE I NE 20$ - 250 BUTALBITAL/ASPIRIN/CAFFEINE 50 $- 250 I NF U V I TE A D L I NF 2 V L S Y S$ - 250 PNEUMOCOCCAL VACCINE INJ, 2.5M $- 250 D OP A M I NE 200 MG /5 M L I N J ECT I ON$ - 250 NALBUPHINE 10MG/ML INJ $- 250 A L B U TERO L 90 MCG / A CT U A T I ON I N H A$ - 250 RITUXIMAB 10MG/ML, 10ML VIAL $- 250 GENTE A L PM LU BE Y EO I NT, 3.5 G$ - 250 DEXTROSE 10% 1000ML INJ $- 250 P H Y SOST I GM I NES A L I C Y L A TE 1 MG / M$ - 250 GENTAMICIN 0.3% OPHTHALMIC OIN $- 250 D EXTROSE 5$ - 250 CLOBETASOL PROPIONATE 0.05% TO $- 250 OX A L I P L A T I N 100 MG / V I L (5 MG / M L)$ - 250 DANTROLENE 20MG/ML VIAL $- 250 A MOX I C I LL I N / C L A V UL A N A TE 250 MG -$ - 250 LAMIVUDINE 150MG & ZIDOVUDINE $- 250 M A GNES I U MC H L OR I D EM D V 20$ - 250 BUPIVACAINE 0.75% W/ DEXTROSE, $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 102 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION IODIPAMIDE MEGLUMINE 52% INJ $- 250 D EXTROSESO L 50$ - 250 FACTOR VII-A (RECOMBINANT) 5,0 $- 250 BER A CT A NT I NTR A TR A C H E A L S U SP, 8$ - 250 SODIUM CHLORIDE 0.9% NASAL SOL $- 250 T H ER A C Y SBCG L I V ES D V$ - 250 DIAZEPAM 10MG/2ML INJ $- 250 DECAVAC TETANUS & DIPTH TOXOID$ - 250 TETRACAINE 1% 2ML INJ, AKOR $- 250 I PR A TROP I U MBR 17 MCG / A CT U A T I ON$ - 250 DDAVP DESMOPRESSIN RHINAL TUBE $- 250 H Y A LU RON I D A SE V I TR A SEO V I NE U S$ - 250 FULVESTRANT 50MG/ML 5ML SYRING $- 250 F LU ORESCE I N 2$ - 250 CIPROFLOXACIN 0.3% OPHTHALMIC $- 250 H EP A R I N 1, 000 U N I TS / M L, 10 M L$ - 250 FLUNISOLIDE 0.025% NASAL SOLN $- 250 M Y COP H ENO L A TEMOFET I L 250 MGC A$ - 250 CHLORHEXIDINE GLUCONATE 0.12% $- 250 F U ROSEM I D E 10 MG / M L, 60 M LL I Q$ - 250 TICARCILLIN/CLAVULANTE 3.1GM I $- 250 H EP A R I NN A 1000 U N I TS / M L V I A L$ - 250 MICAFUNGIN SODIUM MYCAMINE 100 $- 250 F LU T I C A SONE 110 MCG / A CT U A T I ON I$ - 250 BELLADONNA/PHENOBARBITAL 7.5MG $- 250 BET A MET H A SONE D I PROP I ON A TE 0.0$ - 250 TOBRAMYCIN/DEXAMETHASONE 0.3%- $- 250 L I D OC A I NE 1$ - 250 PANTOPRAZOLE SOD DR 40MG UD $- 250 D EX A MET H A SONE 0.1$ - 250 PENTAMIDINE 300MG VIAL $- 250 CEFT A Z I D I ME 6 GM I N J$ - 250 RANITIDINE 50MG/0.45% NACL 50M $- 250 MET H OTREX A TE 25 MG / M L (2 M L) PRE$ - 250 KOATE DVI (510U/VIAL) $- 250 POT A SS I U MC H L OR I D E 10 MEQE / RT$ - 250 ACETAMINOPHEN WITH CODEINE 30M $- 250 TOT A L P A RENTER A L N U TR I T I ON 250$ - 250 CARBOPROST TROMETHAMINE 250MCG $- 250 D EC I T A B I NE 50 MG V I A L$ - 250 METHOTREXATE 25MG/ML, 2ML VIAL $- 250 E L SP A R A SP A R A G I N A SE 10, 000 U N I$ - 250 NONDC-PRESCRIPTIONS $- 250 BEC L OMET H A SONE 80 MCG I N H A L ER$ - 250 SORBITOL 70% SOLN $- 250 C Y A NOCOB A L A M I N 1000 MCG / M L I N J$ - 250 BUDESONIDE 0.5MG/2ML NEBULIZER $- 250 TOBR A M Y C I N 0.3$ - 250 METHOTREXATE 25MG/ML (10ML) PR $- 250 L I D OC A I NE 2$ - 250 POTASSIUM PHOSPHATE 4.4MEQ/ML $- 250 DIATRIZOATE (MEGLUMINE & SODIU$ - 250 DOBUTAMINE 250MG/250ML INJ $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 103 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION IPRATROPIUM BROMIDE 0.02% NEBU $- 250 TETR A C A I NE 0.5$ - 250 MPB FEIBA ANTI-INHIBITOR COAGU $- 250 C A RB A C H O L 0.01$ - 250 QUINIDINE GLUCONATE 324MG ER T $- 250 PEG - I NTRONRE D I P 120 MCG /0.5 M L$ - 250 INDOMETHACIN INJ 1MG/AMP $- 250 O L A NZ A P I NE 10 MGR A P I D - D I S I NTEG$ - 250 IPRATROPIUM 0.5MG/ALBUTEROL 3M $- 250 I SOF LU R A NE (A NEST H ET I C) I N H A L A$ - 250 DIGOXIN IMMUNE FAB 40MG/ML INJ $- 250 ORT H OE V R A 150 MCG - 20 MCG /24 H O U$ - 250 ALBUTEROL 0.5% NEBULIZER SOLUT $- 250 C Y A N I D E K I T$ - 250 NUVARING 0.12MG/0.015MG/24 HOU $- 250 D OXO r u bi c in CON V ENT I ON A L 2 MG / M$ - 250 VINCRISTINE 1MG/1ML INJ $- 250 O L A NZ A P I NEZ Y PREX A I MS D V 10 MG$ - 250 IXABEPILONE 15MG KIT INJ $- 250 PRE D N I SO L ONE 0.12$ - 250 BACITRACIN 500 UNITS/GM OPHTHA $- 250 CET U X I M A B 2 MG / M L, 50 M L V I A L$ - 250 EPOETIN 10,000 UNITS/ML, 2 ML $- 250 MEPER I D I NE 100 MG / M L V I A L$ - 250 MULTI-AD FLUID TRANSFER SET $- 250 D OCET A XE L 80 MG / V I A L I N J$ - 250 PEGINTERFERON 120MCG/0.5ML KIT $- 250 N A P H A ZO L I NE / A NT A ZO L I NE 0.05$ - 250 MIDAZOLAM 1MG/ML 5ML/VIAL INJ $- 250 D A RBEPOET I N A L F A 25 MCG /0.42 M L$ - 250 DARBEPOETIN ALFA 60MCG/0.3ML P $- 250 A L PROST A D I L (PGE - 1) 500 MCG / M L$ - 250 TETANUS TOXOID ADULT 0.5ML VL $- 250 C H OR I ON I CGON A D OTROP I N 10, 000$ - 250 EPOETIN ALFA 10,000 UNITS/ML, $- 250 MORP H I NE 1 MG / M L 10 M L / A MP I N J$ - 250 PHENOBARBITAL 30MG/7.5ML ELIXI $- 250 P H EN Y L EP H R I NE 1$ - 250 EPINEPHRINE 1:1,000 TUBEX $- 250 NEOST I GM I NE 1 : 1000 (1 MG / M L), 1$ - 250 BUPIVACAINE 0.5% W/EPI,MPF 30M $- 250 C H L ORPROM A Z I NE 25 MG / M L I N J$ - 250 BEVACIZUMAB 25MG/ML, 4ML VIAL $- 250 L I D OC A I NE 1$ - 250 PAMIDRONATE 90MG INJ $- 250 A M I NO A C I D S / D EXTROSE 4.25$ - 250 SODIUM PHOSPHATE 3MMOL/ML 15ML $- 250 ESTROGENS, CON J U G A TE D 0.625 MG$ - 250 DOBUTAMINE 12.5MG/ML, 20ML IN $- 250 D A L TEP A R I N 25, 000 U N I TS / M L I N J$ - 250 LIDOCAINE XYLOCAINE MDV 2% 10M $- 250 I R I NOTEC A N H C L 20 MG / M L, 5 M L V I$ - 250 DILTIAZEM 180MG CD $- 250 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 104 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION LANSOPRAZOLE 30 MG INJ. SDV $- 250 D I L T I A ZEMS D V 5 MG / M L 5 M L$ - 250 CYCLOPENTOLATE 1% OPH SOL 15ML $- 250 B I SM U T H S U BS A L I C Y L A TE 262 MGC H$ - 250 VERAPAMIL 2.5MG/ML, 2ML SDV IN $- 250 NOREP I NEP H R I NE 1 MG / M L, 4 M L V I A$ - 250 POTASSIUM CL 10MEQ IN 100ML BA $- 250 M UL T I TR A CE 5 S D V 1 M L$ - 250 ERYTHROMYCIN 500MG VIAL $- 250 R A CEP I NEP H R I NE I N H .2.25$ - 250 GUIAFENESIN 100MG/CODEINE 10MG $- 250 E D ROP H ON I U M 10 MG / M L, 15 M L M D V$ - 250 CALCIUM GLUCONATE SDV 10% 50ML $- 250 M I L R I NONE 1 MG / M L, 20 M L V I A L$ - 250 LACTATED RINGERS 1000ML INJ $- 250 W A TERFOR I N J, B - ST A T I C 30 M L$ - 250 WATER FOR INJ., STERILE 500ML $- 250 F A TEM UL S I ON 20$ - 250 NOVO-SEVEN RT 5MG VIAL $- 250 F A TEM UL S I ON 20$ - 250 TEST 25MG/ML 4ML VIAL INJ $- 250 C Y C L OPENTO L A TE 1$ - 250 DIVALPROEX 250MG $- 250 F LU M A ZEN I L 0.1 MG / M L, 10 M L$ - 250 WATER FOR INJ, STERILE 1000ML $- 250 A MOX I C I LL I N 500 MG W / C L A V 125 MG$ - 250 IMIPENEM-CILASTATIN 500MG INJE $- 250 M Y D FR I N 2.5$ - 250 MINERAL OIL HEAVY, 480ML $- 250 R I SPER D A L R I SPER D ONE 2 MG, U / D$ - 250 OXYCODONE 40MG EXTENDED-RELEAS $- 250 P A NC U RON I U M 1 MG / M L, 10 M L I N J$ - 250 Q9966 LOCM 200-299MG/ML IODINE 1ML $- 255 Q 9967 I SO V U E 300 - 150 M L$ 149.00 255 Q9957 INJ PERFLUTREN LIP MICROS 1ML $- 255 Q 9965 L OCM 100 - 199 MG / M L I O D I NE 1 M L$ - 255 Q9967 ISOVUE 370 76% 200ML BTL $139.00255 Q 9955 I N J PERF L EX A NE L I PM I CROS 1 M L$ - 255 A9576 INJ PROHANCE MULTIPACK PER 1 ML $194.00255 Q 9967 I SO V U E 37076$ 39.00 255 Q9950 INJ SULF HEXA LIPID MICROSPH $- 255 Q 9956 I N J OCT A F LU OROPROP A NEM I C 1 M L$ - 255 POTASSIUM CL 20MEQ/0.9% SODIUM $- 258 D EXTROSE 10$ - 258 DEXTROSE 5%/SODIUM CHLORIDE 0. $- 258 J 7070 D EXTROSE 5$ - 258 J7050 SODIUM CHLORIDE 0.9% 250ML INJ $- 258 J 7121 D EXTROSE 5$ - 258 J7060 DEXTROSE 5% 500ML BAG INJ $- 258 J 7030 SO D I U MC H L OR I D E 0.9$ - 258 SODIUM CHLORIDE 0.9% 50ML INJ $- 258 M A NN I TO L 20$ - 258 J7120 RINGERS LACTATE INFUSION TO 1000 CC $- 258 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 105 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SODIUM CHLORIDE 0.9% 100ML INJ $- 258 J 7042 D EXTROSE 5$ - 258 DEXTROSE 5%/SODIUM CHLORIDE 0. $- 258 J 7060 D EXTROSE 5$ - 258 J3490 SODIUM CHLORIDE 0.45% 500ML IN $- 258 D EXTROSE 50$ - 258 DEXTROSE 5% /SODIUM CHLORIDE 0 $- 258 J 7040 SO D I U MC H L OR I D E 0.9$ - 258 BELT PELVIC TRACTION 26X30 $75.00270 S U T U REPRO L ENE 0 CT - 136/ BX$ - 270 INCENTIVE SPIROMETER $58.00270 COB A N 2"$ 17.00 270 CATHETER URETHRAL 8FR $10.00270 V ENO U SPRESS U RE$ 51.00 270 IRRIGATION SET Y TYPE TUR/ $- 270 EN D OTR A C H T U BE 9.5 C U FF$ - 270 TROCAR CATH 20FR 10/BX $- 270 TROC A R 10 MM$ 569.00 270 BLADE,SZ 11 STAINLESS SURGICAL $- 270 B A N D A GEP L A STERP A R I S 2"$ 11.00 270 CATHETER FOLEY 26FR 5CC $20.00270 B A N D A GE W EBR I L 4"$ 6.00 270 SYRINGE SLIP TIP 20CC $10.00270 OX Y GEN / H R - 12 L I TER$ 10.00 270 NEEDLE EAR SUCTION $70.00270 TROC A RC A T H ETER$ 24.00 270 CERVICAL COLLAR SMALL $19.00270 T U BES A L EMS U MP W / SENT 12 FR$ 22.00 270 OXY TANK REFILL /22 CU FT $35.00270 T U B I NGPENROSE 1/2" X 18"$ 8.00 270 MASK AEROSOL-PEDS $11.00270 H U M I D I F I C A T I ONC H A MBER II A U TO$ - 270 CASTING,4”X4YD FIBERGLASS $- 270 MENISCUS MENDER II #10714$ 107.00 270 LUNG VOLUMES $44.00270 SET A D M I N V ENTE D PR I M 60 D R$ 29.00 270 DISP. NDL 22Gx1-1/4”,10BX/CS $- 270 SP L I NT, 1/2 X 9 A LU M I N U MFO A M$ - 270 CATHETER URETHRAL 10FR $10.00270 M I CROBORE 60" EXTSET$ 14.00 270 SPANDAGE ALL SIZES $5.00270 T U BESTOM A C H 18 FRX 50"$ 9.00 270 BANDAGE WEBRIL 2” $7.00 270 PACK NASAL RHINO 7.5CM A-P BIL #752$ 150.00 270 CATHETER FOLEY 30FR 35CC $23.00270 TROC A R, V ERS A PORT V 2 W / F I X A T I ON$ - 270 NEONATAL PERCUSSOR 12/CS $- 270 NEE D L E, 18 G x 1 - 1/2 F I L TER$ - 270 SUTURE PROLENE 3-0 RB-1 36/BX $- 270 T U BEEN D OTR A C H W / H O L D ER 3.0 MM$ 41.00 270 SUSPENSORY SCROTAL SUPPORT SML $41.00270 RE A D I - C A T 2 B A R I U MS UL F A TE$ - 270 SPONGE RHINO ROCHET MED $60.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 106 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION INTUBATION SET JACKSON $- 270 S U T U REP L A I N 054" ST D$ 17.00 270 TRAY OB PRECIPITATE $61.00270 T U BEFEE D I NG 8 FRX 42"$ 9.00 270 KIT CHOLECYSTECTOMY LK001 $1, 080.00270 D RESS I NG A D A PT I C$ 10.00 270 STRAP CLAVICLE-MEDIUM $75.00270 K MO DH E A TT H ER A P Y P U MP$ 7.00 270 MONOSOF 2-0,30”,C17 CUTTING, $- 270 T U BETR A C H W I T H V A L V E A N D C A NN UL A$ 1,061.00 270 RESUSCITATOR-AMBU SET DISP-ADULT $152.00270 A 4565 S L I NG, SM A LL PERSON A L A RM$ 19.00 270 BELT RIBS 30”X36” FEMALE $55.00270 SOFS I L K 3 - 0, 18", C 14 C U TT I NG,$ - 270 TUBE ENDOTRACH W/CUFF 8.5M $27.00270 C A T H ETER H Y STEROSB H 6.8$ 37.00 270 TRAY MINOR SET $185.00270 EN D OTR A C H T U BE 6.0 C U FF$ - 270 TRAY STEINMANN PIN $76.00270 P I NR U S H$ 56.00 270 FULL FACE MASK $219.00270 B L A D E, SZ 10 S U RG I C A L 100/ BX$ - 270 NEEDLE INFUS INTRAOSSEOUS $130.00270 C A T H ETERS U CT I ON 5/6 FR$ 9.00 270 KIT CATHETER INTRODUCER $321.00270 C A T H ETERFO L E Y 8 FR 3 CC$ 33.00 270 ENDOTRACH TUBE 8.5 CUFF $- 270 TR A Y TROC A T H - A D UL T$ 53.00 270 CATHETER FOLEY 26FR 30CC $23.00270 A 4414 STOM A H ES I V E W A FER W / F L EX I .$ - 270 NDL,25Gx3/4 BLOOD COLLECTION $- 270 B A N D A GEP L A STERP A R I S 5"$ 39.00 270 NUGAUZE PLAIN 2” $39.00270 T U BETR A C H EOSTOM Y 26 FRSZ - 4$ 482.00 270 SPLINT REV FING KNUCK BEND $20.00270 S L I PPERFO A M A D UL TME D$ 9.00 270 PACK VAGINAL FURACIN $21.00270 A 6457 B A N D A GE, T U B I GR I PSZ - BE L A S -$ - 270 CATHETER FOLEY 22FR 5CC $27.00270 C A T H ETERM A L ECOT$ 25.00 270 HEEL TIP WALKING $6.00270 BONECEMENT H I P$ 308.00 270 MASK AEROSOL-ADULT $16.00270 C U FF W R I STRESTR A I NT$ 175.00 270 CLOSED INJECTATE DELIVERY $- 270 S I L K B L K BR 30"2 - 0$ 12.00 270 LEAD PACING $882.00270 I MMOB I L I ZER, X - L GS H O UL D ER 1/ E A$ - 270 DISP. NDL 21Gx1”,10BX/CS $- 270 EN D OC L I P II 10 M 6/ CS$ - 270 TUBE,14FR VENTROL LEVIN 50/CS $- 270 PEEP V A L V E A D J U ST A B L E$ 29.00 270 TUBE STOMACH 14FR $9.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 107 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION PAD DUO THERM HEAT DISP $41.00270 TR A Y NEO V - C A T H S I NG L E - LU MEN 2.0 FR$ 532.00 270 DIALYZER DIACAPS LOPS15 20/CS $- 270 G A U ZESTRETC H 6"$ 7.00 270 TROCAR REDUCER 5MM $39.00270 SO D I U MC L I RR I G 3000 CCB A G$ 30.00 270 LUMBO SACRO CORSETT $268.00270 GR A FT D EB A K B I F 19 X 9.5 MM$ 381.00 270 GAUZE STRETCH 2” $7.00270 D Y N A F L EXM UL T I L A Y ERCOMPRESS .$ - 270 GAUZE PETROLATUM 1/2”X72” $13.00270 I NS Y TEC A T H .24 G x 3/4"$ - 270 SUTURE BOOTIES $11.00270 T U BETR A C H EOSTOM Y 39 FRSZ - 10$ 256.00 270 BELT RIBS 42”X48” MEN $76.00270 NEE D L E A - V F I ST UL A$ 9.00 270 ACO-P ANTI COAG SOLUTION $55.00270 PENROSE D R A I N, SZ 18 X 3/410/ BX$ - 270 SUTURE VICRYL 2-0 12/BX $- 270 H U M I D I F I ERB U BB L E 50/ CS$ - 270 TUBE ENDOTRACH W/ HOLDER 2.0MM $19.00270 ET H I L ONB L K MONO 18"3 - 0$ 41.00 270 A6449 BANDAGE,4” ELASTIC 10BX 5BX/CS $- 270 PO L Y SORB 2 - 0, 60", L I G A T I NGREE L$ - 270 COLOSTOMY BAG-ADULT $20.00270 C A T H ETERS U CT I ON 14 FR 22"$ 8.00 270 BANDAGE WEBRIL 6” $11.00270 E 4546 DK 200 M L Q U I C K - F I TTR I P A K$ - 270 MONOSOF 3-0,30”,C13 CUTTING, $- 270 P A C K A RT H ROSCOP Y$ 128.00 270 IRRIGATION SPIKE, VENTED $40.00270 SP L I NT, A CROM I OC L A V I C UL A R 1/ E A$ - 270 IV EXTENSION $8.00270 SP L I NT, 4 X 15 ONE - STEPSCOTC H -$ - 270 TUBE CONICAL GRADUATED 50ML $9.00270 T U BE, Y A N K A U ERS U CT I ON H A N D L E$ - 270 TUBE ENDOTRACH W/ CUFF 9MM $25.00270 H A N D EXERC I SERFO A M$ 11.00 270 SILASTIC SPG-1/4 BLOCK $29.00270 PO U C H ES, 3 X 8 TO W ER D U A L PEE L$ - 270 NEBULIZER REFILL $17.00270 NEE D L E A RG Y L E 3/16$ 26.00 270 SPLINT ONE-STEP 5”X30” $116.00270 TR A YW / BET A D I NES K I NPREP$ 23.00 270 BAIR HUGGER BLANKET UPPERBODY $- 270 P A CEM A K ER L E A D I NTROTEMP$ 53.00 270 DRAINABLE POUCH 1-1/4 $- 270 CR U TC H C U S H I ON$ 16.00 270 REGULATOR,LARGE 2-15 LP $- 270 P A C K C Y STOSCOP Y$ 23.00 270 SET EXTENSION SECUR-LOK MIC $70.00270 C A T H, 3.5 FR U MB V ESSE L 10/ BX$ - 270 TUBING PENROSE 5/8”X18” $11.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 108 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION MONOSOF 3-0,30”,C17 CUTTING, $- 270 I V EXTENS I ON W / LU ER L OC K PE D S$ 9.00 270 SET REPL PERCUT 8.3FR $86.00270 C A T H ETERB A RT H O L I NG L A N D 10/12 FR$ 100.00 270 MONOSOF 1,60”,GS26 TAPER, $- 270 PO U C H ES, 7.5 x 13 D U A L PEE L$ - 270 DUODERM DRESSING 2.5”X2.5” $30.00270 B A N D A GEC A ST I NGT A PE 4" X 4 Y D$ 34.00 270 SPLINT ONE-STEP 3”X12” $54.00270 A 4414 STOM A H ES I V E 1 - 3/4 (45 MM)$ - 270 COLOSTOMY FLANGE-PEDS $30.00270 D i s p os ab l e O x im e t er P ro b e$ - 270 BANDAGE WEBRIL 3” $8.00270 C A T H ETERS I L A ST I C$ 54.00 270 MONITORING KIT PRESSURE INTRA- $- 270 A 6456 B A N D A GE, 3" GE L OC A ST 12 BX / CS$ - 270 SET IV-PEDS $11.00270 OX Y GEN / H R - 14 L I TER$ 11.00 270 A4565 SLING,X-SMALL PERSONAL ARM $19.00270 T U BE, 3.0 MM U NC U FFM / ETR A C H E A L$ - 270 DISP. NDL 22Gx1-1/2”,10BX/CS $- 270 N U G A U ZEP L A I N 1/4"$ 27.00 270 TUBE LUKENS 14FR $11.00270 D I A L Y ZER H I PS 2020/ CS$ - 270 A6448 BANDAGE,2” ELASTOPLAST 36BX/CS $17.00270 D I SP . N D L 26 G x 1/2", 10 BX / CS$ - 270 TUBE,28FR RECTAL 50/BX $- 270 A 4657 S Y R I NGE W / W ON D L$ 84.00 270 TUBE ENDOTRACH W/CUFF 10MM $25.00270 CER V I C A L CO LL A R L A RGE$ 19.00 270 CATH,14FR FOLEY 5CC 2WAY $- 270 T U B I NGPENROSE 5/16" X 18"$ 9.00 270 ENDOTRACH TUBE 5.0 CUFF $- 270 TR A Y E A R I RR I G A T I ON$ 12.00 270 LIMB HOLDER-FOAM CUFF /PR $26.00270 MECON I U M A SP I R A TOR$ 33.00 270 TUBE,3/8 I.D. PENROSE DRAIN $- 270 A I R W A Y, A D UL TSM A LL OR A L 80 MM$ - 270 NEPHRO PERCUTANEOUS 8.3FR $169.00270 C A T H ETERFO L E Y 16 FR 5 CC$ 22.00 270 OXYGEN, LARGE $150.00270 A 4320 I RR I G A T I ONTR A Y P I STONS Y R$ - 270 BLADE MICRO SUPER SHARP $11.00270 V e n t i - M a s k$ - 270 OXYGEN/HR-5 LITER $10.00270 EXTERN A L CSF D R A I N A GES Y STEM$ 654.00 270 TUBE ORAL SUCTION ORAVAC $9.00270 I LL I OSTOM Y D R A I N A B L EPO U C H$ - 270 SPONGE RHINO ROCKET LGE $70.00270 K I TC H O L EC Y STECTOM Y L K 007$ 1,080.00 270 SYSTEM AEROSOL DRAINAGE $- 270 A 6457 B A N D A GE, T U B I GR I PSZ - GE L A S -$ - 270 EXER-TUBING (PER 1 FT) $6.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 109 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION NUGAUZE PLAIN 1/2” $30.00270 P A DD EF I BR I LL A TOR$ 34.00 270 BELT RIBS 42”X48” FEMALE $48.00270 H A N DH E L D NEB UL I ZER K I T$ 11.00 270 SUPPORT WAIST/VEST/CHEST $99.00270 N I PP L ES, S I NG L E H O L E 240/ CS$ - 270 TAPE DRESS MICROPORE 1/2X1 $8.00270 D I SP . N D L 21 G x 1 - 1/2", 10 BX / CS$ - 270 TUBE ENDOTRACH W/CUFF 6.5M $24.00270 MOTORP U MP A L TERN A TOR$ 482.00 270 CATH,8FR DELEE SUCT. W/MUCUS $- 270 L ESSONSRTBR A I N - RE A D / W RT$ 33.00 270 NASAL RAE 4.5 (UNCUFFED) $- 270 I NF A NTBRE A T H I NGC I RC U I T$ 287.00 270 LARYNGEAL MASK AIRWAY S-5 $225.00270 TR A Y M Y E L OGR A M$ 92.00 270 SPLINT,L&L LARGE ANKLE DELUXE $- 270 SP L I NT, R I G H T / ME D W R I ST / FORE A RM$ - 270 DRAIN BAG F/APD 15LITER $- 270 S U T U RET A C I TQ U I C K A NC H OR$ 905.00 270 TUBE RECTAL $9.00270 A RMBO A R D W / CO V ER 5"$ 10.00 270 SHUNT HYDROCEPHALUS $833.00270 D I SP . N D L 21 G x 1 - 1/4", 10 BX / CS$ - 270 LEAD INTRO SUBCLAVIAN 11FR $520.00270 C A T H ETERFO L E Y 18 FR 30 CC$ 30.00 270 KIT,MONITORING W/DOME SINGLE $- 270 I NS Y TEC A T H .22 G x 1"$ - 270 SB123 CONCENTRATE K0 CA 2.5 $- 270 T U BEEN D OTR A C H W / C U FF 8 MM$ 24.00 270 TRAY BURN DRESSING $25.00270 ET H I L ONB L K MONO 30"3 - 0$ 22.00 270 MECONIUM ASPIRATOR 40/CS $- 270 CENTR A L V ENO U S A CCESS K I T$ 28.00 270 A4367 OSTOMY BELT 29-49” LARGE 10/BX $- 270 D I SPOS A B L ETR A NS D U CER K I T$ - 270 HOLDER,PERSONAL LIMB 16/BX $- 270 SETS U CT I ON Y A N K A U ER$ 20.00 270 NEEDLE BIOPSY $27.00270 TROC A RC A T H 8 FR 10/ BX$ - 270 AIRWAY,ADULT LARGE ORAL 100MM $- 270 H EMOEX I TS I TEC H A RGE$ 205.00 270 TRAY TRACHEOTOMY $38.00270 COB A N 1"$ 12.00 270 DRESSING TRANSP 2X3 $6.00270 C A T H ETER U RET H R A L 18 FR$ 13.00 270 TRAY I&D $22.00270 SETTR A C H E A C A RE$ 17.00 270 PADDING,3X4YD SYNTHETIC CAST $- 270 NEE D L E, 15 GX 1 F I ST UL A 50/ BX$ - 270 IV PUMP SET (TUBING) $29.00270 SET U ROG A TE$ 14.00 270 PAD EYE DRESSING $7.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 110 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION DISP. NDL 22Gx1”,10BX/CS $- 270 SET U N D ER W A TER D R A I N$ 65.00 270 SUCTION CANNISTER 2000CC $25.00270 S U T U REST A N D A R D$ 20.00 270 TUBE,14FR STOMACH 50/CS $- 270 T U B I NGPENROSE 7/8" X 18"$ 9.00 270 A4371 STOMAHESIVE POWDER 1OZ $- 270 T U BE, 12 FRX 43 FEE D I NG 10/ BX$ - 270 COLOSTOMY CLAMP-ADULT $19.00270 A RMBO A R D 7" C H I L D$ 12.00 270 PACKING NASAL $10.00270 R A D I A L A RTER Y C A T HK I T 50 S$ - 270 NDL,PRO BLOC II,INSULATED 80MM $- 270 V ESTCR I SS - CROSSRESTR A I NTX L G$ 109.00 270 STOCKING,LARGE ELASTIC 12PR/CS $- 270 L I G A C L I P L T 300 ME D / L GET I T A N I U M$ 54.00 270 INFUSION 19GAx7/8 SET $- 270 CONC H A P A K$ 108.00 270 THERAPLAST CENTRAL SUPPLY ROOM $14.00270 OX Y GEN / H R V ENT I L A TOR$ 31.00 270 TRAY EPIDURAL ANESTHESIA $52.00270 B L A D E, SZ 21 S U RG I C A L 100/ BX$ - 270 GAUZE TUBEGAUZE W/ APPL #4 $240.00270 C A T H ETER I U PMON I TOR I NG$ 218.00 270 SPLINT,5X30 ONE-STEP SCOTCH- $- 270 S Y R I NGE I RR I GC / T I P 50 CC$ 8.00 270 HUMID-VENT-1 $80.00270 TR A Y, PE D / I NF A NT LU M / P U NCT U RE$ - 270 BANDAGE CASTING TAPE 3”X 4 YD $34.00270 D I SP . N D L 23 G x 1", 10 BX / CS$ - 270 CATHETER URETHRAL 16FR $13.00270 A 6457 B A N D A GE, T U B I GR I PSZ - A E L A S -$ - 270 AIRWAY 60MM-PEDS $10.00270 T U BEN A SOG A ST W / SENT 18 FR$ 21.00 270 ARMBOARD W/ COVER 2.5” $10.00270 CER V I C A L CO LL A RME D I U M$ 19.00 270 AIRWAY,60MM NS CHILD ORAL $- 270 A 4413 D R A I N A B L EPO U C H W / F I L TER 44 MM$ - 270 DRESSING TRANSP 4X5 $8.00270 K I TC A T H ETERC A RE$ 6.00 270 PACK,LAPAROTOMY 6PK/CS $- 270 P . E . T U BE$ 54.00 270 HOLLOW FIBER DIALYZER $254.00270 T U BE, 4.0 MMOR A L R A ETR A C H E A L$ - 270 HOPE ADULT NEBULIZER WITH $- 270 SEC . SET 20 D RP V ENT / U N V ENT$ - 270 CATHETER THORACIC 24FR $29.00270 T U BEEN D OTR A C H W / OC U FF 3 MM$ 16.00 270 CIRCUIT VENTILATOR-ADULT $58.00270 TO W ER D U A L PEE L T U B I NG 6 I N$ - 270 SUTURE SUTUPAK 6-12X18” $15.00270 H EMOEMERGENG Y C A RE$ 80.00 270 NEBULIZER W/TEE ADAPTER 50/CS $- 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 111 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SUTURE VICRYL 1 CT-1 36/BX $- 270 S K I NST A P L ES 4 BX / CS$ - 270 A4413 DRAINABLE POUCH W/FILTER 70MM $- 270 TR A Y LU MB A RP U NCT U RE - A D UL T$ 48.00 270 RESUSCITATOR-AMBU SET DISP-PEDS $148.00270 A I R W A Y, TOM A CS I NG L E U SE$ - 270 GAUZE STRETCH 4” $8.00270 SP L I NT, 3 X 12 ONE - STEPSCOTC H -$ - 270 SET TUR SINGLE $43.00270 A D A PTERM A L E D B LLL C L E A RCBP$ 25.00 270 TUBE,4.5MM ORAL RAE TRACHEAL $- 270 SB 111 CONCENTR A TE K 2 C A 3$ - 270 CRUTCH,5’10”-6’6” LARGE ADULT $- 270 A 6453 B A N D A GE, E L A STOP L A ST 1 X 5 Y D$ - 270 PRESSURE MONITOR $205.00270 I . M . V . S Y STEMCOMP L ETE 15/ CS$ - 270 ARMBOARD W/ COVER 18” $10.00 270 SCALPEL BLADE #10 W/ HANDLE$ 10.00 270 BANDAGE ACE 3” $13.00270 C A T H ETERS U CT I ON 18 FR 22"$ 7.00 270 GAUZE DRESSING 2X2 $7.00 270 BLADE SURGICAL #10,11,15$ 6.00 270 HANDLE, YANKAUER SUCTION $- 270 TR A Y T H OR A COTOM Y$ 38.00 270 NEEDLE,21Gx1 MULTISAMPLE $- 270 H EMO V A C 400 M L D . D .1/4"19 F$ 212.00 270 BELT RIBS 30”X36” MEN $54.00270 SPONGE, 12 - 7 MMGE L FO A MSTER I L E$ - 270 GAUZE TUBEGAUZE W/ APPL #1 $15.00270 A EROC H A MBER W / M A S K PE D I A TR I C$ - 270 TUBE,6.0MM ORAL RAE TRACHEAL $- 270 CR U TC H, 3^{'} 5" - 4^{'} C H I L D 10 PR / CS$ - 270 SPLINT FINGER WIRE FOAM $35.00270 B U TTERF L Y 23 G A X 3/4"$ 9.00 270 SURGICAL SPEARS-WECK CEL $5.00270 T U BEEN D OTR A C H W / C U FF 4 MM$ 31.00 270 SET ENTERAL PUMP W/ BAG 1000CC $29.00 270 PACK NASAL RHINO 7.5CM A-P BIL #755$ 475.00 270 PIN HOLDER BOHLER $96.00270 PE D S I NT U B A T I ON K I T 3.5$ 32.00 270 A4615 NASAL CANNULA ADULT W/TUBING $14.00270 CR U TC H T I P$ 13.00 270 PACK ORTHO $63.00270 M A S K B I L I R U B I N$ 27.00 270 RESUSCITATOR MANUAL DISP $15.00270 C A NN I STERS U CT I ON 1500 CC$ 20.00 270 SUTURE CHROMIC 1 CTX 36/BX $- 270 T U BE - TC A TTE LL 12 FR$ 100.00 270 THERABAND (PER 1 FT) $6.00270 M I CRO D ON$ 54.00 270 NEEDLE SPINAL 18GAX5.0” $66.00270 TR A Y C U T D O W N$ 25.00 270 TUBE SALEM SUMP W/ SENT 10FR $22.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 112 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SB111CENTRISOLCA-3.0K20 4GA/CS $- 270 C A ST I NG, 3" X 4 Y D F I BERG L A SS$ - 270 TUBE ENDOTRACH W/ CUFF 6MM $21.00270 C A NN UL A N A S A L O 27 FT - I NF A NT$ 16.00 270 TROCAR CATH 12FR 10/BX $- 270 SETSC A L P V E I N$ 8.00 270 SYRINGE BULB $17.00270 P A C K, CES A RE A NB I RT H 4 P K / CS$ - 270 TROCAR CATH 16FR 10/BX $- 270 L I G A C L I PTC 200 ME D T I T A N I U M$ 31.00 270 TRAY IRRIGATION $15.00270 S Y R I NGEC A T H ETERT I P 60 CC D I SP$ 9.00 270 TUBE,16FR VENTROL LEVIN 50/CS $- 270 SP L I NTF I NGER A LU M 1/2" X 9"$ 15.00 270 PLASTIBELL $6.00270 SET A RTER I A L$ 19.00 270 P.E. BOBBIN $67.00270 A 4657 S Y R I NGE W / W ONEE D L E$ - 270 DISPOSIBLE NEEDLE 25GX5/8 $- 270 BLADE SCALPEL #15$ 6.00 270 SPLINT,SZ 4 PLASTIC FINGER $- 270 STOPCOC K 4 - W A YW / M A L E LU ER$ - 270 SPLINT,LFTHAND/LARGE COLLES $- 270 SET H A L F Y ME D S Y STEM III$ 39.00 270 PEDS INTUBATION KIT 3.0 $32.00270 T U BEEN D OTR A C H W / C U FF 5.5 M$ 24.00 270 SPLINT,1X7 SML THUMB FINGER $- 270 SETMETR I B U RRETRO$ 36.00 270 BANDAGE ACE 6” $19.00270 TR A Y P A R A CENTES I S$ 38.00 270 AIRWAY,26FR NASOPHARYNGEAL $- 270 TR A CT I ONSTR I P (S K I NTR A C) L GE$ 142.00 270 LEAD INTRO SUBCLAVIAN 10FR $520.00270 FEM A L EC A T H ETER K I T$ 44.00 270 NEURO PATTIES 3/4X3/4 $19.00270 V ESTCR I SS - CROSSRESTR A I NT L GE$ 109.00 270 MASK OXYGEN-INFANT $27.00270 PE D I A TR I CBRE A T H I NGC I RC U I T$ - 270 SUTURE CHROMIC 2-0 CT-1 36/BX $- 270 A 6449 ST A - T I TE 3 X 5 E L A ST I CB A N D A GE$ - 270 TUBE ENDOTRACHEAL HOLDER 10/BX $- 270 S U T U RE V I CR L Y 4 - 036/ BX$ - 270 OXYGEN, SMALL $55.00270 V E L CRO (PER 6")$ 6.00 270 TRAY SKIN PREP GEL PVP CBP $25.00270 S Y R I NGE LU ER L OC K T I P 60 CC$ 7.00 270 SUTURE MINI QUICK ANCHOR $880.0027099070 SPEC I A L S U PP L I ESP H Y S / Q H P$ - 270 DRESSING TEGADERM 8INX12IN $28.00270 H E A D - H A L TER W / OB A R - Y O U T H$ 97.00 270 SPLINT FINGER SPRING COIL $35.00270 TR A YV EN I SECT I ON$ 38.00 270 PACK PERI/GYN $44.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 113 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SET IV-ADULT $12.00270 ET H I L ONB L K MONO 18"2 - 0$ 23.00 270 MOUTHPIECE FLOW METER DISP $- 270 B U C K TR A CT I ONSM 1/ E A$ - 270 TUBING PENROSE 1”X18” $9.00270 NEE D L E, D I SP .23 GX 3/4100/ BX$ - 270 A6457 BANDAGE,TUBIGRIP SZ-C ELAS- $- 270 K I TE L ECTR I CBRE A STP U MP$ 48.00 270 SPLINT CAP COIL EXT WIRE FOAM $35.00270 T U BEO 2 CONNECT I NG$ 9.00 270 CANOPIES TENT OXYGEN AERSOL $- 270 D I SP . N D L 18 G x 1 - 1/2", 10 BX / CS$ - 270 A6457 STOCKINETTE,6X30 IMPERVIOUS $- 270 D I SP . N D L 30 G x 1", 10 BX / CS$ - 270 SYRINGE CANNISTER 2GAL $23.00270 NE U ROP A TT I ES 1/2 X 1/2$ 19.00 270 IV EXTENSION W/ STP COCK $15.00270 L A R Y NGE A L M A S K A I R W A Y SZ - 1.5$ 227.00 270 TUBING CONNECTING 1/4”X12’ $17.00270 S U T U REPRO L ENE 3 - 0 K S 36/ BX$ - 270 CATHETER FOLEY 12FR 30CC $25.00270 C A T H ETER U RET H R A L 12 FR$ 10.00 270 OXISENSOR-INFANT $114.00270 S U RG I G U T 4 - 0, 18", P 12 C U TT I NG,$ - 270 SUTURE VICRYL 4-0 KS 36/BX $- 270 A 6449 B A N D A GE, 3" E L A ST I C 10 BX 5 BX / CS$ 32.00 270 SPLINT,X-LARGE CLAVICAL 4-WAY $- 270 [R o w s 16001 - 17000 :] CPT / H CPCSMO D I F I ERC H A RGE D ESCR I PT I ONPR I CERE V EN U ECO D ECO D EN D L, 22 G x 3/4 GR I PPERPORT - A -$ - 270 AIRWAY,32FR NASOPHARYNGEAL $- 270 S I GMO I D OSCOPE$ 20.00 270 MASK OXYGEN-PEDS $16.00270 S U T U RERETENT I ONBR I D GE$ 54.00 270 SET REPL PERCUT 10FR $86.00270 W R A P, A N K L EE L A ST I CSZ U N I V$ - 270 TRAY NASAL $11.00270 T U BE, 5 FRX 36" FEE D I NG 50/ BX$ - 270 Non-Rebreather Mask $- 270 SETS U CT I ONPOO L E$ 30.00 270 SUPPORT,SMALL CRISSCROSS/LUMBO $- 270 N I PROF I ST UL A NEE D L E 15 GX 1$ - 270 IRRIGATION SPIKE, NONVENTED $45.00270 NEE D L EM UL T I - S A M 21 G A X 1"$ 6.00 270 CLAMP INSERTS 86MM F/F CBP $220.00270 EN D O L OOP V I CR Y L$ 169.00 270 FILTER-MASK POCKET $12.00270 T U BETR A C H EOSTOM Y 30 FRSZ - 6$ 346.00 270 SILK BLK BR 18” 4-0 $22.00270 D R A I N A B L EPO U C H 1 - 3/4"$ - 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 114 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION A6450 STA-TITE 6X5 ELASTIC BANDAGE $- 270 C A T H ETERT H OR A C I C 32 FR$ 28.00 270 DRESSING MICROSURG 2X4 $10.00270 A I R W A Y, 24 FRN A SOP H A R Y NGE A L$ - 270 FELT ORTHO 1/4” $26.00270 SETS U T U REREMO V A L D I SP$ 11.00 270 MONOSOF 5-0,18”,C13 CUTTING, $- 270 C A T H ETERFO L E Y 20 FR 30 CC$ 22.00 270 LIGACLIP TC300 LGE TITANIUM $40.00 270 A4206 1 CC sterile syringe&needle$ - 270 Q4029 CAST SUP LONG LEG ADULT PLASTER $- 270 SP L I NTCO LL ES (Z I MMER)$ 35.00 270 TROCAR 5MM $582.00270 N U G A U ZE I O D OFORM 1/4"$ 29.00 270 LEAD INTRO SUBCLAVIAN 12FR $520.00270 T U BE, C L E A RN / CON D U CT I V ECONN .$ - 270 OXYGEN ANALYSIS/ANALYSER $38.00270 C U FF A N K L ERESTR A I NT$ 175.00 270 CUSHION INVALID RING $23.00 270 BLADE SURGICAL CLIPPER #9660$ 26.00 270 CATHETER FOLEY 12FR 5CC $20.00270 C A T H ETERP LU G$ 7.00 270 T-CONNECTOR WITH M.L.S. $12.00270 C A T H, 5 FR U MB V ESSE L 10/ BX$ - 270 TUBING PENROSE 1/4”X18” $9.00270 SO D A SORB 12/ CS$ - 270 BANDAGE CASTING TAPE 5”X 4 YD $40.00270 H E A D - H A L TER W / OB A R - A D UL T$ 97.00 270 SUTURE VICRYL 3-0 CT-1 12/BX $- 270 D I A L Y ZER D I A C A P H I F L O 2320/ CS$ - 270 TRAY MINOR SUTURE $27.00270 C A T H ETER U MB I L I C A L A RT 3.5 FR$ 63.00 270 TUBE TRACHEOSTOMY 36FR SZ-8 $439.00270 ST U MPSOC K$ 34.00 270 SPLINT ONE-STEP 4”X15” $77.00270 S K I NB A RR I ER W / F L O A T I NG 57 MM$ - 270 ADULT,LUMBER PUNCTURE TRAY $- 270 NEE D L E, 16 G x 1 F I ST UL A 50/ BX$ - 270 SURGIPRO 3-0,36”,V20 TAPER, $- 270 A 4565 S L I NG, ME D I U MPERSON A L A RM$ 19.00 270 KIT IV PREP W/ CHLORAPREP $7.00270 M I N I C A T H W / O 19 - 21$ 8.00 270 BREAST PUMP $23.00270 C A T H ETERFO L E Y 24 FR 30 CC$ 23.00 270 TUBE ENDOTRACH W/CUFF 7.5M $21.00270 SETENEM A D I SP$ 13.00 270 MONOSOF 6-0,18”,C12 CUTTING, $- 270 D I SP . L A RGE V O LU MENEB UL I ZER$ - 270 A6449 BANDAGE,4” ELASTOPLAST 36BX/CS $26.00270 S L I PPERFO A M Y O U T H$ 7.00 270 TUBE ESOPHAGEAL COMBITUBE $260.00270 C A T H ETERS U CT I ON A RG Y L E 10 FR$ 68.00 270 CVP CATHETER $107.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 115 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION RESUSCITATOR INFANT W/RELIEF $- 270 PO U C H ES, 5 - 1/2 X 10 TO W ERSE L F$ - 270 CERVICAL COLLAR-PEDS $38.00270 N A S A L R A E 4.0 (U NC U FFE D)$ - 270 OXYGEN/HR-10 LITER $15.00270 K A NG A ROOFEE D I NGB A G 1600 M L$ - 270 BANDAGE CASTING TAPE 2”X 4 YD $23.00270 A 4615 N A S A L C A NN UL A PE D 50/ CS$ 13.00 270 CRUTCHES ADJ-YOUTH $86.00270 SP I N A L NEE D L E 25 GX 3 - 1/2$ - 270 A6449 STA-TITE 4X5 ELASTIC BANDAGE $- 270 A 6448 B A N D A GE, 2" E L A ST I C 10 BX 5 BX / CS$ - 270 TRAY CERVICAL BIOPSY $27.00270 TR A Y, B A S I CB I OPS Y 10/ CS$ - 270 TRAY PER-Q-CATH SINGLE-LUMEN 2.0FR $213.00 270 BLADE SCALPEL #12$ 6.00 270 TRAY LIVER BIOPSY $22.00270 C A T H ETERT H OR A C I C 28 FR$ 24.00 270 MINI RESUSCITATION EQUIP BAG $- 270 D I SP . N D L 18 G x 1", 100 BX 10 BX / CS$ - 270 VENTILATOR,CIRCUIT DISPOSABLE $- 270 SP L I NT, RG H T H A N D / ME D CO LL ES$ - 270 REGULATOR,SMALL 2-15 LP $- 270 D I A L Y ZER H I PS 1520/ CS$ - 270 ADAPTER,AEROSOL T 50/CS $10.00270 G A U ZE V A SE L I NEPRE - P A C K$ 8.00 270 REGULATOR,OXYGEN SMALL 1/EA $- 270 CR U TC H, 4^{'} 1" - 4^{'} 10" Y O U T H$ - 270 ENDOTRACH TUBE 6.5 CUFF $- 270 T U BEEN D OTR A C H RE I NFORCE D 7.5 FR$ 330.00 270 SUTURE VICRYL 2-0 CT-1 12/BX $- 270 L A R Y NGE A L M A S K A I R W A Y SZ - 3$ 227.00 270 INTUBATION SET CATALAND LACH $- 270 A RMBO A R D 5" x 1 FT x 7" CO V ERS$ - 270 KIT EPIDURAL CATH REPAIR $555.00270 UL TR A T U B I NG Y - SET$ 35.00 270 A4414 STOMAHESIVE WAFER SZ-32(1-1/4) $- 270 H OPEPE D I A TR I CNEB UL I ZER$ - 270 MORGAN MEDI-FLO LENS $125.00270 ET H I L ONB L K MONO 18"4 - 0$ 42.00 270 NEEDLE INTRACATH $24.00270 NEE D L E, 25 GX 5" T WW H I T A CRE$ - 270 NEEDLE,19Gx1-1/2 FILTER THIN $- 270 S K I NB A RR I ER W / F L O A T I NG 70 MM$ - 270 BIPAP CIRCUIT ADULT $62.00270 G A U ZEXEROFORM 5" X 9"$ 10.00 270 BELT PELVIC TRACTION 48X64 $84.00270 A I R W A Y, 20 FRN A SOP H A R Y NGE A L$ - 270 SUPPORT LUMBOSACRAL MED/LGE $131.00270 B L A D EG I G L I S A W$ 35.00 270 NUGAUZE IODOFORM 8”X10YD $161.00270 T U BETR A C H EOSTOM Y NEO 3.0$ 355.00 270 JUGULAR GRNFLD V.CAVA FILT $1,960.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 116 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION COLOSTOMY BAG-PEDS $24.00270 A 6266 I O D OFORMP A C K I NGSTR I P 1/4 I N$ - 270 TRAY GAUZE 4X4 $9.00270 CONNECTOR - T W / M A L E LU ER$ 10.00 270 GAUZE FURACIN $9.00270 GR A D U A TE D CONT A I NER$ 7.00 270 FINGER PRESSURE WRAP $22.00270 TO W ER D U A L PEE L T U B I NG 4 I N 1 M L$ - 270 COBAN 3” $20.00270 CR U TC H, 5^{'} 2" t o 5^{'} 10" ME D I U M$ - 270 PADDING,6X4YD SYNTHETIC CAST $- 270 RESER V O I RS U CT I ON 100 M L S$ - 270 DRESSING TEGADERM 6INX6IN $23.00270 A D A PTER, METER D OSE I N H A L ER$ - 270 A6448 Lt compres band <3”/yd $- 270 T U B I NGCONNECT I NG 3/16" X 6^{'}$ 10.00 270 SET PUMP FLEXIFLO $15.00270 SP I R A L E L ECTRO D E 50/ CS$ - 270 BLADE STR FLUTE STERNUM $128.00270 STOC K I NG, ME D I U ME L A ST I C$ - 270 BANDAGE SLING $10.00270 C A T H ETER U RETER A L CONET I P 6 FR$ 55.00 270 LARYNGEAL MASK AIRWAY SZ-1 $227.00270 B A N D A GEP L A STERP A R I S 4"$ 20.00 270 POLYCUSHION 6”X6” $6.00270 TROC A RC A T H 32 FR 10/ BX$ - 270 BAIR HUGGER BLANKET PEDIATRIC $- 270 T U BE, 3.5 MMOR A L R A ETR A C H E A L$ - 270 C2627 CATH SUPRAPUBIC/CYSTOSCOPIC $- 270 K I TFET A L SC A L PP H$ 18.00 270 PACK C/S BIRTH $117.00270 TR A Y, P A R A CER V I C A L P U D EN D A L$ - 270 SHUNT VENTRI PERITONEAL $741.00270 NEE D L E L OOSEE Y E$ 7.00 270 MITTS SECURE $179.00270 I V SM 20 - D ST A TM A STER$ 9.00 270 TRAY TRACH INTRODUCER 100-A-HC $896.00270 P A C K, OBSTETR I C A L 6 P K / CS$ - 270 SPLINT,LEFT/LG WRIST/FOREARM $- 270 MONOSOF 6 - 0, 18", C 13 C U TT I NG,$ - 270 SUPPORT LUMBOSACRAL SML/MED $258.00270 OX Y GEN / H R - 4 L I TER$ 9.00 270 HEMO ACUTE CARE 1HR $194.00270 J ET - OX Y GEN H U D SON H U M I D I F I ER$ - 270 PLASTER ORTHOPLEX $25.00270 N A S A L R A E 6.0 (U NC U FFE D)$ - 270 CRUTCH HAND GRIP $16.00270 H A N D GR I PSPR I NG$ 14.00 270 CATH,8FR UMB VESSEL 10/BX $- 270 H EMO D I A L Y S I SC A T H ER I Z A T I ON$ - 270 SUSPENSORY SCROTAL X-LGE $50.00270 NEE D L ESP I N A L 20 G A X 3 - 1/2"$ 13.00 270 AMNIHOOK AMNIOTIC MEMBRANE $22.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 117 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION A6457 BANDAGE,TUBIGRIP SZ-F ELAS- $- 270 A 6457 B A N D A GE, T U B I GR I PSZ - EE L A S -$ - 270 CATH-URETERAL CONE TIP 8FR $165.00270 NEE D L E, 18 G x 3 - 1/2 SP I N A L 25/ BX$ - 270 TUBE ENDOTRACH W/ HOLDER 2.5MM $44.00 270 GAUZE TUBEGAUZE W/ APPL #2$ 15.00 270 SPLINT FINGER EXT WIRE FOAM $34.00270 C A T H ETERFO L E Y 14 FR 30 CC$ 26.00 270 DIANEAL SOLN 1.5% 2L BAG $45.00270 N U G A U ZEP L A I N 1"$ 28.00 270 INSYTE CATH. 18Gx1-1/4” $- 270 F L EX I B L EENEM AA D M I N U N I T$ - 270 CATHETER FOLEY 10FR 5CC $25.00270 SP L I NT, SZ 1 P L A ST I CF I NGER$ - 270 STOCKING,X-LARGE ELASTIC $- 270 I N J ECTORSTER I L E D I SP$ 461.00 270 SLIPPER FOAM ADULT X-LGE $8.00270 ST A P L EZ I M A L O Y$ 67.00 270 NASAL CANNULA INFANT OXYGEN $- 270 H EMO K I T W / O U T D I A L Y ZER$ - 270 CERVICAL COLLAR-INFANT $38.00270 P A C K, EXTREM I T Y 6 P K / CS$ - 270 CASTING,2”X4YD FIBERGLASS $- 270 STER I L E, L A PSPONGE 18 X 185 P K$ - 270 OXYGEN/HR-13 LITER $11.00270 STR A P, SM A LL C L A V I C L E 4 - W A Y$ - 270 NEEDLE,17Gx1 FISTULA 50/BX $- 270 R U 60 RE L O A D$ 66.00 270 SUPPORT LUMBOSACRAL LGE $117.00270 N A S A L R A E 3.5 (U NC U FFE D)$ - 270 CATHETER THORACIC 20FR $20.00 270 SPLINT,L&L MED ANKLE DELUXE$ - 270 ARMBOARD FOAM ADULT 100/CS $- 270 SP L I NT, 1 X 18 A LU M I N U MFO A M$ - 270 TUBE GASTROSTOMY 14FR $110.00270 NEE D L ESP I N A L 25 G A X 3 - 1/2"$ 14.00 270 OXYGEN/HR-1 LITER $6.00270 P A C K, C Y STO 14 P K / CS$ - 270 CONNECTOR PLASTIC $7.00270 A I R W A Y 100 MM - A D UL T$ 10.00 270 CERVICAL COLLAR FOAM LGE $46.00270 SET A D M I NGR A V I T Y F L O W$ 40.00 270 NEPHRO PERCUTANEOUS 10FR $184.00270 D I SP . N D L 19 G x 1 - 1/2", 10 BX / CS$ - 270 DISP. NDL 27Gx1/2”,10BX/CS $- 270 C I RC U I T, NC 3 L 20/ CS V I T A L S I GN$ - 270 CRUTCHES ADJ-ADULT MED $90.00270 EN D OTR A C H T U BE 9.0 C U FF$ - 270 SILK BLK BR 18” 2-0 $22.00270 OX Y GEN, ME D I U M$ 100.00 270 TUBE NASOGAST W/ SENT 14FR $17.00270 P A CE A I D M A C H I NE$ 128.00 270 TUBING PRESSURE 48” CBP $20.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 118 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION BOOTS,LARGE VINYL CAST $- 270 N A S A L R A E 5.5 (U NC U FFE D)$ - 270 SPLINT,3/4X18 ALUMINUM FOAM $- 270 REG UL A TOR, OX Y GEN L A RGE 1/ E A$ - 270 SUTURE SUPER QUICK ANCHOR $955.00270 NEE D L E, M A GNET I CM A T D I SP 20 CT$ - 270 SUTURE VICRYL 4-0 FS-2 36/BX $- 270 BRONC H I A L D O U B L E - LU MENT U BE$ - 270 BLADE SCALPEL #10 $6.00270 S L I PPERFO A MSM A LL$ 7.00 270 BELT RIBS 36”X42” FEMALE $44.00270 SP L I NTONE - STEP 2" X 10"$ 47.00 270 KIT,5.5FR PED. MULTI-LUMEN $- 270 SP L I NT, SETP L A ST I CF I NGER$ - 270 PT-HOT PACKS-15 MIN $32.00270 C A ST I NG, 5" X 4 Y D F I BERG L A SS$ - 270 NEEDLE BX TRAVENOL $154.00270 B L A D E H A LL STR A I G H T$ 39.00 270 PLEUR EVAC ADULT/PEDIATRIC $- 270 C A T H ETERTROC A R 10 FR$ 90.00 270 PLUG DECANNULATION $44.00270 SP L I NT, R I G H T / L G W R I ST / FORE A RM$ - 270 COMPRESSOGRIP BAND (/1 FT) $9.00270 S H EEN Y I NC U SREP L A CE$ 210.00 270 HEAD-HALTER $27.00270 H EMO A C U TEC A RE A FTER 1 ST H O U R$ 144.00 270 NIPPLE NEWBORN ORTHO 250/CS $- 270 STR A PC L A V I C L E - X L A RGE$ 85.00 270 HME-ADULT FLEX 50/CS $- 270 I V A NG I OC A T H 20 G A X 1 - 1/4$ 13.00 270 SET CONT BLADDER IRRIG $26.00270 C A T H ETERFO L E Y 24 FR 5 CC$ 20.00 270 BLADE SCALPEL #11 $6.00270 C A T H, 10 FRS U CT I ONC A T H / G L O V E$ - 270 LANCET FINGER BLOOD $6.00270 C I RC U I TB I P A P D I SPOS A B L E 10/ CS$ - 270 TUBE,7.5MM ORAL RAE TRACHEAL $- 270 T U B I NGP L A ST I CEMERSON$ 76.00 270 SPLINT,SZ 2 PLASTIC FINGER $- 270 D I SP . N D L 25 G x 1", 10 BX / CS$ - 270 HUBER INFUSION SET(GRIPPER) $- 270 C I RC U I T, 4 FT . I NF A NTRESP .$ - 270 MDI INLINE MULTI ADAPTOR $12.00270 T U BE, 5.0 MMOR A L R A ETR A C H E A L$ - 270 ANALYZER-AV PACING SYSTEM $698.00270 STOM AA DH ES I V E 4 X 4/ E A$ 25.00 270 SPLINT ONE-STEP 5”X45” $142.00270 CO LL A RTR A C H$ 49.00 270 NEEDLE,20Gx3-1/2 SPINAL 25/BX $- 270 T U BESTOM A C H 16 FRX 50"$ 9.00 270 VEST CRISS-CROSS RESTRAINT MED $109.00270 SPONGER H I NOROC K ETX L GE$ 85.00 270 GAUZE SURGITUBE 5/8”/2FT $1.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 119 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SPLINT,MEDIUM CLAVICAL 4-WAY $- 270 NEB UL I ZER W / T - A D A PTOR$ 12.00 270 TUBE GASTROSTOMY 24FR $113.00270 C A T H ETERS U CT I ON 10 FR 22"$ 8.00 270 TUBE ENDOTRACH REINFORCED 7.0 FR $330.00270 CONTPOS A I R W A Y PRESS U RE$ 16.00 270 TIP SUCTION YANKAUER $10.00270 C A T H ETERFO L E Y 30 FR 5 CC$ 23.00 270 FILTER PALL $22.00270 N A S A L R A E 7.0 (C U FFE D)$ - 270 INJECTION CAP $6.00270 S U SPENSOR Y SCROT A LL GE$ 34.00 270 SUPPORT,12” MED LUMBOSACRAL $- 270 Q 4025 C A STS U P H I PSP I C AA D UL TP L A STER$ - 270 CATHETER DUAL LUMEN 11.5FRX13.5CM $524.00270 N I PP L EPREM A T U RE 250/ CS$ - 270 BUTTERFLY 25GAX3/8” $10.00270 A 6449 B A N D A GE, 3" E L A STOP L A ST 36 BX / CS$ - 270 MINICATH WTIH 19-21 $13.00270 C A T H ETER U RETER A L F L EX I T I PRT$ 80.00 270 TUBE ENDOTRACH W/O CUFF 3.5MM $29.00270 G A U ZEGE L FO A M$ 31.00 270 TUBE-T CATTELL 16FR $100.00270 C A T H ETER U RETER A L CONET I P 5 FR$ 85.00 270 PEDS INTUBATION KIT 2.5 $41.00270 C A T H ETER U RET H R A L 20 FR$ 13.00 270 TUBE, VACUTAINER LI HEP PLASMA $- 270 TROC A RC A T H 24 FR 10/ BX$ - 270 TUBE,3.0MM ORAL RAE TRACHEAL $- 270 A I R W A Y 80 MM - A D UL T$ 10.00 270 OXYGEN/HR-3 LITER $8.00270 F I NGERCOT - SM L$ 14.00 270 LIGACLIP LS300 LGE STEEL $44.00270 M I N I M A SS A GER$ 100.00 270 CANNISTER SUCTION 1200CC $30.00270 V E L A FO A M (PER 6")$ 9.00 270 ENDOTRACH TUBE 5.5 CUFF $- 270 C A T H, 12 FRFO L E Y 5 CC 12/ BX$ - 270 SET IV BLOOD-VI9 $18.00270 SET U RETER A L BR U S H B I OPS Y$ 71.00 270 RESUSCITATOR ADULT W/RELIEF $- 270 BE L TR I BS 24" X 30" FEM A L E$ 40.00 270 SILK BLK BR 18” 3-0 $18.00270 T U BEEN D OTR A C H W / C U FF 5 MM$ 23.00 270 POUCHES,4X8 TOWER DUAL PEEL $- 270 PO L Y SORB 3 - 0, 36" GS 21 T A PER,$ - 270 TUBE ENDOTRACH UNCUFF 4.0MM $41.00270 SP L I NT, L A RGEC L A V I C A L 4 - W A Y$ - 270 TRACTION STRIP (SKIN TRAC) MED $61.00270 C A T H ETER U MB I L I C A L A RT 5 FR$ 15.00 270 CYSTO SUPUB DRAIN 330-8 $97.00270 NEE D L E V ERESS 150 MM D I SP$ 256.00 270 CATHETER THERMOD VIP $735.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 120 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION BANDAGE PLASTER PARIS 6” $45.00270 GR A FT D EB A K E Y B I F 16 X 8 MM$ 381.00 270 KIT,BRIDGE TRANSDUCER $- 270 PROMPT I NOC UL A T I ONS Y STEM - D$ - 270 LEAD INTRO SUBCLAVIAN 9FR $1, 056.00270 I NF A NT D I SPOS A B L ESENSOR$ - 270 NASAL RAE 7.5 (CUFFED) $- 270 S U T U RE V I CR Y L 0 CT - 136/ BX$ - 270 BELT RIBS 36”X42” MEN $72.00270 CO LL A R, SM A LL CER V I C A L 1/ E A$ - 270 TROCAR CATH 28FR 10/BX $- 270 S U SPENSOR Y SCROT A L ME D$ 47.00 270 SB152 CONCENTRATE LOW CALCIUM $- 270 C A T H ETER D U A LLU MEN 11.5 FRX 19.5 CM$ 557.00 270 BLADE DERMATONE $41.00270 S U RG I G U T 1, 60", L I G A T I NGREE L,$ - 270 FLEXI CUFF W/RETENTION 48/CS $- 270 T U BEEN D OTR A C H W / C U FF 4.5 M$ 31.00 270 AIRWAY,ADULT MEDIUM ORAL 90MM $- 270 SP L I NT K N U C K L EBEN D ER$ 20.00 270 BALL URET DIL SET 5FRX65CM $200.00 270 SCALPEL BLADE #15 W/ HANDLE$ 10.00 270 CATHETER CUTDOWN $9.00270 A RMBO A R D W / CO V ER 4"$ 10.00 270 STRAP,LARGE CLAVICLE 1/EA $- 270 N I PROF I ST UL A NEE D L E 17 G A$ - 270 TAPE UMBILICAL 1/8”X18” $7.00270 BONECEMENT K NEE$ 219.00 270 NEBULIZER PREFILLED $15.00270 OX Y GEN / H R - 9 L I TER$ 14.00 270 CATHETER SUCTION 8FR DELEE $13.00270 S U PPORT, L A RGECR I SSCROSS / LU MBO$ - 270 BLOOD PUMP $31.00270 STOC K I NG, SM A LL E L A ST I C 12 P K / BX$ - 270 CATHETER FOLEY 28FR 5CC $20.00270 A RTER I A L - V ENO U ST U B I NG$ 70.00 270 TRACHTALK $69.00270 A I R W A Y, 40 MMNEON A T A L 12/ BX$ 10.00 270 NEEDLE INTRAOSSEOUS $29.00270 A EROC H A MBER A D UL T$ - 270 NEEDLE, DISP. 23GX1 100/BX $- 270 S U T U RE V I CR Y L 2 - 0 S H 12/ BX$ - 270 A6209 Foam drsg ⇐16 sq in w/o bdr $- 270 P A DD I NG, 4 X 4 Y D S Y NT H ET I CC A ST$ - 270 LIGACLIP TC400 XLGE TITANIUM $51.00270 S Y R I NGE I NS UL I N 1 CCM / F I NE$ 6.00 270 TRAY TROCATH-INFANT $53.00 270 BLADE SCALPEL #20$ 6.00 270 SET H4500 FEED $17.00270 NEE D L EBONEM A RRO W 18 G A$ 128.00 270 GAUZE SURGITUBE 1”/2FT $2.00 270 Y & ELBOW W/PRESSURE SENSOR$ - 270 IMMOBILIZER,18” PERFORATED $- 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 121 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION PACK LAP $51.00270 T U BETR A C H EOSTOM Y X L T 6.0 MM$ 555.00 270 TUBE LARYNGECTOMY W/ROT LO $58.00270 A RTER I A LL I NE A RRO W$ 51.00 270 SUTURE VICRYL 3-0 12/BX $- 270 RES U SC I T A TOR - A MB U SET D I SP - I NF A NT$ 93.00 270 TROCAR BLUNT TIP 12 MM DISP $905.00270 T U BEOR A L R A EC U FFE D 5.0 MM$ 30.00 270 SET IV CARTRIDGE-NEONATAL $16.00270 C A T H ETERTROC A R 16 FRSTR L$ 36.00 270 DISP. NDL 20Gx1-1/2”,10BX/CS $- 270 EN D O L OOPC H ROM I C$ 154.00 270 KIT VESSEL CATHETERIZATION 20GA $131.00270 T U BE, 5.5 MMOR A L R A ETR A C H E A L$ - 270 SPLINT,L&L SMALL ANKLE DELUXE $- 270 L A R Y NGE A L M A S K A I R W A Y S - 4$ 225.00 270 KIT,PERCATHANEOUS SHEATH $- 270 SET 2 Y ME D S Y STEM III$ 69.00 270 TRAY URETHRAL CATHETERIZATION 14FR $20.00270 ST A P L ES K I NEXTR A CTOR$ 41.00 270 AIRWAY,34FR. NASOPHARYNGEAL $- 270 T U BEEN D OTR A C H W / C U FF 7 MM$ 23.00 270 ANOSCOPE DISP $12.00270 A 4406 STOM A H ES I V ET U BESQ 1830$ - 270 Partial Rebreather Mask $- 270 NEE D L ESP I N A L 22 G A X 1 - 1/2"$ 15.00 270 BLADE,SZ 22 SURGICAL 100/BX $- 270 S U RG I G U T 3 - 0, 30", GS 21 T A PER,$ - 270 DISP. NDL 23Gx3/4”,10BX/CS $- 270 SPONGE K I TNER$ 23.00 270 JACKSON-PRATT SILICONE DRAIN $- 270 SET I V C A RTR I D GE - A D UL T$ 16.00 270 A6456 BANDAGE,4” GELOCAST 12BX/CS $- 270 T U BETR A C H EOSTOM Y NEO 3.5$ 355.00 270 SPLINT HAND COCK-UP $94.00270 H EMORR H O I D O - R I NGS 1 - 10$ 15.00 270 OXYGEN/HR-8 LITER $13.00270 K I T, A RRO WV ESSE L C A T H . (S L, 20 G)$ - 270 SUTURE LABRYNTH 12X18” $70.00270 G A U ZESTRETC H 3"$ 8.00 270 TRAY MAJOR SET $233.00270 D I SP . N D L 25 G x 1 - 1/2", 10 BX / CS$ - 270 SYRINGE SLIP TIP 30CC $10.00270 K I TPORT - A - C A T H 9 FR - PRE A SB L$ 1,030.00 270 STOPCOCK, 3 WAY W/FEMALE LL $- 270 PE A K F L O W METER, S U BSEQ U ENT$ 38.00 270 PEDS INT JUG PUNCT KIT $45.00270 C A T H ETERFO L E Y 10 FR 30 CC$ 20.00 270 HEMO KIT 20/CS $- 270 C A T HK I T I NF A NT 5 FR$ 23.00 270 CATHETER FOLEY 28FR 30CC $22.00270 SET I V A D M I N H EMO$ 9.00 270 TUBE ENDOTRACH W/CUFF 9.5M $26.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 122 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION ADAPTER,TRACH T 50/CS $- 270 NEE D L ESP I N A L 22 G A X 3 - 1/2"$ 13.00 270 PURSE STRING DEVICE $143.00270 C A B L E, I N V A S I V EMON I TOR I NG,$ - 270 A4358 Urinary leg or abdomen bag $- 270 H E A TREF L ECT I NGP A TC H ES 100 BX$ - 270 STRAP CLAVICLE-SMALL $70.00270 STR A PC L A V I C L E - L A RGE$ 80.00 270 NDL,23Gx3/4 BLOOD COLLECTION $- 270 W ETMO U NT, B A CTER I A F U NG I$ 28.00 270 CERVICAL COLLAR FOAM MED $57.00270 T U BEEN D OTR A C H W / C U FF 3.5 M$ 17.00 270 AIRWAY 90MM-ADULT $10.00270 T U BE, 4.0 MMEN D OTR A C H E A L 10/ BX$ - 270 TUBE NASAL RAE CUFFED 3.5MM $33.00270 D I A NE A L SO L N 4.25$ 45.00 270 SPLINT,1X19 MED THUNB FINGER $- 270 D R A I N A B L EPO U C H 1 - 1/4 W /10$ - 270 SUTURE VICRYL 3-0 SH 12/BX $- 270 BLADE SCALPEL #21$ 6.00 270 STOPCOCK, 3 WAY W/EXTENSION $- 270 M A I C I RC U I T D I SP$ 34.00 270 PROTECTION PACK $11.00270 A I R W A Y, 30 FRN A SOP H A R Y NGE A L$ - 270 OXYGEN/HR-11 LITER $10.00270 D PT - 448 D E L TR A N I V D I SPOS I B L E$ - 270 IRRIGATION PUMP $25.00270 L E A D I NTROS U BC L A V I A N 8 FR$ 114.00 270 IV SM60-D STAT MASTER $9.00270 PRO L ENE 5.030 I N 36/ BX$ - 270 TUBE NASOGASTRIC 20FR-ADULT $485.00270 T U B I NGPENROSE 3/8" X 18"$ 14.00 270 CERVICAL COLLAR-FELT $72.00270 OX Y T A N K REF I LL /11 C U FT$ 21.00 270 CATHETER URETHRAL 26FR $10.00270 A 4565 Sl in g s$ - 270 SPLINT,X-SMALL CLAVICAL 4-WAY $- 270 F I NGERCOT - ME D$ 14.00 270 CATHETER FOLEY 3-WAY $107.00270 K I TS U CT I ONC A T H ETER$ 28.00 270 NEEDLE SPINAL 18GAX3-1/2” $17.00270 T U BEEN D OTR A C H U NC U FF 5.0 MM$ 44.00 270 A4913 MISC DIALYSIS SUPPLY $27.00270 K I T - MON - 1295 K MS I NG L E L I NE$ 229.00 270 PEAK FLOWMETER, INITIAL $166.00270 EN D OTR A C H T U BE 8.0 C U FF$ - 270 A4615 Cannula nasal $- 270 T U B I NGCORR U G A TE D$ 16.00 270 SET PUMP KANGAROO SCREW CAP $19.00270 TR A Y LU MB A RP U NCT U RE - PE D S$ 53.00 270 PACK,LAPAROSCOPY 10PK/CS $- 270 B A N D A GE A CE 4"$ 14.00 270 SUTURE VICRYL 0 UR-6 36/BX $- 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 123 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION CERVICAL COLLAR X-LARGE $19.00270 A RMBO A R D W / CO V ER 9" D I SP$ 10.00 270 TUBE-T CATTELL 18FR $105.00270 NEE D L EGR I PPERPORT - A - C A T H$ 35.00 270 CRUTCH TIP WIDE BASE $17.00270 B L A D E, SZ 15 S U RG I C A L 100/ BX$ - 270 TUBE SALEM SUMP W/ SENT 16FR $7.00270 T U BEEN D OTR A C H W / OC U FF 2.5 MM$ 12.00 270 GAUZE XEROFORM 1”X8” $15.00270 K I TOB V A C UU M D E L I V ER Y$ 321.00 270 SLIPPER FOAM-ADULT $8.00270 A 6450 B A N D A GE, 6" E L A ST I C 50/ CS$ - 270 TRAY TRACH INTRODUCER 100-HC $922.00270 A 6457 B A N D A GE, T U B I GR I PSZ - D E L A S -$ - 270 INSYTE CATH. 20Gx1-1/4” $- 270 S U CT I ONC A NN I STER L I NER 1500 CC$ 16.00 270 TUBE,7.0MM ORAL RAE TRACHEAL $- 270 NEE D L E, 14 G x 4.5 B I OPS Y 10/ BX$ - 270 SUTURE PLAIN GUT 0 12/BX $- 270 C I RC U I T V ENT I L A TOR - I NF A NT$ 42.00 270 TUBE LARYNGECTOMY S-10 STN $47.00270 SP L I NT, L EFT / ME D W R I ST / FORE A RM$ - 270 CATHETER FOLEY 18FR 5CC $29.00270 T U BEFEE D I NG 5 FR$ 9.00 270 GAUZE VASELINE PETROLATUM 3”X8” $8.00270 S U T U RE V I CR Y L 112/ BX$ - 270 NUGAUZE IODOFORM 1/2” $31.00270 I NF U S I ONSET 20 D RPC H EC K V A L V E$ - 270 OXYGEN/HR-7 LITER $12.00270 SP L I NT, A D UL T L GC L A V I C A L 4 - W A Y$ - 270 SPONGE,SZ 100 GELFOAM STERILE $- 270 S Y R I NGEECCENTR I CT I P 60 CC$ 9.00 270 MASK OXYGEN-ADULT $9.00270 S Y R I NGES L I PT I P 10 CC$ 10.00 270 Respiraguard Nebulizer $- 270 S U RG I G U T 4 - 0, 30", V 20 T A PER,$ - 270 BANDAGE ACE 2” $9.00270 A D A PTOR, NEON A T A L TEMP . PROBE$ - 270 SPLINT,SZ 5 PLASTIC FINGER $- 270 A 4426 PO U C H, 2 - P I ECEOSTOM Y S Y S .$ - 270 DIANEAL SOLN 2.5% 2L BAG $45.00270 NEE D L E V ERESS 120 MM D I SP$ 249.00 270 PADDING,2X4YD SYNTHETIC CAST $- 270 P A D A B D OM I N A L$ 7.00 270 CATHETER URETHRAL 24FR $10.00270 P A C I NGE L ECTRO D EEXTERN A L$ 59.00 270 A6449 Lt compres band >=3” <5”/yd $- 270 A 4624 T r a c h e a l s u c t i o n t u b e$ - 270 NUGAUZE IODOFORM 1” $32.00270 D I SP . N D L 25 G x 5/8", 10 BX / CS$ - 270 SUCTION (PROCEDURE) $38.00270 STOM AA DH ES I V E 8 X 8/ E A$ 30.00 270 KIT TRANSCERV INTRAUTERINE $25.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 124 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SUTURE VICRYL 4-0 SH-1 36/BX $- 270 A 4565 S L I NG, X - L A RGEPERSON A L A RM$ 19.00 270 TUBE,6.5MM ORAL RAE TRACHEAL $- 270 SP L I NT, 1/2 X 18 A LU M I N U MFO A M$ - 270 TUBE,18FR VENTROL LEVIN 50/CS $- 270 T U BE, 8 FRX 15 FEE D I NG 50/ BX$ - 270 WIRE DRILL PASS $89.00270 A SSESSPE A K F L O W METER 12/ CS$ - 270 KIT MONITOR SORENSON $103.00270 M I N I C A P W I T H PRO V I D I NE$ 15.00 270 SB152CONCENTLOW-CAL CA-2.5 K20 $- 270 T U BE, EXTENS I ON 50/ CS$ - 270 BLADE,SZ 20 SURGICAL 100/BX $- 270 C A T H, 10 FR D E L EES U CT . W / M U C U S$ - 270 SPLINT KNUCKLE BENDER REV $20.00270 C A T H ETERFO L E Y 20 FR 5 CC$ 22.00 270 TRAY, SUTURE REMOVAL 50/CS $- 270 B A N D A GE K ER L I X$ 12.00 270 TUBE,16FR STOMACH 50/CS $- 270 A 4565 S L I NG, L A RGEPERSON A L A RM$ 19.00 270 CATHETER FOGARTY 2FR $142.00270 TROC A R, V ERS A PORT D I SP .5 - 10 MM$ - 270 ENDOTRACH TUBE 7.5 CUFF $- 270 OX Y GEN / H R - 15 L I TER$ 12.00 270 KIT CHEMO PREP ADMIN $176.00270 L I MBST A B I L I ZER W E D GE$ 39.00 270 SPLINT,RIGHT/SML WRIST/FOREARM $- 270 K I T - MON - 1295 KHD O U B L E L I NE$ 253.00 270 FINGER COT-LGE $14.00270 NEE D L E, 22 GX 5" SP I N A L Q U I NC .$ - 270 KIT PORT-A-CATH 9FR-UNASBL $955.00270 SPONGE, 12 - 3 MMGE L FO A MSTER I L E$ - 270 CERVICAL COLLAR FOAM SML $23.00270 TROC A RC A T H 10 FR 10/ BX$ - 270 THREAD ADJ STABILITY 5MM $50.00270 T U B I NG U . V . A . C .$ 69.00 270 OXY TANK REFILL /200 CU FT $58.00270 S U RG I G U T 0, 36", GS 21 T A PER,$ - 270 NEEDLE-FREE VALVE ALARIS $14.00270 D I A L Y ZER H I PS 1220/ CS$ - 270 BLADE,SZ 12 SURGICAL 100/BX $- 270 C A T H ETERB A LL OON V ER I P A CE$ 734.00 270 REGULATOR & TANK FOR O2 $300.00270 A 4618 B re a t hin g c i rc u i t s$ - 270 BAIR HUGGER BLANKET FULL BODY $- 270 L I G A C L I P L S 400 X L GESTEE L$ 57.00 270 CATHETER THORACIC 36FR $20.00270 C A T H ETERFO L E Y 16 FR 30 CC$ 23.00 270 TUBE,12FRX37 FEEDING 10/BX $- 270 C A T H ETERFO L E Y 22 FR 30 CC$ 23.00 270 SET URI-METER $24.00270 FE L TORT H O 1/2"$ 61.00 270 BANDAGE PLASTER PARIS 3” $21.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 125 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION CRUTCHES ADJ-ADULT LGE $97.00270 T U BES A L EMS U MP W / SENT 18 FR$ 14.00 270 DERMACARRIERS II $47.00270 D I SP . N D L 19 G x 1", 100 BX 10 BX / CS$ - 270 COLLAR,X-LARGE CERVICAL 1/EA $- 270 A D A PTOR, PRESS U RE L I NE 50/ CS$ - 270 LAP SPONGE, 4X18 20PK/CS $- 270 T U BEN A SOG A ST W / SENT 12 FR$ 16.00 270 BUTTERFLY 25GAX3/4” $10.00270 A MN I H OO K 100/ BX$ - 270 SYRINGE ASCEPTO DISP $29.00270 L A F A Y ETTEB A ROB A GENEM A K I T$ - 270 STUMP SHRINKER $76.00270 PO L Y SORB 4 - 0, 36", P 12 C U TT I NG,$ - 270 NEEDLE,22Gx1-1/2 SPINAL 25/BX $- 270 MEF I X D RESS I NG 2" X 11 Y D$ 42.00 270 SPONGE RHINO ROCKET SML $55.00270 D I SPENSEF I L TERS Y STEM 13 MM$ - 270 CATHETER FOLEY 30FR 30CC $22.00270 A RMBO A R D 18" D I SP . S L EE V E$ - 270 TUBING CONNECTING 1/4”X6’ $10.00270 T U BES A L EMS U MP W / SENT 14 FR$ 14.00 270 SKIN BARRIER W/FLOATING 44MM $- 270 T U BE, 3.5 MM U NC U FFM / TTR A C H E A L$ - 270 SURGIGUT 1,30”,GS21 TAPER, $- 270 A 6448 ST A - T I TE 2 X 5 E L A ST I CB A N D A GE$ - 270 PACE AID MACHINE PAD DISP $36.00270 T U BE I V EXTENS I ON$ 9.00 270 INSYTE CATH. 16Gx1-1/4” $- 270 PER I C A RE$ 13.00 270 TRESHOLD PEP VALVE $179.00270 W OO L S Y NT H ET I C$ 78.00 270 ENBALMING SUPPLIES $400.00270 NE U ROP A TT I ES 1 X 1$ 19.00 270 POLYSORB 2-0,36”,GS21 TAPER, $- 270 T U BE, 4.5 TR A C H E A L 10/ BX$ - 270 NUGAUZE IODOFORM 2” $50.00 270 PACK NASAL RHINO 5.5CM ANT #550$ 200.00 270 RESUSCITATOR CHILD 1/CS $- 270 T U BEN A SOG A STR I C 8 FR$ 77.00 270 ENDOTRACH TUBE 7.0 CUFF $- 270 STR A P, ME D I U MC L A V I C L E 4 - W A Y$ - 270 STAPLE EPHIPHISEL $38.00270 TONS I L SN A RE$ 6.00 270 OXYGEN/HR-2 LITER $7.00270 COMPRESSE D A I R / H O U R$ 12.00 270 SET EXTENSION MICROBORE QUAD-LEG $55.00270 C A T H ETER A RRO W 3 - LU MEN 7 FR$ 712.00 270 CHROMIC GUT 2-0,36”,GS21 TAPER $- 270 TR A CT I ONSTR I P (S K I NTR A C) SM L$ 104.00 270 3-WAY STPCOK W/O EXTN $9.00270 T U BE - TC A TTE LL 14 FR$ 100.00 270 CATH KIT PEDS 8FR $23.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 126 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION CATHETER MUSHROOM $21.00270 M A S K TR A C H EOSTOM Y$ 16.00 270 SUTURE VICRYL 4-0 12/BX $- 270 D I A L Y ZER H I PS 1820/ CS$ - 270 SPLINT,LFTHAND/MED COLLES $- 270 A 4367 OSTOM Y A PP L I A NCEBE L T 42", 1/ E A$ - 270 SET CARDIAC OUTPUT $290.00 270 SCALPEL BLADE #11 W/ HANDLE$ 10.00 270 PD TRANSFER SET W/MINICAP $355.00270 NEE D L ESP I N A L W H I T A CRE 25 G A X 5$ 90.00 270 CATHETER FOLEY 14FR 5CC $28.00270 SP L I NTF I NGER A LU M 3/4" X 18"$ 13.00 270 LIGACLIP TC100 SML TITANIUM $27.00270 K I TC A T H M A H U R K A R 2 - LU MEN$ 769.00 270 13.5FRX36CM COLOSTOMY FLANGE-ADULT $36.00270 BONE W A X$ 9.00 270 IV PUMP SET (SYRINGE) $33.00270 A I R W A Y, 28 FRN A SOP H A R Y NGE A L$ - 270 SET NEPHROSTOMY PNS-100 $248.00270 NEE D L EBONEM A RRO W 15 G A$ 69.00 270 SPLINT,LEFT/SML WRIST/FOREARM $- 270 I MMOM I L I ZER, 22" PERFOR A TE D$ - 270 ARTHRO-FLOW IRRIGATOR $441.00270 OX Y H OO D$ 15.00 270 BODY RESTRAINT $73.00270 T U BEEN D OTR A C H U NC U FF 4.5 MM$ 41.00 270 NEEDLE BX CHIBA DISP $28.00270 SP L I NT, SZ 6 P L A ST I CF I NGER$ - 270 OXISENSOR-ADULT $101.00270 OX Y GEN / H R - 6 L I TER$ 11.00 270 HEEL/ELBOW PROTECTOR $72.00270 D I SP . N D L 23 G x 1 - 1/4", 10 BX / CS$ - 270 HOLDER BREEZELINE PELVIC LGE $76.00270 A 4413 D R A I N A B L EPO U C H W / F I L TER 57 MM$ - 270 SURGIGUT 1,36”,GS25 TAPER, $- 270 H U M I D I F I ER$ 17.00 270 SPLINT,SZ 3 PLASTIC FINGER $- 270 S U T U RE V I CR Y L 0 D S - 436/ BX$ - 270 TROCAR 12MM $645.00270 C A T H ETERS U CT I ON 8 FR 15"$ 8.00 270 TUBE NASOGAST W/ SENT 16FR $17.00270 SP L I NT, A N K L E A I R 1/ E A$ - 270 TUBING PENROSE 3/4”X18” $10.00270 C A T H ETER U RET H R A L 14 FR$ 10.00 270 GAUZE DRESSING 4X4 $7.00270 C A T H ETER U RETER A L SP I R A L T I P$ 85.00 270 SET NEPHROSTOMY PNS-100A $77.00270 H O L D ERBREEZE L I NEPE L V I CME D$ 76.00 270 MESH MARLEX 10”X14” $94.00270 T U BEFEE D I NG 8 FRX 15"$ 9.00 270 KIT EPIDURAL CATHETER $1, 005.00270 T U BEB L A K EMORE$ 139.00 270 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 127 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION SILK 3.0 30IN 36/BX $- 270 BOOTS, ME D I U M V I N Y L C A ST$ - 270 DISPENSE FILTER SYSTEM 16MM $- 270 SP L I NTF I NGER A LU M 1" X 18"$ 30.00 270 SET NEPHROSTOMY 8FR $682.00270 A 4570 Spl in t$ - 270 A6413 ADHESIVE BANDAGE, FIRST-AID $- 270 A 6234 D RESS, 4 X 4 XTR A T H I N D U O D ERM$ - 272 A6235 DRESSING,6X6 DUODERM STERILE $44.00272 A 4314 TR A Y, 14 FRFO L E Y C A T H W /5 CC$ - 272 A6457 SURGILAST SZ-06 1/BX $- 272 A 6259 OPS I TE 10" X 5.5" TR A NSP A RENT$ - 272 A7521 TRACHEOSTOMY TUBE CUFF SZ 10 $- 272 A 6253 D RESS I NG, 30 X 10 TR A U M A 50/ CS$ - 272 A6224 DRESSING,6X36 PETROLATUM GAUZE $- 272 A 4338 C A T H, 16 FRFO L E Y 30 CC 12/ BX$ - 272 A6457 SURGILAST SZ-02 1/BX $- 272 C 1751 T W I NC A T H M UL T I P L E LU MENPER I -$ - 272 C1751 KIT,MULTI LUMEN CENTRAL VENOUS $- 272 A CT I CO A T A NT I M I CROB I A L D RESS I N$ - 272 5M1735 DIALYZER CA170 $- 272 C 1729 TR A Y, T H OR A CENTES I S 16 G x 3"$ 165.00 272 ACL 100 ROTORS $- 272 A 7520 TR A C H EOSTOM Y T U BE W / L O W$ - 272 A7521 TRACHEOSTOMY TUBE CUFF SZ 6 $- 272 A 6257 B I OC LU S I V E 3" X 4" TR A NSP A RENT$ - 272 A7521 TRACHEOSTOMY TUBE CUFF SZ 8 $- 272 A 6222 D RESS, 4 X 4 XEROFORMPETRO L A T U M$ - 272 A7520 TRACHEOSTOMY PED. SIZE0 $- 272 A 7520 TR A C H EOSTOM Y NEOS I ZE 4.0$ - 272 A4314 TRAY, 16FR FOLEY CATH W/5CC $- 272 A 4624 C A T H, 12 FRS U CT I ONM I N I P A C K$ - 272 A6216 SPONGE GAUZE 3X3 4PLY 50/BX $- 272 A 6235 D RESS, 6 X 6 XTR A T H I N D U O D ERM$ 44.00 272 A6457 SURGILAST SZ-05 1/BX $- 272 A 4624 C A T H, 18 FRS U CT I ONC A T H / G L O V E$ - 272 A6457 SURGILAST SZ-01 1/BX $- 272 A 7520 T U BE, 2.0 MM U NC U FFM / TTR A C H E A L$ 19.00 272 C1751 KIT,TWO LUMEN CENTRAL VENOUS $591.00272 A 7521 TR A C H EOSTOM Y T U BEC U FFSZ 4$ - 272 A4351 CATH,8FR ROBINSON 12/BX $- 272 A 4624 C A T H, 8 FRS U CT I ONM I N I TR A Y$ - 272 A4338 CATH,22FR FOLEY 5CC 12/BX $- 272 A 7520 TR A C H EOSTOM Y PE D . S I ZE 2$ - 272 C1751 TWIN CATH MULTIPLE LUMEN $- 272 A 6223 D RESS, 5 X 9 XEROFORMPETRO L A T U M$ - 272 A4346 CATH,22FR FOLEY 30CC 3WAY $- 272 A 6222 D RESS, 2 X 2 XEROFORMPETRO L A T U M$ - 272 A4338 CATH,8FR FOLEY 3CC 10/BX $- 272 A 6253 A CC U - SORB 8 X 7.5 STER . COMB I NE$ - 272 A6234 DRESSING,4X4 DUODERM STERILE $- 272 A 6457 S U RG I L A STSZ - 101/ BX$ - 272 A4624 CATH,14FR SUCTION MINI TRAY $- 272 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 128 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION A7520 TRACHEOSTOMY PED. SIZE 3 $- 272 A 4338 C A T H, 18 FRFO L E Y 5 CC 2 W A Y$ - 272 A4338 CATH,24FR FOLEY 30CC 12/BX $- 272 A 4351 C A T H, 16 FRROB I NSON 12/ BX$ - 272 A4351 CATH,14FR VINYL URETHRAL $- 272 C 1751 S W A NG A NZC A T H ETER 7.5 F$ - 272 A4334 CATH,MEDIUM EXTERNAL MALE $- 272 A 7520 TR A C H EOSTOM Y PE D . S I ZE 1$ - 272 A7520 TRACHEOSTOMY PED. SIZE00 $- 272 A 6257 B I OC LU S I V E 4" X 5" TR A NSP A RENT$ - 272 A4605 CATH,14FR CLOSED TRACHEAL $- 272 A 4605 C A T H, 8 FRS U CT I ON (PE D) 50/ BX$ - 272 A4562 NON-RUBBER PESSARY ANY TYPE $- 272 A 4344 C A T H, 16 FRFO L E Y 5 CC 10/ BX$ - 272 A4338 CATH,18FR FOLEY 30CC 12/BX $- 272 A 6457 S U RG I L A STSZ - 091/ BX$ - 272 A6253 ACCU-SORB 8X10 STERILE COMBINE $- 272 A 4561 R U BBERPESS A R Y A N Y T Y PE$ - 272 A6196 ALGINATE DRESSING, SORBSAN 4X4 $- 2725 M 1732 D I A L Y ZERC A 110$ - 272 A7520 TRACHEOSTOMY NEO SIZE 3.0 $- 272 A 6457 S U RG I L A STSZ - 031/ BX$ - 272 A6402 PAD,SZ 3X4 STER. TELFA 12BX/CS $6.00272 A 6222 D RESS, 1 X 8 XEROFORMPETRO L A T U M$ - 272 A6219 PAD,SZ 2X3 STER. TELFA 12BX/CS $5.00272 A 6259 OPS I TE 6" X 11" TR A NSP A RENT$ - 272 A6403 PAD,SZ 3X8 STER. TELFA 12BX/CS $5.00272 A 4351 C A T H, 18 FRROB I NSON 50/ BX$ - 272 A4624 CATH,5/6FR SUCTION CATH/GLOVE $- 272 A 6222 D RESS I NG, 1/2 X 72 PETRO L A T U M$ - 272 5M1736 DIALYZER CA210 $- 272 A 7520 TR A C H EOSTOM Y PE D . S I ZE 4$ - 272 A4624 CATH,10FR SUCTION W/INFECT $- 2725 M 1734 D I A L Y ZERC A 150$ - 272 A6258 OPSITE 4X4-3/4” TRANSPARENT $- 272 A 6457 S U RG I L A STSZ - 081/ BX$ - 272 A6457 SURGILAST SZ-04 1/BX $- 272 A 6222 D RESS I NG, 1 X 8 PETRO L A T U MG A U ZE$ - 272 A7520 TRACHEOSTOMY NEO SIZE 0 $- 272 A 6223 D RESS I NG, 3 X 9 PETRO L A T U MG A U ZE$ - 272 A4338 CATH,10FR FOLEY 3CC 2WAY(PED) $- 272 A 4351 C A T H, 12 FRROB I NSON 10/ BX$ - 272 A6257 BIOCLUSIVE 1.5X1.5 TRANSPARENT $- 272 A 4351 C A T H, 14 FRROB I NSON 12/ BX$ - 272 A6257 OPSITE 2”X3” TRANSPARENT $- 272 A 6257 OPS I TE 2" X 4" TR A NSP A RENT$ - 272 A6457 SURGILAST SZ-07 1/BX $- 272 A 4605 C A T H, 10 FRC L OSE D TR A C H E A L$ - 272 L0120 Cerv flex n/adj foam pre ots $- 274 L 0120 CO LL A R, SMX W I D ESERPENT I NE$ - 274 L0120 COLLAR,MEDIUM XLONG SERPENTINE $- 274 L 1830 I MMOB I L I ZER, SM A LL K NEE$ 233.00 274 L1830 IMMOBILIZER,MEDIUM KNEE $198.00 274 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 129 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION L3670 IMMOBILIZER,SMALL SHOULDER $- 274 L 3670 I MMOB I L I ZER, L A RGES H O UL D ER$ - 274 L0120 COLLAR,MEDIUM SERPENTINE FOAM $- 274 L 3670 I MMOB I L I ZER, L A RGES H O UL D ER$ - 274 L1830 IMMOBILIZER,LARGE KNEE $208.00274 L 0120 SERPENT I NEFO A MCER V I C A L$ - 274 L3650 IMMOBILIZER,UNIV ADULT SHOULD $- 274 L 3670 I MMOB I L I ZER, ME D I U MS H O UL D ER$ - 274 L1830 IMMOBILIZER,X-LARGE KNEE $308.00274 V 2632 POSTER I ORC H A MBR I O L$ - 276 C1750 HICKMAN CATH 13.5FR 36CMX19CM $- 278 C 1788 I MP L I N D W E LL I NGPORT$ - 278 C1750 HEMO CATH(HEMOSTAR)14.5FR $- 278 A 4648 I MP L A NT A B L ET I SS U EM A R K ER$ - 278 C1768 VENAFLO II VASCULAR GRAFT $- 278 C 1781 MES H (I MP L A NT A B L E)$ - 278 99002 DEVICE HANDLING PHYS/QHP $35.0027996549 U N L I STE D C H EMOT H ER A P Y PROCE D U RE$ 220.50 280 E0110 CRUTCH FOREARM PAIR $- 290 E 0114 C r u t c h u n d er a r m p ai r n o w oo d$ - 290 E0424 Stationary compressed gas 02 $- 29090296 D I P H T H ER I AA NT I TOX I NEQ U I NE$ - 636 J1885 KETOROLAC 30MG/ML (1ML/VI) INJ $- 63690661 F LU V A CCCE LL C UL TPRS V FREE$ - 636 90686 FLU VAC NO PRRV 4 VAL 3 YRS + $- 636 J 1050 ME D ROX Y PROGESTERONE 150 MG / M L I$ 40.00 636 J1050 Medroxyprogesterone acetate $40.00636 J 2543 P I PER A C I LL I N / T A ZOB A CT A M 2.25 GM$ - 636 J1956 LEVOFLOXACIN 500MG IN D5W 100M $- 636 J 2540 PEN I C I LL I NGPOT A SS I U M 20 M I L . U$ - 636 J9171 DOCETAXEL INJECTION 1 MG $- 63690396 V A R I CE LL A - ZOSTER I G I M$ - 636 J0290 AMPICILLIN SODIUM 500MG/VIAL I $- 636 J 3475 M A GNES I U MS UL F A TE 5 GM /10 M L 50$ - 636 90378 RSV IG IM 50MG $- 636 J 2765 METOC L OPR A M I D E H C L TO 10 MG$ - 636 J3490 ETOMIDATE 2MG/ML $- 636 J 2310 N A L OXONE 0.4 MG / M L I N J$ - 636 J2550 PROMETHAZINE 25MG/ML INJ $- 636 J 2250 M I D A ZO L A M 1 MG / M L 2 M L / V I A L PF I$ - 636 J1644 HEPARIN 5,000 UNITS/ML (10 ML) $- 636 J 3430 P H Y TON A D I ONE 1 MG /0.5 M L I N J$ - 636 J2930 METHYLPREDNISOLONE SOD.SUCC. 5 $- 636 J 2430 P A M I D RON A TE D I SO D I U M 30 MG I N J .$ - 636 C9290 SPINAL ANESTHESIA(BUPIVACINE) $- 636 J 3480 POT A SS I U MC H L OR I D E 20 MEQ /10 M L$ - 636 J1165 PHENYTOIN 100MG/2ML AMPULE INJ $- 636 J 1650 ENOX A P A R I N 30 MG /0.3 M L I N J$ - 636 J3430 PHYTONADIONE 10MG/ML INJ $- 636 J 3411 T H I A M I NE 100 MG / M L I N J$ - 636 90672 FLU VACCINE 4 VALENT NASAL $- 636 J 3370 V A NCOM Y C I N 500 MG I N J$ - 636 J9000 DOXORUBICIN HCL INJECTION 10 MG $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 130 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90687 IIV4 VACCINE 6-35MONTHS IM $- 636 J 9305 I N J PEMTREXE D 10 MG$ - 636 J3490 BUPIVACAINE 0.5% PF INJ., 30ML $- 636 J 3490 SO D I U MB I C A RBON A TE 8.4$ - 636 J0690 CEFAZOLIN SODIUM INJECTION 500 MG $- 636 J 2405 ON D A NSETRON 2 MG / M L, 2 M L V I A L$ - 636 J2001 LIDOCAINE 1%, 20ML VIAL $- 63690744 H EPB V A CCPE D / A D O L 3 D OSE I M$ - 636 J3490 DEXTROSE 50% 25GM SYRINGE INJ $- 63690714 T D V A CCNOPRES V >= 7 Y RS I M$ - 636 J3315 INJ TRIPTORELIN PAMOATE 3.75 MG $- 636 J 1750 I RON D EXTR A N 50 MG / M L 2 M L / V I A L$ - 636 J1940 LASIX INJ TO 20 MG $- 636 J 0702 BET A MET H A SONE 6 MG / M L I N J, 5 M L$ - 636 J3490 METRONIDAZOLE 500MG/100ML INJ $- 63690477 OR A LL I V ET Y PE 7 A D ENO V I R U S$ - 636 90654 FLU VACCINE NO PRESERV ID $- 636 P 9047 A L B U M I N (H U M A N) 25$ - 636 J0881 DARBEPOETIN ALFA 100MCG/ML VIA $- 63690716 C H I C K ENPOX V A CC I NESC$ - 636 90698 DTAP-HIB-IP VACCINE IM $- 636 C 9113 P A NTOPR A ZO L E 40 MG I N J .$ - 636 J1650 INJ LOVENOX 10 MG $- 636 J 1200 BEN A D R Y L I N J ECT I ONTO 50 MG$ - 636 J2250 MIDAZOLAM 5MG/ML 10ML/VIAL IN $- 636 J 3490 F A MOT I D I NE 20 MG /0.9$ - 636 J0561 PEN-G BENZATHINE 1.2 MIL UNIT $- 636 J 1580 GENT A M I C I N 20 MG /2 M L I N J$ - 636 90653 IIV ADJUVANT VACCINE IM $- 63690680 R V 5 V A CC 3 D OSE L I V EOR A L$ - 636 P9041 ALBUMIN, PLASBUMIN (HUMAN) 5%, $- 63690740 He p b v a cc i llp a t 3 d ose im$ - 636 J2270 MORPHINE SULFATE INJ TO 10 MG $- 636 J 1940 F U ROSEM I D E 10 MG / M L I N J 4 M L$ - 636 J0696 CEFTRIAXONE 1GM INJ $- 636 J 1631 H A L OPER I D O L D EC A NO A TE 100 MG / M L$ - 636 90732 Pneumococcal vaccine >=2 yrs $- 63690691 T Y P H O I D V A CC I NE I M$ - 636 J3490 AMINOCAPROIC ACID 250MG/ML INJ $- 636 J 0698 CEFOT A X I ME 2 GM I N J$ - 636 90660 FLU VACCINE NASAL $- 636 J 2560 P H ENOB A RB I T A L 130 MG / M L, 1 M L V I$ - 636 90743 HEP B VACC ADOL 2 DOSE IM $- 636 J 1100 D EX A MET H A SONE 4 MG / M L, 5 M L I N J$ - 636 J1642 HEPARIN LOCK 10 UNIT/ML PF, 10 $- 636 J 3490 V A SOPRESS I N 20 U N I TS / M L I N J$ - 636 J0696 CEFTRIAXONE 1GM ADD-VANTAGE IN $- 636 J 2405 ZOFR A N I N J PER 1 MG$ - 636 Q0163 DIPHENHYDRAMINE 12.5MG/5ML ORA $- 636 J 1410 ESTROGENS, CON J U G A TE D 25 MG I N J$ - 636 90633 HEPA VACC PED/ADOL 2 DOSE IM $- 636 J 9206 I R I NOTEC A N I N J ECT I ON 20 MG$ - 636 J0885 EPOETIN 10,000 UNITS/ML INJ $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 131 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION J3490 NITROGLYCERIN 5MG/ML 10ML INJ $- 636 J 2790 R H O D I MM U NEG L OB UL I N I N J 300$ - 636 MICROGRAMS (1500 IU) 90655 FLU VACCINE NO PRESERV 6-35M $- 636 J 0295 A MP I C I LL I N / S UL B A CT A M 1.5 GM / V I A$ - 636 J2997 TPA INJ 1 MG $- 636 J 1885 K ETORO L A C 60 MG /2 M L S Y R I NGE I N J$ - 636 90376 RABIES IG HEAT TREATED $- 636 J 0698 CEFOT A X I ME 1 GM I N J$ - 636 J3490 NICARDIPINE IV 20MG/200ML PREM $- 636 J 2997 A L TEP L A SE 2 MG /2 M L C A T H F L O W$ - 636 J2540 PENICILLIN G POTASSIUM 5MIL.UN $- 63690681 ROT A V I R U S V A CC 2 D OSEOR A L$ - 636 90586 IV BCG FOR BLADDER CA $- 636 J 3475 M A GNES I U MS UL F A TE 1 GM /2 M L, 50$ - 636 J3420 VITAMIN B-12 INJECTION TO 1000 MCG $- 636 J 3490 FO L I C A C I D 5 MG / M L, 10 M L M D V$ - 636 J1950 LUPRON DEPOT INJ PER 3.75 MG $- 636 J 3490 SO D I U MC H L OR I D E 0.45$ - 636 90734 MENINGOCOCCAL VACCINE IM $- 63690688 F LU V A CC 4 V A L 3 Y RSP LU S I M$ - 636 J0640 Leucovorin calcium injection $- 636 J 3105 TERB U T A L I NE 1 MG / M L A MP$ - 636 J2543 PIPERACILLIN/TAZOBACTAM 2.25GM $- 636 J 3490 C L I N D A M Y C I N 900 MG /6 M L V I A L I N J$ - 636 J0702 BETAMETHASONE MDV 6MG/ML 5ML I $- 636 J 0834 COS Y NTROP I N 0.25 MG I N J$ - 636 J3490 DILTIAZEM 100MG ADD-VANTAGE VI $- 636 J 2270 MORP H I NES UL F A TE I N J TO 10 MG$ - 636 J1580 GENTAMICIN 40MG/ML 20ML/VIAL I $- 636 J 9355 TR A ST U Z U M A B I N J ECT I ON 10 MG$ - 636 90739 HEPB VACC 2 DOSE ADULT IM $- 636 Q 0169 PROMET H A Z I NE 25 MGT A B$ - 636 J0456 AZITHROMYCIN 500MG INJ $- 63690710 MMR VV A CC I NESC$ - 636 J1100 Dexamethasone sodium phos $- 636 J 1644 H EP A R I N 5000 U N I TS / M L, 1 M L M D V$ - 636 J2501 PARICALCITOL INJ 1 MCG $- 636 J 3490 K ET A M I NE 100 MG / M L V L 5 M L$ - 636 90697 DTAP-IPV-HIB-HEB VACCINE IM $- 636 J 3260 TOBR A M Y C I N 80 MG /2 M L I N J$ - 636 J3490 LABETALOL 5MG/ML, 20ML/VIAL IN $- 63690647 H I B V A CC I NEPRP - OMP I M$ - 636 J9395 FULVESTRANT 25 MG INJ $- 636 J 0713 CEFT A Z I D I ME 1 GM I N J$ - 636 J2501 PARICALCITOL 5MCG/ML, 1ML/VIAL $- 636 J 2430 P ami d ro na t e d i so d i u m /30 MG$ - 636 P9046 ALBUMIN, MPB VA PLASBUMIN 25% $- 636 J 2185 MEROPENEM 500 MG I N J$ - 636 J3380 INJECTION, VEDOLIZUMAB 1 MG $- 636 J 0881 D A RBEPOET I N A L F A NON - ESR D 1$ - 636 MICROGRAM J3475 MAGNESIUM SULFATE 4GM/100ML ST $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 132 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION J0280 AMIODARONE HCL 50MG/ML, 3ML AM $- 636 J 1756 I RONS U CROSE 20 MG / M L 5 M L / V I A L$ - 636 J1631 HALOPERIDOL DECANOATE 50MG/MLI $- 636 J 7512 PRE D N I SONE 10 MGT A B$ - 636 J1726 HYDROXYPROGESTERONE 250MG/ML $- 63690732 PNE U MOCOCC A L V A CC I NE 0.5 M L S Y R >= 2$ - 636 YRS 90649 H PAPILLOMA VACC 3 DOSE IM $- 636 J 0171 EP I NEP H R I NE 1 : 1, 000 (1 MG / M L) A$ - 636 J2930 METHYLPREDNISOLONE INJ TO 125 MG $- 636 J 3370 V A NCOM Y C I N 1 GM A DD - V A NT A GE I N J$ - 636 J0330 SUCCINYLCHOLINE 20MG/ML, 10ML $- 63690673 R I V 3 V A CC I NENOPRESER V I M$ - 636 J1120 ACETAZOLAMIDE 500MG INJ $- 636 J 1265 D OP A M I NE 400 MG /250 M L D 5 W I N J$ - 636 J2274 MORPHINE 1MG/ML 10ML PRESERVAT $- 636 J 0131 A CET A M I NOP H EN 1000 MG /100 M L OF I$ - 636 90702 DT VACCINE UNDER 7 YRS IM $- 636 J 0696 CEFTR I A XONE 250 MG I N J$ - 636 J2310 NALOXONE 1MG/ML INJ $- 63690676 R A B I ES V A CC I NE I D$ - 636 J0132 ACETYLCYSTEINE 200MG/ML 30ML I $- 636 J 1170 H Y D ROMORP H ONE 2 MG / M L I N J$ - 636 Q0163 DIPHENHYDRAMINE 25MG CAP $- 636 J 2060 L OR A ZEP A M 2 MG / M L (1 M L / V I A L) I N$ - 636 Q0162 ONDANSETRON 4MG TAB $- 63690585 PERCBCGFORTB$ - 636 J0461 ATROPINE SULFATE 0.4MG/1ML, 20 $- 636 J 3480 POT A SS I U MC L 20 MEQ I N D 5/0.45 N$ - 636 [Rows 17001-17967:] CPT/HCPCS MODIFIER CHARGE DESCRIPTION PRICE REVENUE CODE CODE J1650 ENOXAPARIN 40MG/0.4ML INJ $- 636 J 1020 D EPO - ME D RO L 20 MG I N J$ - 636 90644 HIB-MENCY VACC 6WK-18MO IM $- 636 J 3010 FENT A N Y L 100 MCG /2 M L I N J$ - 636 90650 2VHPV VACCINE 3 DOSE IM $- 636 90656 FLU VACCINE NO PRESERV 3 & >$ - 636 90736 ZOSTER VACC SC $- 636 J 9280 M I TOM Y C I N 5 MG V I A L I N J$ - 636 J7512 PREDNISONE 2.5MG TAB $- 636 J 1094 I nj d e x am e t ha so n e a ce t a t e$ - 636 J7190 ANTIHEMOPHILIC FACTOR VIII $- 636 J 2280 A V E L OXMOX I F L OX A C I N H C L 400 MG$ - 636 J3262 TOCILIZUMAB INJECTION 1 MG $- 636 J 9060 C i s pl a t in 10 MG inj ec t i o n$ - 636 J3010 FENTANYL 250MCG/5ML VIAL INJ $- 636 J 2250 M I D A ZO L A M 5 MG / M L 2 M L / V I A L I N J$ - 636 J2270 MORPHINE 25MG/ML 20ML SDV INJ $- 63690670 PNE U MOCOCC A L V A CC 13 V A L I M$ - 636 J0696 ROCEPHIN INJECTION PER 250 MG $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 133 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION J0280 AMIODARONE 360MG/200ML DEXTROS $- 636 J 0690 CEF A ZO L I N 1 GM A DD - V A NT A GE V I A L$ - 636 J2543 PIPERACILLIN/TAZOBACTAM 3.375G $- 636 J 0456 A Z I T H ROM Y C I N 500 MG I N J$ - 636 J3490 METOPROLOL 1MG/ML 5ML/VIAL INJ $- 636 J 3475 M A GNES I U MS UL F A TE 1 GM /100 M L D E$ - 636 J2597 DESMOPRESSIN (DDAVP) 4MCG/ML I $- 636 J 0289 A MP H OTER I C I N - B L I POSOME 50 MG I$ - 636 J9070 CYCLOPHOSPHAMIDE 500MG/VIAL IN $- 636 J 1040 MET H Y L PRE D N I SO L ONE A CET A TE 80 M$ - 636 J2543 PIPERACILLIN/TAZOBACTAM 3.375G $- 636 J 3490 N I TROG L Y CER I N 50 MG / D EXTROSE 5$ - 636 90371 HEPATITIS-B IMMUNE GLOBULIN 5M $- 63690715 T D A P V A CC I NE > 7 Y RS I M$ - 636 J0882 DARBEPOETIN ALFA ESRD USE 1 $- 636 M I CROGR A M J 2680 PRO L I X I N D EC A NO A TE I N J TO 25 MG$ - 636 J3490 SODIUM BICARBONATE 8.4% 50ML S $- 63690630 F LU V A CC II V 4 NOPRESER V I D$ - 636 J7042 5% dextrose/normal saline $- 636 J 3490 G L Y COP Y RRO L A TE 0.2 MG / M L I N J, 5$ - 636 J1940 FUROSEMIDE 10MG/ML INJ 2ML $- 63690476 OR A L A D ENO V I R U ST Y PE 4$ - 636 Q9968 METHYLENE BLUE 1% 10ML/VIAL IN $- 636 J 1650 ENOX A P A R I N 100 MG / M L I N J$ - 636 90707 MEASLES/MUMPS/RUBELLA VACCINE $- 63690700 D T A P V A CC I NE < 7 Y RS I M$ - 636 J2354 OCTREOTIDE 100MCG/ML INJ $- 636 J 1756 I RONS U CROSE I N J 1 MG$ - 636 J2765 METOCLOPRAMIDE 5MG/ML 2ML/VIAL $- 636 P 9041 A L B U M I N, NORM A L H U M A NSER U M, 5$ - 636 J3490 DOXYCYCLINE 100MG INJ $- 636 J 2405 ON D A NSETRON 2 MG / M L 20 M L / V I A L I$ - 636 J3490 FAMOTIDINE 10MG/ML, 4ML VIAL I $- 636 J 0610 C A L C I U MG LU CON A TE 100 MG / M L I N J$ - 636 J7512 PREDNISONE 20MG TAB $- 636 J 0280 A M I O D A RONE 150 MG /100 M L D EXTROS$ - 636 J3475 MAGNESIUM SULFATE 2GM/50ML STE $- 636 J 2250 V ERSE D I N J PER 1 MG$ - 636 J3370 VANCOMYCIN 1GM/VIAL INJ $- 636 J 9055 I N J CET U X I M A B 10 MG$ - 636 J1644 HEPARIN 10,000 UNITS/ML 1ML $- 636 J 2185 MEROPENEM 1 GM I N J$ - 636 J1442 Inj, filgrastim g-csf 1mcg $- 636 J 3490 F LU M A ZEN I L 0.1 MG / M L, 5 M L V I A L$ - 636 J1644 HEPARIN 1,000 UNITS/ML, 10ML $- 636 J 0278 A M I K A C I NS UL F A TE 500 MG /2 M L I N J$ - 636 J1165 PHENYTOIN 50MG/ML, 5ML VIAL IN $- 636 J 1720 H Y D ROCORT I SONE 250 MG /2 M L I N J$ - 636 J9035 INJ BEVACIZUMAB 10 MG $- 63690648 H I B V A CC I NEPRP - T I M$ - 636 J0744 CIPROFLOXACIN 400MG/200ML IVPG $- 636 J 1940 F U ROSEM I D E 10 MG / M L 10 M L I N J$ - 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 134 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90723 DTAP-HEP B-IPV VACCINE IM $- 63690634 H EP A V A CCPE D / A D O L 3 D OSE$ - 636 J3101 TENECTEPLASE 50MG INJ $- 636 J 2590 OX Y TOC I N 10 U N I TS / M L I N J$ - 636 90713 POLIOVIRUS IPV SC/IM $- 636 Q 0162 ON D A NSETRON 4 MGOR A L - D I S I NTEGR$ - 636 J9201 GEMCITABINE 200MG VIAL INJ $- 636 P 9046 A L B U M I N, H U M A N 25$ - 636 J2210 METHYLERGONOVINE 0.2MG/ML INJ $- 636 J 0290 A MP I C I LL I NSO D I U M 1 GM / V I A L I N J$ - 636 J3475 MAGNESIUM SULFATE 40MG/ML 1000 $- 636 J 2250 M I D A ZO L A M 5 MG / M L 1 M L / V I A L I N J$ - 636 J3301 TRIAMCINOLONE ACETONIDE 40MG/M $- 63690632 H EP A T I T I S A V A CC 1440 U, 1 M L V I$ - 636 90662 FLU VACC PRSV FREE INC ANTIG $- 636 J 2354 OCTREOT I D E 500 MCG / M L I N J$ - 636 J1050 MEDROXYPROGESTERONE 150MG/ML I $40.00636 J 2704 PROPOFO L 1$ - 636 90747 Hepb vacc ill pat 4 dose im $- 636 J 1670 TET A N U S I MM U NEG L OB 250 U N I TS$ - 636 90657 FLU VACCINE 3 YRS IM $- 63690717 SQ L I V E Y E LL O W FE V ER V A CC I NE$ - 636 J7515 CYCLOSPORINE 100MG CAP $- 636 J 1630 H A L OPER I D O LL A CT A TE 5 MG / M L (P L$ - 636 J0153 ADENOSINE 6MG/2ML VIAL INJ $- 636 J 0706 C A FFE I NEC I TR A TE 20 MG / M L 3 M L / V$ - 636 J9025 AZACITIDINE 100MG VIAL INJ $- 636 J 2175 MEPER I D I NE 50 MG / V I A L I N J$ - 636 J1953 LEVETIRACETAM 100MG/ML, 5ML VI $- 63690620 MENBRP W / OM VV A CC I NE I M$ - 636 J3490 CLINDAMYCIN 600MG/4ML VIAL INJ $- 636 J 3010 FENT A N Y L 100 MCG V I A L$ - 636 J0171 EPINEPHRINE 1MG/10ML SYRINGE I $- 63690715 T d a p v a cc in e >= 7 yrs im$ - 636 90621 MENB-FHBP VACC 2/3 DOSE IM $- 63690690 OR A LL I V ET Y P H O I D V A CC I NE$ - 636 J3480 POTASSIUM CHLORIDE 10MEQ 100ML $- 63690675 R A B I ES V A CC I NE I M$ - 636 J1580 GENTAMICIN 40MG/ML/2ML VIAL IN $- 636 J 3490 N I C A R D I P I NE 2.5 MG / M L 10 M L V I A L$ - 636 J0133 ACYCLOVIR 500MG/VIAL INJ $- 636 J 2930 MET H Y L PRE D N I SO L ONESO D . S U CC .2$ - 636 90685 FLU VAC NO PRCV 4 VAL 6-35 M $- 63690375 R A B I ES I G I N J ECT I ON I M / SQ$ - 636 J0515 BENZTROPINE 1MG/ML, 2ML AMP $- 636 J 1750 I N J I RON D EXTR A N 50 MG$ - 636 90651 9VHPV VACCINE 3 DOSE IM $- 63690733 MEN I NGOCOCC A L V A CC I NESC$ - 636 J1200 DIPHENHYDRAMINE 50MG/ML VIAL, $- 63690738 I N A CT I V A TE D J E V A CC I M$ - 636 90371 HEPATITIS B IMMUNE GLOBULIN 0. $- 636 J 0690 CEF A ZO L I N 1 GM I N J$ - 636 J7510 PREDNISOLONE 15MG/5ML ORAL SOL $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 135 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90746 HEPB VACCINE 3 DOSE ADULT IM $- 636 J 1170 D I L A U D I D U PTO 4 MG$ - 636 J3490 NITROGLYCERIN 100MG IN D5W, 25 $- 636 J 0696 CEFTR I A XONE 2 GM I N J$ - 636 J9041 BORTEZOMIB 3.5MG VIAL INJ $- 636 J 3490 ROC U RON I U M 10 MG / M L, 5 M L M D V I N$ - 636 90696 DTAP-IPV VACC 4-6 YR IM $- 636 J 1160 D I GOX I N 0.5 MG /2 M L I N J$ - 636 J0694 CEFOXITIN 1GM VIAL $- 636 J 1642 H EP A R I NP . F .100 U N I TS / M L S D V$ - 636 J2920 METHYLPREDNISOLONE INJ TO 40 MG $- 636 J 3420 C Y A NOCOB A L A M I N 1000 MCG / M L I N J$ - 636 J1100 DEXAMETHASONE 4MG/ML , 1ML INJ $- 636 J 7512 PRE D N I SONE 5 MGT A B$ - 636 J2060 LORAZEPAM 2MG/ML, 10ML MDV $- 636 J 3301 TR I A MC I NO L ONE A CETON I D E 40 MG / M$ - 636 J0360 HYDRALAZINE 20MG/ML INJ $- 636 J 0295 A MP I C I LL I N / S UL B A CT A M 3 GM / V I A L$ - 636 J0461 ATROPINE 0.1MG/ML 10ML SYRINGE $- 63690385 R H O I G H U M A NM I N I - D OSE I M$ - 636 J0290 AMPICILLIN 250MG/VIAL INJ $- 636 J 9264 P A C L I T A XE L PROTE I NBO U N D 1 MG$ - 636 J3480 POTASSIUM CHLORIDE 40MEQ/20ML $- 63690636 H EP A / H EPB V A CC A D UL T I M$ - 636 J1450 FLUCONAZOLE 200MG/100ML INJ $- 636 Q 0163 D I P H EN H Y D R A M I NE 50 MGC A P$ - 636 J9190 FLUOROURACIL INJECTION 500 MG $- 636 J 3490 D I L T I A ZEM 5 MG / M L I N J ., 10 M L$ - 636 90674 CCII4 VAC NO PRSV 0.5ML IM $- 636 J 2175 D EMERO L 100 MG / M L I N J$ - 636 J0744 CIPROFLOXACIN 200 MG /100 ML D $- 636 J 1720 H Y D ROCORT I SONE 100 MG /2 M L V I A L$ - 636 J9263 OXALIPLATIN INJ 0.5 MG $- 636 J 0171 EP I NEP H R I NE 0.3 MG /0.3 M L A U TO - I$ - 636 J3430 PHYTONADIONE 1MG/0.5ML DISP SY $- 636 J 2020 L I NEZO L I D I . V .600 MG /300 M L$ - 636 J2370 PHENYLEPHRINE 10MG/ML INJ $- 636 90658 FLU VACCINE 3 YRS & > IM$ - 636 90384 RHO IG HUMAN FULL DOSE IM $- 636 J 7298 L E V ONORGESTRE L I U M I REN A, 52 MG$ - 636 J7300 Intraut copper contraceptive $- 636 J 7304 C o n t r a ce pt i v es u ppl y, p a t c h$ - 636 J7301 Levonorgestrel iu 13.5 mg $- 63690748 H EPB / H I B V A CC I NE I M$ - 636 J1561 IMMUNE GLOBULIN I.V. 20GM (10% $- 63690666 F LU V A CP A N D EMPRSR V FREE I M$ - 636 J7307 ETONOGESTREL IMPLANT SYSTEM $771.5063690281 H U M A N I G I M V A CC I NE$ - 636 90283 IGIV HUMAN FOR IV USE $- 636 J 7303 C o n t r a ce pt i v es u ppl y, r in g$ - 636 J7300 PARAGARD INTRAUTERINE COPPER C $- 636 J 7307 ETONOGESTRE L 68 MG I MP L A NT$ - 636 J7297 LILETTA (LEVONORGESTREL) 52MG $- 636 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 136 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 90389 TETANUS IG HUMAN IM $- 63690668 F LU V A CP A N D EM I CSP L I T I M$ - 636 J9031 Bcg live intravesical vac $- 636 J 9310 R I T U X I M A B 10 MG / M L, 50 M L V I A L I$ - 636 J1030 METHYLPREDNISOLONE ACETATE 40M $- 636 J 1610 Gl u c a g o nh y d roc h l or i d e /1 MG$ - 636 J1610 GLUCAGON 1MG INJ $- 636 POT A SS I U MC H L OR I D E 20 MEQERT$ - 637 NITROGLYCERIN 0.2MG/HOUR TRANS $- 637 G U I A FENES I N 100 MG /5 M L OR A L S Y R$ - 637 IRBESARTAN/HYDROCHLOROTHIAZIDE $- 637 FE L O D I P I NEER 5 MGT A B$ - 637 HALOPERIDOL 1MG TAB $- 637 M I SOPROSTO L 200 MCGT A B$ - 637 VALPROIC ACID 250MG/5ML ORAL S $- 637 M UL T I V I T A M I NS W / M I NER A L ST A B$ - 637 MULTIVITAMIN PEDIATRIC 5ML SDV $- 637 TR I A MC I NO L ONE 0.5$ - 637 SODIUM BIPHOSPHATE/SODIUM PHOS $- 637 PROPOX Y P H ENE H C L 65 MGC A P .$ - 637 CHLORPROMAZINE 25MG TAB $- 637 Z I NCOX I D ETOP I C A L O I NTMENT$ - 637 SULFAMETHOXAZOLE/TRIMETHOPRIM $- 637 D OC U S A TESO D I U M 100 MG /10 M L OR A$ - 637 PYRIDOXINE 50MG TAB $- 637 C L ON I D I NE 0.1 MGT A B$ - 637 ZIPRASIDONE GEODON 40MG CAP $- 637 FO L I C A C I D 1 MGT A B$ - 637 LIDOCAINE/PRILOCAINE 2.5%-2.5% $- 637 A C Y C L O V I R 400 MGT A B$ - 637 CEPHALEXIN 125MG/5ML ORAL SUSP $- 637 C L OZ A P I NE 100 MGT A B U / D$ - 637 WARFARIN 2.5MG TAB $- 637 TR I A ZO L A M 0.25 MGT A B U / D$ - 637 LEVOTHYROXINE 0.075MG TAB $- 637 C L ON I D I NE 0.3 MG /24 H O U RSTR A NS$ - 637 TAMSULOSIN CAP 0.4MG, 90/BT $- 637 METOPRO L O L 50 MGERT A B$ - 637 IRON/VITAMIN B12/FOLIC ACID 15 $- 637 N Y ST A T I NTOP I C A L PO W D ER, 15 GM$ - 637 CLINDAMYCIN 1% TOPICAL GEL $- 637 N I FE D I P I NE 30 MGERT A B$ - 637 TRINESSA 28-DAY TAB $- 637 H Y D ROCORT I SONEPO W D ER U SP, 25 G$ - 637 GENTIAN VIOLET 2% TOPICAL SOLN $- 637 L OR A ZEP A M 1 MGT A B$ - 637 DEMECLOCYCLINE HCL 300MG TAB $- 637 A M I O D A RONE 200 MGT A B$ - 637 POTASSIUM CHLORIDE 10MEQ TAB $- 637 T H EOP H Y LL I NE 200 MGERT A B$ - 637 ALUMINUM/MAGNESIUM/SIMETHICONE $- 637 MET H OTREX A TE 2.5 MGT A B$ - 637 AMOXICILLIN/CLAVULANATE 875MG- $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 137 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION HYDROCORTISONE 5MG TAB $- 637 BENZTROP I NE 2 MGT A B$ - 637 TRIAZOLAM 0.125MG TAB $- 637 I B U PROFEN 100 MG /5 M L OR A L S U SP$ - 637 CARVEDILOL 6.25MG TAB $- 637 A TR I P L A 600 MG - 200 MG - 300 MGT A B$ - 637 J8540 DEXAMETHASONE 1MG TAB $- 637 R I SPER I D ONE 1 MGT A B$ - 637 HEMORRHOIDAL HYDROCORTISONE 25 $- 637 SOT A L O L 80 MGT A B$ - 637 CLARITHROMYCIN 250MG/5ML ORAL $- 637 PERMET H R I N 1$ - 637 OLANZAPINE 5MG TAB $- 637 S I MET H I CONE 40 MG /0.6 M L OR A L D R$ - 637 ORA-PLUS ORAL SUSPENDING VEHIC $- 637 PERMETR I N 5$ - 637 CHERRY SYRUP $- 637 H Y D R A L A Z I NE 10 MGT A B$ - 637 OSELTAMIVIR 30MG CAP $- 637 H A L OPER I D O L 2 MG / M L OR A L SO L N$ - 637 OLANZAPINE 15MG TAB $- 637 POT A SS I U MC H L OR I D E 10 MEQC A P .$ - 637 STERILE TALC POWDER 5 G $- 637 A C I D OP H I LU SC A PT A B W A T, 100$ - 637 ACETAMINOPHEN 160MG/5ML ORAL E $- 637 C L I N D A M Y C I N 600 MG /50 M L I V PG$ - 637 FLUDROCORTISONE 0.1MG TAB $- 637 F U ROSEM I D E 20 MGT A B$ - 637 VERAPAMIL 240MG ER TAB $- 637 FENT A N Y L 75 MCG / H O U RTR A NS D ERM A$ - 637 AMOXICILLIN 125MG/5ML ORAL SUS $- 637 H EMORR H O I D A L RECT A L S U PPOS I TOR$ - 637 VERAPAMIL 180MG ER TAB $- 637 A Z I T H ROM Y C I N 200 MG /5 M L OR A L S U$ - 637 PHENYTOIN 30MG CAP $- 637 A M I O D A RONE 200 MGT A B$ - 637 TAMSULOSIN 0.4MG CAP $- 637 P H ENOB A RB I T A L 30 MGT A B, U / D$ - 637 NICOTINE 21MG/24 HOUR TRANSDER $- 637 H Y D R A L A Z I NE 50 MGT A B$ - 637 CALAMINE TOPICAL LOTION $- 637 SO D I U MB I C A RBON A TE 4.2$ - 637 DRONABINOL 2.5 MG CAPSULE $- 637 A SCORB I C A C I D 500 MGT A B$ - 637 RANITIDINE 150MG TAB $- 637 L A CT UL OSE 10 GM /15 M L OR A L SO L N$ - 637 OLANZAPINE TAB 20MG UD,100 $- 637 D I L T I A ZEM 120 MGERC A P$ - 637 ONDANSETRON 8MG ORAL-DISINTEGR $- 637 A L B U TERO L 2 MG /5 M L OR A L S Y R U P$ - 637 PHENOBARBITAL 32.4MG TAB $- 637 H Y D ROMORP H ONE 4 MGT A B$ - 637 MINOXIDIL 10MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 138 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION AMOXICILLIN/CLAVULANATE 500MG- $- 637 F LU CON A ZO L E 100 MGT A B$ - 637 NEOMYCIN/POLYMYXIN/HYDROCORTIS $- 637 TERB U T A L I NE 5 MGT A B$ - 637 SUNITINIB SUTENT 12.5MG CAP, 2 $- 637 TR I A MC I NO L ONECRE A M 0.1$ - 637 CLOZAPINE 25MG TAB $- 637 N Y ST A T I N 100, 000 U N I TS / GMTOP I$ - 637 NEOMYCIN/POLYMYXIN/HYDROCORTIS $- 637 MORP H I NE 20 MG /5 M L OR A L SO L N$ - 637 CHLORPROMAZINE 100MG TAB $- 637 H Y D R A L A Z I NE 25 MGT A B U / D$ - 637 LEVETIRACETAM 100MG/ML ORAL SO $- 637 I B U PROFEN 600 MGT A B$ - 637 NYSTATIN 100,000 UNITS/ML ORAL $- 637 H Y D R A L A Z I NE 10 MGT A B, U / D 100$ - 637 ALUMINUM/MAGNESIUM/SIMETHICONE $- 637 C H A RCO A L, A CT I V A TE D 25 GMS U SP$ - 637 MEPERIDINE 50MG TAB $- 637 BROMOCR I PT I NE 2.5 MGT A B$ - 637 LEVONORGESTREL 0.75MG TAB $- 637 L E V OT H Y ROX I NE 0.1 MGT A B$ - 637 BACITRACIN/POLYM/NEOM OINT, 1/ $- 637 PROMET H A Z I NE 6.25 MG /5 M L OR A L S$ - 637 LACTULOSE 20GM/30ML CUP ORAL S $- 637 D I L T I A ZEM 240 MGERC A P$ - 637 NICOTINE POLACRILEX 4MG CHEWIN $- 637 C H L OROSEPT I COR A LL OZENGE$ - 637 LEVOTHYROXINE 0.025MG TAB $- 637 C A L C I TR I O L 0.25 MCGC A P$ - 637 LUER LOCK W/TIP CAP $- 637 N I TROG L Y CER I N 2$ - 637 PROPRANOLOL 20MG TAB $- 637 MORP H I NE 15 MGT A B U / D$ - 637 MULTIVITAMINS /MINERALS/FOLIC $- 637 M U P I ROC I N 2$ - 637 LORAZEPAM 2MG TAB $- 637 P A NTOPR A ZO L E 40 MGECT A B$ - 637 PERMETHRIN 1% LOTION, 60ML/BT $- 637 J 8540 D EX A MET H A SONE 0.5 MGT A B$ - 637 SODIUM POLYSTYRENE 15GM/60ML S $- 637 P H ENOB A RB I T A L 20 MG /5 M L OR A L E L$ - 637 OLANZAPINE 15MG TAB U/D $- 637 MONTE LU K A ST I RT A B 10 MG, 90$ - 637 ACYCLOVIR 200MG CAP $- 637 A LU M I N U M / M A GNES I U M / S I MET H I CONE$ - 637 ABILIFY 10MG UD,100 $- 637 C L ON I D I NE 0.2 MG /24 H O U RSTR A NS$ - 637 NIFEDIPINE 60MG ER TAB $- 637 C I PROF L OX A C I N 500 MGT A B$ - 637 ZIDOVUDINE 50MG/5ML ORAL SYRUP $- 637 D I A ZEP A M 5 MGT A B U / D$ - 637 NICOTINE 14MG/24 HOUR TRANSDER $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 139 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION LINEZOLID 600MG TAB $- 637 H Y D ROX Y Z I NE H C L 25 MGT A B$ - 637 CIPROFLOXACIN 250MG TAB $- 637 B A C I TR A C I N 500 U N I TS / GMTOP I C A$ - 637 J1815 INSULIN HUMAN 70/30 (REGULAR/N $- 637 T A MOX I FENC I TRT A B 10 MG, 60$ - 637 CODEINE SULFATE 30MG TAB $- 637 L OR A ZEP A M 1 MGT A B$ - 637 HALOPERIDOL 5MG TAB $- 637 S U M A TR I PT A N 50 MGT A B$ - 637 MORPHINE 30MG ER TAB U/D $- 637 MEGESTRO L A CET A TE 200 MG /5 M L OR$ - 637 RECLIPSEN 28-DAY TAB $- 637 L OR A ZEP A M 2 MGT A B U / D$ - 637 ACYCLOVIR 800MG TAB $- 637 TR I A MC I NO L ONE 0.1$ - 637 ISONIAZID 50MG/5ML ORAL SYRUP $- 637 PS Y LL I U M 12 GM / P A C K ETOR A L PO W D$ - 637 OSELTAMIVIR 75MG CAP $- 637 L OPER A M I D E H C L 1 MG /5 M L OR A L SO$ - 637 TAMOXIFEN 10MG TAB $- 637 NOR - Q D 0.35 MG 28 - D A Y T A B$ - 637 DINOPROSTONE CERVICAL GEL 0.5M $- 637 C A R V E D I L O L 3.125 MGT A B$ - 637 SENNA LAX TAB, 100 $- 637 A M I TR I PT Y L I NE 10 MGT A B$ - 637 LEVONORGESTREL 1.5MG TAB $- 637 N I TROG L Y CER I N 0.1 MG / H O U RTR A NS$ - 637 CLINDAMYCIN 900MG/50ML IVPG $- 637 LU BR I C A NT (M I NER A L O I L / PETRO L A$ - 637 CEPHALEXIN 250MG/5ML ORAL SUSP $- 637 POT A SS I U MC H L OR I D E 20 MEQ /15 M L$ - 637 ITRACONAZOLE 100MG CAPSULE $- 637 T H ROMB I N 5, 000 U N I TS / V I A L I N J$ - 637 GABAPENTIN 250MG/5ML ORAL SOLN $- 637 A C I D OP H I LU S 25 M I LL I ON L I V ECE$ - 637 HYOSCYAMINE 0.125MG SL TAB $- 637 EMOQ U ETTE 28 - D A Y T A B$ - 637 ZINC SULFATE 220MG CAP $- 637 A CET A M I NOP H EN 325 MGRECT A L S U P$ - 637 AMLODIPINE 1MG/ML ORAL SUSPENS $- 637 PRE D N I SONE 1 MGT A B$ - 637 RANITIDINE 75MG/5ML ORAL SUSP $- 637 C A D EXOMER I O D I NE 0.9$ - 637 HYDRALAZINE 25MG TAB $- 637 PROMET H A Z I NE 12.5 MGRECT A L S U P$ - 637 GUAIFENESIN 200MG/10ML SYRUP U $- 637 P A NTOPR A ZO L E 40 MG / P A C K ETOR A L$ - 637 FLUTICASONE 50MCG/ACTUATION NA $- 637 D I L T I A ZEM 180 ERC A P$ - 637 J1815 INSULIN INJ PER 5 UNITS $- 637 SO D I U MC H L OR I D E 1 GMT A B$ - 637 HYDROCHLOROTHIAZIDE 12.5MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 140 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION METOPROLOL SUCCINATE 50MG ER T $- 637 L I T H I U MC I TR A TES Y R U P$ - 637 NIFEDIPINE 90MG ER TAB $- 637 ON D A NSETRON 4 MGO D TT A B$ - 637 METOPROLOL SUCCINATE 25MG ER T $- 637 A M I TR I PT Y L I NE 25 MGT A B$ - 637 POLYETHYLENE GLYCOL 3350 ORAL $- 637 J 1815 I NS UL I NREG UL A R 100 U N I TS / M L I$ - 637 HYOSCYAMINE 0.125MG SL TAB $- 637 TR I A MC I NO L ONE 0.1$ - 637 BUPROPION 300MG (XL) ER TAB $- 637 N A PROXEN 125 MG /5 M L OR A L S U SP$ - 637 ACETAZOLAMIDE 500MG ER CAP $- 637 E Y E W A S H I RR I G A T I NGSO L N$ - 637 PYRIDOXINE 50MG TAB $- 637 A C Y C L O V I R 5$ - 637 MINOXIDIL 2.5MG TAB $- 637 F U ROSEM I D E 40 MGT A B$ - 637 PHENOBARBITAL TAB 32.4MG UD $- 637 M A GNES I U M H Y D ROX I D EOR A LL I Q U I$ - 637 FERROUS SULFATE DROPS 15MG/0.6 $- 637 P H EN Y TO I N 100 MGERC A P$ - 637 HYDROCERIN CREAM, 4OZ $- 637 N I COT I NEPO L A CR I L EX 4 MGM I NT L$ - 637 ACETAMINOPHEN 80MG/0.8ML ORAL $- 637 C A R V E D I L O L 12.5 MGT A B$ - 637 CHLORAL HYDRATE 500MG/5ML ORA $- 637 H A L OPER I D O L 2 MGT A B$ - 637 PROPRANOLOL 10MG TAB $- 637 B I SM U T H S U BS A L I C Y L A TE 262 MG /15$ - 637 METHYLERGONOVINE 0.2MG TAB $- 637 Z I PR A S I D ONE 40 MGC A P$ - 637 NITROGLYCERIN 0.4MG/HOUR TRANS $- 637 G L I P I Z I D EER 2.5 MGT A B$ - 637 DEXAMETHASONE 0.75MG TAB $- 637 SO D I U M H Y A LU RON A TE / C H ON D RO I T I N$ - 637 VERAPAMIL 120MG ER TAB $- 637 C L I N D A M Y C I N 75 MG /5 M L OR A L SO L N$ - 637 FERROUS SULFATE 325MG TAB $- 637 M I SOPROSTO L 100 MCGT A B$ - 637 ZIPRASIDONE 20MG CAP $- 637 H Y D ROP H I L I CTOP I C A L O I NTMENT$ - 637 ACETAMINOPHEN 650MG RECTAL SUP $- 637 H Y D ROCORT I SONE 2.5$ - 637 METHYLPHENIDATE 20MG ER TAB $- 637 NECON 77728 - D A Y T A B$ - 637 LEVOFLOXACIN 750MG TAB $- 637 N I TROG L Y CER I N 2$ - 637 DIMENHYDRINATE 50MG TAB, U/D $- 637 C L A R I T H ROM Y C I N 500 MGERT A B$ - 637 LEVOTHYROXINE 0.15MG TAB $- 637 A L PR A ZO L A M 0.5 MGT A B$ - 637 LISINOPRIL 2.5MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 141 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION MISOPROSTOL 100MCG TAB $- 637 CO A L T A R 5$ - 637 DEMECLOCYCLINE HCL 150MG TAB $- 637 C L ON A ZEP A M 0.5 MGT A B, U / D$ - 637 ACETAMINOPHEN 325MG TAB $- 637 A Z I T H ROM Y C I N 250 MGT A B$ - 637 LEVORA 0.15/30 28-DAY TAB $- 637 I B U PROFEN 800 MGT A B$ - 637 TACROLIMUS 1MG CAP $- 637 SS D CRE A M 1$ - 637 FUROSEMIDE 20MG TAB $- 637 R A N I T I D I NE 150 MGT A B$ - 637 OXYCODONE/ACETAMINOPHEN 5MG-32 $- 637 FENT A N Y L C I TR A TE 600 MCGOR A L$ - 637 BENZTROPINE 1MG TAB $- 637 MET H A D ONE 10 MGT A B$ - 637 TACROLIMUS 1MG CAP, 100/BT $- 637 Z I PR A S I D ONE 20 MGC A P, 60$ - 637 FLUCONAZOLE 150MG TAB $- 637 R I SPER I D ONE 2 MGT A B$ - 637 ARIPIPRAZOLE 15MG TAB $- 637 A MMON I U M L A CT A TE 12$ - 637 AMOXICILLIN/CLAVULANATE 400MG- $- 637 T H EOP H Y LL I NE 100 MGERT A B$ - 637 CYCLOSPORINE 100MG/ML ORAL SOL $- 637 POT A SS I U MC H L OR I D E 10 MEQERC A$ - 637 TRIAZOLAM 0.125MG TAB U/D $- 637 F I N A STER I D E 5 MGT A B$ - 637 LIDOCAINE 4% TOPICAL SOLN, 50M $- 637 H Y D ROC H L OROT H I A Z I D E 12.5 MGC A P$ - 637 ARIPIPRAZOLE 30MG TAB $- 637 PROMET H A Z I NE 25 MGRECT A L S U PPO$ - 637 CALCIUM ALGINATE 4.4 TOPICAL W $- 637 E U CER I NTOP I C A L CRE A M$ - 637 PETROLATUM TOPICAL OINTMENT $- 637 A Z I T H ROM Y C I N 200 MG /5 M L OR A L S U$ - 637 ARIPIPRAZOLE 10MG TAB $- 637 D I V A L PROEXSO D I U M 250 MGT A B U /$ - 637 POTASSIUM IODIDE 1GM/ML ORAL S $- 637 FERRO U SS UL F A TE 325 MGT A B$ - 637 SELENIUM SULFIDE 2.5% TOPICAL $- 637 S I L V ERS UL F A D I A Z I NE 1$ - 637 BACITRACIN 500 UNITS/GM TOPICA $- 637 A CET A M I NOP H EN 120 MGRECT A L S U P$ - 637 ASCORBIC ACID 250MG TAB $- 637 G U A I FENES I N D M 100 MG - 10 MG /5 M L$ - 637 NICOTINE POLACRILEX 2MG MINT L $- 637 P H EN Y TO I N 50 MGC H E W A B L ET A B$ - 637 OXYCODONE HCL 5MG TAB. $- 637 L E V OT H Y ROX I NE 0.1 MGT A B, U / D$ - 637 OLANZAPINE 10MG TAB $- 637 P H Y TON A D I ONE 5 MGT A B$ - 637 LORAZEPAM 1MG TAB U/D $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 142 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION METRONIDAZOLE 250MG TAB $- 637 P A NTOPR A ZO L E D R 40 MGT A B$ - 637 ZIDOVUDINE 100MG CAP $- 637 C L OZ A P I NE 100 MGT A B$ - 637 SULFAMETHOXAZOLE/TRIMETHOPRIM $- 637 A CET A M I NOP H EN 120 MGRECT A L S U P$ - 637 NICOTINE 7MG/24 HOUR TRANSDERM $- 637 G U A I FENES I N 100 MG /5 M L OR A L S Y R$ - 637 DIAZEPAM 5MG TAB $- 637 N I TROG L Y CER I N 0.4 MGS L T A B$ - 637 METHADONE 10MG TAB U/D $- 637 A CET A M I NOP H EN / CO D E I NE 120 MG - 12$ - 637 DOCUSATE SODIUM 100MG CAP $- 637 A C Y C L O V I R 200 MGC A P, U / D$ - 637 J1815 INSULIN LISPRO 100 UNITS/ML IN $- 637 H Y D ROX Y Z I NE H C L 10 MGT A B$ - 637 KETOCONAZOLE 2% TOPICAL CREAM $- 637 A Z A T H I OPR I NE 50 MGT A B$ - 637 LEUCOVORIN CALCIUM 5MG TAB $- 637 C I PROF L OX A C I N 250 MGT A B, BT$ - 637 GLIPIZIDE 5MG ER TAB $- 637 C L I N D A M Y C I N 1$ - 637 CLONIDINE 0.3MG TAB $- 637 J 3590 CO LL A GEN A SES A NT Y L TOP I C A L O I N$ - 637 AMOXICILLIN 250MG/5ML ORAL SUS $- 637 GEO D ONZ I PR A S I D ONE 80 MGC A P, 6$ - 637 NICOTINE POLACRILEX 2MG CHEWIN $- 637 OX Y CO D ONE / A CET A M I NOP H ENT A B 5 M$ - 637 GLYBURIDE 2.5MG TAB $- 637 A MOX I C I LL I N / C L A V UL A N A TE 875 MG -$ - 637 THIAMINE 100MG TAB $- 637 A Z I T H ROM Y C I N 500 MGT A B$ - 637 CARBAMAZEPINE 200MG ER TAB $- 637 I B U PROFEN 400 MGT A B$ - 637 OXYMETAZOLINE 0.05% NASAL SOLN $- 637 J 1815 I NS UL I NG L A RG I NE 100 U N I TS / M L$ - 637 FERROUS SULFATE 15MG ELEMENTAL $- 637 B A C I TR A C I N / PO L Y M Y X I N / NEOM Y C I N$ - 637 SUCRALFATE 1GM TAB $- 637 C Y A NOCOB A L A M I N 1, 000 MCGT A B$ - 637 CLONIDINE 0.2MG TAB $- 637 D I A ZEP A M 2 MGT A B$ - 637 METHOCARBAMOL 750MG TAB $- 637 SCOPO L A M A L I NE 0.33 MG /24 H O U RT$ - 637 FERROGELS FORTE CAP $- 637 C L I N D A M Y C I N 2$ - 637 FENTANYL 100MCG/HOUR TRANSDERM $- 637 R I SPER I D ONE 4 MGT A B$ - 637 CALCIPOTRIENE 0.005% TOPICAL O $- 637 G L Y CER I NS U PP . (I NF A NTS)$ - 637 DIVALPROEX SODIUM 500MG TAB U/ $- 637 PENTOX Y F Y LL I NE 400 MGERT A B$ - 637 IMATINIB 400MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 143 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION TRANEXAMIC ACID 1000MG/10ML IN $- 637 A T A Z A N A V I RS UL F A TE 300 MGC A PS$ - 637 TRIAMCINOLONE 0.025% TOPICAL C $- 637 D I GOX I N 0.125 MGT A B$ - 637 ZIPRASIDONE 80MG CAP $- 637 L E V ET I R A CET A M 500 MGT A B$ - 637 MEDROXYPROGESTERONE 2.5MG TAB $- 637 G L Y CER I NPE D I A TR I CRECT A L S U PP$ - 637 DIPHENOXYLATE/ATROPINE TAB U/D $- 637 H Y D ROCORT I SONE 2.5$ - 637 CARBIDOPA/LEVODOPA 25/100 TAB $- 637 D I L T I A ZEM 300 MGERC A P$ - 637 SODIUM CITRATE/CITRIC ACID 500 $- 637 I SOSORB I D EMONON I TR A TE 60 MGER$ - 637 POTASSIUM CITRATE 1,080MG ER T $- 637 METOC L OPR A M I D E 10 MGT A B$ - 637 COLCHICINE 0.6MG TAB $- 637 F LU CON A ZO L E 100 MGT A B, 100$ - 637 HYDRALAZINE 50MG TAB U/D $- 637 METRON I D A ZO L E 500 MGT A B$ - 637 PEG-3350/ELECTROLYTES ORAL POW $- 637 H Y D ROX Y U RE A 500 MGC A P$ - 637 HYDROXYZINE CAP 25MG $- 637 A C Y C L O V I R 5$ - 637 NELFINAVIR MESYLATE 625MG TAB $- 637 SO D I U MB I C A RBON A TE 650 MGT A B$ - 637 MULTIVITAMIN ORAL DROPS $- 637 M I NOC Y C L I NE 100 MGC A P$ - 637 NORETHINDRONE 0.35MG TAB $- 637 PO V I D ONE I O D I NE 10$ - 637 LIDOCAINE 5% PATCH $- 637 D I P Y R I D A MO L E 25 MGT A B$ - 637 J1815 INSULIN HUMULIN 70/30 (NPH/REG $- 637 L E V OT H Y ROX I NE 0.125 MGT A B$ - 637 J8540 DEXAMETHASONE 4MG TAB $- 637 G LU COTRO L X L T A B 2.5 MG, 30$ - 637 HYDROXYZINE 10MG TAB U/D $- 637 A M I TR I PT Y L I NE 50 MGT A B$ - 637 DIGOXIN 0.25MG TAB $- 637 S A Q U I N A V I RMES Y L A TE 500 MGT A B$ - 637 GLYCERIN ADULT RECTAL SUPPOSIT $- 637 N Y ST A T I N 500, 000 U N I TT A B$ - 637 GLIPIZIDE 10MG ER TAB $- 637 I SOSORB I D EMONON I TR A TE 30 MGER$ - 637 CHLORHEXIDINE GLUCONATE 0.12% $- 637 MET H OC A RB A MO L 500 MGT A B$ - 637 FLUTICASONE/SALMETEROL 250MCG/ $- 637 V I T A M I NE 400 U N I TC A P$ - 637 LEVOTHYROXINE 0.25MG TAB U/D $- 637 D I B U C A I NE 1$ - 637 LEVOTHYROXINE 0.025MG TAB U/D $- 637 O L A NZ A P I NE 20 MGT A B$ - 637 IODINE,STRONG TINCTURE, 473ML/ $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 144 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION AMINOCAPROIC ACID 500MG TAB $- 637 A CET A M I NOP H EN / CO D E I NE 300 MG - 30$ - 637 LEVOFLOXACIN 500MG TAB $- 637 BENZOC A I NE W / TETR A C A I NE A EROSO$ - 637 CALCIUM CITRATE+ VIT D CAPL, 6 $- 637 I B U PROFEN 800 MGT A B$ - 637 CAPSAICIN 0.025% TOPICAL CREAM $- 637 I SOPROTERENO L 1 MG /5 M L A MP UL E I$ - 637 CLOTRIMAZOLE 1% TOPICAL CREAM $- 637 H Y D ROCORT I SONE 1$ - 637 KETOROLAC 10MG TAB $- 637 C Y C L A FEM 1/3528 - D A Y T A B$ - 637 RENAL VITAMIN CAP $- 637 L I D OC A I NE 5$ - 637 ALPRAZOLAM TAB 0.25MG $- 637 J 1815 I NS UL I NNP H 100 U N I TS / M L I N J EC$ - 637 PROPRANOLOL 40MG TAB $- 637 C L ON I D I NE 0.1 MG /24 H O U RSTR A NS$ - 637 NORINYL 1/35 28-DAY TAB $- 637 CO A L T A R 2.5$ - 637 SODIUM BICARBONATE 10GR UD TAB $- 637 C H L ORPROM A Z I NE 50 MGT A B$ - 637 METOPROLOL SUCCINATE 100MG ER $- 637 B A C I / PO L Y / NEOM Y C I NO I NT 1/32 O$ - 637 DIPYRIDAMOLE 50MG TAB $- 637 A MOX I C I LL I N 400 MG /5 M L OR A L S U S$ - 637 METOCLOPRAMIDE 5MG/5ML ORAL SY $- 637 M A GNES I U MOX I D E 400 MGT A B$ - 637 MAGNESIUM CITRATE ORAL SOLN $- 637 L E V OT H Y ROX I NE 0.2 MGT A B$ - 637 CLONAZEPAM 0.5MG TAB $- 637 TR I A ZO L A M 0.25 MGT A B$ - 637 HYDROXYZINE 25MG CAP U/D $- 637 C A RB A M I D EPEROX I D E 6.5$ - 637 PHENYTOIN 125MG/5ML ORAL SUSP $- 637 B A C L OFEN 10 MGT A B$ - 637 AMANTADINE 100MG CAP $- 637 G U A I FENES I N / CO D E I NE 100 MG /10 MG$ - 637 ACETAMINOPHEN 80MG CHEWABLE TA $- 637 N I TROG L Y CER I N 2$ - 637 SENNOSIDES 8.6MG TAB $- 637 J 7297 M I REN A (L E V ONORGESTRE L) 52 MG I$ - 637 FLUOXETINE 20MG CAP $- 637 TOP I R A M A TE 100 MGT A B$ - 637 DILTIAZEM 240MG CD CAP $- 637 A C A RBOSE 100 MGT A B$ - 637 METFORMIN 850 MG TAB. U/D $- 637 SERTR A L I NE 25 MGT A B$ - 637 THIOTHIXENE 10MG CAP $- 637 W A RF A R I N 6 MGT A B$ - 637 BENZOCAINE 15MG LOZENGES $- 637 G L I P I Z I D E 10 MGT A B$ - 637 CITALOPRAM 20MG TAB UD, 100 $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 145 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION GABAPENTIN 300MG CAP $- 637 ESC I T A L OPR A M 10 MGT A B$ - 637 TEMAZEPAM 30MG CAP $- 637 BET H A NEC H O L 10 MGT A B$ - 637 LABETALOL 300MG TAB $- 637 M I RT A Z A P I NE 30 MGT A B$ - 637 TERBINAFINE 250MG TAB $- 637 OX A ZEP A M 10 MGC A P$ - 637 GLIPIZIDE 5MG TAB $- 637 A LL OP U R I NO L 300 MGT A B$ - 637 BISOPROLOL 10MG TAB $- 637 I SON I A Z I D 300 MGT A B U / D$ - 637 MEBENDAZOLE 100MG CHEW $- 637 TENOFO V I R 300 MGT A B$ - 637 PENICILLAMINE 250MG CAP $- 637 I M I PR A M I NE 25 MGT A B$ - 637 LISINOPRIL 10MG TAB $- 637 ZO L P I D EM 10 MGT A B$ - 637 QUETIAPINE 200MG TAB $- 637 D I L T I A ZEM 300 MGC D C A P$ - 637 LITHIUM CARBONATE 300MG TAB $- 637 A TOR V A ST A T I N 80 MGT A B$ - 637 CLARITHROMYCIN 500MG TAB $- 637 W A RF A R I N 4 MGT A B$ - 637 METFORMIN 1000MG TAB $- 637 PEN I C I LL I N V K 500 MGT A B$ - 637 CEPHALEXIN 500MG CAP $- 637 FOS I NOPR I L 20 MGT A B$ - 637 DAPSONE 100MG TAB UD,30 $- 637 D OX Y C Y C L I NE 100 MGC A P$ - 637 OXYCODONE 10MG SR TAB $- 637 A SP I R I N 81 MGECT A B$ - 637 OMEPRAZOLE 20MG CAP U/D $- 637 SERTR A L I NE 50 MGT A B$ - 637 CILOSTAZOL TAB 100MG, 60 $- 637 D I V A L PROEX 500 MGECT A B$ - 637 ERYTHROM 250MG TAB $- 637 ME D ROX Y PROGESTERONE 10 MGT A B$ - 637 ACITRETIN 10MG CAP $- 637 C I T A L OPR A M 20 MGT A B$ - 637 VERAPAMIL 120MG TAB $- 637 A M L O D I P I NE 5 MGT A B$ - 637 EFAVIRENZ 600MG TAB $- 637 S I M V A ST A T I NT A B 10 MG U D, 100$ - 637 PRAVASTATIN 20MG TAB $- 637 PENTOX Y F Y LL I NE 400 MGT A B$ - 637 NADOLOL 40MG TAB $- 637 PREG A B A L I N 50 MGC A P$ - 637 WARFARIN 3MG TAB $- 637 G U I A FENES I N D M U / D, 10 M L$ - 637 METHIMAZOLE 5MG TAB $- 637 C A L C I U M A CET A TE 667 MGC A P$ - 637 LABETALOL 100MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 146 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION DAPSONE 25MG TAB $- 637 ET H A MB U TO L 100 MGT A B$ - 637 ACARBOSE 50MG TAB U/D $- 637 A P I X A B A N 5 MGT A B$ - 637 ALPRAZOLAM 2MG TAB $- 637 S I L D EN A F I L 50 MGT A B$ - 637 LOVASTATIN 20 MG TAB $- 637 Q U ET I A P I NE 100 MGT A B$ - 637 METFORMIN 500MG TAB $- 637 OX Y CO D ONE 5 MG I MME D I A TE - RE L E A S$ - 637 SIMVASTATIN 10MG TAB $- 637 W A RF A R I N 1 MGT A B$ - 637 CANDESARTAN 32MG TAB $- 637 R I V A ROX A B A N 20 MGT A B$ - 637 METOPROLOL SUCCINATE 100MG TAB $- 637 METFORM I N 1000 MGT A B$ - 637 SITAGLIPTIN 50MG TAB $- 637 B I S A CO D Y L 10 MGRECT A L S U PPOS I T$ - 637 NAPROXEN 250MG TAB U/D $- 637 V EN L A F A X I NE 75 MGT A B$ - 637 DOXAZOSIN 2MG TAB $- 637 R I F A MP I NC A P 150 MG U D, 30$ - 637 GATIFLOXACIN 400MG TAB $- 637 SE V OF LU R A NE 250 M L, A BBOT A U STR$ - 637 MECLIZINE 25MG TAB $- 637 A D EFO V I R 10 MGT A B$ - 637 LISINOPRIL 5MG TAB $- 637 L A MOTR I G I NET A B 25 MG U D, 100$ - 637 LINAGLIPTIN 5MG TAB $- 637 D A PSONE 100 MGT A B$ - 637 ULORIC FEBUXOSTAT 80MG TAB, 30 $- 637 BENZOC A I NE 15 MG L OZENGES$ - 637 PHOSPHOROUS 250MG TAB $- 637 S I M V A ST A T I N 20 MG U D T A B, 100$ - 637 URSODIOL 300MG CAP $- 637 N A PROXEN 500 MGT A B$ - 637 DILTIAZEM 30MG TAB $- 637 C L ON A ZEP A M 2 MGT A B, U / D$ - 637 LOVASTATIN 40MG TAB $- 637 I SOSORB I D E D I N I TR A TE 20 MGT A B$ - 637 THIORIDAZINE 25MG TABS $- 637 A TOR V A ST A T I NT A B 40 MG U D, 100$ - 637 TRAZODONE 50MG TAB $- 637 A LL OP U R I NO L 100 MGT A B, 10 0^{'} S$ - 637 LOPERAMIDE 2MG CAP $- 637 D ONEPEZ I L 5 MGT A B$ - 637 PYRAZINAMIDE 500MG TAB $- 637 I SON I A Z I D 300 MGT A B U / U, 30/ B$ - 637 CILOSTAZOL 100MG TAB $- 637 PR A Z I Q U A NTE L 600 MGT A B$ - 637 ORAL SYRINGE 1ML $- 637 I SOSORB I D E 10 MGT A B U / D$ - 637 METHYLPHENIDATE 5MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 147 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION NAVANE CAP 20MG $- 637 C A PTOPR I L 25 MGT A B$ - 637 ZOLPIDEM 5MG TAB U/D $- 637 PREG A B A L I N 150 MGC A P$ - 637 NIFEDIPINE 10MG CAP $- 637 N I TROF U R A NTO I N 100 MGC A P$ - 637 CINACALCET 30MG TAB $- 637 C L ON A ZEP A M 1 MGT A B$ - 637 MIRTAZAPINE 15MG TAB $- 637 MET H Y L P H EN I D A TE 10 MGT A B$ - 637 VERAPAMIL 240MG SR TAB $- 637 C Y C L OBENZ A PR I NE 10 MGT A B$ - 637 MYCOPHENOLATE MOFETIL 500MG TA $- 637 D I V A L PROEX 250 MGECT A B$ - 637 BENZONATATE 100MG CAP $- 637 L A MOTR I G I NE 100 MGT A B,$ - 637 RIFAMPIN 150MG CAP $- 637 T I C L OP I D I NE 250 MGT A B$ - 637 SEVELAMER 800MG TAB $- 637 F LU OXET I NE 10 MGC A P$ - 637 GUANFACINE 1MG TAB $- 637 G L Y B U R I D E 3 MGT A B$ - 637 ASPIRIN 325MG TAB $- 637 D A B I G A TR A N 150 MGC A P$ - 637 LAMOTRIGINE 25MG TAB $- 637 A M L O D I P I NE 10 MGT A B$ - 637 TICAGRELOR 90MG TAB $- 637 A C I TRET I N 25 MGC A P$ - 637 DOXYCYCLINE 50MG CAP $- 637 W A RF A R I N 5 MGT A B$ - 637 METHYLPHENIDATE 20MG TAB $- 637 PR A ZOS I N 1 MGC A P$ - 637 SELEGILINE 5MG TAB $- 637 A SP I R I N 81 MGC H E W A B L ET A B$ - 637 DOXAZOSIN 4MG TAB $- 637 OX Y B U T Y N I N 5 MGT A B$ - 637 SIMVASTATIN 40MG TAB UD,100 $- 637 A TENO L O L 100 MGT A B$ - 637 CYCLOSPORINE 25MG CAP $- 637 METOPRO L O L T A RTR A TE 25 MGT A B$ - 637 AMOXICILLIN 500MG CAP $- 637 G A B A PENT I N 100 MGC A P$ - 637 LORATADINE 10MG TAB $- 637 L I T H I U MC A RBON A TE 300 MGC A P$ - 637 EZETIMIBE 10MG TAB $- 637 H Y D ROC H L OROT H I A Z I D E 50 MGT A B$ - 637 NAPROXEN 500MG TAB $- 637 FENOF I BR A TE 160 MGT A B$ - 637 FERROUS GLUCONATE 325MG TAB $- 637 L A BET A L O L 100 MGT A B$ - 637 TRIHEXYPHENIDYL 2MG TAB $- 637 OX Y CO D ONE 20 MGEXTEN D E D - RE L E A S$ - 637 FEBUXOSTAT 40MG TAB $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 148 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION MYCOPHENOLATE CAP 250MG, 100 $- 637 D A S A T I N I B 50 MGT A B$ - 637 SILDENAFIL 25MG TAB $- 637 D OXEP I N 50 MGC A P$ - 637 THIOTHIXINE 10MG CAP, 100/BT $- 637 I SOSORB I D ET A B 20 MG$ - 637 TYLENOL 325MG TAB, UD $- 637 A MOX I C I LL I N 250 MGC A P$ - 637 DASATINIB 70MG TAB $- 637 PREG A B A L I N 75 MGC A P$ - 637 SPIRONOLACTONE 100MG TAB $- 637 Q U ET I A P I NE 200 MGT A B U / D$ - 637 ANASTROZOLE TAB 1MG UD $- 637 A N A STROZO L E 1 MGT A B$ - 637 ACARBOSE 25MG TAB $- 637 N A PROXEN 250 MGT A B$ - 637 PRAVASTATIN 10MG TAB $- 637 METOPRO L O L T A RTR A TE 50 MGT A B$ - 637 GEMFIBROZIL 600MG TAB U/D $- 637 M UL T I V I T A M I N A D UL T 10 M L S D V I N$ - 637 ZOLPIDEM 5MG TAB $- 637 B U PROP I ON 100 MGT A B$ - 637 RIBAVIRIN 200MG TAB, 168/BT $- 637 L OPER A M I D E 2 MGC A P$ - 637 DOXAZOSIN 1MG TAB $- 637 METO L A ZONE 5 MGT A B$ - 637 ASPIRIN 81 MG SAFETY-COATED TA $- 637 A LL OP U R I NO L 100 MGT A B$ - 637 AMCINONIDE 0.1% LOTION, 60ML $- 637 P A ROXET I NE 10 MGT A B$ - 637 ERLOTINIB 150 MG TABLET $- 637 L OS A RT A N 100 MGT A B$ - 637 URSODIOL CAP 300MG $- 637 METOPRO L O L 50 MGT A B$ - 637 GLYBURIDE 5MG TAB $- 637 TR A M A D O L 50 MGT A B$ - 637 BUPROPION SR 150MG TAB $- 637 V ER A P A M I L 180 MGSRT A B$ - 637 ALLOPURINOL 300MG TAB, 100’S $- 637 OX Y CO D ONE 5 MG I MME D I A TE - RE L E A S$ - 637 CHLORTHALIDONE 25MG TAB $- 637 SERTR A L I NE 100 MGT A B$ - 637 SUNITINIB SUTENT 25MG CAP, 28 $- 637 A SP I R I N 325 MGECT A B$ - 637 PENICILLIN V 250MG TAB, 100 $- 637 L I S I NOPR I L 30 MGT A B$ - 637 CHLORPHENIRAMINE 4MG TAB $- 637 I SON I A Z I D 300 MGT A B$ - 637 SULINDAC 200MG TAB $- 637 V EN L A F A X I NE 100 MGT A B$ - 637 VARENICLINE 1MG TAB $- 637 C A R V E D I L O L 25 MGT A B$ - 637 CLINDAMYCIN 150MG CAP $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 149 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION CAPTOPRIL 25MG $- 637 N I A C I N 500 MGT A B$ - 637 INDOMETHACIN 50MG CAP $- 637 A TENO L O L 25 MGT A B$ - 637 METHIMAZOLE 10MG TAB $- 637 A TOR V A ST A T I N 80 MGT A B$ - 637 METFORMIN 850MG TAB $- 637 A SP I R I N 600 MGRECT A L S U PPOS I TO$ - 637 CYCLOSERINE 250MG CAP $- 637 P Y R I MET H A M I NE 25 MGT A B$ - 637 CARVEDILOL 25MG TAB UD, 100 $- 637 G L Y B U R I D E 3 MGM I CRONT A B, 100$ - 637 ACARBOSE 50MG TAB $- 637 H Y D ROC H L OROT H I A Z I D E 25 MGT A B$ - 637 METHYLDOPA 250MG TAB $- 637 SP I RONO L A CTONE 25 MGT A B$ - 637 LOSARTAN 50MG TAB $- 637 A TENO L O L 50 MGT A B$ - 637 ATORVASTATIN 40MG TAB $- 637 R I F A MP I N 300 MGC A P$ - 637 PHENAZOPYRIDINE 100MG TAB $- 637 ER Y T H ROM Y C I NB A SE 500 MGT A B$ - 637 CAPECITABINE 500MG TAB $- 637 GEMF I BROZ I L 600 MGT A B$ - 637 SIMETHICONE 80MG CHEWABLE TAB $- 637 S I M V A ST A T I N 40 MGT A B$ - 637 ERYTHROMYCIN BASE 250MG TAB $- 637 L A BET A L O L 300 MGT A B U / D$ - 637 ETHAMBUTOL 400MG TAB $- 637 A M L O D I P I NE 10 MGT A B$ - 637 CALCIUM CARBONATE 500MG CHEWAB $- 637 S I L D EN A F I L 20 MGT A B$ - 637 AL & MG OH & ALG TAB $- 637 C A RB A M A ZEP I NE 100 MGC H E W A B L E$ - 637 QUETIAPINE 25MG TAB $- 637 I M I PR A M I NE 25 MGT A B, U / D$ - 637 TERAZOSIN 2MG CAP $- 637 G L I MEP I R I D E 2 MGT A B$ - 637 ZOLPIDEM 10MG TAB U/D $- 637 C L ON A ZEP A M 1 MGT A B, U / D$ - 637 FISH OIL 1,000MG CAP $- 637 PROP Y L T H I O U R A C I L 50 MGT A B$ - 637 CLOPIDOGREL 75MG TAB $- 637 MONTE LU K A ST 10 MGT A B$ - 637 ETHOSUXIMIDE 250MG CAP $- 637 PSE U D OEP H E D R I NE 60 MGT A B$ - 637 SULFASALAZINE 500MG TAB $- 637 L OR A T A D I NE 10 MGT A B .$ - 637 ATORVASTATIN 20MG TAB $- 637 D OXEP I N 25 MGC A P$ - 637 NIACIN 100MG TAB $- 637 L A MOTR I G I NE 200 MGT A B$ - 637 CLINDAMYCIN 300MG CAP $- 637 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 150 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION PRAZOSIN 2MG CAP $- 637 Q U ET I A P I NE 300 MGT A B$ - 637 ENALAPRIL 10MG TAB $- 637 L EX A PROT A B 10 MG U D NF$ - 637 BUSPIRONE 5MG TAB $- 637 ROS U V A ST A T I N 20 MGT A B$ - 637 CLONAZEPAM 2MG TAB $- 637 G L I MEP I R I D E 1 MGT A B$ - 637 NICARDIPINE 20MG CAP $- 637 B I S A CO D Y L 5 MGECT A B$ - 637 MEFLOQUINE 250MG TAB $- 637 A TOR V A ST A T I N 10 MGT A B$ - 637 INDOMETHACIN 25MG CAP $- 637 L OS A RT A N 25 MGT A B$ - 637 NADOLOL 80MG TAB $- 637 F LU OXET I NC A P 10 MG$ - 637 GLYBURIDE 6MG TAB $- 637 L OR A T A D I NE 10 MGT A B U D$ - 637 DOXEPIN 50MG CAP U/D $- 637 N I MO D I P I NE 30 MGC A P$ - 637 LOSARTAN 50MG TAB, 1000 $- 637 H Y D ROX Y C H L OROQ U I NE 200 MGT A B$ - 637 CEPHALEXIN 250MG CAP $- 637 W A RF A R I N 2 MGT A B$ - 637 ASPIRIN 81MG EC TAB U/D $- 637 N I TROF U R A NTO I N 50 MGC A P$ - 637 DOXAZOSIN 1MG TAB $- 637 L A BET A L O L 100 MGT A B, U / D$ - 637 OMEPRAZOLE 20MG EC CAP $- 637 MEC L I Z I NE 25 MGT A B$ - 637 GUAIFENESIN MUCINEX 600MG TAB, $- 637 COENZ Y MEQ - 10100 MGC A P$ - 637 CARBAMAZEPINE 200MG TAB $- 637 C L A R I T H ROM Y C I N 250 MGT A B .$ - 637 SEROQUEL QUETIAPINE 300MG TAB $- 637 B U PROP I ON 75 MGT A B$ - 637 LISINOPRIL 20MG TAB $- 637 FOS I NOPR I L 10 MGT A B$ - 637 DILTIAZEM 60MG TAB $- 637 OX Y CO D ONE 10 MGEXTEN D E D - RE L E A S$ - 637 DOXYCYCLINE 100MG TAB $- 637 PEN I C I LL I N V K 250 MGT A B$ - 637 LISINOPRIL 40MG TAB $- 637 B I S A CO D Y L 5 MGT A B, U / D$ - 637 ATORVASTATIN 20MG TAB $- 637 REGOR A FEN I B 40 MGT A B$ - 637 NITROFURANTOIN 50MG CAP UD $- 637 L I S I NOPR I L 10 MGT A B$ - 637 [Rows 17968-18006:] CPT MOD Description Price COVID Related? © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 151 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 87635 SARS-COV-2 COVID-19 AMP PRB $153.93 Y U 0003 S A RS - CO V - 2 CO V I D - 19 A MPPRB H TT$ 300.00 Y U0004 SARS-COV-2 COVID-19 AMP PRB HTT, NON $300.00 Y C D CG 2023 SPEC I MENCO LL ECTCO V I D - 19$ 70.38 Y G2024 SPEC COLL SNF/LAB COVID-19 $76.38 Y G 2066 TCREMOTE I NTEROG D E V C 30 D TEC H N I C A L$ 114.09 SUPPORT 0650T REMOTE PRGRMG DEV EVAL SCRMS $114.0999441 P H ONEE / MB Y P H Y S 5 - 10 M I N$ 66.15 Y 99453 26 REM MNTR PHYSIOL PARAM SETUP $63.87 Y 9945426 REMMNTRP H Y S I O L P A R A M D E V$ 213.75 Y 99457 26 REM PHYSIOL MNTR 1ST 20 MIN $100.89 Y 9945826 REMP H Y S I O L MNTRE AA DD L 20$ 100.89 Y 99473 26 SELF-MEAS BP PT EDUCAJ/TRAIN $37.86 Y 9947426 SE L F - ME A SBP 2 RE A D GB I D 30 D$ 27.72 Y G0508 26 CRIT CARE TELEHEA CONSULT 60 $658.65 Y G 050926 CR I TC A RETE L E H E A CONS UL T 50$ 604.29 Y G0406 INPT/TELE FOLLOW UP 15 $122.19 Y G 0459 TE L E H E A L T H I NPTP H A RMMGMT$ 129.24 Y G0425 INPT/ED TELECONSULT30 $313.56 Y G 0426 I NPT / E D TE L ECONS UL T 50$ 426.72 Y G0427 INPT/ED TELECONSULT70 $632.31 Y U 00012019 - NCO V D I A GNOST I CP A NE L$ 107.73 Y U0002 COVID-19 LAB TEST NON-CDC $153.93 Y G 2012 BR I EFC H EC K I NB Y M D / Q H P$ 41.01 Y G2010 REMOT IMAGE SUBMIT BY PT $28.98 Y 99421 ON L I NE D I G I T A L E / MS V CESTPT < 7 D 5 - 10$ 41.01 Y 99422 ONLINE DIGITAL E/M SVC EST PT <7 D 11-20 $83.97 Y 99423 ON L I NE D I G I T A L E / MS V CESTPT < 7 D 21 +$ 133.59 Y G2061 QUAL NONMD EST PT 5-10M $37.83 Y G 2062 Q U A L NONM D ESTPT 11 - 20 M$ 66.66 Y G2063 QUAL NONMD EST PT 21>MIN $103.26 Y 81240 F 2 GENE A N A L Y S I S 20210 G > A V A R I A NT$ 197.07 N 81241 F5 COAGULATION FACTOR V ANAL LEIDEN $220.11 N 67912 CORRECTE Y E L I D W I MP L A NT$ 5,805.60 N 67912 26 CORRECT EYELID W IMPLANT $1, 578.21 N 67900 REP A I ROFBRO W PTOS I S$ 5,805.60 N 67900 26 REPAIR OF BROW PTOSIS $1, 646.73 N 58572 TCT L H U TER U SO V ER 250 G$ 16,826.22 N 58573 TC TLH W/T/O UTERUS OVER 250 G $16, 826.22 N 96413 C H EMO I V I NF U S I ON 1 H R$ 2,305.00 N 96416 CHEMO PROLONG 8+ HRS INFUSE W/PUMP $2,200.00 N [Rows 18007-18015:] CPT MOD Description Price Comments 81229 CYTOGENOM CONST MICROARRAY COPY NUMBER & SNP$ 3,480.00 VAR 91300 SARSCOV2 VACCINE DIL RECON 30 MCG/0.3 ML IM USE - Pfizer-Biontech Covid-19 Vaccine. A fee will be assigned once Medicare identifies the reimbursement rate. 91301 SARSCOV2 VACCINE 100 MCG/0.5 ML IM USE - Moderna Covid-19 Vaccine. A fee will © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 152 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION be assigned once Medicare identifies the reimbursement rate. 0001A IMM ADMIN SARSCOV2 30MCG/0.3 ML DIL RECON 1ST $50.82 D OSE 0002 A I MM A D MNS A RSCO V 230 MCG /0.3 M L D I L RECON 2 N D$ 85.17 DOSE 0011A IMM ADMN SARSCOV2 100 MCG/0.5 ML 1ST DOSE $50.820012 A I MM A D M I NS A RSCO V 2100 MCG /0.5 M L 2 N DD OSE$ 85.17 Q0239 INJECTION, BAMLANIVIMAB, 700 MG - A fee will be assigned once Medicare identifies the reimbursement rate. Q0243 INJECTION, CASIRIVIMAB AND IMDEVIMAB, 2400 MG $- Q 0245 I N J ECT I ON, B A M L A N I V I M A B A N D ETESE V I M A B, 2100 MG$ - Q0247 SOTROVIMAB $7, 182.00 Q 0249 TOC I L I Z U M A BFORCO V I D - 19$ 19.71 M0201 COVID·19 VACCINE HOME ADMIN $106.50 M 0220 T I X A GE V A N D C I L G A V I N J$ 451.50 M0221 TIXAGEV AND CILGAV I NJ HM $751.50 M 0222 BEBTE L O V I M A B I N J ECT I ON$ 1,051.50 M0239 INTRAVENOUS INFUSION, BAMLANIVIMAB $928.80 M 0240 C A S I R I A N D I M D E V REPE A T$ 1,350.00 M0241 CASIRI AND I MDEV REPEAT HM $2, 250.00 M 0243 I NTR A V ENO U S I NF U S I ON, C A S I R I V I A N D I M D E V I$ 928.80 M0243 CASIRIVI AND I MDEVI INJ $1, 350.00 M 0244 C A S I R I V I A N D I M D E V II N J H M$ 2,250 M0245 INTRAVENOUS I NFUSION, BAMLAN AND ETESEV $928.80 M 0245 B A M L A N A N D ETESE V I NF U S I ON$ 1,350.00 M0246 BAMLAN AND ETESEV INFUS HOME $2, 250.00 M 0247 SOTRO V I M A B I NF U S I ON$ 1,350.00 M0248 SOTROVIMAB INF, HOME ADMIN $2, 250.00 M 0249 A D MTOC I L I Z U CO V I D - 191 ST$ 1,350.00 M0250 ADM TOCILIZU COVID-19 2ND $1, 350.00 G 300226 C H RON I CP A I NMGMT 30 M I NS$ 225.54 960 G3003 26 CHRONIC PAIN MGMT ADDL 15M $78.57960 D i sc l aim ers : Pl e a se n o t e t ha tt h e f ees l i s t e d a re a ppl i c ab l e u n l ess t h ec u rre n tM e d i c a rer a t e i s hi g h er, in w hi c h c a se t h ec u rre n tM e d i c a rer a t e w i ll a ppl y in s t e a d o f t h er a t e l i s t e d ab o v e . A f ee ma y b ec ha r g e df orser v i ces n o t s p ec i f i e d ab o v e . De p e n d in g o n t h eser v i ceor i t e m, t h e f ee w i ll b e ba se d o n t h e a c t u a l cos t o f p ro v i d in g t h eser v i ce pl u so v er h e a d cos t; an d / orco m p a re d t o ma r k e tp r i ce . I t e m s w i t h o u t a p r i ce (or a$ 0.00 value), will have a fee based on the actual cost of providing the service plus overhead costs; and/or compared to market price. SUPPLIES (Prices are subject to change, based on cost plus a markup percentage) PHARMACEUTICALS - will be based on AWP; and/or (acquisition cost of drugs + acq cost of any supplies used in compounding) plus a markup percentage; whichever is appropriate given the circumstances. Modified, 1 CMC § 3806(a). © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 153 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION History: Amdts Adopted 46 Com. Reg. 51459 (Nov. 15, 2024); Amdts Proposed 45 Com. Reg. 51321 (Sept. 15, 2024); Amdts Adopted 46 Com. Reg. 50760 (Mar. 15, 2024); Amdts Proposed 45 Com. Reg. 50547 (Oct. 28, 2023); Amdts Adopted 45 Com. Reg. 50325 (Sept. 28, 2023); Amdts Proposed 45 Com. Reg. 50039 (July 28, 2023); Amdts Adopted 45 Com. Reg. 50322 (Sept. 28, 2023); Amdts Proposed 45 Com. Reg. 50032 (July 28, 2023); Amdts Adopted 44 Com. Reg. 49229 (Nov. 28, 2022); Amdts Proposed 44 Com. Reg. 49019 (Sept. 28, 2022); Amdts Adopted 44 Com. Reg. 48669 (July 28, 2022); Amdts Proposed 44 Com. Reg. 48397 (Apr. 28, 2022); Amdts Adopted 43 Com. Reg. 47890 (Nov. 28, 2021); Amdts Proposed 43 Com. Reg. 47718 (Oct. 28, 2021); Amdts Adopted 43 Com. Reg. 46395 (June 28, 2021); Amdts Proposed 43 Com. Reg. 45582 (Mar. 28, 2021); Amdts Adopted 43 Com. Reg. 45069 (Feb. 28, 2021); Amdts Proposed 42 Com. Reg. 44676 (Dec. 28, 2020); Amdts Adopted 42 Com. Reg. 43639 (June 28, 2020); Amdts Proposed 42 Com. Reg. 43515 (Apr. 28, 2020); Amdts Adopted 42 Com. Reg. 43064 (Jan. 28, 2020); Amdts Proposed 41 Com. Reg. 42881 (Nov. 28, 2019); Amdts Adopted 41 Com. Reg. 42761 (Aug. 28, 2019); Amdts Proposed 41 Com. Reg. 42071 (June 28, 2019); Amdts Adopted 41 Com. Reg. 42021 (June 28, 2019); Amdts Proposed 41 Com. Reg. 41637 (Apr. 28, 2019); Adopted 41 Com. Reg. 041326 (Jan. 28, 2019) )(repealing and replacing subchapter 140-10.8); Proposed 40 Com. Reg. 041013 (Nov. 28, 2018) (repealing and replacing subchapter 140-10.8); Amdts Adopted 39 Com. Reg. 40222 (Oct. 28, 2017); Amdts Proposed 39 Com. Reg. 39410 (Mar. 28, 2017); Amdts Adopted 39 Com. Reg. 39218 (Feb. 28, 2017); Amdts Proposed 36 Com. Reg. 35137 (July 28, 2014); Amdts Adopted 27 Com. Reg. 25393 (Dec. 30, 2005); Amdts Proposed 27 Com. Reg. 25239 (Nov. 25, 2005); Amdts Adopted 26 Com. Reg. 21895 (Feb. 23, 2004); Amdts Proposed 26 Com. Reg. 21659 (Jan. 22, 2004); Amdts Proposed 22 Com. Reg. 17094 (Apr. 20, 2000); Amdts Proposed 21 Com. Reg. 16899 (Aug. 23, 1999); Amdts Proposed 21 Com. Reg. 16594 (Mar. 18, 1999); Amdts Adopted 21 Com. Reg. 16627 (Mar. 18, 1999); Amdts Proposed 21 Com. Reg. 16421 (Jan. 18, 1999); Amdts Adopted 21 Com. Reg. 16444 (Jan. 18, 1999); Amdts Proposed 20 Com. Reg. 16302 (Nov. 15, 1998); Amdts Adopted 20 Com. Reg. 16300 (Nov. 15, 1998); Amdts Proposed 20 Com. Reg. 16097 (Aug. 15, 1998); Amdts Adopted 20 Com. Reg. 16101 (Aug. 15, 1998); Amdts Proposed 20 Com. Reg. 15922 (June 15, 1998); Amdts Adopted 20 Com. Reg. 15953 (June 15, 1998); Amdts Proposed 20 Com. Reg. 15861 (Feb. 15, 1998); Amdts Adopted 19 Com. Reg. 15733 (Oct. 15, 1997); Amdts Proposed 19 Com. Reg. 15391 (June 15, 1997); Amdts Adopted 19 Com. Reg. 15420 (July 15, 1997); Amdts Proposed 19 Com. Reg. 15360 (May 15, 1997); Amdts Adopted 19 Com. Reg. 15418 (July 15, 1997); Amdts Proposed 19 Com. Reg. 15367 (May 15, 1997); Amdts Adopted 19 Com. Reg. 14888 (Jan. 15, 1997); Amdts Proposed 18 Com. Reg. 14383 (Oct. 15, 1996); Amdts Adopted 18 Com. Reg. 14203 (July 15, 1996); Amdts Proposed 18 Com. Reg. 14156 (June 15, 1996); Amdts Adopted 18 Com. Reg. 13931 (Jan. 15, 1996); Amdts Proposed 17 Com. Reg. 13915 (Dec. 15, 1995); Amdts Adopted 17 Com. Reg. 13922 (Dec. 15, 1995); Amdts Proposed 17 Com. Reg. 13816 (Nov. 15, 1995); Amdts Adopted 17 Com. Reg. 13717 (Sept. 15, 1995); Amdts Proposed 17 Com. Reg. 13657 (Aug. 16, 1995); Amdts Adopted 17 Com. Reg. 13293 (Apr. 15, 1995); Amdts Proposed 17 Com. Reg. 12752 (Feb. 15, 1995). Commission Comment: [Historical comments removed.] Part 200 - BEH Fees § 140-10.8-201 BEH Fees Commonwealth Healthcare Corporation Bureau of Environmental Health Section Category Description Rate Fixed establishment vending food/drink directly to the 101 Food or Drink Service consumer 101.1 Seating Capacity: up to 20 chairs $90.00 101.2 Restaurant, Fast Food, Bar & Grill, Seating Capacity: 21- 50 chairs$ 225.00 Snack Bar, Café/ Coffee Shop, 101.3 Lounge, Cafeteria Seating Capacity: 51- 75 chairs $340.00101.4 S e a t in g C a p a c i t y : 76 - 100 c hai rs$ 450.00 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 154 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 101.5 Seating Capacity: 100+ chairs $500.00101.6 B a rs / t a v er nWi t h o u t f oo d ser v i ce$ 120.00 101.7 Karaoke Lounge $120.00101.8 N i g h tCl u b$ 120.00 101.9 Kitchenette/ Catering On-site and off-site catering operations. Does not include temporary food service operations, snack mobile, delivery vehicle $140.00 F i x e d es t ab l i s hm e n t d i s p e n s in gg oo d s d i rec tl y t o 102 R e t ai lO u tl e t c u s t o m er 102.1 R e t ai l / C o n v e ni e n tSt ore (S ma ll) E s t ab l i s hm e n tl ess t han 500 s q . f ee t in s i ze,$ 90.00 102.2 Retail/ Convenient Store (Medium) Between 500- 1,000 sq. ft. $180.00102.3 R e t ai l / C o n v e ni e n tSt ore (L a r g e) L a r g er 1, 000 s q . f t . a re a$ 270.00 102.4 Gift Shop Specialty establishment vending cosmetics, vitamins, supplements $90.00103 F i x e d or m o bi l ero a d s i d eor t e m p or a rye v e n t s a l e 103.1 O u t d oor BBQSt an d St an d - a l o n es t r u c t u re, e q u i pp e d w i t h w a s t e d i s p os a l, r u nnin g w a t er, re f r i g er a t i o nan d p re p a r a t i o na re a$ 90.00 103.2 Sale of Refreshment Sale of processed prepackage food, soup, salad & beverages $90.00103.3 P ro d u ce d V e n d or S a l eo f r a w v e g e t ab l es$ 90.00 103.4 Fish Vendor Sale of freshly caught seafood $90.00 103.5 Fish & Produce Vendor Sale of fresh (within 24 hrs. harvest) vegetable & seafood$ 90.00 103.6 Delivery Vehicle Transport food/drink vehicle (operating in conjunction with permitted base operation) $90.00103.7 M o bi l es na c k v e hi c l e v e n d in g p rocesse d, p re p a c ka g e f oo d S na c k M o bi l e d i rec tl y t oc u s t o m er .$ 90.00 103.8 Temporary Food Service Operates for a period of no more than 30 days in conjunction with a single event or celebration. $90.00 R oo ma cco mm o d a t i o n r an g es f ro m Ho u sere n t a l 104 S h e lt er in g (s in g l er m .) t o l a r g e h o t e l o p er a t i o n 104.1 Ho t e l s - S ma ll (1 - 50 roo m s)$ 140.00 104.2 Hotels-Medium (51-100 rooms) $150.00 104.3 Hotels-Large (101 & Above)$ 220.00 104.4 Motel (1-40 rooms) $140.00104.5 Ot h erroo ma cco m o d a t i o n s A n ys t r u c t u reor p or t i o n o f an ys t r u c t u reco n t ainin g 4 or m ore gu es t roo m s an d in t e n d e df oro v er ni g h t or h o u r l y a cco m o d a t i o n s .$ 140.00 104.6 Staff Housing -Small (1-10 rms.) $140.00104.7 St a ff Ho u s in g - M e d i u m (11 - 20 r m s .)$ 150.00 104.8 Staff Housing -Large (21 rms. & Above) $220.00104.9 Dor mi t ory - B o a r d in g Ho u se (p er b u i l d in g)$ 140.00 104.10 House Room Rental/ Guest Each single rental unit/house House $140.00105 B u l k s t or a g e / p rocess in g pl an t 105.1 P a c kin g P ro d u ceo n l y$ 90.00 105.2 Meat or other food processing Meat Processing (Butcher & Packing) / Manufacture of Food $140.00105.3 Wa t er b o ttl in g Pl an t Wa t er / I ce P rocess in g Pl an t$ 140.00 105.4 Bakery Other Manufactured Food (Bakery) $140.00105.5 R e t ai l / w h o l eso m es t or a g e Wa re h o u s in g an d v e n d in g s i t e$ 140.00 105.6 Wholesale-Storage Facility Dry/ Cold Storage only $140.00106 B e a u t i f i c a t i o n S h o pB o d i l yser v i ces p ro v i d e df ro m f i x e d b u i l d in g 106.1 B a r b er S h o p / B e a u t y S h o p$ 90.00 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 155 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 106.2 Massage Parlor $90.00106.3 F a c ia l / mani c u re / p e d i c u re$ 90.00 106.4 Tattoo and/or body piercing shops $140.00 School, Health centers, 107 Pharmaceutical drugs and devices outlets & public facility 107.1 Schools Private or public operated pre, qrade, middle, high & post HS$ 220.00 107.2 Daycare Center Pre-school center $220.00107.3 S ani t a r i u m s$ 140.00 107.4 Health Clinic Private and public operated health centers $140.00107.5 De n t a lCl ini c$ 140.00 107.6 Pharmaceutical & devices outlet Outlets dispensing OTC and prescription drugs and/or medical devices $140.00107.7 Opt i c a lCl ini c$ 140.00 107.8 Gymnasium, Indoor Recreation Center $140.00107.9 S a u na / s p a / ba t hin g h o u ses$ 140.00 107.10 Swimming Pool and water parks Does not apply to private residential property $140.00107.11 F u n er a lE s t ab l i s hm e n t / A c t i v i t i esre l a t e d t o t h e p re p a r a t i o nan d a rr an g e m e n t s f or C re ma t or i u m / C e m e t ery t h e f u n er a l, t r an s p or t a t i o n, b u r ia l, cre ma t i o n oro t h er d i s p os i t i o n o fd e a d h u manb o d i es .$ 90.00 Other BEH permits, certificates Issuances of new, renew, duplicate or temporary 108 Issuance and administrative permits or certificates services 108.1 Food Handlers Certificate Completes PE & FST $35.00108.2 D u pl i c a t e F oo d H an d l ers C o p y f or n e w e m pl oy m e n t, re pl a ce m e n tC er t i f i c a t e$ 15.00 108.3 Duplicate Sanitary Permit 50% of permit fee. May apply to existing permitted food/drink facilities selling at temporary events. 108.4 Onsite Food Handlers Training Minimum of 10 participants @ $250.00, A dd i t i o na lp a r t i c i p an t s @$ 25.00 per person $250.00108.5 V er i f i c a t i o n o f U n w h o l eso m e f oo d R e q u i rere q u es t er t os u bmi tt o BE Ho ff i ce in v e n t ory l i s t in g . d i s p os a l D i s p os a l / p er h o u rr a t e$ 90.00 108.6 Ship Clearance Commercial Cargo Vessel $150.00108.7 Der a tt in g C er t i f i c a t e I n s p ec t i o n o f p o t e n t ia l v ec t oro n v esse l$ 190.00 108.8 Cruise Ship Clearance 1 or 4 food/drink outlets for guest with employee cafeteria $595.00108.9 C r u i ses hi pC r u i ses hi pw i t h < 4 or m ore f oo d / d r ink o u tl e t s, e a c h o u tl e tw o u l d p a y a dd i t i o na l$ 30.00 per outlet $30.00108.10 BE H A d mini s t r a t i v erese a rc h or A d mini s t r a t i v ecos tt o v a l i d a t e an d a u t h e n t i c a t ere q u es t f i e l d w or k v er i f i c a t i o nin f or ma t i o n f ro mk ey C H CC o ff i ces, f ro m f i l esor f i e l d w or k v er i f i c a t i o n .$ 50.00 108.11 Translation Language interpreter (non-English speaker) contracted by BEH office to moderator/facilitate 1 time communication/training. Minimum of 10 participants . $30.00108.12 F o ll o w - u p in s p ec t i o n E s t ab l i s hm e n t mana g e m e n t re q u es t re - in s p ec t i o n t o v a l i d a t ecorrec t i v e a c t i o n s t ak e n$ 90.00 108.13 Expired Sanitary Permit 50% (half price) plus the cost of permit for the 1st month (after 10 days grace period); subsequent months will be full price of permit per month 108.14 Noncompliant establishment Resuming Ceased Operation $560.00108.15 B u r ia lP er mi tP . L 11 - 117 - pl o t a ss i g nm e n tT ana p a g an d M a r p i C e m e t ery, o n l y$ 50.00 108.16 Sea Burial P.L. 11-117: Cost for 1 field supervisor and trainee to witness burial (up to 3hrs) $100.00 © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 156 of 157

TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION 108.17 Exhumation Permit P.L. 11-117: Cost for 1 field supervisor and trainee to witness exhumation (up to 3hrs) $100.00 New fees, enforcement 109 New promulgated fees for existing services penalties 109.10 Copy & printing$ 0.75 per page and $10.00 p er h o u r f or f i l erese a rc han dd oc u m e n tp re p a r a t i o n (Op e n G o v er nm e n t A c t) 109.2 S ani t a ry P er mi t Vi o l a t i o n s R e p e a t o ff e n se u pt o$ 500.00, Subsequent offense- up to $1, 000.00 f ore a c h o ff e n se 109.3 E x p i re d F oo d H an d l er C er t i f i c a t e$ 500.00 for each employee with an additional $500.00 f or t h ee m pl oyer 109.4 Wa s t e C o n t ain er L i d R e q u i re m e n tP . L .14 - 15 :$ 100 for each violation and additional $50.00 f ore a c h d a y 109.5 E x p e d i t e d in s p ec t i o n N e w, R e n e w a l or F o ll o w - u p in s p ec t i o n w i t hin 24 h rsor p r i or t o t h e f o ll o w - u p d a t e n o t e d o nin s p ec t i o n re p or t .$ 500.00 History: Amdts Adopted 41 Com. Reg. 42021 (June 28, 2019); Amdts Proposed 41 Com. Reg. 41637 (Apr. 28, 2019); Adopted 41 Com. Reg. 041326 (Jan. 28, 2019) (repealing and replacing subchapter 140-10.8); Proposed 40 Com. Reg. 041013 (Nov. 28, 2018) (repealing and replacing subchapter 140-10.8). Commission Comment: In January, 2019, when codifying 41 Com. Reg. 041326 (Jan. 28, 2019), the Commission left the source history of the subchapter intact for research purposes, but removed the source history for § 140-10.8-201. © 2024 by The Commonwealth Law Revision Commission (Nov. 15, 2024) Page 157 of 157

Source: CNMI Law Revision Commission

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TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION

Chapter 10.8. TITLE 140: COMMONWEALTH HEALTHCARE CORPORATION

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