Calendar Year 2016 Maryland Workers' Compensation ... · 0413T G2 $1,392.20 $1,869.45 0414T J8...

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MDWCC ASC 2016 HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates 0099T D5 $0.00 $0.00 0100T J8 $91,490.68 $122,853.69 0101T G2 $813.76 $1,092.72 0102T G2 $1,339.58 $1,798.79 0123T D5 $0.00 $0.00 0171T J8 $7,886.65 $10,590.19 0182T D5 $0.00 $0.00 0230T G2 $459.71 $617.30 0238T J8 $9,819.12 $13,185.11 0249T G2 $1,301.02 $1,747.01 0253T G2 $1,793.90 $2,408.85 0263T G2 $1,685.98 $2,263.93 0264T G2 $1,685.98 $2,263.93 0265T G2 $1,685.98 $2,263.93 0269T G2 $1,899.43 $2,550.55 0270T G2 $1,223.86 $1,643.40 0271T G2 $1,223.86 $1,643.40 0274T G2 $2,486.22 $3,338.50 0275T G2 $2,486.22 $3,338.50 0282T J8 $3,993.90 $5,363.01 0283T J8 $21,258.56 $28,545.99 0284T G2 $1,223.86 $1,643.40 0288T G2 $1,301.02 $1,747.01 0299T R2 $126.13 $169.37 0301T G2 $1,223.47 $1,642.88 0302T J8 $7,663.75 $10,290.88 0303T J8 $5,787.01 $7,770.80 0304T J8 $5,787.01 $7,770.80 0307T G2 $1,392.20 $1,869.45 0308T J8 $17,629.47 $23,672.85 0313T G2 $1,223.86 $1,643.40 0314T G2 $1,223.86 $1,643.40 0315T G2 $1,223.86 $1,643.40 0316T J8 $21,258.56 $28,545.99 0331T Z2 $619.83 $832.31 0332T Z2 $619.83 $832.31 0338T G2 $2,287.57 $3,071.75 0339T G2 $2,287.57 $3,071.75 0340T G2 $2,302.86 $3,092.28 0342T G2 $1,685.98 $2,263.93 0377T G2 $1,301.02 $1,747.01 0387T J8 $9,819.12 $13,185.11 0388T G2 $1,256.68 $1,687.47 0392T G2 $3,277.62 $4,401.19 0393T G2 $2,010.99 $2,700.36 0394T Z2 $108.68 $145.94 0395T Z2 $389.31 $522.77 0409T J8 $19,581.49 $26,294.02 0410T J8 $5,787.01 $7,770.80 0411T J8 $5,787.01 $7,770.80 0412T G2 $1,392.20 $1,869.45 0413T G2 $1,392.20 $1,869.45 0414T J8 $19,581.49 $26,294.02 0415T G2 $482.30 $647.63 0416T G2 $789.12 $1,059.63 0419T R2 $239.70 $321.87 0420T R2 $239.70 $321.87 Calendar Year 2016 Maryland Workers' Compensation Commission Fee Guide ASC Covered Surgical Procedures - Effective January 1, 2016 (including surgical procedures for which payment is packaged and ancillary services approved by CMS) UPDATED NOVEMBER 2015 Page 1 of 90 EFFECTIVE JANUARY 1, 2016

Transcript of Calendar Year 2016 Maryland Workers' Compensation ... · 0413T G2 $1,392.20 $1,869.45 0414T J8...

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

0099T D5 $0.00 $0.000100T J8 $91,490.68 $122,853.690101T G2 $813.76 $1,092.720102T G2 $1,339.58 $1,798.790123T D5 $0.00 $0.000171T J8 $7,886.65 $10,590.190182T D5 $0.00 $0.000230T G2 $459.71 $617.300238T J8 $9,819.12 $13,185.110249T G2 $1,301.02 $1,747.010253T G2 $1,793.90 $2,408.850263T G2 $1,685.98 $2,263.930264T G2 $1,685.98 $2,263.930265T G2 $1,685.98 $2,263.930269T G2 $1,899.43 $2,550.550270T G2 $1,223.86 $1,643.400271T G2 $1,223.86 $1,643.400274T G2 $2,486.22 $3,338.500275T G2 $2,486.22 $3,338.500282T J8 $3,993.90 $5,363.010283T J8 $21,258.56 $28,545.990284T G2 $1,223.86 $1,643.400288T G2 $1,301.02 $1,747.010299T R2 $126.13 $169.370301T G2 $1,223.47 $1,642.880302T J8 $7,663.75 $10,290.880303T J8 $5,787.01 $7,770.800304T J8 $5,787.01 $7,770.800307T G2 $1,392.20 $1,869.450308T J8 $17,629.47 $23,672.850313T G2 $1,223.86 $1,643.400314T G2 $1,223.86 $1,643.400315T G2 $1,223.86 $1,643.400316T J8 $21,258.56 $28,545.990331T Z2 $619.83 $832.310332T Z2 $619.83 $832.310338T G2 $2,287.57 $3,071.750339T G2 $2,287.57 $3,071.750340T G2 $2,302.86 $3,092.280342T G2 $1,685.98 $2,263.930377T G2 $1,301.02 $1,747.010387T J8 $9,819.12 $13,185.110388T G2 $1,256.68 $1,687.470392T G2 $3,277.62 $4,401.190393T G2 $2,010.99 $2,700.360394T Z2 $108.68 $145.940395T Z2 $389.31 $522.770409T J8 $19,581.49 $26,294.020410T J8 $5,787.01 $7,770.800411T J8 $5,787.01 $7,770.800412T G2 $1,392.20 $1,869.450413T G2 $1,392.20 $1,869.450414T J8 $19,581.49 $26,294.020415T G2 $482.30 $647.630416T G2 $789.12 $1,059.630419T R2 $239.70 $321.870420T R2 $239.70 $321.87

Calendar Year 2016 Maryland Workers' Compensation Commission Fee Guide ASC Covered Surgical Procedures - Effective January 1, 2016

(including surgical procedures for which payment is packaged and ancillary services approved by CMS)

UPDATED NOVEMBER 2015 Page 1 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

0422T Z2 $51.48 $69.1310021 P3 $73.43 $98.6010022 P3 $92.78 $124.5810030 P2 $526.74 $707.3110035 N1 $0.00 $0.0010036 N1 $0.00 $0.0010040 N1 $0.00 $0.0010060 P2 $65.89 $88.4810061 P3 $111.04 $149.1010080 P2 $127.65 $171.4110081 P3 $170.15 $228.4810120 P3 $105.67 $141.8910121 A2 $790.85 $1,061.9510140 P3 $102.09 $137.0910160 P3 $82.03 $110.1510180 A2 $790.85 $1,061.9511000 P3 $32.24 $43.2911001 N1 $0.00 $0.0011010 A2 $526.74 $707.3111011 A2 $127.65 $171.4111012 A2 $790.85 $1,061.9511042 A2 $126.13 $169.3711043 A2 $239.70 $321.8711044 A2 $526.74 $707.3111045 N1 $0.00 $0.0011046 N1 $0.00 $0.0011047 N1 $0.00 $0.0011055 N1 $0.00 $0.0011056 N1 $0.00 $0.0011057 P3 $41.91 $56.2811100 P3 $72.00 $96.6811101 N1 $0.00 $0.0011200 N1 $0.00 $0.0011201 N1 $0.00 $0.0011300 N1 $0.00 $0.0011301 N1 $0.00 $0.0011302 N1 $0.00 $0.0011303 N1 $0.00 $0.0011305 N1 $0.00 $0.0011306 N1 $0.00 $0.0011307 P3 $97.43 $130.8311308 N1 $0.00 $0.0011310 P3 $82.39 $110.6311311 P3 $68.06 $91.3911312 P3 $109.61 $147.1811313 P3 $119.64 $160.6511400 P3 $88.48 $118.8111401 P3 $98.15 $131.8011402 P3 $107.82 $144.7811403 P3 $117.13 $157.2811404 A2 $526.74 $707.3111406 A2 $790.85 $1,061.9511420 P3 $82.75 $111.1211421 P3 $98.87 $132.7611422 P3 $108.89 $146.2211423 P3 $119.28 $160.1711424 A2 $790.85 $1,061.9511426 A2 $790.85 $1,061.9511440 P3 $94.57 $126.9911441 P3 $107.82 $144.7811442 P3 $117.85 $158.25

UPDATED NOVEMBER 2015 Page 2 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

11443 P3 $130.75 $175.5711444 A2 $526.74 $707.3111446 A2 $790.85 $1,061.9511450 A2 $790.85 $1,061.9511451 A2 $790.85 $1,061.9511462 A2 $790.85 $1,061.9511463 A2 $790.85 $1,061.9511470 A2 $790.85 $1,061.9511471 A2 $790.85 $1,061.9511600 P3 $127.88 $171.7211601 P3 $146.51 $196.7311602 P3 $157.97 $212.1211603 P3 $170.86 $229.4311604 A2 $526.74 $707.3111606 A2 $790.85 $1,061.9511620 P3 $129.31 $173.6411621 P3 $147.22 $197.6911622 P3 $160.83 $215.9611623 P3 $176.95 $237.6111624 A2 $790.85 $1,061.9511626 A2 $790.85 $1,061.9511640 P3 $134.69 $180.8611641 P3 $152.24 $204.4311642 P3 $168.00 $225.5911643 P3 $184.12 $247.2411644 A2 $526.74 $707.3111646 A2 $790.85 $1,061.9511719 N1 $0.00 $0.0011720 N1 $0.00 $0.0011721 N1 $0.00 $0.0011730 N1 $0.00 $0.0011732 N1 $0.00 $0.0011740 N1 $0.00 $0.0011750 P3 $122.15 $164.0211752 P3 $184.83 $248.1911755 P3 $85.25 $114.4711760 G2 $239.70 $321.8711762 P3 $171.22 $229.9111765 N1 $0.00 $0.0011770 A2 $790.85 $1,061.9511771 A2 $790.85 $1,061.9511772 A2 $790.85 $1,061.9511900 N1 $0.00 $0.0011901 N1 $0.00 $0.0011920 P3 $107.46 $144.3011921 P3 $122.87 $164.9911922 N1 $0.00 $0.0011950 P3 $41.91 $56.2811951 P3 $49.07 $65.8911952 P3 $63.76 $85.6211954 P3 $84.54 $113.5211960 A2 $1,195.26 $1,605.0011970 A2 $2,486.22 $3,338.5011971 A2 $790.85 $1,061.9511976 P3 $73.43 $98.6011980 N1 $0.00 $0.0011981 N1 $0.00 $0.0011982 N1 $0.00 $0.0011983 N1 $0.00 $0.0012001 N1 $0.00 $0.0012002 N1 $0.00 $0.00

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

12004 N1 $0.00 $0.0012005 A2 $65.89 $88.4812006 A2 $65.89 $88.4812007 A2 $126.13 $169.3712011 N1 $0.00 $0.0012013 N1 $0.00 $0.0012014 N1 $0.00 $0.0012015 G2 $65.89 $88.4812016 A2 $65.89 $88.4812017 A2 $65.89 $88.4812018 A2 $65.89 $88.4812020 A2 $239.70 $321.8712021 A2 $239.70 $321.8712031 P2 $126.13 $169.3712032 P2 $126.13 $169.3712034 A2 $126.13 $169.3712035 A2 $126.13 $169.3712036 A2 $239.70 $321.8712037 A2 $789.12 $1,059.6312041 P2 $65.89 $88.4812042 P2 $126.13 $169.3712044 A2 $126.13 $169.3712045 A2 $126.13 $169.3712046 A2 $126.13 $169.3712047 A2 $239.70 $321.8712051 P2 $126.13 $169.3712052 P2 $126.13 $169.3712053 P2 $126.13 $169.3712054 A2 $65.89 $88.4812055 A2 $126.13 $169.3712056 A2 $65.89 $88.4812057 A2 $126.13 $169.3713100 A2 $789.12 $1,059.6313101 A2 $239.70 $321.8713102 N1 $0.00 $0.0013120 A2 $239.70 $321.8713121 A2 $239.70 $321.8713122 N1 $0.00 $0.0013131 A2 $239.70 $321.8713132 A2 $239.70 $321.8713133 N1 $0.00 $0.0013151 A2 $239.70 $321.8713152 A2 $239.70 $321.8713153 N1 $0.00 $0.0013160 A2 $1,195.26 $1,605.0014000 A2 $789.12 $1,059.6314001 A2 $789.12 $1,059.6314020 A2 $789.12 $1,059.6314021 A2 $789.12 $1,059.6314040 A2 $789.12 $1,059.6314041 A2 $789.12 $1,059.6314060 A2 $789.12 $1,059.6314061 A2 $789.12 $1,059.6314301 G2 $1,195.26 $1,605.0014302 N1 $0.00 $0.0014350 A2 $1,195.26 $1,605.0015002 A2 $789.12 $1,059.6315003 N1 $0.00 $0.0015004 A2 $239.70 $321.8715005 N1 $0.00 $0.0015040 A2 $239.70 $321.87

UPDATED NOVEMBER 2015 Page 4 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

15050 A2 $239.70 $321.8715100 A2 $1,195.26 $1,605.0015101 N1 $0.00 $0.0015110 A2 $789.12 $1,059.6315111 N1 $0.00 $0.0015115 A2 $789.12 $1,059.6315116 N1 $0.00 $0.0015120 A2 $1,195.26 $1,605.0015121 N1 $0.00 $0.0015130 A2 $789.12 $1,059.6315131 N1 $0.00 $0.0015135 A2 $789.12 $1,059.6315136 N1 $0.00 $0.0015150 A2 $1,195.26 $1,605.0015151 N1 $0.00 $0.0015152 N1 $0.00 $0.0015155 A2 $789.12 $1,059.6315156 N1 $0.00 $0.0015157 N1 $0.00 $0.0015200 A2 $1,195.26 $1,605.0015201 N1 $0.00 $0.0015220 A2 $789.12 $1,059.6315221 N1 $0.00 $0.0015240 A2 $789.12 $1,059.6315241 N1 $0.00 $0.0015260 A2 $789.12 $1,059.6315261 N1 $0.00 $0.0015271 G2 $789.12 $1,059.6315272 N1 $0.00 $0.0015273 G2 $1,195.26 $1,605.0015274 N1 $0.00 $0.0015275 G2 $789.12 $1,059.6315276 N1 $0.00 $0.0015277 G2 $1,195.26 $1,605.0015278 N1 $0.00 $0.0015570 A2 $1,195.26 $1,605.0015572 A2 $1,195.26 $1,605.0015574 A2 $789.12 $1,059.6315576 A2 $789.12 $1,059.6315600 A2 $1,195.26 $1,605.0015610 A2 $1,195.26 $1,605.0015620 A2 $1,195.26 $1,605.0015630 A2 $789.12 $1,059.6315650 A2 $1,195.26 $1,605.0015731 A2 $1,195.26 $1,605.0015732 A2 $1,195.26 $1,605.0015734 A2 $1,195.26 $1,605.0015736 A2 $789.12 $1,059.6315738 A2 $1,195.26 $1,605.0015740 A2 $789.12 $1,059.6315750 A2 $789.12 $1,059.6315760 A2 $1,195.26 $1,605.0015770 A2 $1,195.26 $1,605.0015775 A2 $126.13 $169.3715776 A2 $126.13 $169.3715777 N1 $0.00 $0.0015780 P3 $500.77 $672.4315781 P2 $268.77 $360.9015782 P3 $472.48 $634.4515783 P2 $239.70 $321.8715786 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 5 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

15787 N1 $0.00 $0.0015788 N1 $0.00 $0.0015789 P2 $126.13 $169.3715792 N1 $0.00 $0.0015793 N1 $0.00 $0.0015819 G2 $789.12 $1,059.6315820 A2 $789.12 $1,059.6315821 A2 $789.12 $1,059.6315822 A2 $789.12 $1,059.6315823 A2 $789.12 $1,059.6315824 A2 $1,195.26 $1,605.0015825 A2 $1,195.26 $1,605.0015826 A2 $789.12 $1,059.6315828 A2 $1,195.26 $1,605.0015829 A2 $1,195.26 $1,605.0015830 A2 $2,039.38 $2,738.4815832 A2 $790.85 $1,061.9515833 A2 $790.85 $1,061.9515834 A2 $790.85 $1,061.9515835 A2 $790.85 $1,061.9515836 A2 $790.85 $1,061.9515837 G2 $790.85 $1,061.9515838 G2 $790.85 $1,061.9515839 A2 $790.85 $1,061.9515840 A2 $1,195.26 $1,605.0015841 A2 $1,195.26 $1,605.0015842 G2 $789.12 $1,059.6315845 A2 $1,195.26 $1,605.0015847 N1 $0.00 $0.0015850 G2 $789.12 $1,059.6315851 P3 $65.91 $88.5015852 N1 $0.00 $0.0015860 N1 $0.00 $0.0015876 A2 $1,195.26 $1,605.0015877 A2 $1,195.26 $1,605.0015878 A2 $1,195.26 $1,605.0015879 A2 $1,195.26 $1,605.0015920 A2 $790.85 $1,061.9515922 A2 $789.12 $1,059.6315931 A2 $790.85 $1,061.9515933 A2 $790.85 $1,061.9515934 A2 $789.12 $1,059.6315935 A2 $1,195.26 $1,605.0015936 A2 $789.12 $1,059.6315937 A2 $1,195.26 $1,605.0015940 A2 $790.85 $1,061.9515941 A2 $790.85 $1,061.9515944 A2 $1,195.26 $1,605.0015945 A2 $1,195.26 $1,605.0015946 A2 $1,195.26 $1,605.0015950 A2 $790.85 $1,061.9515951 A2 $790.85 $1,061.9515952 A2 $789.12 $1,059.6315953 A2 $1,195.26 $1,605.0015956 A2 $789.12 $1,059.6315958 A2 $789.12 $1,059.6316000 N1 $0.00 $0.0016020 N1 $0.00 $0.0016025 A2 $126.13 $169.3716030 A2 $126.13 $169.3716035 G2 $239.70 $321.87

UPDATED NOVEMBER 2015 Page 6 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

17000 N1 $0.00 $0.0017003 N1 $0.00 $0.0017004 P3 $96.36 $129.3917106 P3 $197.01 $264.5517107 P2 $239.70 $321.8717108 P3 $342.09 $459.3617110 N1 $0.00 $0.0017111 N1 $0.00 $0.0017250 N1 $0.00 $0.0017260 N1 $0.00 $0.0017261 N1 $0.00 $0.0017262 N1 $0.00 $0.0017263 N1 $0.00 $0.0017264 P2 $126.13 $169.3717266 P3 $138.27 $185.6717270 P3 $96.72 $129.8817271 P3 $102.45 $137.5717272 N1 $0.00 $0.0017273 P3 $125.01 $167.8617274 P3 $141.49 $189.9917276 P3 $156.18 $209.7217280 N1 $0.00 $0.0017281 P3 $108.18 $145.2617282 P3 $121.79 $163.5417283 P2 $126.13 $169.3717284 P2 $126.13 $169.3717286 P2 $126.13 $169.3717311 P2 $239.70 $321.8717312 N1 $0.00 $0.0017313 P2 $239.70 $321.8717314 N1 $0.00 $0.0017315 N1 $0.00 $0.0017340 N1 $0.00 $0.0017360 N1 $0.00 $0.0017380 R2 $239.70 $321.8719000 P3 $80.95 $108.7019001 N1 $0.00 $0.0019020 A2 $790.85 $1,061.9519030 N1 $0.00 $0.0019081 G2 $526.74 $707.3119082 N1 $0.00 $0.0019083 G2 $526.74 $707.3119084 N1 $0.00 $0.0019085 G2 $790.85 $1,061.9519086 N1 $0.00 $0.0019100 A2 $526.74 $707.3119101 A2 $1,223.47 $1,642.8819105 P3 $2,023.87 $2,717.6519110 A2 $1,223.47 $1,642.8819112 A2 $1,223.47 $1,642.8819120 A2 $1,223.47 $1,642.8819125 A2 $1,223.47 $1,642.8819126 N1 $0.00 $0.0019281 N1 $0.00 $0.0019282 N1 $0.00 $0.0019283 N1 $0.00 $0.0019284 N1 $0.00 $0.0019285 N1 $0.00 $0.0019286 N1 $0.00 $0.0019287 N1 $0.00 $0.0019288 N1 $0.00 $0.00

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

19296 J8 $3,137.01 $4,212.3819297 N1 $0.00 $0.0019298 J8 $3,137.01 $4,212.3819300 A2 $1,223.47 $1,642.8819301 A2 $1,223.47 $1,642.8819302 A2 $2,039.38 $2,738.4819303 A2 $2,039.38 $2,738.4819304 A2 $1,223.47 $1,642.8819316 A2 $2,039.38 $2,738.4819318 A2 $2,039.38 $2,738.4819324 A2 $2,039.38 $2,738.4819325 J8 $3,137.01 $4,212.3819328 A2 $1,223.47 $1,642.8819330 A2 $1,223.47 $1,642.8819340 A2 $2,039.38 $2,738.4819342 J8 $3,137.01 $4,212.3819350 A2 $1,223.47 $1,642.8819355 A2 $1,223.47 $1,642.8819357 J8 $3,137.01 $4,212.3819366 A2 $2,039.38 $2,738.4819370 A2 $2,039.38 $2,738.4819371 A2 $1,223.47 $1,642.8819380 A2 $2,039.38 $2,738.4819396 G2 $1,223.47 $1,642.8820005 G2 $790.85 $1,061.9520103 G2 $526.74 $707.3120150 G2 $1,339.58 $1,798.7920200 A2 $790.85 $1,061.9520205 A2 $790.85 $1,061.9520206 A2 $526.74 $707.3120220 A2 $526.74 $707.3120225 A2 $790.85 $1,061.9520240 A2 $790.85 $1,061.9520245 A2 $790.85 $1,061.9520250 A2 $1,339.58 $1,798.7920251 A2 $1,339.58 $1,798.7920500 P3 $55.88 $75.0420501 N1 $0.00 $0.0020520 P3 $130.03 $174.6020525 A2 $790.85 $1,061.9520526 P3 $39.76 $53.3920527 P3 $44.42 $59.6520550 P3 $30.09 $40.4020551 P3 $31.52 $42.3320552 P3 $30.09 $40.4020553 P3 $35.10 $47.1320555 R2 $813.76 $1,092.7220600 P3 $22.57 $30.3120604 P3 $38.33 $51.4720605 P3 $24.00 $32.2320606 P3 $41.55 $55.7920610 P3 $29.01 $38.9520611 P3 $48.36 $64.9420612 P3 $33.67 $45.2120615 P3 $155.82 $209.2420650 A2 $1,339.58 $1,798.7920662 R2 $813.76 $1,092.7220663 R2 $1,339.58 $1,798.7920665 G2 $50.98 $68.4620670 A2 $790.85 $1,061.9520680 A2 $790.85 $1,061.95

UPDATED NOVEMBER 2015 Page 8 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

20690 A2 $2,486.22 $3,338.5020692 A2 $3,532.70 $4,743.7120693 A2 $1,339.58 $1,798.7920694 A2 $813.76 $1,092.7220696 J8 $7,886.65 $10,590.1920697 P2 $613.12 $823.3020822 G2 $1,339.58 $1,798.7920900 A2 $1,339.58 $1,798.7920902 A2 $3,532.70 $4,743.7120910 A2 $239.70 $321.8720912 A2 $1,195.26 $1,605.0020920 A2 $789.12 $1,059.6320922 A2 $1,195.26 $1,605.0020924 A2 $1,339.58 $1,798.7920926 A2 $1,195.26 $1,605.0020930 N1 $0.00 $0.0020931 N1 $0.00 $0.0020950 G2 $268.77 $360.9020972 G2 $2,486.22 $3,338.5020973 R2 $2,486.22 $3,338.5020975 N1 $0.00 $0.0020979 N1 $0.00 $0.0020982 G2 $1,339.58 $1,798.7920983 G2 $2,302.86 $3,092.2820985 N1 $0.00 $0.0021010 A2 $1,994.21 $2,677.8321011 P3 $231.40 $310.7221012 R2 $790.85 $1,061.9521013 P3 $305.91 $410.7821014 R2 $790.85 $1,061.9521015 G2 $790.85 $1,061.9521016 G2 $790.85 $1,061.9521025 A2 $1,994.21 $2,677.8321026 A2 $904.15 $1,214.0921029 A2 $904.15 $1,214.0921030 P3 $334.57 $449.2621031 P3 $272.95 $366.5221032 P3 $277.97 $373.2621034 A2 $1,994.21 $2,677.8321040 A2 $904.15 $1,214.0921044 A2 $1,994.21 $2,677.8321046 A2 $1,994.21 $2,677.8321047 A2 $1,994.21 $2,677.8321048 R2 $1,994.21 $2,677.8321050 A2 $1,994.21 $2,677.8321060 A2 $1,994.21 $2,677.8321070 A2 $1,994.21 $2,677.8321073 P3 $258.27 $346.8021076 P2 $385.63 $517.8221077 P3 $1,210.74 $1,625.7821079 P3 $830.68 $1,115.4421080 P3 $934.20 $1,254.4421081 P3 $872.59 $1,171.7121082 P3 $855.76 $1,149.1121083 P3 $839.28 $1,126.9921084 P3 $952.11 $1,278.4921085 P2 $385.63 $517.8221086 P3 $907.34 $1,218.3821087 P3 $904.83 $1,215.0121088 R2 $1,994.21 $2,677.8321100 A2 $1,994.21 $2,677.83

UPDATED NOVEMBER 2015 Page 9 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

21110 P2 $385.63 $517.8221116 N1 $0.00 $0.0021120 A2 $1,994.21 $2,677.8321121 A2 $904.15 $1,214.0921122 A2 $904.15 $1,214.0921123 A2 $904.15 $1,214.0921125 A2 $904.15 $1,214.0921127 A2 $1,994.21 $2,677.8321137 G2 $904.15 $1,214.0921138 G2 $1,994.21 $2,677.8321139 G2 $1,994.21 $2,677.8321150 G2 $1,994.21 $2,677.8321181 A2 $1,994.21 $2,677.8321198 G2 $904.15 $1,214.0921199 G2 $1,994.21 $2,677.8321206 A2 $1,994.21 $2,677.8321208 A2 $1,994.21 $2,677.8321209 A2 $1,994.21 $2,677.8321210 A2 $1,994.21 $2,677.8321215 A2 $1,994.21 $2,677.8321230 A2 $1,994.21 $2,677.8321235 A2 $904.15 $1,214.0921240 A2 $1,994.21 $2,677.8321242 A2 $1,994.21 $2,677.8321243 J8 $7,886.65 $10,590.1921244 A2 $1,994.21 $2,677.8321245 A2 $1,994.21 $2,677.8321246 A2 $1,994.21 $2,677.8321248 A2 $1,994.21 $2,677.8321249 A2 $1,994.21 $2,677.8321260 G2 $1,994.21 $2,677.8321267 A2 $1,994.21 $2,677.8321270 A2 $1,994.21 $2,677.8321275 A2 $1,994.21 $2,677.8321280 A2 $1,994.21 $2,677.8321282 A2 $904.15 $1,214.0921295 A2 $385.63 $517.8221296 A2 $904.15 $1,214.0921310 A2 $72.30 $97.0821315 A2 $904.15 $1,214.0921320 A2 $904.15 $1,214.0921325 A2 $904.15 $1,214.0921330 A2 $904.15 $1,214.0921335 A2 $904.15 $1,214.0921336 A2 $1,339.58 $1,798.7921337 A2 $904.15 $1,214.0921338 A2 $1,994.21 $2,677.8321339 A2 $904.15 $1,214.0921340 A2 $1,994.21 $2,677.8321345 A2 $385.63 $517.8221355 A2 $1,994.21 $2,677.8321356 A2 $904.15 $1,214.0921360 G2 $1,994.21 $2,677.8321390 G2 $1,994.21 $2,677.8321400 A2 $385.63 $517.8221401 A2 $385.63 $517.8221406 G2 $1,994.21 $2,677.8321407 G2 $1,994.21 $2,677.8321421 A2 $1,994.21 $2,677.8321440 P3 $457.79 $614.7221445 A2 $1,994.21 $2,677.83

UPDATED NOVEMBER 2015 Page 10 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

21450 A2 $174.99 $234.9821451 A2 $904.15 $1,214.0921452 A2 $904.15 $1,214.0921453 A2 $1,994.21 $2,677.8321454 A2 $1,994.21 $2,677.8321461 A2 $1,994.21 $2,677.8321462 A2 $1,994.21 $2,677.8321465 A2 $1,994.21 $2,677.8321480 A2 $72.30 $97.0821485 A2 $385.63 $517.8221490 A2 $1,994.21 $2,677.8321495 G2 $904.15 $1,214.0921497 A2 $385.63 $517.8221501 A2 $790.85 $1,061.9521502 A2 $813.76 $1,092.7221550 G2 $526.74 $707.3121552 G2 $790.85 $1,061.9521554 G2 $790.85 $1,061.9521555 G2 $790.85 $1,061.9521556 G2 $790.85 $1,061.9521557 G2 $790.85 $1,061.9521558 G2 $790.85 $1,061.9521600 A2 $1,339.58 $1,798.7921610 A2 $813.76 $1,092.7221685 G2 $904.15 $1,214.0921700 A2 $813.76 $1,092.7221720 A2 $813.76 $1,092.7221725 A2 $127.65 $171.4121805 D5 $0.00 $0.0021820 A2 $96.37 $129.4121920 P3 $176.24 $236.6621925 A2 $790.85 $1,061.9521930 G2 $790.85 $1,061.9521931 G2 $790.85 $1,061.9521932 G2 $790.85 $1,061.9521933 G2 $790.85 $1,061.9521935 G2 $790.85 $1,061.9521936 G2 $790.85 $1,061.9522102 G2 $1,339.58 $1,798.7922103 N1 $0.00 $0.0022305 A2 $96.37 $129.4122310 A2 $132.80 $178.3222315 A2 $613.12 $823.3022505 A2 $613.12 $823.3022510 G2 $1,339.58 $1,798.7922511 G2 $1,339.58 $1,798.7922512 N1 $0.00 $0.0022513 G2 $3,532.70 $4,743.7122514 G2 $3,532.70 $4,743.7122515 N1 $0.00 $0.0022551 J8 $7,886.65 $10,590.1922554 J8 $7,886.65 $10,590.1922612 G2 $3,532.70 $4,743.7122614 N1 $0.00 $0.0022900 G2 $790.85 $1,061.9522901 G2 $790.85 $1,061.9522902 G2 $790.85 $1,061.9522903 G2 $790.85 $1,061.9522904 G2 $790.85 $1,061.9522905 G2 $790.85 $1,061.9523000 A2 $790.85 $1,061.95

UPDATED NOVEMBER 2015 Page 11 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

23020 A2 $1,339.58 $1,798.7923030 A2 $790.85 $1,061.9523031 A2 $790.85 $1,061.9523035 A2 $813.76 $1,092.7223040 A2 $1,339.58 $1,798.7923044 A2 $1,339.58 $1,798.7923065 P3 $126.09 $169.3123066 A2 $790.85 $1,061.9523071 G2 $790.85 $1,061.9523073 G2 $790.85 $1,061.9523075 G2 $790.85 $1,061.9523076 G2 $790.85 $1,061.9523077 G2 $790.85 $1,061.9523078 G2 $790.85 $1,061.9523100 A2 $813.76 $1,092.7223101 A2 $1,339.58 $1,798.7923105 A2 $1,339.58 $1,798.7923106 A2 $1,339.58 $1,798.7923107 A2 $1,339.58 $1,798.7923120 A2 $1,339.58 $1,798.7923125 A2 $1,339.58 $1,798.7923130 A2 $1,339.58 $1,798.7923140 A2 $813.76 $1,092.7223145 A2 $1,339.58 $1,798.7923146 A2 $2,486.22 $3,338.5023150 A2 $1,339.58 $1,798.7923155 A2 $1,339.58 $1,798.7923156 A2 $2,486.22 $3,338.5023170 A2 $813.76 $1,092.7223172 A2 $1,339.58 $1,798.7923174 A2 $1,339.58 $1,798.7923180 A2 $1,339.58 $1,798.7923182 A2 $813.76 $1,092.7223184 A2 $1,339.58 $1,798.7923190 A2 $1,339.58 $1,798.7923195 A2 $2,486.22 $3,338.5023330 A2 $526.74 $707.3123333 G2 $790.85 $1,061.9523334 G2 $790.85 $1,061.9523350 N1 $0.00 $0.0023395 A2 $3,532.70 $4,743.7123397 A2 $1,339.58 $1,798.7923400 A2 $2,486.22 $3,338.5023405 A2 $1,339.58 $1,798.7923406 A2 $1,339.58 $1,798.7923410 A2 $2,486.22 $3,338.5023412 A2 $2,486.22 $3,338.5023415 A2 $1,339.58 $1,798.7923420 A2 $2,486.22 $3,338.5023430 A2 $2,486.22 $3,338.5023440 A2 $1,339.58 $1,798.7923450 A2 $1,339.58 $1,798.7923455 A2 $2,486.22 $3,338.5023460 A2 $1,339.58 $1,798.7923462 A2 $2,486.22 $3,338.5023465 G2 $3,532.70 $4,743.7123466 A2 $2,486.22 $3,338.5023480 A2 $1,339.58 $1,798.7923485 G2 $3,532.70 $4,743.7123490 A2 $3,532.70 $4,743.7123491 G2 $3,532.70 $4,743.71

UPDATED NOVEMBER 2015 Page 12 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

23500 A2 $96.37 $129.4123505 A2 $613.12 $823.3023515 A2 $2,486.22 $3,338.5023520 A2 $613.12 $823.3023525 A2 $96.37 $129.4123530 A2 $1,339.58 $1,798.7923532 A2 $2,486.22 $3,338.5023540 A2 $96.37 $129.4123545 A2 $96.37 $129.4123550 A2 $2,486.22 $3,338.5023552 G2 $3,532.70 $4,743.7123570 A2 $96.37 $129.4123575 A2 $613.12 $823.3023585 A2 $3,532.70 $4,743.7123600 P2 $96.37 $129.4123605 A2 $813.76 $1,092.7223615 G2 $3,532.70 $4,743.7123616 J8 $7,886.65 $10,590.1923620 P2 $132.80 $178.3223625 A2 $613.12 $823.3023630 A2 $2,486.22 $3,338.5023650 A2 $96.37 $129.4123655 A2 $613.12 $823.3023660 A2 $1,339.58 $1,798.7923665 A2 $613.12 $823.3023670 A2 $2,486.22 $3,338.5023675 A2 $613.12 $823.3023680 G2 $3,532.70 $4,743.7123700 A2 $613.12 $823.3023800 G2 $3,532.70 $4,743.7123802 G2 $3,532.70 $4,743.7123921 A2 $789.12 $1,059.6323930 A2 $790.85 $1,061.9523931 A2 $790.85 $1,061.9523935 A2 $813.76 $1,092.7224000 A2 $1,339.58 $1,798.7924006 A2 $1,339.58 $1,798.7924065 P3 $173.73 $233.2824066 A2 $790.85 $1,061.9524071 G2 $790.85 $1,061.9524073 G2 $790.85 $1,061.9524075 G2 $790.85 $1,061.9524076 G2 $790.85 $1,061.9524077 G2 $790.85 $1,061.9524079 G2 $790.85 $1,061.9524100 A2 $813.76 $1,092.7224101 A2 $1,339.58 $1,798.7924102 A2 $1,339.58 $1,798.7924105 A2 $813.76 $1,092.7224110 A2 $1,339.58 $1,798.7924115 A2 $1,339.58 $1,798.7924116 A2 $1,339.58 $1,798.7924120 A2 $813.76 $1,092.7224125 A2 $1,339.58 $1,798.7924126 A2 $1,339.58 $1,798.7924130 A2 $1,339.58 $1,798.7924134 A2 $2,486.22 $3,338.5024136 A2 $1,339.58 $1,798.7924138 A2 $1,339.58 $1,798.7924140 A2 $1,339.58 $1,798.7924145 A2 $1,339.58 $1,798.79

UPDATED NOVEMBER 2015 Page 13 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

24147 A2 $1,339.58 $1,798.7924149 G2 $1,339.58 $1,798.7924152 G2 $1,339.58 $1,798.7924155 A2 $1,339.58 $1,798.7924160 A2 $1,339.58 $1,798.7924164 A2 $1,339.58 $1,798.7924200 P3 $136.12 $182.7824201 A2 $790.85 $1,061.9524220 N1 $0.00 $0.0024300 G2 $613.12 $823.3024301 A2 $1,339.58 $1,798.7924305 A2 $1,339.58 $1,798.7924310 A2 $1,339.58 $1,798.7924320 A2 $1,339.58 $1,798.7924330 A2 $1,339.58 $1,798.7924331 A2 $1,339.58 $1,798.7924332 G2 $813.76 $1,092.7224340 A2 $2,486.22 $3,338.5024341 A2 $1,339.58 $1,798.7924342 A2 $1,339.58 $1,798.7924343 G2 $1,339.58 $1,798.7924344 G2 $2,486.22 $3,338.5024345 A2 $1,339.58 $1,798.7924346 G2 $3,532.70 $4,743.7124357 G2 $813.76 $1,092.7224358 G2 $1,339.58 $1,798.7924359 G2 $1,339.58 $1,798.7924360 A2 $2,486.22 $3,338.5024361 J8 $7,886.65 $10,590.1924362 J8 $7,886.65 $10,590.1924363 J8 $7,886.65 $10,590.1924365 G2 $3,532.70 $4,743.7124366 J8 $7,886.65 $10,590.1924370 J8 $7,886.65 $10,590.1924371 J8 $7,886.65 $10,590.1924400 A2 $2,486.22 $3,338.5024410 J8 $7,886.65 $10,590.1924420 A2 $1,339.58 $1,798.7924430 G2 $3,532.70 $4,743.7124435 J8 $7,886.65 $10,590.1924470 A2 $1,339.58 $1,798.7924495 A2 $1,339.58 $1,798.7924498 G2 $3,532.70 $4,743.7124500 A2 $132.80 $178.3224505 A2 $613.12 $823.3024515 G2 $3,532.70 $4,743.7124516 G2 $3,532.70 $4,743.7124530 A2 $132.80 $178.3224535 A2 $613.12 $823.3024538 A2 $1,339.58 $1,798.7924545 J8 $7,886.65 $10,590.1924546 J8 $7,886.65 $10,590.1924560 A2 $96.37 $129.4124565 A2 $613.12 $823.3024566 A2 $1,339.58 $1,798.7924575 G2 $3,532.70 $4,743.7124576 A2 $132.80 $178.3224577 A2 $613.12 $823.3024579 G2 $3,532.70 $4,743.7124582 A2 $1,339.58 $1,798.7924586 G2 $3,532.70 $4,743.71

UPDATED NOVEMBER 2015 Page 14 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

24587 J8 $7,886.65 $10,590.1924600 A2 $96.37 $129.4124605 A2 $613.12 $823.3024615 A2 $2,486.22 $3,338.5024620 A2 $613.12 $823.3024635 A2 $3,532.70 $4,743.7124640 P3 $86.69 $116.4124650 P2 $96.37 $129.4124655 A2 $613.12 $823.3024665 A2 $2,486.22 $3,338.5024666 G2 $3,532.70 $4,743.7124670 A2 $96.37 $129.4124675 A2 $613.12 $823.3024685 A2 $2,486.22 $3,338.5024800 A2 $2,486.22 $3,338.5024802 G2 $3,532.70 $4,743.7124925 A2 $1,339.58 $1,798.7925000 A2 $813.76 $1,092.7225001 G2 $813.76 $1,092.7225020 A2 $813.76 $1,092.7225023 A2 $1,339.58 $1,798.7925024 A2 $1,339.58 $1,798.7925025 A2 $1,339.58 $1,798.7925028 A2 $813.76 $1,092.7225031 A2 $813.76 $1,092.7225035 A2 $1,339.58 $1,798.7925040 A2 $1,339.58 $1,798.7925065 P3 $175.52 $235.6925066 A2 $790.85 $1,061.9525071 G2 $790.85 $1,061.9525073 G2 $790.85 $1,061.9525075 G2 $790.85 $1,061.9525076 G2 $790.85 $1,061.9525077 G2 $526.74 $707.3125078 G2 $790.85 $1,061.9525085 A2 $1,339.58 $1,798.7925100 A2 $1,339.58 $1,798.7925101 A2 $813.76 $1,092.7225105 A2 $813.76 $1,092.7225107 A2 $1,339.58 $1,798.7925109 G2 $813.76 $1,092.7225110 A2 $813.76 $1,092.7225111 A2 $813.76 $1,092.7225112 A2 $813.76 $1,092.7225115 A2 $813.76 $1,092.7225116 A2 $813.76 $1,092.7225118 A2 $813.76 $1,092.7225119 A2 $1,339.58 $1,798.7925120 A2 $1,339.58 $1,798.7925125 A2 $1,339.58 $1,798.7925126 A2 $1,339.58 $1,798.7925130 A2 $1,339.58 $1,798.7925135 A2 $1,339.58 $1,798.7925136 A2 $1,339.58 $1,798.7925145 A2 $1,339.58 $1,798.7925150 A2 $1,339.58 $1,798.7925151 A2 $1,339.58 $1,798.7925210 A2 $1,339.58 $1,798.7925215 A2 $1,339.58 $1,798.7925230 A2 $1,339.58 $1,798.7925240 A2 $1,339.58 $1,798.79

UPDATED NOVEMBER 2015 Page 15 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

25246 N1 $0.00 $0.0025248 A2 $813.76 $1,092.7225250 A2 $813.76 $1,092.7225251 A2 $1,339.58 $1,798.7925259 G2 $613.12 $823.3025260 A2 $813.76 $1,092.7225263 A2 $1,339.58 $1,798.7925265 A2 $1,339.58 $1,798.7925270 A2 $1,339.58 $1,798.7925272 A2 $1,339.58 $1,798.7925274 A2 $1,339.58 $1,798.7925275 A2 $1,339.58 $1,798.7925280 A2 $1,339.58 $1,798.7925290 A2 $813.76 $1,092.7225295 A2 $813.76 $1,092.7225300 A2 $1,339.58 $1,798.7925301 A2 $1,339.58 $1,798.7925310 A2 $1,339.58 $1,798.7925312 A2 $1,339.58 $1,798.7925315 A2 $1,339.58 $1,798.7925316 A2 $2,486.22 $3,338.5025320 A2 $1,339.58 $1,798.7925332 A2 $1,339.58 $1,798.7925335 A2 $1,339.58 $1,798.7925337 A2 $1,339.58 $1,798.7925350 A2 $3,532.70 $4,743.7125355 A2 $1,339.58 $1,798.7925360 A2 $2,486.22 $3,338.5025365 A2 $3,532.70 $4,743.7125370 A2 $1,339.58 $1,798.7925375 A2 $1,339.58 $1,798.7925390 A2 $2,486.22 $3,338.5025391 G2 $3,532.70 $4,743.7125392 A2 $1,339.58 $1,798.7925393 A2 $1,339.58 $1,798.7925394 G2 $1,339.58 $1,798.7925400 A2 $2,486.22 $3,338.5025405 A2 $3,532.70 $4,743.7125415 A2 $2,486.22 $3,338.5025420 G2 $3,532.70 $4,743.7125425 A2 $1,339.58 $1,798.7925426 A2 $1,339.58 $1,798.7925430 G2 $1,339.58 $1,798.7925431 G2 $2,486.22 $3,338.5025440 A2 $2,486.22 $3,338.5025441 J8 $7,886.65 $10,590.1925442 J8 $7,886.65 $10,590.1925443 A2 $2,486.22 $3,338.5025444 J8 $7,886.65 $10,590.1925445 A2 $2,486.22 $3,338.5025446 J8 $7,886.65 $10,590.1925447 A2 $1,339.58 $1,798.7925449 A2 $2,486.22 $3,338.5025450 A2 $1,339.58 $1,798.7925455 A2 $1,339.58 $1,798.7925490 A2 $1,339.58 $1,798.7925491 A2 $3,532.70 $4,743.7125492 A2 $1,339.58 $1,798.7925500 P2 $96.37 $129.4125505 A2 $613.12 $823.3025515 A2 $2,486.22 $3,338.50

UPDATED NOVEMBER 2015 Page 16 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

25520 A2 $613.12 $823.3025525 A2 $2,486.22 $3,338.5025526 A2 $3,532.70 $4,743.7125530 P2 $96.37 $129.4125535 A2 $132.80 $178.3225545 A2 $2,486.22 $3,338.5025560 P2 $96.37 $129.4125565 A2 $613.12 $823.3025574 A2 $2,486.22 $3,338.5025575 G2 $3,532.70 $4,743.7125600 P2 $132.80 $178.3225605 A2 $613.12 $823.3025606 A2 $1,339.58 $1,798.7925607 A2 $2,486.22 $3,338.5025608 A2 $2,486.22 $3,338.5025609 A2 $2,486.22 $3,338.5025622 P2 $96.37 $129.4125624 A2 $613.12 $823.3025628 A2 $1,339.58 $1,798.7925630 P2 $96.37 $129.4125635 A2 $613.12 $823.3025645 A2 $1,339.58 $1,798.7925650 P2 $132.80 $178.3225651 G2 $1,339.58 $1,798.7925652 G2 $2,486.22 $3,338.5025660 A2 $132.80 $178.3225670 A2 $813.76 $1,092.7225671 A2 $813.76 $1,092.7225675 A2 $132.80 $178.3225676 A2 $2,486.22 $3,338.5025680 A2 $132.80 $178.3225685 A2 $813.76 $1,092.7225690 A2 $613.12 $823.3025695 A2 $1,339.58 $1,798.7925800 G2 $3,532.70 $4,743.7125805 A2 $3,532.70 $4,743.7125810 G2 $3,532.70 $4,743.7125820 A2 $2,486.22 $3,338.5025825 A2 $2,486.22 $3,338.5025830 A2 $2,486.22 $3,338.5025907 A2 $813.76 $1,092.7225922 A2 $813.76 $1,092.7225929 A2 $789.12 $1,059.6325931 G2 $813.76 $1,092.7226010 P2 $127.65 $171.4126011 A2 $526.74 $707.3126020 A2 $813.76 $1,092.7226025 A2 $813.76 $1,092.7226030 A2 $813.76 $1,092.7226034 A2 $813.76 $1,092.7226035 G2 $813.76 $1,092.7226037 G2 $813.76 $1,092.7226040 A2 $813.76 $1,092.7226045 A2 $813.76 $1,092.7226055 A2 $813.76 $1,092.7226060 A2 $813.76 $1,092.7226070 A2 $813.76 $1,092.7226075 A2 $813.76 $1,092.7226080 A2 $813.76 $1,092.7226100 A2 $1,339.58 $1,798.7926105 A2 $813.76 $1,092.72

UPDATED NOVEMBER 2015 Page 17 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

26110 A2 $813.76 $1,092.7226111 G2 $790.85 $1,061.9526113 G2 $790.85 $1,061.9526115 G2 $790.85 $1,061.9526116 G2 $790.85 $1,061.9526117 G2 $790.85 $1,061.9526118 G2 $790.85 $1,061.9526121 A2 $813.76 $1,092.7226123 A2 $1,339.58 $1,798.7926125 N1 $0.00 $0.0026130 A2 $813.76 $1,092.7226135 A2 $813.76 $1,092.7226140 A2 $813.76 $1,092.7226145 A2 $813.76 $1,092.7226160 A2 $813.76 $1,092.7226170 A2 $813.76 $1,092.7226180 A2 $813.76 $1,092.7226185 A2 $813.76 $1,092.7226200 A2 $813.76 $1,092.7226205 A2 $1,339.58 $1,798.7926210 A2 $813.76 $1,092.7226215 A2 $1,339.58 $1,798.7926230 A2 $813.76 $1,092.7226235 A2 $813.76 $1,092.7226236 A2 $813.76 $1,092.7226250 A2 $813.76 $1,092.7226260 A2 $1,339.58 $1,798.7926262 A2 $813.76 $1,092.7226320 A2 $790.85 $1,061.9526340 G2 $613.12 $823.3026341 P3 $63.40 $85.1326350 A2 $1,339.58 $1,798.7926352 A2 $1,339.58 $1,798.7926356 A2 $1,339.58 $1,798.7926357 A2 $1,339.58 $1,798.7926358 A2 $1,339.58 $1,798.7926370 A2 $1,339.58 $1,798.7926372 A2 $1,339.58 $1,798.7926373 A2 $1,339.58 $1,798.7926390 A2 $2,486.22 $3,338.5026392 A2 $2,486.22 $3,338.5026410 A2 $813.76 $1,092.7226412 A2 $1,339.58 $1,798.7926415 A2 $813.76 $1,092.7226416 A2 $1,339.58 $1,798.7926418 A2 $813.76 $1,092.7226420 A2 $1,339.58 $1,798.7926426 A2 $1,339.58 $1,798.7926428 A2 $1,339.58 $1,798.7926432 A2 $813.76 $1,092.7226433 A2 $813.76 $1,092.7226434 A2 $1,339.58 $1,798.7926437 A2 $813.76 $1,092.7226440 A2 $813.76 $1,092.7226442 A2 $813.76 $1,092.7226445 A2 $813.76 $1,092.7226449 A2 $813.76 $1,092.7226450 A2 $1,339.58 $1,798.7926455 A2 $813.76 $1,092.7226460 A2 $813.76 $1,092.7226471 A2 $1,339.58 $1,798.79

UPDATED NOVEMBER 2015 Page 18 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

26474 A2 $813.76 $1,092.7226476 A2 $813.76 $1,092.7226477 A2 $1,339.58 $1,798.7926478 A2 $813.76 $1,092.7226479 A2 $813.76 $1,092.7226480 A2 $813.76 $1,092.7226483 A2 $1,339.58 $1,798.7926485 A2 $813.76 $1,092.7226489 A2 $1,339.58 $1,798.7926490 A2 $1,339.58 $1,798.7926492 A2 $1,339.58 $1,798.7926494 A2 $1,339.58 $1,798.7926496 A2 $1,339.58 $1,798.7926497 A2 $1,339.58 $1,798.7926498 A2 $1,339.58 $1,798.7926499 A2 $1,339.58 $1,798.7926500 A2 $1,339.58 $1,798.7926502 A2 $1,339.58 $1,798.7926508 A2 $813.76 $1,092.7226510 A2 $813.76 $1,092.7226516 A2 $813.76 $1,092.7226517 A2 $1,339.58 $1,798.7926518 A2 $1,339.58 $1,798.7926520 A2 $813.76 $1,092.7226525 A2 $813.76 $1,092.7226530 A2 $1,339.58 $1,798.7926531 A2 $2,486.22 $3,338.5026535 A2 $1,339.58 $1,798.7926536 A2 $2,486.22 $3,338.5026540 A2 $1,339.58 $1,798.7926541 A2 $1,339.58 $1,798.7926542 A2 $1,339.58 $1,798.7926545 A2 $1,339.58 $1,798.7926546 A2 $1,339.58 $1,798.7926548 A2 $1,339.58 $1,798.7926550 A2 $1,339.58 $1,798.7926555 A2 $1,339.58 $1,798.7926560 A2 $813.76 $1,092.7226561 A2 $1,339.58 $1,798.7926562 A2 $1,339.58 $1,798.7926565 A2 $1,339.58 $1,798.7926567 A2 $1,339.58 $1,798.7926568 A2 $1,339.58 $1,798.7926580 A2 $813.76 $1,092.7226587 A2 $1,339.58 $1,798.7926590 A2 $813.76 $1,092.7226591 A2 $1,339.58 $1,798.7926593 A2 $1,339.58 $1,798.7926596 A2 $1,339.58 $1,798.7926600 P2 $96.37 $129.4126605 A2 $132.80 $178.3226607 A2 $613.12 $823.3026608 A2 $813.76 $1,092.7226615 A2 $1,339.58 $1,798.7926641 P2 $132.80 $178.3226645 A2 $613.12 $823.3026650 A2 $813.76 $1,092.7226665 A2 $1,339.58 $1,798.7926670 P2 $132.80 $178.3226675 A2 $613.12 $823.3026676 A2 $813.76 $1,092.72

UPDATED NOVEMBER 2015 Page 19 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

26685 A2 $1,339.58 $1,798.7926686 A2 $1,339.58 $1,798.7926700 P2 $132.80 $178.3226705 A2 $613.12 $823.3026706 A2 $613.12 $823.3026715 A2 $1,339.58 $1,798.7926720 P2 $96.37 $129.4126725 P2 $132.80 $178.3226727 A2 $813.76 $1,092.7226735 A2 $1,339.58 $1,798.7926740 P2 $132.80 $178.3226742 A2 $613.12 $823.3026746 A2 $1,339.58 $1,798.7926750 P2 $96.37 $129.4126755 G2 $132.80 $178.3226756 A2 $813.76 $1,092.7226765 A2 $813.76 $1,092.7226770 G2 $96.37 $129.4126775 P2 $116.24 $156.0926776 A2 $813.76 $1,092.7226785 A2 $1,339.58 $1,798.7926820 A2 $1,339.58 $1,798.7926841 A2 $1,339.58 $1,798.7926842 A2 $2,486.22 $3,338.5026843 A2 $2,486.22 $3,338.5026844 A2 $2,486.22 $3,338.5026850 A2 $1,339.58 $1,798.7926852 A2 $1,339.58 $1,798.7926860 A2 $1,339.58 $1,798.7926861 N1 $0.00 $0.0026862 A2 $1,339.58 $1,798.7926863 N1 $0.00 $0.0026910 A2 $1,339.58 $1,798.7926951 A2 $813.76 $1,092.7226952 A2 $813.76 $1,092.7226990 A2 $1,339.58 $1,798.7926991 A2 $1,339.58 $1,798.7927000 A2 $813.76 $1,092.7227001 A2 $1,339.58 $1,798.7927003 A2 $1,339.58 $1,798.7927033 A2 $1,339.58 $1,798.7927035 A2 $813.76 $1,092.7227040 A2 $526.74 $707.3127041 A2 $526.74 $707.3127043 G2 $790.85 $1,061.9527045 G2 $790.85 $1,061.9527047 G2 $790.85 $1,061.9527048 G2 $790.85 $1,061.9527049 G2 $790.85 $1,061.9527050 A2 $813.76 $1,092.7227052 A2 $813.76 $1,092.7227059 G2 $790.85 $1,061.9527060 A2 $813.76 $1,092.7227062 A2 $1,339.58 $1,798.7927065 A2 $1,339.58 $1,798.7927066 A2 $1,339.58 $1,798.7927067 A2 $1,339.58 $1,798.7927080 A2 $1,339.58 $1,798.7927086 A2 $790.85 $1,061.9527087 A2 $1,339.58 $1,798.7927093 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 20 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

27095 N1 $0.00 $0.0027097 A2 $1,339.58 $1,798.7927098 A2 $813.76 $1,092.7227100 A2 $2,486.22 $3,338.5027105 A2 $1,339.58 $1,798.7927110 A2 $1,339.58 $1,798.7927111 A2 $1,339.58 $1,798.7927193 A2 $132.80 $178.3227194 A2 $132.80 $178.3227200 P2 $96.37 $129.4127202 A2 $1,339.58 $1,798.7927220 G2 $132.80 $178.3227230 A2 $96.37 $129.4127238 A2 $613.12 $823.3027246 A2 $132.80 $178.3227250 A2 $96.37 $129.4127252 A2 $613.12 $823.3027256 G2 $96.37 $129.4127257 A2 $613.12 $823.3027265 A2 $132.80 $178.3227266 A2 $613.12 $823.3027267 G2 $613.12 $823.3027275 A2 $613.12 $823.3027279 J8 $7,886.65 $10,590.1927301 A2 $790.85 $1,061.9527305 A2 $1,339.58 $1,798.7927306 A2 $813.76 $1,092.7227307 A2 $1,339.58 $1,798.7927310 A2 $1,339.58 $1,798.7927323 A2 $790.85 $1,061.9527324 A2 $790.85 $1,061.9527325 A2 $778.70 $1,045.6427326 A2 $778.70 $1,045.6427327 G2 $790.85 $1,061.9527328 G2 $790.85 $1,061.9527329 G2 $790.85 $1,061.9527330 A2 $1,339.58 $1,798.7927331 A2 $1,339.58 $1,798.7927332 A2 $1,339.58 $1,798.7927333 A2 $1,339.58 $1,798.7927334 A2 $1,339.58 $1,798.7927335 A2 $2,486.22 $3,338.5027337 G2 $790.85 $1,061.9527339 G2 $790.85 $1,061.9527340 A2 $1,339.58 $1,798.7927345 A2 $1,339.58 $1,798.7927347 A2 $1,339.58 $1,798.7927350 A2 $1,339.58 $1,798.7927355 A2 $1,339.58 $1,798.7927356 J8 $7,886.65 $10,590.1927357 A2 $2,486.22 $3,338.5027358 N1 $0.00 $0.0027360 A2 $1,339.58 $1,798.7927364 G2 $790.85 $1,061.9527370 N1 $0.00 $0.0027372 A2 $790.85 $1,061.9527380 A2 $1,339.58 $1,798.7927381 A2 $2,486.22 $3,338.5027385 A2 $1,339.58 $1,798.7927386 A2 $2,486.22 $3,338.5027390 A2 $1,339.58 $1,798.79

UPDATED NOVEMBER 2015 Page 21 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

27391 A2 $1,339.58 $1,798.7927392 A2 $1,339.58 $1,798.7927393 A2 $1,339.58 $1,798.7927394 A2 $1,339.58 $1,798.7927395 A2 $1,339.58 $1,798.7927396 A2 $1,339.58 $1,798.7927397 A2 $1,339.58 $1,798.7927400 A2 $1,339.58 $1,798.7927403 A2 $813.76 $1,092.7227405 A2 $1,339.58 $1,798.7927407 A2 $2,486.22 $3,338.5027409 A2 $1,339.58 $1,798.7927415 G2 $3,532.70 $4,743.7127416 G2 $2,486.22 $3,338.5027418 A2 $2,486.22 $3,338.5027420 A2 $2,486.22 $3,338.5027422 A2 $1,339.58 $1,798.7927424 A2 $1,339.58 $1,798.7927425 A2 $1,339.58 $1,798.7927427 A2 $2,486.22 $3,338.5027428 G2 $3,532.70 $4,743.7127429 G2 $3,532.70 $4,743.7127430 A2 $1,339.58 $1,798.7927435 A2 $1,339.58 $1,798.7927437 A2 $3,532.70 $4,743.7127438 J8 $7,886.65 $10,590.1927440 J8 $7,886.65 $10,590.1927441 J8 $7,886.65 $10,590.1927442 J8 $7,886.65 $10,590.1927443 G2 $3,532.70 $4,743.7127446 J8 $7,886.65 $10,590.1927475 G2 $1,339.58 $1,798.7927479 G2 $1,339.58 $1,798.7927496 A2 $1,339.58 $1,798.7927497 A2 $813.76 $1,092.7227498 A2 $813.76 $1,092.7227499 A2 $1,339.58 $1,798.7927500 A2 $132.80 $178.3227501 A2 $132.80 $178.3227502 A2 $613.12 $823.3027503 A2 $613.12 $823.3027508 A2 $132.80 $178.3227509 A2 $2,486.22 $3,338.5027510 A2 $613.12 $823.3027516 A2 $96.37 $129.4127517 A2 $613.12 $823.3027520 A2 $96.37 $129.4127524 G2 $1,339.58 $1,798.7927530 A2 $96.37 $129.4127532 A2 $613.12 $823.3027538 A2 $132.80 $178.3227550 A2 $132.80 $178.3227552 A2 $613.12 $823.3027560 A2 $96.37 $129.4127562 A2 $132.80 $178.3227566 A2 $1,339.58 $1,798.7927570 A2 $613.12 $823.3027594 A2 $1,339.58 $1,798.7927600 A2 $1,339.58 $1,798.7927601 A2 $1,339.58 $1,798.7927602 A2 $813.76 $1,092.72

UPDATED NOVEMBER 2015 Page 22 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

27603 A2 $790.85 $1,061.9527604 A2 $1,339.58 $1,798.7927605 A2 $813.76 $1,092.7227606 A2 $1,339.58 $1,798.7927607 A2 $1,339.58 $1,798.7927610 A2 $1,339.58 $1,798.7927612 A2 $1,339.58 $1,798.7927613 P3 $168.00 $225.5927614 A2 $790.85 $1,061.9527615 G2 $790.85 $1,061.9527616 G2 $790.85 $1,061.9527618 G2 $790.85 $1,061.9527619 G2 $790.85 $1,061.9527620 A2 $1,339.58 $1,798.7927625 A2 $1,339.58 $1,798.7927626 A2 $1,339.58 $1,798.7927630 A2 $813.76 $1,092.7227632 G2 $790.85 $1,061.9527634 G2 $790.85 $1,061.9527635 A2 $1,339.58 $1,798.7927637 A2 $2,486.22 $3,338.5027638 A2 $2,486.22 $3,338.5027640 A2 $1,339.58 $1,798.7927641 A2 $1,339.58 $1,798.7927647 A2 $813.76 $1,092.7227648 N1 $0.00 $0.0027650 A2 $1,339.58 $1,798.7927652 A2 $2,486.22 $3,338.5027654 A2 $2,486.22 $3,338.5027656 A2 $1,339.58 $1,798.7927658 A2 $1,339.58 $1,798.7927659 A2 $1,339.58 $1,798.7927664 A2 $1,339.58 $1,798.7927665 A2 $2,486.22 $3,338.5027675 A2 $1,339.58 $1,798.7927676 A2 $1,339.58 $1,798.7927680 A2 $1,339.58 $1,798.7927681 A2 $1,339.58 $1,798.7927685 A2 $1,339.58 $1,798.7927686 A2 $1,339.58 $1,798.7927687 A2 $1,339.58 $1,798.7927690 A2 $1,339.58 $1,798.7927691 A2 $1,339.58 $1,798.7927692 N1 $0.00 $0.0027695 A2 $1,339.58 $1,798.7927696 A2 $1,339.58 $1,798.7927698 A2 $1,339.58 $1,798.7927700 A2 $2,486.22 $3,338.5027704 A2 $1,339.58 $1,798.7927705 A2 $1,339.58 $1,798.7927707 A2 $1,339.58 $1,798.7927709 A2 $3,532.70 $4,743.7127720 G2 $2,486.22 $3,338.5027726 G2 $2,486.22 $3,338.5027730 A2 $1,339.58 $1,798.7927732 A2 $1,339.58 $1,798.7927734 A2 $1,339.58 $1,798.7927740 A2 $1,339.58 $1,798.7927742 A2 $1,339.58 $1,798.7927745 G2 $3,532.70 $4,743.7127750 A2 $132.80 $178.32

UPDATED NOVEMBER 2015 Page 23 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

27752 A2 $613.12 $823.3027756 A2 $2,486.22 $3,338.5027758 G2 $3,532.70 $4,743.7127759 G2 $3,532.70 $4,743.7127760 A2 $96.37 $129.4127762 A2 $613.12 $823.3027766 A2 $1,339.58 $1,798.7927767 P2 $132.80 $178.3227768 G2 $613.12 $823.3027769 G2 $2,486.22 $3,338.5027780 A2 $96.37 $129.4127781 A2 $613.12 $823.3027784 A2 $2,486.22 $3,338.5027786 A2 $132.80 $178.3227788 A2 $132.80 $178.3227792 A2 $2,486.22 $3,338.5027808 A2 $96.37 $129.4127810 A2 $613.12 $823.3027814 A2 $2,486.22 $3,338.5027816 A2 $132.80 $178.3227818 A2 $613.12 $823.3027822 A2 $2,486.22 $3,338.5027823 G2 $3,532.70 $4,743.7127824 A2 $132.80 $178.3227825 A2 $613.12 $823.3027826 A2 $2,486.22 $3,338.5027827 G2 $3,532.70 $4,743.7127828 G2 $3,532.70 $4,743.7127829 A2 $1,339.58 $1,798.7927830 A2 $96.37 $129.4127831 A2 $613.12 $823.3027832 A2 $2,486.22 $3,338.5027840 A2 $96.37 $129.4127842 A2 $613.12 $823.3027846 A2 $1,339.58 $1,798.7927848 A2 $1,339.58 $1,798.7927860 A2 $613.12 $823.3027870 J8 $7,886.65 $10,590.1927871 G2 $3,532.70 $4,743.7127884 A2 $1,339.58 $1,798.7927889 A2 $1,339.58 $1,798.7927892 A2 $1,339.58 $1,798.7927893 A2 $1,339.58 $1,798.7927894 A2 $813.76 $1,092.7228001 P3 $178.39 $239.5428002 A2 $813.76 $1,092.7228003 A2 $813.76 $1,092.7228005 A2 $1,339.58 $1,798.7928008 A2 $813.76 $1,092.7228010 P3 $122.87 $164.9928011 A2 $813.76 $1,092.7228020 A2 $1,339.58 $1,798.7928022 A2 $1,339.58 $1,798.7928024 A2 $813.76 $1,092.7228035 A2 $778.70 $1,045.6428039 G2 $790.85 $1,061.9528041 G2 $790.85 $1,061.9528043 G2 $790.85 $1,061.9528045 G2 $790.85 $1,061.9528046 G2 $790.85 $1,061.9528047 G2 $790.85 $1,061.95

UPDATED NOVEMBER 2015 Page 24 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

28050 A2 $813.76 $1,092.7228052 A2 $813.76 $1,092.7228054 A2 $813.76 $1,092.7228055 A2 $778.70 $1,045.6428060 A2 $813.76 $1,092.7228062 A2 $1,339.58 $1,798.7928070 A2 $813.76 $1,092.7228072 A2 $813.76 $1,092.7228080 A2 $813.76 $1,092.7228086 A2 $1,339.58 $1,798.7928088 A2 $813.76 $1,092.7228090 A2 $813.76 $1,092.7228092 A2 $813.76 $1,092.7228100 A2 $1,339.58 $1,798.7928102 A2 $2,486.22 $3,338.5028103 A2 $2,486.22 $3,338.5028104 A2 $813.76 $1,092.7228106 A2 $1,339.58 $1,798.7928107 A2 $2,486.22 $3,338.5028108 A2 $813.76 $1,092.7228110 A2 $813.76 $1,092.7228111 A2 $813.76 $1,092.7228112 A2 $813.76 $1,092.7228113 A2 $813.76 $1,092.7228114 A2 $1,339.58 $1,798.7928116 A2 $813.76 $1,092.7228118 A2 $1,339.58 $1,798.7928119 A2 $1,339.58 $1,798.7928120 A2 $1,339.58 $1,798.7928122 A2 $813.76 $1,092.7228124 P3 $300.18 $403.0828126 A2 $813.76 $1,092.7228130 A2 $1,339.58 $1,798.7928140 A2 $813.76 $1,092.7228150 A2 $813.76 $1,092.7228153 A2 $813.76 $1,092.7228160 A2 $813.76 $1,092.7228171 A2 $813.76 $1,092.7228173 A2 $813.76 $1,092.7228175 A2 $813.76 $1,092.7228190 P3 $187.34 $251.5628192 A2 $790.85 $1,061.9528193 A2 $790.85 $1,061.9528200 A2 $1,339.58 $1,798.7928202 A2 $2,486.22 $3,338.5028208 A2 $1,339.58 $1,798.7928210 A2 $2,486.22 $3,338.5028220 P3 $282.27 $379.0328222 A2 $813.76 $1,092.7228225 A2 $813.76 $1,092.7228226 A2 $813.76 $1,092.7228230 P3 $276.18 $370.8528232 P3 $260.77 $350.1628234 A2 $813.76 $1,092.7228238 A2 $1,339.58 $1,798.7928240 A2 $813.76 $1,092.7228250 A2 $1,339.58 $1,798.7928260 A2 $813.76 $1,092.7228261 A2 $1,339.58 $1,798.7928262 A2 $2,486.22 $3,338.5028264 A2 $813.76 $1,092.72

UPDATED NOVEMBER 2015 Page 25 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

28270 A2 $813.76 $1,092.7228272 P3 $257.55 $345.8428280 A2 $813.76 $1,092.7228285 A2 $813.76 $1,092.7228286 A2 $813.76 $1,092.7228288 A2 $813.76 $1,092.7228289 A2 $1,339.58 $1,798.7928290 A2 $1,339.58 $1,798.7928292 A2 $1,339.58 $1,798.7928293 A2 $2,486.22 $3,338.5028294 A2 $1,339.58 $1,798.7928296 A2 $1,339.58 $1,798.7928297 A2 $3,532.70 $4,743.7128298 A2 $1,339.58 $1,798.7928299 A2 $1,339.58 $1,798.7928300 A2 $2,486.22 $3,338.5028302 A2 $1,339.58 $1,798.7928304 A2 $2,486.22 $3,338.5028305 A2 $2,486.22 $3,338.5028306 A2 $1,339.58 $1,798.7928307 A2 $1,339.58 $1,798.7928308 A2 $1,339.58 $1,798.7928309 A2 $2,486.22 $3,338.5028310 A2 $1,339.58 $1,798.7928312 A2 $1,339.58 $1,798.7928313 A2 $813.76 $1,092.7228315 A2 $813.76 $1,092.7228320 G2 $3,532.70 $4,743.7128322 A2 $2,486.22 $3,338.5028340 A2 $813.76 $1,092.7228341 A2 $813.76 $1,092.7228344 A2 $1,339.58 $1,798.7928345 A2 $813.76 $1,092.7228400 A2 $132.80 $178.3228405 A2 $132.80 $178.3228406 A2 $1,339.58 $1,798.7928415 A2 $3,532.70 $4,743.7128420 J8 $7,886.65 $10,590.1928430 P2 $96.37 $129.4128435 A2 $613.12 $823.3028436 A2 $1,339.58 $1,798.7928445 A2 $2,486.22 $3,338.5028446 G2 $2,486.22 $3,338.5028450 P2 $132.80 $178.3228455 P3 $167.64 $225.1128456 A2 $3,532.70 $4,743.7128465 A2 $2,486.22 $3,338.5028470 P2 $96.37 $129.4128475 P2 $96.37 $129.4128476 A2 $1,339.58 $1,798.7928485 A2 $1,339.58 $1,798.7928490 P2 $96.37 $129.4128495 P2 $96.37 $129.4128496 A2 $1,339.58 $1,798.7928505 A2 $1,339.58 $1,798.7928510 P3 $79.88 $107.2628515 P3 $103.88 $139.4928525 A2 $1,339.58 $1,798.7928530 P3 $75.22 $101.0128531 A2 $1,339.58 $1,798.7928540 P2 $96.37 $129.41

UPDATED NOVEMBER 2015 Page 26 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

28545 A2 $1,339.58 $1,798.7928546 A2 $813.76 $1,092.7228555 A2 $3,532.70 $4,743.7128570 P2 $96.37 $129.4128575 A2 $613.12 $823.3028576 A2 $813.76 $1,092.7228585 A2 $1,339.58 $1,798.7928600 P2 $132.80 $178.3228605 A2 $96.37 $129.4128606 A2 $1,339.58 $1,798.7928615 A2 $2,486.22 $3,338.5028630 P3 $90.63 $121.7028635 A2 $613.12 $823.3028636 A2 $1,339.58 $1,798.7928645 A2 $1,339.58 $1,798.7928660 P3 $67.34 $90.4228665 A2 $116.24 $156.0928666 A2 $1,339.58 $1,798.7928675 A2 $813.76 $1,092.7228705 J8 $7,886.65 $10,590.1928715 J8 $7,886.65 $10,590.1928725 G2 $3,532.70 $4,743.7128730 G2 $3,532.70 $4,743.7128735 J8 $7,886.65 $10,590.1928737 G2 $3,532.70 $4,743.7128740 G2 $3,532.70 $4,743.7128750 A2 $2,486.22 $3,338.5028755 A2 $1,339.58 $1,798.7928760 A2 $2,486.22 $3,338.5028810 A2 $813.76 $1,092.7228820 A2 $813.76 $1,092.7228825 A2 $813.76 $1,092.7228890 P3 $199.16 $267.4329000 G2 $116.24 $156.0929010 P2 $116.24 $156.0929015 P2 $116.24 $156.0929035 P2 $116.24 $156.0929040 G2 $116.24 $156.0929044 P2 $66.68 $89.5429046 G2 $116.24 $156.0929049 P3 $49.07 $65.8929055 P2 $116.24 $156.0929058 P3 $70.92 $95.2329065 P3 $62.69 $84.1829075 P3 $57.31 $76.9629085 P3 $62.33 $83.7029086 P3 $55.52 $74.5529105 P3 $54.45 $73.1229125 N1 $0.00 $0.0029126 N1 $0.00 $0.0029130 N1 $0.00 $0.0029131 N1 $0.00 $0.0029200 P3 $15.40 $20.6829240 N1 $0.00 $0.0029260 N1 $0.00 $0.0029280 N1 $0.00 $0.0029305 P2 $116.24 $156.0929325 P2 $116.24 $156.0929345 P3 $80.95 $108.7029355 P3 $79.88 $107.2629358 P3 $103.88 $139.49

UPDATED NOVEMBER 2015 Page 27 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

29365 P3 $76.30 $102.4629405 P3 $51.22 $68.7829425 P3 $48.36 $64.9429435 P3 $70.21 $94.2829440 P3 $22.93 $30.7929445 P3 $67.34 $90.4229450 P3 $65.91 $88.5029505 P3 $56.95 $76.4729515 P3 $44.06 $59.1629520 N1 $0.00 $0.0029530 N1 $0.00 $0.0029540 P3 $11.46 $15.3929550 N1 $0.00 $0.0029580 P3 $31.52 $42.3329581 P3 $53.37 $71.6729582 P3 $58.39 $78.4129583 P3 $34.75 $46.6629584 P3 $58.39 $78.4129700 P3 $40.48 $54.3629705 P3 $36.90 $49.5529710 P3 $68.06 $91.3929720 P3 $58.39 $78.4129730 P3 $35.46 $47.6229740 P3 $54.09 $72.6329750 P3 $41.19 $55.3129800 A2 $1,339.58 $1,798.7929804 A2 $1,339.58 $1,798.7929805 A2 $1,339.58 $1,798.7929806 A2 $2,486.22 $3,338.5029807 A2 $2,486.22 $3,338.5029819 A2 $1,339.58 $1,798.7929820 A2 $1,339.58 $1,798.7929821 A2 $1,339.58 $1,798.7929822 A2 $1,339.58 $1,798.7929823 A2 $1,339.58 $1,798.7929824 A2 $1,339.58 $1,798.7929825 A2 $1,339.58 $1,798.7929826 N1 $0.00 $0.0029827 A2 $2,486.22 $3,338.5029828 G2 $2,486.22 $3,338.5029830 A2 $813.76 $1,092.7229834 A2 $1,339.58 $1,798.7929835 A2 $1,339.58 $1,798.7929836 A2 $1,339.58 $1,798.7929837 A2 $1,339.58 $1,798.7929838 A2 $1,339.58 $1,798.7929840 A2 $1,339.58 $1,798.7929843 A2 $1,339.58 $1,798.7929844 A2 $1,339.58 $1,798.7929845 A2 $1,339.58 $1,798.7929846 A2 $1,339.58 $1,798.7929847 A2 $1,339.58 $1,798.7929848 A2 $813.76 $1,092.7229850 A2 $813.76 $1,092.7229851 A2 $813.76 $1,092.7229855 A2 $3,532.70 $4,743.7129856 A2 $3,532.70 $4,743.7129860 A2 $1,339.58 $1,798.7929861 A2 $1,339.58 $1,798.7929862 A2 $2,486.22 $3,338.5029863 A2 $1,339.58 $1,798.79

UPDATED NOVEMBER 2015 Page 28 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

29866 G2 $2,486.22 $3,338.5029870 A2 $1,339.58 $1,798.7929871 A2 $1,339.58 $1,798.7929873 A2 $1,339.58 $1,798.7929874 A2 $1,339.58 $1,798.7929875 A2 $1,339.58 $1,798.7929876 A2 $1,339.58 $1,798.7929877 A2 $1,339.58 $1,798.7929879 A2 $1,339.58 $1,798.7929880 A2 $1,339.58 $1,798.7929881 A2 $1,339.58 $1,798.7929882 A2 $1,339.58 $1,798.7929883 A2 $1,339.58 $1,798.7929884 A2 $1,339.58 $1,798.7929885 A2 $2,486.22 $3,338.5029886 A2 $1,339.58 $1,798.7929887 A2 $1,339.58 $1,798.7929888 A2 $3,532.70 $4,743.7129889 J8 $7,886.65 $10,590.1929891 A2 $1,339.58 $1,798.7929892 A2 $1,339.58 $1,798.7929893 A2 $813.76 $1,092.7229894 A2 $1,339.58 $1,798.7929895 A2 $1,339.58 $1,798.7929897 A2 $1,339.58 $1,798.7929898 A2 $1,339.58 $1,798.7929899 G2 $3,532.70 $4,743.7129900 A2 $1,339.58 $1,798.7929901 A2 $1,339.58 $1,798.7929902 A2 $813.76 $1,092.7229904 G2 $1,339.58 $1,798.7929905 G2 $1,339.58 $1,798.7929906 G2 $813.76 $1,092.7229907 G2 $3,532.70 $4,743.7129914 G2 $2,486.22 $3,338.5029915 G2 $3,532.70 $4,743.7129916 G2 $3,532.70 $4,743.7130000 P2 $72.30 $97.0830020 P2 $174.99 $234.9830100 P3 $106.39 $142.8630110 P3 $168.00 $225.5930115 A2 $904.15 $1,214.0930117 A2 $904.15 $1,214.0930118 A2 $904.15 $1,214.0930120 A2 $904.15 $1,214.0930124 R2 $904.15 $1,214.0930125 A2 $1,994.21 $2,677.8330130 A2 $904.15 $1,214.0930140 A2 $904.15 $1,214.0930150 A2 $1,994.21 $2,677.8330160 A2 $1,994.21 $2,677.8330200 P3 $84.90 $114.0030210 P3 $107.46 $144.3030220 A2 $385.63 $517.8230300 N1 $0.00 $0.0030310 A2 $904.15 $1,214.0930320 A2 $385.63 $517.8230400 A2 $904.15 $1,214.0930410 A2 $1,994.21 $2,677.8330420 A2 $1,994.21 $2,677.8330430 A2 $904.15 $1,214.09

UPDATED NOVEMBER 2015 Page 29 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

30435 A2 $1,994.21 $2,677.8330450 A2 $1,994.21 $2,677.8330460 A2 $1,994.21 $2,677.8330462 A2 $1,994.21 $2,677.8330465 A2 $1,994.21 $2,677.8330520 A2 $904.15 $1,214.0930540 A2 $1,994.21 $2,677.8330545 A2 $1,994.21 $2,677.8330560 A2 $174.99 $234.9830580 A2 $1,994.21 $2,677.8330600 A2 $1,994.21 $2,677.8330620 A2 $1,994.21 $2,677.8330630 A2 $904.15 $1,214.0930801 A2 $385.63 $517.8230802 A2 $904.15 $1,214.0930901 N1 $0.00 $0.0030903 A2 $72.30 $97.0830905 A2 $72.30 $97.0830906 A2 $72.30 $97.0830915 A2 $1,256.68 $1,687.4730920 A2 $1,256.68 $1,687.4730930 A2 $904.15 $1,214.0931000 P3 $139.34 $187.1131002 R2 $385.63 $517.8231020 A2 $904.15 $1,214.0931030 A2 $1,994.21 $2,677.8331032 A2 $1,994.21 $2,677.8331040 R2 $904.15 $1,214.0931050 A2 $1,994.21 $2,677.8331051 A2 $1,994.21 $2,677.8331070 A2 $1,994.21 $2,677.8331075 A2 $1,994.21 $2,677.8331080 A2 $1,994.21 $2,677.8331081 A2 $1,994.21 $2,677.8331084 A2 $1,994.21 $2,677.8331085 A2 $1,994.21 $2,677.8331086 A2 $1,994.21 $2,677.8331087 A2 $1,994.21 $2,677.8331090 A2 $1,994.21 $2,677.8331200 A2 $1,994.21 $2,677.8331201 A2 $904.15 $1,214.0931205 A2 $904.15 $1,214.0931231 P2 $79.02 $106.1131233 A2 $209.77 $281.6831235 A2 $580.15 $779.0331237 A2 $580.15 $779.0331238 A2 $580.15 $779.0331239 A2 $1,113.86 $1,495.6931240 A2 $580.15 $779.0331254 A2 $1,714.73 $2,302.5431255 A2 $1,714.73 $2,302.5431256 A2 $1,113.86 $1,495.6931267 A2 $1,714.73 $2,302.5431276 A2 $1,714.73 $2,302.5431287 A2 $1,714.73 $2,302.5431288 A2 $1,714.73 $2,302.5431295 P2 $1,714.73 $2,302.5431296 P2 $1,714.73 $2,302.5431297 P2 $1,714.73 $2,302.5431300 A2 $904.15 $1,214.0931320 A2 $1,994.21 $2,677.83

UPDATED NOVEMBER 2015 Page 30 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

31400 A2 $1,994.21 $2,677.8331420 A2 $1,994.21 $2,677.8331500 G2 $72.30 $97.0831502 G2 $72.30 $97.0831505 P3 $60.54 $81.2931510 A2 $1,113.86 $1,495.6931511 A2 $79.02 $106.1131512 A2 $1,113.86 $1,495.6931513 A2 $580.15 $779.0331515 A2 $209.77 $281.6831520 G2 $209.77 $281.6831525 A2 $580.15 $779.0331526 A2 $580.15 $779.0331527 A2 $1,113.86 $1,495.6931528 A2 $1,113.86 $1,495.6931529 A2 $1,113.86 $1,495.6931530 A2 $580.15 $779.0331531 A2 $1,113.86 $1,495.6931535 A2 $1,113.86 $1,495.6931536 A2 $1,113.86 $1,495.6931540 A2 $1,113.86 $1,495.6931541 A2 $1,113.86 $1,495.6931545 A2 $1,113.86 $1,495.6931546 A2 $1,714.73 $2,302.5431560 A2 $1,714.73 $2,302.5431561 A2 $1,113.86 $1,495.6931570 A2 $1,113.86 $1,495.6931571 A2 $1,113.86 $1,495.6931575 P3 $72.36 $97.1731576 A2 $580.15 $779.0331577 A2 $209.77 $281.6831578 A2 $1,113.86 $1,495.6931579 P3 $123.94 $166.4331580 A2 $1,994.21 $2,677.8331582 A2 $1,994.21 $2,677.8331588 A2 $1,994.21 $2,677.8331590 A2 $1,994.21 $2,677.8331595 A2 $1,994.21 $2,677.8331603 A2 $385.63 $517.8231605 G2 $385.63 $517.8231611 A2 $904.15 $1,214.0931612 A2 $1,994.21 $2,677.8331613 A2 $904.15 $1,214.0931614 A2 $1,994.21 $2,677.8331615 A2 $385.63 $517.8231620 D5 $0.00 $0.0031622 A2 $580.15 $779.0331623 A2 $580.15 $779.0331624 A2 $580.15 $779.0331625 A2 $580.15 $779.0331626 G2 $1,714.73 $2,302.5431627 N1 $0.00 $0.0031628 A2 $1,113.86 $1,495.6931629 A2 $1,113.86 $1,495.6931630 A2 $1,113.86 $1,495.6931631 A2 $1,714.73 $2,302.5431632 N1 $0.00 $0.0031633 N1 $0.00 $0.0031634 G2 $1,714.73 $2,302.5431635 A2 $580.15 $779.0331636 A2 $1,714.73 $2,302.54

UPDATED NOVEMBER 2015 Page 31 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

31637 N1 $0.00 $0.0031638 A2 $1,714.73 $2,302.5431640 A2 $1,113.86 $1,495.6931641 A2 $1,113.86 $1,495.6931643 A2 $580.15 $779.0331645 A2 $580.15 $779.0331646 A2 $209.77 $281.6831647 G2 $1,714.73 $2,302.5431648 G2 $1,113.86 $1,495.6931649 G2 $580.15 $779.0331651 N1 $0.00 $0.0031652 G2 $1,113.86 $1,495.6931653 G2 $1,113.86 $1,495.6931654 N1 $0.00 $0.0031717 A2 $209.77 $281.6831720 N1 $0.00 $0.0031730 A2 $580.15 $779.0331750 A2 $1,994.21 $2,677.8331755 A2 $1,994.21 $2,677.8331820 A2 $904.15 $1,214.0931825 A2 $904.15 $1,214.0931830 A2 $904.15 $1,214.0932400 A2 $526.74 $707.3132405 A2 $526.74 $707.3132550 G2 $1,217.41 $1,634.7432552 G2 $269.99 $362.5432553 G2 $574.18 $771.0132554 G2 $269.99 $362.5432555 G2 $269.99 $362.5432556 G2 $675.36 $906.8732557 G2 $269.99 $362.5432960 G2 $269.99 $362.5432998 G2 $2,302.86 $3,092.2833010 A2 $269.99 $362.5433011 A2 $269.99 $362.5433206 J8 $7,663.75 $10,290.8833207 J8 $7,663.75 $10,290.8833208 J8 $7,663.75 $10,290.8833210 J8 $5,787.01 $7,770.8033211 J8 $5,787.01 $7,770.8033212 J8 $5,787.01 $7,770.8033213 J8 $7,663.75 $10,290.8833214 J8 $7,663.75 $10,290.8833215 G2 $482.30 $647.6333216 J8 $5,787.01 $7,770.8033217 J8 $5,787.01 $7,770.8033218 G2 $1,392.20 $1,869.4533220 G2 $1,392.20 $1,869.4533221 J8 $12,615.66 $16,940.3133222 A2 $789.12 $1,059.6333223 A2 $789.12 $1,059.6333224 J8 $7,663.75 $10,290.8833225 N1 $0.00 $0.0033226 G2 $1,256.68 $1,687.4733227 J8 $5,787.01 $7,770.8033228 J8 $7,663.75 $10,290.8833229 J8 $12,615.66 $16,940.3133230 J8 $19,581.49 $26,294.0233231 J8 $26,657.76 $35,796.0433233 J8 $5,787.01 $7,770.8033234 G2 $1,392.20 $1,869.45

UPDATED NOVEMBER 2015 Page 32 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

33235 G2 $1,392.20 $1,869.4533240 J8 $19,581.49 $26,294.0233241 G2 $1,392.20 $1,869.4533249 J8 $26,657.76 $35,796.0433262 J8 $19,581.49 $26,294.0233263 J8 $19,581.49 $26,294.0233264 J8 $26,657.76 $35,796.0433270 J8 $26,657.76 $35,796.0433271 J8 $5,787.01 $7,770.8033273 G2 $1,392.20 $1,869.4533282 J8 $5,787.01 $7,770.8033284 G2 $526.74 $707.3133419 N1 $0.00 $0.0033508 N1 $0.00 $0.0034490 G2 $1,256.68 $1,687.4735188 A2 $1,256.68 $1,687.4735207 A2 $1,256.68 $1,687.4735460 G2 $2,287.57 $3,071.7535475 P3 $1,314.98 $1,765.7635476 P3 $1,244.41 $1,670.9935572 N1 $0.00 $0.0035761 G2 $1,256.68 $1,687.4735875 A2 $2,122.27 $2,849.7835876 A2 $2,122.27 $2,849.7836000 N1 $0.00 $0.0036002 G2 $233.07 $312.9736005 N1 $0.00 $0.0036010 N1 $0.00 $0.0036011 N1 $0.00 $0.0036012 N1 $0.00 $0.0036013 N1 $0.00 $0.0036014 N1 $0.00 $0.0036015 N1 $0.00 $0.0036100 N1 $0.00 $0.0036120 N1 $0.00 $0.0036140 N1 $0.00 $0.0036147 P2 $482.30 $647.6336148 N1 $0.00 $0.0036160 N1 $0.00 $0.0036200 N1 $0.00 $0.0036215 N1 $0.00 $0.0036216 N1 $0.00 $0.0036217 N1 $0.00 $0.0036218 N1 $0.00 $0.0036221 N1 $0.00 $0.0036222 N1 $0.00 $0.0036223 N1 $0.00 $0.0036224 N1 $0.00 $0.0036225 N1 $0.00 $0.0036226 N1 $0.00 $0.0036227 N1 $0.00 $0.0036228 N1 $0.00 $0.0036245 N1 $0.00 $0.0036246 N1 $0.00 $0.0036247 N1 $0.00 $0.0036248 N1 $0.00 $0.0036251 N1 $0.00 $0.0036252 N1 $0.00 $0.0036253 N1 $0.00 $0.0036254 N1 $0.00 $0.0036260 A2 $1,256.68 $1,687.47

UPDATED NOVEMBER 2015 Page 33 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

36261 G2 $1,392.20 $1,869.4536262 G2 $1,392.20 $1,869.4536400 N1 $0.00 $0.0036405 N1 $0.00 $0.0036406 N1 $0.00 $0.0036410 N1 $0.00 $0.0036415 N1 $0.00 $0.0036416 N1 $0.00 $0.0036420 N1 $0.00 $0.0036425 N1 $0.00 $0.0036430 P3 $34.39 $46.1836440 R2 $195.24 $262.1736450 R2 $195.24 $262.1736455 G2 $195.24 $262.1736468 N1 $0.00 $0.0036470 P3 $106.03 $142.3836471 P3 $108.54 $145.7536475 A2 $1,256.68 $1,687.4736476 N1 $0.00 $0.0036478 A2 $1,256.68 $1,687.4736479 N1 $0.00 $0.0036481 N1 $0.00 $0.0036500 N1 $0.00 $0.0036510 N1 $0.00 $0.0036511 G2 $585.89 $786.7336512 G2 $585.89 $786.7336513 G2 $585.89 $786.7336514 G2 $585.89 $786.7336515 P2 $1,685.98 $2,263.9336516 P2 $1,685.98 $2,263.9336522 G2 $1,685.98 $2,263.9336555 A2 $482.30 $647.6336556 A2 $482.30 $647.6336557 A2 $1,256.68 $1,687.4736558 A2 $1,256.68 $1,687.4736560 A2 $1,256.68 $1,687.4736561 A2 $1,256.68 $1,687.4736563 A2 $2,122.27 $2,849.7836565 A2 $1,256.68 $1,687.4736566 A2 $2,122.27 $2,849.7836568 A2 $482.30 $647.6336569 A2 $482.30 $647.6336570 A2 $1,256.68 $1,687.4736571 A2 $1,256.68 $1,687.4736575 A2 $269.99 $362.5436576 A2 $482.30 $647.6336578 A2 $1,256.68 $1,687.4736580 A2 $482.30 $647.6336581 A2 $1,256.68 $1,687.4736582 A2 $1,256.68 $1,687.4736583 A2 $2,122.27 $2,849.7836584 A2 $482.30 $647.6336585 A2 $1,256.68 $1,687.4736589 A2 $269.99 $362.5436590 A2 $482.30 $647.6336591 N1 $0.00 $0.0036592 N1 $0.00 $0.0036593 P3 $30.81 $41.3736595 P3 $453.13 $608.4636596 G2 $482.30 $647.6336597 G2 $482.30 $647.63

UPDATED NOVEMBER 2015 Page 34 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

36598 P3 $83.46 $112.0736600 N1 $0.00 $0.0036620 N1 $0.00 $0.0036625 N1 $0.00 $0.0036640 A2 $1,256.68 $1,687.4736680 N1 $0.00 $0.0036800 A2 $1,256.68 $1,687.4736810 A2 $2,122.27 $2,849.7836815 A2 $1,256.68 $1,687.4736818 A2 $1,256.68 $1,687.4736819 A2 $2,122.27 $2,849.7836820 A2 $1,256.68 $1,687.4736821 A2 $1,256.68 $1,687.4736825 A2 $2,122.27 $2,849.7836830 A2 $2,122.27 $2,849.7836831 A2 $1,256.68 $1,687.4736832 A2 $2,122.27 $2,849.7836833 A2 $2,122.27 $2,849.7836835 A2 $1,256.68 $1,687.4736860 A2 $482.30 $647.6336861 A2 $2,122.27 $2,849.7836870 A2 $2,287.57 $3,071.7537184 G2 $2,122.27 $2,849.7837185 N1 $0.00 $0.0037186 N1 $0.00 $0.0037187 G2 $2,122.27 $2,849.7837188 G2 $1,256.68 $1,687.4737197 G2 $1,256.68 $1,687.4737200 G2 $2,122.27 $2,849.7837202 D5 $0.00 $0.0037211 G2 $2,122.27 $2,849.7837212 G2 $482.30 $647.6337220 G2 $2,287.57 $3,071.7537221 J8 $5,984.06 $8,035.4037222 N1 $0.00 $0.0037223 N1 $0.00 $0.0037224 G2 $2,287.57 $3,071.7537225 J8 $5,984.06 $8,035.4037226 J8 $5,984.06 $8,035.4037227 J8 $9,819.12 $13,185.1137228 J8 $5,984.06 $8,035.4037229 J8 $9,819.12 $13,185.1137230 J8 $9,819.12 $13,185.1137231 J8 $9,819.12 $13,185.1137232 N1 $0.00 $0.0037233 N1 $0.00 $0.0037234 N1 $0.00 $0.0037235 N1 $0.00 $0.0037236 J8 $5,984.06 $8,035.4037237 N1 $0.00 $0.0037238 J8 $5,984.06 $8,035.4037239 N1 $0.00 $0.0037241 J8 $5,984.06 $8,035.4037242 J8 $5,984.06 $8,035.4037243 J8 $5,984.06 $8,035.4037250 D5 $0.00 $0.0037251 D5 $0.00 $0.0037252 N1 $0.00 $0.0037253 N1 $0.00 $0.0037500 A2 $2,122.27 $2,849.7837607 A2 $1,256.68 $1,687.47

UPDATED NOVEMBER 2015 Page 35 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

37609 A2 $790.85 $1,061.9537650 A2 $1,256.68 $1,687.4737700 A2 $1,256.68 $1,687.4737718 A2 $1,256.68 $1,687.4737722 A2 $1,256.68 $1,687.4737735 A2 $1,256.68 $1,687.4737760 A2 $1,256.68 $1,687.4737761 R2 $1,256.68 $1,687.4737765 P3 $342.09 $459.3637766 P3 $385.79 $518.0437780 A2 $1,256.68 $1,687.4737785 A2 $1,256.68 $1,687.4737790 A2 $1,254.53 $1,684.5838200 N1 $0.00 $0.0038204 N1 $0.00 $0.0038206 G2 $585.89 $786.7338220 P3 $123.94 $166.4338221 P3 $117.85 $158.2538230 G2 $1,685.98 $2,263.9338232 G2 $1,685.98 $2,263.9338241 G2 $1,685.98 $2,263.9338242 R2 $585.89 $786.7338243 R2 $585.89 $786.7338300 A2 $790.85 $1,061.9538305 A2 $790.85 $1,061.9538308 A2 $1,223.47 $1,642.8838500 A2 $1,223.47 $1,642.8838505 A2 $526.74 $707.3138510 A2 $1,223.47 $1,642.8838520 A2 $1,223.47 $1,642.8838525 A2 $1,223.47 $1,642.8838530 A2 $1,223.47 $1,642.8838542 A2 $2,010.99 $2,700.3638550 A2 $1,223.47 $1,642.8838555 A2 $2,039.38 $2,738.4838570 A2 $2,010.99 $2,700.3638571 A2 $3,277.62 $4,401.1938572 A2 $3,277.62 $4,401.1938700 G2 $2,039.38 $2,738.4838740 A2 $2,010.99 $2,700.3638745 A2 $2,010.99 $2,700.3638760 A2 $1,223.47 $1,642.8838790 N1 $0.00 $0.0038792 N1 $0.00 $0.0038794 N1 $0.00 $0.0038900 N1 $0.00 $0.0040490 P3 $82.39 $110.6340500 A2 $904.15 $1,214.0940510 A2 $904.15 $1,214.0940520 A2 $904.15 $1,214.0940525 A2 $904.15 $1,214.0940527 A2 $1,994.21 $2,677.8340530 A2 $904.15 $1,214.0940650 A2 $385.63 $517.8240652 A2 $385.63 $517.8240654 A2 $385.63 $517.8240700 A2 $1,994.21 $2,677.8340701 A2 $1,994.21 $2,677.8340702 R2 $1,994.21 $2,677.8340720 A2 $1,994.21 $2,677.8340761 A2 $1,994.21 $2,677.83

UPDATED NOVEMBER 2015 Page 36 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

40800 P2 $127.65 $171.4140801 A2 $385.63 $517.8240804 N1 $0.00 $0.0040805 P3 $277.25 $372.2940806 P3 $104.95 $140.9340808 P3 $154.03 $206.8340810 P3 $160.48 $215.4940812 P3 $204.89 $275.1340814 A2 $904.15 $1,214.0940816 A2 $904.15 $1,214.0940818 A2 $174.99 $234.9840819 A2 $904.15 $1,214.0940820 P3 $223.52 $300.1440830 G2 $174.99 $234.9840831 A2 $385.63 $517.8240840 A2 $904.15 $1,214.0940842 A2 $1,994.21 $2,677.8340843 A2 $904.15 $1,214.0940844 A2 $1,994.21 $2,677.8340845 A2 $1,994.21 $2,677.8341000 P3 $114.63 $153.9341005 A2 $174.99 $234.9841006 A2 $385.63 $517.8241007 A2 $385.63 $517.8241008 A2 $904.15 $1,214.0941009 A2 $174.99 $234.9841010 A2 $385.63 $517.8241015 A2 $174.99 $234.9841016 A2 $904.15 $1,214.0941017 A2 $904.15 $1,214.0941018 A2 $385.63 $517.8241019 G2 $904.15 $1,214.0941100 P3 $117.13 $157.2841105 P3 $118.21 $158.7341108 P3 $109.61 $147.1841110 P3 $157.97 $212.1241112 A2 $904.15 $1,214.0941113 A2 $904.15 $1,214.0941114 A2 $904.15 $1,214.0941115 P3 $185.19 $248.6741116 A2 $904.15 $1,214.0941120 A2 $1,994.21 $2,677.8341250 N1 $0.00 $0.0041251 A2 $174.99 $234.9841252 A2 $385.63 $517.8241500 A2 $904.15 $1,214.0941510 A2 $904.15 $1,214.0941512 G2 $1,994.21 $2,677.8341520 A2 $1,994.21 $2,677.8341530 R2 $904.15 $1,214.0941800 N1 $0.00 $0.0041805 P3 $215.64 $289.5641806 P3 $256.12 $343.9241820 R2 $904.15 $1,214.0941821 G2 $385.63 $517.8241822 P3 $207.76 $278.9841823 P3 $293.01 $393.4541825 P3 $164.42 $220.7841826 P3 $232.12 $311.6941827 A2 $1,994.21 $2,677.8341828 P3 $193.79 $260.22

UPDATED NOVEMBER 2015 Page 37 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

41830 P3 $270.80 $363.6341850 R2 $904.15 $1,214.0941870 G2 $1,994.21 $2,677.8341872 P3 $261.85 $351.6141874 P3 $263.64 $354.0242000 A2 $174.99 $234.9842100 P3 $101.37 $136.1242104 P3 $156.54 $210.2042106 P3 $198.80 $266.9542107 A2 $1,994.21 $2,677.8342120 A2 $904.15 $1,214.0942140 A2 $904.15 $1,214.0942145 A2 $1,994.21 $2,677.8342160 P3 $166.57 $223.6742180 A2 $174.99 $234.9842182 A2 $904.15 $1,214.0942200 A2 $1,994.21 $2,677.8342205 A2 $1,994.21 $2,677.8342210 A2 $1,994.21 $2,677.8342215 A2 $1,994.21 $2,677.8342220 A2 $1,994.21 $2,677.8342225 G2 $1,994.21 $2,677.8342226 A2 $1,994.21 $2,677.8342227 G2 $1,994.21 $2,677.8342235 A2 $1,994.21 $2,677.8342260 A2 $904.15 $1,214.0942280 P3 $107.10 $143.8142281 G2 $904.15 $1,214.0942300 A2 $385.63 $517.8242305 A2 $904.15 $1,214.0942310 A2 $174.99 $234.9842320 A2 $174.99 $234.9842330 P3 $149.73 $201.0642335 P3 $251.46 $337.6642340 A2 $904.15 $1,214.0942400 P3 $78.45 $105.3442405 A2 $904.15 $1,214.0942408 A2 $904.15 $1,214.0942409 A2 $904.15 $1,214.0942410 A2 $1,994.21 $2,677.8342415 A2 $1,994.21 $2,677.8342420 A2 $1,994.21 $2,677.8342425 A2 $1,994.21 $2,677.8342440 A2 $1,994.21 $2,677.8342450 A2 $1,994.21 $2,677.8342500 A2 $904.15 $1,214.0942505 A2 $1,994.21 $2,677.8342507 A2 $1,994.21 $2,677.8342509 A2 $1,994.21 $2,677.8342510 A2 $1,994.21 $2,677.8342550 N1 $0.00 $0.0042600 A2 $904.15 $1,214.0942650 P3 $55.52 $74.5542660 P3 $80.60 $108.2342665 A2 $1,994.21 $2,677.8342700 A2 $174.99 $234.9842720 A2 $904.15 $1,214.0942725 A2 $1,994.21 $2,677.8342800 P3 $106.03 $142.3842804 A2 $904.15 $1,214.0942806 A2 $904.15 $1,214.09

UPDATED NOVEMBER 2015 Page 38 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

42808 A2 $904.15 $1,214.0942809 N1 $0.00 $0.0042810 A2 $904.15 $1,214.0942815 A2 $1,994.21 $2,677.8342820 A2 $904.15 $1,214.0942821 A2 $904.15 $1,214.0942825 A2 $1,994.21 $2,677.8342826 A2 $904.15 $1,214.0942830 A2 $1,994.21 $2,677.8342831 A2 $904.15 $1,214.0942835 A2 $904.15 $1,214.0942836 A2 $904.15 $1,214.0942860 A2 $1,994.21 $2,677.8342870 A2 $904.15 $1,214.0942890 A2 $1,994.21 $2,677.8342892 A2 $1,994.21 $2,677.8342900 A2 $385.63 $517.8242950 A2 $1,994.21 $2,677.8342955 A2 $385.63 $517.8242960 A2 $72.30 $97.0842962 A2 $904.15 $1,214.0942970 R2 $72.30 $97.0842972 A2 $904.15 $1,214.0943030 G2 $1,994.21 $2,677.8343130 G2 $1,994.21 $2,677.8343180 G2 $904.15 $1,214.0943191 G2 $416.80 $559.6843192 G2 $608.39 $816.9543193 G2 $608.39 $816.9543194 G2 $608.39 $816.9543195 G2 $608.39 $816.9543196 G2 $608.39 $816.9543197 P3 $131.46 $176.5243198 P3 $140.06 $188.0743200 A2 $416.80 $559.6843201 A2 $608.39 $816.9543202 A2 $416.80 $559.6843204 A2 $416.80 $559.6843205 A2 $608.39 $816.9543206 G2 $608.39 $816.9543210 G2 $1,679.99 $2,255.8943211 G2 $608.39 $816.9543212 G2 $1,679.99 $2,255.8943213 G2 $608.39 $816.9543214 G2 $608.39 $816.9543215 A2 $608.39 $816.9543216 A2 $1,107.43 $1,487.0643217 A2 $608.39 $816.9543220 A2 $608.39 $816.9543226 A2 $608.39 $816.9543227 A2 $608.39 $816.9543229 G2 $1,107.43 $1,487.0643231 A2 $608.39 $816.9543232 A2 $608.39 $816.9543233 G2 $608.39 $816.9543235 A2 $416.80 $559.6843236 A2 $416.80 $559.6843237 A2 $608.39 $816.9543238 A2 $608.39 $816.9543239 A2 $416.80 $559.6843240 A2 $1,107.43 $1,487.06

UPDATED NOVEMBER 2015 Page 39 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

43241 A2 $416.80 $559.6843242 A2 $608.39 $816.9543243 A2 $416.80 $559.6843244 A2 $608.39 $816.9543245 A2 $608.39 $816.9543246 A2 $608.39 $816.9543247 A2 $416.80 $559.6843248 A2 $416.80 $559.6843249 A2 $608.39 $816.9543250 A2 $608.39 $816.9543251 A2 $608.39 $816.9543252 G2 $608.39 $816.9543253 G2 $608.39 $816.9543254 G2 $608.39 $816.9543255 A2 $608.39 $816.9543257 A2 $1,107.43 $1,487.0643259 A2 $608.39 $816.9543260 A2 $1,107.43 $1,487.0643261 A2 $1,107.43 $1,487.0643262 A2 $1,107.43 $1,487.0643263 A2 $1,107.43 $1,487.0643264 A2 $1,107.43 $1,487.0643265 A2 $1,107.43 $1,487.0643266 G2 $1,679.99 $2,255.8943270 G2 $608.39 $816.9543273 N1 $0.00 $0.0043274 G2 $1,679.99 $2,255.8943275 G2 $1,107.43 $1,487.0643276 G2 $1,679.99 $2,255.8943277 G2 $1,107.43 $1,487.0643278 G2 $1,107.43 $1,487.0643450 A2 $416.80 $559.6843453 A2 $608.39 $816.9543653 A2 $2,010.99 $2,700.3643752 G2 $107.35 $144.1543753 N1 $0.00 $0.0043754 N1 $0.00 $0.0043755 G2 $72.55 $97.4243756 G2 $56.31 $75.6143757 G2 $416.80 $559.6843760 A2 $111.73 $150.0343761 A2 $416.80 $559.6843870 A2 $1,107.43 $1,487.0643886 G2 $1,195.26 $1,605.0043887 G2 $1,195.26 $1,605.0043888 G2 $1,195.26 $1,605.0044100 A2 $608.39 $816.9544312 A2 $1,195.26 $1,605.0044340 A2 $1,195.26 $1,605.0044360 A2 $416.80 $559.6844361 A2 $608.39 $816.9544363 A2 $608.39 $816.9544364 A2 $608.39 $816.9544365 A2 $608.39 $816.9544366 A2 $608.39 $816.9544369 A2 $608.39 $816.9544370 A2 $1,679.99 $2,255.8944372 A2 $608.39 $816.9544373 A2 $608.39 $816.9544376 A2 $608.39 $816.9544377 A2 $608.39 $816.95

UPDATED NOVEMBER 2015 Page 40 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

44378 A2 $608.39 $816.9544379 A2 $1,679.99 $2,255.8944380 A2 $416.80 $559.6844381 G2 $416.80 $559.6844382 A2 $416.80 $559.6844384 G2 $1,679.99 $2,255.8944385 A2 $420.93 $565.2244386 A2 $420.93 $565.2244388 A2 $420.93 $565.2244389 A2 $420.93 $565.2244390 A2 $420.93 $565.2244391 A2 $420.93 $565.2244392 A2 $420.93 $565.2244394 A2 $420.93 $565.2244401 G2 $420.93 $565.2244402 G2 $1,679.99 $2,255.8944403 G2 $420.93 $565.2244404 G2 $420.93 $565.2244405 G2 $420.93 $565.2244406 G2 $420.93 $565.2244407 G2 $420.93 $565.2244408 G2 $420.93 $565.2244500 G2 $269.99 $362.5444701 N1 $0.00 $0.0045000 A2 $929.09 $1,247.5845005 A2 $929.09 $1,247.5845020 A2 $929.09 $1,247.5845100 A2 $929.09 $1,247.5845108 A2 $1,301.02 $1,747.0145150 A2 $929.09 $1,247.5845160 A2 $929.09 $1,247.5845171 G2 $1,301.02 $1,747.0145172 G2 $1,301.02 $1,747.0145190 A2 $929.09 $1,247.5845300 P3 $92.42 $124.1045303 P2 $420.93 $565.2245305 A2 $929.09 $1,247.5845307 A2 $929.09 $1,247.5845308 A2 $929.09 $1,247.5845309 A2 $929.09 $1,247.5845315 A2 $929.09 $1,247.5845317 A2 $420.93 $565.2245320 A2 $1,301.02 $1,747.0145321 A2 $929.09 $1,247.5845327 A2 $1,679.99 $2,255.8945330 P3 $135.76 $182.3045331 A2 $275.37 $369.7745332 A2 $420.93 $565.2245333 A2 $275.37 $369.7745334 A2 $420.93 $565.2245335 A2 $275.37 $369.7745337 A2 $420.93 $565.2245338 A2 $420.93 $565.2245340 A2 $420.93 $565.2245341 A2 $420.93 $565.2245342 A2 $929.09 $1,247.5845346 G2 $420.93 $565.2245347 G2 $1,679.99 $2,255.8945349 G2 $420.93 $565.2245350 G2 $420.93 $565.2245378 A2 $420.93 $565.22

UPDATED NOVEMBER 2015 Page 41 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

45379 A2 $420.93 $565.2245380 A2 $420.93 $565.2245381 A2 $420.93 $565.2245382 A2 $420.93 $565.2245384 A2 $420.93 $565.2245385 A2 $420.93 $565.2245386 A2 $420.93 $565.2245388 G2 $420.93 $565.2245389 G2 $1,679.99 $2,255.8945390 G2 $420.93 $565.2245391 A2 $420.93 $565.2245392 A2 $929.09 $1,247.5845393 G2 $420.93 $565.2245398 G2 $420.93 $565.2245500 A2 $929.09 $1,247.5845505 A2 $1,301.02 $1,747.0145520 N1 $0.00 $0.0045541 G2 $1,301.02 $1,747.0145560 A2 $1,301.02 $1,747.0145900 A2 $275.37 $369.7745905 A2 $929.09 $1,247.5845910 A2 $929.09 $1,247.5845915 A2 $929.09 $1,247.5845990 A2 $929.09 $1,247.5846020 A2 $929.09 $1,247.5846030 A2 $420.93 $565.2246040 A2 $929.09 $1,247.5846045 A2 $929.09 $1,247.5846050 A2 $275.37 $369.7746060 A2 $929.09 $1,247.5846070 G2 $929.09 $1,247.5846080 A2 $929.09 $1,247.5846083 P2 $115.54 $155.1546200 A2 $929.09 $1,247.5846220 A2 $929.09 $1,247.5846221 P3 $176.60 $237.1446230 A2 $929.09 $1,247.5846250 A2 $929.09 $1,247.5846255 A2 $929.09 $1,247.5846257 A2 $929.09 $1,247.5846258 A2 $1,301.02 $1,747.0146260 A2 $1,301.02 $1,747.0146261 A2 $1,301.02 $1,747.0146262 A2 $1,301.02 $1,747.0146270 A2 $929.09 $1,247.5846275 A2 $929.09 $1,247.5846280 A2 $929.09 $1,247.5846285 A2 $929.09 $1,247.5846288 A2 $1,301.02 $1,747.0146320 P3 $118.21 $158.7346500 P3 $139.70 $187.5946505 G2 $929.09 $1,247.5846600 N1 $0.00 $0.0046601 N1 $0.00 $0.0046604 P3 $587.82 $789.3246606 P3 $180.18 $241.9546607 G2 $420.93 $565.2246608 A2 $420.93 $565.2246610 A2 $929.09 $1,247.5846611 A2 $420.93 $565.2246612 A2 $929.09 $1,247.58

UPDATED NOVEMBER 2015 Page 42 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

46614 P3 $89.55 $120.2546615 A2 $929.09 $1,247.5846700 A2 $929.09 $1,247.5846706 A2 $1,301.02 $1,747.0146707 G2 $1,301.02 $1,747.0146750 A2 $1,301.02 $1,747.0146753 A2 $1,301.02 $1,747.0146754 A2 $929.09 $1,247.5846760 A2 $1,301.02 $1,747.0146761 A2 $1,301.02 $1,747.0146762 A2 $1,679.99 $2,255.8946900 P2 $126.13 $169.3746910 P3 $181.61 $243.8746916 P2 $126.13 $169.3746917 A2 $929.09 $1,247.5846922 A2 $929.09 $1,247.5846924 A2 $929.09 $1,247.5846930 P3 $144.36 $193.8546940 P3 $136.12 $182.7846942 P3 $135.40 $181.8246945 P3 $222.09 $298.2246946 A2 $929.09 $1,247.5846947 A2 $1,301.02 $1,747.0147000 A2 $526.74 $707.3147001 N1 $0.00 $0.0047382 G2 $2,302.86 $3,092.2847383 G2 $2,302.86 $3,092.2847500 D5 $0.00 $0.0047505 D5 $0.00 $0.0047510 D5 $0.00 $0.0047511 D5 $0.00 $0.0047525 D5 $0.00 $0.0047530 D5 $0.00 $0.0047531 N1 $0.00 $0.0047532 N1 $0.00 $0.0047533 G2 $1,217.41 $1,634.7447534 G2 $1,217.41 $1,634.7447535 G2 $1,217.41 $1,634.7447536 G2 $1,217.41 $1,634.7447537 G2 $269.99 $362.5447538 G2 $2,302.86 $3,092.2847539 G2 $2,302.86 $3,092.2847540 G2 $2,302.86 $3,092.2847541 G2 $1,217.41 $1,634.7447542 N1 $0.00 $0.0047543 N1 $0.00 $0.0047544 N1 $0.00 $0.0047552 A2 $1,217.41 $1,634.7447553 A2 $2,302.86 $3,092.2847554 A2 $2,302.86 $3,092.2847555 A2 $1,217.41 $1,634.7447556 A2 $2,302.86 $3,092.2847560 D5 $0.00 $0.0047561 D5 $0.00 $0.0047562 G2 $2,010.99 $2,700.3647563 G2 $2,010.99 $2,700.3647564 G2 $2,010.99 $2,700.3647630 D5 $0.00 $0.0048102 A2 $526.74 $707.3149082 G2 $269.99 $362.5449083 G2 $269.99 $362.54

UPDATED NOVEMBER 2015 Page 43 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

49084 G2 $269.99 $362.5449180 A2 $526.74 $707.3149250 A2 $1,460.91 $1,961.7149320 A2 $2,010.99 $2,700.3649321 A2 $2,010.99 $2,700.3649322 A2 $2,010.99 $2,700.3649324 G2 $2,010.99 $2,700.3649325 G2 $2,010.99 $2,700.3649326 N1 $0.00 $0.0049327 N1 $0.00 $0.0049400 N1 $0.00 $0.0049402 A2 $1,460.91 $1,961.7149406 G2 $790.85 $1,061.9549407 G2 $526.74 $707.3149411 P3 $408.36 $548.3549418 G2 $1,217.41 $1,634.7449419 A2 $1,256.68 $1,687.4749421 G2 $1,460.91 $1,961.7149422 A2 $1,256.68 $1,687.4749423 G2 $675.36 $906.8749424 N1 $0.00 $0.0049426 A2 $1,460.91 $1,961.7149427 N1 $0.00 $0.0049429 G2 $1,256.68 $1,687.4749435 N1 $0.00 $0.0049436 G2 $675.36 $906.8749440 G2 $608.39 $816.9549441 G2 $608.39 $816.9549442 G2 $929.09 $1,247.5849446 G2 $608.39 $816.9549450 G2 $269.99 $362.5449451 G2 $269.99 $362.5449452 G2 $269.99 $362.5449460 G2 $269.99 $362.5449465 G2 $56.31 $75.6149495 A2 $1,460.91 $1,961.7149496 A2 $1,460.91 $1,961.7149500 A2 $1,460.91 $1,961.7149501 A2 $1,460.91 $1,961.7149505 A2 $1,460.91 $1,961.7149507 A2 $1,460.91 $1,961.7149520 A2 $1,460.91 $1,961.7149521 A2 $1,460.91 $1,961.7149525 A2 $1,460.91 $1,961.7149540 A2 $1,460.91 $1,961.7149550 A2 $1,460.91 $1,961.7149553 A2 $1,460.91 $1,961.7149555 A2 $1,460.91 $1,961.7149557 A2 $1,460.91 $1,961.7149560 A2 $1,460.91 $1,961.7149561 A2 $1,460.91 $1,961.7149565 A2 $1,460.91 $1,961.7149566 A2 $1,460.91 $1,961.7149568 N1 $0.00 $0.0049570 A2 $1,460.91 $1,961.7149572 A2 $1,460.91 $1,961.7149580 A2 $1,460.91 $1,961.7149582 A2 $1,460.91 $1,961.7149585 A2 $1,460.91 $1,961.7149587 A2 $1,460.91 $1,961.7149590 A2 $1,460.91 $1,961.71

UPDATED NOVEMBER 2015 Page 44 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

49600 A2 $1,460.91 $1,961.7149650 A2 $2,010.99 $2,700.3649651 A2 $2,010.99 $2,700.3649652 G2 $2,010.99 $2,700.3649653 G2 $2,010.99 $2,700.3649654 G2 $3,277.62 $4,401.1949655 G2 $3,277.62 $4,401.1949656 G2 $3,277.62 $4,401.1949657 G2 $3,277.62 $4,401.1950080 J8 $5,926.16 $7,957.6550081 J8 $5,926.16 $7,957.6550200 A2 $790.85 $1,061.9550382 G2 $842.37 $1,131.1350384 G2 $842.37 $1,131.1350385 G2 $842.37 $1,131.1350386 P3 $626.50 $841.2650387 G2 $675.36 $906.8750389 G2 $293.28 $393.8250390 A2 $526.74 $707.3150391 P3 $46.93 $63.0250392 D5 $0.00 $0.0050393 D5 $0.00 $0.0050394 D5 $0.00 $0.0050395 A2 $1,254.53 $1,684.5850396 A2 $293.28 $393.8250398 D5 $0.00 $0.0050430 N1 $0.00 $0.0050431 N1 $0.00 $0.0050432 G2 $842.37 $1,131.1350433 G2 $842.37 $1,131.1350434 G2 $293.28 $393.8250435 G2 $293.28 $393.8250551 A2 $1,254.53 $1,684.5850553 A2 $1,744.29 $2,342.2350555 A2 $1,254.53 $1,684.5850557 J8 $5,926.16 $7,957.6550561 A2 $1,744.29 $2,342.2350562 G2 $1,254.53 $1,684.5850570 G2 $842.37 $1,131.1350572 G2 $293.28 $393.8250574 G2 $293.28 $393.8250575 G2 $1,744.29 $2,342.2350576 G2 $842.37 $1,131.1350580 G2 $842.37 $1,131.1350590 G2 $1,744.29 $2,342.2350592 G2 $2,302.86 $3,092.2850593 G2 $2,302.86 $3,092.2850606 N1 $0.00 $0.005060F N1 $0.00 $0.0050684 N1 $0.00 $0.0050686 P2 $72.55 $97.4250688 A2 $675.36 $906.8750690 N1 $0.00 $0.0050693 G2 $1,254.53 $1,684.5850694 G2 $1,254.53 $1,684.5850695 G2 $1,254.53 $1,684.5850705 N1 $0.00 $0.0050706 N1 $0.00 $0.0050727 G2 $1,254.53 $1,684.5850947 A2 $2,010.99 $2,700.3650948 A2 $3,277.62 $4,401.19

UPDATED NOVEMBER 2015 Page 45 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

50951 A2 $842.37 $1,131.1350953 A2 $1,254.53 $1,684.5850955 A2 $1,254.53 $1,684.5850957 A2 $1,744.29 $2,342.2350961 A2 $842.37 $1,131.1350970 A2 $293.28 $393.8250972 A2 $293.28 $393.8250974 A2 $1,744.29 $2,342.2350976 A2 $1,744.29 $2,342.2350980 A2 $1,254.53 $1,684.5851020 A2 $1,254.53 $1,684.5851030 A2 $1,254.53 $1,684.5851040 A2 $842.37 $1,131.1351045 A2 $842.37 $1,131.1351050 A2 $1,744.29 $2,342.2351065 A2 $1,744.29 $2,342.2351080 A2 $526.74 $707.3151100 P3 $31.16 $41.8451101 P3 $85.61 $114.9651102 A2 $842.37 $1,131.1351500 A2 $1,460.91 $1,961.7151520 A2 $1,254.53 $1,684.5851535 G2 $1,254.53 $1,684.5851600 N1 $0.00 $0.0051605 N1 $0.00 $0.0051610 N1 $0.00 $0.0051700 P3 $49.43 $66.3751701 N1 $0.00 $0.0051702 N1 $0.00 $0.0051703 P2 $72.55 $97.4251705 P3 $56.60 $76.0051710 A2 $269.99 $362.5451715 A2 $1,254.53 $1,684.5851720 P3 $51.22 $68.7851725 P3 $110.69 $148.6351726 A2 $293.28 $393.8251727 P3 $205.25 $275.6151728 P3 $209.91 $281.8751729 P3 $213.49 $286.6751736 N1 $0.00 $0.0051741 N1 $0.00 $0.0051784 P2 $72.55 $97.4251785 A2 $115.54 $155.1551792 N1 $0.00 $0.0051797 N1 $0.00 $0.0051798 N1 $0.00 $0.0051880 A2 $842.37 $1,131.1351992 A2 $2,010.99 $2,700.3652000 A2 $293.28 $393.8252001 A2 $842.37 $1,131.1352005 A2 $842.37 $1,131.1352007 A2 $1,254.53 $1,684.5852010 A2 $293.28 $393.8252204 A2 $842.37 $1,131.1352214 A2 $842.37 $1,131.1352224 A2 $842.37 $1,131.1352234 A2 $1,254.53 $1,684.5852235 A2 $1,254.53 $1,684.5852240 A2 $1,254.53 $1,684.5852250 A2 $1,254.53 $1,684.5852260 A2 $842.37 $1,131.13

UPDATED NOVEMBER 2015 Page 46 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

52265 P3 $253.25 $340.0652270 A2 $842.37 $1,131.1352275 A2 $842.37 $1,131.1352276 A2 $842.37 $1,131.1352277 A2 $1,254.53 $1,684.5852281 A2 $842.37 $1,131.1352282 A2 $1,254.53 $1,684.5852283 A2 $842.37 $1,131.1352285 A2 $842.37 $1,131.1352287 G2 $842.37 $1,131.1352290 A2 $842.37 $1,131.1352300 A2 $842.37 $1,131.1352301 A2 $1,254.53 $1,684.5852305 A2 $1,744.29 $2,342.2352310 A2 $842.37 $1,131.1352315 A2 $842.37 $1,131.1352317 A2 $1,254.53 $1,684.5852318 A2 $1,744.29 $2,342.2352320 A2 $1,254.53 $1,684.5852325 A2 $1,254.53 $1,684.5852327 A2 $1,254.53 $1,684.5852330 A2 $1,254.53 $1,684.5852332 A2 $1,254.53 $1,684.5852334 A2 $1,254.53 $1,684.5852341 A2 $1,254.53 $1,684.5852342 A2 $1,254.53 $1,684.5852343 A2 $842.37 $1,131.1352344 A2 $1,254.53 $1,684.5852345 A2 $1,254.53 $1,684.5852346 A2 $1,744.29 $2,342.2352351 A2 $1,254.53 $1,684.5852352 A2 $1,254.53 $1,684.5852353 A2 $1,744.29 $2,342.2352354 A2 $1,254.53 $1,684.5852355 A2 $1,744.29 $2,342.2352356 G2 $1,744.29 $2,342.2352400 A2 $1,254.53 $1,684.5852402 A2 $1,254.53 $1,684.5852450 A2 $1,254.53 $1,684.5852500 A2 $1,254.53 $1,684.5852601 A2 $1,744.29 $2,342.2352630 A2 $1,744.29 $2,342.2352640 A2 $1,254.53 $1,684.5852647 A2 $1,744.29 $2,342.2352648 A2 $1,744.29 $2,342.2352649 G2 $1,744.29 $2,342.2352700 A2 $1,254.53 $1,684.5853000 A2 $1,254.53 $1,684.5853010 A2 $1,744.29 $2,342.2353020 A2 $842.37 $1,131.1353025 R2 $842.37 $1,131.1353040 A2 $1,254.53 $1,684.5853060 P3 $80.60 $108.2353080 A2 $842.37 $1,131.1353085 G2 $842.37 $1,131.1353200 A2 $1,254.53 $1,684.5853210 A2 $1,744.29 $2,342.2353215 A2 $1,744.29 $2,342.2353220 A2 $1,254.53 $1,684.5853230 A2 $1,254.53 $1,684.5853235 A2 $1,744.29 $2,342.23

UPDATED NOVEMBER 2015 Page 47 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

53240 A2 $1,744.29 $2,342.2353250 A2 $842.37 $1,131.1353260 A2 $842.37 $1,131.1353265 A2 $842.37 $1,131.1353270 A2 $1,254.53 $1,684.5853275 A2 $1,254.53 $1,684.5853400 A2 $1,744.29 $2,342.2353405 A2 $1,744.29 $2,342.2353410 A2 $1,744.29 $2,342.2353420 A2 $1,744.29 $2,342.2353425 A2 $1,744.29 $2,342.2353430 A2 $1,254.53 $1,684.5853431 A2 $1,744.29 $2,342.2353440 J8 $5,926.16 $7,957.6553442 A2 $1,744.29 $2,342.2353444 J8 $5,926.16 $7,957.6553445 J8 $11,836.71 $15,894.3353446 A2 $1,744.29 $2,342.2353447 J8 $11,836.71 $15,894.3353449 A2 $1,744.29 $2,342.2353450 A2 $1,254.53 $1,684.5853460 A2 $1,254.53 $1,684.5853502 A2 $1,254.53 $1,684.5853505 A2 $1,744.29 $2,342.2353510 A2 $1,744.29 $2,342.2353515 A2 $1,744.29 $2,342.2353520 A2 $1,744.29 $2,342.2353600 P3 $36.54 $49.0753601 N1 $0.00 $0.0053605 A2 $842.37 $1,131.1353620 P3 $53.73 $72.1553621 P3 $57.31 $76.9653660 P3 $43.34 $58.2053661 N1 $0.00 $0.0053665 A2 $842.37 $1,131.1353850 P2 $842.37 $1,131.1353852 P3 $1,499.45 $2,013.4653855 P2 $293.28 $393.8253860 P2 $842.37 $1,131.1354000 A2 $842.37 $1,131.1354001 A2 $842.37 $1,131.1354015 A2 $526.74 $707.3154050 N1 $0.00 $0.0054055 P3 $70.21 $94.2854056 N1 $0.00 $0.0054057 A2 $789.12 $1,059.6354060 A2 $789.12 $1,059.6354065 A2 $789.12 $1,059.6354100 A2 $526.74 $707.3154105 A2 $790.85 $1,061.9554110 A2 $1,254.53 $1,684.5854111 A2 $1,744.29 $2,342.2354112 J8 $5,926.16 $7,957.6554115 A2 $790.85 $1,061.9554120 A2 $1,254.53 $1,684.5854150 A2 $842.37 $1,131.1354160 A2 $842.37 $1,131.1354161 A2 $842.37 $1,131.1354162 A2 $842.37 $1,131.1354163 A2 $842.37 $1,131.1354164 A2 $842.37 $1,131.13

UPDATED NOVEMBER 2015 Page 48 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

54200 P3 $64.84 $87.0754205 A2 $1,744.29 $2,342.2354220 A2 $115.54 $155.1554230 N1 $0.00 $0.0054231 P3 $61.61 $82.7354235 P3 $44.78 $60.1354240 P3 $34.75 $46.6654250 P3 $10.39 $13.9554300 A2 $1,254.53 $1,684.5854304 A2 $1,254.53 $1,684.5854308 A2 $1,744.29 $2,342.2354312 A2 $1,254.53 $1,684.5854316 A2 $1,744.29 $2,342.2354318 A2 $1,254.53 $1,684.5854322 A2 $1,254.53 $1,684.5854324 A2 $1,254.53 $1,684.5854326 A2 $1,744.29 $2,342.2354328 A2 $1,254.53 $1,684.5854340 A2 $1,254.53 $1,684.5854344 A2 $1,744.29 $2,342.2354348 A2 $1,254.53 $1,684.5854352 A2 $1,744.29 $2,342.2354360 A2 $1,254.53 $1,684.5854380 A2 $1,254.53 $1,684.5854385 A2 $1,254.53 $1,684.5854400 J8 $5,926.16 $7,957.6554401 J8 $11,836.71 $15,894.3354405 J8 $11,836.71 $15,894.3354406 A2 $1,254.53 $1,684.5854408 A2 $1,744.29 $2,342.2354410 J8 $11,836.71 $15,894.3354415 A2 $1,254.53 $1,684.5854416 J8 $11,836.71 $15,894.3354420 A2 $842.37 $1,131.1354435 A2 $842.37 $1,131.1354437 G2 $842.37 $1,131.1354440 A2 $1,254.53 $1,684.5854450 A2 $115.54 $155.1554500 A2 $790.85 $1,061.9554505 A2 $1,254.53 $1,684.5854512 A2 $1,254.53 $1,684.5854520 A2 $1,254.53 $1,684.5854522 A2 $1,254.53 $1,684.5854530 A2 $1,460.91 $1,961.7154550 A2 $1,460.91 $1,961.7154560 G2 $842.37 $1,131.1354600 A2 $1,254.53 $1,684.5854620 A2 $842.37 $1,131.1354640 A2 $1,460.91 $1,961.7154660 A2 $1,744.29 $2,342.2354670 A2 $842.37 $1,131.1354680 A2 $842.37 $1,131.1354690 A2 $2,010.99 $2,700.3654692 G2 $2,010.99 $2,700.3654700 A2 $842.37 $1,131.1354800 A2 $790.85 $1,061.9554830 A2 $1,254.53 $1,684.5854840 A2 $1,254.53 $1,684.5854860 A2 $1,254.53 $1,684.5854861 A2 $1,254.53 $1,684.5854865 A2 $1,254.53 $1,684.58

UPDATED NOVEMBER 2015 Page 49 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

54900 A2 $842.37 $1,131.1354901 A2 $1,254.53 $1,684.5855000 P3 $61.97 $83.2155040 A2 $1,460.91 $1,961.7155041 A2 $1,460.91 $1,961.7155060 A2 $1,254.53 $1,684.5855100 A2 $526.74 $707.3155110 A2 $1,254.53 $1,684.5855120 A2 $842.37 $1,131.1355150 A2 $1,254.53 $1,684.5855175 A2 $1,254.53 $1,684.5855180 A2 $1,744.29 $2,342.2355200 A2 $842.37 $1,131.1355250 A2 $842.37 $1,131.1355300 N1 $0.00 $0.0055400 A2 $1,254.53 $1,684.5855450 P3 $189.13 $253.9655500 A2 $1,254.53 $1,684.5855520 A2 $1,254.53 $1,684.5855530 A2 $1,254.53 $1,684.5855535 A2 $1,460.91 $1,961.7155540 A2 $1,460.91 $1,961.7155550 A2 $2,010.99 $2,700.3655600 R2 $842.37 $1,131.1355680 A2 $842.37 $1,131.1355700 A2 $842.37 $1,131.1355705 A2 $1,254.53 $1,684.5855706 G2 $1,254.53 $1,684.5855720 A2 $842.37 $1,131.1355725 A2 $1,254.53 $1,684.5855860 G2 $1,254.53 $1,684.5855870 P3 $76.66 $102.9455873 J8 $5,926.16 $7,957.6555875 A2 $1,254.53 $1,684.5855876 P3 $69.85 $93.7955920 G2 $1,460.91 $1,961.7156405 P3 $50.87 $68.3156420 P3 $65.19 $87.5456440 A2 $1,040.74 $1,397.5156441 A2 $1,040.74 $1,397.5156442 A2 $1,040.74 $1,397.5156501 P3 $69.13 $92.8356515 A2 $1,195.26 $1,605.0056605 P3 $39.04 $52.4256606 N1 $0.00 $0.0056620 A2 $1,040.74 $1,397.5156625 A2 $1,040.74 $1,397.5156700 A2 $1,040.74 $1,397.5156740 A2 $1,040.74 $1,397.5156800 A2 $1,040.74 $1,397.5156805 G2 $1,040.74 $1,397.5156810 A2 $1,040.74 $1,397.5156820 P3 $51.94 $69.7556821 P3 $66.27 $88.9957000 A2 $1,040.74 $1,397.5157010 A2 $1,040.74 $1,397.5157020 A2 $1,040.74 $1,397.5157022 R2 $790.85 $1,061.9557023 A2 $790.85 $1,061.9557061 P3 $62.69 $84.1857065 A2 $1,040.74 $1,397.51

UPDATED NOVEMBER 2015 Page 50 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

57100 P3 $41.19 $55.3157105 A2 $1,040.74 $1,397.5157120 G2 $1,809.89 $2,430.3257130 A2 $1,040.74 $1,397.5157135 A2 $1,040.74 $1,397.5157150 N1 $0.00 $0.0057155 A2 $1,040.74 $1,397.5157156 G2 $140.30 $188.3957160 P3 $41.91 $56.2857170 P3 $25.07 $33.6657180 A2 $78.61 $105.5657200 A2 $1,040.74 $1,397.5157210 A2 $1,040.74 $1,397.5157220 A2 $1,809.89 $2,430.3257230 A2 $1,040.74 $1,397.5157240 A2 $1,809.89 $2,430.3257250 A2 $1,809.89 $2,430.3257260 A2 $1,809.89 $2,430.3257265 A2 $1,809.89 $2,430.3257267 N1 $0.00 $0.0057268 A2 $1,040.74 $1,397.5157287 G2 $1,040.74 $1,397.5157288 A2 $1,809.89 $2,430.3257289 A2 $2,476.18 $3,325.0157291 A2 $1,040.74 $1,397.5157295 G2 $1,040.74 $1,397.5157300 A2 $1,040.74 $1,397.5157310 G2 $2,476.18 $3,325.0157320 G2 $1,809.89 $2,430.3257400 A2 $1,040.74 $1,397.5157410 A2 $1,040.74 $1,397.5157415 A2 $1,040.74 $1,397.5157420 P3 $53.37 $71.6757421 P3 $69.85 $93.7957426 G2 $2,476.18 $3,325.0157452 P3 $49.79 $66.8657454 P3 $61.61 $82.7357455 P3 $64.84 $87.0757456 P3 $61.97 $83.2157460 P3 $172.66 $231.8557461 P3 $185.91 $249.6457500 P3 $81.31 $109.1857505 P3 $55.16 $74.0757510 P3 $56.60 $76.0057511 P3 $68.78 $92.3657513 A2 $1,040.74 $1,397.5157520 A2 $1,040.74 $1,397.5157522 A2 $1,040.74 $1,397.5157530 A2 $1,040.74 $1,397.5157550 A2 $1,040.74 $1,397.5157556 A2 $1,809.89 $2,430.3257558 A2 $1,040.74 $1,397.5157700 A2 $1,040.74 $1,397.5157720 A2 $1,040.74 $1,397.5157800 P3 $30.09 $40.4058100 P3 $49.07 $65.8958110 N1 $0.00 $0.0058120 A2 $1,040.74 $1,397.5158145 A2 $1,040.74 $1,397.5158260 G2 $1,809.89 $2,430.3258262 G2 $1,809.89 $2,430.32

UPDATED NOVEMBER 2015 Page 51 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

58301 P3 $45.13 $60.6058321 P3 $41.19 $55.3158322 P3 $42.63 $57.2458323 P3 $6.45 $8.6658340 N1 $0.00 $0.0058345 R2 $1,040.74 $1,397.5158346 A2 $1,040.74 $1,397.5158350 A2 $1,809.89 $2,430.3258353 A2 $1,809.89 $2,430.3258356 P3 $1,644.89 $2,208.7658541 G2 $2,010.99 $2,700.3658542 G2 $3,277.62 $4,401.1958543 G2 $3,277.62 $4,401.1958544 G2 $3,277.62 $4,401.1958545 A2 $2,010.99 $2,700.3658546 A2 $3,277.62 $4,401.1958550 A2 $2,010.99 $2,700.3658552 G2 $3,277.62 $4,401.1958553 G2 $3,277.62 $4,401.1958554 G2 $3,277.62 $4,401.1958555 A2 $1,040.74 $1,397.5158558 A2 $1,040.74 $1,397.5158559 A2 $1,809.89 $2,430.3258560 A2 $1,809.89 $2,430.3258561 A2 $1,809.89 $2,430.3258562 A2 $1,040.74 $1,397.5158563 A2 $1,809.89 $2,430.3258565 A2 $1,809.89 $2,430.3258570 G2 $3,277.62 $4,401.1958571 G2 $3,277.62 $4,401.1958573 G2 $3,277.62 $4,401.1958600 G2 $1,040.74 $1,397.5158615 G2 $1,040.74 $1,397.5158660 A2 $2,010.99 $2,700.3658661 A2 $2,010.99 $2,700.3658662 A2 $2,010.99 $2,700.3658670 A2 $2,010.99 $2,700.3658671 A2 $2,010.99 $2,700.3658672 A2 $2,010.99 $2,700.3658673 A2 $2,010.99 $2,700.3658800 A2 $1,040.74 $1,397.5158805 G2 $1,040.74 $1,397.5158820 A2 $1,040.74 $1,397.5158900 A2 $1,040.74 $1,397.5158970 A2 $356.12 $478.2058974 A2 $140.30 $188.3958976 A2 $140.30 $188.3959000 P3 $70.57 $94.7659001 R2 $140.30 $188.3959012 G2 $140.30 $188.3959015 P3 $61.61 $82.7359020 P3 $34.03 $45.7059025 P3 $18.27 $24.5359070 G2 $140.30 $188.3959072 G2 $140.30 $188.3959074 G2 $140.30 $188.3959076 G2 $140.30 $188.3959100 R2 $1,040.74 $1,397.5159150 G2 $2,010.99 $2,700.3659151 G2 $2,010.99 $2,700.3659160 A2 $1,040.74 $1,397.51

UPDATED NOVEMBER 2015 Page 52 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

59200 P3 $38.33 $51.4759300 P3 $90.63 $121.7059320 A2 $1,040.74 $1,397.5159412 G2 $1,040.74 $1,397.5159414 G2 $1,040.74 $1,397.5159812 A2 $1,040.74 $1,397.5159820 A2 $1,040.74 $1,397.5159821 A2 $1,040.74 $1,397.5159840 A2 $1,040.74 $1,397.5159841 A2 $1,040.74 $1,397.5159866 G2 $140.30 $188.3959870 A2 $1,040.74 $1,397.5159871 A2 $1,040.74 $1,397.5160000 A2 $385.63 $517.8260100 P3 $54.09 $72.6360200 A2 $2,010.99 $2,700.3660210 G2 $2,010.99 $2,700.3660212 G2 $2,010.99 $2,700.3660220 G2 $2,010.99 $2,700.3660225 G2 $2,010.99 $2,700.3660240 G2 $2,010.99 $2,700.3660280 A2 $2,010.99 $2,700.3660281 A2 $2,010.99 $2,700.3660300 P3 $82.03 $110.1560500 G2 $1,994.21 $2,677.8361000 R2 $327.22 $439.3961001 R2 $327.22 $439.3961020 A2 $327.22 $439.3961026 A2 $125.12 $168.0161050 A2 $327.22 $439.3961055 A2 $327.22 $439.3961070 A2 $269.99 $362.5461215 A2 $1,899.43 $2,550.5561330 G2 $1,994.21 $2,677.8361770 G2 $1,899.43 $2,550.5561781 N1 $0.00 $0.0061782 N1 $0.00 $0.0061783 N1 $0.00 $0.0061790 A2 $778.70 $1,045.6461791 A2 $778.70 $1,045.6461880 G2 $1,223.86 $1,643.4061885 J8 $14,797.32 $19,869.8461886 J8 $21,258.56 $28,545.9961888 J8 $3,993.90 $5,363.0162160 N1 $0.00 $0.0062194 A2 $778.70 $1,045.6462225 A2 $675.36 $906.8762230 A2 $1,899.43 $2,550.5562252 P3 $39.04 $52.4262263 A2 $459.71 $617.3062264 A2 $459.71 $617.3062267 G2 $526.74 $707.3162268 A2 $327.22 $439.3962269 A2 $526.74 $707.3162270 A2 $327.22 $439.3962272 A2 $327.22 $439.3962273 A2 $327.22 $439.3962280 A2 $459.71 $617.3062281 A2 $459.71 $617.3062282 A2 $459.71 $617.3062284 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 53 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

62287 A2 $1,899.43 $2,550.5562290 N1 $0.00 $0.0062291 N1 $0.00 $0.0062292 R2 $778.70 $1,045.6462294 A2 $327.22 $439.3962302 N1 $0.00 $0.0062303 N1 $0.00 $0.0062304 N1 $0.00 $0.0062305 N1 $0.00 $0.0062310 A2 $327.22 $439.3962311 A2 $327.22 $439.3962318 A2 $459.71 $617.3062319 A2 $459.71 $617.3062350 A2 $1,899.43 $2,550.5562355 A2 $778.70 $1,045.6462360 J8 $12,887.49 $17,305.3262361 J8 $12,887.49 $17,305.3262362 J8 $12,887.49 $17,305.3262365 A2 $1,899.43 $2,550.5562367 P3 $23.28 $31.2662368 P3 $31.88 $42.8162369 P3 $97.07 $130.3562370 P3 $95.28 $127.9463001 G2 $2,486.22 $3,338.5063003 G2 $2,486.22 $3,338.5063005 G2 $2,486.22 $3,338.5063020 G2 $2,486.22 $3,338.5063030 G2 $2,486.22 $3,338.5063042 G2 $2,486.22 $3,338.5063044 N1 $0.00 $0.0063045 G2 $2,486.22 $3,338.5063046 G2 $2,486.22 $3,338.5063047 G2 $2,486.22 $3,338.5063055 G2 $2,486.22 $3,338.5063056 G2 $2,486.22 $3,338.5063600 A2 $778.70 $1,045.6463610 A2 $778.70 $1,045.6463615 R2 $778.70 $1,045.6463650 J8 $3,993.90 $5,363.0163655 J8 $14,797.32 $19,869.8463661 G2 $778.70 $1,045.6463662 G2 $1,223.86 $1,643.4063663 J8 $3,993.90 $5,363.0163664 J8 $3,993.90 $5,363.0163685 J8 $21,258.56 $28,545.9963688 A2 $1,223.86 $1,643.4063744 A2 $1,899.43 $2,550.5563746 A2 $778.70 $1,045.6464400 P3 $82.75 $111.1264402 N1 $0.00 $0.0064405 P3 $63.04 $84.6564408 P3 $52.30 $70.2364410 A2 $327.22 $439.3964412 D5 $0.00 $0.0064413 P3 $73.07 $98.1264415 A2 $459.71 $617.3064416 G2 $459.71 $617.3064417 A2 $327.22 $439.3964418 P3 $97.07 $130.3564420 A2 $327.22 $439.3964421 A2 $327.22 $439.39

UPDATED NOVEMBER 2015 Page 54 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

64425 P3 $67.34 $90.4264430 A2 $327.22 $439.3964435 P3 $80.95 $108.7064445 P3 $82.03 $110.1564446 G2 $459.71 $617.3064447 P3 $68.42 $91.8764448 G2 $459.71 $617.3064449 G2 $459.71 $617.3064450 P3 $52.30 $70.2364455 P3 $19.70 $26.4564461 P3 $83.46 $112.0764462 N1 $0.00 $0.0064463 P3 $98.15 $131.8064479 A2 $327.22 $439.3964480 N1 $0.00 $0.0064483 A2 $327.22 $439.3964484 N1 $0.00 $0.0064486 N1 $0.00 $0.0064487 N1 $0.00 $0.0064488 N1 $0.00 $0.0064489 N1 $0.00 $0.0064490 G2 $459.71 $617.3064491 N1 $0.00 $0.0064492 N1 $0.00 $0.0064493 G2 $459.71 $617.3064494 N1 $0.00 $0.0064495 N1 $0.00 $0.0064505 P3 $53.01 $71.1864508 P3 $18.63 $25.0264510 A2 $327.22 $439.3964517 A2 $459.71 $617.3064520 A2 $327.22 $439.3964530 A2 $459.71 $617.3064553 J8 $3,993.90 $5,363.0164555 J8 $3,993.90 $5,363.0164561 J8 $3,993.90 $5,363.0164565 J8 $3,993.90 $5,363.0164566 P3 $104.95 $140.9364568 J8 $21,258.56 $28,545.9964569 J8 $3,993.90 $5,363.0164570 G2 $1,899.43 $2,550.5564575 J8 $3,993.90 $5,363.0164580 J8 $14,797.32 $19,869.8464581 J8 $3,993.90 $5,363.0164585 A2 $1,223.86 $1,643.4064590 J8 $14,797.32 $19,869.8464595 A2 $1,223.86 $1,643.4064600 A2 $459.71 $617.3064605 A2 $778.70 $1,045.6464610 A2 $778.70 $1,045.6464611 P3 $68.78 $92.3664612 P3 $73.43 $98.6064615 P3 $59.46 $79.8464616 P3 $56.60 $76.0064617 P3 $111.40 $149.5964620 A2 $459.71 $617.3064630 A2 $459.71 $617.3064632 P3 $40.12 $53.8764633 G2 $778.70 $1,045.6464634 N1 $0.00 $0.0064635 G2 $778.70 $1,045.64

UPDATED NOVEMBER 2015 Page 55 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

64636 N1 $0.00 $0.0064640 P3 $88.48 $118.8164642 P3 $72.00 $96.6864643 N1 $0.00 $0.0064644 P3 $86.33 $115.9264645 N1 $0.00 $0.0064646 P3 $74.15 $99.5764647 P3 $87.76 $117.8464650 P3 $49.43 $66.3764653 P3 $58.39 $78.4164680 A2 $459.71 $617.3064681 A2 $459.71 $617.3064702 A2 $778.70 $1,045.6464704 A2 $778.70 $1,045.6464708 G2 $778.70 $1,045.6464712 G2 $778.70 $1,045.6464713 G2 $778.70 $1,045.6464714 G2 $778.70 $1,045.6464716 A2 $778.70 $1,045.6464718 A2 $778.70 $1,045.6464719 A2 $778.70 $1,045.6464721 A2 $778.70 $1,045.6464722 A2 $778.70 $1,045.6464726 A2 $778.70 $1,045.6464727 N1 $0.00 $0.0064732 A2 $778.70 $1,045.6464734 A2 $778.70 $1,045.6464736 A2 $778.70 $1,045.6464738 A2 $778.70 $1,045.6464740 A2 $778.70 $1,045.6464742 A2 $778.70 $1,045.6464744 A2 $778.70 $1,045.6464746 A2 $778.70 $1,045.6464763 G2 $778.70 $1,045.6464766 G2 $1,899.43 $2,550.5564771 A2 $778.70 $1,045.6464772 A2 $778.70 $1,045.6464774 A2 $778.70 $1,045.6464776 A2 $778.70 $1,045.6464778 N1 $0.00 $0.0064782 A2 $778.70 $1,045.6464783 N1 $0.00 $0.0064784 A2 $778.70 $1,045.6464786 A2 $1,899.43 $2,550.5564787 N1 $0.00 $0.0064788 A2 $778.70 $1,045.6464790 A2 $778.70 $1,045.6464792 A2 $1,899.43 $2,550.5564795 A2 $778.70 $1,045.6464802 A2 $778.70 $1,045.6464820 G2 $778.70 $1,045.6464821 A2 $1,339.58 $1,798.7964822 G2 $1,339.58 $1,798.7964823 G2 $813.76 $1,092.7264831 A2 $1,899.43 $2,550.5564832 N1 $0.00 $0.0064834 A2 $1,899.43 $2,550.5564835 A2 $1,899.43 $2,550.5564836 A2 $1,899.43 $2,550.5564837 N1 $0.00 $0.0064840 A2 $1,899.43 $2,550.55

UPDATED NOVEMBER 2015 Page 56 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

64856 A2 $1,899.43 $2,550.5564857 A2 $1,899.43 $2,550.5564858 A2 $1,899.43 $2,550.5564859 N1 $0.00 $0.0064861 A2 $1,899.43 $2,550.5564862 A2 $1,899.43 $2,550.5564864 A2 $1,899.43 $2,550.5564865 A2 $1,899.43 $2,550.5564872 N1 $0.00 $0.0064874 N1 $0.00 $0.0064876 N1 $0.00 $0.0064885 A2 $1,899.43 $2,550.5564886 A2 $1,899.43 $2,550.5564890 A2 $1,899.43 $2,550.5564891 A2 $1,899.43 $2,550.5564892 A2 $1,899.43 $2,550.5564893 A2 $1,899.43 $2,550.5564895 A2 $1,899.43 $2,550.5564896 A2 $1,899.43 $2,550.5564897 A2 $1,899.43 $2,550.5564898 A2 $1,899.43 $2,550.5564901 N1 $0.00 $0.0064902 N1 $0.00 $0.0064905 A2 $1,899.43 $2,550.5564907 A2 $1,899.43 $2,550.5564910 G2 $1,899.43 $2,550.5565091 A2 $1,403.75 $1,884.9665093 A2 $1,403.75 $1,884.9665101 A2 $1,403.75 $1,884.9665103 A2 $1,403.75 $1,884.9665105 A2 $1,403.75 $1,884.9665110 A2 $1,403.75 $1,884.9665112 A2 $1,403.75 $1,884.9665114 A2 $1,403.75 $1,884.9665125 G2 $783.51 $1,052.1065130 A2 $1,403.75 $1,884.9665135 A2 $1,403.75 $1,884.9665140 A2 $1,403.75 $1,884.9665150 A2 $1,403.75 $1,884.9665155 A2 $1,403.75 $1,884.9665175 A2 $1,403.75 $1,884.9665205 N1 $0.00 $0.0065210 N1 $0.00 $0.0065220 N1 $0.00 $0.0065222 N1 $0.00 $0.0065235 A2 $976.17 $1,310.8065260 A2 $976.17 $1,310.8065265 A2 $976.17 $1,310.8065270 A2 $783.51 $1,052.1065272 A2 $783.51 $1,052.1065275 A2 $1,403.75 $1,884.9665280 A2 $1,793.90 $2,408.8565285 A2 $1,793.90 $2,408.8565286 P3 $459.58 $617.1265290 A2 $1,403.75 $1,884.9665400 A2 $389.59 $523.1465410 A2 $783.51 $1,052.1065420 A2 $783.51 $1,052.1065426 A2 $783.51 $1,052.1065430 N1 $0.00 $0.0065435 P3 $45.49 $61.08

UPDATED NOVEMBER 2015 Page 57 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

65436 P3 $208.48 $279.9565450 G2 $145.97 $196.0165600 P3 $238.92 $320.8265710 A2 $1,793.90 $2,408.8565730 A2 $1,793.90 $2,408.8565750 A2 $1,793.90 $2,408.8565755 A2 $1,793.90 $2,408.8565756 G2 $1,793.90 $2,408.8565757 N1 $0.00 $0.0065770 G2 $2,261.69 $3,037.0065772 A2 $389.59 $523.1465775 A2 $783.51 $1,052.1065778 N1 $0.00 $0.0065779 N1 $0.00 $0.0065780 A2 $1,403.75 $1,884.9665781 A2 $1,793.90 $2,408.8565782 A2 $1,403.75 $1,884.9665785 R2 $1,793.90 $2,408.8565800 A2 $976.17 $1,310.8065810 A2 $976.17 $1,310.8065815 A2 $976.17 $1,310.8065820 A2 $1,793.90 $2,408.8565850 A2 $976.17 $1,310.8065855 P3 $174.81 $234.7365860 P3 $175.52 $235.6965865 A2 $976.17 $1,310.8065870 A2 $976.17 $1,310.8065875 A2 $976.17 $1,310.8065880 A2 $976.17 $1,310.8065900 A2 $976.17 $1,310.8065920 A2 $976.17 $1,310.8065930 A2 $976.17 $1,310.8066020 A2 $976.17 $1,310.8066030 A2 $976.17 $1,310.8066130 A2 $783.51 $1,052.1066150 A2 $1,793.90 $2,408.8566155 A2 $976.17 $1,310.8066160 A2 $976.17 $1,310.8066170 A2 $976.17 $1,310.8066172 A2 $976.17 $1,310.8066174 A2 $976.17 $1,310.8066175 A2 $1,793.90 $2,408.8566179 G2 $1,793.90 $2,408.8566180 A2 $1,793.90 $2,408.8566183 G2 $1,793.90 $2,408.8566184 G2 $976.17 $1,310.8066185 A2 $976.17 $1,310.8066220 A2 $976.17 $1,310.8066225 A2 $976.17 $1,310.8066250 A2 $783.51 $1,052.1066500 A2 $976.17 $1,310.8066505 A2 $976.17 $1,310.8066600 A2 $976.17 $1,310.8066605 A2 $976.17 $1,310.8066625 A2 $976.17 $1,310.8066630 A2 $976.17 $1,310.8066635 A2 $976.17 $1,310.8066680 A2 $976.17 $1,310.8066682 A2 $976.17 $1,310.8066700 A2 $976.17 $1,310.8066710 A2 $783.51 $1,052.10

UPDATED NOVEMBER 2015 Page 58 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

66711 A2 $976.17 $1,310.8066720 A2 $783.51 $1,052.1066740 A2 $783.51 $1,052.1066761 P3 $185.19 $248.6766762 P2 $246.26 $330.6866770 P2 $246.26 $330.6866820 G2 $976.17 $1,310.8066821 A2 $246.26 $330.6866825 A2 $976.17 $1,310.8066830 A2 $976.17 $1,310.8066840 A2 $976.17 $1,310.8066850 A2 $976.17 $1,310.8066852 A2 $1,793.90 $2,408.8566920 A2 $976.17 $1,310.8066930 A2 $1,793.90 $2,408.8566940 A2 $976.17 $1,310.8066982 A2 $976.17 $1,310.8066983 A2 $976.17 $1,310.8066984 A2 $976.17 $1,310.8066985 A2 $976.17 $1,310.8066986 A2 $976.17 $1,310.8066990 N1 $0.00 $0.0067005 A2 $976.17 $1,310.8067010 A2 $976.17 $1,310.8067015 A2 $976.17 $1,310.8067025 A2 $976.17 $1,310.8067027 A2 $2,261.69 $3,037.0067028 P3 $48.00 $64.4567030 A2 $976.17 $1,310.8067031 A2 $246.26 $330.6867036 A2 $976.17 $1,310.8067039 A2 $1,793.90 $2,408.8567040 A2 $1,793.90 $2,408.8567041 G2 $976.17 $1,310.8067042 G2 $1,793.90 $2,408.8567043 G2 $1,793.90 $2,408.8567101 P3 $457.43 $614.2467105 P2 $246.26 $330.6867107 G2 $1,793.90 $2,408.8567108 G2 $1,793.90 $2,408.8567110 P3 $452.77 $607.9867112 D5 $0.00 $0.0067113 G2 $1,793.90 $2,408.8567115 A2 $976.17 $1,310.8067120 A2 $976.17 $1,310.8067121 A2 $976.17 $1,310.8067141 A2 $145.97 $196.0167145 P2 $246.26 $330.6867208 P2 $145.97 $196.0167210 P2 $246.26 $330.6867218 A2 $1,403.75 $1,884.9667220 P2 $246.26 $330.6867221 P3 $158.69 $213.0967225 N1 $0.00 $0.0067227 G2 $1,403.75 $1,884.9667228 P3 $177.67 $238.5867229 R2 $246.26 $330.6867250 A2 $783.51 $1,052.1067255 A2 $976.17 $1,310.8067311 A2 $783.51 $1,052.1067312 A2 $1,403.75 $1,884.96

UPDATED NOVEMBER 2015 Page 59 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

67314 A2 $783.51 $1,052.1067316 A2 $783.51 $1,052.1067318 A2 $783.51 $1,052.1067320 N1 $0.00 $0.0067331 N1 $0.00 $0.0067332 N1 $0.00 $0.0067334 N1 $0.00 $0.0067335 N1 $0.00 $0.0067340 N1 $0.00 $0.0067343 A2 $783.51 $1,052.1067345 P3 $124.30 $166.9167346 A2 $1,403.75 $1,884.9667400 A2 $1,403.75 $1,884.9667405 A2 $783.51 $1,052.1067412 A2 $783.51 $1,052.1067413 A2 $783.51 $1,052.1067414 G2 $1,403.75 $1,884.9667415 A2 $783.51 $1,052.1067420 A2 $1,403.75 $1,884.9667430 A2 $1,403.75 $1,884.9667440 A2 $1,403.75 $1,884.9667445 A2 $1,403.75 $1,884.9667450 A2 $1,403.75 $1,884.9667500 G2 $145.97 $196.0167505 P3 $41.91 $56.2867515 P3 $44.78 $60.1367550 A2 $1,403.75 $1,884.9667560 A2 $1,403.75 $1,884.9667570 A2 $1,403.75 $1,884.9667700 P2 $145.97 $196.0167710 P3 $185.19 $248.6767715 A2 $783.51 $1,052.1067800 P3 $74.51 $100.0567801 P3 $90.98 $122.1767805 P3 $117.13 $157.2867808 A2 $783.51 $1,052.1067810 P3 $126.81 $170.2867820 N1 $0.00 $0.0067825 P3 $75.22 $101.0167830 A2 $389.59 $523.1467835 A2 $783.51 $1,052.1067840 P3 $198.09 $266.0067850 P3 $148.30 $199.1467875 G2 $389.59 $523.1467880 A2 $783.51 $1,052.1067882 A2 $783.51 $1,052.1067900 A2 $783.51 $1,052.1067901 A2 $783.51 $1,052.1067902 A2 $1,403.75 $1,884.9667903 A2 $783.51 $1,052.1067904 A2 $783.51 $1,052.1067906 A2 $1,403.75 $1,884.9667908 A2 $783.51 $1,052.1067909 A2 $783.51 $1,052.1067911 A2 $783.51 $1,052.1067912 A2 $783.51 $1,052.1067914 A2 $783.51 $1,052.1067915 P3 $218.51 $293.4267916 A2 $783.51 $1,052.1067917 A2 $783.51 $1,052.1067921 A2 $783.51 $1,052.10

UPDATED NOVEMBER 2015 Page 60 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

67922 P3 $215.64 $289.5667923 A2 $783.51 $1,052.1067924 A2 $783.51 $1,052.1067930 P3 $227.82 $305.9267935 A2 $783.51 $1,052.1067938 P2 $145.97 $196.0167950 A2 $783.51 $1,052.1067961 A2 $783.51 $1,052.1067966 A2 $783.51 $1,052.1067971 A2 $783.51 $1,052.1067973 A2 $783.51 $1,052.1067974 A2 $1,403.75 $1,884.9667975 A2 $783.51 $1,052.1068020 P3 $66.63 $89.4768040 P3 $31.16 $41.8468100 P3 $120.00 $161.1468110 P3 $158.33 $212.6168115 A2 $783.51 $1,052.1068130 A2 $783.51 $1,052.1068135 P3 $86.33 $115.9268200 N1 $0.00 $0.0068320 A2 $783.51 $1,052.1068325 A2 $1,403.75 $1,884.9668326 A2 $1,403.75 $1,884.9668328 A2 $783.51 $1,052.1068330 A2 $976.17 $1,310.8068335 A2 $1,403.75 $1,884.9668340 A2 $783.51 $1,052.1068360 A2 $1,403.75 $1,884.9668362 A2 $783.51 $1,052.1068371 A2 $783.51 $1,052.1068400 P3 $220.30 $295.8268420 P3 $234.98 $315.5368440 P3 $65.55 $88.0268500 A2 $1,403.75 $1,884.9668505 A2 $1,403.75 $1,884.9668510 A2 $783.51 $1,052.1068520 A2 $1,403.75 $1,884.9668525 A2 $783.51 $1,052.1068530 P2 $145.97 $196.0168540 A2 $783.51 $1,052.1068550 A2 $1,403.75 $1,884.9668700 A2 $783.51 $1,052.1068705 P2 $145.97 $196.0168720 A2 $1,403.75 $1,884.9668745 A2 $1,403.75 $1,884.9668750 A2 $1,403.75 $1,884.9668760 P3 $135.40 $181.8268761 P3 $95.28 $127.9468770 A2 $783.51 $1,052.1068801 N1 $0.00 $0.0068810 A2 $145.97 $196.0168811 A2 $783.51 $1,052.1068815 A2 $783.51 $1,052.1068816 G2 $783.51 $1,052.1068840 P3 $79.88 $107.2668850 N1 $0.00 $0.0069000 P2 $127.65 $171.4169005 P3 $132.54 $177.9769020 P2 $127.65 $171.4169100 P3 $69.49 $93.31

UPDATED NOVEMBER 2015 Page 61 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

69105 P3 $109.61 $147.1869110 A2 $790.85 $1,061.9569120 A2 $904.15 $1,214.0969140 A2 $1,994.21 $2,677.8369145 A2 $790.85 $1,061.9569150 A2 $904.15 $1,214.0969200 N1 $0.00 $0.0069205 A2 $526.74 $707.3169209 N1 $0.00 $0.0069210 N1 $0.00 $0.0069220 N1 $0.00 $0.0069222 P3 $166.57 $223.6769300 A2 $904.15 $1,214.0969310 A2 $1,994.21 $2,677.8369320 A2 $1,994.21 $2,677.8369420 P3 $140.42 $188.5669421 A2 $904.15 $1,214.0969424 P3 $96.36 $129.3969433 P3 $144.00 $193.3669436 A2 $904.15 $1,214.0969440 A2 $1,994.21 $2,677.8369450 A2 $1,994.21 $2,677.8369501 A2 $1,994.21 $2,677.8369502 A2 $1,994.21 $2,677.8369505 A2 $1,994.21 $2,677.8369511 A2 $1,994.21 $2,677.8369530 A2 $1,994.21 $2,677.8369540 P3 $163.70 $219.8269550 A2 $1,994.21 $2,677.8369552 A2 $1,994.21 $2,677.8369601 A2 $1,994.21 $2,677.8369602 A2 $1,994.21 $2,677.8369603 A2 $1,994.21 $2,677.8369604 A2 $1,994.21 $2,677.8369605 A2 $1,994.21 $2,677.8369610 P3 $213.13 $286.1969620 A2 $904.15 $1,214.0969631 A2 $1,994.21 $2,677.8369632 A2 $1,994.21 $2,677.8369633 A2 $1,994.21 $2,677.8369635 A2 $1,994.21 $2,677.8369636 A2 $1,994.21 $2,677.8369637 A2 $1,994.21 $2,677.8369641 A2 $1,994.21 $2,677.8369642 A2 $1,994.21 $2,677.8369643 A2 $1,994.21 $2,677.8369644 A2 $1,994.21 $2,677.8369645 A2 $1,994.21 $2,677.8369646 A2 $1,994.21 $2,677.8369650 A2 $1,994.21 $2,677.8369660 A2 $1,994.21 $2,677.8369661 A2 $1,994.21 $2,677.8369662 A2 $1,994.21 $2,677.8369666 A2 $904.15 $1,214.0969667 A2 $904.15 $1,214.0969670 A2 $1,994.21 $2,677.8369676 A2 $904.15 $1,214.0969700 A2 $385.63 $517.8269711 A2 $1,994.21 $2,677.8369714 J8 $7,886.65 $10,590.1969715 J8 $7,886.65 $10,590.19

UPDATED NOVEMBER 2015 Page 62 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

69717 G2 $2,486.22 $3,338.5069718 G2 $3,532.70 $4,743.7169720 A2 $1,994.21 $2,677.8369740 A2 $1,994.21 $2,677.8369745 A2 $1,994.21 $2,677.8369801 P3 $117.49 $157.7769805 A2 $1,994.21 $2,677.8369806 A2 $1,994.21 $2,677.8369820 A2 $1,994.21 $2,677.8369840 A2 $1,994.21 $2,677.8369905 A2 $1,994.21 $2,677.8369910 A2 $1,994.21 $2,677.8369915 A2 $1,994.21 $2,677.8369930 J8 $28,266.61 $37,956.4069990 N1 $0.00 $0.0070010 N1 $0.00 $0.0070015 N1 $0.00 $0.0070030 N1 $0.00 $0.0070100 N1 $0.00 $0.0070110 N1 $0.00 $0.0070120 N1 $0.00 $0.0070130 N1 $0.00 $0.0070134 N1 $0.00 $0.0070140 N1 $0.00 $0.0070150 N1 $0.00 $0.0070160 N1 $0.00 $0.0070170 N1 $0.00 $0.0070190 N1 $0.00 $0.0070200 N1 $0.00 $0.0070210 N1 $0.00 $0.0070220 N1 $0.00 $0.0070240 N1 $0.00 $0.0070250 N1 $0.00 $0.0070260 N1 $0.00 $0.0070300 N1 $0.00 $0.0070310 N1 $0.00 $0.0070320 N1 $0.00 $0.0070328 N1 $0.00 $0.0070330 N1 $0.00 $0.0070332 N1 $0.00 $0.0070336 Z2 $152.96 $205.3970350 N1 $0.00 $0.0070355 N1 $0.00 $0.0070360 N1 $0.00 $0.0070370 N1 $0.00 $0.0070371 N1 $0.00 $0.0070373 D5 $0.00 $0.0070380 N1 $0.00 $0.0070390 N1 $0.00 $0.0070450 Z2 $62.90 $84.4670460 Z3 $104.95 $140.9370470 Z3 $127.52 $171.2370480 Z2 $62.90 $84.4670481 Z2 $132.45 $177.8570482 Z2 $132.45 $177.8570486 Z2 $62.90 $84.4670487 Z3 $111.40 $149.5970488 Z2 $132.45 $177.8570490 Z2 $62.90 $84.4670491 Z2 $132.45 $177.8570492 Z2 $132.45 $177.85

UPDATED NOVEMBER 2015 Page 63 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

70496 Z2 $132.45 $177.8570498 Z2 $132.45 $177.8570540 Z2 $152.96 $205.3970542 Z2 $254.05 $341.1470543 Z2 $254.05 $341.1470544 Z2 $152.96 $205.3970545 Z2 $254.05 $341.1470546 Z2 $254.05 $341.1470547 Z2 $152.96 $205.3970548 Z2 $254.05 $341.1470549 Z2 $254.05 $341.1470551 Z2 $152.96 $205.3970552 Z3 $229.61 $308.3270553 Z2 $254.05 $341.1470554 Z2 $152.96 $205.3970555 Z2 $152.96 $205.3970557 Z2 $152.96 $205.3970558 Z2 $254.05 $341.1470559 Z2 $1,520.33 $2,041.5071010 Z3 $12.90 $17.3271015 Z3 $16.48 $22.1371020 Z3 $16.48 $22.1371021 N1 $0.00 $0.0071022 N1 $0.00 $0.0071023 N1 $0.00 $0.0071030 N1 $0.00 $0.0071034 N1 $0.00 $0.0071035 N1 $0.00 $0.0071100 N1 $0.00 $0.0071101 N1 $0.00 $0.0071110 N1 $0.00 $0.0071111 N1 $0.00 $0.0071120 N1 $0.00 $0.0071130 N1 $0.00 $0.0071250 Z2 $62.90 $84.4671260 Z2 $132.45 $177.8571270 Z2 $194.44 $261.0971275 Z2 $132.45 $177.8571550 Z2 $152.96 $205.3971551 Z2 $254.05 $341.1471552 Z2 $254.05 $341.1472010 D5 $0.00 $0.0072020 N1 $0.00 $0.0072040 N1 $0.00 $0.0072050 N1 $0.00 $0.0072052 N1 $0.00 $0.0072069 D5 $0.00 $0.0072070 N1 $0.00 $0.0072072 N1 $0.00 $0.0072074 N1 $0.00 $0.0072080 N1 $0.00 $0.0072083 Z2 $107.35 $144.1572084 Z2 $107.35 $144.1572090 D5 $0.00 $0.0072100 N1 $0.00 $0.0072110 N1 $0.00 $0.0072114 N1 $0.00 $0.0072120 N1 $0.00 $0.0072125 Z2 $62.90 $84.4672126 Z3 $167.64 $225.1172127 Z2 $132.45 $177.85

UPDATED NOVEMBER 2015 Page 64 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

72128 Z2 $62.90 $84.4672129 Z2 $132.45 $177.8572130 Z2 $132.45 $177.8572131 Z2 $62.90 $84.4672132 Z3 $166.92 $224.1472133 Z2 $132.45 $177.8572141 Z3 $148.66 $199.6272142 Z3 $234.27 $314.5872146 Z3 $149.01 $200.0972147 Z3 $231.40 $310.7272148 Z3 $147.94 $198.6572149 Z3 $230.33 $309.2972156 Z2 $254.05 $341.1472157 Z2 $254.05 $341.1472158 Z2 $254.05 $341.1472170 N1 $0.00 $0.0072190 N1 $0.00 $0.0072191 Z2 $132.45 $177.8572192 Z2 $62.90 $84.4672193 Z2 $132.45 $177.8572194 Z2 $132.45 $177.8572195 Z2 $152.96 $205.3972196 Z2 $254.05 $341.1472197 Z2 $254.05 $341.1472200 N1 $0.00 $0.0072202 N1 $0.00 $0.0072220 N1 $0.00 $0.0072240 N1 $0.00 $0.0072255 N1 $0.00 $0.0072265 N1 $0.00 $0.0072270 N1 $0.00 $0.0072275 N1 $0.00 $0.0072285 N1 $0.00 $0.0072295 N1 $0.00 $0.0073000 N1 $0.00 $0.0073010 N1 $0.00 $0.0073020 N1 $0.00 $0.0073030 N1 $0.00 $0.0073040 N1 $0.00 $0.0073050 N1 $0.00 $0.0073060 N1 $0.00 $0.0073070 N1 $0.00 $0.0073080 N1 $0.00 $0.0073085 N1 $0.00 $0.0073090 N1 $0.00 $0.0073092 N1 $0.00 $0.0073100 N1 $0.00 $0.0073110 N1 $0.00 $0.0073115 N1 $0.00 $0.0073120 N1 $0.00 $0.0073130 N1 $0.00 $0.0073140 N1 $0.00 $0.0073200 Z2 $62.90 $84.4673201 Z3 $164.42 $220.7873202 Z2 $132.45 $177.8573206 Z2 $132.45 $177.8573218 Z2 $152.96 $205.3973219 Z2 $254.05 $341.1473220 Z2 $254.05 $341.1473221 Z2 $152.96 $205.3973222 Z2 $254.05 $341.14

UPDATED NOVEMBER 2015 Page 65 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

73223 Z2 $254.05 $341.1473500 D5 $0.00 $0.0073510 D5 $0.00 $0.0073520 D5 $0.00 $0.0073525 N1 $0.00 $0.0073530 D5 $0.00 $0.0073540 D5 $0.00 $0.0073550 D5 $0.00 $0.0073560 N1 $0.00 $0.0073562 N1 $0.00 $0.0073564 N1 $0.00 $0.0073565 N1 $0.00 $0.0073580 N1 $0.00 $0.0073590 N1 $0.00 $0.0073592 N1 $0.00 $0.0073600 N1 $0.00 $0.0073610 N1 $0.00 $0.0073615 N1 $0.00 $0.0073620 N1 $0.00 $0.0073630 N1 $0.00 $0.0073650 N1 $0.00 $0.0073660 N1 $0.00 $0.0073700 Z2 $62.90 $84.4673701 Z2 $132.45 $177.8573702 Z2 $132.45 $177.8573706 Z2 $132.45 $177.8573718 Z2 $152.96 $205.3973719 Z2 $254.05 $341.1473720 Z2 $254.05 $341.1473721 Z2 $152.96 $205.3973722 Z2 $254.05 $341.1473723 Z2 $254.05 $341.1474000 N1 $0.00 $0.0074010 N1 $0.00 $0.0074020 N1 $0.00 $0.0074022 N1 $0.00 $0.0074150 Z2 $62.90 $84.4674160 Z2 $132.45 $177.8574170 Z2 $132.45 $177.8574174 Z2 $194.44 $261.0974175 Z2 $132.45 $177.8574176 Z2 $107.35 $144.1574177 Z2 $194.44 $261.0974178 Z2 $194.44 $261.0974181 Z2 $152.96 $205.3974182 Z2 $254.05 $341.1474183 Z2 $254.05 $341.1474190 N1 $0.00 $0.0074210 N1 $0.00 $0.0074220 N1 $0.00 $0.0074230 N1 $0.00 $0.0074235 N1 $0.00 $0.0074240 Z2 $56.31 $75.6174241 Z2 $56.31 $75.6174245 Z2 $107.35 $144.1574246 Z2 $56.31 $75.6174247 Z2 $56.31 $75.6174249 Z2 $107.35 $144.1574250 Z2 $56.31 $75.6174251 Z2 $107.35 $144.1574260 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 66 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

74261 Z2 $62.90 $84.4674262 Z2 $132.45 $177.8574270 N1 $0.00 $0.0074280 Z2 $107.35 $144.1574283 Z2 $107.35 $144.1574290 N1 $0.00 $0.0074300 N1 $0.00 $0.0074301 N1 $0.00 $0.0074305 D5 $0.00 $0.0074320 D5 $0.00 $0.0074327 D5 $0.00 $0.0074328 N1 $0.00 $0.0074329 N1 $0.00 $0.0074330 N1 $0.00 $0.0074340 N1 $0.00 $0.0074355 N1 $0.00 $0.0074360 N1 $0.00 $0.0074363 N1 $0.00 $0.0074400 Z2 $107.35 $144.1574410 Z2 $107.35 $144.1574415 Z2 $107.35 $144.1574420 Z2 $196.67 $264.0974425 N1 $0.00 $0.0074430 N1 $0.00 $0.0074440 N1 $0.00 $0.0074445 N1 $0.00 $0.0074450 N1 $0.00 $0.0074455 N1 $0.00 $0.0074470 N1 $0.00 $0.0074475 D5 $0.00 $0.0074480 D5 $0.00 $0.0074485 N1 $0.00 $0.0074710 N1 $0.00 $0.0074712 Z2 $152.96 $205.3974740 N1 $0.00 $0.0074742 N1 $0.00 $0.0074775 Z2 $107.35 $144.1575557 Z2 $152.96 $205.3975559 Z2 $246.80 $331.4075561 Z2 $254.05 $341.1475563 Z3 $354.27 $475.7175565 N1 $0.00 $0.0075571 N1 $0.00 $0.0075572 Z2 $132.45 $177.8575573 Z2 $132.45 $177.8575574 Z2 $132.45 $177.8575600 N1 $0.00 $0.0075605 N1 $0.00 $0.0075625 N1 $0.00 $0.0075630 N1 $0.00 $0.0075635 N1 $0.00 $0.0075658 N1 $0.00 $0.0075705 N1 $0.00 $0.0075710 N1 $0.00 $0.0075716 N1 $0.00 $0.0075726 N1 $0.00 $0.0075731 N1 $0.00 $0.0075733 N1 $0.00 $0.0075736 N1 $0.00 $0.0075741 N1 $0.00 $0.0075743 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 67 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

75746 N1 $0.00 $0.0075756 N1 $0.00 $0.0075774 N1 $0.00 $0.0075791 N1 $0.00 $0.0075801 N1 $0.00 $0.0075803 N1 $0.00 $0.0075805 N1 $0.00 $0.0075807 N1 $0.00 $0.0075809 N1 $0.00 $0.0075810 N1 $0.00 $0.0075820 N1 $0.00 $0.0075822 N1 $0.00 $0.0075825 N1 $0.00 $0.0075827 N1 $0.00 $0.0075831 N1 $0.00 $0.0075833 N1 $0.00 $0.0075840 N1 $0.00 $0.0075842 N1 $0.00 $0.0075860 N1 $0.00 $0.0075870 N1 $0.00 $0.0075872 N1 $0.00 $0.0075880 N1 $0.00 $0.0075885 N1 $0.00 $0.0075887 N1 $0.00 $0.0075889 N1 $0.00 $0.0075891 N1 $0.00 $0.0075893 N1 $0.00 $0.0075894 N1 $0.00 $0.0075896 D5 $0.00 $0.0075898 N1 $0.00 $0.0075901 N1 $0.00 $0.0075902 N1 $0.00 $0.0075945 D5 $0.00 $0.0075946 D5 $0.00 $0.0075962 N1 $0.00 $0.0075964 N1 $0.00 $0.0075966 N1 $0.00 $0.0075968 N1 $0.00 $0.0075970 N1 $0.00 $0.0075978 N1 $0.00 $0.0075980 D5 $0.00 $0.0075982 D5 $0.00 $0.0075984 N1 $0.00 $0.0075989 N1 $0.00 $0.0076000 Z3 $38.33 $51.4776001 N1 $0.00 $0.0076010 N1 $0.00 $0.0076080 N1 $0.00 $0.0076098 N1 $0.00 $0.0076100 N1 $0.00 $0.0076101 Z2 $56.31 $75.6176102 Z2 $107.35 $144.1576120 N1 $0.00 $0.0076125 N1 $0.00 $0.0076376 N1 $0.00 $0.0076377 N1 $0.00 $0.0076380 N1 $0.00 $0.0076496 N1 $0.00 $0.0076497 N1 $0.00 $0.0076498 Z2 $152.96 $205.3976499 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 68 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

76506 N1 $0.00 $0.0076510 N1 $0.00 $0.0076511 N1 $0.00 $0.0076512 N1 $0.00 $0.0076513 N1 $0.00 $0.0076514 N1 $0.00 $0.0076516 N1 $0.00 $0.0076519 N1 $0.00 $0.0076529 N1 $0.00 $0.0076536 N1 $0.00 $0.0076604 N1 $0.00 $0.0076641 N1 $0.00 $0.0076642 N1 $0.00 $0.0076700 Z3 $82.39 $110.6376705 Z3 $61.97 $83.2176770 Z3 $76.66 $102.9476775 N1 $0.00 $0.0076776 Z2 $85.88 $115.3276800 N1 $0.00 $0.0076801 Z3 $73.43 $98.6076802 N1 $0.00 $0.0076805 Z2 $85.88 $115.3276810 N1 $0.00 $0.0076811 Z3 $84.54 $113.5276812 N1 $0.00 $0.0076813 N1 $0.00 $0.0076814 N1 $0.00 $0.0076815 N1 $0.00 $0.0076816 N1 $0.00 $0.0076817 N1 $0.00 $0.0076818 Z3 $67.70 $90.9176819 Z3 $49.79 $66.8676820 N1 $0.00 $0.0076821 N1 $0.00 $0.0076825 Z3 $194.51 $261.1976826 Z3 $123.58 $165.9476827 N1 $0.00 $0.0076828 N1 $0.00 $0.0076830 Z2 $85.88 $115.3276831 Z3 $82.39 $110.6376856 Z3 $75.58 $101.4976857 Z3 $22.57 $30.3176870 N1 $0.00 $0.0076872 Z3 $60.54 $81.2976873 Z2 $85.88 $115.3276881 Z3 $83.82 $112.5576882 N1 $0.00 $0.0076885 N1 $0.00 $0.0076886 N1 $0.00 $0.0076930 N1 $0.00 $0.0076932 N1 $0.00 $0.0076936 Z2 $123.21 $165.4576937 N1 $0.00 $0.0076940 N1 $0.00 $0.0076941 N1 $0.00 $0.0076942 N1 $0.00 $0.0076945 N1 $0.00 $0.0076946 N1 $0.00 $0.0076948 N1 $0.00 $0.0076965 N1 $0.00 $0.0076970 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 69 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

76975 N1 $0.00 $0.0076977 Z3 $3.94 $5.2976998 N1 $0.00 $0.0076999 N1 $0.00 $0.0077001 N1 $0.00 $0.0077002 N1 $0.00 $0.0077003 N1 $0.00 $0.0077011 N1 $0.00 $0.0077012 N1 $0.00 $0.0077013 N1 $0.00 $0.0077014 N1 $0.00 $0.0077021 N1 $0.00 $0.0077022 N1 $0.00 $0.0077053 N1 $0.00 $0.0077054 N1 $0.00 $0.0077071 N1 $0.00 $0.0077072 N1 $0.00 $0.0077073 N1 $0.00 $0.0077074 N1 $0.00 $0.0077075 N1 $0.00 $0.0077076 N1 $0.00 $0.0077077 N1 $0.00 $0.0077078 Z2 $34.00 $45.6677080 Z3 $30.81 $41.3777081 Z3 $16.84 $22.6177084 Z2 $152.96 $205.3977085 N1 $0.00 $0.0077086 N1 $0.00 $0.0077280 Z2 $93.19 $125.1477285 Z2 $163.15 $219.0877290 Z2 $163.15 $219.0877295 Z3 $269.37 $361.7177299 Z2 $60.05 $80.6477300 Z3 $34.03 $45.7077301 Z2 $574.18 $771.0177306 Z3 $77.01 $103.4177307 Z3 $138.98 $186.6277316 Z2 $60.05 $80.6477317 Z3 $150.81 $202.5177318 Z2 $163.15 $219.0877321 Z3 $43.70 $58.6877331 Z3 $18.63 $25.0277332 Z3 $54.81 $73.6077333 Z3 $9.31 $12.5077334 Z3 $89.19 $119.7677336 Z2 $60.05 $80.6477338 Z2 $163.15 $219.0877370 Z2 $93.19 $125.1477385 Z2 $282.68 $379.5877386 Z2 $282.68 $379.5877387 N1 $0.00 $0.0077399 Z2 $60.05 $80.6477401 Z3 $24.36 $32.7177402 Z2 $61.70 $82.8577407 Z2 $61.70 $82.8577412 Z2 $108.68 $145.9477417 N1 $0.00 $0.0077422 Z3 $25.79 $34.6377423 Z3 $51.22 $68.7877424 Z2 $2,373.02 $3,186.4977425 Z2 $2,373.02 $3,186.49

UPDATED NOVEMBER 2015 Page 70 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

77435 N1 $0.00 $0.0077470 Z3 $47.64 $63.9777520 Z2 $282.68 $379.5877522 Z2 $643.45 $864.0277523 Z2 $643.45 $864.0277525 Z2 $643.45 $864.0277600 Z2 $108.68 $145.9477605 Z2 $389.31 $522.7777610 Z2 $282.68 $379.5877615 Z2 $282.68 $379.5877620 Z2 $282.68 $379.5877750 Z2 $108.68 $145.9477761 Z3 $192.72 $258.7877762 Z3 $221.01 $296.7777763 Z3 $285.13 $382.8777767 Z2 $108.68 $145.9477768 Z2 $108.68 $145.9477770 Z2 $389.31 $522.7777771 Z2 $389.31 $522.7777772 Z2 $389.31 $522.7777776 D5 $0.00 $0.0077777 D5 $0.00 $0.0077778 Z3 $367.16 $493.0277785 D5 $0.00 $0.0077786 D5 $0.00 $0.0077787 D5 $0.00 $0.0077789 Z3 $60.54 $81.2977790 N1 $0.00 $0.0077799 Z2 $61.70 $82.8578012 Z2 $186.01 $249.7778013 Z2 $186.01 $249.7778014 Z2 $186.01 $249.7778015 Z2 $186.01 $249.7778016 Z2 $186.01 $249.7778018 Z2 $186.01 $249.7778020 N1 $0.00 $0.0078070 Z2 $186.01 $249.7778071 Z2 $186.01 $249.7778072 Z2 $246.80 $331.4078075 Z2 $619.83 $832.3178099 Z2 $186.01 $249.7778102 Z2 $186.01 $249.7778103 Z2 $186.01 $249.7778104 Z2 $186.01 $249.7778110 Z2 $186.01 $249.7778111 Z2 $186.01 $249.7778120 Z2 $186.01 $249.7778121 Z2 $186.01 $249.7778122 Z2 $246.80 $331.4078130 Z2 $186.01 $249.7778135 Z2 $186.01 $249.7778140 Z2 $186.01 $249.7778185 Z2 $186.01 $249.7778190 Z2 $619.83 $832.3178191 Z2 $186.01 $249.7778195 Z2 $186.01 $249.7778199 Z2 $186.01 $249.7778201 Z2 $186.01 $249.7778202 Z2 $186.01 $249.7778205 Z2 $186.01 $249.7778206 Z2 $186.01 $249.77

UPDATED NOVEMBER 2015 Page 71 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

78215 Z2 $186.01 $249.7778216 Z2 $186.01 $249.7778226 Z2 $186.01 $249.7778227 Z2 $186.01 $249.7778230 Z2 $186.01 $249.7778231 Z2 $186.01 $249.7778232 Z2 $186.01 $249.7778258 Z2 $186.01 $249.7778261 Z2 $186.01 $249.7778262 Z2 $186.01 $249.7778264 Z2 $186.01 $249.7778265 Z2 $186.01 $249.7778266 Z2 $246.80 $331.4078270 Z2 $186.01 $249.7778271 Z2 $186.01 $249.7778272 Z2 $186.01 $249.7778278 Z2 $186.01 $249.7778282 Z2 $186.01 $249.7778290 Z2 $186.01 $249.7778291 Z2 $186.01 $249.7778299 Z2 $186.01 $249.7778300 Z2 $186.01 $249.7778305 Z2 $186.01 $249.7778306 Z2 $186.01 $249.7778315 Z2 $186.01 $249.7778320 Z2 $186.01 $249.7778399 Z2 $186.01 $249.7778414 Z2 $246.80 $331.4078428 Z2 $186.01 $249.7778445 Z2 $186.01 $249.7778451 Z2 $619.83 $832.3178452 Z2 $619.83 $832.3178453 Z2 $246.80 $331.4078454 Z2 $619.83 $832.3178456 Z2 $619.83 $832.3178457 Z2 $246.80 $331.4078458 Z2 $186.01 $249.7778459 Z2 $718.65 $965.0078466 Z2 $186.01 $249.7778468 Z2 $186.01 $249.7778469 Z2 $246.80 $331.4078472 Z2 $186.01 $249.7778473 Z2 $186.01 $249.7778481 Z2 $246.80 $331.4078483 Z2 $246.80 $331.4078491 Z2 $718.65 $965.0078492 Z2 $718.65 $965.0078494 Z2 $186.01 $249.7778496 N1 $0.00 $0.0078499 Z2 $186.01 $249.7778579 Z2 $186.01 $249.7778580 Z2 $186.01 $249.7778582 Z2 $246.80 $331.4078597 Z2 $186.01 $249.7778598 Z2 $246.80 $331.4078599 Z2 $186.01 $249.7778600 Z2 $186.01 $249.7778601 Z2 $186.01 $249.7778605 Z2 $246.80 $331.4078606 Z2 $246.80 $331.4078607 Z2 $619.83 $832.31

UPDATED NOVEMBER 2015 Page 72 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

78608 Z2 $718.65 $965.0078610 Z2 $186.01 $249.7778630 Z2 $246.80 $331.4078635 Z2 $246.80 $331.4078645 Z2 $186.01 $249.7778647 Z2 $619.83 $832.3178650 Z2 $619.83 $832.3178660 Z2 $186.01 $249.7778699 Z2 $186.01 $249.7778700 Z2 $186.01 $249.7778701 Z2 $186.01 $249.7778707 Z2 $246.80 $331.4078708 Z2 $246.80 $331.4078709 Z2 $246.80 $331.4078710 Z2 $246.80 $331.4078725 Z2 $139.78 $187.7078730 N1 $0.00 $0.0078740 Z2 $186.01 $249.7778761 Z2 $186.01 $249.7778799 Z2 $186.01 $249.7778800 Z2 $186.01 $249.7778801 Z2 $186.01 $249.7778802 Z2 $246.80 $331.4078803 Z2 $246.80 $331.4078804 Z2 $619.83 $832.3178805 Z2 $619.83 $832.3178806 Z2 $619.83 $832.3178807 Z2 $246.80 $331.4078808 N1 $0.00 $0.0078811 Z2 $718.65 $965.0078812 Z2 $718.65 $965.0078813 Z2 $718.65 $965.0078814 Z2 $718.65 $965.0078815 Z2 $718.65 $965.0078816 Z2 $718.65 $965.0078999 Z2 $186.01 $249.7779005 Z3 $49.07 $65.8979101 Z3 $48.00 $64.4579200 Z3 $58.39 $78.4179300 Z2 $139.78 $187.7079403 Z3 $82.03 $110.1579440 Z3 $50.15 $67.3479445 Z2 $139.78 $187.7079999 Z2 $139.78 $187.7090371 K2 $110.39 $148.2390375 K2 $285.93 $383.9590376 K2 $252.95 $339.6690378 K2 $1,947.49 $2,615.0990385 N1 $0.00 $0.0090396 K2 $1,202.24 $1,614.3790476 N1 $0.00 $0.0090581 N1 $0.00 $0.0090585 K2 $122.88 $165.0090620 K2 $155.70 $209.0790621 K2 $122.70 $164.7690630 L1 $0.00 $0.0090632 N1 $0.00 $0.0090633 N1 $0.00 $0.0090634 N1 $0.00 $0.0090636 N1 $0.00 $0.0090645 D5 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 73 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

90646 D5 $0.00 $0.0090647 N1 $0.00 $0.0090648 N1 $0.00 $0.0090654 L1 $0.00 $0.0090655 L1 $0.00 $0.0090656 L1 $0.00 $0.0090657 L1 $0.00 $0.0090660 L1 $0.00 $0.0090661 L1 $0.00 $0.0090662 L1 $0.00 $0.0090669 D5 $0.00 $0.0090670 L1 $0.00 $0.0090672 L1 $0.00 $0.0090673 L1 $0.00 $0.0090675 K2 $263.54 $353.8890676 K2 $172.30 $231.3690680 N1 $0.00 $0.0090685 L1 $0.00 $0.0090686 L1 $0.00 $0.0090687 L1 $0.00 $0.0090688 L1 $0.00 $0.0090690 N1 $0.00 $0.0090691 N1 $0.00 $0.0090692 D5 $0.00 $0.0090696 N1 $0.00 $0.0090698 N1 $0.00 $0.0090700 N1 $0.00 $0.0090702 N1 $0.00 $0.0090703 D5 $0.00 $0.0090704 D5 $0.00 $0.0090705 D5 $0.00 $0.0090707 N1 $0.00 $0.0090708 D5 $0.00 $0.0090710 N1 $0.00 $0.0090712 D5 $0.00 $0.0090713 N1 $0.00 $0.0090714 N1 $0.00 $0.0090715 N1 $0.00 $0.0090717 N1 $0.00 $0.0090719 D5 $0.00 $0.0090720 D5 $0.00 $0.0090721 D5 $0.00 $0.0090732 L1 $0.00 $0.0090733 K2 $106.49 $142.9990734 K2 $101.36 $136.1190735 D5 $0.00 $0.0090740 F4 $0.00 $0.0090743 F4 $0.00 $0.0090744 F4 $0.00 $0.0090746 F4 $0.00 $0.0090747 F4 $0.00 $0.0090749 N1 $0.00 $0.0091035 Z2 $221.72 $297.7391200 N1 $0.00 $0.0092071 N1 $0.00 $0.0092072 N1 $0.00 $0.0095940 N1 $0.00 $0.0095941 N1 $0.00 $0.00A4218 N1 $0.00 $0.00A4220 N1 $0.00 $0.00A4248 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 74 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

A4262 N1 $0.00 $0.00A4263 N1 $0.00 $0.00A4270 N1 $0.00 $0.00A4300 N1 $0.00 $0.00A4301 N1 $0.00 $0.00A4305 N1 $0.00 $0.00A4306 N1 $0.00 $0.00A4641 N1 $0.00 $0.00A4642 N1 $0.00 $0.00A4648 N1 $0.00 $0.00A4650 N1 $0.00 $0.00A9500 N1 $0.00 $0.00A9501 N1 $0.00 $0.00A9502 N1 $0.00 $0.00A9503 N1 $0.00 $0.00A9504 N1 $0.00 $0.00A9505 N1 $0.00 $0.00A9507 N1 $0.00 $0.00A9508 N1 $0.00 $0.00A9509 N1 $0.00 $0.00A9510 N1 $0.00 $0.00A9512 N1 $0.00 $0.00A9516 N1 $0.00 $0.00A9520 N1 $0.00 $0.00A9521 N1 $0.00 $0.00A9524 N1 $0.00 $0.00A9526 N1 $0.00 $0.00A9527 H2 $7.14 $9.59A9528 N1 $0.00 $0.00A9529 N1 $0.00 $0.00A9531 N1 $0.00 $0.00A9532 N1 $0.00 $0.00A9536 N1 $0.00 $0.00A9537 N1 $0.00 $0.00A9538 N1 $0.00 $0.00A9539 N1 $0.00 $0.00A9540 N1 $0.00 $0.00A9541 N1 $0.00 $0.00A9542 N1 $0.00 $0.00A9544 N1 $0.00 $0.00A9546 N1 $0.00 $0.00A9547 N1 $0.00 $0.00A9548 N1 $0.00 $0.00A9550 N1 $0.00 $0.00A9551 N1 $0.00 $0.00A9552 N1 $0.00 $0.00A9553 N1 $0.00 $0.00A9554 N1 $0.00 $0.00A9555 N1 $0.00 $0.00A9556 N1 $0.00 $0.00A9557 N1 $0.00 $0.00A9558 N1 $0.00 $0.00A9559 N1 $0.00 $0.00A9560 N1 $0.00 $0.00A9561 N1 $0.00 $0.00A9562 N1 $0.00 $0.00A9566 N1 $0.00 $0.00A9567 N1 $0.00 $0.00A9568 N1 $0.00 $0.00A9569 N1 $0.00 $0.00A9570 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 75 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

A9571 N1 $0.00 $0.00A9572 N1 $0.00 $0.00A9575 N1 $0.00 $0.00A9576 N1 $0.00 $0.00A9577 N1 $0.00 $0.00A9578 N1 $0.00 $0.00A9579 N1 $0.00 $0.00A9580 N1 $0.00 $0.00A9581 N1 $0.00 $0.00A9582 N1 $0.00 $0.00A9583 N1 $0.00 $0.00A9584 N1 $0.00 $0.00A9585 N1 $0.00 $0.00A9586 K2 $2,756.00 $3,700.76A9599 N1 $0.00 $0.00A9698 N1 $0.00 $0.00C1713 N1 $0.00 $0.00C1714 N1 $0.00 $0.00C1715 N1 $0.00 $0.00C1716 H2 $45.54 $61.15C1717 H2 $294.04 $394.84C1719 H2 $93.11 $125.03C1721 N1 $0.00 $0.00C1722 N1 $0.00 $0.00C1724 N1 $0.00 $0.00C1725 N1 $0.00 $0.00C1726 N1 $0.00 $0.00C1727 N1 $0.00 $0.00C1728 N1 $0.00 $0.00C1729 N1 $0.00 $0.00C1730 N1 $0.00 $0.00C1731 N1 $0.00 $0.00C1732 N1 $0.00 $0.00C1733 N1 $0.00 $0.00C1749 N1 $0.00 $0.00C1750 N1 $0.00 $0.00C1751 N1 $0.00 $0.00C1752 N1 $0.00 $0.00C1753 N1 $0.00 $0.00C1754 N1 $0.00 $0.00C1755 N1 $0.00 $0.00C1756 N1 $0.00 $0.00C1757 N1 $0.00 $0.00C1758 N1 $0.00 $0.00C1759 N1 $0.00 $0.00C1760 N1 $0.00 $0.00C1762 N1 $0.00 $0.00C1763 N1 $0.00 $0.00C1764 N1 $0.00 $0.00C1765 N1 $0.00 $0.00C1766 N1 $0.00 $0.00C1767 N1 $0.00 $0.00C1768 N1 $0.00 $0.00C1769 N1 $0.00 $0.00C1770 N1 $0.00 $0.00C1771 N1 $0.00 $0.00C1772 N1 $0.00 $0.00C1773 N1 $0.00 $0.00C1776 N1 $0.00 $0.00C1777 N1 $0.00 $0.00C1778 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 76 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

C1779 N1 $0.00 $0.00C1780 N1 $0.00 $0.00C1781 N1 $0.00 $0.00C1782 N1 $0.00 $0.00C1783 N1 $0.00 $0.00C1784 N1 $0.00 $0.00C1785 N1 $0.00 $0.00C1786 N1 $0.00 $0.00C1787 N1 $0.00 $0.00C1788 N1 $0.00 $0.00C1789 N1 $0.00 $0.00C1813 N1 $0.00 $0.00C1814 N1 $0.00 $0.00C1815 N1 $0.00 $0.00C1816 N1 $0.00 $0.00C1817 N1 $0.00 $0.00C1818 N1 $0.00 $0.00C1819 N1 $0.00 $0.00C1820 N1 $0.00 $0.00C1821 N1 $0.00 $0.00C1822 J7 $0.00 $0.00C1830 N1 $0.00 $0.00C1840 N1 $0.00 $0.00C1841 N1 $0.00 $0.00C1874 N1 $0.00 $0.00C1875 N1 $0.00 $0.00C1876 N1 $0.00 $0.00C1877 N1 $0.00 $0.00C1878 N1 $0.00 $0.00C1880 N1 $0.00 $0.00C1881 N1 $0.00 $0.00C1882 N1 $0.00 $0.00C1883 N1 $0.00 $0.00C1884 N1 $0.00 $0.00C1885 N1 $0.00 $0.00C1886 N1 $0.00 $0.00C1887 N1 $0.00 $0.00C1888 N1 $0.00 $0.00C1891 N1 $0.00 $0.00C1892 N1 $0.00 $0.00C1893 N1 $0.00 $0.00C1894 N1 $0.00 $0.00C1895 N1 $0.00 $0.00C1896 N1 $0.00 $0.00C1897 N1 $0.00 $0.00C1898 N1 $0.00 $0.00C1899 N1 $0.00 $0.00C1900 N1 $0.00 $0.00C2613 J7 $0.00 $0.00C2614 N1 $0.00 $0.00C2615 N1 $0.00 $0.00C2616 H2 $16,021.70 $21,513.94C2617 N1 $0.00 $0.00C2618 N1 $0.00 $0.00C2619 N1 $0.00 $0.00C2620 N1 $0.00 $0.00C2621 N1 $0.00 $0.00C2622 N1 $0.00 $0.00C2623 J7 $0.00 $0.00C2624 J7 $0.00 $0.00C2625 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 77 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

C2626 N1 $0.00 $0.00C2627 N1 $0.00 $0.00C2628 N1 $0.00 $0.00C2629 N1 $0.00 $0.00C2630 N1 $0.00 $0.00C2631 N1 $0.00 $0.00C2634 H2 $85.18 $114.38C2635 H2 $35.24 $47.32C2636 H2 $14.24 $19.12C2638 H2 $38.09 $51.15C2639 H2 $36.64 $49.20C2640 H2 $68.78 $92.36C2641 H2 $66.23 $88.93C2642 H2 $86.59 $116.27C2643 H2 $52.18 $70.07C2644 H2 $12.41 $16.66C2698 H2 $38.09 $51.15C2699 H2 $14.24 $19.12C5271 G2 $239.70 $321.87C5272 N1 $0.00 $0.00C5273 G2 $1,195.26 $1,605.00C5274 N1 $0.00 $0.00C5275 G2 $239.70 $321.87C5276 N1 $0.00 $0.00C5277 G2 $789.12 $1,059.63C5278 N1 $0.00 $0.00C8908 Z2 $254.05 $341.14C8909 Z2 $254.05 $341.14C8910 Z2 $152.96 $205.39C8911 Z2 $254.05 $341.14C8912 Z2 $254.05 $341.14C8913 Z2 $152.96 $205.39C8914 Z2 $254.05 $341.14C8918 Z2 $254.05 $341.14C8919 Z2 $152.96 $205.39C8920 Z2 $254.05 $341.14C8931 Z2 $254.05 $341.14C8932 Z2 $152.96 $205.39C8933 Z2 $254.05 $341.14C8934 Z2 $254.05 $341.14C8935 Z2 $152.96 $205.39C8936 Z2 $254.05 $341.14C9025 D5 $0.00 $0.00C9026 D5 $0.00 $0.00C9027 D5 $0.00 $0.00C9113 N1 $0.00 $0.00C9121 K2 $15.14 $20.33C9132 K2 $1.62 $2.18C9248 K2 $4.32 $5.80C9250 N1 $0.00 $0.00C9254 N1 $0.00 $0.00C9257 K2 $1.74 $2.34C9275 N1 $0.00 $0.00C9285 N1 $0.00 $0.00C9290 N1 $0.00 $0.00C9293 K2 $271.24 $364.22C9349 K2 $109.18 $146.61C9352 N1 $0.00 $0.00C9353 N1 $0.00 $0.00C9354 N1 $0.00 $0.00C9355 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 78 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

C9356 N1 $0.00 $0.00C9358 N1 $0.00 $0.00C9359 N1 $0.00 $0.00C9360 N1 $0.00 $0.00C9361 N1 $0.00 $0.00C9362 N1 $0.00 $0.00C9363 N1 $0.00 $0.00C9364 N1 $0.00 $0.00C9399 K7 $0.00 $0.00C9442 D5 $0.00 $0.00C9443 D5 $0.00 $0.00C9444 D5 $0.00 $0.00C9445 D5 $0.00 $0.00C9446 D5 $0.00 $0.00C9447 K2 $492.90 $661.87C9449 D5 $0.00 $0.00C9450 D5 $0.00 $0.00C9451 D5 $0.00 $0.00C9452 D5 $0.00 $0.00C9453 D5 $0.00 $0.00C9454 D5 $0.00 $0.00C9455 D5 $0.00 $0.00C9456 D5 $0.00 $0.00C9457 D5 $0.00 $0.00C9458 K2 $989.33 $1,328.47C9459 K2 $3,300.00 $4,431.24C9460 K2 $15.88 $21.32C9497 K2 $147.34 $197.85C9724 D5 $0.00 $0.00C9725 G2 $275.37 $369.77C9726 N1 $0.00 $0.00C9727 G2 $385.63 $517.82C9728 R2 $574.18 $771.01C9733 N1 $0.00 $0.00C9740 J8 $4,444.17 $5,967.63C9742 G2 $580.15 $779.03C9743 G2 $1,254.53 $1,684.58C9800 R2 $789.12 $1,059.63G0104 P3 $135.76 $182.30G0105 A2 $420.93 $565.22G0121 A2 $420.93 $565.22G0186 R2 $246.26 $330.68G0260 A2 $327.22 $439.39G0276 G2 $2,486.22 $3,338.50G0365 P2 $85.88 $115.32G0458 G2 $1,893.09 $2,542.04J0221 K2 $153.60 $206.25J0256 K2 $4.45 $5.98J0257 K2 $4.11 $5.52J0278 N1 $0.00 $0.00J0280 N1 $0.00 $0.00J0282 N1 $0.00 $0.00J0285 N1 $0.00 $0.00J0287 K2 $12.38 $16.62J0288 N1 $0.00 $0.00J0289 K2 $18.23 $24.48J0290 N1 $0.00 $0.00J0295 N1 $0.00 $0.00J0300 K2 $194.26 $260.85J0330 N1 $0.00 $0.00J0348 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 79 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J0360 N1 $0.00 $0.00J0380 N1 $0.00 $0.00J0390 N1 $0.00 $0.00J0400 N1 $0.00 $0.00J0401 K2 $4.10 $5.51J0456 N1 $0.00 $0.00J0461 N1 $0.00 $0.00J0470 N1 $0.00 $0.00J0475 K2 $170.03 $228.32J0476 K2 $76.07 $102.15J0480 K2 $2,851.52 $3,829.02J0485 K2 $3.80 $5.10J0490 K2 $40.54 $54.44J0500 N1 $0.00 $0.00J0515 N1 $0.00 $0.00J0520 N1 $0.00 $0.00J0558 N1 $0.00 $0.00J0561 K2 $7.84 $10.53J0583 K2 $3.71 $4.98J0585 K2 $5.72 $7.68J0586 K2 $8.06 $10.82J0587 K2 $11.65 $15.64J0588 K2 $4.67 $6.27J0592 N1 $0.00 $0.00J0594 K2 $33.20 $44.58J0595 N1 $0.00 $0.00J0596 K2 $23.29 $31.27J0597 K2 $40.52 $54.41J0598 K2 $54.46 $73.13J0600 K2 $5,594.42 $7,512.19J0610 N1 $0.00 $0.00J0620 N1 $0.00 $0.00J0630 K2 $2,006.85 $2,694.80J0636 N1 $0.00 $0.00J0637 K2 $12.75 $17.12J0638 K2 $91.78 $123.24J0640 N1 $0.00 $0.00J0641 K2 $1.92 $2.58J0670 N1 $0.00 $0.00J0690 N1 $0.00 $0.00J0692 N1 $0.00 $0.00J0694 N1 $0.00 $0.00J0695 K2 $0.42 $0.56J0696 N1 $0.00 $0.00J0697 N1 $0.00 $0.00J0698 N1 $0.00 $0.00J0702 N1 $0.00 $0.00J0706 N1 $0.00 $0.00J0712 K2 $2.14 $2.87J0713 N1 $0.00 $0.00J0714 K2 $75.53 $101.42J0715 N1 $0.00 $0.00J0716 K2 $3,635.80 $4,882.15J0717 K2 $6.62 $8.89J0720 K2 $31.74 $42.62J0725 K2 $22.59 $30.33J0735 N1 $0.00 $0.00J0740 K2 $650.18 $873.06J0743 N1 $0.00 $0.00J0744 N1 $0.00 $0.00J0745 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 80 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J0760 N1 $0.00 $0.00J0770 N1 $0.00 $0.00J0775 K2 $38.06 $51.11J0780 N1 $0.00 $0.00J0795 K2 $7.74 $10.39J0800 K2 $3,468.13 $4,657.00J0833 K2 $101.68 $136.54J0834 N1 $0.00 $0.00J0840 K2 $2,542.98 $3,414.71J0850 K2 $1,064.77 $1,429.77J0875 K2 $14.28 $19.18J0878 K2 $0.76 $1.02J0881 K2 $4.38 $5.88J0885 K2 $12.62 $16.95J0888 N1 $0.00 $0.00J0894 K2 $22.13 $29.72J0895 N1 $0.00 $0.00J0897 K2 $15.24 $20.46J0945 N1 $0.00 $0.00J1000 N1 $0.00 $0.00J1020 N1 $0.00 $0.00J1030 N1 $0.00 $0.00J1040 N1 $0.00 $0.00J1050 N1 $0.00 $0.00J1071 N1 $0.00 $0.00J1094 N1 $0.00 $0.00J1100 N1 $0.00 $0.00J1110 N1 $0.00 $0.00J1120 N1 $0.00 $0.00J1160 N1 $0.00 $0.00J1162 K2 $2,639.26 $3,544.00J1165 N1 $0.00 $0.00J1170 N1 $0.00 $0.00J1190 K2 $146.38 $196.56J1200 N1 $0.00 $0.00J1205 K2 $119.93 $161.04J1212 N1 $0.00 $0.00J1230 N1 $0.00 $0.00J1240 N1 $0.00 $0.00J1245 N1 $0.00 $0.00J1250 N1 $0.00 $0.00J1260 N1 $0.00 $0.00J1265 N1 $0.00 $0.00J1267 N1 $0.00 $0.00J1270 N1 $0.00 $0.00J1290 K2 $402.44 $540.40J1300 K2 $215.92 $289.94J1320 N1 $0.00 $0.00J1322 K2 $221.54 $297.48J1324 K2 $18.63 $25.02J1325 N1 $0.00 $0.00J1327 K2 $32.39 $43.49J1330 N1 $0.00 $0.00J1335 N1 $0.00 $0.00J1364 N1 $0.00 $0.00J1380 N1 $0.00 $0.00J1410 K2 $215.70 $289.64J1430 K2 $404.09 $542.61J1436 N1 $0.00 $0.00J1438 K2 $330.81 $444.21J1439 K2 $1.06 $1.42

UPDATED NOVEMBER 2015 Page 81 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J1442 K2 $1.00 $1.34J1446 D5 $0.00 $0.00J1447 K2 $3.86 $5.18J1450 N1 $0.00 $0.00J1451 K2 $7.01 $9.41J1453 K2 $1.73 $2.32J1455 N1 $0.00 $0.00J1457 N1 $0.00 $0.00J1458 K2 $364.78 $489.83J1459 K2 $38.05 $51.09J1460 N1 $0.00 $0.00J1556 K2 $38.49 $51.68J1557 K2 $37.28 $50.06J1559 K2 $8.47 $11.37J1560 N1 $0.00 $0.00J1561 K2 $40.30 $54.11J1566 K2 $33.11 $44.46J1568 K2 $42.80 $57.47J1569 K2 $38.56 $51.78J1570 N1 $0.00 $0.00J1571 K2 $54.43 $73.09J1572 K2 $35.66 $47.88J1573 K2 $54.43 $73.09J1575 K2 $10.96 $14.72J1580 N1 $0.00 $0.00J1590 N1 $0.00 $0.00J1595 K2 $194.25 $260.84J1599 N1 $0.00 $0.00J1600 N1 $0.00 $0.00J1602 K2 $24.33 $32.67J1610 K2 $190.60 $255.94J1626 N1 $0.00 $0.00J1630 N1 $0.00 $0.00J1631 N1 $0.00 $0.00J1640 K2 $21.77 $29.23J1642 N1 $0.00 $0.00J1644 N1 $0.00 $0.00J1645 N1 $0.00 $0.00J1650 N1 $0.00 $0.00J1652 N1 $0.00 $0.00J1670 K2 $255.21 $342.70J1700 N1 $0.00 $0.00J1710 N1 $0.00 $0.00J1720 N1 $0.00 $0.00J1725 K2 $2.61 $3.50J1740 K2 $116.67 $156.66J1741 N1 $0.00 $0.00J1742 K2 $63.10 $84.73J1743 K2 $497.48 $668.02J1744 K2 $298.90 $401.36J1745 K2 $78.76 $105.76J1750 K2 $12.08 $16.22J1756 N1 $0.00 $0.00J1786 K2 $42.00 $56.40J1790 N1 $0.00 $0.00J1800 N1 $0.00 $0.00J1815 N1 $0.00 $0.00J1817 N1 $0.00 $0.00J1830 K2 $357.22 $479.68J1833 K2 $0.68 $0.91J1840 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 82 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J1850 N1 $0.00 $0.00J1885 N1 $0.00 $0.00J1890 N1 $0.00 $0.00J1930 K2 $47.18 $63.35J1931 K2 $29.45 $39.55J1940 N1 $0.00 $0.00J1945 K2 $235.52 $316.26J1950 K2 $900.87 $1,209.69J1953 N1 $0.00 $0.00J1956 N1 $0.00 $0.00J1960 N1 $0.00 $0.00J1980 N1 $0.00 $0.00J1990 N1 $0.00 $0.00J2001 N1 $0.00 $0.00J2010 N1 $0.00 $0.00J2020 K2 $31.62 $42.46J2060 N1 $0.00 $0.00J2150 N1 $0.00 $0.00J2170 N1 $0.00 $0.00J2175 N1 $0.00 $0.00J2180 N1 $0.00 $0.00J2185 N1 $0.00 $0.00J2210 N1 $0.00 $0.00J2212 N1 $0.00 $0.00J2248 N1 $0.00 $0.00J2250 N1 $0.00 $0.00J2260 N1 $0.00 $0.00J2265 N1 $0.00 $0.00J2270 N1 $0.00 $0.00J2274 N1 $0.00 $0.00J2278 K2 $7.08 $9.51J2280 N1 $0.00 $0.00J2300 N1 $0.00 $0.00J2310 N1 $0.00 $0.00J2315 K2 $3.18 $4.27J2320 K2 $122.78 $164.87J2323 K2 $16.24 $21.81J2325 K2 $72.98 $98.00J2353 K2 $156.94 $210.74J2354 N1 $0.00 $0.00J2355 K2 $417.79 $561.01J2357 K2 $29.91 $40.16J2358 K2 $2.92 $3.92J2360 N1 $0.00 $0.00J2370 N1 $0.00 $0.00J2400 N1 $0.00 $0.00J2405 N1 $0.00 $0.00J2407 K2 $25.07 $33.66J2410 N1 $0.00 $0.00J2425 K2 $15.59 $20.93J2426 K2 $8.45 $11.35J2430 N1 $0.00 $0.00J2440 N1 $0.00 $0.00J2469 K2 $20.53 $27.57J2501 N1 $0.00 $0.00J2502 K2 $251.26 $337.39J2503 K2 $1,031.85 $1,385.57J2504 K2 $281.12 $377.49J2505 K2 $3,772.79 $5,066.10J2507 K2 $1,239.16 $1,663.94J2510 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 83 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J2515 N1 $0.00 $0.00J2540 N1 $0.00 $0.00J2543 N1 $0.00 $0.00J2547 K2 $1.68 $2.26J2550 N1 $0.00 $0.00J2560 N1 $0.00 $0.00J2562 K2 $305.98 $410.87J2590 N1 $0.00 $0.00J2597 K2 $8.97 $12.04J2650 N1 $0.00 $0.00J2670 K2 $1,600.40 $2,149.02J2675 N1 $0.00 $0.00J2680 N1 $0.00 $0.00J2690 N1 $0.00 $0.00J2700 N1 $0.00 $0.00J2710 N1 $0.00 $0.00J2720 N1 $0.00 $0.00J2724 K2 $15.12 $20.30J2730 N1 $0.00 $0.00J2760 K2 $159.00 $213.51J2765 N1 $0.00 $0.00J2770 K2 $311.04 $417.66J2778 K2 $391.41 $525.59J2780 N1 $0.00 $0.00J2783 K2 $227.61 $305.63J2785 N1 $0.00 $0.00J2788 N1 $0.00 $0.00J2790 N1 $0.00 $0.00J2791 N1 $0.00 $0.00J2792 K2 $19.40 $26.05J2793 K2 $24.09 $32.35J2794 K2 $6.91 $9.28J2795 N1 $0.00 $0.00J2796 K2 $57.47 $77.17J2800 N1 $0.00 $0.00J2805 N1 $0.00 $0.00J2810 N1 $0.00 $0.00J2820 K2 $31.68 $42.54J2850 K2 $34.78 $46.70J2860 K2 $8.90 $11.95J2910 N1 $0.00 $0.00J2916 N1 $0.00 $0.00J2920 N1 $0.00 $0.00J2930 N1 $0.00 $0.00J2941 K2 $81.59 $109.56J2950 N1 $0.00 $0.00J2993 K2 $2,301.91 $3,091.00J2995 N1 $0.00 $0.00J2997 K2 $73.74 $99.02J3000 N1 $0.00 $0.00J3010 N1 $0.00 $0.00J3030 N1 $0.00 $0.00J3060 K2 $36.48 $48.99J3070 K2 $121.83 $163.59J3090 K2 $0.12 $0.16J3095 K2 $4.91 $6.59J3101 K2 $93.96 $126.17J3105 N1 $0.00 $0.00J3121 N1 $0.00 $0.00J3145 K2 $1.17 $1.57J3230 N1 $0.00 $0.00

UPDATED NOVEMBER 2015 Page 84 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J3240 K2 $1,432.17 $1,923.12J3243 K2 $2.35 $3.16J3246 K2 $8.94 $12.00J3250 N1 $0.00 $0.00J3260 N1 $0.00 $0.00J3262 K2 $3.85 $5.17J3265 N1 $0.00 $0.00J3280 N1 $0.00 $0.00J3285 K2 $61.24 $82.23J3300 K2 $3.72 $5.00J3301 N1 $0.00 $0.00J3302 N1 $0.00 $0.00J3303 N1 $0.00 $0.00J3310 N1 $0.00 $0.00J3315 K2 $144.59 $194.16J3350 N1 $0.00 $0.00J3355 K2 $64.69 $86.87J3357 K2 $166.99 $224.23J3360 N1 $0.00 $0.00J3364 N1 $0.00 $0.00J3370 N1 $0.00 $0.00J3380 K2 $17.03 $22.87J3385 K2 $346.08 $464.72J3396 K2 $10.99 $14.76J3410 N1 $0.00 $0.00J3411 N1 $0.00 $0.00J3415 N1 $0.00 $0.00J3420 N1 $0.00 $0.00J3430 N1 $0.00 $0.00J3465 K2 $4.19 $5.63J3470 N1 $0.00 $0.00J3471 N1 $0.00 $0.00J3472 N1 $0.00 $0.00J3473 N1 $0.00 $0.00J3475 N1 $0.00 $0.00J3480 N1 $0.00 $0.00J3485 N1 $0.00 $0.00J3486 N1 $0.00 $0.00J3489 K2 $34.97 $46.96J3490 N1 $0.00 $0.00J3530 N1 $0.00 $0.00J3590 N1 $0.00 $0.00J7030 N1 $0.00 $0.00J7040 N1 $0.00 $0.00J7042 N1 $0.00 $0.00J7050 N1 $0.00 $0.00J7060 N1 $0.00 $0.00J7070 N1 $0.00 $0.00J7100 N1 $0.00 $0.00J7110 N1 $0.00 $0.00J7120 N1 $0.00 $0.00J7131 N1 $0.00 $0.00J7178 K2 $1.05 $1.41J7180 K2 $7.41 $9.95J7181 K2 $14.07 $18.89J7183 K2 $1.02 $1.37J7185 K2 $1.42 $1.91J7186 K2 $0.96 $1.29J7187 K2 $0.99 $1.33J7188 K2 $4.90 $6.58J7189 K2 $2.07 $2.78

UPDATED NOVEMBER 2015 Page 85 of 90 EFFECTIVE JANUARY 1, 2016

MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J7190 K2 $0.96 $1.29J7191 K2 $0.20 $0.27J7192 K2 $1.16 $1.56J7193 K2 $1.07 $1.44J7194 K2 $1.19 $1.60J7195 K2 $1.46 $1.96J7196 K2 $103.35 $138.78J7197 K2 $3.37 $4.53J7198 K2 $1.83 $2.46J7200 K2 $1.23 $1.65J7201 K2 $2.81 $3.77J7205 K2 $1.90 $2.55J7308 K2 $292.79 $393.16J7309 K2 $83.69 $112.38J7310 K2 $16,960.00 $22,773.89J7311 K2 $20,138.08 $27,041.41J7312 K2 $201.03 $269.94J7313 K2 $490.95 $659.25J7315 N1 $0.00 $0.00J7316 K2 $1,046.75 $1,405.58J7321 K2 $88.61 $118.99J7323 K2 $152.00 $204.11J7324 K2 $172.63 $231.81J7325 K2 $12.87 $17.28J7326 K2 $578.11 $776.29J7327 K2 $958.45 $1,287.01J7336 K2 $2.81 $3.77J7340 K2 $2.14 $2.87J7500 N1 $0.00 $0.00J7501 K2 $217.30 $291.79J7502 N1 $0.00 $0.00J7504 K2 $1,069.33 $1,435.90J7506 D5 $0.00 $0.00J7507 N1 $0.00 $0.00J7508 K2 $0.39 $0.52J7509 N1 $0.00 $0.00J7510 N1 $0.00 $0.00J7511 K2 $638.49 $857.36J7513 K2 $526.34 $706.77J7515 N1 $0.00 $0.00J7516 N1 $0.00 $0.00J7517 N1 $0.00 $0.00J7518 N1 $0.00 $0.00J7520 N1 $0.00 $0.00J7525 K2 $163.25 $219.21J7527 N1 $0.00 $0.00J7599 N1 $0.00 $0.00J7665 N1 $0.00 $0.00J7674 N1 $0.00 $0.00J7799 N1 $0.00 $0.00J8501 K2 $9.54 $12.81J8510 N1 $0.00 $0.00J8520 N1 $0.00 $0.00J8521 N1 $0.00 $0.00J8530 N1 $0.00 $0.00J8540 N1 $0.00 $0.00J8560 K2 $68.74 $92.30J8597 N1 $0.00 $0.00J8600 N1 $0.00 $0.00J8610 N1 $0.00 $0.00J8650 K2 $34.10 $45.79

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J8655 K2 $474.85 $637.63J8700 K2 $2.66 $3.57J8705 K2 $101.36 $136.11J9000 N1 $0.00 $0.00J9015 K2 $2,667.51 $3,581.93J9017 K2 $59.42 $79.79J9019 K2 $376.49 $505.55J9020 N1 $0.00 $0.00J9025 K2 $3.05 $4.10J9027 K2 $138.38 $185.82J9031 K2 $122.88 $165.00J9032 K2 $31.64 $42.49J9033 K2 $24.66 $33.11J9035 K2 $69.60 $93.46J9039 K2 $96.00 $128.91J9040 N1 $0.00 $0.00J9041 K2 $46.75 $62.78J9042 K2 $119.62 $160.63J9043 K2 $148.66 $199.62J9045 N1 $0.00 $0.00J9047 K2 $31.06 $41.71J9050 K2 $2,973.34 $3,992.60J9055 K2 $53.48 $71.81J9060 N1 $0.00 $0.00J9065 K2 $20.91 $28.08J9070 K2 $48.95 $65.73J9098 K2 $576.48 $774.10J9100 N1 $0.00 $0.00J9120 K2 $1,164.57 $1,563.78J9130 N1 $0.00 $0.00J9150 K2 $26.45 $35.52J9151 K2 $238.86 $320.74J9155 K2 $3.59 $4.82J9171 K2 $3.49 $4.69J9175 N1 $0.00 $0.00J9178 N1 $0.00 $0.00J9179 K2 $102.53 $137.68J9181 N1 $0.00 $0.00J9185 N1 $0.00 $0.00J9190 N1 $0.00 $0.00J9200 K2 $67.69 $90.89J9201 N1 $0.00 $0.00J9202 K2 $281.05 $377.39J9206 N1 $0.00 $0.00J9207 K2 $72.08 $96.79J9208 K2 $32.20 $43.24J9209 N1 $0.00 $0.00J9211 K2 $34.88 $46.84J9213 K2 $733.57 $985.04J9214 K2 $24.05 $32.29J9216 K2 $5,265.95 $7,071.12J9217 K2 $242.80 $326.03J9218 N1 $0.00 $0.00J9219 K2 $168.48 $226.23J9225 K2 $3,012.29 $4,044.90J9226 K2 $22,170.84 $29,771.00J9228 K2 $138.83 $186.42J9230 K2 $241.99 $324.94J9245 K2 $1,285.40 $1,726.04J9250 N1 $0.00 $0.00J9260 N1 $0.00 $0.00

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

J9261 K2 $148.57 $199.50J9262 K2 $2.48 $3.33J9263 K2 $0.48 $0.64J9264 K2 $9.77 $13.12J9266 K2 $6,189.74 $8,311.58J9267 N1 $0.00 $0.00J9268 K2 $1,471.48 $1,975.90J9270 N1 $0.00 $0.00J9271 K2 $45.69 $61.35J9280 K2 $73.03 $98.06J9293 K2 $32.12 $43.13J9299 K2 $25.38 $34.08J9301 K2 $54.21 $72.79J9302 K2 $49.47 $66.43J9303 K2 $100.91 $135.50J9305 K2 $61.21 $82.19J9306 K2 $10.22 $13.72J9307 K2 $212.80 $285.75J9308 K2 $53.97 $72.47J9310 K2 $748.70 $1,005.35J9315 K2 $290.84 $390.54J9320 K2 $324.02 $435.09J9328 K2 $6.84 $9.18J9330 K2 $62.50 $83.93J9340 K2 $630.70 $846.90J9351 N1 $0.00 $0.00J9354 K2 $29.21 $39.22J9355 K2 $87.36 $117.31J9357 K2 $1,117.31 $1,500.32J9360 N1 $0.00 $0.00J9370 N1 $0.00 $0.00J9371 K2 $2,321.82 $3,117.74J9390 N1 $0.00 $0.00J9395 K2 $93.44 $125.47J9400 K2 $8.32 $11.17J9600 K2 $20,438.61 $27,444.97J9999 N1 $0.00 $0.00P9041 K2 $10.91 $14.65P9045 K2 $54.54 $73.24P9046 K2 $22.49 $30.20P9047 K2 $53.44 $71.76Q0138 K2 $0.81 $1.09Q0161 N1 $0.00 $0.00Q0162 N1 $0.00 $0.00Q0163 N1 $0.00 $0.00Q0164 N1 $0.00 $0.00Q0166 N1 $0.00 $0.00Q0167 N1 $0.00 $0.00Q0169 N1 $0.00 $0.00Q0173 N1 $0.00 $0.00Q0175 N1 $0.00 $0.00Q0177 N1 $0.00 $0.00Q0180 N1 $0.00 $0.00Q0181 N1 $0.00 $0.00Q2004 N1 $0.00 $0.00Q2009 N1 $0.00 $0.00Q2017 K2 $3,494.46 $4,692.36Q2034 L1 $0.00 $0.00Q2035 L1 $0.00 $0.00Q2036 L1 $0.00 $0.00Q2037 L1 $0.00 $0.00

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

Q2038 L1 $0.00 $0.00Q2039 L1 $0.00 $0.00Q2043 K2 $36,704.05 $49,286.20Q2049 K2 $508.43 $682.72Q2050 K2 $443.83 $595.97Q3027 K2 $40.52 $54.41Q3031 N1 $0.00 $0.00Q4100 N1 $0.00 $0.00Q4101 N1 $0.00 $0.00Q4102 N1 $0.00 $0.00Q4103 N1 $0.00 $0.00Q4104 N1 $0.00 $0.00Q4105 N1 $0.00 $0.00Q4106 N1 $0.00 $0.00Q4107 N1 $0.00 $0.00Q4108 N1 $0.00 $0.00Q4110 N1 $0.00 $0.00Q4111 N1 $0.00 $0.00Q4112 N1 $0.00 $0.00Q4113 N1 $0.00 $0.00Q4114 N1 $0.00 $0.00Q4115 N1 $0.00 $0.00Q4116 N1 $0.00 $0.00Q4117 N1 $0.00 $0.00Q4118 N1 $0.00 $0.00Q4119 N1 $0.00 $0.00Q4120 N1 $0.00 $0.00Q4121 K2 $36.00 $48.34Q4122 N1 $0.00 $0.00Q4123 N1 $0.00 $0.00Q4124 N1 $0.00 $0.00Q4125 N1 $0.00 $0.00Q4126 N1 $0.00 $0.00Q4127 N1 $0.00 $0.00Q4128 N1 $0.00 $0.00Q4129 N1 $0.00 $0.00Q4130 N1 $0.00 $0.00Q4131 N1 $0.00 $0.00Q4132 N1 $0.00 $0.00Q4133 N1 $0.00 $0.00Q4134 N1 $0.00 $0.00Q4135 N1 $0.00 $0.00Q4136 N1 $0.00 $0.00Q4137 N1 $0.00 $0.00Q4138 N1 $0.00 $0.00Q4139 N1 $0.00 $0.00Q4140 N1 $0.00 $0.00Q4141 N1 $0.00 $0.00Q4142 N1 $0.00 $0.00Q4143 N1 $0.00 $0.00Q4145 N1 $0.00 $0.00Q4146 N1 $0.00 $0.00Q4147 N1 $0.00 $0.00Q4148 N1 $0.00 $0.00Q4149 N1 $0.00 $0.00Q4150 N1 $0.00 $0.00Q4151 N1 $0.00 $0.00Q4152 N1 $0.00 $0.00Q4153 N1 $0.00 $0.00Q4154 N1 $0.00 $0.00Q4155 N1 $0.00 $0.00

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MDWCC ASC 2016

HCPCS Code CMS Payment Indicator CMS 2016 Payment Rate WCC 2016 Payment Rates

Q4156 N1 $0.00 $0.00Q4157 N1 $0.00 $0.00Q4158 N1 $0.00 $0.00Q4159 N1 $0.00 $0.00Q4160 N1 $0.00 $0.00Q5101 K2 $0.97 $1.30Q9950 K2 $0.00 $0.00Q9951 N1 $0.00 $0.00Q9953 N1 $0.00 $0.00Q9954 N1 $0.00 $0.00Q9955 N1 $0.00 $0.00Q9956 N1 $0.00 $0.00Q9957 N1 $0.00 $0.00Q9958 N1 $0.00 $0.00Q9959 N1 $0.00 $0.00Q9960 N1 $0.00 $0.00Q9961 N1 $0.00 $0.00Q9962 N1 $0.00 $0.00Q9963 N1 $0.00 $0.00Q9964 N1 $0.00 $0.00Q9965 N1 $0.00 $0.00Q9966 N1 $0.00 $0.00Q9967 N1 $0.00 $0.00Q9968 K2 $10.80 $14.50Q9975 D5 $0.00 $0.00Q9978 D5 $0.00 $0.00Q9979 D5 $0.00 $0.00V2630 N1 $0.00 $0.00V2631 N1 $0.00 $0.00V2632 N1 $0.00 $0.00V2785 F4 $0.00 $0.00V2790 N1 $0.00 $0.00

IndicatorA2B5D5F4G2H2J7J8K2K7L1L6N1P2P3R2Z2Z3

Payment Indicator DefinitionSurgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight.

Alternative code may be available; no payment made

CPT codes and descriptions only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

Deleted/discontinued code; no payment made.Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost.

Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list;

OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC Device-intensive procedure; paid at adjusted rate.

Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; Unclassified drugs and biologicals; payment contractor-priced.

Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made. New Technology Intraocular Lens (NTIOL); special payment.

Radiology or diagnostic service paid separately when provided integral to a surgical procedure on

Packaged service/item; no separate payment made.Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE

Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE Radiology or diagnostic service paid separately when provided integral to a surgical procedure on

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