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					                                                                 HRSA Outpatient Fee Schedule                                                          CY2010 Q4
                                                                     Washington State Medicaid


                                                 Medicaid Purchasing Administration Outpatient Fee Schedule
                                           (for all hospitals types, effective dates of service on and after Oct 1, 2010)
                                                                       Posted October 1, 2010
                                                                    Link to Legend for Codes
                                                                                                  MAX            APC        RW     NWR     OPPS            OP
  AUTH          CPT     SI   Description                                               COV
                                                                                                  UNITS          2010       2010   2010     Fee            Fee
                00100   N    Anesth, salivary gland                                      1           NA            0
                00102   N    Anesth, repair of cleft lip                                 1           NA            0
                00103   N    Anesth, blepharoplasty                                      1           NA            0
                00104   N    Anesth, electroshock                                        1           NA            0
                00120   N    Anesth, ear surgery                                         1           NA            0
                00124   N    Anesth, ear exam                                            1           NA            0
                00126   N    Anesth, tympanotomy                                         1           NA            0
                00140   N    Anesth, procedures on eye                                   1           NA            0
                00142   N    Anesth, lens surgery                                        1           NA            0
                00144   N    Anesth, corneal transplant                                  1           NA            0
                00145   N    Anesth, vitreoretinal surg                                  1           NA            0
                00147   N    Anesth, iridectomy                                          1           NA            0
                00148   N    Anesth, eye exam                                            1           NA            0
                00160   N    Anesth, nose/sinus surgery                                  1           NA            0
                00162   N    Anesth, nose/sinus surgery                                  1           NA            0
                00164   N    Anesth, biopsy of nose                                      1           NA            0
                00170   N    Anesth, procedure on mouth                                  1           NA            0
                00172   N    Anesth, cleft palate repair                                 1           NA            0
                00174   N    Anesth, pharyngeal surgery                                  1           NA            0
                00176   C    Anesth, pharyngeal surgery                                  1           NA            0                        OR
                00190   N    Anesth, face/skull bone surg                                1           NA            0
                00192   C    Anesth, facial bone surgery                                 1           NA            0                        OR
                00210   N    Anesth, cranial surg nos                                    1           NA            0
                00211   C    Anesth, cran surg, hemotoma                                 1           NA            0                        OR
                00212   N    Anesth, skull drainage                                      1           NA            0
                00214   C    Anesth, skull drainage                                      1           NA            0                        OR
                00215   C    Anesth, skull repair/fract                                  1           NA            0                        OR
                00216   N    Anesth, head vessel surgery                                 1           NA            0
                00218   N    Anesth, special head surgery                                1           NA            0
                00220   N    Anesth, intrcrn nerve                                       1           NA            0
                00222   N    Anesth, head nerve surgery                                  1           NA            0
                00300   N    Anesth, head/neck/ptrunk                                    1           NA            0
                00320   N    Anesth, neck organ, 1 & over                                1           NA            0
                00322   N    Anesth, biopsy of thyroid                                   1           NA            0
                00326   N    Anesth, larynx/trach, < 1 yr                                1           NA            0
                00350   N    Anesth, neck vessel surgery                                 1           NA            0
                00352   N    Anesth, neck vessel surgery                                 1           NA            0
                00400   N    Anesth, skin, ext/per/atrunk                                1           NA            0
                00402   N    Anesth, surgery of breast                                   1           NA            0
                00404   N    Anesth, surgery of breast                                   1           NA            0
                00406   N    Anesth, surgery of breast                                   1           NA            0
                00410   N    Anesth, correct heart rhythm                                1           NA            0
                00450   N    Anesth, surgery of shoulder                                 1           NA            0
                00452   C    Anesth, surgery of shoulder                                 1           NA            0                        OR
                00454   N    Anesth, collar bone biopsy                                  1           NA            0
                00470   N    Anesth, removal of rib                                      1           NA            0
                00472   N    Anesth, chest wall repair                                   1           NA            0
                00474   C    Anesth, surgery of rib(s)                                   1           NA            0                        OR
                00500   N    Anesth, esophageal surgery                                  1           NA            0
                00520   N    Anesth, chest procedure                                     1           NA            0
                00522   N    Anesth, chest lining biopsy                                 1           NA            0
                00524   C    Anesth, chest drainage                                      1           NA            0                        OR
                00528   N    Anesth, chest partition view                                1           NA            0
                00529   N    Anesth, chest partition view                                1           NA            0
                00530   N    Anesth, pacemaker insertion                                 1           NA            0
                00532   N    Anesth, vascular access                                     1           NA            0
                00534   N    Anesth, cardioverter/defib                                  1           NA            0
                00537   N    Anesth, cardiac electrophys                                 1           NA            0
                00539   N    Anesth, trach-bronch reconst                                1           NA            0
                00540   C    Anesth, chest surgery                                       1           NA            0                        OR
                00541   N    Anesth, one lung ventilation                                1           NA            0
                00542   C    Anesth, release of lung                                     1           NA            0                        OR

                                                                                                                                           CPT Codes and Descriptions
                                                                                                                                                        Copyright 2010
                                                                                                                                          American Medical Association
Page 1 of 216                                                                                                                                      All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC    RW     NWR     OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010   2010   2010     Fee            Fee
                00546   C    Anesth, lung,chest wall surg                         1         NA      0                     OR
                00548   N    Anesth, trachea,bronchi surg                         1         NA      0
                00550   N    Anesth, sternal debridement                          1         NA      0
                00560   C    Anesth, heart surg w/o pump                          1         NA      0                     OR
                00561   C    Anesth, heart surg < age 1                           1         NA      0                     OR
                00562   C    Anesth hrt surg w/pmp age 1+                         1         NA      0                     OR
                00563   N    Anesth, heart surg w/arrest                          1         NA      0
                00566   N    Anesth, cabg w/o pump                                1         NA      0
                00567   C    Anesth, cabg w/pump                                  1         NA      0                     OR
                00580   C    Anesth, heart/lung transplnt                         1         NA      0                     OR
                00600   N    Anesth, spine, cord surgery                          1         NA      0
                00604   C    Anesth, sitting procedure                            1         NA      0                     OR
                00620   N    Anesth, spine, cord surgery                          1         NA      0
                00622   C    Anesth, removal of nerves                            1         NA      0                     OR
                00625   N    Anes spine tranthor w/o vent                         1         NA      0
                00626   N    Anes, spine transthor w/vent                         1         NA      0
                00630   N    Anesth, spine, cord surgery                          1         NA      0
                00632   C    Anesth, removal of nerves                            1         NA      0                     OR
                00634   N    Anesth for chemonucleolysis                          1         NA      0
                00635   N    Anesth, lumbar puncture                              1         NA      0
                00640   N    Anesth, spine manipulation                           1         NA      0
                00670   C    Anesth, spine, cord surgery                          1         NA      0                     OR
                00700   N    Anesth, abdominal wall surg                          1         NA      0
                00702   N    Anesth, for liver biopsy                             1         NA      0
                00730   N    Anesth, abdominal wall surg                          1         NA      0
                00740   N    Anesth, upper gi visualize                           1         NA      0
                00750   N    Anesth, repair of hernia                             1         NA      0
                00752   N    Anesth, repair of hernia                             1         NA      0
                00754   N    Anesth, repair of hernia                             1         NA      0
                00756   N    Anesth, repair of hernia                             1         NA      0
                00770   N    Anesth, blood vessel repair                          1         NA      0
                00790   N    Anesth, surg upper abdomen                           1         NA      0
                00792   C    Anesth, hemorr/excise liver                          1         NA      0                     OR
                00794   C    Anesth, pancreas removal                             1         NA      0                     OR
                00796   C    Anesth, for liver transplant                         1         NA      0                     OR
                00797   N    Anesth, surgery for obesity                          1         NA      0
                00800   N    Anesth, abdominal wall surg                          1         NA      0
                00802   C    Anesth, fat layer removal                            1         NA      0                     OR
                00810   N    Anesth, low intestine scope                          1         NA      0
                00820   N    Anesth, abdominal wall surg                          1         NA      0
                00830   N    Anesth, repair of hernia                             1         NA      0
                00832   N    Anesth, repair of hernia                             1         NA      0
                00834   N    Anesth, hernia repair< 1 yr                          1         NA      0
                00836   N    Anesth hernia repair preemie                         1         NA      0
                00840   N    Anesth, surg lower abdomen                           1         NA      0
                00842   N    Anesth, amniocentesis                                1         NA      0
                00844   C    Anesth, pelvis surgery                               1         NA      0                     OR
                00846   C    Anesth, hysterectomy                                 1         NA      0                     OR
                00848   C    Anesth, pelvic organ surg                            1         NA      0                     OR
                00851   N    Anesth, tubal ligation                               1         NA      0
                00860   N    Anesth, surgery of abdomen                           1         NA      0
                00862   N    Anesth, kidney/ureter surg                           1         NA      0
                00864   C    Anesth, removal of bladder                           1         NA      0                     OR
                00865   C    Anesth, removal of prostate                          1         NA      0                     OR
                00866   C    Anesth, removal of adrenal                           1         NA      0                     OR
                00868   C    Anesth, kidney transplant                            1         NA      0                     OR
                00870   N    Anesth, bladder stone surg                           1         NA      0
                00872   N    Anesth kidney stone destruct                         1         NA      0
                00873   N    Anesth kidney stone destruct                         1         NA      0
                00880   N    Anesth, abdomen vessel surg                          1         NA      0
                00882   C    Anesth, major vein ligation                          1         NA      0                     OR
                00902   N    Anesth, anorectal surgery                            1         NA      0
                00904   C    Anesth, perineal surgery                             1         NA      0                     OR
                00906   N    Anesth, removal of vulva                             1         NA      0
                00908   C    Anesth, removal of prostate                          1         NA      0                     OR
                00910   N    Anesth, bladder surgery                              1         NA      0

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 2 of 216                                                                                                                    All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC    RW     NWR     OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010   2010   2010     Fee            Fee
                00912   N    Anesth, bladder tumor surg                           1         NA      0
                00914   N    Anesth, removal of prostate                          1         NA      0
                00916   N    Anesth, bleeding control                             1         NA      0
                00918   N    Anesth, stone removal                                1         NA      0
                00920   N    Anesth, genitalia surgery                            1         NA      0
                00921   N    Anesth, vasectomy                                    1         NA      0
                00922   N    Anesth, sperm duct surgery                           1         NA      0
                00924   N    Anesth, testis exploration                           1         NA      0
                00926   N    Anesth, removal of testis                            1         NA      0
                00928   N    Anesth, removal of testis                            1         NA      0
                00930   N    Anesth, testis suspension                            1         NA      0
                00932   C    Anesth, amputation of penis                          1         NA      0                     OR
                00934   C    Anesth, penis, nodes removal                         1         NA      0                     OR
                00936   C    Anesth, penis, nodes removal                         1         NA      0                     OR
                00938   N    Anesth, insert penis device                          1         NA      0
                00940   N    Anesth, vaginal procedures                           1         NA      0
                00942   N    Anesth, surg on vag/urethral                         1         NA      0
                00944   C    Anesth, vaginal hysterectomy                         1         NA      0                     OR
                00948   N    Anesth, repair of cervix                             1         NA      0
                00950   N    Anesth, vaginal endoscopy                            1         NA      0
                00952   N    Anesth, hysteroscope/graph                           1         NA      0
                01112   N    Anesth, bone aspirate/bx                             1         NA      0
                01120   N    Anesth, pelvis surgery                               1         NA      0
                01130   N    Anesth, body cast procedure                          1         NA      0
                01140   C    Anesth, amputation at pelvis                         1         NA      0                     OR
                01150   C    Anesth, pelvic tumor surgery                         1         NA      0                     OR
                01160   N    Anesth, pelvis procedure                             1         NA      0
                01170   N    Anesth, pelvis surgery                               1         NA      0
                01173   N    Anesth, fx repair, pelvis                            1         NA      0
                01180   N    Anesth, pelvis nerve removal                         1         NA      0
                01190   N    Anesth, pelvis nerve removal                         1         NA      0
                01200   N    Anesth, hip joint procedure                          1         NA      0
                01202   N    Anesth, arthroscopy of hip                           1         NA      0
                01210   N    Anesth, hip joint surgery                            1         NA      0
                01212   C    Anesth, hip disarticulation                          1         NA      0                     OR
                01214   C    Anesth, hip arthroplasty                             1         NA      0                     OR
                01215   N    Anesth, revise hip repair                            1         NA      0
                01220   N    Anesth, procedure on femur                           1         NA      0
                01230   N    Anesth, surgery of femur                             1         NA      0
                01232   C    Anesth, amputation of femur                          1         NA      0                     OR
                01234   C    Anesth, radical femur surg                           1         NA      0                     OR
                01250   N    Anesth, upper leg surgery                            1         NA      0
                01260   N    Anesth, upper leg veins surg                         1         NA      0
                01270   N    Anesth, thigh arteries surg                          1         NA      0
                01272   C    Anesth, femoral artery surg                          1         NA      0                     OR
                01274   C    Anesth, femoral embolectomy                          1         NA      0                     OR
                01320   N    Anesth, knee area surgery                            1         NA      0
                01340   N    Anesth, knee area procedure                          1         NA      0
                01360   N    Anesth, knee area surgery                            1         NA      0
                01380   N    Anesth, knee joint procedure                         1         NA      0
                01382   N    Anesth, dx knee arthroscopy                          1         NA      0
                01390   N    Anesth, knee area procedure                          1         NA      0
                01392   N    Anesth, knee area surgery                            1         NA      0
                01400   N    Anesth, knee joint surgery                           1         NA      0
                01402   C    Anesth, knee arthroplasty                            1         NA      0                     OR
                01404   C    Anesth, amputation at knee                           1         NA      0                     OR
                01420   N    Anesth, knee joint casting                           1         NA      0
                01430   N    Anesth, knee veins surgery                           1         NA      0
                01432   N    Anesth, knee vessel surg                             1         NA      0
                01440   N    Anesth, knee arteries surg                           1         NA      0
                01442   C    Anesth, knee artery surg                             1         NA      0                     OR
                01444   C    Anesth, knee artery repair                           1         NA      0                     OR
                01462   N    Anesth, lower leg procedure                          1         NA      0
                01464   N    Anesth, ankle/ft arthroscopy                         1         NA      0
                01470   N    Anesth, lower leg surgery                            1         NA      0
                01472   N    Anesth, achilles tendon surg                         1         NA      0

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 3 of 216                                                                                                                    All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC    RW     NWR     OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010   2010   2010     Fee            Fee
                01474   N    Anesth, lower leg surgery                            1         NA      0
                01480   N    Anesth, lower leg bone surg                          1         NA      0
                01482   N    Anesth, radical leg surgery                          1         NA      0
                01484   N    Anesth, lower leg revision                           1         NA      0
                01486   C    Anesth, ankle replacement                            1         NA      0                     OR
                01490   N    Anesth, lower leg casting                            1         NA      0
                01500   N    Anesth, leg arteries surg                            1         NA      0
                01502   C    Anesth, lwr leg embolectomy                          1         NA      0                     OR
                01520   N    Anesth, lower leg vein surg                          1         NA      0
                01522   N    Anesth, lower leg vein surg                          1         NA      0
                01610   N    Anesth, surgery of shoulder                          1         NA      0
                01620   N    Anesth, shoulder procedure                           1         NA      0
                01622   N    Anes dx shoulder arthroscopy                         1         NA      0
                01630   N    Anesth, surgery of shoulder                          1         NA      0
                01634   C    Anesth, shoulder joint amput                         1         NA      0                     OR
                01636   C    Anesth, forequarter amput                            1         NA      0                     OR
                01638   C    Anesth, shoulder replacement                         1         NA      0                     OR
                01650   N    Anesth, shoulder artery surg                         1         NA      0
                01652   C    Anesth, shoulder vessel surg                         1         NA      0                     OR
                01654   C    Anesth, shoulder vessel surg                         1         NA      0                     OR
                01656   C    Anesth, arm-leg vessel surg                          1         NA      0                     OR
                01670   N    Anesth, shoulder vein surg                           1         NA      0
                01680   N    Anesth, shoulder casting                             1         NA      0
                01682   N    Anesth, airplane cast                                1         NA      0
                01710   N    Anesth, elbow area surgery                           1         NA      0
                01712   N    Anesth, uppr arm tendon surg                         1         NA      0
                01714   N    Anesth, uppr arm tendon surg                         1         NA      0
                01716   N    Anesth, biceps tendon repair                         1         NA      0
                01730   N    Anesth, uppr arm procedure                           1         NA      0
                01732   N    Anesth, dx elbow arthroscopy                         1         NA      0
                01740   N    Anesth, upper arm surgery                            1         NA      0
                01742   N    Anesth, humerus surgery                              1         NA      0
                01744   N    Anesth, humerus repair                               1         NA      0
                01756   C    Anesth, radical humerus surg                         1         NA      0                     OR
                01758   N    Anesth, humeral lesion surg                          1         NA      0
                01760   N    Anesth, elbow replacement                            1         NA      0
                01770   N    Anesth, uppr arm artery surg                         1         NA      0
                01772   N    Anesth, uppr arm embolectomy                         1         NA      0
                01780   N    Anesth, upper arm vein surg                          1         NA      0
                01782   N    Anesth, uppr arm vein repair                         1         NA      0
                01810   N    Anesth, lower arm surgery                            1         NA      0
                01820   N    Anesth, lower arm procedure                          1         NA      0
                01829   N    Anesth, dx wrist arthroscopy                         1         NA      0
                01830   N    Anesth, lower arm surgery                            1         NA      0
                01832   N    Anesth, wrist replacement                            1         NA      0
                01840   N    Anesth, lwr arm artery surg                          1         NA      0
                01842   N    Anesth, lwr arm embolectomy                          1         NA      0
                01844   N    Anesth, vascular shunt surg                          1         NA      0
                01850   N    Anesth, lower arm vein surg                          1         NA      0
                01852   N    Anesth, lwr arm vein repair                          1         NA      0
                01860   N    Anesth, lower arm casting                            1         NA      0
                01916   N    Anesth, dx arteriography                             1         NA      0
                01920   N    Anesth, catheterize heart                            1         NA      0
     L          01922   N    Anesth, cat or MRI scan                              1         NA      0
                01924   N    Anes, ther interven rad, art                         1         NA      0
                01925   N    Anes, ther interven rad, car                         1         NA      0
                01926   N    Anes, tx interv rad hrt/cran                         1         NA      0
                01930   N    Anes, ther interven rad, vei                         1         NA      0
                01931   N    Anes, ther interven rad, tip                         1         NA      0
                01932   N    Anes, tx interv rad, th vein                         1         NA      0
                01933   N    Anes, tx interv rad, cran v                          1         NA      0
                01935   N    Anesth, perc img dx sp proc                          1         NA      0
                01936   N    Anesth, perc img tx sp proc                          1         NA      0
                01951   N    Anesth, burn, less 4 percent                         1         NA      0
                01952   N    Anesth, burn, 4-9 percent                            1         NA      0
                01953   N    Anesth, burn, each 9 percent                         1         NA      0

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 4 of 216                                                                                                                    All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC     RW        NWR       OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010    2010      2010       Fee            Fee
                01958   N    Anesth, antepartum manipul                           1         NA       0
                01960   N    Anesth, vaginal delivery                             1         NA       0
                01961   N    Anesth, cs delivery                                  1         NA       0
                01962   N    Anesth, emer hysterectomy                            1         NA       0
                01963   N    Anesth, cs hysterectomy                              1         NA       0
                01965   N    Anesth, inc/missed ab proc                           1         NA       0
                01966   N    Anesth, induced ab procedure                         1         NA       0
                01967   N    Anesth/analg, vag delivery                           1         NA       0
                01968   N    Anes/analg cs deliver add-on                         1         NA       0
                01969   N    Anesth/analg cs hyst add-on                          1         NA       0
                01990   C    Support for organ donor                              1         NA       0                          OR
                01991   N    Anesth, nerve block/inj                              1         NA       0
                01992   N    Anesth, n block/inj, prone                           1         NA       0
                01996   N    Hosp manage cont drug admin                          1         NA       0
                01999   N    Unlisted anesth procedure                            1         NA       0
                10021   T    Fna w/o image                                        1          1     0002    1.5111    101.86
                10022   T    Fna w/image                                          1          1     0004    4.5991    310.01
                10040   T    Acne surgery                                         1          1     0013    0.8789     59.24
                10060   T    Drainage of skin abscess                             1          1     0006    1.4557     98.12
                10061   T    Drainage of skin abscess                             1          1     0006    1.4557     98.12
                10080   T    Drainage of pilonidal cyst                           1          1     0006    1.4557     98.12
                10081   T    Drainage of pilonidal cyst                           1          1     0007   12.6217    850.78
                10120   T    Remove foreign body                                  1          5     0016    2.7982    188.62
                10121   T    Remove foreign body                                  1          5     0021   17.4975   1179.44
                10140   T    Drainage of hematoma/fluid                           1          1     0007   12.6217    850.78
                10160   T    Puncture drainage of lesion                          1          1     0006    1.4557     98.12
                10180   T    Complex drainage, wound                              1          1     0008   19.4063    1308.1
                11000   T    Debride infected skin                                1          1     0015    1.5412    103.89
                11001   T    Debride infected skin add-on                         1          4     0013    0.8789     59.24
                11004   C    Debride genitalia & perineum                         1          1       0                          OR
                11005   C    Debride abdom wall                                   1          1       0                          OR
                11006   C    Debride genit/per/abdom wall                         1          1       0                          OR
                11008   C    Remove mesh from abd wall                            1          1       0                          OR
                11010   T    Debride skin, fx                                     1          1     0019   4.3625    294.06
                11011   T    Debride skin/muscle, fx                              1          1     0019   4.3625    294.06
                11012   T    Debride skin/muscle/bone, fx                         1          1     0019   4.3625    294.06
                11040   T    Debride skin, partial                                1          1     0015   1.5412    103.89
                11041   T    Debride skin, full                                   1          1     0015   1.5412    103.89
                11042   T    Debride skin/tissue                                  1          1     0016   2.7982    188.62
                11043   T    Debride tissue/muscle                                1          1     0016   2.7982    188.62
                11044   T    Debride tissue/muscle/bone                           1          1     0020   8.2028    552.92
                11055   T    Trim skin lesion                                     1          1     0013   0.8789     59.24
                11056   T    Trim skin lesions, 2 to 4                            1          1     0013   0.8789     59.24
                11057   T    Trim skin lesions, over 4                            1          1     0013   0.8789     59.24
                11100   T    Biopsy, skin lesion                                  1          1     0015   1.5412    103.89
                11101   T    Biopsy, skin add-on                                  1          5     0013   0.8789     59.24
                11200   T    Removal of skin tags                                 0         NC       0
                11201   T    Remove skin tags add-on                              0         NC       0
                11300   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11301   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11302   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11303   T    Shave skin lesion                                    1          1     0015    1.5412    103.89
                11305   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11306   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11307   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11308   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11310   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11311   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11312   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11313   T    Shave skin lesion                                    1          1     0013    0.8789     59.24
                11400   T    Exc tr-ext b9+marg 0.5 < cm                          1          1     0019    4.3625    294.06
                11401   T    Exc tr-ext b9+marg 0.6-1 cm                          1          1     0019    4.3625    294.06
                11402   T    Exc tr-ext b9+marg 1.1-2 cm                          1          1     0019    4.3625    294.06
                11403   T    Exc tr-ext b9+marg 2.1-3 cm                          1          1     0020    8.2028    552.92
                11404   T    Exc tr-ext b9+marg 3.1-4 cm                          1          1     0021   17.4975   1179.44
                11406   T    Exc tr-ext b9+marg > 4.0 cm                          1          1     0021   17.4975   1179.44

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 5 of 216                                                                                                                          All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC     RW        NWR       OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010    2010      2010       Fee            Fee
                11420   T    Exc h-f-nk-sp b9+marg 0.5 <                          1          1     0020    8.2028    552.92
                11421   T    Exc h-f-nk-sp b9+marg 0.6-1                          1          1     0020    8.2028    552.92
                11422   T    Exc h-f-nk-sp b9+marg 1.1-2                          1          1     0020    8.2028    552.92
                11423   T    Exc h-f-nk-sp b9+marg 2.1-3                          1          1     0021   17.4975   1179.44
                11424   T    Exc h-f-nk-sp b9+marg 3.1-4                          1          1     0021   17.4975   1179.44
                11426   T    Exc h-f-nk-sp b9+marg > 4 cm                         1          1     0022    23.388   1576.49
                11440   T    Exc face-mm b9+marg 0.5 < cm                         1          1     0019    4.3625    294.06
                11441   T    Exc face-mm b9+marg 0.6-1 cm                         1          1     0019    4.3625    294.06
                11442   T    Exc face-mm b9+marg 1.1-2 cm                         1          1     0020    8.2028    552.92
                11443   T    Exc face-mm b9+marg 2.1-3 cm                         1          1     0020    8.2028    552.92
                11444   T    Exc face-mm b9+marg 3.1-4 cm                         1          1     0020    8.2028    552.92
                11446   T    Exc face-mm b9+marg > 4 cm                           1          1     0022    23.388   1576.49
                11450   T    Removal, sweat gland lesion                          1          1     0022    23.388   1576.49
                11451   T    Removal, sweat gland lesion                          1          1     0022    23.388   1576.49
                11462   T    Removal, sweat gland lesion                          1          1     0022    23.388   1576.49
                11463   T    Removal, sweat gland lesion                          1          2     0022    23.388   1576.49
                11470   T    Removal, sweat gland lesion                          1          1     0022    23.388   1576.49
                11471   T    Removal, sweat gland lesion                          1          1     0022    23.388   1576.49
                11600   T    Exc tr-ext mlg+marg 0.5 < cm                         1          2     0020    8.2028    552.92
                11601   T    Exc tr-ext mlg+marg 0.6-1 cm                         1          2     0019    4.3625    294.06
                11602   T    Exc tr-ext mlg+marg 1.1-2 cm                         1          2     0019    4.3625    294.06
                11603   T    Exc tr-ext mlg+marg 2.1-3 cm                         1          2     0020    8.2028    552.92
                11604   T    Exc tr-ext mlg+marg 3.1-4 cm                         1          2     0020    8.2028    552.92
                11606   T    Exc tr-ext mlg+marg > 4 cm                           1          2     0021   17.4975   1179.44
                11620   T    Exc h-f-nk-sp mlg+marg 0.5 <                         1          2     0020    8.2028    552.92
                11621   T    Exc h-f-nk-sp mlg+marg 0.6-1                         1          2     0019    4.3625    294.06
                11622   T    Exc h-f-nk-sp mlg+marg 1.1-2                         1          2     0020    8.2028    552.92
                11623   T    Exc h-f-nk-sp mlg+marg 2.1-3                         1          2     0021   17.4975   1179.44
                11624   T    Exc h-f-nk-sp mlg+marg 3.1-4                         1          2     0021   17.4975   1179.44
                11626   T    Exc h-f-nk-sp mlg+mar > 4 cm                         1          2     0022    23.388   1576.49
                11640   T    Exc face-mm malig+marg 0.5 <                         1          2     0020    8.2028    552.92
                11641   T    Exc face-mm malig+marg 0.6-1                         1          2     0020    8.2028    552.92
                11642   T    Exc face-mm malig+marg 1.1-2                         1          2     0020    8.2028    552.92
                11643   T    Exc face-mm malig+marg 2.1-3                         1          2     0020    8.2028    552.92
                11644   T    Exc face-mm malig+marg 3.1-4                         1          2     0021   17.4975   1179.44
                11646   T    Exc face-mm mlg+marg > 4 cm                          1          2     0022    23.388   1576.49
                11719   T    Trim nail(s)                                         1          1     0012    0.4436      29.9
                11720   T    Debride nail, 1-5                                    1          1     0013    0.8789     59.24
                11721   T    Debride nail, 6 or more                              1          1     0013    0.8789     59.24
                11730   T    Removal of nail plate                                1          1     0013    0.8789     59.24
                11732   T    Remove nail plate, add-on                            1          1     0013    0.8789     59.24
                11740   T    Drain blood from under nail                          1          1     0012    0.4436      29.9
                11750   T    Removal of nail bed                                  1          5     0019    4.3625    294.06
                11752   T    Remove nail bed/finger tip                           1          1     0022    23.388   1576.49
                11755   T    Biopsy, nail unit                                    1          1     0019    4.3625    294.06
                11760   T    Repair of nail bed                                   1          1     0133    1.3542     91.28
                11762   T    Reconstruction of nail bed                           1          2     0136   16.0542   1082.15
                11765   T    Excision of nail fold, toe                           1          2     0013    0.8789     59.24
                11770   T    Removal of pilonidal lesion                          1          1     0022    23.388   1576.49
                11771   T    Removal of pilonidal lesion                          1          1     0022    23.388   1576.49
                11772   T    Removal of pilonidal lesion                          1          1     0022    23.388   1576.49
                11900   T    Injection into skin lesions                          1          1     0013    0.8789     59.24
                11901   T    Added skin lesions injection                         1          1     0013    0.8789     59.24
     L          11920   T    Correct skin color defects                           1          1     0134    3.1508    212.38
     L          11921   T    Correct skin color defects                           1         NA     0134    3.1508    212.38
                11922   T    Correct skin color defects                           0         NC       0
                11950   T    Therapy for contour defects                          0         NC       0
                11951   T    Therapy for contour defects                          0         NC       0
                11952   T    Therapy for contour defects                          0         NC       0
                11954   T    Therapy for contour defects                          0         NC       0
     L          11960   T    Insert tissue expander(s)                            1          1     0137   23.9317   1613.14
     L          11970   T    Replace tissue expander                              1          1     0051   46.5786   3139.68
     L          11971   T    Remove tissue expander(s)                            1          1     0022    23.388   1576.49
                11975   E    Insert contraceptive cap                             0         NC       0
                11976   T    Removal of contraceptive cap                         1          1     0019   4.3625    294.06
                11977   E    Removal/reinsert contra cap                          0         NC       0

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 6 of 216                                                                                                                          All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC     RW        NWR       OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010    2010      2010       Fee            Fee
     L          11980   X    Implant hormone pellet(s)                            1          1     0340    0.6693     45.11
     L          11981   X    Insert drug implant device                           1          1     0340    0.6693     45.11
     L          11982   X    Remove drug implant device                           1          1     0340    0.6693     45.11
     L          11983   X    Remove/insert drug implant                           1          1     0340    0.6693     45.11
                12001   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12002   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12004   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12005   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12006   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12007   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12011   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12013   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12014   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12015   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12016   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12017   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12018   T    Repair superficial wound(s)                          1          1     0133    1.3542     91.28
                12020   T    Closure of split wound                               1          1     0135    4.4386    299.19
                12021   T    Closure of split wound                               1          1     0134    3.1508    212.38
                12031   T    Intmd wnd repair s/tr/ext                            1          1     0133    1.3542     91.28
                12032   T    Intmd wnd repair s/tr/ext                            1          1     0134    3.1508    212.38
                12034   T    Intmd wnd repair s/tr/ext                            1          1     0133    1.3542     91.28
                12035   T    Intmd wnd repair s/tr/ext                            1          1     0133    1.3542     91.28
                12036   T    Intmd wnd repair s/tr/ext                            1          1     0134    3.1508    212.38
                12037   T    Intmd wnd repair s/tr/ext                            1          1     0134    3.1508    212.38
                12041   T    Intmd wnd repair n-hf/genit                          1          1     0133    1.3542     91.28
                12042   T    Intmd wnd repair n-hg/genit                          1          1     0133    1.3542     91.28
                12044   T    Intmd wnd repair n-hg/genit                          1          1     0133    1.3542     91.28
                12045   T    Intmd wnd repair n-hg/genit                          1          1     0134    3.1508    212.38
                12046   T    Intmd wnd repair n-hg/genit                          1          1     0134    3.1508    212.38
                12047   T    Intmd wnd repair n-hg/genit                          1          1     0134    3.1508    212.38
                12051   T    Intmd wnd repair face/mm                             1          1     0133    1.3542     91.28
                12052   T    Intmd wnd repair face/mm                             1          1     0133    1.3542     91.28
                12053   T    Intmd wnd repair face/mm                             1          1     0133    1.3542     91.28
                12054   T    Intmd wnd repair, face/mm                            1          1     0133    1.3542     91.28
                12055   T    Intmd wnd repair face/mm                             1          1     0134    3.1508    212.38
                12056   T    Intmd wnd repair face/mm                             1          1     0134    3.1508    212.38
                12057   T    Intmd wnd repair face/mm                             1          1     0134    3.1508    212.38
                13100   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13101   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13102   T    Repair wound/lesion add-on                           1          1     0135    4.4386    299.19
                13120   T    Repair of wound or lesion                            1          1     0134    3.1508    212.38
                13121   T    Repair of wound or lesion                            1          1     0134    3.1508    212.38
                13122   T    Repair wound/lesion add-on                           1          1     0133    1.3542     91.28
                13131   T    Repair of wound or lesion                            1          1     0134    3.1508    212.38
                13132   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13133   T    Repair wound/lesion add-on                           1          1     0134    3.1508    212.38
                13150   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13151   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13152   T    Repair of wound or lesion                            1          1     0135    4.4386    299.19
                13153   T    Repair wound/lesion add-on                           1          1     0134    3.1508    212.38
                13160   T    Late closure of wound                                1          1     0137   23.9317   1613.14
                14000   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14001   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14020   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14021   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14040   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14041   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14060   T    Skin tissue rearrangement                            1          1     0136   16.0542   1082.15
                14061   T    Skin tissue rearrangement                            1          2     0136   16.0542   1082.15
                14301   T    Skin tissue rearrangement                            1          1     0137   23.9317   1613.14
                14302   T    Skin tissue rearrange add-on                         1         NA     0137   23.9317   1613.14
                14350   T    Skin tissue rearrangement                            1          1     0137   23.9317   1613.14
                15002   T    Wound prep, trk/arm/leg                              1          1     0135    4.4386    299.19
                15003   T    Wound prep, addl 100 cm                              1          1     0135    4.4386    299.19
                15004   T    Wound prep, f/n/hf/g                                 1          1     0135    4.4386    299.19

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 7 of 216                                                                                                                          All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC     RW        NWR       OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010    2010      2010       Fee            Fee
                15005   T    Wnd prep, f/n/hf/g, addl cm                          1          1     0135    4.4386    299.19
                15040   T    Harvest cultured skin graft                          1          1     0134    3.1508    212.38
                15050   T    Skin pinch graft                                     1          1     0135    4.4386    299.19
                15100   T    Skin splt grft, trnk/arm/leg                         1          1     0137   23.9317   1613.14
                15101   T    Skin splt grft t/a/l, add-on                         1          1     0137   23.9317   1613.14
                15110   T    Epidrm autogrft trnk/arm/leg                         1          1     0135    4.4386    299.19
                15111   T    Epidrm autogrft t/a/l add-on                         1          1     0135    4.4386    299.19
                15115   T    Epidrm a-grft face/nck/hf/g                          1          1     0135    4.4386    299.19
                15116   T    Epidrm a-grft f/n/hf/g addl                          1          1     0135    4.4386    299.19
                15120   T    Skn splt a-grft fac/nck/hf/g                         1          1     0137   23.9317   1613.14
                15121   T    Skn splt a-grft f/n/hf/g add                         1          1     0137   23.9317   1613.14
                15130   T    Derm autograft, trnk/arm/leg                         1          1     0136   16.0542   1082.15
                15131   T    Derm autograft t/a/l add-on                          1          1     0136   16.0542   1082.15
                15135   T    Derm autograft face/nck/hf/g                         1          1     0136   16.0542   1082.15
                15136   T    Derm autograft, f/n/hf/g add                         1          1     0136   16.0542   1082.15
                15150   T    Cult epiderm grft t/arm/leg                          1          1     0135    4.4386    299.19
                15151   T    Cult epiderm grft t/a/l addl                         1          1     0135    4.4386    299.19
                15152   T    Cult epiderm graft t/a/l +%                          1          1     0135    4.4386    299.19
                15155   T    Cult epiderm graft, f/n/hf/g                         1          1     0135    4.4386    299.19
                15156   T    Cult epidrm grft f/n/hfg add                         1          1     0135    4.4386    299.19
                15157   T    Cult epiderm grft f/n/hfg +%                         1          1     0135    4.4386    299.19
     L          15170   T    Acell graft trunk/arms/legs                          1          1     0135    4.4386    299.19
     L          15171   T    Acell graft t/arm/leg add-on                         1          1     0134    3.1508    212.38
     L          15175   T    Acellular graft, f/n/hf/g                            1          1     0135    4.4386    299.19
     L          15176   T    Acell graft, f/n/hf/g add-on                         1          1     0135    4.4386    299.19
                15200   T    Skin full graft, trunk                               1          1     0136   16.0542   1082.15
                15201   T    Skin full graft trunk add-on                         1          1     0136   16.0542   1082.15
                15220   T    Skin full graft sclp/arm/leg                         1          1     0136   16.0542   1082.15
                15221   T    Skin full graft add-on                               1          1     0135    4.4386    299.19
                15240   T    Skin full grft face/genit/hf                         1          1     0136   16.0542   1082.15
                15241   T    Skin full graft add-on                               1          1     0135    4.4386    299.19
                15260   T    Skin full graft een & lips                           1          1     0136   16.0542   1082.15
                15261   T    Skin full graft add-on                               1          1     0136   16.0542   1082.15
                15300   T    Apply skinallogrft, t/arm/lg                         1          1     0135    4.4386    299.19
                15301   T    Apply sknallogrft t/a/l addl                         1          1     0135    4.4386    299.19
                15320   T    Apply skin allogrft f/n/hf/g                         1          1     0135    4.4386    299.19
                15321   T    Aply sknallogrft f/n/hfg add                         1          1     0135    4.4386    299.19
                15330   T    Aply acell alogrft t/arm/leg                         1          1     0135    4.4386    299.19
                15331   T    Aply acell grft t/a/l add-on                         1          1     0135    4.4386    299.19
                15335   T    Apply acell graft, f/n/hf/g                          1          1     0135    4.4386    299.19
                15336   T    Aply acell grft f/n/hf/g add                         1          1     0135    4.4386    299.19
                15340   T    Apply cult skin substitute                           1          1     0134    3.1508    212.38
                15341   T    Apply cult skin sub add-on                           1          1     0134    3.1508    212.38
                15360   T    Apply cult derm sub, t/a/l                           1          1     0134    3.1508    212.38
                15361   T    Aply cult derm sub t/a/l add                         1          1     0134    3.1508    212.38
                15365   T    Apply cult derm sub f/n/hf/g                         1          1     0134    3.1508    212.38
                15366   T    Apply cult derm f/hf/g add                           1          1     0134    3.1508    212.38
                15400   T    Apply skin xenograft, t/a/l                          1          1     0135    4.4386    299.19
                15401   T    Apply skn xenogrft t/a/l add                         1          1     0135    4.4386    299.19
                15420   T    Apply skin xgraft, f/n/hf/g                          1          1     0135    4.4386    299.19
                15421   T    Apply skn xgrft f/n/hf/g add                         1          1     0135    4.4386    299.19
                15430   T    Apply acellular xenograft                            1          1     0135    4.4386    299.19
                15431   T    Apply acellular xgraft add                           1          1     0135    4.4386    299.19
                15570   T    Form skin pedicle flap                               1          1     0137   23.9317   1613.14
                15572   T    Form skin pedicle flap                               1          1     0137   23.9317   1613.14
                15574   T    Form skin pedicle flap                               1          1     0137   23.9317   1613.14
                15576   T    Form skin pedicle flap                               1          1     0137   23.9317   1613.14
                15600   T    Skin graft                                           1          1     0137   23.9317   1613.14
                15610   T    Skin graft                                           1          1     0137   23.9317   1613.14
                15620   T    Skin graft                                           1          1     0137   23.9317   1613.14
                15630   T    Skin graft                                           1          1     0137   23.9317   1613.14
                15650   T    Transfer skin pedicle flap                           1          1     0137   23.9317   1613.14
                15731   T    Forehead flap w/vasc pedicle                         1          1     0137   23.9317   1613.14
                15732   T    Muscle-skin graft, head/neck                         1          1     0137   23.9317   1613.14
                15734   T    Muscle-skin graft, trunk                             1          1     0137   23.9317   1613.14
                15736   T    Muscle-skin graft, arm                               1          1     0137   23.9317   1613.14

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 8 of 216                                                                                                                          All Rights Reserved
                                                            HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                               Washington State Medicaid


                                                                                           MAX     APC     RW        NWR       OPPS            OP
  AUTH          CPT     SI   Description                                        COV
                                                                                           UNITS   2010    2010      2010       Fee            Fee
                15738   T    Muscle-skin graft, leg                               1          1     0137   23.9317   1613.14
                15740   T    Island pedicle flap graft                            1          1     0136   16.0542   1082.15
                15750   T    Neurovascular pedicle graft                          1          1     0137   23.9317   1613.14
                15756   C    Free myo/skin flap microvasc                         1          1       0                          OR
                15757   C    Free skin flap, microvasc                            1          1       0                          OR
                15758   C    Free fascial flap, microvasc                         1          1       0                          OR
                15760   T    Composite skin graft                                 1          1     0137   23.9317   1613.14
                15770   T    Derma-fat-fascia graft                               1          1     0137   23.9317   1613.14
                15775   T    Hair transplant punch grafts                         0         NC       0
                15776   T    Hair transplant punch grafts                         0         NC       0
                15780   T    Abrasion treatment of skin                           1          1     0022   23.388    1576.49
                15781   T    Abrasion treatment of skin                           1          1     0019   4.3625     294.06
                15782   T    Abrasion treatment of skin                           1          1     0019   4.3625     294.06
                15783   T    Abrasion treatment of skin                           1          1     0016   2.7982     188.62
                15786   T    Abrasion, lesion, single                             1          1     0013   0.8789      59.24
                15787   T    Abrasion, lesions, add-on                            1          1     0013   0.8789      59.24
                15788   T    Chemical peel, face, epiderm                         1          1     0013   0.8789      59.24
                15789   T    Chemical peel, face, dermal                          1          1     0015   1.5412     103.89
                15792   T    Chemical peel, nonfacial                             1          1     0015   1.5412     103.89
                15793   T    Chemical peel, nonfacial                             1          1     0013   0.8789      59.24
                15819   T    Plastic surgery, neck                                0         NC       0
                15820   T    Revision of lower eyelid                             0         NC       0
                15821   T    Revision of lower eyelid                             0         NC       0
   EPA          15822   T    Revision of upper eyelid                             1          2     0137   23.9317   1613.14
   EPA          15823   T    Revision of upper eyelid                             1          2     0137   23.9317   1613.14
                15824   T    Removal of forehead wrinkles                         0         NC       0
                15825   T    Removal of neck wrinkles                             0         NC       0
                15826   T    Removal of brow wrinkles                             0         NC       0
                15828   T    Removal of face wrinkles                             0         NC       0
                15829   T    Removal of skin wrinkles                             0         NC       0
    PA          15830   T    Exc skin abd                                         1          1     0022   23.388    1576.49
                15832   T    Excise excessive skin tissue                         0         NC       0
                15833   T    Excise excessive skin tissue                         0         NC       0
                15834   T    Excise excessive skin tissue                         0         NC       0
                15835   T    Excise excessive skin tissue                         0         NC       0
                15836   T    Excise excessive skin tissue                         0         NC       0
                15837   T    Excise excessive skin tissue                         0         NC       0
                15838   T    Excise excessive skin tissue                         0         NC       0
                15839   T    Excise excessive skin tissue                         0         NC       0
                15840   T    Graft for face nerve palsy                           1          1     0137   23.9317   1613.14
                15841   T    Graft for face nerve palsy                           1          1     0137   23.9317   1613.14
                15842   T    Flap for face nerve palsy                            1          1     0137   23.9317   1613.14
                15845   T    Skin and muscle repair, face                         1          1     0137   23.9317   1613.14
                15847   T    Exc skin abd add-on                                  0         NC       0
                15850   T    Removal of sutures                                   1          1     0016   2.7982    188.62
                15851   T    Removal of sutures                                   1          1     0016   2.7982    188.62
                15852   X    Dressing change not for burn                         1          1     0340   0.6693     45.11
                15860   X    Test for blood flow in graft                         1          1     0340   0.6693     45.11
                15876   T    Suction assisted lipectomy                           0         NC       0
                15877   T    Suction assisted lipectomy                           0         NC       0
                15878   T    Suction assisted lipectomy                           0         NC       0
                15879   T    Suction assisted lipectomy                           0         NC       0
                15920   T    Removal of tail bone ulcer                           1          1     0019    4.3625    294.06
                15922   T    Removal of tail bone ulcer                           1          1     0137   23.9317   1613.14
                15931   T    Remove sacrum pressure sore                          1          1     0022    23.388   1576.49
                15933   T    Remove sacrum pressure sore                          1          1     0022    23.388   1576.49
                15934   T    Remove sacrum pressure sore                          1          1     0137   23.9317   1613.14
                15935   T    Remove sacrum pressure sore                          1          1     0137   23.9317   1613.14
                15936   T    Remove sacrum pressure sore                          1          1     0136   16.0542   1082.15
                15937   T    Remove sacrum pressure sore                          1          1     0137   23.9317   1613.14
                15940   T    Remove hip pressure sore                             1          1     0022    23.388   1576.49
                15941   T    Remove hip pressure sore                             1          1     0022    23.388   1576.49
                15944   T    Remove hip pressure sore                             1          1     0137   23.9317   1613.14
                15945   T    Remove hip pressure sore                             1          1     0137   23.9317   1613.14
                15946   T    Remove hip pressure sore                             1          1     0137   23.9317   1613.14
                15950   T    Remove thigh pressure sore                           1          1     0022    23.388   1576.49

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 9 of 216                                                                                                                          All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             15951     T    Remove thigh pressure sore                           1          1     0022    23.388   1576.49
             15952     T    Remove thigh pressure sore                           1          1     0136   16.0542   1082.15
             15953     T    Remove thigh pressure sore                           1          1     0136   16.0542   1082.15
             15956     T    Remove thigh pressure sore                           1          1     0136   16.0542   1082.15
             15958     T    Remove thigh pressure sore                           1          1     0136   16.0542   1082.15
             15999     T    Removal of pressure sore                             1          1     0019    4.3625    294.06
             16000     T    Initial treatment of burn(s)                         1          1     0013    0.8789     59.24
             16020     T    Dress/debrid p-thick burn, s                         1          1     0015    1.5412    103.89
             16025     T    Dress/debrid p-thick burn, m                         1          1     0015    1.5412    103.89
             16030     T    Dress/debrid p-thick burn, l                         1          1     0015    1.5412    103.89
             16035     T    Incision of burn scab, initi                         1          1     0015    1.5412    103.89
             16036     C    Escharotomy; addl incision                           1          1       0                          OR
             17000     T    Destruct premalg lesion                              1          1     0013   0.8789     59.24
             17003     T    Destruct premalg les, 2-14                           1         13     0012   0.4436      29.9
             17004     T    Destroy premlg lesions 15+                           1          1     0016   2.7982    188.62
             17106     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17107     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17108     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17110     T    Destruct b9 lesion, 1-14                             1          1     0013   0.8789     59.24
             17111     T    Destruct lesion, 15 or more                          1          1     0015   1.5412    103.89
             17250     T    Chemical cautery, tissue                             1          1     0015   1.5412    103.89
             17260     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17261     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17262     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17263     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17264     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17266     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17270     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17271     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17272     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17273     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17274     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17276     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17280     T    Destruction of skin lesions                          1          1     0015   1.5412    103.89
             17281     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17282     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17283     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17284     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17286     T    Destruction of skin lesions                          1          1     0016   2.7982    188.62
             17311     T    Mohs, 1 stage, h/n/hf/g                              1          1     0694   4.9337    332.56
             17312     T    Mohs addl stage                                      1          1     0694   4.9337    332.56
             17313     T    Mohs, 1 stage, t/a/l                                 1          1     0694   4.9337    332.56
             17314     T    Mohs, addl stage, t/a/l                              1          1     0694   4.9337    332.56
             17315     T    Mohs surg, addl block                                1          1     0694   4.9337    332.56
             17340     T    Cryotherapy of skin                                  1          1     0013   0.8789     59.24
             17360     T    Skin peel therapy                                    0         NC       0
             17380     T    Hair removal by electrolysis                         0         NC       0
             17999     T    Skin tissue procedure                                1          1     0012    0.4436    29.9
             19000     T    Drainage of breast lesion                            1          1     0004    4.5991   310.01
             19001     T    Drain breast lesion add-on                           1          1     0002    1.5111   101.86
             19020     T    Incision of breast lesion                            1          1     0008   19.4063   1308.1
             19030     N    Injection for breast x-ray                           1          1       0
             19100     T    Bx breast percut w/o image                           1          1     0004    4.5991    310.01
             19101     T    Biopsy of breast, open                               1          1     0028   24.7516   1668.41
             19102     T    Bx breast percut w/image                             1          1     0005    7.8145    526.74
             19103     T    Bx breast percut w/device                            1          1     0037   15.5003   1044.81
             19105     T    Cryosurg ablate fa, each                             0         NC       0
             19110     T    Nipple exploration                                   1          1     0028   24.7516   1668.41
             19112     T    Excise breast duct fistula                           1          1     0028   24.7516   1668.41
             19120     T    Removal of breast lesion                             1          1     0028   24.7516   1668.41
             19125     T    Excision, breast lesion                              1          1     0028   24.7516   1668.41
             19126     T    Excision, addl breast lesion                         1          1     0028   24.7516   1668.41
             19260     T    Removal of chest wall lesion                         1          1     0021   17.4975   1179.44
             19271     C    Revision of chest wall                               1          1       0                          OR
             19272     C    Extensive chest wall surgery                         1          1       0                          OR
             19290     N    Place needle wire, breast                            1          1       0

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 10 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             19291     N    Place needle wire, breast                            1          1       0
             19295     N    Place breast clip, percut                            1          1       0
             19296     T    Place po breast cath for rad                         1          1     0648   58.2278    3924.9
             19297     T    Place breast cath for rad                            1          1     0648   58.2278    3924.9
             19298     T    Place breast rad tube/caths                          1          1     0648   58.2278    3924.9
   EPA       19300     T    Removal of breast tissue                             1          1     0028   24.7516   1668.41
    L        19301     T    Partical mastectomy                                  1          1     0028   24.7516   1668.41
    L        19302     T    P-mastectomy w/ln removal                            1          1     0030   41.9997   2831.03
    L        19303     T    Mast, simple, complete                               1          1     0029   34.1654   2302.95
    L        19304     T    Mast, subq                                           1          1     0029   34.1654   2302.95
             19305     C    Mast, radical                                        1          1       0                          OR
             19306     C    Mast, rad, urban type                                1          1       0                          OR
             19307     T    Mast, mod rad                                        1          1     0030   41.9997   2831.03
    L        19316     T    Suspension of breast                                 1          1     0029   34.1654   2302.95
   EPA       19318     T    Reduction of large breast                            1          1     0030   41.9997   2831.03
             19324     T    Enlarge breast                                       0         NC       0
             19325     T    Enlarge breast with implant                          0         NC       0
     L       19328     T    Removal of breast implant                            1          1     0029   34.1654   2302.95
     L       19330     T    Removal of implant material                          1          1     0029   34.1654   2302.95
     L       19340     T    Immediate breast prosthesis                          1          1     0030   41.9997   2831.03
     L       19342     T    Delayed breast prosthesis                            1          1     0648   58.2278    3924.9
     L       19350     T    Breast reconstruction                                1          1     0028   24.7516   1668.41
             19355     T    Correct inverted nipple(s)                           1          1     0029   34.1654   2302.95
     L       19357     T    Breast reconstruction                                1          1     0648   58.2278    3924.9
     L       19361     C    Breast reconstr w/lat flap                           1          1       0                          OR
     L       19364     C    Breast reconstruction                                1          1       0                          OR
     L       19366     T    Breast reconstruction                                1          1     0029   34.1654   2302.95
     L       19367     C    Breast reconstruction                                1          1       0                          OR
     L       19368     C    Breast reconstruction                                1          1       0                          OR
     L       19369     C    Breast reconstruction                                1          1       0                          OR
     L       19370     T    Surgery of breast capsule                            1          1     0029   34.1654   2302.95
     L       19371     T    Removal of breast capsule                            1          1     0029   34.1654   2302.95
     L       19380     T    Revise breast reconstruction                         1          1     0030   41.9997   2831.03
             19396     T    Design custom breast implant                         1          1     0029   34.1654   2302.95
             19499     T    Breast surgery procedure                             1          1     0028   24.7516   1668.41
             20000     T    Incision of abscess                                  1          1     0006    1.4557     98.12
             20005     T    Incision of deep abscess                             1          1     0049   22.0149   1483.94
             20100     T    Explore wound, neck                                  1          1     0252    7.6196    513.61
             20101     T    Explore wound, chest                                 1          1     0137   23.9317   1613.14
             20102     T    Explore wound, abdomen                               1          1     0137   23.9317   1613.14
             20103     T    Explore wound, extremity                             1          1     0007   12.6217    850.78
             20150     T    Excise epiphyseal bar                                1          1     0051   46.5786   3139.68
             20200     T    Muscle biopsy                                        1          1     0021   17.4975   1179.44
             20205     T    Deep muscle biopsy                                   1          1     0021   17.4975   1179.44
             20206     T    Needle biopsy, muscle                                1          1     0005    7.8145    526.74
             20220     T    Bone biopsy, trocar/needle                           1          1     0020    8.2028    552.92
             20225     T    Bone biopsy, trocar/needle                           1          1     0021   17.4975   1179.44
             20240     T    Bone biopsy, excisional                              1          1     0022    23.388   1576.49
             20245     T    Bone biopsy, excisional                              1          1     0022    23.388   1576.49
             20250     T    Open bone biopsy                                     1          1     0049   22.0149   1483.94
             20251     T    Open bone biopsy                                     1          1     0049   22.0149   1483.94
             20500     T    Injection of sinus tract                             1          1     0252    7.6196    513.61
             20501     N    Inject sinus tract for x-ray                         1          1       0
             20520     T    Removal of foreign body                              1          1     0019    4.3625    294.06
             20525     T    Removal of foreign body                              1          1     0022    23.388   1576.49
             20526     T    Ther injection, carp tunnel                          1          1     0204    2.5558    172.28
             20550     T    Inj tendon sheath/ligament                           1          1     0204    2.5558    172.28
             20551     T    Inj tendon origin/insertion                          1          1     0204    2.5558    172.28
             20552     T    Inj trigger point, 1/2 muscl                         1          1     0204    2.5558    172.28
             20553     T    Inject trigger points, =/> 3                         1          1     0204    2.5558    172.28
             20555     T    Place ndl musc/tis for rt                            1          1     0050   31.7717    2141.6
             20600     T    Drain/inject, joint/bursa                            1          1     0204    2.5558    172.28
             20605     T    Drain/inject, joint/bursa                            1          1     0204    2.5558    172.28
             20610     T    Drain/inject, joint/bursa                            1          1     0204    2.5558    172.28
             20612     T    Aspirate/inj ganglion cyst                           1          1     0204    2.5558    172.28
             20615     T    Treatment of bone cyst                               1          1     0004    4.5991    310.01

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 11 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             20650     T    Insert and remove bone pin                           1          1     0049   22.0149   1483.94
             20660     T    Apply, rem fixation device                           1          1     0138    4.7946    323.18
             20661     C    Application of head brace                            1          1       0                          OR
             20662     T    Application of pelvis brace                          1          1     0049   22.0149   1483.94
             20663     T    Application of thigh brace                           1          1     0049   22.0149   1483.94
             20664     C    Halo brace application                               1          1       0                          OR
             20665     X    Removal of fixation device                           1          1     0340    0.6693     45.11
             20670     T    Removal of support implant                           1          1     0021   17.4975   1179.44
             20680     T    Removal of support implant                           1          1     0022    23.388   1576.49
             20690     T    Apply bone fixation device                           1          1     0050   31.7717    2141.6
             20692     T    Apply bone fixation device                           1          1     0050   31.7717    2141.6
             20693     T    Adjust bone fixation device                          1          1     0049   22.0149   1483.94
             20694     T    Remove bone fixation device                          1          1     0049   22.0149   1483.94
             20696     T    Comp multiplane ext fixation                         1          1     0050   31.7717    2141.6
             20697     T    Comp ext fixate strut change                         1          1     0139   18.3962   1240.01
             20802     C    Replantation, arm, complete                          1          1       0                          OR
             20805     C    Replant forearm, complete                            1          1       0                          OR
             20808     C    Replantation hand, complete                          1          1       0                          OR
             20816     C    Replantation digit, complete                         1          1       0                          OR
             20822     T    Replantation digit, complete                         1          1     0054   28.2376   1903.38
             20824     C    Replantation thumb, complete                         1          1       0                          OR
             20827     C    Replantation thumb, complete                         1          1       0                          OR
             20838     C    Replantation foot, complete                          1          1       0                          OR
             20900     T    Removal of bone for graft                            1          1     0050   31.7717    2141.6
             20902     T    Removal of bone for graft                            1          1     0050   31.7717    2141.6
             20910     T    Remove cartilage for graft                           1          1     0137   23.9317   1613.14
             20912     T    Remove cartilage for graft                           1          1     0137   23.9317   1613.14
             20920     T    Removal of fascia for graft                          1          1     0136   16.0542   1082.15
             20922     T    Removal of fascia for graft                          1          1     0136   16.0542   1082.15
             20924     T    Removal of tendon for graft                          1          1     0050   31.7717    2141.6
             20926     T    Removal of tissue for graft                          1          1     0135    4.4386    299.19
             20930     C    Sp bone algrft morsel add-on                         1          1       0                          OR
             20931     C    Sp bone algrft struct add-on                         1          1       0                          OR
             20936     C    Sp bone agrft local add-on                           1          1       0                          OR
             20937     C    Sp bone agrft morsel add-on                          1          1       0                          OR
             20938     C    Sp bone agrft struct add-on                          1          1       0                          OR
             20950     T    Fluid pressure, muscle                               1          1     0006   1.4557     98.12
             20955     C    Fibula bone graft, microvasc                         1          1       0                          OR
             20956     C    Iliac bone graft, microvasc                          1          1       0                          OR
             20957     C    Mt bone graft, microvasc                             1          1       0                          OR
             20962     C    Other bone graft, microvasc                          1          1       0                          OR
             20969     C    Bone/skin graft, microvasc                           1          1       0                          OR
             20970     C    Bone/skin graft, iliac crest                         1          1       0                          OR
             20972     T    Bone/skin graft, metatarsal                          1          1     0056   52.5258   3540.55
             20973     T    Bone/skin graft, great toe                           1          1     0056   52.5258   3540.55
    PA       20974     A    Electrical bone stimulation                          1          1       0                         27.12
    PA       20975     N    Electrical bone stimulation                          1          1       0
    PA       20979     X    Us bone stimulation                                  1          1     0340    0.6693    45.11
             20982     T    Ablate, bone tumor(s) perq                           1          1     0051   46.5786   3139.68
             20985     N    Cptr-asst dir ms px                                  0         NC       0
             20999     T    Musculoskeletal surgery                              1          1     0049   22.0149   1483.94
             21010     T    Incision of jaw joint                                1          1     0254   24.9637    1682.7
             21011     T    Exc face les sc < 2 cm                               1          1     0020    8.2028    552.92
             21012     T    Exc face les sc = 2 cm                               1          1     0020    8.2028    552.92
             21013     T    Exc face tum deep < 2 cm                             1          1     0020    8.2028    552.92
             21014     T    Exc face tum deep = 2 cm                             1          1     0020    8.2028    552.92
             21015     T    Resect face tum < 2 cm                               1          1     0021   17.4975   1179.44
             21016     T    Resect face tum = 2 cm                               1          1     0022    23.388   1576.49
             21025     T    Excision of bone, lower jaw                          1          1     0256   42.9827   2897.29
             21026     T    Excision of facial bone(s)                           1          1     0256   42.9827   2897.29
             21029     T    Contour of face bone lesion                          1          1     0256   42.9827   2897.29
             21030     T    Excise max/zygoma b9 tumor                           1          1     0254   24.9637    1682.7
    PA       21031     T    Remove exostosis, mandible                           1          1     0254   24.9637    1682.7
    PA       21032     T    Remove exostosis, maxilla                            1          1     0254   24.9637    1682.7
             21034     T    Excise max/zygoma mlg tumor                          1          1     0256   42.9827   2897.29
             21040     T    Excise mandible lesion                               1          1     0254   24.9637    1682.7

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 12 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             21044     T    Removal of jaw bone lesion                           1          1     0256   42.9827   2897.29
             21045     C    Extensive jaw surgery                                1          1       0                          OR
             21046     T    Remove mandible cyst complex                         1          1     0256   42.9827   2897.29
             21047     T    Excise lwr jaw cyst w/repair                         1          1     0256   42.9827   2897.29
             21048     T    Remove maxilla cyst complex                          1          1     0256   42.9827   2897.29
             21049     T    Excis uppr jaw cyst w/repair                         1          1     0256   42.9827   2897.29
    PA       21050     T    Removal of jaw joint                                 1          1     0256   42.9827   2897.29
    PA       21060     T    Remove jaw joint cartilage                           1          1     0256   42.9827   2897.29
    PA       21070     T    Remove coronoid process                              1          1     0256   42.9827   2897.29
             21073     T    Mnpj of tmj w/anesth                                 1          1     0252    7.6196    513.61
    PA       21076     T    Prepare face/oral prosthesis                         1          1     0254   24.9637    1682.7
             21077     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21079     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21080     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
    PA       21081     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21082     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21083     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21084     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21085     T    Prepare face/oral prosthesis                         1          1     0253   17.1879   1158.57
             21086     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21087     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21088     T    Prepare face/oral prosthesis                         1          1     0256   42.9827   2897.29
             21089     T    Prepare face/oral prosthesis                         1          1     0250    1.1522     77.67
             21100     T    Maxillofacial fixation                               1          1     0256   42.9827   2897.29
             21110     T    Interdental fixation                                 1          1     0252    7.6196    513.61
             21116     N    Injection, jaw joint x-ray                           1          1       0
    PA       21120     T    Reconstruction of chin                               1          1     0254   24.9637    1682.7
    PA       21121     T    Reconstruction of chin                               1          1     0254   24.9637    1682.7
    PA       21122     T    Reconstruction of chin                               1          1     0254   24.9637    1682.7
             21123     T    Reconstruction of chin                               1          1     0254   24.9637    1682.7
    PA       21125     T    Augmentation, lower jaw bone                         1          1     0254   24.9637    1682.7
             21127     T    Augmentation, lower jaw bone                         1          1     0256   42.9827   2897.29
             21137     T    Reduction of forehead                                1          1     0254   24.9637    1682.7
             21138     T    Reduction of forehead                                1          1     0256   42.9827   2897.29
             21139     T    Reduction of forehead                                1          1     0256   42.9827   2897.29
    PA       21141     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21142     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21143     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21145     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21146     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21147     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21150     T    Reconstruct midface, lefort                          1          1     0256   42.9827   2897.29
    PA       21151     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21154     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21155     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21159     C    Reconstruct midface, lefort                          1          1       0                          OR
    PA       21160     C    Reconstruct midface, lefort                          1          1       0                          OR
             21172     T    Reconstruct orbit/forehead                           1          1     0256   42.9827   2897.29
             21175     T    Reconstruct orbit/forehead                           1          1     0256   42.9827   2897.29
             21179     C    Reconstruct entire forehead                          1          1       0                          OR
             21180     C    Reconstruct entire forehead                          1          1       0                          OR
             21181     T    Contour cranial bone lesion                          1          1     0254   24.9637   1682.7
             21182     C    Reconstruct cranial bone                             1          1       0                          OR
             21183     C    Reconstruct cranial bone                             1          1       0                          OR
             21184     C    Reconstruct cranial bone                             1          1       0                          OR
             21188     C    Reconstruction of midface                            1          1       0                          OR
    PA       21193     C    Reconst lwr jaw w/o graft                            1          1       0                          OR
    PA       21194     C    Reconst lwr jaw w/graft                              1          1       0                          OR
    PA       21195     T    Reconst lwr jaw w/o fixation                         1          1     0256   42.9827   2897.29
    PA       21196     C    Reconst lwr jaw w/fixation                           1          1       0                          OR
     L       21198     T    Reconstr lwr jaw segment                             1          1     0256   42.9827   2897.29
     L       21199     T    Reconstr lwr jaw w/advance                           1          1     0256   42.9827   2897.29
    PA       21206     T    Reconstruct upper jaw bone                           1          1     0256   42.9827   2897.29
    PA       21208     T    Augmentation of facial bones                         1          1     0256   42.9827   2897.29
    PA       21209     T    Reduction of facial bones                            1          1     0256   42.9827   2897.29
    PA       21210     T    Face bone graft                                      1          1     0256   42.9827   2897.29

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 13 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
    PA       21215     T    Lower jaw bone graft                                 1          1     0256   42.9827   2897.29
    PA       21230     T    Rib cartilage graft                                  1          1     0256   42.9827   2897.29
             21235     T    Ear cartilage graft                                  1          1     0254   24.9637    1682.7
    PA       21240     T    Reconstruction of jaw joint                          1          1     0256   42.9827   2897.29
    PA       21242     T    Reconstruction of jaw joint                          1          1     0256   42.9827   2897.29
    PA       21243     T    Reconstruction of jaw joint                          1          1     0256   42.9827   2897.29
    PA       21244     T    Reconstruction of lower jaw                          1          1     0256   42.9827   2897.29
    PA       21245     T    Reconstruction of jaw                                1          1     0256   42.9827   2897.29
    PA       21246     T    Reconstruction of jaw                                1          1     0256   42.9827   2897.29
    PA       21247     C    Reconstruct lower jaw bone                           1          1       0                          OR
    PA       21248     T    Reconstruction of jaw                                1          1     0256   42.9827   2897.29
    PA       21249     T    Reconstruction of jaw                                1          1     0256   42.9827   2897.29
    PA       21255     C    Reconstruct lower jaw bone                           1          1       0                          OR
             21256     T    Reconstruction of orbit                              1          1     0256   42.9827   2897.29
             21260     T    Revise eye sockets                                   1          1     0256   42.9827   2897.29
             21261     T    Revise eye sockets                                   1          1     0256   42.9827   2897.29
             21263     T    Revise eye sockets                                   1          1     0256   42.9827   2897.29
             21267     T    Revise eye sockets                                   1          1     0256   42.9827   2897.29
             21268     C    Revise eye sockets                                   1          1       0                          OR
             21270     T    Augmentation, cheek bone                             1          1     0256   42.9827   2897.29
             21275     T    Revision, orbitofacial bones                         1          1     0256   42.9827   2897.29
             21280     T    Revision of eyelid                                   1          1     0256   42.9827   2897.29
             21282     T    Revision of eyelid                                   1          1     0253   17.1879   1158.57
    PA       21295     T    Revision of jaw muscle/bone                          1          1     0252    7.6196    513.61
    PA       21296     T    Revision of jaw muscle/bone                          1          1     0254   24.9637    1682.7
             21299     T    Cranio/maxillofacial surgery                         1          1     0250    1.1522     77.67
             21310     T    Treatment of nose fracture                           1          1     0250    1.1522     77.67
             21315     T    Treatment of nose fracture                           1          1     0253   17.1879   1158.57
             21320     T    Treatment of nose fracture                           1          1     0253   17.1879   1158.57
             21325     T    Treatment of nose fracture                           1          1     0254   24.9637    1682.7
             21330     T    Treatment of nose fracture                           1          1     0254   24.9637    1682.7
             21335     T    Treatment of nose fracture                           1          1     0254   24.9637    1682.7
             21336     T    Treat nasal septal fracture                          1          1     0062   25.8446   1742.08
             21337     T    Treat nasal septal fracture                          1          1     0253   17.1879   1158.57
             21338     T    Treat nasoethmoid fracture                           1          1     0254   24.9637    1682.7
             21339     T    Treat nasoethmoid fracture                           1          1     0254   24.9637    1682.7
             21340     T    Treatment of nose fracture                           1          1     0256   42.9827   2897.29
             21343     C    Treatment of sinus fracture                          1          1       0                          OR
             21344     C    Treatment of sinus fracture                          1          1       0                          OR
             21345     T    Treat nose/jaw fracture                              1          1     0254   24.9637   1682.7
             21346     C    Treat nose/jaw fracture                              1          1       0                          OR
             21347     C    Treat nose/jaw fracture                              1          1       0                          OR
             21348     C    Treat nose/jaw fracture                              1          1       0                          OR
             21355     T    Treat cheek bone fracture                            1          1     0256   42.9827   2897.29
             21356     T    Treat cheek bone fracture                            1          1     0254   24.9637    1682.7
             21360     T    Treat cheek bone fracture                            1          1     0254   24.9637    1682.7
             21365     T    Treat cheek bone fracture                            1          1     0256   42.9827   2897.29
             21366     C    Treat cheek bone fracture                            1          1       0                          OR
             21385     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21386     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21387     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21390     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21395     C    Treat eye socket fracture                            1          1       0                          OR
             21400     T    Treat eye socket fracture                            1          1     0252    7.6196    513.61
             21401     T    Treat eye socket fracture                            1          1     0253   17.1879   1158.57
             21406     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21407     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21408     T    Treat eye socket fracture                            1          1     0256   42.9827   2897.29
             21421     T    Treat mouth roof fracture                            1          1     0254   24.9637    1682.7
             21422     C    Treat mouth roof fracture                            1          1       0                          OR
             21423     C    Treat mouth roof fracture                            1          1       0                          OR
             21431     C    Treat craniofacial fracture                          1          1       0                          OR
             21432     C    Treat craniofacial fracture                          1          1       0                          OR
             21433     C    Treat craniofacial fracture                          1          1       0                          OR
             21435     C    Treat craniofacial fracture                          1          1       0                          OR
             21436     C    Treat craniofacial fracture                          1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 14 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             21440     T    Treat dental ridge fracture                          1          1     0254   24.9637    1682.7
             21445     T    Treat dental ridge fracture                          1          1     0254   24.9637    1682.7
             21450     T    Treat lower jaw fracture                             1          1     0251     3.425    230.87
             21451     T    Treat lower jaw fracture                             1          1     0252    7.6196    513.61
             21452     T    Treat lower jaw fracture                             1          1     0253   17.1879   1158.57
             21453     T    Treat lower jaw fracture                             1          1     0256   42.9827   2897.29
             21454     T    Treat lower jaw fracture                             1          1     0254   24.9637    1682.7
             21461     T    Treat lower jaw fracture                             1          1     0256   42.9827   2897.29
             21462     T    Treat lower jaw fracture                             1          1     0256   42.9827   2897.29
             21465     T    Treat lower jaw fracture                             1          1     0256   42.9827   2897.29
             21470     T    Treat lower jaw fracture                             1          1     0256   42.9827   2897.29
             21480     T    Reset dislocated jaw                                 1          1     0250    1.1522     77.67
             21485     T    Reset dislocated jaw                                 1          1     0253   17.1879   1158.57
             21490     T    Repair dislocated jaw                                1          1     0256   42.9827   2897.29
             21495     T    Treat hyoid bone fracture                            1          1     0253   17.1879   1158.57
             21497     T    Interdental wiring                                   1          1     0253   17.1879   1158.57
             21499     T    Head surgery procedure                               1          1     0250    1.1522     77.67
             21501     T    Drain neck/chest lesion                              1          1     0008   19.4063    1308.1
             21502     T    Drain chest lesion                                   1          1     0049   22.0149   1483.94
             21510     C    Drainage of bone lesion                              1          1       0                          OR
             21550     T    Biopsy of neck/chest                                 1          1     0021   17.4975   1179.44
             21552     T    Exc neck les sc = 3 cm                               1          1     0022    23.388   1576.49
             21554     T    Exc neck tum deep = 5 cm                             1          1     0022    23.388   1576.49
             21555     T    Exc neck les sc < 3 cm                               1          1     0021   17.4975   1179.44
             21556     T    Exc neck tum deep < 5 cm                             1          1     0022    23.388   1576.49
             21557     T    Resect neck tum < 5 cm                               1          1     0021   17.4975   1179.44
             21558     T    Resect neck tum = 5 cm                               1          1     0022    23.388   1576.49
             21600     T    Partial removal of rib                               1          1     0050   31.7717    2141.6
             21610     T    Partial removal of rib                               1          1     0050   31.7717    2141.6
             21615     C    Removal of rib                                       1          1       0                          OR
             21616     C    Removal of rib and nerves                            1          1       0                          OR
             21620     C    Partial removal of sternum                           1          1       0                          OR
             21627     C    Sternal debridement                                  1          1       0                          OR
             21630     C    Extensive sternum surgery                            1          1       0                          OR
             21632     C    Extensive sternum surgery                            1          1       0                          OR
     L       21685     T    Hyoid myotomy & suspension                           1          1     0252    7.6196    513.61
             21700     T    Revision of neck muscle                              1          1     0049   22.0149   1483.94
             21705     C    Revision of neck muscle/rib                          1          1       0                          OR
             21720     T    Revision of neck muscle                              1          1     0049   22.0149   1483.94
             21725     T    Revision of neck muscle                              1          1     0006    1.4557    98.12
             21740     C    Reconstruction of sternum                            1          1       0                          OR
             21742     T    Repair stern/nuss w/o scope                          1          1     0051   46.5786   3139.68
             21743     T    Repair sternum/nuss w/scope                          1          1     0051   46.5786   3139.68
             21750     C    Repair of sternum separation                         1          1       0                          OR
             21800     T    Treatment of rib fracture                            1          6     0129    1.6576    111.73
             21805     T    Treatment of rib fracture                            1          1     0062   25.8446   1742.08
             21810     C    Treatment of rib fracture(s)                         1          1       0                          OR
             21820     T    Treat sternum fracture                               1          1     0129   1.6576    111.73
             21825     C    Treat sternum fracture                               1          1       0                          OR
             21899     T    Neck/chest surgery procedure                         1          1     0250    1.1522     77.67
             21920     T    Biopsy soft tissue of back                           1          1     0020    8.2028    552.92
             21925     T    Biopsy soft tissue of back                           1          1     0022    23.388   1576.49
             21930     T    Exc back les sc < 3 cm                               1          1     0021   17.4975   1179.44
             21931     T    Exc back les sc = 3 cm                               1          1     0022    23.388   1576.49
             21932     T    Exc back tum deep < 5 cm                             1          1     0021   17.4975   1179.44
             21933     T    Exc back tum deep = 5 cm                             1          1     0022    23.388   1576.49
             21935     T    Resect back tum < 5 cm                               1          1     0021   17.4975   1179.44
             21936     T    Resect back tum = 5 cm                               1          1     0022    23.388   1576.49
             22010     C    I&d, p-spine, c/t/cerv-thor                          1          1       0                          OR
             22015     C    I&d, p-spine, l/s/ls                                 1          1       0                          OR
             22100     T    Remove part of neck vertebra                         1          1     0208   49.2256   3318.1
             22101     T    Remove part, thorax vertebra                         1          1     0208   49.2256   3318.1
             22102     T    Remove part, lumbar vertebra                         1          1     0208   49.2256   3318.1
             22103     T    Remove extra spine segment                           1          1     0208   49.2256   3318.1
             22110     C    Remove part of neck vertebra                         1          1       0                          OR
             22112     C    Remove part, thorax vertebra                         1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 15 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             22114     C    Remove part, lumbar vertebra                         1          1       0                          OR
             22116     C    Remove extra spine segment                           1          1       0                          OR
             22206     C    Cut spine 3 col, thor                                1          1       0                          OR
             22207     C    Cut spine 3 col, lumb                                1          1       0                          OR
             22208     C    Cut spine 3 col, addl seg                            1         NA       0                          OR
             22210     C    Revision of neck spine                               1          1       0                          OR
             22212     C    Revision of thorax spine                             1          1       0                          OR
             22214     C    Revision of lumbar spine                             1          1       0                          OR
             22216     C    Revise, extra spine segment                          1         NA       0                          OR
             22220     C    Revision of neck spine                               1          1       0                          OR
             22222     T    Revision of thorax spine                             1          1     0208   49.2256   3318.1
             22224     C    Revision of lumbar spine                             1          1       0                          OR
             22226     C    Revise, extra spine segment                          1         NA       0                          OR
             22305     T    Treat spine process fracture                         1          1     0129    1.6576    111.73
             22310     T    Treat spine fracture                                 1          1     0138    4.7946    323.18
             22315     T    Treat spine fracture                                 1          1     0139   18.3962   1240.01
             22318     C    Treat odontoid fx w/o graft                          1          1       0                          OR
             22319     C    Treat odontoid fx w/graft                            1          1       0                          OR
             22325     C    Treat spine fracture                                 1          1       0                          OR
             22326     C    Treat neck spine fracture                            1          1       0                          OR
             22327     C    Treat thorax spine fracture                          1          1       0                          OR
             22328     C    Treat each add spine fx                              1          1       0                          OR
             22505     T    Manipulation of spine                                1          1     0045   15.2922   1030.79
             22520     T    Percut vertebroplasty thor                           0         NC       0
             22521     T    Percut vertebroplasty lumb                           0         NC       0
             22522     T    Percut vertebroplasty addl                           0         NC       0
             22523     T    Percut kyphoplasty, thor                             0         NC       0
             22524     T    Percut kyphoplasty, lumbar                           0         NC       0
             22525     T    Percut kyphoplasty, add-on                           0         NC       0
    PA       22526     E    Idet, single level                                   1          1       0                          OR
    PA       22527     E    Idet, 1 or more levels                               1          1       0                          OR
             22532     C    Lat thorax spine fusion                              1          1       0                          OR
             22533     C    Lat lumbar spine fusion                              1          1       0                          OR
             22534     C    Lat thor/lumb, addl seg                              1          1       0                          OR
             22548     C    Neck spine fusion                                    1          1       0                          OR
             22554     C    Neck spine fusion                                    1          1       0                          OR
             22556     C    Thorax spine fusion                                  1          1       0                          OR
             22558     C    Lumbar spine fusion                                  1          1       0                          OR
             22585     C    Additional spinal fusion                             1          1       0                          OR
             22590     C    Spine & skull spinal fusion                          1          1       0                          OR
             22595     C    Neck spinal fusion                                   1          1       0                          OR
             22600     C    Neck spine fusion                                    1          1       0                          OR
             22610     C    Thorax spine fusion                                  1          1       0                          OR
             22612     T    Lumbar spine fusion                                  1          1     0208   49.2256   3318.1
             22614     T    Spine fusion, extra segment                          1          1     0208   49.2256   3318.1
             22630     C    Lumbar spine fusion                                  1          1       0                          OR
             22632     C    Spine fusion, extra segment                          1          1       0                          OR
             22800     C    Fusion of spine                                      1          1       0                          OR
             22802     C    Fusion of spine                                      1          1       0                          OR
             22804     C    Fusion of spine                                      1          1       0                          OR
             22808     C    Fusion of spine                                      1          1       0                          OR
             22810     C    Fusion of spine                                      1          1       0                          OR
             22812     C    Fusion of spine                                      1          1       0                          OR
             22818     C    Kyphectomy, 1-2 segments                             1          1       0                          OR
             22819     C    Kyphectomy, 3 or more                                1          1       0                          OR
             22830     C    Exploration of spinal fusion                         1          1       0                          OR
             22840     C    Insert spine fixation device                         1          1       0                          OR
             22841     C    Insert spine fixation device                         1          1       0                          OR
             22842     C    Insert spine fixation device                         1          1       0                          OR
             22843     C    Insert spine fixation device                         1          1       0                          OR
             22844     C    Insert spine fixation device                         1          1       0                          OR
             22845     C    Insert spine fixation device                         1          1       0                          OR
             22846     C    Insert spine fixation device                         1          1       0                          OR
             22847     C    Insert spine fixation device                         1          1       0                          OR
             22848     C    Insert pelv fixation device                          1          1       0                          OR
             22849     C    Reinsert spinal fixation                             1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 16 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             22850     C    Remove spine fixation device                         1          1       0                          OR
             22851     T    Apply spine prosth device                            1          1     0049   22.0149   1483.94
             22852     C    Remove spine fixation device                         1          1       0                          OR
             22855     C    Remove spine fixation device                         1          1       0                          OR
    PA       22856     C    Cerv artific diskectomy                              1          1       0                          OR
    PA       22857     C    Lumbar artif diskectomy                              1          1       0                          OR
    PA       22861     C    Revise cerv artific disc                             1          1       0                          OR
    PA       22862     C    Revise lumbar artif disc                             1          1       0                          OR
             22864     C    Remove cerv artif disc                               1          1       0                          OR
    PA       22865     C    Remove lumb artif disc                               1          1       0                          OR
             22899     T    Spine surgery procedure                              1          1     0049   22.0149   1483.94
             22900     T    Exc back tum deep < 5 cm                             1          1     0022    23.388   1576.49
             22901     T    Exc back tum deep = 5 cm                             1          1     0022    23.388   1576.49
             22902     T    Exc abd les sc < 3 cm                                1          1     0021   17.4975   1179.44
             22903     T    Exc abd les sc > 3 cm                                1          1     0022    23.388   1576.49
             22904     T    Resect abd tum < 5 cm                                1          1     0021   17.4975   1179.44
             22905     T    Resect abd tum > 5 cm                                1          1     0022    23.388   1576.49
             22999     T    Abdomen surgery procedure                            1          1     0049   22.0149   1483.94
             23000     T    Removal of calcium deposits                          1          1     0021   17.4975   1179.44
             23020     T    Release shoulder joint                               1          1     0051   46.5786   3139.68
             23030     T    Drain shoulder lesion                                1          1     0008   19.4063    1308.1
             23031     T    Drain shoulder bursa                                 1          1     0008   19.4063    1308.1
             23035     T    Drain shoulder bone lesion                           1          1     0049   22.0149   1483.94
             23040     T    Exploratory shoulder surgery                         1          1     0050   31.7717    2141.6
             23044     T    Exploratory shoulder surgery                         1          1     0050   31.7717    2141.6
             23065     T    Biopsy shoulder tissues                              1          1     0020    8.2028    552.92
             23066     T    Biopsy shoulder tissues                              1          1     0022    23.388   1576.49
             23071     T    Exc shoulder les sc > 3 cm                           1          1     0022    23.388   1576.49
             23073     T    Exc shoulder tum deep > 5 cm                         1          1     0022    23.388   1576.49
             23075     T    Exc shoulder les sc < 3 cm                           1          1     0021   17.4975   1179.44
             23076     T    Exc shoulder tum deep < 5 cm                         1          1     0021   17.4975   1179.44
             23077     T    Resect shoulder tum < 5 cm                           1          1     0021   17.4975   1179.44
             23078     T    Resect shoulder tum > 5 cm                           1          1     0022    23.388   1576.49
             23100     T    Biopsy of shoulder joint                             1          1     0049   22.0149   1483.94
             23101     T    Shoulder joint surgery                               1          1     0050   31.7717    2141.6
             23105     T    Remove shoulder joint lining                         1          1     0050   31.7717    2141.6
             23106     T    Incision of collarbone joint                         1          1     0050   31.7717    2141.6
             23107     T    Explore treat shoulder joint                         1          1     0050   31.7717    2141.6
             23120     T    Partial removal, collar bone                         1          1     0050   31.7717    2141.6
             23125     T    Removal of collar bone                               1          1     0050   31.7717    2141.6
             23130     T    Remove shoulder bone, part                           1          1     0051   46.5786   3139.68
             23140     T    Removal of bone lesion                               1          1     0049   22.0149   1483.94
             23145     T    Removal of bone lesion                               1          1     0050   31.7717    2141.6
             23146     T    Removal of bone lesion                               1          1     0050   31.7717    2141.6
             23150     T    Removal of humerus lesion                            1          1     0050   31.7717    2141.6
             23155     T    Removal of humerus lesion                            1          1     0050   31.7717    2141.6
             23156     T    Removal of humerus lesion                            1          1     0050   31.7717    2141.6
             23170     T    Remove collar bone lesion                            1          1     0050   31.7717    2141.6
             23172     T    Remove shoulder blade lesion                         1          1     0050   31.7717    2141.6
             23174     T    Remove humerus lesion                                1          1     0050   31.7717    2141.6
             23180     T    Remove collar bone lesion                            1          1     0050   31.7717    2141.6
             23182     T    Remove shoulder blade lesion                         1          1     0050   31.7717    2141.6
             23184     T    Remove humerus lesion                                1          1     0050   31.7717    2141.6
             23190     T    Partial removal of scapula                           1          1     0050   31.7717    2141.6
             23195     T    Removal of head of humerus                           1          1     0050   31.7717    2141.6
             23200     C    Resect clavicle tumor                                1          1       0                          OR
             23210     C    Resect scapula tumor                                 1          1       0                          OR
             23220     C    Resect prox humerus tumor                            1          1       0                          OR
             23330     T    Remove shoulder foreign body                         1          1     0020   8.2028     552.92
             23331     T    Remove shoulder foreign body                         1          1     0022   23.388    1576.49
             23332     C    Remove shoulder foreign body                         1          1       0                          OR
             23350     N    Injection for shoulder x-ray                         1          1       0
             23395     T    Muscle transfer,shoulder/arm                         1          1     0051   46.5786   3139.68
             23397     T    Muscle transfers                                     1          1     0052   88.6521   5975.68
             23400     T    Fixation of shoulder blade                           1          1     0050   31.7717    2141.6
             23405     T    Incision of tendon & muscle                          1          1     0050   31.7717    2141.6

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 17 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             23406     T    Incise tendon(s) & muscle(s)                         1          1     0050   31.7717    2141.6
             23410     T    Repair rotator cuff, acute                           1          1     0051   46.5786   3139.68
             23412     T    Repair rotator cuff, chronic                         1          1     0051   46.5786   3139.68
             23415     T    Release of shoulder ligament                         1          1     0051   46.5786   3139.68
             23420     T    Repair of shoulder                                   1          1     0051   46.5786   3139.68
             23430     T    Repair biceps tendon                                 1          1     0051   46.5786   3139.68
             23440     T    Remove/transplant tendon                             1          1     0051   46.5786   3139.68
             23450     T    Repair shoulder capsule                              1          1     0052   88.6521   5975.68
             23455     T    Repair shoulder capsule                              1          1     0052   88.6521   5975.68
             23460     T    Repair shoulder capsule                              1          1     0052   88.6521   5975.68
             23462     T    Repair shoulder capsule                              1          1     0051   46.5786   3139.68
             23465     T    Repair shoulder capsule                              1          1     0052   88.6521   5975.68
             23466     T    Repair shoulder capsule                              1          1     0051   46.5786   3139.68
             23470     T    Reconstruct shoulder joint                           1          1     0425   118.767   8005.61
             23472     C    Reconstruct shoulder joint                           1          1       0                          OR
             23480     T    Revision of collar bone                              1          1     0051   46.5786   3139.68
             23485     T    Revision of collar bone                              1          1     0052   88.6521   5975.68
             23490     T    Reinforce clavicle                                   1          1     0051   46.5786   3139.68
             23491     T    Reinforce shoulder bones                             1          1     0052   88.6521   5975.68
             23500     T    Treat clavicle fracture                              1          1     0129    1.6576    111.73
             23505     T    Treat clavicle fracture                              1          1     0139   18.3962   1240.01
             23515     T    Treat clavicle fracture                              1          1     0064   65.4752   4413.42
             23520     T    Treat clavicle dislocation                           1          1     0138    4.7946    323.18
             23525     T    Treat clavicle dislocation                           1          1     0138    4.7946    323.18
             23530     T    Treat clavicle dislocation                           1          1     0063   45.4678    3064.8
             23532     T    Treat clavicle dislocation                           1          1     0062   25.8446   1742.08
             23540     T    Treat clavicle dislocation                           1          1     0129    1.6576    111.73
             23545     T    Treat clavicle dislocation                           1          1     0138    4.7946    323.18
             23550     T    Treat clavicle dislocation                           1          1     0063   45.4678    3064.8
             23552     T    Treat clavicle dislocation                           1          1     0063   45.4678    3064.8
             23570     T    Treat shoulder blade fx                              1          1     0129    1.6576    111.73
             23575     T    Treat shoulder blade fx                              1          1     0138    4.7946    323.18
             23585     T    Treat scapula fracture                               1          1     0064   65.4752   4413.42
             23600     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             23605     T    Treat humerus fracture                               1          1     0139   18.3962   1240.01
             23615     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             23616     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             23620     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             23625     T    Treat humerus fracture                               1          1     0139   18.3962   1240.01
             23630     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             23650     T    Treat shoulder dislocation                           1          1     0129    1.6576    111.73
             23655     T    Treat shoulder dislocation                           1          1     0045   15.2922   1030.79
             23660     T    Treat shoulder dislocation                           1          1     0063   45.4678    3064.8
             23665     T    Treat dislocation/fracture                           1          1     0138    4.7946    323.18
             23670     T    Treat dislocation/fracture                           1          1     0064   65.4752   4413.42
             23675     T    Treat dislocation/fracture                           1          1     0129    1.6576    111.73
             23680     T    Treat dislocation/fracture                           1          1     0063   45.4678    3064.8
             23700     T    Fixation of shoulder                                 1          1     0045   15.2922   1030.79
             23800     T    Fusion of shoulder joint                             1          1     0052   88.6521   5975.68
             23802     T    Fusion of shoulder joint                             1          1     0051   46.5786   3139.68
             23900     C    Amputation of arm & girdle                           1          1       0                          OR
             23920     C    Amputation at shoulder joint                         1          1       0                          OR
             23921     T    Amputation follow-up surgery                         1          1     0136   16.0542   1082.15
             23929     T    Shoulder surgery procedure                           1          1     0129    1.6576    111.73
             23930     T    Drainage of arm lesion                               1          1     0008   19.4063    1308.1
             23931     T    Drainage of arm bursa                                1          1     0008   19.4063    1308.1
             23935     T    Drain arm/elbow bone lesion                          1          1     0049   22.0149   1483.94
             24000     T    Exploratory elbow surgery                            1          1     0050   31.7717    2141.6
             24006     T    Release elbow joint                                  1          1     0050   31.7717    2141.6
             24065     T    Biopsy arm/elbow soft tissue                         1          1     0021   17.4975   1179.44
             24066     T    Biopsy arm/elbow soft tissue                         1          1     0021   17.4975   1179.44
             24071     T    Exc arm/elbow les sc = 3 cm                          1          1     0022    23.388   1576.49
             24073     T    Ex arm/elbow tum deep > 5 cm                         1          1     0022    23.388   1576.49
             24075     T    Exc arm/elbow les sc < 3 cm                          1          1     0021   17.4975   1179.44
             24076     T    Ex arm/elbow tum deep < 5 cm                         1          1     0021   17.4975   1179.44
             24077     T    Resect arm/elbow tum < 5 cm                          1          1     0021   17.4975   1179.44

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 18 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             24079     T    Resect arm/elbow tum > 5 cm                          1          1     0022    23.388   1576.49
             24100     T    Biopsy elbow joint lining                            1          1     0049   22.0149   1483.94
             24101     T    Explore/treat elbow joint                            1          1     0050   31.7717    2141.6
             24102     T    Remove elbow joint lining                            1          1     0050   31.7717    2141.6
             24105     T    Removal of elbow bursa                               1          1     0049   22.0149   1483.94
             24110     T    Remove humerus lesion                                1          1     0049   22.0149   1483.94
             24115     T    Remove/graft bone lesion                             1          1     0050   31.7717    2141.6
             24116     T    Remove/graft bone lesion                             1          1     0050   31.7717    2141.6
             24120     T    Remove elbow lesion                                  1          1     0049   22.0149   1483.94
             24125     T    Remove/graft bone lesion                             1          1     0050   31.7717    2141.6
             24126     T    Remove/graft bone lesion                             1          1     0050   31.7717    2141.6
             24130     T    Removal of head of radius                            1          1     0050   31.7717    2141.6
             24134     T    Removal of arm bone lesion                           1          1     0050   31.7717    2141.6
             24136     T    Remove radius bone lesion                            1          1     0050   31.7717    2141.6
             24138     T    Remove elbow bone lesion                             1          1     0050   31.7717    2141.6
             24140     T    Partial removal of arm bone                          1          1     0050   31.7717    2141.6
             24145     T    Partial removal of radius                            1          1     0050   31.7717    2141.6
             24147     T    Partial removal of elbow                             1          1     0050   31.7717    2141.6
             24149     T    Radical resection of elbow                           1          1     0050   31.7717    2141.6
             24150     T    Resect distal humerus tumor                          1          1     0051   46.5786   3139.68
             24152     T    Resect radius tumor                                  1          1     0051   46.5786   3139.68
             24155     T    Removal of elbow joint                               1          1     0051   46.5786   3139.68
             24160     T    Remove elbow joint implant                           1          1     0050   31.7717    2141.6
             24164     T    Remove radius head implant                           1          1     0050   31.7717    2141.6
             24200     T    Removal of arm foreign body                          1          1     0019    4.3625    294.06
             24201     T    Removal of arm foreign body                          1          1     0021   17.4975   1179.44
             24220     N    Injection for elbow x-ray                            1          1       0
             24300     T    Manipulate elbow w/anesth                            1          1     0045   15.2922   1030.79
             24301     T    Muscle/tendon transfer                               1          1     0050   31.7717    2141.6
             24305     T    Arm tendon lengthening                               1          1     0050   31.7717    2141.6
             24310     T    Revision of arm tendon                               1          1     0049   22.0149   1483.94
             24320     T    Repair of arm tendon                                 1          1     0051   46.5786   3139.68
             24330     T    Revision of arm muscles                              1          1     0052   88.6521   5975.68
             24331     T    Revision of arm muscles                              1          1     0051   46.5786   3139.68
             24332     T    Tenolysis, triceps                                   1          1     0049   22.0149   1483.94
             24340     T    Repair of biceps tendon                              1          1     0051   46.5786   3139.68
             24341     T    Repair arm tendon/muscle                             1          1     0051   46.5786   3139.68
             24342     T    Repair of ruptured tendon                            1          1     0051   46.5786   3139.68
             24343     T    Repr elbow lat ligmnt w/tiss                         1          1     0050   31.7717    2141.6
             24344     T    Reconstruct elbow lat ligmnt                         1          1     0052   88.6521   5975.68
             24345     T    Repr elbw med ligmnt w/tissu                         1          1     0050   31.7717    2141.6
             24346     T    Reconstruct elbow med ligmnt                         1          1     0051   46.5786   3139.68
             24357     T    Repair elbow, perc                                   1          1     0050   31.7717    2141.6
             24358     T    Repair elbow w/deb, open                             1          1     0050   31.7717    2141.6
             24359     T    Repair elbow deb/attch open                          1          1     0050   31.7717    2141.6
             24360     T    Reconstruct elbow joint                              1          1     0047   39.8877   2688.67
             24361     T    Reconstruct elbow joint                              1          1     0425   118.767   8005.61
             24362     T    Reconstruct elbow joint                              1          1     0048   58.0838    3915.2
             24363     T    Replace elbow joint                                  1          1     0425   118.767   8005.61
             24365     T    Reconstruct head of radius                           1          1     0047   39.8877   2688.67
             24366     T    Reconstruct head of radius                           1          1     0425   118.767   8005.61
             24400     T    Revision of humerus                                  1          1     0051   46.5786   3139.68
             24410     T    Revision of humerus                                  1          1     0051   46.5786   3139.68
             24420     T    Revision of humerus                                  1          1     0051   46.5786   3139.68
             24430     T    Repair of humerus                                    1          1     0052   88.6521   5975.68
             24435     T    Repair humerus with graft                            1          1     0052   88.6521   5975.68
             24470     T    Revision of elbow joint                              1          1     0051   46.5786   3139.68
             24495     T    Decompression of forearm                             1          1     0050   31.7717    2141.6
             24498     T    Reinforce humerus                                    1          1     0052   88.6521   5975.68
             24500     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24505     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24515     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24516     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24530     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24535     T    Treat humerus fracture                               1          1     0138    4.7946    323.18
             24538     T    Treat humerus fracture                               1          1     0062   25.8446   1742.08

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 19 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             24545     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24546     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24560     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24565     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24566     T    Treat humerus fracture                               1          1     0062   25.8446   1742.08
             24575     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24576     T    Treat humerus fracture                               1          1     0129    1.6576    111.73
             24577     T    Treat humerus fracture                               1          1     0138    4.7946    323.18
             24579     T    Treat humerus fracture                               1          1     0064   65.4752   4413.42
             24582     T    Treat humerus fracture                               1          1     0062   25.8446   1742.08
             24586     T    Treat elbow fracture                                 1          1     0064   65.4752   4413.42
             24587     T    Treat elbow fracture                                 1          1     0064   65.4752   4413.42
             24600     T    Treat elbow dislocation                              1          1     0129    1.6576    111.73
             24605     T    Treat elbow dislocation                              1          1     0045   15.2922   1030.79
             24615     T    Treat elbow dislocation                              1          1     0064   65.4752   4413.42
             24620     T    Treat elbow fracture                                 1          1     0139   18.3962   1240.01
             24635     T    Treat elbow fracture                                 1          1     0064   65.4752   4413.42
             24640     T    Treat elbow dislocation                              1          1     0129    1.6576    111.73
             24650     T    Treat radius fracture                                1          1     0129    1.6576    111.73
             24655     T    Treat radius fracture                                1          1     0138    4.7946    323.18
             24665     T    Treat radius fracture                                1          1     0063   45.4678    3064.8
             24666     T    Treat radius fracture                                1          1     0064   65.4752   4413.42
             24670     T    Treat ulnar fracture                                 1          1     0129    1.6576    111.73
             24675     T    Treat ulnar fracture                                 1          1     0129    1.6576    111.73
             24685     T    Treat ulnar fracture                                 1          1     0063   45.4678    3064.8
             24800     T    Fusion of elbow joint                                1          1     0051   46.5786   3139.68
             24802     T    Fusion/graft of elbow joint                          1          1     0051   46.5786   3139.68
             24900     C    Amputation of upper arm                              1          1       0                          OR
             24920     C    Amputation of upper arm                              1          1       0                          OR
             24925     T    Amputation follow-up surgery                         1          1     0049   22.0149   1483.94
             24930     C    Amputation follow-up surgery                         1          1       0                          OR
             24931     C    Amputate upper arm & implant                         1          1       0                          OR
             24935     T    Revision of amputation                               1          1     0052   88.6521   5975.68
             24940     C    Revision of upper arm                                1          1       0                          OR
             24999     T    Upper arm/elbow surgery                              1          1     0129    1.6576    111.73
             25000     T    Incision of tendon sheath                            1          1     0049   22.0149   1483.94
             25001     T    Incise flexor carpi radialis                         1          1     0049   22.0149   1483.94
             25020     T    Decompress forearm 1 space                           1          1     0050   31.7717    2141.6
             25023     T    Decompress forearm 1 space                           1          1     0050   31.7717    2141.6
             25024     T    Decompress forearm 2 spaces                          1          1     0050   31.7717    2141.6
             25025     T    Decompress forearm 2 spaces                          1          1     0050   31.7717    2141.6
             25028     T    Drainage of forearm lesion                           1          1     0049   22.0149   1483.94
             25031     T    Drainage of forearm bursa                            1          1     0049   22.0149   1483.94
             25035     T    Treat forearm bone lesion                            1          1     0049   22.0149   1483.94
             25040     T    Explore/treat wrist joint                            1          1     0050   31.7717    2141.6
             25065     T    Biopsy forearm soft tissues                          1          1     0020    8.2028    552.92
             25066     T    Biopsy forearm soft tissues                          1          1     0022    23.388   1576.49
             25071     T    Exc forearm les sc > 3 cm                            1          1     0022    23.388   1576.49
             25073     T    Exc forearm tum deep = 3 cm                          1          1     0022    23.388   1576.49
             25075     T    Exc forearm les sc < 3 cm                            1          1     0021   17.4975   1179.44
             25076     T    Exc forearm tum deep < 3 cm                          1          1     0021   17.4975   1179.44
             25077     T    Resect forearm/wrist tum<3cm                         1          1     0021   17.4975   1179.44
             25078     T    Resect forearm/wrist tum=3cm                         1          1     0022    23.388   1576.49
             25085     T    Incision of wrist capsule                            1          1     0049   22.0149   1483.94
             25100     T    Biopsy of wrist joint                                1          1     0049   22.0149   1483.94
             25101     T    Explore/treat wrist joint                            1          1     0050   31.7717    2141.6
             25105     T    Remove wrist joint lining                            1          1     0050   31.7717    2141.6
             25107     T    Remove wrist joint cartilage                         1          1     0050   31.7717    2141.6
             25109     T    Excise tendon forearm/wrist                          1          1     0049   22.0149   1483.94
             25110     T    Remove wrist tendon lesion                           1          1     0049   22.0149   1483.94
             25111     T    Remove wrist tendon lesion                           1          1     0049   22.0149   1483.94
             25112     T    Reremove wrist tendon lesion                         1          1     0049   22.0149   1483.94
             25115     T    Remove wrist/forearm lesion                          1          1     0049   22.0149   1483.94
             25116     T    Remove wrist/forearm lesion                          1          1     0049   22.0149   1483.94
             25118     T    Excise wrist tendon sheath                           1          1     0050   31.7717    2141.6
             25119     T    Partial removal of ulna                              1          1     0050   31.7717    2141.6

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 20 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             25120     T    Removal of forearm lesion                            1          1     0050   31.7717    2141.6
             25125     T    Remove/graft forearm lesion                          1          1     0050   31.7717    2141.6
             25126     T    Remove/graft forearm lesion                          1          1     0050   31.7717    2141.6
             25130     T    Removal of wrist lesion                              1          1     0050   31.7717    2141.6
             25135     T    Remove & graft wrist lesion                          1          1     0050   31.7717    2141.6
             25136     T    Remove & graft wrist lesion                          1          1     0050   31.7717    2141.6
             25145     T    Remove forearm bone lesion                           1          1     0050   31.7717    2141.6
             25150     T    Partial removal of ulna                              1          1     0050   31.7717    2141.6
             25151     T    Partial removal of radius                            1          1     0050   31.7717    2141.6
             25170     T    Resect radius/ulnar tumor                            1          1     0051   46.5786   3139.68
             25210     T    Removal of wrist bone                                1          1     0050   31.7717    2141.6
             25215     T    Removal of wrist bones                               1          1     0050   31.7717    2141.6
             25230     T    Partial removal of radius                            1          1     0050   31.7717    2141.6
             25240     T    Partial removal of ulna                              1          1     0050   31.7717    2141.6
             25246     N    Injection for wrist x-ray                            1          1       0
             25248     T    Remove forearm foreign body                          1          1     0049   22.0149   1483.94
             25250     T    Removal of wrist prosthesis                          1          1     0050   31.7717    2141.6
             25251     T    Removal of wrist prosthesis                          1          1     0050   31.7717    2141.6
             25259     T    Manipulate wrist w/anesthes                          1          1     0139   18.3962   1240.01
             25260     T    Repair forearm tendon/muscle                         1         12     0050   31.7717    2141.6
             25263     T    Repair forearm tendon/muscle                         1          1     0050   31.7717    2141.6
             25265     T    Repair forearm tendon/muscle                         1          1     0050   31.7717    2141.6
             25270     T    Repair forearm tendon/muscle                         1         12     0050   31.7717    2141.6
             25272     T    Repair forearm tendon/muscle                         1         12     0050   31.7717    2141.6
             25274     T    Repair forearm tendon/muscle                         1          1     0050   31.7717    2141.6
             25275     T    Repair forearm tendon sheath                         1          1     0050   31.7717    2141.6
             25280     T    Revise wrist/forearm tendon                          1         10     0050   31.7717    2141.6
             25290     T    Incise wrist/forearm tendon                          1         10     0050   31.7717    2141.6
             25295     T    Release wrist/forearm tendon                         1         12     0049   22.0149   1483.94
             25300     T    Fusion of tendons at wrist                           1          1     0050   31.7717    2141.6
             25301     T    Fusion of tendons at wrist                           1          1     0050   31.7717    2141.6
             25310     T    Transplant forearm tendon                            1          1     0051   46.5786   3139.68
             25312     T    Transplant forearm tendon                            1          1     0051   46.5786   3139.68
             25315     T    Revise palsy hand tendon(s)                          1          1     0051   46.5786   3139.68
             25316     T    Revise palsy hand tendon(s)                          1          1     0052   88.6521   5975.68
             25320     T    Repair/revise wrist joint                            1          1     0051   46.5786   3139.68
             25332     T    Revise wrist joint                                   1          1     0047   39.8877   2688.67
             25335     T    Realignment of hand                                  1          1     0051   46.5786   3139.68
             25337     T    Reconstruct ulna/radioulnar                          1          1     0051   46.5786   3139.68
             25350     T    Revision of radius                                   1          1     0051   46.5786   3139.68
             25355     T    Revision of radius                                   1          1     0051   46.5786   3139.68
             25360     T    Revision of ulna                                     1          1     0051   46.5786   3139.68
             25365     T    Revise radius & ulna                                 1          1     0051   46.5786   3139.68
             25370     T    Revise radius or ulna                                1          1     0051   46.5786   3139.68
             25375     T    Revise radius & ulna                                 1          1     0051   46.5786   3139.68
             25390     T    Shorten radius or ulna                               1          1     0051   46.5786   3139.68
             25391     T    Lengthen radius or ulna                              1          1     0051   46.5786   3139.68
             25392     T    Shorten radius & ulna                                1          1     0050   31.7717    2141.6
             25393     T    Lengthen radius & ulna                               1          1     0051   46.5786   3139.68
             25394     T    Repair carpal bone, shorten                          1          1     0051   46.5786   3139.68
             25400     T    Repair radius or ulna                                1          1     0051   46.5786   3139.68
             25405     T    Repair/graft radius or ulna                          1          1     0052   88.6521   5975.68
             25415     T    Repair radius & ulna                                 1          1     0052   88.6521   5975.68
             25420     T    Repair/graft radius & ulna                           1          1     0052   88.6521   5975.68
             25425     T    Repair/graft radius or ulna                          1          1     0051   46.5786   3139.68
             25426     T    Repair/graft radius & ulna                           1          1     0051   46.5786   3139.68
             25430     T    Vasc graft into carpal bone                          1          1     0051   46.5786   3139.68
             25431     T    Repair nonunion carpal bone                          1          1     0051   46.5786   3139.68
             25440     T    Repair/graft wrist bone                              1          1     0052   88.6521   5975.68
             25441     T    Reconstruct wrist joint                              1          1     0425   118.767   8005.61
             25442     T    Reconstruct wrist joint                              1          1     0425   118.767   8005.61
             25443     T    Reconstruct wrist joint                              1          1     0048   58.0838    3915.2
             25444     T    Reconstruct wrist joint                              1          1     0048   58.0838    3915.2
             25445     T    Reconstruct wrist joint                              1          1     0048   58.0838    3915.2
             25446     T    Wrist replacement                                    1          1     0425   118.767   8005.61
             25447     T    Repair wrist joint(s)                                1          1     0047   39.8877   2688.67

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 21 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             25449     T    Remove wrist joint implant                           1          1     0047   39.8877   2688.67
     L       25450     T    Revision of wrist joint                              1          1     0051   46.5786   3139.68
     L       25455     T    Revision of wrist joint                              1          1     0051   46.5786   3139.68
             25490     T    Reinforce radius                                     1          1     0051   46.5786   3139.68
             25491     T    Reinforce ulna                                       1          1     0051   46.5786   3139.68
             25492     T    Reinforce radius and ulna                            1          1     0051   46.5786   3139.68
             25500     T    Treat fracture of radius                             1          1     0129    1.6576    111.73
             25505     T    Treat fracture of radius                             1          1     0138    4.7946    323.18
             25515     T    Treat fracture of radius                             1          1     0063   45.4678    3064.8
             25520     T    Treat fracture of radius                             1          1     0138    4.7946    323.18
             25525     T    Treat fracture of radius                             1          1     0063   45.4678    3064.8
             25526     T    Treat fracture of radius                             1          1     0063   45.4678    3064.8
             25530     T    Treat fracture of ulna                               1          1     0129    1.6576    111.73
             25535     T    Treat fracture of ulna                               1          1     0129    1.6576    111.73
             25545     T    Treat fracture of ulna                               1          1     0063   45.4678    3064.8
             25560     T    Treat fracture radius & ulna                         1          1     0129    1.6576    111.73
             25565     T    Treat fracture radius & ulna                         1          1     0138    4.7946    323.18
             25574     T    Treat fracture radius & ulna                         1          1     0064   65.4752   4413.42
             25575     T    Treat fracture radius/ulna                           1          1     0064   65.4752   4413.42
             25600     T    Treat fracture radius/ulna                           1          1     0129    1.6576    111.73
             25605     T    Treat fracture radius/ulna                           1          1     0138    4.7946    323.18
             25606     T    Treat fx distal radial                               1          1     0062   25.8446   1742.08
             25607     T    Treat fx rad extra-articul                           1          1     0064   65.4752   4413.42
             25608     T    Treat fx rad intra-articul                           1          1     0064   65.4752   4413.42
             25609     T    Treat fx radial 3+ frag                              1          1     0064   65.4752   4413.42
             25622     T    Treat wrist bone fracture                            1          1     0129    1.6576    111.73
             25624     T    Treat wrist bone fracture                            1          1     0138    4.7946    323.18
             25628     T    Treat wrist bone fracture                            1          1     0063   45.4678    3064.8
             25630     T    Treat wrist bone fracture                            1          7     0129    1.6576    111.73
             25635     T    Treat wrist bone fracture                            1          7     0138    4.7946    323.18
             25645     T    Treat wrist bone fracture                            1          1     0063   45.4678    3064.8
             25650     T    Treat wrist bone fracture                            1          1     0129    1.6576    111.73
             25651     T    Pin ulnar styloid fracture                           1          1     0062   25.8446   1742.08
             25652     T    Treat fracture ulnar styloid                         1          1     0063   45.4678    3064.8
             25660     T    Treat wrist dislocation                              1          1     0129    1.6576    111.73
             25670     T    Treat wrist dislocation                              1          1     0062   25.8446   1742.08
             25671     T    Pin radioulnar dislocation                           1          1     0062   25.8446   1742.08
             25675     T    Treat wrist dislocation                              1          1     0129    1.6576    111.73
             25676     T    Treat wrist dislocation                              1          1     0062   25.8446   1742.08
             25680     T    Treat wrist fracture                                 1          1     0129    1.6576    111.73
             25685     T    Treat wrist fracture                                 1          1     0062   25.8446   1742.08
             25690     T    Treat wrist dislocation                              1          1     0139   18.3962   1240.01
             25695     T    Treat wrist dislocation                              1          1     0062   25.8446   1742.08
             25800     T    Fusion of wrist joint                                1          1     0052   88.6521   5975.68
             25805     T    Fusion/graft of wrist joint                          1          1     0051   46.5786   3139.68
             25810     T    Fusion/graft of wrist joint                          1          1     0052   88.6521   5975.68
             25820     T    Fusion of hand bones                                 1          1     0051   46.5786   3139.68
             25825     T    Fuse hand bones with graft                           1          1     0052   88.6521   5975.68
             25830     T    Fusion, radioulnar jnt/ulna                          1          1     0052   88.6521   5975.68
             25900     C    Amputation of forearm                                1          1       0                          OR
             25905     C    Amputation of forearm                                1          1       0                          OR
             25907     T    Amputation follow-up surgery                         1          1     0049   22.0149   1483.94
             25909     C    Amputation follow-up surgery                         1          1       0                          OR
             25915     C    Amputation of forearm                                1          1       0                          OR
             25920     C    Amputate hand at wrist                               1          1       0                          OR
             25922     T    Amputate hand at wrist                               1          1     0049   22.0149   1483.94
             25924     C    Amputation follow-up surgery                         1          1       0                          OR
             25927     C    Amputation of hand                                   1          1       0                          OR
             25929     T    Amputation follow-up surgery                         1          1     0136   16.0542   1082.15
             25931     T    Amputation follow-up surgery                         1          1     0049   22.0149   1483.94
             25999     T    Forearm or wrist surgery                             1          1     0129    1.6576    111.73
             26010     T    Drainage of finger abscess                           1          1     0006    1.4557     98.12
             26011     T    Drainage of finger abscess                           1          1     0007   12.6217    850.78
             26020     T    Drain hand tendon sheath                             1          1     0053    17.042   1148.73
             26025     T    Drainage of palm bursa                               1          1     0053    17.042   1148.73
             26030     T    Drainage of palm bursa(s)                            1          1     0053    17.042   1148.73

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 22 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             26034     T    Treat hand bone lesion                               1          1     0053    17.042   1148.73
             26035     T    Decompress fingers/hand                              1          1     0053    17.042   1148.73
             26037     T    Decompress fingers/hand                              1          1     0053    17.042   1148.73
             26040     T    Release palm contracture                             1          1     0054   28.2376   1903.38
             26045     T    Release palm contracture                             1          1     0054   28.2376   1903.38
             26055     T    Incise finger tendon sheath                          1          1     0053    17.042   1148.73
             26060     T    Incision of finger tendon                            1          1     0053    17.042   1148.73
             26070     T    Explore/treat hand joint                             1          1     0053    17.042   1148.73
             26075     T    Explore/treat finger joint                           1          1     0053    17.042   1148.73
             26080     T    Explore/treat finger joint                           1          1     0053    17.042   1148.73
             26100     T    Biopsy hand joint lining                             1          1     0053    17.042   1148.73
             26105     T    Biopsy finger joint lining                           1          1     0053    17.042   1148.73
             26110     T    Biopsy finger joint lining                           1          1     0053    17.042   1148.73
             26111     T    Exc hand les sc > 1.5 cm                             1          1     0022    23.388   1576.49
             26113     T    Exc hand tum deep > 1.5 cm                           1          1     0022    23.388   1576.49
             26115     T    Exc hand les sc < 1.5 cm                             1          1     0021   17.4975   1179.44
             26116     T    Exc hand tum deep < 1.5 cm                           1          1     0021   17.4975   1179.44
             26117     T    Exc hand tum ra < 3 cm                               1          1     0021   17.4975   1179.44
             26118     T    Exc hand tum ra > 3 cm                               1          1     0022    23.388   1576.49
             26121     T    Release palm contracture                             1          1     0054   28.2376   1903.38
             26123     T    Release palm contracture                             1          1     0054   28.2376   1903.38
             26125     T    Release palm contracture                             1          1     0053    17.042   1148.73
             26130     T    Remove wrist joint lining                            1          1     0053    17.042   1148.73
             26135     T    Revise finger joint, each                            1          1     0054   28.2376   1903.38
             26140     T    Revise finger joint, each                            1          1     0053    17.042   1148.73
             26145     T    Tendon excision, palm/finger                         1          1     0053    17.042   1148.73
             26160     T    Remove tendon sheath lesion                          1          1     0053    17.042   1148.73
             26170     T    Removal of palm tendon, each                         1          1     0053    17.042   1148.73
             26180     T    Removal of finger tendon                             1          1     0053    17.042   1148.73
             26185     T    Remove finger bone                                   1          1     0053    17.042   1148.73
             26200     T    Remove hand bone lesion                              1          1     0053    17.042   1148.73
             26205     T    Remove/graft bone lesion                             1          1     0054   28.2376   1903.38
             26210     T    Removal of finger lesion                             1          1     0053    17.042   1148.73
             26215     T    Remove/graft finger lesion                           1          1     0053    17.042   1148.73
             26230     T    Partial removal of hand bone                         1          1     0053    17.042   1148.73
             26235     T    Partial removal, finger bone                         1          1     0053    17.042   1148.73
             26236     T    Partial removal, finger bone                         1          1     0053    17.042   1148.73
             26250     T    Extensive hand surgery                               1          1     0053    17.042   1148.73
             26260     T    Resect prox finger tumor                             1          1     0053    17.042   1148.73
             26262     T    Resect distal finger tumor                           1          1     0053    17.042   1148.73
             26320     T    Removal of implant from hand                         1          1     0021   17.4975   1179.44
             26340     T    Manipulate finger w/anesth                           1         30     0138    4.7946    323.18
             26350     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26352     T    Repair/graft hand tendon                             1          1     0054   28.2376   1903.38
             26356     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26357     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26358     T    Repair/graft hand tendon                             1          1     0054   28.2376   1903.38
             26370     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26372     T    Repair/graft hand tendon                             1          1     0054   28.2376   1903.38
             26373     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26390     T    Revise hand/finger tendon                            1          1     0054   28.2376   1903.38
             26392     T    Repair/graft hand tendon                             1          1     0054   28.2376   1903.38
             26410     T    Repair hand tendon                                   1          6     0053    17.042   1148.73
             26412     T    Repair/graft hand tendon                             1          1     0054   28.2376   1903.38
             26415     T    Excision, hand/finger tendon                         1          1     0054   28.2376   1903.38
             26416     T    Graft hand or finger tendon                          1          1     0054   28.2376   1903.38
             26418     T    Repair finger tendon                                 1          1     0053    17.042   1148.73
             26420     T    Repair/graft finger tendon                           1          1     0054   28.2376   1903.38
             26426     T    Repair finger/hand tendon                            1          1     0054   28.2376   1903.38
             26428     T    Repair/graft finger tendon                           1          1     0054   28.2376   1903.38
             26432     T    Repair finger tendon                                 1          1     0053    17.042   1148.73
             26433     T    Repair finger tendon                                 1          1     0053    17.042   1148.73
             26434     T    Repair/graft finger tendon                           1          1     0054   28.2376   1903.38
             26437     T    Realignment of tendons                               1          1     0053    17.042   1148.73
             26440     T    Release palm/finger tendon                           1          5     0053    17.042   1148.73
             26442     T    Release palm & finger tendon                         1          1     0054   28.2376   1903.38

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 23 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             26445     T    Release hand/finger tendon                           1         10     0053    17.042   1148.73
             26449     T    Release forearm/hand tendon                          1          1     0054   28.2376   1903.38
             26450     T    Incision of palm tendon                              1          1     0053    17.042   1148.73
             26455     T    Incision of finger tendon                            1          1     0053    17.042   1148.73
             26460     T    Incise hand/finger tendon                            1          1     0053    17.042   1148.73
             26471     T    Fusion of finger tendons                             1          1     0053    17.042   1148.73
             26474     T    Fusion of finger tendons                             1          1     0053    17.042   1148.73
             26476     T    Tendon lengthening                                   1          1     0053    17.042   1148.73
             26477     T    Tendon shortening                                    1          1     0053    17.042   1148.73
             26478     T    Lengthening of hand tendon                           1          1     0053    17.042   1148.73
             26479     T    Shortening of hand tendon                            1          1     0053    17.042   1148.73
             26480     T    Transplant hand tendon                               1          1     0054   28.2376   1903.38
             26483     T    Transplant/graft hand tendon                         1          1     0054   28.2376   1903.38
             26485     T    Transplant palm tendon                               1          1     0054   28.2376   1903.38
             26489     T    Transplant/graft palm tendon                         1          1     0054   28.2376   1903.38
             26490     T    Revise thumb tendon                                  1          1     0054   28.2376   1903.38
             26492     T    Tendon transfer with graft                           1          1     0054   28.2376   1903.38
             26494     T    Hand tendon/muscle transfer                          1          1     0054   28.2376   1903.38
             26496     T    Revise thumb tendon                                  1          1     0054   28.2376   1903.38
             26497     T    Finger tendon transfer                               1          1     0054   28.2376   1903.38
             26498     T    Finger tendon transfer                               1          1     0054   28.2376   1903.38
             26499     T    Revision of finger                                   1          1     0054   28.2376   1903.38
             26500     T    Hand tendon reconstruction                           1          1     0053    17.042   1148.73
             26502     T    Hand tendon reconstruction                           1          1     0054   28.2376   1903.38
             26508     T    Release thumb contracture                            1          1     0053    17.042   1148.73
             26510     T    Thumb tendon transfer                                1          1     0054   28.2376   1903.38
             26516     T    Fusion of knuckle joint                              1          1     0054   28.2376   1903.38
             26517     T    Fusion of knuckle joints                             1          1     0054   28.2376   1903.38
             26518     T    Fusion of knuckle joints                             1          1     0054   28.2376   1903.38
             26520     T    Release knuckle contracture                          1          1     0053    17.042   1148.73
             26525     T    Release finger contracture                           1          1     0053    17.042   1148.73
             26530     T    Revise knuckle joint                                 1          1     0047   39.8877   2688.67
             26531     T    Revise knuckle with implant                          1          1     0048   58.0838    3915.2
             26535     T    Revise finger joint                                  1          1     0047   39.8877   2688.67
             26536     T    Revise/implant finger joint                          1          1     0048   58.0838    3915.2
             26540     T    Repair hand joint                                    1          1     0053    17.042   1148.73
             26541     T    Repair hand joint with graft                         1          1     0054   28.2376   1903.38
             26542     T    Repair hand joint with graft                         1          1     0053    17.042   1148.73
             26545     T    Reconstruct finger joint                             1          1     0054   28.2376   1903.38
             26546     T    Repair nonunion hand                                 1          1     0054   28.2376   1903.38
             26548     T    Reconstruct finger joint                             1          1     0054   28.2376   1903.38
             26550     T    Construct thumb replacement                          1          1     0054   28.2376   1903.38
             26551     C    Great toe-hand transfer                              1          1       0                          OR
             26553     C    Single transfer, toe-hand                            1          1       0                          OR
             26554     C    Double transfer, toe-hand                            1          1       0                          OR
             26555     T    Positional change of finger                          1          1     0054   28.2376   1903.38
             26556     C    Toe joint transfer                                   1          1       0                          OR
             26560     T    Repair of web finger                                 1          1     0053    17.042   1148.73
             26561     T    Repair of web finger                                 1          1     0054   28.2376   1903.38
             26562     T    Repair of web finger                                 1          1     0054   28.2376   1903.38
             26565     T    Correct metacarpal flaw                              1          1     0054   28.2376   1903.38
             26567     T    Correct finger deformity                             1          1     0054   28.2376   1903.38
             26568     T    Lengthen metacarpal/finger                           1          1     0054   28.2376   1903.38
             26580     T    Repair hand deformity                                1          1     0053    17.042   1148.73
             26587     T    Reconstruct extra finger                             1          1     0053    17.042   1148.73
             26590     T    Repair finger deformity                              1          1     0053    17.042   1148.73
             26591     T    Repair muscles of hand                               1          6     0054   28.2376   1903.38
             26593     T    Release muscles of hand                              1          1     0053    17.042   1148.73
             26596     T    Excision constricting tissue                         1          1     0053    17.042   1148.73
             26600     T    Treat metacarpal fracture                            1          1     0129    1.6576    111.73
             26605     T    Treat metacarpal fracture                            1          1     0129    1.6576    111.73
             26607     T    Treat metacarpal fracture                            1          1     0139   18.3962   1240.01
             26608     T    Treat metacarpal fracture                            1          1     0062   25.8446   1742.08
             26615     T    Treat metacarpal fracture                            1          1     0063   45.4678    3064.8
             26641     T    Treat thumb dislocation                              1          1     0129    1.6576    111.73
             26645     T    Treat thumb fracture                                 1          1     0138    4.7946    323.18

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 24 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             26650     T    Treat thumb fracture                                 1          1     0062   25.8446   1742.08
             26665     T    Treat thumb fracture                                 1          1     0063   45.4678    3064.8
             26670     T    Treat hand dislocation                               1          1     0129    1.6576    111.73
             26675     T    Treat hand dislocation                               1          1     0138    4.7946    323.18
             26676     T    Pin hand dislocation                                 1          1     0062   25.8446   1742.08
             26685     T    Treat hand dislocation                               1          1     0062   25.8446   1742.08
             26686     T    Treat hand dislocation                               1          1     0064   65.4752   4413.42
             26700     T    Treat knuckle dislocation                            1          1     0129    1.6576    111.73
             26705     T    Treat knuckle dislocation                            1          1     0129    1.6576    111.73
             26706     T    Pin knuckle dislocation                              1          1     0139   18.3962   1240.01
             26715     T    Treat knuckle dislocation                            1          1     0062   25.8446   1742.08
             26720     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26725     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26727     T    Treat finger fracture, each                          1          1     0062   25.8446   1742.08
             26735     T    Treat finger fracture, each                          1          1     0062   25.8446   1742.08
             26740     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26742     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26746     T    Treat finger fracture, each                          1         10     0062   25.8446   1742.08
             26750     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26755     T    Treat finger fracture, each                          1          1     0129    1.6576    111.73
             26756     T    Pin finger fracture, each                            1          1     0062   25.8446   1742.08
             26765     T    Treat finger fracture, each                          1          1     0062   25.8446   1742.08
             26770     T    Treat finger dislocation                             1          1     0129    1.6576    111.73
             26775     T    Treat finger dislocation                             1          1     0045   15.2922   1030.79
             26776     T    Pin finger dislocation                               1          1     0062   25.8446   1742.08
             26785     T    Treat finger dislocation                             1          1     0062   25.8446   1742.08
             26820     T    Thumb fusion with graft                              1          1     0054   28.2376   1903.38
             26841     T    Fusion of thumb                                      1          1     0054   28.2376   1903.38
             26842     T    Thumb fusion with graft                              1          1     0054   28.2376   1903.38
             26843     T    Fusion of hand joint                                 1          1     0054   28.2376   1903.38
             26844     T    Fusion/graft of hand joint                           1          1     0054   28.2376   1903.38
             26850     T    Fusion of knuckle                                    1          1     0054   28.2376   1903.38
             26852     T    Fusion of knuckle with graft                         1          1     0054   28.2376   1903.38
             26860     T    Fusion of finger joint                               1          1     0054   28.2376   1903.38
             26861     T    Fusion of finger jnt, add-on                         1          1     0054   28.2376   1903.38
             26862     T    Fusion/graft of finger joint                         1          1     0054   28.2376   1903.38
             26863     T    Fuse/graft added joint                               1          1     0054   28.2376   1903.38
             26910     T    Amputate metacarpal bone                             1          1     0054   28.2376   1903.38
             26951     T    Amputation of finger/thumb                           1          1     0053    17.042   1148.73
             26952     T    Amputation of finger/thumb                           1          1     0053    17.042   1148.73
             26989     T    Hand/finger surgery                                  1          1     0129    1.6576    111.73
             26990     T    Drainage of pelvis lesion                            1          3     0049   22.0149   1483.94
             26991     T    Drainage of pelvis bursa                             1          1     0049   22.0149   1483.94
             26992     C    Drainage of bone lesion                              1          1       0                          OR
             27000     T    Incision of hip tendon                               1          1     0049   22.0149   1483.94
             27001     T    Incision of hip tendon                               1          1     0050   31.7717    2141.6
             27003     T    Incision of hip tendon                               1          1     0050   31.7717    2141.6
             27005     C    Incision of hip tendon                               1          1       0                          OR
             27006     T    Incision of hip tendons                              1          1     0050   31.7717   2141.6
             27025     C    Incision of hip/thigh fascia                         1          1       0                          OR
             27027     T    Buttock fasciotomy                                   1          1     0049   22.0149   1483.94
             27030     C    Drainage of hip joint                                1          1       0                          OR
             27033     T    Exploration of hip joint                             1          1     0051   46.5786   3139.68
             27035     T    Denervation of hip joint                             1          1     0051   46.5786   3139.68
             27036     C    Excision of hip joint/muscle                         1          1       0                          OR
             27040     T    Biopsy of soft tissues                               1          1     0020    8.2028    552.92
             27041     T    Biopsy of soft tissues                               1          1     0020    8.2028    552.92
             27043     T    Exc hip pelvis les sc > 3 cm                         1          1     0022    23.388   1576.49
             27045     T    Exc hip/pelv tum deep > 5 cm                         1          1     0022    23.388   1576.49
             27047     T    Exc hip/pelvis les sc < 3 cm                         1          1     0021   17.4975   1179.44
             27048     T    Exc hip/pelv tum deep < 5 cm                         1          1     0021   17.4975   1179.44
             27049     T    Resect hip/pelv tum < 5 cm                           1          1     0021   17.4975   1179.44
             27050     T    Biopsy of sacroiliac joint                           1          1     0049   22.0149   1483.94
             27052     T    Biopsy of hip joint                                  1          1     0049   22.0149   1483.94
             27054     C    Removal of hip joint lining                          1          1       0                          OR
             27057     T    Buttock fasciotomy w/dbrdmt                          1          1     0049   22.0149   1483.94

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 25 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27059     T    Resect hip/pelv tum > 5 cm                           1          1     0022    23.388   1576.49
             27060     T    Removal of ischial bursa                             1          1     0049   22.0149   1483.94
             27062     T    Remove femur lesion/bursa                            1          1     0049   22.0149   1483.94
             27065     T    Removal of hip bone lesion                           1          1     0049   22.0149   1483.94
             27066     T    Removal of hip bone lesion                           1          1     0050   31.7717    2141.6
             27067     T    Remove/graft hip bone lesion                         1          1     0050   31.7717    2141.6
             27070     C    Partial removal of hip bone                          1          1       0                          OR
             27071     C    Partial removal of hip bone                          1          1       0                          OR
             27075     C    Resect hip tumor                                     1          1       0                          OR
             27076     C    Resect hip tum incl acetabul                         1          1       0                          OR
             27077     C    Resect hip tum w/innom bone                          1          1       0                          OR
             27078     C    Rsect hip tum incl femur                             1          1       0                          OR
             27080     T    Removal of tail bone                                 1          1     0050   31.7717    2141.6
             27086     T    Remove hip foreign body                              1          1     0020    8.2028    552.92
             27087     T    Remove hip foreign body                              1          1     0049   22.0149   1483.94
             27090     C    Removal of hip prosthesis                            1          1       0                          OR
             27091     C    Removal of hip prosthesis                            1          1       0                          OR
             27093     N    Injection for hip x-ray                              1          1       0
             27095     N    Injection for hip x-ray                              1          1       0
             27096     B    Inject sacroiliac joint                              0         NC       0
             27097     T    Revision of hip tendon                               1          1     0050   31.7717    2141.6
             27098     T    Transfer tendon to pelvis                            1          1     0050   31.7717    2141.6
             27100     T    Transfer of abdominal muscle                         1          1     0051   46.5786   3139.68
             27105     T    Transfer of spinal muscle                            1          1     0051   46.5786   3139.68
             27110     T    Transfer of iliopsoas muscle                         1          1     0051   46.5786   3139.68
             27111     T    Transfer of iliopsoas muscle                         1          1     0051   46.5786   3139.68
             27120     C    Reconstruction of hip socket                         1          1       0                          OR
             27122     C    Reconstruction of hip socket                         1          1       0                          OR
             27125     C    Partial hip replacement                              1          1       0                          OR
             27130     C    Total hip arthroplasty                               1          1       0                          OR
             27132     C    Total hip arthroplasty                               1          1       0                          OR
             27134     C    Revise hip joint replacement                         1          1       0                          OR
             27137     C    Revise hip joint replacement                         1          1       0                          OR
             27138     C    Revise hip joint replacement                         1          1       0                          OR
             27140     C    Transplant femur ridge                               1          1       0                          OR
             27146     C    Incision of hip bone                                 1          1       0                          OR
             27147     C    Revision of hip bone                                 1          1       0                          OR
             27151     C    Incision of hip bones                                1          1       0                          OR
             27156     C    Revision of hip bones                                1          1       0                          OR
             27158     C    Revision of pelvis                                   1          1       0                          OR
             27161     C    Incision of neck of femur                            1          1       0                          OR
             27165     C    Incision/fixation of femur                           1          1       0                          OR
             27170     C    Repair/graft femur head/neck                         1          1       0                          OR
             27175     C    Treat slipped epiphysis                              1          1       0                          OR
             27176     C    Treat slipped epiphysis                              1          1       0                          OR
             27177     C    Treat slipped epiphysis                              1          1       0                          OR
             27178     C    Treat slipped epiphysis                              1          1       0                          OR
             27179     T    Revise head/neck of femur                            1          1     0052   88.6521   5975.68
             27181     C    Treat slipped epiphysis                              1          1       0                          OR
     L       27185     C    Revision of femur epiphysis                          1          1       0                          OR
             27187     C    Reinforce hip bones                                  1          1       0                          OR
             27193     T    Treat pelvic ring fracture                           1          1     0129    1.6576    111.73
             27194     T    Treat pelvic ring fracture                           1          1     0045   15.2922   1030.79
             27200     T    Treat tail bone fracture                             1          1     0129    1.6576    111.73
             27202     T    Treat tail bone fracture                             1          1     0063   45.4678    3064.8
             27215     E    Treat pelvic fracture(s)                             1          1       0                          OR
             27216     E    Treat pelvic ring fracture                           1          1       0                          OR
             27217     E    Treat pelvic ring fracture                           1          1       0                          OR
             27218     E    Treat pelvic ring fracture                           1          1       0                          OR
             27220     T    Treat hip socket fracture                            1          1     0129   1.6576    111.73
             27222     C    Treat hip socket fracture                            1          1       0                          OR
             27226     C    Treat hip wall fracture                              1          1       0                          OR
             27227     C    Treat hip fracture(s)                                1          1       0                          OR
             27228     C    Treat hip fracture(s)                                1          1       0                          OR
             27230     T    Treat thigh fracture                                 1          1     0129   1.6576    111.73
             27232     C    Treat thigh fracture                                 1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 26 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27235     T    Treat thigh fracture                                 1          1     0050   31.7717   2141.6
             27236     C    Treat thigh fracture                                 1          1       0                          OR
             27238     T    Treat thigh fracture                                 1          1     0138   4.7946    323.18
             27240     C    Treat thigh fracture                                 1          1       0                          OR
             27244     C    Treat thigh fracture                                 1          1       0                          OR
             27245     C    Treat thigh fracture                                 1          1       0                          OR
             27246     T    Treat thigh fracture                                 1          1     0138   4.7946    323.18
             27248     C    Treat thigh fracture                                 1          1       0                          OR
             27250     T    Treat hip dislocation                                1          1     0129    1.6576    111.73
             27252     T    Treat hip dislocation                                1          1     0045   15.2922   1030.79
             27253     C    Treat hip dislocation                                1          1       0                          OR
             27254     C    Treat hip dislocation                                1          1       0                          OR
             27256     T    Treat hip dislocation                                1          1     0129    1.6576    111.73
             27257     T    Treat hip dislocation                                1          1     0045   15.2922   1030.79
             27258     C    Treat hip dislocation                                1          1       0                          OR
             27259     C    Treat hip dislocation                                1          1       0                          OR
             27265     T    Treat hip dislocation                                1          1     0129    1.6576    111.73
             27266     T    Treat hip dislocation                                1          1     0045   15.2922   1030.79
             27267     T    Cltx thigh fx                                        1          1     0129    1.6576    111.73
             27268     C    Cltx thigh fx w/mnpj                                 1          1       0                          OR
             27269     C    Optx thigh fx                                        1          1       0                          OR
             27275     T    Manipulation of hip joint                            1          1     0045   15.2922   1030.79
             27280     C    Fusion of sacroiliac joint                           1          1       0                          OR
             27282     C    Fusion of pubic bones                                1          1       0                          OR
             27284     C    Fusion of hip joint                                  1          1       0                          OR
             27286     C    Fusion of hip joint                                  1          1       0                          OR
             27290     C    Amputation of leg at hip                             1          1       0                          OR
             27295     C    Amputation of leg at hip                             1          1       0                          OR
             27299     T    Pelvis/hip joint surgery                             1          1     0129    1.6576   111.73
             27301     T    Drain thigh/knee lesion                              1          1     0008   19.4063   1308.1
             27303     C    Drainage of bone lesion                              1          1       0                          OR
             27305     T    Incise thigh tendon & fascia                         1          1     0049   22.0149   1483.94
             27306     T    Incision of thigh tendon                             1          1     0049   22.0149   1483.94
             27307     T    Incision of thigh tendons                            1          1     0049   22.0149   1483.94
             27310     T    Exploration of knee joint                            1          1     0050   31.7717    2141.6
             27323     T    Biopsy, thigh soft tissues                           1          1     0020    8.2028    552.92
             27324     T    Biopsy, thigh soft tissues                           1          1     0022    23.388   1576.49
             27325     T    Neurectomy, hamstring                                1          1     0220     18.72   1261.84
             27326     T    Neurectomy, popliteal                                1          1     0220     18.72   1261.84
             27327     T    Exc thigh/knee les sc < 3 cm                         1          1     0022    23.388   1576.49
             27328     T    Exc thigh/knee tum deep <5cm                         1          1     0021   17.4975   1179.44
             27329     T    Resect thigh/knee tum < 5 cm                         1          1     0021   17.4975   1179.44
             27330     T    Biopsy, knee joint lining                            1          1     0050   31.7717    2141.6
             27331     T    Explore/treat knee joint                             1          1     0050   31.7717    2141.6
             27332     T    Removal of knee cartilage                            1          1     0050   31.7717    2141.6
             27333     T    Removal of knee cartilage                            1          1     0050   31.7717    2141.6
             27334     T    Remove knee joint lining                             1          1     0050   31.7717    2141.6
             27335     T    Remove knee joint lining                             1          1     0050   31.7717    2141.6
             27337     T    Exc thigh/knee les sc > 3 cm                         1          1     0022    23.388   1576.49
             27339     T    Exc thigh/knee tum deep >5cm                         1          1     0022    23.388   1576.49
             27340     T    Removal of kneecap bursa                             1          1     0049   22.0149   1483.94
             27345     T    Removal of knee cyst                                 1          1     0049   22.0149   1483.94
             27347     T    Remove knee cyst                                     1          1     0049   22.0149   1483.94
             27350     T    Removal of kneecap                                   1          1     0050   31.7717    2141.6
             27355     T    Remove femur lesion                                  1          1     0050   31.7717    2141.6
             27356     T    Remove femur lesion/graft                            1          1     0050   31.7717    2141.6
             27357     T    Remove femur lesion/graft                            1          1     0050   31.7717    2141.6
             27358     T    Remove femur lesion/fixation                         1          1     0050   31.7717    2141.6
             27360     T    Partial removal, leg bone(s)                         1          1     0050   31.7717    2141.6
             27364     T    Resect thigh/knee tum >5 cm                          1          1     0022    23.388   1576.49
             27365     C    Resect femur/knee tumor                              1          1       0                          OR
             27370     N    Injection for knee x-ray                             1          1       0
             27372     T    Removal of foreign body                              1          1     0022    23.388   1576.49
             27380     T    Repair of kneecap tendon                             1          1     0049   22.0149   1483.94
             27381     T    Repair/graft kneecap tendon                          1          1     0049   22.0149   1483.94
             27385     T    Repair of thigh muscle                               1          1     0049   22.0149   1483.94

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 27 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27386     T    Repair/graft of thigh muscle                         1          1     0049   22.0149   1483.94
             27390     T    Incision of thigh tendon                             1          1     0049   22.0149   1483.94
             27391     T    Incision of thigh tendons                            1          1     0049   22.0149   1483.94
             27392     T    Incision of thigh tendons                            1          1     0049   22.0149   1483.94
             27393     T    Lengthening of thigh tendon                          1          1     0050   31.7717    2141.6
             27394     T    Lengthening of thigh tendons                         1          1     0050   31.7717    2141.6
             27395     T    Lengthening of thigh tendons                         1          1     0051   46.5786   3139.68
             27396     T    Transplant of thigh tendon                           1          1     0050   31.7717    2141.6
             27397     T    Transplants of thigh tendons                         1          1     0051   46.5786   3139.68
             27400     T    Revise thigh muscles/tendons                         1          1     0051   46.5786   3139.68
             27403     T    Repair of knee cartilage                             1          1     0050   31.7717    2141.6
             27405     T    Repair of knee ligament                              1          1     0051   46.5786   3139.68
             27407     T    Repair of knee ligament                              1          1     0052   88.6521   5975.68
             27409     T    Repair of knee ligaments                             1          1     0051   46.5786   3139.68
    PA       27412     T    Autochondrocyte implant knee                         1          1     0052   88.6521   5975.68
    PA       27415     T    Osteochondral knee allograft                         1          1     0052   88.6521   5975.68
    PA       27416     T    Osteochondral knee autograft                         1          1     0051   46.5786   3139.68
             27418     T    Repair degenerated kneecap                           1          1     0051   46.5786   3139.68
             27420     T    Revision of unstable kneecap                         1          1     0051   46.5786   3139.68
             27422     T    Revision of unstable kneecap                         1          1     0051   46.5786   3139.68
             27424     T    Revision/removal of kneecap                          1          1     0051   46.5786   3139.68
             27425     T    Lat retinacular release open                         1          1     0050   31.7717    2141.6
             27427     T    Reconstruction, knee                                 1          1     0051   46.5786   3139.68
             27428     T    Reconstruction, knee                                 1          1     0052   88.6521   5975.68
             27429     T    Reconstruction, knee                                 1          1     0052   88.6521   5975.68
             27430     T    Revision of thigh muscles                            1          1     0051   46.5786   3139.68
             27435     T    Incision of knee joint                               1          1     0051   46.5786   3139.68
             27437     T    Revise kneecap                                       1          1     0047   39.8877   2688.67
             27438     T    Revise kneecap with implant                          1          1     0048   58.0838    3915.2
             27440     T    Revision of knee joint                               1          1     0047   39.8877   2688.67
             27441     T    Revision of knee joint                               1          1     0047   39.8877   2688.67
             27442     T    Revision of knee joint                               1          1     0047   39.8877   2688.67
             27443     T    Revision of knee joint                               1          1     0047   39.8877   2688.67
             27445     C    Revision of knee joint                               1          1       0                          OR
             27446     T    Revision of knee joint                               1          1     0425   118.767   8005.61
             27447     C    Total knee arthroplasty                              1          1       0                          OR
             27448     C    Incision of thigh                                    1          1       0                          OR
             27450     C    Incision of thigh                                    1          1       0                          OR
             27454     C    Realignment of thigh bone                            1          1       0                          OR
             27455     C    Realignment of knee                                  1          1       0                          OR
             27457     C    Realignment of knee                                  1          1       0                          OR
             27465     C    Shortening of thigh bone                             1          1       0                          OR
             27466     C    Lengthening of thigh bone                            1          1       0                          OR
             27468     C    Shorten/lengthen thighs                              1          1       0                          OR
             27470     C    Repair of thigh                                      1          1       0                          OR
     L       27472     C    Repair/graft of thigh                                1          1       0                          OR
     L       27475     T    Surgery to stop leg growth                           1          1     0050   31.7717   2141.6
     L       27477     C    Surgery to stop leg growth                           1          1       0                          OR
     L       27479     T    Surgery to stop leg growth                           1          1     0050   31.7717   2141.6
     L       27485     C    Surgery to stop leg growth                           1          1       0                          OR
             27486     C    Revise/replace knee joint                            1          1       0                          OR
             27487     C    Revise/replace knee joint                            1          1       0                          OR
             27488     C    Removal of knee prosthesis                           1          1       0                          OR
             27495     C    Reinforce thigh                                      1          1       0                          OR
             27496     T    Decompression of thigh/knee                          1          1     0050   31.7717    2141.6
             27497     T    Decompression of thigh/knee                          1          1     0049   22.0149   1483.94
             27498     T    Decompression of thigh/knee                          1          1     0050   31.7717    2141.6
             27499     T    Decompression of thigh/knee                          1          1     0050   31.7717    2141.6
             27500     T    Treatment of thigh fracture                          1          1     0138    4.7946    323.18
             27501     T    Treatment of thigh fracture                          1          1     0129    1.6576    111.73
             27502     T    Treatment of thigh fracture                          1          1     0139   18.3962   1240.01
             27503     T    Treatment of thigh fracture                          1          1     0129    1.6576    111.73
             27506     C    Treatment of thigh fracture                          1          1       0                          OR
             27507     C    Treatment of thigh fracture                          1          1       0                          OR
             27508     T    Treatment of thigh fracture                          1          1     0129    1.6576    111.73
             27509     T    Treatment of thigh fracture                          1          1     0062   25.8446   1742.08

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 28 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27510     T    Treatment of thigh fracture                          1          1     0138   4.7946    323.18
             27511     C    Treatment of thigh fracture                          1          1       0                          OR
             27513     C    Treatment of thigh fracture                          1          1       0                          OR
             27514     C    Treatment of thigh fracture                          1          1       0                          OR
             27516     T    Treat thigh fx growth plate                          1          1     0129   1.6576    111.73
             27517     T    Treat thigh fx growth plate                          1          1     0129   1.6576    111.73
             27519     C    Treat thigh fx growth plate                          1          1       0                          OR
             27520     T    Treat kneecap fracture                               1          1     0129    1.6576    111.73
             27524     T    Treat kneecap fracture                               1          1     0063   45.4678    3064.8
             27530     T    Treat knee fracture                                  1          1     0129    1.6576    111.73
             27532     T    Treat knee fracture                                  1          1     0139   18.3962   1240.01
             27535     C    Treat knee fracture                                  1          1       0                          OR
             27536     C    Treat knee fracture                                  1          1       0                          OR
             27538     T    Treat knee fracture(s)                               1          1     0129   1.6576    111.73
             27540     C    Treat knee fracture                                  1          1       0                          OR
             27550     T    Treat knee dislocation                               1          1     0129    1.6576    111.73
             27552     T    Treat knee dislocation                               1          1     0045   15.2922   1030.79
             27556     C    Treat knee dislocation                               1          1       0                          OR
             27557     C    Treat knee dislocation                               1          1       0                          OR
             27558     C    Treat knee dislocation                               1          1       0                          OR
             27560     T    Treat kneecap dislocation                            1          1     0129    1.6576    111.73
             27562     T    Treat kneecap dislocation                            1          1     0045   15.2922   1030.79
             27566     T    Treat kneecap dislocation                            1          1     0063   45.4678    3064.8
             27570     T    Fixation of knee joint                               1          1     0045   15.2922   1030.79
             27580     C    Fusion of knee                                       1          1       0                          OR
             27590     C    Amputate leg at thigh                                1          1       0                          OR
             27591     C    Amputate leg at thigh                                1          1       0                          OR
             27592     C    Amputate leg at thigh                                1          1       0                          OR
             27594     T    Amputation follow-up surgery                         1          1     0049   22.0149   1483.94
             27596     C    Amputation follow-up surgery                         1          1       0                          OR
             27598     C    Amputate lower leg at knee                           1          1       0                          OR
             27599     T    Leg surgery procedure                                1          1     0129    1.6576    111.73
             27600     T    Decompression of lower leg                           1          1     0049   22.0149   1483.94
             27601     T    Decompression of lower leg                           1          1     0049   22.0149   1483.94
             27602     T    Decompression of lower leg                           1          1     0049   22.0149   1483.94
             27603     T    Drain lower leg lesion                               1          1     0008   19.4063    1308.1
             27604     T    Drain lower leg bursa                                1          1     0049   22.0149   1483.94
             27605     T    Incision of achilles tendon                          1          1     0055   21.8439   1472.41
             27606     T    Incision of achilles tendon                          1          1     0049   22.0149   1483.94
             27607     T    Treat lower leg bone lesion                          1          1     0049   22.0149   1483.94
             27610     T    Explore/treat ankle joint                            1          1     0050   31.7717    2141.6
             27612     T    Exploration of ankle joint                           1          1     0050   31.7717    2141.6
             27613     T    Biopsy lower leg soft tissue                         1          1     0020    8.2028    552.92
             27614     T    Biopsy lower leg soft tissue                         1          1     0022    23.388   1576.49
             27615     T    Resect leg/ankle tum < 5 cm                          1          1     0021   17.4975   1179.44
             27616     T    Resect leg/ankle tum > 5 cm                          1          1     0022    23.388   1576.49
             27618     T    Exc leg/ankle tum < 3 cm                             1          1     0021   17.4975   1179.44
             27619     T    Exc leg/ankle tum deep <5 cm                         1          1     0021   17.4975   1179.44
             27620     T    Explore/treat ankle joint                            1          1     0050   31.7717    2141.6
             27625     T    Remove ankle joint lining                            1          1     0050   31.7717    2141.6
             27626     T    Remove ankle joint lining                            1          1     0050   31.7717    2141.6
             27630     T    Removal of tendon lesion                             1          1     0049   22.0149   1483.94
             27632     T    Exc leg/ankle les sc > 3 cm                          1          1     0022    23.388   1576.49
             27634     T    Exc leg/ankle tum deep >5 cm                         1          1     0022    23.388   1576.49
             27635     T    Remove lower leg bone lesion                         1          1     0050   31.7717    2141.6
             27637     T    Remove/graft leg bone lesion                         1          1     0050   31.7717    2141.6
             27638     T    Remove/graft leg bone lesion                         1          1     0050   31.7717    2141.6
             27640     T    Partial removal of tibia                             1          1     0051   46.5786   3139.68
             27641     T    Partial removal of fibula                            1          1     0050   31.7717    2141.6
             27645     C    Resect tibia tumor                                   1          1       0                          OR
             27646     C    Resect fibula tumor                                  1          1       0                          OR
             27647     T    Resect talus/calcaneus tum                           1          1     0051   46.5786   3139.68
             27648     N    Injection for ankle x-ray                            1          1       0
             27650     T    Repair achilles tendon                               1          1     0051   46.5786   3139.68
             27652     T    Repair/graft achilles tendon                         1          1     0052   88.6521   5975.68
             27654     T    Repair of achilles tendon                            1          1     0051   46.5786   3139.68

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 29 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27656     T    Repair leg fascia defect                             1          1     0049   22.0149   1483.94
             27658     T    Repair of leg tendon, each                           1          1     0049   22.0149   1483.94
             27659     T    Repair of leg tendon, each                           1          1     0049   22.0149   1483.94
             27664     T    Repair of leg tendon, each                           1          1     0050   31.7717    2141.6
             27665     T    Repair of leg tendon, each                           1          1     0050   31.7717    2141.6
             27675     T    Repair lower leg tendons                             1          1     0049   22.0149   1483.94
             27676     T    Repair lower leg tendons                             1          1     0050   31.7717    2141.6
             27680     T    Release of lower leg tendon                          1          1     0050   31.7717    2141.6
             27681     T    Release of lower leg tendons                         1          1     0050   31.7717    2141.6
             27685     T    Revision of lower leg tendon                         1          1     0050   31.7717    2141.6
             27686     T    Revise lower leg tendons                             1          3     0050   31.7717    2141.6
             27687     T    Revision of calf tendon                              1          1     0050   31.7717    2141.6
             27690     T    Revise lower leg tendon                              1          1     0051   46.5786   3139.68
             27691     T    Revise lower leg tendon                              1          1     0051   46.5786   3139.68
             27692     T    Revise additional leg tendon                         1          1     0051   46.5786   3139.68
             27695     T    Repair of ankle ligament                             1          1     0050   31.7717    2141.6
             27696     T    Repair of ankle ligaments                            1          1     0050   31.7717    2141.6
             27698     T    Repair of ankle ligament                             1          1     0050   31.7717    2141.6
             27700     T    Revision of ankle joint                              1          1     0047   39.8877   2688.67
             27702     C    Reconstruct ankle joint                              1          1       0                          OR
             27703     C    Reconstruction, ankle joint                          1          1       0                          OR
             27704     T    Removal of ankle implant                             1          1     0049   22.0149   1483.94
             27705     T    Incision of tibia                                    1          1     0051   46.5786   3139.68
             27707     T    Incision of fibula                                   1          1     0049   22.0149   1483.94
             27709     T    Incision of tibia & fibula                           1          1     0050   31.7717    2141.6
             27712     C    Realignment of lower leg                             1          1       0                          OR
             27715     C    Revision of lower leg                                1          1       0                          OR
             27720     T    Repair of tibia                                      1          1     0063   45.4678    3064.8
             27722     T    Repair/graft of tibia                                1          1     0064   65.4752   4413.42
             27724     C    Repair/graft of tibia                                1          1       0                          OR
             27725     C    Repair of lower leg                                  1          1       0                          OR
             27726     T    Repair fibula nonunion                               1          1     0063   45.4678   3064.8
             27727     C    Repair of lower leg                                  1          1       0                          OR
     L       27730     T    Repair of tibia epiphysis                            1          1     0050   31.7717    2141.6
     L       27732     T    Repair of fibula epiphysis                           1          1     0050   31.7717    2141.6
     L       27734     T    Repair lower leg epiphyses                           1          1     0050   31.7717    2141.6
     L       27740     T    Repair of leg epiphyses                              1          1     0050   31.7717    2141.6
             27742     T    Repair of leg epiphyses                              1          1     0051   46.5786   3139.68
             27745     T    Reinforce tibia                                      1          1     0052   88.6521   5975.68
             27750     T    Treatment of tibia fracture                          1          1     0129    1.6576    111.73
             27752     T    Treatment of tibia fracture                          1          1     0139   18.3962   1240.01
             27756     T    Treatment of tibia fracture                          1          1     0062   25.8446   1742.08
             27758     T    Treatment of tibia fracture                          1          1     0063   45.4678    3064.8
             27759     T    Treatment of tibia fracture                          1          1     0064   65.4752   4413.42
             27760     T    Cltx medial ankle fx                                 1          1     0129    1.6576    111.73
             27762     T    Cltx med ankle fx w/mnpj                             1          1     0139   18.3962   1240.01
             27766     T    Optx medial ankle fx                                 1          1     0063   45.4678    3064.8
             27767     T    Cltx post ankle fx                                   1          1     0129    1.6576    111.73
             27768     T    Cltx post ankle fx w/mnpj                            1          1     0129    1.6576    111.73
             27769     T    Optx post ankle fx                                   1          1     0063   45.4678    3064.8
             27780     T    Treatment of fibula fracture                         1          1     0129    1.6576    111.73
             27781     T    Treatment of fibula fracture                         1          1     0139   18.3962   1240.01
             27784     T    Treatment of fibula fracture                         1          1     0063   45.4678    3064.8
             27786     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             27788     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             27792     T    Treatment of ankle fracture                          1          1     0063   45.4678    3064.8
             27808     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             27810     T    Treatment of ankle fracture                          1          1     0138    4.7946    323.18
             27814     T    Treatment of ankle fracture                          1          1     0063   45.4678    3064.8
             27816     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             27818     T    Treatment of ankle fracture                          1          1     0138    4.7946    323.18
             27822     T    Treatment of ankle fracture                          1          1     0063   45.4678    3064.8
             27823     T    Treatment of ankle fracture                          1          1     0064   65.4752   4413.42
             27824     T    Treat lower leg fracture                             1          1     0129    1.6576    111.73
             27825     T    Treat lower leg fracture                             1          1     0139   18.3962   1240.01
             27826     T    Treat lower leg fracture                             1          1     0063   45.4678    3064.8

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 30 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             27827     T    Treat lower leg fracture                             1          1     0064   65.4752   4413.42
             27828     T    Treat lower leg fracture                             1          1     0064   65.4752   4413.42
             27829     T    Treat lower leg joint                                1          1     0063   45.4678    3064.8
             27830     T    Treat lower leg dislocation                          1          1     0129    1.6576    111.73
             27831     T    Treat lower leg dislocation                          1          1     0139   18.3962   1240.01
             27832     T    Treat lower leg dislocation                          1          1     0063   45.4678    3064.8
             27840     T    Treat ankle dislocation                              1          1     0138    4.7946    323.18
             27842     T    Treat ankle dislocation                              1          1     0045   15.2922   1030.79
             27846     T    Treat ankle dislocation                              1          1     0063   45.4678    3064.8
             27848     T    Treat ankle dislocation                              1          1     0063   45.4678    3064.8
             27860     T    Fixation of ankle joint                              1          1     0045   15.2922   1030.79
             27870     T    Fusion of ankle joint, open                          1          1     0052   88.6521   5975.68
             27871     T    Fusion of tibiofibular joint                         1          1     0052   88.6521   5975.68
             27880     C    Amputation of lower leg                              1          1       0                          OR
             27881     C    Amputation of lower leg                              1          1       0                          OR
             27882     C    Amputation of lower leg                              1          1       0                          OR
             27884     T    Amputation follow-up surgery                         1          1     0049   22.0149   1483.94
             27886     C    Amputation follow-up surgery                         1          1       0                          OR
             27888     C    Amputation of foot at ankle                          1          1       0                          OR
             27889     T    Amputation of foot at ankle                          1          1     0050   31.7717    2141.6
             27892     T    Decompression of leg                                 1          1     0050   31.7717    2141.6
             27893     T    Decompression of leg                                 1          1     0050   31.7717    2141.6
             27894     T    Decompression of leg                                 1          1     0050   31.7717    2141.6
             27899     T    Leg/ankle surgery procedure                          1          1     0129    1.6576    111.73
             28001     T    Drainage of bursa of foot                            1          1     0007   12.6217    850.78
             28002     T    Treatment of foot infection                          1          1     0049   22.0149   1483.94
             28003     T    Treatment of foot infection                          1          1     0049   22.0149   1483.94
             28005     T    Treat foot bone lesion                               1          1     0055   21.8439   1472.41
             28008     T    Incision of foot fascia                              1          1     0055   21.8439   1472.41
             28010     T    Incision of toe tendon                               1          1     0055   21.8439   1472.41
             28011     T    Incision of toe tendons                              1          1     0055   21.8439   1472.41
             28020     T    Exploration of foot joint                            1          1     0055   21.8439   1472.41
             28022     T    Exploration of foot joint                            1          1     0055   21.8439   1472.41
             28024     T    Exploration of toe joint                             1          1     0055   21.8439   1472.41
             28035     T    Decompression of tibia nerve                         1          1     0220     18.72   1261.84
             28039     T    Exc foot/toe tum sc > 1.5 cm                         1          1     0022    23.388   1576.49
             28041     T    Exc foot/toe tum deep >1.5cm                         1          1     0022    23.388   1576.49
             28043     T    Exc foot/toe tum sc < 1.5 cm                         1          1     0021   17.4975   1179.44
             28045     T    Exc foot/toe tum deep <1.5cm                         1          1     0021   17.4975   1179.44
             28046     T    Resect foot/toe tumor < 3 cm                         1          1     0021   17.4975   1179.44
             28047     T    Resect foot/toe tumor > 3 cm                         1          1     0022    23.388   1576.49
             28050     T    Biopsy of foot joint lining                          1          1     0055   21.8439   1472.41
             28052     T    Biopsy of foot joint lining                          1          1     0055   21.8439   1472.41
             28054     T    Biopsy of toe joint lining                           1          1     0055   21.8439   1472.41
             28055     T    Neurectomy, foot                                     1          1     0220     18.72   1261.84
             28060     T    Partial removal, foot fascia                         1          1     0055   21.8439   1472.41
             28062     T    Removal of foot fascia                               1          1     0055   21.8439   1472.41
             28070     T    Removal of foot joint lining                         1          1     0055   21.8439   1472.41
             28072     T    Removal of foot joint lining                         1          1     0055   21.8439   1472.41
             28080     T    Removal of foot lesion                               1          1     0055   21.8439   1472.41
             28086     T    Excise foot tendon sheath                            1          1     0055   21.8439   1472.41
             28088     T    Excise foot tendon sheath                            1          1     0055   21.8439   1472.41
             28090     T    Removal of foot lesion                               1          6     0055   21.8439   1472.41
             28092     T    Removal of toe lesions                               1          1     0055   21.8439   1472.41
             28100     T    Removal of ankle/heel lesion                         1          1     0055   21.8439   1472.41
             28102     T    Remove/graft foot lesion                             1          1     0056   52.5258   3540.55
             28103     T    Remove/graft foot lesion                             1          1     0056   52.5258   3540.55
             28104     T    Removal of foot lesion                               1          1     0055   21.8439   1472.41
             28106     T    Remove/graft foot lesion                             1          1     0056   52.5258   3540.55
             28107     T    Remove/graft foot lesion                             1          1     0056   52.5258   3540.55
             28108     T    Removal of toe lesions                               1          1     0055   21.8439   1472.41
             28110     T    Part removal of metatarsal                           1          1     0055   21.8439   1472.41
             28111     T    Part removal of metatarsal                           1          1     0055   21.8439   1472.41
             28112     T    Part removal of metatarsal                           1          1     0055   21.8439   1472.41
             28113     T    Part removal of metatarsal                           1          1     0055   21.8439   1472.41
             28114     T    Removal of metatarsal heads                          1          1     0055   21.8439   1472.41

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 31 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             28116     T    Revision of foot                                     1          1     0055   21.8439   1472.41
             28118     T    Removal of heel bone                                 1          1     0055   21.8439   1472.41
             28119     T    Removal of heel spur                                 1          1     0055   21.8439   1472.41
             28120     T    Part removal of ankle/heel                           1          1     0055   21.8439   1472.41
             28122     T    Partial removal of foot bone                         1          1     0055   21.8439   1472.41
             28124     T    Partial removal of toe                               1          1     0055   21.8439   1472.41
             28126     T    Partial removal of toe                               1          1     0055   21.8439   1472.41
             28130     T    Removal of ankle bone                                1          1     0055   21.8439   1472.41
             28140     T    Removal of metatarsal                                1          1     0055   21.8439   1472.41
             28150     T    Removal of toe                                       1          1     0055   21.8439   1472.41
             28153     T    Partial removal of toe                               1          1     0055   21.8439   1472.41
             28160     T    Partial removal of toe                               1          1     0055   21.8439   1472.41
             28171     T    Resect tarsal tumor                                  1          1     0055   21.8439   1472.41
             28173     T    Resect metatarsal tumor                              1          1     0055   21.8439   1472.41
             28175     T    Resect phalanx of toe tumor                          1          1     0055   21.8439   1472.41
             28190     T    Removal of foot foreign body                         1          1     0020    8.2028    552.92
             28192     T    Removal of foot foreign body                         1          1     0021   17.4975   1179.44
             28193     T    Removal of foot foreign body                         1          1     0020    8.2028    552.92
             28200     T    Repair of foot tendon                                1          1     0055   21.8439   1472.41
             28202     T    Repair/graft of foot tendon                          1          1     0055   21.8439   1472.41
             28208     T    Repair of foot tendon                                1          1     0055   21.8439   1472.41
             28210     T    Repair/graft of foot tendon                          1          1     0056   52.5258   3540.55
             28220     T    Release of foot tendon                               1          1     0055   21.8439   1472.41
             28222     T    Release of foot tendons                              1          1     0055   21.8439   1472.41
             28225     T    Release of foot tendon                               1          1     0055   21.8439   1472.41
             28226     T    Release of foot tendons                              1          1     0055   21.8439   1472.41
             28230     T    Incision of foot tendon(s)                           1          1     0055   21.8439   1472.41
             28232     T    Incision of toe tendon                               1          1     0055   21.8439   1472.41
             28234     T    Incision of foot tendon                              1          1     0055   21.8439   1472.41
             28238     T    Revision of foot tendon                              1          1     0056   52.5258   3540.55
             28240     T    Release of big toe                                   1          1     0055   21.8439   1472.41
             28250     T    Revision of foot fascia                              1          1     0055   21.8439   1472.41
             28260     T    Release of midfoot joint                             1          1     0055   21.8439   1472.41
             28261     T    Revision of foot tendon                              1          1     0055   21.8439   1472.41
             28262     T    Revision of foot and ankle                           1          1     0055   21.8439   1472.41
             28264     T    Release of midfoot joint                             1          1     0056   52.5258   3540.55
             28270     T    Release of foot contracture                          1          1     0055   21.8439   1472.41
             28272     T    Release of toe joint, each                           1          1     0055   21.8439   1472.41
             28280     T    Fusion of toes                                       1          1     0055   21.8439   1472.41
             28285     T    Repair of hammertoe                                  1          1     0055   21.8439   1472.41
             28286     T    Repair of hammertoe                                  1          1     0055   21.8439   1472.41
             28288     T    Partial removal of foot bone                         1          1     0055   21.8439   1472.41
             28289     T    Repair hallux rigidus                                1          1     0055   21.8439   1472.41
             28290     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28292     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28293     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28294     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28296     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28297     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28298     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28299     T    Correction of bunion                                 1          1     0057   31.5534   2126.89
             28300     T    Incision of heel bone                                1          1     0056   52.5258   3540.55
             28302     T    Incision of ankle bone                               1          1     0055   21.8439   1472.41
             28304     T    Incision of midfoot bones                            1          1     0056   52.5258   3540.55
             28305     T    Incise/graft midfoot bones                           1          1     0056   52.5258   3540.55
             28306     T    Incision of metatarsal                               1          1     0055   21.8439   1472.41
             28307     T    Incision of metatarsal                               1          1     0055   21.8439   1472.41
             28308     T    Incision of metatarsal                               1          1     0055   21.8439   1472.41
             28309     T    Incision of metatarsals                              1          1     0056   52.5258   3540.55
             28310     T    Revision of big toe                                  1          1     0055   21.8439   1472.41
             28312     T    Revision of toe                                      1          1     0055   21.8439   1472.41
             28313     T    Repair deformity of toe                              1          1     0055   21.8439   1472.41
             28315     T    Removal of sesamoid bone                             1          1     0055   21.8439   1472.41
             28320     T    Repair of foot bones                                 1          1     0056   52.5258   3540.55
             28322     T    Repair of metatarsals                                1          1     0056   52.5258   3540.55
             28340     T    Resect enlarged toe tissue                           1          1     0055   21.8439   1472.41

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 32 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             28341     T    Resect enlarged toe                                  1          1     0055   21.8439   1472.41
             28344     T    Repair extra toe(s)                                  1          1     0055   21.8439   1472.41
             28345     T    Repair webbed toe(s)                                 1          1     0055   21.8439   1472.41
             28360     T    Reconstruct cleft foot                               1          1     0056   52.5258   3540.55
             28400     T    Treatment of heel fracture                           1          1     0129    1.6576    111.73
             28405     T    Treatment of heel fracture                           1          1     0139   18.3962   1240.01
             28406     T    Treatment of heel fracture                           1          1     0062   25.8446   1742.08
             28415     T    Treat heel fracture                                  1          1     0064   65.4752   4413.42
             28420     T    Treat/graft heel fracture                            1          1     0063   45.4678    3064.8
             28430     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             28435     T    Treatment of ankle fracture                          1          1     0129    1.6576    111.73
             28436     T    Treatment of ankle fracture                          1          1     0062   25.8446   1742.08
             28445     T    Treat ankle fracture                                 1          1     0063   45.4678    3064.8
             28446     T    Osteochondral talus autogrft                         1          1     0056   52.5258   3540.55
             28450     T    Treat midfoot fracture, each                         1          1     0129    1.6576    111.73
             28455     T    Treat midfoot fracture, each                         1          1     0129    1.6576    111.73
             28456     T    Treat midfoot fracture                               1          1     0062   25.8446   1742.08
             28465     T    Treat midfoot fracture, each                         1          1     0063   45.4678    3064.8
             28470     T    Treat metatarsal fracture                            1          1     0129    1.6576    111.73
             28475     T    Treat metatarsal fracture                            1          1     0129    1.6576    111.73
             28476     T    Treat metatarsal fracture                            1          1     0062   25.8446   1742.08
             28485     T    Treat metatarsal fracture                            1          1     0063   45.4678    3064.8
             28490     T    Treat big toe fracture                               1          1     0129    1.6576    111.73
             28495     T    Treat big toe fracture                               1          1     0129    1.6576    111.73
             28496     T    Treat big toe fracture                               1          1     0062   25.8446   1742.08
             28505     T    Treat big toe fracture                               1          1     0062   25.8446   1742.08
             28510     T    Treatment of toe fracture                            1          1     0129    1.6576    111.73
             28515     T    Treatment of toe fracture                            1          1     0129    1.6576    111.73
             28525     T    Treat toe fracture                                   1          1     0062   25.8446   1742.08
             28530     T    Treat sesamoid bone fracture                         1          1     0129    1.6576    111.73
             28531     T    Treat sesamoid bone fracture                         1          1     0062   25.8446   1742.08
             28540     T    Treat foot dislocation                               1          1     0129    1.6576    111.73
             28545     T    Treat foot dislocation                               1          1     0062   25.8446   1742.08
             28546     T    Treat foot dislocation                               1          1     0062   25.8446   1742.08
             28555     T    Repair foot dislocation                              1          1     0063   45.4678    3064.8
             28570     T    Treat foot dislocation                               1          1     0138    4.7946    323.18
             28575     T    Treat foot dislocation                               1          1     0139   18.3962   1240.01
             28576     T    Treat foot dislocation                               1          1     0062   25.8446   1742.08
             28585     T    Repair foot dislocation                              1          1     0062   25.8446   1742.08
             28600     T    Treat foot dislocation                               1          1     0129    1.6576    111.73
             28605     T    Treat foot dislocation                               1          1     0129    1.6576    111.73
             28606     T    Treat foot dislocation                               1          1     0062   25.8446   1742.08
             28615     T    Repair foot dislocation                              1          1     0063   45.4678    3064.8
             28630     T    Treat toe dislocation                                1          1     0129    1.6576    111.73
             28635     T    Treat toe dislocation                                1          1     0045   15.2922   1030.79
             28636     T    Treat toe dislocation                                1          1     0062   25.8446   1742.08
             28645     T    Repair toe dislocation                               1          1     0062   25.8446   1742.08
             28660     T    Treat toe dislocation                                1          1     0129    1.6576    111.73
             28665     T    Treat toe dislocation                                1          1     0045   15.2922   1030.79
             28666     T    Treat toe dislocation                                1          1     0062   25.8446   1742.08
             28675     T    Repair of toe dislocation                            1          1     0062   25.8446   1742.08
             28705     T    Fusion of foot bones                                 1          1     0056   52.5258   3540.55
             28715     T    Fusion of foot bones                                 1          1     0052   88.6521   5975.68
             28725     T    Fusion of foot bones                                 1          1     0056   52.5258   3540.55
             28730     T    Fusion of foot bones                                 1          1     0056   52.5258   3540.55
             28735     T    Fusion of foot bones                                 1          1     0056   52.5258   3540.55
             28737     T    Revision of foot bones                               1          1     0056   52.5258   3540.55
             28740     T    Fusion of foot bones                                 1          1     0056   52.5258   3540.55
             28750     T    Fusion of big toe joint                              1          1     0056   52.5258   3540.55
             28755     T    Fusion of big toe joint                              1          1     0055   21.8439   1472.41
             28760     T    Fusion of big toe joint                              1          1     0056   52.5258   3540.55
             28800     C    Amputation of midfoot                                1          1       0                          OR
             28805     T    Amputation thru metatarsal                           1          1     0055   21.8439   1472.41
             28810     T    Amputation toe & metatarsal                          1          1     0055   21.8439   1472.41
             28820     T    Amputation of toe                                    1          1     0055   21.8439   1472.41
             28825     T    Partial amputation of toe                            1          1     0055   21.8439   1472.41

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 33 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             28890     T    High energy eswt, plantar f                          0         NC       0
             28899     T    Foot/toes surgery procedure                          1          1     0129    1.6576    111.73
             29000     S    Application of body cast                             1          1     0058    1.0537     71.03
             29010     S    Application of body cast                             1          1     0426    2.3457    158.11
             29015     S    Application of body cast                             1          1     0426    2.3457    158.11
             29020     S    Application of body cast                             1          1     0058    1.0537     71.03
             29025     S    Application of body cast                             1          1     0058    1.0537     71.03
             29035     S    Application of body cast                             1          1     0426    2.3457    158.11
             29040     S    Application of body cast                             1          1     0058    1.0537     71.03
             29044     S    Application of body cast                             1          1     0426    2.3457    158.11
             29046     S    Application of body cast                             1          1     0426    2.3457    158.11
             29049     S    Application of figure eight                          1          1     0058    1.0537     71.03
             29055     S    Application of shoulder cast                         1          1     0426    2.3457    158.11
             29058     S    Application of shoulder cast                         1          1     0058    1.0537     71.03
             29065     S    Application of long arm cast                         1          1     0426    2.3457    158.11
             29075     S    Application of forearm cast                          1          1     0426    2.3457    158.11
             29085     S    Apply hand/wrist cast                                1          1     0058    1.0537     71.03
             29086     S    Apply finger cast                                    1         10     0058    1.0537     71.03
             29105     S    Apply long arm splint                                1          1     0058    1.0537     71.03
             29125     S    Apply forearm splint                                 1          1     0058    1.0537     71.03
             29126     S    Apply forearm splint                                 1          1     0058    1.0537     71.03
             29130     S    Application of finger splint                         1          1     0058    1.0537     71.03
             29131     S    Application of finger splint                         1          1     0058    1.0537     71.03
             29200     S    Strapping of chest                                   1          1     0058    1.0537     71.03
             29240     S    Strapping of shoulder                                1          1     0058    1.0537     71.03
             29260     S    Strapping of elbow or wrist                          1          1     0058    1.0537     71.03
             29280     S    Strapping of hand or finger                          1          1     0058    1.0537     71.03
             29305     S    Application of hip cast                              1          1     0426    2.3457    158.11
             29325     S    Application of hip casts                             1          1     0426    2.3457    158.11
             29345     S    Application of long leg cast                         1          1     0426    2.3457    158.11
             29355     S    Application of long leg cast                         1          1     0426    2.3457    158.11
             29358     S    Apply long leg cast brace                            1          1     0426    2.3457    158.11
             29365     S    Application of long leg cast                         1          1     0426    2.3457    158.11
             29405     S    Apply short leg cast                                 1          1     0426    2.3457    158.11
             29425     S    Apply short leg cast                                 1          1     0426    2.3457    158.11
             29435     S    Apply short leg cast                                 1          1     0426    2.3457    158.11
             29440     S    Addition of walker to cast                           1          1     0058    1.0537     71.03
             29445     S    Apply rigid leg cast                                 1          1     0426    2.3457    158.11
             29450     S    Application of leg cast                              1          1     0058    1.0537     71.03
             29505     S    Application, long leg splint                         1          1     0058    1.0537     71.03
             29515     S    Application lower leg splint                         1          1     0058    1.0537     71.03
             29520     S    Strapping of hip                                     1          1     0058    1.0537     71.03
             29530     S    Strapping of knee                                    1          1     0058    1.0537     71.03
             29540     S    Strapping of ankle and/or ft                         1          1     0058    1.0537     71.03
             29550     S    Strapping of toes                                    1          1     0058    1.0537     71.03
             29580     S    Application of paste boot                            1          1     0058    1.0537     71.03
             29581     S    Apply multlay comprs lwr leg                         1          1     0058    1.0537     71.03
             29590     S    Application of foot splint                           1          1     0058    1.0537     71.03
             29700     S    Removal/revision of cast                             1          1     0058    1.0537     71.03
             29705     S    Removal/revision of cast                             1          1     0058    1.0537     71.03
             29710     S    Removal/revision of cast                             1          1     0426    2.3457    158.11
             29715     S    Removal/revision of cast                             1          1     0058    1.0537     71.03
             29720     S    Repair of body cast                                  1          1     0058    1.0537     71.03
             29730     S    Windowing of cast                                    1          1     0058    1.0537     71.03
             29740     S    Wedging of cast                                      1          1     0058    1.0537     71.03
             29750     S    Wedging of clubfoot cast                             1          1     0058    1.0537     71.03
             29799     S    Casting/strapping procedure                          1          1     0058    1.0537     71.03
    PA       29800     T    Jaw arthroscopy/surgery                              1          1     0041   29.9198   2016.77
    PA       29804     T    Jaw arthroscopy/surgery                              1          1     0041   29.9198   2016.77
             29805     T    Shoulder arthroscopy, dx                             1          1     0041   29.9198   2016.77
             29806     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29807     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29819     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29820     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29821     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29822     T    Shoulder arthroscopy/surgery                         1          1     0041   29.9198   2016.77

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 34 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             29823     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29824     T    Shoulder arthroscopy/surgery                         1          1     0041   29.9198   2016.77
             29825     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29826     T    Shoulder arthroscopy/surgery                         1          1     0042   48.8176    3290.6
             29827     T    Arthroscop rotator cuff repr                         1          1     0042   48.8176    3290.6
             29828     T    Arthroscopy biceps tenodesis                         1          1     0042   48.8176    3290.6
             29830     T    Elbow arthroscopy                                    1          1     0041   29.9198   2016.77
             29834     T    Elbow arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29835     T    Elbow arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29836     T    Elbow arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29837     T    Elbow arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29838     T    Elbow arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29840     T    Wrist arthroscopy                                    1          1     0041   29.9198   2016.77
             29843     T    Wrist arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29844     T    Wrist arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29845     T    Wrist arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29846     T    Wrist arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29847     T    Wrist arthroscopy/surgery                            1          1     0042   48.8176    3290.6
             29848     T    Wrist endoscopy/surgery                              1          1     0041   29.9198   2016.77
             29850     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29851     T    Knee arthroscopy/surgery                             1          1     0042   48.8176    3290.6
             29855     T    Tibial arthroscopy/surgery                           1          1     0042   48.8176    3290.6
             29856     T    Tibial arthroscopy/surgery                           1          1     0042   48.8176    3290.6
             29860     T    Hip arthroscopy, dx                                  1          1     0042   48.8176    3290.6
             29861     T    Hip arthroscopy/surgery                              1          1     0042   48.8176    3290.6
             29862     T    Hip arthroscopy/surgery                              1          1     0042   48.8176    3290.6
             29863     T    Hip arthroscopy/surgery                              1          1     0042   48.8176    3290.6
             29866     T    Autgrft implnt, knee w/scope                         0         NC       0
             29867     T    Allgrft implnt, knee w/scope                         0         NC       0
             29868     T    Meniscal trnspl, knee w/scpe                         0         NC       0
             29870     T    Knee arthroscopy, dx                                 1          1     0041   29.9198   2016.77
             29871     T    Knee arthroscopy/drainage                            1          1     0041   29.9198   2016.77
             29873     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29874     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29875     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29876     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
    PA       29877     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29879     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29880     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29881     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29882     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29883     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29884     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29885     T    Knee arthroscopy/surgery                             1          1     0042   48.8176    3290.6
             29886     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29887     T    Knee arthroscopy/surgery                             1          1     0041   29.9198   2016.77
             29888     T    Knee arthroscopy/surgery                             1          1     0052   88.6521   5975.68
             29889     T    Knee arthroscopy/surgery                             1          1     0052   88.6521   5975.68
             29891     T    Ankle arthroscopy/surgery                            1          1     0042   48.8176    3290.6
             29892     T    Ankle arthroscopy/surgery                            1          1     0052   88.6521   5975.68
             29893     T    Scope, plantar fasciotomy                            1          1     0055   21.8439   1472.41
             29894     T    Ankle arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29895     T    Ankle arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29897     T    Ankle arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29898     T    Ankle arthroscopy/surgery                            1          1     0041   29.9198   2016.77
             29899     T    Ankle arthroscopy/surgery                            1          1     0042   48.8176    3290.6
             29900     T    Mcp joint arthroscopy, dx                            1          1     0041   29.9198   2016.77
             29901     T    Mcp joint arthroscopy, surg                          1          1     0041   29.9198   2016.77
             29902     T    Mcp joint arthroscopy, surg                          1          1     0041   29.9198   2016.77
             29904     T    Subtalar arthro w/fb rmvl                            1          1     0041   29.9198   2016.77
             29905     T    Subtalar arthro w/exc                                1          1     0041   29.9198   2016.77
             29906     T    Subtalar arthro w/deb                                1          1     0041   29.9198   2016.77
             29907     T    Subtalar arthro w/fusion                             1          1     0042   48.8176    3290.6
             29999     T    Arthroscopy of joint                                 1          1     0041   29.9198   2016.77
             30000     T    Drainage of nose lesion                              1          1     0251    3.425     230.87
             30020     T    Drainage of nose lesion                              1          1     0251    3.425     230.87

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 35 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             30100     T    Intranasal biopsy                                    1          1     0252    7.6196    513.61
             30110     T    Removal of nose polyp(s)                             1          1     0253   17.1879   1158.57
             30115     T    Removal of nose polyp(s)                             1          1     0253   17.1879   1158.57
             30117     T    Removal of intranasal lesion                         1          1     0253   17.1879   1158.57
             30118     T    Removal of intranasal lesion                         1          1     0254   24.9637    1682.7
             30120     T    Revision of nose                                     1          1     0254   24.9637    1682.7
             30124     T    Removal of nose lesion                               1          1     0252    7.6196    513.61
             30125     T    Removal of nose lesion                               1          1     0256   42.9827   2897.29
             30130     T    Excise inferior turbinate                            1          1     0253   17.1879   1158.57
             30140     T    Resect inferior turbinate                            1          1     0254   24.9637    1682.7
             30150     T    Partial removal of nose                              1          1     0256   42.9827   2897.29
             30160     T    Removal of nose                                      1          1     0256   42.9827   2897.29
             30200     T    Injection treatment of nose                          1          1     0252    7.6196    513.61
             30210     T    Nasal sinus therapy                                  1          1     0252    7.6196    513.61
             30220     T    Insert nasal septal button                           1          1     0252    7.6196    513.61
             30300     X    Remove nasal foreign body                            1          1     0340    0.6693     45.11
             30310     T    Remove nasal foreign body                            1          1     0253   17.1879   1158.57
             30320     T    Remove nasal foreign body                            1          1     0253   17.1879   1158.57
             30400     T    Reconstruction of nose                               0         NC       0
             30410     T    Reconstruction of nose                               0         NC       0
             30420     T    Reconstruction of nose                               0         NC       0
             30430     T    Revision of nose                                     0         NC       0
             30435     T    Revision of nose                                     0         NC       0
             30450     T    Revision of nose                                     0         NC       0
             30460     T    Revision of nose                                     1          1     0256   42.9827   2897.29
             30462     T    Revision of nose                                     1          1     0256   42.9827   2897.29
             30465     T    Repair nasal stenosis                                1          1     0256   42.9827   2897.29
             30520     T    Repair of nasal septum                               1          1     0254   24.9637    1682.7
             30540     T    Repair nasal defect                                  1          1     0256   42.9827   2897.29
             30545     T    Repair nasal defect                                  1          1     0256   42.9827   2897.29
             30560     T    Release of nasal adhesions                           1          1     0251     3.425    230.87
             30580     T    Repair upper jaw fistula                             1          1     0256   42.9827   2897.29
             30600     T    Repair mouth/nose fistula                            1          1     0256   42.9827   2897.29
             30620     T    Intranasal reconstruction                            1          1     0256   42.9827   2897.29
             30630     T    Repair nasal septum defect                           1          1     0254   24.9637    1682.7
             30801     T    Ablate inf turbinate, superf                         1          1     0252    7.6196    513.61
             30802     T    Ablate inf turbinate submuc                          1          1     0253   17.1879   1158.57
             30901     T    Control of nosebleed                                 1          1     0250    1.1522     77.67
             30903     T    Control of nosebleed                                 1          1     0250    1.1522     77.67
             30905     T    Control of nosebleed                                 1          1     0250    1.1522     77.67
             30906     T    Repeat control of nosebleed                          1          1     0250    1.1522     77.67
             30915     T    Ligation, nasal sinus artery                         1          1     0092   26.5713   1791.07
             30920     T    Ligation, upper jaw artery                           1          1     0092   26.5713   1791.07
             30930     T    Ther fx, nasal inf turbinate                         1          1     0253   17.1879   1158.57
             30999     T    Nasal surgery procedure                              1          1     0250    1.1522     77.67
             31000     T    Irrigation, maxillary sinus                          1          1     0251     3.425    230.87
             31002     T    Irrigation, sphenoid sinus                           1          1     0252    7.6196    513.61
             31020     T    Exploration, maxillary sinus                         1          1     0254   24.9637    1682.7
             31030     T    Exploration, maxillary sinus                         1          1     0256   42.9827   2897.29
             31032     T    Explore sinus, remove polyps                         1          1     0256   42.9827   2897.29
             31040     T    Exploration behind upper jaw                         1          1     0254   24.9637    1682.7
             31050     T    Exploration, sphenoid sinus                          1          1     0256   42.9827   2897.29
             31051     T    Sphenoid sinus surgery                               1          1     0256   42.9827   2897.29
             31070     T    Exploration of frontal sinus                         1          1     0254   24.9637    1682.7
             31075     T    Exploration of frontal sinus                         1          1     0256   42.9827   2897.29
             31080     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31081     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31084     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31085     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31086     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31087     T    Removal of frontal sinus                             1          1     0256   42.9827   2897.29
             31090     T    Exploration of sinuses                               1          1     0256   42.9827   2897.29
             31200     T    Removal of ethmoid sinus                             1          1     0256   42.9827   2897.29
             31201     T    Removal of ethmoid sinus                             1          1     0256   42.9827   2897.29
             31205     T    Removal of ethmoid sinus                             1          1     0256   42.9827   2897.29
             31225     C    Removal of upper jaw                                 1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 36 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             31230     C    Removal of upper jaw                                 1          1       0                          OR
             31231     T    Nasal endoscopy, dx                                  1          1     0072    1.8425    124.2
             31233     T    Nasal/sinus endoscopy, dx                            1          1     0072    1.8425    124.2
             31235     T    Nasal/sinus endoscopy, dx                            1          1     0074   21.6572   1459.83
             31237     T    Nasal/sinus endoscopy, surg                          1          1     0074   21.6572   1459.83
             31238     T    Nasal/sinus endoscopy, surg                          1          1     0074   21.6572   1459.83
             31239     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31240     T    Nasal/sinus endoscopy, surg                          1          1     0074   21.6572   1459.83
             31254     T    Revision of ethmoid sinus                            1          1     0075   29.2718   1973.09
             31255     T    Removal of ethmoid sinus                             1          1     0075   29.2718   1973.09
             31256     T    Exploration maxillary sinus                          1          1     0075   29.2718   1973.09
             31267     T    Endoscopy, maxillary sinus                           1          1     0075   29.2718   1973.09
             31276     T    Sinus endoscopy, surgical                            1          1     0075   29.2718   1973.09
             31287     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31288     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31290     C    Nasal/sinus endoscopy, surg                          1          1       0                          OR
             31291     C    Nasal/sinus endoscopy, surg                          1          1       0                          OR
             31292     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31293     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31294     T    Nasal/sinus endoscopy, surg                          1          1     0075   29.2718   1973.09
             31299     T    Sinus surgery procedure                              1          1     0250    1.1522     77.67
             31300     T    Removal of larynx lesion                             1          1     0254   24.9637    1682.7
             31320     T    Diagnostic incision, larynx                          1          1     0256   42.9827   2897.29
             31360     C    Removal of larynx                                    1          1       0                          OR
             31365     C    Removal of larynx                                    1          1       0                          OR
             31367     C    Partial removal of larynx                            1          1       0                          OR
             31368     C    Partial removal of larynx                            1          1       0                          OR
             31370     C    Partial removal of larynx                            1          1       0                          OR
             31375     C    Partial removal of larynx                            1          1       0                          OR
             31380     C    Partial removal of larynx                            1          1       0                          OR
             31382     C    Partial removal of larynx                            1          1       0                          OR
             31390     C    Removal of larynx & pharynx                          1          1       0                          OR
             31395     C    Reconstruct larynx & pharynx                         1          1       0                          OR
             31400     T    Revision of larynx                                   1          1     0256   42.9827   2897.29
             31420     T    Removal of epiglottis                                1          1     0256   42.9827   2897.29
             31500     S    Insert emergency airway                              1          1     0094    2.4553     165.5
             31502     S    Change of windpipe airway                            1          1     0078    1.4142     95.33
             31505     T    Diagnostic laryngoscopy                              1          1     0071    0.8007     53.97
             31510     T    Laryngoscopy with biopsy                             1          1     0074   21.6572   1459.83
             31511     T    Remove foreign body, larynx                          1          1     0072    1.8425     124.2
             31512     T    Removal of larynx lesion                             1          1     0074   21.6572   1459.83
             31513     T    Injection into vocal cord                            1          1     0072    1.8425     124.2
             31515     T    Laryngoscopy for aspiration                          1          1     0074   21.6572   1459.83
             31520     T    Dx laryngoscopy, newborn                             1          1     0072    1.8425     124.2
             31525     T    Dx laryngoscopy excl nb                              1          1     0074   21.6572   1459.83
             31526     T    Dx laryngoscopy w/oper scope                         1          1     0074   21.6572   1459.83
             31527     T    Laryngoscopy for treatment                           1          1     0075   29.2718   1973.09
             31528     T    Laryngoscopy and dilation                            1          1     0074   21.6572   1459.83
             31529     T    Laryngoscopy and dilation                            1          1     0074   21.6572   1459.83
             31530     T    Laryngoscopy w/fb removal                            1          1     0074   21.6572   1459.83
             31531     T    Laryngoscopy w/fb & op scope                         1          1     0074   21.6572   1459.83
             31535     T    Laryngoscopy w/biopsy                                1          1     0074   21.6572   1459.83
             31536     T    Laryngoscopy w/bx & op scope                         1          1     0074   21.6572   1459.83
             31540     T    Laryngoscopy w/exc of tumor                          1          1     0074   21.6572   1459.83
             31541     T    Larynscop w/tumr exc + scope                         1          1     0074   21.6572   1459.83
             31545     T    Remove vc lesion w/scope                             1          1     0075   29.2718   1973.09
             31546     T    Remove vc lesion scope/graft                         1          1     0075   29.2718   1973.09
             31560     T    Laryngoscop w/arytenoidectom                         1          1     0075   29.2718   1973.09
             31561     T    Larynscop, remve cart + scop                         1          1     0075   29.2718   1973.09
             31570     T    Laryngoscope w/vc inj                                1          1     0074   21.6572   1459.83
             31571     T    Laryngoscop w/vc inj + scope                         1          1     0075   29.2718   1973.09
             31575     T    Diagnostic laryngoscopy                              1          1     0072    1.8425     124.2
             31576     T    Laryngoscopy with biopsy                             1          1     0074   21.6572   1459.83
             31577     T    Remove foreign body, larynx                          1          1     0073    4.4119    297.39
             31578     T    Removal of larynx lesion                             1          1     0075   29.2718   1973.09
             31579     T    Diagnostic laryngoscopy                              1          1     0073    4.4119    297.39

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 37 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             31580     T    Revision of larynx                                   1          1     0256   42.9827   2897.29
             31582     T    Revision of larynx                                   1          1     0256   42.9827   2897.29
             31584     C    Treat larynx fracture                                1          1       0                          OR
             31587     C    Revision of larynx                                   1          1       0                          OR
             31588     T    Revision of larynx                                   1          1     0256   42.9827   2897.29
             31590     T    Reinnervate larynx                                   1          1     0256   42.9827   2897.29
             31595     T    Larynx nerve surgery                                 1          1     0256   42.9827   2897.29
             31599     T    Larynx surgery procedure                             1          1     0250    1.1522     77.67
             31600     T    Incision of windpipe                                 1          1     0254   24.9637    1682.7
             31601     T    Incision of windpipe                                 1          1     0254   24.9637    1682.7
             31603     T    Incision of windpipe                                 1          1     0252    7.6196    513.61
             31605     T    Incision of windpipe                                 1          1     0252    7.6196    513.61
             31610     T    Incision of windpipe                                 1          1     0254   24.9637    1682.7
             31611     T    Surgery/speech prosthesis                            1          1     0254   24.9637    1682.7
             31612     T    Puncture/clear windpipe                              1          1     0254   24.9637    1682.7
             31613     T    Repair windpipe opening                              1          1     0254   24.9637    1682.7
             31614     T    Repair windpipe opening                              1          1     0256   42.9827   2897.29
             31615     T    Visualization of windpipe                            1          1     0252    7.6196    513.61
             31620     N    Endobronchial us add-on                              1          1       0
             31622     T    Dx bronchoscope/wash                                 1          1     0076   10.3707   699.05
             31623     T    Dx bronchoscope/brush                                1          1     0076   10.3707   699.05
             31624     T    Dx bronchoscope/lavage                               1          1     0076   10.3707   699.05
             31625     T    Bronchoscopy w/biopsy(s)                             1          1     0076   10.3707   699.05
             31626     T    Bronchoscopy w/markers                               1          1     0076   10.3707   699.05
             31627     N    Navigational bronchoscopy                            1          1       0
             31628     T    Bronchoscopy/lung bx, each                           1          1     0076   10.3707    699.05
             31629     T    Bronchoscopy/needle bx, each                         1          1     0076   10.3707    699.05
             31630     T    Bronchoscopy dilate/fx repr                          1          1     0415   25.9024   1745.98
             31631     T    Bronchoscopy, dilate w/stent                         1          1     0415   25.9024   1745.98
             31632     T    Bronchoscopy/lung bx, addl                           1          1     0076   10.3707    699.05
             31633     T    Bronchoscopy/needle bx addl                          1          1     0076   10.3707    699.05
             31635     T    Bronchoscopy w/fb removal                            1          1     0076   10.3707    699.05
             31636     T    Bronchoscopy, bronch stents                          1          1     0415   25.9024   1745.98
             31637     T    Bronchoscopy, stent add-on                           1          1     0076   10.3707    699.05
             31638     T    Bronchoscopy, revise stent                           1          1     0415   25.9024   1745.98
             31640     T    Bronchoscopy w/tumor excise                          1          1     0415   25.9024   1745.98
             31641     T    Bronchoscopy, treat blockage                         1          1     0415   25.9024   1745.98
             31643     T    Diag bronchoscope/catheter                           1          1     0076   10.3707    699.05
             31645     T    Bronchoscopy, clear airways                          1          1     0076   10.3707    699.05
             31646     T    Bronchoscopy, reclear airway                         1          1     0076   10.3707    699.05
             31656     T    Bronchoscopy, inj for x-ray                          1          1     0076   10.3707    699.05
             31715     N    Injection for bronchus x-ray                         1          1       0
             31717     T    Bronchial brush biopsy                               1          1     0073   4.4119    297.39
             31720     S    Clearance of airways                                 1          1     0077   0.4058     27.35
             31725     C    Clearance of airways                                 1          1       0                          OR
             31730     T    Intro, windpipe wire/tube                            1          1     0073    4.4119    297.39
             31750     T    Repair of windpipe                                   1          1     0256   42.9827   2897.29
             31755     T    Repair of windpipe                                   1          1     0256   42.9827   2897.29
             31760     C    Repair of windpipe                                   1          1       0                          OR
             31766     C    Reconstruction of windpipe                           1          1       0                          OR
             31770     C    Repair/graft of bronchus                             1          1       0                          OR
             31775     C    Reconstruct bronchus                                 1          1       0                          OR
             31780     C    Reconstruct windpipe                                 1          1       0                          OR
             31781     C    Reconstruct windpipe                                 1          1       0                          OR
             31785     T    Remove windpipe lesion                               1          1     0254   24.9637   1682.7
             31786     C    Remove windpipe lesion                               1          1       0                          OR
             31800     C    Repair of windpipe injury                            1          1       0                          OR
             31805     C    Repair of windpipe injury                            1          1       0                          OR
             31820     T    Closure of windpipe lesion                           1          1     0254   24.9637   1682.7
             31825     T    Repair of windpipe defect                            1          1     0254   24.9637   1682.7
             31830     T    Revise windpipe scar                                 1          1     0254   24.9637   1682.7
             31899     T    Airways surgical procedure                           1          1     0076   10.3707   699.05
             32035     C    Exploration of chest                                 1          1       0                          OR
             32036     C    Exploration of chest                                 1          1       0                          OR
             32095     C    Biopsy through chest wall                            1          1       0                          OR
             32100     C    Exploration/biopsy of chest                          1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 38 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             32110     C    Explore/repair chest                                 1          1       0                          OR
             32120     C    Re-exploration of chest                              1          1       0                          OR
             32124     C    Explore chest free adhesions                         1          1       0                          OR
             32140     C    Removal of lung lesion(s)                            1          1       0                          OR
             32141     C    Remove/treat lung lesions                            1          1       0                          OR
             32150     C    Removal of lung lesion(s)                            1          1       0                          OR
             32151     C    Remove lung foreign body                             1          1       0                          OR
             32160     C    Open chest heart massage                             1          1       0                          OR
             32200     C    Drain, open, lung lesion                             1          1       0                          OR
             32201     T    Drain, percut, lung lesion                           1          1     0070   5.5521    374.24
             32215     C    Treat chest lining                                   1          1       0                          OR
             32220     C    Release of lung                                      1          1       0                          OR
             32225     C    Partial release of lung                              1          1       0                          OR
             32310     C    Removal of chest lining                              1          1       0                          OR
             32320     C    Free/remove chest lining                             1          1       0                          OR
             32400     T    Needle biopsy chest lining                           1          1     0685   9.6666    651.59
             32402     C    Open biopsy chest lining                             1          1       0                          OR
             32405     T    Biopsy, lung or mediastinum                          1          1     0685   9.6666    651.59
             32420     T    Puncture/clear lung                                  1          1     0070   5.5521    374.24
             32421     T    Thoracentesis for aspiration                         1          1     0070   5.5521    374.24
             32422     T    Thoracentesis w/tube insert                          1          1     0070   5.5521    374.24
             32440     C    Removal of lung                                      1          1       0                          OR
             32442     C    Sleeve pneumonectomy                                 1          1       0                          OR
             32445     C    Removal of lung                                      1          1       0                          OR
             32480     C    Partial removal of lung                              1          1       0                          OR
             32482     C    Bilobectomy                                          1          1       0                          OR
             32484     C    Segmentectomy                                        1          1       0                          OR
             32486     C    Sleeve lobectomy                                     1          1       0                          OR
             32488     C    Completion pneumonectomy                             1          1       0                          OR
             32491     C    Lung volume reduction                                1          1       0                          OR
             32500     C    Partial removal of lung                              1          1       0                          OR
             32501     C    Repair bronchus add-on                               1          1       0                          OR
             32503     C    Resect apical lung tumor                             1          1       0                          OR
             32504     C    Resect apical lung tum/chest                         1          1       0                          OR
             32540     C    Removal of lung lesion                               1          1       0                          OR
             32550     T    Insert pleural cath                                  1          1     0652   30.4602    2053.2
             32551     T    Insertion of chest tube                              1          1     0070    5.5521    374.24
             32552     S    Remove lung catheter                                 1          1     0078    1.4142     95.33
             32553     X    Ins mark thor for rt perq                            1          1     0310   13.7576    927.34
             32560     T    Treat pleurodesis w/agent                            1          1     0070    5.5521    374.24
             32561     T    Lyse chest fibrin init day                           1          1     0070    5.5521    374.24
             32562     T    Lyse chest fibrin subq day                           1          1     0070    5.5521    374.24
             32601     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32602     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32603     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32604     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32605     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32606     T    Thoracoscopy, diagnostic                             1          1     0069   34.0084   2292.37
             32650     C    Thoracoscopy, surgical                               1          1       0                          OR
             32651     C    Thoracoscopy, surgical                               1          1       0                          OR
             32652     C    Thoracoscopy, surgical                               1          1       0                          OR
             32653     C    Thoracoscopy, surgical                               1          1       0                          OR
             32654     C    Thoracoscopy, surgical                               1          1       0                          OR
             32655     C    Thoracoscopy, surgical                               1          1       0                          OR
             32656     C    Thoracoscopy, surgical                               1          1       0                          OR
             32657     C    Thoracoscopy, surgical                               1          1       0                          OR
             32658     C    Thoracoscopy, surgical                               1          1       0                          OR
             32659     C    Thoracoscopy, surgical                               1          1       0                          OR
             32660     C    Thoracoscopy, surgical                               1          1       0                          OR
             32661     C    Thoracoscopy, surgical                               1          1       0                          OR
             32662     C    Thoracoscopy, surgical                               1          1       0                          OR
             32663     C    Thoracoscopy, surgical                               1          1       0                          OR
             32664     C    Thoracoscopy, surgical                               1          1       0                          OR
             32665     C    Thoracoscopy, surgical                               1          1       0                          OR
             32800     C    Repair lung hernia                                   1          1       0                          OR
             32810     C    Close chest after drainage                           1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 39 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW       NWR        OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010     2010        Fee            Fee
             32815     C    Close bronchial fistula                              1          1       0                          OR
             32820     C    Reconstruct injured chest                            1          1       0                          OR
   COE       32850     C    Donor pneumonectomy                                  1          1       0                          OR
   COE       32851     C    Lung transplant, single                              1          1       0                          OR
   COE       32852     C    Lung transplant with bypass                          1          1       0                          OR
   COE       32853     C    Lung transplant, double                              1          1       0                          OR
   COE       32854     C    Lung transplant with bypass                          1          1       0                          OR
   COE       32855     C    Prepare donor lung, single                           1          1       0                          OR
   COE       32856     C    Prepare donor lung, double                           1          1       0                          OR
             32900     C    Removal of rib(s)                                    1          1       0                          OR
             32905     C    Revise & repair chest wall                           1          1       0                          OR
             32906     C    Revise & repair chest wall                           1          1       0                          OR
             32940     C    Revision of lung                                     1          1       0                          OR
             32960     T    Therapeutic pneumothorax                             1          1     0070    5.5521   374.24
             32997     C    Total lung lavage                                    1          1       0                          OR
             32998     T    Perq rf ablate tx, pul tumor                         0         NC       0
             32999     T    Chest surgery procedure                              1          1     0070    5.5521   374.24
             33010     T    Drainage of heart sac                                1          1     0070    5.5521   374.24
             33011     T    Repeat drainage of heart sac                         1          1     0070    5.5521   374.24
             33015     C    Incision of heart sac                                1          1       0                          OR
             33020     C    Incision of heart sac                                1          1       0                          OR
             33025     C    Incision of heart sac                                1          1       0                          OR
             33030     C    Partial removal of heart sac                         1          1       0                          OR
             33031     C    Partial removal of heart sac                         1          1       0                          OR
             33050     C    Removal of heart sac lesion                          1          1       0                          OR
             33120     C    Removal of heart lesion                              1          1       0                          OR
             33130     C    Removal of heart lesion                              1          1       0                          OR
             33140     C    Heart revascularize (tmr)                            0         NC       0
             33141     C    Heart tmr w/other procedure                          0         NC       0
             33202     C    Insert epicard eltrd, open                           1          1       0                          OR
             33203     C    Insert epicard eltrd, endo                           1          1       0                          OR
             33206     T    Insertion of heart pacemaker                         1          1     0089   118.8826 8013.4
             33207     T    Insertion of heart pacemaker                         1          1     0089   118.8826 8013.4
             33208     T    Insertion of heart pacemaker                         1          1     0655   142.1623 9582.59
             33210     T    Insertion of heart electrode                         1          1     0106    48.9361 3298.59
             33211     T    Insertion of heart electrode                         1          1     0106    48.9361 3298.59
             33212     T    Insertion of pulse generator                         1          1     0090    98.1576 6616.41
             33213     T    Insertion of pulse generator                         1          1     0654   108.1692 7291.25
             33214     T    Upgrade of pacemaker system                          1          1     0655   142.1623 9582.59
             33215     T    Reposition pacing-defib lead                         1          1     0105    22.9412 1546.37
             33216     T    Insert 1 electrode pm-defib                          1          1     0106    48.9361 3298.59
             33217     T    Insert 2 electrode pm-defib                          1          1     0106    48.9361 3298.59
             33218     T    Repair lead pace-defib, one                          1          1     0105    22.9412 1546.37
             33220     T    Repair lead pace-defib, dual                         1          1     0105    22.9412 1546.37
             33222     T    Revise pocket, pacemaker                             1          1     0136    16.0542 1082.15
             33223     T    Revise pocket for defib                              1          1     0136    16.0542 1082.15
             33224     T    Insert pacing lead & connect                         1          1     0418   204.1256 13759.29
             33225     T    L ventric pacing lead add-on                         1          1     0418   204.1256 13759.29
             33226     T    Reposition l ventric lead                            1          1     0105    22.9412 1546.37
             33233     T    Removal of pacemaker system                          1          1     0105    22.9412 1546.37
             33234     T    Removal of pacemaker system                          1          1     0105    22.9412 1546.37
             33235     T    Removal pacemaker electrode                          1          1     0105    22.9412 1546.37
             33236     C    Remove electrode/thoracotomy                         1          1       0                          OR
             33237     C    Remove electrode/thoracotomy                         1          1       0                          OR
             33238     C    Remove electrode/thoracotomy                         1          1       0                          OR
             33240     T    Insert pulse generator                               1          1     0107   325.8288 21962.82
             33241     T    Remove pulse generator                               1          1     0105    22.9412 1546.37
             33243     C    Remove eltrd/thoracotomy                             1          1       0                          OR
             33244     T    Remove eltrd, transven                               1          1     0105    22.9412 1546.37
             33249     T    Eltrd/insert pace-defib                              1          1     0108   412.3722 27796.36
             33250     C    Ablate heart dysrhythm focus                         1          1       0                          OR
             33251     C    Ablate heart dysrhythm focus                         1          1       0                          OR
             33254     C    Ablate atria, lmtd                                   1          1       0                          OR
             33255     C    Ablate atria w/o bypass, ext                         1          1       0                          OR
             33256     C    Ablate atria w/bypass, exten                         1          1       0                          OR
             33257     C    Ablate atria, lmtd, add-on                           1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 40 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             33258     C    Ablate atria, x10sv, add-on                          1          1       0                          OR
             33259     C    Ablate atria w/bypass add-on                         1          1       0                          OR
             33261     C    Ablate heart dysrhythm focus                         1          1       0                          OR
    PA       33265     C    Ablate atria, lmtd, endo                             1          1       0                          OR
    PA       33266     C    Ablate atria, x10sv, endo                            1          1       0                          OR
             33282     S    Implant pat-active ht record                         1          1     0680   78.0661   5262.12
             33284     T    Remove pat-active ht record                          1          1     0020    8.2028    552.92
             33300     C    Repair of heart wound                                1          1       0                          OR
             33305     C    Repair of heart wound                                1          1       0                          OR
             33310     C    Exploratory heart surgery                            1          1       0                          OR
             33315     C    Exploratory heart surgery                            1          1       0                          OR
             33320     C    Repair major blood vessel(s)                         1          1       0                          OR
             33321     C    Repair major vessel                                  1          1       0                          OR
             33322     C    Repair major blood vessel(s)                         1          1       0                          OR
             33330     C    Insert major vessel graft                            1          1       0                          OR
             33332     C    Insert major vessel graft                            1          1       0                          OR
             33335     C    Insert major vessel graft                            1          1       0                          OR
             33400     C    Repair of aortic valve                               1          1       0                          OR
             33401     C    Valvuloplasty, open                                  1          1       0                          OR
             33403     C    Valvuloplasty, w/cp bypass                           1          1       0                          OR
             33404     C    Prepare heart-aorta conduit                          1          1       0                          OR
             33405     C    Replacement of aortic valve                          1          1       0                          OR
             33406     C    Replacement of aortic valve                          1          1       0                          OR
             33410     C    Replacement of aortic valve                          1          1       0                          OR
             33411     C    Replacement of aortic valve                          1          1       0                          OR
             33412     C    Replacement of aortic valve                          1          1       0                          OR
             33413     C    Replacement of aortic valve                          1          1       0                          OR
             33414     C    Repair of aortic valve                               1          1       0                          OR
             33415     C    Revision, subvalvular tissue                         1          1       0                          OR
             33416     C    Revise ventricle muscle                              1          1       0                          OR
             33417     C    Repair of aortic valve                               1          1       0                          OR
             33420     C    Revision of mitral valve                             1          1       0                          OR
             33422     C    Revision of mitral valve                             1          1       0                          OR
             33425     C    Repair of mitral valve                               1          1       0                          OR
             33426     C    Repair of mitral valve                               1          1       0                          OR
             33427     C    Repair of mitral valve                               1          1       0                          OR
             33430     C    Replacement of mitral valve                          1          1       0                          OR
             33460     C    Revision of tricuspid valve                          1          1       0                          OR
             33463     C    Valvuloplasty, tricuspid                             1          1       0                          OR
             33464     C    Valvuloplasty, tricuspid                             1          1       0                          OR
             33465     C    Replace tricuspid valve                              1          1       0                          OR
             33468     C    Revision of tricuspid valve                          1          1       0                          OR
             33470     C    Revision of pulmonary valve                          1          1       0                          OR
             33471     C    Valvotomy, pulmonary valve                           1          1       0                          OR
             33472     C    Revision of pulmonary valve                          1          1       0                          OR
             33474     C    Revision of pulmonary valve                          1          1       0                          OR
             33475     C    Replacement, pulmonary valve                         1          1       0                          OR
             33476     C    Revision of heart chamber                            1          1       0                          OR
             33478     C    Revision of heart chamber                            1          1       0                          OR
             33496     C    Repair, prosth valve clot                            1          1       0                          OR
             33500     C    Repair heart vessel fistula                          1          1       0                          OR
             33501     C    Repair heart vessel fistula                          1          1       0                          OR
             33502     C    Coronary artery correction                           1          1       0                          OR
             33503     C    Coronary artery graft                                1          1       0                          OR
             33504     C    Coronary artery graft                                1          1       0                          OR
             33505     C    Repair artery w/tunnel                               1          1       0                          OR
             33506     C    Repair artery, translocation                         1          1       0                          OR
             33507     C    Repair art, intramural                               1          1       0                          OR
             33508     N    Endoscopic vein harvest                              1          1       0
             33510     C    CABG, vein, single                                   1          1       0                          OR
             33511     C    CABG, vein, two                                      1          1       0                          OR
             33512     C    CABG, vein, three                                    1          1       0                          OR
             33513     C    CABG, vein, four                                     1          1       0                          OR
             33514     C    CABG, vein, five                                     1          1       0                          OR
             33516     C    Cabg, vein, six or more                              1          1       0                          OR
             33517     C    CABG, artery-vein, single                            1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 41 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW     NWR     OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010   2010     Fee            Fee
             33518     C    CABG, artery-vein, two                               1          1      0                     OR
             33519     C    CABG, artery-vein, three                             1          1      0                     OR
             33521     C    CABG, artery-vein, four                              1          1      0                     OR
             33522     C    CABG, artery-vein, five                              1          1      0                     OR
             33523     C    Cabg, art-vein, six or more                          1          1      0                     OR
             33530     C    Coronary artery, bypass/reop                         1          1      0                     OR
             33533     C    CABG, arterial, single                               1          1      0                     OR
             33534     C    CABG, arterial, two                                  1          1      0                     OR
             33535     C    CABG, arterial, three                                1          1      0                     OR
             33536     C    Cabg, arterial, four or more                         1          1      0                     OR
             33542     C    Removal of heart lesion                              1          1      0                     OR
             33545     C    Repair of heart damage                               1          1      0                     OR
             33548     C    Restore/remodel, ventricle                           0         NC      0
             33572     C    Open coronary endarterectomy                         1          1      0                     OR
             33600     C    Closure of valve                                     1          1      0                     OR
             33602     C    Closure of valve                                     1          1      0                     OR
             33606     C    Anastomosis/artery-aorta                             1          1      0                     OR
             33608     C    Repair anomaly w/conduit                             1          1      0                     OR
             33610     C    Repair by enlargement                                1          1      0                     OR
             33611     C    Repair double ventricle                              1          1      0                     OR
             33612     C    Repair double ventricle                              1          1      0                     OR
             33615     C    Repair, modified fontan                              1          1      0                     OR
             33617     C    Repair single ventricle                              1          1      0                     OR
             33619     C    Repair single ventricle                              1          1      0                     OR
             33641     C    Repair heart septum defect                           1          1      0                     OR
             33645     C    Revision of heart veins                              1          1      0                     OR
             33647     C    Repair heart septum defects                          1          1      0                     OR
             33660     C    Repair of heart defects                              1          1      0                     OR
             33665     C    Repair of heart defects                              1          1      0                     OR
             33670     C    Repair of heart chambers                             1          1      0                     OR
             33675     C    Close mult vsd                                       1          1      0                     OR
             33676     C    Close mult vsd w/resection                           1          1      0                     OR
             33677     C    Cl mult vsd w/rem pul band                           1          1      0                     OR
             33681     C    Repair heart septum defect                           1          1      0                     OR
             33684     C    Repair heart septum defect                           1          1      0                     OR
             33688     C    Repair heart septum defect                           1          1      0                     OR
             33690     C    Reinforce pulmonary artery                           1          1      0                     OR
             33692     C    Repair of heart defects                              1          1      0                     OR
             33694     C    Repair of heart defects                              1          1      0                     OR
             33697     C    Repair of heart defects                              1          1      0                     OR
             33702     C    Repair of heart defects                              1          1      0                     OR
             33710     C    Repair of heart defects                              1          1      0                     OR
             33720     C    Repair of heart defect                               1          1      0                     OR
             33722     C    Repair of heart defect                               1          1      0                     OR
             33724     C    Repair venous anomaly                                1          1      0                     OR
             33726     C    Repair pul venous stenosis                           1          1      0                     OR
             33730     C    Repair heart-vein defect(s)                          1          1      0                     OR
             33732     C    Repair heart-vein defect                             1          1      0                     OR
             33735     C    Revision of heart chamber                            1          1      0                     OR
             33736     C    Revision of heart chamber                            1          1      0                     OR
             33737     C    Revision of heart chamber                            1          1      0                     OR
             33750     C    Major vessel shunt                                   1          1      0                     OR
             33755     C    Major vessel shunt                                   1          1      0                     OR
             33762     C    Major vessel shunt                                   1          1      0                     OR
             33764     C    Major vessel shunt & graft                           1          1      0                     OR
             33766     C    Major vessel shunt                                   1          1      0                     OR
             33767     C    Major vessel shunt                                   1          1      0                     OR
             33768     C    Cavopulmonary shunting                               1          1      0                     OR
             33770     C    Repair great vessels defect                          1          1      0                     OR
             33771     C    Repair great vessels defect                          1          1      0                     OR
             33774     C    Repair great vessels defect                          1          1      0                     OR
             33775     C    Repair great vessels defect                          1          1      0                     OR
             33776     C    Repair great vessels defect                          1          1      0                     OR
             33777     C    Repair great vessels defect                          1          1      0                     OR
             33778     C    Repair great vessels defect                          1          1      0                     OR
             33779     C    Repair great vessels defect                          1          1      0                     OR

                                                                                                                        CPT Codes and Descriptions
                                                                                                                                     Copyright 2010
                                                                                                                       American Medical Association
Page 42 of 216                                                                                                                  All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                 CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW       NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010     2010       Fee            Fee
             33780     C    Repair great vessels defect                          1          1       0                        OR
             33781     C    Repair great vessels defect                          1          1       0                        OR
             33782     C    Nikaidoh proc                                        1          1       0                        OR
             33783     C    Nikaidoh proc w/ostia implt                          1          1       0                        OR
             33786     C    Repair arterial trunk                                1          1       0                        OR
             33788     C    Revision of pulmonary artery                         1          1       0                        OR
             33800     C    Aortic suspension                                    1          1       0                        OR
             33802     C    Repair vessel defect                                 1          1       0                        OR
             33803     C    Repair vessel defect                                 1          1       0                        OR
             33813     C    Repair septal defect                                 1          1       0                        OR
             33814     C    Repair septal defect                                 1          1       0                        OR
             33820     C    Revise major vessel                                  1          1       0                        OR
             33822     C    Revise major vessel                                  1          1       0                        OR
             33824     C    Revise major vessel                                  1          1       0                        OR
             33840     C    Remove aorta constriction                            1          1       0                        OR
             33845     C    Remove aorta constriction                            1          1       0                        OR
             33851     C    Remove aorta constriction                            1          1       0                        OR
             33852     C    Repair septal defect                                 1          1       0                        OR
             33853     C    Repair septal defect                                 1          1       0                        OR
             33860     C    Ascending aortic graft                               1          1       0                        OR
             33861     C    Ascending aortic graft                               1          1       0                        OR
             33863     C    Ascending aortic graft                               1          1       0                        OR
             33864     C    Ascending aortic graft                               1          1       0                        OR
             33870     C    Transverse aortic arch graft                         1          1       0                        OR
             33875     C    Thoracic aortic graft                                1          1       0                        OR
             33877     C    Thoracoabdominal graft                               1          1       0                        OR
             33880     C    Endovasc taa repr incl subcl                         1          1       0                        OR
             33881     C    Endovasc taa repr w/o subcl                          1          1       0                        OR
             33883     C    Insert endovasc prosth, taa                          1          1       0                        OR
             33884     C    Endovasc prosth, taa, add-on                         1          1       0                        OR
             33886     C    Endovasc prosth, delayed                             1          1       0                        OR
             33889     C    Artery transpose/endovas taa                         1          1       0                        OR
             33891     C    Car-car bp grft/endovas taa                          1          1       0                        OR
             33910     C    Remove lung artery emboli                            1          1       0                        OR
             33915     C    Remove lung artery emboli                            1          1       0                        OR
             33916     C    Surgery of great vessel                              1          1       0                        OR
             33917     C    Repair pulmonary artery                              1          1       0                        OR
             33920     C    Repair pulmonary atresia                             1          1       0                        OR
             33922     C    Transect pulmonary artery                            1          1       0                        OR
             33924     C    Remove pulmonary shunt                               1          1       0                        OR
             33925     C    Rpr pul art unifocal w/o cpb                         1          1       0                        OR
             33926     C    Repr pul art, unifocal w/cpb                         1          1       0                        OR
   COE       33930     C    Removal of donor heart/lung                          1          1       0                        OR
   COE       33933     C    Prepare donor heart/lung                             1          1       0                        OR
   COE       33935     C    Transplantation, heart/lung                          1          1       0                        OR
   COE       33940     C    Removal of donor heart                               1          1       0                        OR
   COE       33944     C    Prepare donor heart                                  1          1       0                        OR
   COE       33945     C    Transplantation of heart                             1          1       0                        OR
             33960     C    External circulation assist                          1          1       0                        OR
             33961     C    External circulation assist                          1          1       0                        OR
             33967     C    Insert ia percut device                              1          1       0                        OR
             33968     C    Remove aortic assist device                          1          1       0                        OR
             33970     C    Aortic circulation assist                            1          1       0                        OR
             33971     C    Aortic circulation assist                            1          1       0                        OR
             33973     C    Insert balloon device                                1          1       0                        OR
             33974     C    Remove intra-aortic balloon                          1          1       0                        OR
             33975     C    Implant ventricular device                           1          1       0                        OR
             33976     C    Implant ventricular device                           1          1       0                        OR
             33977     C    Remove ventricular device                            1          1       0                        OR
             33978     C    Remove ventricular device                            1          1       0                        OR
             33979     C    Insert intracorporeal device                         1          1       0                        OR
             33980     C    Remove intracorporeal device                         1          1       0                        OR
             33981     C    Replace vad pump ext                                 1          1       0                        OR
             33982     C    Replace vad intra w/o bp                             1          1       0                        OR
             33983     C    Replace vad intra w/bp                               1          1       0                        OR
             33999     T    Cardiac surgery procedure                            1          1     0070   5.5521   374.24

                                                                                                                            CPT Codes and Descriptions
                                                                                                                                         Copyright 2010
                                                                                                                           American Medical Association
Page 43 of 216                                                                                                                      All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             34001     C    Removal of artery clot                               1          1       0                          OR
             34051     C    Removal of artery clot                               1          1       0                          OR
             34101     T    Removal of artery clot                               1          1     0088   40.9003   2756.93
             34111     T    Removal of arm artery clot                           1          1     0088   40.9003   2756.93
             34151     C    Removal of artery clot                               1          1       0                          OR
             34201     T    Removal of artery clot                               1          1     0088   40.9003   2756.93
             34203     T    Removal of leg artery clot                           1          1     0088   40.9003   2756.93
             34401     C    Removal of vein clot                                 1          1       0                          OR
             34421     T    Removal of vein clot                                 1          1     0088   40.9003   2756.93
             34451     C    Removal of vein clot                                 1          1       0                          OR
             34471     T    Removal of vein clot                                 1          1     0088   40.9003   2756.93
             34490     T    Removal of vein clot                                 1          1     0088   40.9003   2756.93
             34501     T    Repair valve, femoral vein                           1          1     0088   40.9003   2756.93
             34502     C    Reconstruct vena cava                                1          1       0                          OR
             34510     T    Transposition of vein valve                          1          1     0088   40.9003   2756.93
             34520     T    Cross-over vein graft                                1          1     0088   40.9003   2756.93
             34530     T    Leg vein fusion                                      1          1     0088   40.9003   2756.93
             34800     C    Endovas aaa repr w/sm tube                           1          1       0                          OR
             34802     C    Endovas aaa repr w/2-p part                          1          1       0                          OR
             34803     C    Endovas aaa repr w/3-p part                          1          1       0                          OR
             34804     C    Endovas aaa repr w/1-p part                          1          1       0                          OR
             34805     C    Endovas aaa repr w/long tube                         1          1       0                          OR
             34806     C    Aneurysm press sensor add-on                         1          1       0                          OR
             34808     C    Endovas iliac a device addon                         1          1       0                          OR
             34812     C    Xpose for endoprosth, femorl                         1          1       0                          OR
             34813     C    Femoral endovas graft add-on                         1          1       0                          OR
             34820     C    Xpose for endoprosth, iliac                          1          1       0                          OR
             34825     C    Endovasc extend prosth, init                         1          1       0                          OR
             34826     C    Endovasc exten prosth, addl                          1          1       0                          OR
             34830     C    Open aortic tube prosth repr                         1          1       0                          OR
             34831     C    Open aortoiliac prosth repr                          1          1       0                          OR
             34832     C    Open aortofemor prosth repr                          1          1       0                          OR
             34833     C    Xpose for endoprosth, iliac                          1          1       0                          OR
             34834     C    Xpose, endoprosth, brachial                          1          1       0                          OR
             34900     C    Endovasc iliac repr w/graft                          1          1       0                          OR
             35001     C    Repair defect of artery                              1          1       0                          OR
             35002     C    Repair artery rupture, neck                          1          1       0                          OR
             35005     C    Repair defect of artery                              1          1       0                          OR
             35011     T    Repair defect of artery                              1          1     0653   46.6883   3147.07
             35013     C    Repair artery rupture, arm                           1          1       0                          OR
             35021     C    Repair defect of artery                              1          1       0                          OR
             35022     C    Repair artery rupture, chest                         1          1       0                          OR
             35045     C    Repair defect of arm artery                          1          1       0                          OR
             35081     C    Repair defect of artery                              1          1       0                          OR
             35082     C    Repair artery rupture, aorta                         1          1       0                          OR
             35091     C    Repair defect of artery                              1          1       0                          OR
             35092     C    Repair artery rupture, aorta                         1          1       0                          OR
             35102     C    Repair defect of artery                              1          1       0                          OR
             35103     C    Repair artery rupture, groin                         1          1       0                          OR
             35111     C    Repair defect of artery                              1          1       0                          OR
             35112     C    Repair artery rupture,spleen                         1          1       0                          OR
             35121     C    Repair defect of artery                              1          1       0                          OR
             35122     C    Repair artery rupture, belly                         1          1       0                          OR
             35131     C    Repair defect of artery                              1          1       0                          OR
             35132     C    Repair artery rupture, groin                         1          1       0                          OR
             35141     C    Repair defect of artery                              1          1       0                          OR
             35142     C    Repair artery rupture, thigh                         1          1       0                          OR
             35151     C    Repair defect of artery                              1          1       0                          OR
             35152     C    Repair artery rupture, knee                          1          1       0                          OR
             35180     T    Repair blood vessel lesion                           1          1     0093   35.5969   2399.44
             35182     C    Repair blood vessel lesion                           1          1       0                          OR
             35184     T    Repair blood vessel lesion                           1          1     0093   35.5969   2399.44
             35188     T    Repair blood vessel lesion                           1          1     0088   40.9003   2756.93
             35189     C    Repair blood vessel lesion                           1          1       0                          OR
             35190     T    Repair blood vessel lesion                           1          1     0093   35.5969   2399.44
             35201     T    Repair blood vessel lesion                           1          1     0093   35.5969   2399.44

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 44 of 216                                                                                                                        All Rights Reserved
                                                          HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                             Washington State Medicaid


                                                                                         MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                       COV
                                                                                         UNITS   2010    2010      2010       Fee            Fee
             35206     T    Repair blood vessel lesion                          1          1     0093   35.5969   2399.44
             35207     T    Repair blood vessel lesion                          1          1     0088   40.9003   2756.93
             35211     C    Repair blood vessel lesion                          1          1       0                          OR
             35216     C    Repair blood vessel lesion                          1          1       0                          OR
             35221     C    Repair blood vessel lesion                          1          1       0                          OR
             35226     T    Repair blood vessel lesion                          1          1     0020    8.2028    552.92
             35231     T    Repair blood vessel lesion                          1          1     0093   35.5969   2399.44
             35236     T    Repair blood vessel lesion                          1          1     0093   35.5969   2399.44
             35241     C    Repair blood vessel lesion                          1          1       0                          OR
             35246     C    Repair blood vessel lesion                          1          1       0                          OR
             35251     C    Repair blood vessel lesion                          1          1       0                          OR
             35256     T    Repair blood vessel lesion                          1          1     0093   35.5969   2399.44
             35261     T    Repair blood vessel lesion                          1          1     0653   46.6883   3147.07
             35266     T    Repair blood vessel lesion                          1          1     0653   46.6883   3147.07
             35271     C    Repair blood vessel lesion                          1          1       0                          OR
             35276     C    Repair blood vessel lesion                          1          1       0                          OR
             35281     C    Repair blood vessel lesion                          1          1       0                          OR
             35286     T    Repair blood vessel lesion                          1          1     0653   46.6883   3147.07
             35301     C    Rechanneling of artery                              1          1       0                          OR
             35302     C    Rechanneling of artery                              1          1       0                          OR
             35303     C    Rechanneling of artery                              1          1       0                          OR
             35304     C    Rechanneling of artery                              1          1       0                          OR
             35305     C    Rechanneling of artery                              1          1       0                          OR
             35306     C    Rechanneling of artery                              1          1       0                          OR
             35311     C    Rechanneling of artery                              1          1       0                          OR
             35321     T    Rechanneling of artery                              1          1     0093   35.5969   2399.44
             35331     C    Rechanneling of artery                              1          1       0                          OR
             35341     C    Rechanneling of artery                              1          1       0                          OR
             35351     C    Rechanneling of artery                              1          1       0                          OR
             35355     C    Rechanneling of artery                              1          1       0                          OR
             35361     C    Rechanneling of artery                              1          1       0                          OR
             35363     C    Rechanneling of artery                              1          1       0                          OR
             35371     C    Rechanneling of artery                              1          1       0                          OR
             35372     C    Rechanneling of artery                              1          1       0                          OR
             35390     C    Reoperation, carotid add-on                         1          1       0                          OR
     L       35400     C    Angioscopy                                          1          1       0                          OR
             35450     C    Repair arterial blockage                            1          1       0                          OR
             35452     C    Repair arterial blockage                            1          1       0                          OR
             35454     C    Repair arterial blockage                            1          1       0                          OR
             35456     C    Repair arterial blockage                            1          1       0                          OR
             35458     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35459     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35460     T    Repair venous blockage                              1          1     0083   50.6809   3416.2
             35470     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35471     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35472     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35473     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35474     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35475     T    Repair arterial blockage                            1          1     0083   50.6809   3416.2
             35476     T    Repair venous blockage                              1          1     0083   50.6809   3416.2
             35480     C    Atherectomy, open                                   1          1       0                          OR
             35481     C    Atherectomy, open                                   1          1       0                          OR
             35482     C    Atherectomy, open                                   1          1       0                          OR
             35483     C    Atherectomy, open                                   1          1       0                          OR
             35484     T    Atherectomy, open                                   1          1     0082   93.3244   6290.62
             35485     T    Atherectomy, open                                   1          1     0082   93.3244   6290.62
             35490     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35491     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35492     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35493     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35494     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35495     T    Atherectomy, percutaneous                           1          1     0082   93.3244   6290.62
             35500     T    Harvest vein for bypass                             1          1     0103   17.8436   1202.77
             35501     C    Artery bypass graft                                 1          1       0                          OR
             35506     C    Artery bypass graft                                 1          1       0                          OR
             35508     C    Artery bypass graft                                 1          1       0                          OR

                                                                                                                             CPT Codes and Descriptions
                                                                                                                                          Copyright 2010
                                                                                                                            American Medical Association
Page 45 of 216                                                                                                                       All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW     NWR     OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010   2010     Fee            Fee
             35509     C    Artery bypass graft                                  1          1      0                     OR
             35510     C    Artery bypass graft                                  1          1      0                     OR
             35511     C    Artery bypass graft                                  1          1      0                     OR
             35512     C    Artery bypass graft                                  1          1      0                     OR
             35515     C    Artery bypass graft                                  1          1      0                     OR
             35516     C    Artery bypass graft                                  1          1      0                     OR
             35518     C    Artery bypass graft                                  1          1      0                     OR
             35521     C    Artery bypass graft                                  1          1      0                     OR
             35522     C    Artery bypass graft                                  1          1      0                     OR
             35523     C    Artery bypass graft                                  1          1      0                     OR
             35525     C    Artery bypass graft                                  1          1      0                     OR
             35526     C    Artery bypass graft                                  1          1      0                     OR
             35531     C    Artery bypass graft                                  1          1      0                     OR
             35533     C    Artery bypass graft                                  1          1      0                     OR
             35535     C    Artery bypass graft                                  1          1      0                     OR
             35536     C    Artery bypass graft                                  1          1      0                     OR
             35537     C    Artery bypass graft                                  1          1      0                     OR
             35538     C    Artery bypass graft                                  1          1      0                     OR
             35539     C    Artery bypass graft                                  1          1      0                     OR
             35540     C    Artery bypass graft                                  1          1      0                     OR
             35548     C    Artery bypass graft                                  1          1      0                     OR
             35549     C    Artery bypass graft                                  1          1      0                     OR
             35551     C    Artery bypass graft                                  1          1      0                     OR
             35556     C    Artery bypass graft                                  1          1      0                     OR
             35558     C    Artery bypass graft                                  1          1      0                     OR
             35560     C    Artery bypass graft                                  1          1      0                     OR
             35563     C    Artery bypass graft                                  1          1      0                     OR
             35565     C    Artery bypass graft                                  1          1      0                     OR
             35566     C    Artery bypass graft                                  1          1      0                     OR
             35570     C    Artery bypass graft                                  1          1      0                     OR
             35571     C    Artery bypass graft                                  1          1      0                     OR
             35572     N    Harvest femoropopliteal vein                         1          1      0
             35583     C    Vein bypass graft                                    1          1      0                     OR
             35585     C    Vein bypass graft                                    1          1      0                     OR
             35587     C    Vein bypass graft                                    1          1      0                     OR
             35600     C    Harvest art for cabg add-on                          1          1      0                     OR
             35601     C    Artery bypass graft                                  1          1      0                     OR
             35606     C    Artery bypass graft                                  1          1      0                     OR
             35612     C    Artery bypass graft                                  1          1      0                     OR
             35616     C    Artery bypass graft                                  1          1      0                     OR
             35621     C    Artery bypass graft                                  1          1      0                     OR
             35623     C    Bypass graft, not vein                               1          1      0                     OR
             35626     C    Artery bypass graft                                  1          1      0                     OR
             35631     C    Artery bypass graft                                  1          1      0                     OR
             35632     C    Artery bypass graft                                  1          1      0                     OR
             35633     C    Artery bypass graft                                  1          1      0                     OR
             35634     C    Artery bypass graft                                  1          1      0                     OR
             35636     C    Artery bypass graft                                  1          1      0                     OR
             35637     C    Artery bypass graft                                  1          1      0                     OR
             35638     C    Artery bypass graft                                  1          1      0                     OR
             35642     C    Artery bypass graft                                  1          1      0                     OR
             35645     C    Artery bypass graft                                  1          1      0                     OR
             35646     C    Artery bypass graft                                  1          1      0                     OR
             35647     C    Artery bypass graft                                  1          1      0                     OR
             35650     C    Artery bypass graft                                  1          1      0                     OR
             35651     C    Artery bypass graft                                  1          1      0                     OR
             35654     C    Artery bypass graft                                  1          1      0                     OR
             35656     C    Artery bypass graft                                  1          1      0                     OR
             35661     C    Artery bypass graft                                  1          1      0                     OR
             35663     C    Artery bypass graft                                  1          1      0                     OR
             35665     C    Artery bypass graft                                  1          1      0                     OR
             35666     C    Artery bypass graft                                  1          1      0                     OR
             35671     C    Artery bypass graft                                  1          1      0                     OR
             35681     C    Composite bypass graft                               1          1      0                     OR
             35682     C    Composite bypass graft                               1          1      0                     OR
             35683     C    Composite bypass graft                               1          1      0                     OR

                                                                                                                        CPT Codes and Descriptions
                                                                                                                                     Copyright 2010
                                                                                                                       American Medical Association
Page 46 of 216                                                                                                                  All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             35685     T    Bypass graft patency/patch                           1          1     0093   35.5969   2399.44
             35686     T    Bypass graft/av fist patency                         1          1     0093   35.5969   2399.44
             35691     C    Arterial transposition                               1          1       0                          OR
             35693     C    Arterial transposition                               1          1       0                          OR
             35694     C    Arterial transposition                               1          1       0                          OR
             35695     C    Arterial transposition                               1          1       0                          OR
             35697     C    Reimplant artery each                                1          1       0                          OR
             35700     C    Reoperation, bypass graft                            1          1       0                          OR
             35701     C    Exploration, carotid artery                          1          1       0                          OR
             35721     C    Exploration, femoral artery                          1          1       0                          OR
             35741     C    Exploration popliteal artery                         1          1       0                          OR
             35761     T    Exploration of artery/vein                           1          1     0093   35.5969   2399.44
             35800     C    Explore neck vessels                                 1          1       0                          OR
             35820     C    Explore chest vessels                                1          1       0                          OR
             35840     C    Explore abdominal vessels                            1          1       0                          OR
             35860     T    Explore limb vessels                                 1          1     0093   35.5969   2399.44
             35870     C    Repair vessel graft defect                           1          1       0                          OR
             35875     T    Removal of clot in graft                             1          1     0088   40.9003   2756.93
             35876     T    Removal of clot in graft                             1          1     0088   40.9003   2756.93
             35879     T    Revise graft w/vein                                  1          1     0088   40.9003   2756.93
             35881     T    Revise graft w/vein                                  1          1     0088   40.9003   2756.93
             35883     T    Revise graft w/nonauto graft                         1          1     0088   40.9003   2756.93
             35884     T    Revise graft w/vein                                  1          1     0088   40.9003   2756.93
             35901     C    Excision, graft, neck                                1          1       0                          OR
             35903     T    Excision, graft, extremity                           1          1     0093   35.5969   2399.44
             35905     C    Excision, graft, thorax                              1          1       0                          OR
             35907     C    Excision, graft, abdomen                             1          1       0                          OR
             36000     N    Place needle in vein                                 1          1       0
             36002     S    Pseudoaneurysm injection trt                         1          1     0267   2.3005    155.07
             36005     N    Injection ext venography                             1          1       0
             36010     N    Place catheter in vein                               1          1       0
             36011     N    Place catheter in vein                               1          1       0
             36012     N    Place catheter in vein                               1          1       0
             36013     N    Place catheter in artery                             1          1       0
             36014     N    Place catheter in artery                             1          1       0
             36015     N    Place catheter in artery                             1          1       0
             36100     N    Establish access to artery                           1          1       0
             36120     N    Establish access to artery                           1          1       0
             36140     N    Establish access to artery                           1          1       0
             36147     T    Access av dial grft for eval                         1          1     0676   2.3954    161.46
             36148     N    Access av dial grft for proc                         1          1       0
             36160     N    Establish access to aorta                            1          1       0
             36200     N    Place catheter in aorta                              1          1       0
             36215     N    Place catheter in artery                             1          1       0
             36216     N    Place catheter in artery                             1          1       0
             36217     N    Place catheter in artery                             1          1       0
             36218     N    Place catheter in artery                             1          1       0
             36245     N    Place catheter in artery                             1          1       0
             36246     N    Place catheter in artery                             1          1       0
             36247     N    Place catheter in artery                             1          1       0
             36248     N    Place catheter in artery                             1          1       0
             36260     T    Insertion of infusion pump                           1          1     0623   30.4396   2051.81
             36261     T    Revision of infusion pump                            1          1     0105   22.9412   1546.37
             36262     T    Removal of infusion pump                             1          1     0105   22.9412   1546.37
             36299     N    Vessel injection procedure                           1          1       0
             36400     N    Bl draw < 3 yrs fem/jugular                          1          1       0
             36405     N    Bl draw < 3 yrs scalp vein                           1          1       0
             36406     N    Bl draw < 3 yrs other vein                           1          1       0
             36410     N    Non-routine bl draw > 3 yrs                          1          1       0
             36415     A    Routine venipuncture                                 1          1       0                           OF           2.28
             36416     N    Capillary blood draw                                 1          1       0                                        2.28
             36420     X    Vein access cutdown < 1 yr                           1          1     0035    0.232     15.64
             36425     X    Vein access cutdown > 1 yr                           1          1     0035    0.232     15.64
             36430     S    Blood transfusion service                            1          1     0110   3.3809    227.89
             36440     S    Bl push transfuse, 2 yr or <                         1          1     0110   3.3809    227.89
             36450     S    Bl exchange/transfuse, nb                            1          1     0110   3.3809    227.89

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 47 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             36455      S   Bl exchange/transfuse non-nb                         1          1     0110   3.3809    227.89
             36460      S   Transfusion service, fetal                           1          1     0110   3.3809    227.89
             36468      T   Injection(s), spider veins                           0         NC       0
             36469      T   Injection(s), spider veins                           0         NC       0
             36470      T   Injection therapy of vein                            0         NC       0
             36471      T   Injection therapy of veins                           0         NC       0
             36475      T   Endovenous rf, 1st vein                              0         NC       0
             36476      T   Endovenous rf, vein add-on                           0         NC       0
             36478      T   Endovenous laser, 1st vein                           0         NC       0
             36479      T   Endovenous laser vein addon                          0         NC       0
             36481     N    Insertion of catheter, vein                          1          1       0
             36500     N    Insertion of catheter, vein                          1          1       0
             36510     N    Insertion of catheter, vein                          1          1       0
             36511      S   Apheresis wbc                                        1          1     0111   11.9424    804.99
             36512      S   Apheresis rbc                                        1          1     0111   11.9424    804.99
             36513      S   Apheresis platelets                                  1          1     0111   11.9424    804.99
             36514      S   Apheresis plasma                                     1          1     0111   11.9424    804.99
             36515      S   Apheresis, adsorp/reinfuse                           1          1     0112   33.3206   2246.01
             36516      S   Apheresis, selective                                 1          1     0112   33.3206   2246.01
             36522      S   Photopheresis                                        1          1     0112   33.3206   2246.01
             36555      T   Insert non-tunnel cv cath                            1          1     0621    11.166    752.66
             36556      T   Insert non-tunnel cv cath                            1          1     0621    11.166    752.66
             36557      T   Insert tunneled cv cath                              1          1     0622   25.3344   1707.69
             36558      T   Insert tunneled cv cath                              1          1     0622   25.3344   1707.69
             36560      T   Insert tunneled cv cath                              1          1     0623   30.4396   2051.81
             36561      T   Insert tunneled cv cath                              1          1     0623   30.4396   2051.81
             36563      T   Insert tunneled cv cath                              1          1     0623   30.4396   2051.81
             36565      T   Insert tunneled cv cath                              1          1     0623   30.4396   2051.81
             36566      T   Insert tunneled cv cath                              1          1     0623   30.4396   2051.81
             36568      T   Insert picc cath                                     1          1     0621    11.166    752.66
             36569      T   Insert picc cath                                     1          1     0621    11.166    752.66
             36570      T   Insert picvad cath                                   1          1     0622   25.3344   1707.69
             36571      T   Insert picvad cath                                   1          1     0622   25.3344   1707.69
             36575      T   Repair tunneled cv cath                              1          1     0121    6.3742    429.66
             36576      T   Repair tunneled cv cath                              1          1     0621    11.166    752.66
             36578      T   Replace tunneled cv cath                             1          1     0622   25.3344   1707.69
             36580      T   Replace cvad cath                                    1          1     0621    11.166    752.66
             36581      T   Replace tunneled cv cath                             1          1     0622   25.3344   1707.69
             36582      T   Replace tunneled cv cath                             1          1     0623   30.4396   2051.81
             36583      T   Replace tunneled cv cath                             1          1     0623   30.4396   2051.81
             36584      T   Replace picc cath                                    1          1     0621    11.166    752.66
             36585      T   Replace picvad cath                                  1          1     0622   25.3344   1707.69
             36589      T   Removal tunneled cv cath                             1          1     0121    6.3742    429.66
             36590      T   Removal tunneled cv cath                             1          1     0621    11.166    752.66
             36591     Q1   Draw blood off venous device                         1          1     0624    0.6132     41.33                   13.34
             36592     Q1   Collect blood from picc                              1         NA     0624    0.6132     41.33                   14.67
             36593      T   Declot vascular device                               1          1     0676    2.3954    161.46
             36595      T   Mech remov tunneled cv cath                          1          1     0622   25.3344   1707.69
             36596      T   Mech remov tunneled cv cath                          1          1     0621    11.166    752.66
             36597      T   Reposition venous catheter                           1          1     0621    11.166    752.66
             36598      T   Inj w/fluor, eval cv device                          1          1     0676    2.3954    161.46
             36600     Q1   Withdrawal of arterial blood                         1         UR     0035     0.232     15.64                   9.11
             36620     N    Insertion catheter, artery                           1          1       0
             36625     N    Insertion catheter, artery                           1          1       0
             36640      T   Insertion catheter, artery                           1          1     0623   30.4396   2051.81
             36660     C    Insertion catheter, artery                           1          1       0                          OR
             36680      T   Insert needle, bone cavity                           1          1     0002    1.5111    101.86
             36800      T   Insertion of cannula                                 1          1     0115   30.9784   2088.13
             36810      T   Insertion of cannula                                 1          1     0115   30.9784   2088.13
             36815      T   Insertion of cannula                                 1          1     0115   30.9784   2088.13
             36818      T   Av fuse, uppr arm, cephalic                          1          1     0088   40.9003   2756.93
             36819      T   Av fuse, uppr arm, basilic                           1          1     0088   40.9003   2756.93
             36820      T   Av fusion/forearm vein                               1          1     0088   40.9003   2756.93
             36821      T   Av fusion direct any site                            1          1     0088   40.9003   2756.93
             36822     C    Insertion of cannula(s)                              1          1       0                          OR
             36823     C    Insertion of cannula(s)                              1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 48 of 216                                                                                                                        All Rights Reserved
                                                       HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                           Washington State Medicaid


                                                                                       MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                     COV
                                                                                       UNITS   2010    2010      2010       Fee            Fee
             36825     T    Artery-vein autograft                             1          1     0088   40.9003   2756.93
             36830     T    Artery-vein nonautograft                          1          1     0088   40.9003   2756.93
             36831     T    Open thrombect av fistula                         1          1     0088   40.9003   2756.93
             36832     T    Av fistula revision, open                         1          1     0088   40.9003   2756.93
             36833     T    Av fistula revision                               1          1     0088   40.9003   2756.93
             36835     T    Artery to vein shunt                              1          1     0115   30.9784   2088.13
             36838     T    Dist revas ligation, hemo                         1          1     0088   40.9003   2756.93
             36860     T    External cannula declotting                       1          1     0676    2.3954    161.46
             36861     T    Cannula declotting                                1          1     0115   30.9784   2088.13
             36870     T    Percut thrombect av fistula                       1          1     0653   46.6883   3147.07
             37140     C    Revision of circulation                           1          1       0                          OR
             37145     C    Revision of circulation                           1          1       0                          OR
             37160     C    Revision of circulation                           1          1       0                          OR
             37180     C    Revision of circulation                           1          1       0                          OR
             37181     C    Splice spleen/kidney veins                        1          1       0                          OR
             37182     C    Insert hepatic shunt (tips)                       1          1       0                          OR
             37183     T    Remove hepatic shunt (tips)                       1          1     0229    97.291     6558
             37184     T    Prim art mech thrombectomy                        1          1     0088   40.9003   2756.93
             37185     T    Prim art m-thrombect add-on                       1          1     0088   40.9003   2756.93
             37186     T    Sec art m-thrombect add-on                        1          1     0088   40.9003   2756.93
             37187     T    Venous mech thrombectomy                          1          1     0088   40.9003   2756.93
             37188     T    Venous m-thrombectomy add-on                      1          1     0088   40.9003   2756.93
             37195     T    Thrombolytic therapy, stroke                      1          1     0676    2.3954    161.46
             37200     T    Transcatheter biopsy                              1          1     0623   30.4396   2051.81
             37201     T    Transcatheter therapy infuse                      1          1     0103   17.8436   1202.77
             37202     T    Transcatheter therapy infuse                      1          1     0103   17.8436   1202.77
             37203     T    Transcatheter retrieval                           1          1     0623   30.4396   2051.81
             37204     T    Transcatheter occlusion                           1          1     0082   93.3244   6290.62
             37205     T    Transcath iv stent, percut                        1          1     0229    97.291     6558
             37206     T    Transcath iv stent/perc addl                      1          1     0229    97.291     6558
             37207     T    Transcath iv stent, open                          1          1     0229    97.291     6558
             37208     T    Transcath iv stent/open addl                      1          4     0229    97.291     6558
             37209     T    Change iv cath at thromb tx                       1          1     0623   30.4396   2051.81
    PA       37210     T    Embolization uterine fibroid                      1          1     0229    97.291     6558
             37215     C    Transcath stent, cca w/eps                        1          1       0                          OR
             37216     E    Transcath stent, cca w/o eps                      1          1       0                          OR
             37250     N    Iv us first vessel add-on                         1          1       0
             37251     N    Iv us each add vessel add-on                      1          1       0
             37500     T    Endoscopy ligate perf veins                       1          1     0091   45.0292   3035.24
             37501     T    Vascular endoscopy procedure                      1          1     0092   26.5713   1791.07
             37565     T    Ligation of neck vein                             1          1     0093   35.5969   2399.44
             37600     T    Ligation of neck artery                           1          1     0093   35.5969   2399.44
             37605     T    Ligation of neck artery                           1          1     0091   45.0292   3035.24
             37606     T    Ligation of neck artery                           1          1     0092   26.5713   1791.07
             37607     T    Ligation of a-v fistula                           1          1     0092   26.5713   1791.07
             37609     T    Temporal artery procedure                         1          2     0021   17.4975   1179.44
             37615     T    Ligation of neck artery                           1          1     0092   26.5713   1791.07
             37616     C    Ligation of chest artery                          1          1       0                          OR
             37617     C    Ligation of abdomen artery                        1          1       0                          OR
             37618     C    Ligation of extremity artery                      1          1       0                          OR
             37620     T    Revision of major vein                            1          1     0091   45.0292   3035.24
             37650     T    Revision of major vein                            1          2     0092   26.5713   1791.07
             37660     C    Revision of major vein                            1          1       0                          OR
             37700     T    Revise leg vein                                   1          1     0092   26.5713   1791.07
             37718     T    Ligate/strip short leg vein                       1          1     0092   26.5713   1791.07
             37722     T    Ligate/strip long leg vein                        1          1     0091   45.0292   3035.24
             37735     T    Removal of leg veins/lesion                       1          1     0091   45.0292   3035.24
             37760     T    Ligate leg veins radical                          1          1     0092   26.5713   1791.07
             37761     T    Ligate leg veins open                             1          1     0092   26.5713   1791.07
             37765     T    Phleb veins - extrem - to 20                      0         NC       0
             37766     T    Phleb veins - extrem 20+                          0         NC       0
             37780     T    Revision of leg vein                              1          1     0092   26.5713   1791.07
             37785     T    Ligate/divide/excise vein                         1          1     0092   26.5713   1791.07
             37788     C    Revascularization, penis                          1          1       0                          OR
             37790     T    Penile venous occlusion                           1          1     0181   34.8837   2351.37
             37799     X    Vascular surgery procedure                        1          1     0624    0.6132    41.33

                                                                                                                           CPT Codes and Descriptions
                                                                                                                                        Copyright 2010
                                                                                                                          American Medical Association
Page 49 of 216                                                                                                                     All Rights Reserved
                                                       HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                           Washington State Medicaid


                                                                                       MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                     COV
                                                                                       UNITS   2010    2010      2010       Fee            Fee
             38100     C    Removal of spleen, total                          1          1       0                          OR
             38101     C    Removal of spleen, partial                        1          1       0                          OR
             38102     C    Removal of spleen, total                          1          1       0                          OR
             38115     C    Repair of ruptured spleen                         1          1       0                          OR
             38120      T   Laparoscopy, splenectomy                          1          1     0131    46.84     3157.3
             38129      T   Laparoscope proc, spleen                          1          1     0130   38.054    2565.07
             38200     N    Injection for spleen x-ray                        1          1       0
     L       38204     N    Bl donor search management                        1          1       0                                      Bundled
             38205     B    Harvest allogenic stem cells                      0         NC       0
   COE       38206      S   Harvest auto stem cells                           1          1     0111   11.9424    804.99
             38207      S   Cryopreserve stem cells                           1          1     0110    3.3809    227.89                   30.46
             38208      S   Thaw preserved stem cells                         1          1     0110    3.3809    227.89                   19.12
             38209      S   Wash harvest stem cells                           1          1     0110    3.3809    227.89                    8.23
             38210      S   T-cell depletion of harvest                       1          1     0393    5.7873     390.1                   53.57
             38211      S   Tumor cell deplete of harvst                      1          1     0393    5.7873     390.1                   48.68
             38212      S   Rbc depletion of harvest                          1          1     0393    5.7873     390.1                   32.23
             38213      S   Platelet deplete of harvest                       1          1     0393    5.7873     390.1                    8.23
             38214      S   Volume deplete of harvest                         1          1     0393    5.7873     390.1                   27.79
             38215      S   Harvest stem cell concentrte                      1          1     0393    5.7873     390.1                   32.23
             38220      T   Bone marrow aspiration                            1          1     0003    3.0998    208.95
             38221      T   Bone marrow biopsy                                1          1     0003    3.0998    208.95
   COE       38230      S   Bone marrow collection                            1          1     0112   33.3206   2246.01
   COE       38240      S   Bone marrow/stem transplant                       1          1     0112   33.3206   2246.01
   COE       38241      S   Bone marrow/stem transplant                       1          1     0112   33.3206   2246.01
   COE       38242      S   Lymphocyte infuse transplant                      1          1     0111   11.9424    804.99
             38300      T   Drainage, lymph node lesion                       1          1     0007   12.6217    850.78
             38305      T   Drainage, lymph node lesion                       1          1     0008   19.4063    1308.1
             38308      T   Incision of lymph channels                        1          1     0113   24.6146   1659.17
             38380     C    Thoracic duct procedure                           1          1       0                          OR
             38381     C    Thoracic duct procedure                           1          1       0                          OR
             38382     C    Thoracic duct procedure                           1          1       0                          OR
             38500      T   Biopsy/removal, lymph nodes                       1          1     0113   24.6146   1659.17
             38505      T   Needle biopsy, lymph nodes                        1          1     0005    7.8145    526.74
             38510      T   Biopsy/removal, lymph nodes                       1          1     0113   24.6146   1659.17
             38520      T   Biopsy/removal, lymph nodes                       1          1     0113   24.6146   1659.17
             38525      T   Biopsy/removal, lymph nodes                       1          1     0113   24.6146   1659.17
             38530      T   Biopsy/removal, lymph nodes                       1          1     0113   24.6146   1659.17
             38542      T   Explore deep node(s), neck                        1          1     0114   48.7561   3286.45
             38550      T   Removal, neck/armpit lesion                       1          1     0113   24.6146   1659.17
             38555      T   Removal, neck/armpit lesion                       1          1     0113   24.6146   1659.17
             38562     C    Removal, pelvic lymph nodes                       1          1       0                          OR
             38564     C    Removal, abdomen lymph nodes                      1          1       0                          OR
             38570      T   Laparoscopy, lymph node biop                      1          1     0131     46.84    3157.3
             38571      T   Laparoscopy, lymphadenectomy                      1          1     0132   72.9582   4917.82
             38572      T   Laparoscopy, lymphadenectomy                      1          1     0131     46.84    3157.3
             38589      T   Laparoscope proc, lymphatic                       1          1     0130    38.054   2565.07
             38700      T   Removal of lymph nodes, neck                      1          1     0113   24.6146   1659.17
             38720      T   Removal of lymph nodes, neck                      1          1     0113   24.6146   1659.17
             38724     C    Removal of lymph nodes, neck                      1          1       0                          OR
             38740      T   Remove armpit lymph nodes                         1          1     0114   48.7561   3286.45
             38745      T   Remove armpit lymph nodes                         1          1     0114   48.7561   3286.45
             38746     C    Remove thoracic lymph nodes                       1          1       0                          OR
             38747     C    Remove abdominal lymph nodes                      1          1       0                          OR
             38760      T   Remove groin lymph nodes                          1          1     0113   24.6146   1659.17
             38765     C    Remove groin lymph nodes                          1          1       0                          OR
             38770     C    Remove pelvis lymph nodes                         1          1       0                          OR
             38780     C    Remove abdomen lymph nodes                        1          1       0                          OR
             38790     N    Inject for lymphatic x-ray                        1          1       0
             38792     Q1   Identify sentinel node                            1         UR     0392   2.6817    180.76
             38794     N    Access thoracic lymph duct                        1          1       0
             38999      S   Blood/lymph system procedure                      1          1     0110   3.3809    227.89
             39000     C    Exploration of chest                              1          1       0                          OR
             39010     C    Exploration of chest                              1          1       0                          OR
             39200     C    Removal chest lesion                              1          1       0                          OR
             39220     C    Removal chest lesion                              1          1       0                          OR
             39400      T   Visualization of chest                            1          1     0069   34.0084   2292.37

                                                                                                                           CPT Codes and Descriptions
                                                                                                                                        Copyright 2010
                                                                                                                          American Medical Association
Page 50 of 216                                                                                                                     All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             39499     C    Chest procedure                                      1          1       0                          OR
             39501     C    Repair diaphragm laceration                          1          1       0                          OR
             39502     C    Repair paraesophageal hernia                         1          1       0                          OR
             39503     C    Repair of diaphragm hernia                           1          1       0                          OR
             39520     C    Repair of diaphragm hernia                           1          1       0                          OR
             39530     C    Repair of diaphragm hernia                           1          1       0                          OR
             39531     C    Repair of diaphragm hernia                           1          1       0                          OR
             39540     C    Repair of diaphragm hernia                           1          1       0                          OR
             39541     C    Repair of diaphragm hernia                           1          1       0                          OR
             39545     C    Revision of diaphragm                                1          1       0                          OR
             39560     C    Resect diaphragm, simple                             1          1       0                          OR
             39561     C    Resect diaphragm, complex                            1          1       0                          OR
             39599     C    Diaphragm surgery procedure                          1          1       0                          OR
             40490     T    Biopsy of lip                                        1          1     0251     3.425    230.87
             40500     T    Partial excision of lip                              1          1     0253   17.1879   1158.57
             40510     T    Partial excision of lip                              1          1     0254   24.9637    1682.7
             40520     T    Partial excision of lip                              1          1     0253   17.1879   1158.57
             40525     T    Reconstruct lip with flap                            1          1     0254   24.9637    1682.7
             40527     T    Reconstruct lip with flap                            1          1     0254   24.9637    1682.7
             40530     T    Partial removal of lip                               1          1     0254   24.9637    1682.7
             40650     T    Repair lip                                           1          1     0252    7.6196    513.61
             40652     T    Repair lip                                           1          1     0252    7.6196    513.61
             40654     T    Repair lip                                           1          1     0252    7.6196    513.61
             40700     T    Repair cleft lip/nasal                               1          1     0256   42.9827   2897.29
             40701     T    Repair cleft lip/nasal                               1          1     0256   42.9827   2897.29
             40702     T    Repair cleft lip/nasal                               1          1     0256   42.9827   2897.29
             40720     T    Repair cleft lip/nasal                               1          1     0256   42.9827   2897.29
             40761     T    Repair cleft lip/nasal                               1          1     0256   42.9827   2897.29
             40799     T    Lip surgery procedure                                1          1     0250    1.1522     77.67
             40800     T    Drainage of mouth lesion                             1          1     0006    1.4557     98.12
             40801     T    Drainage of mouth lesion                             1          1     0252    7.6196    513.61
             40804     X    Removal, foreign body, mouth                         1          1     0340    0.6693     45.11
             40805     T    Removal, foreign body, mouth                         1          1     0252    7.6196    513.61
             40806     T    Incision of lip fold                                 1          1     0251     3.425    230.87
             40808     T    Biopsy of mouth lesion                               1          1     0251     3.425    230.87
             40810     T    Excision of mouth lesion                             1          1     0253   17.1879   1158.57
             40812     T    Excise/repair mouth lesion                           1          1     0253   17.1879   1158.57
             40814     T    Excise/repair mouth lesion                           1          1     0253   17.1879   1158.57
             40816     T    Excision of mouth lesion                             1          1     0254   24.9637    1682.7
             40818     T    Excise oral mucosa for graft                         1          1     0251     3.425    230.87
             40819     T    Excise lip or cheek fold                             1          1     0252    7.6196    513.61
             40820     T    Treatment of mouth lesion                            1          1     0253   17.1879   1158.57
             40830     T    Repair mouth laceration                              1          1     0251     3.425    230.87
             40831     T    Repair mouth laceration                              1          1     0252    7.6196    513.61
             40840     T    Reconstruction of mouth                              1          1     0254   24.9637    1682.7
             40842     T    Reconstruction of mouth                              1          1     0254   24.9637    1682.7
             40843     T    Reconstruction of mouth                              1          1     0254   24.9637    1682.7
             40844     T    Reconstruction of mouth                              1          1     0256   42.9827   2897.29
             40845     T    Reconstruction of mouth                              1          1     0256   42.9827   2897.29
             40899     T    Mouth surgery procedure                              1          1     0250    1.1522     77.67
             41000     T    Drainage of mouth lesion                             1          1     0253   17.1879   1158.57
             41005     T    Drainage of mouth lesion                             1          1     0251     3.425    230.87
             41006     T    Drainage of mouth lesion                             1          1     0254   24.9637    1682.7
             41007     T    Drainage of mouth lesion                             1          1     0253   17.1879   1158.57
             41008     T    Drainage of mouth lesion                             1          1     0253   17.1879   1158.57
             41009     T    Drainage of mouth lesion                             1          1     0251     3.425    230.87
             41010     T    Incision of tongue fold                              1          1     0252    7.6196    513.61
             41015     T    Drainage of mouth lesion                             1          1     0251     3.425    230.87
             41016     T    Drainage of mouth lesion                             1          1     0252    7.6196    513.61
             41017     T    Drainage of mouth lesion                             1          1     0252    7.6196    513.61
             41018     T    Drainage of mouth lesion                             1          1     0252    7.6196    513.61
             41019     T    Place needles h&n for rt                             1          1     0254   24.9637    1682.7
             41100     T    Biopsy of tongue                                     1          1     0252    7.6196    513.61
             41105     T    Biopsy of tongue                                     1          1     0253   17.1879   1158.57
             41108     T    Biopsy of floor of mouth                             1          1     0019    4.3625    294.06
             41110     T    Excision of tongue lesion                            1          1     0253   17.1879   1158.57

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 51 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             41112     T    Excision of tongue lesion                            1          1     0253   17.1879   1158.57
             41113     T    Excision of tongue lesion                            1          1     0253   17.1879   1158.57
             41114     T    Excision of tongue lesion                            1          1     0254   24.9637    1682.7
             41115     T    Excision of tongue fold                              1          1     0252    7.6196    513.61
             41116     T    Excision of mouth lesion                             1          1     0253   17.1879   1158.57
             41120     T    Partial removal of tongue                            1          1     0254   24.9637    1682.7
             41130     C    Partial removal of tongue                            1          1       0                          OR
             41135     C    Tongue and neck surgery                              1          1       0                          OR
             41140     C    Removal of tongue                                    1          1       0                          OR
             41145     C    Tongue removal, neck surgery                         1          1       0                          OR
             41150     C    Tongue, mouth, jaw surgery                           1          1       0                          OR
             41153     C    Tongue, mouth, neck surgery                          1          1       0                          OR
             41155     C    Tongue, jaw, & neck surgery                          1          1       0                          OR
             41250     T    Repair tongue laceration                             1          1     0250    1.1522     77.67
             41251     T    Repair tongue laceration                             1          1     0251     3.425    230.87
             41252     T    Repair tongue laceration                             1          1     0252    7.6196    513.61
             41500     T    Fixation of tongue                                   1          1     0254   24.9637    1682.7
             41510     T    Tongue to lip surgery                                1          1     0253   17.1879   1158.57
             41512     T    Tongue suspension                                    1          1     0252    7.6196    513.61
             41520     T    Reconstruction, tongue fold                          1          1     0252    7.6196    513.61
    PA       41530     T    Tongue base vol reduction                            1          1     0254   24.9637    1682.7
             41599     T    Tongue and mouth surgery                             1          1     0250    1.1522     77.67
             41800     T    Drainage of gum lesion                               1          1     0006    1.4557     98.12
             41805     T    Removal foreign body, gum                            1          1     0254   24.9637    1682.7
             41806     T    Removal foreign body,jawbone                         1          1     0253   17.1879   1158.57
             41820     T    Excision, gum, each quadrant                         1          1     0252    7.6196    513.61
             41821     T    Excision of gum flap                                 1          1     0252    7.6196    513.61
             41822     T    Excision of gum lesion                               1          1     0253   17.1879   1158.57
             41823     T    Excision of gum lesion                               1          1     0254   24.9637    1682.7
             41825     T    Excision of gum lesion                               1          1     0253   17.1879   1158.57
             41826     T    Excision of gum lesion                               1          1     0254   24.9637    1682.7
             41827     T    Excision of gum lesion                               1          3     0254   24.9637    1682.7
             41828     T    Excision of gum lesion                               1          4     0253   17.1879   1158.57
             41830     T    Removal of gum tissue                                1          1     0253   17.1879   1158.57
             41850     T    Treatment of gum lesion                              1          1     0253   17.1879   1158.57
             41870     T    Gum graft                                            1          1     0254   24.9637    1682.7
             41872     T    Repair gum                                           1          1     0253   17.1879   1158.57
             41874     T    Repair tooth socket                                  1          1     0254   24.9637    1682.7
    PA       41899     T    Dental surgery procedure                             1          1     0250    1.1522     77.67
             42000     T    Drainage mouth roof lesion                           1          1     0251     3.425    230.87
             42100     T    Biopsy roof of mouth                                 1          1     0252    7.6196    513.61
             42104     T    Excision lesion, mouth roof                          1          1     0253   17.1879   1158.57
             42106     T    Excision lesion, mouth roof                          1          1     0253   17.1879   1158.57
             42107     T    Excision lesion, mouth roof                          1          1     0254   24.9637    1682.7
     L       42120     T    Remove palate/lesion                                 1          1     0256   42.9827   2897.29
     L       42140     T    Excision of uvula                                    1          1     0252    7.6196    513.61
    PA       42145     T    Repair palate, pharynx/uvula                         1          1     0254   24.9637    1682.7
             42160     T    Treatment mouth roof lesion                          1          1     0253   17.1879   1158.57
             42180     T    Repair palate                                        1          1     0251     3.425    230.87
             42182     T    Repair palate                                        1          1     0256   42.9827   2897.29
             42200     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
             42205     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
             42210     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
             42215     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
             42220     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
             42225     T    Reconstruct cleft palate                             1          1     0256   42.9827   2897.29
    PA       42226     T    Lengthening of palate                                1          1     0256   42.9827   2897.29
    PA       42227     T    Lengthening of palate                                1          1     0256   42.9827   2897.29
             42235     T    Repair palate                                        1          1     0253   17.1879   1158.57
             42260     T    Repair nose to lip fistula                           1          1     0254   24.9637    1682.7
             42280     T    Preparation, palate mold                             1          1     0251     3.425    230.87
             42281     T    Insertion, palate prosthesis                         1          1     0253   17.1879   1158.57
     L       42299     T    Palate/uvula surgery                                 1          1     0250    1.1522     77.67
             42300     T    Drainage of salivary gland                           1          1     0253   17.1879   1158.57
             42305     T    Drainage of salivary gland                           1          1     0253   17.1879   1158.57
             42310     T    Drainage of salivary gland                           1          1     0251     3.425    230.87

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 52 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             42320     T    Drainage of salivary gland                           1          1     0251     3.425    230.87
             42330     T    Removal of salivary stone                            1          1     0253   17.1879   1158.57
             42335     T    Removal of salivary stone                            1          1     0253   17.1879   1158.57
             42340     T    Removal of salivary stone                            1          1     0253   17.1879   1158.57
             42400     T    Biopsy of salivary gland                             1          1     0005    7.8145    526.74
             42405     T    Biopsy of salivary gland                             1          1     0254   24.9637    1682.7
             42408     T    Excision of salivary cyst                            1          1     0253   17.1879   1158.57
             42409     T    Drainage of salivary cyst                            1          1     0253   17.1879   1158.57
             42410     T    Excise parotid gland/lesion                          1          1     0256   42.9827   2897.29
             42415     T    Excise parotid gland/lesion                          1          1     0256   42.9827   2897.29
             42420     T    Excise parotid gland/lesion                          1          1     0256   42.9827   2897.29
             42425     T    Excise parotid gland/lesion                          1          1     0256   42.9827   2897.29
             42426     C    Excise parotid gland/lesion                          1          1       0                          OR
             42440     T    Excise submaxillary gland                            1          1     0256   42.9827   2897.29
             42450     T    Excise sublingual gland                              1          1     0254   24.9637    1682.7
             42500     T    Repair salivary duct                                 1          1     0254   24.9637    1682.7
             42505     T    Repair salivary duct                                 1          1     0256   42.9827   2897.29
             42507     T    Parotid duct diversion                               1          1     0256   42.9827   2897.29
             42508     T    Parotid duct diversion                               1          1     0256   42.9827   2897.29
             42509     T    Parotid duct diversion                               1          1     0256   42.9827   2897.29
             42510     T    Parotid duct diversion                               1          1     0256   42.9827   2897.29
             42550     N    Injection for salivary x-ray                         1          1       0
             42600     T    Closure of salivary fistula                          1          1     0253   17.1879   1158.57
             42650     T    Dilation of salivary duct                            1          1     0252    7.6196    513.61
             42660     T    Dilation of salivary duct                            1          1     0251     3.425    230.87
             42665     T    Ligation of salivary duct                            1          1     0254   24.9637    1682.7
             42699     T    Salivary surgery procedure                           1          1     0250    1.1522     77.67
             42700     T    Drainage of tonsil abscess                           1          1     0251     3.425    230.87
             42720     T    Drainage of throat abscess                           1          1     0253   17.1879   1158.57
             42725     T    Drainage of throat abscess                           1          1     0256   42.9827   2897.29
             42800     T    Biopsy of throat                                     1          1     0253   17.1879   1158.57
             42802     T    Biopsy of throat                                     1          1     0253   17.1879   1158.57
             42804     T    Biopsy of upper nose/throat                          1          1     0253   17.1879   1158.57
             42806     T    Biopsy of upper nose/throat                          1          1     0254   24.9637    1682.7
             42808     T    Excise pharynx lesion                                1          1     0254   24.9637    1682.7
             42809     X    Remove pharynx foreign body                          1          1     0340    0.6693     45.11
             42810     T    Excision of neck cyst                                1          1     0254   24.9637    1682.7
             42815     T    Excision of neck cyst                                1          1     0256   42.9827   2897.29
             42820     T    Remove tonsils and adenoids                          1          1     0254   24.9637    1682.7
             42821     T    Remove tonsils and adenoids                          1          1     0254   24.9637    1682.7
             42825     T    Removal of tonsils                                   1          1     0254   24.9637    1682.7
             42826     T    Removal of tonsils                                   1          1     0254   24.9637    1682.7
             42830     T    Removal of adenoids                                  1          1     0254   24.9637    1682.7
             42831     T    Removal of adenoids                                  1          1     0254   24.9637    1682.7
             42835     T    Removal of adenoids                                  1          1     0254   24.9637    1682.7
             42836     T    Removal of adenoids                                  1          1     0254   24.9637    1682.7
             42842     T    Extensive surgery of throat                          1          1     0254   24.9637    1682.7
             42844     T    Extensive surgery of throat                          1          1     0256   42.9827   2897.29
             42845     C    Extensive surgery of throat                          1          1       0                          OR
             42860     T    Excision of tonsil tags                              1          1     0254   24.9637    1682.7
             42870     T    Excision of lingual tonsil                           1          1     0254   24.9637    1682.7
             42890     T    Partial removal of pharynx                           1          1     0256   42.9827   2897.29
             42892     T    Revision of pharyngeal walls                         1          1     0256   42.9827   2897.29
             42894     C    Revision of pharyngeal walls                         1          1       0                          OR
             42900     T    Repair throat wound                                  1          1     0252    7.6196   513.61
             42950     T    Reconstruction of throat                             1          1     0254   24.9637   1682.7
             42953     C    Repair throat, esophagus                             1          1       0                          OR
             42955     T    Surgical opening of throat                           1          1     0254   24.9637   1682.7
             42960     T    Control throat bleeding                              1          1     0250    1.1522    77.67
             42961     C    Control throat bleeding                              1          1       0                          OR
             42962     T    Control throat bleeding                              1          1     0256   42.9827   2897.29
             42970     T    Control nose/throat bleeding                         1          1     0250    1.1522    77.67
             42971     C    Control nose/throat bleeding                         1          1       0                          OR
             42972     T    Control nose/throat bleeding                         1          1     0253   17.1879   1158.57
             42999     T    Throat surgery procedure                             1          1     0250    1.1522     77.67
             43020     T    Incision of esophagus                                1          1     0252    7.6196    513.61

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 53 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             43030     T    Throat muscle surgery                                1          1     0253   17.1879   1158.57
             43045     C    Incision of esophagus                                1          1       0                          OR
             43100     C    Excision of esophagus lesion                         1          1       0                          OR
             43101     C    Excision of esophagus lesion                         1          1       0                          OR
             43107     C    Removal of esophagus                                 1          1       0                          OR
             43108     C    Removal of esophagus                                 1          1       0                          OR
             43112     C    Removal of esophagus                                 1          1       0                          OR
             43113     C    Removal of esophagus                                 1          1       0                          OR
             43116     C    Partial removal of esophagus                         1          1       0                          OR
             43117     C    Partial removal of esophagus                         1          1       0                          OR
             43118     C    Partial removal of esophagus                         1          1       0                          OR
             43121     C    Partial removal of esophagus                         1          1       0                          OR
             43122     C    Partial removal of esophagus                         1          1       0                          OR
             43123     C    Partial removal of esophagus                         1          1       0                          OR
             43124     C    Removal of esophagus                                 1          1       0                          OR
             43130     T    Removal of esophagus pouch                           1          1     0256   42.9827   2897.29
             43135     C    Removal of esophagus pouch                           1          1       0                          OR
             43200     T    Esophagus endoscopy                                  1          1     0141    8.7462    589.55
             43201     T    Esoph scope w/submucous inj                          1          1     0141    8.7462    589.55
             43202     T    Esophagus endoscopy, biopsy                          1          1     0141    8.7462    589.55
             43204     T    Esoph scope w/sclerosis inj                          1          1     0141    8.7462    589.55
             43205     T    Esophagus endoscopy/ligation                         1          1     0141    8.7462    589.55
             43215     T    Esophagus endoscopy                                  1          1     0141    8.7462    589.55
             43216     T    Esophagus endoscopy/lesion                           1          1     0141    8.7462    589.55
             43217     T    Esophagus endoscopy                                  1          1     0141    8.7462    589.55
             43219     T    Esophagus endoscopy                                  1          1     0384   26.4913   1785.67
             43220     T    Esoph endoscopy, dilation                            1          1     0141    8.7462    589.55
             43226     T    Esoph endoscopy, dilation                            1          1     0141    8.7462    589.55
             43227     T    Esoph endoscopy, repair                              1          1     0141    8.7462    589.55
             43228     T    Esoph endoscopy, ablation                            1          1     0422   24.2703   1635.96
             43231     T    Esoph endoscopy w/us exam                            1          1     0141    8.7462    589.55
             43232     T    Esoph endoscopy w/us fn bx                           1          1     0141    8.7462    589.55
             43234     T    Upper GI endoscopy, exam                             1          1     0141    8.7462    589.55
             43235     T    Uppr gi endoscopy, diagnosis                         1          1     0141    8.7462    589.55
             43236     T    Uppr gi scope w/submuc inj                           1          1     0141    8.7462    589.55
             43237     T    Endoscopic us exam, esoph                            1          1     0141    8.7462    589.55
             43238     T    Uppr gi endoscopy w/us fn bx                         1          1     0141    8.7462    589.55
             43239     T    Upper GI endoscopy, biopsy                           1          1     0141    8.7462    589.55
             43240     T    Esoph endoscope w/drain cyst                         1          1     0141    8.7462    589.55
             43241     T    Upper GI endoscopy with tube                         1          1     0141    8.7462    589.55
             43242     T    Uppr gi endoscopy w/us fn bx                         1          1     0141    8.7462    589.55
             43243     T    Upper gi endoscopy & inject                          1          1     0141    8.7462    589.55
             43244     T    Upper GI endoscopy/ligation                          1          1     0141    8.7462    589.55
             43245     T    Uppr gi scope dilate strictr                         1          1     0141    8.7462    589.55
             43246     T    Place gastrostomy tube                               1          1     0141    8.7462    589.55
             43247     T    Operative upper GI endoscopy                         1          1     0141    8.7462    589.55
             43248     T    Uppr gi endoscopy/guide wire                         1          1     0141    8.7462    589.55
             43249     T    Esoph endoscopy, dilation                            1          1     0141    8.7462    589.55
             43250     T    Upper GI endoscopy/tumor                             1          1     0141    8.7462    589.55
             43251     T    Operative upper GI endoscopy                         1          1     0141    8.7462    589.55
             43255     T    Operative upper GI endoscopy                         1          1     0141    8.7462    589.55
             43256     T    Uppr gi endoscopy w/stent                            1          1     0384   26.4913   1785.67
             43257     T    Uppr gi scope w/thrml txmnt                          0         NC       0
             43258     T    Operative upper GI endoscopy                         1          1     0141    8.7462    589.55
             43259     T    Endoscopic ultrasound exam                           1          1     0141    8.7462    589.55
             43260     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43261     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43262     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43263     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43264     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43265     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43267     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43268     T    Endo cholangiopancreatograph                         1          1     0384   26.4913   1785.67
             43269     T    Endo cholangiopancreatograph                         1          1     0384   26.4913   1785.67
             43271     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12
             43272     T    Endo cholangiopancreatograph                         1          1     0151   22.6111   1524.12

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 54 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             43273     T    Endoscopic pancreatoscopy                            1          1     0151   22.6111   1524.12
             43279     C    Lap myotomy, heller                                  1          1       0                          OR
             43280     T    Laparoscopy, fundoplasty                             1          1     0132   72.9582   4917.82
             43281     C    Lap paraesophag hern repair                          1          1       0                          OR
             43282     C    Lap paraesoph her rpr w/mesh                         1          1       0                          OR
             43289     T    Laparoscope proc, esoph                              1          1     0130   38.054    2565.07
             43300     C    Repair of esophagus                                  1          1       0                          OR
             43305     C    Repair esophagus and fistula                         1          1       0                          OR
             43310     C    Repair of esophagus                                  1          1       0                          OR
             43312     C    Repair esophagus and fistula                         1          1       0                          OR
             43313     C    Esophagoplasty congenital                            1          1       0                          OR
             43314     C    Tracheo-esophagoplasty cong                          1          1       0                          OR
             43320     C    Fuse esophagus & stomach                             1          1       0                          OR
             43324     C    Revise esophagus & stomach                           1          1       0                          OR
             43325     C    Revise esophagus & stomach                           1          1       0                          OR
             43326     C    Revise esophagus & stomach                           1          1       0                          OR
             43330     C    Repair of esophagus                                  1          1       0                          OR
             43331     C    Repair of esophagus                                  1          1       0                          OR
             43340     C    Fuse esophagus & intestine                           1          1       0                          OR
             43341     C    Fuse esophagus & intestine                           1          1       0                          OR
             43350     C    Surgical opening, esophagus                          1          1       0                          OR
             43351     C    Surgical opening, esophagus                          1          1       0                          OR
             43352     C    Surgical opening, esophagus                          1          1       0                          OR
             43360     C    Gastrointestinal repair                              1          1       0                          OR
             43361     C    Gastrointestinal repair                              1          1       0                          OR
             43400     C    Ligate esophagus veins                               1          1       0                          OR
             43401     C    Esophagus surgery for veins                          1          1       0                          OR
             43405     C    Ligate/staple esophagus                              1          1       0                          OR
             43410     C    Repair esophagus wound                               1          1       0                          OR
             43415     C    Repair esophagus wound                               1          1       0                          OR
             43420     T    Repair esophagus opening                             1          1     0254   24.9637   1682.7
             43425     C    Repair esophagus opening                             1          1       0                          OR
             43450     T    Dilate esophagus                                     1          1     0140   5.9622    401.89
             43453     T    Dilate esophagus                                     1          1     0140   5.9622    401.89
             43456     T    Dilate esophagus                                     1          1     0140   5.9622    401.89
             43458     T    Dilate esophagus                                     1          1     0141   8.7462    589.55
             43460     C    Pressure treatment esophagus                         1          1       0                          OR
             43496     C    Free jejunum flap, microvasc                         1          1       0                          OR
             43499     T    Esophagus surgery procedure                          1          1     0141   8.7462    589.55
             43500     C    Surgical opening of stomach                          1          1       0                          OR
             43501     C    Surgical repair of stomach                           1          1       0                          OR
             43502     C    Surgical repair of stomach                           1          1       0                          OR
             43510     T    Surgical opening of stomach                          1          1     0141   8.7462    589.55
             43520     C    Incision of pyloric muscle                           1          1       0                          OR
             43600     T    Biopsy of stomach                                    1          1     0141   8.7462    589.55
             43605     C    Biopsy of stomach                                    1          1       0                          OR
             43610     C    Excision of stomach lesion                           1          1       0                          OR
             43611     C    Excision of stomach lesion                           1          1       0                          OR
             43620     C    Removal of stomach                                   1          1       0                          OR
             43621     C    Removal of stomach                                   1          1       0                          OR
             43622     C    Removal of stomach                                   1          1       0                          OR
             43631     C    Removal of stomach, partial                          1          1       0                          OR
             43632     C    Removal of stomach, partial                          1          1       0                          OR
             43633     C    Removal of stomach, partial                          1          1       0                          OR
             43634     C    Removal of stomach, partial                          1          1       0                          OR
             43635     C    Removal of stomach, partial                          1          1       0                          OR
             43640     C    Vagotomy & pylorus repair                            1          1       0                          OR
             43641     C    Vagotomy & pylorus repair                            1          1       0                          OR
             43644     C    Lap gastric bypass/roux-en-y                         0         NC       0
             43645     C    Lap gastr bypass incl smll i                         0         NC       0
    PA       43647     S    Lap impl electrode, antrum                           1          1     0061   86.5171   5831.77
    PA       43648     T    Lap revise/remv eltrd antrum                         1          1     0130    38.054   2565.07
             43651     T    Laparoscopy, vagus nerve                             1          1     0132   72.9582   4917.82
             43652     T    Laparoscopy, vagus nerve                             1          1     0132   72.9582   4917.82
             43653     T    Laparoscopy, gastrostomy                             1          1     0131     46.84    3157.3
    PA       43659     T    Laparoscope proc, stom                               1          1     0130    38.054   2565.07

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 55 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             43752     X    Nasal/orogastric w/stent                             1          1     0272   1.2693     85.56
             43760     T    Change gastrostomy tube                              1          1     0676   2.3954    161.46
             43761     T    Reposition gastrostomy tube                          1          1     0141   8.7462    589.55
             43770     C    Lap place gastr adj device                           0         NC       0
             43771     C    Lap revise gastr adj device                          0         NC       0
             43772     C    Lap rmvl gastr adj device                            0         NC       0
             43773     C    Lap replace gastr adj device                         0         NC       0
             43774     C    Lap rmvl gastr adj all parts                         1          1       0                          OR
    PA       43775     C    Lap sleeve gastrectomy                               1          1       0                          OR
             43800     C    Reconstruction of pylorus                            1          1       0                          OR
             43810     C    Fusion of stomach and bowel                          1          1       0                          OR
             43820     C    Fusion of stomach and bowel                          1          1       0                          OR
             43825     C    Fusion of stomach and bowel                          1          1       0                          OR
             43830     T    Place gastrostomy tube                               1          1     0422   24.2703   1635.96
             43831     T    Place gastrostomy tube                               1          1     0141    8.7462    589.55
             43832     C    Place gastrostomy tube                               1          1       0                          OR
             43840     C    Repair of stomach lesion                             1          1       0                          OR
             43842     E    V-band gastroplasty                                  0         NC       0
             43843     C    Gastroplasty w/o v-band                              0         NC       0
             43845     C    Gastroplasty duodenal switch                         0         NC       0
             43846     C    Gastric bypass for obesity                           0         NC       0
             43847     C    Gastric bypass incl small i                          0         NC       0
             43848     C    Revision gastroplasty                                0         NC       0
             43850     C    Revise stomach-bowel fusion                          1          1       0                          OR
             43855     C    Revise stomach-bowel fusion                          1          1       0                          OR
             43860     C    Revise stomach-bowel fusion                          1          1       0                          OR
             43865     C    Revise stomach-bowel fusion                          1          1       0                          OR
             43870     T    Repair stomach opening                               1          1     0141   8.7462    589.55
             43880     C    Repair stomach-bowel fistula                         1          1       0                          OR
    PA       43881     C    Impl/redo electrd, antrum                            1          1       0                          OR
    PA       43882     C    Revise/remove electrd antrum                         1          1       0                          OR
             43886     T    Revise gastric port, open                            0         NC       0
             43887     T    Remove gastric port, open                            0         NC       0
             43888     T    Change gastric port, open                            0         NC       0
             43999     T    Stomach surgery procedure                            1          1     0141   8.7462    589.55
             44005     C    Freeing of bowel adhesion                            1          1       0                          OR
             44010     C    Incision of small bowel                              1          1       0                          OR
             44015     C    Insert needle cath bowel                             1          1       0                          OR
             44020     C    Explore small intestine                              1          1       0                          OR
             44021     C    Decompress small bowel                               1          1       0                          OR
             44025     C    Incision of large bowel                              1          1       0                          OR
             44050     C    Reduce bowel obstruction                             1          1       0                          OR
             44055     C    Correct malrotation of bowel                         1          1       0                          OR
             44100     T    Biopsy of bowel                                      1          1     0141   8.7462    589.55
             44110     C    Excise intestine lesion(s)                           1          1       0                          OR
             44111     C    Excision of bowel lesion(s)                          1          1       0                          OR
             44120     C    Removal of small intestine                           1          1       0                          OR
             44121     C    Removal of small intestine                           1          1       0                          OR
             44125     C    Removal of small intestine                           1          1       0                          OR
             44126     C    Enterectomy w/o taper, cong                          1          1       0                          OR
             44127     C    Enterectomy w/taper, cong                            1          1       0                          OR
             44128     C    Enterectomy cong, add-on                             1          1       0                          OR
             44130     C    Bowel to bowel fusion                                1          1       0                          OR
   COE       44132     C    Enterectomy, cadaver donor                           1          1       0                          OR
   COE       44133     C    Enterectomy, live donor                              1         NA       0                          OR
   COE       44135     C    Intestine transplnt, cadaver                         1         NA       0                          OR
   COE       44136     C    Intestine transplant, live                           1         NA       0                          OR
   COE       44137     C    Remove intestinal allograft                          1          1       0                          OR
             44139     C    Mobilization of colon                                1          1       0                          OR
             44140     C    Partial removal of colon                             1          1       0                          OR
             44141     C    Partial removal of colon                             1          1       0                          OR
             44143     C    Partial removal of colon                             1          1       0                          OR
             44144     C    Partial removal of colon                             1          1       0                          OR
             44145     C    Partial removal of colon                             1          1       0                          OR
             44146     C    Partial removal of colon                             1          1       0                          OR
             44147     C    Partial removal of colon                             1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 56 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             44150     C    Removal of colon                                     1          1       0                          OR
             44151     C    Removal of colon/ileostomy                           1          1       0                          OR
             44155     C    Removal of colon/ileostomy                           1          1       0                          OR
             44156     C    Removal of colon/ileostomy                           1          1       0                          OR
             44157     C    Colectomy w/ileoanal anast                           1          1       0                          OR
             44158     C    Colectomy w/neo-rectum pouch                         1          1       0                          OR
             44160     C    Removal of colon                                     1          1       0                          OR
             44180     T    Lap, enterolysis                                     1          1     0131    46.84    3157.3
             44186     T    Lap, jejunostomy                                     1          1     0131    46.84    3157.3
             44187     C    Lap, ileo/jejuno-stomy                               1          1       0                          OR
             44188     C    Lap, colostomy                                       1          1       0                          OR
             44202     C    Lap, enterectomy                                     1          1       0                          OR
             44203     C    Lap resect s/intestine, addl                         1          1       0                          OR
             44204     C    Laparo partial colectomy                             1          1       0                          OR
             44205     C    Lap colectomy part w/ileum                           1          1       0                          OR
             44206     T    Lap part colectomy w/stoma                           1          1     0132   72.9582   4917.82
             44207     T    L colectomy/coloproctostomy                          1          1     0132   72.9582   4917.82
             44208     T    L colectomy/coloproctostomy                          1          1     0132   72.9582   4917.82
             44210     C    Laparo total proctocolectomy                         1          1       0                          OR
             44211     C    Lap colectomy w/proctectomy                          1          1       0                          OR
             44212     C    Laparo total proctocolectomy                         1          1       0                          OR
             44213     T    Lap, mobil splenic fl add-on                         1          1     0130   38.054    2565.07
             44227     C    Lap, close enterostomy                               1          1       0                          OR
             44238     T    Laparoscope proc, intestine                          1          1     0130   38.054    2565.07
             44300     C    Open bowel to skin                                   1          1       0                          OR
             44310     C    Ileostomy/jejunostomy                                1          1       0                          OR
             44312     T    Revision of ileostomy                                1          1     0137   23.9317   1613.14
             44314     C    Revision of ileostomy                                1          1       0                          OR
             44316     C    Devise bowel pouch                                   1          1       0                          OR
             44320     C    Colostomy                                            1          1       0                          OR
             44322     C    Colostomy with biopsies                              1          1       0                          OR
             44340     T    Revision of colostomy                                1          1     0137   23.9317   1613.14
             44345     C    Revision of colostomy                                1          1       0                          OR
             44346     C    Revision of colostomy                                1          1       0                          OR
             44360     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44361     T    Small bowel endoscopy/biopsy                         1          1     0142    9.8503    663.97
             44363     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44364     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44365     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44366     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44369     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44370     T    Small bowel endoscopy/stent                          1          1     0384   26.4913   1785.67
             44372     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44373     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44376     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44377     T    Small bowel endoscopy/biopsy                         1          1     0142    9.8503    663.97
             44378     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44379     T    S bowel endoscope w/stent                            1          1     0384   26.4913   1785.67
             44380     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44382     T    Small bowel endoscopy                                1          1     0142    9.8503    663.97
             44383     T    Ileoscopy w/stent                                    1          1     0384   26.4913   1785.67
             44385     T    Endoscopy of bowel pouch                             1          1     0143    9.1051    613.74
             44386     T    Endoscopy, bowel pouch/biop                          1          1     0143    9.1051    613.74
             44388     T    Colonoscopy                                          1          1     0143    9.1051    613.74
             44389     T    Colonoscopy with biopsy                              1          1     0143    9.1051    613.74
             44390     T    Colonoscopy for foreign body                         1          1     0143    9.1051    613.74
             44391     T    Colonoscopy for bleeding                             1          1     0143    9.1051    613.74
             44392     T    Colonoscopy & polypectomy                            1          1     0143    9.1051    613.74
             44393     T    Colonoscopy, lesion removal                          1          1     0143    9.1051    613.74
             44394     T    Colonoscopy w/snare                                  1          1     0143    9.1051    613.74
             44397     T    Colonoscopy w/stent                                  1          1     0384   26.4913   1785.67
             44500     T    Intro, gastrointestinal tube                         1          1     0121    6.3742    429.66
             44602     C    Suture, small intestine                              1          1       0                          OR
             44603     C    Suture, small intestine                              1          1       0                          OR
             44604     C    Suture, large intestine                              1          1       0                          OR
             44605     C    Repair of bowel lesion                               1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 57 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             44615     C    Intestinal stricturoplasty                           1          1       0                          OR
             44620     C    Repair bowel opening                                 1          1       0                          OR
             44625     C    Repair bowel opening                                 1          1       0                          OR
             44626     C    Repair bowel opening                                 1          1       0                          OR
             44640     C    Repair bowel-skin fistula                            1          1       0                          OR
             44650     C    Repair bowel fistula                                 1          1       0                          OR
             44660     C    Repair bowel-bladder fistula                         1          1       0                          OR
             44661     C    Repair bowel-bladder fistula                         1          1       0                          OR
             44680     C    Surgical revision, intestine                         1          1       0                          OR
             44700     C    Suspend bowel w/prosthesis                           1          1       0                          OR
             44701     N    Intraop colon lavage add-on                          1          1       0
   COE       44715     C    Prepare donor intestine                              1          1       0                          OR
   COE       44720     C    Prep donor intestine/venous                          1          1       0                          OR
   COE       44721     C    Prep donor intestine/artery                          1          1       0                          OR
             44799     T    Unlisted procedure intestine                         1          1     0153   27.1855   1832.47
             44800     C    Excision of bowel pouch                              1          1       0                          OR
             44820     C    Excision of mesentery lesion                         1          1       0                          OR
             44850     C    Repair of mesentery                                  1          1       0                          OR
             44899     C    Bowel surgery procedure                              1          1       0                          OR
             44900     C    Drain app abscess, open                              1          1       0                          OR
             44901     T    Drain app abscess, percut                            1          1     0037   15.5003   1044.81
             44950     T    Appendectomy                                         1          1     0153   27.1855   1832.47
             44955     T    Appendectomy add-on                                  1          1     0153   27.1855   1832.47
             44960     C    Appendectomy                                         1          1       0                          OR
             44970     T    Laparoscopy, appendectomy                            1          1     0131     46.84    3157.3
             44979     T    Laparoscope proc, app                                1          1     0130    38.054   2565.07
             45000     T    Drainage of pelvic abscess                           1          1     0155    14.114    951.37
             45005     T    Drainage of rectal abscess                           1          2     0155    14.114    951.37
             45020     T    Drainage of rectal abscess                           1          1     0155    14.114    951.37
             45100     T    Biopsy of rectum                                     1          1     0149   23.9703   1615.74
             45108     T    Removal of anorectal lesion                          1          1     0149   23.9703   1615.74
             45110     C    Removal of rectum                                    1          1       0                          OR
             45111     C    Partial removal of rectum                            1          1       0                          OR
             45112     C    Removal of rectum                                    1          1       0                          OR
             45113     C    Partial proctectomy                                  1          1       0                          OR
             45114     C    Partial removal of rectum                            1          1       0                          OR
             45116     C    Partial removal of rectum                            1          1       0                          OR
             45119     C    Remove rectum w/reservoir                            1          1       0                          OR
             45120     C    Removal of rectum                                    1          1       0                          OR
             45121     C    Removal of rectum and colon                          1          1       0                          OR
             45123     C    Partial proctectomy                                  1          1       0                          OR
             45126     C    Pelvic exenteration                                  1          1       0                          OR
             45130     C    Excision of rectal prolapse                          1          1       0                          OR
             45135     C    Excision of rectal prolapse                          1          1       0                          OR
             45136     C    Excise ileoanal reservior                            1          1       0                          OR
             45150     T    Excision of rectal stricture                         1          1     0149   23.9703   1615.74
             45160     T    Excision of rectal lesion                            1          1     0149   23.9703   1615.74
             45171     T    Exc rect tum transanal part                          1          1     0155    14.114    951.37
             45172     T    Exc rect tum transanal full                          1          1     0149   23.9703   1615.74
             45190     T    Destruction, rectal tumor                            1          1     0149   23.9703   1615.74
             45300     T    Proctosigmoidoscopy dx                               1          1     0146    5.7747    389.25
             45303     T    Proctosigmoidoscopy dilate                           1          1     0147     9.245    623.17
             45305     T    Proctosigmoidoscopy w/bx                             1          1     0147     9.245    623.17
             45307     T    Proctosigmoidoscopy fb                               1          1     0428   22.8208   1538.26
             45308     T    Proctosigmoidoscopy removal                          1          1     0147     9.245    623.17
             45309     T    Proctosigmoidoscopy removal                          1          1     0147     9.245    623.17
             45315     T    Proctosigmoidoscopy removal                          1          1     0147     9.245    623.17
             45317     T    Proctosigmoidoscopy bleed                            1          1     0147     9.245    623.17
             45320     T    Proctosigmoidoscopy ablate                           1          1     0428   22.8208   1538.26
             45321     T    Proctosigmoidoscopy volvul                           1          1     0428   22.8208   1538.26
             45327     T    Proctosigmoidoscopy w/stent                          1          1     0384   26.4913   1785.67
             45330     T    Diagnostic sigmoidoscopy                             1          1     0146    5.7747    389.25
             45331     T    Sigmoidoscopy and biopsy                             1          1     0146    5.7747    389.25
             45332     T    Sigmoidoscopy w/fb removal                           1          1     0146    5.7747    389.25
             45333     T    Sigmoidoscopy & polypectomy                          1          1     0147     9.245    623.17
             45334     T    Sigmoidoscopy for bleeding                           1          1     0147     9.245    623.17

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 58 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             45335     T    Sigmoidoscopy w/submuc inj                           1          1     0146    5.7747    389.25
             45337     T    Sigmoidoscopy & decompress                           1          1     0146    5.7747    389.25
             45338     T    Sigmoidoscopy w/tumr remove                          1          1     0147     9.245    623.17
             45339     T    Sigmoidoscopy w/ablate tumr                          1          1     0147     9.245    623.17
             45340     T    Sig w/balloon dilation                               1          1     0147     9.245    623.17
             45341     T    Sigmoidoscopy w/ultrasound                           1          2     0147     9.245    623.17
             45342     T    Sigmoidoscopy w/us guide bx                          1          1     0147     9.245    623.17
             45345     T    Sigmoidoscopy w/stent                                1          1     0384   26.4913   1785.67
             45355     T    Surgical colonoscopy                                 1          1     0143    9.1051    613.74
             45378     T    Diagnostic colonoscopy                               1          1     0143    9.1051    613.74
             45379     T    Colonoscopy w/fb removal                             1          1     0143    9.1051    613.74
             45380     T    Colonoscopy and biopsy                               1          1     0143    9.1051    613.74
             45381     T    Colonoscopy, submucous inj                           1          1     0143    9.1051    613.74
             45382     T    Colonoscopy/control bleeding                         1          1     0143    9.1051    613.74
             45383     T    Lesion removal colonoscopy                           1          1     0143    9.1051    613.74
             45384     T    Lesion remove colonoscopy                            1          1     0143    9.1051    613.74
             45385     T    Lesion removal colonoscopy                           1          1     0143    9.1051    613.74
             45386     T    Colonoscopy dilate stricture                         1          1     0143    9.1051    613.74
             45387     T    Colonoscopy w/stent                                  1          1     0384   26.4913   1785.67
             45391     T    Colonoscopy w/endoscope us                           1          1     0143    9.1051    613.74
             45392     T    Colonoscopy w/endoscopic fnb                         1          1     0143    9.1051    613.74
             45395     C    Lap, removal of rectum                               1          1       0                          OR
             45397     C    Lap, remove rectum w/pouch                           1          1       0                          OR
             45400     C    Laparoscopic proc                                    1          1       0                          OR
             45402     C    Lap proctopexy w/sig resect                          1          1       0                          OR
             45499     T    Laparoscope proc, rectum                             1          1     0130    38.054   2565.07
             45500     T    Repair of rectum                                     1          1     0149   23.9703   1615.74
             45505     T    Repair of rectum                                     1          1     0150   32.1812   2169.21
             45520     T    Treatment of rectal prolapse                         1          1     0013    0.8789    59.24
             45540     C    Correct rectal prolapse                              1          1       0                          OR
             45541     T    Correct rectal prolapse                              1          1     0150   32.1812   2169.21
             45550     C    Repair rectum/remove sigmoid                         1          1       0                          OR
             45560     T    Repair of rectocele                                  1          1     0150   32.1812   2169.21
             45562     C    Exploration/repair of rectum                         1          1       0                          OR
             45563     C    Exploration/repair of rectum                         1          1       0                          OR
             45800     C    Repair rect/bladder fistula                          1          1       0                          OR
             45805     C    Repair fistula w/colostomy                           1          1       0                          OR
             45820     C    Repair rectourethral fistula                         1          1       0                          OR
             45825     C    Repair fistula w/colostomy                           1          1       0                          OR
             45900     T    Reduction of rectal prolapse                         1          1     0148     5.365    361.63
             45905     T    Dilation of anal sphincter                           1          1     0149   23.9703   1615.74
             45910     T    Dilation of rectal narrowing                         1          1     0149   23.9703   1615.74
             45915     T    Remove rectal obstruction                            1          1     0155    14.114    951.37
             45990     T    Surg dx exam, anorectal                              1          1     0149   23.9703   1615.74
             45999     T    Rectum surgery procedure                             1          2     0148     5.365    361.63
             46020     T    Placement of seton                                   1          1     0149   23.9703   1615.74
             46030     T    Removal of rectal marker                             1          1     0148     5.365    361.63
             46040     T    Incision of rectal abscess                           1          1     0149   23.9703   1615.74
             46045     T    Incision of rectal abscess                           1          1     0149   23.9703   1615.74
             46050     T    Incision of anal abscess                             1          1     0155    14.114    951.37
             46060     T    Incision of rectal abscess                           1          1     0149   23.9703   1615.74
             46070     T    Incision of anal septum                              1          1     0155    14.114    951.37
             46080     T    Incision of anal sphincter                           1          1     0149   23.9703   1615.74
             46083     T    Incise external hemorrhoid                           1          1     0164    2.0194    136.12
             46200     T    Removal of anal fissure                              1          1     0149   23.9703   1615.74
             46220     T    Excise anal ext tag/papilla                          1          1     0155    14.114    951.37
             46221     T    Ligation of hemorrhoid(s)                            1          1     0148     5.365    361.63
             46230     T    Removal of anal tags                                 1          1     0149   23.9703   1615.74
             46250     T    Remove ext hem groups = 2                            1          1     0149   23.9703   1615.74
             46255     T    Remove int/ext hem 1 group                           1          1     0149   23.9703   1615.74
             46257     T    Remove in/ex hem grp & fiss                          1          1     0149   23.9703   1615.74
             46258     T    Remove in/ex hem grp w/fistu                         1          1     0149   23.9703   1615.74
             46260     T    Remove in/ex hem groups = 2                          1          1     0149   23.9703   1615.74
             46261     T    Remove in/ex hem grps & fiss                         1          1     0149   23.9703   1615.74
             46262     T    Remove in/ex hem grps w/fist                         1          1     0149   23.9703   1615.74
             46270     T    Remove anal fist subq                                1          1     0149   23.9703   1615.74

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 59 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             46275     T    Remove anal fist inter                               1          1     0149   23.9703   1615.74
             46280     T    Remove anal fist complex                             1          1     0149   23.9703   1615.74
             46285     T    Remove anal fist 2 stage                             1          1     0149   23.9703   1615.74
             46288     T    Repair anal fistula                                  1          1     0149   23.9703   1615.74
             46320     T    Removal of hemorrhoid clot                           1          1     0149   23.9703   1615.74
             46500     T    Injection into hemorrhoid(s)                         1          2     0155    14.114    951.37
    PA       46505     T    Chemodenervation anal musc                           1          1     0149   23.9703   1615.74
             46600     X    Diagnostic anoscopy                                  1          1     0340    0.6693     45.11
             46604     T    Anoscopy and dilation                                1          1     0147     9.245    623.17
             46606     T    Anoscopy and biopsy                                  1          1     0146    5.7747    389.25
             46608     T    Anoscopy, remove for body                            1          1     0147     9.245    623.17
             46610     T    Anoscopy, remove lesion                              1          1     0428   22.8208   1538.26
             46611     T    Anoscopy                                             1          1     0147     9.245    623.17
             46612     T    Anoscopy, remove lesions                             1          1     0428   22.8208   1538.26
             46614     T    Anoscopy, control bleeding                           1          1     0146    5.7747    389.25
             46615     T    Anoscopy                                             1          1     0428   22.8208   1538.26
             46700     T    Repair of anal stricture                             1          1     0149   23.9703   1615.74
             46705     C    Repair of anal stricture                             1          1       0                          OR
             46706     T    Repr of anal fistula w/glue                          1          1     0150   32.1812   2169.21
             46707     T    Repair anorectal fist w/plug                         1          1     0150   32.1812   2169.21
             46710     C    Repr per/vag pouch sngl proc                         1          1       0                          OR
             46712     C    Repr per/vag pouch dbl proc                          1          1       0                          OR
             46715     C    Rep perf anoper fistu                                1          1       0                          OR
             46716     C    Rep perf anoper/vestib fistu                         1          1       0                          OR
             46730     C    Construction of absent anus                          1          1       0                          OR
             46735     C    Construction of absent anus                          1          1       0                          OR
             46740     C    Construction of absent anus                          1          1       0                          OR
             46742     C    Repair of imperforated anus                          1          1       0                          OR
             46744     C    Repair of cloacal anomaly                            1          1       0                          OR
             46746     C    Repair of cloacal anomaly                            1          1       0                          OR
             46748     C    Repair of cloacal anomaly                            1          1       0                          OR
             46750     T    Repair of anal sphincter                             1          1     0150   32.1812   2169.21
             46751     C    Repair of anal sphincter                             1          1       0                          OR
             46753     T    Reconstruction of anus                               1          1     0149   23.9703   1615.74
             46754     T    Removal of suture from anus                          1          1     0149   23.9703   1615.74
             46760     T    Repair of anal sphincter                             1          1     0150   32.1812   2169.21
             46761     T    Repair of anal sphincter                             1          1     0150   32.1812   2169.21
             46762     T    Implant artificial sphincter                         1          1     0150   32.1812   2169.21
             46900     T    Destruction, anal lesion(s)                          1          1     0016    2.7982    188.62
             46910     T    Destruction, anal lesion(s)                          1          1     0017   21.2653   1433.41
             46916     T    Cryosurgery, anal lesion(s)                          1          1     0015    1.5412    103.89
             46917     T    Laser surgery, anal lesions                          1          1     0017   21.2653   1433.41
             46922     T    Excision of anal lesion(s)                           1          1     0017   21.2653   1433.41
             46924     T    Destruction, anal lesion(s)                          1          1     0017   21.2653   1433.41
             46930     T    Destroy internal hemorrhoids                         1          1     0148     5.365    361.63
             46940     T    Treatment of anal fissure                            1          1     0149   23.9703   1615.74
             46942     T    Treatment of anal fissure                            1          1     0148     5.365    361.63
             46945     T    Remove by ligat int hem grp                          1          1     0155    14.114    951.37
             46946     T    Remove by ligat int hem grps                         1          1     0155    14.114    951.37
             46947     T    Hemorrhoidopexy by stapling                          1          1     0150   32.1812   2169.21
             46999     T    Anus surgery procedure                               1          1     0148     5.365    361.63
             47000     T    Needle biopsy of liver                               1          1     0685    9.6666    651.59
             47001     N    Needle biopsy, liver add-on                          1          1       0
             47010     C    Open drainage, liver lesion                          1          1       0                          OR
             47011     T    Percut drain, liver lesion                           1          1     0037   15.5003   1044.81
             47015     C    Inject/aspirate liver cyst                           1          1       0                          OR
             47100     C    Wedge biopsy of liver                                1          1       0                          OR
             47120     C    Partial removal of liver                             1          1       0                          OR
             47122     C    Extensive removal of liver                           1          1       0                          OR
             47125     C    Partial removal of liver                             1          1       0                          OR
             47130     C    Partial removal of liver                             1          1       0                          OR
   COE       47133     C    Removal of donor liver                               1          1       0                          OR
   COE       47135     C    Transplantation of liver                             1          1       0                          OR
   COE       47136     C    Transplantation of liver                             1          1       0                          OR
   COE       47140     C    Partial removal, donor liver                         1          1       0                          OR
   COE       47141     C    Partial removal, donor liver                         1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 60 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW         NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010       2010       Fee            Fee
   COE       47142     C    Partial removal, donor liver                         1          1       0                           OR
   COE       47143     C    Prep donor liver, whole                              1          1       0                           OR
   COE       47144     C    Prep donor liver, 3-segment                          1          1       0                           OR
   COE       47145     C    Prep donor liver, lobe split                         1          1       0                           OR
   COE       47146     C    Prep donor liver/venous                              1          1       0                           OR
   COE       47147     C    Prep donor liver/arterial                            1          1       0                           OR
             47300     C    Surgery for liver lesion                             1          1       0                           OR
             47350     C    Repair liver wound                                   1          1       0                           OR
             47360     C    Repair liver wound                                   1          1       0                           OR
             47361     C    Repair liver wound                                   1          1       0                           OR
             47362     C    Repair liver wound                                   1          1       0                           OR
             47370     T    Laparo ablate liver tumor rf                         1          1     0174   109.9237   7409.52
             47371     T    Laparo ablate liver cryosurg                         1          1     0174   109.9237   7409.52
             47379     T    Laparoscope procedure, liver                         1          1     0130    38.054    2565.07
             47380     C    Open ablate liver tumor rf                           1          1       0                           OR
             47381     C    Open ablate liver tumor cryo                         1          1       0                           OR
             47382     T    Percut ablate liver rf                               1          1     0423   51.3618    3462.09
             47399     T    Liver surgery procedure                              1          1     0004    4.5991     310.01
             47400     C    Incision of liver duct                               1          1       0                           OR
             47420     C    Incision of bile duct                                1          1       0                           OR
             47425     C    Incision of bile duct                                1          1       0                           OR
             47460     C    Incise bile duct sphincter                           1          1       0                           OR
             47480     C    Incision of gallbladder                              1          1       0                           OR
             47490     T    Incision of gallbladder                              1          1     0152    30.743    2072.26
             47500     N    Injection for liver x-rays                           1          1       0
             47505     N    Injection for liver x-rays                           1          1       0
             47510     T    Insert catheter, bile duct                           1          1     0152    30.743    2072.26
             47511     T    Insert bile duct drain                               1          1     0152    30.743    2072.26
             47525     T    Change bile duct catheter                            1          1     0427   15.3103    1032.01
             47530     T    Revise/reinsert bile tube                            1          1     0427   15.3103    1032.01
             47550     C    Bile duct endoscopy add-on                           1          1       0                           OR
             47552     T    Biliary endoscopy thru skin                          1          1     0152    30.743    2072.26
             47553     T    Biliary endoscopy thru skin                          1          1     0152    30.743    2072.26
             47554     T    Biliary endoscopy thru skin                          1          1     0152    30.743    2072.26
             47555     T    Biliary endoscopy thru skin                          1          1     0152    30.743    2072.26
             47556     T    Biliary endoscopy thru skin                          1          1     0152    30.743    2072.26
             47560     T    Laparoscopy w/cholangio                              1          1     0130    38.054    2565.07
             47561     T    Laparo w/cholangio/biopsy                            1          1     0130    38.054    2565.07
             47562     T    Laparoscopic cholecystectomy                         1          1     0131     46.84     3157.3
             47563     T    Laparo cholecystectomy/graph                         1          1     0131     46.84     3157.3
             47564     T    Laparo cholecystectomy/explr                         1          1     0131     46.84     3157.3
             47570     C    Laparo cholecystoenterostomy                         1          1       0                           OR
             47579     T    Laparoscope proc, biliary                            1          1     0130    38.054    2565.07
             47600     C    Removal of gallbladder                               1          1       0                           OR
             47605     C    Removal of gallbladder                               1          1       0                           OR
             47610     C    Removal of gallbladder                               1          1       0                           OR
             47612     C    Removal of gallbladder                               1          1       0                           OR
             47620     C    Removal of gallbladder                               1          1       0                           OR
             47630     T    Remove bile duct stone                               1          1     0152    30.743    2072.26
             47700     C    Exploration of bile ducts                            1          1       0                           OR
             47701     C    Bile duct revision                                   1          1       0                           OR
             47711     C    Excision of bile duct tumor                          1          1       0                           OR
             47712     C    Excision of bile duct tumor                          1          1       0                           OR
             47715     C    Excision of bile duct cyst                           1          1       0                           OR
             47720     C    Fuse gallbladder & bowel                             1          1       0                           OR
             47721     C    Fuse upper gi structures                             1          1       0                           OR
             47740     C    Fuse gallbladder & bowel                             1          1       0                           OR
             47741     C    Fuse gallbladder & bowel                             1          1       0                           OR
             47760     C    Fuse bile ducts and bowel                            1          1       0                           OR
             47765     C    Fuse liver ducts & bowel                             1          1       0                           OR
             47780     C    Fuse bile ducts and bowel                            1          1       0                           OR
             47785     C    Fuse bile ducts and bowel                            1          1       0                           OR
             47800     C    Reconstruction of bile ducts                         1          1       0                           OR
             47801     C    Placement, bile duct support                         1          1       0                           OR
             47802     C    Fuse liver duct & intestine                          1          1       0                           OR
             47900     C    Suture bile duct injury                              1          1       0                           OR

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 61 of 216                                                                                                                         All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             47999     T    Bile tract surgery procedure                         1          1     0152   30.743    2072.26
             48000     C    Drainage of abdomen                                  1          1       0                          OR
             48001     C    Placement of drain, pancreas                         1          1       0                          OR
             48020     C    Removal of pancreatic stone                          1          1       0                          OR
             48100     C    Biopsy of pancreas, open                             1          1       0                          OR
             48102     T    Needle biopsy, pancreas                              1          1     0685   9.6666    651.59
             48105     C    Resect/debride pancreas                              1          1       0                          OR
             48120     C    Removal of pancreas lesion                           1          1       0                          OR
             48140     C    Partial removal of pancreas                          1          1       0                          OR
             48145     C    Partial removal of pancreas                          1          1       0                          OR
             48146     C    Pancreatectomy                                       1          1       0                          OR
             48148     C    Removal of pancreatic duct                           1          1       0                          OR
             48150     C    Partial removal of pancreas                          1          1       0                          OR
             48152     C    Pancreatectomy                                       1          1       0                          OR
             48153     C    Pancreatectomy                                       1          1       0                          OR
             48154     C    Pancreatectomy                                       1          1       0                          OR
             48155     C    Removal of pancreas                                  1          1       0                          OR
   COE       48160     E    Pancreas removal/transplant                          1          1       0                          OR
             48400     C    Injection, intraop add-on                            1          1       0                          OR
             48500     C    Surgery of pancreatic cyst                           1          1       0                          OR
             48510     C    Drain pancreatic pseudocyst                          1          1       0                          OR
             48511     T    Drain pancreatic pseudocyst                          1          1     0037   15.5003   1044.81
             48520     C    Fuse pancreas cyst and bowel                         1          1       0                          OR
             48540     C    Fuse pancreas cyst and bowel                         1          1       0                          OR
             48545     C    Pancreatorrhaphy                                     1          1       0                          OR
             48547     C    Duodenal exclusion                                   1          1       0                          OR
             48548     C    Fuse pancreas and bowel                              1          1       0                          OR
   COE       48550     E    Donor pancreatectomy                                 1          1       0                          OR
   COE       48551     C    Prep donor pancreas                                  1          1       0                          OR
   COE       48552     C    Prep donor pancreas/venous                           1          1       0                          OR
   COE       48554     C    Transpl allograft pancreas                           1          1       0                          OR
             48556     C    Removal, allograft pancreas                          1          1       0                          OR
             48999     T    Pancreas surgery procedure                           1          1     0004   4.5991    310.01
             49000     C    Exploration of abdomen                               1          1       0                          OR
             49002     C    Reopening of abdomen                                 1          1       0                          OR
             49010     C    Exploration behind abdomen                           1          1       0                          OR
             49020     C    Drain abdominal abscess                              1          1       0                          OR
             49021     T    Drain abdominal abscess                              1          1     0037   15.5003   1044.81
             49040     C    Drain, open, abdom abscess                           1          1       0                          OR
             49041     T    Drain, percut, abdom abscess                         1          1     0037   15.5003   1044.81
             49060     C    Drain, open, retrop abscess                          1          1       0                          OR
             49061     T    Drain, percut, retroper absc                         1          1     0037   15.5003   1044.81
             49062     C    Drain to peritoneal cavity                           1          1       0                          OR
             49080     T    Puncture, peritoneal cavity                          1          1     0070   5.5521    374.24
             49081     T    Removal of abdominal fluid                           1          1     0070   5.5521    374.24
             49180     T    Biopsy, abdominal mass                               1          1     0685   9.6666    651.59
             49203     C    Exc abd tum 5 cm or less                             1          1       0                          OR
             49204     C    Exc abd tum over 5 cm                                1          1       0                          OR
             49205     C    Exc abd tum over 10 cm                               1          1       0                          OR
             49215     C    Excise sacral spine tumor                            1          1       0                          OR
             49220     C    Multiple surgery, abdomen                            1          1       0                          OR
             49250     T    Excision of umbilicus                                1          1     0153   27.1855   1832.47
             49255     C    Removal of omentum                                   1          1       0                          OR
             49320     T    Diag laparo separate proc                            1          1     0130   38.054    2565.07
             49321     T    Laparoscopy, biopsy                                  1          1     0130   38.054    2565.07
             49322     T    Laparoscopy, aspiration                              1          1     0130   38.054    2565.07
             49323     T    Laparo drain lymphocele                              1          1     0130   38.054    2565.07
             49324     T    Lap insertion perm ip cath                           1          1     0130   38.054    2565.07
             49325     T    Lap revision perm ip cath                            1          1     0130   38.054    2565.07
             49326     T    Lap w/omentopexy add-on                              1          1     0130   38.054    2565.07
             49329     T    Laparo proc, abdm/per/oment                          1          1     0130   38.054    2565.07
             49400     N    Air injection into abdomen                           1          1       0
             49402     T    Remove foreign body, adbomen                         1          1     0153   27.1855   1832.47
             49411     X    Ins mark abd/pel for rt perq                         1          1     0310   13.7576    927.34
             49419     T    Insrt abdom cath for chemotx                         1          1     0115   30.9784   2088.13
             49420     T    Insert abdom drain, temp                             1          1     0652   30.4602    2053.2

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 62 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             49421      T   Insert abdom drain, perm                             1          1     0652   30.4602    2053.2
             49422      T   Remove perm cannula/catheter                         1          1     0105   22.9412   1546.37
             49423      T   Exchange drainage catheter                           1          1     0427   15.3103   1032.01
             49424     N    Assess cyst, contrast inject                         1          1       0
             49425     C    Insert abdomen-venous drain                          1          1       0                          OR
             49426      T   Revise abdomen-venous shunt                          1          1     0153   27.1855   1832.47
             49427     N    Injection, abdominal shunt                           1          1       0
             49428     C    Ligation of shunt                                    1          1       0                          OR
             49429      T   Removal of shunt                                     1          1     0105   22.9412   1546.37
             49435      T   Insert subq exten to ip cath                         1          1     0427   15.3103   1032.01
             49436      T   Embedded ip cath exit-site                           1          1     0427   15.3103   1032.01
             49440      T   Place gastrostomy tube perc                          1          1     0141    8.7462    589.55
             49441      T   Place duod/jej tube perc                             1          1     0141    8.7462    589.55
             49442      T   Place cecostomy tube perc                            1          1     0155    14.114    951.37
             49446      T   Change g-tube to g-j perc                            1          1     0141    8.7462    589.55
             49450      T   Replace g/c tube perc                                1          1     0121    6.3742    429.66
             49451      T   Replace duod/jej tube perc                           1          1     0121    6.3742    429.66
             49452      T   Replace g-j tube perc                                1          1     0121    6.3742    429.66
             49460      T   Fix g/colon tube w/device                            1          1     0121    6.3742    429.66
             49465     Q1   Fluoro exam of g/colon tube                          1          1     0276    1.2985     87.53
             49491      T   Rpr hern preemie reduc                               1          1     0154   31.9682   2154.85
             49492      T   Rpr ing hern premie, blocked                         1          1     0154   31.9682   2154.85
             49495      T   Rpr ing hernia baby, reduc                           1          1     0154   31.9682   2154.85
             49496      T   Rpr ing hernia baby, blocked                         1          1     0154   31.9682   2154.85
             49500      T   Rpr ing hernia, init, reduce                         1          1     0154   31.9682   2154.85
             49501      T   Rpr ing hernia, init blocked                         1          1     0154   31.9682   2154.85
             49505      T   Prp i/hern init reduc >5 yr                          1          1     0154   31.9682   2154.85
             49507      T   Prp i/hern init block >5 yr                          1          1     0154   31.9682   2154.85
             49520      T   Rerepair ing hernia, reduce                          1          1     0154   31.9682   2154.85
             49521      T   Rerepair ing hernia, blocked                         1          1     0154   31.9682   2154.85
             49525      T   Repair ing hernia, sliding                           1          1     0154   31.9682   2154.85
             49540      T   Repair lumbar hernia                                 1          1     0154   31.9682   2154.85
             49550      T   Rpr rem hernia, init, reduce                         1          1     0154   31.9682   2154.85
             49553      T   Rpr fem hernia, init blocked                         1          1     0154   31.9682   2154.85
             49555      T   Rerepair fem hernia, reduce                          1          1     0154   31.9682   2154.85
             49557      T   Rerepair fem hernia, blocked                         1          1     0154   31.9682   2154.85
             49560      T   Rpr ventral hern init, reduc                         1          1     0154   31.9682   2154.85
             49561      T   Rpr ventral hern init, block                         1          1     0154   31.9682   2154.85
             49565      T   Rerepair ventrl hern, reduce                         1          1     0154   31.9682   2154.85
             49566      T   Rerepair ventrl hern, block                          1          1     0154   31.9682   2154.85
             49568      T   Hernia repair w/mesh                                 1          1     0154   31.9682   2154.85
             49570      T   Rpr epigastric hern, reduce                          1          1     0154   31.9682   2154.85
             49572      T   Rpr epigastric hern, blocked                         1          1     0154   31.9682   2154.85
             49580      T   Rpr umbil hern, reduc < 5 yr                         1          1     0154   31.9682   2154.85
             49582      T   Rpr umbil hern, block < 5 yr                         1          1     0154   31.9682   2154.85
             49585      T   Rpr umbil hern, reduc > 5 yr                         1          1     0154   31.9682   2154.85
             49587      T   Rpr umbil hern, block > 5 yr                         1          1     0154   31.9682   2154.85
             49590      T   Repair spigelian hernia                              1          1     0154   31.9682   2154.85
             49600      T   Repair umbilical lesion                              1          1     0154   31.9682   2154.85
             49605     C    Repair umbilical lesion                              1          1       0                          OR
             49606     C    Repair umbilical lesion                              1          1       0                          OR
             49610     C    Repair umbilical lesion                              1          1       0                          OR
             49611     C    Repair umbilical lesion                              1          1       0                          OR
             49650      T   Lap ing hernia repair init                           1          1     0131     46.84    3157.3
             49651      T   Lap ing hernia repair recur                          1          1     0131     46.84    3157.3
             49652      T   Lap vent/abd hernia repair                           1          1     0132   72.9582   4917.82
             49653      T   Lap vent/abd hern proc comp                          1          1     0132   72.9582   4917.82
             49654      T   Lap inc hernia repair                                1          1     0132   72.9582   4917.82
             49655      T   Lap inc hern repair comp                             1          1     0132   72.9582   4917.82
             49656      T   Lap inc hernia repair recur                          1          1     0132   72.9582   4917.82
             49657      T   Lap inc hern recur comp                              1          1     0132   72.9582   4917.82
             49659      T   Laparo proc, hernia repair                           1          1     0130    38.054   2565.07
             49900     C    Repair of abdominal wall                             1          1       0                          OR
             49904     C    Omental flap, extra-abdom                            1          1       0                          OR
             49905     C    Omental flap, intra-abdom                            1          1       0                          OR
             49906     C    Free omental flap, microvasc                         1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 63 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW         NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010       2010       Fee            Fee
             49999     T    Abdomen surgery procedure                            1          1     0153   27.1855    1832.47
             50010     C    Exploration of kidney                                1          1       0                           OR
             50020     T    Renal abscess, open drain                            1          1     0162   25.5223    1720.36
             50021     T    Renal abscess, percut drain                          1          1     0037   15.5003    1044.81
             50040     C    Drainage of kidney                                   1          1       0                           OR
             50045     C    Exploration of kidney                                1          1       0                           OR
             50060     C    Removal of kidney stone                              1          1       0                           OR
             50065     C    Incision of kidney                                   1          1       0                           OR
             50070     C    Incision of kidney                                   1          1       0                           OR
             50075     C    Removal of kidney stone                              1          1       0                           OR
             50080     T    Removal of kidney stone                              1          1     0429    46.68     3146.51
             50081     T    Removal of kidney stone                              1          1     0429    46.68     3146.51
             50100     C    Revise kidney blood vessels                          1          1       0                           OR
             50120     C    Exploration of kidney                                1          1       0                           OR
             50125     C    Explore and drain kidney                             1          1       0                           OR
             50130     C    Removal of kidney stone                              1          1       0                           OR
             50135     C    Exploration of kidney                                1          1       0                           OR
             50200     T    Renal biopsy perq                                    1          1     0685    9.6666    651.59
             50205     C    Renal biopsy open                                    1          1       0                           OR
             50220     C    Remove kidney, open                                  1          1       0                           OR
             50225     C    Removal kidney open, complex                         1          1       0                           OR
             50230     C    Removal kidney open, radical                         1          1       0                           OR
             50234     C    Removal of kidney & ureter                           1          1       0                           OR
             50236     C    Removal of kidney & ureter                           1          1       0                           OR
             50240     C    Partial removal of kidney                            1          1       0                           OR
             50250     C    Cryoablate renal mass open                           1          1       0                           OR
             50280     C    Removal of kidney lesion                             1          1       0                           OR
             50290     C    Removal of kidney lesion                             1          1       0                           OR
   COE       50300     C    Remove cadaver donor kidney                          1          1       0                           OR
             50320     C    Remove kidney, living donor                          1          1       0                           OR
   COE       50323     C    Prep cadaver renal allograft                         1          1       0                           OR
   COE       50325     C    Prep donor renal graft                               1          1       0                           OR
   COE       50327     C    Prep renal graft/venous                              1          1       0                           OR
   COE       50328     C    Prep renal graft/arterial                            1          1       0                           OR
   COE       50329     C    Prep renal graft/ureteral                            1          1       0                           OR
             50340     C    Removal of kidney                                    1          1       0                           OR
   COE       50360     C    Transplantation of kidney                            1          1       0                           OR
   COE       50365     C    Transplantation of kidney                            1          1       0                           OR
             50370     C    Remove transplanted kidney                           1          1       0                           OR
   COE       50380     C    Reimplantation of kidney                             1          1       0                           OR
             50382     T    Change ureter stent, percut                          1          1     0162   25.5223    1720.36
             50384     T    Remove ureter stent, percut                          1          1     0161   17.0344    1148.22
             50385     T    Change stent via transureth                          1          1     0162   25.5223    1720.36
             50386     T    Remove stent via transureth                          1          1     0160    7.1342     480.89
             50387     T    Change ext/int ureter stent                          1          1     0427   15.3103    1032.01
             50389     T    Remove renal tube w/fluoro                           1          1     0160    7.1342     480.89
             50390     T    Drainage of kidney lesion                            1          1     0685    9.6666     651.59
             50391     T    Instll rx agnt into rnal tub                         1          1     0126    1.0958      73.86
             50392     T    Insert kidney drain                                  1          1     0161   17.0344    1148.22
             50393     T    Insert ureteral tube                                 1          1     0162   25.5223    1720.36
             50394     N    Injection for kidney x-ray                           1          1       0
             50395     T    Create passage to kidney                             1          1     0162   25.5223    1720.36
             50396     T    Measure kidney pressure                              1          1     0164    2.0194     136.12
             50398     T    Change kidney tube                                   1          1     0427   15.3103    1032.01
             50400     C    Revision of kidney/ureter                            1          1       0                           OR
             50405     C    Revision of kidney/ureter                            1          1       0                           OR
             50500     C    Repair of kidney wound                               1          1       0                           OR
             50520     C    Close kidney-skin fistula                            1          1       0                           OR
             50525     C    Repair renal-abdomen fistula                         1          1       0                           OR
             50526     C    Repair renal-abdomen fistula                         1          1       0                           OR
             50540     C    Revision of horseshoe kidney                         1          1       0                           OR
             50541     T    Laparo ablate renal cyst                             1          1     0130    38.054    2565.07
             50542     T    Laparo ablate renal mass                             1          1     0174   109.9237   7409.52
             50543     T    Laparo partial nephrectomy                           1          1     0131     46.84     3157.3
             50544     T    Laparoscopy, pyeloplasty                             1          1     0130    38.054    2565.07
             50545     C    Laparo radical nephrectomy                           1          1       0                           OR

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 64 of 216                                                                                                                         All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             50546     C    Laparoscopic nephrectomy                             1          1       0                          OR
   COE       50547     C    Laparo removal donor kidney                          1          1       0                          OR
             50548     C    Laparo remove w/ureter                               1          1       0                          OR
             50549     T    Laparoscope proc, renal                              1          1     0130    38.054   2565.07
             50551     T    Kidney endoscopy                                     1          1     0160    7.1342    480.89
             50553     T    Kidney endoscopy                                     1          1     0162   25.5223   1720.36
             50555     T    Kidney endoscopy & biopsy                            1          1     0160    7.1342    480.89
             50557     T    Kidney endoscopy & treatment                         1          1     0162   25.5223   1720.36
             50561     T    Kidney endoscopy & treatment                         1          1     0162   25.5223   1720.36
             50562     T    Renal scope w/tumor resect                           1          1     0160    7.1342    480.89
             50570     T    Kidney endoscopy                                     1          1     0160    7.1342    480.89
             50572     T    Kidney endoscopy                                     1          1     0160    7.1342    480.89
             50574     T    Kidney endoscopy & biopsy                            1          1     0160    7.1342    480.89
             50575     T    Kidney endoscopy                                     1          1     0163   36.2009   2440.16
             50576     T    Kidney endoscopy & treatment                         1          1     0161   17.0344   1148.22
             50580     T    Kidney endoscopy & treatment                         1          1     0161   17.0344   1148.22
             50590     T    Fragmenting of kidney stone                          1          1     0169   41.3626   2788.09
             50592     T    Perc rf ablate renal tumor                           0         NC       0
             50593     T    Perc cryo ablate renal tum                           1          1     0423   51.3618   3462.09
             50600     C    Exploration of ureter                                1          1       0                          OR
             50605     C    Insert ureteral support                              1          1       0                          OR
             50610     C    Removal of ureter stone                              1          1       0                          OR
             50620     C    Removal of ureter stone                              1          1       0                          OR
             50630     C    Removal of ureter stone                              1          1       0                          OR
             50650     C    Removal of ureter                                    1          1       0                          OR
             50660     C    Removal of ureter                                    1          1       0                          OR
             50684     N    Injection for ureter x-ray                           1          1       0
             50686     T    Measure ureter pressure                              1          1     0126    1.0958    73.86
             50688     T    Change of ureter tube/stent                          1          1     0427   15.3103   1032.01
             50690     N    Injection for ureter x-ray                           1          1       0
             50700     C    Revision of ureter                                   1          1       0                          OR
             50715     C    Release of ureter                                    1          1       0                          OR
             50722     C    Release of ureter                                    1          1       0                          OR
             50725     C    Release/revise ureter                                1          1       0                          OR
             50727     T    Revise ureter                                        1          1     0165   20.0243   1349.76
             50728     C    Revise ureter                                        1          1       0                          OR
             50740     C    Fusion of ureter & kidney                            1          1       0                          OR
             50750     C    Fusion of ureter & kidney                            1          1       0                          OR
             50760     C    Fusion of ureters                                    1          1       0                          OR
             50770     C    Splicing of ureters                                  1          1       0                          OR
             50780     C    Reimplant ureter in bladder                          1          1       0                          OR
             50782     C    Reimplant ureter in bladder                          1          1       0                          OR
             50783     C    Reimplant ureter in bladder                          1          1       0                          OR
             50785     C    Reimplant ureter in bladder                          1          1       0                          OR
             50800     C    Implant ureter in bowel                              1          1       0                          OR
             50810     C    Fusion of ureter & bowel                             1          1       0                          OR
             50815     C    Urine shunt to intestine                             1          1       0                          OR
             50820     C    Construct bowel bladder                              1          1       0                          OR
             50825     C    Construct bowel bladder                              1          1       0                          OR
             50830     C    Revise urine flow                                    1          1       0                          OR
             50840     C    Replace ureter by bowel                              1          1       0                          OR
             50845     C    Appendico-vesicostomy                                1          1       0                          OR
             50860     C    Transplant ureter to skin                            1          1       0                          OR
             50900     C    Repair of ureter                                     1          1       0                          OR
             50920     C    Closure ureter/skin fistula                          1          1       0                          OR
             50930     C    Closure ureter/bowel fistula                         1          1       0                          OR
             50940     C    Release of ureter                                    1          1       0                          OR
             50945     T    Laparoscopy ureterolithotomy                         1          1     0131     46.84    3157.3
             50947     T    Laparo new ureter/bladder                            1          1     0131     46.84    3157.3
             50948     T    Laparo new ureter/bladder                            1          1     0131     46.84    3157.3
             50949     T    Laparoscope proc, ureter                             1          1     0130    38.054   2565.07
             50951     T    Endoscopy of ureter                                  1          1     0160    7.1342    480.89
             50953     T    Endoscopy of ureter                                  1          1     0160    7.1342    480.89
             50955     T    Ureter endoscopy & biopsy                            1          1     0162   25.5223   1720.36
             50957     T    Ureter endoscopy & treatment                         1          1     0162   25.5223   1720.36
             50961     T    Ureter endoscopy & treatment                         1          1     0162   25.5223   1720.36

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 65 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             50970     T    Ureter endoscopy                                     1          1     0160    7.1342    480.89
             50972     T    Ureter endoscopy & catheter                          1          1     0160    7.1342    480.89
             50974     T    Ureter endoscopy & biopsy                            1          1     0161   17.0344   1148.22
             50976     T    Ureter endoscopy & treatment                         1          1     0161   17.0344   1148.22
             50980     T    Ureter endoscopy & treatment                         1          1     0162   25.5223   1720.36
             51020     T    Incise & treat bladder                               1          1     0162   25.5223   1720.36
             51030     T    Incise & treat bladder                               1          1     0162   25.5223   1720.36
             51040     T    Incise & drain bladder                               1          1     0162   25.5223   1720.36
             51045     T    Incise bladder/drain ureter                          1          1     0160    7.1342    480.89
             51050     T    Removal of bladder stone                             1          1     0162   25.5223   1720.36
             51060     T    Removal of ureter stone                              1          1     0163   36.2009   2440.16
             51065     T    Remove ureter calculus                               1          1     0162   25.5223   1720.36
             51080     T    Drainage of bladder abscess                          1          1     0008   19.4063    1308.1
             51100     T    Drain bladder by needle                              1          1     0164    2.0194    136.12
             51101     T    Drain bladder by trocar/cath                         1          1     0126    1.0958     73.86
             51102     T    Drain bl w/cath insertion                            1          1     0165   20.0243   1349.76
             51500     T    Removal of bladder cyst                              1          1     0154   31.9682   2154.85
             51520     T    Removal of bladder lesion                            1          1     0162   25.5223   1720.36
             51525     C    Removal of bladder lesion                            1          1       0                          OR
             51530     C    Removal of bladder lesion                            1          1       0                          OR
             51535     T    Repair of ureter lesion                              1          1     0162   25.5223   1720.36
             51550     C    Partial removal of bladder                           1          1       0                          OR
             51555     C    Partial removal of bladder                           1          1       0                          OR
             51565     C    Revise bladder & ureter(s)                           1          1       0                          OR
             51570     C    Removal of bladder                                   1          1       0                          OR
             51575     C    Removal of bladder & nodes                           1          1       0                          OR
             51580     C    Remove bladder/revise tract                          1          1       0                          OR
             51585     C    Removal of bladder & nodes                           1          1       0                          OR
             51590     C    Remove bladder/revise tract                          1          1       0                          OR
             51595     C    Remove bladder/revise tract                          1          1       0                          OR
             51596     C    Remove bladder/create pouch                          1          1       0                          OR
             51597     C    Removal of pelvic structures                         1          1       0                          OR
             51600     N    Injection for bladder x-ray                          1          1       0
             51605     N    Preparation for bladder xray                         1          1       0
             51610     N    Injection for bladder x-ray                          1          1       0
             51700     T    Irrigation of bladder                                1          1     0164   2.0194    136.12
             51701     X    Insert bladder catheter                              1          1     0340   0.6693     45.11
             51702     X    Insert temp bladder cath                             1          1     0340   0.6693     45.11
             51703     T    Insert bladder cath, complex                         1          1     0126   1.0958     73.86
             51705     T    Change of bladder tube                               1          1     0164   2.0194    136.12
             51710     T    Change of bladder tube                               1          1     0121   6.3742    429.66
     L       51715     T    Endoscopic injection/implant                         1          1     0168   31.377     2115
             51720     T    Treatment of bladder lesion                          1          1     0156   3.0214    203.66
             51725     T    Simple cystometrogram                                1          1     0156   3.0214    203.66                   83.81
             51726     T    Complex cystometrogram                               1          1     0156   3.0214    203.66                   138.72
             51727     T    Cystometrogram w/up                                  1          1     0156   3.0214    203.66
             51728     T    Cystometrogram w/vp                                  1          1     0156   3.0214    203.66
             51729     T    Cystometrogram w/vp&up                               1          1     0156   3.0214    203.66
             51736     T    Urine flow measurement                               1          1     0126   1.0958     73.86                   13.56
             51741     T    Electro-uroflowmetry, first                          1          1     0126   1.0958     73.86                   15.56
             51784     T    Anal/urinary muscle study                            1          1     0126   1.0958     73.86                   74.47
             51785     T    Anal/urinary muscle study                            1          1     0164   2.0194    136.12                   85.14
             51792     T    Urinary reflex study                                 1          1     0126   1.0958     73.86                   102.26
             51797     T    Intraabdominal pressure test                         1          1     0164   2.0194    136.12                   58.91
             51798     X    Us urine capacity measure                            1          1     0340   0.6693     45.11
             51800     C    Revision of bladder/urethra                          1          1       0                          OR
             51820     C    Revision of urinary tract                            1          1       0                          OR
             51840     C    Attach bladder/urethra                               1          1       0                          OR
             51841     C    Attach bladder/urethra                               1          1       0                          OR
             51845     T    Repair bladder neck                                  1          1     0202   44.9894   3032.56
             51860     T    Repair of bladder wound                              1          1     0162   25.5223   1720.36
             51865     C    Repair of bladder wound                              1          1       0                          OR
             51880     T    Repair of bladder opening                            1          1     0162   25.5223   1720.36
             51900     C    Repair bladder/vagina lesion                         1          1       0                          OR
             51920     C    Close bladder-uterus fistula                         1          1       0                          OR
             51925     C    Hysterectomy/bladder repair                          1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 66 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             51940     C    Correction of bladder defect                         1          1       0                          OR
             51960     C    Revision of bladder & bowel                          1          1       0                          OR
             51980     C    Construct bladder opening                            1          1       0                          OR
             51990     T    Laparo urethral suspension                           1          1     0131     46.84    3157.3
             51992     T    Laparo sling operation                               1          1     0131     46.84    3157.3
             51999     T    Laparoscope proc, bla                                1          1     0130    38.054   2565.07
             52000     T    Cystoscopy                                           1          1     0160    7.1342    480.89
             52001     T    Cystoscopy, removal of clots                         1          1     0161   17.0344   1148.22
             52005     T    Cystoscopy & ureter catheter                         1          1     0162   25.5223   1720.36
             52007     T    Cystoscopy and biopsy                                1          1     0162   25.5223   1720.36
             52010     T    Cystoscopy & duct catheter                           1          1     0160    7.1342    480.89
             52204     T    Cystoscopy w/biopsy(s)                               1          1     0162   25.5223   1720.36
             52214     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52224     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52234     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52235     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52240     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52250     T    Cystoscopy and radiotracer                           1          1     0162   25.5223   1720.36
             52260     T    Cystoscopy and treatment                             1          1     0161   17.0344   1148.22
             52265     T    Cystoscopy and treatment                             1          1     0160    7.1342    480.89
             52270     T    Cystoscopy & revise urethra                          1          1     0161   17.0344   1148.22
             52275     T    Cystoscopy & revise urethra                          1          1     0162   25.5223   1720.36
             52276     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52277     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52281     T    Cystoscopy and treatment                             1          1     0161   17.0344   1148.22
             52282     T    Cystoscopy, implant stent                            1          1     0163   36.2009   2440.16
             52283     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52285     T    Cystoscopy and treatment                             1          1     0161   17.0344   1148.22
             52290     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52300     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52301     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52305     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52310     T    Cystoscopy and treatment                             1          1     0161   17.0344   1148.22
             52315     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52317     T    Remove bladder stone                                 1          1     0162   25.5223   1720.36
             52318     T    Remove bladder stone                                 1          1     0162   25.5223   1720.36
             52320     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52325     T    Cystoscopy, stone removal                            1          1     0162   25.5223   1720.36
             52327     T    Cystoscopy, inject material                          1          1     0163   36.2009   2440.16
             52330     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52332     T    Cystoscopy and treatment                             1          1     0162   25.5223   1720.36
             52334     T    Create passage to kidney                             1          1     0162   25.5223   1720.36
             52341     T    Cysto w/ureter stricture tx                          1          2     0162   25.5223   1720.36
             52342     T    Cysto w/up stricture tx                              1          1     0162   25.5223   1720.36
             52343     T    Cysto w/renal stricture tx                           1          1     0162   25.5223   1720.36
             52344     T    Cysto/uretero, stricture tx                          1          1     0162   25.5223   1720.36
             52345     T    Cysto/uretero w/up stricture                         1          1     0162   25.5223   1720.36
             52346     T    Cystouretero w/renal strict                          1          1     0162   25.5223   1720.36
             52351     T    Cystouretero & or pyeloscope                         1          1     0162   25.5223   1720.36
             52352     T    Cystouretero w/stone remove                          1          2     0162   25.5223   1720.36
             52353     T    Cystouretero w/lithotripsy                           1          2     0163   36.2009   2440.16
             52354     T    Cystouretero w/biopsy                                1          2     0162   25.5223   1720.36
             52355     T    Cystouretero w/excise tumor                          1          1     0162   25.5223   1720.36
             52400     T    Cystouretero w/congen repr                           1          1     0162   25.5223   1720.36
    PA       52402     T    Cystourethro cut ejacul duct                         1          1     0162   25.5223   1720.36
             52450     T    Incision of prostate                                 1          1     0162   25.5223   1720.36
             52500     T    Revision of bladder neck                             1          1     0162   25.5223   1720.36
             52601     T    Prostatectomy (TURP)                                 1          1     0163   36.2009   2440.16
             52630     T    Remove prostate regrowth                             1          1     0163   36.2009   2440.16
             52640     T    Relieve bladder contracture                          1          1     0162   25.5223   1720.36
             52647     T    Laser surgery of prostate                            1          1     0429     46.68   3146.51
             52648     T    Laser surgery of prostate                            1          1     0429     46.68   3146.51
             52649     T    Prostate laser enucleation                           1          1     0429     46.68   3146.51
             52700     T    Drainage of prostate abscess                         1          1     0162   25.5223   1720.36
             53000     T    Incision of urethra                                  1          1     0166   20.3374   1370.86
             53010     T    Incision of urethra                                  1          1     0166   20.3374   1370.86

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 67 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR        OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010        Fee            Fee
             53020     T    Incision of urethra                                  1          1     0166   20.3374   1370.86
             53025     T    Incision of urethra                                  1          1     0166   20.3374   1370.86
             53040     T    Drainage of urethra abscess                          1          1     0166   20.3374   1370.86
             53060     T    Drainage of urethra abscess                          1          1     0166   20.3374   1370.86
             53080     T    Drainage of urinary leakage                          1          1     0166   20.3374   1370.86
             53085     T    Drainage of urinary leakage                          1          1     0166   20.3374   1370.86
             53200     T    Biopsy of urethra                                    1          1     0166   20.3374   1370.86
             53210     T    Removal of urethra                                   1          1     0168    31.377    2115
             53215     T    Removal of urethra                                   1          1     0166   20.3374   1370.86
             53220     T    Treatment of urethra lesion                          1          1     0168    31.377    2115
             53230     T    Removal of urethra lesion                            1          1     0168    31.377    2115
             53235     T    Removal of urethra lesion                            1          1     0166   20.3374   1370.86
             53240     T    Surgery for urethra pouch                            1          1     0168    31.377    2115
             53250     T    Removal of urethra gland                             1          1     0166   20.3374   1370.86
             53260     T    Treatment of urethra lesion                          1          1     0166   20.3374   1370.86
             53265     T    Treatment of urethra lesion                          1          1     0166   20.3374   1370.86
             53270     T    Removal of urethra gland                             1          1     0166   20.3374   1370.86
             53275     T    Repair of urethra defect                             1          1     0166   20.3374   1370.86
             53400     T    Revise urethra, stage 1                              1          1     0168    31.377    2115
             53405     T    Revise urethra, stage 2                              1          1     0168    31.377    2115
             53410     T    Reconstruction of urethra                            1          1     0168    31.377    2115
             53415     C    Reconstruction of urethra                            1          1       0                           OR
             53420     T    Reconstruct urethra, stage 1                         1          1     0168    31.377     2115
             53425     T    Reconstruct urethra, stage 2                         1          1     0168    31.377     2115
             53430     T    Reconstruction of urethra                            1          1     0168    31.377     2115
             53431     T    Reconstruct urethra/bladder                          1          1     0168    31.377     2115
             53440     S    Male sling procedure                                 1          1     0385   98.0867    6611.63
             53442     T    Remove/revise male sling                             1          1     0168    31.377     2115
             53444     S    Insert tandem cuff                                   1          1     0385   98.0867    6611.63
             53445     S    Insert uro/ves nck sphincter                         1          1     0386    164.32   11076.15
             53446     T    Remove uro sphincter                                 1          1     0168    31.377     2115
             53447     S    Remove/replace ur sphincter                          1          1     0386    164.32   11076.15
             53448     C    Remov/replc ur sphinctr comp                         1          1       0                           OR
             53449     T    Repair uro sphincter                                 1          1     0168    31.377     2115
             53450     T    Revision of urethra                                  1          1     0168    31.377     2115
             53460     T    Revision of urethra                                  1          1     0166   20.3374   1370.86
             53500     T    Urethrlys, transvag w/ scope                         1          1     0168    31.377     2115
             53502     T    Repair of urethra injury                             1          1     0166   20.3374   1370.86
             53505     T    Repair of urethra injury                             1          1     0168    31.377     2115
             53510     T    Repair of urethra injury                             1          1     0166   20.3374   1370.86
             53515     T    Repair of urethra injury                             1          1     0168    31.377     2115
             53520     T    Repair of urethra defect                             1          1     0168    31.377     2115
             53600     T    Dilate urethra stricture                             1          1     0156    3.0214    203.66
             53601     T    Dilate urethra stricture                             1          1     0126    1.0958     73.86
             53605     T    Dilate urethra stricture                             1          1     0161   17.0344   1148.22
             53620     T    Dilate urethra stricture                             1          1     0165   20.0243   1349.76
             53621     T    Dilate urethra stricture                             1          1     0164    2.0194    136.12
             53660     T    Dilation of urethra                                  1          1     0126    1.0958     73.86
             53661     T    Dilation of urethra                                  1          1     0126    1.0958     73.86
             53665     T    Dilation of urethra                                  1          1     0166   20.3374   1370.86
             53850     T    Prostatic microwave thermotx                         1          1     0429     46.68   3146.51
             53852     T    Prostatic rf thermotx                                1          1     0429     46.68   3146.51
             53855     T    Insert prost urethral stent                          1          1     0164    2.0194    136.12
             53899     T    Urology surgery procedure                            1          1     0126    1.0958     73.86
             54000     T    Slitting of prepuce                                  1          1     0166   20.3374   1370.86
             54001     T    Slitting of prepuce                                  1          1     0166   20.3374   1370.86
             54015     T    Drain penis lesion                                   1          1     0008   19.4063    1308.1
             54050     T    Destruction, penis lesion(s)                         1          1     0013    0.8789     59.24
             54055     T    Destruction, penis lesion(s)                         1          1     0017   21.2653   1433.41
             54056     T    Cryosurgery, penis lesion(s)                         1          1     0013    0.8789     59.24
             54057     T    Laser surg, penis lesion(s)                          1          1     0017   21.2653   1433.41
             54060     T    Excision of penis lesion(s)                          1          1     0017   21.2653   1433.41
             54065     T    Destruction, penis lesion(s)                         1          1     0017   21.2653   1433.41
             54100     T    Biopsy of penis                                      1          1     0021   17.4975   1179.44
             54105     T    Biopsy of penis                                      1          1     0022    23.388   1576.49
             54110     T    Treatment of penis lesion                            1          1     0181   34.8837   2351.37

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 68 of 216                                                                                                                         All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR        OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010        Fee            Fee
             54111     T    Treat penis lesion, graft                            1          1     0181   34.8837   2351.37
             54112     T    Treat penis lesion, graft                            1          1     0181   34.8837   2351.37
             54115     T    Treatment of penis lesion                            1          1     0008   19.4063    1308.1
             54120     T    Partial removal of penis                             1          1     0181   34.8837   2351.37
             54125     C    Removal of penis                                     1          1       0                           OR
             54130     C    Remove penis & nodes                                 1          1       0                           OR
             54135     C    Remove penis & nodes                                 1          1       0                           OR
     L       54150     T    Circumcision w/regionl block                         1          1     0183   23.2838   1569.47
     L       54160     T    Circumcision, neonate                                1          1     0183   23.2838   1569.47
     L       54161     T    Circum 28 days or older                              1          1     0183   23.2838   1569.47
             54162     T    Lysis penil circumic lesion                          1          1     0183   23.2838   1569.47
             54163     T    Repair of circumcision                               1          1     0183   23.2838   1569.47
             54164     T    Frenulotomy of penis                                 1          1     0183   23.2838   1569.47
             54200     T    Treatment of penis lesion                            1          1     0164    2.0194    136.12
             54205     T    Treatment of penis lesion                            1          1     0181   34.8837   2351.37
             54220     T    Treatment of penis lesion                            1          1     0164    2.0194    136.12
             54230     N    Prepare penis study                                  1          1       0
             54231     T    Dynamic cavernosometry                               1          1     0165   20.0243   1349.76
             54235     T    Penile injection                                     1          1     0164    2.0194    136.12
             54240     T    Penis study                                          1          1     0126    1.0958     73.86                    20.45
             54250     T    Penis study                                          0         NC       0
             54300     T    Revision of penis                                    1          1     0181   34.8837   2351.37
             54304     T    Revision of penis                                    1          1     0181   34.8837   2351.37
             54308     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54312     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54316     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54318     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54322     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54324     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54326     T    Reconstruction of urethra                            1          1     0181   34.8837   2351.37
             54328     T    Revise penis/urethra                                 1          1     0181   34.8837   2351.37
             54332     T    Revise penis/urethra                                 1          1     0181   34.8837   2351.37
             54336     T    Revise penis/urethra                                 1          1     0181   34.8837   2351.37
             54340     T    Secondary urethral surgery                           1          1     0181   34.8837   2351.37
             54344     T    Secondary urethral surgery                           1          1     0181   34.8837   2351.37
             54348     T    Secondary urethral surgery                           1          1     0181   34.8837   2351.37
             54352     T    Reconstruct urethra/penis                            1          1     0181   34.8837   2351.37
             54360     T    Penis plastic surgery                                1          1     0181   34.8837   2351.37
             54380     T    Repair penis                                         1          1     0181   34.8837   2351.37
             54385     T    Repair penis                                         1          1     0181   34.8837   2351.37
             54390     C    Repair penis and bladder                             1          1       0                           OR
             54400     S    Insert semi-rigid prosthesis                         1          1     0385   98.0867   6611.63
             54401     S    Insert self-contd prosthesis                         0         NC       0
             54405     S    Insert multi-comp penis pros                         0         NC       0
             54406     T    Remove muti-comp penis pros                          1          1     0181   34.8837   2351.37
             54408     T    Repair multi-comp penis pros                         0         NC       0
             54410     S    Remove/replace penis prosth                          0         NC       0
             54411     C    Remov/replc penis pros, comp                         0         NC       0
             54415     T    Remove self-contd penis pros                         1          1     0181   34.8837    2351.37
    PA       54416     S    Remv/repl penis contain pros                         1          1     0386    164.32   11076.15
    PA       54417     C    Remv/replc penis pros, compl                         1          1       0                           OR
             54420     T    Revision of penis                                    1          1     0181   34.8837   2351.37
             54430     C    Revision of penis                                    1          1       0                           OR
             54435     T    Revision of penis                                    1          1     0181   34.8837   2351.37
             54440     T    Repair of penis                                      1          1     0181   34.8837   2351.37
             54450     T    Preputial stretching                                 1          1     0156    3.0214    203.66
             54500     T    Biopsy of testis                                     1          1     0037   15.5003   1044.81
             54505     T    Biopsy of testis                                     1          1     0183   23.2838   1569.47
             54512     T    Excise lesion testis                                 1          1     0183   23.2838   1569.47
             54520     T    Removal of testis                                    1          1     0183   23.2838   1569.47
             54522     T    Orchiectomy, partial                                 1          1     0183   23.2838   1569.47
             54530     T    Removal of testis                                    1          1     0154   31.9682   2154.85
             54535     T    Extensive testis surgery                             1          1     0181   34.8837   2351.37
             54550     T    Exploration for testis                               1          1     0154   31.9682   2154.85
             54560     T    Exploration for testis                               1          1     0183   23.2838   1569.47
             54600     T    Reduce testis torsion                                1          1     0183   23.2838   1569.47

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 69 of 216                                                                                                                         All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW         NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010       2010       Fee            Fee
             54620      T   Suspension of testis                                 1          1     0183   23.2838    1569.47
             54640      T   Suspension of testis                                 1          1     0154   31.9682    2154.85
             54650     C    Orchiopexy (Fowler-Stephens)                         1          1       0                           OR
             54660      T   Revision of testis                                   0         NC       0
             54670      T   Repair testis injury                                 1          1     0183   23.2838    1569.47
             54680      T   Relocation of testis(es)                             1          1     0183   23.2838    1569.47
             54690      T   Laparoscopy, orchiectomy                             1          1     0131     46.84     3157.3
             54692      T   Laparoscopy, orchiopexy                              1          1     0132   72.9582    4917.82
             54699      T   Laparoscope proc, testis                             1          1     0130    38.054    2565.07
             54700      T   Drainage of scrotum                                  1          1     0183   23.2838    1569.47
             54800      T   Biopsy of epididymis                                 1          1     0004    4.5991     310.01
             54830      T   Remove epididymis lesion                             1          1     0183   23.2838    1569.47
             54840      T   Remove epididymis lesion                             1          1     0183   23.2838    1569.47
             54860      T   Removal of epididymis                                1          1     0183   23.2838    1569.47
             54861      T   Removal of epididymis                                1          1     0183   23.2838    1569.47
             54865      T   Explore epididymis                                   1          1     0183   23.2838    1569.47
             54900      T   Fusion of spermatic ducts                            1          1     0183   23.2838    1569.47
             54901      T   Fusion of spermatic ducts                            1          1     0183   23.2838    1569.47
             55000      T   Drainage of hydrocele                                1          1     0004    4.5991     310.01
             55040      T   Removal of hydrocele                                 1          1     0154   31.9682    2154.85
             55041      T   Removal of hydroceles                                1          1     0154   31.9682    2154.85
             55060      T   Repair of hydrocele                                  1          1     0183   23.2838    1569.47
             55100      T   Drainage of scrotum abscess                          1          1     0007   12.6217     850.78
             55110      T   Explore scrotum                                      1          1     0183   23.2838    1569.47
             55120      T   Removal of scrotum lesion                            1          1     0183   23.2838    1569.47
             55150      T   Removal of scrotum                                   1          1     0183   23.2838    1569.47
             55175      T   Revision of scrotum                                  1          1     0183   23.2838    1569.47
             55180      T   Revision of scrotum                                  1          1     0183   23.2838    1569.47
             55200      T   Incision of sperm duct                               1          1     0183   23.2838    1569.47
             55250      T   Removal of sperm duct(s)                             1          1     0183   23.2838    1569.47
             55300     N    Prepare, sperm duct x-ray                            1          1       0
             55400      T   Repair of sperm duct                                 0         NC       0
             55450      T   Ligation of sperm duct                               1          1     0183   23.2838    1569.47
             55500      T   Removal of hydrocele                                 1          1     0183   23.2838    1569.47
             55520      T   Removal of sperm cord lesion                         1          1     0183   23.2838    1569.47
             55530      T   Revise spermatic cord veins                          1          1     0183   23.2838    1569.47
             55535      T   Revise spermatic cord veins                          1          1     0154   31.9682    2154.85
             55540      T   Revise hernia & sperm veins                          1          1     0154   31.9682    2154.85
             55550      T   Laparo ligate spermatic vein                         1          1     0131     46.84     3157.3
             55559      T   Laparo proc, spermatic cord                          1          1     0130    38.054    2565.07
             55600      T   Incise sperm duct pouch                              1          1     0183   23.2838    1569.47
             55605     C    Incise sperm duct pouch                              1          1       0                           OR
             55650     C    Remove sperm duct pouch                              1          1       0                           OR
             55680      T   Remove sperm pouch lesion                            1          1     0183   23.2838    1569.47
             55700      T   Biopsy of prostate                                   1          1     0184   12.4313     837.94
             55705      T   Biopsy of prostate                                   1          1     0184   12.4313     837.94
             55706      T   Prostate saturation sampling                         1          1     0184   12.4313     837.94
             55720      T   Drainage of prostate abscess                         1          1     0162   25.5223    1720.36
             55725      T   Drainage of prostate abscess                         1          1     0162   25.5223    1720.36
             55801     C    Removal of prostate                                  1          1       0                           OR
             55810     C    Extensive prostate surgery                           1          1       0                           OR
             55812     C    Extensive prostate surgery                           1          1       0                           OR
             55815     C    Extensive prostate surgery                           1          1       0                           OR
             55821     C    Removal of prostate                                  1          1       0                           OR
             55831     C    Removal of prostate                                  1          1       0                           OR
             55840     C    Extensive prostate surgery                           1          1       0                           OR
             55842     C    Extensive prostate surgery                           1          1       0                           OR
             55845     C    Extensive prostate surgery                           1          1       0                           OR
             55860      T   Surgical exposure, prostate                          1          1     0165   20.0243    1349.76
             55862     C    Extensive prostate surgery                           1          1       0                           OR
             55865     C    Extensive prostate surgery                           1          1       0                           OR
             55866     C    Laparo radical prostatectomy                         1          1       0                           OR
             55870      T   Electroejaculation                                   0         NC       0
    PA       55873      T   Cryoablate prostate                                  1          1     0674   113.8626   7675.02
             55875     Q3   Transperi needle place, pros                         1          1     0163    36.2009   2440.16
             55876      X   Place rt device/marker, pros                         1          1     0310    13.7576    927.34

                                                                                                                               CPT Codes and Descriptions
                                                                                                                                            Copyright 2010
                                                                                                                              American Medical Association
Page 70 of 216                                                                                                                         All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             55899     T    Genital surgery procedure                            1          1     0126    1.0958    73.86
             55920     T    Place needles pelvic for rt                          1          1     0153   27.1855   1832.47
             55970     E    Sex transformation, M to F                           0         NC       0
             55980     E    Sex transformation, F to M                           0         NC       0
             56405     T    I & D of vulva/perineum                              1          1     0188    1.5277    102.98
             56420     T    Drainage of gland abscess                            1          1     0188    1.5277    102.98
             56440     T    Surgery for vulva lesion                             1          1     0193   20.0452   1351.17
             56441     T    Lysis of labial lesion(s)                            1          1     0193   20.0452   1351.17
             56442     T    Hymenotomy                                           1          1     0193   20.0452   1351.17
             56501     T    Destroy, vulva lesions, sim                          1          1     0017   21.2653   1433.41
             56515     T    Destroy vulva lesion/s compl                         1          1     0017   21.2653   1433.41
             56605     T    Biopsy of vulva/perineum                             1          1     0189    3.4085    229.75
             56606     T    Biopsy of vulva/perineum                             1          1     0188    1.5277    102.98
             56620     T    Partial removal of vulva                             1          1     0193   20.0452   1351.17
             56625     T    Complete removal of vulva                            1          1     0193   20.0452   1351.17
             56630     C    Extensive vulva surgery                              1          1       0                          OR
             56631     C    Extensive vulva surgery                              1          1       0                          OR
             56632     C    Extensive vulva surgery                              1          1       0                          OR
             56633     C    Extensive vulva surgery                              1          1       0                          OR
             56634     C    Extensive vulva surgery                              1          1       0                          OR
             56637     C    Extensive vulva surgery                              1          1       0                          OR
             56640     C    Extensive vulva surgery                              1          1       0                          OR
             56700     T    Partial removal of hymen                             1          1     0193   20.0452   1351.17
             56740     T    Remove vagina gland lesion                           1          1     0193   20.0452   1351.17
             56800     T    Repair of vagina                                     1          1     0193   20.0452   1351.17
             56805     T    Repair clitoris                                      1          1     0193   20.0452   1351.17
             56810     T    Repair of perineum                                   1          1     0193   20.0452   1351.17
             56820     T    Exam of vulva w/scope                                1          1     0188    1.5277    102.98
             56821     T    Exam/biopsy of vulva w/scope                         1          1     0188    1.5277    102.98
             57000     T    Exploration of vagina                                1          1     0193   20.0452   1351.17
             57010     T    Drainage of pelvic abscess                           1          1     0193   20.0452   1351.17
             57020     T    Drainage of pelvic fluid                             1          1     0192    6.7949    458.02
             57022     T    I & d vaginal hematoma, pp                           1          1     0007   12.6217    850.78
             57023     T    I & d vag hematoma, non-ob                           1          1     0008   19.4063    1308.1
             57061     T    Destroy vag lesions, simple                          1          1     0193   20.0452   1351.17
             57065     T    Destroy vag lesions, complex                         1          1     0193   20.0452   1351.17
             57100     T    Biopsy of vagina                                     1          1     0192    6.7949    458.02
             57105     T    Biopsy of vagina                                     1          1     0193   20.0452   1351.17
             57106     T    Remove vagina wall, partial                          1          1     0193   20.0452   1351.17
             57107     T    Remove vagina tissue, part                           1          1     0195   35.2666   2377.18
             57109     T    Vaginectomy partial w/nodes                          1          1     0195   35.2666   2377.18
             57110     C    Remove vagina wall, complete                         1          1       0                          OR
             57111     C    Remove vagina tissue, compl                          1          1       0                          OR
             57112     C    Vaginectomy w/nodes, compl                           1          1       0                          OR
             57120     T    Closure of vagina                                    1          1     0195   35.2666   2377.18
             57130     T    Remove vagina lesion                                 1          1     0193   20.0452   1351.17
             57135     T    Remove vagina lesion                                 1          1     0193   20.0452   1351.17
             57150     T    Treat vagina infection                               1          1     0188    1.5277    102.98
             57155     T    Insert uteri tandems/ovoids                          1          1     0192    6.7949    458.02
             57160     T    Insert pessary/other device                          1          1     0188    1.5277    102.98
             57170     T    Fitting of diaphragm/cap                             1          1     0191     0.132      8.9
             57180     T    Treat vaginal bleeding                               1          1     0188    1.5277    102.98
             57200     T    Repair of vagina                                     1          1     0193   20.0452   1351.17
             57210     T    Repair vagina/perineum                               1          1     0193   20.0452   1351.17
             57220     T    Revision of urethra                                  1          1     0202   44.9894   3032.56
             57230     T    Repair of urethral lesion                            1          1     0195   35.2666   2377.18
             57240     T    Repair bladder & vagina                              1          1     0195   35.2666   2377.18
             57250     T    Repair rectum & vagina                               1          1     0195   35.2666   2377.18
             57260     T    Repair of vagina                                     1          1     0195   35.2666   2377.18
             57265     T    Extensive repair of vagina                           1          1     0202   44.9894   3032.56
             57267     T    Insert mesh/pelvic flr addon                         1          1     0195   35.2666   2377.18
             57268     T    Repair of bowel bulge                                1          1     0195   35.2666   2377.18
             57270     C    Repair of bowel pouch                                1          1       0                          OR
             57280     C    Suspension of vagina                                 1          1       0                          OR
             57282     T    Colpopexy, extraperitoneal                           1          1     0202   44.9894   3032.56
             57283     T    Colpopexy, intraperitoneal                           1          1     0202   44.9894   3032.56

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 71 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             57284     T    Repair paravag defect, open                          1          1     0202   44.9894   3032.56
             57285     T    Repair paravag defect, vag                           1          1     0202   44.9894   3032.56
             57287     T    Revise/remove sling repair                           1          1     0195   35.2666   2377.18
             57288     T    Repair bladder defect                                1          1     0202   44.9894   3032.56
             57289     T    Repair bladder & vagina                              1          1     0195   35.2666   2377.18
             57291     T    Construction of vagina                               0         NC       0
             57292     T    Construct vagina with graft                          0         NC       0
             57295     T    Revise vag graft via vagina                          1          1     0193   20.0452   1351.17
             57296     C    Revise vag graft, open abd                           1          1       0                          OR
             57300     T    Repair rectum-vagina fistula                         1          1     0195   35.2666   2377.18
             57305     C    Repair rectum-vagina fistula                         1          1       0                          OR
             57307     C    Fistula repair & colostomy                           1          1       0                          OR
             57308     C    Fistula repair, transperine                          1          1       0                          OR
             57310     T    Repair urethrovaginal lesion                         1          1     0202   44.9894   3032.56
             57311     C    Repair urethrovaginal lesion                         1          1       0                          OR
             57320     T    Repair bladder-vagina lesion                         1          1     0195   35.2666   2377.18
             57330     T    Repair bladder-vagina lesion                         1          1     0195   35.2666   2377.18
             57335     T    Repair vagina                                        1          1     0195   35.2666   2377.18
             57400     T    Dilation of vagina                                   1          1     0193   20.0452   1351.17
             57410     T    Pelvic examination                                   1          1     0193   20.0452   1351.17
             57415     T    Remove vaginal foreign body                          1          1     0193   20.0452   1351.17
             57420     T    Exam of vagina w/scope                               1          1     0189    3.4085    229.75
             57421     T    Exam/biopsy of vag w/scope                           1          1     0189    3.4085    229.75
             57423     T    Repair paravag defect, lap                           1          1     0202   44.9894   3032.56
             57425     T    Laparoscopy, surg, colpopexy                         1          1     0130    38.054   2565.07
    PA       57426     T    Revise prosth vag graft lap                          1          1     0193   20.0452   1351.17
             57452     T    Exam of cervix w/scope                               1          1     0188    1.5277    102.98
             57454     T    Bx/curett of cervix w/scope                          1          1     0189    3.4085    229.75
             57455     T    Biopsy of cervix w/scope                             1          1     0189    3.4085    229.75
             57456     T    Endocerv curettage w/scope                           1          1     0189    3.4085    229.75
             57460     T    Bx of cervix w/scope, leep                           1          1     0193   20.0452   1351.17
             57461     T    Conz of cervix w/scope, leep                         1          1     0193   20.0452   1351.17
             57500     T    Biopsy of cervix                                     1          1     0192    6.7949    458.02
             57505     T    Endocervical curettage                               1          1     0192    6.7949    458.02
             57510     T    Cauterization of cervix                              1          1     0193   20.0452   1351.17
             57511     T    Cryocautery of cervix                                1          1     0188    1.5277    102.98
             57513     T    Laser surgery of cervix                              1          1     0193   20.0452   1351.17
             57520     T    Conization of cervix                                 1          1     0193   20.0452   1351.17
             57522     T    Conization of cervix                                 1          1     0193   20.0452   1351.17
             57530     T    Removal of cervix                                    1          1     0195   35.2666   2377.18
             57531     C    Removal of cervix, radical                           1          1       0                          OR
             57540     C    Removal of residual cervix                           1          1       0                          OR
             57545     C    Remove cervix/repair pelvis                          1          1       0                          OR
             57550     T    Removal of residual cervix                           1          1     0195   35.2666   2377.18
             57555     T    Remove cervix/repair vagina                          1          1     0195   35.2666   2377.18
             57556     T    Remove cervix, repair bowel                          1          1     0202   44.9894   3032.56
             57558     T    D&c of cervical stump                                1          1     0193   20.0452   1351.17
             57700     T    Revision of cervix                                   1          1     0193   20.0452   1351.17
             57720     T    Revision of cervix                                   1          1     0193   20.0452   1351.17
             57800     T    Dilation of cervical canal                           1          1     0193   20.0452   1351.17
             58100     T    Biopsy of uterus lining                              1          1     0188    1.5277    102.98
             58110     N    Bx done w/colposcopy add-on                          1          1       0
             58120     T    Dilation and curettage                               1          1     0193   20.0452   1351.17
             58140     C    Myomectomy abdom method                              1          1       0                          OR
             58145     T    Myomectomy vag method                                1          1     0195   35.2666   2377.18
             58146     C    Myomectomy abdom complex                             1          1       0                          OR
             58150     C    Total hysterectomy                                   1          1       0                          OR
             58152     C    Total hysterectomy                                   1          1       0                          OR
             58180     C    Partial hysterectomy                                 1          1       0                          OR
             58200     C    Extensive hysterectomy                               1          1       0                          OR
             58210     C    Extensive hysterectomy                               1          1       0                          OR
             58240     C    Removal of pelvis contents                           1          1       0                          OR
             58260     T    Vaginal hysterectomy                                 1          1     0195   35.2666   2377.18
             58262     T    Vag hyst including t/o                               1          1     0195   35.2666   2377.18
             58263     T    Vag hyst w/t/o & vag repair                          1          1     0195   35.2666   2377.18
             58267     C    Vag hyst w/urinary repair                            1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 72 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             58270     T    Vag hyst w/enterocele repair                         1          1     0195   35.2666   2377.18
             58275     C    Hysterectomy/revise vagina                           1          1       0                          OR
             58280     C    Hysterectomy/revise vagina                           1          1       0                          OR
             58285     C    Extensive hysterectomy                               1          1       0                          OR
             58290     T    Vag hyst complex                                     1          1     0202   44.9894   3032.56
             58291     T    Vag hyst incl t/o, complex                           1          1     0202   44.9894   3032.56
             58292     T    Vag hyst t/o & repair, compl                         1          1     0202   44.9894   3032.56
             58293     C    Vag hyst w/uro repair, compl                         1          1       0                          OR
             58294     T    Vag hyst w/enterocele, compl                         1          1     0202   44.9894   3032.56
             58300     E    Insert intrauterine device                           1          1       0                          OR
             58301     T    Remove intrauterine device                           1          1     0188   1.5277    102.98
             58321     T    Artificial insemination                              0         NC       0
             58322     T    Artificial insemination                              0         NC       0
             58323     T    Sperm washing                                        0         NC       0
             58340     N    Catheter for hysterography                           1          1       0
             58345     T    Reopen fallopian tube                                0         NC       0
             58346     T    Insert heyman uteri capsule                          1          1     0193   20.0452   1351.17
             58350     T    Reopen fallopian tube                                0         NC       0
             58353     T    Endometr ablate, thermal                             1          1     0195   35.2666   2377.18
    PA       58356     T    Endometrial cryoablation                             1          1     0202   44.9894   3032.56
             58400     C    Suspension of uterus                                 1          1       0                          OR
             58410     C    Suspension of uterus                                 1          1       0                          OR
             58520     C    Repair of ruptured uterus                            1          1       0                          OR
             58540     C    Revision of uterus                                   1          1       0                          OR
             58541     T    Lsh, uterus 250 g or less                            1          1     0132   72.9582   4917.82
             58542     T    Lsh w/t/o ut 250 g or less                           1          1     0132   72.9582   4917.82
             58543     T    Lsh uterus above 250 g                               1          1     0132   72.9582   4917.82
             58544     T    Lsh w/t/o uterus above 250 g                         1          1     0132   72.9582   4917.82
             58545     T    Laparoscopic myomectomy                              1          1     0130    38.054   2565.07
             58546     T    Laparo-myomectomy, complex                           1          1     0131     46.84    3157.3
             58548     C    Lap radical hyst                                     1          1       0                          OR
             58550     T    Laparo-asst vag hysterectomy                         1          1     0132   72.9582   4917.82
             58552     T    Laparo-vag hyst incl t/o                             1          1     0131    46.84     3157.3
             58553     T    Laparo-vag hyst, complex                             1          1     0131    46.84     3157.3
             58554     T    Laparo-vag hyst w/t/o, compl                         1          1     0131    46.84     3157.3
             58555     T    Hysteroscopy, dx, sep proc                           1          1     0190   22.5926   1522.88
             58558     T    Hysteroscopy, biopsy                                 1          1     0190   22.5926   1522.88
             58559     T    Hysteroscopy, lysis                                  1          1     0190   22.5926   1522.88
             58560     T    Hysteroscopy, resect septum                          1          1     0387   37.2199   2508.84
             58561     T    Hysteroscopy, remove myoma                           1          1     0387   37.2199   2508.84
             58562     T    Hysteroscopy, remove fb                              1          1     0190   22.5926   1522.88
             58563     T    Hysteroscopy, ablation                               1          1     0387   37.2199   2508.84
             58565     T    Hysteroscopy, sterilization                          0         NC       0
             58570     T    Tlh, uterus 250 g or less                            1          1     0131     46.84    3157.3
             58571     T    Tlh w/t/o 250 g or less                              1          1     0131     46.84    3157.3
             58572     T    Tlh, uterus over 250 g                               1          1     0131     46.84    3157.3
             58573     T    Tlh w/t/o uterus over 250 g                          1          1     0131     46.84    3157.3
             58578     T    Laparo proc, uterus                                  1          1     0130    38.054   2565.07
             58579     T    Hysteroscope procedure                               1          1     0190   22.5926   1522.88
             58600     T    Division of fallopian tube                           1          1     0195   35.2666   2377.18
             58605     C    Division of fallopian tube                           1          1       0                          OR
             58611     C    Ligate oviduct(s) add-on                             1          1       0                          OR
             58615     T    Occlude fallopian tube(s)                            1          1     0193   20.0452   1351.17
             58660     T    Laparoscopy, lysis                                   1          1     0131    46.84     3157.3
             58661     T    Laparoscopy, remove adnexa                           1          1     0131    46.84     3157.3
             58662     T    Laparoscopy, excise lesions                          1          1     0131    46.84     3157.3
             58670     T    Laparoscopy, tubal cautery                           1          1     0131    46.84     3157.3
             58671     T    Laparoscopy, tubal block                             1          1     0131    46.84     3157.3
             58672     T    Laparoscopy, fimbrioplasty                           0         NC       0
             58673     T    Laparoscopy, salpingostomy                           1          1     0131    46.84     3157.3
             58679     T    Laparo proc, oviduct-ovary                           1          1     0130   38.054    2565.07
             58700     C    Removal of fallopian tube                            1          1       0                          OR
             58720     C    Removal of ovary/tube(s)                             1          1       0                          OR
             58740     C    Adhesiolysis tube, ovary                             1          1       0                          OR
             58750     C    Repair oviduct                                       0         NC       0
             58752     C    Revise ovarian tube(s)                               0         NC       0

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 73 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             58760     C    Fimbrioplasty                                        0         NC       0
             58770     T    Create new tubal opening                             1          1     0195   35.2666   2377.18
             58800     T    Drainage of ovarian cyst(s)                          1          1     0193   20.0452   1351.17
             58805     T    Drainage of ovarian cyst(s)                          1          1     0195   35.2666   2377.18
             58820     T    Drain ovary abscess, open                            1          1     0195   35.2666   2377.18
             58822     C    Drain ovary abscess, percut                          1          1       0                          OR
             58823     T    Drain pelvic abscess, percut                         1          1     0193   20.0452   1351.17
             58825     C    Transposition, ovary(s)                              1          1       0                          OR
             58900     T    Biopsy of ovary(s)                                   1          1     0193   20.0452   1351.17
             58920     T    Partial removal of ovary(s)                          1          1     0195   35.2666   2377.18
             58925     T    Removal of ovarian cyst(s)                           1          1     0195   35.2666   2377.18
             58940     C    Removal of ovary(s)                                  1          1       0                          OR
             58943     C    Removal of ovary(s)                                  1          1       0                          OR
             58950     C    Resect ovarian malignancy                            1          1       0                          OR
             58951     C    Resect ovarian malignancy                            1          1       0                          OR
             58952     C    Resect ovarian malignancy                            1          1       0                          OR
             58953     C    Tah, rad dissect for debulk                          1          1       0                          OR
             58954     C    Tah rad debulk/lymph remove                          1          1       0                          OR
             58956     C    Bso, omentectomy w/tah                               1          1       0                          OR
             58957     C    Resect recurrent gyn mal                             1          1       0                          OR
             58958     C    Resect recur gyn mal w/lym                           1          1       0                          OR
             58960     C    Exploration of abdomen                               1          1       0                          OR
             58970     T    Retrieval of oocyte                                  0         NC       0
             58974     T    Transfer of embryo                                   0         NC       0
             58976     T    Transfer of embryo                                   0         NC       0
             58999     T    Genital surgery procedure                            1          1     0191    0.132      8.9
             59000     T    Amniocentesis, diagnostic                            1          1     0189   3.4085    229.75
             59001     T    Amniocentesis, therapeutic                           1          1     0192   6.7949    458.02
             59012     T    Fetal cord puncture,prenatal                         1          1     0189   3.4085    229.75
             59015     T    Chorion biopsy                                       1          1     0189   3.4085    229.75
             59020     T    Fetal contract stress test                           1          1     0188   1.5277    102.98                    17.78
             59025     T    Fetal non-stress test                                1          1     0188   1.5277    102.98                    18.71
             59030     T    Fetal scalp blood sample                             1          1     0189   3.4085    229.75
             59050     M    Fetal monitor w/report                               1          1       0                         29.34
             59051     B    Fetal monitor/interpret only                         0         NC       0
             59070     T    Transabdom amnioinfus w/us                           1          1     0188    1.5277    102.98
             59072     T    Umbilical cord occlud w/us                           1          1     0189    3.4085    229.75
             59074     T    Fetal fluid drainage w/us                            1          1     0189    3.4085    229.75
             59076     T    Fetal shunt placement, w/us                          1          1     0189    3.4085    229.75
             59100     T    Remove uterus lesion                                 1          1     0195   35.2666   2377.18
             59120     C    Treat ectopic pregnancy                              1          1       0                          OR
             59121     C    Treat ectopic pregnancy                              1          1       0                          OR
             59130     C    Treat ectopic pregnancy                              1          1       0                          OR
             59135     C    Treat ectopic pregnancy                              1          1       0                          OR
             59136     C    Treat ectopic pregnancy                              1          1       0                          OR
             59140     C    Treat ectopic pregnancy                              1          1       0                          OR
             59150     T    Treat ectopic pregnancy                              1          1     0131     46.84    3157.3
             59151     T    Treat ectopic pregnancy                              1          1     0131     46.84    3157.3
             59160     T    D & c after delivery                                 1          1     0193   20.0452   1351.17
             59200     T    Insert cervical dilator                              1          1     0188    1.5277    102.98
             59300     T    Episiotomy or vaginal repair                         1          1     0193   20.0452   1351.17
             59320     T    Revision of cervix                                   1          1     0193   20.0452   1351.17
             59325     C    Revision of cervix                                   1          1       0                          OR
             59350     C    Repair of uterus                                     1          1       0                          OR
             59400     B    Obstetrical care                                     0         NC       0
             59409     T    Obstetrical care                                     1          1     0193   20.0452   1351.17
             59410     B    Obstetrical care                                     0         NC       0
             59412     T    Antepartum manipulation                              1          1     0193   20.0452   1351.17
             59414     T    Deliver placenta                                     1          1     0193   20.0452   1351.17
             59425     B    Antepartum care only                                 0         NC       0
             59426     B    Antepartum care only                                 0         NC       0
             59430     B    Care after delivery                                  0         NC       0
             59510     B    Cesarean delivery                                    0         NC       0
             59514     C    Cesarean delivery only                               1          1       0                          OR
             59515     B    Cesarean delivery                                    0         NC       0
             59525     C    Remove uterus after cesarean                         1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 74 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             59610     B    Vbac delivery                                        0         NC       0
             59612     T    Vbac delivery only                                   1          1     0193   20.0452   1351.17
             59614     B    Vbac care after delivery                             0         NC       0
             59618     B    Attempted vbac delivery                              0         NC       0
             59620     C    Attempted vbac delivery only                         1          1       0                          OR
             59622     B    Attempted vbac after care                            0         NC       0
             59812     T    Treatment of miscarriage                             1          1     0193   20.0452   1351.17
             59820     T    Care of miscarriage                                  1          1     0193   20.0452   1351.17
             59821     T    Treatment of miscarriage                             1          1     0193   20.0452   1351.17
             59830     C    Treat uterus infection                               1          1       0                          OR
             59840     T    Abortion                                             1          1     0193   20.0452   1351.17
             59841     T    Abortion                                             1          1     0193   20.0452   1351.17
             59850     C    Abortion                                             1          1       0                          OR
             59851     C    Abortion                                             1          1       0                          OR
             59852     C    Abortion                                             1          1       0                          OR
             59855     C    Abortion                                             1          1       0                          OR
             59856     C    Abortion                                             1          1       0                          OR
             59857     C    Abortion                                             1          1       0                          OR
             59866     T    Abortion (mpr)                                       0         NC       0
             59870     T    Evacuate mole of uterus                              1          1     0193   20.0452   1351.17
             59871     T    Remove cerclage suture                               1          1     0193   20.0452   1351.17
             59897     T    Fetal invas px w/us                                  1          1     0191     0.132      8.9
             59898     T    Laparo proc, ob care/deliver                         1          1     0130    38.054   2565.07
             59899     T    Maternity care procedure                             1          1     0191     0.132      8.9
             60000     T    Drain thyroid/tongue cyst                            1          1     0252    7.6196    513.61
             60100     T    Biopsy of thyroid                                    1          1     0004    4.5991    310.01
             60200     T    Remove thyroid lesion                                1          1     0114   48.7561   3286.45
             60210     T    Partial thyroid excision                             1          1     0114   48.7561   3286.45
             60212     T    Partial thyroid excision                             1          1     0114   48.7561   3286.45
             60220     T    Partial removal of thyroid                           1          1     0114   48.7561   3286.45
             60225     T    Partial removal of thyroid                           1          1     0114   48.7561   3286.45
             60240     T    Removal of thyroid                                   1          1     0114   48.7561   3286.45
             60252     T    Removal of thyroid                                   1          1     0256   42.9827   2897.29
             60254     C    Extensive thyroid surgery                            1          1       0                          OR
             60260     T    Repeat thyroid surgery                               1          1     0256   42.9827   2897.29
             60270     C    Removal of thyroid                                   1          1       0                          OR
             60271     T    Removal of thyroid                                   1          1     0256   42.9827   2897.29
             60280     T    Remove thyroid duct lesion                           1          1     0114   48.7561   3286.45
             60281     T    Remove thyroid duct lesion                           1          1     0114   48.7561   3286.45
             60300     T    Aspir/inj thyroid cyst                               1          1     0004    4.5991    310.01
             60500     T    Explore parathyroid glands                           1          1     0256   42.9827   2897.29
             60502     T    Re-explore parathyroids                              1          1     0256   42.9827   2897.29
             60505     C    Explore parathyroid glands                           1          1       0                          OR
             60512     T    Autotransplant parathyroid                           1          1     0022    23.388   1576.49
             60520     T    Removal of thymus gland                              1          1     0256   42.9827   2897.29
             60521     C    Removal of thymus gland                              1          1       0                          OR
             60522     C    Removal of thymus gland                              1          1       0                          OR
             60540     C    Explore adrenal gland                                1          1       0                          OR
             60545     C    Explore adrenal gland                                1          1       0                          OR
             60600     C    Remove carotid body lesion                           1          1       0                          OR
             60605     C    Remove carotid body lesion                           1          1       0                          OR
             60650     C    Laparoscopy adrenalectomy                            1          1       0                          OR
             60659     T    Laparo proc, endocrine                               1          1     0130    38.054   2565.07
             60699     T    Endocrine surgery procedure                          1          1     0114   48.7561   3286.45
             61000     T    Remove cranial cavity fluid                          1          1     0207    7.2002    485.34
             61001     T    Remove cranial cavity fluid                          1          1     0207    7.2002    485.34
             61020     T    Remove brain cavity fluid                            1          1     0207    7.2002    485.34
             61026     T    Injection into brain canal                           1          1     0207    7.2002    485.34
             61050     T    Remove brain canal fluid                             1          1     0207    7.2002    485.34
             61055     T    Injection into brain canal                           1          1     0207    7.2002    485.34
             61070     T    Brain canal shunt procedure                          1          1     0121    6.3742    429.66
             61105     C    Twist drill hole                                     1          1       0                          OR
             61107     C    Drill skull for implantation                         1          1       0                          OR
             61108     C    Drill skull for drainage                             1          1       0                          OR
             61120     C    Burr hole for puncture                               1          1       0                          OR
             61140     C    Pierce skull for biopsy                              1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 75 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             61150     C    Pierce skull for drainage                            1          1       0                          OR
             61151     C    Pierce skull for drainage                            1          1       0                          OR
             61154     C    Pierce skull & remove clot                           1          1       0                          OR
             61156     C    Pierce skull for drainage                            1          1       0                          OR
             61210     C    Pierce skull, implant device                         1          1       0                          OR
             61215     T    Insert brain-fluid device                            1          1     0224   41.0288   2765.59
             61250     C    Pierce skull & explore                               1          1       0                          OR
             61253     C    Pierce skull & explore                               1          1       0                          OR
             61304     C    Open skull for exploration                           1          1       0                          OR
             61305     C    Open skull for exploration                           1          1       0                          OR
             61312     C    Open skull for drainage                              1          1       0                          OR
             61313     C    Open skull for drainage                              1          1       0                          OR
             61314     C    Open skull for drainage                              1          1       0                          OR
             61315     C    Open skull for drainage                              1          1       0                          OR
             61316     C    Implt cran bone flap to abdo                         1          1       0                          OR
             61320     C    Open skull for drainage                              1          1       0                          OR
             61321     C    Open skull for drainage                              1          1       0                          OR
             61322     C    Decompressive craniotomy                             1          1       0                          OR
             61323     C    Decompressive lobectomy                              1          1       0                          OR
             61330     T    Decompress eye socket                                1          1     0256   42.9827   2897.29
             61332     C    Explore/biopsy eye socket                            1          1       0                          OR
             61333     C    Explore orbit/remove lesion                          1          1       0                          OR
             61334     T    Explore orbit/remove object                          1          1     0256   42.9827   2897.29
             61340     C    Subtemporal decompression                            1          1       0                          OR
             61343     C    Incise skull (press relief)                          1          1       0                          OR
             61345     C    Relieve cranial pressure                             1          1       0                          OR
             61440     C    Incise skull for surgery                             1          1       0                          OR
             61450     C    Incise skull for surgery                             1          1       0                          OR
             61458     C    Incise skull for brain wound                         1          1       0                          OR
             61460     C    Incise skull for surgery                             1          1       0                          OR
             61470     C    Incise skull for surgery                             1          1       0                          OR
             61480     C    Incise skull for surgery                             1          1       0                          OR
             61490     C    Incise skull for surgery                             1          1       0                          OR
             61500     C    Removal of skull lesion                              1          1       0                          OR
             61501     C    Remove infected skull bone                           1          1       0                          OR
             61510     C    Removal of brain lesion                              1          1       0                          OR
             61512     C    Remove brain lining lesion                           1          1       0                          OR
             61514     C    Removal of brain abscess                             1          1       0                          OR
             61516     C    Removal of brain lesion                              1          1       0                          OR
             61517     C    Implt brain chemotx add-on                           1          1       0                          OR
             61518     C    Removal of brain lesion                              1          1       0                          OR
             61519     C    Remove brain lining lesion                           1          1       0                          OR
             61520     C    Removal of brain lesion                              1          1       0                          OR
             61521     C    Removal of brain lesion                              1          1       0                          OR
             61522     C    Removal of brain abscess                             1          1       0                          OR
             61524     C    Removal of brain lesion                              1          1       0                          OR
             61526     C    Removal of brain lesion                              1          1       0                          OR
             61530     C    Removal of brain lesion                              1          1       0                          OR
             61531     C    Implant brain electrodes                             1          1       0                          OR
             61533     C    Implant brain electrodes                             1          1       0                          OR
             61534     C    Removal of brain lesion                              1          1       0                          OR
             61535     C    Remove brain electrodes                              1          1       0                          OR
             61536     C    Removal of brain lesion                              1          1       0                          OR
             61537     C    Removal of brain tissue                              1          1       0                          OR
             61538     C    Removal of brain tissue                              1          1       0                          OR
             61539     C    Removal of brain tissue                              1          1       0                          OR
             61540     C    Removal of brain tissue                              1          1       0                          OR
             61541     C    Incision of brain tissue                             1          1       0                          OR
             61542     C    Removal of brain tissue                              1          1       0                          OR
             61543     C    Removal of brain tissue                              1          1       0                          OR
             61544     C    Remove & treat brain lesion                          1          1       0                          OR
             61545     C    Excision of brain tumor                              1          1       0                          OR
             61546     C    Removal of pituitary gland                           1          1       0                          OR
             61548     C    Removal of pituitary gland                           1          1       0                          OR
             61550     C    Release of skull seams                               1          1       0                          OR
             61552     C    Release of skull seams                               1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 76 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             61556     C    Incise skull/sutures                                 1          1       0                          OR
             61557     C    Incise skull/sutures                                 1          1       0                          OR
             61558     C    Excision of skull/sutures                            1          1       0                          OR
             61559     C    Excision of skull/sutures                            1          1       0                          OR
             61563     C    Excision of skull tumor                              1          1       0                          OR
             61564     C    Excision of skull tumor                              1          1       0                          OR
             61566     C    Removal of brain tissue                              1          1       0                          OR
             61567     C    Incision of brain tissue                             1          1       0                          OR
             61570     C    Remove foreign body, brain                           1          1       0                          OR
             61571     C    Incise skull for brain wound                         1          1       0                          OR
             61575     C    Skull base/brainstem surgery                         1          1       0                          OR
             61576     C    Skull base/brainstem surgery                         1          1       0                          OR
             61580     C    Craniofacial approach, skull                         1          1       0                          OR
             61581     C    Craniofacial approach, skull                         1          1       0                          OR
             61582     C    Craniofacial approach, skull                         1          1       0                          OR
             61583     C    Craniofacial approach, skull                         1          1       0                          OR
             61584     C    Orbitocranial approach/skull                         1          1       0                          OR
             61585     C    Orbitocranial approach/skull                         1          1       0                          OR
             61586     C    Resect nasopharynx, skull                            1          1       0                          OR
             61590     C    Infratemporal approach/skull                         1          1       0                          OR
             61591     C    Infratemporal approach/skull                         1          1       0                          OR
             61592     C    Orbitocranial approach/skull                         1          1       0                          OR
             61595     C    Transtemporal approach/skull                         1          1       0                          OR
             61596     C    Transcochlear approach/skull                         1          1       0                          OR
             61597     C    Transcondylar approach/skull                         1          1       0                          OR
             61598     C    Transpetrosal approach/skull                         1          1       0                          OR
             61600     C    Resect/excise cranial lesion                         1          1       0                          OR
             61601     C    Resect/excise cranial lesion                         1          1       0                          OR
             61605     C    Resect/excise cranial lesion                         1          1       0                          OR
             61606     C    Resect/excise cranial lesion                         1          1       0                          OR
             61607     C    Resect/excise cranial lesion                         1          1       0                          OR
             61608     C    Resect/excise cranial lesion                         1          1       0                          OR
             61609     C    Transect artery, sinus                               1          1       0                          OR
             61610     C    Transect artery, sinus                               1          1       0                          OR
             61611     C    Transect artery, sinus                               1          1       0                          OR
             61612     C    Transect artery, sinus                               1          1       0                          OR
             61613     C    Remove aneurysm, sinus                               1          1       0                          OR
             61615     C    Resect/excise lesion, skull                          1          1       0                          OR
             61616     C    Resect/excise lesion, skull                          1          1       0                          OR
             61618     C    Repair dura                                          1          1       0                          OR
             61619     C    Repair dura                                          1          1       0                          OR
             61623     T    Endovasc tempory vessel occl                         1          1     0082   93.3244   6290.62
             61624     C    Transcath occlusion, cns                             1          1       0                          OR
             61626     T    Transcath occlusion, non-cns                         1          1     0082   93.3244   6290.62
             61630     C    Intracranial angioplasty                             0         NC       0
             61635     C    Intracran angioplsty w/stent                         0         NC       0
             61640     E    Dilate ic vasospasm, init                            1          1       0                          OR
             61641     E    Dilate ic vasospasm add-on                           1         UR       0                          OR
             61642     E    Dilate ic vasospasm add-on                           1         UR       0                          OR
             61680     C    Intracranial vessel surgery                          1          1       0                          OR
             61682     C    Intracranial vessel surgery                          1          1       0                          OR
             61684     C    Intracranial vessel surgery                          1          1       0                          OR
             61686     C    Intracranial vessel surgery                          1          1       0                          OR
             61690     C    Intracranial vessel surgery                          1          1       0                          OR
             61692     C    Intracranial vessel surgery                          1          1       0                          OR
             61697     C    Brain aneurysm repr, complx                          1          1       0                          OR
             61698     C    Brain aneurysm repr, complx                          1          1       0                          OR
             61700     C    Brain aneurysm repr, simple                          1          1       0                          OR
             61702     C    Inner skull vessel surgery                           1          1       0                          OR
             61703     C    Clamp neck artery                                    1          1       0                          OR
             61705     C    Revise circulation to head                           1          1       0                          OR
             61708     C    Revise circulation to head                           1          1       0                          OR
             61710     C    Revise circulation to head                           1          1       0                          OR
             61711     C    Fusion of skull arteries                             1          1       0                          OR
             61720     T    Incise skull/brain surgery                           1          1     0221   37.2806   2512.94
             61735     C    Incise skull/brain surgery                           1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 77 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             61750     C    Incise skull/brain biopsy                            1          1       0                          OR
             61751     C    Brain biopsy w/ct/mr guide                           1          1       0                          OR
             61760     C    Implant brain electrodes                             1          1       0                          OR
             61770     T    Incise skull for treatment                           1          1     0221   37.2806   2512.94
             61790     T    Treat trigeminal nerve                               1          1     0220    18.72    1261.84
             61791     T    Treat trigeminal tract                               1          1     0203   13.2439    892.72
             61795     N    Brain surgery using computer                         1          1       0
             61796     B    Srs, cranial lesion simple                           0         NC       0
             61797     B    Srs, cran les simple, addl                           0         NC       0
             61798     B    Srs, cranial lesion complex                          0         NC       0
             61799     B    Srs, cran les complex, addl                          0         NC       0
             61800     B    Apply srs headframe add-on                           0         NC       0
             61850     C    Implant neuroelectrodes                              1          1       0                          OR
             61860     C    Implant neuroelectrodes                              1          1       0                          OR
    PA       61863     C    Implant neuroelectrode                               1          1       0                          OR
    PA       61864     C    Implant neuroelectrde, addl                          1          1       0                          OR
    PA       61867     C    Implant neuroelectrode                               1          1       0                          OR
    PA       61868     C    Implant neuroelectrde, addl                          1          1       0                          OR
             61870     C    Implant neuroelectrodes                              1          1       0                          OR
             61875     C    Implant neuroelectrodes                              1          1       0                          OR
             61880     T    Revise/remove neuroelectrode                         1          1     0687    19.6381 1323.73
    PA       61885     S    Insrt/redo neurostim 1 array                         1          1     0039   206.1011 13892.45
    PA       61886     S    Implant neurostim arrays                             1          1     0315   274.7397 18519.1
             61888     T    Revise/remove neuroreceiver                          1          1     0688    28.6636  1932.1
             62000     T    Treat skull fracture                                 1          1     0254    24.9637  1682.7
             62005     C    Treat skull fracture                                 1          1       0                          OR
             62010     C    Treatment of head injury                             1          1       0                          OR
             62100     C    Repair brain fluid leakage                           1          1       0                          OR
             62115     C    Reduction of skull defect                            1          1       0                          OR
             62116     C    Reduction of skull defect                            1          1       0                          OR
             62117     C    Reduction of skull defect                            1          1       0                          OR
             62120     C    Repair skull cavity lesion                           1          1       0                          OR
             62121     C    Incise skull repair                                  1          1       0                          OR
             62140     C    Repair of skull defect                               1          1       0                          OR
             62141     C    Repair of skull defect                               1          1       0                          OR
             62142     C    Remove skull plate/flap                              1          1       0                          OR
             62143     C    Replace skull plate/flap                             1          1       0                          OR
             62145     C    Repair of skull & brain                              1          1       0                          OR
             62146     C    Repair of skull with graft                           1          1       0                          OR
             62147     C    Repair of skull with graft                           1          1       0                          OR
             62148     C    Retr bone flap to fix skull                          1          1       0                          OR
             62160     N    Neuroendoscopy add-on                                1          1       0
             62161     C    Dissect brain w/scope                                1          1       0                          OR
             62162     C    Remove colloid cyst w/scope                          1          1       0                          OR
             62163     C    Neuroendoscopy w/fb removal                          1          1       0                          OR
             62164     C    Remove brain tumor w/scope                           1          1       0                          OR
             62165     C    Remove pituit tumor w/scope                          1          1       0                          OR
             62180     C    Establish brain cavity shunt                         1          1       0                          OR
             62190     C    Establish brain cavity shunt                         1          1       0                          OR
             62192     C    Establish brain cavity shunt                         1          1       0                          OR
             62194     T    Replace/irrigate catheter                            1          1     0207    7.2002   485.34
             62200     C    Establish brain cavity shunt                         1          1       0                          OR
             62201     C    Brain cavity shunt w/scope                           1          1       0                          OR
             62220     C    Establish brain cavity shunt                         1          1       0                          OR
             62223     C    Establish brain cavity shunt                         1          1       0                          OR
             62225     T    Replace/irrigate catheter                            1          1     0427   15.3103   1032.01
             62230     T    Replace/revise brain shunt                           1          1     0224   41.0288   2765.59
             62252     S    Csf shunt reprogram                                  1          1     0691    2.5406    171.25                   31.12
             62256     C    Remove brain cavity shunt                            1          1       0                          OR
             62258     C    Replace brain cavity shunt                           1          1       0                          OR
             62263     T    Epidural lysis mult sessions                         1          1     0207    7.2002   485.34
             62264     T    Epidural lysis on single day                         1          1     0203   13.2439   892.72
             62267     T    Interdiscal perq aspir, dx                           1          1     0004    4.5991   310.01
             62268     T    Drain spinal cord cyst                               1          1     0207    7.2002   485.34
             62269     T    Needle biopsy, spinal cord                           1          1     0685    9.6666   651.59
             62270     T    Spinal fluid tap, diagnostic                         1          1     0206    3.7221   250.89

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 78 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             62272     T    Drain cerebro spinal fluid                           1          1     0206    3.7221   250.89
             62273     T    Inject epidural patch                                1          1     0206    3.7221   250.89
             62280     T    Treat spinal cord lesion                             1          1     0207    7.2002   485.34
             62281     T    Treat spinal cord lesion                             1          1     0207    7.2002   485.34
             62282     T    Treat spinal canal lesion                            1          1     0207    7.2002   485.34
             62284     N    Injection for myelogram                              1          1       0
             62287     T    Percutaneous diskectomy                              1          1     0221   37.2806   2512.94
             62290     N    Inject for spine disk x-ray                          0         NC       0
             62291     N    Inject for spine disk x-ray                          0         NC       0
             62292     T    Injection into disk lesion                           1          1     0207     7.2002  485.34
             62294     T    Injection into spinal artery                         1          1     0207     7.2002  485.34
             62310     T    Inject spine c/t                                     1          1     0207     7.2002  485.34
             62311     T    Inject spine l/s (cd)                                1          1     0207     7.2002  485.34
             62318     T    Inject spine w/cath, c/t                             1          1     0207     7.2002  485.34
             62319     T    Inject spine w/cath l/s (cd)                         1          1     0207     7.2002  485.34
             62350     T    Implant spinal canal cath                            1          1     0224    41.0288 2765.59
             62351     T    Implant spinal canal cath                            1          1     0208    49.2256  3318.1
             62355     T    Remove spinal canal catheter                         1          1     0203    13.2439  892.72
             62360     T    Insert spine infusion device                         1          1     0224    41.0288 2765.59
             62361     T    Implant spine infusion pump                          1          1     0227   198.6572 13390.69
             62362     T    Implant spine infusion pump                          1          1     0227   198.6572 13390.69
             62365     T    Remove spine infusion device                         1          1     0221    37.2806 2512.94
             62367     S    Analyze spine infusion pump                          1          1     0691     2.5406  171.25                    14.45
             62368     S    Analyze spine infusion pump                          1          1     0691     2.5406  171.25                    22.23
             63001     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63003     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63005     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63011     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63012     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63015     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63016     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63017     T    Removal of spinal lamina                             1          1     0208    49.2256  3318.1
             63020     T    Neck spine disk surgery                              1          1     0208    49.2256  3318.1
             63030     T    Low back disk surgery                                1          1     0208    49.2256  3318.1
             63035     T    Spinal disk surgery add-on                           1          7     0208    49.2256  3318.1
             63040     T    Laminotomy, single cervical                          1          1     0208    49.2256  3318.1
             63042     T    Laminotomy, single lumbar                            1          1     0208    49.2256  3318.1
             63043     C    Laminotomy, addl cervical                            1          1       0                          OR
             63044     C    Laminotomy, addl lumbar                              1          1       0                          OR
             63045     T    Removal of spinal lamina                             1          1     0208   49.2256   3318.1
             63046     T    Removal of spinal lamina                             1          1     0208   49.2256   3318.1
             63047     T    Removal of spinal lamina                             1          1     0208   49.2256   3318.1
             63048     T    Remove spinal lamina add-on                          1         25     0208   49.2256   3318.1
             63050     C    Cervical laminoplasty                                1          1       0                          OR
             63051     C    C-laminoplasty w/graft/plate                         1          1       0                          OR
             63055     T    Decompress spinal cord                               1          1     0208   49.2256   3318.1
             63056     T    Decompress spinal cord                               1          1     0208   49.2256   3318.1
             63057     T    Decompress spine cord add-on                         1          1     0208   49.2256   3318.1
             63064     T    Decompress spinal cord                               1          1     0208   49.2256   3318.1
             63066     T    Decompress spine cord add-on                         1          1     0208   49.2256   3318.1
             63075     T    Neck spine disk surgery                              1          1     0208   49.2256   3318.1
             63076     T    Neck spine disk surgery                              1          1     0208   49.2256   3318.1
             63077     C    Spine disk surgery, thorax                           1          1       0                          OR
             63078     C    Spine disk surgery, thorax                           1          1       0                          OR
             63081     C    Removal of vertebral body                            1          1       0                          OR
             63082     C    Remove vertebral body add-on                         1          1       0                          OR
             63085     C    Removal of vertebral body                            1          1       0                          OR
             63086     C    Remove vertebral body add-on                         1          1       0                          OR
             63087     C    Removal of vertebral body                            1          1       0                          OR
             63088     C    Remove vertebral body add-on                         1          1       0                          OR
             63090     C    Removal of vertebral body                            1          1       0                          OR
             63091     C    Remove vertebral body add-on                         1          1       0                          OR
             63101     C    Removal of vertebral body                            1          1       0                          OR
             63102     C    Removal of vertebral body                            1          1       0                          OR
             63103     C    Remove vertebral body add-on                         1          1       0                          OR
             63170     C    Incise spinal cord tract(s)                          1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 79 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW       NWR        OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010     2010        Fee            Fee
             63172     C    Drainage of spinal cyst                              1          1       0                          OR
             63173     C    Drainage of spinal cyst                              1          1       0                          OR
             63180     C    Revise spinal cord ligaments                         1          1       0                          OR
             63182     C    Revise spinal cord ligaments                         1          1       0                          OR
             63185     C    Incise spinal column/nerves                          1          1       0                          OR
             63190     C    Incise spinal column/nerves                          1          1       0                          OR
             63191     C    Incise spinal column/nerves                          1          1       0                          OR
             63194     C    Incise spinal column & cord                          1          1       0                          OR
             63195     C    Incise spinal column & cord                          1          1       0                          OR
             63196     C    Incise spinal column & cord                          1          1       0                          OR
             63197     C    Incise spinal column & cord                          1          1       0                          OR
             63198     C    Incise spinal column & cord                          1          1       0                          OR
             63199     C    Incise spinal column & cord                          1          1       0                          OR
             63200     C    Release of spinal cord                               1          1       0                          OR
             63250     C    Revise spinal cord vessels                           1          1       0                          OR
             63251     C    Revise spinal cord vessels                           1          1       0                          OR
             63252     C    Revise spinal cord vessels                           1          1       0                          OR
             63265     C    Excise intraspinal lesion                            1          1       0                          OR
             63266     C    Excise intraspinal lesion                            1          1       0                          OR
             63267     C    Excise intraspinal lesion                            1          1       0                          OR
             63268     C    Excise intraspinal lesion                            1          1       0                          OR
             63270     C    Excise intraspinal lesion                            1          1       0                          OR
             63271     C    Excise intraspinal lesion                            1          1       0                          OR
             63272     C    Excise intraspinal lesion                            1          1       0                          OR
             63273     C    Excise intraspinal lesion                            1          1       0                          OR
             63275     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63276     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63277     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63278     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63280     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63281     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63282     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63283     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63285     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63286     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63287     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63290     C    Biopsy/excise spinal tumor                           1          1       0                          OR
             63295     C    Repair of laminectomy defect                         1          1       0                          OR
             63300     C    Removal of vertebral body                            1          1       0                          OR
             63301     C    Removal of vertebral body                            1          1       0                          OR
             63302     C    Removal of vertebral body                            1          1       0                          OR
             63303     C    Removal of vertebral body                            1          1       0                          OR
             63304     C    Removal of vertebral body                            1          1       0                          OR
             63305     C    Removal of vertebral body                            1          1       0                          OR
             63306     C    Removal of vertebral body                            1          1       0                          OR
             63307     C    Removal of vertebral body                            1          1       0                          OR
             63308     C    Remove vertebral body add-on                         1          1       0                          OR
             63600     T    Remove spinal cord lesion                            1          1     0220    18.72   1261.84
             63610     T    Stimulation of spinal cord                           1          1     0220    18.72   1261.84
             63615     T    Remove lesion of spinal cord                         1          1     0220    18.72   1261.84
             63620     B    Srs, spinal lesion                                   0         NC       0
             63621     B    Srs, spinal lesion, addl                             0         NC       0
    PA       63650     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
             63655     S    Implant neuroelectrodes                              1          1     0061    86.5171 5831.77
    PA       63661     T    Remove spine eltrd perq aray                         1          1     0687    19.6381 1323.73
    PA       63662     T    Remove spine eltrd plate                             1          1     0687    19.6381 1323.73
    PA       63663     T    Revise spine eltrd perq aray                         1          1     0687    19.6381 1323.73
    PA       63664     T    Revise spine eltrd plate                             1          1     0687    19.6381 1323.73
    PA       63685     S    Insrt/redo spine n generator                         1          1     0039   206.1011 13892.45
    PA       63688     T    Revise/remove neuroreceiver                          1          1     0688    28.6636  1932.1
             63700     C    Repair of spinal herniation                          1          1       0                          OR
             63702     C    Repair of spinal herniation                          1          1       0                          OR
             63704     C    Repair of spinal herniation                          1          1       0                          OR
             63706     C    Repair of spinal herniation                          1          1       0                          OR
             63707     C    Repair spinal fluid leakage                          1          1       0                          OR
             63709     C    Repair spinal fluid leakage                          1          1       0                          OR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 80 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             63710     C    Graft repair of spine defect                         1          1       0                          OR
             63740     C    Install spinal shunt                                 1          1       0                          OR
             63741     T    Install spinal shunt                                 1          1     0224   41.0288   2765.59
             63744     T    Revision of spinal shunt                             1          1     0224   41.0288   2765.59
             63746     T    Removal of spinal shunt                              1          1     0203   13.2439    892.72
             64400     T    N block inj, trigeminal                              1          1     0204    2.5558    172.28
             64402     T    N block inj, facial                                  1          1     0204    2.5558    172.28
             64405     T    N block inj, occipital                               1          1     0206    3.7221    250.89
             64408     T    N block inj, vagus                                   1          1     0207    7.2002    485.34
             64410     T    N block inj, phrenic                                 1          1     0207    7.2002    485.34
             64412     T    N block inj, spinal accessor                         1          1     0207    7.2002    485.34
             64413     T    N block inj, cervical plexus                         1          1     0206    3.7221    250.89
             64415     T    N block inj, brachial plexus                         1          1     0206    3.7221    250.89
             64416     T    N block cont infuse, b plex                          1          1     0207    7.2002    485.34
             64417     T    N block inj, axillary                                1          1     0206    3.7221    250.89
             64418     T    N block inj, suprascapular                           1          1     0206    3.7221    250.89
             64420     T    N block inj, intercost, sng                          1          1     0206    3.7221    250.89
             64421     T    N block inj, intercost, mlt                          1          1     0207    7.2002    485.34
             64425     T    N block inj, ilio-ing/hypogi                         1          1     0206    3.7221    250.89
             64430     T    N block inj, pudendal                                1          1     0207    7.2002    485.34
             64435     T    N block inj, paracervical                            1          1     0206    3.7221    250.89
             64445     T    N block inj, sciatic, sng                            1          1     0207    7.2002    485.34
             64446     T    N blk inj, sciatic, cont inf                         1          1     0207    7.2002    485.34
             64447     T    N block inj fem, single                              1          1     0206    3.7221    250.89
             64448     T    N block inj fem, cont inf                            1          1     0207    7.2002    485.34
             64449     T    N block inj, lumbar plexus                           1          1     0207    7.2002    485.34
             64450     T    N block, other peripheral                            1          1     0206    3.7221    250.89
             64455     T    N block inj, plantar digit                           1          1     0204    2.5558    172.28
             64479     T    Inj foramen epidural c/t                             1          1     0207    7.2002    485.34
             64480     T    Inj foramen epidural add-on                          1          1     0206    3.7221    250.89
             64483     T    Inj foramen epidural l/s                             1          1     0207    7.2002    485.34
             64484     T    Inj foramen epidural add-on                          1          1     0206    3.7221    250.89
             64490     T    Inj paravert f jnt c/t 1 lev                         1          1     0207    7.2002    485.34
             64491     T    Inj paravert f jnt c/t 2 lev                         1          1     0204    2.5558    172.28
             64492     T    Inj paravert f jnt c/t 3 lev                         1          1     0204    2.5558    172.28
             64493     T    Inj paravert f jnt l/s 1 lev                         1          1     0207    7.2002    485.34
             64494     T    Inj paravert f jnt l/s 2 lev                         1          1     0204    2.5558    172.28
             64495     T    Inj paravert f jnt l/s 3 lev                         1          1     0204    2.5558    172.28
             64505     T    N block, spenopalatine gangl                         1          1     0204    2.5558    172.28
             64508     T    N block, carotid sinus s/p                           1          1     0204    2.5558    172.28
             64510     T    N block, stellate ganglion                           1          1     0207    7.2002    485.34
             64517     T    N block inj, hypogas plxs                            1          1     0207    7.2002    485.34
             64520     T    N block, lumbar/thoracic                             1          1     0207    7.2002    485.34
             64530     T    N block inj, celiac pelus                            1          1     0207    7.2002    485.34
             64550     A    Apply neurostimulator                                0         NC       0
             64553     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
             64555     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
             64560     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
             64561     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
             64565     S    Implant neuroelectrodes                              1          1     0040    65.7095 4429.21
    PA       64573     S    Implant neuroelectrodes                              1          1     0225    157.939 10646.04
             64575     S    Implant neuroelectrodes                              1          1     0061    86.5171 5831.77
             64577     S    Implant neuroelectrodes                              1          1     0061    86.5171 5831.77
             64580     S    Implant neuroelectrodes                              1          1     0061    86.5171 5831.77
             64581     S    Implant neuroelectrodes                              1          1     0061    86.5171 5831.77
             64585     T    Revise/remove neuroelectrode                         1          1     0687    19.6381 1323.73
    PA       64590     S    Insrt/redo pn/gastr stimul                           1          1     0039   206.1011 13892.45
             64595     T    Revise/rmv pn/gastr stimul                           1          1     0688    28.6636   1932.1
    PA       64600     T    Injection treatment of nerve                         1          1     0203    13.2439   892.72
             64605     T    Injection treatment of nerve                         1          1     0220      18.72  1261.84
             64610     T    Injection treatment of nerve                         1          1     0220      18.72  1261.84
             64612     T    Destroy nerve, face muscle                           1          1     0204     2.5558   172.28
             64613     T    Destroy nerve, neck muscle                           1          1     0206     3.7221   250.89
             64614     T    Destroy nerve, extrem musc                           1         10     0206     3.7221   250.89
             64620     T    Injection treatment of nerve                         1          1     0207     7.2002   485.34
             64622     T    Destr paravertebrl nerve l/s                         1          1     0203    13.2439   892.72

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 81 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             64623     T    Destr paravertebral n add-on                         1          1     0207    7.2002    485.34
             64626     T    Destr paravertebrl nerve c/t                         1          1     0207    7.2002    485.34
             64627     T    Destr paravertebral n add-on                         1          1     0204    2.5558    172.28
             64630     T    Injection treatment of nerve                         1          1     0207    7.2002    485.34
             64632     T    N block inj, common digit                            1          1     0204    2.5558    172.28
             64640     T    Injection treatment of nerve                         1          1     0207    7.2002    485.34
    PA       64650     T    Chemodenerv eccrine glands                           1          1     0204    2.5558    172.28
    PA       64653     T    Chemodenerv eccrine glands                           1          1     0204    2.5558    172.28
             64680     T    Injection treatment of nerve                         1          1     0207    7.2002    485.34
             64681     T    Injection treatment of nerve                         1          1     0203   13.2439    892.72
             64702     T    Revise finger/toe nerve                              1          1     0220     18.72   1261.84
             64704     T    Revise hand/foot nerve                               1          1     0220     18.72   1261.84
             64708     T    Revise arm/leg nerve                                 1          1     0220     18.72   1261.84
             64712     T    Revision of sciatic nerve                            1          1     0220     18.72   1261.84
             64713     T    Revision of arm nerve(s)                             1          1     0220     18.72   1261.84
             64714     T    Revise low back nerve(s)                             1          1     0220     18.72   1261.84
             64716     T    Revision of cranial nerve                            1          1     0220     18.72   1261.84
             64718     T    Revise ulnar nerve at elbow                          1          1     0220     18.72   1261.84
             64719     T    Revise ulnar nerve at wrist                          1          1     0220     18.72   1261.84
             64721     T    Carpal tunnel surgery                                1          1     0220     18.72   1261.84
             64722     T    Relieve pressure on nerve(s)                         1          1     0220     18.72   1261.84
             64726     T    Release foot/toe nerve                               1          1     0220     18.72   1261.84
             64727     T    Internal nerve revision                              1          1     0220     18.72   1261.84
             64732     T    Incision of brow nerve                               1          1     0220     18.72   1261.84
             64734     T    Incision of cheek nerve                              1          1     0220     18.72   1261.84
             64736     T    Incision of chin nerve                               1          1     0220     18.72   1261.84
             64738     T    Incision of jaw nerve                                1          1     0220     18.72   1261.84
             64740     T    Incision of tongue nerve                             1          1     0220     18.72   1261.84
             64742     T    Incision of facial nerve                             1          1     0220     18.72   1261.84
             64744     T    Incise nerve, back of head                           1          1     0220     18.72   1261.84
             64746     T    Incise diaphragm nerve                               1          1     0220     18.72   1261.84
             64752     C    Incision of vagus nerve                              1          1       0                          OR
             64755     C    Incision of stomach nerves                           1          1       0                          OR
             64760     C    Incision of vagus nerve                              1          1       0                          OR
             64761     T    Incision of pelvis nerve                             1          1     0220    18.72    1261.84
             64763     T    Incise hip/thigh nerve                               1          1     0220    18.72    1261.84
             64766     T    Incise hip/thigh nerve                               1          1     0221   37.2806   2512.94
             64771     T    Sever cranial nerve                                  1          1     0220    18.72    1261.84
             64772     T    Incision of spinal nerve                             1          1     0220    18.72    1261.84
             64774     T    Remove skin nerve lesion                             1          1     0220    18.72    1261.84
             64776     T    Remove digit nerve lesion                            1          1     0220    18.72    1261.84
             64778     T    Digit nerve surgery add-on                           1          1     0220    18.72    1261.84
             64782     T    Remove limb nerve lesion                             1          1     0220    18.72    1261.84
             64783     T    Limb nerve surgery add-on                            1          1     0220    18.72    1261.84
             64784     T    Remove nerve lesion                                  1          1     0220    18.72    1261.84
             64786     T    Remove sciatic nerve lesion                          1          1     0221   37.2806   2512.94
             64787     T    Implant nerve end                                    1          1     0220    18.72    1261.84
             64788     T    Remove skin nerve lesion                             1          1     0220    18.72    1261.84
             64790     T    Removal of nerve lesion                              1          1     0220    18.72    1261.84
             64792     T    Removal of nerve lesion                              1          1     0221   37.2806   2512.94
             64795     T    Biopsy of nerve                                      1          1     0220    18.72    1261.84
             64802     T    Remove sympathetic nerves                            1          1     0220    18.72    1261.84
             64804     T    Remove sympathetic nerves                            1          1     0220    18.72    1261.84
             64809     C    Remove sympathetic nerves                            1          1       0                          OR
             64818     C    Remove sympathetic nerves                            1          1       0                          OR
             64820     T    Remove sympathetic nerves                            1          1     0220    18.72    1261.84
             64821     T    Remove sympathetic nerves                            1          1     0054   28.2376   1903.38
             64822     T    Remove sympathetic nerves                            1          1     0054   28.2376   1903.38
             64823     T    Remove sympathetic nerves                            1          1     0054   28.2376   1903.38
             64831     T    Repair of digit nerve                                1          1     0221   37.2806   2512.94
             64832     T    Repair nerve add-on                                  1          1     0221   37.2806   2512.94
             64834     T    Repair of hand or foot nerve                         1          1     0221   37.2806   2512.94
             64835     T    Repair of hand or foot nerve                         1          1     0221   37.2806   2512.94
             64836     T    Repair of hand or foot nerve                         1          1     0221   37.2806   2512.94
             64837     T    Repair nerve add-on                                  1          1     0221   37.2806   2512.94
             64840     T    Repair of leg nerve                                  1          1     0221   37.2806   2512.94

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 82 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             64856     T    Repair/transpose nerve                               1          1     0221   37.2806   2512.94
             64857     T    Repair arm/leg nerve                                 1          1     0221   37.2806   2512.94
             64858     T    Repair sciatic nerve                                 1          1     0221   37.2806   2512.94
             64859     T    Nerve surgery                                        1          1     0221   37.2806   2512.94
             64861     T    Repair of arm nerves                                 1          1     0221   37.2806   2512.94
             64862     T    Repair of low back nerves                            1          1     0221   37.2806   2512.94
             64864     T    Repair of facial nerve                               1          1     0221   37.2806   2512.94
             64865     T    Repair of facial nerve                               1          1     0221   37.2806   2512.94
             64866     C    Fusion of facial/other nerve                         1          1       0                          OR
             64868     C    Fusion of facial/other nerve                         1          1       0                          OR
             64870     T    Fusion of facial/other nerve                         1          1     0221   37.2806   2512.94
             64872     T    Subsequent repair of nerve                           1          1     0221   37.2806   2512.94
             64874     T    Repair & revise nerve add-on                         1          1     0221   37.2806   2512.94
             64876     T    Repair nerve/shorten bone                            1          1     0221   37.2806   2512.94
             64885     T    Nerve graft, head or neck                            1          1     0221   37.2806   2512.94
             64886     T    Nerve graft, head or neck                            1          1     0221   37.2806   2512.94
             64890     T    Nerve graft, hand or foot                            1          1     0221   37.2806   2512.94
             64891     T    Nerve graft, hand or foot                            1          1     0221   37.2806   2512.94
             64892     T    Nerve graft, arm or leg                              1          1     0221   37.2806   2512.94
             64893     T    Nerve graft, arm or leg                              1          1     0221   37.2806   2512.94
             64895     T    Nerve graft, hand or foot                            1          1     0221   37.2806   2512.94
             64896     T    Nerve graft, hand or foot                            1          1     0221   37.2806   2512.94
             64897     T    Nerve graft, arm or leg                              1          1     0221   37.2806   2512.94
             64898     T    Nerve graft, arm or leg                              1          1     0221   37.2806   2512.94
             64901     T    Nerve graft add-on                                   1          1     0221   37.2806   2512.94
             64902     T    Nerve graft add-on                                   1          1     0221   37.2806   2512.94
             64905     T    Nerve pedicle transfer                               1          1     0221   37.2806   2512.94
             64907     T    Nerve pedicle transfer                               1          1     0221   37.2806   2512.94
             64910     T    Nerve repair w/allograft                             1          1     0221   37.2806   2512.94
             64911     T    Neurorraphy w/vein autograft                         1          1     0221   37.2806   2512.94
             64999     T    Nervous system surgery                               1          1     0204    2.5558    172.28
             65091     T    Revise eye                                           1          1     0242   39.0115   2629.61
             65093     T    Revise eye with implant                              1          1     0242   39.0115   2629.61
             65101     T    Removal of eye                                       1          1     0242   39.0115   2629.61
             65103     T    Remove eye/insert implant                            1          1     0242   39.0115   2629.61
             65105     T    Remove eye/attach implant                            1          1     0242   39.0115   2629.61
             65110     T    Removal of eye                                       1          1     0242   39.0115   2629.61
             65112     T    Remove eye/revise socket                             1          1     0242   39.0115   2629.61
             65114     T    Remove eye/revise socket                             1          1     0242   39.0115   2629.61
             65125     T    Revise ocular implant                                1          1     0241   26.8396   1809.15
             65130     T    Insert ocular implant                                1          1     0241   26.8396   1809.15
             65135     T    Insert ocular implant                                1          1     0241   26.8396   1809.15
             65140     T    Attach ocular implant                                1          1     0242   39.0115   2629.61
             65150     T    Revise ocular implant                                1          1     0241   26.8396   1809.15
             65155     T    Reinsert ocular implant                              1          1     0242   39.0115   2629.61
             65175     T    Removal of ocular implant                            1          1     0240    18.158   1223.96
             65205     S    Remove foreign body from eye                         1          1     0698    0.9553     64.39
             65210     S    Remove foreign body from eye                         1          1     0698    0.9553     64.39
             65220     S    Remove foreign body from eye                         1          1     0698    0.9553     64.39
             65222     S    Remove foreign body from eye                         1          1     0698    0.9553     64.39
             65235     T    Remove foreign body from eye                         1          1     0233   16.2485   1095.25
             65260     T    Remove foreign body from eye                         1          1     0235    5.8498    394.31
             65265     T    Remove foreign body from eye                         1          1     0237   20.7145   1396.28
             65270     T    Repair of eye wound                                  1          1     0240    18.158   1223.96
             65272     T    Repair of eye wound                                  1          1     0234   24.4021   1644.85
             65273     C    Repair of eye wound                                  1          1       0                          OR
             65275     T    Repair of eye wound                                  1          1     0234   24.4021   1644.85
             65280     T    Repair of eye wound                                  1          1     0237   20.7145   1396.28
             65285     T    Repair of eye wound                                  1          1     0672   39.9643   2693.83
             65286     T    Repair of eye wound                                  1          1     0232    4.5074    303.83
             65290     T    Repair of eye socket wound                           1          1     0243   23.4694   1581.98
             65400     T    Removal of eye lesion                                1          1     0233   16.2485   1095.25
             65410     T    Biopsy of cornea                                     1          1     0233   16.2485   1095.25
             65420     T    Removal of eye lesion                                1          1     0233   16.2485   1095.25
             65426     T    Removal of eye lesion                                1          1     0234   24.4021   1644.85
             65430     S    Corneal smear                                        1          1     0698    0.9553     64.39

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 83 of 216                                                                                                                        All Rights Reserved
                                                          HRSA Outpatient Fee Schedule                                                    CY2010 Q4
                                                             Washington State Medicaid


                                                                                         MAX     APC     RW         NWR       OPPS            OP
  AUTH           CPT   SI   Description                                       COV
                                                                                         UNITS   2010    2010       2010       Fee            Fee
             65435     T    Curette/treat cornea                                1          1     0239    7.6421     515.12
             65436     T    Curette/treat cornea                                1          1     0233   16.2485    1095.25
             65450     S    Treatment of corneal lesion                         1          1     0231    1.9575     131.95
             65600     T    Revision of cornea                                  1          1     0240    18.158    1223.96
             65710     T    Corneal transplant                                  1          1     0244   37.5388    2530.34
             65730     T    Corneal transplant                                  1          1     0244   37.5388    2530.34
             65750     T    Corneal transplant                                  1          1     0244   37.5388    2530.34
             65755     T    Corneal transplant                                  1          1     0244   37.5388    2530.34
             65756     T    Corneal trnspl, endothelial                         1          1     0244   37.5388    2530.34
             65757     N    Prep corneal endo allograft                         1          1       0
             65760     E    Revision of cornea                                  0         NC       0
             65765     E    Revision of cornea                                  0         NC       0
             65767     E    Corneal tissue transplant                           0         NC       0
             65770     T    Revise cornea with implant                          1          1     0293   101.0161   6809.09
             65771     E    Radial keratotomy                                   0         NC       0
             65772     T    Correction of astigmatism                           1          1     0233   16.2485    1095.25
             65775     T    Correction of astigmatism                           1          1     0233   16.2485    1095.25
    PA       65780     T    Ocular reconst, transplant                          1          1     0244   37.5388    2530.34
    PA       65781     T    Ocular reconst, transplant                          1          1     0244   37.5388    2530.34
    PA       65782     T    Ocular reconst, transplant                          1          1     0244   37.5388    2530.34
             65800     T    Drainage of eye                                     1          1     0233   16.2485    1095.25
             65805     T    Drainage of eye                                     1          1     0233   16.2485    1095.25
             65810     T    Drainage of eye                                     1          1     0234   24.4021    1644.85
             65815     T    Drainage of eye                                     1          1     0234   24.4021    1644.85
             65820     T    Relieve inner eye pressure                          1          1     0232    4.5074     303.83
             65850     T    Incision of eye                                     1          1     0234   24.4021    1644.85
             65855     T    Laser surgery of eye                                1          1     0247    5.3014     357.35
             65860     T    Incise inner eye adhesions                          1          1     0247    5.3014     357.35
             65865     T    Incise inner eye adhesions                          1          1     0233   16.2485    1095.25
             65870     T    Incise inner eye adhesions                          1          1     0234   24.4021    1644.85
             65875     T    Incise inner eye adhesions                          1          1     0234   24.4021    1644.85
             65880     T    Incise inner eye adhesions                          1          1     0233   16.2485    1095.25
             65900     T    Remove eye lesion                                   1          1     0233   16.2485    1095.25
             65920     T    Remove implant of eye                               1          1     0234   24.4021    1644.85
             65930     T    Remove blood clot from eye                          1          1     0234   24.4021    1644.85
             66020     T    Injection treatment of eye                          1          1     0233   16.2485    1095.25
             66030     T    Injection treatment of eye                          1          1     0232    4.5074     303.83
             66130     T    Remove eye lesion                                   1          1     0234   24.4021    1644.85
             66150     T    Glaucoma surgery                                    1          1     0234   24.4021    1644.85
             66155     T    Glaucoma surgery                                    1          1     0234   24.4021    1644.85
             66160     T    Glaucoma surgery                                    1          1     0234   24.4021    1644.85
             66165     T    Glaucoma surgery                                    1          1     0234   24.4021    1644.85
             66170     T    Glaucoma surgery                                    1          1     0234   24.4021    1644.85
             66172     T    Incision of eye                                     1          1     0234   24.4021    1644.85
             66180     T    Implant eye shunt                                   1          1     0673    41.884    2823.23
             66185     T    Revise eye shunt                                    1          1     0234   24.4021    1644.85
             66220     T    Repair eye lesion                                   1          1     0672   39.9643    2693.83
             66225     T    Repair/graft eye lesion                             1          1     0673    41.884    2823.23
             66250     T    Follow-up surgery of eye                            1          1     0233   16.2485    1095.25
             66500     T    Incision of iris                                    1          1     0232    4.5074     303.83
             66505     T    Incision of iris                                    1          1     0232    4.5074     303.83
             66600     T    Remove iris and lesion                              1          1     0234   24.4021    1644.85
             66605     T    Removal of iris                                     1          1     0234   24.4021    1644.85
             66625     T    Removal of iris                                     1          1     0233   16.2485    1095.25
             66630     T    Removal of iris                                     1          1     0234   24.4021    1644.85
             66635     T    Removal of iris                                     1          1     0234   24.4021    1644.85
             66680     T    Repair iris & ciliary body                          1          1     0234   24.4021    1644.85
             66682     T    Repair iris & ciliary body                          1          1     0234   24.4021    1644.85
             66700     T    Destruction, ciliary body                           1          1     0233   16.2485    1095.25
             66710     T    Ciliary transsleral therapy                         1          1     0233   16.2485    1095.25
             66711     T    Ciliary endoscopic ablation                         1          1     0233   16.2485    1095.25
             66720     T    Destruction, ciliary body                           1          1     0233   16.2485    1095.25
             66740     T    Destruction, ciliary body                           1          1     0234   24.4021    1644.85
             66761     T    Revision of iris                                    1          1     0247    5.3014     357.35
             66762     T    Revision of iris                                    1          1     0247    5.3014     357.35
             66770     T    Removal of inner eye lesion                         1          1     0247    5.3014     357.35

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 84 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             66820     T    Incision, secondary cataract                         1          1     0232    4.5074    303.83
             66821     T    After cataract laser surgery                         1          1     0247    5.3014    357.35
             66825     T    Reposition intraocular lens                          1          1     0234   24.4021   1644.85
             66830     T    Removal of lens lesion                               1          1     0232    4.5074    303.83
             66840     T    Removal of lens material                             1          1     0245   15.8085   1065.59
             66850     T    Removal of lens material                             1          1     0249   30.3293   2044.38
             66852     T    Removal of lens material                             1          1     0249   30.3293   2044.38
             66920     T    Extraction of lens                                   1          1     0249   30.3293   2044.38
             66930     T    Extraction of lens                                   1          1     0249   30.3293   2044.38
             66940     T    Extraction of lens                                   1          1     0245   15.8085   1065.59
             66982     T    Cataract surgery, complex                            1          1     0246   24.2879   1637.15
             66983     T    Cataract surg w/iol, 1 stage                         1          1     0246   24.2879   1637.15
             66984     T    Cataract surg w/iol, 1 stage                         1          1     0246   24.2879   1637.15
             66985     T    Insert lens prosthesis                               1          1     0246   24.2879   1637.15
             66986     T    Exchange lens prosthesis                             1          1     0246   24.2879   1637.15
             66990     N    Ophthalmic endoscope add-on                          1          1       0
             66999     T    Eye surgery procedure                                1          1     0232    4.5074    303.83
             67005     T    Partial removal of eye fluid                         1          1     0237   20.7145   1396.28
             67010     T    Partial removal of eye fluid                         1          1     0672   39.9643   2693.83
             67015     T    Release of eye fluid                                 1          1     0672   39.9643   2693.83
             67025     T    Replace eye fluid                                    1          1     0237   20.7145   1396.28
             67027     T    Implant eye drug system                              1          1     0672   39.9643   2693.83
             67028     T    Injection eye drug                                   1          1     0238    3.2267     217.5
             67030     T    Incise inner eye strands                             1          1     0237   20.7145   1396.28
             67031     T    Laser surgery, eye strands                           1          1     0247    5.3014    357.35
             67036     T    Removal of inner eye fluid                           1          1     0672   39.9643   2693.83
             67039     T    Laser treatment of retina                            1          1     0672   39.9643   2693.83
             67040     T    Laser treatment of retina                            1          1     0672   39.9643   2693.83
             67041     T    Vit for macular pucker                               1          1     0672   39.9643   2693.83
             67042     T    Vit for macular hole                                 1          1     0672   39.9643   2693.83
             67043     T    Vit for membrane dissect                             1          1     0672   39.9643   2693.83
             67101     T    Repair detached retina                               1          1     0237   20.7145   1396.28
             67105     T    Repair detached retina                               1          1     0247    5.3014    357.35
             67107     T    Repair detached retina                               1          1     0672   39.9643   2693.83
             67108     T    Repair detached retina                               1          1     0672   39.9643   2693.83
             67110     T    Repair detached retina                               1          1     0237   20.7145   1396.28
             67112     T    Rerepair detached retina                             1          1     0672   39.9643   2693.83
             67113     T    Repair retinal detach, cplx                          1          1     0672   39.9643   2693.83
             67115     T    Release encircling material                          1          1     0237   20.7145   1396.28
             67120     T    Remove eye implant material                          1          1     0237   20.7145   1396.28
             67121     T    Remove eye implant material                          1          1     0237   20.7145   1396.28
             67141     T    Treatment of retina                                  1          1     0235    5.8498    394.31
             67145     T    Treatment of retina                                  1          1     0247    5.3014    357.35
             67208     T    Treatment of retinal lesion                          1          1     0235    5.8498    394.31
             67210     T    Treatment of retinal lesion                          1          1     0247    5.3014    357.35
             67218     T    Treatment of retinal lesion                          1          1     0237   20.7145   1396.28
             67220     T    Treatment of choroid lesion                          1          1     0235    5.8498    394.31
             67221     T    Ocular photodynamic ther                             1          1     0235    5.8498    394.31
             67225     T    Eye photodynamic ther add-on                         1          1     0235    5.8498    394.31
             67227     T    Treatment of retinal lesion                          1          1     0237   20.7145   1396.28
             67228     T    Treatment of retinal lesion                          1          1     0247    5.3014    357.35
             67229     T    Tr retinal les preterm inf                           1          1     0247    5.3014    357.35
             67250     T    Reinforce eye wall                                   1          1     0240    18.158   1223.96
             67255     T    Reinforce/graft eye wall                             1          1     0237   20.7145   1396.28
             67299     T    Eye surgery procedure                                1          1     0235    5.8498    394.31
   EPA       67311     T    Revise eye muscle                                    1          1     0243   23.4694   1581.98
   EPA       67312     T    Revise two eye muscles                               1          1     0243   23.4694   1581.98
   EPA       67314     T    Revise eye muscle                                    1          1     0243   23.4694   1581.98
   EPA       67316     T    Revise two eye muscles                               1          1     0243   23.4694   1581.98
   EPA       67318     T    Revise eye muscle(s)                                 1          1     0243   23.4694   1581.98
   EPA       67320     T    Revise eye muscle(s) add-on                          1          1     0243   23.4694   1581.98
   EPA       67331     T    Eye surgery follow-up add-on                         1          1     0243   23.4694   1581.98
   EPA       67332     T    Rerevise eye muscles add-on                          1          1     0243   23.4694   1581.98
   EPA       67334     T    Revise eye muscle w/suture                           1          1     0243   23.4694   1581.98
   EPA       67335     T    Eye suture during surgery                            1          1     0243   23.4694   1581.98
   EPA       67340     T    Revise eye muscle add-on                             1          1     0243   23.4694   1581.98

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 85 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             67343     T    Release eye tissue                                   1          1     0243   23.4694   1581.98
             67345     T    Destroy nerve of eye muscle                          1          1     0238    3.2267     217.5
             67346     T    Biopsy, eye muscle                                   1          1     0699   15.5407   1047.54
             67399     T    Eye muscle surgery procedure                         1          1     0243   23.4694   1581.98
             67400     T    Explore/biopsy eye socket                            1          1     0240    18.158   1223.96
             67405     T    Explore/drain eye socket                             1          1     0241   26.8396   1809.15
             67412     T    Explore/treat eye socket                             1          1     0240    18.158   1223.96
             67413     T    Explore/treat eye socket                             1          1     0241   26.8396   1809.15
             67414     T    Explr/decompress eye socket                          1          1     0242   39.0115   2629.61
             67415     T    Aspiration, orbital contents                         1          1     0240    18.158   1223.96
             67420     T    Explore/treat eye socket                             1          1     0242   39.0115   2629.61
             67430     T    Explore/treat eye socket                             1          1     0242   39.0115   2629.61
             67440     T    Explore/drain eye socket                             1          1     0242   39.0115   2629.61
             67445     T    Explr/decompress eye socket                          1          1     0242   39.0115   2629.61
             67450     T    Explore/biopsy eye socket                            1          1     0242   39.0115   2629.61
             67500     S    Inject/treat eye socket                              1          1     0231    1.9575    131.95
             67505     T    Inject/treat eye socket                              1          1     0238    3.2267     217.5
             67515     T    Inject/treat eye socket                              1          1     0238    3.2267     217.5
             67550     T    Insert eye socket implant                            1          1     0242   39.0115   2629.61
             67560     T    Revise eye socket implant                            1          1     0241   26.8396   1809.15
             67570     T    Decompress optic nerve                               1          1     0242   39.0115   2629.61
             67599     T    Orbit surgery procedure                              1          1     0238    3.2267     217.5
             67700     T    Drainage of eyelid abscess                           1          1     0238    3.2267     217.5
             67710     T    Incision of eyelid                                   1          1     0239    7.6421    515.12
             67715     T    Incision of eyelid fold                              1          1     0240    18.158   1223.96
             67800     T    Remove eyelid lesion                                 1          1     0238    3.2267     217.5
             67801     T    Remove eyelid lesions                                1          1     0239    7.6421    515.12
             67805     T    Remove eyelid lesions                                1          1     0238    3.2267     217.5
             67808     T    Remove eyelid lesion(s)                              1          1     0240    18.158   1223.96
             67810     T    Biopsy of eyelid                                     1          1     0238    3.2267     217.5
             67820     S    Revise eyelashes                                     1          1     0698    0.9553     64.39
             67825     T    Revise eyelashes                                     1          1     0238    3.2267     217.5
             67830     T    Revise eyelashes                                     1          1     0239    7.6421    515.12
             67835     T    Revise eyelashes                                     1          1     0240    18.158   1223.96
             67840     T    Remove eyelid lesion                                 1          1     0239    7.6421    515.12
             67850     T    Treat eyelid lesion                                  1          1     0239    7.6421    515.12
             67875     T    Closure of eyelid by suture                          1          1     0239    7.6421    515.12
             67880     T    Revision of eyelid                                   1          1     0233   16.2485   1095.25
             67882     T    Revision of eyelid                                   1          1     0240    18.158   1223.96
    PA       67900     T    Repair brow defect                                   1          1     0241   26.8396   1809.15
   EPA       67901     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
   EPA       67902     T    Repair eyelid defect                                 1          1     0241   26.8396   1809.15
   EPA       67903     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
   EPA       67904     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
   EPA       67906     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
   EPA       67908     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
    PA       67909     T    Revise eyelid defect                                 1          1     0240    18.158   1223.96
             67911     T    Revise eyelid defect                                 1          1     0240    18.158   1223.96
             67912     T    Correction eyelid w/implant                          1          1     0240    18.158   1223.96
             67914     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67915     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67916     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67917     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67921     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67922     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67923     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67924     T    Repair eyelid defect                                 1          1     0240    18.158   1223.96
             67930     T    Repair eyelid wound                                  1          1     0240    18.158   1223.96
             67935     T    Repair eyelid wound                                  1          1     0240    18.158   1223.96
             67938     S    Remove eyelid foreign body                           1          1     0231    1.9575    131.95
    PA       67950     T    Revision of eyelid                                   1          1     0240    18.158   1223.96
             67961     T    Revision of eyelid                                   1          1     0240    18.158   1223.96
             67966     T    Revision of eyelid                                   1          1     0240    18.158   1223.96
             67971     T    Reconstruction of eyelid                             1          1     0240    18.158   1223.96
             67973     T    Reconstruction of eyelid                             1          1     0241   26.8396   1809.15
             67974     T    Reconstruction of eyelid                             1          1     0240    18.158   1223.96

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 86 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             67975     T    Reconstruction of eyelid                             1          1     0240    18.158   1223.96
             67999     T    Revision of eyelid                                   1          1     0238    3.2267     217.5
             68020     T    Incise/drain eyelid lining                           1          1     0238    3.2267     217.5
             68040     S    Treatment of eyelid lesions                          1          1     0698    0.9553     64.39
             68100     T    Biopsy of eyelid lining                              1          1     0232    4.5074    303.83
             68110     T    Remove eyelid lining lesion                          1          1     0699   15.5407   1047.54
             68115     T    Remove eyelid lining lesion                          1          1     0240    18.158   1223.96
             68130     T    Remove eyelid lining lesion                          1          1     0233   16.2485   1095.25
             68135     T    Remove eyelid lining lesion                          1          1     0239    7.6421    515.12
             68200     S    Treat eyelid by injection                            1          1     0698    0.9553     64.39
             68320     T    Revise/graft eyelid lining                           1          1     0241   26.8396   1809.15
             68325     T    Revise/graft eyelid lining                           1          1     0241   26.8396   1809.15
             68326     T    Revise/graft eyelid lining                           1          1     0240    18.158   1223.96
             68328     T    Revise/graft eyelid lining                           1          1     0241   26.8396   1809.15
             68330     T    Revise eyelid lining                                 1          1     0234   24.4021   1644.85
             68335     T    Revise/graft eyelid lining                           1          1     0241   26.8396   1809.15
             68340     T    Separate eyelid adhesions                            1          1     0240    18.158   1223.96
             68360     T    Revise eyelid lining                                 1          1     0234   24.4021   1644.85
             68362     T    Revise eyelid lining                                 1          1     0234   24.4021   1644.85
    PA       68371     T    Harvest eye tissue, alograft                         1          1     0233   16.2485   1095.25
             68399     T    Eyelid lining surgery                                1          1     0238    3.2267     217.5
             68400     T    Incise/drain tear gland                              1          1     0238    3.2267     217.5
             68420     T    Incise/drain tear sac                                1          1     0240    18.158   1223.96
             68440     T    Incise tear duct opening                             1          1     0238    3.2267     217.5
             68500     T    Removal of tear gland                                1          1     0241   26.8396   1809.15
             68505     T    Partial removal, tear gland                          1          1     0241   26.8396   1809.15
             68510     T    Biopsy of tear gland                                 1          1     0240    18.158   1223.96
             68520     T    Removal of tear sac                                  1          1     0241   26.8396   1809.15
             68525     T    Biopsy of tear sac                                   1          1     0240    18.158   1223.96
             68530     T    Clearance of tear duct                               1          1     0238    3.2267     217.5
             68540     T    Remove tear gland lesion                             1          1     0240    18.158   1223.96
             68550     T    Remove tear gland lesion                             1          1     0241   26.8396   1809.15
             68700     T    Repair tear ducts                                    1          1     0240    18.158   1223.96
             68705     T    Revise tear duct opening                             1          1     0238    3.2267     217.5
             68720     T    Create tear sac drain                                1          1     0241   26.8396   1809.15
             68745     T    Create tear duct drain                               1          1     0241   26.8396   1809.15
             68750     T    Create tear duct drain                               1          1     0241   26.8396   1809.15
             68760     T    Close tear duct opening                              1          1     0238    3.2267     217.5
             68761     T    Close tear duct opening                              1          1     0238    3.2267     217.5
             68770     T    Close tear system fistula                            1          1     0241   26.8396   1809.15
             68801     S    Dilate tear duct opening                             1          1     0698    0.9553     64.39
             68810     T    Probe nasolacrimal duct                              1          1     0238    3.2267     217.5
             68811     T    Probe nasolacrimal duct                              1          1     0240    18.158   1223.96
             68815     T    Probe nasolacrimal duct                              1          1     0240    18.158   1223.96
             68816     T    Probe nl duct w/balloon                              1          1     0240    18.158   1223.96
             68840     S    Explore/irrigate tear ducts                          1          1     0231    1.9575    131.95
             68850     N    Injection for tear sac x-ray                         1          1       0
             68899     T    Tear duct system surgery                             1          1     0238    3.2267    217.5
             69000     T    Drain external ear lesion                            1          1     0006    1.4557    98.12
             69005     T    Drain external ear lesion                            1          1     0008   19.4063   1308.1
             69020     T    Drain outer ear canal lesion                         1          1     0006    1.4557    98.12
             69090     E    Pierce earlobes                                      0         NC       0
             69100     T    Biopsy of external ear                               1          1     0251     3.425    230.87
             69105     T    Biopsy of external ear canal                         1          1     0253   17.1879   1158.57
             69110     T    Remove external ear, partial                         1          1     0021   17.4975   1179.44
             69120     T    Removal of external ear                              1          1     0254   24.9637    1682.7
             69140     T    Remove ear canal lesion(s)                           1          1     0254   24.9637    1682.7
             69145     T    Remove ear canal lesion(s)                           1          1     0021   17.4975   1179.44
             69150     T    Extensive ear canal surgery                          1          1     0252    7.6196    513.61
             69155     C    Extensive ear/neck surgery                           1          1       0                          OR
             69200     X    Clear outer ear canal                                1          1     0340    0.6693    45.11
             69205     T    Clear outer ear canal                                1          1     0022    23.388   1576.49
             69210     X    Remove impacted ear wax                              1          1     0340    0.6693    45.11
             69220     T    Clean out mastoid cavity                             1          1     0013    0.8789    59.24
             69222     T    Clean out mastoid cavity                             1          1     0253   17.1879   1158.57
             69300     T    Revise external ear                                  0         NC       0

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 87 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             69310     T    Rebuild outer ear canal                              1          1     0256   42.9827   2897.29
             69320     T    Rebuild outer ear canal                              1          1     0256   42.9827   2897.29
             69399     T    Outer ear surgery procedure                          1          1     0250    1.1522     77.67
             69400     T    Inflate middle ear canal                             1          1     0251     3.425    230.87
             69401     T    Inflate middle ear canal                             1          1     0251     3.425    230.87
             69405     T    Catheterize middle ear canal                         1          1     0252    7.6196    513.61
             69420     T    Incision of eardrum                                  1          1     0251     3.425    230.87
             69421     T    Incision of eardrum                                  1          1     0253   17.1879   1158.57
             69424     T    Remove ventilating tube                              1          1     0253   17.1879   1158.57
             69433     T    Create eardrum opening                               1          1     0252    7.6196    513.61
             69436     T    Create eardrum opening                               1          1     0253   17.1879   1158.57
             69440     T    Exploration of middle ear                            1          1     0254   24.9637    1682.7
             69450     T    Eardrum revision                                     1          1     0256   42.9827   2897.29
             69501     T    Mastoidectomy                                        1          1     0256   42.9827   2897.29
             69502     T    Mastoidectomy                                        1          1     0254   24.9637    1682.7
             69505     T    Remove mastoid structures                            1          1     0256   42.9827   2897.29
             69511     T    Extensive mastoid surgery                            1          1     0256   42.9827   2897.29
             69530     T    Extensive mastoid surgery                            1          1     0256   42.9827   2897.29
             69535     C    Remove part of temporal bone                         1          1       0                          OR
             69540     T    Remove ear lesion                                    1          1     0253   17.1879   1158.57
             69550     T    Remove ear lesion                                    1          1     0256   42.9827   2897.29
             69552     T    Remove ear lesion                                    1          1     0256   42.9827   2897.29
             69554     C    Remove ear lesion                                    1          1       0                          OR
             69601     T    Mastoid surgery revision                             1          1     0256   42.9827   2897.29
             69602     T    Mastoid surgery revision                             1          1     0256   42.9827   2897.29
             69603     T    Mastoid surgery revision                             1          1     0256   42.9827   2897.29
             69604     T    Mastoid surgery revision                             1          1     0256   42.9827   2897.29
             69605     T    Mastoid surgery revision                             1          1     0256   42.9827   2897.29
             69610     T    Repair of eardrum                                    1          1     0254   24.9637    1682.7
             69620     T    Repair of eardrum                                    1          1     0254   24.9637    1682.7
             69631     T    Repair eardrum structures                            1          1     0256   42.9827   2897.29
             69632     T    Rebuild eardrum structures                           1          1     0256   42.9827   2897.29
             69633     T    Rebuild eardrum structures                           1          1     0256   42.9827   2897.29
             69635     T    Repair eardrum structures                            1          1     0256   42.9827   2897.29
             69636     T    Rebuild eardrum structures                           1          1     0256   42.9827   2897.29
             69637     T    Rebuild eardrum structures                           1          1     0256   42.9827   2897.29
             69641     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69642     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69643     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69644     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69645     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69646     T    Revise middle ear & mastoid                          1          1     0256   42.9827   2897.29
             69650     T    Release middle ear bone                              1          1     0254   24.9637    1682.7
             69660     T    Revise middle ear bone                               1          1     0256   42.9827   2897.29
             69661     T    Revise middle ear bone                               1          1     0256   42.9827   2897.29
             69662     T    Revise middle ear bone                               1          1     0256   42.9827   2897.29
             69666     T    Repair middle ear structures                         1          1     0256   42.9827   2897.29
             69667     T    Repair middle ear structures                         1          1     0256   42.9827   2897.29
             69670     T    Remove mastoid air cells                             1          1     0256   42.9827   2897.29
             69676     T    Remove middle ear nerve                              1          1     0256   42.9827   2897.29
             69700     T    Close mastoid fistula                                1          1     0256   42.9827   2897.29
             69710     E    Implant/replace hearing aid                          0         NC       0
             69711     T    Remove/repair hearing aid                            0         NC       0
    PA       69714     T    Implant temple bone w/stimul                         1          1     0425   118.767   8005.61
    PA       69715     T    Temple bne implnt w/stimulat                         1          1     0425   118.767   8005.61
    PA       69717     T    Temple bone implant revision                         1          1     0425   118.767   8005.61
    PA       69718     T    Revise temple bone implant                           1          1     0425   118.767   8005.61
             69720     T    Release facial nerve                                 1          1     0256   42.9827   2897.29
             69725     T    Release facial nerve                                 1          1     0256   42.9827   2897.29
             69740     T    Repair facial nerve                                  1          1     0256   42.9827   2897.29
             69745     T    Repair facial nerve                                  1          1     0256   42.9827   2897.29
             69799     T    Middle ear surgery procedure                         1          1     0250    1.1522     77.67
             69801     T    Incise inner ear                                     1          1     0254   24.9637    1682.7
             69802     T    Incise inner ear                                     1          1     0254   24.9637    1682.7
             69805     T    Explore inner ear                                    1          1     0256   42.9827   2897.29
             69806     T    Explore inner ear                                    1          1     0256   42.9827   2897.29

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 88 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             69820      T   Establish inner ear window                           1          1     0256    42.9827 2897.29
             69840      T   Revise inner ear window                              1          1     0256    42.9827 2897.29
             69905      T   Remove inner ear                                     1          1     0256    42.9827 2897.29
             69910      T   Remove inner ear & mastoid                           1          1     0256    42.9827 2897.29
             69915      T   Incise inner ear nerve                               1          1     0256    42.9827 2897.29
   EPA       69930      T   Implant cochlear device                              1          1     0259   428.8363 28906.14
             69949      T   Inner ear surgery procedure                          1          1     0250     1.1522   77.67
             69950     C    Incise inner ear nerve                               1          1       0                          OR
             69955      T   Release facial nerve                                 1          1     0256   42.9827   2897.29
             69960      T   Release inner ear canal                              1          1     0256   42.9827   2897.29
             69970      T   Remove inner ear lesion                              1          1     0256   42.9827   2897.29
             69979      T   Temporal bone surgery                                1          1     0250    1.1522    77.67
             69990     N    Microsurgery add-on                                  1          1       0
             70010     Q2   Contrast x-ray of brain                              1          1     0274     7.226   487.08                   60.47
             70015     Q2   Contrast x-ray of brain                              1          1     0274     7.226   487.08                   49.13
             70030      X   X-ray eye for foreign body                           1          1     0260    0.6661     44.9                   11.56
             70100      X   X-ray exam of jaw                                    1          1     0260    0.6661     44.9                   12.89
             70110      X   X-ray exam of jaw                                    1          1     0260    0.6661     44.9                   15.56
             70120      X   X-ray exam of mastoids                               1          1     0260    0.6661     44.9                   14.45
             70130      X   X-ray exam of mastoids                               1          1     0260    0.6661     44.9                   22.01
             70134      X   X-ray exam of middle ear                             1          1     0261    1.1161    75.23                   16.89
             70140      X   X-ray exam of facial bones                           1          1     0260    0.6661     44.9                   11.56
             70150      X   X-ray exam of facial bones                           1          1     0260    0.6661     44.9                   16.89
             70160      X   X-ray exam of nasal bones                            1          1     0260    0.6661     44.9                   13.78
             70170     Q2   X-ray exam of tear duct                              1          1     0263    3.1192   210.25                     BR
             70190      X   X-ray exam of eye sockets                            1          1     0260    0.6661     44.9                   14.45
             70200      X   X-ray exam of eye sockets                            1          1     0260    0.6661     44.9                   17.12
             70210      X   X-ray exam of sinuses                                1          1     0260    0.6661     44.9                   12.45
             70220      X   X-ray exam of sinuses                                1          1     0260    0.6661     44.9                   15.34
             70240      X   X-ray exam, pituitary saddle                         1          1     0260    0.6661     44.9                   11.56
             70250      X   X-ray exam of skull                                  1          1     0260    0.6661     44.9                   14.00
             70260      X   X-ray exam of skull                                  1          1     0261    1.1161    75.23                   17.56
             70300      X   X-ray exam of teeth                                  1          1     0262    0.4469    30.12                    5.11
             70310      X   X-ray exam of teeth                                  1          1     0262    0.4469    30.12                   15.78
             70320      X   Full mouth x-ray of teeth                            1          1     0262    0.4469    30.12                   21.56
             70328      X   X-ray exam of jaw joint                              1          1     0260    0.6661     44.9                   12.23
             70330      X   X-ray exam of jaw joints                             1          1     0260    0.6661     44.9                   20.23
             70332     Q2   X-ray exam of jaw joint                              1          1     0275    3.9361   265.32                   32.90
             70336     Q3   Magnetic image, jaw joint                            1          1     0336    5.1855   349.53                   228.52
             70350      X   X-ray head for orthodontia                           1          1     0260    0.6661     44.9                    6.89
             70355      X   Panoramic x-ray of jaws                              1          1     0260    0.6661     44.9                    6.67
             70360      X   X-ray exam of neck                                   1          1     0260    0.6661     44.9                   10.89
             70370      X   Throat x-ray & fluoroscopy                           1          1     0272    1.2693    85.56                   35.35
             70371      X   Speech evaluation, complex                           1          1     0272    1.2693    85.56                   31.12
             70373     Q2   Contrast x-ray of larynx                             1          1     0263    3.1192   210.25                   34.46
             70380      X   X-ray exam of salivary gland                         1          1     0260    0.6661     44.9                   16.67
             70390     Q2   X-ray exam of salivary duct                          1          1     0263    3.1192   210.25                   46.46
             70450     Q3   Ct head/brain w/o dye                                1          1     0332     2.894   195.07                   92.70
             70460     Q3   Ct head/brain w/dye                                  1          1     0283    4.4066   297.03                   119.60
             70470     Q3   Ct head/brain w/o & w/dye                            1          1     0333    4.9479   333.52                   147.38
             70480     Q3   Ct orbit/ear/fossa w/o dye                           1          1     0332     2.894   195.07                   146.27
             70481     Q3   Ct orbit/ear/fossa w/dye                             1          1     0283    4.4066   297.03                   172.95
             70482     Q3   Ct orbit/ear/fossa w/o&w/dye                         1          1     0333    4.9479   333.52                   200.96
             70486     Q3   Ct maxillofacial w/o dye                             1          1     0332     2.894   195.07                   120.71
             70487     Q3   Ct maxillofacial w/dye                               1          1     0283    4.4066   297.03                   147.83
             70488     Q3   Ct maxillofacial w/o & w/dye                         1          1     0333    4.9479   333.52                   184.73
             70490     Q3   Ct soft tissue neck w/o dye                          1          1     0332     2.894   195.07                   114.48
             70491     Q3   Ct soft tissue neck w/dye                            1          1     0283    4.4066   297.03                   142.27
             70492     Q3   Ct sft tsue nck w/o & w/dye                          1          1     0333    4.9479   333.52                   178.95
             70496     Q3   Ct angiography, head                                 1          1     0662    5.0511   340.47                   334.56
             70498     Q3   Ct angiography, neck                                 1          1     0662    5.0511   340.47                   335.01
             70540     Q3   Mri orbit/face/neck w/o dye                          1          1     0336    5.1855   349.53                   259.65
             70542     Q3   Mri orbit/face/neck w/dye                            1          1     0284    6.2901   423.99                   284.99
             70543     Q3   Mri orbt/fac/nck w/o & w/dye                         1          1     0337    7.9432   535.42                   385.25
             70544     Q3   Mr angiography head w/o dye                          1          1     0336    5.1855   349.53                   319.22
             70545     Q3   Mr angiography head w/dye                            1          1     0284    6.2901   423.99                   317.22

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 89 of 216                                                                                                                        All Rights Reserved
                                                       HRSA Outpatient Fee Schedule                                                  CY2010 Q4
                                                           Washington State Medicaid


                                                                                       MAX     APC    RW       NWR       OPPS            OP
  AUTH           CPT   SI   Description                                     COV
                                                                                       UNITS   2010   2010     2010       Fee            Fee
             70546     Q3   Mr angiograph head w/o&w/dye                      1          1     0337   7.9432   535.42                  507.29
             70547     Q3   Mr angiography neck w/o dye                       1          1     0336   5.1855   349.53                  318.33
             70548     Q3   Mr angiography neck w/dye                         1          1     0284   6.2901   423.99                  333.89
             70549     Q3   Mr angiograph neck w/o&w/dye                      1          1     0337   7.9432   535.42                  507.29
             70551     Q3   Mri brain w/o dye                                 1          1     0336   5.1855   349.53                  264.09
             70552     Q3   Mri brain w/dye                                   1          1     0284   6.2901   423.99                  290.99
             70553     Q3   Mri brain w/o & w/dye                             1          1     0337   7.9432   535.42                  374.58
             70554     Q3   Fmri brain by tech                                0         NC       0
             70555      S   Fmri brain by phys/psych                          0         NC       0
             70557      S   Mri brain w/o dye                                 1          1     0336   5.1855   349.53                    BR
             70558      S   Mri brain w/dye                                   1          1     0284   6.2901   423.99                    BR
             70559      S   Mri brain w/o & w/dye                             1          1     0337   7.9432   535.42                    BR
             71010      X   Chest x-ray                                       1          6     0260   0.6661     44.9                   8.67
             71015      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  11.34
             71020      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  11.78
             71021      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  14.23
             71022      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  17.78
             71023      X   Chest x-ray and fluoroscopy                       1          1     0272   1.2693    85.56                  28.23
             71030      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  17.78
             71034      X   Chest x-ray and fluoroscopy                       1          1     0272   1.2693    85.56                  38.24
             71035      X   Chest x-ray                                       1          1     0260   0.6661     44.9                  14.89
             71040     Q2   Contrast x-ray of bronchi                         1          1     0263   3.1192   210.25                  38.90
             71060     Q2   Contrast x-ray of bronchi                         1          1     0263   3.1192   210.25                  60.02
             71090     N    X-ray & pacemaker insertion                       1          1       0                                       BR
             71100      X   X-ray exam of ribs                                1          1     0260   0.6661     44.9                  12.45
             71101      X   X-ray exam of ribs/chest                          1          1     0260   0.6661     44.9                  14.89
             71110      X   X-ray exam of ribs                                1          1     0260   0.6661     44.9                  15.56
             71111      X   X-ray exam of ribs/chest                          1          1     0261   1.1161    75.23                  20.90
             71120      X   X-ray exam of breastbone                          1          1     0260   0.6661     44.9                  12.89
             71130      X   X-ray exam of breastbone                          1          1     0260   0.6661     44.9                  15.12
             71250     Q3   Ct thorax w/o dye                                 1          1     0332    2.894   195.07                  119.82
             71260     Q3   Ct thorax w/dye                                   1          1     0283   4.4066   297.03                  148.50
             71270     Q3   Ct thorax w/o & w/dye                             1          1     0333   4.9479   333.52                  187.62
             71275     Q3   Ct angiography, chest                             1          1     0662   5.0511   340.47                  246.75
             71550     Q3   Mri chest w/o dye                                 1          1     0336   5.1855   349.53                  292.55
             71551     Q3   Mri chest w/dye                                   1          1     0284   6.2901   423.99                  325.89
             71552     Q3   Mri chest w/o & w/dye                             1          1     0337   7.9432   535.42                  442.60
             71555     B    Mri angio chest w or w/o dye                      0         NC       0
             72010      X   X-ray exam of spine                               1          1     0261   1.1161    75.23                  28.45
             72020      X   X-ray exam of spine                               1          6     0260   0.6661     44.9                   9.34
             72040      X   X-ray exam of neck spine                          1          1     0260   0.6661     44.9                  15.12
             72050      X   X-ray exam of neck spine                          1          1     0261   1.1161    75.23                  21.12
             72052      X   X-ray exam of neck spine                          1          1     0261   1.1161    75.23                  27.57
             72069      X   X-ray exam of trunk spine                         1          1     0260   0.6661     44.9                  14.23
             72070      X   X-ray exam of thoracic spine                      1          1     0260   0.6661     44.9                  12.89
             72072      X   X-ray exam of thoracic spine                      1          1     0260   0.6661     44.9                  15.56
             72074      X   X-ray exam of thoracic spine                      1          1     0260   0.6661     44.9                  19.34
             72080      X   X-ray exam of trunk spine                         1          1     0260   0.6661     44.9                  14.00
             72090      X   X-ray exam of trunk spine                         1          1     0261   1.1161    75.23                  19.12
             72100      X   X-ray exam of lower spine                         1          1     0260   0.6661     44.9                  16.23
             72110      X   X-ray exam of lower spine                         1          1     0261   1.1161    75.23                  22.23
             72114      X   X-ray exam of lower spine                         1          1     0261   1.1161    75.23                  31.12
             72120      X   X-ray exam of lower spine                         1          1     0261   1.1161    75.23                  22.01
             72125     Q3   Ct neck spine w/o dye                             1          1     0332    2.894   195.07                  120.26
             72126     Q3   Ct neck spine w/dye                               1          1     0283   4.4066   297.03                  148.94
             72127     Q3   Ct neck spine w/o & w/dye                         1          1     0333   4.9479   333.52                  187.40
             72128     Q3   Ct chest spine w/o dye                            1          1     0332    2.894   195.07                  119.82
             72129     Q3   Ct chest spine w/dye                              1          1     0283   4.4066   297.03                  148.94
             72130     Q3   Ct chest spine w/o & w/dye                        1          1     0333   4.9479   333.52                  188.07
             72131     Q3   Ct lumbar spine w/o dye                           1          1     0332    2.894   195.07                  119.60
             72132     Q3   Ct lumbar spine w/dye                             1          1     0283   4.4066   297.03                  148.50
             72133     Q3   Ct lumbar spine w/o & w/dye                       1          1     0333   4.9479   333.52                  187.62
             72141     Q3   Mri neck spine w/o dye                            1          1     0336   5.1855   349.53                  232.53
             72142     Q3   Mri neck spine w/dye                              1          1     0284   6.2901   423.99                  290.99
             72146     Q3   Mri chest spine w/o dye                           1          1     0336   5.1855   349.53                  238.08
             72147     Q3   Mri chest spine w/dye                             1          1     0284   6.2901   423.99                  258.76

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 90 of 216                                                                                                                   All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                 CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW       NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010     2010       Fee            Fee
             72148     Q3   Mri lumbar spine w/o dye                             1          1     0336   5.1855   349.53                  237.86
             72149     Q3   Mri lumbar spine w/dye                               1          1     0284   6.2901   423.99                  290.10
             72156     Q3   Mri neck spine w/o & w/dye                           1          1     0337   7.9432   535.42                  368.80
             72157     Q3   Mri chest spine w/o & w/dye                          1          1     0337   7.9432   535.42                  344.34
             72158     Q3   Mri lumbar spine w/o & w/dye                         1          1     0337   7.9432   535.42                  368.35
             72159     B    Mr angio spine w/o&w/dye                             0         NC       0
             72170      X   X-ray exam of pelvis                                 1          1     0260   0.6661    44.9                   10.23
             72190      X   X-ray exam of pelvis                                 1          1     0260   0.6661    44.9                   16.89
             72191     Q3   Ct angiograph pelv w/o&w/dye                         1          1     0662   5.0511   340.47                  238.75
             72192     Q3   Ct pelvis w/o dye                                    1          1     0332    2.894   195.07                  113.60
             72193     Q3   Ct pelvis w/dye                                      1          1     0283   4.4066   297.03                  141.16
             72194     Q3   Ct pelvis w/o & w/dye                                1          1     0333   4.9479   333.52                  188.29
             72195     Q3   Mri pelvis w/o dye                                   1          1     0336   5.1855   349.53                  263.43
             72196     Q3   Mri pelvis w/dye                                     1          1     0284   6.2901   423.99                  288.55
             72197     Q3   Mri pelvis w/o & w/dye                               1          1     0337   7.9432   535.42                  387.91
             72198     B    Mr angio pelvis w/o & w/dye                          0         NC       0
             72200      X   X-ray exam sacroiliac joints                         1          1     0260   0.6661    44.9                    12.00
             72202      X   X-ray exam sacroiliac joints                         1          1     0260   0.6661    44.9                    14.45
             72220      X   X-ray exam of tailbone                               1          1     0260   0.6661    44.9                    11.78
             72240     Q2   Contrast x-ray of neck spine                         1          1     0274    7.226   487.08                   60.47
             72255     Q2   Contrast x-ray, thorax spine                         1          1     0274    7.226   487.08                   54.24
             72265     Q2   Contrast x-ray, lower spine                          1          1     0274    7.226   487.08                   57.35
             72270     Q2   Contrast x-ray, spine                                1          1     0274    7.226   487.08                   88.48
             72275     N    Epidurography                                        1          1       0                                      39.35
             72285     Q2   X-ray c/t spine disk                                 0         NC       0
             72291     N    Perq verte/sacroplsty, fluor                         0         NC       0
             72292     N    Perq verte/sacroplsty, ct                            0         NC       0
             72295     Q2   X-ray of lower spine disk                            0         NC       0
             73000      X   X-ray exam of collar bone                            1          1     0260   0.6661    44.9                   11.34
             73010      X   X-ray exam of shoulder blade                         1          1     0260   0.6661    44.9                   11.78
             73020      X   X-ray exam of shoulder                               1          1     0260   0.6661    44.9                    9.34
             73030      X   X-ray exam of shoulder                               1          1     0260   0.6661    44.9                   11.78
             73040     Q2   Contrast x-ray of shoulder                           1          1     0275   3.9361   265.32                  45.79
             73050      X   X-ray exam of shoulders                              1          1     0260   0.6661    44.9                   15.12
             73060      X   X-ray exam of humerus                                1          2     0260   0.6661    44.9                   11.78
             73070      X   X-ray exam of elbow                                  1          1     0260   0.6661    44.9                   11.56
             73080      X   X-ray exam of elbow                                  1          1     0260   0.6661    44.9                   15.12
             73085     Q2   Contrast x-ray of elbow                              1          1     0275   3.9361   265.32                  39.79
             73090      X   X-ray exam of forearm                                1          1     0260   0.6661    44.9                   11.34
             73092      X   X-ray exam of arm, infant                            1          1     0260   0.6661    44.9                   12.00
             73100      X   X-ray exam of wrist                                  1          1     0260   0.6661    44.9                   12.23
             73110      X   X-ray exam of wrist                                  1          1     0260   0.6661    44.9                   15.34
             73115     Q2   Contrast x-ray of wrist                              1          1     0275   3.9361   265.32                  44.46
             73120      X   X-ray exam of hand                                   1          1     0260   0.6661    44.9                   11.12
             73130      X   X-ray exam of hand                                   1          1     0260   0.6661    44.9                   13.12
             73140      X   X-ray exam of finger(s)                              1          1     0260   0.6661    44.9                   13.34
             73200     Q3   Ct upper extremity w/o dye                           1          1     0332    2.894   195.07                  115.37
             73201     Q3   Ct upper extremity w/dye                             1          1     0283   4.4066   297.03                  142.72
             73202     Q3   Ct uppr extremity w/o&w/dye                          1          1     0333   4.9479   333.52                  190.96
             73206     Q3   Ct angio upr extrm w/o&w/dye                         1          1     0662   5.0511   340.47                  225.63
             73218     Q3   Mri upper extremity w/o dye                          1          1     0336   5.1855   349.53                  267.20
             73219     Q3   Mri upper extremity w/dye                            1          1     0284   6.2901   423.99                  289.21
             73220     Q3   Mri uppr extremity w/o&w/dye                         1          1     0337   7.9432   535.42                  389.91
             73221     Q3   Mri joint upr extrem w/o dye                         1          1     0336   5.1855   349.53                  250.53
             73222     Q3   Mri joint upr extrem w/dye                           1          6     0284   6.2901   423.99                  271.43
             73223     Q3   Mri joint upr extr w/o&w/dye                         1          6     0337   7.9432   535.42                  368.80
             73225     B    Mr angio upr extr w/o&w/dye                          0         NC       0
             73500      X   X-ray exam of hip                                    1          1     0260   0.6661     44.9                    9.78
             73510      X   X-ray exam of hip                                    1          1     0260   0.6661     44.9                   15.12
             73520      X   X-ray exam of hips                                   1          1     0261   1.1161    75.23                   15.34
             73525     Q2   Contrast x-ray of hip                                1          1     0275   3.9361   265.32                   40.01
             73530     N    X-ray exam of hip                                    1          1       0                                        BR
             73540      X   X-ray exam of pelvis & hips                          1          1     0260   0.6661    44.9                    16.23
             73542     Q2   X-ray exam, sacroiliac joint                         1          1     0275   3.9361   265.32                   29.57
             73550      X   X-ray exam of thigh                                  1          1     0260   0.6661    44.9                    11.12
             73560      X   X-ray exam of knee, 1 or 2                           1          1     0260   0.6661    44.9                    11.78

                                                                                                                            CPT Codes and Descriptions
                                                                                                                                         Copyright 2010
                                                                                                                           American Medical Association
Page 91 of 216                                                                                                                      All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                 CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW       NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010     2010       Fee            Fee
             73562      X   X-ray exam of knee, 3                                1          1     0260   0.6661    44.9                   14.67
             73564      X   X-ray exam, knee, 4 or more                          1          1     0260   0.6661    44.9                   16.89
             73565      X   X-ray exam of knees                                  1          1     0260   0.6661    44.9                   13.12
             73580     Q2   Contrast x-ray of knee joint                         1          1     0275   3.9361   265.32                  55.58
             73590      X   X-ray exam of lower leg                              1          1     0260   0.6661    44.9                   10.89
             73592      X   X-ray exam of leg, infant                            1          1     0260   0.6661    44.9                   12.23
             73600      X   X-ray exam of ankle                                  1          1     0260   0.6661    44.9                   11.34
             73610      X   X-ray exam of ankle                                  1          1     0260   0.6661    44.9                   13.34
             73615     Q2   Contrast x-ray of ankle                              1          1     0275   3.9361   265.32                  42.24
             73620      X   X-ray exam of foot                                   1          1     0260   0.6661    44.9                   10.89
             73630      X   X-ray exam of foot                                   1          1     0260   0.6661    44.9                   13.12
             73650      X   X-ray exam of heel                                   1          1     0260   0.6661    44.9                   11.12
             73660      X   X-ray exam of toe(s)                                 1          1     0260   0.6661    44.9                   12.45
             73700     Q3   Ct lower extremity w/o dye                           1          1     0332    2.894   195.07                  115.60
             73701     Q3   Ct lower extremity w/dye                             1          1     0283   4.4066   297.03                  144.05
             73702     Q3   Ct lwr extremity w/o&w/dye                           1          1     0333   4.9479   333.52                  191.40
             73706     Q3   Ct angio lwr extr w/o&w/dye                          1          1     0662   5.0511   340.47                  248.98
             73718     Q3   Mri lower extremity w/o dye                          1          1     0336   5.1855   349.53                  261.87
             73719     Q3   Mri lower extremity w/dye                            1          1     0284   6.2901   423.99                  285.88
             73720     Q3   Mri lwr extremity w/o&w/dye                          1          1     0337   7.9432   535.42                  389.91
             73721     Q3   Mri jnt of lwr extre w/o dye                         1          1     0336   5.1855   349.53                  255.87
             73722     Q3   Mri joint of lwr extr w/dye                          1          6     0284   6.2901   423.99                  274.32
             73723     Q3   Mri joint lwr extr w/o&w/dye                         1          6     0337   7.9432   535.42                  367.68
             73725     B    Mr ang lwr ext w or w/o dye                          0         NC       0
             74000      X   X-ray exam of abdomen                                1          1     0260   0.6661     44.9                   9.56
             74010      X   X-ray exam of abdomen                                1          1     0260   0.6661     44.9                  15.12
             74020      X   X-ray exam of abdomen                                1          1     0260   0.6661     44.9                  15.34
             74022      X   X-ray exam series, abdomen                           1          1     0261   1.1161    75.23                  18.45
             74150     Q3   Ct abdomen w/o dye                                   1          1     0332    2.894   195.07                  112.48
             74160     Q3   Ct abdomen w/dye                                     1          1     0283   4.4066   297.03                  160.50
             74170     Q3   Ct abdomen w/o & w/dye                               1          1     0333   4.9479   333.52                  219.41
             74175     Q3   Ct angio abdom w/o & w/dye                           1          1     0662   5.0511   340.47                  254.53
             74181     Q3   Mri abdomen w/o dye                                  1          1     0336   5.1855   349.53                  232.97
             74182     Q3   Mri abdomen w/dye                                    1          1     0284   6.2901   423.99                  318.56
             74183     Q3   Mri abdomen w/o & w/dye                              1          1     0337   7.9432   535.42                  388.58
             74185     B    Mri angio, abdom w orw/o dye                         0         NC       0
             74190     Q2   X-ray exam of peritoneum                             1          1     0263   3.1192   210.25                    BR
             74210      S   Contrst x-ray exam of throat                         1          1     0276   1.2985    87.53                  34.23
             74220      S   Contrast x-ray, esophagus                            1          1     0276   1.2985    87.53                  38.01
             74230      S   Cine/vid x-ray, throat/esoph                         1          1     0276   1.2985    87.53                  36.68
             74235     N    Remove esophagus obstruction                         1          1       0                                       BR
             74240      S   X-ray exam, upper gi tract                           1          1     0276   1.2985    87.53                  42.68
             74241      S   X-ray exam, upper gi tract                           1          1     0276   1.2985    87.53                  47.35
             74245      S   X-ray exam, upper gi tract                           1          1     0277   2.1001   141.56                  74.25
             74246      S   Contrst x-ray uppr gi tract                          1          1     0276   1.2985    87.53                  51.80
             74247      S   Contrst x-ray uppr gi tract                          1          1     0276   1.2985    87.53                  59.58
             74249      S   Contrst x-ray uppr gi tract                          1          1     0277   2.1001   141.56                  81.81
             74250      S   X-ray exam of small bowel                            1          1     0276   1.2985    87.53                  46.46
             74251      S   X-ray exam of small bowel                            1          1     0277   2.1001   141.56                  177.62
             74260      S   X-ray exam of small bowel                            1          1     0276   1.2985    87.53                  149.83
             74261     Q3   Ct colonography, w/o dye                             0         NC       0
             74262     Q3   Ct colonography, w/dye                               0         NC       0
             74263      E   Ct colonography, screen                              0         NC       0
             74270      S   Contrast x-ray exam of colon                         1          1     0276   1.2985    87.53                   66.02
             74280      S   Contrast x-ray exam of colon                         1          1     0277   2.1001   141.56                   90.70
             74283      S   Contrast x-ray exam of colon                         1          1     0276   1.2985    87.53                   60.69
             74290      S   Contrast x-ray, gallbladder                          1          1     0276   1.2985    87.53                   29.34
             74291      S   Contrast x-rays, gallbladder                         1          1     0276   1.2985    87.53                   28.90
             74300     N    X-ray bile ducts/pancreas                            1          1       0                                       BR
             74301     N    X-rays at surgery add-on                             1          1       0                                       BR
             74305     Q2   X-ray bile ducts/pancreas                            1          1     0263   3.1192   210.25                    BR
             74320     Q2   Contrast x-ray of bile ducts                         1          1     0317   5.6012   377.55                   48.02
             74327     N    X-ray bile stone removal                             1          1       0                                      55.80
             74328     N    X-ray bile duct endoscopy                            1          1       0                                       BR
             74329     N    X-ray for pancreas endoscopy                         1          1       0                                       BR
             74330     N    X-ray bile/panc endoscopy                            1          1       0                                       BR

                                                                                                                            CPT Codes and Descriptions
                                                                                                                                         Copyright 2010
                                                                                                                           American Medical Association
Page 92 of 216                                                                                                                      All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             74340     N    X-ray guide for GI tube                              1          1       0                                         BR
             74355     N    X-ray guide, intestinal tube                         1          1       0                                         BR
             74360     N    X-ray guide, GI dilation                             1          1       0                                         BR
             74363     N    X-ray, bile duct dilation                            1          1       0                                         BR
             74400      S   Contrst x-ray, urinary tract                         1          1     0278     2.546    171.62                  49.57
             74410      S   Contrst x-ray, urinary tract                         1          1     0278     2.546    171.62                  52.02
             74415      S   Contrst x-ray, urinary tract                         1          1     0278     2.546    171.62                  63.36
             74420      S   Contrst x-ray, urinary tract                         1          1     0278     2.546    171.62                    BR
             74425     Q2   Contrst x-ray, urinary tract                         1          1     0278     2.546    171.62                    BR
             74430     Q2   Contrast x-ray, bladder                              1          1     0278     2.546    171.62                  36.90
             74440     Q2   X-ray, male genital tract                            1          1     0278     2.546    171.62                  38.46
             74445     Q2   X-ray exam of penis                                  1          1     0278     2.546    171.62                    BR
             74450     Q2   X-ray, urethra/bladder                               1          1     0278     2.546    171.62                    BR
             74455     Q2   X-ray, urethra/bladder                               1          1     0278     2.546    171.62                  42.46
             74470     Q2   X-ray exam of kidney lesion                          1          1     0263    3.1192    210.25                    BR
             74475     Q2   X-ray control, cath insert                           1          1     0161   17.0344   1148.22                  51.57
             74480     Q2   X-ray control, cath insert                           1          1     0161   17.0344   1148.22                  51.80
             74485     Q2   X-ray guide, GU dilation                             1          1     0161   17.0344   1148.22                  49.80
             74710      X   X-ray measurement of pelvis                          1          1     0261    1.1161     75.23                  14.00
             74740     Q2   X-ray, female genital tract                          1          1     0263    3.1192    210.25                  34.46
             74742     N    X-ray, fallopian tube                                1          1       0                                         BR
             74775      S   X-ray exam of perineum                               1          1     0278    2.546    171.62                     BR
             75557     Q3   Cardiac mri for morph                                1          1     0336   5.1855    349.53                   199.85
             75559     Q3   Cardiac mri w/stress img                             1          1     0336   5.1855    349.53                   307.44
             75561     Q3   Cardiac mri for morph w/dye                          1          1     0337   7.9432    535.42                   289.43
             75563     Q3   Card mri w/stress img & dye                          1          1     0337   7.9432    535.42                   359.68
             75565     N    Card mri vel flw map add-on                          1          1       0                                       48.68
             75571      X   Ct hrt w/o dye w/ca test                             0         NC       0
    PA       75572      S   Ct hrt w/3d image                                    1          1     0383    3.9929    269.15                  136.05
    PA       75573      S   Ct hrt w/3d image, congen                            1          1     0383    3.9929    269.15                  197.40
    PA       75574      S   Ct angio hrt w/3d image                              1          1     0383    3.9929    269.15                  349.46
             75600     Q2   Contrast x-ray exam of aorta                         1          1     0279   29.1126   1962.36                  154.94
             75605     Q2   Contrast x-ray exam of aorta                         1          1     0279   29.1126   1962.36                  104.93
             75625     Q2   Contrast x-ray exam of aorta                         1          1     0279   29.1126   1962.36                  104.48
             75630     Q2   X-ray aorta, leg arteries                            1          1     0279   29.1126   1962.36                  107.59
             75635     Q2   Ct angio abdominal arteries                          1          1     0662    5.0511    340.47                  276.32
             75650     Q2   Artery x-rays, head & neck                           1          1     0280   45.8793   3092.54                  104.93
             75658     Q2   Artery x-rays, arm                                   1          1     0279   29.1126   1962.36                  112.04
             75660     Q2   Artery x-rays, head & neck                           1          1     0280   45.8793   3092.54                  113.37
             75662     Q2   Artery x-rays, head & neck                           1          1     0280   45.8793   3092.54                  127.38
             75665     Q2   Artery x-rays, head & neck                           1          1     0279   29.1126   1962.36                  117.82
             75671     Q2   Artery x-rays, head & neck                           1          1     0280   45.8793   3092.54                  131.82
             75676     Q2   Artery x-rays, neck                                  1          1     0279   29.1126   1962.36                  113.15
             75680     Q2   Artery x-rays, neck                                  1          1     0279   29.1126   1962.36                  122.27
             75685     Q2   Artery x-rays, spine                                 1          1     0279   29.1126   1962.36                  113.37
             75705     Q2   Artery x-rays, spine                                 1          1     0279   29.1126   1962.36                  113.15
             75710     Q2   Artery x-rays, arm/leg                               1          1     0279   29.1126   1962.36                  114.48
             75716     Q2   Artery x-rays, arms/legs                             1          1     0279   29.1126   1962.36                  129.60
             75722     Q2   Artery x-rays, kidney                                1          1     0279   29.1126   1962.36                  110.71
             75724     Q2   Artery x-rays, kidneys                               1          1     0279   29.1126   1962.36                  124.93
             75726     Q2   Artery x-rays, abdomen                               1          1     0279   29.1126   1962.36                  112.71
             75731     Q2   Artery x-rays, adrenal gland                         1          1     0279   29.1126   1962.36                  114.26
             75733     Q2   Artery x-rays, adrenals                              1          1     0279   29.1126   1962.36                  132.05
             75736     Q2   Artery x-rays, pelvis                                1          1     0279   29.1126   1962.36                  113.15
             75741     Q2   Artery x-rays, lung                                  1          1     0279   29.1126   1962.36                  101.15
             75743     Q2   Artery x-rays, lungs                                 1          1     0279   29.1126   1962.36                  106.04
             75746     Q2   Artery x-rays, lung                                  1          1     0668   10.2978    694.13                  108.70
             75756     Q2   Artery x-rays, chest                                 1          1     0668   10.2978    694.13                  115.60
             75774     N    Artery x-ray, each vessel                            1          1       0                                       94.92
             75791     Q2   Av dialysis shunt imaging                            1          1     0676    2.3954    161.46                  137.16
             75801     Q2   Lymph vessel x-ray, arm/leg                          1          1     0317    5.6012    377.55                    BR
             75803     Q2   Lymph vessel x-ray,arms/legs                         1          1     0317    5.6012    377.55                    BR
             75805     Q2   Lymph vessel x-ray, trunk                            1          1     0317    5.6012    377.55                    BR
             75807     Q2   Lymph vessel x-ray, trunk                            1          1     0317    5.6012    377.55                    BR
             75809     Q2   Nonvascular shunt, x-ray                             1          1     0261    1.1161     75.23                  39.35
             75810     Q2   Vein x-ray, spleen/liver                             1          1     0279   29.1126   1962.36                    BR

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 93 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             75820     Q2   Vein x-ray, arm/leg                                  1          1     0668   10.2978    694.13                  50.46
             75822     Q2   Vein x-ray, arms/legs                                1          1     0668   10.2978    694.13                  55.80
             75825     Q2   Vein x-ray, trunk                                    1          1     0279   29.1126   1962.36                  99.37
             75827     Q2   Vein x-ray, chest                                    1          1     0668   10.2978    694.13                  100.48
             75831     Q2   Vein x-ray, kidney                                   1          1     0279   29.1126   1962.36                  101.37
             75833     Q2   Vein x-ray, kidneys                                  1          1     0279   29.1126   1962.36                  109.82
             75840     Q2   Vein x-ray, adrenal gland                            1          1     0279   29.1126   1962.36                  99.81
             75842     Q2   Vein x-ray, adrenal glands                           1          1     0279   29.1126   1962.36                  109.59
             75860     Q2   Vein x-ray, neck                                     1          1     0668   10.2978    694.13                  102.70
             75870     Q2   Vein x-ray, skull                                    1          1     0668   10.2978    694.13                  103.37
             75872     Q2   Vein x-ray, skull                                    1          1     0668   10.2978    694.13                  128.93
             75880     Q2   Vein x-ray, eye socket                               1          1     0668   10.2978    694.13                  52.24
             75885     Q2   Vein x-ray, liver                                    1          1     0279   29.1126   1962.36                  101.37
             75887     Q2   Vein x-ray, liver                                    1          1     0668   10.2978    694.13                  102.92
             75889     Q2   Vein x-ray, liver                                    1          1     0279   29.1126   1962.36                  101.15
             75891     Q2   Vein x-ray, liver                                    1          1     0279   29.1126   1962.36                  101.15
             75893     Q2   Venous sampling by catheter                          1         UR     0279   29.1126   1962.36                  100.70
             75894     N    X-rays, transcath therapy                            1          1       0                                         BR
             75896     N    X-rays, transcath therapy                            1          1       0                                         BR
             75898     Q1   Follow-up angiography                                1          1     0261   1.1161     75.23                     BR
             75900     C    Intravascular cath exchange                          1          1       0                           OF            BR
             75901     N    Remove cva device obstruct                           1          1       0                                       76.92
             75902     N    Remove cva lumen obstruct                            1          1       0                                       32.68
             75940     N    X-ray placement, vein filter                         1          1       0                                         BR
             75945     Q2   Intravascular us                                     1          1     0267   2.3005    155.07                     BR
             75946     N    Intravascular us add-on                              1          1       0                                         BR
             75952     C    Endovasc repair abdom aorta                          1          1       0                           OF            BR
             75953     C    Abdom aneurysm endovas rpr                           1          1       0                           OF            BR
             75954     C    Iliac aneurysm endovas rpr                           1          1       0                           OF            BR
             75956     C    Xray, endovasc thor ao repr                          1          1       0                           OF            BR
             75957     C    Xray, endovasc thor ao repr                          1          1       0                           OF            BR
             75958     C    Xray, place prox ext thor ao                         1          1       0                           OF            BR
             75959     C    Xray, place dist ext thor ao                         1          1       0                           OF            BR
             75960     N    Transcath iv stent rs&i                              1          1       0                                       104.70
             75961     N    Retrieval, broken catheter                           1          1       0                                       100.70
             75962     Q2   Repair arterial blockage                             1          1     0083   50.6809   3416.2                   124.27
             75964     N    Repair artery blockage, each                         1          1       0                                       74.47
             75966     Q2   Repair arterial blockage                             1          1     0083   50.6809   3416.2                   127.16
             75968     N    Repair artery blockage, each                         1          1       0                                       73.58
             75970     N    Vascular biopsy                                      1          1       0                                         BR
             75978     Q2   Repair venous blockage                               1          1     0093   35.5969   2399.44                  122.93
             75980     N    Contrast xray exam bile duct                         1          1       0                                         BR
             75982     N    Contrast xray exam bile duct                         1          1       0                                         BR
             75984     N    Xray control catheter change                         1          1       0                                       45.13
             75989     N    Abscess drainage under x-ray                         1          1       0                                       45.79
             75992     N    Atherectomy, x-ray exam                              1          1       0                                         BR
             75993     N    Atherectomy, x-ray exam                              1          1       0                                         BR
             75994     N    Atherectomy, x-ray exam                              1          1       0                                         BR
             75995     N    Atherectomy, x-ray exam                              1          1       0                                         BR
             75996     N    Atherectomy, x-ray exam                              1          1       0                                         BR
             76000     Q1   Fluoroscope examination                              1          1     0272   1.2693     85.56                   54.46
             76001     N    Fluoroscope exam, extensive                          1          1       0                                         BR
             76010      X   X-ray, nose to rectum                                1          1     0260   0.6661      44.9                   10.89
             76080     Q2   X-ray exam of fistula                                1          1     0263   3.1192    210.25                   20.45
             76098     Q2   X-ray exam, breast specimen                          1          1     0317   5.6012    377.55                    6.67
             76100      X   X-ray exam of body section                           1          1     0261   1.1161     75.23                   57.58
             76101      X   Complex body section x-ray                           1          1     0263   3.1192    210.25                   87.36
             76102      X   Complex body section x-rays                          1          1     0263   3.1192    210.25                   124.04
             76120      X   Cine/video x-rays                                    1          1     0272   1.2693     85.56                   33.35
             76125     N    Cine/video x-rays add-on                             1          1       0                                         BR
             76140      E   X-ray consultation                                   0         NC       0
             76150      X   X-ray exam, dry process                              1          1     0260   0.6661     44.9                     11.56
             76350     N    Special x-ray contrast study                         1          1       0                                         BR
             76376     N    3d render w/o postprocess                            1          1       0                                        38.01
             76377     N    3d rendering w/postprocess                           1          1       0                                        34.46
             76380      S   CAT scan follow-up study                             1          1     0282   1.6291    109.81                    92.48

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 94 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                 CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC    RW       NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010   2010     2010       Fee            Fee
             76390      E   Mr spectroscopy                                      1          1       0                         OF          229.64
             76496      X   Fluoroscopic procedure                               1          1     0272   1.2693    85.56                    BR
             76497      S   Ct procedure                                         1          1     0282   1.6291   109.81                    BR
             76498      S   Mri procedure                                        1          1     0336   5.1855   349.53                    BR
    PA       76499      X   Radiographic procedure                               1          1     0260   0.6661     44.9                    BR
             76506      S   Echo exam of head                                    1          1     0265   0.9267    62.47                  50.46
             76510      T   Ophth us, b & quant a                                1          1     0232   4.5074   303.83                  41.35
             76511      S   Ophth us, quant a only                               1          1     0266   1.4434    97.29                  28.01
             76512      S   Ophth us, b w/non-quant a                            1          1     0266   1.4434    97.29                  23.34
             76513      S   Echo exam of eye, water bath                         1          1     0266   1.4434    97.29                  30.01
             76514      X   Echo exam of eye, thickness                          1          1     0035    0.232    15.64                   2.45
             76516      S   Echo exam of eye                                     1          1     0265   0.9267    62.47                  23.56
             76519      S   Echo exam of eye                                     1          1     0266   1.4434    97.29                  26.45
             76529      S   Echo exam of eye                                     1          1     0265   0.9267    62.47                  22.90
             76536      S   Us exam of head and neck                             1          1     0266   1.4434    97.29                  50.02
             76604     Q3   Us exam, chest                                       1          1     0265   0.9267    62.47                  34.46
             76645      S   Us exam, breast(s)                                   1          1     0265   0.9267    62.47                  38.46
             76700     Q3   Us exam, abdom, complete                             1          1     0266   1.4434    97.29                  56.69
             76705     Q3   Echo exam of abdomen                                 1          1     0266   1.4434    97.29                  43.79
             76770     Q3   Us exam abdo back wall, comp                         1          1     0266   1.4434    97.29                  54.91
             76775     Q3   Us exam abdo back wall, lim                          1          1     0266   1.4434    97.29                  47.57
             76776     Q3   Us exam k transpl w/doppler                          1          1     0266   1.4434    97.29                  64.02
             76800      S   Us exam, spinal canal                                1          1     0266   1.4434    97.29                  42.01
             76801      S   Ob us < 14 wks, single fetus                         1          1     0266   1.4434    97.29                  46.91
             76802      S   Ob us < 14 wks, addl fetus                           1          1     0265   0.9267    62.47                  17.12
             76805      S   Ob us >/= 14 wks, sngl fetus                         1          1     0266   1.4434    97.29                  56.91
             76810      S   Ob us >/= 14 wks, addl fetus                         1          1     0266   1.4434    97.29                  28.23
             76811      S   Ob us, detailed, sngl fetus                          1          1     0267   2.3005   155.07                  58.91
             76812      S   Ob us, detailed, addl fetus                          1          1     0265   0.9267    62.47                  64.69
             76813      S   Ob us nuchal meas, 1 gest                            1          1     0265   0.9267    62.47                  40.01
             76814      S   Ob us nuchal meas, add-on                            1          1     0265   0.9267    62.47                  18.67
             76815      S   Ob us, limited, fetus(s)                             1          1     0265   0.9267    62.47                  34.23
             76816      S   Ob us, follow-up, per fetus                          1          2     0265   0.9267    62.47                  42.01
             76817      S   Transvaginal us, obstetric                           1          1     0265   0.9267    62.47                  38.01
             76818      S   Fetal biophys profile w/nst                          1          2     0266   1.4434    97.29                  40.24
             76819      S   Fetal biophys profil w/o nst                         1         10     0266   1.4434    97.29                  31.34
             76820      S   Umbilical artery echo                                1          1     0265   0.9267    62.47                  14.23
             76821      S   Middle cerebral artery echo                          1          1     0265   0.9267    62.47                  36.01
             76825      S   Echo exam of fetal heart                             1          2     0270   8.8425   596.04                  75.80
             76826      S   Echo exam of fetal heart                             1          1     0269   6.6903   450.97                  46.24
             76827      S   Echo exam of fetal heart                             1          1     0265   0.9267    62.47                  23.12
             76828      S   Echo exam of fetal heart                             1          2     0265   0.9267    62.47                  13.12
             76830      S   Transvaginal us, non-ob                              1          1     0266   1.4434    97.29                  50.91
             76831     Q3   Echo exam, uterus                                    1          1     0267   2.3005   155.07                  50.46
             76856     Q3   Us exam, pelvic, complete                            1          1     0266   1.4434    97.29                  50.91
             76857     Q3   Us exam, pelvic, limited                             1          1     0265   0.9267    62.47                  47.57
             76870     Q3   Us exam, scrotum                                     1          1     0266   1.4434    97.29                  51.57
             76872      S   Us, transrectal                                      1          1     0266   1.4434    97.29                  61.80
             76873      S   Echograp trans r, pros study                         1          1     0266   1.4434    97.29                  58.24
             76880      S   Us exam, extremity                                   1          1     0266   1.4434    97.29                  59.80
             76885      S   Us exam infant hips, dynamic                         1          1     0265   0.9267    62.47                  59.80
             76886      S   Us exam infant hips, static                          1          1     0265   0.9267    62.47                  44.24
             76930     N    Echo guide, cardiocentesis                           1          1       0                                     34.23
             76932     N    Echo guide for heart biopsy                          1          1       0                                       BR
             76936      S   Echo guide for artery repair                         1          1     0096   1.6075   108.36                  120.93
             76937     N    Us guide, vascular access                            1          1       0                                     11.12
             76940     N    Us guide, tissue ablation                            1          1       0                                       BR
             76941     N    Echo guide for transfusion                           1          1       0                                       BR
             76942     N    Echo guide for biopsy                                1          6       0                                     91.59
             76945     N    Echo guide, villus sampling                          1          1       0                                       BR
             76946     N    Echo guide for amniocentesis                         1          1       0                                     12.67
             76948     N    Echo guide, ova aspiration                           1          1       0                                     12.89
             76950     N    Echo guidance radiotherapy                           1          1       0                                     23.79
             76965     N    Echo guidance radiotherapy                           1          1       0                                     36.01
             76970      S   Ultrasound exam follow-up                            1          1     0265   0.9267    62.47                  40.68
             76975     Q2   GI endoscopic ultrasound                             1          1     0267   2.3005   155.07                    BR

                                                                                                                            CPT Codes and Descriptions
                                                                                                                                         Copyright 2010
                                                                                                                           American Medical Association
Page 95 of 216                                                                                                                      All Rights Reserved
                                                      HRSA Outpatient Fee Schedule                                                      CY2010 Q4
                                                           Washington State Medicaid


                                                                                       MAX     APC     RW         NWR       OPPS            OP
  AUTH           CPT   SI   Description                                     COV
                                                                                       UNITS   2010    2010       2010       Fee            Fee
             76977      X   Us bone density measure                           1          1     0340    0.6693     45.11                    5.34
             76998     N    Us guide, intraop                                 1          1       0                                          BR
             76999      S   Echo examination procedure                        1          1     0265    0.9267     62.47                     BR
             77001     N    Fluoroguide for vein device                       1          1       0                                        52.24
             77002     N    Needle localization by xray                       1          1       0                                        26.45
             77003     N    Fluoroguide for spine inject                      1          1       0                                        18.01
             77011     N    Ct scan for localization                          1          1       0                                        384.80
             77012     N    Ct scan for needle biopsy                         1          1       0                                        69.36
             77013     N    Ct guide for tissue ablation                      1          1       0                                          BR
             77014     N    Ct scan for therapy guide                         1          1       0                                        85.81
             77021     N    Mr guidance for needle place                      1          1       0                                        210.52
             77022     N    Mri for tissue ablation                           1          1       0                                          BR
             77031     N    Stereotact guide for brst bx                      1          1       0                                        54.24
             77032     N    Guidance for needle, breast                       1          1       0                                        16.89
             77051     A    Computer dx mammogram add-on                      1          1       0                            OF           5.11
     L       77052     A    Comp screen mammogram add-on                      1          1       0                            OF           5.11
             77053     Q2   X-ray of mammary duct                             1          1     0263    3.1192    210.25                   30.90
             77054     Q2   X-ray of mammary ducts                            1          1     0263    3.1192    210.25                   42.46
             77055     A    Mammogram, one breast                             1          1       0                            OF          29.12
             77056     A    Mammogram, both breasts                           1          1       0                            OF          37.79
     L       77057     A    Mammogram, screening                              1          1       0                            OF          26.68
    PA       77058     B    Mri, one breast                                   0         NC       0
    PA       77059     B    Mri, both breasts                                 0         NC       0
             77071      X   X-ray stress view                                 1          1     0260    0.6661      44.9                   25.34
             77072      X   X-rays for bone age                               1          1     0260    0.6661      44.9                    8.00
             77073      X   X-rays, bone length studies                       1          1     0260    0.6661      44.9                   13.78
             77074      X   X-rays, bone survey, limited                      1          1     0261    1.1161     75.23                   26.90
             77075      X   X-rays, bone survey complete                      1          1     0261    1.1161     75.23                   42.90
             77076      X   X-rays, bone survey, infant                       1          1     0261    1.1161     75.23                   36.01
             77077      X   Joint survey, single view                         1          1     0260    0.6661      44.9                   14.89
             77078      S   Ct bone density, axial                            1          1     0288    1.0755      72.5                   85.14
             77079      S   Ct bone density, peripheral                       1          1     0282    1.6291    109.81                   25.34
             77080      S   Dxa bone density, axial                           1          1     0288    1.0755      72.5                   52.91
             77081      S   Dxa bone density/peripheral                       1          1     0665    0.4318     29.11                   10.67
             77082      X   Dxa bone density, vert fx                         1          1     0260    0.6661      44.9                   12.89
             77083      X   Radiographic absorptiometry                       1          1     0261    1.1161     75.23                    9.11
             77084      S   Magnetic image, bone marrow                       1          1     0336    5.1855    349.53                   266.09
             77261     B    Radiation therapy planning                        0         NC       0
             77262     B    Radiation therapy planning                        0         NC       0
             77263     B    Radiation therapy planning                        0         NC       0
             77280      X   Set radiation therapy field                       1          1     0304    1.5271    102.94                   88.92
             77285      X   Set radiation therapy field                       1          1     0305     3.951    266.32                   159.83
             77290      X   Set radiation therapy field                       1          1     0305     3.951    266.32                   255.87
             77295      X   Set radiation therapy field                       1          1     0310   13.7576    927.34                   224.52
             77299      X   Radiation therapy planning                        1          1     0304    1.5271    102.94                     BR
             77300      X   Radiation therapy dose plan                       1          6     0304    1.5271    102.94                   22.90
             77301      X   Radiotherapy dose plan, imrt                      1          1     0310   13.7576    927.34                  1088.38
             77305      X   Teletx isodose plan simple                        1          1     0304    1.5271    102.94                   19.78
             77310      X   Teletx isodose plan intermed                      1          1     0304    1.5271    102.94                   26.23
             77315      X   Teletx isodose plan complex                       1          1     0305     3.951    266.32                   39.35
             77321      X   Special teletx port plan                          1          1     0305     3.951    266.32                   38.46
             77326      X   Brachytx isodose calc simp                        1          1     0304    1.5271    102.94                   57.35
             77327      X   Brachytx isodose calc interm                      1          1     0305     3.951    266.32                   79.14
             77328      X   Brachytx isodose plan compl                       1          1     0305     3.951    266.32                   101.59
             77331      X   Special radiation dosimetry                       1          6     0304    1.5271    102.94                   11.34
             77332      X   Radiation treatment aid(s)                        1          5     0303    2.8279    190.62                   30.01
             77333      X   Radiation treatment aid(s)                        1          5     0303    2.8279    190.62                   12.45
             77334      X   Radiation treatment aid(s)                        1          5     0303    2.8279    190.62                   54.69
             77336      X   Radiation physics consult                         1          1     0304    1.5271    102.94                   33.12
             77338      X   Design mlc device for imrt                        0         NC       0
             77370      X   Radiation physics consult                         1          1     0304    1.5271     102.94                  68.69
    PA       77371      S   Srs, multisource                                  1          1     0127   108.9558   7344.27                  682.24
             77372     B    Srs, linear based                                 0         NC       0
             77373     B    Sbrt delivery                                     0         NC       0
             77399      X   External radiation dosimetry                      1          1     0304    1.5271    102.94                     BR
             77401      S   Radiation treatment delivery                      1          1     0300    1.3764     92.78                    16.01

                                                                                                                            CPT Codes and Descriptions
                                                                                                                                         Copyright 2010
                                                                                                                           American Medical Association
Page 96 of 216                                                                                                                      All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             77402      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   84.03
             77403      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   74.03
             77404      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   81.81
             77406      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   82.70
             77407      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   136.71
             77408      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   100.26
             77409      S   Radiation treatment delivery                         1          1     0300   1.3764     92.78                   110.93
             77411      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   110.26
             77412      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   130.05
             77413      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   130.93
             77414      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   146.05
             77416      S   Radiation treatment delivery                         1          1     0301    2.303    155.24                   146.72
             77417     N    Radiology port film(s)                               1          1       0                                        9.11
             77418      S   Radiation tx delivery, imrt                          1          1     0412    6.249    421.22                   309.89
             77421     N    Stereoscopic x-ray guidance                          1          1       0                                       54.24
             77422      S   Neutron beam tx, simple                              1          1     0301    2.303    155.24                   124.27
             77423      S   Neutron beam tx, complex                             1          1     0301    2.303    155.24                   141.38
             77427     B    Radiation tx management, x5                          0         NC       0
             77431     B    Radiation therapy management                         0         NC       0
             77432     B    Stereotactic radiation trmt                          0         NC       0
    PA       77435     N    Sbrt management                                      1          1       0                                       413.92
             77470      S   Special radiation treatment                          1          1     0299   5.6461    380.58                   69.58
             77499     B    Radiation therapy management                         0         NC       0
             77520      S   Proton trmt, simple w/o comp                         1          1     0664   13.9796    942.31                    BR
             77522      S   Proton trmt, simple w/comp                           1          1     0664   13.9796    942.31                    BR
             77523      S   Proton trmt, intermediate                            1          1     0667   18.2873   1232.67                    BR
             77525      S   Proton treatment, complex                            1          1     0667   18.2873   1232.67                    BR
             77600      S   Hyperthermia treatment                               1          1     0299    5.6461    380.58                  184.51
             77605      S   Hyperthermia treatment                               1          1     0299    5.6461    380.58                  401.25
             77610      S   Hyperthermia treatment                               1          1     0299    5.6461    380.58                  335.90
             77615      S   Hyperthermia treatment                               1          1     0299    5.6461    380.58                  488.62
             77620      S   Hyperthermia treatment                               1          1     0299    5.6461    380.58                  209.18
             77750      S   Infuse radioactive materials                         1          1     0301     2.303    155.24                  57.13
             77761      S   Apply intrcav radiat simple                          1          1     0312    4.4846    302.29                  100.26
             77762      S   Apply intrcav radiat interm                          1          1     0312    4.4846    302.29                  117.60
             77763      S   Apply intrcav radiat compl                           1          1     0312    4.4846    302.29                  152.05
             77776      S   Apply interstit radiat simpl                         1          1     0312    4.4846    302.29                  107.82
             77777      S   Apply interstit radiat inter                         1          1     0312    4.4846    302.29                  116.49
             77778     Q3   Apply interstit radiat compl                         1          1     0651   13.2555     893.5                  156.72
             77785      S   Hdr brachytx, 1 channel                              1          1     0313   11.5353    777.55                  77.58
             77786      S   Hdr brachytx, 2-12 channel                           1          1     0313   11.5353    777.55                  239.42
             77787      S   Hdr brachytx over 12 chan                            1          1     0313   11.5353    777.55                  369.68
             77789      S   Apply surface radiation                              1          1     0300    1.3764     92.78                  30.23
             77790     N    Radiation handling                                   1         NA       0                                       21.79
             77799      S   Radium/radioisotope therapy                          1          1     0312   4.4846    302.29                     BR
             78000      S   Thyroid, single uptake                               1          1     0389   1.6695    112.53                   35.12
             78001      S   Thyroid, multiple uptakes                            1          1     0389   1.6695    112.53                   44.46
             78003      S   Thyroid suppress/stimul                              1          1     0389   1.6695    112.53                   35.79
             78006      S   Thyroid imaging with uptake                          1          1     0391   3.2894    221.73                   116.49
             78007      S   Thyroid image, mult uptakes                          1          1     0391   3.2894    221.73                   78.69
             78010      S   Thyroid imaging                                      1          1     0390   2.1595    145.56                   79.14
             78011      S   Thyroid imaging with flow                            1          1     0390   2.1595    145.56                   88.03
             78015      S   Thyroid met imaging                                  1          1     0406   4.3034    290.07                   101.37
             78016      S   Thyroid met imaging/studies                          1          1     0406   4.3034    290.07                   154.72
             78018      S   Thyroid met imaging, body                            1          1     0406   4.3034    290.07                   156.72
             78020     N    Thyroid met uptake                                   1          1       0                                       33.35
             78070      S   Parathyroid nuclear imaging                          1          1     0391    3.2894   221.73                   74.03
             78075      S   Adrenal nuclear imaging                              1          1     0408   14.2874   963.06                   219.19
             78099      S   Endocrine nuclear procedure                          1          1     0390    2.1595   145.56                     BR
             78102      S   Bone marrow imaging, ltd                             1          1     0400    3.8342   258.45                   78.47
             78103      S   Bone marrow imaging, mult                            1          1     0400    3.8342   258.45                   104.26
             78104      S   Bone marrow imaging, body                            1          1     0400    3.8342   258.45                   120.04
             78110      S   Plasma volume, single                                1          1     0393    5.7873    390.1                   40.68
             78111      S   Plasma volume, multiple                              1          1     0393    5.7873    390.1                   46.91
             78120      S   Red cell mass, single                                1          1     0393    5.7873    390.1                   42.90
             78121      S   Red cell mass, multiple                              1          1     0393    5.7873    390.1                   47.57

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 97 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             78122     S    Blood volume                                         1          1     0393   5.7873     390.1                   56.24
             78130     S    Red cell survival study                              1          1     0393   5.7873     390.1                   70.69
             78135     S    Red cell survival kinetics                           1          1     0393   5.7873     390.1                   172.06
             78140     S    Red cell sequestration                               1          1     0393   5.7873     390.1                   64.24
             78185     S    Spleen imaging                                       1          1     0400   3.8342    258.45                   99.81
             78190     S    Platelet survival, kinetics                          1          1     0392   2.6817    180.76                   188.29
             78191     S    Platelet survival                                    1          1     0392   2.6817    180.76                   89.14
             78195     S    Lymph system imaging                                 1          1     0400   3.8342    258.45                   162.50
             78199     S    Blood/lymph nuclear exam                             1          1     0400   3.8342    258.45                     BR
             78201     S    Liver imaging                                        1          1     0394   4.3139    290.78                   90.70
             78202     S    Liver imaging with flow                              1          1     0394   4.3139    290.78                   101.81
             78205     S    Liver imaging (3D)                                   1          1     0394   4.3139    290.78                   112.93
             78206     S    Liver image (3d) with flow                           1          1     0394   4.3139    290.78                   170.73
             78215     S    Liver and spleen imaging                             1          1     0394   4.3139    290.78                   94.03
             78216     S    Liver & spleen image/flow                            1          1     0394   4.3139    290.78                   60.91
             78220     S    Liver function study                                 1          1     0394   4.3139    290.78                   66.47
             78223     S    Hepatobiliary imaging                                1          1     0394   4.3139    290.78                   159.61
             78230     S    Salivary gland imaging                               1          1     0395   3.6702    247.39                   79.81
             78231     S    Serial salivary imaging                              1          1     0395   3.6702    247.39                   60.02
             78232     S    Salivary gland function exam                         1          1     0395   3.6702    247.39                   59.35
             78258     S    Esophageal motility study                            1          1     0395   3.6702    247.39                   108.70
             78261     S    Gastric mucosa imaging                               1          1     0395   3.6702    247.39                   120.71
             78262     S    Gastroesophageal reflux exam                         1          1     0395   3.6702    247.39                   119.38
             78264     S    Gastric emptying study                               1          1     0395   3.6702    247.39                   138.49
             78267     A    Breath tst attain/anal c-14                          1          1       0                           OF           8.56
             78268     A    Breath test analysis, c-14                           1          1       0                           OF          73.32
             78270     S    Vit B-12 absorption exam                             1          1     0392   2.6817    180.76                   40.01
             78271     S    Vit b-12 absrp exam, int fac                         1          1     0392   2.6817    180.76                   42.24
             78272     S    Vit B-12 absorp, combined                            1          1     0392   2.6817    180.76                   44.46
             78278     S    Acute GI blood loss imaging                          1          1     0395   3.6702    247.39                   165.61
             78282     S    GI protein loss exam                                 1          1     0395   3.6702    247.39                     BR
             78290     S    Meckels divert exam                                  1          1     0395   3.6702    247.39                   157.83
             78291     S    Leveen/shunt patency exam                            1          1     0395   3.6702    247.39                   116.26
             78299     S    GI nuclear procedure                                 1          1     0395   3.6702    247.39                     BR
             78300     S    Bone imaging, limited area                           1          1     0396   3.6707    247.43                   81.14
             78305     S    Bone imaging, multiple areas                         1          1     0396   3.6707    247.43                   107.15
             78306     S    Bone imaging, whole body                             1          1     0396   3.6707    247.43                   119.15
             78315     S    Bone imaging, 3 phase                                1          1     0396   3.6707    247.43                   164.95
             78320     S    Bone imaging (3D)                                    1          1     0396   3.6707    247.43                   112.71
             78350     E    Bone mineral, single photon                          1          1       0                           OF          12.89
             78351     E    Bone mineral, dual photon                            1          1       0                           OF           9.34
             78399     S    Musculoskeletal nuclear exam                         1          1     0396    3.6707    247.43                    BR
             78414     S    Non-imaging heart function                           1          1     0398    4.5366    305.79                    BR
             78428     S    Cardiac shunt imaging                                1          1     0398    4.5366    305.79                  90.25
             78445     S    Vascular flow imaging                                1          1     0397    2.9679    200.05                  82.92
             78451     S    Ht muscle image spect, sing                          1          1     0377   11.4989    775.09                  152.94
             78452     S    Ht muscle image spect, mult                          1          1     0377   11.4989    775.09                  223.86
             78453     S    Ht muscle image,planar,sing                          1          1     0377   11.4989    775.09                  137.16
             78454     S    Ht musc image, planar, mult                          1          1     0377   11.4989    775.09                  197.40
             78456     S    Acute venous thrombus image                          1          1     0397    2.9679    200.05                  169.39
             78457     S    Venous thrombosis imaging                            1          1     0397    2.9679    200.05                  88.48
             78458     S    Ven thrombosis images, bilat                         1          1     0397    2.9679    200.05                  90.92
    PA       78459     S    Heart muscle imaging (PET)                           1          1     0307   21.2573   1432.87                 1177.60
             78466     S    Heart infarct image                                  1          1     0398    4.5366    305.79                  83.14
             78468     S    Heart infarct image (ef)                             1          1     0398    4.5366    305.79                  104.48
             78469     S    Heart infarct image (3D)                             1          1     0398    4.5366    305.79                  119.38
             78472     S    Gated heart, planar, single                          1          1     0398    4.5366    305.79                  118.49
             78473     S    Gated heart, multiple                                1          1     0398    4.5366    305.79                  154.50
             78481     S    Heart first pass, single                             1          1     0398    4.5366    305.79                  96.48
             78483     S    Heart first pass, multiple                           1          1     0398    4.5366    305.79                  131.38
             78491     S    Heart image (pet), single                            0         NC       0
             78492     S    Heart image (pet), multiple                          0         NC       0
             78494     S    Heart image, spect                                   1          1     0398   4.5366    305.79                   123.60
             78496     N    Heart first pass add-on                              1          1       0                                       40.90
             78499     S    Cardiovascular nuclear exam                          1          1     0398   4.5366    305.79                     BR
             78580     S    Lung perfusion imaging                               1          1     0401   3.0625    206.43                   99.15

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 98 of 216                                                                                                                        All Rights Reserved
                                                           HRSA Outpatient Fee Schedule                                                   CY2010 Q4
                                                              Washington State Medicaid


                                                                                          MAX     APC     RW        NWR       OPPS            OP
  AUTH           CPT   SI   Description                                        COV
                                                                                          UNITS   2010    2010      2010       Fee            Fee
             78584      S   Lung V/Q image single breath                         1          1     0378    4.8032    323.76                  60.02
             78585      S   Lung V/Q imaging                                     1          1     0378    4.8032    323.76                  168.73
             78586      S   Aerosol lung image, single                           1          1     0401    3.0625    206.43                  81.81
             78587      S   Aerosol lung image, multiple                         1          1     0401    3.0625    206.43                  103.59
             78588      S   Perfusion lung image                                 1          1     0378    4.8032    323.76                  158.72
             78591      S   Vent image, 1 breath, 1 proj                         1          1     0401    3.0625    206.43                  82.70
             78593      S   Vent image, 1 proj, gas                              1          1     0401    3.0625    206.43                  96.26
             78594      S   Vent image, mult proj, gas                           1          1     0401    3.0625    206.43                  110.71
             78596      S   Lung differential function                           1          1     0378    4.8032    323.76                  176.73
             78599      S   Respiratory nuclear exam                             1          1     0401    3.0625    206.43                    BR
             78600      S   Brain image < 4 views                                1          1     0403    2.9181     196.7                  88.70
             78601      S   Brain image w/flow < 4 views                         1          1     0402    8.5845    578.65                  105.59
             78605      S   Brain image 4+ views                                 1          1     0403    2.9181     196.7                  96.26
             78606      S   Brain image w/flow 4 + views                         1          1     0402    8.5845    578.65                  162.72
             78607      S   Brain imaging (3D)                                   1          1     0402    8.5845    578.65                  172.28
    PA       78608      S   Brain imaging (PET)                                  1          1     0308   15.3895   1037.34                 1177.60
             78609      E   Brain imaging (PET)                                  0         NC       0
             78610      S   Brain flow imaging only                              1          1     0403    2.9181     196.7                  92.70
             78630      S   Cerebrospinal fluid scan                             1          1     0402    8.5845    578.65                  169.17
             78635      S   CSF ventriculography                                 1          1     0402    8.5845    578.65                  158.94
             78645      S   CSF shunt evaluation                                 1          1     0403    2.9181     196.7                  159.61
             78647      S   Cerebrospinal fluid scan                             1          1     0402    8.5845    578.65                  162.72
             78650      S   CSF leakage imaging                                  1          1     0402    8.5845    578.65                  166.50
             78660      S   Nuclear exam of tear flow                            1          1     0403    2.9181     196.7                  81.36
             78699      S   Nervous system nuclear exam                          1          1     0403    2.9181     196.7                    BR
             78700      S   Kidney imaging, morphol                              1          1     0404    4.8221    325.04                  86.25
             78701      S   Kidney imaging with flow                             1          1     0404    4.8221    325.04                  106.26
             78707      S   K flow/funct image w/o drug                          1          1     0404    4.8221    325.04                  109.15
             78708      S   K flow/funct image w/drug                            1          1     0404    4.8221    325.04                  72.25
             78709      S   K flow/funct image, multiple                         1          1     0404    4.8221    325.04                  166.28
             78710      S   Kidney imaging (3D)                                  1          1     0404    4.8221    325.04                  111.82
             78725      S   Kidney function study                                1          1     0392    2.6817    180.76                  47.35
             78730      S   Urinary bladder retention                            1          1     0389    1.6695    112.53                  38.46
             78740      S   Ureteral reflux study                                1          1     0404    4.8221    325.04                  105.81
             78761      S   Testicular imaging w/flow                            1          1     0404    4.8221    325.04                  98.70
             78799      S   Genitourinary nuclear exam                           1          1     0404    4.8221    325.04                    BR
             78800      S   Tumor imaging, limited area                          1          1     0406    4.3034    290.07                  87.59
             78801      S   Tumor imaging, mult areas                            1          1     0414    7.5722    510.41                  119.38
             78802      S   Tumor imaging, whole body                            1          1     0414    7.5722    510.41                  160.95
             78803      S   Tumor imaging (3D)                                   1          1     0414    7.5722    510.41                  171.17
             78804      S   Tumor imaging, whole body                            1          1     0408   14.2874    963.06                  300.99
             78805      S   Abscess imaging, ltd area                            1          1     0414    7.5722    510.41                  84.25
             78806      S   Abscess imaging, whole body                          1          1     0414    7.5722    510.41                  168.73
             78807      S   Nuclear localization/abscess                         1          1     0406    4.3034    290.07                  170.95
             78808     Q1   Iv inj ra drug dx study                              1          1     0392    2.6817    180.76                  26.45
    PA       78811      S   Pet image, ltd area                                  1          1     0308   15.3895   1037.34                 1177.60
    PA       78812      S   Pet image, skull-thigh                               1          1     0308   15.3895   1037.34                 1177.60
    PA       78813      S   Pet image, full body                                 1          1     0308   15.3895   1037.34                 1177.60
    PA       78814      S   Pet image w/ct, lmtd                                 1          1     0308   15.3895   1037.34                 1177.60
    PA       78815      S   Pet image w/ct, skull-thigh                          1          1     0308   15.3895   1037.34                 1177.60
    PA       78816      S   Pet image w/ct, full body                            1          1     0308   15.3895   1037.34                 1177.60
             78999      S   Nuclear diagnostic exam                              1          1     0389    1.6695    112.53                    BR
             79005      S   Nuclear rx, oral admin                               1          1     0407    3.2356     218.1                  33.57
             79101      S   Nuclear rx, iv admin                                 1          1     0407    3.2356     218.1                  36.46
             79200      S   Nuclear rx, intracav admin                           1          1     0413    5.2007    350.56                  40.46
             79300      S   Nuclr rx, interstit colloid                          1          1     0407    3.2356     218.1                    BR
    PA       79403      S   Hematopoietic nuclear tx                             1          1     0413    5.2007    350.56                  56.69
             79440      S   Nuclear rx, intra-articular                          1          1     0413    5.2007    350.56                  32.01
             79445      S   Nuclear rx, intra-arterial                           1          1     0407    3.2356     218.1                    BR
             79999      S   Nuclear medicine therapy                             1          1     0407    3.2356     218.1                    BR
             80047     A    Metabolic panel ionized ca                           1          1       0                           OF           6.95
             80048     A    Metabolic panel total ca                             1          1       0                           OF           6.95
             80050      E   General health panel                                 1          1       0                           OF          36.67
             80051     A    Electrolyte panel                                    1          1       0                           OF           6.95
             80053     A    Comprehen metabolic panel                            1          1       0                           OF           9.29
             80055      E   Obstetric panel                                      1          1       0                           OF          57.05

                                                                                                                              CPT Codes and Descriptions
                                                                                                                                           Copyright 2010
                                                                                                                             American Medical Association
Page 99 of 216                                                                                                                        All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                                CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW       NWR      OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010     2010      Fee            Fee
             80061   A    Lipid panel                                          1          1       0                        OF          14.58
             80069   A    Renal function panel                                 1          1       0                        OF           6.95
             80074   A    Acute hepatitis panel                                1          1       0                        OF          51.84
             80076   A    Hepatic function panel                               1          1       0                        OF           6.95
             80100   A    Drug screen, qualitate/multi                         1          1       0                        OF          15.83
             80101   E    Drug screen, single                                  1          1       0                        OF          14.99
             80102   A    Drug confirmation                                    1          1       0                        OF          14.42
             80103   N    Drug analysis, tissue prep                           1          1       0                                      BR
             80150   A    Assay of amikacin                                    1          1       0                        OF          16.41
             80152   A    Assay of amitriptyline                               1          1       0                        OF          19.49
             80154   A    Assay of benzodiazepines                             1          1       0                        OF          20.13
             80156   A    Assay, carbamazepine, total                          1          1       0                        OF          15.85
             80157   A    Assay, carbamazepine, free                           1          1       0                        OF          14.43
             80158   A    Assay of cyclosporine                                1          1       0                        OF          19.65
             80160   A    Assay of desipramine                                 1          1       0                        OF          18.73
             80162   A    Assay of digoxin                                     1          1       0                        OF          14.46
             80164   A    Assay, dipropylacetic acid                           1          1       0                        OF          14.74
             80166   A    Assay of doxepin                                     1          1       0                        OF          16.88
             80168   A    Assay of ethosuximide                                1          1       0                        OF          17.79
             80170   A    Assay of gentamicin                                  1          1       0                        OF          17.84
             80172   A    Assay of gold                                        1          1       0                        OF          17.73
             80173   A    Assay of haloperidol                                 1          1       0                        OF          15.85
             80174   A    Assay of imipramine                                  1          1       0                        OF          18.73
             80176   A    Assay of lidocaine                                   1          1       0                        OF          15.99
             80178   A    Assay of lithium                                     1          1       0                        OF           7.19
             80182   A    Assay of nortriptyline                               1          1       0                        OF          14.74
             80184   A    Assay of phenobarbital                               1          1       0                        OF          12.47
             80185   A    Assay of phenytoin, total                            1          1       0                        OF          14.43
             80186   A    Assay of phenytoin, free                             1          1       0                        OF          14.98
             80188   A    Assay of primidone                                   1          1       0                        OF          18.07
             80190   A    Assay of procainamide                                1          1       0                        OF          18.23
             80192   A    Assay of procainamide                                1          1       0                        OF          18.23
             80194   A    Assay of quinidine                                   1          1       0                        OF          15.89
             80195   A    Assay of sirolimus                                   1          1       0                        OF          14.94
             80196   A    Assay of salicylate                                  1          1       0                        OF           7.72
             80197   A    Assay of tacrolimus                                  1          1       0                        OF          14.94
             80198   A    Assay of theophylline                                1          1       0                        OF          15.41
             80200   A    Assay of tobramycin                                  1          1       0                        OF          17.55
             80201   A    Assay of topiramate                                  1          1       0                        OF          12.97
             80202   A    Assay of vancomycin                                  1          1       0                        OF          14.74
             80299   A    Quantitative assay, drug                             1          1       0                        OF          14.90
             80400   A    Acth stimulation panel                               1          1       0                        OF          35.49
             80402   A    Acth stimulation panel                               1          1       0                        OF          94.64
             80406   A    Acth stimulation panel                               1          1       0                        OF          85.18
             80408   A    Aldosterone suppression eval                         1          1       0                        OF          136.62
             80410   A    Calcitonin stimul panel                              1          1       0                        OF          87.46
             80412   A    CRH stimulation panel                                1          1       0                        OF          345.83
             80414   A    Testosterone response                                1          1       0                        OF          56.21
             80415   A    Estradiol response panel                             1          1       0                        OF          60.83
             80416   A    Renin stimulation panel                              1          1       0                        OF          143.69
             80417   A    Renin stimulation panel                              1          1       0                        OF          47.90
             80418   A    Pituitary evaluation panel                           1          1       0                        OF          610.19
             80420   A    Dexamethasone panel                                  1          1       0                        OF          78.40
             80422   A    Glucagon tolerance panel                             1          1       0                        OF          50.16
             80424   A    Glucagon tolerance panel                             1          1       0                        OF          37.88
             80426   A    Gonadotropin hormone panel                           1          1       0                        OF          150.33
             80428   A    Growth hormone panel                                 1          1       0                        OF          72.02
             80430   A    Growth hormone panel                                 1          1       0                        OF          84.83
             80432   A    Insulin suppression panel                            1          1       0                        OF          147.04
             80434   A    Insulin tolerance panel                              1          1       0                        OF          110.09
             80435   A    Insulin tolerance panel                              1          1       0                        OF          111.38
             80436   A    Metyrapone panel                                     1          1       0                        OF          79.83
             80438   A    TRH stimulation panel                                1          1       0                        OF          54.67
             80439   A    TRH stimulation panel                                1          1       0                        OF          72.90
             80440   A    TRH stimulation panel                                1          1       0                        OF          63.29
             80500   X    Lab pathology consultation                           1          1     0433   0.2482   16.73                  11.12

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 100 of 216                                                                                                                  All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                                CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW       NWR      OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010     2010      Fee            Fee
             80502   X    Lab pathology consultation                           1          1     0342   0.1546   10.42                   38.46
             81000   A    Urinalysis, nonauto w/scope                          1          1       0                        OF            3.45
             81001   A    Urinalysis, auto w/scope                             1          1       0                        OF            3.45
             81002   A    Urinalysis nonauto w/o scope                         1          1       0                        OF            2.78
             81003   A    Urinalysis, auto, w/o scope                          1          1       0                        OF            2.45
             81005   A    Urinalysis                                           1          1       0                        OF            2.36
             81007   A    Urine screen for bacteria                            1          1       0                        OF            2.80
             81015   A    Microscopic exam of urine                            1          1       0                        OF            3.31
             81020   A    Urinalysis, glass test                               1          1       0                        OF            4.01
             81025   A    Urine pregnancy test                                 1          1       0                        OF            4.10
             81050   A    Urinalysis, volume measure                           1          1       0                        OF            3.26
             81099   A    Urinalysis test procedure                            1          1       0                        OF             BR
             82000   A    Assay of blood acetaldehyde                          1          1       0                        OF           13.49
             82003   A    Assay of acetaminophen                               1          1       0                        OF           19.65
             82009   A    Test for acetone/ketones                             1          1       0                        OF            4.92
             82010   A    Acetone assay                                        1          1       0                        OF            8.90
             82013   A    Acetylcholinesterase assay                           1          1       0                        OF           12.16
             82016   A    Acylcarnitines, qual                                 1          1       0                        OF           15.09
             82017   A    Acylcarnitines, quant                                1          1       0                        OF            5.98
             82024   A    Assay of acth                                        1          1       0                        OF           39.89
             82030   A    Assay of adp & amp                                   1          1       0                        OF           28.08
             82040   A    Assay of serum albumin                               1          1       0                        OF            5.39
             82042   A    Assay of urine albumin                               1          1       0                        OF            5.63
             82043   A    Microalbumin, quantitative                           1          1       0                        OF            6.30
             82044   A    Microalbumin, semiquant                              1          1       0                        OF            4.99
             82045   A    Albumin, ischemia modified                           1          1       0                        OF           36.95
             82055   A    Assay of ethanol                                     1          1       0                        OF           11.76
             82075   A    Assay of breath ethanol                              1          1       0                        OF           13.12
             82085   A    Assay of aldolase                                    1          1       0                        OF           10.56
             82088   A    Assay of aldosterone                                 1          1       0                        OF           44.36
             82101   A    Assay of urine alkaloids                             1          1       0                        OF           32.67
             82103   A    Alpha-1-antitrypsin, total                           1          1       0                        OF           14.62
             82104   A    Alpha-1-antitrypsin, pheno                           1          1       0                        OF           15.74
             82105   A    Alpha-fetoprotein, serum                             1          1       0                        OF           18.26
             82106   A    Alpha-fetoprotein, amniotic                          1          1       0                        OF           18.26
             82107   A    Alpha-fetoprotein l3                                 1          1       0                        OF           70.12
             82108   A    Assay of aluminum                                    1          1       0                        OF           27.73
             82120   A    Amines, vaginal fluid qual                           1          1       0                        OF            1.82
             82127   A    Amino acid, single qual                              1          1       0                        OF           15.09
             82128   A    Amino acids, mult qual                               1          1       0                        OF           15.09
             82131   A    Amino acids, single quant                            1          1       0                        OF           18.36
             82135   A    Assay, aminolevulinic acid                           1          1       0                        OF           17.92
             82136   A    Amino acids, quant, 2-5                              1          1       0                        OF            5.98
             82139   A    Amino acids, quan, 6 or more                         1          1       0                        OF            5.98
             82140   A    Assay of ammonia                                     1          1       0                        OF           15.86
             82143   A    Amniotic fluid scan                                  1          1       0                        OF            7.48
             82145   A    Assay of amphetamines                                1          1       0                        OF           16.93
             82150   A    Assay of amylase                                     1          1       0                        OF            7.06
             82154   A    Androstanediol glucuronide                           1          1       0                        OF           31.39
             82157   A    Assay of androstenedione                             1          1       0                        OF           31.87
             82160   A    Assay of androsterone                                1          1       0                        OF           27.22
             82163   A    Assay of angiotensin II                              1          1       0                        OF           22.34
             82164   A    Angiotensin I enzyme test                            1          1       0                        OF           15.89
             82172   A    Assay of apolipoprotein                              1          1       0                        OF           16.86
             82175   A    Assay of arsenic                                     1          1       0                        OF           15.80
             82180   A    Assay of ascorbic acid                               1          1       0                        OF           10.76
             82190   A    Atomic absorption                                    1          1       0                        OF           13.31
             82205   A    Assay of barbiturates                                1          1       0                        OF           12.47
             82232   A    Assay of beta-2 protein                              1          1       0                        OF           17.61
             82239   A    Bile acids, total                                    1          1       0                        OF           18.65
             82240   A    Bile acids, cholylglycine                            1          1       0                        OF           28.93
             82247   A    Bilirubin, total                                     1          1       0                        OF            5.02
             82248   A    Bilirubin, direct                                    1          1       0                        OF            5.02
             82252   A    Fecal bilirubin test                                 1          1       0                        OF            4.95
             82261   A    Assay of biotinidase                                 1          1       0                        OF            5.98
             82270   A    Occult blood, feces                                  1          1       0                        OF            3.54

                                                                                                                         CPT Codes and Descriptions
                                                                                                                                      Copyright 2010
                                                                                                                        American Medical Association
Page 101 of 216                                                                                                                  All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW     NWR     OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010   2010     Fee            Fee
             82271   A    Occult blood, other sources                          1          1      0                      OF            3.54
             82272   A    Occult bld feces, 1-3 tests                          1          1      0                      OF            3.54
             82274   A    Assay test for blood, fecal                          1          1      0                      OF           17.31
             82286   A    Assay of bradykinin                                  1          1      0                      OF            7.49
             82300   A    Assay of cadmium                                     1          1      0                      OF           25.19
             82306   A    Vitamin d, 25 hydroxy                                1          1      0                      OF           32.22
             82308   A    Assay of calcitonin                                  1          1      0                      OF           29.15
             82310   A    Assay of calcium                                     1          1      0                      OF            5.62
             82330   A    Assay of calcium                                     1          1      0                      OF           14.87
             82331   A    Calcium infusion test                                1          1      0                      OF            5.63
             82340   A    Assay of calcium in urine                            1          1      0                      OF            6.57
             82355   A    Calculus analysis, qual                              1          1      0                      OF           12.60
             82360   A    Calculus assay, quant                                1          1      0                      OF           14.01
             82365   A    Calculus spectroscopy                                1          1      0                      OF           14.04
             82370   A    X-ray assay, calculus                                1          1      0                      OF           13.64
             82373   A    Assay, c-d transfer measure                          1          1      0                      OF           19.65
             82374   A    Assay, blood carbon dioxide                          1          1      0                      OF            5.32
             82375   A    Assay, carboxyhb, quant                              1          1      0                      OF           13.42
             82376   A    Assay, carboxyhb, qual                               1          1      0                      OF            6.52
             82378   A    Carcinoembryonic antigen                             1          1      0                      OF           20.65
             82379   A    Assay of carnitine                                   1          1      0                      OF            5.98
             82380   A    Assay of carotene                                    1          1      0                      OF           10.04
             82382   A    Assay, urine catecholamines                          1          1      0                      OF           18.72
             82383   A    Assay, blood catecholamines                          1          1      0                      OF           27.28
             82384   A    Assay, three catecholamines                          1          1      0                      OF           18.94
             82387   A    Assay of cathepsin-d                                 1          1      0                      OF            4.28
             82390   A    Assay of ceruloplasmin                               1          1      0                      OF           11.69
             82397   A    Chemiluminescent assay                               1          1      0                      OF           14.27
             82415   A    Assay of chloramphenicol                             1          1      0                      OF           13.79
             82435   A    Assay of blood chloride                              1          1      0                      OF            5.00
             82436   A    Assay of urine chloride                              1          1      0                      OF            5.47
             82438   A    Assay, other fluid chlorides                         1          1      0                      OF            4.15
             82441   A    Test for chlorohydrocarbons                          1          1      0                      OF            6.54
             82465   A    Assay, bld/serum cholesterol                         1          1      0                      OF            4.74
             82480   A    Assay, serum cholinesterase                          1          1      0                      OF            8.58
             82482   A    Assay, rbc cholinesterase                            1          1      0                      OF            8.36
             82485   A    Assay, chondroitin sulfate                           1          1      0                      OF           22.48
             82486   A    Gas/liquid chromatography                            1          1      0                      OF           19.65
             82487   A    Paper chromatography                                 1          1      0                      OF           17.38
             82488   A    Paper chromatography                                 1          1      0                      OF           23.26
             82489   A    Thin layer chromatography                            1          1      0                      OF           20.13
             82491   A    Chromotography, quant, sing                          1          1      0                      OF           19.65
             82492   A    Chromotography, quant, mult                          1          1      0                      OF           19.65
             82495   A    Assay of chromium                                    1          1      0                      OF           22.08
             82507   A    Assay of citrate                                     1          1      0                      OF           29.77
             82520   A    Assay of cocaine                                     1          1      0                      OF           16.49
             82523   A    Collagen crosslinks                                  1          1      0                      OF           20.35
             82525   A    Assay of copper                                      1          1      0                      OF           11.76
             82528   A    Assay of corticosterone                              1          1      0                      OF           24.50
             82530   A    Cortisol, free                                       1          1      0                      OF           18.19
             82533   A    Total cortisol                                       1          1      0                      OF           17.75
             82540   A    Assay of creatine                                    1          1      0                      OF            5.05
             82541   A    Column chromotography, qual                          1          1      0                      OF           19.65
             82542   A    Column chromotography, quant                         1          1      0                      OF           19.65
             82543   A    Column chromotograph/isotope                         1          1      0                      OF           19.65
             82544   A    Column chromotograph/isotope                         1          1      0                      OF           19.65
             82550   A    Assay of ck (cpk)                                    1          1      0                      OF            7.09
             82552   A    Assay of cpk in blood                                1          1      0                      OF           14.58
             82553   A    Creatine, MB fraction                                1          1      0                      OF           12.57
             82554   A    Creatine, isoforms                                   1          1      0                      OF           12.92
             82565   A    Assay of creatinine                                  1          1      0                      OF            5.58
             82570   A    Assay of urine creatinine                            1          1      0                      OF            5.63
             82575   A    Creatinine clearance test                            1          1      0                      OF           10.28
             82585   A    Assay of cryofibrinogen                              1          1      0                      OF            9.32
             82595   A    Assay of cryoglobulin                                1          1      0                      OF            7.05
             82600   A    Assay of cyanide                                     1          1      0                      OF           21.12

                                                                                                                      CPT Codes and Descriptions
                                                                                                                                   Copyright 2010
                                                                                                                     American Medical Association
Page 102 of 216                                                                                                               All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW     NWR     OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010   2010     Fee            Fee
             82607   A    Vitamin B-12                                         1          1      0                      OF           16.41
             82608   A    B-12 binding capacity                                1          1      0                      OF           15.59
             82610   A    Cystatin c                                           1          1      0                      OF           14.80
             82615   A    Test for urine cystines                              1          1      0                      OF            5.36
             82626   A    Dehydroepiandrosterone                               1          1      0                      OF           27.51
             82627   A    Dehydroepiandrosterone                               1          1      0                      OF           24.21
             82633   A    Desoxycorticosterone                                 1          1      0                      OF           18.03
             82634   A    Deoxycortisol                                        1          1      0                      OF           22.17
             82638   A    Assay of dibucaine number                            1          1      0                      OF           13.33
             82646   A    Assay of dihydrocodeinone                            1          1      0                      OF           22.48
             82649   A    Assay of dihydromorphinone                           1          1      0                      OF           27.98
             82651   A    Assay of dihydrotestosterone                         1          1      0                      OF           28.10
             82652   A    Vit d 1, 25-dihydroxy                                1          1      0                      OF           41.91
             82654   A    Assay of dimethadione                                1          1      0                      OF           15.07
             82656   A    Pancreatic elastase, fecal                           1          1      0                      OF           12.56
             82657   A    Enzyme cell activity                                 1          1      0                      OF           19.65
             82658   A    Enzyme cell activity, ra                             1          1      0                      OF           19.65
             82664   A    Electrophoretic test                                 1          1      0                      OF           17.73
             82666   A    Assay of epiandrosterone                             1          1      0                      OF           23.39
             82668   A    Assay of erythropoietin                              1          1      0                      OF           20.47
             82670   A    Assay of estradiol                                   1          1      0                      OF           30.42
             82671   A    Assay of estrogens                                   1          1      0                      OF           35.16
             82672   A    Assay of estrogen                                    1          1      0                      OF           23.61
             82677   A    Assay of estriol                                     1          1      0                      OF           26.33
             82679   A    Assay of estrone                                     1          1      0                      OF           21.92
             82690   A    Assay of ethchlorvynol                               1          1      0                      OF           18.82
             82693   A    Assay of ethylene glycol                             1          1      0                      OF            9.99
             82696   A    Assay of etiocholanolone                             1          1      0                      OF           25.67
             82705   A    Fats/lipids, feces, qual                             1          1      0                      OF            5.06
             82710   A    Fats/lipids, feces, quant                            1          1      0                      OF           18.29
             82715   A    Assay of fecal fat                                   1          1      0                      OF            3.03
             82725   A    Assay of blood fatty acids                           1          1      0                      OF           10.74
             82726   A    Long chain fatty acids                               1          1      0                      OF           19.65
             82728   A    Assay of ferritin                                    1          1      0                      OF           14.83
             82731   A    Assay of fetal fibronectin                           1          1      0                      OF           70.12
             82735   A    Assay of fluoride                                    1          1      0                      OF           20.19
             82742   A    Assay of flurazepam                                  1          1      0                      OF           21.55
             82746   A    Blood folic acid serum                               1          1      0                      OF           16.01
             82747   A    Assay of folic acid, rbc                             1          1      0                      OF           18.85
             82757   A    Assay of semen fructose                              1          1      0                      OF           18.88
             82759   A    Assay of rbc galactokinase                           1          1      0                      OF           23.39
             82760   A    Assay of galactose                                   1          1      0                      OF           12.19
             82775   A    Assay galactose transferase                          1          1      0                      OF           22.93
             82776   A    Galactose transferase test                           1          1      0                      OF            9.13
             82784   A    Assay, iga/igd/igg/igm each                          1          1      0                      OF           10.12
             82785   A    Assay of ige                                         1          1      0                      OF           17.93
             82787   A    Igg 1, 2, 3 or 4, each                               1          1      0                      OF            4.57
             82800   A    Blood pH                                             1          1      0                      OF            7.10
             82803   A    Blood gases: pH, pO2 & pCO2                          1          1      0                      OF           13.27
             82805   A    Blood gases w/02 saturation                          1          1      0                      OF           26.49
             82810   A    Blood gases, O2 sat only                             1          1      0                      OF            9.50
             82820   A    Hemoglobin-oxygen affinity                           1          1      0                      OF           10.88
             82926   A    Assay of gastric acid                                1          1      0                      OF            4.23
             82928   A    Assay of gastric acid                                1          1      0                      OF            6.02
             82938   A    Gastrin test                                         1          1      0                      OF           19.27
             82941   A    Assay of gastrin                                     1          1      0                      OF           19.20
             82943   A    Assay of glucagon                                    1          1      0                      OF           15.55
             82945   A    Glucose other fluid                                  1          1      0                      OF            4.27
             82946   A    Glucagon tolerance test                              1          1      0                      OF           16.41
             82947   A    Assay, glucose, blood quant                          1          1      0                      OF            4.27
             82948   A    Reagent strip/blood glucose                          1          1      0                      OF            3.45
             82950   A    Glucose test                                         1          1      0                      OF            5.17
             82951   A    Glucose tolerance test (GTT)                         1          1      0                      OF           14.01
             82952   A    GTT-added samples                                    1          1      0                      OF            4.26
             82953   A    Glucose-tolbutamide test                             1          1      0                      OF           16.49
             82955   A    Assay of g6pd enzyme                                 1          1      0                      OF           10.56

                                                                                                                      CPT Codes and Descriptions
                                                                                                                                   Copyright 2010
                                                                                                                     American Medical Association
Page 103 of 216                                                                                                               All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW     NWR     OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010   2010     Fee            Fee
             82960   A    Test for G6PD enzyme                                 1          1      0                      OF            6.59
             82962   A    Glucose blood test                                   1          1      0                      OF            1.97
             82963   A    Assay of glucosidase                                 1          1      0                      OF           23.39
             82965   A    Assay of gdh enzyme                                  1          1      0                      OF            8.41
             82975   A    Assay of glutamine                                   1          1      0                      OF           15.99
             82977   A    Assay of GGT                                         1          1      0                      OF            7.84
             82978   A    Assay of glutathione                                 1          1      0                      OF           15.52
             82979   A    Assay, rbc glutathione                               1          1      0                      OF            7.49
             82980   A    Assay of glutethimide                                1          1      0                      OF           19.94
             82985   A    Glycated protein                                     1          1      0                      OF           12.77
             83001   A    Gonadotropin (FSH)                                   1          1      0                      OF           18.64
             83002   A    Gonadotropin (LH)                                    1          1      0                      OF           18.94
             83003   A    Assay, growth hormone (hgh)                          1          1      0                      OF           18.00
             83008   A    Assay of guanosine                                   1          1      0                      OF           18.27
             83009   A    H pylori (c-13), blood                               1          1      0                      OF           73.32
             83010   A    Assay of haptoglobin, quant                          1          1      0                      OF           13.70
             83012   A    Assay of haptoglobins                                1          1      0                      OF           18.72
             83013   A    H pylori (c-13), breath                              1          1      0                      OF           73.32
             83014   A    H pylori drug admin                                  1          1      0                      OF            8.56
             83015   A    Heavy metal screen                                   1          1      0                      OF           20.50
             83018   A    Quantitative screen, metals                          1          1      0                      OF            9.11
             83020   A    Hemoglobin electrophoresis                           1          1      0                      OF           10.94
             83021   A    Hemoglobin chromotography                            1          1      0                      OF           19.65
             83026   A    Hemoglobin, copper sulfate                           1          1      0                      OF            2.57
             83030   A    Fetal hemoglobin, chemical                           1          1      0                      OF            9.01
             83033   A    Fetal hemoglobin assay, qual                         1          1      0                      OF            5.68
             83036   A    Glycosylated hemoglobin test                         1          1      0                      OF           10.56
             83037   A    Glycosylated hb, home device                         1          1      0                      OF           10.56
             83045   A    Blood methemoglobin test                             1          1      0                      OF            5.40
             83050   A    Blood methemoglobin assay                            1          1      0                      OF            7.97
             83051   A    Assay of plasma hemoglobin                           1          1      0                      OF            7.96
             83055   A    Blood sulfhemoglobin test                            1          1      0                      OF            5.36
             83060   A    Blood sulfhemoglobin assay                           1          1      0                      OF            9.01
             83065   A    Assay of hemoglobin heat                             1          1      0                      OF            7.49
             83068   A    Hemoglobin stability screen                          1          1      0                      OF            9.22
             83069   A    Assay of urine hemoglobin                            1          1      0                      OF            4.29
             83070   A    Assay of hemosiderin, qual                           1          1      0                      OF            5.17
             83071   A    Assay of hemosiderin, quant                          1          1      0                      OF            7.48
             83080   A    Assay of b hexosaminidase                            1          1      0                      OF            5.98
             83088   A    Assay of histamine                                   1          1      0                      OF           32.15
             83090   A    Assay of homocystine                                 1          1      0                      OF           18.36
             83150   A    Assay of for hva                                     1          1      0                      OF            7.62
             83491   A    Assay of corticosteroids                             1          1      0                      OF           19.07
             83497   A    Assay of 5-hiaa                                      1          1      0                      OF           14.04
             83498   A    Assay of progesterone                                1          1      0                      OF           29.57
             83499   A    Assay of progesterone                                1          1      0                      OF           27.44
             83500   A    Assay, free hydroxyproline                           1          1      0                      OF           20.31
             83505   A    Assay, total hydroxyproline                          1          1      0                      OF           26.46
             83516   A    Immunoassay, nonantibody                             1          1      0                      OF           12.56
             83518   A    Immunoassay, dipstick                                1          1      0                      OF            9.23
             83519   A    Ria nonantibody                                      1          1      0                      OF           13.82
             83520   A    Immunoassay quant nos nonab                          1          1      0                      OF           14.09
             83525   A    Assay of insulin                                     1          1      0                      OF           12.45
             83527   A    Assay of insulin                                     1          1      0                      OF           14.10
             83528   A    Assay of intrinsic factor                            1          1      0                      OF           17.31
             83540   A    Assay of iron                                        1          1      0                      OF            7.05
             83550   A    Iron binding test                                    1          1      0                      OF            9.52
             83570   A    Assay of idh enzyme                                  1          1      0                      OF            9.10
             83582   A    Assay of ketogenic steroids                          1          1      0                      OF           15.09
             83586   A    Assay 17- ketosteroids                               1          1      0                      OF           13.94
             83593   A    Fractionation, ketosteroids                          1          1      0                      OF           28.63
             83605   A    Assay of lactic acid                                 1          1      0                      OF           11.63
             83615   A    Lactate (LD) (LDH) enzyme                            1          1      0                      OF            6.57
             83625   A    Assay of ldh enzymes                                 1          1      0                      OF           13.93
             83630   A    Lactoferrin, fecal (qual)                            1          1      0                      OF           21.36
             83631   A    Lactoferrin, fecal (quant)                           1          1      0                      OF           21.36

                                                                                                                      CPT Codes and Descriptions
                                                                                                                                   Copyright 2010
                                                                                                                     American Medical Association
Page 104 of 216                                                                                                               All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW     NWR     OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010   2010     Fee            Fee
             83632   A    Placental lactogen                                   1          1      0                      OF           22.00
             83633   A    Test urine for lactose                               1          1      0                      OF            5.99
             83634   A    Assay of urine for lactose                           1          1      0                      OF           12.55
    L        83655   A    Assay of lead                                        1          1      0                      OF           13.18
             83661   A    L/s ratio, fetal lung                                1          1      0                      OF           18.94
             83662   A    Foam stability, fetal lung                           1          1      0                      OF           20.60
             83663   A    Fluoro polarize, fetal lung                          1          1      0                      OF           20.60
             83664   A    Lamellar bdy, fetal lung                             1          1      0                      OF           20.60
             83670   A    Assay of lap enzyme                                  1          1      0                      OF            9.98
             83690   A    Assay of lipase                                      1          1      0                      OF            7.49
             83695   A    Assay of lipoprotein(a)                              1          1      0                      OF           14.09
             83698   A    Assay lipoprotein pla2                               1          1      0                      OF           36.95
             83700   A    Lipopro bld, electrophoretic                         1          1      0                      OF           12.25
             83701   A    Lipoprotein bld, hr fraction                         1          1      0                      OF            6.98
             83704   A    Lipoprotein, bld, by nmr                             1          1      0                      OF           16.11
             83718   A    Assay of lipoprotein                                 1          1      0                      OF            8.91
             83719   A    Assay of blood lipoprotein                           1          1      0                      OF           12.66
             83721   A    Assay of blood lipoprotein                           1          1      0                      OF           10.38
             83727   A    Assay of lrh hormone                                 1          1      0                      OF           18.72
             83735   A    Assay of magnesium                                   1          1      0                      OF            7.30
             83775   A    Assay of md enzyme                                   1          1      0                      OF            8.03
             83785   A    Assay of manganese                                   1          1      0                      OF           26.77
             83788   A    Mass spectrometry qual                               1          1      0                      OF           19.65
             83789   A    Mass spectrometry quant                              1          1      0                      OF           19.65
             83805   A    Assay of meprobamate                                 1          1      0                      OF           19.19
             83825   A    Assay of mercury                                     1          1      0                      OF           17.70
             83835   A    Assay of metanephrines                               1          1      0                      OF           18.44
             83840   A    Assay of methadone                                   1          1      0                      OF           17.78
             83857   A    Assay of methemalbumin                               1          1      0                      OF           11.69
             83858   A    Assay of methsuximide                                1          1      0                      OF           16.13
             83864   A    Mucopolysaccharides                                  1          1      0                      OF           21.67
             83866   A    Mucopolysaccharides screen                           1          1      0                      OF           10.72
             83872   A    Assay synovial fluid mucin                           1          1      0                      OF            6.38
             83873   A    Assay of csf protein                                 1          1      0                      OF           18.73
             83874   A    Assay of myoglobin                                   1          1      0                      OF           14.06
             83876   A    Assay, myeloperoxidase                               0         NC      0
             83880   A    Natriuretic peptide                                  1          1      0                      OF           36.95
             83883   A    Assay, nephelometry not spec                         1          1      0                      OF           14.80
             83885   A    Assay of nickel                                      1          1      0                      OF           26.67
             83887   A    Assay of nicotine                                    1          1      0                      OF           25.78
             83890   A    Molecule isolate                                     1          1      0                      OF            5.74
             83891   A    Molecule isolate nucleic                             1          1      0                      OF            5.74
             83892   A    Molecular diagnostics                                1          1      0                      OF            5.74
             83893   A    Molecule dot/slot/blot                               1          1      0                      OF            5.74
             83894   A    Molecule gel electrophor                             1          1      0                      OF            5.74
             83896   A    Molecular diagnostics                                1          1      0                      OF            5.74
             83897   A    Molecule nucleic transfer                            1          1      0                      OF            5.74
             83898   A    Molecule nucleic ampli, each                         1          1      0                      OF           24.01
   EPA       83900   A    Molecule nucleic ampli 2 seq                         1          1      0                      OF           36.50
             83901   A    Molecule nucleic ampli addon                         1          1      0                      OF           24.01
             83902   A    Molecular diagnostics                                1          1      0                      OF           12.31
             83903   A    Molecule mutation scan                               1          1      0                      OF           24.01
             83904   A    Molecule mutation identify                           1          1      0                      OF           24.01
             83905   A    Molecule mutation identify                           1          1      0                      OF           18.25
             83906   A    Molecule mutation identify                           1          1      0                      OF           18.25
    PA       83907   A    Lyse cells for nucleic ext                           1          1      0                      OF           14.54
    PA       83908   A    Nucleic acid, signal ampli                           1          1      0                      OF           18.25
   EPA       83909   A    Nucleic acid, high resolute                          1          1      0                      OF           18.25
             83912   A    Genetic examination                                  1          1      0                      OF            5.74
    PA       83913   A    Molecular, rna stabilization                         1          1      0                      OF           14.54
    PA       83914   A    Mutation ident ola/sbce/aspe                         1          1      0                      OF           18.25
             83915   A    Assay of nucleotidase                                1          1      0                      OF           12.14
             83916   A    Oligoclonal bands                                    1          1      0                      OF           15.18
             83918   A    Organic acids, total, quant                          1          1      0                      OF           23.58
             83919   A    Organic acids, qual, each                            1          1      0                      OF           17.92
             83921   A    Organic acid, single, quant                          1          1      0                      OF           17.92

                                                                                                                      CPT Codes and Descriptions
                                                                                                                                   Copyright 2010
                                                                                                                     American Medical Association
Page 105 of 216                                                                                                               All Rights Reserved
                                                         HRSA Outpatient Fee Schedule                                             CY2010 Q4
                                                            Washington State Medicaid


                                                                                        MAX     APC    RW     NWR     OPPS            OP
  AUTH        CPT    SI   Description                                        COV
                                                                                        UNITS   2010   2010   2010     Fee            Fee
             83925   A    Assay of opiates                                     1          1      0                      OF           21.18
             83930   A    Assay of blood osmolality                            1          1      0                      OF            7.19
             83935   A    Assay of urine osmolality                            1          1      0                      OF            6.98
             83937   A    Assay of osteocalcin                                 1          1      0                      OF           32.50
             83945   A    Assay of oxalate                                     1          1      0                      OF           14.01
             83950   A    Oncoprotein, her-2/neu                               1          1      0                      OF           70.12
             83951   A    Oncoprotein, dcp                                     0         NC      0
             83970   A    Assay of parathormone                                1          1      0                      OF           44.93
             83986   A    Assay ph body fluid nos                              1          1      0                      OF            3.13
             83987   A    Exhaled breath condensate                            1          1      0                      OF           17.28
             83992   A    Assay for phencyclidine                              1          1      0                      OF           16.00
             83993   A    Assay for calprotectin fecal                         1          1      0                      OF           21.36
             84022   A    Assay of phenothiazine                               1          1      0                      OF           13.82
             84030   A    Assay of blood pku                                   1          1      0                      OF            5.81
             84035   A    Assay of phenylketones                               1          1      0                      OF            2.29
             84060   A    Assay acid phosphatase                               1          1      0                      OF            7.20
             84061   A    Phosphatase, forensic exam                           1          1      0                      OF            8.61
             84066   A    Assay prostate phosphatase                           1          1      0                      OF           10.52
             84075   A    Assay alkaline phosphatase                           1          1      0                      OF            5.63
             84078   A    Assay alkaline phosphatase                           1          1      0                      OF            7.95
             84080   A    Assay alkaline phosphatases                          1          1      0                      OF           16.10
             84081   A    Amniotic fluid enzyme test                           1          1      0                      OF           17.99
             84085   A    Assay of rbc pg6d enzyme                             1          1      0                      OF            7.34
             84087   A    Assay phosphohexose enzymes                          1          1      0                      OF           11.24
             84100   A    Assay of phosphorus                                  1          1      0                      OF            5.16
             84105   A    Assay of urine phosphorus                            1          1      0                      OF            5.63
             84106   A    Test for porphobilinogen                             1          1      0                      OF            4.66
             84110   A    Assay of porphobilinogen                             1          1      0                      OF            8.82
             84119   A    Test urine for porphyrins                            1          1      0                      OF            9.38
             84120   A    Assay of urine porphyrins                            1          1      0                      OF           16.01
             84126   A    Assay of feces porphyrins                            1          1      0                      OF           16.10
             84127   A    Assay of feces porphyrins                            1          1      0                      OF           12.68
             84132   A    Assay of serum potassium                             1          1      0                      OF            5.00
             84133   A    Assay of urine potassium                             1          1      0                      OF            4.68
             84134   A    Assay of prealbumin                                  1          1      0                      OF           15.88
             84135   A    Assay of pregnanediol                                1          1      0                      OF           20.82
             84138   A    Assay of pregnanetriol                               1          1      0                      OF           20.61
             84140   A    Assay of pregnenolone                                1          1      0                      OF           22.50
             84143   A    Assay of 17-hydroxypregneno                          1          1      0                      OF           24.84
             84144   A    Assay of progesterone                                1          1      0                      OF           22.38
             84145   A    Procalcitonin (pct)                                  1          1      0                      OF           21.10
             84146   A    Assay of prolactin                                   1          1      0                      OF           21.10
             84150   A    Assay of prostaglandin                               1          1      0                      OF            9.52
             84152   A    Assay of psa, complexed                              1          1      0                      OF           20.02
             84153   A    Assay of psa, total                                  1          1      0                      OF           20.02
             84154   A    Assay of psa, free