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1 Conversion Factor: $ per unit - Effective 7/1/2013 Rates for time based codes are calculated using base units plus time codes, descriptions and other data only are copyright 2008 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. CPT is a registered trademark of the American Medical CodeDescriptionTime Based Codes - Base UnitsOccurrence Based Codes - $Rate00100 ANESTHESIA FOR PROCEDURES ON SALIVARY GLANDS, INCLUDING BIOPSY 500102 ANESTHESIA FOR PROCEDURES INVOLVING PLASTIC REPAIR OF CLEFT LIP 600103 ANESTHESIA FOR RECONSTRUCTIVE PROCEDURES OF EYELID (EG, BLEPHAROPLASTY.)

2 PTOSIS 500104 ANESTHESIA FOR ELECTROCONVULSIVE THERAPY 400120 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; 500124 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; 400126 ANESTHESIA FOR PROCEDURES ON EXTERNAL, MIDDLE, AND INNER EAR INCLUDING BIOPSY; 400140 ANESTHESIA FOR PROCEDURES ON EYE; NOT OTHERWISE SPECIFIED 500142 ANESTHESIA FOR PROCEDURES ON EYE; LENS SURGERY 400144 ANESTHESIA FOR PROCEDURES ON EYE; CORNEAL TRANSPLANT 600145 ANESTHESIA FOR PROCEDURES ON EYE; VITREORETINAL SURGERY 600147 ANESTHESIA FOR PROCEDURES ON EYE; IRIDECTOMY 400148 ANESTHESIA FOR PROCEDURES ON EYE.

3 OPHTHALMOSCOPY 400160 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; NOT OTHERWISE SPECIFIED 500162 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; RADICAL SURGERY 700164 ANESTHESIA FOR PROCEDURES ON NOSE AND ACCESSORY SINUSES; BIOPSY, SOFT TISSUE 4 The information contained in the schedule is made available to provide information and is not a guarantee by the State or the Department or its employees as to the present accuracy of the information contained herein.

4 For example, coverage as well as an actual rate may have been revised or updated and may no longer be the same as posted on the CodesUpdated: 5/28/2014 Occurrence based codes (01953, 01967, 01968, 01969, and 01996) are paid a flat dollar 1 of 13 Procedure CodeDescriptionTime Based Codes - Base UnitsOccurrence Based Codes - $Rate00170 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; NOT OTHERWISE SPECIFIED 500172 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; REPAIR OF CLEFT PALATE 600174 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; EXCISION OF 600176 ANESTHESIA FOR INTRAORAL PROCEDURES, INCLUDING BIOPSY; RADICAL SURGERY 700190 ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; NOT OTHERWISE SPECIFIED 500192 ANESTHESIA FOR PROCEDURES ON FACIAL BONES OR SKULL; RADICAL SURGERY (INCLUDING 700210 ANESTHESIA FOR INTRACRANIAL PROCEDURES.)

5 NOT OTHERWISE SPECIFIED 1100211 ANESTHESIA FOR CRANIOTOMY OR CRANIECTOMY FOR EVACUATION OF HEMATOMA 1000212 ANESTHESIA FOR INTRACRANIAL PROCEDURES; SUBDURAL TAPS 500214 ANESTHESIA FOR INTRACRANIAL PROCEDURES; BURR HOLES, INCLUDING VENTRICULOGRAPHY 900215 ANESTHESIA FOR INTRACRANIAL PROCEDURES; CRANIOPLASTY OR ELEVATION OF DEPRESSED 900216 ANESTHESIA FOR INTRACRANIAL PROCEDURES; VASCULAR PROCEDURES 1500218 ANESTHESIA FOR INTRACRANIAL PROCEDURES; PROCEDURES IN SITTING POSITION 1300220 ANESTHESIA FOR INTRACRANIAL PROCEDURES; CEREBROSPINAL FLUID SHUNTING PROCEDURES 1000222 ANESTHESIA FOR INTRACRANIAL PROCEDURES.

6 ELECTROCOAGULATION OF INTRACRANIAL NERVE 600300 ANESTHESIA FOR ALL PROCEDURES ON THE INTEGUMENTARY SYSTEM, MUSCLES AND NERVES 500320 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, THYROID, LARYNX, TRACHEA AND 600322 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS, THYROID, LARYNX, TRACHEA AND 300326 ANESTHESIA FOR ALL PROCEDURES ON THE LARYNX AND TRACHEA IN CHILDREN LESS THAN 1 700350 ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK; NOT OTHERWISE SPECIFIED 1000352 ANESTHESIA FOR PROCEDURES ON MAJOR VESSELS OF NECK.

7 SIMPLE LIGATION 500400 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, 300402 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, 500404 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, 500406 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, 13 Page 2 of 13 Procedure CodeDescriptionTime Based Codes - Base UnitsOccurrence Based Codes - $Rate00410 ANESTHESIA FOR PROCEDURES ON THE INTEGUMENTARY SYSTEM ON THE EXTREMITIES, 400450 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; NOT OTHERWISE SPECIFIED 500452 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA; RADICAL SURGERY 600454 ANESTHESIA FOR PROCEDURES ON CLAVICLE AND SCAPULA.

8 BIOPSY OF CLAVICLE 300470 ANESTHESIA FOR PARTIAL RIB RESECTION; NOT OTHERWISE SPECIFIED 600472 ANESTHESIA FOR PARTIAL RIB RESECTION; THORACOPLASTY (ANY TYPE) 1000474 ANESTHESIA FOR PARTIAL RIB RESECTION; RADICAL PROCEDURES (EG, PECTUS EXCAVATUM) 1300500 ANESTHESIA FOR ALL PROCEDURES ON ESOPHAGUS 1500520 ANESTHESIA FOR CLOSED CHEST PROCEDURES; (INCLUDING BRONCHOSCOPY) NOT OTHERWISE 600522 ANESTHESIA FOR CLOSED CHEST PROCEDURES; NEEDLE BIOPSY OF PLEURA 400524 ANESTHESIA FOR CLOSED CHEST PROCEDURES; PNEUMOCENTESIS 400528 ANESTHESIA FOR CLOSED CHEST PROCEDURES; MEDIASTINOSCOPY AND DIAGNOSTIC 800529 ANESTHESIA FOR CLOSED CHEST PROCEDURES.

9 MEDIASTINOSCOPY AND DIAGNOSTIC 1100530 ANESTHESIA FOR PERMANENT TRANSVENOUS PACEMAKER INSERTION 400532 ANESTHESIA FOR ACCESS TO CENTRAL VENOUS CIRCULATION 400534 ANESTHESIA FOR TRANSVENOUS INSERTION OR REPLACEMENT OF PACING 700537 ANESTHESIA FOR CARDIAC ELECTROPHYSIOLOGIC PROCEDURES INCLUDING RADIOFREQUENCY 700539 ANESTHESIA FOR TRACHEOBRONCHIAL RECONSTRUCTION 1800540 ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, PLEURA, DIAPHRAGM, AND 1200541 ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, PLEURA, DIAPHRAGM, AND 1500542 ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, PLEURA, DIAPHRAGM, AND 1500546 ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, PLEURA, DIAPHRAGM, AND 1500548 ANESTHESIA FOR THORACOTOMY PROCEDURES INVOLVING LUNGS, PLEURA, DIAPHRAGM.

10 AND 1700550 ANESTHESIA FOR STERNAL DEBRIDEMENT 1000560 ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIAL SAC, AND GREAT VESSELS OF 1500561 ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIAL SAC, AND GREAT VESSELS OF 25 Page 3 of 13 Procedure CodeDescriptionTime Based Codes - Base UnitsOccurrence Based Codes - $Rate00562 ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIAL SAC, AND GREAT VESSELS OF 2000563 ANESTHESIA FOR PROCEDURES ON HEART, PERICARDIAL SAC, AND GREAT VESSELS OF 2500566 ANESTHESIA FOR DIRECT CORONARY ARTERY BYPASS GRAFTING WITHOUT PUMP OXYGENATOR 2500567 ANESTHESIA FOR DIRECT CORONARY ARTERY BYPASS GRAFTING WITH PUMP OXYGENATOR